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Turning a lifestyle intervention for type 2 diabetes into a game significantly increased participants' physical activity, especially if an element of competition was introduced, the randomized iDiabetes trial found.

In this 1-year trial of an intervention that included a wrist device to track steps and game elements such as points and levels, participants randomized to small teams in which they competed for leaderboard status significantly increased their mean daily step count relative to a control group (606 more steps, 95% CI 201 to 1,011, P=0.003), noted Mitesh Patel, MD, MBA, of the Crescenz Veterans Affairs Medical Center in Philadelphia, and colleagues of the .

Participants randomized to a group that received social support from a family member or friend also significantly increased their mean daily step count relative to controls (503 more steps, 95% CI 103 to 903, P=0.01). However, those randomized to small teams that collaborated did not significantly increase their daily steps (adjusted difference 280 steps, 95% CI -115 to 674, P=0.16), the group reported online in .

All groups also had significant reductions in body weight and hemoglobin A1c (HbA1c) levels from baseline, but there were no significant differences in these outcomes among any of the gamification interventions and the control group, which also had a wrist device to track steps but without any game elements.

"In this study, our objective was to conduct a longer-term randomized clinical trial to test the effectiveness of gamification interventions that incorporated behavioral insights and used supportive, collaborative, or competitive social incentives to promote physical activity and weight loss among adults with overweight or obesity and uncontrolled type 2 diabetes. Patients were remotely monitored for 1 year by using wearable devices, a smart weight scale, and an automated technology platform," the researchers wrote.

The trial included 361 participants; mean age was 52, mean HbA1c was 9.6%, and mean body mass index was 37. Approximately half (56%) were women, 40% were white, and 51% were Black. Nearly three-quarters (72%) were on insulin, and 40% were taking an oral diabetes medication.

Participants were randomized to a control group that received feedback from their wrist devices, but no other intervention, and one of three gamification study arms -- a competitive arm, support arm, and collaborative arm.

The competitive arm consisted of groups of three. These patients typically did not know each other before the study but were introduced by email. At the end of each week, they received an email with a leaderboard that ranked them on their cumulative points in the study and displayed their level. This was intended to encourage participants to compete for the top spot among the group.

The support arm did not include teams. Instead, participants chose a family member or friend to be their sponsor. Sponsors were emailed weekly reports on their participant's performance in the game over the past week and their targets for the upcoming week. Sponsors were told to do their best to support participants in their progress.

The collaborative arm also consisted of groups of three who were introduced to each other by email. Each day, one member was randomly selected to represent their team for that day. If that person had weighed in on the previous day, the team kept the points they had earned. If the person did not, the team lost points. In this design, accountability to the others was intended to induce a collaborative effort to meet daily goals.

The primary outcomes of the trial were changes in daily step counts, body weight, and HbA1c levels from baseline. The step count increases were on the order of 12% to 13%, Patel's group said, noting that even such modest increases in physical activity can have health benefits.

In an , Paul Hebert, PhD, of the Puget Sound Healthcare System in Seattle, said that game elements are increasingly being incorporated into health interventions. "The results of the iDiabetes trial by Patel et al represent the latest in a series of pathbreaking studies of the effects of incorporating game mechanics into interventions to help people improve health behaviors. Researchers at the Penn Medicine Nudge Unit have devised elegant and exceptional simple game mechanics that are rooted in behavioral economic principles and are effective," he wrote.

"This study adds substantially to the Nudge Unit body of work by showing that gamified interventions can help people maintain higher levels of physical activity for a longer period of time in a population more economically and demographically diverse than has been shown in previous studies," he added.

However, the collaborative arm of the study might have produced better results with improved design, Hebert noted. It included a collective loss due to an individual's failure, which is a standard collaborative principle, but it did not allow team members to come to each other's aid, which is another gaming principle that has been shown to be effective, he explained.

Another limitation was the study did not collect data on any physical activity other than daily step counts, which could have influenced the results, Patel's group said. In addition, the study did not collect information on communications or interactions between individuals in the competitive or collaborative arms, which could have helped explain the successes and failures of these groups, they noted.

"The results of the iDiabetes trial indicate that gamification designed to incorporate behavioral insights and delivered through an automated and remotely monitored platform is a promising approach to increase physical activity among adults with type 2 diabetes, but that gamification may need to be combined with other approaches to promote weight loss or changes in glycemic control," they concluded.

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