PUBLIC HEALTH
Judy More Paediatric Dietitian and Member of the Infant & Toddler Forum (ITF) Judy has specialised in Paediatric nutrition for over 25 years. She has worked in both Australia and the UK in NHS teaching hospitals and community trusts, as well as in private clinics. Judy is a lecturer and accomplished food and nutrition writer.
REFERENCES Please visit the Subscriber zone at NHDmag.com
FROM THE INFANT & TODDLER FORUM
SUPPORTING PARENTS TO UNDERSTAND PORTION SIZES It can be difficult for parents to determine how much food to offer young children. Recently, Public Health England (PHE) has warned that children are eating three times more sugar in a day than their recommended allowance, with half of this coming from unhealthy snacks and sugary drinks. Research from the Infant & Toddler Forum (ITF) has shown that parents are unwittingly giving their toddlers too much food. The survey asked 1000 UK parents to look at images of portion sizes and decide which ones they felt would be appropriate to give to their one- to four-year-olds.1 The majority (79%) of respondents routinely offered portions bigger than the recommended size range for preschoolers and around 10% of parents usually served their child close to an adult-size portion when serving popular meals. With evidence linking larger portion sizes to excess weight gain2 and with one in five being overweight by the time they start school,3 parents need more practical advice.
PORTION SIZES FOR TODDLERS
The ITF has developed a user-friendly guide on how much food to offer children aged one to four years. The visual guide is presented as a factsheet at www.infantandtoddlerforum.org/healthchildcare-professionals/factsheets and shows how many portions from each of the food groups should be offered each day and the portion size range of each particular food to offer. Following this guidance will meet the nutritional needs for activity, growth and development. Portion size ranges are used due to the fact that precise, or fixed portion sizes are not useful for one- to fouryear-olds. This is because the amount of food they eat varies considerably from meal to meal and from day to day. The
Figure 1: Sample day’s menu for a toddler with portion sizes
BREAKFAST
Y2~1slice wholemeal toast 2-4 Tbs scrambled egg
LUNCH
2-4 Tbs grated cheese Y2-1slice wholemeal bread 1-4 cherry tomatoes
DINNER
SNACKS
'/4-1small fillet salmon 1-4 small florets broccoli 2-4 medium potato wedges
) Y2-lkiwifruit
'/2-1small pancake 3-10 small berries
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www.NHDmag.com April 2018 - Issue 133
1pot of yoghurt (125mil
3-10 cherries
Table1: Healthcare professionals can advise the following: Include foods from all food groups each day to provide all the nutrients. Have a routine and offer three meals and two to three nutritious snacks each day; don’t allow grazing on food. Offer two courses at each main meal. Limit high calorie low nutrient foods - crisps, packet snacks, pastries, cakes and biscuits to very small amounts. Avoiding them altogether may lead to unsocial behaviour when a toddler does encounter them. Avoid high-sugar drinks including fruit juices and smoothies. Toddlers need to be offered a drink of 3-4oz or 120mLs with each meal and snack. Water is the best choice. Limit milk drinks, as toddlers need much less milk than babies and an excess intake can lead to iron deficiency and anaemia.
ranges have been developed by comparing them with reported average amounts eaten by healthy young children in the ALSPAC studies and the 1995 UK National Diet and Nutrition Survey for children one and half to four and a half years of age4-8 and in other countries.8,9 They were published along with the scientific rationale in The Journal of Human Nutrition and Dietetics in 2015.10 The energy and nutrient content of daily combinations of a variety of the foods from the ranges were calculated using the midpoint of the portion size range. These daily combinations meet the UK estimated average energy requirements11 and Reference Nutrient Intakes (RNIs)12 for this age group for all nutrients except vitamin D which is not expected to be met by food alone. Practitioners can use these portion size ranges to help parents to understand when they may be overfeeding and to reassure parents who worry that their toddler is not eating enough. Other factsheeets for practitioners can be found on the ITF website (see below). These explain in more detail the aspects of the behavioural side of feeding toddlers well. ALLOWING CHILDREN TO EAT TO THEIR APPETITE
Over a week, most toddlers regulate their appetite to meet their energy and growth needs quite accurately and so can be allowed to eat to their appetite - to stop eating when they have had enough. Toddlers signal satiation by saying “no”, shutting their mouth, turning their heads
away or pushing the food away. When parents offer large portion sizes and coerce children to eat everything on their plate, they can inadvertently override children’s self-regulation systems. Larger portions can then begin to form acceptance about what is an appropriate amount to eat and this then becomes the ‘norm’. Most toddlers will overeat sweet foods; carefully observing portion sizes can prevent this. REWARDING WITH ATTENTION, NOT FOOD
Toddlers are best rewarded with attention such as hugging, playing, reading, or talking with them. If food or drinks are given as a reward, treat, or for comfort, this can encourage eating when not hungry and can develop comfort eating. It’s best to give fruit or a nutritious pudding as a second course, thereby providing a wider range of nutrients at the meal and not using this sweet course as a reward for eating the first savoury course, or for good behaviour. THE ITF: WHAT WE DO
The ITF promotes best practice in healthy habits from pregnancy to pre-school through reliable clear evidence-based advice and simple practical resources aimed at practitioners and healthcare professionals. ITF is supported by an unrestricted educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests.
More information and practical advice on supporting families: Portion sizes: For parents - www.infantandtoddlerforum.org/portionsizes and the range of ITF Fact sheets for healthcare professionals - www.infantandtoddlerforum.org/health-childcare-professionals/factsheets For email more information on face-to-face training, contact info@infantandtoddlerforum.org @InfTodForum or www.facebook.com/InfantandToddlerForum - www.infantandtoddlerforum.org/ www.NHDmag.com April 2018 - Issue 133
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PUBLIC HEALTH
Supporting parents to understand portion sizes Table 2: Examples of portion sizes within each food group Bread, rice, potatoes, pasta and other starchy foods - offer a serving at each meal and some snacks. • ½-1 slice wholegrain or white bread or ¼-3/4 bread roll • 3-6 heaped tbs wholegrain or fortified breakfast cereal without a sugar coating Fruit and vegetables - offer at least one to two servings at each meal and also offer them with some snacks. • 3-10 small berries or grapes • 2-4 tbs raw, freshly cooked, stewed or mashed fruit Milk, cheese and yoghurt - serve three times each day. • 3-4oz (100-120ml) whole cow’s milk as a drink in a cup • 1 small pot (125ml) yoghurt or 2 x 60g pots of fromage frais • About 20g cheese Meat, fish, eggs, nuts and pulses - serve two to three times per day - twice for young children eating meat and fish and three times a day for vegetarians. • 2-4 tbs ground, chopped or cubed lean meats, fish or poultry • ½-1 whole egg Oils, butter and fat spreads - include small amounts twice a day, and choose high omega-3 oils, e.g. rapeseed, olive and soya oils. • 1 tsp oil • 1 tsp butter or fat spread Sugary foods and packet snacks: • Toddlers under two years of age have lower energy requirements and should not be offered any sweet puddings, cakes, biscuits, confectionery, chocolate or savoury snacks such as crisps. • Over two years of age offer small amounts of sweet foods and salty snack foods but these should be limited to: – once a day: ½ -1 digestive biscuit or 1-2 small biscuits or 1 small slice cake or pudding. – if given, limit to once a week only: 4-6 crisps, or 2-4 sweets, or 1 small fun-sized chocolate bar, 1 sweet drink.
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