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Supporting Healthy Decision Making

Buckworth, Janet, Ph.D., FACSM

doi: 10.1249/FIT.0000000000000400
Columns: Enhancing Your Behavioral Toolkit

Janet Buckworth, Ph.D., FACSM,has spent more than 25 years studying exercise adherence and theory-based behavior change interventions. She has master’s degrees in Clinical Social Work and Health Education and a Ph.D. in Exercise Psychology, with work experiences in medical and college settings. Dr. Buckworth is a fellow of the American College of Sports Medicine, serving on the Behavioral Strategies Special Interest Group. Dr. Buckworth is department head in Kinesiology at the University of Georgia.

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The fitness professional can play an important role in helping clients make effective decisions to enhance healthy behaviors or to manage health challenges. The need to make a decision is sparked by a challenge (injury or disease) or an opportunity (company introduces new wellness programs). An initial step in decision making is appraising the challenge or opportunity that provoked the need to make a decision. Are there more than two options? Is this a decision that has to be made now? What are the consequences of inaction? If a health care provider tells someone he has some risk factors for type 2 diabetes, the client can consider if this is a serious enough problem to require immediate action. For clinical populations, motivation to address the risk of a medical concern such as diabetes can be framed through how much of a threat the health condition poses. The Health Belief Model explains and predicts the likelihood of taking action based on perceived threat, that is, the perceived seriousness of the condition that would result from inaction and the perception of susceptibility to the condition. Diabetes might be seen as something very serious, but if the client does not believe he is likely to develop this disease, he is more inclined not to take any action or to make only minor changes to diet and physical activity because the perceived threat is low. The fitness professional can help the client identify options and weigh the different aspects of the alternatives, including not taking action, and in terms of benefits to self and others, costs to self and others, and approval and disapproval from self and others. Although the perception of threat for being diagnosed with diabetes is low, not taking action may provoke concern from family that shifts the balance to favor a more significant change in physical activity or diet.

In general, we are more likely to take action if we believe that overall, the benefits of the behavior outweigh the costs. Evaluating the pros and cons of an option is an essential element of decisional making and an integral part of the Transtheoretical or Stages of Change Model. People in the earlier stages of change have not taken action in part because they perceive more disadvantages than advantages. Their evaluation of the pros and cons of a health-related behavior reflects more extrinsic motivation because of the role situational reinforcements play in making a choice to act or not. For example, the balance can be shifted to act if a health care provider encourages a client to start an exercise program after reviewing results of an annual physical.

People who are contemplating beginning an exercise program or making other lifestyle changes can benefit from help in decision making. They have considerable ambivalence about change, although they intend to take action at some point. The goal for the fitness professional is to help the client explore the consequences of adopting healthy behaviors, with an emphasis on increasing the perception of benefits and decreasing the costs or negatives, shifting the decisional balance to more pros than cons. Once a client has made the decision to change, evidence supports the benefits of this method to strengthen commitment to change for exercise and weight loss. Helping a client thoroughly explore the pros and cons of the alternatives available also can reduce doubts and regret about the choice they end up making. People in the preparation or action stages who have already made a decision and have taken some steps, such as stocking up on fruits and vegetables or signing up for an exercise class, also are helped by emphasizing the pros of changing, enabling them to justify and strengthen their decision. Helping the client to compile a substantial and meaningful array of benefits of healthy behaviors can strengthen motivation to adhere as the behavior becomes more established and motivation becomes more intrinsic (1).

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Sidebar: Ways to Facilitate Decision Making

  • Stimulate thorough search for information
  • ○ Internal (attitudes, beliefs, expectations, values)
  • ○ External (attitudes, resources, expectations)
  • Foster appraisal of pros and cons
  • Prepare for negative feedback
  • ○ Identify barriers (personal and environmental)
  • ○ High-risk situations

To help a client with decision making, the first step is to get more information about what has sparked the need for a decision. What is the challenge or opportunity that puts him or her on a path that splits two or more ways? For example, Mary brought out her spring clothes and discovered that her favorite shorts are too tight. She is challenged to make a decision about how to respond. Does she throw them out and buy new shorts in a larger size? Or does she take action to address her weight gain? Ideas from Behavioral Choice Theory provide insight into how people decide about available behavioral options, which can help the fitness professional select strategies to foster sound decisions (3). Clients will consider different options based on the amount of effort, perception of choice, and immediacy of rewards and then evaluate options based on costs and benefits. Consideration of the amount of effort necessary for an option influences a behavioral choice. Mary knows that getting bigger shorts won’t take as much effort as losing the extra weight. However, when she evaluates the costs and benefits of these two options, she sees that the long-term costs of taking the easy way out are greater than the short-term benefits. The fitness professional can guide Mary through what it will take to learn to cook healthier meals and/or attend regular exercise classes. Identifying all the steps to realize a behavioral option will enable her to decide if the necessary resources are in place; and if not, what needs to be done to successfully commit to a healthier diet and exercise. Mary might not have realized that she needs a nonstick frying pan to make some of the new dishes or that preparing a vegetable dish would take more time. She needed to know that she had to take the time to pack a workout bag to be able to go to the fitness center straight from work.

The value in having a choice is a common thread through many theories of behavior change, and comes into play here in how people decide among options. A sense of choice fosters a sense of autonomy and enhances intrinsic motivation, according to the Self-Determination Theory (1). If a client is trying to decide about joining a fitness center, providing a range of possible membership plans and exercise classes can strengthen his or her sense of agency and control over his or her fitness program.

The factor from Behavioral Choice Theory about the immediacy of the rewards, that is, the time delay between making the choice and experiencing the consequences of a decision, is important for fitness professionals to understand. We know from Behavior Modification Theory that more immediate consequences have a greater impact on repeating a behavior than anticipated long-term outcomes. Although someone knows that choosing to have fruit instead of cake for dessert can help with weight management, the immediate gratification of eating a piece of cake can be a stronger situational reinforcement. It is the fitness professional’s challenge to highlight the long-term benefits of healthy choices and strengthen awareness of immediate positive consequences.

Once a decision has been made, the fitness professional can have a role in supporting a client acting on the decision. Going through the process should have led to realistic expectations of what is involved in taking action, but the client can be armed with plans for managing barriers to following through. If John has decided to become a vegetarian to reduce his risk of cardiovascular disease, helping him to identify personal and environmental barriers will prepare him for obstacles to sticking with his decision. Identifying vegetarian meals at his favorite restaurants, recipes for nutrient-dense and appealing vegetarian meals, and reminders of the benefits of a meatless diet can help with logistical challenges as he settles into this lifestyle change. It also is important to be aware that some family members and friends might not agree with his decision, and could try to persuade him to return to a typical American diet. If John knows that his decision could be challenged, he can plan ahead for positive responses. Strategies from relapse prevention also would be useful for John to identify and manage high-risk situations for not sticking with his dietary resolution (2).

Helping new clients with decision making will give them the skills to manage challenges to maintenance of their healthy choices. They will be able to identify and evaluate their options and make the best decisions to foster long-term adherence. Fostering a healthy decisional balance is necessary, but not enough for long-term adherence. Other strategies that have been explored in the Toolkit columns, such as goal setting and motivation enhancement, complement skills in making decisions.

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1. Buckworth J. Building motivation from basic needs: choose, accomplish, connect. ACSMs Health Fit J. 2017;21(2):29–30.
2. Buckworth J. Identifying and managing relapse risk. ACSMs Health Fit J. 2018;22(2):34–5.
3. Sbrocco T, Nedegaard RC, Stone JM, Lewis EL. Behavioral choice treatment promotes continuing weight loss: preliminary results of a cognitive-behavioral decision-based treatment for obesity. J Consult Clin Psychol. 1999;67(2):260–6.
© 2018 American College of Sports Medicine.