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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
  1. Melanie Jay1,
  2. Stephanie L Orstad2,
  3. Soma Wali3,
  4. Judith Wylie-Rosett4,
  5. Chi-Hong Tseng5,
  6. Victoria Sweat2,
  7. Sandra Wittleder2,
  8. Suzanne B Shu6,
  9. Noah J Goldstein6,
  10. Joseph A Ladapo5
  1. 1 Departments of Medicine and Population Health, New York University School of Medicine, New York, New York, USA
  2. 2 Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, New York, USA
  3. 3 Department of Medicine, Olive View–University of California Los Angeles (UCLA) Medical Center, Sylmar, California, USA
  4. 4 Division of Health Promotion and Nutrition Research, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
  5. 5 Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
  6. 6 Anderson School of Management at UCLA, University of California Los Angeles, Los Angeles, California, USA
  1. Correspondence to Dr Joseph A Ladapo; jladapo{at}


Introduction Obesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals’ utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual’s skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone.

Methods and analysis We are recruiting 795 adults, aged 18–70 years with a body mass index ≥30 kg/m2, from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months.

Ethics and dissemination Human research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View–UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders.

Trial registration number NCT03157713.

  • behavioral economics
  • behavioral intervention
  • BMI
  • cost-effectiveness
  • health behavior change
  • health disparities
  • quality of life
  • overweight
  • physical activity
  • self-monitoring

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  • MJ and SLO contributed equally.

  • Contributors JAL and MJ initiated collaboration, conceived of and obtained funding for the project. JW-R, SBS and NJG helped with study design. JAL, MJ, SLO, C-HT, SW, JW-R, SBS and NJG developed the survey and data collection tools. C-HT and JAL devised the statistical analysis plan, and SLO and C-HT monitor data collection. MJ and SLO developed the conceptual model. SLO developed intervention materials and protocols. SLO is managing the project day to day and supervising staff. MJ, SLO, and VS administer the trial in New York City, and SW administers the trial in LA County. SLO, JAL and MJ drafted and revised the paper. All coauthors contributed to the conception and/or design of the work and critically reviewed and approved the final manuscript.

  • Funding This research is supported by the US Department of Health and Human Services National Institute of Minority Health and Health Disparities grant number R01MD011544. This research is supported in part by the NYU CTSA grant number UL1TR001445 from the National Center for Advancing Translational Sciences, NIH.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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