Prescribing Pleasure and Meaning

IntroductionRegular physical activity such as daily walking has numerous health benefits.1USDHHSPhysical activity and health: a report of the Surgeon General. CDC, National Center for Chronic Disease Prevention and Health Promotion, Atlanta GA1996Google Scholar Walking is a simple type of physical activity that can be done almost anywhere and is the most commonly reported form of physical activity among adults. CDC data show that people who walk are three times more likely to meet the physical activity guidelines than those who do not.2CDCVital signs: walking among adults—U.S., 2005 and 2010.MMWR Morb Mortal Wkly Rep. 2012; 61: 595-601PubMed Google Scholar, 3Physical Activity Guidelines Advisory CommitteePhysical Activity Guidelines Advisory Committee report, 2008. USDHHS, Washington DC2008Google Scholar Encouraging inactive individuals to integrate walking into their daily routine has the potential to yield significant public health benefits.To promote walking among Americans and achieve these benefits, new population-wide initiatives are being launched, including an upcoming Surgeon General’s Walking Call to Action (planned release Fall 2014) and the EveryBody Walk! initiative. How health professionals and organizations communicate about walking brands it to the public4Segar M.L. Eccles J.S. Richardson C.R. Rebranding exercise: closing the gap between values and behavior.Int J Behav Nutr Phys Act. 2011; 8: 94Crossref PubMed Scopus (68) Google Scholar and will influence the ultimate success of this new walking movement.Messages to promote walking that deliver accurate health information but ignore evidence-based principles of motivation and decision making, the underlying mechanisms of behavioral sustainability, will inadvertently undermine these population-level initiatives. To optimize the behavioral impact of these national initiatives, the messaging to promote walking delivered in communities and health clinics should be informed by relevant affective and behavioral science.It is important to shift from a medical to a marketing paradigm to move beyond simply delivering health education to actually motivating consistent walking behavior. Although counterintuitive, the benefits of walking typically emphasized by clinicians and social marketing, such as “better health” and “disease prevention,” are not the same ones that will optimally motivate inactive individuals. This Current Issue reviews key evidence-based concepts to reframe the motivation for walking and inform more strategic walking messages to deliver in apps, interventions, clinical visits, and population-level health initiatives.Adherence Through AutonomySelf-determination theory (SDT) addresses how to foster optimal types of motivation and investigates how “controlled” and “autonomous” types of motivation distinctly influence behavioral adherence.5Ryan R.M. Deci E.L. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being.Am Psychol. 2000; 55: 68-78Crossref PubMed Scopus (19885) Google Scholar Controlled motivations reflect when people consider walking as a “should”—something they need to do to avoid a punishment (e.g., higher healthcare premiums) or comply with an external pressure (e.g., following a clinician prescription to lose weight). By contrast, when people have autonomous motivations, they deeply value the benefits they get from walking or the inherent pleasure and satisfaction that walking brings.Having autonomous motivation for physical activity results in better behavioral pursuit, self-regulation, and sustainability. A systematic review6Teixeira P.J. Carraca E.V. Markland D. Silva M.N. Ryan R.M. Exercise, physical activity, and self-determination theory: a systematic review.Int J Behav Nutr Phys Act. 2012; 9: 78Crossref PubMed Scopus (1364) Google Scholar of SDT and physical activity found consistent support for a positive relationship between more autonomous forms of motivation and physical activity. It also reported that controlled forms of motivation were positively, negatively, or had no association with participation. Although having a controlled form of motivation can motivate people to start exercising, in general, it has less consistent and often negative relationships with ongoing participation compared to autonomous motivation.In other words, when people’s core needs and goals drive their decision to walk, they have higher-quality motivation and are more likely to maintain it compared to walking to comply with external mandates or “shoulds.” Furthermore, this review suggested that “intrinsic” motivation, or being active for the inherent pleasure it brings, was the type of motivation most strongly associated with sustainability. Thus, walking messages promoting autonomy and intrinsic experiences such as pleasure will better motivate regular walking.Affect Influences DecisionsOther research relevant to designing walking communications relates to how physical activity influences people’s affect (e.g., feelings). Positive affect refers to pleasant feelings whereas negative affect refers to unpleasant ones. The affective response from walking is important to consider because affect drives people’s daily decisions,7Chang H.H. Pham M.T. Affect as a decision-making system of the present.J Consum Res. 2013; 40: 42-63Crossref Scopus (91) Google Scholar and regular walking is determined by whether people consistently decide to walk.Furthermore, people’s behavioral choices are motivated by their feelings about the outcomes from their decisions in the present.7Chang H.H. Pham M.T. Affect as a decision-making system of the present.J Consum Res. 2013; 40: 42-63Crossref Scopus (91) Google Scholar People approach what feels good and avoid what feels bad.8Petruzzello S.J. Doing what feels good (and avoiding what feels bad)–a growing recognition of the influence of affect on exercise behavior: a comment on Williams et al.Ann Behav Med. 2012; 44: 7-9Crossref PubMed Scopus (9) Google Scholar At the point of decision, how people feel about walking compared to the alternative options will influence whether they decide to walk out the door or stay on the couch. Thus, whether people have positive or negative feelings about the process of walking has important implications for sustainability.Affect Is Influenced by Exercise IntensityInfluential researchers have been studying the impact of differing exercise intensities on individuals’ ratings of affect for over two decades.9Ekkekakis P. Redrawing the model of the exercising human in exercise prescriptions. From headless manikin to a creature with feelings.in: Rippe J.M. Lifestyle medicine. 2nd ed. Wiley Blackwell, Hoboken NJ2013Crossref Google Scholar A review10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar of studies on the relationship between exercise intensity and affect concluded that, in general, there is an inverse relationship between exercise intensity and affective responses while exercising that follows a dose–response pattern. In other words, the harder someone exercises the more their pleasure decreases.Furthermore, when people exercise at intensities that exceed the “ventilatory threshold” (i.e., the point at which it is hard to hold a conversation during exercise), not only is their pleasure significantly reduced but displeasure increases as well. Interestingly, this review also found that when people decide on their own to exercise at high intensities they tolerate it better and experience less displeasure compared to when higher intensity exercise is imposed on them.Thus, although sub-ventilatory threshold exercise (e.g., walking below the point of heavy breathing) tends to result in greater pleasure and lower displeasure, when someone autonomously chooses to exercise at higher intensities their affective response is not undermined.10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar This finding aligns with the SDT literature. When a practitioner or message recommends that individuals “walk in ways that feel good” it gives people permission to self-determine how they want to walk. Therefore, framing walking as a strategy to enhance well-being and pleasure explicitly encourages people to autonomously determine how they want to walk (e.g., intensity).Traditionally, physical activity recommendations have been one-size-fits-all prescriptions based on a “dose–response” concept from research linking physical activity dose to health biomarkers and illness prevalence. As Ekkekakis et al.10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar discuss, there is growing awareness among leading organizations such as the American College of Sports Medicine of the influence of intensity on affect and adherence. Furthermore, although walking to fulfill the current intensity Activity Guidelines Advisory CommitteePhysical Activity Guidelines Advisory Committee report, 2008. USDHHS, Washington DC2008Google Scholar is likely to be pleasant for it in research and other key P. Redrawing the model of the exercising human in exercise prescriptions. From headless manikin to a creature with feelings.in: Rippe J.M. Lifestyle medicine. 2nd ed. Wiley Blackwell, Hoboken NJ2013Crossref Google Scholar that physical activity in based to optimize health outcomes inadvertently autonomy and positive affect and negative a for to avoid than approach Affect and into promoting walking for pleasure and other positive feelings should enhance adherence. The of is in two different and of and 9: PubMed Scopus Google Scholar a or that approach behavior. to a this that that there is a positive association between a (e.g., and a such as pleasure (i.e., should a to walk, and consistently motivate walking physical activity to participation having and was in the and Richardson C.R. into of a physical activity Health PubMed Scopus Google Scholar their about physical activity from an to a that good to At the on a in participation compared to research messages positive affective benefits (e.g., messages (e.g., in physical activity. whether affective or messages about the benefits of physical activity more participation among exercise affective or 2011; PubMed Scopus Google Scholar This found that messages affective benefits consistently in higher participation than the ones among compared the of and affective benefits from exercising at with participation at P. and for physical activity in 2012; PubMed Scopus Google Scholar benefits not participation but benefits that health as the for walking is a optimal that most people value being people’s for walking is to their health they not experience that their individuals from behavioral when they do not that they are the of Scholar for will not be as motivating as pleasure (i.e., G. to health PubMed Scopus Google Scholar Furthermore, walking and with other daily Thus, to achieve people consider walking to be to other daily ed. Health in the ed. American of Health Promotion, and professionals be that promoting walking for pleasure will people to walk to achieve health when people are to their walking based on positive feelings they intensities that approach the Parfitt G. the be to exercise Sports 40: PubMed Scopus Google Scholar Thus, research that walking for pleasure can to in and the concept of in a with the of can have negative to because they associated it with a of and an for outcomes experiences actually be health promoting because they are associated with and and Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar also have a Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar and people to their most goals walking for pleasure as a strategy to daily and it from a into an autonomous of what This new for walking gives people permission to out for and Richardson C.R. into of a physical activity Health PubMed Scopus Google Scholar it also walking into a M.L. Eccles J.S. Richardson C.R. Rebranding exercise: closing the gap between values and behavior.Int J Behav Nutr Phys Act. 2011; 8: 94Crossref PubMed Scopus (68) Google Scholar In this strategy is and people their their other ed. Health in the ed. American of Health Promotion, that and distinctly to walking as a to and goals walking into a and Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar This is important for because autonomous goals that reflect people’s most of behavioral pursuit, P. D. From motivation to the of in the 2012; PubMed Scopus Google prescription over the benefits as the for physical has not most people to active A prescription to exercise to optimize of how it people good medicine. the is not motivated to and public health benefits will be this new of health decisions and motivation are to outcomes and are at of because of numerous and alternative choices that are a of their daily is in of the for promoting physical activity with new messaging based on relevant to to promote walking as a to experience pleasure and is and also follows recommendations from a systematic A systematic review of three for physical activity what messages and what are J Behav Nutr Phys Act. PubMed Scopus Google Scholar that physical activity messages be and to the this into and will and because it a about to be messaging should the and for such as and this new strategy walking as that feels good but also what in autonomous By people to the positive of walking and how these their in their most health professionals can walking more relevant and and better the consistent decision making, motivation, and that behavioral and better IntroductionRegular physical activity such as daily walking has numerous health benefits.1USDHHSPhysical activity and health: a report of the Surgeon General. CDC, National Center for Chronic Disease Prevention and Health Promotion, Atlanta GA1996Google Scholar Walking is a simple type of physical activity that can be done almost anywhere and is the most commonly reported form of physical activity among adults. CDC data show that people who walk are three times more likely to meet the physical activity guidelines than those who do not.2CDCVital signs: walking among adults—U.S., 2005 and 2010.MMWR Morb Mortal Wkly Rep. 2012; 61: 595-601PubMed Google Scholar, 3Physical Activity Guidelines Advisory CommitteePhysical Activity Guidelines Advisory Committee report, 2008. USDHHS, Washington DC2008Google Scholar Encouraging inactive individuals to integrate walking into their daily routine has the potential to yield significant public health benefits.To promote walking among Americans and achieve these benefits, new population-wide initiatives are being launched, including an upcoming Surgeon General’s Walking Call to Action (planned release Fall 2014) and the EveryBody Walk! initiative. How health professionals and organizations communicate about walking brands it to the public4Segar M.L. Eccles J.S. Richardson C.R. Rebranding exercise: closing the gap between values and behavior.Int J Behav Nutr Phys Act. 2011; 8: 94Crossref PubMed Scopus (68) Google Scholar and will influence the ultimate success of this new walking movement.Messages to promote walking that deliver accurate health information but ignore evidence-based principles of motivation and decision making, the underlying mechanisms of behavioral sustainability, will inadvertently undermine these population-level initiatives. To optimize the behavioral impact of these national initiatives, the messaging to promote walking delivered in communities and health clinics should be informed by relevant affective and behavioral science.It is important to shift from a medical to a marketing paradigm to move beyond simply delivering health education to actually motivating consistent walking behavior. Although counterintuitive, the benefits of walking typically emphasized by clinicians and social marketing, such as “better health” and “disease prevention,” are not the same ones that will optimally motivate inactive individuals. This Current Issue reviews key evidence-based concepts to reframe the motivation for walking and inform more strategic walking messages to deliver in apps, interventions, clinical visits, and population-level health initiatives.Adherence Through AutonomySelf-determination theory (SDT) addresses how to foster optimal types of motivation and investigates how “controlled” and “autonomous” types of motivation distinctly influence behavioral adherence.5Ryan R.M. Deci E.L. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being.Am Psychol. 2000; 55: 68-78Crossref PubMed Scopus (19885) Google Scholar Controlled motivations reflect when people consider walking as a “should”—something they need to do to avoid a punishment (e.g., higher healthcare premiums) or comply with an external pressure (e.g., following a clinician prescription to lose weight). By contrast, when people have autonomous motivations, they deeply value the benefits they get from walking or the inherent pleasure and satisfaction that walking brings.Having autonomous motivation for physical activity results in better behavioral pursuit, self-regulation, and sustainability. A systematic review6Teixeira P.J. Carraca E.V. Markland D. Silva M.N. Ryan R.M. Exercise, physical activity, and self-determination theory: a systematic review.Int J Behav Nutr Phys Act. 2012; 9: 78Crossref PubMed Scopus (1364) Google Scholar of SDT and physical activity found consistent support for a positive relationship between more autonomous forms of motivation and physical activity. It also reported that controlled forms of motivation were positively, negatively, or had no association with participation. Although having a controlled form of motivation can motivate people to start exercising, in general, it has less consistent and often negative relationships with ongoing participation compared to autonomous motivation.In other words, when people’s core needs and goals drive their decision to walk, they have higher-quality motivation and are more likely to maintain it compared to walking to comply with external mandates or “shoulds.” Furthermore, this review suggested that “intrinsic” motivation, or being active for the inherent pleasure it brings, was the type of motivation most strongly associated with sustainability. Thus, walking messages promoting autonomy and intrinsic experiences such as pleasure will better motivate regular walking.Affect Influences DecisionsOther research relevant to designing walking communications relates to how physical activity influences people’s affect (e.g., feelings). Positive affect refers to pleasant feelings whereas negative affect refers to unpleasant ones. The affective response from walking is important to consider because affect drives people’s daily decisions,7Chang H.H. Pham M.T. Affect as a decision-making system of the present.J Consum Res. 2013; 40: 42-63Crossref Scopus (91) Google Scholar and regular walking is determined by whether people consistently decide to walk.Furthermore, people’s behavioral choices are motivated by their feelings about the outcomes from their decisions in the present.7Chang H.H. Pham M.T. Affect as a decision-making system of the present.J Consum Res. 2013; 40: 42-63Crossref Scopus (91) Google Scholar People approach what feels good and avoid what feels bad.8Petruzzello S.J. Doing what feels good (and avoiding what feels bad)–a growing recognition of the influence of affect on exercise behavior: a comment on Williams et al.Ann Behav Med. 2012; 44: 7-9Crossref PubMed Scopus (9) Google Scholar At the point of decision, how people feel about walking compared to the alternative options will influence whether they decide to walk out the door or stay on the couch. Thus, whether people have positive or negative feelings about the process of walking has important implications for sustainability.Affect Is Influenced by Exercise IntensityInfluential researchers have been studying the impact of differing exercise intensities on individuals’ ratings of affect for over two decades.9Ekkekakis P. Redrawing the model of the exercising human in exercise prescriptions. From headless manikin to a creature with feelings.in: Rippe J.M. Lifestyle medicine. 2nd ed. Wiley Blackwell, Hoboken NJ2013Crossref Google Scholar A review10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar of studies on the relationship between exercise intensity and affect concluded that, in general, there is an inverse relationship between exercise intensity and affective responses while exercising that follows a dose–response pattern. In other words, the harder someone exercises the more their pleasure decreases.Furthermore, when people exercise at intensities that exceed the “ventilatory threshold” (i.e., the point at which it is hard to hold a conversation during exercise), not only is their pleasure significantly reduced but displeasure increases as well. Interestingly, this review also found that when people decide on their own to exercise at high intensities they tolerate it better and experience less displeasure compared to when higher intensity exercise is imposed on them.Thus, although sub-ventilatory threshold exercise (e.g., walking below the point of heavy breathing) tends to result in greater pleasure and lower displeasure, when someone autonomously chooses to exercise at higher intensities their affective response is not undermined.10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar This finding aligns with the SDT literature. When a practitioner or message recommends that individuals “walk in ways that feel good” it gives people permission to self-determine how they want to walk. Therefore, framing walking as a strategy to enhance well-being and pleasure explicitly encourages people to autonomously determine how they want to walk (e.g., intensity).Traditionally, physical activity recommendations have been one-size-fits-all prescriptions based on a “dose–response” concept from research linking physical activity dose to health biomarkers and illness prevalence. As Ekkekakis et al.10Ekkekakis P. Parfitt G. Petruzzello S.J. The pleasure and displeasure people feel when they exercise at different intensities: decennial update and progress towards a tripartite rationale for exercise intensity prescription.Sports Med. 2011; 41: 641-671Crossref PubMed Scopus (682) Google Scholar discuss, there is growing awareness among leading organizations such as the American College of Sports Medicine of the influence of intensity on affect and adherence. Furthermore, although walking to fulfill the current intensity Activity Guidelines Advisory CommitteePhysical Activity Guidelines Advisory Committee report, 2008. USDHHS, Washington DC2008Google Scholar is likely to be pleasant for it in research and other key P. Redrawing the model of the exercising human in exercise prescriptions. From headless manikin to a creature with feelings.in: Rippe J.M. Lifestyle medicine. 2nd ed. Wiley Blackwell, Hoboken NJ2013Crossref Google Scholar that physical activity in based to optimize health outcomes inadvertently autonomy and positive affect and negative a for to avoid than approach Affect and into promoting walking for pleasure and other positive feelings should enhance adherence. The of is in two different and of and 9: PubMed Scopus Google Scholar a or that approach behavior. to a this that that there is a positive association between a (e.g., and a such as pleasure (i.e., should a to walk, and consistently motivate walking physical activity to participation having and was in the and Richardson C.R. into of a physical activity Health PubMed Scopus Google Scholar their about physical activity from an to a that good to At the on a in participation compared to research messages positive affective benefits (e.g., messages (e.g., in physical activity. whether affective or messages about the benefits of physical activity more participation among exercise affective or 2011; PubMed Scopus Google Scholar This found that messages affective benefits consistently in higher participation than the ones among compared the of and affective benefits from exercising at with participation at P. and for physical activity in 2012; PubMed Scopus Google Scholar benefits not participation but benefits that health as the for walking is a optimal that most people value being people’s for walking is to their health they not experience that their individuals from behavioral when they do not that they are the of Scholar for will not be as motivating as pleasure (i.e., G. to health PubMed Scopus Google Scholar Furthermore, walking and with other daily Thus, to achieve people consider walking to be to other daily ed. Health in the ed. American of Health Promotion, and professionals be that promoting walking for pleasure will people to walk to achieve health when people are to their walking based on positive feelings they intensities that approach the Parfitt G. the be to exercise Sports 40: PubMed Scopus Google Scholar Thus, research that walking for pleasure can to in and the concept of in a with the of can have negative to because they associated it with a of and an for outcomes experiences actually be health promoting because they are associated with and and Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar also have a Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar and people to their most goals walking for pleasure as a strategy to daily and it from a into an autonomous of what This new for walking gives people permission to out for and Richardson C.R. into of a physical activity Health PubMed Scopus Google Scholar it also walking into a M.L. Eccles J.S. Richardson C.R. Rebranding exercise: closing the gap between values and behavior.Int J Behav Nutr Phys Act. 2011; 8: 94Crossref PubMed Scopus (68) Google Scholar In this strategy is and people their their other ed. Health in the ed. American of Health Promotion, that and distinctly to walking as a to and goals walking into a and Richardson of the well-being benefits of and Psychol. 2013; 8: Scopus Google Scholar This is important for because autonomous goals that reflect people’s most of behavioral pursuit, P. D. From motivation to the of in the 2012; PubMed Scopus Google prescription over the benefits as the for physical has not most people to active A prescription to exercise to optimize of how it people good medicine. the is not motivated to and public health benefits will be this new of health decisions and motivation are to outcomes and are at of because of numerous and alternative choices that are a of their daily is in of the for promoting physical activity with new messaging based on relevant to to promote walking as a to experience pleasure and is and also follows recommendations from a systematic A systematic review of three for physical activity what messages and what are J Behav Nutr Phys Act. PubMed Scopus Google Scholar that physical activity messages be and to the this into and will and because it a about to be messaging should the and for such as and this new strategy walking as that feels good but also what in autonomous By people to the positive of walking and how these their in their most health professionals can walking more relevant and and better the consistent decision making, motivation, and that behavioral and better