Gamifying Fitbit With Competitive Element Boosts Outcomes

Nancy A. Melville

September 09, 2019

Using a wearable device alone isn't always enough to motivate individuals to exercise, so adding fun with gaming elements can boost performance, and now a new randomized study of more than 600 overweight and obese adults indicates that adding a competitive element gives the best results.

"We have seen behaviorally designed gamification lead to sustained behavior change in other studies, but this was the largest and longest study of its kind to date," first author Mitesh S. Patel, MD, Perelman School of Medicine, University of Pennsylvania, Philadelphia, told Medscape Medical News.

"It may have been that competition was the best intervention for building habits that were sticky and remained in place even when the game was over."

Mobile apps in the fitness/wellness realm have soared in popularity, and in previous research, Patel and colleagues found nearly two thirds of health and fitness mobile apps incorporate elements of gamification.

However, research has been lacking on which specific gamification models yield the best results.

And some commentators have warned that gamifying some aspects of healthcare could be of concern in some individuals, as noted in a recent review in the American Journal of Managed Care by Eli G. Phillips Jr, PharmD, JD, of Cardinal Health Specialty Solutions, Cardinal Health, Dublin, Ohio, and colleagues.

"Although gamification in healthcare has the potential to modify behaviors, participating in gaming is innately a behavior that may result in unintended consequences," they caution.

Financial Incentives to Enroll in STEP UP Trial

In the new study, published online September 9 in JAMA Internal Medicine, Patel and colleagues compared interventions involving three different social incentives —support, collaboration and competition — in a fitness program.

They enrolled 602 overweight and obese participants from 40 US states in the Social Incentives to Encourage Physical Activity and Undertand Predictors (STEP UP) step-counting clinical trial, conducted from February 2018 to March 2019.

Participants, who were a mean age of 39 years and employees of Deloitte Consulting, were invited to participate by email. They were compensated $25 for enrolling, $50 for completing the 24-week intervention, and another $50 for completing the 12-week follow-up and surveys.

Mean body mass index (BMI) of participants was 30 kg/m2, and 70% were male.

Competing for the Top Spot

Participants were provided with wearable devices to track daily steps.

A control group was comprised of participants who received only feedback from the wearable device and no other interventions for the study duration.

Participants in the intervention arms (support, n = 151; collaboration, n = 150; and competition, n = 150) were entered into a game with points and levels that was run automatically (participants did not have to actively play the game, just strive for step goals) and provided a daily notification of their progress.

For the support arm, participants identified a family member or friend who was emailed weekly reports on the participant's progress, including points and level, and was encouraged to provide support.

For the collaboration arm, participants, who typically did not know each other, were placed in teams of three, and one member of the group was randomly selected to represent the team each day. If the selected participant met his or her step goal the previous day, the team kept their points. If he or she did not meet the goal, the entire team lost points. Each person was accountable to their teammates and the design was intended induce a collaborative effort to meet daily goals.

The competition arm also involved three-member teams who typically did not know each other. Members received a weekly email with a leaderboard that ranked participants based on their cumulative points and showed their achieved level, with the expectation that participants would compete for top spot in their group.

Small Tweaks to Design of Gamification Can Yield Big Differences

The results showed that, after the 24-week intervention, those in all three arms had significantly greater increases in mean daily steps compared with the control arm, with the highest increases in the competition arm (adjusted difference in daily steps, 920; P < .001), followed by the support arm (adjusted difference, 689; P < .001), and collaboration arm (n = 150; adjusted difference, 637; P = .001).

But the real difference between study arms was seen in the 3 months after gamification was turned off, note the researchers.

In the post-intervention follow-up, increases in physical activity remained higher in the competition arm compared with the control arm (adjusted difference in mean daily steps, 569; P = .009) but improvements were no longer significantly different in the support arm (adjusted difference, 428; P = .04) or collaboration arm (adjusted difference, 126; P = .49) compared with the control arm.

"During the 9-month trial, the average person in the competition arm walked about 100 miles more than the average person in [the] control [arm]," said Patel in a press release from his institution.

The findings underscore that "small changes to the design of gamification can lead to important differences in effectiveness," the authors stress.

They note that, contrary to many popular fitness programs using gamification, the STEP UP program used key principles of behavioral economics.

In addition to the social incentives, the measures include precommitment to goals, achievable goal gradients, and the "fresh start effect," resetting with a new set of rewards, such as points, at the beginning of a time period.

"To our knowledge, this was one of the first national evaluations of a behaviorally designed gamification intervention," the authors say.

"Because gamification is often used within workplace wellness programs and digital health applications, incorporating these behavioral insights could improve intervention design to affect a broader population."

Matching the Right Intervention to the Right Patient

Patel added that he and his team are continuing to investigate the important issue of which participant characteristics are most responsive to certain interventions.

Part of the reason for conducting the STEP UP trial was to try to "understand how to match the right intervention to the right patient," he explained. "While we don't have data on that yet, we plan to analyze and publish that data soon."

"Beyond demographic characteristics, we think that other factors such as personality type, social network factors, and risk preferences will help to predict the best intervention for each person," he said.

Review author Phillips stressed to Medscape Medical News that care must be taken with some individuals: "The brain has reward mechanisms in response to winning...this is true of lottery games, board games, or even health-related videogames."

"While this may not be a problem for most individuals, for some individuals the desire to receive that reward mechanism can be difficult to control," he observed.

"This can become a concern when balance is lost and the need to receive the reward mechanism outweighs the benefit of the activity."

With that in mind, one approach to reduce the risk of addictive tendencies could be to tie the reward mechanism to compliance within an acceptable range of activity, as opposed to asking individuals to achieve as much as possible, he explained. 

Phillips and colleagues also suggest the concept of a "digital practitioner" who could monitor progress and select the most appropriate intervention for a given patient.

The study was supported by Deloitte Consulting and the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. Patel has reported receiving personal fees as the owner of Catalyst Health, stock options from LifeVest Health, personal fees and stock options from HealthMine, personal fees from Holistic Industries, and personal fees from Deloitte Consulting outside the submitted work. Disclosures for the other authors are listed with the article.

JAMA Internal Medicine. Published September 9, 2019. Abstract

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