photo by Tobyotter
Academics have a new term for our fat-inducing society, with its vast portions and a push-button culture: “obesogenic.” Eight out of ten British men and seven out of ten women will be obese by 2020, according to a recent National Heart Forum report led by Klim McPherson at Oxford University. And the toll on public finances is growing in line with our girth: in England, obesity costs an estimated £4.2bn a year, or about 5 per cent of the English NHS budget. Some £2.3bn of this goes on treating obesity itself, the remainder is the cost of associated diseases such as diabetes, coronary heart disease, stroke and colorectal cancer. That figure will rise to £6.3bn by 2015 if no “effective action” is taken.
Decades of health information campaigns have failed to avert the crisis. Bariatric surgery (such as gastric bands), is the most effective long-term treatment, but it’s risky and expensive, costing over £5,000 per patient. Now, a controversial new strategy has arrived: paying fat people to lose weight. Such schemes are already well established in the US, and the first British trial has just finished in Kent.
“Nothing to date has been effective, so suddenly this idea is coming to prominence—in parallel with the rise of behavioural economics and the notion of incentivising people with money,” says Theresa Marteau of King’s College London, a leading authority on financial incentives and health. The concept is not only applicable to obesity. Harvard University is running a large trial offering rewards for school attendance. And in Britain, new laws have created financial rewards for installing green energy in homes and businesses.
But how much cash will it take to persuade the nation to lose weight? Winton Rossiter thinks he knows the answer. His private company Weight Wins has just finished administering the Kent trial—known as the Pounds for Pounds scheme—which was funded by the local primary care trust at a cost of £75,000.
The NHS pilot had 402 participants. Weight Wins is analysing this data, along with statistics from an additional 343 dieters who paid to join a private scheme, conducted nationwide over the internet. In the NHS trial, participants “earned” from £80 up to £425, while the maximum reward for the (still ongoing) private scheme is £3,000—for weight loss of over ten stone achieved and maintained over two years.
Three-quarters of participants dropped out of the NHS trial, but those who completed it lost more than 25lb on average. Rossiter enthuses that financial incentives are “the single best weapon that public health can use on the general obesity problem.” He points out that although the dropout rate was high, only 30 per cent of the dropouts failed to lose any weight.
But Claire Martin, acting assistant director of public health for the Kent trust, reported “mixed results” and says more research is needed. Peer-reviewed research evidence for financial incentives and weight loss is limited. A 2008 meta–analysis of nine trials in the US found that they didn’t help weight loss and maintenance after 12 to 18 months. Kevin Volpp, director of the University of Pennsylvania’s Centre for Health Incentives, says payments seem to work best for smoking and drug misuse rather than obesity, where initial loss is often regained. “There’s not enough evidence yet for the NHS to invest heavily in schemes,” he argues. But Joshua Price, of the University of Texas, Arlington, thinks they still hold potential. “We need to find the precise financial mechanism that will incentivise people to lose weight and keep it off. We haven’t found that yet.”
One danger is the potential for “gaming,” when people put on weight or take up smoking in order to qualify for cash when they stop. Despite this, American incentive schemes are powering ahead. Weight-loss betting sites like fatbet.net, where you wager that you can lose weight against your friends and family, are proliferating. Private companies like Tangerine run schemes for businesses faced with higher insurance costs for fatter workers. There’s anecdotal evidence that these schemes are working—though it’s not clear that what works in the US will translate to Britain.
Marteau warns us not to fear new initiatives, but stresses the importance of more research. Financial incentives are not a “magic bullet,” she points out, but just one of many policies that might help solve a complex and intractable problem. “We already know what we should do, which is why public information campaigns don’t work,” she adds. “Our limited cognitive capacity and autonomic impulse system override our good intentions.”
The state might have to take more responsibility to influence our eating habits. Latest policy is in fact avoiding paternalism with Andrew Lansley, the health secretary, attempting to free the food industry from the “burden of regulation” so it can contribute to the Changes4Life anti-obesity campaign, and also asking people to take more responsibility for their weight (fat chance, suggest many health campaigners). But we accept taxes on cigarettes and alcohol to reduce consumption. Ultimately, charging top whack for a vat of fried chicken could be the only way.