How deposits and lotteries increased short-term weight loss by 10 pounds

Intervention Health

Abstract

Finding cost-effective approaches to achieve sustained weight loss has always been a challenge. At the Philadelphia VA Medical Centre, researchers introduced participants to behavioral economic concepts such as prospect theory, loss aversion, and regret, in order to effectively design a weight loss intervention program using financial incentives.

In comparison to the control group, the intervention group achieved a larger net weight loss of 9.2 lb at the end of 7 months. Ultimately, financial incentives based on behavioral economics were able to induce significant weight loss during the intervention, however, it was not sustained.

Rating: 3/5 (randomized trial; no sustainable results in the long term)

How behavioural-financial incentives impacted short-term weight loss results
Condition Results
Control group Mean weight loss of 3.9 lbs
Deposit contract Mean weight loss of 14 lbs
Lottery contract Mean weight loss of 13.1 lbs

Key Concepts

Incentives: Anything that motivates someone to do something, such as salespeople earning additional money based on what the quantity that they sell, or “working on commission.”

Loss Aversion: A cognitive bias that describes why the loss felt from money, or any other valuable object, can feel worse than gaining the same thing.

Regret Aversion: This occurs when a decision is made to avoid regretting an alternative decision in the future, people sometimes make decisions in order to avoid this outcome.

The Problem

Previous attempts to promote weight loss

An effective treatment for obesity is a significant clinical challenge – it’s difficult to achieve weight loss at a relatively cost-effective level, especially weight loss that lasts for more than 12 months. Behavioral interventions and pharmacotherapy are costly and tend to produce follow-up weight loss of only 3 to 5 kilograms. An alternative, surgical treatment, comes with incredibly high costs and high complication rates, though it is effective in inducing weight loss for larger individuals.

Why incentives need to be in the home

Many advantageous effects of behavioral economics have not been tested in combination with incentive studies in the past. Some incentive-based approaches in the past have applied incentives to physicians rather than participants – these approaches may not have the desired effect, as health care delivery deficiency only accounts to 10% of premature mortality, in contrast to unhealthy behaviors (smoking, poor diet, or sedentary lifestyles) that account for 40% of premature mortality in the US.

Design

Theoretical background

To improve on past studies and current literature, this study aimed to combine the advantageous effects of behavioral economics and financial incentives. Researchers incorporate the CrI2SP behavior change framework and designed the intervention with three key research findings in mind:

  1. Small rewards and punishments can create a great incentive effect if they occur immediately.
  2. Individuals are motivated by past rewards and the prospect of future rewards, in addition to being especially attracted to the small probability of large rewards.
  3. The desire to avoid regret is very powerful in decision making under risk.

Who did they study?

In this study, eligible participants fell between the ages of 30-70 and had a Body Mass Index (BMI) of 30-40. The effects of the incentives were tested against a control group in a Randomized Controlled Trial (RCT). The weight-monitoring program lasted 16 weeks, involving monthly weigh-ins. Participants were randomized into three groups: two intervention groups and one control group. The two intervention groups received the following incentives:

  1. Deposit contract: participants were allowed to contribute between $0.01 and $3 per day for a month, with a refund occurring if they had met or exceeded the weight loss goal. As an incentive for participants to contribute, the study matched the participant’s contribution in addition to a $3 daily fixed payment. Participants were aware that each day that they called in and reported a weight at or below their goal, they would accumulate rewards and receive an almost instant text message letting them know how much they had earned that day. 
  2. Lottery contract: participants in the lottery who reported a weight at or below their goal were eligible for a daily lottery prize with an expected value of $3 per day. This lottery was designed to provide infrequent large payoffs, a 1% chance of a $100 reward, and frequent small payoffs, a 20% chance of a $10 reward. Again, participants received almost instant daily feedback via text message about their daily payoff.

Nonadherent participants in both incentive groups also received rapid text message feedback on what their payoff would have been, had they met their weight goal. Participants who lost 20 lb or more during the 16 week study also received a bonus of $50.

To reduce the chance of participant dropout at the end of the month for participants whose weight was higher than their goal, they were given a fresh start at the start of the month. This adjusted the slope of the weight trajectory whilst keeping the overall weight loss goal the same. Follow-up weigh-ins were conducted 7 months after the start of the study. 

Results and Application

A 10-pound difference

After 16 weeks, both incentive groups produced a mean weight loss greater than the control group. The deposit contract group had a mean weight loss of 14 lb and the lottery contract group lost a mean of 13.1 lb. In contrast, the control group only lost a mean of 3.9 lb.

There were qualitatively similar patterns regardless of the participant’s age, income or BMI at the start of the study. Furthermore, 36.8% of participants in the deposit contract group lost at least 20 lb, compared to 26.3% in the lottery group and 5.3% in the control group.

Limitations

However, it is also important to note that participants in both incentive groups gained weight between the completion of the incentive intervention and the 7 month follow-up. Though the net weight loss at the start of the study and after 7 months was greater in the incentive groups, at 6.2 lb for the deposit contract group and 9.2 lb for the lottery contract, than in the control group, 4.4 lb.

Industry

Application

Climate & Energy Incentives and rapid feedback could be incorporated into programs that aim to reduce individual water or energy consumption. Providing consumers with information on their water or energy usage, in addition to incentives to meet certain targets, may help reduce consumption.
Financial Services In banks, incentives and rapid feedback for customers may help them to save more of their earnings, similar to incentivized weight loss programs.
Health & Wellbeing Deposit and lottery systems could be extended to other health initiatives, such as anti-smoking campaigns. Individuals wanting to quit or cut down their cigarette use could have similar financial incentives to rewards days or months without smoking.

Ethics

  • While weight loss can increase health and longevity, there were no effective long-term results, suggesting the intervention does not have long-term positive impacts on its participants
  • The study was fairly homogenous and does not provide insight on other groups’ responses to financial weight loss incentives
  • Participants were required to pass eligibility criteria in order to participate, to ensure their safety

Yes

Room for improvement

Insufficient information/Not applicable

Welfare
Does the intervention demonstrably improve the lives of those affected by it? During the incentive intervention, it improves the lives of those affected. However, further research is needed for a sustained effect (12+ months).
Does the intervention respect the privacy (including the privacy of identity) of those it affects? Participant privacy is not addressed in this paper.
Does the intervention have a plan to monitor the safety, effectiveness, and validity of the intervention? Yes, the study implemented eligibility requirements to ensure participants would be able to safely participate in the intervention.
Autonomy
Does the intervention abide by a reasonable degree of consent? Yes, though participants were incentivized, they were not coerced in any way to provide daily check-ins.
Does the intervention respect the ability of those it affects to make their own decisions? Yes, participants were able to make decisions on whether or not they provided daily check-ins.
Does the intervention increase the number of choices available to those it affects? No effect on the number of choices available to those it affects.
Equity
Does the intervention acknowledge the perspectives, interests, and preferences of everyone it affects, including traditionally marginalized groups? The study addresses the participants preferences and interests. However, there is no mention of how it affects traditionally marginalized groups.
Are the participants diverse? Participants were predominantly male, there is room for improvement in this area, specifically by including other genders.
Does the intervention help ensure a just, equitable distribution of welfare? Equitable distribution of welfare is not mentioned or addressed in the paper.

Related TDL Content

Can Money Buy Good Health? – RCT of Financial Incentives for Weight Loss: This perspective by The Decision Lab outlines how people are particularly attracted to tangible and immediate incentives, and how studies have used this knowledge to introduce effective financial incentives for weight loss.

The Stages of Change: How to Motivate, Facilitate, and Reinforce Desired Behaviors: Changing habits isn’t exactly straightforward. The Decision Lab explores the difficulty and conscious effort required to break down learned behavioral patterns to change our habits, in addition to the challenges associated with learning a new behavior.

How Loss Aversion Affects Our Perceptions of Weight: Loss aversion demonstrates how we register losses more acutely than we do gains, and that we tend to make decisions in the interest of avoiding potential losses. This perspective by The Decision Lab explores the role loss aversion plays in weight gain.

Sources

Volpp, K. G., John, L. K., Troxel, A. B., Norton, L., Fassbender, J., & Loewenstein, G. (2008). Financial Incentive–Based Approaches for Weight Loss: A Randomized Trial. JAMA, 300(22), 2631. https://doi.org/10.1001/jama.2008.804