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
SOUTH TEXAS SURGEONS, P.A. COUNSELING SERVICES
GOAL: Track Your Physical Hunger
Physical
Headache
A lot of Growling
No Growling
Dizzy Shaking
Growling
Empty
Starving
Emotional
Really Hungry
Anxious
Nervous
Hungry
Calm Alert
Stressed
Energized/Focused
Stomach Pain
Relaxed
Fullness
Lethargic
Satisfied
Really Full
Stuffed
Bored Sad
Mindless Eating/Eating Fast
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
o
o
o
o
Eat slow (20-30 minutes a meal): put fork down between bites, 10-15 chews/bite
No activity while eating
Eat on smaller plates
Eat with non-dominate hand
No drinking at meals (0-30 Rule)
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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
Had a fight with my partner.
Did not plan my lunch, starving.
(POST-OP)
Behavior
Consequence
Grabbed a chocolate bar.
Guilt, weight gain, low energy….
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).”
“When I choose _________________ (behavior), I choose ________________ (result).”
“When I choose _________________ (behavior), I choose ________________ (result).”
“When I choose _________________ (behavior), I choose ________________ (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.
SouthTexasSurgeons,P.A.CounselingServices
Change Your Behavior By Changing Your Internal Self Talk
NegativeSelf‐Talk “good and bad”
PositiveSelf‐Talk
“I choose to move forward in my healthy lifestyle.”
“Today, I moved backwards in my healthy lifestyle.”
(“I did bad today at lunch.”)
“right and wrong”
“I ate healthy and/or unhealthy today.”
“Every meal is an opportunity to eat healthy.”
(It’s not right to eat that.”)
“on and off”
“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 got off track this month.”)
“all or nothing”
“I am in control of what I eat.”
“I choose what I eat.”
(“I cheated on my diet.”)
(“NO MORE sweets, starting tomorrow!”)
“Food does not control me.”
“only”
“I am achieving my goals.” “I am successful.”
(“I only lost 2 pounds.”)
“I accept all parts of my body and health.”
“trying”
(“I’m trying to change my habits and diet.”)
“I am eating less at meals.”
“I am not journaling my food.”
“successful and failure”
(“I failed this month.”)
“Today, I am more aware of my eating habits.”
“Today, I have more energy since I started eating healthier.”
(“I’m not where I wanted to be.”)
“I am not where I was last month.”
“must and should”
“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.””
(“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.”)
StaringWeight
“ONDIET”
“I ate good today.”
“I am good.”
SELFAFFIRMATIONS “I choose what I eat.”
“Today,Iweigh__________.”
“IamnotwhereIwasyesterday/lastmonth/lastyear.“
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.
“Food does not emotionally satisfy me.”
“I LIVE
A HEALTHY
LIFESTYLE.”
GoalWeight
“I accept ALL parts of me.”
“I am successful.”
“I am in control of my food intake.”
“OFFDIET”
“I AM good. I AM Enough.”
“Today, I moved forward towards my weight loss goal.”
“I ask for help and support from others.”
“I moved backwards in my wellness goals today.”
“I am NOT defined by what I choose to eat.”
“I ate bad today.”
“I am bad.”
4
The patient is psychologically
Insight Level:
Affect:
Mood:
Presentation:
Cognition:
an appropriate bariatric candidate at this time.
questionable bariatric candidate at this time.
Significant
Some
Minimal
Superficial
Lacks
Neutral
Excited
Broad
Flat
Blunted
Labile
Sad
Neutral
Cheerful
Anxious
Depressed
Hostile
Angry
Calm
Alert
Restless
Agitated
Preoccupied
Withdrawn
Goal-Oriented
Oriented
Confused
Delusional
Tangential
Loose Associations
Overall patient’s understanding of the: LAPBAND
SLEEVE
BYPASS
1. Surgical procedure:
Poor
Unsatisfactory
Satisfactory
2. Potential complications/risks associated with bariatric surgery:
Poor
Unsatisfactory
Satisfactory
3. Requirements of aftercare and lifestyle changes:
Poor
Unsatisfactory
Satisfactory
4. Consequences of non-compliance/non-adherence to prescribed nutrition and behavior regimens.
Poor
5.
Unsatisfactory
Satisfactory
Good
Good
Very Good
Good
Very Good
Good
Very Good
Very Good
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 before surgery due to the following reasons:
↑WLS insight/education
↑ support for emotional/behavioral eating
Needs to watch/complete EMMI:
LAPBAND
SLEEVE
Psychiatrist Evaluation
Psychiatrist Clearance Letter
Follow up after surgery
Join support group
Undecided procedure
BYPASS
Complete/Re-test Assessment
Counselor referral
Weight Timeline:
Birth
Childhood
Teenager
Adult
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Today
Post-Op Goal