Hostname: page-component-cd9895bd7-dk4vv Total loading time: 0 Render date: 2024-12-27T05:22:20.712Z Has data issue: false hasContentIssue false
  • English
  • Français

Applying the transtheoretical model to eating behaviour change: challenges and opportunities

Published online by Cambridge University Press:  14 December 2007

Caroline C. Horwath
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

This review provides a rigorous investigation of the question of whether the transtheoretical model (TTM) (or stages of change model) is applicable to eating behaviour change. The TTM is currently the most popular of a number of stage theories being used to examine health behaviour change. Stage theories specify an ordered set of ‘stages of readiness to change’ into which people can be classified and identify the factors that can facilitate movement from one stage to the next. If eating behaviour change follows a stage process, then nutritionists could identify the predominant stage or stages in a population and focus resources on those issues most likely to move people to the next stage (e.g. from no intention of changing, to thinking about changing). In addressing this question, the review draws on the defining characteristics of stage theories as clarified by Weinstein et al. (1998), provides an in-depth coverage of methodological considerations, and a detailed summary table of dietary studies applying the TTM. Specific recommendations are made for improving the accuracy of dietary stage classifications. Among the key conclusions are: (1) dietary studies using the TTM have been hampered by a focus on nutritional outcomes such as dietary fat reduction, rather than clearly understood food behaviours (e.g. five servings of fruit and vegetables per day); (2) accurate stage classification systems are possible for food-based goals, but major misclassification problems occur with nutrient-based goals; (3) observation of an association between stage and dietary intake is not sufficient to demonstrate the validity of the model for dietary behaviour; (4) there is a need for valid questionnaires to measure all aspects of the TTM, and more research on the whole model, particularly the ‘processes of change’, rather than on single constructs such as ‘stage’ (5) cross-sectional studies generally support the predicted patterns of between-stage differences in decisional balance, self-efficacy, and processes of change; (6) studies which test the key hypothesis that different factors are important in distinguishing different stages are rare, as are prospective studies and stage-matched interventions. Only such studies can conclusively determine whether the TTM is applicable to eating behaviour. Since the ultimate test of the TTM will be the effectiveness of stage-matched dietary interventions, the review ends by exploring the requirements for such studies.

Keywords

Transtheoretical modelStage theoriesBehaviour changeFood choice
Type
Research Article
Information
Nutrition Research Reviews , Volume 12 , Issue 2 , December 1999 , pp. 281 - 317
Copyright
Copyright © CABI Publishing 1999

References

Ajzen, I & Madden, TJ (1986) Prediction of goal-directed behaviour: attitudes, intentions and perceived behavioural control. Journal of Experimental & Social Psychology 22, 453–474.CrossRefGoogle Scholar
Auld, GW, Nitzke, SA, McNulty, J, Bock, MA, Bruhn, CM, Gabel, K, Lauritzen, G, Lee, YF, Medeiros, D, Newman, R, Ortiz, M, Read, M, Schutz, H & Sheehan, E (1998) A stage-of-change classification system based on actions and beliefs regarding dietary fat and fiber. American Journal of Health Promotion 12, 192–201.CrossRefGoogle ScholarPubMed
Bandura, A (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall.Google Scholar
Bandura, A (1997) The anatomy of stages of change. American Journal of Health Promotion 12, 8–10.CrossRefGoogle ScholarPubMed
Beresford, SAA, Curry, SJ, Kristal, AR, Lazovich, D, Feng, Z & Wagner, EH (1997) A dietary intervention in primary care practice: The eating patterns study. American Journal of Public Health 87, 610–616.CrossRefGoogle ScholarPubMed
Bettman, JR (1979) An Information Processing Theory of Consumer Choice. Reading, MA: Addison-Wesley.Google Scholar
Birkett, NJ & Boulet, J (1995) Validation of a food habits questionnaire: poor performance in male laborers. Journal of the American Dietetic Association 95, 558–563.Google Scholar
Birkett, NJ, Hotz, SC & Allston, J (1993) Dietary fat reduction: Challenges in applying the stages of change model. Presented at the First International Heart Health ConferenceVictoria, BC.Google Scholar
Block, G, Hartmann, AM, Dresser, CM, Carroll, MD, Gannon, J & Gardner, LA (1986) A data-based approach to diet questionnaire design and testing. American Journal of Epidemiology 124, 453.Google Scholar
Bowen, DJ, Meischke, H & Tomoyasu, N (1994) Preliminary evaluation of the processes of changing to a low fat diet. Health Education Research 9, 85–94.CrossRefGoogle Scholar
Brug, J, Glanz, K & Kok, G (1997) The relationship betwen self-efficacy, attitudes, intake compared to others, consumption, and stages of change related to fruit and vegetables. American Journal of Health Promotion 12, 25–30.CrossRefGoogle Scholar
Brug, J, Glanz, K, Van Assema, P, Kok, G & van Breukelen, GJP (1998 a) The impact of computer-tailored feedback and iterative feedback on fat, fruit and vegetable intake. Health Education & Behaviour 25, 517–531.CrossRefGoogle ScholarPubMed
Brug, J, Steenhuis, IHM, Van Assema, P & De Vries, H (1996) The impact of a computer-tailored nutrition intervention. Preventive Medicine 25, 236–342.CrossRefGoogle ScholarPubMed
Brug, J, Steenhuis, IHM, Van Assema, P, Glanz, K & De Vries, H (1998 b) The impact of two computer-tailored nutrition education interventions. Health Education Research 13, 1–11.Google Scholar
Brug, J, Van Assema, P, Lenderink, T, Glanz, K & Kok, G (1994) Self-rated dietary fat intake: association with objective assessment of fat, psychosocial factors and intention to change. Journal of Nutrition Education 26, 218–223.CrossRefGoogle Scholar
Campbell, MK, De Vellis, B, Strecher, V, Ammerman, A, De Vellis, R & Sandler, R (1994) Improving dietary behaviour: The effectiveness of tailored messages in primary care settings. American Journal of Public Health 84, 783–787.Google Scholar
Campbell, MK, Reynolds, KD, Havas, S, Curry, S, Bishop, D, Nicklas, T, Palombo, R, Buller, D, Feldman, R, Topor, M, Johnson, C, Beresford, SAA, Motsinger, BM, Morrill, C & Heimendinger, J (1999) Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-day for better health community studies. Journal of Health Education & Behaviour 26, 513–534.CrossRefGoogle Scholar
Campbell, MK, Symons, M, Demark-Wahnefried, W, Polhamus, B, Bernhardt, JM, McClelland, JW & Washington, C (1998) Stages of change and psychosocial correlates of fruit and vegetable consumption among rural African-American church members. American Journal of Health Promotion 12, 185–191.Google Scholar
Curry, SJ (1993) Commentary: In search of how people change: applications to addictive behaviours. Diabetes Spectrum: From Research to Practice 6, 10–14.Google Scholar
Curry, SJ, Kristal, AR & Bowen, DJ (1992) An application of the stage model of behaviour change to dietary fat reduction. Health Education Research 7, 494–503.CrossRefGoogle Scholar
de Graaf, C, Van der Gaag, M, Kafatos, A, Lennernas, M & Kearnery, JM (1997) Stages of dietary change among nationally representative samples of adults in the European Union. European Journal of Clinical Nutrition 51, Suppl. 2, S47–S56.Google ScholarPubMed
DiClemente, CC (1981) Self efficacy and smoking cessation maintainance: A preliminary report. Cognitive Therapy and Research 5, 175–187.Google Scholar
DiClemente, CC & Prochaska, JO (1982) Self-change and therapy change of smoking behaviour. A comparison of processes of change in cessation and maintenance. Addictive Behaviour 7, 133–142.Google Scholar
DiClemente, CC, Prochaska, JO & Gilbertini, M (1985) Self-efficacy and the stages of self-change in smoking. Cognitive Therapy and Research 9, 181–200.CrossRefGoogle Scholar
Domel, SB, Baranowski, T, Davis, HC, Thompson, WO, Leonard, SB & Baranowski, J (1996) A measure of stages of change in fruit and vegetable consumption among fourth and fifth grade school children: reliability and validity. Journal of the American College of Nutrition 15, 56–64.CrossRefGoogle ScholarPubMed
Farkas, AJ, Pierce, JP & Zhu, S-H (1996) Addiction versus stages of change models in predicting smoking cessation. Addiction 91, 1271–1280.Google Scholar
Glanz, K & Eriksen, MP (1993) Individual and community models for dietary behaviour change. Journal of Nutrition Education 25, 80–86.CrossRefGoogle Scholar
Glanz, K, Kristal, AR, Tilley, BC & Hirst, K (1998 a) Psychosocial correlates of healthful diets among male auto workers. Cancer Epidemiology, Biomarkers and Prevention 7, 119–126.Google ScholarPubMed
Glanz, K, Patterson, RE, Kristal, AR, DiClemente, CC, Heimendinger, J, Linnan, L & McLerran, D (1994) Stages of change in adopting healthy diets: fat, fibre and correlates of nutrient intake. Health Education Quarterly 21, 499–519.Google Scholar
Glanz, K, Patterson, RE, Kristal, AR, Feng, Z, Linnan, L, Heimendinger, J & Hebert, JR (1998 b) Impact of work site health promotion on stages of dietary change: The working well trial. Health Education and Behaviour 25, 448–463.Google Scholar
Glanz, K & Rimer, BK (1997) Theory at a Glance: A Guide for Health Promotion Practice. Washington, DC: US Dept of Health and Human Services Public Health Service, National Institutes of Health.Google Scholar
Greene, GW & Rossi, SR (1998) Stages of change for reducing dietary fat intake over 18 months. Journal of the American Dietetic Association 98, 529–534.Google Scholar
Greene, GW, Rossi, SR & Reed, GR (1993) The effect of feedback on dietary intent to reduce fat intake. Topics in Clinical Nutrition 9, 20–28.CrossRefGoogle Scholar
Greene, GW, Rossi, SR, Reed, GR, Willey, C & Prochaska, JO (1994) Stages of change for dietary fat reduction to 30% of calories or less. Journal of the American Dietetic Association 94, 1105–1110.CrossRefGoogle ScholarPubMed
Gulliver, P (1998) Development and validation of scales to measure dimensions of the Transtheoretical Model for increasing milk product intake in women. PhD Thesis, University of Otago, Dunedin, New Zealand.Google Scholar
Herrick, AB, Stone, WJ & Mettler, MM (1997) Stages of change, decisional balance, and self-efficacy across four health behaviours in a worksite environment. American Journal of Health Promotion 12, 49–56.CrossRefGoogle Scholar
Horwath, CC & Gulliver, P (1998) The challenge of behaviour change. New Zealand Science Monthly 9, 8–9.Google Scholar
Janz, NK & Becker, MH (1984) The health belief model: A decade later. Health Education Quarterly 11, 1–47.CrossRefGoogle ScholarPubMed
Jeffery, RW, French, SA & Rothman, AJ (1999) Stage of change as a predictor of success in weight control. Health Psychology (In the Press).CrossRefGoogle ScholarPubMed
Kreuter, MW & Strecher, VJ (1996) Do tailored behaviour change messages enhance the effectiveness of health risk appraisal? Results from a randomised trial. Health Education Research 11, 97–105.Google Scholar
Kristal, AR, SeLett, AC, Henry, AJ & Fowler, AS (1990) Rapid assessment of dietary intake of fat, fiber and saturated fat. Validity of an instrument suitable for community intervention research and nutritional surveillance. American Journal of Health Promotion 4, 288–295.Google Scholar
Laforge, RG, Greene, GW & Prochaska, JO (1994) Psychoscial factors influencing low fruit and vegetable consumption. Journal of Behavioral Medicine 17, 361–374.Google Scholar
Lamb, R & Joshi, MS (1996) The stage model and processes of change in dietary fat reduction. Journal of Human Nutrition and Dietetics 9, 43–53.Google Scholar
Ling, AM (1999) Stages of change, self-efficacy and decisional balance for the fruit, vegetables and grains dietary guidelines: A random population study of Chinese Singaporeans. PhD Thesis, University of Otago.Google Scholar
Ling, A & Horwath, CC (1999 a) Self-efficacy and consumption of fruit and vegetables: validation of a summated scale. American Journal of Health Promotion 13, 290–298.CrossRefGoogle ScholarPubMed
Ling, AM & Horwath, CC (1999 b) Design and validation of stage of change algorithms for fruit, vegetable and grain recommendations among Chinese Singaporeans. Journal of the American Dietetic Association (In the Press).Google Scholar
McConnaughy, EA (1989) Stages of change in psychotherapy: A follow-up report. Psychotherapy 26, 494–503.Google Scholar
Marlatt, GA (1982) Relapse prevention: A self-control program for the treatment of addictive behaviours. In Adherence, Compliance and Generalization in Behavioral Medicine [Stuart, RB, editor]. New York: Brunner/Mazel, Inc.Google Scholar
Marcus, BH, Emmons, KM, Simkin-Silverman, L, Linnan, LA, Taylor, ER, Bock, BC, Roberts, MB, Rossi, JS & Abrams, DB (1999) Evaluation of motivationally-tailored versus standard self-help physical activity interventions at the workplace. American Journal of Health Promotion (In the Press).Google Scholar
Marcus, BH, Rossi, JS, Selby, VC, Niaura, RS & Abrams, DB (1992) The stages and processes of exercise adoption and maintenance in a worksite sample. Health Psychology 11, 386–395.Google Scholar
Miller, WR & Rollnick, S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press.Google Scholar
Ni Mhurchu, C, Margetts, BM & Speller, VM (1997) Applying the Stages-of-Change model to dietary change. Nutrition Reviews 55, 10–16.CrossRefGoogle ScholarPubMed
O'Connell, D & Velicer, WF (1998) A decisional balance measure and the stages of change model for weight loss. International Journal of Addiction 23, 729–750.CrossRefGoogle Scholar
Orleans, CT, Schoenbach, VJ & Salmon, MA (1988) Effectiveness of self-help quit smoking strategies. Four National Cancer Institute-funded self-help smoking cessation trials: Interim results and emerging patterns. Annual meeting of the Association for the Advancement of Behavior Therapy, New YorkWashington DCNational Cancer Institute.Google Scholar
Ounpuu, S (1997) Methodological considerations for applications of the Transtheoretical Model to dietary fat reduction. PhD Thesis, University of Guelph.Google Scholar
Ounpuu, S, Woolcott, DM & Greene, GW (1999 a) Precontemplation or maintenance? Defining stage of change for lower fat eating. Journal of the American Dietetic Association (In the Press).Google Scholar
Ounpuu, S, Woolcott, DM & Rossi, SR (1999 b) Self efficacy as an intermediate outcome variable in the Transtheoretical Model: Validation of a measurement model for applications to dietary fat reduction. Journal of Nutrition Education (In the Press).Google Scholar
Prochaska, JO (1979) Systems of Psychotherapy: A Transtheoretical Analysis. Pacific Grove, CA: Brooks-Cole.Google Scholar
Prochaska, JO (1991) Assessing how people change. Cancer 67, 805–807.3.0.CO;2-4>CrossRefGoogle ScholarPubMed
Prochaska, JO & DiClemente, CC (1983) Stages and processes of self-change of smoking: toward an integrative model of change. Journal of Consulting & Clinical Psychology 51, 390–395.Google Scholar
Prochaska, JO & DiClemente, C (1985) Common processes of change in smoking, weight control and psychological distress. In Coping and Substance Use: A Conceptual Framework, pp. 345–363 [Shiffman, S and Wills, T, editors]. New York: Academic Press.Google Scholar
Prochaska, JO, DiClemente, CC & Norcross, JC (1992 a) In search of how people change: Applications to addictive behaviors. American Psychologist 47, 1102–1114.Google Scholar
Prochaska, JO, DiClemente, CC, Velicer, W, Ginpil, S & Norcross, JC (1985) Predicting change in smoking status for self changers. Addictive Behaviors 10, 395–406.Google Scholar
Prochaska, JO, Norcross, JC, Fowler, JL, Follick, MJ & Abrams, DB (1992 b) Attendence and outcome in a work site weight control program: Processes and stages of change as process and predictor variables. Addictive Behaviors 17, 35–45.Google Scholar
Prochaska, JO, Velicer, WF, DiClemente, CC & Fava, J (1988) Measuring the processes of change: Applications to the cessation of smoking. Journal of Consulting and Clinical Psychology 56, 520–528.Google Scholar
Prochaska, JO, Redding, C & Evers, K (1997) The Transtheoretical Model of Behavior Change. In Health Behavior and Health Education: Theory, Research and Practice, 2nd ed. pp. 60–84 [Glanz, K, Lewis, FM and Rimer, BK, editors]. San Francisco, CA: Jossey-Bass.Google Scholar
Prochaska, JO & Velicer, WF (1997) Misinterpretations and misapplications of the Transtheoretical Model. American Journal of Health Promotion 12, 11–12.Google Scholar
Prochaska, JO, Velicer, WF, DiClemente, CC & Rossi, JS (1993) Standardised, individualised, interactive and personalised self-help programs for smoking cessation. Health Psychology 12, 399–405.Google Scholar
Prochaska, JO, Velicer, WF, Guadagnali, E, Rossi, JS & DiClemente, CC (1991) Patterns of change: dynamic typology applied to smoking cessation. Multivariate Behavioral Research 26, 83–107.CrossRefGoogle ScholarPubMed
Prochaska, JO, Velicer, WF, Rossi, JS, Goldstein, MG, Marcus, BH, Rakowski, W, Fiore, C, Harlow, LL, Redding, CA, Rosenblom, D & Rossi, SR (1994) Stage of change and decisional balance for 12 problem behaviors. Health Psychology 13, 39–46.CrossRefGoogle ScholarPubMed
Rossi, JS (1992 a) Stages of change for 15 health risk behaviours in an HMO population. Paper presented at the 13th annual meeting of the Society for Behavioural MedicineNew York.Google Scholar
Rossi, JS (1992 b) Common processes of change across nine problem behaviours. Paper presented at the 100th annual convention of the American Psychological AssociationWashington, DC.Google Scholar
Rossi, JS, Blais, LM, Redding, CA & Weinstock, MA (1995 a) Preventing skin cancer through behaviour change: Implications for interventions. Dermatologic Clinics 13, 613–622.Google Scholar
Rossi, JS, Marcus, BH, Rossi, SR, Snow, MG, Velicer, WF & Prochaska, JO (1991 a) Processes of change for smoking, exercise, weight and alcohol abuse. Paper presented at the 99th annual convention of the American Psychological AssociationSan Francisco, CA.Google Scholar
Rossi, JS, Rossi, SR, Velicer, WF & Prochaska, JO (1995 b) Motivational readiness to control weight. In Handbook of Assessment Methods for Eating Behaviours and Weight-related Problems: Measures, Theory and Research, pp. 387–430 [Allison, DB, editor]. Thousand Oaks, CA: Sage.Google Scholar
Rossi, SR (1993) Dietary fat reduction behavior profiles across five categories of high fat food sources for five stages of change. Paper presented at the 13th annual meeting of the Society for Behavioral MedicineSan Francisco, CA.Google Scholar
Rossi, SR, Greene, GW, Reed, G & Prochaska, JO (1993 a) A comparison of four stage of change algorithms for dietary fat reduction. Annals of Behavioral Medicine 15, (Suppl.), A63.Google Scholar
Rossi, SR, Greene, GW, Reed, G, Prochaska, JO & Velicer, WF (1994 b) Continued investigation of a processes of change measure for dietary fat reduction. Paper presented at the 14th annual convention of the Society for Behavioral MedicineBoston, MA.Google Scholar
Rossi, SR, Reed, G, Greene, GW, Rossi, JS, Prochaska, JO & Velicer, WF (1994 a) Development of a self-efficacy questionnaire for dietary fat reduction. Paper presented at the 14th annual convention of the Society for Behavioral MedicineBoston, MA.Google Scholar
Rossi, SR, Reed, G, Greene, GW, Rossi, JS, Prochaska, JO & Velicer, WF (1994 c) Cross validation of a decisional balance measure for dietary fat reduction. Paper presented at the 14th annual convention of the Society for Behavioral MedicineBoston, MA.Google Scholar
Rossi, SR & Rossi, JS (1993) Processes of change for dietary fat reduction. Paper presented at the 13th annual convention of the Society for Behavioral MedicineSan Francisco, CA.Google Scholar
Rossi, SR, Rossi, JS & Prochaska, JO (1991 b) Processes of change for weight control: a follow up study. Paper presented at the 99th Annual Convention of the American Psychological AssociationSan Francisco, CA.Google Scholar
Rossi, SR, Rossi, JS, Prochaska, JO & Velicer, WF (1993 b) Measurement structure of a decisional balance questionnaire for dietary fat reduction. American Psychological Association, Toronto, Canada.Google Scholar
Rossi, SR, Rossi, JS, Rossi-Del Prete, LM, Prochaska, JO, Branspach, SW & Carlton, RH (1994 d) A process of change model for weight control for participants in community based weight loss programmes. International Journal of the Addictions 29, 161–177.Google Scholar
Ruggiero, L & Prochaska, JO (1993) Readiness for change: application of the Transtheoretical Model to diabetes. Diabetes Spectrum: From Research to Practice 6, 21–60.Google Scholar
Safer, MA, Tharps, Q, Jackson, T & Leventhal, H (1979) Determinants of three stages of delay in seeking care at a medical clinic. Medical Care 17, 11–29.Google Scholar
Schmid, TL, Jeffery, RW & Hellerstedt, WL (1989) Direct mail recruitment to house-based smoking and weight control program: A comparison of strengths. Preventive Medicine 18, 503–517.CrossRefGoogle Scholar
Schwarzer, R (1992) Self-efficacy in the adoption and maintenance of health behaviors: theoretical approaches and a new model. In Self-efficacy: Thought Control of Action, pp. 217–243 [Schwarzer, R, editor]. Washington, DC: Hemisphere.Google Scholar
Shiffman, S (1996) “Addiction versus stages of change models” vs. “Addiction and stages of change models”. Addiction 91, 1289–1290.Google Scholar
Sigman-Grant, M (1996) Stages of change: A framework for nutrition interventions. Nutrition Today 31, 162–170.CrossRefGoogle Scholar
Sorensen, G, Stoddard, A & Macario, E (1998) Social support and readiness to make dietary changes. Health Education & Behaviour 25, 586–598.Google Scholar
Sporny, LA & Contento, IR (1995) Stages of change in dietary fat reduction: Social psychological correlates. Journal of Nutrition Education 27, 191–199.Google Scholar
Stafleu, A, de Graaf, C, van Staveren, WA & Schroots, JJ (1991/1992) A review of selected studies assessing socialpsychological determinants of fat and cholesterol intake. Food Quality & Preferences 3, 183–200.CrossRefGoogle Scholar
Steptoe, A, Wijetunge, S, Doherty, S & Wardle, J (1996) Stages of change for dietary fat reduction and associations with food intake, decisional balance and motives for food choice. Health Education Journal 55, 108–122.CrossRefGoogle Scholar
Sutton, S (1996) Further support for the stages of change model? Addiction 91, 1287–1289.Google Scholar
Velicer, WF, DiClemente, CC, Prochaska, JO, Abrams, DB, Emmons, KM & Pierce, JP (1995) Distribution of smokers by stage in three representative samples. Preventive Medicine 24, 401–411.Google Scholar
Velicer, WF, DiClemente, CC, Prochaska, JO & Brandenberg, N (1985) Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology 48, 1279–1289.Google Scholar
Velicer, WF, DiClemente, CC, Rossi, JS & Prochaska, JO (1990) Relapse situations and self-efficacy: an integrative model. Addictive Behaviors 15, 271–283.Google Scholar
Weinstein, ND, Rothman, AJ & Sutton, SR (1998) Stage theories of health behaviour: conceptual and methodological issues. Health Psychology 17, 290–299.Google Scholar
Weinstein, ND & Sandman, PM (1992) A model of the precaution adoption process: evidence from home radon testing. Health Psychology 11, 170–180.Google Scholar