Diet and Health

Healthy eating and physical activity are essential foundations of growth and development in childhood. To help children develop healthy eating patterns from an early age it is important that the food and eating patterns they are exposed to both in and outside the home promote positive attitudes to food and good nutrition (1).Growing children need to eat a variety of foods to ensure they have enough energy and nutrients to grow and develop well. There is evidence that the diets of children under the age of 5 living in Britain are low in vitamins A, C, iron and zinc. Their diets also contain too much salt and cariogenic sugars with poor intakes of fruit and vegetables. Some children also have a low vitamin D status which can lead to poor bone health (2).Obesity, heart disease and some cancers can be linked to diet (3). The prevalence of childhood obesity has increased dramatically between 1993 and 2005 (4).The document Healthy Weight, Healthy Lives (2008) states “Introducing children to healthy foods, controlling portion size and limiting snacking on foods high in fat and sugar in the early years can all help to prevent children becoming overweight or obese” (5).

The Caroline Walker Trust (1) states that the number of children who spend time cared for outside the home has risen considerably with an estimated 1.5 million registered childcare places in England in 2005 compared to approximately 637,000 in 1997. 52% of these were in day nurseries, 21% with childminders and 24% in out of school clubs. A significant proportion of the total food eaten by a large number of children, many of whom are under 5 years of age is therefore supplied by day care providers. It is therefore important that children in these settings are provided with nutritionally appropriate food and drink. The Early Years Foundation Stage, (compulsory from September 2008) includes the requirement that all meals, snacks and drinks provided for children must be healthy, balanced and nutritious (5).

The Caroline Walker Trust

The Caroline Walker Trust (CWT) was established in 1988 to improve health through good food choices. The CWT has published nutritional guidelines for children under 5 years of age in child care (1). These apply to all childcare settings including childminders and nursery schools.

Methodology

10 nurseries across Hampshire were recruited to participate in this project.

Sampling

Each nursery was asked to supply an average sized serving of all food and drinks given to a representative 3 year old throughout the day, for 1 week. The meals and snacks were collected during the week by a member of the Trading Standards department. Food from each nursery was sent to Hampshire Scientific Services to determine the nutritional content. The samples were analysed for energy, protein, carbohydrate, sugars, sucrose, fat, saturated fat, salt, calcium, iron, zinc, and fibre. The results were interpreted by a paediatric dietician. Each nursery was also asked to supply a copy of the menu for the week analysed, and any other relevant information which related to food provision at the nursery.

Questionnaire

At the same time a short questionnaire (adapted from that previously designed by East Sussex Trading Standards department), was sent out to each of the participating Nurseries. The aim of the questionnaire was to obtain additional information regarding meal provision and nutrition, in relation to the CWT guidelines.

Interpretation of results

Data from the nutritional analysis and the questionnaire was used to investigate how each nursery compared to the CWT nutrient based standards. Areas for improvement were also identified where appropriate. A formal report was produced for Hampshire Trading Standards Department with individual reports for each nursery.

Follow up

A member of the Trading Standards department arranged to visit each nursery with the individual reports to discuss the findings.

The Guidelines

Nutrient based standards

The CWT nutrient based standards for food prepared for 1-4 year olds provide figures for the recommended energy and nutrient content of an average day’s food and drink for an average child based on the recommended average nutrient content of meals and snacks provided over a one week period. This comprises:

• Mid morning snack

• Lunch

• Mid afternoon snack

• Tea

Breakfast is not included as it is presumed that this is given at home in most circumstances.

The CWT guidelines are derived from average Dietary Reference Values (7) (DRV’s) for boys and girls and additional recommendations for salt intakes (8). The guidelines are based on 70% of a child’s DRV requirement for energy and most nutrients, and no more than 70% of the maximum recommended amount of non milk extrinsic sugars (NMES) and sodium/salt. The remaining 30% is expected to be achieved at home. The recommendations apply to children who attend all forms of childcare including playgroups, nursery units and reception classes.

Dietary Reference Values (DRV’s)

The DRV’s were published in 1991 by the Department of Health (7) and are benchmark intakes of energy and nutrients that a group of people in a certain age range (and sometimes gender) need for good health.

Energy

Energy is the amount of calories (Kcal) the food will provide when eaten. Energy comes from fat, carbohydrate and protein (and in adults from alcohol). 70% of this for a 1-4year old child is 903Kcal / day. Young children need diets which are relatively high in energy as they need energy for growth and development as well as for everyday activities.

Fat

Fat provides the most concentrated form of energy in the diet. Fat also provides vitamins A, D and E. Some fat is essential for growth and functioning of the body’s systems. Young children need 'essential fatty acids’ for healthy development. The optimal amount of fat required is calculated as about 35% of food energy, which equates to 35g / day. Fats can be divided into saturated fats derived mainly from animal sources and unsaturated fats(including omega – 3 fats) from plants and fish. Children under 5 should not be given low fat foods designed for adults (with the exception of semi-skimmed milk after the age of 2 years if children are eating and growing well).

Saturated fats

No guidelines are available for the requirement for saturated fat for young children. Recommendations for children and adults age 5 and over state that saturates should make up no more than 11% of food energy; however it is known that for children under 5 their intake is usually around 16% due to their necessary milk consumption. Thus 16% has been used as a maximum requirement figure which equates to approximately 15g / day.

Carbohydrate

Carbohydrate describes both starch and sugar in foods. Carbohydrate should provide about 50% of the total energy per day (120.4g / day). Most of this should come from starch, intrinsic sugars (sugars found naturally as part of the cell structure of unprocessed foods such as fruit and vegetables), and sugars found in milk (milk sugars). Foods such as confectionary, chocolate and soft drinks are not necessary in the diet. They provide energy but few other nutrients and can contribute to dental caries. Children do not need sugar for energy but can get all the energy they need from other carbohydrate foods.

Non -Milk Extrinsic Sugars (NMES)

NMES includes table sugar (sucrose) added to drinks such as tea and coffee, cereals , cakes biscuits and the sugar in soft drinks, confectionery and fruit juice including honey , glucose, maltose and fructose. The maximum level of NMES should not be higher than 11% of food energy (equating to 26.6g / day), as these cause tooth decay and provide few nutrients. The analysis for this project was for total sugars and sucrose only. Total sugars includes intrinsic sugars, milk sugars and non- milk extrinsic sugars and the analysis for sucrose excludes other non- milk extrinsic sugars. Therefore there is no figure for NMES to compare to the CWT guidelines and the total sugars and sucrose analysis cannot be commented upon.

Protein

Protein is needed for growth, maintenance and repair of body tissues .Good sources include meat, poultry, fish, dairy foods, eggs, soya and pulses. The CWT recommends 70% of the DRV should be provided (equating to 11g / day). Most children in Britain eat in excess of their requirement, so although 11g / day is the guideline for this project, it was expected that the levels eaten would be considerably higher.

Iron

Iron is needed for the function of several body systems including the pigment haemoglobin which carries oxygen in red blood cells. Iron is found in meat, fish, poultry, dried fruits and pulses including lentils and chick peas. A diet poor in iron can cause iron deficiency anaemia. Iron deficiency anaemia can lead to lethargy, vulnerability to infection and may affect immediate and long-term intellectual development and behaviour. 84% of children in Britain have iron intakes below the DRV and almost one in five have very low intakes (2). The CWT therefore recommends that 80% of the DRV for Iron should be provided in day-care (5.5mg /day).

Zinc

Zinc is needed by every organ of the body and the immune system. Young children in Britain have been shown to have poor intakes (2). The CWT guideline therefore sets 80% of the DRV (4.3mg /day) as the standard. Zinc can be found in meat, eggs, milk, cheese, wholegrain cereals, pulses and nuts.

Calcium

70% of the DRV for Calcium equates to 260mg /day. Calcium is necessary for many body systems and for building strong bones. Dairy foods are the best source of calcium.

Salt

The main source of salt is from that added to manufactured foods, used in cooking or at the table. High salt intakes can lead to elevated blood pressure in later life. Children who regularly eat foods such as salami, ham, tinned baked beans and spaghetti in sauce and salty savoury snacks are likely to be consuming too much salt. The salt guidelines from the Scientific Advisory Committee on Nutrition (SACN) are used (8). SACN have set targets for the maximum level allowed in the diet at 2.3g /day; thus 70% of this equates to 1.6g /day. Salt should not be added to the food of under 5’s.

Fibre

No guidelines are available for the requirement for fibre for children. Therefore it has been estimated based on the adult recommendation of 18g / day. Proportionately 1-4 year olds require no more than 8.1g / day. Fibre is found in fruits and vegetables, oats, wholegrain cereals and pulses. Caution should be exercised to ensure young children are not given excessive fibre intakes as this can interfere with absorption of some minerals and cause diarrhoea.

Incomplete data

Some of the nurseries did not supply all drinks required for all 5 days for comparison against the CWT nutrient based standards. In these instances average portion sizes (9) and nutritional content (10) per portion were added to the data from the public analyst in order to make each nursery directly comparable.

Portion size

The data for each nutrient from each nursery was formatted to equal an average portion size, in instances when the portion provided by the nursery appeared unusually large or small. This enabled each nursery’s meals to be directly compared with the CWT guidelines , against each other and to enable comparisons with the original East Sussex Trading Standards project to be made. The average weight of food eaten for 1-4 year olds ranges from 445g to 650g / day (range due to age) thus the average portion size used for a day’s worth of nursery meals equals 547g / day (6) (table 1).

Table 1 Nutrient based standards

Expected Weight(g)	547
Energy (kcal)	903
Fat (g)	35
Saturates	15
Total CHO(g)	120
NME Sugars (g)	26.6
Fibre(g)	8.1
Protein(g)	11
Fe (mg)	5.5
Ca (mg)	260
Zinc(mg)	4.3
Salt(g)	1.6

Other standards

As well as the nutrient based standards listed above, there are a second set of recommendations which are made based on the frequency of food groups offered (Table 2).

Starchy Food

Starchy foods such as bread, pasta, rice, potato, couscous and other cereals should be offered at each meal plus as snacks.

Fruit and Vegetables

Overall 5 portions of fruit and vegetables should be offered per day. They are particularly important for good health because of the vitamins and antioxidants they provide. The best way to offer these is 1-2 portions of fruit as pudding or as a snack and 2-3 portions of vegetables either served as part of a meal or as part of a snack.

Meat, Fish and Alternatives

These should be offered at each main meal, thus in the nursery setting this should be at both lunch and tea.

Oily Fish

Oily fish provide omega 3 fats in the diet. These are important for brain development in young children and also good for a healthy heart in adults. Children are recommended to have 1 portion of oily fish per week; however they should not have in excess of this as these fish can contain high levels of mercury which is considered to be toxic.

Table 2 Other standards

Food Group	Frequency to be offered
Starchy Food	At each meal plus snack
Fruit	1-2 /day
Vegetables	2-3/day
Dairy	2-3/day
Meat, fish & alternatives	At each meal
Oily fish	Once per week