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Gross AC, Freese RL, Bensignor MO, Bomberg EM, Dengel DR, Fox CK, Rudser KD, Ryder JR, Bramante CT, Raatz S, Lim F, Hur C, Kelly AS. Financial Incentives and Treatment Outcomes in Adolescents With Severe Obesity: A Randomized Clinical Trial. JAMA Pediatr 2024; 178:753-762. [PMID: 38884967 PMCID: PMC11184501 DOI: 10.1001/jamapediatrics.2024.1701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/13/2024] [Indexed: 06/18/2024]
Abstract
Importance Adolescent severe obesity is usually not effectively treated with traditional lifestyle modification therapy. Meal replacement therapy (MRT) shows short-term efficacy for body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) reduction in adolescents, and financial incentives (FIs) may be an appropriate adjunct intervention to enhance long-term efficacy. Objective To evaluate the effect of MRT plus FIs vs MRT alone on BMI, body fat, and cardiometabolic risk factors in adolescents with severe obesity. Design, Setting, and Participants This was a randomized clinical trial of MRT plus FIs vs MRT alone at a large academic health center in the Midwest conducted from 2018 to 2022. Participants were adolescents (ages 13-17 y) with severe obesity (≥120% of the 95th BMI percentile based on sex and age or ≥35 BMI, whichever was lower) who were unaware of the FI component of the trial until they were randomized to MRT plus FIs or until the end of the trial. Study staff members collecting clinical measures were blinded to treatment condition. Data were analyzed from March 2022 to February 2024. Interventions MRT included provision of preportioned, calorie-controlled meals (~1200 kcals/d). In the MRT plus FI group, incentives were provided based on reduction in body weight from baseline. Main Outcomes and Measures The primary end point was mean BMI percentage change from randomization to 52 weeks. Secondary end points included total body fat and cardiometabolic risk factors: blood pressure, triglyceride to high-density lipoprotein ratio, heart rate variability, and arterial stiffness. Cost-effectiveness was additionally evaluated. Safety was assessed through monthly adverse event monitoring and frequent assessment of unhealthy weight-control behaviors. Results Among 126 adolescents with severe obesity (73 female [57.9%]; mean [SD] age, 15.3 [1.2] years), 63 participants received MRT plus FIs and 63 participants received only MRT. At 52 weeks, the mean BMI reduction was greater by -5.9 percentage points (95% CI, -9.9 to -1.9 percentage points; P = .004) in the MRT plus FI compared with the MRT group. The MRT plus FI group had a greater reduction in mean total body fat mass by -4.8 kg (95% CI, -9.1 to -0.6 kg; P = .03) and was cost-effective (incremental cost-effectiveness ratio, $39 178 per quality-adjusted life year) compared with MRT alone. There were no significant differences in cardiometabolic risk factors or unhealthy weight-control behaviors between groups. Conclusions and Relevance In this study, adding FIs to MRT resulted in greater reductions in BMI and total body fat in adolescents with severe obesity without increased unhealthy weight-control behaviors. FIs were cost-effective and possibly promoted adherence to health behaviors. Trial Registration ClinicalTrials.gov Identifier: NCT03137433.
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Affiliation(s)
- Amy C Gross
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Rebecca L Freese
- Biostatistical Design and Analysis Center, University of Minnesota Clinical and Translational Science Institute, Minneapolis
| | - Megan O Bensignor
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Eric M Bomberg
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Donald R Dengel
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- University of Minnesota School of Kinesiology, Minneapolis
| | - Claudia K Fox
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Kyle D Rudser
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis
| | - Justin R Ryder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Carolyn T Bramante
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Medicine, University of Minnesota, Minneapolis
| | - Sarah Raatz
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Aaron S Kelly
- University of Minnesota Center for Pediatric Obesity Medicine, Minneapolis
- Department of Pediatrics, University of Minnesota, Minneapolis
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Boonmanunt S, Pattanaprateep O, Ongphiphadhanakul B, McKay G, Attia J, Vlaev I, Thakkinstian A. Evaluation of the Effectiveness of Behavioral Economic Incentive Programs for Goal Achievement on Healthy Diet, Weight Control and Physical Activity: A Systematic Review and Network Meta-analysis. Ann Behav Med 2023; 57:277-287. [PMID: 36367428 PMCID: PMC10094952 DOI: 10.1093/abm/kaac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the incentivization effectiveness. This study compares and ranks the effectiveness of standard and behavioral incentivization for healthy diet, weight control, and physical activity promotion. PURPOSE To investigate whether behavioral-economic insights improve incentivization effectiveness. METHODS A systematic search of Medline and Scopus was performed from database inception to December 2020. Study characteristics, program designs, and risk ratio (RR) were extracted. A two-stage network meta-analysis pooled and ranked intervention effects. RESULTS There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant with pooled RRs and 95% confidence intervals (CI) of 1.21 (0.94, 1.56), 1.79 (1.04, 3.05), 1.45 (0.99, 2.13), and 1.73 (0.83, 3.63). For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI, with pooled RRs of 1.38 (1.13, 1.68), 1.63 (1.24, 2.14) and 1.43 (1.14, 1.80), respectively. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI, with pooled RRs of 1.39 (1.11, 1.73). CONCLUSION Deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. Behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity. However, the imprecise intervention effects were major concerns.
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Affiliation(s)
- Suparee Boonmanunt
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Pyathai, Bangkok 10400, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Pyathai, Bangkok 10400, Thailand
| | - Boonsong Ongphiphadhanakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Pyathai, Bangkok 10400, Thailand
| | - Gareth McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, 97 Lisburn Road, Whitla Medical Building, BT9 7BL Belfast, UK
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Kookaburra Circuit, John Hunter Hospital Campus, New Lambton, NSW 2305, Australia
- Hunter Medical Research Institute, Kookaburra Circuit, John Hunter Hospital Campus, New Lambton, NSW 2305, Australia
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry CV4 7AL, UK
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Pyathai, Bangkok 10400, Thailand
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Hohmann NS, Hastings TJ, Jeminiwa RN, Qian J, Hansen RA, Ngorsuraches S, Garza KB. Patient preferences for medication adherence financial incentive structures: A discrete choice experiment. Res Social Adm Pharm 2021; 17:1800-1809. [PMID: 33608244 DOI: 10.1016/j.sapharm.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 11/24/2020] [Accepted: 01/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior. OBJECTIVES The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care. METHODS A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level. RESULTS In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income. CONCLUSIONS Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.
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Affiliation(s)
- Natalie S Hohmann
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, 1202F Walker Building, Auburn, AL, USA.
| | - Tessa J Hastings
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, 715 Sumter St, CLS 311E, Columbia, SC, USA.
| | - Ruth N Jeminiwa
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Richard A Hansen
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Surachat Ngorsuraches
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Kimberly B Garza
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
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Boonmanunt S, Pattanaprateep O, Ongphiphadhanakul B, McKay G, Attia J, Thakkinstian A. 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. BMJ Open 2020; 10:e046035. [PMID: 33371052 PMCID: PMC7754655 DOI: 10.1136/bmjopen-2020-046035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Suparee Boonmanunt
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | | | - Gareth McKay
- Centre for Public Health, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
| | - John Attia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
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Luong MLN, Hall M, Bennell KL, Kasza J, Harris A, Hinman RS. The Impact of Financial Incentives on Physical Activity: A Systematic Review and Meta-Analysis. Am J Health Promot 2020; 35:236-249. [PMID: 32672050 DOI: 10.1177/0890117120940133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the effects of financial incentives on physical activity (PA). DATA SOURCES MEDLINE, Embase, 7 other databases, and 2 trial registries until July 17, 2019. STUDY INCLUSION AND EXCLUSION CRITERIA Randomized controlled trials with adults aged ≥18 years assessing the effect of financial incentives on PA. Any comparator was eligible provided the only difference between groups was the incentive strategy. DATA EXTRACTION Two independent reviewers extracted data and assessed study quality. Of 5765 records identified, 57 records (51 unique trials; n = 17 773 participants) were included. DATA SYNTHESIS Random-effects models pooling data for each of the 5 PA domains. RESULTS Financial incentives increase leisure time PA (gym or class attendance; standardized mean difference [95% CI], 0.46 [0.28-0.63], n = 5057) and walking behavior (steps walked; 0.25 [0.13-0.36], n = 3254). No change in total minutes of PA (0.52 [-0.09 to 1.12], n = 968), kilocalories expended (0.19 [-0.06 to 0.44], n = 247), or the proportion of participants meeting PA guidelines (risk ratio [95% CI] 1.53 [0.53-4.44], n = 650) postintervention was observed. After intervention has ceased, incentives sustain a slight increase in leisure time PA (0.10 [0.02-0.18], n = 2678) and walking behavior (0.11 [0.00-0.22], n = 2425). CONCLUSIONS Incentives probably improve leisure time PA and walking at intervention end, and small improvements may be sustained over time once incentives have ceased. They lead to little or no difference in kilocalories expended or minutes of PA. It is uncertain whether incentives change the likelihood of meeting PA guidelines because the certainty of the evidence is low.
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Affiliation(s)
- My-Linh Nguyen Luong
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Michelle Hall
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Kim L Bennell
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Jessica Kasza
- Biostatistics Unit, 161667School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Anthony Harris
- Centre for Health Economics, Monash Business School, Monash University, Victoria, Australia
| | - Rana S Hinman
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
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Mitchell MS, Orstad SL, Biswas A, Oh PI, Jay M, Pakosh MT, Faulkner G. Financial incentives for physical activity in adults: systematic review and meta-analysis. Br J Sports Med 2019; 54:1259-1268. [DOI: 10.1136/bjsports-2019-100633] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/02/2019] [Accepted: 04/12/2019] [Indexed: 01/08/2023]
Abstract
ObjectiveThe use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults.Data sourcesMedline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH.Eligibility criteriaRandomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA.DesignA simple count of studies with positive and null effects (‘vote counting’) was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods.Results23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9).ConclusionDemonstrating rising interest in financial incentives, 23 RCTs were identified. Modest incentives ($1.40 US/day) increased PA for interventions of short and long durations and after incentives were removed, though post-intervention ‘vote counting’ and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive ‘dose’ may promote sustained PA.
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