One in five children starting school in England is classed as overweight or obese. It is clear measures to tackle obesity need to reach children and their parents earlier.
Early years settings such as nurseries, pre-schools and childminders are well-placed to encourage healthy eating at an early stage, embedding knowledge and understanding that will help a child make healthy choices throughout their life, explains Jo Baranek, lead early years adviser at the National Day Nurseries Association (NDNA).
"Educating children and encouraging healthy eating as a habit from early on is crucial," she says. "Nurseries have that close contact with families and can work together on giving children the best nutritional start."
How well settings do this does vary, according to Diana Hawdon, nutrition and care setting adviser at the Soil Association, which extended its Food for Life accreditation scheme to early years settings in 2016. "But generally early years practitioners are more clued up than schools are," she adds.
In May this year a health select committee report called for more training for the early years workforce around healthy eating. The committee also noted that many initiatives put forward in the government's obesity plan, published in 2016, have not yet seen the light of day, including a healthy rating scheme for primary schools.
One initiative that did take place was the development of revised menus for early years settings, which were incorporated into voluntary guidelines put together by charity The Children's Food Trust in 2016. But in 2017 the charity closed due to lack of funding. Action for Children has taken on leadership of its Eat Better, Start Better programme, which includes training and resources designed to help improve children's food in early years settings. The charity is also now guardian of the food and drink guidelines, which are currently still hosted on the Children's Food Trust website.
In June this year the government published the second part of its obesity plan. The report acknowledges the importance of tackling habits and behaviours that result in obesity before they become entrenched. It also commits Ofsted to undertaking research into what a curriculum that supports good physical development in the early years looks like, including how children are taught about the importance of sleep and healthy eating.
However, the regulator's approach has come under fire. Ofsted's recently-published report on how schools should encourage healthy eating was criticised by the Soil Association, which was so opposed to its findings it insisted its name be removed from the final document. The report suggested schools should focus their efforts on building up knowledge and skills through the curriculum, rather than taking the whole-school, community-led approach advocated by the Soil Association.
"Our obesity study provided no evidence of a relationship between a school's approach to healthy living and the levels of obesity in the school," says an Ofsted spokesperson. "What it did find is that where schools were teaching their pupils effectively about healthy eating and exercise, many of those children and their parents were making positive changes as a result."
Ofsted looks at issues relating to healthy eating in its early years inspections, both as part of the curriculum and in terms of the food children are given. Inspectors look at the personal development, behaviour and welfare of young children, which includes checking the extent to which settings are promoting and supporting young children's knowledge of how to keep themselves healthy. The statutory framework for the Early Years Foundation Stage includes requirements about food and drink, such as "where children are provided with meals, snacks and drinks, they must be healthy, balanced and nutritious".
However, many settings feel their efforts are not recognised. "There isn't enough recognition of the lengths you have to go to serve really good food," says Kimberly Munro, owner of Cheshire nursery Blue Grass Purple Cow - see below.
Emma Comer, managing director of Tall Trees Kindergarten in Somerset agrees that Ofsted appears not to prioritise the issue. Her setting holds a gold Food for Life award, a Soil Association programme that centres on four areas of development: food quality and where food comes from; food leadership and food culture; food education; and community, partnerships and parent engagement. Settings must sign up to commitments including ensuring at least 75 per cent of dishes are freshly prepared from unprocessed ingredients and growing food with the children using safe organic methods.
Sound nutrition facts
The menu at Tall Trees is 95 per cent organic in line with the setting's natural ethos. Comer's interest in early years nutrition arose when her son was born weighing only a pound. "I wanted to give him the best nutrition in his first five years," she says. "Everything is based on sound nutritional facts: we don't use salt or refined sugars, we provide lots of high-calorie foods which include good fats such as local butter or organic olive oil. We always use slow-release carbs, so children don't experience that crash."
Most day nurseries either prepare their own food or buy it in from a nearby school or catering company. "Having an on-site kitchen and chef is great until they are off work for whatever reason," says the NDNA's Baranek. "It does depend on the size of the nursery as some employ a team of chefs. You also have to make sure you comply with all regulations and have visits from the environmental health officer."
However, cooking in-house means a nursery can control what's going into the food including the amount of salt and what allergens are present. Buying in meals from school caterers can be inappropriate for early years settings, since very young children have different dietary requirements. Funding pressures on school caterers over the last 12 months have also resulted in a fall in quality in some cases, with healthier items replaced by cheaper products.
Some nurseries say providing healthy food does not have to cost more. "If we are making a beef casserole we get organic meat from Abel and Cole, but we will mix with organic haricot beans which makes the meat go further," says Comer, who believes the cost of a full-time chef is the real challenge. Tall Trees' approach is very popular with parents, who are willing to pay extra for the reassurance it provides.
However, not all nurseries can pass costs on to parents, even when they are charging for meals. "Some nurseries charge parents of funded children for meals, but that money doesn't tend to cover everything such as the cost of a chef and running a kitchen, so it's a challenge on current funding rates," says Baranek.
There are a number of schemes that aim to help nurseries with the cost of providing healthy food. For example, some 200 nurseries use the FareShare FoodCloud scheme, which enables charities and community groups to collect surplus good-quality food from participating Tesco or Waitrose stores for free. Meanwhile more than 400 children in six nurseries are part of a pilot programme run by the NDNA and global charity Vitamin Angels. Each nursery receives free weekly deliveries of fresh fruit and vegetables, along with protein-rich foods like beans, eggs and yoghurt. Staff can select food from a list of options to complement the snacks or meals they already offer.
Little Rascals Pre-school in Lincolnshire is one of the nurseries taking part. Manager Corrina Wells says the setting is able to provide a wider range of food than before. "One boy who is a bit of a fussy eater had never had hummus before; he took it home with some carrot and cucumber and mum has started to buy him that sort of thing now." Since taking part in the programme Little Rascals has been improving the quality of the food it offers such as filling jacket potato skins with a mix of potato and veg.
Young children learn from watching adults, so early years practitioners have to make sure they practice what they preach when it comes to healthy eating. "This is tricky because you can't tell staff what they can and can't eat, but you can insist on what they eat in front of the children," says the NDNA's Baranek. "In high-quality nurseries, staff sit and eat with the children but must never eat anything inappropriate like crisps."
Training and support is available for nurseries that want to improve the way they approach healthy eating. The NDNA recommends Henry, a charity set up to help young children get a healthy start in life, while its own publications include Healthy Snacks, Happy Children and Let's Bake and Create. With obesity in children starting school rising for the second year in a row, it has never been more important to promote healthy eating in the first years of life, stresses Baranek.
"Encouraging eating healthily in nursery sets the children up with the knowledge and understanding for life," she concludes.
Child measurement scheme
Understanding the impact of work to promote healthy eating and exercise at an early age is an important part of the equation when it comes to tackling childhood obesity.
In May this year the health select committee recommended the development of a national system along the lines of the Child Health and Monitoring Programme (Champ) scheme developed in Manchester, which gathers data on school-age children and is now being tested in early years settings.
Six per cent of children in Manchester are severely obese. In 2016 Manchester University NHS Foundation Trust - then Central Manchester University Hospitals NHS Foundation Trust - committed to measure every primary-aged child every year as part of efforts to tackle the problem.
Around 46,000 measurements a year are carried out by school nurses. Parents are invited by text, email or letter to keep abreast of their child's growth via an online portal, where they can access a digital growth chart, communicate with health professionals and learn more about healthy growth through childhood. Being able to access this data at a time and place of their choosing can alleviate the anxiety and anger some parents feel when told their child is over or underweight.
The scheme also helps health and other partners monitor overall trends and take action and there is evidence it is making a difference to individual families.
"Through annual measurements, Manchester has unprecedented intelligence regarding the growth patterns of the primary school population," explains a Manchester University NHS Foundation Trust spokesperson. "Children of families who receive online growth feedback are more likely to follow healthy growth trajectories than those whose families are not engaged with the system."
The scheme is currently being tested in nurseries, with a pilot scheme offering parents feedback on their child's growth from an earlier age.
Children help prepare healthy meals
Forget fairy cakes - the children at Blue Grass Purple Cow are more likely to be preparing a pesto with home-grown basil and rocket, or creating a crumble with apples harvested from the nursery garden.
"Every week the pre-school children make something the rest of the nursery will enjoy," says owner Kimberly Munro. "They learn where ingredients come from, plus all that learning that comes from measuring, reading a recipe, writing a label, turn-taking, developing fine motor skills. It's all relevant to the Early Years Foundation Stage curriculum."
Munro oversees two cooks, drawing on her own experience and her additional training in catering for specialist groups. "It is important to me that we serve freshly prepared food every day, with no added salt or sugar but lots of herbs to make it flavoursome," she says. "We provide a huge variety of colour, taste, and texture, and that gives children a strong foundation for healthy eating for the rest of their lives."
Afternoon tea consists of bread fresh from the oven with a topping and fruit or vegetable, such as cream cheese and olives or apricot jam and dried apricots. "Some people say dried apricots are a no-no because they are so full of sugar, but I am teaching children they can reach for a natural sugar treat not a processed one, and that fruit comes in all forms," says Munro.
Babies are also well catered for, with purees freshly made on site. The nursery supports baby-led weaning in consultation with parents and health visitors, par-boiling vegetables so they are soft enough for babies to feed themselves.
Munro adapts meals to fit with topics the children are exploring, hence "cowboy casserole", or "caveman pie". "If we are reading The Rainbow Fish, for example, we might have salmon, tuna and cod on the menu but the next week we might not have fish at all," she says.
Children rewarded for trying new foods
At lunchtime children at New Beginnings' three Essex day nurseries might be munching homemade Thai fishcakes served with mixed vegetables, while teatime might see them tucking into sweet potato and butternut squash soup. The menus, which are revised every term and rotate on a monthly basis, have been put together with support from the Soil Association. At the beginning of the year the group obtained a Food for Life Early Years Award from the association.
Trainee quality assurance manager Ellie Wiggins plans the menus, alongside the group's cooks. "We message parents to get suggestions and feedback, and look at the menu to ensure we include five fruit and vegetables a day, as well as a vegetarian alternative," she explains. "We pay particular attention to teas and try to make them varied for the children as often that is something nurseries struggle with."
At New Beginnings the cooks are part of the everyday life of the nursery. "We encourage them to cook with the children," says Wiggins. "We also have a growing area. Children plant fruit and vegetables and when they are ready to be picked take them to the cook and they are used in dishes."
The cooks are also involved with the nursery's Eater of the Day award. "Every day a child from each room gets a sticker," says Wiggins. "It's not just rewarding children who eat everything on their plate - maybe a child tried something they didn't really want to. The cook comes in with the sticker and asks who it will be for, and we promote it on social media for those who are allowed to be identified."
Learning about healthy eating is not confined to the dinner table. "At circle time we might ask the children to identify what is healthy and what isn't from a box of foods," says Wiggins. "We use flashcards so the children can try identifying fruit and vegetables, we run food tasting activities, so children can try different textures and flavours, especially if they are fussy eaters not keen on certain foods."