WEIGHT LOSS 101: A HEALTHY WEIGHT LOSS PROGRAM FOR COLLEGE STUDENTS

Abstract: Obesity and overweight are complex conditions that contribute to many chronic diseases. Treatment should include a dietary regimen, physical activity, and behavior therapy. This manuscript describes Weight Loss 101: A Healthy Approach to Weight Loss, a college student health center based program that is designed to facilitate college students exerting self-control over their nutritional habits as part of a healthy weight loss process. The nutrition education covers such issues as a personal diet plan, portion control, and label reading. Self-monitoring, stimulus control, and problem solving skills are behavior change techniques included in Weight Loss 101. A step-by-step program model is provided.

The National Heart, Lung and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998) state that the U.S. has approximately 97 million overweight and/or obese adults. Outcomes of the Third National Health and Nutrition Examination Survey (NHANES III) show that the prevalence of obesity in the United States continues to increase (Kuczmarski, Flegal, Campbell, & Johnson, 1994).

The NHLBI (1998) linked obesity and overweight to conditions such as hypertension, type 2 diabetes, heart disease, and cancers. Even moderate weight loss has been shown (NHLBI, 1998) to reduce the chance of developing obesity-related chronic diseases. The increasing prevalence of obesity and overweight also affects mortality rates and health care costs. In 1995, approximately $99.2 billion of health care expenditures were attributed to obesity related diseases and conditions (NHLBI, 1998). Dietary factors and sedentary lifestyle contributed to 300,000 potentially avoidable deaths (McGinnis & Foege, 1993)

Lifestyle factors that contribute to excess weight are usually broken into nutrition and activity factors. An over consumption of food energy often plays a major role in weight gain, especially when coupled with physical inactivity. Americans have cut back their intake of fat; however, they have not decreased the total amount of food energy consumed (Rippe, Crossley, & Ringer, 1998). Physical inactivity also contributes to weight gain by Americans. Only 22% of American adults regularly exercise at 30 minutes per day while 24% are sedentary (Rippe, Crossley & Ringer, 1998).

GUIDELINES FOR DEVELOPMENT OF EFFECTIVE WEIGHT LOSS PROGRAMS
The NHLBI document Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (1998), identifies three goals of weight loss and weight management programs. The goals are to:

Reduce body weight,
Maintain a lower body weight over the long term, and
Prevent further weight gain.
The goals of healthy weight loss programs are most effectively promoted by helping individuals learn to equalize energy consumed and energy used. A diet for weight loss and maintenance must also be adequate in protein, carbohydrates, dietary fat, dietary fiber, vitamins, and minerals (Nonas, 1998). Dietary treatment for weight loss should consist of a calorie restricted nutrient dense diet that promotes steady consistent weight loss. Usually a calorie reduction of 500 to 1000 calories per day will be sufficient to decrease weight at the rate of 1 to 2 pounds per week (Lau, 1999; NHLBI, 1998).

Health educators must also recognize the importance of behavior therapy in promoting the changes needed for individuals to successfully adhere to a weight loss regimen. New eating and eating-related habits often must be learned. The following behavior change strategies can be useful when paired with dietary treatments for weight control:

Self-monitoring,
Stimulus control,
Problem solving,
Cognitive restructuring
Self-monitoring helps an individual become more aware of behaviors that promote excess weight. Selfmonitoring may consist of such strategies as recording food intake including amounts, calorie and nutrient content, and fat grams, and recording events or feelings that promote overeating (NHLBI, 1998; Foreyt, & Poston, 1998). Stimulus control involves teaching the individual how to identify environmental stimuli that trigger overeating. By identifying these stimuli, one can learn to alter their environment by avoiding high-risk situations (NHLBI, 1998; Foreyt & Poston, 1998). After triggers are identified, problem-solving skills are taught to assist the individual in choosing a healthy way to alter their environment. Problem solving skills are used to identify problems, formulate a variety of solutions, then choose and implement the healthy solution that best fits their individual needs and interests (NHLBI, 1998; Shape Up America, 1996). Cognitive restructuring is an important technique that deals with one's self-talk. If an obese or overweight individual's self-talk is negative, it could undermine the efficacy of the weight loss diet. Cognitive restructuring consists of exercises that promote realistic goals and beliefs about weight loss and good nutrition (NHLBI, 1998; Foreyt & Poston, 1998). Table 1 provides some examples of methods used to address each of these behavior change strategies in the Weight Loss 101 program.

WEIGHT LOSS PROGRAMS DESIGNED FOR COLLEGE STUDENTS

Weight loss programs have been widely offered to a variety of participants and in many different settings. It is important to recognize that while some basic concepts (i.e. the calorie equation) contained in such programs may be universal, programs must also take into account the unique characteristics of the target audience. This is true not only in terms of the individual goals participants bring to the program but must also address convenience of access, economic factors and other important characteristics. In order to successfully conduct such a program for college students, health educators should consider the following points:

Students have limited time and funds
Easy accessibility to the program is needed
Students will come a variety of ethnic groups.
Program times must consider the class schedule of the university.
The Centers for Disease Control (CDC) (1998) also established important guidelines to help plan effective nutrition education for young adults including:

Learning new skills not just new facts
Opportunities to practice nutritious eating skills and,
Nutritious education activities that are fun and innovative.
The 5-A-Day promotion of fruits and vegetables (Nicklas, Johnson, Farris, Rice, Lyon, & Shi, 1997) used in high schools, found that appealing and relevant nutrition education was very effective in helping young adult populations make and maintain dietary changes.

Weight Loss 101: A Healthy Approach to Weight Loss is a university sponsored program offered by the University's Student Health Center. The program utilizes the services of a Graduate Assistant trained in Nutrition/Dietetics and supervised by a Registered Dietitian.

The program offers basic nutrition and weight control education in a one day per week (50 min/session) format over a period of four weeks. It is offered free of charge to students enrolled at the University. To accommodate students' time constraints, Weight Loss 101 offers a flexible schedule. Students may choose a 4-week program that meets every Tuesday or one that meets every Thursday. Classes are held at the Student Health Center on campus to enhance student accessibility. Weight Loss 101 can be administered by a Health Education or Health Promotion graduate student who has a Bachelor of Science degree in nutrition or a similar subject. Also, experience dealing with weight loss programs would be helpful. The graduate student is not authorized to prescribe diets without approval from the registered dietitian supervising the program. The registered dietitian should also be available for consultation should any special conditions or contraindications be noted.

Weight Loss 101 is advertised throughout campus, targeting areas most often utilized by students (i.e. student recreation center, student health center, etc). Upon registration in the program a student's height, weight, age, and activity level are measured. As the student returns to participate in the class they receive information on nutrition education and behavior modification. Exercise is strongly encouraged, and assistance with developing a safe and effective program is available to students through referral ro the university's student recreation center. All full time students receive membership to the recreation center as part of tuition and fees.

Specific nutrition education content areas are included in the program based on documented effectiveness (Shape Up America, 1996; Domell, Alford, Cattlett, & Gench, 1992; Shannon, Linton, Hsu, Rollins, & Schwartz, 1986). Included are such issues as the Food Guide Pyramid, portion control, reading the Nutrition Facts Label, the importance of exercise, and education about their personal diet regimen. Research has also reinforced the importance of theory driven behavior change programming, which is included in each education session to assist the individual in initiating and maintaining necessary lifestyle alterations (NHLBI, 1998; Foreyt & Poston, 1998; Shape Up America, 1996; Shannon et al., 1986). Each educational session consists of a brief presentation covering a specific nutritional topic, appropriate activities, discussions, and appropriate visual aids (a content outline is contained in Table 2).

Since the main focus of Weight Loss 101 is to lose weight, the education modules will focus on principles of healthy caloric deficit diets. The method used in Weight Loss 101 to determine calorie needs involves the following steps:

Determine the basal energy expenditure (BEE) based on height, current weight, and age,
Multiply the BEE times the appropriate activity factor e.g. sedentary, moderately active or very active,
Subtract 500 to 1000 calories from that to create an energy deficit (NIH, 1998; Shape Up America, 1996).
Two of the education sessions, “Your Weight Loss Diet” and “What is a Portion”, are focused on educating students about their diet and how to use it to its fullest potential. The weight loss plan presented consists of an Exchange Lists diet and portion control is taught through the practice of measuring skills and use of the Plate Model.

Exchange Lists are lists of foods that are similar in caloric and nutrient content. They are used because they promote consistency in calorie levels, while also offering a variety of food choices. Each food on a particular list has the same amount of carbohydrate, protein, fat, and calories in one serving. Since one serving of one food on a list is equal to one serving of another food on the same list, the foods can be “exchanged” for one another (McCarren, 1997). There are exchange lists for breads or starches, fruits, milk, vegetables, meats, and fats.

After an appropriate calorie level is determined, the total number of calories desired is divided in the correct amount of carbohydrates, proteins, and fats. The carbohydrates, proteins, and fats are then divided between the different exchange lists. The result is a meal plan that allows an individual a set number of servings of from each list for each meal (McCarren, 1997). The individual can choose any combination of food items from the different lists to reach the approved number of servings. This meal plan offers a variety of healthy choices along with a consistent amount of nutrient-dense foods.

A key element to adequately using exchange lists is portion control. A person must consume the suggested serving sizes to be assured of consistency. Since portion control is very important, Weight Loss 101 utilizes an effective method of teaching portion control known as the Plate Model (Camelon, Hadell, Jamsen, Ketonen, Kohtamaki, Makimatilla, Tormala & Valve, 1998). The Plate Model offers a visual representation of what the appropriate amounts of vegetable, milk, breads, meats, and fruits look like arranged on a plate (Camelon et al., 1998). The Plate Model offers one half of the plate to vegetables, one fourth of the plate to grains, and the final one fourth of the plate to meats or meat substitutes. A roll, piece of fruit, and milk are adequate side dishes (Camelon et al., 1998).

The Plate Model is utilized in Weight Loss 101 as a visual strategy for learning portion control. First, the students will be given their own plate with the three sectors divided. By memorizing these sectors, the student recognizes the constituents of the meal (Camelon et al., 1998). During the hands-on activities, students are asked to use portioned food models to design healthy meals that fit their meal plan. This exercise helps the students to know what an appropriate portion size looks like on their plate. Students are encouraged to divide their plates as such at home and use measuring utensils to determine appropriate serving sizes.

Evaluation is important to determine the effectiveness of the program and to determine the participant's progress of the participants. A nutrition knowledge pretest and post-test relevant to the nutrition content areas is offered. Students are weighed weekly in order to reinforce progressive weight loss and the behavior change efforts made in the program. Those who are not making progress with weight loss are offered individual counseling with the graduate student in order to help identify factors limiting their success. Alterations in the diet plans, strategies to alter environmental cues, and other remedial strategies may be developed at that time. Food recalls gathered at the first and last meeting are used to indicate behavior changes in the area of food selection. It is anticipated that an increase in nutrition knowledge and skill development will contribute to a healthier final 24-hour recall when compared to the first recall. During class activities, students are asked to read food labels and determine certain factors, demonstrate healthy food selection using the food labels and food models, and demonstrate proper portion control that fits their meal plan by using The Plate Model. They are then provided with feedback concerning the accuracy with which each of the skills have been demonstrated and further instruction is given if necessary to reinforce the goals of the program.

Legend for Chart:
A-Behavior Change Strategy
B-Program Application
C-Session(s)
Table 1. Program Activities Designed to Address Behavior
Change Strategies
A
B
C
Self-Monitoring
• Nutrition pre-test
• 24-hour dietary recalls
• Nutrition post-test
1,2,4
Stimulus Control
• Review of recall data to Identify
“triggers” of eating behaviors
3
Problem Solving
• Decision-making based on Nutrition Facts Label
• Solutions for overeating
3
Cognitive Restructuring
• Food Guide Pyramid instruction
• Practice portion control using Plate Model and
Exchange Lists
1,2,3
Legend for Chart:
A-SESSION NAME & NUMBER
B-NUTRITION TOPIC
C-BEHAVIOR MODIFICATION
D-ACTIVITIES OR DISPLAYS
Table 2. Weight Loss Nutrition Content Area Outline.
A
B
C
D
1a. Getting started
* Nutrition Pre-test and 24-hour recall
N/A
* Nutrition pre-test and 24-hour recall
1b. What is a healthy diet?
* Food Guide Pyramid
* Education about The Plate Model.[*]
* Discuss goals, need, & importance of weight loss.
* Look at food models of correct portions.
1c. What is a Portion?
* Explanation of portion control.
* Discuss portion control when dinning out.
* Review 24-hour recall. Identify problem areas.
* Practice portion control using The Plate Model.
* Given certain food models, have students choose most
appropriate and tell why.
2. Your Personal Weight Loss Diet
* Explanation of diet.
* Explanation of Exchange Lists.[**]
* Relate portion control to Exchange Lists.
* Discuss follow the meal plan when dinning out.
* Explain and begin self-monitoring through food records.
* Discuss problem-solving techniques for overeating.
* Divide each student's exchange diet into a meal pattern.
* Using food models, make meals and snack that fit the personal
meal plan.
3. Nutritious Reading
* Explain how to easily read the Nutrition Facts Label.
* Explain how to use the Nutrition Facts Label in relation to
the diet.
* Continuous instruction on self-monitoring via food records.
* Look at previous week of self-monitoring to identify stimuli
to overeating.
* Problem solving practice: how to make the right decision based
on the Nutrition Facts Label.
* Look at examples.
* Have students read and discuss various labels.
* Given certain food packages, have students make a choice and
tell why.
4. Weight Loss 101 Finale
* Discussion of exercise as it relates to weightless and weight
maintenance.
* Go over any final questions pertaining to the diet or
self-monitoring.
* Discuss any questions.
* Discuss the changes in follow-up 24-hour recall.
* Discuss exercise behaviors.
* Discuss plans to maintain weight or continue weight loss after
program concludes.
* Nutrition post-test,
* Follow-up 24-hour recall.
* Final weight.
Sources Table 1: Mattfeldt et al., 1999; Camelon et al., 1998 *;
NIH, 1998; Shape Up America, 1996; Domel et al., 1992.
REFERENCES
Camelon, K.M., Hadell, K., Jamsen, P.T., Ketonen, K.J., Kohtamaki, H.M., Makimatilla, S., Tormala, M.L., & Valve, R.H. (1998). The Plate Model: a visual method of teaching meal planning. Journal of the American Dietetic Association, 98 (10), 1155–1158.

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesityin Adults. (1998). Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication # 98-4083.

Domel, S.B., Alford, B.B., Cattlett, H.N., & Gench, B.E. (1992). Weight control for black women. Journal of the American Dietetic Association, 92 (3), 346–347.

Exchange Lists for Weight Management. (1995). American Diabetes Association, Inc. and The American Dietetic Association.

Foreyt, J.P., & Poston, W.S.C. (1998). The role of the behavioral counselor in obesity treatment. Journal of the American Dietetic Association, 98 (10), S27–S30.

Guidance for Treatment of Adult Obesity. (1996). Bethesda, MD: Shape Up America! and American Obesity Association.

Kuczmarski, R.L., Flegal, K.M., Campbell, S.M., and Johnson, C.L. (1994). Increasing prevalence of overweight among US adults: the National Health and Nutrition Examination Surveys, 1960–1991. Journal of the American Medical Association, 272, 205–211.

Lau, D.C.W. (1999). Call for action: prevention and managing the expansive and expensive obesity epidemic. Canadian Medical Association Journal, 160 (4), 503–506.

Mattfeldt-Beman, M.K., Corrigan, S.A., Stevens, V.J., Sugars, C.P., Dalcin, A.T., Givi, M.J., & Copeland, K.C. (1999). Participant's evaluation of a weight-loss program. Journal of the American Dietetic Association, 99 (1), 66–71.

McCarren, M. (1997). Why use exchanges? Diabetes Forecast, 50 (5), 40–41.

McGinnis, J.M., and Foege, W.H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270 (18), 2207–2211.

Nicklas, T.A., Johnson, C.C., Farris, R., Rice, R., Lyon, L., and Shi, R. (1997). Development of a school-based nutrition intervention for high school students: Gimme 5. American Journal of Health Promotion, 11 (5), 315–322.

Nonas, C.A. (1998). A model of chronic care of obesity through dietary treatment. Journal of the American Dietetic Association, 98(10), S16–S22.

Rippe, J.M., Crossley, S., and Ringer, R. (1998). Obesity as a chronic disease: modern medical and lifestyle management. Journal of the American Dietetic Association, 9 (10), S9–S15.

Shannon, B., Linton, B., Hsu, L., Rollins, P., and Schwartz, R.M. (1986). Development of a nutrition and weight control program for Atlantic Richfield Company employees. Journal of Nutrition Education, 18 (1), S47–S50.

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By Barry P. Hunt, EdD, Associate Professor of Health Education at Mississippi State University.; Virginia Bogle, MS, RD, Dietician at Southeast Alabama Medical Center.; Andy Gillentine, PhD, Associate Professor of Physical Education at Mississippi State University. and Clay Daughtrey, PhD, Assistant Professor of Marketing at Metropolitan State College of Denver.

Address all Correspondence to Dr. Hunt at the Department of HPERS; Box 6186; MSU, MS 39762; phone: 662-325-2963; FAX: 662-325-4525; email: bhunt@colled.msstate.edu.

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