Paid incentives, games boost daily steps for people at high risk for heart disease
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Key takeaways:
- Gamification and financial incentives upped daily steps for participants with elevated 10-year ASCVD risk.
- Gameful thinking and monetary rewards were especially effective when combined vs. daily text messages.
ATLANTA — In a study of behavioral economics, researchers reported benefits of gamification and money incentives to boost daily step count for patients at high risk for CVD.
Results of the BE ACTIVE randomized controlled trial that enrolled participants at high 10-year atherosclerotic CVD risk with a daily step count below 7,500 were presented the American College of Cardiology Scientific Session and simultaneously published in Circulation.
“The CDC now recommends 150 minutes per week of moderate to vigorous physical activity, but we know few people exercise that much, especially older adults with the highest risk of cardiovascular disease,” Alexander Fanaroff, MD, assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine, said during the late-breaking clinical trial presentation. “Short-term studies of both gamification and financial incentives increase physical activity, but it’s not certain how long these events lasted or which approach is better. For this reason, we conducted the BE ACTIVE randomized controlled trial.”
Fanaroff and colleagues evaluated strategies including behaviorally designed gamification, loss-framed financial incentives and both in combination and compared those strategies with daily text messaging with the goal to increase physical activity for adults with elevated 10-year ASCVD risk or established vascular disease.
For BE ACTIVE trial, participants were required to have a Penn Medicine primary care physician; own a smartphone or tablet capable of transmitting data from a wearable device provided by the investigators (Fitbit); and a baseline daily step count below 7,500.
Overall, 950 volunteers completed the 12-month intervention and the subsequent 6-month follow-up period (mean age, 67 years; 25% black).
Baseline average step count was 5,000 per day, with a goal increase of 1,500 steps.
Gamification included a point system by which participants lost points for every day they walked fewer than 7,500 steps. Participants received daily texts with their updated scores and a weekly email to a designated support partner chosen by the participant.
During the 12-month intervention, gamification resulted in an average of 1,954 more daily steps from the baseline average and 538 more daily steps compared with controls. During 6-month follow-up, gamification resulted in an average of 1,708 more daily steps from baseline and 460 more daily steps compared with controls.
The financial incentive intervention involved adding $14 to participants’ virtual accounts every week. Every day they did not meet their goal of 7,500 steps, $2 were removed.
During the intervention period, the financial incentive intervention resulted in an average of 1,915 more daily steps from the baseline average and 492 more daily steps compared with controls. During the follow-up period, the financial incentive intervention resulted in an average of 1,576 more daily steps from baseline and 328 more daily steps compared with controls. The researchers also tested an intervention that combined both gamification and financial incentives.
During the intervention period, the combination intervention resulted in an average of 2,297 more daily steps from the baseline average and 868 more daily steps compared with controls. During the follow-up period, the combination intervention resulted in an average of 1,831 more daily steps from baseline and 576 more daily steps compared with controls.
“In observational studies, there’s an inverse association between steps per day and outcomes, mortality and cardiovascular events. Based on the changes that we saw in this study, an increase in mean daily steps by 1,700 steps per day from 5,000 step baseline should be associated with 1.2 years longer life expectancy,” Fanaroff said during the presentation. “We think that these highly scalable, automatically delivered interventions increase physical activity over long-term periods of patients in high-risk of cardiovascular events and could improve outcomes.”
References:
- Fanaroff A, et al. Circulation. 2024;doi:10.1161/CIRCULATIONAHA.124.069531.
- Incentives prompt increased daily walking in patients at risk for heart disease. https://www.acc.org/About-ACC/Press-Releases/2024/04/07/11/39/incentives-prompt-increased-daily-walking-in-patients-at-risk-for-heart-disease. Published April 7, 2024. Accessed April 7, 2024.
- Short-term incentives for exercise can lead to sustained increases in activity. https://www.nhlbi.nih.gov/news/2024/short-term-incentives-exercise-can-lead-sustained-increases-activity. Published April 7, 2024. Accessed April 7, 2024.
Perspective
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Edward T.A. Fry, MD, FACC, FSCAI
From the insurance industry, there had been a lot of initiatives early on in terms of giving people personal health monitors, like step monitors, and then discounts related to insurance premiums. In fact, we did that in our health system in the early 2000s, and we were self-insured. That has gone away and I’m not exactly sure why, but it has been tried. Maybe it was just that the reward was not tangible enough to the individual. The reward in this trial is tangible, in terms of either seeing point scoring or financial incentives.
It seems like there’s some basic human behavior involved here.
Just by participating in the trial, you’ve already selected people with maybe slightly different motivation who may be more receptive to the intervention. Whether it’s selected or not, there is a competitive streak in human nature. But again, it’s a self-selected group of people.
If you saw it in broader practice, I would not be surprised to see that the financial piece would be more powerful. If you think about it, Apple Watches, Fitbits or things like that, the points part of this study, there’s not a lot of rigorous scientific data around those.
Broader used of this intervention would depend on the mechanism of follow-up. It’s not necessarily even holding your feet to the fire, but you just have to own up to your results. The concept is not that far removed from cardiac rehab. There’s nothing magic that goes on in cardiac rehab, but it’s clear that if you complete the 36 paid sessions, your outcomes are dramatically better, including a 30% mortality benefit if it’s for heart attack or heart failure. But this accountability piece sort of eyes the problem.
One thing I thought interesting here is that average daily step count was about 5,000 at baseline, which was higher than I would’ve thought. Then, to increase daily steps by almost 1,900, that gets you to close to 7,000. There was a trial in patients with HF that found no additional incremental benefit once you get past around 8,000 daily steps.
This study highlights a couple things. No. 1, inherent competition is still a good health motivator. No. 2, is that you’ve got to have contact with the health system to sustain all those things. Again, as an analogy to cardiac rehab.
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Fanaroff A, et al. Late-breaking clinical trials II. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
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