EATING AWARENESS CHECKLIST

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1 EATING AWARENESS CHECKLIST Am I sitting down? Am I multitasking or truly focused on my meal? Ask, How hungry am I? What do I need or want, besides food? Where am I on my hunger scale? o Is my stomach growling or am I bored, stressed, tired, anxious, mad/frustrated or upset? Am I eating slow or fast? o Putting the fork down between bites o Waiting at least 1 minute between bites Am I mindlessly munching or noticing each bite? o Chewing at least 10-15X per bite o Not drinking with my meal (0-30 Rule) Am I choosing foods that improve my health? Am I eating the foods on my plate, in the correct order? o Eat solid the protein first, before the vegetables and fruits SOUTH TEXAS SURGEONS, P.A. COUNSELING SERVICES

2 SOUTH TEXAS SURGEONS, P.A. COUNSELING SERVICES GOAL: Track Your Physical Hunger Physical Headache A lot of Growling No Growling Energized/Focused Stomach Pain Dizzy Shaking Growling Empty Relaxed Fullness Lethargic Starving Really Hungry Hungry Satisfied Really Full Stuffed Emotional Anxious Nervous Calm Alert Bored Sad Mindless Eating/Eating Fast Stressed Depressed Mindful Eating/Eating Slow Anger Guilt 1. Before you eat at each meal, write down your hunger level in a journal. 2. Have an action plan for each level. a. Eat when you are between levels 3-4, this is TRUE PHYSICAL HUNGER! b. Eat slowly to avoid going beyond level 7. This is the difference between satisfied and full/stuffed. c. What can you do, besides eat when you are not at levels 3-4? 3. After eating, write down your fullness level. a. At what level do you want to stop eating? 4. How do you avoid levels 1-2 and 9-10? Above the neck hunger? 1. Thinking about food, scheduled eating 2. Smelling food 3. Hearing people talk about food, popcorn popping 4. Vision: seeing commercials, food on the counter, at your desk or on your plate Increase Mindful Eating Techniques o Eat slow (20-30 minutes a meal): put fork down between bites, chews/bite o No activity while eating o Eat on smaller plates o Eat with non-dominate hand o No drinking at meals (0-30 Rule)

3 SOUTH TEXAS SURGEONS, P.A. COUNSELING SERVICES GOAL: Track Your Mood and Food ABC food and mood diary: A- Activator- the trigger (situation and/or emotion) that come before eating. B- Behavior- the behavior of eating. What and how much you ate. C- Consequence- the result of behavior. Activator Behavior Consequence Had a fight with my partner. Grabbed a chocolate bar. Guilt, weight gain, low energy. Did not plan my lunch, starving. (POST-OP) Ate fast food-hamburger. Ate fast. Vomited food, felt sick/pain and didn t finish meal. Hungry 1 hour later, ate chips. Gaining wt, frustrated. When I choose not to talk about my feelings (behavior), I choose my weight gain, by eating chocolate. (result). One thing I can do today to improve my health is,. GOAL: Know Your Triggers Identify the emotions that you typically go to food such as: o Anxiety o Stress o Tired o Bored o Sad o Depressed/Lonely o Anger Ask yourself: o How much of my eating is emotionally related? (above the neck hunger?) o What triggers can I identify in my journal? My behavior goals this month: 1. 2.

4 Change Your Behavior By Changing Your Internal Self Talk South Texas Surgeons, P.A. Counseling Services Negative Self Talk good and bad ( I did bad today at lunch. ) right and wrong (It s not right to eat that. ) on and off ( I got off track this month. ) all or nothing ( I cheated on my diet. ) ( NO MORE sweets, starting tomorrow! ) only ( I only lost 2 pounds. ) trying ( I m trying to change my habits and diet. ) successful and failure ( I failed this month. ) ( I m not where I wanted to be. ) must and should ( I shouldn t have eaten fried food last night. ) ( I must eat perfect this month. ) ( I should eat the sweets, because it was given to me. ) Positive Self Talk I choose to move forward in my healthy lifestyle. Today, I moved backwards in my healthy lifestyle. I ate healthy and/or unhealthy today. Every meal is an opportunity to eat healthy. Today, I am here(wt, pant size, BP#, Glucose #, etc). I am not where I was last month. I am living a healthy life. I am in control of what I eat. I choose what I eat. Food does not control me. I am achieving my goals. I am successful. I accept all parts of my body and health. I am eating less at meals. I am not journaling my food. Today, I am more aware of my eating habits. Today, I have more energy since I started eating healthier. I am not where I was last month. I know what is good for me. I want fried foods when I am upset. Food does NOT emotionally satisfy my needs. I choose ME. I choose my health. I choose what I eat. Staring Weight SELF AFFIRMATIONS Goal Weight I choose what I eat. Today, I weigh. I am not where I was yesterday/last month/last year. I accept ALL parts of me. I am successful. I am in control of my food intake. Food does not emotionally satisfy me. An affirmation is a declaration that something is true. (even if you don t believe it 100% today, you will.) Being in the middle of your polarizing thoughts, affirming different for yourself is where LIFESTLYE changes occur. ON DIET I LIVE A HEALTHY LIFESTYLE. I AM good. I AM Enough. OFF DIET I ate good today. Today, I moved forward towards my weight loss goal. I ate bad today. I am good. I ask for help and support from others. I am bad. I moved backwards in my wellness goals today. I am NOT defined by what I choose to eat.

5 The patient is psychologically an appropriate bariatric candidate at this time. questionable bariatric candidate at this time. 4 Insight Level: Significant Some Minimal Superficial Lacks Affect: Neutral Excited Broad Flat Blunted Labile Sad Mood: Neutral Cheerful Anxious Depressed Hostile Angry Presentation: Calm Alert Restless Agitated Preoccupied Withdrawn Cognition: Goal-Oriented Oriented Confused Delusional Tangential Loose Associations Overall patient s understanding of the: LAPBAND SLEEVE BYPASS 1. Surgical procedure: Poor Unsatisfactory Satisfactory Good Very Good 2. Potential complications/risks associated with bariatric surgery: Poor Unsatisfactory Satisfactory Good Very Good 3. Requirements of aftercare and lifestyle changes: Poor Unsatisfactory Satisfactory Good Very Good 4. Consequences of non-compliance/non-adherence to prescribed nutrition and behavior regimens. Poor Unsatisfactory Satisfactory Good Very Good 5. Behavioral and emotional support is essential for undergoing weight loss surgery: Poor Unsatisfactory Satisfactory Good Very Good Therapist recommendations and treatment goals discussed with patient: Follow up after surgery Join support group Follow up before surgery due to the following reasons: WLS insight/education support for emotional/behavioral eating Undecided procedure Needs to watch/complete EMMI: LAPBAND SLEEVE BYPASS Psychiatrist Evaluation Psychiatrist Clearance Letter Complete/Re-test Assessment Counselor referral Weight Timeline: Birth Childhood Teenager Adult Today Post-Op Goal South Texas Surgeons, P.A. Counseling Services

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