August 2013, Vol 6 ADA 2013 Highlights - Health Economics
Wayne Kuznar

San Francisco, CA—The impact of obesity on patients with diabetes is well-established. Weight loss can significantly impact diabetes. In a recent study, obese patients who were offered modest financial incentives over an extended period of time as part of a weight-loss program were significantly more likely to maintain their weight loss than patients in an identical program without the financial incentives, according to Steven L. Driver, MD, MPH, Internal Medicine Resident, Department of Internal Medicine, Mayo Clinic, Rochester, MN, at the 2013 American College of Cardiology annual meeting.

Many employers and insurers have already instituted workplace wellness programs that include financial incentives aimed at improving engagement and outcomes, Dr Driver said. However, when the financial incentives are ultimately removed, the participants tend to regain the lost weight. In an attempt to achieve sustained weight loss, Dr Driver and colleagues designed a novel, long-term, continuous financial incentive scheme based on research in behavioral economics.

The effectiveness of the program was studied in 100 healthy adult employees and their dependents who had a body mass index (BMI) between 30 kg/m2 and 39.9 kg/m2, which is classified as obese BMI. Each participant was randomly assigned to 1 of 4 weight-loss groups: 12 once-weekly education sessions with and without financial incentives, or the education sessions combined with a structured behavior modification plan with and without financial incentives. All participants were given a weight-loss goal of 4 lb monthly, with the goal adjusted based on the monthly weight. Weigh-ins occurred monthly for 1 year.

“Participants in the incentive groups who showed up for their weigh-ins earned $10 and those who met their 4-lb weight-loss goal received $20 per month,” said Dr Driver. However, if they failed to meet their weight-loss goals, they paid a $20 penalty into a bonus pool. The bonus pool was later awarded via lottery among participants who completed the study.

The financial incentive groups maintained greater participation rates and lost more weight than the control groups. Completion rates were 62% and 26%, respectively, in the incentive groups and nonincentive groups. Even participants who were subject to financial penalties were more likely to continue to participate than those in the groups without financial incentives, possibly because taking this risk also made them eligible to earn rewards.

On an intent-to-treat analysis, mean weight loss was 9.08 lb for the combined incentive groups versus 2.34 lb for the combined nonincentive groups. The estimated effect of the incentives was 6.5 lb.

Effective Incentive Components
Effective incentive programs have 3 components, said Dr Driver. “They have to have appropriate magnitude, so there has to be enough money to matter; there has to be a proximity to the desired behavior change, which is why we had people pay out the $20 they owed while they were still standing on the scale; and they have to have salience,” he said. “The most powerful of the 3 was probably the negative incentive. People tend to be motivated about 2.5 times more by losing money as they would by the prospect of gaining the same amount of money.”

Previous studies have shown that financial incentives are effective in empowering people to exercise and to lose weight over the short-term. This is the first study to examine the effects of a long-term incentive plan to help employees achieve sustained weight loss for 1 full year.

“We need to understand better what drives people and what works long-term,” said Vera A. Bittner, MD, MSPH, Section Head of Preventive Cardiology, University of Alabama at Birmingham School of Medicine, who was not involved in the study. “The investigators should be commended for trying to get at the science…instead of doing real-life experiments in the community.”

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