What constitutes a healthy diet for babies and toddlers under five years old? Sarah Almond, a registered dietician, discusses this query with reference to examples of the nutritional standards of food served in a range of childcare settings

As an extension of their work on healthy eating in schools, East Sussex County Council Trading Standards recently conducted the Nippers’ Nutrition study, to look at the nutritional content of food provided to children in childcare. Increasingly, children are spending full days at nursery so their main source of nutrition will be obtained there. Eating patterns are established in childhood, and if the current trend in obesity and other dietary related illnesses is to be reversed, action should be taken here.

There is a recognised link between poor diet and ill health. Diseases such as coronary heart disease, obesity and some cancers are directly linked to food. A nutritionally balanced diet can protect from such diseases and ill health later in life. Children’s diets have been a national concern for several years; the rate of childhood obesity has doubled since 1992 (DoH, 2004). The most recent National Diet and Nutrition Survey revealed that the diets of children under five were low in vitamins A and C, iron and zinc. They were also high in sugars and high in salt. This group of children is also known to have low blood vitamin D status and a poor intake of fruit and vegetables (Gregory et al1995).

Nippers’ Nutrition
There are no detailed legislative guidelines for meals provided in childcare settings. The current Ofsted guidelines (2001) and the DfES publication Healthy School Lunches for Pupils in Nursery Schools/Units (2000) are unspecific and open to interpretation. Further research is contained in the Ofsted publications Starting Early (2004) and Food for Thought (2006), but these have not been widely publicised. There are 104 nurseries in East Sussex that provide meals for their children. All were invited to join in the survey and 10 volunteered. This accounted for 600 children, of whom 329 ate meals in the settings. The 10 settings represented a comprehensive coverage of socio-economic status, with a mixture of nurseries preparing their own meals and others obtaining their meals from outside caterers.

Structure of the survey
One week’s worth of meals (breakfast, snacks, lunch and supper) was taken from each of the nurseries. The nurseries were asked to ensure that each portion represented what they would typically serve to a child. The samples were collected daily to avoid any errors and were submitted for laboratory analysis to ascertain the exact nutritional content of each meal.

Each nursery also completed a questionnaire on their food and their healthy eating policy. The results were analysed by a paediatric dietician, who compared them with the nutritional guidelines produced by the Caroline Walker Trust (2006). Mini-reports were then written for each nursery, grading them on their food and providing them with advice and guidance on how to make improvements where necessary.

Each nursery was given one-to-one training on how to improve their menus, including advice on how to read food labels and interpret nutritional information. They were also given a healthy eating advice booklet, sample menu plan and a recipe ideas booklet for future reference. Fun events for the children also took place, including a ‘Taste, touch and smell session’ with fruit and vegetables, along with displays and information leaflets for parents.

Results of the survey
The main finding from this project was that the majority of nurseries appear to be confused or misinformed about what healthy eating for children under five entails. The majority of nurseries were providing food that was too low in energy and fat and too high in fruit and vegetables. Portion sizes were small because the food was too filling. It appeared that nurseries were applying the principles of adult healthy eating to the food they were supplying to young children, putting children at risk of developing nutritional deficiencies. In brief, the survey found that only:

  • 2/10 nurseries excelled in their provision of meals
  • 2/10 nurseries provided the correct portion sizes
  • 3/10 nurseries provided adequate energy
  • 2/10 nurseries provided adequate fat
  • 2/10 nurseries met the guidelines for salt levels
  • 3/10 nurseries were providing oily fish once a week.
  • All the nurseries failed to meet the requirement for iron.

This project has highlighted the lack of detailed regulation surrounding nutrition for infants and young children. The Caroline Walker Trust guidelines used in this project are voluntary guidance only, despite being produced by a multidisciplinary expert group. There appears to be confusion about what constitutes healthy eating for children under five. Nurseries receive advice from a variety of authorities such as local authority bodies, early years advisers, Ofsted, dental hygiene advisers and the Food Standards Agency. However, some of this advice may at times be conflicting. Finally, the media appears to be responsible for projecting an image of a growing obesity problem amongst the young, which may have made nurseries adopt extreme measures regarding healthy eating.

Within the welfare requirements of the Early Years Foundation Stage there is a requirement that, where children are provided with meals, snacks and drinks, they must be healthy, balanced and nutritious. However, even with proper guidance it is clear that there is a need for training on infant and toddler nutrition for all practitioners in childcare settings, to help them to interpret guidelines for the production of nutritionally balanced meals and snacks.

What constitutes a healthy diet for children under five years old?

Healthy eating for under-fives differs significantly from that for school-age children and adults. For growth, young children need a plentiful source of energy from carbohydrates and fats, alongside protein, vitamins and minerals. This can be achieved by ensuring that, every day, children eat from the four main food groups:

  • bread, cereals and potatoes
  • fruit and vegetables
  • milk and dairy foods
  • meat, fish, eggs and vegetarian proteins (eg beans, pulses, soya).

Energy

Energy-rich foods are needed for normal growth and activity. This is fundamental in children under five, as this is when muscles and bones are growing rapidly and the brain is developing. Fat, protein and carbohydrate all supply the body with energy. The amount each child needs is determined by their growth rate and activity level.

Fat
Fat is the most energy-dense nutrient. Infants need 50% of their energy from fat; by the age of five this is reduced to 35% – the same as adults. Fat provides essential fatty acids that cannot be obtained from anywhere else in the diet, nor can they be synthesised in the body. Fat is also an excellent source of vitamins A and E.

There are two types of fat: saturated and unsaturated. Saturated fats (mainly from animal sources) are harmful in large quantities, so it is better for children to have unsaturated sources such as vegetable and olive oils and spreads, and oily fish. Young children should have whole milk until they are at least two, when they can change to semi-skimmed so long as the rest of their diet is balanced with full-fat dairy products such as cheese, yoghurts and fromage frais. All ‘light’, ‘low fat’ or ‘diet’ products should be avoided.

Omega-3 fats or ‘fish oils’ are proven to be important for brain development in infancy and beneficial for ensuring a healthy heart in adults. Oily fish are the best source of Omega 3 and also contain a wealth of other important nutrients such as protein, zinc and iron, and so are nutritionally superior to supplements. The recommendation is for two portions of fish per week. However, only one portion should be an oily fish, due to the high levels of mercury that these farmed fish contain.

Carbohydrate
Most of the energy the body needs should come from carbohydrate – sugars and starches. Sugars are not needed in the diet but, as a small amount can make foods more palatable, a little sugar is acceptable. The majority of carbohydrates should be starches – found in bread and flour, potatoes, pasta, breakfast cereals, rice and other grains. The speed at which different carbohydrates are digested is called the glycaemic index. Low-GI foods are absorbed more slowly and are preferable. But too many low-GI foods can hinder small appetites, so care should be taken when applying this principle to young children.

Fibre
The indigestible part of cereal foods, fruit and vegetables, fibre is found in the wholegrain versions of bread and flour goods, breakfast cereals, brown rice and pasta. It helps to prevent constipation, as it bulks out the stool, making it softer and easier to pass. But high-fibre foods are filling and often have a low GI, and can interfere with the absorption of iron and zinc; so limit their use for children under five .

Protein
Protein is needed for growth and repair of the body’s tissues. In the UK we all eat ample protein for our needs. Protein-rich foods are meat, poultry, fish, soya, beans and pulses, eggs and dairy products. Even children following a vegetarian diet eat plenty of protein.

Vitamins and minerals
Eating a balance of foods from each of the four food groups should ensure that adequate vitamins and minerals are obtained in the diet. However as the diets of British preschool children are known to be inadequate, the Department of Health recommends that all children up to five years receive drops containing vitamins A, C and D. These are available free of charge through the Healthy Start Scheme.

Special considerations for children under five
Young children have small stomach capacities, so small portions are necessary. However, kilo for kilo, they have far higher nutrient requirements than adults and their needs cannot be met from meals alone. It is therefore recommended that they should be offered three small snacks in between meals to ensure that nutrient requirements are met, while not ruining their appetites. Healthy snack ideas include toast with butter or margarine, breadsticks or crackers with dips such as tzatziki or houmous, cheese and crackers, crumpets or scones.

References

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