Where does making behavior change effortless overlap with making it fun? Charlene Wong, a pediatrician and health services researcher at Duke University, poses this question about healthy habits to Peter Ubel, a professor of business, public policy, and medicine at Duke, and Roy Rosin, Chief Innovation Officer for Penn Medicine.

“In some cases, the behavior that we want — and need — is effort, in and of itself,” says Rosin. “Making things effortless doesn’t work as well when you need people to move and exercise. That’s where making things more fun gets interesting.” He mentions Pokémon Go. Research indicates that players walked a tremendous amount to capture augmented reality creatures: 144 billion steps, according to Microsoft, or 2,000 additional steps a day, according to Duke. “That’s a great example of how fun gets you out of your chair to go do something,” he says.

Building on that example, Ubel describes patients of his who were veterans, who would go to public golf courses to play and ride around on carts with their buddies. “Stopping the cart 10 yards early and walking to the ball every other shot, that’s something they really enjoy — they’re not even thinking about exercise,” he says. “It’s not exercise; it’s just out having fun.”

Rosin describes a move and recover project his team worked on, inspired by one of their nurses. The nurse, whose nickname was “Turtledove,” would hide paper turtledoves in the artwork around the floor, challenging his patients to go find them. Rosin’s team asked what they could do to both create destinations and clear expectations in hospitals and to make it fun. They created game zones challenging patients to collect cards around their floor, and it worked — people walked more. “The number of people meeting their goals for being discharged more than doubled,” he says.

This reminds Wong, as a mother of young children, of hiding things to get her kids to do something. “You have to make it fun, especially when you’re talking about very young children,” she says. “They’re not going to do the ‘no pain, no gain thing.’”

Rosin adds that he has trouble resisting his wife’s baking. After learning about Paul Rozin’s salad bar study, he decided to try moving her baked goods. But moving them to a different room — even to the basement — didn’t work. “What’s interesting is, there are a bunch of foods I eat that I shouldn’t, and when they’re not in my house, my laziness factor beats out my lack of willpower,” he says. “I’m not going to leave my house to go to the store to get the thing.” Having a nicotine addiction will likely get you out of the house to buy more cigarettes, but for food, it’s much less likely.

“I would say, clear it out for the stuff that’s bad, but for the stuff that’s good, make it fun,” says Wong. She describes broccoli and cauliflower “trees” that she stands up for her kids, and only eating the “best” green beans. Wong also describes Duke’s childhood obesity treatment program. She used to sell the program’s benefits to her teens first — that a team helps them learn what to eat and how to exercise. But now, her first message is about how fun that program is: It takes place in parks with a bunch of their peers working on the same goals, and who speak the same language (i.e., Spanish). She tells parents, involved in shared decision-making, that the program is covered by insurance — they won’t have to pay for a gym membership.

Selling nutrition to teens can be trickier, however. It’s a social norm to consume sugary beverages, for example. When with friends, they might go to the store together afterschool and buy a drink like AriZona tea, which some teens think is healthier because it’s tea rather than soda. Wong has also heard that Sprite is better than Coke. “Even though providing information alone isn’t going to be adequate, in some populations, particularly when you’re talking about younger populations, they may not have heard these messages yet, so providing some of that information is also really still critical,” says Wong.

From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.