Are our preschoolers getting good nutrition?

As a health care professional, social worker, parenting educator or early childhood educator, it is common for parents or carers to share with us the eating habit of their preschoolers. How can we, as professionals, advise parents on establishing healthy eating habit in their children? This article will guide you through some credible and practical healthy eating tips for preschoolers to share with parents and carers.

What and how much preschoolers should eat?

When we talk about what kind of food a preschooler should eat and how much to eat, we may think of the Healthy Eating Food Pyramid. The variety of foods and examples of servings covered in the Healthy Eating Food Pyramid for Children (2-5 years old) are listed in Table 1:

Table 1: Daily Food Portions as guided by the Healthy Eating Food Pyramid for Children (2-5 years old)

Food Groups   Example(s) of a serving
Grains 1.5-3 bowls 1 bowl =
  • 1 bowl of white rice or
  • 1.5 bowls macaroni or
  • 2 slices of bread (8 slices per pound) or
  • 5 pieces of potato (size of an egg)
Vegetables At least 1.5 servings 1 serving =
  • 1/2 bowl of cooked vegetables or
  • 1 bowl of uncooked vegetables
Fruits At least 1 serving 1 serving =
  • 1 medium-sized fruit (e.g. orange or apple) or
  • 1/2 bowl of diced fruit
Meat, Fish, Egg and Alternatives 1.5-3 tael 1 tael =
  • meat in the size of a table tennis ball or
  • 1 chicken egg or
  • 1/4 block of firm tofu or
  • 6-8 tablespoons cooked beans
Milk and Alternatives 2 cups 1 cup =
  • 1 cup of milk or
  • 2 slices of low fat processed cheese
Fat and oil Maximum 6 servings 1 serving =
  • 1 teaspoon of vegetable oil or
  • 1 tablespoon of regular salad dressing

1 cup = 240ml; a bowl = 250-300ml

Furthermore, preschoolers need about 4-5 cups of fluid (including water, milk or clear soup) a day.

Choice of “3 Low 1 High”

Children should enjoy meals at the table with the family by 2 years old. Parents can act as role models and provide opportunities for their children to establish a balanced eating habit. Parents should try to offer “3 Low 1 High” choices, that is low saturated fat, low salt, low sugar and high fibre, as far as possible.

Choice of a variety from food groups

Examples from each of the 5 food groups from the Healthy Eating Food Pyramid are introduced below:

Grains

Apart from rice, parents can offer pasta or noodles (such as rice vermicelli, udon, Alfabeto etc.), bread or oatmeal to increase novelty. Whole grains such as brown rice, whole wheat bread or oatmeal increase satiety, prevent constipation and promote intestinal health. Parents may also want to offer starchy vegetables like corns, potato or sweet potato for their children to try. These ingredients can turn into attractive dishes like rice with corns, baked or mashed potato. Low fat alternatives such as noodles in soup, toast, plain bread (like white bread, dinner roll etc.) and boiled corns can replace high-fat choices like stir-fried rice or noodles, instant noodles, deep-fried toast, cakes, puff pastry (like croissant), stuffed buns or biscuits.

Vegetables

Choose fresh vegetables (including leafy vegetables, squashes, or mushrooms) for children. Avoid vegetables loaded with added oil, salt and sugar (e.g. pickled vegetables like pickle relish, preserved mustard green, canned vegetables, deep-fried seaweed etc.) Offer two or more choices of vegetables in main meals can help expose children to different vegetable varieties.

It is important to remind parents not to be overly anxious when their children refuse trying some vegetables. Preaching usually does not work. Forcing them to eat is not desirable. Parents can observe children's preference on the texture (too hard or too soft), colour (e.g. some children prefer orange-yellow vegetables), size or presentation (e.g. some do not like mixing vegetables in rice). This can help to inspire changes in cooking method (e.g. making vegetable soup). Research suggested that parental modeling to try novel vegetables1,2, repeated exposure3,4 to novel vegetables and rewarding with non-food incentives5, e.g. sticker after children tried the vegetables, can increase children's acceptance to the vegetables. Therefore, encourage parents to keep providing vegetables of different kinds so as to increase their children's exposure to vegetables.

Fruits

Fresh fruits are the best choice in the ‘Fruit' group and they can be served whole, in slices or dices. One may need several fruits to make a cup of fruit juice, however, the dietary fibre it contains is actually less than a whole fruit. Even without added sugar, pure fruit juice gives too much sugar and energy to our children and yet not filling. So, remind parents to reduce the volume and frequency of fruit juice offer to their children.

Recent research suggested that parental modeling increases young children's acceptance on novel fruit6. Daily life experiences with parents increase young children's knowledge and exposure to different fruits as well as arouse their interest to try novel fruits.

Tips to parents to increase children's exposure to fruits:

  • Take them to fruit shops
  • Use fruits in cooking (e.g. using fresh pineapple, peach, kiwifruit or dragon fruit and stir-fry with beef, pork, chicken or fish)
  • Invite children to make healthy snacks with fruit (e.g. adding the child's favourite fruit in dice to plain yoghurt, cut watermelon in cubes and thread onto skewers to make watermelon ice lollies with no added sugar)

Visit the ‘EatSmart@school.hk' Campaign website for healthier recipe ideas!

Meat, Fish, Egg and Alternatives

Offer fresh lean meat (with visible fat removed) or skinned poultry for children. Avoid using processed or canned meat (e.g. sausages) or ready-made meatball products (e.g. pork ball, siu-mai, etc.) in cooking. Instead of minced pork of high-fat cut, parents can add oatmeal or egg white in minced lean pork to make meat patties softer and smoother. To make a switch, parents can try adding some bread crumbs, diced vegetables (like onion or water chestnut, etc.) and herbs to minced lean pork to make home-made burger meat. This healthier burger option can be served with spaghetti, small buns or pita bread.

Apart from meat, fish, eggs and tofu, dried beans (e.g. red kidney beans, black eyed beans, etc.) and nuts/seeds (e.g. cashews, almonds, etc.) are rich in protein and iron. We can add these dried beans, nuts/seeds in soup and boil to soft. This is a quick and easy idea to increase meat variety for our children.

Milk and Alternatives

Young children do not need formula milk generally. Children aged 2 or above can choose low fat milk or calcium-added soy milk. Children aged 5 or above can choose skimmed milk to reduce fat intake. Generally speaking, 360 to 480ml of milk (not more than 2 cups) a day is adequate to meet their calcium needs. Limit fruit or chocolate-flavoured milk choices, as they contain added sugar that increase risk for tooth decay and obesity.

Children may consume less milk as they become older. Parents can offer milk alternatives such as cheese, yoghurt, firm tofu and calcium-added soy milk. Try to choose more dark green vegetables, sesame or nuts to boost calcium intake in main meals or snack time. The following food items contain calcium content similar to 1 cup of milk:

  • 2 slices of processed cheese (56g)
  • 1 carton (150g) of yoghurt
  • 1 cup of calcium added soy milk
  • 1/2 block of firm tofu (set with calcium salt) (around 175g)
  • Dried tofu 100g
  • 3 tablespoons of sesame
  • Kale or bok choi 200g (around 5 taels)
  • Choy sum 300g (around 1/2 catty)

Also, remind parents to allow their children to expose their arms or legs in sunlight while going outdoors. This helps the body to produce vitamin D which help the calcium absorption in the guts and maintain bone health.

How can preschoolers drink healthily?

Water is the best replenishing choice. Preschoolers may adjust their fluid intake according to their physical activity, the weather, or water content of foods. Have water readily available at a prominent place, for example, on the dining table, helps to encourage them to drink. For refreshment, try to put sliced fruits (e.g. lemon, strawberries, etc.) in water. Low fat milk, low sugar soy milk and clear soup are some other healthy fluid options too.

The World Health Organization (WHO) recommended that children should limit their free sugars intake to less than 10% of their daily energy intake7. Free sugars refer to all mono- and di-saccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrup and fruit juices in diets. Generally speaking, a 2- to 5-year-old child should limit his free sugars intake to less than 25-30g per day (i.e. 5-6 teaspoons). Parents should avoid offering drinks with added sugar, such as soft drinks, sugar-added fruit juice/drinks, yoghurt drinks, sports drinks, packaged drinks, fruit or chocolate flavoured milk. Having sweet drinks frequently increases children's preference for them. It also affects their teeth and body weight. If you want to know more about the sugar content of these drinks, visit the Centre for Food Safety Nutrition Information Inquiry System website. You may visit the website on Reduction on Dietary Sodium and Sugar to learn more about sugars.

Tips

The WHO published the ‘Set of recommendations on the marketing of foods and non-alcoholic beverages to children'8 in 2010. It suggested that settings where children gather should be free from all forms of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt. Such settings include, but are not limited to, nurseries, schools, school grounds, pre-school centres, playgrounds, family and child clinics, paediatric services and during any sporting and cultural activities that are held on these premises.

On top of that, we can provide a healthy eating promoting environment in our workplace for preschoolers, for example:

  • Give stickers or other non-food little gifts in place of candies as treats when preschoolers attend your office;
  • Introduce and promote websites with healthy recipes (e.g. the Department of Health ‘EatSmart@school.hk' Campaign website) to parents during parents' interview or consultation
  • Use non-food rewards or presents for preschoolers' good behaviour, e.g. commending them openly like ‘Andy, well done!', stickers, painting/drawing set, story books or allowing them to have the priority to participate in their preferred game or fun activity.

If you want to know more about healthy eating for young children, you can visit the ‘StartSmart@school.hk' Campaign website: http://www.startsmart.gov.hk. You may introduce the website to parents for tips to establish healthy eating habit in young children.

References

  1. Wardle J, Cooke LJ, Gibson EL, Sapochnik M, Sheiham A, Lawson M. Increasing children's acceptance of vegetables; a randomized trial of parent-led exposure. Appetite. 2003 Apr;40(2):155-62.
  2. Wyse R, Campbell KJ, Brennan L, Wolfenden L. A cluster randomised controlled trial of a telephone-based intervention targeting the home food environment of preschoolers (The Healthy Habits Trial): the effect on parent fruit and vegetable consumption. Int J Behav Nutr Phys Act. 2014 Dec 24;11:144.
  3. Cooke L. The importance of exposure for healthy eating in childhood: a review. J Hum Nutr Diet. 2007 Aug;20(4):294-301.
  4. Fildes A, van Jaarsveld CHM, Wardle J, and Cooke L. Parent-Administered Exposure to Increase Children's Vegetable Acceptance: A Randomized Controlled Trial. J Acad Nutr Diet. 2014 Jun;114(6): 881-888.
  5. Remington A, Añez E, Croker H, Wardle J, Cooke L. Increasing food acceptance in the home setting: a randomized controlled trial of parent-administered taste exposure with incentives. Am J Clin Nutr. 2012 Jan;95(1):72-7.
  6. Blissett J, Bennett C, Fogel A, Harris G, Higgs S. Parental modelling and prompting effects on acceptance of a novel fruit in 2-4-year-old children are dependent on children's food responsiveness.Br J Nutr. 2016 Feb;115(3):554-64.
  7. WHO. Sugars intake for adults and children guideline. Available at:
    http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/ (accessed 14 March 2016)
  8. WHO. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Available at:
    http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/ (accessed 14 March 2016)