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Original Investigation
September 9, 2019

Effectiveness of Behaviorally Designed Gamification Interventions With Social Incentives for Increasing Physical Activity Among Overweight and Obese Adults Across the United States: The STEP UP Randomized Clinical Trial

Author Affiliations
  • 1Department of Medicine, Perelman School of Medicine, Philadelphia, Pennsylvania
  • 2Department of Health Care Management, Wharton School of the University of Pennsylvania, Philadelphia
  • 3Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
  • 4Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 5Department of Statistics, Wharton School of the University of Pennsylvania, Philadelphia
  • 6Deloitte Consulting, Philadelphia, Pennsylvania
JAMA Intern Med. 2019;179(12):1624-1632. doi:10.1001/jamainternmed.2019.3505
Key Points

Question  What is the best way to incorporate social incentives within a behaviorally designed gamification intervention to increase physical activity among overweight and obese adults?

Findings  In this randomized clinical trial of 602 overweight and obese adults from 40 states across the United States, gamification interventions with support, collaboration, and competition significantly increased physical activity compared with the control group during the 24-week intervention. The competition arm had the greatest increase in physical activity from baseline during the intervention; during the 12-week follow-up, physical activity was lower in all arms, but remained significantly greater in the competition arm than in the control arm.

Meaning  Small changes to the design of gamification can lead to important differences in effectiveness.


Importance  Gamification, the use of game design elements in nongame contexts, is increasingly being used in workplace wellness programs and digital health applications. However, the best way to design social incentives in gamification interventions has not been well examined.

Objective  To assess the effectiveness of support, collaboration, and competition within a behaviorally designed gamification intervention to increase physical activity among overweight and obese adults.

Design, Setting, and Participants  This 36-week randomized clinical trial with a 24-week intervention and 12-week follow-up assessed 602 adults from 40 states with body mass indexes (calculated as weight in kilograms divided by height in meters squared) of 25 or higher from February 12, 2018, to March 17, 2019.

Interventions  Participants used a wearable device to track daily steps, established a baseline, selected a step goal increase, were randomly assigned to a control (n = 151) or to 1 of 3 gamification interventions (support [n = 151], collaboration [n = 150], and competition [n = 150]), and were remotely monitored. The control group received feedback from the wearable device but no other interventions for 36 weeks. The gamification arms were entered into a 24-week game designed using insights from behavioral economics with points and levels for achieving step goals. No gamification interventions occurred during follow-up.

Main Outcomes and Measures  The primary outcome was change in mean daily steps from baseline through the 24-week intervention period.

Results  A total of 602 participants (mean [SD] age, 39 [10] years; mean [SD] body mass index, 30 [5]; 427 [70.9%] male) were included in the study. Compared with controls, participants had a significantly greater increase in mean daily steps from baseline during the intervention in the competition arm (adjusted difference, 920; 95% CI, 513-1328; P < .001), support arm (adjusted difference, 689; 95% CI, 267-977; P < .001), and collaboration arm (adjusted difference, 637; 95% CI, 258-1017; P = .001). During follow-up, physical activity remained significantly greater in the competition arm than in the control arm (adjusted difference, 569; 95% CI, 142-996; P = .009) but was not significantly greater in the support (adjusted difference, 428; 95% CI, 19-837; P = .04) and collaboration (adjusted difference, 126; 95% CI, −248 to 468; P = .49) arms than in the control arm.

Conclusions and Relevance  All 3 gamification interventions significantly increased physical activity during the 24-week intervention, and competition was the most effective. Physical activity was lower in all arms during follow-up and only remained significantly greater in the competition arm than in the control arm.

Trial Registration  ClinicalTrials.gov identifier: NCT03311230

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