With nearly a quarterof Reception-year children in Birmingham overweight or obese, the Startwell programme was set up in January 2018 to help promote healthy lifestyles in early years settings through physical activity and healthy eating. 
Startwell is an award-based programme commissioned by Birmingham City Council. It allows PVI settings, nursery schools and Children’s Centres in Birmingham to work towards set criteria in order to achieve a Startwell award.
Local childminders can also access the programme’s training sessions, while the Startwell website provides resources to all practitioners. All of it is free.
Startwell team leader Sarah Bates explains, ‘We wanted to come up with a programme that really engages practitioners and children and embeds basic healthy eating and physical activity principles in their everyday routines. There were already programmes targeting schools, but we wanted to make this more applicable to the early years.’
Staff often lack confidence when it comes to imparting strong healthy eating and exercise messages, Bates says.
‘Settings often haven’t explained to children why healthy eating and physical activity are important,’ she adds. ‘Staff already have so much they need to cover, and Ofsted doesn’t ask a lot about food and drink, so staff are not being challenged on it. When messages about nutrition come through things like the Public Health England guidelines, they’re quite complex, not that well publicised, and are voluntary. You need a good knowledge base to understand exactly what they mean.’
HOW IT WORKS
Food training sessions support staff on topics such as weaning, fussy eating and the mealtime environment, while settings must conform to Startwell menu guidelines for the early years. 
Startwell uses cartoon characters, including Two Snacks Max, Fay Five a Day and Active Azra to deliver health-based messages, based on research linking the use of characters with young children to successful behaviour changes, such as greater willingness to eat fruit.
‘Hopefully, it’s catchy,’ Bates says. ‘Although some of the messages are obvious, when practitioners first start the programme, they might not know exactly why we have a character named 180 Katie, for example. But once it has been explained that the Chief Medical Officer recommends pre-schoolers spend at least 180 minutes a day on a variety of physical activities, it’s easier for it to stick in their heads.’
The award is valid for two years, as long as settings continue to provide evidence that they are meeting required standards.
‘We didn’t want it to be a tick-box exercise,’ says Bates. ‘We wanted it to be something that really did embed. So we are clear from the beginning that it isn’t a short process. It might take 12 months; it might take longer. We want to make sure settings are confident with it, and that it can be sustained.’
For some settings, staff turnover can pose a challenge to getting the award finished. ‘It can be a big problem,’ says Bates. ‘Everything can be delayed when a lead leaves and all the work has to be handed over. That’s one of the reasons we want to make sure it is truly embedded; so it is cascaded down and doesn’t rely too heavily on one person. We want everyone to be upskilled.’
Settings meet with members of the Startwell team every four to six weeks during the accreditation process, while logging progress online, attending staff training sessions and keeping in touch by phone or email.
‘It’s important that we go and witness what is happening in a setting in person,’ Bates says. ‘That’s partly why it takes time to get signed off, because we want to be absolutely sure that activities are truly high intensity, for example.’
ORAL HEALTH
Since the revised EYFS introduced a focus on oral health, the programme has registered significantly more practitioners on its oral health training sessions, with around a quarter of children in Birmingham suffering decayed, missing or filled teeth, higher than the national average. 
‘In the training we go through evidence-based practice on things like toothbrushing,’ Bates explains.
‘We provide lots of activities for families to do at home, and ideas for practitioners to promote Smiley Shen’s oral health messages.’
BEYOND THE AWARD
Across Birmingham, 91 nurseries and eight of the city’s ten Children’s Centres have now completed the award. Some of these are then invited to complete the programme’s advanced award, too.
‘The advanced award has criteria to stretch settings more,’ Bates says. ‘We look in more detail at things like a whole menu review, the outdoor environment, or physical activity planning.’ 
A report on the programme by Coventry University found that staff in Startwell settings had greater confidence, better staff training and better access to resources for nutrition and physical activity than in control settings.
Bates says, ‘We know everyone engages in a different way, so we try to cover as many engagement routes as possible.’
case study: The Elms Day Nursery at the University of Birmingham
Staff at The Elms Day Nursery at the University of Birmingham already considered physical health and nutrition a priority when they signed up for the Startwell award.
Deputy manager Vicki Wall explains, ‘We were so focused on ensuring our children were getting good meals and did lots of activity, it seemed a natural progression to join. I wouldn’t say we needed help, but we felt it would be something to set us apart.’ 
In the process, however, Wall says staff learned a lot. ‘The initial training definitely gave us new ways to look at things,’ she acknowledges. ‘Some elements were a real eye-opener, especially in relation to oral health, like how many children have cavities. Now, when we’re inducting parents into the nursery, we always ask whether their child is registered with a dentist.
‘Staff sometimes struggle to come up with ideas for physical activities, so it was a nice way to get inspiration, and remind them to join in too. The Suzy Startwell character is designed to make sure we are role models in physical activity. We made sure staff were doing yoga and dance sessions and only drinking water, so that was what children saw.’
Staff developed a ‘skill for the month’ initiative to help children’s physical development, and undertook an audit of the outdoor environment to make sure it was well set up to support physical activity. ‘We introduced different areas for children outside,’ Wall says. ‘We’ve now got space for children to be relaxed and calm, as well as space where they are free to express themselves. We added growing areas with planters for veg, and different gradients.’
Using characters also helps children process healthy eating messages, Wall adds.
After receiving the Startwell award, the setting went on to achieve the advanced award, and the ongoing training and support from Startwell has been invaluable, Wall says. ‘It gives staff so much insight and confidence.’ 
Eating well
Xanthi Maragdouaki, an Early Years Nutrition Partnership (EYNP) registered nutrition professional, discusses preparing children for enjoying school meals
A key part of the EYNP approach is to support early years educators to engage parents regarding their children’s nutrition. We often see around this time parents with children who are about to leave the early years and begin school starting to think about school meals or packed lunches. These changes can be a big challenge to established nutritional habits, and parents often turn to their trusted early years providers for some pointers.
If children are getting school meals, then there is the risk that every day they will make the same choice, depending on what the school offers, a choice that parents might not necessarily approve of. It is important to encourage children to make good, nutritious choices. Encourage parents to get hold of the menu if they can and go through it with their child, discussing how each meal offered can benefit them. For example, ‘eating your protein will help you grow and eating your vegetables will make your body stronger’. At the same time, most schools also offer a ‘treat’ day. It is important for children to be part of this, so parents and carers should avoid demonising food.
Alternatively, many parents may be considering packed lunches. The aim of getting five different fruits and vegetables in the lunchbox can be a challenge, but they should try to offer a balanced, nutritious spread of these items across the week and alternate protein sources from day to day. For the main part of the meal, there is no need to overcomplicate. Some pasta with chicken pieces, hummus with vegetables and bread, or sandwiches with different fillings like cooked fish, egg and meat-free options. Chicken nuggets, fish fingers and bean burgers also make an easy option as well as leftovers. If children prefer a warm lunch, these are possible using lunchboxes with an incorporated thermostat. However, overall, the message should be to try to keep lunchboxes simple, varied and colourful.
A positive attitude towards food based on good foundations is a strong predictor of healthy nutrition habits later in life. Most importantly, lunchtime is also a big part of school life, so it’s important for parents and carers not only to focus on what children eat but also on whether it was a fun time and if they had any interesting discussions with their friends. Lunch needs to be nutritious but also enjoyable!
If you would like to discuss any of the issues raisedin this column or any other matter around early years nutrition, please contact Jonathan Lucas at hello@eynpartnership.org to arrange a conversation with one of the EYNP’s registered nutrition professionals. For more information, see www.eynpartnership.org