Missouri Council for Adult - Missouri Department of …health.mo.gov/living/healthcondiseases/obesity/pdf/...Missouri Council for Activity & Nutrition The United States is in the midst

activitynutrition&

TOOL KIT

M CANMissouri Council forActivity & Nutrition

Health Care Provider

AdultAdult

CO

NT

EN

TS

• How to Use This Tool Kit

• Introduction

• Physician ResourcesPocket Guide — Assessement and Treatment of Adult Overweight and ObesityBody Mass Index (BMI) ChartMissouri Consensus Diabetes Management Guideline for Adults (15 page guide is available byclicking on title)State of Missouri Consensus Screening Guidelines for Pre-diabetes and Diabetes in a MedicalSettingCommunication Guidelines to Promote Health Behavior ChangeApplying the Stages of Change Model to Assess ReadinessPatient Readiness ChecklistTips for Nutrition Counseling

• Patient HandoutsA. Are You Ready and Motivated to Lose Weight?B. Food Weight-Loss TipsC. Nutrition Facts Label—An OverviewD. Tips for Dining OutE. Grocery Shopping GuideF. MyPlateG. Making Physical Activity Part of Your Life: Tips for Being More ActiveH. Overcoming Barriers to Physical ActivityI. Tips to Make Small Changes—That Add Up to Big SuccessJ. Developing Your Success Plan!K. Goal WorksheetL. Personal Pledge to Better HealthM. Daily Food and Activity Diary

• Resources and References

• Evaluation Form

http://www.dhss.mo.gov/diabetes/FinalManagementGuideline.pdf

How to Use This Tool Kit

The Health Care Work Group from the Missouri Council for Activity and Nutrition (MoCAN)developed this tool kit to provide you with all of the information you need to effectively assess and treatyour overweight and obese adult patients. In addition, this kit offers pertinent information for providersto consider when discussing healthy lifestyles, including physical activity and healthy eating behaviors,with all patients.

The Health Care Work Group consists of leaders from Missouri health plans, academic medical centers,physician practices as well as other health care professionals, including advance practice nurses anddietitians. These professionals shared their daily experiences of working to address the growing obesityepidemic in their practices and communities to determine the materials presented within this tool kit.

The physician resources and patient handouts address assessing readiness to change, goal setting anddiet and physical activity information. These handouts have been designed for you to copy and explainto your patients.

An evaluation form is also included in the tool kit. Your feedback is important for continuing our workto provide health care providers with effective tools for encouraging patients to adopt healthy behaviors.Instructions for completing and returning the evaluation can be found on the evaluation form.

Thank you for joining MoCAN’s efforts to reverse obesity trends by utilizing these resources developedby health care providers for health care providers.

Additional materials can be downloaded on the Missouri Department of Health and Senior Services(DHSS) web site at: http://www.dhss.mo.gov/Obesity/Publications.html.

M CANMissouri Council forActivity & Nutrition

The United States is in the midst of an escalatingepidemic of obesity. Over one-third of the adultpopulation in the United States is currently obeseand the prevalence of obesity is growing rapidly.Physicians can play a critical role in stemming thisgrowing epidemic through their frequent patientcontact and have unique opportunities to encouragephysical activity, dietary and behavior changes. Thistool kit proposes a model for the assessment andtreatment of obesity in clinical practice, including assessment of risk factors for obesity,recommending lifestyle and behavior modifications, and instituting pharmacologic therapy orsurgery when appropriate. Resources to help guide your patient in making these changes are alsoprovided as handouts. By utilizing this tool kit, physicians can unite with other health careprofessionals in the fight to effectively help prevent and treat the chronic disease of obesity.

Missouri Statistics• 62% of Missouri adults are overweight or obese. (Centers for Disease Control and

Prevention [CDC] Behavioral Risk Factor Surveillance System, 2004)• 24% of non-Hispanic white adults and 39% of non-Hispanic black adults in Missouri are

obese. (CDC BRFSS, 2004)• Only 20.2% of adults eat 5 servings of fruits and vegetables daily.• Only 45.1% of adults meet the CDC’s physical activity recommendations.

Causes of Overweight and Obesity• Overweight and obesity result from an imbalance involving excessive calorie

consumption and/or inadequate physical activity.• Body weight is the result of a combination of behavioral, genetic, metabolic,

environmental, cultural, and socioeconomic influences and is different for eachindividual.

• Behavioral and environmental factors are large contributors to overweight and obesityand provide the greatest opportunity for actions and interventions designed for preventionand treatment. (Department of Health and Human Services [DHHS]).

Health Consequences of ObesityAccording to the 2001 U.S. Surgeon General’s Call to Action to Prevent and DecreaseOverweight and Obesity, those who are overweight or obese are at a greater risk for thefollowing health conditions:

Premature Death:• Individuals who are obese have a 50 to 100% increased risk of premature death from all

causes, compared to individuals with a healthy weight.• An estimated 300,000 deaths per year may be attributable to obesity.• The risk of death rises with increasing weight.

INT

RO

DU

CT

ION

Assessment and Treatment of Adult Overweight and Obesity

• Even moderate weight excess (10 to 20 pounds for a person of average height) increases the riskof death, particularly among adults aged 30 to 64 years.

Heart Disease:• The incidence of heart disease is increased in persons who are overweight or obese.• High blood pressure is twice as common in adults who are obese than in those who are at a

healthy weight.• Obesity is associated with elevated triglycerides and decreased HDL cholesterol.

Diabetes:• A weight gain of 11 to 18 pounds increases a person’s risk of developing type 2 diabetes to twice

that of individuals who have not gained weight.• More than 80% of people with diabetes are overweight or obese.

Cancer:• Overweight and obesity are associated with an increased risk for some types of cancer including

endometrial (cancer of the lining of the uterus), colon, gallbladder, prostate, kidney andpostmenopausal breast cancer.

• Women gaining more than 20 pounds from age 18 to midlife double their risk of postmenopausalbreast cancer, compared to women whose weight remains stable.

Breathing Problems:• Obesity is associated with a higher prevalence of asthma.

Arthritis:• For every two-pound increase in weight, the risk of developing arthritis is increased by 9 to 13%.

Reproductive Complications:• In addition to many other complications, women who are obese during pregnancy are more

likely to have gestational diabetes and problems with labor and delivery.

Benefits of Weight Loss• Weight loss, as modest as 5 to 10% of total body weight in a person who is overweight or obese,

reduces the risk factors for some diseases, particularly heart disease.• A person with a Body Mass Index (BMI) above the healthy weight range may benefit from

weight loss, especially if he or she has other health risk factors, such as high blood pressure, highcholesterol, smoking, diabetes, a sedentary lifestyle, and a personal and/or family history of heartdisease.

• Weight loss can result in lower blood pressure, lower blood sugar, and improved cholesterollevels.

Obesity-Related Medical Conditions (American Obesity Association)The prevalence of various medical conditions increases with overweight and obesity for men andwomen as shown below.

Table 1. Prevalence of Medical Conditions by Body Mass Index (BMI) for Men

Medical Condition Body Mass Index

18.5 to 24.9 25 to 29.9 30 to 34.9 > 40

Prevalence Ratio (%)Type 2 Diabetes 2.03 4.93 10.10 10.65Coronary Heart Disease 8.84 9.60 16.01 13.97High Blood Pressure 23.47 34.16 48.95 64.53Osteoarthritis 2.59 4.55 4.66 10.04

Source: National Health and Nutrition Examination Survey (NHANES) III, 1988 - 1994.

This publication was supported by Cooperative Agreement Number U58/CCU722795-02 from the Centers for Disease Control and Prevention.Its contents are solely the responsibility of the authors and do not represent the official views of CDC.

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER Services provided on a nondiscriminatory basis.

Metabolic SyndromeAccording to the National Cholesterol Education Program Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), metabolic syndrome isdefined as having three or more of the traits shown below. Identification of metabolic syndrome requireseven greater urgency for the treatment of overweight or obesity.

Table 2. Prevalence of Medical Conditions by Body Mass Index (BMI) for Women

Medical Condition Body Mass Index

18.5 to 24.9 25 to 29.9 30 to 34.9 >40

Prevalence Ratio (%)Type 2 Diabetes 2.38 7.12 7.24 19.89Coronary Heart Disease 6.87 11.13 12.56 19.22High Blood Pressure 23.26 38.77 47.95 63.16Osteoarthritis 5.22 8.51 9.94 17.19

Abdominal obesity Waist circumference Men >40 in (>102 cm) Women >35 in (>88 cm)

Triglycerides >150 mg/dL

High-density lipoprotein(HDL) cholesterol Men <40 mg/dL Women <50 mg/dL

Blood pressure >130/>85 mmHg

Fasting glucose 110-125 mg/dL (ATP III defines as >110)

Risk factor Defining level

Source: NHANES III, 1988 - 1994.

Framework for Implementing an Adult Weight Loss ProgramIndicated for BMI levels of 25.0 and over

Initial Visit:Determine BMI.Measure waist circumference.Determine risk status (blood pressure, triglyceride and cholesterol levels, blood sugar level).Assess nutrition and physical activity habits and readiness to change health behaviors.Determine if patient should be treated. If yes:

o Identify patient’s contributing factors (for example: depression, environmental influences on foodchoices and physical activity, such as access to healthy foods and a safe place to engage in physicalactivity, family dynamics and support systems).

o Assist patient in setting goals for making health behavior changes related to eating and/or physicalactivity utilizing patient-centered counseling techniques.

o Prescribe weight loss medication, if indicated. A referral to a licensed psychologist and/or licensedregistered dietitian may also be helpful to assist with behavior changes before medication is considered.

First Four Months:Weekly communication for the following purposes:

o Weight monitoring.o Problem resolution, if indicated (medicine, diet or physical activity).o Group meetings on exercise, nutrition and behavior change.

Second Four Months:Biweekly meetings for the following purposes:

o Weight monitoring.o Group meetings on exercise, nutrition and behavior change.o Problem resolution, if indicated (medicine, diet or physical activity).o If after six months, patient has not made or been able to maintain any behavior changes related to eating,

consider pharmacotherapy. A referral to a licensed psychologist and/or licensed registered dietitian mayalso be helpful to assist with behavior changes before medication is considered.

Follow-up Visits:Six months after initial visit:

o Weight monitoring.o Problem-resolution, if indicated (medicine, dietary or physical activity).o Monthly group meetings for next six months on exercise, nutrition and behavior change topics.

One year after initial visit:o Weight monitoring.o Problem resolution, if indicated (medicine, dietary or physical activity).o Corrective actions, as needed (medication, re-education, etc.).o If no or limited weight loss has occurred by the end of one year, consider surgery.o Referral to local support groups for continued weight maintenance.

Continued follow-up at annual visits:o The amount of follow-up provided will depend on your patient’s needs (recommendation should be based

on what the patient has done previously - were they not ready for change, but now they are? Did theyparticipate in a program, but regained weight? Did they agree to make behavior changes but did notfollow through?).

o Weight monitoring.o Problem resolution, if indicated (medicine, dietary and/or physical activity).

Physician Resources

do it for yourself . . .

Step

7b.

Rec

omm

end

Phys

ical

Act

ivity

Gui

delin

es:

Han

dout

s F,

G

BM

I C

ateg

ory

Tre

atm

ent

2

5-2

6.9

2

7-2

9.9

30

-34

.93

5-3

9.9

>4

0

Die

t, p

hys

ical

acti

vity

&

beh

avio

r

chan

ge

+ +

+

+

+

Pha

rmac

o

ther

apy

W

ith

com

or-

bid

itie

s

+

+

Sur

gery

+

-

Wit

h

com

or-

bid

itie

s

Step

7.

Rec

omm

end

Trea

tmen

t Opt

ions

• Ta

ilor t

reat

men

t to

indi

vidu

al n

eeds

of p

atie

nt.

Step

7a.

Pre

scrib

e D

ieta

ry T

hera

py:

Han

dout

s B

, C, D

, E•

Red

uce

calo

ries b

y 50

0 to

1,0

00 c

alor

ies/

day

from

the

curr

ent l

evel

and

hav

e pa

tient

kee

p fo

od d

iary

.•

Rec

omm

end

eatin

g a

varie

ty o

f nut

rient

-den

sefo

ods f

rom

the

basi

c fo

od g

roup

s and

lim

it in

take

of

satu

rate

d an

d tra

ns fa

ts, a

dded

suga

rs, s

alt,

and

alco

hol.

• Pr

evio

usly

sede

ntar

y pe

ople

shou

ld st

art w

ith sh

ort

sess

ions

(5-1

0 m

inut

es) o

f phy

sica

l act

ivity

and

grad

ually

bui

ld u

p to

the

desi

red

leve

l of a

ctiv

ity.

• T

o re

du

ce c

hro

nic

dis

ease

ris

k:

Be

phys

ical

lyac

tive

for a

t lea

st 3

0 m

inut

es o

n m

ost o

r all

days

of

the

wee

k.•

To

lose

wei

ght:

Be

phys

ical

ly a

ctiv

e fo

r 60

to 9

0m

inut

es a

day

.

Step

7c.

Sug

gest

Beh

avio

r The

rapy

:H

ando

uts

H, I

, J, K

, L

• A

ddre

ss th

e pa

tient

’s b

arrie

rs a

bout

abi

lity

to m

ake

and

mai

ntai

n ne

eded

cha

nges

.•

Rec

omm

end

spec

ific

lifes

tyle

cha

nges

.•

Cre

ate

a pl

an to

pro

mot

e w

eigh

t los

s or p

reve

ntfu

rther

wei

ght g

ain.

Step

7d.

Con

side

r Add

ition

al T

reat

men

t Opt

ions

(if n

eede

d)P

har

mac

oth

erap

y•

Med

icat

ions

shou

ld o

nly

be c

onsi

dere

d if

lifes

tyle

chan

ges d

o no

t ind

uce

wei

ght l

oss a

fter 6

mon

ths.

• W

eigh

t los

s dru

gs (F

DA

app

rove

d) m

ay b

e us

ed a

spa

rt of

a w

eigh

t los

s pro

gram

for p

atie

nts:

• W

ith a

BM

I >=3

0 w

ith n

o ac

com

pany

ing

obes

ity-r

elat

ed ri

sk fa

ctor

s or d

isea

ses O

R•

With

a B

MI >

=27

with

acc

ompa

nyin

g ob

esity

-re

late

d ris

k fa

ctor

s or d

isea

ses.

Step

4.

Ass

ess R

eadi

ness

to C

hang

e: H

ando

ut A

• A

sk y

our p

atie

nt to

fill

out H

ando

ut A

tode

term

ine

read

ines

s to

mak

e he

alth

y ch

ange

s.•

A p

atie

nt th

at is

not

read

y to

mak

e ch

ange

s may

still

ben

efit

from

a d

iscu

ssio

n ab

out t

he im

por-

tanc

e of

wei

ght l

oss a

nd th

e he

alth

risk

s ass

oci-

ated

with

ove

rwei

ght a

nd o

besi

ty.

Step

5.

Det

erm

ine

Trea

tmen

t

Step

6.

Set G

oals

• Se

t rea

sona

ble

wei

ght g

oals

that

are

a h

igh

prio

rity

for t

he p

atie

nt a

nd in

volv

e sm

all c

hang

es.

• In

volv

e a

varie

ty o

f hea

lth c

are

prof

essi

onal

sw

hen

poss

ible

(e.g

., R

egis

tere

d D

ietit

ian

orB

ehav

ioris

t).

Redu

cing

wei

ght b

y 5%

- 10

% c

an d

ecre

ase

chro

nic

dise

ase

risk

fact

ors.

Wei

ght l

oss s

houl

dno

t exc

eed

1-2

lbs/w

eek

and

shou

ld b

e ba

sed

ona

calo

rie d

efic

it of

500

- 1,

000

kcal

/day

.

Ass

essm

ent

and

Tre

atm

ent

of A

du

ltO

verw

eigh

t an

d O

bes

ity

Step

1.

Mea

sure

Hei

ght,

Wei

ght &

Wai

st C

ircum

fere

nce

How

to

mea

sure

wai

st c

ircu

mfe

ren

ce:

Loca

te th

e up

per h

ip b

one

and

the

top

of th

erig

ht il

iac

cres

t. P

lace

a m

easu

ring

tape

in a

horiz

onta

l lan

e ar

ound

the

abdo

men

at t

hele

vel o

f the

ilia

c cr

est.

Bef

ore

read

ing

the

tape

mea

sure

, ens

ure

that

the

tape

is sn

ug,

but d

oes n

ot c

ompr

ess t

he sk

in, a

nd is

para

llel t

o th

e flo

or.

The

mea

sure

men

t is

mad

e at

the

end

of a

nor

mal

exp

iratio

n.*H

igh-

Ris

k W

aist

Circ

umfe

renc

e:M

en: >

40 in

(>10

2 cm

)W

omen

: >35

in (>

88 c

m)

Step

2.

Det

erm

ine

Bod

y M

ass I

ndex

(BM

I)

Use

BM

I C

har

t or

on

e of

th

e fo

rmu

las

bel

ow:

BM

I = w

eigh

t (kg

)/hei

ght s

quar

ed (m

eter

s)If

pou

nds a

nd in

ches

are

use

d:B

MI =

[wei

ght (

lbs)

x 7

03]/h

eigh

t squ

ared

(inc

hes)

Cla

ssB

MI

Und

erw

eigh

t<1

8.5

Nor

mal

Wei

ght

18.5

-24.

9O

verw

eigh

t25

-29.

9O

besi

ty (C

lass

I)30

-34.

9O

besi

ty (C

lass

II)

35-3

9.9

Extre

me

Obe

sity

(Cla

ss II

I)>4

0

Step

3.

Ass

ess r

isk

or e

xist

ence

of c

omor

bid

cond

ition

sPa

tient

s can

be

clas

sifie

d as

bei

ng a

t hig

h ab

solu

te ri

skfo

r obe

sity

-rel

ated

dis

orde

rs if

they

hav

e th

ree

or m

ore

of th

e m

ultip

le ri

sk fa

ctor

s lis

ted

belo

w:

• C

igar

ette

Sm

okin

g•

Hyp

erte

nsio

n•

Fam

ily h

isto

ry o

f pre

mat

ure

CH

D•

Hig

h LD

L ch

oles

tero

l (>

160

mg/

dL)

• Lo

w H

DL

chol

este

rol (

< 35

mg/

dL)

• Im

paire

d fa

stin

g gl

ucos

e (1

10-1

25 m

g/dL

)

Step

7b.

Rec

omm

end

Phys

ical

Act

ivity

Gui

delin

es:

Han

dout

s F,

G

Su

rger

y•

Wei

ght l

oss s

urge

ry is

a p

ossi

ble

optio

n in

pat

ient

sw

ho e

ncom

pass

the

follo

win

g:•

Clin

ical

ly se

vere

obe

sity

(i.e

., pe

rson

s with

a B

MI

>=40

or w

ith a

BM

I >=3

5 w

ith c

omor

bid

cond

i-tio

ns).

• Le

ss in

vasi

ve m

etho

ds h

ave

faile

d.•

At h

igh

risk

for o

besi

ty-r

elat

ed m

orbi

dity

and

mor

talit

y (N

HLB

I).

Step

8.

Con

tinue

Mon

itorin

g an

d Fo

llow

-up

• C

ondu

ct p

erio

dic

wei

ght,

BM

I, an

d w

aist

circ

umfe

renc

e ch

ecks

.

Alg

orith

m o

f Ass

essm

ent a

nd T

reat

men

t

BM

I >25

or w

aist

circ

umfe

renc

e >3

5 in

. [fe

mal

e]; w

aist

circ

umfe

renc

e >4

0 in

. [m

ale]

Ass

ess r

isk

fact

ors

His

tory

of B

MI >

25?

BM

I > 3

0 or

BM

I 25

to 2

9.9

or w

aist

circ

umfe

renc

e >

35in

ches

[fem

ale]

> 4

0 in

ches

[mal

e] a

nd >

2 ri

sk fa

ctor

sYes

No

Ye

s

Doe

s pat

ient

wan

t to

lose

wei

ght?

No

Clin

icia

n an

d pa

tient

dev

ise

goal

s and

trea

tmen

t stra

tegy

for w

eigh

t los

s and

risk

fact

or c

ontro

l

Yes

Ass

ess r

easo

ns fo

rfa

ilure

to lo

se w

eigh

t

Prog

ress

bei

ng m

ade?

Goa

l ach

ieve

d?

No

Yes

Mai

nten

ance

cou

nsel

ing:

• D

ieta

ry T

hera

py•

Beh

avio

r The

rapy

• Ph

ysic

al A

ctiv

ity

Yes

No

Perio

dic

wei

ght,

BM

I, an

d w

aist

circ

umfe

renc

e ch

eck

Sour

ce:

Ada

pted

from

Kus

hner

, RF,

Roa

dmap

s for

Clin

ical

Pra

ctic

e: C

ase

Stud

ies i

n D

isea

se P

reve

ntio

n an

d H

ealth

Prom

otio

n-A

sses

smen

t and

Man

agem

ent o

f Adu

lt O

besi

ty:

A P

rimer

for P

hysi

cian

s. C

hica

go, I

ll: A

mer

ican

Med

ical

Ass

ocia

tion;

200

3.

This

pub

licat

ion

was

supp

orte

d by

Coo

pera

tive

Agr

eem

ent

Num

ber U

58/C

CU

7227

95-0

2 fr

om th

e C

ente

rs fo

r Dis

ease

Con

trol a

nd P

reve

ntio

n. I

ts c

onte

nts a

re so

lely

the

resp

onsi

bilit

y of

the

auth

ors a

nd d

o no

t rep

rese

ntth

e of

ficia

l vie

ws o

f CD

C.

AN

EQ

UA

L O

PPO

RTU

NIT

Y/A

FFIR

MAT

IVE

AC

TIO

N E

MPL

OY

ER S

ervi

ces p

rovi

ded

on a

nond

iscr

imin

ator

y ba

sis.

Adv

ise

to m

aint

ain

wei

ght/a

ddre

ssot

her r

isk

fact

ors

No

Yes

Brie

f rei

nfor

cem

ent/

educ

ate

on w

eigh

t man

age-

men

t

No

Yes

BM

I19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

Heig

ht

(in

ch

es)

Bo

dy W

eig

ht

(po

un

ds)

5891

9610

010

511

011

511

912

412

913

413

814

314

815

315

816

216

717

217

718

118

619

119

620

120

521

021

522

022

422

923

423

924

424

825

325

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Communication Guidelines to Promote Health Behavior Change

Ask permissionWould you be willing to spend a few minutes discussing your weight?Would you like to talk about different ways to exercise and eat?

Share BMIYour BMI falls within the _________category.The target BMI for someone your height is _______.Ask for the patient’s interpretation: “What does this mean to you?”Add your own interpretation or advice as needed after eliciting the patient’s response.

Offer optionsThere are a number of ways to achieve a healthy weight.

Exercise and be physically active.Cut back on TV and computer time.Eat at least 5 servings of fruits and vegetables each day.Cut down on soda, juice, other sugary drinks and alcoholic beverages.

Is there any one of these you’d like to discuss further today? Or perhaps you have another idea that I didn’t mention?

Assess readinessOn a scale of 0 to 10, how ready are you to consider _____________ [option chosen above]

Not Ready Ready0 1 2 3 4 5 6 7 8 9 10

Straight question: Why a 5?Backward question: Why a 5 and not a 3?Forward question: What would it take to move you from a 5 to a 7?

Explore ambivalenceStep 1: Ask a pair of questions to help the patient explore the pros and cons of the issue.

What are the things you think are important or that you like about __________?What are the problems, or things, you don’t like about __________?

Step 2: Summarize ambivalenceAsk: Did I get it right?

Tailor the interventionState of Readiness Key QuestionsNOT READY 0-3 Would you be interested in knowing more about reaching a healthy weight?

Raise Awareness How can I help?Elicit Change Talk What needs to be different for you to consider making a change in the future?Advise and Encourage

UNSURE 4-6 Where does that leave you now?Evaluate Awareness What do you see as the next steps?Elicit Change Talk What are you thinking/feeling at this point?Advise and Encourage Where does ________ fit into your future?

READY 7-10 Why is this important to you now?Strengthen Commitment What are your ideas for making this work?Elicit Change Talk What might get in the way? How can you deal with that?Facilitate Action Planning How might you reward yourself along the way?

CloseSummarize.Show appreciation. Acknowledge willingness to discuss change.Offer advice, emphasize choice, establish realistic goals, and express confidence.Confirm next steps and arrange for follow-up.Source: Adapted from the Adolescent Provider Tool Kit, Adolescent Health Working Group, 2004.

Applying the Stages of Change Model to Assess Readiness

Stage Characteristic Patient verbal cue Appropriate intervention Sample dialogue

Precontemplation Unaware of problem “I’m not interested Provide information “Would you like to readno intesest in change in weight loss. It’s not about health risks and information about the

a problem.” benefits of weight loss health aspects of aging.”

Contemplation Aware of problem “I know I need to lose Help resolve “Let’s look at the benefitsbeginning to think weight, but with all ambivalence and of weight loss, as well asof changing that’s going on in my discuss barriers what you may need to

life right now, I’m not change.”sure I can.”

Preparation Realizes benefits of “I have to lose weight Teach behavior “Let’s take a closer lookmaking changes and and I’m planning to modification; provide at how you can reducethinking about how do that.” education some of the calories youto change eat and how to increase

your activity during the day.”

Action Actively taking steps “I’m doing my best. Provide support and “It’s terrific that you’retoward change This is harder than guidance, with a focus working so hard. What

I thought.” on the long term problems have you had so far? How have you solved them?”

Maintenance Initial treatment goals “I’ve learned a lot Relapse control “What situations continuethrough this process.” to tempt you to overeat?

What can be helpful for the next time you face such a situation?”

Adapted from Prochaaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WR, ed. TreatingAddictive Behaviors. New York, NY: Plenum; 1986:3-27

Source: Kushner, R.F.

This checklist includes a list of more detailed questions that correspond with the National Heart, Lung,and Blood Institute and North American Association for the Study of Obesity Practical Guidelines forevaluating readiness. They can be used to more thoroughly assess patients’ readiness and to evaluate forother medical conditions.

Motivation/support• How important is it that you lose weight at this time?• Have you tried to lose weight before?

• What factors have led to your success and what has made weight loss difficult? (Forexample, cost, peer pressure, family, etc.)

• Who of your family and friends is supportive of your decision to begin a weight lossprogram?

• What do you consider the benefits of weight loss?• What would you have to give up in order to lose weight?

Stressful life events• Are there events in your life right now that might make losing weight especially difficult?

(For example, work responsibilities, family commitments?)

Psychiatric issues• What is your mood like most of the time? Do you feel you have the needed energy to lose

weight? Do you feel that you eat what most people would consider a large amount of food ina short period of time? Do you feel out of control during this time?

• Do you ever forcibly vomit, use laxatives, or engage in excessive physical activity as ameans of controlling weight?

Time availability/constraints• How much time are you able to devote to physical activity on a weekly basis?• Do you believe that you can make time to record your caloric intake?

Weight-loss goals/expectations• How much weight do you expect to lose?• How fast do you expect to lose weight?

Source: Kushner, R.F.

Patient Readiness Checklist

Tips for Nutrition Counseling

Educational efforts should pay particular attention to the following topics:

• Energy value of different foods.• Food composition: fats, carbohydrates (including dietary fiber), and proteins.• Evaluation of nutrition labels to determine caloric content and food composition.• New habits of purchasing—give preference to low-calorie foods.• Food preparation: avoid adding high-calorie ingredients during cooking (e.g., fats and oils).• Avoiding over consumption of high-calorie foods (both high-fat and high-carbohydrate foods).• Adequate water intake (at least eight, 8 oz. glasses per day).• Reduction of portion sizes.• Limiting alcohol consumption.

What diet should I recommend?Aim for a slow, steady weight loss in your patients by decreasing calorie consumption, maintainingadequate nutrient intake, and increasing physical activity. Consider the following options to determinecalorie needs to support weight loss.

• To lose weight, in general, diets containing 1,000 to 1,200 kcal/day should be selected for mostwomen; diets between 1,200 kcal/day and 1,600 kcal/day should be chosen for men and may beappropriate for women who weigh 165 pounds or more, or who exercise regularly. If the patientcan stick with the 1,600 kcal/day diet but does not lose weight you may want to try the 1,200kcal/day diet. If a patient on either diet is hungry, you may want to increase the kcals/day by 100to 200.

• Go to www.mypyramid.gov and enter patient’s information (age, sex, weight, height andphysical activity level) to receive a customized food guide and recommended calorie level forweight maintenance. These amounts can then be modified by a reduction of approximately 500calories a day for weight loss. The MyPyramid food plans are based on average calorie needs forgroups of people and may not exactly match your patient’s calorie needs. Monitor weight andrecommend adjustments in the calorie level as needed.

• If patient is not losing weight through calorie reduction, consider resting metabolic rate (RMR)testing to more specifically determine patient’s calorie needs.

• If possible, refer patient to a Licensed Registered Dietitian for an in-depth dietary assessment.

• Recommend your patient keep a Daily Food and Activity Diary (Patient Handout M) and weigh/measure food portions for increased accuracy of calorie intake. Awareness is an important partof making lasting changes for healthy living. Keeping a diary will increase awareness of whatthey eat, why they eat (such as hunger levels or eating triggers) and physical activity patterns.


Patient Handouts


Are You Ready and Motivated to Lose Weight?

Answer these quick questions to assess how ready you are to achieve a healthier weight.

1. Is there a reason you are seeking treatment at this time?____________________________________________________________________________________

2. What are your goals about weight control and management?____________________________________________________________________________________

3. Your level of interest in losing weight is: (circle the number that indicates your level of interest)

Not Interested 1 2 3 4 5 Very Interested

4. Are you ready for lifestyle changes to be a part of your weight control program?

Not Ready 1 2 3 4 5 Very Ready

5. How much support can your family provide?

No Support 1 2 3 4 5 Much Support

6. How much support can your friends provide?

No Support 1 2 3 4 5 Much Support

7. What is the hardest part about managing your weight?____________________________________________________________________________________

____________________________________________________________________________________

8. What do you believe will be of most help to assist you in losing weight?_____________________________________________________________________________________________

____________________________________________________________________________________

9. How confident are you that you can lose weight at this time?

Not Confident 1 2 3 4 5 Very Confident

Source: Adapted from Kushner, R.F.

Patient Handout A

do it for yourself. . .do it for yourself . . .

1. Establish regular meal times.Skipping meals leads to overeating later in the day.If you don’t have time for a full meal, try to eat ahealthy snack or meal replacement bar instead.

2. Read food labels when buying food items.Pay attention to the portion size, the number ofcalories in each portion, and the amount ofsaturated fat in each portion. This can help youmake the healthiest food choices.

3. Make small substitutions in your diet tocut calories.For example, drink water, diet soda, orunsweetened iced tea instead of high-caloriedrinks. Choose low-calorie and low-fat versions ofsalad dressing, cheese, sour cream, andmayonnaise. Go easy on fried foods — bake, broil,poach, or grill your food instead. To find out theaverage amount of calories you should beconsuming every day, go to www.mypyramid.gov.

4. Identify “guilty pleasures” such as ice cream,cookies, or potato chips.Continue to enjoy them by trying the low-calorieversions or eating less of the regular versions.

5. Pre-portion your servings to control theamount.For example, scoop your ice cream in a bowlinstead of eating it out of the carton. Bag potatochips or cookies to single-serving sized containersor zip-lock bags. Eat the serving size only whenyou have a craving. Remember to pass on seconds.

6. Control calories when dining out.At fast-food restaurants, “down-size” food anddrinks instead of “super-sizing” them. Checkfavorite fast- food restaurant web sites for nutritioninformation to select the healthiest options.

7. Share an entrée with a friend at sit-downrestaurants.However, order a personal salad or side ofvegetables. Ask restaurants to: “Please hold thecheese,” “Leave the sauce on the side,” “Use low-fat salad dressing,” and “Please substitutevegetables for French fries.” As always, try toavoid fried dishes.

8. Pre-plan meals and snacks, and make certainto have the food on hand.This makes it easier to resist trips to the vendingmachine and unhealthy, unplanned snacking.

9. Avoid places and situations that triggereating.For example, if walking past the donut shop causesdonut cravings, try changing your route. Replacethe candy on your desk with fruit or avoid walkingnear the office candy bowl. Avoid eating whilewatching television, reading, or driving. Manypeople do not recall what they’ve eaten whiledoing other things.

10. Try substituting other activities for eating.For example, take a walk, talk to a friend, or listento music. These activities avoid the extra caloriesand can be more satisfying than eating.

Food Weight-Loss Tips

Patient Handout B

Source: Adapted from the American Medical Association: Roadmaps for Clinical Practice Series.


The Nutrition Facts Label - An Overview

When you’re at the grocery store it’s hard to take the extra minute to look at the food labels of the itemsyou’re buying. But reading the label is really the only way to know for sure what you’re eating. Thischeat sheet will make the process a little easier.

In the following Nutrition Facts label, certain sections have been colored to help you focus on the areasthat will be explained in detail. You will not see these colors on the food labels on products youpurchase.

This list gives percentages that arebased on recommended dailyallowances based on a 2,000 calorieper day diet. However manypeople’s calorie needs may besignificantly less than 2,000.

For example, a label may show that aserving of food provides 30% of thedaily recommended amount of fiber.This means you may need another70% to meet the recommended goal.Remember this is just an estimate,but it serves as a good guide.

Nutrition FactsServing Size 1 cup (228g)Servings Per Container 2

Amount Per Serving

Calories 250 Calories from Fat 110

% Daily Value*

Total Fat 12 g 18% Saturated Fat 3 g 15% Trans Fat 3 gCholesterol 30 mg 10%Sodium 470 mg 20%

Total Carbohydrate 31 g 10% Dietary Fiber 0g 0% Sugars 5 gProtein 5 g

Vitamin A 4%Vitamin C 2%Calcium 20%Iron 4%

*Percent Daily Values are based on a 2,000 caloriediet. Your Daily Values may be higher or lowerdepending on your calorie needs.

Calories: 2,000 2,500Total Fat Less than 65g 80g Sat Fat Less than 20g 25gCholesterol Less than 300mg 300mgSodium Less than 2,400mg 2,400mgTotal Carbohydrate 300g 375g Dietary Fiber 25g 30g

Source: Adapted from healthiergenerations.org and http://www.cfsan.fda.gov/~dms/foodlab.html

Try to keep sugars low. More sugarmeans more calories.

The less cholesterol and sodiumyou eat, the better. The latestrecommendation for sodium is lessthan 2,300 mg per day for adults.

Check the serving size, particularlyhow many servings there are in thecontainer. If there are 2 and you eatthe whole container, you’re eatingdouble the calories that are on thelabel!

Try to minimize saturated and transfat. These are both bad fats thatclog arteries.

Get enough fiber, vitamins A andC, calcium and iron.

Patient Handout C


Tips for Dining Out

The new National Heart, Lung, and Blood Institute Obesity Guidelines say that whether or not you’retrying to lose weight, you can eat healthy when dining out, if you know how.

So, if you’re treating yourself to a meal out, here are some tips to help make it a dining experience thatis both tasty and good for you.

ASK!Will the restaurant:

• Serve fat free (skim) milk rather than whole milk or cream?

• Trim visible fat from poultry or meat?

• Leave all butter, gravy or sauces off a dish?

• Serve salad dressing on the side?

• Accommodate special requests?

• Use less cooking oil when cooking?

• Provide a take-out box when your meal arrives? Put half the dinneraway immediately, even before your fork hits the plate.

ACT!Select foods which are:

• Steamed

• Garden fresh

• Broiled

• Baked

• Roasted

• Poached

• Lightly sautéed or stir-fried

DO YOUR HOMEWORK!• If possible, obtain nutritional information of menu items at the restaurant you will be dining at

before you leave for your meal. Try www.calorieking.com or the restaurant’s web site.

Patient Handout D

Source: Adapted from The National Heart, Lung, and Blood Institute in cooperation with the National Institute of Diabetesand Digestive and Kidney Diseases, National Institutes of Health.

do it for yourself. . .

Grocery Shopping Guide

The new National Heart, Lung, and Blood Institute Obesity Guidelines say that you can reduce the timeyou spend cooking healthy by using a shopping list and keeping a well-stocked kitchen. Read the labelsas you shop and pay attention to serving size and servings per container. Compare the total calories insimilar products and choose the lowest calorie ones. So, shop for quick low fat food items and fill yourkitchen cupboards with a supply of lower calorie basics like the following:

Patient Handout E

Source: Adapted from The National Heart, Lung, and Blood Institute in cooperation with the National Institute of Diabetesand Digestive and Kidney Diseases, National Institutes of Health.

Low Fat Dairy• Fat free or low fat milk, yogurt, cheese, and

cottage cheese

Whole Grain Carbohydrates• Whole grain sandwich breads, bagels, pita

bread, English muffins• Soft corn tortillas, low fat flour tortillas• Low fat, low sodium crackers• Whole grain cereal, dry or cooked• Brown rice or whole wheat pasta

Meat/Poultry/Seafood• White meat chicken or turkey (remove skin)• Fish and shellfish (not battered)• Beef: round, sirloin, chuck arm, loin and extra

lean ground beef• Pork: leg, shoulder, tenderloin• Dry beans and peas• Eggs/egg substitutes

Fruits and Vegetables• Fresh, frozen, canned fruits in water, juice or

light syrup• Fresh, frozen, or no salt added canned

vegetables (rinse regular canned vegetables toreduce sodium)

Fats and Oils• Monounsaturated fats

− Olive Oil− Canola Oil

• Light or diet margarine• Low fat or nonfat salad dressings

Condiments• Mustard and catsup• Low sugar jam or jelly• Herbs and spices• Salsa

Beverages• Water or sugar-free flavored water• Milk - fat free or low fat• 100% juice• Diet soda• Tea and coffee


What’son your plate?

Make half your plate fruits and

vegetables.

Switch to skim or 1% milk.

Vary your protein food choices.

Make at least half your grains

whole.

Before you eat, think about what and how much food goes on your plate or in your cup or bowl. Over the day, include foods from all food groups: vegetables, fruits, whole grains, low-fat dairy products, and lean protein foods.

ChooseMyPlate.gov

Grains

DairyFruits

VegetablesProtein

August 2011

USDA is an equal opportunity provider and employer.

Cut back on sodium and empty calories from solid fats and added sugars

Look out for salt (sodium) in foods you buy. Compare sodium in foods and choose those with a lower number.

Drink water instead of sugary drinks. Eat sugary desserts less often.

Make foods that are high in solid fats—such as cakes, cookies, ice cream, pizza, cheese, sausages, and hot dogs—occasional choices, not every day foods.

Limit empty calories to less than 260 per day, based on a 2,000 calorie diet.

Be physically active your wayPick activities you like and do each for at least 10 minutes at a time. Every bit adds up, and health benefits increase as you spend more time being active.

Children and adolescents: get 60 minutes or more a day.

Adults: get 2 hours and 30 minutes or more a week of activity that requires moderate effort, such as brisk walking.risk

minuteds up, and health

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Vegetables Fruits Grains Dairy Protein Foods

Eat more red, orange, and dark-green veg-gies like tomatoes, sweet potatoes, and broccoli in main dishes.

Add beans or peas to salads (kidney or chickpeas), soups (split peas or lentils), and side dishes (pinto or baked beans), or serve as a main dish.

Fresh, frozen, and canned vegetables all count. Choose “reduced sodium” or “no-salt-added” canned veggies.

Use fruits as snacks, salads, and desserts. At breakfast, top your cereal with bananas or strawberries; add blueberries to pancakes.

Buy fruits that are dried, frozen, and canned (in water or 100% juice), as well as fresh fruits.

Select 100% fruit juice when choosing juices.

Substitute whole-grain choices for refined-grain breads, bagels, rolls, break-fast cereals, crackers, rice, and pasta.

Check the ingredients list on product labels for the words “whole” or “whole grain” before the grain ingredient name.

Choose products that name a whole grain first on the ingredi-ents list.

Choose skim (fat-free) or 1% (low-fat) milk. They have the same amount of calcium and other essential nutrients as whole milk, but less fat and calories.

Top fruit salads and baked potatoes with low-fat yogurt.

If you are lactose intolerant, try lactose-free milk or fortified soymilk (soy beverage).

Eat a variety of foods from the protein food group each week, such as seafood, beans and peas, and nuts as well as lean meats, poultry, and eggs.

Twice a week, make seafood the protein on your plate.

Choose lean meats and ground beef that are at least 90% lean.

Trim or drain fat from meat and remove skin from poultry to cut fat and calories.

For a 2,000-calorie daily food plan, you need the amounts below from each food group. To find amounts personalized for you, go to ChooseMyPlate.gov.

Eat 2½ cups every day

What counts as a cup? 1 cup of raw or cooked vegetables or vegetable juice; 2 cups of leafy salad greens

Eat 2 cups every day

What counts as a cup? 1 cup of raw or cooked fruit or 100% fruit juice; ½ cup dried fruit

Eat 6 ounces every day

What counts as an ounce?1 slice of bread; ½ cup of cooked rice, cereal, or pasta; 1 ounce of ready-to-eat cereal

Get 3 cups every day

What counts as a cup? 1 cup of milk, yogurt, or fortified soymilk; 1½ ounces natural or 2 ounces processed cheese

Eat 5½ ounces every day

What counts as an ounce?1 ounce of lean meat, poultry, or fish; 1 egg; 1 Tbsp peanut butter; ½ ounce nuts or seeds; ¼ cup beans or peas

Patient Handout G

There are 1,440 minutes in every day...schedule 30 of them for physical activity.

Making Physical Activity Part of Your Life: Tips for Being More Active


Adults need recess too! With a little creativity and planning, even the person with the busiest schedule canmake room for physical activity. For many folks, before or after work or meals is often an available timeto cycle, walk, or play. Think about your weekly or daily schedule and look for or make opportunities to bemore active. Every little bit helps. Consider the following suggestions:

• Walk, cycle, jog, skate, etc., to work, school, the store, or place of worship.• Park the car farther away from your destination.• Get on or off the bus several blocks away.• Take the stairs instead of the elevator or escalator.• Play with children or pets. Everybody wins. If you find it too difficult to be active after work,

try before work.• Take fitness breaks-walking or doing desk exercises-instead of taking cigarette or coffee breaks.• Perform gardening or home repair activities.• Avoid labor-saving devices-turn off the self-propel option on your lawn mower or vacuum

cleaner.• Use leg power-take small trips on foot to get your body moving.• Exercise while watching TV (for example, use hand weights, stationary bicycle/treadmill/

stairclimber, or stretch).• Dance to music.• Keep a pair of comfortable walking or running shoes in your car and office. You’ll be ready for

activity wherever you go!• Make a Saturday morning walk a group habit.• Walk while doing errands.

Tips for People Who Have Been Inactive for a WhileUse a sensible approach by starting out slowly.

• Begin by choosing moderate-intensity activities you enjoy the most. Bychoosing activities you enjoy, you’ll be more likely to stick with them.

• Gradually build up the time spent doing the activity by adding a fewminutes every few days or so until you can comfortably perform aminimum recommended amount of activity (30 minutes per day).As the minimum amount becomes easier, gradually increaseeither the length of time performing an activity or increasethe intensityof the activity, or both.

• Vary your activities, both for interest and to broadenthe range of benefits.

• Explore new physical activities.• Reward and acknowledge your efforts.

Given the health benefits of regular physical activity, we might have to ask why two out of three (60%)Americans are not active at recommended levels. There are barriers that keep Americans from being, orbecoming, regularly physically active. Understanding common barriers to physical activity and creatingstrategies to overcome them may help you make physical activity part of your daily life.

Identify available time slots. Monitor your daily activities for one week. Identify at least three30-minute time slots you could use for physical activity.

Add physical activity to your daily routine. For example, walk or ride your bike to work orshopping, organize school activities around physical activity, walk the dog, exercise while youwatch TV, park farther away from your destination, etc.

Make time for physical activity. For example, walk, jog, or swim during your lunch hour, ortake fitness breaks instead of coffee breaks.

Select activities requiring minimal time, such as walking, jogging, or stairclimbing.

Explain your interest in physical activity to friends and family. Ask them to support yourefforts.

Invite friends and family members to exercise with you. Plan social activities involvingexercise.

Develop new friendships with physically active people. Join a group, such as the YMCA or ahiking club.

Schedule physical activity for times in the day or week when you feel energetic.

Convince yourself that if you give it a chance, physical activity will increase your energy level;then, try it.

Plan ahead. Make physical activity a regular part of your daily or weekly schedule and write iton your calendar.

Invite a friend to exercise with you on a regular basis and write it on both your calendars.

Join an exercise group or class.

Learn how to warm up and cool down to prevent injury.

Learn how to exercise appropriately considering your age, fitness level, skill level, and healthstatus.

Choose activities involving minimum risk. Select activities requiring no new skills, such aswalking, climbing stairs, or jogging.

Exercise with friends who are at the same skill level as you are.

Find a friend who is willing to teach you some new skills.

Take a class to develop new skills.

Fear of Injury

Patient Handout H

Suggestions for Overcoming Physical Activity Barriers

“If you can find a path with no obstacles, it probably doesn’t lead anywhere.” —Anonymous

Overcoming Barriers to Physical Activity

Lack of Time

Social Influence

Lack of Energy

Lack of Motivation

Lack of Skill

Lack of Resources Select activities that require minimal facilities or equipment, such as walking,jogging, jumping rope, or calisthenics.

Identify inexpensive, convenient resources available in your community(community education programs, park and recreation programs, worksite programs,etc.).

Develop a set of regular activities that are always available regardless of weather(indoor cycling, aerobic dance, indoor swimming, calisthenics, stair climbing, ropeskipping, mall walking, dancing, gymnasium games, etc.)

Look on outdoor activities that depend on weather conditions (cross-country skiing,outdoor swimming, outdoor tennis, etc.) as “bonuses”-extra activities possible whenweather and circumstances permit.

Put a jump rope in your suitcase and jump rope.

Walk the halls and climb the stairs in hotels.

Stay in places with swimming pools or exercise facilities.

Join the YMCA or YWCA (ask about reciprocal membership agreement).

Visit the local shopping mall and walk for half an hour or more.

Bring a small tape recorder and your favorite aerobic exercise tape.

Trade babysitting time with a friend, neighbor, or family member who also hassmall children.

Exercise with the kids-go for a walk together, play tag or other running games, getan aerobic dance or exercise tape for kids (there are several on the market) andexercise together. You can spend time together and still get your exercise.

Hire a babysitter and look at the cost as a worthwhile investment in your physicaland mental health.

Jump rope, do calisthenics, ride a stationary bicycle, or use other home gymnasiumequipment while the kids are busy playing or sleeping.

Try to exercise when the kids are not around (e.g., during school hours or their naptime).

Encourage exercise facilities to provide child care services.

Look upon your retirement as an opportunity to become more active instead of less.Spend more time gardening, walking the dog, and playing with your grandchildren.Children with short legs and grandparents with slower gaits are often great walkingpartners.

Learn a new skill you’ve always been interested in, such as ballroom dancing,square dancing, or swimming.

Now that you have the time, make regular physical activity a part of every day. Gofor a walk every morning or every evening before dinner. Treat yourself to anexercycle and ride every day while reading a favorite book or magazine.

Source: Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and HealthPromotion.

Suggestions for Overcoming Physical Activity Barriers (continued)

Weather Conditions

Travel

Family Obligations

Retirement Years

1. Walk to work.2. Use fat free milk instead of whole milk.3. Do sit-ups in front of the TV.4. Walk during lunch hour.5. Drink water before a meal.6. Eat leaner red meat and poultry.7. Eat half your dessert.8. Walk instead of driving whenever you can.9. Take family walk after dinner.10. Skate to work instead of driving.11. Avoid food portions larger than your fist.12. Mow lawn with push mower.13. Increase the fiber in your diet.14. Walk to your place of worship instead of driving.15. Walk kids to school.16. Get a dog and walk it.17. Join an exercise group.18. Drink diet soda.19. Replace Sunday drive with Sunday walk.20. Do yard work.21. Eat off smaller plates.22. Get off a stop early and walk.23. Don’t eat late at night.24. Skip seconds.25. Work around the house.26. Skip buffets.27. Grill, steam or bake instead of frying.28. Bicycle to the store instead of driving.29. Take dog to the park.30. Ask your doctor about taking a multi-vitamin.31. Go for a half-hour walk instead of watching TV.32. Use vegetable oils over solid fats.33. More carrots, less cake.34. Fetch the newspaper yourself.35. Sit up straight at work.36. Wash the car by hand.37. Don’t skip meals.38. Eat more celery sticks.39. Run when running errands.40. Pace the sidelines at kids’ athletic games.41. Take wheels off luggage.42. Choose an activity that fits into your daily life.

43. Try your burger with just lettuce, tomato, andonion.

44. Ask a friend to exercise with you.45. Make time in your day for physical activity.46. Exercise with a video if the weather is bad.47. Bike to the barbershop or beauty salon instead

of driving.48. Keep to a regular eating schedule.49. If you find it difficult to be active after work,

try it before work.50. Take a walk or do desk exercises instead of a

cigarette or coffee break.51. Perform gardening or home repair activities.52. Avoid laborsaving devices.53. Take small trips on foot to get your body

moving.54. Play with your kids 30 minutes a day.55. Dance to music.56. Keep a pair of comfortable walking or running

shoes in your car and office.57. Make a Saturday morning walk a group habit.58. Walk briskly in the mall.59. Choose activities you enjoy and you’ll be more

likely to stick with them.60. Stretch before bed to give you more energy

when you wake.61. Take the long way to the water cooler.62. Explore new physical activities.63. Vary your activities, for interest and to broaden

the range of benefits.64. Reward and acknowledge your efforts.65. Choose fruit for dessert.66. Consume alcoholic beverages in moderation, if

at all.67. Take stairs instead of the escalator.68. Conduct an inventory of your meal/snack and

physical activity patterns.69. Share an entree with a friend.70. Grill fruits or vegetables.71. Eat before grocery shopping.72. Choose a checkout line without a candydisplay.73. Make a grocery list before you shop.

Tips to Make Small Changes - That Add Up to Big Success

Patient Handout I

74. Buy 100% fruit juices over soda and sugarydrinks.

75. Stay active in winter. Play with your kids.76. Flavor foods with herbs, spices, and other low

fat seasonings.77. Remove skin from poultry before cooking to

lower fat content.78. Eat before you get too hungry.79. Eat breakfast every day.80. Stop eating when you are full.81. Snack on fruits and vegetables.82. Top your favorite cereal with apples or

bananas.83. Try brown rice or whole-wheat pasta.84. Include several servings of whole grain food

daily.85. When eating out, choose a small or medium

portion.86. If main dishes are too big, choose an appetizer

or a side dish instead.87. Ask for salad dressing “on the side”.88. Park farther from destination and walk.89. Try a green salad instead of fries.90. Bake or broil fish.91. Walk instead of sitting around.92. Eat sweet foods in small amounts.93. Take your dog on longer walks.94. Drink lots of water.95. Cut back on added fats or oils in cooking or

spreads.96. Buy a set of hand weights and play a round of

Simon Says with your kids - you do it with theweights, they do without.

97. Walk to a co-worker’s desk instead of emailingor calling them.

98. Carry your groceries instead of pushing a cart.99. Use a snow shovel instead of a snow blower.100. Cut high-calorie foods like cheese and

chocolate into smaller pieces and only eata few pieces.

101. Use nonfat or low-fat sour cream, mayo,sauces, dressings, and other condiments.

102. Replace sugar sweetened beverages with water and add a twist of lemon or lime.

103. Replace high-saturated fat/high calorieseasonings with herbs grown in a small herbgarden in your kitchen window.

104. Refrigerate prepared soups before you eatthem. As the soup cools, the fat will rise tothe top. Skim it off the surface for reducedfat content.

105. When eating out, ask your server to put halfyour entrée in a to-go bag.

106. Substitute vegetables for other ingredients inyour sandwich.

107. Every time you eat a meal, sit down, chewslowly, and pay attention to flavors andtextures.

108. Try a new fruit or vegetable (ever had jicama,plantain, bok choy, starfruit or papaya?)

109. Make up a batch of brownies with applesauceinstead of oil or shortening.

110. Instead of eating out, bring a healthy, lowcalorie lunch to work.

111. Ask your sweetie to bring you fruit or flowersinstead of chocolate.

112. Speak up for the salad bar when yourco-workers are picking a restaurant for lunch,and remember calories count, so payattention to how much and what you eat.

113. When walking, go up the hills instead ofaround them.

114. Walk briskly through the mall and shop ‘tilyou drop ... pounds.

115. Clean your closet and donate clothes that aretoo big.

116. Take your body measurements to gaugeprogress.

For more information, visithttp://www.smallstep.gov

Tips to Make Small Changes -That Add Up to Big Success (continued)


Developing Your Success Plan!

There are several steps in developing a workable plan for weight management- 1st set realistic goals- 2nd develop a plan to meet goals- 3rd record behavior to see if goals are met- 4th reward yourself for meeting goals

Realistic goals- Can be achieved without making drastic changes- Can be described as lifestyle behavior changes for healthy living- Can make you feel good when you meet them

Characteristics of realistic goalsRealistic goals are . . . . . easily understood

measurable behavior-related achievable

It is important to have time frames set for achieving goals

- Long-term goalsSet your sights on what you can achieve in 1-3 years

Example: Your long-term goal may be to lose 5% - 10% of your body weight.

- Short-term goalsBehaviors and weight don’t change overnight, so setting goals for three months is a goodidea.

Example: Your short-term goal may be to eat 5 servings of fruits and vegetableseach day or to increase physical activity to at least 30 minutes on most days perweek.

- Weekly goalsWeekly goals are your small steps taken toward your short-term goal.

Example: Your weekly goals may be to take the stairs at work 3 days this weekor to eat a piece of fruit with breakfast and lunch every day.

Patient Handout J


Healthy Eating Goal

Physical Activity Goal

Environment Goal

Goal Worksheet

What do you want to achieve in the next 7 days?

Healthy Eating:

What do you need to do to achieve it? __________________________________________________________________

What roadblocks do you need to address?

_______________________________________________________________

How can you overcome the roadblocks?_________________________________________________________________

Physical Activity:

What do you need to do to achieve

it?___________________________________________________________________

What roadblocks do you need to address?_______________________________________________________________

How can you overcome the roadblocks? ________________________________________________________________

Changing Environment:

What do you need to do to achieve it? __________________________________________________________________

What roadblocks do you need to address?_______________________________________________________________

How can you overcome the roadblocks?______________________________________________________

Recording Behavior


Patient Handout K

Behavior Record for 7 Days – Place a in the boxes for the days you meet a goal.

Sun Mon Tues Wed Thurs Fri Sat

How Will You Reward Yourself?

Name 3 things that you value and could use and rewards for meeting your goal at the end of the week:

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

√√√√√

I, __________________________, pledge to [write goal(s)]1)2)

for the next 3 weeks. I will reward myself with

when I have made this a habit.

_____________________________ __________

personal pledgeInstructions: Before completing the personal pledge to betterhealth, think about the 1-2 goal(s) you wish to achieve tobecome healthier and the reward(s) you will give yourself whenyou are successful.

Signature Date

Record your goals in the Goal Log for each week on the reverseside of this personal pledge to better health.

Patient Handout L


goal logIn the calendar, off each day that you meet your goal(s). Good luck!

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

week 1

week 2

week 3

week 1

week 2

week 3

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

activitynutrition&

. . .time for reward!

GOAL 1

GOAL 2

SundaySundaySundaySundaySunday MondayMondayMondayMondayMonday TuesdayTuesdayTuesdayTuesdayTuesday WednesdayWednesdayWednesdayWednesdayWednesday ThursdayThursdayThursdayThursdayThursday FridayFridayFridayFridayFriday SaturdaySaturdaySaturdaySaturdaySaturday

SundaySundaySundaySundaySunday MondayMondayMondayMondayMonday TuesdayTuesdayTuesdayTuesdayTuesday WednesdayWednesdayWednesdayWednesdayWednesday ThursdayThursdayThursdayThursdayThursday FridayFridayFridayFridayFriday SaturdaySaturdaySaturdaySaturdaySaturday

Daily Food and Activity Diary

Research has shown that keeping a food and activity diary is an important tool for losing weight andkeeping it off. Diaries can help target areas for improvement. To find out the food and activity behav-iors to focus on, keep a diary before making any changes in your meals and activities. Discuss yourdiary and make a nutrition and activity plan with your health care professional.

INSTRINSTRINSTRINSTRINSTRUCTIONSUCTIONSUCTIONSUCTIONSUCTIONS

1. Fill out the following sections of your diary.

Time:Write the time of day you ate the food.

Food/Drink:Describe the type of food or drink you consumed. Be as specific as you can. Include sauces andgravies. Don’t forget to write down “extras,” such as soda pop, salad dressing, mayonnaise, butter,sour cream, sugar and ketchup.

Amount:In this space note the amount of the item you ate or drank (not how much was served). Use measur-ing cups and spoons to describe most foods (examples: 1 cup Cheerios, ½ cup 2% milk) or use sizeor shape to describe foods that don’t fit into a cup or spoon (examples: 8 inch corn tortilla, 3 x 3 x 1inch chocolate cake with frosting, 1 medium chicken breast).

Where:Write what room or part of the house you were in when you ate. If you ate in a restaurant, fast-foodchain or your car, write that location down.

Mood:How were you feeling while you were eating (for example, sad, happy, depressed)?

Hunger Scale:Rate how hungry you were before you began eating using the hunger scale.

Empty Starving Hunger Pains Hunger Slight Hunger Neutral Contented Slightly Full Full Overfed Nausea

0 1 2 3 4 5 6 7 8 9 10

Activity:Write down all your activities in the day, including day-to-day activities such as a 15-minute walk towork, or 30 minutes spent vacuuming, as well as more formal exercise (e.g, 50-minute aerobics class)._______________________________________________________________________________________

______________________________________________________________________________________

____________________________________________________________________________________

Patient Handout M

HUNGER SCALE

2. Advice for keeping a Food Diary.

Write down everything you eat and drink. A piece of candy, a handful of pretzels or a can of sodapop may not seem like much at the time, but over a week these calories add up!

Tell the truth. There’s nothing to be gained by trying to look good on these forms. Your health careprovider can help you only if you record what you really eat.

Do it now. Don’t depend on your memory at the end of the day. Record your eating as you go.

Remember the little things like butter, margarine, jelly, sugar, sauces, gravies, salad dressings, etc.

Remember to include snacks and beverages while cooking, between meals and before bed.

Note what is in a mixed food. (Example: stew [1/4 cup meat, 1/4 cup potatoes, 1/4 cup carrots, 1/4cup gravy])

Describe how a food was prepared. (Example: 1 chicken breast fried with PAM spray)


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SWeb SitesAmerican Academy of Family Physicians (AAFP)Practical Advice for Family Physicians to Help Overweight Patients (2003)http://www.aafp.org/PreBuilt/afpmonograph_obesity.pdf

American College of Preventive Medicine (ACPM)Weight Management Counseling of Overweight Adults (2001)www.acpm.org/polstmt_weight.pdf

American Medical AssociationAssessment and Management of Adult Obesity: A Primer for Physicians.www.ama-assn.org/ama/pub/category/10931.html

National Heart, Lung, and Blood Institute (NHLBI)Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998)www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

NHLBI’s Obesity Education Initiative provides the Clinical Guidelines on Overweight and Obesity in Adults to physicians ina free interactive program for use on handheld electronic devices. This electronic resource allows physicians to generateindividualized assessment and treatment recommendations at the point of care.http://hin.nhlbi.nih.gov/obgdpalm.htm

Health Information CenterThis center presents a wealth of information on the prevention and treatment of heart, lung, and blood diseases. Patienteducational materials and publications intended for health professionals are available on many topics including cholesterol,high blood pressure, heart disease, exercise, and obesity. Clinical practice guidelines on high blood cholesterol, high bloodpressure, and obesity are also made available.www.nhlbi.nih.gov/health/infoctr/index.htm

Aim for a Healthy WeightThis Web site offers information for both health professionals and the general public. The educational materials for healthcare professionals include clinical guidelines for obesity, a BMI calculator and table, and access to continuing medicaleducation courses.www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.html

North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and Blood Institute (NHLBI)The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (2000)www.nhlbi.nih.gov/guidelines/obesity/practgde.htm

America on the Move (AOTM)Partnership to Promote Healthy Eating and Active LivingThe AOTM program is accessible to all Americans through an interactive Web site, which offers several tools forparticipants to track their steps and progress.www.AmericaOnTheMove.org

Fruits & Veggies - More MattersNational Cancer Institute (NCI), Produce for Better Health FoundationThe national program is designed to encourage Americans to eat more servings of fruits and vegetables every day. Theprogram provides consumers with practical and easy ways to incorporate more fruits and vegetables into their daily eatingpatterns. For health care professionals, it offers promotional and educational materials as well as information and access toadditional resources.http://www.fruitsandveggiesmorematters.org

Steps to a HealthierUSU.S. Department of Health and Human Services (DHHS)Steps to a HealthierUS is an initiative from DHHS that encourages physical activity, a nutritious diet, healthy choices, andpreventive screenings.www.healthierUS.gov

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Center for Nutrition Policy and PromotionU.S. Department of Agriculture (USDA)This Web site translates nutrition research into publications and reports for use by physicians, and also into brochures and informationfor the general public. The new personalized food guide pyramid, dietary guidelines, and recipes are among the resources available.www.usda.gov/cnpp

Division of Nutrition, Physical Activity, and ObesityCenters for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)The CDC developed this site to address the role of nutrition and physical activity in living a healthy lifestyle and reducing chronicillnesses. It serves as a resource for guidelines, fact sheets, and other types of publications on topics related to nutrition and physicalactivity. In addition, a section designed specifically for health professionals offers access to data and statistics, programs, andrecommendations.www.cdc.gov/nccdphp/dnpa

Food and Nutrition Information CenterUSDA Agricultural Research Service (ARS)The ARS collects and disseminates information on food and human nutrition. It contains dietary guidelines, the food guide pyramid,links to various databases, additional resources, and much more.www.nal.usda.gov/fnic

Mayo ClinicThe Mayo Clinic Web site contains up-to-date information, programs, and interactive tools that include health management programs,health decision guides, a personal health scorecard, and various health centers that address food and nutrition, fitness and sportsmedicine, women’s health, men’s health, and more.www.mayoclinic.com

Weight Control Information NetworkNational Institute of Diabetes and Digestive and Kidney DiseasesThe network disseminates science-based information on obesity, weight control, and nutrition to health care professionals and thegeneral consumer. It also offers various types of statistics, publications, and videotapes on clinical weight loss and control.http://win.niddk.nih.gov/index.htm

Nutrition.govThis national resource provides access to all on-line federal government information about nutrition, healthy eating, physical activity,and food safety.www.nutrition.gov

American Heart AssociationThe American Heart Association is committed to reducing disability and death from cardiovascular diseases and stroke. Itscomprehensive Web site presents detailed information on topics regarding heart disease and health, as well as numerous health toolssuch as the cardiovascular disease risk assessment tool, exercise diary, and the body mass index Web calculator for use by the generalconsumer. Health care professionals can retrieve scientific publications, statistics, patient information sheets, treatment decision tools,guidelines, and performance measures.www.americanheart.org

Calorieking.comThis site provides information and tools to control weight and lead a healthy lifestyle. An on-line food and exercise diary, and mealplans are available, as is a food and diet diary for computers and handheld devices.www.calorieking.com/handheld/

American Dietetic AssociationThis is the nation’s largest organization of food and nutrition professionals and it serves the public by promoting optimal nutrition,health, and well-being. The Web site provides resources and information on food and nutrition, as well as a referral service that linksconsumers with registered dietetic professionals. Additionally, its professional reference publications section offers patient educationalmaterials and books for physicians.www.eatright.org



References

The American Obesity Association, http://www.obesity.org.

Kushner, R.F. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion-Assessment and Management of Adult Obesity: A Primer for Physicians. Chicago, Ill: American MedicalAssociation; 2003.

National Heart, Lung, and Blood Institute (NHLBI) and National Institute for Diabetes and Digestive and KidneyDiseases (NIDDKD). Clinical guidelines on the identification, evaluation, and treatment of overweight andobesity in adults: evidence report. Obesity Research. 1998; 6(suppl 2): 51S–210S. Available at http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm.

Healthy Missourians Initiative. Preventing Obesity and Other Chronic Diseases: Missouri’s Nutrition andPhysical Activity Plan. Missouri Department of Health and Senior Services, 2005.

J. Shalwitz, D. Bushman, K. Davis, S. Williams (2005).San Francisco, CA: Adolescent Health Working Group,San Francisco. Body Basics: An Adolescent Provider Toolkit.

Screening for obesity in adults: recommendations and rationale. United States Preventive Services Task Force -Independent Expert Panel. 1996 (revised 2003 Dec 2). 13 pages. NGC:003163, Available at:http://www.guideline.gov.

P.A. Estabrooks. R.E. Glasgow, D.A. Dzewaltowski. Physical Activity Promotion through Primary Care, JAMA,June 11, 2003 – Vol 289, No. 22.

The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001. Forward from theSurgeon General, U.S. Department of Health and Human Services. http://www.surgeongeneral.gov/topics/obesity/calltoaction/toc.htm.

Weight Management Counseling of Overweight Adults. United States Preventive Services Task Force –Independent Expert Panel. National Guideline Clearinghouse. Available at http://www.guideline.gov.

The Center for Nutrition Policy and Promotion, an organization of the U.S. Department of Agriculture.http://www.mypyramid.gov.

Department of Health and Human Services, Centers for Disease Control and Prevention. National Center forChronic Disease Prevention and Health Promotion. Division of Nutrition, Physical Activity, and Obesity.

Alliance for a Healthier Generation. William J. Clinton Foundation/American Heart Association.http://www.healthiergeneration.org.

Food and Drug Administration/Center for Food Safety & Applied Nutrition. http://www.cfsan.fda.gov/~dms/foodlab.html.

U.S. Department of Health & Human Services. http://www.smallstep.gov.

The National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of HighBlood Cholesterol in Adults (Adult Treatment Panel III). The National Heart, Lung, and Blood Institute (NHLBI)launched the National Cholesterol Education Program (NCEP).

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If your answer is “strongly agree” or “agree,” please check which items you will continue to use in your day-to-day practice: Physician Resources __ Pocket Guide—Assessment and Treatment of Overweight and Obesity __ BMI Chart __ Diabetes Management Guidelines __ Missouri Consensus Screening Guidelines __ Communication Guideline to Promote Health Behavior Change __ Applying the Stages of Change Model to Assess Readiness __ Patient Readiness Checklist __ Tips for Nutrition Counseling Patient Handouts __ Are You Ready and Motivated to Lose

Weight? __ Food Weight-Loss Tips __ Nutrition Facts Label __ Tips for Dining Out __ Grocery Shopping Guide __ MyPyramid __ Making Physical Activity Part of Your Life __ Overcoming Barriers to Physical Activity __ Tips to Make Small Changes __ Developing Your Success Plan! __ Goal Worksheet __ Personal Pledge to Better Health __ Daily Food and Activity Diary

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Documents

Missouri Council for Adult - Missouri Department of …health.mo.gov/living/healthcondiseases/obesity/pdf/...Missouri Council for Activity & Nutrition The United States is in the midst