Appendix

The group treatment sessions were 75 to 90 minutes and were held weekly from weeks 1 to 20, every other week from weeks 21 to 40, and every 8 weeks from weeks 41 to 104. Groups included 8 to 12 participants and only contained persons assigned to the same diet condition (low-carbohydrate or low-fat). Once the group sessions began, no additional members were added, and participants could not attend other group sessions. There was 1 brief (15 minute) individual session at week 30 that focused on assessing progress and goal setting for the future.

During weeks 1 to 20, participants were instructed in traditional behavioral methods of weight control, such as self-monitoring, stimulus control, slowed eating, shaping, and reasonable goal setting. During weeks 21 to 104, there was a focus on skills to maintain weight loss, such as continuing to record food intake regularly, measuring and recording body weight regularly, consuming a low-carbohydrate or a high-carbohydrate diet, identifying high-risk situations, differentiating lapse from relapse, responding effectively to overeating episodes, and learning to reverse small weight gains as they occur. Group sessions varied between the 2 treatment conditions only in the type of diet plan that was prescribed. Sample group leader protocols (week 2) for each treatment condition are included under “week 2” of the section “Low Carbohydrate.”

Groups were conducted by a registered dietitian or psychologist with experience in weight control. Group leaders attended an initial, 2-day, in-person training in Philadelphia, and all group leaders attended biweekly calls throughout the study. The calls were led by a psychologist with extensive experience in behavioral methods of weight control. The calls focused on any clarifications of the protocol and the discussion of nonadherent participants.

Low Carbohydrate

Week 2

I. Welcome (5 minutes)

A. Begin with reintroduction (names only). If new members, include reasons for weight loss as in week 1 but keep abbreviated and limit your comments.

B. Ask for volunteers to recall as many names as possible.

C. Address any questions left from last week.

D. Briefly review tonight's agenda. This week we will focus on making changes in eating habits.

II. SAFE (Handout) (10 minutes)

A. Indicate that we want to provide a way for members to check in briefly at the beginning of each group. For the next few weeks, everyone will check in but over time (depending on the number of persons in the group, guest lecturers, etc), participants may take turns. Remind about the need to avoid spending too much time on any one individual.

B. SAFE was chosen to remind us that we want this to be a safe place to discuss eating and exercise habits. (Remind about confidentiality). It also reminds us about the key things to concentrate on each week.

1. S~self care—Important to view weight loss as self-care rather than as punitive. It's something to do for yourself rather than some punishment that is imposed. Also important to develop non-food alternatives to nurture self. Each week participants to report things they did to take care of themselves that did not include food. Should be things focused on the participant rather than her/his family, job, etc. (e.g., massage, going to movie that they have been wanting to see, pedicure, manicure, small “gift”; being inaccessible to others for brief times; going home on time). See “Self-Care” handout for more examples. Part of long-term success is being nice to yourself. Complete “Self-Care” handout and pick at least one thing each week.

2. A~adherence—How were you able to achieve your goals this week? This includes skill development each week (slow eating, limiting times, etc) as well as individualized goals (special situations, behaviors from goal worksheet). Review particular successes or difficulties. This is a way to get individual attention as well as help the group sharpen its problem-solving skills.

3. F~food records—Review progress with keeping records of food and other activities. This is the primary tool of weekly assessment.

4. E~exercise—The physical activity that you performed this week (type, duration, frequency).

C. Note that W~(weight) is not included in the weekly review. Review reasons why weight is a poor short-term measure of success (Brownell, pp. 48–49).

1. salt intake

2. water shifts, menstrual cycle, humidity

3. no relation between weight and weekly behavior

D. Focus on SAFE and weight loss will follow.

E. Next week, we will use SAFE to check in.

III. Skill Review (15 minutes)

A. Ask participants to describe rationale for self-monitoring from week 1 (Brownell, pp. 14–15).

B. Ask about participants' experiences with recording.

Was it helpful?

What patterns emerged?

What were the barriers to recording?

What were participants' experiences with recording in previous programs?

Was it difficult to record overeating episodes?

Did friends or family members comment about record keeping?

C. It is especially important that participants believe in the utility of keeping records, so be sure to assess this before suggesting ways to record better. Focus on any barriers (time, size of record booklets, embarrassment, forgetting) with specific suggestions. Use group to come up with benefits and suggestions. Emphasize that this is a skill that is critical for individualized treatment.

D. Review the weekly food records and how to complete them (time, amount, type and description of food, add carbohydrates this week). Stress importance of recording ASAP after eating or it will be difficult to recall. Tally carbohydrate later if necessary. Recommend that they subtotal carbohydrate throughout the day. They can calculate carbohydrate using the carbohydrate counter we will distribute tonight. Briefly review how the book is organized.

E. Indicate that you will collect food record booklets each week and make brief comments about any patterns you observe. This review should be brief (2 minutes) and include positive comments. Emphasize that these records are for the participants' benefit not yours. You are trying to provide a structure to make record keeping easier.

IV. Goal Setting (15 minutes) (Brownell, pp. 61–62)

A. Weight

1. Ask participants to think about how much weight they expect to lose over the next 20 weeks. Record them on the board. Ask several participants to describe how they arrived at their numbers. Point out that they are probably making assumptions about the benefits (e.g., losing 40 pounds will make me feel/look twice as good as losing 20 pounds) as well as the costs (e.g., losing the second 20 pounds will be similar to losing the first 20 pounds). Are these assumptions about additional weight loss correct? Review faulty assumptions briefly. Avoid getting into a contest of wills about how much weight people can or should lose. Ultimately, the decision is the participant's.

2. Compare participants' goals on the board to what can be reasonably expected (1–2 lb per week) (see Brownell, p. 38). Use Brownell diagram (pp. 100–101) to illustrate that when outcomes (what is achieved) do not match goals (what is expected) there are typically negative effects on self-evaluation. How would participants feel if they did not reach their desired weight goals? Probably tend to blame self rather than program or unrealistic goals. Use examples (based on their weight goals) of how same outcomes can be viewed differently based on what was expected.

3. Actual weight loss will vary due to differences in weight, metabolism and genetics (we will review causes of overweight next week). Typical weight loss is 1–2 pounds per week (see Atkins, p. 177). Rather than setting a final weight goal now, we recommend that participants focus on behavior change and observe what weight loss is accomplished. Weight loss after week 12 will probably be representative of monthly weight loss during the program.

4. We recommend an initial goal of a 10% reduction because it is associated with improvements in medical conditions and most persons can achieve it with modest changes in eating and exercise. When 10% is reached, another goal can be set based on costs/benefits. Remind participants that body composition will be measured at week 26 so they can make an informed decision about further weight loss. It is impossible and imprudent to set a long-term weight goal now because of the lack of information about costs/benefits.

B. Behavior

1. Have participants think about one change in their eating that they would like to make (over the next 4 weeks) that would lead to weight loss. Use several examples to discuss the following characteristics of effective goal setting (see handout).

a. specific—define precisely what is to be accomplished. Specific goals such as “walk two times this week after work on Tuesday and Thursday in the park are more likely to be accomplished that general ones such as, “walk more this week.” Similarly, “eat 20 grams of carbohydrate per day” is more likely to be accomplished than “eat less carbohydrate this week.”

b. reasonable—make small changes. If you're not walking at all, do not try to walk every day. The smaller the difference between your current behavior and your goal behavior the greater the chances you will accomplish it. Small successes lead to big successes.

c. active—define your goals in terms of what to do rather than what not to do. For example, “eat every four hours” instead of “stop going all day without eating” or “walk after dinner” rather than “stop lying on the couch after dinner.”

d. short-term—assess your goals over short intervals (no more than a week). Sometimes, even shorter intervals are helpful (day by day). Reviewing your progress after short periods will enable you to review your accomplishments and troubleshoot any difficulties.

e. limited—select no more than two goals per week. Selecting more will decrease your focus and make adherence more difficult. Once your goals have been accomplished and maintained, you can select new goals.

f. record—it is helpful to keep a written record of your goals and progress each week. It will increase awareness of your goal and provide an accurate record of your progress. The simplest and easiest records work best. Do what works for you.

2. Instruct each participant to select one behavioral goal for the next week (using the handout as a guide) and have them record it in the front of their weekly record. There will not be time in group to review each goal. They will discuss this goal under “A” of SAFE next week.

V. Weight Loss: Short-Term Dieting Versus Long-Term Behavior Change (10 minutes)

A. Before establishing a carbohydrate prescription for weight loss, let's review how this approach to long-term weight control differs from dieting. (Brownell, pp. 6–7, 12–13).

1. Diets are all-or-none. For many people a diet implies short-term dietary change. You're either on the diet or off the diet; you've had either a good day or a bad day. There is no middle ground (Brownell, pp. 220–221).

2. Long-term weight control is based on a regular pattern of eating that avoids extremes and deprivation. It is important to note that the Induction stage of the program is only a temporary period designed to initiate the process of consuming a low carbohydrate diet. Subsequent stages of the program incorporate a larger variety of foods. Long-term weight control emphasizes changes that last. It is based on choosing foods that you enjoy while making healthy carbohydrate choices. The basic theme of any good nutritional approach is adaptability. Adding new carbohydrate containing foods slowly and carefully will help you learn good eating habits. You will be less prone to feeling hungry, irritated, and unhappy. These are feelings that lead to overeating.

Some days will be better than others; it is not realistic to assume that you should eat the same amount every day. The goal is to consume a variety of acceptable foods that you enjoy. The goal is not perfection. Eating is not a moral issue. It is inaccurate an ineffective to make self-evaluations based on eating and exercise behavior.

VI. Induction (15 minutes) (Atkins' New Diet Revolution, pp. 121–144)

A. Review principles of Induction:

1. To switch from a high carbohydrate eating plan to a controlled carbohydrate eating plan.

2. To lose weight while eating palatable foods.

3. To realize that the Induction phase is not going to be your lifelong way of eating.

B. In order for Induction to work, it must be followed precisely; therefore, we suggest that participants follow these guidelines (see Induction Guidelines handout, also on pages 122–124 in Atkins' New Diet Revolution):

1) Eat 3 regular-size meals a day or 4–5 smaller meals and do not go for more than 4 waking hours without eating.

2) Eat liberal amounts of fat and protein foods (i.e., poultry, fish, shellfish, red meat). When you consume fat, use butter, mayonnaise, olive oil, safflower oil, sunflower oil and other vegetable oils rather than margarine. See pamphlet for rules regarding egg and shellfish consumption.

3) Eat no more than 20 grams of carbohydrate per day (primarily in the form of salad greens or other permitted vegetables).

4) Do not eat any fruit, bread, pasta, grains, starchy vegetables, dairy product (other than cheese, cream, or butter), or protein/carbohydrate foods (legumes).

5) Only eat acceptable foods (group leaders, see Atkins, pp. 124–129) listed in the Instruction for Induction pamphlet.

6) Adjust quantities of non-carbohydrate containing foods to suit your appetite (amount that makes you feel satisfied, not stuffed).

7) Read food labels and check carbohydrate content (see Be a Carbohydrate Detective handout).

8) Be aware for hidden carbohydrates in gravies, sauces, and dressings when eating out. For example, gravy is often made with flour or cornstarch and sugar is sometimes added to salad dressings.

9) Drink at least eight 8-oz glasses of water per day (for hydration, to avoid constipation).

10) Alcohol is not a source of nutritive carbohydrate and shouldn't be consumed in place of food (Atkins for Life, p. 46). Alcoholic beverages should be avoided during Induction for a variety of reasons:

a) acts as alternate fuel source

b) decreases hydration

c) decreases self-control

C. Do not try to do a low-fat version of the program as it will disrupt weight loss (Atkins, p. 127).

D. In addition to these rules, we ask you to also take a multivitamin each day.

E. This approach counts carbohydrates rather than calories. Although you will not be counting calories, calories do matter. Gaining weight results from eating more calories than you burn, so eat until satisfied and do not gorge (Atkins, p. 143).

VII. Carbohydrate Counting (10 minutes)

A. Explain the general concept of carbohydrate counting using a household budget or bank account as a model. Review the basic principles of carbohydrate counting.

1. You receive a 20-gram carbohydrate deposit each day, which you can spend according to your own personal preferences. You decide how to spend your carbohydrates. This will require you to consider how much you enjoy a particular food versus what it costs. You can have 4 cups of salad vegetables per day. However, if you would like to add vegetables that contain slightly higher carbohydrate contents (limited to 1 cup per day), you must reduce your intake of salad vegetables from 4 to 3 cups per day. Emphasize that participants cannot simply eat the maximum amount of servings from each food group listed in the pamphlet because they will likely go over the 20-gram limit. The sample menu handout provides some meal ideas during Induction.

2. Using your carbohydrate counter and food labels, record the number of carbohydrates that you spend each day in your weekly record.

3. Using the handout, briefly review key aspects of the food label and review how to calculate net carbohydrate.

4. Tally your carbohydrate consumption. The key factor is to consume no more than 20 grams of carbohydrate per day. Point out that grams of carbohydrate are based on serving size, so measuring utensils and scale (distributed during baseline food intake measurement) should be used to accurately determine the amount consumed. Need to weigh and measure foods in the short-term (2 weeks) to become accustomed to actual portions. Review guidelines for estimating portion sizes when measuring utensils are not available (see weekly record). Over time, can perform occasional checks or weigh novel foods.

B. Review two principal benefits of carbohydrate counting.

C. You can lose weight while eating high protein and/or fat foods. Fish, shellfish, fowl, meat, and butter are unrestricted.

D. Does not involve self-deprivation or hunger. This eating plan consists of a variety of foods that are palatable, pleasant, and filling (Atkins, pg. 5, 19, 32).

E. Tips for consuming a reduced carbohydrate diet.

1. Eliminate unnecessary, hidden carbohydrates, which you do not need such as sugar in sodas and coffee, and choose lower carbohydrate alternatives such as saccharin or sucralose. Limit sweeteners to 3 packets a day (Atkins, p. 144).

2. Plan ahead. Examine your schedule and prime your environment. Stock up on low carbohydrate snacks and eliminate high carbohydrate temptations. Some examples of low carbohydrate snacks are turkey and cheese roll, single serving can of tuna, hard boiled eggs, Laughing Cow cheese or string cheese, seeds, nuts or nut butter on a celery stick, and sugar free Jello. Carbohydrate controlled foods are generally found around the periphery of the grocery store.

3. Avoid deprivation. Eat regularly (every 4 hours) to prevent hunger. Have a small carbohydrate controlled snack high in fat or protein if you are hungry between meals (Atkins, p. 153).

4. Eat primarily unprocessed foods but when you eat packaged foods (i.e., cheese), read the food labels carefully. Generally, “low fat” means “high carbohydrate.”

NOTE: Although ATKINS Ready to Drink Shakes (up to 1 per day), ATKINS Shake Mix (up to 2 scoops per day), and ATKINS ADVANTAGE BARS (up to 1 per day) can be consumed in place of whole foods during Induction, this option should only be initiated when it has been determined that the individual cannot incorporate whole foods into his/her eating plan (like during crunch times). At this point it would be premature to offer this as an option. ATKINS Endulge products cannot be consumed during Induction.

F. Inform participants that they may experience some undesirable symptoms (i.e., headaches, constipation) after the second day of Induction (see back of Instructions for Induction sheet). Call participants after the third day of Induction and ask about their progress and whether they are experiencing any problems. Do not specifically ask about symptoms. Example: “I am calling to see how you are doing on your new eating plan and to find out whether you have any questions or are experiencing any problems so far.”

VIII. Skill Building (Handout) (5 minutes)

1. Follow Induction diet.

2. Take one multivitamin each day.

3. Record all food (time, amount, type and description of food, carbohydrates).

4. Use the carbohydrate counter and food labels to determine carbohydrate intake. Key thing is to eat a wide variety of acceptable foods.

5. Record one personal goal for this week in the beginning of the weekly record and assess progress as appropriate.

IX. Handouts

1. SAFE Handout

2. Self-Care Handout

3. Effective Goal Setting Handout

4. Induction Guidelines Handout

5. Instructions for Induction Pamphlet

6. Sample Menus

7. Be a Carbohydrate Detective Handout

8. Carbohydrate Gram Counter Handout

9. Skill Builder

10. Weekly Record

Low Fat

Week 2

I. Welcome (5 minutes)

A. Begin with reintroduction (names only). If new members, include reasons for weight loss as in week 1, but keep abbreviated and limit your comments.

B. Ask for volunteers to recall as many names as possible.

C. Address any questions left from last week.

D. Briefly review tonight's agenda. This week we will focus on making changes in eating habits.

II. SAFE (Handout) (10 minutes)

A. Indicate that we want to provide a way for members to check in briefly at the beginning of each group. For the next few weeks, everyone will check in but over time (depending on the number of persons in the group, guest lecturers, etc), participants may take turns. Remind about the need to avoid spending too much time on any one individual.

B. SAFE was chosen to remind us that we want this to be a safe place to discuss eating and exercise habits. (Remind about confidentiality). It also reminds us about the key things to concentrate on each week.

1. S~self care—Important to view weight loss as self-care rather than as punitive. It's something to do for yourself rather than some punishment that is imposed. Also important to develop non-food alternatives to nurture self. Each week participants to report things they did to take care of themselves that did not include food. Should be things focused on the participant rather than her/his family, job, etc. (e.g., massage, going to movie that they have been wanting to see, pedicure, manicure, small “gift”; being inaccessible to others for brief times; going home on time). See “Self-Care” handout for more examples. Part of long-term success is being nice to yourself. Complete “Self-Care” handout and pick at least one thing each week.

2. A~adherence—How were you able to achieve your goals this week? This includes skill development each week (slow eating, limiting times, etc) as well as individualized goals (special situations, behaviors from goal worksheet). Review particular successes or difficulties. This is a way to get individual attention as well as help the group sharpen its problem-solving skills.

3. F~food records—Review progress with keeping records of food, exercise and other activities. This is the primary tool of weekly assessment.

4. E~exercise—The physical activity that you performed this week (type, duration, frequency).

C. Note that W~(Weight) is not included in the weekly review. Review reasons why weight is a poor short-term measure of success (Brownell, pp. 48–49).

1. salt intake

2. water shifts, menstrual cycle, humidity

3. no relation between weight and weekly behavior

D. Focus on SAFE and weight loss will follow.

E. Next week, we will use SAFE to check in.

III. Skill Review (10 minutes)

A. Ask participants to describe rationale for self-monitoring from week 1 (Brownell, pp. 14–15).

B. Ask about participants' experiences with recording.

1. Was it helpful?

2. What patterns emerged?

3. What were the barriers to recording?

4. Did they have difficulty estimating portions?

5. What were participants' experiences with recording in previous programs?

6. Was it difficult to record overeating episodes?

7. Did friends or family members comment about record keeping?

C. It is especially important that participants believe in the utility of keeping records, so be sure to assess this before suggesting ways to record better. Focus on any barriers (time, size of record booklets, embarrassment, forgetting) with specific suggestions. Use group to come up with benefits and suggestions. Emphasize that this is a skill that is critical for individualized treatment.

D. Review the new food record booklets and how to complete them (time, amount, type and description, add calories this week). Stress importance of recording ASAP after eating or it will be difficult to recall. Tally calories later if necessary. Recommend that they subtotal calories throughout the day. They can calculate calories using the calorie counter we will distribute tonight. Briefly review how the book is organized.

E. Indicate that you will collect food record booklets each week and make brief comments about any patterns you observe. This review should be brief (2 minutes) and include positive comments. Emphasize that these records are for the participants' benefit not yours. You are trying to provide a structure to make record keeping easier.

IV. Goal Setting (Brownell, pp. 61–62) (15 minutes)

A. Weight

1. Ask participants to think about how much weight they expect to lose over the next 20 weeks. Record them on the board. Ask several participants to describe how they arrived at their numbers. Point out that they are probably making assumptions about the benefits (e.g., losing 40 pounds will make me feel/look twice as good as losing 20 pounds) as well as the costs (e.g., losing the second 20 pounds will be similar to losing the first 20 pounds). Are these assumptions about additional weight loss correct? Review faulty assumptions briefly. Avoid getting into a contest of wills about how much weight people can or should lose. Ultimately, the decision is the participant's.

2. Compare participants' goals on the board to what can be reasonably expected (1–2 lb per week) (see Brownell p. 38). Use Brownell diagram (pp. 100–101) to illustrate that when outcomes (what is achieved) do not match goals (what is expected) there are typically negative effects on self-evaluation. How would participants feel if they did not reach their desired weight goals? Probably tend to blame self rather than program or unrealistic goals. Use examples (based on their weight goals) of how same outcomes can be viewed differently based on what was expected.

3. Actual weight loss will vary due to differences in weight, metabolism and genetics (we will review causes of overweight next week). Typical weight loss is 1–2 pounds per week (see Brownell p. 38). Rather than setting a final weight goal now, we recommend that participants focus on behavior change and observe what weight loss is accomplished. Weight loss after week 12 will probably be representative of monthly weight loss during the program.

4. We recommend an initial goal of a 10% reduction because it is associated with improvements in medical conditions and most persons can achieve it with modest changes in eating and exercise. When 10% is reached, another goal can be set based on costs/benefits. Remind participants that body composition will be measured at week 26 so they can make an informed decision about further weight loss. It is impossible and imprudent to set a long-term weight goal now because of the lack of information about costs/benefits.

B. Behavior

1. Have participants think about one change in their eating that they would like to make (over the next 4 weeks) that would lead to weight loss. Use several examples to discuss the following characteristics of effective goal setting (see handout).

a. specific—define precisely what is to be accomplished. Specific goals such as “walk two times this week after work on Tuesday and Thursday in the park are more likely to be accomplished that general ones such as, “walk more this week.” Similarly, “eat 1200–1400 calories per day” is more likely to be accomplished than “eat less this week.”

b. reasonable—make small changes. If you're not walking at all, do not try to walk every day. If you're eating 10 candy bars each week, do not attempt to eat only 2. The smaller the difference between your current behavior and your goal behavior the greater the chances you will accomplish it. Small successes lead to big successes.

c. active—define your goals in terms of what to do rather than what not to do. For example, “eat every four hours” instead of “stop going all day without eating” or “walk after dinner” rather than “stop lying on the couch after dinner.”

d. short-term—assess your goals over short intervals (no more than a week). Sometimes, even shorter intervals are helpful (day by day). Reviewing your progress after short periods will enable you to review your accomplishments and troubleshoot any difficulties.

e. limited—select no more than two goals per week. Selecting more will decrease your focus and make adherence more difficult. Once your goals have been accomplished and maintained, you can select new goals.

f. record—it is helpful to keep a written record of your goals and progress each week. It will increase awareness of your goal and provide an accurate record of your progress. The simplest and easiest records work best. Do what works for you.

2. Instruct each participant to select one behavioral goal for the next week (using the handout as a guide) and have them record it in the front of their weekly record. There will not be time in group to review each goal. They will discuss this goal under “A” of SAFE next week.

V. Weight Loss: Short-Term Dieting Versus Long-Term Behavior Change (10 minutes)

A. Before establishing a caloric prescription for weight loss, let's review how our approach to long-term weight control differs from dieting (Brownell, pp. 6–7, 12–13).

1. Diets are all-or-none. For many people a diet implies short-term dietary change. You're either on the diet or off the diet; you've had either a good day or a bad day. There is no middle ground (Brownell, pp. 220–221). Furthermore, many diets are based on fads, extremes, and severe deprivation. As such, they are only successful in the short-term. Can only make dramatic changes for a short time.

2. Long-term weight control is based on a regular pattern of eating that avoids extremes and deprivation. It emphasizes small changes that last. It is based on choosing foods that you enjoy while staying within the boundaries of daily caloric allowances. There are no forbidden foods. Allow yourself to have some special foods or treats and work them into daily/weekly/monthly allowances. You will be less prone to feeling deprived, irritated, unhappy. These are feelings that lead to overeating.

B. There are no absolutes (never, always, must) in successful weight control. Some days will be better than others; it is not realistic to assume that you should eat the same amount every day. The goal is to consume a variety of foods that you can enjoy and sustain balanced eating over the long haul. The goal is not perfection. Eating is not a moral issue. It is inaccurate and ineffective to make self-evaluations based on eating and exercise behavior.

VI. Picking a Calorie Range (10 minutes) (Brownell, pp. 44–46)

A. Review principles of energy balance:

1. Intake > Output = Weight Gain

2. Intake < Output = Weight Loss

3. Intake = Output = Weight Maintenance

B. 3500 calories = 1 pound. To lose one pound/week, you'll need to eat 3500 calories less than you burn. Easier to decrease intake than to increase output (i.e., easier to eat 500 calories less per day than it is to exercise 500 calories more per day). Give examples. That's why exercise alone is not the best method for weight loss. Regular physical activity, however, is the best predictor of maintaining weight loss.

C. We are recommending a calorie range (1200–1500 calories/d for women and 1500–1800 calories/d for men); participants will decide how to “spend” those calories using the principles below. As above, need to observe weight loss over 1-month period.

VII. A Calorie Account (10 minutes)

A. Explain the general concept of a calorie account using a household budget or bank account as a model. Review the basic principles of using a calorie account. The sample menu handouts provide some meal ideas.

1. You receive a 1200–1500 (women) or 1500–1800 (men) calorie deposit each day, which you can spend according to your own personal preferences. You decide how to spend your calories. This will require you to consider how much you enjoy a particular food versus what it costs calorically.

2. Using your fat and calorie counter, record the number of calories that you spend each day in your weekly record. Point out that calories are based on serving size, so measuring utensils and scale (distributed during baseline food intake measurement) should be used to accurately determine the amount consumed. Need to weigh and measure foods in the short-term (2 weeks) to become accustomed to actual portions. Review guidelines for estimating portion sizes when measuring utensils are not available (see weekly record). Over time, can perform occasional checks or weigh novel foods. Briefly review some basic components (e.g. serving size, calories) of the food label using the “Be a Calorie Detective” handout.

3. Tally your calorie account as expenditures are made. Although you are allotted a certain number or calories each day, you will not spend this amount every day. You can save calories for special occasions, just as you save money. For example, a person could save 100 calories per day, Monday through Friday, and spend the extra 500 calories over the weekend. You may also spend less to adjust for an unusually large expenditure.

4. The key factor is that the calorie ledger must balance (i.e., average 1200–1500 calories/day or 1500–1800 calories/day) in order for your rate of weight loss to remain constant. It is best to review your ledger for a weekly balance (8400–10,500 calories per week).

B. Review two principal benefits of keeping a calorie account.

1. Allows for flexibility and variety.

2. No single overeating episode is paramount, since you can balance your calorie account with adjustments.

C. Tips for reducing caloric intake.

1. Reduce or eliminate unnecessary, hidden calories which you do not need or really enjoy (e.g., eliminate butter, sugar in sodas and coffee, reduce use of cream, choose lower calorie alternatives if similar taste).

2. Plan ahead. Examine your schedule and prime your environment. Stock up on low calorie snacks and eliminate high fat and calorie temptations. Be conscious of the caloric cost of food choices. Are the calories worth it? If they are, fine; if not, skip it or choose an alternative. Examples of low calorie snacks can be found on the handout. Encourage participants to consume a variety of foods.

NOTE: Although meal replacement shakes and bars (e.g., Slim-Fast) can be consumed in place of whole foods, this option should only be initiated when it has been determined that the individual cannot incorporate whole foods into his/her eating plan (like during crunch times). At this point it would be premature to offer this as an option.

3. Avoid deprivation. It's a short-term solution to a long-term problem. Do not totally eliminate foods that you really enjoy. Find a way to work them in. Make changes that you can live with.

4. Eat regularly (every 4 hours) to prevent hunger. This will be addressed in greater detail next week when we discuss developing an eating schedule.

D. Remind participants to take a multivitamin each day.

E. Inform participants that they may experience some undesirable symptoms. Call participants within the first three days to ask about their progress and whether they are experiencing any problems. Do not specifically ask about symptoms. Example: “I am calling to see how you are doing on your new eating plan and to find out whether you have any questions or are experiencing any problems so far.”

VIII. Skill Building (Handout) (5 minutes)

1. Eat a diet that is consistent with your calorie goal (1200–1500 calories per day for women, 1500–1800 calories per day for men).

2. Record all food (time, amount, type and description, calories).

3. Use the calorie counter and food labels to determine calorie intake. Key thing is to eat a wide variety of foods.

4. Record one personal goal for this week in beginning of the food record and assess progress as appropriate.

IX. Handouts

1. SAFE Handout

2. Self-Care Handout

3. Effective Goal Setting Handout

4. Tip the Calorie Balance Handout

5. Be a Calorie Detective Handout

6. Enjoy the Variety-Healthy Food Choices

7. Sample Menus

8. Calorie King

9. Skill Builder

10. Weekly Record