Respectful Language and Care in Childhood Obesity

For many years, obesity has been the most prevalent chronic disease in the United States. In pediatrics, obesity is classified as follows: body mass index (BMI) of 95% or greater of the 95th percentile as class I (mild), BMI of 120% or greater of the 95th percentile as class II (moderate), and BMI of 140% or greater of the 95th percentile as class III (severe). Current estimates suggest that 16.8% of youths between the ages of 2 and 20 years and 39.6% of adults have obesity.¹ The rate of severe obesity is increasing most rapidly, with severe obesity now affecting approximately 5 million youths. Nevertheless, the medical community has been slow to discard pervasive thinking of obesity more as a lifestyle choice than as a complex multifactorial disease.

Obesity results from the interaction of genetics, environment, development, and behavior. The American Medical Association resolved that obesity should be regarded as a disease in 2013,² but the adoption of this view is not yet universal.² Even among physicians, understanding of the biological basis for obesity is incomplete.³ The combination of high prevalence and inadequate care for the children affected means that obesity represents one of the most serious threats to a lifetime of health for children today. Modeling of growth rates suggest that 57% of current children are likely to have obesity by the time they reach the age of 35 years.⁴

The Harm of Weight Stigma

Stigma causes harm that rivals or exceeds the physical harm of obesity. That harm is especially great in children and adolescents. It begins as early as the age of 3 years. Some physicians and parents mistakenly believe that stigma and shame will motivate individuals to lose weight, but instead it leads to long-lasting negative health consequences. Research has documented that avoidance of medical care, binge eating, less physical activity, and increased weight gain are more likely when patients experience bias and stigma.⁵ Youths are especially vulnerable.⁵

The physical harm of obesity accumulates slowly over time and may not be seen clinically for years, but the harm that stigma causes is immediate and profound. Bullying, depression, anxiety, substance abuse, low self-esteem, and poor body image are important risks that increase when a child or adolescent experiences weight stigma.

The Importance of Respectful Language

Unfortunately, patients report that health care workers often never see past a patient’s obesity. They find that symptoms they present to health care workers are of ten attributed to obesity even when they are medically unrelated. When a physician labels a patient as obese, it establishes such thinking at the outset. In few other diseases may it be so commonplace for patients to be labeled with a disease than it is with obesity. The best practice is to be clear that the patient has a disease but that they are not defined by it.

We rarely see patients referred to as diabetic, and it is even less common to apply such labels to patients who have cancer. However, in everyday interactions with patients and in the medical literature, we often see the terms fat, obese, and morbidly obese even though these terms are the most stigmatizing and least motivating. This response to such language has been documented both for adults and in a study of parents with children between the ages of 2 and 18 years.^5,6

Language can set the tone for productive dialogue with youths and parents or it can prevent dialogue from ever happening. Research suggests that a physician labeling a child with stigmatizing language can lead to parents seeking a different physician or avoiding medical appointments for their children altogether. Labeling children with stigmatizing language leaves parents feeling blamed for their child’s condition. Not only is blame counterproductive, it obscures the complexity of the many factors that cause obesity.

Guidance for Respectful Language

In a recent joint policy statement, the American Academy of Pediatrics (AAP) and The Obesity Society called for action to reduce the significant harm associated with bias and stigma that children and adolescents with obesity endure.⁵ Their statement documented the harm that stigma can cause and proposed 10 actions to reduce that harm. A key element of these recommendations focuses on the use of respectful language, including people-first language such as a patient with obesity as opposed to obese patient. Such language offers a respectful framework for separating discussions of the condition from the identity ofthe patient. Fat, obese, and morbidly obese are examples of terminology that is unhelpful.

The goal, as recommended by AAP, is for physicians to model unbiased language and behavior as a step toward reducing the harm of weight stigma and bias. The AAP encourages using neutral terms, such as weight and body mass index, for a more positive response from patients and parents coping with obesity. Terms such as obese, morbid obesity, and excessively fat set up a demeaning conversation. Using people-first language means that the patient comes first and obesity surfaces as only a medical condition. Physicians should take cues from patients and parents about acceptable terminology. Motivational interviewing skills can help in finding constructive language. In addition, the clinic environment, including staff and physical facilities, can play a role in either stigmatizing or welcoming patients and families with obesity.⁵ But in no case does labeling a patient as an obese child enhance a child’s self-concept.

Consistent with AAP guidance, the American Medical Association (AMA) House of Delegates passed a resolution (H-440.821) at its 2017 annual meeting to “discourage the use of stigmatizing terms including obese, morbidly obese, and fat,” and to encourage the use of people-first language throughout obesity-related literature.⁷ Though obesity journals are more uniformly adheringto AMA style regarding people-first language,⁸ the lack of people-first language in obesity-related literature can still be found in many major medical journals.

Advancing the Quality of Care for Obesity

Respectful language is a first step toward respectful care for patients with obesity.⁹ Language alone cannot guarantee that interactions with patients and families will be effective and centered on the needs of patients and families. However, without a foundation of respect signaled by respectful language, patient-and family-centered care will not be possible for families facing the challenges that obesity presents.

Systemic issues remain to be solved so that pediatricians can more consistently deliver evidence-based care for childhood obesity. Respectful language is an important step toward resolving one of those issues: pervasive bias and stigma. We encourage JAMA Pediatrics to require that the articles that it publishes adhere to the guidance of AMA style and consistently use people-first language in publications regarding obesity.