Weight is an important data point in assessments of health. It remains unique, however, from other measures clinicians use to assess their patients' well-being as it is also intimately connected to identity and stigma outside of medical settings.
Though "obesity" and "obese" are still considered clinical terms, evidence continues to accrue that these words carry with them negative connotations unrelated to assessments of health. When clinicians use these stigmatized words within a medical setting, studies increasingly show that they cause negative feelings and responses from patients and actively hinder those patients' ability to collaborate with their practitioners toward medically-advised weight loss goals.
"The language that you use should communicate empathy, compassion, and respect," says Rebecca Puhl PhD, a professor at the Rudd Center for Food Policy and Obesity at the University of Connecticut, as well as the author of many recent studies about obesity bias, including the comprehensive review, "_What Words Should We Use To Talk About Weight? A Systematic Review of Quantitative and Qualitative Studies Examining Preferences for Weight-Related Terminology," recently published in the journal _Obesity Reviews.
According to Dr. Puhl, people dealing with obesity are subject to weight-based bias and discrimination long before they enter into discussions of how their size may affect their health and mortality. Thus, the words clinicians use to initiate these conversations directly impact their efficacy. Dr. Puhl points to an increasing amount of evidence which demonstrates that when clinicians use words that are associated with stigma and bias when speaking to their patients about weight, it actively compromises efforts to assist those patients in medically-advised weight loss.
Dr. Puhl emphasizes that most major medical organizations and scholarly journals, including the American Medical Association and the Academy of Pediatrics, have reacted to the mounting evidence that the use of stigmatizing language in clinical settings undermines care by changing their policies and publishing statements advising clinicians to pay close attention to the words they use when discussing their patients' weight.
While Dr. Puhl's research has made it increasingly clear that it erodes trust between clinician and patient and hurts health outcomes for patients when clinicians use language that reinforces shame and stigma, she says it is still less clear which words patients prefer health care practitioners use when commenting on their weight.
Since the American Medical Association determined obesity to be a disease in 2013, the medical community has moved toward people-first language as a solution to this issue that has been a barrier to successful communication between patients and health care providers around the topic of weight in the past. Dr. Puhl notes that the Obesity Society and other obesity organizations have made people-first language the standard in scholarly publications and doctor-patient communication.
People-first language has long been used to describe patients with other health conditions and disabilities both physical and psychological. The practice of saying that a patient living with a health condition is a person first and then naming their condition second may seem semantic, but it has been shown to have an effect on reducing stigma and bias felt by the patient when discussing health conditions such as obesity for which they have experienced mistreatment and shaming in the past. It comes from other stigmatized communities such as people with disabilities. Rather than call a patient handicapped or paraplegic, which were once medically acceptable terms, people-first language refers to that same patient as a person who uses a wheelchair, acknowledging their personhood first.
To use people-first language most effectively when speaking to patients regarding their weight, first ask them what term they would prefer you use while having the conversation, says Dr. Puhl. Patients tend to prefer words that are neutral and objective as opposed to words that carry judgement or are descriptive. Neutral words include "weight" and even "gained too much weight." In this example, rather than describing a patient as "obese," a clinician would be advised to begin a conversation with the patient about their weight and to describe their obesity as a health condition that is something they live with but does not define them.
Using Patient First Language in Obesity Treatment
Preferred language: "A person who would like to lose weight"
Less preferred language: "An overweight patient"
Preferred language: "A person undergoing treatment for obesity"
Less preferred language: "An obese patient"
Preferred language: "A person with diabetes"
Less preferred language: "A diabetic"
Most and least preferred terms and phrases for discussing medically advised weight loss across studies from Puhl's paper in Obesity Reviews include:
Most preferred
"Weight"
"Unhealthy weight"
"Your weight may be damaging your health."
"You are above your healthy weight range."
Least acceptable and most undesirable
"Fat"
"Fatness"
"Obese"
"Morbidly obese"
Initiate an Unbiased Conversation About Weight With a Patient
Conversations about weight are fraught and difficult for patients and clinicians alike. For patients, it is essential that the topic be broached using neutral language, as well as in a tone that is helpful and allows them to make their own decisions and choices about their health.
Motivational interviewing techniques give the patient that authority over their health and place the clinician in a supportive and collaborative role, as opposed to a disciplinary one; the latter of which has been repeatedly shown to backfire and result in less adherence to weight loss goals.
"In our research, there is evidence of what kinds of words patients want, and what kinds of words they don't want. As a health care provider, you can make changes to the language that you use to make your patients feel more empowered and supported, as opposed to shamed and stigmatized," says Dr. Puhl. She suggests using the following motivational interviewing techniques to put the patient at ease and in control of the conversation.
Motivational Interviewing for Weight Loss
1. Start any discussion about weight loss by asking the patient if they want to have that conversation and letting them decide.
"Is it okay if we talk about your weight now?"
2. If the patient gives you permission to discuss their weight, ask them what words they would prefer you use to do so.
"What words do you feel most comfortable with while we have this conversation?"
3. Don't assume that the patient wants to lose weight.
"How are you feeling about your weight?"
4. Don't imply that the patient has not tried to lose weight before using diet and exercise, or that their obesity is caused by moral or personal failure or a lack of discipline or willpower. Remember to use neutral language and acknowledge how complicated it is to lose weight.
"I know it's difficult to lose weight, and that your body and metabolism can work against you if you have dieted or lost weight in the past. Obesity is not your fault. It is caused by a complicated interaction of genetic, biological, and environmental factors."
5. If the patient says they do want to lose weight, offer to help and present them with a full range of treatment options including weight-loss medications, and connect them to resources and specialists such as nutritionists, diabetes educators, and trainers.
"You don’t have to do this alone. There are many resources to help patients like you who have found weight loss elusive. Here are some ways we can approach your treatment, including medications that can help you lose a higher percentage of your body weight and can help increase the amount of weight you can lose if you’ve found that diet and exercise are not working.”
"Personal behavior is a piece of the puzzle, but it's only one piece," says Dr. Puhl. "If we only focus on that one piece of the puzzle, it won't be solved. Including some education on the complex causes of body weight regulation is important as well, because otherwise it's very easy for clinicians to communicate that patients have to work harder and eat less, which isn't helpful."