Financial vs. Non-Financial Rewards for Weight Loss and Weight Maintenance

Project Background: Behavioral economics suggests that the chronic inability to make the
daily behavioral changes that can help us lose weight may be the result of "present bias,"
which is a tendency to value small, immediate rewards over large rewards in the distant
future. For many of us, the immediate gratification of eating an unhealthy food is a more
powerful motivator than is the elusive dissatisfaction of the long-run health consequences of
an unhealthy diet. Patient rewards may overcome present bias by moving the rewards for
healthy behaviors forward in time. In a patient reward program, patients are given tangible,
timely rewards for achieving specific health goals, such as losing one pound per week over 16
weeks. Meta analyses of randomized trials have found that rewards for weight loss are
effective during the reward period, but the weight loss was not sustained after the reward
was removed. Thus, the key challenge to a reward program is not achieving weight loss, but
maintaining it. The proposed study tests the hypothesis that the significant weight regain
found in prior reward trials can be attributed to use of financial rewards-e.g., cash or the
equivalent of cash-in those trials. Experiments in behavioral economics have found that
providing participants with financial rewards for participating in a study invokes behavior
defined by reciprocity-the effort the participants gave in the study was proportional to the
amount of money that they were given. When participants were given non-financial rewards,
they exhibited no reciprocity-the effort was consistently high and did not vary with the
quantity of the non-financial reward. By using financial rewards, prior trials may have
invoked money-market norms of reciprocity, such that patients' efforts toward weight loss
were high when rewards were offered, and reduced when they were discontinued. The
investigators hypothesize that non-financial rewards, like tickets to a Seattle Mariners
baseball game, will not invoke reciprocity or the consequent weight regain.

Project Objectives: The goal of this study is to test, through a randomized trial, the
effectiveness of providing overweight Veterans with financial or non-financial rewards for a
one pound weight loss per week over 16 weeks. The primary outcome is weight loss at 32
weeks-16 weeks after the discontinuation of the rewards. Secondary outcomes include weight
loss at 16 weeks and 12 months.

Project Methods: The investigators will conduct a three-armed randomized trial of patient
rewards for losing one pound per week over 16 weeks. The three treatment groups will receive
financial rewards, non-financial rewards, or no rewards. The investigators hypothesize that:
1) patients who receive non-financial rewards for weight loss over 16 weeks will have greater
weight loss at 32 weeks than patients who do not receive rewards; 2) patients who receive
non-financial rewards for weight loss over 16 weeks will experience weight loss at 16 weeks
that is not inferior to the weight loss of patients who receive financial rewards; and 3)
weight regain will be greater among patients who received financial rewards compared to
patients who received non-financial rewards or no rewards. The investigators will also
conduct post-intervention qualitative interviews and perform a cost analysis.

Inclusion Criteria:

- Veteran

- BMI>=30 at enrollment

- weigh less than 390lbs

- Active patient in primary care or women's clinic (1+ visit in last year)

- Access to a text capable phone in the Veteran's household or active email address

- live in Seattle area the entire year

- access to the internet

Exclusion Criteria:

- behavioral flag

- serious mental illness or anti-psychotic medication

- eating disorder and/or sexual trauma

- MOVE! participation in past 4 months

- pregnant or planning to become pregnant

- prisoner/employee/student

- inability to independently stand

- inability to read

- insulin dependent

- impaired decision making

- no access to a cell phone or phone that can receive text messages

- inability to remove socks & shoes

- >5% of body weight lost in last 6 months (clinical data and self-report)

- unable to pass cognitive screening