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University of Pennsylvania researchers recently won a $25 million grant to see if they can fight heart disease with a game that promotes a healthy behavior — walking.

The intervention works by tracking how many steps a person takes each day and assigning points and levels accordingly. Participants get text messages with their daily tally.

The Penn team previously tested the concept in a clinical trial with 1,062 patients and found the approach increased participants’ activity by an average of nearly 2,000 steps daily.

Now, with funding from the nonprofit Patient-Centered Outcomes Research Institute, they hope to show that their game cannot only promote exercise, but can also reduce the incidence of heart events.

Dozens of studies have already shown that people who take more steps a day experience fewer heart attacks and strokes. However, these findings have largely been based on observational data, which is not proof of a cause-and-effect relationship.

The Penn team will be using the $25 million grant to pursue the gold standard for establishing scientific causality: a randomized controlled trial. Patients will get divided into two groups — one gets to play the game, and the other does not — so researchers can compare their outcomes.

The clinical trial involving 18,000 participants will launch in a year and a half and run for roughly five years. Patients will be recruited through a partnership with the private healthcare system Ascension, which spans 15 states and the District of Columbia.

Scientists theorize that walking could help by reducing blood pressure, blood sugar, and inflammation. Activity may also improve the way muscles get oxygen from the blood, “so that your heart doesn’t have to work as hard,” said Alexander Fanaroff, a Penn cardiologist and one of the lead researchers on the project.

The research team will see whether the participants who had access to the game sustained significantly fewer instances of stroke, heart attack, or heart failure.

Only people with an elevated risk of heart disease can take part in the trial.

Making walking into a game

As a cardiologist, Fanaroff spends a lot of time telling patients to exercise more.

It doesn’t always work.

“The hardest thing for people to do is change their behavior,” he said.

The Penn team has spent the last decade using concepts from behavioral economics — a field that combines psychology and economics to understand human decision-making — to hone an intervention to promote exercise.

The current program design, which works like a game, is the product of three previous clinical trials that showed the potential of Penn’s game-based approach to improving physical activity.

Here’s how it works: First, participants establish their baseline step count over two weeks, and then set a goal to increase their daily steps by 33% to 50%.

Each week, patients are given 70 points — that’s 10 per day. Every day that they meet their goal, they keep their points. If they fail to keep up, they lose 10 points.

They move up or down levels each week, based on the cumulative points.

Patients need only to own a smartphone to participate, since their steps are tracked by the built-in sensors now in most devices.

Daily results are delivered through text.

“If you have an app on your phone, you might not look at it, but if you’re getting a text message every day, you’re engaged,” Fanaroff said.

Participants also identify a support partner, such as a family member or friend, who will get weekly email updates on how the person is doing in the game.

The study is entirely remote, with patients enrolling via a web platform.

Participants who are not sorted into the game approach will receive “usual care,” which consists of medical providers simply telling patients to be more physically active. They will also download a standard exercise app, which normally monitors their steps without turning it into a game.

Trying to improve health and reduce costs

The trial will enroll adults who have a 10% or higher chance of a cardiovascular event over the next 10 years, as determined by the American Heart Association’s PREVENT calculator.

This includes anybody who has ever had a heart attack or stroke, or received a stent, Fanaroff said. It also includes almost all people over 65 with multiple cardiovascular risk factors such as high blood pressure, high cholesterol, obesity, or diabetes.

“It’s not everybody, but it is a good-sized chunk of the population,” he said.

If successful, he hopes the evidence could convince insurers to fund programs that increase physical activity.

The Penn team estimates the game could be delivered for less than $50 per person.

“If it’s effective at reducing cardiovascular events, it would actually probably be cost-saving to the health system,” Fanaroff said.

He also hopes the results can guide doctors to better counsel patients.

“We just don’t know the best way to get people to increase physical activity at all, so all we wind up doing is telling people, ‘Physical activity is important for your health,’” he said.