Healthy Living Program

Facilitators’ Program Guide

Acknowledgements

The Healthy Living Program: Facilitator’s Program Guide and Participant Guide were developed to support a multidisciplinary effort for nutrition, exercise specialists and behavioral health in the Healthy Living Program (HLP) designated in AFI 10-248, FitnessProgram. This multidisciplinary group was tasked by the Air Force Medical Service Agency. Our goal was to provide a useful guide, reference and tool for your work with the HLP. The multidisciplinary effort stemmed out of the recognition that these disciplines, working together, have a great deal of expertise that can benefit our population in tackling one of the most difficult public health problems: developing and maintaining adequate fitness.

Our hope is that you will use these materials to allow for a standard program across the Air Force. We recognize that you may choose to tailor them to best meet the needs of your base population but our hope is that you will remain consistent with the basic outline.

1Healthy Living Program: Facilitators’ Guide16 Aug 07

TABLE OF CONTENTS

Structure……………..………………………………………………………………...……….… 4

Introduction and Background …………………………………….…………………..………….. 5

Who Attends the Healthy Living Program? ……………………………………………………….8

Behavioral Health Skill Set for Facilitating the Healthy Living Program .………………..….….10

Nutrition Skill Set for Facilitating the Healthy Living Program …….……….….….10

Fitness Skill Set for Facilitating the Healthy Living Program ………………………………...... 11

Basics of Motivational Interviewing …………………….……….…………………..….…….…12

HealthyLivingProgramWeight Screening.....………………………………………………… 13

Coding and Documenting...... ………………………………………………………...... ……....18

HLP Evaluation Form ……………………………………………………………………………19

Recommended Readings & References………….………………….……………………..…….20

Structure

Learning Objectives:

Fitness

  • Learn the basic components of a good fitness program
  • Identify personal barriers to following the FITT principle and develop a plan for overcoming these barriers
  • Develop written plan for improving personal fitness

Nutrition

  • Optimize performance through good nutrition
  • Evaluate body weight and associated risk factors to determine risk category and readiness to change
  • Balance calorie intake through controlling portion size and maximizing nutrient density

Behavioral Health

  • Increase motivation for change
  • Refine personalized plan for reasonable fitness and/or dietary changes

Structure:

  • The provider’s guide to teaching HLP will be found in the speaker notes of the PowerPoint. To teach the class well, it is critical to be familiar with the content of the slides, speaker notes, and the participant’s guide. The presentation’s success depends on being able to be interactive with the clients in setting their own plans.
  • The HLP is designed to last 2-2½ hours.
  • 30 min each of nutrition and exercise physiology.
  • 60-90 min of behavioral health using Motivational Interviewing techniques.
  • Includes PowerPoint presentation, education, group interaction, individual assessments and goal setting activities.
  • Optimally, the behavioral health, fitness, and nutrition professionals will be available for the entire workshop. Given busy work demands, it is recognized that this may not always be possible.
  • A class size of 10-20 clients is ideal. It is preferable that the class size be closer to ten as group interaction is essential. However, ten clients may not be feasible based on demands at each individual base.
  • You will need to bring pencils or pens for the clients as the class is designed around personalized and interactive workbook assignments.

Materials Needed To Hand Out

HLP Evaluation- hand out at the beginning of the class and collect at end of class

HLP Participant Guide

HLP Weight Nutrition Screen - nutritionpersonnel may decide to hand out during

their portion of the class

Materials Needed for Nutrition (if portion control exercise is used)

Bowls of various sizes and measuring cups (full set)

Box of cereal

Introduction and Background

Introduction

The HLP is for individuals who score in the poor fitness categories according to the Air Force fitness standards. It is designed as an interactive class to provide information related to nutrition and exercise that is needed to improve fitness and to identify motivational factors and behavior change strategies needed to implement and maintain a lifestyle change. The workshop is intended as a collaborative effort among behavioral health providers, dietitians, and fitness experts. The first hour is split between nutrition and fitness experts. The fitness expert provides information about the components of a healthy exercise program. Nutrition professional provide information on the components of a healthy diet. Behavioral health providers lead the second half of the workshop, preparing clients for change through the use of behavioral change tools such as motivational interviewing/enhancement, establishing realistic goals, problem solving, and maintenance/relapse prevention. Together, the behavioral health provider, nutrition professional, and fitness expert help the workshop clients develop a comprehensive individualized plan for fitness. Clients in the poor fitness category will be enrolled in the Fitness Improvement Program (FIP) and continue HLP with monthly follow-ups with the exercise physiologist. Also, those clients in the poor fitness category who have an abdominal circumference > 35 inches for women and > 40 inches for men will be enrolled in the Body Composition Improvement Program.

Background

Health and fitness are areas of great importance in the military, having implications for readiness to perform military missions, general population health, utilization of medical care, discipline, and retention. Active duty personnel who are unfit are of particular concern because the health, social, occupational and economic costs are so high. Guidelines released by the National Heart, Lung, and Blood Institute (NHLBI) in 1998 recommend maintaining body mass index (BMI) < 25 with those with BMI > 25 being at increased health risk. Based on these standards, the Air Force has not escaped the same weight management problems that the United States civilian population is experiencing.

The health consequences related to excess weight are well documented and include diabetes, high cholesterol, hypertension, coronary heart disease, stroke, gallstones, and osteoarthritis of knees and hips (Pi-Sunyer, 1993; Willet, 2001). In a recent study examining hospital costs for obesity related conditions in active duty Navy personnel, researchers estimated that nearly 6 million dollars is spent annually just for inpatient care of obesity related diagnoses (Bradham, et al., 2001). Robbins and colleagues estimate over $28 million in annual cost to the USAF as a result of overweight and obesity (Robbins, Chao, Russ, & Fonseca, 1997). Additionally, abdominal circumference has been shown to independently predict poor health outcomes for people with normal and overweight BMIs (NHLBI, 1998; Janssen, Katzmarzyk, & Ross, 2002). Cornier, Tate, Grunwald, and Bessesen (2002) found that abdominal circumference was a better predictor of high health care costs than BMI. Higher levels of abdominal fat have been found to put individuals at increased risk for diabetes, dyslipidemias, and artherosclerosis (Gasteyger & Tremblay, 2002), cardiovascular disease (Sharma, 2002; Zhu, et al, 2002), pancreatitis (Mery, et al, 2002), and high blood pressure (Siani, et al, 2002). Due to these recent research findings, the Air Force fitness standards incorporate BMI with an abdominal circumference measure to evaluate body composition. To reduce the potential health risks and increased healthcare costs associated with higher levels of abdominal fat as measured by abdominal circumference, research has shown that higher levels of physical fitness lead to reduced levels of abdominal fat at all levels of BMI (Ross & Katzmarzyk, 2003). Additionally, Mayo, Grantham, and Balasekaran (2003) found that when people lose weight through exercise, abdominal fat is lost at a faster rate than fat in other areas of the body.

As we know, knowledge about living a fit healthy life does not necessarily lead to behavior change. Readiness to change one’s behavior has been an area of extensive clinical interest and research, and has been applied across multiple domains of health-related behavior (see Weinstein, Rothman, & Sutton, 1998 for a review). Approximately 50% of persons at health risk are believed to be at the precontemplation stage based on the transtheoretical model (Prochaska et al., 1994). Research has provided strong support for the importance of including concepts about readiness for change, balancing benefits and consequences for diet change, weight control, and exercise acquisition in interventions to improve fitness (Prochaska et al., 1994; Rosen, 2000). Additionally, research suggests that including cognitive-affective strategies (such as consciousness raising, considering consequences to self and others) as well as behavioral strategies (such as facilitating commitment to change, encouraging helping relationships and social support, and reinforcement) may promote progress across stages of change (Rosen, 2000). Understanding and weighing the pros and cons of prospective health behaviors was found to be very important to change, with a positive relationship existing between the number of pros versus cons and higher stages of change (Prochaska, 1994).

Motivational Interviewing (MI) methods appear to be a good fit for helping individuals make lifestyle change (Miller & Rollnick, 2002). In a recent meta-analysis, MI yielded moderate effect sizes when applied to problems with diet and exercise (Burke, Arkowitz, & Menchola, 2003). Motivational interviewing is defined as a directive, client-centered counseling style for eliciting behavior change by helping people to explore and resolve normal ambivalence and to reduce discrepancy between goals and behavior (Rollnick & Miller, 1995; Draycott & Dabbs, 1998). Confrontation behaviors by the counselor are avoided because they tend to evoke high levels of resistance in people and make it less likely that behavior change will occur. Rather, the MI counselor expresses empathy through careful reflective listening, and seeks to elicit reasons from the client for behavior change, while maintaining a supportive and nonjudgmental atmosphere. The goal of the interaction is to increase the individual’s awareness of the discrepancies between present behaviors (e.g., lack of exercise and imprudent eating) and future goals. The individual is viewed as responsible for and capable of behavior change, while the counselor is an active supporter.

MI began as a brief intervention for helping people with alcohol problems (Miller, 1983) and has since demonstrated surprisingly powerful effects as a stand-alone intervention and as preparation for more intensive alcohol treatment (Miller, 1996; Noonan & Moyers, 1997). Recent research shows that MI has potential in improving dietary adherence (Berg-Smith, et al., 1999; Mhurchu, Margetts & Speller, 1998) and increasing physical activity (Harland, et al., 1999). Motivational interviewing is showing increasing promise as a brief intervention tool for successful negotiation of health behavior change (Rollnick, Heather, & Bell, 1992). A motivational interviewing component added to a weight-control/fitness program may significantly enhance adherence to recommendations (Smith, Heckemeyer, Kratt & Mason, 1997).

Given what we know about the importance of health, fitness, and associated disease risk factors and the challenges involved in changing behaviors to live a healthy lifestyle, the Healthy Living Program was developed as an interdisciplinary effort to help individuals develop a fitness plan and improve their ability to implement the plan. The remainder of this manual provides facilitators with the resources needed to successfully lead this workshop.

* Note: The PowerPoint presentation that was designed to assist with the HLP includes critical speaker notes to aid the interactive portion of the workshop. The presentation will be maintained in a separate document to allow for more frequent revision and distribution to the field.

Who Attends the Healthy Living Program?

Promoting Improved Fitness in the Air Force

Our expeditionary mission demands that our forces be ready to deploy and support the mission at a moment’s notice, in austere and demanding environments, and for extended periods of time. These stresses demand that our forces be fit to fight, ready for any challenge. Being fit and strong is necessary for the Air Force mission and for the health of our airmen.

The Air Force fitness standards present an opportunity to change the way Air Force members address their own physical fitness. Being physically and mentally fit is critical to an individual’s overall health and ability to serve in today’s Air Force. The goal is to emphasize that individuals have a personal responsibility to be physically fit for themselves, their family, their team, the Air Force and the country that they serve.

Objectives

The Composite Score:

The composite score consists of aerobic fitness, muscular fitness, and a body composition component scores. An Air Force scientific team developed this scoring methodology based on established civilian health and fitness data. The process was then reviewed and validated by an outside panel of nationally recognized experts. The great benefit of the composite score is it places greater emphasis on fitness, while also assessing the member’s health risk.

We know aerobic fitness is the single, best indicator of overall fitness; therefore, half of the score is determined from the aerobic component. Using a 1.5-mile run as the primary method of testing allows units to carry out the majority of the testing.

The second component is muscular fitness. While extremely important for readiness, there isn’t specific scientific research that identifies the number of push-ups and crunches that will result in positive health outcomes. We know strength training is beneficial to long-term health so numbers were determined based on what a normal population could accomplish. Each exercise contributes 10 percent to the composite score. The important point to remember for muscular fitness is that all members will benefit from including strength training in their exercise routine.

The final component, body composition, is an important indicator of long-term health and disease risk. Studies indicate that abdominal circumference is an important factor in weight and body fat assessment. Fat distribution is just as important as body fat that accumulates around the waist and stomach area poses a greater health risk than fat stored in the lower half of the body.

A single abdominal measure is easier to administer and interpret. The member can do this simple measurement anywhere and know the results. To track their progress, all they would need is a string or simply monitor their pants size. Although there is some correlation between the two, we cannot equate abdominal circumference to a specific body fat percentage. Abdominal circumference measures fat concentrated around the abdomen, which is associated with the greatest health risk. Body fat percentage is less specific; it indicates total fat distributed throughout the body. Studies show that the health risk associated with high abdominal circumference is independent of height and age. This may be due to the fact that the abdominal measurement does not include any bones in the measurement so is independent of body frame size.

  1. Aerobic assessment—1.5 mile run, 3 mile walk or cycle ergometry (50%)
  2. Body composition (30%) Abdominal Circumference
  3. Muscular Strength—Pushups (10%)
  4. Muscular Strength—Crunches (10%)

The 0-100 scale provides a fitness continuum. An individual’s score is scaled (gender/age neutral) for equal comparison of fitness level. A range of categories allows for more tailored education and intervention.

Categories based on composite score:

Excellent (90-100 points)

Exercise at least 3 times / week

Retest in one year

Good (75-89.9 points)

Exercise at least 3 times / week

Retest in one year

Poor (0-74.9 points)

Attend Healthy Living Program

Enrolled in Fitness Improvement Program

Enrolled in Body Composition Improvement Program if AC is 40 males; 35 females

Monitored exercise 4-5 times / week

Retest within 90 days

Tiered fitness risk stratification provides the following advantages:

-Greater chance for success by offering tailored intervention

-Focus is more on member health, physical activity and fitness as a lifestyle rather than only a once a year test

-Moves toward evidence-based, health-related criteria vs. arbitrary/traditional fitness test standards

-Moderate risk provides window of opportunity for successful health prevention/intervention before member becomes high risk

-Identifies members at greater risk for disease/injury (high risk)

-Connects physical fitness requirement to members that have extra body fat

-Exercise and nutrition behavior changes are both necessary and interdependent

-Increases test frequency for those members requiring greater follow-up treatment for low-fit/sedentary lifestyle (similar to other medical conditions such as hypertension, high cholesterol)

Skill Sets for Facilitating the Healthy Living Program (HLP)

Behavioral Health
  • Personnel from the LifeSkillsSupportCenter, or other behavioral health clinic, are the best choice for leading for the behavioral health portion of the HLP. A Life Skills provider should be, at minimum, responsible for approving the behavior change curriculum and workshop facilitators.
  • While Behavioral Health providers will often be the ideal instructors, workshop facilitators may be drawn from other health care professionals (e.g. technicians, psychiatric nurses, etc..) with the appropriate skill set.
  • Facilitators will need to possess the following skill sets (which may be acquired through a combination of formal courses, on-the-job training and/or self-study):

-Ability to reinforce existing motivation for change and encourage new commitment to healthy behavior (i.e. basic motivational interviewing/enhancement skills)

-Ability to facilitate an interactive group intervention

-Appreciation of the principles of effective educational instruction

-Basic understanding of behavior change strategies and techniques

-Basic knowledge of nutrition, weight loss, dieting, and physical fitness.

  • HLP facilitators must be able to demonstrate enthusiasm for teaching the workshop, display empathy for individuals having difficulties achieving fitness goals and embrace the goals of the Air Force Fitness Program.
  • HLP facilitators do not need to achieve a particular level of fitness themselves to be qualified to teach, but must be able to credibly persuade the clients they lead a healthy lifestyle or are engaged in appropriate movement towards improved fitness.
Nutrition
  • Facilitators must possess the following skill set which may be acquired through a combination of formal courses, on-the-job training and/or self-study:

-A registered dietitian or diet therapy technician/other medical provider who must be authorized by USAF registered dietitian to teach the nutrition component of the HLP and BCIP