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BACKGROUND AND RATIONALE:
The public health infrastructure is being overwhelmed by problems related to over-eating and under-exercising, and it has become clear that many, perhaps most, people have difficulty assimilating and implementing information on optimal diet and physical activity. Furthermore, the emotional, cognitive, and logistical complexities of diabetes management have resulted in a situation where a large fraction of patients are in sub-optimal glycemic control, leading to poor clinical outcomes and high expenses. Even if individuals are willing to adhere to professional and public health guidance, it is hard to navigate the emotional demands, environmental choices and opportunity cost issues that present themselves at the point of decision. This is the cause of failure for many approaches seeking to promote positive behavioral changes, which is of particular concern for individuals with obesity and diabetes.
Online communities and virtual worlds with avatars (animated characters representing oneself or others) are increasingly a component of the everyday social world for many people. Virtual Reality (VR) technologies might prove useful in bridging the gap between information (healthy population guidance or therapeutic lifestyle change guidance for obesity and diabetes) and sustainable behavior change. VR technology allows users to interact with (rather than simply observe) computer-simulated environments, typically with adapted flat-screen monitor displays or stereoscopic goggles, but also sometimes with tactile (“haptic”) or other sensory feedbacks including taste and smell.
VR applications are currently in development and use for a number of health- and medicine-related issues, notably rehabilitation medicine (stroke, Parkinson’s disease, pain control in burn victims), behavioral medicine (phobias, post-traumatic stress disorder, drug addiction, autism), and surgery (technical training, robotics, remote site treatment). However, except for small studies in clinical eating disorders (anorexia, binge eating), there has been almost no development of the VR field in relation to common issues of food intake, food choice and encouragement of physical activity among the broader population.
VR technology could be used to complement motivational interviewing, assess emotional states of readiness for behavioral change, and help patients to grapple with their emotional reactions to food choices. The visual presentations could assist patients in adjusting their distorted assessments of portion sizes; correcting their unrealistic expectations of the rate of weight loss; managing sensory experiences that occur as a result of behavior change, such as hunger or satiety from altered consumption patterns, or delayed muscle soreness from unaccustomed exercise; and enhancing their sense of self-efficacy by giving them successful experiences in navigating virtual environments.
VR also might be suitable for addressing adherence barriers in cardiovascular exercise rehabilitation (particularly for coronary artery disease, heart failure, and peripheral arterial disease) such as perceived exertion, anxiety, and capacity to walk to a prescribed duration and intensity. Another clinical use of VR might be in the provision of non-judgmental support for patients with various medical conditions through virtual coaches, and it might be especially suitable for housebound or reclusive individuals with social anxieties or mobility restrictions due to morbid obesity or other medical conditions. VR could be used in the therapeutic setting as a component of patient visits, to help guide and select educational materials and strategies and timelines. It might be an especially suitable modality for children, adolescents and young adults, who already are becoming familiar with VR as an entertainment technology. VR could also be applicable to individuals with low verbal or numerical literacy who may be more oriented to pictorial (vs. written or abstract) information.
An evolving body of evidence indicates that poor sleep behaviors and insufficient sleep may be causally linked with disordered endocrine and appetite regulation and with risk of metabolic syndrome, diabetes, hypertension and clinical cardiovascular disease.
VR technology presents new opportunities to apply recent advances in sleep research in relation to obesity and diabetes risk by objectively evaluating individual sleep and alertness status, delivering personalized guidance on healthy sleep behaviors, implementing physician-recommended treatments (e.g., positive airway pressure devices, light therapy), and assessing treatment outcomes in terms of changes in sleepiness, psycho-motor vigilance, and ocular markers of sympathetic tone. Sleep parameters (e.g., schedules, phasing, quality and quantity), perceptive and affective aspects of sleepiness (e.g., cognizance of sleepiness, self-monitoring of sleep habits), and sleep deprivation consequences (slower reaction times and impairments in memory, cognition, emotional processing, judgment, and decision-making) are all amenable to study with VR.
VR has some unique characteristics as a research tool. The virtual environments can be designed to address specific hypotheses, and data on the study participant’s response to the intervention can be collected in high detail without additional intrusiveness. Phenomena that are amenable to study, and also treatment, include cue responsiveness and extinction through virtual exposure, a feature that has been used to advantage in treatment of phobias and addictions. Visual presentations can be tailored to the user, along with therapeutic guidance to modify affective reactions and choices, and can prepare the user for future “real-world” encounters, thus making VR suitable for role-playing and training. Performance feedback, an essential component of learning and skill acquisition, can occur in real-time; thus VR can be used as a teaching tool and also to study cognitive processing of information presented in increasingly complex (‘hierarchical”) environments, a research approach that often is not practical in “real world” settings. Also, the capability to distribute identical virtual environments across multiple locations gives new meaning to the concept of multi-site data collection.
For researchers, an advantage is that the VR approach can simultaneously deliver an intervention and collect data on how it is utilized, particularly with regard to the cognitive and emotional processes involved. Study design and methodology challenges include: identification of appropriate control groups and control conditions, and of characteristics of rigorous efficacy and effectiveness studies of VR; exploration of ethical issues with different types of studies such as direct comparison designs (Standard of Care (SOC) vs. VR) and additive designs (SOC vs. SOC+VR); characterization of how participant traits (such as age, literacy and numeracy level, motivation and other cognitive and psychosocial traits), and previous gaming experience moderate technology usability and study outcomes; development of well-defined metrics for assessment of interventions and outcomes, including actual as well as intended VR “dose”; development of VR research tools that could be used in group or multi-site formats (e.g. classrooms); and development of methods for mining data from existing health games for research purposes.
SELECTED RESEARCH EXAMPLES:
There is a need for both developmental VR research leading to new methods and technologies and marketable commercial products. There is also the need for research that provides a venue for well-powered effectiveness trials of the new interventions. Progress in the field will be enhanced by multidisciplinary collaborations between the technology industry and academia, and among researchers with diverse expertise in biomedical sciences (such as endocrinology, nutrition, and exercise physiology), behavioral science and pedagogical disciplines, and computer sciences including VR technologies. There is a need to document and evaluate currently available off-the-shelf programs. Projects will need to be clearly defined with regard to: research questions, technical approach, VR platforms, target population (by age, health condition, psychological status, education or literacy level, etc), and research outcomes. Many projects can be usefully conducted taking advantage of already existing tools, games, and software, although there is also a need to develop unique technologies.
Applications must involve development, use or adaptation of immersive or non-immersive VR environments. Those projects focusing only on electronic means of research data collection (so-called “e-tools”), without VR components, will not be considered responsive.
Potential areas for hypothesis-testing research, and for exploratory, developmental or evaluation research, include (but are not limited to):
Using VR to foster desirable eating, physical activity, and other health-related behaviors:
Using VR to motivate by “fast-forwarding” to the future:
Utilizing social network capabilities of VR:
Utilizing motivational and teaching aspects of VR technology:
Using VR to extend the availability and capacity of health care providers: