Personal Information Management (PIM) and Behavior Analysis

  

"Self-knowledge is conceptualized as a self digest that summarizes one's relations to the world and the personal consequences of these relations" (Higgins, 1996). Although self knowledge is as critical as world knowledge and knowledge about how other people think and behave I do not ever recall being taught, by my family or any teacher or professor, how to assess and inventory my own capabilities. I do, however, recall a lesson from a Little League coach.

During my first year as a player for the Gallagher Giants, a baseball team sponsored by the neighborhood oil company, I tried mightily to hit the ball whenever it was my turn to bat. I was physically strong as a boy and I could swing the bat with hypervelosity, but despite many, many opportunities, my bat never connected with the ball. The fact that I was inept at baseball hitting was obvious to the two cigar-smoking coaches that stood with wide stances along the chalk line running from third base to home plate. They did not know my name and they did not speak to me, but I did overhear one comment related to my struggle: "If that kid ever connects with the ball he'll hit a home run". I remember the coach's bromide as well as I recall the last game of the season. During the final game a new coach stood along the chalk line, his name was Mr. O'Halloran and he was slated to be the replacement head coach for the next season. He looked at me over the top of his glasses as I stepped up to the plate to take my turn at bat. After I swung and missed the first pitch, he said: "Hey Mike, come mere, you swing too soon kid, you gotta wait another second". "I do?". "Yeah, wait another second and you'll hit it outta the park" (that's how we talked in Pawtucket, Rhode Island). So, I went back to the plate repeating the rule, waited for the pitch, delayed my swing by a second, heard the crack of the ball against the bat, and watched the ball bounce off the outfield fence post and into center field. A triple, I hit a triple. I followed Mr. O'Halloran's advice and I delayed my swing. I had a new rule and I quickly learned that the rule resulted in favorable consequences. So, I went home on that autumn evening and wrote down Mr. O'Halloran's advice in a spiral notebook I kept between my mattress and box spring - and that was the first time I ever recorded information about how I should carry-on in the world. 
As a young boy, I was interested in cataloging the conditions under which I would successfully hit and catch baseballs. Today, as a behavior analyst concerned with human ingestive behavior, I am interested in studying the conditions under which adults successfully manage their health.
Henry David Thoreau

The frontiers are not east or west, north or south, but wherever a person fronts a fact. 

When Cameron Behavioral Medicine Network (CBMN) members first start the ten-stage Transformative Health program they do not typically possess any organized knowledge centered on: (1) the conditions under which they are able to successfully manage their nutrition, body weight, and exercise routines, and (2) the conditions under which they are most vulnerable and likely to lose personal control on a momentary (e.g., over the weekend) or extended basis (e.g., for a week or more). From my perspective, as a CBMN group facilitator, it is important to teach members how to assess cause and effect, and this requires the organization of a series of highly personal health experiments. Sustainable weight control and fitness involves a process of self-study, experimentation, and cataloging relevant information. I believe that if a person cannot verbally describe their own proactive and reactive strategies for managing their wellness and decreasing the likelihood of their own disease states, they are not optimally positioned to produce changes for lasting health.
A Series of Experiments
When CBMN members first begin the Transformative Health program, it is not uncommon for members to report physical discomfort taking the form of:

• Reflux
• Gastrointestinal problems (diarrhea, constipation, irritable bowel syndrome)
• Abdominal distension 
• Indigestion 
• Disruptions in their sleep/awake cycle 
• Tiredness 
• Migraines 

In response to these physical difficulties it is typical for members to take: antacids, H2 blockers, laxatives, fiber supplements, ranitidine, prescription and over-the-counter sleeping aids, nonsteroidal anti-inflammatory drugs (NSAIDs), and analgesics. Members report that their health management decisions were influenced by television advertisements (e.g., a humorous advertisement for antacids) or their Primary Care Physician. Interestingly, not a simple CBMN member has ever been through the guided process of systematically evaluating the relationship between the foods they eat and their physical discomfort, rather, they have been guided toward pharmaceuticals and pharmacy products. 


Since all people consume a variety of foods, an elementary evaluation for physical discomfort requires: (1) an objective measure of the problem (e.g., esophageal pH monitoring), (2) the development of an intervention, such as the exclusion of high fat foods, spicy foods, fast foods, and food high in sugar content, (3) a re-evaluation (e.g., a repeat esophageal pH level), and (4) ongoing monitoring of symptoms (e.g., sore throat, hoarseness, difficulty swallowing). Evaluations can run along a continuum from the simplistic (such as the one described above) to the more sophisticated. A more advanced evaluation would involve a component analysis based on mathematical combinations and would be used for people with recurrent and treatment resistant problems. Behavior analysis provides the conceptual frame for conducting such evaluations, moreover, these forms of assessments should be done in collaboration with a Primary Care Physician or a naturopathic doctor such as our consultant, Dr. Janet Beaty


Cameron Behavioral Medicine Network members are not only required to identify foods that evoke physical distress, but also foods that produce a sense of fullness (e.g., high satiety foods) and optimize energy (e.g., oatmeal, citrus fruit, beans). Once a CBMN member understands the impact of a particular food, they will use their own Personal Information Management (PIM) system to catalog the critical information. It is essential that each group member conduct a series of mico-experiments and record the outcomes in their PIM system.  
Personal Information Management (PIM) and Behavior Analysis
According to Jones (2008), Personal Information Management refers to the "practice and the study of the activities a person performs in order to acquire or create, store, organize, maintain, retrieve, use, and distribute the information needed to complete tasks". Although PIM is not discussed in terms of health management, I think everyone would agree that personal health management is one of our most important tasks. In consequence, members of the CBMN are required to document the activities they perform in order to optimize their own health. Each member is given a customized Excel file with a PIM page to enter their personal information. By way of example, CBMN members are required to identify and document the following information as the result of a series of mico-experiments: 

1. Their exercise preferences, including "comfort" (high probability) workouts.
2. Trouble spots (e.g., weekends, restaurants, late nights).
3. Favorite high satiety foods (e.g., high protein foods producing a sense of fullness).
4. Foods that produce cravings and hunger (e.g., sugar, fast food).
5. Favorite high nutrient, low calorie foods (e..g, from the Aggregate Nutrient Density Index).  
6. Diverse meals falling within a caloric (as well as fat, sugar, and salt) target.
7. Conditions likely to produce adherence and non-adherence to a food plan.
8. Conditions likely to produce adherence and non-adherence to an exercise plan.
9. Educational articles (e.g., visualization of portion sizes).
10. Kedge goals (e.g., a 30-day Bikram challenge) that pull a person toward their health objectives. 

Our research shows that there is a correlation between active member responding (e.g., completing and submitting a PIM worksheet prior to the weekly behavioral community video conference call), weight loss, exercise adherence, and weekly progress. In short, adherence to weekly responsibilities produces optimal health benefits. In closing, it is our belief that a well organized Personal Information Management system functions as a self-generated guide for a person who drifts from their health objectives or experiences a relapse. Moreover, the field of behavior analysis provides the appropriate conceptual frame needed to optimize and sustain personal health. More to the point, behavior analysis provides the structures to systematically conduct the mico-experiments that are necessary to build self knowledge. 

CBMN Summary Points  

• It is critical that members acquire and create a digest of self knowledge regarding the conditions that will optimize their health.
• The field of behavior analysis provides the conceptual frame and requisite processes for acquiring self knowledge.
• A series of mico-experiments is required to understand the conditions that will optimize your health.
• A Personal Information Management (PIM) is needed to catalog critical information.
• Members need to acquire the ability to provide a comprehensive and fluent description of the proactive and reactive strategies they have acquired to optimize their health and reduce the likelihood of disease states.
• The entire process we follow must be data-driven and not subjective.

I am here for me, I am here for you.

Dr. Michael J. Cameron 
behavioralhealth.cameron@gmail.com

Food Mediated Executive Dysfunction

2 January 2011


Oscar Wilde
Oscar Fingal O'Flahertie Wills Wilde is one of my favorite authors. By way of introduction (if you need one), he was an Irish writer, poet, and prominent aesthete who died destitute in Paris at the age of forty-six. I discovered Wilde  in my early twenties when I came across The Picture of Dorian Gray in the College Hill Bookstore in Providence, Rhode Island. Since then, I have read most of his works and have developed a keen appreciation for his intelligence and epigrams. One of my favorite Oscar Wilde observations is this: 

"The final mystery is oneself"

The pith of the epigram is both insightful and substantive. Insightful I assert because to a great extent he is right, people do not quite understand the network of factors that influence their own behavior. In my opinion, many people consider the controlling determinants of their behavior to be a bit of a mystery. I claim the observation is substantive because if people did understand the factors controlling their behavior they would be in a better position to manage the prevailing contingencies and promote their own health, abundance, and happiness. I have dedicated my career to the study of such influences and teaching others how to optimize their own lives and the lives of others. In fact, I would say that is my primary professional aim. Related to that goal, I have a particular interest in teaching people how to optimize their behavior in relation to food and exercise. 
B.F. Skinner and the Buffet Table
At the same time I was reading Oscar Wilde and advancing my literary interests, I was also reading another author, B.F. Skinner, while pursuing the study of experimental psychology. I was a freshman in college when I read Skinner's book Science and Human Behavior. I confess, I did not read the book because of a specific interest in behaviorism, rather, my motivation was induced by the human services organization that I worked for at the time. Specifically, the behaviorally-oriented administrators of the agency gave each employee $20.00 for every chapter read, providing the employee could pass an exam and show mastery of the material. I quickly learned that $20.00 (circa 1976) would fill my little red TR-6 with gas and stock my cupboards with groceries for seven days. In consequence, I read a chapter each week, took an exam, and pocketed the twenty dollars. However, something curious happened - by the end of the third chapter in the book, entitled Why Organisms Behave, I was fascinated and I began "studying" the text rather than reading for cursory comprehension and a $20.00 reward. I have been studying the philosophy of behaviorism and the science of human behavior ever since. I found Skinner's analysis of human behavior compelling. In fact, I recall one particular insight that is relevant to the current post, that is, Skinner asserts that there is no requirement for a person to understand the contingencies that control their behavior. I think that this observation has particular relevance regarding our actions in the presence of food, that is, many people are governed by food in ways they cannot describe. Anyone that has lost personal control connected to food will be able to relate to Skinner's observation. For example, you may be unaware of the network of factors controlling your ingestive behavior, such as: biochemical influences; your chemosensory system; social factors; time of day; the amount of time between meals; alcohol and nicotine usage; visual stimuli in your environment (e.g., the LOVIN IT sign on the side of a bus or commercials on the television); your private verbal behavior; the body weight of your closest companions, your spouse, or partner; your physical activity level; your hormone levels (e.g., Leptin); and prescription medications. In short, you may regard your eating behavior to be the byproduct of unidentifiable and unnameable forces. As a behavior analyst interested in human ingestive behavior, I can tell you that there are discoverable, identifiable, and manageable factors controlling your eating behavior that you can learn to manage. If Skinner observed the current obesity epidemic in the United States, he would encourage us to systematically study the ingestive behavior of individuals, identify the variables that give rise to unhealthy eating and weight gain, methodically manipulate putative controlling variables, and evaluate the results. I have no doubt that Skinner would encourage us to sharpen our pencils, observe people at the buffet table, and record their patterns of behavior as a natural scientist would observe and record any other phenomenon: with curiosity and without judgement. 
Healthy People Plan Actions 
For members of the Cameron Behavioral Medicine Network (CBMN) there are two practices that conduce a behavioral cusp. A cusp, incidentally, is "a behavior change that has consequences for the organism beyond the change itself, some of which may be considered important". A behavioral cusp provides a person with opportunities to: 

• Access diverse reinforcers (e.g., self control and self efficacy) 
• Make contact with new contingencies
• Access relevant environments
• Access new associated behaviors (generativeness)
• Engage in behaviors that compete with aberrant repertoires (e.g., nonstandard eating patterns)
• Impact an entire network of people that agree on the social relevance of the behavior change

The two practices that promote a behavioral cusp are: (1) meal and snack planing (including restaurant planning), and (2) recording your adherence to your food plan. In my experience with CBMN group members, I can say without hesitation that disorganization, poor regulation, and ambiguity around food is evidence of a certain kind of an executive functioning problem; in fact, I will refer to this problem as Food Mediated Executive Dysfunction (FMED). In order to develop structure around food, the following skills are required: 

1. Planning and decision making 
2. Dynamic adjustment and troubleshooting 
3. Preparation for unexpected events (e.g., being hungry while attending a social gathering) 
4. Preparation for events that require the overcoming of strong behavioral responses 

The skills outlined above are essential, and once acquired, differentiates the "thinking" person's approach to weight control and health management from a person who simply restricts calories and deprives themselves. More to the point, the thinking person's approach can be compared to a hypo-caloric diet wherein you severely restrict your caloric intake. The latter approach requires only a single thought (restrict calorie intake) and ultimately the thought, and the results, are unsustainable. The former approach requires the development of a rich repertoire of essential skills that will produce desired results and lasting change. 
The process for activating "a thinking person's approach" involves a food category preference assessment (i.e., an assessment of preferences for foods from the primary food groups: grains, vegetables, fruits, healthy oils, daily, and protein). Subsequently, multiple versions of meal and snack menus need to be created. The menu below (for breakfast) is an excellent example of food planning from one of the CBMN members. It is important to note that the options below are based on personal preference, nutritional balance, response effort (e.g., preparation time), and the desire for variation. 
"THE WEEKENDER # 1" BREAKFAST SANDWICH: 1 egg +1 white on Ezekiel muffin w/ 1 oz melted cheddar cheese, 1 slice fat free Canadian bacon & tomato (350 calories)
"THE WEEKENDER # 2" ENGLISH LOX: 3 oz lox, 1 T whipped cream cheese on Ezekiel muffin w/ red onion & tomato (350 calories)
VEGGIE CHEDDAR OMELET: 1 egg + 1 white, 1 oz Swiss cheese, onion, spinach omelet (275 calories)
HOT CINNAMON OATMEAL:1 C steel cut oatmeal, 1/4 C skim milk, 1T protein powder, 1/4 C pomegranate (or 2 T raisins) 4 crumbled walnut halves, cinnamon & cardamom (325 calories)
THE OLE': 1/2 avocado on Ezekiel muffin with red onion & tomato slices (300 calories).


Restaurant planning can be accomplished by viewing a restaurant's menu on-line and deciding what foods will be ordered prior to entering the restaurant. This practice allows a member to develop clear language around food rather than entering the restaurant with ambiguous intentions. Once a member has completed their menu and restaurant planning, they generate a daily "adherence score", that is, they report on the percentage of the plan they followed. Subsequently, they will report their adherence to their behavioral community. The process of menu and restaurant planning is particularly important around the holidays when the likelihood of defaulting to previous established behavioral patterns (e.g., eating until you have to unfasten your pant button or belt) is high.
I agree with Wilde, the "final mystery is oneself". However, I believe that Skinner has given use the conceptual frame to identify the variables that control human behavior. The Cameron Behavioral Medicine Network seeks to study each individual's pattern of ingestive behavior and identify the critical variables to promote their optimal health.
CBMN Summary Points

• There are multiple discoverable, identifiable, and manageable factors related to nonstandard eating patterns. Skinner would encourage us to study an individual's ingestive patterns. 
• Members must develop a rich repertoire of planning and problem solving skills and take a "thinking person's approach" to weight control and optimal health. This is in contrast to a hypo-caloric diet and a "single thought approach" (i.e., restrict calories). 
• Many of the difficulties centered on dysregulated eating can be traced to a general level of disorganization around food - I refer to this as Food Mediated Executive Dysfunction.
• An essential component of the CBMN model includes menu and restaurant planning. Planning is particularly important during high risk situations (e.g., weekends, holidays, vacation).
• Once a plan is develop, an "adherence score" should be generated on a daily basis and reported to the behavioral community.

I am here for me, I am here for you. Happy New Year!                                       Dr. Michael J. Cameron 

Odysseus and Self Monitoring

26 December 2010



Odysseus

In Greek mythology the Sirens are half bird half women enchantresses that lure sailors with their melodic song. With seductive voices the Sirens would summon crews into the rocky coast and instigate them to jump overboard or run their ship aground. In order to avoid the spell of the Sirens, steersmen in the proximity of the island would cork their ears with beeswax and cover their eyes with cloth. Odysseus, however, was an exception, he choose to face the seduction and ordered his crew to tether his arms and body to his ship's mast while he navigated. As he passed the Sirens' island, he forced himself to look at the beautiful creatures and listen to their entrancing song. In the end, he resisted their temptation and the Sirens, distraught by the loss of power, plunged themselves into the sea, thus ending their wicked maritime influence.


A Lesson From Odysseus


Like the Sirens, food and easiness are seductive influences in our lives and sing their own enticing song. As all of you are aware, a lifestyle involving unregulated eating and inactivity renders wrecked health and loss of personal control. Furthermore, disorganization centered on food and exercise results in many people running aground, and in at least one part of their lives, they feel marooned. I have compassion for such people.

In my work with members of the Cameron Behavioral Medicine Network (CBMN) devoted to transformative health, I see a commitment comparable to Odysseus, especially in the area of self monitoring. That is, I have witnessed members secure themselves to a vertical spar called dedication, force themselves to look without blinders at the food they consume, and examine their personal movement patterns. Within that process, they resist the temptation of avoidance and begin recording, without judgment or self-criticism, their own patterns of behavior. Such a recording commitment is necessary since self monitoring is one of the basic and fundamental components of a behavioral weight management program. Moreover, self monitoring is the antidote to behavioral discounting, that is, the universal tendency to devalue rewards and punishers that are not immediately available. The purpose of this post is to provide some guidelines, for new members, centered on the self monitoring process.  The guidelines are based on the following assumptions:

• An effective weight control program is one that involves the systematic study and quantification of a person's patterns of eating behavior and movement.
• An effective program is one that focuses on global health and quality of life changes rather than just the dial on a body scale and calories consumed and burned. 
• An effective program is one that promotes self control, self efficacy, and self determination. 

Begin With The End In Mind 

An appropriate weight control and fitness program should produce improvements in many aspects of your life, including changes in: 1) nutrition; 2) cholesterol, triglyceride, and blood glucose levels; 3) physiological measures such as blood pressure, resting heart rate, and recovery heart rate; 4) caloric, fat, sugar, and salt intake; and 5) your scores on a Functional Movement Screening (FMS). In short, self monitoring should involve a data collection system that captures all of these measures. Some measures will be captured daily (e.g., caloric, fat, sugar, salt intake, and nutritional balance) while others will be recorded on a monthly (e.g., recovery heart rate) or a quarterly basis (e.g., FMS). However, data should be collected routinely to verify and quantify the impact of your weight control and fitness program. Therefore, "begin with the end in mind", expect changes across many aspects of your life, and begin using a self monitoring system to study the effects of your program. In addition, use a self recording method that aligns with your natural routines.


Use A Self Recording Method That Comes Naturally 

For many people, a low technology method of self recording is preferred. For example, some individuals prefer to use 3 X 5 index cards as a Daily Food and Water Tracker. Guidelines for using paper-based methods for monitoring can be found on the D*I*Y Planner website. For those individuals who work on a desktop computer during the course of the day, there are some excellent Internet-based programs that are easy to use, programs such as Calorie King and Spark People certainly fall into that category. Finally, for those that are partial to mobile computing and have an iPhone, an iPad, Droid, or Blackberry, there are many applications that are convenient; the application My Fitness Pal is a favorite among CBMN members. On a weekly basis, all health group members convert their data over to a customized Excel file and forward their spreadsheet to a group facilitator for analysis. The facilitator is a "pattern seeking" behavior analyst that identifies trends related to food, ingestive behavior, and movement.


Interesting Patterns To Evaluate

Your CBMN facilitator will look for specific patterns centered on food and movement. By way of example, your nutritional balance will be evaluated to determine whether you are maintaining a proper menu of protein, fruits and vegetables, grains, dairy, and healthy oils. Our consulting Naturopathic Doctor, Dr. Janet Beaty, evaluates the Excel files of members and provides individualized feedback on nutritional balance and the healthiness of food choices. Your group facilitator will also evaluate the amount of time between snacks and meals, this is referred to as your inter-response interval (IRI). People with healthy eating patterns will avoid states of deprivation that result in impulsive food choices and the consumption of high volumes of food. In contrast, it is not uncommon for a person with a healthy eating routine to consume a small amount of food (e.g., fruit, vegetables, nuts) every two hours. Your facilitator will look for a correlation between long IRIs, impulsive food choices, and a caloric intake in excess of your daily target.

In summary, an appropriate weight control and fitness program relies on a data-driven process for decision making and incremental changes in your overall health program. In fact, this is what distinguishes a behaviorally based program from generic programs often used by the pubic.


What Would Odysseus Do? 

If Odysseus found himself being lured by food and easiness, I suspect he would commit himself to confronting the seduction and closely examining the source of his temptation. Self monitoring is an essential part of all behavioral weight control programs that prevents us from corking our ears and covering our eyes. Therefore, it is essential that members begin and sustain the process of self monitoring and use a system most conducive to close continuous contact with essential information.

I am here for me, I am here for you.


Dr. Michael J. Cameron