temporal and stimulus factors in self-monitoring by obese persons

BEHAVIOR THERAPY 9, 328-341 (1978)

Temporal and Stimulus Factors in Self-Monitoring by Obese Persons

LEON GREEN

Rutgers University

Subjects in the Discriminative Stimulus Pattern (DSP) Condition monitored discriminative cues for their consumptive behavior, those in the Consumptive Stimulus Pattern (CSP) Condition monitored their rate of consumption of calories, and those in the Monitoring Daily Moods (MDM) Condition monitored their moods. Subjects in the Premonitoring and Postmonitoring Conditions performed their self-monitoring prior and subsequent to their consumption of food, respectively. The temporal-monitoring patterns of half of the subjects in each condition were monitored by external observers (Observer vs No Observer Condition). At post-treatment and follow-up, self-monitoring CSP was more effective in produc- ing weight reduction than self-monitoring DSP or MDM. Self-monitoring DSP was more effective than self-monitoring MDM at a 4-week follow-up. Temporal- monitoring patterns did not contribute significantly to weight reduction. In some groups, the reactivity to the external observer was a significant factor in observed weight reduction, DSP, CSP, and observers were major factors in the maintenance of weight loss.

Several studies have explored self-monitoring as an important and effective component of the behavioral self-control process (e.g., Kanfer & Karoly, 1972; Kazdin, 1974a, 1974b; Lipinski & Nelson, 1974; Mahoney, Moore, Wade, & Moura, 1973; Nelson, Lipinski, & Black, 1975; Sieck & McFall, 1976). Other research, however, has indicated that self- monitoring produces either no reactive effects or contradictory effects (e.g., Kanfer, 1970; Mahoney, Moura, & Wade, 1973; McFalI, 1971; Simkins, 1971a, 1971b). Gottman and McFall (1972), Johnson and White (1971), and Mahoney, et al. (1973) have found that self-monitoring appro-

This research was conducted in partial fulfillment of the requirements for the doctoral dissertation at Rutgers University. I give special thanks and gratitude to G. Terence Wilson, Dissertation Chairman, for his assistance. Special thanks also go to Julane Green, Lisa Kimmelman, and Christine Suanders. Requests for reprints should be sent to Leon Green, Department of Clinical Psychology, Graduate School of Applied and Professional Psychol- ogy, Rutgers University, Piscataway, NJ 08854.

328

0005-7894/78/0093-0328501.00/0 Copyright © 1978 by Association for Advancement of Behavior Therapy. All fights of reproduction in any form reserved.

SELF-MONITORING AND OBESITY 329

priate academic behavior produces an increase in the behavior. Lipinski and Nelson (1974) and Nelson et al. (1975) have found that the opposite effect occurs when an undesirable behavior is self-monitored. Large dec- rements in face-touching behavior occurred in spite of the inadequate agreement levels between unaware self-observers and independent observers. Perhaps more important, all groups decreased their face-touching behavior even when "expectancy sets" indicated no change or an increase. These results conflict with McFall's (1970) finding that self- monitoring increases the frequency of smoking and also with Layne, Rickard, Jones, and Lyman's (1976) finding that self-monitoring produces only temporarily reactive effects. Future studies should explore the self- monitoring process with designs containing multiple comparisons of self-monitoring strategies and subjects with different characteristics and different problematic behaviors. Simply asking whether self-monitoring is reactive or not is simplistic and unanswerable. The appropriate question, as Sieck and McFall (1976) point out, is what effects occur, under which conditions, with which behaviors, and with subjects having what characteristics, as a function of which specific self-monitoring procedure.

Several investigators (e.g., Penick, Filion, Fox, & Stunkard, 1971; Stuart, 1967; Wollersheim, 1970) have demonstrated the effectiveness of behavioral self-control programs for weight reduction but failed to separate the effects of self-monitoring from those of the entire self-control program. Mahoney, et al. (1973) separated these effects and concluded that self-monitoring produced nonsignificant decreases in weight. Mahoney (1974) later found that self-monitoring produced a significant and substantial decrease in weight but no additional decrease after a 4-week period. In contrast, Romanczyk, Tracey, Wilson, and Thorpe (1973) and Romanczyk (1974) found that self-monitoring caloric intake was significantly more effective than either a no treatment control group or a self-monitoring daily weight group and as effective as self-control procedures. This discrepancy may be attributable to the fact that Mahoney's groups self-monitored primarily the quality of their eating habits, whereas Romanczyk's groups self-monitored their daily cumulative caloric intake. Quality of eating habits and caloric intake can be conceptualized as discriminative and consumptive stimuli, respectively. Based upon this conceptualization, self-monitoring eating habits focuses upon discriminative factors relevant to what, when, how, where, and with whom one eats, rather than upon factors directly relevant to weight loss or gain. Self-monitoring caloric intake focuses on discriminative and consequential factors relevant to how much food one consumes, factors directly related to weight loss or gain. Since the object of self-monitoring is an important variable in both the occurrence and the extent of reactive self-monitoring effects (Franks & Wilson, 1974-1975), we can anticipate

330 LEON GREEN

different levels of reactivity due to self-monitoring discriminative stimuli versus consumptive stimuli.

Bellack, Rozensky, and Schwartz (1974) compared a group which monitored discriminative and consumptive stimuli prior to eating (premonitoring) with one which monitored these stimuli after eating (postmonitoring). Only the premonitoring condition was more effective than the control condition in reducing weight although there was no significant difference between the premonitoring and the postmonitoring condition (see Franks & Wilson, 1975). A replication using these and additional procedures to assess adherence to designated temporal-monitoring patterns is warranted.

The present study investigated: (1) the effects of premonitoring and postmonitoring upon weight loss (Temporal Dimension), (2) the differen- tial effects of self-monitoring discriminative and consumptive stimulus patterns (Stimulus Dimension), and (3) the interaction effects of these two dimensions. The study assessed and compared the reactivity produced by external observation and self-observation. Subjects ' adherence to their designated temporal-monitoring patterns was examined. Finally, the role of self-monitoring in the maintenance of behavior change was examined.

METHOD

Subjects Subjects consisted of 61 obese women with a mean age of 39.82 years, a mean of 75.76 lb

overweight, a mean of 63.17 percentage overweight, and a mean overweight chronicity of 15.8 years. Subjects did not have a history of obesity-related problems and were not under the care of a physician for such problems. Subjects were excluded if they were involved in other weight-control programs, took medication for weight control, or reported recent dramatic weight changes within the last month. All subjects who were pregnant or had a t score ~> 70 on any of the MMPI clinical scales, other than Si, were eliminated from the study.

Therapists and External Observers

The author and a graduate student served as experimenters for all five groups, rotating sessions across therapists throughout the experiment. All subjects designated an adult member of their household to serve as a home observer. Half of the observers of each group were selected and trained.

Procedure and Design An incomplete 3 × 2 × 2 factorial design with random sampling from stratified blocks to

five groups was employed. The factors were three conditions of stimulus patterns [Dis- criminative Stimulus Patterns (DSP), Consumptive Stimulus Patterns (CSP), and Monitoring Daily Moods (MDM)], two conditions of temporal patterns (Premonitoring vs Postmonitor- ing), and two conditions of external observations (Observer vs No Observer). The factorial design was incomplete because there was no temporal-pattern condition in Control Group 5 as there was in Groups 1-4. Treatment sessions were conducted for 5 consecutive weeks.


All subjects completed the Biographical Questionnaire Pertaining to Obesity,' Rotter's I-E Scale (Rotter, 1966), and the MMPI. Subjects were ranked according to their initial percentage overweight and randomly assigned from stratified blocks to Groups 1-5. Each group contained 12 subjects with the exception of Group 3 which contained 13 subjects. Subjects were instructed to weigh themselves daily and to plot their weights on graphs collected at each session. All subjects were required to submit a $30.00 service fee. Regardless of weight loss, $5.00 was returned each week contingent upon attendance at each scheduled meeting.

To avoid contratherapeutic expectancies, self-monitoring procedures were not presented as a preliminary to a more effective treatment program. During each 1.5-hr session, subjects were weighed privately. They reported to their respective groups the amount of weight lost, problems in avoiding overeating, and problems in adhering to their specific self-monitoring procedures. Therapists were prohibited from providing guidelines for changing eating patterns and for instituting self-control strategies. Treatment sessions were recorded to ensure that information provided in each session was identical for groups in the same stimulus- pattern condition and to ensure therapists' avoidance of inappropriate experimental procedures and adherence to appropriate procedures.

Stimulus-pattern conditions. These conditions included the DSP, CSP, and MDM Condi- tions in which subjects self-monitored stimuli directly related to obesity. The DSP Condition consisted of subjects in Groups 1 and 2. Subjects were instructed to monitor and to keep a cumulative record of discriminative stimuli that cued them to eat or immediately preceded their desire to eat. These discriminative stimuli were occasions, times, places, activities, specific foods, specific persons, feelings, hunger pangs, and urges, Subjects received def- initions and procedures for recording each class of discriminative stimuli. During each weekly session, subjects were trained to recognize their individual patterns of occurrences of discriminative stimuli, interactions between different classes of discriminative stimuli, sequential occurrences of intraclass and/or interclass discriminative stimuli, and covaria- tions between the occurrences of different discriminative stimuli. At the end of each session, subjects received appointment cards for the next session with a reminder to self-monitor discriminative stimuli.

The CSP Condition consisted of subjects in Groups 3 and 4. These subjects were instructed to monitor and keep a cumulative record of the kinds of food items and liquids consumed, their quantities, caloric values, and rates of consumption, They received def- initions and procedures for recording each class of consumptive stimuli. Estimates of caloric values for each food item were obtained from Count your calories (1968). The therapeutic procedures and training sessions for subjects in this condition were the same as those provided in the DSP Condition with the exception that consumptive-stimulus patterns were analyzed, examined, discussed, and monitored instead of discriminative stimulus patterns.

The MDM Condition consisted of subjects in Group 5. These subjects monitored and kept a record of their moods twice each day, once in the morning and once at night. These moods were categorized as either positive or negative. This condition served as a minimal treatment and attention control. The subjects received supportive psychotherapy and discussed how their emotional problems related to overeating (Grant, 1951; Kosofsky, 1957). These subjects engaged in weekly discussion topics which included feelings of hostility, inferiority, depression, inadequacy, dissatisfaction, frustration, and marital problems. At the end of each session, appointment cards were distributed to the subjects. These cards reminded them to self-monitor their daily mood patterns.

The BQPO is a modification of the Rutgers WEIGHT REDUCTION Program Question- naire employed by G. Terence Wilson and his associates in the Rutgers Weight Reduction Program. The modification includes questions on alcoholism based upon items from the In-Take Drinking Scale (Boggs, 1967).

332 LEON GREEN

Temporal-pattern conditions. The Premonitoring Condition consisted of subjects in Groups 1 and 3 and the Postmonitoring Condition consisted of subjects in Groups 2 and 4. Subjects in the Premonitoring Condition monitored and recorded their discriminative or consumptive stimuli within 2 rain before eating whereas those in the Postmonitoring Condi- tion recorded these stimuli within 2 rain after eating.

External-observation conditions. Using the split-half method, half of the subjects of each group were placed in the Observer Condition and the other half were placed in the No Observer Condition. Home observers of subjects in the Observer Condition were trained during a 1.5-hr session to monitor their respective subjects' eating patterns and the temporal patterns of the subjects" self-monitoring. At the end of training, the observers' mean agreement was 96.4%, with a range of 93.3 to 100.0%.

After training, observers selected 3 days in each week to observe their respective subject's temporal monitoring pattern during a 3-hr period. This involved 12 days of observations. Observers were instructed to record whether their respective subjects recorded eating patterns in the Weight Control Notebook 2 rain before eating, after eating, or neither. The observers recorded "neither" if the subjects did not eat during that period or if the subjects ate but did not record the information. Observers were instructed to be as unobtrusive as possible and not to criticize the subjects or share their observations with the subjects.

A three-way ANOVA for use with a block covariate and unequal Ns (Stimulus Patterns x Temporal Patterns × External Observation) was performed on the percentage overweight of subjects in Groups 1--4 remaining at the post-treatment session (Table I). Similar analyses comparing Group 5 with Groups 1 and 2 and Groups 3 and 4 were also performed. There was no significant difference among the DSP, CSP, and MDM Conditions, between the Pre- monitoring and Postmonitoring Conditions, or between the Observer and No Observer Conditions.

Follow-up Session

A follow-up session occurred during the fourth week after treatment. All subjects were weighed privately and their self-monitoring data were collected. The therapists refunded $5.00 of their service fee for attending this session. All subjects were offered an additional 4-week weight reduction program based on that of Stuart and Davis (1972).

RESULTS

F e i n s t e i n ' s (1959) we igh t - r educ t ion index was used to con t ro l for rela- t ive initial deg ree o f obes i t y and var ia t ions in height and b o d y weight . S ince the weight loss and the r educ t i on - index va r iab les a re s imilar , on ly weight loss will be p r e sen t ed .

W h e n G r o u p s 1-4 are c o m p a r e d , the i r t r e a t m e n t ef fec ts a re a n a l y z e d by a t h r e e - w a y A N O V A involv ing two cond i t ions o f s t imulus p a t t e r n s (DSP and CSP) , two cond i t ions o f t empora l pa t t e rn s (P remoni to r ing and Pos tmon i to r ing ) , two cond i t ions o f ex t e rna l o b s e r v a t i o n s ( O b s e r v e r and N o Obse rve r ) , and a b lock covar i a t e . W h e n the t r e a t m e n t effects o f G r o u p 5 are c o m p a r e d to those o f G r o u p s 1 and 2 o r G r o u p s 3 and 4, these effects a re a n a l y z e d b y a t w o - w a y A N O V A with two cond i t ions o f s t imulus pa t t e rn s (DSP and M D M or C S P and M D M ) , two cond i t ions o f ex t e rna l o b s e r v a t i o n s ( O b s e r v e r and N o Obse rve r ) , and a b l o c k cova r i a t e (Cohen , 1968).

F i f ty- f ive sub jec t s r e m a i n e d in the s tudy at the p o s t - t r e a t m e n t sess ion .

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334 LEON GREEN

One subject in Group 5 was omitted from the data analyses because of her involvement in another weight-reduction program. All subjects, except one from Group 5, attended their follow-up sessions.

External Observations of Temporal Patterns

Subjects in the Premonitoring and Postmonitoring Conditions were observed self-monitoring their stimulus patterns in their preassigned temporal patterns, 68.18 and 87.88%, respectively, of the occasions observed by the observers. There is a significant association, X2(1) = 43.16, p < .001, between preassigned temporal patterns and observed temporal patterns. How often subjects adhered to their preassigned temporal patterns is not associated with the amount of weight they lost.

Weight Loss at Post-treatment and Follow-up

Groups 3 and 4 exhibit greater weight reduction than Groups 1,2, and 5 during the treatment and follow-up periods (Fig. 1). There appears to be

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very little difference between Groups 1 and 5 during the treatment period but a noticeable difference at follow-up. Group 2's weight-reduction index's changes depict a pattern in between that of Groups 1 and 3.

Comparisons of Groups I-4. Two separate three-way ANOVAs for use with a block covariate and unequal Ns (Stimulus Patterns x Temporal Patterns × External Observations) are performed on the mean weight loss for Groups 1-4 at post-treatment and follow-up, respectively (Table 2). The CSP Condition is significantly more effective than the DSP Condition at post-treatment, F(1,35) = 13.79, p < .001, and at follow-up, F(1,35) = 11.09, p < .005. The difference between the Observer and No Observer Conditions is nonsignificant at post-treatment, but the Observer Condi- tion is significantly more effective than the No Observer Condition at follow-up, F(1,35) = 4.69, p < .05. The Premonitoring and the Post- monitoring Conditions do not produce a significant difference in weight loss at either post-treatment or follow-up. At post-treatment, the interaction between stimulus patterns and external observations is significant, F(1,35) = 4.92,p < .05. Analysis of this interaction indicates that subjects who were in both the DSP Condition and the Observer Condition achieved greater weight loss than those who were in both the DSP and the No Observer Conditions. At follow-up the interaction effect of the stimulus patterns' factor and the temporal patterns' factor is significant, F(1,35) = 4.60, p < .05. Subjects who were in both the CSP and the Premonitor- ing Conditions had a greater weight loss than those who were in both the CSP and the Postmonitoring Conditions. Subjects who were in both the DSP and the Postmonitoring Conditions exhibited a greater weight loss than those who were in both the DSP and the Premonitoring Conditions. In addition, subjects who were in both the CSP and the Premonitoring Conditions exhibited greater weight loss than those in both the DSP and the Premonitoring Conditions. All other interactions are nonsignificant.

Comparisons of Groups 1, 2, and 5. Two separate two-way ANOVAs for use with a block covariate and unequal Ns (Stimulus Patterns x External Observations) were performed on the mean weight loss for Groups 1,2, and 5 at post-treatment and at follow-up, respectively (Table 2). There is a nonsignificant difference between the DSP and the MDM Conditions at post-treatment, but at follow-up the DSP Condition is significantly more effective than the MDM Condition, F(1,26) = 6.50,p < .025. The Observer Condition is significantly more effective than the No Observer Condition at post-treatment, F(1,27) = 4.39, p < .05, and at follow-up, F(I , 26) = 4.05, p < .05. The interaction between stimulus patterns and external observations is significant at post-treatment, F(1,27) = 6.07, p < .025, but not at follow-up. At post-treatment, subjects who were in both the DSP and Observer Conditions obtained greater weight loss than those who were in both the DSP and No Observer Conditions.

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Comparisons of Groups 3-5. Two separate two-way ANOVAs for use with a block covariate and unequal Ns (Stimulus Patterns × External Observations) were used to analyze the mean weight loss for Groups 3-5 at post-treatment and at follow-up, respectively (Table 2). The CSP Con- dition is significantly more effective than the MDM Condition at post- treatment, F(1,29) = 14.39, p < .001, and at follow-up, F(1,28) = 22.56, p < .001. The external observations factor and the interaction between stimulus patterns and external observations are nonsignificant at post- treatment and at follow-up.

Maintenance of weight loss. Maintenance of weight loss is defined as the percentage of subjects maintaining or achieving additional weight loss by the end of the follow-up period. The percentages of subjects maintaining their weight losses in the DSP, CSP, MDM, Premonitoring, Post- monitoring, Observer, and No Observer Conditions are 76.19, 62.23, 30.00, 70.83, 70.00, 71.43, and 53.85%, respectively.

Supplementary Measures

To determine whether factors that are generally assumed to be related to obesity (Mahoney, 1975; Stuart & Davis, 1972) are also significantly correlated with changes in obesity, the weight-reduction index was correlated with subjects' ratings of situations responsible for overweight, perceived self-control over personal actions, disbelief in chance control of life situations, and perceived degree of self-discipline. These correlations are nonsignificant other than that between weight reduction and perceived self-control, r(53) = 0.29, p < .015. Also there are nonsignificant correlations between the weight loss or weight-reduction index and age, chronicity, past degree of maintenance, weight loss prediction, confidence in prediction, and Rotter I-E Control Scale.

DISCUSSION

Stimulus patterns selected as targets of self-monitoring can be important factors in determining the degree, stability, and duration of the reactive effects produced upon the target behavior. More specifically, self-monitoring caloric intake produced more rapid, substantial, and dur- able weight reduction than self-monitoring discriminative stimuli or emotional states. Although self-monitoring discriminative stimulus patterns was not more effective than self-monitoring moods at post-treatment, it was more effective at follow-up. Weight reduction produced by self- monitoring mood states each day was minimal and this small gain at- tenuated rapidly in the absence of therapist's and group contacts. The effects produced by self-monitoring caloric patterns or discriminative stimulus patterns are particularly important since they persisted and in- creased at follow-up in the absence of therapist's and group contacts.

338 LEON GREEN

In the present study, the temporal order of the self-recording did not independently affect weight reduction. At follow-up, this factor did interact significantly with stimulus patterns. Premonitoring was more effective when calories were being monitored and postmonitoring was more effective when discriminative cues were being monitored.

The effects of the external observation factor are inconsistent; they are significant only when the analyses included data from Groups 1 and 2. When these groups were included in these analyses, the presence of observers produced greater weight reduction in comparison to the conditions in which they were absent. The results suggest that the presence or absence of an external observer differentially affects the amount of weight loss produced when self-monitoring discriminative cues.

The weight reduction index and the weight loss variables were correlated separately with several possible predictors of weight loss and several factors related to obesity. In general results support Mahoney's (1974) negative conclusions. The correlation between the weight-reduction index and perceived self-control over personal actions is the only exception. Subjects who reported greater self-control generally had larger weight losses. However, the correlation of .29 accounts for only 8.41% of the variance, indicating the need for additional research to explore a possible association between degree of perceived self-control and self-determined or externally determined procedures.

The present results, consistent with Romanczyk et al. (1973), indicate the importance of monitoring caloric intake in behavioral weight- reduction programs. They do not support the importance of temporal patterns in self-monitoring (as indicated by Bellack et al., 1974). Doubt is cast upon temporal-monitoring pattern as a significant and independent factor in weight reduction.

From pretreatment to follow-up, the subjects in the present study who monitored calories had a higher median weight loss (10.25 lb) than subjects in Mahoney's (1974) study who used self-reinforcement for weight loss (5.0 lb) and those who used self-reinforcement for improvement in good eating habits (8.3 lb) for an identical period of time. In the CSP Condition, the subjects' mean weight loss (8.58 lb) at post-treatment compares favorably to the mean weight loss (10.33 lb) of subjects in Wollersheim's (1970) study who received an entire self-management program over a longer period of time (12 weeks). Wollersheim's subjects received self-monitoring, self-control training, relaxation training, behavior-management training, and stimulus-control training. By combin- ing treatment and follow-up periods in the present study, we obtain 8 weeks of self-monitoring. This combination may be more appropriate for comparison with the treatment period in Wollersheim's study. In this comparison, subjects in both studies have the same mean weight loss (10.33 lb).


The contrasting findings among self-monitoring calories, discriminative cues, and moods may have theoretical significance. They suggest a crucial role for feedback (Kazdin, 1974a, 1974b), standards of performance or goals (Kazdin, 1974a, 1974b), and valence or value of the behavior (Kaz- din, 1974a, 1974b; Sieck & McFall, 1976) in self-monitoring but do not provide clear support for either the feedback theory (Kanfer & Karoly, 1972; Kazdin, 1974b) or the operant consequence theory of self- monitoring (Kazdin, 1974b). When calories, discriminative cues, and moods are self-monitored, they all provide feedback relevant to obesity or overeating. The difference among them may lie in the explicitness of the feedback and the relevance of the feedback to performance standards and the value of the behavior. Sieck and McFall 0976) demonstrated that neither self-monitoring nor knowing the valence of the behavior is sufficient to produce a significant reactive effect alone, but their combination can produce a significant reactive effect. The direction of this reactive effect depends upon the target behavior valence, and its magnitude depends upon the performance standard or goal. The performance standard is not necessary for the occurrence of the reactive effect (Kazdin, 1974a).

It is hypothesized that the different levels of reactivity produced by self-monitoring calories, as opposed to self-monitoring discriminative cues or mood patterns, may be due to the performance standards implicit in self-monitoring calories and the culturally accepted negative valence of caloric intake. Although discriminative cues have been shown to be relevant to overeating (Schachter, 1971; Schachter & Gross, 1968; Stuart & Davis, 1972) and weight reduction (Mahoney, 1974; Stuart, 1971 ; Stuart & Davis, 1972), subjects may not readily perceive their relevance to self-monitoring because there are no negative cultural standards or values pertaining to the range of discriminative cues for eating. For self- monitoring discriminative cues to be effective, subjects would have to learn an association between discriminative cues and eating in inappropriate situations and to establish performance standards or goals for these situations. Self-monitoring mood patterns twice daily would only make the learning of this association and corresponding performance standards more difficult because subjects would often monitor irrelevant moods and the feedback on mood patterns would not indicate ways of changing them.

Future research should focus upon training self-monitoring in group versus individual format. In the present study, the possible social influence involved when clients interact with each other may have been a facilitat- ing factor in clients' adherence to their training programs and their own goals to lose weight. The effects of schedules of self-monitoring upon weight reduction also need to be examined. For example, are continuous schedules of self-monitoring more effective than intermittent schedules of self-monitoring upon weight reduction or in reducing inappropriate eating

340 LEON GREEN

patterns? Ultimately, we need to examine the relationship of particular stimulus factors to inappropriate behavior and to determine the extent to which self-monitoring these factors differentially affects the effectiveness of different self-control strategies.

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RECEIVED: June 15, 1976; REVISED: September 4, 1976 FINAL ACCEPTANCE: October 1, 1976

temporal and stimulus factors in self-monitoring by obese persons

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