Can Activity Trackers, Financial Incentives Improve Long-term Outcomes?

Even with the addition of financial incentives, regular use of a wearable tracker that monitors and offers feedback on physical activity did not raise exercise levels enough to produce significant health benefits, according to results published in The Lancet Diabetes & Endocrinology.¹

Physical inactivity is the fourth leading risk factor for global mortality, according to research published in 2012.² However, the increasing popularity of activity trackers—1 in 10 US adults owns one of these devices³—may help people achieve recommended levels of exercise and reduce their risk for noncommunicable diseases like diabetes and heart disease. Moreover, employers, insurers, and government agencies are encouraging the use of activity trackers in the hopes of improving the population’s health.⁴

To determine whether activity trackers combined with financial incentives increase exercise levels, researchers conducted the TRIPPA trial (A Randomized Trial of Economic Incentives to Promote Walking Among Full Time Employees; ClinicalTrials.gov identifier: NCT01855776). A total of 800 employees aged 21 to 65 years from 13 organizations in Singapore were recruited for the study.

Between June 13, 2013, to August 15, 2014, the researchers randomly assigned participants to 1 of 4 groups: control, meaning no tracker or incentives (n=201), use of an activity tracker (Fitbit Zip; n=203), use of the tracker plus charity incentives (n=199), and use of the tracker plus cash incentives (n=197). Both the charity and cash groups were told they could earn up to S$15 (Singapore dollars) per week if they logged between 50,000 and 70,000 steps or S$30 if they logged more than 70,000 steps.

The charity group donated this money to a charity of their choice while the cash group kept the money for themselves. To maintain engagement, the control and activity tracker only groups received S$4 weekly regardless of step count. Incentives ceased after 6 months, but participants were allowed to keep the activity tracker.

The amount of moderate-to-vigorous physical activity served as the primary outcome, and step count, weight, blood pressure, cardiorespiratory fitness, and self-reported quality of life at baseline and 6 and 12 months later were also recorded.

At 6 months, both mean daily steps and moderate-to-vigorous physical activity declined in the control group and remained stable in the charity incentive and activity tracker only groups. In contrast, participants in the cash incentive group experienced a 570-step increase in mean daily steps (95% CI, 210-930; P =.0016) and were 8% (95% CI, 0-17; P =.0458) more likely to meet the 70,000 weekly step target.¹ 

The researchers noted, however, that moderate-to-vigorous physical activity only increased by 22 minutes per week (95% CI, 5-38; P =.0096) for those who were insufficiently active at baseline.¹

Additionally, at 6 months, compared with the control group, participants in the cash incentive group recorded 29 more minutes of moderate-to-vigorous physical activity per week (95% CI, 10-47; P =.0024) and those in the charity incentive group recorded 21 more minutes per week (95% CI, 2-39; P =.031).¹

There were no significant differences between the control and activity tracker only groups or between the cash and charity incentive groups and the activity tracker only group.

Despite initial increases in physical activity, at 12 months—6 months after incentives were stopped—physical activity declined to near-baseline levels in the cash incentive group. Participants in the activity tracker only group, however, had improved levels of physical activity, logging an additional 16 minutes of moderate-to-vigorous physical activity per week (95% CI, 2-30; P =.0301).¹

The researchers reported no improvements in health outcomes at either 6 or 12 months.

“[W]e found no evidence that the device promoted weight loss or improved blood pressure or cardiorespiratory fitness, either with or without financial incentives,” lead study author Eric Finkelstein, PhD, of Duke-NUS Medical School in Singapore, said in a press release.⁵ “While there was some progress early on, once the incentives were stopped, volunteers did worse than if the incentives had never been offered, and most stopped wearing the trackers.”

In light of their findings, Dr Finkelstein and colleagues hypothesized that the type and length of financial incentive may be crucial to its effectiveness.

“Our findings suggest that coupling the incentives to daily steps may not be the way to go. However, tying them to MVPA (moderate-to-vigorous physical activity) or aerobic steps is worth considering, as these are the type of steps most likely to improve health. Yet, the results also suggest that any incentive strategy would need to be in place for a longer period of time to generate any noticeable improvements in health benefits and to avoid undermining effect from their removal,” he added.

The researchers also pointed out that about 40% of participants stopped using the tracker during the first 6 months and only about 10% were still wearing the tracker at 12 months.

“We saw a large drop-off in usage as the study went on,” study co-author Robert Sloan, PhD, of Kagoshima University Graduate School of Medical and Dental Sciences in Japan, explained in the press release. “People use these devices for a while, but with time the novelty wears off—this is consistent with how people use trackers in real life.”

The researchers cited several study limitations. Notably, participants volunteered for the study and therefore may have been healthier or more interested in being physically active than the general population. They also stated that the control group’s decrease in physical activity may have resulted from baseline physical activity that was “artificially high as a result of joining the study or wearing the accelerometer for the first time.” There was also potential for contamination, as participants within worksites but in different study groups may have interacted with each other.

In a related commentary, Courtney M. Monroe, PhD, of the University of South Carolina in Columbia, stated that the “timely” trial fills gaps in the scientific literature about the combined effect of financial incentives and use of these new wearable devices. She underscored the relevance of the findings as well as opportunities for more research.⁶

“Future incentive-based studies targeting physical activity should include measures of motivation and examine how different aspects of these approaches (eg, incentive distribution patterns, reward intervals, and incentive amount) can be manipulated to positively affect intrinsic motivation and physical activity in a cost-effective manner,” she wrote.

“Testing the use of financial incentives, wearables, or both, in conjunction with other financial incentives, wearables, or both, in conjunction with other technologies and strategies that have great potential as components of physical activity promotion.. is a logical future step.”

Disclosures: The researchers report no conflicts of interest. Dr Monroe reports no conflicts of interest.

References

1. Finkelstein EA, Haaland BA, Bilger M, et al. Effectiveness of activity trackers with and without incentives to increase physical activity (TRIPPA): a randomized controlled trial. Lancet Diabetes Endocrinol. 2016 Oct 4. doi:10.1016/S2213-8587(16)30284-4 [Epub ahead of print]
2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; for the Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380: 219–229. doi:10.1016/S0140-6736(12)61031-9.
3. Ledger D, McCaffrey D. Inside wearables: how the science of human behaviour change offers the secret to long-term engagement. Endeavour Partners, 2014. http://endeavourpartners.net/assets/Endeavour-Partners-Wearables-White-Paper-20141.pdf. Accessed September 6, 2016.
4. Zulman DM, Damschroder LJ, Smith RG, et al. Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults. Transl Behav Med. 2013;3:357–369. doi:10.1007/s13142-013-0211-6.
5. Even with charity or cash incentives, activity trackers do not appear to improve health [news release]. New York, NY: Lancet Journals Press Office; October 4, 2016. Accessed October 13, 2016.
6. Monroe CM. Valuable steps ahead: promoting physical activity with wearables and incentives. Lancet Diabetes Endocrinol. 2016 Oct 4. doi:10.1016/S2213-8587(16)30264-9 [Epub ahead of print].

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This article originally appeared on Endocrinology Advisor