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VENICE, ITALY — Text messaging with a financial incentive significantly improves weight loss among men with obesity, often from socially deprived groups, lending support to efforts to achieve successful weight management in this often hard-to-access population, showed a study in the United Kingdom.

Viewing text messages without the financial incentive was not significantly better than the control group, comprising access to a website with weight management information.

Presenting the findings at the European Congress on Obesity (ECO) 2024 was Pat Hoddinott, MD, professor at the Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland. It was also published simultaneously in the May 14 edition of JAMA.

"We recruited a really unusual population of men — an underserved group of men who seldom take part in health promotion activities. Weight management programs are traditionally intensive, often with a weigh-in every week or 2. In Game of Stones, there are just four brief 10-minute weigh-ins over a year. No intervention is delivered by the staff at the weigh-ins, so minimal staff training is required, and no referral is needed to join," said the researchers and former general practitioner (GP).

"Men and NHS [National Health Service] staff really valued this low-burden approach, and it has the potential to address health inequalities. It was a win-win for all," added Hoddinott.

Recruited From Hard-to-Reach Populations — Men and Socially Deprived

The "Game of Stones" trial recruited 585 men living in Belfast, Bristol, and Glasgow, all cities in the United Kingdom. Participant diversity comprised 39% who lived in disadvantaged areas, 71% lived with at least one obesity-related long-term condition, 40% with multiple long-term conditions, 29% were categorized as having disability, and 25% had a diagnosed mental health condition, while a further 24% reported low mental health scores.

Of particular significance in this study was obtaining the buy-in not only for recruitment but also from the staff needed to implement it. "We designed this with men for men. We wanted the study to be low burden for participants and NHS staff, inclusive and low risk, promoting self-care, and to be sustainable, scalable, and affordable for health services," explained Hoddinott.

The researchers recruited with GP letters and posters, stood outside of supermarkets and shopping malls, and posted on social media.

Participants were randomized to three groups: Text messaging with financial incentives, the same text messages without any financial incentives, or a website where participants had access to weight management information.

Daily automated text messages were sent that drew on men's experiences of weight loss from an earlier feasibility trial. "We took men's stories and turned them into texts — and we included evidence-based links, some facts, and some humor," said Hoddinott. "They used the voices of other men in the text — so effectively peer influence — for example, one read, 'Dave says that some folks need the arm around the shoulder, some folks need the boot up the backside. Do you have enough arms and boots around when needed?'"

They also drew on different behavioral change strategies, and they did not tell men what to do, stressed Hoddinott. "We focused on why and how they were going to change and how they were going to keep it going over a whole year, replacing old habits with new ones."

In financial terms, they included endowment incentives that reflected behavioral economic theory whereby the prospect of losing money is more motivating than gaining the same amount, explained Hoddinott. Men were told at the start that £400 (approximately $500 US) would be put in a bank account for them, and they were given a mock check for that amount. The participants had strict weight goals — they had to lose 5% by 3 months or lose £50 ($63); lose 10% by 6 months or lose £150 ($190); and maintain that 10% weight loss by 12 months or lose £200 ($254). Strict weighing rules meant the weigh-in had to be carried out within 3 weeks of target date on the study scales. At study end, they were paid by bank transfer.

Text Messages With Financial Incentives Most Successful

Men in the text messages with financial incentives group lost significantly more weight than those in the control group, while those in the text messages alone group did not differ significantly from those in the control group, reported Hoddinott.

Mean weight loss over the 12-month study period was approximately 5% (mean, 5.7 kg) in men who received the texts with incentives, 3% (3 kg) in those who received the texts alone, and approximately 1% (mean 1.5 kg) in those in the control group lost.

Referring to numbers needed to treat — a measure that aids policymakers in comparing different interventions, Hoddinott said that, "We found four men would need to enroll in the trial for one to lose 5% or more of their weight over 12 months, and five would need to enroll for one man to lose 10% or more in the same time period," reported the researcher and former GP.

Men in the group that received texts with financial incentives also scored higher on the quality-of-life scale at 12 months but showed no differences in mental health and weight stigma compared with the other groups. They were also significantly more satisfied with their weight loss progress than the others.

In terms of payouts, 62% (90/196) of overall participants lost 5% of weight and received some money, while 14% (27/196) received the full £400, and the average incentive payment was £128 ($162).

Real Strengths in Obesity Research — Participant Diversity and Intervention Scalability

Reflecting on the significance of the participant diversity, Hoddinott said it shows that text messages with financial incentives work but also that "it engaged men who don't usually attend weight management services, which could help to address health inequalities."

Finally, she asserted that the intervention is ready to scale-up and is relatively low cost. "We see this as one more tool in the toolbox that helps us address the complex obesity problem."

Linda Bauld, OBE, FFPH, Bruce and John Usher Professor of Public Health, The University of Edinburgh, Edinburgh, Scotland, said the study "provides important new evidence on effective weight loss interventions for men — including those from more disadvantaged areas. This is a group that we know are unlikely to want to take part in traditional weight loss programs."

"It adds to existing evidence that financial incentives for behavior change work, particularly when combined with additional support via text messages," she pointed out. "The results should now be considered by those developing guidelines for practice in the UK and elsewhere."

David Blane, GP and senior clinical lecturer in General Practice and Primary Care, University of Glasgow, Glasgow, Scotland, also welcomed this new evidence based around weight management for men living with obesity. "I work in a Deep End GP practice — an area of high socioeconomic disadvantage — where levels of obesity and its complications are high and opportunities for healthy eating and physical activity can be limited," he said.

"It's a real strength of this study that they were able to recruit men from more socioeconomically deprived areas, with high levels of health problems, and achieve positive results."

Hoddinott had no disclosures. Neither Blane nor Bauld had financial disclosures.