Stages of Change for Healthy Eating in Diabetes Relation to demographic, eating-related, health care utilization, and psychosocial factors MICHAEL VALLIS, PHD 1 LAURIE RUGGIERO, PHD 2 GEOFFREY GREENE, PHD 3 HELEN JONES, RN, MSN 4 BERNARD ZINMAN, MD 4 SUSAN ROSSI, RN, PHD 3 LYNN EDWARDS, PDT, MHSA 1 JOSEPH S. ROSSI, PHD 3 JAMES O. PROCHASKA, PHD 3 OBJECTIVES — To identify diabetes-related characteristics of individuals at different stages of readiness to change to healthy, low-fat eating. RESEARCH DESIGN AND METHODS — Stage-based differences in demographic, eating-related, health care utilization, and psychosocial factors were examined in a sample of 768 overweight (BMI 27 kg/m 2 ) individuals with diabetes enrolled in a randomized behavioral intervention trial. RESULTS — Stage-based differences occurred for type 1 diabetic participants on percent of calories from fat and number of daily vegetable servings. For type 2 diabetic participants, sex, disease-specific quality of life, percent calories from fat, and number of daily vegetables servings differed across stages. Those in action stages were more likely to be female and have a better quality of life and healthier eating habits. Type 2 diabetic insulin-requiring participants in action stages were more likely to be married. Social support was highest for those in the contemplation stage and lowest for those in the action stage. Type 2 diabetic participants on pills in the action stages were older, had a lower BMI, ate more fruit, were nonsmokers, recently attended diabetes education, had a better quality of life and social support, and had less stress. One anomalous finding for type 2 diabetic participants was that precontemplators scored similarly to those in action stages. CONCLUSIONS — These data validate the Transtheoretical Model, where those in the ac- tion stages displayed healthier eating. They also indicate that demographic and psychosocial factors may mediate readiness to change diet. Precontemplators were a heterogeneous group and may need individually tailored interventions. Diabetes Care 26:1468 –1474, 2003 W ithin the fields of diabetes and health promotion, a change is occurring in how we help those individuals who are unable to consis- tently follow through on behavioral rec- ommendations (1). Behavioral self-care has always been important in diabetes management, given the complex behav- ioral demands involved (2). Achieving optimal blood glucose control requires a complex regimen of behaviors that must be followed consistently over a lifetime. Insulin/medication administration and adjustment, self-testing blood glucose levels, and managing food intake and ac- tivity patterns represent significant be- havioral demands. Traditionally, health care providers have focused on action- oriented interventions (education, skills acquisition, problem solving [3]). These interventions work well with individuals in a motivational state of readiness to change. However, those not motivated to follow through have benefited less from these interventions. The Transtheoretical Model (TTM) of behavior change has been beneficial to those interested in enhancing motivation for self-care. In this model, five distinct motivational stages are identified (1,4): ● Precontemplation. The individual is not intending to change in the foreseeable future, usu- ally measured as the next 6 months. ● Contemplation. The individual is not prepared to take action at present, but is intending to within the next 6 months. ● Preparation. The individual is actively considering changing his or her behavior in the im- mediate future (e.g., within the next month). ● Action. The individual has actually made an overt behavior change in the recent past, but the changes are not well estab- lished (i.e., for 6 months or less) ● Maintenance. The individual has changed his or her behavior for 6 months and is working to sustain the overt change. Individuals in the first three stages (pre- contemplation, contemplation, and prep- aration) were considered to be in the ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada; 2 University of Illinois at Chicago, Chicago, Illinois; 3 University of Rhode Island, Kingston, Rhode Island; and 4 Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada. Address correspondence and reprint requests to Michael Vallis, Ph.D., Diabetes Management Centre, Room 330, Bethune Bldg., Queen Elizabeth II Health Sciences Centre, 1278 Tower Rd., Halifax, Nova Scotia B3H 2Y9, Canada. E-mail: tvallis@is.dal.ca. Received for publication 5 September 2002 and accepted in revised form 25 November 2002. M.V., L.R., H.J., B.Z., S.R., and J.S.R. have received honoraria and/or research funding from Lifescan, Inc. Abbreviations: DISC, Diabetes Stages of Change; PTC, Pathways to Change Diabetes; TAU, treatment as usual; TTM, Transtheoretical Model. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2003 by the American Diabetes Association. See accompanying editorial, p. 1624. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E 1468 DIABETES CARE, VOLUME 26, NUMBER 5, MAY 2003