Money? Gadgets? Incentivizing Healthy Behaviors Questioned Once Again

The use of fitness trackers to aid in weight loss efforts has taken another hit in a new study that also tested the effects of financial and charitable incentives.

Wearable step counters have been popular in recent years for the everyday consumer curious about how many miles they walk in a given day, but recent research has shown they have limited influence on weight loss and overall cardiovascular health.

“I think about fitness trackers the same way I think about weighing scales,” lead author of the TRIPPA study, Eric Finkelstein, PhD (Duke-NUS Medical School, Singapore), told TCTMD. “To me they are a measurement tool that tells you something about how much you walk or how much you weigh, but they are not an intervention. So just getting on a scale to me is not going to get people to weigh less just like knowing how many steps you take in a day does not get you to take more steps—it just quantifies what you probably already know.”

With the original hypothesis that adding an activity tracker to a weight-loss program would not improve outcomes, Finkelstein explained that his team also wanted to test whether financial incentives in combination might have a larger effect. For 6 months, they randomized 800 participants employed by 13 companies in Singapore to one of four groups:

• Control (n = 201): received information about physical activity and S$4 (about $3 USD) per week
• Activity Tracker (n = 203): received a FitBit Zip and S$4 (about $3 USD) per week
• Cash (n = 197) or charity (n = 199) incentive: received a FitBit Zip and S$15 (about $11 USD) for every week that they logged between 50,000 and 70,000 steps, or about S$30 (about $22 USD) for every week they logged more than 70,000 steps to keep or donate to a charity of their choice

After 6 months, the incentives stopped, and all participants were followed through a year. Their results, published online October 4, 2016, ahead of print in The Lancet: Diabetes & Endocrinology, show that the cash incentive was the most effective method of increasing the amount of moderate-to-vigorous physical activity of the participants. At 6 months, this group reported an average of 29 additional minutes per week compared with controls (P = 0.0024), while the charity and activity tracker groups reported 21 (P = 0.0310) and 16 (P = 0.0854) more minutes, respectively.

But as soon as the cash incentives disappeared, so did their effects. At 12 months, those in the activity tracker and charity groups recorded an additional 37 (P = 0.0001) and 32 minutes (P = 0.0013) of moderate-to-vigorous physical activity per week compared with controls. Still, there were no improvements in any health outcomes—including weight and blood pressure—at any time point for any group.

More ‘Multifaceted’ Interventions Needed

The biggest takeaway from the study, according to Finkelstein, is “don’t assume that you can give out a bunch of FitBits and suddenly people will become healthier. . . . You need to do something more of an intervention that is more multifaceted.”

Step trackers “might be part of a more comprehensive solution, but they are certainly not sufficient on their own,” he continued. Another limitation is that most of the steps participants were taking were considered “light steps, not the kind that really get your heart rate elevated,” Finkelstein explained. “If you really want to get people healthier, we should incentivize active steps or active minutes because those are the ones that really lead to health outcomes.”

Additionally, his experience in health economics has shown that incentives work to make people respond in “predictable ways,” Finkelstein said. Another recent study using cash incentives to successfully motivate smokers to quit supported this theory. “But the problem with cash incentives is that employers just don’t really want to spend the money,” he added.

“When it comes to incentives, we are not quite at a point where we can give good recommendations,” Finkelstein said. Future studies should “try incentivizing aerobic steps or minutes” and work toward pinpointing the ideal candidate who would have actual health benefits from wearing an activity tracker, he suggested.

In an accompanying editorial, Courtney Monroe, PhD (University of South Carolina, Columbia), writes that “the fact that the removal of cash incentives resulted in a substantial reduction in both intervention engagement and physical activity in Finkelstein and colleagues’ study brings into focus a potential issue related to financial incentives and motivation to be physically active. That is, cash incentives are an extrinsic motivator, and their removal might undermine or stifle the chance to develop intrinsic motivation, which is a strong predictor of physical activity adherence.”

While the TRIPPA study did not measure motivation, she noted, future studies should do so in order to “examine how different aspects of these approaches (eg, incentive distribution patterns, reward intervals, and incentive amount) can be manipulated to positively affect intrinsic motivation and physical activity in a cost-effective manner.”

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