# Pediatric Obesity Consultation > Guide a non-stigmatising pediatric obesity consultation using the 5As framework (Ask, Assess, Advise, Agree, Assist) and 4Ms assessment (Metabolic, Mechanical, Mental Health, Social Milieu), based on the CMAJ 2025 guideline. Trigger when a clinician asks how to approach a weight conversation with a child or family, how to use the 5As for obesity, how to assess a child with obesity, or how to conduct a non-judgmental obesity visit. - Skill: `dromlakhani/pediatric-obesity-consultation` (Agent Skill) - Install (CLI): `npx skillmds@latest add dromlakhani/pediatric-obesity-consultation` - Raw SKILL.md: https://api.skillmd.com/api/skills/dromlakhani/pediatric-obesity-consultation/raw - Safety review: pending (external: skill-scanner PASS, skillspector PASS) - Works with: Claude Code, Claude.ai, OpenAI Codex - Category: Coding & Dev Tools - Author: dromlakhani (https://skillmd.com/u/dromlakhani) - Updated: 2026-09-08 - Page: https://skillmd.com/skills/dromlakhani/pediatric-obesity-consultation --- # Pediatric Obesity: Non-Stigmatising Consultation (5As + 4Ms) A step-by-step guide for conducting a pediatric obesity consultation that supports shared decision-making, reduces stigma, and leads to an actionable management plan. Based on CMAJ 2025 Clinical Practice Guideline (Ball et al., doi: 10.1503/cmaj.241456) and the 5As of Pediatric Obesity Management framework. --- ## Before You Start — Language Checklist Use person-first, weight-neutral language throughout the visit: | Instead of... | Say... | |---|---| | "Obese child" | "Child with obesity" | | "Fat" / "overweight" | "BMI", "weight", "growth" | | "You need to lose weight" | "Let's talk about your health and how you're feeling" | | "This is caused by poor diet" | "Obesity has many causes — genetics, environment, and more" | | "You just need to exercise more" | "Physical activity is one part of a bigger picture" | --- ## Step 1 — ASK (Permission and Setting) Before any weight-related conversation, **ask permission.** - *"Would it be okay if we talked about your health and weight today?"* - *"Some families prefer to discuss this privately — would you like [child/caregiver] to step out for part of our conversation?"* **Decide who is in the room:** - Young children: caregiver-led conversation - Adolescents: consider child-only portion + caregiver-only portion + together - Default: include both, but follow the child's preference **If the family declines the conversation today:** Respect that. Document and offer to revisit. --- ## Step 2 — ASSESS (4Ms Framework) Work through all four domains systematically: ### Metabolic - Blood pressure (hypertension risk) - Fasting glucose / insulin / HOMA-IR (insulin resistance, pre-diabetes, T2DM) - Fasting lipids: TG, HDL-C, LDL-C, total cholesterol - ALT (non-alcoholic fatty liver disease) - BMIz using WHO criteria and sex- and age-specific charts - Obstructive sleep apnea symptoms (snoring, daytime sleepiness, apnoeic episodes) ### Mechanical - Musculoskeletal pain (knees, back, hips — common in childhood obesity) - Exercise tolerance and physical activity barriers - Mobility (does weight affect play, sports, daily activities?) ### Mental Health *(do not skip)* - Depression and anxiety (use validated screen: e.g., PHQ-A, GAD-7 for adolescents) - **Eating disorder screen:** binge eating, restriction, purging, compensatory behaviours - Body image concerns and weight-based self-esteem - Bullying (weight-based teasing is common and has lasting effects) - Caregiver mental health (parental stress, anxiety, depression can affect child outcomes) ### Social Milieu - Food security (access to nutritious food at home) - Neighbourhood safety (affects outdoor activity, active transportation) - Screen time patterns - Family routines (mealtimes, sleep schedule, activity norms) - Cultural factors affecting diet and body image - Access to health care and obesity management services > 📋 Document findings across all 4Ms — this forms the basis of your intervention plan. --- ## Step 3 — ADVISE (Present Options Without Bias) Present all three categories of intervention — do not withhold any option: 1. **Behavioural and psychological interventions** — multicomponent programs (physical activity + nutrition + psychology); available in most settings 2. **Pharmacotherapy** — GLP-1RAs, metformin (age ≥12); always combined with behavioural therapy 3. **Surgical interventions** — LSG or RYGB (age ≥13, specialised centres); conditional on multidisciplinary assessment > ⚠️ No stepwise hierarchy is required — present all options and let the family's values and circumstances guide selection. There is no mandate to "fail" behavioural therapy before pharmacotherapy or surgery. For each option, communicate: - What the intervention involves - Expected benefits (with honest magnitude: often small to moderate for most outcomes) - Expected harms and side effects - Availability and access issues (cost, wait times, geography) --- ## Step 4 — AGREE (Shared Decision-Making) Work with the child and family to align on: - **Goals that matter to them** — not just BMI reduction. Ask: - *"What would you most like to be different about your health?"* - *"What activities do you wish you could do that feel hard right now?"* - Common priorities: energy levels, mood, mobility, peer relationships, sleep - **Preferred intervention(s)** based on the discussion above - **Realistic expectations** — obesity is chronic and relapsing; success is not linear - **Roles and responsibilities** — who does what (child, caregiver, clinician, team) Document the agreed plan explicitly, including what will be tried and the follow-up timeline. --- ## Step 5 — ASSIST (Connect and Support) Provide tangible next steps before the family leaves: - **Referrals:** Dietitian, kinesiologist, psychologist, social worker, paediatric obesity program (as needed) - **Resources:** Casebook for health care providers; guide for caregivers (Obesity Canada / Obesity Canada–OC) - **Follow-up appointment:** Book before they leave — long-term support is essential - **If surgical referral indicated:** Initiate multidisciplinary assessment process - **If pharmacotherapy agreed:** Prescribe + enrol in/confirm behavioural program simultaneously > ⚠️ Remind the family: obesity requires long-term management. You and your team are partners in this — it is not the family's "fault" and not their problem to solve alone. --- ## Clinical Guardrails - **Eating disorder vigilance throughout:** Monitor at every visit. If screening suggests risk → refer to specialist before or instead of standard obesity interventions - **Don't focus on weight alone.** Improved HRQoL, mood, energy, and cardiometabolic markers are valid and often more meaningful outcomes for families - **Acknowledge stigma explicitly:** Many families have had negative experiences with healthcare. Naming this builds trust - **Social determinants are modifiable — refer accordingly.** Food bank referral, community programs, social worker involvement - **Technology-only approaches:** Insufficient evidence — do not use as a standalone - **Transition to adult care:** Begin planning from age 16; obesity does not resolve at 18 --- ## Source CMAJ 2025 Clinical Practice Guideline: *Managing obesity in children.* Ball GDC et al. CMAJ 2025 April 14; 197:E372–89. doi: [10.1503/cmaj.241456](https://doi.org/10.1503/cmaj.241456) 5As of Pediatric Obesity Management: Vallis et al. / Obesity Canada. Updated version: June 3, 2025.