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• To enhance your understanding of the link between a healthy diet and overall health and well-being
• To ensure your knowledge of the latest dietary recommendations and guidance remains up to date
• To consider various methods you could use in your practice to support patients to eat healthily
Maintaining a balanced and nutritious diet is essential to support optimal health and well-being. However, rates of overweight and obesity in the UK and internationally have risen significantly, alongside increases in food portion sizes. While it can be challenging to work in partnership with patients towards achieving a healthy weight, it is crucial that nurses are able to offer patients advice and support to assist them in following dietary guidelines. This article explores the development and practical application of recommended dietary guidelines such as the Eatwell Guide. It also discusses practical interventions that nurses can use to advise patients on healthy eating, such as using the hands as a guide to portion size.
Nursing Standard. doi: 10.7748/ns.2021.e11670Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Hicking-Woodison LE (2021) Providing patient education on portion control and healthy eating. Nursing Standard. doi: 10.7748/ns.2021.e11670
Published online: 25 March 2021
In healthcare, the terms obesity and overweight refer to an abnormal or excessive accumulation of body fat, and both have significant implications for people’s health and well-being. In particular, being obese or overweight is associated with an increased risk of developing non-communicable diseases such as diabetes mellitus, cardiovascular disease and some cancers (World Health Organization (WHO) 2020a).
Obesity and overweight represent a major public health concern in the UK and internationally. In 2016, it was estimated that worldwide more than 1.9 billion adults aged 18 years or above were overweight, while 650 million adults were classified as obese (WHO 2020a). In addition, the worldwide prevalence of obesity almost tripled between 1975 and 2016 (WHO 2020a). In England, it is estimated that obesity is responsible for more than 30,000 deaths each year, while an individual who is obese is deprived of an extra nine years of life on average (Public Health England (PHE) 2017).
The financial burden of obesity and being overweight is also significant. In 2014-15, it was estimated that the cost to the NHS attributed to overweight and obesity-related ill-health was £6.1 billion (PHE 2017). NHS costs attributed to obesity and being overweight were projected to reach £9.7 billion by 2050, with the costs to society in general anticipated to reach £49.9 billion per year (PHE 2017).
This article provides information on the latest dietary guidelines and recommendations, and details the methods that nurses can use to support healthy eating in patients.
• Being obese or overweight is associated with an increased risk of developing non-communicable diseases such as diabetes mellitus, cardiovascular disease and some cancers
• The Eatwell Guide arranges the five main food groups into straightforward pictorial health-promotion advice, with the aim of assisting individuals to make educated dietary choices that support optimal health
• Barriers to achieving long-term dietary changes include misconceptions about healthy eating, distorted views of portion sizes and the importance of achieving value for money
• Nurses can use the ‘hand-size method’ to educate people on appropriate portion size, which enables healthy portions to be visualised without the need for scales or measuring devices
The UK’s first national healthy eating template was produced in 1994 and entitled The Balance of Good Health (Department of Health (DH) 1994). It was produced through collaboration between the DH, the Ministry of Agriculture, Fisheries and Food, and the Health Education Authority. The template showed five segments representing various food groups: fruit and vegetables; bread, cereals and potatoes; meat, fish and alternatives; foods and drinks containing fat and sugar; and milk and dairy foods.
The segment sizes depicted in The Balance of Good Health were designed to reflect the proportions required for a healthy diet. The aim was to use a nationally recognised guide to food selection to contribute towards achieving targets for improvements in population health in areas such as coronary heart disease and stroke, which had been set out in the Health of the Nation white paper (DH 1992).
While the advice contained within The Balance of Good Health was considered a useful aid in prompting members of the public to consider their diet, from 2000 onwards healthcare professionals began to request that it be updated (PHE 2016a). For example, while the proportions associated with the different food classification groups were easy to understand, these had not been properly reviewed.
Following consumer testing, the Eatwell Plate was launched in 2007 by the Food Standards Agency, which was then responsible for public health nutrition advice (NHS Wales 2007, PHE 2016a). The contents were changed from The Balance of Health template, significantly in some cases. For example, the pink segment was renamed from ‘Meat, fish and alternatives’ to ‘Meat, fish, eggs, beans and other non-dairy sources of proteins’ to emphasise the potential contribution of non-meat foods to an individual’s protein intake. However, the Eatwell Plate still included a segment entitled ‘Food and drinks high in fat and/or sugar’, which implied that these were part of a balanced diet. The Eatwell Plate was refreshed again in 2014, then subsequently revised two years later in 2016 and renamed the Eatwell Guide (PHE 2016a).
The Eatwell Guide was developed by PHE in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland (PHE 2016a, Food Standards Scotland 2021). The Eatwell Guide differed from the Eatwell Plate in several important areas. For example, the image of the knife and fork was not included in the Eatwell Guide because it was no longer considered appealing, and the images of the various food types were depicted by illustrations rather than photographs. A recommendation that foods with a high fat, salt and sugar content should only be eaten occasionally was included, as were messages regarding optimal hydration and food packaging (PHE 2016b). The Eatwell Guide is shown in Figure 1.
The guidance depicted in the Eatwell Guide was based on a report from the Scientific Advisory Committee on Nutrition (SACN) (2015). This report focused on carbohydrates and health, and reviewed more than 600 prospective cohort studies, randomised controlled trials (RCTs) and revised dietary recommendations for fibre and sugar intake (SACN 2015). The report advised the UK’s health agencies to reduce the recommended average intake of free sugars from 11% of an individual’s total energy intake per day to no more than 5%. It also recommended an increase in the average daily fibre intake, from 23.5g per day to 30g per day (SACN 2015, Patience 2020).
The Eatwell Guide (PHE 2016c) arranges the five main food groups into straightforward pictorial health-promotion advice, with the aim of assisting individuals to make educated dietary choices that support optimal health (British Nutrition Foundation 2016). Individuals are encouraged to consume an assortment of foods from each segment of the Eatwell Guide, as well as drinking appropriate quantities of fluids, to achieve and maintain a healthy weight (British Heart Foundation (BHF) 2021). Table 1 shows the portions of each food group that individuals should aim to consume during one day.
|Category||Amount per day|
|Fruit and vegetables||Five or more portions|
|Potatoes, bread, rice, pasta and other starchy carbohydrates||Seven to eight portions|
|Dairy and alternatives||Three portions|
|Beans, pulses, fish, eggs, meat and other proteins||Two to three portions|
|Oils and spreads||Small amounts|
|Fluids||Six to eight glasses|
Despite the updated recommendations depicted in the Eatwell Guide, there was some controversy surrounding its publication. For example, Harcombe (2017) criticised the fact that some of its contributors were associated with the food industry, and that there was an overemphasis on carbohydrates rather than saturated fat reduction. In response, 21 leading health, consumer and professional organisations published a joint statement through the World Cancer Research Fund (2016) supporting the Eatwell Guide. However, this controversy demonstrates the importance of healthcare practitioners being aware of ongoing debates concerning the evidence base for national dietary guidelines.
In the recent past, the increased production and availability of processed foods has led to a change in dietary habits. The WHO (2020b) stated that, globally, individuals are consuming more high-calorie, high-energy foods than they did previously, while many people also do not consume enough fruit and vegetables.
A portion size comprises the amount of food that is recommended to be eaten in one sitting (BHF 2013). However, over time, perceptions of portion sizes have changed, and research has suggested that although progress has been made on food labelling, many people remain confused about appropriate portion sizes (BHF 2013). Similarly, one study by Fukuoka et al (2014), which explored people’s understanding, knowledge and attitudes concerning food, identified a common misconception that portion control does not matter provided the food being consumed is considered healthy.
Researchers at the BHF compared portion sizes of own-brand supermarket products in 1993 with those available in 2013 (BHF 2013). They found that a plain sweetmeal biscuit was 17% larger in 2013 than the comparable biscuit in 1993. This would mean that eating one biscuit per day in 2013 would add another 3,300kcals to an individual’s diet per year compared with eating the same product in 1993. The largest portion size growth found by the BHF researchers was a frozen chicken curry with rice, which was approximately 53% larger in 2013 compared with 1993. Conversely, the size of a standard bar of milk chocolate was slightly smaller in 2013 than it had been in 1993. However, overall, the BHF (2013) research suggested that most food portions had become significantly larger between 1993 and 2013, and that these larger portions were becoming normalised. The BHF researchers called for industry guidance that would enable standardisation of portion sizes, which would subsequently assist individuals to make informed dietary choices and reduce the burden of diet-related ill health (BHF 2013).
Even when people are not consuming food, they may be experiencing cravings for food. According to Wansink and Sobal (2007), people make more than 200 decisions about food each day. Various factors, such as ‘supersize’ or ‘all-you-can-eat’ servings in restaurants, and ‘buy-one-get-one-free’ promotions in supermarkets, can contribute to confusion concerning what constitutes a healthy portion size. As a result, many individuals find it challenging to estimate how much food they are actually consuming, particularly when eating out (Cook 2016).
There are several factors that can affect how much food an individual consumes; however, most adults underestimate their consumption (Block et al 2013). One Cochrane review of 72 RCTs concluded that people will consume more food if they are offered larger portion sizes than if they are offered smaller portion sizes (Hollands et al 2015). In addition, the researchers suggested that individuals will consume more food if they are offered it, irrespective of whether they are hungry. However, if a person regularly consumes larger portions, these become normalised, while smaller portions that were once deemed normal begin to appear inadequate (Hollands et al 2015).
An individual’s relationship with food is developed from an early age. For example, many people do not like to waste food because of messages reinforced throughout their childhood such as ‘finish what’s on your plate before you leave the table’. In addition, for many families, mealtimes themselves can be challenging, particularly in terms of encouraging children to eat unfamiliar nutritious food. Coercing children to eat healthily can be counterproductive, leading to mealtimes being associated with stress and tension (University of Rochester Medical Centre 2021).
One qualitative study by Macdiarmid et al (2013) examined the barriers to long-term dietary changes by asking 50 participants to consume a healthy diet for three days. Thematic analysis of the subsequent interviews identified participants’ misconceptions about healthy eating and their distorted views of portion sizes. For example, unhealthy or ‘junk’ food was regarded as representing improved value for money compared with healthier options. In addition, consuming a healthy diet that did not contain any ‘treats’ or ‘snacks’ such as chocolate was regarded as a challenge by many participants. Another barrier to healthy eating cited by participants was a lack of interest in cooking (Macdiarmid et al 2013).
de Ridder et al (2017) undertook a systematic literature review to examine peoples’ understanding of a healthy diet. The review findings suggested that people had a relatively low understanding of a healthy diet, while the protective benefits of healthy nutrients were also not well understood. The researchers also identified that educational interventions had a limited effect on people’s willingness to adopt a healthy diet.
One of the most significant barriers to long-term dietary change is the cost of food and the perception that healthier choices are more expensive than less healthy foods (Snow 2018). One study by Jones et al (2014) concluded that since 2002, healthy food and beverages had been consistently more expensive than less healthy options. The study calculated the price of 94 major food items between 2002 and 2012, considering their calorie and nutrient contents. The findings suggested that healthier foods were three times as expensive than less healthy foods. Jones et al (2014) concluded that these factors could affect people’s ability to adopt healthy lifestyles, as well as compounding health inequalities. While the Jones et al (2014) study did contribute to the knowledge base concerning food prices in the UK, there were limitations to the findings, such as the small range of foods and drinks included.
Another source of food that is perceived as cheap is takeaway meals. Takeaway websites and smartphone applications are easy to use and mean that food can be ordered conveniently and quickly. However, while takeaways represent a cheap and convenient alternative to cooking, they often exceed acceptable levels of salt and fat (NHS 2018). Brophy (2020) stated that people who follow a healthy diet are less likely to treat themselves to unhealthy food such as takeaways, and that some takeaway companies are investing in developing meals that offer improved options for health-conscious customers.
Adopting and maintaining a healthy lifestyle, particularly attempting to lose weight, can be complex and challenging. Obesity is a multifactorial condition, with genetic, biological, psychological, behavioural, familial, social, cultural, and environmental factors all influencing its development. Strategies to improve weight loss, maintain a healthy weight, and reduce the related comorbidities will typically integrate various options, including dietetic, nutritional, physical, behavioural and psychological interventions, and if necessary, pharmacological and surgical strategies (Castelnuovo et al 2017).
Nurses have a vital role in health promotion and education, one element of which is supporting individuals to engage in healthy eating behaviours using a range of interventions. These include opportunistic patient education using resources such as the Eatwell Guide (PHE 2016c), setting dietary targets, and providing ongoing support. However, according to Power (2018), elevated rates of obesity, unhealthy eating behaviours and low levels of physical exercise have also been found among nurses themselves. There are various workplace factors that may contribute to unhealthy lifestyles among nurses, including working long hours, regularly missing breaks and working in shift patterns, all of which can result in nurses not having enough time to eat healthily.
Nicholls et al (2017) identified that nurses’ workplace environment can have a significant influence on their unhealthy eating habits, which may contribute to increased levels of obesity. Power (2018) suggested that supporting nurses to improve their eating behaviours can have a positive effect on their health and may enhance their ability to care for patients. Healthcare organisations should seek to empower nurses with knowledge about how healthy food choices can improve their health, alongside recommending lifestyle changes such as adequate sleep, which together can decrease nurses’ risk of developing long-term conditions (Reed 2014).
Nurses have an important role in the prevention and treatment of obesity, but many lack confidence in their ability to manage patients who are obese or overweight (Zhu et al 2013). When seeking to educate patients on the benefits of healthy eating, nurses need to use a person-centred approach that involves developing rapport and demonstrating empathy, alongside shared decision-making. This requires nurses to use their clinical judgement as to how and when to raise the issue of weight and healthy eating with patients, and to use their communications skills to engage in an open discussion about weight in a non-judgemental and respectful manner (Brown 2016).
Another method of improving people’s diets is by identifying their unhealthy eating habits and replacing them with positive behaviours. For example, eating too fast is a common issue. It takes approximately 20 minutes from the time an individual starts to eat for the brain to send out signals that the stomach is full (Steen 2016).
Eating too fast can cause a person to miss this feeling of fullness, which can result in suboptimal digestion and overeating. Individuals who take time to chew their food experience improved digestion, and research has suggested that, on average, slower eaters have a smaller waist circumference and a lower body mass index compared with faster eaters (Hurst and Fukuda 2018)
Traditional methods of encouraging healthy eating include asking individuals to complete food diaries, count calories and weigh their food. These approaches are time-consuming and not always possible, particularly when food is frequently consumed at work for example, where there is no access to scales or other methods of measuring portion size (Gibson et al 2016). Therefore, nurses may consider that portion control provides a more practical method of encouraging individuals to eat healthily on a daily basis.
Innovative methods that nurses can use to support portion control include using the Eatwell Guide (PHE 2016c) as a tool to educate patients. Because the Eatwell Guide is split into the five main food groups, each with related portion guidance, this enables nurses to recommend the appropriate portion size in each food group.
Another technique that nurses can use to raise people’s portion awareness is to compare portion sizes to everyday objects, (Medline Plus 2021). For example, one serving of meat or poultry could be represented by a deck of cards; a half-cup (approximately 80g) of cooked rice, pasta or snacks such as crisps could be represented by a tennis ball; and two tablespoons of peanut butter could be represented by a ping-pong ball.
Nurses can also use the ‘hand-size method’ to educate people on appropriate portion size (Gibson et al 2016). This provides a flexible, practical and inexpensive method for visualising healthy portions without the need for scales or measuring devices. The hand-size method uses the physiology of the hand to represent portion size, for example one handful, half a handful, a cupped hand, a fist, thumb, or tip of the thumb. Figure 2 demonstrates the relationship between various food groups and the physiology of the hand.
While the accuracy of the hand-size method has not been fully tested, and using the hands as a guide is not an exact science, using hand-size portions may assist individuals in planning meals and controlling portion sizes. Gibson et al (2016) asserted that the hand-size method is portable, inexpensive and universal, as well as easier to understand than measures such as weighing food and calorie-counting (Gibson et al 2016).
The use of simple tools such as the hand-size method and the Eatwell Guide (PHE 2016c) may enhance the confidence of nurses in providing patient education on optimal nutrition.
Overall, it is important for nurses to be aware that the barriers to achieving a healthy diet are complex and that progress can be slow (Patience 2020). One review noted that between 1986 and 2012, the UK public’s adherence to dietary recommendations concerning the consumption of fruit and vegetables, salt, oily fish, and red and processed meat, was low to moderate, but had improved over time (Yau et al 2019). Further studies incorporating a wider range of foods and in specific population groups, such as younger and older people and those with lower education levels, will assist with future strategies for encouraging healthy eating across whole populations.
Obesity is a multifactorial condition, and the ability to adopt and maintain a healthy lifestyle and lose weight is complex, requiring various interventions and approaches. In the recent past, the number of individuals who are overweight or obese has risen significantly in the UK and worldwide, while portion sizes have also increased. Controlling food portion sizes can assist people to achieve and maintain a healthy weight; however, many individuals may not recognise what constitutes an appropriate amount of each food group to consume.
Nurses have a vital role in the management of obesity, working collaboratively with patients to promote healthy eating habits and assisting them in understanding that small changes in their diet, such as exercising portion control, can significantly improve their health and well-being.
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