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Weight Loss Strategies Kids Can Count On: The 5, 4, 3, 2, 1 Habit

Thirty years ago, there was often a chunky kid or two in a given class at school. But today, especially in low-income areas, overweight school-aged children are no longer the exception. Not only do these children face emotional pressure, they are also at high risk for developing serious medical conditions such as diabetes—and for becoming obese adults.

Below, Katherine Kaufer Christoffel, MD, MPH, founder of the Nutrition Evaluation Clinic at Children's Memorial Hospital in Chicago and of the Consortium to Lower Obesity in Chicago Children, discusses how families can permanently change their eating and exercise habits so that their children keep fat off and stay healthy.

Why are rates of obesity rising in children?
Rates of obesity in childhood have about tripled over the last 30 years. The only way that a person becomes overweight is to take in more calories than they burn. So we have to look at things that contribute to increased calories in and to decreased calories out. And it's easy to see both in children today.

The intake of fried and high-sugar foods, particularly in the form of some fast foods and sugar-sweetened drinks, has gone up tremendously. One reason for that is it is less expensive to buy some of these foods than it is to buy healthier foods. And it's been well documented that people who don't know if they'll be able to buy food for their families at the end of the month go for calories per dollar.

People are also eating out much more than they were previously, and portion size is more difficult to control when you eat out. People are not sitting down to eat at regularly scheduled meals and instead tend to graze during the day. And, for people who are prone to gain weight easily, that kind of grazing ends up providing more calories.

On the "calories out" side, we know that screen time—video games, television, computers—have become very prevalent during these last few decades. In inner cities, where the concentration of overweight kids appears to be the highest, there is fear of letting kids play outside because their neighborhoods are not safe. Children in all neighborhoods are also less likely to walk to school. The rates of participation in organized sports are also really remarkably low among kids.

How does obesity in children affect their overall health?
Obesity is a risk factor for many medical conditions, which means that overweight kids are more likely to suffer from conditions such as elevated blood pressure, high cholesterol and obstructive sleep apnea (difficulty breathing at night due to obstruction of the airway). Young children may develop bone problems because immature bones may deform when they can't handle the weight. Nowadays, nonalcoholic steatohepatitis, or NASH, which is fatty infiltration of the liver, is probably the most common form of liver disease in children. We also see acanthosis nigricans, an increased pigmentation and thickening of the skin, most commonly in children of color, which can be associated with increased insulin resistance. Type 2 diabetes, which we used to call "adult-type" diabetes because we didn't see it in childhood, is now being seen in childhood and adolescence. That increase is linked to increases in obesity.

But probably the most common associated conditions are psychological, particularly among girls. Self-esteem tends to fall and depression tends to increase with obesity, particularly in adolescence. There is at least one study that documents a remarkably lowered quality of life for children who are very overweight.

Why is obesity prevention a better strategy than treating obesity?
The body tends to defend its weight. There are physiological processes that protect fatty tissue, probably because the fat cells secrete hormones that regulate appetite. So once you've got fat cells on board, they're going to ask to be fed and their request is going to be hard to resist. Therefore, it is much better to keep weight off in the first place.

At what age should obesity prevention begin?
The approach that we take in CLOCC, the Consortium to Lower Obesity in Chicago Children, is a primary prevention approach. What we have learned—and what the literature tells us—is that the likelihood of staying obese goes up remarkably if a child becomes overweight between the ages of 4 and 6. So if a child is heavy at age 7, the chances of remaining overweight as an adolescent become markedly increased. If you are overweight as an adolescent, it is overwhelmingly likely that you will be overweight as an adult.

There are four times in life when all of us add fat cells. The first one is during the last trimester of gestation. The next time is this period between ages 4 and 6. The third time that we all put on fat cells is in adolescence, which is another critical period in the development of obesity. And, for childbearing women, pregnancy is the fourth time. It is possible to add fat cells at other times if you eat enough, but we all add fat cells at those times. In between, what we usually do when we gain weight is make our fat cells bigger, not add new ones.

So in the general population, we are trying to work with families starting when the kids are three and to get them through that early fat-cell growth period at a healthy weight.

Why is family involvement in obesity prevention critical?
Young children's eating and activity patterns are largely set by their adults. Also, obesity tends to run in families and, in general, the child is not the only overweight person in the family. For both reasons, we focus on the need for changes to occur at a family level. For example, the availability of soda—which I call sugar pop—has to be changed for everybody in the household, not just for the child. So there has to be a commitment from the family. We don't talk about diets, we make small changes gradually with the idea that they will become permanent.

What are some strategies you suggest to the family?
One of the interventions that we almost always recommend is regular meals and snacks. There should be times for eating and times for not eating. For young children, we typically recommend three meals and three snacks a day. For older children, three meals and two snacks a day. For a lot of families, that is quite a change, and that might be the only change we would make at a first visit.

Another common change we make is reducing the percentage of fat in the milk the family drinks. If people are on whole milk, we cut back to 2 percent. If they are on 2 percent, we cut back to 1 percent. For children over age two, we want to end up with 1 percent or skim milk. Often, people can taste the difference in the short term, but they adjust rather quickly.

We try to get the sugar pop out of the house. We're OK with artificially sweetened beverages and water, but we suggest limiting juice to 8 ounces a day or less. Parents often think that by giving juice, they are giving their children healthy food and that's usually not true. Some juices contain vitamins, but almost every serving of juice contains the same amount of sugar as sugar pop.

Sometimes kids are eating fast-food meals every day. At some fast-food restaurants, it is now possible to make healthy choices. But if going to a fast-food restaurant means eating a burger and fries, it should be considered an exceptional treat and not the norm. We don't object to having quick meals. There are frozen meals that are just as fast, and not very different in cost. We also encourage increased use of uncooked foods, such as an (unmelted) cheese sandwich with an apple.

What are first steps in getting in more exercise?
Our goal is 30 to 60 minutes of physical activity a day for children. If they are already active, we say, "Great, continue what you are doing and add 30 to 60 minutes."

We take a similar approach to physical activity as we do to eating. We try to figure out what the resources are that are available to the family. For example, it is not unusual to discover that a family doesn't know about the nearest park, or the Boys' and Girls' Club or the Y, so we will help them to identify these places for play and other inexpensive physical activities.

We certainly encourage kids to sign up for sports teams and karate and dance classes, if they are interested. But we also always encourage lifestyle activity because we know that, over the lifespan, that is what makes the most difference. So we encourage walking stairs, dancing to the radio. We promote walking a great deal, because it's inexpensive and convenient. We often suggest that the whole family go for a walk for half an hour before or after dinner.

What is your overall weight control advice to people caring for children?
To prevent children from becoming overweight, it is important to recognize that in our society it is easy to be inactive and to eat too much and it is hard to be sufficiently active and to eat in a healthy manner. So we have to be vigilant and go to some effort to make sure that we are putting together healthy lives for our children.

What that means is making sure that the "5, 4, 3, 2, 1" rule is followed. That is, every day should include 5 fruits and vegetables, 4 glasses of water, 3 servings of low-fat dairy products, less than 2 hours of screen time and 1 hour of physical activity. And we have to look at each one of those and figure out how we are going to make these practices a habit.

What are your recommendations for the parents of overweight children?
If parents are concerned about their child's weight, they should talk to their pediatrician. They can advise the family about degree of overweight and how to manage it. The steps are pretty much the same as the ones we use for preventing obesity.

For overweight children, we always have to look for health problems associated with being overweight. So we check the blood pressure, the blood lipid levels and so on.

It is important to have realistic expectations. For example, the overweight child is probably not going to end up skinny, and shouldn't. On the other hand, if a child has not stopped growing yet, s/he has the opportunity to grow into the excess weight, as long as no more is gained.

We don't recommend dietary restrictions that are so severe that they lead to hunger, resentment, and inadequate nutrients for normal growth. We work with the family to develop a reasonable plan for eating and physical activity, one which will prevent continuing weight gain or promote slow weight loss.