We have repeatedly proposed that health promotion and especially worksite health promotion is stuck in ways of doing things based on outdated beliefs rather than the most current scientific evidence. When I was discussing this concept recently on a LinkedIn group, a colleague disagreed with my contention and sent me a 2011 article titled “Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial.” This was an opportunity simply too good to pass up. Here was a chance to put to rest (again) two of the most pervasive oxymoron’s of traditional health promotion: incentives for behavior change and extended weight loss. No one could have published research that lends itself to this task better if they had set out to do so; from a teaching perspective, this was – as good as it gets!
Before discussing the study details, a few comments about these two issues are in order.
- Extended Weight Loss. This is clearly the easier of the two concepts to grasp. We are all quite aware of the complete lack of evidence that weight-loss programs result in long-term weight loss for all but a small minority of participants. In fact, decades of research in this area consistently demonstrate almost identical outcomes: short-term weight loss during the program, followed by weight regain when the program ends. The article authors acknowledge this in their opening paragraph, saying:
“Weight loss interventions have generally been unsuccessful in achieving sustained weight loss.”
And in case you were wondering about weight loss at the workplace – one of the most common of all employee wellness initiatives – Dr. Dee Edington perhaps said it best:
“Weight loss money is money down the toilet.”
- Incentives for Behavior Change. Like weight-loss programs, incentives often result in short-term change but rarely result in long-term success. This is true for a wide variety of applications and is certainly true in the area of health-behavior change.
Using incentives for behavior change has its roots in the mid-20th century work of B.F. Skinner. Skinner believed all human actions were merely “repertoires of behaviors” that could be fully explained by the environmental consequences that followed them. He saw humans as mindless machines simply responding to their environment claiming that:
“There is no place in the scientific analysis of behavior for a mind or a self.”
According to Skinner, we answer the telephone when it rings because someone on the other end (hopefully not a telemarketer) answers. Theoretically, if we responded to the ringing phone enough times without someone answering, we would eventually stop doing so. Although this makes intuitive sense, Skinner went way beyond this, concluding that all human behaviors were so determined. His take on love, for example, is that when two people meet:
“One of them is nice to the other and predisposes the other to be nice to him, and that makes him even more likely to be nice. It goes back and forth, and it may reach the point at which they are very highly disposed to do nice things to the other and not to hurt. And I suppose that is what would be called being in love.”
Pretty romantic, don’t you think? Anyway, to make a long story short, the Skinnerian behavioral approach to motivation (extrinsic rewards and punishments) is ubiquitous in our culture and rarely questioned in spite of the fact that decades of studies have convincingly demonstrated that it does not work for most people in most situations.
Additionally, the research strongly suggests that extrinsic motivation leads to a number of unwanted, negative consequences, not the least of which is a decrease in intrinsic motivation (see “Punished By Rewards” byAlfie Kohn). This conclusion holds true for health behavior change – as multiple studies with weight loss, smoking cessation, seat-belt use, etc., have demonstrated (see Robison, “To Reward?…Or Not To Reward?: Questioning the Wisdom of Using External Reinforcement in Health Promotion Programs,” and “Drive: The Surprising Truth about What Motivates Us,” by Daniel Pink).
Let’s get back to the 2011 research study; a 32-week, randomized, controlled trial of the use of financial incentives for extended weight loss. Here are the details:
- 66 men between the ages of 30 and 70, with BMIs from 30-40, from a VA hospital, were assigned to one of three groups (22 in each group).
- Subjects in the two experimental groups met with a dietitian and put up money (matched by the program) that they could then win or lose based on their self-report of whether they met their weight-loss goals (1 pound per week) over the course of the next 24 weeks.
- One of the experimental groups was told that weeks 24 through 32 constituted a maintenance period, while the other was not told this.
- The control group met with a dietitian and received no incentives, but was followed for the same period of time.
- The main measure was weight loss at 32 weeks. As a secondary measure, weight loss was again assessed 36 weeks after the initial 32 weeks.
And the results:
- Over the course of the first 32 weeks, subjects in the two experimental groups lost an average of about 8 or 9 pounds, as compared to the control group’s 1 pound average loss.
- At the end of the “maintenance period” (additional 36 weeks), “participants regained weight post-intervention” and there was “no difference between the incentive and control groups.”
These results are not the least bit surprising given the decades of research and hundreds of studies that have reached precisely the same conclusions. Of course, as is almost always the case with health-promotion interventions, iatrogenic consequences (problems caused by the intervention) were not assessed.
So, what lessons can we take from this study and decades of eerily similar findings? Both weight loss interventions and incentives work in the short term for many and in the long term for very few. Did we really need one more study to tell us this? Apparently we did and somehow evidently we still do. Here are the authors’ conclusions:
“This is the first study to demonstrate that deposit contract incentives can successfully help keep off weight for 32 weeks… however, participants regained weight post-intervention.”
“Future research is needed to devise techniques that promote sustained weight loss over longer periods of time.”
How many more times do we have to subject people to the humiliating and health-compromising consequences of weight cycling that always results from these interventions before we realize that:
“Insanity is doing the same things over and over again and expecting different results.”