Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial. A Pilot Study Testing the Effect of Different Levels of Financial Incentives on Weight Loss Among Overweight Employees Financial incentive-based approaches for weight loss: a randomized trial. Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial Effectiveness of Financial Incentives in a Worksite Diabetes Prevention Program Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Promoting weight control at the worksite: a pilot program of self-motivation using payroll-based incentives. A work-site weight control program using financial incentives collected through payroll deduction. Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors Individual- Versus Group-Based Financial Incentives for Weight Loss Rationale and design of REWARD (revving-up exercise for sustained weight loss by altering neurological reward and drive): a randomized trial in obese endometrial cancer survivors. Strengthening behavioral interventions for weight loss: a randomized trial of food provision and monetary incentives. Long-term effects of interventions for weight loss using food provision and monetary incentives. A Randomized Controlled Trial of Employer Matching of Employees’ Monetary Contributions to Deposit Contracts to Promote Weight Loss A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) - A randomized controlled trial. Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program.
There is a paucity of evidence on the heterogeneous impacts of financial incentives on weight loss .  Between March 2010 and January 2012 , in a r and omized controlled trial , we assigned 700 obese persons to three experimental arms . We test whether particular subgroups react differently to financial incentives for weight loss . Two treatment groups obtained a cash reward ( € 150 and € 300 with 237 and 229 participants , respectively ) for achieving an individually-assigned target weight within four months ; the control group ( 234 participants ) was not incentivized . Participants and administrators were not blinded to the intervention . We find that monetary rewards effectively induced  obese individuals to reduce weight across all subgroups . However , there is no evidence for treatment-effect heterogeneity for those groups that were incentivized . Among those who were in the € 300 group , statistically significant and large weight losses were observed for women , singles , and those who are not working ( all above 4 kg in four months ) . In addition , the magnitude of the reward matters only for women and migrants . The effectiveness of financial incentives to reduce weight nevertheless raises sensitive ethical issues that should be taken into consideration by policymakers Objective : To test the ability of two levels of modest financial incentives to encourage weight loss among overweight employees . Methods : This study used a r and omized design with measurements at baseline , 3 , and 6 months and two levels of financial incentives ( $ 7 and $ 14 per percentage point of weight lost ) . Payments were structured so that all participants had equal ability to obtain the incentives during the study period . Results : At 3 months , participants with no financial incentive lost 2 pounds , those in the $ 7 group lost approximately 3 pounds , and those in the $ 14 group lost 4.7 pounds . Between baseline and 6 months , when the financial gains were equalized , weight losses were similar across groups . Conclusion : This study revealed that modest financial incentives can be effective in motivating overweight employees to lose weight CONTEXT Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity . OBJECTIVE To determine whether common decision errors identified by behavioral economists such as prospect theory , loss aversion , and regret could be used to design an effective weight loss intervention . DESIGN , SETTING , AND PARTICIPANTS Fifty-seven healthy participants aged 30 - 70 years with a body mass index of 30 - 40 were r and omized to 3 weight loss plans : monthly weigh-ins , a lottery incentive program , or a deposit contract that allowed for participant matching , with a weight loss goal of 1 lb ( 0.45 kg ) a week for 16 weeks . Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008 . MAIN OUTCOME MEASURES Weight loss after 16 weeks . RESULTS The incentive groups  lost significantly more weight than the control group ( mean , 3.9 lb ) . Compared with the control group , the lottery group lost a mean of 13.1 lb ( 95 % confidence interval [ CI ] of the difference in means , 1.95 - 16.40 ; P = .02 ) and the deposit contract group lost a mean of 14.0 lb ( 95 % CI of the difference in means , 3.69 - 16.43 ; P = .006 ) . About half of those in both incentive groups met the 16-lb target weight loss : 47.4 % ( 95 % CI , 24.5%-71.1 % ) in the deposit contract group and 52.6 % ( 95 % CI , 28.9%-75.6 % ) in the lottery group , whereas 10.5 % ( 95 % CI , 1.3%-33.1 % ; P = .01 ) in the control group met the 16-lb target . Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups ( 9.2 lb ; t = 1.21 ; 95 % CI , -3.20 to 12.66 ; P = .23 , in the lottery group and 6.2 lb ; t = 0.52 ; 95 % CI , -5.17 to 8.75 ; P = .61 in the deposit contract group ) than in the control group ( 4.4 lb ) , these differences were not statistically significant . However , incentive participants weighed significantly less at 7 months than at the study start ( P = .01 for the lottery group ; P = .03 for the deposit contract group ) whereas controls did not . CONCLUSIONS The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained . The longer-term use of incentives should be evaluated . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00520611 ABSTRACT BACKGROUND Previous efforts to use incentives for weight loss have result ed in substantial weight regain after 16 weeks . OBJECTIVE To evaluate a longer term weight loss intervention using financial incentives . DESIGN A 32-week , three-arm r and omized controlled trial of financial incentives for weight loss consisting of a 24-week weight loss phase during which all participants were given a weight loss goal of 1 pound per week , followed by an 8-week maintenance phase . PARTICIPANTS Veterans who were patients at the Philadelphia Veterans Affairs Medical Center with BMI s of 30–40.INTERVENTION Participants were r and omly assigned to participate in either a weight-monitoring program involving a consultation with a dietician and monthly weigh-ins ( control condition ) , or the same program with one of two financial incentive plans . Both incentive arms used deposit contracts ( DC ) in which participants put their own money at risk ( matched 1:1 ) , which they lost if they failed to lose weight . In one incentive arm participants were told that the period after 24 weeks was for weight-loss maintenance ; in the other , no such distinction was made . MAIN MEASUREWeight loss after 32 weeks . KEY RESULTS Results were analyzed using intention-to-treat . There was no difference in weight loss between the incentive arms ( P = 0.80 ) . Incentive participants lost more weight than control participants [ mean DC = 8.70 pounds , mean control = 1.17 , P = 0.04 , 95 % CI of the difference in means ( 0.56 , 14.50 ) ] . Follow-up data 36 weeks after the 32-week intervention had ended indicated weight regain ; the net weight loss between the incentive and control groups was no longer significant ( mean DC = 1.2 pounds , 95 % CI , -2.58–5.00 ; mean control = 0.27 , 95 % CI , -3.77–4.30 , P = 0.76 ) . CONCLUSIONS Financial incentives produced significant weight loss over an 8-month intervention ; however , participants regained weight post-intervention Purpose To evaluate the effect of financial incentive in a diabetes prevention weight loss program at worksites . Design Group-level r and omized intervention study . Setting Four long-term care facilities , r and omly assigned to “ incentive-IG ” or “ non incentive-NIG ” groups . Participants Ninety-nine employees , all overweight or obese ( BMI = mean 34.8±7.4 kg/m2 ) and at risk for type 2 diabetes . Intervention A 16 week weight loss program ( diabetes prevention program ) with a 3 month follow up . IG could either choose a " st and ard incentive " to receive cash award when achieving the projected weight loss or to participate in a " st and ard plus deposit incentive " to get additional money matched with their deposit for projected weight loss . All of the participants received a one-hour consultation for a healthy weight loss at the beginning . Measures Weight-loss , diabetes risk score ( DRS ) , and cardiovascular risk outcomes . Analyses Linear and logistic regressions for completed cases with adjustments for clustering effect at group level . Results IG lost on average more pounds ( p=0.027 ) , reduced BMI ( p=0.04 ) , and reduced in DRS ( p=0.011 ) compared to NIG at week 16 . At the 12-week follow-up period , those in IG plus deposit subgroup had twice the odds ( OR=2.2 , p=0.042 ) and those in the st and ard IG had three times the odds of achieving weight loss goals than NIG ; those in the IG plus deposit group reduced DRS by 0.4 ( p=0.045 ) . Conclusion Monetary incentives appear to be effective in reducing weight and diabetes risk Employers commonly use adjustments to health insurance premiums as incentives to encourage healthy behavior , but the effectiveness of those adjustments is controversial . We gave 197 obese participants in a workplace wellness program a weight loss goal equivalent to 5 percent of their baseline weight . They were r and omly assigned to a control arm , with no financial incentive for achieving the goal , or to one of three intervention arms offering an incentive valued at $ 550 . Two intervention arms used health insurance premium adjustments , beginning the following year ( delayed ) or in the first pay period after achieving the goal ( immediate ) . A third arm used a daily lottery incentive separate from premiums . At twelve months there were no statistically significant differences in mean weight change either between the control group ( whose members had a mean gain of 0.1 pound ) and any of the incentive groups ( delayed premium adjustment , -1.2 pound ; immediate premium adjustment , -1.4 pound ; daily lottery incentive , -1.0 pound ) or among the intervention groups . The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive design s , larger incentives , or both Thirty-six individuals participated in a worksite weight-loss program  in which the central component was a self-motivation program of biweekly payroll deductions refunded contingent on meeting self-selected weight-loss goals . Half were assigned to early treatment and the remainder to a delayed treatment control group .  Nine additional individuals also enrolled at the time of  delayed treatment  and were included in descriptive analyses of factors associated with weight loss . Results showed low program attrition over 6 months ( 6 % ) and mean weight losses ( 12.3 lb ) that are competitive with those obtained in clinical setting s. Although not different at baseline , participants in the delayed treatment group lost more than twice as much weight as those in the early treatment condition . This difference was interpreted as either a strong seasonal effect or a critical mass effect related to the proportion of employees at the worksite participating in the program . We conclude that self-motivation programs for health behavior change using the payroll system as an organization framework offer a promising new methodology for promoting healthful behaviors in work setting In a work-site weight control program using a self-motivational program of financial incentives implemented through payroll deduction , 131 university employees chose weight loss goals ( 0 to 60 lb ) and incentives ( + 5 to + 30 ) to be deducted from each paycheck for six months . Return of incentive money was contingent on progress toward weight goals . Participants were assigned r and omly to one of four protocol s , involving group educational sessions v self-instruction only and required v optional attendance at weigh-ins and sessions . Overall , dropout rates ( 21.4 % ) and mean weight loss ( 12.2 lb ) were encouraging , especially compared with those of other work-site programs . Weight loss was positively associated with attendance at weigh-ins and educational sessions . However , requiring attendance did not increase program effectiveness and seemed also to discourage enrollment among men . The weight control program was equally effective when offered with professionally led educational sessions or when accompanied by self-instructional material s only Consider the following paradox : few people would balk if research ers offered smokers $ 1,000 to participate in a year-long r and omized trial of a smoking cessation intervention , yet many would find it distasteful for a large employer to pay its smoking employees an extra $ 1,000 if they remained smoke-free for one year . Such discrepant judgments are underst and able from the perspective of classical economics . Research participants merit compensation for the risks and opportunity costs they endure in the service of public health , whereas individuals should need no reward for promoting their own well being . However , contrary to traditional theories of rationality , people frequently fail to make health-promoting choices , particularly when such choices require short-term sacrifices to foster long-term goals .1,2 Thus , corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health – particularly cardiovascular health – while hopefully increasing productivity and restraining costs.3 , 4 Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,5 , 6 weight loss,7 , 8 and cholesterol reduction.9  Incentives are also currently being studied as a means of promoting warfarin adherence.10 Although the results of these early studies are promising , further research is needed to determine which incentive structures and amounts are optimal , assess the ability of incentives to produce sustained behavior changes , and evaluate the cost-effectiveness of implementing incentive programs  . Ethical dimensions of the incentives themselves are also in need of further analysis . For example , some have charged that financial incentive programs are coercive , inequitable , and inconsistent with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay , we outline the rationale for incentive programs to promote cardiovascular health , identify the ethical arguments that have been used to challenge such programs , and assess the merits of these arguments BACKGROUND Data on the effectiveness of employer-sponsored financial incentives for employee weight loss are limited . OBJECTIVE To test the effectiveness of 2 financial incentive design s for promoting weight loss among obese employees . DESIGN R and omized , controlled trial . ( Clinical Trials.gov : NCT01208350 ) SETTING Children 's Hospital of Philadelphia . PARTICIPANTS 105 employees with a body mass index between 30 and 40 kg/m2 . INTERVENTION 24 weeks of monthly weigh-ins ( control group ; n = 35 ) ; individual incentive , design ed as $ 100 per person per month for meeting or exceeding weight-loss goals ( n = 35 ) ; and group incentive , design ed as $ 500 per month split among participants within groups of 5 who met or exceeded weight-loss goals ( n = 35 ) . MEASUREMENTS Weight loss after 24 weeks ( primary outcome ) and 36 weeks and changes in behavioral mediators of weight loss ( secondary outcomes ) . RESULTS Group-incentive participants lost more weight than control participants ( mean between-group difference , 4.4 kg [ 95 % CI , 2.0 to 6.7 kg ] ; P < 0.001 ) and individual-incentive participants ( mean between-group difference , 3.2 kg [ CI , 0.9 to 5.5 kg ] ; P = 0.008 ) . Twelve weeks after incentives ended and after adjustment for 3-group comparisons , group-incentive participants maintained greater weight loss than control group participants ( mean between-group difference , 2.9 kg [ CI , 0.5 to 5.3 kg ] ; P = 0.016 ) but not greater than individual-incentive participants ( mean between-group difference , 2.7 kg [ CI , 0.4 to 5.0 kg ] ; P = 0.024 ) . LIMITATION Single employer and short follow-up . CONCLUSION A group-based financial incentive was more effective than an individual incentive and monthly weigh-ins at promoting weight loss among obese employees at 24 weeks . PRIMARY FUNDING SOURCE National Institute on Aging BACKGROUND Obesity is a leading risk factor for endometrial cancer ( EC ) , particularly Type I forms , which are increasing in the U.S. Although death rates from most cancers have been decreasing , overall mortality in EC is increasing in the U.S. EC survivors ' poor fitness combined with their surgical treatments may make weight loss particularly challenging . High intensity exercise increases neurotrophins and neurological reward via altered striatal dopamine in animals , and , in humans , chronic high intensity exercise enhances meal-induced satiety and may reduce hedonic eating . " Assisted " exercise , a mode of exercise whereby a patient 's voluntary exercise rate is augmented mechanically , may modulate brain dopamine levels in Parkinson 's Disease patients but has not been previously evaluated as a treatment for obesity . METHODS We describe the rationale and design of the REWARD trial , which has the overarching goal of r and omizing 120 obese EC survivors to " assisted " or voluntary rate cycling  to evaluate the efficacy of " assisted " exercise in enhancing and sustaining weight loss . Patients in both arms will receive 3 days/week of supervised exercise and 1 day/week of a group dietary behavioral intervention for 16 weeks and , then , will be followed for 6 months . OUTCOMES The primary outcome is weight loss . Secondary outcomes include measures for body composition , fitness , eating behavior , exercise motivation and , quality of life as well as cognition and food reward and motivation as assessed by functional magnetic resonance imaging ( fMRI ) tasks . CONCLUSIONS If successful , the REWARD program could be extended to help sustain weight loss in obese cancer and non-cancer patients Behavioral treatments for obesity seek to modify eating and exercise behaviors by a change in their antecedents and consequences . More direct modification of antecedents and consequences by ( a ) the provision of food to patients and ( b ) the provision of financial rewards for weight loss was hypothesized to improve treatment outcomes . Two hundred two men and women were r and omly assigned to no treatment , st and ard behavioral treatment ( SBT ) , SBT plus food provision , SBT plus incentives , or SBT plus food provision and incentives . The major finding was that food provision significantly enhanced weight loss . Weight losses with  SBT  averaged 7.7 , 4.5 , and 4.1 kg at 6 , 12 , and 18 months , respectively , compared with 10.1 , 9.1 , and 6.4 kg , respectively , at the same intervals with the addition of food . Food provision also enhanced attendance , completion of food records , quality of diet , and nutrition knowledge . We conclude that the provision of food to weight-loss patients is a promising methodology that deserves further exploration One hundred seventy-seven men and women who had participated in an 18-month trial of behavioral interventions involving food provision and financial incentives  were examined 12 months later . Food provision , but not financial incentives , led to better weight loss than st and ard behavioral treatment during the 18-month trial , but over 12 additional months of no-treatment follow-up , all treated groups gained weight , maintained only slightly better weight losses than a no-treatment control group , and did not differ from each other . Weight loss success during both active treatment and maintenance was associated with increase in exercise , decrease in percentage of energy from fat , increase in nutrition knowledge , and decrease in perceived barriers to adherence . Obesity treatment research should focus on developing better ways to maintain changes in the diet and exercise behaviors needed for sustained weight loss Purpose : To test whether employer matching of employees ’ monetary contributions increases employees ’ ( 1 ) participation in deposit contracts to promote weight loss and ( 2 ) weight loss . Design : A 36-week r and omized trial . Setting : Large employer in the northeast United States . Participants : One hundred thirty-two obese employees . Interventions : Over 24 weeks , participants were asked to lose 24 pounds and r and omized to monthly weigh-ins or daily weigh-ins with monthly opportunities to deposit $ 1 to $ 3 per day that was not matched , matched 1:1 , or matched 2:1 . Deposits and matched funds were returned to participants for each day they were below their goal weight . Measures : Rates of making ≥1 deposit , weight loss at 24 weeks ( primary outcome ) , and 36 weeks . Analysis : Deposit rates were compared using χ2 tests . Weight loss was compared using t tests . Results : Among participants eligible to make deposits , 29 % made ≥1 deposit and matching did not increase participation . At 24 weeks , control participants gained an average of 1.0 pound , whereas 1:1 match participants lost an average of 5.3 pounds ( P = .005 ) . After 36 weeks , control participants gained an average of 2.1 pounds , whereas no match participants lost an average of 5.1 pounds ( P = .008 ) . Conclusion : Participation in deposit contracts to promote weight loss was low , and matching deposits did not increase participation . For deposit contracts to impact population health , ongoing participation will need to be higher Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors The prevalence of overweight and obesity has more than doubled in the past three decades , leading to rising rates of non-communicable diseases . This study tests whether adding a payment/rewards ( term reward ) program to an existing evidence -based weight loss program can increase weight loss and weight loss maintenance . We conducted a parallel-group r and omized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals r and omized to either control or reward arm in a 1:2 ratio . Control and reward arm participants received a four month weight loss program at the LIFE ( Lifestyle Improvement and Fitness Enhancement ) Centre at Singapore General Hospital . Those in the reward arm paid a fee of S$165.00 ( 1 US$ = 1.35S$ ) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals . Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value . The primary outcome was weight loss at months 4 , 8 , and 12 . 161 participants were r and omized to control ( n = 54 ) or reward ( n = 107 ) arms .  Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded ( 3.4 kg vs 1.4 kg , p < 0.01 ) , month 8 when rewards concluded ( 3.3 kg vs 1.8 kg , p < 0.05 ) , and at month 12 ( 2.3 kg vs 0.8 kg , p < 0.05 ) . These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence -based weight loss program . Future efforts should attempt to replicate this approach and identify how to cost effectively exp and these programs to maximize their reach . This study is registered at www . clinical trials.gov ( Identifier : NCT01533454 ) Exercise is important for long-term weight loss , but few studies have examined ways to improve exercise adherence in overweight subjects participating in a behavioral weight loss program . This paper presents two studies , one conducted at the University of Pittsburgh and one at the University of Minnesota , that sought to improve exercise adherence by exerting more direct control over the environmental antecedents and consequences controlling exercise . Study 1 investigated the use of a personal trainer who called participants regularly and met them at their home or office at scheduled times for a walk . Study 2 investigated the effect of a lottery incentive for exercise adherence . In both studies , the effect of these manipulations was examined in the context of a 24-week st and ard behavioral weight control program with three supervised exercise sessions per week . Neither intervention achieved statistically significant improvements in exercise adherence compared to control conditions , perhaps due in part to the limited statistical power of the studies . Future studies should focus on better underst and ing the barriers to exercise and design ing behavioral interventions that address these barriers
Group refunds , deposit not paid as lump sum , participants setting their own deposit size and additional behaviour change techniques were associated with greater weight loss during treatment .
Post-treatment , there was no significant effect of MCCs on weight loss .
There was a significant small-to-medium effect of MCCs on participant retention during treatment .
Research er-set deposits paid as one lump sum , refunds delivered on an all-or-nothing basis and refunds contingent on attendance at classes were associated with greater retention during treatment .
Post-treatment , there was no significant effect of MCCs on participant retention .
The results support the use of MCCs to promote weight loss and participant retention up to the point that the incentive is removed and identifies the conditions under which MCCs work best
Financial incentives to improve health have received increasing attention , but are subject to ethical concerns .
Monetary Contingency Contracts ( MCCs ) , which require individuals to deposit money that is refunded contingent on reaching a goal , are a potential alternative strategy .
This review evaluates systematic ally the evidence for weight loss – related MCCs .