evaluation report: impact and...

Better, Start Better programme: Evaluation Phase 2

Eat Better, Start Better programme Phase 2 (2012-2013)

Evaluation report: impact and

recommendations

Patricia Mucavele

Laura Sharp

Claire Wall

Eleanor Pryde

Susan Wood

Children’s Food Trust

Sheffield

October 2013

Better, Start Better programme: Evaluation Phase 2 and recommendations

Table of Contents

1 EXECUTIVE SUMMARY ............................................................................................................... 4

1.1 Key findings ........................................................................................................................ 5 1.2 Recommendations for future roll out of Eat Better, Start Better programme nationally ..... 6

2 THE EAT BETTER, START BETTER PROGRAMME .......................................................................... 7

2.1 Background ........................................................................................................................ 7 2.2 Aims and key deliverables .................................................................................................. 7 2.3 Supporting national child health priorities and programmes .............................................. 8 2.4 Supporting local child health priorities and programmes .................................................... 9

3 OVERVIEW AND IMPACT OF THE PROGRAMME: Phase 2 (2012-2013) ..................................... 10

3.1 Overview of the Eat Better, Start Better programme: Phase 2 .......................................... 10 3.2 Training for early years and health professionals: Phase 2 ................................................ 12 3.3 Training for early years practitioners in Phase 2 ............................................................... 15 3.4 Phase 2: Evaluation of early years settings’ approach to and provision of food and drink . 17 3.5 Phase 2: Delivery of cooking sessions, and impact on families’ cooking knowledge, skills and confidence ............................................................................................................................ 30

4 KEY FINDINGS, LIMITATIONS AND RECOMMENDATIONS .......................................................... 34

4.1 Key findings ...................................................................................................................... 34 4.2 Limitations ....................................................................................................................... 36 4.3 Recommendations ........................................................................................................... 36

5 APPENDICES ............................................................................................................................ 40

6 ACKNOWLEDGMENTS .............................................................................................................. 64

7 REFERENCES ............................................................................................................................ 65

List of appendices

APPENDIX 1: CHILD HEALTH STATISTICS FOR PHASE 2 LOCAL AUTHORITIES ......................................................................... 40

APPENDIX 2: COURSE 1 AIM AND LEARNING OBJECTIVES ............................................................................................... 41

APPENDIX 3. EAT BETTER START BETTER COURSE 1 TRAINING PROGRAMME ...................................................................... 42

APPENDIX 4: PHASE 2 CONFIDENCE SCORES OF COURSE 1 DELEGATES BEFORE AND AFTER THE TRAINING COURSE ........................ 43

APPENDIX 5: COURSE 2 AIMS, LEARNING OUTCOMES ................................................................................................... 44

APPENDIX 6. EAT BETTER START BETTER COURSE 2 HEALTHY FOOD AND COOKING FOR FAMILIES’ TRAINING PROGRAMME ............ 45

APPENDIX 7: PHASE 2 BASELINE AND FOLLOW UP AUDITS - APPROACH TO FOOD AND NUTRITION ............................................ 47

APPENDIX 8: PHASE 2 BASELINE AND FOLLOW UP AUDITS - ACCORDANCE WITH FOOD AND DRINK GUIDELINES ............................ 50

APPENDIX 9. CASE STUDIES FROM PHASE 2 LOCAL AUTHORITIES AND EARLY YEARS SETTING ................................................... 54

Eat Better, Start Better programme: Evaluation Phase 2 and recommendations

List of tables

TABLE 1. HOW THE EAT BETTER, START BETTER PROGRAMME SUPPORTS KEY THEMES WITHIN NATIONAL CHILD

HEALTH PROGRAMMES ................................................................................................................................. 9

TABLE 2. AVERAGE KNOWLEDGE AND CONFIDENCE SCORES FOR HEALTH AND EARLY YEARS PROFESSIONALS BEFORE AND

AFTER COURSE 1: PHASE 2 ....................................................................................................................... 14

TABLE 3: FOOD PROVISION IN THE EARLY YEARS SETTINGS WHERE BASELINE AND FOLLOW UP AUDITS WERE

COMPLETED AS PART OF PHASE 2 OF THE EAT BETTER, START BETTER PROGRAMME ....................................... 19

TABLE 4: MEAN NUMBER OF RECOMMENDATIONS (N=38) MET AT BASELINE AND FOLLOW UP BY SETTING TYPE ......... 21

TABLE 5: MEAN NUMBER OF GUIDELINES MET AT BASELINE AND FOLLOW UP BY SETTING TYPE ................................ 24

TABLE 6: ACCORDANCE WITH PART A RECOMMENDATIONS AND PART B GUIDELINES BY COURSE 2 TRAINING

ATTENDANCE ........................................................................................................................................... 28

TABLE 7: LEVEL OF DEPRIVATION AND HEALTH INEQUALITIES IN PHASE 2 LOCAL AUTHORITIES ................................ 40

TABLE 8. PHASE 2 COURSE 1 DELEGATES CONFIDENCE SCORES BEFORE AND AFTER THE TRAINING COURSE............... 43

TABLE 9. NUMBER OF SETTINGS MEETING BEST PRACTICE RECOMMENDATIONS FOR DEVELOPING A FOOD POLICY ....... 47

TABLE 10. NUMBER OF SETTINGS MEETING BEST PRACTICE RECOMMENDATIONS FOR COMMUNICATING WITH CHILDREN

AND FAMILIES .......................................................................................................................................... 47

TABLE 11. NUMBER OF SETTINGS MEETING BEST PRACTICE RECOMMENDATIONS FOR MENU PLANNING AND FOOD AND

DRINK GUIDELINES ................................................................................................................................... 48

TABLE 12. NUMBER OF SETTINGS MEETING BEST PRACTICE RECOMMENDATIONS FOR SPECIAL DIETARY NEEDS AND

TRAINING ................................................................................................................................................ 48

TABLE 13. NUMBER OF SETTINGS MEETING BEST PRACTICE RECOMMENDATIONS FOR THE EATING ENVIRONMENT AND

SOCIAL ASPECTS OF MEALS ........................................................................................................................ 49

TABLE 14. NUMBER OF SETTINGS MEETING FOOD AND DRINK GUIDELINES FOR BREAKFAST AT BASELINE AND FOLLOW

UP .......................................................................................................................................................... 50

TABLE 15. NUMBER OF SETTINGS MEETING FOOD AND DRINK GUIDELINES FOR SNACKS AT BASELINE AND FOLLOW UP 50

TABLE 16. NUMBER OF SETTINGS MEETING FOOD AND DRINK GUIDELINES FOR LUNCH AT BASELINE AND FOLLOW UP .. 51

TABLE 17. NUMBER OF SETTINGS MEETING FOOD AND DRINK GUIDELINES FOR TEA AT BASELINE AND FOLLOW UP ...... 51

TABLE 18. NUMBER OF SETTINGS MEETING FOOD AND DRINK GUIDELINES THAT APPLY ACROSS THE DAY AT BASELINE

AND FOLLOW UP ....................................................................................................................................... 52

List of figures

FIGURE 1. OVERVIEW OF THE EAT BETTER, START BETTER PROGRAMME AND TIMELINES FOR PHASE 2. .................................... 11

FIGURE 2: NUMBER OF DELEGATES (N=286) IN PHASE 2 REPORTING FEELING ‘CONFIDENT’ OR ‘VERY CONFIDENT’ IN THE SIX LEARNING

OUTCOMES FOR COURSE 1 BEFORE AND AFTER THE TRAINING COURSE ...................................................................... 14

FIGURE 3. MEAN NUMBER OF RECOMMENDATIONS FOR APPROACH TO FOOD AND NUTRITION (N=38) ‘MET’ AT BASELINE AND

FOLLOW UP BY 282 SETTINGS AUDITED IN 15 LOCAL AUTHORITIES PARTICIPATING IN PHASE 2. ....................................... 20

FIGURE 4. MEAN NUMBER OF RECOMMENDATIONS ‘MET’ AT BASELINE AND FOLLOW UP FOR EACH OF THE PRINCIPLES INCLUDED IN

THE EARLY YEARS CODE OF PRACTICE FOR FOOD. ............................................................................................... 21

FIGURE 5. MEAN NUMBER OF FOOD AND DRINK GUIDELINES (N=79) ‘MET’ AT BASELINE AND FOLLOW UP BY 292 SETTINGS AUDITED

IN 15 LOCAL AUTHORITIES PARTICIPATING IN PHASE 2. ......................................................................................... 24

FIGURE 6. MEAN NUMBER OF FOOD AND DRINK GUIDELINES ‘MET’ AT BASELINE AND FOLLOW UP BY SETTINGS ACROSS THE

AUTHORITIES IN PHASE 2 (BY MEAL AND SNACK). ................................................................................................ 25


1 EXECUTIVE SUMMARY The Children’s Food Trust early years food and nutrition programme ‘Eat Better, Start Better’ aims to support healthier food provision in early years settings and in families with young children aged between one and five years; and increase the food, nutrition and healthy cooking knowledge, skills and confidence of early years and health practitioners and parents. The two year programme, funded by the Department for Education (DfE) Voluntary and Community Sector (VCS) grant, involved the development and publication of the first Voluntary Food and Drink Guidelines for Early Years Settings in England, setting a national benchmark for the approach to and provision of food in early years settings. The Trust’s Eat Better, Start Better programme has been implemented over two phases. As part of Phase 1 (2011-2012) of the programme, the Trust worked with five local authority areas to develop and pilot an integrated food and nutrition training and evaluation package. These authorities were targeted to cover areas with higher than average levels of childhood overweight and obesity, higher than average deprivation and geographical spread. Following successful delivery in Phase 11, the integrated training programme was rolled out nationally to include a further 20 local authorities across England between April 2012 to September 2013, these authorities we also targeted based on health inequalities and deprivation. The design and delivery of the two-tiered food, nutrition and healthy cooking training and evaluation package helps to provide local authority commissioners with a supportive framework to build capacity of the early years and health workforce so that they can knowledgeably, skilfully and confidently cascade age-appropriate nutrition advice in a consistent manner to early years settings and families on how to meet the nutritional requirements of young children. In each case the Trust was commissioned by the authorities (and/or the Primary Care Trusts) to support the delivery and implementation of the Eat Better, Start Better programme within their area. The integrated food, nutrition and healthy cooking programme included the delivery of two train-the-trainer courses, cascading the food and nutrition knowledge and skills to settings and families, dissemination of guidance and resources, and regular monitoring of impact using standardised evaluation tools.

Course 1 was delivered to 450 health and early years professionals and practitioners and focused on using the food and drink guidelines and practical tools with early years settings and monitoring their impact.

Course 2 was delivered to 354 delegates from 188 early years settings and focused on how to apply the food and drink guidelines to their setting and when running healthy cooking sessions with families.

Delegates from Course 1 conducted baseline and follow up audits in 292 early years settings assessing the impact of the guidelines and training on the settings’ approach to and provision of food.

Delegates from Course 2 delivered a total of 1,002 healthy cooking sessions with 4,526 parents/carers and 272 community food activities involving a further 3,952 other family members. The impact of the cooking sessions was captured via the submission of 1,274 online activity reports.

Overall the Eat Better, Start Better Phase 2 programme trained 804 early years and health practitioners and reached a total of 8,478 families.


1.1 Key findings

The evaluation of the Eat Better, Start Better programme in the twenty Phase 2 local authorities has shown that all three programme outcomes were successfully met.

1.1.1 Outcome 1: Increased food, nutrition and healthy cooking knowledge, skills and

confidence for early years and childcare workforce

Impact of Course 1: The results from a quiz before and after the one day course ‘The Voluntary Food and Drink Guidelines for Early Years Settings in England and practical tools for health and early years professionals’ show that on average the early years and health professionals significantly increased their knowledge, skills and confidence to support local settings to provide healthy food for children aged between one and five years, and monitor the impact of the guidelines and training on their settings approach to and provision of food (see section 3.2).

Feedback on Course 2: Results from a feedback form completed after Course 2 shows that virtually all delegates (n=339, 99.7%) reported that the aim “To teach you about the Voluntary Food and Drink Guidelines for Early Years Settings in England, and to apply these to help families cook healthy and nutritious meals at home” was met, and likewise 96% of delegates (n=325) reported that the aim “to help you develop confidence in running healthy cooking sessions with families” was also met (see section 3.3).

1.1.2 Outcome 2: Improved healthier food provision for children aged one to five years

and childcare settings and at home

Changes in food provision in early years settings: a total of 292 baseline and follow up audits were conducted in Phase 2 to evaluate local settings’ approach to and provision of food. Analysis of these audits revealed that there was a significant increase in the number of recommendations and food and drink guidelines ‘met’, showing an overall shift in both settings’ approach to food and their provision of healthier menus. This shift was observed across all 15 local authorities where baseline and follow up data was available, and all types of setting. The main areas of impact were the increased use of food policies within settings, and engagement with parents and children around food activities. In terms of food provision there was increased diversity in the types of food provided (e.g. starchy foods and protein sources provided with meals), and increased use of foods lower in salt and sugar (e.g. breakfast cereals, yogurts). These changes mean that overall food and drink provision in the settings involved in the programme has got “healthier, more balanced and nutritious” (see section 3.4).

1.1.3 Outcome 3: Increased food and nutrition knowledge and practical cooking skills

for parents and families attending early years settings.

Impact of cooking sessions: Early years practitioners from 172 early years settings participating in Course 2 delivered a total of 1,002 healthy cooking sessions involving 4,526 parents/carers of young children. These sessions focused on increasing the parent’s knowledge, practical cooking skills and confidence to buy, prepare and cook healthy meals. The settings also ran 272 community food activities engaging an additional 3,952 family members around healthy cooking. The settings reported anecdotal information in their online reports, describing how the sessions had a positive impact on both the parents’ and practitioners’ skills and confidence to cook from scratch at home, adapt recipes and cook with children. The training sessions inspired the settings to use interactive activities in the cooking sessions to support parents to read food labels and limit the amount of sugar and salt in their family’s diet, particularly in relation to healthy packed lunches and snack options. The cooking sessions also provided an opportunity for parents to socialise with their children and their peers, encouraging them to try new foods. The settings also used the cooking sessions within their educational programmes to support children’s development in the prime and specific areas of learning within the EYFS (see section 3.5).


1.2 Recommendations for future roll out of Eat Better, Start Better programme nationally

For full details of recommendations, including evidence and rationale for each one, see section 4.3. Recommendation 1: Health and Wellbeing Boards to consider incorporating the Eat Better, Start Better programme into their joint Health and Wellbeing strategies and action plans as part of the universal and targeted offer within the early years and health services. This early intervention will help support the promotion of healthier lifestyles, tackle childhood obesity and improve health and social outcomes for children. Recommendation 2: Public Health directorates and early years and childcare departments to work in close collaboration, to develop a system-wide commitment, shared vision and integrated approach to early years food and nutrition within the education and health service. Exploring opportunities for incorporating the delivery of the evidence-based programmes such as Eat Better, Start Better across the early years sector. Recommendation 3: Local authority commissioners to explore opportunities to embrace, extend and embed the Eat Better, Start Better programme, for example by:

increasing awareness and use of the voluntary food and drink guidelines

encouraging early years settings to sign up to the Early Years Code of Practice for Food and Drink, and considering setting a local target for settings to achieve the Code of Practice

disseminating the findings from the Phase 2 evaluation across the early years and health sector to help inform future policies and practices and develop a shared vision how to encourage young children to eat well.

support local early years settings to ensure their approach to food, and meals and snacks provided, meet EYFS welfare requirements and the Voluntary Food and Drink Guidelines for Early Years Settings in England.

sharing good practice through setting up a network and mentoring system to encourage early years settings to share their knowledge and skills of delivering food and nutrition activities and healthy cooking sessions with parents, children and the wider community with settings currently not involved in running food and nutrition activities.

increasing opportunities for food, nutrition and healthy cooking training for early years and health staff, using peer-reviewed accredited train the trainer programmes or endorsed e-learning courses.

Recommendation 4: Department for Education, Department of Health and local authorities to incorporate the Voluntary Food and Drink Guidelines and delivery of the Eat Better, Start Better programme into the roll out of national initiatives, including the ‘early learning for two-year-olds’ offer, and as part of the integrated health and education review of children aged 2-2½ years. Recommendation 5: Local authorities to develop food plans, consulting and building links with settings and parents wherever possible in regard to food provision, For example, consider using lessons learned from Eat Better, Start Better to inform the delivery of cooking sessions in the wider community, including community halls and kitchens, and at food banks. Recommendation 6: Local authorities to consider incorporating the Trust’s standardised evaluation checklist into early years quality improvement processes and work in partnership with settings to encourage them to evaluate their approach to food, supporting them to meet EYFS welfare requirements and the Voluntary Food and Drink Guidelines for Early Years Settings in England.


2 THE EAT BETTER, START BETTER PROGRAMME

2.1 Background Children’s early years provide a crucial time to help them to develop healthy eating patterns,2 3 4 and to reduce health inequalities which persist across the life course.5 The quality of early years experiences, including education, can have a fundamental impact on development,6 and an increasing number of children in England are attending full day care.7 Early years settings therefore provide an ideal opportunity to help children eat well and establish healthy eating habits.8 With more than one in five children overweight or obese by the time they start primary school, and reducing the health and economic burden of obesity a key public health priority in the UK,9 it is also vital that children and their families are supported to develop healthy eating habits during their early years, to help ensure appropriate weight gain and development. The Early Years Foundation Stage (EYFS) framework (2008, revised 2012) sets standards for the learning, development and care of children attending early years settings from birth to five years.10 It includes a welfare requirement for the provision of “healthy, balanced and nutritious” food and drink, but until recently, there was limited practical guidance to explain what this meant in practice.11 In February 2010, the Children’s Food Trust (‘the Trust’; formerly the School Food Trust) was commissioned by the Department for Education (DfE) to establish and manage an Advisory Panel on Food and Nutrition in Early Years (the Advisory Panel). The Advisory Panel considered the need for revised guidance or standards on food provision in early years settings, and recommended the development of national guidance for early years settings that included age-appropriate advice on how to meet the nutritional requirements of young children, and the need for a well-trained, knowledgeable and confident early years and health workforce.12 Dame Clare Tickell’s review of the EYFS supported the need for further practical guidance for practitioners,13 and the Trust’s ‘Eat Better, Start Better’ programme has been developed to address both of these recommendations.

2.2 Aims and key deliverables In April 2011, the Trust was awarded funding under the DfE Voluntary and Community Sector (VCS) grant to deliver a two-year programme to improve food provision for children aged one to five years in early years settings and at home; and to increase the food, nutrition and healthy cooking knowledge and skills for the early years and childcare workforce and parents. The key deliverables of the Eat Better, Start Better Programme14 15 include:

Development and publication of Voluntary Food and Drink Guidelines for Early Years Settings in England and practical support tools, including an Early Years Code of Practice for Food and Drink, self-evaluation checklists and seasonal menus and recipes.

Development, piloting and roll out of a comprehensive integrated training package to five (pilot) and up to 20 (roll out) targeted local authorities and primary care trusts in England.

Monitoring and evaluating the impact of the introduction of the food and drink guidelines and the training programme on the approach to, and provision of, food and drink in early years settings, and the changes in family food habits.

Dissemination of the guidelines and practical resources and associated good practice via the Trust’s website, peer-reviewed articles, national and regional workshops and seminars.

A practical guide (outlining the Voluntary Food and Drink Guidelines for Early Years Settings in England) and a series of supporting practical tools were published by the Trust in January 2012.16 The guidelines and supporting practical tools were pilot tested by a diverse range of early years settings and extensively reviewed to ensure they are aligned to current government nutrition and food


safety advice for children aged one to five years, and outline best practice for encouraging young children to eat well. An integrated programme including food and nutrition training courses for health and early years professionals and early years practitioners was developed and piloted in five local authorities in England. The programme was targeted to areas with higher than average levels of deprivation (defined using free school meal eligibility data for primary school by local authority (2010 data)17 and higher than average levels of health inequalities (defined using the percentage of overweight and obese children in reception year of school by local authority in 2009-10)18 for the region. Twenty local authorities/Primary Care Trusts were invited to take part in the Phase 2 (2012-2013) and commissioned the subsidised programme. This report describes the impact of the Eat Better, Start Better programme for the twenty authorities that participated in Phase 2.

2.3 Supporting national child health priorities and programmes

A number of influential independent reviews commissioned by government have highlighted the importance of early intervention and support for families with young children, to help reduce health inequalities in the UK, and ensure that families have access to the services they need to give their children the best start in life.5,19,20,21 Early intervention, reducing health inequalities and supporting families with young children are also key themes of the joint DfE and DH ‘Families in the Foundation Years’ vision statement published in 2011, which sets out the Government’s vision for the services that should be available to children and their families during the ‘foundation years’ of pregnancy to five years.22 Specific recommendations for commissioners to identify and support vulnerable families were published by the Wave Trust in January 2013, in collaboration with the Department for Education.23 The delivery of the Healthy Child programme24 has also been strengthened during children’s early years, and the Health Visitor Implementation Plan 2011-15 commits to increasing numbers of health visitors to lead the Healthy Child programme and to provide community, universal and targeted services where needed for families with young children.25

A childcare commission was announced by the Government in summer 2012, to look at reducing the cost of childcare for working families and reducing the burden on childcare providers.26 In January 2013, ‘More great childcare’ was published by the Department for Education, including proposals to deliver high quality education in early years and support parents back to work.27 Table 1 overleaf outlines how the Eat Better, Start Better programme has been designed to support the key themes and areas included within national child health programmes.


Table 1. How the Eat Better, Start Better programme supports key themes within national child health programmes

Key theme How Eat Better, Start Better supports themes Tackling health inequalities The Eat Better, Start Better programme is targeted to local authority areas with

above average levels of overweight and obesity in reception year of school, and free

school meal eligibility

The Voluntary Food and Drink Guidelines provide a national benchmark for food

provision to ensure all children in all early years settings are provided with healthy,

balanced and nutritious meals and snacks Child development The Voluntary Food and Drink Guidelines provide practical resources that can be

used to ensure meals and snacks provided for all children in all early years settings meet children’s nutritional requirements, to maintain healthy growth and development

Early intervention The Eat Better, Start Better programme provides information and training to help

ensure that children aged 1-5 years are provided with healthy, balanced and

nutritious meals and snacks in early years settings and at home, to help them develop healthy eating habits

Provision of evidence-based , age-appropriate nutrition advice

and training

The training and resources produced as part of the programme are evidence-based,

constructed from the recommendations of the Advisory Panel, and consistent with current government guidance

A skilled confident professional

workforce The programme includes two training sessions; one for early years/health

professionals and one for early years practitioners to disseminate evidence-based, age-appropriate nutrition information and advice to use in their area

Effective partnership working The Eat Better, Start Better programme fosters collaboration by delivering joint

training to the health and early years workforce, and encourages a common understanding of healthy eating to support the settings and families in their area

Engaging parents The programme engages parents through practical cookery sessions to give them

the knowledge, skills and confidence to purchase and prepare healthy balanced

nutritious meals, and to support their family to eat well.

2.4 Supporting local child health priorities and programmes The Eat Better, Start Better programme has been designed to support the Phase 1 and Phase 2 local authorities to meet the priorities set out in their local health and wellbeing and child health strategies. Each of the twenty Phase 2 local authorities had a shadow Health and Wellbeing Board in place at the time of the pilot, these became fully operational as statutory bodies on 1st April 2013. Joint Strategic Needs Assessments (JSNAs) produced on behalf of the Health and Wellbeing Boards and/or local authorities bring together up to date information on the health and wellbeing of the people living in the area, and outline priority areas for targeting services over the next 5-10 years. Health and wellbeing strategies are commonly written following a ‘life course approach’ focussing on priorities for different population groups within the area. These often include a ‘starting well’ theme, focusing on children during their early years and include priorities for maintaining a healthy weight, areas which the Eat Better, Start Better programme is well placed to target.


3 OVERVIEW AND IMPACT OF THE PROGRAMME: Phase 2 (2012-

2013)

3.1 Overview of the Eat Better, Start Better programme: Phase 2 Figure 1 shows an overview of the Eat Better, Start Better programme in Phase 2 with twenty local authorities.

One day training courses for 450 health and early years professionals, and two day practical cookery courses for 354 early years practitioners from 188 early years settings were run between June 2012 and March 2013.I

Following the training, delegates from the one day training conducted baseline and follow up audits of food provision in 292 early years settings across 15II of the 20 areas.

A total of 172 early years settings who attended the practical cookery training ran 1002 cooking sessions, involving 4,526 parents/carers and 272 community events involving a further 3,952 family members.

Evaluation was conducted in collaboration with all the authorities at each stage of the programme to measure the impact it had on the practitioners, settings, families and children. Learning from the Phase 1 pilot was used to inform and offer a more flexible package to the 20 local authorities commissioning the Eat Better, Start Better programme in Phase 2. This tailored approach has enabled the Eat Better, Start Better programme to compliment the work already ongoing in these authorities, helping it to be embedded in local policies and practices, thus increasing the likelihood of its impact and sustainability in the future. Tailored packages include:

Salford: the authority had previously evaluated the food provision within settings, and was keen to build on this aspect of the programme rather than deliver the healthy cooking sessions to families. To accommodate this requirement and maximize the number of settings benefiting from the training and evaluation the Trust delivered two modified one day Course 1s, the first was targeted to private nurseries, and the second to childminders. The evaluation component was also modified to build on the previous evaluation work already completed in the area.

Middlesbrough: the authority had already developed and implemented a food and nutrition scheme for nurseries (Food4Health Early Years), and was keen to maintain the recognized branding. Middlesbrough Council commissioned the Trust to update the Food4Health guidance in line with the Voluntary Food and Drink Guidelines, and deliver seminar sessions to early years settings to support them to interpret and follow the guidelines.

In two of the Phase 2 areas, the local authorities and/or Primary Care Trusts commissioned the Trust to deliver additional aspects to the Eat Better, Start Better programme (e.g. additional practical cookery training) to increase the spread of the programme within the local area.

I Note: Five half day seminars were delivered in Middlesbrough in April 2013 after the Food4Health guidance had been aligned to the Voluntary Food and Drink Guidelines for Early Years Settings in England. II Note: 15 of the 20 local authorities participating in Phase 2 Eat Better, Start Better programme conducted

both baseline and follow up audits; four authorities conducted baseline only and one authority did not conducted any audits.


Figure 1. Overview of the Eat Better, Start Better programme and timelines for Phase 2.

One day training for health and early years professionals on the Voluntary Food and Drink Guidelines for Early Years Settings in England in each area

Two day training (plus one day follow up) for early years practitioners from early years settings on healthy food and cooking with families in each area

Settings run cooking sessions and

community events with families and

complete online activity reports

Audits completed by health and early years professionals to 292 settings in 15 areas to evaluate at two time points:

Approach to food and nutrition

How meals and snacks met the food and drink guidelines

Course feedback (see section 3.2)

Knowledge and confidence quiz (see section 3.2)

Phase 2 Jun-12 to April-13

TIMELINES COMPONENT EVALUATION

Course feedback (see section 3.3)

Phase 2 Jul-12 to Mar-13

Setting audit visits (see section 3.4)

Phase 2 Baseline: Jul 12 to Aug 2013 Follow up: Jan 13 to Sept 2013

Overview of cooking

session activity

reports (see section

3.5)

Phase 2

July 2012 - Aug 2013


3.1.1 Promoting and supporting the implementation of Eat Better, Start Better in each

authority

During the Eat Better, Start Better programme, each authority implemented a number of additional activities to raise the profile of the programme in the area, and to encourage early years settings to access and use the Voluntary Food and Drink Guidelines for Early Years Settings in England. These activities included:

Raising awareness: local authorities raised awareness of the Voluntary Food and Drink guidelines for Early Years Settings in England through newsletters, professional network meetings and events.

Dissemination: a number of local authorities purchased additional copies of the Voluntary Food and Drink guidelines and menu booklets to give to settings within the local area. Delegates who attended the training cascaded the knowledge and skills gained through the training to other staff members and at meetings and events with colleagues.

Support: local authorities and the Trust provided support to early years settings throughout the duration of the Eat Better Start Better programme via telephone support, completing funding claim forms and online activity reports, face to face at support meetings, support to develop cooking sessions and delivery of healthy packed lunch sessions.

3.2 Training for early years and health professionals: Phase 2 A one day training course titled ‘The Voluntary Food and Drink Guidelines for Early Years Settings in England and practical tools for health and early years professionals’ (Course 1) was delivered in 20 Phase 2 local authorities between June 2012 and March 2013III. Each course was delivered by two or three trainers from a team of six trainers (all Registered/Associate Nutritionists) from the Children’s Food Trust, and included a combination of information, practical sessions and discussion. The overall aim of the course was ‘To enhance the knowledge, skills and confidence of early years and health professionals to support early years settings to understand and use the new national food and drink guidelines for early years settings and evaluate their impact on food and drink provision.’ A full list of learning outcomes for the course is shown in Appendix 2. Delegates were provided with a copy of ‘Voluntary Food and Drink Guidelines for Early Years Settings in England: A practical guide’, an autumn/winter or spring/summer menu and recipe document and a delegate pack including all the resources required for cascading the training. During the course delegates became familiar with the Voluntary Food and Drink Guidelines for Early Years Settings in England, and how to work with settings to support them to understand and use the guidelines, practical resources and tools to encourage children to eat well. The delegates were also given an overview of the evaluation process and an opportunity to use the standardised audit tools to give them the skills and confidence to monitor and measure the impact of the guidelines.

3.2.1 Profile of delegates attending Course 1 in Phase 2

In Phase 2, 450 delegates attended Course 1, information on the professions of these delegates was available for 311. Of these, three-quarters (73.6%, n=229) were early years professionals and practitioners, a fifth (19.3%, n=60) were health professionals and 7% (n=22) were other professionals such as caterers and environmental health officers.

III

Note: Five half day seminars were delivered in Middlesbrough in April 2013 after the Food4Health guidance had been aligned to the Voluntary Food and Drink Guidelines for Early Years Settings in England. The seminars did not include a quiz, so the change in knowledge and confidence of these delegates before and after the training was not measured. The results reported in this section pertain to 19 of the 20 Phase 2 authorities.


The quality of the delivery of the training course and its impact on the delegates’ knowledge and confidence was evaluated using three different approaches, see section 3.1.

3.2.2 Delegate feedback on the quality of the delivery of Course 1

Feedback forms were received from 421 delegates in Phase 2. 88% of delegates (n=370) reported the training fully met its aim. 65% of delegates (n=272) rated the training as ‘excellent’, and 28% (n=116 as ‘good’. The majority of delegates (n=383; 91%) reported that they would recommend the course to other health and early years professionals. This mirrored the feedback received during Phase 1 with the majority of delegates reporting that the aim of the course was ‘fully met’ and 100% rating Course 1 as ‘good’ or ‘excellent’.

3.2.3 Impact of the training programme on delegate’s knowledge and confidence

A quiz was developed to measure delegates’ knowledge about healthy eating for children aged one to five, and their confidence in supporting early years settings to meet the EYFS welfare requirements for food and drink. The quiz was completed at the start and the end of the training course. Complete quiz data was obtained from 286 delegates attending Course 1 in Phase 2. Overall there was a significant increase in the delegates’ knowledge. The average quiz score (out of 32) increased from 21 before the training, to 28 after the training. Overall the delegates’ confidence also increased significantly, the confidence scores increased from an average of 16 (out of 30) before the training to 23 after the training. Table 8 in Appendix 4 shows the change in confidence amongst Phase 2, Course 1 delegates by learning outcome before and after the training course. Figure 2 overleaf illustrates the number of delegates that reported being ‘confident’ or ‘very confident’ before and after the training course for each of the six learning outcomes. The graph shows that before the training less than a third of delegates felt ‘confident’ or ‘very confident’ in each of the six learning outcomes. At the end of the training at least two-thirds of the participants reported they felt ‘confident’ or ‘very confident’ in each of the six learning outcomes. The largest increases were observed for the following learning outcomes: to provide advice on appropriate portion sizes (learning outcome 2, from 12% to 76%), to plan and evaluate menus (learning outcome 4, from 13% to 69%), to provide advice on types of food to provide (learning outcome 1, from 17% to 72%), and to support settings to demonstrate they are meeting the welfare requirements of the EYFS (learning outcome 6, from 18% to 71%).


Figure 2: Number of delegates (n=286) in Phase 2 reporting feeling ‘confident’ or ‘very confident’ in

the six learning outcomes for Course 1 before and after the training course

To demonstrate the appropriateness of Course 1 for both early years and health professionals, the quiz scores and delegate feedback on their confidence level were compared at the start and end of the course.

Table 2 below shows that the average knowledge and confidence scores before and after training increased for both health and early years professionals in Phase 2. Table 2. Average knowledge and confidence scores for health and early years professionals before and after

Course 1: Phase 2 Knowledge scores (out of 32) Confidence scores (out of 30)

Profession Number Average score before training

Average score after training

Average score before training

Average score after training

Health

professionals 55 21.7 29.4 15.6

23.2

Early years professionals & practitioners 202

20.4 27.6 15.4

23.2

All 257 20.7 28.0 15.5 23.2

*‘Other’ professionals such as caterers were excluded from this comparison due to low numbers. ** This does not include Middlesbrough as delegates did not complete a quiz

In Phase 2 there was a significant difference between the knowledge scores of health and early years professionals and practitioners before the training (non-paired t-test, p=0.028). As expected the average score of the health professionals (21.7) was significantly higher compared to the average score of the early years professionals and practitioners (20.4). Both professional groups significantly increased their knowledge scores at the end of the course (paired t-test, p<0.001). In Phase 2 the difference in the knowledge scores between the two groups of professionals after the course remained significant (non-paired t-test, p<0.001). There was also a significant increase after the training in the average confidence scores of both health professional and early years professionals

0102030405060708090

advice on typesof food to

provide

advice onappropriateportion sizes

interpretingfood labels

planning andevaluating

menus

support settingsto encourage

children to eatwell

support settingsto demonstratethey meet the

welfarerequirementsfor food and

drink

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rce

nta

ge o

f d

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gate

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Learning outcomes

'Confident' or 'very confident' before the training

'Confident' or 'very confident' after the training


and practitioners (paired t-test, p<0.001). There was no significant difference in the confidence scores between the health professionals and the early years professionals and practitioners before the training (non-paired t-test, p=0.792) and after the training (non-paired t-test, p=1.0). Overall the quiz results and delegate feedback for Course 1 in Phase 2 show that the training consistently increased for both the health and early years professionals’ and practitioners’ knowledge, skills and confidence of early years food and nutrition, mirroring the results from Phase 1. To ensure the delegates continue to feel supported and the level of knowledge and confidence is sustained, the Trust has continued to offer support via a helpline. The delegates can call or email the Trust’s nutritionists if they require further advice on the interpretation or implementation of the Voluntary Food and Drink Guidelines for Early Years Settings in England or the audit process.

3.3 Training for early years practitioners in Phase 2 A two day training course titled ‘Healthy food and cooking with families’ (Course 2) with a one day follow up (Course 2b) was delivered in 18 of the 20 local authorities in Phase 2 between July 2012 and March 2013. Each course was delivered by two Children’s Food Advisors with expertise in delivering ‘train the trainer’ courses on running cooking sessions with children and families. The overall aims of the 2a and 2b courses were:

- To teach you about the Voluntary Food and Drink Guidelines for Early Years Settings in England, and to apply these to help families cook healthy and nutritious meals at home.

- To help you develop confidence in running healthy cooking sessions with families. A full list of the learning outcomes for the course is shown in Appendix 5. During the two day course delegates learnt how to use the Voluntary Food and Drink Guidelines for Early Years Settings, set up and run successful, healthy cooking sessions for families and how to involve families and the local community in food activities and events. As part of the course, settings were provided with a hard copy of the Voluntary Food and Drink Guidelines for Early Years Settings in England and an autumn/winter or spring/summer menu and recipe document. Delegates also received a delegate pack which included session plans, 16 recipesIV and hand-outs to help them to deliver cooking sessions with families. Each of the early years settings attending the training also received a £300 grant towards the cost of small pieces of cooking equipment and ingredients. 3.3.1 Profile of delegates attending Course 2 in Phase 2 A total of 354 delegates from 188 early years settings attended Course 2 in Phase 2. The majority of delegates were practitioners from early years settings, however in some authorities the course was also extended to include early years and/or health professionals from the local authority workforce to help them develop a clear understanding of how the overall programme could run in the area. The training course was evaluated using a training feedback form completed by delegates at the end of Course 2a.

IV 16 simple tried and tested, low cost recipes suitable for families with young children were purposively selected from the Let’s Get Cooking programme recipe portfolio.


3.3.2 Delegate feedback on the quality of delivery of Course 2 A training evaluation form was completed at the end of Course 2a by 340 delegates. In Phase 2 virtually all delegates (n=339, 99.7%) reported that the aim “To teach you about the Voluntary Food and Drink Guidelines for Early Years Settings in England, and to apply these to help families cook healthy and nutritious meals at home” was met and, likewise, 96% of delegates (n=325) reported that the aim “To help you develop confidence in running healthy cooking sessions with families” was also met. The delegates also consistently rated the delivery of Course 2 very highly, 88% (n=300) of delegates rated the course as ‘excellent’, the remaining delegates rating the course either ‘very good’ (11%, n=39) or ‘good’ (0.3%, n=1). This was an increase in the rating of this course from Phase 1, where 83% delegates rated the Course 2 as ‘excellent’, 18% rated it ‘very good’.


3.4 Phase 2: Evaluation of early years settings’ approach to and provision

of food and drink The impact of the guidelines and the training programme on early years settings’ approach to, and provision of, food and drink was monitored using a standard evaluation checklist. Each local authority involved in the Eat Better, Start Better programme was given a target by the Trust to conduct audits in up to 50 settingsV. The Trust provided guidance on the types of settings to include as part of the audit processVI to encourage the authorities to reflect the diversity of early years provision within their area. The final decision about the audit process and which settings were audited was made by each authority.

3.4.1 Overview of the audit process

The Phase 2 evaluation has been undertaken using the same standardised evaluation checklist and process used in Phase 1 of the programme. Feedback from Phase 1 was used to produce additional tools and guidance to support Phase 2 local authorities in the process. This included:

A ‘step-by-step’ document outlining the standard approach to conducting setting audit visits; this was sent to each authority in advance of their Course 1 training to help them decide prior to the training the approach they will use for the audit process.

Standard tools including letters, information sheets and certificates given to the authorities to support them when contacting settings and encouraging them to take part in the evaluation. A short guidance sheet on how to complete the checklist was also produced for settings who completed the checklist on a self-evaluation basis.

Evaluation checklists were collected at two time points (baseline and follow up) in 15 of the 20 local authority areas. Four authorities completed audits at baseline only and one authority did not undertake any audits.

The Phase 2 local authorities carried out the audit process in three main ways:

Independent assessment: auditors (who attended Course 1 training) conducting visits to settings

Self-evaluation: settings complete and return evaluation checklists

Supported self-evaluation: settings complete evaluation checklist, and then receive a visit from an independent auditor (who attended Course 1 training) to check the information before it is submitted.

In seven (Greenwich, Luton, Derby, Hartlepool, Walsall, Enfield and Southend) of the local authority Phase 2 areas, the audits were carried out by health or early years professionals who had attended the Course 1 training, as an independent assessment. These professionals had obtained an in-depth knowledge of the Voluntary Food and Drink Guidelines for Early Years Settings in England and first-hand experience of using the evaluation checklist during the course, so they could feel confident to act as an independent auditor and evaluate settings’ approaches against the national best practice outlined in the guide. Four authorities (Peterborough, Isle of Wight, Thurrock and Middlesbrough) adopted a self-evaluation approach rather using independent auditors, these authorities considered this approach

V The target of 50 settings was set to maximise the number of settings included within the programme, and to

support the programme overall to reach its Key Performance Indicators as specified in the Trust’s grant agreement. VI

The Trust recommended including as part of the audit process: the 10 settings who attended the cooking with families training, a range of different types of early years settings, different types of provision (e.g. full day care and sessional care), a variety of catering types, and range of meal and snack provision.


was the most practical and sustainable. The remaining eight authorities (North East Lincolnshire, Hull, South Tyneside, Leicester, Lincolnshire, East Sussex, Lewisham and Salford) carried out a mixture of self-evaluations and independent assessments. This approach helped to reach a wider number of settings where staff capacity was limited and in cases, where self-evaluation was supported by an independent auditor this helped to maintain an element of quality assurance. In each authority, the settings’ participation in the audit process was voluntary. Typically, settings were contacted by letter to invite them to participate, with pre-arranged visits to the settings who volunteered to be part of the audit process. The individual auditors then contacted the settings they were asked to visit, and arranged a date for a baseline audit. To evaluate the setting’s approach to food and nutrition against the principles outlined in the Early Years Code of Practice for Food and Drink the auditor discussed the setting’s approach to food with setting staff (including the manager and cook where appropriate). They also observed a meal or snack, and reviewed written policies and other information such as menus and information for parents before completing Part A of the standardised checklist. To assess the setting’s provision of food and drink against the Voluntary Food and Drink Guidelines, and complete Part B of the checklist, the auditor reviewed the setting’s current menus (for breakfast, snacks, lunch and tea) and discussed with staff the types and amounts of food and drink provided.

Following the baseline visit, each setting was given a copy of the completed evaluation checklist, which acted as an action plan to highlight where their approach ‘met’ or ‘did not meet’ national best practice.

The Trust requested each area to complete the baseline and follow up audits within nine months of the Course 1 date, and it was recommended that settings were each given three to four months between audits to allow sufficient time to implement any identified actions. The mean time between baseline and follow up audits was four and a half months (139 days) across all areas completing baseline and follow up audits. Between the baseline and follow up audits, each setting had access to the Trust’s helpline and some were contacted and offered additional support by the auditors (depending on capacity within the authority). After an agreed time frame (usually around three months), the auditor returned to the setting, and completed a follow up checklist, to record any changes in the setting’s approach to food. Electronic copies of the completed baseline and follow up checklists were submitted to the Trust. The checklists were uploaded to an Access database, and subsequently analysed using Statistics Package for the Social Sciences.28

3.4.2 Profile of the settings audited

Baseline audits were conducted in 399 settings across the 19 local authority areas. Follow up audits took place in 292 of these settings,VII and the results in this section are based on these 292 complete sets of baseline and follow up audits.

In most of the local authorities, settings were selected to participate in the setting audit visits by the commissioners and/or some of the delegates who had attended Course 1 training (who would be conducting the audits). These settings were selected to provide a good representation of early years

VII

Follow up audits were not received for 19 settings where baseline audits were completed. In three cases, the setting had ceased operating before the follow up visit was completed. In the remaining 16 cases, the setting could not be contacted to arrange a follow up visit, the auditor was unable to complete the visit, or the paperwork from the follow up visit was not sent to the Trust to be included in the analysis.


provision within the authorities, (including a range of different types of settings e.g. children’s centres, private nurseries, childminders and pre-schools). The authorities selected settings based on a range of different criteria depending on the priorities in the area including, settings based in areas with higher than average levels of childhood obesity, settings where relationships with the authority already existed, or settings located in areas easily reachable by the Course 1 delegates who would conduct the audits. In some areas where a self-evaluation approach took place settings included were those who agreed to participate and had the capacity to complete both the baseline and follow up audit.

Each authority was encouraged to include the settings (up to 10) that attended the Course 2 training in this part of the evaluation, in order to evaluate any additional impact of this training on the settings’ approach to food, or the meals and snacks they provided. In total, 75 settings who attended the Course 2 training also received baseline and follow up audit visits, these are show in Table 6.

Local authorities were given a target of 50 audits at each time point. Many of the local authorities faced difficulties in achieving this target due to staff capacity, re-structuring of local authority health and early years teams and competing priorities. Baseline and follow up audits were conducted in eight to forty settings within each local authority area. Four local authorities provided audits at baseline only. For these areas analysis was carried out on the baseline data to provide the local authority with an indication of how the settings were currently meeting the food and drink guidelines.

The 292 baseline and follow up audits were completed in 160 nurseries, 45 pre-schools, 41 children’s centres, 31 childminders, seven playgroups and six crèches (there was missing information for two settings). Details of meals and snacks they provided at the time of the visits are shown in Table 3.

Table 3: Food provision in the early years settings where baseline and follow up audits were completed as part of Phase 2 of the Eat Better, Start Better programme

Setting type No.

visited No. providing

breakfast

No. providing snacks

No. providing

lunch

No. providing

tea Nursery 160 146 156 149 145 Childminder 31 28 30 29 26

Children’s centre 41 15 39 16 12 Pre-school 45 8 43 9 2 Playgroup 7 0 7 0 0 Creche 6 0 6 0 0

Total 292 197 281 204 187

Note: details of settings included in this table are where details of the meal/snack were provided at both the baseline and follow up visit. On 12 occasions, a meal/snack was provided at baseline but not at follow up, or vice versa, and have therefore been excluded from the analysis.

3.4.3 Impact of the guidelines and training on settings’ approach to food and nutrition

Part A of the evaluation checklist evaluates a setting’s approach to food and nutrition, and provides a more comprehensive version of the Trust’s Code of Practice checklist, as included in the practical guide.16 Part A of the checklist evaluates each setting’s approach to food and nutrition in seven areas (aligned to the seven principles included in the Early Years Code of Practice for Food and Drink) and includes 38 recommendations overall. The average number of recommendations ‘fully met’ by settings increased significantly (p<0.001) between baseline (n=30) and follow up (n=34), and the number of recommendations ‘not met’ decreased significantly (p<0.001) from baseline (n=3) to follow up (n=1). The number of ‘not applicable’ recommendations did not change significantly (p=0.67). These results are in line with those seen in early years settings in Phase 1 and suggest that settings’ approach to food and


nutrition more closely matched that set out in the Early Years Code of Practice for Food and Drink at the time of the follow up audits compared to baseline. See Figure 3.

Figure 3. Mean number of recommendations for approach to food and nutrition (n=38) ‘met’ at baseline and follow up by 282 settings audited in 15 local authorities participating in Phase 2. *Increase in recommendations ‘fully met’ and decrease in recommendations ‘partially met’ and ‘not met’ statistically significant at p<0.001 (paired t-test).

The mean number of recommendations ‘fully met’ or ‘not applicable’ ranged from 26-35 at baseline, and 32-36 at follow up. The mean number of recommendations either ‘fully met’ or ‘not applicable’, in 13 of the 14VIII authorities that had sufficient data to compare, increased significantly between baseline and follow up (paired t-tests, p<0.001-p=0.004). This suggests that the improvements in approach to food and nutrition seen overall in the Phase 2 authorities, was also seen in the majority of the individual areas. The mean number of recommendations ‘fully met’ by different types of early years setting at baseline and follow up is shown in Table 4. The mean number of recommendations either ‘fully met’ or ‘not applicable’ in four of the six types of settings (children’s centres, nurseries, play groups and pre-schools) significantly increased between baseline and follow up (paired t-tests; p<0.01). The mean number of recommendations ‘fully met’, between baseline and follow up also increased for childminders and crèches, the difference was not statistical significant; these results suggests that the improvement in approach to food and nutrition was seen in all types of early years setting.

VIII Although 15 local authorities completed baseline and follow up audits, only 14 of these local authorities had sufficient data for Part A of the checklist to compare baseline and follow up.

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Table 4: Mean number of recommendations (n=38) met at baseline and follow up by setting type

Setting type No visited Mean no. recommendations

(n=38) met at baseline Mean no. recommendations

(n=38) met at follow up Nursery 157 31.4 34.5

Childminder 29 31.3 33.4 Children’s centre 40 26.7 33.4 Pre-school 42 29.5 33.2 Playgroup 7 29.6 33.4 Creche 6 31.7 32.0

Total 281 30.4 33.9

Note: details of settings included in this table are where details of the meal/snack were provided at both the baseline and follow up visit. On 14 occasions, a meal/snack was provided at baseline and not to follow up or vice versa, and have therefore been excluded.

Details of the number of settings which ‘met’ each of the 38 individual recommendations representing a best practice approach to food and nutrition can be found sections 3.4.4.1 to 3.4.4.5 below and shown in Table 9 to Table 13. A summary of this information is shown in Figure 4.

Figure 4. Mean number of recommendations ‘met’ at baseline and follow up for each of the principles included in the Early Years Code of Practice for Food. Note: Data not included for principles 4 and 7, as these include only one recommendation.

3.4.3.1 Developing and using a food policy

As shown in Table 9, 246 settings (84%) had written food polices in place at the time of the baseline audit (recommendation 1a). This increased to 270 settings (92%) by the time of the follow up audit, showing an increase in use of written policies within settings. A shift was also seen in the way that these policies were used between the baseline and follow up visits. The proportion of settings including all relevant detail within the policy (1b) increased from 48% to 73%, which will help to ensure that the policy sets out all aspects of a setting’s approach to food and where it describes how food is used to support learning within the setting (1h), increased from less than half (43%) of settings at baseline to over two thirds (69%) at follow up. Increases were also seen in the proportion of settings that ensured the policy was easily accessible (1c; increasing from 69% to 85%), shared with families (1e; increasing from 71% to 87%), and staff and families were consulted about the policy (1g; increasing from 58% to 77% of settings). Together, these changes suggest that the settings involved in the audit process developed more comprehensive policies, which were more

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widely shared and used within their settings, which in turn helps to ensure children receive consistent messages about food and nutrition. Areas for settings, and the authorities supporting them, to concentrate on in the future include continuing to ensure food polices include all relevant information about food and nutrition ‘not met’ by over a quarter (27%) settings at follow up, consulting staff and families on the policy ‘not met’ by over a fifth (23%) of settings at follow up) and, describing how food is used to support learning ‘not met’ by nearly a third ( 31%) of settings at follow up.

3.4.3.2 Communicating with children and families

The proportion of settings meeting each of the seven recommendations for communicating with children and families increased between the baseline and follow up audits. At the time of the follow up audit more settings liaised with families about timing for meals and snacks (2a; increasing from 86% to 92%), displayed the menus within the setting for families to see (2c; increasing from 78% to 90%), provided opportunities for families to give feedback on menus (2d; increasing from 85% to 91%), involved children in planning new menus (2e; increasing from 62% to 75%) and invited families to attend food events at the setting (2f; increasing from 55% to 66% of settings). As the relationship with parents is a key aspect of the Early Years Foundation Stage (EYFS) framework, it is recommended that settings could consider using food events as an effective strategy to engage parents (2f; ‘not met’ by over a third of settings at follow up).

3.4.3.3 Menu planning, food provision and the food and drink guidelines

In the majority of settings (91% at baseline and 92% at follow up), children were reported to eat regularly (3a). Increases were seen in the proportion of settings planning menus in advance (3b; increasing from 83% to 90%), introducing new menus at least twice a year (3c; increasing from 61% to 81% settings) and ensuring that menus are varied (3d; increasing from 76% to 84% settings). All of these changes will help to ensure that menus for children are balanced, and include a wider variety of different foods, introducing them to new flavours and textures, which is important for dietary diversity. At the time of the baseline audit, as would be expectedIX, a relatively small proportion of settings (approximately one third) were using the food and drink guidelines to plan their menus (4a). By the time of the follow up audit, this had increased so that three quarters of settings were fully using the guidelines, and a further 10% were partially using the guidelines).

3.4.3.4 Special dietary needs and diverse diets

There was very little change in settings’ approaches to meeting children’s dietary requirements, as the majority of settings in all local authorities met these recommendations at baseline and follow up. More than 95% of settings were aware of children’s dietary requirements (5a) and aimed to meet the needs of the children they cared for (5b) and 92% of settings provided food from different cultures for children (5c) at both baseline and follow up. There was a small increase in the number of settings where staff preparing food had received appropriate training (6a; increasing from 86% to 90%).

3.4.3.5 The eating environment and social aspects of mealtimes

The recommendations for approach to food and nutrition include 13 recommendations on the eating environment, which aim to ensure that meal occasions provide an environment for children

IX The Voluntary Food and Drink Guidelines for Early Years Settings in England- A Practical Guide was published in January 2012 approximately a year before the baseline visits were started in the local authority areas.


to learn about food, try new foods and develop social and other skills. Of these recommendations, there were several which were met consistently by settings in each local authority. More than 95% of settings met recommendations at follow up for providing an appropriate eating area (7a), ensuring children wash their hands before eating (d), encouraging children to feed themselves (7g), giving children sufficient time to eat (7i) and allowing children to have seconds (7k). Between the baseline and follow up audits, increases were seen in the proportion of settings meeting some of the other recommendations, including those relating to developing children’s social and motor skills. The proportion of settings involving children in helping to set up and clear away after meals increased (7e; from 77% to 88%), as did the proportion of settings encouraging children to make choices at mealtimes (7f; from 80% to 89%), using mealtimes to develop children’s social skills (7h; from 86% to 90%) and having a standard approach in place to manage fussy eating (7j; increasing from 83% to 92%). The impact of these changes will help to encourage children to eat well and develop good eating habits.

3.4.4 The impact of the guidelines and training on settings’ provision of food and drink

in accordance with food and drink guidelines

Part B of the standard evaluation checklist replicates the five-page menu planning checklist included in section 6 of the practical guide, which can be used to evaluate meal and snack provision against the Voluntary Food and Drink Guidelines for Early Years Settings in England.16 The food and drink guidelines describe how often, how much, and which types of food from each of the four food groups (starchy foods; fruit and vegetables; meat, fish, eggs, beans and non-dairy sources of protein; and milk and dairy foods) should be provided for children aged one to five years. There are a total of 79 guidelines listed in part B of the evaluation checklist, split into 12 sections – four meal occasions (breakfast, snacks, lunch and tea), the four food groups, and four other categories (portion weights; drinks; reducing saturated fat, sugar and salt; other foods to avoid). If these food and drink guidelines are used by all settings to plan meals and snacks for children it will help to make sure that all children eat a healthy, balanced diet, whether they attend full day care in one setting, or attend several different settings throughout the week. Figure 5 shows the mean number of guidelines met overall by the 292 settings in 15 authorities who received baseline and follow up audit visits. At baseline, settings ‘fully met’ on average 47 guidelines, with five ‘partially met’X. At follow up this increased significantly to 53 guidelines ‘fully met’ and three ‘partially met’ (p<0.001). The number of guidelines ‘not met’ fell significantly from a mean of six at baseline to two at follow up (p<0.001). The number of ‘not applicable’ guidelines fell significantly from 19 to 18 (p=0.01). These results mirror the improvements observed amongst the early years settings that participated Phase 1 Eat Better, Start Better programme.1

X ‘Partly met’ included occasions where settings met a specific guideline on some, but not all, days of the week, or where a guideline included two points, and only one was met by the setting.


Figure 5. Mean number of food and drink guidelines (n=79) ‘met’ at baseline and follow up by 292 settings audited in 15 local authorities participating in Phase 2. *Increase in guidelines ‘fully met’ and decrease in guidelines ‘partially met’ and ‘not met’ statistically significant at p≤0.001 (paired t-test).

The mean number of guidelines ‘fully met’ or ‘not applicable’ in the 15 local authorities ranged from 53-75 at baseline, and 62-77 at follow up. The mean number of guidelines either ‘fully met’ or ‘not applicable’ significantly increased between baseline and follow up (paired t-test, P<0.001), demonstrating that the overall improvement in accordance with the food and drink guidelines seen was also reflected in each of the individual areas. The mean number of guidelines fully ‘met’ or ‘not applicable’ by different types of early years setting is shown in Table 5. The mean number of guidelines either ‘fully met’ or ‘not applicable’ significantly increased between baseline and follow up for four (childminders, children centres, nurseries and playgroups) out of six setting types (paired t-test, <0.01 P=0.01). There was an increase in the mean number of recommendations ‘fully met’, between baseline and follow up for crèches but the difference was not statistical significant. There was no change in the average number of guidelines met by pre-schools. These results suggest that the majority of setting types improved their food provision in accordance with the food and drink guidelines during the audit process.

Table 5: Mean number of guidelines met at baseline and follow up by setting type

Setting type No.

visited Mean no. guidelines

(n=79) met at baseline Mean no. guidelines

(n=79) met at follow up Nursery 160 64.2 71.6 Childminder 31 68.3 73.5

Children’s centre 41 71.0 75.7 Pre-school 45 66.0 65.9 Playgroup 7 67.0 72.0 Creche 6 76.0 76.5

Total 290* 66.2 71.6

*Total number of settings with baseline and follow up audits (n=292) but data on setting type was missing for two settings. Details of the number of settings which ‘met’ each of the 79 food and drink guidelines can be found sections 3.4.4.1 to 3.4.4.5 below and shown in Table 14 to Table 18 in Appendix 7. A summary of this information is shown in Figure 6.

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Figure 6. Mean number of food and drink guidelines ‘met’ at baseline and follow up by settings across the authorities in Phase 2 (by meal and snack). Base = Breakfast; 195 settings, snacks; 280 settings, lunch; 204 settings, tea 185 settings.

3.4.4.1 Breakfast

Two-thirds (n=195 of the 292) of settings provided breakfast at baseline and follow up. As shown in Table 14, there was a shift in the proportion of these settings meeting the food and drink guidelines applying to breakfast. Almost all settings provided a portion of starchy food for children as part of breakfast (guideline 1.1; met by 97% at baseline and 99% at follow up). Between baseline and follow up the variety of starchy foods provided increased (1.2, with the proportion of settings providing more than three varieties during the week increasing from 77% to 91%) and the balance of white and wholegrain starchy foods improved (1.3; with the proportion of settings providing a variety of both during the week increasing from 78% to 91%). A shift was also seen in the types of breakfast cereals provided, with an increase in the proportion of settings choosing ‘low’ or ‘medium’ sugar varieties, which will help to limit children’s intake of added sugar (1.4; met by 80% settings at baseline and 93% at follow up). Less than half (43%) of settings provided children with a portion of fruit or vegetables as part of breakfast at baseline (1.5), but this increased to three quarters (75%) at follow up, which will help ensure children have five portions of fruit and vegetables each day. An area of future focus for settings and the professionals, who support them, includes continuing to encourage settings to provide a portion of fruit at breakfast, as one quarter (25%) of settings did not fully meet this guideline at follow up.

3.4.4.2 Snacks

Ninety six per cent (n=280 of the 292) of settings provided snacks. Table 15 details the number of settings meeting the seven food and drink guidelines for snacks at baseline and follow up audit. As with breakfast provision, overall, settings made positive changes to their snack provision between the baseline and follow up audits. It is recommended that a starchy food should be included as part of snacks at least once a day, to ensure that children have sufficient energy and carbohydrate in their diet (guideline 2.1). Between

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Mean no. met at baseline

Mean no. met at follow up


the baseline and follow up audits, the proportion of settings meeting this recommendation increased (from 63% to 87%), and the variety of starchy foods provided also increased (2.2; with 61% settings providing at least three varieties a week at baseline, and 83% at follow up). It is recommended that dried fruit is not provided as part of snacks (as it contains sugar that can stick to and damage children’s teeth, 2.4) Less than half of settings (45%) met this recommendation at baseline, but this increased to over three-quarter (78%) at follow up. Likewise, the proportion of settings avoiding other sweet foods between meals increased (2.7; from 77% to 86%) which will also help to protect children’s teeth. The main areas of impact on snack provision between the baseline and follow up audits were the decrease in use of dried fruit as part of snacks (helping to protect children’s teeth) and the increase in variety of starchy foods and meat, fish and alternatives provided (which helps to ensure children get a good balance of nutrients and encourages children to try new foods). Areas for further action include continuing to encourage settings not to provide dried fruits and sweet foods as part of snack provision recommended to help protect children’s teeth.

3.4.4.3 Lunch

Two thirds of the settings (n=204 of the 292) provided lunch at baseline and follow up. Table 16 details the number of settings meeting the 13 Voluntary Food and Drink Guidelines for lunch at the baseline and follow up audit. Almost all settings (95% at baseline and 95% at follow up) provided lunch as a two course meal (guideline 3.1). To ensure that children receive the appropriate balance of energy and nutrients from lunch, main courses should include a portion of starchy food (3.2), a portion of meat or an alternative protein source (3.7) and a portion of vegetables or fruit (3.6). At baseline, 4% settings did not always provide a starchy food as part of lunches, but this proportion decreased, and at follow up was fully met by virtually all (99%) settings. Between baseline and follow up the variety of starchy foods provided increased (3.3; with the proportion of settings providing more than three varieties during the week increasing from 86% to 96%) and the balance of white and wholegrain starchy foods improved (3.4; with the proportion of settings providing a variety of both during the week increasing from 54% to 75%) and limiting fried starchy food to once a week (3.5; from 81% to 85%). The proportion of settings providing a portion of meat or an alternative as part of each lunch increased between baseline and follow up (from 77% to 90%), and the variety of foods from this group provided at lunchtime also increased (3.8; with the proportion of settings providing at least three varieties a week increasing from 88% to 94%). The proportion of settings using a ‘vegetarian’ source of protein in a meal for all children each week also increased between baseline and follow up (3.9; from 58% to 76%), and the proportion of settings providing oily fish at lunchtime (3.10; important to maintain a healthy heart, and to introduce children to eating oily fish) increased from just under half (48%) to nearly three-quarters (72%). The changes made to lunch provision between baseline and follow up show a shift towards a more balanced and varied provision. Areas of future focus for settings and the professionals supporting them include, continuing to meet the guidelines not consistently met at follow up, such as providing a balance of white and wholegrain starchy foods, providing a meat alternative for all each week, and providing oily fish on the menu.


3.4.4.4 Tea

Nearly two-thirds (n=185 of the 292) settings provided tea at baseline and follow up. Table 17 details the number of settings meeting the 13 food and drink guidelines for tea at the baseline and follow up audit. Research suggests that tea tends to be a lighter meal than lunch,33 which is generally provided as the ‘main meal’ of the day in settings. However, it is recommended that tea is provided as a two course meal, to ensure that children receive sufficient energy and nutrients (guideline 4.1). Tea was provided as a two course meal by 74% settings at baseline, and 82% at follow up. As with lunch, tea should include a portion of starchy food (4.2), a portion of fruit or vegetables (4.6) and a portion of meat or an alternative (4.7) to ensure an appropriate balance of nutrients. Between the baseline and follow up audits, the proportion of settings including these food groups as part of tea increased (from 96% to 98% for starchy foods; from 68% to 85% for fruit and vegetables; and from 50% to 70% for meat and alternatives). The diversity of foods provided as part of tea also increased with more variety of starchy foods provided (4.3; from 84% to 90%), a better balance of white and wholegrain starchy foods (4.4; increasing from 63% to 83%), more variety of meat or meat alternatives provided (4.8; from 65% to 83%), and different desserts provided (4.11; increasing from 61% to 76% settings providing a variety across the week). The proportion of settings using a ‘vegetarian’ source of protein for all children at tea each week also increased between baseline and follow up (4.9; from 62% to 79%), and the proportion of settings providing oily fish at teatime (3.10; increased from just under half (43%) to nearly three-quarters (74%). The changes made to tea provision between baseline and follow up show a similar shift towards a more balanced and varied provision as observed with the lunch provision. Areas of future focus for settings and the professionals supporting them include, continuing to meet the guidelines not consistently met at follow up, such as a better variety of desserts, providing a meat alternative for all each week, and providing oily fish on the menu.

3.4.4.5 Guidelines that apply across the day

A number of the guidelines in Part B of the evaluation checklist apply to the amount of food and the type of products chosen and used in early years settings across all meals and snacks provided. Sixty per cent of settings (n=178) provided lunch and tea at baseline and follow up. Between the baseline and follow up audits, changes were reported in the types of products used by these settings, including:

An increase in the proportion of settings providing portion sizes for meals and snacks in line with the typical example portion sizes in the practical guide (5.1; fully met by 78% settings at baseline and 94% settings at follow up).

An increase in the proportion of settings checking food labels and choosing products lower in salt, for example bread and bread products (6.2; increasing from 66% to 85% settings) and reduced sugar and salt baked beans (7.7; increasing from 67% to 82% settings).

A reduction in the use of ready-made sauces, stocks and soups, which can be high in salt (11.3; limited by 76% settings at baseline and 90% at follow up).

An increase in the proportion of settings checking food labels, and selecting products lower in added sugar, for example the proportion of settings choosing yoghurts lower in sugar increased from 70% to 85% settings.

A reduction in provision of sweet foods between meals (11.6; avoided by 76% settings at baseline and 84% at follow up).


The impact of these changes will particularly help to limit the amount of added sugar and salt in young children’s diets.

3.4.4.6 Overall impact on food provision within settings

The changes to food provision made by the 292 early years settings that received baseline and follow up audit visits show an overall shift towards accordance with the Voluntary Food and Drink Guidelines for Early Years Settings in England. Particular areas of impact, as outlined in sections 3.4.4.1 to 3.4.4.5 of this report include greater diversity in terms of the starchy foods and meat and alternatives provided to children, a reduction in provision of dried fruit between meals, which will help to protect children’s teeth, increased provision of oily fish at lunch and tea, increased checking of food labels to choose products (including bread and yoghurts) lower in salt and sugar, and a reduction in the use of products which are high in salt (e.g. ready-made sauces). The changes observed mean that the overall food and drink provision in settings is “healthier, more balanced and nutritious” as result of the programme. If these changes are maintained they will help to encourage children to eat well. 3.4.4.7 The impact of Course 2 on the degree of accordance with Early Years Code of Practice for Food and Drink Of the 292 settings who received baseline and follow up audits, 51 settings attended the ‘Healthy food and cooking with families Course 2 training, and 541 settings did not attend this training. Table 6 shows the mean number of Part A recommendations and Part B guidelines either ‘fully met’ or ‘not applicable’ for settings that did and did not attend Course 2 training. There were no significant differences in the number of recommendations met at baseline or follow up between settings that attended or did not attend the training (Independent sample t-tests, p=0.562; p=0.797). These results suggests that settings who had not attended the Course 2 training were still able to make comparable improvements in their overall approach to food and nutrition, and the meals and snacks provided for children.

Table 6: Accordance with Part A recommendations and Part B guidelines by course 2 training attendance

No.

settings

Part A - no. recommendations

(n=38) met at baseline

Part A - no. recommendations

(n=38) met at follow up

Part B - no guidelines (n=79) met at baseline

Part B - no. guidelines (n=79) met at follow up

Attended Course 2 training

52 29.8 35.2 68.9 74.3

Did not attend Course 2 training

240 31.7 34.0 65.3 70.9

Total

292 31.3 34.2 66.0 71.6

3.4.4.8 The Early Years Code of Practice for Food and Drink

Early years settings are encouraged to sign up to and display the Trust’s Early Years Code of Practice for Food and Drink, if they have met the seven principles relating to their approach to food. The evaluation checklist completed during the audit visits can be used to evaluate whether settings have met these criteria. Since Phase 1 (the pilot) of the Eat Better, Start Better programme (and in response to feedback from some of the auditors involved in the audit process), the Trust has produced more detailed guidance on which recommendations and guidelines included in the checklist should be met in order for the setting to display the Code of Practice. During the pilot it was up to individual auditors to decide when they considered settings had sufficiently met the principles, and so could display the Code of Practice.


The Trust has identified ‘essential’ criteria within Part A and Part B of the checklist, and would consider the principles of the Code of Practice to be fully met if settings have met at least 29 of these ‘essential criteria’ from the 38 recommendations in Part A, and at least 70 of the ‘essential criteria’ from the 79 guidelines in Part B. When the results from the follow up audits have been retrospectively checked against these criteria, 177 (60.1%) of the 292 settings met the ‘essential criteria’ for Part A (their approach to food and nutrition), over half (n=155, 53.1%) met sufficient ‘essential criteria’ for Part B (the meals and snacks they provided), and more than a third (n=103, 35.3%) settings met the ‘essential criteria’ for both Part A and Part B, and therefore have robust evidence of meeting the seven principles of the Code of Practice.


3.5 Phase 2: Delivery of cooking sessions, and impact on families’ cooking

knowledge, skills and confidence One of the key aims of the Trust’s Eat Better, Start Better programme is to improve the provision of healthier food in families. As part of the programme each of the early years settings that had participated in Course 2: ‘Healthy food and cooking with families’ were asked to apply the knowledge and skills obtained during the course to deliver a minimum of six healthy cooking sessions with families and two community healthy food activities following the date of their Course 2 cooking with families training with all cooking sessions expected to be delivered by August 2013. Eighteen of the twenty commissioning authorities delivered cooking sessions with familiesXI. Cooking sessions were typically held in small groups (depending on number of helpers, space and equipment) and involved group leaders and families preparing and eating different types of recipes together. Participants were typically invited to attend a short course of sessions. Community events were larger scale events, often held as part of other events within the setting or at other locations, with group members preparing food for others to taste or eat. The cooking sessions and community events were based on the model developed by the Trust as part of a Change4Life pilot, which involved running cooking sessions with families in 60 Sure Start Children’s Centres in the South West region of England. The Let’s Get Cooking model is built upon the Chinese proverb “What I hear, I forget. What I see, I remember. What I do, I understand”. By seeing, hearing, and doing the participants will build their confidence, competence and capacity to cook healthily. The early years settings were given a £300 grant to contribute to the cost of running the cooking sessions. This funding could be used to purchase small pieces of equipment and ingredients. After each cooking session had taken place, settings submitted an online report via the Trust’s website. The reports describe what food was prepared, the skills developed, and how many families were involved in the cooking sessions. In some cases early years settings also provided anecdotal information on how the sessions had impacted on attitudes of families and staff to healthy food and cooking, and their confidence to cook at home. In Phase 2 of the programme, the early years settings that had attended Course 2 submitted a total of 1,274 activity reports with details of 1002 cooking sessions and 272 community events; this was lower than the target number specified (total of 1,596 activity reports; 1,156 and 401 respectively).XII There were a number of reasons why the settings did not meet their target number of sessions including re-structuring of children centres, early years settings and other services within the authority, often reducing the staff capacity to deliver the programme as there were less staff available and many competing priorities. Notwithstanding these challenges the programme managed to involve a total of 8,478 families; 4,526 family members in the cooking sessions and a further 3,952 family members participated in the community food activities.

XI Two local authorities have commissioned a tailored Eat better, Start Better programme to compliment the work already ongoing in the authority. In Salford the Trust delivered two modified one day Course 1s, the first was targeted to private nurseries, and the second to childminders this course also included practical cooking skills to demonstrate how to safely cook with children and incorporate food activities into the EYFS. In Middlesbrough the authority had already developed and implemented a food and nutrition scheme for nurseries (Food4Health Early Years). The Trust supported the authority to update their guidance in line with the Voluntary Food and Drink Guidelines, and deliver seminar sessions to early years settings to support them to interpret and follow the guidelines. XII The number of healthy cooking sessions and community food activities reported here are based on the data received in the activity reports submitted by each setting.


This report reflects the information in the activity reports submitted up to the deadline of 31st August 2013.XIII The Trust has been made aware, through follow up telephone conversations with a number of the settings involved in the programme, that a larger number of cooking sessions and community events have been delivered compared to the numbers reported. The cooking sessions in the Phase 2 authorities covered four main areas; increasing family cooking skills and confidence, increasing the food and nutrition knowledge of parents, encouraging children and peer to peer support.

3.5.1 Increasing family cooking skills and confidence

A suite of simple tried and tested, low cost recipes suitable for families with young children were purposively selected from the Let’s Get Cooking programme recipe portfolio to build up the parents and carers repertoire of basic cooking skills. The recipes were purposively selected to demonstrate the different themes covered in the sessions, e.g. how to cook from scratch, how to batch cook, how to successfully adapt recipes to reduce the sugar and salt content and maintain flavour, how to use seasonal ingredients, and tips to save time and money. The parents learnt how to peel and chop different fruits and vegetables safely, use a range of mixing, rubbing and kneading techniques, to make and adapt versatile recipes such as soup, ragu sauces, scones, muffins, bread and pastry from scratch. Many of the settings in Phase 2 reported the increase in confidence of parents to cook from scratch at home with some parents sharing dishes they had cooked at home with their peers in their cooking sessions. Some settings also encouraged parents to use their new cooking skills and confidence to support the delivery of community events cooking recipes for a large number of people, being involved in a ‘ready, steady, cook’ style event and also, in one nursery, helping the cook in the nursery kitchen to prepare the children’s lunch. One setting reported “All parents made last week’s recipes at home and were keen to have more recipes. Really enjoying it and got their children involved at home” and another setting stated in their online report “parent’s reported that after this session they went home and cooked this [dish] for their families and all had a great response [from the family] so will be cooking it again”. Developing the parents and carers confidence to adapt recipes was a key aspect of the cooking sessions, primarily focusing on how to make family favourites and takeaway dishes healthier and how to meet family preferences, for example using meat alternatives for vegetarians, or adding and varying the types of herbs and spices used. The families were also provided with tips how to modify the recipes to take advantage of seasonal ingredients. One parent was reported saying “I will try at home, everything was fresh and I’m used to using things from jars so I am going to try fresh things at home.” Increasing parents’ confidence to cook with their children was the main outcome of a number cooking sessions delivered in Phase 2 with many parents reporting that they now involve their children in cooking at home. There are many benefits to involving children in cooking activities both at home and in early years settings including, developing their fine motor skills, learning to weigh and measure. Anecdotal evidence from the cooking sessions suggests that children are more likely to try new foods if they had been involved in preparing and cooking them, the case study from Marfleet Children’s Centre in North East Lincolnshire clearly illustrates how their cooking sessions gave parents the confidence to cook with their children see Appendix 9.

XIII

Note: The Trust received a significant number of online reports after the deadline from four local authorities which, in these cases the additional online reports received after the deadline (up to 18th September) were also included in the analysis.


3.5.2 Increasing the food and nutrition knowledge of parents

The cooking sessions took a number of different approaches to increase the parents’ food and nutrition knowledge, for example looking at appropriate portion sizes of different foods, how to make healthier versions of family favourites and takeaways, reading food labels to look at the sugar and salt content of pre-prepared foods, and ways to increase the fruit and vegetable content of different dishes. Some of the settings supported families to understand more about the Eatwell PlateXIV, 29 and why it was important to eat a healthy balanced diet as well as looking at appropriate portion sizes for the family. Many settings used visual aids of activities such as weighing out portion sizes used at home and comparing them to the recommended amounts and involving children by asking them to design healthy eating placemats. There is a further example of how one early years setting (Belgrave Children’s Centre in Leicester) used cooking sessions to improve the food and nutrition knowledge of parents see Appendix 9. In addition, the cooking sessions and community food activities reported by the early years settings resulted in an increased awareness amongst families of the amount of saturated fat, sugar and salt content in many manufactured foods and takeaways, and increased their understanding how to read food labels to choose healthier versions of products such as breakfast cereals and yoghurts. The cooking sessions also gave the families the confidence to cook foods from scratch to enable them to reduce the amount of sugar and salt in their diets, for example encouraging them to substituting jars of pasta and curry sauce and pizzas for homemade versions. The case study from Immingham Children’s Centre in North East Lincolnshire shows how they used inspiration from a TV show to get parents thinking about the nutritional benefits of the food they were cooking and instil enthusiasm for cooking from scratch amongst families see Appendix 9. In some areas the cooking sessions and community events were used as an opportunity to link to other local providers of health information such as the local dental health team. Many of the settings used the cooking sessions as an opportunity to provide families with lots of ideas and support to provide healthy lunch boxes and snack foods. By encouraging families to provide healthy food in packed lunches settings can ensure consistent messages are provided to all children about healthy eating and that all children are able to have a healthy lunch. In one area, the settings also used the information and knowledge they had gathered from the healthy cooking and families training to update the menus within the settings, incorporating recipes used in the cooking sessions.

3.5.3 Encouraging children and families to eat well

Many early years settings used the cooking sessions to encourage families to eat well; including trying new foods, incorporating food into education programmes to support children’s development in the EYFS and trying foods from different cultures. Cooking sessions provide a crucial opportunity for children and families to try different food. This is important because the more varied families’ diets are the more likely they are to get the right balance of nutrients for their requirements. Many families found that children were more likely to try new foods if they had been involved in preparing and cooking the food. For example, on setting reported that “it was really useful to involve the children in the tasting session as the parents were surprised by what foods their children tried and

XIV

Note: Healthy eating advice for children aged five and over and for adults is illustrated by the eatwell plate, which shows the types of food to eat, and in what proportions, for a well- balanced and healthy diet. Since, young children are growing quickly and have high energy and nutrient requirements the low fat, high fibre diet based on the proportions set out by the eatwell plate is not appropriate for young children particularly those aged under two years, as it may not provide enough energy, fat, iron or zinc, and is too high in fibre.


enjoyed” and another setting stated “we learnt about… how you should get children taking part in cooking and how they learn to make food and they enjoy to eat what they make”. There is more evidence of how the cooking sessions support families to manage fussy eating in the case study from All Saint’s and Biddick Hall and Whiteleas Children's Centres, South Tyneside see Appendix 9. Learning about and through food can be linked to all seven areas of learning and development that shape the Early Years Foundation Stage (EYFS) curriculum. Food activities can help ignite children’s curiosity and enthusiasm for learning as well as helping to establish good eating habits. Settings used popular stories ‘Teddy Bears Picnic’ and ‘The Hungry Caterpillar’ as opportunities to develop literacy skills. To support children’s understanding of the world one setting used ‘around the world’ theme day during which children were provided with opportunities to learn about different cultures and the associated food customs. Some settings also incorporated growing vegetables or herbs into their cooking session. Settings encouraged children to describe the tastes and textures of different foods and their likes and dislikes, this helped to support the development of their communication skills and personal and social development. Involving children in the preparing and cooking of foods also supports the development of their fine motor skills through mixing and kneading, and their mathematic skills by weighing and measuring ingredients. One good example of how a setting incorporated different aspect of learning into cooking can be found in the case study from Lampits Pre-school in Thurrock. This setting used a cuddly toy with a diary to encourage families to cook at home and for children to record what they had done and share this with their peers, helping to develop their communication skills - see Appendix 9. Settings also frequently used the sessions to cook a meal (either lunch or tea) and the parents, children, and/or staff all ate the meal together. Many of the children’s centres reported the positive impact of parents and children spending time cooking and eating together, this type of session allowed them to spend quality time together (something one parent said they could not do easily at home) and provided the added benefits from modelling positive eating behaviours such as trying new foods, developing social skills talking about their cooking experiences, and fine motor skills when handling a knife and fork were also observed. One children’s centre commented that “sitting together as a group the children learn from each other, mimicking positive behaviour, for example how to use a spoon, fork, and trying new foods and how to sit well at the table.” The time families spent cooking and eating together also supported communication between parents and their children with one setting reporting the “interaction between parents and children is brilliant”.

3.5.4 Peer to peer support

Anecdotal feedback from the settings clearly showed that parents felt the sessions provided them with an opportunity to socialise with other parents through group work. Club co-ordinators felt that sessions helped to develop skills such as team working amongst parents, and encouraged peer-to-peer support. For example, one setting commented that everyone working around one large table and requiring families to share ingredients was a great ‘ice breaker’ to get families and the club co-ordinator socialising. Another setting asked parents to make scones at home and bring these to the next cooking session, giving them the opportunity to share their experiences of cooking at home with their contemporaries. The cooking sessions also empowered some parents to volunteer to help deliver some of the healthy cooking sessions to families and also support the delivery of community food events. There is also evidence that families involved in the cooking sessions wanted to share their new skills and confidence with other family members and friends, with one family reporting “I can’t wait to show off my new cooking skills to family and friends and to teach them too”.


4 KEY FINDINGS, LIMITATIONS AND RECOMMENDATIONS

4.1 Key findings The Children’s Food Trust in collaboration with the early years and health sectors in 20 local authority areas successfully rolled out the ‘Eat Better, Start Better’ programme over a 14 month period (June 2012 to August 2013). The integrated food, nutrition and healthy cooking programme involved the delivery of two train-the-trainer courses, cascading food and nutrition knowledge and skills to settings and families, dissemination of guidance and resources, and regular monitoring of the impact of the programme using standardised evaluation tools.

Course 1 was delivered to 450 health and early years professionals and practitioners in Phase 2 (2012-2013). This course focused on how to use the food and drink guidelines and practical tools with early years settings and monitor their impact.

Course 2 was delivered to 354 delegates from 188 early years settings in Phase 2 (2012-2013). This course focused on the food and drink guidelines and running healthy cooking sessions with families.

Delegates from Course 1 conducted baseline and follow up audits in 292 early years settings assessing the impact of the guidelines and training on the settings’ approach to and provision of food.

Delegates from Course 2 delivered 1,002 healthy cooking sessions with 4,526 parents/carers and 272 community food activities involving a further 3,952 other family members. The impact of the cooking sessions was captured via the submission of 1,274 online activity reports.

Overall the Eat Better, Start Better Phase 2 programme trained 804 early years and health practitioners and reached a total of 8,478 families

The evaluation of the Eat Better, Start Better programme has shown that all three outcomes of the programme were successfully met in each of the 20 local authority areas. Sections 4.1.1-4.1.3 summarise the impact and key findings for each outcome. 4.1.1 Outcome 1: Increased food, nutrition and healthy cooking knowledge and skills for the

early years and childcare workforce

Impact of Course 1: The results from a quiz before and after the one day course ‘The Voluntary Food and Drink Guidelines for Early Years Settings in England and practical tools for health and early years professionals’ show that on average the early years and health professionals significantly increased their knowledge, skills and confidence to support local settings to provide healthy food for children aged between one and five years, and monitor the impact of the guidelines and training on their settings approach to and provision of food (see section 3.2).

Feedback on Course 2: Results from a feedback form completed after course 2 shows that virtually all delegates (n=339, 99.7%) reported that the aim “To teach you about the Voluntary Food and Drink Guidelines for Early Years Settings in England, and to apply these to help families cook healthy and nutritious meals at home” was met, and likewise 96% of delegates (n=325) reported that the aim “To help you develop confidence in running healthy cooking sessions with families” was also met. (see section 3.3)

4.1.2 Outcome 2: Improved, healthier food provision for children aged 1-5 in early years and

childcare settings and at home.

Changes in food provision in early years settings: a total of 292 baseline and follow up audits were conducted in Phase 2 to evaluate local settings’ approach to and provision of food. Analysis of these audits revealed that there was a significant increase in the number of


recommendations and food and drink guidelines ‘met’, showing an overall shift in both settings’ approach to food and their provision of healthier menus. This shift was observed across all 15 local authorities where baseline and follow up data was available, and all types of setting. The main areas of impact were the increased use of food policies within settings, and engagement with parents and children around food activities. In terms of food provision there was increased diversity in the types of food provided (e.g. starchy foods and protein sources provided with meals), and increased use of foods lower in salt and sugar (e.g. breakfast cereals, yogurts). These changes mean that overall food and drink provision in the settings involved in the programme has got “healthier, more balanced and nutritious”” (see section 3.4).

4.1.3 Outcome 3: Increased food and nutrition knowledge and practical cooking skills for

parents and families attending early years settings

Impact of cooking sessions: Early years practitioners from 172 early years settings participating in Course 2 delivered a total of 1,002 healthy cooking sessions involving 4,526 parents/carers of young children. These sessions focused on increasing the parent’s knowledge, practical cooking skills and confidence to buy, prepare and cook healthy meals. The settings also ran 272 community food activities engaging an additional 3,952 family members around healthy cooking. The settings reported anecdotal information in their online reports, describing how the sessions had a positive impact on both the parents’ and practitioners’ skills and confidence to cook from scratch at home, adapt recipes and cook with children. The training sessions inspired the settings to use interactive activities in the cooking sessions to support parents to read food labels and limit the amount of sugar and salt in their family’s diet, particularly in relation to healthy packed lunches and snack options. The cooking sessions also provided an opportunity for parents to socialise with their children and their peers, encouraging them to try new foods. The settings also used the cooking sessions within their educational programmes to support children’s development in the prime and specific areas of learning within the Early Years Foundation Stage (EYFS) curriculum (see section 3.5).


4.2 Limitations The Trust provided standardised benchmarking data collection protocols and tools, training and support to use these to monitor the impact of the Eat Better, Start Better programme. However, many different individuals were involved in data collection which makes consistent adherence to evaluation protocols a challenge, specifically with regard to maintaining objectivity and response rates.

4.2.1 Setting audit visits - Limitations

The main limitations of the audit part of the evaluation is the purposive approach used to select settings, they were either self-selected (as they volunteered to take part) or were selected because of their location, setting type or meal provision. Since, the settings were not randomly selected from all settings within the area. It is not known how representative these settings are of provision across the participating authorities or nationally so the findings should not be generalised or extrapolated. The Phase 2 local authorities carried out the audit process in three main ways: i) independent assessment: auditors (who attended Course 1 training) conducting visits to settings; ii) self-evaluation: settings complete and return evaluation checklists and iii) supported self-evaluation: settings complete evaluation checklist, and then receive a visit from an independent auditor (who attended Course 1 training) to check the information before it is submitted. The impact of using these different approaches and many auditors is unknown, it may have affected the consistency and in some cases the objectivity, and the interpretation of the recommendations and guidelines included in the evaluation checklist.

4.3 Recommendations Evaluation was an integral part of the Eat Better, Start Better programme. Despite the limitations described above the evaluation provides some important insights into the impact of the Eat Better, Start Better programme on knowledge, skills and confidence of the early years and health workforce, and the approach to and provision of healthier food in early years settings and at home. These have been used to inform recommendations for the future roll out of the Eat Better, Start Better programme across England.

Rationale/evidence for recommendation 1: This would directly support the commissioning board to fulfil its mandate under the 2012 Health and Social Act,30 particularly in regard to early intervention, tackling health inequalities, and encouraging a joined-up approach to addressing the needs and improving the health outcomes of young children as outlined in the Public Health Outcomes Framework31 and the Better Health Outcomes for Children and Young People Pledge.32

Recommendation 1: Health and Wellbeing Boards to consider incorporating the Eat Better, Start Better programme into their joint Health and Wellbeing strategies and action plans as part of the universal and targeted offer within the early years and health services. This early intervention will help support the promotion of healthier lifestyles, tackle childhood obesity and improve health and social outcomes for children.


Rationale/evidence for recommendation 2: The Eat Better, Start Better programme has been designed to help foster collaboration between the early years and public health sectors, to encourage a system-wide commitment, shared vision and integrated approach to early years food and nutrition within the education and health service as depicted in Southend and Derby case studies (see Appendix 9). It is recommended that the local authorities participating in the Eat Better, Start Better programme build upon and strengthen the collaboration developed between the health and early years teams during the delivery of this programme, and explore the opportunities for using the evidence-based programme across the early years sector as part of wider community, family-based healthy weight programmes. This early intervention can be used to develop a life course approach to healthier lifestyles giving early years and health practitioners the knowledge, skills and confidence to empower parents to make informed food and nutrition choices for their child’s and their whole family’s health and wellbeing.

Rationale/evidence for recommendation 3: Ensuring that all regulated settings (children’s centres, private, voluntary and independent nurseries, pre-schools and childminders) and unregulated settings (parent and toddler groups), are aware of, and use, the Voluntary Food and Drink Guidelines for Early Years Settings in England will help ensure consistent practice across all settings. Continuing to encourage all settings to sign up to the Early Years Code of Practice for Food and Drink will enable them to demonstrate to parents, Ofsted and quality assurance schemes that their approach to food is aligned to national best practice. The setting audit visits highlighted areas of settings’ approach to food and meal and snack provision that do not currently meet national best practice. The findings in this evaluation report and the Trust’s recently published pre-school food

Recommendation 2: : Public Health directorates and early years and childcare departments to work in close collaboration, to develop a system-wide commitment, shared vision and integrated approach to early years food and nutrition within the education and health service. Exploring opportunities for incorporating the delivery of the evidence-based programmes such as Eat Better, Start Better across the early years sector.

Recommendation 3: Local authority commissioners to explore opportunities to embrace, extend and embed the Eat Better, Start Better programme, for example by:

increasing awareness and use of the voluntary food and drink guidelines

encouraging early years settings to sign up to the Early Years Code of Practice for Food and Drink, and considering setting a local target for settings to achieve the Code of Practice

disseminating the findings from the Phase 2 evaluation across the early years and health sector to help inform future policies and practices and develop a shared vision how to encourage young children to eat well.

support local early years settings to ensure their approach to food, and meals and snacks provided, meet EYFS welfare requirements and the Voluntary Food and Drink Guidelines for Early Years Settings in England.

sharing good practice through setting up a network and mentoring system to encourage early years settings to share their knowledge and skills of delivering food and nutrition activities and healthy cooking sessions with parents, children and the wider community with settings currently not involved in running food and nutrition activities.

increasing opportunities for food, nutrition and healthy cooking training for early years and health staff, using peer-reviewed accredited train the trainer programmes or endorsed e-learning courses.

.


survey33 can be used to target these specific areas, to ensure settings can meet these recommendations in the future. Disseminating a summary of findings from the evaluation would support settings to improve their own approach to food and nutrition by highlighting common areas of good practice, and areas for improvement seen across the audited settings. It would also help promote awareness of the national food and drink guidelines amongst settings that were not involved in the audits. Disseminating findings to other professionals working with settings (and also families) would help to ensure consistency of messages and advice for people providing food for young children. Cascading quality assured, flexible, affordable and accessible training in early years food and nutrition to all early years practitioners and supporting staff such as cooks/chefs, will support them to provide food and drink meeting young children’s needs. This training could also consider practical ways to tackle the barriers that prevent young children and their families from eating healthily, and incorporate a physical activity component. During Phase 2 of the Eat Better, Start Better programme the Trust applied for and were successful in obtaining accreditation by the Royal Society of Public Health (RSPH) for the Eat Better, Start Better Course 1. This peer review has helped to quality assure the content and deliver of the training. The Trust has also successfully converted the Course 1 face to face training into three early years food and nutrition online learning courses:

Course 1: Providing a healthy diet for young children

Course 2: Meeting the food and drink guidelines for early years setting

Course 3: Encouraging young children in your care to eat well) All three courses have been endorsed by the Council for Awards in Care, Health and Education (CACHE). These online courses have primarily been developed to increase the accessibility and affordability of the Trust’s evidence-based training, particularly for childminders and health visitors. The online courses can be accessed via the Children’s Food Trust Learning Network.34 The Learning Network is a one stop shop for information on children’s food, providing the learner with webcasts on topical issues, opportunities to participate in webchats with industry experts and contribute to forum.

Rationale/evidence for recommendation 4: Incorporation of the Voluntary Food and Drink Guidelines and delivery of the Eat Better, Start Better programme will help increase consistency in healthy eating messages. Delivering healthy cooking sessions as part of the ‘Achieving two-year-olds’ offer35 would contribute to tackling health inequalities, child development and early intervention. Extending the healthy cooking sessions as bespoke support for parents/carers of two year olds in receipt of the entitlement to 15 hours free early education may help stimulate parental demand and take up of the entitlement as well as support them to meet their child’s education and nutritional needs. Simultaneously, settings delivering the including the ‘early learning for two-year-olds’ offer should be encouraged to work towards the Code of Practice for Food and Drink to help enhance the quality of their food provision to best meet the nutritional requirements of two-year-olds.

Recommendation 4: Department for Education, Department of Health and local authorities to incorporate the Voluntary Food and Drink Guidelines and delivery of the Eat Better, Start Better programme into the roll out of national initiatives, including the ‘including the ‘early learning for two-year-olds’ offer, and as part of the integrated health and education review of children aged 2-2½ years. Local authorities to also consider how the work already completed as part of the Eat Better, Start Better programme could help inform their Big Lottery ‘Fulfilling Lives: A Better Start’ stage 2 application and future delivery of local interventions designed to improve early years nutrition and promote healthy lifestyles. years.


Using the Food and Drink Guidelines as part of the integrated health and education review for children aged 2- 2 ½ years36 will enable early years practitioners and health visitors to use evidence-based age appropriate nutrition information, and help to ensure that parents receive consistent messages around healthy eating from both sectors.

Evidence/rationale for recommendation 5: It is recommended that local authorities use the lessons learned from the successful delivery of the healthy cooking sessions via early years settings which achieved high parental engagement to develop a flexible approach to running cooking sessions in the future. For example using a variety of community facilities, and building on relationships with community groups and food banks could help to increase parental participation in cooking sessions, this would also help to target food poverty amongst young families a growing concern nationally. Parents and other carers play the single biggest role in determining their children’s diets, whether through cooking at home, or influencing their child’s early years setting to improve its catering. The Trust has used the lessons learned from the delivery of the successful Let’s Get Cooking and Eat Better, Start Better programmes to launch Let’s Get Cooking at Home.37 This new website for parents and carer provides access to more than 300 healthy recipes, tips, and tuition on all aspects of cooking good, simple food from scratch on a budget and is completely free to use. Evidence/rationale for recommendation 6: It is recommended that local authorities consider incorporating the Trust’s standardised evaluation checklist into their early years quality improvement processes, and included it as part of the annual EYFS Safeguarding and Welfare audit. Regular monitoring will help assess the impact of the guidelines, training and cooking sessions and maintain quality improvement in the approach to and provision of food within the early years sector by identifying any deviations from national good practice and training gaps. This approach also provides a useful mechanism for peer to peer support and sharing best practice. To this end it is also recommended that authorities consider formalising the role of Environmental Health to help sustain the future impact of the Eat Better, Start Better programme. The findings generated from annual audits can also be used as evidence for Health and Wellbeing boards to inform future policies and programmes around early years food and nutrition.

Recommendation 5: Local authorities to consult and build links with parents wherever possible in regard to food provision, and to consider expanding cooking sessions into the wider community, for example by delivering in community halls and kitchens, and at food banks to increase parental engagement and participation.

Recommendation 6: Local authorities to consider incorporating the Trust’s standardised evaluation checklist into early years quality improvement processes and work in partnership to assist settings to help maintain and further enhance their approach to food.


5 APPENDICES

Appendix 1: Child health statistics for Phase 2 local authorities

Table 7: Level of deprivation and health inequalities in Phase 2 local authorities

Region Local Authority Percentage of nursery and

primary school pupils entitled to

free school meals (2011)38

Percentage of overweight/obese

children in reception year of school

(2011-12)39

North East South Tyneside 27.3 21.9

Hartlepool 26.0 23.6

Middlesbrough 29.5 22.6

North West Salford 29.2 22.8

Yorkshire and

Humber

Hull 30.3 23.2

North East Lincolnshire 19.1 24.3

East Midlands Derby 19.7 21.7

Leicester 23.1 22.9

Lincolnshire 12.3 23.8

West

Midlands

Wolverhampton 26.7 24.1

Walsall 22.1 22.9

East of

England

Luton 22.3 23.1

Peterborough 20.5 22.2

Thurrock 17.8 25.4

Southend 18.9 23.3

London Greenwich 27.8 27.2

Enfield 28.4 28.2

Lewisham 25.4 24.8

South East Isle of Wight 18.4 23.1

East Sussex 16.1 20.4


Appendix 2: Course 1 aim and learning objectives

Aim: To enhance the knowledge, skills and confidence of early years and health professionals so they can help early years settings understand and use the Voluntary Food and Drink Guidelines for Early Years Settings in England, and evaluate their impact on food and drink provision. Specific objectives - To:

enhance knowledge and understanding of why good nutrition is important for young children

enhance understanding of the Voluntary Food and Drink Guidelines for Early Years Settings in England

extend knowledge and skills of how to plan menus and provide appropriate types, amounts and frequencies of food and drink to ensure it is healthy and nutritionally balanced across a day and week

develop an understanding of the practical resources and tools available to settings

develop an understanding of the auditing process and requirements for accordance with the Early Years Code of Practice for Food and Drink.

Learning outcomes - To be able to:

demonstrate an understanding of why nutrition is important for young children

demonstrate an understanding of the Voluntary Food and Drink Guidelines for Early Years Settings in England and supporting practical tools

demonstrate an understanding of appropriate types, frequency and amounts of food and drink to provide to meet the nutrient requirements of children aged one to five years

confidently support early years settings to understand and use the food and drink guidelines and practical resources and tools to plan their menus in accordance with the food and drink guidelines

support settings to encourage children to eat well, including having appropriate portion sizes for different ages

support their early years settings to self-evaluate their approach to and provision of food and drink, and to identify areas for improvement

confidently audit early years settings’ approach to and provision of food and drink to measure the impact of the introduction of the Voluntary Food and Drink Guidelines for Early Years Settings in England.


Appendix 3. Eat Better Start Better Course 1 training programme

Training Programme

Session Time Activity

9.00-9.30 Arrival and registration

1 9.30-10.00 a. Welcome b. Overview and outline of the Children’s Food Trust Eat Better, Start

Better programme c. Activity - What I would like to get from the course?

2 10.00-10.15 Evidence and rationale for the food and drink guidelines: a. the importance of early intervention and addressing local priorities b. the current health and nutritional status of children aged one to five

years c. the recommendations of the Advisory Panel on Food and Nutrition in

Early Years.

3 10.15-10.30 Pre-training quiz: early years food and nutrition

4 10.30-11.15 Young children’s diets a. Activity – What food and drinks do young children consume? b. What is a healthy, balanced and nutritious diet for children aged one

to five years? c. How does a healthy, balanced diet for children aged one to five years

differ from that needed by older children and adults?

11.15-11.30 Refreshment break

5 11.30-12.15 The Voluntary Food and Drink Guidelines for Early Years Settings in England a. Development of the guidelines b. Interpreting the guidelines c. An overview of the guidelines d. The nutrient framework explained

6 12.15-13.00 Activity – Reading food labels

13.00-13.45 Lunch

7 13.45-14.00 Activity – Portion sizes for children aged one to five years

8 14.00-14.30 How to encourage children to eat well – an introduction to section 5 of the practical guide

9 14.30-15.00 An overview of the practical tools – an introduction to section 6 of the practical guide

Comfort break

10 15.00-16.00 Activity: planning a one-week menu to meet the food and drink guidelines Activity: checking a one-week menu against the food and drink guidelines

11 16.00-16.30 Collecting evidence and evaluating the impact of Eat Better, Start Better programme – an overview of the process and data collection tools

12 16.30-17.00 Accessing further support and next steps a. Further support and advice b. Follow up activities c. Post-training quiz and course evaluation


Appendix 4: Phase 2 confidence scores of Course 1 delegates before and after the training course

Table 8. Phase 2 Course 1 delegates confidence scores before and after the training course

Before training After training

1

Not at all confident 2 3 4

5 Very

confident

1 Not at

all confident

2

3

4

5 Very

confident

Confidence about n % n % n % n % n % n % n % n % n % n %

1. advising settings on the types of food and drink to

provide for children aged one to five years?

43 15 88 31 105 37 37 13 13 5 8 3 6 2 67 23 150 52 55 19

2. advising settings on appropriate portion sizes

for children aged one to five years?

65 23 100 35 86 30 24 8 11 4 8 3 8 3 54 19 152 53 64 22

3. interpreting food labels to identify products lower in saturated fat, salt and

sugar?

43 15 83 29 82 29 57 20 21 7 8 3 11 4 44 15 139 49 84 29

4. planning and evaluating menus that meet the nutritional requirements

of children aged one to five years?

61 21 98 34 91 32 24 8 12 4 6 2 10 3 73 26 147 51 50 17

5. supporting settings to encourage children to eat

well and convey the importance of food and nutrition in early years to parents?

30 10 79 28 103 36 54 19 20 7 7 2 9 3 60 21 136 48 74 26

6. supporting settings to demonstrate they are meeting the welfare requirements for food and drink?

53 19 92 32 89 31 35 12 17 6 8 3 11 4 63 22 139 49 65 23

Base=286


Appendix 5: Course 2 aims, learning outcomes Course aims: Delegates will become familiar with the new national, voluntary food and drink guidelines for early years settings, and experience practical training in developing the skills and knowledge required to confidently set up and run cooking sessions for families. Course outcomes:

a) Understand why nutrition is important for young children. b) Learn about the national, voluntary food and drink guidelines for early years and how they

apply to settings. c) Improve awareness of food safety and hygiene. d) Develop food preparation and handling skills. e) Prepare a range of healthy, nutritious, low-cost family meals. f) Understand how to adapt recipes to make them healthier and suitable for one to five-year-

olds. g) Improve understanding of appropriate portion sizes for one to five-year-olds. h) Improve knowledge of how to read food labels. i) Experience and practise different approaches to demonstrating cooking skills. j) Understand how to run effective training sessions and manage cooking groups. k) Understand how to support families to plan and shop for healthy food on a budget. l) Understand how to use the ready-made cooking session plans with families and to run

community food activities. m) Understand how to complete the Eat Better, Start Better online reports and how to

administer the food behaviour questionnaires with families.


Appendix 6. Eat Better Start Better Course 2 Healthy food and cooking for families’ training programme

Course 2a – Day 1

9.15-13:00 Morning session

Registration and refreshments

Welcome, introductions and aims

Food safety an introduction

Scone making

Food safety part two

Break

Why is nutrition important for 1-5 year olds

Demonstration methods

Making lunch

13:00-13:45 Lunch

13:45-16:00 Afternoon session

Portions

Batching, storing and freezing

Fussy eaters and diverse diets

Break

Adapting recipes

What have you signed up for?

Plenary

16:00 Finish

Course 2a – Day 2




Recap activity

Reading food labels

How to plan menus shop and budget

Break

Discussion of 100 calorie and child’s perfect day activity

Demonstrating techniques and lunch demonstration

Making lunch

12:40 -13:30 Lunch


Storing, batching, freezing and adapting recipes for 1-5 years

Cooking with children

Effective training sessions

Online reports and food behaviour questionnaires (if applicable

Break

Planning your sessions

Next steps

Feedback

16:00 Finish


Course 2b




Practical demonstration-healthy bakes

Sharing successes and ‘useful disasters

Break

Revising food labels - and the sugar mountain task

Practical demonstration - handling raw meat

Lunch activity - ‘make your own take-away’

13:25 Lunch


Adapting recipes (allergies and intolerances

Food behaviour questionnaires and online reporting

Take-home activity - making bread-in-a-bag

Next steps for your club

Planning your sessions

Skills and knowledge questionnaires (if applicable)

Questions and feedback

15:30 Finish


Appendix 7: Phase 2 baseline and follow up audits - approach to food and nutrition

Table 9. Number of settings meeting best practice recommendations for developing a food policy

Recommendation Baseline Follow up Comment on impact Fully met

Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

1a. Written policy in place

246 16 28 2 270 7 8 7 +ve Increase in settings with written policy

1b. Policy covers all

relevant areas

140 109 35 8 212 57 8 15 +ve Increase in detailed

policies 1c. Policy is clearly displayed/accessible

202 27 53 10 249 8 18 17 +ve Increase in accessibility of policy

1d. Staff are familiar

with policy

217 26 34 15 248 14 6 24 +ve Increase in staff

familiarity with policy

1e. Policy shared with families

208 34 43 7 254 12 11 15 +ve Increase in sharing policy with families

1f. Policy reviewed

annually

214 21 50 7 253 10 16 13 +ve Increase in review of

policy

1g. Staff and families are consulted

170 45 70 7 226 33 19 14 +ve Increase in consultation around policy

1h. Describes how food supports learning

127 47 106 12 201 37 36 18 +ve Increase in linkages between policy and curriculum

Base = 292 settings where baseline and follow up audits were conducted Comments: +ve positive change; -ve negative change; -- no change.

Table 10. Number of settings meeting best practice recommendations for communicating with children and families


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

2a. Liaise with families about timing for meals

253 20 11 8 269 9 1 13 +ve Increase in liaising with families around timing of meals

2b. Families given

regular information

265 12 0 15 267 6 0 19 +ve Small increase in

giving families information

2c. Menus on display or available on

request

227 21 37 7 262 11 7 12 +ve Increase in displaying menus

2d. Families can give feedback

248 15 26 3 265 15 5 7 +ve Increase in families giving feedback about food

2e. Children included

when planning menus

181 61 42 8 218 41 22 11 +ve Increase in including

children in menu planning

2f. Families can

attend food events

160 25 66 41 193 21 35 43 +ve Increase in inviting families to food

events 2g. Breastfeeding is supported

177 35 20 60 195 28 11 58 +ve Increase in supporting

Base = 292 settings where baseline and follow up audits were conducted. Comments: +ve positive change; -ve negative change; -- no change.


Table 11. Number of settings meeting best practice recommendations for menu planning and food and drink guidelines


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

3a. Children eat regularly

266 9 4 13 269 6 1 16 +ve Increase in regular meals and snacks

3b. Menus planned in advance

242 17 23 10 263 10 3 16 +ve Increase in menus planned in advance

3c. New menus at least twice a year

223 19 22 27 244 10 6 32 +ve Increase in regular new menus

3d. Menus are varied

260 23 5 4 272 9 1 10 +ve Increase in varied menus

4a. Menus planned to meet the guidelines

97 62 113 20 223 30 17 22 +ve Increase in menu planning to meet guidelines


Table 12. Number of settings meeting best practice recommendations for special dietary needs and training


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

5a. Setting is aware of needs of all children

283 5 0 4 284 0 0 9 +ve Small increase in settings awareness

of children’s needs

5b. Aims to meet special dietary needs

287 3 0 2 283 2 0 7 -- No change - majority met at baseline

5c. Provides food from different cultures

268 17 2 5 269 11 1 11 +ve Small increase in provision

6a. Staff received appropriate training

251 29 8 4 263 14 4 11 +ve Increase in number fully met



Table 13. Number of settings meeting best practice recommendations for the eating environment and social aspects of meals


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

7a. Appropriate eating areas are used

283 5 1 3 282 2 0 8 -ve Small decrease but

mainly movement to N/A

7b. Appropriate tables, chairs, plates used

276 11 1 4 277 4 1 10 +ve Small icrease in appropriate plates

and cutlery

7c. Distractions avoided at mealtimes

276 7 4 5 271 9 0 12 -ve Small decrease but mainly movement to N/A

7d. Children wash hands before eating

270 14 4 4 280 4 0 8 +ve Increase in hand washing

7e. Children help set up or clear away

226 45 15 6 256 25 2 9 +ve Increase in involving children

7f. Encouraged to make choices

235 41 7 9 260 17 2 13 +ve Increase in children

encouraged to making own food choices

7g. Encouraged to

feed themselves

268 14 3 7 285 0 0 11 +ve Increase in children

feeding themselves 7h. Meals used to develop social skills

252 23 9 8 263 17 0 12 +ve Increase in using meals to teach skills

7i. Children given

sufficient time to eat

281 6 2 3 279 4 0 9 -ve Small decrease but

mainly movement to N/A

7j. Approach to manage fussy eating

241 35 9 7 270 10 1 11 +ve Increase in management of

fussy eating 7k. Children can have seconds

261 15 4 12 285 9 0 17 +ve Increase in children allowed seconds

7l. Food not used as punishment or reward

248 15 25 4 248 12 21 11 -- No change in number fully met.

7m. Setting monitors food choices and intake

257 15 7 13 269 4 3 16 +ve Increase in monitoring food choices

7n. Food from home is appropriate stored

191 18 5 78 204 7 3 78 +ve Increase in

appropriate storage of food bought in from home



Appendix 8: Phase 2 baseline and follow up audits - accordance with food and drink guidelines

Table 14. Number of settings meeting food and drink guidelines for breakfast at baseline and follow up

Guideline Baseline Follow up Comment on impact Fully met

Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

1.1 Starchy food provided

190 5 0 0 194 1 0 0 +ve Increase in number providing starchy food

1.2 Variety starchy

food provided

150 24 21 0 177 11 7 0 +ve Increase in variety

provided 1.3 W/grain & white starchy food

152 23 20 0 178 12 5 0 +ve Increase in split of w/grain and white

1.4 Low/med sugar

cereals

155 29 8 3 181 13 0 1 +ve Increase in use of

low/med sugar breakfast cereals

1.5 Fruit/veg provided

84 18 93 0 145 17 33 0 +ve Increase in fruit/veg at breakfast

1.6 Juice diluted

50:50

70 5 22 98 99 4 7 85 +ve Increase in appropriate

dilution 1.7 Water is available

192 1 1 1 194 0 0 1 +ve Small increase in water available

Base = 195 settings providing breakfast at baseline and follow up Comments: +ve positive change; -ve negative change; -- no change.

Table 15. Number of settings meeting food and drink guidelines for snacks at baseline and follow up

Guideline Baseline Follow up Comment Fully met

Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

2.1 Starchy food provided at least one snack/day

175 38 64 3 243 20 12 5 +ve Increase in provision of starchy food

2.2 Variety starchy food provided

170 32 66 12 233 20 14 13 +ve Increase in variety of starchy food

2.3 Fruit/veg provided with some snacks

254 21 5 0 274 5 1 0 +ve Increase in fruit and veg at breakfast

2.4 Dried fruit not provided

126 37 93 24 217 23 20 20 +ve Decrease in dried fruit provision

2.5 Meat/alternatives

can be provided occasionally

87 20 123 50 140 20 67 53 +ve Increase in settings

proving food from this food group

2.6 Only water/milk provided with snacks

246 15 19 0 270 7 2 1 +ve Decrease in settings providing other drinks

2.7 Sweet foods avoided

215 37 22 6 240 27 6 7 +ve Increase in settings avoiding sweet snacks

Base = 280 settings providing snacks at baseline and follow up Comments: +ve positive change; -ve negative change; -- no change.


Table 16. Number of settings meeting food and drink guidelines for lunch at baseline and follow up


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

3.1 Lunch includes main and dessert

193 5 6 0 193 7 4 0 -- No change - most met at baseline

3.2 Portion of starchy food provided at lunch

195 7 1 1 202 2 0 0 +ve Increase in starchy food provision

3.3 At least 3 different starchy foods/week

175 19 8 2 195 7 2 0 +ve Increase in starchy food variety

3.4 W/grain & white starchy food provided

111 29 62 2 153 23 26 2 +ve Increase in mix of wholegrain & white

3.5 Fried starchy food

limited

165 8 5 26 174 5 2 23 +ve Increase in starchy

food limited 3.6 Portion of fruit and/or veg provided

174 24 6 0 196 7 0 0 +ve Increase in fruit and veg provided

3.7 Portion of meat or

an alternative provided

158 30 15 1 184 16 4 0 +ve Increase in meat or

alternative provision 3.8 Variety of meat or alternatives provided

179 12 12 1 191 8 5 0 +ve Increase in meat or alternatives variety

3.9 Meat alternative

for all each week

119 32 50 3 155 26 20 3 +ve Increase in settings

providing meat alternatives

3.10 Oily fish provided > once each 3 weeks

98 21 83 2 147 16 38 3 +ve Increase in settings providing oily fish

3.11 Variety of desserts each week

173 10 13 8 190 4 5 5 +ve Increase in dessert variety

3.12 Juice diluted half juice half water

74 5 17 108 93 4 6 101 +ve Small increase in juice dilution

3.13 Access to fresh

drinking water

201 1 0 2 200 0 0 4 -- No change: most

met at baseline

Base = 204 settings providing lunch at baseline Comments: +ve positive change; -ve negative change; -- no change.

Table 17. Number of settings meeting food and drink guidelines for tea at baseline and follow up


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

4.1 Tea includes main and dessert

136 10 35 4 150 10 23 2 +ve Increase in two course teas

4.2 Portion of starchy food provided at tea

178 5 2 0 181 2 2 0 +ve Increase in starchy food at tea

4.3 At least 3 different starchy foods/week

157 20 7 1 167 14 2 2 +ve Increase in starchy food variety

4.4 W/grain & white starchy food provided

117 27 40 1 154 16 14 1 +ve Increase in mix w/grain & white

4.5 Fried starchy food

limited

145 3 5 32 149 1 4 31 +ve Increase in limiting

starchy foods

4.6 Portion of fruit and/or veg provided

126 30 28 1 158 19 7 1 +ve Increase in fruit and veg provision

4.7Portion of meat or an alternative provided

92 43 48 2 129 29 24 3 +ve Increase in meat/alt provision

4.8 Variety of meat or alternatives provided

121 24 39 1 154 14 16 1 +ve Increase in variety of meat/alternatives

4.9 Meat alternative for all each week

114 17 53 1 146 15 23 1 +ve Increase in settings providing this

4.10 Oily fish provided

> once each 3 weeks

79 16 87 3 136 11 33 5 +ve Increase in oily fish

provision 4.11 Variety of desserts each week

112 22 41 10 141 16 21 7 +ve Increase in dessert variety

4.12 Juice diluted half

juice half water

71 5 17 92 85 6 4 90 +ve Increase in diluting

juice 4.13 Access to fresh drinking water

183 0 1 1 182 0 0 3 -- No change: most met at baseline

Base = 185 settings providing tea at baseline and follow up Comments: +ve positive change; -ve negative change; -- no change.


Table 18. Number of settings meeting food and drink guidelines that apply across the day at baseline and follow up


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

5.1 Portion sizes are in line with guidelines

138 13 15 12 168 5 0 5 +ve Increase in portion

sizes meeting guidelines

Starchy foods

6.1 3 Varieties provided across each day

162 10 5 1 172 4 2 0 +ve Increase in variety of starchy food across day

6.2 Bread with low salt

content chosen

118 28 26 6 152 16 8 2 +ve Increase in checking

bread for salt content

6.3 Canned pasta limited

149 3 8 18 158 0 3 17 +ve Decrease in canned pasta use

6.4 Dried flavoured rice avoided

148 12 4 14 154 7 2 15 +ve Decrease in dried pasta/rice

Fruit and veg

7.1 5 Portion of fruit

and veg across the day

152 19 6 1 169 5 1 3 +ve Increase in providing

5 fruit & veg/day

7.2 Variety of fruit and veg provided

153 14 10 1 170 6 1 1 +ve Increase in fruit and veg variety

7.3 Dried fruit provided at mealtimes only

73 21 60 24 129 14 12 23 +ve Increase in settings avoiding dried fruit as snack

7.4 Canned fruit

provided at mealtimes only

136 11 6 25 151 3 4 20 +ve Increase in canned

fruit at meals only

7.5 Canned veg/pulses in water chosen

127 12 13 26 144 6 6 22 +ve Increase in use of canned veg in water

7.6 Canned fruit in juice chosen

138 7 9 24 149 4 5 20 +ve Increase in canned fruit in juice

7.7 Reduced sugar/salt baked beans used

119 20 32 7 146 15 9 8 +ve Increase in use of reduced salt and sugar beans

Meat and alternatives

8.1 Vegetarians have

2-3 portions per day

103 20 21 34 132 10 7 29 +ve Increase in sufficient portions of protein

for vegetarians

8.2 Meat products limited

141 16 9 12 148 13 4 13 +ve Increase in settings limiting meat products

8.3 Fish products limited

156 7 2 13 163 2 0 13 +ve Increase in limiting fish products

8.4 Meat alternative products limited

153 9 2 14 160 3 1 14 +ve Decrease in meat products provision

8.5 Raw eggs/ shellfish & whole nuts avoided

163 1 0 14 164 0 0 14 +ve Small decrease in provision of raw eggs/shellfish and whole nuts

Milk and dairy

9.1 3 portions of milk and dairy daily

156 11 9 2 166 6 3 3 +ve Increase in sufficient portions of dairy provided

9.2 Full fat milk provided for children 1-2 yrs

153 14 4 7 167 4 0 7 +ve Small increase in use of full fat milk for 1-2 years

9.3 Full fat dairy

products provided for children 1-2 years

158 5 8 7 165 3 4 6 +ve Increase in full fat

dairy products for 1-2 years

9.4 Skimmed milk and skimmed milk products avoided

166 3 3 6 171 3 0 4 +ve Increase in avoiding skimmed milk and dairy products


Table 18. Number of settings meeting food and drink guidelines that apply across the day at baseline and follow up


Partially met

Not met

N/A Fully met

Partially met

Not met

N/A

9.5 Yoghurts lower in

sugar chosen

124 31 16 7 152 18 5 3 +ve Increase in lower

sugar yoghurts 9.6 Ice cream avoided between meals

161 12 3 2 165 7 0 6 +ve Increase in avoiding ice cream as snack

9.7 Canned &

sweetened milk avoided

151 11 9 7 163 4 2 9 +ve Decrease in canned

and sweetened milk

9.8 Unpasteurised milk and cheese avoided

171 0 0 7 168 0 0 10 -- No change; all met where applicable

Drinks

10.1 Access to drinking water through

day

175 1 0 2 176 0 0 2 +ve Small increase in access to drinking

water 10.2 Only water and milk between meals

154 13 9 2 167 6 3 2 +ve Increase in milk or water only

10.3 Diluted fruit juice provided with meals

only

70 14 14 80 92 9 5 72 +ve Increase in settings diluting juice

10.4 Squash, fizzy drinks, soft drinks avoided

142 7 10 19 152 4 5 17 +ve Decrease in provision of soft drinks

10.5 Tea, coffee and cola avoided

158 0 0 20 157 0 0 21 -- No change: all met where applicable

Fat, sugar and salt

11.1 Pastry is limited 151 6 12 9 162 4 5 7 +ve Decrease in

provision of pastry

11.2 Salt not used in cooking/on tables

164 2 4 8 168 1 1 8 +ve Decrease in salt in cooking and on

tables

11.3 Ready made sauces, stocks and gravy granules limited

136 26 11 5 157 10 5 6 +ve Increase in limiting ready made sauces, stocks and gravy granules

11.4 Condiments limited

161 5 4 8 159 4 1 14 -- No change: Movement to n/a only

11.5 Salty snacks

avoided

151 13 5 9 159 8 1 10 +ve Increase in avoiding

crisps 11.6 Sweet foods avoided between meals

135 26 11 6 150 16 5 7 +ve Increase in avoiding sweet snacks

11.7 Confectionery is

limited

171 1 1 5 171 1 0 6 -- No change: Movement to n/a

only 12.1 Artificial

sweeteners, colours avoided

156 7 5 10 160 4 3 11 +ve Increase in avoiding

sweeteners, colours

12.2 Takeaways and functional foods avoided

162 2 1 13 162 2 1 13 -- No change: most met at baseline where applicable

Base = 178 settings providing lunch and tea at baseline and follow up Comments: +ve positive change; -ve negative change; -- no change.


Appendix 9. Case studies from Phase 2 local authorities and early years setting

Marfleet Children’s Centre, Hull

Marfleet Children’s Centre in Hull had been running basic cooking sessions with parents for a while – making simple snacks like fruit salad. But when they got the chance to join our Eat Better, Start Better training on running cooking sessions with families, Gemma Long and her colleague Glenda jumped at the opportunity to take it to the next level and get more parents involved. Gemma tells us more… How did you get started after the training? We invited four parents to our first cooking sessions back at the children’s centre - all parents from a hard-to-reach area near us. First we made the sundried tomato and feta scones from the training, and tomato and basil soup. Some of the parents didn’t know how to chop an onion, one was so nervous about it and kept saying she wouldn’t be able to do it – but after we showed her she went home and did it again, making the soup for her little boy. In the later sessions we made things like lasagne and traffic light rice – parents were worried about putting spices in the rice; they said they didn’t like spicy food, but tried it and loved it! They told us they’re not buying jars of pasta sauce any more now that they know how to make them from scratch. In the last session we did a smoothie week, and got children involved too to help with preparing the fruit. Then we surprised the parents with a little award ceremony where they all got certificates and prizes of chopping boards to take home. And helping parents with reading recipes has been a big part of this? Yes. We ran a second phase of cooking sessions with another six parents and it was a big thing for them. One mum said she always followed a recipe from the bottom up; she couldn’t understand why dishes never worked out. We gave these guys a file of recipes each and showed them how to use the Let’s Get Cooking website to find more – it’s amazing to see what they picked up. To see someone cook something that they never would have made before, and learning little tips which make them much safer for doing things like chopping and grating in the kitchen, is amazing. How did you encourage parents to turn up to every session? We actually charged them a fiver for the block of four sessions. And while you might think that would put parents off, they turned up every time. Many would pay us as soon as they arrived – they saw it as great value, as they’d be cooking and taking home two meals each every week. It also meant we could partly cover the costs of ingredients and little prizes. Have your sessions changed how parents cook with their kids at home? Definitely – most of the parents who took part say they’ve been finding new recipes and trying them out. After we did a session on reading food labels and looking at the amount of salt in a can of soup, one parent who had a little boy says she’d given away all her tins of soup to other people on the estate. She’d gone home and made the carrot and coriander soup from scratch. Social workers who support the parents who took part have been really impressed – parents are using it as evidence of their skills to care for their children, so there’s a bigger picture here too. Proudest moment?


When one of the mums who took part in our first sessions ended up in tears when we gave her a certificate for the cooking she’d done. She said it was the first certificate she’d ever been given in her life. It really was a major thing for her – you don’t realise the impact learning to cook can have. That same lady is now trying all sorts of recipes and even adapting them with new twists like chicken in lasagne instead of beef. Running the sessions is always tiring but it’s so rewarding to know that the parents have gone home with a tasty, healthy meal to eat with their kids tonight. Would you recommend Eat Better, Start Better training to other children’s centres? Definitely. The people who ran the course were absolutely fantastic and gave us lots of great tips (I’m using the one about cutting chillies with a fork at home myself!). It’s been great for all of us; I do a lot of cooking anyway but it’s even made me think more about ways to reduce salt in food for my own sons as well. We’re planning to get more staff trained up to run cooking sessions so that we can have several classes going at the same time – we’ve got a waiting list of parents who want to take part, and staff at other children’s centres in our area really want to get cooking sessions going too. To other centres thinking about doing it, I’d say: don’t miss out: it’s a fantastic opportunity, and I’m so glad we did it.


Immingham Children’s Centre, North East Lincolnshire

Knowing that childhood obesity is on the rise in her home town, Hannah Atkin, from Immingham Children’s Centre in North East Lincolnshire, joined Eat Better, Start Better to see how getting families cooking could help. She spills the beans on how they’ve done it, with a bit of inspiration from a hit TV show… What made you want to start cooking sessions at the centre? It’s about helping our parents make well-informed decisions about nutrition and portion size, to help make sure the kids we care for get the best possible start in life. Obesity levels in reception-aged children shot up in Immingham between 2011 and 2012, so we want to do our bit to try and prevent it getting even worse. How do you get families on board? We try to target those who we feel are most in need. If our team meets a mum who’s lacking confidence, they’ll say: “Why don’t you come to along to our new cooking club” The key is making it fun – messages about healthy eating and living are more likely to sink in if you’re having a good time. So what’s their favourite activity? I love the ‘Come Dine With Me’ programme and do it with the girls at home. It’s such a giggle that I tried it in our Let’s Get Cooking sessions. Parents will make something in the cooking session, we all try it and score each other in private. The winner gets two certificates –one goes up in our kitchen and one gets stuck on the fridge at home. It’s just a bit of fun but really gets us all thinking about different nutrients and how to get them into meals. It’s fun and informal so they relax and open up. It’s turned out to be such a good way to get adults to try foods they wouldn’t usually eat – a big part of it is not wanting to let each other down. If a parent turns round and says: “Oh, I don’t eat that”, I ask them how they can expect their child to eat it if they won’t. What benefits have you seen? It’s inspired families to cook more at home – they’ve even taken photos of meals to show me and asked me for more recipes to try. Cooking’s helping them open up so our relationships with parents are getting better too. And because we encourage them to get their kids to join in the cooking at home, we know it’s helping them communicate better with their own children too. What’s been the biggest surprise for parents? That by making meals from scratch, they can have more control over what their children eat. Things like making sauces from scratch and realising you don’t have to serve what comes in a jar, have come as a big surprise. When I show them the receipts for ingredients , they’re genuinely made up by how much they save. Would you encourage other childcare providers to run cooking sessions with families too? Definitely. If everyone working with families did a little bit, it can only have a positive impact on children’s health.


All Saint’s and Biddick Hall and Whiteleas Children's Centres, South Tyneside

Gemma and Dawn, outreach workers in South Tyneside, took part in our Eat Better, Start Better Cooking with Families training. They're now running cooking sessions at All Saint’s and Biddick Hall and Whiteleas children's centres, in partnership with Lynn, the school cook from nearby Stanhope Primary school. Gemma tells us more… Why did you get involved with Eat Better, Start Better? I really wanted to be involved in this fantastic initiative as I’m interested in healthy eating and in helping families to be able to achieve this on a budget -which is what Eat Better, Start Better promotes. We have 1,490 children within our reach area and many accessing the centre, including vulnerable families, many of whom don't have a balanced diet. For example, one child was reluctant to eat any solids and mainly ate soft foods like beans, yoghurts and baby jars, while another child predominantly ate white bread and chips. What do parents say? We ran the sessions in three week blocks so parents could try a variety of recipes and things they may not have tried before. They really enjoyed it and were sad when we said it was the last week. They said they’d like to move on to slightly more advanced recipes if we ran it again, like stir-fries. They definitely wanted to increase their skills and knowledge and could see how much their children had enjoyed the sessions. How have your cooking sessions helped parents deal children who are fussy eaters? We encourage parents to try the food and eat with the children. There was one little boy who was an extremely fussy eater and I've seen the challenge this has been for his mum. However, he absolutely loved the soup and actually picked bits of fruit up, smelling them and putting them on his tongue; something he would never have done before. The family took the ingredients home and tell us he’s eating a lot more now. It was quite touching and amazing the way he was really happy and asking to come along to the course. That was the biggest and nicest surprise. Do you have any top tips for other centres working on cooking with vulnerable families? With anything new, our parents are initially quite apprehensive as they don’t know what to expect. We’re always really positive and enthusiastic; we explained how they would get to take recipes and ingredients home, which got them along to the first session. And because we really enjoyed the training, I think that enthusiasm rubbed off! We started with simple recipes like soups, then we moved on to something more complicated like pizza. One dad was quite difficult at first but he and his son interacted really well and you could tell they got quite a lot out of it. By keeping our sessions relaxed and informal, the parents all enjoyed themselves. What have you got planned for the future? We’ve had the parents who took part asking us to run another course, so our plan is to carry on. We’re also going to re-run the basic course for new families so that we engage as many as possible. We're looking forward to repeating the sessions in September; it’s been really worthwhile as the families genuinely enjoyed it. I’d advise everyone to give it a go.


Belgrave Children’s Centre in Leicester

Anu Chopra’s a Childcare Early Learning Officer at Belgrave Children’s Centre in Leicester. Staff there have used our Eat Better, Start Better training to build their confidence at running cooking sessions – with great results… Why did you want to get involved with Eat Better, Start Better? We were already running the odd cooking session in half term with parents and children, but we wanted to use Eat Better, Start Better to give parents lots more ideas and recipes, and to promote our services to them. We saw it as a great way to be getting messages to parents about things like having 5-A-Day, too. Families are referred to us by health visitors, early years support teachers and lots of other colleagues, and we’ve been running sessions ever since. How have you used the training? We’ve been led by parents about the dishes they want to make, so they’ve tried all sorts including pasta, pancakes and crumbles. But the biggest hit was the scone recipe, because you can use it for so many other things, including pizza. They’re getting much more confident now: parents are really eager to tell us what they’ve been making at home. We give out the Eat Better, Start Better recipes and word of mouth is great for getting more parents interested. We’re running our sessions again this term and we’re even hoping to do some community events too. Would you recommend the Eat Better, Start Better training to other children’s centres? I would – it really builds your confidence that you know what you’re talking about, and staff have been using what they’ve learned at home themselves; experimenting with the recipes and trying new things. What would be your top tip for other children’s centres wanting to start cooking sessions? Use the sugar game! It was a massive hit with our parents – one was drinking eight cans of cola a day, and really cut down when she found out how many teaspoons of sugar that actually means. We also used the game at a community event and parents and children were really interested in how much sugar they might be consuming without even realising it.


Lampit’s Pre-school, Thurrock

Lampits Pre-School in Corringham, Essex, has been working hard to get families cooking with their children at home after taking part in our Eat Better, Start Better training. Deputy Supervisor, Janice, told us how they’ve had a helping hand from a certain cheeky monkey…

“This all started with the training. We wanted to find a way to get the cooking activities out to parents and the wider community, and I came up with the idea of using a soft toy. It was something we already do for celebrating children’s birthdays and it works really well – I had a look on eBay and found the sort of thing I wanted, a cuddly monkey toy wearing a chef’s outfit.

“We told the children we had this monkey who needed to learn to cook; they voted on his name – Herbie is what got picked out of the hat! He goes home with a family for two sleeps, together with an overnight bag and diary so that they can record what they make together. We ask families to make a breakfast, a lunch, a dinner or something else with Herbie, and they’ve cooked all kinds: spaghetti bolognese, picnics, sandwiches, meatballs, fried yams – it’s been great to see foods from different cultures coming through as well. Some of the families actually write their recipe in the diary so we’re hoping to get a whole Herbie recipe book together eventually. It’s been so popular that parents are fighting to have Herbie to stay!

“What’s been wonderful is that it’s given us a way to expand on what we already do. So parents might come into pre-school to listen to stories with their children, and we’ll now incorporate a cooking activity too. We read one story about a bear making a picnic for a trip into space; we had all of the foods for the picnic laid out and the children got involved with making things. It’s the children taking the lead and the parents participating – families might not sign up to join a cooking activity but if it’s tagged onto something else, their children will get them involved! It’s also been a great way to show parents they don’t need to be afraid of mess when their children are cooking – we even get our little ones doing the washing up as this can be fun too.

“My top tip for other settings would be to give the soft toy route a try – it can work so well. Give parents really simple cooking activities to try with your bear, monkey or other toy at home. We’ve had families calling us from the supermarket and messaging us on Facebook to ask us what ingredients they need for a recipe we have tried with the children in the setting; they then spend the weekend making it at home, which is fantastic. Some have brought in small samples to try.

“The next step for us is running cooking activities with children at our out-of-school and breakfast clubs. During half-term we’re planning to cook several different things through the week so that the children make something different for lunch every day. It’s Halloween time so pumpkin soup will definitely be on the menu!”

Janice recommends that some toy retailers might give your setting a discount on a cuddly toy if you have charity status.


Southend-on-Sea Borough Council, Public Health and Early Years Teams

Our Eat Better, Start Better programme isn’t just helping nurseries, children’s centres, childminders and families in their work to get children off to a great start with food. It’s also helping the teams who support them at local authorities around the country. Angela Caten, Preschool Learning Alliance Early Years Training Officer at Southend-on-Sea Borough Council and Lee Watson, Health Improvement Practitioner Specialist for the council’s public health team, tell us more… Why did you want to get involved with Eat Better, Start Better? Lee: This was an opportunity to really strengthen the relationship between our public health team and early years teams in Southend; it was a perfect fit for that. In fact, for public health I’d say that this relationship is now the strongest we have with any team in the council. Angela: We’d also had such a positive response from early years settings at our training conferences wanting to do more on nutrition. We thought it was such a good opportunity to get out to all of them. So how has this changed how you work together in practice? Angela: We’ve gained knowledge from each other about what services are available for children in their early years and the teams can now work together, which is great for both professionals and settings. Lee: And out in settings, it’s bridged a gap really nicely between a public health intervention that we’ve been running for a few years – in which a chef goes into some of our settings to run healthy eating sessions – and being able to provide cooking and food preparation workshops within all early years settings. It’s adding value for all of them, topping and tailing what we’ve been already able to do – great for working on joint bids for funding. One of the major positives is that it’s been really integrated. The early years team obviously has great relationships with settings, which the public health team didn’t really have. The Eat Better, Start Better training’s been a conduit for us in public health to get settings engaged with what we do. The relationship we’ve developed has meant we can plan further joint working, including joint applications to external funding sources to further improve the health and wellbeing of people in Southend-on-Sea. Angela: In the past, settings might have been getting mixed messages – but now it’s consistent right across the partnership, which helps build even stronger relationships with settings, health and early years. So what’s next for the Eat Better, Start Better work in Southend? Angela: The cooking sessions with families have gone really well, and we’re extending those. Settings which haven’t yet had the chance to run them are really keen; they’re linking up with other settings on training to deliver the sessions to their parents and children. Plus, every early years setting and childminder in Southend has been given the Eat Better, Start Better guidelines and will be doing an annual audit of their food and nutrition approach, so we can see how everyone’s getting on. Would you recommend Eat Better, Start Better to other local authorities? Angela: Definitely. And the menu books are fabulous, they’ve been really well accepted by settings. The programme is such a useful approach of getting the basic cooking and nutritional information


across to everyone. Our success has been down to delivering this in partnership and having both sides on board. Lee: We would have loved to have got even more health visitors and health officials involved with the initial training on the food and nutrition guidelines – helping to bridge the gap between health visiting and early years. My tip for other local authorities is that Eat Better, Start Better isn’t something you can simply commission and just leave. It’s the other things you do around it, to support and integrate it, which really make it work.


Derby City Council Carol Gotheridge is a Family Learning Development Worker for Derby City Council. She’s used our Eat Better, Start Better training to support family visitors in the community. She tells us more… Why you were so keen to be part of Eat Better, Start Better? I support practitioners to prepare children for school readiness at age five. We linked up with the Public Health Directorate to identify key factors, like obesity and healthy eating, which influence school readiness. Eat Better, Start Better’s training fitted well with these factors and would give us the tools we needed to address them. Coupled with this, some of the Sure Start Children Centres here qualified for government funding towards the programme. All of this made Eat Better, Start Better the obvious choice for us. Which part of the programme did you expect to make the most impact with your teams? We always knew that sending the practitioners on the Eat Better, Start Better training would have a big impact and that we’d be able to deliver the number of sessions necessary to access the funding. However, as we near the end of the programme, events are continuing and are planned for the future, which is great! What I wasn’t expecting was how much of an impact the Eat Better, Start Better food provision checklist would have on our practices. We thought we focussed well on healthy eating and good practice in this area, but as a result of that part of the course we’ve revised all of our food and drink policies and snack menus across all centres. We’ve also changed the way we present and serve food to make it more interactive and educational. Children now help to get their own snacks ready. The children are becoming more independent and practising their fine motor skills, and the parents are seeing this too. They’re beginning to explore food together, which is lovely to watch. How has the training improved your relationships within the local community? The family visitors have been up-skilled. Part of their role is to work with families one-on-one, in their own homes, to help them improve their family’s health and manage their finances. The Eat Better, Start Better training’s given the family visitors the skills to do this more effectively. For instance, they can teach families how to cook affordable meals from scratch, and they now have resources they can use to show families that take-aways are more expensive than cooking at home. They’ve also focussed on how healthy home-made meals can be, comparing the sugar, fat and salt content of ready meals with families. The families who’ve benefitted from guidance at home really value it. As well as working with families who use the Sure Start Children Centres, we’ve run ‘healthy eating’ sessions in primary schools too. We were asked to deliver one event on healthy lunches for 75 children and 60 parents! This has really helped strengthen the relationships between centres and schools, as well as the parents and children who attend them. Has it been a confidence boost for staff? Absolutely. Even those staff members who didn’t consider themselves to be cooks before the course are now confident advising on good practice in early years settings when it comes to food, and delivering healthy cooking activities with families and children. And in fact, the team who attended the Eat Better, Start Better training have done such a great job in hitting their targets that we’ve all received special commendation from the council. Would you recommend Eat Better, Start Better to other local authorities?


Without a doubt. The training, resources and ideas were all excellent, and the people delivering the training were all very responsive to our specific needs. For instance, they gave us lots of help on adapting recipes to suit people who may not necessarily own much cooking equipment. I feel we got a huge amount from the programme, and the best part is that we’re only just starting out. We’ve embedded the practice from the programme into our everyday work so we’re set to improve the health of even more families in the future.


6 ACKNOWLEDGMENTS

The Children’s Food Trust would like to thank the following people for their support:

The 20 local authorities for commissioning the Children’s Food Trust Eat Better, Start Better programme.

The early years and health professionals in each of the commissioning local authorities and Primary Care Trust areas for coordinating the Eat Better, Start Better programme

The delegates who attended the Course 1 for their participation and enthusiasm during the training and subsequently their commitment to support settings use the voluntary food and drink guidelines.

The auditors for their time and commitment to conduct baseline and follow visits in settings to monitor the changes in the settings’ approach to food and nutrition.

The delegates who attend the Course 2 for their participation and enthusiasm during the training and subsequently their commitment and support to engage with families and children in healthy cooking activities

The settings who organized and ran the cooking sessions with families, and who diligently reported on their activities to include in this evaluation report

The families who participated in the cooking sessions and shared their on what differences these cooking sessions made to their knowledge, skills and confidence about healthy eating.


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http://www.dh.gov.uk/health/files/2013/02/Pledge-web-version-2.pdf

http://www.childrensfoodtrust.org.uk/research/earlyyearsresearch/preschoolsurvey

http://learningnetwork.childrensfoodtrust.org.uk/?requesturl=%2flearningnetwork

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/free%20entitlement%20to%20early%20education/b0070114/eefortwoyearolds

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/delivery/free%20entitlement%20to%20early%20education/b0070114/eefortwoyearolds

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/early/a00192398/supporting-families-inthe-foundation-years

http://www.education.gov.uk/childrenandyoungpeople/earlylearningandchildcare/early/a00192398/supporting-families-inthe-foundation-years

http://www.letsgetcookingathome.org.uk/

http://www.education.gov.uk/rsgateway/DB/SFR/s001071/index.shtml

http://www.ic.nhs.uk/searchcatalogue?productid=10135&returnid=1685

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