MAKE BETTER CHOICES!

AN INTERVENTION PACKAGE TO ENCOURAGE

HEALTHY EATING IN ADULTS

by

Ashley Lawal

JULIANNE LASLEY, PhD, Faculty Mentor and Chair

LISA DRUMB, PhD, Committee Member

ANDREA MURRAY, PhD, School Member

Joshua L. Stanley, EdD, Dean

School of Social and Behavioral Sciences

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Capella University

April 2024
© Ashley Lawal, 2024
 Abstract

Healthy eating behaviors impact the individual and society as a whole and thus shape our well-

being. Despite the abundance of dietary guidelines and recommendations, individuals

consistently struggle with maintaining healthy eating choices that lead to better dietary habits.

Previous research has indicated several interventions to improve health-related behaviors.

Conversely, there are still limited behavior-analytic interventions to encourage healthier eating

choices. Drawing on the theoretical framework of the matching law, this study investigated the

impact of gamification and a self-monitoring system on an individual’s choices between healthy

and unhealthy foods. Utilizing a changing criterion design, data was collected from three adult

female participants between the ages of 21 and 40. Data analysis involved the observation of

daily food journals for breakfast, lunch, dinner, and snacks, along with completing a self-

monitoring checklist. Participants raced to earn the most points for meeting weekly criteria for

engaging in healthy eating choices and recording them in the electronic food journal. Findings

indicate that gamification and self-monitoring did not consistently increase healthy eating

choices across participants. Consistent self-monitoring for two participants was correlated with

minimal healthy eating choices, while gamification served as a powerful reinforcer for one

participant. Further research is warranted to examine intervention components that involve

better-individualized goal-setting and comparison of reinforcement schedules for making healthy

choices. These findings highlight the complexity of promoting healthy dietary choices and the

need for personalized approaches to behavior change interventions.

 Dedication

I dedicate this dissertation to the individuals whose impact has shaped my journey in

pursuing knowledge and understanding the significance of healthy eating choices. In the loving

memory of my maternal grandfather and his sudden passing led me to a transition and an

ongoing commitment to a healthy lifestyle and is a reminder of the critical importance of

addressing heart health and any disease affected by poor nutrition choices. The memories of my

grandfather and other family members who have passed away from disease have shaped the

direction of this dissertation, emphasizing the significance of nutrition in preventing chronic and

obesity-related ailments. May this work propel us towards a collective effort to promote heart

health and prevent the impact of cardiovascular diseases through mindful nutrition. May this

work be a tribute to my grandfather, grandmother, aunts, and all family members who have

passed. An ongoing conversation about preventing nutrition-related disease through informed

and healthy choices continues to be much needed. I am indebted to my husband and kids for their

unwavering encouragement and understanding during the long, challenging nights immersed in

this work. To my husband, your belief in me never wavered, even when mine did. Your steadfast

support and encouragement were my pillars of strength, propelling me forward when the path

seemed arduous.

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 Acknowledgments

I extend my most profound appreciation to my mentor, Dr. Julianne Lasley, and my

committee chair, whose invaluable guidance and insightful recommendations have been

instrumental in shaping the trajectory of this research. Dr. Lasley’s expertise and support have

enriched my academic journey, and I am grateful for her mentorship.

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 Table of Contents

Acknowledgments.................................................................................................. iv

List of Tables ....................................................................................................... viii

List of Figures ........................................................................................................ ix

CHAPTER 1. INTRODUCTION ........................................................................................1

Background of the Problem .....................................................................................1

Statement of the Problem .........................................................................................3

Purpose of the Study ................................................................................................6

Significance of the Study .........................................................................................6

Research Questions ..................................................................................................7

Definition of Terms..................................................................................................7

Research Design.......................................................................................................9

Assumptions and Limitations ................................................................................10

Assumptions ...................................................................................................10

Limitations ......................................................................................................11

Organization of the Remainder of the Study .........................................................13

CHAPTER 2. LITERATURE REVIEW ...........................................................................15

Methods of Searching ............................................................................................15

Theoretical Orientation for the Study ....................................................................15

Review of the Literature ........................................................................................19

Findings..................................................................................................................42

Critique of Previous Research Methods ................................................................44

Summary ................................................................................................................45

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CHAPTER 3. METHODOLOGY .....................................................................................47

Purpose of the Study ..............................................................................................47

Research Questions ................................................................................................47

Research Design.....................................................................................................48

Target Population and Sample ...............................................................................49

Population .......................................................................................................49

Sample ............................................................................................................50

Procedures ..............................................................................................................51

Participant Selection .......................................................................................51

Protection of Participants ................................................................................51

Data Collection ...............................................................................................52

Data Analysis ..................................................................................................57

Ethical Considerations ...........................................................................................58

Summary ................................................................................................................58

CHAPTER 4. RESULTS ...................................................................................................60

Background ............................................................................................................60

Description of the Sample ......................................................................................60

Results ……………………………………………………………………………61

Summary ...........................................................................................................….67

CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS ....................69

Summary of the Results .........................................................................................69

Discussion of the Results .......................................................................................69

Conclusions Based on the Results .........................................................................70

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 Limitations .............................................................................................................72

Implications for Practice ........................................................................................74

Recommendations for Further Research ................................................................74

Conclusion .............................................................................................................75

REFERENCES ..................................................................................................................77

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 List of Tables

Table 1. Leaderboard Results by Research Participants ...................................................61

Table 2. Initial Criterion Changes by Participants ...........................................................61

Table 3. Exact Agreement IOA Across Participants for 20% of Days .............................65

Table 4. Percentage of Self-Monitoring Checklist Tasks Across Days in Intervention

Phases for All Participants .................................................................................66

Table 5. Participant Social Validity Results ....................................................................67

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 List of Figures

Figure 1. Participant Two Changing Criterion Design of Fruit and Vegetable

Consumption .......................................................................................................63

Figure 2. Participant Three Changing Criterion Design of Fruit Consumption ................64

Figure 1. Participant Four Changing Criterion Design of Fruit and Vegetable

Consumption .......................................................................................................65

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 CHAPTER 1. INTRODUCTION

Healthy eating behaviors are extensive and encompass various aspects of nutrition,

psychology, behavior change, and public health (Marijn et al., 2018). Numerous nations and

institutions have formulated dietary recommendations grounded in scientific evidence to

encourage adopting healthy eating habits (Herforth et al., 2019). These guidelines often

recommend consuming different food groups, portion sizes, nutrient requirements, and strategies

for maintaining a healthy and balanced diet. The significance of healthy eating behavior extends

beyond sustenance; it plays a crucial role in maintaining overall well-being and preventing

chronic diseases. Food affects physical health, mental well-being, and longevity (Hung et al.,

2023). Nutrient-rich diets fuel our bodies and support their optimal function (Cena & Calder,

2020).

Unfortunately, we live in a vast world of fast food and processed meals dominating our

daily lives. It is easy to engage in the behavior of choosing quick and often unhealthy options.

Understanding the behavioral aspects of eating is crucial for promoting healthy eating habits.

What does healthy eating mean? It is not about strict diets or depriving ourselves of enjoyment.

Instead, it is about finding a sustainable approach that suits our needs and preferences. It is about

understanding the importance of consuming a diversified variety of nutrient-rich foods in

appropriate portions and developing a positive relationship with what we eat. Embracing healthy

eating behavior is about making deliberate choices that prioritize nutrition and balance.

Background of the Problem

Healthy eating behaviors, encompassing dietary choices and consumption patterns,

represent a critical determinant of overall well-being and disease prevention. In a world

characterized by evolving food diversity and changing lifestyles, the challenge of fostering

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healthy dietary habits has emerged as a multifaceted and pressing concern. Unhealthy eating

practices have become pervasive, culminating in a surge of chronic diseases, obesity, and

associated health issues. The issue unfolds with a broad spectrum of settings, from individual

households and workplaces to the broader community and societal level. The consequences

ripple across demographics, affecting individuals of all ages, socio-economic backgrounds, and

cultural contexts. The pervasive nature of the problem extends its impact on public health

systems, economics, and the overall quality of life within societies.

In recent years, the global prevalence of diet-related diseases has reached alarming levels,

posing significant health, social, and economic burdens. As of 2016, over 650 million adults

were obese (WHO, 2021). Furthermore, WHO (2021) reports that globally, obesity is more

prevalent than underweight, indicating a higher occurrence of individuals classified as obese.

The escalating rates of obesity, cardiovascular disorders, and other chronic conditions have shed

light on the crucial need to address unhealthy eating behaviors (Mozaffarian et al., 2018; Ng et

al., 2014). As researchers, practitioners, and policymakers strive to combat these complex issues,

it is imperative to delve into the multifaceted aspects that underlie dietary choices (WHO, 2020).

Understanding human behavior is essential when it comes to promoting healthy eating

behaviors. Obesity is a personal health issue, but its consequences also affect society. The

healthcare system spends billions of dollars treating chronic health conditions related to

unhealthy eating (Musich et al., 2016). Behavior analysis, a field rooted in psychology, focuses

on studying how individuals' actions are influenced by their environment and how behavior can

be modified or reinforced. Addressing healthy eating behaviors using behavior analysis pinpoints

a systematic approach to increase healthy eating choices, monitor them, and use behavioral

approaches (Tronieri et al., 2022). Furthermore, it provides a lens through which environmental

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variables could be understood and investigated to find solutions to increase the healthy eating

behavior of adults. The matching law, pioneered by Hernstein (1961), emerges as the guiding

theoretical approach to this study. This theory posits that individuals allocate their behavior to

maximize reinforcement in a manner that aligns with the distribution of available reinforcers.

Regarding healthy eating, this implies that individuals are likely to make dietary choices based

on the perceived reinforcement or reward associated with different food options. The matching

law emphasizes the importance of understanding the reinforcing value of various options, such as

foods within one’s environment. From a philosophical standpoint, the theoretical orientation of

the matching law aligns with a pragmatic and empirical approach to behavior change. It indicates

that interventions to promote healthy eating should be grounded in observable and measurable

variables. This aligns with behaviorism, which emphasizes the significance of studying behavior

systematically and objectively. Understanding and manipulating environmental variables can

lead to meaningful and sustainable behavior change by considering the reinforcing value of

healthy and unhealthy food options.

Statement of the Problem

Individuals in the United States face chronic disease and obesity challenges due to their

current dietary choices. The widespread problem is that many people need help changing their

food choices to healthy ones, resulting in poor diet and nutrition. The current food system

contributes to detrimental food consumption, with foods high in sugar, fat, and processed foods,

which have prompted obesity and increased micronutrient and fiber deficiencies (Alsaffar,

2016). A diet like this has significant health and economic costs (Sterling & Bowen, 2019). The

specific problem is a need for effective interventions to address poor food choices among adults,

resulting in multiple social health issues (Rafacz, 2019). According to federal recommendations,

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fruit and vegetable consumption only occurs in 1 in 10 adults in the United States (Sterling &

Bowen, 2019). Relatively 9 in 10 Americans consume high salt intake, and approximately 173

billion dollars are spent on healthcare for obesity (Centers for Disease Control and Prevention,

2022).

Behavior analytic interventions are underexamined regarding healthy eating, specifically

poor food choices and self-selected behaviors. Previous studies have found, amongst ABA-

specific journals, that many of the research studies on healthy eating behaviors focused on

behaviors such as food selectivity (Crowley et al., 2020; Peterson et al., 2019; Tiger & Hanley,

2006), eating disorders (Zeleny et al., 2020;2019), food preferences (Zonneveld et al., 2018), and

food refusal (Sharp et al., 2012). Additional studies have also examined the effectiveness of

behavior-analytic intervention in improving physical activity (Washington et al., 2014). Journals

outside of ABA, such as Frontiers in Nutrition, Annals of Behavioral Medicine: A Publication of

the Society of Behavioral Medicine, Nutrients and Physiology and Behavior, have further studies

regarding healthy eating. Prevalent interventions to increase healthy eating have consistently

focused on educating individuals on health benefits without long-lasting effects (Shavit et al.,

2021). Marcum et al. (2018) suggest studies that evaluated interventions on food choice have

centered around habitual actions, total calories on a plate, and environmental factors such as

placing healthy foods first. Previous studies have also found that food choice delays and factors

affecting food's reinforcing value (Temple, 2014) have predicated food choice. Much of the

literature using behavior analysis to increase health-related behaviors has primarily targeted

increasing some physical activity. For example, one study completed a systematic literature

review where self-monitoring was evaluated as an effective intervention. Many studies that used

self-monitoring to increase some forms of physical activity still could not determine what self-

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monitoring components were practical (Page et al., 2020). Very few research studies employ

behavior strategies for behavior change related to healthy eating. Other behavior-analytic

interventions that focused on increasing healthy eating behavior were reinforcer pairing and

fading (Tiger & Hanley, 2006), reinforcement and cueing (Stark et al., 1986), and prompting,

feedback, and social reinforcement (Stock & Milan, 1993). Recent research has also looked at

innovative ways behavior analysis may contribute to increasing healthy behaviors. With the

recent increase in the popularity of video games and utilizing health apps, gamification presents

a potential avenue for behavior analysts to enhance the well-being of individuals (Morford et al.,

2014). Therefore, we need to know if games (gamification) and self-monitoring can ameliorate

healthy food choices by understanding the theoretical orientation of the matching law.

The research literature lacks a comprehensive examination of behavior analytic

interventions regarding healthy eating, particularly in addressing poor food choices and self-

selected behaviors. As seen previously, existing studies within behavior analysis have touched

upon aspects like food selectivity, eating disorders, and physical activity. There are notable gaps

concerning empirically effective interventions targeting healthy eating behaviors specifically.

Most prevalent interventions, even outside of ABA journals, tend to focus on short-term

educational approaches, often lacking sustained impact. Behavior change strategies regarding

healthy eating are widespread. However, there are a limited number of behavior analytic studies

exploring effective interventions such as reinforcer pairing, fading, reinforcement, cueing,

prompting, feedback, and social reinforcement. Remarkably, the intersection of behavior analysis

and gamification in promoting healthy eating has gained attention in recent studies. For instance,

Jones et al. (2014) investigated the impact of the FIT game, a gamified intervention, on

increasing fruit and vegetable consumption among school children. The study's results indicated

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a significant increase in fruit and vegetable consumption, showcasing the potential of

gamification elements in reinforcing positive eating behaviors. Despite these promising findings,

the literature exploring the gamification of healthy eating within the behavior analytic framework

remains limited. This underscores a critical area for future research, as gamification emerges as

an effective intervention that sustainably promotes healthier dietary choices.

Purpose of the Study

This study evaluated the effects of a self-monitoring system and gamification on making

healthy food choices and increasing and maintaining healthy eating behaviors in adults. With a

growing prevalence of diet-related diseases and an alarming rise in obesity rates, particularly in

the United States, there is a pressing need for effective behavior-analytic interventions that go

beyond traditional educational approaches. The selection of self-monitoring and gamification is

grounded in theoretical considerations, aligning with the principles of the matching law and

practical insights from the existing literature, which underscores their potential impact on

behavior change. The research seeks to bridge the gap in behavior analysis studies related to

healthy eating, offering a systematic examination of interventions that may pave the way for

practical and sustainable solutions to address the complex issue of unhealthy food choices.

Significance of the Study

Healthy eating behaviors are more than just personal choices; they hold the power to

shape our well-being, transform communities, and revolutionize the field of behavior analysis.

By nourishing our bodies with wholesome nutrition, we foster physical and mental health and lay

the foundation for a healthier society. Understanding and promoting the social significance of

healthy eating behaviors can unlock the potential for individual empowerment, social

transformation, and advancements in behavior analysis research and practice (Rafacz, 2019).

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Social and Economic Implications

Using gamification and a self-monitoring system to encourage healthy eating choices has

significant social and economic implications. On a social level, successful interventions can

improve public health by reducing the prevalence of diet-related diseases and fostering an

environment of enhanced well-being and quality of life. It also aims to empower individuals to

self-select healthier eating behaviors. This approach addresses the broader issues of diet-related

diseases and caters to individuals' unique needs and choices. The behavioral shift within

communities towards healthier choices may influence social norms and create a supportive

atmosphere for sustained change. Empowering individuals through gamification and self-

monitoring enhances autonomy, contributing to a sense of control over one’s health.

Economically, a population with healthier eating habits translates to reduced healthcare costs at

the individual and systemic levels. Increased productivity in the workforce, coupled with reduced

absenteeism, contributes to a more efficient and economically productive society.

Research Questions

How do gamification and a self-monitoring system affect selecting healthy versus

unhealthy foods?

Definition of Terms

Here is a list of terms that will assist in understanding the research study; the following

definitions are provided:

Applied Behavior Analysis (ABA). A systematic approach to understanding and

modifying behavior by applying learning principles (Cooper et al., 2019). Environmental

variables that influence socially significant behavior are identified systematically to develop

individualized and practical interventions (Yu et al., 2020).

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 Gamification. Using game elements and principles, such as earning points and badges, to

engage and motivate individuals in non-game contexts (Deterding et al., 2011).

Healthy Eating. Healthy eating involves a balanced diet that provides essential nutrients

to support overall well-being (WHO, 2023).

Matching Law. A mathematical formula that describes the allocation of behavior

between different response options based on the rate of reinforcement obtained from each option

(Hernstein, 1961).

Participant characteristics. Adults ages 18 and older with the following inclusion and

exclusion criteria: Inclusion criteria- internet access on a mobile device or computer/laptop,

expressed a desire to improve healthy eating, self-report that he or she currently has some

healthy eating habits, and 18 years of age or older. Exclusion criteria-self-report that he or she is

under a doctor-supervised weight loss program, has a disorder or illness that a non-physician

supervised plan is contraindicated, is currently in any weight-loss program, self-report whether

he or she has a chronic condition or obesity challenges, and are a family member or close friend

of the researcher.

Positive Reinforcement. Presenting a stimulus to increase the likelihood of a behavior in

the future (Skinner, 1953).

Prompt. A cue or assistance is provided to an individual to facilitate the correct response

or behavior.

Self-monitoring. An individual observes and records their behavior to gain awareness

and potentially modify it (Kanfer, 1970).

Self-selected behavior. An individual chooses to engage in a specific behavior rather than

someone else choosing it.

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 Research Design

Single-subject design (SSD) is a research methodology that is widely used in the

behavior analysis field. We can systematically study the change in behavior over time using

single-subject research design methods. Within the experimental analysis of behavior, single-

subject research can study an individual's behavior by measuring and repeatedly assessing

functional relations amongst the individual in all conditions of the experiment, thus serving as

their control group (Barlow & Nock, 2009). Direct repeated observation and monitoring of

participants' behavior are essential to answer the research question regarding the effect of self-

monitoring and gamification on maintaining healthy eating behaviors and choice behavior

(choosing healthy versus unhealthy food). A changing criterion design (CCD) is appropriate

when the objective is to increase healthy eating behavior systematically for a particular duration.

A CCD employs incremental benchmarks to modify a dimension of behavior that is already part

of an individual's skill set (Klein et al., 2015). As part of the study, an inclusion criterion for

participants was to have some healthy eating habits already established. For most, there has not

been a time when a person has been able to incorporate healthy eating behavior and maintain it

consistently and voluntarily. This underscores the challenges many individuals face in adopting

and maintaining healthy eating habits of their own accord. This difficulty is one factor

influencing the choice of a changing criterion design within this study. The design is specifically

chosen to address and facilitate a gradual and systematic progression toward healthier eating

choices, recognizing the historical struggle of individuals to sustain such behaviors voluntarily.

(Epstein et al., 2007). Participants were given a prescribed obtainable goal that was broken into

steps. Additionally, the steps had a prescribed varying criterion change.

Assumptions and Limitations

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Assumptions

In promoting healthy eating choices, behavior analytic assumptions form the bedrock of

this research study. These assumptions provide a solid foundation for investigating the

effectiveness of interventions aimed at shaping individuals' dietary behaviors. By embracing the

fundamental principles of behavior analysis, we can uncover valuable insights into the

determinants of food choices, the impact of environmental factors, and the potential for behavior

change.

Behavior analysis assumes that behavior is lawful and determined by environmental

factors. Practitioners believe that human behavior, including food choices, is shaped by the

consequences that follow it. This assumption emphasizes the importance of understanding the

antecedents and consequences of eating behaviors. Moreover, behavior can be shaped through

the application of interventions. The changing criterion design does not adhere strictly to a

predefined standard; alternately, it systematically increases or decreases the behavioral criterion

to facilitate the desired improvements (McDougall et al., 2006). Researchers believe that adult

individuals can alter their behavior and benefit from interventions promoting positive change

(U.S. Committee on Health and Behavior: Research, Practice, and Policy, 2001). Using a

changing criterion design assumes that behavior is influenced by the environment in which it

occurs, and altering environmental contingencies will lead to observable changes in behavior.

Secondly, behavior analysis assumes that the principles of reinforcement and punishment

influence behavior. They recognize that individuals are likelier to engage in behaviors followed

by favorable consequences or rewards and less likely to engage in behaviors followed by

negative consequences. The application of gamification within the intervention package relies on

behavior-analytic principles employing positive reinforcement, such as earning points,

10
progressing through levels, and attaining digital badges for engaging in healthy eating behaviors.

These tangible rewards serve as positive consequences, aligning with behavior analytic

assumptions and fostering the desired behavioral changes. Furthermore, a self-monitoring system

provides real-time, immediate feedback to participants, a form of reinforcement.

Limitations

While behavior analytic assumptions provide a valuable framework for studying effective

interventions for healthy eating choices, it is essential to acknowledge the limits inherent in this

approach. First, behavior analysis primarily focuses on observable behavior and may overlook

the underlying psychological and cognitive processes influencing food choices. Factors such as

individual preferences, beliefs, and emotions significantly shape eating behaviors but may not be

fully captured within the behavior analytic framework. Secondly, behavior analytic research

often relies on controlled laboratory settings or structured interventions, which may need to

reflect the complexity and variability of real-world eating environments fully. A wide range of

contextual factors influence human eating behaviors.

The effectiveness of self-monitoring and gamification may vary across different

populations and settings. This approach's assumptions may be more applicable to specific

individuals (e.g., those motivated by game-like elements) and may not generalize to all

individuals or diverse cultural contexts. Therefore, the findings may have limited generalizability

beyond this research study.

Self-monitoring relies on individuals accurately and consistently reporting their eating

behaviors. However, self-report data can be subject to biases, such as social desirability bias or

memory limitations. Participants may need to report their food intake or include specific details,

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which can impact the validity and reliability of the data collection. This can limit the accuracy of

the results and the ability to draw meaningful conclusions.

Furthermore, while a changing criterion design allows for incremental behavior change, it

may not address the challenges of long-term maintenance of healthy eating habits. The

assumption that gradually increasing expectations will lead to sustained behavior change may not

consider other factors that influence long-term adherence, such as social, psychological, or

environmental factors.

There is also the potential for unintended consequences. The gamification components of

this study may introduce unintended consequences or undermine the intrinsic motivation for

healthy eating. While gamification can enhance motivation in the short term, over-reliance on

external rewards and game-like elements may diminish an individual's intrinsic motivation to

make healthy food choices for their well-being.

Delimitations

In delineating the study's parameters for encouraging healthy eating choices through

gamification and self-monitoring, several key delimitations shape the scope and applicability of

this research. Firstly, the focus is on adults acknowledging that findings may not demonstrate

generalizability to diverse age groups. Participant recruitment, facilitated through social media,

such as Facebook and LinkedIn, introduces a unique set of delimitations. The utilization of these

social media platforms may influence the demographic composition of the sample, and

participants may possess distinct characteristics compared to those who did not engage through

this channel. Moreover, the study encompasses participants located in different time zones and

countries. This geographical diversity adds a layer of complexity, acknowledging potential

cultural, dietary, and lifestyle variations among participants based on their respective locations.

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Furthermore, demographic information such as weight and Body Mass Index (BMI) was not

collected at the commencement and conclusion of the study. This omission acknowledges a

limitation in assessing potential changes in these variables throughout the intervention period.

Finally, this study did not use a specific gamification app, which may limit the opportunity to

explore and analyze specific features that could encourage healthy eating choices. Not using a

specific gamification app could restrict the generalizability of the results. Moreover, the decision

not to use a gamification app may limit insights into the influence of technology itself, such as

using certain variables within the app like notifications, in-app rewards, points, and community

engagement.

Organization of the Remainder of the Study

Chapter 1 detailed the nature of healthy eating behaviors, encompassing nutrition,

psychology, behavior change, and public health. It highlights the development of dietary

guidelines by countries and organizations to promote healthy eating. Healthy eating is

emphasized for sustenance and its critical role in overall well-being and disease prevention. The

prevalence of unhealthy eating behaviors, resulting in chronic diseases and obesity, is a global

concern, leading to the need for interventions. There is a significant need to understand human

behavior in promoting healthy eating. Behavior analysis is introduced as a field rooted in

psychology that focuses on how the environment influences behavior. The study evaluated

whether gamification and self-monitoring can promote and sustain healthy eating behaviors. The

significance of the study lies in the potential to transform communities and advance behavior

analysis research and practice.

The remainder of this study will extensively review existing literature on healthy eating

behaviors and the previous research on behavior analysis and healthy eating in Chapter 2. It will

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provide a comprehensive understanding of the lack of interventions for increasing healthy eating

in this field. Chapter 3 will detail the research design. This includes addressing the data

collection methods and procedures used in this study and explaining how gamification and a self-

monitoring system were used to investigate the impact on increasing healthy eating choices. This

chapter will also describe participant characteristics and inclusion/exclusion criteria. Chapter 4

will present the findings of the study. Finally, Chapter 5 will interpret the results and discuss the

implications of the study of promoting healthy eating behaviors, both in research and practical

applications. Recommendations for future research and potential interventions will be outlined

based on the study's outcomes.

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 CHAPTER 2. LITERATURE REVIEW

The previous chapter briefly introduced the topic, its relevance to the behavior analysis

field, and the study's assumptions and limitations. This chapter will expand upon the study's

theoretical orientation, discussing behaviorism, the matching law, and concurrent schedules of

reinforcement and their relation to choosing healthy food options. Finally, a review of the

literature, followed by a critique of previous research methods, will be presented.

Methods of Searching

This section provides a brief, detailed description of the research methods and procedures

used to identify relevant studies from various sources. Databases such as Google Scholar,

PsycINFO, and PsycARTICLES were used, as well as specific behavior analytic journals,

including the Journal of Applied Behavior Analysis (JABA), Journal of the Experimental

Analysis of Behavior (JEAB), Behavior Analysis in Practice, Behavioral Interventions, and

Perspectives on Behavior Science. The search terms that were utilized encompassed topics

related to dietary intake and healthy eating, including “dietary intake,” “food,” “healthy eating

behavior,” and “dietary consumption.” Furthermore, behavior analytic concepts such as the

matching law, concurrent schedules of reinforcement, changing criterion design, self-monitoring,

and gamification were searched. All years were included in the search, allowing for the inclusion

of seminal research studies as well as recent advancements in the field. Moreover, efforts were

made to include studies explicitly focusing on healthy eating research in behavior analytic

journals, but these were limited.

Theoretical Orientation for the Study

Behaviorism

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 Behaviorism serves as the guiding framework for this study. Behaviorism is the

philosophy of the science of overt behavior as opposed to the study of psychological constructs

and inward experiences, such as covert behavior. Although Watson argued for observable

behavior, not consciousness (Cooper et al., 2019), his work significantly impacted Skinner's

operant research (Guercio, 2018). At the core of behaviorism lies the concept of stimulus-

response associations. Stimulus-response associations refer to the connections or links between

specific stimuli and the corresponding behavioral responses they elicit in individuals or

organisms. Developed by B.F. Skinner, operant conditioning is a central pillar in behaviorism. It

suggests that behaviors are continually learned and modified based on consequences (Overskeid,

2018; Lieberman, 2012). Positive reinforcement, where rewards are provided following desired

behavior to increase the likelihood of those behaviors happening again, is an essential concept of

operant conditioning and its influence on consequences in shaping behavior.

The Matching Law and Concurrent Schedules of Reinforcement

Examining the effectiveness of gamification and self-monitoring on healthy eating

behaviors is rooted in the theoretical orientation of the matching law. The matching law

proposed by Hernstein in 1961 shares fundamental principles with behaviorism. It describes

behavior-environment relations and how behavior is distributed towards specific reinforcement

alternatives or choices (Reed & Kaplan, 2011). The matching law suggests that individuals

allocate their behavior based on different options' relative reinforcement or reward. The

matching law rooted in behavioral economics and operant conditioning offers a lens to examine

how individuals allocate their behavior among various choices, including those related to dietary

decisions. In the context of healthy eating behaviors, the matching law suggests how individuals

distribute their food choices between healthy and less healthy options based on the perceived

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reinforcement value of each option. Healthier foods such as fruits and vegetables are often

associated with delayed or less immediate reinforcement due to long-term health benefits. On the

other hand, less healthy options, such as sugary snacks and fast food, offer immediate

gratification through taste and sensory reinforcement. As a result, the matching law predicts that

individuals might allocate more of their food choices to less healthy options, even if they are

aware of the long-term health consequences. Several factors influence matching behavior

regarding food choice and healthy eating. The ease of access to different food options can

influence their reinforcement value.

Reinforcements can be accessible for multiple categories of responses rather than being

limited to a single type of behavior (Myerson & Hale, 1984). When examining how individuals,

whether human or animal, respond to varying types of rewards, concurrent schedules of

reinforcement prove beneficial. Concurrent schedules of reinforcement employ a mathematical

equation, B1/B2 = (R1/R2)a x k, to describe how organisms distribute their behavior among

different options based on the rates of reinforcement associated with those options (Madden &

Perone, 1999). B1 and B2 denote the levels of behavior associated with two distinct aspects

under consideration. R1 and R2 represent the frequency of receiving rewards for these respective

aspects. k functions as a parameter indicating preferences between the two. a signifies the degree

of sensitivity to reward changes (Madden & Perone, 1999). Applying the principles inherent in

concurrent schedules of reinforcement and the matching equation offers valuable insights into

how individuals navigate choices between healthier and unhealthy food options. For example,

consider deciding between a nutritious salad and a meal at McDonald’s. The rewards linked to

each choice encompass more than mere taste, extending to factors such as post-meal satiety,

sustained energy levels, and the body’s overall response over time. Using the previous matching

17
equation, B1 and B2 represent the behaviors linked to choosing the salad or McDonald's. R1 and

R2 correspond to the positive outcomes of each choice (delayed feeling of sustained energy

levels and post-meal satiety or the immediate satisfaction of greasy, tasty food). k denotes the

inherent inclination towards one option, encompassing prior experiences, cultural influences, and

personal preference. Finally, a represents and involves contemplating both alternatives' health

advantages and potential disadvantages. Concurrent schedules of reinforcement can be

established to reinforce an alternative response rather than focus solely on eliminating

undesirable behavior (Myerson & Hale, 1984).

Several studies have contributed to understanding reinforcement schedules and the

matching law that effectively shaped behavior in various contexts. Platzer and Feuerbacher

(2022) investigated the reinforcer efficacy of different grains in horses based on their nutritional

content using a progressive ratio schedule. The results indicated variability in horses’ responses

to grains with different nonstructural carbohydrate (NSC) content, thus demonstrating choices

contingent upon reinforcement associated with each option. May and Treadwell (2020)

investigated a modified lottery system to increase exercise intensity in individuals with

developmental disabilities and demonstrated positive outcomes. This study evaluated elements of

a concurrent schedule when variable reinforcement schedules were used. Participants could

choose different activity levels based on the delivered reinforcement rates, indicating increases in

target heart rates (May & Treadwell, 2020). Crowley et al. (2020) analyzed treating food

selectivity in autistic children and utilized a concurrent schedule addressing resistance to changes

in food selection. This study was based on the matching law that involved presenting an

alternative food alongside the child's resistant food in a paired-choice arrangement, which

extended the Fisher et al. (2019) study. Again, concurrent schedules proved effective for some

18
children as they ate the alternative food option more often when rewarded. Although not

specifically related to increasing healthy eating behavior, all three studies demonstrated the use

of concurrent schedules of reinforcement in varying contexts. Platzer and Feuerbacher (2022),

May and Treadwell (2020), and Crowley et al. (2020) examined how behavior choices are

influenced under concurrent reinforcement conditions. Conversely, limitations for these studies

arose regarding their external validity. Platzer and Feuerbacher (2022), May and Treadwell

(2020), and Crowley et al. (2020) had limitations regarding generalizability. Specifically, Platzer

and Feuerbacher (2022) lacked long-term outcome measures and did not address generalization

to real-world settings. May and Treadwell (2020) failed to control extraneous variables

systematically. It is essential to recognize the broader implications of the above limitations.

Specifically, the constraints on generalizability observed across the studies by Platzer and

Feuerbacher (2022), May and Treadwell (2020), and Crowley et al. (2020) underscore the critical

need for research that considers real-world applicability and diverse populations.

Review of the Literature

In surveying the research using the keywords behavioral interventions to increase healthy

versus unhealthy foods, increasing diet, healthy diet, food choice, and nutrition, many studies

called for a need for individuals to change their behavior through behavior change interventions.

The research literature on healthy eating behaviors indicates that adult modeling, peer modeling,

exposure to taste, and food availability have predicted food choices in individuals at a young age,

influencing food preferences across the lifespan and leading to chronic disease (Zonneveld et al.,

2018). Behavioral economics suggests making healthier choices easier (Wisdom et al., 2010).

Common interventions to increase healthy eating have consistently focused on educating

individuals on health benefits without long-lasting effects (Shavit et al., 2021). Marcum et al.

19
(2018) suggested that studies that evaluated interventions on food choice have centered around

habitual actions, total calories on a plate, and environmental factors such as placing healthy

foods first. Previous studies have also found that food choice delays and factors affecting food's

reinforcing value (Temple, 2014) have predicated food choice. Much of the literature using

behavior analysis to increase health-related behaviors has primarily targeted increasing some

physical activity. For example, the study of Page et al. (2020) completed a systematic literature

review where self-monitoring was evaluated as an effective intervention. It continued to note that

many studies that used self-monitoring to increase some forms of physical activity still

determined what self-monitoring components were practical (Page et al., 2020).

Similarly, Patel et al. (2020) examined if participants could continuously use a self-

monitoring system using an app and compared whether consistency with self-monitoring was

related to weight loss. Results indicated that 1 in 4 participants could consistently self-monitor

their behavior using a self-monitoring app over 12 weeks (Patel et al., 2020). Unfortunately,

consistency with self-monitoring using an app could not be correlated with weight loss. The

authors suggested that future research should incorporate ways in which self-monitoring can be

done efficiently and allow individuals to maintain it (Patel et al., 2020).

Conversely, some research has been directly related to healthy eating behaviors.

Interventions such as reinforcer pairing and fading (Tiger & Hanley, 2006), reinforcement and

cueing (Stark et al., 1986), and prompting, feedback, and social reinforcement (Stock & Milan,

1993) have been suggested. Butryn et al. (2020) study used self-monitoring to increase weight

loss by examining eating, physical activity, and weight. This showed that eating was not a target

behavior by itself. Recent research also looked at innovative ways behavior analysis can increase

healthy behaviors. With the recent increase in the popularity of video games, gamification could

20
be a way for behavior analysts to help improve the well-being of others (Morford et al., 2014).

Gamification can foster motivation for various behaviors, including choosing healthier food

items (Sailer et al., 2017).

Barriers to Healthy Eating Behaviors

Engaging in healthy eating choices is essential for overall well-being. However, it is

often associated with many barriers, including socioeconomic constraints, cultural influences,

psychological factors, social and environmental cues, and individual taste preferences (Chen &

Antonelli, 2020). There are considerable challenges in adopting and maintaining healthy dietary

behaviors. Antecedents and consequences are pivotal in influencing barriers to healthy eating

behavior, highlighting the need for antecedent and consequence interventions for effective

behavior change (Normand et al., 2021). The following paragraphs will discuss some barriers to

healthy eating.

Socioeconomic Factors

Numerous socioeconomic factors often impede healthy eating habits, significantly

influencing access, affordability, and educational and health disparities surrounding food

choices. Some studies suggested that those with favorable socioeconomic status (SES), in other

words, those living in high-income areas, have better access to supermarkets with an abundance

of fruits and vegetables to consume, and those with unfavorable SES have limited access to

supermarkets that will allow healthier food choices (Costa et al., 2019). Food access includes

physical access to stores and encompasses affordability, quality, and culturally appropriate foods

(Rose et al., 2010). Wolfsen et al. (2019) examined barriers to healthy food access and household

income with cooking and eating behaviors by surveying adults in the United States. Results of

the study indicated that difficulties in accessing healthy food were due to affordability and lack

21
of time. Healthy food access was also associated with individual cooking and consuming healthy

foods. Although this study relied on self-reported data, this study underscored the need to

mitigate barriers regarding access to healthy foods.

Affordability to nutritious foods compared to less healthy alternatives often limits access

to balanced diets for individuals and families facing financial constraints. Affordability

influences access to nutritious foods and plays a significant role in determining the extent to

which healthy eating is achievable. Lewis et al. (2021) gathered quantitative data from a survey

to assess the habitual dietary intake of households with different socioeconomic groups in

Australia. Dietary habits consisted of adherence to the Australian Dietary Guidelines and

consuming discretionary foods such as foods high in saturated fat and added salt and sugar

(Lewis et al., 2021). Results indicated that low socioeconomic groups reported significantly

lower intake of healthy foods and beverages than higher socioeconomic groups due to cost

barriers. Similarly, French et al. (2019) studied food purchasing and gathered information on

food purchase data for urban households, revealing that lower-income households purchase less

healthful foods than higher-income households.

Access to healthy food choices is often a detriment to chronic disease. The link between

SES and health outcomes related to poor dietary choices is a critical concern. Disparities in

access to nutritious foods and health education significantly impact the well-being of individuals

from marginalized socioeconomic backgrounds (Ohri-Vachaspati et al., 2019). Individuals of

marginalized socioeconomic backgrounds face barriers such as limited financial resources,

inadequate transportation, and living in areas with limited access to grocery stores offering

produce, leading to dietary choices that increase their risk of developing chronic diseases related

22
to poor nutrition (Hallum et al., 2020; Hilmers et al., 2012). Education in healthy nutrition plays

a vital role in informed decision-making about healthy eating choices.

Socioeconomic factors may influence nutrition knowledge and awareness, shaping an

individual’s understanding of healthy eating habits and access to resources for making informed

dietary choices (Wadolowska et al., 2021). Research has shown that individuals from lower

socioeconomic backgrounds tend to have lower levels of nutrition knowledge compared to

individuals with higher socioeconomic backgrounds, which may limit access to healthy foods,

thus making unhealthy eating choices (Azizi Fard et al., 2021; Alkerwi et al., 2015). Access to

nutritional knowledge enables individuals to make informed decisions on the types of food to

purchase and compliance with national dietary recommendations and standards. However,

barriers to accessing nutritional information extend beyond limited resources. Socioeconomic

factors such as educational levels also contribute to a need for nutritional awareness.

Cultural Influences

While socioeconomic factors significantly shape dietary choices, cultural factors also

profoundly affect how individuals make food choices. Cultural factors such as beliefs, traditions,

and practices may shape an individual’s behavior toward food consumption. Cultural traditions

act as antecedents and consequences in impacting dietary choices. Cultural practices become

societal norms and dictate food preferences, meal patterns, and cooking methods, ultimately

impacting dietary choices. The Centers for Disease Control and Prevention (2022) stated that

culturally prepared food is defined as nutritious foods that meet the needs of their cultural

identity. Eating choices based on cultural influences place many considerations on the selection

and consumption of food. Many cultures have certain restrictions on food, such as avoiding

certain meats or restricting eating certain foods during religious holdings or fasting periods.

23
Furthermore, many cultures have varying perceptions regarding body image, which can

influence food choices. Meal structure, timing, and portion sizes also affect the dietary intake of

many cultures. Yu et al. (2020) addressed the cultural influences of African and Hispanic

Americans' preparation of meals and their perceptions of the nutritional information they receive

from healthcare providers. Results indicated that cultural influences significantly impacted

choosing foods to cook at home for their families. It also indicated that nutrition

recommendations from healthcare providers may not always align with their cultural

circumstances (Yu et al., 2020). This study contributes to the significance of cultures’ role in

informing and influencing the decisions of individuals and their families regarding food choices.

Future interventions that address the promotion of healthier eating choices should consider the

diverse cultural needs of communities battling obesity and other health-related diseases impacted

by unhealthy eating. Kong et al. (2015) proposed culturally adopted behavior interventions to

improve diet and weight outcomes in individuals, specifically among African American women,

as they are disproportionately impacted by obesity. However, a literature review revealed a need

for studies measuring cultural variables in behavior interventions targeting African American

women. Those that examined behavior intervention effectiveness with cultural components were

inconclusive regarding its effects. Further research is needed to utilize culturally adopted

behavior interventions to encourage healthier lifestyles (Kong et al., 2015).

Psychological Factors

Beyond socioeconomic factors, nutritional knowledge, access to healthy foods, cultural

influences, and psychological factors play an essential role in shaping dietary choices to maintain

a healthy diet. Psychological factors impacting dietary choice include emotions, beliefs,

attitudes, habits, and other cognitive processes observable through behavior. These psychological

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experiences can impede individuals from eating healthy because of their role as antecedents and

consequences in impacting food-related behaviors. Food selection based on emotions forms

habits developed through reinforcement (Pearce et al., 2022). Decision-making and self-control

play into the selection and consumption of healthy eating behavior. Difficulties in self-control

can result in eating behaviors, including overconsumption of high-calorie foods and impulse

eating of less nutritious foods, which make it challenging to maintain a healthy diet.

Social and Environmental Cues

Social cues and peer modeling can reinforce specific eating behaviors, influencing

choices between healthy and unhealthy options, thus impacting healthy eating habits and overall

well-being (Kim et al., 2019). Environmental cues serve as antecedents contributing to

maintaining and modifying eating behavior (Jeffery et al., 1993). Individuals often seek approval

and attend to others' social norms. Peer modeling, familial eating habits, and cultural traditions

shape individuals' perceptions of food and influence their dietary preferences. Peer modeling

operates through both direct observation and positive reinforcement (Higgs, 2015). For example,

if peers consistently opt for unhealthy food options or engage in indulgent eating behaviors,

individuals may feel pressured to engage in these norms. Conversely, if peers consume healthy

foods, this may result in social endorsement leading to satisfaction or relief from discomfort,

which may be primed for recurrence. Peer modeling may offer motivation and accountability as

it reinforces positive eating behavior.

The availability and accessibility of food options in an individual environment also

significantly impacts food choices (Chen & Antonelli, 2020). Environments with an abundance

of fast-food restaurants, convenience shops, and other outlets encourage the consumption of

unhealthy foods. Moreover, how foods are marketed and advertised at these establishments also

25
encourages unhealthy food choices (Tsochantaridou et al., 2023; Smith et al., 2019). As a result,

social and environmental cues will continue to maintain unhealthy eating behaviors.

Individual Preferences and Taste

Choice responding and the sensory appeal of food can shape an individual's decisions in

food selection, purchasing, preparation, and consumption. Motivating factors tied to the sensory

characteristics regarding our senses influence food consumption and choices (Imityaz et al.,

2021). Foods with pleasant sensory elements are more likely to be selected and consumed. The

selection and consumption of food align with the principles posited by the matching law.

Moreover, as individuals develop preferences for specific sensory features, this underscores the

importance of considering individual differences in food preferences to tailor reinforcement

schedules that align with individual preferences. Implementing interventions can then be

effective in improving healthy eating choices. This further emphasized that individuals allocate

behavior based on their reinforcement history. Incorporating gamification elements such as

rewards or challenges may enhance the appeal of interventions promoting healthy eating

behavior. Furthermore, integrating a self-monitoring system with gamification could increase

awareness and, thus, higher rates of healthy food consumption.

Reinforcement Magnitude

Reinforcement magnitude, defined as the strength or intensity of a reinforcer that follows

a behavior and increases its likelihood of recurrence, is a pivotal factor in shaping behavior

across various contexts (Hoch et al., 2002). Regarding positive reinforcement, where the

presentation of positive stimuli reinforces behaviors, the magnitude of the reinforcer significantly

influences the strength of the learned association between the behavior and the positive outcome

(Shahan, 2017). The intensity and effectiveness of the reinforcer are linked to its magnitude.

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Larger and more powerful reinforcers tend to be more effective in strengthening the associated

behavior. This influence extends to situations involving choices, where the magnitude of

reinforcement often dictates the selection and repetition of behaviors, particularly when one

behavior leads to a more substantial or preferred reinforcer. Critical reinforcement magnitude

factors include timing, consistency, and context.

Crutchfield and Kollins (2001) studied how different amounts of money influence

people's choices. They found that when given the option between receiving a smaller amount of

money immediately or a more considerable amount after a delay, participants chose the smaller,

immediate reward. This tendency to favor immediate gains over more immense but delayed

rewards is called delay discounting. The study provided insights into how the timing of rewards

influences an individual's decisions. Furthermore, its relevancy to the concept of reinforcement

magnitude is in the context of decision-making. In decision-making, individuals may receive a

smaller, immediate reward rather than waiting for a larger one available after an unavoidable

delay. Delay discounting also influences food purchasing, which can be seen as an antecedent to

dietary choice, as food purchasing is correlated to dietary intake (Appelhans et al., 2019). Delay

discounting relating to food choice suggests that individuals will choose unhealthy foods because

it provides immediate positive reinforcement. Appelhans et al. (2019) studied whether individual

differences in delay discounting rates contribute to variations in food purchasing outcomes

through its Study of Household Purchasing Patterns, Eating, and Recreation (SHoPPER) study.

The study utilized a comprehensive food purchase assessment protocol spanning 14 days to

objectively capture information on food and beverage purchases from various sources.

Researchers hypothesized that higher delay discounting rates would be associated with lower

overall diet quality. Results suggested that steeper discounting rates indicated a preference for

27
immediate rewards, thus associated with specific patterns in food and beverage purchases

(Appelhans et al., 2019). Temporal discounting is a crucial aspect of intertemporal choice, which

involves decisions about how individuals allocate resources, effort, or attention across different

points in time (Critchfield & Kollins, 2001).

Research suggested that responding under concurrent-operant (i.e., choice) arrangements

is influenced by various reinforcement parameters, such as the quality or magnitude of

reinforcement (Trosclair-Lasserre et al., 2008). Parameters affecting choice responses include

quality reinforcers, higher magnitudes of reinforcers, and more immediate access to reinforcers.

Zonneveld et al. (2018) examined children's food choices regarding their preference for healthy

and less-healthy foods. As a result, food choice was measured as quality or immediacy based on

the concurrent availability of food. (Zonneveld et al., 2018). When individuals are provided

multiple (two or more) options to choose from, varying schedules of reinforcement are assessed

(Epstein et al., 2007). Food choice often matches concurrent schedules of reinforcement

(Shurtleff & Silberberg, 1990) and is, therefore, essential in increasing an individual's choice of

healthy versus unhealthy foods. Concurrent schedules of reinforcement allow an individual to

respond to and choose between one of two reinforcement schedules (Borrero et al., 2010).

Changing Criterion Design Research Studies

A changing criterion design (CCD) is a research methodology rooted in behavior

analysis, offering a dynamic approach to studying behavior change (Klein et al., 2017). Unlike

traditional experimental designs, CCD enables researchers to implement incremental adjustments

in the criteria for reinforcement, allowing for a systematic examination of behavioral shifts over

time. A CCD aligns with the fundamental principles in behavior analysis, notably reinforcement

and shaping. The design operates on the underpinning that behavior change is a gradual process,

28
where small, successive approximations lead to the desired outcome. Notable contributions from

Skinner’s work and subsequent studies have laid the theoretical foundation for the design’s

application in understanding and modifying behavior.

One key aspect of the literature review is the examination of interventions utilizing CCDs

to increase behaviors. Nastasi et al. (2020) used a CCD to increase step goals for adults with

developmental disabilities and behavioral diagnoses in a residential group home using a token-

economy contingency management intervention. Participants received tokens as positive

reinforcement for increasing physical activity daily over eight weeks. Three out of the four

participants were able to increase steps during the intervention phase (Nastasi et al., 2020).

Unrelated to dietary habits, noteworthy studies such as Frank-Crawford et al. (2021), Nastasi et

al. (2020), and Bloomfield et al. (2019) exemplify the effectiveness of changing criterion design

in fostering and emphasizing the need for systematic adjustments in criteria for reinforcement to

observe and promote meaningful behavioral changes over time. Wheatley et al. (2019) used a

CCD to examine the effects of a Differential Negative Reinforcement of Other Behavior

(DNRO) intervention on the duration of wearing an anti-strip suit to prevent inappropriate bowel

movement behavior. The CCD proves effective in that DNRO increased tolerance with wearing

the anti-strip for extended periods in an educational setting. Despite the effects, a reversal was

not implemented, which could have strengthened experimental control for this study. A CCD

design was also used by Ravid et al. (2021) to successfully transition children from co-sleeping

with parents to sleeping independently. The CCD was effective when a bedtime pass procedure

with extinction successfully reduced co-sleeping behaviors (Ravid et al., 2021).

In promoting healthy eating behaviors, implementing a CCD design holds potential

efficacy. For example, consider a study aimed at increasing vegetable consumption. The criteria

29
for reinforcement might initially focus on incorporating one additional serving per day, gradually

progressing to higher targets. This approach allows for personalized adjustments and

accommodates diverse dietary preferences. No studies, especially behavior analytic studies, have

used a CCD to increase vegetable consumption. The benefits of adopting changing criterion

design in behavioral interventions are multifaceted. Implementing a changing criterion design is

sensitive to small changes and allows researchers to capture subtle shifts in behavior, providing a

more nuanced understanding of the intervention's impact. Additionally, the designs' adaptability

to individual differences enhances its applicability across diverse populations.

Healthy Eating Interventions

As previously mentioned, there is a critical need to combat the current health crisis

regarding healthy eating behavior. Not only is understanding the factors influencing healthy

eating behaviors crucial, but developing effective interventions to improve healthy eating is as

well. Over the past few decades, researchers have spent considerable time examining effective

interventions to promote healthier food choices. These studies have led to an increasing

knowledge base regarding food consumption, food-related diseases, and physical activity, most

recently within the behavior analytic field (Rafacz, 2019). The following discussion will examine

seminal and current research findings that present an array of interventions examined to

encourage healthy eating.

Several studies targeting healthy eating began in the 1980s and 1990s (Rafacz, 2019).

Wagner and Winett (1988) extended the Mayer et al. (1986) survey using prompts and fliers in a

cafeteria to increase the sales of low-fat entrée choices. Wagner and Winett (1988) examined

prompts to promote one low-fat, high-fiber menu item selection at a fast-food restaurant. In

another study, the effects of labeling a low-calorie food item on the probability of purchasing the

30
low-calorie food item were tested (Dubbert et al., 1984). Early research (Wagner & Winett,

1988; Dubbert et al., 1984) regarding healthy eating utilized behavior-analytic principles such as

prompts and labeling techniques. Their studies demonstrated the efficacy of environmental

prompts and cues in increasing the selection of low-fat entrees in the cafeteria. Prompting-based

interventions use environmental cues or reminders to prompt individuals to engage in target

behaviors, such as choosing nutritious food. When prompts are utilized, such as in a cafeteria

setting or grocery store, researchers aim to prompt individuals to influence their decision-making

processes due to recent learning histories to encourage healthy eating. Prompts serve as

antecedent stimuli that signal the availability of certain behaviors. Loro et al. (1979) compared

external cues for eating, also known as situational engineering (SE), employing an eating

behavior control (EBC) procedure and self-control strategies to reduce weight in obese

individuals. Participants experienced different interventions (SE, EBC, and self-control

strategies) that revealed their impact on eating behavior and weight management. The

interventions either manipulated external cues related to eating or fostered self-control strategies

in managing dietary habits. The researchers monitored changes due to the prompting of external

stimuli and positive reinforcement in eating habits and weight management. Results indicated

that participants exposed to SE had considerable changes to their dietary habits due to external

cues, and participants exposed to self-control strategies noticed heightened levels of awareness

and restraint in managing eating habits. Despite limitations of generalizability, sample size,

demographics, intervention period, and the possibility of confounding variables, this study

proved that external cues, which can be considered as prompts and self-control, can improve

eating behavior and weight management among individuals (Loro et al., 1979).

31
 Currently, there is limited research on healthy eating interventions. For example,

Sigurdsson et al. (2014) examined the shelf placement of food items at the checkout to purchase

healthy products. An alternating treatment design embedded with a multiple baseline design

across stores was used, including baseline, checkout placement, and advertisement conditions

(Sigurdsson et al., 2014). Results indicated that participants chose healthy food items when

placed at checkout, but adding an advertisement was not significant enough. Sigurdsson et al.

(2014) highlighted the importance and effectiveness of environmental cues in shaping behavior,

specifically in shaping dietary decisions. One component of this study, the use of advertisements,

presented a limitation as it exemplifies the need for research to identify the most effective

interventions for encouraging healthier dietary behaviors. The addition of advertisements did not

enhance the selection of healthy food items among participants in this study. Furthermore,

Fergus Lowe’s Food Dudes program was based on behavior change interventions such as peer

modeling, rewards, and repeated tasting (Lowe et al., 2011). These interventions increased fruit

and vegetable consumption in school-aged children and decreased unhealthy food consumption.

Peer modeling was practical in promoting healthy eating habits among school-aged children in

this study. When peers demonstrate positive eating behaviors, children will likely observe that

behavior and imitate the behavior of other peers, thus encouraging behavior and lasting dietary

behavior change. Moreover, rewards in the Food Dudes program provided immediate

reinforcement, making healthy eating choices desirable. Finally, repeated exposure to food, as

presented in this study, can lead to increased acceptance and preference for foods. Both studies

offered practical implications for interventions aimed at improving dietary behavior, advancing

the understanding of behavior analytic principles in the context of healthy eating interventions,

32
and designing effective interventions. As the diversification of behavior-analytic interventions

increases, contemporary approaches to healthy eating have emerged.

Advancements in technology can impact various settings in promoting behavior change,

specifically regarding healthy eating choices. Saboia et al. (2020) examined the effectiveness of

social media challenges in encouraging healthier eating habits through peer support and social

accountability. Digital platforms, mobile applications, and wearable devices are used in

technology-based interventions to support behavior principles such as self-monitoring and

concepts beyond behavior analysis, such as gamification. Saboia et al. (2020) demonstrated the

significance of social media challenges as an effective strategy for encouraging healthier eating

behaviors. Engaging in social media challenges increases participants' likelihood of adhering to

dietary recommendations and adopting healthier eating habits. These strategies utilize feedback

and social support to encourage healthier eating behavior. Technology-enabled interventions,

such as mobile applications and wearable devices, allow individuals to monitor food intake and

nutritional content and set goals, eventually increasing their engagement and motivation toward

healthier choices.

Moreover, emerging research has examined psychological factors influencing dietary

behaviors. Sairanen et al. (2015) and Goodwin et al. (2012) examined the role of psychological

flexibility, mindfulness, and acceptance-based behavior therapy in promoting healthy eating.

Sairanen et al. (2015) investigated whether mindfulness and psychological flexibility promoted

intuitive eating. Intuitive eating was described as eating motivated by physical reasons versus

eating due to emotional or environmental motivators (Tylka, 2006). Participants interested in the

study were overweight individuals with health concerns. Those who demonstrated better

psychological flexibility were also related to better mindfulness skills and had higher levels of

33
intuitive eating. Goodwin et al. (2011) evaluated the effects of acceptance-based behavioral

therapy (ABBT) on increasing heart-healthy behavior using behavior recommendations for

cardiac patients. Patients completed psychoeducation involving specific behavioral technology

for adhering to a heart-healthy lifestyle, self-monitored weekly goals, and willingness to

experience distressing thoughts surrounding healthy lifestyle changes and track diet and physical

activity. All participants began the study by self-reporting an unhealthy lifestyle. The results

indicated that ABBT is helpful for participants as there were moderate to significant changes in

healthy lifestyles. Participants saw improvements in weight, physical activity, and other dietary

intake measures such as calories, sodium, and saturated fat. Examining psychological factors

offers a holistic alternative to reducing unhealthy eating. Furthermore, Potts et al. (2022)

introduced Acceptance and Commitment Therapy (ACT) as an approach for addressing weight-

related stigma and facilitating dietary modifications among overweight and obese individuals.

Participants utilized an ACT self-help book with coaching or email prompts. Some participants

were also on a waitlist condition to evaluate the effects of using either of these combinations to

improve weight-related self-stigma. Results reported that participants had high engagement and

satisfaction with the self-help book without the addition of phone coaching or email prompts.

However, phone coaching and email prompts both reduced weight-related stigma. Furthermore,

phone coaching consistently improved eating and physical activity compared to the email prompt

condition. This proved the significance of weight self-stigma on health outcomes. The study

suggested ACT as another behavior intervention to improve some health-related behaviors,

including healthy eating.

Studies on Self-monitoring

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 In operant conditioning, behavior is shaped and maintained by its consequences-

reinforcement and punishment (Staddon & Cerutti., 2003). Applying these principles to self-

observation and self-regulation forms the basis of self-monitoring as a behavioral intervention.

Individuals systematically observe their own behavior, recording and analyzing it, with

subsequent consequences influencing the likelihood of future occurrences (Duckworth & Gross,

2020). Self-monitoring's fundamental principles, grounded in operant conditioning and radical

behaviorism, include the identification of target behaviors, systematic recording methods, and

implementing reinforcement or punishment strategies. The precision of behavioral observation,

the immediacy of consequences, and the consistency of reinforcement contribute to the

effectiveness of self-monitoring interventions.

The relationship between self-monitoring and self-control is dynamic, with self-

monitoring playing a pivotal role in improving self-control. Individuals engaged in cognitive

processes resist immediate gratification and make conscious decisions aligned with long-term

goals. Self-management, an extension of self-control, involves individuals actively regulating

their behavior (Duckworth et al., 2016). Self-monitoring provides a systematic approach within

the broader framework of self-control and self-management, fostering increased self-awareness

and accountability.

Research findings consistently affirm the effectiveness of self-monitoring in behavior

modification, particularly in promoting healthy behaviors (Olateju et al., 2021; Compernolle et

al., 2019). Self-monitoring, not mainly related to healthy eating behaviors, has been studied and

applied across various domains, such as physical activity, medication adherence, academic

performance, and emotional regulation. Self-monitoring is an effective strategy for each domain

to track individual behaviors, identify patterns, and make informed decisions to achieve desired

35
outcomes. Several studies have demonstrated the effectiveness of self-monitoring interventions

in various contexts (Bruhn et al., 2022; Junaid et al., 2021; Levin et al., 2022; Raiff et al., 2021;

Risse et al., 2023; Shardt et al., 2019). Self-monitoring interventions proved effective in

educational settings for improving academic engagement and behavior among students. Students

utilized a technology-based self-monitoring tool during independent work that helped improve

academic engagement (Shardt et al., 2019). Moreover, self-monitoring combined with

differential reinforcement demonstrated efficacy in reducing disruptive behavior.

Self-monitoring is an effective behavior modification intervention that can increase an

individual's behavior without many resources. Research suggests that it has also been effective in

changing health-related behaviors. Self-monitoring facilitated behavior change in diabetes

management when diet, exercise, and insulin management were utilized (Raiff et al., 2021).

Similarly, in promoting healthier habits among college students, a technology-based self-

monitoring intervention effectively increased physical activity and improved dietary choices

(Junaid et al., 2021). A literature review examined how individuals' self-monitoring can increase

physical activity (Page et al., 2020). Results indicated that studies that used a self-monitoring

procedure with technology increased various forms of physical activity among individuals but

could not be maintained (Page et al., 2020).

Similarly, self-monitoring, reinforcement, goal setting, and feedback increased children's

physical activity, increasing their recess steps (Hayes & Van Camp, 2015). Self-monitoring can

be an effective intervention to improve and maintain self-selected eating behaviors. This means

selecting an eating behavior to increase based on an individual's preferences reflects an

individualized approach to eating. We can monitor our behavior to ensure we pick healthy

choices over unhealthy ones because the benefits or the reinforcement (i.e., natural

36
reinforcement) received is more significant than not eating healthy. Some natural reinforcers that

may be received for eating healthy may be less bloated, decreased disease, better digestion, taste

good to some degree, and mood increases. Natural reinforcers of unhealthy eating may be better

tasting, fulfill cravings, and convenience. Suppose an individual allocates their responses by

analyzing or monitoring their behavior to match the healthier choice. In that case, they prefer

healthy foods over unhealthy ones because of the reinforcement they receive (Reed & Kaplan,

2011). This would also be the same as if an individual received some tangible reward or

reinforcement for eating healthier options versus unhealthy ones. Finally, self-monitoring has the

potential to serve as an efficient and practical intervention for promoting positive behavior

change across diverse contexts.

Despite the effectiveness of self-monitoring interventions, limitations exist. One

fundamental limitation is the reliance on self-report measures, which can cause inaccuracies in

assessing behavior change (Bruhn et al., 2015). Other limitations of implementing self-

monitoring interventions include being tedious, boring, or provoking other health implications

such as depression and specific eating disorders (Orji et al., 2018). Furthermore, the long-term

effects of using a self-monitoring intervention may not be feasible, warranting further

investigation to examine their lasting impact on behavior change (Hutchesson et al., 2016).

Studies on Gamification

Gamification is using game design elements for socially significant behavior change

(Morford et al., 2014). Although gamification is a relatively new term, it has been used before in

other seminal research studies, such as being referred to as serious games (Thompson et al.,

2010), pervasive games (Bogost, 2007), and alternative reality games (McGonigal, 2010, 2011).

Deterding et al. (2011) defined gamification by looking at the behavioral topographies of games

37
and play. This implies that gamification is similar to adding game-like elements to everyday

tasks so that they are more engaging, thus encouraging others to participate and enjoy it.

Furthermore, Deterding et al. (2011) described gamification as including five levels of game

design elements to bring about game-playing behavior in non-game contexts. Many of the

elements include behavior analytic principles. First, game design interface patterns, such as

visual cues presented on screen, are used. Examples of visual cues such as badges and

leaderboards serve as discriminative stimuli. Additionally, players experience recurring

contingencies through storytelling, competition, and character levels through game design

patterns and mechanics. The last three levels involve verbal behavior. Principles and rules guide

the game designer's decisions. Then, specific conceptual frameworks are used to understand the

player’s experiences. Finally, game methods are general game design strategies, such as user

playtesting.

Morford et al. (2014) presented gamification as a promising area for intervention research

with broad applications in technology. From a behavior analytic perspective, gamification

extends the principles of game design to influence behavior in various settings. Gamification

may integrate both antecedent and consequence-based behavior approaches. By combining

behavior principles with the engaging aspects of games, interventions become more interactive

and potentially more effective. The concept of "serious games" aligns with this idea, referring to

video games that go beyond entertainment and have tangible, real-world impacts on players. This

suggests that gamification can lead to meaningful and practical changes in an individual's

behavior outside gaming.

Game elements such as rewards, challenges, and feedback align with behavior change

principles. Those principles include operant conditioning, goal-setting, and feedback. The

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rewards in games serve as positive reinforcement. When players exhibit desired behavior

(completing tasks, achieving goals), they receive rewards (points, badges, items), reinforcing the

likelihood of those behaviors occurring again. Moreover, contingency management becomes

important as those rewards are contingent on specific behaviors. Challenges in games represent

goal setting. Larger objectives are broken down into smaller, achievable challenges. When goals

are broken down, individuals are motivated to engage in behavior that helps them overcome

challenges and progress in the game. For example, a fitness app may start by rewarding small

steps toward a larger goal, encouraging users to engage in healthier behavior progressively.

Finally, timely and specific feedback is given, helping individuals understand the consequences

of their behavior and facilitating learning and behavior modification.

A few studies utilized gamification using behavior analytic principles and showed

effectiveness in promoting healthy eating behaviors. Those studies that used gamification as an

intervention sought to increase fruit and vegetable intake. Jones et al. (2014) studied whether

children's fruit and vegetable consumption increased using the FIT game. Results indicated that

it effectively increased fruit and vegetable consumption to about 39%. Another study revealed

gamification effectiveness with children in a school setting. Using an alternating treatment

design, fruit and vegetable consumption were added daily to consume more of it (Jones et al.,

2014). Results indicated that it significantly increased fruit and vegetable consumption among

kindergarten through eighth-grade students. Lowe's Food Dudes program is a noteworthy

example of the successful application of gamification and behavior analytic principles to

promote healthy eating behaviors (Lowe & Horne, 2009). The program has demonstrated

effectiveness in encouraging individuals, particularly children, to increase their consumption of

fruits and vegetables. The Food Dudes program aligns with the gamification approach by

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incorporating game design elements that leverage the concepts of reinforcement. Many game

design elements used in gamification use the concept of reinforcement. Earning tokens, badges,

and accolades for various behaviors (i.e., recording dietary intake and weighing) makes that

behavior more likely to happen (Johnson et al., 2016). The research on schedules of

reinforcement suggests that behavior is contingent upon what, how much, and when

reinforcement is received. Suppose an individual is rewarded after every instance of appropriate

or correct behavior. In that case, this does not match true natural reinforcement, and an

individual's behavior becomes stagnant due to the satiation of the reinforcer. To maintain

behavior over time, in this case, healthy eating, if reinforcer magnitude was delivered to allow an

individual to choose more healthy foods, we could see an increase in eating healthy and a

decrease in eating unhealthy foods, thus affecting overall health.

A gamification intervention’s success in promoting healthy eating lies in its ability to

engage individuals through interactive game elements like tokens and badges. This engagement

is vital for sustaining interest in health-related activities and fostering long-term habits.

Gamification boosts motivation through positive reinforcement. Earning rewards such as tokens

and badges serves as immediate reinforcement, motivating individuals to continue positive

behaviors like recording dietary intake and increasing the likelihood of their repetition. The

notable increase in fruit and vegetable consumption showcases the effectiveness of incorporating

game elements, with success observed across diverse populations in a school setting (Jones et al.,

2014). There is a need for strategic delivery of reinforcement, as constant reinforcement may

lead to satiation. The goal is to align reinforcement with natural contingencies. This approach

encourages individuals to make healthier choices for sustained behavior change autonomously.

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 In a recent feasibility study, Nour et al. (2019) explored the dynamic interplay between

self-monitoring, gamification, and social media in promoting healthy eating behaviors among

young adults. This research study shed light on the potential effects of integrating gamification

and self-monitoring strategies within a health intervention. Examining the engagement patterns

of young adults with vegetable intake using a self-monitoring app delves into the effectiveness

and feasibility of combining game-like elements with self-monitoring practices. The findings

offered valuable insights into the potential of this integrated approach for fostering sustained

behavior change regarding dietary habits among individuals. Unfortunately, few studies used

gamification and self-monitoring as an intervention package for healthy eating behaviors.

Benefits and Limitations of a Behavior Analytic Study

Behavior analysis shares commonalities with other fields geared toward public health. It

seeks to assess and mitigate behaviors of social significance using evidenced-based behavior

interventions at the individual level and on a widescale (Normand et al., 2021). Implementing

antecedent interventions compared to consequence-based interventions targeting any behavior,

including health behaviors, is compelling. Rafacz (2019) indicates that studies have been geared

toward antecedent and consequence interventions for preparing and consuming healthy foods.

However, methodological limitations, intervention effectiveness, and confounding variables have

affected the relativeness of studies regarding healthy eating behaviors. A behavior-analytic study

of dietary behavior will contribute to understanding healthy choice-making through natural

choice conditions (Rafacz, 2019). Moreover, a behavior analytic study emphasizes research into

evidence-based interventions and necessitates practical implementation for generalizability

within behavior analysis (Slocum et al., 2014).

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 However, limitations may arise when using a behavior analytic study to promote healthy

eating behaviors. Recruiting individual’s representative of the population may be challenging

due to variations in individual preferences, motivations, and habits regarding dietary intake.

Furthermore, competing priorities and environmental influences may detract from motivation to

improve healthy eating behavior. Competing priorities and environmental influences should not

be dismissed as excuses but recognized as significant barriers that may hinder the success of

behavior analytic interventions in facilitating behavior change. Furthermore, eating behaviors are

multifaceted. Other factors, such as psychological states, habitual routines, and social norms,

may impact intervention effectiveness.

Findings

The findings of this literature review suggest a need for an accurate experimental study

focusing on the social significance of food choice and consumption among adults. There is also a

gap within the literature in finding effective interventions to increase healthy eating using a

theoretical orientation of the matching law, an operant conditioning principle of behaviorism,

that can be applied within the real world. Many of the studies reviewed that utilized self-

monitoring and gamification were not based on increasing a healthy diet among adults nor

analyzed adult preference in choosing healthy versus unhealthy foods. Although different diets

contradict the CDC definition of healthy eating (Centers for Disease Control and Prevention

[CDC], 2021), effective interventions based on behaviorism that promote behavior monitoring

are motivating and effective for actual behavior change.

Healthy eating has been a cause for concern for many years as more people are becoming

overweight and diagnosed with diseases related to food choice and nutrition (Deshpande et al.,

2009). Food selection regarding healthy eating is a necessary social behavior requiring

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behavioral analytic solutions. The hope is to find a self-monitoring intervention to increase

healthy eating using behavior-analytic strategies such as motivation and reinforcement. This

study contributed to the existing knowledge to fill the gap in the matching law and its application

to choosing healthy compared to unhealthy foods, its relation to concurrent schedules of

reinforcement, and how both concurrent schedules of reinforcement and environmental variables

affect choice.

Healthy eating is a pressing public health issue, and this current literature review

underscores the urgency of developing evidence-based interventions to encourage healthy eating

behaviors. A few studies examined behavioral interventions such as self-monitoring and

gamification for behavior change regarding healthy eating. Conversely, many research studies

aimed to increase other health-related behaviors, such as physical activity. Furthermore, some

studies did not represent healthy eating but demonstrated the effectiveness of using specific

behavior analytic principles such as reinforcement magnitude and CCDs. Further research

focusing on the matching law should be adopted to tailor interventions to motivate individuals to

monitor and improve their dietary choices while understanding concurrent schedules of

reinforcement, environmental cues, and food choices.

One significant theme that emerged is the effectiveness of behavior-analytic

interventions, such as self-monitoring and gamification, in encouraging behavior change across

various domains. While many studies reviewed did not specifically target self-selected healthy

eating behaviors among adults, they provided valuable insight into the advantages of using

behavior-analytic strategies to improve dietary choices. For example, Jones et al. (2014) and

Lowe & Horne (2009) demonstrated the efficacy of gamification in increasing children's fruit

and vegetable consumption. The effectiveness of using gamification as an intervention highlights

43
the potential applicability of using behavior analytic interventions in improving healthy eating

behavior in adults.

Another emerging theme is the individual differences influencing dietary behavior.

Behavior analytic principles such as reinforcement play a role in shaping behavior. The literature

also suggested environmental cues, social norms, and psychological states influencing food

choice. While behaviorism provides a foundation for understanding and modifying behavior,

other fields of study can be used to examine further complex factors that may contribute to

dietary behavior. The study by Nour et al. (2019) provided an example of how collaboration

among other disciplines can effectively address health-related behaviors.

Moreover, a few reviewed studies emphasized the significance of goal setting in

motivating individuals for behavior change. Goal-setting was seen in studies that utilized self-

monitoring as an intervention for behavior change. Setting goals and monitoring their behavior

allows individuals to track their progress and make needed adjustments to improve. Goal-setting

and reinforcement are potent strategies for encouraging dietary behavior so that individuals can

take ownership and make decisions regarding their health. Finally, through empirical research

and practical implementation, practitioners in behavior analysis can contribute significantly to

improving healthy eating at both individual and societal levels.

Critique of Previous Research Methods

Behavior interventions regarding health-related behaviors, including healthy eating, have

been examined. However, they are limited within the behavioral analytic field, especially when

using the matching law to study the effects of behavior interventions on dietary choices. Previous

research in the literature demonstrated the use of behavior analytic principles such as

reinforcement magnitude, self-monitoring, and gamification, but again, these studies needed a

44
theoretical orientation of the matching law. Moreover, previous literature reviewed used

methodologies that did not align with behavior analysis, such as qualitative analysis, regression

analysis, spatial analysis, and other observational research methods, but were included to show

how limited research is on the use of behavior analytic interventions and methods to improve

health-related behaviors. Alkerwi et al. (2015) utilized regression analysis to examine

demographic and socioeconomic disparities in nutrition. Similarly, Costa et al. (2019) conducted

an ecological study to analyze access to healthy food based on SES and food store type—studies

such as these present limitations. Limitations for non-behavior analytic research methods include

the potential for confounding variables to influence observed relationships. Without adequate

control for those variables, findings may be misleading. Furthermore, using these studies has

limits within the theoretical orientation of the matching law. Reliance on regression analysis and

other research methods can potentially overlook environmental contingencies that may impact

intervention effectiveness.

Literature that utilized behavior analytic methodologies was diverse and addressed

various behavior modification aspects. Regarding the matching law, few studies demonstrated

varying degrees of adherence to the matching law principles. Critchfield and Kollins (2001) and

Zonneveld et al. (2018) align with the matching law by examining reinforcement strength on

behavior selection. Participants chose options with larger or more immediate reinforcers,

consistent with the matching law principles. However, literature regarding self-monitoring and

gamification was limited to applying the matching law principles. Although practical, studies

that used self-monitoring as an intervention saw that the reliance on self-report measures was

effective in behavior change but did not compare reinforcement schedules on increases in certain

behaviors. Similarly, studies that utilized gamification, although engaging and motivating, did

45
not align with natural contingencies of reinforcement. Literature examining healthy eating

behaviors and other behaviors showed considerable gaps in the literature regarding effective

behavior analytic interventions to improve healthy eating in adults, self-monitoring, and

gamification focusing on the principles of the matching law.

Summary

To the best of my knowledge, very few behavioral analytic studies focused on dietary

intake, especially regarding effective interventions to increase healthy food consumption.

Despite this limitation, research supports the effectiveness of self-monitoring and gamification

interventions in increasing health-related and non-health-related behaviors. Healthy eating

continues to be a rising concern as more people are becoming overweight and diagnosed with

diseases related to food choice and nutrition (Deshpande et al., 2009). Food selection regarding

healthy eating is a necessary social behavior requiring innovative behavioral analytic solutions

that utilize the principles of the matching law and combine self-monitoring and gamification for

self-selected behaviors. This intervention package highlights the importance of more rigorous

behavioral analytic research methodologies grounded in the matching law to advance our

understanding of behavior-environment contingencies and develop more effective interventions

to encourage healthy dietary choices.

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 CHAPTER 3. METHODOLOGY

In Chapters 1 and 2, the groundwork for the research, exploring current interventions for

healthy eating behavior, was established. Chapter 1 introduced the research topic, provided

background information, and clarified the study's purpose. Chapter 2's literature review carefully

examined existing research, pinpointing gaps and illustrating the current approaches to

addressing healthy eating challenges. Chapter 3 clarifies the research design, participant

recruitment, and the systematic approach that helped answer the research question. Ethical

concerns were addressed and discussed in the research.

Purpose of the Study

This research investigated the effectiveness of an intervention package of gamification

and a self-monitoring system to increase self-selected healthy eating choices in adults. Diet plays

a substantial role in an individual's overall health (Dai et al., 2020; WHO, 2003). The prevalence

of adults making unhealthy food choices relies on varying factors such as geographical location,

cultural influences, and socioeconomic status. The CDC reports that many people have a poor

diet consisting of high sodium intake, saturated fat, and sugar (CDC, 2022). The general purpose

of this study was to contribute to the behavior analytic literature, as public health problems are

behavior problems (LeBlanc et al., 2020). More specifically, the study filled the gap in effective

interventions to encourage healthy eating behavior that went beyond mere education.

Research Questions

How do gamification and a self-monitoring system affect selecting healthy versus

unhealthy foods?

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 Research Design

The experimental design used to address the research question was a changing criterion

design. For the current study, the independent variables were gamification and self-monitoring,

and the dependent variable was self-selected eating behavior (fruit and vegetable consumption,

fruit consumption only). The CCD involves systematically modifying the criteria for behavior

change throughout the study. By doing so, the researcher aimed to assess the impact of

gamification and a self-monitoring system at various stages of incremental increases in choosing

healthy foods by providing an understanding of its influence on the desired behavioral outcome.

Hartman and Hall (1976) describe the CCD design as consisting of a baseline phase followed by

a treatment phase associated with stepwise criteria for a given target behavior. For this design,

experimental control is demonstrated when a systematic and controlled adjustment of the criteria

is made and replicated across the different phases to assess consistency in the behavioral

changes.

A CCD was chosen for this study as an immediate increase in healthy eating behavior

would be less sustainable. Furthermore, a CCD was selected to target behaviors already in the

individual's repertoire, focusing on healthy eating foods and incrementally increasing this

behavior in a stepwise fashion. A CCD can be expected to be used with other single-case

experimental designs, such as multiple-baseline designs (McDougall et al., 2006). For this

research, that was not the case. No other research design was used to evaluate the research

question. A commonality with using an MBD is the use of reversals. Utilizing a CCD does not

require a reversal. Furthermore, using an MBD to evaluate the effects of a study focused on

healthy eating behaviors would have ethical implications. Lastly, using a CCD, the treatment

phase did not require delay.

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 While using a CCD resulted in immediate improvements in healthy eating behaviors

without necessitating a treatment phase delay, it is essential to acknowledge the limitations

associated with a CCD. Limitations include the potential influence of individual motivations, the

impact of unaccounted external environmental factors on food choices, variability in social

support, inconsistencies in participant compliance with recording protocols, and unmeasured

stressors that could independently affect participants' eating behaviors. Designating support

persons and implementing end-of-the-week prompts by the researcher addressed potential

confounding variables related to social support. This contributed to minimizing participant

fatigue and increasing the reliability of recorded data.

Target Population and Sample

The impact of making healthy eating choices is profound and has far-reaching effects on

various aspects, including individual well-being, public health, and the overall healthcare system.

When individuals decide on their diets, the consequences extend beyond personal health to

broader societal implications such as healthcare costs and disease prevalence (Cena & Calder,

2020). It is crucial to comprehend how interventions can influence these choices to address the

multifaceted challenges individuals who strive for a healthy lifestyle face. Although many

studies have examined dietary behaviors, it is important to focus specifically on adults actively

seeking ways to improve their dietary choices (Powell et al., 2019). By targeting this

demographic group, we gain a deeper understanding of effective interventions and ensure that

our findings benefit those grappling with the complexities of dietary decision-making processes.

Population

Adults interested in improving current eating habits were targeted for the study. This

population is particularly relevant as more individuals are interested in improving health and

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nutrition behavior, especially using social media groups and other technology (Ghahramani et

al., 2022; Xu et al., 2020; Klassen et al., 2018; Santarossa et al., 2018). Recruiting efforts

targeted adults 18 years of age and older. Many studies regarding health-related behaviors and

healthy eating behaviors have targeted children as participants. Using adults for the study

allowed for the self-selection of healthy eating behavior.

Sample

The sampling frame for the study consisted of adults who were members of specific

groups on social media platforms and followers of the researcher’s personal media page.

Additionally, participants who had internet access on a mobile device or computer laptop

expressed the desire to improve healthy eating and self-reported that they currently have some

healthy eating habits were considered eligible. Those who self-reported they were under a

doctor-supervised weight loss program, had a disorder or illness that a non-physician supervised

plan is contraindicated, are currently in any weight loss program, self-reported they had a chronic

condition or obesity challenges, and were a family member or close friend of the researcher were

excluded from the study.

The sample size for the study was four participants who voluntarily engaged in the

research. Unfortunately, one participant chose to discontinue involvement, as indicated by the

absence of recorded entries in the food journal. As a result, the final analyzed sample size stands

at three participants. The decision to employ a single-subject research design with this limited

sample size is grounded in the specific nature of the study’s focus. Single-subject designs are

often utilized when investigating interventions on individual cases, allowing for an in-depth

examination of the impact within a controlled context. As in this study, a smaller sample size can

yield valuable insights when the research question centers around individual behavior.

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Historically, prior research has utilized a diverse sample size, often favoring larger participant

groups (Hahn et al., 2021). Adopting a single-subject research design in this study is intentional

and provides clinical relevance.

Procedures

A changing criterion design was utilized to investigate the impact of gamification and a

self-monitoring system on an individual’s choices between healthy and unhealthy foods.

Utilizing a convenience sampling approach, participants were tasked with maintaining a daily

food journal, documenting all consumed items, and a self-monitoring checklist. This checklist

covered their selection of healthy foods, the quantity consumed, the extent to which their support

person reinforced recording, and their preference for healthy choices. The study incorporated a

competitive element, which served as the gamification aspect of the study, with participants

earning points and digital badges as they competed against each other to make healthier food

choices.

Participant Selection

Flyers for recruitment were distributed in several private Facebook groups and on the

researcher’s personal Facebook page. The recruitment flyer contained the researcher’s contact

information and research details, including the purpose of the study, an explanation of what

participants would be doing, inclusion and exclusion criteria for eligibility, and the duration of

the study. Interested participants either contacted the researcher or scanned the QR code on the

flyer that directed them to participate in a screening survey immediately. Any questions were

answered, and participants who met the criteria were emailed a consent form.

Protection of Participants

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 This research was initiated by obtaining explicit permission from designated private

Facebook groups. Subsequently, participants were provided access to their digital food journal

and self-monitoring checklist. Both documents were shared exclusively between the participants,

the researcher, and the researcher's supervisor to safeguard participant confidentiality. Identifiers

devoid of personal information were used to further protect participant privacy. Additionally,

generic identifiers, such as Participant 1 and Participant 2, were employed when posting the

leaderboard, ensuring anonymity, and preventing disclosing any personally identifiable

information in shared materials. The study's protocol, including participant protection measures,

received approval from Capella University's Institutional Review Board (IRB). Participants were

informed of their right to withdraw from the study at any point without facing adverse

consequences, emphasizing the principle of voluntary participation and respect for individual

autonomy.

Data Collection

Participants

All study participants were at least 18 years old and were interested in improving and

making healthier eating choices. Participants participated in a demographic survey that provided

participant characteristics. Participant 1 stopped recording in the food journal after week 2 of the

intervention phase. Her demographic information is reported here to demonstrate the

characteristics of each participant. Additional demographic information, including Body Mass

Index (BMI) and weight, has been intentionally omitted from this study as it is not deemed

relevant to the research question under investigation.

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 Participant 1. Participant 1 is a woman following within the 51-60 age range. She works

in the education industry and reports that she would like to work on increasing fruit and

vegetable consumption.

Participant 2. Participant 2 is a woman following within the 31-40 age range. She works

in the education industry and reported that she would like to work on increasing fruit and

vegetable consumption.

Participant 3. Participant 3 is a woman following within the 21-30 age range. She works

in the healthcare industry and wants to increase fruit consumption.

Participant 4. Participant 4 is also a woman following within the 31-40 age range. She

works in an unspecified industry denoted as “other.” She reported wanting to increase fruit and

vegetable consumption.

Setting

This study was conducted in diverse settings, reflecting the participants’ daily

environments. Participants engaged with the study in a variety of locations, including home,

school, and work, where participants may have eaten healthy foods. Additionally, participants

lived in different geographic regions.

Materials

Each participant was required to have internet access on a mobile device or a

computer/laptop capable of completing a food journal and a self-monitoring checklist in Google

Sheets. Google Sheets was used as a form of a digital food journal that the researcher could see

as it updated automatically. Participants were also provided with a hand-sized portion sheet from

Precision Nutrition. Leaderboard results were created using LeaderboardHQ, a free website.

Finally, digital badges were created using Canva and emailed to participants when applicable.

53
Measure

Self-selected Healthy Eating Behavior. A self-selected healthy eating behavior was

defined based on two criteria. Participants could choose a whole dietary pattern or a single food

group. A whole dietary pattern is defined as the regular consumption of a balanced mix of fruits,

vegetables, whole grains, lean proteins, and healthy fats, consistent with established dietary

guidelines. For example, a Mediterranean diet, a vegetarian diet, a vegan diet, and a Pescetarian

diet were considered a whole dietary pattern for this research. A single food group is defined as

consistently selecting and consuming a specific category of foods, such as fruits, vegetables, or a

designated food category (i.e., lean meat, whole foods, and dairy). Through the demographic

survey, each participant identified and selected a healthy eating behavior they would like to

increase. Goals that did not go beyond the recommended daily fruit and vegetable consumption

were individually preselected and defined (they were then further broken down into achievable

weekly goals to meet the end goal and determined based on the baseline level of healthy eating

behavior). A further breakdown into achievable weekly goals and the criterion changes were

considered. The eating behavior was reported in the digital food journal as hand-sized portions in

addition to reporting other food and drinks consumed that day.

Interobserver Agreement

The exact agreement Interobserver Agreement (IOA) was measured in 20% of trials. For

this research, each date was considered a trial. The researcher counted the number of healthy

foods consumed in each participant's digital food journal and compared it with the data from the

self-monitoring checklist that reported the number of hand-size portions of the healthy foods

consumed by the participants. To determine if the data agrees, IOA was formulated based on the

number of agreements compared to the number of trials and multiplied by 100.

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Social Validity

Social validity was measured using a questionnaire through Google Forms. A statement

was provided in which participants anonymously rated their level of agreement with the

statements. A Likert scale was used to score their agreements, ranging from 1 (strongly disagree)

to 5 (strongly agree). The questionnaire was provided via a link to each participant's email.

Design

A CCD was used to evaluate the effects of the intervention on healthy eating choices.

The intervention phase commenced with all participants immediately after the baseline phase.

The gamification portion of the intervention stopped during the last two weeks to measure

maintenance effects. The baseline and intervention phases were one week and nine weeks,

respectively.

Conditions

All participants were communicated with by the researcher via email only. They were

provided with the exact email instructions for the baseline phase and provided a separate email

detailing the tasks during the intervention phases. Participants who did not meet weekly criteria

were emailed separately with an adjustment to their weekly criteria goal.

Baseline. Participants were emailed a link to a Google Sheets document where they

entered food and drink consumed. Participants were told to record all food and drink

consumption. A model was provided on the Google sheet document. At this time, only

participants had access to the digital food journal. Baseline data were collected for seven days.

The week for the research started on Monday and ended on Sunday.

Intervention. At the beginning of week two, all participants were emailed an overview

of the intervention plan on the tasks required for the duration of the study. All participants had an

55
individualized goal broken down into smaller goals with increasing mastery criteria by week. For

example, one participant’s goal was to consume four fist-size portions of fruits and vegetables

combined on at least four out of seven days for two weeks. Then, four and a half fist-size

portions of fruits and vegetables combined on at least five out of seven days a week for the next

two weeks. The criterion was changed for participants if they did not meet the criteria for the

week. Criterion phases were determined using the baseline mean (Alberto et al., 2006).

In the Intervention phase, the participants chose a designated support person to encourage

daily self-monitoring. Encouragement of daily self-monitoring included the support person

providing a prompt (reminder) to record eating habits and complete the self-monitoring checklist

(the checklist was made visible to participants the same day the intervention plan overview was

provided). The support person also had to provide a small reward based on the participant's

preference for healthy eating during Weeks 1-9 of the intervention. Lastly, participants were

provided instructions on the reward system. In weeks 1-7, two points were earned for meeting

the criteria daily, one point was earned for meeting the criteria at least three out of seven days,

and half a point was earned for not meeting the criteria for the day but still recording. Five bonus

points were also provided for meeting the criteria seven days consecutively, allowing them to

level up. At each level, the participants had the opportunity to earn extra points. All participants

started at level one, earning a one-point multiplier; level two earned two times the point

multiplier, and level three earned three times the point multiplier. During weeks eight and nine,

all participants earned no points. Precision Nutrition’s hand-size portion guide was also provided

for accurate measurements. On the last day of each week, the researcher provided a prompt via

email to record all food and fill out the self-monitoring checklist. On the first day of the

following week, the researcher allocated points to all participants based on the number of healthy

56
foods eaten recorded on the self-monitoring checklists, and all participants were emailed the

leaderboard results. If the participants were eligible to move up a level, digital badges were

emailed on the same day the leaderboard results were emailed.

Data Analysis

The principal method of data analysis for single-subject experimental design is visual

analysis. Therefore, visual analysis was utilized to determine whether a functional relation exists

between the independent and dependent variables by inspecting and analyzing the data's trend,

level, and variability (Dowdy et al., 2022; Ledford et al., 2018). Data were entered into Google

Sheets and were graphically depicted with sessions plotted on the x-axis. The response frequency

of healthy foods (a whole dietary eating pattern or single food group) was plotted on the y-axis.

The introduction of gamification and self-monitoring commenced simultaneously for all

participants as they were competing for points and earning badges. Participants logged their food

in the digital food journal during the baseline phase. The baseline level served as a benchmark,

providing insight into the behavior before determining criterion changes and introducing the

intervention phase. The analysis of variability was based on the predetermined criterion changes

set for each participant every week. Based on meeting the specific weekly criteria, it had to meet

the mastery criteria for earning points, thus providing insights into the overall trend of the

participant's pattern of behavioral responses. The predetermined criterion changes provided a

systematic approach and ensured that changes were controlled, minimizing the influence of

extraneous variables. The participants were not only required to meet the weekly criteria but had

to meet mastery criteria to earn points. This requirement contributed to the study’s internal

validity.

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Ethical Considerations

The decision to focus on a whole dietary pattern or a single food group is ethically

guided, addressing concerns surrounding dietary guidelines and consumption patterns. These

guidelines are further reinforced by the adherence to the Behavior Analyst Certification Board's

(2020) ethical code, with its explicit directives on practicing within the boundaries of

competence, obtaining informed consent, safeguarding participant confidentiality, managing

potential conflicts of interest, and ensuring precise data handling. Guided by the principles

articulated in the Belmont Report (1979), the study is rooted in the ethical imperative to treat all

participants with respect, practice beneficence by avoiding harm, carefully weigh benefits and

risks, and uphold principles of fairness and justice (U.S Department of Health and Human

Services, 1979). The Collaborative Institutional Training Initiative (CITI) program was

completed to substantiate this commitment. Capella University's IRB approved all methods and

informed consent of the research. Additionally, informed consent was obtained by all

participants. Limited demographic information was utilized to detail participant characteristics

concerning the research question. Lastly, all study-related data was stored on a password-

protected laptop, removing identifiers immediately upon collection. Data will be retained for up

to seven years and digitally erased at the end of the retention period.

Summary

The study aimed to evaluate the effectiveness of gamification and a self-monitoring

intervention to promote healthy eating choices in adults who wanted to improve healthy eating

behavior and already had some healthy eating habits. The interventions were evaluated using a

CCD with the methods approved by Capella University’s IRB. Ethical considerations included

58
obtaining informed consent, adherence to dietary guidelines, the BACB’s ethical code, and the

Belmont Report. Chapter 4 will discuss the findings of the study.

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 CHAPTER 4. RESULTS

This chapter will present the findings regarding the research question on the effects of

gamification and a self-monitoring system on the decisions individuals make about food. A brief

overview of the general sample will be addressed, which may aid in presenting the results and

their impact on their food choices. Additionally, the results of the participant's engagement with

the gamification and self-monitoring components of the intervention phase will be discussed.

Background

This study aimed to evaluate the effects of gamification and self-monitoring on choosing

healthy over unhealthy foods using a changing criterion design. Understanding how food

preferences intersect with environmental contingencies is crucial for developing effective

interventions that encourage healthier choices when presented with multiple available food

options (Rafacz., 2019). Previous behavior analytic research studies, while limited, have

attempted to increase healthier eating, yet the scope of these efforts underscores the ongoing

need for a more comprehensive examination and analysis. The results of the study are discussed

below.

Description of the Sample

Eight adult participants were interested in participating in the study. Of the eight

participants, one did not meet eligibility requirements. Another participant did not return a

consent form, two never started participation in the baseline and intervention phases, and another

started but stopped recording food intake after the second day of the intervention phase.

Therefore, three participants completed the study from the baseline to the intervention phase.

Participants who completed the study were women between the ages of 21 and 40. Participants

reported being employed in education, healthcare, and a category designated other.

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 Results

Three participants completed the study using a gamification system (competing and

earning points for the healthiest eating consumption), showing minimal increases in healthy

eating choices for all participants from baseline. When analyzing the leaderboard results pictured

in Table 1, by the end of the study, Participant 3 earned the most points, reaching Level 3 and

earning a digital badge at the end of the corresponding week via email for Levels 2 and 3. Once

she reached Level 3, she earned points based on this level. Notably, Participant 3 reached Level

2 at the end of the first week and Level 3 in the second week. Participants 2 and 4 consistently

stayed at Level 1 weekly throughout the intervention phase. Each participant was provided a

preselected criterion change goal sheet with varying mastery criteria. Table 2 presents the

criterion change goals for each participant.

Table 1
Leaderboard Results by Research Participants
Rank Participants Total
1 Participant 3 250
2 Participant 2 27
3 Participant 4 26

Table 2

Initial Criterion Changes by Participants

Participants Criterion Changes

2 Weeks 1-3: Increase intake by 1 fist-size portion of fruits and vegetables on
at least 4 out of 7 days weekly.
Weeks 4-5: Increase intake by 2 fist-size portions of fruits and vegetables
combined on at least 5 out of 7 days each week.
Weeks 6-7: Increase intake by adding 2 fist-size portions of fruits on all 7
days.
Weeks 8-9: Maintain intake of 2 fist-size portions of fruits and vegetables
combined without earning points.

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 3 Weeks 1-2: Increase intake by 1.5 fist-size portions of fruits daily for 4 out
of 6 days each week.
Weeks 3-4 Increase intake by 2 fist-size portions of fruits daily for 5 out of
6 days each week.
Weeks 5-6: Increase intake by adding 2 fist-size portions of fruits daily for
all 6 days.
Week 7: Increase intake of 2 fist-sized portions of fruits daily for all 7
days.
Weeks 8-9: Maintain intake of 2 fist-size portions for all 7 days without
earning points.
4 Weeks 1-2: Increase intake by 4 fist-size portions of fruits and vegetables
combined on at least 4 out of 7 days each week.
Weeks 3-4: Increase intake by 4.5 fist-size portions of fruits and vegetables
on at least 5 out of 7 days each week.
Weeks 5-6: Increase intake by adding 5 fist-size portions of fruits and
vegetables on at least 6 out of 7 days each week.
Week 7: Increase intake by adding 5 fist-size portions of fruits and
vegetables this week.
Weeks 8-9: Maintain intake of 5 fist-size portions of fruits and vegetables
for all 7 days without earning points.

Baseline Data

Baseline data collection occurred for one week for all participants. They were not

provided with information except to record all food and drink consumption in the electronic food

journal, Google Sheets. The frequency of servings of fruits and vegetables and just fruits were

determined for each participant depending on the healthy eating goal they chose to increase. The

frequency of healthy foods is shown in Figures 1, 2, and 3 for each participant. The frequency of

healthy foods eaten was determined to establish the first criteria for intervention, as shown in

Table 2.

Intervention Data

Figure 1. displays the results for Participant 2. Upon analyzing the trend depicted in

Figure 1., it becomes evident that there is a high degree of variability throughout the intervention

phase. The data points exhibit fluctuations without a clear overall upward or downward

62
trajectory. Instead, the trend remains stable, and the level is low. In the first criterion change,

Participant 2 met or exceeded the required frequency of one-fist size portion of fruits and

vegetables combined for the initial three weeks. The second criterion change occurred at the

beginning of week 5, prompted by the participant needing to achieve mastery criteria in week 4.

A new criterion was set requiring attainment across 4 out of 7 days. In the third change, while

meeting the criteria in the first week, there were gaps in recording food intake on some days.

There were considerable gaps in data in the fourth criterion and maintenance phase.

Figure 1

Participant 2 Changing Criterion Design of Fruit and Vegetable Consumption

Fruit and Vegetable Consumption

7 Baseline Goal 1 Goal 2 Goal 3 Goal 4 Maintenance
Frequency of Hand-sized Portions (Servings)

0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70
Days

Participant 3 consistently exceeded the established criteria in criterion change goals one

to three, depicted in Figure 2. The researcher opted to increase the criteria for subsequent

changes. However, the participant did not meet the new criteria during the last two changes, but

the researcher did not want to lower it beyond the current level. The intervention phase resulted

in a low level with a stable trend. At baseline, she had a high variability of healthy eating

63
choices. At the start of the third week, Participant 3 consistently scored three times the points for

exceeding the mastery criteria for the criterion changes.

Figure 2

Participant 3 Changing Criterion Design of Fruit Consumption

Fruit Consumption
7 Baseline Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Maintenance
Frequency of Hand Size Portions (Servings)

0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70
Days

Finally, for Participant 4, mastery criteria were not met during the criterion changes, but

she earned points for recording in the food journal, presented in Figure 3. Even with a change in

the criteria during the second criterion change, the participant continued failing to meet the

revised goals. The level of making healthy fruit and vegetable choices remained consistently

low, showing neither an increase nor a decrease in trend throughout the intervention phase.

Toward the middle of the dataset, there was an emergence of high variability.

Figure 3

64
Participant 4 Changing Criterion Design of Fruit and Vegetable Consumption

Fruit and Vegetable Consumption

7

Frequency of Hand size portions (servings)

Baseline Goal 1 Goal 2 Goal 3 Goal 4 Maintenance
6

0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70
Days

Table 3 displays the interobserver agreement (IOA) results across participants for

recording the frequency of hand-size portions of self-selected eating behaviors over 20% of the

observed days. Participant 2 demonstrated a high agreement of 78% when the researcher served

as an observer, indicating a strong and consistent fruit and vegetable consumption recording.

However, Participants 3 and 4 exhibited lower agreement levels at 21% and 0%, respectively.

Notably, Participant 3 tended to overestimate the frequency of fruit consumption, while

Participant 4 consistently underestimated the frequency of fruit and vegetable consumption.

Table 3

Exact Agreement IOA Across Participants for 20% of Days

Participant Percentage of Exact Agreement

2 78%
3 21%
4 0%

Self-reporting Data

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 All participants completed a self-monitoring checklist in the intervention phase, as

displayed in Table 3. Participant 2 completed the self-monitoring checklist across 38 days out of

63 days. She demonstrated a 44% selection of healthy food items and a 55% daily logging rate

for all meals and drinks. Notably, the designated support person rewarded her on average 44% of

the time for adhering to healthy eating and logging behaviors. However, Participants 3 and 4,

who completed all 63 days in the intervention phases, consistently adhered to the self-monitoring

checklist. Both participants demonstrated a 100% selection of healthy food items and a 100%

logging rate for all meals and drinks and were rewarded by their designated support persons

100% of the time.

Table 4

Percentage of Self-monitoring Checklist Tasks Across Days in Intervention Phases for All

Participants.

Participants Total Percentage of The percentage Average number of

number of healthy food items of all meals and times the support person
days in the chosen drinks was rewarded participant for
intervention logged daily healthy eating and
phase logging?
2 38 44% 55% 44%
3 63 100% 100% 100%
4 63 100% 100% 100%

Social Validity

A social validity questionnaire was emailed to all participants the following day, the last

day of the intervention phase. A Likert scale was used to assess social validity. Points were

assigned ranging from one to five, with one indicating the participant strongly disagreed with the

statement and five the participant agreed. The average number of responses was used to identify

the mean social validity score. All participants found that making healthy choices is essential to

66
them. While many participants reported positive motivation from earning points and competing

with others for healthier choices, one participant provided a lower score of 2 for this aspect.

Furthermore, that same participant did not find having a support person beneficial in rewarding

them for making healthy choices and logging eating consumption.

Table 5

Participant Social Validity Results

Social Validity Question Mean Results

Making healthy eating choices is important to me. 5
Self-monitoring my eating choices allowed me to
4.67
eat healthier.
Earning points and competing with others who are
looking to improve healthy eating motivated me 4
to make healthier choices.
Self-monitoring my eating choices is something I
4.67
can continue doing.
Having a support person helped me remember to
4
record what I ate throughout the day.
I was motivated to continue making healthier
choices because of the types of rewards received
4.33
(i.e., better sleep, increase in energy levels, better
mood, weight loss, and less bloating).

Summary

Overall, the results suggested that the gamification component of the intervention

package yielded minor improvements in healthy eating choices for all participants. Despite this,

with the gamification system and self-monitoring components, Participants 3 and 4 could

maintain self-selected eating behavior across criterion changes with low variability. In the initial

weeks, Participant 2 slightly increased fruit and vegetable consumption and then had inconsistent

logging and fruit and vegetable intake consumption. Participant 3 excelled, earning points and

reaching Level 3, securing digital badges each time according to the self-recording data.

Conversely, Participants 2 and 4 consistently remained at Level 1 throughout the intervention

67
phase. Social validity results in Table 5 indicated positive perceptions overall, with all

participants acknowledging the importance of healthy choices. However, one participant

expressed lower motivation from earning points and competition and found the support person

less beneficial. In the following chapter, Chapter 5, the focus will be on discussing the

meaningful implications of these findings and offering recommendations for future research.

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 CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS

The previous chapter discussed the study’s findings. In Chapter 5, a summary and discussion

of the results will be presented. Limitations and practical implications for the behavior analysis

field and other related disciplines will be addressed, leading to recommendations for further

research, followed by the conclusion.

Summary of the Results

Healthy eating is a behavior that has been difficult to increase across one's lifespan, with

studies indicating poor nutrition affects individuals at a very young age (Nyardi et al., 2013).

Limited behavior analytic literature demonstrates effective interventions for increasing healthy

eating behavior. This research study aimed to examine the effects of gamification and a self-

monitoring system on healthy dietary choices to encourage healthier lifestyles in individuals. A

CCD was used to evaluate the effects of gamification and self-monitoring on gradual,

incremental increases in self-selected eating behaviors. Preselected criteria change goals were

determined for each participant, including point allocation for healthy food consumption. Using

visual analysis, Participant 3 earned the most points and was the only one who reached Level 3.

Despite reaching Level 3 early in the competition, healthy food consumption (fruit) remained at

three fists full daily. Participant 2 had the most difficulty earning points and badges and

recording and consuming healthy fruits and veggies, which was demonstrated by high variability

in the data. Participant 4 consistently remained at a low level of healthy choices despite goal

adjustments.

Discussion of the Results

The results suggest that gamification and a self-monitoring system had varying effects on

participants choosing and consuming healthy foods. Minimal increases in healthy eating choices

69
were observed in the electronic food journal and reported on the self-monitoring checklists.

There were inconsistencies, such as no reporting of meals for Participant 2, which underscores

the effects of the self-monitoring checklists as Participants 3 and 4 consistently self-monitored

daily. Participants 3 and 4 demonstrated a positive correlation between consistent self-

monitoring and sustained healthier choices, although increases were minimal for Participant 4.

The competitive nature and reward system represented by earning points and digital badges may

have been a powerful reinforcer for Participant 3, who earned 250 points. The gamification

component of the intervention aligns with the matching law, emphasizing that individuals choose

healthy versus unhealthy foods based on perceived reinforcement.

Conclusions Based on the Results

All three participants showed minimal but consistent increases in self-selected healthy

eating choices across criterion changes. These results suggest that gamification and a self-

monitoring system can encourage increased healthy eating if future research examines the effects

of utilizing specific gamification apps, such as Noom or other health-related apps, as the features

and functionalities, such as the gamifying components, may differ significantly in commercial

health apps compared to the simple gamification and self-monitoring components utilized in this

study. For example, Noom, a widely recognized commercial health app, uses behavioral science,

tailored recommendations, and feedback based on individual preferences, goals, and progress.

Conversely, this study's gamification and self-monitoring components were relatively

rudimentary. Furthermore, Noom offers other features such as meal planning assistance,

educational content, social support, and real-time coaching and feedback (Sysko et al., 2022).

Challenges were also evident, mainly when participants needed help to meet the set

criteria, possibly due to traveling or holidays, emphasizing the need for a flexible and more

70
individualized approach to goal setting. Some participants demonstrated motivation by earning

points, but it did not uniformly translate into increased healthy food choices for all participants.

Participants who completed the self-monitoring checklist were positively correlated with making

healthy food choices. However, some participants did not record the quantity of healthy foods

consumed. Finally, social validity measures were assessed through participant feedback, which

indicated overall satisfaction with the gamification and self-monitoring components—however,

concerns about the interventions' effectiveness warrant further examination to enhance successful

behavior change.

Comparison of the Findings with the Theoretical Framework

The results supported the need for effective interventions to encourage healthy eating, as

previous literature highlighted the challenges or the lack thereof of effective behavior analytic

interventions (Rafacz, 2019). This study examined how gamification and self-monitoring as

interventions influenced the allocation of behavior toward healthier food choices. The number of

points earned eventually influenced one participant's choices of unhealthy versus healthy foods,

which aligned with the matching law. However, this was not observed across all participants,

which may suggest individual differences and responses to reinforcement contingencies.

Houston et al. (2021) stated that the matching law serves a dual function by examining how

behavior determines rewards and how rewards influence behavior. In the study, participants'

choices between unhealthy and healthy foods were impacted with varying degrees of consistency

by the accumulation of points, highlighting a gap in the literature for the applicability of the

matching law to dietary decision-making. The points were reinforcement, encouraging

participants to allocate self-selected eating behavior to healthier options. Although previous

research suggested gamification effectively encourages motivation for non-game contexts, it may

71
not be enough to increase health-related behaviors like eating (Mazeas et al., 2022).

Furthermore, the findings contribute to the broader literature on behavior and operant

conditioning by illustrating how external stimuli and reinforcement play pivotal roles in

determining and modifying behaviors (Staddon & Cerutti, 2003). Conversely, challenges and

variability in meeting revised criteria observed among Participants 2 and 4 may suggest that the

gamification component could have been more effective in consistently choosing healthy foods,

highlighting the importance of further refinement and individualization of gamification strategies

to enhance maintenance and generalization of dietary behavior change.

The study's results also underscored the significant role of the support person, including

the support person's presence and the rewards provided to the participant. Participant 3, who

earned more points than the rest of the participants, may have been more effectively supported or

motivated by the support person compared to the other participants.

Limitations

While the study contributes valuable insights, addressing elements that could improve the

results in future research endeavors is essential. Notably, this study included a small sample size,

which may limit the generalizability of the findings and was affected by individual interests in

participation. Furthermore, the participant's characteristics may only partially represent broader

populations. Future research efforts should expand the participant pool, ensuring a more diverse

and representative study population. Additionally, the reliance on self-reported data, introducing

the potential for reporting bias, is noteworthy. Participants may provide socially desirable

responses or inaccurately recall healthy food consumption. Utilizing a support person may affect

the accuracy of using the self-monitoring checklist. For example, the support person’s level of

engagement and encouragement could have influenced participants' reporting and consumption

72
of healthy eating. Furthermore, stimuli provided by the support person for each person were not

specified. Not specifying the type of reward provided to each participant may have impacted the

consistency and effectiveness of the interventions. The lack of specification regarding the reward

for choosing healthy foods and completing the self-monitoring checklist may have influenced the

participant's motivation and behavior towards making healthier choices, thus warranting

consideration in future studies aiming to replicate or build upon these limitations. Moreover,

participants may have felt pressured to conform to the perceived expectations regarding their

dietary choices in the support person’s presence. The support person's perceived expectations

could lead to bias in reporting on the self-monitoring checklist. Support person involvement

should be addressed by considering efficient objective measures for the support person’s

participation.

Acknowledging the influence of external factors on participants' behaviors, such as

environmental variables or personal circumstances, is a critical aspect of maintaining internal

validity. Practitioners or researchers could explore additional controls or observational measures

to better account for external influences, thus strengthening the study’s internal validity. For the

gamification aspect of this study, competing and earning points may have limited the motivation

to choose and eat healthy foods. While some participants demonstrated increased motivation and

engagement in choosing and consuming healthy foods in response to the competitive aspect and

point system, others exhibited limited responsiveness. Participants 2 and 4, for example,

consistently earned points for recording but did not show a corresponding increase in healthy

food choices. Results may have differed if participants knew one another or interacted more

during the study. Peer modeling could have played a role in shaping participants’ choices.

73
 Moreover, the design of the leaderboard and its visual elements could have influenced

participant's motivation and engagement with the gamification aspect of the study. This study

utilized a straightforward leaderboard designed with LeaderboardHQ, a free online leaderboard

maker. However, this elementary design lacked a visual presentation that may enhance

motivation and promote healthy participant competition. While the study incorporated a social

validity questionnaire to gauge participant experiences, the questionnaire may have yet to

capture full intervention effectiveness. A thorough review and potential revision of the social

validity questionnaire to ensure it more comprehensively addresses the acceptability of

intervention procedures, the interventions' outcomes, effectiveness, and the overall impact on

targeted behaviors may be warranted.

Implications for Practice

Despite the limitations inherent within this study, the findings provide further insight into

how designing and implementing effective interventions aimed at behavior change for healthy

eating behavior can inform future research endeavors in the behavior analysis field and other

related fields. As practitioners and researchers seek to enhance the impact of behavior-analytic

interventions in promoting healthier lifestyles, several vital considerations emerge.

Within the field of behavior analysis, researchers can further improve components of

gamification and self-monitoring to address behavior challenges not explicitly limited to dietary

choices. They can further examine how reinforcement magnitude impacts behavior allocation to

support matching law. Interventions such as these, which are tailored to provide immediate

feedback, have the potential for individuals to understand the consequences of their choices.

Additionally, effective behavior analytic interventions provide a deeper understanding of

immediate versus delayed primary reinforcers if future research refines interventions to examine

74
these effects. Behavior interventions that address behavior change regarding sustained positive

lifestyles will improve chronic health conditions with a more adaptive and supportive approach.

Furthermore, behavior-analytic interventions can complement other medical treatments, thus

providing a holistic approach to managing health conditions.

Recommendations for Further Research

Future research should carefully address limitations and delimitations derived from the

current study. Future studies should prioritize more extensive and diverse participant samples to

enhance the generalizability of findings considering factors such as age, socioeconomic status,

and cultural background. The current study used two participants from West Africa, indicating a

different cultural background than those living in the United States. A larger participation group

and expanding research to include participants from diverse geographical locations would prove

beneficial to examine how cultural factors influence healthy versus unhealthy choices.

Additionally, future research should establish systematic protocols for the involvement of

support persons, ensuring consistent and controlled support across participants, including

specifying preferences for and types of reinforcers used. More specifically, feedback could

improve the research findings as more than weekly prompt reminders may have been needed to

ensure treatment fidelity of the self-monitoring and recording of healthy eating. Finally, future

research should address intervention components. There was an absence of using gamification

app. Future research should explicitly focus on developing or using an existing app, assessing the

impact of specific gamification components on participant adherence, and choosing healthy and

unhealthy foods. Technology is increasing, and a gamification app could also address data

collection accuracy. Implementing a concurrent reinforcement schedule embedded in the

gamification app that focuses on the principles of matching law would contribute to the sustained

75
engagement of participants, and researchers could provide comparisons of reinforcement

schedules for making healthy choices.

Conclusion

The results provided insights into the efficacy of gamification and self-monitoring

interventions in influencing behavior allocation toward healthier food choices. Although all

participants showed minimal increases in healthy food consumption, implications for practice

and further research offer actionable steps for professionals and researchers. Despite limitations,

this study contributes significantly to understanding behavior-analytic interventions for healthy

eating. However, it also requires the collaboration of other disciplines to foster sustained positive

health outcomes that consider individual preferences, integrate technology for engagement and

motivation, and inform decision-making.

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 REFERENCES

Alberto, P., Troutman, A. C., & Axe, J. B. (2006). Applied behavior analysis for teachers (pp. 1-

474). Pearson Merrill Prentice Hall.

Alkerwi, A., Vernier, C., Sauvageot, N., Crichton, G. E., & Elias, M. F. (2015). Demographic and

socioeconomic disparity in nutrition: application of a novel Correlated Component

Regression approach. BMJ open, 5(5), e006814. [Link]

006814

Appelhans, B. M., Tangney, C. C., French, S. A., Crane, M. M., & Wang, Y. (2019). Delay

discounting and household food purchasing decisions: The SHoPPER study. Health

Psychology, 38(4), 334-342. [Link]

Alsaffar, A. A. (2016). Sustainable diets: The interaction between food industry, nutrition, health,

and the environment. Food Science and Technology International, 22(2), 102-111.

[Link]

Arntzen, E., & Eilertsen, J. M. (2020). Using stimulus-equivalence technology to teach skills

about nutritional content. Perspectives on Behavior Science, 43(3), 469-485.

[Link]

Azizi Fard, N., De Francisci Morales, G., Mejova, Y., & Schifanella, R. (2021). On the interplay

between educational attainment and nutrition: A spatially-aware perspective. EPJ Data

Science, 10(1), 1-21. [Link]

Barlow, D. H., & Nock, M. K. (2009). Why can't we be more idiographic in our research?

Perspectives on Psychological Science, 4(1), 19–21. [Link]

6924.2009.01088.x

77
Behavior Analyst Certification Board (2022). Applied behavior analysis subspecialty areas.

[Link]

Bloomfield, B. S., Fischer, A. J., Clark, R. R., & Dove, M. B. (2019). Treatment of food

selectivity in a child with Avoidant/Restrictive food intake disorder through parent

teleconsultation. Behavior Analysis in Practice, 12(1), 33–43.

[Link]

Bogost I. Persuasive games: the expressive power of video games. Cambridge: MIT Press; 2007.

Borrero, C. S. W., Vollmer, T. R., Borrero, J. C., Bourret, J. C., Sloman, K. N., Samaha, A. L., &

Dallery, J. (2010). Concurrent reinforcement schedules for problem behavior and

appropriate behavior: Experimental applications of the matching law. Journal of the

Experimental Analysis of Behavior, 93(3), 455–469. [Link]

455

Bruhn, A., Gilmour, A., Rila, A., Van Camp, A., Sheaffer, A., Hancock, E., Fernando, J., &

Wehby, J. (2022). Treatment components and participant characteristics associated with

outcomes in self-monitoring interventions. SAGE Publications.

[Link]

Bruhn, A., McDaniel, S., & Kreigh, C. (2015). Self-monitoring interventions for students with

behavior problems: A systematic review of current research. Behavioral Disorders, 40(2),

102-121. [Link]

Butryn, M. L., Godfrey, K. M., Martinelli, M. K., Roberts, S. R., Forman, E. M., & Zhang, F.

(2020). Digital self‐monitoring: Does adherence or association with outcomes differ by

self‐monitoring target? Obesity Science & Practice, 6(2), 126–133.

[Link]

78
Cena, H., & Calder, P. C. (2020). Defining a healthy diet: Evidence for the role of contemporary

dietary patterns in health and disease. Nutrients, 12(2), 334.

[Link]

Centers for Disease Control and Prevention. (2022). Poor nutrition. Retrieved from

[Link]

Cero, I. and Falligant, J.M. (2020). Application of the generalized matching law to chess

openings: A gambit analysis. Journal of Applied Behavior Analysis, 53: 835-845.

Chen, P. J., & Antonelli, M. (2020). Conceptual Models of Food Choice: Influential Factors

Related to Foods, Individual Differences, and Society. Foods (Basel, Switzerland), 9(12),

1898. [Link]

Compernolle, S., DeSmet, A., Poppe, L., Crombez, G., De Bourdeaudhuij, I., Cardon, G., van der

Ploeg, Hidde P, & Van Dyck, D. (2019). Effectiveness of interventions using self-

monitoring to reduce sedentary behavior in adults: A systematic review and meta-

analysis. The International Journal of Behavioral Nutrition and Physical Activity, 16(1),

63-63. [Link]

Cooper, J. O., Heron, T. E., & Heward, W. L. (2019). Applied behavior analysis (3rd edition).

Pearson Education.

Costa, B.V. L., Menezes, M. C., Oliveira, C. D. L. et al. (2019). Does access to healthy food vary

according to socioeconomic status and to food store type? An ecologic study. BMC

Public Health, 19 775. [Link]

Critchfield, T. S., & Kollins, S. H. (2001). Temporal discounting: basic research and the analysis

of socially important behavior. Journal of Applied Behavior Analysis, 34(1), 101–122.

[Link]

79
Crowley, J. G., Peterson, K. M., Fisher, W. W., & Piazza, C. C. (2020). Treating food selectivity

as resistance to change in children with autism spectrum disorder. Journal of Applied

Behavior Analysis, 53(4), 2002-2023. [Link]

Dai, J., Cone, J., & Moher, J. (2020). Perceptual salience influences food choices independently

of health and taste preferences: Principles and Implications. Cognitive Research, 5(1), 1-

13. [Link]

Deterding, S., Dixon, D., Khaled, R., Nacke, L. (2011). From game design elements to

gamefulness: Defining gamification. Conference: Proceedings of the 15th International

Academic MindTrek Conference: Envisioning Future Media Environments. 9-15.

[Link]

Deshpande, S., Basil, M. D., & Basil, D. Z. (2009). Factors influencing healthy eating habits

among college students: An application of the health belief model. Health Marketing

Quarterly, 26(2), 145-164. [Link]

Dowdy, A., Jessel, J., Saini, V., & Peltier, C. (2022;2021;). Structured visual analysis of single‐

case experimental design data: Developments and technological advancements. Journal

of Applied Behavior Analysis, 55(2), 451–462. [Link]

Dubbert, P. M., Johnson, W. G., Schlundt, D. G., & Montague, N. W. (1984). The influence of

caloric information on cafeteria food choices. Journal of Applied Behavior

Analysis, 17(1), 85–92. [Link]

Duckworth, A. L., & Gross, J. J. (2020). Behavior change. Organizational Behavior and Human

Decision Processes, 161(Suppl), 39-49. [Link]

80
Duckworth, A. L., Gendler, T. S., & Gross, J. J. (2016). Situational strategies for self-control.

Perspectives on Psychological Science, 11(1), 35-55.

[Link]

Epstein, L. H., Leddy, J. J., Temple, J. L., & Faith, M. S. (2007). Food reinforcement and eating:

a multilevel analysis. Psychological Bulletin, 133(5), 884–906.

[Link]

Fisher, W. W., Felber, J. M., Phillips, L. A., Craig, A. R., Paden, A. R., & Niemeier, J.

J. (2019). Treatment of resistance to change in children with autism. Journal of Applied

Behavior Analysis, 52, 974–993.

Fogel, V. A., Miltenberger, R. G., Graves, R., & Koehler, S. (2010). The effects of exergaming on

physical activity among inactive children in a physical education classroom. Journal of

Applied Behavior Analysis, 43(4), 591-600.

Foroozanfar, Z., Moghadami, M., Mohsenpour, M. A., Houshiarrad, A., Farmani, A., Akbarpoor,

M. A., & Shenavar, R. (2022). Socioeconomic determinants of nutritional behaviors of

households in Fars Province, Iran, 2018. Frontiers in Nutrition, 9, 956293.

[Link]

Frank-Crawford, M. A., Hallgren, M. M., McKenzie, A., Gregory, M. K., Wright, M. E., &

Wachtel, L. E. (2021). Mask compliance training for individuals with intellectual and

developmental disabilities. Behavior Analysis in Practice, 14(4), 883–892.

[Link]

French, S. A., Tangney, C. C., Crane, M. M., Wang, Y., & Appelhans, B. M. (2019). Nutrition

quality of food purchases varies by household income: The SHoPPER study. BMC Public

Health, 19(1), 231-231. [Link]

81
Galbraith, L. A., & Normand, M. P. (2017). Step it up! Using the good behavior game to increase

physical activity with elementary school students at recess. Journal of Applied Behavior

Analysis, 50(4), 856–860.

Ghahramani, A., de Courten, M., & Prokofieva, M. (2022). "the potential of social media in

health promotion beyond creating awareness: An integrative review". BMC Public

Health, 22(1), 2402–2402. [Link]

Goodwin, C. L., Forman, E. M., Herbert, J. D., Butryn, M. L., & Ledley, G. S. (2012). A pilot

study examining the initial effectiveness of a brief acceptance-based behavior therapy for

modifying diet and physical activity among cardiac patients. Behavior Modification,

36(2), 199-217. [Link]

Guercio, J. M. (2018). The importance of a deeper knowledge of the history and theoretical

foundations of behavior analysis: 1863–1960. Behavior Analysis: Research and

Practice, 18(1), 4–15. [Link]

Guenther, P. M., & Dodd, K. W. (2006). Most Americans eat much less than the recommended

amounts of fruits and vegetables. Journal of the American Dietetic Association, 106(9),

1371–1379.

Hahn, S. L., Linxwiler, A. N., Huynh, T., Rose, K. L., Bauer, K. W., & Sonneville, K. R. (2021).

Impacts of dietary self-monitoring via myfitnesspal to undergraduate women: A

qualitative study. Body Image, 39, 221-226. [Link]

Hallum, S. H., Hughey, S. M., Wende, M. E., Stowe, E. W., & Kaczynski, A. T. (2020). Healthy

and unhealthy food environments are linked with neighbourhood socio-economic

disadvantage: An innovative geospatial approach to understanding food access inequities.

Public Health Nutrition, 23(17), 3190-3196. [Link]

82
Hartmann, D. P., & Hall, R. V. (1976). The changing criterion design. Journal of Applied

Behavior Analysis, 9(4), 527–532. [Link]

Hausman, N. L., Borrero, J. C., Fisher, A., & Kahng, S. (2017). Teaching young children to make

accurate portion size estimations using a stimulus equivalence paradigm. Behavioral

Interventions, 32(2), 121-132. [Link]

Hayes, L. B., & Van Camp, C. M. (2015). Increasing physical activity of children during school

recess. Journal of Applied Behavior Analysis, 48(3), 690-695.

[Link]

Herforth, A., Arimond, M., Álvarez-Sánchez, C., Coates, J., Christianson, K., & Muehlhoff, E.

(2019). A Global Review of Food-Based Dietary Guidelines. Advances in Nutrition

(Bethesda, Md.), 10(4), 590–605. [Link]

Herrnstein R. J. (1961). Relative and absolute strength of response as a function of frequency of

reinforcement. Journal of the Experimental Analysis of Behavior. 1961;4:267–272

Higgs, S. (2015). Social norms and their influence on eating behaviours. Appetite, 86, 38-44.

[Link]

Hilmers, A., Hilmers, D. C., & Dave, J. (2012). Neighborhood disparities in access to healthy

foods and their effects on environmental justice. American Journal of Public Health

(1971), 102(9), 1644-1654. [Link]

Hoch, H., McComas, J. J., Johnson, L., Faranda, N., & Guenther, S. L. (2002). The effects of

magnitude and quality of reinforcement on choice responding during play activities.

Journal of Applied Behavior Analysis, 35(2), 171-181.

[Link]

83
Horne, P., Hardman, C., Lowe, C., Tapper, K., Le Noury, J., Madden, P., Patel, P., & Doody,

M. (2009). Increasing parental provision and children's consumption of lunchbox fruit

and vegetables in Ireland: The Food Dudes intervention. European Journal of Clinical

Nutrition 63(5), 613–618.

Horne, P., Tapper, K., Lowe, C. F., Hardman, C. A., Jackson, C., & Wollner, J. (2004). Increasing

children's fruit and vegetable consumption: A peer-modelling and rewards-based

intervention. European Journal of Clinical Nutrition, 58(12), 1649–1660.

Houston, A. I., Trimmer, P. C., & McNamara, J. M. (2021). Matching behaviours and

rewards. Trends in Cognitive Sciences, 25(5), 403–415.

[Link]

Hung, S. T., Cheng, Y. C., Wu, C. C., & Su, C. H. (2023). Examining Physical Wellness as the

Fundamental Element for Achieving Holistic Well-Being in Older Persons: Review of

Literature and Practical Application in Daily Life. Journal of multidisciplinary

healthcare, 16, 1889–1904. [Link]

Hutchesson, M. J., Tan, C. Y., Morgan, P., Callister, R., & Collins, C. (2016). Enhancement of

self-monitoring in a web-based weight loss program by extra individualized feedback and

reminders: Randomized trial. Journal of Medical Internet Research, 18(4), e82-e82.

[Link]

Imtiyaz, H., Soni, P., & Yukongdi, V. (2021). Role of Sensory Appeal, Nutritional Quality,

Safety, and Health Determinants on Convenience Food Choice in an Academic

Environment. Foods (Basel, Switzerland), 10(2), 345.

[Link]

84
Institute of Medicine (U.S.) Committee on Health and Behavior: Research, Practice, and Policy.

(2001). Chapter 5: Individuals and families: Models and interventions. In Health and

behavior: The interplay of biological, behavioral, and societal influences. National

Academies Press (U.S). [Link]

Jeffery, R. W., Wing, R. R., Thorson, C., Burton, L. R., Raether, C., Harvey, J., & Mullen, M.

(1993). Strengthening behavioral interventions for weight loss: A randomized trial of

food provision and monetary incentives. Journal of Consulting and Clinical Psychology,

61(6), 1038-1045. [Link]

Johnson, D., Deterding, S., Kuhn, K. A., Staneva, A., Stoyanov, S., & Hides, L. (2016).

Gamification for health and well-being: A systematic review of the literature. Internet

Interventions, 6, 89–106. [Link]

Jones, B. A., Madden, G. J., & Wengreen, H. J. (2014). The FIT Game: preliminary evaluation

of a gamification approach to increasing fruit and vegetable consumption in

school. Preventive Medicine, 68, 76–79. [Link]

Junaid, H., Bulla, A. J., Benjamin, M., Wind, T., & Nazaruk, D. (2021). Using self-management

and social media to increase steps in sedentary college students. Behavior Analysis in

Practice, 14(3), 734–744. [Link]

Kanfer, F. H. (1970). Self-monitoring: Methodological limitations and clinical

applications. Journal of Consulting and Clinical Psychology, 35(2), 148–

152. [Link]

Kim, E. B., Chen, C., & Cheon, B. K. (2019). Using remote peers' influence to promote healthy

food choices among preschoolers. Developmental Psychology, 55(4), 703-708.

[Link]

85
Klassen, K. M., Douglass, C. H., Brennan, L., Truby, H., & Lim, M. S. C. (2018). Social media

use for nutrition outcomes in young adults: A mixed-methods systematic review. The

International Journal of Behavioral Nutrition and Physical Activity, 15(1), 70-

70. [Link]

Klein, L. A., Houlihan, D., Vincent, J. L., & Panahon, C. J. (2015). Best Practices in Utilizing the

Changing Criterion Design. Behavior Analysis in Practice, 10(1), 52–61.

[Link]

Kong, A., Tussing-Humphreys, L. M., Odoms-Young, A. M., Stolley, M. R., & Fitzgibbon, M. L.

(2014). Systematic review of behavioural interventions with culturally adapted strategies

to improve diet and weight outcomes in African American women. Obesity reviews : an

official Journal of the International Association for the Study of Obesity, 15 Suppl 4(0 4),

62–92. [Link]

Kronfli, F. R., Lloveras, L. A., & Vollmer, T. R. (2021). Applications of the matching law to

observe shifts in problem behavior: A proof‐of‐concept study. Behavioral Interventions,

36(4), 764-777. [Link]

LeBlanc, L. A., Lerman, D. C., & Normand, M. P. (2020). Behavior analytic contributions to

public health and telehealth. Journal of Applied Behavior Analysis, 53(3), 1208-1218.

[Link]

Ledford, J. R., Lane, J. D., & Severini, K. E. (2018). Systematic use of visual analysis for

assessing outcomes in single case design studies. Brain Impairment, 19(1), 4-17.

[Link]

86
Lee-Kwan, S. H., Moore, L. V., Blanck, H. M., Harris, D. M., & Galuska, D. (2017). Disparities

in state-specific adult fruit and vegetable consumption–United States, 2015. MMWR:

Morbidity and Mortality Weekly Report, 66(45), 1241–1247.

Levin, M. E., Krafft, J., Seifert, S., & Lillis, J. (2022). Tracking valued and avoidant functions

with health behaviors: A randomized controlled trial of the acceptance and commitment

therapy matrix mobile app. Behavior Modification, 46(1), 63-89.

[Link]

Lewis, M., McNaughton, S. A., Rychetnik, L., Chatfield, M. D., & Lee, A. J. (2021). Dietary

Intake, Cost, and Affordability by Socioeconomic Group in Australia. International

Journal of Environmental Research and Public Health, 18(24), 13315.

[Link]

Lieberman D. A. (2012). Human Learning and Memory. Cambridge University Press.

Loro Jr, A. D., Fisher Jr, E. B., & Levenkron, J. C. (1979). comparison of established and

innovative weight-reduction treatment procedures. Journal of Applied Behavior Analysis,

12(1), 141-155. [Link]

Lowe, C. F., & Horne, P. J. (2009). Food Dudes: Increasing children's fruit and vegetable

consumption. Cases in Public Health Communication and Marketing, 3, 161–185.

Lowe, C. F., Horne, P. J., Tapper, K., Bowdery, M., & Egerton, C. (2004). Effects of a peer

modelling and rewards-based intervention to increase fruit and vegetable consumption in

children. European Journal of Clinical Nutrition, 58(3), 510-22.

[Link]

Lowe, F., Horne, P. J., Viktor, S., Kelly, P. A., Pears, S. L., & Anthony, T. (2010). Case study:

Food Dudes healthy eating programme: Learning to like fruit and vegetables. In J.

87
 French, R. Merritt, & L. Reynolds (Eds.), Social marketing case book (pp. 218–233).

Sage Publications.

Lytle, L., Seifert, S., Greenstein, J., & McGovern, P. (2000). How do children's eating patterns

and food choices change over time? Results from a cohort study. American Journal of

Health Promotion, 14(4), 222–228.

Madden, G., & Perone, M. (1999). Human sensitivity to concurrent schedules of reinforcement:

Effects of observing schedule-correlated stimuli. Journal of the Experimental Analysis of

Behavior, 71(3), 303–318. [Link]

Marcum, C. S., Goldring, M. R., McBride, C. M., & Persky, S. (2018). Modeling dynamic food

choice processes to understand dietary intervention effects. Annals of Behavioral

Medicine: A Publication of the Society of Behavioral Medicine, 52(3), 252–261.

[Link]

Marijn Stok, F., Renner, B., Allan, J., Boeing, H., Ensenauer, R., Issanchou, S., Kiesswetter, E.,

Lien, N., Mazzocchi, M., Monsivais, P., Stelmach-Mardas, M., Volkert, D., & Hoffmann,

S. (2018). Dietary Behavior: An Interdisciplinary Conceptual Analysis and

Taxonomy. Frontiers in Psychology, 9, 1689. [Link]

May, B. K., & Treadwell, R. E. (2020). Increasing exercise intensity: Teaching high-intensity

interval training to individuals with developmental disabilities using a lottery

reinforcement system. Behavior Analysis in Practice, 13(4), 826–837.

[Link]

Mayer, J. A., Heins, J. M., Vogel, J. M., Morrison, D. C., Lankester, L. D., & Jacobs, A. L.

(1986). Promoting low-fat entree choices in a public cafeteria. Journal of Applied

Behavior Analysis, 19(4), 397-402. [Link]

88
Mazeas, A., Duclos, M., Pereira, B., & Chalabaev, A. (2022). Evaluating the Effectiveness of

Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized

Controlled Trials. Journal of Medical Internet Research, 24(1), e26779.

[Link]

McCallum, S. (2012). Gamification and serious games for personalized health. Studies in Health

Technology and Informatics. 177. 85–96.

McDougall, D., Hawkins, J., Brady, M., & Jenkins, A. (2006). Recent innovations in the

changing criterion design: Implications for research and practice in special education. The

Journal of Special Education, 40(1), 2-15.

[Link]

McGonigal, J. (2010). Jane McGonigal: Gaming can make a better world. [Video

file]. [Link]

McGonigal J. Reality is broken: why games make us better and how they can change the world.

Penguin; 2011.

Mikkilä, V., Räsänen, L., Raitakari, O. T., Pietinen, P., & Vilkari, J. (2004). Longitudinal changes

in diet from childhood into adulthood with respect to risk of cardiovascular diseases: The

Cardiovascular Risk in Young Finns Study. European Journal of Clinical

Nutrition, 58(7), 1038–1045.

Morford, Z. H., Witts, B. N., Killingsworth, K. J., & Alavosius, M. P. (2014). Gamification: The

intersection between behavior analysis and game design technologies. Behavior Analyst,

37, 25-40. [Link]

89
Morris, E. K., Altus, D. E., & Smith, N. G. (2013). A study in the founding of applied behavior

analysis through its publications. The Behavior Analyst, 36(1), 73–107.

[Link]

Mozaffarian, D., Angell, S. Y., Lang, T., & Rivera, J. A. (2018). Role of government policy in

nutrition—barriers to and opportunities for healthier eating. BMJ (Online), 361, k2426-

k2426. [Link]

Musich, S., MacLeod, S., Bhattarai, G. R., Wang, S. S., Hawkins, K., Bottone, F. G., Jr, & Yeh,

C. S. (2016). The Impact of Obesity on Health Care Utilization and Expenditures in a

Medicare Supplement Population. Gerontology & Geriatric Medicine, 2,

2333721415622004. [Link]

Myerson, J., & Hale, S. (1984). Practical implications of the matching law. Journal of applied

behavior analysis, 17(3), 367–380. [Link]

Nastasi, J. A., Sheppard, R. D., & Raiff, B. R. (2020). Token‐economy‐based contingency

management increases daily steps in adults with developmental disabilities. Behavioral

Interventions, 35(2), 315–324. [Link]

Ng, M., Fleming, T., Robinson, M., Thomson, B., Graetz, N., Margono, C., Mullany, E. C.,

Biryukov, S., Abbafati, C., Abera, S. F., Abraham, J. P., Abu-Rmeileh, N. M., Achoki,

T., AlBuhairan, F. S., Alemu, Z. A., Alfonso, R., Ali, M. K., Ali, R., Guzman, N. A.,

Ammar, W., … Gakidou, E. (2014). Global, regional, and national prevalence of

overweight and obesity in children and adults during 1980-2013: a systematic analysis for

the Global Burden of Disease Study 2013. Lancet (London, England), 384(9945), 766–

781. [Link]

90
Normand, M. P., & Burji, C. (2020). Using the Step it UP! Game to increase physical activity

during physical-education classes. Journal of Applied Behavior Analysis, 53(2), 1071-

1079.

Normand, M. P., & Osborne, M. R. (2010). Promoting healthier food choices in college students

using individualized dietary feedback. Behavioral Interventions, 25(3), 183-190.

[Link]

Nour, M., Chen, J., & Allman-Farinelli, M. (2019). Young adults' engagement with a self-

monitoring app for vegetable intake and the impact of social media and gamification:

Feasibility study. JMIR Formative Research, 3(2), e13324. [Link]

Nyaradi, A., Li, J., Hickling, S., Foster, J., & Oddy, W. H. (2013). The role of nutrition in

children's neurocognitive development, from pregnancy through childhood. Frontiers in

Human Neuroscience, 7, 97--. [Link]

Ohri-Vachaspati, P., DeWeese, R. S., Acciai, F., DeLia, D., Tulloch, D., Tong, D., Lorts, C., &

Yedidia, M. (2019). Healthy food access in low-income high-minority communities: A

longitudinal assessment-2009-2017. International Journal of Environmental Research

and Public Health, 16(13), 2354. [Link]

Olateju, I. V., Ogwu, D., Owolabi, M. O., Azode, U., Osula, F., Okeke, R., & Akabalu, I. (2021).

Role of behavioral interventions in the management of obesity. Curēus (Palo Alto, CA),

13(9), e18080-e18080. [Link]

Orji, R., Lomotey, R., Oyibo, K., Orji, F., Blustein, J., & Shahid, S. (2018). Tracking feels

oppressive and ‘punishy’: Exploring the costs and benefits of self-monitoring for health

and wellness. Digital Health, 4, 2055207618797554-2055207618797554.

[Link]

91
Otterbring, T., Gidlöf, K., Rolschau, K., & Shams, P. (2020). Cereal deal: How the physical

appearance of others affects attention to healthy foods. Perspectives on Behavior Science,

43(3), 451-468. [Link]

Overskeid, G. (2018). Do we need the environment to explain operant behavior? Frontiers in

Psychology, 9. [Link]

Page, E. J., Massey, A. S., Prado-Romero, P. N., & Albadawi, S. (2020). The use of self-

monitoring and technology to increase physical activity: A review of the literature.

Perspectives on Behavior Science, 43(3), 501-514. [Link]

00260-0

Patel, M. L., Brooks, T. L., & Bennett, G. G. (2020). Consistent self-monitoring in a commercial

app-based intervention for weight loss: Results from a randomized trial. Journal of

Behavioral Medicine, 43. 391-401. [Link]

Pearce, A. L., Fuchs, B. A., & Keller, K. L. (2022). The role of reinforcement learning and value-

based decision-making frameworks in understanding food choice and eating behaviors.

Frontiers in Nutrition (Lausanne), 9, 1021868-1021868.

[Link]

Peterson, K. M., Piazza, C. C., Ibañez, V. F., & Fisher, W. W. (2019). Randomized controlled

trial of an applied behavior analytic intervention for food selectivity in children with

autism spectrum disorder. Journal of Applied Behavior Analysis, 52(4), 895-917.

[Link]

Platzer, J., & Feuerbacher, E. N. (2022). Reinforcer efficacy of grain for horses. Journal of the

Experimental Analysis of Behavior, 118, 302-315.

92
Potts, S., Krafft, J., & Levin, M. E. (2022). A pilot randomized controlled trial of acceptance and

commitment therapy guided self-help for overweight and obese adults high in weight

self-stigma. Behavior Modification, 46(1), 178-201.

[Link]

Powell, P. K., Durham, J., & Lawler, S. (2019). Food Choices of Young Adults in the United

States of America: A Scoping Review. Advances in Nutrition (Bethesda, Md.), 10(3),

479–488. [Link]

Rafacz, S. D. (2019). Healthy eating: Approaching the selection, preparation, and consumption

of healthy food as choice behavior. Perspectives on Behavior Science, 42(3), 647-674.

[Link]

Raiff, B. R., Burrows, C., & Dwyer, M. (2021). Behavior-analytic approaches to the management

of diabetes mellitus: Current status and future directions. Behavior Analysis in Practice,

14(1), 240–252. [Link]

Ravid, A., Lagbas, E., Johnson, M., & Osborne, T. L. (2021). Targeting co-sleeping in children

with anxiety disorders using a modified bedtime pass intervention: A case series using a

changing criterion design. Behavior Therapy, 52(2), 298-312.

[Link]

Reed, D. D & Kaplan, B. A. (2011). The matching law: A tutorial for practitioners. Behavior

Analysis in Practice, 4(2), 15–24. [Link]

Risse, M. R., Blair, K. C., & Russo, D. A. (2023). Evaluating Technology-Based Self-Monitoring

of Performance with Differential Reinforcement for Students with

Disabilities. Behavioral Sciences (Basel, Switzerland), 13(6), 508.

[Link]

93
Rose, D., Bodor, J. N., Hutchinson, P. L., & Swalm, C. M. (2010). Importance of a multi-

dimensional approach for studying the links between food access and consumption. The

Journal of Nutrition, 140(6), 1170–1174. [Link]

Saboia, I., Almeida, A. M. P., Sousa, P., & Pernencar, C. (2020). Are you ready for the challenge?

social media health challenges for behaviour change. Perspectives on Behavior Science,

43(3), 543-578. [Link]

Santarossa, S., Kane, D., Senn, C. Y., & Woodruff, S. J. (2018). Exploring the role of in-person

components for online health behavior change interventions: Can a digital person-to-

person component suffice? Journal of Medical Internet Research, 20(4), e144-

e144. [Link]

Sailer, M., Hence, J. U., Mayr, S. K., & Mandl, H. (2017). How gamification motivates: An

experimental study of specific game design elements on psychological need satisfaction.

Computers in Human Behavior, 69 371-380. [Link]

Sairanen, E., Tolvanen, A., Karhunen, L., Kolehmainen, M., Järvelä, E., Rantala, S., Peuhkuri,

K., Korpela, R., & Lappalainen, R. (2015). Psychological flexibility and mindfulness

explain intuitive eating in overweight adults. Behavior Modification, 39(4), 557-579.

[Link]

Schardt, A. A., Miller, F. G., & Bedesem, P. L. (2019). The effects of CellF-monitoring on

students’ academic engagement: A technology-based self-monitoring intervention.

Journal of Positive Behavior Interventions, 21(1), 42-49.

[Link]

94
Schenk, M. J., & Reed, D. D. (2020). Experimental evaluation of matching via a commercially

available basketball video game. Journal of Applied Behavior Analysis, 53(1), 209-221.

[Link]

Shahan, T. A. (2017). Moving beyond reinforcement and response strength. Perspectives on

Behavior Science, 40(1), 107-121. [Link]

Sharp, W. G., Odom, A., & Jaquess, D. L. (2012). Comparison of upright and flipped spoon

presentations to guide treatment of food refusal. Journal of Applied Behavior

Analysis, 45(1), 83-96. [Link]

Shavit, Y., Roth, Y., & Teodorescu, K. (2021). Promoting healthy eating behaviors by

incentivizing exploration of healthy alternatives. Frontiers in Nutrition, 8,

[Link]

Shurtleff, D., & Silberberg, A. (1990). Income maximizing on concurrent ratio-interval schedules

of reinforcement. Journal of the Experimental Analysis of Behavior, 53(2), 273-284.

[Link]

Sigurdsson, V., & Fagerstrøm, A. (2020). An introduction to the special section on “Health,

technology, & behavior science”. Perspectives on Behavior Science, 43(3), 445-449.

[Link]

Skinner, B. F. (1953). Some contributions of an experimental analysis of behavior to psychology

as a whole. The American Psychologist, 8(2), 69-78. [Link]

Slocum, T. A., Detrich, R., Wilczynski, S. M., Spencer, T. D., Lewis, T., & Wolfe, K. (2014). The

Evidence-Based Practice of Applied Behavior Analysis. The Behavior Analyst, 37(1), 41–

56. [Link]

95
Smith, R., Kelly, B., Yeatman, H., & Boyland, E. (2019). Food marketing influences children's

attitudes, preferences and consumption: A systematic critical review. Nutrients, 11(4),

875. [Link]

Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology, 54,

115–144. [Link]

Stark, L. J., Collins Jr, F. L., Osnes, P. G., & Stokes, T. F. (1986). Using reinforcement and

cueing to increase healthy snack food choices in preschoolers. Journal of Applied

Behavior Analysis, 19(4), 367-379. [Link]

Sterling, S. R., & Bowen, S. (2019). The potential for plant-based diets to promote health among

blacks living in the united states. Nutrients, 11(12), 2915.

[Link]

Stock, L. Z., & Milan, M. A. (1993). Improving dietary practices of elderly individuals: the

power of prompting feedback, and social reinforcement. Journal of Applied Behavior

Analysis, 26(3), 379–387. [Link]

Sysko, R., Bibeau, J., Boyar, A., Costello, K., Michaelides, A., Mitchell, E. S., Susanin, A., &

Hildebrandt, T. (2022). A 2.5-year weight management program using noom health:

Protocol for a randomized controlled trial. JMIR Research Protocols, 11(8), e37541-

e37541. [Link]

Temple, J. L. (2014). Factors that influence the reinforcing value of foods and beverages.

Physiology and Behavior, 136, 97–103. [Link]

Thompson, D., Baranowski, T., Buday, R., Baranowski, J., Thompson, V., Jago, R., & Griffith,

M. J. (2010). Serious Video Games for Health How Behavioral Science Guided the

96
 Development of a Serious Video Game. Simulation & gaming, 41(4), 587–606.

[Link]

Tiger, J. H., & Hanley, G. P. (2006). Using reinforcer pairing and fading to increase the milk

consumption of a preschool child. Journal of Applied Behavior Analysis, 39(3), 399-403.

[Link]

Tronieri, J. S., Wadden, T. A., Walsh, O., Berkowitz, R. I., Alamuddin, N., & Chao, A. M.

(2020). Measures of adherence as predictors of early and total weight loss with intensive

behavioral therapy for obesity combined with liraglutide 3.0 mg. Behaviour Research and

Therapy, 131, 103639-7. [Link]

Trosclair-Lasserre, N. M., Lerman, D. C., Call, N. A., Addison, L. R., & Kodak, T. (2008).

Reinforcement magnitude: An evaluation of preference and reinforcer efficacy. Journal of

Applied Behavior Analysis, 41(2), 203, 220. [Link]

Tsochantaridou, A., Sergentanis, T. N., Grammatikopoulou, M. G., Merakou, K., Vassilakou, T.,

& Kornarou, E. (2023). Food advertisement and dietary choices in adolescents: An

overview of recent studies. Children (Basel), 10(3), 442.

[Link]

Tylka, T. L. (2006). Development and psychometric evaluation of a measure of intuitive eating.

Journal of Counseling Psychology, 53(2), 226-240. [Link]

0167.53.2.226

U.S. Department of Health & Human Services (2022). Cultural food preferences in food service.

[Link]

[Link].

97
U.S. Department of Health and Human Services. (1979). The Belmont Report: Ethical principles

and guidelines for the protection of human subjects of research.

[Link]

Wadolowska, L., Kostecka, M., Kowalkowska, J., Jeruszka-Bielak, M., Tomaszewska, M.,

Danielewicz, A., & Hamulka, J. (2021). Sustainability of a multi-component education

program (ABC of healthy eating) after three months and nine months: The

socioeconomic context in improving nutrition knowledge in polish teenagers. Nutrients,

13(5), 1661. [Link]

Wagner, J. L., & Winett, R. A. (1988). Prompting one low-fat, high-fiber selection in a fast-food

restaurant. Journal of Applied Behavior Analysis, 21(2), 179–185.

[Link]

Washington, W. D., Banna, K. M., & Gibson, A. L. (2014). Preliminary efficacy of prize-based

contingency management to increase activity levels in healthy adults. Journal of Applied

Behavior Analysis, 47(2), 231–245. [Link]

Wheatley, T. L., Goulet, M., Mann, K., & Lanovaz, M. J. (2020). Differential negative

reinforcement of other behavior to increase compliance with wearing an anti‐strip suit.

Journal of Applied Behavior Analysis, 53(2), 1153–1161. [Link]

Wisdom, J., Downs, J. S., & Loewenstein, G. (2010). Promoting healthy choices: Information

versus convenience. American Economic Journal. Applied Economics, 2(2), 164-178.

[Link]

Wolfson, J. A., Ramsing, R., Richardson, C. R., & Palmer, A. (2019). Barriers to healthy food

access: Associations with household income and cooking behavior. Preventive Medicine

Reports, pp. 13, 298–305. [Link]

98
World Health Organization. (2023). Nutrition. [Link]

topics/nutrition#tab=tab_1

World Health Organization (2021). Obesity and overweight. [Link]

room/fact-sheets/detail/obesity-and-overweight

World Health Organization (2020). Healthy diet. [Link]

sheets/detail/healthy-diet

Xu, Z., Geng, J., Zhang, S., Zhang, K., Yang, L., Li, J., & Li, J. (2020). A mobile-based

intervention for dietary behavior and physical activity change in individuals at high risk

for type 2 diabetes mellitus: Randomized controlled trial. JMIR mHealth and

uHealth, 8(11), e19869-e19869. [Link]

Yu, K., Wu, F., & Eisenberg Colman, M. H. (2021). Low-income caregivers’ attitudes and

behaviors on Children’s diets: Emergent themes on cultural influences and perceived

value of nutrition information from healthcare providers. Journal of Primary Care &

Community Health, 12, 21501327211003686-21501327211003686.

[Link]

Yu, Q., Li, E., Li, L., & Liang, W. (2020). Efficacy of interventions based on applied behavior

analysis for autism spectrum disorder: A meta-analysis. Psychiatry Investigation, 17(5),

432–443. [Link]

Zeleny, J. R., Volkert, V. M., Ibañez, V. F., Crowley, J. G., Kirkwood, C. A., & Piazza, C. C.

(2020;2019;). Food preferences before and during treatment for a pediatric feeding

disorder. Journal of Applied Behavior Analysis, 53(2), 875–888.

[Link]

99
Zonneveld, K. L. M., Neidert, P. L. Dozier, C. L., Gureghian, D. L., & Bayles, M. W. (2018).

Assessing factors that influence young children’s food preferences and choices. Journal

of Applied Behavior Analysis, 52(1), 240-257. [Link]

[Link]/10.1002/jaba.521

100
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