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Adding financial incentives to meal replacement therapy for teens with severe obesity helped improve weight and body fat, although not cardiometabolic risk factors, a randomized clinical trial found.

After adjusting for insurance type and baseline body mass index (BMI), the combined approach reduced mean BMI by 5.9 percentage points (95% CI -9.9 to -1.9, P=0.004) more than did meal replacement alone at 52 weeks, reported Amy Gross, PhD, of the University of Minnesota in Minneapolis, and colleagues.

Adjusted reduction in total body fat mass was greater by 4.8 kg (10.6 lb, P=0.03) with financial incentives, the researchers noted in .

However, no significant differences were observed between the groups in the change in cardiometabolic risk factors, including blood pressure, triglyceride to high density lipoprotein cholesterol ratio, heart rate variability, or arterial stiffness.

For the some 8% of U.S. youth who have severe obesity, Gross and colleagues noted, "traditional lifestyle modification therapies alone are often ineffective for providing meaningful and durable reduction of excess adiposity."

Meal replacement therapy was previously shown to be effective in adolescents, and financial incentives improve health behaviors and are acceptable to parents and teenagers. Thus, "combining these approaches in adolescents with severe obesity may promote enhanced treatment outcomes," the researchers wrote.

For their study, 126 adolescents ages 13 to 17 were provided prepared meals consisting of approximately 1,200 kilocalories per day. The teens were instructed to eat only the provided meals, which were free of charge and delivered to their homes.

Participants were evenly randomized between the treatment groups. The financial incentive group got a $20 gift card for every 0.5% reduction in body weight from baseline. The payments were made to participants at 2, 4, 6, 8, 10, and 12 months, and the mean total payment over 52 weeks in the combined group was $330.77.

"Sustained weight loss is unbelievably difficult," Aaron Carroll, MD, of AcademyHealth in Washington, D.C., wrote in an accompanying the study in JAMA Pediatrics. "It's so hard that even providing people with their food, already prepared and for free -- for a year! -- doesn't work. These enterprising researchers, refusing to give up, decided to pay teenagers on top of that."

"If there were no other option, I might understand," Carroll wrote. However, "[t]here are other options today," he continued, pointing to new drugs like semaglutide (Wegovy) and tirzepatide (Zepbound).

"Behavioral interventions keep getting more and more complicated because they don't work well, except in extreme circumstances, and often in ways that defy implementation," Carroll concluded. "Maybe it's time to stop focusing on them."

The study was conducted at a large academic health center in the Midwest from 2018 to 2022. Participants had severe obesity -- the mean BMI was 40.6 -- and 89 participants completed the 52-week visit.

Nearly 58% of participants were female, and their mean age was 15.3 years. Among participants with race data, 83 were white, 19 Black, 15 multiracial, and three American Indian. Among participants with ethnicity data, 14 were Hispanic.

Adding financial incentives to meal replacement therapy was cost-effective over 1 year, with an incremental cost-effectiveness ratio of $39,178 per quality-adjusted life year compared with meal replacement alone, Gross and colleagues reported.

There was no significant difference between groups in quality of life at 52 weeks or endorsement of unhealthy weight-control behaviors, such as laxative use or vomiting.

Limitations of the study included the possibility that, even though the study was blinded, participants could have learned about financial incentives through communication with non-study personnel, Gross and colleagues noted.

Additionally, all participants, regardless of group, were reimbursed for completing study visit assessments at a rate of up to $700 ($100 for each of the seven in-person visits). Gross and colleagues noted that this reimbursement was intended to mitigate potential burden but could have led to an underestimation of the financial incentive effect.

Furthermore, there was a lack of adherence data, and it is believed that the study's conduct during the pandemic led to a higher than expected attrition of about 30%, they noted.

Finally, the cost-effectiveness analysis did not include other interventions, such as anti-obesity medications or metabolic or bariatric surgery, they added.

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