Health-protecting behaviors such as physical activity are crucial for health, yet positive behavior changes are often accompanied by setbacks and relapses. Previous research suggests that critical fluctuations in behavioral time series might foreshadow relapses as early warning signals. This study examines the association between critical fluctuations, quantified as dynamic complexity (DC), and impending sudden changes in physical activity, here walking behavior. We analyzed step count data from 21,425 participants during enrollment in a digital physical activity intervention, covering a total of 5,474,501 person-days. Step counts were recorded via smartphones or wearables. Generalized multilevel models revealed a positive association between DC and impending sudden losses in walking (odds ratios [OR] 1.93–1.32). In contrast, the association between DC and impending sudden gains was weaker and less consistent (OR = 1.10–0.89). These findings provide evidence for the role of critical fluctuations as early warning signals for sudden losses in walking behavior and highlight their potential in designing timely and targeted interventions, notably just-in-time adaptive interventions.

Health-protecting behaviors such as walking are crucial for health, yet positive behavior changesare often accompanied by setbacks and relapses. Previous research suggests that critical fluctuations in behavioral time series might foreshadow relapses as early warning signals. This study examines the association between critical fluctuations, quantified as dynamic complexity(DC), and impending sudden changes in walking behavior. We analyzed step count data from 21,425 participants during enrollment in a digital physical activity intervention, covering a total of 5,474,501 person-days. Step counts were recorded via smartphones or wearables. Generalized multilevel models revealed a positive association between DC and impending sudden losses in walking (odds ratios [OR] 1.93 - 1.32). In contrast, the association between DC and impending sudden gains was weaker and less consistent (OR = 1.10 - 0.89). These findings provide evidence for the role of critical fluctuations as early warning signals for sudden losses in walking behaviorand highlight their potential in designing timely and targeted interventions.

Background: Despite the promising efficacy of gamified digital interventions in promoting physical activity, we currently have limited evidence on the theory-based mechanisms responsible for effects of these interventions on behavior change. Objectives: As part of the DIPPAO intervention randomized controlled trial, we examined the effects of a digital, gamified adapted physical activity program (KiplinTM) on autonomous motivation and weight stigma processes among obese patients with type 2 diabetes and tested candidate psychological mechanisms underlying these effects based on self-determination theory and the social identity approach. Methods: Participants (N = 50, M age = 47.90 years, SD = 12.49; 74% female) were randomized to either the KiplinTM digital intervention program or a usual care control group and followed the program for three months. Outcome measures of device-assessed physical activity and psychological variables (motivation, need satisfaction, in-group identification, weight stigma) were assessed at baseline and 6-month follow-up. Data were analyzed using mixed-effects models and partial least squares structural equation modeling. Results: Autonomous motivation increased significantly in both groups, but with no significant between-group differences. Structural equation modeling did not support the proposed theory-based mechanisms for intervention effects. Conclusion: Current data do not support motivation and weight stigma changes as potential mechanisms for the efficacy of the digital intervention over traditional programs. Future research should investigate additional candidate psychological mechanisms that account for program effects using designs with adequate statistical power and sufficiently sensitive measures, consider psychological mediators representing reflective and automatic behavioral determinants, and employ appropriate control or comparison groups. Trial Registration: ClinicalTrials.gov NCT04887077; https://clinicaltrials.gov/study/NCT04887077

Background:Physical activity (PA) is a cornerstone of obesity treatment. However, changes in self-perceptions during supervised PA interventions remain insufficiently understood, particularly regarding their temporal dynamics and maintenance after intervention completion. Moreover, because individuals with obesity tend to avoid in-person PA due to fear of stigma, digital PA programmes may represent a particularly relevant alternative. Methods:This article reports a multi-time-point intervention study using a dual-independent cohort design. Changes in self-esteem and body image facets during supervised PA interventions in women with obesity were explored in two independent longitudinal studies. Global self-esteem (GSE), physical self-worth (PSW) and its four subdomains (sport competence, physical condition, physical strength and body attractiveness), body dissatisfaction and body appreciation were assessed at baseline, monthly during each intervention, and at three-month follow-up. Results:In Study 1, women who completed the face-to-face intervention (n = 63) showed significant increases in GSE, PSW and its four subdomains, and body appreciation, along with a significant decrease in body dissatisfaction. In Study 2, women who completed the digital intervention (n = 19) showed similar patterns of change, except that GSE, physical strength, and sport competence did not significantly differ from pre-to post-intervention. Across both studies, most changes were observed within the first month, plateaued over the remaining two months, and were maintained at follow-up. A similar pattern was observed across both modalities. Conclusion:These findings suggest that supervised PA interventions, delivered either face-to-face or digitally, may be associated with improvements in self-esteem and body image among women with obesity and that the first weeks of a supervised PA programme may represent a critical moment for these variables. These findings are relevant in the context of the obesity epidemic, as these variables are key indicators of mental health and predictors of healthy behaviours and long-term weight loss.

Adapted physical activity (PA) programs benefit patients with non‑communicable diseases, but access barriers limit reach. Hybrid programs mixing in‑person and telehealth sessions may overcome these constraints. The purpose of this study was to evaluate the acceptability and effectiveness of a 3‑month hybrid APA program compared with usual face‑to‑face care and to examine whether benefits persist up to 36 months. Twenty patients with chronic diseases completed an APA program that began onsite and transitioned to videoconference plus home exercises. A historical cohort of 100 patients who received the standard onsite program and matched baseline characteristics served as controls. Changes in self-reported PA, physical capacities, and body composition of patients from both programs were measured at baseline and 3, 6, 12, 4, 36 months and analyzed using random-effect models. Adherence and satisfaction were also evaluated. Participants in the hybrid program showed high adherence and acceptability to the program, significant improvements in cardiorespiratory capacity, and reported increased PA levels. Overall effect sizes between the two groups were small. Importantly, the effects of both programs on these variables persisted 3 months after the end of the program with meaningful effect sizes and up to 33 months after the end of the program for 6 MWT. However, dropout rates during follow-up were high. Despite high acceptability and adherence for most patients of the hybrid group, some patients demonstrated lower participation. In conclusion, a hybrid program including telehealth was feasible, well‑accepted, and produced durable, clinically meaningful gains in cardiorespiratory fitness, and physical activity that matched conventional rehabilitation. Larger randomized trials are warranted to confirm these findings.

Background:Digital health interventions and gamification hold promise for managing chronic diseases, but evidence comparing their efficacy, long-term effectiveness, and cost-efficiency with those of usual care is limited. Moreover, there is a growing need for randomized controlled trials (RCTs) evaluating digital physical activity interventions to incorporate idiographic approaches and intensive longitudinal assessments that capture individual variability and the dynamic nature of behavior change. Objective:This 2-arm parallel RCT with embedded N-of-1 analyses examined whether a digital intervention integrating gamification and telecoaching (Kiplin program) outperformed a supervised, face-to-face, adapted physical activity program (usual care) in improving physical activity, clinical outcomes, and cost-effectiveness among adults with obesity and type 2 diabetes (T2D). Methods:We randomized (1:1) 50 patients with obesity or T2D (mean age 47.90, SD 12.49 years; 37/50, 74% female) referred to the University Hospital of Clermont-Ferrand, France, to either the Kiplin digital program or the usual care group. Both programs lasted 3 months, with a 6-month follow-up. The Kiplin intervention included 2 face-to-face and 20 online supervised sessions and 3 mobile app games, whereas the control group completed a standard hospital-based adapted physical activity (APA) program with 3 individual face-to-face, supervised sessions per week (36 sessions). The primary outcome was the change in daily step count, measured objectively and continuously via wearable devices from baseline to the end of the intervention. Secondary outcomes included changes in accelerometer-assessed physical activity, quality of life, body composition, physical capacities, and daily steps over 9 months. Program adherence was also evaluated. Mixed-effects models and generative additive models were conducted to analyze both between- and within-person evolutions in physical activity. A cost-utility analysis was computed to compare the cost-effectiveness of the programs. Results:Compared with usual care, Kiplin participants achieved greater increases in daily steps during both the 3-month intervention (+1085 steps/day) and follow-up (+1775 steps/day), with sustained effects over time. Idiographic analyses revealed marked heterogeneity, showing substantial between- and within-person variability, with 9 participants exhibiting nonlinear patterns and divergent individual trajectories, with some participants showing no improvement. No significant group differences were observed in secondary clinical outcomes, except for change in moderate-to-vigorous physical activity, in favor of the Kiplin group. Cost-utility analyses showed no significant difference between programs. Kiplin participants attended an average of 14.68 of 22 possible APA sessions and engaged in an average of 2.6 games. In contrast, usual care patients attended an average of 30.27 of 36 APA sessions. Conclusions:This study demonstrates the potential of digital gamified interventions to promote and sustain physical activity, offering an alternative to face-to-face programs. However, individual heterogeneity in the response to the intervention highlights the need for screening tools and tailored approaches. Further large-scale studies are warranted to evaluate the long-term clinical and economic impact of such interventions.

BackgroundDigital interventions integrating gamification features hold promise to promote daily steps. However, results regarding the effectiveness of this type of intervention are heterogeneous and not yet confirmed in real-life contexts. ObjectiveThis study aims to examine the effectiveness of a gamified intervention and its potential moderators in a large sample using real-world data. Specifically, we tested (1) whether a gamified intervention enhanced daily steps during the intervention and follow-up periods compared to baseline, (2) whether this enhancement was higher in participants in the intervention than in nonparticipants, and (3) what participant characteristics or intervention parameters moderated the effect of the program. MethodsData from 4819 individuals who registered for a mobile health Kiplin program between 2019 and 2022 were retrospectively analyzed. In this intervention, participants could take part in one or several games in which their daily step count was tracked, allowing individuals to play with their overall activity. Nonparticipants were people who registered for the program but did not take part in the intervention and were considered as a control group. Daily step counts were measured via accelerometers embedded in either commercial wearables or smartphones of the participants. Exposure to the intervention, the intervention content, and participants’ characteristics were included in multilevel models to test the study objectives. ResultsParticipants in the intervention group demonstrated a significantly greater increase in mean daily steps from baseline than nonparticipants (P<.001). However, intervention effectiveness depended on participants’ initial physical activity. The daily steps of participants with <7500 baseline daily steps significantly improved from baseline both during the Kiplin intervention (+3291 daily steps) and the follow-up period (+945 daily steps), whereas participants with a higher baseline had no improvement or significant decreases in daily steps after the intervention. Age (P<.001) and exposure (P<.001) positively moderated the intervention effect. ConclusionsIn real-world settings and among a large sample, the Kiplin intervention was significantly effective in increasing the daily steps of participants from baseline during intervention and follow-up periods compared to nonparticipants. Interestingly, responses to the intervention differed based on participants’ initial steps, with the existence of a plateau effect. Drawing on the insights of self-determination theory, we can assume that the effect of gamification could depend of the initial motivation and activity of participants.

Cognitive asymmetry is an effortless self-control strategy observed in successful self-regulators, for whom exposure to temptations (e.g., sedentary [SED] opportunities) increases the cognitive accessibility of long-term goals (e.g., physical activity [PA]), whereas exposure to goals should not increase the cognitive accessibility of the temptations. However, this mechanism has rarely been observed in the context of PA, and a recent high-powered study did not replicate it in the academic context. Therefore, additional replication studies are needed to support the existence of the phenomenon, or not. The present study attempted to replicate the cognitive asymmetry mechanism in the PA context based on a high-powered design. To do so, 257 participants completed a primed lexical decision task including PA-related (i.e., goal) and SED-related (i.e., temptation) stimuli target words preceded by a relevant SED-related and PA-related prime, respectively, or an irrelevant-related prime (i.e., neutral words). Results showed significant priming effects-SED-related primes increased the cognitive accessibility of PA-related words and PA-related primes increased the cognitive accessibility of SED-related words. However, we did not replicate the hypothesized cognitive asymmetry pattern between temptations and goals. These findings were consistent with a recent replication study by demonstrating that the automatic associations between goals and temptations were more likely to be symmetric (i.e., bidirectional linkage facilitation) than asymmetric (i.e., activation of the goal by temptations, but inhibition of the temptations by goals).

BackgroundCardiorespiratory fitness and muscle strength are valid markers of health and strong predictors of mortality and morbidity. The tests used to measure these variables require in-person visits with specialized equipment and trained personnel-leading to organizational constraints both for patients and hospitals, and making them difficult to implement at a large scale. In this context, technologies embedded in smartphones offer new opportunities to develop remote tests. ObjectivesThis study aimed to test the validity and reliability of MediEval, a newly developed app-based medical device that allows individuals to perform the 6-minute walk test (6MWT) and the 30-second sit-to-stand (30s-STS) test on their own using GPS signal and camera detection with a skeleton extraction algorithm. MethodsA total of 53 healthy adults performed the two tests in three different sessions to determine the intra- and inter-day reproducibility. Test validity was assessed by comparing the results obtained from the app to gold standard measures. Pearson correlations and concordance correlation coefficients, the relative measurement error, intraclass correlation coefficients, the standard error of measure and the minimal detectable change were computed for each test.s ResultsThe results revealed high to excellent validity of the app in comparison to gold standards (& rho; = 0.84 for the 6MWT and & rho; = 0.99 for the 30s-STS test) with low relative measurement error. The mean differences between the app and the gold standard measures were 8.96m for the 6MWT and 0.28 repetition for the 30s-STS test. Both tests had good test-retest reliability (ICCs = 0.77). The minimal detectable changes were respectively 97.56 meters for the 6MWT and 7.37 repetitions for the 30s-STS test. ConclusionThe MediEval medical device proposes valid and reproducible measures of the 6MWT and the 30s-STS test. This device holds promise for monitoring the physical activity of large epidemiologic cohorts while refining patient experience and improving the scalability of the healthcare system. Considering minimal detectable change values, it may be important to ask participants to perform several tests and average them to improve accuracy. Future studies in clinical context are needed to evaluate the responsiveness and the smallest detectable changes of the device for specific populations with chronic diseases.

IntroductionPhysical inactivity and excessive sedentary behaviours are major preventable causes in both the development and the treatment of obesity and type 2 diabetes mellitus (T2DM). Nevertheless, current programmes struggle to engage and sustain physical activity (PA) of patients over long periods of time. To overcome these limitations, the Digital Intervention Promoting Physical Activity among Obese people randomised controlled trial (RCT) aims to evaluate the effectiveness of a group-based digital intervention grounded on gamification strategies, enhanced by social features and informed by the tenets of the self-determination theory and the social identity approach.Methods and analysisThis trial is a two-arm parallel RCT testing the effectiveness of the Kiplin digital intervention on obese and patients with T2DM in comparison to the usual supervised PA programme of the University Hospital of Clermont-Ferrand, France. A total of 50 patients will be randomised to one of the two interventions and will follow a 3-month programme with a 6-month follow-up postintervention. The primary outcome of the study is the daily step count change between the baseline assessment and the end of the intervention. Accelerometer data, self-reported PA, body composition and physical capacities will also be evaluated. To advance our understanding of complex interventions like gamified and group-based ones, we will explore several psychological mediators relative to motivation, enjoyment, in-group identification or perceived weight stigma. Finally, to assess a potential superior economic efficiency compared with the current treatment, we will conduct a cost–utility analysis between the two conditions. A mixed-model approach will be used to analyse the change in outcomes over time.Ethics and disseminationThe research protocol has been reviewed and approved by the Local Human Protection Committee (CPP Ile de France XI, No 21 004-65219). Results will inform the Kiplin app development, be published in scientific journals and disseminated in international conferences.Trial registration numberNCT04887077.

Background: Gamification refers to the use of game elements in nongame contexts. The use of gamification to change behaviors and promote physical activity (PA) is a promising avenue for tackling the global physical inactivity pandemic and the current prevalence of chronic diseases. However, there is no evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature. Objective: The aim of this systematic review and meta-analysis is to evaluate the effectiveness of gamified interventions and their health care potential by testing the generalizability and sustainability of their influence on PA and sedentary behavior. Methods: A total of 5 electronic databases (PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials published in English from 2010 to 2020. Eligibility criteria were based on the components of the participants, interventions, comparators, and outcomes framework. Studies were included when they used gamified interventions in daily life with an active or inactive control group and when they assessed a PA or sedentary behavior outcome. We conducted meta-analyses using a random-effects model approach. Sensitivity analyses, influence analyses, and publication bias analyses were performed to examine the robustness of our results. Results: The main meta-analysis performed on 16 studies and 2407 participants revealed a small to medium summary effect of gamified interventions on PA behavior (Hedges g=0.42, 95% CI 0.14-0.69). No statistical difference among different subgroups (adults vs adolescents and healthy participants vs adults with chronic diseases) and no interaction effects with moderators such as age, gender, or BMI were found, suggesting good generalizability of gamified interventions to different user populations. The effect was statistically significant when gamified interventions were compared with inactive control groups, such as waiting lists (Hedges g=0.58, 95% CI 0.08-1.07), and active control groups that included a nongamified PA intervention (Hedges g=0.23, 95% CI 0.05-0.41). This suggests that gamified interventions are not only efficient in changing behavior but also more effective compared with other behavioral interventions. The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) was weaker, with a very small to small effect (Hedges g=0.15, 95% CI 0.07-0.23). Conclusions: This meta-analysis confirms that gamified interventions are promising for promoting PA in various populations. Additional analyses revealed that this effect persists after the follow-up period, suggesting that it is not just a novelty effect caused by the playful nature of gamification, and that gamified products appear effective compared with equivalent nongamified PA interventions. Future rigorous trials are required to confirm these findings.

Understanding what predicts behavior change is a hot topic in health psychology, especially with regard to physical activity. While existing research has revealed key factors of physical activity (e.g., reasoned cognitions, automatic processes), it fails to accurately identify those that are specific to the most inactive populations (e.g., older adults, obese individuals, women, people living with chronic disease). In this commentary, we propose to articulate current approaches of health behavior change with the social psychology of stereotypes, based on the observation that inactive groups are often targeted by negative stereotypes. This articulation may allow to better identify the barriers to physical activity that are specific to individuals from the most inactive groups. More particularly, we propose that low self-control resources, indexed by perceived fatigue, and negative self-perceptions may be key factors of physical inactivity in these individuals. This proposition could in turn help to explain why some behavioral change techniques that are efficient in healthy or young adults are inefficient in other individuals.

Abstract Despite the accumulation of scientific evidence supporting the benefits of physical activity, the general population remains insufficiently active and this situation is even worsened for some specific populations such as obese people (Barker et al., 2019). It is therefore becoming urgent to develop interventions that can effectively change individuals' behavior. In this context, “e-health” interventions and gamification appear to be a particularly promising avenue to improve physical activity and reduce attrition rates of current programs. This study protocol aims to present a randomized, two-arm intervention design that will examine the efficacy of a digital intervention based on play and teamwork for an obese sample. Fifty patients will be recruited at the hospital of Clermont-Ferrand, France and randomized into two groups: the experimental group will receive digital supervised sessions of PA in videoconference and a gamification of PA through a mobile app and will be compared to an active control group representing the traditional care program (supervised physical activity three times per week during three months). Informed by the tenets of the social identity approach and built around behavior change techniques, implemented via the principles of gamification, this three-month intervention has the objective to improve physical activity adherence. Objective and self-reported PA, quality of live, physical condition and psychological variables like motivation or perceived discrimination will be assessed before, at the end of the intervention and then at the issue of a 6-month follow up in order to evaluate the long-term effect of the intervention. We make the assumption that the intervention will be efficient by the development of an intrinsic motivation through the process of gamification on the one hand. On the other hand, through the in-group collaboration with other people who share the same stigmatized criteria that will help participants to overcome weight stigmas, acting generally as physical activity barriers. This poster presentation will introduce the conception of the intervention, the experimental design and proposed evaluation of the trial. If the effectiveness of this intervention is confirmed, its implementation in the health circuit could reduce the costs and constraints associated to face-to-face support.

Understanding what predicts behavior change is a hot topic in health psychology, especially with regard to physical activity. While existing research has revealed key factors of physical activity (e.g., reasoned cognitions, automatic processes), it fails to accurately identify those that are specific to the most inactive populations (e.g., older adults, obese individuals, women, people living with chronic disease). In this commentary, we propose to articulate current approaches of health behavior change with the social psychology of stereotypes, based on the observation that inactive groups are often targeted by negative stereotypes. This articulation may allow to better identify the barriers to physical activity that are specific to individuals from the most inactive groups. More particularly, we propose that low self-control resources and self-perceptions may be key factors of physical inactivity in these individuals. This proposition could in turn help to explain why some behavioral change techniques that are efficient in healthy or young adults are inefficient in other individuals.

BACKGROUND The use of gamification to change behaviors and promote physical activity is a promising avenue to tackle the global physical inactivity pandemic and the current prevalence of chronic diseases. However, we do not have yet evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature. OBJECTIVE This systematic review and meta-analysis aimed to evaluate the effectiveness of gamified interventions and their healthcare potential by testing the scalability and sustainability of their influence on physical activity (PA) and sedentary behaviors (SB). METHODS Five electronic databases (Pubmed, EMBASE, Scopus, Web of Science and CENTRAL) were searched for randomized controlled trials (RCTs) published since 2010. Eligibility criteria were based on components of PICO (participants, interventions, comparators, and outcomes). Studies were included when they used gamified interventions in daily life with an active or inactive control group, and when they assessed a PA or SB outcome. Studies were excluded when the intervention was based on an active video game using a gaming console. We conducted meta-analyses using a random effects model approach. Sensitivity analyses, influence analyses and publication bias analyses were performed to examine the robustness of our results. RESULTS The main meta-analysis performed on 16 studies and 2407 participants, revealed a small to medium summary effect of gamified interventions on PA behavior (g = 0.42 (95%CI [0.14, 0.69]). No statistical difference was found between different subgroups (adults vs adolescents, healthy participants vs adults with chronic diseases) and no interaction effects with moderators like age, gender or BMI, suggesting good scalability of gamified interventions. Moreover, the effect appears better on the step count (MD = +1609.56 steps per day (95%CI [372.39, 2846.73]) than on moderate-to-vigorous PA (g = 0.31 (95%CI [-0.19, 0.80]). The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) is more volatile with a very small to small effect (g = 0.15, [0.07, 0.23]). CONCLUSIONS This meta-analysis confirms that gamified interventions are promising to promote PA in various publics. However, if the effect persists after the end of the program, suggesting that it is not just a novelty effect due to the playful nature of gamification, it seems volatile with a small long-term effect. The integration of gamification in more global healthcare interventions could be a way to address this low sustainability. Future rigorous trials are needed to explore these perspectives.

Développement et évaluation d'une intervention digitale fondée sur la gamification pour promouvoir l'activité physique de personnes atteintes de maladie chronique Face à la prévalence grandissante de l’inactivité physique et des comportements sédentaires, il n’a jamais été aussi important de développer des interventions permettant de promouvoir efficacement et durablement un style de vie actif chez les patients atteints de maladies chroniques. Si un certain nombre d’initiatives existent dans ce sens, les programmes actuels se heurtent généralement à la difficulté d’engager les patients et de changer le comportement sur le long terme. De plus, ces programmes dispensés en présentiel sont associés à une série d’enjeux logistiques et économiques qui limitent leur impact et dissémination à grande échelle. Dans cette optique, la gamification et les nouvelles technologies apparaissent comme des outils prometteurs pour favoriser le changement de comportement en contexte écologique et proposer des interventions efficaces et fiables à distance. Néanmoins, à ce jour la littérature scientifique n’avait pas démontré l’efficacité de tels outils pour la prise en charge de l’activité physique. Ainsi, la question centrale de ce travail doctoral était de savoir si et dans quelles condition l’utilisation d’intervention digitales et de la gamification pouvait être pertinente pour promouvoir l’activité physique de patients atteints de maladies chroniques. Au travers de 6 études, les résultats de ce travail doctoral soulignent les perspectives prometteuses de la gamification pour promouvoir l’activité physique de différentes populations, quel que soit leur âge ou état de santé, à la fois sur le court et le moyen terme. Les résultats de cette thèse suggèrent également qu’un programme digital intégrant de la gamification et du telecoaching pourrait être une plus-value intéressante dans la prise en charge de l’obésité et du diabète de type 2. Ces conclusions viennent enrichir la littérature dans le domaine et mettent en évidence un certain nombre d’implications cliniques, d’enjeux de développement et de perspectives de recherche afin de comprendre plus finement ces interventions et d’en optimiser leur efficacité.