2022 Building H Index
The 2022 Building H Index ranks 37 companies in four industries – entertainment, food, housing and transportation – on how their products and services impact the health of their customers and consumers. The ranking reflects how companies score across five health-related behaviors: healthy eating, physical activity, sleep, social engagement, and time spent outdoors.
Our goal is to gauge the net health impact of common products and services used by many Americans in everyday life. We believe these health outcomes are too often overlooked, if not altogether ignored, and by shining a light on them we hope to inspire more creators and leaders in the corporate world to consider the consequences that their products and services have on the health of their customers and consumers. We ask them to Own the Outcome.
It’s important to note what the Building H Index does NOT evaluate. The Index does not focus on health products or services explicitly designed to influence health; it does not consider any social impact or charitable activities these companies might undertake to improve health; it does not consider how these companies might care for their employees, or how they engage in their local communities, or how their production processes affect their surrounding environments. While worthy efforts, we believe these considerations are second-order factors, where we focus on the direct - if underestimated - health consequences of using these companies and products, the products that form so much of the fabric of our everyday lives.
Overall Rankings
overall rank
Company
INDUSTRY
INDUSTRY RANK
The Big Idea
The U.S. is mired in an epidemic of chronic health conditions, from obesity to diabetes to heart disease to mental health or mood disorders. These conditions are often labeled “lifestyle diseases” because they are closely linked to our everyday behaviors – the ways in which we eat, move our bodies, sleep and socialize – all of which have shifted, often gradually, but still dramatically, over several decades. We eat more and often worse, move less (outside of defined “exercise”), sleep less and are increasingly lonely.
The numbers here are staggering: More than 42% of American adults live with obesity. 10% now have diabetes and another 30% are pre-diabetic. Half of Americans have underlying heart conditions. The Surgeon General has recently issued an advisory on the alarming rise of mental health issues among teens and youth. The numbers – and the human toll associated with them – continue to rise year after year. And they’re projected to get worse: by the end of the decade, the prevalence of diabetes is predicted to grow by nearly 50% and, by one estimate, 50% of Americans will be living with obesity and nearly half of them will be considered to have “severe” obesity.
In the past decade, we’ve seen a profusion of innovations intended to help people change their behaviors: step and sleep trackers, diet apps, meditation apps. We’re seeing some of the most sophisticated technologies on earth being applied to the detection of chronic heart conditions and other warning signs. And yet, more than 10 years into the digital health era, our collective health keeps getting worse.
Too many of these innovations have focused on individual change, putting the onus on individuals to overcome the challenges that modern life creates. At Building H, we believe it’s time to flip the script. In addition to helping people tackle the challenges, society needs to foster a collective effort to reduce these challenges – to make it less hard to be healthy.
At the heart of that challenge is what we call the “product environment,” which we must understand as a major determinant of health. A set of key industries have become enormously successful at delivering outstanding, consumer experiences that delight us, engage us, demand our attention – and shape our behaviors. Automobiles have become more and more reliable and luxurious, taking the sting out of longer commutes – and soon they will drive themselves. Televisions have gotten bigger and sharper – and are now delivering extraordinary, diverse content, including Oscar-winning original films, in surround sound, 24/7, on demand. Houses are bigger and more private. And food is not only precision-engineered to meet our cravings, it is now being delivered with breathtaking efficiency.
These products and services deeply influence how we live — how we eat, how much we move our bodies, how we interact with our friends and neighbors, how we spend our leisure time, and how much sleep we get. And by doing so, they influence our health. The Building H Index is intended to make the role of the product environment more visible, to establish a platform for accountability, and to start a conversation about how and why companies should take responsibility for the effect their products have on their customers’ health. Indeed, our research shows that 72% of consumers want companies to take this responsibility and to own the outcome that their products create.
The Takeaways
Each product/service was rated on a scale across 5 categories to create an overall H-Score, which reflects its overall influence on health behaviors. A higher H-Score (50 and above, on a 100-point scale) reflects a stronger positive influence on health. The companies are ranked both within their industry as well as overall.
findings
The 37 products and services we examined show a wide range of influences on health, with some having very positive influences and some quite negative. 45% of the profiled products have net-positive influences, showing that it is very much possible to design products in these industries that lead customers to healthy behaviors. The distribution of scores, by industry, is shown below. Apartment management companies did very well, fast food ranked poorly, and video streaming received the feeblest results.
The nature of the product/service was a much stronger determinant of its score than the particular company’s implementation of that product/service. Scores for companies in the same product category, such as meal kit services and video streaming services, tended to cluster within fairly narrow ranges. For example, six video streaming services all scored between 20 and 28. This clustering reflects the degree to which product designs and tactics tend to mimic one another. Video streaming services, for example, all use a form of autoplay as a technique to keep viewers watching. All restaurant chains use some form of digital prompting to encourage users to add more items to their carts before they check out.
Products had influences across multiple behaviors. When we think of food companies, we can imagine their influence on our eating habits, but our analyses showed chain restaurants also influence physical activity, getting outdoors and even sleep. Similarly, while much has been written about television viewing and physical activity, the video streaming services were also rated poorly for their influences on sleep, eating and getting outdoors. On a more positive note, micromobility providers Bird and Lime, had positive influences on social connection and getting outdoors in addition to physical activity. Notably, only 21% of all product/behavior ratings were zero (0), meaning a neutral influence (no influence or off-setting influences).
The housing industry has a strong influence on health behavior. We examined both single-family home builders and apartment managers and developers and found considerable influences on all five behaviors. Location was a primary driver of this impact – neighborhood characteristics such as walkability and access to fresh food had ripple effects across multiple behaviors. Single-family home builders we examined are largely building in car-dependent neighborhoods, often with limited access to fresh food and to green spaces like public parks. Apartment management firms, particularly those that focus on denser neighborhoods, scored highly on multiple behaviors.
A number of product categories reinforce recent trends of staying home. While food companies varied considerably in their influences on people’s eating habits, nearly all are focused on providing people with access to food without having to leave their houses. The video streaming services, as their quality approaches the theatrical experience, also encourage people to stay in. Home builders, as they make homes more private (with fewer front porches) and emphasize private, as opposed to public, amenities, also contribute to this trend. It’s a trend that served us well during COVID, but that creates long-term concerns around sedentary, indoor lifestyles and social isolation.
Services that counter prevailing industry trends demonstrated highly positive influences. Niantic’s origin story is based on the challenge of creating entertainment that offers a compelling alternative to staying inside in front of a screen. As a result, its AR-based mobile games challenge users to get out of their homes and be active, often with friends. Culdesac, the top-scoring company in the Building H Index and the only company to score positively on each of the five behaviors, chose to create a car-free apartment development, bucking the trend of building in car-dependent locations and intentionally creating an environment that supports multiple healthy behaviors.
Every product could have a healthier version of itself. Some product categories will always be challenged to heave positive influences, given the nature of the category. For example, there are limits to how healthy video streaming can be, because it is typically a sedentary indoor activity. However, we found that there are always feature changes, tweaks in algorithms and defaults, and shifts in direction that can lead to healthier experiences for their customers. Throughout the profiles we developed, we identified dozens of opportunities for companies to adapt their products and services in ways that could lead to positive changes. Companies measure what matters to them, and when they prioritize key performance indicators that boost engagement at the expense of health, their users suffer the consequences.
OppoRtunities
We’ve included specific opportunities in each of the product profiles. And several opportunities cut across multiple product categories.
Follow the lead of the contrarians. Some of the highest-scoring companies were those that went against the grain of their industries. Culdesac ignored the cultural attachment to automobiles in the development they’re building. Niantic pushed back against the trend of entertainment moving more and more indoors. And Bird and Lime created new opportunities for active transportation, rather than coming up with more efficient ways to drive or be driven. Seizing these opportunities will require companies to think more broadly about the businesses they are actually in (e.g. are automobile manufacturers in the car business or the mobility business, is Netflix in the television business or the entertainment business or the leisure time business?).
Stop pushing excess consumption. While this opportunity certainly goes against our cultural norms about business, a number of unhealthy behaviors are driven by companies pushing their customers to watch more or eat more. By eliminating features like auto-play or prompts to add more items to one’s order, companies could show greater respect for their customers’ intentions.
Ask for user preferences and honor them. It is hard for people to discipline their behavior, especially when user experiences are designed to push them away from their own well-being. By asking for user goals and preferences around diet, transportation modes, sleep and other issues – and then honoring those choices through service designs – a company can help its customers better meet their goals.
Use defaults to normalize healthy behaviors. The defaults in our services communicate cultural norms. When a map offers driving directions for a short trip, it normalizes the behavior of driving short distances. When a streaming service automatically plays new episodes over and over again, it normalizes binge-watching. Conversely, setting the default to walking for short distances, or setting the default to pickup instead of delivery for nearby restaurants normalizes these healthier behaviors.
Develop and embed rating systems for the healthfulness of food items, meals and restaurants. Simple rating systems could avoid the complexity of nutrition advice by replacing it with general guidelines that could then be embedded into searching and ordering systems, enabling opportunities for users to act more effectively on their dietary preferences and for platforms to be proactive in helping users find healthy options.
Establishing bedtime modes across services. Both Apple’s iOS and Google’s Android operating systems recognize user-defined bedtime periods and then adapt their services to respect those preferences. The bedtime mode could be extended across other services, such as video streaming, games, and even food delivery.
While this report discusses a number of specific opportunities, both above and within the product profiles, the fundamental opportunity, for all companies, is to become allies with their customers to choose to support them in leading healthier lives.
Takeaways
The Building H Index should not serve as an indictment of the companies that were rated poorly. Few companies outside of healthcare or food have been asked historically to take responsibility for the health impacts of their products, and few have been asked to examine any behavioral influences, let alone such a wide range of behaviors.
For that reason, it’s less important where a company scores in this edition of the Building H Index and more important what they do next. Will they use the framework to examine the way their products interact with their users? Will they seek out more information about how their products are used? Will they engage with the opportunities presented, using them as a springboard to generate their own ideas of how they could adapt their products? Will they follow through on some of those ideas?
In some ways, the key finding of the Building H Index is that greater accountability on health is possible - and necessary. The product environment can be broken down and measured.
New technologies and new innovations have led to untold modern marvels, and have provided lifestyles of comfort and convenience that our forebears couldn’t have imagined. But we’ve learned that the chronic disease epidemic marches in lockstep with these luxuries. Halting, let alone reversing, this epidemic will take intention and action on a massive scale. It will take a collective effort to design new products and services that re-fashion that environment such that it supports our health and not just our appetites.
We call on the leaders – the executives, product managers, designers and engineers – at the companies profiled in this report, and their peers whom we have not yet rated, to own the outcome of their products and services. We ask them to ask themselves one question: Are they making it easier or harder for their customers to lead healthy lives?
Results by Industry
Findings across each industry and detailed profiles of each company are found in the following sections:
Methodology
The development of the Building H Index is based on six stages: product/service selection, product research, influence analysis, company input; crowd rating and calculation of the H-Score. Each of these stages is described below in general terms; specific measures used for different types of products and services are discussed in the methodology sections for the different industries and product categories.
PRODUCT/SERVICE SELECTION
The Building H Index focuses on everyday products from four industries – entertainment, food, housing, and transportation – that shape most of the context in which people live their day-to-day lives. Within each industry, we selected product categories that are proximate to user behavior, are amenable to the types of analyses we conduct, and, in some cases, represent emerging categories that speak to the future of an industry. Within each category, we start with market leaders and then, in some instances, add in smaller companies that contrast in approach from the market leaders and thus offer instructive alternatives.
PRODUCT RESEARCH
After selecting the products and services, the Building H team researched them using a combination of: company documents, such as blogs, press releases and SEC reports; news stories and product reviews; original consumer survey research on the experience of different product categories and associated health behaviors; open data, such as real estate listings and data about restaurant locations from Google and Yelp; where feasible, actual experience using the product or service.
INFLUENCE ANALYSIS
The Building H team mapped its understanding of each product or service to possible influences on each of the five behaviors. Wherever possible, we used scientific literature or industry reports to identify links between product use (often by product category if not the specific product) and effects on behavior. In some cases, such as the inference that most scooter riding takes place outdoors, the links are self-evident. We then summarize these analyses into a draft profile of each product or service that lays out the possible influences, along with supporting evidence, for each of the five behaviors.
COMPANY INPUT
After a draft profile is developed, Building H contacts the company, typically through the Press or Social Impact office, to seek input. We ask for validation of the accuracy of the profile, for feedback on the analyses, and for information that would help to fill gaps in our understanding of the products/services and how they’re used. The Building H team reviews any feedback or new information and makes adjustments, when appropriate, to the profiles. Where feedback from one company has implications for other companies within an industry, we make adjustments across all the relevant profiles.
CROWD RATING
The product profiles provide a qualitative assessment of the ways in which each product or service influences the five behaviors. While the direction of any particular influence is clear, determining the significance of influence – and how to weigh multiple conflicting influences – is more of a subjective exercise. In order to gather this subjective input, Building H recruited 80 volunteers, who all had backgrounds in public health, health care or health policy, to review the profiles and rate the influences on a scale of +3 (a strong positive influence) to -3 (strong negative). Each reviewer rated four or five profiles and all profiles received at least 10 reviews. In order to provide a degree of comparability across similar services, each reviewer was given a random selection of profiles within the same industry.
H-SCORE
The reviewer scores for each behavior were averaged (with some adjustments for extreme outliers) and rounded to the nearest half point on a +3/-3 scale. Building H calculated the final H-Score, which has a scale of 0-100, by first weighting the scores for each of the five behaviors equally to arrive at a score of between +15 and -15 and then using a simple linear transform. For example, a score of +2 (a moderate positive influence) two on each of the five behaviors, would lead to an H-Score of 83. A score of -1 (slight negative influence) on each of the behaviors would result in an H-Score of 33.
The 0-100 scale does not align with a traditional academic grading scale. One can interpret any H-Score of 50 or more having a net-positive influence on health behavior. In practice, both very high and very low scores are unlikely due to the low likelihood of having significant (and correlated) influences on each of the five behaviors.
Acknowledgments
Team
Steve Downs and Thomas Goetz, co-founders at Building H, conceived and developed the Building H Index and wrote the report.
Sara Singer, MBA, PhD, Professor of Medicine and, by courtesy, Organizational Behavior at Stanford University School of Medicine and Stanford Graduate School of Business, served as a methodological advisor throughout the project.
Nathaniel Braun and Esther Olsen, both of Stanford University School of Medicine, and Samir Khanna conducted product research and drafted influence analyses. Brittany Sigler, doctoral candidate at the Johns Hopkins Bloomberg School of Public Health, contributed to the influence analyses.
Ali Rostami, PhD candidate in computer science and Ramesh Jain, Emeritus Bren Professor, Computer Science at Donald Bren School of Information and Computer Sciences, University of California, Irvine, developed nutritional analyses of meal kit recipes and provided access to chain restaurant location data.
Wael Kanj, master’s student at the Rutgers University Edward J. Bloustein School of Planning and Public Policy, contributed research, connection to data services, data management and calculation of metrics.
Samara Shima contributed to the development of the opportunities sections of the product profiles.
VOLUNTEER RATERS
Building H is grateful for the contributions of its community of volunteer raters, who reviewed and scored the profiles we drafted. These raters include: Eliah Aronoff-Spencer, Ella Auchincloss, Hassina Bahadurzada, Ileana Balcu, David Ball, Ellen Beckjord, Shay Bluemer-Miroite, Laryssa Boyko, Amy Bucher, Jamie Bussel, Alison Byrne Fields, Alex Chen, Ellen Clewett, Maureen Cozine, Steven Cutbirth, Karen Davenport, Steven Dean, Fred Dillon, Amy Edgar, Erica Frenkel, Samuel Fuchs, Jeff Fuller, Sixtine Gurrey, David Harlow, Bridget Healey, Yusyin Hsin, Marianne Hurewitz, Erin Jackson-Ward, Grace Joseph, Minna Jung, DeRonn Kidd, Manali Kulkarni, Katherine Lao, Deb Levine, Sarah Lisker, Ramon Llamas, Silver Lumsdaine, Carlo Martinez, Suzy Mayers, Gregg Masters, Angie McGowan, Russell McIntire, Megan McVay, Bobby Milstein, Annie Minondo, Erin Moore, Shali Pai, Marjorie Paloma, Tina Park, Angela Pfammatter, Brian Quinn, Jillian Racoosin, Jody Ranck, Neil Rowen, Randall Sampson, Susan Schaffler, Samuel Seward, Jordan Shlain, Madelyn Slamka, Michael Sobolev, Gina Solomon, Katherine Sun, Nishwant Swami, Alex Tam, Benjamin Tingey, Quynh Tran, Brooke Van Roekel, Kathryn Wehr, Drew Weilage, John Wilbanks, Kelly Worden, and Jean Wright.
Additional Support
Support for Building H’s consumer research that informed our analyses was provided by Robert Wood Johnson Foundation. Carlo Martinez, Brittany Sigler, Sara Singer, Steve Downs and Thomas Goetz conceived, developed, fielded and analyzed the data from those surveys.
Abigail Horn, PhD, Assistant Professor of Clinical Population and Public Health Sciences, Keck School of Medicine and Incoming Research Computer Scientist, Information Sciences Institute, Viterbi School of Engineering at the University of Southern California, provided access to the Restaurant Nutrition Quality scores for the chain restaurants we profiled.
Abby King from the Stanford Prevention Research Center reviewed the methodology for the initial Building H Index report.
Linda Hwang and Sadiya Muqueeth from the Trust for Public Land provided technical support for the ParkServe utility.
Ethan Mayers, CEO of the FutureProof Agency, contributed valuable strategic advice.