Fibre And Fibre Supplements

Fibre (roughage) is the part of plant food that is not digested. It stays in your gut and is passed in the stools (faeces). Fibre adds bulk to the stools. This helps your bowels to work well, and helps to prevent some bowel and anal conditions.



Why is fibre important?

Stools (faeces or motions) are usually soft and easy to pass if you eat enough fibre, and drink enough fluid. We should aim to eat 30-35 grams of fibre per day. (However, the average person in the UK eats only about 20 grams of fibre each day.) A diet with plenty of fibre will help to:
prevent constipation.
prevent diverticulosis (a common bowel condition).
prevent haemorrhoids (piles) and anal fissure (a painful condition of the anus).
reduce weight. Fibre is filling but not fattening as it has no calories and is not digested.
reduce the risk of developing bowel cancer.

High fibre foods include the following
Wholemeal or whole-wheat bread and biscuits.
Wholemeal flour used for baking and cooking.
Fruit and vegetables. Aim to eat at least five portions of a variety of fruit and vegetables each day. One portion is: one large fruit such as an apple, pear, banana, orange, or a large slice of melon or pineapple, OR; two smaller fruits such as plums, satsumas, etc, OR; one cup of small fruits such as grapes, strawberries, raspberries, cherries, etc, OR; two large tablespoons of fruit salad, stewed or canned fruit, OR; one tablespoon of dried fruit, OR; one glass of fresh fruit juice (150ml), OR; a normal portion of any vegetable (about two tablespoons), OR; one dessert bowl of salad.
Whole-grain breakfast cereals such as All Bran, Bran Flakes, Weetabix, Shredded Wheat, muesli, etc. A simple thing like changing your regular breakfast cereal can make a big difference to the amount of fibre you eat each day.
Brown rice, and wholemeal spaghetti and other wholemeal pasta.

Fibre supplements (sometimes called bulk-forming laxatives)

You may need to take extra fibre supplements if you have constipation or other bowel problems. Several are available. You can buy them at pharmacies or health food shops.
Unprocessed bran is a cheap fibre supplement. If you take bran, it is best to build up the amount gradually. Start with two teaspoons a day, and double the amount every five days until you reach about about 1-3 tablespoons per day. You can sprinkle bran on breakfast cereals, or mix it with fruit juices, milk, stews, soups, crumbles, pastries, scones, etc.
Other fibre supplements such as ispaghula husk, sterculia or methylcellulose are alternatives if you find bran unpalatable. Ispaghula husk is also gluten-free.


Note: have lots to drink when you eat a high fibre diet or fibre supplements. Drink at least two litres (about 8-10 cups) per day. You may find that if you eat more fibre or fibre supplements, you may have some bloating and wind at first. This is often temporary. As your gut becomes used to extra fibre or fibre supplements, the bloating or wind tends to settle over a few weeks.

Five Choices to Help You Stay Healthy

This leaflet gives a summary of five major choices that you can make to help you stay healthy. The main benefit of these lifestyle choices is that in the future you are less likely to develop heart disease, stroke, diabetes, liver problems, lung problems, and certain cancers.



What can I do to help stay healthy?

You should not smoke
If you smoke, stopping smoking is often the single most effective thing that you can do to reduce your risk of future illness. The risk to health falls rapidly as soon as you stop smoking (but takes a few years before the increased risk reduces completely). If you find it hard to stop smoking, then see your practice nurse for help. Medication may be advised to help you to stop.

Do some regular physical activity
Anything that gets you mildly out of breath and a little sweaty is fine. For example: jogging, heavy gardening, swimming, cycling, etc. A brisk walk each day is what many people do - and that is fine. However, it is thought that the more vigorous the activity, the better. To gain most benefit you should do at least 30 minutes of physical activity on most days. Two shorter bursts is thought to be just as good. For example, two 15 minute bouts of activity at different times in a day.

Eat a healthy diet
Briefly, a healthy diet means:
AT LEAST five portions, and ideally 7-9 portions, of a variety of fruit and vegetables per day.
THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables.
NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads.
INCLUDE 2-3 portions of fish per week. At least one of which should be 'oily' (such as herring, mackerel, sardines, kippers, pilchards, salmon, or fresh tuna).
If you eat meat it is best to eat lean meat, or poultry such as chicken.
If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.
Try not to add salt to food, and limit foods which are salty.

Try to lose weight if you are overweight or obese
You don't need to get to a perfect weight. If you are overweight you can gain great health benefits by losing 5-10% of your weight. This is often about 5-10 kg. (10 kg is about one and a half stone.)

Don't drink too much alcohol
A small amount of alcohol is usually fine, but too much can be harmful. Men should drink no more than 21 units per week (and no more than 4 units in any one day). Women should drink no more than 14 units per week (and no more than 3 units in any one day). One unit is in about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits.

Healthy Eating - A Summary

Eating healthily helps to prevent diseases such as heart disease, stroke, diabetes, obesity, certain gut disorders, and certain cancers. This leaflet gives a brief summary on healthy eating. There are other more detailed leaflets called 'Healthy Eating' and 'Eat More Fruit and Vegetables'.



Basic principles of a healthy diet

Eat plenty of starchy foods (complex carbohydrates)
The main part of most meals should be starchy foods such as bread, cereals, potatoes, rice, and pasta, together with fruit and vegetables. Some people wrongly think that starchy foods are 'fattening'. In fact, they contain about half the calories than the same weight of fat.

Eat at least five portions of a variety of fruit and vegetables each day
One portion is: one large fruit such as an apple, pear, banana, orange, or a large slice of melon or pineapple, OR; two smaller fruits such as plums, satsumas, etc, OR; one cup of small fruits such as grapes, strawberries, raspberries, cherries, etc, OR; two large tablespoons of fruit salad, stewed or canned fruit, OR; one tablespoon of dried fruit, OR; one glass of fresh fruit juice (150ml), OR; a normal portion of any vegetable (about two tablespoons), OR; one dessert bowl of salad.

Eat protein foods in moderation
Meat, fish, nuts, pulses, chicken, and similar foods are high in protein. You need some protein to keep healthy. However, most people eat more protein than is needed. Choose poultry such as chicken, or lean meat. Oily fish is thought to help protect against heart disease. For example, herring, sardines, mackerel, salmon, kippers, pilchards, and fresh tuna (not tinned tuna). Aim to eat at least two portions of fish per week, at least one of which should be oily.

Don't eat too much fat
Try not to fry much food. It is better to grill, bake, poach, barbecue, or boil food. If you do fry, use unsaturated oil such as corn, sunflower or olive oil. Drain off the oil before eating.
Choose lean cuts of meat, and cut off any excess fat.
Try not to add unnecessary fat to food. For example, use low fat spreads, spread less butter or margarine on bread, measure out small portions of oil for cooking, etc.
Watch out for hidden fats that are in pastries, chocolate, cakes, and biscuits.
Have low-fat milk, cheeses, yoghurts, and other dairy foods rather than full-fat varieties.
Avoid cream. Use low fat salad cream, or low-fat yoghurt as a cream substitute.

Don't have too many sugary foods and drinks
These are high in calories, and too much may cause weight gain (and they are bad for your teeth).

Try not to eat too much salt
Use small amounts of salt with cooking, and don't add more salt at the table.

Don't drink too much alcohol
A small amount of alcohol (1-2 units per day) may help to protect you from heart disease. One unit is about half a pint of normal strength beer, or two thirds of a glass of wine, or one pub measure of spirits. However, too much can be harmful. Men should drink no more than 21 units per week (and no more than four units in any one day). Women should drink no more than 14 units per week (and no more than three units in any one day).

A Low Fat and Healthy Diet

A diet that is generally low fat and healthy can help you to lose weight, or maintain your weight. It can also help to you to lower your cholesterol level.



Example of a diet sheet



Food Type


Foods that can be eaten regularly (little or no fat and/or 'healthy' foods)


Foods to be eaten in moderation


Foods to avoid or to eat rarely (high in fat and/or 'unhealthy' foods)



Cereal foods

Wholemeal flour and bread
Porridge oats
High fibre breakfast cereals
Wholegrain rice and pasta

White flour and bread
Low fibre breakfast cereals
White rice and pasta
Plain biscuits
Plain or fruit scones


Croissants
Fried bread
Most cakes and biscuits
Pastries
Suet pudding



Fruit, Veg and Nuts


All fresh and frozen vegetables and fruit
Dried beans and lentils
Baked potatoes
Dried fruit
Walnuts


Oven chips
Avocado pears
Olives
Almonds
Pecans
Hazelnuts


Chips
Fried or roast potatoes
Fried, creamed, buttered or cheesed vegetables
Crisps and potato snacks
Coconut
Brazils
Roasted peanuts



Fish


All white fish
Oily fish such as herring, mackerel, sardines, kippers, pilchards, or salmon (not tinned in oil)


Shellfish


Fishroe
Caviar



Meat


Lean white meat such as chicken and turkey breast (without skin)


Lean ham, beef, pork, and lamb
Lean mince
Liver and kidney


Visible fat on meat
Crackling
Sausages
Pates
Duck, goose
Meat pies/pasties



Eggs, Dairy Foods


Skimmed or semi-skimmed milk
Cottage or curd cheese
Low fat yoghurt
Egg whites


Edam
Camembert
Parmesan
Up to 3 egg yolks a week


Whole milk
Cream
Ice cream
Most hard cheeses
Chocolate
Cream cheese



Fats and Spreads


None


Low fat spreads
Margarine (high in polyunsaturates)
Corn, sunflower & olive oil


Butter
Dripping & Lard
Margarine not high in polyunsaturates



Drinks and Soups


Tea and Coffee
Mineral water
Fruit juices


Packet soups
Alcoholic drinks


Cream soups
Milky drinks
Sugary drinks



Low fat diets and weight loss or weight maintenance

The list of foods above is just a guide as to the best sort of foods to eat that in general contain less fat and calories 'weight for weight' or 'portion for portion'.

If you want to lose weight, you need to eat less calories per day than you have been eating (or do more exercise). In general, foods high in fat contain a lot of calories. However, there are other foods that contain a lot of calories. In particular, sweets and sugar do not contain fat, but are high in calories. Therefore, in addition to a low fat diet, you also have to watch out for other types of foods such as sweets and sugary foods.

There is a separate leaflet called 'Healthy Eating' for a more general overview of food and health, and a leaflet called 'Weight Reduction - How to Lose Weight' which gives advice if you are planning to lose weight.

More about fats

Not all fat is bad! Although all fats are high in calories, we need some fat in our diet, and some types of fat are actually good for our health. The different types of fat include the following.

Saturated fats
These are mainly found in the harder fats such as the fat on meat, lard, and the fat in dairy products such as butter, full cream milk, etc. There are also fats called 'Trans Fats' (Hydrogenated Vegetable Oils). These are oils which come from vegetables but have been processed to make them hard and similar to saturated fats. They are often used in processed foods, and in commercially made cakes, biscuits and pastries.

We should try to limit our intake of saturated fats and trans fats as they contribute to weight gain and a raised cholesterol level.

Unsaturated fats
These mainly come from vegetables, nuts and fruits. They are divided into:
Polyunsaturated fats such as sunflower oil, and corn oil.
Monounsaturated fats such as olive oil and rapeseed oil.
Omega 3 fatty acids. These come mainly from oily fish such as pilchards, sardines, salmon mackerel and fresh (not tinned) tuna. Some omega 3 fatty acids are found in various plant foods and vegetable oils.

Unsaturated fats are 'good fats' as they are less likely to raise your cholesterol level. Omega 3 fatty acids are also thought to help prevent heart disease and may help to improve our health in other ways. There is a separate leaflet called 'Cholesterol' which gives more details about reducing your cholesterol level.

Food labels

Foods that contain fat often contain a mixture of saturated and unsaturated fats. Food labels often list the amounts of each type of fat in the food (or at least how much of the fat in the food is saturated). As a rule, we should aim to limit our intake of saturated fats, and when we use fats and oils, to mainly choose those high in unsaturates. Food labels also show how many calories are in the food. So, it may be a good idea to get into the habit of reading food labels when you shop.

Healthy Eating

A healthy diet helps to prevent, or reduce the severity of, diseases such as heart disease, stroke and diabetes. A healthy diet may also help to reduce the risk of developing some cancers. Also, a main way of combating obesity and overweight is to eat a healthy diet. This leaflet gives the principles of a healthy diet.


Eat plenty of starchy foods (complex carbohydrates)

Starchy foods such as bread, cereals, potatoes, rice, and pasta, together with fruit and vegetables, should provide the bulk of most meals. Some people wrongly think that starchy foods are 'fattening'. In fact, they contain about half the calories than the same weight of fat. (However, it is easy to add fat to some starchy foods. For example, by adding butter to jacket potatoes or bread, or by adding oil to potatoes to make chips, etc.)

Also, starchy foods often contain a lot of fibre (roughage). When you eat starchy foods, you get a feeling of fullness (satiety) which helps to control appetite. Tips to increase starchy foods include:
For most meals, include generous portions of rice, pasta, baked potatoes, or bread.
For more fibre, choose wholemeal bread. When baking, use at least 1/3 wholemeal flour.
If you have cereals for breakfast, choose porridge, high fibre cereals, or wholemeal cereals (without sugar coating).
Have tea breads, and plain or fruit scones, instead of sugary cakes and biscuits.
Eat plenty of fruit and vegetables

Is is recommended that we eat at least five portions, and ideally 7-9 portions, of a variety of fruit or vegetables each day. If you eat a lot of 'fruit and veg', then your chance of developing heart disease, a stroke, or bowel cancer are reduced. In addition, 'fruit and veg':
contain lots of fibre which help to keep your bowels healthy. Problems such as constipation and diverticular disease are less likely to develop.
contain plenty of vitamins and minerals, which are needed to keep you healthy.
are naturally low in fat.
are filling but are low in calories.
One portion of fruit or vegetables is roughly equivalent to one of the following.
One large fruit such as an apple, pear, banana, orange, or a large slice of melon or pineapple.
Two smaller fruits such as plums, kiwis, satsumas, clementines, etc.
One cup of small fruits such as grapes, strawberries, raspberries, cherries, etc.
Two large tablespoons of fruit salad, stewed or canned fruit in natural juices.
One tablespoon of dried fruit.
One glass of fresh fruit juice (150ml).
A normal portion of any vegetable (about two tablespoons).
One dessert bowl of salad.
Some tips on how to increase fruit and vegetables in your diet include:
Try some different types which you have not tried before. The variety of tastes and textures may be surprising. Juices, frozen, canned, and dried varieties all count.
Try adding chopped bananas, apples, or other fruits to breakfast cereals.
Aim to include at least two different vegetables with most main meals. Do not over-boil vegetables. Steaming, stir-frying, or lightly boiling are best to retain the nutrients.
Always offer fruit or fruit juice to accompany meals.
Try new recipes which include fruit. For example, some curries or stews include fruit such as dried apricots. Have fruit based puddings. Fruit with yoghurt is a common favourite.
How about cherry tomatoes, carrot sticks, dried apricots, or other fruits as part of packed lunches? A banana sandwich is another idea for lunch.
Fruit is great for snacks. Encourage children to snack with fruit rather than with sweets.

Eat plenty of fibre (roughage)

Fibre is the part of food that is not digested. It is filling, but has few calories. It helps the bowels to move regularly, which reduces constipation and other bowel problems. Fibre may also help to lower your cholesterol level. Starchy foods, and fruit and vegetables contain the most fibre. So the tips above on starchy foods and fruit and vegetables will also increase fibre. Have plenty to drink when you eat a high fibre diet (at least 6-8 cups of fluid a day).

Eat protein foods in moderation

Meat, fish, nuts, pulses, chicken, and similar foods are high in protein. You need a certain amount of protein to keep healthy. However, most people eat more protein than is necessary. Beware, some meats are also high in fat. Choose poultry such as chicken, or lean meat. Also, many meat based recipes include creamy or fatty sauces which are high in calories.

Fish. There is some evidence that eating oily fish helps to protect against heart disease. Oily fish include: herring, sardines, mackerel, salmon, fresh tuna (not tinned), kippers, pilchards, trout, whitebait, anchovies and swordfish. It is probably the 'omega-3 fatty acids' in the fish oil that helps to reduce the build up of atheroma (furring of the arteries) which causes angina and heart attacks. Aim to eat at least two portions of fish per week, one of which should be oily.

Do not eat too much fat

A low-fat diet helps to reduce the chance of developing diseases such as heart disease and stroke. It will also help you to reduce weight. The total amount of fat should be low. Also, the type of fat is important. You should not have much saturated fats such as butter, lard, dripping, and unspecified margarine. Unsaturated fats are better such as corn oil, sunflower oil, olive oil, and low fat spreads. Tips to reduce fat in your diet include the following.
Whenever possible, do not fry food. It is better to grill, bake, poach, barbecue, or boil food. If you do fry, use unsaturated oil. Drain the oil off the food before eating.
Choose lean cuts of meat, and cut off any excess fat.
Avoid adding unnecessary fat to food. For example, use low fat spreads, spread less butter or margarine on bread, measure out small portions of oil for cooking, etc.
Watch out for hidden fats that are in pastries, chocolate, cakes, and biscuits.
Have low-fat milk, cheeses, yoghurts, and other dairy foods rather than full-fat varieties.
Avoid cream. Use low fat salad cream, or low-fat yoghurt as a cream substitute.
Do not have too many sugary foods and drinks

Sugary foods and drinks are high in calories, and too much may cause weight gain. It isn't just the amount of sugar that may be bad. Eating small amounts of sugary foods (sweets etc) too often is bad for teeth. Tips include:
Try not to add sugar to tea, coffee, and breakfast cereals. Your taste for sweetness often changes with time. Use artificial sweeteners only if necessary.
Reduce sugar in any kind of recipe. Use fruit as an alternative to add sweetness to recipes.
Try sugar-free drinks. Give children water as their main drink.
If you eat chocolate or sweets, try and keep the quantity down. Eating them as part of a meal, and then brushing your teeth, is better than between meals as snacks.
Do not eat too much salt

Too much salt increases the risk of developing high blood pressure. Government guidelines recommend that we should have no more than 5-6 grams of salt per day. (Most people in the UK currently have more than this.) If you are used to a lot of salt, try to gradually reduce the amount that you have. Your taste for salt will eventually change. Tips on how to reduce salt include:
Use herbs and spices to flavour food rather than salt.
Limit the amount of salt used in cooking, and do not add salt to food at the table.
Choose foods labelled 'no added salt'.
As much as possible, avoid processed foods, salt-rich sauces, take-aways, and packet soups which are often high in salt.
Keep alcohol within the recommended limits

There is some evidence that drinking 1-2 units of alcohol per day may help to protect against heart disease. But, drinking above the recommended limits can lead to serious problems. For example, drinking heavily can damage the liver, brain, stomach, pancreas, and heart. It can also cause high blood pressure. Also, alcohol contains a lot of calories, and too much can cause weight gain.
Men should drink no more than 21 units of alcohol per week (and no more than four units in any one day).
Women should drink no more than 14 units of alcohol per week (and no more than three units in any one day).
Pregnant women - the amount that is safe is not known, so many women have little or no alcohol when they are pregnant.
What is a unit of alcohol?
One unit of alcohol is 10 ml (1 cl) by volume, or 8 g by weight, of pure alcohol. For example:

One unit of alcohol is about equal to:
Half a pint of ordinary strength beer, lager, or cider (3–4% alcohol by volume), or
A small pub measure (25 ml) of spirits (40% alcohol by volume), or
A standard pub measure (50 ml) of fortified wine such as sherry or port (20% alcohol by volume).
There are one and a half units of alcohol in:
A small glass (125 ml) of ordinary strength wine (12% alcohol by volume), or
A standard pub measure (35 ml) of spirits (40% alcohol by volume).

Eat More Fruit and Vegetables

Healthy eating includes eating at least five portions, and ideally 7-9 portions, of a variety of fruit or vegetables each day. Fruit and vegetables include fresh, frozen, tinned, or dried varieties, and fruit juice. On average, people who eat lots of 'fruit and veg' tend to be healthier and live longer.



What are the health benefits if I eat enough fruit and vegetables?
You have a lower chance of developing cardiovascular diseases due atheroma ('hardening of the arteries'). For example, heart disease, peripheral vascular disease, or a stroke.
You have a lower chance of developing some cancers such as bowel and lung cancer.
Fruit and vegetables also:
contain lots of fibre which help to keep your bowels healthy. Problems such as constipation and diverticular disease are less likely to develop.
contain plenty of vitamins and minerals, which are needed to keep you healthy.
are naturally low in fat.
are filling but are low in calories. So, are ideal to keep your weight in control.

One study showed that, for people of the same age, there were about a quarter less deaths in those who ate lots of fruit and vegetables compared to those who did not. This was mainly due to a reduction from three common causes of death in the UK - heart disease, stroke, and cancer.

How do fruit and vegetables prevent illness?

They are rich in vitamins and minerals which keep the body healthy. They also contain chemicals called 'anti-oxidants', such as carotene, which are thought to protect against damaging chemicals that get into the body. However, the exact way in which they prevent illness is not fully understood.
One portion of fruit or vegetables is roughly equivalent to:
One large fruit such as an apple, pear, banana, orange, or a large slice of melon, or
Two smaller fruits such as plums, kiwis, satsumas, clementines, etc, or
One cup of small fruits such as grapes, strawberries, raspberries, cherries, etc, or
Two large tablespoons of fruit salad, stewed or canned fruit, or
One tablespoon of dried fruit, or
One glass of fresh fruit juice (150ml), or
A normal portion of any vegetable (about two tablespoons), or
One dessert bowl of salad.
Some tips on how to increase fruit and vegetables in your diet
Try some different types which you have not tried before. The variety of tastes and textures may be surprising. Juices, frozen, canned, and dried varieties all count.
Try adding chopped bananas, apples, or other fruits to breakfast cereals.
Aim to include at least two different vegetables with most main meals. Do not over-boil vegetables. Steaming, stir-frying, or lightly boiling are best to retain the nutrients.
Always offer fruit or fruit juice to accompany meals.
How about cherry tomatoes, carrot sticks, dried apricots, or other fruits as part of packed lunches? A banana sandwich is another idea for lunch.
Fruit is great for snacks. Encourage children to snack with fruit rather than with sweets

Bariatric surgery

surgery for severe, refractory obesity

The risks of severe obesity are well known. Helping patients to lose weight is never easy but surgery must be regarded as a last resort. NICE accepts that it has a place and evidence grows of its potential value as part of a treatment plan. Long term follow-up and personal discipline are still needed.

Epidemiology: A BMI between 25 and 30 is defined as overweight, over 30 is obese and a BMI over 40 is defined as morbidly obese. A person with a BMI of between 40 and 50 weighs literally twice their ideal weight.
According to NICE,1 in 1998, an estimated 0.6% of men and 1.9% of women in England and Wales had a BMI of 40 or more. This represents 124,000 men and 412,700 women or 2500 people for a typical primary care trust population of 200,000. The prevalence of obesity is rising as the average BMI increases. Between 1994 and 1998 the average BMI increased by 0.44 for men and 0.57 for women.
In the USA the figure for morbid obesity in 20004 was given as 5% of the total population.2
In recent years much publicity has been given to the very real and serious and rapidly growing problem of childhood obesity.
In 2002 there were around 200 such operations performed in the UK annually and many were privately funded.

Risk factors: Risks are well known and many are listed by NICE.1 Obesity carries an increased morbidity and mortality. Risk rises for cardiovascular disease, hypertension, type 2 diabetes, various cancers, musculo-skeletal disease, reproductive disorders and respiratory disorders. Metabolic syndrome X and polycystic ovary syndrome have cardiovascular and other risks. In the young we are seeing type 2 diabetes in adolescence, called MODY ( maturity onset diabetes in the young). In addition, people with a BMI greater than 35 have a rate of mortality at any given age double that of someone with a healthy BMI of 20 to 25. Obesity decreases quality of life. The social stigma attached to obesity produces prejudice and discrimination. It adversely affects mobility, employment and psychosocial wellbeing, with many obese people left feeling depressed, defensive and unable to live life to the full.

Morbid obesity occurs when the intake of calories substantially exceeds expenditure over a long period of time and patients who complain that, "I scarcely eat enough to keep a sparrow alive," are still in denial, not facing reality and not likely to benefit from any intervention.

Criteria for treatment: NICE1 recommend that such treatment may be offered if the patient fulfils all the following criteria:
this type of surgery should be considered only for people who have been receiving intensive management in a specialised hospital obesity clinic
individuals should be aged 18 years or over
there should be evidence that all appropriate and available non-surgical measures have been adequately tried but have failed to maintain weight loss
there should be no specific clinical or psychological contra-indications to this type of surgery
individuals should be generally fit for anaesthesia and surgery
individuals should understand the need for long-term follow-up.

Surgery should normally be reserved for those with a BMI of 40 or more but NICE accept that it may be offered to those with a BMI in excess of 35 if they have associated morbidities that may benefit from weight reduction.

Operations: A number of operations have been devised over the years and modifications have been made. This diversity is one complicating factor when trying to analyse the evidence. Criteria for acceptance or rejection for operation vary. Another problem is that the surgery is just one of many components of the management plan. A PubMed search for "bariatric surgery systematic review" yielded over 100 references published in 2005 alone. It is valid to ask why the world needs so many systematic reviews and the answer would seem to lie in the interpretation of the data.
Surgical procedures can be divided into categories:
Malabsorptive surgery bypasses parts of the gastrointestinal tract to limit the absorption of food.
Restrictive surgery reduces the size of the stomach so the feeling of fullness occurs with less food. Malabsorptive procedures include jejunoileal bypass, gastric bypass and biliopancreatic diversion, while restrictive procedures include gastroplasty and gastric banding. There is an increasing trend towards using laparoscopic rather than open techniques.
Endoscopic placement of something in the stomach. This tends to be a shorter procedure, requiring sedation rather than general anaesthesia.

Pre-operative assessment: Careful assessment is essential. Motivation is mandatory and yet failure to loose weight before operation should not be seen as a reason to refuse surgery. The patient must see it as an aid to dietary control rather than a magical cure or yet another hurdle to stumble over and deny any personal responsibility. "I even had an operation but it didn't work."
Morbidity and mortality can be reduced by careful selection of patients but it may be those most at risk who are most at need.

Operative risk: Postoperative care is vital. It includes managing complications as they occur but also dietary and possibly psychological advice to help modify eating habits. There may be complications such as vomiting, dumping syndrome and diarrhoea, especially after malabsorptive procedures.
People who are so grossly obese are at increased risk of almost every possible risk after surgery including chest infection, urinary tract infection, deep vein thrombosis and pulmonary embolism, wound infection and dehiscence. These can probably be reduced by laparoscopic techniques but this is not easy with such gross obesity and laparoscopic surgery may take rather longer, increasing risk associated with time on the operating table. Clinical Evidence states that complications are common but the risk of death is 0 to 1.5%.3 Perioperative complications were common, including: subphrenic abscess (7%), atelectasis or pneumonia (4%), wound infection (4%), and pulmonary symptoms (6.2%).

Benefits of surgery: As mentioned previously, surgery is just a part of management and so it is inappropriate to call comparisons medical versus surgical treatment. With so many reviews it is difficult to know where to turn but Clinical Evidence3 found that, by and large, surgery produced better weight loss and that it was sustained for longer compared with very low calorie diets alone.
The same team from Clinical Evidence compared laparoscopic with open surgery.4 They found consistent evidence that laparoscopic surgery reduced the incidence of wound and incisional hernia complications compared with open surgery but numbers were too small to compare other complications. There was no difference in resultant weight loss.
Another systematic review and meta-analysis concluded that effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery and that a substantial majority of patients with diabetes, hyperlipidaemia, hypertension, and obstructive sleep apnoea obtained complete resolution or improvement.2
NICE summed up the problems of poor evidence with recommendations for further research with the words, with few exceptions, studies of surgery for obesity have been uncontrolled and short-term with no comparators. Carefully planned and executed randomised controlled trials comparing obesity therapies with the best alternative modern treatments and with currently standard non-surgical treatment are required and should be started soon. Randomised controlled trials are required to compare different surgical techniques with regard to effectiveness, costs and quality of life of patients in both the short and long term.

Surgery in the young: Health promotion for children and adolescents is obviously failing as obesity becomes an epidemic, even in the young. NICE give 18 as a threshold for surgical intervention. In the young, dietary modification, exercise programmes and cognitive and behavioural therapy remain the basis of management but a considered paper from Australia concludes that Bariatric surgery may be indicated in carefully selected, older, severely obese adolescents.5

Implantable gastric balloon: The Bioenterics gastric balloon is placed in the stomach at endoscopy and it is inflated to give a feeling of fullness. The procedure takes 10 to 20 minutes and so is shorter and safer than surgery. An Italian double blind crossover trial in which patients were on a 1,000 calories diet but also had a balloon placed that was either inflated to 500ml or not showed significantly greater weight loss when the balloon was inflated.6

Implantable gastric stimulation: Antral gastric stimulation was first used experimentally to reduce spontaneous feeding in pigs7 but after 10 years of clinical use it was reported to have achieved significant weight loss without side-effects, with improvement of insulin sensitivity and with reduction of gastro-oesophageal reflux.8 The physiological mechanism is poorly understood and the technique is in its infancy to the extent that much of the literature still relates to animal experiments. It does seem that this technique offers much promise for both obesity and gastroparesis.9 The technique may be more acceptable in young people but it must have appeal to all ages. However, it is not a substitute for diet, exercise, and behavioural change.10

Economic implications: NICE does not shy away from financial costs.1 Obesity has considerable costs for society, both direct, in terms of healthcare, and indirect, in terms of earnings lost through mortality or sickness. Direct costs of obesity in England in 1998 have been estimated at £480 million, or 1.5% of NHS expenditure, and indirect costs at £2.1 billion. NICE found 4 papers about cost-effectiveness of such procedures but all had flaws. Modeling for projections relating to the NHS were based on many assumptions. They thought that 600,000 people have a BMI over 40 but that number again may have a BMI over 35 plus a related morbidity and this 1.2 million could grow by 5% per year. Previous studies suggesting take up of operations at between 2 and 4% of this group may be an underestimate for the NHS. Cost are around £5,500 per procedure, over and above the cost of other continuing care. Capacity will have to rise sharply to meet demand and costs could rise from £1.7 million in the first year to £27 million after 8 years. These calculations are based on very rough guesses about uptake and assuming that other, cheaper techniques, such as the endoscopic placement of balloons or pacers, are not used.

Obesity Management in Adults

The management of obesity has several facets:
The prevention of obesity
The correction of obesity
The population based approach
The individual approach.

Prevention is better than cure and rather easier. The population based approach is very important but the doctor in his surgery will have to cope with the individual, and so this will be the thrust of this article.
Basic Principles
It is an irrefutable fact that if energy intake exceeds energy expenditure then weight will be gained. If the two are in equilibrium weight will be static and the only way to loose weight is for energy intake to be less than energy expenditure. A small but consistent excess of intake over expenditure will summate to a large gain in weight over the years.
Intake is not the only variable and it is possible to vary expenditure too.
There is no quick fix. Loosing weight is a long and arduous task. The World Health Organisation sees obesity as a chronic disease. Management is not simply helping to shed some unwanted weight but a long-term approach to change attitude, habits and values for the rest of that person's life.
Presentation
A patient may present directly asking for help.
Confrontation of the problem may arise opportunistically when the patient presents for something else.
It may be a related problem for the patient with diabetes, coronary heart disease, osteoarthritis or snoring.

Urine should be tested for glucose unless the patient is already known to be diabetic or there has been a recent negative test. Fasting blood lipids and glucose may also be required. Otherwise, there is little indication for investigation unless directed by history or examination and routine assessment of thyroid function is unlikely to be rewarding.

The majority of obese patients can be managed successfully by the Primary Health Care team with only a very few requiring referral for specialist help.

The following groups are particularly in need of help and advice:
Obesity treatment or advice should be offered to:

Patients with a BMI >30
Patients with a BMI >28 and co-morbidities such as COPD,ischaemic heart disease and diabetes.
Patients who are overweight and have diabetes, other severe risk factors or serious disease.
Patients who appropriately self refer.
Parents of families with more than one obese member. This group may need special consideration and more intensive support.
Prevention advice should be offered to high risk individuals e.g. those with a family history of obesity, smokers, people with learning disabilities, low income groups.
Table adapted from National Obesity Forum Guidelines1


Aims of Management

The following should be included in a plan of action:
Identify the causes that have made the person obese. There are probably several contributory factors.
Reiterate why the patient wants to lose weight to emphasise potential benefits and incentives and perhaps to ascertain the degree of motivation.
Examine what can be done to facilitate weight loss (e.g exercise programme).
Set realistic targets for rate of loss of weight and desired end point. For a person who has a BMI above 35, the aim of a BMI of less than 25 is probably unrealistic.

Consider cognitive and behavioural therapy to assist in behaviour modification - i.e. help the patient to identify the wrong attitudes and actions in their lives, understand why they are wrong and need to be rectified, identify correct responses and to implement them. There may be "comfort eating" or even clinical depression that needs treatment.

Many practices offer weight management clinics but this is not the only source of help. Some people may prefer to attend Weight Watchers or similar groups.

Aim for both dietary modification and the initiation of exercise. Losing weight without exercise is very difficult. This is one reason for early intervention, before exercise is severely limited by morbid obesity, coronary heart disease, severe COPD, severe osteoarthritis or other such diseases that prevent physical exertion.
Dietary Modification
Cognition

The first problem may be to convince the patient that he is eating too much. Patients may be adamant they "don't eat enough to keep a sparrow alive". Whilst this may conjure up an amusing picture of an extremely wide sparrow with bowed legs trying to get airborne, it is important to explain to the patient that the equation about calories in and calories out has no exception and the presence of so much surplus fat is testament to a substantial excess of calories over the years. It may be helpful to ask the patient to keep a food diary, including all snacks taken during the day.
Dietary History

The food diary will be over perhaps a week and will reflect a typical day's intake. Do not forget snacks, sweets and treats. Do not forget drinks, whether tea or coffee that may contain sugar or alcoholic drinks. There may be obvious targets for modification. Replace sugar by sweeteners or try to do without them. Use skimmed rather than full fat milk. Perhaps alcohol should be reduced rather than banned as it may represent an important quality of life issue. Alcohol is very high in calories and suppresses blood glucose levels and so can enhance appetite.
Diets

There are many different approaches to dieting and it is important to be flexible to find the one that suits the individual. It is very unpleasant being hungry and rather than just cutting back on all food, it may be easier to move to a diet with less fat and more fibre in it. Counting calories requires obsession and may be counterproductive by making the person more fixated on food than ever. Magazines and the Internet advertise easy ways to lose weight but if there were an easy way, we would all use it. Losing weight is hard and takes tenacity. Herbal and "natural" wonders are also to be avoided as are diets promoted by "celebrities".

Beware of the heartsink patient who wants to tell you how "utterly useless" are all the diets he or she has tried. He is trying to deflect responsibility for his failure away from himself, on to the "failed" diet.

There may be occasions where there is benefit in referral to a dietician. However, if more than a tiny fraction of obese people within the catchment area are referred, it would swamp the service. The practice may have diet sheets to hand out. A simple couple of pages of advice is available online from the Norfolk and Norwich University Hospital.2
Times of Meals

Those who advise about diet almost invariably counsel that breakfast is the most important meal of the day and those who do not have breakfast should introduce it. Eating late at night is bad as the food rapidly turns to fat. This may be true but the evidence for these assertions is limited at best.
Exercise

People who are obese may have done no exercise for many years. It is important to discuss the options to find something appropriate and sustainable. The age and current level of fitness of the individual must be taken into account. It must also be something that the individual will enjoy or he will not persevere. This is very important as the ethos of exercise is not just for the duration of weight loss, that is a very long process, but for life.
Realistic Expectation

Discuss options and expectations. An overambitious programme is doomed to failure. A programme that is so unambitious that it is pathetically inadequate will confer no benefit. The article on physical training discusses a number of issues related to weight loss, including the concept of the "fat burning zone".
Insulin Suppression

Insulin is highly "anti-lipolytic". This means that it strongly opposes the breakdown of fat. Exercise must be of such duration and intensity to facilitate suppression of insulin levels. People with type 2 diabetes or impaired glucose tolerance, have insensitivity to insulin and basal levels are high. However, this insensitivity includes being less sensitive to its anti-lipolytic actions, so that diabetics are still able to exercise, suppress insulin levels and burn fat.
Expert Advice

Expert advice is that patients should be encouraged to take 30 to 40 minutes of sustained exercise at least 5 times per week3 and introduce more exercise into their daily routine. The initial aim should be towards a daily 500 Kcal deficit of energy requirements through change in dietary habits and exercise. 4 Encouragement and support should be given to the patient from the Primary Care Team and regular follow up offered. Ideally a 10% weight loss should be achieved to gain significant health benefits,1 but realistic targets should be tailored to each individual.
Diet and Exercise

The value of exercise is more than just the calories expended in the session. It tends to increase basal metabolic rate and after vigorous exercise, metabolism is stimulated for the next 36 hours. It also helps people to feel good about themselves. When people start to diet, weight often falls away quite fast at first but the rate of loss then tails away, causing dismay. When people start exercise, weight loss may be slow and disheartening at first as muscle is built, and with it bone for a stronger skeleton. Hence, weight being static may represent fat being replaced by muscle. Not only is muscle more aesthetically satisfying than surplus fat, it is much healthier in terms of improving mobility and preventing falls and it has a much higher basal metabolic rate. Reducing body fat content may improve such parameters as lipid profiles. Exercise will also help and a better diet.
Drugs

See drug management of obesity.
Drug therapy should not be used from the outset. It is an adjunct and not a substitute for either diet or exercise. Sibutramine5 and orlistat.6 have been reviewed by NICE, who also outline the limited indications for prescription.7

How can I lose weight?

Motivation is crucial
No weight-loss plan will work unless you have a serious desire to lose weight. You may not feel that being overweight or obese is a problem to you, and have little motivation or desire to lose weight. That is fine, so long as you understand the health risks.

Current food intake
It is helpful to know exactly how much you currently eat. An estimate is often inaccurate. Therefore, a detailed diary of every amount of food and drink that you have over an average week is more helpful. You can discuss this with a nurse or dietician. The number of calories that you eat in a typical week can then be calculated. The simple fact is that, to lose weight, you must eat less than your current food intake.

Eat a healthy balanced diet
Another leaflet in this series called 'Healthy Eating' gives more details. Briefly a healthy diet means:
AT LEAST five portions of a variety of fruit and vegetables per day.
THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables.
NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads.
INCLUDE 2-3 portions of fish per week. At least one of which should be 'oily' (such as herring, mackerel, sardines, kippers, pilchards, salmon, or fresh tuna).
If you eat meat it is best to eat lean meat, or poultry such as chicken.
If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.
Try not to add salt to food, and avoid foods that are salty.

It is best to eat three healthy meals each day, including breakfast. Eat each meal slowly. Don't skip meals. Skipping meals will just make you feel more hungry, make you think more about food, and you are more likely to overeat in the evening. Do not snack between meals. Cut back on alcohol if you drink a lot.

Physical actvity
If you are able, aim to do at least 60-90 minutes of moderate physical activity on at least five days a week. (All adults should aim for at least 30 minutes on five days a week. However, 60-90 minutes is recommended if you are overweight or obese and are aiming to lose weight.) Moderate physical activity includes: brisk walking, jogging, dancing, swimming, badminton, tennis, etc. In addition, try to do more in your daily routines. For example, use stairs instead of lifts, walk or cycle to work or school, etc. See separate leaflet called 'Physical Activity for Health' for details.

Be realistic
Some people aim to get down to a 'perfect' weight. However, if this target is too low, you may become fed up about poor progress, and give up. As mentioned, in most cases most health benefits come from losing the first 5-10% of your weight (often about 5-10 kg). Also, to diet for 3-4 months is the most that many people can manage. It is difficult to remain motivated after this. To lose 5 kg is considered good. To lose 10 kg is excellent. (10 kg is about one and a half stone.)

Lose weight gradually
It is best not to lose weight too fast. If you lose more than a kilogram per week, you may lose muscle tissue rather than fat. It is best to lose an average of ½-1 kg per week (about 1-2 lb per week). To do this you need to eat 500-1000 calories per day less than you did before your diet. You will lose 6-12 kg if you keep this up for three months. Don't be disheartened by minor increases or levelling off in weight for a few days. Look for the overall trend over several months.

Depression or other mental health problems
These may cause you to eat for comfort, or to binge eat. This may lead to weight gain, which may make you more depressed, and so on. See a doctor if you feel that you have depression or another mental health problem. Treatment often helps.

Other general points
The first kilogram is the easiest to lose. This is because you lose water from your body at first as well as fat. It is important to be aware that the initial kilogram or so may seem to fall off, but then the weight loss commonly slows down. Regular weighing, advice, and encouragement by a nurse or dietician is often helpful.

Special diets which are often advertised are not usually helpful. This is because after losing weight, if your old eating habits remain, the weight often goes straight back on. It is usually not a special diet that is needed, but changing to a normal healthy balanced diet - for good.

Medical treatments
Medicines to help with weight loss are an option in some cases. They may help, but they are not wonder-drugs, and you still need to eat less. Doctors are given guidelines on when to prescribe these medicines.

Counselling is sometimes useful, but may not be available in all areas. This may be done 'one-to-one', or in a group setting. The kind of topics discussed may include:
how to choose meals that are lower in fat and calories.
how to recognise and resist cues that may make you want to eat when you are not hungry.
tips on how to reduce the number and size of meals.
how to eat more slowly.
how to separate eating from other activities, such as eating in front of the TV.

Surgery is an option if you are very obese. Results are usually good.

Keeping the weight off

Many people lose weight but, at the end of the 'diet', the weight goes back on. To keep the weight off, it is vital that you have a permanent change in your attitudes and lifestyle. This usually means
keeping to a healthy diet.
exercising regularly, if possible.
possibly, a change for the whole household. It is difficult for one member of a household to shop and eat differently to the rest. It is best that the whole household eat a healthy diet.
It does not mean less enjoyment of food. However, it may take a while to learn to enjoy different foods, meals, and recipes.

Some people need more support to keep to a reduced weight than when they were actually dieting and losing weight. A local support group may be useful for this.

Obesity and Overweight

If you are obese or overweight, you have an increased risk of developing various health problems. A realistic aim for many people is to lose 5-10% of your weight over three months. This is often about 5-10 kg. (10 kg is about one and a half stone.) This modest amount of weight loss will greatly reduce your increased health risks. The best chance of losing weight, and keeping the weight off, is to be committed to a change in lifestyle. This includes eating a healthy diet and doing some regular physical activity.

Are you obese or overweight?

Body mass index
Your body mass index (BMI) is a good estimate of how much of your body is made up of fat. It relates your weight to your height. You can work out your BMI by dividing your weight (in kilograms) by the square of your height (in metres).

So, for example, if you weigh 70 kg and are 1.75 metres tall, your BMI is 70 / 1.75 x 1.75, which is 22.9. Alternatively, your practice nurse can measure and weigh you, and tell you your BMI.BMI Classed As Health Risk
Less than 18.5 Underweight Some health risk
18.5 to 24.9 Ideal Normal
25 to 29.9 Overweight Moderate health risk
30 to 39.9 Obese High health risk
40 and over Very obese Very high health risk


Waist size
Your increased health risk is greater when the extra fat is mainly around your waist ('apple shaped'), rather than mainly on your hips and thighs ('pear shaped'). As a rule, a waist measurement of 102 cm or above for men (92 cm for Asian men) and 88 cm or above for women (78 cm for Asian women) is a significant health risk.

In short, the heavier you are, the longer your carry the extra weight, and the more the fat is around your waist, the greater your health risk.

How common is obesity and overweight?

More than half the adults in the UK are heavier than recommended. About 2 in 5 adults are overweight, and about a further 1 in 5 are obese. The number of obese people in the UK is rising, particularly among young adults. Since 1980, the number of obese adults in the UK has nearly tripled. This has been called the 'obesity epidemic'.

What are the benefits of losing weight?

It is difficult to measure how much 'quality of life' is improved if you lose some weight. Many people feel better, and have more energy. Some people notice an improvement in their self-esteem.

There are also definite health benefits from losing some weight. Many diseases are more common in obese and overweight people, and you are less likely to develop them if you lose some weight. They include: diabetes, high blood pressure, stroke, heart problems, some types of cancer, arthritis of the back and legs, gallstones, menstrual problems, incontinence of urine, breathing problems, some complications of pregnancy, and depression.

What is more, for most obese or overweight people, much of the health benefits come with losing the first 5-10% of your weight. This is often about 5-10 kg. (10 kg is about one and a half stone.) If you are obese, on average, if you reduce your weight by 10%:
You are much less likely to develop the conditions listed above, such as diabetes.
If you already have high blood pressure, osteoarthritis, or diabetes, these conditions are likely to improve. If you are taking medication for these problems, you may need a reduced dose.
Your chance of dying at any given age is reduced by about 20%. This is mainly because you are less likely to die from heart disease, stroke, diabetes, or obesity related cancers.
What is the cause of being overweight or obese?

In some respects, the cause sounds simple. You put on weight if the amount of energy in the foods and drinks that you eat is greater than the amount of energy that you use. Energy from foods and drinks that you do not use is converted into fat, and stored in the body.

A common wrong belief is to think that if you are overweight or obese, you have a low metabolic rate. (Your metabolic rate or 'metabolism' is the amount of energy that you need to keep your body's functions going.) In fact, if you are obese or overweight you have a normal, or even high, metabolic rate (as you use up more energy carrying the extra weight).

The reasons why 'energy taken in' may not balance 'energy used up', and result in weight gain, include the following.

Food and drink intake
Most people in the UK live where tasty food can be found at almost any time of day or night. Many of the foods that we eat are those with the most energy (fatty and sugary foods). Although our body gives us a feeling of fullness after eating enough (satiety), we can easily ignore this feeling if we are enjoying tasty foods. In short, many people simply eat more than their body needs.

Remember too: alcohol contains a lot of calories, and heavy drinkers are often overweight.

Activity and exercise
Most people in the UK do not do enough physical activity. Less people have jobs which are energetic than previously. The variety of labour saving devices and gadgets in most homes, and the overuse of cars, means that most people need to use-up much less energy compared to previous generations. The average person in the UK watches 26 hours of television per week, and many even more (the 'couch potato' syndrome).

A lack of physical activity by many people is thought to be a major cause of the increase in obesity in recent years.

Inheritance
You are more likely to be obese if one or both of your parents are obese. This may be partly due to learning bad eating habits from overeating parents. However, some people inherit a tendency that makes them prone to overeat. Therefore, for some people, part of the problem is genetic.

It is not fully understood how this 'genetic factor' works. It has something to do with the control of appetite. When we eat, certain hormones and brain chemicals send messages to parts of the brain to say that we have had enough, and to stop eating. In some people, this control of appetite and the feeling of fullness (satiety) may be faulty, or not as good as it is in others.

If you do inherit a tendency to overeat, it is not inevitable that you will become overweight or obese. You can learn about the power of your appetite, ways to resist it, be strict on what you eat, and do some regular physical activity. However, you are likely to struggle more than most people to prevent or overcome weight gain.

Medical problems
Less than 1 in 100 obese people have a 'medical' cause. Conditions such as Cushing's disease and an underactive thyroid are rare causes of weight gain. Some medicines such as steroids, some antidepressants, sulphonylureas and sodium valproate may contribute to weight gain. If you give up smoking, your appetite may increase.

How to Lose Weight

Lifestyle change for life

To lose weight and to keep it off, it is vital that you are motivated, really want to lose weight, and want to improve aspects of your lifestyle. Some people lose weight by strict dieting for a short period. However, as soon as the diet is over, they often go back to their old eating habits, and the weight goes straight back on. Losing weight, and then keeping it off, needs a whole change of attitude and lifestyle for life. This includes such things as:
the type of foods and drink that you normally buy.
the type of meals that you eat.
your pattern of eating.
the amount of physical activity that you do.
Top tip - ask family or friends to help and encourage you to keep to a healthy lifestyle.

Be realistic

What is your goal weight? Many people aim to get down to a 'perfect' weight. This is often unrealistic and may never be achieved. If the weight that you aim for is too low, you are likely to become fed up about slow progress, and give up. To lose 5 kg is good. To lose 10 kg is excellent. (10 kg is about one and a half stone.)

Top tip - in most cases, most health benefits come from losing the first 5-10% of your weight. This is often about 5-10 kg.

Timescale

What is your planned timetable? A weight reducing diet for about three months is realistic. After about three months, many people find it difficult to keep motivated. It may be useful to have a start and finish date for your weight-reducing diet.

It is best not to lose weight too fast. If you lose more than a kilogram per week, you may lose muscle tissue rather than fat. It is best to lose an average of ½-1 kg per week (about 1-2 lb per week). To do this you need to eat 500-1000 calories per day less than you did before your diet. You will lose 6-12 kg if you keep this up for three months. Don't be disheartened by minor increases or levelling off in weight for a few days. Look for the overall trend over several months.

Top tip - aim to lose weight steadily for about three months.

Healthy eating and understanding food

Do you know which foods are the best to eat? In general, a healthy diet consists of foods high in starchy carbohydrates, fruits and vegetables, but low in fat, sugar, alcohol, and salt. Can you list several common foods that are in each category? It may take some effort and reading to become familiar with this. Your practice nurse or dietician will have leaflets that list foods in each category. Another leaflet in this series called 'Healthy Eating' gives more details. Also, many books on food and health give these details.

Top tip - low-fat foods are generally best. But remember, some low-fat foods and drinks are high in calories, such as alcohol, sugary drinks, and sweets.

Food diaries

It is helpful to know how much you normally eat. Estimating from memory is not very accurate. It is best to keep a diary, and write down every amount of food and drink that you have over a week or so. Include even the smallest of snacks. Add up the number of calories that you eat and drink each day. You may need advice from a practice nurse or dietician to calculate calories. However, there are plenty of books that give calorie counts for different foods.

It may be helpful to keep up the diary for several weeks to see the difference in calories that you eat before and after a change to a healthier diet. To lose weight, you must eat less calories each day than previously.

Top tip - do not forget the drinks. Some drinks contain lots of calories, such as alcoholic drinks and sugary drinks.

Planning what you eat

It is important to plan ahead. Perhaps you could plan each day's meals and recipes the day before. In this way you will know exactly how much food you will be eating. This is better than looking in the cupboard and fridge before mealtimes or snacks to see what is there.

It is best to separate eating from other activities, as this helps to you keep to your planned eating for the day. So, try not to eat whilst on the move, whilst watching TV, during meetings, etc.

Top tip - plan tomorrows eating today.

Change of eating habits

Do you have any eating habits that can improve?
Are you eating larger and larger portions when you have a meal? Try to deliberately take smaller portions when you have a meal. Do not feel that you have to 'empty your plate'. Perhaps change the plates that you have in your cupboard (which may be large) to more medium sized plates. In this way you will naturally serve up smaller portions.
What do you have for snacks? Try changing chocolates or cakes for fruit.
Do you have second helpings at meal times when you are really already full?
Skipping meals is usually a bad idea. It sounds a good idea, but many people just become hungry, and have snacks later in the day, and eat too much at the next meal. Eating at regular mealtimes may be a first important change. Three healthy meals a day is best.
Do you always have a pudding? Will a light yoghurt do instead of a sweet pastry?
Do you eat quickly? Are you ready for a second helping before most people have half finished their first plateful? Obese people, on average, eat faster than non-obese people. It is best to train yourself to chew each mouthful for longer, and to eat slowly.

Top tip - three healthy meals each day, including breakfast, is better than skipping meals. Eat slowly, chew longer.

Shopping

One step towards improving eating habits is to change the contents of your shopping basket. For example, if you never buy biscuits, they will not be in the cupboard to tempt you. Most food labels say what is in the food, so it is easy to buy 'healthy' food. Some people argue that you should plan a shopping list, and stick to it. However, whilst you are learning which are the healthier foods, it may be better to spend some time comparing food labels before deciding on what to buy.

Top tip - do not shop for food when you are hungry. After a meal is best.

Recipes

Most people have a standard set of recipes and meals that they repeat. These may be old favourites, but may need to be abandoned in favour of new, healthier recipes. It takes time and effort to find recipes that you like.

Top tip - when you are on a weight reducing diet, try to learn a new 'healthy' recipe each week. When the weight reducing diet is over, you should then have plenty of new healthy meal ideas to help keep your weight down.

Drink mainly water

Many people use drinks full of calories to quench their thirst. Sugary drinks such as cola, tea and coffee with milk and sugar, milk, and alcoholic drinks, all contain calories. One of the easiest ways to cut back on calories is simply to drink water as your main drink.

Top tip - keep some water in a plastic bottle in the fridge. Chilled water is surprisingly refreshing.

Physical activity

If you are able, aim to do at least 60-90 minutes of moderate physical activity on at least five days a week. (All adults should aim for at least 30 minutes on five days a week. However, 60-90 minutes is recommended if you are overweight or obese and are aiming to lose weight.) Moderate physical activity includes: brisk walking, jogging, dancing, swimming, badminton, tennis, etc. In addition, try to do more in your daily routines. For example, use stairs instead of lifts, walk or cycle to work or school, etc. See separate leaflet called 'Physical Activity for Health' for details.

Top tip - If you are not used to physical activity, try starting with a 30 minute brisk walk every day and then building up from there.

Morale

The first kilogram is the easiest to lose. This is because you lose water from your body at first as well as fat. Be aware that the first kilogram or so may seem to fall off, but then the weight loss slows down. This is normal, so don't get disheartened!

Top tip - regular weighing and encouragement by a practice nurse or dietician is often helpful.

Special diets

Special 'wonder' diets are often advertised, but they are often not helpful. This is because your old eating habits will usually return after a short 'special diet', and weight often goes back on.

Top tip - it is not usually a special diet that you need, but a life-long change to a healthy diet.

Tempting situations and special occasions

It is important to recognise that holidays, festivals, eating out, etc, may interfere with your everyday food choices and eating schedule. Also, do you find that watching food programmes on TV makes you hungry? How about smells from the kitchen from someone cooking who is not aware that you are trying to lose weight? Do you get pressure from family or friends to eat or drink more?

You will be tempted by different situations to abandon your planned food intake. Can you identify any tempting situations? Can you avoid them? If not, how do you cope with them?

Top tip - go and clean your teeth when you are tempted to eat between meals.

Stress and depression

Many people eat as a comfort, or as a way of coping with stress. How do you cope with stress? Is stress, unhappiness, depression, etc, a reason for you to overeat or to binge eat? If so, can you plan alternative strategies. For example, relaxation tapes, going for a walk, talking to a friend, etc.

Top tip - see a doctor if you feel that depression is a problem. Depression can often be treated.

The power of the appetite

The appetite is a very powerful feeling. This is why many people find it so difficult to lose weight. There is no easy answer to this. Some people feel hungry more often than others. Feeling hungry does not always mean the body needs food. You have to be aware of the power of your appetite, and try to resist eating as soon as you feel hungry. One way of helping with a strong appetite is to fill up at meal times with vegetables and fruit which have a lot of fibre and bulk, but are low in calories.

Top tip - drink lots or water, and eat lots of fruit and vegetables to help counter appetite.

Medical treatments
Medicines to help with weight loss are an option in some cases. They may help, but they are not wonder-drugs, and you still need to eat less. Doctors are given guidelines on when to prescribe these medicines.
Counselling or referral to a dietician for advice is sometimes useful, but may not be available in all areas. Counselling may be done 'one-to-one', or in a group setting.
Surgery is an option if you are very obese. Results are usually good, but surgery is not without some risk. And, you still have to reduce the amount that you eat afterwards.

Keeping to a reduced weight

Many people who lose weight soon put it back on again when they stop their weight reducing diet. The main reason this happens is because the weight reducing diet was only a temporary cut back of an unhealthy diet. Once you have lost some weight, to keep the weight off you need to stick to a healthy diet. An active lifestyle with more physical activity would also help. Even better is for the whole family or household to have changed to healthy eating habits and a healthy lifestyle.

To keep your weight down you will still need to eat less and/or do more physical actvity than previously. For example, if you have lost 10kg, to keep this off and maintain your weight you will still need to:
eat about 300 calories per day less than you did prior to the weight loss diet, or
do more physical activity to 'burn up' an extra 300 calories per day, or
a combination of the two.

Top tip - after losing some weight, weigh yourself once a week to keep a check on your weight

Workout Routines and Splits

Workout routines are what exercises, how many sets, how many reps etc. that you do for each muscle. For example, 3 sets of the flat bench press, 3 sets on the incline bench press, and 2 sets of flat bench dumbell flyes is an example of one of the many chest weightlifting workout routines. A workout split is a term given to how you split up your workout. What days you do what muscle on. For example, doing biceps back and legs on Monday, and doing triceps shoulders and chest on Thursday is a workout split. Here i will give you some sample workout routines, the routine I use, and tell you how to make your own workout routine.

One rule when making weightlifting workout programs is to make sure to split it so that you aren't overtraining. Doing chest on Monday, then triceps on Tuesday, then shoulders on Wednesday will overtrain your triceps. Why? Because just about every chest and shoulder exercise works the triceps secondary. And almost every back exercise works the biceps secondary. So, you would need to do 1 of 3 things when making your workout routines and splits:

1) Work chest, triceps and shoulders on the same day, and biceps and back on the same day so that it's ok if the secondary muscles get worked that day, because your doing them anyway.
2) Separate those muscles that work a secondary muscle so that they are far enough apart not to overtrain you. For example, do Chest Monday, triceps on Wednesdays, and shoulders Friday... and biceps Monday with chest, and back Wednesday or Friday.
3) This is personally what I prefer, and do myself. Do chest and triceps Monday, and shoulders Thursday, and back and biceps together on Friday.

Sample Splits

Coming up with weightlifting workout routines and splits and programs isn't really rocket science, once you understand the basics you can create your own. But, here are a few sample split routines and programs off the top of my head I have either used at one time, or are commonly used by other people

Monday - Chest/Triceps
Tuesday - off
Wednesday - Biceps/Back
Thursday - off
Friday - Shoulders/Legs
Saturday - off
Sunday - off

Monday - Chest/Biceps
Tuesday - off
Wednesday - Shoulders/Legs
Thursday - off
Friday - Back/Triceps
Saturday - off
Sunday - off

Monday - Chest/Back
Tuesday - Shoulders
Wednesday - off
Thursday - Biceps/Triceps
Friday - Legs
Saturday - off
Sunday - off

Remember, these are just sample programs. Some people like to workout on the weekends, and I don't. So in all the samples I made them off days. It all depends on what days you have time to workout and/or when you want to workout which is why these are just samples, not splits you have to use.


Sample Weightlifting Workout Routines

This is hard. There are so many exercises for each muscle, and so many ways to split them up and make a routine out of them. So instead of listing 10,000 workout routines, I'll just list what I think are the most effective muscle building exercises for each muscle and later on you can decide which to use in your own workout routines.

Chest
Flat Bench Press
Incline Bench Press
Flat Bench Dumbell Flyes
Incline Dumbell Flyes

Back
Deadlift
Lat Pulldown (or weighted pull ups)
Seated Cable Row
Bent Over Barbell Row
Bent Over 1 Arm Dumbell Rows

Biceps
Standing Barbell Curls
Preacher Curls (with dumbells or barbell)
Seated/Standing Dumbell Curls

Triceps
Tricep Press Down
Dips
French Press

Legs
Squats
Calve Raises

Shoulders
Seated/Standing Military Press (with barbell or dumbells)
Lateral Raises
Shrugs

Abs
Abs are an important muscle and should be worked, but most people are just soooo confused when it comes to ab workouts. So, for more information on how "important" ab workouts are, and how to put abdominal exercises into your workout, click here.


My Weightlifting Workout Routine And Split

I've tried a bunch of different workout routines, and this one is probably my favorite. Remember, I'm not selling this. It's just what I do. I'm not saying because I do it and it works for me, that you should do it and that it will work for you.

Monday - Chest/Triceps
Tuesday - Legs
Wednesday - off
Thursday - Shoulders
Friday - Back/Biceps
Saturday - off
Sunday - off

Chest
Flat Bench Press 4 sets
Incline Hammer Strength Machine 2 sets
Dumbell Flyes 2 sets

Back
Deadlift 3 sets
Lat Pull down 3 sets
Seated Cable Row 2 sets

Biceps
Standing Barbell Curls 3 sets
Preacher Curls (with dumbells) 1 set

Triceps
Tricep Press down 2 sets
Dips (weighted) 2 sets

Legs
Squats 4 sets
Leg Extension 2 sets
Leg Curl 2 sets
Seated/Standing Calve Raises 5 sets total (2 or 3 sets each way)

Shoulders
Seated Military Press (with dumbells) 4 sets
Lateral Raises 3 sets
Shrugs 3 sets


*Note, on all exercises I do 6-10 reps. As I increase the weight, I decrease the reps. For example, if I'm doing dumbell military presses, it might be 60lb dumbells for 8 reps, then 65lbs for 6 reps.

Now, some questions you might have about weightlifting workout routines, splits, programs and what I do.

Why do you do the incline hammer strength machine and not the incline bench press? Well, I used to do the incline bench press, but I never felt right on it. I can't really explain it, but I couldn't get into a groove so to speak. So I went to the next best thing to free weights (by the way, free weights are the best thing for building muscle mass) which are hammer strength machines. They are the closest thing to free weights, and I happen to love the incline hammer machine, so I use it.

Why do you do so little? Wouldn't you be better off doing 10 sets for biceps or doing 15 sets for the chest? Nope, I tried that and it didn't work. After trying a bunch of different workout routines and programs, I discovered that the one I am using now works, so I use it. 10 sets for biceps might work for you but it doesn't for me. For more information on this, read the Important Facts section where I explain this in more detail.

If you did for example, biceps and back on different days, or triceps and chest on different days, would you do more for the secondary muscles, biceps and triceps? This is hard to answer. You see, I never did triceps on a different day than chest, or biceps on a different day than back. Like I said, this routine works for me, so I stuck with it. But I would guess, if I did them on different days, I would probably end up doing a few more sets for biceps and triceps.

Best Cholesterol Lowering Diets

A diet to reduce cholesterol needs to reduce the amount of fat in your diet. It is also important to reduce the amount of salt you eat. By eating lots of low-fat options and reducing your fat and salt intake, your cholesterol should be lowered. The following tips will help reduce the amount of fat
and salt in your diet.
Eat lots of low-fat foods like fresh fruit and vegetables.
Limit the amount of red meat you consume. Choose fish, turkey or chicken instead of red meat. When you do eat meat, choose low-fat options and trim away all visible fat.
Choose a margarine that is designed to help lower cholesterol levels.
Avoid using margarine as much as possible. Use only a small bit of margarine on your sandwiches. Do not add margarine to vegetables and popcorn.
Choose unsalted and unbuttered nuts and seeds.
Stay away from pastries, chips etc and take away food and sweets.
Choose whole grain breads instead of white breads.
Choose vegetable-based sauces instead of dairy-based sauces that use a lot of cheese, cream or milk.
Choose low-fat dairy products.
Benefits of a Low Cholesterol DietRate this Article
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A low cholesterol diet will have the effect of lowering your cholesterol. In addition, other health benefits can result by consuming cholesterol lowering diet.
A diet to lower cholesterol will also help you lose weight if you are overweight.
A low cholesterol diet will reduce the risk of developing heart disease.
A low cholesterol diet will reduce the chance of heart attacks.
A low cholesterol diet will often increase general health, and lead to people feeling generally healthier and more energetic than they did before.
Scientific Evidence For The Benefits of a Low Cholesterol Diet
A low cholesterol, low fat diet has been scientifically proven to be beneficial to health, lower cholesterol and reduce the risk of heart disease and other complications. Many medical organizations and heart organizations endorse a low-cholesterol, low-fat diet. Nutritionists and doctors also recommend a low-cholesterol, low-fat diet to increase health and lower cholesterol levels.

A low fat diet plan is not only good for people with high cholesterol levels, but it is a healthy option for everyone. Most doctors and nutritionists recommend a low fat diet plan as part as an overall healthy eating plan. People who have high cholesterol will reduce the risk of heart disease by following a cholesterol lowering diet. A low cholesterol diet can benefit everyone and it is one of the healthiest diets to follow.
Related Articles

Consider These Delicious Foods That Lower Cholesterol!

Your diet contributes greatly to the cholesterol in your body .If your cholesterol level is high you can check it with low cholesterol diets that has the potential to control the cholesterol. The low cholesterol diets are becoming increasingly popular nowadays. Even if you do not have cholesterol if you are in your mid forties it is advisable to take these low cholesterol diets. Read
more.This article covers
Low Cholesterol Diet Options
Foods that Are Low In Fat
Best Cholesterol Lowering Diets
A low cholesterol diet is to help people lower their cholesterol. It may be suggested by your doctor if you have too high levels of cholesterol. It involves cutting down on foods that contribute to high cholesterol and will usually include a low fat diet plan.
Low Cholesterol Diet Options
There are a few different types of cholesterol lowering diets. Cholesterol lowering diets involve reducing fat and following a low fat diet plan, as fats have the greatest impact on raising the level of cholesterol in the system. Here are some of the popular ways to lower cholesterol with diet.
Mediterranean diet. This diet includes eating lots of grains, fruits and vegetables. You are allowed only a small amount of red meat. Fish and poultry can be eaten and some dairy products are allowed. Wine is consumed with every meal.
Vegetarian diet. People on this diet must not eat any meat, poultry or fish. It includes lots of fruits, vegetables and grains. Nuts, seeds and soy products may be eaten.
Mayo Clinic Diet. The Mayo Clinic Diet is designed to lower cholesterol, as well as lower high blood pressure. It involves eating lots of fruit and vegetables, and including healthy servings from all food groups.
Low fat diet. A low fat diet plan will involve reducing the amount of fat that you consume in your diet. It is a very good diet for cholesterol lowering, for losing weight and for other health benefits. Foods that are low in fat (like fruit and vegetables) can be eaten regularly. Foods that high in fat (like red meat, butter and margarine) must be eaten sparingly. Low fat dairy products should be eaten, instead of full fat options.
Foods that Are Low In Fat
In order to lower cholesterol with diet, you will need to reduce the amount of fat in your diet. People who want to lower their cholesterol will need to eat mostly low-fat foods. Here are some of the low-fat, low-cholesterol foods you can choose from.
Fruit;
Vegetables;
Seeds;
Nuts;
Fish;
Whole grains;
Brown rice;
Cereals.

Ingredients Of Healthy Dieting Food

A healthy diet will contain a certain amount of carbohydrates and calories depending on your age, sex and activities, foods that burn calories and plenty of fruit and vegetables. Fibre helps digestions and comes mainly from vegetables and wholemeal products such as bran and
bread. The way food is prepared when you are on a diet is just as important as what it is that
you eat exactly. You can choose healthy options but if you fry all your food, all your effort will go amiss. Examples of healthy dieting food are:
Vegetables and Fruits
Providing necessary vitamins and fibre, fruits and vegetables would make up the bulk of your diet if you want to lose weight. As healthy options to eat instead of sweets and snack in between meals, fruits contain no fat can be consumed anytime. Made into shakes or as a fruit salad of just peeled and sliced, fruit is a healthy and relatively cheap option if you know where to shop. Most vegetables and fruits need a lot of energy to digest making them foods that burn calories.
Grain Products
Grain products such as wheat and bran, wholemeal bread and cereals make up an important part of your diet. Without any of these products dieting could cause problems with digestion. Fibres coming from these products are necessary to keep your digestive tract and bowels healthy and clean as they stimulate bowel movement. The best time of the day to eat grains is in the morning when the body needs a kick-start to get going and as grains digest slowly, a healthy breakfast will keep you going for hours.
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Lean meats and fish such as tuna, chicken and turkey contain lots of protein. Protein will help maintain muscle tissue when dieting and if you incorporate a sufficient amount of protein into your diet this will help burn fats and sugars in the body faster. Protein helps to build muscles and will help you keep up your strength when dieting. Dieting the healthy way will be easier if you eat more protein.
Benefits of Dieting
Maintaining a healthy diet and weight combined with regular excercise will help keep the body and muscles healthy. Benefits of dieting are:
A healthy heart and body. Exercising at least ten minutes a day will keep you fit and healthy and will help keep resistance levels up.
Losing weight will put less weight and strain on your muscles and joints resulting in less muscle pain.
Using less sugar and carbohydrates will make you feel less tired, as the body needs less time to break these foods down.
Prevent Dieting Dangers
Eating small amounts regularly (or sticking to a plan of three meals and two healthy snacks a day) will keep your energy levels up. Eating too little food or a strict form of low carb dieting will make you feel drowsy and hungry. If you are starting to feel like this and have difficulty concentrating remember that your body is sending you signals. You need to eat something and drink some water after which you will feel better, eating too little food can never be part of any healthy dieting plan.

10 Dieting Secrets You Would Be Glad To Know

It has become quiet common nowadays for everyone to observe diet .By diet t it doesn't mean renouncing the food as such but food high in fat content. There are certain ground rules which if you don't follow will affect your health adversely. The article reveals you the ten secrets in
dieting.This article covers
10 Dieting Secrets You Would Be Glad To Know
Importance of healthy diet
Ingredients of Healthy Dieting Food
Nearly every person has been on a diet at some point in his or her life. Low carb dieting, soup or cabbage diets, healthy dieting, we've all been there. Whether you need to lose weight for medical reasons or you are interested in losing a few pounds or in dieting the healthy way, this article will offer you some tips.
Never Skip Breakfast
Skipping breakfast is never a good idea, especially not when dieting. After a long period of fasting (during sleep) your body needs to wake up again and start the process of digestion and calorie burning. The body needs some food to start up that process and to give you plenty of energy for the day to come. Eating a healthy breakfast is necessary to avoid hunger pangs or mood swings due to fluctuating blood sugar levels.
Chew the Food Thoroughly
Chewing properly aids digestion so food will leave the system sooner. Badly chewed food cannot be processed by the body and can cause stomach aches.
Do Not Fry Food
Frying food will add more calories to any type of food because in frying a lot of fat is added to the food. Preparing food under a grill, steam pan or oven will help the food keep its vitamin content and will not add additional calories to food.
Don't Eat While Watching Television
Watching television or reading a book when eating will take your attention away from the food. It is likely that you will not notice your body's signals when it is full and you continue eating. This will make you consume too many calories, one of the dangers of dieting and not paying attention to what you eat.
Drink Plenty of Water
Water helps keep the system clean and aids in digestions. Drink at least 6-8 glasses of water a day starting in the morning. Your skin will look better and hydrated and you will feel less hungry during the day when dieting.
Don't Eat White Foods
White bread and cakes should be avoided, they contain a lot of starch. Sugars and salt and should be replaced with fibrous wholemeal products. Starchy products will make you feel bloated and won't keep you feeling full for long.
Prepare Your Food
Restaurants will offer low-calorie meals but often they make use of processed ingredients containing lots of sugar and salt. You are better off preparing your own lunch to take to work, you will know what went into it and next to that you will save money!
Exercise
Increasing your exercise will help digestion and burns of calories! Exercise and dieting tips are all you need to get you started on your way to a healthier life. Twenty minutes of exercise a day is recommended. Try cycling, swimming or brisk walking as gentle exercise and work your way up to jogging or speed walking.

With all these tips in mind, all you need it to fill your kitchen with healthy ingredients to start your health plan. Fad diets don't work and the only healthy diet with staying power is the one that provides you with healthy food, enabling you to lose weight slowly.

Don't Let Diabetics Rob You of All Tasty Delights

People often believe that diets for diabetics mean it will always be bland without life. Certainly not. In fact diabetes diets are also tastier many people say. The diet for diabetic simply means a diet without high sugar or fats. It can also be tried out by people who are obese at times. Check
out the article for more details on diabetics diet.This article covers
Controlling diabetes with diet
Diabetes Diet Guidelines
Types of Diabetes
Controlling diabetes with diet does not have to be difficult. A diet for diabetes can even taste great. It can also force you to make changes in your life that will leave you feeling healthier and more energized. You need to pay strict attention to the food that you eat when you have diabetes and diet guidelines need to be followed. However, this does not mean that your days now need to be filled with boring tasteless food. Many people find that their new diabetes diet plan actually tastes better and is more satisfying that the food they were eating beforehand.
Diabetes Diet Guidelines
For people with diabetes, diet and nutrition can play a very big part in keeping their diabetes under control. Firstly, people with diabetes will need to start following a healthy eating plan. This includes following the healthy food pyramid, with lots of fruit and vegetables and carbohydrates, limited meat and dairy products and only a small amount of sugars and fats.
Carbohydrates
Carbohydrates are important when controlling diabetes with diet as they play a role in keeping blood glucose levels at the correct level. You need to include lots of grains, beans and starchy vegetables. This includes breads, whole grains, brown rice and potatoes. A lot of people enjoy eating carbohydrates, so this should not be a problem. Try making your own homemade specialty breads for something extra special.
Fresh Fruit And Vegetables
It is important to include a lot of fresh fruit and vegetables in your diet. Most western countries have a wide range of fruit and vegetables available at any time of the year. You should be able to find at least a few types that you really enjoy. Try experimenting and eating different fruits and vegetables until you find ones that you are happy to include in your diet.
Dairy And Meat Products
You need to include less dairy and meat products when following a diabetes diet plan. When eating dairy and meat products you need to choose for low fat options. Fish and poultry is better than red meat. Lean cuts of meat should be chosen and all visible fat should be removed.
Sugar And Fats
Sugars and fats should be eaten sparingly. It may seem difficult to cut down on sugars and fats at first, but by changing the habit you will soon get used to your new way of eating. Stop using sugar in coffee and tea. Avoid sugary drinks, like soft drinks. Use less margarine on your sandwiches. Use less fat when cooking. After a while, you will find you are used to (and may even prefer) consuming less fats and sugars. Remember, you can also use artificial sweeteners as a substitute for sugar.
Planning Meals
People with diabetes need to spend some time planning their meals. Firstly, they need to ensure that they have the right foods to prepare a healthy, nutritional meal. People with diabetes should eat fewer smaller meals, instead of one or two large meals in a day. It is also best to eat at the same time every day.