Key learning points:
– More than 20% of two to four year olds are overweight or obese
– Large portion sizes might be one of the many factors contributing to childhood obesity
– Advising parents and carers on appropriate portion sizes for preschool children may help prevent and manage childhood obesity
With childhood obesity considered to be one of the most serious public health concerns of the 21st century, understanding how best to support families to eat healthily has never been so important. Eating habits established early in life will continue through childhood into adulthood; therefore it’s important that children are encouraged to eat healthily from a young age. This paper considers how large portion sizes might be a contributing factors to childhood obesity and the advice that healthcare professionals might offer to parents of preschool-aged children (between one to four years of age) about healthy eating and suitable portion sizes.
Obesity in preschool children
It is estimated that more than one in five children in England aged two to four years are overweight or obese.1 Obese children are likely to become obese adults and have an increased risk of developing various health problems, such as type 2 diabetes, before they even reach adulthood. In addition, some risk factors for heart disease, including high blood pressure, high blood cholesterol and insulin insensitivity are starting to appear in some obese children.2 Being overweight or obese during childhood has been linked to a number of chronic diseases in adult life, including type 2 diabetes, heart disease, and middle-age mortality.1 Immediate health consequences of childhood obesity may also include musculoskeletal problems, obstructive sleep apnoea, asthma and a number of psychological issues such as depression.2 The preschool age is an important window of opportunity to create healthy lifestyle habits and preferences to reduce the risk of obesity in later childhood and adulthood.
Evidence suggests that as many as 90% of parents underestimate the weight status of their overweight or obese preschool-aged child, meaning these parents may be less likely to offer them the support they need to achieve a healthy weight.1 Healthcare professionals can contribute to wider efforts to both prevent and manage childhood obesity by advising parents about healthy eating in childhood.
Portion size and obesity
Factors in our surroundings encourage us to eat unhealthily and not do enough exercise have contributed to the recent rise in obesity.3 One factor in the ‘obesogenic environment’ that is thought to contribute to excess intake is large portion sizes of energy dense foods.4 The trend towards bigger portion sizes is most apparent in the USA where portion sizes of numerous foods have increased significantly since the 1980s.5 Portion size changes in the UK are less well documented but are thought to mirror those in the USA, particularly for snacks and fast foods. For example, larger pack sizes of foods such as crisps and confectionery and an increase in ready meal serving sizes were noted in the UK in 2008.6 There is also the suggestion that, in the home, bigger plates and drinking vessels can encourage people to serve larger portions and over eat.7
Establishing early healthy eating patterns that include appropriate portion sizes of energy dense foods is considered to be a part of a comprehensive approach to obesity prevention.8 Helping parents acknowledge the potential impact of unsuitable portion sizes in young children in the development of obesity will encourage them to consider whether they are feeding their child appropriately. It is paramount that healthy eating messages are communicated to parents when their child is of preschool age, before food habits become entrenched and before their child reaches an age when they have more control of when, what and how much they eat.
Portion size regulation in preschool children
While very young children tend to be good at regulating their energy intake, this can change as they grow older when environmental cues and parental behaviours begin to influence food choice and portion control.9 Although the age at which this happens is unclear, research suggests that by the time children reach three years old, they tend to be influenced by factors other than biological signals of hunger and fullness.5 There is also some interesting evidence suggesting that certain children are more genetically predisposed to overeating than others and eat more in response to environmental cues, such as the amount of food on their plate.10
Children have a natural preference for sweet, energy-dense foods11 and can very quickly become accustomed to eating too much of these foods. Therefore, it is really important that parents feed their child in a way that encourages them to eat appropriate amounts of food and to develop preferences for healthy foods. Forcing toddlers to finish everything on their plate and using puddings/sweets as rewards to finish other courses are some of the ways in which parents can have a negative impact on children’s ability to self-regulate food intake.12
Guidelines for portion sizes in preschool children
Appropriate portion sizes for preschool children can be complex to determine, with a variety of factors to consider including energy and nutrient content; context, for example, whether the food is eaten on its own or as part of a meal/snack; and the child’s age, weight and activity level. Yet this information will help parents and caregivers of preschool children to understand how to feed their child a healthy, balanced diet that provides enough energy to meet their child’s needs for activity, growth and development but not too much to cause inappropriate weight gain. A common anxiety among parents is that their toddler is not eating enough.13 Guidance on appropriate food intake and portion sizes might reassure parents and reduce the likelihood of them pushing their child to consume inappropriately large portions of food.
However, there are currently no official government recommendations on the proportion or amounts of foods from the four main food groups; bread, other cereals and potatoes, fruit and vegetables, milk and dairy foods and meat, fish and alternatives such as: eggs, pulses, nuts that preschool children should be eating. This is apart from the suggestion that between two and five years, children should gradually move to eating the same food as the rest of the family in the proportions shown on the Department of Health’s eatwell plate (see resources section).
Several organisations including Caroline Walker Trust,5 Scottish Executive,16 and Children’s Food Trust,17 have made recommendations about the proportions of the main food groups in preschool children’s diet and the portion sizes of foods within those groups. In all of these, the recommendations are for children to eat a varied diet made up of foods chosen from the four main food groups every day. Preschool-aged children receiving adequate amounts of foods from these four main food groups should receive all the nutrients they require (with the exception of vitamin D, where supplements are recommended for under-fives). But what are appropriate portion sizes?
Following a government review in 2010, portion sizes have been usefully outlined in the Children’s Food Trust Voluntary Food and Drink Guidelines for Early Years Settings in England.17 They suggest a range of portion sizes for meal and snack foods, which are designed to meet the nutritional needs of children aged one to four years. It is important to bear in mind that these are guidelines rather than precise recommendations as the needs of young children will vary due to differences in age and weight but also on a day-to-day basis dependent on activity and appetite.
Recently, the British Nutrition Foundation has produced a guide on healthy eating for one to three year olds (see resources section) designed to help parents, carers, health professionals and early years providers understand the basics of healthy eating in this age group and suitable portion sizes. This evidence-based resource was developed with input from an expert group; a full description of its development has been published.11
The guide gives examples of foods and portion sizes suitable for children aged one to three years and advises that each day children of this age group need three meals and some snacks made up of five portions of starchy foods, five portions of fruit and vegetables, three portions of dairy foods and two portions of protein foods (three portions if the child is vegetarian). Users of this guide must remember that a toddler’s appetite tends to fluctuate - they may eat lots of food one day and much less the next – and that some toddlers will need more foods than others, therefore a range of portion sizes are provided. The recommendations in this guide are largely similar to others; however they may vary slightly due to being developed using different methods and for different age ranges.
To halt the tide of childhood obesity, intervention in the very early years is necessary. Health care professionals can play an important role in influencing the health and wellbeing of young children because of the opportunity of contact and the trust that their patients have in their advice. This can include providing information to parents and carers about how to establish healthy eating in the early years.
British Nutrition Foundation’s guide to the eatwell plate:
British Nutrition Foundation guide on healthy eating for one to three year olds:
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14. Public Health England. Your guide to the eatwell plate. 2014. www.gov.uk/government/uploads/system/uploads/attachment_data/file/340869/2014-250_-_eatwell_plate_Final_version_2014.pdf (accessed 26 May 2015)
15. Crawley H. Eating well for under-5s in child care. Practical and nutritional guidelines St Austell: Caroline Walker Trust. 2006. www.cwt.org.uk/wp-content/uploads/2014/07/Under5s.pdf (accessed 26 May 2015)
16. Armstrong J. Nutritional guidance for early years: food choices for children aged 1-5 years in early education and childcare settings: Scottish Executive; 2006. www.gov.scot/resource/doc/89729/0021563.pdf (accessed 26 May 2015)
17. Children’s Food Trust (2012) Eat better start better: voluntary food and drink guidelines for early years settings in England – a practical guide. www.childrensfoodtrust.org.uk/pre-school/resources/guidelines (accessed 26 May 2015)
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