Thursday, March 23, 2023
| First author, year, country | Settinga | Populationb | Number incentive group/nonincentive group | Program description | Intervention duration, final measurement periodc | Program health indicators of interest | Study quality ratingsd |
|---|---|---|---|---|---|---|---|
| Almeida et al, 2015, US (26) | Internet-based, worksite programe | Participants aged ≥18 years, BMI ≥25 kg/m2, not currently pregnant, free of serious medical conditions (eg, recent heart attack), access to internet | 789/1,001 | Intervention group received nutrition and physical activity incentives for weight loss and incentives. Comparison group received educational materials focused on nutrition and physical activity without incentives | 12 Months; final measurement at month 6 | Weight, BMI, cholesterol | Fair |
| Bennett et al, 2012, US (27) | Community health centers | Participants aged ≥21 years, BMI of 30–50 kg/m2, weight <180 kg, and diagnosed hypertension | 180/185 | Intervention group participated in weight loss activities, engaged with CHWs, and received incentives; comparison group received a self-help booklet and no incentives | 24 months, final measurement at month 24 | Weight, BMI, systolic and diastolic blood pressure | Fair |
| Desai et al, 2020, US (30) | Primary care clinics | Participants aged 18–74 years at risk for type 2 diabetes and enrolled in Medicaid | 568/279 | Intervention group received the 12-month group-delivered DPP, based on the CDC National DPP and incentives. Comparison group received no incentives | 12 months, final measurement at month 12 | Weight | Fair |
| Dombrowski et al, 2020, Scotland (31) | Two public health care regionsf | Men aged ≥18 years, BMI ≥30 kg/m2 and/or waist circumference of ≥40 inches, access to a cellular telephone | 36/33g | Intervention group received narrative text message engagement, physical activity and nutrition components, and incentives. Comparison group received no incentives | 12 months, final measurement at month 12 | Weight, BMI | Fair |
| Faghri and Li, 2014, US (32) | Worksite, long-term nursing home facilities | Employees of long-term care facility overweight or with obesity, and at risk for type 2 diabetes | 35/38h | Intervention group received physical activity and nutrition components and incentives. Comparison group received no incentives | 16 weeks, final measurement at week 16 | Weight, BMI, systolic and diastolic BP | Fair |
| Finkelstein et al, 2017, Singapore (33) | Fitness center at Singapore General Hospital | Participants aged 21–65 years; BMI of 25–40 kg/m2 | 107/54 | Intervention group received goal setting and tracking, diet and nutrition management, physical activity resources, and incentives. Comparison group received no incentives | 8 months, final measurement at month 8 | Weight | Fair |
| John et al, 2011, US (34) | Veterans Affairs Medical Center | Veterans aged 30–70 years, BMI of 30–40 kg/m2 | A:22, B:22/ control:22 | Intervention groups received a weight monitoring program (dietary counseling and weight loss), and 1of 2 incentive plans. Comparison group received no incentives | 32 weeks, final measurement at week 32 | Weight | Fair |
| Leahey et al, 2015, US (35) | Internet-based programe | Participants aged 18–70 years, BMI ≥25 kg/m2 | 89/91 | Intervention group received nutrition, physical activity, weight tracking resources, and incentives. Comparison group received no incentives | 3 months, final measurement at month 3 | Weight | Good |
| Leahey et al, 2016, US (29) | Internet-based programe | Participants aged 18–70 years, |
A:25, B:26/ control:24 | Intervention group received coaching, a web-based weight maintenance program based on National DPP, and incentives with either a professional coach or peer coach. Comparison group received a single 1-hour group session and no incentives | 12 months, final measurement at month 12 | Weight | Fair |
| Morgan et al, 2011, Australia (25) | Worksite wellness program | Male shift workers at an aluminum company aged 18–65 years who were overweight or had obesity | 65/45 | Intervention group received a group session on nutrition and physical activity, self-monitoring, goal setting, and incentives. Comparison group was placed on a wait list and did not receive incentives | 12 weeks, final measurement at week 14 | Weight, BMI, systolic and diastolic blood pressure | Fair |
| Petry et al, 2011, US (36) | Setting not specified | Participants aged 18–65, BMI of 30–39.9 kg/m2, and blood pressure of 110/70–140/90 mm Hg | 28/28 | Intervention group received nutrition and physical activity components through supportive lifestyle counseling and incentives. Comparison group received no incentives | 12 weeks, final measurement at week 12 | Weight | Limited |
| Rounds et al, 2020, US (37) | Internet-based programe | Men aged 18–65 years and a BMI of 25–40 kg/m2 | 34/24 | Intervention group received nutrition and physical activity components, online lessons, and incentives. Comparison group received no incentives | 12 weeks, final measurement at week 24 | Weight | Fair |
| Shin et al, 2017, South Korea (38) | Academic institution | Male students aged 19–45 years, BMI ≥27 kg/m2, access to smartphone | 35/35i | Intervention groups received an individualized education session on nutrition and physical activity and incentives. Comparison group received no incentives | 12 weeks, final measurement at week 12 | Weight, BMI, systolic and diastolic BP, cholesterol | Fair |
| Teychenne et al, 2015, Australia (28) | Health and fitness centers or home | Participants aged 40–75 years with type 2 diabetes or BMI ≥25 kg/m2 | 162/156 | Intervention group received supervised group exercise sessions, behavioral counseling, newsletters, and incentives. Comparison group received the supervised group exercise sessions and no incentives | 12 months, final measurement at month 12 | Weight, BMI, HbA1c | Limited |
| VanEpps et al, 2019, US (39) | Community health center, Medicaid managed care plan center, or a local YMCA | Participants aged 18- 64 years, and at risk for type 2 diabetes | 170/170j | Intervention group received group sessions with physical activity and nutrition components based on the National DPP, and incentives. Comparison group received no incentives | 16 weeks, final measurement at week 16 | Weight | Good |
| Voils et al, 2020, US (40) | University medical center | Participants aged 18–70 years, BMI ≥30 kg/m2, access to a cellular telephone with a data plan | 23/24k | Intervention group received the standard behavioral weight loss sessions, nutrition and physical activity components, motivational text messages, and incentives. Comparison group received the standard behavioral weight loss sessions and no incentives | 24 weeks, final measurement at week 24 | Weight | Fair |
| Volpp et al, 2008, US (41) | Veterans Affairs medical center | Participants aged 30–70 years, BMI of 30–40 kg/m2 | A:19, B:19/ control:19 | Intervention group received an individual session with a dietician, physical activity, nutrition components, and 1 of 2 incentive plans. Comparison group received no incentives | 16 weeks, final measurement at week 16 | Weight | Good |
| West et al, 2020, US (42) | Internet-based programe | Participants aged ≥18 years, BMI |
206/212 | Intervention group received online group-based behavioral weight control sessions based on the National DPP, with physical activity and nutrition components and incentives. Comparison group received no incentives | 6 months, final measurement at month 6 | Weight | Fair |
| Yancy et al, 2018, US (43) | Internet-based programe | Participants enrolled in Weight Watchers aged 30–80 years, BMI of 30–45 kg/m2 | A:75, B:77/ control: 39 | Intervention group received physical activity and nutrition components, text message engagement, and was assigned to 1 of 2 incentive plans. Comparison group received no incentives | 6 months, final measurement at month 6 | Weight | Good |
Table 1. Characteristics of Study Participants and Programs, Randomized Controlled Trials (N = 19) of Chronic Disease Lifestyle Modification Programs, January 2008–August 2021
Abbreviations: BP, blood pressure; BMI, body mass index; CDC, Centers for Disease Control and Prevention, CHW, community health worker; National DPP, National Diabetes Prevention Program; YMCA, Young Men’s Christian Association.
a The location where the study took place or the location of the principal investigators where participants would report.
b Because age, BMI, and gender (if focused only on males or females) were consistently reported in the included studies, we were able to include this demographic information across all studies for the populations of focus. Other demographic information such as race, was not consistently reported across the studies and we therefore did not include it here.
c The length of time that participants receive program support. We defined final measurement period as the last point at which health indicators were measured and the incentive groups were still receiving support — this is the health indicator measure used for our meta-analysis.
d Consists of 3 categories — good, fair, and limited — measuring across 6 categories: description, sampling, measurement, analysis, interpretation of results, and other. These ratings are explained in the Guide to Community Preventive Services assessment tool [15].
e Defined as a lifestyle modification program that is delivered via the internet, including access to program materials and engagement with program facilitators and peers if applicable.
f Scotland is divided into health care regions in which the public receives health care services.
g This study had 3 arms. For the purposes of our analysis, we compared the arm that received the intervention plus incentives to the arm that received only the intervention versus the wait-list control arm.
h This study had 3 arms. For the purposes of our analysis, we compared the collective arm that combined both incentive groups to the control group.
i This study had 3 arms. For the purposes of our analysis, we compared the arm that received the intervention plus incentives to the control group.
j This study had 4 arms. For the purposes of our analysis, we compared the arm that received a combination of incentives to the control group.
k This study had 4 arms. For the purposes of our analysis, we compared the arm that received incentives for weight loss and self-monitoring to the control group.
| Author, year | Incentive description | Incentive typea | Monetary valueb | Recipientc | Frequencyd | Attainment certaintye | Schedulef |
|---|---|---|---|---|---|---|---|
| Almeida et al, 2015, (26) | Participants could receive cash based on percentage weight loss at quarterly weigh-ins (eg, 1% weight loss = $1.00, 2% weight loss = $2.00). Maximum potential earnings, ~$5 USD | Cash | Low | Individual | Multiple | Criteria-based guaranteed | Variable |
| Bennett et al, 2012 (27) | Participants could receive a grocery card ($50 USD) at completion of baseline, 6-, 12-, and 18-month visits and a grocery card ($75 USD) at 24 months. Participants also received a scale at 12-month visit and a blood pressure monitor at 18-month visit. Maximum potential earnings, $125 USD | Mixed | Low | Individual | Multiple | Guaranteed | Variable |
| Desai et al, 2020 (30) | Participants could receive incentives via a reloadable debit card for attendance and weight loss goals over the 12 months. Maximum potential earnings, $520 USD | Noncash financial | High | Mixed | Multiple | Criteria-Based Guaranteed | Variable |
| Dombrowski et al, 2020 (31) | At baseline, researchers deposited £400 GBP (~$550 USD) in a hypothetical bank account, and participants could secure/lose certain amounts when specific targets were reached/not reached. Maximum potential earnings, £400 GBP (~$550 USD) | Cash | High | Individual | Once | Criteria-Based Guaranteed | Variable |
| Faghri et al, 2014 (32) | Participants could receive cash for every 1 to 1.5 lb lost. Participants could choose 1 of 2 incentive plan: simple financial reward of $10 per lb of weight loss (maximum earnings, $260 USD) or simple financial reward plus deposit where participants could deposit $1–$5 per lb. of weight loss including a 1:1 match from the researchers. Maximum potential earnings, $340 USD | Cash | High | Individual | Once | Criteria-based guaranteed | Mixed |
| Finkelstein et al, 2017 (33) | Participants first paid a refundable fee to participate in the incentive plan. Participants could receive guaranteed cash payments or lottery cash prizes. Maximum potential earnings, S$600 SGD ($488 USD) | Cash | High | Individual | Multiple | Criteria-based guaranteed | Variable |
| John et al, 2011 (34) | Participants deposited their own money ($1–$3 per day) into a hypothetical account with a 1:1 match from the researchers. Incentive group A had a weight maintenance period weeks 25–32 and incentive group B did not. Maximum potential net earnings, $672 USD | Cash | High | Mixed | Multiple | Criteria-based guaranteed | Variable |
| Leahey et al, 2016 (29) | Participants could receive cash payments ($1–$10) weekly for submitting self-monitoring records and diet or activity information. An additional $25 was provided for maintaining weight loss. Maximum potential earnings, $185 USD | Cash | Low | Individual | Multiple | Criteria-based guaranteed | Variable |
| Leahey et al, 2015 (35) | Participants could receive cash payments ($1–$10) for submitting weight, nutrition, and activity information to be distributed after their 3-month assessment. Maximum potential earnings, $45 USD | Cash | Low | Individual | Once | Mixed | Variable |
| Morgan et al, 2011 (25) | Participants could receive sporting store gift vouchers (AU$50 [$37 USD]) per crew member based on the group that achieved the greatest mean weight loss and program completion. Maximum value, AU$100 (~$73 USD) | Noncash financial | Low | Group | Multiple | Criteria-based guaranteed | Fixed |
| Petry et al, 2011 (36) | Participants drew from a bowl with a chance to receive small incentives (healthy snacks, bottled water, toiletries) or large incentives ($20 gift cards, weight sets) worth $1–$100 USD for weight loss and completing weight loss activities. | Mixed | NA | Individual | Multiple | Criteria based lottery | Variable |
| Rounds et al, 2020 (37) | Participants could receive escalating incentives weekly for weight loss with a reset contingency if weekly weight loss goals were not met, starting at $4 USD in the first week. Maximum potential Earnings, $312 USD | Cash | High | Individual | Multiple | Criteria-based guaranteed | Variable |
| Shin et al, 2017 (38) | Participants could receive incentives for meeting daily physical activity goals and weight loss goals. Maximum potential earnings, ₩ 320,000 KRW (~$270 USD) | Cash | High | Individual | Multiple | Criteria-based guaranteed | Variable |
| Teychenne et al, 2015 (28) | Participants could receive motivational incentives such as a sports bag or water bottle. | Nonfinancial | NA | Individual | Multiple | Guaranteed | Fixed |
| VanEpps et al, 2019 (39) | Participants could receive incentives for attending group sessions and meeting weight loss goals. Maximum potential earnings, $240 USD | Cash | Low | Individual | Multiple | Criteria-based guaranteed | Fixed |
| Voils et al, 2020 (40) | Participants could receive incentives weekly (up to $30 USD per week on a reloadable debit card) for dietary self-monitoring and weight loss. Maximum potential earnings, $300 USD | Noncash financial | High | Individual | Multiple | Criteria-based guaranteed | Mixed |
| Volpp et al, 2008 (41) | Participants could receive incentives through a deposit contract or lottery incentive plan for meeting weight loss goals. The deposit contract required participants to deposit their own money ($1–$3) daily, which was matched 1:1 with an extra fixed payment of $3 per day and was refundable upon meeting or exceeding weight loss goals. The lottery plan offered a chance to receive daily incentives with a value of $3. Maximum net potential earnings, $168 USD | Cash | Low | Mixed | Multiple | Criteria-based guaranteed | Variable |
| West et al, 2020 (42) | Participants could receive incentives ($10–$15 per week via Amazon gift card) for submitting diet records and meeting weight loss goals. Maximum potential earnings, $230 USD | Noncash financial | Low | Individual | Multiple | Criteria-based guaranteed | Variable |
| Yancy et al, 2018 (43) | Participants could receive incentives through direct payments or lottery incentive plans for meeting weight loss goals. Maximum potential earnings, ~$590 USD | Cash | High | Individual | Multiple | Criteria-based guaranteed | Mixed |
Table 2. Summary of Incentive Domain Characteristics, Randomized Controlled Trials (N = 19) of Chronic Disease Lifestyle Modification Programs, January 2008–August 2021
Abbreviations: NA, not applicable; USD, US dollar; GBP, British pound sterling; SGD, Singapore dollar; AU, Australian dollar; KRW, South Korean won.
a The format of the incentive. Cash incentives were provided to participants in $USD currency or the currency of the study country’s location. Noncash financial incentives had a monetary value in a form other than currency (eg, gift cards, childcare or dependent assistance, transportation or store vouchers, health care premium discounts). Nonfinancial incentives were in kind and did not have a specific monetary value (eg, fitness equipment, products, various prizes). Mixed incentives were a combination of 2 or more incentive types.
b The worth of incentives provided to recipients for their participation in the program. A high amount, as defined by the authors, had a value of $270 or more. A low amount was defined as a value less than $270. This value was chosen because it is the median amount of money that participants could earn in 17 of the 19 studies included in our review.
c Who received the incentive: individuals, a group of individuals, or mixed (a combination of both).
d How often the incentive was provided to the recipient. Incentives could be given either once or multiple times throughout the intervention timeframe.
e How certain it was that a recipient would receive an incentive. Guaranteed = provided regardless of criteria being met; criteria-based guaranteed = must complete an activity or meet a milestone before the incentive is provided; criteria-based lottery = must complete an activity, task, or milestone to become eligible for an incentive lottery; lottery = an uncertain chance of receiving an incentive that could be based on completing an activity or meeting a milestone; mixed = a combination of 2 or more of these strategies.
f How the amount of the incentive was provided to recipients. Rates were based on what the recipient could potentially receive and were usually contingent on an activity, task, or timing. Fixed = the same incentive amount was given to recipients each time no matter what they did or achieved; variable = a varying incentive amount was provided to recipients over the intervention period; mixed = a combination of both.
| Incentive domain and subgroup | N (mean difference) [95% CI] | P Valuea | I2 (%) | Difference between subgroupsb |
|---|---|---|---|---|
| Weight | ||||
| Typec | ||||
| Cash | 12 (−1.79) [−2.53 to −1.05] | <.001 | 42.14 | Q = 0.15, P = .69 |
| Other types | 7 (−2.03) [−3.01 to −1.06] | <.001 | 64.85 | |
| Monetary valued | ||||
| High | 9 (−2.04) [−2.77 to −1.32] | <.001 | 0.00 | Q = 0.00, P = .95 |
| Low | 8 (−2.01) [−3.05 to −0.96] | <.001 | 73.93 | |
| Attainment certaintye | ||||
| Criteria-based guaranteed | 15 (−2.20) [−3.01 to −1.40] | <.001 | 57.59 | Q = 4.92, P = .03 |
| Other | 4 (−1.15) [−1.63 to −0.66] | <.001 | 0.00 | |
| Schedulef | ||||
| Fixed | 3 (−2.02) [−4.00 to −0.03] | .046 | 84.15 | Q = 0.04, P = .83 |
| Other schedules | 16 (−1.80) [−2.39 to −1.20] | <.001 | 34.97 | |
| Body mass index (weight in kg divided by height in m2) | ||||
| Typec | ||||
| Cash | 4 (−0.44) [−0.86 to −0.03] | .034 | 47.98 | Q = 0.14, P = .71 |
| Other types | 3 (−0.55) [−0.93 to −0.17] | .005 | 64.51 | |
| Monetary Valued | ||||
| High | 3 (−0.65) [−1.12 to −0.19] | .010 | 6.81 | Q = 0.20, P = .65 |
| Low | 3 (−0.50) [−0.99 to −0.00] | .048 | 76.73 | |
| Attainment certaintye | ||||
| Criteria-based guaranteed | 5 −0.69 [−1.21 to −0.18] | .008 | 68.67 | Q = 1.15, P = .28 |
| Other | 2 (−0.39) [−0.57 to −0.22] | <.001 | 0.00 | |
| Schedulef | ||||
| Fixed | 2 (−0.82) [−1.79 to −0.15] | .097 | 81.84 | Q = 0.77, P = .38 |
| Other schedules | 5 (−0.37) [−0.64 to −0.10] | .007 | 33.58 | |
Table 3. Moderator Analysis of Incentive Domain Subgroups by Diabetes-Related Health Indicators, Randomized Controlled Trials (N = 19) of Chronic Disease Lifestyle Modification Programs, January 2008–August 2021
Abbreviations: Q, Cochrane Q statistic.
a Refers to whether the association between the incentive domain subgroup and the health indicator was significant, based on the z value in the mixed-effects analysis.
b Refers to whether the mean differences for the 2 subgroups were statistically different from each other, based on the Q value in the mixed-effects analysis.
c Cash is currency provided to participants; other types include noncash financial, nonfinancial, or mixed.
d High includes studies that provided incentives valued at $270 or more; low includes studies that provided incentives valued at less than $270. For weight, the Petry et al (36) and Teychenne et al (28) studies were not included in the moderator analysis because they did not have a cash value. For BMI, the Teychenne et al (28) study was not included because it did not have a cash value.
e Criteria-based guaranteed includes studies where an activity, task, or milestone must have been met before incentives were provided; other includes guaranteed (incentive provided regardless of criteria being met), criteria-based lottery (an activity, task, or milestone must be completed to be eligible for an incentive lottery), and mixed (a combination of 2 or more of these strategies).
f Fixed means the same incentive amount was given to recipients each time, no matter what they did or achieved; other schedules include variable (a varying incentive amount was given to recipients over the intervention period) and mixed (a combination of both schedules).
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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 A1C (HbA1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators.
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 I 2 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]).
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 A1c (−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.
Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.
