Health Psychology © 2011 American Psychological Association

2011, Vol. 30, No. 6, 771–779 0278-6133/11/$12.00 DOI: 10.1037/a0024500

Longitudinal Motivational Predictors of Dietary Self-Care and Diabetes

Control in Adults With Newly Diagnosed Type 2 Diabetes Mellitus
Arie Nouwen Teri Ford
University of Birmingham Staffordshire University

Andreea Teodora Balan Jos Twisk

University of Birmingham VU Medical Centre, Amsterdam and VU University, Amsterdam

Laurie Ruggiero David White

University of Illinois at Chicago Staffordshire University

Objective: This prospective study examined relationships between constructs from social– cognitive
theory (Bandura, 1986) and self-determination theory (Deci & Ryan, 1985; Deci & Ryan, 1991) and the
diabetes outcomes of dietary self-care and diabetes control. Method: Longitudinal data were collected
from 237 people newly diagnosed with Type 2 diabetes who filled in questionnaires on dietary self-care,
and motivational factors derived from social– cognitive theory and self-determination theory. Blood
samples were taken to assess diabetes control (HbA1c). Repeated measurements were taken every 3– 4
months for a total of five time points over 18 months. Predictor measures included autonomy support,
autonomous and controlled motivation, amotivation, dietary self-efficacy, positive and negative outcome
expectancies for dietary self-care and self-evaluation. Age, sex, BMI, and diabetes knowledge were
included as control measures. Results: Using Generalized Estimating Equations (GEE) analyses two
models were tested: a standard model reflecting longitudinal associations between absolute values of
predicted and outcome variables; and a change model examining motivational predictors of changes over
time in diabetes outcomes of dietary self-care and diabetes control (HbA1c). Dietary self-care was
longitudinally associated with self-efficacy, self-evaluation (the strongest predictor) autonomy support
and autonomous motivation, but not with controlled motivation or outcome expectancies. Changes in
dietary self-care were predicted by changes in self-efficacy, self-evaluation, and controlled motivation
but not by changes in autonomous motivation or autonomy support. Negative outcome expectancies
regarding diet were longitudinally associated with HbA1c, and changes in negative outcome expectancies
predicted changes in HbA1c. However, there were indications that dietary self-care predicted changes in
HbA1c. Conclusions: The results indicate that autonomy support, self-efficacy and, in particular,
self-evaluation are key targets for interventions to improve dietary self-care.

Keywords: type 2 diabetes, dietary self-care, HbA1c, motivation

Following a well-balanced diet is considered a key component
for the successful management of Type 2 diabetes and may reduce
the risk of diabetes complications even at the early stages after
diagnosis (Manley et al., 2000). However, a qualitative study
This article was published Online First June 27, 2011.
Arie Nouwen and Andreea Teodora Balan, School of Psychology, Uni-
versity of Birmingham, Birmingham, UK; Teri Ford, Staffordshire Uni-
versity, Stoke-on-Trent, UK; Jos Twisk, Department of Epidemiology and
Biostatistics, VU Medical Centre, Amsterdam & Department of Health
Sciences, VU University, Amsterdam, Netherlands; Laurie Ruggiero,
Community Health Sciences and Institute for Health Research and
Policy, School of Public Health, University of Illinois at Chicago;
David White, Department of Psychology and Mental Health, Stafford-
shire University, Stoke-on-Trent, UK.
Correspondence concerning this article should be addressed to Arie
Nouwen, PhD, School of Psychology, University of Birmingham, Edg-
baston, Birmingham B15 2TT, Great Britain. E-mail: a.nouwen@
bham.ac.uk
reported that people with Type 2 diabetes do not associate their
condition with lifestyle changes such as dietary self-management,
but instead believe diabetes to be a unmodifiable condition (Stack,
Elliott, Noyce, & Bundy, 2008). Even when they are convinced
that following a healthy diet would be beneficial for the control of
diabetes they frequently consider it to be burdensome (Gorter,
Tuytel, de Leeuw, van der Bijl, Bensing & Rutten, 2010) and the
most difficult part of their diabetes self-management regimen
(Rubin & Peyrot, 2001). In people with Type 2 diabetes, the
tendency to overeat at diagnosis was associated with dietary
intake and weight gain four years after diagnosis (van Strien et
al., 2007). Motivational factors have been shown to be associ-
ated with adherence to dietary self-care in people with long-
standing Type 2 diabetes (Senécal, Nouwen, & White, 2000;
Williams, Freedman, & Deci, 1998). However, to date, for
those newly diagnosed with diabetes there is no information as
to the motivational processes during the developmental phase of
skills regarding dietary adherence. Thus, further research is
needed to better understand the motivational factors involved in

771
772 NOUWEN ET AL.
adopting and maintaining dietary self-care activities during the
critical period following diagnosis.
Although many motivational theoretical frameworks have been
proposed to account for dietary self-care behaviors, generally only
those theories that have included the construct of self-efficacy or a
similar construct have been predictive of these behaviors (Ban-
dura, 1997). For example, Senécal et al. (2000) demonstrated the
importance of self-efficacy derived from social– cognitive theory
(Bandura, 1986), in conjunction with autonomous self-regulation
derived from self-determination theory (Deci & Ryan, 1985), in
the prediction of dietary self-care in people with Type 2 diabetes.
Using structural equation modeling, Senécal et al. (2000) showed
that both self-efficacy and autonomous motivation were positively
associated with adherence to dietary self-care activities. However,
self-efficacy was significantly more associated with adherence to
the dietary self-care activities than autonomous motivation. On the
other hand, a small recent study found that autonomous motiva-
tion, but not self-efficacy was related to dietary self-care (Shigaki
et al., 2010). These studies were based on cross-sectional data and
provide no evidence about the longitudinal relationships of the
constructs. It is notable that self-efficacy has generally been ex-
amined individually, outside the context of its full theoretical
framework, thereby limiting our interpretation of their role within
or across theoretical frameworks. To help understand these con-
structs within the context of their full theoretical frameworks, this
study will briefly review both social– cognitive theory and self-
determination theories. Furthermore, to expand our understanding
of these potentially important predictors, they will be longitudi-
nally examined within the full set of constructs from both theories.
Social–Cognitive Theory and Dietary Self-Care
Self-efficacy beliefs concern a judgment of one’s abilities to
produce given attainments when confronted with impediments and
thus determines the amount of effort and perseverance expended in
attempting to achieve their goal (Bandura, 1997). Self-efficacy in
Type 2 diabetes is associated with higher self-rated adherence,
metabolic control, and treatment satisfaction (Kavanagh, Gooley,
& Wilson, 1993; Padget, 1991; Skelly, Marshall, Haughey, Davis,
& Dunford, 1995; Xu, Toobert, Savage, Pan, & Whitmer, 2008)
and, more specifically, dietary self-care (Aljasem, Peyrot, Wissow,
& Rubin, 2001; King et al., 2010). In a prospective study, self-
efficacy was associated with adherence to self-care behaviors
which were predictive of HbA1c levels six and 12 months later
(Nakahara, Yoshiuchi, Kumano, Hara, Suematsu, & Kuboki,
2006). Moreover, interventions that increase dietary self-efficacy
also result in improved dietary self-care (Anderson, Funnell, But-
ler, Arnold, Fitzgerald, & Feste, 1995; Trief, Teresi, Eimicke,
Shea, & Weinstock, 2009).
Social– cognitive theory proposes that cognitive motivators also
include positive and negative outcome expectancies and self-
evaluation. Whereas, self-efficacy concerns a judgment of one’s
abilities to produce given attainments, outcome expectancies con-
cern the perceived consequences of that attainment (i.e., being
stigmatized, feeling stressed). In terms of causal linkage, self-
efficacy beliefs come prior to outcome expectancies (Bandura,
1997, p. 22) and are hypothesized to affect outcomes both directly
and indirectly via outcome expectancies (Bandura, 2000). How-
ever, others have shown that the relationships between self-
efficacy and outcome expectancies are reciprocal (Schwarzer &
Fuchs, 1996). Outcome expectancies are considered particularly
important during the initial phase of behavioral change (Schwarzer
& Renner, 2000).
Social– cognitive theory also postulates that people motivate
themselves by setting personal standards and by their level of
self-evaluative reactions to their performance. However, to date,
no study has examined the role of outcome expectancies and
self-evaluation in relation to self-care activities in people with
Type 2 diabetes. Self-evaluation has been studied in the education
literature, but has been overlooked by health psychology. At the
heart of self-evaluation is self-monitoring or reflection (Archer,
2010). Reflection can lead to a better understanding of the indi-
vidual’s behavior, but only if the individual’s perceptions of their
own behavior are accurate. If they are inaccurate this will result in
persistence in inappropriate strategies and behaviors (Eva & Re-
gehr, 2005). Effective external feedback can help to ensure that
self perceptions are accurate (Archer, 2010).
There is evidence that self-evaluation is subject to modification
and is associated with improved performance (Kitsantas, Reiser &
Doster, 2004). Informed self-evaluative judgments can result in
improved quality of work, improved self satisfaction and a better
understanding of the causal links between performance and their
outcomes (Kitsantas et al., 2004). Self-satisfaction with perfor-
mance and the outcomes achieved will result in perseverance with
the task, whereas dissatisfaction will lead to its abandonment
(Dijkstra & Buunk, 2008; Bandura, 1997).
Self-Determination Theory and Dietary Self-Care
Autonomous motivation (Deci & Ryan, 1985) refers to behav-
iors that are self-initiated because they are important to the indi-
vidual and ties into their values and goals system. While autono-
mous motivation is central to self-determination theory, perceived
competence, a construct similar to self-efficacy, is an integral part
of the theory. Furthermore, self-determination theory proposes that
autonomous motivation and competence is determined by the level
of autonomy support health care professionals provide through
acknowledgment of the patients’ perspectives, support of their
initiatives, and offering choices for treatment options while min-
imizing pressure and control (Williams, McGregor, Zeldman,
Freedman, & Deci, 2004). Autonomous motivation has been as-
sociated with diabetes self-care activities, life satisfaction and
diabetes control (Julien, Senécal, & Guay, 2009; Williams,
McGregor, Zeldman, Freedman, Deci, & Elder, 2005; Williams et
al., 1998). Deci and Ryan (1985) contrast autonomy behaviors
from controlled behaviors, which occur when a person is pressured
either by their interpersonal environment (externally motivated) or
intrapsychic forces such as guilt or fear (introjected motivation).
While both autonomous and controlled behaviors are intentional
and motivated, individuals can also be amotivated in that they
either do not follow their diet or follow it without intent.
In summary, research is needed to examine longitudinal rela-
tionships between motivational variables and diabetes outcomes
during the critical period after diagnosis (Lawton, Peel, Parry,
Araoz, & Douglas, 2005) and to examine these constructs within
and across their full theoretical frameworks.
Therefore, the aim of this study was to longitudinally examine
the relationships between motivational factors from social–
 LONGITUDINAL MOTIVATIONAL PREDICTORS
cognitive theory (self-efficacy, positive and negative outcome
expectancies, and self-evaluation) and self-determination theory
(autonomous motivation and autonomy support) and outcomes of
dietary self-care and diabetes control in a sample of newly diag-
nosed people with Type 2 diabetes. We also examined whether the
motivational variables predicted changes over time in the outcome
measures.
Method
Participants
Participants in the study were 237 (male N ⫽ 154) people who
had been newly diagnosed with Type 2 diabetes mellitus. Diag-
nosis of Type 2 diabetes was ascertained by the participant’s
physician using WHO criteria (World Health Organization, 1985)
and was based on a fasting plasma glucose test of ⱖ 7 mmol/L, or
a 2h oral glucose tolerance test (OGTT) ⱖ 11.1 mmol/L in
symptomatic patients. For nonsymptomatic patients, a second con-
firmatory test was also needed.
Participants were recruited through primary care sources in two
predominantly rural counties in the West-Midlands of England and
through diabetes registers from the major hospitals in those two
counties. Inclusion criteria for the study were (a) being diagnosed
with Type 2 diabetes in the previous eight weeks, and (b) being
fully literate and articulate in English. A total of 326 potential
participants were referred, of whom three were excluded on liter-
acy/articulacy grounds, and two had been diagnosed with diabetes
for more than eight weeks. Of the remaining referrals, 237 agreed
to take part in the study, constituting a 74% recruitment rate.
Participants were aged between 25 and 82 years of age (mean
age ⫽ 55.5 years, SD ⫽ 10.9). The majority of participants
(78.8%) were living with a partner. The sample was well educated
with most (62.7%) having completed secondary education and a
third (33.3%) further education. Despite this, at baseline only half
the sample was employed (37.7% full time); the majority of
participants (67.7%) earned less than £20,000/year.
More than half of the participants 136 (57.9%) controlled their
diabetes with diet only, 99 participants (42.1%) used oral medica-
tion and only one person was prescribed insulin (one person had
missing data). Ninety-six (41%) participants reported suffering
from hypertension, 27 (11%) from heart problems, 23 (10%) from
retinopathy, 7 (3%) from a diabetic foot, and 4 (2%) from renal
disease. In addition, 74 (31.1%) participants suffered from one
additional health problem, 56 (23.7%) from two additional health
problems and 60 people (25.4%) from three or more additional
health problems. Attrition rates were as follows: 7.5% at Time 2;
5.9% at Time 3; 3.4% at Time 4; and 2.5% at Time 5, not including
23 participants who were not followed-up at Time 5 due to end of
available funding.
Measures
All alphas quoted in the text below are based on measures
collected at the first time point. Correlations between the fourth
and fifth time points (three months apart) for all questionnaire data
were conducted to indicate test–retest reliability. These time points
were chosen as they were the most stable periods.
773
Sociodemographic and illness-related variables. Sociode-
mographic variables included age, gender and educational, occu-
pational, family, and economic status. The following variables
were assessed at all five time points: self-reported presence and
number of diabetes complications, dietary recommendations, pre-
scribed diabetes medication, height, weight, presence and number
of other medical conditions, and number of hospitalizations be-
cause of diabetes.
Outcome Variables
Diabetes control. Glycosylated hemoglobin (HbA1c) levels
were measured using the DCA-2000 (Bayer Corporation, Elkhart,
IN, U.S.A., now Siemens). Sensitivity of the assay was 2.5%
(Siemens Health Care Diagnostics, Tarrytown, IN, U.S.A.).
Dietary self-care. The 5-item dietary subscale of the Sum-
mary of Diabetes Self-Care Activities questionnaire (SDSCA;
Toobert & Glasgow, 1994) was used to assess adherence to rec-
ommended dietary self-care activities over the previous seven
days. The validity of this measure is well-established (Eigenmann,
Colagiuri, Skinner, & Trevena, 2009). For the current sample, the
correlation between the scale at Time 4 and Time 5 was 0.73 and
Cronbach’s alpha was 0.68, indicating good test-retest and ade-
quate internal consistency, respectively.
Autonomy support. The Modified Health Care Climate
Questionnaire (HCCQ, Williams, Grow, Freedman, Ryan, Deci,
1996) was used to assess participants’ perceptions of the degree of
autonomy supportiveness versus the degree of controllingness of
their health care provider. Items included statements such as ‘I feel
health care professionals understand how I see things with respect
to my diet.’ The 5-item scale was scored on a 7-point Likert scale,
ranging from 1 (not at all true) to 7 (very true). The validity of the
HCCQ in people with diabetes was established using structural
equation modeling (Williams, McGregor, King, Nelson, & Glas-
gow, 2005). Test–retest reliability over a 6 – 8 month period was
0.6 (Williams et al., 1998). For the current sample, the correlation
between Times 4 and Time 5 was 0.77 and Cronbach’s alpha was
0.93, indicating good test–retest reliability and internal consis-
tency, respectively.
Autonomous motivation. The Treatment Self-Regulation
Questionnaire (TSRQ, Ryan & Connell, 1989) was used to assess
autonomous and controlled motivation and lack of motivation
(amotivation) to health eating. The scale was comprised of 15
statements that represented possible reasons for eating a healthy
diet. Participants rated the extent to which these reasons applied to
them. The TSRQ consisted of three subscales, namely, autono-
mous motivation (six items, Cronbach’s alpha ⫽ .87), controlled
motivation (six items, Cronbach’s alpha ⫽ .84) and amotivation
(three items, Cronbach’s alpha ⫽ .49). Items were rated on 7-point
Likert scales ranging from 1 (not at all true) to 7 (very true).
Sample items included ‘. . . because I feel that I want to take
responsibility for my own health’ (autonomous motivation), ‘. . .
because I would feel guilty or ashamed of myself if I did not eat
a healthy diet’ (controlled motivation—introjected) and ‘. . . be-
cause others would be upset with me if I did not’ (controlled
motivation— external) and ‘. . . I really don’t think about it’ (amo-
tivation). Because of the low internal consistency of the amotiva-
tion subscale, only the autonomous and controlled motivation
subscales were used in the analyses.
774 NOUWEN ET AL.
Correlations between the same subscales at Time 4 and Time 5
were 0.70 for autonomous motivation and 0.76 for controlled
motivation, indicating good test–retest reliability for both sub-
scales.
Dietary self-efficacy. Participants rated their confidence in
their ability to follow recommended dietary self-care activities
given 30 common barriers, for example, ‘How confident are you
that you can follow your dietary plan on a regular basis . . . . when
preparing food for others . . . when eating at a restaurant . . .’
Ratings are on a 100-point scale at intervals of 10 ranging from 0
(not at all confident) to 100 (totally confident). Construct validity
was shown by significant associations with dietary self-care and
life-satisfaction (Senécal et al., 2000). For the current sample,
correlations between the scale at Time 4 and Time 5 were 0.87 and
Cronbach’s alpha was 0.98, indicating high test–retest reliability
and internal consistency, respectively.
Outcome expectancies for dietary self-care. Positive and
negative expected outcomes of following their diet on a regular
basis were assessed with a 14-item scale developed for the purpose
of this study. The positive outcome expectancy scale included 11
items (Cronbach’s alpha ⫽ .91) and the negative outcome expec-
tancy scale three items (Cronbach’s alpha ⫽ .74). The items, that
included beneficial and detrimental social, physical and self-
evaluative effects of following the recommended dietary require-
ments on a regular basis, were based on results of semistructured
interviews with people with Type 2 diabetes.
Positive outcome expectancy items included statements such as
‘following my dietary plan on a regular basis . . . will have a
positive effect on my weight control . . . will have a positive effect
on my self-image,’ while the negative items included ’. . . will
make me feel hungry all the time,’ ‘will restrict my social activi-
ties’, and ‘will restrict my family’s eating habits’. Ratings were
made on a 100-point Likert scales at intervals of 10 ranging from
0 (do not expect at all) to 100 (expect totally). Correlations
between the scale at Time 4 and Time 5 were 0.66 for the positive
outcome expectancies and 0.67 for the negative outcome expec-
tancy subscale, indicating adequate test–retest reliability, respec-
tively.
Self-evaluation. Self-evaluation was assessed by asking par-
ticipants whether they were satisfied/dissatisfied with their level of
adherence to recommended dietary self-care activities as described
in the 5-item dietary subscale of the SDSCA (Toobert & Glasgow,
1994). Items included statements such as ‘How satisfied or dissat-
isfied are you with how you followed your dietary plan over the
last seven days?’ Ratings were made on a ⫺3 (very dissatisfied) to
⫹3 (very satisfied) Likert scale. For the current sample, correla-
tions between the same subscales at Time 4 and Time 5 were 0.73,
and Cronbach’s alpha was 0.89, indicating good test–retest reli-
ability and internal consistency, respectively.
Control measures. Sociodemographic variables, age, gender,
BMI, and diabetes knowledge were included in the analyses as
control measures because of their association with the outcome
variables HbA1c (e.g., age and gender, Undén, Elofsson, André-
asson, Hillered, Eriksson, & Brismar, 2008: BMI, Yamamoto,
Okazaki, & Ohmori, 2011; diabetes knowledge, Bains & Egede,
2011) and dietary self-care (age, Toobert, Hampson, & Glasgow,
2000; Wilson, Ary, Biglan, Glasgow, Toobert, & Campbell, 1986;
diabetes knowledge, Ruggiero et al., 1997) and with predictor
variables autonomous motivation (sex, Williams et al., 1998) and
self-efficacy (sex and BMI, Bartfield, Ojehomon, Huskey, Davis,
& Wee, 2010; dietary knowledge, Slater, 1989).
The Diabetes Knowledge Scale (DKS, Dunn, Bryson, Hoskins,
Alford, Handelsman, & Turtle, 1984) was used to measure knowl-
edge of the rudimentary physiology of diabetes and basic princi-
ples of diabetes self-care. It consists of 14 multiple choice ques-
tions. For the current sample, correlations between the scale at
Time 4 and Time 5 were 0.74, and Kuder–Richardson Formula 20
(KR20) was 0.62, indicating good test–retest reliability and ac-
ceptable internal consistency, respectively.
Procedure
Ethical approval was sought and obtained from the Multi-
Region Ethics Authority in Birmingham, England, and subsequent
approval was obtained from the appropriate regional authorities.
Primary care centers provided a list of potential participants who
were informed about the study and had consented to being con-
tacted by the researcher. The researcher contacted the potential
participants by telephone to confirm eligibility and, when they
agreed to participate, the questionnaires were mailed to them and
an appointment was made for an HbA1c measurement and to
collect the completed questionnaire. Repeated measurements were
taken every 3– 4 months for a total of five time points over 18
months.
Data Analysis
To analyze the longitudinal relationships between HbA1c and
dietary self-care on the one hand and motivational factors (auton-
omy support, autonomous and controlled motivation, dietary self-
efficacy, positive and negative outcome expectancies, self-
evaluation) on the other, Generalized Estimating Equations (GEE)
analyses were used. GEE is a regression technique that adjusts for
the correlation between the repeated measurements within a person
and which is not sensitive to the effects of unequal numbers of
observations and unequally space time-intervals (Twisk, 2004).
First, a standard GEE model was used to examine the relationships
between the variables. However, because standard GEE analysis
pools together both cross-sectional and longitudinal relationships,
we also examined whether a change in motivational variables over
two adjacent time periods was associated with changes in outcome
measures during the same period (model of changes; Twisk, 2004).
For each GEE model, a backward selection procedure was used to
create a longitudinal prediction model. To correct for serial de-
pendency, an a priori “working” correlation structure was specified
for each outcome variable based on the within-subject correlations.
For the standard models, an exchangeable working correlation
structure was most appropriate, while for the change models in-
dependent “working” correlation structures were deemed most
appropriate. All analyses were adjusted for potential confounders
likely associated with diabetes outcomes of dietary self-care and
HbA1c. These were age, sex, BMI, and diabetes knowledge.
Results were analyzed using PASW-17.
Results
Independent sample t tests were conducted to compare retained
and lost participants. There was no significant difference in demo-
 LONGITUDINAL MOTIVATIONAL PREDICTORS 775

graphic, control or outcome variables at any time point, nor did the level. This association was positive, with more negative outcome
two groups significantly differ in predictor variables. expectancies predicting poorer diabetes control (standardized re-
Table 1 shows descriptive information of the variables used in gression coefficient ␤ ⫽ 0.11, p ⫽ .004; see Table 2). Similarly,
the present study at the different time points. Results of the GEE when modeling changes, only changes in negative outcome expec-
analyses can be found in Table 2. tancies predicted changes in HbA1c (standardized regression co-
efficient ␤ ⫽ 0.19, p ⬍ .001) across time.
Dietary Self-Care
Univariable analyses showed that, with the exception of nega- Relationships Between Dependent Variables
tive outcome expectancies, all the motivational variables were
Dietary self-care was not a significant predictor of HbA1c
significantly related to dietary self-care. In the final prediction
(standardized regression coefficient ␤ ⫽ ⫺0.04; p ⬎ .34). How-
model, only autonomy support (standardized regression coefficient
ever, dietary self-care was significantly associated with changes in
␤ ⫽ 0.05, p ⫽ .05), autonomous motivation (standardized regres-
HbA1c (standardized regression coefficient ␤ ⫽ 0.11, p ⫽ .001).
sion coefficient ␤ ⫽ 0.09, p ⫽ .006), dietary self-efficacy (stan-
dardized regression coefficient ␤ ⫽ 0.21, p ⬍ .0001), and self-
evaluation (standardized regression coefficient ␤ ⫽ 0.50, p ⬍ Discussion
.0001) remained significantly associated with dietary self-care (see
The purpose of this study was to examine longitudinally the
Table 2).
relationships between motivational factors from social– cognitive
When changes between two adjacent time points in dietary
theory (self-efficacy, positive and negative outcome expectancies,
self-care were modeled, univariable analyses showed that changes
and self-evaluation; Bandura, 1997) and self-determination theory
in autonomous motivation (standardized regression coefficient
(autonomous self-regulation and autonomy support; Deci & Ryan,
␤ ⫽ 0.17, p ⫽ .004), controlled motivation (standardized regres-
1985, 1991) and dietary self-care, and diabetes control in a sample
sion coefficient ␤ ⫽ 0.15, p ⫽ .003), self-efficacy (standardized
of newly diagnosed people with Type 2 diabetes. Two models of
regression coefficient ␤ ⫽ 0.25, p ⫽ .0001) and self-evaluation
associations over time were tested, namely a standard model
(standardized regression coefficient ␤ ⫽ 0.51, p ⬍ .0001) were
reflecting a combination of cross-sectional and longitudinal asso-
predictive of changes in dietary self-care. These variables re-
ciations between absolute levels of predictor and outcome vari-
mained significant in the final prediction change model with the
ables, and a change model in which the cross-sectional part is
exception of autonomous motivation (see Table 2).
“removed” from the analysis.
The results of the standard model of this study show that, with
Diabetes Control
the exception of negative outcome expectancies, all motivational
In both the univariable and multivariable analyses only negative variables were significantly associated with reported dietary self-
outcome expectancies were significantly associated with HbA1c care in a sample of people newly diagnosed with Type 2 diabetes.

Table 1
Means (SD) of Main Study Variables Across Time

Time 1 Time 2 Time 3 Time 4 Time 5

Measure Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Duration of follow-up in days (SD) 0 118 (13.2) 240 (18.4) 358 (23.7) 474 (31.3)
N ⫽ 237 N ⫽ 222 N ⫽ 207 N ⫽ 200 N ⫽ 172
Dietary self-care 4.07 (.62) 3.94 (.65) 3.89 (.65) 3.88 (.63) 3.92 (.67)
N ⫽ 235 N ⫽ 214 N ⫽ 205 N ⫽ 199 N ⫽ 171
HbA1c (mmol/l) 7.5 (1.7) 6.8 (1.1) 6.9 (1.2) 7.0 (1.4) 7.1 (1.4)
N ⫽ 236 N ⫽ 218 N ⫽ 207 N ⫽ 198 N ⫽ 171
Body Mass Index (kg/m2) 30.49 (5.26) 30.13 (5.38) 30.27 (5.57) 30.14 (5.66) 30.16 (5.63)
N ⫽ 230 N ⫽ 214 N ⫽ 204 N ⫽ 196 N ⫽ 168
Diabetes Knowledge 8.7 (2.5) 9.0 (2.4) 9.4 (2.5) 9.5 (2.4) 9.5 (2.2)
N ⫽ 236 N ⫽ 215 N ⫽ 206 N ⫽ 199 N ⫽ 171
Autonomy support 5.0 (1.8) 4.9 (1.8) 4.9 (1.8) 4.9 (1.7) 4.8 (1.8)
N ⫽ 235 N ⫽ 213 N ⫽ 201 N ⫽ 196 N ⫽ 169
Autonomous motivation 5.8 (1.2) 5.9 (1.2) 5.9 (1.1) 6.0 (1.0) 5.9 (1.1)
N ⫽ 236 N ⫽ 214 N ⫽ 206 N ⫽ 199 N ⫽ 171
Controlled motivation 3.5 (1.6) 3.5 (1.5) 3.7 (1.5) 3.7 (1.5) 3.6 (1.5)
N ⫽ 236 N ⫽ 214 N ⫽ 206 N ⫽ 199 N ⫽ 171
Dietary self-efficacy 74.5 (19.7) 73.8 (19.3) 73.2 (19.7) 73.7 (19.5) 73.4 (19.3)
N ⫽ 235 N ⫽ 213 N ⫽ 203 N ⫽ 199 N ⫽ 170
Self-evaluation 1.6 (1.3) 1.5 (1.3) 1.3 (1.4) 1.3 (1.3) 1.4 (1.4)
N ⫽ 235 N ⫽ 214 N ⫽ 204 N ⫽ 199 N ⫽ 171
Positive outcome expectancies 76.4 (19.7) 77.6 (17.9) 78.3 (17.5) 78.5 (17.4) 76.4 (17.9)
N ⫽ 234 N ⫽ 213 N ⫽ 201 N ⫽ 195 N ⫽ 169
Negative Outcome expectancies 70.5 (24.5) 30.5 (26.6) 30.5 (27.2) 30.7 (27.0) 30.8 (26.7)
N ⫽ 233 N ⫽ 211 N ⫽ 198 N ⫽ 194 N ⫽ 167
776 NOUWEN ET AL.

Table 2
Standardized Regression Coefficients (␤) and 95% Confidence Intervals (CI), Adjusted For Age, Gender, BMI, and Diabetes
Knowledge, For The Univariable and Multivariable Analyses Regarding The Longitudinal Development of Dietary Self-Care and
HbA1c, and Motivational Variables Over A Period of 18 Months Following The Diagnosis of Type 2 Diabetes

Multivariable Multivariable
Univariable analyses analyses Univariable analyses analyses

Predictor variable ␤ (95% CI) ␤ (95% CI) ␤ (95% CI) ␤ (95% CI)

Dietary Self-Care HbA1c

Autonomy support 0.15ⴱⴱⴱ (0.09; 0.22) 0.05ⴱ (0.01; 0.10) ⫺0.06 (⫺0.14; ⫺0.02)
Autonomous motivation 0.29ⴱⴱⴱ (0.22; 0.36) 0.09ⴱⴱ (0.02; 0.15) ⫺0.05 (⫺0.13; 0.02)
Controlled motivation 0.10ⴱⴱ (0.03; 0.17) ⫺0.05 (⫺0.12; 0.03)
Dietary self-efficacy 0.49ⴱⴱⴱ (0.39; 0.61) 0.21ⴱⴱⴱ (0.12; 0.27) ⫺0.08 (⫺0.18; ⫺0.01)
Positive outcome expectancies 0.08ⴱ (0.0; 0.17) ⫺0.05 (⫺0.12; ⫺0.00)
Negative outcome expectancies ⫺0.05 (0; 0.10) 0.11ⴱⴱ (0.04; 0.18) 0.11ⴱⴱ (0.04; 0.18)
Self-evaluation 0.60ⴱⴱⴱ (0.50; 0.69) 0.49ⴱⴱⴱ (0.39; 0.58) ⫺0.01 (⫺0.06; 0.08)

Change in Dietary Self-Care Change in HbA1c

Change in autonomy support 0.04 (0.04; 0.13) ⫺0.03 (⫺0.11; 0.05)
Change in autonomous motivation 0.17ⴱⴱ (0.06; 0.29) ⫺0.01 (⫺0.11; 0.09)
Change in controlled motivation 0.15ⴱⴱ (0.05; 0.26) 0.09ⴱ (0.01; 0.17) 0.02 (⫺0.05; 0.09)
Change in dietary self-efficacy 0.25ⴱⴱⴱ (0.14; 0.36) 0.11ⴱ (0.02; 0.21) ⫺0.06 (⫺0.17; 0.05)
Change in positive outcome expectancies 0.00 (⫺0.09; 0.12) ⫺0.03 (⫺0.11; 0.06)
Change in negative outcome expectancies 0.00 (⫺0.13; 0.06) 0.19ⴱⴱⴱ (0.10; 0.29) 0.19ⴱⴱⴱ (0.10; 0.29)
Change in self-evaluation 0.51ⴱⴱⴱ (0.39; 0.62) 0.47ⴱⴱⴱ (0.36; 0.58) 0.01 (⫺0.06; 0.08)
a b
Adjusted for age, gender, BMI, and diabetes knowledge. Adjusted for age, gender, change in BMI, and change in diabetes knowledge.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

However, when considered together associations with autonomy
support, autonomous motivation, self-efficacy and self-evaluation
remained significant, but not those with controlled motivation and
positive outcome expectancies. These results, therefore, support
Senécal et al. (2000) and confirm the role of autonomous motiva-
tion, and, more strongly, dietary self-efficacy as cross-sectional
predictors of dietary self-care. These results also confirm, in part,
previous studies regarding the longitudinal effects of autonomy
support, autonomous motivation (Julien et al., 2009; Williams et
al., 2004), and self-efficacy (King et al., 2010; Trief et al., 2009)
on dietary self-care in people with long-standing Type 2 diabetes.
When changes over time were considered, a somewhat different
picture emerged. While changes in dietary self-efficacy and self-
evaluation predicted changes in dietary self-care confirming the
longitudinal role of self-efficacy (King et al., 2010; Trief et al.,
2009), neither changes in autonomy support from health care
providers or changes in autonomous motivation were associated
with changes in dietary self-care. It is important to note that we did
not test a specific autonomy support intervention. Therefore, it is
possible that the changes in autonomy support participants per-
ceived from their health care professionals may not have been
sufficient to produce significant effects over the 18-month study
period. These data do indicate, however, that internalization of
healthy eating into participant’s value system had not (yet) taken
place over this period.
The results from the change model further indicated that al-
though the level of controlled motivation was not significantly
associated with dietary self-care, changes in controlled motivation
were predictive of improvements in dietary self-care. Thus, people
for whom a healthy diet is part of their value system eat more
healthily. When people improved dietary self-care between time
points, this occurred because of increasing guilt or shame and/or
perceived increasing pressure from others (e.g., health care pro-
fessionals, family members) rather than them having internalized
healthy eating into their value system. Overall, the results of the
current study indicate that changes in dietary self-care in people
with newly diagnosed Type 2 diabetes is best predicted by changes
in controlled motivation, self-efficacy and self-evaluations.
Self-evaluation or participants’ evaluation of how well they felt
they were performing their self-care actions was the single stron-
gest predictor in both the standard and change model of dietary
self-care. Self-evaluation is a construct proposed by Bandura
(1997) but not widely studied except in the education literature.
There is evidence that self-evaluation is subject to modification
and is associated with improved performance (Kitsantas et al.,
2004; Zimmerman, 2002). Self-evaluation can be modified by
realistic and timely feedback, although there is disagreement about
the scope for modification (Lew, Alwis & Schmidt, 2010). These
findings suggest a strategy for improving dietary self-care by
encouraging self monitoring and evaluating the strategies adopted
to control dietary self-care.
Effective interventions will include interviewing patients in a
nondirective fashion to facilitate their expression of their own
views, gently challenging those views to test their accuracy and
provide feedback to the patient about their own self-evaluation
(Arnold, Butler, Anderson, Funnell, & Feste, 1995; Williams,
Saizow & Ryan, 1999). This should be followed by helping the
patient to set realistic goals which can be extended incrementally
(Atienza, King, Oliveira, Ahn & Gardner, 2008; Block et al., 2008;
Haapala, Barengo, Biggs, Surakka & Manninen, 2009). It is im-
portant that patients temper their expectations so that their goals
are attainable.
 LONGITUDINAL MOTIVATIONAL PREDICTORS
Among this sample of people newly diagnosed with diabetes,
self-reported dietary self-care, did not predict diabetes control, as
measured by HbA1c. This is in contrast to findings on people with
longer established diabetes (e.g., Chiu & Wray, 2010; Khattab,
Yousef, & Abdelkarim Ajlouni, 2010). However, changes in
HbA1c over two adjacent time periods were associated with earlier
dietary self-care. It is possible that early after diagnosis, the
influence of dietary self-care activities on weight and glycemic
control may be limited until the condition and the medical treat-
ment plan are stable. Yet, establishing good dietary adherence is a
priority in the early months following diagnosis of diabetes as the
tendency to overeat at diagnosis is associated with subsequent
weight gain later (van Strien et al., 2007).
Just as dietary self-care does not strongly predict diabetes con-
trol in the early months following diagnosis, nor in general do the
psychological constructs studied predict diabetes control in the
early months following diagnosis. The exception is negative out-
come expectancies: those who perceive more negative conse-
quences of following a healthy eating plan show poorer glycemic
control. This relationship is longitudinal in nature. One possible
explanation is that the perceptions of negative outcome of healthy
eating result in increased stress levels, which in turn adversely
affect HbA1c. Although further research is needed to elucidate this
relationship, the results of the current study strongly suggest that
health care providers monitor outcome expectancies in people with
newly diagnosed Type 2 diabetes.
There is evidence that the relationship between diabetes control and
other motivational variables (e.g., self-efficacy, Nakahara et al., 2006;
autonomous motivation, William et al., 2004) is not a direct one but
that this relationship is mediated by self-care activities including diet.
This was not supported in the current study as dietary self-care did not
significantly predict HbA1c, although it did predict changes in
HbA1c. While the samples in Nakahara et al. (2006) and Williams et
al. (2004) were composed of people with longstanding Type 2 dia-
betes, the current sample only included people with newly diagnosed
diabetes. It is possible that the link between dietary self-care and
HbA1c only becomes clear when both self-care and diabetes control
have been stabilized. Unfortunately, our study did not include a
sample of people with long-standing diabetes and, therefore, we
cannot determine this hypothesis.
In a cross-sectional study on the joint effect of self-efficacy and
autonomous motivation (Senécal et al., 2000), both variables were
found to be independent contributors to the prediction dietary
self-care in people with Type 2 diabetes. The present study extends
these findings over time in a sample with newly diagnosed indi-
viduals. Moreover, the present study showed that other variables
derived from those theories (outcome expectancies, self-evaluation
and autonomy support) also need to be considered in predicting
dietary self-care over time.
As in any study, there were also limitations. First, the study did not
include a group of people with long-standing diabetes and as such it
is impossible to determine whether the patterns of findings are due to
the fact that participants were newly diagnosed with diabetes. Second,
data were collected using a battery of questionnaires supplemented by
interviews to provide some triangulation of findings. The dietary
self-care measures were also derived from a questionnaire. This
means that there is shared method variance between predictor and
outcome measures, which may lead to an overestimation of the
strength of the relationship between the two measures (Doty & Glick,
777
1998). Moreover, shared method variance may also account for the
relative lack of predictors for HbA1c.
The strengths of the present study were that it included the full
range of constructs identified by social– cognitive theory and self-
determination theory to allow fuller evaluations of the two theories
to be undertaken and overlap between the two theories to begin to
emerge. The study was longitudinal so that both concurrent and
lagged relationships could be studied, improving understanding of
causal relationships between predictor and outcome measures.
Control measures were included in the analyses to reduce the
impact of confounding factors. Finally, the study was conducted
on people with newly diagnosed diabetes and so allowed exami-
nation of the early emergence of the skills needed for effective
lifetime diabetes control.
In summary, the use of a prospective longitudinal design helped
clarify the complex and significant relationships between con-
structs from social– cognitive and self-determination theories and
the diabetes outcomes of dietary self-care and diabetes control in
individual newly diagnosed with Type 2 diabetes. The findings
from this study suggest that autonomy support, self-efficacy and,
in particular, self-evaluation may be key targets for interventions
to improve dietary self-care in people newly diagnosed with Type
2 diabetes.
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