Abstract
This survey study evaluates responses to people-first language and terms for describing a body mass index of 40 or more among patients seeking bariatric surgery and explores patients’ receptivity to discussing weight stigma in weight management.
People with obesity—particularly those with the highest body mass indices (BMIs)—face societal stigma.1 Words used by health care practitioners when discussing weight may contribute to this stigma. For example, words such as fat and morbid obesity are perceived by persons with obesity as more undesirable and stigmatizing than terms such as BMI.2,3 The use of people-first language4 (ie, person with obesity rather than obese person or the obese) and weight sensitivity training have been promoted among health care professionals to reduce weight stigma. To our knowledge, no study to date has assessed patients’ responses to the use of people-first language or the discussion of weight stigma in treatment settings.
This study evaluated responses to people-first language and terms for describing a BMI of 40 or more (calculated as weight in kilograms divided by height in meters squared) among patients seeking bariatric surgery. We also explored patients’ receptivity to discussing weight stigma in a weight management setting.
Methods
As part of a substudy within a larger investigation, questionnaires were distributed from December 1, 2015, to December 31, 2017, to patients seeking bariatric surgery at a university-based hospital. Ninety-seven questionnaires were completed (by 84 women and 13 men; mean [SD] age, 46.3 [12.5] years), with permission to access patients’ electronic medical records. The University of Pennsylvania institutional review board approved all study procedures, and patients provided written informed consent.
Questionnaires included the Stigma Preferences Questionnaire, the Weight Bias Internalization Scale (WBIS),5 and the Everyday Discrimination Scale.6 The Stigma Preferences Questionnaire was developed for the current study based on prior research.2,3 Participants were asked to state their preference for obese person or person with obesity to describe an individual with a BMI of 30 or more. Participants rated how much they liked these and other proposed terms on a scale of 1 to 7 (where 1 indicated strongly dislike and 7 indicated strongly like), along with terms to describe a BMI of 40 or more. Participants were also asked whether they had “ever discussed weight stigma in a treatment or weight management setting;” how important, helpful, and necessary (on a scale of 1-7) they thought it was to discuss weight stigma “as part of weight management” (scores for 3 items were averaged; α = .96); and why they might want to discuss it in this setting (from a list of proposed reasons).
The WBIS is an 11-item scale (on a scale of 1-7, where 1 indicated strongly disagree and 7 indicated strongly agree) assessing the extent to which individuals devalue themselves because of their weight. The 9-item Everyday Discrimination Scale evaluates the frequency of perceived “microaggressions” (eg, being treated with less respect than others) and reasons for these experiences (eg, race/ethnicity or weight). Participant demographics were obtained from self-report and electronic medical records, and BMI was obtained from electronic medical records.
Descriptive statistics were computed for all outcomes. Logistic and linear regression analyses were used to identify predictors (age, race/ethnicity, sex, BMI, WBIS scores, and weight discrimination) of patient preferences. All P values were from 2-sided tests, and results were deemed statistically significant at P < .05.
Results
Participant characteristics are presented in Table 1. Compared with the 605 participants who did not participate in this substudy, those who did were more likely to be white (odds ratio, 2.1; 95% CI, 1.3-3.2; P = .001), older (ηp2 = 0.02; 95% CI, 0.01-0.04; P < .001), and have lower BMIs (ηp2 = 0.01; 95% CI, 0.00-0.02; P = .02).
Table 1. Participant Characteristics.
| Characteristic | No. (%) (N=97) |
|---|---|
| Sex | |
| Male | 13 (13) |
| Female | 84 (87) |
| Race (could select more than 1) | |
| White | 60 (62) |
| Black/African American | 36 (37) |
| American Indian/Alaska Native | 2 (2) |
| Asian | 1 (1) |
| Hispanic and/or Latino/a | 3 (3) |
| Age, mean (SD), y | 46.3 (12.5) |
| Body mass index, mean (SD)a | 45.4 (7.2) |
| <40 | 20 (21) |
| 40-49.9 | 59 (61) |
| ≥50 | 18 (19) |
| Weight Bias Internalization Scale score, mean (SD) | 4.0 (1.1) |
| Everyday Discrimination Scaleb | |
| At least 1 item | 53 (55) |
| Main reason for discrimination | 40 (41) |
Calculated as weight in kilograms divided by height in meters squared.
At least 1 item = reported experiencing weight discrimination “a few times a year” or more (vs “less than once a year” or “never”) in response to at least 1 item; main reason for discrimination = weight identified as the main reason for everyday discrimination.
Most participants preferred the term person with obesity to obese person (74 [76%] vs 21 [22%]). Women were more likely than men to prefer people-first language (69 of 84 [82%] vs 5 of 13 [39%]; odds ratio, 6.9; 95% CI, 1.7-28.2; P = .007). Person with obesity had the second highest rating (mean [SD] score, 4.9 [1.7]), behind person with elevated BMI (mean [SD] score, 5.3 [1.6]) (Table 2). Class III obesity was the highest-rated term for describing a BMI of 40 or more (mean [SD] score, 4.4 [2.0]).
Table 2. Participants’ Ratings of Obesity-Related Terms.
| Term | Rating, Mean (SD)a |
|---|---|
| To describe a person with a BMIb ≥30 | |
| Person with elevated BMI | 5.3 (1.6) |
| Person with obesity | 4.9 (1.7) |
| Person with excess weight | 4.7 (1.8) |
| Heavy person | 3.8 (2.0) |
| Obese person | 3.0 (1.6) |
| Person with excess fat | 2.8 (2.0) |
| Fat person | 1.8 (1.5) |
| To describe having a BMI ≥40 | |
| Class III obesity | 4.4 (2.0) |
| Severe BMI | 3.9 (1.9) |
| Extreme BMI | 3.9 (1.9) |
| Severe obesity | 3.5 (1.8) |
| Extreme obesity | 3.3 (1.8) |
| Morbid obesity | 2.6 (1.7) |
Abbreviation: BMI, body mass index.
Terms were rated on a scale of 1-7, where 1 = strongly dislike and 7 = strongly like. The full Stigma Preferences Questionnaire is available by request from the corresponding author. P values for all comparisons are as follows: person with elevated BMI vs person with obesity, P = .06; person with elevated BMI vs person with excess weight, P = .002; person with obesity vs person with excess weight, P = .25; heavy person vs obese person, P = .002; obese person vs person with excess fat, P = .39; class III obesity vs severe BMI, P = .05; class III obesity vs extreme BMI, P = .04; severe BMI vs extreme BMI, P = .73; severe BMI vs severe obesity, P = .02; severe BMI vs extreme obesity, P = .005; extreme BMI vs severe obesity, P = .04; extreme BMI vs extreme obesity, P = .004; severe obesity vs extreme obesity, P = .30; and extreme obesity vs morbid obesity, P = .001. All other P values were <.001.
Calculated as weight in kilograms divided by height in meters squared.
In all, 36 participants (37%) reported discussing weight stigma in a treatment or weight management setting. Participants with higher WBIS scores rated weight stigma as more important, helpful, or necessary to discuss (mean [SD], 5.3 [1.4]; β = 0.31; P = .003). A total of 42 participants (43%) reported that discussing weight stigma would help them lose more weight. Participants also reported that discussing weight stigma would help them feel better about themselves (47 [49%]), and feel more understood (48 [50%]) and comfortable (39 [40%]) with their health care practitioner.
Discussion
Results of our study suggest that people-first language has strong support among patients seeking bariatric surgery. In addition, participants in this study wished to discuss weight stigma in weight management settings. More research is needed to identify potential benefits to patients of discussing weight stigma in bariatric and other medical settings.
References
- 1.Papadopoulos S, Brennan L. Correlates of weight stigma in adults with overweight and obesity: a systematic literature review. Obesity (Silver Spring). 2015;23(9):1743-1760. doi: 10.1002/oby.21187 [DOI] [PubMed] [Google Scholar]
- 2.Wadden TA, Didie E. What’s in a name? patients’ preferred terms for describing obesity. Obes Res. 2003;11(9):1140-1146. doi: 10.1038/oby.2003.155 [DOI] [PubMed] [Google Scholar]
- 3.Puhl R, Peterson JL, Luedicke J. Motivating or stigmatizing? public perceptions of weight-related language used by health providers. Int J Obes (Lond). 2013;37(4):612-619. doi: 10.1038/ijo.2012.110 [DOI] [PubMed] [Google Scholar]
- 4.Kyle TK, Puhl RM. Putting people first in obesity. Obesity (Silver Spring). 2014;22(5):1211. doi: 10.1002/oby.20727 [DOI] [PubMed] [Google Scholar]
- 5.Durso LE, Latner JD. Understanding self-directed stigma: development of the Weight Bias Internalization Scale. Obesity (Silver Spring). 2008;16(S2)(suppl 2):S80-S86. doi: 10.1038/oby.2008.448 [DOI] [PubMed] [Google Scholar]
- 6.Williams DR, Yan Yu, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335-351. doi: 10.1177/135910539700200305 [DOI] [PubMed] [Google Scholar]