Can financial incentives help lower cardiovascular disease risk?

UB researchers are conducting a clinical trial to assess the effectiveness of structured financial incentives in lowering cardiovascular disease (CVD) risk among African Americans facing food insecurity.

Rebekah Walker, associate professor in the Department of Medicine, Jacobs School of Medicine and Biomedical Sciences at UB, and chief of the Division of Population Health, is principal investigator on a five-year, $3.28 million grant from the National Institute on Minority Health and Health Disparities, part of the National Institutes of Health.

“If successful, this intervention will simultaneously address food insecurity and lower CVD risk for individuals at high risk,” says Walker. “It will also help to shift the focus away from addressing food insecurity as an issue of food alone and provide evidence for how to integrate social and medical care to improve health outcomes.”

Nearly 127 million people in the United States have cardiovascular disease, which is the leading cause of death, both in the U.S. and worldwide.

Food insecurity is associated with increased cardiovascular risk and excess death due to CVD, and while 10.5% of the U.S. population experience food insecurity, more than 20% of African Americans experience it, according to Walker.

“Most food insecurity interventions focus on identifying people who are food insecure and referring them to resources, providing food supplementation through a variety of ways such as farmers markets or stockboxes, or providing rebates or grocery store discounts to improve access to food,” Walker says.

“All of these methods focus on food itself, but do not address the underlying driver of food insecurity, which is poverty, or address the long-term health risks that result from food insecurity,” she notes.

The clinical trial, “Cardiovascular Risk Reduction for Adults with Food Insecurity Using Structured Incentives (CVD-FIT),” will test an intervention that combines three components:

• Monthly income supplementation to address the underlying poverty faced by individuals who are food insecure.
• Financial incentives conditional on the purchase of healthy food aimed at increasing the likelihood of food-insecure individuals eating a healthier diet.
• Education and skills training specific to reducing CVD risk.

“Our study aims to change the focus on the singular aspect of increasing food access without accounting for underlying poverty, which is the reason people are food insecure,” Walker says.

Her research team has been investigating the role behavioral economics can play in improving health outcomes for adults with diabetes through using financial incentives.

Behavioral economics theorizes that financial incentives provide an extrinsic motivation in the form of a financial reward for behavior change. Provided over time and linked to healthy behaviors, this initial extrinsic motivation can transition to intrinsic motivation to continue engaging in healthy behaviors, Walker adds.

Income supplementation provides funds to maintain a basic living standard and helps address material needs, such as housing or nutrition.

“This work has been very promising; however, incentives alone may not allow individuals struggling with food insecurity to change behavior,” Walker says.

She points out that some studies of income supplementation show impacts on lowering food insecurity, but there are few income-supplementation studies that target health outcomes.

“We are hypothesizing that we need a combination of income supplementation to address underlying poverty, financial incentives to incentivize behavior change surrounding food purchasing, and education to help support overall behavior change to reduce CVD risk,” she says. “So, our intervention incorporates all three components.”

Researchers will recruit study participants directly from the community, enrolling adults 40 years or older who self-report as African American or Black, and screen positive for food insecurity risk and CVD risk.

“There are many risk factors for developing CVD, including high blood pressure, high cholesterol, smoking, Type 2 diabetes and having excess weight or obesity,” Walker says. “Individuals with any of these risk factors will be eligible for this study.”

Researchers will randomize 200 clinical trial participants to receive either the multi-component intervention (monthly income supplementation, weekly financial incentives for healthy food purchase and CVD risk-reduction education) or CVD risk-reduction education alone.

“Each participant will be followed for 12 months and will participate in four study visits where we will measure CVD risk indicators and complete questionnaires to capture social and psychosocial factors,” Walker says.

“Following the study, we will compare the two groups to test if the intervention resulted in greater improvement of their 10-year CVD risk score compared to the education and skills training control group,” she adds. “We are also planning to see if the intervention improves quality of life and if it is cost effective.”

Leonard E. Egede, the Charles and Mary Bauer Endowed Professor and Chair of the Department of Medicine, is a co-investigator. His NIH-funded study through the National Institute of Diabetes and Digestive and Kidney Diseases investigating the use of financial incentives to improve diabetes outcomes was one of the drivers behind the current study. 

Other co-investigators from the Division of Population Health are Jennifer A. Campbell, associate professor of medicine; Obinna Ekwunife, assistant professor of medicine; and Raphael Fraser, research associate professor of medicine.

Individuals interested in enrolling in the study can contact research staff in the Division of Population Health at 716-888-4899 or 716-829-5499.