Respectful language and putting the person first with obesity

This commentary refers to ‘Obesity modifies the energetic phenotype of dilated cardiomyopathy’, by J.J. Rayner et al., https://doi.org/10.1093/eurheartj/ehab663 and the discussion piece ‘Investigating the disease is the key to the obesity stigma’, by J.J. Rayner and O.J. Rider, https://doi.org/10.1093/eurheartj/ehab840.

In their article ‘Obesity Modifies the Energetic Phenotype of Dilated Cardiomyopathy’, Rayner et al.¹ highlight distinct energetic pathways in obesity cardiomyopathy as it relates to reduced myocardial efficiency and maintained adenosine triphosphate (ATP) delivery. Although their findings may help better target metabolic treatments in patients with obesity and cardiomyopathy, the authors neglected to use people-first language with ‘obese individuals’ and ‘obese group’ throughout the text. Adjectival labels such as ‘obese’ are problematic as they suggest personal blame and that individuals are defined by their weight status alone.

Indeed, encountering dehumanizing labels such as ‘obese’ reinforces weight stigma and can have injurious psychological ramifications.² In a phenomenon known as stereotype embodiment, individuals internalize the stigma they witness or experience, incorporating negative depictions into their self-concept. This individual-level mechanism is compounded by interpersonal interactions as physicians across all specialties, including cardiologists, demonstrate significant anti-fat implicit bias.³ Stigmatizing attitudes lead patients with obesity to be less likely to access care, adhere to treatment, and successfully lose weight.⁴ Structural levers, such as cultural norms and media depictions, also alienate individuals with obesity. Physicians must more rigorously assess their weight biases in all contexts, and the language employed in academic writing should not further deny dignity and respect to people with obesity. Certainly, eliminating the label of ‘obese’ will not absolve the pervasiveness of weight bias, but it is an integral, long-overdue step to begin dismantling stigmatizing conventions.

Indeed, guidelines in the 11th edition of the American Medical Association (AMA) Manual of Style direct authors to ‘avoid labelling (and thus equating) people with their disabilities or diseases (eg, the blind, schizophrenics, epileptics). Instead, put the person first’.⁵ We would encourage the authors to be more mindful of their language and to identify their study participants as ‘individuals with obesity’ instead of ‘obese individuals’ and ‘group with obesity’ instead of ‘obese group’. The authors never describe ‘DCM individuals’ or a ‘DCM group’, always being careful to use people-first language for cardiomyopathy. We believe this courtesy should be extended to obesity as well. As such, we also recommend that the European Heart Journal updates its author guidelines to explicitly require people-first language for all chronic conditions in line with the AMA Manual of Style and the precedent established by Obesity and Obesity Research and Clinical Practice. As a leader in the cardiology literature, European Heart Journal has a responsibility not only to advance medicine but also to actively combat dehumanizing language in its journal. Deracinating weight stigma is a shared responsibility for us all.

Funding

The study was supported by the National Institutes of Health and Massachusetts General Hospital Executive Committee on Research (ECOR) (F.C.S.) and National Institutes of Health NIDDK P30 DK040561 (F.C.S.) and L30 DK118710 (F.C.S.).

Conflict of interest: There are no conflicts of interests with the authors.