Financial vs. Non-Financial Rewards for Weight Loss and Weight Maintenance
Condition: Obesity
MeSH terms: Weight Loss
Study type: Interventional

Summary: 
      Three of every four Veterans are overweight or obese, and weight loss is associated with
      reduced morbidity and mortality. The VA MOVE! program for weight loss is moderately effective
      but only reaches a small percentage of overweight Veterans. This proposed study will test
      whether a patient incentive program that gives Veterans non-financial incentives, such as
      Seattle Mariners baseball tickets, for losing one pound per week over 16 weeks is effective.
      An effective patient-incentive program could help more Veterans lose weight without requiring
      a substantial increase in VA staff.
    

Detailed description: 
      Project Background: Behavioral economics suggests that the 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 rewards may overcome present bias by moving the rewards for
      healthy behaviors forward in time. In a patient reward 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 rewards for weight loss are
      effective during the reward period, but the weight loss was not sustained after the reward
      was removed. Thus, the key challenge to a reward program is not achieving weight loss, but
      maintaining it. The proposed study tests the hypothesis that the significant weight regain
      found in prior reward trials can be attributed to use of financial rewards-e.g., cash or the
      equivalent of cash-in those trials. Experiments in behavioral economics have found that
      providing participants with financial rewards for participating in a study invokes behavior
      defined by reciprocity-the effort the participants gave in the study was proportional to the
      amount of money that they were given. When participants were given non-financial rewards,
      they exhibited no reciprocity-the effort was consistently high and did not vary with the
      quantity of the non-financial reward. By using financial rewards, prior trials may have
      invoked money-market norms of reciprocity, such that patients' efforts toward weight loss
      were high when rewards were offered, and reduced when they were discontinued. The
      investigators 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 rewards 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 rewards. Secondary outcomes include weight
      loss at 16 weeks and 12 months.

      Project Methods: The investigators will conduct a three-armed randomized trial of patient
      rewards for losing one pound per week over 16 weeks. The three treatment groups will receive
      financial rewards, non-financial rewards, or no rewards. The investigators hypothesize that:
      1) patients who receive non-financial rewards for weight loss over 16 weeks will have greater
      weight loss at 32 weeks than patients who do not receive rewards; 2) patients who receive
      non-financial rewards 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 rewards; and 3)
      weight regain will be greater among patients who received financial rewards compared to
      patients who received non-financial rewards or no rewards. The investigators will also
      conduct post-intervention qualitative interviews and perform a cost analysis.
    

Intervention name(s): Financial rewards; Non-Financial rewards
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Veterans in the financial reward arm receive all of the services of the usual care arm, plus rewards that are earned in two ways: an assured portion, and a random portion. For the assured reward, they will receive compensation at the end of each month (defined as a four week period) that they are at or below their target weight. For the random portion, each week that a participant is at or below their target weight, the patient is entered into a drawing to win additional compensation. Over the first eight weeks the patient has a 1-in-8 chance of winning. Over the 17-32 week period, Veterans in this group will receive token incentives for tracking and reporting their weekly weights regardless of whether it was on target. Each week that the patient enters their weight into the portal, s/he will have a 1-in-8 chance to earn the token incentive, such as a t-shirt or movie ticket. The participant will receive reminder text messages.; Procedures for the non-financial rewards arm are identical to procedures for the financial reward arm, except that the Veteran will earn points rather than cash. Each weekly random drawing will be for 20 points. Veterans will choose non-financial rewards associated with the number of points they earn.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: motivation; patient incentives