Power to Prevent - National Diabetes Education Program - National ...

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Pre-Program Questionnaire - Demographics (Optional Pre-Session 1 Demographics Questionnaire) Name or other identifer (such as initials with day and month of birth): ______________________ How did you fnd out about the program? Please check all of the following that apply. Neighbors Church members Family members Flyers Posters Newsletter Newspaper Radio Doctor or clinic Other:_________________________________________________________________________ General Information . What is your sex? Male Female 2.What is your race: (Check all that apply.) Black or African American American Indian or Alaska Native White or Caucasian Asian Native Hawaiian or other Pacifc Islander Other: ___________________________ 3. Are you of Latino or Hispanic ethnicity? Yes No Don’t know 4. What is your date of birth (month/day/year): _______ / _______ / _______ Please put your name (or your initials with day and month of birth) on this questionnaire and give it to your program leader. NDEP Power to Prevent Appendices 43
Pre-Session 3 Questionnaire (Fill out this questionnaire at the beginning of session 3) Name or other identifer (such as initials with day and month of birth): ______________________ 1. 2. 3. Don’t know or refused Three healthful meals that I can prepare for myself (and my family) are: (Check “Don’t know or refused” if you do not know or do not want to answer.) Nutrition-Related Lessons Please circle one number to indicate how strongly you agree or disagree with each of the following statements. (Check “Don’t know or refused” if you do not know or do not want to answer.) 1. I know how to create healthful lunches. 2. I eat less healthily when I feel stressed. 3. I am confdent I can eat more fruits and vegetables every day (or that I am at my goal for this). 4. I understand what a single serving for my favorite foods is. 5. I understand how to read food labels to choose foods lower in fat. 6. I can think of healthy food choices I like to eat. 7. I know how to identify drinks with added sugar. 8. I can fnd healthy food choices at my favorite fast food restaurants. 9. I know ways to control overeating or eating high-fat foods when I eat out. 10. I can think of small steps that I can take to eat more healthily. 11. I am confdent I can take small steps in healthy eating that will lead to a big reward of improved health. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 Don’t know or refused NDEP Power to Prevent Appendices 44
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Power to Prevent A Family Lifestyle
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Credits and Acknowledgments NDEP Af
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Table of Contents Foreword. . . . .
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Appendix Materials and Resources Th
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Additional Resources for Program Le
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Organizations Black Women’s Healt
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in the Forward/Introduction section
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NDEP GAME PLAN Food and Activity Tr
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Session No. and Title Session 10 Pa
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Session Duration Each session is de
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Session Preparation As program lead
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Refreshments and healthful snacks,
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Conducting the Session NOTE: Times
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Say: “Let’s fll in our Individu
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The program leader ends the session
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NOTE: You could choose other sticke
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NDEP Power to Prevent Program Leade
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Getting Started Getting started wit
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NDEP Power to Prevent Program Leade
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Key to Icons Used in Power To Preve
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At least two helpers to assist peop
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Say: “The objectives for today’
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What are some of the Complications
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Pledge Possible Improvements I’ll
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NDEP Power to Prevent Session 0
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Purchase stickers (stars, smiling f
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Discussion Points Say: “Small Ste
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Preparation and Reminders for the N
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Advance Preparation NOTE: The NDEP
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Discussion Points Say: “Healthy e
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Activity Take a 5- to 0-minute brea
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Tips for Inviting a Registered Diet
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NDEP Power to Prevent Session 3 0
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Appendix U: Why Physical Activity I
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in silence. Suggest that if partici
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Ask participants to name ways that
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Optional Activities 4.1 Visit an At
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also be downloaded from the NDEP We
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Say: “Cooking can be a fun activi
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Brochure 7 Principles for Controlli
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Conducting the Session Welcome Welc
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List answers on a fipchart, and mak
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Conducting the Session Welcome Welc
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Activity Take a 5- to 0-minute brea
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Advance Preparation In addition to
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Further Information on Diabetes Pre
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Obtain copies of Appendix Q: Energi
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Review of Discussion Points Say:
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My Pyramid Some people in your grou
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Bring copies of menus from several
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Example of better “I statement”
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If you plan do to the Optional Acti
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It is recommended that people with
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Optional Activities 1.1 Review the
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Discussion Points Say: “Making ch
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Page 131 and 132: Make photocopies of the Post-progra
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Page 137 and 138: NDEP Power to Prevent Appendices 2
Page 139 and 140: Sample Letter to Potential Partners
Page 147 and 148: Black Women’s Health Imperative w
Page 151 and 152: Community newspaper organizations S
Page 153 and 154: Selecting and Securing a Regular Me
Page 155 and 156: Reward participants for fnishing th
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Page 161 and 162: “I can accept failure. Everyone f
Page 171 and 172: Session Questionnaire Intent 1 Pre-
Page 173 and 174: Where Am I Right Now? Thinking abou
Page 175 and 176: The next questionnaire is an option
Page 177: Feelings About Having Diabetes Plea
Page 181 and 182: Post-Session 3 Questionnaire (Fill
Page 183 and 184: Pre-Session 4 Questionnaire (Fill o
Page 187 and 188: Please answer the following. (Check
Page 189 and 190: Check Ups Please check “Yes” or
Page 191 and 192: How confdent are you now? Please ci
Page 195 and 196: Where Am I Right Now? Thinking abou
Page 199 and 200: 1 Start Here 2 Check Calories 3 Lim
Page 213 and 214: The Plate Method The Plate Method c
Page 223 and 224: Spotting Denial Denial has a few ca
Page 225 and 226: If you have three or more of these
Page 227 and 228: Let Anger Be Your Ally The goal is
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Learning to Relax There are many wa
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NDEP Power to Prevent Appendices 96
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Si Usted Tiene Diabetes, ¡Sepa los
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Small Steps. Big Rewards. Prevent T
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Publications and Resources for Chil
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Team Care: Comprehensive Lifetime M
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Team Care: Comprehensive Lifetime M
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New Beginnings: A Discussion Guide
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