Assessing motivation and readiness to change for weight management and control: an in-depth evaluation of three sets of instruments

Abstract

It is highly recommended to promptly assess motivation and readiness to change (RTC) in individuals who wish to achieve significant lifestyle behavior changes in order to improve their health, overall quality of life, and well-being. In particular, motivation should be assessed for those who face the difficult task to maintain weight, which implies a double challenge: weight loss initially and its management subsequently. In fact, weight-control may be as problematic as smoking or drugs-taking cessation, since they all share the commonality of being highly refractory to change. This paper will examine three well-established tools following the Transtheoretical Model, specifically assessing RTC in weight management: the University of Rhode Island Change Assessment Scale, the S-Weight and the P-Weight and the Decisional Balance Inventory. Though their strengths and weaknesses may appear to be rather homogeneous and similar, the S-Weight and P-Weight are more efficient in assessing RTC in weight management and control. Assessing motivation and RTC may be a crucial step in promptly identifying psychological obstacles or resistance toward weight-management in overweight or obese hospitalized individuals, and it may contribute to provide a more effective weight-control treatment intervention.

Full text

REVIEW
published: 11 May 2015
doi: 10.3389/fpsyg.2015.00511
Edited by:
Wolfgang Tschacher,
University of Bern, Switzerland
Reviewed by:
Sabrina Cipolletta,
University of Padua, Italy
Mario Pfammatter,
University of Bern, Switzerland
*Correspondence:
Martina Ceccarini and Gianluca
Castelnuovo,
Psychology Department, University
of Bergamo, C/O Catholic University
of the Sacred Heart, Milan,
Via Nirone 15, 20123 Milano, Italy
martina.ceccarini@unibg.it;
gianluca.castelnuovo@auxologico.it
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 09 February 2015
Paper pending published:
28 March 2015
Accepted: 10 April 2015
Published: 11 May 2015
Citation:
Ceccarini M, Borrello M,
Pietrabissa G, Manzoni GM
and Castelnuovo G (2015) Assessing
motivation and readiness to change
for weight management and control:
an in-depth evaluation of three sets
of instruments.
Front. Psychol. 6:511.
doi: 10.3389/fpsyg.2015.00511
Assessing motivation and readiness
to change for weight management
and control: an in-depth evaluation
of three sets of instruments
Martina Ceccarini1,2*, Maria Borrello2, Giada Pietrabissa1,3,GianMauroManzoni
1and
Gianluca Castelnuovo1,3*
1Istituto Auxologico Italiano IRCCS – Ospedale San Giuseppe, Verbania, Italy, 2Psychology Department, University of
Bergamo, Italy, 3Psychology Department, Catholic University of Milan, Milan, Italy
It is highly recommended to promptly assess motivation and readiness to change (RTC)
in individuals who wish to achieve significant lifestyle behavior changes in order to
improve their health, overall quality of life, and well-being. In particular, motivation should
be assessed for those who face the difficult task to maintain weight, which implies a
double challenge: weight loss initially and its management subsequently. In fact, weight-
control may be as problematic as smoking or drugs-taking cessation, since they all
share the commonality of being highly refractory to change. This paper will examine
three well-established tools following the Transtheoretical Model, specifically assessing
RTC in weight management: the University of Rhode Island Change Assessment Scale,
the S-Weight and the P-Weight and the Decisional Balance Inventory. Though their
strengths and weaknesses may appear to be rather homogeneous and similar, the S-
Weight and P-Weight are more efficient in assessing RTC in weight management and
control. Assessing motivation and RTC may be a crucial step in promptly identifying
psychological obstacles or resistance toward weight-management in overweight or
obese hospitalized individuals, and it may contribute to provide a more effective
weight-control treatment intervention.
Keywords: motivation, readiness to change, weight-management, Transtheoretical Model, assessment, obesity,
overweight
Introduction
Morbid obesity and overweight are a widespread epidemic (‘Globesity’) reported in both industri-
alized as well as developing countries (Wadden et al., 2002). There is a consensus among health
professionals and scientists about the existence of environmental factors favoring the rise of this
global epidemic (World Health Organization [WHO], 2014). Such features influence the compat-
ibility between what is offered nutrition-wise by the socio-psycho-economic living context, and
what is biologically needed by the human body to reach an optimal functionality and to survive
(Toft et al., 2007). Healthy nutrition and regular physical activity are considered essential protective
factors in health promotion and risk prevention of chronic diseases (Britt et al., 2004). Nonetheless,
the sole knowledge of healthy nutrition standards and of healthy dietary prescriptions and of reg-
ular physical activity programs is not enough to achieve optimum lifestyle, or to reduce excessive
food-consumption and bodyweight (Resnicow et al., 2008).
Frontiers in Psychology | www.frontiersin.org 1May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
According to Bautista-Castaño et al. (2004), the majority of
obese and overweight individuals do not continue weight-loss
programs, and only a few of them who do so, actually lose
weight. Empirical research demonstrated that the majority of
obese people, who managed to lose weight during hospital-
based interventions, go back to their original weight in three
to 5 years after treatment (Castelnuovo et al., 2010). In other
words, the problem is not to start a diet but to continue
it, avoiding regaining the previously lost weight and slipping
into a vicious cycle (Tremblay and Sánchez, 2012). In this
respect, readiness to change (RTC) seems to be one of the
most promising factors promoting behavior change in individ-
uals who need to modify their lifestyle for health purposes.
Personal motivation can, in fact, dramatically influence treatment
adherence and effectiveness as well as the choice of interven-
tion (Resnicow et al., 2008). Several studies have pointed out
that motivational techniques encourage weight-loss by favor-
ing adherence to weight-loss and weight management pro-
grams, with positive results (Ryan and Deci, 2000;Wilson and
Schlam, 2004;Pietrabissa et al., 2012). This has also been high-
lighted by Salvini et al. (2012) who pointed out how Miller
and Rollnick’s (1991) motivational interview (MI) and the Self-
Determination Theory (SDT, by Ryan and Deci, 2000), evidence
that motivational dynamics can be resourceful elements help-
ing individuals become proactive participants in their behavior
change.
The vast majority of motivational measures adopted in the
clinical setting have been developed for substance-addiction
(Di Clemente and Prochaska, 1982, 1985;Prochaska and Di
Clemente, 1983, 1984, 1986;Prochaska et al., 1992a;Velicer
et al., 1995) and generally relate to Prochaska and Di Clemente’s
Transtheoretical Model (TTM) based on RTC and on the Stages
of Change (SOC; Prochaska and Di Clemente, 1984;Prochaska
et al., 1994, 2008;Prochaska and Velicer, 1997;Prochaska
and Norcross, 2006). The TTM offers a comprehensive the-
oretical framework determining RTC and promoting tailored
interventions according to the patient’s motivation in weight
management (Prochaska et al., 1992b), also preventing dropouts
(Rossi et al., 1995;Johnson et al., 2008). This model defines the
relationships between the stages and the processes of change,
decisional balance (DB; i.e., advantages and disadvantages of
behavior change), self-efficacy, and relapse (Prochaska and Di
Clemente, 1986). The SOC of the TTM are: Precontemplation,
Contemplation, Preparation, Action, and Maintenance, in which
individuals move forward and at times backward, re-starting
the cycle. Though individuals may go back to a stage they
had already been through, previous experiences still consti-
tute a useful step for behavior change. This is the reason
why the model is best depicted as a spiral (Prochaska and Di
Clemente, 1983;Di Clemente and Prochaska, 1985;Prochaska
et al., 1992a).
During the initial Precontemplation stage, individuals are not
willing to change within the next 6 months. While some could
totally refuse the change, others may wish to achieve it at some
point in the future, though not within the next 6 months. During
the Contemplation stage, individuals are thinking about chang-
ing their target-behavior within the next 6 months and are keen
to receive information on their problem. The Preparation stage
is characterized by a commitment toward the change, possi-
bly within the next months. Generally, individuals at this phase
have already tried changing their dysfunctional behavior before,
or they have been making efforts to prepare for change. In the
Action stage individuals have put into practice their attempts
to change, and actually operated this modification within the
past 6 months. At this level, the risk of relapsing is rather high,
since individuals are engaged in something totally new. Hence,
they need to pay a great deal of attention in order to avoid
falling straight back into their old unhealthy lifestyles. In the
final stage, Maintenance, individuals have actually changed their
problematic behavior for at least 6 months. At this level, the
change has become part of their life and they are less likely to
relapse than in the previous stages, although relapse prevention
is still advisable (Prochaska and Velicer, 1997;Redding et al.,
2000).
Assessing RTC usually coincides with classifying an individual
at a given stage to identify his/her level of the problem awareness
(reasons for change), his/her willingness to change (commit-
ment for change), and his/her actions for change. Questionnaires
assessing TTM constructs in weight management are frequently
adapted from other tools designed to measure RTC in addic-
tive disorders (Greene and Rossi, 1998;Marshall and Biddle,
2001). In the context of weight management, the assessment
of RTC and SOC has generally been carried out with separate
evaluations of dietary behavior change and physical exercise.
According to Horwath (1999), using specific measures of both
dietary behavior and exercise can contribute to provide a reliable
and efficient assessment in weight-management, according to the
TTM constructs.
Many clinician-rated and patient-rated instruments have been
developed to measure RTC in the clinical setting during the
last 20 years. However, a motivational assessment in obese hos-
pitalized in-patients does not always correspond to an early,
accurate use of suitable tools. This paper aims at evaluating three
major assessment instruments, the University of Rhode Island
Change Assessment Scale (URICA; McConnaughy et al., 1983,
1989;Rossi et al., 1995), the S-Weight/P-Weight (Andrés et al.,
2011), and the Decisional Balance Inventory (DBI; O’Connell and
Velicer, 1988). This work intends to provide an in-depth compar-
ison between these tools, identifying which one is more suitable in
detecting RTC in weight-management within obese hospitalized
in-patients.
The selection of the three measures was based upon specificity
regarding SOC, processes of change and motivation in weight
management and more generally, the decision of whether or not
to maintain weight according to the SOC of the TTM model.
Thus, strengths and weakness of these three sets of questionnaires
analyzed in this brief review will be pointed out and the most
recommendable tool will be clearly identified. It is important
to verify which instrument is more useful to evaluate motiva-
tional levels in weight-management amongst obese or overweight
individuals. This is because an efficient appraisal in this con-
text could be fundamental in later providing patients with the
best possible psychological support and most suitable weight-loss
treatment.
Frontiers in Psychology | www.frontiersin.org 2May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
The Assessment of Readiness to
Change in Weight Management and
Weight Control
The URICA is the most widely studied measure of readi-
ness for change designed for an adult target population.
The questionnaire was originally used for patients in psy-
chotherapy reporting on their specific problem in treatment
(McConnaughy et al., 1989). However, the measure can be
applied to assess the respondent’s RTC on a range of differ-
ent problems such as addictions, smoking cessation, alcohol,
and cocaine use (Rossi et al., 1995). The URICA has been suc-
cessfully used with other problematic behaviors including obe-
sity, diet and weight management (Prochaska et al., 1992b).
The scale is a 32-item self-report measure that includes four
subscales measuring Prochaska and Di Clemente’s TTM SOC:
Precontemplation, Contemplation, Action, and Maintenance
(Prochaska and Velicer, 1997). Responses are given on a 5-point
Likert scale ranging from 1 (strong disagreement) to 5 (strong
agreement). The test contains eight items for each of the sub-
scales. The latter can be combined arithmetically (by summing
up scores on the Contemplation, Action, and Maintenance sub-
scales and by subtracting the score on the Precontemplation
subscale) to yield a second-order continuous RTC score assessing
RTC at treatment entrance (Prochaska et al., 1994;Greene et al.,
1999).
The URICA is designed to be a continuous measure; sub-
jects can obtain high scores on more than one of the four stages.
Higher total scores indicate a greater RTC. For each subscale,
individuals can score from a minimum of 1 to a maximum
of 40 and a total test score ranging from a minimum of 1
to a maximum of 160 can be obtained. An overall low RTC
level corresponds to a total score below 80, while a high RTC
is represented by total scores above 80 (McConnaughy et al.,
1989;Andrés et al., 2011). The URICA considers the transition
between the SOC as being a gradual progression rather than
a discontinuous and casual movement (McConnaughy et al.,
1983). In the clinical setting, professionals may utilize this instru-
ment to evaluate an individual’s motivation for change level and
use this material to monitor and carry out specific and per-
sonalized treatment interventions. In fact, the four subscales
scores of the test can be used to delineate modifications in
attitudes related to the target-behavior, according to the indi-
vidual’s specific SOC (McConnaughy et al., 1989;Andrés et al.,
2011).
The URICA has good internal consistency with coefficient
alphas ranging from 0.79 to 0.89 across the four subscales, even
in follow-up studies (Andrés et al., 2011). Good reliability, con-
struct validity and psychometric properties of the URICA have
been established for a range of behavioral conditions (Willoughby
and Edens, 1996;Pantalon et al., 2002;Dozois et al., 2004;
Henderson et al., 2004). The construct validity of the URICA
has been supported through factor and cluster analyses demon-
strating that the SOC are associated with different behavioral
profiles (McConnaughy et al., 1989). The latter reflect the pos-
sibility that respondents are likely to engage in actions and
behavior representing more than one stage at a time. Moreover,
the correlations between the questionnaire subscales suggest that
adjacent stages are more strictly linked than non-adjacent ones
(Rossi et al., 1995). There is consistent evidence supporting the
transtheoretical four-factor structure of the URICA given by
both principal component analysis (PCA) and structural equa-
tion modeling (McConnaughy et al., 1989;Andrés et al., 2011).
Furthermore, the measure showed a good predictive validity,
in foreseeing attendance and weight-loss in a study carried out
by Prochaska et al. (1992b). In fact, the authors found that
attendance was significantly predicted by higher scores on the
Action subscale and by lower Precontemplation and Maintenance
subscales scores.
Additionally, the URICA can also be used to measure pro-
cesses and outcome variables for a range of health and addictive
behaviors. Nonetheless, because the relationships among sub-
scales shift as individuals move into Action and Maintenance,
particular attention should be paid in assessing changes in pre-
post design studies (Prochaska et al., 1992a). The questionnaire
is very easy to administer since it only requires 5–10 min for
completion and it can also be self-administered. Furthermore, no
specific training is required for administration and the scoring
can be carried out by any staff member by hand, in 5–10 min.
The authors particularly recommend applying the questionnaire
to evaluate progress during treatment and the outcome of spe-
cific interventions such as weight-loss and weight-maintenance
(Andrés et al., 2011). In fact, the tool demonstrated to be reliable
in a study on 184 hospital staff members engaged in a 10-week
treatment program for weight-control (Prochaska et al., 1992b).
However, the structure and internal consistency of the scale
on weight-control samples is still somewhat unclear. Moreover,
the questionnaire scale scores relate to simple unit weighting
of items and thus involve either a total score or a mean scale
score, which may require cluster analysis and standardized scor-
ing if used in large sample sizes (Prochaska and Norcross,
2006).
The S-Weight and P-Weight are two self-report question-
naires respectively investigating the SOC and the processes of
change defined by Prochaska and Di Clemente (1985). The S-
Weight consists of five mutually exclusive items; respondents
areaskedtochooseoneofthefiveSOCtobeallocatedto
among Precontemplation, Contemplation, Preparation, Action,
and Maintenance (Di Clemente et al., 1991). The S-Weight is
designed to measure the SOC as applied to weight management
asking respondents to choose the answer that best corresponds
to their current weight-loss situation (Andrés et al., 2009). The
P-Weight consists of 34 items measuring individuals’ readiness
to engage in a diet and in physical activity. The questionnaire is
based on the hypothesised processes which individuals use across
the SOC in order to manage their body weight (Andrés et al.,
2011).
On the P-Weight, answers are given on a five-point Likert
scale ranging from 1 (strong disagreement) to 5 (strong agree-
ment). The four processes of change measured by the P-
Weight that are implicated in weight management are: Emotional
Re-evaluation (EmR), Weight Management Actions (WMA),
Environmental Restructuring (EnR), and Weight Consequences
Frontiers in Psychology | www.frontiersin.org 3May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
Evaluation (WCE). The EmR process scale is comprised of 13
items, the WMA process scale is assessed by seven items, and
the WCE process scale consists of nine items while the EnR pro-
cess scale is evaluated by five items. Scores for each of the four
processes of change can be calculated by summing up the scores
obtained on items belonging to the same subscale. None of the
items are reverse scored (Andrés et al., 2011). The measurement
structure has four freely correlated first-order factors as revealed
by the PCA and the confirmatory factor analysis (CFA). Four
scores corresponding to the four processes of change can there-
fore be obtained from this questionnaire. However, the scores
from the different subscales should be transformed onto a scale
from 0 to 100 (from a minimum of 0 reflecting no use of a given
processofchangetoamaximumof100beingfull-useofthat
process), in order to be comparable with one another. A higher
use of a process is represented by scores above 50 (Andrés et al.,
2011).
The P-Weight has good internal consistency with Cronbach’s
alpha coefficients ranging from 0.781 to 0.938 for the different
factors, while it has excellent internal consistency when con-
sidering the whole scale (the total scale Cronbach’s alpha is
0.960). Corrected item-total correlations of the measure are also
adequate, ranging from 0.322 to 0.865 (Andrés et al., 2011).
Moreover, the questionnaire has satisfactory convergent validity
with the ‘drive for thinness’ subscale of the EDI-3 and the ‘diet’
subscale of the EAT-40. The four subscales of the P-Weight posi-
tively correlate with other scales measuring concern with dieting.
This has been demonstrated by the original validation study con-
ducted on 556 University students and on 167 overweight and
obese patients enrolled in a hospital-based weight management
program (Andrés et al., 2011).
The S-Weight and the P-Weight questionnaires are thus able
to assess the relationship between stages and processes of change
in weight-management. In this respect, the two measures allow
identifying which processes of change individuals use the most
according to the stage of change they are in, for what concerns
weight-control (Andrés et al., 2011). The P-Weight question-
naire is very easy to administer since it requires less than 10 min
for completion and it can be self-administered. No trained staff
is necessary for administration and the scoring can be car-
ried out by hand, in around 15 min time. However, in order
to obtain the processes of change scores (from the P-Weight),
across the SOC (from the S-Weight), more complex data ana-
lytic processes are needed, and the use of a statistical software is
advisable.
The DBI was designed to evaluate decision making for weight-
control considering two main dimensions, the pros and cons of
losing weight (O’Connell and Velicer, 1988). Within the context
of the TTM, the pros and cons demonstrate a close association
between decision-making and an individual’s stage of change.
Part of the decision to move from one stage to the next is based
on the relative weight given to the pros and cons of changing
the target-behavior. In fact, the comparative weighing of the pros
and cons varies depending on the individual’s stage of change
(Prochaska et al., 1994). Factor analytic studies (Prochaska et al.,
1994, p. 27, 28; Andrés et al., 2011) have consistently supported
the importance of the pros and cons of behavior change and the
relationship between the SOC and DB (O’Connell and Velicer,
1988).
The DBI is a self-report measure consisting of two con-
structs addressing cognitive and motivational aspects of human
decision-making based on Janis and Mann’s (1977) decision mak-
ing model (O’Connell and Velicer, 1988, p. 46) and the TTM
theoretical framework (Prochaska and Di Clemente, 1982). The
test evaluates motivation with two main subscales, namely the
‘pros’ and the ‘cons’ of change. The two-factor structure of the
test has been confirmed by PCA (Prochaska et al., 1994). The DBI
has 20 items (10 items per subscale), asking to rate the impor-
tance of each statement in influencing the respondent’s decision
on whether or not to lose weight. Answers are given on a five-
point Likert Scale ranging from 1 (Not important at all), to 5
(Extremely important), and the questionnaire completion only
takes about 5 min model (O’Connell and Velicer, 1988). The
scoring is very simple and straightforward: by summing up the
scores obtained from all even numbered questions it is possi-
ble to gain the score of the Pros scale while by summing up the
scores obtained from all odd numbered questions a score for the
Cons scale is attained. Thus, the range of possible total scores on
each subscale ranges from a minimum of 10 to a maximum of
50. A total DB score is calculated by subtracting the cons score
from the pros one. A higher DB score is associated with a greater
motivation and RTC in weight-management. No trained staff is
required neither for scoring nor for administration (O’Connell
and Velicer, 1988).
The DBI has very good internal consistency with Cronbach’s
alpha coefficients of 0.91 and 0.84, respectively, for the pros and
cons scales. The measure construct validity was assessed by the
validation study on 264 college students (O’Connell and Velicer,
1988). Findings revealed that the cons of weight-loss were sig-
nificantly higher than the pros in the precontemplation stage,
while in the contemplation, action and maintenance stages the
trend was reversed. Thus, there is a clear pattern of relation-
ships between weight-loss pros and cons and the TTM SOC. Such
results were also found in several other studies on various health
behavior problems (Prochaska et al., 1994;Redding et al., 2000).
Up to date, the most recent validation of the DBI has been car-
ried out in a study on the pros and cons of reducing dietary
fat consumption in a large sample of adolescents (Rossi et al.,
2001). However, more research on the psychometric properties of
the DBI within the clinical setting and on adults’ weight-control
samples is needed.
Readiness to Change in Weight
Management and Weight Control
Instruments: Implications for Research
and Clinical Practice
Among the tools analyzed throughout this paper, the URICA, the
S-Weight and the P-Weight and the DBI, some measures appear
to be more advantageous within the weight-management con-
text. In fact, the S-Weight and the P-Weight, as shown in the
summary provided in Ta b l e 1, seem to be the most consistent
Frontiers in Psychology | www.frontiersin.org 4May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
TABLE 1 | Measurements characteristics.
Measure
name
Validation study No. of
items
Tool characteristics Advantages Disadvantages
S-Weight
and
P-Weight
Andrés et al. (2011), “The
Transtheoretical Model
(TTM) in Weight
Management: validation of
the Processes of Change
Questionnaire”, Obes
Facts; 4:433–442
Andrés et al. (2009),
“Establishing the stages
and processes of change
for weight loss by
consensus of experts,”
Obesity; 17:1717–1723.
S-Weight:
five items,
P-Weight:
34 items
Self-report measures assessing the stages and the
processes of change.
The S-Weight has five mutually exclusive items each
representing the five stages of change (SOC;
Precontemplation, Contemplation, Preparation, Action and
Maintenance) in weight-management.
The P-Weight has 34 items measuring four processes of
change: emotional re-evaluation (EmR), Weight
Management Actions (WMA), Environmental Restructuring
(EnR) and Weight Consequences Evaluation (WCE).
Responses on a 5-point Likert scale ranging from 1 (strong
disagreement) to 5 (strong agreement).
Item distribution is uneven: 13 items score for EmR, seven
items score for WMA, nine items score for WCE, and five
items score for EnR. Subscales scores are calculated by
summing up scores obtained on items belonging to the
same subscale. Each subscale score should be
transformed onto a scale from 0 to 100 (a minimum score
of 0 =no use of that process, a maximum score of
100 =full-use of the process). A higher use of a process is
represented by scores above 50, while a lower use of a
process by scores blow 50.
The S-Weight and the P-Weight
questionnaires assess the relationship
between stages and processes of change
in weight-management.
The S-Weight is able to detect five SOC
(including the Preparation phase).
The four-factor structure of the P-weight
has been supported by principal
component analysis (PCA) and
confirmatory factor analysis (CFA).
The P-Weight has good internal
consistency (Cronbach’s alpha coefficients
from 0.781 to 0.938 for the different
subscales).
The total scale has excellent internal
consistency (total Cronbach’s alpha is
0.960) and adequate item-total correlations
(Cronbach’s alpha from 0.322 to 0.865).
It has satisfactory convergent validity with
the other scales measuring concern with
dieting (‘drive for thinness’ subscale of the
EDI-3 and the ‘diet’ subscale of the
EAT-40).
The S-Weight and the P-Weight have been
validated in both non-clinical (556 University
students) and clinical samples (overweight
and obese patients enrolled in a
hospital-based weight-management
program).
Simple and short Likert-scale scoring;
trained personnel are not required for
administration for both tests. Scoring of
both S-Weight and P-Weight can be carried
out by hand, in around 15 min.
Subscales scores should be transformed
onto a scale from 0 to 100 in order to be
comparable with one another.
To obtain the processes of change scores
(from the P-Weight), across the SOC (from
the S-Weight), more complex data analytic
processes are needed, and the use of a
statistical software is advisable.
Unknown test–retest reliability.
Clinical cut-offs of the P-Weight subscales
are unknown.
(Continued)
Frontiers in Psychology | www.frontiersin.org 5May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
TABLE 1 | Continued
Measure
name
Validation study No. of
items
Tool characteristics Advantages Disadvantages
University of
Rhode Island
Change
Assessment
Scale
(URICA)
McConnaughy et al. (1983).
SOC in psychotherapy:
Measurement and sample
profiles. Psychotherapy:
Theory, Research, and
Practice, 20, 368–375.
McConnaughy et al. (1989).
SOC in psychotherapy: a
follow-up report.
Psychotherapy, 26,
494–503.
32 items Self-report measure assessing SOC on four subscales:
Precontemplation, Contemplation, Action, and
Maintenance.
Responses on a 5-point Likert scale ranging from 1 (strong
disagreement) to 5 (strong agreement).
Item distribution is perfectly even: eight items for each of
the four subscales.
Subscales score range from a minimum of 1 to a maximum
of 40. A continuous readiness to change (RTC) score is
calculated by summing up scores on Contemplation, Action
and Maintenance subscales and by subtracting the
Precontemplation score.
The total score ranges from a minimum of 1 to a maximum
of 160. Scores below 80 reveal a total low readiness, while
a high RTC is represented by a total score above 80.
Widely studied measure of RTC designed
for an adult target population. It can be
applied on a wide range of different
problems (addictions, smoking cessation,
and weight-control).
Mainly useful for assessing patients in
psychotherapy reporting on their specific
problem in treatment.
The four-factor structure of the test has
been supported by principal component
analysis (PCA) and structural equation
modeling.
In the clinical setting, the four subscales
scores can be used to define behavior
modifications according to the individual’s
specific SOC.
It has good internal consistency even in
follow-up studies (coefficient alphas from
0.79 to 0.89 across subscales). Good
construct validity is supported by factor and
cluster analyses. It has good predictive
validity, in foreseeing treatment attendance
and weight-loss.
Very easy to administer, it takes short time
for completion and scoring (can be carried
out by any staff by hand) and it does not
require trained personnel.
It evaluates RTC on four SOC leaving out
the Preparation one. It does not consider
the processes of change.
Weak test–retest reliability.
Unclear structure and internal consistency
on weight-control samples.
The total score or the mean scale score
may require cluster analysis and
standardized scoring in large sample sizes.
Clinical cut-offs in weight-management are
unknown.
Changes in pre–post design studies do not
consider subscale shifts (into Action and
Maintenance).
Cluster profiling can reveal an overlap of
subscales endorsement: a subscale score
may be very close to the next, with
potential underreporting of respondents
who are ready to move to another stage.
Decisional
Balance
Inventory
(DBI)
O’Connell and Velicer
(1988). A decisional
balance (DB) measure for
weight loss. Intern. J. of
Addictions, 23, 729–750
Rossi et al. (2001).
Validation of DB and
temptation measures for
dietary fat reduction in a
large school-based
population of adolescents.
Eating Behavior 2, 1–18.
20 Items Self-report measure assessing decision-making for
weight-control on two subscales: the pros and cons of
losing weight.
The test two-factor structure is supported by factor
analyses and principal component analyses (PCA).
Item distribution is perfectly even: 10 items per subscale.
Responses on a 5-point Likert scale ranging from 1 (Not
important at all), to 5 (Extremely important).
The score of the Pros scale is calculated by summing up
the scores obtained from all even numbered questions; the
score of the cons scale is calculated by summing up the
scores obtained from all odd numbered questions.
Subscales score range from a minimum of 10 to a
maximum of 50. A total DB score is gained by subtracting
the cons score from that of the pros, with possible scores
ranging from -40 to +40. Higher scores indicate more
perceived cons than pros in managing weight.
It has very good internal consistency
(Cronbach’s alpha coefficients of 0.91 and
0.84, respectively, for the pros and cons
scales).
It has fair construct validity on various
health behavior problems (Prochaska et al.,
1994;Redding et al., 2000).
Completion brevity (5 min or less)
Simple and short Likert-scale scoring;
trained personnel are neither required for
administration nor scoring.
It evaluates RTC only according to the pros
and cons of decision-making. It does not
consider the stages and the processes of
change.
No test–retest reliability.
No data on factor structure or internal
consistency on weight-control samples.
Clinical cut-offs in weight-management are
unknown.
No published study has evaluated the
psychometric properties of this measure in
overweight or obese adults engaged in
weight-loss treatments.
Frontiers in Psychology | www.frontiersin.org 6May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
tools in assessing RTC in weight-control. Though the instru-
ments described earlier may appear to be homogeneous in their
strengths and weaknesses, the S-Weight and the P-Weight are
more efficient toward a sound RTC assessment for what concerns
weight-control, for several reasons. All three sets of question-
naires are appreciable given their short time completion and the
unnecessary presence of trained personnel for administration.
However, the S-Weight and the P-Weight are the only question-
naires among the abovementioned which at present, have been
fully validated on overweight and obese in-patients. Moreover,
these instruments seem to adequately and accurately detect spe-
cific RTC associated with weight-management, by measuring
both processes of change and SOC according to the TTM (Andrés
et al., 2011).
While the DBI only assesses decision making for weight-
control by focusing on the pros and cons of losing weight
(O’Connell and Velicer, 1988), it does not specifically concen-
trates on the stages nor on the processes of change individuals
may go through when engaged in a weight-loss program. The
theoretical framework of the DBI lies within the TTM model of
change as decision-making processes are strictly related to the
pros and cons depending on the individual’s stage of change (Di
Clemente et al., 1991). Nonetheless, the tool has no specificity for
what concerns the relationship between the SOC and individu-
als’ RTC in weight-management. Thus, the two-factor structure
of the DBI only allows evaluating the respondent’s decision on
whether or not to lose weight and it can be useful to gain a general
total score on weight-management RTC (O’Connell and Velicer,
1988). Additionally, the questionnaire has only been validated on
college students (O’Connell and Velicer, 1988), and in a large
sample of adolescents undergoing a dietary fat reduction program
(Rossi et al., 2001). Hence, research using the DBI in the clini-
cal setting and on adults’ weight-control samples still needs to be
carried out.
The URICA evaluates readiness for change in problem behav-
iors such as obesity, diet and weight management according
to four SOC of the TTM model, namely Precontemplation,
Contemplation, Action, and Maintenance (Prochaska and
Velicer, 1997). The test global RTC score can be obtained by
combining the scores from each of the four subscales. However,
classifying participants into specific stages simply on the basis of
the subscale scores can be difficult (Di Clemente and Hughes,
1990;Carney and Kivlahan, 1995). In other words, determin-
ing the numbers of cluster profiles may cause an overlap of
subscales endorsement, suggesting that one’s stage designation
may be somewhat uncertain. An individual’s score for one stage
may be very close to the border of the next stage; for exam-
ple, a precontemplation score might be very close to being a
contemplation score. This could under report the number of
respondents who are nearly ready to consider a move to make
a meaningful change in their behavior (Blanchard et al., 2003).
Moreover, the scale does not account for the processes of change
which are important elements influencing behavior modifica-
tion. Thus, the URICA represents only one way of evaluating
motivation.
In addition, the questionnaire is not appropriate for a pre-post
evaluation of treatment because some of the subscales change
in direction and strength of endorsement as individuals aban-
don their dysfunctional behavior (Carney and Kivlahan, 1995;Di
Clemente et al., 2004; Di Clemente, 2005). Thus, while results
from the URICA provide adequate data by placing respondents
into a representative category of a target-behavior and it is there-
fore a strong predictor at pre-treatment, this linear combination
of subscales does not function well in post-treatment evaluations.
This is due to the fact that time in treatment and recovery seems
to change the relationships of the subscales outcomes (Carney
and Kivlahan, 1995;Di Clemente et al., 2004; Di Clemente,
2005). Since the URICA is still being validated within the weight-
management context, it is advisable to mainly utilize it for
research purposes. Therefore, to date there have been no cut-off
norms established to determine what constitutes high, medium or
low on a particular stage in weight-control (McConnaughy et al.,
1983, 1989).
Many motivational measures specifically developed for
weight-management have not been adequately tested, while
others may present some weaknesses (Palmeira et al., 2007).
Amongst the ones selected and described by this paper, the
S-Weight and P-Weight appear to be more useful and straight-
forward in evaluating RTC for weight-control, with the advan-
tages regarding brevity and the constructs they analyze. Firstly,
the S-Weight and P-Weight are able to measure both SOC
that focus on when people change, as well as the processes of
change which refer to how people change (Andrés et al., 2011).
Secondly, unlike the DBI which concentrates on the DB formu-
lated by the pros and cons of change, and the URICA which
only measures four SOC, the S-Weight is able to detect five
SOC, therefore adding the Preparation phase (Andrés et al., 2011)
while the P-Weight provides information on the processes of
change too.
In fact, the S-Weight and P-Weight are able to measure
not only the corresponding motivational stage of the TTM
model for weight-control, but they also focus on overt and
covert activities that individuals engage in when they attempt
to manage their weight, represented by the processes of change
(Di Clemente et al., 1991). In fact, these are powerful predic-
tors of behavior change and they can give crucial information
on weight-management interventions efficacy (Prochaska et al.,
1992b). Hence, assessing the processes of change can reveal
how the patient is tackling his or her weight problem while
the SOC classification complements the motivational evalua-
tion by identifying when behavior change occurs. For such rea-
sons, the use of the S-Weight and P-Weight to assess RTC in
weight-management appears to be more resourceful than that
of the URICA and the DBI. Finally, it must be considered that
contrarily to the URICA and the DBI, the the S-Weight and
P-Weight have been clinically validated in a sample of over-
weight and obese patients enrolled in a hospital-based weight-loss
treatment.
The stage of change construct of the TTM model can facilitate
intervention-tailoring by matching specific treatment strategies
to individuals’ motivation and RTC (Jordan and Nigg, 2002).
In other words, a stage-matched intervention for at-risk partic-
ipants such as overweight and obese individuals can contribute
to increase the chances of becoming more physically active
Frontiers in Psychology | www.frontiersin.org 7May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
and to decrease dietary fat intake, compared to a non-stage
matched intervention (Steptoe et al., 2001). Promptly identify-
ing stages and processes of change in weight-management can
therefore help clinicians and other professionals developing a
more suitable weight-specific intervention in order to deter-
mine which behaviors an individual should target for change, at
various points during treatment. In this respect, the S-Weight
and P-Weight seem to be more advantageous compared to the
DBI and the URICA, considering their specificity and their
psychometric properties in obese and overweight hospitalized
in-patients.
Limitations of the Review
This review presents some relevant limitations as the selec-
tion of the three suggested set of instruments entirely refers
to the specific motivational framework proposed by Prochaska
and Di Clemente’s RTC and SOC concepts of the TTM
(Prochaska et al., 1994, 2008;Prochaska and Velicer, 1997;
Prochaska and Norcross, 2006). Therefore, other important
instruments which are often used in the clinical practice
to evaluate weight-management motivation in overweight or
obese individuals may have been left out. For example, the
paper does not take into account two well-established instru-
ments in this field such as the Treatment Self-regulation
Questionnaire (TSRQ; Levesque et al., 2007) and the Weight-
Efficacy Lifestyle Questionnaire Short Form (WEL-SF; Ames
et al., 2012).
The TSRQ examines autonomous and controlled motiva-
tion on entering a weight-loss program (baseline) and contin-
uing the program participation (follow-up). This questionnaire
evaluates the motivational level of people engaged in weight-
management treatments, and the reasons why they enter, follow
and continue weight-loss programs. Thus, the scale investigates
on the degree to which a person’s motivation for their health
behavior is relatively autonomous (Levesque et al., 2007). The
WEL-SF was developed to explore a sense of self-efficacy for
dieting. The scale evaluates participants’ confidence in their abil-
ity to lose weight on five main dimensions: Negative Emotions,
Availability, Social Pressure, Physical Discomfort, and Positive
Activities. The TSRQ and the WEL-SF are often used within
the primary care setting in order to identify specific RTC in
weight-management, within overweight and obese individuals
engaged in weight-loss treatment interventions (Ames et al.,
2012).
Conclusion
TheTTMconceptualizesRTCacrossawiderangeofbehaviors,
defining the relationships between stages and processes of change,
DB, self-efficacy and relapse (Prochaska and Di Clemente, 1986).
The use of the TTM constructs can enhance motivational tech-
niques and encourage weight-loss by favoring adherence to
weight-loss and weight management programs, with positive
results (Wilson and Schlam, 2004;Ryan et al., 2011;Pietrabissa
et al., 2012). In fact, the SOC can provide fundamental informa-
tion toward the creation of well-tailored interventions according
to the patient’s specific motivational level in weight-management
(Prochaska et al., 1992b;Norcross et al., 2011). Questionnaires
evaluating TTM constructs in the context of weight-management
are usually adapted from instruments designed to measure moti-
vation in addictive disorders (Greene and Rossi, 1998;Marshall
and Biddle, 2001). In weight management, the assessment of
stages and processes of change is usually carried out through the
assessment of dietary fat reduction and exercise, separately. Using
specific measures of both these behaviors at once, can contribute
to offer a reliable and efficient assessment of weight-management
motivation (Horwath, 1999).
Assessing motivation and RTC levels in weight-management
can have an important impact on the outcome of efficient weight-
control treatment interventions. By promptly identifying psycho-
logical obstacles or resistance to change in overweight or obese
individuals engaged in a weight-loss treatment, could dramati-
cally favor positive effects. Indeed, specific weight-loss interven-
tions could be tailored according to certain behaviors individual
should achieve in order to change, at different stages during
treatment. It is fundamental to determine the motivational level
of overweight or obese individuals enrolled in specific weight-
loss programs, especially considering that most of them later go
back to their original weight in three to 5 years after treatment
(Castelnuovo et al., 2010).
In this respect, the URICA, the DBI and the S-Weight and
P-Weight questionnaires are specifically able to measure RTC
toward weight-control, according to the TTM model. Though
all questionnaires appear to be all advantageous given their
short-time completion and scoring and for the fact that no
special training is required for administration, the S-Weight
and P-Weight seem to be more efficient. Unlike the URICA
and the DBI, the S-Weight and P-Weight specifically focus on
RTC for weight-control by evaluating both stages and pro-
cesses of change. These are two interrelated dimensions for the
adequate assessment of behavioral modification. Moreover, the
S-Weight and P-Weight have been validated in an overweight
and obese in-patients sample, contrarily to the URICA and
the DBI.
Thus, the S-Weight and P-Weight seem to provide a more
adequate assessment of RTC in weight-control in-patients com-
pared to the URICA and the DBI. They can therefore be of great
help to clinicians and professionals who wish to provide patients
with the best and most suitable weight-loss intervention. In fact,
the S-Weight and P-Weight seem to be sound instruments in
appraising RTC in weight-management, by giving a clear picture
of which SOC individuals are in, and of the processes of change
they are using. This information could favor the decrease or min-
imization of resistant and ambivalent behavior toward change.
All in all, among the three sets of questionnaire analyzed in this
work, the S-Weight and P-Weight are the most reliable and bene-
ficial tools in assessing RTC in individuals engaged in weight-loss
programs.
Frontiers in Psychology | www.frontiersin.org 8May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
References
Ames, G. E., Heckman, M. G., Grothe, K. B., and Clark, M. M. (2012). Eating
self-efficacy: development of a short-form WEL. Eat. Behav. 13, 375–378. doi:
10.1016/j.eatbeh.2012.03.013
Andrés, A., Saldaña, C., and Gómez-Benito, J. (2009). Establishing the stages
and processes of change for weight loss by consensus of experts. Obesity 17,
1717–1723. doi: 10.1038/oby.2009.100
Andrés, A., Saldaña, C., and Gómez-Benito, J. (2011). The Transtheoretical model
in weight management: validation of the processes of change questionnaire.
Obes Facts 4, 433–442. doi: 10.1159/000335135
Bautista-Castaño, I., Molina-Cabrillana, J., Montoya-Alonso, J. A., and Serra-
Majem, L. (2004). Variables predictive of adherence to diet and physical activity
recommendations in the treatment of obesity and overweight, in a group of
Spanish subjects. Int. J. Obes. 28, 697–705. doi: 10.1038/sj.ijo.0802602
Blanchard, K. A., Morgenstern, J., Morgan, T. J., Labouvie, E., and Bux, D. A.
(2003). Motivational subtypes and continuous measures of readiness for
change: concurrent and predictive validity. Psychol. Addic. Behav. 17, 56–65.
doi: 10.1037/0893-164X.17.1.56
Britt, E., Hudson, S. M., and Blampied, N. M. (2004). Motivational interviewing in
health settings: a review. Patient Educ. Couns. 53, 147–155. doi: 10.1016/S0738-
3991(03)00141-1
Carney, M. M., and Kivlahan, D. R. (1995). Motivational subtypes among veterans
seeking substance abuse treatment: profiles based on stages of change. Psychol.
Addic. Behav. 9, 1135–1142. doi: 10.1037/0893-164X.9.2.135
Castelnuovo, G., Manzoni, G. M., Cuzziol, P., Cesa, G. L., Tuzzi, C., Villa, V., et al.
(2010). TECNOB: study design of a randomized controlled trial of a multi-
disciplinary telecare intervention for obese patients with type-2 diabetes. BMC
Public Health 10:204. doi: 10.1186/1471-2458-10-204
Di Clemente, C. C. (2005). Conceptual models and applied research: the ongo-
ing contribution of the transtheoretical model. J. Addict. Nurs. 16, 5–12. doi:
10.1080/10884600590917147
Di Clemente, C. C., and Hughes, S. O. (1990). Stages of change profiles
in alcoholism treatment. J. Subst. Abuse 2, 217–235. doi: 10.1016/S0899-
3289(05)80057-4
Di Clemente, C. C., and Prochaska, J. O. (1982). Self-change and therapy change
of smoking behavior: a comparison of processes of change in cessation and
maintenance. Addict. Behav. 7, 133–144. doi: 10.1016/0306-4603(82)90038-7
Di Clemente, C. C., and Prochaska, J. O. (1985). “Processes and stages of self-
change: coping and competence in smoking behavior change,” in Coping and
Substance Abuse, eds S. Shiffman and T. Wills (San Diego: Academic Press),
319–343.
Di Clemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez,
M. M., and Rossi, J. S. (1991). The processes of smoking cessation: an analysis of
precontemplation, contemplation, and preparation stages of change. J. Consult.
Clin. Psychol. 59, 295–304. doi: 10.1037/0022-006X.59.2.295
Di Clemente, C. C., Schlundt, D., and Gemmell, L. (2004). Readiness and
stages of change in addiction treatment. Am. J. Addict. 13, 103–119. doi:
10.1080/10550490490435777
Dozois, D. J., Westra, H. A., Collins, K. A., Fung, T. S., and Garry, J. K. (2004).
Stages of change in anxiety: psychometric properties of the University of Rhode
Island Change Assessment (URICA) scale. Behav. Res. Ther. 42, 711–729. doi:
10.1016/S0005-7967(03)00193-1
Greene, G. W., and Rossi, S. R. (1998). Stages of change for reducing dietary
fat over 18 months. J. Am. Diet. Assoc. 98, 529–534. doi: 10.1016/S0002-
8223(98)00120-5
Greene,G.W.,Rossi,S.R.,Rossi,J.S.,Velicer,W.F.,Fava,J.S.,andProchaska,
J. O. (1999). Dietary applications of the stages of change model. J. Am. Diet.
Assoc. 99, 673–678. doi: 10.1016/S0002-8223(99)00164-9
Henderson, M. J., Saules, K. K., and Galen, L. W. (2004). The predictive validity
of the University of Rhode Island change assessment questionnaire in a heroin-
addicted polysubstance abuse sample. Psychol. Addict. Behav. 18, 106–112. doi:
10.1037/0893-164X.18.2.106
Horwath, C. C. (1999). Applying the transtheoretical model to eating behaviour
change: challenges and opportunities. Nutr. Res. Rev. 12, 281–317. doi:
10.1079/095442299108728965
Janis, I. L., and Mann, L. (1977). Decision Making: A Psychological Analysis of
Conflict, Choice, and Commitment. New York, NY: Macmillan.
Johnson, S. S., Paiva, A. L., Cummins, C. O., Johnson, J. L., Dyment, S. J., Wright,
J. A., et al. (2008). Transtheoretical model-based multiple behavior interven-
tion for weight management: effectiveness on a population basis. Prev. Med. 46,
238–246. doi: 10.1016/j.ypmed.2007.09.010
Jordan, P. J., and Nigg, C. R. (2002). “Applying the Transtheoretical Model: tai-
loring interventions to stages of change,” in Promoting Exercise and Behavior
Change in Older Adults:Inter ventions with the Transtheoretical Model, eds P. M.
Burbank and D. Riebe (New York, NY: Springer), 181–207.
Levesque, C. S., Williams, G. C., Elliot, D., Pickering, M. A., Bodenhamer, B., and
Finley, P. J. (2007). Validating the theoretical structure of the treatment self-
regulation questionnaire ( TSRQ) across three differe nt health behaviors. Health
Educ. Res. 22, 691–702. doi: 10.1093/her/cyl148
Marshall, S. J., and Biddle, S. J. H. (2001). The transtheoretical model of behavior
change: a meta-analysis of applications to physical activity and exercise. Ann.
Behav. Med. 23, 229–246. doi: 10.1207/S15324796ABM2304_2
McConnaughy, E. A., Di Clemente, C. C., Prochaska, J. O., and Velicer, W. F.
(1989). Stages of change in psychotherapy: a follow-up report. Psychotherapy
26, 494–503. doi: 10.1037/h0085468
McConnaughy, E. A., Prochaska, J. O., and Velicer, W. F. (1983). Stages of change
in psychotherapy: measurement and sample profiles. Psychother. Theory Res.
Prac. 20, 368–375. doi: 10.1037/h0090198
Miller, W. R., and Rollnick, S. (1991). Motivational Interviewing: Preparing People
to Change. Addictive Behaviour. New York, NY: Guilford Press.
Norcross, J. C., Krebs, P. M., and Prochaska, J. O. (2011). Stages of change. J. Clin.
Psych. 67, 143–154. doi: 10.1002/jclp.20758
O’Connell, D., and Velicer, W. F. (1988). A decisional balance measure for weight
loss. Int. J. Addict. 23, 729–750.
Palmeira, A. L., Teixeira, P. J., Branco, T. L., Martins, S. S., Minderico, C. S.,
Barata, J. T., et al. (2007). Predicting short-term weight loss using four lead-
ing health behavior change theories. Int. J. Behav. Nutr. Phys. Act. 4, 14. doi:
10.1186/1479-5868-4-14
Pantalon, M. V., Nich, C., Frankforter, T., and Carroll, K. M. (2002). University
of rhode island change assessment. the URICA as a measure of motivation
to change among treatment-seeking individuals with concurrent alcohol and
cocaine problems. Psychol. Addict. Behav. 16, 299–307. doi: 10.1037/0893-
164X.16.4.299
Pietrabissa, G., Manzoni, G. M., Corti, S., Vegliante, N., Molinari, E.,
and Castelnuovo, G. (2012). Addressing motivation in globesity treat-
ment: a new challenge for clinical psychology. Front. Psychol. 3:317. doi:
10.3389/fpsyg.2012.00317
Prochaska, J. O., and Di Clemente, C. C. (1982). Transtheoretical therapy: toward
a more integrative model of change. Psychother. Theory Res. Prac. 19, 276–288.
doi: 10.1037/h0088437
Prochaska, J. O., and Di Clemente, C. C. (1983). Stages and processes of self-change
of smoking: toward an integrative model of change. J. Consult. Clin. Psychol. 51,
390–395. doi: 10.1037/0022-006X.51.3.390
Prochaska, J. O., and Di Clemente, C. C. (1984). The Transtheoretical Approach:
Crossing the Traditional Boundaries of Therapy. Malabar: Krieger.
Prochaska, J. O., and Di Clemente, C. C. (1985). “Common processes of self-
change in smoking, weight control, and psychological distress,” in Coping and
Substance Abuse, eds S. Shiffman and T. Wills (San Diego, Academic Press),
345–363.
Prochaska, J. O., and Di Clemente, C. C. (1986). “Toward a comprehensive model
of change,” in Treating Addictive Behaviors: Processes of Change,edsW.R.
Miller and N. Heather (New York, NY: Plenum), 3–27 doi: 10.1007/978-1-4613-
2191-0_1
Prochaska, J. O., Di Clemente, C. C., and Norcross, J. C. (1992a). In search of how
people change: applications to addictive behaviors. Am. Psychol. 47, 1102–1114.
doi: 10.1037/0003-066X.47.9.1102
Prochaska, J. O., Norcross, J. C., Folwer, J. L., Follick, M. J., and Abrams, D. B.
(1992b). Attendance and outcome in a work-site weight control program:
Processes and stages of change as proces s and predictor variables. Ad dict. Behav.
17, 35–45. doi: 10.1016/0306-4603(92)90051-V
Prochaska, J. O., and Norcross, J. C. (2006). Systems of Psychotherapy: A
Transtheoretical Analysis, 6th Edn. Pacific Grove, CA: Brooks-Cole.
Prochaska, J. O., Spring, B., and Nigg, C. R. (2008). Multiple health behavior
change research: an introduction and overview. Prev. Med. 46, 181–188. doi:
10.1016/j.ypmed.2008.02.001
Frontiers in Psychology | www.frontiersin.org 9May 2015 | Volume 6 | Article 511

Ceccarini et al. Assessing motivation for weight management
Prochaska, J. O., and Velicer, W. F. (1997). The transtheoretical model of health
behavior change. Am.J.HealthPromot.12, 38–48. doi: 10.4278/0890-1171-
12.1.38
Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B.,
Rakowski, W., et al. (1994). Stages of change and decisional balance for
12 problem behaviors. Health Psychol. 13, 39–46. doi: 10.1037/0278-6133.
13.1.39
Redding, C. A., Rossi, J. S., Rossi, S. R., Velicer, W. F., and Prochaska, J. O. (2000).
Health Behavior Models. Int. EJ. of Health Educ. 3, 180–193.
Resnicow, K., Davis, R. E., Zhang, G., Konkel, J., Strecher, V. J., Shaikh, A. R.,
et al. (2008). Tailoring a fruit and vegetable intervention on novel motivational
constructs: results of a randomized study. Ann. Behav. Med. 35, 159–169. doi:
10.1007/s12160-008-9028-9
Rossi, J. S., Rossi, S. R., Velicer, W. F., and Prochaska, J. O. (1995). “Motivational
readiness to control weight,” in Handbook of Assessment Methods for Eating
Behaviors and Weight-Related Problems: Measures, Theory, and Research, ed.
D. B. Allison (Thousand Oaks, CA: Sage), 387–430.
Rossi, S. R., Greene, G. W., Rossi, J. S., Plummer, B. A., Benisovich, S. V.,
Keller, S., et al. (2001). Validation of decisional balance and tempta-
tion measures for dietary fat reduction in a large school-based popu-
lation of adolescents. Eat. Behav. 2, 1–18. doi: 10.1016/S1471-0153(00)
00019-2
Ryan, R. M., and Deci, E. L. (2000). Self-determination theory and the facilitation
of intrinsic motivation, social development, and well-being. Am. Psychol. 55,
68–78. doi: 10.1037/0003-066X.55.1.68
Ryan, R. M., Lynch, M. F., Vansteenkiste, M., and Deci, E. L. (2011).
Motivation and autonomy in counseling, psychotherapy, and behavior
change: A Look at Theory and Practice. Counse. Psychol. 39, 193–260. doi:
10.1177/0011000009359313
Salvini, A., Faccio, E., Mininni, G., Romaioli, D., Cipolletta, S., and Castelnuovo, G.
(2012). Change in and through psychotherapy: a dialogical analysis single-
case study of a patient with bulimia nervosa. Front. Psychol. 3:546. doi:
10.3389/fpsyg.2012.00546
Steptoe, A., Kerry, S., Rink, E., and Hilton, S. (2001). The impact of behavioural
counseling on stage of change in the fat intake, physical activity, and cigarette
smoking in adults at increased risk of coronary heart disease. Am. J. Public
Health 91, 265–269. doi: 10.2105/AJPH.91.2.265
Toft, U. N., Kristoffersen, L. H., Aadahl, M., von Huth Smith, L., Pisinger, C., and
Jørgensen, T. (2007). Diet and exercise intervention in a general population
mediators of participation and adherence. Eur. J. Public Health 17, 455–463.
doi: 10.1093/eurpub/ckl262
Tremblay, A., and Sánchez, M. (2012). “Environmental toxins as triggers for obe-
sity,” in Food and Addiction, a Comprehensive Handbook,edsK.D.Brownell
and M. S. Gold (New York, NY: Oxford University).
Velicer, W. F., Hughes, S. L., Fava, J. L., Prochaska, J. O., and Di Clemente, C. C.
(1995). An empirical typology of subjects within stages of change. Addict. Behav.
20, 299–320. doi: 10.1016/0306-4603(94)00069-B
Wadden, T. A., Brownell, K. D., and Foster, G. D. (2002). Obesity: responding to
the global epidemic. J. Consult. Clin. Psychol. 70, 510–525. doi: 10.1037/0022-
006X.70.3.510
World Health Organization [WHO]. (2014). Obesity and Overweight. Fact Sheet N
311, Geneva: World Health Organization.
Willoughby, F. W., and Edens, J. F. (1996). Construct validity and predictive util-
ity of the stages of change scale for alcoholics. J. Subst. Abuse 8, 275–291. doi:
10.1016/S0899-3289(96)90152-2
Wilson, G. T., and Schlam, T. R. (2004). The transtheoretical model and motiva-
tional interviewing in the treatment of eating and weight disorders. Cli. Psych.
Rev. 24, 361–378. doi: 10.1016/j.cpr.2004.03.003
Conflict of Interest Statement: The authors declare that the research was con-
ducted in the absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.
Copyright © 2015 Ceccarini, Borrello, Pietrabissa, Manzoni and Castelnuovo. This
is an open-access article distributed under the terms of the Creative Commons
Attribution License (CC BY). The use, distribution or reproduction in other forums
is permitted, provided the original author(s) or licensor are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
Frontiers in Psychology | www.frontiersin.org 10 May 2015 | Volume 6 | Article 511