Childhood obesity has become a global epidemic, but it is not easy to treat. Now a scheme proven to help children shed pounds by asking them and their families to make numerous lifestyle changes has been adopted across Denmark.
A Danish paediatrician claims his pilot project has made a significant breakthrough in the battle against childhood obesity.
The scheme, in the town of Holbaek, has treated 1,900 patients and helped 70% of them to maintain normal weight by adjusting about 20 elements of their lifestyles.
The way it tackles all aspects of the children's lives - and those of their families - sets it apart from traditional "small steps" approaches to losing weight.
According to the US Centre for Disease Control, one in three children is now overweight and the incidence of obesity amongst adolescents has quadrupled over the past 30 years.
Dr Jens Christian Holm, who runs the scheme, urges other nations to learn from their experiences in confronting this global health challenge.
"In general, obese children are neglected. They are often lonely and many of them don't participate in activities with their peers. They lack self-confidence. With this scheme there is a real hope they can lose weight and have a good quality of life."
Obesity is an illness that is very hard for children to fight on their own, he says.
"We create the environment and tools with which the children and their families can overcome this."
'This is tough'
At the beginning of the programme, children are admitted to hospital for 24 hours for extensive testing, including body scans to measure their body fat.
They also answer a detailed questionnaire about their eating habits and behaviour patterns.
Jakob is scanned to assess his body fat content
"We're not doing this for fun. This is tough," Dr Holm tells 10-year-old Jakob Christiansen during a consultation.
A typical weight loss programme
The child's doctor creates a tailored plan with 15-20
strategies, which could include:
1 - No crunchy muesli or fruit yoghurts for breakfast,
choosing oatmeal, dark brown bread, meat and fish
2 - No fast food or white bread for lunch; choose brown
bread, meat, fish and vegetables instead
3 - Portions served up in the kitchen - no pots and pans
at the dining table
4 - Plate proportions for dinner should be: half vegetables,
a quarter brown rice, pasta or potatoes, and a quarter
low fat fish or meat
5 - Wait 20 minutes before having second helpings,
this allows time for the body to feel full
6 - Feel satisfied after each meal
7 - Only two pieces of fruit per day
8 - Fast food only once a month
9 - Sweets only once a week
10 - Snack only once a week
11 - Limit juice, iced tea, cocoa, soda or lemonade to
once weekly - only half a litre in total
12 - Cycle or walk to school
13 - Organised physical activity eg dancing, handball
14 - Free physical activities like walking/biking after
school, walking the dog or trampolining
15 - Screen time (television, computer or tablet)
limited to two hours per day
16 - No television/computer access until 5pm
17 - Set a regular, early bedtime
Jakob weighs 72kg (11st 4lbs), at least 20 (3st 2lbs) too many. He's been bullied at school, has been depressed, and has been eating sweets for comfort.
"He was hiding them," says his mother Elisabet.
"We just want the doctors to help Jakob lose weight so he can be a happy boy again."
Jakob informs Dr Holm that he cycles three kilometres to school. But exercise alone is not enough to combat what the paediatrician calls "this chronic disease".
"It's going to be really tough, but I'll fight as hard as I can. I'm sure I'll miss sugar and the fact that I can no longer laze around," says Jakob.
In between tests, Jakob breaks for lunch of skinless chicken breast, raw carrots, red peppers and green salad.
The programme requires wholesale changes in lifestyle to defeat the body's natural resistance to losing fat, and each child has a personalised treatment plan which targets 15-20 daily habits.
Dr Holm says that, unless children and their parents change this many habits, "the obesity will persist. People will get very frustrated, sad, and they will be lost".
Research showed that by following the programme, 70% of patients maintained their weight loss for four years.
This success rate was achieved with an average of just over five hours of medical consultation per child per year.
It has now been adopted in eight other Danish municipalities, and Dr Holm believes other countries should establish similar treatment programmes.
The district of Hedensted, in Mid Jutland, Western Denmark, is one of the places to have embraced Dr Holm's methods.
The programme is run by Rikke Christensen, a health visitor, who says it seems to work much better than the many approaches they tried in the past.
"Sadly, we experienced time and again, that it was difficult to recruit and motivate families. Now we see that we have finally found a method that works and families have really embraced."
The programme requires the whole family to embrace it.
One of her success stories is a nine-year old-boy who entered treatment with 40% body fat and high blood pressure. He was introverted, failed to thrive in school, and shunned physical exercise.
He is still undergoing treatment but has reduced his body fat by a quarter. He is more outgoing, has participated in a five kilometre fun run, started to play football and "he's got a twinkle in his eye".
Dr Holm is vigorously targeting the passive time spent playing on computers or watching television. Some children are glued to their screens for up to 12 hours a day and the limit, he says, should be two.
"Their entire life needs to be changed, because they tend to be lonely, tend to be ashamed of themselves so they need to do this, and to interact with other children in their daily lives."
Participants also have a set bed time to ensure more sleep. Previous research suggests this helps counter obesity by regulating hormones and reducing the urge to eat unhealthily when tired.
Mike Nelausen, 14, has become a standard bearer for the Holbaek project.
He used to weigh 85kg (13st 5lbs), but having embraced Dr Holm's evangelism, he has slimmed down by 23kg (3st 8lbs), and is no longer the target of playground bullies.
Mike's determination to lose weight helps him brave the rainy weather for his evening runs.
"To begin with it was hard but then it became a part of my daily routine and it's much easier," says Mike, at his home in the village of Ugerlose.
"I was sad because I was bullied. But now I'm smaller. I'm far happier, I've got more energy. And I no longer get upset when I stand on the scales."
As she scrapes and shreds carrots for a low calorie dish with minced beef, his mother Karina breaks down and weeps.
"It was extremely hard to see him like that. We tried everything but he just kept on gaining weight. So when it finally started to work, we were really happy."
At supper, Mike only consumes one portion instead of his previous three, and sips a sparkling water.
And then, despite the fact that it is raining, he slips out of the house for his nightly run around the village, a look of steely determination on his face.
As Dr Holm says, the programme isn't easy. But the results are gratifying.