Diet

Short Text

This pathway covers interventions, programmes and strategies to encourage children and adults to have a healthy, balanced diet. The pathway also includes recommendations about dietary supplements for children and women before, during and after pregnancy.

Introduction

Having a healthy balanced diet helps prevent obesity, cardiovascular and many other conditions. This pathway covers recommendations for everyone about diet and lifestyle, and recommendations for health professionals on interventions to encourage people to follow a healthy diet. It is for mothers and children, particularly those from low-income households, and on weight management before and during pregnancy.
The pathway also includes NICE's recommendations on local and national strategy for diet to prevent cardiovascular disease, and recommendations for schools, and the leisure and weight management industries.
The pathway also includes recommendations about dietary supplements for children and women before, during and after pregnancy. It does not cover breastfeeding. Recommendations on breastfeeding are in the postnatal care pathway.
Align actions to improve diet with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see the obesity: working with local communities pathway).

Source guidance

The NICE guidance that was used to create the pathway.
Obesity. NICE clinical guidance 43 (2006)
Weight management before, during and after pregnancy. NICE public health guidance 27 (2010)
Prevention of cardiovascular disease. NICE public health guidance 25 (2010)
Maternal and child nutrition. NICE public health guidance 11 (2008)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Pathway information

Diet and obesity

Although body weight and weight gain are influenced by many factors, including people's genetic makeup and the environment in which they live, the individual decisions people make also affect whether they maintain a healthy weight.
A person needs to be in 'energy balance' to maintain a healthy weight – that is, their energy intake (from food) should not exceed the energy expended through everyday activities and exercise.
People tend to gain weight gradually, and may not notice this happening. Many people accept weight gain with age as inevitable but the main cause is gradual changes in their everyday lives, such as a tendency to being less active, or small changes to diet. People also often gain weight during particular stages of their life, such as during and after pregnancy, the menopause or while stopping smoking.
Small, sustained improvements to daily habits help people maintain a healthy weight and have wider health benefits – such as reducing the risk of coronary heart disease, type 2 diabetes and some cancers. But making changes can be difficult and is often hindered by conflicting advice on what changes to make.

Women and children from disadvantaged groups

Women from disadvantaged groups have a poorer diet and are less likely to take folic acid or other supplements than those who are better off. They are more likely to be overweight or show low weight gain during pregnancy and their babies are more likely to have a low birth weight.
Mothers from these groups are also less likely to breastfeed and more likely to introduce solid foods earlier than recommended. As a result of many of these factors, their children are more likely to be underweight as infants while also being more prone to obesity later in childhood.

Cardiovascular disease: a national framework for action

Cardiovascular disease (CVD) is a major public health problem. Changes in the risk factors can be brought about by intervening at the population and individual level. Government has addressed – and continues to address – the risk factors at both levels.
Interventions focused on changing an individual's behaviour are important. But changes at the population level could lead to further substantial benefits.
Population-level changes may be achieved in a number of ways but national or regional policy and legislation are particularly powerful levers.
The national framework would be established through policy, led by the Department of Health. It would involve government, government agencies, industry and key, non-governmental organisations working together.
The final decision on whether these policy options are adopted – and how they are prioritised – will be determined by government through normal political processes.

Local authorities and their partners in the community

Concerns about safety, transport links and services have a huge impact on people's ability to eat healthily and be physically active. Effective interventions often require multidisciplinary teams and the support of a range of organisations.

Schools

Improving diet and physical activity levels helps children develop a healthy lifestyle that will prevent them becoming overweight or obese in adulthood. Other benefits may include higher motivation and achievement at school, and better health in childhood and later life.

Workplaces

An organisation's policies and incentive schemes can help to create a culture that supports healthy eating and physical activity. Action will have an impact, not only on the health of the workforce but also in savings to industry.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Updates to this pathway

11 March 2014 Minor maintenance updates
20 January 2014 Minor maintenance updates
2 January 2014 Minor maintenance updates
17 December 2013 Minor maintenance updates
17 October 2013 Link to the NICE pathway on 'Obesity: working with local communities' added to this pathway.
30 August 2013 Minor maintenance updates
10 August 2012 Minor maintenance updates
25 May 2012 Minor maintenance updates
25 October 2011 Minor maintenance updates

Supporting information

Support for workplaces

Health professionals such as occupational health staff and public health practitioners should establish partnerships with local businesses and support the implementation of workplace programmes to prevent and manage obesity.

Changing behaviour

Evidence-based behaviour change advice includes:
  • understanding the short, medium and longer-term consequences of people's health-related behaviour
  • helping people to feel positive about the benefits of health-enhancing behaviours and changing their behaviours
  • recognising how people's social contexts and relationships may affect their behaviour
  • helping plan people's changes in terms of easy steps over time
  • identifying and planning situations that might undermine the changes people are trying to make and plan explicit 'if–then' coping strategies to prevent relapse.
For more information see the NICE pathway on behaviour change.

Glossary

Diet interventions and advice for adults

Dietary interventions and advice for adults

General principles

General principles

General principles

Interventions to improve diet (and reduce energy intake) should be multicomponent (for example, including dietary modification, targeted advice, family involvement and goal setting), be tailored to the individual and provide ongoing support.
Interventions may include promotional, awareness-raising activities, but these should be part of a long-term, multicomponent intervention rather than one-off activities (and should be accompanied by targeted follow-up with different population groups).
Health professionals should discuss weight, diet and activity with people at times when weight gain is more likely, such as during and after pregnancy, the menopause and while stopping smoking.

Source guidance

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Stopping smoking

Supporting people who are stopping smoking

Supporting people who are stopping smoking

All interventions to support smoking cessation should:
  • ensure people are given information on services that provide advice on prevention and management of obesity if appropriate
  • give people who are concerned about their weight general advice on long-term weight management, in particular encouraging increased physical activity.
See smoking cessation interventions in NICE's smoking pathway.

Source guidance

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Nutrition and pregnancy

Nutrition in pregnancy and while breastfeeding

Nutrition in pregnancy and while breastfeeding

Folic acidThis is part of a recommendation from Maternal and child nutrition (NICE public health guidance 11).

Health professionals should:
  • use any appropriate opportunity to advise women who may become pregnant that they can most easily reduce the risk of having a baby with a neural tube defect (for example, anencephaly and spina bifida) by taking folic acid supplements. Advise them to take 400 micrograms (µg) daily before pregnancy and throughout the first 12 weeks, even if they are already eating foods fortified with folic acid or rich in folate
  • advise all women who may become pregnant about a suitable folic acid supplement, such as the maternal Healthy Start vitamin supplements
  • encourage women to take folic acid supplements and to eat foods rich in folic acid (for example, fortified breakfast cereals and yeast extract) and to consume foods and drinks rich in folate (for example, peas and beans and orange juice).
PCTs should ensure local education initiatives aimed at health professionals include information on the importance of folic acid supplements. They should provide the maternal Healthy Start vitamin supplements (folic acid, vitamins C and D) for eligible women. They should also ensure women who are not eligible for Healthy Start can obtain the supplements from their local pharmacy.
GPs should prescribe 5 milligrams of folic acid a day for women who are planning a pregnancy, or are in the early stages of pregnancy, if they:
  • (or their partner) have a neural tube defect
  • have had a previous baby with a neural tube defect
  • (or their partner) have a family history of neural tube defects
  • have diabetes.

Vitamin D

During the booking appointment at the beginning of pregnancy, midwives should offer every woman information and advice on the benefits of taking a vitamin D supplement (10 micrograms [µg] per day) during pregnancy and while breastfeeding. They should explain that it will increase both the mother's and her baby's vitamin D stores and reduce the baby's risk of developing rickets.
Health professionals should take particular care to check that women at greatest risk of deficiency are following advice to take a vitamin D supplement during pregnancy and while breastfeeding. These include women who are obese, have limited skin exposure to sunlight or who are of South Asian, African, Caribbean or Middle Eastern descent.
Midwives and health visitors should advise all pregnant and breastfeeding women about the availability of suitable vitamin D supplements such as the Healthy Start vitamin supplements. Women who are not eligible for Healthy Start benefit can obtain the vitamin supplement from their local community pharmacy.

Healthy Start

Health professionals should advise pregnant women and parents of children under 4 years about the Healthy Start scheme. They should ensure all women who may be eligible receive an application form as early as possible in pregnancy.
Health professionals should use every opportunity they have to offer those parents who are eligible for the Healthy Start scheme practical, tailored information, support and advice on:
  • how to use Healthy Start vouchers to increase their fruit and vegetable intake.
Health professionals should offer the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D) to pregnant women who are (or who may be) eligible.
Community pharmacists should ensure the Healthy Start maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge.

Diet in pregnancyThis recommendation is from Maternal and child nutrition NICE public health guidance 11).

Early in pregnancy, discuss the woman's diet and eating habits and find out and address any concerns she may have about her diet.
Provide information on the benefits of a healthy diet and practical advice on how to eat healthily throughout pregnancy. This should be tailored to the woman's circumstances. The advice should include: eat five portions of fruit and vegetables a day and one portion of oily fish (for example, mackerel, sardines, pilchards, herring, trout or salmon) a week.

Diet for breastfeeding

Advise mothers that a healthy diet is important for everyone and that they do not need to modify their diet to breastfeed.
See also the NICE clinical guideline on hypertension in pregnancy, the pathway on diabetes in pregnancy, advice about diet and nutritional supplements in the antenatal care pathway, and lifestyle advice on diet and physical activity in this pathway.

Implementation tools

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Source guidance

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Diet and weight management

Diet and weight management

Advising on weight loss programmes

Self-help, commercial and community weight management programmes

Self-help, commercial and community weight management programmes

Best practice

Primary care organisations and local authorities should recommend to patients, or consider endorsing, self-help, commercial and community weight management programmes only if they follow best practiceBased on information from the British Dietetic Association Weight Wise Campaign; the advice on target weights is the opinion of the Clinical Management Guidance Development Group. by:
  • helping people assess their weight and decide on a realistic healthy target weight (people should usually aim to lose 5–10% of their original weight)
  • aiming for a maximum weekly weight loss of 0.5–1 kg
  • focusing on long-term lifestyle changes rather than a short-term, quick-fix approach
  • being multicomponent, addressing both diet and activity, and offering a variety of approaches
  • using a balanced, healthy-eating approach
  • recommending regular physical activity (particularly activities that can be part of daily life, such as brisk walking and gardening) and offering practical, safe advice about being more active
  • including some behaviour change techniques, such as keeping a diary and advice on how to cope with 'lapses' and 'high-risk' situations
  • recommending and/or providing ongoing support.

Advice and support from health professionals

Health professionals should discuss the range of weight management options with people who want to lose or maintain their weight, or are at risk of weight gain, and help them decide what best suits their circumstances and what they will be able to sustain in the long term.
General practices and other primary or secondary care settings recommending commercial, community and/or self-help weight management programmes should continue to monitor patients and provide support and care.
Health professionals should check that any commercial, community or self-help weight management programmes they recommend to patients meet the best-practice standards described above.

Implementation tools

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Source guidance

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Reducing calorie intake

Reducing calorie intake for adults who are obese

Reducing calorie intake for adults who are obese

Advice on diet and making changes

Dietary changes should be individualised, tailored to food preferences and allow for flexible approaches to reducing calorie intake.
Unduly restrictive and nutritionally unbalanced diets should not be used, because they are ineffective in the long term and can be harmful.
People should be encouraged to improve their diet even if they do not lose weight, because there can be other health benefits.
The main requirement of a dietary approach to weight loss is that total energy intake should be less than energy expenditure.
Diets that have a 600 kcal/day deficit (that is, they contain 600 kcal less than the person needs to stay the same weight) or that reduce calories by lowering the fat content (low-fat diets), in combination with expert support and intensive follow-up, are recommended for sustainable weight loss.
Low-calorie diets (1000–1600 kcal/day) may also be considered, but are less likely to be nutritionally complete.
Very-low-calorie diets (less than 1000 kcal/day) may be used for a maximum of 12 weeks continuously, or intermittently with a low calorie diet (for example for 2–4 days a week), by people who are obese and have reached a plateau in weight loss.
Any diet of less than 600 kcal/day should be used only under clinical supervision.
In the longer term, people should move towards eating a balanced diet, consistent with other healthy eating advice.
See also lifestyle in this pathway, and the obesity pathway.

Source guidance

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Pregnancy

Weight management before, during and after pregnancy

Advice for all women

Advice for all women

Advice for all women

Pregnant womenThis recommendation is from 'Weight management before, during and after pregnancy' (NICE public health guidance 27).

Context

If a pregnant woman is obese this will have a greater influence on her health and the health of her unborn child than the amount of weight she may gain during pregnancy. That is why it is important, when necessary, to help women lose weight before they become pregnant. Dieting during pregnancy is not recommended as it may harm the health of the unborn child. Many pregnant women ask health professionals for advice on what constitutes appropriate weight gain during pregnancy. However, there are no evidence-based UK guidelines on recommended weight-gain ranges during pregnancy. The amount of weight a woman may gain in pregnancy can vary a great deal. Only some of it is due to increased body fat – the unborn child, placenta, amniotic fluid and increases in maternal blood and fluid volume all contribute.

What action should be taken?

At the earliest opportunity, for example, during a pregnant woman's first visit to a health professional, discuss her eating habits and how physically active she is. Find out if she has any concerns about diet and the amount of physical activity she does and try to address them.
Advise that a healthy diet and being physically active will benefit both the woman and her unborn child during pregnancy and will also help her to achieve a healthy weight after giving birth. Advise her to seek information and advice on diet and activity from a reputable sourceReputable sources of information and advice about diet and physical activity for women before, during and after pregnancy include: 'The pregnancy book' (Department of Health (2009) The pregnancy book. London: Department of Health), 'Birth to five' (Department of Health (2009) Birth to five. London: Department of Health) and the 'Eat well' website. .
Offer practical and tailored information. This includes advice on how to use Healthy Start vouchers to increase the fruit and vegetable intakeThis is an edited extract from a recommendation that appears in 'Maternal and child nutrition' (NICE public health guidance 11). of those eligible for the Healthy Start scheme (women under 18 years and those who are receiving benefit payments).
Dispel any myths about what and how much to eat during pregnancy. For example, advise that there is no need to 'eat for two' or to drink full-fat milk. Explain that energy needs do not change in the first 6 months of pregnancy and increase only slightly in the last 3 months (and then only by around 200 calories per day).
Advise that moderate-intensity physical activity will not harm her or her unborn child. At least 30 minutes per day of moderate intensity activity is recommended.
Give specific and practical advice about being physically active during pregnancySee exercise in pregnancy.:
  • recreational exercise such as swimming or brisk walking and strength conditioning exercise is safe and beneficial
  • the aim of recreational exercise is to stay fit, rather than to reach peak fitness
  • if women have not exercised routinely they should begin with no more than 15 minutes of continuous exercise, three times per week, increasing gradually to daily 30-minute sessions'Obesity' (NICE clinical guideline 43) recommends adults should be encouraged to do at least 30 minutes of at least moderate-intensity physical activity on 5 or more days a week. The activity can be in one session or several lasting 10 minutes or more.
  • if women exercised regularly before pregnancy, they should be able to continue with no adverse effects.
Explain to those women who would find this level of physical activity difficult that it is important not to be sedentary, as far as possible. Encourage them to start walking and to build physical activity into daily life, for example, by taking the stairs instead of the lift, rather than sitting for long periods.
Measure weight and height at the first contact with the pregnant woman, being sensitive to any concerns she may have about her weight. If these data are not available at their first booking appointment, then the midwife should do this. Do not rely on self-reported measures of weight and height. Clearly explain why this information is needed and how it will be used to plan her care. Weigh her in light clothing using appropriate, calibrated weighing scales that are regularly checked. Calculate BMI by dividing weight (kg) by the square of height (m2), or use the BMI calculator after measuring and weighing. Use BMI percentile charts for pregnant women under 18 years, as a BMI measure alone does not take growth into account and is inappropriate for this age groupSee a BMI calculator for children and young people under 18..
Weight, height and BMI should be recorded in notes, the woman's hand-held record and the patient information system. If a hand-held record is not available, use local protocols to record this information.
Do not weigh women repeatedly during pregnancy as a matter of routine. Only weigh again if clinical management can be influenced or if nutrition is a concernThis is an edited extract from a recommendation that appears in 'Antenatal care' (NICE clinical guideline 62)..

Supporting women after childbirthThis is part of a recommendation from 'Weight management before, during and after pregnancy' (NICE public health guidance 27).

Use the 6–8-week postnatal check as an opportunity to discuss the woman's weight. Ask those who are overweight, obese or who have concerns about their weight if they would like any further advice and support now – or later. If they say they would like help later, they should be asked whether they would like to make an appointment within the next 6 months for advice and support.
During the 6–8-week postnatal check, or during the follow-up appointment within the next 6 months, provide clear, tailored, consistent, up-to-date and timely advice about how to lose weight safely after childbirth. Ensure women have a realistic expectation of the time it will take to lose weight gained during pregnancy. Discuss the benefits of a healthy diet and regular physical activity, acknowledging the woman's role within the family and how she can be supported by her partner and wider family. Advice on healthy eating and physical activity should be tailored to her circumstances. For example, it should take into account the demands of caring for a baby and any other children, how tired she is and any health problems she may have (such as pelvic floor muscle weakness or backache).
Health professionals should advise women, their partners and family to seek information and advice from a reputable source. Women who want support to lose weight should be given details of appropriate community-based services.
See also the physical activity pathway.

Source guidance

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BMI more than 30

Advice for women with a BMI of more than 30

Advice for women with a BMI of more than 30

Preparing for pregnancy: women with a BMI of 30 or moreThis is part of a recommendation from 'Weight management before, during and after pregnancy' (NICE public health guidance 27).

Health professionals should use any opportunity, as appropriate, to provide women with a BMI of 30 or more with information about the health benefits of losing weight before becoming pregnant (for themselves and the baby they may conceive). This should include information on the increased health risks their weight poses to themselves and would pose to their unborn child.
GPs, dietitians and other appropriately trained health professionals should advise, encourage and help women with a BMI of 30 or more to reduce weight before becoming pregnant. They should explain that losing 5–10% of their weight (a realistic target) would have significant health benefits and could increase their chances of becoming pregnant. Further weight loss, to achieve a BMI within the healthy range (between 24.9 and 18.5 kg/m2) should also be encouraged, using evidence-based behaviour change techniques. Losing weight to within this range may be difficult and women will need to be motivated and supported.
Health professionals should encourage women to check their weight and waist measurement periodically or, as a simple alternative, check the fit of their clothes.
Health professionals should offer a weightloss support programme involving diet and physical activity. The programme should follow the principles of good practice, as outlined in self-help, commercial and community weight management programmes in this pathway.
Health professionals should offer specific dietary advice in preparation for pregnancy, including the need to take daily folic acid supplements. This includes professionals working in pre-conception clinics, fertility clinics, sexual and reproductive health services and children's centres.
Explain to women with a booking appointment BMI of 30 or more how this poses a risk, both to their health and the health of the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy.
Offer women with a booking appointment BMI of 30 or more a referral to a dietitian or appropriately trained health professional for assessment and personalised advice on healthy eating and how to be physically active. Encourage them to lose weight after pregnancy.

Support for women with a BMI of 30 or more after childbirthThis recommendation is from 'Weight management before, during and after pregnancy' (NICE public health guidance 27).

Explain the increased risks that being obese poses to them and, if they become pregnant again, their unborn child. Encourage them to lose weight.
Offer a structured weight-loss programme. If more appropriate, offer a referral to a dietitian or an appropriately trained health professional. They will provide a personalised assessment, advice about diet and physical activity and advice on behaviour change strategies such as goal setting. Women who are not yet ready to lose weight should be provided with information about where they can get support when they are ready.
Use evidence-based behaviour change techniques to motivate and support women to lose weight.
Encourage breastfeeding and advise women that losing weight by eating healthily and taking regular exercise will not affect the quantity or quality of their milk.

Changing behaviour

Evidence-based behaviour change advice includes:
  • understanding the short, medium and longer-term consequences of people's health-related behaviour
  • helping people to feel positive about the benefits of health-enhancing behaviours and changing their behaviours
  • recognising how people's social contexts and relationships may affect their behaviour
  • helping plan people's changes in terms of easy steps over time
  • identifying and planning situations that might undermine the changes people are trying to make and plan explicit 'if–then' coping strategies to prevent relapse.
For more information see the NICE pathway on behaviour change.

Source guidance

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Paths in this pathway

Pathway created: May 2011 Last updated: March 2014

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