A Pragmatic Intervention Using Financial Incentives for Pregnancy Weight Management: Feasibility Randomized Controlled Trial

Rebecca Krukowski, Brandi Johnson, Hyeonju Kim, Saunak Sen, Riad Homsi, Rebecca Krukowski, Brandi Johnson, Hyeonju Kim, Saunak Sen, Riad Homsi

Abstract

Background: Excessive gestational weight gain (GWG) is common and can result in maternal and child health complications. Pragmatic behavioral interventions that can be incorporated into standard obstetric care are needed, and financial incentives are a promising approach.

Objective: The aim of this study is to evaluate the feasibility of recruitment, randomization, and retention, as well as treatment engagement and intervention satisfaction, in a behavioral program. The program provided small incentives for meeting behavioral goals of self-weighing and physical activity as well as larger outcome incentives for meeting GWG goals.

Methods: We recruited 40 adult women in their first trimester of pregnancy from February 2019 to September 2019 at an obstetric clinic. Participants were randomized to 3 intervention components using a 2×2×2 factorial design: daily incentives for self-weighing (lottery vs certain loss), incentives for adhering to the Institute of Medicine's GWG guidelines based on BMI category (monthly vs overall), and incentives for reaching physical activity goals (yes vs no). Participants were asked to complete daily weigh-ins using the Withings Body wireless scale provided by the study, as well as wear a physical activity tracker (Fitbit Flex 2). Feasibility outcomes of recruitment, randomization, and retention, as well as treatment engagement and intervention satisfaction, were assessed. Weight assessments were conducted at baseline, 32-week gestation, and 36-week gestation.

Results: Participants were enrolled at, on average, 9.6 (SD 1.8) weeks' gestation. Of the 39 participants who were oriented to their condition and received the intervention, 24 (62%) were Black or African American, 30 (77%) were not married, and 29 (74%) had an annual household income of less than US $50,000. Of the 39 participants, 35 (90%) completed the follow-up data collection visit. Participants were generally quite positive about the intervention components, with a particular emphasis on the helpfulness of, and the enjoyment of using, the e-scale in both the quantitative and qualitative feedback. Participants who received the loss incentive, on average, had 2.86 times as many days of self-weighing as those who received the lottery incentive. Participants had a relatively low level of activity, with no difference between those who received a physical activity incentive and those who did not.

Conclusions: A financial incentive-based pragmatic intervention was feasible and acceptable for pregnant women for promoting self-weighing, physical activity, and healthy GWG. Participants were successfully recruited early in their first trimester of pregnancy and retained for follow-up data collection in the third trimester. Participants demonstrated promising engagement in self-weighing, particularly with loss-based incentives, and reported finding the self-weighing especially helpful. This study supports further investigation of pragmatic, clinic-based financial incentive-based interventions for healthy GWG behaviors.

Trial registration: ClinicalTrials.gov NCT03834194; https://ichgcp.net/clinical-trials-registry/NCT03834194.

Keywords: physical activity; pregnancy; self-weighing; weight.

Conflict of interest statement

Conflicts of Interest: None declared.

©Rebecca Krukowski, Brandi Johnson, Hyeonju Kim, Saunak Sen, Riad Homsi. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.12.2021.

References

    1. Macdonald-Wallis C, Tilling K, Fraser A, Nelson SM, Lawlor DA. Gestational weight gain as a risk factor for hypertensive disorders of pregnancy. Am J Obstet Gynecol. 2013 Oct;209(4):327.e1–17. doi: 10.1016/j.ajog.2013.05.042. S0002-9378(13)00531-0
    1. Brunner S, Stecher L, Ziebarth S, Nehring I, Rifas-Shiman SL, Sommer C, Hauner H, von Kries R. Excessive gestational weight gain prior to glucose screening and the risk of gestational diabetes: a meta-analysis. Diabetologia. 2015 Oct;58(10):2229–37. doi: 10.1007/s00125-015-3686-5.10.1007/s00125-015-3686-5
    1. Thorsdottir I, Torfadottir JE, Birgisdottir BE, Geirsson RT. Weight gain in women of normal weight before pregnancy: complications in pregnancy or delivery and birth outcome. Obstet Gynecol. 2002 May;99(5 Pt 1):799–806. doi: 10.1016/s0029-7844(02)01946-4.S0029784402019464
    1. Stotland NE, Cheng YW, Hopkins LM, Caughey AB. Gestational weight gain and adverse neonatal outcome among term infants. Obstet Gynecol. 2006 Sep;108(3 Pt 1):635–43. doi: 10.1097/01.AOG.0000228960.16678.bd.108/3/635
    1. Phelan S. Pregnancy: a "teachable moment" for weight control and obesity prevention. Am J Obstet Gynecol. 2010 Feb;202(2):135.e1–8. doi: 10.1016/j.ajog.2009.06.008. S0002-9378(09)00628-0
    1. Mamun A, Kinarivala M, O'Callaghan MJ, Williams GM, Najman JM, Callaway LK. Associations of excess weight gain during pregnancy with long-term maternal overweight and obesity: evidence from 21 y postpartum follow-up. Am J Clin Nutr. 2010 May;91(5):1336–41. doi: 10.3945/ajcn.2009.28950.ajcn.2009.28950
    1. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington: National Academies Press; 2009.
    1. Hu Z, Tylavsky FA, Han JC, Kocak M, Fowke JH, Davis RL, Lewinn K, Bush NR, Zhao Q. Maternal metabolic factors during pregnancy predict early childhood growth trajectories and obesity risk: the CANDLE Study. Int J Obes (Lond) 2019 Oct;43(10):1914–22. doi: 10.1038/s41366-019-0326-z. 10.1038/s41366-019-0326-z
    1. Liao X, Yu Y, Marc I, Dubois L, Abdelouahab N, Bouchard L, Wu Y, Ouyang F, Huang H, Fraser WD. Prenatal determinants of childhood obesity: a review of risk factors. Can J Physiol Pharmacol. 2019 Mar;97(3):147–54. doi: 10.1139/cjpp-2018-0403.
    1. Deputy NP, Sharma AJ, Kim SY. Gestational Weight Gain - United States, 2012 and 2013. MMWR Morb Mortal Wkly Rep. 2015 Nov 06;64(43):1215–20. doi: 10.15585/mmwr.mm6443a3. doi: 10.15585/mmwr.mm6443a3.
    1. Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry. 1994 Jul;51(7):568–76. doi: 10.1001/archpsyc.1994.03950070060011.
    1. Pope L, Harvey-Berino J. Burn and earn: a randomized controlled trial incentivizing exercise during fall semester for college first-year students. Prev Med. 2013 Mar;56(3-4):197–201. doi: 10.1016/j.ypmed.2012.12.020.S0091-7435(12)00637-8
    1. Mitchell MS, Goodman JM, Alter DA, John LK, Oh PI, Pakosh MT, Faulkner GE. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med. 2013 Nov;45(5):658–67. doi: 10.1016/j.amepre.2013.06.017.S0749-3797(13)00436-4
    1. Strohacker K, Galarraga O, Williams DM. The impact of incentives on exercise behavior: a systematic review of randomized controlled trials. Ann Behav Med. 2014 Aug;48(1):92–9. doi: 10.1007/s12160-013-9577-4.
    1. Jeffery RW. Financial incentives and weight control. Prev Med. 2012 Nov;55 Suppl:S61–7. doi: 10.1016/j.ypmed.2011.12.024. S0091-7435(11)00526-3
    1. West DS, Krukowski RA, Finkelstein EA, Stansbury ML, Ogden DE, Monroe CM, Carpenter CA, Naud S, Harvey JR. Adding financial incentives to online group-based behavioral weight control: an RCT. Am J Prev Med. 2020 Aug;59(2):237–46. doi: 10.1016/j.amepre.2020.03.015. S0749-3797(20)30158-6
    1. Kullgren JT, Troxel AB, Loewenstein G, Asch DA, Norton LA, Wesby L, Tao Y, Zhu J, Volpp KG. Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial. Ann Intern Med. 2013 Apr 02;158(7):505–14. doi: 10.7326/0003-4819-158-7-201304020-00002. 1671710
    1. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA. 2008 Dec 10;300(22):2631–7. doi: 10.1001/jama.2008.804. 300/22/2631
    1. Finkelstein EA, Linnan LA, Tate DF, Birken BE. A pilot study testing the effect of different levels of financial incentives on weight loss among overweight employees. J Occup Environ Med. 2007 Sep;49(9):981–9. doi: 10.1097/JOM.0b013e31813c6dcb.00043764-200709000-00008
    1. Wilson SM, Newins AR, Medenblik AM, Kimbrel NA, Dedert EA, Hicks TA, Neal LC, Beckham JC, Calhoun PS. Contingency management versus psychotherapy for prenatal smoking cessation: a meta-analysis of randomized controlled trials. Womens Health Issues. 2018;28(6):514–23. doi: 10.1016/j.whi.2018.05.002. S1049-3867(17)30655-2
    1. Higgins ST, Washio Y, Heil SH, Solomon LJ, Gaalema DE, Higgins TM, Bernstein IM. Financial incentives for smoking cessation among pregnant and newly postpartum women. Prev Med. 2012 Nov;55 Suppl:S33–40. doi: 10.1016/j.ypmed.2011.12.016. S0091-7435(11)00514-7
    1. Phillips JK, Skelly JM, Roberts LM, Bernstein IM, Higgins ST. Combined financial incentives and behavioral weight management to enhance adherence with gestational weight gain guidelines: a randomized controlled trial. Am J Obstet Gynecol MFM. 2019 Mar;1(1):42–9. doi: 10.1016/j.ajogmf.2019.02.002.S2589-9333(19)30004-7
    1. Paul-Ebhohimhen V, Avenell A. Systematic review of the use of financial incentives in treatments for obesity and overweight. Obes Rev. 2008 Jul;9(4):355–67. doi: 10.1111/j.1467-789X.2007.00409.x.OBR409
    1. Volpp KG, Asch DA, Galvin R, Loewenstein G. Redesigning employee health incentives--lessons from behavioral economics. N Engl J Med. 2011 Aug 04;365(5):388–90. doi: 10.1056/NEJMp1105966.
    1. Phelan S, Jankovitz K, Hagobian T, Abrams B. Reducing excessive gestational weight gain: lessons from the weight control literature and avenues for future research. Womens Health (Lond) 2011 Nov;7(6):641–61. doi: 10.2217/whe.11.70.
    1. Zheng Y, Klem ML, Sereika SM, Danford CA, Ewing LJ, Burke LE. Self-weighing in weight management: a systematic literature review. Obesity (Silver Spring) 2015 Feb;23(2):256–65. doi: 10.1002/oby.20946. doi: 10.1002/oby.20946.
    1. Lombard C, Harrison C, Kozica S, Zoungas S, Ranasinha S, Teede H. Preventing weight gain in women in rural communities: a cluster randomised controlled trial. PLoS Med. 2016 Jan;13(1):e1001941. doi: 10.1371/journal.pmed.1001941. PMEDICINE-D-15-01731
    1. Vanwormer JJ, French SA, Pereira MA, Welsh EM. The impact of regular self-weighing on weight management: a systematic literature review. Int J Behav Nutr Phys Act. 2008 Nov 04;5:54. doi: 10.1186/1479-5868-5-54. 1479-5868-5-54
    1. Linde JA, Jeffery RW, French SA, Pronk NP, Boyle RG. Self-weighing in weight gain prevention and weight loss trials. Ann Behav Med. 2005 Dec;30(3):210–6. doi: 10.1207/s15324796abm3003_5.
    1. Shin DW, Yun JM, Shin J, Kwon H, Min HY, Joh H, Chung WJ, Park JH, Jung K, Cho B. Enhancing physical activity and reducing obesity through smartcare and financial incentives: a pilot randomized trial. Obesity (Silver Spring) 2017 Feb;25(2):302–10. doi: 10.1002/oby.21731.
    1. Ries A, Blackman L, Page R, Gizlice Z, Benedict S, Barnes K, Kelsey K, Carter-Edwards L. Goal setting for health behavior change: evidence from an obesity intervention for rural low-income women. Rural Remote Health. 2014;14:2682. 2682
    1. Jeffery R, Wing RR, Sherwood NE, Tate DF. Physical activity and weight loss: does prescribing higher physical activity goals improve outcome? Am J Clin Nutr. 2003 Oct;78(4):684–9. doi: 10.1093/ajcn/78.4.684.
    1. Brown MJ, Sinclair M, Liddle D, Hill AJ, Madden E, Stockdale J. A systematic review investigating healthy lifestyle interventions incorporating goal setting strategies for preventing excess gestational weight gain. PLoS One. 2012;7(7):e39503. doi: 10.1371/journal.pone.0039503. PONE-D-11-14987
    1. Volpp KG, Pauly MV, Loewenstein G, Bangsberg D. P4P4P: an agenda for research on pay-for-performance for patients. Health Aff (Millwood) 2009;28(1):206–14. doi: 10.1377/hlthaff.28.1.206. 28/1/206
    1. O'Donoghue T, Rabin M. The economics of immediate gratification. J Behav Decis Making. 2000 Apr;13(2):233–50. doi: 10.1002/(sici)1099-0771(200004/06)13:2<233::aid-bdm325>;2-u.
    1. Loewenstein G, Asch DA, Volpp KG. Behavioral economics holds potential to deliver better results for patients, insurers, and employers. Health Aff (Millwood) 2013 Jul;32(7):1244–50. doi: 10.1377/hlthaff.2012.1163.32/7/1244
    1. Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Framing financial incentives to increase physical activity among overweight and obese adults: a randomized, controlled trial. Ann Intern Med. 2016 Mar 15;164(6):385–94. doi: 10.7326/M15-1635. 2491916
    1. Leahey TM, Subak LL, Fava J, Schembri M, Thomas G, Xu X, Krupel K, Kent K, Boguszewski K, Kumar R, Weinberg B, Wing R. Benefits of adding small financial incentives or optional group meetings to a web-based statewide obesity initiative. Obesity (Silver Spring) 2015 Jan;23(1):70–6. doi: 10.1002/oby.20937. doi: 10.1002/oby.20937.
    1. Kanfer FH, Goldstein AP. Helping People Change: A Textbook of Methods. Oxford, United Kingdom: Pergamon Press; 1986.
    1. Gardner B, Wardle J, Poston L, Croker H. Changing diet and physical activity to reduce gestational weight gain: a meta-analysis. Obes Rev. 2011 Jul;12(7):e602–20. doi: 10.1111/j.1467-789X.2011.00884.x.
    1. Asch DA, Volpp KG. On the way to health. LDI Issue Brief. 2012;17(9):1–4.
    1. Sen AP, Sewell TB, Riley EB, Stearman B, Bellamy SL, Hu MF, Tao Y, Zhu J, Park JD, Loewenstein G, Asch DA, Volpp KG. Financial incentives for home-based health monitoring: a randomized controlled trial. J Gen Intern Med. 2014 May 13;29(5):770–7. doi: 10.1007/s11606-014-2778-0.
    1. Thaler RH, Tversky A, Kahneman D, Schwartz A. The effect of myopia and loss aversion on risk taking: an experimental test. Quarterly J Econ. 1997 May 01;112(2):647–61. doi: 10.1162/003355397555226.
    1. Committee on Obstetric Practice Committee Opinion No. 650 Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet Gynecol. 2015 Dec;126(6):e135–42. doi: 10.1097/aog.0000000000001214.
    1. Cadmus-Bertram L, Marcus BH, Patterson RE, Parker BA, Morey BL. Use of the Fitbit to measure adherence to a physical activity intervention among overweight or obese, postmenopausal women: self-monitoring trajectory during 16 weeks. JMIR Mhealth Uhealth. 2015 Nov 19;3(4):e96. doi: 10.2196/mhealth.4229. v3i4e96
    1. Oken E, Taveras EM, Kleinman KP, Rich-Edwards JW, Gillman MW. Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol. 2007 Apr;196(4):322.e1–8. doi: 10.1016/j.ajog.2006.11.027. S0002-9378(06)02399-4
    1. Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical research. J Psychiatr Res. 2011 May;45(5):626–9. doi: 10.1016/j.jpsychires.2010.10.008. S0022-3956(10)00292-X
    1. Collins L. Optimization of Behavioral, Biobehavioral, and Biomedical Interventions: The Multiphase Optimization Strategy (MOST) Cham: Springer; 2018.
    1. Harrison CL, Teede HJ, Lombard CB. How effective is self-weighing in the setting of a lifestyle intervention to reduce gestational weight gain and postpartum weight retention? Aust N Z J Obstet Gynaecol. 2014 Aug;54(4):382–5. doi: 10.1111/ajo.12207.
    1. Finkelstein EA, Tham K, Haaland BA, Sahasranaman A. Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) - A randomized controlled trial. Soc Sci Med. 2017 Jul;185:63–70. doi: 10.1016/j.socscimed.2017.05.030.S0277-9536(17)30331-3
    1. Giles EL, Becker F, Ternent L, Sniehotta FF, McColl E, Adams J. Acceptability of financial incentives for health behaviours: a discrete choice experiment. PLoS One. 2016;11(6):e0157403. doi: 10.1371/journal.pone.0157403. PONE-D-16-08129
    1. McGill B, O'Hara BJ, Grunseit AC, Bauman A, Osborne D, Lawler L, Phongsavan P. Acceptability of financial incentives for maintenance of weight loss in mid-older adults: a mixed methods study. BMC Public Health. 2018 Feb 13;18(1):244. doi: 10.1186/s12889-018-5136-z. 10.1186/s12889-018-5136-z
    1. Pereira MA, Rifas-Shiman SL, Kleinman KP, Rich-Edwards JW, Peterson KE, Gillman MW. Predictors of change in physical activity during and after pregnancy: project viva. Am J Prev Med. 2007 Apr;32(4):312–9. doi: 10.1016/j.amepre.2006.12.017. S0749-3797(06)00566-6
    1. Choi J, Fukuoka Y, Lee JH. The effects of physical activity and physical activity plus diet interventions on body weight in overweight or obese women who are pregnant or in postpartum: a systematic review and meta-analysis of randomized controlled trials. Prev Med. 2013 Jun;56(6):351–64. doi: 10.1016/j.ypmed.2013.02.021. S0091-7435(13)00066-2
    1. Krukowski RA, West D, DiCarlo M, Shankar K, Cleves MA, Tedford E, Andres A. A behavioral intervention to reduce excessive gestational weight gain. Matern Child Health J. 2017 Mar;21(3):485–91. doi: 10.1007/s10995-016-2127-5.10.1007/s10995-016-2127-5
    1. Chen MS, Lara PN, Dang JH, Paterniti DA, Kelly K. Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials. Cancer. 2014 Apr 01;120 Suppl 7:1091–6. doi: 10.1002/cncr.28575. doi: 10.1002/cncr.28575.
    1. Haughton CF, Silfee VJ, Wang ML, Lopez-Cepero AC, Estabrook DP, Frisard C, Rosal MC, Pagoto SL, Lemon SC. Racial/ethnic representation in lifestyle weight loss intervention studies in the United States: a systematic review. Prev Med Rep. 2018 Mar;9:131–7. doi: 10.1016/j.pmedr.2018.01.012. S2211-3355(18)30013-5
    1. Renjilian DA, Perri MG, Nezu AM, McKelvey WF, Shermer RL, Anton SD. Individual versus group therapy for obesity: effects of matching participants to their treatment preferences. J Consult Clin Psychol. 2001 Aug;69(4):717–21.
    1. Hill B, Skouteris H, Fuller-Tyszkiewicz M. Interventions designed to limit gestational weight gain: a systematic review of theory and meta-analysis of intervention components. Obes Rev. 2013 Jun;14(6):435–50. doi: 10.1111/obr.12022.
    1. Phelan S, Wing RR, Brannen A, McHugh A, Hagobian TA, Schaffner A, Jelalian E, Hart CN, Scholl TO, Munoz-Christian K, Yin E, Phipps MG, Keadle S, Abrams B. Randomized controlled clinical trial of behavioral lifestyle intervention with partial meal replacement to reduce excessive gestational weight gain. Am J Clin Nutr. 2018 Feb 01;107(2):183–94. doi: 10.1093/ajcn/nqx043. 4911447

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa