1 Completing Your PAL Forms 1
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Completing Your PAL Forms
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PAL Forms
• PAL: Personal Awareness Log• Paperwork you will be COMPLETING and
TURNING IN on a weekly basis during Stage I of the Dr. Dean Ornish Program for Reversing Heart Disease.
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The Benefits of PAL and Other Forms• Research shows that self-monitoring is one of the
most important tools used for succeeding at lifestyle change.
• Self-monitoring using PAL and other forms helps you:– Outline clear goals for nutrition, exercise, group and
stress management.– Self-assess how you are doing on a daily basis.– Recognize and celebrate the areas in which you’re
doing well.– Identify the areas in which you need to focus.
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Is all this paperwork necessary?
• The PAL forms assist the Ornish team in:– identifying any barriers– helping you reach goals – customizing the Program to meet your needs
• Careful monitoring will ensure good nutrition and safe and effective participation in all four elements as well as ensure maintenance to lifestyle change.
• The PAL forms are a tool to help the Ornish team help you. – They are not meant to be judgmental.
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How to Complete Your
Nutrition PAL Formand Weekly Food Diary
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Step 1: Identify the foods you have eaten and the amount consumed.
• Sample Dinner Meal– 1 Boca Burger on 1 Whole-Wheat Bun
• 1 Tbsp ketchup, 1 lettuce leaf, 1 tomato slice
– ½ cup Vegetarian Baked Beans– 1 cup Field Green Salad
• 2 Tbsp fat-free French dressing
– 1 cup Fresh Cubed Melon
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Step 2: Determine corresponding food groups based on the Reversal Food Pyramid.
Food Eaten Food Group
Boca Burger Protein
Whole-Wheat Bun Whole Grain
Lettuce, Tomato Vegetable
Vegetarian Baked Beans Protein
Field Green Salad Vegetable
Fat-free French Dressing Free Food
Melon Fruit
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SERVING SIZE reference found on back of Nutrition PAL Form.
Step 3: Determine the amount of servings eaten.
Food Eaten Food Group # Servings
Boca Burger Protein 1 burger = 1 svg
Whole-Wheat Bun Whole Grain 1 bun = 2 svg
Lettuce, Tomato Vegetable1 piece lettuce,
1 tomato slice = < 1 svg
Vegetarian Baked Beans Protein ½ cup = 1 svg
Field Green Salad Vegetable 1 cup = 1 svg
Fat-free French Dressing Free Food 2 Tbsp = 1 svg
Fresh Cubed Melon Fruit 1 cup = 1 svg
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Step 4: Record information on food diary.
Food EatenFood
Group# Servings
WW Bun Whole Grain 1 bun = 2 svg
Lettuce, Tomato Vegetable1 piece lettuce, 1 tom. slice = <
1 svg
Field Green Salad Vegetable 1 cup = 1 svg
Fresh Melon Fruit 1 cup = 1 svg
Boca Burger Protein 1 burger = 1 svg
Veg. Baked Beans Protein ½ cup = 1 svg
FF French Drsg Free Food 2 Tbsp = 1 svg
WEEKLY FOOD DIARYGrains (6+ whole grains)1 whole wheat bun (2)Vegetables (3+)1 lettuce, 1 tomato slice (<1)1 cup field greens (1)Fruits (2-4)I cup melon (1) Full Fat Soy (1)
Other Protein (1-3)I Boca Burger (1) I/2 cup veg baked beans (1) Nonfat Dairy (0-2)
Sweets (0-2)/Alcohol (0-1)
Free Food:2 T FF French dressing (1)
Record all meals and snack.
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Step 5: Transfer servings to Nutrition PAL Form.
Protein Sources
Food Group
Servings
Whole Grains
6 or more
Veggie
3 or more
Fresh Fruit
2 to 4
Full Fat Soy Food
1
Other Protein Foods*
1 to 3
NonfatDairy
0 to 2
Sweets
0 to 2
Mon 8 4+ 3 1 2 1 0
Tues
Wed
Thurs
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Food Group
Servings
Low-Fat Foods
<3g Fat**
0 to 3
Suppl
√ for all
NO
Caffeine
LIMITED
Alcohol
FO
OD
GR
OU
P
TO
TA
L
Mon 1 0 0Tues
Wed
Thurs
Step 5: Continued
MAJOR GUIDELINES:
Please indicate if you were able to follow the nutrition guidelines with a Y (YES) or N (NO).
NO
ADDED FAT
AND OIL
NO
MEAT
FISH
POULTRY
DIE
TA
RY
GU
IDE
LIN
E
TO
TA
L
Y Y
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Leave shaded areas blank. For staff use.
Know Your PAL Form
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Low-Fat Foods ≤ 3 grams Fat Per Serving
LOW-FAT FOOD = An Ornish-friendly food with 3 grams of fat or less per serving, which also contains trace amounts of unsaturated fat(s) as a minor ingredient. 0-3 SERVINGS ALLOWED/DAY.
Veggie PenneNutrition Facts
Serving Size: 1 package (300g)
Calories 220 Calories from Fat 15
Total Fat 1.5g
Saturated Fat 0g
Cholesterol 30mg
Sodium 730mg
Total Carbohydrate 36g
Dietary Fiber 4g
Sugars 7g
Protein 12g
INGREDIENTS:WATER, TOMATOES, ENRICHED PENNE PASTA (DURUM SEMOLINA, NIACIN, FERROUS SULFATE (IRON), THIAMINE MONONITRATE, RIBOFLAVIN, FOLIC ACID), ROASTED RED PEPPERS, ONIONS, TEXTURED SOY PROTEIN (NON-GMO), TOMATO PASTE, BURGUNDY WINE, TEXTURED WHEAT PROTEIN, ROASTED GARLIC, SALT, ORGANIC EVAPORATED CANE JUICE, CORNSTARCH, SPICES, EXPELLER PRESSED OLIVE OIL, NATURAL FLAVOR, MALT EXTRACT, CITRIC ACID, GARLIC POWDER, ONION POWDER, CARRAGEENAN (FROM SEAWEED), SESAME OIL.
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INGREDIENTS:WATER, SOY PROTEIN CONCENTRATE, WHEAT GLUTEN, CONTAINS LESS THAN 2% OF NATURAL FLAVOR, SALT, MALTODEXTRIN, DRIED ONION, YEAST EXTRACT, SESAME OIL, DEFATTED WHEAT GERM, CARAMEL COLOR, HYDROLYZED CORN, SOY AND WHEAT GLUTEN, SOY SAUCE (WATER, SOYBEANS, WHEAT, SALT), AUTOLYZED YEAST EXTRACT, NATURAL AND ARTIFICIAL FLAVOR (CONTAINS COTTONSEED), METHYLCELLULOSE, DISODIUM GUANYLATE, DISODIUM INOSINATE, SUCCINIC ACID
Nutrition Facts:
Serving Size: 1 burger (71g)Servings Per Container: 4
Amount Per ServingCalories 90 Calories from Fat 10
Total Fat 1g
Saturated Fat 0g
Cholesterol 0mg
Sodium 350mg
Total Carbohydrate 6g
Dietary Fiber 4g
Sugars 0g
Protein 13g
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3 1
Weekly Food Diary Name: ________________MondayFood & Amount:
Other Grains1 cup Yves Veggie Penne **
Vegetables (3+)½ cup tomato sauce
Fruits (2-4)
Full Fat Soy (1)
Other Protein (1-3)1 Boca Burger (1) *
Nonfat Dairy (0-2)
Low fat Foods (0-3)1 Boca Burger (1)2 servings Yves Veggie Penne
Sweets (0-2) / Alcohol (0-1)
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Tips for Nutrition PALs:• Always include accurate amounts for all foods and
beverages recorded. Don’t forget snacks or drinks.• Save food labels and bring them to the next session if
unsure of a packaged food.• Always refer to the serving sizes listed of the back of the
Nutrition PAL form when estimating servings.• Write legibly.• Be as accurate and descriptive as possible, using “FF” for
fat-free foods, “WG” or “WW” for whole-grains and whole- wheat foods.
• Indicate whether vegetables are cooked or raw, and fruits are fresh or canned.
Stress Management, Exercise and
Group Support
PAL Forms
Sample Week PAL FormMONDAY
• 30 minutes meditation
• 30 minutes yoga poses
• 45 minutes swimming
TUESDAY – CLASS
• 60 minutes – Ornish yoga class
• 50 minutes treadmill
WEDNESDAY – BAD DAY!
• 15 minutes deep breathing
THURSDAY – CLASS
• 60 minutes Ornish yoga class
• 45 minutes treadmill
FRIDAY
• 15 minutes imagery
• 15 minutes deep relaxation
• 15 minutes yoga poses
• 40 minutes biking
SATURDAY
• 60 minutes relaxation/yoga CD
• 30 minutes resistance band
SUNDAY
• 60 minutes relaxation/yoga CD
01/02/09
30 30 60
45
treadmill
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50 12 treadmill
60
15 sitting in traffic 15
60
15 15 15
Relax CD
30
30
12
12
8
8
2
2
8
8
60
60
45
360 51 minutes
bike 40 14
swim
45 14
bands 30 12
180 minutes
yard 30
yard 30
2
3
3
4 4
4
4
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4
25
Ornish yoga class
Ornish yoga class
4
6 5
2
4
Relax CD
Leave shaded area blank. For staff use.
More PAL Tips
• Total your weekly minutes for stress management and exercise.
• Don’t forget to record exercise and stress management done during weekly class time.
• Add comments about encounters or stressful situations you may have had during the day/week.
• Write down any questions or concerns you may have during the week on the back of any one of your forms for the staff to address.
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Questions
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