Shelby County Annual Youth Fitness Congress For.docx

Shelby County Annual Youth Fitness Congress
For an Active and Healthier Youth Community
TABLE OF
CONTENT
PAGE 1. Event
Overview 2
2. Event Description 4-5
3. Time Line
6
4. Event Management

6
5. Marketing Plan
6
6. Venue 7
7. Logistic 7
8. Infrastructure 8
9. Safety 8
10. Décor 9
11. Technology 9
12. Event Program
9-11
13. Evaluations 12
14. Budget
14
15. Information (Data) Management 15
16. Appendix

16-22
1. EVENT OVERVIEW
a. Title
The Shelby County Youth Fitness Congress: For an Active and
Healthier Youth
Community
b. Plan
ii. Mission
The Shelby County Youth Fitness Congress Mission is
promoting increased
participation in physical activity in children and highlighting a
governmental current
initiative in relation to physical activity among youth
population. In addition, this event
will promote the community’s commitment to addressing the
growing epidemic of
physical inactivity and childhood obesity in Shelby County.
iii. Goals, Objectives, Strategies, Evaluation
a. Goal 1: Describe, present and outline components of the U.S

Department of
Health and Humans Services (The Division of Adolescents and
School Health)
initiative to increase physical activity among youth population.
This initiative is
called “Be active and Play 60 minutes every day”
i. Objective 1
Describe best practices related to physical activity among youth
population based on evidence provided for the U. S Department
of Health
and Humans Services
1. Strategy: Two parallel sessions will be health at this youth
congress. First, best practices will be explained to the youth
audience and also practical sessions will be held during the
event. In addition, a parents/teachers session will address the
same topics that the youth audience would be receiving, but the
information provided to them will be orientated to build
awareness about obesity in Shelby County community.
2. Evaluation: Each session will be evaluated by participants
through a satisfaction survey.
ii. Objective 2
Provide available tools that would improve best practices
related to
physical activity among youth population based on the evidence
provided for the U. S Department of Health and Humans
Services
1. Strategy: Tools and resources and the “Be active and Play 60
minutes every day” user guide will be provided to parents and
teachers. They will be trained in how to use the guide, power
point presentations and handouts in their community. An on-line

resource that has been developed by the U.S Department of
Health and Humans Services will be provided to the youth
audience. Proposed activities will be developed during sessions
in the congress.
2. Evaluation: Each session will be evaluated by participants
through a satisfaction survey at the end of each session.
b. Goal 2: To promote physical activity as a fundamental part of
a
healthier life and convey future complications related to the
lack of
physical activity among youth community
i. Objective 1
Describe all benefits that physical activity will provide to the
youth community by using available scientific data.
1. Strategy: Present in a friendly way according the
target audience different benefits of physical
activity. Each session will have a practicum part
where participants will be able to apply what has
been recommended to improve their current
physical activity time. For example, each speaker
will be asked to prepare an appropriate activity for
different age groups. A parallel section for parents
and teachers will cover the intervention that they
can introduce to improve this issue in the
community

2. Evaluation: Each session will be evaluated by
participants through a satisfaction survey at the
end of each session
ii. Objective 2
Provide evidence about possible complications in life related
to lack of physical activity.
1. Strategy: Present real examples about the
Shelby County community, the effect of lack of
physical activity in health community.
2. Evaluation: Satisfaction survey about the presentation
c. Goal 3: Provide information and resources about physical
activity
for special youth groups.
i. Objective 1
Provide resources and information about physical activities
for youth population with physical disabilities and certain
diseases.
1. Strategy: A conference about this topic will be
provided by an expert on physical activities in this
type of population.
2. Evaluation: Satisfaction survey about the conference

2. EVENT DESCRIPTION
a. Overview
The Shelby County Annual Youth Fitness Congress will take
place at the University
of Memphis. It will take place at the end of the school year on
May 23-24. This two
day event
is result of a charitable foundation initiative in the Shelby
county community. The target,
audience for the event is the youth population in the county.
However, parents and school
teachers from the county will have parallel sessions during this
innovative event. Current and
valid initiative promoted by the U.S Department of Health and
Humans Services will be the base
of this event. The keynote speaker for the event will be an
expert from the Centers of Diseases
and Control Programs who have implemented this initiative in
other states in the U.S.
b. Six Critical Event Dimensions
Anticipation: The youth event will be promoted in the Shelby
County public and private
school system. The marketing plan will use the effectiveness
that this strategy has had in other
states to attract the audience. Evidence about physical activity
improvements in other
communities will be shared. In addition, the fact that during the

event tools and resources will be
provided, it would attract audience to attend. It is important to
mention that physical activity for
youth with disabilities and chronic diseases will be cover during
the event for an expert in this
topic.
In addition to inter-school campaign of this event, the media
campaign will convey the
importance of the promotion of physical activity. A web-site for
the event will be created.
Participants can review information about the event and the
setting through the Web. In addition
the registration process can be done by this site. Flyers and
posters will be located in strategic
place around the city. The most representative business
managers in the city will be contacted to
give them information about the event.
Arrival: Travel arrangements will be done for the speakers. A
specific person from the
staff will coordinate with the hotel personnel details related to
the speakers arrival (hotel
registration, entertainment, ground transportation).
Welcome signs will be located in the event site. At the event
location, the welcome entrance will
be well decorated according to the event motives. Special
parking access will be provided for
special sponsors and participants with any disability. A help
desk will be able for any
inconvenient or unexpected problem.
Atmosphere: This will be a casual event. The venue will be
decorated using the same
concepts that will be developed during the congress. Decorative
effects will be added based on

the target audience preferences.
Appetite: The catering service from the event site will be used
for the youth congress. The
catering service will provide buffet food service for
participants. Healthy meals will be offered
during this event.
Activity: Music and dance will be incorporated to this event.
Moreover, a special time
with the Memphis Tigers will take place during the event.
Participant will have the opportunity
to meet and take pictures with the University of Memphis
basketball team.
Amenities: In general a sport bag will be provided to
participants. The bag will contain a
“Health Agenda”; the agenda will contain some daily
recommendation to get fit. All participants
will receive a T-shirt with the event motives and some prizes in
the diverse congress sessions.
Participants will receive a certification after the event.
c. Event Elements
1. Educational Sessions:
ce Room rental

Tasks related:
Tasks related:
c Band
Task related:
5. Marketing and
Task related:
6. Vendors and
volunteers

7. Evaluations
* See Appendix 1 for task descriptions
3. TIME LINE
TASKS* January Febraruy March April May
SCOPE MANAGEMENT,
FINACIAL MANAGEMENT
TIME MANAGEMENT
SITE MANAGEMENT
COMUNICATION MANAGEMENT
HUMAN RESOURCES MANAGEMENT
RISK MANAGEMENT
PROCUREMENT MANAGEMENT
CLOSEOUT & EVALUATION
4. EVENT MANAGEMENT
Collateral materials that will be used in the Shelby County
Youth Fitness Congress include
all the didactic material that has been developed as a part of the
“Be active and Play 60 minutes
every day” initiative. These materials includes: user guides,

Power Point presentation, flyers and
handouts (Appendix 2). In addition, all material for the
registration process and the event agenda
can be included in this category. All participants will receive a
binder with the material required
by the instructor in each session.
The admission control system will be based on the on-line
registration. Participants will need
to present the payment confirmation for this event. It is
important to point out that the only
method of registration for the event would be via online. It is
necessary to ask for the parents’
consent for the event. The event will include physical activities
were the participant can be
injured.
Different services will be provided to the audience. During the
Youth Fitness Congress,
participants will be provided of two meals each day and two
refreshments per day. There will be
water available for participants during the event. Transportation
will be coordinated only for
speakers.
5. MARKETING PLAN
In order to reach the goal for this activity, a partnership will be
done with the Shelby county
Health Department. This institution will encourage school
principals to have an active role in the
event. A meeting with physical education teachers and
principals will be held in order to have a
better idea what they expect to be included in this congress. In

addition, they will be asked about
previous experiences in order to apply any learned lesson from
the past.
There are different factors that will contribute to the uniqueness
of this event. First, materials that
will be taught during the congress have been developed by a
governmental institution. Second,
the event is the beginning of an ongoing initiative; participant
will be able to use materials after
the congress. Participants will have further assistance, if they
ask for it. On the other hand, the
main goal of this event is a global concern. Parents will be
motivated to learn about the best
practices for their children. Youth participants can be engaged
to this event for the nature of the
topics.
Different marketing strategies would be used for the event. First
the promotional
campaign will include a series of material that will provide the
reason for attending to the event,
when and where the event will take place. Flyers will be
delivered to students in the public and
private school system in the Shelby County. Parents will be
contacted via email to give them
information about the event. Posters will be located in strategic
places within the Shelby County
public and private school system. Then, the event advertisement
will be depicted by radio and

television as a part of Shelby County health interventions to
encourage healthy practices among
youth population. The items that I would include for the press
kit will be the press release, the
flyer and the e- mail that would be used for the e-marketing
(Appendix 3, 4 and 5).
6. VENUE
The University of Memphis (U of M) will be the site for the
Shelby County Youth Fitness
Congress. There are different reasons why this facility has been
chosen for the event. This
facility possesses the necessary infrastructure for the scope of
this event. Since, different sessions
will be delivered simultaneously, it is necessary to have enough
conference rooms for the event.
In addition, there is an outdoor area that would facilitate the
physical activities that will be part of
the congress. The main building that will be used for the event
is the University Center, this
building have a computer laboratory where participants will be
able to take the session that
requires access to computers. The catering service is provided
for the same institution for a
reasonable price. The U of M is well recognized for Shelby
County community for their
involvement in sport activities in different level. There are
different parking areas that will cover
the needs for the event. (See diagram, Appendix 6).

7. LOGISTICS
There are several needs to cover for the each element for the
youth congress. A registration
area will be set up for the event. Since participant’s data were
obtained through the online
registration, personnel at the registration table for youth
participants will use the confirmation
number that they have received via email. Parents should have
registered at the same time. The
same confirmation number will work for this process. On the
other hand two registration tables
will be located to have an organized registration process.
Teachers and event staff (speakers,
volunteers and others) will be able to pick up their congress
material in their respective table.
Participant will receive a sport bag that will contain the
material that will be needed for
congress sessions. A name badge will be provided to
participants and event staff.
The didactic material for classes and registration material will
be included in the event budget.
Participant will receive at the end of the event program a
participation certificate and some
amenities.
8. INFRAESTRUCTURE

Most of the details for the infrastructure will be required to the
event site administration. The
power needs for the conferences is the same as the required for
regular classes. The event
coordinator will assure that the power needs for the outdoor
activity would be covered by the
current capabilities at the U of M. However, an electrical
engineer will evaluate if any
intervention should be done before the event. The toilet
requirements for the congress will be
covered by current building infrastructure. Accessibility to
drinking water will be added to the
budget. A contingency plan will contain possible options to
solve unexpected problems related to
the event infrastructure. Utilities for the event will be cover by
the event site. The waste
management process for the event will be in charge of the
cleaning personnel at the U of M.
Local attendees will be able to use public transportation,
taxicabs or their car to attend to the
Youth Fitness Congress. The possible options for public
transportation will be described on the
website for the event. In addition, maps of the event site and the
permitted parking areas will be
available for attendees. Transportation of the materials and
supplies for the congress will be done
by the coordination team. The event coordinator will work with
U of M authorities in order to
receive the required permits for the event. General Permitted
Parking areas will be available for
the event.

9. SAFETY
At least three contact personnel at the U of M will be identified.
They must be available to
assist and solve unexpected problems during the event
development. The U of M police
department will be aware of the event.
Potential hazards will be identified and safety practices will be
discussed with the event site
contacts before the event. Plans will be developed according to
identified issues. Will be
coordinated paramedic assistance during the event in case is
needed.
10. DÉCOR
The main entrance and auditorium will be decorated by using
the same colors and themes that
will be part of the event program. Balloons decoration will be
used. The signs will include the
event name and the initiatives names that will be promote over
the event. For example, the “Be
active and Play 60 minutes every day” will be part of the
signage of the event. In addition, each
conference room that will be used for the event will be
decorated with signage about the physical

activity initiatives that will be promoted during the event
development.
11. TECHNOLOGY
Equipment required for conferences:
Computer: Windows (PC) or Mac
Microphone
Microphone, Wireless
Projection Screen
Projector, 16mm Film
Television/Monitor Wireless
Mouse
Internet connection
12. EVENT PROGRAM
AGENDA DAY 1
Time Topic: Youth Audience Topic: Parents and Instructors
7:30 AM –
8:30 AM
Welcome/Orientation/ Breakfast
Describe purpose of congress
Review briefly program and materials
Welcome/Orientation/ Breakfast
Describe purpose of congress
Review briefly program and materials
8:30 AM –

9:30 AM
Session 1: Only 60 minutes every day
Information about “Be active and play 60
minutes every day” will be shared in this
session.
Best practices for different age- group
Session 1: Only 60 minutes every day
Parents and Physical Activity teachers
role within implementing the “Be active
and play 60 minutes every day initiative”
9:30 AM –
10:30 AM
Session 2 –Putting into Practice
Practicum about previous session
Session 2 –Putting into Practice
10
10:30 AM –
10:45 AM

Break Break
10:45 AM –
11:45 AM
Session 3- Technology and Physical
Activity
Online resources to improve physical
activity
Session 3- Technology and Physical
Activity
Online resources to improve physical
activity
11:45 AM –
12:45 PM
Lunch Lunch
12:45PM –
1:45PM
Session 4 – Putting into Practice
Session 4 – Putting into Practice
1:45 PM –
2:45 PM
Session 5 – Why Should I Increase my
Physical Activity?
Benefits about physical activity (evidence)

Session 5 – Why Should I Encourage
Them?
Benefits about physical activity
(evidence)
2:45 PM –
3:00 PM
Break Break
3:00 PM –
4:30 PM
“Music and Exercise”
Entertainment activities
“Music and Exercise”
AGENDA DAY 2
7:30 AM –
8:30 AM
Welcome/ Breakfast Welcome/ Breakfast
8:30 AM –
9:30 AM
Session 1: What is happening in Shelby
County?
Information about results of lack of physical
activity in general and specific information

about the county.
Session 1: What is happening in Shelby
County?
Information about results of lack of
physical activity in general and specific
information about the county.
11
9:30 AM –
10:30 AM
Session 2 – Do we have resources in our
county?
Available resources and programs to increase
physical activities in Shelby
Session 2 – Do we have resources in
our county?
Available resources and programs to
increase physical activities in Shelby
County County
10:30 AM –
10:45 AM

Break Break
10:45 AM –
11:45 AM
Session 3- When I cannot exercise?
Especial situations to talk about: youth with
disabilities and chronic diseases
Session 3- When they cannot exercise?
Recommendations about especial
situations: youth with disabilities and
chronic diseases
11:45 AM –
12:45 PM
Lunch Lunch
12:45PM –
1:45PM
Session 4 – Safety is Essential!
Safety issues will be covered during this
session.
Session 4 – Safety is Essential!
Safety issues will be covered during this
session.
1:45 PM –
3:15 PM
Session 5 –Where are we now? Where are
we going?
Participants will provide group projects

about how to improve Shelby County
Physical Activities Programs within schools
and community.
Session 5 –Where are we now? Where
are we going?
Participants will provide group projects
about how to improve Shelby County
Physical Activities Programs within
schools and community.
3:15 PM –
3:30 PM
Break Break
3:30 PM –
5:00 PM
“Dancing and Wining”
Competition and Awards
“Dancing and Wining”
Entertainment Component:
The main entertainment component for the event will take place
at the end of the each
day. The first day they will have a “Music and Exercise”
activities. Multiple activities will be
available for participants. Physical instructors will be
conducting certain classes and exercise
equipment display will be available. The second day, the event

will close with the “Dancing and
12
Wining” activity. Participant will be invited to a dance
competition during this entertainment
time. Different awards will be provided during this time for
those who decide to participate
Logistical requirement:
It will be necessary to set up the stage for the band music. The
first day activity will take
place in the Students Activity Plaza at the U of M. In addition,
it would be necessary to establish
the transportation process for the equipment that physical
instructors require for their
demonstration. Finally, the second day entertainment activity
will take place in the main
auditorium at the University Center. The awards and
certification of the event will be provided at
the end of this session. Awards and certificates will be included
in the event budget. Some
principal vendors that will need to be hired to develop the
program are: (a) the production
company that will develop the event entertainment activities,
(b) the staging company, (c)
catering, (d) equipment rental, (e) graphic designer, (f)
electrical engineers, and (g) sound
engineers. There are other needs that will be cover by the event

site resources.
13. EVALUATION
In order to evaluate vendors an evaluation instrument will be
developed to asses each seller.
This instrument will be based on some criteria that will permit
the event coordinator ranking the
bids or proposals. The proposals should contain the product
specifications, prices and method of
payment. Quality, price and experience will be some of the
criteria that will be evaluated.
Finally, the event coordinator will assure that the seller has
included all cost associated to the
delivery of the product or service. Moreover, required licenses
will be verified. Once vendors are
selected, all of appropriated contractual documents will be
addressed by the event coordinator.
Participant evaluation will be based in satisfaction survey about
each session. At the end of the
session participants will be asked to evaluate the material that
was used (content usefulness,
didactic material quality, etc.), the speaker, and they will asked
to provide suggestions and
recommendation for further events.
Vendors and volunteers will be asked to give a feedback about
their experience in the
event development. A survey will be developed to have
standardized data about their opinion.
Vendors and volunteers will receive the survey via online.
Finally, an evaluation from the
charitable organization that is founding the event will be done.
The event coordinator will

develop an evaluation form that covers different event elements.
Organization director will be
asked to evaluate each element by using a scale (Likert scale) to
convey his/her opinion about the
overall event. This evaluation will be completed via online after
all event documentation is done.
13
14. BUDGET
Annual Shelby County Youth Fitness Congress Two Days
Congress
Official budget of the Shelby County Youth Fitness Congress
Estimated attendees 300
Meals and materials Per person>> $
70.00
1. Namebadge and holder (.33 if purchased from Exec. Office)
$
1.20
2. Meal #1 (Breakfast Day 1) $

4.00
3. Meal #2 (Lunch Day 1) $
8.00
4. Meal #3 (Breakfast Day 2) $
4.00
5. Meal #4 (Lunch day 2) $
8.00
6. Break(s)(2 per day) $
20.00
7. Bags and binder $
7.00
8. Handouts at conference (approx 5 per each sesion(10) x 10
cents) $
5.00
9. Session evaluations copies (approx 10 per person x 10 cents
= 1 dollar) $
1.00
10. Materials "“Be active and play 60 minutes every day
initiative” $
5.80

10. Extra activities materials $
3.00
11. Participat certificate $
3.00
Other Expenses
Congress Committee Expenses Total Comitt.> $
460.00
Congress Committee Appreciation Dinner (20 x 15) $
300.00
Small tokens of appreciation for speakers (8) (conference
participation recognition) $
160.00
Keynote Speaker $
1,700.00
14

Honoraria $
500.00
Lodging/Airfare/mileage/meals/ $
1,200.00
Publicity Total Publicity> $
1,300.00
Promotional items to hand out at national conference (300) $
300.00
Graphic Designer $
500.00
Promotional items /marketing plan $
500.00
Rentals: Total Rentals> $
6,000.00
Audio-visual Rental $
1,500.00
Physical Activities Equipment rental $
1,500.00
Facility room Rental $

3,000.00
Entertainment: Total Entertain> $
2,000.00
Music Band (500 per day) $
1,000.00
Sound and Electric Engineers $
500.00
Stage preparation $
500.00
Supplies: Total Supplies> $
1,150.00
Signs on the event site $
50.00
Decoration supplies $
1,000.00
Office Supplies $
100.00
Complimentary Registrations Comp Registr> $
960.00

Speakers (8 x 60) $
480.00
Volunteers (8 X 60) $
480.00
Other Costs: Total Other > $
200.00
Small tokens of appreciation (awards) $
200.00
These are the TOTAL Costs $
13,770.00
Total cost: $ 13,770 + (300 x 70)
Total cost: $ 13,770 + 21000 = 34, 770
15
15. INFORMATION (DATA) MANAGEMENT

General contact information from event audience will be
collected through the online
registration process. In addition, session’s evaluation and
participant’s recommendations will be
obtained during the event. Stakeholders will be asked to
evaluate the event overall via online.
Vendors, volunteers and budget information will be stored for
future event opportunities.
Templates in a word processor will be created for
correspondence, memorandums proposals,
budgets, contracts, job orders, and reports. The filing system for
the event will be located in the
event coordinator office. Each category will be identified by
colors. A short manual will be
available in order to make the document retrieval easier. This
document will outline how each
category was assigned for the available colors in the filing
system. Confidential records and
important documents will be stored separately in a fire proof
filing cabinet with a locking
mechanism. The original document and a copy for important
documents generated for the event
will be stored in the cabinet. Moreover, an electronic backup for
legal and important document
will be saved on the computer system. All financial and legal
documents will be scanned in order
to have the electronic copy.
The production book for the Shelby County Youth Fitness
Congress will include all key
documents related to the event operations and local policies that
might be needed during the
event development. The production book will be organized by
using colors; the front page will
describe what documents correspond to each color. The key

personal will have a copy of the
production book. They will be able to monitor the progress of
the congress by using a
chronological schedule. A directory will be included in the
production book. Contact information
from vendors, key stakeholder, instructors and speakers will be
described in the production book.
Finally, verification document such as final contract for the
different services, confirmations,
purchase orders and required licenses will be included.
Management
All the data obtained from the evaluation activities from each
educational session will be
entered in a computer database. The analysis from this
information will be stored and used for
future events coordination. The results from the last session will
be provided to the Shelby
County Health Department (It is expected that participant will
provide recommendation to
improve physical activity in Shelby County community).
Moreover, if there are some general
suggestions for the event coordination, these will be taking into
account for any further event.
Information obtained through the congress will contribute to the
improvement of further
experiences and also to the improvement of future interventions
about physical activity among
youth population.
16

Appendix 1. Time Line. Tasks Description
SCOPE MANAGEMENT HUMAN RESOURCES
MANAGEMENT
Assessment Stakeholders
Definition/Design Org. structure
Change Control Support Staffing
Evaluation Labor Needs
FINACIAL MANAGEMENT Volunteers
Resource Definition Mgmt/Leadership
Cost Estimation RISK MANAGEMENT
Budgeting Identification
Cost control Analysis
TIME MANAGEMENT Response Planning
Task Definition Monitoring Control
Sequencing Compliance
Duration Estimation Insurance

Schedule Development PROCUREMENT MANAGEMENT
Schedule Control Definition/Planning
SITE MANAGEMENT Socialization
Specifications Selection
Inspection/ADA Quality Control
Selection Contract
Layout/Diagrams CLOSEOUT & EVALUATION
COMUNICATION MANAGEMENT Performance Review
Definition/Planning Evaluations
Info Acquisition Financial Reports
Info Distribution
Reporting
Documentation
17
Appendix 2. Collateral Materials

18
Appendix 2. Collateral Materials
19
Appendix 3. Press Release
SHELBY COUNTY HEALTH DEPARTMENT
FOR IMMEDIATE RELEASE
For more information: Xxxxx XXXX (901) 222-2222
SHELBY COUNTY ANNUAL YOUTH FITNESS CONGRESS

MEMPHIS, TENNESSE –December 5, 2011--Awareness of the
importance of physical activity
can be increased by community activities such as a youth fitness
congress. The event will take
place on May 25, and May 26, 2011. The target audience is the
Shelby County Youth Community.
Private and Public Schools in the county will be participating in
this event. The event will take
place in The University of Memphis installations. Participants
will meet new friends and will have
more information about the importance of being active for good
health. In addition, community
participants will have an opportunity to support Shelby County
Schools System for improved
physical activity programs that will be provided during the
event. The main purpose for this event
is promoting increased participation in physical activity in
children and highlighting a
governmental current initiative in relation to physical activity
among youth population. This
congress will promote the community’s commitment to
addressing the growing epidemic of
physical inactivity and childhood obesity in Shelby County.
The event is sponsored by an “X Charitable Foundation”.
On line registration and fees information is available in the
following link
www.shelbycountyyouthfitnesscongress.com
# # #
http://www.shelbycountyyouthfitnesscongress.com/

20
Appendix 4. Flyer
21
Appendix 5. E-mail for Media Coverage Request
Subject line: “Shelby County Youth Fitness Congress” Media
Coverage request
For an Active and Healthier Youth Community”
Youth community will exercise, have fun and learn by attending
the Shelby County Youth
Fitness Congress: For an Active and Healthier Youth
Community”. Public and Private School
system will be benefited by the event. We are looking for your
company support. Coverage
media is essential for the event success. The event will take
place at the University of Memphis
installations on May 25-26, 2011. More information is available

in the following link
www.shelbycountyyouthfitnesscongress.com Looking forward
to getting you support.
For further information you can contact me:
Xxxxx (901) 222--2222
[email protected]
http://www.shelbycountyyouthfitnesscongress.com/
mailto:[email protected]
22
Appendix 6. Map
23
UC: University Center, University of Memphis
Auditorium staging

24
TABLE OF CONTENTb. Planii. Missioniii. Goals, Objectives,
Strategies, Evaluationi. Objective 1ii. Objective 2i. Objective
1ii. Objective 2i. Objective 12. EVENT DESCRIPTIONb. Six
Critical Event Dimensionsc. Event Elements3. TIME LINE5.
MARKETING PLAN6. VENUE7. LOGISTICS8.
INFRAESTRUCTURE9. SAFETY10. DÉCOR11.
TECHNOLOGY12. EVENT PROGRAM AGENDA DAY
1AGENDA DAY 213. EVALUATION14. BUDGET15.
INFORMATION (DATA) MANAGEMENTSHELBY COUNTY
ANNUAL YOUTH FITNESS CONGRESS
Nutrition and Older Adults
Class Objectives
By the end of this class, the student will be able to:
Understand the theories of aging.
Recognize physiological changes that occur with aging and
nutritional implications.
Describe the effectiveness of nutrition screening tools.
Understand the interactions of medications on nutrients.
Recognize nutrition recommendations and nutrients of concern
during aging.

Know how to calculate energy and nutrient requirements.
Know about nutrition programs serving older adults.
2
What Counts as Old?
There is no one age that defines “old”
70 – DRI category
60—the Elderly Nutrition Program
65—Eligibility for Medicare
60 - World Health Organization
U.S. Census Bureau uses:
“young old”
“aged”
“oldest old”
“Geriatric”
3
A Picture of the Aging Population:
Vital Statistics
More Americans are living longer
Currently, ~17.4% are >65 yrs
By 2050, ~19% will be >65 yrs
Persons ≥85 are the fastest growing population group
4

Institutionalized Elderly
2008: 1.6 M (4%) aged > 65 years live in institutional setting
1.3% 65 – 74 years
3.8% 75 – 84 years
15.4% > 85 years
Have medical problems that impact diet and dependent on
others for eating
5
Global Population Trends: Life Expectancy and Life Span
Life expectancy
Average number of yrs of life remaining for persons in a
population cohort or group; most commonly reported as life
expectancy from birth
Life expectancy at birth in the United States is 78.5 years
Life span
Maximum number of yrs someone might live; human life span is
projected to range from 110 to 120 yrs
6
Aging Theories – Two Groups
1) Programmed aging
Programmed cell replication – natural limit to cell division

Hayflick’s theory of limited cell replication
Modular clock theory
2) Wear and tear theories of aging
Free-Radical or Oxidative stress theory
Rate of living theory
7
Theories – ‘Wear and Tear’
Cellular mutations – Drugs, UV light, mutagens and radiation
cause a decrease in DNA repair activity
Free radicals – Environmental exposures via radiation, natural
body processes causes macromolecular damage
Cross-linking – Glycation causes cross-linking between protein
molecules
8
Calorie Restriction to Increase Longevity
Animal studies show that an energy-restricted diet that meets
micronutrient needs can prolong healthy life
Calorie Restriction research ensures nutrient in diets of study
subjects
Nutrient density used to decrease chronic disease risk
Spindler. Ann N Y Acad Sci 2001;928:296–304.
Mattison et al. Exp Gerontol 2003;38:35–46.
Bordone & Guarente. Nat Rev Mol Cell Biol 2005;6:298–305.
Lee et al. Science 1999;285:1390–3.

9
CALEREI Study – Completed April 2012
Comprehensive Assessment of the Long-term Effects of
Reducing Energy Intake
25% caloric restriction intervention on non-obese x 24 months –
2 Phases
n=220 across 3 sites (Tufts, Pennington, Washington
University)
Men 21-50 y, Women 21-47 y initial BMI≥22 kg/m2
Randomized
25% Calorie Restriction (Intensive behavioral coupled with
dietary modifications and daily self-monitoring of calories)
Control group (ad libitm diet)
Rickman et al. Contemporary Clinical Trials 32 (2011) 874–881
Theories of Aging
Decreased Hormonal Secretions
Growth Hormone
Testosterone in Males
Estrogen in Females
11
Chronic Diseases in the Elderly
80-85% of seniors have one or more chronic diseases that
require dietary intervention

Cardiovascular disease due to heart conditions and hypertension
is the leading cause of death among the elderly
Cancer follows a close second as the most common cause of
death of elderly
25% of females and 20% of males dying from cancer
40% of elderly after age of 80 are afflicted by diabetes
12
Chronic Diseases in the Elderly
Hypertension (39%), High blood cholesterol (70% of Seniors),
obesity (30%)
Visual impairments are common such as cataracts
Dementia (2/3 Is Alzheimer's Disease) afflicts 8-15% of Elderly
40% of females over the age of 65 will experience a fracture as
a result of osteoporosis
13
Body Composition Changes
Lean body mass (LBM)
Sum of fat-free tissues, mineral as bone, & water
Sarcopenia
Term used for loss of LBM associated with aging
“Cachexia”: loss of weight and muscle mass associated with

underlying illness
LBM decreases 2-3% from age 20 to 70
Older people have lower mineral, muscle, & water reserves
14
Muscles: Use It or Lose It
In older adults, weight-bearing & resistance exercise increase
lean muscle mass & bone density
Regular physical activity helps maintain functional status
15
Mean (±SE) Changes in Muscle Strength after Exercise,
Nutritional Supplementation, Neither, or Both.
Fiatarone MA et al. N Engl J Med 1994;330:1769-1775.
n=100 nursing home residents 70 years + x 10 weeks
16
Weight Gain
Weight gain accompanies aging, but is not inevitable
Mean body weight gradually increases with aging, peaking
between 50 & 59 y
Physical activity moderates weight gain & increases in body fat
Lack of estrogen promotes fat accumulation

17
BMI - Adults > 65 yearsBMIInterpretation< 24May be
associated with health problems in some elderly24.0 –
29.0Healthy weight> 29.0May be associated with health
problems in some elderly
18
Unintentional Weight Loss
Epidemiology
The incidence of involuntary weight loss in community-
dwelling elderly is between 5-15% of that population and more
than 25% in frail elderly receiving home care services.
One year documented weight loss of greater than 4-5% was the
single best predictor of death within two years.
Newman et al. J Am Geriatr Soc. Oct 2001;49(10):1309-1318.
Wallace et al. J Am Geriatr Soc. Apr 1995;43(4):329-337
Risk Factors for Malnutrition in Older Adults
Decrease in body functions
Disease
Multiple medications – “Polypharmacy”
Greater than 65% of elderly use more than one drug daily to
treat a medical condition
3-8% of hospital admissions are due to adverse drug reactions
and one third of these cases are elderly persons

20
EXAMPLES OF DRUG SIDE EFFECTS ON NUTRITIONAL
STATUS
21
Adverse Effects of Drugs on Nutrient Metabolism
Antivitamin drugs block action of vitamins
inhibiting their absorption
binding to them in the body to make them unavailable to the
tissues
enhancing their catabolism
enhancing their excretion
causing an inhibition of their activation in the body to an active
form.
22
Cholesterol lowering drugs that are bile acid sequestrants
(cholestyramine)
prevent reabsorption of bile salts and thus decrease fat soluble

vitamin absorption
Damage to the GI tract will also cause decreased nutrient
absorption from use of antibiotic drugs (neomycin)
destroy intestinal mucosa, villi and microvilli and inhibit brush
border enzymes
23
Anti-inflammatory drugs
inhibit the lactase enzyme
directly damage the gut and decrease fat and micronutrient
absorption
Laxatives can contain emollients such as mineral oil
Dissolve fat and fat-soluble vitamins that are then excreted in
the feces rather than be absorbed
Decreased transit time from the use of laxatives and mineral oil
can cause decreased nutrient absorption in terms of Ca and K
losses.
24
Loop diuretics (furosemide) used for blood pressure control
increase renal excretion of thiamin which can cause cardiac
abnormalities as a result of excessive use

Other diuretics (thiazide) and corticosteroids
can cause potassium depletion, which increases the risk of
cardiac arrhythmias
Aspirin increases folate excretion
by binding to folate binding sites on plasma protein normally
involved with blood transport of the vitamin (albumin) causing
increased urinary excretion folate
Anti-ulcer drugs (cimetidine) cause decreased HCl production
which decreases the amount of B12 released from foods and less
B12 is available for binding with intrinsic factor for absorption
Drugs Associated with Diarrhea
Antibiotics
Temporary alteration of colonic bacteria
Damage to small intestinal mucosa
Osmotic Agents (Laxatives, Antacids)
Antimetabolites (Methotrexate)
27
Needs assistance with self-care
Physical disabilities such as decreased eyesight and bone
fractures decrease abilities to procure and prepare food

Surgery, injury, infection increase nutritional needs and
decrease food intake
Tooth loss or oral pain
Loss of teeth and dentures make chewing less effective and
increases the risk of choking
28
Taste and Smell
“Anorexia of Aging”
Food Intake Declines
Taste & smell senses decline with age
Decline in ability to identify smells varies by gender
Women retain their sense of smell better than men do
Disease & medications affect taste & smell more than aging
29
Appetite and Thirst
Appetite
Hunger & satiety cues weaken with age
Older adults may need to be more conscious of food intake
levels since appetite-regulating mechanisms may be blunted
Thirst
Thirst-regulating mechanisms decrease with age
Studies support that dehydration occurs more quickly after fluid
deprivation & rehydration is less effective in older men

30
Chewing and Swallowing
Oral health depends on:
GI secretions (saliva)
Skeletal systems (teeth & jaw)
Mucus membrane
Muscles (tongue & jaw)
Taste buds
Olfactory nerves (smell & taste)
31
32
.
Eating poorly
Tend to eliminate whole food groups such as fruits and
vegetables
Economic hardship
High rate of poverty among elderly
Reduced social contact
Loss of vision and hearing increases social isolation
Loneliness and depression due to loss of loved one

33
Nutritional Risk Factors
Risk factors for older adults are:
Hunger, poverty, low food & nutrient intake
Functional disability
Social isolation or living alone
Urban & rural demographic areas
Depression, dementia, dependency
Poor dentition & oral health
Diet-related acute or chronic diseases
Polypharmacy
Minority, advanced age
34
Assessing Risk of Malnutrition
Malnutrition observed in 2 – 38% of institutionalized older
adults, 37 – 62% considered at risk
Consequences: Increased mortality, loss of strength, depression,
lethargy, immune dysfunction, pressure ulcers, delayed recovery
from illness, increased hospital admission, poor wound healing
Unintended weight loss indicator of undernutrition
35
DETERMINE Checklist

Developed by the:
American Academy of Family Physicians
Academy of Nutrition and Dietetics
National Council on Aging
Integrates a list of warning signs of poor nutritional health in
older adults
36
Determine Your Nutritional Health Checklist
37
MNA Nutritional Screening and Assessment
The MNA short form uses six screening items
More extensive includes:
Dietary intake
Anthropometrics
Blood chemistries
mna-elderly.com
38

Nutrient Recommendations
Nutrient recommendations change as scientists learn more about
effects of foods on human functions
Specific DRI for those >51 yrs were 1st established in 1997
Estimating Energy Needs
Decrease in physical activity & BMR from early to late
adulthood results in 70-100 fewer calories needed
39
Carbohydrate and Fiber
Carbohydrate
AMDR between 45 to 65% of calories
A listing of food that provides at least 50% of carbohydrates
with fiber levels is in
Minimum of 22 to 28 grams of dietary fiber daily for older
females and males
40
Protein
Inactive, older adults living alone may have low protein intakes
Several researchers report protein needs for older adults are 1 to
1.3 g/kg body wt (higher than the DRI of 0.8 g)
Nitrogen balance is easier to achieve when:
Protein is a high quality
Adequate calories are consumed
Individuals participate in resistance training

41
Fats and Cholesterol
Minimize saturated fat & keep total fat between 20 to 35% of
calories
Even though eggs are high in cholesterol, they are a nutrient-
dense, convenient, & safe food for older adults that do not have
lipid disorders
42
Recommendations for Fluid
The total amount of water decreases with age, resulting in a
smaller margin of safety for staying hydrated
≥6 glasses of fluid/day will prevent dehydration in most older
adults
To individualize fluid recommendations, 1 mL of fluid/kcal
consumed, with a minimum of 1500 mL
43
Age-associated Changes: Nutrients of Concern
Vitamin D, Calciferol
Factors that put older adults at risk for deficiency:
Limited exposure to sunlight
Institutionalization or homebound

Certain medications (barbiturates, cholestyramine, Dylantin,
laxatives)
Gloth et al. JAMA. 1995; 274: 1683-6.
% of Individuals with
25(OH)D levels
< 25 nmol/L
44
Age-associated Changes in Metabolism: Nutrients of Concern
Calcium
Need adequate intake for bone health and to reduce
hypertension
UL has been lowered because of toxic effects
Magnesium
Need adequate intake for bone health, nerve activity, glucose
utilization
Excessive intake from supplements can cause overdose
45
Vitamin B12
B12 levels
atrophic
gastritis) in aged persons resulting in inability to split B12 from
protein carriers

Synthetic or purified B12 is not protein bound and is much
better absorbed
46
Atrophic Gastritis
Inflammation of stomach mucosa
Increased prevalence with aging
Results in decreased secretion of HCL, pepsin and intrinsic
factor
Type A: Pernicious Anemia
Type B: Inflammatory Disorder associated with H. pylori
infection
Folate, Folic acid
Absorption may be impaired
Some medications used can affect folate metabolism
Folate deficiency can mask B12 deficiency, which is a more
common problem in elderly
Folate supplementation may decrease dementia like symptoms
and increase mental functioning among elderly.
48
Other Nutrients May Inhibit Age-Related Diseases
Vitamins C and E decrease incidence of cataracts.

Antioxidants play a role in Age-Related Macular Degeneration
May improve mental ability in old age and prevent some forms
of dementia
Intake of fish and fish oils has also been implicated in better
cognitive performance among elderly.
Community Food and Nutrition Programs
Nutrition Programs Serving Older Adults—
USDA’s Supplemental Nutrition Assistance Program (SNAP)
Seniors’ Farmers Market Nutrition Programs
Commodity Supplemental Foods
Child and Adult Care Food Program
50
Community Food and Nutrition Programs
Nutrition Programs Serving Older Adults—
The U.S. Department of Health and Human Services (HHS)
administers the Older Americans Act programs
Meals on Wheels-Home delivered meal programs
51
Geriatric Nutrition Case Study: Mrs. H
Chief Complaint:

Mrs. Heraldo is a 78 year old Latina woman brought in by her
niece. The niece is concerned that Mrs. H looks much thinner.
Mrs. H seems unconcerned about her weight loss and just
repeats she is old now and “just not hungry.”
Mrs. H has no idea if she has lost weight. However, her chart
documents that she is 5’4” tall and weighed 174 lbs 3 months
ago. Today she weighs 154 lbs.
52
Continuation of Chief Complaint:
The niece explains that her aunt lives alone in a subsidized,
senior housing facility. She does not go out much. Mrs. Heraldo
tells you that her two children, both grown, live in California
and Arizona and she sees them about once a year. Her husband
died 5 years ago. Her eyes tear a bit as she tells you this.
Discussion Question 1
What is the percentage of body weight that Mrs. H has lost in
the last three months?
Given that Mrs. H’s BMI is still in the overweight range, is her
weight loss currently a significant issue? Why or why not?
Discussion Questions 2
What should our weight goals for Mrs. H be at this point?
Is Mrs. H’s weight loss to be expected at her age? Why or why
not?

How do the physical effects of weight loss from decreased
energy intake (reduced calories) differ from cachexia? What are
the physiological effects of both?
What are some of the causes of inadequate food intake in the
elderly?
Brief 24 Hour Food Recall
Mrs. H lives alone and reports that she shops and cooks for
herself. She says that she eats two meals a day and that she eats
pretty much the same thing every day. Her 24 food recall for
yesterday is:
Morning: 1 cup of instant coffee with non-dairy creamer, 1 tsp
sugar and 1 slice toast with 1 tsp margarine and 1 tsp jam.
Noon: 1/2 can chicken noodle soup, 3-4 saltines and 1 slice
American cheese.
Evening: 1 broiled chicken thigh, 1 spoonful of string beans and
1 spoonful rice.
She drinks at least 5 cups of water a day and sometimes has a
cup of tea with 1 teaspoon sugar and 2-3 vanilla wafer cookies
before bed.
She takes a daily multivitamin/mineral supplement.
Approximately how many calories is Mrs. H eating each day?

Breakfast?
Lunch?
Dinner?
Evening Snack?
Total: On a good day, maybe 1000 calories!
Breakfast: ~200 calories
Lunch: ~200-300 calories
Dinner: ~200-300 calories
Evening Snack: ~ 200 calories
What formula could we use to quickly estimate Mrs. H’s total
daily caloric requirements?
What formula should we use to calculate Mrs. H’s ideal protein
intake?
What dietary recommendations would be appropriate given Mrs.
H’s current reported diet and health history?

Use the MNA – short form to assess Mrs. H’s risk for
malnutrition?
Chart15438
%
54%
38%
Sheet1%Homebound Elderly54Nursing Home Residents38To
resize chart data range, drag lower right corner of range.
Adolescent Nutrition
Class Objectives
By the end of this class, the student will be able to:
Identify normal biological changes that occur during
adolescence
Recognize changes in nutrient needs and eating behaviors
Recognize differences in diagnostic criteria for eating disorders
Identify treatments for eating disorders
2
Normal Physical Growth and Development
Variations in reaching sexual maturity affect nutrition

requirements of adolescents
Sexual maturation (or biological age)—not chronological age—
should be used to assess growth and development and
nutritional needs
3
Sexual Maturation Rating or “Tanner Stages”
Sexual Maturation Rating (SMR) (“Tanner Stages”)—scale of
secondary sexual characteristics used to assess degree of
pubertal maturation
SMR 1=prepuburtal growth & development
SMR 2-5=occurrences of puberty
SMR 5= sexual maturation has concluded
4
Table 14-1 p363
5
Tanner’s Sexual Maturation Ratings (SMR)

Females
Males
Changes in Weight, Body Composition, and Skeletal Muscles in
Females
Peak weight gain follows linear growth spurt by 3 to 6 months
Gain of ~18.3 pounds per year
Average lean body mass decreases
44% increase in lean body mass (LBM)
120% increase in body fat
17% body fat is required for menarche to occur
25% body fat needed to maintain normal menstrual cycles
7
Changes in Weight, Body Composition, and Skeletal Muscles in
Males
Peak wt gain at the same time as peak linear growth & peak
muscle mass accumulation
Peak wt gain, ~20 lb per year
Body fat decreases to ~12%
~Half of bone mass is accrued in adolescence
8

Health and Eating-Related Behaviors During Adolescence
Factors affecting eating behaviors
Peer influence
Parental modeling
Food availability, preferences, cost , convenience
Personal & cultural beliefs
Mass media
Body image
9
Vegetarian Diets During Adolescence
~4% follow a vegetarian diet
Reasons:
Cultural or religious beliefs
Moral or environmental concerns
Health beliefs
To restrict fat and/or calories
A means of independence from family
10
Energy and Nutrient Requirements of Adolescents
Increases in lean body mass, skeletal mass and body fat
Energy & nutrient needs during adolescence exceed those of any
other point in life
Needs correspond to physical maturation stage

11
Energy Requirements of Adolescents
Energy needs are influenced by:
Activity level
Basal metabolic rate (BMR)
Pubertal growth & development
Males greater increases in ht, wt, & lean body mass higher
caloric needs than females
Level of physical activity declines during adolescence decr
energy requirements
12
Protein Requirements of Adolescents
Protein requirements influenced by protein needed:
To maintain existing LBM
For growth of new LBM
Recommendation is 0.85 g/kg body wt
Low protein intakes linked to:
Reductions in linear growth
Delays in sexual maturation
Reduced LBM
13
Requirements for Selected Nutrients of Adolescents

Carbohydrates:
130 g/day or 45-65% of calories
Dietary Fiber:
DRI recommends
26 g/day for adolescent females
31 g/day for males <14 years of age
38 g/day for older adolescent males
14
Requirements for Selected Nutrients of Adolescents
Fat:
Required as dietary fat and essential fatty acids for growth and
development
25-35% of calories from total fat
<10% calories from saturated fat
15
Requirements for Selected Micronutrients of Adolescents
Iron: Increased needs related to rapid rate of linear growth,
increase in blood volume, menarche in females
Deficiency 2-11% among adolescents
Folate: Deficiency leads to Megaloblastic anemia
DRI 400 mcg
Calcium: Adequate intake is critical to ensure peak bone mass
~4 times more calcium retained during early adolescence
compared to early adulthood
DRI for ages 9-18 years is 1300 mg/d
Average intake is: 948 mg for females, 1260 mg for males

+ Vitamin D: RDA – 600 IU/day
16
Three Main Eating Disorders
Anorexia nervosa
Characterized by extreme wt loss, poor body image, & irrational
fears of wt gain & obesity
Bulimia nervosa
Characterized by recurrent episodes of rapid uncontrolled eating
of large amounts of food in a short period of time frequently
followed by purging
Binge-eating disorder
Characterized by periodic binge eating not followed by
vomiting or use of laxatives
17
Etiology of Eating Disorders
Environmental factors:
Media Influences
Societal and cultural norms
Food availability and accessibility
Family factors:
Family dynamics
Interpersonal factors:
Peer norms and behaviors
Abuse experiences

Personal factors:
Biological, Psychological
Knowledge, attitudes and behaviors
18
Prognosis for People with Anorexia Nervosa
Early diagnosis & treatment improves chances for recovery
Recovery rates
<50% fully recover
~33% show improvement
~20% chronically affected
19
Anorexia Nervosa – Diagnostic Criteria
No Known Medical or Psychiatric (Schizophrenia, Obsessive
Compulsive) Illness Accounting for Anorexia and Weight Loss
Body Weight Between 15-20% Below That Expected Weight
Intense Fear of Weight Gain Even When Underweight
20
Eating disorders in the form of anorexia nervosa and bulimia is
believed to affect as many as 2 million teens mostly female (<

10% of cases are males) in USA.
Typically observed in white, middle and upper income classes
and with depression and family dyfunction.
Diagnostic criteria include:
No known medical or psychiatric (schizophrenia, obsessive
compulsive) illness accounting for anorexia and weight loss
Body weight between 15-20% below that expected weight.
Intense fear of weight gain even when underweight
In females malnutrition causes the absence of at least 3
menstrual cycles
Disturbed self image including denial of recognizing food
needs, desired body image of extreme thinness. Normally
associated with anxious, fearful and dependent personality.
Psychological profile includes achievement oriented families,
withdrawal from peer relationships, psychopathology in family
setting.
Anorexia Nervosa – Diagnostic Criteria
In Females Malnutrition Causes the Absence of at Least 3
Menstrual Cycles
Disturbed Self Image Including Denial of Recognizing Food
Needs, Desired Body Image of Extreme Thinness
Restrictive Type - No Purging Behavior
Binging/purging Type - Binging Followed by Vomiting,
Diuretics or Laxatives
21
Can have restrictive types in which there is no purging behavior
or can have binging/purging type in which there is binging
behavior followed by purging in the form of vomiting, diuretics

or laxatives.
Health Risks of Anorexia Nervosa
Mortality Rates Between 2 and 20% Due to Multiple Organ
System Failure Including
Electrolyte Imbalance Leading to Cardiovascular Abnormalities
(Irregular Heart Beat and Inefficient Heart Pumping Due to
Weakened Heart Muscles)
22
Gastrointestinal symptoms are common causing symptoms
similar to GI illnesses such as Crohn’s disease (ulcerative
inflammatory disease of colon) which involve diarrhea,
cramping and fever which may be difficult to diagnose as the
onset of the disease can occur in teens and in young adult.
Cessation of menstruation is common due to diminished body
fat and the physiological and psychological stresses associated
with this condition.
Is a dangerous condition as studies indicate mortality rates
between 2 and 20% and some have suggested that this condition
is the biggest killer of young women.
Serious cases require hospitalization with an interdisciplinary
approach using doctors, psychiatrics, family therapists and
dietitians.
Decreased Blood Pressure

Kidney Dysfunction
Muscle Wasting and Decreased BMR
Defective Thermoregulation
23
Cessation of Menstruation
Change in Body Functions Characteristic of Starvation –
Dry Skin
Hirsutism (Excessive Body Hair)
Thin Brittle Dry Hair, Hair Loss
Dehydration and Edema
Gastrointestinal Symptoms - Diarrhea, Cramping and Fever
24
Restriction of food intake results in a progression towards
starvation resulting in cessation of menstruation or a delay in
the onset of menstruation (due to decreased estrogen). Only half
recover normal menstrual cycles.
A change in body functions characteristic of starvation occurs.
Changes include dry skin, hirsutism (excessive body hair), thin
brittle dry hair, hair loss, dehydration and edema.

Growth Ceases and Atrophy of GI Tract
High Risk of Premature Bone Loss Greatly Increasing the Risk
of Osteoporosis in Early Adulthood
25
Growth ceases and atrophy of GI tract.
Anorexia causes a high risk of premature bone loss causing
osteopenia (reduced bone mass density more than 1 standard
deviation (SD) but less than 2.5 SD below the young adult
mean) and consequently greatly increasing the risk of
osteoporosis in early adulthood as well as later in later.
Untimately death due to a multiple organ system failure
including an electrolyte imbalance leading to cardiovascular
abnormalities (irregular heart beat and inefficient heart pumping
due to weakened heart muscles), decreased blood pressure and
kidney dysfunction. Also, death may be due to Wernicke’s
encephalopathy (irreversible brain damage due to thiamin
deficiency).
Recovery involves slow and gradual infusion of calories
nagogastric nutrition or TPN (hypertonic solution through the
catheter into superior vena cava- central vein which dilutes the
solution).
Female Athlete Triad
Eating Disorder
Restrictive Dieting
Overexercising
Lack of Body Fat

Weight Loss
Osteoporosis
Loss of Calcium from Bones
Amenorhhea
Diminished Hormones
26
Prognosis for People with Bulimia Nervosa
~2-3% die from disease
Recovery rates
~48% full recovery
~26% improvement
~26% chronicity
27
Bulimia –Diagnostic Criteria
Binging Twice a Week Followed by Purging for 3 Months
Binging Involves Eating in a Discrete Period of Time an
Excessive Amount of Food and a Lack of Control During the
Eating
28

Bulimia is a separate eating disorder from anorexia nervosa but
this condition may be present in anorexics and one eating
disorder can lead to another. In both types of eating disorders
there is an over-concern with body weight, a tendency to
drastically undereat and perceive foods as forbidden and give in
to binge eating.
Observed primarily but not exclusively in adolescent females
who are preoccupied with body image and their self-worth are
tied to feelings about their bodies. Some studies suggest that up
to 20% of females in late adolescence experience bulimia.
Bulimia typically occurs in late adolescence or early adulthood
after a series of unsuccessful weight reducing diets. Typically
observed in outwardly successful and busy individuals who have
a delay in psychosocial development into adulthood and are
more easily frustrated individuals.
Although bulimia is usually observed in individuals of normal
weight, there is also weight fluctuation of 10 lbs in a short
space of time.
Diagnosis includes:
(1) binging twice a week followed by purging for 3 months in
which the binging involves eating in a discrete period of time an
excessive amount of food and a lack of control during the
eating.
Compulsion to eat is not a response to hunger but a means to
dull various emotional states including depression and stress by
binging and vomiting.
Compensatory Behavior to Prevent Weight Gain
Purging Which Involves Regular Self-induced Vomiting,
Laxatives, Diuretics, Enemas
A of bulimia called bulimarexia, in which purging type involves
use of exercise or fasting in which the fasting is accompanied

by a depleted nutritional state.
29
There is compensatory behavior to prevent weight gain. Purging
which involves regular self-induced vomiting, laxatives,
diuretics, enemas.
A non-purging type of bulimia called bulimarexia, which
involves use of exercise or fasting in which the fasting is
accompanied by a depleted nutritional state.
Bulimics can also undergo rigid dieting so that the binge is
worsened and accelerated by hunger.
Distorted/ill-informed Attitudes Regarding Food and Nutrition
Self Evaluation According to Body Shape and Weight and a
Fear of Gaining Too Much Weight
30
There are distorted/ill-informed attitudes regarding food and
nutrition ( cookie could be considered as a binge and cause
great concern
Bulimics self evaluate according to body shape and weight and
a fear of gaining too much weight.

There is a preoccupation with body weight and food with
secretive binge eating involving several emotional states
including anticipation, anxiety, urgency to begin, rapid and
uncontrolled intake of food, relief and relaxation followed by
disappointment and shame.
Health Risks of Bulimia
Vomiting Behavior Causes
Irritation and Infection of Esophagus, Salivary Glands
Erosion of Teeth and Dental Caries
Electrolyte Imbalances
31
Risks to bulimia include irritation and infection of esophagus,
salivary glands, erosion of teeth and dental caries and
electrolyte imbalances due to the vomiting behavior.
Fluid and electrolyte imbalances can cause abnormal heart
rhythms and kidney injury due to urinary tract infections.
Health Risks of Bulimia
Abnormal Heart Rhythms Due to Fluid and Electrolyte
Imbalances From the Overuse of Emetics, Drugs Used to Induce
Vomiting
Kidney Injury Due to Urinary Tract Infections
Increased Risk of Sub-clinical Malnutrition

32
Overuse of emetics, drugs used to induce vomiting, can cause
heart failure due to electrolyte imbalances. Also increased risk
of sub-clinical malnutrition.
Non-specified eating disorders
Non-specific eating disorders could involve fear of obesity, fear
of hypercholesterolemia which cause reduced food intake.
can also include binge eaters who consume less than during
binge, rarely purge and show less restraint in dieting
Binge eaters show similar emotions to other eating disorders
feeling out of control, embarrassment and guilt about binges
and self-disgust, depression and anxiety regarding their own
body size.
These disorders could cause delayed sexual maturation and
deteriorating linear growth which is preceded normally by
reduced food intake and by 1-2 years of inadequate weight gain.
33
Also can have atypical eating disorders in teens which do not fit
in pattern of other eating disorders such as pica or rumination
disorders.
These could involve fear of obesity, fear of
hypercholesterolemia which cause reduced food intake. These
disorders could cause delayed sexual maturation and
deteriorating linear growth which is preceded normally by
reduced food intake and by 1-2 years of inadequate weight gain.
Non-specified eating disorders can also include binge eaters
who consume less than during binge, rarely purge and show less
restraint in dieting. Binge eaters show, however, similar
emotions of feeling out of control, embarrassment and guilt

about binges and self-disgust, depression and anxiety regarding
their own body size.
Treating Eating Disorders
Goal of eating-disorder treatment programs
Restore body weight
Improve social and emotional well-being
Normalize eating behaviors
34
Core components of programs:
Treatment of medical comorbidities
Restoration of body weight to normal
Nutrition education & counseling
Individualized psychotherapy
Family therapy
Group therapy
35
A multidisciplinary team approach
Team may consist of
Physician
Dietitian
Nurse
Psychologist
Psychiatrist

36
Contemporary Clinical Trials 32 (2011) 874–881
Contents lists available at ScienceDirect
Contemporary Clinical Trials
journal homepage: www.elsevier.com/locate/conclintrial
The CALERIE Study: Design and methods of an innovative 25%
caloric
restriction intervention☆
Amy D. Rickman a,⁎,1, Donald A. Williamson b,1, Corby K.
Martin b,1, Cheryl H. Gilhooly c,1,
Richard I. Stein d,1, Connie W. Bales e,f,1, Susan Roberts c,1,
Sai Krupa Das c,1
a University of Pittsburgh, Pittsburgh, PA, USA
b Pennington Biomedical Research Center, Baton Rouge, LA,
USA
c Jean Mayer US Department of Agriculture Human Nutrition
Research Center on Aging at Tufts University, Boston, MA,
USA
d Department of Internal Medicine, Washington University
School of Medicine, St. Louis, MO, USA
e Durham VA Medical Center, Durham, NC, USA
f Department of Medicine, Duke University Medical Center,
Durham, NC, USA

a r t i c l e i n f o
☆ Funding support: This research was supported by g
06, 5U01AG020478-06, 5U01AG020487-07 and 5U01A
National Institute on Aging and K23 DK068052 (NIDD
Institutes of Health.
⁎ Corresponding author at: University of Pittsburgh
Weight Management Research Center, Suite 600, Birm
Wharton St., Pittsburgh, PA 15203, USA. Tel.: +1 412 4
488 4174.
E-mail address: [email protected] (A.D. Rickman)
1 For the CALERIE Study Group.
1551-7144/$ – see front matter © 2011 Elsevier Inc.
doi:10.1016/j.cct.2011.07.002
a b s t r a c t
Article history:
Received 19 January 2011
Received in revised form 23 June 2011
Accepted 1 July 2011
Available online 8 July 2011
Animal studies have shown that life span is extended by caloric
restriction (CR). This
manuscript describes the design and methodology of an
innovative CR intervention, which is
the treatment arm of the CALERIE Study. This study is a multi-
center, randomized controlled
trial examining the effects of 2 years of CR on biomarkers of
longevity among non-obese
(BMI≥22 kg/m2 and b28 kg/m2) adults. CALERIE is the first
investigation of the effects of long-
term CR on the aging process in non-obese humans. 220 healthy
volunteers across 3 sites were
recruited beginning in May 2007. Participants were randomized
in a 2:1 ratio between the CR

or control group (i.e., ad libitum diet). An intensive
intervention was designed to assist
participants in adhering to the 25% CR prescription for a two-
year duration. The intervention
was designed to optimize the likelihood that 25% CR would be
achieved through a variety of
nutritional and behavioral strategies, several of which are
innovative methods for achieving CR.
The intervention includes the following components: an
intensive, “mixed” format schedule of
group/individual sessions, meal provision phase with exposure
to various diets, Personal
Digital Assistants to monitor caloric intake, unique portion
estimation training, tailored
treatment using a computer tracking system, toolbox strategies
and algorithms, as well as
comprehensive coverage of nutrition and behavioral topics in
order to assist participants in
meeting their CR goal. This manuscript provides an overview of
the CR intensive intervention
and may be of assistance for other researchers and clinicians in
designing future trials.
© 2011 Elsevier Inc. All rights reserved.
Keywords:
Caloric restriction
Randomized controlled trial
Aging
Intervention
rants 5U01AG022132-
G020480-06 from the
K) of the U.S. National
, Physical Activity and
ingham Towers, 2100
88 1770; fax: +1 412

.
All rights reserved.
1. Introduction
The purpose of the Comprehensive Assessment of the
Long-term Effects of Reducing Energy Intake (CALERIE) Study
is to examine the effects of long-term 25% caloric restriction
(CR) on non-obese humans. The study was undertaken to
examine 2 years of sustained CR on: a) slowing aging as
assessed by proxy indicators and b) protecting against age-
related disease processes.
The distinct difference between CALERIE and previous
weight loss studies is that CALERIE emphasizes adherence to a
prescribed CR goal rather than to a specified degree of weight
http://dx.doi.org/10.1016/j.cct.2011.07.002
mailto:[email protected]
http://dx.doi.org/10.1016/j.cct.2011.07.002
http://www.sciencedirect.com/science/journal/15517144
875A.D. Rickman et al. / Contemporary Clinical Trials 32
(2011) 874–881
loss. When CR is maintained past the point when weight
stability is established, information will be gained as to
whether the effects of CR become stable or whether these
effects are transitory. The distinct challenge of this study is to
assist participants in achieving and maintaining the 25% CR
goal for 24 months. Thus, a CR intervention was designed to
assist participants with adhering to CR with no specific mac-
ronutrient composition (other than nutritional adequacy)
being recommended.

1.1. Theoretical framework for CR intervention
A central purpose of CALERIE is to determine the simi-
larities and differences between CR's effects in humans
compared to previous studies in laboratory animal models,
which have shown an extended life span through CR [1–4].
Evidence from animal studies demonstrates that when CR is
sustained, weight is relatively stable once the initial phase of
weight loss has ended [5–7]. Thus, to achieve the goals of
CALERIE, the period of initial weight loss must be followed by
a period of relative weight stability during which adherence
to the specified degree of CR is maintained. The Phase 1 study
results of CALERIE demonstrated the feasibility of CR over
12 months and revealed that if CALERIE participants succeed
in maintaining adherence to 25% CR it may take up to
12 months or possibly longer for the initial period of weight
loss to end [8–11]. Therefore, the CALERIE Phase 2 interven-
tion was designed to optimize the likelihood that: 1) the % CR
that participants achieve will be substantial, and 2) the % CR
participants achieve will be sustained at a relatively constant
level over the two-year intervention.
The available literature that provided the framework for
this study focused on weight loss interventions. In most long-
term weight loss studies in humans, the initial period of
weight loss was followed by a period, due to weight regain,
body weights actually were increasing faster in the treatment
than in the control group [12,13]. The CALERIE Study design
offers an opportunity to avoid this shortcoming.
A distinct challenge is that CALERIE participants are not
obese, and some are in the “healthy” weight range (BMI 22 to
25 kg/m2). Therefore, when designing the intervention the
following assumptions were made: 1) compared to obese
persons, CALERIE participants may have decreased motiva-
tion for weight loss and adhering to CR on the basis of the

presumed health benefits and 2) CALERIE participants'
dietary habits with regard to energy intake are likely to differ
less from accepted nutritional guidelines than do those of
obese persons.
1.2. Participant recruitment and screening
Two-hundred and twenty healthy volunteers across 3 sites
(Tufts University, Pennington Biomedical Research Center,
and Washington University School of Medicine) were re-
cruited beginning in May 2007. Study participants are men
within the age range of 21–50 years and women between
21 and 47 years who have an initial BMI≥22 kg/m2 and
b28 kg/m2. Participants have been randomized in a 2:1 ratio
into the CR or control group (i.e., ad libitum diet). Potential
participants were screened during a series of physical and
psychological tests/interviews to identify healthy individuals
who agreed to make the necessary commitments to partici-
pate in a two-year intensive CR-oriented lifestyle modification
program.
1.3. Intervention design
The CALERIE Study was designed to optimize the
likelihood that a substantial degree of CR is achieved through
a variety of nutritional and behavioral strategies. The
conceptual framework of the CR intervention was developed
from experiences during two landmark clinical trials: the
Diabetes Prevention Program and the Look AHEAD Study [14–
17]. These studies have successfully achieved weight loss and
subsequent weight maintenance through an intensive life-
style intervention [12,14–17]. A very brief description of the
CALERIE intervention is also mentioned in a separate
manuscript outlining the overall study design, extensive
methodology, and the various biomarkers being collected,
which were chosen based on previous research findings

[18,19].
The primary goal of the CR intervention is to achieve and
maintain a sustained reduction in caloric intake rather than a
specified weight loss, with weight change being a proxy
indicator of sustained CR. A two-year CR period was selected
to attempt to provide for a sustained period of weight
stability following weight loss. It is expected that the period
of weight loss will last 6 to 12 months. A major emphasis of
the intervention is on adherence to prescribed CR using a
proactive and comprehensive plan described below for
providing the participants with an array of supporting
services to aid in this effort.
1.4. 25% CR intervention
The CR intervention can be conceptualized as an intensive
behavioral approach [20–22] coupled with dietary modifica-
tions and daily self-monitoring of calories, designed to
promote adherence to long-term CR [23–26]. All CALERIE
participants are advised of the current health recommenda-
tions for physical activity of 30 min/day of a moderate level
on a minimum of 5 days/week, but no efforts are made to
change participants' exercise habits or activity levels. In order
to determine the discrete effects of CR, participants are
instructed not to alter their activity habits during the course
of the study. The CALERIE intervention approach was based
on strategies that have been found to be effective in long-
term weight management studies and in short-term studies
supporting dietary composition changes for enhanced satiety
and reduced hunger including the provision of meals and
structured meal plans [23–26]. Within the range of recom-
mended amounts, no specific macronutrient composition of
the diet is prescribed, although participants are encouraged
to incorporate concepts such as volumetrics, lower glycemic
index foods, and adequate protein and fiber at meals in order

to make CR adherence easier and more satisfying. In the
present intervention, each participant is provided with an
individualized CR prescription for 25% CR from baseline ad
libitum energy intake as determined by doubly-labeled water
(DLW). Group adherence to the prescribed diet is then
assessed by a combination of measures of energy expenditure
using the doubly labeled water technique and precise
876 A.D. Rickman et al. / Contemporary Clinical Trials 32
(2011) 874–881
changes in body composition by dual X-ray absorptiometry
(DXA) at 6, 12, 18, and 24 months [18,27]. Six day food
records are also collected at these time points [18]. However,
these measurements are outcome measurements and not
used to assess intervention adherence during the study; the
intervention is guided by individual information recorded for
each participant in a computer tracking system (CTS).
2. Key innovative features of the CALERIE Study
2.1. Intensive mixed format schedule
Longer duration of contact with participants has been
found to be associated with better adherence to interventions
that promote health behavior change [26]. In order to assist
participants with meeting their 25% CR goal, individual
counseling sessions were chosen as the primary mode for
delivering the intervention, with group counseling sessions
serving as an important secondary component for the
provision of information and enhancement of social support
for CR adherence. A “mixed” format (i.e., individual and group
sessions) was selected in order to combine the strengths of
individual and group interactions. Through individual and
group counseling sessions, participants are provided with
information (e.g., on potential satiating effects of higher fiber

intake), material aids for adherence (e.g., food scales and
Personal Digital Assistants [PDAs] for self-monitoring food
intake), provision of food for the first month and thereafter on
an as needed basis, and incentives to enhance adherence. An
overview and schedule of the individual and group counsel-
ing sessions for weeks 1–24 are provided in Table 1. A similar
format was used for weeks 5–104 covering a wide variety of
nutrition and behavioral topics.
Table 1
Overview of individual and group session topics. Participant
schedule: weeks 1–24.
Week Individual session Individual topic
1 X-FP Welcome/CR goal/PDA instruction
2 X-FP Getting started, tipping the energy balance/P
3 X-FP Portion and stimulus control/PDA review
4 X-FP Managing hunger, satiety, and distress tolera
review/formal CR goal
5 X Social support/PDA review
6
7 X Problem solving/PDA review
8
9 X How are you doing? Progress review/PDA re
10
11 X Barriers and meal replacements/PDA review
12
13 X Eating out with CR/PDA review
14
15 X Motivation/PDA review
16
17 X Thoughts/PDA review
18
19 X Social support/PDA progress review/PDA rev
20

21 X Food cravings/PDA review
22
23 X Review of goals/PDA review
24
2.1.1. Individual counseling sessions
Individual counseling sessions, the cornerstone of the
CALERIE intervention, provide a regular opportunity to attend
to individual participant needs and an opportunity to tailor
the intervention to these specific needs. The group counseling
sessions are designed to complement the individual session
topics and provide social support. Problems with adherence
to 25% CR prescription are directly addressed in individual
sessions using various pre-specified strategies, described in
more detail below. The DPP and the Look AHEAD Study have
used a similar approach with success [14,15].
Each participant interacts with both a Counselor who is a
behavioral expert (e.g., has a Master's or doctoral degree in
psychology) and a Counselor who is an expert in nutrition
(i.e., a Registered Dietitian). Both Counselors work closely
with the participant to assist him/her with various aspects of
CR adherence. Participants enter CALERIE and are assigned a
primary Counselor who follows them in individual sessions
throughout the program, beginning in week one. Individual
sessions occur weekly for the first month (weeks 1–4), while
the participants are developing skills in estimating their
caloric intake with additional training on portion size
estimation and calorie content of foods. The participant
and Counselor develop a mutually-agreed-upon individual
dietary/behavioral plan to achieve the targeted degree of CR
within the scope of the intervention design. This plan reflects
the participant's input based on his/her preferences, needs
and experience with differing types of provided meals, as well
as the Counselor's expertise concerning nutritional and
behavioral strategies to achieve and maintain 25% CR.

For months 2 through 12 (weeks 5–53), individual
sessions occur twice monthly, with additional biweekly
phone contact. These twice-monthly individual sessions
provide continued support and allow the Counselor to closely
FP = food provision to participants. X = required
individual/group sessions.
Group session Group topic
DA review
nce/PDA X Portion control
X Hunger and satiety
X Putting problem solving into practice
view
X Goal setting
X Barriers to CR
X Eating away from home
X Maintaining motivation
X Mastering positive thinking
iew
X Enlisting social support
X Urge management of food cravings
X Relapse prevention

(2011) 874–881
track progress. For months 13 through 24 (weeks 54–104),
the participant attends monthly individual counseling ses-
sions; additional sessions are added “as needed.” These
monthly sessions reduce time demands for the participant,
yet allow the Counselor to continue to track adherence to CR.
2.1.2. Group counseling sessions
Group sessions occur twice monthly, beginning at week
four of the intervention after the participant has progressed
through the initial four individual sessions. Group session
content is designed to complement the information given in
individual sessions as well as provide social support.
Participants attend 12 group sessions at regular intervals
during the first 26 weeks of the study. From weeks 27 to 104,
participants attend group sessions once a month. The groups
utilize open enrollment, which allows participants to begin
attending group sessions as soon as they enroll in the study.
This group format utilizes “modules” of group sessions that
cover information that is appropriate for the participant,
given the length of time that the participant has been enrolled
in the study. Other studies that initially provided an intensive
intervention but then held infrequent or no continuing group
sessions found that participants rapidly lost momentum,
regained lost weight, or increased consumption of higher-fat
foods [26]. Thus, attendance at group sessions is closely
monitored and recorded in the computer tracking system
(CTS). Poor attendance or missed sessions trigger a rapid
response by the Counselors, as described later in the paper.
2.2. Meal-provision phase and exposure to various diets

Participants randomized to the CR group are provided
with their meals for the first 27 days of the intervention and
are encouraged to strictly adhere to the foods and menus
provided. Participants are required to pick up the provided
meals at the centers using site-specific schedules. Participants
rotate through 3 different diet patterns which include a low
fat (20% fat, 20% protein, 60% carbohydrate), a Mediterranean
(35% fat, 15% protein, 50% carbohydrate) and a low glycemic
load diet (30% fat, 30% protein, 40% carbohydrate). These
varied diets were provided for educational purposes related
to food selection and portion size. Three-day cycle menus
are used, and each participant is on each diet type for 9 days.
For participants who want to follow a vegetarian (ovo-lacto)
diet, a 3-day cycle vegetarian menu (30% fat, 20% protein,
50% carbohydrate) is provided. All diets provide 14 g
fiber/1000 kcal. Two-thirds of a cup (80 kcal, 19 g fiber) of
Fiber One® bran cereal is also provided as an optional daily
addition to the menus during the meal-provision phase.
Alcohol is not served by the centers and its use is discouraged
during the meal-provision phase in order to maintain the 25%
CR level. However, alcohol is permitted after the 4-week
feeding phase for the remainder of the intervention (not
more than 2 drinks per day and no more than 14 drinks per
week for men and 10 drinks per week for women).
The same menu templates are used at all 3 study sites,
with minor adjustments (in spices, brands) allowed to
accommodate regional preferences and vendor availability.
The CR prescription level for each participant is calculated
from the baseline TEE results derived from DLW and was
rounded up or down to the nearest hundred for the meal
provision phase.
2.3. Self-monitoring dietary intake and portion size estimation
training

Recording food intake, as well as portion size estimation,
are critical tools in helping participants achieve and maintain
their 25% CR goal. The meal provision phase allows for
frequent contact with the participants and during this phase,
participants are required to meet with the Study Dietitian 2–3
times per week to maximize adherence to the provided food
and to complete training on recording their food intake and
estimating portion sizes.
On Day 1 of the intervention, participants assigned to the
CR treatment arm are provided with a PDA that contains diet
software and are asked to self-monitor their dietary intake
throughout the two-year study. Participants complete train-
ing worksheets both on site and at home throughout the meal
provision phase and work with the Study Dietitian to
complete on-site training in order to become proficient
with this critical behavior right at the beginning of CR.
Adherence to self-monitoring is tracked in the computerized
tracking system (described in Section 3.1).
To help with the accuracy of self-monitoring of dietary
intake, participants are provided with food scales and
measuring cups and spoons and also complete portion
estimation training. Test meals using study foods are used
to determine each participant's ability to accurately estimate
portions without the use of a food scale or household
measuring utensil. Participants complete portion estimation
training at the start of CR and during weeks 2 and 4 of the
meal provision phase. The Study Dietitian determines the
participant's accuracy by comparing the reported portion size
with the actual size of the foods and provides the participant
with immediate feedback on his/her accuracy. Discrepancy
scores are also calculated for each portion training session,
and if a participant's mean discrepancy score for a test visit is
greater than +/−30%, then the participant receives further
training until accuracy criteria are met.

Counselors enter dietary self-monitoring data into the
CTS, and participants graphically observe self-reported
calories consumed over the two-year period. The CTS creates
a graph displaying the reported dietary intake compared to
each participant's CR goal. Counselors record attendance at
individual and group counseling sessions. Adherence to self-
monitoring is defined as 70% complete entries during months
1–6, 50% complete entries during months 7–12 and at least
30% complete entries during months 13–24.
3. Tailoring treatment
3.1. Computer tracking system
Reliance on a treatment manual promotes treatment
integrity among Counselors and across study sites however,
the CALERIE Study also allows for individual tailoring of the
intervention to meet the needs of each participant. One
innovative component of the intervention is the use of a
sophisticated computer tracking system (CTS) to guide
delivery of individual counseling sessions. The CTS tracks
878 A.D. Rickman et al. / Contemporary Clinical Trials 32
(2011) 874–881
changes in body weight in relation to the expected changes
based on a model developed with results from CALERIE Phase
1
[28].
Information from the CTS is used by CALERIE intervention
team leaders to observe adherence on a study-wide basis, for
each of the three sites, and for each individual participant.
Reports are generated from the CTS to describe session atten-

dance, self-monitoring, dietary adherence, and weight loss.
These reports serve as an index of adherence to the inter-
vention and can be used by the treatment team to evaluate
compliance. Aggregated data on individual participants is
compiled according to site (Boston, Baton Rouge, St. Louis) for
evaluation by Counselors and Investigators. The CTS tracks
pre-specified strategy usage (based on Toolbox/algorithms
described below), and it records whether the strategy was
effective for promoting improved adherence. The CTS also
tracks monetary expenditures associated with the use of
some of these strategies.
3.2. Toolbox/algorithms
The CTS alerts Counselors if participants have sub-optimal
adherence to several study-related behaviors and provides
Counselors with suggested treatment strategies, in the form
of toolbox options. The toolbox methodology has been used
successfully in previous clinical trials [14,15]. By systemati-
cally following the same pre-specified decision rules, it is
possible to intervene quickly in order to overcome obstacles
to success and improve CR adherence. This systematic
approach also fosters treatment fidelity among Counselors
and across sites. Additionally, the toolbox allows Counselors
to tailor treatment to address personal preferences and
lifestyles, as well as regional, cultural and ethnic differences
among participants. At each site, approximately $150 per
participant per year is allocated for utilization of toolbox
options, such as provided meals or incentives such as gift
certificates.
The CTS automatically determines whether participants
are in or out of compliance for the following study-related
behaviors: 1) adherence to CR prescription, where weight is
used as a proxy, 2) session attendance, and 3) self-monitoring.
Additionally, specific criteria have been developed to assist

Counselors in determining if any of the following behaviors
are interfering2 with adherence to the intervention: 1) poor
dietary knowledge, 2) binge eating, and/or 3) emotional
problems. There are two types of toolbox options that are
tracked in the CTS: 1) “Open Toolbox” and 2) “Closed
Toolbox.” “Open Toolbox” options are generally used first
and are always available for the Counselor and participant to
use in order to increase adherence. In contrast, “Closed
Toolbox” options, which are not available until week 5, are
used only when pre-defined adherence problems are detected
by the CTS, as they typically require additional resources for
implementation.
The effectiveness of selected toolbox strategies for these
behaviors is evaluated by the Counselor every 2 to 4 weeks
through objective criteria specific to each toolbox. By tracking
2 Dr. Williamson was the primary developer of these algorithms
for the
Look AHEAD Study.
this process, it is possible to empirically evaluate the efficacy
of different intervention strategies as these relate to partic-
ular study-related behaviors.
Toolbox algorithms (examples illustrated in Figs. 1–2)
guide the decision-making process for tailoring treatment to
the unique needs of each participant. The CALERIE algorithms
were specifically adapted from the Look AHEAD Study2 [14].
The algorithms operationally define specific types of adher-
ence problems that trigger the opening of the Closed Toolbox
and explicitly describe the most common intervention
options that should be considered to resolve the problem as
quickly as possible. The General Conceptual Framework,
illustrated in Fig. 1, describes the basic conceptual scheme
for individual tailoring during the first 6 months of the
CALERIE intervention. This conceptual framework uses a
social problem-solving approach where a problem is identi-

fied; solutions are brainstormed and selected, and then tested
for a specific period of time. If the solution effectively resolves
the problem, then the strategy is continued until consistent
behavior change is observed. If the solution is unsuccessful
after a specific time period, e.g., 4 weeks, the strategy is
terminated and a new option for solving the problem is
selected and tested for a specific period of time.
The Counselors track the events that open both the “Open
Toolbox” and “Closed Toolbox” and record use of Toolbox
options in the CTS in order to track participant progress. A
coding system enables the Counselor and Investigator to
track: 1) the target problem that opened the Toolbox, 2) the
“Open Toolbox” and “Closed Toolbox” options that are used,
3) resolution of the problem, and 4) estimated monetary
amount spent on each “Closed Toolbox” option. Using this
process, it is possible to empirically evaluate the efficacy of
different “clinical decisions” or at least to translate these
“clinical decisions” into a set of behavioral strategies that can
be objectively described. All strategies are evaluated for
effectiveness every 2 to 4 weeks or at the next scheduled
individual session.
In some cases, the participant may be unable to develop a
treatment plan that is viable. For example, the person may
refuse to initiate a portion-controlled diet or referral to a
specialist. In such cases, motivational enhancement methods
are employed to facilitate acceptance of the clinical recom-
mendation. Counselors are aware that use of toolbox options
is a collaborative process between the Counselor and
participant. As such, the Counselor emphasizes the role of
the participant in brainstorming solutions for inadequate
adherence or potential areas of difficulty.
3.3. Measuring and tracking changes in body weight

Changes in body weight were selected as a proxy indicator
for CR adherence. At the start of an individual session,
Counselors initially weigh participants and then enter the
participant's weight into the CTS, which graphs the partici-
pant's predicted weight loss (based upon his/her caloric
prescription) against his or her actual weight loss. This graph
is used by the Counselor to determine the participant's
adherence to the intervention and is then discussed during
the individual counseling session.
A weight loss algorithm (Fig. 3), which is based on data
from the CALERIE Phase I Study, is a guide for expected
weight
Target Behavior here.
Definition here.
Present
Option(s) to
Participants
Develop a
Specific Plan of
Action with
Time Limit
Improve?
CONTINUE
Strategy
Evaluate Process & Problems

(e.g., other obstacles to
successful behavior change)
Re-examine
Options
Significant problem, defined
by:
Specific problem that will
prompt Counselor to use Open
Toolbox or Closed Toolbox and
begin tracking intervention
strategies
Select one
or more
Intervention Options
(Closed Toolbox):
• Should only be suggested
and used by Counselor
when criterion is met for a
particular problem
• Mandated when
participant meets criteria
for opening toolbox
• Follow-up and tracking is
mandatory using the
computer tracking system
(CTS)
YES

NO
Intervention Options
(Open Toolbox):
Can be used by Counselor
and participant at any
time to increase
adherence
Fig. 1. General conceptual framework.
Present
Option(s) to
Participant
Develop a
specific plan of
action with
time limit
Improve?
CONTINUE
Strategy
Evaluate Process & Problems
(e.g., other obstacles to
successful behavior change)

Select one
or more
options
Re-examine
Options
Intervention Options (Closed Toolbox):
• Modify obstacles for preparing & obtaining
foods, e.g., home delivery
• Invite family members/ friends to individual
sessions
• Talk with family members/ friends using
telephone conference
• Talk with family/ friends using telephone (non-
conference)
• Provide additional equipment for estimating
portion sizes and caloric content
• Use of structured meal plans, recipes, and
shopping lists
• Use of meal replacements/portion controlled
meals
• Provision of food by research center
• Referral for medical problem
• Referral for mental health problem
Adherence:
Refer to
individual’s
weight chart. If
weight falls
below 10

th
percentile or
above the 80
th
percentile, the
participant is
considered non-
adherent.
Intervention Options (Open Toolbox):
Schedule additional contact with staff
• Motivational Interviewing and Enhancement
strategies
• Cognitive-behavioral strategies
• Problem-solving strategies utilizing behavioral
contracts
• Increased training in portion size and caloric
estimation skills
• Modify eating behavior/ meal patterns
• Enhance environmental prompts
• Direct dietary modification
- Modifying variety in diet
- Increase dietary fiber
- Increase water consumption
- Modify macronutrient content
- Decrease energy dense foods
- Decrease liquid calories
NO

YES
Fig. 2. Primary problem of sub-optimal adherence to 25%
calorie restriction. Sub-optimal adherence with CR prescription
is defined by an inability to stay within appropriate
parameters on an individual participant’s weight chart as
represented in the CTS (e.g., if weight falls below the 10th
percentile or above the 80th percentile, the participant is
considered non-adherent). “Closed Toolbox” strategies should
be applied when a participant’s weight is outside the adherence
curve. This process should occur immediately
whenever a weight measurement falls outside the adherence
curve. The system shall not consider a participant to be out of
adherence for this toolbox until the participant
enters the 5th week of the study. “Closed Toolbox” strategies
may be discontinued when the participant no longer meets
criteria necessary to open the Closed Toolbox.
(2011) 874–881
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ie
g
h
t
(l
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Shelby County Annual Youth Fitness Congress For.docx

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