An Initial Evaluation of the Impact of Pok
emon GO on Physical Activity
Ying Xian, MD, PhD; Hanzhang Xu, PhDc, BSN; Haolin Xu, MS; Li Liang, PhD; Adrian F. Hernandez, MD, MHS;
Tracy Y. Wang, MD, MHS, MSc; Eric D. Peterson, MD, MPH
Background-—Pok
emon GO is a location-based augmented reality game. Using GPS and the camera on a smartphone, the game
requires players to travel in real world to capture animated creatures, called Pok
emon. We examined the impact of Pok
emon GO on
physical activity (PA).
Methods and Results-—A pre-post observational study of 167 Pok
emon GO players who were self-enrolled through recruitment
flyers or online social media was performed. Participants were instructed to provide screenshots of their step counts recorded by
the iPhone Health app between June 15 and July 31, 2016, which was 3 weeks before and 3 weeks after the Pok
emon GO release
date. Of 167 participants, the median age was 25 years (interquartile range, 21–29 years). The daily average steps of participants
at baseline was 5678 (SD, 2833; median, 5718 [interquartile range, 3675–72 79]). After initiation of Pok
emon GO, daily activity
rose to 7654 steps (SD, 3616; median, 7232 [interquartile range, 5041–9744], pre-post change: 1976; 95% CI, 1494–2458, or a
34.8% relative increase [P<0.001]). On average, 10 000 “XP” points (a measure of game progression) was associ ated with 2134
additional steps per day (95% CI, 1673–2595), suggesting a potential dose-response relationship. The number of participants
achieving a goal of 10 000+ steps per day increased from 15.3% before to 27.5% after (odds ratio, 2.06; 95% CI, 1.70–2.50).
Increased PA was also observed in subgroups, with the largest increases seen in participants who spent more time playing
Pok
emon GO, those who were overweight/obese, or those with a lower baseline PA level.
Conclusions-—Pok
emon GO participation was associated with a significant increase in PA among young adults. Incorporating PA
into gameplay may provide an alternative way to promote PA in persons who are attracted to the game.
Clinical Trial Registration-—URL: http://www.clinicaltrials.gov. Unique identifier: NCT02888314. ( J Am Heart Assoc. 2017;6:
e005341. DOI: 10.1161/JAHA.116.005341.)
Key Words: exercise • mobile games • physical exercise
I
nsufficient physical activity (PA) has been identified as the
fourth leading cause of mortality, accounting for 6% of
death globally.
1
Despite well-documented health benefits of
regular exercise, PA levels remain low in many countries.
2
As
a result, the World Health Organization recommends regular
and adequate levels of PA among all age groups.
1
However,
nearly 50% of Americans are not regularly active at the
recommended levels.
3
While lack of enjoyment and time are
commonly cited reasons for not adopting an active lifestyle,
playing mobile games has become an increasingly popular
leisure pastime. It is estimated that more than 50% of mobile
phone users in the United States play mobile games.
4,5
While mobile gaming is often considered a sedentary
behavior, a new trend is to incorporate PA into gameplay.
Pok
emon GO is a location- based augmented reality game
developed by Niantic, Inc, for iOS and Android devices.
6
Making use of the GPS and camera functions in the
smartphone, Pok
emon GO players are encouraged to ambu-
late (eg, walk, bike, or drive) to various physical locations in
the real world to capture virtual creatures called Pok
emon.
Since its release on July 6, 2016, Pok
emon GO has been
downloaded more than 500 million times worldwide.
Despite the incentive for being active in this game, there
are limited data examining the potential impact of Pok
emon
GO on PA.
7,8
An online survey of Pok
emon GO players
demonstrated a signi fi cant increase in self-reported PA.
9
Two
more recent studies found 1000 to 1500 additional steps per
day counted by iPhone or Microsoft Band after playing
Pok
emon GO.
10,11
However, the gaming experience may vary
From the Duke Clinical Research Institute (Y.X., Haolin X., L.L., A.F.H., T.Y.W.,
E.D.P.) and Department of Neurology (Y.X.), Duke University Medical Center,
Durham, NC; Duke University School of Nursing, Durham, NC (Hanzhang X.).
An abstract from this study was presented at the American Heart Association
EPI|LIFESTYLE Scientific Sessions, March 8, 2017, in Portland, OR.
Correspondence to: Ying Xian, MD, PhD, Duke Clinical Research Institute,
Received December 14, 2016; accepted March 21, 2017.
ª 2017 The Authors. Published on behalf of the American Heart Association,
Inc., by Wiley. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial License, which permits use, distribu-
tion and reproduction in any medium, provided the original work is properly
cited and is not used for commercial purposes.
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 1
ORIGINAL RESEARCH
considerably among players. Persons who are attracted to the
game may behave differently than occasional players. As
players are encouraged to ambulate and are rewarded by
capturing free-roaming Pok
emon, a dose-response relation-
ship between Pok
emon GO engagement and PA might be
expected. Therefore, we conducted a retrospective observa-
tional study among Pok
emon GO players in September 2016
and analyzed their level of PA in ter ms of step count as
reported on the iPhone Health app 3 weeks before and
3 weeks after initiation of Pok
emon GO play. Specifically, we
sought to compare changes in PA level before and after
playing Pok
emon GO and whether such changes differ by age,
sex, baseline PA level, body mass index, and level of
engagement in the game. The latter included a subjective
measure of self-reported playing time as well as an objective
measure of game progression indicating players’ level of
engagement.
Methods
Study Design and Participants
We launched an online survey in September 2016 to leverage
existing PA data recorded by the iPhone Health app. iPhone
users who were 18 years or older and had played Pok
emon
GO in July 2016 were eligible for the study. Study participants
were instructed to upload screenshots of the “Pok
emon GO
Trainer Profile” and all recorded daily steps displayed on the
iPhone Health dashboard between June 15, 2016, and July 31,
2016, which were 3 weeks before and 3 weeks after the
Pok
emon GO release date (Figure 1). The number of steps
were automatically recorded by the iPhone Health app without
the requirement of a third-party app or device. The Trainer
Profile indicates when the player started playing Pok
emon GO
and his/her XP, a measure of progression in Pok
emon GO
that can be used to quantify the level of engagement in the
game. On average, a player is rewarded a minimum of 100 XP
points for each Pok
emon captured. The survey also included
questions that characterized each player’s demographics and
attitude toward the game, such as self-reported nu mber of
hours playing Pok
emon GO and self-reported PA level after
playing Pok
emon GO.
To attract Pok
emon players, recruitment flyers were placed
at “Pok
eStops” around Duke University campus, Durham,
North Carolina. Pok
eStops are locations where players can
collect items such as Pok
e Balls, Potions, and Eggs to capture
more Pok
emon. The recruitment flyers contained a link and a
quick response code. Clicking on the link or scanning the
quick response code us ing the iPhone would automatically
direct to the survey website by Qualtrics, an online survey
software program. Similar flyers were also posted on Face-
book, Twitter, Reddit, and WeChat to maximize global
representation of the study. The first 100 participants were
compensated monetarily ($5 Amazon gift card) for completing
the survey. All participants were automatically entered into a
prize drawing for a $100 Amazon gift card.
Measures and Statistical Analysis
The average steps per day and per centage of days
>10 000 steps per day were calculated based on the number
of steps counted by the iPhone Health app for each
participant. Paired t test and Wilcoxon signed-rank test were
used to compare the changes in average steps per day and
percentage of days >10 000 steps per day before and after
playing Pok
emon GO. The more an individual plays Pok
emon
GO, the more likely he/she will capture Pok
emon and gain
higher XP points. We used average XP points gained per day
as a proxy for the level of engagement. The average XP value
was calculated as the total XP points displayed on the
Pok
emon GO Trainer Profile (Figure 1), divided by the number
of days from the date of game download to the date of survey.
Ordinal least squares regression was used to evaluate the
relationship between XP value and changes in daily step count
after Pok
emon GO.
Because individuals’ PA may vary during holidays and exam
weeks, sensitivity analysis was performed by excluding dates
when a participant was taking a vacation or final exam. A
separate sensitivity analysis was performed by excluding
individuals who did not carry their phones when not playing
the game, because the number of steps could be underes-
timated in these participants. In addition, exploratory post hoc
subgroup analyses were performed by age, sex, body mass
index, baseline PA level before Pok
emon GO, self-reported
hours playing Pok
emon GO per day as a subjective measure
of level of engagement in the game, use of wearable devices,
and how often playing Pok
emon GO when cycling or in a
moving vehicle.
The study was approved by the institutional review board
at Duke University. All study p articipants gave informed
consent. The study team had no association or financial
interest with Niantic, Inc; Nintendo; or Apple. A prespecified
sample size calculation indicated 73 participants would be
required to detect a 2000-step differenc e (SD, 6000) after
playing Pok
emon GO. All tests were evaluated at a 2-sided
significance level of P<0.05. The analyses were performed
using SAS 9.4 software (SAS Institute Inc).
Results
A total of 167 volunteers from North America , South America,
Europe, Australia, and Asia completed the online survey
between August 31 and September 30, 2016. Baseline
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 2
Pok
emon GO and Physical Activity Xian et al
ORIGINAL RESEARCH
characteristics are shown in the Table. The median age was
25 years (interquartile range [IQR], 21–29), with a median
body mass index of 23.4 kg/m
2
(IQR, 20.5–25.6). Nearly half
of the study participants (80 of 167) were women. The
majority (84.4%) downloaded Pok
emon GO within 1 week of
the initial release date of July 6, 2016. The median self-
reported time playing Pok
emon GO was 2.0 h/d (IQR, 1.0–
2.5). Although only a few participants reported always played
Pok
emon GO in a moving vehicle (4.2%), >90% participants
self-reported ever playing Pok
emon GO in a car. Nonetheless,
>85% participants self-reported an increase in their PA level
since playing Pok
emon GO.
The distr ibution of daily steps for each individual is shown
in Figure 2. The average number of steps per day was 5678
(SD, 2833; median, 5718 [IQR, 3675–7279]) before Pok
emon
GO and 7654 (SD, 3616; median, 7232 [IQR, 5041–9744])
after th e initiation of Pok
emon GO. On average, study
participants walked 1976 additional steps per day (95% CI,
1494–2458, or a 34.8% relative increase; P<0.001) after
playing Pok
emon GO. The percentage of days with
>10 000 steps per day increased from 15.3% before to
27.5% after playing Pok
emon GO (a 12.2% increase; 95% CI,
8.7–15.6% [P<0.001]). A generalized linear model with
generalized estimating equations accounting for within-
subject correlation of measurements at multiple time points
found a similar increase in step count (1948 per day; 95% CI,
1489–2408 [P<0.001]) and a greater likelihood of reaching
the goal of 10 000+ steps per day (odds ratio, 2.06; 95% CI,
1.70–2.50 [P< 0.001]) after playing Pok
emon GO.
The mean Pok
emon GO XP points gained per day was
10 293 points (SD, 8651; median, 8295 [95% CI, 3706–
14 183]), suggesting study participants captured as many as
100 Pok
emon per day if the player did not gain XP points
through other ways such as hatching an Egg, winning a Gym
Battle, or receiving a bonus. Figure 3 shows a potential linear
relationship between Pok
emon GO XP value and changes in
steps per day after Pok
emon GO. On average, every 10 000
XP points gained in Pok
emon GO were associated with 2134
additional steps per day (95% CI, 1673–
2595; P<0.001
[R
2
=0.33]), suggesting a potential dose-response relationship,
in which the more an individual played, the higher level of PA
could be achieved.
Figure 1. Examples of Pok
emon GO trainer profile and step count automatically recorded by the iPhone
Health app. Image from Pok
emon GO used with permission from Niantic, Inc.
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 3
Pok
emon GO and Physical Activity Xian et al
ORIGINAL RESEARCH
Except for participants who played Pok
emon GO for <1h/d,
those younger than 20 years, and those with the highest
baseline PA level, post hoc subgroup analyses found a
consistent pattern of higher PA level after the initiation of
Pok
emon GO (Figure 4). Among all exploratory subgroups, the
largest differences were seen in participants 30 years or older
(3320 additional steps per day; 95% CI, 2118–4523),
individuals with the lowest PA at baseline (2899 additional
steps; 95% CI, 2030–3767), overweight/obese (3031 addi-
tional steps; 95% CI, 2132–3929), or individuals who spent
more time playing Pok
emon GO (2–2.5 h/d: 2861 additional
steps [95% CI, 1884–3837]; >2.5 h/d: 2238 additional steps
[95% CI, 1008–3467]). Increased level of PA was also
observed after excluding data from dates of vacations or
Table. Baseline Characteristics of Study Participants
Characteristics Total (N=167)
Age, median (IQR), y 25 (21–29)
Women, No. (%) 80 (47.9)
Body mass index, median (IQR), kg/m
2
23.4 (20.5–25.6)
Student, No. (%) 90 (53.9)
Location, No. (%)
North America 146 (87.4)
Europe 15 (9.0)
Australia 4 (2.4)
Asia 1 (0.6)
South America 1 (0.6)
Took a vacation during the study period, No. (%) 57 (34.1)
Took exams during the study period, No. (%) 6 (7.2)
Carry iPhone when not playing Pok
emon GO,* No. (%)
In hand 28 (16.7)
On a belt holster 1 (0.6)
In pocket 115 (68.9)
On the table 29 (17.4)
Other 17 (10.2)
Used wearable devices, No. (%) 34 (20.4)
Self-reported time playing Pok
emon GO per day,
median (IQR), h
2.0 (1.0–2.5)
Self-reported changes in physical activity after
playing Pok
emon GO, No. (%)
Much higher 20 (20.0)
Moderately higher 52 (31.1)
Slightly higher 71 (42.5)
About the same 24 (14.4)
Slightly lower 0 (0)
Moderately lower 0 (0)
Much lower 0 (0)
Played Pok
emon GO in a moving vehicle
Always 7 (4.2)
Most of the time 29 (17.4)
About half the time 32 (19.2)
Sometimes 85 (50.9)
Never 14 (8.4)
Played Pok
emon GO when cycling
Always 7 (4.2)
Most of the time 12 (7.2)
About half the time 7 (4.2)
Sometimes 19 (11.4)
Never 122 (73.1)
IQR indicates interquartile range.
*Individual could choose more than one option.
Figure 2. Average steps per day before and after playing
Pok
emon GO. IQR indicates interquartile range.
Figure 3. Relationship between Pok
emon GO “XP” (a measure of
game progression) and changes in step count per day after playing
Pok
emon GO.* *The figure excluded 2 observations ≤1st per-
centiles and 2 observations ≥99th percentiles.
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 4
Pok
emon GO and Physical Activity Xian et al
ORIGINAL RESEARCH
examinations (2141 additi onal steps per day; 95% CI, 1683–
2599) or excluding individuals who did not usually carry their
phones (2094 additional steps; 95% CI, 1603–2585).
Discussion
Regular PA is one of the most important things people can do
to improve their health, yet achieving regular PA is often
challenging. By encouraging players to ambulate in the real
world to locations that would permit capture of Pok
emon in
the virtual world, Pok
emon GO provides an enjoyable way to
engage peo ple in PA. Our analysis is among the first rigorously
designed studies to evaluate the effect of Pok
emon GO on
PA.
10,11
While players subjectively reported an increase in PA,
automatically recorded step count objectively corroborated an
increase in PA level associated with Pok
emon GO playing. On
average, an individual can walk nearly 2000 additional steps
per day and is more likely to achieve 10 000+ steps per day
after playing Pok
emon GO. While the differences appear
modest, doing some PA is better than doing none.
1
Previous
study findings indicate that an increase of 2000 steps per day
decreases the risk of cardiovascular events by 8% in high-risk
individuals.
12
Considering the higher prevalence of physical
inactivity worldwide,
13
games such as Pok
emon GO may
provide an enjoyable alternative to engage people who would
otherwise never exercise.
Consistent with anecdotal reports on the Internet,
13–15
we
observed that Pok
emon GO players spent a significant portion
of their day playing the game. The median self-reported
playtime was 2.0 h/d among our study volunteers. However,
Figure 4. Sensitivity and subgroup analyses.
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 5
Pok
emon GO and Physical Activity Xian et al
ORIGINAL RESEARCH
the attraction of the game had effects in that the more an
individual plays, the higher level of PA can be achieved.
Participants who reported spending 2 to 2.5 hours playing
Pok
emon GO can walk 2861 additional steps per day. In
contrast, there was no significant increase in step count
among occasional gamers who played <1 h/d. While self-
reported playtime is subject to recall bias, we used Pok
emon
GO XP points as a proxy of level of engagem ent and found a
potential dose-response relationship with PA level. On aver-
age, 10 000 more XP points gained in the game would
translate into 2134 additional steps per day, suggesting that
Pok
emon GO can help increase PA level for those who play it
regularly.
Do games like Pok
emon GO help people who live a sedentary
lifestyle? Interestingly, we found a low level of PA at baseline in
our study participants, suggesting that people who are attracted
to the game might be more sedentary. Importantly, participants
with the lowest baseline activity level and who were overweight
or obese appear to be those who benefit most from the game.
Individuals with the lowest PA level atbaseline (≤3659 steps per
day) walked nearly 3000 additi onal steps per day after playing
Pok
emon GO. Individuals with a body mass index ≥25 kg/m
2
walked 3031 addi tional steps per day, which almost doubled the
changes from lower-weight players (1512 additional steps).
While they are not intentionally designed or marketed as PA or
exercise apps, games such as Pok
emon GO have the potential to
promote PA and decrease sedent ary behaviors.
9,16
Nonethe-
less, it should be noted that there has been no study evaluating
energy expenditure when playing Pok
emon GO. Although it is
likely lower than more intense exercise modalities such as
running and swimming, the best form of PA is the one that peo ple
will do, not necessarily the ones with the highest energy
expenditure. It is unlikely that marathon runners or regular
joggers would benefit from Pok
emon GO. However, Pok
emon
GO may provide an alternative way to engage people who live a
sedentary lifestyle and otherwise would never participate in any
traditional form of exercise.
Despite the potential health benefits of playing Pok
emon
GO, we did observe risky behavior among Pok
emon GO players.
More than 90% of players in our study reported ever playing the
game in a moving vehicle. Although we could not determine
whether it was the driver or the passenger playing Pok
emon GO,
a systemic review of Twitter postings found that Pok
emon GO
creates a distraction for drivers, passengers, and pedestrians.
17
A recent update of the Pok
emon GO app includes a speed limi t
warning. However, the efficacy of such safety messages
remains to be seen.
Study Limitations
Our study should be interpreted in the context of the following
limitations. First, our study participants were self-selected.
Those who participated in the study were more likely to be avid
Pok
emon GO fans. Their gaming experience may not be
representative of the general population. In addition, Pok
emon
GO was first released in the United States. Therefore, there
were fewer participants outside of North America. Second, the
majority of the study participants were young adults. Although
we found increased levels of PA overall and in many subgroups,
further evaluation is needed to determine the extent to which
these findings can be generalized to targeted populations such
as children, adolescents, the elderly, and persons with more
vulnerable health profiles. Third, we used step count recorded
by the iPhone Health app to measure PA level. The accuracy of
the iPhone Health app has not been well validated in the
literature. Inaccuracies notwithstanding, our study utilized a
pre-post design and each individual was treated as his/her own
control. In addition, we excluded conditions that may influence
PA level in sensitivity analyses. Therefore, the degree of change
in steps occurring before and after Pok
emon GO should be less
subject to measurement errors. Fourth, although the primary
end point of change in step count was prespecified, all post hoc
subgroup analyses were exploratory and might be subject to
type I error. Finally, this study is retrospective, using 6 weeks of
PA data. While we found a significant increase in PA level after
playing Pok
emon GO, the initial interest in the game may
decline over time. Unfortunately, Apple released the new
operation system iOS 10 at the end of September, and the
iPhone Health app is now turned off by default. We are unable to
evaluate the sustainability of Pok
emon GO over time because of
the lack of follow-up data. Indeed, 2 recent studies found an
initial increase in daily number of steps after Pok
emon GO but it
gradually attenuated over time.
10,11
google Trends analysis also
indicates that search interests related to Pok
emon GO are
nearly back to prerelease volumes.
18
A constant stream of new
functionality in Pok
emon GO or other apps is needed to
promote participation and maintain sustained PA.
Conclusions
By playing Pok
emon GO, an individual could walk nearly 2000
additional steps per day and is more likely to achieve a goal of
10 000+ steps per day, especially among those who spend
more time playin g Pok
emon GO and those who are over-
weight/obese or have a lower baseline PA level. Games such
as Pok
emon GO may provide an alternative way to adopt an
active lifestyle for persons who play them regularly.
Author Contributions
All authors were involved in the study design, analysis, and
manuscript revision. All authors read and approved the final
manuscript. Dr Xian is the guarantor who accepts full
DOI: 10.1161/JAHA.116.005341 Journal of the American Heart Association 6
Pok
emon GO and Physical Activity Xian et al
ORIGINAL RESEARCH
responsibility for the work and the conduct of the study, had
access to the data, and controlled the decision to publish.
Acknowledgments
Special thanks to all study participants for volunteering their time.
Niantic, Inc, granted permission to use the images of Pok
emon GO in
the study.
Disclosures
The study team had no association or financial interest with
Niantic, Inc; Nintendo; or Apple.
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