November 17, 2014

Towards better decision making: empty stomach, full bladder and lemonade

By Daniel Cabrera

Authors: Daniel Cabrera, MD & Cameron Wangsgard, M.D.



Use under Creative Commons License from @sage_solar (flickr)


Your visceral needs affect how you make decisions.


There is quite a bit of evidence that people guided by impulse will perform worse in situations involving complex decision making as they tend to opt for immediate gratification rather than aiming for solutions in line with long term values or objectives.  In other words, when decision making is driven by visceral impulse, the most immediate needs are put over the more complicated end goals. At the same time, decision making that is not related to visceral needs is strongly influenced by other domain impulses (e.g., when shopping for groceries, hungry people will tend to spend more, due to visceral decision making, compared to those that have just recently eaten).

However, in the recent years, the idea of impulsivity related to visceral stimuli affecting the quality of decision making has been questioned. Tuk et al. published an often cited paper where they discussed that the urge to urinate facilitated the ability to resist impulsivity in monetary decisions. In addition, recently De Ridder et al. showed that hungry people were able to resist impulsivity and make better decisions about gambling in the Iowa Gambling Task test

Both of these two studies appear to show that visceral impulsivity can actually improve the quality of decision making.  Interestingly, this is in contrast to the previously held thoughts that impulsivity was in and of itself an important factor in poor decision making.  One possible explanation for this phenomena is based on dual process theory.  The outcome of appropriate decisions modulated by urge is potentially explained as decisions were initially routed to a System 1 model by the cognitive pattern processor, but then directed and finally managed by a System 2 model after the the stress of the urge may have activated the dysrationalia override.




The theory is interesting but is met with conflicting results.  In looking at a paper by Masicampo et al., iniindividuals were found to make better decisions if they have a dose of glucose (as lemonade) prior to the decision making process compared to the group with no glucose supplementation. This appears to show that high order decision making is phisically and mentally exhausting and the absence of "mental fuel" will shunt the decision making to a more economical pathway (from System 2 to System 1); while the restoring of mental capacity by sugar, among other things, would allow for the taxing and consuming System 2 process.




All in all, the culmination of these studies go against a largest body of literature emphasizing the negative effect of impulsivity on complex decision making.  Therefore, at least at this point in time, there is not a lot we can generalize from them to change our decision making process in our day to day lives. What these papers may show however is a type of threshold effect where a strong impulse can lead to a bad decision by incorrectly overcoming the dysrationalia override and a moderate intensity urge can lead to improved outcomes re-routing a decision process from a System 1 to a System 2 after the stress associated to the urge facilitated the recognition  of a non-evident pattern.

It is difficult to make more conclusions from just these two papers, but in any complex decision making process (like the ones we perform daily in Emergency Medicine) it is very important to assign the decision task itself to the correct cognitive pathway. This allows for our intricate checks and balances we unconsciously have to reject decisions that appear to be irrational or incorrect.  Ultimately, the current hot state and in the game approach to decision making is valid in the sense that after basic visceral needs are covered (sleeping, eating and sphincter management) we are able to effectively utilize our unconscious dual or quasirational processes to take over the decision making management without a loss of frontal/conscious control.




  • Masicampo EJ, Baumeister RF. Toward a physiology of dual-process reasoning and judgment: lemonade, willpower, and expensive rule-based analysis. Psychol Sci. 2008 Mar;19(3):255–60.
  • De Ridder D, Kroese F, Adriaanse M, Evers C. Always Gamble on an Empty Stomach: Hunger Is Associated with Advantageous Decision Making. PLoS ONE. 2014 Oct 23;9(10):e111081.
  • Tuk MA, Trampe D, Warlop L. Inhibitory spillover: increased urination urgency facilitates impulse control in unrelated domains. Psychol Sci. 2011 May;22(5):627–33.
  • Byrne A. Mental workload as a key factor in clinical decision making. Adv in Health Sci Educ. 2013 Aug 1;18(3):537–45.
  • Croskerry P. A universal model of diagnostic reasoning. Academic Medicine. 2009;84(8):1022–8.


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