by Jason Block, MD, MPH

I see patients with obesity both in my primary care clinic and in a weight management clinic. I have long wondered how to best communicate with them regarding their weight problem. Typically, I start by explaining to them that they fall into the “obese” weight category. I further describe this as a clinical term that is only helpful in describing their risk for health problems. But, should I change my words? Should I tell them they have a “weight problem” or an “unhealthy weight”? Burgeoning research on weight stigma suggests that my current practice may be missing the mark.

Weight stigma increasingly recognized

How common is weight-related stigma? Researchers at Yale’s Rudd Center have published several recent studies concluding that it’s fairly common. In an analysis of television news stories about obesity, 2/3 of overweight/obese adults and ¾ of similar children were portrayed negatively, often “headless”, with shots only of their bodies or while engaging in unhealthy behaviors. Even venerable medical journals present images this way.

In another study, among adolescents attending a weight loss camp, 2/3 experienced teasing or bullying because of their weight, which was much more common than teasing or bullying because of race or school performance. Of those teased or bullied, 2/3 had been the victim of physical aggression related to their weight.

A recent online survey of 1,064 adults examined experiences with weight-based discrimination. More than half of respondents with obesity and 20% with overweight reported prior weight-based discrimination.

Communicating with patients about their weight

In the same online survey above, participants gave their perceptions of 10 words that doctors might use to communicate about a weight problem. “Morbidly obese”, “fat”, and “obese” emerged as the most stigmatizing. “Weight”, “unhealthy weight”, and “weight problem” were the most desirable with “unhealthy weight” and “overweight” perceived as the most motivating to change behavior. Results were similar if respondents were normal weight or overweight/obese. Men had less variation in their preferences, rating all terms as more neutral than women.  While there is some variability in preferences across other studies, “weight” related terminology rises to the top while “fat” and “obese” do not.

Learning how to better communicate with patients is not only important for establishing rapport, but it could help physicians address weight as a health problem. It turns out that physicians often don’t talk with patients about their weight, in part because they don’t feel comfortable doing so. And, their discussion of it can be stigmatizing, perhaps leading to negative consequences, both psychological and physical. Individual experiences with weight-based discrimination, not just from physicians, also has been associated with weight gain over time.

Toward a solution

The Rudd Center is doing something about the media portrayal of weight stigma. They have created non-stigmatizing photos and videos that are freely available for use. Physicians and health care professionals can address these challenges as well. I certainly will take these studies to heart and will use “weight problem”, “unhealthy weight”, and “overweight” more and “obesity” less. Since not all patients are the same, I may just ask patients their preferred terminology. Obesity is a remarkably prevalent condition across the world, and treatment is challenging for patients. The least we can do is get our words right.


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