0:00

Welcome to Public Health

0:02

on Call, a podcast from

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the Johns Hopkins Bloomberg School

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of Public Health, where

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we bring evidence, experience,

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and perspective to make sense

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of today's leading health challenges.

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If you have questions or

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ideas for us, please

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send an email to

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Public Health Question at

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JHU.EDU. That's Public Health

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Question at JHU.EDU. for

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future podcast episodes. Hey listeners,

0:30

it's Lindsay Smith Rogers. Today,

0:33

the Building H Index, a

0:35

rating of consumer products and services

0:37

for how they influence the health

0:39

of their users. Steve Downs, a

0:42

co-founder of the Building H

0:44

Index, talks with Dr. Josh Sharfstein

0:46

about the origins of the ratings,

0:49

how it works, and what companies

0:51

rate the highest and lowest for

0:53

health. The Building H Index, by

0:56

the way, does not receive any

0:58

funds from the companies that are

1:01

rated. It is a program of

1:03

the nonprofit Public Health

1:05

Institute. Let's listen. Steve Downs,

1:07

thanks so much for joining

1:09

me today on Public Health

1:11

on Call. To talk about

1:14

the Building H Index, it

1:16

stands for Health. You are

1:18

absolutely correct, it does. And the

1:20

index in the building each index

1:22

is like a ranking of companies

1:25

for how they relate to health.

1:27

Exactly right. Yeah, the building

1:29

age index rates and ranks

1:31

everyday products and services on

1:34

how they impact the health

1:36

behaviors of their users. So

1:38

we look at. products and

1:40

services across four industries, entertainment,

1:42

food, housing, and transportation. These

1:44

are products like Netflix, Uber,

1:47

Dordash, also restaurants like Chick-fil-A,

1:49

and Taco-Bell, automobile manufacturers like

1:51

Ford and Toyota, and even

1:53

the nation's largest homebuilders and

1:55

apartment managers. And we ask,

1:57

how do they affect the...

2:00

we eat, how much physical activity we

2:02

have, how we sleep, how we socialize,

2:04

and how much time we spend outdoors.

2:07

And last fall we released a report

2:09

rating more than 75 popular products and

2:11

services. I think what's interesting is that

2:14

the companies behind these products are not

2:16

in the health business, but what we're

2:18

showing is that they have very real

2:21

impacts on health and impacts that we

2:23

believe factor into the rise of preventable

2:25

chronic illness in the U.S. Now where

2:27

did this idea come from? Thomas and

2:30

I founded Bill, Thomas Gatz, my co-founder,

2:32

and I started building it several years

2:34

ago because we believe that it's actually

2:37

become pretty hard to be healthy in

2:39

the US. It's hard to eat right,

2:41

hard to get enough physical activity, hard

2:44

to get consistent, sufficient sleep, and even

2:46

hard to spend enough quality time with

2:48

friends and family. I think we all

2:51

struggled with this to varying degrees. Part

2:53

of the reason is that... We have

2:55

so many products and services, products that

2:58

are really kind of woven into the

3:00

fabric of our everyday lives, that too

3:02

often push against these healthy behaviors. In

3:05

effect, they're creating conditions that need to

3:07

be overcome in order to be healthy.

3:09

And I've often said that in order

3:12

to be healthy in the US, you

3:14

have to swim upstream every day, and

3:16

that I think our societal response to

3:18

that in a lot of ways is

3:21

to try to help people become better

3:23

swimmers. And that's good, and it's actually

3:25

quite necessary and important. But we also

3:28

need to focus on how we might

3:30

be able to reverse the river, to

3:32

really change the landscape of products and

3:35

services that shape our health behaviors, so

3:37

that they become much more supportive of

3:39

our health. Such an interesting idea. Can

3:42

you take me a little deeper into

3:44

the ranking for one of your products

3:46

or your analysis of one of these

3:49

products? Sure, why don't I actually start

3:51

with the top rated product? I can

3:53

also do the bottom rated, but the

3:56

top rated is actually a small company

3:58

called Cult. which is a real estate

4:00

developer who built a car-free apartment community

4:02

outside of Phoenix, Arizona. And so if

4:05

you just start with that implication, right,

4:07

you can't own and store a car

4:09

on premises, but it has access to

4:12

public transportation, they have lots of rentable

4:14

bikes and scooters, and they provide discounts,

4:16

I think, for ride hailing as well.

4:19

And so that really gets you into

4:21

active transportation, you know, so you're gonna

4:23

be much more physical on the transportation

4:26

side. But they've also gone further, they

4:28

provide access to fresh foods in the

4:30

kind of community there. and they designed

4:33

the community to create a lot of

4:35

outdoor social spaces. So people are able

4:37

to spend time outdoors, they're able to

4:40

be very social, and they even, for

4:42

good measure, designed the apartments architecturally to

4:44

have as much natural light in the

4:47

units as possible, and that can help

4:49

with sinking up your circadian rhythmsms, which

4:51

can be beneficial to sleep. So they

4:53

really kind of hit on all five

4:56

of the behaviors that we actually look

4:58

at in terms of the index. for

5:00

a particular population or is it for

5:03

anyone? It's for anyone. I think it

5:05

is, it's a round market rate or

5:07

maybe slightly higher than market rate for

5:10

the community. That's an example of a

5:12

really positive one. At the bottom end

5:14

of the scale is actually Netflix. And

5:17

I always sort of feel funny about

5:19

talking about Netflix because as a consumer,

5:21

I think there's probably much to like

5:24

about Netflix. But if you think about

5:26

it. TV watching, actually there's a lot

5:28

of studies that show a negative impact

5:31

on diet. It's obviously in most instances

5:33

a very sedentary activity, so not a

5:35

lot of physical activity. It's definitely, we're

5:37

almost definitely indoors most of the time.

5:40

And you know, it's sort of a

5:42

plus or minus on social connection. It

5:44

depends how it's how it's used. I

5:47

look at your index and I think

5:49

the kinds of services that are at

5:51

the top are things that could really...

5:54

Get me out and about moving maybe

5:56

more social and the ones at the

5:58

bottom are the ones that maybe um

6:01

on my couch and kind of doing

6:03

by myself for hours at a time.

6:05

Yeah, I think that's a pretty fair

6:08

way to parse it. I think one

6:10

of the trends that's sort of long

6:12

term here is this sort of idea

6:14

that you can do pretty much everything

6:17

now from the comfort of your own

6:19

home. I mean, it used to be

6:21

that if you thought about entertainment, that

6:24

was something that was often very public

6:26

and shared. Think about going to the

6:28

movie theater or something like that. But

6:31

now we have bigger and bigger screens

6:33

and 24-7 content. And so you do

6:35

it at home. Same with food. The

6:38

restaurants did come back after the pandemic,

6:40

but they're making their money off delivery

6:42

and takeout, not on going out and

6:45

being social. Anything surprising in this ranking?

6:47

Like if I were to spend a

6:49

lot of time looking at these different

6:51

companies, I have to tell you I'm

6:54

not shocked that Netflix is kind of

6:56

towards the bottom here. Anything surprising in

6:58

terms of... you know, companies that you

7:01

might not think are designing their products

7:03

in a way that is conducive to

7:05

health, but actually they are doing some

7:08

things that might be helpful. Yeah, I

7:10

would say there are actually two categories

7:12

of products that were a bit of

7:15

a surprise, and one is automobiles. It's

7:17

been quite negative. It's a less active

7:19

form of transportation. They allowed us to

7:21

sort of move further apart from each

7:24

other. But I think as a consequence

7:26

of all that, they've actually become then

7:28

very, very necessary for people in today's

7:31

world, particularly in communities that are quote-unquote

7:33

car-dependent. And so in order to get

7:35

groceries to cook healthy dinners, you need

7:38

a car. For all of us who

7:40

are not living in that apartment complex

7:42

for all of us who are not

7:45

in the in the little yeah in

7:47

the cul-de-sac outside of Phoenix exactly and

7:49

I think so even seeing your friends

7:52

often requires a car if you want

7:54

to do outdoor recreation you often need

7:56

to drive there and so what you

7:58

could say It's an artifact of our

8:01

index, is that we look at how

8:03

does the product affect health in the

8:05

world today that exists, not necessarily how

8:08

it happened over time. I think a

8:10

similar thing happened a little bit with

8:12

social media, and the companies didn't score

8:15

great, social media. Our scale is zero

8:17

to 100, with zero being negative, strong

8:19

negative on all five behaviors, 100, strong

8:22

positive, and then 50 is kind of

8:24

neutral. the social media companies were sort

8:26

of in the high, these low 40s.

8:28

And I think they did better for

8:31

a couple of reasons. You know, because

8:33

I think they're often singled out for

8:35

a lot of health harms. But there

8:38

are a couple of things that happen.

8:40

One is that a lot of the

8:42

research is pretty mixed and inconclusive on

8:45

social media. And so you see that

8:47

often the effects are not quite uniform

8:49

across people, and they're people that have

8:52

very positive experiences, as well as negative

8:54

experiences. We actually did our own consumer

8:56

research for this work, where we asked

8:59

a lot of questions about social media

9:01

use and the different health behaviors. It

9:03

actually found some sort of interesting paradoxes.

9:05

People that used social media more often

9:08

were also more likely to report being

9:10

lonely, but they also reported that it

9:12

had a more positive impact on their

9:15

social connection than people who used it

9:17

less. And similarly, people who use social

9:19

media, there were a lot reporting. that

9:22

they were using it a lot before

9:24

they go to bed, just before they

9:26

go to bed, and even waking up

9:29

during the middle of the night to

9:31

use it. And yet, they actually reported

9:33

some of the same numbers around overall

9:35

sleep duration that people who are using

9:38

it less. So I think what happened

9:40

is that on the one hand, we

9:42

sort of had to report all these

9:45

mixed research conclusions, and I think our

9:47

reviewers who scored all of the products

9:49

reflect, their scores reflected that. The other

9:52

thing is I think not unlike automobiles,

9:54

social media is a little bit like

9:56

it's there. This is actually where you

9:59

find people and so if you want

10:01

to connect to people it's sort of

10:03

hard to avoid it in a lot

10:06

of ways. Talk to me more about

10:08

your methodology because my initial picture was

10:10

you and your co-founder watching a lot

10:12

of Netflix and writing down your scores.

10:15

No. But it sounds like it's a

10:17

little bit more elaborate than that. It

10:19

is pretty rigorous. So first we research

10:22

all the products. We look at how

10:24

they're designed, how people use them, and

10:26

what's known about how they influence each

10:29

of the five behaviors that we focus

10:31

on. So we use information from the

10:33

company. We go through news stories, market

10:36

research reports, products reviews. We do do

10:38

do some testing ourselves, just mainly to

10:40

understand the functions. We rely heavily on

10:42

the scientific literature for studies that link

10:45

the different types of products with the

10:47

different health behaviors. So for example, I

10:49

mentioned there's a robust literature on TV

10:52

viewing and diet. And then we actually

10:54

conducted a lot of, I mentioned a

10:56

lot of original consumer survey research that

10:59

looked at how people use the products,

11:01

their overall health behaviors, and how the

11:03

products are connected to those health behaviors.

11:06

And then what we do is we

11:08

actually take all that information, we synthesize

11:10

it, and develop profiles of each product,

11:13

and where we go in and say,

11:15

is our analysis of how each product

11:17

affects each behavior, along with any evidence

11:19

we have to support that. And then

11:22

we go to the companies and say,

11:24

hey, did we get anything factually wrong?

11:26

Is there anything you feel like we

11:29

are just flat out wrong about? But

11:31

then when we finalized the profiles, we

11:33

actually sent them to volunteer reviewers, and

11:36

we were so lucky we managed to

11:38

recruit nearly 200 people with backgrounds in

11:40

public health and health care and health

11:43

policy, and then they would take our

11:45

analyses and convert it to numerical scores.

11:47

So they would say, well, based on

11:49

what you've said about Netflix and sleep,

11:52

we think it's a moderately negative influence.

11:54

And then we take all the numbers

11:56

and aggregate them and everybody gets a

11:59

score from zero to 100. So yeah,

12:01

it's a lot. How would you like

12:03

people to use this index? Well, I

12:06

think there are two levels to this

12:08

and I think One of it is

12:10

to think about consumers and have some

12:13

thoughts for them, although it is primarily

12:15

not aimed at consumers. But let me

12:17

go through the consumers first. And I

12:20

think that the issue there is that

12:22

I think it's helpful for consumers to

12:24

be aware of how these projects work,

12:26

and particularly when they're being manipulated by

12:29

the products. So we're certainly not suggesting

12:31

that people go out and start boycotting

12:33

the companies that scored low. But I

12:36

think pushing back against some of those

12:38

manipulations. So for example, when fast food

12:40

companies are upselling you at the checkout

12:43

process, resist, turn off the notifications designed

12:45

to pull you back into your social

12:47

media platform when you're getting ready to

12:50

go to bed, disable auto play on

12:52

your streaming service, and so the next

12:54

episode doesn't begin before you've had a

12:56

chance to think about whether you want

12:59

to watch it. You know, actually, smartphones

13:01

have bedtime settings. So if you haven't

13:03

set that on your phone, go do

13:06

that. But I think these are sort

13:08

of small tweaks that users can control,

13:10

but I think it's really important that

13:13

the challenge not be laid at the

13:15

feet of consumers. I think we really

13:17

have to change this environment, not simply

13:20

encourage people to try to overcome it.

13:22

And so when I think about what

13:24

we want people to do about this,

13:27

is I think this is about an

13:29

idea and really getting an idea into

13:31

the mainstream discussion. And that idea... is

13:33

that the products and services of everyday

13:36

life are creating an environment that you

13:38

have to overcome in order to be

13:40

healthy. And that instead of just saying,

13:43

well, we've got plenty of health care

13:45

and we can treat that all with

13:47

health care, or instead of saying, well,

13:50

we have to figure out how to

13:52

help people overcome the environment, let's actually

13:54

change it so that it doesn't become

13:57

so much more unhealthy. And I think

13:59

this is especially urgent because we have

14:01

a history of applying technology. to making

14:03

environments unhealthy and we are on the

14:06

cusp of a revolution in technology that

14:08

is probably going to shape our behaviors

14:10

even further. And so we have to

14:13

do something about that. Any indication that

14:15

companies are paying attention? There is. Certainly

14:17

we've engaged them in the process and

14:20

a lot of them have been very

14:22

responsive to that. I think they've been

14:24

providing helpful information. I think we've gotten

14:27

some pushback at times, which is good,

14:29

but it's always been respectful. I think

14:31

actually one of the most exciting things

14:34

that we saw was that we had

14:36

done this report in a smaller version

14:38

of this report in 2022. And when

14:40

we look back at some of the

14:43

companies that we had made recommendations to,

14:45

which is another part of our process,

14:47

we actually don't just critique or rate,

14:50

we actually say, here are some suggestions

14:52

for ways you could adapt your products.

14:54

We actually found that a number of

14:57

the suggestions that we'd made in 2022

14:59

were actually now happening in some of

15:01

the companies in 2024. So that was

15:04

really exciting to see some of that.

15:06

Well Steve Downs this is the building

15:08

H index we're talking about good luck

15:10

with this process and I hope that

15:13

in the course of evaluating all these

15:15

products you're able to keep your own

15:17

sanity first and Continue to help the

15:20

rest of us to figure out how

15:22

best to use them Thank you very

15:24

much. It's been a pleasure talking about

15:27

it. I really appreciate the opportunity Public

15:29

Health on call is a podcast from

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the Johns Hopkins Bloomberg School of Public

15:34

Health Lindsay Smith Rogers, Stephanie Desmond, and

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Grace Fernandez-Sissieri. Audio production by J.B. Arbogast,

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Michael Bonfills, Spencer Greer, Matthew Martin, and

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Philip Porter, with support from Chip Hickey.

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Distribution by Nick Moran. Production coordination by

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Fernandez-Sissieri. Analytics by Elisa Rosen. If you

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for listening. So, You