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  • Three Cheers for Ambivalence!

    by Greg Margason | Oct 13, 2022
    Sunset photo

    One element of the many skills developed as part of a coaching approach is the use of motivational interviewing (MI)(1). MI first emerged as a means of supporting people to manage significant and enduring addictions; however, its efficacy generally in supporting behavioral change is well documented. MI is a collaborative and conversational engagement with the client that does not give primacy to expert knowledge. Rather, this knowledge is offered “just in time” and only when absolutely necessary to support behavioral change. 

    One of the very useful features of motivational interviewing is the conceptualization of ambivalence. Coming from two Latin words, ambivalence literally represents the idea of “both options having strength” to the person. In practice, ambivalence is often seen as a problem to be overcome in the client, and this can lead very quickly to the health care provider engaging in an ultimately unhelpful tug-of-war — trying to pull the client toward a particular behavioral change while the client pulls equally strongly, arguing for the value they see in not changing. 

    But ambivalence ought not be seen in this problematic way. Rather, it can be viewed as an opportunity to celebrate purpose and drive. Why? The person experiencing ambivalence is feeling driven toward two (or more) quite different outcomes. If ambivalence can be conceptualized in this way, it ceases to be a problem to be solved and can be looked upon as an energy or impetus within the client to be worked with — much better to have a desire for multiple possible outcomes than no desire for any. 

    We all experience ambivalence, and we experience it frequently throughout life. If you’ve ever scanned a café menu and felt an urge for two different breakfast options, or experienced the pleasurable dilemma of being invited to two social events occurring simultaneously, or felt thrilled and terrified at the same time as your roller coaster car crests the top of the rise, you’ve had an experience of ambivalence. 

    How can coaches work effectively with ambivalence to support client autonomy and create the conditions most favorable to health behavior change? 

    Firstly, employ the fundamental tools of engaging communication and connection — deep listening, reflection of what is being said (and not said) and open inquiry to understand more. While there are many types of reflection in interpersonal communication, two approaches that particularly support working with ambivalence are empathy reflections and double-sided reflections(2). An empathy reflection seeks to reflect the full experience of the person, not only their words: 

    Client: I really wanted to get to 30 minutes of continuous walking this week, but I just couldn’t. 

    Coach: You’re feeling disappointed that you didn’t reach the goal you set for yourself. 

    A double-sided reflection seeks to capture all aspects of a person’s feelings about change, not only those related to the benefits of change: 

    Client: I know that moving more could help, but I’m just so afraid of ending up in the sort of pain I was in last year. 

    Coach: You’re keen to experience the benefits of more movement, and wary of unintended setbacks too. 

    Learn the signs that indicate ambivalence. It frequently shows up in consultations as a combination of change talk and sustain talk(1) or as the client beginning to redirect or correct your efforts to influence their choice. Change talk embodies the client expressing desires, abilities, reasons or needs to make a change. Sustain talk, on the other hand, represents views expressed by the client that seek to justify or legitimize not changing. As a practice point, it’s important to avoid what Miller and Rollnick refer to as “the righting reflex” — the tendency of the practitioner to respond to sustain talk with change talk. This leads to a polarizing interaction in which the practitioner more and more strongly occupies the change talk space and the client strongly occupies the sustain talk space. If this continues, the client will likely become irritated or agitated with the coach and feel unheard and misunderstood. In practice, the polarizing interaction could look like this: 

    Coach: If you were to begin to gently increase the amount of exercise that you do, what do you think might be the benefits? 

    Client: Well, I’m not sure. Last time I tried that, the pain in my knees was unbearable.  

    Coach: A short-term increase in pain is to be expected here, but it’s important that you understand that your condition won’t improve if you don’t start moving more. 

    Client: But I just couldn’t stand any more pain than I have already … 

    If you think you recognize ambivalence, then don’t just do something — instead, sit there. Resist the urge, if present, to convince the client through force, facts or fear about the imperative of change. Instead, take time to listen and understand the value the client sees in continuing along their current path. This can be done by using the decisional balance tool(3). 

    The decisional balance tool provides a means for dispassionately exploring the client’s perceived benefits and disadvantages of modifying their behavior, and also continuing as they are; however, it is best approached in a particular order, beginning with the perceived advantages of not changing. This meets the client at the strongest point of their ambivalence. It also demonstrates a desire to understand the reasons for this and avoids the perception on the part of the client that the coach may be pushing for change. 

    From here, move to inquiring of the client the disadvantages they perceive in modifying or changing their behavior. Once this has been explored and reflected, inquiry about the disadvantages of not changing may be explored. Finally, conclude with a discussion about the perceived advantages of modifying behavior. When undertaken in this way, the client has walked systematically through all areas of their perceptions and concerns, and if appropriate, the discussion can continue, focused on what the client might do to begin the process of change. A decisional balance process may look like this: 

    Coach: What are the benefits you see for yourself in not making any changes to your exercise and activity habits? 

    Client: Well for one thing I won’t get the pain — it’s a killer when that happens. I really can’t stand it. 

    Coach: Mm-hmm. What about the disadvantages you see in increasing the amount of exercise that you do? 

    Client: Apart from the pain, I guess I’d have to re-organize some things in my day to make time for it. And I’m really not sure if I’d be doing the right thing — it’s a long time since I exercised. And I don’t know what’s going to be helpful and what may not be. 

    Coach: OK. You’re uncertain about the steps to take and whether they’re the right ones. Tell me about the risks you see in not making any changes. 

    Client: All the things you and I have spoken about already — my mobility will continue to decline, and the pain I get probably won’t ever really go away completely. And in a few years’ time I may find that I’m even less able to do things I want to do. And as I say that now, I worry about that because I really want to travel after I retire. 

    Coach: Right. You need mobility for your vision for the future. So what are the benefits to you of making a change to your patterns of exercise? 

    Client: I do know that exercise will help — and I do really want to be able to move around more freely and without pain. My wife and I have been talking for years about walking the Camino de Santiago when we retire … 

    Lastly, remember the central role that autonomy plays in human behavior. Autonomy is a primary psychological need of all sentient creatures(4,5). If you want to see it in action, observe your dog next time you try and encourage him or her to move away from a scent that’s exciting and interesting. The drive to preserve autonomy may also be particularly strong in those who have experienced trauma. Nothing guarantees that any particular client will engage in behavioral change; however, honoring autonomy maximizes the likelihood that the client will engage in a behavior that has meaning and value to them and which they will be able to sustain in the long term. 

    So we should not be afraid of ambivalence — instead, quietly celebrate the energy and interest your client has in exploring and experiencing so many dimensions of life. By always honoring autonomy, and systematically reviewing all dimensions of a possible change, we can help build a solid foundation on which lasting change — driven by deeply held values — can be cultivated. 

     

    References 

    1. Miller WR and Rollnick S. Motivational Interviewing: Helping People Change. Guilford Press; 2012. 482 p. 

    2. Moore M, Jackson E, Tschannen-Moran, R. The Coaching Psychology Manual. 2nd ed. Lippincott Williams; 2015. 82-85 p. 

    3. Miller WR and Rose GS. Motivational interviewing and decisional balance: contrasting responses to client ambivalence. Behav Cogn Psychother. 2015 Mar;43(2):129-41. doi: 10.1017/S1352465813000878. 

    4. Deci EL, Ryan RM. Self‐determination. In Craighead WE, Nemeroff C, editors. The Corsini Encyclopedia of Psychology; 2010. p. 1-2. 

    5. Deci EL, Ryan RM. 1985. Intrinsic Motivation and Self-Determination in Human Behavior. Boston: Springer; 1985. 11-40 p. 

    Simon Matthews is a Psychologist, Board Certified Lifestyle Medicine Professional and Fellow of the Australasian Society of Lifestyle Medicine. He is a member of the Wellcoaches Faculty and CEO of Wellcoaches Australia. 

  • A Sedentary Lifestyle Is Linked to Functional Decline, But Any Movement Can Help

    by Greg Margason | Oct 07, 2022

    A Sedentary Lifestyle Is Linked to Functional Decline, But Any Movement Can HelpTechnological advancements in the past 60 years have led to an increasingly sedentary lifestyle. Changes in transportation, communication, the workplace and domestic entertainment have fostered environments in occupational, home and social settings that now demand or encourage sedentary behavior throughout most of the day. In recent years, we have become more aware of the negative impact of a sedentary lifestyle on health and longevity. Research shows that being sedentary for long periods of time increases risk for diabetes, heart disease, some cancers and death. However, less is known about the relationship between sedentary behavior and quality of life outcomes such as physical function. As we age, maintaining mobility and preventing disability are keys to living independently; thus, identifying modifiable risk factors to target to prevent loss of physical function is critical to support healthy aging. 

    Current studies on the relationship between sedentary behavior and declines in physical function have yielded mixed results. In addition, little is known about what type of physical activity should replace sedentary time to prevent declines in physical function. Our study, published in Medicine & Science in Sports & Exercise®, sought to address these questions. We analyzed data from a U.S. national study of over 5,000 middle-aged and older adults. In the study, a physical activity monitor was used to measure a person’s movements and sedentary time throughout the day for one week. We then measured the participants’ physical function an average of 3.6 years later. 

    We found that greater time spent sedentary was linked to poorer physical function at follow-up. For example, participants who were more sedentary performed slower on both timed walk and chair-stand tests, and self-rated their physical function to be poorer. But we found that sedentary behavior didn’t have the same effect for people who engaged in regular moderate- or vigorous-intensity physical activity (i.e., exercise). Sedentary behavior was not linked to poorer physical function at follow-up for people who engaged in ~50 minutes or more per week of exercise. In other words, modest amounts of regular exercise may protect against the harms of sedentary behavior as it relates to declines in physical function. 

    Using the collected data, we also estimated how substituting time spent sedentary with time being physically active would affect physical function at follow-up. As expected, we found that replacing 30 minutes of sedentary time with moderate- or vigorous-intensity physical activity would yield the greatest improvements in physical function. But notably, we also found that swapping the same amount of sedentary time for light-intensity physical activity also would yield improvements in physical function. This finding underscores an important public health message: Any physical activity, no matter how intense, provides health benefits. 

    Ultimately, our findings show that a sedentary lifestyle may be linked to declines in physical function over time. However, physical activity of any intensity may protect against these declines. While regular exercise still provides the best “bang for your buck,” our findings are good news for people who may not have the time, ability or desire to exercise. The road to an active lifestyle that promotes healthy aging is more accessible and achievable than we thought. 

    Keith Diaz
    Keith Diaz, Ph.D.    , is an ACSM Certified Exercise Physiologist® and the Florence Irving Associate Professor of Behavioral Medicine at Columbia University Medical Center. Dr. Diaz is director of the Exercise Testing Laboratory and Wearable Device Reading Center at the Center for Behavioral Cardiovascular Health. He conducts scientific research to elucidate the role of prolonged sedentary behavior in the development of chronic diseases, with a specific focus of optimizing feasible, sustainable and cost-effective guidelines for reducing prolonged sitting. Dr. Diaz is a member of ACSM and serves on the Pronouncements Committee. 

    Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB. 

  • Resistance Exercise Increases Gastrointestinal Symptoms, Markers of Gut Permeability, and Damage in Resistance-Trained Adults

    by Greg Margason | Sep 30, 2022
    Resistance Exercise Increases Gastrointestinal Symptoms, Markers of Gut Permeability, and Damage in Resistance-Trained Adults

    Gastrointestinal (GI) discomfort can occur as an unfortunate byproduct of physical exercise. While this phenomenon has been thoroughly outlined in endurance athletes, only one study to date has measured and reported increased markers of GI injury following resistance exercise that coincided with decreased nutrient absorption.

    Grand View Market research estimates the global digestive health market will reach $58 billion by 2025. Currently, dietary supplements and food products (e.g., probiotics, prebiotics, green powders, fermented drinks) aimed at improving GI function are heavily marketed toward active individuals with anecdotal or limited peer-reviewed evidence indicating the occurrence of GI damage in resistance-trained individuals. We sought to replicate these earlier findings while providing additional data on GI symptoms and permeability in resistance-trained individuals.

    In our study recently published in Medicine & Science in Sports & Exercise®, we examined the effect of acute resistance exercise on GI symptomology, damage and permeability in resistance-trained individuals. 

    To accomplish this, we utilized GI symptom questionnaires previously implemented with aerobic athletes and measured common blood markers of GI damage (intestinal fatty-acid binding protein) and GI permeability (lactulose/rhamnose ratio). Our trained participants (15 men and 15 women aged 23.9 [± 3.9] years with 6.3 [± 3.9] years of resistance training experience) completed a hypertrophy-style workout consisting of exercises that produce high amounts of intra-abdominal pressure (i.e., squat, deadlift, leg press) as we hypothesized that intra-abdominal pressure was likely a primary contributing mechanism for GI damage and distress during resistance exercise.

    Our results suggest that resistance exercise induces significant GI distress, with 70% of participants reporting at least one GI symptom, most commonly nausea, and 60% reporting at least one moderate symptom after the exercise session, with no differences between sexes. Similar to studies examining GI distress following aerobic exercise, it appears that biomarkers of GI injury do not seem to consistently relate to subjective symptoms. Furthermore, resistance exercise induced elevation in GI permeability (measured by lactulose/rhamnose ratio) with males experiencing a greater magnitude of permeability compared to females. Additionally, males experienced a greater magnitude of GI damage following exercise (measured by intestinal fatty-acid binding protein) compared to the female conditions.

    So, do males experience more GI distress from lifting weights? Interestingly, our findings indicated that the magnitude of GI damage following exercise is directly correlated with absolute strength. Thus, it is likely that our male participants experienced more GI distress because they lifted heavier absolute loads resulting in higher amounts of intra-abdominal pressure.

    Our findings suggest that resistance exercise produces GI distress and that absolute load may be a primary mechanism. Our data are also in agreement with aerobic exercise studies, which demonstrate that GI symptoms do not always correlate to markers of GI damage following exercise.

    With limited research in this area, our results emphasize the need for examining further implications of increased GI permeability, damage and subjective GI symptoms in resistance-trained athletes. We hope our study encourages future work to identify strategies (e.g., dietary supplements, nutritional regimens) that alleviate these side effects to optimize performance and nutrient utilization.

    About the Authors:

    Tricia Hart

    Tricia Hart, M.S.    , is a Ph.D. student in nutritional sciences at Penn State University in State College, Pennsylvania. Her research interests include nutritional strategies to improve sport performance and resistance training and nutritional interventions to mitigate chronic disease.


    Jeremy Townsend

    Jeremy R. Townsend, Ph.D.    , is an associate professor in exercise and nutrition science at Lipscomb University in Nashville, Tennessee. His research focuses on resistance training and nutritional interventions for optimizing sport performance and recovery.


    Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

  • Tips for Presenting an Award-Winning Poster at an ACSM Regional Chapter Meeting

    by Caitlin Kinser | Sep 26, 2022

    Woman talking to a man and pointing to a research posterAs graduate students, we spend tireless hours collecting data, gaining knowledge about our field, and learning new laboratory techniques (often into the wee hours of the morning). Conferences provide us an opportunity to finally showcase our hard work. Presenting your research at conferences is one of the best opportunities to tell your story as a graduate student.  

    This spring I presented a poster at the Rocky Mountain ACSM Regional Chapter meeting and was ultimately named the 2022 ACSM President’s Cup winner at the national annual meeting. However, long before I presented my poster at the Regional Chapter, I went through several iterations of red-inked proofreads. I learned a lot about what to do and what not to do. If you are planning to present a poster at an ACSM regional chapter meeting, consider these tips to increase the effectiveness of your presentation.

    Read every part of your poster out loud (even the references).

    Making errors when creating a poster is inevitable, but reading your poster out loud helps you catch these errors. Remember, your research should tell a story. As you read your poster out loud, listen and make sure your poster is clear and easy to follow from start to end. 

    Use fellow students as resources.

    Research is rarely completed alone, and therefore you should not complete your poster alone. Rely on your fellow students to proofread. Often other people can catch errors that you might miss, especially if you created the poster while sleep deprived (we have all been there!).

    Create a visually appealing poster.

    It is important to create a poster that stands out among the competition. Breaking up the text on your poster with scientific images is a key way to make your poster stand out. Consider supplementing your introduction section with an image demonstrating your aims and hypotheses or consider implementing a protocol schematic into your methods section. An excellent resource is BioRender. It is free and has thousands of relevant life-science icons.

    Set aside extra time to print your poster.

    Often when you print your poster, you will catch formatting errors or blurry images that you did not see on your computer screen. It is immensely helpful to have extra time to fix and re-print your poster when any of these issues arise. It is worth the time to fix these issues before you leave for your conference.

    Be familiar with the judging rubric.

    Seek out the judging rubric specific to the conference. For the ACSM regional chapter, the judging rubric equally weighs significance, innovation, project design, ability to respond to questions and poster design/presentation skills. It is important that you spend time working on each part. It is tempting to focus solely on the visual aspect of the rubric, but the oral aspect of the rubric is equally important.

    Craft a compelling elevator pitch.

    An elevator pitch is a quick (~30 second) synopsis of your research story that appeals to your audience.  Once you get the attention of your audience, you can go into detail about your experimental design and relevant results. When you are at the conference, there will come a point in time where the judge will approach your poster and ask you to explain your project. If done well, this is a moment where you can shine.
    lightbulb iconTIP: Implement the “ABT” formula (ABT=And, But, Therefore) to nail your elevator pitch. The “ABT” formula is a universal story structure which is highly successful in scientific communication. Use the word “and” to set up the scientific story by establishing a few facts. Next, use the word “but” to establish the problem or a gap in knowledge. Finally, use the word “therefore” to suggest the solution that your research attempts to address; you can think of this as your purpose statement.

    Field questions from people with a variety of backgrounds.

    The judges assigned to your poster will likely have diverse scientific backgrounds. Therefore, when preparing for your poster presentation, practice fielding questions from people with a variety of backgrounds. Present your poster to your mom, your classmates, your professors–heck, you could even present your poster to your crazy neighbor. Consider how someone from an industry perspective might perceive your research compared to someone from a molecular science perspective. Not only will this prepare you for any question you may receive, but it will also allow you to consider your research from a broader viewpoint.

    Make sure your poster adheres to the ACSM Regional Chapter guidelines.

    Every conference has slightly different poster guidelines. Make sure you follow the guidelines closely. Be familiar with specific poster requirements like the size requirements, inclusion/exclusion of an abstract and recommended sections headers. This is a small, but crucial, way to demonstrate your attention to detail.

    Ultimately, presenting your research at conferences is a fun opportunity to showcase your work and knowledge. When done well, a poster presentation can help you build a reputation as a highly rigorous scientist with impeccable research skills and attention to detail. Good luck as you prepare for ACSM regional chapter meetings!

    Watch Sophie's Winning presentation: "One Week of Time-Restricted Eating Improves Markers of Cardiometabolic Health in Healthy Adults."

     


    Sophie Seward, MS, is a Ph.D. candidate at Colorado State University in the Sleep and Metabolism Laboratory. She is specifically interested in the impact of lifestyle interventions to improve cardiovascular health such as exercise, diet, heat therapy and sleep in people at risk for cardiovascular impairments. She is the winner of the 2022 Presidents Cup at the ACSM Annual Meeting, representing the Rocky Mountain chapter. 

  • Capitalizing on Accelerometry to Measure Performance Fatigability in Older Adults

    by Greg Margason | Sep 23, 2022

    Capitalizing on Accelerometry to Measure Performance Fatigability in Older AdultsFatigability is not a new concept in the exercise physiology realm. Researchers have long paired physical activity measures with ratings of perceived exertion or contractions of isolated muscle groups during tasks to quantify self-reported or muscle fatigability. Of late, the term “fatigability” has evolved and is widely used in aging research to represent a whole-body trait of an individual’s vulnerability to fatigue anchored to standardized physical task(s) of specific duration and intensity. This represents a sensitive prognostic marker of deleterious aging. More severe fatigability is associated with lower physical activity levels, higher chronic inflammation, greater cardiovascular burden and brain atrophy. Importantly, older adults manifesting more severe fatigability are at greater risk for functional limitations, mobility decline, frailty and even death.

    Fatigability is highly prevalent, with more than one in four older adults ≥ 60 years of age reporting feeling more severe physical fatigability in their everyday life. Sensitive and validated tools exist to measure perceived fatigability (i.e., what an individual thinks they can do). A common method is to rate one’s perceived effort following a standardized physical task or via self-administered questionnaire (e.g., Pittsburgh Fatigability Scale) that includes physical activities ranging across type, intensity and duration. Another construct of fatigability, performance fatigability (i.e., what an individual does do), is quantified as decline in velocity or decrement in performance during a physical task (primarily walking-based). However, the assessment of performance fatigability lacks validated objective measurements. With advances in technology and statistical methods, we can now detect detailed features of walking patterns with wearable devices. Thus, we developed the Pittsburgh Performance Fatigability Index (PPFI) to objectively quantify performance deterioration during in-lab walking tasks using accelerometry.

    Our study, published in the October 2022 issue of Medicine & Science in Sports & Exercise®, described the derivation of the PPFI using wrist-worn tri-axial raw accelerometer data. Conceptually, PPFI quantifies the percentage of cadence decline during a walking task from participants’ own maximal cadence. We applied PPFI in a study of 63 older adults (mean age 78 years, 56% women) and calculated PPFI scores during fast-paced and usual-paced 400-meter walks. The PPFI scores from both types of walks were associated with physical function, gait speed, chair-stands speed, physical fitness and mobility. Collectively, these findings revealed that PPFI is a valid and sensitive objective measure of performance fatigability for older adults.

    The novelties of the PPFI include the objectiveness of quantifying granular-level slowing down and the ability to compare scores across various in-lab walking tasks. Using accelerometry makes it easier to measure performance fatigability in large population-level studies, and more importantly it enables an early detection of minimal performance decrement to inform clinical decisions. Additionally, utilizing accelerometry opens up the potential to continuously monitor fatigability in real-world settings as older adults tend to over-perform in the lab. Objectively measuring performance fatigability “in the wild” may better represent what one can actually do. Including PPFI in future studies and clinical practice can deepen our understanding of causes and potential therapeutic targets to ameliorate the adverse effects of fatigability in older adults to prevent disablement, mitigate disease burden and promote healthy aging.

    Nancy GlynnNancy W. Glynn, Ph.D., is an associate professor of epidemiology and director of master’s degree programs at the University of Pittsburgh School of Public Health. She is a physical activity epidemiologist with advanced training in exercise physiology. Dr. Glynn’s work focuses on novel methods of measuring fatigability and physical activity in older adults to understand their role in the disablement pathway. She designed and validated the novel Pittsburgh Fatigability Scale, a widely used tool to measure perceived physical and mental fatigability in older adults that is currently available in 16 languages. Dr. Glynn is a member of ACSM and serves as chair of the Aging Interest Group.

    Yujia Susanna Qiao
    Yujia (Susanna) Qiao, Sc.M.    , is a doctoral student in the University of Pittsburgh Department of Epidemiology. She is trained as an epidemiologist and specializes in accelerometry, physical activity, physical function and aging. Her research interests center on wearable technology for human health and performance monitoring. Her dissertation work focuses on utilizing accelerometer-derived gait patterns to understand the disablement pathway. She plans to graduate in 2023 and is excited to apply her current research to real-world big data.

    Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

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