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VIII
Discussion

DAVID DINGES: I would like to make one comment about what we have called today cognitive variables and neurobehavioral variables and alertness. From the standpoint of output, these are very far downstream. When something is wrong with them, we cannot always work backwards and figure out what caused that, which is why experiments where we use these neurobehavioral variables usually need to be structured to test a countermeasure or something. In other words, it is very hard to use these downstream variables in some logic path to figure out what part of the brain or what nutrient or what circadian phase caused the problem, and inevitably it is only correlational.

But they are, nevertheless, powerful variables from the ecological validity standpoint, and they are the functional outcomes that most people want to know about. We talked about apnea in truck drivers, and there is a huge media piece on it. I told a reporter that the public really does not care if a truck driver has hemorrhoids; they only care if hemorrhoids affect driving.



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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability VIII Discussion DAVID DINGES: I would like to make one comment about what we have called today cognitive variables and neurobehavioral variables and alertness. From the standpoint of output, these are very far downstream. When something is wrong with them, we cannot always work backwards and figure out what caused that, which is why experiments where we use these neurobehavioral variables usually need to be structured to test a countermeasure or something. In other words, it is very hard to use these downstream variables in some logic path to figure out what part of the brain or what nutrient or what circadian phase caused the problem, and inevitably it is only correlational. But they are, nevertheless, powerful variables from the ecological validity standpoint, and they are the functional outcomes that most people want to know about. We talked about apnea in truck drivers, and there is a huge media piece on it. I told a reporter that the public really does not care if a truck driver has hemorrhoids; they only care if hemorrhoids affect driving.

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability In very much the same way, in many applied scenarios, while we may care medically, what matters is that final output, that final piece, but it is hard to track back without doing assessments and careful countermeasures. DOUGLAS WILMORE: I have sort of a broad generic question for the group of people who talked about behavioral things. It would seem to me that it would be worthwhile trying to think about how you could build a monitoring system into the actual task that the person was doing. I think Mary tipped me to this idea. If you had a computer operator, you could build the ability to shift or to spell wrong or even time variables into that particular task. And Harris, if you are looking at these guys shoving shells into that big gun that you had, it would seem to me that you could time throughout the day the speed with which they were loading the big gun or something like that. I was wondering if that is not the evolution of all of this, that instead of asking people to stop what they are doing and do their cognitive function testing, to somehow build a monitoring system into their specific task. It may even get to the place where that foot device that looked at how many steps people take could even be programmed to do that, because you slow down and you get sore feet, and all that sort of thing. HARRIS LIEBERMAN: Some of those things have actually been implemented, in part. Certain occupations that require the use of a computer to do a job are monitored by the supervisor or a higher level to measure individuals' efficiency on a day-to-day basis, and they are given feedback or they can even be fired if their performance does not meet the specs. What they will do is they will look at the average specs of a telephone operator because that is all automated right now, and if somebody is falling off the bottom of the distribution, that person is in significant trouble. There are some ethical questions there, certainly, but that can be done legally right now. In terms of actually what you are asking, what is their final output, are they firing more shells? It turns out that in that particular example it is extremely difficult to get enough information to relate it back to any measure of performance, because there is so much variability in the individual unit. Some batteries are just better than other batteries, so when you try to get the individual performance data, it all gets confounded with whatever treatment you have got out there. Now, in a situation where, say, there were environmental variations over the course of a long period of time, it might be possible to relate that to some kinds of performance in a correlative kind of way and that would be valuable. That is a good idea. MARY MAYS: Another really good example that is relatively easy to track is the motion of your eyes, where they are going and what they are looking at and so

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability forth. We are doing some pretty nice studies of tracking the eye in doing tasks, exactly what Harris Lieberman so graphically described. Your head begins to drop, so your eyes compensate by looking up, and then the next thing you know your eyes are just rolling back in your head. One of the classic tests for drunkenness is not being able to control those saccadic movements and so forth, that are real common with sleepiness. That is my point about behavior sampling. If we could just use our brains and we were sharp about this and smart, we ought to be able to sample the behavior that is ongoing as a part of the whole military performance. Again, sometimes that is instrumenting and eye-tracking devices, and sometimes that is just taking at face value how many shells they loaded per hour, and so forth. I think we have to move to that. We have to be ingenious about it. I also really agree with something else David Dinges said, and that is, some of the biggest charlatans are the ones who claim that they can monitor your ongoing behavior and make a sophisticated judgment about finger movements or head nods in a car and that it all means something. They can tell you exactly what it means, and they can even tell you exactly which No-Doz you need and how much you ought to take. Just based on that, we need to be very, very careful that our behavior sampling is meaningful, valid, and reliable, and that we test it out before we just take it at face value. What I kind of disagree with is something that each of us, including me, said, that it is all that hard to determine what we should be measuring and that it is all that complex and that we really cannot do it that well. I think we are doing every bit as good a job as some of the other people are who measure interleukin (IL)-2s and IL-8s and IL-10s. I am not pointing my finger at my friends, necessarily, but we are doing as good as some other people are, but we are the first ones to always criticize ourselves. We are the first ones to point and say we do not do it well, we do not really know what it is. JOHN VANDERVEEN: I was wondering about something. They are getting very, very light cameras now that can record for long hours. Is it possible to mount those on the individual, and see what he sees all day long and learn anything from that type of thing? MARY MAYS: Yes and no. They can play football with cameras on their heads. The problem is, having been a graduate student in a laboratory where my major professor wanted us to do that, sitting in front of a videotape, analyzing frame by frame what went on for hours and hours and trying to reduce the data, turning them into something that you can use is tough and filled with subjectivity. JOHN VANDERVEEN: But they are even doing computerized analysis of these types of things now.

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability GINGER WATSON: We actually took a year and a half to cross-validate one of our studies where we had gathered camera data out on the road. I know it was very, very time consuming, and we were always having to make qualitative judgments. I would also like to mention that even in the case of eye-tracking, which is fairly automated, it is still not a very precise science right now. We use eye-tracking in driving to see where the person is looking, and we still are forced to go back in many, many cases to make qualitative assessments. DAVID DINGES: We are making neurobehavioral assessments. No matter what you do, I submit that the brain is the fundamental organ of operation. Because we can technologically monitor the environment or the face of the individual or the heart rate or anything else does not mean we know what is going on. In response to your question, we actually tried this at NASA with the pilots. We got all the pilots and all the engineers and asked whether we could find one thing that occurs in the cockpit that is an operationally relevant measure that everybody agrees on. There were zero. We tried it not one time, but three times. There is nothing that occurs in the cockpit that everybody agrees is an operationally relevant measure. So there is another way to ask the question, which is the way I ask it: Tell me the worst thing that could happen in this job. A meltdown of a reactor? Grounding a vessel on a shoal? Tell me the absolute worst thing. Now, tell me the people who would be involved in that. Now I can measure something that tells you what their capability is at any given time, and that is as close as I can come to predicting the likelihood, the probability, that they may make a fatal mistake. JOHN VANDERVEEN: I want to ask David Dinges two questions. You said the person who could sleep anytime was in trouble, perhaps, but I want to know about the person who can sleep anywhere. I have watched crew members sleep in an airplane. When it is time for them to take their rest, they get up in the bunk and go to sleep. Is there a problem if they can just automatically go to sleep? DAVID DINGES: No, no, I really overstated the case. Regarding that kind of prophylactic napping, we just finished a study on sleep in the cockpit bunk as opposed to the chair. Obviously, it is very adaptive. One of the nice things about having young people in the military is that they are at an age where they can turn that homeostatic drive on and allow themselves to sleep pretty quickly. Most of us are far enough along in years that it is a lot harder to just turn that on and off; we are regulated by the clock much more. It is when you are literally falling asleep everywhere and you misattribute that to your ability that you are in trouble.

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability JOHANNA DWYER: I was very much taken by the self-monitoring quality that might be possible in some of these devices, both the ones we have talked about this afternoon and others, and also very much taken with the notion of prophylactic naps. In trying to put this all together into things like tanks, where there is noise and heat, people are hungry, they cannot eat, or they get six Meals, Ready-to-Eat and they are all chicken a la king for years and years, the problem is how virtual does the virtual reality of a situation like that have to be to get data that are really meaningful to the people who are supposed to be helping the enlisted people? MARY MAYS: I am not sure I understood your question. JOHANNA DWYER: There are multiple variables here that all have to be considered. I was taken by a comment on our last report, Not Eating Enough,1 from someone who was in Vietnam for several years. He mentioned that all these things were great, but that all the factors we talked about really did not include fear and a whole bunch of other things. MARY MAYS: At the Human Engineering Laboratory at Aberdeen Proving Ground they have a tank simulator very much like the one Ginger Watson has talked about—I think you must have worked with these people—and they do exactly that. They do not just make it move in 6 degrees of freedom, but they make it very hot, they make it very dry, they make it incredibly noisy. I think all of us are trying to build a high-fidelity simulation. The Rangers were the perfect example. You had fear, real live fear, you had lots of performance anxiety about what was the worst thing that can happen. I can be thrown out of here, I can be humiliated, and I can die. All of those things were readily apparent every day. Some of my data that I have not talked about very much are that their motivation levels, instead of increasing over time, went down. The more successful they were in Ranger training, the less they cared about being in Ranger training. DAVID SCHNAKENBERG: I have sat in a lot of different meetings over the last few years where people were talking about future simulated battlefields. We are talking here about senior leaders scattered across the country doing their war games but they are doing it at a level of intensity that is very high. I've tried to talk to these folks to tell them that at some point they need to be working on a test bed to see what difference it makes if the leader is tired and sleepy versus well rested? 1   Institute of Medicine. 1995. Not Eating Enough, Overcoming Underconsumption of Military Operational Rations, B.M. Marriott, ed. A report of the Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press.

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability MARY MAYS: We spend a huge amount of money in the Army studying the 18 and 19 year olds. We just do not spend much time, even in our physiological studies, with our subjects (the lieutenant colonels, battalion commanders) who are 40 to 45 years of age. They are not young any more, and I do not care how good a shape they are in or what great leaders they are. They are not going to deal with all these conditions. EDWARD HIRSCH: The Marines are much smarter. (Laughter) With regard to continuous operations, they have a defined policy where after X number of hours there are designated people to take over the company, to take over the command and control after X number of hours of sleep deprivation. MARY MAYS: We had that same policy and we had lectures on it and we had signs posted on it and the first guy to violate it was the battalion commander. We had a whole daytime Tactical Operations Center (TOC) crew and a whole nighttime TOC crew. This was not an exercise. This was real live combat, and we were ready to go. But the minute that things got really exciting, the daytime TOC crew started trying to run the nighttime TOC crew because they did not trust these guys, because all during the preliminaries it was the daytime TOC crew that were the actual commanders and echelon staff. You can have those policies, but as soon as the going gets rough, everybody wants to stay up 20 hours out of the day, and they do not go to sleep until they fall asleep. DAVID DINGES: There was a study done at Dr. Wilmore's institution, the Brigham and Women's, that Drs. Czeisler and Richardson2 did, where they protected the time. They had two groups of residents and they protected the time for sleep of one group but not the other. The obvious hypothesis is that the protected time guys are going to get more sleep. It was the opposite. They did not sleep when they could, because they said, ''Well, I'll get my chance in protected." When they got to that point, they worked and did other things, and the net result was they actually got less sleep, which illustrates this point, the whole issue of what happens when you take a countermeasure into the field. That is the second level of research you have got to do. You have to then check to see how people actually use it, whether it is a nutritional countermeasure or a nutritional one plus sleep. I mean, all of these energy recovery systems have got to be looked at in terms of how they were actually applied. 2   Wolf, M.A., G. Richardson, and C.A. Czeisler, 1990. Improved sleep: A means of reducing the stress of internship. Trans. Am. Clin. Climatol. Assoc. 102:225-229.

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability GINGER WATSON: I was going to say something along that line. Virtual reality in different systems is certainly nice, but good research is good research regardless of where it is done, when you go into the lab or when you go into the virtual reality environment. You have to try to set up everything as concretely as you can to do good research, but you also have to know when to drop that sort of research and go out into the field, because it takes both. There are people in simulation who would kill me right now, but all of the simulation and virtual reality in the world cannot replace some of that information that you gather out in the field. It has to be both. DOUGLAS WILMORE: But you have to have buy-in, and here you have to have buy-in by commanders. You have to be court-martialed or you have to lose your pay or something like that. You have to have buy-in at an upper level if you are going to do these sorts of things. ROBERT NESHEIM: That is the difficulty. You can have all kinds of training in that regard and all kinds of standards that are set up for it, but unless the person really buys into it and really agrees to it, and then does it when the time comes … DOUGLAS WILMORE: And sets the example. ROBERT NESHEIM: And sets the example, you do not have the control that you might like otherwise. I think we have had a great 2 days. We have had exposure to some very interesting concepts and potential technologies, that were very thought provoking, that will generate a lot of thinking that we have to do, everybody that is here has to do, in terms of what the potential application is of these for the types of research that USARIEM and other people in the military might do and what kind of payoff we might expect from some of these and where the military should focus its effort in the near term, and maybe long term, thinking about maybe some of the things that ought to be done within the military and those things which ought to be monitored by the military but done outside by others who can bring the data better to fruition, whether it be to USARIEM or other places. I think these are going to be some very thought-provoking times, and we as a committee have our challenge to sort through this and to come up with some way that we are going to summarize and present this in a way that will be useful to James Vogel and to the Surgeon General and to other people who will be looking at this report. I also anticipate that the summary of all the wonderful papers that were presented here, which we are expecting all the speakers to provide in a timely man-

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Emerging Technologies for Nutrition Research: Potential for Assessing Military Performance Capability ner, is going to be a report that will be in high demand, because it has brought together so many ideas, so many innovative approaches, in one place. You rarely find that much in a report like this, so I think it is going to be something that is going to be highly visible and, again, puts more of a challenge on us as a committee and staff to try to be very, very careful and innovative in how we respond to that. The committee will be meeting tomorrow morning to start the process of figuring out how we are going to do this. I would like to thank all of the speakers and all the participants for their involvement in this. Unfortunately, a lot of our speakers have had to leave. I think this has been one of the most stimulating couple of days that I have sat through. I certainly learned a lot of vocabulary I did not know anything about 45 years ago. Some of the concepts that are expressed here are very, very new, even in all the readings that I have been doing over recent years. So I want to thank everybody for their commitment, for their time in this.