Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website
Publication Briefs

Online Game Improves Glucose Control in Veterans with Diabetes

Diabetes self-management education (DSME) is a core component of comprehensive quality care for type 2 diabetes. A novel form of online education (termed 'spaced education' [SE]) presents clinical case scenarios accompanied by multiple-choice questions. Participants are then asked to submit answers and are immediately presented with the correct answer(s) and an explanation of the topic. Moreover, team-based competition within SE games has been shown to generate significantly stronger engagement among participants. Conducted from July 2014 to June 2015, this randomized trial sought to determine whether a team-based SE game on DSME topics delivered to VA patients with type 2 diabetes could generate sustained improvements in their HbA1c levels. Veterans were randomly assigned to either a DSME game (with a civics booklet containing content derived from the US Citizenship and Immigration Services Practice Test; n=227) or a civics game (with a DSME booklet; n=229). The six-month games sent two questions twice weekly via email or mobile app. Veterans accrued points based on performance. Winning teams and individuals received modest financial rewards (i.e., $100 gift certificate). The primary outcome measure was HbA1c change over 12 months.


  • The SE game delivering DSME content generated significant improvements in HbA1c over 12 months among Veterans with type 2 diabetes, with the difference between cohorts (DSME [-0.74%] vs. civics game [-0.44%]) manifesting primarily in the 6 months following the games. Among DSME game patients with elevated HbA1c at baseline (>9%), the overall reduction in HbA1c (-1.5%) was comparable to that of starting a new diabetes medication.
  • Reductions in HbA1c over the trial were not significantly associated with improvement in DSME knowledge over the course of the game (final score), with patients' engagement in the game (number of questions answered), and/or their overall performance on the game (game points).
  • Empowerment (defined using the Diabetes Empowerment Scale or DES, which measures diabetes-related psychosocial self-efficacy) increased among the DSME game patients in the six-month intervention period, while those of the civics patients decreased. There also were greater reductions in diabetes distress among DSME game patients during the intervention period, but this was not statistically significant.


  • The online, interactive methodology used in this intervention may be an effective and scalable method by which to improve health outcomes in Veterans with diabetes and other chronic diseases.


  • Limited outcome data were gathered from study participants, so investigators were unable to provide evidence of a clear mechanism to explain the effects of the intervention.
  • Enrollment in the trial required Internet and email access, thereby limiting the participants to those who were comfortable using online technology.

All authors, except Dr. McMahon, are part of the VA Boston Healthcare System.

PubMed Logo Kerfoot B, Gagnon D, McMahon G, Orlander J, Kurgansky K, and Conlin P. A Team-based Online Game Improves Blood Glucose Control in Veterans with Type 2 Diabetes: A Randomized Controlled Trial. Diabetes Care. September 2017;40(9):1218-25.

Related Briefs

» next 62 Diabetes Briefs...

What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.