Exercise Program Adherence - A Review of The Literature

Exercise Program Adherence 1
Exercise Program Adherence: A Review of the Literature

Amanda J. Sheldon
ESS589 DIR READ IN ESS (3 Credits)
Department of Exercise & Sport Sciences
University of Miami
Fall Semester, 2004
Exercise Program Adherence: A Review of the Literature
Introduction: Why is exercise program adherence important?
Americans spend nearly $15 billion dollars on fitness &
recreational sports centers each year (Economic Census, 2002).
Local, state and federal governments spend additional taxpayer
dollars on exercise promotion and programming. Yet, the six
month attrition rate for exercise program adherence hovers
around fifty percent (USDHHS, 1999). Meanwhile, forty percent of
Americans will never even attempt to become physically active
(NCHS, 1995; USDHHS, 1996). According to the U.S. Department of
Health and Human Services [USDHHS], only 26 percent of U.S.
adults engage in vigorous leisure-time physical activity three
or more times per week, [and] about 59 percent of adults do no
vigorous physical activity at all in their leisure time
(USDHHS, 2007). Other sources report numbers as low as only 10-
15% of adults as participating in regular vigorous exercise
(Weingberg and Gould, 2007). Meanwhile, approximately 65% of
Americans are obese or overweight, (Higgins, 2004) largely due
to this lack of regular exercise. Additionally, the direct cost
of physical inactivity may be as high as $24.3 billion (USDHHS,
2007).
The devastating consequences of overweight and obesity are
widely known and indisputable, and a regular exercise regimen is
a critical component of weight loss and/or long-term weight
maintenance program (Wing & Phelan, 2005). Researchers concur
that inclusion of an exercise training program is important to
prevent a decrease in fat-free mass, promote a decrease in
visceral fat-mass, improve dietary compliance and eventually
maintain long-term weight control (Hansen et al., 2007).
Numerous adaptive responses take place with physical training.
These adaptations result in a more efficient system for oxygen
transfer to muscle, which is now able to better utilize the
unlimited lipid stores instead of the limited carbohydrate
reserves available.In addition, [any] reduced adipose tissue
mass represents an important mechanical advantage, [and allows
for] better long-term work (Poirier and Desprs 2001).
Encouragingly, even with minimal weight loss, an obese
individual who has a good level of cardio-respiratory fitness
has a lower risk for cardiovascular related mortality than a
lean individual with a poor level of cardio-respiratory fitness.
Finally, physical activity is related to long-term weight
maintenance (Wing & Hill, 2001), as physical training helps
counteract the permissive and affluent environment that
predisposes reduced-obese subjects to regain weight (Poirier
and Desprs 2001).
Exercise is equally beneficial for individuals of normal
weight as well. Physical activity can facilitate weight
maintenance through direct energy expenditure, and can also
improve physical fitness which facilitates the amount and
intensity of daily activities (Elfhag & Rossner, 2005). Beyond
weight loss and maintenance, there are numerous additional
benefits of regular physical activity. Exercise elevates
feelings of well-being through the release of endogenous
chemicals like, endorphins, epinephrine, and other hormones.
Exercise decreases aches and pains, reduces depression and
anxiety, increases energy, and contributes to improved self-
esteem. Physical activity helps fight chronic disease, while HDL
cholesterol levels increase to protect the heart. Calcium
absorption increases to help prevent osteoporosis and increased
insulin production supports efficient glucose metabolism and
offsets diabetes. Exercise improves virility. Increased systemic
circulation leads to more endurance, and increased testosterone
levels contribute to an increased libido (in both males and
females). Muscle tone will improve, and will likely lead to
looking and feeling more physically attractive. In a study by
Levy & Ebbeck (2005) higher levels of reported exercise were
associated with higher levels of physical self-perceptions for
women. Regular exercise can even save money. The health care
costs of physical inactivity are apparent; and just by opening
the front door and walking outside, unnecessary spending on a
movie ticket and popcorn is averted. Finally, Field et al.
(2001) found a positive correlation of physical activity levels
with academic performance and life satisfaction. Bottom line, a
regular exercise program adherence is just smart.
Definition: What is exercise program adherence?
For the purpose of this review it is important to define
èxercise program adherence.' The USDA recommends 60 to 90
minutes of daily moderate-intensity physical activity to sustain
weight loss in adulthood (USDA, 2006). ACSM and AHA propose two
options: 1) moderately intense cardio 30 minutes per day on 5
days per week or 2) vigorously intense cardio 20 minutes a day
on 3 days a week and 8 to 10 strength-training exercises, 8 to
12 repetitions of each exercise, twice a week (Haskell et. al.
2007). Ninety-four percent of National Weight Loss Registry
members self-defined regular exercise as an average of one hour
per day over a term of 5.5 years to preserve an average weight
loss of 66 pounds (Catenacci et. al., 2008). Psychological
frameworks, such as the Transtheoretical Model (TTM), define an
individual as entering the exercise `maintenance stage' when
changes in exercise behavior have been consistent for six months
or more. However, to reach the `termination stage' in the TTM,
one must demonstrate maintenance of said exercise behavior at
least 5 years (Fallon et al., 2005). The standardized criteria
for defining successful exercise program adherence are broad.
Abrams et al. (1998) noted that the degree to which an
individual adheres to an exercise program is also important.
The problem of defining exercise program adherence has been most
recently considered by Anshel & Siepel, (2008) who noted that
what is acceptable adherence in one study or for one exerciser
might be non-adherence in another study or for someone else.
Additionally, a call was made for future studies to include
partial adherence variations for both short- and long-term
exercise adherences, to help in understanding the factors that
contribute to different variations of exercise maintenance
(Anshel & Siepel, 2008). Furthermore, here questions are raised
on the standard for longevity of short- vs. long-term exercise
program adherence, which must now also be delineated.
Noticeably, there is a need in the scientific community for
a set of specific criteria that provides a `gold-standard' of
exercise program adherence (Rand & Weeks, 1998). The idyllic
definition may contain workings of all of the above while
simultaneously maintaining such standards continuously over a
lifetime. There is considerable research on physical activity,
exercise behavior, and short-term exercise program adherence.
The majority of research in exercise adherence and attrition is
found in combination with weight-loss and nutritional initiative
components, while protocol lengths range mostly from 8 to 12
weeks (short-term). There are fewer studies with protocols or
follow-ups ranging from six months to three years (long-term).
This review will mainly attempt to circumvent extraneous
variables and focus primarily on exercise, as can be abided save
taking data out of context. Unfortunately, because studies
containing long-term data (> 6 months) on exercise program
adherence are extremely limited, studies containing information
on short-term exercise program adherence will also be considered
in an attempt to explore opportunities for achieving long-term
exercise program adherence.
Ultimately, this review will attempt two aims: 1) offer a
universal definition of exercise program adherence including
parameters for frequency, duration, intensity, mode and
longevity of behavior, and 2) suggest the best approach to
achieving the parameter for longevity of behavior, as well as
how the parameters of frequency, duration, intensity, and mode
can be best manipulated for success.
Literature Review
A brief summary of the literature
Despite the overwhelming evidence in favor of the benefits
of regular exercise (exercise program adherence) there is
worldwide research attempting to understand why individuals are
either successful or unsuccessful in engaging in it. It is
apparent that an individual's knowing and understanding the
benefits of regular exercise, and even the genuine desire to
change one's behavior, is simply not enough to guarantee
success. Karoly (2005) summarized the problem aptly when he
wrote: The assumption of human autonomy and rational decision-
making not withstanding, a regrettable disconnect often exists
between intention and action in the exercise domain. This
`disconnect' has generated the design of a plethora of
interventions across ages, races, and genders attempting to
close this gap. Research examining the science behind health
behavior can be traced back to models of motivation originating
in the 1960's (Cofer and Appley, 1964). Throughout the mid
1980's and late 1990's psychological theories on behavior change
flourished, producing such popular models as Rosenbaum's Learned
Resourcefulness, Self-Determination Theory, Goal Setting Theory,
and Transtheoretical Model of Behavior Change. Research
exploring, comparing, and manipulating these theories for
maximum effectiveness, continues today. Unfortunately, most
reviewers of the effectiveness of exercise interventions across
diverse populations have concluded that measurable increases in
physical activity tend to be relatively rare, rather modest in
degree, and transitory (Karoly, 2005). The long-term data
supporting the success of these interventions is paltrier still.
Despite this gap in the research, several of these theories have
nearly become accepted as a standard component in the design and
implementation of exercise programs.
The variables affecting exercise program adherence are
deeply intertwined. The interactions of different factors make
addressing them separately almost impractical. However, the
following individual aspects all have a potential impact on
exercise program adherence and will be explored and discussed:
motives (plus obstacles and strategies) for beginning/
maintaining, evolution of motives with increased duration,
differences between regular and irregular exercisers
(personality), attrition, influence of demographics (age,
gender, socio-economic), and physiological parameters (mode,
frequency, intensity, duration) of exercise program adherence.
An in depth examination of the psychological parameters
influencing exercise will be made including the most commonly
researched behavioral theories and models, the evidence of their
effectiveness, the identification of ideas that warrant further
research and about where the future of exercise program
adherence is headed.
Motives/Obstacles/Strategies
Motives for participating in an exercise program are vast.
Motives may range from fear, such as an individual pledging to
change his lifestyle following a heart attack; to enjoyment,
like a child playing soccer with his friends in the park. Dreams
of scholarships, money and fame may be a motivator for a high
school student to join the football team. A housewife may go to
her weekly yoga class to relax and catch up on the latest gossip
(socialize) with her friends. Recovery from an injury, improving
physical appearance, weight loss, increasing energy, better
health, disease prevention. and the list goes on. There are
seemingly countless motivators of exercise participation, but
research has shown that there are several important differences
among them.
For example, Frederick and Ryan (1993) found that
individuals participating in a sport-related activity had
greater interest/enjoyment motives, while those participating in
a fitness-related activity had a higher body-related motive.
Later research noted that appearance and weight management were
important motivators in the early stage of an exercise program,
while enjoyment and energy renewal were the main motivators for
exercise program adherence beyond six months (Ingledew et al.,
1998). Interestingly, individuals whose exercise participation
was motivated by appearance and weight management also tended to
have a negative body image (Ingledew & Sullivan, 2002).
Initial data from (two separate and unrelated 10-week)
studies by Ryan et al., (1997) supported the use of intrinsic
motivators for long-term exercise adherence. In one study, Tae
Kwan Do participants reported higher enjoyment and competence
motives, while aerobics class participants reported higher
appearance (body) related motives (and extrinsic motivator).
Statistical analysis also revealed that higher exercise
adherence was correlated with higher enjoyment motives. In a
second study, exercise adherence in individuals who joined a
fitness club was tracked. Initial motives for beginning an
exercise program included enjoyment, competence, and social
interaction. However, adherence was not associated with motives
focusing on fitness or appearance.
Motivation is one of the major components of the premises
behind several behavioral theories including Self-Determination
Theory (SDT) and Goal-Setting Theory, as will be further
detailed later in this discussion. More recently however,
Ingledew and Markland (2008) developed the `general motivational
model of exercise participation' which postulates that
personality traits influence exercise participation motives
which in turn dictate the behavioral regulation of exerciseto
ultimately affect exercise participation. Ingledew and
Markland's research sought to differentiate between exercise
participation motivesthe what (e.g. SDT), and behavioral
regulation of exercisethe why (e.g. Goal Theory). Based on
their literature review of health related behaviors, they
further proposed a link between personality traits and
motivation levels, but were unable to find any consistent
patterns or answers to whether or not motives for participation
depended on personality traits. Surprisingly, findings
ultimately supported the effects of motives on participation
[as] being entirely mediated by behavioral regulation...and
participation motives [as] being influenced by personality
(Ingledew and Markland, 2008). A summary of these findings has
been compiled in Table 1.
Table 1. Summary of Personality Trait & Motives on Exercise Participation
(Ingledew and Markland, 2008)
Personality
Trait
Motive Regulation
Effect on
Exercise
Participation
neuroticism appearance/weight + external negative
openness health/fitness + identified negative
n/a social engagement + intrinsic neutral
conscientiousness n/a - external,
- introjected
n/a
The evidence concerning externally regulated motives for
exercise adherence is conflicted. There are definite
implications that adherence strategies should connect to an
individual's desire to improve their appearance and loose weight
in the early months of a program. However, such externally
regulated motives are not likely to sustain long-term adherence
(Ingledew & Markland, 2008). In contrast, further investigation
has shown that individuals, maintaining long-term exercise,
cited external reasons for their behavior more often than
individuals with less program longevity (Kennett et al., 2009).
The idea that beliefs about and motives for exercise adherence
evolve over time may offer a resolution to this conflict.
Previously is has been put forth that variations in the degree
to which individuals internalize the value of exercise may
determine those who adhere to exercise program over time.
[Additionally,] between initial adoption of and adherence to a
regular exercise program, an individual's motivational focus is
likely to shift from less to more self-determined (Edmunds et
al., 2007). Ultimately, it appears that for long-term exercise
program adherence, motivation must eventually progress from more
extrinsic regulation to more intrinsic regulation (Weingberg and
Gould, 2007).
Motivation is lost when an individual becomes deterred by
an obstacle or barrier to the desired behavior. Kennet et al.
(2009) suggests that having higher coping [skills].promotes the
use of the behavioral processes to maintain a regular exercise
routine. If so, this would support moving attention from
teaching the components of an exercise to focusing on coping
with barriers to exercise. The number one obstacle to engaging
in exercise is sited as `lack of time' by 66% of survey takers.
Other common barriers include `lack of energy' and `lack of
motivation' itself (Weingberg and Gould, 2007). Barriers can be
divided into two main categories: personal and environmental,
with environmental barriers being the most common. In addition
to those mentioned above, personal (individual) barriers include
fears (e.g. about injury, discomfort, or failure),
misconceptions (e.g. beliefs, risks), and history (e.g.
childhood experience, poor results). Environmental barriers
comprise things such as cost of joining a fitness club, poor
weather conditions, lack of child care, lack of support from
family and friends, and lack of safe or accessible grounds or
facilities (Klein, 2007; Weingberg and Gould, 2007). These
perceived obstacles are highly variable between individuals and
likewise change with time and with variations in life
circumstances. Additionally common barriers can be linked to
certain personality types and can offer insight on
predisposition to attrition.
Regular vs. Irregular Exercisers
Key research by Karoly et al. (2005) was predicated on the
view that goal cognition and the individual's pursuit of
multiple goals can provide useful insights into why exercise
intentions often go awry. Participants were collage students
who completed a battery of surveys examining exercise habits and
goals in relation to other life goals. Survey analysis found
that regular exercisers tended to exhibit positive associations
for all types of goals (academic, social and familial) and
especially so for exercise goals, more so than irregular
exercisers. Additionally, regular exercisers were better at
self-monitoring goals that interfered with exercise goals, and
were better at self-monitoring of all types of goals. Also
important was the discovery that regular exercisers tended to
rate both exercise and interfering goals equivalently, in
contrast to the irregular exercisers who clearly assigned
greater motivational significance to their interfering goals.
For example, social goals interfered most with exercise goals
for 23% of irregular exercisers, but interfered most for only
17% of regular exercisers. That is, irregular exercisers
manifested a pattern of goal regulatory thinking favoring their
interfering goal relative to their exercise goal (Karoly et al,
2005). These differences between regular and irregular
exercisers begin to offer insight into the importance of goal
priority and personality type (goal regulatory thinking) in
achieving exercise program adherence.
Personality
In a 9 month weight control program, which included an
exercise component, researchers identified two distinct belief
systems or `self-efficacy types.' One type (assureds) displayed
personality characteristics of being goal directed,
independent, persistent [and self-confident]. The other type
(disbelievers) believed they lacked inner-strength and self-
control, and reflected doubt, self-recrimination, and marked
dependency (Dennis and Goldberg, 1996). At six-month
measurement points, assured types lost more weight and had
greater increases in self-esteem than disbelievers.
Interestingly, disbelievers who shifted their belief systems
throughout the course of the program (and finished as assureds)
lost more weight than those who remained disbelievers. Also,
disbelievers actually showed a significant decrease in program
behaviors at both six and nine month measurement points. Again,
it seems likely that a personality that flourishes in a goal
oriented environment may enjoy greater success in exercise
program adherence.
Attrition
There are a range of explanations for exercise attrition
throughout the literature. Common reasons include many of the
same personal and environmental obstacles discussed previously;
however, environmental obstacles are generally more prevalent.
Other research suggests personality type can predispose an
individual to exercise program dropout. An additional important
reason often cited for attrition is general disgruntlement with
the exercise program itself. Furthermore, exercise attrition may
be prompted by any combination of individual or environmental
obstacles, personality characteristics, and discouragement due
to disappointing outcomes (Karoly, 2005; Grassi et al., 2006; De
Panfilis et. al., 2008).
One of the most comprehensive studies attempting to
pinpoint causes of program attrition was done by Dalle Grave et
al. (2005) in one-thousand participants, over a period of 36
months, in fifteen obesity treatment centers. Although, the
study did not contain specific outcome measures on exercise,
clues may be inferred by examining reasons for attrition from
the obesity treatment programs, as physical activity was
included as a vital component of such. Attrition rates were as
follows: After the initial visit for treatment, 20% of
participants dropped out; by the 12 month marker 58% of
participants had abandoned the program; at the end of 36 months,
84.3% of participants were no longer attending. In a post hoc
study, researchers were able to contact 76% of the participants
who dropped out of the treatment program through follow-up
telephone interviews. The most frequently cited reason for
attrition, by 22.4% of participants, was recorded as `treatment
did not work' (i.e. lack of results). The remainder of
explanations was a conglomerate of environmental obstacles (52%)
including `family problems' by 19.7%, `work problems' by 18.7%
and `travel problems' by 13.6% of participants. When former
participants were asked to express other reasons why they
dropped out of the program, not previously codified, the most
common answers given were `lack of encouragement' and `sense of
abandonment' (Grassi et al., 2006).
Alternate research has examined predisposition to exercise
program attrition based on personality characteristics. A six
month weight loss treatment program, with recommendations for
exercise, compared personalities of individuals who completed
the program against those who dropped out. Sixty-two out of
ninety-two participants (67.4%) completed treatment. Information
on four temperaments (novelty-seeking, harm-avoidance, reward-
dependence and persistence) and three characteristics (self-
directedness, cooperativeness and self-transcendence) was
collected. Surprisingly, of the seven traits examined, there was
no significant difference found between the completers and non-
completers in six of these traits. Only the temperament trait of
reward-dependence was higher in participants who completed the
program. Also noteworthy was the finding that individuals who
did not complete the program had a greater occurrence of anxiety
disorder diagnosis than those who completed the program.
Investigators concluded that program attrition coincided with
difficulty in accepting support from others (i.e. low reward-
dependence temperament), while program completion is associated
with a high reward-dependence temperament and absence of an
anxiety disorder diagnosis (De Panfilis et. al., 2008). The link
between attrition and motivation/barriers and personality is
apparent once again. Considering all of these elements in
accordance will be necessary to understanding the answers to
Demographics
The majority of data available has primarily noted
differences with gender and age with regards to exercise program
adherence. As mentioned prior, exclusive of interventions geared
toward changing multiple health behaviors, statistics derived
solely from measurements of exercise program adherence are rare.
However, consideration of weight loss program adherence records
can offer insight, because an exercise program is a vital
component of these. The literature on weight loss programs shows
that males are more likely to adhere than females, and that
increased age correlated with and increased likelihood of
adherence. Familial history predicts the least likelihood of
program adherence. Individuals with a history of parental
obesity were less likely to complete a program, as were
individuals with a history of childhood obesity. Recommendations
for including moderate exercise were likewise less effective for
women, younger individuals, and those who had previously made
unsuccessful attempts at loosing weight (Bautista-Castao et
al., 2004). Interestingly, one of the most effective ways to
stave off exercise attrition is by mutual spousal support. The
retention rate of a married person, alone, in an exercise
program was about 57%; but when couples participated in the
exercise program together the retention rate held at an
astounding 93.7% (Weingberg and Gould, 2007).
In a two year study, differences between adolescents who
lost vs. gained weight were explored. A key element for weight-
losing adolescents was engaging in intense, daily exercise.
Interestingly, the weight-losing adolescents also were more
likely to describe a transformative experience, which changed
their view of themselves in the world with regard to weight and
activity (Lieberman et. al., 2009). Inquiries of older adults
(` 40 years) indicate that ideas about physical activity vary
depending on gender and change with increasing age. Regarding
physical activity, women 55 and under expressed confident `just
do it' self-talk, whereas women over 55 had a more cautious
`take it easy' approach. On the other hand, men 55 and younger
articulated a more laid back `think about it' reasoning, while
men over 55 were ìffy' and lacked sufficient benefit to risk
ratio for engaging in physical activity. Researchers suspect
that the social experiences of age and gender had influenced
their broad perspectives and specific thinking (Cousins and
Gillis, 2005).
In a cognitive-behavioral physical-activity intervention
women increased their use of individual self-management
strategies (vs. control group in a general health education
course) to increase physical activity, however the same was not
true for men. Fourteen self-management strategies were taught
during a fifteen-week intervention, which was further continued
with 18 months of post-intervention follow up. Self-management
strategies included methods such as record-keeping, scheduling,
rewards, and positive affirmations. Of the women's self-
management strategies, the most effective was goal setting.
However, throughout the entire follow-up period, the use of any
or all self-management strategies was always positively
correlated with the women's physical activity. That is, an
increase in use of strategies always coincided with an increase
in physical activity (Saelens, 2000).
Further evidence of gender differences with long-term
exercise program adherence was compiled by Fallon et al. (2005).
Time management strategies and developing coping strategies for
anticipated events that may interfere with exercise plans are
important for both men and women. However, environmental
barriers affect women at different stages of exercise program
adherence than men. Development of strategies to conquer
environmental barriers is most important for women between one-
half and five years of exercise program adherence (e.g. TTM
maintenance), but is most important for men beyond five years of
exercise program adherence (e.g. TTM termination). Furthermore
for men, it is important for interventions to focus overcoming
laziness, anger, and extreme stress. For women, interventions
need to focus on social liberation, such that women are
encouraged to evaluate their choice to become active and their
commitment to their behavior change (Fallon et al. 2005).
Clearly, nuances of demographics in exercise program adherence
exist. Designing and implementing effective programming
accounting for these differences remains an important concern.
Physiological parameters: Mode/Frequency/Intensity/Duration
Physiological parameters of an exercise program may play a
significant role in the likelihood of continuance. The old adage
that you only get one chance to make a first impression comes to
mind with a study examining exercise intensity and a person's
response to an initial exercise experience. Previously sedentary
individuals, who reported a positive experience during and after
engaging in a single bout of exercise, were more likely to
repeat this behavior more often. More minutes of exercise, both
six and twelve months later, were reported by those who had a
positive initial exercise experience versus those who did not.
The authors of the study provide an example of how an
individual's positive affect can be used to design an effectual
prescription for exercise intensity: Participants might be
asked to exercise at the highest intensity possible before
experiencing a negative turn in affective valence. Given the
present findings...one would expect that a prescription such as
this would lead to greater adherence than a prescription based
[on a predetermined] intensity (Williams et al., 2008). This
finding not only illustrates the importance of making sure that
an individual's first experience with exercise is a positive
one, it also suggests the important role of positive feelings in
exercise maintenance.
Furthermore, a twelve month treatment intervention for
overweight women explored whether or not greater duration and/or
intensity of exercise would result in greater weight loss.
Interestingly, although weight loss occurred in all
participants, there were no significant weight loss differences
attributed to exercise duration and/or intensity. It should be
noted that extensive behavioral and dietary interventions were
included in the study design and implementation (Jakicic, 2003).
Because `lack of results' has been cited as a cause of
attrition, it is important to keep in mind that increased
intensity does not necessarily yield increased results. A high-
intensity program may actually impede manifestation of a
positive affect, thus decreasing the likelihood that an
individual will repeat this behavior.
The intensity of exercise program design may be more
critical when considering long-term adherence (> 6 months) than
when considering weight loss/maintenance. A review by Hansen et
al., (2007) concerning physiological exercise program variables
concluded that the amount of training forms a more important
predictor of fat-mass loss than training intensity. Fat-mass
loss was however influenced by mode of exercise. Walking and
cycling have been found to enhance fat loss, where as swimming
has not. Likewise, resistance training did not increase fat
loss, but it did increase fat-free muscle mass, thereby
increasing fat metabolism (Hansen et al., 2007). Here again the
opposition of positive affect with adequate results must be
considered.
As there is also no apparent influence of training
intensity on fat loss, a low to moderate intensity may be
preferred for increasing enjoyment and compliance (Hansen et
al., 2007). Parfitt & Gledhill (2004) also found that
preference for mode of exercise can influence psychological
responses both during and after exercise. Allowing participants
to choose their exercise intensity certainly offers an
additional avenue for further improving exercise enjoyment and
adherence. Additionally, encouraging exercisers to choose from
certain fat-loss boosting modes of exercise may further
contribute to enjoyment and adherence.
Where exercise is performed may be of some consequence when
considering exercise adherence. For example, exercise does not
need to be done in a high-tech state of the art fitness
facility. In fact, just the opposite may be more conducive to
exercise adherence. Prichard & Tiggemann (2008) identified that
individuals who spent more time exercising in a fitness center
environment had stronger tendencies toward self-objectification
and disordered eating than those who exercised outside such an
environment. Since appearance is not a strong motivator of
long-term exercise adherence, getting out of the gym may
actually help individuals shift their motives to those
associated with long-term adherence. When exercise is performed,
on the other hand, may not be as important. An abstract
presented by Guelfi in 2009, found that for weight management
the time of day that exercise is performed had no significant
impact on caloric intake. Interestingly, exerciseregardless of
the time of the dayactually led to a decrease in caloric
intake. These results suggest that for individuals attempting
to manage their weight, it is not critical whether exercise is
performed in the morning or afternoon, as long as it is
performed and a healthy lifestyle is maintained (Guelfi et al.,
2009). Overall, important physiological parameters promoting
exercise program adherence seem to be those that have the most
effect on enjoyment; namely, intensity and mode. Although
additional parameters should not be ignored, when designing and
implementing a prescription for adherence, choice of intensity
and mode may be well left to the discretion of the exerciser.
Psychological Science and Exercise Program Adherence
Early tactics for promoting exercise participation and
adherence (mid 1970's to mid 1980's) focused largely on social-
cognitive theories as determining health behavior. Strategies
were focused on the importance of personal characteristics (e.g.
age, gender), environment (e.g. external cues), and emotions
(e.g. fear) in exercise involvement (Gebhardt and Maes, 2001).
The integration of stage and goal related theories for exercise
adherence began taking shape in the early 1990's and has since
dominated the field of health behavior research.
Currently, the focus of the scientific community for
promoting exercise program adherence remains primarily
psychological. Specifically, behavioral psychology and cognitive
behavioral therapy have been of greatest interest. For example,
during a weight loss program in obese women using cognitive
behavioral treatment, physical activity output generally doubled
over a ten week period. Furthermore, this increase in physical
activity was found to have been maintained at six month and
twelve month follow ups (Rapoport et al., 2000). Likewise, as
previously mentioned, a cognitive-behavioral physical-activity
intervention that taught the use of self-management strategies,
such as self-monitoring, goal setting, and positive self-talk
led to an increase in physical activity for at least two years
following the intervention (Saelens, 2000). The use of cognitive
behavioral approaches has also shown potential for increasing
exercise adherence in elderly populations. An intervention
comparing the relative abilities of cognitive mediating
variables (i.e., self-efficacy beliefs and outcome
expectancies/realizations) versus a social mediating variable
(i.e., exercise-related social support) found higher adherence
to exercise with association to cognitive mediating variables at
both 7 and 12 month follow ups (Brassington et al., 2002).
Health related behavior change is a psychology sub-field
that has received unprecedented attention in the last decade.
However, concrete evidence supporting long-term success of these
theories remains obscure. Among the more mainstream theories
targeting health behaviors are Rausenbaum's self-control
schedule (SCS) and learned resourcefulness, self-determination
theory (SDT), the transtheoretical model (TTM), and various goal
setting theories (Rausenbaum, 1980; 1990; Deci & Ryan, 1985;
Prochaska & Velicer, 1997; Locke & Letham, 1985; Locke &
Lerener, 1995 and Gebhardt & Maes, 2001).
Rosenbaums Self-Control Scale (Rosenbaum, 1980)
Rosenbaum first proposed the use of a self-control schedule
(SCS) to identify and measure behavioral processes in 1980.
Self-control behaviors were categorized in the following way:
(a) use of cognitions and `self-statements' to control emotional
and physiological responses, (b) the application of problem
solving strategies (e.g., planning, problem definition,
evaluating alternatives, anticipation of consequences), (c) the
ability to delay immediate gratification, and (d) perceived
self-efficacy (Rosenbaum, 1980). A high SCS score is generally
indicative of a person having an ìnternal locus of control.' An
individual with an ìnternal locus of control' holds the belief
that the outcomes of his or her actions are contingent on what
he or she does. Conversely, èxternal locus of control' is the
belief that the outcomes of one's actions are contingent on
events outside one's personal control. The assumption is that
the greater a person's ìnternal locus of control,' the greater
success they will have at changing their behavior. In 1990,
Rosenbaum further expanded the SCS to create a `self-control
model' using a principle he called learned-resourcefulness.
Learned-resourcefulness is a skill that can be taught, and the
more resourcefulness a person has (or gains), the more
successful they are at achieving their goals. Rosenbaum's SCS
and model of learned-resourcefulness have been used to predict
the likelihood of a person making successful health behavior
changes, as well as to build awareness of and to teach new
behavior patterns in people seeking to change their behavior
(Rosenbaum, 1980; 1990).
Because the SCS and learned-resourcefulness are primarily
used to predict exercise behavior, it may be most helpful in the
use of identifying specific needs of particular individuals on
the road to exercise program adherence, rather than in actual
program design. The only study uncovered using the SCS to
examine the relationship between learned resourcefulness and
exercise was made in new members of a fitness club. As
anticipated, regularly attending members were found to have
better skills in problem solving and self-regulation (Levesque
et al., 2003). SCS and learned-resourcefulness may be better
considered as useful tools in the development of future methods
of exercise program adherence.
Self-Determination Theory (SDT) (Deci & Ryan, 1985)
Self-Determination Theory focuses on the degree to which
human behaviors are volitional or self-determinedthat is, the
degree to which people endorse their actions at the highest
level of reflection and engage in the actions with a full sense
of choice. SDT was originally developed by Deci & Ryan in 1985
at Rochester University. A person is said to have achieved self-
determination when they experience a shift in their perceptions
as to the cause or control of their behavior (Deci & Ryan,
1985). An individual will perform a behavior for intrinsic
reasons, emanating from the self; rather than for extrinsic
reasons, originating outside the self. Ultimately, individuals
are intrinsically motivated when they engage in an activity for
the inherent satisfaction that they derive from the activity
(e.g. Ì exercise because it's fun'). They are extrinsically
motivated when they engage in an activity for separable outcomes
that they attain through the activity, whether rewards attained
or punishments avoided (Ingledew & Markland, 2008). SDT also
assumes that an internal milieu of independence will cultivate
the fulfillment of three basic psychological needs: autonomy,
relatedness and competence. Once these needs are fulfilled it is
granted that motivation will be self-determined enough to
influence and control behavior (e.g. exercise), cognition (e.g.
commitment), and well-being (e.g. vigor). On the reflective,
when the basic psychological needs are not met, motivation is
diminished and outcomes are impeded (Edmunds et al., 2007).
Predictions about an individual's behavior can be made using
ones social framework. Whether this framework supports or erodes
ones participation in said behavior, will determine the
likelihood of success (Deci & Ryan, 1996).
Evidence for the role of SDT in facilitating long term-
exercise program adherence is less than congruent. For example,
overweight/obese individuals who adhered to a three month
exercise program reported more self-efficacy, to overcome
barriers to exercise, than individuals who did not adhere to the
program (Edmunds et al., 2007). However, other reviewers
exploring SDT and the psychology of exercise concluded that
there are very little experimental and intervention studies
adopting the principles of the Self-Determination Theory to
effect change in exercise behavior. Even still, they admitted
that SDT is rapidly becoming a leading theoretical perspective
in the field of exercise, and the future looks bright for
researchers and practitioners alike as the theory has much to
offer in terms of predicting behavior, understanding behavioral
mechanisms, and designing interventions (Haggar and
Chatzisarantis, 2008).
Goal-Setting Theory (Locke & Latham, 1985)
Goal-Setting Theory, presented by Locke & Latham (1985),
operates under ten specific conditions. 1) Goals must be highly
specific. 2) Goals must be quantitative; that is, goals need to
be measurable or time-bound. 3) Goals must be difficult or at
least challenging, but also realistic and achievable. A goal
that is too easy to achieve will yield less than maximum
performance, while a goal that is too difficult will undermine
success by securing failure. 4) Short-term (weekly) and long-
term (3 months) goals need to be set. 5) Goal setting focuses
directives, regulates effort, enhances persistence, and promotes
development of new strategies for improving performance. 6)
Goals must be reviewed at regular (ideally weekly) intervals.
Accountability to, quantification of performance by, and
feedback from someone or something (a coach) must be obtained.
7) When goals that are difficult, a high level of commitment
will yield performance that is directly proportional. 8) Goals
must be accepted by the individual. Techniques used for goal
commitment include direct request, supportiveness,
participation, training, selection, and rewards. 9) Goal
achievement is facilitated when a larger plan is broken down
into smaller tasks. 10) Competition goals are dynamic and
promote greater commitment and higher performance as goal levels
are set higher and higher (Locke & Latham, 1985).
A literature review by Shilts et al. (2004) showed goal
setting had a statistically significant positive effect
on.[overcoming] physical activity behaviors. Likewise the
writings examined thus far have shown evidence that goal-linked
directives are found in regular exercisers and in individuals
with a high likelihood of succeeding at health behavior change.
Transtheoretical Model of Health Behavior Change (Prochaska
& Velicer, 1997)
One of the most heavily studied and widely accepted tools
for facilitating behavior change is Prochaska & Velicer's (1997)
Transtheoretical Model of Health Behavior Change (TTMHBC). Prior
research involving use of the original transtheoretical model
(TTM) was compiled to develop a model specifically channeled to
changing health behaviors. The primary premise of TTMHBC says
that changes in behavior occur in six distinct and identifiable
stages: pre-contemplation, contemplation, preparation, action,
maintenance, and termination. Additionally, each stage follows
an established and predicable timeline. Each stage also ties in
to specific prompts that will help goad an individual to
progress to the next stage of change (SOC). For example, an
individual in the pre-contemplation stage (average duration, 6
months) has no interest in, or consideration for, changing a
behavior. Someone in pre-contemplation mostly requires new
information on the desired health behavior change. During
contemplation (average duration, 6 months), an individual is
considering making a behavior change and is best served by
gaining an understanding of the risks and benefits of changing
the behavior. A person enters the preparation stage (average
duration, 1 month), when the decision to change the behavior is
made. During preparation, it is critical that a goal specific
behavior change is defined. The action stage (average duration,
3 to 6 months) begins to take shape when the individual fully
engages in the desired behavior. For success in the health
behavior change model, a person must attain a criteria that
scientists and professionals agree is sufficient to reduce risks
for disease (Moore et al., 2004). For this reason, outlining
the desired behavior change as a specific and measurable goal is
also vitally important. A person is categorized as having
progressed to the action stage when desired behaviors are
successfully maintainedwithout relapsefor six months. Research
indicates that, after 12 months in the action stage, chances of
relapse hover around 50%. However, after 5 years of
uninterrupted health behavior change, the relapse rate drops to
under 10%, and the person is said to have entered the
termination phase. Official entrance to the termination stage is
also contingent upon a person reporting no temptation to abandon
their new health behavior, and complete self-efficacy to sustain
it (Prochaska & Velicer, 1997; Moore et al., 2004).
1
Additional constructs of the TTMHBC include processes of
change (POC), decisional balance, self-efficacy, and temptation.
POC consist of ten itemized actions people employ as they move
through various SOC. POC details will not be discussed here, but
simply noted that these items can be used as markers for
researchers to map how an individual moves through the SOC.
Decisional balance simply refers to the pros and cons of
changing a behavior. Self-efficacy is defined as the situation-
specific confidence people have that they can cope with high-
risk situations without relapsing to their unhealthy or high-
risk habit. Temptation is a measure of the level of desire to
return to old behaviors, especially in the face of undesirable
circumstances or an unfavorable environment (Prochaska &
Velicer, 1997).
Finally, it should be further noted that TTMHBC makes seven
important assumptions: 1) no single theory can explain all
behaviors, but theories can evolve; 2) behavior change occurs in
stages over time; 3) stages are stable yet malleable; 4) change
requires intervention; 5) `traditional' action-focused health
promotion will not work for individuals outside the action SOC;
1
The case can made that the termination stage is purely theoretical because
it is in a practical sense, nearly unachievable. Consequently, there is
little, if any, definitive research to support its constitution.
6) intervention must match SOC; and 7) self-control, biology,
and sociology influence behavior change; TTMHBC address self-
control (Prochaska & Velicer, 1997).
Changes in exercise behavior have been associated with the
TTM SOC framework and accompanying constructs of POC, decision
balance, and self-efficacy (Ay & Temel, 2008). With a basic
understanding of the TTMHBD, research examining its use in
exercise program adherence can be explored. In support of the
validity of TTM for explaining exercise behavior, and in an
attempt to pinpoint the most important components of TTM for
changing exercise behavior, detailed questionnaires were
gathered from a group of 228 students. Analysis of the results
indicated that the behavioral POC had the strongest correlation
to specific stages of exercise behavior. Additionally, self-
efficacy increased as students progressed from the pre-
contemplation all the way to the maintenance stage. Finally,
the students in the pre-contemplation and contemplation stages
had significantly lower [decision balance] pros associated with
exercise in comparison to those in the maintenance stage (Kim,
2007).
Opendacker et al. (2009) evaluated the effectiveness of TTM
on increasing physical activity in a group of nearly 700 women
over a period of six months. The goal was to identify which
constructs were most critical to changing physical activity
behaviors, thereby allowing researchers and professionals to
focus intervention measures more effectively. The minimal-
contact protocol consisted of one 90-minute intervention
meeting, a self-help booklet, and five monthly reminder letters.
Over 45% of participants were excluded due to drop out or
varying levels of non-compliance. Results showed that women who
completed the program increased their use of behavioral POC,
while the control group exhibited a decrease in POC. However in
contrast to Kim (2007), there were no significant changes in
decision balance or self-efficacy.
Rosenbaums self-control scale vs. TTM (Kennett et al.,
2009)
Although there are notable similarities among theories of
behavior change, a primary difference between Rosenbaum's self-
control scale (SCS) and the TTM is the absence of the `learned
resourcefulness' construct in the later. An additional important
difference is that TTM is only appropriate if an individual has
not yet made an intrinsic decision to change their behavior,
whereas Rosenbaum's model addresses the individual with a
definitive desire to change. Kennett et al. (2009) explored the
use of SCS for use in the maintenance of exercise behavior
rather than the traditional constructs of TTM. Data collected
revealed that participants in the maintenance SOC had a higher
SCS score than participants in any other stage. Meanwhile,
participants in the contemplation, preparation and action SOC
had similar SCS scores. Most individuals in the maintenance SOC
scored very high in resourcefulness on the SCS. Conversely,
those in the action, contemplation, and pre-contemplation SOC
generally had lower and very similar scores in resourcefulness.
The primary motivators for exercise of people in the maintenance
SOC, regardless of resourcefulness level, were social reasons,
followed by external reasons as the second most important
motivators. However for maintenance SOC individuals with low
resourcefulness scores, the primary motivators for exercise were
cited as external reasons (Kennett et al., 2009).
Commercial Industry and Exercise Program Adherence
Despite the general dichotomy between the scientific study
and commercial industry of exercise program adherence, the
commercial industry is vastly successful in a capitalistic
sense, and sometimes successful in a practical sense. Therefore,
a brief examination of the practical seems reasonable.
Wellcoaches (Moore & Highstein, 2004)
Wellcoaches combines components of TTM, (Prochaska &
Velicer, 1997) Motivational Interviewing (Miller, 1983), Choice
Theory/Reality Therapy (Glasser, 1998), and Solution Oriented
Psychotherapy (O'Hanlon and Weiner-Davis, 1989) to promote long-
term health behavior change, including exercise program
adherence. Developers of the Wellcoaching model predicted that
Wellcoaching could ultimately become a major force in health
promotion/disease prevention, weight management, and fitness
programs. (Moore & Highstein, 2004) The primary platform for
Wellcoaching is an interactive website which a Wellcoach uses as
a tool during telephone conferences with their clients typically
over a twelve week period. The initial meeting involves
assisting the client to create a vision of herself at her ideal
level of health and wellness. From this vision, three month
goals are designed and are further broken down each week into
smaller goals. Wellcoach and client continue meeting weekly to
discuss the previous week's goals and set new goals for the
upcoming week. Wellcoaching is promoted as being appropriate
when an individual is committed and ready to make behavioral
changes. Having been identified as being in preparation SOC (1
month), the Wellcoach can assist the client with a fluid
transition into the action SOC (3 to 6 months). At the end of
three months, coach and client reevaluate long-term goals and
determine if weekly meetings are still needed. For example, if
the individual is fully engaging in their desired behaviors,
meetings can be reduced to bi-monthly, monthly, quarterly and so
on as self-efficacy increases. If obstacles and barriers are
still affecting the client's progress, weekly meetings may still
be needed to prevent relapse and ensure retention of healthy new
behaviors.
About such venues as are employed by Wellcoaches,
researches wrote the following: The most promising outcomes to
date have been found with computer-based individualized and
interactive interventions. The most promising enhancement to the
computer-based programs are personalized counselors (Prochaska
& Velicer, 1997). Web-based health behavior change programs may
be more successful in the area of weight management than in many
other health-related areas (Verheijden, 2007).
Personal Training
Opinions and testimonials praising the effectiveness of the
working with a personal trainer
2
abound, but hardcore statistical
research is scarce. According to International Association of
Fitness Professional (IDEA), only 25% of the people that
exercise achieve the results they want; of that 25%, 90% use
personal trainers. In a small sample of thirty participants in
a twenty week exercise program, individuals who had weekly
contact with a personal trainer had the greatest early adherence
In the context of this review the title `personal trainer' is used with
certain assumptions. A qualified Personal Trainer should hold a minimum of a
four year degree in a health related field and be certified by one or both of
the top credentialing agencies, American College of Sports Medicine (ACSM)
and National Strength and Conditioning Association (NSCA). It is of great
disturbance that there are currently no regulatory provisions governing
personal trainers anywhere in the United States. Professional licensure has
been proposed in Washington D.C., New Jersey, Maryland, and Georgia, but no
bill has been passed to date. With no disrespect to the profession intended,
an additional example of disproportion in regulatory standards is found in
cosmetology. A hair stylist has to undergo accredited schooling, supervised
practical hours, extensive testing, and licensure process, yet an individual
who is going to potentially be responsible for your entire wellbeing has to
undergo nothing. This is an additional issue that should be addressed for the
future success of exercise program adherence.
to a personalized exercise program. Adherence after eight weeks
was 82% with a personal trainer, versus 61% without. Although
the sample was too small for statistical analysis, the
implication that meeting weekly with a personal trainer may
result in greater adherence can be made (Williams, 2001). Not
only can supervision, program planning, focused attention, and
motivation from a personal trainer potentially increase exercise
adherence, it can also increase exercise efficiency. Greater
efficiency of exercise would help to offset the perceived
barrier `lack of time,' as individuals would be able to obtain
maximal results in minimal time. Since an additional reported
reason for dropout is lack of results (Grassi et al., 2006),
better results will also lead to increased adherence. Research
on a group of forty-six women exercising in a health-club
setting found that those who had the aid of a personal trainer
actually worked harder than those who did not. It was discovered
that the majority of healthy women tested in health clubs self-
selected resistance training intensities that were considered
relatively low.especially for lower-body exercises (Ratamess,
2008). In fact, the intensities self-selected were lower than
what is recommended by ACSM. On the other hand, women who used a
personal trainer self-selected greater intensities, by nearly
10%. Rating of perceived exertion (RPE) and 1-Repetionion
Maximum (1RM) were all so significantly higher in the group of
women who had the assistance of a personal trainer. Several
other interesting findings shed light on how personal trainers
help clients adhere to an exercise program. For example, on pre-
exercise program questionnaires, 70% of all the women in the
study reported that their primary exercise goal was increased
muscle tone, but that they were not interested in doing heavy
resistance training. Post-exercise program, women in the
personal training group reported using a variety of exercise
equipment, including machines, barbells, and dumbbells. Women
who did not have a personal trainer reported only having used
machines for resistance training. Post-exercise reporting also
revealed that nearly double the number of women in the non-
personal training group believed that any type of resistance
training would lead to excessive muscular hypertrophy or, in
their terms, `to the development of large, bulky muscles.' Most
importantly, women in the personal training group reported high
satisfaction of the personal training being related to their
goals, and that the workouts were very challenging despite the
moderate loading (Ratamess, 2008).
All of these findings support the idea that the use of a
personal trainer can help a person achieve greater performance,
greater efficiency, engage a greater variety of exercise modes,
and provide education and increased knowledge to dispel myths,
fears, and misconceptions about exercise. Collectively all of
these factors can lead to an individual having a more effective
and enjoyable workout experience, which can contribute to
greater exercise program adherence (Williams et al., 2008).
Personal Training and TTM
Recently, researchers found that the use of a personal
trainer had a significant impact on three of the four TTM
constructs. Data was collected via surveys of experimental
(personal trainer) and control (no personal trainer) groups to
measure process of change, decisional balance, and self-
efficacy. All construct measures remained stable in the
experimental group but, decreased in the control group. Also
noted was that initiation of exercise behavior was related to
self-efficacy regarding task performance, while adherence to
exercise behavior coincided with self-efficacy relating to time-
management. The authors further concluded that use of a personal
trainer led to a more positive pattern of exercise behavior
change and may help prevent SOC regression & relapse (Fischer
and Bryant 2008).
Personal Training and Wellcoaching
For an exercise program over and eight week period,
individuals used of a self-monitoring checklist (experimental
group) yielded significantly greater adherence than individuals
who did not (control group). Both groups were initially
administered the self-monitoring checklist prior to commencement
of the exercise program and each individual was matched with a
coach to provided instruction, remediation, and feedback and
to encourage adherence to pre-determined targeted exercise
behaviors. Individuals from both groups met weekly with their
coach thereafter. Exercise programs were tailored to meet
individuals' needs and goals, as well as to increase the
likelihood of program adherence. Interestingly, in both groups,
the number of individuals who adhered to aerobic training
program was nearly double the number who adhered to both aerobic
and strength training programs during the first week. Also, in
both groups, frequency of exercise increased slightly after the
first week. Subsequently, however, frequency of exercise
steadily decreased in the control group; while frequency of
exercise in the experimental group fluctuated slightly, but was
maintained overall, during the eight week period (Anshel &
Siepel, 2008). These findings offer support for the idea that
the mere action of meeting with a trainer or coach does not
ensure exercise adherence. The use of a self-monitoring check-
list may have affected exercise adherence by increasing
participants' awareness, sense of accountability, and clearer
understanding of goals. That is for coaching/training to be more
effective, some individual work must also be done outside of the
coach/trainer meeting. Additionally, research noted significant
improvements in fitness regardless of whether individuals
received coaching by phone, in person or a combination thereof
(Castro & King, 2002).
Personal Fitness Coaching: A New Hybrid
Low-cost yet effective programs are desperately needed to
involve the mainstream population in regular physical activity
(Opendacker et al. 2009). Perhaps a combined approach of a
personal trainer/Wellcoach will provide an intervention offering
the best of both worlds: physiological and psychological
exercise program design and intervention. Simply working with a
personal trainer, 30 to 60 minutes two or three times a week,
may be insufficient and impractical for assisting most
individuals in achieving a lifetime of exercise program
adherence. The remaining 23 hours a client spends away from
their personal trainer surely have an additional influence on
their success or failure. During this time away, accountability
to a Wellcoach may be a viable solution. To this end, the
Wellcoaching component can be interwoven into the client's
experience with their personal trainer, so that following some
exercise instruction and behavioral changes, self-efficacy for
exercise program adherence can be developed.
A picture of a new hybrid professional in the fight against
inactivitya Personal Fitness Coach
3
emerges. After a period of
Sadly, over recent years `personal trainer' has sometimes become a bad word.
Lack of regulation, education, certification, liability coverage, continuing
four to twelve weeks (depending on the individual's SOC
progress) weekly, monthly or even quarterly meetings the
Wellcoach entity may provide enough psychological assistance,
encouragement, support and accountability for an individual to
truly adhere to their exercise program. Likewise, as an
individual's physiological exercise parameters progress or
personal circumstances change, the Personal Trainer entity can
make adjustments to an individuals program to ensure continued
enjoyment, results, safety and adherence.
The Biggest Looser/Celebrity Fit Club/Rehabilitation Units
A brief mention should also be made about the rise in
reality television programming concerning weight loss and
exercise program adherence. Although the evidence thus far is
primarily anecdotal, shows like NBC's The Biggest Looser,
education, and experience, has lead to qualified trainers getting a bad rap.
The commercial exercise industry knows this and has begun changing the buzz-
word to things like Fitness Coach, Personal Coach, or Exercise Coach.
Tragically however, that is precisely all that has changed; these new names
do not make a personal trainer any more qualified than he or she was before.
In fact, this new nomenclature may even be a pre-curser to creating a loop-
hole pending future regulation of personal trainers, as the push for
regulation in several states is growing. For example, this problem currently
exists in the field of nutrition, but uneducated consumers are rarely aware
of professional designations and distinctions. Hundreds of entrepreneurs use
advertisements on business cards, web sites, and in magazines to continue to
claim the profession and title of `nutritionist,' but, without proper
education and licensing this is actually illegal in almost every state. The
only person who can rightly declare the prestige of nutritionist is a
Registered Dietitian who has also passed the necessary pre-requisites and
exams to carry the title of Licensed Nutritionist. Not even (and especially)
a Registered Dietetic Technician can claim to be a nutritionist, even though
they have completed an undergraduate degree in dietetics and have passed a
national registration exam by the Commission on Dietetic Registration (CDR).
The same predicament persists in personal training, but it is not illegal,
just immoral. In fact, personal trainers do not have to even be certified to
call themselves such.
VH1's Celebrity Fit Club, Oxygen's Dance Your Ass Off and
Discovery Health's Inside Brookhaven Obesity Clinic are highly
successful; both in changing peoples' behavior and in drawing
viewers' ratings. Currently, there are reports of the British
Government mandating enrollment at `fat camps' for obese
children and adolescents (Fox News, 2009). The expectation is
that implementing fat camp attendance, as a preventative
measure, will offset the lifelong health problems and disease
states related to overweight and obesity. There is clearly a
need and a desire for people to participate in and observe these
embodiments of extreme dedication. What the long-term outcome
for these contestants/patients is remains to be seen, but these
extreme camps and rehabilitation units certainly show promise
for embellishing implementation of behavior change and exercise
program adherence.
A Summary of Success
Of the behavior change theories the two that show the most
potential are Goal-Setting Theory and TTM. Experts agree that
goal setting has shown some promise in promoting. physical
activity behavior change among adults (Shilts et al., 2004).
And the founders of TTMHBC assert the following: Applied
research has demonstrated dramatic improvements in recruitment,
retention, and progress using stage-matched interventions.If
results with stage-matched interventions continue to be
replicated, health promotion programs will be able to produce
unprecedented impacts on entire at-risk populations (Prochaska
& Velicer, 1997). Although, the success of TTM is well
documented for goading the decision making process involved in
initiation of an exercise program, there remains little research
beyond three to six months of adhering to an exercise program
(Fallon et al., 2005).
Honorable Mention: National Weight Control Registry (NWCR)
It is important to give special notice to one of the
largest and well-known data bases which provides information on
exercise adherence, The National Weight Control Registry (NWCR).
The NWCRaccessed via the internet at www.nwcr.orgis a global
registry and database which has been collecting information on
how people have loss weight and successfully controlled their
losses. Eligibility for membership in the registry is defined as
someone, who is at least 18 years of age with a weight loss of
30 pounds or more, which has been maintained for at least one
year (Wing & Hill, 1994). Again it is noted, there is a great
fount of understanding about exercise program adherence that can
be drawn from information on the success of weight loss and
long-term weight management methods. Researchers and
practitioners would do well to consider the information compiled
in the NWCR for inspiration for design and implementation of
programs for exercise adherence.
Contraindications
Of the research explored, there was only one definitive
case to report a method that may be counterproductive to
exercise program adherence, self-talk. Self-talk was reported
by both active and inactive individuals, and this raises the
possibility that awareness of self-talk may NOT be particularly
helpful to motivation for physical activity. While elite
athletes may benefit from purposeful self-talk; everyday people
may experience self-talk less effectively by letting it rule
them rather unconsciously (Cousins and Gillis, 2005).
Limitations
Limitations in the exercise adherence literature share
similarities common to any scientific research (sample size,
study design, statistical analysis and other practicalities).
For example, due to the extensive commitment, effort, and
duration participants and researchers need to put forth for
intervention studies; sample size is frequently an issue. Not
only may individuals be reluctant to participate in the first
place, high attrition rates also gravely affect the outcome of
participant numbers. In a review of studies using SDT to promote
exercise adherence, the most common design was cross sectional.
This approach hampers the ability to clarify mechanisms that
affect motivation. A longitudinal design method, on the other
hand, would allow examination of the currently presumed
internalization process of SDT (Edmunds et al., 2007).
Likewise, longitudinal studies are necessary to understand
how TTM facilitates individuals' progression through the various
stages of change. Hence, longitudinal studies using the TTM to
investigate exercise maintenance are warranted (Fallon et al.,
2005). The lack of consistent research findings can possibly be
attributed to a lack of statistical power, as very few studies
on exercise program adherence report power calculations.
Additionally, the absence of power calculations prohibits a
judgment on the adequacy of sample size.
Methodological issues have also been noted in several
studies examining the effectiveness of goal setting in promoting
physical activity (Shilts et al., 2004). Self-report measures
are often a cause of measurement errors. Longitudinal designs
would help reduce this type of error by the incorporation of
objective measures such as body composition and performance
testing (Fallon et al., 2005). Finally, as noted previously,
duration of studies limits the ability to determine the long-
term success most exercise interventions. For example, to date
the termination stage of TTM remains largely hypothetical.
Additional multi-year and meta-analytical studies may also be
helpful in gaining concrete support for the long-term success of
TTM.
As abundant as the research regarding TTM and exercise
adherence is, there also seems to be a generous amount to
challenge it. An extensive literature review by Adams and White
(2005) questioned the effectiveness of TTM in promoting long-
term exercise program adherence. The major critique of the
current literature was that only 4 out of 15 studies followed
participants beyond six months and that support for long-term
exercise program adherence was limited and disappointing.
However all 15 studies reviewed, regardless of duration,
reported that stage-based interventions were more effective
than control conditions (Adams and White, 2005). Other
researchers noted that TTM interventions are limited to the
extent that they fail to use systematic review methods, or focus
upon a specific behavior (Briddle et al., 2005).
Future Research
Noticeably there is a need in the scientific community for
a set of specific criteria that provides a `gold-standard' of
exercise program adherence (Rand & Weeks, 1998). Many of the
commentators have also suggested that, in concert with
methodological advances, the field's theoretical arsenal is in
need of expansion (Karoly, 2005). Identifying the working
components of physical activity interventions remains an
important challenge for future studies because it is a necessary
step in the development of low-cost effective interventions that
are able to reach the major inactive part of our population
(Opendacker et al. 2009). A therapeutic alliance addressing
these issues has a large potential to reduce treatment
interruption and to improve outcome in obesity (Grossi, et.
al., 2006).
Practical difficulties and psychological problems are the
most important reasons for attrition reported by patients. From
the previous examination of gender differences scientists note
that additional research is required to improve and tailor
physical activity interventions for women and men. In addition
to offering insight into potential gender differences, this
study also highlighted the need for a more thorough examination
of participants' use of self-management strategies.and the
relation between strategy use and outcomes (Saelens, 2000).
In consideration of Rosenbaum's theories further
investigations examining the relationship between learned
resourcefulness and exercise are warranted (Kennett et al.,
2009). As to the specifics of research surrounding TTM, critics
advise that additional research evaluating the effectiveness of
the TTM may not be the most useful avenue to pursue. An
important goal for future research should be to establish an
evidence base not in terms of effectiveness, but rather with
respect to the central propositions of the TTM. Future research
should also endeavor to report sufficient details regarding both
methodology and intervention. Regarding the former, better
reporting of methods will improve either the actual or the
appraised quality of the evidence base and in so doing allow
reviewers to draw more useful conclusions. Regarding the latter,
there is a need for more thorough descriptions of interventions,
especially in terms of content. Despite a large evidence base,
important questions concerning intervention content remain
unanswered (Briddle et al., 2005).
New Trends
There is a hot new exercise trend that offers a new twist
on an old training premise: BOOT CAMP. There is some data
supporting like success of a Boot Camp style exercise program
for achieving rapid results in weight loss and management. For
example, in a twenty week (five month) basic military training
program, with no dietary restrictions, the mean weight loss in a
group of obese (BF >35%) young males was 23.5 pounds.
Noteworthy, is that the majority of the weight loss was evident
by the end of the second month. (Lee et al., 1994) There is
definite potential for the role of Boot Camp style workouts in
exercise program adherence. Quick results may forestall
attrition and the social aspect may increase enjoyment and
adherence. Drawbacks include a program that is not tailored to
the individual, high-intensity parameters that may decrease
enjoyment, discourage novices, and injure the de-conditioned.
However these drawbacks can easily be circumvented by a
qualified instructor who has the ability to modify prescribed
exercise to customize intensity, reinforce success for
beginners, and dispel fears for those at risk for injury.
Discussion
By examining the literature on exercise program adherence
from both a physiological and psychological perspective, the
need for reflectionon several conceptsfilters out.
1. Getting Support: It is clear that support is a critical
component for initiation and promotion of exercise program
adherence. The support can come from a family member or friend
in the form of side by side participation, encouraging words,
and even shouldering responsibility for an exerciser's
interfering goals (e.g. baby sitting, errands, or household
chores). Support can be self-directed with the use of
educational materials, self-help literature, and computer
tracking software, or on-line programs and support groups. The
support can be professional in nature, a coach, a trainer or
even a therapist can help with a program of exercise and
adherence. A professional can offer insight as to the best
physiological and psychological approach based on the unique
characteristics of an exerciser. A professional can also help
by providing accountability and program designs that ensure
efficient, effective, and enjoyable activities. Ultimately a
professional can assist with all of the concepts further
outlined in this final discussion.
2. Connecting to Motives: Identifying why an individual
maintains exercise program adherence is advantageous at all
stages of an exercise program. Sometimes it is difficult for
an exerciser to overtly identify `motivators' for exercise
adherence. It is important for practitioners to remember that
motives can be thought of as benefits, as this may help
individual better connect to reasons why they want and/or need
to continue their exercise program Because motives vary from
person to person and change as exercise longevity increases,
there is no one formula for sorting them. Different motives
are linked to different regulatory processes and can affect
exercise adherence positively or negatively. Finally, our
review revealed that initial regulatory motives for embarking
on an exercise program are often extrinsic, but for successful
long-term adherence, self-efficacy and intrinsic regulatory
motives must be expanded.
3. Identification of obstacles/barriers: Identifying obstacles
to exercise is the firstand perhaps most criticalelement to
overcoming them. For example, upon probing further into the
previously identified notion of individuals not having enough
time to exercise, it typically becomes apparent that the
barrier, `lack of time,' is merely a smoke screen, and that
the real barrier is competing activities and the priorities
individuals place on them. If individuals can anticipate and
pinpoint barriers ahead of their interference with exercise
goals, strategies can be developed and steps can be taken to
offset them. Disaster planning and relapse prevention present
an additional opportunity for supporting exercise program
adherence.
4. Consideration for different personality types: Two key
ideas emerge about personality when comparing regular and
irregular exercisers: 1) people who exercise regularly derive
more enjoyment from exercising than irregular exercisers and
2) regular exercisers afford exercise goals a higher priority
than irregular exercisers. However, these findings also raise
several new questions. Does regular participation lead to
increased enjoyment of exercising, or does enjoyment of the
exercise lead to increased participation? How can irregular
exercisers be persuaded to give exercise goals a higher
priority relative to other life goals? Because irregular
exercisers place higher priority on social goals, another hint
for exercise program adherence may include a social aspect. If
irregular exercisers could blend or merge social activities
with physical activities, there could be less competing
interference from social goals and more exercise program
adherence.
The literature also supports the idea that different
interventions may offer more effective ways to target specific
personality types. To successfully maintain exercise
involvement, a behavior-change strategy that is effective for
one individual may not be as useful to someone else with
different personality factors. Also, when and how a behavior
change strategy is used throughout an exercise program may be
dependant on different personality factors as well (Levesque
et al., 2003). An additional note of importance is the message
that belief systems can be changed. Working to change an
individual's belief system may be a critical component in
achieving exercise program adherence.
5. Take note of age and gender differences: Men and women may
benefit from gender targeted programming. Women will likely
gain advantages by using planning, coping, and management
strategies, whereas men may not. Married couples will do well
to embark on an exercise program together. Young people may
find less cognition and more action more helpful than an older
individual who may need more decision balance and support. As
a final note, gender differences have been reported in the
adaptation of adipose tissue metabolism to aerobic exercise
training (Poirier and Desprs 2001). This may also be an
important consideration when designing physiological
parameters for males and female to maximize results & exercise
program adherence.
6. Make sure expectations are in check: Drop out from an
exercise program due to the treatment not working, feelings of
abandonment, and lack of encouragement seem to be the most
tragic reasons of all. The implication can be made that
attrition often occurs simply because of subjective reasons.
In fact, the extent to which patients are satisfied or
dissatisfied with the results of a program is highly dependent
on their expectations (Dalle Grave et al., 2004, 2005). Two
potential solutions emerge: 1) implementation of coaching
and/or personal training to provide support and encouragement,
and 2) education about realistic expectations and outcomes
resulting from exercise program adherence.
Fashion, fitness, marketing, television and movie media
generate an ideal image of a body that is literally
unachievable for the average person. For example, professional
fitness models are generally already born with aesthetically
ideal genetics; engage in multiple exercise bouts per day;
calculate and consume a perfect down to the gram of
macronutrient diet; and may even engage in the use of
dangerous and illegal supplementation. In addition, these
individuals cultivate an obsessive like dedication to making
modeling and body-building a full-time career. Delineating
these idealistic images from the average population is an
important topic for education that may help individuals to
form more realistic about expectations about outcomes of their
7. Define the exerciser's needs and goals: When Arnold
Schwarzenegger was asked for his single best piece of advice
he said, You've got to have a goal. If his achievements are
proof of that statement, there isn't much left to say.
Appropriate goal setting is undoubtedly crucial to maintaining
adherence. Goals should be SMART, SpecificMeasurable
AchievableRealisticand Time-Bound. Both long-term (` 3 month
time frame) and short-term (weekly) goals should be created.
The literature shows that goal directed personality types are
more likely to adhere to an exercise program. Additionally,
people who exercise regularly use self-monitoring of goals and
goal regulatory thinking to maintain adherence. Keeping in
mind that belief systems and behavior can change over time,
for a non-goal oriented person, just practicing goal-setting
may be a first step. Eventually achievement will ensue. The
benefits of goal-setting have been accented throughout the
literature and have clearly shown significance in improving
adherence to an exercise program.
8. Plan activity as a lifestyle: Physical activity should
ideally be integrated as a part of an individual's everyday
life. With one simple move the majority of people would
overcome the most popular barrier to exercise and have more
than enough time to add thirty minutes of it into their lives.
It is this: TURN OFF THE TELEVISION! Just taking a brisk walk
at the end of the day, before or after dinner, can change
everything. Anyone can benefit from feeling the stress of the
day melt away; discovering a beautiful sunset; or spending
quality time with oneself, a spouse or one's children (while
setting a wonderful example for them). If the weather is bad,
switching out cable for an exercise disc can work just as
well. (Pushing the furniture up against the walls will give
everyone a chance to participate.) Many videos are available
in retail stores today for less than ten dollars each, so
èxcessive cost' poses no barrier. Finally, enlightening
individuals to work on shifting thinking from I have to start
exercising soon to I will take my walk after lunch today,
may just go a long way to making regular exercise adherence a
lifestyle.
9. Seek out enjoyable activities: A theory emerges by blending
the previously outlined findings of Karoly et al. (2005),
Parfitt & Gledhill (2004), Jackic (2003), and Williams et al.
(2008). Perhaps an important factor in discovering the secret
to exercise adherence lies herein. A primary difference
between regular and irregular exercisers is that regular
exercisers derive happiness (positive affect) from their
exercise. (Karoly et al., 2005). Exercise is more enjoyable
when choice of exercise mode is left to the exerciser (Parfitt
& Gledhill, 2004). Intensity and duration do not rank with the
same critical importance as consistency and longevity do when
it comes to exercise for weight loss (Jackic, 2003). There is
an affirmative relationship between a positive initial
exercise experience and increased potential for future
exercise participation. (Williams et al., 2008) A successful
formula for exercise program adherence may be to èngage in
some physical activity you find enjoyable, particularly when
starting out on an exercise program.'
While future research could evaluate the impact of
allowing exercisers choice in both mode and intensity, it
would seem from a health promotion perspective that the mode
of exercise is a desirable factor to leave to the individual's
choice, when intensity needs to be prescribed to enhance
cardiovascular health (Parfitt & Gledhill, 2004). On the
other hand low to moderate intensity exercise are better than
no (intensity) exercise. So if the negative affect of
intensity level is a potential trigger for attrition, it may
be better to allow individuals to choose their intensity level
as well; especially until one is well into the maintenance
stage of change.
10. Review goals and progress/completion each week: It is
important to review goals regularly. Personal needs and
circumstances can change in an instant. Personal desires,
employment, living arrangements, relationships, family units,
and health status are all subject. When changes occur, goals
need adjustment. Also, a goal that was achieved with little
effort should be adjusted and made progressively more
challenging. A goal that was barely achieved may need to be
modified to promote future success. Reviewing goals helps keep
awareness of motivators and obstacles fresh, while staying
sharp on strategies to overcome them. A goal review should be
done with a partner, coach, or someone else who can help by
providing accountability. Often just a little insight and
perspective from an alternate point of view can help an
individual find ways around issues that could not be seen
through alone. Goal review is one of the ten conditions under
which goal-setting theory operates. It is a key ingredient in
the formula for exercise program adherence.
11. If adherence does not improve utilize professional
assistance and programming. (See `1. Getting Support')
12. Consider additional physiological parameters: Study
results indicate the practical importance of considering an
individual's preference for exercise intensity, mode, and
personal schedule when exercise program adherence is at issue.
Tailoring of these parameters to meet an individual's specific
needs and goals can contribute to maximal results, increased
enjoyment, and ultimately longevity of adherence.
Physiological parameters for exercise program adherence should
include engaging in a physical activity that you enjoy at a
comfortable intensity for at least a half hour a day on most
days of the week, for at least a six month period. In the
experience of this author, practice makes perfect. When
individuals return after attrition from a previous exercise
program, the likelihood that an individual will maintain a
successive program for a longer and longer period of time
increases. There seems to be a point at which an awakening
occurs, and individuals intrinsically understand the need for
exercise as a part of their regular lifestyle. Even if they
again cede their exercise program a second or third time, the
plan to return to a lifestyle of regular exercise is ever-
whispered for their immediate future. For this reason it is
important that if individuals do not achieve a six-month
program longevityor go beyond that but still drop out at a
later datethat attempts are made always made to reintegrate
exercise back into their life as soon as possible. With
persistence, practice, and perseverance, sooner or later they
will get it right.
Conclusion
At the conclusion of this review two ideals have been
attempted: 1) a universal definition for design and
implementation of exercise program adherence including
parameters for frequency, duration, intensity, mode and
longevity of behavior, and 2) the best approach to achieving the
parameter for longevity of behavior, as well as how the
parameters of frequency, duration, intensity, and mode can be
best manipulated for success.
Let the following criteria serve as: 1) a universal minimum
practical recommendation for exercise program adherence design
and implementation:
Frequency: `4 days/week
Duration: `30 minutes
Intensity: as high as tolerable to the individual
before discomfort ensues
Mode: the most enjoyable to the individual
Longevity: ` 6 months
Based on this review of the literature, the following
parameters are proposed as: 2) a minimum practical
recommendation for the promotion and longevity of exercise
program adherence:
1. Get support
2. Connect to motives
3. Identify obstacles/barriers
4. Consider personality
5. Note age and gender
6. Check expectations
7. Define needs/goals
8. Plan activity
9. Find enjoyment
10. Review weekly
11. Seek professional assistance as needed
12. Include physiological parameters
o Frequency: most days of the week (` 4days/week)
o Duration: `30-60 minutes
o Intensity: as high as tolerable to the
individual before discomfort ensues
o Mode: the most enjoyable to the individual
o Longevity: ` 6 month intervals
Acknowledgements
This review was completed with the extreme patience and
understanding of Dr. Walter Secada and Dr. Arlette Perry. Thank
you.
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