Gamification has become an increasingly popular strategy for promoting healthy behaviors from medication adherence to chronic condition management.

A new study published in JAMA Network examined the effectiveness of gamification in promoting physical activity and weight loss among adults with uncontrolled Type 2 diabetes.

"Gamification is commonly used in wellness programs and smartphone apps, but often is not designed to incorporate insights on how people behave and have not been well-tested over longer periods," Dr. Mitesh Patel, the director of Penn Medicine's Nudge Unit and the lead author of the study, said in a statement. 

The one-year intervention gave participants a wearable, electronic step counter and an electronic scale, both from Withings, and randomly separated them into four arms – one control group and three gamification groups.

Participants in the control arm only received feedback from the devices and the study’s smartphone application, but the intervention groups were also entered into a game with points and levels, and were provided a daily notification on their progress. The three gamification arms were divided into groups that centered on collaboration, competition and support.

TOP-LINE DATA

After the one-year intervention, each of the gamification groups increased their physical activity (as measured by step count) more than the control arm. The support, competition and collaboration groups on average increased their steps by 503, 606 and 280, respectively, more than the control groups.

Although the collaboration group did increase its step count, it was not enough to be considered a significant finding, according to the researchers.

"In this one-year trial, we found that gamification worked best to increase activity levels when it was designed using behavioral insights to encourage either competition with others or support from a family member or friend,” Patel said. “This is encouraging and suggests that these interventions could be an effective way to build a lasting, new exercise habit for this population."

Across the board, each group lost weight and lowered their blood sugar levels. However, there was no significant difference between the groups for these measurements.

Despite the fact that the results from this study represented a modest increase in physical activity, the researchers note that evidence suggests even small increases or light-intensity physical activity can lead to health benefits, particularly for more sedentary individuals.

"This study is a great first step on building a lasting exercise habit," Patel said. "However, more work is needed to help promote weight loss and better glycemic control. Future studies could combine gamification with other approaches to target changes in clinical outcomes."

HOW IT WAS DONE

The four-arm randomized control trial ran from January 23, 2017, to January 27, 2020, and included 361 adults with Type 2 diabetes with hemoglobin A1c levels greater than or equal to 8% and a body mass index greater than or equal to 25.

The average age was 52.5 years, most (52%) were female and a majority (51.2%) identified as Black.

The study included an initial baseline in-person visit followed by one year of remotely monitored intervention using Way to Health, a research technology platform at the University of Pennsylvania used previously for remote monitoring and behavioral interventions.

Participants in the competition arm were separated into a group of three. Each week they received an email with a leaderboard that ranked them on their cumulative points in the study at the time, and displayed their level.

In the collaboration group, participants were again placed into groups of three, but were working as a team. Each day, one member was randomly selected to represent their team for that day and to strive for points and level up on behalf of everyone.

The support arm instructed participants to choose someone outside of the study who would get email updates on their progress to motivate or cheer them on as they progressed.

THE LARGER TREND

Outside of chronic condition management, gamified treatments are popular for cognitive and neurological conditions.

One such example is Akili Interactive’s FDA-cleared EndeavorRx digital therapeutic for children with ADHD. Akili recently announced they were studying EndeavorRx as a potential treatment for cognitive impairments in COVID-19 survivors.

Swiss neurogaming company MindMaze also has an FDA-cleared treatment for stroke and traumatic injury patients. The company recently grew its geographical footprint in Latin America, the Middle East, Spain and Switzerland through a series of new partnerships.

Neurobics, or brain games, can even prevent postoperative delirium in older adults when played leading up surgeries, according to research from the Ohio State University Wexner Medical Center.

ON THE RECORD

"Wearable devices and digital weight scales are increasingly being adopted," Dr. Kevin Volpp, the study’s senior author and the director of the Penn Center for Health Incentives and Behavioral Economics, said in a statement.

"In addition to our findings about gamification, we believe that our clinical trial shows these technologies are powerful when combined with behavioral science to guide people toward better habits and better health."