Healthy Weight

Nutriquiz data or can use alcohol, physical activity, and fruits and vegetables questions (core sections 10-12, pages 44-49) from 2019 Behavioral Risk Factor Surveillance System Questionnaire developed by Centers for Disease Control and Prevention.

Setting SMART Goals

Ask patient about their interest in weight loss. How do they expect their lives may change from losing weight?

Congratulate participant on their decision to improve their health. Acknowledge and validate their reasons.

Acknowledge there are many strategies that can assist in helping people lose weight. The strategy that works best will be one you can sustain and maintain over time. Over the course of the next 3-4 months, we will work together to help you discover what really works for you. Together, we will work on behavior changes and strategies that will help you lose weight over time. On average, you can expect to lose anywhere from 0.5 – 2 pounds per week. While you may think this sounds a little slower than you were hoping, it’s important to acknowledge that behavior change takes time and practice, and weight loss follows behavior change.

Complete nutrition assessment and health history. Document current weight and BMI. Document any labs that may be affected by weight loss (Hemoglobin A1C, lipid panel, blood pressure).

Discuss benefits of 5-10% initial weight loss. Review handout.

Review handout to help patient set initial weight loss goal (do the math with them to help them determine how much weight they need to lose to achieve 10% body weight). Ask patient to set an initial weight loss goal of up to 10% of current weight.

Help patient identify one behavior they would like to start working on. The behavior should come from the patient, not the clinician. If the patient is struggling to figure out where to start, draw from the nutrition history you have taken and make some suggestions the patient could consider (examples-replacing a sugar-sweetened beverage with water, reducing number of times going out to fast food restaurant, adding a vegetable to a meal).

Once the patient has identified one change they would like to commit to, help the patient make this a specific and measurable goal. Assess their confidence in their ability to make the change, and help the patient readjust the goal as needed. For example, if the patient identifies they want to decrease their sugary beverage intake, ask them to commit to how much they want to decrease.

Wrap up session by again congratulating patient on decision to improve health. Ask patient to start weekly weight checks.* Explain that patient should self-weigh first thing in the morning, without shoes or clothing, and after having gone to the bathroom. Schedule session 2 appointment at a one-week interval.

How to Build a Balanced Plat and Portion Guidelines

EERS spreadsheet

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on the goal they set in session one. Did they achieve the goal?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today I would like start a conversation about healthy eating, portion sizes, and calories. Does this sound ok to you?

Introduce patient to the Foodsmart My Healthy Plate method of eating. Review key points below as well as portion sizes from the Healthy Plate. Patients may also be interested in handout on portion sizes using common items (such as baseball, etc. for dining situations that don’t allow them to measure food).

This is an example of a healthy plate. You don’t have to like all of the foods on this plate, but this plate represents the types and amounts of foods recommended for good health on a daily basis. This method of eating also supports weight loss. Ideally, if you eat 3 meals per day, 2 of your meals would look something like this.

Half of your plate is filled with non-starchy vegetables. Non-starchy vegetables are every vegetable in the world you can think of except potatoes, peas, corn, and winter squash (butternut squash, pumpkin). It’s not that potatoes, peas and corn are bad for us, they just don’t take up half of our plate.

Eating this amount of vegetables (2-4 cups per meal) can help with weight loss due to the “fill factor.” In other words, non-starchy vegetables take up a lot of space in your stomach to help you feel full. Non-starchy vegetables require time to chew-it’s hard to scarf a giant plate of vegetables down in a few minutes, so incorporating more non-starchy vegetables into your meals may help you slow down eating a little. Non-starchy vegetables are low in calories and also have vitamins, minerals, and plant chemicals that promote health and also protect us from diseases such as heart disease and cancer. If possible, try to get a variety of different colored vegetables every day to expose yourself to a variety of health promoting plant compounds. When selecting vegetables, you can choose fresh, frozen, or canned. You can eat them cooked or raw. If you aren’t comfortable with how to prepare vegetables, we can take time to discuss ways to include vegetables you like into your everyday eating habits. This tends to be an area most of us can improve on.

The other half of your plate is made up of lean proteins and healthy carbohydrates, with a small amount of healthy fats.

Lean proteins can add satiety to your meal. In other words, adding some protein to your meal helps prevent you from being hungry in between meals. However, the amount of protein we need tends to be smaller than we may be accustomed.

Healthy carbohydrate foods include starchy vegetables like potatoes, peas and corn, as well as fruits, breads, pasta, rice, quinoa, oatmeal, and just about any other grain you can think of. Carbohydrates are not bad-our body requires them. However, carbohydrates tend to be something we may be likely to overeat. The serving sizes you see here may be smaller than you are accustomed.

Healthy fats also promote satiety and fullness. They give our food flavor. Without fats for cooking or seasoning, we wouldn’t get the same amount of pleasure in eating.

It’s ok if your plate doesn’t look like this now. This is something to strive for. It’s also important to note that your “plate” may sometimes be a bowl, such as a salad greens and other vegetables with some lean proteins and healthy fats (give examples based on food preferences) or it may be a soup with meat and vegetables.

If you do have a “plate”, try using smaller plates (9 inches) or try using disposable plates that have dividers (like you might use at a picnic or reunion, with the sections that have half of the plate you can use for non-starchy vegetables and the two smaller sections for protein and healthy carbohydrates).

One way to start getting more vegetables into your current eating habits is to try to incorporate more vegetables into the meals you already enjoy. For example, try half of the amount of pasta or rice you would normally have, but add plenty of your favorite non-starchy vegetables. Add veggies to your favorite sandwich or soup, or have for a snack.

After reviewing the healthy plate method of eating, ask the patient if there are any specific areas of the plate they might like to work on, and if so, ask them to consider setting a new or additional behavioral goal this week related to a section of the plate (i.e., fill half of plate with non-starchy vegetables for one meal, 4 days per week, etc.)

Discuss self-monitoring with patient. Let patient know that they have starting self-monitoring their weight with weekly weigh-ins. Other self-monitoring techniques that support weight loss and help people stay on track include food journaling. Food journaling can be done with pen and paper, or the patient may wish to use an app that includes calorie tracking.*

Use Mifflin-St. Jeor from EERS spreadsheet to calculate patient calorie goals to support weight loss, OR see calorie recommendations based on current weight from Daily Food and Physical Activity Diary.

Assess patient willingness to start tracking calories. If patient is willing to try, prescribe patient a range of calories to support weight loss. Explain that it may not be feasible to eat the exact same number of calories ever day, that having a goal range of calories better helps support hunger and still contributes to an overall calorie deficit. If patient is not interested in tracking calories, encourage them to still keep a food diary to improve awareness of foods eaten. Explain that self-monitoring food and calorie tracking doesn’t have to be done forever, but it is one of the behaviors that supports successful weight loss and management over time.

If patient is not willing to use a food diary, encourage patient to self-monitor using healthy plate method.

Set new weekly goal. Based on earlier discussion, patient may opt for any of the following:

If patient was successful in achieving last week’s goal, patient may wish to keep the goal the same, or may make a slight change (example-add an additional day of drinking only 1 cup of sweetened tea or decrease to 0 cups of sweetened tea 3 days per week, etc).

If patient was successful, patient may opt for above option PLUS one new behavioral goal. Patient may wish to set a goal related to the healthy plate, or may opt for something completely different. Remember, this is the patient’s goal to select, the clinician is there to guide and support.

If patient was not successful in achieving last week’s goal, reassess importance of the goal that was set. Discuss altering goal based on barriers presented earlier in discussion.

Once the patient has decided on the goal, make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.

Wrap up session. Remind patient about weekly weight check and addition of self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 3 at one week interval. If patient is unable to meet in one week, try to schedule second appointment within two weeks.

Dissecting the Nutrition Label

Scaling Back on Sneaky Sugars
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Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on the goal they set in session two. Did they achieve the goal?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today’s focus is on using the nutrition label to help make food choices. I’d first like to get a sense of what you already know about the nutrition label. How do you currently use the label, if at all? Are there specific things you look for on the nutrition label right now? Discuss what patient currently looks for on nutrition label. Correct any misinformation patient may have. If patient has diabetes, discuss total carbs patient should aim for at a meal. Also discuss any concerns related to types of fat and cholesterol.

Focus on added sugars. Discuss the difference between total sugars and added sugars. Make sure patient understands that sugars are carbohydrates, and everyone needs to have some carbohydrates. Provide example that plain cow’s milk has natural sugar, called lactose. If you look at a carton of plain white milk, you will notice one cup has 12 grams of sugars. Now compare this to flavored milk, such as chocolate milk. The label for chocolate milk has 22 grams of total sugars, but 10 of the grams are added sugars.*

Review suggestions for cutting down on added sugars. Let patient know aside from obvious sources of added sugars such as pastries, candy, and sugar-sweetened beverages, added sugars may also be lurking in salad dressings, soups, condiments, yogurts, and cereals. Ask patient to start looking at labels of food items in house to determine if any foods they enjoy having include added sugars.

Discuss added sugar guidelines. Added sugars are inflammatory and do not provide much nutritional benefit. American Heart Association Guidelines are no more than 25 grams of added sugars per day for women (6 teaspoons) and no more than 36 grams of added sugars per day for men (9 teaspoons). Provide examples of what 25-36 grams added sugar looks like (i.e. a 12 oz can of soda has 32 grams, a regular size candy bar may have anywhere from 20-30 grams added sugar).

Encourage patient to consider removing food sources of added sugars out of their diet. By getting rid of added sugars from foods they consider healthy, they may find that over time, they don’t crave sweets as much. This also allows the patient to leave room for an occasional treat with the knowledge that their only source of added sugar was an intentional treat, rather than other foods they thought were healthy.

Set new weekly goal. Based on earlier discussion, patient may opt for any of the following:

If patient was successful in achieving last week’s goal, patient may wish to keep the goal the same, or may make a slight change (example-add an additional day or meal of filling half of plate with non-starchy vegetables, etc).

If patient was successful, patient may opt for above option PLUS one new behavioral goal. Patient may wish to set a goal related to added sugars, the healthy plate, or may opt for something completely different. Remember, this is the patient’s goal to select, the clinician is there to guide and support.

If patient was not successful in achieving last week’s goal, reassess importance of the goal that was set. Discuss altering goal based on barriers presented earlier in discussion.

Once the patient has decided on the goal, make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.

Wrap up session. Remind patient about weekly weight check self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 4 at a one-week interval. If patient is unable to meet in one week, try to schedule second appointment within two weeks.

The Importance of Physical Activity

Weekly Fitness Routine

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on the goal they set in session three. Did they achieve the goal? Are they still working on other goals from first 2 weeks?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today’s focus is on physical activity. Open the discussion by asking what, if any, types of physical activity the patient is currently doing. Praise patient for any physical activity they are currently doing. If patient is not currently engaging in physical activity, ask patient what is getting in their way of being active.

Discuss four elements of physical activity handout. Ask patient to identify current elements they are meeting and/or gaps. Discuss exercise guidelines for weight loss (300 minutes per week) and weight maintenance (150 minutes per week). Let patient know if they aren’t close to these guidelines right now, this is ok, is something to strive for over time.

Discuss health benefits of physical activity. Let patient know that any physical activity is better than no physical activity. Physical activity has health benefits beyond weight management. People who are more physically active, even if they are a higher weight, are healthier than people who are sedentary.

If appropriate for patient’s ability, review the walk handout. In addition to health benefits mentioned on the handout, no special equipment is required other than a good pair of walking shoes. Walking can be done year-round; may need to change time of day due seasons (taking into account hours of daylight and temperatures). Discuss appropriate layering and safety guidelines for cooler weather walking. Discuss appropriate hydration, especially in warmer weather walking. Determine if patient is interested in starting a walking program (see example on handout).

If patient would like to start walking, a good pace is one that doesn’t make you completely out of breath. You can still speak a sentence, but you are breathing more heavily than when you are leisure walking. Another good analogy is you are running late for an appointment and walking a little bit faster to get there.

If appropriate for patient’s ability and interest, discuss core strengthening exercises. Emphasize the importance of a strong core for prevention of back pain.

Encourage patient to set a goal related to physical activity. Help patient problem solve any barriers that may prevent them from engaging in physical activity. If patient is not currently active at all, encourage them to start with small goals, perhaps a 10-minute walk or a couple of flights of stairs.

If patient is not interested in setting a physical activity goal, review previous goals to build upon. Make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.

Wrap up session. Remind patient about weekly weight check self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 5 at a two-week interval. If patient is unable to meet in two weeks, week, try to schedule next appointment within three weeks.

A Beginner’s Guide to Mindful Eating

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on exercise goal from last session. Discuss any other goals the patient is working on.

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today’s focus is on tuning into your hunger. Open discussion by starting with patient’s current eating patterns. Ask patient if their current meal patterns are based on when they feel hungry vs. a structured schedule based on external factors (meetings, etc.). Be prepared for a variety of answers.

If patient is a late-night eater or snacker, patient may not feel hungry in the morning. Discuss benefits of having last meal at least two hours before bedtime (going to bed on a full stomach can be uncomfortable and can also interfere with getting a good night’s rest. Also discuss benefits of having 12-hour overnight fast (i.e., your breakfast meal should be at least 12 hours later than your evening meal, so if you finish dinner at 7:00 p.m., aim to have breakfast the next morning at 7:00 a.m. or later).

Review the hunger/fullness scale handout with patient. Discuss benefits of avoiding extremes of the hunger scale. It is just as painful to be “starving” and lightheaded from not eating as it is to be “Thanksgiving Day Full.” Encourage patient to start paying attention to hunger cues at meals. When sitting down to eat, have patient ask themselves if they are truly hungry right now? If not, what is motivating them to eat? Explore factors that may motivate patient to eat. Explain that sometimes we eat for reasons other than hunger, and this is part of normal eating. Some days we eat more than enough and some days we don’t eat enough, but the goal is to practice getting in tune with hunger.

Ask patient to self-check in the middle of the meal to determine if hunger is still present. If patient is not still hungry, but would still like more food and is not full, then patient should give him/herself permission to continue to eat. Take time between bites to assess hunger. Aim to stop eating by the time you are feeling a 6 or a 7 on the hunger scale.

Review mindfulness handout and slow down you eat too fast handout to discuss the role of multi-tasking and overeating as well as eating too fast and overeating. Ask patient if there are any strategies s/he would be willing to try.

Encourage patient to set new behavioral goal around today’s topic. Patient may decide to make a point to slow down eating at one meal by putting down their forks between bites. Other suggestions could be eating in a distraction-free environment while sitting down at a table (no phone, newspaper, television, etc., just focus on the meal and enjoying the food).

If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon. Make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.

Wrap up session. Remind patient about weekly weight check self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 6 at a two-week interval. If patient is unable to meet in two weeks, week, try to schedule next appointment within three weeks.

Make Healthier Restaurant Choices

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
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Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on goals from last session. Did patient apply any mindful eating/slow down strategies?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today I would like to talk about strategies for making healthy choices when going out to restaurants. Tell me a little about your current restaurant eating habits? How often are you eating out? What kinds of restaurants do you like to go to/order from? What questions or concerns do you have about trying to eat healthy when dining out?
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​Review restaurant dining tips handout with patient for selection guidelines and portion control. Other suggestions include asking server to bring a carry out box to table with meal to plan on immediately taking half of dinner size portion home, OR ordering an appetizer as the meal and asking bread and chips to be served with the meal instead of before the meal.

Encourage patient to set new behavioral goal around today’s topic.

If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon. Make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.

Wrap up session. Remind patient about weekly weight check self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 7 at a two-week interval. If patient is unable to meet in two weeks, week, try to schedule next appointment within three weeks.

Plan and Shop Like a Pro

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on goals from last session. Did patient apply any dining out strategies discussed?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today’s topic is healthy meal planning. As you start to prepare and eat more of your meals at home, it becomes increasingly important to have a meal plan.

Discuss strategies patient current uses for meal planning. What is or isn’t going well for patient?

Discuss the importance of a well-stocked pantry. Encourage patient to keep a supply of shelf-stable canned and dried options that can be paired with fresh and frozen foods. Examples include whole grains such as brown rice, quinoa, oats, barley, whole grain pastas and breads; canned vegetables (low-sodium when possible), dried herbs an spices, healthy cooking oils, frozen vegetables, and frozen protein choices.

Encourage patient to purchase fresh produce in the amounts that will be eaten over next 4-7 days. Discuss shelf-life of various produce items and strategies for incorporating produce with lower shelf-life into meals earlier in the week.

Discuss meals patient likes to eat or prepare. Help patient plan meals by determining what they have on hand and what needs to be purchased.

Review recipes in foodsmart app as well as tools for developing grocery lists.

Review grocery shopping educational handout.
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Encourage patient to set new behavioral goal around today’s topic.
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If patient is not interested in working on this goal, review previous goals and ask what they would like to continue or build upon. Make sure to assess confidence on ability to achieve the goal, using the 1-10 confidence scale introduced in session 1. Make sure to help patient adjust goal if confidence is less than 7.
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Wrap up session. Remind patient about weekly weight check self-monitoring food and/or calories using the Healthy Plate Method and/or food journal or app. Schedule appointment for session 8 at a two-week interval. If patient is unable to meet in two weeks, week, try to schedule next appointment within three weeks.

Curb Your Cravings

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.
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Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.
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Check in with patient on goals from last session. Did patient apply any meal planning strategies discussed?

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today we will discuss cravings. A few weeks ago, we discussed hunger. It’s important to recognize the difference between cravings and hunger. Cravings are a psychological desire to have something. We may have a craving for something sweet after a meal, even though we may not be hungry or in fact be very full. Sometimes, we crave food when we pass a restaurant we like, when someone mentions a favorite food of ours. You might also crave food out of boredom.

Discuss strategies for dealing with cravings. First, tune in with your hunger and ask yourself if you are really hungry, or just having a craving. If you are having a craving, try using the distraction strategy. Find something else to do, away from the kitchen or placement of the food. You could go for a walk or call a friend. Cravings usually pass after 10-20 minutes.
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Navigating Slips and Setbacks

Pushing Through Plateaus

Special Occasion Eating

Check in with patient by first asking if there are any specific questions they have from last week or points they would like to make sure you cover today.

Check in with patient on calorie tracking and food journaling. If patient is currently tracking calories, document average self-reported daily intake.

Review food diary and/or conduct 24-hour recall.

Check in with patient on goals from last session.

Ask patient for current weight. Document weight and BMI.

New topic introduction: Today we will review all of the progress you have made over the past several months. Calculate percentage weight loss and praise patient for changes made over the past several months.

Regardless of the amount of weight you may have lost, your focus on sustainable lifestyle changes has helped you get where you are today.

Clinician should take a moment to reflect on changes patient has made. This likely includes some of the following:

Changes to eating patterns (not skipping meals, not eating late in evening, dining out less).

Changes to food intake (more fruits, vegetables, and whole grains; less added sugars, processed foods, meats).

Increased mindfulness/in tune with hunger (pt pays attention to hunger cues, stops eating when no longer hungry or when satisfied/not overly-full).

Increased physical activity.

Clinician should ask patient how s/he feels about changes made. Which are the easiest to continue? Are there any new habits you are worried about no longer being able to keep? If so, discuss with patient any concerns they are having and help them problem-solve solutions in advance. For example, if a patient is worried about an anticipated change of schedule affecting physical activity, discuss alternate plans patient could make.

Discuss the importance of self-monitoring weight and food intake as a way of staying accountable to self and as a way of staying on course and maintaining progress. This is especially important if weight starts to gradually increase. Explain that daily tracking and weekly weighing can bring awareness to the situation before it’s too late/there has been a large weight regain. Bottom line: self-monitoring is one of the most important long-term habits for maintaining weight loss.

Discuss any concerns patient may have about staying motivated. Ask patient to reflect on how far they have come, and ask them what they would like to continue working on. What are some new habits that the patient is really proud of? Have patient make a list of all benefits/improvements over past few months to keep as a reminder in the event that patient is having a low motivation day.

Ask patient about any new goals they may have. Encourage patient to come up with non-food rewards for achievements.

Encourage patient to schedule a one month follow up/check-in appointment for accountability and encouragement.

Patient may wish to continue to follow up with RDN on monthly basis. Follow up sessions should be used for encouragement, problem-solving, and goal-setting as needed.

10 Health Gains from a 10% Weight Loss

Set your weight loss goals

Foodsmart Healthy Plate

Daily Food and Physical Activity Diary

Portion Size Guide

Cut Down on Added Sugars

Added Sugars (FDA)

Total and Added Sugars Fact Sheet (FDA)

Added Sugars Infograph from American Heart Association

The Four Elements of Fitness

Hunger and Fullness

Slow Down, You Eat Too Fast

Mindful Eating