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

Exploring factors of adherence to weight loss interventions in population with overweight/obesity: an umbrella review

Adherence is key for achieving the optimal benefits from a weight loss intervention. Despite the number of studies on factors that promote adherence, their findings suggest inconsistent and fragmented evidence. The aim of this study was to review the existing factors of adherence to weight loss interventions and to find factors that facilitate the design of effective intervention programs. Six databases were searched for this umbrella review; after the screening process, 21 studies were included. A total of 47 factors were identified in six groups as relevant for adherence: (i) sociodemographic (n = 7), (ii) physical activity (n = 2), (iii) dietary (n = 8), (iv) behavioral (n = 4), (v) pharmacological (n = 3), and (vi) multi-intervention (n = 23). In addition, a map of adherence factors was created. The main findings are that with respect to demographic factors, the development of personalized intervention strategies based on the characteristics of specific populations is encouraged. Moreover, self-monitoring has been shown to be effective in behavioral, dietary, and multi-interventions, while technology has shown potential in dietary, behavioral, and multi-interventions. In addition, multi-interventions are adherence-promoting strategies, although more evidence is required on adherence to pharmacological interventions. Overall, the factor map can be controlled and modified by researchers and practitioners to improve adherence to weight loss interventions.

Comparison of a Telehealth-Based Intensive Treatment Program with a Rewarding App vs. On-Site Care for Youth with Obesity: A Historical Cohort Study

The recommended treatment for children with obesity includes numerous consultations by a multidisciplinary team, which is very cumbersome. Telehealth can assist in administering frequent care to children with obesity, yet the exact approaches and modes of delivery are still explored. During the COVID-19 pandemic, we developed an intensive telehealth-based treatment program that included a rewarding app for children with obesity. The aim of this study was to compare 6-month changes in body mass index (BMI) and body fat percent between participants in the program (n = 70) vs. children that underwent historic on-site care (n = 87). After 6 months, more participants in the telehealth group continued treatment compared to the on-site group (79% vs. 60%, p < 0.001). A significant reduction in the median BMI z-score (zBMI) was seen after 6 months in both groups (p < 0.01), with a similar proportion of zBMI reductions (71% in the telehealth group, 75% in the comparison group, p = 0.76). No statistically significant differences were found between the study groups in 6-month changes in BMI, zBMI, body fat percent or fat z-scores. We conclude that our telehealth program, which was executed during the COVID-19 pandemic, resulted in a high proportion of children with zBMI reduction that was comparable with the more personal on-site care.

Effectiveness of Incentives for Improving Diabetes-Related Health Indicators in Chronic Disease Lifestyle Modification Programs: a Systematic Review and Meta-Analysis

Introduction

We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A_1C (HbA_1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators.

Methods

We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I² statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]).

Results

Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (−1.85kg; 95% CI, −2.40 to −1.29; P < .001), BMI (−0.47kg/m²; 95% CI, −0.71 to −0.22; P < .001), and both systolic blood pressure (−2.59 mm HG; 95% CI, −4.98 to −0.20; P = .03) and diastolic blood pressure (−2.62 mm Hg; 95% CI, −4.61 to −0.64; P = .01). A reduction in cholesterol level was noted but was not significant (−2.81 mg/dL; 95% CI, −8.89 to −3.28; P = .37). One study found a significant reduction in hemoglobin A_1c (−0.17%; 95% CI, −0.30% to −0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful.

Conclusion

Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.

Weight loss outcomes achieved by adults accessing an online programme offered as part of Public Health England's 'Better Health' campaign

Effective use of health technology may offer a scalable solution to the obesity pandemic. Online digital programmes provide a convenient and flexible way for more people to access regular support. This service evaluation aims to determine whether adults accessing an online weight management programme via a national campaign are successful in losing weight.

Data was analysed for adults registering with Slimming World’s online programme using a discounted membership offered as part of PHE’s ‘Better Health’ campaign between July and December 2020. Last-weight carried forward was used to calculate weight outcomes for participants who had the opportunity to complete 12-weeks and recorded ≥ one weight besides baseline. Engagement was determined using number of online weekly weights recorded with high engagers having weight data for ≥ 9 occasions. Socioeconomic status was assessed using postcode data. Resubscription and uploaded weight data were used to determine numbers who continued beyond the offer period.

Twenty-seven thousand two hundred forty-eight adults (5.3% males) with mean age 41.0 ± 11.4 years met inclusion criteria. Mean baseline BMI was 33.4 ± 6.8 kg/m² (29.2% 30–34.9, 18.3% 35–39.9 and 15.1% > 40 kg/m²). Mean weight loss at 12 weeks was 2.7 (± 3) kg representing a mean loss of 3% (± 3.1) body weight with 42.3% achieving ≥ 3% and 22.1% weight loss ≥ 5%. Median number of weigh-ins was six. Men had greater weight losses compared to women (p < 0.001). High engagers, both men and women, achieved greater weight losses (p < 0.001). Absolute weight loss was associated with joining BMI (r_s = -0.15, p < 0.001) but for % weight change only small differences were seen (max effect size = 0.03) with no differences in weight change for high engagers between different baseline BMI categories (p > 0.05). 30.9% were in the lowest two IMD quintiles and absolute and percentage weight change did not differ across deprivation quintiles (p > 0.05). 34.9% continued to access the online support after the offer period.

This service evaluation shows that an online programme, offered as part of a national campaign, can offer effective support to a large number of people with different starting BMIs and from different socioeconomic backgrounds. An increased level of engagement leads to better weight losses.

Effectiveness and cost-effectiveness of text messages with or without endowment incentives for weight management in men with obesity (Game of Stones): study protocol for a randomised controlled trial

BACKGROUND

Obesity increases the risk of type 2 diabetes, heart disease, stroke, mobility problems and some cancers, and its prevalence is rising. Men engage less than women in existing weight loss interventions. Game of Stones builds on a successful feasibility study and aims to find out if automated text messages with or without endowment incentives are effective and cost-effective for weight loss at 12 months compared to a waiting list comparator arm in men with obesity.

METHODS

A 3-arm, parallel group, assessor-blind superiority randomised controlled trial with process evaluation will recruit 585 adult men with body mass index of 30 kg/m² or more living in and around three UK centres (Belfast, Bristol, Glasgow), purposively targeting disadvantaged areas. Intervention groups: (i) automated, theory-informed text messages daily for 12 months plus endowment incentives linked to verified weight loss targets at 3, 6 and 12 months; (ii) the same text messages and weight loss assessment protocol; (iii) comparator group: 12 month waiting list, then text messages for 3 months. The primary outcome is percentage weight change at 12 months from baseline. Secondary outcomes at 12 months are as follows: quality of life, wellbeing, mental health, weight stigma, behaviours, satisfaction and confidence. Follow-up includes weight at 24 months. A health economic evaluation will measure cost-effectiveness over the trial and over modelled lifetime: including health service resource-use and quality-adjusted life years. The cost-utility analysis will report incremental cost per quality-adjusted life years gained. Participant and service provider perspectives will be explored via telephone interviews, and exploratory mixed methods process evaluation analyses will focus on mental health, multiple long-term conditions, health inequalities and implementation strategies.

DISCUSSION

The trial will report whether text messages (with and without cash incentives) can help men to lose weight over 1 year and maintain this for another year compared to a comparator group; the costs and benefits to the health service; and men's experiences of the interventions. Process analyses with public involvement and service commissioner input will ensure that this open-source digital self-care intervention could be sustainable and scalable by a range of NHS or public services.

TRIAL REGISTRATION

ISRCTN 91974895 . Registered on 14/04/2021.

The Outcomes of App-Based Health Coaching to Improve Dietary Behavior Among Nurses in a Tertiary Hospital: Pilot Intervention Study

Background

At the workplace, health care workers face multiple challenges in maintaining healthy dietary behaviors, which is the major factor behind obesity. A hospital-wide mass health screening exercise showed an increasing trend in the prevalence of obesity and median BMI from 2004 to 2019, as well as a higher crude obesity rate among shift workers.

Objective

We aimed to evaluate the effectiveness of mobile app–based health coaching and incentives for achieving weight loss from better dietary choices among hospital nurses.

Methods

We conducted a pilot study from June 2019 to March 2020, involving the use of a health-coaching app by 145 hospital nurses over 6 months. Weight and BMI were self-reported, and food scores were calculated. Data among overweight nurses, shift work nurses, and incentive groups were analyzed.

Results

A total of 61 nurses were included in the final analysis. Of these 61 nurses, 38 (62%) lost weight. The median percentage weight loss was 1.2% (IQR 0%-2.9%; P<.001), and the median decrease in BMI was 0.35 (IQR −0.15 to 0.82; P<.001), but they were not clinically significant. The median improvement in the food score was 0.4 (IQR 0-0.8). There was no difference between the incentive and nonincentive groups. A total of 49 (34%) participants engaged for ≥8 weeks.

Conclusions

The study demonstrated an association between the use of app-based health coaching and the attainment of some weight loss in nurses, without a significant improvement in the food score. Incentives may nudge on-boarding, but do not sustain engagement.

Can incentives improve antipsychotic adherence in major mental illness? A mixed-methods systematic review

OBJECTIVES

Incentives have been effectively used in several healthcare contexts. This systematic review aimed to ascertain whether incentives can improve antipsychotic adherence, what ethical and practical issues arise and whether existing evidence resolves these issues.

DESIGN

Systematic review of MEDLINE, EMBASE and PsycINFO. Searches on 13 January 2021 (no start date) found papers on incentives for antipsychotics. Randomised controlled trials (RCTs), cohort studies, qualitative research and ethical analyses were included. Papers measuring impact on adherence were synthesised, then a typology of ethical and policy issues was compiled, finally the empirical literature was compared with this typology to describe current evidence and identify remaining research questions.

RESULTS

26 papers were included. 2 RCTs used contingent financial incentives for long-acting injectable antipsychotic preparations. Over 12 months, there were significantly larger increases in adherence among the intervention groups versus control groups in both RCTs. There were no consistently positive secondary outcomes. 39 ethical and practical issues were identified. 12 of these are amenable to empirical study but have not been researched and for 7 the current evidence is mixed.

CONCLUSIONS

In keeping with other areas of healthcare, antipsychotic adherence can be increased with financial incentives. Payments of 2.5 times minimum wage changed behaviour. The typology of issues reported in this systematic review provides a template for future policy and ethical analysis. The persistence of the effect and the impact of incentives on intrinsic motivation require further research.

PROSPERO REGISTRATION NUMBER

CRD42020222702.

Factors associated with the implementation of health-promoting telework from the perspective of company decision makers after the first COVID-19 lockdown

Aim

Owing to the COVID-19 pandemic, many companies shifted to telework, with few insights into its implementation, organisational conditions or the role of workplace health promotion and management. This study focused on a multifactorial investigation of conditions in companies which implemented and evaluated telework during the first lockdown in 2020 as well as on their future intentions to facilitate teleworking under health-promoting working conditions.

Subject and methods

The research hypotheses relate to an extended technology acceptance model. In a mixed-methods design, expert interviews were fed into the development of an online questionnaire. Out of 1858 contacted companies representing a broad range of Austrian businesses, 192 responses (general management, workplace health managers, etc.) were analysed using descriptive and multivariate statistics.

Results

The degree of implementation and claim to teleworking increased significantly during the first lockdown and did not return to pre-pandemic levels afterwards. Changes depended on preparation and experience: evaluation of teleworking and willingness to continue offering teleworking were conditional on preparation and the degree of implementation. Prerequisites for future intentions to implement health-promoting teleworking included readiness, general willingness and existing workplace health promotion/management structures.

Conclusion

This paper demonstrates the potential of health-promoting organisational cultures for development processes – particularly in times of crisis. Anchoring health-focused structures in companies helps to create health-promoting frameworks. Health-promoting teleworking can be developed from workplace health promotion/management using established approaches. It is essential to build on in-house capacities and competencies to develop awareness for a holistic culture for health-promoting (tele)work and to encourage deliberations about potential measures.

Examining Ways to Improve Weight Control Programs' Population Reach and Representativeness: A Discrete Choice Experiment of Financial Incentives

BACKGROUND

Both theoretical and empirical evidence supports the potential of modest financial incentives to increase the reach of evidence-based weight control programs. However, few studies exist that examine the best incentive design for achieving the highest reach and representativeness at the lowest cost and whether or not incentive designs may be valued differentially by subgroups that experience obesity-related health disparities.

METHODS

A discrete choice experiment was conducted (n = 1232 participants; over 90% of them were overweight/obese) to collect stated preference towards different financial incentive attributes, including reward amount, program location, reward contingency, and payment form and frequency. Mixed logit and conditional logit models were used to determine overall and subgroup preference ranking of attributes. Using the National Health and Nutrition Examination Survey data sample weights and the estimated models, we predicted US nationally representative participation rates by subgroups and examined the effect of offering more than one incentive design. External validity was checked by using a completed cluster randomized control trial.

RESULTS

There were significant subgroup differences in preference toward incentive attributes. There was also a sizable negative response to larger incentive amounts among African Americans, suggesting that higher amounts would reduce participation from this population. We also find that offering participants a menu of incentive designs to choose from would increase reach more than offering higher reward amounts.

CONCLUSIONS

We confirmed the existence of preference heterogeneity and the importance of subgroup-targeted incentive designs in any evidence-based weight control program to maximize population reach and reduce health disparities.

Rethinking COVID-19 and Beyond: Prevention, Remedies, and Recovery

In a relatively short timeframe, millions of deaths and illnesses associated with COVID-19 have been reported, accompanied by substantial economic losses, and overall, negatively impacting society. This experience should serve as a wakeup call to those in public health and healthcare, along with politicians and citizens: COVID-19 is considered a predictable and preventable disaster. While various reactive responses to address the pandemic were implemented, some with adverse effects, proactive measures in the years before COVID-19 were neglected. Predominately this involved the development of a preventable overfat pandemic, which played a key role in both rising rates of chronic disease, the comorbidities that increase the risk for COVID-19, along with associated inflammation and malnutrition. This increased the risk of infection in billions of people worldwide, which, in essence, primed society for high rates of COVID-19 infection. Excess body fat evolves primarily from poor nutrition, particularly the overconsumption of sugar and other refined carbohydrates, which replace the vital nutrients needed for optimal immune function. Sugar and refined carbohydrates must be considered the new tobacco, as these foods are also devoid of nutrients, and underly inflammatory chronic diseases. A balanced diet of nutrient-dense wholefood must be emphasized to combat infectious and inflammatory diseases. Implementing proactive preventive lifestyle changes must begin now, starting with simple, safe, and inexpensive dietary modifications that can quickly lead to a healthier population.

Randomized controlled trial of financial incentives during weight-loss induction and maintenance in online group weight control

OBJECTIVE

This study examined the impact of a financial incentive scheme integrating process and outcome incentives across weight-loss induction and weight maintenance on 18-month weight outcomes.

METHODS

This was a randomized controlled trial. Participants with overweight or obesity (n = 418; 91% female; 28% racial/ethnic minority) were randomized to an 18-month, online, group-based behavioral weight-control program (Internet-Only) or the same program with financial incentives provided for 12 months, contingent on self-regulatory weight-control behaviors (self-weighing, dietary self-monitoring, and physical activity) and weight-outcome benchmarks (Internet+Incentives). No financial incentives were provided from Months 13 to 18 to examine the durability of weight-control behaviors and outcomes without incentives.

RESULTS

Weight-loss induction at Month 6 was significantly greater for Internet+Incentives than Internet-Only (6.8% vs. 4.9%, respectively, p = 0.01). Individuals receiving incentives were significantly more likely to maintain weight loss ≥ 5% at Month 12 (45% in Internet+Incentives vs. 32% in Internet-Only, p < 0.02) and remain weight stable (39% vs. 27%, respectively, p < 0.01). Internet+Incentives participants also reported significantly greater behavioral engagement through Month 12. However, once incentives ceased, there were no differences in sustained weight outcomes (Month 18), and engagement declined dramatically.

CONCLUSIONS

Despite promoting greater treatment engagement and initial weight loss, financial incentives as offered in this study did not promote better extended weight control.

Impacts of chronic disease prevention programs implemented by private health insurers: a systematic review

BACKGROUND

Chronic diseases contribute to a significant proportion (71%) of all deaths each year worldwide. Governments and other stakeholders worldwide have taken various actions to tackle the key risk factors contributing to the prevalence and impact of chronic diseases. Private health insurers (PHI) are one key stakeholders, particularly in Australian health system, and their engagement in chronic disease prevention is growing. Therefore, we investigated the impacts of chronic disease prevention interventions implemented by PHI both in Australia and internationally.

METHOD

We searched multiple databases (Business Source Complete, CINAHL, Global Health, Health Business Elite, Medline, PsycINFO, and Scopus) and grey literature for studies/reports published in English until September 2020 using search terms on the impacts of chronic disease prevention interventions delivered by PHIs. Two reviewers assessed the risk of bias using a quality assessment tool developed by Effective Public Healthcare Panacea Project. After data extraction, the literature was synthesised thematically based on the types of the interventions reported across studies. The study protocol was registered in PROSPERO, CRD42020145644.

RESULTS

Of 7789 records, 29 studies were eligible for inclusion. There were predominantly four types of interventions implemented by PHIs: Financial incentives, health coaching, wellness programs, and group medical appointments. Outcome measures across studies were varied, making it challenging to compare the difference between the effectiveness of different intervention types. Most studies reported that the impacts of interventions, such as increase in healthy eating, physical activity, and lower hospital admissions, last for a shorter term if the length of the intervention is shorter.

INTERPRETATION

Although it is challenging to conclude which intervention type was the most effective, it appeared that, regardless of the intervention types, PHI interventions of longer duration (at least 2 years) were more beneficial and outcomes were more sustained than those PHI interventions that lasted for a shorter period.

FUNDING

Primary source of funding was Geelong Medical and Hospital Benefits Association (GMHBA), an Australian private health insurer.

A modelling analysis of financial incentives for hepatitis C testing and treatment uptake delivered through a community-based testing campaign

Financial incentives may reduce opportunity costs associated with people who become lost to follow-up in hepatitis C treatment programs. We estimated the impact that different financial incentive amounts would need to have on retention in care to maintain the same unit cost per (1) RNA-positive person completing testing (defined as awareness of RNA status) and (2) RNA diagnosed person initiating treatment. Costing data were obtained from a 2019 community-based testing campaign focused on engaging people who inject drugs. For different financial incentive amounts, we modelled the corresponding improvements in retention in care that would be needed to maintain the same overall (1) unit cost per testing completion and (2) unit cost per treatment initiation. In the testing campaign, the unit cost per RNA-positive person completing testing was A$3215 and the unit cost per RNA diagnosed person initiating treatment was A$1055. Modelling found that an incentive of A$500 per RNA-positive person completing testing would result in more people completing testing for the same unit cost if the percentage of attendees receiving their test results increased from 63% to 74%. An incentive of A$200 per RNA diagnosed person initiating treatment would result in more people initiating treatment for the same unit cost if the percentage initiating treatment increased from 67% to 83%. Monetary incentives for completing testing and initiating treatment may be an effective way to increase retention in care without increasing the overall unit cost of completing testing/initiating treatment.

Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis

OBJECTIVE

To determine if the characteristics of behavioural weight loss programmes influence the rate of change in weight after the end of the programme.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Trial registries, 11 electronic databases, and forward citation searching (from database inception; latest search December 2019). Randomised trials of behavioural weight loss programmes in adults with overweight or obesity, reporting outcomes at ≥12 months, including at the end of the programme and after the end of the programme.

REVIEW METHODS

Studies were screened by two independent reviewers with discrepancies resolved by discussion. 5% of the studies identified in the searches met the inclusion criteria. One reviewer extracted the data and a second reviewer checked the data. Risk of bias was assessed with Cochrane's risk of bias tool (version 1). The rate of change in weight was calculated (kg/month; converted to kg/year for interpretability) after the end of the programme in the intervention versus control groups by a mixed model with a random intercept. Associations between the rate of change in weight and prespecified variables were tested.

RESULTS

Data were analysed from 249 trials (n=59 081) with a mean length of follow-up of two years (longest 30 years). 56% of studies (n=140) had an unclear risk of bias, 21% (n=52) a low risk, and 23% (n=57) a high risk of bias. Regain in weight was faster in the intervention versus the no intervention control groups (0.12-0.32 kg/year) but the difference between groups was maintained for at least five years. Each kilogram of weight lost at the end of the programme was associated with faster regain in weight at a rate of 0.13-0.19 kg/year. Financial incentives for weight loss were associated with faster regain in weight at a rate of 1-1.5 kg/year. Compared with programmes with no meal replacements, interventions involving partial meal replacements were associated with faster regain in weight but not after adjustment for weight loss during the programme. Access to the programme outside of the study was associated with slower regain in weight. Programmes where the intensity of the interaction reduced gradually were also associated with slower regain in weight in the multivariable analysis, although the point estimate suggested that the association was small. Other characteristics did not explain the heterogeneity in regain in weight.

CONCLUSION

Faster regain in weight after weight loss was associated with greater initial weight loss, but greater initial weight loss was still associated with reduced weight for at least five years after the end of the programme, after which data were limited. Continued availability of the programme to participants outside of the study predicted a slower regain in weight, and provision of financial incentives predicted faster regain in weight; no other clear associations were found.

STUDY REGISTRATION

PROSPERO CRD42018105744.

Financial incentive strategy for weight loss and maintenance of weight loss

Introduction

The aim of this study was to investigate the effect of financial incentives on weight loss, maintain in obese women and biochemical factors.

Methods

This quasi-experimental study was conducted on 103 women with body mass index (BMI) ≥ 30 kg/m². The participants were assessed over a 12-month follow-up in eight phases. Money payment for losing weight was incentive intervention in this study. The participants were given diet and physical activity.

Results

Mean of BMI was 34.78 ± 4.29 kg/m² in baseline, that reduced to 32.41 ± 3.51 kg/m² in the sixth phase, and 31.64 ± 3.71 kg/m² in the final phase (P < 0.001). At baseline, mean of percentage of body fat (PBF) was 40.77 ± 2.81 that reduced to 37.34±4.02 at the end of the study (P < 0.001). Waist to hip ratio (WHR) and lean body mass (LBM) decreased significantly over the 12-month (P < 0.001). At the end of each phase, the mean of BMI reduction of 0.39 units was observed in the subjects, and 9 units of change were achieved by the end of the study compared to the baseline. The mean of triglyceride in the first, fourth and seventh phases were 128.57 ± 13.33, 101.43 ± 57.99 and 87.40 ± 57.59 mg/dl, respectively (P = 0.003). The mean of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamate-pyruvate transaminase (SGPT) decreased significantly over the 12-month, P = 0.052 and P = 0.005, respectively.

Conclusions

Financial incentives can effectively help to weight loss and maintenance of weight, and improve lipid profiles; blood sugar and liver enzymes. The use of motivational factors with proper training (diet and physical activity) will have a better result.

Randomized controlled trials of self-monitoring interventions with or without incentives for diet and exercise among individuals with overweight or obesity: Psychological and behavioural effects

OBJECTIVES

To test the effects of three behavioural interventions (daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only) on psychological constructs and fruit and vegetable consumption or physical activity behaviour change among a sample of adults with overweight or obesity.

DESIGN

A pair of 3-arm longitudinal randomized controlled trials compared daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only interventions for either fruit and vegetable consumption or physical activity.

METHODS

Individuals reporting elevated weight status and insufficient engagement in one of the target behaviours were randomly assigned to one of three 3-week interventions. All three interventions involved daily self-monitoring of the behaviour, and two provided monetary incentives contingent upon reported behaviour. Participants completed measures of psychological constructs and reported behaviour at baseline, the end of the intervention, and two and four weeks post-intervention.

RESULTS

Participants across all three intervention conditions demonstrated increased engagement in the target behaviour from pre- to post-intervention and reported behaviour remained above baseline levels at both follow-up time points. Increases in reported behaviour during the intervention were associated with increases in self-efficacy, and this enhanced self-efficacy prospectively predicted sustained reported behaviour at follow-up. However, contrary to hypotheses, the incentive interventions including self-monitoring were not more efficacious than self-monitoring alone, and increased reported behaviour was not associated with enhancements in attitudes.

CONCLUSIONS

Self-monitoring interventions can aid behaviour change efforts, and behavioural practice during these interventions can increase self-efficacy. However, among adults with overweight or obesity who are seeking behaviour change interventions, incentive-based self-monitoring approaches may not be superior to self-monitoring alone in driving behaviour change and maintenance.

Evaluation of the effectiveness of behavioural economic incentive programmes for the promotion of a healthy diet and physical activity: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Obesity and being overweight are major risk factors for metabolic syndrome and non-communicable diseases. Despite the recommendation that a healthy diet and physical activity can reduce the severity of these diseases, many fail to adhere to these measures. From a behavioural economic perspective, adherence to such measures can be encouraged through financial incentives. However, additional related behavioural economic approaches may improve the effectiveness of an incentive programme. As such, we have developed a protocol for a systematic review and network meta-analysis to summarise the current evidence from financial incentive programmes with and without behavioural economic insights for promoting healthy diet and physical activity.

METHODS AND ANALYSIS

Previous systematic reviews, meta-analyses and individual studies were identified from Medline and Scopus in June 2020 and will be updated until December 2020. Individual studies will be selected and data extracted by two reviewers. Disagreement will be resolved by consensus or adjudicated by a third reviewer. A descriptive analysis will summarise the effectiveness of behavioural economic incentive programmes for promoting healthy diet and physical activity. Moreover, individual studies will be pooled using network meta-analyses where possible. I² statistics and Cochran's Q test will be used to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as the overall strength of the evidence.

ETHICS AND DISSEMINATION

Ethics approval for a systematic review and meta-analysis is not required. The findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020198024.

Text messaging and financial incentives to encourage weight loss in men with obesity: the Game of Stones feasibility RCT

Background

In 2016, 26% of UK men were estimated to be obese. Systematic reviews suggest that few men engage in formal weight loss interventions that support weight reduction and improve health.

Objective

To co-produce, with patient and public involvement, an acceptable and feasible randomised controlled trial design to test a men-only weight management intervention.

Design

This was a two-phase feasibility study. Phase 1 was the development of intervention components, study procedures and materials including a discrete choice experiment with survey questions. Phase 2 was an individually randomised three-arm feasibility trial over 12 months. Qualitative interviews were conducted at 3 and 12 months.

Setting

The setting was two sites in Scotland that had disadvantaged urban and rural areas and differed in employment levels and ethnic groups.

Participants

In phase 1, 1045 men with obesity were recruited by Ipsos MORI (London, UK; www.ipsos.com/ipsos-mori/en-uk) to represent the UK population. In phase 2, 105 men with obesity were recruited in the community or through general practice obesity registers. Qualitative interviews were conducted with 50 men at 3 months and with 33 men at 12 months.

Interventions

The trial arms were narrative short message service (SMS) for 12 months (SMS only), financial endowment incentive informed by loss aversion and linked to achievement of weight loss targets plus narrative SMS for 12 months (SMS + I), and waiting list control group for 12 months followed by 3 months of an alternative SMS style developed based on feedback from men who had received the narrative SMS (control).

Main outcome measures

The main outcome measures were acceptability and feasibility of recruitment, retention, engagement, intervention components and trial procedures. Outcomes were assessed by examining procedural, quantitative and qualitative data at 3, 6 and 12 months.

Results

The most acceptable incentive strategy, based on the discrete choice experiment results, was to verify weight loss of 5% at 3 months, verify weight loss of 10% at 6 months and maintain weight loss of 10% at 12 months. Overall, 105 men with obesity from across the socioeconomic spectrum were successfully recruited to target, 59% of whom lived in more disadvantaged areas. Retention at 12 months was acceptable (74%) and was higher among individuals from disadvantaged areas. Narrative SMS were acceptable to many men, with a minority reporting negative reactions. Incentives were acceptable but were not the primary motivation for behaviour change. Twelve men in the incentive arm (33%) secured at least some money and three (8%) secured the full amount. Both intervention arms lost some weight, with greater weight loss in the arm that received SMS and incentives. The alternative SMS based on men’s feedback received no strong negative reactions.

Limitations

Fewer participants from the SMS + I arm (64%) completed the study at 12 months than did those in the SMS-only (79%) and control (83%) arms. The reasons for this difference were complex.

Conclusions

The men-only weight management intervention consisting of narrative SMS and financial incentives was acceptable and feasible, meeting the progression criteria for a full trial. Tailoring of SMS may improve acceptability and retention.

Future work

Minor refinements to the intervention components based on the study findings will be made prior to testing in a multisite definitive randomised controlled trial.

Trial registration

ClinicalTrials.gov NCT03040518.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

Are workplace health promotion programmes effective for all socioeconomic groups? A systematic review

Decreasing socioeconomic health inequalities is considered an important policy priority in many countries. Workplace health promotion programmes (WHPPs) have shown modest improvements in health behaviour. This systematic review aims to determine the presence and magnitude of socioeconomic differences in effectiveness and the influence of programme characteristics on differential effectiveness of WHPPs. Three electronic databases were searched for systematic reviews published from 2013 onwards and for original studies published from 2015 onwards. We synthesised the reported socioeconomic differences in effectiveness of WHPPs on health behaviours, and calculated effectiveness ratios by dividing the programme effects in the lowest socioeconomic group by the programme effects in the highest socioeconomic group. Thirteen studies with 75 comparisons provided information on the effectiveness of WHPPs across socioeconomic groups. Ten studies with 54 comparisons reported equal effectiveness and one study with 3 comparisons reported higher effectiveness for lower socioeconomic groups. Quantitative information on programme effects was available for six studies with 18 comparisons, of which 13 comparisons showed equal effectiveness and 5 comparisons showed significantly higher effect sizes among workers in low socioeconomic position. The differential effectiveness of WHPPs did not vary across programme characteristics. In this study no indications are found that WHPPs increase socioeconomic inequalities in health behaviour. The limited quantitative information available suggests that WHPPs may contribute to reducing socioeconomic inequalities. Better insight is needed on socioeconomic differences in effectiveness of WHPPs to develop strategies to decrease socioeconomic inequalities in health in the workforce.

Game of Stones: feasibility randomised controlled trial of how to engage men with obesity in text message and incentive interventions for weight loss

OBJECTIVES

To examine the acceptability and feasibility of narrative text messages with or without financial incentives to support weight loss for men.

DESIGN

Individually randomised three-arm feasibility trial with 12 months' follow-up.

SETTING

Two sites in Scotland with high levels of disadvantage according to Scottish Index for Multiple Deprivation (SIMD).

PARTICIPANTS

Men with obesity (n=105) recruited through community outreach and general practitioner registers.

INTERVENTIONS

Participants randomised to: (A) narrative text messages plus financial incentive for 12 months (short message service (SMS)+I), (B) narrative text messages for 12 months (SMS only), or (C) waiting list control.

OUTCOMES

Acceptability and feasibility of recruitment, retention, intervention components and trial procedures assessed by analysing quantitative and qualitative data at 3, 6 and 12 months.

RESULTS

105 men were recruited, 60% from more disadvantaged areas (SIMD quintiles 1 or 2). Retention at 12 months was 74%. Fewer SMS+I participants (64%) completed 12-month assessments compared with SMS only (79%) and control (83%). Narrative texts were acceptable to many men, but some reported negative reactions. No evidence emerged that level of disadvantage was related to acceptability of narrative texts. Eleven SMS+I participants (31%) successfully met or partially met weight loss targets. The cost of the incentive per participant was £81.94 (95% CI £34.59 to £129.30). Incentives were acceptable, but improving health was reported as the key motivator for weight loss. All groups lost weight (SMS+I: -2.51 kg (SD=4.94); SMS only: -1.29 kg (SD=5.03); control: -0.86 kg (SD=5.64) at 12 months).

CONCLUSIONS

This three-arm weight management feasibility trial recruited and retained men from across the socioeconomic spectrum, with the majority from areas of disadvantage, was broadly acceptable to most participants and feasible to deliver.

TRIAL REGISTRATION NUMBER

NCT03040518.

Effects of Intervention Characteristics on Willingness to Initiate a Weight Gain Prevention Program

PURPOSE

To determine characteristics of weight gain prevention programs that facilitate engagement.

DESIGN

Randomized factorial experiment (5 × 2).

SETTING

Recruited nationally online.

PARTICIPANTS

Adults aged 18 to 75 with body mass index ≥25 who decline a behavioral weight loss intervention (n = 498).

MEASURES

Participants were randomly presented with one of 10 possible descriptions of hypothetical, free weight gain prevention programs that were all low dose and technology-based but differed in regard to 5 behavior change targets (self-weighing only; diet only; physical activity only; combined diet, physical activity, and self-weighing; or choice between diet, physical activity, and self-weighing targets) crossed with 2 financial incentive conditions (presence or absence of incentives for self-monitoring). Participants reported willingness to join the programs, perceived program effectiveness, and reasons for declining enrollment.

ANALYSIS

Logistic regression and linear regression to test effects of program characteristics offered on willingness to initiate programs and programs' perceived effectiveness, respectively. Content analyses for open-ended text responses.

RESULTS

Participants offered the self-weighing-only programs were more willing to initiate than those offered the programs targeting all 3 behaviors combined (50% vs 36%; odds ratio [OR] = 1.79; 95% confidence interval [CI], 1.01-3.13). Participants offered the programs with financial incentives were more willing to initiate (50% vs 33%; OR = 2.08; 95% CI, 1.44-2.99) and anticipated greater intervention effectiveness (β = .34, P = .02) than those offered no financial incentives. Reasons for declining to initiate included specific program features, behavior targets, social aspects, and benefits.

CONCLUSION

Targeting self-weighing and providing financial incentives for self-monitoring may result in greater uptake of weight gain prevention programs.

STUDY PREREGISTRATION

https://osf.io/b9zfh, June 19, 2018.

BWHealthy Weight Pilot Study: A randomized controlled trial to improve weight-loss maintenance using deposit contracts in the workplace

Objective

Deposit contracts, where participants “bet” on achieving a goal and get their money back only if successful, have been shown to be effective for short-term weight-loss. This pilot study examined their effect on weight-loss maintenance.

Methods

From 2016 to 2018, we conducted a pilot, 50-week randomized controlled trial among 42 hospital employees (19 intervention and 23 control), in Boston, Massachusetts, who lost ≥10 lb (4.5 kg) in the two years prior to enrollment. Participants were recruited primarily in-person. Both control and intervention participants were asked to attend a weigh in weekly and received weekly email communication. Intervention participants also entered into a deposit contract to maintain baseline weight within ≤2 lb (0.9 kg). We examined weight change from baseline to 50 weeks (primary outcome) and maintenance of baseline weight at 50 weeks (secondary outcome; binary – yes v. no). Participants completed baseline and follow-up surveys and received incentives for completion.

Results

At baseline, mean (SD) weight was 83.2 (15.5 kg) among intervention and 80.7 (14.5 kg) among control participants. After 50 weeks, intervention participants had slightly less but non-significant weight gain (adjusted β −1.12 kg; 95% CI −5.28, 3.05) than control participants; 73.7% of intervention v. 39.1% of control participants met their weight-loss maintenance goal by study end (adjusted OR 4.78; 95% CI 1.01, 22.71).

Conclusions

A deposit contract was not associated with differences in weight but led to more participants meeting their weight-loss maintenance goals; a deposit contract for weight-loss maintenance should be tested in a full-scale intervention. Most intervention participants viewed the deposit contract as acceptable.

Going beyond health efficiency: What really matters?

Both citizens and policymakers demand the best possible results from a country's healthcare system. It is of utmost importance to accurately and objectively assess the efficiency of a healthcare system and to note the key indicators, where resources are lost, and possibilities for improvement. This paper evaluates the efficiency of health systems in 38 countries, mainly members of the Organization for Economic Co-operation and Development, using data envelopment analysis (DEA). In the first stage, bootstrapped Ivanovic distance is used to generate weights for the indicators, thus taking into consideration different country's goals, but not to the extent of reducing the possibility of comparison. The analysis shows that human resources are the most important health system resource and countries should pay special attention to developing and employing competent medical workers. The reorganization of human resources and the funds allocated to them could also increase efficiency. The second stage examines environmental indicators to find the causes of inefficiency. No proof is found that any one basic health system funding model produces better health outcomes than the others. Obesity is identified as a major issue.

The effect of commitment-making on weight loss and behaviour change in adults with obesity/overweight; a systematic review

Background

Adherence to weight loss interventions is crucial to successful outcomes, yet little is known about how best to improve it. This suggests a need for developing and improving adherence strategies, such as formal commitments. This review aims to identify the effect of including a commitment device alongside lifestyle interventions on weight loss, and identify the most appropriate delivery mechanisms and target behaviours.

Methods

We searched five databases and hand-searched reference lists for trials of behavioural interventions to achieve weight loss among adults with excess weight or obesity. Interventions incorporating commitment devices were included in a narrative review and meta-analysis where appropriate. Commitment devices with financial incentives were excluded.

Results

Of 2675 unique studies, ten met the inclusion criteria. Data from three randomised trials including 409 participants suggests that commitment interventions increases short-term weight loss by a mean of 1.5 kg (95% CI: 0.7, 2.4). Data from two randomised trials including 302 patients suggests that benefits were sustained at 12 months (mean difference 1.7 kg; 95% CI: 0.0, 3.4). Commitment devices appeared most successful when made publicly, and targeting diet rather than physical activity.

Conclusions

Using commitment devices, such as behavioural contracts, as part of a weight loss intervention may be useful in improving weight loss outcomes and dietary changes, at least in the short-term. However, evidence is limited and of variable quality so results must be interpreted with caution. Poor reporting of intervention details may have limited the number of identified studies. More rigorous methodology and longer term follow-ups are required to determine the effectiveness of behavioural contracts given their potential for use in public health interventions.

Combined financial incentives and behavioral weight management to enhance adherence with gestational weight gain guidelines: a randomized controlled trial

BACKGROUND

Excessive gestational weight gain, particularly among overweight and obese women, is associated with adverse perinatal outcomes. Current interventions to limit gestational weight gain have achieved only modest success.

OBJECTIVE

We sought to improve adherence to gestational weight gain guidelines with a dual intervention of financial incentives and antenatal behavioral weight management.

STUDY DESIGN

This was a prospective randomized controlled trial at a single academic medical center in which women were assigned randomly to the intervention group or standard care. The primary outcome was adherence to gestational weight gain guidelines. Secondary outcomes included total gestational weight gain, mode of delivery, birthweight, neonatal intensive care unit admission, and development of gestational diabetes mellitus and hypertensive disorders of pregnancy.

RESULTS

A total of 136 women were assigned randomly, with data available for analysis of 124 women. Gestational weight gain within the Institutes of Medicine guidelines was similar (30% vs 29%) in the intervention and standard care groups, respectively. There were no statistically significant differences in total gestational weight gain or perinatal outcomes. There was a nonstatistically significant decrease in macrosomia in the intervention compared with standard care condition.

CONCLUSION

A combined financial incentive and behavioral weight management intervention did not improve adherence to gestational weight gain guidelines. Modifications to the intervention may achieve improved results.

A descriptive study of potential participant preferences for the design of an incentivised weight loss programme for people with type 2 diabetes mellitus attending a public hospital in Lima, Peru

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.