|Year : 2020 | Volume
| Issue : 1 | Page : 39-43
The effect of monetary incentives on promoting weight loss in individuals with obesity
Assim A Alfadda1, Norah A Alsaber2, Amr S Moustafa3, Shaffi A Shaik4
1 Obesity Research Center, College of Medicine, King Saud University; Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Obesity Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Obesity Research Center, College of Medicine, King Saud University; Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
4 Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||16-Feb-2019|
|Date of Decision||26-Mar-2019|
|Date of Acceptance||12-Jun-2019|
|Date of Web Publication||06-Jan-2020|
Assim A Alfadda
Obesity Research Center, College of Medicine, King Saud University, P.O. Box. 2925 (98), Riyadh 11461
Source of Support: None, Conflict of Interest: None
Objectives: This study evaluated the effect of a cash reward program on promoting weight loss and whether this effect will last after 1 year of follow-up. Materials and Methods: This is a retrospective analysis of a 4-month program that provides cash reward for losing weight. The study individuals were weight loss program participants, aged 18–65 years, reached after 1 year (n = 162). Participants were categorized according to their main reason for joining the program as follows: those for whom incentive was the primary reason to enroll (incentive-motivated) and those who participated mainly to lose weight regardless of the incentive (self-motivated). Results: There was a significant weight loss in all participants at the end of the 4-month program compared with that at baseline (89.49 ± 18.86 vs. 96.09 ± 20.38 kg,P < 0.001). Approximately 58% of all participants lost ≥5% of their initial body weight, and almost 55% remained above this threshold at 1 year. The incentive-motivated group lost more weight than the self-motivated group at the end of the program but did not lose any further weight, whereas the self-motivated group continued to lose weight. After 1 year, both groups had achieved the same weight loss. Conclusions: The cash reward program was effective in inducing short-term weight loss. The optimal duration for financial incentive-based programs in inducing a sustainable weight loss and their cost-effectiveness are important questions for further investigation.
Keywords: Financial incentives, motivation, obesity, weight loss
|How to cite this article:|
Alfadda AA, Alsaber NA, Moustafa AS, Shaik SA. The effect of monetary incentives on promoting weight loss in individuals with obesity. J Nat Sci Med 2020;3:39-43
|How to cite this URL:|
Alfadda AA, Alsaber NA, Moustafa AS, Shaik SA. The effect of monetary incentives on promoting weight loss in individuals with obesity. J Nat Sci Med [serial online] 2020 [cited 2020 Jan 21];3:39-43. Available from: http://www.jnsmonline.org/text.asp?2020/3/1/39/269754
| Introduction|| |
Obesity is a major public health problem that has reached epidemic proportions with >60% of adults in the Kingdom of Saudi Arabia who are either obese or overweight. Individuals with overweight and obesity are at risk for developing comorbid medical problems, including cardiovascular disease, Type 2 diabetes mellitus, and dyslipidemia. As a major cause of morbidity and mortality, obesity is increasingly attributable to behavior and lifestyle. Interventions to change individual behaviors, including the use of financial incentives, are gaining considerable attention.,, Programs used to change individual behaviors vary widely in their design and outcome. Individuals' decision to change their behavior is not always based on their long-term health goals. It has been observed that individuals tend to be more motivated by immediate rather than delayed gratification.,
The effect of financial incentives in changing individual behaviors has been studied for more than three decades. While some studies have suggested that financial incentives were more effective for promoting simple, short-term behaviors, such as attendance for vaccination, other studies have shown less favorable outcomes in terms of managing more complex, long-term behaviors, such as smoking cessation and body weight reduction. The use of financial incentives in the treatment of overweight and obesity is still an area of debate. Studies on such subject vary widely. However, more recent evidence showed that financial incentives can induce weight loss, at least in the short term., Only few studies have reported the effectiveness of a cash prize used competitively for the greatest weight loss achieved by participants., The following several important questions regarding the use of financial incentives to promote weight loss have not yet been clearly answered: what types of incentive structures could be utilized, how the accomplished weight loss for the long term could be maintained, and why this intervention could be successful for some individuals and not for others.
The primary goal of this study is to evaluate the effect of a financial incentive rewarded at the end of a 4-month weight loss program with a 1-year follow-up. The secondary goal includes determining whether there are any differences in weight loss and weight maintenance between those for whom the incentive was the primary reason to enroll in the program (incentive motivated) and those who participated mainly to lose weight and improve their health regardless of the incentive (self-motivated). The competition for the cash prizes based on the greatest weight loss achieved is an area that was not comprehensively evaluated previously, and hence would make the current study of high significance.
| Materials and Methods|| |
We performed a retrospective analysis of a university-based weight loss program using competition for cash prizes as an incentive, i.e., “lose and win,” which was conducted in 2016. Ethical approval was obtained for this study from the local institutional review board (E-16-2002), and all participants provided their consent to participate.
Participants were recruited to the program via posters and flyers at university colleges and advertisement in the university local newspaper. The advertisements stated that a cash incentive will be offered to those who achieved the highest weight reduction (as a percentage from baseline weight) at the end of the program. Ten cash prizes were assigned: the first prize was 6000 SAR (~1600 USD); second, 5000 SAR (~1333 USD); third, 4000 SAR (~1067 USD); and fourth to tenth, 1000 SAR (~267 USD).
Upon arrival to the program site, anthropometric measures, including height and weight, were obtained while the participants were wearing light clothing, and the body mass index (BMI) was calculated. Body height (in meters) was measured using a standing stadiometer. Body weight (in kilograms) was measured to the nearest 0.1 kg using a calibrated digital scale. The BMI was calculated as body weight divided by height squared (kg/m2). The participants were advised to reduce their body weight by focusing on reduced calorie intake and increased physical activity. They were asked to visit again after 4 months to have their weight re-measured. The eligible participants (1) were students, staff, or visitors of the university and (2) were between the ages of 18 and 65 years. The exclusion criteria included self-reported pregnancy or lactation, diabetes mellitus, end-stage renal disease, ischemic heart disease, untreated thyroid disease, and use of weight loss medications in the past 6 months.
One year following the completion of the program, a telephone interview was conducted with the participants to fill in the study questionnaire. The questionnaire contained demographic questions and lifestyle-related questions, which included dietary habits and physical activity. The participants were asked to report their current body weight and to indicate their main reason for joining the program. The choices included were as follows: (1) to win the prize (incentive-motivated group) or (2) to increase the motivation to lose weight regardless of the incentive (self-motivated group). The data were then entered to an electronic database for the analysis of the weight at the end of the program and 1 year after the completion of the program.
Data were analyzed using SPSS PC+ 21.0 version statistical software (IBM Inc., Chicago, USA). Descriptive statistics (means and standard deviations) were used to describe the quantitative variables. The Kolmogorov–Smirnov test was used to test the data distribution. Before the statistical analysis, a logarithmic transformation of the nonnormally distributed parameters was performed to approximate a normal distribution. The Student's independent t-test was used to compare the differences in the clinical characteristics and magnitude of weight loss between the self-motivated and incentive-motivated groups, and Pearson's Chi-square test was used to compare the distribution of the categorical characteristics of the study participants across the two groups. Student's paired t-test was used to compare the magnitude of weight loss in each of the two groups (self-motivated and incentive motivated). P < 0.05 was considered statistically significant.
| Results|| |
A total of 682 participants enrolled in the program and underwent the baseline measurements. Of them, 230 participants came for the second visit after 4 months, and 162 participants (who are the participants of this study) were willing to undergo a telephone interview and to fill in the study questionnaire. The characteristics of the study participants are shown in [Table 1]. Approximately half of the participants indicated that their primary reason for joining the program was their motivation to lose weight regardless of the incentive. The participants were mainly university students and employees; two-third were men; and most were obese with a mean BMI of 33.24 ± 5.55 kg/m2.
The mean baseline weight of all participants was 96.09 ± 20.38 kg. The mean weight was significantly lower at the end of the program than at the baseline (89.49 ± 18.86 kg, P < 0.001). The mean weight remained significantly lower at the 1-year follow-up than at the baseline (88.72 ± 19.19 kg, P < 0.001); however, there was no significant difference between the weight at the end of the program and 1-year follow-up (P = 0.0987). Approximately 58% of all participants lost ≥5% of their initial body weight, and almost 55% remained above this threshold at 1 year.
We analyzed the data based on the primary reason of the participants for joining the program. In 82 (50.6%) participants, the primary reason was the financial incentive (incentive-motivated group), and in the remaining 80 (49.4%) participants, the primary reason was their motivation to lose weight regardless of the incentive (self-motivated group). There was no significant difference in the age, baseline weight, monthly income, level of education, and occupation between the two groups [Table 1].
Interestingly, the incentive-motivated group lost more weight than the self-motivated group at the end of the program, but did not lose any further weight during the following year [Table 2]. Although the self-motivated group had lost less weight than the other group at the end of the program, they continued to lose weight afterward [Table 2]. One year after the completion of the program, both groups had almost the same weight loss compared with that at baseline [Figure 1].
|Table 2: Changes in the body weight of the self-motivated and incentive-motivated groups|
Click here to view
|Figure 1: Changes in the body weight of the incentive-motivated and self-motivated groups at the end of the program and 1-year follow-up. The incentive-motivated group lost more weight than the self-motivated group at the end of the program, but did not lose any further weight at the 1-year follow-up. The self-motivated group lost less weight than the other group at the end of the program, but continued to lose weight afterward. At the 1-year follow-up, both groups had almost the same weight loss compared with that at baseline. Data were presented as means ± standard errors.#Significant change in the weight compared with the baseline. #Significant change in the weight compared with the weight at the end of the program. P < 0.05 was considered statistically significant|
Click here to view
We inquired the participants if they were still following a healthy lifestyle after 1 year of completing the program; approximately 76% answered yes. Interestingly, more participants continued to adopt a healthy lifestyle in the self-motivated group than in the incentive-motivated group; however, this did not reach any statistical significance (82.5% vs. 70.3%, P = 0.07).
| Discussion|| |
This study demonstrated that the financial incentive program, in the form of a cash reward, was effective in promoting weight loss in a cohort with obesity. This incentive was intended to stimulate competition between peers and to change their behavior to induce significant weight loss. Further, it can be reported that programs that encourage individuals to lose weight and modify their lifestyle are effective to make them stick to their new healthier lifestyle for several months thereafter.
The amount of weight loss obtained with the intervention in this study is comparable with that of previous reports, and the fact that approximately half of the participants were able to lose ≥5% of their weight and to maintain this for a year thereafter is encouraging. Several studies have shown that ≥5% weight loss is considered significant in improving cardiovascular risk factors and reducing the incidence of obesity-related comorbidities, mainly type 2 diabetes mellitus.,,
Although the main idea of this intervention was to encourage participants to lose weight competitively, we noticed that approximately half of our study sample participated on the basis that this program would motivate them to follow a healthier lifestyle. The weight loss pattern in the two groups (incentive-motivated group and self-motivated group) is interesting. The participants whose main reason for joining the program was to obtain the incentive lost more weight at the end of the program than the others. This indicates that the incentive-motivated group may have followed a stricter diet and became more physically active during the program because their main aim was to lose weight as much and as fast as possible. However, after the conclusion of the program, this group did not lose any further weight; in fact, their mean weight followed an upward trend. Conversely, the self-motivated group lost less weight during the program than the other group, but continued to lose weight up to 1 year following the program. This finding suggests that, although the incentive design used in this program was effective at the short term to promote weight loss, it was less successful in sustaining the weight reduction effects thereafter. Similar patterns have been reported by other studies.,,
Weight regain is one of the main problems in treating obesity. Previous research has shown that individuals regain the majority of their lost weight within a few years even in the most intensive well-designed lifestyle interventions. Weight regain is a result of a complex interaction of environmental, biological, behavioral, and cognitive factors, which are only partially understood. Weight loss induced by financial incentives is equally susceptible to regain as is weight loss without the use of incentives once treatment is withdrawn.
Several studies have examined the effectiveness of financial incentive-based programs on long-term weight maintenance. These were based primarily on the assumption that loss of motivation is the reason behind the decline in the ability of an individual to lose weight and that motivation can be improved by increasing or extending financial rewards over time. Some of these studies showed encouraging results, whereas other studies did not.,, The incentive-based program in this study was not designed to test long-term weight maintenance. However, the difference between the incentive-motivated and self-motivated groups in terms of weight loss pattern points toward an important aspect: the financial reward could be considered as an extrinsic motivation, and participants may not necessarily have self-motivation to lose weight.
This study recruited primarily students and employees from an academic institute; it is unknown how the effectiveness of this type of program might differ in a community-based population. The incentive design focused on short-term rapid weight reduction, with the assumption that it will encourage participants to continue losing weight afterward. This was not the case. Therefore, studying different designs for incentive-based programs that would encourage sustainable weight reduction is important. Furthermore, we were not able to track down the weight pattern for participants who dropped out. Finally, we used weight loss as the main outcome measure, which provided only limited information on the effect of weight loss on the risk factors of chronic diseases. Many unanswered questions remain in this field. For example, what would be the best amount for financial incentives? What is the optimal duration and frequency of the incentives to assure weight loss maintenance? And what would be the method of administration of financial incentives that would assure the maximum motivation of participants?
| Conclusions|| |
This study showed that the cash reward program was effective in inducing weight loss over a 4-month intervention period, which was sustained at 1 year. Further research is needed to design alternative incentive programs and to test their effectiveness and cost-effectiveness in promoting sustained weight loss over longer periods.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Nozha MM, Al-Mazrou YY, Al-Maatouq MA, Arafah MR, Khalil MZ, Khan NB, et al.
Obesity in Saudi Arabia. Saudi Med J 2005;26:824-9.
Kurti AN, Davis DR, Redner R, Jarvis BP, Zvorsky I, Keith DR, et al.
review of the literature on remote monitoring technology in incentive-based interventions for health-related behavior change. Transl Issues Psychol Sci 2016;2:128-52.
Ananthapavan J, Peterson A, Sacks G. Paying people to lose weight: The effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity – A systematic review. Obes Rev 2018;19:605-13.
Tambor M, Pavlova M, Golinowska S, Arsenijevic J, Groot W. Financial incentives for a healthy life style and disease prevention among older people: A systematic literature review. BMC Health Serv Res 2016;16 Suppl 5:426.
Ball K, Hunter RF, Maple JL, Moodie M, Salmon J, Ong KL, et al.
Can an incentive-based intervention increase physical activity and reduce sitting among adults? The ACHIEVE (Active choices incEntiVE) feasibility study. Int J Behav Nutr Phys Act 2017;14:35.
Kelly MP, Barker M. Why is changing health-related behaviour so difficult? Public Health 2016;136:109-16.
Haff N, Patel MS, Lim R, Zhu J, Troxel AB, Asch DA, et al.
The role of behavioral economic incentive design and demographic characteristics in financial incentive-based approaches to changing health behaviors: A meta-analysis. Am J Health Promot 2015;29:314-23.
Paloyo AR, Reichert AR, Reuss-Borst M, Tauchmann H. Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial. Soc Sci Med 2015;145:44-52.
Kullgren JT, Troxel AB, Loewenstein G, Asch DA, Norton LA, Wesby L, et al.
Individual- versus group-based financial incentives for weight loss: A randomized, controlled trial. Ann Intern Med 2013;158:505-14.
Breaux-Shropshire TL, Whitt L, Oster RA, Lewis D Jr. Shropshire TS, Calhoun DA, et al.
Results of an academic, health care worksite weight loss contest for Southeastern Americans: Scale back Alabama 2011-2013. Workplace Health Saf 2015;63:165-9.
Finkelstein EA, Tham KW, Haaland BA, Sahasranaman A. Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) – A randomized controlled trial. Soc Sci Med 2017;185:63-70.
Look AHEAD Research Group, Pi-Sunyer X, Blackburn G, Brancati FL, Bray GA, Bright R, et al.
Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: One-year results of the look AHEAD trial. Diabetes Care 2007;30:1374-83.
Vidal J. Updated review on the benefits of weight loss. Int J Obes Relat Metab Disord 2002;26 Suppl 4:S25-8.
Look AHEAD Research Group, Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: Four-year results of the look AHEAD trial. Arch Intern Med 2010;170:1566-75.
Jeffery RW. Financial incentives and weight control. Prev Med 2012;55 Suppl: S61-7.
Look AHEAD Research Group, Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, et al.
Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013;369:145-54.
Montesi L, El Ghoch M, Brodosi L, Calugi S, Marchesini G, Dalle Grave R, et al.
Long-term weight loss maintenance for obesity: A multidisciplinary approach. Diabetes Metab Syndr Obes 2016;9:37-46.
Jeffery RW, Forster JL, French SA, Kelder SH, Lando HA, McGovern PG, et al.
The healthy worker project: A work-site intervention for weight control and smoking cessation. Am J Public Health 1993;83:395-401.
John LK, Loewenstein G, Troxel AB, Norton L, Fassbender JE, Volpp KG, et al.
Financial incentives for extended weight loss: A randomized, controlled trial. J Gen Intern Med 2011;26:621-6.
[Table 1], [Table 2]