Raising Step Counts to Combat Obesity

A new study examines the possibility of increasing physical activity among veterans by turning daily step counts into a game.

University of Pennsylvania researchers revealed that a group of overweight or obese veterans grew their daily step counts by over 1200, on average, when personalized goals were combined with a game and the possibility of losing reward money if targets weren’t met. The study, which appeared in JAMA Network Open, is thought to be the first of its kind.

“To our knowledge, there really hasn’t been a lot of gamification remote monitoring trials amongst the VA population—specifically using step counts and a mix of different types of gamification,” said Anish K Agarwal, MD, MPH, MS, an assistant professor of emergency medicine at the University of Pennsylvania and a clinical innovation manager at the Penn Medicine Center for Health Care Innovation.

The randomized clinical trial included a total of 180 overweight or obese veterans with a mean age of 56.5 years and a mean body mass index of 33. The participants were divided into three groups: 60 in the control group, 60 in the gamification with social support group, and 60 in the gamification with social support and loss-framed financial incentives group. All participants chose a step goal and were provided with a wearable device to track their step counts.

The first (control) group received feedback only from their devices. “The first group was really just given a step counter and made sure to follow their own counts and be individually inspired to reach a goal and maintain it,” Dr Agarwal told Veterans Health Today.

Those in the gamification groups took part in a 12-week game that included points, levels, and a support partner. In the beginning, participants identified someone (such as a friend, family member, or coworker) who would receive an email ping notifying them of progress made along the way. “We know that that sort of social linkage, or social support, can be a motivating factor for some people,” he explained.

The third cohort also experienced gamification coupled with social support, but members of this group had a “loss-framed” financial incentive as well. They had $120 in a virtual account and stood to lose $10 if they failed to meet their weekly goals.

During the intervention period, veterans in the gamification with financial incentives group experienced a modest increase in daily steps (by an average of 1,224) compared to the control group. Gamification without incentives also positively impacted step count but not to the same extent; participants in this group increased their average step count by 433.

After the games concluded, the researchers continued to track participants’ step counts for eight weeks. During this timeframe, neither group maintained the type of progress seen during the intervention compared to participants who did not take part in the games. The group with financial incentives still had an average increase of over 500 steps in their daily counts. However, the group without financial incentives experienced a drop in daily steps by an average of 160.

The findings suggest that the combination of gamification, social support, and loss-framed financial incentives “can modestly increase physical activity” in obese and overweight veterans, the researchers concluded. Future investigations should include a more representative sample of veterans and may need to incorporate other approaches to achieve larger changes in physical activity and to help sustain those changes over time.

If physicians simply tell their patients that they need to exercise more, most patients will probably agree, said study co-author Kim Waddell, PhD, OTR/L, a postdoctoral fellow at the Center for Health Equity Research and Promotion at the VA Philadelphia Medical Center. But in traditional care models, patients have had to return home and figure out how to incorporate that physical activity on their own.

Patients who don’t have wearables probably aren’t aware of how many steps they are taking over the course of any given day. And for the most part, no one is going to know about their progress or lack thereof. The study, published in JAMA Network Open, demonstrates the importance of closing this feedback loop and incentivizing activity every day, she told Veterans Health Today, which may be something for the VA to consider moving forward.

Recommendations to exercise more may be a good starting point, Dr Agarwal added, but these recommendations can potentially be combined with some sort of competition, social support, or game. And different approaches may lead to different results. The social incentive used in this study was “really, really mild,” he pointed out. It involved just a weekly email sent to a chosen contact.

Practitioners could consider all sorts of possibilities to “dial it up a bit” by enhancing the social connection and competition elements. A daily check-in rather than a weekly, passive correspondence may make a difference, for example, and varying the financial incentive amounts may also impact motivation.

Sticking with the status quo of hoping people can exercise and fit it in on their own may work for some people, Dr Agarwal acknowledged, but he believes there are opportunities to incorporate game-design elements earlier on to help proactively motivate change.

Rather than telling patients they ought to be walking four times a week, for example, “You probably have a better chance if we try to have a robust and integrated way to hover over that patient while they’re not in front of you and while they’re living their daily lives,” he said. And there are now plenty of remote, low-touch digital ways of encouraging behavior change by providing patients with their data and helping them better understand “where they are, where they’ve been, and where they’re going.”