Stress fractures are one of the most common and potentially serious overuse injuries reported in athletes, both elite and recreational. With this in mind, Andrew Hamilton looks at recent evidence linking stress fractures and nutritional status… MORE
Sports Psychology: the importance of long-term behaviour when creating a nutrition plan
The transtheoretical model of behaviour change for improving eating behaviour.
Nutritionists, coaches and athletic trainers need to do so much more than just create plans and track progress. As Amanda Carlson explains, they also need to help athletes change their mindset about why and how they do things and then create better behaviours that become the new norm…
It’s not easy to change an athlete’s nutritional behaviour, especially when you often have only limited access to that athlete. As a sports nutritionist, I spent the first couple of years of my practice building complete meal plans, personalised programmes, and very descriptive directions for each of the athletes who I worked with. For some, this worked well. However, for many others, I would find all of my hard work was left somewhere in the training area, or possibly discarded along with the trash!
What is the transtheoretical model?
Sometimes we judge nutritional success as getting the recommend grams of carbohydrate, drinking the perfect hydration mix and having the exact amount of carbohydrate and protein in the post-workout recovery shake. This can mean success for some athletes, but with many it is a constant struggle simply to get them to stop eating fast food so often, drink more water, increase their fruit and vegetable intake or just eat more frequently. The transtheoretical model of behaviour change (TTM) involves focusing on big behaviours rather than the finite.
Prochaska and DiClemente created TTM as a way to explain how people modify their own behaviours (1). It is a model of intentional change that focuses on the decision-making abilities of the individual, and has been found to be useful in determining a nutritional counselling strategy(2,3,4,5). TTM explains intentional behaviour change in a way that includes both cognitive and performance-based components. These stages create definitions for not only the current behaviour, but also the intention to change future behaviours. The five stages of change identified in the change process are: pre-contemplation; contemplation; preparation; action; and maintenance (6).
Pre-contemplation is the stage in which an individual has no intent to change behaviour in the near future (at least not in the next six months). This can be defined as a period of resistance because the athlete believes either ‘I don’t want to’ or ‘I can’t’. They may appear to be unmotivated and tend to avoid information, discussion or any thought with regard to the targeted health behaviour. They may not see the benefit of a change and be benignly ignorant. For example, a successful footballer who eats a cheeseburger with fries and a Coke before each game does not see the reason why he should change his behaviour. Or the elite distance runner who eats very little, if anything, prior to races, yet still does well, so she does not see the need to add in more fuel prior to and during her runs. We need to help them see that the pros of change can overcome the cons.
Contemplation is the stage in which the individual is seriously thinking about changing the behaviour in the next six months. Individuals openly state their intent to change and are more conscious of the benefits of changing, but are still quite aware of the costs of change and how difficult it may be. Athletes in this stage can be quite ambivalent and often master procrastinators. It is important here to discuss why the athlete wants to change and then link those reasons to the behaviour change strategy. In terms of a change in nutrition behaviour for an athlete at this stage, it is important to be the information provider, helping the athlete to gather as much information as possible about solutions and actions. During this stage it is important that self re-evaluation is stressed. A plan should not yet be discussed in this stage.
Preparation is the stage where the individual is seriously thinking about changing behaviour in the next month and may have tried to make a similar type of change in the past year. This stage has been viewed as a transitionary stage rather than a stable one, as individuals will either move forwards or backwards in the following 30 days. This is the stage where the athlete will most often reach out. They are gathering up all the information needed to make a change and asking ‘What should I eat before a game?’ or ‘What should my meals look like?’ At this stage it is important to analyse the decision with the athlete to reaffirm the need and desire to change behaviour. It is also time to start developing a plan and discussing what appropriate goals would be.
Action is the period of zero to six months after the individual has made the overt change to the behaviour; however, this stage can last from six months to five years. This is the stage when the athlete is actively working to make changes. They have pulled it together and are working the plan that you develop for them. At this stage it is important to focus on helping them foresee obstacles, motivate them through setbacks and lapses, continue to provide them with evidence as to the positive outcomes of their behaviour change, and finally always be there to support them through the process. In this phase they need you to be their nutritional coach .
Maintenance is the final stage, where individuals are working to consolidate gains and are working to prevent relapse. Those in this stage have the highest belief in themselves and are least tempted to revert back to their old ways. It is important to help the athlete identify times when they may revert into old behaviours and help them identify what to do when they see themselves as falling off the wagon. Here is when you let your athlete go, knowing and assuring them that they are capable, but letting them know that you will always be there for support.
Tables 1-5 below (adapted from University of California Los Angeles Center for Human Nutrition) summarise the states of behaviour change in terms of characteristics, motivation, techniques and timescales.
Stair, step or slide?
When it comes to working your athlete through these stages, you should not necessarily expect a steady progression. TTM is considered to be more of a circular progression than a completely linear one. Relapse (or reverting back to the previous behaviour) is common and should be expected. This is exemplified by the athlete who eats clean and achieves body composition and performance goals, but then completely reverts back to old habits and shows up at pre-season training over-fat, overweight, and de-conditioned.
However, this doesn’t mean that he or she has to progress through all of the stages again. TTM is more of a ‘spiral model of change’; when someone regresses, they typically do not fall back to where they started and they may subsequently advance through each of the stages faster as lessons are learned from previous mistakes (see figure 1).
Internal vs external
In recent years TTM has been applied to more general health behaviour changes (6). Additional aspects of the model have been developed that factor in other independent variables, specific to the problem area. These are the external and internal environment.
The external environment includes any interventions in the area that needs changing, or changes in the individual’s natural environment that could affect behaviour. The internal environment includes overall personality characteristics, cognitive ability, available monetary resources and events that have happened in the athlete’s past that might impact the problem area. An example here would be a fitness coach talking and intervening with an athlete about their body composition where the athlete has some deep-rooted issues with emotional eating.
When working with an athlete, it is critical to help them identify the external and internal variables that are going to help their overall efforts and those that are going to hurt them. For example, many of the athletes I work with do not cook their own meals – their wives or girlfriends do. So, in order to set them up for success you must bring the partners into the equation. Similarly, many younger athletes do not do their own grocery shopping; it is important therefore, to relay messages to the parents, because they control the external variables.
Coaches shouldn’t make the mistake of forgetting the complexity of changing a nutritional behaviour. Make it a habit to assess the stage of change and ask your athletes ‘On a scale of 1 to 10, how ready are you to make this change?’ If they answer lower than a 4, then they are not ready. Too much at one time or creating a nutrition plan that is not matched to the correct stage will slow their natural progression through the stages and possibly lead to complete failure. You should work foster self-efficacy and self-confidence in the athlete so that they truly believe they are capable of succeeding.
1. Psychotherapy: Theory, Research and Practice, 1982, (7), 133-142.
2. Topics Clin Nutr 1994 (9): 64-69.
3. J Am Diet Assoc. 2006 Sep;106(9):1405-11.
4. Int J Obes Relat Metab Disord. 2001 May;25 Suppl 1:S85-8.
5. Endocrinol Metab Clin North Am. 2008 Dec;37(4):905-22.
6. Am J Health Promot. 1997 Sep-Oct;12(1):38-48.