Weight Loss: The Journey of a Thousand Miles Begins with One Step

Patient Presentation
A 6-year-old male came to clinic for a health supervision visit. The entire family was overweight or obese. The family had instituted some healthier eating habits after a 40+ year old uncle had a heart attack. The boy said that he was choosing the 1% white milk at school, but on Fridays he would have his treat of chocolate milk. The mother said that they were eating out only 1 time per week and were trying to choose better options such as having a hamburger instead of a cheeseburger. The boy said that he liked to cook “his” vegetable too. His mother explained that he would choose one vegetable for the family that he would help prepare during the week. The family had switched to 1% milk from whole milk. The family was trying to be more active too by going for a walk to the local park once per week. “I’d like to do it more, but with work, school and other things, we don’t get to it,” the mother stated. The mother remarked that she had lost about 3 pounds in the past 3 months too.

The pertinent physical exam showed a happy male with a slightly elevated blood pressure at 115/68. His body mass index was 20.1. His weight was 250 g down from his weight 3 months ago. His height was 1 cm increased from 3 months ago, and 1.75 cm over the past 6 months. The rest of his examination was negative. The laboratory evaluation from an examination 6 months ago had a normal non-fasting HDL and total cholesterol, glucose, BUN and creatinine were normal. The diagnosis of obesity was made. The physician applauded the family for making some very good changes to their diet. The physician encouraged them to make additional changes over the next few weeks including trying to exercise at least 3 times per week and to change the milk to skim milk. “That will save about 20 calories a glass,” she noted. When the boy said that pizza was often a choice at school, the physician encouraged him to choose cheese or cheese and vegetable pizza over meat pizza. “Most of the meat on the pizza has a lot of fat,” she said. The physician encouraged the mother to decrease the salt intake by using fewer prepared foods or switching to a lower salt version. The family was to followup in another 3 months.

Obesity is unfortunately a growing problem in the United States that is multifactorial. It’s even harder to understand when food insecurity is also a growing problem in the United States. In both obesity and food insecurity, poor nutrition is a common denominator.

Learning Point
Any time someone is trying to change a behavior such as poor nutrition in their life, it can be very difficult. The ultimate goal often seems unreachable but helping people to set reachable intermediate goals and supporting their effort to attain those goals is key to long-term success. While there can be many choices as to which steps to start with on the journey of a thousand miles to better nutrition, there are 3 main elements – amount of food, type of food and the amount of exercise.

  • Amount of food or portion size
    • A child and their family need to understand portion size. In general a portion is the size of the fist, or palm of the hand. A slice of bread or one apple is one portion for an adult, but may be 2-3 for a child.
    • Children and families need to understand what a reasonable amount of food is and stop when that is eaten or before. It is fine to have a slice or two of pizza for a meal, but it is not okay to eat a whole pizza.
    • This is also true of beverages. Soda pop at a national fast food restaurant serves the following sizes:
      • Kids 12 ounces, 110 calories
      • Small 16 ounces, 150 calories
      • Medium 21 ounces, 210 calories
      • Large 32 ounces, 310 calories
      • Diet soda is 0 calories.
      • Apple juice is 100 calories/8 ounces and is another alternative
  • Food type or choosing a healthier option
    • A variety of foods is important for a healthy diet including fats.
      Fats because they are calorically dense (9 calories/gram, versus protein and carbohydrates 5 calories/gram, and ethanol 7 calories/gram) are sometimes vilified, but they are critical for good nutrition.
      Fat however is often hidden in foods and the same/similar taste and texture can often be achieved by choosing alternatives.

    • For example, whole milk has about 3.25% fat and has 146 calories/8 ounces, while 2% milk has 122 calories and skim milk has 83 calories.
      Changing from whole milk to 2% saves 24 calories, and changing to skim milk saves 63 calories. After only ~9 gallons of 2% milk or 3.5 gallons of skim milk, the equivalent of 1 pound of weight can be lost (~3600 calories).

    • Similarly, when eating at a fast food restaurant, choosing a hamburger instead of a cheeseburger eliminates ~95 calories (1 slice American cheese). Choosing cheese pizza instead of a meat pizza eliminates ~50 calories/slice. Chocolate milk has 170 calories instead of 146 calories for white milk.
  • Shopping for food
    • Shop at the perimeter of an US food store where the cold refrigeration is. This is where fresh fruits and vegetables, meats and dairy cases are. Processed foods have longer shelf lives and therefore are often located in the middle of the store.
    • Purchasing food that only one’s grandparents would recognize. While there are many improvements in food quality and convenience through improved packaging, processed foods also often have unnecessary fats, salt and other ingredients that do not necessarily add to their nutritional quality. Processing may also decrease their nutritional quality. They also are frequently more expensive.
    • Having the children choose one or more foods to prepare at home also helps them to be invested in their own nutrition.
  • Exercising more
    • There are many ways to increase exercise in one’s daily life including walking (park at the far end of a lot and walk in), climbing stairs (walk up 1-2 flights instead of taking the elevator) and even just playing on a playground for 30 minutes (~200 calories).
    • For more information about exercise see How Far is 10,000 Steps?
  • Miscellaneous
    • “Saving up calories” for a special treat or extra portion once in a while is perfectly fine, but planning for it when possible helps.
      If the family knows that there is going to be a birthday party, then they can plan to not have a dessert or not have a third portion of another food to “save the calories” for the birthday cake.

    • Have another alternative generally available such as a diet soda, popcorn, graham crackers, etc. for the unexpected social occasion where food and drink would be expected.

Questions for Further Discussion
1. What other nutrition counseling tips do you have?
2. What obesity screening laboratories are recommended?
3. What local resources are available for food insecurity?
4. What local resources are available for exercise opportunities?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Obesity in Children, Exercise for Children, and Child Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Pollan M. Food Rules. Penguin Press. New York, NY. 2009.

McDonald’s. McDonald’s USA Nutrition Facts for Popular Menu Items. Available from the Internet at http://nutrition.mcdonalds.com/nutritionexchange/nutritionfacts.pdf (rev. 9/9/11 cited 5/21/2012).

US Department of Agriculture. ChooseMyPlate.gov. Available from the Internet at http://www.choosemyplate.gov/ (cited 5/21/2012).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital