Motiv Emot (2017) 41:294–307
DOI 10.1007/s11031-017-9608-8
ORIGINAL PAPER
Change in physical and psychological health over time in patients
with cardiovascular disease: on the benefits of being self-
determined, physically active, and eating well
Camille Guertin1   · Luc G. Pelletier1 · Claudie Émond2 · Gilles Lalande2
Published online: 28 March 2017
© Springer Science+Business Media New York 2017
Abstract  This study tested a longitudinal model examin-
ing the roles of motivation and perceived competence in the
prediction of physical activity (PA) and healthy eating (HE)
in individuals with cardiovascular diseases, and the effects
of adopting these behaviors on individuals’ health. Partici-
pants completed measures of global motivation (baseline),
contextual motivation and perceived competence for PA
and HE (3 months), and self-reports of PA and HE behav-
iors (6 months). Physiological indicators and life satisfac-
tion were assessed at the baseline and at 12 months. Struc-
tural equation modeling supported that individuals with
self-determined motivation (SDM) were more likely to
feel competent in changing their lifestyle and to engage in
moderate and strenuous (vs. mild) exercise and HE behav-
iors, which had beneficial effects on individuals’ physi-
ological and psychological health. This research confirms
the respective roles of SDM and perceived competence
in the health behavior change process and emphasizes the
key function of SDM in the adherence of healthy behaviors
over time.
* Camille Guertin
cguer052@uottawa.ca
Luc G. Pelletier
Luc.Pelletier@uottawa.ca
Claudie Émond
Claudie_Emond@uqac.ca
Gilles Lalande
Gilles_Lalande@uqac.ca
1
University of Ottawa, 136 Jean Jacques Lussier, Ottawa,
ON K1N 6N5, Canada
2
Université du Québec à Chicoutimi, 555 Boul. de
l’Université, Chicoutimi, QC G7H 2B1, Canada
13
Vol:.(1234567890)
 
Keywords  Motivation · Perceived competence ·
Exercise · Healthy eating · Cardiovascular diseases
Introduction
Substantial progress in the medical field has been made
over the past decade in the fight against cardiovascu-
lar diseases (CVD) in North American societies (Heart
and Stroke Foundation 2015). Research has been directed
toward surgical procedures, drug therapies and prevention
efforts to manage and reduce the prevalence of CVD (Heart
and Stroke Foundation 2015). Despite remarkable efforts,
CVD still account for approximately 17.3  million global
deaths per year and this number is expected to rise up to
23.6  million by the year of 2030 (American Stroke Asso-
ciation 2014). Although some of the main causes of CVD
are out of individuals’ control, adopting healthy behaviors
can often prevent these diseases.
A healthy lifestyle remains the cornerstone of CVD pre-
vention and also constitutes an integral part of the reha-
bilitation process for patients with established CVD. More
specifically, recommendations for heart disease prevention
and recovery from the Heart and Stroke Foundation (2014)
and the American College of Cardiology/American Heart
Association Task Force (Jensen et  al. 2013) include mak-
ing healthy food choices and engaging in various types of
physical activities daily. Although patients with CVD are
recommended to modify their lifestyle by adopting physi-
cal activity (PA) and healthy eating (HE) behaviors, no
research has yet examined whether individuals who receive
a diagnosis of CVD implement changes in both behaviors
simultaneously and to what extent these behaviors con-
tribute to individual’s health. Achieving and maintaining
behavior change is a challenge for many individuals; thus,
Motiv Emot (2017) 41:294–307 295
investigating the processes that govern short- and long-term
maintenance of these behaviors is an important avenue of
research. Using constructs from self-determination theory
(SDT), this research aims to address these issues.
Self‑determination theory
Self determination theory (SDT; Deci and Ryan 2008) is a
theory of human motivation that focuses on the processes
through which individuals come to self-regulate and inte-
grate behavior into their lives. Within SDT, two broad types
of motivations (self-determined and non-self-determined)
are distinguished and can be divided into behavioral regu-
lations that fall along a continuum of self-determination.
Non-self-determined motivation (NSDM) concerns behav-
ior that is engaged in for no specific reason (amotivation),
out of coercion or obligation (external regulation), and/or
internal pressures of guilt (introjected regulation). Self-
determined motivation (SDM) is related to behavior that
is engaged in because it is considered important (identified
regulation), it is congruent with other life goals and values
(integrated regulation), and/or it is inherently pleasurable
(intrinsic regulation). According to SDT, the different types
of regulations evolve through the process of internaliza-
tion, which refers to the active transformation of experi-
ences initially regulated by external factors, into a coherent
sense of self where the individual becomes more autono-
mous when enacting the activity. This internalization can
occur at different levels of generality (global, contextual or
situational) and each level is thought to influence the next
proximal level through top-down and bottom-up processes
(Vallerand 1997). In the health domain, SDM is consid-
ered critical because the more autonomous an individual
is in the regulation of an activity, the more likely the indi-
vidual will demonstrate effort, engagement, and persistence
toward the behavior (Patrick and Williams 2012; Ryan and
Deci 2000).
Research has repeatedly documented the benefits of
self-determined (vs. non-self-determined) motivation both
in the exercise (Verloigne et  al. 2011; Silva et  al. 2008,
2011; Russell and Bray 2009) and eating regulation (Hart-
maan et al. 2015; Pelletier et al. 2004; Hagger et al. 2006)
domains. For instance, in the PA domain, Verloigne et  al.
(2011) demonstrated that higher scores of relative auton-
omy, intrinsic, and identified regulations were related to
higher levels of total PA, sports participation, and active
transportation in a sample of obese adolescents who were
undertaking an obesity treatment program. In another
obese sample, Silva and colleagues (2011) examined the
relationship between motivational regulations and exer-
cise behavior (i.e., moderate/vigorous and lifestyle PA) and
their results revealed that only intrinsic motivation was pos-
itively associated with moderate/vigorous PA, but not with
lifestyle PA. In relation to the eating regulation domain,
Hartmaan et  al.(2015) examined the relationship between
body weight motivation (i.e., autonomous, introjected, and
external regulations) and changes in food choices in an
adult population and results showed that only autonomous
motivation was predictive of long-term dietary improve-
ments. Previous research has also demonstrated that global
motivation positively predicts contextual motivation for PA
and HE in patients with CVD (Guertin et al. 2015; Pelletier
et al. 2004, study 3; Slovinec-D’Angelo et al. 2007, 2014).
Although much of SDT research focuses on under-
standing the relationship between motivation and behav-
ior regulation, another central concept of SDT that can
help explain why individuals engage in healthy behaviors
is perceived competence. According to SDT, perceived
competence refers to an individuals’ sense of capability in
interacting with the social environment and experiencing
opportunities to exercise one’s capacities (Deci and Ryan
2002). Although the concepts of perceived competence
and self-efficacy, a central mechanism of social cognitive
theory (Bandura 1997), have been shown to conceptually
and statistically differ from one another, they are simi-
lar in the sense that (1) they both contribute to goal pur-
suit and attainment; (2) they are both considered processes
in nature, such that they promote behavioral engagement;
and (3) they are both cyclical in the sense that successful
experiences predict higher perceived competence (or self-
efficacy beliefs), whereas failure experiences predict lower
perceived competence (or self-efficacy beliefs; Rodgers
et  al. 2014). The similarities between both constructs are
important, considering that scholars (Rothman et al. 2004)
have recently proposed that motivation and self-efficacy
play unique roles in the behavior change process. More
specifically, the researchers propose that self-efficacy is of
prime importance during the initiation phases of behavior
change and that, as an individual moves toward the main-
tenance phases of behavior change, motivation becomes
more prominent. To remain consistent with the SDT frame-
work, perceived competence (as opposed to self-efficacy)
will be used in the present study.
Integrating motivation and perceived competence
in behavior change models
Of interest to the present research, three studies have
investigated Rothman et  al. (2004) propositions in behav-
ior change models amongst patients with CVD. In the
first study, Slovinec-D’Angelo et  al. (2007) examined the
roles of both constructs in predicting the initiation, which
was represented by intentions, and maintenance, which
was represented by planning, of exercise behavior during
cardiac rehabilitation. Their results provided support for
Rothman et  al. (2004) propositions by demonstrating that
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self-efficacy was more related to patients’ intentions to
exercise, whereas SDM was more related to patients’ plan-
ning of exercise. In the second study, Slovinec-D’Angelo
et  al. (2014) reported similar results, such that SDM and
self-efficacy were both predictors of short-term (6-month)
exercise behavior, but only SDM was a significant predic-
tor of long-term (12-month) exercise behavior. Finally, in
the context of eating regulation, Guertin et al. (2015) found
that self-determined, relative to non-self-determined, moti-
vation was positively associated with self-efficacy toward
HE at 3 months, which, in turn, led to healthier eating hab-
its at 6 months and improved physiological indicators (i.e.,
triglycerides, waist circumference and cholesterol) and life
satisfaction at 12 months. To establish the roles of motiva-
tion and self-efficacy in the initiation and maintenance of
behavior change, two different models were tested in all
three studies. The first model examined self-efficacy as a
mediator between motivation and PA or HE behaviors. The
second model examined motivation as a mediator between
self-efficacy and PA or HE behaviors. The results were
consistent across all studies; the models examining self-
efficacy as a mediator showed a better fit than the alterna-
tive models that examined motivation as a mediator.
Objectives and hypotheses
The previous studies provide interesting results by suggest-
ing that individuals need to feel motivated and confident in
their abilities to initiate behavior change, and that SDM is
especially important for the maintenance of behavior in the
long-term. Although these studies have important implica-
tions for understanding motivational processes involved in
the initiation and maintenance of health behaviours, a limi-
tation of these studies is that only one health behavior (i.e.,
PA or HE) was examined in the models. The examination
of the regulation of PA and HE in combination is impor-
tant since patients with CVD are often recommended to
modify their overall lifestyle by engaging in both behaviors
to improve their health (Jensen et  al. 2013; Teixeira et  al.
2015). More specifically, following a cardiac incident, indi-
viduals should be active and should follow a healthy diet to
experience maximum health benefits and recover from their
illness. To address this limitation, this study will extend the
model proposed by Guertin et  al. (2015) by adding PA to
their model. The primary aim of the present study was thus
to investigate how global and contextual motivation and
perceived competence predict the adoption of PA and HE
behaviors jointly, and whether the adoption of these behav-
iors predicts improvements in physiological and psycho-
logical health over time. In line with Guertin et al. (2015)
study, life satisfaction represented psychological health in
the present study since life satisfaction has been shown to
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Motiv Emot (2017) 41:294–307
be associated with mortality and adverse health behaviors
(Baumann et al. 2015; Koivumaa-Honkanen et al. 2000).
Furthermore, regarding PA behaviors, in agreement with
recommendations from the Surgeon General (U.S. Depart-
ment of Health and Human Services 1999), Godin (2011)
suggested that only moderate and strenuous (vs. mild) types
of PA are strong contributors to health benefits. Although
some research recommends individuals with CVD to
engage in moderate/strenuous PA to reverse their illnesses
(e.g., Thompson et al. 2003; Pate et al. 1995), no study has
yet examined the comparative roles of moderate/strenuous
and mild PA in the prediction of improved health amongst
individuals with CVD. In order to examine this propo-
sition, the secondary aim of this paper was to investigate
whether moderate/strenuous PA, in comparison to mild
PA, predict changes in individual’s health over time. It is
noteworthy that the present study extends upon the study of
Guertin et al. (2015) by examining (1) whether motivation
and perceived competence predict individuals’ engagement
in two (vs. one) health behaviors and (2) whether moder-
ate/strenuous PA predict more variance than mild PA in the
prediction of individuals’ physical and psychological health
over time.
As depicted in Fig.  1 and consistent with past
research, it is expected that (1) global SDM at baseline
will positively predict contextual SDM for PA and HE
behaviors at 3 months, which should further be posi-
tively associated with perceived competence for PA and
HE behaviors at 3 months. In contrast, (2) global NSDM
at baseline should positively predict contextual NSDM
for PA and HE behaviors at 3 months, which should
further be negatively associated with perceived compe-
tence for PA and HE behaviors at 3 months. Considering
that individuals in the current sample needed to signifi-
cantly change their behaviors to improve their health, it
is expected that (3) perceived competence for PA at 3
months will mainly predict the engagement in moder-
ate/strenuous PA at 6 months and to a lesser extent the
engagement in mild PA at 6 months and that (4) per-
ceived competence for HE at 3 months will positively
predict HE behaviors at 6 months. In line with Godin’s
(2011) suggestion, it is also expected that (5) only mod-
erate/strenuous PA at 6 months will predict reductions
in physiological indicators (triglycerides, cholesterol,
and waist circumference) at 12 months, while mild PA
will not predict changes in the physiological indicators.
Finally, in agreement with previous research (Guertin
et  al. 2015; Pelletier et  al. 2004, study 3) (6) HE at 6
months should predict reductions in the three physiolog-
ical indicators and (7) both moderate/strenuous PA and
HE behaviors at 6 months should predict improvement in
life satisfaction at 12 months, while mild PA should not.
Motiv Emot (2017) 41:294–307 297
Since measures of waist circumference differ between
genders (Stevens et al. 2010; World Health Organization
2008), this variable was included as a potential covariate
in the model.
Methodology
Participants
Participants (N = 525; 124 women and 401 men) aged
28–75 years old (M = 60.83; SD = 8.50) were recruited
from the Hospital Centre for Health and Social Services
in Chicoutimi (HCHSSC) in Québec (Canada), following
a major cardiac incident. Information on the study was
given to the participants immediately after an annual cor-
onary angiography or after having received a confirmed
diagnosis of myocardial infarction or acute coronary syn-
drome. Individuals aged 18–78 who had received a con-
firmed diagnosis of atherosclerotic CVD were eligible to
participate in the study. Individuals who suffered from
physical (e.g., neoplasia, renal failure, neuromuscular
diseases), cognitive, or psychiatric illnesses that affected
daily activities were excluded from the study. Some
of the participants (33.2%) worked full-time, whereas
almost half of the sample (45.9%) was retired. Most of
the participants were married (73.9%) and made, on aver-
age, a household income of 55,000$ CDN/year. The aver-
age waist circumference of the participants at the base-
line was 99.80  cm (SD = 13.09) and the average weight
was 80.66  kg (SD = 17.46). Triglyceride and choles-
terol levels were quite high (Mtriglycerides = 1.70  mmol/L,
SD = 0.96, where levels >1.70  mmol/L is considered
problematic and Mcholesterol = 4.42, SD = 1.26, where lev-
els >5.20 mmol/L is considered problematic) and 20.8%
of the participants were diabetic. At the baseline, 2% of
the sample were members of a regional fitness club and
the majority of the participants did not engage in moder-
ate (61.1%) or strenuous (82.4%) PA, while 68% of the
participants reported that they were engaged in mild PA
as defined by the Godin Leisure-Time Exercise Question-
naire (GLTQ; Godin and Shephard 1985). 23.7% of the
participants smoked on a daily basis, 7.4% had recently
stopped smoking, 46.6% had stopped smoking more than
6 months before their diagnosis, and 22.3% had never
smoked. Regarding alcohol consumption, 30.2% of the
participants engaged in 5–20 consumption per week,
34.6% engaged in 1–5 consumption per week, and 35.2%
did not consume alcohol. Close to 36% of the sample had
already been admitted to the hospital for cardiac arrest.
Participants provided written informed consent prior to
participation in the study.
Procedure
Participants were recruited immediately after receiving a
diagnosis of CVD by one of four cardiologists associated
to the present research. Following their recruitment, they
were invited to meet with a trained nurse and they were
asked to complete psychological and behavioral measures
at four time points during a period of 12 months. At the
baseline, which occurred a few days after receiving a diag-
nosis of CVD, patient’s physiological indicators (triglycer-
ides, cholesterol, waist circumference) were assessed, and
participants completed measures of their global SDM and
NSDM, their level of strenuous, moderate and mild PA,
their HE behaviors, and finally, life satisfaction. At Time
2 (3 months), participants completed contextual measures
of SDM and NSDM, and perceived competence for PA and
HE behaviors. At Time 3 (6 months), self-reports of PA
and HE behaviors were measured again. Finally, at Time 4
(12 months), physiological indicators (triglycerides, choles-
terol, waist circumference) and life satisfaction were meas-
ured again to examine changes in the patients’ physiologi-
cal and psychological health over time, due to the adoption
of a healthier lifestyle. Please see Table 1 for an indication
of the measures that were administered and the participant
flow at the different time points during the study.
Measures
Demographic information
Demographic information such as marital status, gender,
education level, personal and household income, smoking
and alcohol status, along with the participants’ medical and
cardiovascular history, was assessed at the baseline.
Global motivation
The Global Motivation Scale (GMS; Pelletier and Dion
2007; Pelletier et al. 2004) was administered to the partici-
pants to measure their global levels of SDM and NSDM in
their daily lives. The GMS is an 18-item (three items per
subscale) questionnaire that measures the behavioral regu-
lations proposed by SDT. Participants are asked to indicate,
using a 7-point Likert scale, the reasons why they gener-
ally do different things (e.g., “…in order to show others
what I am capable of”). In this study, internal consistency
was good for all subscales (α > 0.70) and acceptable for the
identified (α = 0.66) subscale. Mean scores were calculated
for all subscales and the intrinsic, integrated and identified
mean scores were used to create the self-determined latent
variable, and the introjected, external and amotivation
mean scores were used to create the non-self-determined
latent variable in the model.
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Table 1  Measures administered at the different time points and participant flow
Measures
Demographics
 1 Gender
Physiological measures
 1 Triglycerides
 2 Cholesterol
 3 Waist circumference
Physiological measures
 1 Global motivation
 2 Physical activity
 3 Healthy eating
 4 Life satisfaction
 5 Motivation for the regulation of PA
 6 Motivation for the regulation of HE
 7 Perceived competence for the regulation of PA
 8 Perceived competence for the regulation of HE
Participant flow
‘x’ represents the measures that were completed by the participants at the different time points during the 12-month period
PA physical activity, HE healthy eating
Physical activity
The GLTQ (Godin and Shephard 1985) was administered
to the participants to measure their PA levels. Participants
reported how often they had participated in 15-minute
bouts of mild (e.g., yoga), moderate (e.g., leisure sports)
and strenuous (e.g., running) PA in a typical week, during
the last six months. In order to examine whether moderate/
strenuous (vs. mild) PA more strongly contributed to indi-
viduals’ health, PA was divided into two separate variables:
the first variable represented individuals’ engagement in
moderate/strenuous PA levels and the second variable rep-
resented individuals’ engagement in mild PA levels, exclu-
sively. Following Godin’s (2011) recommendations, the
moderate/strenuous PA observed variable was calculated
using the formula ((9 × strenuous) + (5 × moderate)) and
the mild PA observed variable in the model was calculated
using the formula (3 × mild). Mild and moderate/strenuous
PA were treated as separate variables, given that activities
in the moderate/strenuous categories of the GLTQ are more
likely to contribute to health benefits than a score obtained
using a combination of activities in all categories (i.e.,
mild, moderate and strenuous; Godin 2011).
Healthy eating
Healthy eating was measured using the HE Habits Scale
(HEHS; Otis and Pelletier 2008; Pelletier et  al. 2004),
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Motiv Emot (2017) 41:294–307
Time 1 (baseline) Time 2 (3 months) Time 3 (6 months) Time
4 (12
months)
x
x x
x x
x x
x
x x
x x
x x
x
x
n = 525 n = 352 n = 307 n = 262
a questionnaire inspired by the Canadian Food Guide.
The scale includes eight items, with four items measur-
ing healthy foods and four items measuring foods that
should be consumed in moderation. In this study, the
HE latent variable was composed of four items, in which
three items represented healthy foods (e.g., “I eat a vari-
ety of foods from each of the four groups recommended
by the Canadian Food Guide’’) and one item represented
reversed-coded foods to be eaten in moderation (e.g., “I
eat foods such as chips, chocolate, and candies”). All
items were rated using a 5-point Likert scale (1 = not at
all; 5 = all the time). Cronbach alpha was acceptable at
the baseline (α =  0.68) and good at 6 months (α = 0.75).
Life satisfaction
Life satisfaction was assessed using the Satisfaction
with Life Scale (SWLS; Diener et  al. 1985). The SWLS
includes five items that are rated on a 7-point Lik-
ert scale, going from “not at all agree” to “completely
agree”. Internal consistency was good at the baseline and
at 12 months (α = 0.89 at both time points). The scores of
the five items were used as the indicator variables for the
life satisfaction latent variables in the model.
Motiv Emot (2017) 41:294–307 299
Contextual motivation for physical activity and healthy
eating
Motivation for PA and HE was assessed using a scale
developed by Sheldon and Elliot (1999) to measure indi-
viduals’ motivation to achieve personal goals. Participants
were asked why they adopt PA and HE behaviors (e.g., “…
because it is important to improve my health”). Six items
for each of the behaviors were rated on a 7-point Likert
scale and each item represented a different form of regu-
lation from the self-determination continuum. Two vari-
ables were created for both PA and HE behaviors. The
mean scores of the self-determined forms of motivation
(i.e., intrinsic, integration and identified) were calculated
separately for both behaviors to create the self-determined
observed variables in the model, and the mean scores of
the non-self-determined forms of motivation (i.e., intro-
jected, extrinsic and amotivation) were calculated to create
the non-self-determined observed variables in the model.
Because only one item measured the different behavio-
ral regulations proposed by SDT, observed variables were
used to represent contextual motivation for PA and HE in
the model. In this study, internal consistency was accept-
able for contextual SDM for PA (α = 0.69) and poor for
contextual NSDM for PA (α = 0.40), contextual SDM and
NSDM for HE (α = 0.54 and α = 0.43, respectively). These
low alphas typically result from the simplex structure of
the correlations between the different types of motivation
(Ferguson and Sheldon 2010; Ryan and Connell 1989), in
which adjacent dimensions on the internalization contin-
uum are expected to be somewhat correlated, but the value
of the correlation coefficient diminishes as the type of
motivation moves away on the continuum of self-determi-
nation. However, the addition of the different types of SDM
and NSDM has been used in previous studies (e.g., For-
tier et  al. 2007; Guertin et  al. 2015; Williams et  al. 2002,
2005) because the two motivational orientations (i.e., self-
determined and non-self-determined) represent broader
and more parsimonious ways to represent the two types of
motivation.
Perceived competence for physical activity and healthy
eating
Perceived competence for PA and HE was measured using a
modified version of the Perceived Competence Scale (PSC;
Williams and Deci 1996). The PSC is a well-validated four
items scale that assesses individuals’ feelings of compe-
tence toward a specific behavior. In this study, the partici-
pants reported how competent they felt toward engaging in
PA (e.g., “I feel able to engage in regular physical activ-
ity”) and HE (e.g., “If I wanted to, I could easily commit to
adopt healthier eating habits”). Responses ranged from 1 to
7 and the internal consistency was good for both behaviors
(α = 0.89 for PA, and α = 0.86 for HE) at 3 months.
Physiological indicators
The three physiological indicators (triglycerides, choles-
terol and waist circumference) were measured at the base-
line and at 12 months by a medical team. Both triglycer-
ides and cholesterol were measured in millimoles per litre
(mmol/L) through a blood test. Before each appointment,
participants were asked to fast for a total of 12 h. For tri-
glycerides, levels between 1.7 and 2.25 mmol/L are consid-
ered borderline high, levels between 2.26 and 5.65 mmol/L
are considered high, and anything above 5.65  mmol/L is
considered very high. For cholesterol, levels between 5.20
and 6.20 mmol/L are considered borderline high and any-
thing above 6.20 mmol/L is considered high (Miller et al.
2011). Waist circumference (in centimetres), the measure-
ment between the hip bone and the bottom of the ribs, was
measured using a tape measure. Measurements close to
102  cm for men and 88  cm for women indicate levels of
internal fat deposits, which are related to heart disease and
stroke (Heart and Stroke Foundation 2015).
Analyses and results
Analyses
Structural equation modeling (SEM) was used to analyze
the relationships between global and contextual motivation
and perceived competence, PA and HE self-reported behav-
iors, and finally, physiological and psychological health
indicators. SEM has been shown to be applicable to the
analysis of longitudinal multivariate models of latent and
observed variables (McArdle and Nesselroade 2014; Rosel
and Plewis 2008), which constituted the model examined in
the present study. First, the measurement model was tested
to examine whether the observed variables loaded appro-
priately onto their factors. Second, the hypothesized struc-
tural model was tested and examined using the following
fit indices: the Chi square goodness-of-fit (χ2), the com-
parative fit index (CFI), the Tuker-Lewis index (TLI) and
the root mean square error of approximation (RMSEA).
The model was tested in SPSS AMOS v22 (IBM 2013),
and missing data was imputed using the stochastic regres-
sion imputation for maximum likelihood estimation. This
method allows the analysis of incomplete data by comput-
ing maximum likelihood estimates based on cases with
complete data on all variables. The descriptive statistics of
the variables included in the hypothesized model are shown
in Table 2.
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300 Motiv Emot (2017) 41:294–307

Table 2  Descriptive statistics of the variables included in the model

Variables Mean Standard Range
deviation

Physiological indicators
 1 Triglycerides—mmol/L (baseline) 1.70 0.96 0.30–7.50
 2 Cholesterol—mmol/L (baseline) 4.43 1.26 1.60–12.10
 3 Waist circumference—cm(baseline) 99.78 13.04 61–142
 4 Triglycerides—mmol/L (12 months) 1.52 1.04 0.20–8.50
 5 Cholesterol—mmol/L (12 months) 3.74 0.93 1.1–7.2
 6 Waist circumference—cm (12 months) 99.38 12.02 65–134
Self-determined motivation—baseline
 1 Intrinsic motivation 5.70 1.09 2.33–7
 2 Integrated motivation 5.48 1.33 1.33–7
 3 Identified motivation 5.24 1.30 1–7
Non-self-determined motivation—baseline
 1 Introjected motivation 4.09 1.68 1–7
 2 Extrinsic motivation 3.33 1.70 1–7
 3 Amotivation 3.14 1.61 1–7
Physical activity—baseline
 1 Mild—in units 11.92 19.85 0–180
 2 Moderate/strenuous—in units 14.69 32.30 0–285
Healthy eating—baseline
 1 Item 1 3.40 1.09 1–5
 2 Item 2 3.10 1.15 1–5
 3 Item 5 3.52 1.08 1–5
 4 Item 6 3.74 0.85 1–5
Life satisfaction—baseline
 1 Item 1 4.95 1.65 1–7
 2 Item 2 5.32 1.57 1–7
 3 Item 3 5.42 1.55 1–7
 4 Item 4 5.40 1.62 1–7
 5 Item 5 4.71 2.00 1–7
Self-determined motivation for physical activity—3 months 5.38 1.38 1–7
Non-self-determined motivation for physical activity—3 months 3.22 1.20 1–7
Self-determined motivation for healthy eating—3 months 5.53 1.18 2–7
Non-self-determined motivation for healthy eating—3 months 3.51 1.23 1–7
Perceived competence for physical activity—3 months
 1 Item 1 5.24 1.79 1–7
 2 Item 2 4.48 1.80 1–7
 3 Item 3 4.51 1.98 1–7
 4 Item 4 4.72 1.90 1–7
Perceived competence for healthy eating—3 months
 1 Item 1 5.52 1.53 1–7
 2 Item 2 5.09 1.52 1–7
 3 Item 3 5.31 1.46 1–7
 4 Item 4 5.55 1.33 1–7
Physical activity—6 months
 1 Mild physical activity—in units 11.56 15.19 0–120
 2 Moderate/strenuous—in units 19.82 28.14 0–185
Healthy eating—6 months
 1 Item 1 3.62 1.00 1–5

13
Motiv Emot (2017) 41:294–307 301
Table 2  (continued)
Variables
 2 Item 2
 3 Item 5
 4 Item 6
Life satisfaction—12 months
 1 Item 1
 2 Item 2
 3 Item 3
 4 Item 4
 5 Item 5
N = 525; men = 401, female = 124
Before testing the hypothesized model, correlations
amongst the variables included in the model were exam-
ined (please see Table 3 for the correlations). As expected,
global SDM and to a lesser extent, global NSDM at the
baseline, were significantly positively correlated with
contextual SDM for PA and HE at 3 months. Contextual
SDM for PA and HE were then significantly positively
correlated with perceived competence for PA and HE at 3
months, whereas contextual NSDM for PA and HE were
non-significantly correlated with perceived competence for
PA and HE. Perceived competence for PA was then posi-
tively significantly correlated with moderate/strenuous PA
and non-significantly correlated with mild PA at 6 months,
and perceived competence for HE was significantly posi-
tively correlated with HE at 6 months. Concerning the
relationships between moderate/strenuous and mild PA
and the physiological indicators, moderate/strenuous PA
was significantly negatively correlated with cholesterol and
non-significantly correlated with triglycerides and waist
circumference at 12 months, whereas mild PA was non-sig-
nificantly correlated with neither of the three physiological
indicators. In contrast, HE was non-significantly correlated
with triglycerides and cholesterol, and was significantly
negatively correlated with individuals’ waist circumference
at 12 months. Finally, moderate/strenuous PA was non-
significantly correlated with life satisfaction, whereas mild
PA, and to a greater extent, HE were significantly positively
correlated with life satisfaction at 12 months.
Testing the measurement model
To confirm that each variable loaded appropriately onto
their factors, a confirmatory factor analysis (CFA) was con-
ducted. In total, the model included 23 variables, in which
eight variables were latent and 15 variables were observed
variables. At the baseline, the factors represented four latent
variables: global SDM (three indicators), global NSDM
Mean Standard Range
deviation
3.72 0.97 1–5
3.76 0.94 1–5
4.15 0.49 3–5
5.46 1.32 2–7
5.75 1.28 2–7
5.84 1.27 2–7
5.68 1.28 2–7
5.26 1.66 1–7
(three indicators), HE (four indicators), and life satisfaction
(five indicators), and six observed variables: triglycerides,
cholesterol, and waist circumference, moderate/strenuous
PA, and mild PA, and gender (the variable was dummy
coded, -1 for women and 1 for men). At 3 months, there
were four observed variables: SDM and NSDM for PA and
HE, and two latent variables: perceived competence for PA
(4 indicators) and perceived competence for HE (four indi-
cators). At 6 months, the model included one latent varia-
ble: HE (four indicators) and two observed variables: mod-
erate/strenuous PA and mild PA. Finally, at 12 months, the
model included one latent variable: life satisfaction (five
indicators) and three observed variables: triglycerides, cho-
lesterol, and waist circumference. The CFA confirmed that
the measurement model had a good fit (χ2(796) = 1153.03,
CFI = 0.95, TLI = 0.93, RMSEA = 0.03), indicating that all
indices measured the appropriate latent constructs.
Testing the structural model
The majority of the paths in the hypothesized model pro-
posed in Fig. 1 were significant and in the expected direc-
tion, and the results indicated that the model had a good fit:
(χ2(969) = 1623.31, CFI = 0.91, TLI = 0.89, RMSEA = 0.04).
The model demonstrated that individuals who were gener-
ally self-determined in their lives were more likely to be
self-determined in the context of PA and HE. In turn, indi-
viduals who reported being self-determined (vs. non-self-
determined) in the context of PA and HE reported higher
levels of perceived competence to engage in both behaviors
at Time 2 (3 months). Perceived competence for PA and
HE at Time 2, in turn, predicted engagement in moderate/
strenuous PA and HE at Time 3 (6 months), but not mild
PA. The effects of HE, moderate/strenuous, and mild PA on
life satisfaction and the three physiological indicators were
examined after accounting for the measures of life satisfac-
tion and the three physiological indicators at the baseline.
13


Table 3  Correlations between all variables in the hypothesized structural model

302

Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

13
 1 Triglycerides (T1) –
 2 Cholesterol (T1) 0.30* –
513
 3 Waist circumference (T1) 0.21* −0.11* –
503 502
 4 Global SDM (T1) −0.01 0.04 −0.05 –
495 494 495
 5 Global NSDM (T1) 0.04 −0.05 0.08 0.42* –
493 492 493 503
 6 Moderate/strenuous PA (T1) −0.08 0.01 −0.07 0.07 0.04 –
436 436 437 440 438
 7 Mild PA (T1) 0.01 0.05 −0.01 −0.08 −0.03 0.15* –
468 467 469 463 471 442
 8 HE (T1) −0.13* −0.10* −0.14* 0.17* −0.02 0.02 0.03 –
499 498 499 505 503 444 477
 9 Life satisfaction (T1) −0.10* −0.10 0.05 0.24* −0.05 0.03 −0.04 0.20* –
492 491 492 499 498 438 470 502
 10 SDM for PA (T2) −0.03 0.02 −0.16* 0.34* 0.09 0.11 0.03 0.18* 0.14* –
304 303 301 296 296 260 285 300 296
 11 NSDM for PA (T2) 0.13* −0.02 0.09 0.07 0.23* −0.05 −0.06 −0.05 −0.06 0.14* –
303 303 300 295 295 259 284 299 295 308
 12 SDM for HE (T2) −0.03 −0.01 −0.11 0.38* 0.19* 0.09 0.001 0.16* 0.14* 0.59* 0.14* –
314 313 312 306 206 270 295 310 306 309 308
 13 NSDM for HE (T2) 0.09 0.01 0.11 0.14* 0.29* 0.02 0.02 −0.10 −0.003 0.11 0.55* 0.30* –
314 313 312 306 206 270 295 310 306 309 308 320
 14 Perceived competence for PA (T2) −0.08 −0.006 −0.16* 0.19* 0.07 0.13* 0.001 0.08 0.14* 0.45* 0.008 0.30* −0.04 –
316 315 314 307 307 270 296 311 307 308 307 318 318
 15 Perceived competence for HE (T2) −0.05 0.08 −0.11* 0.22* 0.04 0.11 −0.03 0.24* 0.17* 0.29* 0.06 0.39* 0.01 0.33* –
318 317 313 309 309 272 298 313 309 309 308 320 320 322
 16 Moderate/strenuous PA (T3) −0.02 0.08 −0.05 0.12 0.06 0.32* 0.06 0.12 −0.02 0.11 16 0.08 0.10 0.08 0.16* 0.12227 –
245 245 346 234 234 220 232 237 235 215 225 225 225
 17 Mild PA (T3) −0.07 −0.06 −0.01 0.07 0.05 −0.02 0.13* 0.04 0.02 −0.03 −0.03 −0.08 0.002 0.02 −0.003 0.20* –
263 262 263 251 251 228 247 255 252 236 235 244 245 244 246 244
 18 HE (T3) −0.002 0.13* −0.13 0.13* −0.04 0.09 0.03 0.52* 0.20* 0.20* −0.006 0.21* −0.10 0.20* 0.42* 0.13* 0.001 –
287 286 286 275 275 244 268 279 275 256 255 265 265 266 268 250 268
 19 Triglycerides (T4) 0.57* 0.03 0.11 −0.03 0.05 −0.13 0.02 −0.07 −0.07 −0.004 0.08 0.08 0.11 −0.09 −0.10 −0.13 −0.02 −0.01 –
267 266 266 257 257 226 249 261 257 246 245 249 249 251 252 219 238 260
 20 Cholesterol (T4) 0.13* 0.33 −0.03 −0.06 0.02 0.08 −0.06 −0.05 −0.09 −0.04 0.07 −0.03 0.11 −0.08 −0.007 −0.15* −0.04 −0.05 0.35* –
267 266 266 257 257 226 249 261 257 246 245 249 249 251 252 219 238 260 273
 21 Waist circumference (T4) 0.24* −0.11 0.83* −0.09 0.10 −0.12 0.04 −0.13* −0.11 −0.17* 0.03 −0.12 0.12 −0.18* −0.21* −0.07 −0.03 −0.19* 0.23* 0.06 –
267 266 266 258 258 229 251 262 258 243 242 247 247 249 250 220 238 260 267 267
 22 Life satisfaction (T4) −0.07 −0.04 −0.04 0.19* 0.05 −0.13 −0.04 0.19* 0.49* 0.20* −0.06 0.18* −0.06 −0.18* 0.22* 0.09 0.11 0.33* −0.06 −0.13* −0.11 –
268 267 268 259 259 227 250 263 259 245 244 249 249 251 252 219 238 260 269 269 269

The numbers under the correlation coefficients correspond to the numbers of participants
SDM self-determined motivation, NSDM non-self-determined motivation PA physical activity, HE healthy eating
Motiv Emot (2017) 41:294–307

*p < .05
Motiv Emot (2017) 41:294–307 303
Although it was hypothesized that engaging in HE and
moderate/strenuous PA would lead to changes in all the
physiological and psychological health indicators, HE at
Time 3 (6 months) was only predictive of improved life sat-
isfaction and a reduction in waist circumference, whereas
moderate/strenuous PA was predictive of reductions in tri-
glycerides and cholesterol levels, as well as the waist cir-
cumference at Time 4 (12 months). Mild PA did not have
any beneficial effects on both the physiological indicators
and life satisfaction at Time 4 (12 months). It is important
to note that in the examination of the effects between mod-
erate/strenuous PA and HE and waist circumference, gen-
der was used as a control variable on waist circumference
at 12 months. The results indicate that men were less likely
to decrease their waist circumference over time.
Consistent with previous research (Guertin et  al. 2015;
Slovinec-D’Angelo et al. 2007, 2014), an alternative model
in which global motivation predicted perceived competence
for PA and HE, and perceived competence for PA and HE
predicted contextual motivation for PA and HE behav-
iors was also examined. In line with the previous stud-
ies, the alternative model had a worse fit than the hypoth-
esized model (χ2(969) = 1746.87, CFI = 0.89, TLI = 0.87,
RMSEA  = 0.04), suggesting that contextual SDM and
NSDM for PA and HE reinforces or weakens feelings of
competence for PA and HE, which further predicts the
engagement or disengagement in PA and HE self-reported
behaviors over time. Values of the Akaike information cri-
terion (AIC) were examined to compare the fits of both
models and considering that the AIC value of the hypoth-
esized model was lower, results confirmed that the alterna-
tive model had a worse fit (AIC = 2035.31 for the hypoth-
esized model and AIC = 2158.87 for the alternative model).
Discussion
The primary aim of this research was to test a longitudinal
model investigating whether individuals who experienced
self-determined (vs. non-self-determined) motivation in
their daily lives would be more likely to experience self-
determined (vs. non-self-determined) motivation for PA
and HE behaviors and feel efficacious in adopting PA and
HE behaviours over time, which would further lead to the
adoption of both behaviours and improved physiological
indicators (i.e., triglycerides, cholesterol and waist circum-
ference) and life satisfaction over a 12-month period. The
secondary aim of this study was to examine the contribu-
tions of moderate/strenuous and mild PA on individuals’
health. The present study extends up previous research
(Guertin et  al. 2015; Pelletier et  al. 2004, study 3; Slovi-
nec-D’Angelo et  al. 2007, 2014) that has examined the
respective roles of motivation and perceived competence
in behavior change models amongst patients with CVD, in
the sense that it examined (1) whether motivation and per-
ceived competence predicted individuals’ engagement in
two (vs. one) health behaviors following a cardiac incident
and (2) whether moderate/strenuous PA predicted more
variance than mild PA on physiological and psychological
health indicators over time.
In relation to the primary objective of the study, con-
sistent with previous research (e.g., Guertin et  al. 2015;
Slovinec-D’Angelo et  al. 2007, 2014), the results suggest
that when patients report being self-determined, they feel
confident in their abilities to engage in lifestyle changes and
are therefore more likely to integrate healthy behaviour into
their lives. By opposition, when patients report being non-
self-determined, they feel less confident in their abilities to
engage in lifestyle changes and are therefore less likely to
adopt and maintain behaviour change and to improve their
health. Contextual self-determined (vs. non-self-deter-
mined) motivation for PA and HE was positively related to
perceived competence for PA and HE at 3 months, which,
in turn, significantly positively predicted self-reported HE
and the engagement in moderate/strenuous PA, but not in
mild PA at 6 months. The adoption of moderate/strenuous
PA at 6 months was then shown to mainly contribute to
changes in physiological indicators, while the adoption of
HE at 6 months was shown to mainly contribute to changes
in waist circumference and life satisfaction at 12 months.
Altogether, this study provides some information on the
processes that could explain why some individuals are
more likely to succeed at the regulation of the behaviours
that could positively influence their health, while others are
more likely to fail in regulating the same behaviours over
time.
With regards to the secondary aim, this study also pro-
vides support to the proposition that the adoption of moder-
ate and strenuous, compared to mild, PA are more likely to
contribute to changes in physical health. The results are in
line with Godin (2011), who suggested that only moderate/
strenuous PA are important contributors of health benefits
and has important implications for the specific types of PA
that should be recommended to patients with CVD. The
findings suggest, however, that only individuals who were
self-determined and who felt more competent in chang-
ing their behavior were more likely to engage in moderate/
strenuous PA. Although little research has examined this
proposition in a clinical population, the results corroborate
the conclusions of other studies that have investigated the
association between behavioral regulations or self-efficacy
(or perceived competence) in predicting mild, moderate
and strenuous PA. For instance, Silva et  al. (2011) dem-
onstrated that only autonomous motivation (vs. external
and introjected regulations) predicted long-term moderate/
strenuous PA in a sample of overweight and obese women.
13

304
Fig. 1  The hypothesized structural model for physical activity and healthy eating behaviours. Solid lines indicate significant relationships at
p < .05 and dotted lines indicate non-significant relationships. SDM self-determined motivation; NSDM non-self-determined motivation
Concerning the direct association between self-efficacy and
PA, Millen and Bray (2009) found that individuals follow-
ing an intervention reported higher levels of self-efficacy
and outcome expectations after cardiac rehabilitation com-
pared to a wait-list control group, and that self-efficacy for
resistance band training mediated the intervention effects
on resistance band training 3 months later. In sum, the fact
that self-determined individuals were more likely to engage
in moderate/strenuous (vs. mild) PA is quite promising for
patients with CVD, given that only moderate/strenuous
types of PA were shown to significantly predict improved
physiological health (i.e., triglyceride and cholesterol
levels).
Although it was hypothesized that both PA and HE
would predict changes in all physiological and psycho-
logical indicators at 12 months, PA mainly contributed to
improving physiological health and HE mainly contrib-
uted to reducing waist circumference and improving life
satisfaction. Although it is not entirely clear why these
effects occurred, it may be possible that when both behav-
iors are examined simultaneously, PA and HE interact in
such a way that once individuals eat more healthily, they
may also adopt a more active lifestyle or vice-versa. As a
result, both variables, in combination, may contribute to
the adoption of a healthier lifestyle and change in physical
13
Motiv Emot (2017) 41:294–307
and psychological health over time. It would be interesting
for future research to examine whether SDM could lead to
the adoption of other healthy behaviors (e.g., smoking ces-
sation, medication adherence) associated with CVD, and
whether the adoption of all behaviors equally influence
health over time.
Future research could also examine whether need sup-
port from different sources (e.g., physicians, family mem-
bers) contribute more or less to the development of moti-
vation (or perceived competence) and lifestyle changes
in individuals with CVD over time. This is particularly
important since several healthcare professionals (i.e., car-
diologists, doctors, rehabilitation specialists) could influ-
ence patient’s self-determined (or non-self-determined)
motivation during cardiac rehabilitation and the results
demonstrated that SDM is one of the main determinants of
the adoption and maintenance of healthy behaviors. One
of the defining features of SDT is the assumption that the
social context can facilitate the process of behavioral inter-
nalization by supporting individual’s efforts in adopting
and maintaining behavior change (Deci and Ryan 2008).
Research in SDT has demonstrated the importance of sup-
porting individual’s basic psychological needs of auton-
omy, competence and relatedness to promote the develop-
ment of optimal motivation and eliciting behavior change
Motiv Emot (2017) 41:294–307 305
for several health behaviors, including PA and HE (Ng
et  al. 2012). Although this study provides evidence that
SDM is a critical component of sustained behavior change,
the environmental context in which lifestyle modifications
occurred was not taken into account. Research could ben-
efit from future studies examining the full motivational
sequence proposed by SDT, that is, need supportive (or
need thwarting) climate provided by the social context →
patient’s satisfaction (or dissatisfaction) of basic psycho-
logical needs → self-determined (or non-self-determined)
motivation → presence (or absence) of behavior change,
amongst patients with CVD.
Given that perceived competence also plays an impor-
tant role in the behavior change process, healthcare pro-
fessionals should acknowledge individuals’ feelings of
competence toward adopting PA and HE behaviors during
cardiac rehabilitation. Interventions could easily be tai-
lored to the specific needs of individuals in regards to their
motivational tendencies and their confidence levels. For
instance, individuals who are generally self-determined and
who have high levels of perceived competence might ben-
efit from an intervention that exclusively promotes SDM,
whereas individuals who are generally self-determined but
lack confidence in their abilities may benefit from an inter-
vention that promotes both SDM and competence (Slovi-
nec-D’Angelo et  al. 2014; Guertin et  al. 2015). Consider-
ing that SDM and competence have been shown to be some
of the best predictors of PA and HE during obesity-related
interventions, it has been proposed that healthcare profes-
sionals should be trained to target both constructs during
practice (Teixeira et al. 2015).
Although the present study has important implications
for research, some limitations warrant discussion. First,
self-reports of PA and HE were assessed and only few
items from the HEHS were used to measure HE. Future
studies could measure PA in a more objective way by using
tools such as accelerometers and other tools designed to
assess the quality of eating behaviors (Labonté et al. 2012)
could be used to examine the relationships between HE and
health benefits. Second, the addition of other physiologi-
cal (e.g., low- and high-density lipoproteins, blood pres-
sure, glucose levels) and psychological (e.g., well-being,
depression) indicators could also help further identify the
type of benefits that could result from a healthier lifestyle.
Although the physiological (triglycerides, cholesterol and
waist circumference) and psychological (life satisfaction)
indicators that were examined in the present model are rel-
evant to individuals with CVD (Alberti et al. 2009), moder-
ate/strenuous PA and HE might help improve other impor-
tant health indicators that were not assessed in the present
study. Finally, since the present study was longitudinal and
the sample consisted of individuals who suffered from a
life-threatening illness, participation attrition was a concern
in the sense that half of the sample had incomplete data by
the end of the study. Although missing data was imputed
using maximum likelihood estimations, readers should be
mindful of this attrition when interpreting the results.
To conclude, the present study examined whether indi-
viduals engaged in both self-reported PA and HE behaviors
following a critical diagnosis of CVD and how both behav-
iors contribute to physiological and psychological health
over time. It is noteworthy that this study included a clini-
cal population that was exclusively composed of individu-
als who had just experienced a major cardiac event, rather
than individuals who were only at risk of CVD. Also,
the study included both physiological and psychological
measures assessed at the baseline and at 12 months. The
inclusion of this type of data, in addition to motivational
variables derived from SDT, allowed the examination of
the critical role that motivational variables could play in
our understanding of the processes that could lead to the
adoption of a healthier lifestyle and health improvement
over time. Although few studies have examined behavior
change for PA and HE independently, to the best of the
author’s knowledge, this study is the first to examine the
benefits associated with the engagement in both behaviors
simultaneously. The motivational model that was examined
provided support for the proposition that not all motivation
for significant and long-lasting behavior change could be
beneficial. In agreement with SDT, the promotion of SDM
could play a critical role in the promotion of sustained life-
style, whereas NSDM that results from coercion or external
pressures to change may not lead to behavior change and
health benefits over time.
Funding  This project was funded by a Pfizer Independent Medical
Grant No. NRA2581119.
Compliance with ethical standards 
Conflict of interest  All authors declare no conflict of interests.
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