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A growing wave of clinical trials is testing whether principles from behavioral economics can improve adherence to weight management strategies, one of the most persistent challenges in obesity care.

Several randomized trials illustrate the three approaches shaping recent research. The first tests financial incentives, including cash rewards, lotteries, and deposit contracts designed to leverage loss aversion and motivate sustained behavior change. The financial incentives and deposit contracts for weight loss were tested in a 2008 randomized trial. It found that participants receiving financial incentives achieved greater short-term weight loss than those receiving standard behavioral counseling.

A second approach focuses on commitment devices and gamified behavioral reinforcement, including structured goal systems, social competition, and precommitment strategies designed to increase accountability. This type of reinforcement was the subject of a 2019 randomized trial that examined gamification with social incentives to increase physical activity among adults with overweight or obesity. It found that behavioral game design strategies modestly increased physical activity.

A third, newer category involves digital or adaptive behavioral interventions, in which mobile apps, wearable data, and algorithm-driven prompts deliver personalized “nudges” based on patient behavior.

For instance, a 2024 randomized clinical trial published in JAMA tested a dynamically adaptive digital weight-loss program designed to adjust behavioral support based on participant engagement. Another recent example is the Game of Stones randomized clinical trial published in 2024, also in JAMA, which evaluated whether behavioral text messaging combined with financial incentives could improve weight loss among men with obesity.

Together, these studies are helping researchers explore whether subtle shifts in behavioral design, rather than new medications or procedures, could improve the long-term sustainability of weight management interventions.

Addressing the Adherence Problem

The focus on behavioral economics reflects a fundamental challenge in obesity care: maintaining adherence to lifestyle interventions over time.

Although intensive lifestyle programs can produce meaningful weight loss in clinical trials, real-world results are often less durable. Many patients become less engaged with diet and physical activity programs after the initial months of treatment.

“Weight gain is biological, behavioral, psychological, environmental, and social,” said Tammy Ouellette, PsyD, a clinical health and neuropsychologist at Providence St. Jude Medical Center in Fullerton, California. “Because it’s so multifaceted, people usually need more support than just an app or financial incentive.”

“We all know that many patients regain weight after stopping GLP-1 medications — often a large proportion of what they lost within a year,” said Thomas Tsang, MD, chief medical officer at Omada Health. “In many cases, it’s because patients never had the opportunity to learn the behavioral skills and lifestyle tools needed to sustain those changes after the medication is stopped.”

Tsang said newer obesity therapies may create an opportunity for behavioral interventions to take hold.

“Patients often describe thinking more clearly and feeling less driven by food cravings,” he said. “When that ‘food noise’ quiets down, it can create an opportunity to build new habits around nutrition, exercise, and long-term lifestyle change.”

He described this period as a potential “window of opportunity” in which patients may be more receptive to developing durable habits — particularly if behavioral support programs are introduced alongside pharmacologic treatment.

Financial Incentives and Commitment Contracts

Some of the earliest behavioral-economics studies in obesity focused on financial incentives.

These interventions often involve deposit contracts, in which participants commit their own money and lose it if weight-loss goals are not met, or lottery-based rewards that provide intermittent financial incentives tied to behavioral targets. Clinical trials have generally found that such strategies can produce modest improvements in short-term weight loss, particularly when incentives are framed in ways that emphasize potential losses rather than gains.

However, the durability of these effects remains uncertain.

“Research supports short-term weight loss that often isn’t sustained once the intervention ends,” said Stephanie Walsh, MD, an obesity specialist and founder of ProCare Consultants and ProCare TeleHealth.

Tsang also expressed caution about programs that rely primarily on financial incentives.

“If the incentive is purely financial, the concern is whether the behavior change will last after the incentive disappears,” he said. “What matters more is helping people develop durable habits and confidence that they can sustain over time.”

“When the reward disappears, the brain often goes back to what it knows,” Ouellette said. “And eating is a very rewarding behavior.”

Gamification and social incentives are another branch of research focused on gamification, which applies behavioral-economics principles such as competition, collaboration, and social accountability.

In randomized trials, participants may be placed into teams or social networks, earn points for completing health behaviors, or participate in goal-based competitions designed to reinforce physical activity or dietary adherence.

Some studies have shown that gamified interventions can increase physical activity or engagement with lifestyle programs during the intervention period. However, similar to financial incentives, the magnitude of clinical impact tends to be modest, and long-term sustainability remains uncertain.

The Rise of Digital Nudges

More recent trials have integrated behavioral-economics concepts into digital health platforms, including mobile apps, wearable devices, and automated messaging systems.

These interventions allow researchers to deliver frequent, low-intensity behavioral prompts — or “nudges” — designed to reinforce healthy behaviors. Some systems use adaptive algorithms that modify the timing or type of nudges based on user engagement.

“I often get asked which app is the best, and I always say ‘whatever one you will actually use,’” Walsh said. “If digital tools are helpful and bring joy to patients, we support using them as part of care.”

She noted that coaching and personalization appear to improve outcomes.

“One of the key components for long-term adherence seems to be coaching and personalization,” Walsh said. “That’s something that apps are still trying to replicate.”

Potential Role in Primary Care

For primary care clinicians, behavioral-economics strategies may offer an additional tool to support patients attempting long-term lifestyle change.

Walsh emphasized that these tools should be viewed primarily as strategies to support healthier behaviors rather than as weight-loss treatments on their own.

“These incentives are designed to improve health behaviors — not weight loss,” she said. “Obesity is a disease, and the treatment is more complex than simply exercising more and eating less.”

Some experts believe these approaches could complement pharmacologic therapies such as GLP-1 receptor agonists by improving adherence to diet and physical activity interventions that remain foundational to obesity treatment.

Others caution that behavioral interventions alone are unlikely to produce large weight reductions, particularly in patients with severe obesity or significant metabolic disease.

Instead, they may function best as adjuncts to broader treatment strategies, helping patients maintain engagement with lifestyle programs or medication regimens.

Implementation Questions Remain

Despite growing interest in behavioral-economics approaches, several practical questions remain unanswered.

Researchers continue to debate which strategies produce the most durable behavior change, whether financial incentives are ethically appropriate in clinical care, and how such interventions could be implemented in resource-constrained primary care settings.

Tsang also raised ethical concerns about programs that rely heavily on financial incentives, particularly if they disproportionately target economically vulnerable populations.

“There’s a fine line between rewarding progress and essentially paying people to lose weight,” he said. “We want patients focused on health and sustainable behavior change, not just achieving a short-term goal for a financial reward.”

For now, most experts view behavioral-economics interventions as promising but still evolving tools.

As the obesity treatment landscape expands — particularly with the rapid adoption of new pharmacologic therapies — understanding how behavioral design can support long-term adherence may become an increasingly important area of research.

Ouellette and Tsang reported having no disclosures. Walsh reported being an advisor to Novo Nordisk.