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.
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.
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).
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]).
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.
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.
Accepted for Publication: June 4, 2018.
Corresponding Author: Rebecca L. Pearl, PhD, Perelman School of Medicine at the University of Pennsylvania, 3535 Market St, Ste 3026, Philadelphia, PA 19104 (email@example.com).
Published Online: September 5, 2018. doi:10.1001/jamasurg.2018.2702
Author Contributions: Dr Pearl had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Pearl, Wadden.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Pearl.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Pearl.
Administrative, technical, or material support: Pearl, Walton, Allison.
Conflict of Interest Disclosures: Dr Pearl reported serving as a consultant for Weight Watchers, Int. Dr Allison reported receiving funding from an investigator-initiated study from Novo Nordisk. Dr Tronieri reported serving as a consultant for Novo Nordisk. Dr Wadden reported serving on advisory boards for Novo Nordisk and Weight Watchers, Int. No other disclosures were reported.
Funding/Support: Dr Pearl’s work on this study was supported, in part, by a mentored patient-oriented research career development award (K23HL140176) from the National Heart, Lung, and Blood Institute/National Institutes of Health.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Brooke Bailer, PhD, Raymond Carvajal, PsyD, Kristoffel Dumon, MD, Courtney McCuen-Wurst, PsyD, LCSW, Colleen Tewskbury, MPH, RD, LPN, and Noel Williams, MD, Perelman School of Medicine at the University of Pennsylvania, and the Penn Metabolic and Bariatric Surgery staff helped to facilitate data collection. They were not compensated for their contributions.