Can New Haven “Gamify” Diabetes?

Lucy Gellman PhotoBetter health in New Haven’s black and Latino communities may lie as much in games like the “Bon Appetite Arcade” as in the changing world of hospitals and doctor’s offices.

Or so argued Margaret Grey, dean of the Yale School of Nursing, as she and other New Haven leaders addressed the future of community health care in the Elm City.

Grey joined Yale-New Haven Hospital CEO Marna Borgstrom and dean of the Yale School of Public Health Paul D. Cleary for a panel entitled “What Will Healthcare in New Haven Look Like in 2024?” Held last Saturday morning in Harkness Auditorium on Cedar Street, the event was offered to alumni of Yale’s School of Medicine as part of Reunion Weekend 2014.

While the 40-minute session included broad commentary on where the health care system at large is headed – namely, the phasing out of individual and group practices and rise of Accountable Care Organizations (ACOs), which seek to create a continuum of care through consolidation and centralization of practice – members of the panel focused their attention on how leaders hope to tackle the city’s major health problems long before people reach the emergency room.

Grey and Borgstrom emphasized the need to zero in on care beyond the hospital, particularly in New Haven’s poorest neighborhoods, which often double as food deserts and unsafe spaces for extended physical activity.

Some of the most promising solutions may lie in smartphone apps and computer games, Grey suggested.

“Gamification is coming,” she told the crowd, “whether you like it or not.”

During her comments, she focused on patients with chronic illness, identifying a quiet killer running rampant in New Haven’s black and Latino communities: diabetes, particularly Type II, which has a high strike rate among children and adolescents who do not (or are not able to) practice proper nutrition.

Yale School of Nursing“By the time children are in high school in the New Haven public schools, 50 percent of them are overweight or obese. It’s a terrible, terrible thing. And we know that what happens in that trajectory is that they will stay overweight .. and develop the diseases of older adults that are now happening in young people, including type II diabetes in people as young as the age of 5,” Grey (pictured) said, dropping a staggering statistic on the largely white, male and upper-class crowd.

The solution, she suggested, is multi-part: “What we know from our work in the schools is that ... These kids never learn nutrition. It is not taught ... [and] there’s no safe place to be physically active. If we don’t create the built environment and the accessibility of healthy foods, the deck is completely stacked against these kids for the rest of their lives. Any of us who believe we can fix this through medical care and health care alone. ... we’re just doomed to fail.”

Any solution will also include some serious 21st century incentivization, Grey added. “80 percent of people with diabetes nationwide do not meet proper treatment goals. That is the cost of care, and that’s what drives the cost up. I believe that there will be an increase of physician’s assistants and nurses in combination with technology.”

“Technology” does not mean just convenient and cost-efficient advances like pharmacy records sent to providers’ offices or patients sending in blood glucose samples virtually. It also translates to increased use of apps like Fooducate or Glucose Buddy and games (there are a lot more where “Bon Appetite Arcade” came from) that help patients meet their goals and keep their illnesses in check. 

“Cool Incentives”


In her remarks, Borgstrom said Yale-New Haven has sought to influence the health habits of young New Haveners in part through increased involvement in the public schools and ventures to create safe play spaces.

She also said Yale-New Haven is exploring building on its partnership with New Haven Promise, a program that rewards public-school students who keep their grades up with college scholarships. The goal is to get kids through school—and to do so healthfully.

“What we’re really hoping is by getting into the school systems and creating cool incentives” to stay healthy, Borgstrom said. She said the hospital is considering proposing a cash payment at graduation to New Haven Promise students who have managed to “maintain weight within a certain level.” The idea would be to “give them a significant amount of cash to prepare to go to college.”

“One of the things that I think, and we at the system believe is going to be critical to evolving healthcare and good health in our communities, is not just providing health care and transforming health care, but it’s going to be supporting and making appropriate investments in safe housing, in good education and access to good food, and exercise,” Borgstrom said, citing New Haven as one of the United States’ 20 poorest mid-sized cities.

“What’s evolving is a way to knit the system together so we can move from what we call a volume-based healthcare system to one that focuses on the value of what we provide,” she added. She noted that the neighborhood-based Hill Health and Fair Haven Health centers currently serve much of New Haven’s non-Yale population, a population which has had high rates of using crisis mental-health services and using the hospital emergency room for non-emergencies. 

One alum pointedly asked Borgstrom: “How do you get people to be more responsible for their own healthcare? And how do you get people to underutilize unnecessary care?”

“I’ll start by saying I don’t really know the answer to that. I don’t think anybody knows the answer to that,” Borgstrom began. “In inner-city populations like New Haven, for the next ten years and beyond, we’re going to be doing a lot of acute care, because there are people who are hitting late Medicaid, late Medicare, co-insurance status, who have chronic heart disease, chronic cancers, who have all sorts of chronic diseases ... We’re simply not effectively going to change their habits. What we’re going to do is try and manage their care a little bit more efficiently.”

Fortunately, both health care mavens have found a silver lining in the younger generation’s tech-savvy (or tech-obsessed) outlook. Here’s to hoping better long-term health is just a click, app store search, or java update away. 

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posted by: THREEFIFTHS on June 2, 2014  4:09pm

Go Vegetarian & Vegan.

posted by: Jill_the_Pill on June 2, 2014  5:53pm

“the hospital is considering proposing a cash payment at graduation to New Haven Promise students who have managed to “maintain weight within a certain level.” 

What a horrid idea.  With all of the other obstacles these kids have to overcome to get to college, let’s add one more crazy hoop for them to jump through.

posted by: Shadow The Cat on June 2, 2014  6:34pm

Threatening to withhold scholarships from students who don’t meet a certain weight requirement is a terrible idea. As a student of the New Haven public school system, I thought we were supposed to be taught that everyone deserves an equal opportunity regardless of their race, gender, weight, or any other arbitrary characteristic?

posted by: Theodora on June 3, 2014  9:09am

Reading is fundamental, folks. There was no threat to withhold the scholarship. She said that there could be additional benefit to those who showed health and vitality.

And the problem, Jill the Pill, is that too many children are so out of shape they’d be unable to jump through any hoop.

If you have not been to a school ground lately, take a look at just how unhealthy a growing percentage of kids are.

posted by: Jill_the_Pill on June 3, 2014  10:42am

Theordora, reading is fundamental, but reading between the lines can also be useful.  It would not be unheard of for “additional” money to be shifted from one group to another, lessening scholarships to fund incentives. 

“Health and vitality,” as you put it, should be its own reward and the lack thereof is punishment enough.  Help the kids get in shape through nutrition programs and safe outdoor activities; I agree 100%.  But college money for weight-loss is inviting crash diets, eating disorders, weight shame, discrimination, and stress. Just not what the kids need.

ps—why no incentives for non-smokers, teetotalers, handwashers, helmet and seatbelt wearers? If this were truly only about health ... ?

posted by: nurse96 on June 3, 2014  1:40pm

I agree with “Jill the Pill” that monitary incentive is not a good idea. As with all people, eating healthy comes at significant financial cost. Take a look at the dollar menu at McDonald’s and then take a look at fresh fruit and vegetable prices in your grocery store. Many families can’t afford to eat healthy. I spend a great deal of money on nutritious food every week. Not to mention the time it takes to pack healthy lunches and prepare good meals. Schools are stuggling to offer healthy food while under budget constraints too. Healthy affordable food, education of parents and children, and exercise are key. In the end it all boils down to funding.

posted by: Brewski on June 4, 2014  7:03am

Offering a cash prize to a child for hitting a weight target is just a bad idea. Weight is very easy to measure, but it is not the ultimate indicator of health. Actually, people suffering the physical and psychological impact of eating disorders (which this reward would encourage) can be at much higher risk of injury. Also, this is particularly offensive at a time when many school systems are cutting physical activities and serving unhealthy food. You should see what the kids are given for breakfast in our “heathy” schools. Sugary cereals and cookies.

Yes, we do have an obesity problem in the US. How about offering an incentive for completing a physical fitness challenge? Offer daily morning runs, “boot camps”, walking hikes, swims, and other activities. Kids can check of what they’ve done until they meet a certain criteria. But offering cash for skinny kids seems like they are picking on the heavy kids. Not a healthy approach to the problem.