Introduction
Poor dietary intake represents a major modifiable risk factor for chronic diseases including obesity, cardiovascular disease, and some cancers [
1,
2]. In particular, low intake of fruits and vegetables, combined with a high intake of energy-dense, nutrient-poor, discretionary foods and beverages (high in salt, added sugars, and/or saturated fat) has been attributed to a range of chronic health conditions [
3,
4]. The first years of life are a critical period for establishing good dietary habits, as they have been found to track into adulthood [
2], and can influence child growth, general health, and developmental trajectories [
5‐
7]. For example, unhealthy dietary intakes in children as young as 3 years of age have been found to influence cardiovascular disease markers, including obesity, dyslipidaemia, and high blood pressure, which can persist through to adulthood [
8‐
11]. Despite this, international data indicates that in infants and young children, approximately 30% of total daily energy intake comes from discretionary (energy-dense, nutrient-poor) foods, and over 90% of this population are not consuming the recommended serves of vegetables [
12,
13].
Early childhood education and care (ECEC) is increasingly acknowledged as a setting that can offer the foundations for lifelong child learning and development [
14]. ECEC services are inclusive of regulated care services such as long day care, preschools, nurseries, kindergartens, occasional care, and family day care services that cater for children up to 6 years, prior to compulsory schooling [
15]. In high-income countries such as Australia, Canada, the UK, Denmark, Norway, and Germany, approximately 80 to 90% of children aged under 5 years attend some form of ECEC, for an average of up to 30 h per week [
16‐
19]. Given that ECEC services represent a captive setting, where children can consume up to two thirds of their recommended daily intake [
20], it represents a promising avenue for targeting dietary behaviours in infants and young children [
21‐
23].
The Determinants of Nutrition and Eating (DONE) framework (2.0) suggests that a range of factors can influence dietary choices [
24]. Such determinants include food availability and accessibility, portion sizes, food beliefs and habits, the eating environment, and exposure to food promotion and marketing [
24]. Thus, in most countries with regulated ECEC services, licensing and accreditation standards exist to support child wellbeing and healthy eating, by requiring ECEC services to implement practices and policies to support children to consume nutritious foods that help meet the social, cultural, and educational needs of the children [
25,
26]. Additional standards related to ECEC nutrition policies, education, and role modelling for ECEC staff are also encouraged [
25]. As such, ECEC is a recommended setting for influencing child diet due to its broad reach and available infrastructure to support the delivery of healthy eating interventions.
An umbrella review including 12 systematic reviews by Matwiejczyk and colleagues [
27] indicated that most ECEC-based interventions seeking to improve children’s eating habits were typically found to improve at least one measured dietary component including food groups and/or nutrient intakes [
27], further suggesting that the most impactful interventions were those focused on environmental changes such as menu modifications, policy, and changes to food provision coupled with technical support and training [
27]. It must be highlighted however that these conclusions are based on systematic review searches conducted over 3 years ago and may not reflect updated intervention approaches and findings, given the continued policy and public health commitment to the sector [
28,
29]. Therefore, the aim of this systematic review is to undertake an updated systematic literature search to evaluate the effectiveness of ECEC-based healthy eating interventions for improving child diet. This review will report additional relevant policy decision-making outcomes including cost-effectiveness and adverse effects of ECEC-based healthy eating interventions, which have not been previously reported on in other reviews [
30].
Discussion
Poor dietary intakes can have implications for child short-term and long-term health status [
54]. As the ECEC setting provides significant opportunity to deliver public health interventions to improve child diet, identifying effective healthy eating interventions in this setting is critical for supporting population-wide obesity prevention efforts [
55]. This systematic review seeks to provide an up-to-date synthesis of healthy eating interventions in ECEC services and describe their effect on child diet, anthropometrics, cardiovascular disease risk markers, and other related health outcomes including cognition, mental health, and quality of life.
Such a synthesis is particularly important in this sector as identifying effective interventions in this setting remains an ongoing area of global public health interest and investment [
21]. Further, recognising the influence of this setting on child health and wellbeing, there has been a rapid progression of the evidence base, with a large number of RCTs being conducted in this setting in recent years. A review of RCTs provides level 1 evidence of causality to support policy and investment decisions [
56]. Additionally, this review seeks to describe potential adverse events, and the absolute-cost/cost-effectiveness of ECEC-based healthy eating interventions, to further support the selection of interventions which are effective, safe, and cost-effective to deliver.
Publishing this systematic review protocol is expected to reduce the possibility of duplication and offers transparencies to the methods and processes used. It also allows outcomes to be pre-specified reducing the risk of reporting biases. Thus, any important protocol amendments will be recorded in PROSPERO. The results from the completed systematic review and meta-analysis will be presented at relevant national/international conferences and will be submitted for peer-review journal publication. The results of this systematic review are expected to support public health practitioners and policy decision-makers by summarising the updated evidence base for healthy eating interventions within the ECEC setting.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.