Partial Meal Replacement Program

THE PARTIAL MEAL REPLACEMENT PROGRAM

Welcome to the Partial Meal Replacement Program ...... A-1 Eating Healthfully One Plate at a Time –– The Plate Method ...... B-1 Creating a Healthy Lifestyle ...... C-1 Change, Fluids and Alcohol, What Do I Need to Change? ...... D-1 Label Reading ...... E-1 Gut-Brain and Healthy Cooking...... F-1 Fiber – Fiber Facts ...... G-1 Choosing Healthful Fats and Oils – All About Fats ...... H-1 Menu Planning: Putting Together Healthy Meals ...... I-1 Dealing with Stress ...... J-1 Phytonutrients and Antioxidants ...... K-1 Healthy Shopping and Sugar Substitutes...... L-1 Being Assertive ...... M-1 My Body Image: Writing Assignment ...... N-1 Fit for My Life...... O-1 Dining Out and Travel...... P-1 Maintaining A Healthy Lifestyle ...... Q-1 Eating Mindfully...... R-1 Resistance Training...... S-1 Healthy Lifestyle Support Resources ...... T-1 Program Evaluation ...... U-1

Each session begins with the session title and the following points: GOALS — Information to help me understand the purpose of the topic and set goals to achieve positive change in my life. PLANS — A variety of materials encourage me to make plans to achieve my goals. CHALLENGES — Identifying obstacles in the way I think, feel, believe, and behave that may prevent me from achieving my goals and strategies to overcome those challenges. TOPICS — Each session includes information pertinent to the topic as well as other helpful information. • The more time and effort I put into each topic, the more I will get out of it. • I will take time to read through the material, practice the various techniques suggested and reflect on what I have done or learned at the completion of the topic. • I will be sure to bring The Partial Meal Replacement Guidebook to group each week.

Revised: 10/3/2019

WELCOME TO THE PARTIAL MEAL REPLACEMENT PROGRAM!

CLASS • Be prepared to exercise! Every Partial Meal Replacement session will include exercise. Please bring or wear close-toed comfortable shoes to wear during the exercise portion of the class. • Please bring your Partial Meal Replacement Guidebook binder to group each week.

GOALS What Can the Partial Meal Replacement Program Do? • Help you meet your health and social needs if you have 10 to 40 pounds to lose. • Provide you with strategies for weight loss and weight management without feelings of food deprivation. • Assist you in a behavioral change process focusing on nutrition, exercise, and a variety of behavior modification tools. • Allow you to have a place for encouragement and support of other participants in your group. Fellow group members can help motivate you along the way to the lifestyle changes you will need to be successful.

PLANS • Follow the workout plan. Begin, increase, or enhance your formal exercise program. • Follow the Partial Meal Replacement eating plan. • Keep Daily Behavior Records the first week of the program. • Complete the Request for Support form p.19 for everyone in your life who can help support you (and/or sabotage your efforts). • Review The Partial Meal Replacement Program Responsibilities. • Identify new strategies to overcome your problem areas.

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Your body stores energy in your muscles, liver and fat cells. On the Partial Meal Replacement program we desire that you lose the energy stored in your fat cells or lose fat weight. Weight loss simply refers to a lower number on a scale. Fat loss is much more complicated than weight loss — it involves a process where the body starts to breakdown fat cells and convert them into energy the body can use. The only way to burn fat is through proper nutrition and exercise. In some cases, you can lose fat and maintain the same body weight, or even gain weight in the form of muscle. Don’t panic if this happens to you. If you’re losing inches, you’re losing fat weight.

On the Partial Meal Replacement eating plan you will be consuming approxiamately 1100 to 1300 calories, which is a caloric reduction for most people coming into the Partial Meal Replacement program. When calories decrease, your body is forced to find alternative fuel sources to burn for energy. Ideally, your body would ONLY burn your stored body fat as an alternative fuel source, however, most often your body will burn your muscle tissue, leaving fat tissue alone for survival purposes. Exercise will help you maintain your lean muscle tissue so your body will pull stored energy from the fat cells.

MONITOR It’s important to know your measurements and how much of your weight is deposited as either fat or lean muscle tissue. During the Body Analysis appointment before the program, your weight and initial measurements were taken. Use the following chart to keep track of your weight and measurements during the program. Your counselor can measure your inches around your waist and hips during the Partial Meal Replacement Program to make sure you are losing inches.

Date: Date: Date: Weight

Waist (inches)

Hip (inches)

At the end of the program your measurements along with a body fat test will be completed at the Re-Test Body Analysis appointment. After finishing 18 weeks of Partial Meal Replacement call the Positive Choice Appointment line at (858) 616-5600 to schedule your Re-Test appointment.

In addition to the Body Analysis appointments, Positive Choice can assist you in measuring your body composition. The SECA Body Composition Analyzer, now available at Positive Choice, measures body composition using many frequencies of electro-magnetic waves, making it the most accurate measurement of body composition available today.

Partial Meal Replacement participants can take advantage of these two services: • The SECA Basic Analysis Includes: measurement of body fat, muscle mass, fluid balance, energy needs, and cellular health. Check out positivechoice.org for pricing.

• The SECA Special Includes: 3 measurements; a baseline, a midway, and a follow-up that can help you see if you have enough muscle mass for long-term maintenance success. Check out positivechoice.org for pricing. A- 2

To schedule a SECA Body Composition Test call the Positive Choice Department at (858) 616-5600. It is recommended that you share the results of your SECA test(s) with your Partial Meal Replacement Counselor. The SECA services are optional for Partial Meal Replacement participants.

THE PARTIAL MEAL REPLACEMENT WORKOUT PLAN IS DESIGNED SPECIFICALLY TO: • Maximize your fat loss while maintaining muscle. • Enhance fat utilization for fuel during and after exercise. • Promote increased cardiovascular fitness and muscular strength. • Provide adequate recovery which decreases the risk of injury from overtraining as well as burnout. • Achieve a mental sense of accomplishment.

HOW TO MOST EFFECTIVELY USE THE WORKOUT PLAN:

The Partial Meal Replacement Workout Plans A, B and C are designed to increase your VO2, improve your aerobic base and anaerobic threshold, and enhance strength.

• Workouts are best completed in the order they are written. If you must change the order of things, try to avoid back to back strength days, as well as back to back interval days. • Each week there will be one to two Active Recovery days. These are very important as it lets your body absorb the training from the week and adapt. • Try to avoid missing workouts as much as possible. However, in the event you miss a workout, don't feel the need to make up for it and double up on the next day. Simply move on with the plan! If you are constantly missing workouts, reprioritize and do your best to make time to get them in. It will be WELL worth it! • Strength workout ideas can be found on our website, positivechoice.org, under the exercise and fitness menu.

KEEPING RECORDS Research shows that those who keep track of their intake and exercise are more successful with weight loss and weight maintenance than those who don’t. For Exercise: When you’ve completed your workouts for the week, check off the box at the end of the row on workout schedule A, B or C that says Done! Show your exercise record to your counselor for feedback. For Eating and Exercise: The first week of the program you are required to fill out five days of Daily Behavior Records found on pages 23 to 30. In addition, your counselor may suggest that you record your food intake and exercise on pages 12 and 13 for additional support during the program. For exercise, all participants are asked to keep track of their activity on the Partial Meal Replacement Workout Plan A (Monday classes), B (Tuesday classes) or C (Wednesday classes) by marking the box Done! at the end of the week. Show your records to your counselor for feedback.

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Partial Meal Replacement Workout Plan A Goal = 2.5-5 Hours (150-300 Minutes) each Week WK Mon Tues Wed Thurs Fri Sat Sun Time Done!

1 ST 20 CVM 30 CVL 50 AR CVM 30 ST 20 AR 150 MINS MINS MINS MINS

2 ST 20 CVM 30 CVL 50 AR CVM 30 ST 20 AR 150 MINS MINS MINS MINS

3 ST 20 CVM 45 CVL 50 AR CVM 35 ST 20 AR 170 MINS MINS MINS MINS

4 ST 20 CVM 45 CVL 50 AR CVM 35 ST 20 AR 170 MINS MINS MINS MINS

5 ST 20 CVM 50 CVL 60 AR CVM 40 ST 20 AR 190 MINS MINS MINS MINS

6 ST 20 CVM 50 CVL 60 AR CVM 40 ST 20 AR 190 MINS MINS MINS MINS

7 ST 20 CVM 50 CVL 60 AR CVM 45 ST 20 AR 220 MINS MINS MINS MINS CVM 25

8 ST 20 CVM 50 CVL 60 AR CVM 45 ST 20 AR 220 MINS MINS MINS MINS CVM 25

9 ST 20 CVM 50 CVL 60 CVH 20 CVM 45 ST 20 AR 240 MINS MINS MINS MINS MINS CVM 25

10 ST 20 CVM 50 CVL 60 CVH 20 CVM 45 ST 20 AR 240 MINS MINS MINS MINS MINS CVM 25

11 ST 20 CVM 55 CVL 60 CVH 40 CVM 45 ST 20 AR 270 MINS MINS MINS MINS MINS CVM 30

12 ST 20 CVM 55 CVL 60 CVH 40 CVM 45 ST 20 AR 270 MINS MINS MINS MINS MINS CVM 30

13 ST 20 CVM 55 CVL 65 CVH 40 CVM 45 ST 20 AR 280 MINS MINS MINS MINS MINS CVM 35

14 ST 20 CVM 55 CVL 65 CVH 40 CVM 45 ST 20 AR 280 MINS MINS MINS MINS MINS CVM 35

15 ST 20 CVM 55 CVL 70 CVH 40 CVM 45 ST 20 AR 290 MINS MINS MINS MINS MINS CVM 40

16 ST 20 CVM 55 CVL 70 CVH 40 CVM 45 ST 20 AR 290 MINS MINS MINS MINS MINS CVM 40

17 ST 20 CVM 55 CVL 70 CVH 50 CVM 45 ST 20 AR 300 MINS MINS MINS MINS MINS CVM 40

18 ST 20 CVM 55 CVL 70 CVH 50 CVM 45 ST 20 AR 300 MINS MINS MINS MINS MINS CVM 40

Cardiovascular Exercise: Refers to activities that elevate your heart rate for the duration of the workout. Try brisk walking, jogging, cycling, swimming, hiking, elliptical and/or playing sports. CVL - Cardiovascular Long Easy — Keep your intensity in the conversational zone throughout the workout, or about a 5-6 on a scale of 1-10. You should not be able to sing. CVM - Cardiovascular Moderate — Your intensity should be at about a 6-7 on a scale of 1-10. You're pushing it a bit, but can still sustain the effort for a prolonged period. CVH - Cardiovascular Hard — After an easy 5 min warm up, push the intensity beyond your comfort zone, or an 8-9 on a scale of 1-10. You can still talk, but with pauses between sentences. The duration will be shorter to account for the higher effort. ST – Strength Training — Use free weights, resistance bands, machines or body weight exercises. Be sure to overload the muscles so you are slightly sore the next day. AR – Active Recovery — Continue to move more and sit less, but take a break from working out.

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc Partial Meal Replacement Workout Plan B Goal = 2.5-5 Hours (150-300 Minutes) each Week WK Mon Tues Wed Thurs Fri Sat Sun Total Time Done!

1 CVM 30 ST 20 CVM 30 AR ST 20 CVL 50 AR 150 MINS MINS MINS MINS

2 CVM 30 ST 20 CVM 30 AR ST 20 CVL 50 AR 150 MINS MINS MINS MINS

3 CVM 35 ST 20 CVM 45 AR ST 20 CVL 50 AR 170 MINS MINS MINS MINS

4 CVM 35 ST 20 CVM 45 AR ST 20 CVL 50 AR 170 MINS MINS MINS MINS

5 CVM 40 ST 20 CVM 50 AR ST 20 CVL 60 AR 190 MINS MINS MINS MINS

6 CVM 40 ST 20 CVM 50 AR ST 20 CVL 60 AR 190 MINS MINS MINS MINS

7 CVM 45 ST 20 CVM 50 AR ST 20 CVL 60 AR 220 MINS MINS MINS CVM 25 MINS

8 CVM 45 ST 20 CVM 50 AR ST 20 CVL 60 AR 220 MINS MINS MINS CVM 25 MINS

9 CVM 45 ST 20 CVM 50 CVH 20 ST 20 CVL 60 AR 240 MINS MINS MINS MINS CVM 25 MINS

10 CVM 45 ST 20 CVM 50 CVH 20 ST 20 CVL 60 AR 240 MINS MINS MINS MINS CVM 25 MINS

11 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL 60 AR 270 MINS MINS MINS MINS CVM 30 MINS

12 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL 60 AR 270 MINS MINS MINS MINS CVM 30 MINS

13 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL 65 AR 280 MINS MINS MINS MINS CVM 40 MINS

14 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL 65 AR 280 MINS MINS MINS MINS CVM 40 MINS

15 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL 70 AR 290 MINS MINS MINS MINS CVM 40 MINS

16 CVM 45 ST 20 CVM 55 CVH 40 ST 20 CVL AR 290 MINS MINS MINS MINS CVM 40 70MINS

17 CVM 45 ST 20 CVM 55 CVH 50 ST 20 CVL 70 AR 300 MINS MINS MINS MINS CVM 40 MINS

18 CVM 45 ST 20 CVM 55 CVH 50 ST 20 CVL 70 AR 300 MINS MINS MINS MINS CVM 40 MINS

©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc Partial Meal Replacement Workout Plan C Goal = 2.5-5 Hours (150-300 Minutes) each Week WK Mon Tues Wed Thurs Fri Sat Sun Total Time Done!

1 CVM 30 CVM 30 ST 20 AR ST 20 CVL 50 AR 150 MINS MINS MINS MINS

2 CVM 30 CVM 30 ST 20 AR ST 20 CVL 50 AR 150 MINS MINS MINS MINS

3 CVM 35 CVM 45 ST 20 AR ST 20 CVL 50 AR 170 MINS MINS MINS MINS

4 CVM 35 CVM 45 ST 20 AR ST 20 CVL 50 AR 170 MINS MINS MINS MINS

5 CVM 40 CVM 50 ST 20 AR ST 20 CVL 60 AR 190 MINS MINS MINS MINS

6 CVM 40 CVM 50 ST 20 AR ST 20 CVL 60 AR 190 MINS MINS MINS MINS

7 CVM 45 CVM 50 ST 20 AR ST 20 CVL 60 AR 220 MINS MINS MINS CVM 25 MINS

8 CVM 45 CVM 50 ST 20 AR ST 20 CVL 60 AR 220 MINS MINS MINS CVM 25 MINS

9 CVM 45 CVM 50 ST 20 CVH 20 ST 20 CVL 60 AR 240 MINS MINS MINS MINS CVM 25 MINS

10 CVM 45 CVM 50 ST 20 CVH 20 ST 20 CVL 60 AR 240 MINS MINS MINS MINS CVM 25 MINS

11 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL 60 AR 270 MINS MINS MINS MINS CVM 30 MINS

12 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL 60 AR 270 MINS MINS MINS MINS CVM 30 MINS

13 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL 65 AR 280 MINS MINS MINS MINS CVM 40 MINS

14 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL 65 AR 280 MINS MINS MINS MINS CVM 40 MINS

15 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL 70 AR 290 MINS MINS MINS MINS CVM 40 MINS

16 CVM 45 CVM 55 ST 20 CVH 40 ST 20 CVL AR 290 MINS MINS MINS MINS CVM 40 70MINS

17 CVM 45 CVM 55 ST 20 CVH 50 ST 20 CVL 70 AR 300 MINS MINS MINS MINS CVM 40 MINS

18 CVM 45 CVM 55 ST 20 CVH 50 ST 20 CVL 70 AR 300 MINS MINS MINS MINS CVM 40 MINS

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GUIDELINES FOR SUCCESS ON A PARTIAL MEAL REPLACEMENT

1. Always use all four packets of the OPTIFAST 800 supplement plus the recommended food at regular three to four hour intervals, with no more than five hours elapsing between them. 2. Take all of your shakes. Drinking less does not result in a more rapid weight loss. Fewer shakes lower the metabolism so that fewer calories are utilized. 3. Prepare the supplement by mixing one packet with 8 to 10 ounces of cold water or other non-caloric beverage such as diet soda or sparkling flavored water. The supplement tastes best when mixed in a blender. Add ice to the mixture, before blending, to give it a frothier texture. If you don't use a blender, be sure to mix the supplement until it is well blended. Be careful when using carbonated beverages in a shaker; they can easily explode. The supplement may form clumps if you allow it to sit too long after mixing and may need to be re-mixed. You may want to mix it just before you plan to consume it. The supplement can be warmed gently, if desired. 4. You can purchase a small battery operated portable mixer or portable blender to use when a regular blender is not handy. They are available at most discount and drug stores. 5. Store supplement packets at room temperature. However, once you mix the supplement, refrigerate and consume it within 24 hours. 6. Be sure to wash your shaker, glass, and blender thoroughly after each use. 7. Drink a total of eight 8 oz. glasses of fluid per day. This includes the liquids used to mix the OPTIFAST 800 supplement. 8. Limit your intake of caffeinated beverages to no more than 16 oz a day. 9. If necessary, have up to two servings per day of the chicken bouillon in addition to the supplements. Bouillon can be purchased at the front desk. 10. Have no more than three servings of artificial sweetener per day. A serving is equal to one 12 oz. can of diet soda or one packet of artificial sweetener. 11. Do not take potassium supplements. Potassium is contained in the supplement. 12. To prevent constipation, include one of the following fiber sources daily: NutriSOURCE™ (sold at Positive Choice) 1–2 tablespoons of Miller's Bran™ Sugar-free Metamucil™, as directed 14. If you are taking vitamin supplements, please review them with your counselor.

15. Each OPTIFAST 800 supplement contains: 160 calories 14 grams of protein 3 grams of fat 20 grams of carbohydrate 230 milligrams of sodium

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc PARTIAL MEAL REPLACEMENT PROGRAM THINGS TO KNOW WHEN CHECKING IN WEEK TWO

▪ The OPTIFAST 800 supplement shakes are available in vanilla, chocolate, and strawberry. Soups are available in creamy chicken and creamy tomato and bars are available in apple cinnamon, chocolate and peanut butter chocolate. Select your flavors ahead of time so you can let the receptionist know your choices when you check in. ▪ You will receive four boxes of the OPTIFAST 800 supplement each week starting the second week of the program. Three of your boxes choices need to be supplemental shakes, the fourth can be a shake, soup or bar. ▪ We recommend you purchase an extra box on your first or second week of the meal replacement so you can have extras on hand in case of an emergency. It is helpful to store a few extra packets in your desk, car and other appropriate places. ▪ Your counselor will give you the OPTIFAST 800 supplement at the end of your group each week.

SOUP ▪ New Direction® Fulfill Bouillon Chicken Flavored soup is available and you can consume up to two servings a day in addition to your four daily OPTIFAST 800 supplements. ▪ For some people with pre-existing medical conditions, the soup will be a required addition and an essential part of your program for medical reasons. You will be notified by the medical personnel if this applies to you. ▪ Soup is ordered at the same time as your regular OPTIFAST 800 supplements.

FIBER ▪ Dietary fiber helps promote and maintain normal bowel function. You will receive fiber in the foods prescribed to be eaten in combination with your OPTIFAST 800 supplements, but some may find that the fiber amount is not enough for their bowels to move regularly. If you need extra fiber, NutriSOURCE® Fiber is available for purchase at Positive Choice and offers an easy way to add fiber without the flavor or texture you get from many other fiber supplements. NutriSOURCE, a soluble dietary fiber, has been processed to easily mix with beverages. Each tablespoon of NutriSOURCE adds three grams of fiber to your diet.

LAB WORK • Blood lab work is required beginning on the third week, and every three weeks thereafter, to ensure medical safety while you are on the OPTIFAST 800 supplement. For some people, additional blood lab work may be required. The medical staff will notify you if this applies to you. • Lab work can be completed at Positive Choice just prior to your scheduled group or it can be done at any other San Diego Kaiser Permanente Lab within 24 hours of your group. (Kaiser Permanente members only. Nonmembers must have lab work done at the Positive Choice Integrative Wellness Center.)

IF YOU HAVE ANY QUESTIONS, PLEASE ASK YOUR COUNSELOR!

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The Partial Meal Replacement is a well-balanced food plan that combines a nutritious supplement with self-prepared food. The approximate daily total caloric intake is listed below for each week. The Partial Meal Replacement is designed to help you learn how to manage portion sizes, and select nutritious foods. Weekly product purchase to maintain 4 servings of Optifast 800 is mandatory through week 10, or until a BMI of 18.5 to 24.9 is reached. Five days of daily behavior records are required to be turned in the first week. After week 1 you may stay on four servings a day of Optifast 800 supplements until week 16 of your program. If you would like to transition off the product before week 16, the following table shows how and when to eliminate the product, while simultaneously introducing food. Talk to your counselor about your preference. See page 10 for suggested foods to consume from each food group listed below. Product and Week 1- 2 Weeks 2-14 Weeks 14-15 Weeks 15-16 Weeks 16-17 Food Group and 17-18 OPTIFAST 800 0 4 3 2 1 Lean Proteins 12 oz. 4 oz. 8 oz. 10 oz. 12 oz. Vegetables minimum 4 minimum 4 - minimum 4 - minimum 4 - minimum 4 - - unlimited unlimited unlimited unlimited unlimited Fruits 3 1 2 2 2 Grains/Legumes/Starchy 2 1 1 2 2 Vegetables Healthy Fats 4 1 2 3 4 Milk/Soymilk/Yogurt 2 0 0 0 1 Calories 1340 1105 1230 1285 1250

At week 16, your counselor will change your status to per box rate. This means that you are no longer obligated to purchase four boxes of product each week. Per box rate allows you the flexibility to purchase the two extra boxes (14 packets) of product you’ll need to complete weeks 16 and 17 (Please note that you will lose the four box a week bundled price break when you change to per box rate.)

Transferring from the OPTIFAST 800 supplements to food: • Continue to eat at regular intervals. • Use the Plate Method, found in the Eating Healthfully section, to transfer from Optifast 800 to food. • Replace OPTIFAST 800 with the specific foods recommended on the food plan. • Be conscious of what you are eating. • Be sure to taste your food. Note: This program is designed to maximize weight loss. Please do not substitute or include foods not on the plan. A- 9

Suggested Food and Timing Optifast 800® Partial Meal Replacement Program

7 am 10 am 1 pm 4 pm 7 pm Week 1-2 2 oz. protein 1 fruit 4 oz. protein 4 oz. protein 2 oz. protein and 17-18 1 fruit 1 healthy fat 2 cups 2+ cups 1 fruit 1 grain vegetables vegetables 1 milk/soymilk/ 1 healthy fat 1 grain 1 healthy fat or yogurt 1 milk/soy 1 healthy fat Calories 1340 milk/or yogurt Weeks 2–14 OPTIFAST 800 OPTIFAST 800 OPTIFAST 800 4 oz. protein OPTIFAST 800 1 grain 1 fruit 2 cups salad 1 healthy fat 2 cups cooked Calories 1,105 vegetables Weeks 14-15 2 oz. protein OPTIFAST 800 OPTIFAST 800 4 oz. protein OPTIFAST 800 1 fruit 2 oz. protein 2 cups salad 1 grain 1 fruit 2 cups cooked 1 healthy fat vegetables Calories 1230 1 healthy fat Weeks 15-16 2 oz. protein OPTIFAST 800 4 oz. protein 4 oz. protein OPTIFAST 800 1 fruit 2 cups salad 2 cups cooked 1 fruit 1 grain 1 grain vegetables 1 healthy fat 1 healthy fat 1 healthy fat Calories 1285 Weeks 16-17 2 oz. protein OPTIFAST 800 4 oz. protein 4 oz. protein 2 oz. protein 1 fruit 1 healthy fat 2 cups salad 2 cups cooked 1 fruit 1 grain 1 grain vegetables 1 healthy fat 1 healthy fat 1 healthy fat 1 milk/soy milk/ Calories 1250 or yogurt

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc FOODS TO CONSUME FROM EACH FOOD GROUP LEAN PROTEIN (or Meat) Servings Vegetarian - Count as Protein and Grain, 3 Tbsp = 1 oz. Beef – Sirloin, Flank or Round Trimmed Beans (Pinto, Black, etc.) Chicken Breast Lentils Cottage Cheese, ¼ c = 1 oz. Legumes Cream Cheese, Fat Free, 2 Tbsp = 1 oz Quinoa Egg Whites, 3 = 1 oz Soybeans Fish, Wild – all kinds Split Peas Pork Loin Tofu Turkey Breast Veggie Meats (Burgers, Lunch Meat, etc)

GRAIN/LEGUME/STARCHY VEG. —maximum 100 calories and minimum of 5 grams Fiber per Serving GRAIN LEGUMES - Count as Protein and Grain, 3 Tbsp = 1 oz. STARCHY Bagel Thin, whole wheat Beans (Pinto, Black, etc.) VEGETABLES Barley, ½ c Hummus ½ cup = 1 serving Bread, whole wheat, 1 slice Lentils of any of the Cereal (5 to 15 grams Fiber), ¾ c Legumes following: English Muffin, whole wheat Quinoa Butternut Squash Oatmeal, 2/3 c cooked Soybeans Corn Pita, whole wheat Split Peas Peas (green) Rice, Brown, 1/3 c cooked Tofu Sweet Potatoes Tortilla, corn or whole wheat Veggie Meats Yams

VEGETABLES – ½ cooked = 1 serving. All Non-Starchy vegetables are allowed, including the following list: Artichokes Fennel Peppers* Arugula Garlic Radishes Asparagus Green beans Snow peas Beets Jicama Spaghetti squash Broccoli* Kale* Spinach Brussels sprouts* Leeks Summer squash Carrots Lettuce, romaine Tomatoes* Cauliflower* Mushrooms Zucchini Eggplant Onions Water chestnuts

SALAD A salad containing approximately 2 cups of dark green, leafy vegetables, (Arugula, Endive, Escarole, Romaine, and/or Spinach), a minimum of ½ cup of added vegetables (see above), should be consumed once a day. You may use up to 20 calories of non-fat salad dressing, vinegar, lemon juice, or salsa for your salad. *These vegetables may cause excess gas and indigestion. If you have a problem, switch to the other vegetable choices until your body adjusts. FRUIT 1 cup, or 1 piece that fits into the palm of your hand = 1 serving Apple Dates Mangos Plums Apricots Figs Melons (cantaloupe, watermelon, etc.) Pineapple Bananas Grapes Oranges Pomegranate Berries Grapefruit (1/2) Peaches/Nectarines Strawberries Cherries Kiwi Pears Tangerines

MILK - Be sure each serving provides 8 to 20 g protein and no more than 100-120 calories. 8 oz or 1 cup = 1 serving of any of the following: 1% or Nonfat Milk Soymilk Yogurt

HEALTHY FATS Avocado (⅛ avocado) Nuts-all kinds (6-10) Oil (Canola or Olive) (1 tsp.) Chia Seeds (1/8 cup) Nut Butters- Peanut, Almond, etc.(2 tsp.) Sunflower Seeds (1/8 cup) Flax Seeds (1/8 cup) Olives (6) Sesame Oil (1 tsp.)

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Food/Exercise Records for Weeks # 2 to 10 – 4 Supplements/Day Name:______

Daily Lean Vegetables Fruits Grains/ Healthy Fats Milk/Yogurt Opti 800 Water/ Calories Proteins Legumes/ Non- Caloric minimum 4 – Starchy Veg. Fluids. # of unlimited 8-oz. 1105 cal 4 oz. servings 1 serving 1 serving 1 serving 0 serving 4 servings servings Monday

Date:____

Tuesday

Date:____

Wed.

Date:____

Thursday

Date:____

Friday

Date:____

Saturday

Date:____

Sunday

Date:____

Calories

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Off Cardio Exercises Off Weight Training

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc Food/Exercise Records for Maintenance – 0 Supplements/Day Name:______Water/ Daily Lean Vegetables Fruits Grains/ Healthy Fats Milk/Yogurt Opti 800 Non- Calories Proteins Legumes/ Caloric Fluids. minimum 4 – Starchy Veg. # of 8-oz. unlimited servings 1340 cal 12 oz servings 3 servings 2 servings 4 servings 2 servings 0 servings Monday

Date:____

Tuesday

Date:____

Wed.

Date:____

Thursday

Date:____

Friday

Date:____

Saturday

Date:____

Sunday

Date:____

Calories

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Off Cardio Exercises Off Weight Training

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc SUGGESTED SAMPLE MENUS AND TIME FRAMES Week 1 and Maintenance 7 am 10 am 1 pm 4 pm 7 pm Week 1 and 2 oz. protein 1 fruit 4 oz. protein 4 oz. protein 2 oz. protein Maintenance 1 fruit 1 healthy fat 2 cups 2+ cups 1 fruit 1 grain vegetables vegetables 1 milk/soymilk/ 1 healthy fat 1 grain 1 healthy fat or yogurt 1 milk/soy 1 healthy fat milk/ or yogurt

Servings Approximate Fat Fiber Protein Calories (g.) (g.) (g.)

7 AM 2 oz. protein 4 egg whites, or ½ cup liquid 70 0 0 16 egg whites 1 fruit 1 small banana 60 0 2 0 1 grain/legume/st.veg ½ c. Fiber One™ cereal 60 1 14 2 1 healthy fat ⅛ cup almonds 45 5 2 1 1 milk/yogurt 8 oz. soy milk 90 1 0 8

10 AM 1 fruit 1 apple 60 0 6 0 1 healthy fat 2 tsp. natural peanut butter 100 8 1 1

1 PM 4 oz. protein 4 oz. chicken breast 140 8 0 28 2 cups vegetables 1 c. raw carrots 50 0 6 1 mushrooms, lettuce, tomato 1 grain/legume ½ cup quinoa 100 1 4 3 1 healthy fat ⅛ avocado 45 5 0 0

4 PM 4 protein/meat 4 oz. baked salmon/halibut 220 12 0 28 2 vegetables 2 ½ c. salad/1 tbsp. 50 0 3 0 non-fat dressing

2 vegetables 1 c. steamed broccoli 25 0 3 0

1 healthy fat 1 tsp. olive oil 45 5 0 0

7 PM 2 protein 1 cup cottage cheese 70 0 0 14 1 fruit 1 cup berries 60 0 3 0 1 milk/yogurt 8 oz. Greek yogurt 100 1 0 8 Calories Fat Fiber Protein 1,340 47 44 137

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SUGGESTED SAMPLE MENUS AND TIME FRAMES

Weeks 2-10

Weeks 2-10 OPTIFAST 800 OPTIFAST 800 OPTIFAST 800 4 oz. protein OPTIFAST 800 1 grain 1 fruit 2 cups salad 1 healthy fat 2 cups cooked vegetables

4 OPTIFAST 800 supplements per day 3–4 oz. lean protein 2 or more cups cooked or raw vegetables 2 or more cups leafy green salad with ½ cup free vegetables per day and appropriate salad dressing 1 fruit 1 grain/legume/starchy vegeatable 1 healthy fat

7 AM OPTIFAST 800 supplement 1 grain ½ c. Fiber One™ cereal 1 healthy fat 1/8 cup almonds

10 AM OPTIFAST 800 supplement

1 PM OPTIFAST 800 supplement 1 fruit 1 cup blueberries

4 PM 4 protein/meat 4 oz. baked salmon/halibut 2 vegetables 2½ c. salad/1 tbsp non-fat dressing

2 + vegetables 2 c. steamed broccoli

7 PM OPTIFAST 800 supplement

* NOTE: EAT FOOD AND DRINK SUPPLEMENTS AT REGULAR INTERVALS. SEE YOUR COUNSELOR TO ADJUST EATING TIMES TO FIT YOUR PERSONAL NEEDS.

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SUGGESTED SAMPLE MENUS AND TIME FRAMES

Weeks 11-13

Weeks 11-13 2 oz. protein OPTIFAST 800 OPTIFAST 800 4 oz. protein OPTIFAST 800 1 fruit 2 oz. protein 2 cups salad 1 grain 1 fruit 2 cups cooked 1 healthy fat vegetables 1 healthy fat

7 AM 2 oz. protein 6 egg whites 1 fruit 1 small banana 1 grain/legume/st.veg ½ c. Fiber One™ cereal 1 healthy fat ⅛ cup almonds

10 AM OPTIFAST 800 supplement

1 PM OPTIFAST 800 supplement 2 proteins 1 cup cottage cheese 1 fruit 1 fresh orange

4 PM 4 protein/meat 4 oz. baked salmon/halibut 2 vegetables 2½ c. salad/1 tbsp non-fat dressing

2 + vegetables 2 c. roasted Brussels sprouts

7 PM OPTIFAST 800 supplement

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Suggested Food and Timing Optifast HP® Partial Meal Replacement Program

Note: As an alternative to Optifast 800®, Optifast High Protein (HP) may be medically prescribed. This plan is only to be used by those taking Optifast HP.

7 am 10 am 1 pm 4 pm 7 pm Week 1 and 2 oz. protein 1 fruit 4 oz. protein 4 oz. protein 2 oz. protein Maintenance 1 fruit 1 healthy fat 2 cups 2+ cups 1 fruit 1 grain vegetables vegetables 1 milk/soymilk/ 1 healthy fat 1 grain 1 healthy fat or yogurt 1 milk/soy 1 healthy fat milk/or yogurt Weeks 2–11 OPTIFAST HP OPTIFAST HP 1 fruit 4 oz. protein OPTIFAST HP 1 grain 1 healthy fat 2 cups salad 1 healthy fat 2 cups cooked vegetables Weeks 2 oz. protein OPTIFAST HP 2 oz. protein 4 oz. protein OPTIFAST HP 12–13 1 fruit 1 grain 2 cups salad 1 grain 1 fruit 2 cups cooked 1 healthy fat 1 healthy fat vegetables 1 milk/soy milk 2 healthy fats /yogurt Weeks 2 oz. protein OPTIFAST HP 4 oz. protein 4 oz. protein 2 oz. protein 14–18 1 fruit 1 healthy fat 2 cups salad 2 cups cooked 1 fruit 1 grain 1 grain vegetables 1 healthy fat 1 healthy fat 1 healthy fat 1 milk/soy milk/ or yogurt

Product and Weeks 2-10 Weeks 11-13 Weeks 14-18 Week 1 and Food Group Maintenance OPTIFAST HP 3 2 1 0 Lean Proteins 4 oz. 8 oz. 10 oz. 12 oz. Vegetables minimum 4 - minimum 4 - minimum 4 - minimum 4 unlimited unlimited unlimited - unlimited Fruits 1 2 2 3 Grains/Legumes/Starchy 1 1 2 2 Vegetables Healthy Fats 1 2 3 4 Milk/Soymilk/Yogurt 0 0 0 2 Calories 1225 1310 1325 1340

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TIME SAVING PREP IDEAS FOR YUMMY PARTIAL MEAL REPLACEMENTS

SEASON MEAT 3 WAYS USING 1 PAN If you’re sticking to lean meats like chicken, the same flavors can get tedious. Save time by preparing two or three variations of chicken at once, using aluminum foil dividers in your pan. Lemon pepper, salsa, fresh rosemary — you can have them all in one pan! Refrigerate or freeze leftovers and use them for meals during the week.

CHOP OR SPIRALIZE RAW VEGETABLES IN ADVANCE Too busy to eat dinner at an early hour, 4 to 5 pm? Cut veggies in bulk ahead of time to avoid wasting precious minutes chopping. Zucchini noodles (zoodles) will stay fresh in the fridge for 3 to 5 days, and chopped vegetables like carrots, onion and peppers will last a week when refrigerated properly in a sealed plastic bag or tupperware.

ROAST DIFFERENT VEGETABLES WITH THE SAME COOKING TIME Roasting vegetables is a great way to bring out their natural sweetness, but waiting 30 to 45 minutes for the vegetables to roast can be time-consuming. Prepare a large batch of veggies when you have time. Pair them based on roasting time. Fast-cooking vegetables that can bake in the same pan include asparagus, mushrooms and cherry tomatoes; slow-roasting vegetables include carrots, cauliflower, onions, and parsnips.

SKEWER MEATS FOR QUICK PORTIONS By weighing your meat (chicken, salmon, beef, etc.) cubing them and putting them on wooden skewers you can control how much you’re eating in one sitting. Cook up a batch and save some skewers for the rest of the week. If you’re using wooden skewers, soak them in water for 20 minutes before using them so they won’t catch fire in your grill or oven.

PRE-ASSEMBLE JARRED SALADS By using a glass jar, you can save your veggies from getting mushy before you eat them. Put your dressing at the bottom of the jar, layer sturdier vegetables like peppers and beets, add your protein and then save the leafy greens for the top. Put a paper towel square at the top to absorb moisture if you’re storing the salad for multiple days.

SEASONINGS AND CONDIMENTS Feel free to season your foods without adding extra calories. The following are some seasoning suggestions: Basil (fresh) Curry Lemon/ Lemon Juice Oregano Celery seeds Dill Lemon pepper Paprika Cinnamon Garlic Lime/ Lime Juice Pepper Chili powder Garlic powder Mint Rosemary Chives Herbs Onion powder Salsa

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SELECTING A PREPARED ENTRÉE On occasion a frozen entree may be substituted for a self prepeared meal. If choosing a frozen entrée look for the following nutritional guidelines: 200–320 calories 6–12 grams of fat or less (approx. 3 grams of fat or less per 100 calories) 800 milligrams of sodium or less 12–14 grams of protein or more • If the prepared entrée does not include a vegetable, add 2 cups of cooked or 2 to 4 cups raw vegetables.

ALCOHOLIC BEVERAGES Studies show that in the short term, alcohol stimulates food intake and can also increase feelings of hunger. Having your judgment impaired and stimulating your appetite can sabotage your efforts if you are trying to lose weight. Use the following chart to assess the carbohydrate and calorie content of alcoholic beverages before you drink.

BEVERAGE Alcohol Carbohydrate Calories Servings (g.) (g.) BEER: regular beer 12 oz. 13.0 13.8 151 1 grain; 2 fats light beer 12 oz. 10.1 6 90 2 fat DISTILLED SPIRITS: 86 proof (gin, rum, vodka, 1½ oz. 15.3 trace 107 2 fats whiskey, scotch)

TABLE WINES: red or rosé 4 oz. 11.6 1.0 85 2 fats dry white 4 oz. 11.3 .4 80 2 fats 1 sweet wine 4 oz. 11.8 4.9 102 /3 grain; 2 fats wine coolers 12 oz. 15.0 22.0 192 1½ fruit, 3 fats

SPARKLING WINES: champagne 4 oz. 11.9 3.6 98 2 fats

1 fat = 45 calories; 0 carbohydrates; 0 g. protein; 5 g. fat. 1 grain = 80 calories; 15 g. carbohydrates; 3 g. protein; trace fat. 1 fruit = 60 calories; 15 g. carbohydrates; 0 g. protein; 0 g. fat.

Tips for calorie reduction if you choose to drink alcohol: • Always have food in your stomach before you have a drink. • Keep water available to quench your thirst while you drink an alcoholic beverage. • Learn to sip your drink to make it last longer.

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REQUEST FOR SUPPORT

Dear ______,

I am in the Positive Choice Integrative Wellness Center Partial Meal Replacement Program learning how to change my actions, thoughts, and feelings as they relate to food and eating. In order to reach my goal of taking charge of my weight, I need your support and encouragement.

You can encourage me by complimenting me whenever you notice me taking positive actions such as celebrating fitness or keeping records of what I am eating.

You can support me by showing a positive attitude regarding my program. Well meant words of advice or suggestions are not helpful. Saying such things as “Are you dieting again?” or “Why do you want to lose weight, you look good to me.” are counterproductive to my efforts.

I need experience in using the new behaviors I am learning. Please include me in social activities while I am learning these new behaviors.

Thank you for your support and encouragement.

Sincerely,

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POSITIVE CHOICE INTEGRATIVE WELLNESS CENTER PARTIAL MEAL REPLACEMENT PROGRAM RESPONSIBILITIES

Positive Choice Clinic and Staff Responsibilities: 1. Begin weekly group on time. 2. Establish guidelines and teach successful methods for behavioral changes that support a healthy lifestyle. 3. Provide informative educational materials in a timely manner. 4. Provide product and medical supervision as indicated by individual program protocol. 5. Explain all assignments and answer questions, offer positive feedback and encouragement for people throughout program. 6. Offer weight maintenance options after initial core program. 7. Be available to assist you before and after group. (If you have a concern to discuss with your counselor, it is advisable to call ahead so that your counselor can put aside adequate time for you.) 8. Provide information on additional support opportunities and literature. 9. Offer a consistent day and time for weekly meetings.

Your Responsibilities: 1. Be willing to make weight management a priority. 2. Arrive at group on time. 3. Attend groups regularly missing no more than one group every eight weeks to enhance your support and group cohesiveness. 4. Complete lab work as directed by medical staff. 5. Purchase 4 boxes of Optifast 800® or 3 boxes of Optifast HP® through week 10. After week 10, continue to purchase the same amount of product, or reduce the amount of boxes purchased by dropping to a “per box” rate. Work with your counselor to wean off the product. Make payment for supplement not purchased when absent. 6. Arrange for childcare during group sessions. 7. Complete assigned Daily Behavior Records between Weeks 1 and 2 (prerequisite for Partial Meal Replacement beginning supplement). 8. Complete the weekly exercise plan. Mark “done” and show the record to your counselor, and/or complete a weekly food/exercise record. 9. Establish and maintain a regular exercise program. 10. Notify nursing of any changes in medical status or medications. 11. Abstain from all alcohol and street drugs. 12. Notify Reception of telephone or address change. 13. Have exact change for weekly program fee if paying cash. 14. Be receptive, positive, and keep current with reading and other assignments. 15. Turn off all cell phones during group.

We look forward to assisting you in achieving your goal! CONGRATULATIONS ON YOUR CHOICE FOR A HEALTHIER LIFESTYLE! (858) 616-5600

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KEEP ALL YOUR RECEIPTS

The IRS recognizes obesity as a disease and allows people who meet the IRS qualifications to claim weight-loss expenses as a medical deduction. In order to claim the deduction, you have to participate in a weight loss program for a medically valid reason. In order to take the deduction, you must also itemize your deductions and the deductions must represent a specified percentage of your income. This percentage changes from time to time, so check with qualified tax preparer to see if you may take the deduction.

Positive Choice items that may be considered for a medical deduction include:

• Your Body Assessment appointment. • Your program fee (but not any supplements).

In order to claim the deduction, you must be certain to keep all of your receipts for the above items (that means keeping your receipt every time you check in for a group meeting or an appointment). Positive Choice will not provide any additional copies of receipts once they have issued the original receipt to you.

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DIRECTIONS FOR DAILY BEHAVIOR RECORDS

• Allow at least one line for each food item (please print). • Include the amount eaten in household measurements, such as: ounces, cups, tablespoons, slices, or units. Example: One 9-inch banana or one whole wheat slice of bread. • Note the method the food was prepared, such as fried, baked, barbecued, boiled, fresh, frozen, etc. • For combination foods (casseroles), list the ingredients and amounts of each ingredient consumed, as accurately as possible. • For packaged or canned foods, include the sauce or liquid, such as: 2 peach halves packed in their own juices or ½ cup raw broccoli with 2 tbsp. cheese sauce.

ATTENTION:

You MUST hand in four to five days of food records in order to begin OPTIFAST 800® supplements at Week 2.

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Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time 7 a.m. 12:30 p.m. 4:30 p.m. 7 p.m. 9 p.m. of day

Meal or M M S M S Snack? (M/S)

Special K™ cereal Turkey sandwich Chocolate BBQ chicken, corn on Peanuts Food skim milk Wheat bread, cookies the cob, butter, flour Eaten banana turkey, (homemade) tortilla, refried beans lettuce, tomato, mayo

1 c.; 4 oz.; 1 med. 2 slices, 4 oz., 4 8 oz.; 1 (8” ear); 1 c. Portion 2 leaves, 2 slices, 1 tsp.; 2 (12”);1 c. 1 tbsp.

H.R.* 3 3 2 2 1 (0 to 3)

# of Min. 5 10 3 15 3

Where? Kitchen Work In the car Kitchen Bedroom

Situation. Leaving for work. With co-workers. Talking to significant Watching Doing other. T.V. what else? With whom?

Thinking about Starved! Tired. I deserve this! Need Thoughts work. This tastes something to and good. Rushed. Talking about work. Tastes good. Enjoying the meal and munch on. Feelings company.

Food is satisfying. A reward I ate too much. Habit. What did Should have a for a you learn midmorning snack. stressful about why day. I need you eat? more sleep.

Fluids X X X X X X *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry A-24

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-25 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-26 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-27 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-28 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-29 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

Name: Date: Daily Behavior Record for (circle one): M T W Th F Sat Sun

Daily Fitness:

Breakfast Snack Lunch Snack Dinner Snack Time of day

Meal or Snack? (M/S)

Food Eaten

Portion

H.R.* (0 to 3)

# of Min.

Where?

Situation. Doing what else? With whom?

Thoughts and Feelings

What did you learn about why you eat?

Fluids If you need more writing space, please use the back of this page. *H.R.= Hunger Rating: 0=no hunger, 1=slightly hungry, 2=hungry, 3=very hungry

A-30 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial fast curriculum 2019\for print new\a1-introduction 2019.doc

PARTIAL MEAL REPLACEMENT – EATING HEALTHFULLY ONE PLATE AT A TIME

THE PLATE METHOD

The plate method is a basic strategy to begin with when I start to eat healthfully. Use a 9” plate. Visualize my plate divided into 3 to 5 sections as described below. • Fill half of my plate with steamed, stir-fried, sautéed, baked or roasted vegetables. Vegetables are full of healthy vitamins, minerals, and antioxidants, water and healthy fiber. Vegetables help my stomach feel full without adding a lot of calories to my meal. • Think of the vegetable portion as being the centerpiece of the meal, with protein, whole grains, and healthy fats (olive or canola oil, raw nuts and seeds, and avocado) serving as the condiments or flavor-enhancers for my meal. • Fill a fourth of my plate with healthy lean protein such as baked chicken, fish, eggs, lean meat or meat substitute, or milk, soymilk or yogurt. • Add a serving of healthy fats like raw nuts and/or seeds. • Fill the remaining fourth of my plate with healthy complex carbohydrates such as brown rice, quinoa, sweet potato, legumes or beans, or whole-grain bread. Avoid highly refined, white-floured foods. For further weight loss, avoid eating complex carbohydrates after 2:00 pm.

The picture below displays the plate method:

Fruit and/or [Milk, Soy Milk or Yogurt] Remember to drink fluids. The Institute of Medicine panel (part Lean Protein High Fiber Grain of the National Academy of Science) and or recommends that fluid intake should be Legume Starchy Veg driven by thirst but that an adequate Fats intake (AI) for men is roughly 3 liters and (about 13 cups) of total beverages a day. Oils The AI for women is 2.2 liters (about 9 cups) of total beverages a day. Vegetables Throughout the day drink water or non- caloric beverages.

B-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\b2-one plate at a time.doc UNDERSTANDING THE WHAT, WHEN, WHERE, WHY, AND HOW OF YOUR EATING

THERE ARE MANY REASONS WHY YOU CHOOSE WHAT YOU EAT. These reasons include your childhood food culture, your stress-management habits, the social and food influences of your family and friends, the time you allocate to meals and meal planning, and your emotional responses to various cues throughout your day. Part of the process of making positive changes in your lifestyle include understanding how your body uses the food you eat. • CURRENT LIFESTYLE. Current research shows that high stress levels, poor nutrition, lack of support, feeling isolated, and the lack of exercise are more significant determinants of overall health than just being overweight or obese. The Partial Meal Replacement program is designed to help you resolve some of these critical issues in your quest for health and weight management. WHAT IS FOOD? Food is the fuel which your body uses to make the energy you need. Energy from the foods you eat is measured in the form of calories. There are six major components of food: fats, proteins, carbohydrates, vitamins, minerals and water. While all these components are essential, only fats, proteins, and carbohydrates contain calories and help your body produce energy. HOW MANY CALORIES DO YOU NEED? Experts estimate that daily caloric intake for weight maintenance for sedentary women and men averages 1,200 to 1,400 calories per day for most women and 1,400 to 1,800 calories for most men. Increased daily activity (exercise) and more lean tissue (muscle) increases your caloric needs. • FIND OUT HOW MANY CALORIES YOU BURN DAILY. To determine your average daily calorie needs, keep accurate food records, carefully monitor weight gain or loss, and make adjustments in your food intake and exercise based on the results. You may also schedule a metabolic rate test offered at the Positive Choice Integrative Wellness Center. Metabolic testing measures your resting metabolic rate (the calories you burn at rest) and helps determine how many calories you need to maintain your current weight. Call (858) 573-0090 or visit positivechoice.org to sign up for a metabolic rate test. WHEN DO YOU NEED TO EAT? A normal Meal Replacement blood sugar level is between 70 to 150 milligrams per deciliter. When your blood sugar is within this range, you feel most comfortable and your body works most efficiently. If you let your blood sugar drop too low by waiting too long to eat, you may feel irritable, shaky, confused, and unable to concentrate, or you may have a headache. You can avoid blood sugar lows by eating meals or snacks every three to five hours. WHERE DO YOU EAT? Be sure to eat in an environment that you can really taste your food. When you eat in your car, at your desk, at the computer, in front of the TV, or standing up and walking around, you typically don’t taste and enjoy the foods you eat. Sit down at a table and relax while eating. WHY DO YOU NEED TO EAT? Physiologically the reason why you eat is because your body needs fuel and nutrients at regular intervals for optimal health and performance. There may be many other reasons, however (such as boredom, depression, anxiety, social pressures, the need for companionship, or the need to relieve stress), that explain why you eat what you eat.

B-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\b2-one plate at a time.doc TO WORK ON MANAGING YOUR WEIGHT, FIRST ASK YOURSELF: WHAT’S MY OPTIMAL, HEALTHIEST WEIGHT? Sometimes your optimal, healthiest weight isn’t the standardized, medically recommended BMI. It’s important to know your measurements and how much of your weight is deposited as either fat or lean muscle tissue. You are a unique individual. Find the weight your body seems most comfortable with and work to be the healthiest person you can be at that weight by reducing stress, learning to eat more healthfully, developing a supportive relationship network, and incorporating more physical activity into your day.

FINDING THE EATING STYLE THAT FITS YOU BEST CAN MAKE A SIGNIFICANT DIFFERENCE TO YOUR HEALTH AND WEIGHT MANAGEMENT. The best compromise for healthy eating is to eat a wide variety of healthful foods from a broad range of food categories and adjust for your individual body type, lifestyle, and health needs. Changing what and how you eat can also support the treatment and resolution of many health conditions and can help prevent health conditions from occurring.

HOW DO YOU EAT NOW? Do you eat fast? Did you know it takes about 20 minutes for your brain to get the message that you’re full. By eating slowly, you will most likely eat less food. When you eat more slowly, you give yourself the pleasure of really tasting food and you are less prone to overeat.

Self Check: Are you eating at regular intervals? List your meal and snack times: ______Where do you usually eat? ______Besides physical hunger, what are some reasons why you eat? ______How long does it usually take you to finish your food? ______How are you practicing conscious eating? ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

• How confident are you that you will/can meet the goal you have set for yourself for the coming week? Confidence level _____%. • Remember to adjust the various components of your goal so that you can honestly say you are 70% or greater in your confidence level. B-3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\b2-one plate at a time.doc

PARTIAL MEAL REPLACEMENT – CREATING A HEALTHY LIFESTYLE

If you can create your ideal self in your mind, you can create it in your life.

MANTRA

• A mantra is a phrase that is repeated frequently to help your mind focus on a positive direction.

• Begin your mantra by first deciding what you would like your ultimate outcome of health and wellness to be.

• Start your mantra in the present tense, as if you’ve already arrived.

Write your mantra here: (Example: I am healthy, fit, happy and active.)

I AM ______

______

• In the beginning, repeat your mantra every hour and then continue to repeat it regularly after it’s programmed in your mind.

• Refer to your mantra often throughout the Partial Meal Replacement program and beyond.

C -1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\c3-creating a healthy lifestyle.doc MINDFULNESS

What is mindfulness? Mindfulness can be defined as paying undistractible attention to the present moment. It is an awareness process and not a thinking process. Mindfulness is about being able to consciously direct, broaden, or focus on different aspects of your experience. You can learn to direct your attention to the here and now. Paying attention in this moment to what you notice, what you hear, and what you sense. This process allows you to experience the reality of each moment rather than living according to the past and future oriented mind. Research on mindfulness shows that it is helpful for depression, relapse prevention from weight loss, anxiety, substance abuse, eating disorders and binge eating, insomnia, chronic pain, psoriasis, type 2 diabetes, fibromyalgia, rheumatoid arthritis, attention-deficit/hyperactivity disorder, cancer and heart disease.

Signs that mindfulness may be helpful in your life: Do you find yourself; • Breaking things, spilling things, being clumsy, having accidents because of carelessness, inattention or thinking about something else? • Forgetting someone’s name as soon as you hear it? • Listening to someone with one ear while doing something else at the same time? • Getting lost in your thoughts and feelings? • Distracting yourself with things like eating, alcohol, pornography, drugs, work? • Eating without being aware of eating?

Why is mindfulness important in terms of weight, eating, and overall health? • Prevents living on auto pilot. • Reduces stress and increases clarity. • Separates you from the chatter in your mind and allows you to make healthy, clear, and value-based decisions. • Allows us to truly be present to experience our lives. • Reminds us that we have the power to choose in the moment despite what our mind says. • Our mind might try to talk us into making poor nutrition choices but we can be aware of it when it happens and acknowledge that it is just a thought without power unless we listen to it.

The Importance of Practice Mindfulness takes consistent practice and self-support. Each time you practice try to gently remind yourself to come back to the present moment when you notice your mind is distracted. Our minds are designed to problem solve, plan, and chatter. When they attempt to hook us during practice, they are merely doing their job. Our job then is to practice guiding our attention where it serves us the most rather than simply following what our mind suggests. Many times what our mind is offering is not based in reality and it does not serve us to listen. Through the ongoing practice of mindfulness, we are given a choice in the moment to observe what the mind is offering and decide whether or not it is helpful to listen. Practice, patience, and self-kindness are key!

C -2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\c3-creating a healthy lifestyle.doc PROVEN LONG TERM WEIGHT LOSS STRATEGIES

SUCESSFUL WEIGHT MAINTENANCE STRATEGIES According to research, there are several strategies that successful weight maintainers use to keep their weight off. (A successful weight maintainer is described as a person who successfully lost at least 30 pounds and has maintained the loss for more than one year).

The following are seven suggested strategies used by successful weight loss maintainers: 1. Consume a low-kilocalorie, low-fat diet. According to one study the participants who consumed 1,300 to 1,680 kilocalories per day, 25% of which are from fat, kept off their weight better than those who ate more. 2. Have a consistent food intake from day to day. Eat about four to five times per day. 3. Consistently eat breakfast. 4. Be physically active. The average person in one study exercised for about 60 to 90 minutes per day at moderate intensity. If they chose to walk, they took about 11,000 to 12,000 steps per day, which is the equivalent of almost 6 miles. 5. Monitor your weight regularly — weekly or even daily. 6. Limit television viewing to less than 10 hours per week. 7. Do not allow even a small amount of weight gain to occur without corrective action. Deliberately responded to small weight gains by reducing your food intake and/or increasing your exercise level.

PLAN YOUR OWN LONG TERM WEIGHT LOSS STRATEGIES Create a healthy lifestyle. Plan to please yourself. Make changes towards a healthy lifestyle to change your life. Remember that you are the most important reason to maintain your healthy lifestyle.

• Set realistic goals. Develop your plan around short-term, attainable goals. Plan for gradual change, it’s healthier and easier to maintain. • Every day emphasize a healthy eating regimen with high-fiber foods, lots of fresh fruits and vegetables, lean proteins and healthy fats. • Develop a fitness program that you enjoy and want to do regularly. • Be consistent on your food intake and make breakfast a priority. • Celebrate success. Your weight loss doesn't need to be an all-or-nothing venture. Small changes in your weight and fitness can make a significant difference in your health and reduce your risk for disease.

List 3 healthy lifestyle goals 1.

2. 3.

C -3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\c3-creating a healthy lifestyle.doc RELY ON YOUR SUPPORT SYSTEM Social support and accountability are essential to successful weight loss and management. In order to lose weight and keep it off, support is needed. Studies show that just one support person can help you lose weight and maintain the weight loss.

DEVELOP A SUPPORT SYSTEM A supportive partner increases the enjoyment factor of physical activity and healthful eating. Make lifestyle changes with a spouse, friend, or family member. • Enlist support. Involve the people who will be intimately involved with the new you and make them part of your new, healthful lifestyle. • Supportive family and friends can help identify your strengths and weaknesses and help make your new lifestyle plan more realistic and achievable. • Make new friends. Surround yourself with people who will help you be successful for a lifetime. • Join a support group and attend regular meetings. Support of like-minded people can help you stay on track, allow you a place to safely vent, and provide important information. Ask your counselor about support options at Positive Choice Integrative Wellness Center.

Name 3 support system plans

GIVE YOURSELF INCENTIVES AND REWARDS Even though you are planning for a lifetime, develop achievable short-term goals. • Give yourself non-food incentives each day to stick to your healthful changes. • Plan small rewards for sticking to your plan and achieving your goals. • Reward yourself when you achieve your short-term goals.

What 3 incentives or rewards will you use to spur you on? 1.

C -4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\c3-creating a healthy lifestyle.doc IMPROVE YOUR HEALTH BY SETTING A GOAL THIS WEEK

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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PARTIAL MEAL REPLACEMENT – CHANGE, FLUIDS AND ALCOHOL

WHAT DO I NEED TO CHANGE?

PROGRAM RESEARCH Dr. Vincent J. Felitti, the original Medical Director for the Positive Choice Integrative Wellness Center, was very committed to finding out what the Program could do to enhance your long-term success. In the past, he met hundreds of overweight people in an attempt to determine what the root cause of obesity is. Below is a summary of what his research has revealed:

What Does Not Appear to Cause Obesity 1. Being born overweight. 2. Poor metabolism. 3. Love of food. 4. Lack of nutrition-related knowledge.

What Appears to Cause Obesity 1. People need to make themselves feel better with food. 2. People need to feel safe: excess weight provides a protective benefit.

PEOPLE USE FOOD TO … Do you find yourself turning to the refrigerator even when you are not hungry? Or, at times, eating completely out of control? The majority of people who struggle with their weight, use food to relieve stress, to meet emotional needs, or to avoid uncomfortable feelings. The following continuum has been useful in helping people recognize some of their reasons for overeating.

Celebrate and

Enhance Pleasure

Minimize Frustration in Reduce Relieve Difficult Relationships Sexual Stress Threat

Compensate for Avoid Uncomfortable Depression or Loss Feelings, (Anger, Loneliness)

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PERSONAL CHANGE FROM THE INSIDE OUT

• Personal change requires using long-term techniques to develop healthy nutrition, fitness, communication, stress management and relaxation strategies. • Focus on what you can do, rather than on what you can’t do. • Create a willingness to learn — accepting change is an attitude. Attitude is a choice. • Learn to really appreciate all you have and are; your talents, skills, and abilities. • Learn to forgive yourself. Hold yourself to the same standard that you hold others. • Understand that change is uncomfortable and messy. • There are no quick fixes. Choose to make change a lifelong commitment.

ARE YOU READY TO CHANGE?

Are you willing and able to make a long-term commitment to a new lifestyle of healthy eating and regular physical activity? Yes No

Is your life in a place that will allow you to make weight management a high priority and give it the attention it requires for the rest of your life? Yes No

Are you willing to use behavioral self-management techniques, such as keeping records of your eating and exercise behavior, even though you may initially find record keeping annoying or burdensome? Yes No

Are you able to restructure your personal environment to succeed at weight management? (For example, if you do not have control over the selection and preparation of your food, can you get the cooperation of the person who does? Will you rearrange your schedule or allocate your time Yes No differently?)

Are you willing to bear the responsibility for your choices, acknowledging that the choices you make ultimately determine your results? Yes No

Are you willing to strive for a positive attitude toward yourself and your weight management efforts, knowing that there will be periodic slips and setbacks? Yes No

Are you able to put past failures behind and think positively about your ability to succeed this time? Yes No

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FOOD CUES/EVENTS

Step 1 Step 2 Using the same food or event, reframe my thoughts and feelings so that my actions lead to a more positive outcome for me. 1. Name an event that is a food cue for me. Event

2. What self-talk or thoughts do I engage in Thoughts regarding this event?

3. What sensations or feelings do I experience in this Feelings situation?

4. What behaviors or actions typically occur in Actions response to my event, self-talk, and feelings?

5. What is the result of my coping behavior? Results

D- 3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\d4-change, fluids and alcohol.doc WATER, FLUIDS AND ALCOHOL

Health benefits of water Water is your body's principal component and makes up about 60 percent of your body weight. Every system in your body depends on water. For example, water flushes toxins out of vital organs, carries nutrients to your cells and provides a moist environment for ear, nose and throat tissues. Lack of water can lead to dehydration, a condition that occurs when you don't have enough water in your body to carry out normal functions. Even mild dehydration can drain your energy and make you tired. How many glasses of water should we drink each day to be hydrated and healthy? Every day you lose water through your breath, perspiration, urine and bowel movements. For your body to function properly, you must replenish its water supply by consuming beverages and foods that contain water. The Institute of Medicine panel (part of the National Academy of Science) recommends that fluid intake should be driven by thirst but that an adequate intake (AI) for men is roughly 3 liters (about 13 cups) of total beverages a day. The AI for women is 2.2 liters (about 9 cups) of total beverages a day.

Exercise If you exercise or engage in any activity that makes you sweat, you need to drink extra water to compensate for the fluid loss. An extra 1½ to 2½ cups of water should suffice for short bouts of exercise, but intense exercise lasting more than an hour (for example, running a marathon) requires more fluid intake. How much additional fluid you need depends on how much you sweat during exercise and the duration and type of exercise. Also, continue to replace fluids after you're finished exercising.

Staying safely hydrated Generally, if you drink enough fluid so that you rarely feel thirsty and produce 1½ liters (6.3 cups) or more of colorless or light yellow urine a day, your fluid intake is probably adequate. To ward off dehydration and make sure your body has the fluids it needs, make water your beverage of choice. It's also a good idea to: • Drink a glass of water or other calorie-free or low-calorie beverage with each meal and between each meal. • Drink water before, during and after exercise. Although uncommon, it is possible to drink too much water. When your kidneys are unable to excrete the excess water, the electrolyte (mineral) content of the blood is diluted, resulting in low sodium levels in the blood, a condition called hyponatremia.

High Calories from Beverages. Did you know? • Soda is the top source of sugar in the American diet. • Sugary drinks do not make you feel full and may make you hungrier after drinking them. • Americans consume 300 more calories per day than we did 30 years ago. Almost 50 percent of those calories come from sugary drinks. • Drinking just one, 20-ounce bottle of soda each day for a year can result in gaining 25 extra pounds. Many vitamin waters have fewer calories and less sugar than soda, but they still have a lot. Avoid sports drinks unless you are participating in a triathlon or other very strenuous exercise. Consuming just one of these drinks every day for a year will result in a 10 to 13 pound weight gain.

D- 4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\d4-change, fluids and alcohol.doc Energy drinks are often full of sugar and caffeine. Drink just one per day and you'll see about 20 pounds added to your weight. The average coffee drink adds over 300 calories to your day. That can mean 30 extra pounds of weight gain per year. If you need a quick fix, tea or coffee drinks made with nonfat milk are better choices.

Compare average sugar and calorie content per serving in some of the most popular drinks. Beverage Serving Size Calories per Grams of Sugar Teaspoons of Serving per Serving Sugar per Serving Soda 20 oz. 240 calories 67.5 grams 17 tsp. Sweetened tea 16 oz. 220 calories 46 grams 9 tsp. drink Energy drink 24 oz. 270 calories 72 grams 18 tsp. Sports drink 16 oz. 200 calories 54 grams 14 tsp. Sweetened coffee 16 oz. 380 calories 45 grams 11 tsp. drink Water Unlimited 0 0 0

Instead of sugary drinks, try other refreshing thirst-quenchers: • Add a slice of orange, lemon, watermelon, lime, or cucumber to your water for a boost of flavor. • Mix sparkling water with a splash of your favorite fruit juice. • Mix in just a bit of pomegranate or cranberry juice and lime in your unsweetened iced tea or add cut-up peaches and fresh mint sprigs if you like it sweetened.

Guidelines for Seniors The aging process often alters important physiological control systems associated with feeling thirsty and satiety. If you're 70 or older, you may need to make an effort to drink more fluids, even if you’re not feeling thirsty.

ALCOHOLIC BEVERAGES Alcohol can make weight loss more difficult. In addition to supplying empty calories, it interfers with fat burning in the liver. Normally the liver metabolizes fats, but when you drink alcohol, the liver burns the alcohol instead of burning fat. Alcohol also stimulates your appetite and increase feelings of hunger. On the Partial Meal Replacement program your calorie budget is between 1100 to 1300 calories a day. For fat loss, you need to be careful how you spend your calories. If you follow the Partial Meal Replacement plan, you will consume Optifast® shakes along with nutrient-rich foods that will allow your body to supply energy to your muscles, while burning fat. A few alcoholic drinks can cost you around 500 calories, or almost one half your daily calorie needs, and can slow or stop your weight loss attempts.

D- 5 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\d4-change, fluids and alcohol.doc Use the following chart to assess your alcoholic beverage before you drink. Beverage Ounces Alcohol (g.) Carbs (g.) Calories Servings ** BEER: regular beer 12 oz. 13 g. 13.8 g. 151 1 grain; 2 fats light beer 12 oz. 10 g. 6 g. 90 2 fats DISTILLED SPIRITS: *86 PROOF 1 ½ oz. 15 g. trace 107 2 fats (gin, rum, vodka, scotch whiskey,) TABLE WINES: red 4 oz. 12 g. 1 g. 100 2 fats dry white 4 oz. 11 g. .4 g. 95 2 fats 1 sweet wine 4 oz. 12 g. 5 g. 120 /3 grain, 2 fats wine coolers 12 oz. 15 g. 22 g. 200 1 ½ fruit, 3 fats SPARKLING WINES: champagne 4 oz. 12 g. 4 g. 100 2 fats

*Proof is a way of stating the percentage of alcohol. Liquor that is 100 proof is 50% alcohol.

**1 fat = 45 calories; 0 carbohydrates; 0 g. protein; 5 g. fat. 1 grain = 80 calories; 15 g. carbohydrates; 3 g. protein; trace fat. 1 fruit = 60 calories; 15 g. carbohydrates; 0 g. protein; 0 g. fat.

Tips for alcohol consumption for weight loss and weight maintenance: • Always have food in your stomach before you have a drink. • Keep water available to quench your thirst while you drink an alcoholic beverage. • Learn to sip your drink to make it last longer. • Don’t drink while you’re trying to lose weight. • When maintining your weight, only drink occasionally, such as one drink on a weekend. • Count the calories into your daily calorie budget. • Watch the fatty foods that seem to accompany alcoholic beverages. • If you choose to drink (sensibly and moderately) enjoy without guilt.

D- 6 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\d4-change, fluids and alcohol.doc Name three ways you will manage your calorie consumption from alcoholic beverages to lose and maintain weight:

1.______

2.______

3. ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

• How confident are you that you will/can meet the goal you have set for yourself for the coming week? Confidence level _____%.

• Remember to adjust the various components of your goal so that you can honestly say you are 70% or greater in your confidence level.

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PARTIAL MEAL REPLACEMENT – LABEL READING

2% Milk Nutrition Facts SERVING SIZE Serving Size 1 cup (244g) Serving sizes are determined by the CALORIES manufacturer and are usually close to Are figured from the amount of fat, amounts that people consume. Amount per Serving carbohydrate, and protein in the food. Be sure to compare the manufacturer’s serving size with what you consider Calories 122 Calories from Fat 43 a serving. CALORIES FROM FAT TOTAL FAT % Daily Value* Tells you how many of the calories Compare the fat grams per serving to in the product are contributed by your personal fat budget to see how the Total Fat 5g 7% fat. Your intake should be a minimum food fits into your intake. 20%of to a maximum of 35% of calories. Saturated Fat 2g 15% from fat. TRANS FATS Trans Fat 0g CHOLESTEROL Trans fats should constitute no more than 2 Cholesterol 20mg 7% grams of your daily fat budget according Limit yourself to 300 milligrams a day. to U.S. government recommendations Sodium 100mg 4% and less (zero) is better. TOTAL CARBOHYDRATE Total Carbohydrate 12g 4% This number combines all carbohydrate SODIUM forms (starches, simple sugars, sugar alcohols, soluble and insoluble fiber). Limit yourself to between 1,000–3,000 Dietary Fiber 0g 0% milligrams a day. DIETARY FIBER Sugars 12g Soluble & insoluble fiber are not digested. Aim for at least 25 grams per day. PROTEIN Protein 8g SUGARS Most experts recommend that your protein Simple sugars are absorbed into the intake be somewhere between 15 and Vitamin A 9% Vitamin C 1% Calcium 29% bloodstream as quickly as one minute. 30% of total daily calories. Iron 0%

Percent Daily Values are based on DAILY VALUES PERCENTAGES a 2,000 calorie diet. Your Daily AND FOOTNOTES Values may be higher or lower Both the Daily Value footnotes provided depending on your calorie needs: at the bottom of the label and the % Daily Value data found higher on the 2,000 2,500 Nutrient Calories Calories label assume a diet of either 2,000 NUTRIENTS or 2,500 calories. Also, the Daily Expressed as a percentage of the Daily Total Fat Less than 65g 80g Value for fat assumes you want to Sat Fat Less than 20 g 25g Value—a recommended daily amount Cholesterol Less than 300mg 300mg limit fat to 30% of calorie intake. based on a 2,000-calorie diet—this may Sodium Less than 2,400 mg 2,400mg If you’re aiming for fewer calories not reflect your personal requirements. Total Carbohydrate 300g 375g or less fat, this information Fiber 25g 30g overestimates your needs. Calories per gram*: Fat 9 Carbohydrates 4 Protein 4

CALORIES PER GRAM FOOTNOTE Every gram of fat has 9 calories. A gram of carbohydrate or protein has 4 calories each. To find the calories per gram, multiply the total grams by either 9 for fat or 4 for carbohydrates and proteins.

Manufactures of packaged foods will be required to use a new label by July 26, 2018. The new Nutrition Facts label hopes to make it easier for consumers to make better informed food choices.

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Note: Both labels represent fictional products.

What’s Different? • An increased type size for “Calories,” and the “Serving size”. • Manufacturers must declare the actual amount, in addition to percent Daily Value of vitamin D, calcium, iron and potassium. • The footnote is changing to better explain what percent Daily Value means. • “Added sugars,” in grams and as percent Daily Value, will be included on the label. • The list of nutrients that are required or permitted to be declared is being updated. Vitamin D and potassium will be required on the label along with Calcium and iron. • While continuing to require “Total Fat,” “Saturated Fat,” and “Trans Fat” on the label, “Calories from Fat” is being removed because research shows the type of fat is more important than amount. • By law, serving sizes must be based on amounts of foods and beverages that people are actually eating, not what they should be eating. How much people eat and drink has changed since the previous serving size requirements were published in 1993. • For certain products that are larger than a single serving but that could be consumed in one sitting or multiple sittings, manufacturers will have to provide “dual column” labels to indicate the amount of calories and nutrients on both a “per serving” and “per package”/“per unit” basis. With dual-column labels available, people will be able to easily understand how many calories and nutrients they are getting if they eat or drink the entire package/unit at one time.

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1. Check the serving size Pay attention to the serving size and the servings per container. All of the nutrition information is based on the serving size. Serving sizes are set by the FDA not by the manufacturer. 2. How many calories? On average a woman needs 1,200 calories and a man needs 1,500 calories for their basal metabolism to function properly.

3. How much fat, and what type? Shoot for less than or equal to three grams of fat per 100 calories for prepared entrees and nutrition bars. Your total fat intake will range from 30 to 50 grams depending on how many calories you are eating. Limit saturated fat to less than 10 grams a day and avoid all trans fats.

4. Check the sodium status The recommended daily sodium intake is about 2,300 mg/day. If you have high blood pressure, diabetes or kidney disease limit your sodium intake to 1,500 mg a day. Watch for high sodium levels in low fat foods. Keep frozen entrees to less than 700 mg.

5. Check the carbohydrate, sugar and fiber breakdown The National Institute of Medicine recommends that for good brain function, 130 grams of carbohydrates are needed per day. Two things to look for in the carbohydrate section are sugar and fiber. Sugar intake should be kept within 25 to 38 grams per day. A good rule of thumb is if the sugars are over half the amount of carbs, avoid that food. Strive to get 25 to 35 grams of fiber a day. Fiber helps you move the food through your digestive track.

6. Is there enough protein? The DRI (Dietary Reference Intake) recommends 0.8 grams of protein per kilogram of body weight, or 0.36 grams per pound. This amounts to 56 grams per day for an average man, 46 grams for an average woman. For snacks and meals, try to get six grams of protein per 100 calories of food. Use five grams per 100 calories as a minimum for food bars and packaged meals. Use two grams of protein to one gram carb ratio as a quick check as well.

7. Check the ingredients The first five ingredients make up the majority of the product. Remember, the ingredients are listed in order of greatest to least present in the food. As a rule, the shorter the ingredient list, the more natural the product.

Daily Goals at a Glance Calories Calories Total Saturated Trans Sodium Carbo- Sugar Fiber Protein Protein Needs for Needs for Daily Fat Fat mgs hydrate grams grams grams grams Average Average Fat grams grams Women Men Women Men grams 1,200 1,500 30-50 < 10 0 1,500 – 130 25-40 25-35 46 56 2,300

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Added sugar is hiding in foods that many of us consider healthy, like yogurt and energy bars. It is also added to savory foods, such as ketchup, breads, salad dressing and pasta sauce.

The American Heart Association (AHA) recommends no more than 9 teaspoons (38 grams) of added sugar per day for men, and 6 teaspoons (25 grams) per day for women. The AHA limits for children vary depending on their age and caloric needs, but range between 3 to 6 teaspoons (12 to 25 grams) per day.

The FDA restricts use of the term sugar to sucrose, which is obtained from sugar cane or sugar beets. Yet there are many other sweeteners besides sucrose. Any of the sweeteners in the following table, besides sucrose, can be added into a sugar-free product.

Agave nectar Glucose solids Barbados sugar Golden sugar Barley malt Golden syrup Barley malt syrup Grape sugar Beet sugar HFCS (High-Fructose Corn Syrup) Brown sugar Honey Buttered syrup Icing sugar Cane juice Invert sugar Cane juice crystals Malt syrup Cane sugar Maltodextrin Caramel Maltol Carob syrup Maltose Castor sugar Mannose Coconut palm sugar Maple syrup Coconut sugar Molasses Confectioner's sugar Muscovado Corn sweetener Palm sugar Corn syrup Panocha Corn syrup solids Powdered sugar Date sugar Raw sugar Dehydrated cane juice Refiner's syrup Dehydrated Cane Sugar Rice syrup Demerara sugar Saccharose Dextrin Sorghum Syrup Dextrose Sucrose Evaporated cane juice Sugar (granulated) Free-flowing brown sugars Sweet Sorghum Fructose Syrup Fruit juice Treacle Fruit juice concentrate Turbinado sugar Glucose Yellow sugar

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LABEL READING EXERCISE

Nutrition Facts Serving size: 4 Cookies (32g) Servings Per Container: about 8 Amount Per Serving Calories 160 Calories from Fat 70 % Daily Value* Total Fat 7g 11% Saturated Fat 5g 25% Trans Fat 0g Cholesterol 0mg 0% Sodium 105mg 4% Total Carbohydrate 22g 7% Dietary Fiber 1g 4% Sugars 11g Protein 2g Vitamin A 0% Vitamin C 0% Calcium 0% Iron 6%

INGREDIENTS: 1. Enriched flour (wheat flour, niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid), 2. sugar, 3. vegetable oil shortening (palm kernel and palm oils), 4. cocoa (processed with alkali), 5. caramel color, 6. high fructose corn syrup, 7. salt, 8. baking soda, 9. soy lecithin, 12. peppermint oil, 13. natural and artificial flavor

1. Name the first 5 ingredients: ______, ______, ______, ______, ______.

2. What does the word “enriched” mean in the first ingredient? ______

3. How many teaspoons of sugar are in one serving? (Hint: 1 teaspoon of sugar = 4 g) ______

4. How many grams of trans fat are in one serving? ______Now check the ingredient list. What word indicates that the cookies contain some trans fat? ______. (In the United States if a food has less than 0.5 grams of trans fat in a serving, the food label can read 0 grams trans fat. Trans fats both raise your LDL ("bad") cholesterol and lower your HDL ("good") cholesterol which increases your risk of heart disease). 5. ______is manufactured by heating sugars. ______is produced from commercially available sweeteners consisting of fructose, glucose, invert sugar, sucrose, malt syrup, molasses, and/or starch hydrolysates (from wheat).

6. What kind of cookie is this? ______

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Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

E-6 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\e5-label reading, sugar.doc PARTIAL MEAL REPLACEMENT – GUT-BRAIN AXIS and HEALTHY COOKING

MAINTAINING A HEALTHY GUT WITH PREBIOTICS AND PROBIOTICS The Gut-Brain Axis: Two Brains are Better than One!

The gut, which is comprised of the stomach, small intestine and large intestine, strongly influences various centers of the brain that govern behavior, immune function and even emotions. This has led many to refer to the gastrointestinal (GI) tract as the second brain, or “Gut Brain”. Both brains, the cranial brain and gut brain, communicate back and forth along a pathway of nerves that form what is known as the “Gut- Brain Axis (GBA)”. This interaction between microbiota and GBA appears to be bidirectional, namely through signaling from gut-microbiota to brain and from brain to gut-microbiota. Perhaps what is most fascinating is the living entity within the lower GI tract, or large intestine, referred to as the “Micribiome”. It consists of approximately 100 trillion bacterial cells of varying types (also referred to as “microbiota”, or “gut flora”). These bacteria must remain in balance to ensure a healthy organism. A disruption in this balance can directly affect cognitive function, leading to states of anxiety, depression, as well as suppressed immunity leading to disease. On the other hand, chronic stress and anxiety, as well as infection can be the direct cause of a microbiome disruption, leading to problems with the lower GI tract. Some common forms include irritable bowel syndrome (IBS) and colitis. Certain food additives/preservatives, toxins from harmful bacteria overgrowth, direct ingestion of harmful bacteria (i.e. salmonella or e-coli) can also destroy healthy microbiota, thus throwing off the balance of the microbiome. The overuse of antibiotics is another common offender.

Taking Care of your Microbiome

There are several ways that you can maximize the health of your microbiome so that your gut brain functions at full capacity. First, it’s important to eat a diet high in whole plant fibers. Some of these fibers are actually fermented by the healthy strains of bacteria in the colon, allowing them to produce a by- product called butyric acid. This compound has many beneficial roles, but perhaps the most important is how it acts as a fuel source for the microbiota to keep them healthy, well fed and proliferating. It also serves as a regulator for gastric motility, as well as an anti-inflammatory agent. All of these factors contribute to a healthier lining of the large intestine. Foods that are high in whole fibers are referred to as prebiotic foods. Another effective way of maintaining a healthy microbiome is to consume foods that have live strains of healthy bacteria in them. Fermented foods such as sauerkraut, kimchi, tempeh, miso, kefir, and yogurt to name a few, are referred to as probiotic foods. By consuming foods that contain these healthy bacteria, we can help ensure that the balance of our microbiome remains intact. Probiotics must be taken or eaten regularly in order to maintain colonization in the digestive tract. General recommendations call for F-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\f6-gut-brain and healthy cooking.doc ingesting 1 to 25 billion colony-forming units (CFUs) daily. To put these guidelines into perspective, most store-bought probiotic yogurts contain about 1 billion CFUs per serving. To get the maximum benefit from fermented foods, choose foods that contain active, live cultures and contain raw, unpasteurized, perishable ingredients. Organic brands are the best choices, as they are not typically heat- treated after fermentation, so more of the good bacteria are present. Fermented foods can also be made at home. Though the probiotic content will vary by batch, home fermenting is a safe way to ensure that you are ingesting beneficial bacteria, as various cultures around the world have done for centuries.

Finally, probiotic supplementation has become more and more popular now that the word is out on the importance of a healthy microbiome. The supplements are usually found in pill form, or in small yogurt- like drinks. Because these supplements actually contain live bacteria, they are typically found in the refrigerated supplement section of health food stores. Not only can probiotic supplements help maintain a healthy, balanced microbiome, but they can also be instrumental in restoring balance when it has been disrupted due to infection and antibiotics.

Newer in the research is the possible beneficial effects of probiotic supplementation on various cognitive disorders such as anxiety, depression and even autism. The premise for this lies in the previously mentioned gut-brain axis, where our two brains (the one in the head and the one in gut) continuously communicate and affect one another.

HEALTHY COOKING

Healthy cooking doesn't mean that you have to become a gourmet chef or invest in expensive cookware. Use the following basic cooking techniques to prepare food in healthy ways.

How Do You Start? Do A Recipe Makeover. 1. Reduce the amount of fat, sugar and salt You often can reduce the amount of fat, sugar and salt without sacrificing flavor in healthy recipes. General guidelines:

Fat. For baked goods, use half the butter, shortening or oil and replace the other half with unsweetened applesauce, mashed banana or prune puree. Remember that each tablespoon (about 15 grams) of oil you use when frying adds about 135 calories to your meal.

Sugar. Reduce the amount of sugar by one-third to one-half. Instead, add spices such as cinnamon, cloves, allspice and nutmeg, or flavorings such as vanilla or almond extract to boost sweetness.

Salt. For most main dishes, salads, soups and other foods, you can reduce the salt by half or even eliminate it. You can reduce salt by half in baked goods that don't require yeast too.

2. Make healthy substitutions Healthy substitutions not only reduce the amount of fat, calories and salt in your recipes but also can boost the nutritional content.

F-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\f6-gut-brain and healthy cooking.doc • Increase vegetables. When making meals, use less meat or poultry or fish and increase the amount of vegetables. You will gain more vitamins, minerals and fiber. • Whole wheat instead of white flour. Use whole wheat flour instead of enriched. Whole wheat flour includes the outer shell of the grain and provides vitamins, minerals and fiber. • Use natural peanut butter over reduced-fat peanut butter. Reduced fat versions of peanut butter can actually have added sugar, hydrogenated fat, and an extra-long list of artificial additives. • Fat-free products. Try using fat-free substitutes as long as they are not loaded with added sugar or salt to maintain flavor. For example, by using fat-free milk instead of whole milk in recipes you can save 66 calories and almost 8 grams of fat per cup.

3. Reduce or Eliminate Some Ingredients In some recipes, reduce or eliminate an ingredient. • Condiments: Reduce condiments such as butter, mayonnaise, syrup, and jelly, which can have large amounts of salt, sugar, fat and calories. Instead of syrup or jelly, try fresh berries that are mashed, or thin slices of fresh apples, peaches or pears. Use less soy sauce (or use reduced sodium soy sauce) than a recipe calls for to decrease the amount of salt. • Reduce cheeses: If a recipe calls for 1 cup of shredded cheese (455 calories), use ¼ cup (115 calories) instead. A savings of 340 calories! • Toppings: In baking eliminate items you generally add out of habit or for appearance, such as frosting, coconut or whipped cream toppings, which are all high in fat and calories.

Reduce the Amount of Fat, Sugar and Salt in Baked Goods Reduce the amount of fat, sugar and salt without sacrificing flavor in healthy recipes by using these general guidelines: • Reduce fat: For baking, use half the butter, shortening or oil and replace the other half with unsweetened applesauce, mashed banana or prune puree. • Reduce sugar: Reduce the amount of sugar by one-third to one-half by adding spices such as cinnamon, cloves, allspice and nutmeg, or flavorings such as vanilla extract or almond flavoring to enhance the sweetness of the sugar traditionally used. • Reduce salt: Reduce salt by one-half in baked goods that don't require yeast. (For foods that require yeast, don't reduce the amount of salt, which is necessary for leavening. Without salt, such foods may become dense and flat.) For most main dishes, salads, soups and other foods, reduce the salt by one- half or even eliminate it completely.

Downsize Your Portion Sizes and Slow Down Your Eating No matter how much you reduce, substitute or eliminate ingredients, some recipes may still be high in sugar, fat and/or salt. Maintain your calorie intake by downsizing portion sizes. Check portion sizes. Many portions today are so large you may not recognize a true portion. Retrain yourself by using 9 inch plates. Concentrate on reducing servings of calorie-dense foods (grains, meats, etc.) and eating more of calorie-sparse but nutrient-dense foods (salads and above-ground vegetables). Learn to use common visual cues to understand serving sizes. One serving of meat, poultry or fish is about the size of a deck of cards, for example. Slow down. Eat your meals slowly to give your hunger feedback systems time to register that you are filling up. Give your digestive system a chance to absorb the vitamins, minerals and other micro-nutrients F-3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\f6-gut-brain and healthy cooking.doc you need to be healthy. Your brain and stomach register feelings of fullness after about 20 minutes. During this time, receptors inform the brain that your body is receiving nutrients by sending hormone signals. The hormone cholecystokinin is released by your intestines and the hormone leptin is released by your fat cells. Leptin tells your brain about your long-term needs and overall feeling of fullness based on how much energy your body is storing. If you eat too fast, these hormones may not have enough time to properly communicate. Slow down your eating to optimize your health and allow your body to respond appropriately to feeling full.

Check out this Roasted Vegetables with Salmon or Chicken - one pan recipe.

Roasted Vegetables with Salmon or Chicken To make this, you’ll need… • a 13 x 9 baking pan (or similar) • salmon or chicken breast filets (4 – 4 ounce pieces) • roasting vegetables (green beans, tomatoes, asparagus or broccoli would be great). • olive oil • salt For additional flavors try 1 Tbsp. fresh lemon juice, 1 clove minced garlic, or 2 Tbsp. fresh herbs

Place the salmon skin filets side down (if there’s any skin) in the middle of the pan, put vegetables on each side of the salmon. Drizzle olive oil over the vegetables and sprinkle with salt to taste. Add approximately 1 tablespoon of a lemon, garlic or fresh herbs (optional) on top of each filet. Bake at 400 degrees for approximately 20 minutes (or until salmon or chicken is cooked through).

Roasted Vegetables with Salmon or Chicken Check out this salmon or chicken and vegetables - one pan recipe. To make this, you’ll need… • a 13 x 9 baking pan (or similar) • salmon or chicken breast filets (4 – 4 ounce pieces) • roasting vegetables (green beans, tomatoes, asparagus or broccoli would be great). • olive oil • salt For additional flavors try 1 Tbsp. fresh lemon juice, 1 clove minced garlic, or 2 Tbsp. fresh herbs

F-4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\f6-gut-brain and healthy cooking.doc

List the ingredients you would need to create this dish at home: 1. ______2. ______3. ______4. ______5. ______

Or create your own alternative recipe to have as your Partial Meal Replacement meal:

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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PARTIAL MEAL REPLACEMENT – FIBER Fiber Facts Dietary fiber, also known as roughage or bulk, includes all parts of plant foods that your body can't digest or absorb. Your body doesn’t digest fiber. Fiber passes virtually unchanged through your stomach and small intestine and into your colon. The average person in the United States consumes about 10 to 14 grams of dietary fiber daily. Experts recommend that the average adult consume 25 to 35 grams of fiber per day. High fiber foods usually contain fewer calories than many low-fiber foods. Meat, milk, eggs, fats, and oils are virtually devoid of fiber. By increasing the fiber content of your diet, you can feel more full and satisfied while eating more food and less calories! Fiber is often classified into two categories: those that don't dissolve in water (insoluble fiber) and those that do dissolve in water (soluble fiber). • Insoluble fiber: This type of fiber promotes the movement of material through your digestive system and increases stool bulk, so it can be of benefit to those who struggle with constipation or irregular stools. Whole-wheat flour, wheat bran, nuts and many vegetables are good sources of insoluble fiber. • Soluble fiber: This type of fiber absorbs water and forms a gel-like material. It can help lower blood cholesterol and glucose levels. You can find generous quantities of soluble fiber in oats, peas, beans, apples, citrus fruits, carrots, barley and psyllium.

A high-fiber diet has many benefits, which include: • Prevents constipation. Dietary fiber increases the weight and size of your stool and softens it. A bulky stool is easier to pass, decreasing your chance of constipation. If you have loose, watery stools, fiber may also help to solidify the stool because it absorbs water and adds bulk to stool. • Lowers blood cholesterol levels. Soluble fiber found in beans, oats, flaxseed and oat bran may help lower total blood cholesterol levels by lowering low-density lipoprotein, or bad, cholesterol levels. • Aids in weight loss. High-fiber foods generally require more chewing time, which gives your body time to register when you're no longer hungry, so you're less likely to overeat. Also, a high-fiber diet tends to make a meal feel larger and linger longer, so you stay full for a greater amount of time. And high-fiber diets also tend to be less energy dense, which means they have fewer calories for the same volume of food.

A Word of Caution: Increase your fiber intake gradually. Adding too much fiber too quickly can cause gas, bloating, and cramping. As you increase your fiber intake, be sure to drink plenty of fluids. Fiber absorbs fluids, thus increasing your fluid needs. Some studies have indicated that in rare cases, too much dietary fiber, especially overuse of fiber powders and pills, can block the absorption of other nutrients (calcium, magnesium, iron, zinc, and chromium).

G-1

©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\g7-fiber.doc FIBER CONTENT The following chart lists the content of fiber in foods. Some highly processed foods such as all-purpose flour and white rice are shown to illustrate how low in fiber processed foods are relative to whole, unprocessed foods. The inclusion of brand-name products does not necessarily imply endorsement by Kaiser Permanente Positive Choice Integrative Wellness Center.

GRAMS OF SERVING CALORIES FIBER VEGETABLES (cooked) Brussels sprouts ½ cup 25 3.5 Cauliflower ½ cup 15 2.8 Carrots ½ cup 25 2.7 Parsnip ½ cup 50 2.7 Spinach ½ cup 20 2.5 Broccoli ½ cup 20 2.2 Beans, green ½ cup 15 2 Cabbage, red and white ½ cup 30 2 VEGETABLES (raw) Tomato 1 medium 25 2 Celery 2 stalks 20 1.4 Onion ½ cup 30 1.3 Lettuce 1 ½ cup 20 1 FRUITS Apple or Pear with skin 1 medium 80 4.5 Blueberries ½ cup 40 4.4 Strawberries 1 cup 55 3.9 Orange 1 medium 60 3.8 Banana 1 medium 100 3 Raisins ¼ cup 110 3 Prunes, dried 4 100 2.5 Apricots, dried 8 halves 60 2.2 Peach or Nectarine 1 medium 35 2 Pineapple ¾ cup 60 1.8 Cherries 15 large 50 1.5 Grapefruit ½ 40 1.4 Cantaloupe 1 cup or ¼ melon 30 1.2

BRANS and SUPPLEMENTS Psyllium seed husks 2 tbsp. 8 Wheat Bran 2 tbsp. 3.2 Benefiber™ 1 tbsp. 3 Wheat Germ ¼ cup 3 Oat Bran ¼ cup 2

G-2

©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\g7-fiber.doc FIBER CONTENT, CONT’D. GRAMS OF SERVING CALORIES FIBER CEREALS, Cold All Bran — Extra Fiber™ ½ cup 60 13 Fiber-One™ ½ cup 60 13 All Bran™ ½ cup 105 10 High Fiber Cereal (Trader Joes) 2/3 cup 90 9

CEREALS, Cooked Barley 1 cup 114 6 Oatmeal (Quaker™) 1 cup cooked 129 4

FLOUR Whole Wheat or Rye 1 cup 15 Soy 1 cup 14 Cornmeal, stone ground 1 cup 13 All Purpose 1 cup 3.5

BREADS Whole Wheat Flour Tortillas 1 90 13 Whole Wheat Pita 1 pita (2 oz.) 160 5 Whole Wheat Bread (100%) 1 slice 60–80 2–5

BEANS and PEAS (cooked) Black-eyed peas ½ cup 80 10 Chickpeas ½ cup 145 7 Kidney beans ½ cup 110 7 Lima beans ½ cup 130 7 Pinto beans ½ cup 110 7 Split peas ½ cup 110 6.5 Black beans ½ cup 57 4 Lentils ½ cup 115 4 Navy beans ½ cup 110 3

OTHERS Fiber Cakes (Zen Bakery) 1 80 13 Bulgar (cracked wheat) 1 cup 0 8 Whole Wheat Spaghetti 1 cup 120 4–8 Brown Rice 1 cup 230 3.2 Air Popped Popcorn 1 cup 25 2.5 White Rice 1 cup 218 1.6

G-3

1. Eating a high-fiber diet may help: o Promote a healthy digestive system. o Reduce the risk of certain types of cancers. o Lower blood cholesterol levels and reduce the risk of heart disease. o All of the above.

2. How much fiber should you get each day? o 8 to 10 grams. o 25 to 35 grams. o 100 grams. o You don't need any.

3. How can you add more fiber in your day? o Eat a ½ cup of cereal with more than 10 grams of fiber in it. o Eat fresh or frozen vegetables. o Eat ½ cup of cooked beans. o All of the above.

4. How many calories does the body absorb from fiber? o Less than 1 gram. o About 4 grams. o About 8 grams. o None, because fiber is not digested and does not release calories.

I will increase my fiber this week by doing the following: ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

G-4

All About Fats Types of Dietary Fat — Fats and oils are made up of basic units called fatty acids. Each type of fat or oil is a mixture of different fatty acids. Some fats are found on multiple lists because of their mixed properties. Fat should make up about 25% to 30% of our daily intake. Based on a 1,200 kcal diet, the total daily fat allowance is about 33 to 40 g.

• Trans Fats are the type of fat that’s created when hydrogen is added to the chemical structure of a fat, typically vegetable oil. The addition of hydrogen helps to make the fat (and therefore the food it’s used in) more shelf-stable, preventing it from easily spoiling when left out unrefrigerated. Partial hydrogenation (the process of adding hydrogen to fat) also creates a semi-solid fat, which is necessary in order to prevent foods from melting at room temperature. Trans fats have no nutritional value. Trans fats decrease the level of HDL (“good” cholesterol) in the bloodstream, increasing the risk of heart disease. While it’s impossible to completely avoid all trans fats due to their presence in nature, the National Academy of Sciences advises cutting them out of your diet as much as possible, and the best place to start is avoiding all foods with the phrase partially hydrogenated anywhere in the ingredients list. The main sources of trans fat in our diet are: baked goods cakes crackers frosting pastries biscuits cookies deep-fried foods margarine snack foods

How fats plug up your blood stream:

• Saturated Fats, which tend to be solid at room temperature and include animal, dairy and certain vegetable fats, are necessary in the diet, but too many can adversely affect cholesterol levels by increasing the LDL, or bad cholesterol. For this reason, they should be limited to less then 10 grams of your total fat per day, but not avoided. Despite the bad press they have received in recent decades, saturated fats play many important roles in our body chemistry. Some of these vital uses include cell membrane support, calcium deposition in bone, liver protection, and cardiac (heart) muscle support.

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Food sources high in saturated fats include: bacon cheese cocoa butter cream cheese lard butter coconut oil cream egg yolks palm (kernel) oil

• Polyunsaturated Fats (PUFAs) contain omega-3 and omega-6 fatty acids. The omega-3 and omega-6 fatty acids are essential, meaning that we cannot make them in our body and therefore must get them from food.

Omega-3 Fatty Acids (n-3 polyunsaturated fatty acids) are dietary nutrients offering human health plus disease preventing/managing potential. Omega-3 fatty acids can lower elevated triglyceride levels, curb stiffness and joint pain, lower levels of depression. boost the effects of antidepressants, and may help the depressive symptoms of bipolar disorder. Omega-3 fatty acids are also important for visual and neurological development in infants, can reduce the symptoms of Attention Deficit Hypertensive Disorder (ADHD) and may help protect the effects of gradual memory loss linked to aging. • Marine Sources — wild-caught cold-water fish (salmon, sardines, halibut, trout) contain beneficial omega-3 fatty acids EPA and DHA (stand for eicosapentaenoic acid and docosahexaenoic acid respectively). These fatty acids reduce the risk of heart disease, improve nervous system and immune function, balances hormones and reduces inflammation, and reduce the risk of lung, breast, prostate, ovarian, colon, and pancreatic cancers.

• Plant Sources — certain plant sources (and derived vegetable oils) such as flaxseed, canola oil, walnuts, etc. contain significant amounts of the plant-based omega-3 fatty acid known as a-linolenic acid ALA. Alpha-linolenic acid is popular for preventing and treating diseases of the heart and blood vessels. It is used to prevent heart attacks, lower high blood pressure, lower cholesterol, and reverse hardening of the blood vessels (atherosclerosis). Omega-6 Fatty Acids (arachidonic acids (AA)) are used for reducing the risk of heart disease, and reducing cancer risk. Omega-6 fatty acids are mostly consumed as linoleic acid from plant oils such as corn oil, soybean oil, and sunflower oil, as well as from nuts and seeds. This AA fat, while critical for good health in modest quantities, will cause chronic inflammation when not held in check by a healthy dose of EPA and DHA omega-3s. The Western diet is rich in omega 6, because the oils are cheap, stable, and prolong the shelf life of processed foods. The food industry therefore replaces more healthy fats and oils with omega-6 fatty acids leading to an imbalance of omega-6s to omega-3s in the typical Western diet. Polyunsaturated fats improve your cholesterol levels and boost your metabolism. According to research, adding a minimum of two weekly servings of fish high in omega-3s (salmon, tuna, mackerel or sardines), while cutting back calories, helps you lose more fat than cutting calories alone.

Food sources high in PUFAs include: chia seeds hempseed sesame seeds sunflower seeds wild fish flaxseed sardines soybeans walnuts whole grain wheat

H- 2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\h8-choosing healthful fats and oils.doc • Monounsaurated Fats (MUFAs) Foods containing monounsaturated fats reduce low-density lipoprotein (LDL) cholesterol. Research also shows that monounsaturated fats may benefit insulin levels and blood sugar control. Food sources high in MUFAs include:

avocados grapeseed oil nut butters olives sesame oil canola oil macadamia nuts (cashews) olive oil sunflower oil nut oil

The types of fats you eat can impact your health more than the amount of fats you eat.

Always remember that the factor that has the most profound impact on cholesterol levels (aside from genetics) is being at a healthy weight. Fat is a concentrated source of calories (9 kcal/g compared to 4 kcal/g for carbohydrate and protein), eating too much may lead to weight gain.

The body needs fat! Not only does the integrity of every cell membrane depend on fat, but the absorption of fat-soluble vitamins (A, D, E and K) does as well. Fat satiates. Here are some major reasons why you should include fats in your diet: • Appetite suppressant — fats help us feel full. Fats take four to eight times longer to digest than carbohydrates, therefore blood sugar levels are more stable when fats are included at meals. This makes them very important in a diabetic diet. • Environmental protection — healthy fats and oils keep skin and body hair healthy and functioning properly providing a barrier to infection, disease and toxins. • Hormonal system — fats are necessary for hormone production and hormonal balance, particularly cholesterol, vitamin D, stress hormones adrenaline, noradrenaline, and cortisol, and sex hormones testosterone and estrogen. • Immune system — fats are integral to optimal immune system function and a healthy balance between the inflammatory and anti-inflammatory responses. Essential fats omega-6 and omega-3 control the inflammatory and anti-inflammatory responses in the body; both responses are necessary for healing injuries and repairing cellular damage. • Internal protection — healthy fats help reduce the risk of, or prevent, heart disease, stroke, autoimmune diseases and certain cancers and reduce serum cholesterol levels. • Nutrient transport — oils transport fat-soluble nutrients (vitamins A, D, E, K, and beta-carotenes) throughout the body. • Phospholipids — fats constitute the membranes that enclose all cells in the body.

H- 3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\h8-choosing healthful fats and oils.doc Activity: Find the fats! Choose 5 new healthy fats that you will begin to add to your daily breakfast plan.

Healthy Fat Source Breakfast Idea 1. 2. 3. 4. 5.

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

H- 4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\h8-choosing healthful fats and oils.doc PARTIAL MEAL REPLACEMENT - MENU PLANNING PUTTING TOGETHER HEALTHY MEALS Why Healthy Menu Planning?

Healthy menu planning is the same as any other part of your life. If you don’t plan, it most likely won’t happen. Not planning can result in falling into the fast food trap. Healthy menu planning is essential. Not only will it give you a healthy eating plan, it will also save time and money. Healthy menu planning is how you can put your new food knowledge together when it comes to breakfast, lunch, and dinner. With healthy menu planning, you can vary your menu each week, just by making small changes in the ingredients.

Healthy menu planning tips: • Strive for balance. Incorporating sweet, tart, sour, savory, and slightly spicy in the same menu can awaken your taste buds. • Emphasize variety. Try including a wide variety of foods from day to day. Vary the types of main courses you make. Include different foods and prepare them in a variety of ways. Try new or unfamiliar foods occasionally. • Add contrast. Incorporate the texture of foods as well as their taste and appearance. Fluffy, crunchy, crisp, and smooth textures are some to keep in mind. Avoid having too much of the same type of food in the same meal. Use an eye-catching combination of different sizes and shapes. • Use color. Avoid using too much of the same color in the same meal. Vegetables and fruits are great for adding natural color to side dishes as well as entrees. Use colorful foods in combination with those that have little or no color. • Eye appeal. Visualize how your meal will look on the plate. Is it something you would enjoy eating? How can you make it look more appetizing? • Shop with convenience in mind. Buy healthy frozen foods in bulk, such as fruits, vegetables, chicken breasts or fish fillets, and remove and thaw out only the amount you need. • Cook a batch and freeze single portions. Many foods freeze well, including meats, fruits, vegetables, whole grains, nuts and seeds. Freezing food keeps it fresh longer and helps prevent waste. Make a high-protein, vegetable-rich casserole or stew and freeze individual-size servings. Then grab and go as needed. Be sure to write the date and contents on packages and move older servings forward as you add new foods to the freezer. • Prepare one-dish meals. For quick and simple cooking, choose dishes that serve as the whole meal. For example, cook dishes that include foods from several food groups, such as meat or fish, quinoa or legumes and vegetables. • Use extras wisely. Plan meals so that you can use the extra food in new dishes. For example, bake chicken for a meal and use the leftovers in soups or toss with greens, fruit, and nuts for a tasty salad. • Hit the books and/or look up recipes online. Cookbooks and online recipes are great resources that can provide practical advice and helpful tips for cooking and selecting healthy foods, planning menus, shopping and reading food labels.

I-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc Planning Future Healthy Breakfasts Healthy breakfast choices are sound nutritional choices to start my day because they provide fiber, antioxidants, vitamins, and minerals. Suggested Breakfast Combination: 2 oz. protein 1 fruit 1 grain 1 healthy fat 1 milk/soy milk/or yogurt

• Choose 2 oz. (or 14 grams), or 2 servings of lean proteins at breakfast. (One ounce = 7 grams of protein). A few good choices are cottage cheese, egg whites, Canadian bacon, lox, and fat free cream cheese. LEAN PROTEIN (or Meat) Servings Vegetarian - Count as Protein and Grain, 3 Tbsp = 1 oz. Beef – Sirloin, Flank or Round Trimmed Beans (Pinto, Black, etc.) Canadian bacon Lentils Chicken Breast Legumes Cottage Cheese, ¼ c = 1 oz. Quinoa Cream Cheese, Fat Free, 2 Tbsp = 1 oz Soybeans Egg Whites, 3 = 1 oz Split Peas Fish or Lox, Wild – all kinds Tofu Pork Loin Veggie Meats (Burgers, Lunch Meat, etc) Turkey Breast

• Choose fruit. Just a few great choices for breakfast fruit are cantaloupe, grapefruit, strawberries, oranges, bananas, pears, and apples. FRUIT 1 cup, or 1 piece that fits into the palm of your hand = 1 serving Apple Dates Mangos Plums Apricots Figs Melons (cantaloupe, watermelon, etc.) Pineapple Bananas Grapes Oranges Pomegranate Berries Grapefruit (1/2) Peaches/Nectarines Strawberries Cherries Kiwi Pears Tangerines

• Choose whole-grain cereals and other whole-grain products. Good choices for breakfast include whole grain bagel thins, high fiber cereal, old-fashioned or steel-cut oatmeal, pinto beans, or a whole grain tortilla. GRAIN/LEGUME/STARCHY VEG. —maximum 100 calories and minimum of 5 grams Fiber per Serving GRAIN LEGUMES - Count as Protein and Grain, 3 Tbsp = 1 oz. STARCHY Bagel Thin, whole wheat Beans (Pinto, Black, etc.) VEGETABLES Barley, ½ c Hummus ½ cup = 1 serving Bread, whole wheat, 1 slice Lentils of any of the Cereal (5 to 15 grams Fiber), ¾ c Legumes following: English Muffin, whole wheat Quinoa Butternut Squash 2 Oatmeal, /3 c cooked Soybeans Corn Pita, whole wheat Split Peas Peas (green) 1 Rice, Brown, /3 c cooked Tofu Sweet Potatoes Tortilla, corn or whole wheat Veggie Meats Yams

I-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc • Choose a healthy fat. Great healthy fats at breakfast can be sprinkled chia or sunflower seeds, all natural peanut butter, avocado or nuts. HEALTHY FATS Avocado (⅛ avocado) Nuts-all kinds (6-10) Oil (Canola or Olive) (1 tsp.) 1 1 Chia Seeds ( /8 cup) Nut Butters- Peanut, Almond, etc.(2 tsp.) Sunflower Seeds ( /8 cup) 1 Flax Seeds ( /8 cup) Olives (6) Sesame Oil (1 tsp.) • Add milk, soy milk or yogurt to your breakfast menu. • MILK - Be sure each serving provides 8 to 20 g protein and no more than 100 to 120 calories. +8 oz or 1 cup = 1 serving of any of the following: 1% or Nonfat Milk Soymilk Yogurt

Healthy Breakfast

Suggested Your Meal

M m i l k Lean Protein High Fiber or Grain or l Legume Starchy Veg k ,

Fats S o and y Oils M i l k Fresh Fruit o r

Y o g u r t

I-3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc Planning Future Healthy Lunches

• Try water-packed tuna, sliced chicken, turkey, or tofu on whole-grain bread or a lettuce wrap. LEAN PROTEIN (or Meat) Servings Vegetarian - Count as Protein and Grain, 3 Tbsp = 1 oz. Beef – Sirloin, Flank or Round Trimmed Beans (Pinto, Black, etc.) Chicken Breast Lentils Cottage Cheese, ¼ c = 1 oz. Legumes Cream Cheese, Fat Free, 2 Tbsp = 1 oz Quinoa Egg Whites, 3 = 1 oz Soybeans Fish, Wild – all kinds Split Peas Pork Loin Tofu Turkey Breast Veggie Meats (Burgers, Lunch Meat, etc) • Load up on vegetables. Include vegetables like carrots, broccoli, cauliflower, lettuce and peppers. VEGETABLES – ½ cooked = 1 serving. All Non-Starchy vegetables are allowed, including the following list: Artichokes Eggplant Onions Asparagus Fennel Peppers* Beets Garlic Snow peas Broccoli* Green beans Spaghetti squash Brussels sprouts* Kale* Summer squash Carrots Leeks Tomatoes* Cauliflower* Mushrooms Zucchini

SALAD A salad containing approximately 2 cups of dark green, leafy vegetables (arugula, endive, escarole, romaine, and/or spinach). A minimum of ½ cup of raw, Fresh Free vegetables (see below), and 1 tablespoon of approved salad dressing should be consumed once a day. Fresh Free Vegetable Options (½ cup minimum) Salad Dressing Options Broccoli*, Green or wax beans, Cabbage*, Carrots, Celery, • 1 tsp. olive oil with 2 tsp. vinegar of choice (counts Cucumber, Green onion, Jicama, Mushrooms, Onions, as 1 healthy fat) or Peppers*, Radishes, Sprouts-Alfalfa and Bean, Tomatoes, • 1 tbsp. or no more than 20 calories of non-fat salad Water chestnuts dressing, vinegar, lemon juice, or salsa. *These vegetables may cause excess gas and indigestion. If you have a problem, switch to the other vegetable choices until your body adjusts. • Consume one serving of a grain, legume or starchy vegetable. Try fiber-rich bean, split pea, vegetable, minestrone soups, kidney or garbanzo beans. If you make your own soup, use broth or skim milk to keep the fat content lower.

I-4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc GRAIN/LEGUME/STARCHY VEG. —maximum 100 calories and minimum of 5 grams fiber per serving GRAIN LEGUMES - Count as Protein and Grain, 3 Tbsp = 1 oz. STARCHY Bagel Thin, whole wheat Beans (Pinto, Black, etc.) VEGETABLES Barley, ½ c Hummus ½ cup = 1 serving Bread, whole wheat, 1 slice Lentils of any of the Cereal (5 to 15 grams fiber), ¾ c Legumes following: English Muffin, whole wheat Quinoa Butternut Squash 2 Oatmeal, /3 c cooked Soybeans Corn Pita, whole wheat Split Peas Peas (green) 1 Rice, Brown, /3 c cooked Tofu Sweet Potatoes Tortilla, corn or whole wheat Veggie Meats Yams • Choose a healthy fat. Great healthy fats at lunch can be olives, avocados, oils, nuts and seeds. To decrease calories, use mustard instead of mayonnaise. HEALTHY FATS Avocado (⅛ avocado) Nuts-all kinds (6 to 10) Oil (Canola or Olive) (1 tsp.) 1 1 Chia Seeds ( /8 cup) Nut Butters- Peanut, Almond, etc. (2 tsp.) Sunflower Seeds ( /8 cup) 1 Flax Seeds ( /8 cup) Olives (6) Sesame Oil (1 tsp.)

Eat these foods less often or eliminate: • Processed lunch meats. • Fried meat. • Fried chicken. • Fried fish. • Creamy salads. • French fries. • Rich creamy desserts. • High-fat baked goods. • High-fat cheeses. Healthy Lunch Suggested Your Meal

M m i l k Lean Protein High Fiber or Grain or l • Legume Starchy Veg k , • S Fats o and y Oils • M i • l k Fresh Fruit • o r

Y o g u r t I-5 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc Planning Future Healthy Snacks For snacks pair a fruit or vegetable with a protein, milk/yogurt, or healthy fat.

• Make a raw vegetable platter made with a variety of vegetables such as carrots, snow peas, cauliflower, broccoli, and green beans. Prepare dips with non-fat plain yogurt or non-fat sour cream as the base. • Make a big fruit salad and keep it on hand for snacks. Add plain yogurt mixed with cinnamon. • When thirsty, drink water, herbed tea, or water with a twist of lime or lemon.

Plan Healthy Snacks

Protein, Milk/Yogurt, or Healthy Fats Paired with a Fruit or Vegetable

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

Planning Future Healthy Dinners

Suggested Dinner Combination: 4 oz. protein 2+ cups vegetables 1 healthy fat (1 fruit)

Choose main dishes that call for lean proteins like fish, chicken, or turkey. Remove the skin and visible fat from poultry and trim the fat from meat. Some good choices are: • Wild salmon • Baked white fish, with lemon and fennel. • Chicken cacciatore Italian-style. • Chicken curry served over steamed cauliflower. • Oriental pork made with lean pork loin, green peppers, and pineapple chunks served with zucchini noodles.

I-6 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc LEAN PROTEIN (or Meat) Servings Vegetarian - Count as Protein and Grain, 3 Tbsp = 1 oz. Beef – Sirloin, Flank or Round Trimmed Beans (Pinto, Black, etc.) Chicken Breast Lentils Cottage Cheese, ¼ c = 1 oz. Legumes Cream Cheese, Fat Free, 2 Tbsp = 1 oz Quinoa Egg Whites, 3 = 1 oz Soybeans Fish, Wild – all kinds Split Peas Pork Loin Tofu Turkey Breast Veggie Meats (Burgers, Lunch Meat, etc)

• Eat a variety of vegetables like broccoli, Brussels sprouts, cauliflower, cabbage, spinach, and kale. For old favorites, like green beans, skip the butter and sprinkle with lemon juice or herbs. VEGETABLES – ½ cooked = 1 serving. All Non-Starchy vegetables are allowed, including the following list: Artichokes Eggplant Onions Asparagus Fennel Peppers* Beets Garlic Snow peas Broccoli* Green beans Spaghetti squash Brussels sprouts* Kale* Summer squash Carrots Leeks Tomatoes* Cauliflower* Mushrooms Zucchini

• Cook vegetables and proteins in olive or sesame oil, or sprinkle with same. HEALTHY FATS Avocado (⅛ avocado) Nuts-all kinds (6-10) Oil (Canola or Olive) (1 tsp.) Chia Seeds (1/8 cup) Nut Butters- Peanut, Almond, etc.(2 tsp.) Sunflower Seeds (1/8 cup) Flax Seeds (1/8 cup) Olives (6) Sesame Oil (1 tsp.)

• For dinner, or after dinner, choose a dessert that gives lots of nutrients like a baked apple or banana sprinkled with cinnamon, or a cup of cubed fresh fruit with mint. FRUIT 1 cup, or 1 piece that fits into the palm of your hand = 1 serving Apple Dates Mangos Plums Apricots Figs Melons (cantaloupe, watermelon, etc.) Pineapple Bananas Grapes Oranges Pomegranate Berries Grapefruit (1/2) Peaches/Nectarines Strawberries Cherries Kiwi Pears Tangerines

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Healthy Dinner Suggested Your Meal

M m i l k Lean Protein High Fiber or Grain or l Legume Starchy Veg k ,

S Fats o

and y Oils M i l k Fresh Fruit o r

Y o g u r t

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

I-8 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\i9-menu planning.doc PARTIAL MEAL REPLACEMENT – DEALING WITH STRESS Stress is the emotional and physical response to pressures from your internal and external environments. It's impossible to live without some stress but when stress gets out of control, it can damage your health, harm your relationships, and interfere with the enjoyment of your life. Stress can cause both emotional and physical symptoms and the effects of stress are different for different people. Many addictive coping mechanisms are linked to a stressful lifestyle, such as overeating, smoking, and drug and alcohol abuse. To understand stress, imagine living thousands of years ago, at a time when your caveperson ancestors were a part of other animals’ food supply. Constantly threatened by hungry animals such as bears, lions, and wolves, successful humans evolved the ability to react instantly to stressful situations. Under stress, the body pumps out the stress hormones adrenaline, noradrenaline, and cortisol preparing the body for the fight or flight response. Most of the time in modern life, the fight or flight response doesn’t help you. Your stress response hasn’t evolved to be able to tell the difference between being attacked by a hungry animal and the alarm clock going off at 6 a.m. Stress hormones flood your system in both situations, preparing you for extreme physical action. If you are under chronic stress, the life-saving stress response of your ancient ancestors can and does seriously harm your physical and emotional health.

How Stress Can Harm You Recent studies indicate that physical changes associated with chronic stress may significantly contribute to America’s leading causes of death; heart disease and cancer. It is estimated that two-thirds of all doctor visits are stress-related.

The negative effects of chronic stress include:

• Chronic fatigue, digestive upsets, headaches, and back pain. • Diminished or impaired immune response. • Increased risk of heart attack and stroke. • Increased incidence of autoimmune diseases such as arthritis and asthma. • Dependence on potentially addictive behaviors such as overeating, smoking, drinking, and drug abuse. • Chronically elevated cortisol levels that cause fat to be deposited as visceral fat in the abdomen. (This type of fat is very biologically active and contributes to food cravings and chronic overeating).

When dealing with a stressful event like a saber tooth tiger attack, having your mind and heart race, pupils dilate, blood pressure rise, and glucose and fatty levels increase, is helpful. For most of us, however, the fight or flight response is more likely to be triggered by things like traffic, job stress, financial problems, and relationship issues. In other words, instead of having an occasional brief, but intense, life threatening event, you feel stressed constantly.

J-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\j10-dealing with stress.doc Stress and Weight Gain

When stress activates the flight or fight response in your central nervous system, digestion can shut down. Your central nervous system shuts down blood flow, affects the contractions of your digestive muscles, and decreases secretions needed for digestion. Stress hormones, and the access to high-fat, sugary and salty foods can push you toward overeating. Weight gain is linked to stress. In the short term, your hypothalamus produces corticotropin-releasing hormones, which suppresses appetite. The brain also sends messages to the adrenal glands atop the kidneys to pump out the hormone epinephrine (also known as adrenaline). Epinephrine helps trigger the body's fight-or-flight response and temporarily puts eating on hold. If stress persists, it's a different story. The adrenal glands release another hormone called cortisol. Cortisol increases your appetite and may also ramp up motivation in general, including the motivation to eat! Once a stressful episode is over, cortisol levels should fall, but if the stress doesn't go away — or if your stress response gets stuck in the "on" position, cortisol may stay elevated. In Summary: Epinephrine or Adrenaline: Increases heart rate, blood pressure and blood sugar levels; decreases appetite; short-lived. The body does not want to eat while under the influence of adrenaline. Cortisol: Increases blood sugar, increases insulin production, enhances appetite; long-lived. This is the hormone that kicks in later, after the stress has passed and drives us to eat. • Visceral (abdominal fat) is most receptive to insulin. This is why cortisol is often deemed the belly fat hormone. • Chronically elevated levels of cortisol can lead to decreased muscle mass, reduced bone density, and gum disease (which can be a contributor to heart disease). • Starvation and long gaps between meals can prompt the body to release cortisol into the system.

STRESSED = DESSERTS Why Desserts? There’s a reason why most of us tend to choose sugary or refined carbohydrates (i.e., cookies, ice cream, candy, bread, crackers, cake, etc.) in response to a stressor. See the diagram below.

Stressful event Fight or Flight Rest and Recovery

New brain pattern: Dopamine Sugar/refined Eat refined/ (feel better) carbs = stress sugary carbs relief

Dynorphine (eat Brain releases Blood sugar spike more) endorphins

J-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\j10-dealing with stress.doc Use the checklists below to identify my personal signs of stress: Changes in my behavior. When I am stressed I often experience…

WHAT ARE MY PERSONAL SIGNS OF STRESS?

__ Problems sleeping (too much, too little, sleep disturbances). __ Overeating or bingeing episodes. __ Excessive drinking or using recreational drugs to relax. __ A strong need to get away.

Changes in my thoughts. When I am stressed I often have difficulties… __ Focusing or concentrating. __ Remembering things. __ Thinking positively. __ Obsessing over things.

Changes in my feelings and emotions. When I am stressed I often feel… __ Irritable. __ Anxious. __ Worried. __ Sad or melancholic. __ Tense. __ Angry. __ Helpless. __ Hopeless. __ Depressed.

Changes in my physical health and bodily functions. When I am stressed I often have… __ Backaches and neck aches. __ Muscular tension. __ Nervous stomach. __ Other digestive problems. __ Breathing problems (shortness of breath, shallow, and rapid breathing). __ Chronic tiredness or fatigue. __ Dizziness.

J-3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\j10-dealing with stress.doc LEARNING TO MANAGE MY STRESS AND STRESS EATING

There are five simple things I can do to help my body and mind manage my stress better. Following these simple guidelines will help improve my immune system, my energy level, my self-esteem, my sense of well being, and help control stress eating.

1. Relaxation • Set aside 15 minutes daily, whether I am feeling stressed or not, just to relax. • Go through whatever relaxation procedures work best for me. Deep breathing, meditation, prayer, yoga or tai chi exercises, stretching, progressive muscle relaxation, or a short nap. I will find some relaxation method to regularly practice.

2. Regular physical activity • Regular physical activity reduces harmful stress hormone levels better than any other technique. • Regular physical activity helps me look better, sleep better, concentrate better, and strengthen my immune response. It improves mood and increases self-esteem. The best exercise is aerobic activity such as brisk walking, jogging, bicycling, aerobic dancing, swimming, rowing, skating, cross-country skiing, and stair stepping. • Start with walking. Walk briskly for about 20 minutes, three times a week. As my fitness level improves, take longer walks, or switch to a more vigorous form of activity. • Whenever possible, exercise in nature. The quietness and change of scene will help lower my stress levels.

3. Eating healthier foods • Eating healthier foods will give me a sense of control that can help to reduce my stress levels, as well as making me feel physically good. My body and brain need the proper nutrition to be healthy and tolerate stress. Eat lots of fresh vegetables and fruits, raw nuts and seeds, lean meats, and healthy oils.

4. Minimize or eliminate chemical stimulants • Alcohol, drugs, caffeine, nicotine, and highly refined sugar and flour products are commonly abused in an effort to deal with stress. These drugs only temporarily mask the symptoms of stress and I am likely to feel even more stressed than ever when the effects wear off.

5. Learn to calmly respond. Four useful techniques for calmly responding are: • Time out. Stop the activity or conversation that was causing me stress. If I can move away, leave or go for a short walk. If moving away isn’t possible, silently count to 10 before I speak again. • Breathing. Check my breathing by placing one hand on my chest and one hand on my belly. If my chest hand moves and not my belly hand I am stress breathing. To de-stress and belly breathe, let my stomach relax. Breathe in deeply, then breathe all the air out. Let my lungs fill naturally with air again, while my stomach expands. Whenever I am stressed, worried, or tense, use my breathing to help calm down. Take a deep breath and quietly let it go out completely, then let my abdomen expand as the air comes back into my lungs. • Progressive muscle relaxation. Close my eyes and breathe deeply two or three times. Start with my face. Squint my eyes, tighten my teeth and jaw, and wrinkle my forehead. Feel the tension while I count silently to five and let go. Pull my shoulders up until they nearly touch my ears. Feel the

J-4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\j10-dealing with stress.doc tension while I count silently to five and let go. Progress through the rest of my body, tightening muscles while I count slowly to five, then letting the tension go. • Thought-stopping. When I become aware of negative thoughts, just say stop! I may need to repeat stop! several times until the negative thoughts are interrupted.

Exercise: • What do I need to change in my life to better manage my stress? ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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PARTIAL MEAL REPLACEMENT – PHYTONUTRIENTS and ANTIOXIDANTS

Phytonutrients are plant nutrients or chemical compounds in vegetables and fruits that demonstrate nutritional, health-promoting and disease-preventing functionality in the body. Antioxidants promote the function of the immune system, and help prevent or stop cell damage caused by oxidants. Oxidants are free radicals that you find in the environment, but they're also produced naturally in your body. Antioxidants are associated with the treatment or prevention of cancer, cardiovascular disease (CVD) and autoimmune diseases. Below is a listing of phytonutrients and antioxidants:

Know Your Colors Food Color Phytonutrients & Antioxidants Best food sources Green Thiocyanates, indoles, lutein, Cabbage, beet greens, collard greens, zeaxanthin, sulforaphane, arugula, broccoli, Brussels sprouts, kale, isothicyanates mustard greens Yellow Limonene Lemons and other citrus fruits Orange Carotenes Mangos, carrots, apricots, cantaloupe, peppers, squash, sweet potatoes, yams, pumpkins Red Lycopene Tomatoes, watermelons, pink grapefruit Purple, orange, red Resveratrol, ellagic acid, Red wine, grapes, grape juice, cyanidin, quercetin strawberries, raspberries Brown Genistein, phytosterols, saponins, Soybeans, mung beans, peanuts, protease inhibitors dried beans White Allium, allyl sulfide, quercetin Chives, leeks, garlic, onions, apples

COLORFUL FRUITS AND VEGETABLES

Choose at least one item from each color group daily.

NOTE: Serving sizes below represent optimal antioxidant and phytonutrient effect.

RED FOOD SERVING SIZE CALORIES FIBER ❑ Pink grapefruit 1 whole fruit 75 3 ❑ Tomato juice 1 cup 40 1 ❑ Tomato sauce/puree 1 cup 100 5 ❑ Tomatoes, cooked 1 cup 70 3 ❑ Tomatoes, raw 1 large 40 2 ❑ Watermelon 1 cup balls 50 1 RED/PURPLE ❑ Beets, cooked 1 cup 75 3 ❑ Blackberries 1 cup 75 8 ❑ Blueberries 1 cup 110 5 ❑ Cherries 1 cup 85 3 ❑ Cranberries 1 cup raw 60 5

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RED/PURPLE (Cont’d) FOOD SERVING SIZE CALORIES FIBER ❑ Eggplant, cooked 2 cups 60 5 ❑ Grapes 1 cup 115 2 ❑ Peppers, red bell 1 large 45 3 ❑ Plums 3 small 100 3 ❑ Prunes 5 whole 100 3 ❑ Red apple 1 medium 100 4 ❑ Red cabbage, cooked 2 cups 60 6 ❑ Red pear 1 medium 100 4 ❑ Strawberries 1½ cups, sliced 75 6 ORANGE ❑ Acorn squash, baked 1 cup 85 6 ❑ Apricot 5 whole 85 4 ❑ Cantaloupe ½ medium 80 2 ❑ Carrot juice 1 cup 95 2 ❑ Carrots, cooked 1 cup 70 5 ❑ Carrots, raw 3 medium 75 6 ❑ Mango ½ large 80 3 ❑ Pumpkin, cooked 1 cup 50 3 ❑ Sweet potato 1 small, 2” x 5” 100 2 ❑ Winter squash, baked 1 cup 70 7 ORANGE/YELLOW ❑ Nectarine 1 large 70 2 ❑ Orange 1 large 85 2 ❑ Papaya ½ large 75 3 ❑ Peach 1 large 70 3 ❑ Pineapple 1 cup, diced 75 2 ❑ Tangerine 2 medium 85 5 ❑ Yellow grapefruit 1 fruit 75 2 YELLOW/GREEN ❑ Avocado ½ average fruit 80 2 ❑ Collard greens, cooked 2 cups 100 10 ❑ Corn ½ cup kernels, 1 ear 75 2 ❑ Green beans, cooked 2 cups 85 8 ❑ Green peas ½ cup 70 4 ❑ Green bell peppers 1 large 45 3 ❑ Kiwi 1 large 55 3 ❑ Mustard greens, cooked 2 cups 40 6 ❑ Romaine lettuce 4 cups 30 4 ❑ Spinach, cooked (raw) 2 cups (4 cups) 80 (30) 8 (4) ❑ Turnip greens, cooked 2 cups 60 10 ❑ Yellow bell peppers 1 large 50 2 ❑ Zucchini with skin, cooked 2 cups 60 5 GREEN ❑ Broccoli, cooked 2 cups 85 9 ❑ Brussels sprouts, cooked 1 cup 60 4 K-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\k11-phytonutrients and antioxidants.doc ❑ Cabbage, cooked 2 cups 70 8 ❑ Cabbage, raw 2 cups 40 4 ❑ Cauliflower, cooked 2 cups 55 6 ❑ Chinese cabbage, cooked 2 cups 40 5 ❑ Kale, cooked 2 cups 70 5 ❑ Swiss chard, cooked 2 cups 70 7 WHITE/GREEN ❑ Artichoke 1 medium 60 6 ❑ Asparagus 18 spears 60 4 ❑ Celery 3 large stalks 30 3 ❑ Chives 2 tablespoons 2 0 ❑ Endive, raw ½ head 45 8 ❑ Garlic 1 clove 4 0 ❑ Leeks, cooked 1 medium 40 1 ❑ Mushrooms, cooked 1 cup 40 3 ❑ Onion 1 large 60 3

From What Color is Your Diet? By David Heber, MD, PhD, Susan Bowerman, 2003 by Regan Books

Eat lots of COLOR! Eat foods that have color, life and texture. Eating from the rainbow ensures that you will be receiving a variety of nutrients. The richer the color – the better. Stimulate your taste buds and open your mind to new flavors.

Plan high fiber and high phytonutrient foods into your eating this week:

Breakfast:______

Fruit (with Optifast):______

Dinner:______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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PARTIAL MEAL REPLACEMENT – HEALTHY SHOPPING AND SUGAR SUBSTITUTES

Healthy Shopping Tips

• Select Superfoods over regular foods. Superfoods are healthier in general and have clinically demonstrated disease fighting/preventive nutrients. • Always use a shopping list and stick to the list. • Try a new fruit or vegetable each week. Don’t know how to prepare it? Google is your friend.

BE AWARE OF THE EFFECTS OF ADVERTISING Know What Supermarket Managers Know Understanding some of these tricks of the trade may help you save money and shop more healthfully. • The more time you spend in a supermarket, the more money you spend. Shop with a list. • Supermarket layouts are carefully planned so that you spend the maximum amount of money on as many unplanned purchases as possible. In fact, only a third of shoppers come with a list and only one third of purchases are planned. • Fifty percent of supermarkets open with produce; the rest open with flowers. This gives the consumer the impression of freshness, crispness, color, and beauty. This first impression influences where you will shop. • The more time you spend shopping along the sides and back of the supermarket, the more money the store makes. Usually about half a store’s profits come from items from the store perimeter, such as produce, dairy, and meat. Processed foods have a lower profit margin. • Every inch of space for items in the middle of the store is carefully planned. There is tremendous competition for shelf space. Large supermarkets often charge slotting fees for shelf space. The center aisles of the store are where the less profitable items are compared to the store perimeter. • Products shelved at eye level, the best viewing angle — 51 to 53 inches off the floor — sell best. When items are placed in special in-aisle gondolas or end caps, sales increase five times. • The UPC price code scanner allows retailers to know what customers are buying, where the item was located, when they are buying, and at what price.

BE AWARE OF THE EFFECTS OF MARKETING The food business in America is a multi-billion dollar industry. Advertising, supermarket layout, and packaging are designed to get you to buy on impulse at the highest possible profit margin. Tremendous resources in money and psychological marketing expertise are expended to get you to buy food items you never thought you needed or wanted. It works because we are usually unaware of how we are being conned and manipulated. Food manufacturers in the U.S. produce 3500 calories per person per day, and they want to sell all the food they produce.

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1. Serving Size – To be certain on what you’re consuming, pay attention to the serving size and the servings per container. All of the nutrition information is based on the serving size. In general, the serving size doesn’t represent a normal serving. Marketers like to use this trap to make a product appear as if it’s healthier. 2. Redundant Claims – Promises on packages that are unnecessary like “Gluten-Free” on a package of seaweed. Since gluten is found in wheat, barley, rye and any foods made with these grains seaweed would not have gluten in it in the first place. 3. Fortifying a Product to Up-Sell – Fortifying is the process of adding synthetic compounds (manufactured vitamins, minerals and antioxidants) to processed foods in an attempt to make them appear healthier. The vitamins, minerals and antioxidants used to fortify are usually sprayed on or mixed in during the manufacturing. Fortified or enriched foods are not necessarily the best choice. Vitamin-padded junk food is often peddled as nutritious, even though it isn’t. 4. ‘Natural’ Claim – There is no definition for the word ‘Natural’ according to the FDA. This means any package can claim that it’s 100% Natural without having to answer to regulation. 5. Sugar Deception – Currently the FDA claims that there are no recommendations for the total amount of sugar to eat in a day. Food marketers take advantage of this loophole to avoid the enormous amount of sugar that is present in processed foods. Remember, the American Heart Association recommends no more than 25 to 37.5 grams of sugar a day, which is roughly 6 to 9 teaspoons per day. 6. Trans-Fats – Words like ‘Hydrogenated’ or ‘Partially Hydrogenated’ directly imply that the product has heart disease causing trans-fats. Some products like a package of 100 Calorie Snack Cookies claim zero grams of trans fat, yet in the ingredients, they list partially hydrogenated oil (ie, trans fat). They get away with this because the FDA allows manufacturers to express any trans fat that is less than .5 grams per serving as zero. Since the 100 Calorie Snack Cookies have 6 servings per package, you could have up to .5 grams of trans fat per serving. That’s 3 grams of trans fat! 7. Asterisk – If a food has an asterisk with a health claim like *may lower the risk of heart disease, you may want to question why the food needs to promote itself that way. Claims with asterisks are usually based on weak observational studies. 8. Multi-Grain Empty Promise – The FDA has no definition for the claim ‘Multi-Grain’. These words can be used liberally on any packaging. To buy healthier grain products, look for the words “whole wheat flour” listed as the first ingredient on a package.

Call the manufacturer for information If information is not listed on the label, write or call the manufacturer’s customer service number, or try 1-800-555-1212 and ask for an 800 listing for the specific manufacturer.

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SUGAR SUBSTITUTES

Limit 3 servings or less per day for all the Sugar Substitutes and Novel Sweeteners listed below: One serving is equal to: One 12 oz diet beverage, One 6 oz. sugar-free yogurt or One packet

APPROVED SUGAR SUBSTITUTES Aspartame (NutraSweet™, Equal™) Phenylalanine, methanol, and aspartic acid. Is found in more than 6,000 products. Approved by the (FDA) for general use in 1981. Discovered in 1965. 200 times sweeter than sucrose. Saccharin (Sweet ‘n Low™, Sugar Twin™) Benzoic sulfilimine. 1912 stated that saccharin was not harmful. Warning label attached 1977. Approved by the (FDA) for general use in 2000. Discovered in 1879. 200 to 700 times sweeter than sucrose. Sucralose (Splenda™) Chlorination of sucrose. Substitutes three of the hydroxyl groups with chlorine. Approved by the (FDA) for general use in 1998. Discovered in 1976. 320 to 1,000 times sweeter than sucrose. Acesulfame K (Sunett™) Potassium salt of methyl, oxathiazine and dioxide. Approved by the (FDA) for general use in 2003. Discovered in 1967. 200 times sweeter than sucrose. Neotame Aspartic acid and phenylalanine. Approved by the (FDA) for general use in 2002. 5000 to 8000 sweeter than sucrose. Advantame A water-soluble, crystalline white powder made from aspartame and vanillin. Approved by the (FDA) for general use in 2014. 20,000 times sweeter than sugar and 100 times sweeter than aspartame.

NOVEL SWEETENERS Stevioside (Stevia extracts, Pure Via, Truvia) From leaves of a South American plant. Not FDA-approved. It can be sold in the U.S. as a dietary supplement only. 300 times sweeter than sucrose. Tagatose Found in dairy products. Approved by the (FDA) for general use in 2001. 92% as sweet as sucrose. Trehalose Disaccharide formed by a bond between two glucose units. Approved by the (FDA) for general use in 2000. 45% as sweet as sucrose.

SUGAR ALCOHOLS Sugar alcohols — Carbohydrates with a chemical structure partially resembling sugar and alcohol (ie, erythritol, hydrogenated starch hydrolysate, isomalt, lactitol, malitol, manitol, sorbitol, xylitol). Sugar alcohols occur naturally in plant foods in small amounts, such as berries and fruits. As a group, sugar alcohols are not as sweet as sucrose, and they have less food energy than sucrose.

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\l12-healthy shopping and sugar substitutes.doc Possible health benefits of sugar substitutes One benefit of sugar substitutes is that they don't contribute to tooth decay and cavities. They may also help with weight control. One of the most appealing aspects of sugar substitutes is that they are non- nutritive — they have virtually no calories. In contrast, each gram of regular table sugar contains 4 calories. A teaspoon of sugar is about 4 grams. For perspective, consider that one 20-ounce bottle of a sweetened cola contains 16 teaspoons of added sugar, or about 240 calories. If you're trying to lose weight or prevent weight gain, products sweetened with sugar substitutes rather than with higher calorie table sugar may be an attractive option. On the other hand, some research has suggested that consuming sugar substitutes may be associated with increased weight, but the cause is not yet known.

Possible health concerns with sugar substitutes Sugar substitutes have been the subject of intense scrutiny for decades. Sugar substitutes are regulated by the Food and Drug Administration (FDA) as food additives. They must be reviewed and approved by the FDA before being made available for sale. The FDA has established an Acceptable Daily Intake (ADI) for each sugar substitute. The ADI is the maximum amount considered safe to consume each day over the course of your lifetime. ADIs are intended to be about 100 times less than the smallest amount that might cause health concerns. To this date, there is no sound scientific evidence that any of the sugar substitutes approved for use in the U.S. cause cancer or other serious health problems. The bottom line is that there is a fair amount of evidence to confirm the safety of sweeteners at levels consumed within the Acceptable Daily Intake levels.

Novel Sweeteners and Sugar Alcohols Novel sweeteners are a combination of various types of sweeteners. Novel sweeteners, such as stevia, are hard to fit into one particular category because of what they're made from and how they're made. Note that although the FDA has approved highly refined stevia preparations as a novel sweetener, it has not approved whole-leaf stevia or crude stevia extracts for this use. Tagatose and Trehalose are considered novel sweeteners because of their chemical structure. Tagatose is a low-carbohydrate sweetener similar to fructose that occurs naturally, but is also manufactured from lactose in dairy products. Foods containing Tagatose cannot be labeled as sugar-free. Trehalose is found naturally in mushrooms. Sugar alcohols (polyols) are carbohydrates that occur naturally in certain fruits and vegetables, but they also can be manufactured. As with sugar substitutes, the FDA regulates the use of sugar alcohols. When added to foods, sugar alcohols add sweetness, bulk, and texture. They also help food stay moist, prevent browning when heated, and add a cooling sensation to products. Sugar alcohols are often combined with sugar substitutes to enhance sweetness.

Improve your health by setting a goal this week • Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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The Advantages of Assertiveness • How you interact with others to get your needs met can be a source of considerable stress which can lead to weight gain. • When you are assertive, you can be more relaxed in interpersonal situations. • You are assertive when you stand up for your rights in such a way that the rights of others are not violated. • By being assertive you can: o Take care of your needs directly and openly. o Express your personal likes and interests spontaneously. o Talk about yourself without being self-conscious. o Accept compliments comfortably. o Disagree with someone openly. o Ask for clarification, and say no without feeling guilt or fear.

Getting Your Needs Met: What’s Your Style? • Your first step in becoming more assertive is to identify how you use the four basic styles of interpersonal behavior. • Your behavior is probably a combination of the four styles listed below. • Identify your dominant style of inter-personal behavior. • Identify strategies to maximize your assertive behavior. Aggressive Style: Aggressive behavior often causes others to want to ignore or reject your needs. You are behaving aggressively when you accuse, threaten, and step on people without regard for their feelings. The advantage of this kind of behavior is that people do not push you around. The disadvantage is that people do not want to be around you. Passive Style: Passive behavior often leaves other people confused about your needs. You are behaving passively when you allow others to push you around, when you do not stand up for yourself, and when you do what you are told, regardless of how you feel about it. The advantage of being passive is that you rarely experience direct rejection. The disadvantage is that you are used and taken advantage of, and you store up a heavy burden of resentment and anger. Passive-Aggressive Style: Passive-Aggressive behavior appears passive on the surface but is actually aggressive, acting out of anger or resentment in a subtle, indirect manner. You often feel powerless and victimized, incapable of dealing directly with the people you are angry with or who you resent. You seem to be cooperative, but actually you try to sabotage. Like passive behavior, you rarely experience direct rejection or conflict, but your anger drives you to get even rather than get your needs met. Assertive Style: Assertive behavior allows you to clearly state your needs making it easier for people to meet them. You behave assertively when you stand up for yourself, express your true feelings, and do not let others take advantage of you. At the same time, you are considerate of others' feelings. The advantage of being assertive is that you get what you want, usually without upsetting or making others angry. If you are assertive, you can act in your own best interest, and not feel guilt or fear about it.

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©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\m13-being assertive.doc List an example of a time you behaved aggressively and how you felt as a result of that behavior.

List an example of a time you behaved passively and how you felt as a result of that behavior.

List an example of a time you behaved passive-aggressively and how you felt as a result of that behavior.

List an example of a time you behaved assertively and how you felt as a result of that behavior.

How can you learn to be assertive most of the time and get your needs met more often? • Identify your needs.

• Identify who can help you meet your needs.

• Present your needs clearly and specifically.

• Present your needs when they can be heard.

• Have a back-up plan.

• Start learning to use your new assertiveness by completing My Assertiveness Script below:

(Adapted with permission by New Harbinger Publications, Oakland, CA; www.newharbinger.com from the Relaxation & Stress Reduction Workbook by Davis M, Eshelman E, and McKay M.)

M-2

2. How do I feel about needing something from others? ______

3. Who can help me meet my need? ______

4. What specifically do I want from him or her? ______

5. Will he or she be willing and/or able to help me meet my need? ______

6. How likely will he or she be to give me what I need? ______

7. How will I know I have gotten what I need? ______

8. What will I do if I don’t get my need met? ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

• How confident are you that you will/can meet the goal you have set for yourself for the coming week? Confidence level _____%.

M-3

PARTIAL MEAL REPLACEMENT – MY BODY IMAGE

WRITING ASSIGNMENT “While walking through the mall the other day, I caught a glimpse of myself in a full-length mirror. At first I thought…”

CHALLENGES • What problem areas can I identify with my body image? What strategies can I use to overcome those problem areas?

N- 1

1. The heavier me loves to:

2. The heavier me would say:

3. The heavier me at a party would:

4. The heavier me would wear:

5. The heavier me needs:

6. The heavier me is:

1. The slimmer me loves to:

2. The slimmer me would say:

3. The slimmer me at a party would:

4. The slimmer me wears:

5. The slimmer me deserves:

6. The slimmer me is:

N- 2

• How do I feel? • What do I need? • Do I need support? If so, what kind, and from whom? • Are my expectations reasonable? • Are my thoughts positive and powerful? • Am I using weight to express myself? • Do I honor and accept my body? • How does my body feel? • Am I taking care of my body? • Is my healthcare effective? • Am I eating regularly? • Am I eating only when I’m hungry? • Is my food both healthy and pleasurable? • Am I physically active? • Am I engaging in meaningful activities? • Am I taking time to restore myself? Check one area that I will work on this week! My plan is:

Adapted from Solutions by Laurel Mellin, MA, RD.

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

N- 3

PARTIAL MEAL REPLACEMENT – FIT FOR MY LIFE

CALCULATE MY TARGET HEART RATE ZONE Determine my Heart Rate % by: Subtract my age from 220 = ______. This is my maximum heart rate. Multiply my maximum heart rate by:

0.5 for 50% = ______= Beginning exercise

0.6 for 60% = ______= Moderate exercise

0.7 for 70% = ______= Regular exercise

CHALLENGES Identify any problem areas that may keep me from regularly exercising. ______

Develop strategies to overcome my problem areas. ______

O-1

• Improves overall physical health. • Improves reaction time, concentration level, and memory. • Releases muscular tension. • Reduces stress and aids relaxation. • Improves the quality of sleep. • Improves mood and combats depression and anxiety. • Helps control weight and maintains overall fitness. • Increases enthusiasm and encourages a sense of well-being. • Enhances self-image and confidence. • Reduces appetite. • Increases balance, stability, and coordination. • Encourages positive changes in other life-style habits (e.g., eating patterns). • Reduces the risk, in women, of developing both breast cancer and cancer of the reproductive organs by enhancing the immune function. • Strengthens bones and muscles. • Improves the endurance of heart, lungs, and circulatory system. • Reduces the incidence or severity of cardiovascular disease, heart attack, and stroke. • Reduces the incidence or severity of type 2 diabetes. • Reduces the incidence or severity of auto immune diseases such as arthritis. • Reduces resting heart rate and improves heart rate recovery. • Increases blood supply to the heart and muscles. • Increases strength of the heart muscle contraction and reduces resting blood pressure. • Reduces risk of premature hardening of the arteries and reduces serum cholesterol and triglycerides. • Increases levels of high density lipoproteins (HDLs) and reduces low density lipoproteins (LDLs).

Choose my top important benefit of exercise from the list above.

What type of exercise do I think will provide the best benefit for my choice?

O-2

Aerobic Activity, Flexibility, and Building Muscular Strength Aerobic activities that increase your heart rate are a must for good cardiovascular health. Regular aerobic activity is also critical to burn body fat, and is a primary component of any weight loss and weight maintenance program. Important side benefits include the strong positive effect that regular aerobic exercise has on managing your stress, reducing depression and anxiety, and increasing your self-esteem. Two other important components of fitness are flexibility (stretching) and building muscle and endurance. You will want to include all three types of exercise in your exercise program in order to achieve good coordination, balance, agility, power, speed, and reaction time. All of these physical abilities help to slow the effects of aging and increase your quality of life. In actuality, if you can move gracefully and maintain your strength and endurance, you will live a longer, healthier, and happier life. A small investment of your time and energy now can make a BIG difference in the quality of your life for years to come. Aerobic Activities If you don’t know whether or not the exercise you are doing is aerobic, ask yourself these three questions. You should be able to answer yes to all three questions if your exercise is aerobic: 1. Does the exercise use the large muscle groups of your body (buttocks, thighs or back)? 2. Does it raise your heart rate, and can you continue the activity for at least 20 minutes without stopping once you are in condition? 3. Does it cause you to feel warm, perspire, and breathe heavily without being really out of breath and without feeling burning sensations in your muscles?

Flexibility Exercises My ability to move a part of my body through its full range of motion is referred to as flexibility. Limitations on my flexibility are usually caused by tight muscles, tight ligaments, and tight tendons. Appropriate stretching exercises can help me make significant improvements in my flexibility and, as I get older, flexibility and strength will help me avoid injury and falls.

Strength Building Activities Strong muscles, particularly in the back and abdomen, encourage good posture. Strong muscles also prevent back pain and help avoid injury from falls. People who have strong muscles are able to lift heavy objects, carry things, push things, jump, and do almost any activity more easily and gracefully. After age 30, adults on average begin to lose 8% of their muscle mass (lean body weight) each decade if they do nothing to build and maintain their muscle. The rate at which my body burns fat, (my metabolic rate), is largely determined by my lean body mass (amount of muscle I have). The more muscle mass I have, the higher my metabolic rate will be and I will burn fat faster and lose weight faster. Aerobic exercise helps me lose weight and temporarily increases fat metabolism. But, if I really want to be fit and increase my metabolic rate (have my body burn more calories 24 hours per day), I must include some strength building exercises in my fitness plan. Losing fat, toning muscle, and increasing muscle strength also helps me feel more positive about myself. I’ll feel better about my appearance and my posture. I’ll have a better attitude and higher self-esteem. And, after a great workout, my muscles will be tired, but I will feel relaxed and energized.

O-3

The tranquil feeling that follows vigorous exercise has been linked to brain chemicals called endorphins. Endorphins are strong, natural painkillers that are produced in my body. They are released when I exercise. Endorphins remain in my bloodstream for hours after exercising and give me an overall feeling of happiness and well being. Note: Positive Choice Integrative Wellness Center fitness specialists can help you customize a diversified fitness program to fit your physical condition and your lifestyle. The Exercise and Nutrition Consultation is a great investment in your overall fitness. We strongly recommend that you take advantage of this service as you begin to design your fitness program. Positive Choice Wellness Center offers Yoga and Muscle Toning classes. The classes are fun and you will learn appropriate stretching techniques. We recommend that you also consider scheduling a comprehensive Fitness Test to help evaluate your physical condition and design an overall fitness plan. MAKING EXERCISE A HABIT 1. Clarify why I want to exercise. What are my exercise goals? What do I hope to achieve?

2. Recognize that I am shifting my priorities. What will I do to deal with barriers to my exercise? How will I allocate my time?

3. Allow space for my emotions. I may blame myself for being so out of shape or feel depressed over leaving my old sedentary habits behind. I can allow these normal feelings to occur, but I won't give in to them. What can I tell myself when I feel emotional?

4. Develop a constructive attitude. I will try to focus not on what I've given up, but on what new options I'll have. What can I do to develop a constructive attitude?

O-4

5. Focus on establishing a habit. I won't worry about target heart rates, time, distance, etc. I will set realistic goals (e.g., “I will walk three days per week.”) and make it a priority. How can I help myself establish exercise as a habit?

6. Do something I like. Do I like to exercise alone, with a friend, in a class, at home, or at a fitness facility? If the first activity I try doesn't appeal to me, I’ll try another until I find activities I like. What types of activities do I like?

7. Open myself up. I will try new activities. I might enter a walking event or sign up for a stretching class. I won't know if I like it until I try it. And, remember, it's OK if I don't like it! What new things am I willing to try?

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

• How confident are you that you will/can meet the goal you have set for yourself for the coming week? Confidence level _____%.

O-5

©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\o15- fit for my life.doc • Remember to adjust the various components of your goal so that you can honestly say you are 70% or greater in your confidence level.

O-6

DINING OUT You can use smart eating strategies when you dine out by planning ahead, choosing the right restaurants when possible, making substitutions, controlling your portions and ordering well.

Have a plan. If you know ahead of time that you're going to a restaurant, cut back on calories during other meals during the day.

Know menu terms and cooking basics to make ordering easier. Look for foods that are steamed, broiled, baked or grilled, and limit or avoid fried and sautéed items or foods described as crispy, rich or au gratin.

Choosing a Restaurant Think ahead. Look for places with a wide range of menu items. Check online menus, if available, for nutrition information ahead of time.

Eat slowly. It takes about 20 minutes for your brain to get the message from your stomach that you are no longer hungry. Fast eaters often are overeaters, while slow eaters tend to eat less and are still satisfied. Make Substitutions. Round out your meal by ordering healthy side dishes, such as a side salad with low- fat dressing, or fruit to substitute for fried or starchy foods. Control portions. Many restaurants serve huge portions, sometimes enough for multiple people. Order menu items that contain fewer calories and eat a smaller portion. Bring leftovers home for another meal. Or, order an appetizer in place of an entrée and add a small salad.

Be deliberate and assertive when ordering. • Many restaurants honor requests, so be assertive, ask menu questions and make special requests to meet your nutritional needs. • Ask for salad dressings/sauces on the side. Dip your fork into the dressing then take a forkful of salad. Salads that come dressed with commercial products may be wearing as much as 500 extra calories from unhealthy fats. • Ask for substitutes such as steamed veggies prepared without sauces and butter. Ask for olive oil instead. Substitute salsa as a topping. • Ask for sliced tomatoes or fresh fruit instead of french fries, fried potatoes, potato salad, potatoes or white rice. Ask for whole grain bread, toast, and crackers. • Look for freshly made entrée salads that give you balance in a bowl. For example, entrée salads with baked or grilled chicken or seafood provide protein along with fiber and other nutrients.

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The Bottom Line… Be sure to get some extra exercise on days that you eat out. This chart shows how much exercise is needed to burn the calories associated with some common restaurant meals:

Restaurant Meal Calories Exercise needed to burn it off (for 180 lb. person) Chicken Fajitas 1484 2.5 hours aerobics class (moderate) Spinach/Artichoke Dip 1161 2.5 hours easy cycling (10 mph) Philly Cheesesteak/Fries 1593 3 hours easy swimming Shrimp Pad Thai (3 cup) 900 2 hours kayaking (moderate) Chicken Caesar Salad 720 2 hours golf (walking) Bistro Shrimp Pasta (Cheesecake 2290 8 hours walking @ 3 mph Factory) Islands Big Wave Burger with 1040 3 hours water aerobics (moderate) cheese One basket of chips and salsa— 480 1¾ hours light strength training Chili’s Restaurant Vegetarian Pizza (½) 885 3.5 hours bowling (Sammy’s Wood Fire)

Restaurant Desserts If you want a taste of a dessert, go ahead and order it. Practice the three small bites rule — take up to three small bites and either offer the rest to others at the table, or call the waiter or waitress to remove the rest.

TRAVEL PLAN Prior to leaving on your trip plan what foods you will definitely avoid, and what foods you are willing to slide on. This helps you prepare yourself and will help ease the stressful food decisions that arise during your trip. Try to limit your slides so you can avoid digestive distress during your trip.

HOTELS Try to stay in hotels that offer mini-refrigerators. You can save money by not eating out every meal and have fresh produce, lean proteins and dairy products available for breakfast, lunch, and snacks. Check out grocery stores near your hotel.

FLYING When flying, use a cooler bag and carry-on food. Use gel ice packs or put ice from a drink shop into a sealable plastic bag to keep foods cool inside the cooler bag. For long flights that include layovers prepare a meal to-go before you leave the house. Large salads with plenty of protein will help you make it to your destination without you having to rely on processed pretzels and cookies frequently handed out on flights, to fill you up.

P-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\p16- dining out.doc FOOD You can easily take a variety of perishable and nonperishable items with you depending on the length of your trip, and how much room you have to pack food. Options for travel foods include:

• Raw vegetables like carrots and celery. • Hard boiled eggs. • Greek yogurts. • Meats like shrimp or chicken and beef pre-cut into strips. • Single serving packs of guacamole.

List ideas for healthy foods you will choose for travel: ______e foods

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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PARTIAL MEAL REPLACEMENT - MAINTAINING A HEALTHY LIFESTYLE

“If you don't know where you are going,

you will probably end up somewhere else.” - Laurence J. Peter

Healthy Lifestyle Changes In the Partial Meal Replacement Program you are encouraged to: • Develop a nutritional plan that will allow for weight loss during your program, and weight maintenance after. • Develop a plan to incorporate strength training, exercise, movement, and consistent activity into your daily routine. Check out the exercise videos under the nutrition and fitness tab on the positivechoice.org website for new fitness ideas. • Develop a long-term plan for healthy food intake. • Create a healthy lifestyle. • Plan, shop for, and cook healthy, nutritious meals. • Utilize stress management techniques to first identify stressors and then reduce and manage stress and stress eating. Identify and utilize coping strategies other than eating. • Learn tools and strategies for dealing with challenging food environments when you eat out, travel, during holidays and special occasions. • Practice assertive communication techniques and effective anger management. • Investigate your body image and develop new ways of looking at yourself in mind and body.

Q -1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\q17-maintaining my healthy lifestyle.doc WHAT IS MOTIVATION?

Motivation is the force that moves you and makes it possible for you to make lifestyle changes. Even if you are clear about what’s important to you and what you want to do, you may find that actually doing it is difficult. Many people have difficulty finding the motivation to exercise and shop for, prepare and eat healthy meals.

Have you ever thought about what is most important to you in your life? You may have a general idea, but may not have ever taken the time to think about what your values really are.

How does your list of values compare to how you spend your time? If your values don’t match your actions, you may find that you don’t feel satisfied with your life. Most people find that they have trouble finding enough time, energy and motivation to do the things that need to be done, and often food and exercise choices are left at the end of each day’s to-do list.

When your values, your priorities and your actions are lined up in a way that puts your health first, it opens up a world of possibilities! With good eating and exercise you can have more energy and more time for family, friends, hobbies, and other activities that are important to you.

How will you continue with new behaviors moving forward? With some thought about what you want to accomplish and a plan to help you achieve it, you can continue to maintain and improve your health.

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The first step is to make note of where you are now in terms of your health. The next step is goal setting, which starts with deciding what you want to accomplish. Then you can make a specific plan to help you reach your goal. Once you put the plan into action, you can measure your progress and make changes to the goal or plan if you need to. This will keep you moving forward without feeling overwhelmed or getting frustrated and feeling like you want to give up. Name five important lifestyle changes you want to make and goals to make the changes like health, nutrition, fitness, stress reduction, communication, body image and/or creating a healthy lifestyle. Let your thoughts and feelings flow. Put them into writing.

1. Lifestyle Change: ______Goal to Make the Change:______2. Lifestyle Change: ______Goal to Make the Change:______3. Lifestyle Change: ______Goal to Make the Change:______4. Lifestyle Change: ______Goal to Make the Change:______5. Lifestyle Change: ______Goal to Make the Change:______

Based on your list, choose one category you would like to focus on, perhaps one which you have not given that much importance to.

Q -3 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\q17-maintaining my healthy lifestyle.doc Meditate on it.

Once you have fulfilled a certain goal, move on to the next. Before you know it, you will have addressed many areas of your health.

How will these lifestyle changes make your life more successful? ______

If you find that you run out of motivation, here are some ideas that can help: Focus on what you want to do by setting a reasonable goal. Follow the plan that you have set up to meet your goal. Try to identify obstacles that may get in your way and problem solve in advance. Forgive yourself when things don’t go according to plan. Every day is a new opportunity to start again. Flex your plan when you get off track. Fix what went wrong and set new goals that are challenging but realistic. The more you practice your goals, the more automatic your new behavior will become. Your new behaviors will become new habits. Any step you take today will make forming good new habits easier to do in the future

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • This week’s goal:

Q -4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\q17-maintaining my healthy lifestyle.doc PARTIAL MEAL REPLACEMENT – EATING MINDFULLY

What is Mindfulness? Sometimes it can help to start by thinking about its opposite: mindlessness. What is mindlessness?

Mindlessness: • Breaking things, spilling things, clumsiness, accidents because of carelessness, inattention or thinking about something else. • Failing to notice subtle or not-so-subtle feelings of physical discomfort, pain, tension etc. • Forgetting someone’s name as soon as you hear it. • Listening to someone with one ear while doing something else at the same time. • Getting so focused on goals that I lose touch with what I am doing right now. • Getting lost in my thoughts and feelings. • Being preoccupied with the future or the past. • Eating without being aware of eating. • Having periods of time where you have difficulty remembering the details of what happened – running on autopilot. • Reacting emotionally in certain ways – feeling like an emotion just came out of nowhere. • Daydreaming or thinking of other things when doing chores. • Doing several things at once rather than focusing on one thing at a time. • Distracting yourself with things like eating, alcohol, pornography, drugs, and work.

Why Eat Mindfully? • To free yourself from unhealthy, reactive, and habitual eating patterns. • To promote balance, choice, wisdom, and acceptance. • To acknowledge responses to food without judgment. • To experience insights about how to achieve healthy eating goals. • To accept that your eating experiences are unique to you.

Mindful eating involves paying full attention to the experience of eating and drinking, both inside and outside the body. We pay attention to the colors, smells, textures, flavors, temperatures and even the sounds of our food. We also pay attention to the mind. While avoiding judgment or criticism, we watch when the mind gets distracted, pulling away from full attention to what we are eating or drinking. We watch the impulse that arises to grab a book, turn on the TV, or call someone on our cell phone, after we have taken a few sips or bites. We notice the impulse and return to just eating. We notice how eating affects our mood and how our emotions, like anxiety, influence our eating. Gradually we regain the sense of ease and freedom with eating that we had in childhood. Eating returns to an intuitive process; one we do not need to constantly think (and stress) about.

R-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\r18-eating mindfully, meditation and cravings.docx Living on Auto-Pilot vs Living Mindfully

Living on Auto-Pilot: Living Mindfully:

Thoughts are Reality; it’s as if what we’re Thoughts are merely sounds, words, stories, thinking is actually present, here and now! bits of language, passing through our heads.

Thoughts are The Truth; we literally believe Thoughts may or may not be true. We don’t them! automatically believe them.

Thoughts are Important; we take them Thoughts may or may not be important. We seriously, and give them our full attention! pay attention only if they’re helpful.

Thoughts are Orders; we automatically obey Thoughts are not orders. We don’t have to them! obey them.

Thoughts are Wise; we assume they know best Thoughts may or may not be wise. We don’t and we follow their advice! automatically follow their advice.

Helpful questions for thoughts: Is this thought in any way useful or helpful? Is this an old story? Have I heard this one before? What would I get for buying into this story? Could this be helpful, or is my mind just babbling on? Does this thought help me take effective action? Am I going to trust my mind or my experience?

Whenever you eat or drink something, take a minute to breathe. Pay attention as you eat, consciously consuming this food for your physical health. Bring awareness to seeing your food, smelling your food, tasting your food, chewing your food, and swallowing your food

R-2 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\r18-eating mindfully, meditation and cravings.docx MEDITATION FOR WEIGHT CONTROL

Anyone who has struggled to stay within a healthy weight range knows that it can be very challenging. Exercise and eating healthy foods are only part of the battle. Another piece is adjusting your mindset to make a change in your life. Meditation can help rewire your brain to make the necessary changes. People eat because of physical hunger and emotional hunger. Meditation focuses on emotional hunger, but meditation also addresses physical hunger by raising your metabolism up to the point that it becomes self-regulating and in a state of homeostasis, which means that the body’s internal environment remains stable. In the Partial Meal Replacement Program, practicing meditation will help you clear your mind of the stresses of the day and help you refocus on your goals at hand. While doing this, you will also learn to alleviate anxiety associated with reaching your weight loss goals. In addition, meditation helps you practice acceptance of yourself as a valuable and loveable human being. Meditation has been practiced for thousands of years all over the world. The goal of the mindful meditation method is not to empty your mind, but to allow it to be quiet, yet stay alert.

Meditation Benefits: • Alleviate anxiety, depression, pain and stress. • Bring healing to the body. • Give strength to intentions including acceptance. • Boost motivation. • Increase energy.

Meditation Technique: 1. Sit in a comfortable location, preferably a quiet place where you won’t be disturbed. 2. Begin by gently closing your eyes and taking in some deep breaths. 3. Starting at your toes relax all the muscles up through your body ending with your forehead. 4. In your mind say your mantra or a positive statement to yourself. 5. When you become aware that your mind has become distracted (which it will), simply return to silently repeating your mantra. 6. When you ready, stop repeating your mantra. Start with a few minutes a day and then extend the time to 20 to 30 minutes a day.

The benefits of meditation are the greatest when practiced daily. Try to meditate first thing in the morning upon rising, and/or at the end of the day as a release valve to allow stress to drift away.

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In thinking about strategies, it’s important to know what you’ve already tried. In terms of food and eating, think of what’s worked in the past and what hasn’t worked. Do you keep trying strategies that you know won’t work? Remember: The definition of insanity is doing the same thing over and over again, hoping for a different outcome. Instead of just trying the same things, try some new strategies:

What’s worked to overcome cravings? ______

What hasn’t worked to overcome cravings? ______

What are you committed to doing to overcome cravings? ______

Improve your health by setting a goal this week

• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

R-4 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\r18-eating mindfully, meditation and cravings.docx PARTIAL MEAL REPLACEMENT – RESISTANCE TRAINING

THE THREE FACETS OF FITNESS (Vital Strategies for Healthy Weight Management)

Benefits Recommendations Suggestions

Cardiovascular • Strengthens heart/lungs. F.I.T.T. Principle: • Always warm up: • Frequency: 5-6 times/week 3 to 5 minutes of (Aerobic Training) • Burns fat for fuel. light activity to • Intensity: (220–your age) x .60 • Burns calories consumed. stretch muscles to .85 = Your training heart rate and ease the stress • Speeds up muscle cell • Time: 10 minutes working up metabolism. on the heart. to 60 minutes as you become • Always cool • Helps regulate your more conditioned. metabolism. down: 3 to 5 • Type of exercise: rhythmic minutes of light continuous movement (walking, activity to bicycling, etc.). minimize muscle soreness and prevent cramping.

Flexibility Training • Increases range of motion • Frequency: 2 to 3 times/week. • Yoga, personal in the joints. training with • Hold stretches for 10–30 emphasis on • Improves elasticity of seconds. flexibility, gym tendons, ligaments, and • Repeat four times per stretch flexibility classes, muscles. for each major muscle group.* stretching and • Uses up calories. yoga videos are all good options. • Reduces risk of injury. • Improves circulation to extremities.

Strength Training • Builds muscles. F.I.R.S.T. Principles: • Personal training, • Increases resting • Frequency: 2–3 times/week (48 strength training metabolic rate. hours between sessions). equipment, • Uses up calories. • Intensity: low to moderate with strength/sculpting • Helps strengthen bones. goal to progressively challenge classes, home muscles. weights, strength • Repetition: 8 to 15 per exercise. training videos. • Sets: 1 to 2 for each muscle group. • Type: full range of motion resistance for major muscle groups.

S-1 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\s19-resistance, cardio and flexibility.doc MIXIMIZE Your Cardio with Interval Training

The benefits of cardiovascular exercise are well understood. To name a few, these include fat loss, lowered blood pressure, improved cholesterol profile, better blood sugar balance, reduced depression and even improved sleep. However, did you know you can squeeze even more benefits out of your workouts by simply incorporating intervals? These can include improved fitness levels, better post exercise fat burn, and augmented endorphin release leading to the elusive “exercise high”. Intervals can also help add variety to a monotonous routine, and even spark new weight loss during plateaus.

What is an interval? In an exercise sense, it is a brief period of time where you increase the intensity to go beyond the aerobic zone. Cardio workouts should generally be done at a conversational pace (i.e. able to talk to someone while exercising). Intervals, however, should push you above this zone. You should feel like you couldn’t sustain this intensity for very long. The interval is followed by an easy period, or recovery. This allows the heart rate to come back down in to the aerobic zone. The process is then repeated.

How can intervals be incorporated into a cardio session? No matter what your current ability or fitness level is, there are ways to mix it up and maximize (hence the word miximize) your workouts so the beneficial returns will be even greater. The most important thing is to be smart and safe about it. As with all workouts, a proper easy warm up of 5 min should be done beforehand. Always listen to your body. If you feel that you need a longer recovery or a shorter, less intense interval, then so be it, particularly if you are new to exercising. Lastly, consult with your physician periodically to make sure you are medically fit to exercise at higher intensities.

Try these three methods of interval training: 1) Fartlek Training — this method is the easiest to do because it requires no time keeping, but generally works only for those exercising outdoors. The term fartlek is a Swedish term that literally means speed play. Choose a number of intervals you’d like to incorporate into your workout. Then simply complete them by picking a spot or object in the distance and increasing your speed to get to it. Recover until you feel conversational again. Repeat. Choose objects of varying distances to change up your interval lengths.

2) Standard Timed Intervals — this method uses specifically timed periods, therefore a stopwatch is necessary. Generally, the longer time interval will be at an easy, or recovery pace, and the shorter interval at a high, close to maximal effort intensity. A very basic example would be splitting a three minute block into two minutes easy and one minute hard. This is a great method for gym goers who use treadmills and other cardio machines. Incline can be used in place of speed for walkers.

3) Build Intervals — this is a more complex method of #2 which involves an easy interval, a moderate interval and a hard interval. So in essence, the intensity builds throughout the time block. A basic example (4 min time block): Two minutes easy, one minute moderate and one minute hard.

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Assuming a cardio session of 30 min, here are some examples of incorporating intervals using the three methods. For longer sessions, simply add more repetitions of the intervals/time blocks.

Fartlek Method: -5 min easy warm up. -50 yd interval (pick a tree, or a street sign that appears to be about half a football field away), recover until comfortable breathing returns. -100 yd interval (choose an object double the distance of the first interval), recover. -25 yd interval, recover. -50 yd interval, recover. *Repeat for 20 min. -5 min easy cool down.

Standard Timed Method: -5 min easy warm up. -2 min easy to moderate x 7 Reps -1 min hard -5 min easy cool down (I know, this adds up to 31 min—so sorry!).

Build Interval Method: -5 min easy warm up. -2 min easy to moderate -1 min moderate to hard x 5 Reps -1 min hard (max) -5 min easy cool down.

Strength Training A. Benefits 1. Builds muscle and increases resting metabolic rate (RMR). 2. Reduces body fat. 3. Uses up calories. 4. Helps strengthen bones.

B. FIRST Principle: ACSM recommendations 1. Frequency: 2 to 3 times a week, with at least 48 hours between bouts. 2. Intensity: progressive overload principle. 3. Repetitions: 8 to 12 per exercise, 15 maximum. 4. Sets: 1 to 2 for each major muscle group. 5. Type: full range of motion resistance for each major muscle group. a. Major muscle groups—legs (quadriceps, hamstrings, gluteals, calves), chest (pectorals), back (latissimus dorsi, rhomboids, trapezius), shoulders (deltoids), biceps, triceps, core (abdominals, obliques, erector spinae or lower back).

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Healthy Strategies for Weight Loss A. A combination of exercise and good eating helps maintain or increase fat-free mass, keeping RMR elevated, thereby aiding in optimal weight loss and its maintenance. B. Compared to dieting alone, a combination of exercise and diet leads to a larger percent of fat lost. C. Dieting alone causes a decrease in fat-free mass, which can decrease RMR.

Calculate my target heart rate zone Determine my Heart Rate % by: Subtract my age from 220 = ______. This is my maximum heart rate. Multiply my maximum heart rate by:

0.5 for 50% = ______= Beginning exercise

0.6 for 60% = ______= Moderate exercise

0.7 for 70% = ______= Regular exercise

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Benefits of Stretching

Stretching tight muscles feels good. In addition to feeling good, a consistent stretching program helps me gain flexibility and joint movement. Stretching does not have to involve a large time commitment, but stretching can end up giving me large results. As I age, my muscles tighten and the range of motion in my joints is reduced. Tasks that used to be simple, such as zipping up a dress or reaching for a can off of the top shelf, can now become difficult. A regular stretching program can help lengthen my muscles and make daily living activities easier. Everyone can learn to stretch, regardless of age or flexibility. Stretching can be a healthy addition to my daily routine, whether I exercise regularly or not. There are simple stretches I can do while watching TV, on the computer, or getting ready for bed. If I am doing strength training exercises, I can stretch in between sets. Here are just a few of the benefits I can expect from a regular stretching program: • Reduced muscle tension. • Increased range of movement in the joints. • Enhanced muscular coordination. • Increased circulation of the blood to various parts of the body. • Increased energy levels (resulting from increased circulation).

One of the greatest benefits of stretching is that I’m able to increase my range of motion, which means my limbs and joints can move further before injury. Post-exercise stretching can also aid in workout recovery, decrease muscle soreness, and ensure that my muscles and tendons stay healthy. The more conditioned my muscles and tendons are, the better they can handle the rigors of sport and exercise, and the less likely that they'll become injured.

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General Guidelines: • Never stretch cold muscles! • Always warm up my muscles properly prior to any flexibility program. I can do some aerobic exercise for a few minutes to warm up (walking, stair-stepping, cycling, etc.) • Perform 2 to 3 repetitions of each stretch, holding them for 15 to 20 seconds each • Be sure to hold the stretch evenly, and refrain from bouncing. • Breathe into the stretch! Try to exhale as I increase the intensity of the stretch. • Find other stretches to incorporate into my routine on the Internet, in books, in DVD’s, on my On-Demand cable access, for example.

Seated Hamstring Stretch Sitting on the edge of a chair with a straight back, extend one leg out in front, knee straight and toes flexed upwards. On an exhalation, hinge at the hips, dropping the navel first, followed by the chest and shoulders. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Be sure to keep the knee from bending. Repeat on other side. Muscles stretched: Back of thigh (hamstring), and calf (gastrocnemius)

Chair Quadriceps Stretch Sitting with one leg on the edge of a chair, drop the other knee so that the thigh is perpendicular to the floor, knee is an inch or two off the floor. Tuck the tailbone in as you continue to push the knee back. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Repeat on other side. Muscles stretched: Front of thigh (quadriceps) and hip flexors.

S-6 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\s19-resistance, cardio and flexibility.doc Chair Elbow Hang Sitting in a chair, feet outside of the chair legs, grasp both elbows and slowly drop them towards the floor in front of the chair as you exhale. Drop one vertebrae at a time, starting with the head, followed by the shoulders, chest, middle back and lower back. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. On an inhalation, slowly breathe yourself up, lifting one vertebrae at a time. The head should come up very slowly to avoid light headedness. Muscles stretched: back (erector spinae), legs (gluteals and hamstrings).

Spinal Twist Sit in a chair, feet to the left side, back straight. Place the right hand on outside of the left knee, left hand on the back of the chair. On an inhalation, raise the sternum to lengthen the spine. On an exhalation, twist to the left, starting with the navel, followed by the chest, shoulders and head. Imagine wringing out the spine like a towel. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Repeat on other side. Muscles stretched: Core (back, abdominals and obliques).

S-7 ©2019 Kaiser Permanente. All rights reserved SCPMG Positive Choice Integrative Wellness Center, San Diego s:\cim positive choice_and\partial meal replacement program\partial meal replacement curriculum 2019\for print new\s19-resistance, cardio and flexibility.doc Soleus Stretch Stand behind a chair or wall, one foot forward, one foot length in front of the other. Both feet should be pointing directly forwards. Drop your body weight directly down towards the floor in between your feet. Bend the back knee, keeping the heel flat on the floor. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Repeat on other side. Muscles stretched: Calf (soleus, gastrocnemius)

Chest Stretch Sitting or standing, lift the sternum as you pull the elbows back. Hands are out to the side, back is straight. Relax the neck and upper back muscles. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Muscles stretched: Chest (pectoralis major and minor), shoulders (deltoids)

Calf Stretch Stand behind a chair or wall, one foot forward, two foot lengths in front of the other. Both feet should be pointing directly forwards. Push the back heel into the ground, keeping the back knee locked, and lifting upwards on the toes of the back foot. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Repeat on other side. Muscles stretched: Calf (gastrocnemius, soleus)

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Upper Back Stretch Sitting or standing, press the sternum back as you extend the arms forward, interlacing the fingers. Drop the head in between the arms, and continue to spread the shoulder blades apart. Hold the stretch evenly (no bouncing) for 10 to 20 seconds. Muscles stretched: Upper Back (rhomboids, trapezius)

Standing Shoulder Stretch In a standing position, place hands behind the back, one in the other. Pull the shoulder blades back, and rotate the elbows inwards. Drop the shoulders away from the ears, and slowly lower the chin towards the chest. Hold the stretch evenly (no bouncing) for 10 to 20 seconds.

Muscles stretched: Shoulders (deltoids), chest (pectorals)

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• Remember that habit changing and goal setting are about trial and adjustment, not trial and error. • Goal:

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WEIGHT LOSS, FITNESS, AND HEALTHY EATING AT THE POSITIVE CHOICE INTEGRATIVE WELLNESS CENTER ▪ Nutrition/Fitness Forum: Receive free fitness and nutrition advice from dietitians and exercise physiologist. Walk-ins welcome. At the Wellness Center at Garfield Specialty Center.: Monday thru Thursday; 5 to 5:30 pm; Tuesdays, 11:45 am to 12:15 pm; San Marcos: 1st and 3rd Thursday of mo., 6 to 6:30 pm, Building 4, Classroom C; Otay Mesa: Monday, 5 to 5:30 pm, Building 4, Classroom 3. You can also visit our website to find out how you can attend a virtual session from your computer, ipad or phone. Visit positivechoice.org. ▪ H.E.A.T. — Healthy Eating and Training: Have your body fat, muscle strength, cardiovascular fitness, and flexibility measured. Then work with a personal trainer to develop a weight management and wellness plan. Initial testing and consult is followed by individual personal training sessions and consultations. Optional use of one to two OPTIFAST 800® meal replacements a day to help with weight loss is available. $425* ▪ Personal Training: Workout with a personal trainer to achieve personal fitness goals. $55* ▪ Muscle Toning or Yoga Classes: Eight, one-hour sessions $72* for Yoga, $55* for Muscle Toning. ▪ Healthy Cooking Classes: See website for class descriptions, dates, and times. $45* per class. ▪ Healthy Balance: A 16-week full food weight management program. Lose weight on a full food plan with a focus on exercise and mindful eating. Kaiser Permanente members –– No Cost; Non-members –– $160*. ▪ Solutions, Recovery from Food Addiction: 12-session program. $420* ▪ Biofeedback — Stress management: Individual appointments with a therapist using biofeedback sensory equipment to help learn relaxation responses. $95* ▪ MFEL — Mindfulness For Everyday Living: Eight week class. Create a healthier and happier life by learning to live in the moment, instead of on autopilot. $280* ▪ Integrative Medicine Services: Treatment options include traditional medicine practices, but alternative medical therapies that have evidence supporting their merit, are also utilized. Initial Consult $250*, $125* for follow-up visits. ▪ Kaiser Permanente Health Education: Members only. Programs include: Tobacco Cessation, Pregnancy, Parenting, Mind Body Stress Management, Depression and Anxiety Recovery, Headache Relief, Insomnia Recovery, Urinary Incontinence, Diabetes and pre-diabetes, Child and Teen Nutrition, Preventing Falls. Call for information and scheduling: (619) 641-4194. ▪ Wellness Coaching by Phone: Members may receive individual coaching by phone for these topics: Quitting Tobacco; Get Active; Eat Healthy; Manage Weight; or Reduce Stress. No fee. (866) 862-4295. ▪ Help for Depression and Anxiety: Kaiser Permanente Department of Psychiatry and Addiction Medicine, members only. (877) 496-0450. Psychiatric Emergency: 24-hour Behavioral Health Hotline, members only. (800) 900-3277. *Fees for these services/programs are subject to change. Please call or check online for current fees.

COMMUNITY SUPPORT OPTIONS ▪ Free On-line calorie and Fitness Trackers: Sparkpeople.com; Loseit.com; Calorieking.com; Myfitnesspal.com. ▪ Food Addicts in Recovery: A 12-step recovery program that offers a structured food plan and weekly support meetings throughout San Diego County. No FEE. Call (510) 505-4141 or visit foodaddicts.org for more information. ▪ Overeaters Anonymous: A 12-step program that provides support for compulsive overeating, binging, and bulimia. See website for details, meeting locations, and times: oasandiego.org. ▪ City of San Diego Crisis Line: (888) 724-7240. ▪ San Diego County Drug and Alcohol Services: (619) 692-8200.

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Positive Choice Program Evaluation Day of Class: M T W Th Class Time: ______Name (Optional) Counselor: Group #: Location: Clairemont Otay Mesa Bostonia San Marcos Date:

Program (Circle one) 20-Week Meal Replacement Partial Meal Replacement Teen, Solutions, Healthy Balance (NutriMed®) (OPTIFAST® 800)

Tell us about your experience with our reception staff: (Circle one number or NA [not applicable] for each question.) When you called Positive Choice, was the service 1 2 3 4 NA representative who answered the phone helpful in Definitely no Somewhat no Somewhat yes Definitely yes addressing your needs? Do the receptionists who check you in each week treat 1 2 3 4 you with courtesy? Definitely no Somewhat no Somewhat yes Definitely yes Are the receptionists who check you in weekly helpful? 1 2 3 4 Definitely no Somewhat no Somewhat yes Definitely yes Overall, how satisfied are you with the experiences you 1 2 3 4 5 6 7 8 9 10 have with our reception staff? Very Very dissatisfied satisfied

Tell us about your experience with our medical assistant staff: Do the medical assistants who do your lab testing and 1 2 3 4 NA take your blood pressure treat you with courtesy? Definitely no Somewhat no Somewha Definitely yes t yes Are the medical assistants who assist you before class 1 2 3 4 helpful? Definitely no Somewhat no Somewha Definitely yes t yes Do the medical assistants who assist you before class 1 2 3 4 show care and concern towards you? Definitely no Somewhat no Somewha Definitely yes t yes How long do you typically wait to have your blood 1 2 3 4 NA drawn after checking in? No wait 0-5 min 5-10 min Over 10 min Overall, how satisfied are you with the experiences you 1 2 3 4 5 6 7 8 9 10 have with our medical assistants? Very Very dissatisfied satisfied

Tell us about your experience with our Positive Choice healthcare providers: How courteous and respectful are the nurse 1 2 3 4 5 NA practitioner(s) or physician assistant(s) (NP/PA)? Not courteous Very courteous How well does the NP or PA listen to your concerns 1 2 3 4 5 NA and questions and understand your medical needs? Not at all Very well If you left phone messages for a NP or PA, how long is 1 2 3 4 5 NA it before you received a response? Never rec’d a More than a Same week Within 2 Same day response week days Overall, how satisfied are you with the experiences you 1 2 3 4 5 6 7 8 9 10 have with our NP/PA staff?? Very Very dissatisfied satisfied

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Tell us about your course materials: List three topics/lessons that were the most 1. helpful to you: 2. 3.

List three topics/lessons that were the least 1. helpful to you: 2. 3.

Tell us about your experience with your counselor: How helpful is your counselor in helping you achieve 1 2 3 4 5 NA your goals? Not helpful Very helpful Is your counselor available to you before and 1 2 3 4 5 NA after class? Never Rarely Sometimes Frequently Always How often do you exercise in your group? 1 2 3 4 5 NA Never Sometimes Often Almost Every week every week If you leave a message for your counselor, how long is 1 2 3 4 5 NA it before you receive a response? Never rec’d a More than a Same week Within 2 Same day response week days Overall, how satisfied are you with the experience you 1 2 3 4 5 6 7 8 9 10 have with your counselor? Very Very dissatisfied satisfied

What would you like to see added or changed in the program you are attending?

Additional comments:

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