Shortened Title
Scholarly Project

NU 799
Deborah L Bialas, BSN, RN

Title: The Construction of a Patient Education Manual for use in the Fen/Phen Weight
Management Program

Shortened Title: The Construction of a Patient Education Manual

Abstract
Scholarly Project
NU 799

Deborah L. Bialas, BSN, RN

Title: The Construction of a Patient Education Manual for use in the Fen/Phen Weight

Management Program

With patient education achieving a position of prominence in today’s healthcare
industry, tools to make the process easier and more effective are necessary. Printed

educational materials are the most common form of instructional materials used, and the
most economical. Obese patients participating in the Fen/Phen Weight Management

Program, require detailed instruction in three major areas, proper usage of the anorexiant

drugs dl fenfluramine and phentermine, a healthy eating plan, and an exercise program.
A patient education manual was constructed following the Evaluating Printed
Education Materials (EPEM) Model developed by Bernier and Yasko (1991). The manual

discusses medication administration and side effects, a healthy eating plan, and an exercise

program. The SMOG formula, developed by McLaughlin (1969), was used to place the
manual at the eighth grade readability level.

Thesis Nurs. 1997 B576c
c. 2
Bialas, Deborah L.
The construction of a
patient education
1997.

The Construction of a Patient Education Manual
for the Fen/Phen Weight Management Program

by

Deborah L. Bialas, BSN, RN

Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree

Approved by:

Zjtidith Schilling, CRNP//PhD
(/ Committee Chairperson of
Edinboro University of
Pennsylvania

O

y______

jt^Geisel, PhD, RN
dmmittee Member of
dinboro University of
Pennsylvania

2/4

p7

Date

c

ii

Table of Contents
Chapter

Page

1. Introduction

1

Theoretical Framework

4

Statement of the Purpose

6

Assumptions

6

Definition of Terms

7

Summary

7

2. Review of the Literature

Obesity

9

9

Etiology of Obesity

11

Anorexiant Medications

12

Studies of Anorexiant Use and

Weight Loss

14

Educating Patients with Printed
Materials

17

Printed Educational Materials

Development

18

The EPEM Model

19

Summary

20

iii

3. Methodology

21

Project Design and Procedures

21

Summary

23

Appendixes

A. SMOG Testing

25

B. Managing Your Weight With Fen/Phen..

27

References

38

1

Chapter 1

Introduction

Patient education has always been an integral part

of quality health care. In recent years, it has achieved
even greater importance as medical knowledge grows at an

exponential pace, and economics dictates that more and
more health care be provided on an outpatient basis.

Expanded knowledge of the benefits of health promotion
and disease prevention also place health education in a

position of prominence today (Whitman, Graham, Gleit, &
Boyd, 1992) .

Although no one method of patient education is

perfect for all patients and situations, printed
educational materials represent an economical way to

provide information to patients and families (Bernier &
Yasko,

1991) . They represent the most common form of

instructional materials used and are the backbone of a

comprehensive patient education program. Printed
materials allow ready access to information in a
consistent and presentable manner, reinforce oral

discussion, and enhance the learning of the patient

(Farrell-Miller & Gentry, 1989). They also provide the
patient with a ready resource when at home.

A wealth of materials exist for patient education.
At times, however, available materials fail to meet the

2

requirements of a particular setting,
or a need is
discovered for which no teaching materials exist.
It is
then necessary to design appropriate materials
(Lange,
1989).
Obesity is a chronic condition that complicates or
contributes to multiple medical problems, Many of these
conditions, such as hypertension, diabetes,
hyperlipidemia, and osteoarthritis, will improve with

weight loss (Pi-Sunyer, 1993) . Despite increased public
awareness of the hazards of obesity, the incidence of
significant obesity in America has been increasing (Elks,

1996). While there is well documented evidence that

hypocaloric diets result in weight loss, adherence is a
major problem. Exercise regimens alone rarely result in
major weight changes- but appear to be of significant

importance in the maintenance of weight loss (Elks,
1996) . Adjunctive use of appetite suppressants has

resulted in successful weight loss for some patients
(Weintraub, 1992a).

To successfully manage a multi-factorial weight loss
program, patients must learn specific skills to decrease

caloric intake, and to increase energy expenditure. If
appetite suppressants are used to augment treatment,

patients must also learn the correct dosage, frequency of

3

administration, actions, and major side effects of these
drugs.
The

Fen/Phen Weight Management Program" is based on

the work of Michael Weintraub, MD, of the University of

Rochester School of Medicine and Dentistry. In his long­
term study, Dr. Weintraub followed the effects of

anorexiant medications for over 4 years, concluding that
the medications provided beneficial therapy for obesity
over and above combination treatment with behavior

modification, exercise, and caloric restriction
(Weintraub, 1992a). He also found no evidence of abuse or

serious side effects in the over 100 people studied.
Patients participating in the "Fen/Phen Weight

Management Program” are obese people over the age of 18,
seeking weight reduction. This program consists of diet

instruction, an exercise plan, and the use of medications
for appetite suppression. The manual designed for this

project addresses all three components using methods

suggested in the literature. The manual was developed
because available materials did not adequately meet

program needs for patient education.

4

Theoretica1 -Framework
Theories concerning cognitive learning have been

widely used in patient education. Although there are
many viewpoints, theorists share beliefs about the ways

individuals process and master information (Whitman et
al., 1992).

R.M. Gagne (1974), an educational psychologist,
developed a model showing an eight phase sequence of
learning and remembering:
1. Motivation can be external or internal. External

requires that others generate an expectation in the
learner that rewards will result from the learning.

Internal motivation refers to the fundamental human urge

to master the environment; to achieve some goal and be

rewarded for it.
2. Apprehending describes the motivated learner
first receiving the stimulation that will eventually

enter into essential learning and be stored in his
memory. The stimuli must gain the attention of the
learner, then be correctly perceived. Perception is based

on previous learning and descrimination abilities.
3. Acquisition is considered the phase that includes
the essential learning incident; the moment in time at
which some newly formed entity is entered into short term
memory.

5

4 . Retention refers
to material previously

apprehended and stored in the nervous system as memory.
Some things learned may undergo " fading," so that one is
able to recall fewer details. "Interference" may also

occur in that newer memories may obscure older ones.
5. Recall occurs when retrieval of new information

during this phase makes what is stored accessible. Cues
for retrieval may be affected by external stimuli such as

verbal reminders, pictures, events.

6. Generalization is the recall and transfer of what
has been learned and its applications to new and
different contexts.

7. Performance is observable behavior that
demonstrates what has been learned. A single instance of

performance often suffices as evidence of learning.
8. Feedback refers to the learning loop that is
closed by reinforcement. The state of expectancy

established during the motivation phase results in
feedback that confirms or denies this expectancy.
Learning is activated by a variety of stimuli from

the learner's environment. As an instructor, the nurse
practitioner's job is to plan, design, select, and in

some cases serve as the verbal stimulus for the

activation of the learning process. Obese patients

6

present as motive ted learners. Previous experience has
activated a desire for weight loss.
The phases of apprehending and acquisition occur

through oral presentation and discussion. Without a
written manual to assist with review and retention of
information, the learned information may fade or be

obscured. Patient performance either confirms or denies

that long-term learning has occurred. If it has occurred,
the patient enjoys a command of the information necessary

to comply with the program, in addition to the positive
feedback of successful weight loss.

Statement of the Purpose
The purpose of this project is to design and

construct a patient education manual that will assist
patients in the retention of information concerning the

Fen/Phen Weight Management Program, in order that they
may attain their weight loss goals.

Assumptions
For the purposes of this project, the following

assumptions are made:
1. Patients are able to read minimally at the eighth
grade level.

2. Patients are motivated to learn.

7

Definition of Terms

The following definitions are included for clarity:
1. Learning is a persistent change in behavior
as a

result of experience (Whitman et al, 1992).
2. Printed education materials are written or

printed booklets, leaflets, pamphlets, or information

sheets whose purpose is to provide information about
health promotion, disease prevention, diagnostic
procedures, treatment modalities, and self-care regimens

(Bernier, 1993).
3. Obesity is body weight that is 20% or more above

desirable, a relative weight of 120% or more, or a Body
Mass Index above 2 6.4 for men and 25.8 for women (U.S.

Public Health Service, 1994).
4. Fen/Phen is an abbreviation for the protocol

devised by Dr. Michael Weintraub, MD, using the drugs
fenfluramine and phentermine, both anorectic medications

(Weintraub, 1992b).

Summary
Patient education has achieved a high level of
importance as health promotion and disease prevention

benefits become known, More care is also being provided
on a short-term or outpatient basis reguiring that

patients and families become more knowledgable. Printed
educational materials provide a consistent, easily

8

accessible, economical source of information that can be

used for immediate instruction, and referred to at home.

Nurse practitioners are frequently called upon to use
these materials, or to develop them if appropriate

teaching materials do not exist.

Obesity is a chronic condition that contributes to

multiple medical problems and is resistant to traditional
treatment of diet and exercise. The use of appetite
suppressants has met with some success. The "Fen/Phen

Weight Management Program” offers appetite suppressants
in addition to diet and exercise. Because of the multiple
components of the program and the importance of patient’s

knowledge for program compliance, a patient education
manual was constructed. The theory of R.M. Gagne provided
the theoretical framework for the project.

9

Chapter 2

Review of the Literature
The purpose of this project is to design and

construct a patient education manual for participants in
the Fen/Phen Weight Management Program. Participants are

120-6 or greater of ideal body weight and over the age of

18.
This literature review will address obesity, the
health and economic consequences of obesity, the etiology

of obesity, and obesity’s resistance to intervention. It
will also examine the use of anorexiant drugs in the

treatment of obesity, with emphasis on the Fen/Phen
program. Finally, this review examines the literature on

constructing written patient education materials,
including the Evaluating Printed Education Materials
(EPEM) model.

Obesity

Obesity, defined as a body weight 20% or more above

ideal or desirable (Public Health Service, 1990), is a

major problem for Americans, and is associated with
adverse health and economic consequences. Lemonick (1996)

reported that the United States is one of the fattest
countries on earth, with nearly one-fourth of the
population meeting the criteria for clinical obesity.

10

At any one time, 50% of women and 25% of men report

that they are dieting (Baron,1996)

In efforts to lose

weight, Americans spend an estimated $33 billion
every
year on diet books, over the counter medications, health
club memberships, and low calorie foods (Lemonick, 1996).
In his analysis of studies addressing the medical

hazards of obesity, Pi-Sunyer (1993) found obesity to be
associated with an increased risk for insulin resistance,

hypertension, dyslipidemia, cardiovascular disease, noninsulin dependent diabetes mellitus, gallstones and
cholecystitis, respiratory dysfunction, and certain forms

of cancer. Wolf and Colditz (1996), in their study of the

social and economic effects of body weight, observed the
total direct cost of illness for individuals with a body

mass index considered to be healthy (BMI 23-24.9) was
$5.89 billion. The direct costs, however, continued to
rise with increasing BMIs reflecting the elevated risk of
disease even at a moderate BMI of 25. Wolf and Colditz

also found that if obesity were prevented, the US could
have saved $45.8 billion in 1990 alone, or 6.8% of the

Similarly, 52.9
nation’s health care expenditures.
would have been
million days of lost productivity
averted, saving employers approximately $4 billion.
Despite the consequences , obesity has been
For most persons,
notoriously resistant to intervention.

11

weight loss involves breaking ingrained activity
and
dietary habits (Elks, 1996) . These changes cause major
disruptions in all aspects of personal and family life,

and are difficult to achieve and maintain. In response to
the health and economic implications of obesity, the

government has targeted reduction in the prevalence of

obesity as a major health goal for the year 2000 (Public
Health Service, 1990) .
In a study of weight loss comparing participants

assigned to a diet-only group, an exercise-only group,
and a combination diet and exercise group, Skender et al.
(1996) found no significant long-term weight loss

differences among the groups. During the study, the diet-

only group lost 6.8 kg, the exercise group lost 2.9 kg,

and the combination group lost 8.9 kg. At the end of 2
years, nearly all weight was regained by the

participants. Baron (1996) reported that in several
studies done in university settings using standard

treatment measures of diet and exercise, only 20% of
patients lost 20 pounds at 2 year follow up, while only

5% lost 40 pounds during the same period of time.
Etiology of Obesity

Although the exact mechanisms are not yet known, the
etiology of obesity is thought to be under both genetic
and environmental influences (Bray, 1992). A study of 12

12

pairs of young adult male monozygotic twins, who were
overfed by 1000 kcal/day over a 100 day period. showed a
significantly similar response within each pair
(Bouchard, Tremblay & Despres, 1990). Body weight,

percentage of body fat, fat mass, and estimated
subcutaneous fat produced a variance about three times

more among pairs than within pairs.
Another study of 673 pairs of twins reared apart

found genetic influences on body mass index to be
significant, whereas childhood environment had little or
no influence (Stunkard, Harris, Pederson, & McClearn,

1990). According to Bray and Gray (1988), environmental

factors such as physical activity and food choices
influence body weight, as do medical illnesses such as

thyroid disorders, Cushing’s syndrome, and major

depression.
Anorexiant Medications
Medications for the treatment of obesity, known as

anorexiants, are available over the counter and by
prescription (Elks, 1996). The broad chemical class known

as adrenergic agents includes phentermine (Adipex,
Fastin, lonamin), manzindol (Sanorex), and
phenylpropanolamine (Dexatrim) . The other class of
Included are
anorexiants is the serotonergic group.

13

dl fenfluramine (Pondamin) , d fenfluramine (Redux),
and
fluoxetine (Prozac) (Elks).
Many of these drugs are not new. Fenfluramine and
phentermine were approved for short term use in 1973
(Lemonick, 1996). It was not until the work of Weintraub
et al. (1992) that they were used in combination and

became popularly known as "Fen/Phen". D fenfluramine, an
isomer of dl fenfluramine, has only recently been

isolated and marketed as the brand name drug "Redux". In
contrast to amphetamines, the highly addictive diet drugs
of the past, the serotonergic drugs stimulate the

production and availability of the neurotransmitter
serotonin in the brain (Moreau, 1995). Serotonin triggers

a sense of physical and emotional satisfaction and a more
general feeling of well-being. Side effects from the

serotonergic agents include fatigue, drowsiness,
depressive feelings, and other central nervous system

(CNS) complaints. The most serious side effect from the

use of anorexiants, particularly d and dl fenfluramine is
primary pulmonary hypertension (PPH)

(Deitch, 1996).

Persons who have used anorexiants longer than 3 months
have a nine times higher risk of developing PPH than nonusers. The incidence of PPH for people taking anorexiants

is now estimated to be between 23 and 46 cases per
million patients per year, as opposed to the general

14

population of non-users which is 1
to 2 per year
(Deitsch).
The adrenergic agents cause fewer and less
severe
adverse reactions from CNS stimulation than do

amphetamines, and are much less addicting (Moreau, 1995).
The most common side effects are dry mouth, sleep

disturbance, dizziness, and gastrointestinal complaints.
The anorexiant properties of these drugs are thought to

come from direct stimulation of the hypothalamus, but may

involve other CNS and metabolic effects (Moreau).
Studies of Anorexiant Use and Weight Loss

A 1993 analysis of 36 studies using manzindol with
dl fenfluramine showed that after a median duration of 12

weeks, this combination resulted in a mean weight loss
that was 3 kg greater than with placebo (Stahl &

Imperiale, 1993). In these studies, discontinuation of
the drugs commonly resulted in weight gain.

After studying the use of medications in weight

control, Weintraub, Sundaresan, Maden, et al.

(1992)

developed the hypothesis that using medications having
different pharmacologic properties might be a useful way
to reduce adverse effects while maintaining therapeutic

benefit. They designed a 4 year study based on behavorial

, ,4_.
, .
restriction,, exercise, and the use
modification,
caloric resuiuuAu

of appetite suppressants fenfluramine 60 mg and

15

phentermine 15 mg daily, study participants were between
the ages of 18 and 60, 130 180% of ideal body weight,
and
in otherwise good health. Caloric limits ranged from 1500

to 1800 kcal per day for men and 1000 to 1200 kcal per
day for women. Supplemental vitamins were recommended.

Participants were advised to begin a graded exercise

program with a goal of expending, on at least three
occasions per week, 300 kcal over and above their usual

exercise and activities of daily living. Of the 121
participants who began the study, 51 completed 210 weeks.
A mean weight loss of 9.4 kg was observed after 3 years,

at which time medications were withdrawn. Diet, exercise,
and behavorial modification continued. After cessation of

medications, the weights of participants continued back

up toward baseline with some maintaining a weight below
baseline.

These findings indicate that participants had
difficulty maintaining weight loss without anorexiant
medications (Weintraub, 1992b). No signs or symptoms of
withdrawl nor laboratory abnormalities were noted in
participants after 3 1/2 years of therapy with

anorexiants. At week 210, serum total cholesterol:HDL

ratio was 8% less than week 0, and triglyceride levels
were 16% below baseline. The authors concluded that the

16

results indicate the potential need for very long
treatment periods in selected obese people.

According to Elks (1996), while there are some risks
associated with the use of appetite suppressants, they

are less life threatening than the complications of
obesity. Thus, Elks concluded, it is reasonable and
logical to selectively use appetite suppressants in obese

patients with complications, and in those at risk for
these complications. Baron (1996) noted that considerable

controversy exists as to the effectiveness and specific

indications for the use of anorexiant agents. Barriers to
their use include the public perception of obesity as a
lack of willpower, the expectation that medications

should cure obesity, limited research on long-term safety

and efficacy, and abuse potential of some of the drugs.
A National Institutes of Health workshop on the

pharmacologic treatment of obesity concluded that
pharmacologic agents may be effective in reducing body

weight over time, but should only be used as one
component of a comprehensive weight reduction program

(Atkinson & Hubbard, 1994). The workshop participants

also recommended that additional research be done on the

long-term efficacy and safety of drugs for the treatment

of obesity.

17

Educating Patients with Printed Materials
Education about preventive health practices and
health promotion is considered an essential component of
comprehensive health care. Health care practitioners have

a major role in this educational process (Whitman,
Graham, Gleit, & Boyd, 1992).
According to Mathis (1989), health care in the

United States has changed from a paternalistic model to

one that encourages more personal responsibility for
wellness. She also writes that health care providers must

educate consumers using many different modalities in
order to improve their overall health status.

Teaching aides such as audio-visual materials,
television graphics, games, demonstrations, and written

materials are commonly used to supplement oral
communication (Whitman, Graham, Gleit, & Boyd, 1992).
Printed educational materials are one of the most

economical and effective instructional mediums available,
and provide effective instructional assistance in the
hospital as well as at home (Bernier & Yasko, 1991). The
use of materials at home permits the patient and family
to choose the appropriate time and place for reviewing
to stimulate questions.
the contents. and often serves
Lange (1989) in her article on developing printed

materials for patient

education, recognized that in many

18

teaching situations materials already exist to meet the
need. However, when available materials
fail to meet the

needs of a particular setting, or no literature exists on
the subject, the practitioner should consider designing
the material. Bernier & Yasko (1991) agreed.

Erint_ed Educational Materials Development
The literature on developing printed materials for

patient education tends to be somewhat repetitious in

content, and consequently clear in direction. Lange
(1989) stressed the necessity for a needs assessment, an

advisory committee, a well defined goal, and content

selection based on what the patient needs to know. She
also emphasized the use of figures and diagrams for

clarity of content, the repetition of key points, and the
use of bold letters, underlining, and bright colors for
interest.

In addition to the points discussed by Lange, Mathis

(1989) advised authors to write simply, use as few words
of more than 2 syllables as possible, be precise, be

accurate, and involve the reader. The length of the
material should be as short as possible, and the size,

managable. The patient should be able to comfortably read
the material in bed or carry it in a purse.
The quality of educational materials is often

determined by

readability (Farrell-Miller & Gentry,

19

1989). Information written at a level appropriate to

assure patient understanding, increases recall and
compliance with treatment measures. While it is estimated

that the majority of people in the U.S. read at an Sth
grade level or lower, approximately 68% of the
educational materials available are written above a 9th
grade level (Doak, Doak, & Root, 1985). Because this is

such a common problem, the use of a formula to measure

readability is advised (Farrell-Miller & Gentry). The
SMOG Readability Test (Mclaughlin, 1969) is considered
among the easiest and quickest to perform (see Appendix
A). Colleague review of the designed materials and
evaluation by a representative group of patients were

also listed as important ways to inhance quality and
detect problems in the materials.
Finally, Bernier & Yasko (1991) provide the EPEM
model which serves as a comprehensive checklist or
standard for creating a quality product. It can also be

used to evaluate already prepared materials.
The EPEM Model
The EPEM model (Bernier & Yasko, 1991) divides the
process of preparing printed education materials into
includes establishing a
five stages. The pre-design phase
purpose, goal, intended audience, and objectives. The

design phase

contains guidelines for developing content,

20

with emphasis on organization, motivational features,

linguistics, and graphics. The pilot testing phase
suggests that both professionals and patients review the

materials and provide feedback so that revisions to the
draft can be made. Learning potential is maximized during
the implementation and distribution phase by providing
the material at a time when it is needed. Finally, the

evaluation phase is carried out on a formal or informal

basis using a small, representative sample of patients,
or a large, random sample.
Summary

To construct printed education materials for
patients in the Fen/Phen Weight Management Program, it
was necessary to review the literature on obesity, its

problems, and its treatment measures. The literature

available on models for construction of printed education
materials was also reviewed.

21

Chapter 3

Methodology
Gagne’s (1974) learning theory provided the
theoretical framework for this project.
The total act of
learning occurs in a series of phases,
and is influenced
by external stimuli such as verbal or written

instruction. The phase of information retention follows
the information acquisition phase, and makes possible the

confirmation of learning, as demonstrated by the

learner’s performance of what has been learned. In this

project, a printed education manual was designed for use
in the Fen/Phen Weight Management Program. The EPEM model

(Bernier & Yasko, 1991) for designing new patient

education materials, or critiquing existing ones, was
followed.

Project Design & Procedures.
This project was designed using the five phase, EPEM

model (Bernier & Yasko, 1991) for the production of

patient education materials. During the pre-design phase,
the need for a simple, concise, instructional manual was

determined through discussion with health professionals
involved in the program, through an extensive search of

currently available literature, and through an informal
for the needs
patient assessment. The accessed population
sample of thirty obese male
assessment was a convenience

22

and female patients over the age of 18.
All in the sample
group were patients of one family medical
practice
located in a small, northwest Pennsylvania town
of 8,000
people. Permission to survey patients for a needs
assessment was obtained from the physician medical

director. Learning objectives were established based on
the three areas of educational content: medications,

diet, and exercise.

During the design phase, the educational content
was determined and verified as accurate by two
physicians, two nurses, and a sample group of five

patients. As content was organized, points of particular
significance were presented first. Careful attention was

given to the necessity for expressing only one idea per

paragraph, keeping sentences short and simple, and using
one and two syllable words whenever possible, Content was

examined for readability using the SMOG formula
(McLaughlin,

1969) . To emphasize points of content,

illustrations were selected.
The pilot phase of this project involved testing a

draft of the manual with several patients and health
professionals, including the physician medical director

of the Fen/Phen

Weight Management Program. Feedback on

clarity of content

and intended outcomes led to minor

revisions in the manual.

23

During the distribution phase, the manuals

were

delivered to the medical director 1s office with

instructions for implementation and distribution to
patients. The completed manual, contained in Appendix B,
was made available to all new and continuing participants

in the program.
The final phase in the process involved evaluation
of the material. This was done formally through a small

sample of patients who reviewed the manual. They
evidenced understanding by explaining what they had read.

Questions asked by patients at follow-up appointments may

provide information for possible future revisions.
Summary

Following the learning theory of R.M. Gagne, the

author developed a manual to augment the learning of
patients in the Fen/Phen Weight Management Program. The
manual was constructed using the EPEM model for designing

and evaluating printed educational materials. The process

consisted of 5 phases, including a pre-design phase,

where the project assessment was completed, and a design
phase, where the first draft was
three phases

written. The remaining

included the pilot testing, distribution,

and final evaluation of the manual.

Appendixes

25

Appendix A

SMOG TESTING
I he SMOG formula was originally developed by G. I larry
McLaughlin in 1969. It will predict lhe grade-level difficulty of a
passage within 1.5 grades in 68% of lhe passages tested. That
may be close enough for your purposes, Il is simple Io use and
faster than most other measures. The procedure is presented

below.
Instructions
1. You will need 30 sentences. Count out 10
consecutive sentences near lhe beginning, 10
consecutive from lhe middle, and 10 from the
end. For this purpose, a sentence is any string of
words punctuated by a period (.), an
exclamation point (I), or a question mark (?).

2. From the entire 30 sentences, count lhe words
containing three or more syllables, including
repetitions.

.

3. Obtain lhe grade level from Table 4-1, or you
may calculate lhe grade level as follows:
Determine lhe nearest perfect square root of lhe
total number of words of three or more syllables
and then add a constant of 3 Io lhe square root
Io obtain lhe grade level.

1 olal number of multisyllabic (3 or more
syllables) words
Nearest perfect square
Square rool
Add constant of 3

67
64
8
I I This Is lhe
grade level.

26

Table 4-1.
SMOG Conversion Table
Word Coiml

Grade Level

0-2
3-6

4
5

7-12
13-20

6
7

21-30
31-42

B
9

43-56

10

57-72
73-90
91-1 10

I I
12
13

111-132

14
15
16

133-156

157-182
1B3-2I0
211-240

17
IB

Developed by: Harold C.
McGraw, Office of
Hdiicalional Research,
Baltimore County Public
Schools, Towson, Maryland.

Appendix B

J
/

Managing Your Weight
With Fen/Phen

Ml
!
J

I
/

28

A New Beginning
As you begin the Fen/Phen Weight Management Program, you
will have questions about your medications, diet, and exercise
program. This manual is designed to answer many of those
questions.
The decision to begin this Program means that you are
committed to a healthier lifestyle.
Many Americans struggle with the problem of being overweight.
1 in 4 are 20% or more above their ideal body weight and at risk
for serious health problems. Obesity can lead to diabetes, high
blood pressure, heart disease, high blood cholesterol, and even
certain forms of cancer.

Until lately, obesity was thought to be a problem with self­
control or bad eating habits. Now, it is thought to be a chronic
illness. While lack of will-power, little exercise, and bad eating
habits may still be part of the problem, your body's biochemistry
is another part. This may explain why so many diet and exercise
programs have failed for most people in the past.
Many experts now think that drug treatment for obesity is much
like using drugs to treat diabetes or high blood pressure. They
make a needed change in the body's chemistry, and may be
required long-term. But the drugs will not work alone. A healthy
eating plan and regular exercise are needed for long-term
success.

r N

mi

29

What is "Fen/Phen"?
’’Fen/Phen” is a popular term for the drug combination of
fenfluramine and phentermine. These nonaddicting drugs affect
chemicals in the brain known as neurotransmitters that send
messages to other parts of the body. Fenfluramine causes an
increase in serotonin which makes you feel satisfied, like you've
had enough to eat. Phentermine raises levels of norepinephrine
which also seems to decrease appetite.

Why does this combination work?
In the past, each drug was used alone to treat obesity but in
higher doses. Because higher doses caused greater problems
with side effects, success rates were low. By using the drugs
together, but in smaller doses, you will have good appetite
control and fewer side effects.

How fast will I lose weight?
When the medications are effective, you can expect to lose 1015% of your starting weight within 6-12 months. Everyone's
experience will not be the same, however. You may lose faster
or slower than someone else. If your weight loss is not at least 4
pounds within the first month of treatment, your health care
provider may recommend a different approach. Generally, a
healthy weight loss is 2 pounds per week, but even 1 pound per
week shows progress.

Ma
J/

30

When should I take Fen/Phen?
The usual schedule begins with one 15mg. phentermine
(lonamin) capsule when you first awaken in the morning.
Because it may have a mild stimulant effect that could disrupt
sleep, you should not take phentermine after noontime.

Fenfluramine (Pondimin), 20mg., may be taken anytime between
2:00 pm. and 6:00 pm. Taken in this manner, your hunger should
be controlled for most of the day. If you still have hungry times
that you cannot control, your health care provider may add a
second or third dose of fenfluramine to your schedule.

Will I have any side effects?
You may experience a dry mouth, nervousness, constipation, and
insomnia from phentermine. Fenfluramine can cause drowsiness,
diarrhea, dry mouth, and less frequently, dizziness and urinary
frequency. With the exception of dry mouth, most of these side
effects become less bothersome with time.

Although Fen/Phen is considered safe when taken as prescribed,
there is a small risk of a life-threatening condition that you
should know about. It is called primary pulmonary hypertension
(PPH). If 1 million people took Fen/Phen for 1 year, it is
estimated that between 23 and 46 of them would develop PPH.
This is compared to only 1 or 2 cases of PPH each year among
1 million people not taking Fen/Phen.
Warning signs of PPH include shortness of breath, chest pain,
fainting, and swelling of the feet, ankles or legs. Contact your
health care provider if your are experiencing any troublesome or
unexpected symptoms.

31

Who should not take Fen/Phen?
If you are pregnant, nursing, under 18 years of age, or less than
20% overweight, you should not take Fen/Phen. In these cases
the risks are greater than the benefits. If you have uncontrolled
diabetes, hypertension, or another serious illness, your health
care provider will treat your illness first.

How long will 1 take Fen/Phen?
If you and your health care provider are pleased with your
progress, you may decide to keep taking the medications long­
term. You may also decide to taper down the dosage once your
target weight is reached, and maintain your weight with healthy
eating and exercise. For some, a maintenance dose may be
needed to remain at a target weight.

How often will I see my health care
provider?
An every two week schedule for the first 2 or 3 visits will help
your health care provider to assess your progress and answer
your questions. Once you are both content with your progress,
monthly visit is advised.

What healthy eating plan is best?
The American Heart Association recommends a 1200-1500
calorie/day diet for women, and a 1500-1800 calorie/day diet for
men. The average person will lose 1-2 pounds per week with
tins number of calories and with regular exercise

A low fat intake, less than 30% of calories consumed per day, is
also advised for weight reduction and good health. You may ’
wish to add a multivitamin to your daily routine.

An excellent source for healthy eating is the Food Guide
Pyramid, published by the U.S. Department of Agriculture and
the U.S. Department of Health and Human Services. A copy of
the pyramid, nutrition tips, and sample menus is included at the
end of this manual.
Keeping a food diary for the first several weeks of the Program
will help you and your health care provider to evaluate your
eating patterns. It will not only help you to count calories, but it
will also help you to examine food groups for healthy eating.

What should I do for exercise?
Your exercise program should include activities you enjoy and
can do on a regular basis. Swimming, cycling, jogging, weight
lifting, and walking are examples of aerobic exercises that can
help you bum extra calories. Walking is probably the easiest
activity for most people to perform. It requires only a supportive
pair of shoes and comfortable clothing.

A healthy heart is another reason for regular aerobic exercise.
By spending only 40 minutes every other day, you can bum
calories and have a healthier heart.

33

Begin your exercise session with slow, gentle stretching for five
minutes. Follow the stretching with five minutes of slow walking
to prepare your body for the aerobic exercise.
Twenty minutes of aerobic activity at a steady pace is next. By
keeping your heart rate in the exercise heart target zone (see
chart), you should be able to comfortably talk , but not sing, as
you go. How to take your pulse is explained below.

Cool down next by walking slowly for five minutes, then stretch
again for five minutes to help you to end your session feeling
relaxed and invigorated.

Heart Exercise Target Zone
Age

Target Zone (beats per minute)

20
30
40
50
60
65+

140-170
133-166
126-153
119-145
112-136
90-132

Remember to keep a comfortable pace. Exercise should be fun.
Slow down if you feel faint, weak, or have a hard time breathing.

How to take your pulse
Place your first two fingers on the inside of your wrist just below
your thumb. Count the number of beats for 10 seconds and
multiply by 6 to determine your pulse rate.

34

A New You
Your decision to take control of your weight is the first big step.
With medications to assist with appetite control, and a plan for
sensible eating and regular exercise, you can reach and maintain
a healthier weight and lifestyle.

Fats, Oils, & Sweets
USE SPARINGLY

Milk, Yogurt,
& Cheese
Group
2-3 SERVINGS

Meat, Poultry, Fish,
Dry Beans, Eggs,
& Nuts Group
2-3 SERVINGS

Vegetable
Group
3-5 SERVINGS

Fruit
Group
2-4 SERVINGS

Bread, Cereal,
Rice, & Pasta
Group
\
6-11
\ SERVINGS

The Food Guide Pyramid: A Guide to Good Eating.

Dear Patient:
To improve your diet and reduce your risk of
developing cancer or heart disease, practice
these healthy eating habits.
EATING MORE FRUITS, VEGETABLES,
AND GRAINS

1. Add more vegetables and less meat than
called for in stir-fries, casseroles, soups, and
other recipes.
2. If time is a problem, purchase prepack­
aged salads in the grocery store.
3. When possible, choose dark green leaves
for salads—the darker the leaves, the more
nutritious they are.
4. Experiment with unfamiliar vegetables
and fruits. Try collards, kale, red-leaf lettuce,
broccoflower, dandelion greens, jicama, mango,
kiwifruit, star fruit, and more.
5. Instead of fruit yogurt, try plain nonfat or
low-fat yogurt mixed with chopped apples and
cinnamon, crushed pineapple with a drop of
coconut extract, or raisins and your favorite
cereal.
6. Prepare your own “fruit-sicles.” Combine
fruit juice with small chunks of fruit, pour it into
a paper cup, add a Popsicle stick, and freeze
until firm.
7. Make a refreshing, low-calorie beverage by
mixing fruit juice with seltzer and crushed ice.
8. Add more vegetables to sandwiches.
Lettuce and tomato are fine, but so are cucum­
ber rounds, diced carrots, sprouts, green and red
pepper strips, and broccoli.
9. Supplement pasta sauce and dishes like
meat loaf with finely chopped veggies: fresh
onions, green and red peppers, spinach, celery,
or mushrooms.
10. Add more beans to soups, stews, and sal­
ads or use them in burritos instead of beef.
11. Try tofu and other soy products. They’re
a good source of vegetable protein.
12. To ensure adequate nutrition, supplement
a reduced-fat frozen meal with a tossed salad,
skim milk, and fruit for dessert
13. Take a break from rice with kasha, couscous bulgur, barley, wild rice, millet, and other
less-familiar grains. Check cookbooks for ideas.

50 TOP
NUTRITION

14. Boost the fiber in your favorite cereal by
sprinkling on a teaspoon or two of unprocessed
bran or adding 100% bran cereal. Drink plenty
of fluids when increasing the fiber in your diet.
15. Turn baked potatoes into a main dish by
topping with reduced-fat cheese and a generous
helping of steamed, fresh broccoli. Or top with
a mixture of black beans, browned ground
turkey breast, com, and salsa.
SUBSTITUTING THE FAT

35

RFi Ik fl
I | Hl
I I
Ill J

A-

\

16. Poach fish witlfreduced-sodium
_
or wine and fresh herbs. Of bake fish imfoilwith
thinly sliced fresh vegetablesktad.o^liv^oil,
and fresh baST
17. ExperimentywntE7yarious^aV0red vine-’
gars on saladsror in ofli^f^he^^^kash of, /

W'X

raspberry vbiegaron
samic vinegar' on-albrdwnijiap^^d with
chopped fresh fomatoey,an^6asil.I^^es^>^>^
18. SauttCfoods;ini
stead of oil or butter.
19. Try using only half^-n^i^end^^t'
in recipes.
4
20. Substitute evaporatedvskimfmilkMdr
whipping cream m many-recipes^
21. In baking, try unsweetened.‘^pfeSauce?J,
for a portion of the fat-Aisuany,.up'to^6ne^fiau <^
For recipes that call for chocol^^nkeqanine
puree because it’s more compauble^with The”
stronger flavor.
22. In many recipes, you can replace each
ounce of unsweetened chocolate with ^table­
spoons of unsweetened cocoa powder for the
same flavor without the fat.
23. Much of the fat in cake comes fromhhe
frosting. Top instead with slices of fresfiMuit,
fruit sauce, or a sprinkle of powdered sugar.
24. Those innocent-looking muffins and
scones may be just as high in fat as pastry and
doughnuts. Choose bagels instead and spread
with just a light layer of reduced-fat cream
cheese or jelly.
25. In recipes that call for fat-free cream
cheese or sour cream, use reduced-fat versions.
The few grams of fat will give your food better
taste and texture..
26. On sandwiches, replace mayonnaise with

fee
A

36

For a low-fat and tasty meal bake fish in foil
with thinly sliced fresh vegetables,
a tad of olive oil, and fresh basil.
mustard or salsa.
27. Try broth-based soups—they’re far
lower in fat than cream-based alternatives.
28. At salad bars, skip the mayonnaise-laden
salads and oily marinated beans. Select fresh
greens and vegetables with fat-free or reducedfat dressing.
29. When eating pizza, blot the surface with
a paper napkin to absorb fat. Order vegetable
toppings instead of extra cheese, pepperoni, or
ground beef.
30. Enjoy a fat-free cookie or two, but
remember that “no fat” doesn’t mean “no calo­
ries.”
31. Keep healthy, low-fat snacks on hand:
flavored rice cakes, sliced fruit, fat-free caramel
popcorn, vegetable sticks with salsa, baked tor­
tilla chips, unsalted pretzels with mustard, fruit
bars, or dry cereal.
32. To prepare low-fat guacamole, try using
canned asparagus or cooked peas instead of
avocado. The result will be surprisingly similar
to the real thing!
33. Try powdered butter substitute as a lowfat alternative to butter or margarine. It’s won­
derful on pasta, potatoes, hot cereal, rice, and
recipes that call for a buttery flavor.
34. You can substitute two egg whites or %
cup egg substitute for each whole egg in most
recipes.
35. Adapt the cooking directions on the back
of processed foods to control fat or salt. For
example, use two-thirds of the seasoning pack­
et in a rice mix or make macaroni and cheese
mix without the butter.
LIVING HEALTHY

36. Always eat a variety of foods for good
health. Cancer-fighting nutrients vary from food
to food.
37. Too busy to cook during the week? Set
aside some time on the weekend to prepare a
low-fat vegetable lasagna or vegetable bean
stew that can be refrigerated for a quick meal
on busy days.
38. When dining out, ask about ingredients
and preparation methods. Most restaurants will
go out of their way to make you happy.
39. If you eat at fast-food restaurants, choose
meals carefully to control fat and calories.
Consider the grilled chicken breast with mus­

tard (no special sauce), a single hamburger,
skim milk, a fat-free muffin, a low-fat milk
shake, or fat-free frozen yogurt.
40. Prepare a pot of turkey chili, hearty
minestrone soup, or a vegetable casserole; store
in individual containers and freeze. Defrost in
the microwave for a quick supper or a nutritious
lunch at work.
41. Roast a turkey breast, slice it, and sepa­
rate the meat into portions of 2 to 3 ounces.
Place portions in their own plastic zipper bags
and freeze to use later in stir-fries, casseroles,
and sandwiches.
42. When traveling by air, call ahead to
request a low-fat or low-calorie meal.
43. Avoid charring or overcooking grilled
foods. Remove any visible fat before grilling to
help eliminate flare-ups and the formation of
cancer-causing substances.
44. To prevent foodbome illness, always
cook poultry and other meats thoroughly.
Never cut fruits and vegetables with the same
knife or on the same cutting board you use
for raw meat.
45. When reading food labels, always look at
the serving size first so you’ll know how much
food the nutrient analysis refers to.
46. If you’re trying to manage your weight,
don’t deprive yourself. Just eat smaller portions
of your high-fat favorites less often. Fill up on
fresh fruits, vegetables, and whole grains to feel
more satisfied.
47. At times, people eat for reasons other
than physical hunger: for social and psycholog­
ical reasons and in response to the smell, taste,
and appearance of food. Listen to your body
and try to eat only when you’re really hungry.
48. When eating out, try ordering a salad and
a low-fat appetizer (or two appetizers) instead
of an entree.
49. Experiment with herbs and spices as sub­
stitutes for fat and salt. Try rosemary with peas,
dill with green beans, oregano with zucchini, or
basil with tomatoes.
50. Above all, remember to enjoy food—for
its wonderful variety of flavors, textures, colors,
and nutritional qualities, fl
This leaching aid may be photocopied by health care professionals for use in
their clinical practice. Hospitals and other institutions that wish to
this material must fust contact the Copyright Clearance Center al (508) 7508400. © 1996 Springhouse Corporation. Springhouse. Pa. Reprinted with per­
mission from the American Institute for Cancer Research.

37

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Reference
Atkinson, R., & Hubbard, V.

(1994). Report on the

NIH workshop on pharmacologic treatment of obesity.

American Journal _of Clinical Nutrition
Baron, R.

£(1(2), 153-156.

(1996, March 12). Understanding obesity

and weight loss [On-line]. Available:
File:///A/OBESITY.HTM.
Bernier, M.

(1993). Developing and evaluating

printed education materials: A prescriptive model for

quality. Orthopaedic Nursing, 12(6), 39-46.
Bernier, M., & Yasko, J.

(1991). Designing and

evaluating printed education materials: Model and

instrumentation development. Patient Education and
Counseling, 18, 253-262.

Bray, G.

(1992). Pathophysiology of obesity.

American Journal of Clinical Nutrition,. 5.5(2 suppl),
488S-494S.

Bray, G., & Gray, D.

(1988). Obesity. Part 1-

Pathogenesis. Western Journal of Medicine.*. 149(4), 429441.
Bouchard, C., Tremblay, A., & Despres, J.

(1990).

The response of long term overfeeding in identical twins.
1477-1482.
New England Journal of Medicine,_ 122(21),
Deitch, M.

Redux [Letter]

(1996, August 22). Important update_on
Philadelphia: Wyeth-Ayerst Laboratories.

39

Doak, C., Doak, L., & Root, J.
paX.xe.nts—with low literacy skills

(1985). Teaching
Philadelphia:

Lippincott.

Elks, M.

(1996). Appetite suppressants as adjuncts

in the treatment of obesity. The Journal of Family
, 287-292.

Farrell-Miller, P., & Gentry, P.

(1989). How

effective are your patient education materials?
Guidelines for developing and evaluating written
educational materials. The Diabetes Educator, 15(5), 418-

422.
Gagne, R.

instruction

(1974). Essentials of learning for

Hinsdale, NY: Dryden Press.

Geyman, J.

(1980). How effective is patient

education? Journal of Family Practice/. 15, 973-974.
Lange, J.

(1989). Developing printed materials for

patient education. Dimensions of Critical Care. Nursing..,.

5.(4), 250-259.

Lemonick, M.

(1996) . The new miracle drug? Time

145(15) , 61-67.
Mathis, D.
D.

(1989). Writing patient education

materials. Qrtiwa^dLc_^^
McLaughlin, H.

readability formula.

39-42.

(1969). SMOG grading-A new
639-645.

40

Moreau, D.

(Ed.).

(1995). Physician's drug handbook

(6th ed.) Springhouse, PA.: Springhouse.
Pi-Sunyer, F.

(1993). Medical hazards of obesity.

Annals of Internal Medicine

112(7), 655-660.

Rankin, S. & Stallings, K.
education.

(1990). Patient

(2nd ed.). Philadelphia: Lippincott.

Rippe, J.

(1996). Overweight and health:

Communications challenges and opportunity. American
Journal of Clinical Nutrition, fLQ. (s upp 1) , 470S-473S.
Skender, M., Goodrick, G., Del Junco, D., Reeves,
R., Darnell, L., Gotto, A., & Foreyt, J.

(1996).

Comparison of 2-year weight loss trends in behavioral

treatment of obesity: Diet, exercise, and combination
interventions. Journal of the American Dietetic

Association, 96(4), 342-346.
Stahl, K., & Imperiale, T.

(1993). An overview of

the efficacy and safety of fenfluramine and manzindol in
the treatment of obesity. Archives of Family Medicine 2,

1033-1037.

Stunkard, A., Harris, J./ Pederson, N., & McClearn,
(1990). The body mass index of twins who have been
322(21),
reared apart. New England Journal of Medicine.*.

G.

1483-1487.

41

United States Public Health Service.

(1990). Healthy

People—2-000 ;—national health promotion and disease
prevention objectives (DHHS publication phs 90-50212).

United States Public Health Service.

(1994).

Clinician’s Handbook of Preventive services

(pp.141-

144). Waldorf, MD: American Nurses Publishing.
Weintraub, M.

(1992a). Long term weight control: The

National Heart, Lung, and Blood Institute Funded
Multimodal Intervention Study. Clinical Pharmacology

Therapeutics, 51(5), 581-585.

Weintraub, M.

(1992b). Long-term weight control

study: Conclusions. Clinical Pharmacology Therapeutics/

hi±5) , 642-646.
Weintraub, M., & Bray, G.

(1989). Drug Treatment of

Obesity. Medical Clinics of North America/. 73 (1), 237249.
Weintraub, M., Sundaresan, P., Madan, M., Schuster,

B., Balder, A., Lasagna, L., & Cox, C.

(1992). Long-term

Clinical
weight control study 1(weeks 0 to 34).
Pharmacology Therapeutics.*. 51(5), 586-594.

Weintraub, M., Sundaresan, P., & Schuster, B.
(weeks 0 to
(1992). Long-term weight control study VII
51 (5), 634-641.
210) . Clinical Pharmacology Therapeutics^
Weintraub, M., Sundaresan, p., Schuster, B.,

Averbuch, M., Stein, C., & Byrne, L.

(1992). Long-term

42

weight control study V (weeks 190 to 210). Clinical
Ehaxmacology Therapeutics, 51(5), 615-618.

Whitman, N., Graham, B., Gleit, C., & Boyd, M.
(1992). Teaching in nursing practice (2nd ed.). Norwalk,
CT: Appleton & Lange.
Wolf, A., & Colditz, G. (1996). Social and economic

effects of body weight in the United States. Amexioan
Journal of Clinical Nutrition, 63(supp1), 466S-469S.