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

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Where Am I Right Now? Please answer the following questions thinking about your physical activity and eating over the past fve weeks. Please circle one number to indicate how strongly you agree or disagree with the following statements. (Check “Don’t know or refused” if you do not know or do not want to answer.) Right now: Strongly agree Agree Not sure Disagree Strongly disagree 1. I eat healthily. 5 4 3 2 1 2. I get enough physical activity. 5 4 3 2 1 3. I want to eat more healthily. 5 4 3 2 1 4. I want to be more physically active. 5 4 3 2 1 Physical Activity During the past week, what was the highest level of physical activity you got? (Check the best answer below.) Don’t know or refused No specifc physical activity routine (just activities of daily living such as walking in the house or at work) Light intensity physical activity (for example, slowly walking the dog, breathing and heart beat are not faster) Moderate intensity physical activity (brisk walking, light yard work e.g. raking leaves or mowing lawn, biking at a casual pace) Vigorous physical activity (jogging/running, swimming laps, playing basketball or soccer) During the last week, how many days were you physically active at the level you checked above for at least 30 minutes per day? None 3 to 5 days to 2 days 6 to 7 days Eating How do you usually decide what to eat? (Please check all that apply.) Count calories Count carbohydrates Avoid sweets and sugars Limit amount of fat Eat anything I want or whatever is convenient Other: ________________________________________________________________________ NDEP Power to Prevent Appendices 5
Please answer the following. (Check only one response for each question.) (Check “Don’t know or refused” if you do not know or do not want to answer.) 1. How often do you skip a meal and then snack or overeat? 2. How often do you eat foods high in fat, like fried foods or lots of butter, cheese or lard? 3. How often do you eat more than you think you should? Daily or more More that weekly but less than daily Weekly More than monthly but less than weekly No more than once a month 5 4 3 2 1 5 4 3 2 1 5 4 3 2 1 How confdent are you that you can make changes now? Please circle one number to indicate how confdent you are that you can make the following changes. (Check “Don’t know or refused” if you do not know or do not want to answer.) Activity Sure I can Think I can Not sure I can Don’t think I can 1. Get physical activity more often 4 3 2 1 2. Be physically active for longer time 4 3 2 1 Eating Sure I can Think I can Not sure I can Don’t think I can 3. Eat more healthful food 4 3 2 1 4. Overeat less often 4 3 2 1 Medication Taking (if Applicable) 5. Miss fewer medications Sure I can 4 Think I can 3 Not sure I can 2 Don’t think I can 6. Take medications on time 4 3 2 1 General Health Sure I can Think I can Not sure I can 1 Don’t think I can 7. Lose weight 4 3 2 1 8. Get support from family/friends 4 3 2 1 9. Get blood pressure under control 4 3 2 1 10. Handle stress better 4 3 2 1 Don’t know or refused Don’t know or refused Don’t know or refused Don’t know, refused or not taking medication Don’t know or refused 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 52
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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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Pledge Have participants make an in
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Advance Preparation for Session 12
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Make photocopies of the Post-progra
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Review of Discussion Points Say:
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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
Page 157 and 158: People bring their children to the
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 and 178: Feelings About Having Diabetes Plea
Page 179 and 180: Pre-Session 3 Questionnaire (Fill o
Page 181 and 182: Post-Session 3 Questionnaire (Fill
Page 183 and 184: Pre-Session 4 Questionnaire (Fill o
Page 185: Post-Session 5 Questionnaire (Fill
Page 189 and 190: Check Ups Please check “Yes” or
Page 191 and 192: How confdent are you now? Please ci
Page 193 and 194: Post-Session 11 Questionnaire (Fill
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
Page 229 and 230: Learning to Relax There are many wa
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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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NDEP Power to Prevent Appendices 2
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New Beginnings: A Discussion Guide
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