Behavioral Gamification Intervention Promotes Physical Activity in Adults With T2D

Smiling woman giving high five to her friend after exercising. Woman looking happy after a successful workout session outdoors.
The researchers’ goal was 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.

Behavior-focused gamification interventions can increase physical activity in adults with uncontrolled type 2 diabetes, according to research results published in JAMA Network Open. Other approaches must be explored in combination with gamification to promote either weight loss or change in glycemic control.

Researchers conducted a 4-arm randomized clinical trial (iDiabetes; Identifier: NCT02961192) between 2017 and 2020 to evaluate the efficacy of gamification interventions incorporating behavioral insights to promote both physical activity and weight loss in a population of adults with overweight or obesity and uncontrolled type 2 diabetes.

Eligible participants received a wearable device and underwent baseline assessment to establish step count. Following this, participants had an in-person visit with the study team and a baseline weigh-in.

Participants were then randomly assigned to 1 of 4 groups: a control arm and 3 gamification arms. Those in the gamification arms completed goal setting sessions during the in-person visit, including a hemoglobin A1c (HbA1c) reduction goal, a weight-loss goal, and a step count increase goal. These participants were also entered into a game that incorporated points and levels, as well as daily progress notifications.

One of the gamification arms was collaborative, with participants working on a team of 3 participants. On a daily basis, a team member was selected to represent the team via weigh-in. Another gamification arm was competitive; these participants (n=3) received a weekly email with a leaderboard that ranked each team member on cumulative points. The final arm was supportive, in which participants were tasked with identifying a friend or family member who would serve as a support sponsor and receive a weekly report on the participant’s progress.

The primary study outcome included change in daily step count and HbA1c level from baseline to 12 months. Secondary outcomes included changes in low-density lipoprotein cholesterol (LDL-C) from baseline to 12 months and change in daily steps, weight, HbA1c, and LDL-C from baseline to 6 months.

The total cohort included 361 participants (mean age, 52.5±10.1 years; HbA1c, 9.6%; 4632 daily steps; weight, 107.4±20.8 kg; body mass index (BMI), 37.1±6.6 kg/m2) who were randomly assigned to 1 of the 4 study arms. Of the participants, 56% were women and 51.2% were Black. In total, 87 participants were in the control group, 92 were in the gamification with support group, 95 were in the gamification with collaboration group, and 87 were in the gamification with competition group, with balanced baseline characteristics across all 4 arms.

At the start of the trial, mean daily step count decreased from baseline in the control group but increased in the 3 gamification arms. By month 3, control participants had a mean of 4421 steps (vs 4410 steps at baseline) compared with 5257 steps, 4909 steps, and 4285 in the gamification with competition, support, and collaboration arms, respectively.

In adjusted models, the researchers found that compared with the control group, there was a significant increase in the mean number of daily steps from baseline in the gamification with support group (adjusted difference, 503 steps; 95% CI, 103-903) and the gamification with competition group (adjusted difference, 606 steps; 95% CI, 201-1011 steps).

In models evaluating physical activity trajectory from the first 6 months to the final 6 months, the investigators found that the trajectory decreased significantly in the gamification with support group (-423 steps; 95% CI, -624 to -223), while gamification with competition did not (-143; 95% CI, -414 to 218). The gamification with collaboration group also significantly decreased (-394 steps; 95% CI, -512 to -276).

In terms of weight, all study arms experienced decreases in mean weight from baseline to 6 months. Between months 6 and 12, the control arm experienced a slight increase in mean weight vs slight decreases in the gamification arms. By month 12, though, all study arms experienced significant mean weight decreases from baseline: -2.0 kg in the control arm, -3.6 kg in the gamification with support arm, -3.4 kg in the gamification with collaboration arm, and -2.9 kg in the gamification with competition arm.

At baseline, 72.3% of participants were receiving insulin, and 39.9% were using an oral diabetes medication. By 6 months, HbA1c level declined in all arms; these levels remained steady through 12 months. In adjusted models, there were no significant HbA1c changes from baseline vs the control group in any gamification arms.

Also at baseline, 49.6% of participants reported the use of a statin medication. Results of adjusted models showed no significant changes in LDL-C levels from baseline in any gamification groups vs the control group at 1 year.

One participant in the gamification with collaboration group reported arthritic knee pain during the study period, and 3 participants died from causes not related to the study.

Most patients who completed a post-study survey reported satisfaction with the wearable device (80.2%). Perceptions of the trial’s effect on the study outcomes were similar across arms: 71.6% for increasing physical activity, 50.6% for helping with weight loss, and 56.8% for improving diabetes control.

Study limitations include the use of a single health system to recruit participants and requirements that participants have access to a smartphone or tablet, limiting generalizability; a lack of measures other than step count to evaluate physical activity; and missing step count data, which was highest in the control group. Investigators also did not collect information on “communications or interactions between participants in the competition or collaboration groups,” rendering them unable to further evaluate the success or lack of these mechanisms.

“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 change in glycemic control,” the researchers concluded.

Disclosure: Some study authors declared affiliations with the biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Patel MS, Mall DS, Harrison JD, et al. Effect of behaviorally designed gamification with social incentives on lifestyle modification among adults with uncontrolled diabetes: a randomized clinical trial. JAMA Netw Open. Published online May 24, 2021. doi:10.1001/jamanetworkopen.2021.10255