Effect of Behaviorally Designed Gamification With Social Incentives on Lifestyle Modification Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

Abstract

Importance: Gamification is increasingly being used to promote healthy behaviors. However, it has not been well tested among patients with chronic conditions and over longer durations.

Objective: To test the effectiveness of behaviorally designed gamification interventions to enhance support, collaboration, or competition to promote physical activity and weight loss among adults with uncontrolled type 2 diabetes.

Design, setting, and participants: A 4-arm randomized clinical trial with a 1-year intervention was conducted from January 23, 2017, to January 27, 2020, with remotely monitored intervention. Analyses were conducted between February 10 and October 6, 2020. Participants included 361 adults with type 2 diabetes with hemoglobin A1c levels greater than or equal to 8% and body mass index greater than or equal to 25.

Interventions: All participants received a wearable device, smart weight scale, and laboratory testing. Participants in the control group received feedback from their devices but no other interventions. Participants in the gamification arms conducted goal setting and were entered into a 1-year game designed using insights from behavioral economics with points and levels for achieving step goals and weight loss targets. The game varied by trial arm to promote either support, collaboration, or competition.

Main outcomes and measures: Co-primary outcomes included daily step count, weight, and hemoglobin A1c level. Secondary outcome was low-density lipoprotein cholesterol level. Intention-to-treat analysis was used.

Results: Participants had a mean (SD) age of 52.5 (10.1) years; hemoglobin A1c level, 9.6% (1.6%); daily steps, 4632 (2523); weight, 107.4 kg (20.8 kg); and body mass index, 37.1 (6.6). Of the 361 participants, 202 (56.0%) were women, 143 (39.6%) were White, and 185 (51.2%) were Black; with 87 (24.1%) randomized to control; 92 (25.4%) randomized to gamification with support and intervention; 95 (26.3%) randomized to gamification with collaboration; and 87 (24.1%) randomized to gamification with competition. Compared with the control group over 1 year, there was a significant increase in mean daily steps from baseline among participants receiving gamification with support (adjusted difference relative to control group, 503 steps; 95% CI, 103 to 903 steps; P = .01) and competition (606 steps; 95% CI, 201 to 1011 steps; P = .003) but not collaboration (280 steps; 95% CI, -115 to 674 steps; P = .16). All trial arms had significant reductions in weight and hemoglobin A1c levels from baseline, but there were no significant differences between any of the intervention arms and the control arm. There was only 1 adverse event reported that may have been related to the trial (arthritic knee pain).

Conclusions and relevance: Among adults with uncontrolled type 2 diabetes, a behaviorally designed gamification intervention in this randomized clinical trial significantly increased physical activity over a 1-year period when designed to enhance either support or competition but not collaboration. No differences between intervention and control groups were found for other outcomes.

Trial registration: ClinicalTrials.gov Identifier: NCT02961192.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Patel reported receiving personal fees from Catalyst Health LLC as owner, personal fees from Life.io as an advisory board member, stock options and personal fees from HealthMine Services as an advisory board member, and stock options and personal fees from Holistic Industries as an advisory board member outside the submitted work. Ms Hilbert reported receiving grants from the Doris Duke Charitable Foundation during the conduct of the study. Dr Volpp reported receiving grants from the Doris Duke Charitable Foundation with payment to the University of Pennsylvania (the institution) and grants from the National Institute on Aging to the institution during the conduct of the study; grants from Humana, Vitality/Discovery, Hawaii Medical Services Association, and WW not related to this study; a gift to the institution from Independence Blue Cross; personal fees from the Center for Corporate Innovation, Greater Philadelphia Business Coalition, Vizient, Lehigh Valley Medical Center, American Gastroenterological Association Tech Conference, Bridges to Population Health, and the Irish Medtech Summit; is part owner of VAL Health; and has received grants from CVS Health not related to this study outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Consolidated Standards of Reporting Trials Flow Diagram

Participants in all trial arms received a wearable device and smart weight scale and established baseline measures. Participants in the control group received regular feedback from the wearable device, weight scale, and its smartphone application but no other interventions. Participants in the gamification arms set goals for daily steps, weight loss, and hemoglobin A1c level targets and then were entered into 1 of 3 gamification interventions that ran automatically for 1 year.

Figure 2.. Unadjusted Outcomes

Depicted are outcome measures using imputed data as the mean number of daily steps for each arm by month (A); mean weight at baseline, 6 months, and 12 months (B); and mean hemoglobin A1c level at baseline, 6 months, and 12 months. To convert hemoglobin A1c to proportion of total hemoglobin, multiply by 0.01.

Figure 3.. Smart Weight Scale Use

Depicted are the proportion of participants who weighed in at least once per week by trial arm.