Planning a Program to Help Students Shed Pounds

Helping Students Shed PoundsJulie Luht and Leah Kasowitz1

I have this friend who has a love affair with diet books. Like many people, shes always looking for the latest and the greatest diet. I dont know quite how she does it, but shes always really up on latest diet, pill, or gizmo. While I was getting ready for this presentation, I shared my outline with her. She came back with, So are you going to talk about Sensa? I really think that guy is on to something.Now, I didnt know what Sensa was so I googled it.

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SCAMAnd heres the website. Now Sensa comes in salty and sweet flavor packets and you sprinkle it on your food. Then some kind of magic involving the olfactory glands occurs and youre not hungry anymore and you lose weight. Too good to be true, right?Of course it is. Actually, when you search Sensa, google auto populates the search box with Sensa Scan.

Im not bringing this up to point out that theres a diet scam on the market; there are 100s of diet scams. This is just an example of our mindset as a society. As a society, we are looking for a way to fix obesity, were sidetracked by all of these scams and diets. At the same time, were hearing this super simplistic message to eat less and exercise more. Meanwhile none of this is working. Its not a coincidence that we started the HEALS program with food service and fitness and didnt touch weight management until now. Its because weight management is a really complex subject.

Unfortunately we dont have a magic bullet for you and want to make sure that you dont trust anyone who claims to have this magic bullet. Something about evaluations. 3In One SentenceAll diets workwhen you stick to them.

4Learning ObjectivesDescribe the state of the science in weight management research. Articulate a realistic approach to weight management in Job Corps.Utilize tools to help students manage their weight.

So today were not selling you a gimmick. We are going to outline the current science available in weight management and from that science, were going to talk about realistic expectations and strategies in Job Corps. We are also going to outline some of the information available on the HEALS website and help you apply some of those tools.Sound like a plan?5

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7Why is obesity on the rise?Part 1: Identifying the ProblemBefore we launch into solutions, were going to talk a little bit about the problem. Why is this a problem? Why now? What has changed in our society?8Minute 6. Food in the natural environment

Environmentnatural to eat as much as we canNo way to turn signal off

Were not programmed to live in a society where food is everywhere.How does this apply to the JC environment? 9

Why is it so much harder for some people?Why do some people stay thin in this environment? What separates thin from overweight?

101:297:20Kind of overwhelming, huh? Do you think people can overcome this genetic predisposition to eat when tasty food is present? Of importance, the video didnt show that the expression of this gene peaks around age 20the same age as many of our students.

I can see this in the different ways my husband and I behave around food thats lying around. When there is food around, he eats pretty much nonstop. He will walk into my parents house and go right for the queso dip and chips. Then hell pretty much snack nonstop until dinner, eat dinner, and dessert, then heat up leftovers later at night. Theres an all-you-can eat switch that goes off and even though hes not hungry, he cant stop eating.

And as much as I understand whats going on biologically, I get so frustrated with him, when he says that he wants to lose 20 pounds and then 5 minutes later goes into the kitchen for another snack. Lets think of this in terms of how we feel towards JC students. On an evaluation from a recent webinar, someone suggested noncompliance of morbidly obese students as a topic for a future webinar. Its really easy to get frustrated with students who seriously need to lose weight but do everything wrong.

We deal with some pretty serious discrimination surrounding obesity. Fat bias has been called the last acceptable form of bias in America. In this section, I really want you to take away that eating available food is our natural way and the drive to eat fattening food in large quantities is genetic. Thats really the scope of our problem. 11In SummaryA toxic, obesity-causing environmentGenetics that tell use to eat when food is availableContradictory information about whats healthyOverly simplistic messages to eat less and exercise more12How do we turn this around?Part 2: Solving the ProblemFor this portion of the presentation, we are going to talk about ways to maximize students chances of achieving or maintaining a healthy weight.

13Lesson #1Youre not going to save everyone.Every time we do a presentation about this program, someone asks a question about a very overweight student thats a source of frustration in the wellness center. Its the noncompliant morbidly obese student. This student doesnt listen to advice, visits the cafeteria line repeatedly and doesnt exercise. He might even say that he wants to lose weight. But his actions dont show it.

Im going to ask you to hold back from throwing things at me when I say this, and I know that many of you will disagree with me, but I think that this person should be lower on your list of priorities than students who are ready to change their behavior regardless of weight. Heres the reasoning: Your time is valuable and you simply dont have the time to devote to a really challenging case. 14Success DefinedDrop out rate of less than 20%20-40% maintain weight lossWeight loss is modest, sustained, and clinically significant8 pounds=reduced diabetes6 pounds=reduced BP/drugs1.8 pounds=24% reduction in all-cause mortality at 10.5 yrs.Source: Powell, L.H. et al. (2007). Effective obesity treatments. American Psychologist. 62(3); 234-246.15What Makes a Program Successful?Intensive phase followed by indefinite follow upMeet at least once a weekSpecific dietary changes, calorie reduction, and exercise combinedDraw on skills of experienced behavior professionals (self-monitoring, modeling, environmental restructuring, and group and individual support)

Source: Powell, L.H. et al. (2007). Effective obesity treatments. American Psychologist. 62(3); 234-246.Lesson #2Dont push.

The Stages of Change and MIMI QuestionsOn a scale of 1-10, how ready do you feel to change your eating patterns or lifestyle behaviors? What would it take to move you to a [higher number]?How is your current weight affecting your life right now? How do you feel about that?

Source: Puhl, R. (2011). The Obese Patient in the Healthcare Environment. Available at: http://www.medscape.com/viewarticle/749440?src=mp&spon=17

MI QuestionsWhat strategies have worked for you in the past?What makes you feel like you can continue to make progress if you decide to?What are your obstacles? How do you think you can overcome [insert obstacle]?

MI QuestionsWhat are your hopes for the future if you are able to become healthier?How would your life be different if you lost weight and adopted a healthier lifestyle?

Intake ActivityAssess readiness for changeRefer appropriately

What Not to DoMandatory groupsShort-term competitions/programs (more harm than good)

Weight CyclingSource: Cereda, E. (2011). Weight cycling is associated with body weight excess and abdominal fat: A cross-sectional study. Clinical Nutrition. [Epub ahead of print]Lesson #3Focus just as much energy on normal and overweight students as obese students.Trends

BenefitsSocietal benefitsPopulation focusMaintaining weight is a whole lot easier than losing weightIntegration into parenting classesLesson #4Focus on behavior, not weight.Change FocusWe focus too much on diet and not enough on physical activity; and we focus too much on losing weight and not enough on keeping it offMost weight loss programs focus primarily on dietary restriction, and we know those are not generally successful(http://xnet.kp.org/permanentejournal/sum03/registry.html)According to the National weight control Registry we focus too much on diet and not enough on physical activity and we focus too much on losing weight and not enough on keeping it off. If most weight loss programs focus on dietary restrition and we know those are not successful what can we do? We need to change the focus from diets to healthy eating, but more importantly we need to get students active! If the strict diets are not successful why keep focusing on them?

33SMART GoalsUse SMART goals SpecificMeasurableAttainableRealisticTimely

Change the focus from losing weight to being healthy. If you take away the focus of the scale and the pressure associated with a number you can replace it with feeling better and possibly looking better but making small changes. 34What is not a SMART goal?Walk 5 minutes a dayJoin a sports team/dance teamGet healthyWalk 1 mile per day, 5 days a weekWhich of these are SMART goals? Can you spot the difference in the one that is not? Can we get some examples of Job Corps friendly examples? Even the smallest behavior change can impact their health. If we focus only on BMI we are setting our self up for failure. If we aim to have each student leave job corps with 1 healthy new behavior that sticks with them for life can we measure that as succes35SMART ActivityGoal Setting WorksheetDiscussion questions

How would you use this on your center?Is anyone using this on center now?Pass out the Goal setting worksheet. Take a few minutes to fill out as yourself (not as a student on center!) After a few minutes I am going to have you partner up and go over the sheet. As group: Have people give a few examples of good ones they have. How can these be used on center? Anyone using this now? How is it going? How did you use it?

Using A to begin and maybe 6 weeks later do follow up with part B on the back to see how you did making changes and rate the progress. 36Link to HEALsHealthy Eating 101Cooking 101Nutrition JeopardyMove It!-Making Physical Activity Fun

Along with the Goal setting worksheet there are many other links to the HEALs program. These are just a few that I really liked37Move It!Sports (soccer, volleyball, softball, basketball, running club, jogging club, walking club, etc.)Dance (hip hop dance, Greek organization stepping, Latin dance, belly dancing, urban dance, aerobics class, step class, dance competitions)Mind/Body or Stress Reduction ActivitiesGym WorkoutInteractive Gaming [Wii Sports or Wii Fit games, video dance games like Dance, Dance Revolution (DDR)]While there is limited evidence on the long-term efficacy of Active Video Games it cannot hurt! (Active Video Games to Promote Physical Activity in Children and Youth A Systematic Review) There are so many creative ways to move and here we have just a sample listed on the HEALs website. What are you currently doing on your center?38Step Up to HelpMaking a Difference MSNBC- Obesity Story in DC Step up to Helphttp://www.msnbc.msn.com/id/21134540/vp/43286952#43286952

Here is a story clip about a local DC story. I know these girls may be younger than those on center.. But the idea is the same, finding an activity they love and a space to do it safely and without judgement. 39A ConsiderationNeed to consider the specific needs of overweight teens/young adultsOverweight children may experience negative consequences of participation in activities considered appropriate for normal-weight childrenAmerican Heart Association Childhood Obesity Research Summit: Executive Summary

Activities that are easily mastered should be considered. Recommendations based on clear, attainable goals that gradually increase in volume and intensity over time should be established. Such structuring will help ensure that overweight children experience initial success40Lesson #5Make sure the environment supports health.Adding Healthy ChoicesSource: Boutelle, K.N. et al. (2011). Nutritional quality of lunch meal purchased for children at a fast-food restaurant. Childhood Obesity. 7(4), 316-322.Food Selection (teenson a visit to McDonalds)PercentageFrench Fries33.0%AppleDippers0.3%Soda96.7%Milk and apple juice combined3.3%Bakedapple pie8.6%Fruitand yogurt parfait0.8%Placement StrategiesPlace the most nutritious foods at the front of the line (increase 10-15%)Use descriptive food labels (increase 27%)Give choices of vegetablesUse trays (promotes salad consumption)Shrink the breakfast bowl (decrease serving by 24%)Pull the salad bar away from the wallPut fruit in colorful bowlsSource: Wansink, B. et al. (2010). Lunch line redesign. New York Times. http://www.nytimes.com/interactive/2010/10/21/opinion/20101021_Oplunch.html. The PointServing healthy food increases the chances that people will eat healthy, but it doesnt mean that people will choose itNeed some tricksDiscussion Topics and WorksheetsHow Can You Eat Healthy When You Eat Out?Navigating a Grocery StoreHealthy ChoicesFamily and FoodLesson #6Create positive feelings and mitigate negative ones.Motivation46Types of MotivationNo MotivationExtrinsic MotivationIntrinsic MotivationN/AExternalSomewhat ExternalSomewhat InternalInternalInternalWill not make a change on their ownExternal rewards and punishments, controlled by others

Self-control,ego, avoid guilt, prideAccepted as personally important, value systemBehavior is part of the person, synthesis, outcome basedInterested in behavior, find enjoyment in the processSource: Ryan RM, Deci EL. Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist. 55(2000)68-78.47Ignore the boring visual. I didnt have a fun way of showing this.

We all had motivational interviewing in the general session. We learned the motivation is a state, not a trait. We all know what no motivation looks like. Intrinsic motivation is the opposite. Internal motivation is doing something because you enjoy the process. Tell me something that youre intrinsically motivated to do. You do it because you enjoy the process.

A couple of things about this this isnt something that you either have for your entire life or you do not. It comes and goes with a lot of things. For exercise, a person who has never been interested in exercise before tries out a dance class. They love it. They start going three times a week. They take this class because they love it. The instructor breaks her leg. They replace dance with wait lifting. Our person tries it, doesnt like it and stops exercising. Can somebody give me another example? It doesnt have to be exercise related.

Heres the double edged sword. You cant teach it. By definition, intrinsic motivation comes from within. You can offer classes or healthy food you think may be enjoyable and it might be a catalyst to move someone into intrinsic motivation, but thats something they need to find for themselves.

What you can do is help students move along the line toward higher levels of extrinsic motivation. The rule is, the higher the level, the more likely the person is to continue with the behavior. Theres debate as to whether this is a continuum. The thought process is, people often move along the continuum, however, sometimes situations arise that cause people to enter and exit at different places.

Our lowest level of extrinsic motivation involves getting rewards from others. Like a water bottle or t-shirt. Now, I probably dont have to tell you, this creates an initiation surge of motivation. But something happens quickly. People either revert to no motivation or they climb up the motivation ladder. External rewards just arent enough to keep someone motivated. Its not discounting giveaways. People need a place to start. But they also need a place to grow and they need it quickly.

So, as youre moving up the behavior becomes more internal. Its linked to your ego, your self concept, your value system. And even if its not a hobby, it might be a habit.

Before I tell you, does anyone have any ideas to help students internalize their motivation?

[1] Ryan RM, Deci EL. Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist. 55(2000)68-78.

Support48There are three ways to move students into the higher levels of motivation. Researchers have found that all three of these need to be present to increase motivation.

Support and connectedness is the first step in helping people internalize motivation. You probably already know that kids with strong family connection do better in school. Its the same general concept. Now, most kids who do well are probably not doing well because their parents pay them $10 for each A. Remember, that only fosters the very basic level of motivation. While its not up to you to give them rewards and punishments, a supportive, mentoring and encouraging relationship will help foster motivation. It needs to be approached in the positive.

This goes back to who you select to run your program. Somebody who the students view as caring. This is also where you can incorporate peer support into a program.

ns do better in school. This goes along with some of the things we talked about before about choosing the right leader for the program.

We actually found something interesting in our data collection. Its something that goes against all of the published research out there. We found that programs were more successful if an adult was supporting or mentoring than if students were supporting or mentoring. Peer support normally trumps an adult support set up. What might have happenedTheres a chance that students were told to support each other, but were never trained how to do that. There probably wasnt a peer mentor, just a group of students. Kind of like the blind leading the blind. Perhaps a mix of encouraging peer support and the involvement of staff leadership is the way to go.

Choice and Autonomy49This might sound a little strange. We just talked about how important it is for a student to feel connected. Now were talking about autonomy. They might feel like opposites. Students need to be supported in their choices, but they need to make their own choices.

Think about your motivation at work. How motivated are you when youre working on a project that your boss asks you to do. Its okay hopefully you do it because its your job. You do it mostly for that external reward. Your paycheck. What happens when you have an idea for something new and different to do on your center. You get excited about it. Thats where choice and autonomy comes in. Then, think about how support is incorporated. Your boss likes your idea and maybe gives you some resources to follow through.

How do we relate this to exercise?

Let go of their hand. They need to feel like they are successful with out help. Dont push them to an activity. They need to determine the activity themselves. Focus on choice and opportunities for them to direct themselves.Have a lot of activities available

Foster Competence50Third and finally, to stay motivated, your students have to feel successful.

Foster a feeling of competence. Offer positive feedback and communication. Tell them that they are doing a good job. Congratulate their efforts. Concentrate only on the positive. Do not even think about what they could do better. That will only discourage them. Help them start off slow with something that is easy to masterwalking on the treadmillTell them only what they did rightLook to the futureDiscuss only their accomplishmentsSetting students up to succeedStay away, far away, from threats, deadlines, directives, and imposed goals. Forcing students to participate will not motivate them.Dont make people feel bad about their bodyIn this study, called Fat n Happy, researchers followed 376 adolescent girls in Minneapolis/St. Paul for 5 years. The girls rated their feelings about 10 body parts on a scale of 1-5 (1 = low satisfaction, 5 = high satisfaction). Girls with the highest body satisfaction had the very lowest weight gain. On the flip side, the girls who were least happy with their bodies gained the most weight. The authors hypothesized that those who disliked their bodies had lower self esteem. Those with lower self esteem did not take care of themselves as well as those with higher self esteem. Girls who were unhappy with their body tended to exercise less and eat unhealthy foods.

Think about the project at your job that we just talked about. Your boss liked your idea and offered support, you were given freedom with your project, and you are experiencing initial success with your project. Youre motivated to continue your effort.

What Drives Eating Decisions?HealthTasteCostConvenience Source: OHagan, M. (2011). State still seeks winning strategy against childhood obesity. The Seattle Times. June 20, 2011. 51The Correct OrderTasteCostConvenience HealthSource: OHagan, M. (2011). State still seeks winning strategy against childhood obesity. The Seattle Times. June 20, 2011. 52What Drives Eating Decisions?TasteCostConvenience HealthSource: OHagan, M. (2011). State still seeks winning strategy against childhood obesity. The Seattle Times. June 20, 2011. 53Fiber one is an example of a company that has been successful using health claims to market their product, but is trying to branch out to the much larger audience. Health claims work on those people who want to be healthy, but drive the others away. This commercial is trying to get those people to try the fiber one bars.

http://www.youtube.com/watch?v=59r3mc8Bk5E 54

How did you like your snack?

Unhealthy=Tasty IntuitionPeople enjoy food more if they think its unhealthyBelief about the food affects the experienceSource: Raghunathan, R. (2006). The unhealthy=tasty intuition and its effects on taste inferences, enjoyment, and choice of food products. Journal of Marketing. 70(4), 170-184.

DecadentHealthyWe have a problem here in marketing healthy food. People with all kinds of beliefs about health perceive unhealthy food as tasty. A group of market researchers tested this out at a party. They served traditional Indian food and handed the guests descriptions of each food. All of the guests received the same information, except for the mango lassi. At the end of the party, they were asked to rate the food. The guests who received the card that described the mango lassi as decadent overwhelmingly rated the product higher. Even the people who described themselves as health conscious rated the product higher.57McDonalds McLean Burger

What happens if you label a food lean or light? -Turn away the people

Why do restaurants do this?

So these chains arent making any money off of them?No. There's a lot of cost to develop and introduce these items. They're doing it to broaden their appeal, to cancel out veto votes [when one person resists eating at a restaurant that doesn't offer healthy menu items]. It gives them something to talk about. There are a lot of reasons to do it.

Mintels exclusive consumer research finds that 27% of restaurant-goers are interested in ordering a healthy restaurant meal; yet, 56% order what they want at that moment, rather than whats healthy.

58http://www.youtube.com/watch?v=ZtLyIXxWqBM

Some of this depends on how well healthy eating education is integrated and embraced throughout your center. The whole point of this is that listing calories alone isnt going to get the majority of your students to eat healthy foods. 59Positive Food Exposure Therapy

The HommosThese are the best kabobs ever.

Making an IntroductionCultural nightsTasting partiesCookoutsBody Image

Beauty Boot Camp at Oneonta JCCActivityBody Image WorksheetDiscussionWhat did you get out of this worksheet?/What would a student get out of this worksheet?How could you use this on center?

Lesson #7Focus on skills. Knowledge alone rarely leads to behavior change.Education ChangeHealth education is the most common approach to obesity treatment in clinical practice today despite the absence of empirical support for its efficacy. Education may be necessary but does not appear to be sufficient to promote any lasting change.Source: Powell, L.H. et al. (2007). Effective obesity treatments. American Psychologist. 62(3); 234-246.Take a Different Perspective

Perspective ChangeWhen knowledge alone rarely leads to behavior change what do we do?Change your perspectiveSmall changes should become habits and become a way of life

Like julie pointed out before, these short term biggest loser type competitions are not enough for many to make these practices a way of life. Eating healthy foods and exercise for only a few weeks or even months will not always give you long-term, successful weight loss.

Its only thing to know about health, nutrition, working out but its another to master a skill. Lowering fat intake, walking 2 miles every other day, eat 3 fruits and vegetables per day.

The Mayo Clinic says http://www.mayoclinic.com/health/weight-loss/HQ01625/NSECTIONGROUP=2

69Supportive Environment Now and LaterIndividuals with obesity receive numerous instructions about what to do to address their weight, but very few are given appropriate long-term guidance or support with which to follow through those instructions Understanding the positive role of social networks may be particularly important in engaging individuals in physical activity Source: They all work...when you stick to themIn Job corps they may have a supportive network/group. What about when they leave? Use facebook, blogs, twitter to create a support network that can help keep you on track, go for a walk with you, recommend fun activities or local groups that meet. Use twitter, facebook, online supportive networking tools

The Internet also affords a means of giving and receiving social support and sharing information and personal experiences with others through participation in online communities (The impact of Internet use for weight loss- Saperstein)

70Now What?Often times students learn basic nutritional information but why not teach them to cook?Others may be afraid to try new foods

But back to what you can do to help students now while they are on center. Many times students will have a basic understanding of nutrition with terms like fat, carbohydrates and protein but do they know how to make nutritious food? If you walked into a super market and did not know what these weird things are would you buy them and know what to do with them or how to eat them? I know I wouldnt! (lets watch this short video from Jamie Oliver)71Jamie Oliver Video

72Navigating the Grocery StoreWhat we can do in Job Corps? We can use HEALsThe Grocery store fieldtrip suggestion in the heals toolkit

So we have seen that kids today do not know how to cook even the most basic meal how can we expect them to have proper nutrition? How can we ask them to eat healthy and be active when they graduate from Job Corps if we do not give them the skills to success. This can be an ideal thing to incorporate in CTT. Its located in HEALs online as well. 73Navigating the Grocery Store

Post Field Trip ReflectionDid the cost of any item(s) surprise you? If so, which item(s)? Which items were the least expensive? Generic? Small containers? Sale items?Would you always buy the least expensive item? What other factors might you take into consideration?If you were to double this recipe (i.e., make it twice), how do you think it would affect the cost?You may have leftovers of some of your ingredients after you make the recipe. What could you do with the leftover ingredients?Would you consider your recipe healthy? Why or why not?How much do you think this meal would cost if you purchased it in a restaurant?How confident do you feel that you will be able to grocery shop for recipe ingredients after you leave Job Corps?

74Lesson #8Small victories.Nothing Succeeds Like SuccessGoal Setting: Think again to SMART goals to set yourself up for success and not failureConsecutive goals that move you ahead in small steps are the best way to reach a distant pointConsecutive rewards keep the overall effort invigoratedPart of the WE CAN! Program from nhlbiMeasuring success as weight loss only is setting them up for failure. Having small obtainable goals are great but what happens when you reach them? Should you celebrate them all?

Part of the WE CAN! Program from http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/behavior.htm76RewardsReward Success (But Not With Food!!)A movie or music CD, or a payment toward buying a more costly itemDefine SuccessStepping on the scale daily vs. trying on an old pair of jeans you want to wear again.

An effective reward is something that is desirable, timely, and dependent on meeting your goal. The rewards you choose may be material (e.g., a movie or music CD, or a payment toward buying a more costly item) or an act of self-kindness (e.g., an afternoon off from work or just an hour of quiet time away from family). Frequent small rewards, earned for meeting smaller goals, are more effective than bigger rewards that require a long, difficult effort.

How do you define success or how would you like to? Do you every get frustrated seeing a number or not seeing a number on a scale what about when you try on your old jeans that you want to fit again? Scale does not change more than a few pounds but now you can zip those jeans. Can you feel that success?77Fighting the FightWe as humans are programmed to eat, we are pleasure seekersBut if we are able to teach ONE new skill or healthy behavior, we should consider it a success.

Lets set ourselves and the students up to succeed. Maybe taking 1 thing away with them when the graduate like learning to cook, learning nutrition skills, exercising via WII, starting a new sport can be a win

What are you currently doing on center to reward successes?

Anything specific that you learned that you can take back to your centers from today's discussion? 78Supportive EnvironmentJob Corps is the environment in which to make positive health changesGiving students a solid foundation at the center is the best way to start in an supportive environmentKeep in mind things are sometimes beyond our control

go but remember not to set yourselves up to fail. 79