Financial Incentives for Weight Reduction Study
Condition: Obese
Study type: Interventional

Summary: 
      Financial incentives for motivating changes in health behavior, particularly for weight loss
      in obese individuals, are increasingly being tested by health insurers, employers, and
      government agencies. However, a key unanswered question regarding weight loss is how to
      structure these incentive programs to maximize their effectiveness, acceptability to
      patients, and economic sustainability. Focusing on obese patients living in neighborhoods
      with a high concentration of low socioeconomic status households, the investigators will
      compare the impact of financial incentives for weight loss on sustained weight loss, use of
      evidenced-based therapy, and quality of life, and they will determine their short-term and
      long-term return on investment.
    

Detailed description: 
      Financial incentives for motivating changes in health behavior, for weight loss in obese
      individuals, are increasingly being tested by health insurers, employers, and government
      agencies. However, a key unanswered question regarding weight loss is how to structure these
      incentive programs to maximize their (1) effectiveness, underscored by the fact that most
      programs have not resulted in significant long-term weight loss; and (2) economic
      sustainability, as defined by their return on investment-a major factor in public and private
      decision-making.

      Obese patients represent an important population to target for effective weight loss
      interventions because they suffer from a high prevalence of serious obesity-related
      illnesses-including diabetes, hypertension, dyslipidemia, heart disease, stroke, sleep apnea,
      and cancer-disproportionately have a low socioeconomic status, and impose $147 billion in
      costs on the healthcare system annually. While prior studies testing financial incentives in
      this population have had variable short-term success and few have yielded long-term weight
      loss, a fundamental question remains unanswered and may partially explain variability in
      weight loss outcomes: specifically, it is unknown whether goal-directed incentives
      (incentives for achieving evidence-based, intermediate goals that increase weight loss but
      are underutilized, like dietary counseling, physical activity, behavioral self-monitoring,
      and intensive weight management programs) or outcome-based incentives (like incentives for
      successfully losing weight) are more effective for promoting weight loss. Prior studies of
      weight loss incentives have largely emphasized only the latter.

      The investigators propose a three-arm randomized controlled trial that will address this
      important knowledge gap among obese patients living in socioeconomically disadvantaged
      neighborhoods, with implications for other serious chronic health conditions. Comparing
      goal-directed incentives to outcome-based incentives and usual care, the investigators will
      assess their impact on weight loss (≥5% of baseline weight), use of evidenced-based therapy,
      and quality of life, and evaluate their short-term and long-term return on investment.
    

Intervention name(s): Goal-Directed Financial Incentives; Enhanced Usual Care; Outcome-based Financial Incentives
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Patients will receive financial incentives for using a food diary, verified by entries in in the BookFactory Food Diary or another food diary, including internet/app-based diaries ($30 monthly); achieving 75 minutes of physical activity per week in first three months, as verified by a wearable fitness tracker ($20 monthly); achieving 150 minutes of physical activity per week in last three months, as verified by a wearable fitness tracker ($20 monthly); enrollment in a clinic-based or commercial weight loss program ($150 one time); and active participation in clinic-based or commercial weight loss program, as verified by the program ($60 monthly).; Patients will receive a food diary (BookFactory Food Diary), wearable fitness tracker (Fitbit), exercise and nutrition education materials (American Heart Association's Walking For Better Health and How to Eat Healthy), and referral information for intensive weight loss programs. This information will comprise these commercial and hospital-based weight loss programs that are evidence-based: Weight Watchers and Jenny Craig; the Veterans Administration's MOVE! and TeleMOVE! programs; Bellevue Hospital's Medical Weight Management Clinic and Intensive Nutritional Treatment programs; and New York University Langone Medical Center's Weight Management Program. We will also provide brief instructions on how to use the food diary and Fitbit Charge HR.; Patients will receive financial incentives for clinically significant weight loss, as confirmed at monthly weigh-ins. At 30 days, they will receive $50 if they lose ≥1.5% to <2.5% of baseline weight or $100 if they lose ≥2.5% of baseline weight. At 2 months and 3 months, they will receive $50 if they lose ≥2.5% to <5% of baseline weight or $100 if they lose ≥5% of baseline weight. At 4, 5, and 6 months, they will receive $100 if they lose ≥2.5% to <5% of baseline weight or $150 if they lose ≥5% of baseline weight. To employ the behavioral economic concept of regret aversion, patients will be given feedback at each assessment point about incentives they would have received had they achieved a loss of at least 2.5% of baseline weight.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Obesity; Weight-loss; Financial Incentives; Behavioral Economics