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People lost more weight when they were offered cash incentives

The study focused on low-income individuals, who tend to have a tougher time losing weight.
Image: A woman stands on a scale.  A study published Monday in the JAMA Internal Medicine found that offering people cash can help them shed excess pounds.
A study published Monday in JAMA Internal Medicine found that offering people cash can help with weight loss. Gareth Fuller / AP

Offering people cash can help them shed excess pounds, a study published Monday in JAMA Internal Medicine finds.

Participants who were offered cash incentives for either pounds lost or for completing certain activities were more likely to lose weight compared with those who were simply offered tools, such as diet books, fitness trackers and access to a weight loss program, the study found.

The patients in the study were low income — a group that tends to have a tougher time losing weight, said senior study author Dr. Melanie Jay, the co-director of NYU Langone Health’s Comprehensive Program on Obesity in New York City. “Forty percent of Americans have obesity and the prevalence is higher in people from low income and minoritized populations,” she said.

When it comes to weight loss, “there are a lot of barriers for those with low incomes,” Jay said, including lack of access to healthy foods or a gym, and the time needed for exercise.

Giving people the tools and information to lose weight often isn’t sufficient.

“One thing we continuously struggle with is keeping patients engaged,” said Colleen Tewksbury, an assistant professor of nutrition science at the University of Pennsylvania and a spokesperson for the Academy of Nutrition and Dietetics.

“This shows giving people tools, such as scales and ways to track eating and exercise, might not be enough,” said Tewksbury, who was not involved with the new research. “They might need financial incentives.” 

Cash for weight loss

To explore whether financial incentives could help people lose excess pounds, Jay and her colleagues recruited 688 patients, ages 18 to 70, with obesity (body mass index greater than or equal to 30), who were seeing a doctor at either Bellevue Hospital or NYU Langone Brooklyn, both in New York City, or Olive View-UCLA Medical Center in Los Angeles.

The participants were randomly assigned to one of three groups. All were given a year’s membership to WW Freestyle (formerly known as Weight Watchers), a Fitbit, health education, a food diary to keep track of what they ate, a scale and monthly one-on-one check-in visits. For the control group, no other intervention was added.

The remaining participants were split into two groups: the outcome-based group, which received payments based on the percentage of weight lost; or the goal-directed group, which received payments for sticking with certain weight loss behaviors, such as attending weekly program sessions, maintaining a food diary at least five days a week, and getting at least 75 minutes of physical activity each week.

Participants in both groups could earn up to $750.

The participants were mostly female, 81%, and Hispanic, 72.6%. The average weight of the participants was about 218 pounds at the start of the study. At six months, 22.1% of the patients in the control group lost at least 5% of their initial body weight, compared with 39% of those in the goal-directed group and 49.1% of those in the outcome-based group.

On average, participants in the goal-directed group earned $440.44, as compared to $303.56 in the outcome-based group.

Although more of the outcome-based group lost 5% of their body weight over six months than the goal-directed group, Jay believes that the goal-directed approach may turn out to have more lasting effects because it’s teaching people healthy habits.

“Even if less weight is lost, adopting lifelong physical activity or better eating habits may be more important,” she said.

Dr. Robert Kushner, a nutrition and weight management specialist and a professor at the Northwestern University Feinberg School of Medicine in Chicago, said it was very impressive that the study participants were able to manage their weight better and get healthier.

Kushner, who was not involved with the new study, agreed that low-income people face extra challenges when it comes to weight loss. He sees similar patients in his practice.

“They have a difficult time changing their behaviors because of all the other life challenges they face,” he said.

What’s not clear, however, is how the strategy of offering cash for weight loss could be implemented in a real-world setting, outside of academia. “Politically and culturally we’re going to be hard-pressed to pay people to get healthy,” Kushner said. “There are a lot of headwinds.”

Still, he noted, “insurance companies have used similar approaches, by lowering premiums or offering extra memberships for people who lose weight.”

Tewksbury said she suspects that organizations that pay for health care might be open to this kind of strategy.

“It may be a great opportunity for employers, health insurers, government agencies like Medicare and Medicaid,” she said. “Anyone currently spending money on health care costs could benefit by leveraging this strategy to lower health care costs.”

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