Adding Financial Incentives to Online Group-Based Behavioral Weight Control: An RCT


      Internet-delivered behavioral weight control is promising for expanding the reach and availability of weight management, but online programs produce lower weight losses than typically achieved in person. Financial incentives have been shown to increase weight losses. This study examined whether adding financial incentives for self-monitoring and achieving target weight losses increases weight losses attained in a fully online, group-based behavioral weight management program compared with the same program alone.

      Study design

      This study was an RCT.


      Adults with overweight and obesity (n=418; 91% female; 28% minority) were recruited from 2 clinical centers.


      The intervention was a 24-session online group-based behavioral weight control program with weekly synchronous chat sessions (Internet-only) or the same program with weekly financial incentives for self-monitoring body weight and dietary intake daily and for achieving target weight losses at 2 and 6 months (Internet + incentives).

      Main outcome measures

      This study measured weight loss at 6 months and treatment engagement (attendance, self-monitoring of body weight, dietary intake, and physical activity). Data were collected between February 2016 and August 2018, and analyses were completed in 2019.


      Participants randomized to the Internet + incentives group lost more weight (−6.4 [SD=5.5] kg) than those in the Internet-only group (−4.7 [SD=6.6] kg; p<0.01). Further, a higher proportion of the Internet + incentives group achieved ≥5% weight loss (55%) than those in the Internet-only group (40%; p<0.05). Treatment engagement was higher in the Internet + incentives condition, with greater self-monitoring of behaviors targeted by incentives, as well as higher rates of behaviors not targeted and higher self-reported physical activity. Study retention was higher among those in the Internet + incentives condition (91%) than those in the Internet-only condition (81%; p=0.003).


      Adding financial incentives to a program delivered fully online increases weight losses compared with the program alone and can achieve weight losses comparable to in-person programs, offering potential for substantial geographic reach.

      Trial registration

      This study is registered at NCT02688621.
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        • Knowler WC
        • Barrett-Connor E
        • Fowler SE
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • X Pi-Sunyer
        • Blackburn G
        • et al.
        • Look AHEAD Research Group
        Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the Look AHEAD trial.
        Diabetes Care. 2007; 30: 1374-1383
        • Gregg EW
        • Flores MR.
        The impact of intentional weight loss on major morbidity and mortality.
        in: Wadden TA Bray GA Handbook of Obesity Treatment. Second Edition. Guilford Publications, New York, NY2018: 185-207
        • Harvey-Berino J
        • West D
        • Krukowski R
        • et al.
        Internet delivered behavioral obesity treatment.
        Prev Med. 2010; 51: 123-128
        • West DS
        • Harvey JR
        • Krukowski RA
        • Prewitt TE
        • Priest J
        • Ashikaga T
        Do individual, online motivational interviewing chat sessions enhance weight loss in a group-based, online weight control program?.
        Obesity (Silver Spring). 2016; 24: 2334-2340
        • Finkelstein EA
        • Verghese NR.
        Incremental cost-effectiveness of evidence-based non-surgical weight loss strategies.
        Clin Obes. 2019; 9: e12294
        • Jeffery RW
        Financial incentives and weight control.
        Prev Med. 2012; 55: S61-S67
        • Paul-Ebhohimhen V
        • Avenell A.
        Systematic review of the use of financial incentives in treatments for obesity and overweight.
        Obes Rev. 2008; 9: 355-367
        • Gong Y
        • Trentadue TP
        • Shrestha S
        • Losina E
        • Collins JE
        Financial incentives for objectively-measured physical activity or weight loss in adults with chronic health conditions: a meta-analysis.
        PLoS One. 2018; 13e0203939
        • Leahey TM
        • Subak LL
        • Fava J
        • et al.
        Benefits of adding small financial incentives or optional group meetings to a web-based statewide obesity initiative.
        Obesity (Silver Spring). 2015; 23: 70-76
        • Burns RJ
        • Donovan AS
        • Ackermann RT
        • Finch EA
        • Rothman AJ
        • Jeffery RW
        A theoretically grounded systematic review of material incentives for weight loss: implications for interventions.
        Ann Behav Med. 2012; 44: 375-388
        • Volpp KG
        • Pauly MV
        • Loewenstein G
        • Bangsberg D
        P4P4P: an agenda for research on pay-for-performance for patients.
        Health Aff (Millwood). 2009; 28: 206-214
        • Jay M
        • Orstad SL
        • Wali S
        • et al.
        Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial.
        BMJ Open. 2019; 9e025278
        • Hashemi A
        • You W
        • Boyle KJ
        • Parmeter CF
        • Kanninen B
        • Estabrooks PA
        Identifying financial incentive designs to enhance participation in weight loss programs.
        J Obes Weight Loss Ther. 2015; 5: 1-8
        • Bandura A.
        Social Foundations of Thought and Action: a Social Cognitive Theory.
        Prentice Hall, Inc, Englewood Cliffs, NJ1986
        • Wadden TA
        • West DS
        • et al.
        • The Look AHEAD Research Group
        The Look AHEAD Study: a description of the lifestyle intervention and the evidence supporting it.
        Obesity (Silver Spring). 2006; 14: 737-752
        • Diabetes Prevention Program (DPP) Research Group
        The Diabetes Prevention Program (DPP): description of lifestyle intervention.
        Diabetes Care. 2002; 25: 2165-2171
        • Jakicic JM
        • Tate DF
        • Lang W
        • et al.
        Objective physical activity and weight loss in adults: the step-up randomized clinical trial.
        Obesity (Silver Spring). 2014; 22: 2284-2292
        • Krukowski RA
        • Harvey-Berino J
        • Bursac Z
        • Ashikaga T
        • West DS
        Patterns of success: online self-monitoring in a web-based behavioral weight control program.
        Health Psychol. 2013; 32: 164-170
        • Zheng Y
        • Klem ML
        • Sereika SM
        • Danford CA
        • Ewing LJ
        • Burke LE
        Self-weighing in weight management: a systematic literature review.
        Obesity (Silver Spring). 2015; 23: 256-265
        • Burke LE
        • Wang J
        • Sevick MA
        Self-monitoring in weight loss: a systematic review of the literature.
        J Am Diet Assoc. 2011; 111: 92-102
        • Wing RR
        • Hamman RF
        • Bray GA
        • et al.
        Achieving weight and activity goals among Diabetes Prevention Program lifestyle participants.
        Obes Res. 2004; 12: 1426-1434
        • West DS
        • Dutton G
        • Delahanty LM
        • et al.
        Weight loss experiences of African American, Hispanic, and non-Hispanic white men and women with type 2 diabetes: the Look AHEAD trial.
        Obesity (Silver Spring). 2019; 27: 1275-1284
        • Rothman AJ
        • Bartels RD
        • Wlaschin J
        • Salovey P
        The strategic use of gain- and loss-framed messages to promote healthy behavior: how theory can inform practice.
        J Commun. 2006; 56: S202-S220
        • Jensen JD
        • Ratcliff CL
        • Yale RN
        • Krakow M
        • Scherr CL
        • Yeo SK
        Persuasive impact of loss and gain frames on intentions to exercise: a test of six moderators.
        Commun Monogr. 2018; 85: 245-262
        • Lim JS
        • Noh G-Y.
        Effects of gain-versus loss-framed performance feedback on the use of fitness apps: mediating role of exercise self-efficacy and outcome expectations of exercise.
        Comput Hum Behav. 2017; 77: 249-257
        • Unick JL
        • Neiberg RH
        • Hogan PE
        • et al.
        Weight change in the first 2 months of a lifestyle intervention predicts weight changes 8 years later.
        Obesity (Silver Spring). 2015; 23: 1353-1356
        • Unick JL
        • Leahey T
        • Kent K
        • Wing RR
        Examination of whether early weight loss predicts 1-year weight loss among those enrolled in an Internet-based weight loss program.
        Int J Obes (Lond). 2015; 39: 1558-1560
        • Groenwold RH
        • Donders AR
        • Roes KC
        • Harrell Jr., FE
        • Moons KG
        Dealing with missing outcome data in randomized trials and observational studies.
        Am J Epidemiol. 2012; 175: 210-217
        • Sullivan TR
        • White IR
        • Salter AB
        • Ryan P
        • Lee KJ
        Should multiple imputation be the method of choice for handling missing data in randomized trials.
        Stat Methods Med Res. 2018; 27: 2610-2626
        • Dolan P
        • Galizzi MM.
        Like ripples on a pond: behavioral spillovers and their implications for research and policy.
        J Econ Psychol. 2015; 47: 1-16
        • Charness G
        • Gneezy U
        Incentives to exercise.
        Econometrica. 2009; 77: 909-931
        • Finch EA
        • Linde JA
        • Jeffery RW
        • Rothman AJ
        • King CM
        • Levy RL
        The effects of outcome expectations and satisfaction on weight loss and maintenance: correlational and experimental analyses–a randomized trial.
        Health Psychol. 2005; 24: 608-616
        • Volpp KG
        • John LK
        • Troxel AB
        • Norton L
        • Fassbender J
        • Loewenstein G
        Financial incentive–based approaches for weight loss: a randomized trial.
        JAMA. 2008; 300: 2631-2637
        • Finkelstein EA
        • Linnan LA
        • Tate DF
        • Birken BE
        A pilot study testing the effect of different levels of financial incentives on weight loss among overweight employees.
        J Occup Environ Med. 2007; 49: 981-989
        • John LK
        • Loewenstein G
        • Troxel AB
        • Norton L
        • Fassbender JE
        • Volpp KG
        Financial incentives for extended weight loss: a randomized, controlled trial.
        J Gen Intern Med. 2011; 26: 621-626
        • Kullgren JT
        • Troxel AB
        • Loewenstein G
        • et al.
        Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial.
        Ann Intern Med. 2013; 158: 505-514
        • Kullgren JT
        • Troxel AB
        • Loewenstein G
        • et al.
        A randomized controlled trial of employer matching of employees’ monetary contributions to deposit contracts to promote weight loss.
        Am J Health Promot. 2016; 30: 441-452
        • Patel MS
        • Asch DA
        • Troxel AB
        • et al.
        Premium-based financial incentives did not promote workplace weight loss in a 2013‒15 study.
        Health Aff (Millwood). 2016; 35: 71-79
        • Paloyo AR
        • Reichert AR
        • Reuss-Borst M
        • Tauchmann H
        Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial.
        Soc Sci Med. 2015; 145: 44-52
        • Driver SL
        • Hensrud D.
        Financial incentives for weight loss: a one-year randomized controlled clinical trial.
        J Am Coll Cardiol. 2013; 61: E1459
        • VanEpps EM
        • Troxel AB
        • Villamil E
        • et al.
        Effect of process- and outcome-based financial incentives on weight loss among prediabetic New York Medicaid patients: a randomized clinical trial.
        Am J Health Promot. 2019; 33: 372-380
        • Jeffery RW
        • Thompson PD
        • Wing RR
        Effects on weight reduction of strong monetary contracts for calorie restriction or weight loss.
        Behav Res Ther. 1978; 16: 363-369
        • Finkelstein EA
        • Bilger M
        • Baid D
        Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: a systematic review.
        Soc Sci Med. 2019; 232: 340-350
        • Nackers LM
        • Ross KM
        • Perri MG
        The association between rate of initial weight loss and long-term success in obesity treatment: does slow and steady win the race.
        Int J Behav Med. 2010; 17: 161-167
        • Thirumurthy H
        • Asch DA
        • Volpp KG
        The uncertain effect of financial incentives to improve health behaviors.
        JAMA. 2019; 321: 1451-1452