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

Section 4 Other important aspects to consider

"A checklist of actions and considerations"

Encouraging eating well

All staff and professionals working in, or supporting work linked to, residential care settings are encouraged to demonstrate a commitment to the principles of health promotion, good nutrition and healthy eating. These principles should be considered when deciding how best to encourage children and young people in your care to eat well.

Residential care settings provide a primary home environment where children and young people live their lives. As such, implementing nutritional guidelines within this setting should be approached sensitively.

"I'd rather be able to just sit down and watch the telly or something, that's what I would do at my mum's. Just sit and watch the telly with my tray…" (Male, secure unit)

Listening to children and young people

Children and young people who are new to living life in a residential care establishment may require time to adopt healthier behaviours and additional support to adjust and feel comfortable eating in a group or dining room environment.

Good communication between staff and children and young people should be encouraged. Actively seeking the views of children and young people around their views on food and food-related issues should be integral to the day-to-day activities of the establishment.

"It depends what the cook's like. Some of them are ok and some aren't. It would be good if we saw them more and they were around the unit then we could talk to them ourselves about the food." (Female, secure unit)

Involving children and young people

All residential establishments are encouraged to involve children and young people in all matters relating to healthy eating such as food purchasing, developing ' food agreements' and menu planning.

Staff should recognise the need for children and young people to develop practical knowledge and skills around budgeting, shopping, food preparation and cooking so that they are better able to make appropriate choices, particularly when they are preparing to leave the residential care establishment.

Staff should be encouraged to develop a healthy eating policy for the residential establishment and fully involve children and young people in the process.

Staff as positive role models

Staff should be aware of their influence on the behaviour and attitude of children and young people living in residential care. As such, the opportunity to act as a positive role model should be encouraged. The principles of the ' eatwell plate' apply equally to children and adults. Where possible, staff and professionals should apply those principles to their own eating habits throughout the week along with their general attitude towards healthy eating and physical activity, when around children and young people.

"I didn't know how to cook toast and cheese but one of the staff she said to me: 'I will learn you how to cook French toast', and she learned me how to cook French toast, it was good. I was so happy for that staff because she said: 'I will teach you.'" (Male, children's unit)

Staff development and training

Staff should have access to suitable and appropriate training to support healthy eating for children and young people. The Scottish Institute for Residential Child Care and the Royal Environmental Health Institute of Scotland websites provide information and support on relevant training and development. You may also wish to contact the following for information and advice on staff development and training:

• Local authority
• Looked After and Accommodated Children Nurse ( LAAC)
• Local NHS Health Improvement Department
• Local NHS Dietetic Department

Purchasing of food

The importance of food procurement in supporting good nutrition for children and young people in residential care settings should be recognised. It should be noted that those purchasing and preparing food do so on behalf of children and young people in their corporate care. As a result, the type and quality of food purchased should meet the health and wellbeing needs of children and young people across the 24-hour day to ensure flexibility within a positive home environment. In order to ensure the thoughts and views of young people are taken on board, residential managers need to liaise fully with external food procurement officers.

"No, the shopping gets delivered. However, you can ask for stuff if you want it added to the shopping list. For example, we asked for younger drinks [drinks young people prefer] and magnum ice cream." (Male, children's unit)

"He's wasting money as well… We're telling him: 'We don't like it, naebody's going to eat it, you're wasting money putting it on', but he still puts in on. It just sits in the tray and gets wasted. (Male, residential school)

Religious and cultural needs

Staff are encouraged to familiarise themselves with different religious and cultural needs of children and young people in their care and to ensure that appropriate foods are provided which reflect their views and beliefs.

"Most Afghani boys, they do not like sweets, more they like spicy things... We've already told them we don't like them [sweet things], but they buy them anyway." (Male, children's unit)

Vegetarian and vegan diets

Many children and young people choose to eat a vegetarian or vegan diet. Staff should find out about the diets children and young people in their care are following and ensure that this is as varied as possible. In particular they should make sure that their diets include good sources of iron, zinc, protein and calcium.

Food intolerance & food allergies

Food intolerance is defined as an unpleasant reaction to a specific food or ingredient; a food allergy is a form of food intolerance. Common foods which can occasionally cause severe reactions include peanuts, shellfish, eggs, wheat and other cereals. If any child or young person living in a residential care establishment has a medically-diagnosed food allergy, appropriate medical advice and any dietary requirements which avoid specific foods or ingredients must be closely followed. Medical advice should always be sought before a large number of specific foods are excluded from the diet.

Special diets

Children and young people who have a special diet, such as gluten-free or lactose-free, must have these needs accommodated. Most local authorities have a special diet policy to ensure that these requirements are provided appropriately and efficiently. Staff should ensure that they are familiar with the procedures (where these exist) for accessing a special diet, and ensure that these are followed. It is important that staff preparing the food for a child with a special diet has sufficient information and training in order provide what is required. Medical advice should be sought if any member of staff is unsure about which foods are appropriate for a child with a special diet.

Children and young people with additional support needs

Children and young people with additional support needs may have particular problems associated with eating and require assistance and support. These problems must be detailed in an individual's care plan and should not be a barrier to enjoyment and participation in meals and food choice or to learning about healthy eating. Staff should have training to ensure that they can give the best and most appropriate assistance. Residential care facilities should develop appropriate policies for children and young people with additional support needs.

Meal time considerations

Breakfast

Children and young people should be encouraged to rise early enough to enjoy eating breakfast every day. Studies show that eating breakfast prepares individuals for the day ahead both mentally and physically and that eating first thing in the morning helps to stabilise blood sugar levels, which can help control appetite and energy.

Packed lunch

It is recommended that if providing packed lunches, they contain at least a third of the nutritional daily requirement of children and young people, and take account of the nutritional guidance in Section 3. Packed lunches should contain the following: a starchy food (e.g. bread, chapatti, pasta, wrap); a source of protein (meat, fish, or alternative such as cheese or eggs); two portions of fruit and vegetables; and a portion of milk and dairy foods (yoghurt, milk, cheese). A suitable drink should also be included. They should also take into account the rest of the food provided for that day, to ensure variety. Children and young people could be encouraged to be involved in preparing their packed lunch themselves, where possible.

Evening meal

A warm and friendly atmosphere should be encouraged at mealtimes where children and young people feel comfortable, have time to sit and talk to each other and are able to enjoy food. The quality and presentation of the food should look appealing to children and young people, especially when new foods are introduced.

Snacks and suppers

Children and young people may want to snack between meals to meet their daily requirement, especially if they are physically active or going through growth spurts. Snacks should be varied and nutritious foods encouraged rather than sweets, crisps and fizzy drinks.

Special occasions

This nutritional guidance should apply equally to food and drink provided for special occasions and celebrations. However, it is recognised that there may be times where people may choose to eat differently. It is important that food and drink can be used in this way within residential establishments. Suggestions may be to encourage themes or special nights which will offer variety. Children and young people should be involved in the planning of these events and their views taken into account. Consideration should be given to all food types when considering special occasions. It is important that some are marked with food that happens to be healthy whilst still being perceived as "special" rather than everyday. Foods such as exotic or out of season fruit, if experienced on a "special occasion" can then be more highly valued by association with the occasion.

Trips and outings

Staff should think carefully about food and drink when planning trips and outings. When eating outside the residential establishment, children and young people should be exposed to a wide variety of food outlets. Access to fast food-outlets should be limited and staff should avoid using these as treats for children and young people.

Important health issues for children and young people

Growth and development

Any concerns relating to a child or young person not growing adequately should be brought to the attention of relevant medical professionals for advice and guidance.

Promoting physical and recreational activity

Physical activity can enhance quality of life and self-esteem, prevent the onset of obesity and improve appetites for underweight children and young people. Staff should encourage children and young people to participate in physical activity of at least moderate intensity such as brisk walking, active play, sports and dance, for at least one hour per day.

"The staff are good at saying, like, if they think you need to start more exercise and that… 'We're worried about you being overweight'…, saying we can help you… Like, the nurse she comes in and does an exercise plan with you an' she's got, like, diet things for you with lots of information on them to help you." (Male, secure unit)

Mental and emotional wellbeing

Good mental and emotional health is a fundamental and underpinning component of positive health and wellbeing. Food and nutrition can play an important role in the mental health and wellbeing of children and young people, manifesting in a number of related issues such as self-esteem, body image and eating disorders. Staff are therefore encouraged to promote and foster a positive attitude within residential establishments towards emotional wellbeing, respect and caring.

Healthy body weight and image

Staff are encouraged to address issues around under/overweight sensitively. For many people, relationships between food eating and body weight can be complex and some children and young people may eat more or less food in response to emotional issues in their lives. Staff should also be aware of any teasing or bullying relating to appearance or weight and take appropriate steps to deal with the issue in a sensitive manner.

Eating disorders

Worries about weight, shape and eating are common, especially among teenage girls. A lot of young people, many of whom are not overweight in the first place, strive to be thinner for varying reasons. For some, worries about weight can become obsessive, leading to an eating disorder. Eating disorders are a group of conditions related to body image and abnormal eating behaviour. They can involve eating too much, eating too little, or using harmful ways to get rid of calories. Eating disorders can have a damaging effect on both physical and emotional health. The most common eating disorders are: anorexia nervosa; bulimia nervosa; compulsive eating or binge-eating disorder. Staff should seek medical support if they are concerned about a child or young person in their care.

Dental and oral health

The promotion of good oral health generally involves three key messages: healthy eating, good tooth-brushing skills and regular visits to the dentist and staff are encouraged to reflect this approach within the day-to-day running of residential establishments.

Nutritional records

Staff must maintain accurate and up-to-date nutritional records as part of each child or young person's individual personal plan. This must include the food allergies and special dietary requirements and meet the cultural or religious needs of the child or young person. It should also include their food preferences.

(This is to meet regulation 35 (b) (1) of The Looked After Children (Scotland) Regulations 2009 supported by the National Care Standards ( Standard 10 for care homes and Standard 11 for school care accommodation).

For additional information on these and related issues, you may wish to look at Caring About Health: Improving the health of looked after and accommodated children in Scotland which contains a series of short focused documents.