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Ten things you should know about healthy eating ...

Sarah Schenker
BSc SRD PhD
Nutrition Scientist British Nutrition Foundation
London

How many times have you been asked by a patient, 'Can I eat chocolate?', 'Are crisps OK?', 'Is it all right to eat biscuits?' Sound familiar?
 
Increasingly people seem to be far more diet- and health-conscious. Almost every day there is a media story on some aspect of food and nutrition. Every month there seems to be a new diet promising miraculous weight loss, yet the prevalence of overweight and obesity remains at around 60% of the adult population - the highest it has ever been since records have been kept.
 
Given the amount of confusion surrounding the impact of diet on health and the continuous flow of mixed messages fed to the public, it is hardly surprising that patients will seek reassurance from the practice nurse on what they should and shouldn't eat.
To help you give sound practical advice, there are ten key points to achieving a healthy balanced diet. Further detailed information can be found in a book written by BNF nutritionists especially for community nurses.(1)

Following these ten guidelines can help optimise nutritional intake, which in turn can help reduce premature morbidity and mortality from a number of modern diseases, including heart disease, stroke, some cancers, type 2 diabetes and obesity.

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1. Food should be enjoyable
The most important thing to remember when someone is thinking about making changes to their diet is that food should be enjoyable. Many people think that they cannot eat healthily because they would not like the food.

Foods should not be classified as either good or bad: in fact any food, no matter how bad its reputation, can be included in a healthy diet as long as the overall balance of nutrients in the diet is right. All foods provide energy and nutrients, and it is achieving the correct intake of those nutrients that is important for health.

2. A healthy balance
We need energy to live, but the balance between carbohydrate, fat and protein must be right for us to remain healthy. Too little protein can interfere with growth and other body functions; too much fat can lead to obesity and heart disease.

It is recommended that half of our total energy intake is provided by carbohydrate foods (mainly starchy foods); energy intake from fat, on average, should be reduced to 35%; and the remaining 15% should be provided by protein.(2) These figures are intended as population averages, not as targets for individuals. They refer to the habitual diet, so do not necessarily need to be met on a daily basis and certainly not by individual meals or foods.

To help people achieve the correct balance of protein, fat and carbohydrate, the former Health Education Authority produced the "Balance of Good Health" (pictured). This pictorial food selection guide has now been adopted by the Foods Standards Agency, and is intended to help people to understand and enjoy healthy eating and achieve the correct balance between the foods that make up their diet. Copies of this are available from the Foods Standards Agency.

3. Government guidelines
The Balance of Good Health(3) is based on the government's "Eight Guidelines for a Healthy Diet":

  1. Enjoy your food.
  2. Eat a variety of different foods.
  3. Eat the right amount to be a healthy weight.
  4. Eat plenty of foods rich in starch and fibre.
  5. Eat plenty of fruit and vegetables.
  6. Don't eat too many foods that contain a lot of fat.
  7. Don't have sugary foods and drinks too often.
  8. If you drink alcohol, drink sensibly.

The guide applies to all people including those who are overweight, vegetarian and people of all ethnic origins. It does not apply to children under two years of age.

4. Health risks of obesity
Being obese or overweight has serious implications for health status.(4,5) The risk of diseases such as diabetes, heart disease and some cancers is higher with increasing weight. An overweight patient should try to lose weight slowly and sensibly. Fad diets and crash dieting may work to begin with but don't usually have long-lasting weight loss effects, and some can be dangerous to health.(6)

To lose weight effectively and keep it off, small changes to the diet should be made, one or two at a time, such as taking a homemade lunch to work or swapping the usual mid-morning biscuits for a banana at break time.

It is also important to be more active. This does not necessarily mean formal exercise like aerobics classes - walking and activities such as gardening can make a difference if carried out regularly.

Meals should not be skipped as this just increases the likelihood of overindulging in another food later. Encourage patients to be organised when it comes to food. Suggest that they make sure there are always sufficient low-calorie snacks that they like to hand; having an apple with them may help stop them reaching for the biscuits if they become hungry.

5. Increase starch
Eating more starchy foods such as bread, potatoes, rice and pasta can help reduce the amount of fat and increase the amount of fibre in the diet. However, beware of using them as vehicles for adding extra fat, such as butter or margarine on bread or potatoes, or creamy sauces on rice or pasta.

Changing the balance of carbohydrate to fat can be achieved at each meal. For example, the balance of a sandwich can be improved by using thicker slices of bread, less filling and less spread and by adding plenty of salad, or the balance of a rice or pasta dish can be improved by having more rice or pasta with less sauce, again with salad or vegetables.

6. Lowering fat
To help patients lower their fat intake, particularly if they need to lose weight or have raised blood lipid levels, advise them to choose leaner cuts of meat and lower-fat versions of foods such as milk and cheese. Offer other tips such as trimming all visible fat and skin from meat and poultry and choosing cooking methods that do not add fat - for example, grilling food instead of frying it.

7. Types of fat
Explain to patients that there are different types of fat in the diet and reassure them that some fat in the diet is necessary. Olive oil and rapeseed oil are both good sources of monounsaturates; nuts, seeds and vegetable oils provide polyunsaturates, as does oily fish. Both monounsaturates and polyunsaturates can help to lower cholesterol levels in the blood.
A high intake of saturates, on the other hand, found in cooking fats and spreads (eg, butter, margarine and lard), fatty meats and meat products, wholemilk and full-fat dairy products, chips, biscuits, cakes, pastries and confectionery can raise blood cholesterol levels. The fat in oily fish such as sardines and salmon can help to lower the risk of dying from a heart attack,(7) so encourage patients to eat at least one portion of oily fish per week.

8. Sugar's not so sweet
Frequent consumption of foods containing sugar increases the risk of tooth decay.(8) Sugar-containing foods and drinks can be part of a healthy balanced diet, but patients should be advised to consume these foods as part of a meal, to limit frequency of consumption, rather than constantly throughout the day.

9. Five alive
Encourage the consumption of at least five portions of fruit and vegetables every day.

All fruits and vegetables count towards this target except for potatoes (which are in the starchy foods group). The fruits and vegetables do not need to be fresh or raw: canned, dried, frozen and juiced are just as good.

Fruit and vegetable juices count as just one portion, however much of them is consumed in a single day, and the same rule applies to beans and pulses such as baked beans.

Fruits and vegetables are low in fat and high in fibre, so they help to achieve the right balance between the various nutrients in the diet. They also contain vitamins, minerals and other substances known as phytochemicals, which may help to protect against diseases such as cancer and heart disease (this is the topic of an ongoing study by the BNF Task Force, the report of which will be published in 2002).

10. Alcohol consumption
Current guidelines on alcohol consumption are that men should consume no more than 3-4 units a day, and that women should consume no more than 2-3 units per day.

Emphasise to patients that this is a daily, not a weekly recommendation, so as to discourage them from binge drinking.

References

  1. Buttriss J, Wynne A, Stanner S.  Nutrition  - A handbook for community nurses. London: Whurr Publishers; 2001.
  2. Department of Health. Dietary Reference Values for Food Energy and Nutrients in the United Kingdom. Report on Health and Social Subjects 41. London: HMSO; 1991.
  3. Food Standards Agency. The Balance of Good Health. London: Food Standards Agency; 2001.
  4. British Nutrition Foundation. Obesity. The report of the British Nutrition Foundation Task Force. Oxford: Blackwell Science; 1999.
  5. National Audit Office. Tackling Obesity in England: Report by the Comptroller and Auditor General. London: The Stationery Office; 2001.
  6. Schenker S. Dieting crazes. Nutr Bull 2001;26:117-19.
  7. British Nutrition Foundation. Omega-3 Fatty Acids and Health Briefing Paper. London: British Nutrition Foundation; 1999.
  8. British Nutrition Foundation. Oral Health Diet and Other Factors. The report of the British Nutrition Foundation Task Force. Amsterdam: Elsevier; 1999.

Resources
British Nutrition Foundation
W:www.nutrition.org.uk
Food Standards Agency
W:www.food-standards.gov.uk
E:foodstandards@eclogistics.co.uk

Further reading
Buttriss J, Wynne A, Stanner S. Nutrition - A handbook for community nurses.
London: Whurr Publishers; 2001.
This book is available via the British Nutrition Foundation at a cost of £16 (inclusive of postage within the UK) - see website for details