NHLBI Working Group
Virtual Reality Technologies for Research and
Education in Obesity and Diabetes

Executive Summary

The National Heart, Lung, and Blood Institute (NHLBI) convened a workshop entitled “Virtual Reality Technologies for Research and Education in Obesity and Diabetes,” on July 15-16, 2010, in Bethesda, Maryland. The purpose of the meeting was to explore the research potential of VR technologies for behavioral and neuroscience studies in diabetes and obesity, and the practical potential of VR technologies for regimen adherence, nutrition, physical activity and other behavioral lifestyle changes associated with diabetes and obesity. The workshop was sponsored by 6 NIH institutes/offices (NHLBI, National Cancer Institute, National Institute of Child Health and Human Development, National Institute of Diabetes and Digestive and Kidney Diseases, the NIH Office of Behavioral and Social Sciences Research, and the NIH Office of Research on Women’s Health) and the Department of Defense Telemedicine and Advanced Technology Research Center (TATRC).

Background

A significant portion of the US population has difficulty implementing public health or therapeutic guidance on optimal diet and physical activity.  Even among those motivated to adhere to dietary and physical activity recommendations, numerous environmental factors serve as barriers to change.  As a result, those who are obese or who have diabetes find it difficult to make the necessary long-term lifestyle changes to lose weight or manage their illness.   Therefore, available behavior-based approaches are not sufficient to address the current public health and medical management challenges in the areas of obesity and diabetes.

Virtual Reality (VR) technology allows users to interact with computer-simulated environments, typically via enhanced auditory and graphical displays although tactile and other sensory feedback can be used as well. (Note: a useful brief overview of VR is found at: http://en.wikipedia.org/wiki/Virtual_reality ). The computer simulations can be tailored to the user, along with therapeutic guidance to modify affective reactions and prepare the user for future “real-world” encounters.  Virtual Reality applications are currently being evaluated and applied to a number of medical care procedures, notably rehabilitation medicine for stroke and Parkinson subjects, surgery procedures (technical training, robotics, remote site treatment), social and functional skills training for autism and schizophrenia, and exposure-based therapies for anxiety and substance abuse disorders.  However, with the exception of a few small studies of clinical eating disorders (anorexia, binge eating), there has been essentially no research on VR applications for common weight control factors such as food selection, portion control, cued eating, and physical activity.   
VR technology might prove a useful tool for producing sustainable behavior change to manage weight.  The technology could be used to complement motivational interviewing, assess emotional states of readiness for behavioral change, and help subjects to grapple with their emotional reactions to food choices. The visual presentations could assist subjects in adjusting distorted assessments of portion sizes, correcting unrealistic expectations of the rate of weight loss, and managing adverse and positive sensory experiences from behavior change. Virtual reality also could be used as part of patient visits to personalize treatment.   

VR has some unique characteristics as a research tool.  The virtual environments can be designed to address specific hypotheses, and detailed data on the study participant’s response to the intervention can be collected without additional intrusiveness.  Phenomena that are amenable to study, and also treatment, include cue responsiveness and extinction through virtual exposure, which has been used in the study 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. 

Discussion

This workshop brought together a diverse group of participants ranging from diabetologists to videogame developers.  The first part of the workshop was devoted to exploring public health challenges and how technical approaches might provide new tools for addressing these challenges.  First, workshop participants reviewed adult and child diabetes management, including the various difficulties that diabetes subjects and their healthcare providers have in managing their diabetes.  Second, workshop participants provided various examples of virtual reality, such as 3D computer simulations, video games, and simulated social environments.  Applications of VR to related areas of research such as substance use were also presented. 

During the presentations, participants discussed the potential applications of VR for the management of diabetes and obesity and considered the possibility that VR applications within traditional interventions may increase motivation for treatment, particularly among adolescent and young adult subjects. Participants suggested that VR provides an opportunity to match interventions to various ”ages and stages”.   To enhance motivation, participants felt that the VR design needed to be reinforcing to the patient.  Systems that encouraged goal setting, monitored behavior, and provided regular feedback and rewards were considered important to motivating behavior change.  Participants also considered the option of embedding weight management education in existing video games and other consumer-based VR products. 

VR has been used in eating disorders to modify distorted perception of body image and could be used similarly in obesity.  Participants also discussed the potential of VR to provide social networks and support to help children with diabetes who feel isolated and that they are different from everyone else.  VR could provide a virtual support system to those with obesity and/or diabetes via virtual social networks.  VR could also encourage family interactions in an environment where parents and children could more easily work on diabetes management concerns.  Some social network environments could provide credits for healthy eating and engaging in regular physical activity and other health-enhancing behaviors (such as smoking cessation and good sleep habits).   These virtual social networks were considered by participants to be applicable to extending healthcare provider services.  In addition to using VR to train healthcare providers in weight and diabetes management (including reduction of bias and blaming), VR social networks could be used by subjects and providers to deliver interventions between visits and in a more accessible manner particularly if there are barriers of transportation or mobility. 

Participants discussed the use of VR for virtual cue exposure.  VR has been used to facilitate cue-exposure interventions for a number of behavioral problems such as phobias, post-traumatic stress disorder (PTSD), and substance abuse.  Using similar methodology, VR cue exposure could be used to evaluate the effects of various cues on perceived hunger, food intake, and physical activity, and retrain the emotional and behavioral responses to these cues. 

Challenges related to the accessibility, availability and use of VR applications were noted.  There is a need for VR applications that are easy to use and intuitive, even for older populations, or for those with low vision and other sensory/physical disabilities.  Technologies should accommodate user populations and study participants having low health literacy and low numeracy; VR is potentially a useful approach for understanding how health and nutrition information is processed and used by these groups.  Cautions include the need to minimize the possibility that messages imbedded in the technology should appear manipulative, controlling or prescriptive, rather they need to be facilitative.  In addition, it is important to understand the potential for adverse effects such as lack or loss of social skills through displacement to VR, or dysfunctional avatar transference.  Usage costs in various settings (research or private use; home, health-care facility, school) need evaluation as they can include but are not limited to  purchase and maintenance expenses and time burden (amount of time spent in use; convenience of scheduling of interventions or sessions). 

Recommendations

Workshop participants met in small working groups on the second day to consider study designs to address the identified needs and to develop recommendations from one of five perspectives: motivating the desire for change, instilling healthier eating patterns, visualizing physical activity, managing daily life with diabetes, and improving clinical effectiveness. The working group leaders presented their groups’ conclusions and recommendations for consideration and discussion among all workshop participants.  It was noted that progress in the field will be enhanced by multidisciplinary collaborations between the technology industry and academia, and among scientists with diverse expertise (medical, biological, behavioral, pedagogical, and computer sciences).  The integrated summary of these recommendations is listed below.

Topics for research and technology development and evaluation include:

• Using VR to foster desirable eating, physical activity, and other health-related behaviors
• Making smarter eating choices in various locations (such as home, restaurants, school cafeteria)
• Training for more healthful food purchasing and food use decisions (including shopping lists, budgeting, menu planning and food preparation skills)
• Counteracting food marketing efforts
• Assist parents in teaching small children better eating habits (e.g. eat at table, eat variety of foods, try new foods, eat fruits and vegetables)
• Training in portion size effects on weight gain and loss
• Retraining conditioned emotional and behavioral responses to food and eating contexts (cue-exposure of unhealthful foods or contexts where unhealthful eating behaviors occur)
• Assessing reliability and outcomes of existing “health games” or “serious games”
• Improving self-efficacy by VR-guided practice of desired behaviors, including role-playing, scenario navigation, and presentation of information matched to individual learning style and motivational factors

• Using VR to motivate by “fast-forwarding” to the future
• Illustrating how changes in physical activity or diet will lead to changes in weight and body size
• Using avatars or intelligent agents to show consequences of unhealthful behavior and to model healthful behavior
• Understanding characteristics of avatars that modify effectiveness of interventions, including the degree to which they must be sufficiently similar to how user views self
• Modifying perception of body image and other aspects of appearance
• Modeling effects of changes in community food choice availability and built environments on weight, physical activity, health, and illness  
  
  
• Utilizing social network capabilities of VR
• Evaluating impact of social network systems with reward systems (points or credits) for desirable health-related behaviors (buying or eating healthful foods; engaging in physical activity; improving sleep habits; improving diabetes self-monitoring)
• Exploring how social context affects  competitive or collaborative activities
• Providing and evaluating family interventions
• Evaluating usefulness of  VR for social support for diabetes

• Utilizing motivational and teaching aspects of VR technology
• Embedding obesity and diabetes education and motivation in existing VR games and systems
• Using VR to make behavior change more enjoyable and participatory
• Monitoring behavior and providing individualized feedback, including rewards and goal-setting
• Understanding the cognitive processes involved in learning and applying health- and nutrition-related information
• Understanding the short-term vs. long-term motivational aspects of VR, including attenuation of novelty, and how this influences effectiveness and adherence

• Using VR to extend the availability and capacity of health care providers
• Establishing extended classrooms for diabetes education
• Providing less threatening and more accessible behavioral coaching for children
• Enhancing displays and presentations of patient data for review by health care providers
• Providing clinician training in how to counsel subjects on weight management

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)
• Development of methods for mining data from existing health games for research purposes

Publication Plans

The proceedings will be published in the Journal of Diabetes Science and Technology.

Appendices

• Meeting Agenda ( 63KB),  
• Speaker and Planning Committee Roster ( 104KB)

Last Updated: November 2010