LAUSR

Fear of hypoglycemia (FOH) is associated with poor glycemic control, higher risk for diabetes complications and reduced quality of life.1 Psychological interventions such as Cognitive-Behavior Therapy have demonstrated some efficacy in coping with FOH,2 however the need to develop immediate, cost-effective and remotely accessible interventions is evident. Biofeedback, a method used to promote coping with stress-related disorders, has been shown to, improve outcomes in patients with diabetes including better glycemic control.3 Virtual reality (VR) applications enable users to experience simulated environments as real and have been increasingly implemented in treatment of various stressrelated medical disorders.4 Here we present a smartphone application combining biofeedback and VR, designed to assist patients with type-1 diabetes (T1D) to cope with FOH. The system rationale is based on operant learning models that reinforce desired behaviors. In this context, the enhanced behavior was the participants' ability to reach relaxation in the presence of virtual images associated with hypoglycemia. Participants were presented with a virtual trigger—mildlow glucometer readings (85-125 mg/dl) on their mobile phone screen. Positive biofeedback for successful relaxation was achieved using a Galvanic Skin Response (GSR) system. In the biofeedback +VR group another reinforcement was an image of the patients’ feared facial expression that shifted to their own smiling face upon relaxation. A smile has the potential to produce positive emotions and consequently to improve attention,5 thus improve coping with FOH (Figure 1A). One male and 4 female adults with T1D and significant FOH, were randomly assigned to biofeedback or biofeedback+VR conditions. FOH was defined as ≥3 points in the Hypoglycemia Fear Survey-II-worries (HFS-W) scale.6 Participants included in the study had diverse characteristics, with a wide age range (24-73 years), great variability of diabetes duration (7-53 years) and baseline HbA1c measurements (6.5%-8.9%). The primary outcome was the change in HFS-W subscale measured after 3 weeks of 10-minutes daily use of the application (Figure 1B). The baseline scores were on average 48.4 (10), 35 (4.8), and 83.4 (14.4) for HFS-W, Behaviors (HFS-B), and HFStotal (HFS-T) respectively. Participants reported no negative side effects and the system seemed feasible. Although the sample size was small, 4 of 5 reported an improvement in their HFS-W score at 3 weeks post-intervention (Figure 1C) and this effect appeared to be sustainable for a 2-month follow-up (Figure 1D). No difference between biofeedback +VR and the biofeedback alone was noted. To the best of our knowledge, this is the first time that a combined biofeedback+VR paradigm is reported to assist in coping with FOH. This system offers a convenient, accessible, and cost-effective intervention which warrants further investigation in a larger cohort. Biofeedback helps to communicate body and mind, while VR is a paradigm that facilitates the realization and illustration of fantastic ideas. Pairing these 2 evolving domains may lead to an integrated approach to FOH treatment. 1013380 DSTXXX10.1177/19322968211013380Journal of Diabetes Science and TechnologyShiri et al research-article2021