Obesity is a widespread health concern, affecting a significant portion of the population. According to the most recent data from the National Health and Nutrition Examination Survey (NHANES) and the American Heart Association 2025 Heart Disease and Stroke Statistics Update, approximately 71% of adults and 40% of children and adolescents in the United States are considered overweight or obese. Recognizing the severity of this issue, healthcare providers and researchers are actively engaged in developing innovative strategies to combat obesity and its associated health risks.
This article delves into Madison Payne's inspiring weight loss story, highlighting the challenges she faced and the support system that helped her achieve her health goals. Furthermore, it explores the broader context of obesity research and intervention strategies, including the use of financial incentives to promote adherence to behavioral weight loss programs.
Overcoming Health Challenges: Aiden's Story
Before delving into Madison's journey, it's important to acknowledge that weight management is not always a simple matter of choice. In some cases, underlying medical conditions can contribute to weight gain or make it more difficult to lose weight. Aiden Downey's story exemplifies this.
Aiden was diagnosed with a metabolic liver condition, which impacted his weight. As part of his treatment, he enrolled at the Healthy Weight and Wellness Clinic at Nemours Children’s Hospital, Delaware. This multidisciplinary clinic provided him with the support and guidance he needed to improve his health and well-being.
Now 13, Aiden is proud of the lifestyle changes he’s made working with the clinic. He’s increased his physical activity and added healthy foods to a balanced diet that still includes some teen favorites.
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Madison's Transformation: A Teen's Journey to Wellness
Madison Payne's weight loss journey is a testament to the power of support, motivation, and a structured approach to healthy living. With the guidance of the Nemours Healthy Weight and Wellness Clinic, Madison embarked on a path towards improved health and well-being.
The Importance of Structure and Accountability
“Knowing that she had an appointment every week, healthy choices became a priority,” said Madison’s dad, Mike Payne. This highlights the significance of regular check-ins and accountability in maintaining motivation and adherence to a weight loss plan.
Building a Supportive Community
Over time, Madison became friendly with other teens in the program. This camaraderie fostered a sense of community and provided a platform for sharing experiences and encouragement. In the spring, friends and family members would meet up at the Nemours Estate to walk together, guided by a Nemours exercise physiologist. This demonstrates the importance of social support in promoting physical activity and overall well-being.
The Power of Shared Experiences
Thao-Ly Phan, MD, MPH, Senior Research Scientist with the Center for Healthcare Delivery Science and Medical Director of the Healthy Weight and Wellness Clinic, both located at Nemours Children’s Hospital, Delaware, praised the teens and caregivers for sharing their experiences as part of the symposium and supporting each other in their health goals. “Understanding the lived experiences of families is critical to conducting research that is meaningful,” she said.
Innovative Approaches to Obesity Prevention and Treatment
Both Jefferson and Nemours Children’s are engaged in innovative studies in the field of obesity and diabetes prevention. These research endeavors aim to identify effective strategies for preventing and treating obesity, particularly among vulnerable populations.
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Addressing Social Determinants of Health
At Nemours, Carissa Baker-Smith, MD, MS, MPH, Director of Pediatric Preventive Cardiology Program and Codirector, Nemours Center for Cardiovascular Research and Innovation, investigates the way social drivers of health affect a child’s risk of developing heart disease. This research recognizes that factors such as socioeconomic status, access to healthy food, and neighborhood safety can significantly impact a child's health outcomes.
Group Sessions for Weight Loss
At Jefferson, Amy Cunningham, PhD, MPH, has just launched a four-year study funded by the Patient-Centered Outcomes Research Institute (PCORI), aimed at examining the effectiveness of group sessions to help patients lose weight. Cunningham explained that the program will be run by advanced-practice clinicians with a mix of virtual and in-person visits. This study explores the potential benefits of group support and guidance in promoting weight loss and behavior change.
Financial Incentives: A Tool for Improving Adherence
Recognizing that adherence to behavioral weight loss interventions can be challenging, researchers have explored the use of financial incentives to motivate individuals and improve their outcomes. Operant conditioning principles suggest that rewarding desired behaviors can increase their likelihood of being repeated.
Designing Effective Incentive Programs
In designing financial incentive programs, one issue is whether to use positive or negative reinforcement. The two typically have not been compared head-to-head. Most RCTs have used negative reinforcement, where nonadherent participants lose money [22, 25, 29, 30]. One significant drawback to negative reinforcement is that individuals with lower incomes may be unable to “buy into” such programs or may suffer disproportionately if they enroll but fail to lose weight. Thus, positive-reinforcement programs may be preferable.
A second design issue concerns incentive type. Earlier RCTs involving positive reinforcement used gifts or lotteries as incentives [31-33]. These incentive types are limited because gifts are differentially valued and lotteries do not guarantee a reward. Money may be preferred because it can be exchanged for valued goods and services.
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A third design issue-and one that is being investigated in this study-is whether to incentivize the desired clinical outcome of weight loss or a behavioral skill that supports weight loss. Dietary self-monitoring is one of the strongest predictors of initial weight loss and subsequent weight loss maintenance [34]. Incenting weight loss alone may not ensure that dietary self-monitoring will be learned because less enduring behavioral strategies, such as extreme caloric restriction, might be used. Similarly, incenting dietary self-monitoring alone may not ensure that sufficient weight loss will be achieved, as people may exceed caloric or macronutrient recommendations even as they record their intake. We anticipate that incentivizing both initial weight loss and dietary self-monitoring will yield better initial weight loss than incentivizing just one.
A Pilot Study: Evaluating Feasibility and Acceptability
In preparation for an adequately powered RCT to evaluate the effectiveness of various incentive strategies for improving short- and long-term weight loss, we conducted a Phase IIb randomized pilot study per the Obesity-Related Behavioral Intervention Trials (ORBIT) model of intervention development [40]. The goals of this pilot were to: (a) assess the feasibility and acceptability of the trial protocol, as assessed by screening-to-enrollment ratio, dropout, and retention rates for all conditions and postqualitative interviews, and (b) seek evidence of a clinically significant signal over noise, indicated by weight loss in the intervention conditions compared to control condition and nondifferential dropout in the control condition.
Participants were randomized in a 2 × 2 factorial design to receive financial incentives for both dietary self-monitoring and weekly weight loss, just one, or neither. We conducted this study in three successive cohorts to evaluate study procedure changes. In each cohort, four weight loss groups were created, one corresponding to each condition. Also, in each cohort, participants in all four conditions received the same 24 week, group-based weight loss program; the only difference between conditions was the incentive structure: Participants could earn incentives for both dietary self-monitoring and weekly weight loss, just one, or neither.
Optimizing Recruitment, Retention, and Text Messaging
Through successive cohorts, we optimized recruitment and retention strategies and text messaging. An adequately powered trial is warranted to evaluate the efficacy of these incentive structures for reducing weight.
The Importance of Dietary Self-Monitoring
Dietary self-monitoring is one of the strongest predictors of initial weight loss and subsequent weight loss maintenance [34]. By tracking their food intake, individuals become more aware of their eating habits and can make informed choices to support their weight loss goals.
Overcoming Barriers to Weight Loss
Obesity rates and intervention outcomes can vary by race/ethnicity. Black and Latinx American adults have higher rates of obesity than non-Hispanic White adults [7] and tend to be underrepresented in weight loss studies, engage in fewer weight loss behaviors [8, 9], have lower rates of intervention adherence, and experience lower average weight loss [9-11]. For these reasons, it is important to ensure the representation of these racial/ethnic minority groups in weight loss studies.
The Role of Operant Conditioning
Operant conditioning refers to the process of learning voluntary behavior. Operant conditioning is rooted in Edward Thorndike’s Law of Effect, which states that behavior is altered in strength by its consequences [12, 13]. Thus, if an action is followed by a desired outcome, then the likelihood of that behavior being repeated increases; in contrast, if an action produces an undesirable outcome, then the likelihood of it being repeated decreases. Operant conditioning can occur via reinforcement (establishing a behavior pattern) or punishment (reducing a behavior pattern) [14]. Both reinforcement and punishment may be positive (provision of a stimulus) or negative (removal of a stimulus).
Reinforcement Schedules
Reinforcement (and punishment) may be delivered on different types of schedules. A continuous reinforcement schedule involves the provision of a reward after every performance of the desired behavior. In contrast, an intermittent schedule involves the provision of a reward after either a certain number of responses (ratio interval) or a certain amount of time (interval ratio). Intermittent schedules can be characterized as either fixed (delivered after every n responses or time) or variable (delivered after a mean of n responses or time). Following the withdrawal of a reinforcer, the response rate typically declines, a process referred to as extinction.
The Timing of Reinforcement
In addition to quality/quantity, reinforcement timing is critical. Humans can perceive a contingent relationship between a desired response and a delayed reward. Yet, across populations and reward types, the further the reward is provided from the occurrence of the desired response, the less its perceived present value [16]. For example, when people are presented with the option of receiving a small amount of money immediately versus a large amount later, they tend to prefer the smaller, immediate reward [17].
Applying Operant Conditioning to Health Behavior
Researchers have applied these principles to shape human health behavior. For example, researchers have tested whether the provision of financial incentives in the form of cash or material items increases smoking cessation [19], abstinence from alcohol or illicit substances [20], and medication adherence [21]. These applications have involved the comparison of reinforcement schedules (e.g., a guaranteed reward for achieving the desired outcome [fixed ratio] vs. the chance of receiving a reward via lottery [variable ratio]), positive versus negative reinforcement (e.g., receiving money vs. having money taken away via a deposit contract or payroll deduction [22]), amount and type of incentive [23], and whether rewards are contingent on individual versus group performance [24, 25].
Weight Loss Programs: Key Components
The principles of operant conditioning have been applied to improve short-term and long-term weight loss in research studies and implemented in real-world programs. For example, employers and payers have offered financial incentives of various forms (e.g., vouchers for goods and insurance premium discounts) for weight loss [26-28].
Dietary Approaches: Low-Carbohydrate vs. Low-Fat
One goal of this pilot study was to determine the optimal dietary approach for a future RCT. We considered both a low-carbohydrate diet (LCD) and a reduced fat and calorie diet (or low-fat diet, LFD) because RCTs have shown similar 24 month outcomes for each [44]. We prescribed an LCD in two cohorts and an LFD in the other. For the LCD, carbohydrate intake was restricted to 20 g/day, but there was no caloric prescription [45]. For the LFD, total fat intake was restricted to less than 30% of daily energy intake, and saturated fat was restricted to less than 10% of daily energy intake. We provided each LFD participant with an individualized calorie budget, which we calculated by subtracting 500 calories per day from the maintenance energy requirement using sex and weight obtained at the screening visit.
The Importance of Group Support
We delivered the incentives intervention alongside a standard, 24 week weight loss program that is delivered in groups in person [43]. We use a highly efficacious weight loss program so that any lack of effect of incentives on weight loss could be attributed minimally to the weight loss program. The program involved biweekly group sessions that lasted 1-1.5 hr. Each group met on the same day of the week and at the same time of the day.
Utilizing Technology for Dietary Monitoring
Regardless of the dietary approach, all participants were asked to enter all food and liquid intake into MyFitnessPal. At the first meeting, staff provided participants with a lay press diet book (corresponding to LCD [46] or LFD [47]), handouts developed in a previous weight management RCT [48], and a BodyTrace scale. Participants downloaded the MyFitnessPal mobile phone app to their smartphones and set up accounts (with assistance if needed).
Real-Time Feedback and Incentives
We overcome these limitations by incentivizing weekly weight loss and providing incentives in near real time. To do so, we utilized a software solution that collates data from a dietary smartphone application (app) and a cellular body weight scale [38, 39]. The software includes preprogrammed algorithms that analyze the data each week to determine whether participants meet the criteria to receive a financial incentive.