Skip to main content

A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus


Purpose of Review

The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM.

Recent Findings

We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors.


Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.

This is a preview of subscription content, access via your institution.

Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Levitan EB, Song Y, Ford ES, Liu S. Is nondiabetic hyperglycemia a risk factor for cardiovascular disease?: a meta-analysis of prospective studies. Arch Intern Med. 2004;164:2147–55.

    Article  PubMed  Google Scholar 

  2. 2.

    Grundy SM. Pre-diabetes, metabolic syndrome, and cardiovascular risk. J Am Coll Cardiol. 2012;59:635–43.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010;362:800–11.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343–50.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the diabetes prevention program outcomes study. Lancet. 2009;374:1677–86.

    Article  PubMed Central  Google Scholar 

  6. 6.

    Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Van Gaal L, Scheen A. Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care. 2015;38:1161–72.

    Article  PubMed  Google Scholar 

  8. 8.

    Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, et al. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39:2065–79.

    Article  PubMed  Google Scholar 

  9. 9.

    Standards of Medical Care in Diabetes-2017. Summary of revisions. Diabetes Care. 2017;40:S4–5.

    Article  Google Scholar 

  10. 10.

    Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C. Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ. 2011;183:E115–27.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Vojta D, Sa JD, Prospect T, Stevens S. Effective interventions for stemming the growing crisis of diabetes and prediabetes: a national payer’s perspective. Health Aff. 2012;31:20–6.

    Article  Google Scholar 

  12. 12.

    Vojta D, Koehler TB, Longjohn M, Lever JA, Caputo NF. A coordinated national model for diabetes prevention: linking health systems to an evidence-based community program. Am J Prev Med. 2013;44:S301–6.

    Article  PubMed  Google Scholar 

  13. 13.

    Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014 Atlanta: US Department of Health and Human Services; [Internet]. 2014. Available from:

  14. 14.

    Yang K, Lee Y-S, Chasens ER. Outcomes of health care providers’ recommendations for healthy lifestyle among U.S. adults with prediabetes. Metab Syndr Relat Disord. 2011;9:231–7.

    Article  PubMed  Google Scholar 

  15. 15.

    Okosun IS, Lyn R. Prediabetes awareness, healthcare provider’s advice, and lifestyle changes in American adults. Int J Diabetes Mellit. 2010 [cited Aug 29] 2012; Available from:

  16. 16.

    Ruge T, Nyström L, Lindahl B, Hallmans G, Norberg M, Weinehall L, et al. Recruiting high-risk individuals to a diabetes prevention program: how hard can it be? Diabetes Care. 2007;30:e61.

    Article  PubMed  Google Scholar 

  17. 17.

    Gopalan A, Lorincz IS, Wirtalla C, Marcus SC, Long JA. Awareness of prediabetes and engagement in diabetes risk–reducing behaviors. Am J Prev Med. 2015;49:512–9.

    Article  PubMed  Google Scholar 

  18. 18.

    Selvin E, Parrinello CM, Sacks DB, Coresh J. Trends in prevalence and control of diabetes in the U.S., 1988–1994 and 1999–2010. Ann Intern Med. 2014;160:517.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Wang Y, Bolge SC, Lopez JMS, Zhu VJ, Stang PE. Changes in body weight among people with type 2 diabetes mellitus in the United States, NHANES 2005–2012. Diabetes Educ. 2016;42:336–45.

    Article  PubMed  Google Scholar 

  20. 20.

    Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA. 2007;298:2415–7.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    O’Donoghue T, Rabin M. Doing it now or later. Am Econ Rev. 1999;89:103–24.

    Article  Google Scholar 

  22. 22.

    Loewenstein G. Out of control: visceral influences on behavior. Adv. Behav. Econ. Princeton: Princeton University Press; 2004. p. 689–723.

    Google Scholar 

  23. 23.

    Svenson O. Are we all less risky and more skillful than our fellow drivers? Acta Psychol. 1981;47:143–8.

    Article  Google Scholar 

  24. 24.

    Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica. 1979;47:263–91.

    Article  Google Scholar 

  25. 25.

    Charness G, Gneezy U. Incentives to exercise. Econometrica. 2009;77:909–31.

    Article  Google Scholar 

  26. 26.

    Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, et al. Framing financial incentives to increase physical activity among overweight and obese adults: a randomized, controlled trial. Ann Intern Med. 2016;164:385–94.

    Article  PubMed  Google Scholar 

  27. 27.

    Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Fletcher MA, et al. A randomized trial of social comparison feedback and financial incentives to increase physical activity. Am J Health Promot. 2016;30:416–24.

    Article  PubMed  Google Scholar 

  28. 28.

    Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Eberbach K, et al. Individual versus team-based financial incentives to increase physical activity: a randomized, controlled trial. J Gen Intern Med. 2016;31:746–54.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Pope L, Harvey J. The efficacy of incentives to motivate continued fitness-center attendance in college first-year students: a randomized controlled trial. J Am Coll Heal. 2014;62:81–90.

    Article  Google Scholar 

  30. 30.

    Mitchell MS, Goodman JM, Alter DA, John LK, Oh PI, Pakosh MT, et al. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med. 2013;45:658–67.

    Article  PubMed  Google Scholar 

  31. 31.

    Strohacker K, Galárraga O, Emerson J, Fricchione SR, Lohse M, Williams DM. Impact of small monetary incentives on exercise in university students. Am J Health Behav. 2015;39:779–86.

    Article  PubMed  Google Scholar 

  32. 32.

    Royer H, Stehr MF, Sydnor JR. Incentives, commitments and habit formation in exercise: evidence from a field experiment with workers at a Fortune-500 company [internet]. Massachusetts: National Bureau of Economic Research; 2012. Report No.: 18580. Available from:

    Book  Google Scholar 

  33. 33.

    Thorndike AN, Sonnenberg L, Riis J, Barraclough S, Levy DE. A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices. Am J Public Health. 2012;102:527–33.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive–based approaches for weight loss: a randomized trial. JAMA. 2008;300:2631–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    John LK, Loewenstein G, Troxel AB, Norton L, Fassbender JE, Volpp KG. Financial incentives for extended weight loss: a randomized, controlled trial. J Gen Intern Med. 2011;26:621–6.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Kullgren JT, Troxel AB, Loewenstein G, Norton LA, Gatto D, Tao Y, et al. A randomized controlled trial of employer matching of employees’ monetary contributions to deposit contracts to promote weight loss. Am J Health Promot. 2016;30:441–52.

    Article  PubMed  Google Scholar 

  37. 37.

    Jeffery RW. Financial incentives and weight control. Prev Med. 2012;55:S61–7.

    Article  PubMed  Google Scholar 

  38. 38.

    Jeffery RW, Wing RR, Thorson C, Burton LR, Raether C, Harvey J, et al. Strengthening behavioral interventions for weight loss: a randomized trial of food provision and monetary incentives. J Consult Clin Psychol. 1993;61:1038–45.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Jeffery RW, Gerber WM, Rosenthal BS, Lindquist RA. Monetary contracts in weight control: effectiveness of group and individual contracts of varying size. J Consult Clin Psychol. 1983;51:242–8.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Jeffery RW, Bjornson-Benson WM, Rosenthal BS, Kurth CL, Dunn MM. Effectiveness of monetary contracts with two repayment schedules on weight reduction in men and women from self-referred and population samples. Behav Ther. 1984;15:273–9.

    Article  Google Scholar 

  41. 41.

    Kullgren JT, Troxel AB, Loewenstein G, Asch DA, Norton LA, Wesby L, et al. Individual-versus group-based financial incentives for weight loss: a randomized, controlled trial. Ann Intern Med. 2013;158:505–14.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Leahey TM, Subak LL, Fava J, Schembri M, Thomas G, Xu X, et al. Benefits of adding small financial incentives or optional group meetings to a web-based statewide obesity initiative. Obesity. 2015;23:70.

    Article  PubMed  Google Scholar 

  43. 43.

    Leahey T, Rosen J. Diet bet: a web-based program that uses social gaming and financial incentives to promote weight loss. JMIR Serious Games. 2014 [cited 2016 Dec 26]; 2. Available from:

  44. 44.

    Finkelstein EA, Linnan LA, Tate DF, Birken BE. A pilot study testing the effect of different levels of financial incentives on weight loss among overweight employees. J Occup Environ Med. 2007;49:981–9.

    Article  PubMed  Google Scholar 

  45. 45.

    Cawley J, Price JA. A case study of a workplace wellness program that offers financial incentives for weight loss. J Health Econ. 2013;32:794–803.

    Article  PubMed  Google Scholar 

  46. 46.

    Lahiri S, Faghri PD. Cost-effectiveness of a workplace-based incentivized weight loss program. J Occup Environ Med. 2012;54:371–7.

    Article  PubMed  Google Scholar 

  47. 47.

    Volpp KG, Loewenstein G, Troxel AB, Doshi J, Price M, Laskin M, et al. A test of financial incentives to improve warfarin adherence. BMC Health Serv Res. 2008;8:272.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Kimmel SE, Troxel AB, Loewenstein G, Brensinger CM, Jaskowiak J, Doshi JA, et al. Randomized trial of lottery-based incentives to improve warfarin adherence. Am Heart J. 2012;164:268–74.

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Reese PP, Kessler JB, Doshi JA, Friedman J, Mussell AS, Carney C, et al. Two randomized controlled pilot trials of social forces to improve statin adherence among patients with diabetes. J Gen Intern Med. 2016;31:402–10.

    Article  PubMed  Google Scholar 

  50. 50.

    Downs JS, Loewenstein G, Wisdom J. Strategies for promoting healthier food choices. Am Econ Rev. 2009;99:159–64.

    Article  Google Scholar 

  51. 51.

    Liu PJ, Wisdom J, Roberto CA, Liu LJ, Ubel PA. Using behavioral economics to design more effective food policies to address obesity. Appl Econ Perspect Policy. 2014;36:6–24.

    Article  Google Scholar 

  52. 52.

    Keller PA, Harlam B, Loewenstein G, Volpp KG. Enhanced active choice: a new method to motivate behavior change. J Consum Psychol. 2011;21:376–83.

    Article  Google Scholar 

  53. 53.

    Ariely D, Wertenbroch K. Procrastination, deadlines, and performance: self-control by precommitment. Psychol Sci. 2002;13:219–24.

    Article  PubMed  Google Scholar 

  54. 54.

    Giné X, Karlan D, Zinman J. Put your money where your butt is: a commitment contract for smoking cessation. Am Econ J Appl Econ. 2010;2:213–35.

    Article  Google Scholar 

  55. 55.

    Halpern SD, Asch DA, Volpp KG. Commitment contracts as a way to health. BMJ. 2012;344:e522.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Rogers T, Milkman KL, Volpp KG. Commitment devices: using initiatives to change behavior. JAMA. 2014;311:2065–6.

    CAS  Article  PubMed  Google Scholar 

  57. 57.

    Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.

    Article  Google Scholar 

  58. 58.

    Lorincz IS, Lawson BCT, Long JA. Provider and patient directed financial incentives to improve care and outcomes for patients with diabetes. Curr Diab Rep. 2013;13:188–95.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Paul-Ebhohimhen V, Avenell A. Systematic review of the use of financial incentives in treatments for obesity and overweight. Obes Rev. 2008;9:355–67.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    • Faghri PD, Li R. Effectiveness of financial incentives in a worksite diabetes prevention program. Open Obes J. 2014;6:1–12. This study tested financial incentives for weight loss among employees at high risk for developing T2DM

    Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Mehrotra A, An R, Patel DN, Sturm R. Impact of a patient incentive program on receipt of preventive care. Am J Manag Care. 2014;20:494–501.

    PubMed  PubMed Central  Google Scholar 

  62. 62.

    Park P, Simmons RK, Prevost AT, Griffin SJ. A randomized evaluation of loss and gain frames in an invitation to screening for type 2 diabetes: effects on attendance, anxiety and self-rated health. J Health Psychol. 2010;15:196–204.

    Article  PubMed  Google Scholar 

  63. 63.

    • Sallis A, Bunten A, Bonus A, James A, Chadborn T, Berry D. The effectiveness of an enhanced invitation letter on uptake of National Health Service Health Checks in primary care: a pragmatic quasi-randomised controlled trial. BMC Fam Pract. 2016 [cited 2017 Feb 13];17. Available from: This study tested whether an enhanced invitation letter using insights from behavioral science could increase attendance at National Health Service Health Checks in the UK.

  64. 64.

    Austin S, Wolfe B. The effect of patient reminders and gas station gift cards on patient adherence to testing guidelines for diabetes. Wis Med J. 2011;110:132–7.

    Google Scholar 

  65. 65.

    • Gopalan A, Paramanund J, Shaw PA, Patel D, Friedman J, Brophy C, et al. Randomised controlled trial of alternative messages to increase enrolment in a healthy food programme among individuals with diabetes. BMJ Open. 2016;6:e012009. This study compared the effectiveness of T2DM-focused messaging strategies at increasing enrollment in a healthy food program among adults with T2DM

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  66. 66.

    • Gopalan A, Tahirovic E, Moss H, Troxel AB, Zhu J, Loewenstein G, et al. Translating the hemoglobin A1C with more easily understood feedback: a randomized controlled trial. J Gen Intern Med. 2014;29:996–1003. This study tested the effect of two alternative communication formats of HbA1c values on improving glycemic control among patients with poorly controlled T2DM

    Article  PubMed  PubMed Central  Google Scholar 

  67. 67.

    Grady JL, Entin EB, Entin EE, Brunyé TT. Using message framing to achieve long-term behavioral changes in persons with diabetes. Appl Nurs Res. 2011;24:22–8.

    Article  PubMed  Google Scholar 

  68. 68.

    • Hochberg I, Feraru G, Kozdoba M, Mannor S, Tennenholtz M, Yom-Tov E. Encouraging physical activity in patients with diabetes through automatic personalized feedback via reinforcement learning improves glycemic control. Diabetes Care. 2016;39:e59–60. This study examined whether a mobile phone application with a learning algorithm could improve adherence to exercise in patients with T2DM

    Article  PubMed  Google Scholar 

  69. 69.

    Huntsman MAH, Olivares FJ, Tran CP, Billimek J, Hui EE. Pain reduction and financial incentives to improve glucose monitoring adherence in a community health center. PLoS One. 2014;9:e114875.

    Article  PubMed  PubMed Central  Google Scholar 

  70. 70.

    Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized controlled trial. Ann Intern Med. 2012;156:416–24.

    Article  PubMed  PubMed Central  Google Scholar 

  71. 71.

    • Misra-Hebert AD, Hu B, Taksler G, Zimmerman R, Rothberg MB. Financial incentives and diabetes disease control in employees: a retrospective cohort analysis. J Gen Intern Med. 2016;31:871–7. This study examined whether financial incentives could increase participation in disease management and improve measures of disease control among employees with T2DM

    Article  PubMed  PubMed Central  Google Scholar 

  72. 72.

    Myers R. Moderating the effectiveness of messages to promote physical activity in type 2 diabetes. Grad Theses Diss 2010; Available from:

  73. 73.

    Raiff BR, Jarvis BP, Dallery J. Text-message reminders plus incentives increase adherence to antidiabetic medication in adults with type 2 diabetes. J Appl Behav Anal. 2016;49:947–53.

    Article  PubMed  PubMed Central  Google Scholar 

  74. 74.

    • Sen AP, Sewell TB, Riley EB, Stearman B, Bellamy SL, Hu MF, et al. Financial incentives for home-based health monitoring: a randomized controlled trial. J Gen Intern Med. 2014;29:770–7. This study tested whether financial incentives could increase adherence to home self-monitoring of blood glucose, blood pressure, and weight among patients with poorly controlled T2DM

    Article  PubMed  PubMed Central  Google Scholar 

  75. 75.

    19th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care [Internet]. Towers Watson. 2014; [cited 2014 Nov 10]. Available from:

  76. 76.

    Claxton G, Rae M, Long M, Damico A, Whitmore H, Foster G. Health benefits in 2016: family premiums rose modestly, and offer rates remained stable. Health Aff. 2016;35:1908–17.

    Article  Google Scholar 

  77. 77.

    Group TDPPR. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012;35:723–30.

    Article  Google Scholar 

  78. 78.

    Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq. 2000;11:227–68.

    Article  Google Scholar 

  79. 79.

    Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55:68–78.

    CAS  Article  PubMed  Google Scholar 

  80. 80.

    Kullgren JT, Williams GC, An LC. Patient-centered financial incentives for health: can employers get change for their dollars? Healthcare. 2013;1:82–5.

    Article  PubMed  Google Scholar 

  81. 81.

    Kullgren JT, Williams GC, Resnicow K, An LC, Rothberg A, Volpp KG, et al. The promise of tailoring incentives for healthy behaviors. Int J Workplace Health Manag. 2016;9:2–16.

    Article  Google Scholar 

  82. 82.

    Thaler RH. Toward a positive theory of consumer choice. J Econ Behav Organ. 1980;1:39–60.

    Article  Google Scholar 

  83. 83.

    Strotz RH. Myopia and inconsistency in dynamic utility maximization. Rev Econ Stud. 1955;23:165–80.

    Article  Google Scholar 

  84. 84.

    Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med. 2015;372:2108–17.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We are grateful for the assistance of Judy Smith of the Taubman Health Sciences Library at the University of Michigan for her assistance with developing and refining the search strategy for our scoping review. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. Support was provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr. Kullgren is a VA HSR&D Career Development awardee at the Ann Arbor VA. This study also received support from the National Institute of Diabetes and Digestive and Kidney Diseases (Grant Number P30DK092926 (MCDTR)).

Author information



Corresponding author

Correspondence to Jeffrey T. Kullgren.

Ethics declarations

Conflict of Interest

Jeffrey T. Kullgren has received consulting fees from SeeChange Health and HealthMine and speaking honoraria from AbilTo, Inc. Dina Hafez, Michele Heisler, and Allison Fedewa declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Economics and Policy in Diabetes

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kullgren, J.T., Hafez, D., Fedewa, A. et al. A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus. Curr Diab Rep 17, 73 (2017).

Download citation


  • Behavioral economics
  • Diabetes
  • Self-management
  • Prevention
  • Interventions
  • Scoping review