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Reducing Nonessential Food Intake by Accelerating Water consumption via Prompt

Author: Dario Shuyuan Liu
Advisor: Dr. Sharon Armstrong
by 03, 2021 

Introduction

Many eating disorders exist, such as anorexia nervosa, bulimia nervosa, and binge eating disorder. The common characteristics of these disorders relate to various psychological conditions that cause unhealthy eating habits, such as obsessions with food, physical appearance, and body weight.

 

The COVID-19 outbreak significantly changed the way I live. Due to strict quarantine policies, I began staying at home and stockpiling food. My long-term sedentary life created boredom or a void, significantly associated with my greater energy consumption. In addition, repetitively listening to and watching the news about the COVID-19 pandemic also created stress and depression for me. Being involved in stressful events can lead people to overeat nonessential foods, especially those “comfort eating foods” characterized as processed, rich in sugar, and contains many carbohydrates. Such foods reduce stress because serotonin is produced and enhances mood (Renzo et al, 2020). Although I am satisfied with the stress reduction caused by consuming a great deal of nonessential food, I also like the feeling of fullness. These senses of satisfaction cause me to engage in the same behavior whenever the prompt appears repetitively. I gained significant weight as a result, which increased my concerns about my physical appearance.

 

Whether an individual performs a behavior depends on the event that occurs before (maintaining antecedents) and after (maintaining consequences) behavior in question (Spiegler, 2016). People tend to engage in a behavior when they have the motivation, knowledge, or resources, which are known as prerequisites. People are also likely to engage in a behavior when stimulated by a prompt or a series of setting events. Maladaptive behaviors are maintained because the consequence serves as a reinforcement, which strengthens the likelihood that the same behavior will be performed in the future. To eliminate maladaptive behavior, a person must identify its antecedents and consequences.

 

As noted, I experienced much stress at home, and I tended to reach for snacks at random points throughout the day to fill up my stomach and reduce my anxiety and stress significantly. This behavior occurred at random times as long as I felt stressed and bored. When I did not consume sufficient food to keep my stomach full while I was under the stress of working and studying, I experienced an attention deficit that prevented me from focusing on my work. I developed and maintained this maladaptive behavior because the consequences of feeling full and satisfied reduced my anxiety and stress and gave me a sense of energy that enabled me to focus on my homework again. The consequences of my random eating behavior serve as positive reinforcements to perform the same behavior in similar situations in the future. Thus, my nearby snack basket, which prompts me to engage in my maladaptive nonessential food intake behavior to curtail my stress and boredom, served as negative reinforcement. As noted above, my target behavior (TB) occurred as an intermittently ratio, which mainly explains long-term behavior maintenance (Speigler, 2016).

 

The measurement began when I landed and underwent quarantine in Shanghai. Due to the restrictive local policy and grim setting and events, I was not allowed to leave my quarantine camp. Because I was exposed to a small, dim, and lonely environment, I was more likely to experience stress and boredom, and because I was allowed to order food delivery through my phone, the daily frequency of my nonessential food intake was reached 10 times a day averagely at baseline level, which directly caused me to gain unwanted weight. Therefore, my phone prompted me to consume food indirectly by continuously ordering food delivery.

 

Various behavior treatments can be used to treat repetitive maladaptive behaviors. My maladaptive target behavior (i.e., deceleration behavior), non-essential food intake, occurs too often each day and needs to be decelerated. Therefore, treatments can be generalized in two ways: direct deceleration by punishing my misbehavior (i.e., aversion therapy) or indirect deceleration by reinforcing an alternative, healthy behavior that can serve the same function. More specifically, decelerating a target behavior by directly changing the maintaining condition would cause an incomplete solution. The problem behavior is stressful, distressing, and annoying but it serves some function and fills time in a person’s life, so the individual would feel a void if the maladaptive behavior were reduced or eliminated directly. In addition, the use of a punitive method to decelerate the individual’s behavior would also create problematic results. Introducing aversion stimuli or associating the target behavior with an unpleasant condition would cause the individual to experience anxiety, stress, or even hostility during the treatment (Domínguez, Vega, & Parga, 2020). In contrast, modifying a maladaptive behavior by substituting an accelerating behavior would elicit a competing response that serves the same function and fill the temporary void with appropriate behavior, so the individual would not have the chance to perform the decelerating behavior (Speigler, 2016).

 

In Australia, Dawson et al. (2021) conducted a study about text message interventions for dietary behaviors for people receiving maintenance hemodialysis. They collected a sample of 130 patients, 48% eligible to participate in the six-month study. With a retention rate of 88% and a 2% withdrawal rate, they found that the group receiving a one-way text message reminder intervention about receiving hemodialysis experienced significant improvements in dietary intake compared with those who did not experience the intervention. The study showed that more intervention participants (93%) adhere to four or more of eight dietary guidelines than usual care participants (73%). According to the report, this efficacy calculation was undermined, meaning that using text messages as prompts to adhere to dietary guidance is far more effective than expected. In other words, the text intervention to alter patients’ food intake behavior was feasible and acceptable. The motivation generated by the text intervention encouraged the participants to complete the daily task. This study illustrated that poor adherence to dietary guidelines could be altered via prompt alternation. Hence, I could use a similar treatment to decelerate my nonessential food intake by increasing my awareness of the altered prompt that elicits my accelerating behavior: accelerating water intake.

Method

Accelerating water intake via a prompt to substitute decelerating my excess nonessential food intake would serve similar functions as I engage my problem behavior. Feeling fullness, relieving boredom, and reducing stress by consuming food are the maintenance conditions for my maladaptive behavior of nonessential food intake, so accelerating water consumption could be served as a substitute for my maladaptive nonessential food intake because it serves similar functions and maintains similar conditions: feeling fullness, relieving boredom, and reducing stress by consuming a substitute subject. Therefore, the prompt could be introduced to elicit my accelerating water consumption behavior.

 

I designed the procedure using an ABAB reversal study, systematically introducing and withdrawing the treatment to evaluate its efficacy in causing the behavior change. The study was divided into four phases: baseline, treatment, reversal, and reinstatement of treatment.

 

In the first phase, I obtained the baseline of my target behavior by measuring my TB’s daily frequency (i.e., the number of times I consumed nonessential food each day) over seven days. I measured my target behavior in terms of the natural level of the behavior performance as it occurred so I could understand the efficacy of my treatment in the treatment state compared to the target behavior at baseline. The measurement was a self-record. I took advantage of my camera to video record my daily nonessential food consumption behavior (try to minimize my reactivity to my measurement) and measure the frequency of my unnecessary food consumption by checking the recorded video daily at 11:00 p.m. and recording the data (TB frequency) in an Excel file.

 

In the second phase (i.e., the treatment phase), I introduced the treatment for my TB as I continuously measured my daily TB frequency over seven days. I introduced an environmental prompt in the form of a reminder on my food basket and table to measure the efficacy of my treatment. I used a prompt similar to Dawson et al. (2021) in their studies. Specifically, I used an environmental prompt, a reminder tag with the words “GO DRINK WATER” attached to my snack basket, wall, and table, to accelerate my drinking behavior. Theoretically, I would alter my nonessential eating behavior to consuming water as I reached for a snack and saw the reminder on my snack basket. Consequently, I would feel complete, less bored, and less stressed and experience a sense of “mission completed” after water consumption. This serves as positive reinforcement that could maintain my water consumption behavior in the future.

 

The third phase is the reversal phase, which withdraws the treatment to evaluate whether any confounding variables might influence the change in the target behavior. For another seven days, I continued the assessment without my prompt treatment to analyze whether my therapy introduction was responsible for my behavior change. If the frequency of my unnecessary food consumption returned to the baseline level, my introduction of the environmental prompt would extensively explain the change in nonessential consumption.

 

Finally, the treatment was reintroduced to evaluate whether I would benefit continuously from treatment via prompt. For the last seven days, I arranged the same environmental prompts on my studying table and snack basket. I kept measuring the daily frequency of nonessential food intake behavior to reinforce my treatment’s effectiveness so I could still benefit from my treatment to decelerate my nonessential food intake behavior. Therefore, if my environmental prompt elicited the competing response results, my target behavior would be reduced again. I could more confidently conclude that the treatment is effective on my target behavior.

The third phase is the reversal phase, which withdraws the treatment to evaluate whether any confounding variables might influence the change in the target behavior. For another seven days, I continued the assessment without my prompt treatment to analyze whether my therapy introduction was responsible for my behavior change. If the frequency of my unnecessary food consumption returned to the baseline level, my introduction of the environmental prompt would extensively explain the change in nonessential consumption.

 

Finally, the treatment was reintroduced to evaluate whether I would benefit continuously from treatment via prompt. For the last seven days, I arranged the same environmental prompts on my studying table and snack basket. I kept measuring the daily frequency of nonessential food intake behavior to reinforce my treatment’s effectiveness so I could still benefit from my treatment to decelerate my nonessential food intake behavior. Therefore, if my environmental prompt elicited the competing response results, my target behavior would be reduced again. I could more confidently conclude that the treatment is effective on my target behavior.

RESULTS

Based on my measurement of my TB (nonessential food intake), Figure 1 indicates the daily frequency of nonessential food consumption across the study’s four phases: baseline, treatment, reversal, and reinstatement. The measurement was based on the frequency of nonessential food intake illustrated by the y-axis. The x-axis represents the seven-day assessment periods I counted as phases (sessions). The baseline indicates that the frequency of daily unnecessary food consumption was at the standard level associated with the average frequency of 7.14 times a day. With the introduction of the treatment, the frequency of daily nonessential food intake was reduced to an average of 1.14 times a day, which yielded the lowest means for frequency of my non-essential food intake engagement.

 

During the reversal phase, my daily nonessential food intake returned to normal levels, with an average daily frequency of 8 times per day over the seven-day assessment period. During the reinstatement phase, the average daily frequency of my target behavior decreased to 1.29 times a day, proving my treatment's additional effectiveness. In conclusion, my treatment for my decelerating nonessential food intake via prompt is effective for me and makes a clinically significant difference in these four-phase treatment periods.

DISCUSSION

The treatment effectively reduced the frequency of my daily nonessential food intake via prompts to engage in substitution behavior by water consumption. The average daily frequency of nonessential food intake was low during the study’s treatment and reinstatement phases and high during the baseline and reverse phases. However, I did not perform a statistical analysis due to the limitation of the reverse study for the lack of enough samples, so I could not conclude whether my treatment caused my behavior change in a statistically significant manner.

 

Even though the treatment did not reduce the frequency of my problematic behavior engagement to zero during the treatment and reinstatement phases, I achieved the general goal of my behavioral therapy in that the average frequency of my problematic behavior engagement decreased significantly from 7.14 times a day to 1.14 times a day. This illustrates the clinical significance of my treatment effectiveness for my problematic behavior during the reversal study period. Because of my treatment for my decelerating nonessential food intake via a prompt to engage in accelerating water consumption behavior, my chances of drinking sodas or other non-water beverages were also reduced, which indirectly promoted my health because I drank only water. Thus, in general, a change occurred during my treatment session.

 

Without an assessment of the adaptability and social acceptability of the therapy for my target behavior by appropriately qualified people, the social validity of my treatment cannot be assessed. Due to the limitations of the quarantine policy during the COVID-19 pandemic, I was strictly confined to the quarantine camp, so the transferability of this change cannot be determined. With limited sessions of the reversal study and undetermined transferability of change, the durability of change also needs to be determined. Therefore, I need to obtain follow-up assessments and assess the adaptability or transfer of the change to determine long-term maintenance.

 

The meaningfulness of clinical change is the degree to which an individual’s life quality improves (Speigler, 2016). Mine successfully and consistently self-recorded and administrated treatment meet the criteria for adaptability. Even though the frequency of my daily nonessential food intake decreased significantly. The effectiveness and benefits of the treatment were generalizable to other aspects of my target behavior, I still need more evidence to determine the clinical significance of my treatment, such as the effectiveness of the transfer of change and the social validity of the treatment, as I mentioned above.

 

The limitations of my reversal study should be addressed. First, my reactivity to self-recorded assessments and self-administered treatment could hardly be eliminated, which caused my results to be inconclusive. In other words, I overestimated or underestimated my daily food intake frequency. Second, the causal relationship between my behavior change and the introduction of my treatment cannot be determined. Third, with limited assessment sessions, the effectiveness and durability of change for the target behavior cannot be measured accurately. In addition, the self-adherence assessment cannot be guaranteed because there might be days on which the daily frequency was not recorded (e.g., personal emergencies), which might led to inaccurate results. Finally, because this is a case study, the treatment for my target can only be generalized to some.

REFERENCE

Dawson, J., Campbell, K. L., Craig, J. C., Tong, A., Teixeira-Pinto, A., Brown, M. A., . . . Lee, V. W. (2021). A text messaging intervention for dietary behaviors for people receiving maintenance hemodialysis: A feasibility study of Kidneytext. American Journal of Kidney Diseases, VV(ii), xx–yy. https://doi.org/10.1053/j.ajkd.2020.11.015

 

Di Renzo, L., Gualtieri, P., Pivari, F., Soldati, L., Attinà, A., Cinelli, G., . . . De Lorenzo, A. (2020). Eating habits and lifestyle changes during COVID-19 lockdown: An Italian survey. Journal of Translational Medicine, 18(1), xx–yy. https://doi.org/10.1186/s12967-020-02399-5

 

Domínguez, N., Vega, J., & Parga, M. (2020). The aversive side of social interaction revisited. Behaving Badly: Aversive Behaviors in Interpersonal Relationships., 32. https://doi.org/http://www.psicothema.com/pdf/4591.pdf

 

Spiegler, M. D., & Guevremont, D. (2020). Contemporary behavior therapy. Wadsworth.

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