1. Make sure you are complete and accurate in your volume and type of food consumed on your daily food log. Do this for one day a week. 2. Fill out the feelings associated with eating at each mini meal, at the time the food is eaten. Do this for one day. Use the feelings face worksheet, write the feeling during each mini meal in your daily food log while eating. Code your feelings in the mindful-eating log accordingly. For example; Happy=H Calm=C Sad/depressed=SD Bored=B Stressed=S Angry=A Anxious/worried=AW Tired = T Each feeling equals 1 point. On your Mindful eating log in the totals column at the bottom of the chart, place the # of positive face/feelings points and the total # of negative face/feelings points. 3. Once the daily diary is complete count up for example, how many servings of grains you consumed at breakfast and put the number under G=grains on the mindful-eating log under breakfast. Do the same for each of the mini meals throughout the day. 4. Count up each of the food group servings at each mini meal and place the number of them in the V=vegetable, F=fruit, M&A=meat/meat alternative, GF=good fats, FF=deep fat fried foods, and S-sweets section’s. Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
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5. Under rate self-column put a numerical number from 1-5 on how well you believe you did with your food. 6. Read through the Mindful Eating Log questionnaire once each day at night and give yourself points based on your eating behaviors each day. Place the number of points earned from the questionnaire that day in the box under the day you are on and the week you are in.
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
Š 2013 STRIVE MD, LLC. All Rights Reserved.
Mindful Eating – Date: ____________ Wk # _______Name: ______________________________________Weight: _______ What I actually ate:
Food Servings
(Fill in times)
(Enter amounts) G = Grains, F= Fruits, V-Vegetables, D = Dairy, M & A Meat and meat alternatives, GF = Fats, S = Sweets , FF = Fried foods
G
F
V
D
M&A
GF
S
Feelings: Happy=H Calm=C Sad/depressed=SD Bored=B Stressed=S Angry=A Anxious/worried=AW Tired = T (Each feeling =1 point) FF
Physical Hunger Scale 1-10 (1 being least)
Rate Self
Who did I eat with?
1-5 (1 being least)
Wake Up: Breakfast: Time: Mini Meal: Time: Lunch: Time: Mini Meal: Time: Dinner: Time: Mini Meal: Time:
Total Servings: Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
© 2013 STRIVE MD, LLC. All Rights Reserved.
Where did I eat?
Amount
Type
Duration
Type
Fluid Intake in ounces Caffeinated Beverages in ounces
Physical Activity (type and minutes) Total points earned from feelings category on the mindful eating log
Positive feelings points
Negative feelings points
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
Š 2013 STRIVE MD, LLC. All Rights Reserved.
STRIVE 24-Hour Food Diary Today’s Food Diary – (from the time you awoke to the time went to sleep) Time Mini Meal was consumed
What was eaten
Amount consumed ( ½, cup etc…)
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
© 2013 STRIVE MD, LLC. All Rights Reserved.
How many times did you eat out last week, counting ALL restaurants, fast food and take-out? ____________
How many times a week are you exercising? ____________________________________________________
Grams of protein consumed: ___________________________
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
Š 2013 STRIVE MD, LLC. All Rights Reserved.
Client Questionnaire to Code the Mindful-Eating Log: (Client eats every 3-4 hours) Yes =1 point No= 0 point (Bariatric client keeps starch foods to 2 servings a day) Yes=1 point No=0 point (Non-Bariatric client keeps starch foods to 3-5 servings a day) Yes=1 point No=0 point (Client drinks only fluids that contain 0-15 calories per serving) Yes=1 point No=0 point (Client drinks 64 or more ounces of fluids a day) Yes=1 point No= 0 point (Client drinks no more than 20 ounces of caffeinated beverages a day) Yes = 1 point No =0 point (Client exercises outside of their normal activity routine for 3-4 days a week for at least 30 min or more) Yes=1 point No=0 point (Client makes healthy low fat, low sugar, high fiber food choices) Yes=1 point No=0 point (Client eats 2 fruits or more per day) Yes=1 point No=0 point (Client eats 2 or more non-starch vegetables per day) Yes=1 point No=0 point (Client is meeting their protein needs) NOTE: Lean meat fish and seafood is ~ 7 grams of protein per ounce so 3 ounces/deck of playing cards size = 21 grams of protein Yes=1 point No=0 point (Client eats no more than 1-2 servings of sweets/Deep fat fried foods a week as a treat that is portion controlled) Yes=1 point No=0 point Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
© 2013 STRIVE MD, LLC. All Rights Reserved.
(Client eats out 1-2 times a week maximum) Yes=1 point No=0 points (Client is getting at least 7-8 hours of sleep) Yes=1 point No =0 points
1. Place the total points acquired at the bottom of your mindful-eating log before turning them in. (There are 13 points total to be earned)
Dietitian Contact Information: Nancy Lum RD, LDN: 443-490-1240 Materials Developed by Nancy Lum RD, LDN 1/04/13
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
© 2013 STRIVE MD, LLC. All Rights Reserved.
Stressed
Happy
Sad/depressed
Bored
Angry
Anxious
Calm
Tired
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
Š 2013 STRIVE MD, LLC. All Rights Reserved.
WEEK # 2
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
3 4 5 6 7
Mindful Eating Food Log (rev. 5-17-2013) | STRIVE Series I
© 2013 STRIVE MD, LLC. All Rights Reserved.