Warning: This Program May Be Hazardous to Your Health!

On a recent LinkedIn piece a wellness vendor promoting his incentivized weight loss challenge cited a study from the revered Mayo Clinic to support his claim that programs like his can result in successful weight loss. This is not the first time I have been sent a link to this study towards the same end. Making a quick trip to Google and typing in Mayo Clinic Incentives for Weight Loss pulled up some 374,000 entries from 2013 on with titles like:

• Mayo Clinic Study: Financial Incentives Further Weight Loss
• Mayo Clinic Proves Effectiveness of Financial Incentives on Driving Long-Term Behavioral Changes
• Money Talks When It Comes To Losing Weight

Not being a big fan of either weight loss or incentive programs, but wanting to be open minded about possibilities, I was anxious to check out the study.

The Study

One hundred healthy Mayo employees or their adult dependents, with a body mass index of 30 or over were assigned to one of four weight-loss groups: two with financial incentives and two without. (Note that participants were all labeled as “healthy” even though they were also labeled as having the disease of “obesity”). The goal for all participants was to lose four pounds per month up to a predetermined goal weight.  They were weighed monthly for one year. Participants in the incentive groups received $20 per month if they met their goals, while those who failed to meet their targets paid $20 each month into a bonus pool. Participants in both incentive groups who completed the study were eligible to win the pool by lottery. 

The Results

• 38% of the participants in the incentive groups dropped out during the year long program.
• Those that remained in the incentive groups lost an average 9.08 pounds compared with 2.34 pounds for the no incentive groups.
• Participants in the incentive group who paid penalties were more likely to continue their participation in the study than were those in the no incentive groups.

The Claims

So, what conclusions did the study reach? According to the lead author:

“The take-home message is that sustained weight loss can be achieved by financial incentives. The financial incentives can improve results and improve compliance and adherence.”

Not at all surprisingly, David Roddenberry, co-founder of HealthyWage, a wellness program provider, chimed in supportively saying:

“This is yet another study validating that the most successful programs will leverage both loss aversion and competitive drive… both the threat of losing of money and also the opportunity to win large prizes—and bragging rights as in a weight loss ‘bet.’ ”

And Michael Levy, president of Online Rewards, another provider of employee incentive programs added with just a touch of judgment:

“You’d like to believe that a long, healthy life is reward enough. The truth is, a $50 gift card works better.”

It might appear at first blush that indeed these incentives increased the likelihood of successful weight loss. But are we missing something?

The Reality

Let’s examine the study’s claim that “sustained weight loss” can be achieved using financial incentives. We can for discussion purposes separate the two components of the intervention; the focus on weight loss and the use of incentives.

Weight Loss:  Every weight loss program that has been studied over the past 3 decades, regardless of the population involved, the length and intensity of the program, the type of exercise and/or food intervention, the credentials of the people running the program, and every other variable imaginable has come up with the same set of results:

• Many people lose weight during the program.

• When the program is over, people begin to gain their weight back.
• Within a year or two most people have gained back most of their weight.
• Some people end up weighing more than when they started the program.

Incentives: The research over the same period of time is just as consistently conclusive that incentives (rewards and punishments) do not lead to sustained behavior change for behaviors that involve even a modicum of thinking and creativity. In addition, they often engender significant iatrogenic consequences including:

• Diminished performance
• Diminished creativity

• Increased short-term thinking
• Cheating, lying, and taking shortcuts
• Reduced intrinsic motivation

So, how does the Mayo program stack up against the research? During the 12- month program the difference between the average weight loss in the incentive and non incentive groups was a whopping 6.74 pounds; at about 1 BMI unit, hardly something to shout about from the rooftops!

But there is more. Remember that the program ended with the final weight measurement. So the claim of “sustained” weight loss is really disingenuous.  Given that not one of the hundreds of studies over the past 3 decades has demonstrated the ability of any but a small fraction of participants to keep their weight off after program’s end; it is presumptuous at best to think this case will be any different. Without documentation of what happened to the participants’ weights once the program ended, it is impossible to tell whether the program or the incentives had any real “sustained” effect.

Of course the vendor citing the study pointed out that because we don’t have that data it is possible that the weight would be maintained and therefore the incentives might be shown to be effective. If this were the first or second weight loss study (or any other behavior change study for that matter) using incentives, this might be a reasonable conclusion. But remember that over the past 3 decades there have been hundreds of studies, all different populations and manipulations and yet the outcomes are always the same.

And though not surprisingly most of the studies don’t bother to check to see what happens to participants after the program ends, some actually have. And from such studies we can get a pretty good idea of what is most likely to occur in this case.

A very similar study just a few years earlier by some of the leading behavioral economists in the country provides the likely answer. This was another randomized controlled trial; this time a 32 week program with two incentive groups in which people deposited money which they then lost or retained depending on whether or not they reached their weight loss goals of one pound per week. The control group met with a dietitian and had their weights taken monthly.

As expected, participants in the incentive group lost more weight (8.7 pounds) during the program than did the controls (1.17 pounds). Interestingly, this is about the same 1 BMI unit difference that we saw in the first study. In this case however, participants were followed for about 9 months after the program ended. And not at all surprisingly, in the author’s own words:

“Financial incentives produced significant weight loss over an 8-month intervention; however, participants regained weight post-intervention.”

Unlike the Mayo Study, at least this paper entitled Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial, reached a conclusion that was supported by the evidence.

The Take Home

It is time for people promoting weight loss programs to stop making claims that are misleading at best and disingenuous at worst. Unless participants are followed after the program is over, their is no weight loss maintenance, sustained weight loss or long-term weight loss. And so far, no study has demonstrated that any but a small minority are able to buck the weight regain trend.

Therefore at the very least, like a pack of cigarettes, every weight loss program, contest and competition should include a disclaimer that reads something like:

“The vast majority of people who participate in this program will gain their weight back after the program ends. Some will gain back more than they lose and the resulting weight cycling may be hazardous to their health.”

And it is time for health professionals involved in these programs to actually read the studies before citing them as evidence of successful, sustained or long term weight loss. If we want the people we serve to trust us, which is the only way it will be possible for us to be helpful and not harmful, this is the very least we can do!