Introduction

Increasing moderate to brisk physical activity most days of the week is a core component of dyslipidemia management, yet often a clinical challenge. Lack of regular physical exercise and sedentary lifestyles are in part to blame for the obesity epidemic in America today.¹ This public health crisis has forced the US Department of Health and Human services² to ask an important question: How do we incentivize overweight and obese adults to increase their physical activity? A recently published randomized clinical trial in the JAMA Internal Medicine³ sought to provide an answer. Their solution was to use a "gamification" intervention. In other words, make physical activity into a game.

Gamification is the idea of applying elements of game playing such as competition against others, scoring points, and strategy in non-game contexts.^4-6 It is a behavioral change technique that amplifies an existing experience using game-like elements to motivate and reinforce engagement.⁷ Popular examples are Fitocracy⁸ or the Zombies, Run! mobile app⁹ where participants use workouts to earn points, unlock achievements, or compete with other users to win virtual games, making exercise a more enjoyable experience.

One of the biggest challenges in healthcare is encouraging patients to modify their behavior – whether it is quitting smoking, improving their diet, or exercising more.¹⁰ Technology created with the intention of promoting healthy lifestyles – such as exercise apps, calorie-tracking apps, step counting apps, etc. – have not been proven to have a clear long-term benefit when it comes to increasing physical activity, modifying important health outcomes, and preventing chronic disease.^11,12 The authors of this study believe that this is because the technology available has not been paired with the right incentive. They sought to determine if gamification theory could be paired with technology to help promote physical activity.

Methods

In this study, 602 overweight and obese adults (BMI >25 kg/m²) from across the United States who were employees of a consulting firm were enrolled. Each participant was given a wearable device to track daily steps. A baseline step count was established after following the participants for two weeks. The participants were then informed of their baseline step count and were asked to create a step count goal that was anywhere from 33% to 50% higher, so long as it was at least 1,500 steps greater than their baseline. Thereafter, the participants were randomly assigned into one of four groups, each with different gamification interventions, and monitored for 36 weeks.

The first group served as a control group. They were asked to reach their step count goal and they received feedback from their wearable device/smartphone, but no other gamification intervention was performed. The remaining participants in the gamification groups were entered into a game with points and levels. Every Monday, each participant received 70 points. If they did not reach the step count goal the day prior, they lost 10 points. Depending on the score, participants could move up or down levels from blue (lowest), bronze, silver, gold, or platinum (highest) with each participant starting in silver. While each group within the gamification arms employed known behavioral change principles to help motivate behavior (pre-commitment, ramp-up period, loss framing, fresh start), they differed in the social incentive employed. The social incentives arms were support, collaboration, and competition.

The support arm included a family member or friend who would be emailed a weekly report of the participant's performance including points and levels. The family member or friend was asked to do their best to support the participant in their progress during the study period. Within the collaboration arm, the participants were split into groups of three. Each day, one member was randomly chosen to represent the group. The team kept or lost 10 points based on the performance of the randomly selected representative.

The competition arm was also divided into groups of three. At the end of each week, participants received an email with a scoreboard listing points and levels, thereby encouraging participants to compete for the top spot. The incentives were employed within the gamification groups until week 24. After week 24, the gamification interventions ceased and participants entered the follow-up period during which step counts were monitored between the groups.

Results

During the intervention period, each gamification arm (support, collaboration, and competition) had significantly higher average step counts (6975 vs. 6297, 6814 vs. 6120, 7237 vs. 6313) than the control group (6162 vs. 6086) when compared to baseline. No significant differences were found between the gamification arms during the intervention period. However, in the follow-up period, only the competition arm had significantly greater average step counts (6592 vs. 6313) than the control group (5899 vs. 6086). The differences in step counts for the support arm (6432 vs. 6297) and the collaboration arm (6038 vs. 6120) during the follow up period were not statistically significant.

Implications

The results of this study demonstrate that social incentives, theories of behavioral change, and principles of gamification can be paired with available technology to increase exercise and physical activity among overweight and obese adults.

Each social incentive (support, collaboration, and competition) increased overall physical activity during the intervention period, but only the competition arm had significantly higher step count averages in the follow-up period. The authors hypothesize that competition may be a better driver for behavioral change among strangers. However, they note that the effect of social incentive may vary based on social connection among participants, as prior studies show collaboration to be useful in increasing physical activity within family members.¹³ Irrespective of which social incentive is ideal in differing circumstances, it is important to note that social incentives can have a significant impact in motivating behavior change.

This study also uses behavioral change techniques, such as pre-commitment, fresh start, and goal gradients, that can be directly applied to clinical practice. For example, pre-commitment (a pledge to strive to achieve a goal) can be used to help encourage tobacco cessation. Physical activity or dietary goals can be initiated with a contract. Goal gradients (the notion that the next highest level is achievable) and fresh start (the tendency for aspirational behavior around temporal landmarks such as the beginning of the year, month, or week) can be applied to help make realistic and achievable dietary changes for patients. The effectiveness of each technique will need to be further studied in clinical contexts.

The gamification principles employed could also be utilized in areas where health, technology, and patient participation overlap. For example, the Corrie Health® app is a digital health platform created by Johns Hopkins and Apple that incorporates gamification principles to encourage adherence to guideline-directed management to improve cardiovascular risk prevention. In the version created for acute myocardial infarction (MI) patients, it incorporates principles including pre-commitment and goal gradients.¹⁴ Furthermore, it is strategically delivered to patients immediately after surviving an MI to encourage a fresh start at adopting a heart healthy lifestyle.

Gamification and behavioral change principles could help insurance companies further incentivize plan members to stay active in exchange for lower premiums.^15,16 It can also reach into the realm of public health by encouraging physical activity within schools and colleges through virtual "exergames" such as Pokémon Go and other mobile health apps that combine exercise and gaming.¹⁷ On the whole, gamification principles could encourage patients to become active participants in their own health.

The study has potentially broad applications, but is not without limitations. The demographics of the participants, which primarily included college-educated, consulting firm employees with access to a smartphone or tablet, limits the generalizability of the results. Further studies are needed in patients older than 65 years of age and in more diverse populations considering that racial, ethnic, and socioeconomic disparities are large contributors to overall health.¹⁸ A recent Apple initiative to study the relationship between heart health and movement using data obtained from the Apple Watch can prove to be a valuable source of information across varying populations.¹⁹ It could also be a chance to study further gamification interventions.

Conclusion

As clinicians, our goal should be to use every means possible to help patients achieve the American Heart Association physical activity goal of at least "150 minutes of moderate aerobic activity a week."² We believe that technology, with the right incentives and personalization, can help patients achieve that goal. Yet, we recognize that the guideline recommendation of 150 minutes is different than the steps reported by fitness trackers. This speaks to a need for greater alignment of guideline recommendations with what our patients are measuring. Meanwhile, the STEP UP trial provides insight into the roles that social incentives, behavioral change principles, and gamification play in helping clinicians and patients achieve that goal.

References

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2. Piercy K L, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA 2018;320:2020-28.
3. Patel MS, Small DC, Harrison JD, et al. Effectiveness of behaviorally designed gamification interventions with social incentives for increasing physical activity among overweight and obese adults across the United States: The STEP UP randomized clinical trial. JAMA Intern Med 2019;1-9[Epub ahead of print].
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13. Patel MS, Benjamin EJ, Volpp KG, et al. Effect of a game-based intervention designed to enhance social incentives to increase physical activity among families: the BE FIT randomized clinical trial. JAMA Intern Med 2017;177:1586-93.
14. Spaulding EM, Marvel FA, Lee MA, et al. Corrie Health digital platform for self-management in secondary prevention after acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2019;12:e005509.
15. Chokshi NP, Adusumalli S, Small DS, et al. Loss‐framed financial incentives and personalized goal‐setting to increase physical activity among ischemic heart disease patients using wearable devices: the ACTIVE REWARD randomized trial. J Am Heart Assoc 2018;7:pi:e009173..
16. Patel MS, Asch DA, Rosin R, et al. Individual versus team-based financial incentives to increase physical activity: a randomized, controlled trial. J Gen Intern Med 2016;31:746-54.
17. Howe KB, Suharlim C, Ueda P, Howe D, Kawachi I, Rimm EB. Gotta catch'em all! Pokémon GO and physical activity among young adults: difference in differences study. BMJ 2016;355:i6270.
18. Galea S, Tracy M, Hoggatt KJ, Dimaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. Am J Public Health 2011;101:1456-65.
19. Apple announces three groundbreaking health studies. Apple Newsroom. Sep 10, 2019. Available at: https://www.apple.com/newsroom/2019/09/apple-announces-three-groundbreaking-health-studies/.

Keywords: Dyslipidemias, Motivation, Sedentary Behavior, Patient Participation, Body Mass Index, Cardiovascular Diseases, Follow-Up Studies, Smoking Cessation, Risk Factors, Overweight, Exercise, Obesity, Mobile Applications, Chronic Disease, Demography, Biomedical Technology, Myocardial Infarction, Telemedicine

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