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Systematic Review
To assess the effectiveness of healthy eating interventions delivered in ECEC settings for improving dietary intake in children aged six months to six years, relative to usual care, no intervention or an alternative, non‐dietary intervention.
Secondary objectives were to assess the impact of ECEC‐based healthy eating interventions on physical outcomes (e.g. child body mass index (BMI), weight, waist circumference), language and cognitive outcomes, social/emotional and quality‐of‐life outcomes.
We also report on cost and adverse consequences of ECEC‐based healthy eating interventions.
We included 52 studies that investigated 58 interventions (described across 96 articles). All studies were cluster‐RCTs. Twenty‐nine studies were large (≥ 400 participants) and 23 were small (< 400 participants). Of the 58 interventions, 43 targeted curriculum, 56 targeted ethos and environment, and 50 targeted partnerships. Thirty‐eight interventions incorporated all three components. For the primary outcomes (dietary outcomes), we assessed 19 studies as overall high risk of bias, with performance and detection bias being most commonly judged as high risk of bias.
ECEC‐based healthy eating interventions versus usual practice or no intervention may have a positive effect on child diet quality (SMD 0.34, 95% confidence interval (CI) 0.04 to 0.65; P = 0.03, I2 = 91%; 6 studies, 1973 children) but the evidence is very uncertain. There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely increase children's consumption of fruit (SMD 0.11, 95% CI 0.04 to 0.18; P < 0.01, I2 = 0%; 11 studies, 2901 children). The evidence is very uncertain about the effect of ECEC‐based healthy eating interventions on children's consumption of vegetables (SMD 0.12, 95% CI −0.01 to 0.25; P =0.08, I2 = 70%; 13 studies, 3335 children). There is moderate‐certainty evidence that ECEC‐based healthy eating interventions likely result in little to no difference in children's consumption of non‐core (i.e. less healthy/discretionary) foods (SMD −0.05, 95% CI −0.17 to 0.08; P = 0.48, I2 = 16%; 7 studies, 1369 children) or consumption of sugar‐sweetened beverages (SMD −0.10, 95% CI −0.34 to 0.14; P = 0.41, I2 = 45%; 3 studies, 522 children).
ECEC‐based healthy eating interventions may be cost‐effective but the evidence is very uncertain (6 studies). ECEC‐based healthy eating interventions may have little to no effect on adverse consequences but the evidence is very uncertain (3 studies).
Few studies measured language and cognitive skills (n = 2), social/emotional outcomes (n = 2) and quality of life (n = 3).
Two studies reported on language and cognitive outcomes. Ray 2020 reported on the effect of vegetable tasting sessions and nutrition games on cognitive self‐regulation skills using five items derived from the Child Social Behaviour Questionnaire, rated on a scale of 1 to 3, previously used in the Millennium Cohort Study on three year olds. The study found evidence of a between‐group difference (SMD 0.05, 95% −0.14 to 0.24; 432 children).
Puder 2011 found varying evidence of an effect of the intervention on measures of concentration, assessed using a validated measure, Konzentrations‐Handlungsverfahren für Vorschulkinder. The study found a reduction in attention measured in minutes (SMD −0.06, 95% CI −0.29 to 0.16; 309 children) and an increase in attention measured by number of correct cards (SMD 0.02, 95% CI −0.17 to 0.21; 434 children), and in spatial working memory (SMD 0.12, 95% CI −0.07 to 0.31; 434 children).
Three studies comparing an ECEC‐based healthy eating intervention with usual practice or no intervention reported on a measure of quality of life. All measures were validated, score‐based and continuous, including the Paediatric Quality of Life Inventory (PedsQL) 4.0 (Kipping 2019; Puder 2011), and parent proxy version of KIDSCREEN‐10 (Yoong 2020a). Pooled analysis of all three studies found no evidence of effect of those receiving the ECEC‐based healthy eating intervention on child quality of life (SMD 0.07, 95% CI −0.09 to 0.23; P = 0.37, I2 = 0%; 644 children; Analysis 12.1).
ECEC‐based healthy eating interventions may improve child diet quality slightly, but the evidence is very uncertain, and likely increase child fruit consumption slightly. There is uncertainty about the effect of ECEC‐based healthy eating interventions on vegetable consumption. ECEC‐based healthy eating interventions may result in little to no difference in child consumption of non‐core foods and sugar‐sweetened beverages. Healthy eating interventions could have favourable effects on child weight and risk of overweight and obesity, although there was little to no difference in BMI and BMI z‐scores. Future studies exploring the impact of specific intervention components, and describing cost‐effectiveness and adverse outcomes are needed to better understand how to maximise the impact of ECEC‐based healthy eating interventions.