Financial vs. Non-financial Rewards for Weight Loss and Weight Maintenance: A Randomized Controlled Trial

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Project Background: Behavioral economics suggests that our chronic inability to make the daily behavioral changes that can help us lose weight may be the result of “present bias,” which is a tendency to value small, immediate rewards over large rewards in the distant future. For many of us, the immediate gratification of eating an unhealthy food is a more powerful motivator than is the elusive dissatisfaction of the long-run health consequences of an unhealthy diet. Patient incentives may overcome present bias by moving the rewards for healthy behaviors forward in time. In a patient incentive program, patients are given tangible, timely rewards for achieving specific health goals, such as losing one pound per week over 16 weeks. Meta analyses of randomized trials have found that incentives for weight loss are effective during the incentive period, but the weight loss was not sustained after the incentive was removed. Thus, the key challenge to an incentive program is not achieving weight loss, but maintaining it. The proposed study tests the hypothesis that the significant weight regain found in prior incentive trials can be attributed to use of financial incentives—e.g., cash or the equivalent of cash—in those trials. Experiments in behavioral economics have found that providing subjects with financial incentives for participating in a study invokes behavior defined by reciprocity—the effort the subjects gave in the study was proportional to the amount of money that they were given. When subjects were given non-financial incentives, they exhibited no reciprocity—the effort was consistently high and did not vary with the quantity of the non-financial incentive. By using financial incentives, prior trials may have invoked money-market norms of reciprocity, such that patients’ efforts toward weight loss were high when incentives were offered, and reduced when they were discontinued. We hypothesize that non-financial rewards, like tickets to a Seattle Mariners baseball game, will not invoke reciprocity or the consequent weight regain. Project Objectives: The goal of this study is to test, through a randomized trial, the effectiveness of providing overweight Veterans with financial or non-financial incentives for a one pound weight loss per week over 16 weeks. The primary outcome is weight loss at 32 weeks—16 weeks after the discontinuation of the incentives. Secondary outcomes include weight loss at 16 weeks and 12 months. Project Methods: We will conduct a three-armed randomized of patient incentives for losing one pound per week over 16 weeks. The three treatment groups will receive financial incentives, non-financial incentives, or no incentives. We hypothesize that: 1) patients who receive non-financial incentives for weight loss over 16 weeks will have greater weight loss at 32 weeks than patients who do not receive incentives; 2) patients who receive non-financial incentives for weight loss over 16 weeks will experience weight loss at 16 weeks that is not inferior to the weight loss of patients who receive financial incentives; and 3) weight regain will be greater among patients who received financial incentives compared to patients who received non-financial incentives or no incentives. We will also conduct post-intervention qualitative interviews and perform a cost analysis.