Quality – eating more for less
Simply put, when losing weight a ‘kilojoule is a kilojoule’. However, a person would have to eat a lot more carrots than potato chips to consume 1000 kJ. An important aspect for sustainability of an eating plan is feeling satisfied. A useful approach is to encourage patients to think about kilojoules as if it were money – that is, to feel satisfied on an ‘energy budget’ they need to ‘spend’ their kilojoules wisely. By choosing healthier, less energy-dense foods such as vegetables, fruit, wholegrains, reduced fat dairy products and lean protein foods, patients can eat more for less kilojoules (Figure 3).20 This will also help to establish long-term healthy eating habits for optimal health.
Quantity – portion caution
Many patients may already have good nutritional knowledge and be eating a reasonably healthy diet. It is still possible to overeat, even on nutritious foods. The fact that larger portions have more energy may seem intuitive; however, most people tend to eat whatever they are served. In today’s society we have become accustomed to larger portions. To accommodate our larger portions, our bowls, plates and cups have also increased in size. A ‘normal’ portion is often much more than we actually need to eat.
Environmental factors impacting portion sizes are ubiquitous and can strongly influence the amount we eat or drink.21 Larger packaging and serve ware have been shown to unknowingly increase the amount served.22,23 As most people eat more when there is more in front of them, overserving leads to overeating. It is also not simply a matter of telling people that the bias exist, even nutrition experts – after being lectured extensively on the topic – still served themselves 56.8% more ice cream when given a larger bowl and larger spoon compared with those who were given a smaller bowl and smaller spoon.24 Reducing the size of serve ware will concurrently reduce portion size without necessitating vigilance and portion distortion can be used as an advantage (Figure 3).20
A healthy plate model using the Healthy Eating for Adults brochure can be a simple way to educate patients on appropriate types and proportions of foods to consume for main meals (see Figure 4 and Box 2 listing useful websites and online resources).
Patients should be encouraged to increase their daily physical activity. The goal is to achieve at least 150 to 300 minutes of moderate or 75 to 150 minutes of vigorous activity per week. Moderate activity is to a level that increases breath and heart rate above normal. Vigorous activity leads to harder breathing (i.e. puffing and panting) and substantially raised heart rate, depending on the level of fitness. People should find the activity somewhat hard or harder. It is also important to encourage patients to reduce their ‘inactivity’, in particular their sitting time, and to stand more. Research suggests that sedentary behaviour that is detrimental to a person is not just the lack of physical activity but also prolonged uninterrupted periods of sedentary time, which is associated with metabolic risk variables (including waist circumference, BMI, triglyceride level and two-hour plasma glucose level).25,26 Pedometers or smart phone applications may be useful to self-monitor activity and to set daily or weekly targets; these can be gradually increased. Patients should aim for 10,000 to 14,000 steps (depending on stride length) per day (or 10 km). Any increase in physical activity is good and should be encouraged, even if targets are not met immediately. A dose response occurs with greater activity, leading to increased health benefits, regardless of whether weight loss is achieved.27,28 Hydrotherapy and/or aqua aerobics are useful alternatives for people with osteoarthritis or those who experience pain on exercise. Referring the patient to an exercise physiologist may also be helpful. The most important factor is finding an activity that the patient enjoys and is likely to maintain in the longer term.