1 Session 5 Audience: Alberta adults 18+ who are quitting smokingLength: 60 – 70 minutes Location: Various Outcomes Materials needed/Introduction By the end of this presentation participants will be able to: Describe Steps to a Healthier You key messages Set SMART goals for healthy eating Describe what they need to eat to stay or become healthy Describe ways to get more physical activity Electronic copy of presentation Handouts (supplied by QuitCore) QuitKit participant handbook Handouts (found on the Quit Core disc) Eating Well with Canada’s Food Guide (HC) Healthy Snacking (AHS, 2013) Quick and Easy Meals (AHS 2016) Setting SMART Goals - Adult (AHS, 2013) Getting Started: Setting SMART Goals – Adult (AHS, 2013) Label Reading the Healthy Way – (AHS, 2016) Wake Up to Breakfast Everyday (AHS, 2015) Handy Guide to Serving Sizes (AHS, 2015) Physical Activity Tips for Adults (PHAC) Optional props (for optional activities) Blue Portion Size Kit (AH) Empty food packages with nutrition facts table (e.g. cereal, granola bars, canned vegetables, yogurt containers etc.) Box of cereal (e.g. Cheerios) © 2011 Alberta Health Services May, 2013 All rights reserved. This presentation may not be changed or reproduced without written permission from Alberta Health Services (contact This is general information only and should not replace the advice of your Registered Dietitian or Nutritionist, doctor, or other health professional. Alberta Health Services is not liable in any way for actions based on the use of information in this presentation.

2 What we will talk about in this session…What I need to eat to stay or become healthy Ways to be more physically active to stay or become healthy Making a plan to help address my food cravings References Surgeon General. (2008). Clinical practice guideline: Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services. Smoking Cessation Rounds. (2008). Smoking cessation and weight gain: A common challenge and a unique opportunity [Online]. Minto Prevention and Rehabilitation Centre, University of Ottawa Heart Institute and Addiction Medicine Service, Centre for Addiction and Mental Health, University of Toronto. Retrieved from Chiolero, A., Faeh, D., Paccaud, F., & Cornuz, J. (2008). Consequences of smoking for body weight, body fat distribution and insulin resistance. American Journal of Clinical Nutrition, 87, 801–809. Toll, B. A., Katulak, N. A., Williams-Piehota, P., & O’Malley S. (2008). Validation of a scale for the assessment of food cravings among smokers. Appetite, 50(1), 25–32. Epub May 18, 2007. Freedhoff, Y., & Sharma, A. M. (2010). Lifestyle assessment. In: Best weight: A practical guide to office-based obesity management. Edmonton (AB): Canadian Obesity Network. pp. 37–40. Health Canada. Food and Nutrition. (n.d.). Canadian guidelines for body weight classification in adults [Online]. Retrieved May 20, 2011, from Alberta Health Services Nutrition and Food Services. (2011). Healthy eating starts here: Steps to a healthier you. Key messages [Draft; April 20, 2011]. Edmonton, AB: Author. Health Canada. (2007). Eating well with Canada’s Food Guide [Online]. Retrieved May 20, 2011, from Health Canada. (2007). Eating well with Canada’s Food Guide: A resource for educators and communicators [Online]. Retrieved May 20, 2011, from Dietitians of Canada. (n.d.). EATracker [Online]. Retrieved May 20, 2011, from Alberta Health Services Nutrition Services. (2009). SMART goals for a healthy lifestyle—Adult. Revised. Edmonton, AB: Author. Alberta Health Services Nutrition Services. (2010). Healthy snacking. Edmonton, AB: Author. Alberta Health Services HealthLink Alberta. 6 Steps to a healthier you—Step 6: Prepare healthy foods [Online]. Retrieved May 2, 2011, from Dietitians of Canada. (2011). Recipe analyzer. Retrieved from Dietitians of Canada. (n.d.). Let’s make a meal. Retrieved from Health Canada. (n.d.). Nutrition labelling [Online]. Retrieved May 20, 2011, from Alberta Health Services Nutrition Services. (2009). Label reading the healthy way. Revised. Edmonton, AB: Author. Canadian Diabetes Association and Dietitians of Canada. Nutrition labelling education centre. Healthy eating is in store for you. Retrieved from Alberta Health Services Nutrition Services. (2010). Boost your vegetable and fruit intake. Edmonton, AB: Author. Alberta Health Services HealthLink Alberta. 6 Steps to a Healthier You—Step 5: Choose whole grains. Retrieved May 2, 2011, from Alberta Health Services Nutrition Services. (2010). What’s a healthy portion size? Edmonton, AB: Author. Department of Health and Human Services and National Institutes of Health. (2008). Portion distortion [Online]. Retrieved August 26, 2008, from Subway. (n.d.). Nutrition [Online]. Retrieved March 1, 2010, from world.subway.com/Countries/frmNutrition.aspx?CC=CAN&LC=ENG&Mode=.

3 Discussion Who hasn’t used tobacco for 1 week? Today? What helped?What good things have you noticed? How have you rewarded yourself? References (continued) 24. Earls Restaurant. (n.d.). Nutrition [Online]. Retrieved February 19, 2009, from [accessed 2009 Feb 19]. 25. Hurley, J., & Liebman, B. (2006). Good cup bad cup: how to survive in latte land. In: Nutrition Action Health Letter [Online]. Toronto (ON): Centre for Science in the Public Interest. Retrieved August 26, 2008, from 26. Tim Hortons. (n.d.). Canadian nutrition calculator [Online]. Retrieved March 1, 2010, from 27. Center for Disease Control and Prevention. (n.d.). Rethink your drink [Online]. Retrieved May 2, 2011, from

4 Homework review Rewarded yourself every day?Developed your stress management plan? Identified stressors? Lowered your stress levels? Reviewed and updated “My Quit Plan”?

5 Quitting and Food What have your experiences been with eating since you have started to cut down on tobacco? Outcome Participants will begin to share their thoughts/concerns with eating after quitting tobacco. Key Message Many people have different experiences with food after they quit tobacco. Facilitator Notes Points Answers will likely vary. If they are having a hard time coming up with answers. Ask if they have noticed any increases/differences in appetite, weight, or types of food they eat.

6 Weight & quitting tobacco useSome people may experience weight gain when they quit using tobacco. Average weight gain is around 5 to 6 pounds and is often temporary. Outcome Participants will understand weight gain in relation to smoking cessation. Key Message If you gain a few pounds when you quit, do not dwell on it. Instead, feel proud that you are improving your health. Facilitator Notes Points Average weight gain is around 5 to 6 pounds, upwards of 10 pounds (1). It is often temporary and will plateau after a few months as the body adjusts to being smoke free. Most of the weight gain occurs within the first 1 to 2 months of cessation (2). Some people may state they lost some weight. Reasons vary but some people may avoid meal time interactions if this is what they associate with tobacco use or increase physical activity to substitute tobacco use. 57

7 Reasons people may experience a small weight gainYour body is burning calories at a normal rate again. You may snack more and have food cravings. Your hunger may increase. Food will start to taste and smell better. To combat boredom or keep your hands busy, you may be eating or drinking more. Outcome Participants will understand weight gain in relation to smoking cessation. Key Messages Your body is burning calories at a normal rate again. A small weight gain may be your body returning to its natural weight. You may feel more hungry and, therefore, eat more than before. This feeling usually goes away after several weeks. Facilitator Notes Reference QuitKit participant handbook page __, Weight Gain and Quitting Smoking Points Each cigarette causes your body to burn calories faster for a short time. For example 1.5 packs of cigarettes burns about 200 calories. It’s likely because nicotine increases heart rate and releases adrenaline; therefore, when a person stops smoking there may be a modest weight gain because those calories are no longer being burned off but are being stored in the body (3). It is common for people to crave sweet, crunchy or high-fat snacks (4) and drink more alcohol after they quit smoking. Nicotine causes an increase in brain serotonin, as do carbohydrates; therefore, once smoking has been stopped, carbohydrate-rich foods may be consumed to increase serotonin, improve mood and shut off appetite—just as the nicotine formerly did (5). Reminder: Smoking is not a healthy way to burn calories. Background Information There are 20 cigarettes in a pack (25 in a king size). Thus, 1.5 packs equals 30 cigarettes. When smoking, 1 cigarette produces a 3% increase in energy expenditure (3). QuitKit page __: 48 hours after cessation, the ability to smell and taste is enhanced.

8 Food Cravings How can I cope with food cravings?Eat a snack or meal every 3 to 4 hours. This gives your body energy and helps you think and feel better. Drinking water may reduce your feeling of hunger. Prepare healthy ‘grab and go’ snacks in advance. crunchy vegetable sticks fresh fruit, such as apples air-popped popcorn yogurt Pretzels lower fat cheese (20% MF) low-fat crackers sparkling water What are some other examples? Outcome: Participants will learn strategies for dealing with food cravings Key Messages Here are a few tips to help cope with cravings. What works is unique to each individual. Facilitator Notes Handouts: Healthy Snacking (AHS) Points: These are some ideas for dealing with food cravings: Eat a snack or meal every 3 to 4 hours – This will help prevent you from becoming very hungry and reaching for unhealthy food. Prepare healthy snacks in advance to grab and go. When a craving strikes, you will have something healthy to reach for. Drink water throughout the day to stay hydrated. Drink a glass of water to reduce feelings of hunger. Other ideas: Try sugar free gum or suck on a small sugar-free candy – note: sorbitol (the sweetener often found in sugar-free candies) may cause diarrhea when eaten in large amounts Try going for a walk (or another physical activity) to help take your mind off of food. Activities: Divide into small groups and brainstorm ways to combat food cravings. Allow each group to share a few of their best ideas with the rest of the class and write these down for the entire class to see. Reveal the bullet points above (click) to go through the ideas on the slide. Have participants discuss non food options to deal with cravings (physical activity, hobbies, etc.)

9 Making Healthy Eating EasyPlan healthy foods you want to eat A variety of meals and snacks Make a list to buy at the store Prepare when you have time Make leftovers for the next day Pre cut fruit and vegetables Pack foods for easy use Grab and go ideas Freezer meals Outcome Participants will be able to identify strategies to help prepare meals and snacks Key Message Planning, preparing, and packing healthy choices helps make healthy eating easier. Facilitator Notes Handouts: Quick and Easy Meals (AHS) Reference QuitKit participant handbook page __ Points Having a plan will help make things easier through the week. Plan meals and snacks with a variety of food from Canada’s Food Guide based on your schedule and time available to prepare food. There are many ways you can be time efficient when preparing food. Make extra for later in the week and have have everything cut up to make it more likely you will eat it. Having foods packed will make it easy to grab if your on the run or you have a snack craving. Use your fridge and freezer to store meals for your week so you have an easy meal option at home or work.

10 It is important to rememberRegular tobacco use puts as much stress on your body as being 75 to 125 pounds overweight! Eating healthfully and being more active can help with managing weight and improving health. Avoid fad diets. Outcome Participants will understand what are their recommended Food Guide Servings per day Key Messages Regular smoking (e.g. one pack a day) puts as much stress on the body as being more than 75 to 125 pounds overweight (2). Eating well and being active can help with managing weight and improving health. Facilitator Notes Reference QuitKit participant handbook page __, Weight Gain and Quitting Smoking Points Regular smoking puts stress on the body. Stress leads to increased metabolic rate. Smoking is not an effective or safe way to control weight. Maintaining a healthy weight throughout life may be one of the ways to protect against cancer, high blood pressure, heart disease, stroke and type 2 diabetes. Avoid fat diets. Although some may help you lose weight quickly, they usually involve certain types of food and the effects don’t last one you return to a normal diet.

11 If you are concerned about your weight…Consult your doctor or another health care professional for a more complete assessment of your weight and health risk. If you are looking for resources to manage your weight there are many options available. Outcome Participants will understand what are their recommended Food Guide servings per day. Key Message Consult your doctor or another health-care professional for a complete assessment of weight and health risk. Facilitator Notes Reference QuitKit participant handbook page __, Weight Gain and Quitting Smoking Points Discuss the many resources available to participants if they want assistance in managing their weight. Registered Dietitians are available through AHS, PCN’s and through private businesses depending on your community.

12 Optional slide.

13 Quitting Support Technique #17 Healthy eating starts hereGOAL Set goals for healthier eating Choose and prepare healthy food Eat more vegetables and fruit Choose whole grains Know your portions Choose healthy drinks Outcome Participants are introduced to key messages for Steps to a Healthier You – Alberta Health Services Nutrition Campaign (7). Key Messages The information that I am presenting this next hour is information for you (participants) to consider (not mandatory). You are doing an amazing thing by quitting tobacco. This is your primary focus. Facilitator Notes Points Healthy eating can help in the journey of quitting. It does not mean you have to do all the strategies I am going to share with you. Take the ones that might work for you. Background Information Healthy Eating Starts Here – Steps to a Healthier You is an AHS Nutrition Campaign (7). Consistent key nutrition messages will be used throughout AHS. 59

14 Set goals for healthier eatingUse Canada’s Food Guide to help you set goals to improve your eating habits. Set “SMART” goals: Specific, Measurable, Achievable, Rewarding, Time Frame. Outcome Participants will understand that small changes over time add up. Key Messages Changing eating habits takes time and effort, but even small changes can make a difference. Use Canada’s Food Guide a starting point to help set goals to improve your eating habits (8). Facilitator Notes Reference QuitKit participant handbook page ___, 1. Set Goals for Healthier Eating Handouts SMART Goals for a Healthy Lifestyle—Adult (optional) (11) Eating well with Canada’s Food Guide Points Changing eating habits takes time and effort. It is important to recognize that each small change is a step in the right direction. Knowing how your diet compares to the amount and type of food recommended in Canada’s Food guide can help you set goals to improve your eating habits (8). Background Information Eating Well with Canada's Food Guide—A Resource for Educators and Communicators(9) provides background information, tips and tools to complement each recommendation in Canada's Food Guide. You can view a copy on the Web site (see below), download a PDF version or order a print copy: You can also customize your own personal food guide in the My Food Guide section of the website. 59

15 What are your recommended Food Guide servings per day?Include a small amount mL (2 to 3 Tbsp) of unsaturated fat each day. This includes oil used for cooking, salad dressings, margarine and mayonnaise. Try vegetable oils such as canola, olive and soybean. Choose soft margarines that are low in saturated and trans fats. Outcome Participants will understand what are their recommended Food Guide Servings per day. Key Messages Eating Well with Canada’s Food Guide describe what amount of food people need and what type of food is part of a healthy eating pattern (8). The recommended number of servings is different for people at different stages of life and is different for males and females. The recommended number of Food Guide servings is an average amount that people should try to eat each day. Facilitator Notes Reference QuitKit participant handbook page __, 1. Set Goals for Healthier Eating Points The eating pattern in Canada’s Food Guide includes foods from each of the four food groups—vegetables and fruit, grain products, milk and alternatives, and meat and alternatives—plus a certain amount of added oils and fats. Following the eating pattern in Canada’s Food Guide will help people: Get enough vitamins, minerals and other nutrients; Reduce the risk of obesity, type 2 diabetes, heart disease, certain types of cancer and osteoporosis; Achieve overall health and vitality; and Achieve energy balance to meet their individual energy needs without promoting excess weight gain (9). Activities Allow time for participant to look up the recommended servings based on their age and gender. Review a few examples of Food Guide Servings from each food group. Optional online activity: EATracker (www.eatracker.ca) lets you track your day's food and activity choices and compares them to the guidelines laid out by Health Canada. It also determines your body mass index (BMI) and provides information to help you achieve and maintain a healthy weight.

16 Example of a SMART goal GOALI will eat at least seven servings of vegetables and fruit a day. Specific Measureable Achievable Rewarding Time frame Outcome Participants will see an example of how to write a SMART goal. Key Message When writing goals, choose strategies that are specific, measurable, achievable, rewarding and have a time frame. Facilitator Notes Reference QuitKit participant handbook page __: 1. Set Goals for Healthier Eating Handouts Setting SMART Goals (AHS) (11) Healthy Snacking (AHS) (12) Points Review SMART Goal in Quit Core Manual page__ (I will eat at least 7 servings of vegetables and fruit a day). Specific: Decide what you are going to do and how to do it. Measurable: Keep track of how you are doing. Achievable: Pick something you think you can do; start with small changes. Rewarding: Think of how good you will feel when you make small changes. Time Frame: Give yourself a time limit to reach your goal (11). Activities Provide Setting SMART Goals (AHS) Handout. Provide a couple minutes for participants to go through worksheet and think about a healthy eating habit they want to work on (optional) (11). Provide Healthy Snacking (AHS) handout. As a group come up with a Healthy Snacking Goal and discuss strategies that are specific, measureable, achievable, rewarding and have a time frame (optional) (12).

17 2. Choose and prepare healthy foodUse healthy cooking methods Bake, steam, broil, BBQ, sauté in broth or microwave. Make healthy food choices when eating out Include vegetables in your meal, ask for sauces on the side Choose healthy foods at the grocery store Plan a menu and make a grocery list Outcome Participants will learn about choosing and preparing healthy foods. Key Messages Use healthy cooking methods to prepare foods. Make healthy food choices when eating out. Facilitator Notes Points Use healthy cooking methods Bake, steam, barbeque, broil, grill, sauté with broth or juice, or microwave your meals. Choose lean cuts of meat and trim any visible fat Chill gravy, stews or soup until the fat hardens then remove the fat layer. Look for foods that are grilled, broiled, barbequed or baked rather than fried. Ask for lower fat dressings and sauces on the side (13). Look for options that include vegetables. Look for healthier options listed on menus or check online restaurant nutrient content. Choose healthy foods at the grocery store Plan a menu for the week. This will help when you are developing your grocery list so you know what food items you need to prepare meals and snacks for the week. Eat a snack before you shop. Shopping when you are hungry can lead to purchasing more convenience high-fat, high-sugar foods. Stick to the outer edges of the grocery store. Healthier choices are usually found along the outer edges (vegetables and fruits, bread (grain products), milk and milk alternatives and meat and meat alternatives. Some packaged goods in the center aisles and displays at the end of aisles are high in fat and salt. Read labels and choose carefully. Skip the snack food aisle to help avoid temptation (13). Activities Refer participants to tools on the Dietitians of Canada website (www.dietitians.ca) The Recipe Analyzer will tell you what nutrients are in your favorite recipes, how many Food Guide Servings your recipe provides and give tips on ingredient substitutions to make your recipe healthier (14). “Let’s Make a Meal” guide: Participants can build a one day menu using the guide and see how their choices compare to the food guide (15). 60

18 Read food labels Nutrition facts Ingredient list Nutrition claimsHealth claims INGREDIENTS: Whole wheat, wheat bran, sugar/glucose-fructose, salt, malt (corn flour, malted barley), vitamins (thiamine hydrochloride, pyridoxine hydrochloride, folic acid, d-calcium pantothenate), minerals (iron, zinc oxide). “Good source of fibre” Outcome Participants will learn where nutrition information is found on food labels. Key Message Food labels give you information to help you make healthy food choices and compare similar foods. Facilitator Notes Points Nutrition information is found in three different places on food labels: Nutrition Facts Table: Provides information on serving size, calories and at least 13 different nutrients in an easy to read table. Use the Nutrition Facts table to compare similar foods. Ingredient list: The ingredient list provides an overview of what is in the food. Ingredients are listed by weight from most to least. Thus, the first few ingredients are the ones in the highest amounts. Certain food allergens must now be listed on food labels using commonly used words. Nutrient content claims and health claims: These claims must meet regulations and standards set by Health Canada. Nutrient content claims are statements that describe how much of a healthy nutrient is in a food (e.g., “a very high source of fibre”). Health claims describe a link between what you eat and certain diseases (e.g., “a healthy diet low in saturated and trans fats may reduce the risk of heart disease”) (16). “A healthy diet…”

19 Read food labels Serving Size Calories Fat % Daily ValueSaturated and Trans Fat Fibre % Daily Value Cholesterol Sodium Carbohydrate Outcome Participants will learn how to read a Nutrition Facts label. Key Messages The Nutrition Facts table provides information on serving size, calories and at least 13 different nutrients in an easy to read table Use the Nutrition Facts table to compare similar foods. Choose foods that are higher in fibre, vitamins, calcium and iron and lower in sugar, salt and fat. Facilitator Notes Handout: Label Reading the Healthy Way (AHS) Points The information in this table is based on the amount of food listed at the top of the Nutrition Facts table. This amount is the serving size. If you eat more or less than the listed serving size you have to adjust the nutrient content listed below. For example, if you were to eat half of this muffin you would divide all the nutrient values in half. Use % Daily Value to see if a food has a little or a lot of a nutrient compared to what is recommended. Quick guide to % Daily Value: 5% or less is low. Use for fat, saturated and trans fat, cholesterol and sodium. 15% or more is high. Use for fibre, iron, vitamins A and C and calcium. Calories are the amount of energy in one serving. Fat is the total amount of fat in one serving. Four grams of fat is equal to one teaspoon of fat. Saturated and trans fats are part of the total amount of fat. Saturated and trans fats raise “bad” blood cholesterol. Choose foods that are lower in saturated and trans fats. Fibre helps to promote a healthy heart and control blood sugars. Choose foods that are higher in fibre. Cholesterol is the amount of dietary cholesterol in one serving. A product may have no cholesterol but still be high in saturated and trans fat. Sodium is the amount of sodium in one serving. Look for foods with less than 5% Daily Value. Look for seasonings and condiments that are low or no sodium. Carbohydrate is the total amount of starch, sugar (natural and added) and fibre in one serving (17). Activity Label reading videos are available at If there is time (and an internet connection), this is a option for learning about label reading (18). Background Information Health Canada. Nutrition Labeling. (16)

20 Breakfast Breakfast may help in managing weightHaving breakfast can help in preventing chronic disease Skipping breakfast is connected to stress in people who smoke Outcome Participants will see benefits of having breakfast. Key Message Having breakfast daily may help manage weight and prevent chronic disease. It may also help people feel full and make better choices throughout the day. Facilitator Notes Handouts: Wake up to Breakfast Everyday Reference •BMI was lowest for those with the highest %daily caloric intake at breakfast despite having an higher daily energy intake. Independent of age, sex, smoking or PA (Purslow et al, 2008). •Breakfast among ON high school students. 36% smoked, less than half eat breakfast. More boys than girls consumed breakfast. Active students were more likely to eat breakfast tobacco use was associated with skipping breakfast in boys but not girls. •Mekary et al. followed men 16 yrs and found 21% higher risk of T2DM in breakfast skippers. •In Japan, breakfast skipping found to be more prevalent < 50 yrs, and for non smokers was associated with stress. Many more men smoke than women. Combined impact of breakfast skipping and tobacco use associated with increased incidence of T2DM, odds ratio of 4.68. Points Breakfast is considered any food you eat within 2 hours of waking. For example people may choose to bring breakfast to eat at work versus eating as soon as they awake.

21 Tobacco and Flavour Foods that enhance the taste of tobaccoAlcohol Caffeinated drinks Meats Dairy Foods that worsen the taste of tobacco Fruit Vegetables Non-caffeinated drinks Eating foods that worsen the taste of tobacco can help Outcome Participants will see understands what foods affect the flavour of tobacco. Key Message Having meals and snacks with these foods can affect the taste of tobacco. Some can make tobacco taste better while others can make tobacco taste worse. Facilitator Notes Reference Speaker notes- “Nutrition and Tobacco Cessation” by Barbara Cantwell March Points Ask participants ideas of how fruits and vegetables and non caffeinated drinks can be used to help with their cessation plan

22 3. Eat more vegetables and fruitPlan to eat 7 to 10 servings of vegetables and fruit every day: Add sliced fruit to cereal or yogurt At lunch or supper add a salad made from spinach, romaine, green or red leaf lettuce Keep washed and sliced vegetables in the fridge for a great crunchy snack Grab easy on the go fruit snacks like bananas, apples, pears and oranges Outcome Participants will understand how to increase fruit and vegetable consumption. Key Messages Vegetables and fruit should be the food group that you choose from the most. Vegetables and fruit are naturally low in energy and high in fibre, so tend to fill you up leaving less room for high-calorie snack foods. Facilitator Notes Points Vegetables and fruit have important nutrients such as vitamins, minerals and fibre. They usually are low in fat and calories. A healthy diet rich in vegetables and fruit may help reduce the risk of cardiovascular disease and some types of cancer. Eat at least one dark green and one orange vegetable each day. Go for dark green vegetables such as broccoli, romaine lettuce and spinach. Go for orange vegetables such as carrots, sweet potatoes and winter squash. Certain vegetables and fruits are rich in antioxidants, which help combat the damaging effects of smoking ad may help prevent cancer (8). Start your day with a fruit-based smoothie. Vegetables that are already washed and cut up make it easy to grab for a snack. Have fruits visible as a reminder to choose them first. Keep higher fat snack foods out of sight. Remember the saying “out of sight, out of mind.” Canned, frozen, and/or fresh vegetables are all good sources of nutrients. Choose vegetables and fruit that do not have added fats, sugars and salt. Keep your kitchen stocked with quick and easy frozen and canned vegetables and fruit such as frozen broccoli, frozen berries and peaches in canned juice (19). Add vegetables to casseroles and soups. Activity Ask participants to pull out a copy of Eating Well with Canada’s Food Guide (8). Background Information Eating well with Canada’s Food Guide—A resource for Educators and Communicators: (9). 62

23 One serving is equal to 1 medium piece (about size of a tennis ball)½ cup fresh, frozen, or canned fruit or vegetables 1 cup salad ½ cup 100% pure vegetable or fruit juice (limit to ½ cup per day) Outcome Participants will understand what one serving of vegetables and fruit is equal to. Key Messages This food group makes up the largest proportion of the Food Guide servings in the healthy eating pattern and includes vegetable and fruits in many forms: fresh, frozen, as juice, canned and dried Canada’s Food Guide recommends that people choose vegetable and fruit more often than juice to get more fibre. It can help people feel full and satisfied, which may help reduce the risk of obesity. Facilitator Notes Points In general, one medium fresh vegetable or fruit or 125 mL (1/2 cup) cut up is equivalent to one Food Guide serving. One Food Guide Serving of salad or raw leafy greens is 250 mL (1 cup) and 125 mL (1/2 cup) of cooked leafy green vegetables. A Food Guide serving of dried fruit is 60 mL (1/4 cup). A Food Guide Serving of juice is equivalent to 125 mL (1/2 cup) (8). Background Information Eating Well with Canada’s Food Guide: A Resource for Educator and Communicators: (9).

24 4. Choose whole grains Eat whole grains to increase your fibre intake.Look at ingredient list for words “whole grain.” Try whole grains like barley, oats, millet, quinoa or brown rice. Outcome Participants will understand how to find whole grain foods. Key Message Choose a variety of whole grains daily such as whole grain breads, cereals and crackers, and brown rice. Facilitator Notes Points Eat whole grains to increase your fibre intake. Look at the ingredient list, and choose foods where the word “whole” appears before the word “grain” at the beginning of the list. Do not rely on the words like “enriched wheat flour”, “multigrain”, or “12 grain” as these products may not be whole grain products (20). Try whole grains like amaranth, buckwheat, bulgur, pot barley, whole rye, whole oats or oatmeal, millet or brown rice. Whole grains can be eaten on their own or used as ingredients in products or recipes such as buckwheat in pancakes, oats in cereal, quinoa (keen-wah) in a pilaf or whole grain wheat in bread (9). Background Information Eating Weil With Canada’s Food Guide—A Resource for Educators and Communicators. (9) Whole grains and whole grain foods are composed of all three edible layers of the grain seed or kernel. Each layer provides a unique combination of nutrients. The outer bran layer provides all the fibre as well as B vitamins, minerals such as magnesium, iron and zinc, phytochemicals and some protein. This middle endosperm layer accounts for most of the weight of the grain and is composed mainly of carbohydrates and protein. The inner germ layer provides B vitamins, unsaturated fats, vitamin E, minerals and phytochemicals (9). 63

25 High fibre diet Protects against heart disease and cancerHelps you feel full: this may help to control weight Prevents constipation Helps control levels of sugar and fat in your blood Outcome Participants will understand the benefits of eating a high-fibre diet. Key Message Fibre makes you feel full, helps control blood cholesterol and blood sugar, and lowers risk of disease. Facilitator Notes Points A high-fibre diet can lower your risk of colon cancer, heart disease, and digestive problems like diverticulitis. Fibre can also help with controlling weight gain by making you feel full so that you eat less. Fibre keeps your digestive system healthy and prevents constipation A high-fibre diet can improve blood sugars and lower blood cholesterol and triglyceride levels. Dietary fibre is the part of the plant based foods that our bodies cannot fully digest and absorb. Most people eat less than half the fibre they require daily. A healthy diet should include 25 to 38 grams of fibre a day. Increase fibre in your diet slowly and eat fibre often to reduce gas and bloating. Drink at least 8 cups of fluid such as water each day. Fibre works with water to create bulk in the intestinal tract, which is what helps promote regularity (20, 9). Background Information Eating Well With Canada’s Food Guide—A Resource for Educators and Communicators: (9)

26 Ways to boost fibre intakeIncrease fruit and vegetable intake Add bran, flax seed or a very high fibre cereal to your favorite cereal in the morning Add barley, beans, peas or lentils to soups and casseroles Outcome Participants will discuss ideas on how to boost fibre in their day. Key Message Fibre can be found in a variety of foods that can be used at every meal/snack. Facilitator Notes Activity Have participant talk come up with ways to add fibre to their day. If they are having trouble with ideas, remind them high fibre choices include fruits and vegetables, whole grains, beans lentils, and seeds Show examples on slide and get them to explain their choices With fruit and vegetables, ideas from the Fruit and Vegetable slides can be used.

27 5. Know your portions A portion is the amount of food a person eats.A serving is a specific amount of food according to Canada’s Food Guide. The portion you eat may be more or less than a serving size as outlined in Canada’s Food Guide. Outcome Participants will understand the difference between a portion and a serving. Key Messages A portion is the amount of food a person eats. A serving is a specific amount of food according to Canada’s Food Guide. The portion you eat may be more or less than a serving size as outlined in Canada’s Food Guide. Facilitator Notes Handout: Handy Guide to Serving Size (Eat Right Ontario) Points When you are given a large amount of food you are likely to eat more. These larger portions can make you gain weight. The portions you eat in a restaurant or at home are often larger than what you need to feel full and meet your nutrient needs. Eating smaller portions of food can help you control your weight. To find out how many servings of food you and other family members need in a day, see Canada’s Food Guide. The portion you eat may be more or less than a serving size as outlined in Canada’s Food Guide. Be sure to consider this when you are looking at your daily food intake (21). Background Information Eating Well With Canada’s Food Guide—A Resource for Educators and Communicators: 64

28 Portion distortion How many calories are in this turkey sandwich?Outcome Participants will be able to see how portion sizes have increased over time. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points A sandwich 20 years ago was 320 calories. Today’s typical sandwich is more like a submarine sandwich and has 820 calories (22). The difference is 500 calories. This would take about 1 hour and 25 minutes of biking for a 130 pound person to burn off (22). An extra 500 calories each day leads to 1 pound weight gain in a week. We need to be aware of the larger portions available because we tend to eat everything that is in front of us, thinking that this is how much food we should eat. High-fat or sugary foods can easily provide double the calories of a lower fat food without an increase in volume. Thus, it is easier to consume too much fat and sugar. Background Information (may not wish to give restaurant name) A 12 inch (foot long) sub is equal to about five slices of bread (five servings of Grain Products from Canada’s Food Guide). A 12 inch turkey breast sub from Subway with 2 tablespoons mayonnaise, 2 pieces cheese, lettuce, tomato contains 870 calories (23). 820 Calories 320 Calories Calorie difference: 500 calories!

29 Portion distortion How many calories are in these restaurant meals?Outcome Participants will be able to see how portion sizes can impact calorie intake when eating out. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points Often when we prepare meals at home we have better control on the portion size and also the ingredients that are added. Restaurant meals are often harder to control. Some of the meals have the calories that some people need for the entire day. This could be due to the ingredients used but also the large amount of food in the dish. We can make healthier choices by choosing less healthy items less often, but also by watching how much of it we eat at a time. Activity Brainstorm with participants some strategies they can use when they eat out (e.g., order a half-size portion, share with someone, pack half for another meal or ask for dressing on side). Background Information The purpose of this slide to is show participants that there are some obvious unhealthy choices; others that appear to be healthier, like salad, aren’t always that much better. It is not meant to discourage participants from eating out but really to encourage them to consider their choices. Portion size is definitely a culprit too. Menu descriptions for items from Earl’s (24) restaurant (may not wish to disclose restaurant name): Pasta: tossed with grilled chicken, grana padano parmesan and cracked black pepper Burger: cured bacon, vine ripened tomatoes, onion, pickles, mayonnaise and mustard, on a freshly baked brioche bun Salad: feta, avocado, black beans, dates, in peanut lime vinaigrette, chicken Always a good idea to take a look at restaurant websites to see what is in each meal and find better options. Chicken fettuccini pasta Bacon cheddar burger & fries Santa Fe chicken salad 1350 calories 94 g fat 1140 mg sodium 1490 calories 82 g fat 2430 mg sodium 880 calories 44 g fat 2100 mg sodium

30 Portion distortion 2 servings reasonable portion 3 ½ servingscoffee shop size 5 servings large grocery store size Outcome Participants will be able to see how portion sizes can impact daily intake. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points Have group guess how many food guide servings are in each muffin. The first muffin about the size of a home made muffin. Compare this to ones you purchase at the store.

31 Portion distortion How many cups of pasta are in this portion?3 cup portion How many Food Guide Servings would this be? = 6 servings of Grain Products from Canada’s Food Guide Outcome Participants will be able to see how portion sizes can impact calorie intake when eating out. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points Have participants guess how many cups of pasta is on the plate and how many servings of Grain Products this is. Explain that this is more than half of your daily Grain servings on Canada’s Food Guide. When you have pasta out or even at home this is usually the amount you see on a plate!

32 Portion distortion How many cups of pasta are in this portion?2 cup portion How many Food Guide Servings would this be? = 4 servings of Grain Products from Canada’s Food Guide Outcome Participants will be able to see how portion sizes can impact calorie intake when eating out. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points Have participants guess how many cups of pasta is on the plate and how many servings of Grain Products this is. This one is less than the last photo but still many servings for one meal. Even though it is half a plate, it is piled quite high.

33 Portion distortion How many cups of pasta are in this portion?1 cup portion How many Food Guide Servings would this be? = 2 servings of Grain Products from Canada’s Food Guide Outcome Participants will be able to see how portion sizes can impact calorie intake when eating out. Key Messages Making healthier choices involves choosing moderate portion sizes. Sometimes it is hard to remember what a moderate portion size is when the average size of portions at restaurants and of prepackaged foods are getting bigger and bigger. Facilitator Notes Points Have participants guess how many cups of pasta is on the plate and how many servings of Grain Products this is. This plate has a smaller portion of pasta that. Ask if they have ever seen a portion this size when eating out. Have group discuss what they could add to the plate to have other food groups. Examples Mix in vegetables with the pasta sauce along with beans or meat Have a meat sauce on the pasta with a salad on the side

34 What is a healthy plate? ¼ plate meat or a meat alternative½ plate vegetables and fruits ¼ plate grain products Outcome: Participants will learn how the healthy plate can be used to ensure they are following Canada’s Food Guide. Key Message Imagine your plate divided into three sections: ½ of the plate vegetables and fruit, ¼ of the plate grain products, ¼ of the plate Meat and alternatives. Facilitator Notes Reference Quit Kit participant handbook page __ Points The divided plate shows what a healthy portion size is for all four food groups. It also is a tool to achieve balance and variety in your meals, helping you meet the recommended servings from Canada's Food Guide: ½ plate: vegetables (2 different types if possible) ¼ plate: grain products (1 or 2 servings of pasta, rice, bread, etc) ¼ plate: meat and alternatives (1 or 2 servings fish, poultry, meat, beans, tofu, eggs) Complete your meal with: Milk and alternatives (1 serving: 1 cup of milk or ¾ cup yogurt) Fruit for dessert if still hungry. Now that you have an idea of what your meals should look like, it might be easier to plan for them. It may help to take one day in the week to plan and shop for all of your meals at one time. Save your menus from week to week, and soon you will have several to work from just making seasonal changes, or changes to adapt to your changing schedule, and to add variety. You can also freeze leftovers in individual containers using the healthy plate model for a quick and healthy meal that’s ready to go when you’re short on time (21).

35 Healthy Plate What are some example meals you could have using the healthy plate? Outcome: Participants will learn how the healthy plate can be used to ensure they are following Canada’s Food Guide. Key Message The healthy plate model can be used for all meals, even one that are mixed together. Facilitator Notes Activity Have participants provide examples of how they could use the healthy plate when making meals or eating out. Examples include: Adding a salad to their restaurant meal as a side. Portioning their “meat and potatoes” supper similar to the healthy plate portion. Adding extra vegetable toppings to their sandwich and having a piece of fruit with their lunch. Use pictures on slide as a couple examples. Explain that the healthy plate works for meals that are mixed together also (example pastas and casseroles). The idea is to keep in mind the idea to increase fruit and vegetables in their meal while keeping meat and alternatives and grain and products at the portions described in the last slide.

36 Tips to help you eat healthier portionsEat within two hours of waking. Eat at least three meals a day. Eat more vegetables and fruit at meals than other foods. Turn off the TV or computer. Distractions can lead to mindless eating. Wait 20 minutes after eating before taking a second helping. Outcome Participants will be able to identify strategies to help eat healthier portions. Key Message Being very hungry may cause you to choose less healthy choices. Facilitator Notes Reference QuitKit participant handbook page __ Points You heard right, breakfast is an important meal. It allows your body to “break” from the “fast” that happened between the last time you ate overnight and waking up. Eating breakfast starts your metabolism (analogy: revving car engine). Eating food is like putting gas in your car. To get an even ride, you would want gas to fill the system constantly. Eating every 4 to 6 hours means eating at least three times over the day. If you are hungry between meals, have a small snack (refer to following slides) or have 5 or 6 small meals (21). Background Information Some participants in previous sessions were worried that eating constantly would mean they are overeating. It is important to stress listening to their body cues of hunger and satiety and so long as snack foods are healthy choices, the risk of overeating will be minimized.

37 6. Choose healthy drinks Drink water throughout the day.Keeps you hydrated, flushes out toxins, and reduces cravings. Limit drinks with added sugar. It is very easy to drink in anywhere from an extra 500 to 1000 calories a day. Drink milk at meals. Aim for two cups of low-fat or fat-free milk per day. Outcome Participants will understand how to choose healthy drinks. Key Messages Drink water throughout the day. Water should be chosen first as a healthy drink It is very easy to “drink in” anywhere from an extra 500 to 1000 calories a day. Facilitator Notes Reference QuitKit participant handbook page __ Points Your body needs water to regulate body temperature and to carry nutrients to all your organs. Water also transports oxygen to your cells, removes waste, and protects your joints and organs. Water is naturally calorie free and should be chosen first as a healthy drink. Drink water throughout the day. There are many drinks that are marketed as water that still have sugar or artificial sweeteners added. Be sure to check the label so that it contains no calories or artificial sweeteners. Extra calories often come from pop and other sugar-sweetened drinks such as iced tea, fruity beverages, sports drinks and ice slushes. With the rise of the chain coffee houses, creamy coffee drinks are also popular (28). Calories from drinks can really add up and can contribute to excess weight gain. Think of these as “liquid candy” as they are high in sugar content and have no nutrients. Alcoholic drinks also provide additional calories but do not have any nutritional value. One 350 mL (12 ounce) bottle of beer is about 150 calories, and one 125 mL (4 ounce) glass of wine or 50 mL (1.5 ounces) of spirits (gin, rum, vodka or whisky) is about 100 calories. Choose milk or milk alternatives (fortified with calcium and vitamin D) every day. Low-fat and fat-free milks are the best option. Milk contains calcium, vitamin D and protein. Adults should aim to have 2 cups of milk a day to help meet vitamin D and calcium requirements. 65

38 Portion distortion How many calories are in this coffee? 305 calories!20 Years Ago: Coffee (whole milk and sugar) Today: Mocha Coffee (whole milk and mocha syrup) Calorie difference 305 calories! Outcome Participants will be able to see how portion sizes have increased over time. Key Message It is very easy to drink in extra calories. Facilitator Notes Points A cup of coffee with 2 milk and 2 sugar has approximately 45 calories. Today’s typical coffee choice may be more like a mocha coffee. It is 350 calories (22). The difference is 305 calories. It would take a 130 pound person about 1 hour and 20 minutes of walking to expend this number of calories (22). Background Information (Note: may not wish to disclose the brand or company name) Starbucks grande cafe mocha with whole milk (16 ounce) has 400 calories, 14 grams saturated and trans fat Starbucks grande hot chocolate with whole milk and whipped cream (16 oz) has 450 calories and 14 grams saturated fat (equivalent to eating three hot dogs). Tim Hortons large Hot Smoothee (14 ounce) has 330 calories (equivalent to eating 8 strips of bacon because of the powder mixes and flavour ingredients). Second Cup medium Green Tea Latte (16 ounce) has almost 470 calories and 12 grams saturated and trans fat, which is almost as much as a McDonald’s quarter pounder with cheese (25). Tim Horton's “double double” medium has about 150 calories, and a large has about 230 calories (26). Soy milk has about the same calories as 1% milk and about the same fat as 2% milk (27). 45 calories 8 ounces (250 mL) 350 calories 16 ounces (500 mL)

39 Tips for choosing healthy drinksUse fresh lemon or lime slices to flavour water. Take a water bottle with you. Keep cold water in the fridge. Add a splash of 100% juice to plain sparkling water for a refreshing low-calorie drink. If you do choose a sugar-sweetened beverage, go for the small size. Outcome Participants will be able to identify strategies to help choose healthy drinks. Key Messages Drink water throughout the day. Water should be chosen first as a healthy drink It is very easy to “drink in” anywhere from an extra 500 to 1000 calories a day. Facilitator Notes Reference Quit Kit participant handbook page __ Points Use fresh lemon, lime or other citrus fruit slices to flavour your water. Cucumber slices can also add a refreshing taste. Take a water bottle with you wherever you go. Keep water bottles clean by washing daily in hot soapy water and rinsing well. Keep a jug of cold water in the fridge. Avoid stocking the fridge with sugar-sweetened beverages.

40 Quitting Support Technique #18 Physical activityGOAL To “burn” calories To stop the hunger To cut down on urges (hard to use tobacco while exercising) To make you feel good To help with stress, boredom and tension Outcome Participants will be able to describe ways to be more physically active to stay or become healthy. Key Message Canada’s Physical Activity Guide offers more guidance on being physically active for good health. Facilitator Notes Reference QuitKit participant handbook page __ Handout Canadian Physical Activity Guidelines for adults Years Points Being active has many benefits (refer to bullet points) and can be a positive distraction during your quit journey. Regular physical activity can help protect you from heart disease and stroke, high blood pressure, type 2 diabetes, obesity, back pain and osteoporosis; can improve your mood; and can help you to better manage stress. Be sure to talk to your doctor before starting a physical activity program to help minimize your risk of overworking your heart as your body adjusts to being smoke free. Background Information For a health benefit, experts recommend that you do 150 minutes of aerobic activity a week and some type of muscle strengthening activity at least 2 days a week. Those with poor mobility should do physical activities to enhance balance and prevent falls. (CSEP, 2010) If you have been inactive for a while, you may want to start slowly with less strenuous activities such as walking or swimming at a comfortable pace. Beginning at a slow pace will allow you to become physically fit without straining your body. Once you are in better shape, you can gradually do more strenuous activity. Find copies of the Canadian Physical Activity Guidelines at: 67

41 Quitting Support Technique #18 Physical activityFind an activity you enjoy and stick with it. Fit activities into your day: Take the stairs, walk after eating, park farther away. Get enough sleep. Stay positive: Make time for yourself each day, reward yourself. Consider streaming the Dr. Mike Evans 23.1/2 hours video from the QuitCore facilitator video folder. It is also available on YouTube on the My Favourite Medicine Channel. 67

42 Homework Do not use tobacco. Follow the steps for healthy eating.Use the strategies to reduce food cravings. Choose healthy foods. Increase physical activity. Review and Update “My Quit Plan.”