Health Promotion Guidance: Nutritional Guidance for Children and Young People in Residential Care Settings

Section 3 Nutrition Guidance

"A practical guide for providing a healthy diet for children and young people in residential care"

Introduction

Children and young people need the right balance of food and nutrients to develop and grow. Healthy eating is about getting that balance right in order to provide enough of the important nutrients (such as vitamins, minerals and protein) and fibre without too much fat (especially saturated fat), sugar and salt.

Imbalances in diet can contribute to children and young people developing a number of serious diet-related diseases and conditions over the course of their lifetime. On the other hand, improvements to the diet of children and young people can positively influence their current and future health.

Childhood obesity is widely recognised as an increasing problem. Obesity can affect many aspects of children's lives including their physical, mental and emotional wellbeing. In addition, obesity may continue into adulthood and lead to a number of serious health conditions including some types of cancers, diabetes, coronary heart disease and stroke.

In terms of dental health, there has been a positive improvement in children's dental health in the last 30 years. Nevertheless, Scotland's children compare poorly with the rest of the UK and by primary 7, more than a third show signs of obvious decay. Diet plays a significant role in the prevention of poor oral health. The main cause of tooth decay is related to the amount and frequent consumption of sugary foods and drinks. Evidence shows that the incidence of dental erosion is increasing in industrialised countries. This is a condition where tooth enamel is eroded due to acids present primarily in drinks such as soft drinks (carbonated and still) and fruit juices.

The ' eatwell plate' shows the types and proportions of foods needed to make up a healthy balance diet. The balance can be achieved over the period of a week by choosing:

• Plenty fruit and vegetables - at least five a day
• Plenty of bread, rice, potatoes, pasta and other starchy foods - choose wholegrain varieties whenever you can
• Some milk and dairy foods - choose lower fat varieties
• Some meat, fish, eggs, beans and other non-dairy sources of protein - choose lower fat meat and meat products. Include at least one portion of oily fish a week
• Just a small amount of foods high in fat and/or sugar
• Fewer salty foods

This section offers guidance on putting the principles of a healthy balanced diet into practice when planning menus and making food choices. In making changes to food provision in residential establishments, the aim is to ensure children and young people have access to a healthy diet that supplies their requirements for growth and development and reduces their risk of diet related diseases now and into the future.

Offer a variety of foods

Children and young people need a healthy balanced diet which is rich in fruit, vegetables and starchy foods. They need to be encouraged to choose a variety of foods to help ensure that they obtain the wide range of nutrients they need to stay healthy. For more information on the good sources of nutrients refer to Healthy Eating in Schools- A guide to implementing the nutritional requirements for food and drink in schools (Scotland) Regulations 2008.

Increase fruit and vegetables

Why is this important?

It is desirable to increase fruit and vegetable intake because:

• Fruit and vegetables provide a wide range of vitamins, minerals, fibre and other naturally occurring beneficial components. Current recommendations are to eat at least five portions of a variety of fruit and vegetables each day as part of a healthy balanced diet.
• Very few Scottish children and young people eat the recommended amount of five or more portions of fruit and vegetables a day.
• Low consumption of fruit and vegetables remains one of the most concerning features of the Scottish diet.

How much should be provided?

To ensure children and young people eat the recommended amount of fruit and vegetables a day, a choice of fruit and/or vegetables should be provided every day as part of all meals and snacks.

• Minimum of five portions of fruit and/or vegetables a day.

"They always give you vegetables, you canny talk round it." (Male, children's unit)

What is a suitable portion of fruit or vegetables for children and young people?

The amount of fruit and vegetables that children and young people should eat depends on their age. For young people of secondary school age and adults, a portion of fruit or vegetables is approximately 80g. There are no set portions for children. However, a guide for children of primary school age would be to serve at least half an adult portion at the early stages and move towards a full adult portion toward the end of primary.

What fruit and vegetables should be included?

All types of fruit and vegetables whether fresh, frozen, canned or dried can be included. Fruit and vegetables that are added to dishes such as fruit jelly, fruit crumble, soups, stews, casseroles, pasta-based dishes and sandwiches can count as a portion if the fruit or vegetables are added in sufficient amounts. Fruit juice can count as a portion, but only once per day.

Pulses (e.g. beans and lentils)

Pulses, for example baked beans, kidney beans, lentils and chick peas can be classified as either a protein food or vegetable. However, they can only make up a maximum of one portion of vegetables each day, even if several portions are available. This is because pulses don't give the same range of vitamins, minerals and other nutrients as other vegetables.

What foods are not counted as a fruit or vegetable portion?

Potatoes

Potatoes do not count as a vegetable portion because they are classified as starchy foods which are also an important part of a balanced diet.

Products canned in tomato sauce, e.g. canned spaghetti

Canned spaghetti in tomato sauce and similar products cannot be counted as a vegetable portion. This is because spaghetti is a starchy food, and tomato sauce does not contain the same mix of fibre and vitamins and minerals as a standard portion of vegetables.

Practical guidance

• Different fruits and vegetables contain different combinations of fibre, vitamins, minerals and other nutrients so offer a variety of fruit and/or vegetables at every meal and snack occasion, and over the week for children and young people to get the most benefit. For example, peas should not be on the menu every day and, if serving salads regularly, try to include different types of fruit and vegetables.
• Offering colourful foods with a variety of tastes and textures stimulates children and young people's interest in fruits and vegetables as well as challenging their palates.
• All staff should be aware of the benefits of eating fruit and vegetables. Where practical, they should encourage children and young people to enjoy these.
• Add extra vegetables and pulses to stews, casseroles or other dishes, and add fresh, canned fruit in natural juice or dried fruit into desserts and puddings.
• Children and young people may prefer raw vegetables (e.g. cucumber, tomato, carrots, celery). Offering them repeatedly may improve acceptance.
• Soups are popular with children and young people and are a useful way of increasing vegetable intake; vegetable-based soup should contain a minimum of one portion of vegetables per serving, and can then be counted as one portion of vegetables. If using manufactured vegetable soups, it is important to look for lower fat, saturated fat and salt varieties.
• Add fruit to breakfast cereal, yoghurt or porridge.
• Fruit juice is recommended to be given only at meal times. It has a high sugar content and is acidic, and therefore drinking this outwith meal times can contribute to tooth decay.
• Dried fruit has a high sugar content and is recommended to be given at meal times only, as it sticks to teeth and can cause tooth decay.
• Fruit-based desserts, fruit crumble, fruit jelly or fruit pie, are popular options. When adding fruit to these dishes, try to ensure that each serving contains at least one portion of fruit.

Maximising desirable nutrients

Some vitamins and minerals can be easily lost when fruit and vegetables are prepared, cooked or stored so bear the following in mind.

• Use fresh fruit and vegetables soon after purchase as the vitamin content will decrease the longer they are stored.
• Frozen fruit and vegetables can be used as their vitamin content is retained.
• Cook fruit and vegetables as soon as possible after preparing. If this is not possible, cover and chill them.
• Cook in a minimum amount of water - steaming, microwaving, or boiling in minimal water.
• Serve vegetables as soon after cooking as possible.

Minimising salts, sugars and fats in canned foods

• Use fruits canned in natural fruit juice.
• Use vegetables and pulses canned in plain water or natural juice without added salt or sugar.
• To limit the amount of salt, reduce the use of pickled vegetables, e.g. pickled onions and pickled beetroot as these can be high in salt.

Increase oily fish

Why is this important?

Oily fish are those which contain certain types of beneficial fats in their flesh. They are a rich source of long-chain omega-3 fatty acids which have a number of health benefits including helping maintain a healthy heart. Children in Scotland and other parts of the UK do not eat enough oily fish and need encouragement to consume more in their diet.

How much should be provided?

Oily fish is recommended to be provided a minimum of once a week.

What fish are included?

Examples of oily fish include fresh, canned or frozen salmon, mackerel, trout, herring, sardines, or pilchards and fresh or frozen tuna.

What fish are not included?

While canned tuna is a healthy choice, it does not count as an oily fish as the majority of long-chain omega-3 fatty acids are lost in the canning process for tuna. Other canned oily fish are not affected in the same way.

White fish have only very small amounts of these fats in their flesh, so do not count as oily fish, but they do provide valuable minerals and protein.

Practical guidance

• Offer regular small taster portions to introduce children and young people to fish dishes they may not have tried before. Small tasters are a very good way of helping children to accept new or less familiar foods.
• Offer a variety of dishes over time to encourage children and young people to keep eating oily fish. Try fish in dishes that children and young people are familiar with such as curry, pasta and pizza.
• Kippers on toast could be offered as an option at breakfast.
• Use oily fish as a filling for sandwiches, wraps, kebabs and baked potatoes. It can also be used to make paté or served with salad.
• Mix oily fish such as salmon and white fish to make fish cakes, gradually increasing the proportion of oily fish used.
• If purchasing manufactured fish products, it is important to make sure they are lower fat, saturated fat and salt varieties.

Increase starchy foods and fibre

Why is this important?

Starchy foods such as bread, pasta, rice and potatoes provide energy, a range of vitamins and minerals and are a good source of fibre. Children and young people should be encouraged to fill up on these types of foods to satisfy their appetites.

How much should be provided?

Starchy foods should make up about a third of the food we eat. Every meal and most snacks should contain a portion or portions of starchy food.

What foods are included?

Bread, potatoes, pasta, rice, breakfast cereals, oats, noodles, maize, millet, cornmeal and other cereals.

Practical guidance

Bread

• Most types of breads are low in fat so are acceptable. These include brown, wholemeal, granary, high-fibre white and white breads, pittas and rolls. The form of the bread does not matter, so sliced bread, home-made bread, baguettes, bagels, and chapattis may all be used.
• Promote wholegrain, wholemeal or brown bread varieties as much as possible as they contain more fibre than white bread.
• Some breads have a lot of fat added to them and this makes them unsuitable to offer every day. These include butteries, croissants, parathas and garlic bread.
• Bread is one of the main sources of salt in the diets of people in the UK. When purchasing bread, it is important to select varieties with the lowest sodium content.
• Providing extra bread as a meal accompaniment is recommended and should be easily accessible at mealtimes to encourage children and young people to eat it, for example, a bread basket on the table. Preferably, extra bread should be served without the addition of fats or spreads.
• Bread is a good basis for snacks, for example, toast and sandwiches. Offer different types of bread to provide variety.

Breakfast cereals

• Breakfast cereals may be offered at breakfast time or as a snack. Many varieties are fortified with iron, folate and other nutrients providing an important source of these in the diet. As they are served with milk, this provides additional calcium and nutrients.
• Try to choose cereals that have less added sugars and salt, for example wheat biscuits, cornflakes, rice snaps and unsweetened puffed wheat.

Other starchy foods

• Use a variety of starchy foods to provide a good selection and variety on the menu. For example couscous or noodles as an alternative to rice or potatoes.
• Wholegrain varieties such as wholegrain pasta and rice are suitable for children and young people and contain more fibre and nutrients.
• Try to ensure that sauces and dressing are low in fat and salt and served separately where possible.
• Fresh cooked potatoes can be served in many different ways which provides a variety of textures: mashed, boiled, oven baked or as potato wedges.
• Potatoes cooked in oil such as chips or other shaped potato products should be served less frequently due to their fat content. If served, they should be oven baked rather than fried.
• Baked potatoes are a good snack item and can also be served as part of a main meal as an alternative to other varieties of potato.

Reduce fat

Why is this important?

As part of a healthy diet, it is not only important to cut down on the amount of total fat eaten, but also to replace saturated fats with unsaturated fats (e.g. polyunsaturated and monounsaturated fats), which are a healthier alternative. Foods that are high in fat are also high in calories and therefore can contribute to obesity.

"Last night, it was lasagne, and cauliflower and broccoli cheese sauce. They've both got cheese sauce on them, that canny be healthy." (Male, residential school)

Saturated fats contribute to the risk of heart disease by raising blood cholesterol levels. Both polyunsaturated and monounsaturated fats have less of an effect on blood cholesterol levels and therefore help in reducing the risk of heart disease.

What foods are included?

Oils, fat spreads such as butter and margarine, deep-fried foods and other foods that are high in fat such as pastry-based products, mayonnaise, fatty and processed meat.

Foods that are deep-fried either in the kitchen or during the manufacturing process are high in saturated fat. It is important to challenge the culture in Scotland of regularly eating chips and other deep-fried foods and aim to encourage children and young people to eat a healthy balanced diet containing a variety of types of food.

Practical guidance

• Fat spreads rich in monounsaturated/polyunsaturated fats are the most suitable. These include rapeseed, olive oil, sunflower and soya-based choices. These can be spread on breads and used in cooking and baking.
• Oils which are rich in monounsaturated and/or polyunsaturated fats are the most suitable. These include olive, rapeseed (canola), safflower, sunflower, corn, soya, walnut, linseed, sesame seed and nut oils.
• Use oils and fat spreads sparingly by:
  • limiting the amount of oils in cooking and dressings; and
  • limiting the amount of fat spreads added to bread, sandwiches, potatoes and vegetables. If using mayonnaise in fillings for baked potatoes and sandwiches then it is not necessary to also use spread.
• Grill or bake rather than fry items.
• When frying, always use clean oil, ensure that the oil is at the appropriate temperature and the food is not immersed in the oil for too long. It is advised to change your oil before it foams, froths, smokes, changes colour or smells rancid. Using the right temperature and timing helps prevent too much fat being absorbed.
• The number of times deep-fried foods appear on the menu should be limited. For example chips, potato waffles, pakora, and battered and breaded products such as fish fingers and potato shapes.
• If serving chips, they should only be served as part of a meal and not on their own.
• If purchasing manufactured products, it is important to make sure they are lower fat, saturated fat and salt varieties.
• Where possible, use leaner cuts of meat (e.g. about 10% fat).
• Remove skin from poultry before cooking (except when roasting) and trim visible fat from meat during preparation.
• Limit processed meat products such as sausages as these tend to be high in fat.
• Limit the frequency of high-fat or pastry-based desserts and pastry items on the menu.
• Reduce the use of high-fat snacks (see page 23).
• Avoid over use of cheese and creamy sauces which can be high in saturated fat. Use semi-skimmed milk instead. Small amounts of strong cheese will provide all the flavour but with less fat.

For more specific guidance about which oils and fat spreads to use please refer to Healthy Eating in Schools guidance.

Reduce salt intake

Why is this important?

Most children and young people consume more salt than they need. Consuming too much salt increases the risk of high blood pressure, which may then lead to heart disease or stroke. It is the sodium in salt that can have harmful affects on health. Some foods contain other forms of sodium, such as those used as flavour enhancers (e.g. monosodium glutamate) and raising agents (e.g. sodium bicarbonate).

"Everything's reduced salt in here - tomato sauce, mayonnaise - everything… They've just started buying reduced salt baked beans." (Male children's unit)

What foods are included?

Foods that are high in salt such as savoury snacks and manufactured products, salt added at the table and during cooking.

Practical guidance

• Limit the amount of salt used in cooking, and replace it with other flavourings such as garlic, lemon juice, herbs and spices.
• Choose foods that have a lower salt content when purchasing manufactured foods such as boullion or stock cubes for soup.
• Reduce the use of ready-made products and sauces which may be high in salt. Try home-made alternatives.
• Do not add salt to food after the cooking process. It should only be given on request and not be freely available.
• Limit the use of condiments (e.g. tomato ketchup, brown sauce, salad cream, pickles and relishes). These are generally very high in salt. Do not sit these on tables where children and young people have easy access, and allow only small portion sizes for example a couple of teaspoons.
• If serving condiments as part of a meal, serve separately, for example, tomato sauce with a burger.
• Reduce the frequency of high-salt snacks (see advice on snacks).

Reduce sugar

Why is this important?

Foods which contain large amounts of added sugar are high in energy but provide very few nutrients. In Scotland, we eat more sugar than is required which can affect both obesity rates and dental decay.

Limiting sugary drinks and confectionery will help to improve dental health by reducing the frequency that children and young people consume sugars. It will also improve the overall diet by restricting foods high in sugar and fats that may be over consumed and lead to overweight and obesity. Sugar-free sweets also provide little nutritional value and push out other more nutritious food from the diet.

What is included?

Confectionery and sweets, sugary drinks, desserts, cakes, biscuits, pastries, ice-cream, and added sugar are all included. Please also see advice about sugary drinks.

Practical guidance

• Adding sugar to tea, coffee and on breakfast cereal should be discouraged. Sugar should only be given on request and not freely available.
• Desserts should only be served as part of a meal.
• As much as possible, desserts offered should be fruit- and/or milk-based.
• Desserts can be made more nutritionally beneficial by modifying recipes:
  • to include fresh fruit, canned fruit in natural juice or dried fruit
  • to include nutrient-rich and fibre-rich ingredients such as oats and wholemeal flour to reduce the fat and sugar content.
• Limit the portion size of desserts.
• Children and young people should always have a healthier dessert choice available, for example fruit, yoghurts, and fruit-based desserts such as fruit salad and baked apples.
• If you are purchasing any manufactured dessert products, e.g. ice-cream, fruit pies and sponge puddings, look to buy lower sugar and fat varieties.
• It is recommended that confectionery is provided on limited occasions only. Limit the frequency of cakes, biscuits, ice-cream and tray bakes on the menu. Cakes and biscuits should not be a substitute for confectionery.
• Cocoa powder (not drinking chocolate) can be used in cakes, biscuits, puddings as an alternative to using confectionery or chocolate.

Advice on snacks

Children and young people who are active or who are going through a growth spurt may have big appetites and want snacks between meals. Children and young people should be able to choose snacks as part of a healthy balance diet. This means keeping high fat, salt and sugar choices to a minimum. It is recommended that fruit, bread and sandwich fillings are always available. Crisps and biscuits can be provided on occasion but their consumption is not recommended on a daily basis.

Suggested snacks

• Any type of bread including white, brown or wholemeal bread, fruit bread, crumpets, teacakes, muffins, fruit buns, malt loaf, bagels, pitta bread, raisin toast, and scones.
• Sandwiches made with any type of bread. Suggested spreads and fillings include: hard-boiled egg, peanut butter, banana, hummus, cheese, cheese spread, mashed avocado, any lean meat, tinned fish, a vegetable or salad such as tomatoes, lettuce, cucumber, peppers, watercress, salad leaves and combinations of any of these. Toasted sandwiches can also be made.
• Plain biscuits such as crackers, oatcakes, rice cakes, melba toast, and crispbread.
• Plain popcorn without added salt or sugar.
• Raw vegetables such as carrots, celery, cucumber, peppers or tomato can be served with dips made from for example fromage frais and soft cheese, hummous, yoghurt and cucumber, avocado and salsa.
• Any fresh or tinned fruit. Dried fruit such as raisins, sultanas, apricots, dates and figs may also be provided to offer variety, but it is advisable to keep these to meal times due to their high sugar content and the effect on teeth.
• Dairy foods such as yoghurts, small cheese cubes, frozen yoghurt and rice pudding.
• Breakfast cereals.
• Vegetable-based soups.
• Unsalted nuts and seeds. Please also see Section 4 for advice on food intolerances and allergies.

Reduce high-fat and salt snacking

Why is this important?

Children and young people need to be encouraged to eat a healthy balanced meal. Savoury snacks such as crisps tend to be high in fat and salt and can push foods out of the diet which may contain important nutrients.

What is included?

Savoury snacks such as crisps, salted nuts and seeds, corn puff or corn snacks, tortilla chips, pretzels, sweetened or salted popcorn, prawn crackers, and flavoured rice cakes and Bombay mix.

Practical guidance

Savoury snacks should, where possible, be low in fat, salt and sugar. For a recommended product specification refer to Healthy Eating in Schools- A guide to implementing the nutritional requirements for food and drink in schools (Scotland) Regulations 2008.

• Crisps can be offered as part of a snack or meal option as an alternative texture and taste but as they are mostly high in fat and salt, the portion size and frequency with which they are offered should be limited.
• Combinations of nuts, seeds and dried fruit, plain popcorn and fruit and vegetable snacks can all be served provided they have no added salt or sugar but keep in mind that nuts are naturally high in fat.
• Be aware of nut allergies. Always refer back to allergy policies.

Advice on drinks

There is significant concern about the level of sugar consumption by children and young people in Scotland, particularly in relation to sugary soft drinks.

Sugary soft drinks provide little in nutritive value except calories from sugars, and these sugars can contribute to tooth decay. The excess consumption of sugary soft drinks also imbalances the diet, which in turn may displace important nutrients in the diet or may contribute to weight gain.

It is recognised that the frequent consumption of soft drinks, including sugar-free varieties (e.g. sugar-free/diet fizzy drinks and flavoured waters), can also contribute to tooth erosion because of the acidic nature of these drinks (e.g. from acidic flavourings). Limiting any drinks containing sugar to mealtimes is beneficial as more saliva is produced which will reduce the acid in the mouth.

We recommend that the most suitable drinks to be served are those listed below:

• Plain water (tap or carbonated)
• Skimmed, semi-skimmed milk and other lower fat milks
• Milk drinks and drinking yoghurts
• Fruit juices and vegetable juices
• Pure fruit smoothies
• Drinks made with a combination of fruit juice and water

Other drinks which could be served occasionally include:

• Diluting juice (including those with no added sugar)
• Tea and coffee
• Fizzy drinks (including sugar-free varieties)

Practical guidance

• When fruit is juiced or blended, sugars are released from the cells of the fruit. It is advisable to limit fruit juice, pure fruit smoothies and drinks made with a combination of fruit juice and water to mealtimes.
• If children and young people are thirsty, encourage them to drink water, particularly between meals.
• Milk is an important source of nutrients, and in particular, calcium which is important for growth. Plain skimmed, semi-skimmed and other lower fat milks are ideal drinks and can be encouraged as a drink between meals.
• Fizzy drinks (including diet varieties) should only be provided on limited occasions. Using fizzy water to dilute fruit juice is an acceptable alternative.
• Sports drinks and energy drinks can be popular but are high in sugar and calories. For this reason we recommend that they are only provided on limited occasions.
• Tea and coffee may reduce the amount of iron absorbed from food. Therefore it is advisable not to serve these drinks to young children whose intakes of iron may be low due to small appetites.

For further advice on drinks see the Healthy Eating in Schools guidance.

Menu planning

Menu planning is very important in achieving a well-balanced and healthy diet for children and young people in your care. It should take account of the guidance given above, and be based on the 'eatwell plate' (below), which shows the types and proportions of foods needed to make up a well-balanced, healthy diet over the period of a week. This can be used to develop a written menu covering all food provided, i.e. meals, snacks and drinks.

In many residential settings, a child or young person's full daily dietary intake will be provided by the establishment, in others they may have lunch at school, college or work. Menu planning should take into account the overall balance of the diet as illustrated by the ' eatwell plate':

• the number of meals and snacks being served
• variety in taste, texture and nutrients
• providing choices acceptable to the children and young people. This will also be dependent on children's prior experience with food
• that this is a home-type setting for children and young people
• the facilities and equipment which are available.

Changes to menus should be introduced gradually to ensure they are accepted by children and young people. They should be consulted at the development stage of planning a menu to ensure their opinions, tastes and ideas can be incorporated where possible. Planning menus at least a week in advance is advisable and these can also be shared with the children and young people. Feedback on menus should also be regularly collected to ensure that these continue to be appealing.

"Aye, I go to [cash and carry] with them but they buy it in bulk… They pre make the list… Sometimes they ask you - 'what do you think of this or do you want that?' - but it's a very rare occasion." (Male, residential school)