BE ACTIVE: Gaming for Points and Money Can Boost Step Counts

ATLANTA, GA—Techniques borrowed from behavioral economics, including a participating in a game that awards people points and small sums of money, may help patients increase their daily physical activity levels, the BE ACTIVE study suggests.

Participants with or at increased risk for atherosclerotic cardiovascular disease (ASCVD) were allowed to set their own step goals after using a commercially available fitness tracker given to them by the researchers. Once their baseline was established, they were asked to increase their steps by 33%, 40%, or 50% above baseline and that number served as their personal daily walking goal.

While those randomized to winning points increased their daily steps by 538 more than did the nonincentivized control group, and those randomized to winning money increased by 491 steps more than controls, patients who received points plus money in the game saw the greatest increase and the only one that was statistically significant, at 868 steps per day.

Presentation ACC 2024

Gamification, Financial Incentives, or Both to Increase Physical Activity Among Patients at High Risk of Cardiovascular Events: The BE ACTIVE Randomized Controlled Trial

Alexander C. Fanaroff, MD (University of Pennsylvania, Philadelphia), the study’s lead author, presented BE ACTIVE at the American College of Cardiology 2024 Scientific Session. It was simultaneously published in Circulation.

For most participants, their daily baseline was about 5,000 steps, which previous studies suggest is in line with what the typical American reports but about half the commonly cited goal of 10,000 steps per day, Fanaroff told TCTMD. The mean goal increase was about 1,800 steps per day.

“If we tell people they should strive to reach 10,000 steps a day, that can be really demotivating,” he said. “I think there’s a lot to be said for telling our patients to do what you’re doing now, but do just do a little more.”

It has to be important to you for you to want to engage with it, and that is a big challenge in preventive medicine. Alexander C. Fanaroff

Commenting for TCTMD, ACC President Cathleen Biga, MSN, RN (Cardiovascular Management of Illinois, Woodridge), agreed with that perspective, noting that with many people sitting for upwards of 80% of their day, participating in a game that pays out something in return for playing may entice those who say they struggle to fit even a little exercise into their work-life balance.

“If we can get sedentary people to do 5,000 steps a day, they will lose weight and they will drop their blood pressure and their lipids,” she noted. “Letting people set their own goals may take away some of the fear that they can’t do it or that they shouldn’t even bother to try.”

Gamification Motivation

Fanaroff and colleagues randomized 1,062 patients (mean age 67 years; 60% women) to a control group, gamification, financial incentives, or gamification plus financial incentives. Those participating in gamification received 70 points each week and progressed to the next level if they hit their step goal and lost points for each day they did not meet it. The financial incentives group received $14 per week if they met their step goal and lost $2 for each day they did not meet it. Patients also selected a support partner who received weekly email updates on their progress.

The fitness tracker was used in conjunction with a smartphone or tablet as part of an evidence-based patient engagement platform to transmit the step count information and receive messages from the study team. Financial incentive participants had a bank card attached to their accounts so their winnings could be deposited or removed as they progressed through the study. Control patients received only text messages about their step count goal.

During the main intervention period, gamification plus financial incentives was superior to financial incentives (P = 0.0102) and resulted in about 10 more minutes per week of exercise than the other interventions.

After 12 months, patients no longer received points or money, but for the next 6 months all continued to receive text messages daily reporting their step count from the previous day. Still, the effect of the intervention was sustained, with 459.8 more steps per day than baseline in the gamification group (P = 0.0171), 327.9 more steps in the financial incentives group (P = 0.09), and 576.2 more steps in the gamification plus incentives group (P = 0.0028).

Maintaining Motivation and Scalability Questions

“What we found interesting is that people told us they weren’t necessarily motivated by the money or the game. They were motivated by getting healthier, [and] they saw this as a fun avenue to exercise. I think most people who don’t exercise regularly have a hard time getting started, so this is a nudge in the right direction,” Fanaroff told TCTMD. “It's not Farmville, it's not Wordle, but it gets people going and it maintains their intrinsic motivation. It has to be important to you for you to want to engage with it, and that is a big challenge in preventive medicine.”

At 18 months, 70% of the participants reported that they were still wearing their fitness tracker every day.

While the study didn’t look at how the exercise intervention affected outcomes, Fanaroff said that’s the next logical step. “We have something that we know increased physical activity, so now we need to see if it can improve clinical outcomes that matter to patients,” he added.

If you live in an unsafe neighborhood, a mile and a half is a very long way. Cathleen Biga

To TCTMD, Biga said the intervention is creative and the results are impressive, but she wondered how scalable it would be for busy practices. “The big question in my mind is who’s going to pay for it?” she said, adding that the deeper question for payers is how to balance the cost of the intervention with the potential of getting patients off medications and preventing adverse events and expensive hospitalizations.

“You also have the issue of who is going to keep track of this in terms of running the program and following patients’ progress,” Biga said. Beyond that, there are socioeconomic considerations such that some patients may not be able to participate because they don’t have spaces to walk.

“If you live in an unsafe neighborhood, a mile and a half is a very long way,” she noted. “So, there are mitigating circumstances that have to be taken into consideration to make a program like this doable for everyone. It’s a great idea, [but] like many great ideas the challenge is how to we implement it outside of a research setting.”