University of Pennsylvania School of Medicine, Department of Psychiatry, 3535 Market Street, Philadelphia, PA 19104. E-mail: Wadden@mail.med.upenn.edu
Objective: To determine the terms that obese individuals find undesirable or desirable for their doctors to use to describe excess weight of 27.3 kg (i.e., 50 lb) or more.
Research Methods and Procedures: The study surveyed 167 women and 52 men with a mean BMI of 35.3 and 35.1 kg/m2, respectively, who participated in one of two randomized trials on the treatment of obesity. An additional sample consisted of 105 extremely obese women (i.e., mean BMI of 52.5 kg/m2) who sought bariatric surgery. Patients rated the desirability of 11 terms used to describe excess weight. Ratings were made on five-point scales, ranging from very desirable (+2) to neutral (0) to very undesirable (−2).
Results: Obese women (N = 167) rated as undesirable to very undesirable the terms fatness (mean rating = −1.8), excess fat (−1.4), obesity (−1.4), and large size (−1.3). These four terms were rated as significantly more (all p ≤ 0.001) undesirable than the seven remaining descriptors, which included weight, heaviness, BMI, excess weight, unhealthy body weight, weight problem, and unhealthy BMI. The term weight received a mean rating of 1.1, a value significantly more (all p ≤ 0.001) desirable than that for all other descriptors. Highly similar ratings of the terms were provided by obese men (N = 52) and extremely obese women (N = 105).
Discussion: Practitioners may wish to avoid the use of potentially derogatory terms such as fatness and obesity when broaching the topic of weight management with patients.
Primary care providers have been encouraged to play a more active role in the management of obesity (1, 2, 3, 4, 5, 6), which is defined as a BMI ≥30 kg/m2 (7). Their efforts are needed to help halt an epidemic that now afflicts 30.5% of adult Americans; an additional 34% are overweight, as defined by a BMI of 25.0 to 29.9 kg/m2 (8). Several expert panels have reviewed the empirical literature to determine the best methods of assessing and treating obesity (7, 9, 10). A treatment algorithm has been proposed that identifies an appropriate intervention based on a patient's BMI and risk of health complications (10, 11).
Before health care providers pull out such algorithms with patients, however, they may want to consider how best to broach the topic of obesity. It is a sensitive issue. For many years, obesity has been viewed more as a moral or esthetic failing than as a medical condition (12, 13, 14). Historically, the public has used the words “obese” and “fat” in a pejorative manner (15), as in “you fat….” Numerous studies have shown that obese individuals, whether children or adults, are subjected to pervasive prejudice and discrimination (16, 17, 18, 19). Health professionals seem to share society's negative attitudes toward obesity (20, 21).
As health care providers who specialize in weight management, we have observed repeatedly that our patients do not like, and are often offended by, the terms obesity and fatness. The comments of a woman with a BMI of 38 kg/m2 are representative: “I'm not obese. That's for people who are really fat. It's gross.” Thus, well-intentioned primary care physicians may get off to a bad start by initiating a discussion: “Mrs. Jones, I want to talk with you about your obesity.” Mrs. Jones may be too upset to listen after hearing that she is obese.
This study was designed to identify the terms that obese individuals find undesirable or desirable for describing excess weight. We anticipated that the terms obesity and fatness would be rated as very undesirable.
Research Methods and Procedures
Participants were 167 women and 52 men who were volunteers in two randomized clinical trials on the treatment of obesity by physical activity or weight loss medication. Eligibility criteria included having a BMI of 30 to 40 kg/m2. As shown in Table 1, women had a mean age of 47.5 ± 10.1 years and a mean BMI of 35.3 ± 5.1 kg/m2. Corresponding values for men were 45.6 ± 8.8 years and 35.1 ± 4.1 kg/m2, respectively. Twenty-two percent of the women were minority members as were 6% of the men (see Table 1). A third sample consisted of 105 women who were consecutive applicants to our institution's bariatric surgery program. They had a mean age of 42.7 ± 10.0 years and a mean BMI of 52.7 ± 10.4 kg/m2 (22% were minority members; Table 1). They were included to determine if patients with extreme obesity (i.e., BMI ≥ 40 kg/m2) who sought the most aggressive therapy possible preferred different terms to describe excess weight. (Men seeking bariatric surgery were not included in this report because of the small number of applicants.) The study protocol was approved by the University of Pennsylvania's Committee on Studies Involving Human Beings.
Table 1. Demographic characteristics of patients in three groups
Sample included 132 white women, 30 African-American women, and 5 women of “other” race/ethnicity.
Included 49 white and 3 African-American men.
Included 82 white women, 21 African-American women, and 2 women of “other” race/ethnicity.
Participants completed a Weight Preferences Questionnaire that read: “Imagine that you are visiting your doctor for a check-up. The nurse has measured your weight and found that you are at least 50 lb over your recommended weight. The doctor will be in shortly to speak with you. Doctors can use different terms to describe weight. Please indicate how desirable or undesirable you would find each of the following terms if your doctor used it.”
Participants used a five-point scale (i.e., 1 = very desirable, 2 = desirable, 3 = neutral, 4 = undesirable, and 5 = very undesirable) to rate each of 11 terms that was introduced by the phrase, “Good morning. I want to talk with you about your:” (1) weight; (2) heaviness; (3) obesity; (4) BMI; (5) excess weight; (6) fatness; (7) excess fat; (8) large size; (9) unhealthy body weight; (10) weight problem; and (11) unhealthy BMI. We selected these terms with the assistance of several obese patients from our clinic (who did not participate in the study). The terms were presented in the order listed above. They were presented in reverse order (with unhealthy BMI first and weight last) to 50 of 324 total patients to determine if order of presentation influenced ratings. These 36 women and 14 men were participants in the randomized trial of physical activity.
For each of the three patient groups (i.e., men, women, and extremely obese women), a multivariate ANOVA (MANOVA)1 was performed using the SAS GLM procedure (SAS Institute, Cary, NC). Each of the three MANOVAs yielded highly significant results (all p < 0.0001). Within each group (i.e., men, women, extremely obese women), the mean rating for each term was compared with that for each of the 10 other terms using Tukey's Studentized Range test. To control for the large number of tests conducted, the experiment-wise error rate for each family of comparisons (i.e., men, women, etc.) was set at 0.05. Ratings for two terms were considered significantly different only for p ≤ 0.001. Differences in the ratings of moderately obese women and men, moderately and extremely obese women, and obese white and African-American women were assessed by ANOVA. Differences between groups, for ratings of individual terms, were considered statistically significant only for p ≤ 0.005.
A MANOVA revealed that there were no statistically significant differences in the ratings of the 11 terms when weight was presented as the first item and unhealthy BMI as the last compared with when this order was reversed (i.e., unhealthy BMI first and weight last). Thus, ratings of the terms did not seem to be influenced by the order in which they were presented.
Obese Women's Ratings
The 167 women rated the terms fatness, excess fat, obesity, and large size as undesirable to very undesirable. For ease of understanding, Figure 1 presents these data transformed to a scale of +2 to −2 in which +2 = very desirable, 0 = neutral, and −2 = very undesirable. As shown, fatness received a mean rating of −1.8 ± 0.5, a value that was significantly more (p ≤ 0.001) undesirable than that for all other terms. The terms excess fat, obesity, and large size received ratings of −1.4 ± 0.8, −1.4 ± 0.8, and −1.3 ± 0.9, respectively; these ratings were significantly more (all p ≤ 0.001) undesirable than those for all other descriptors except fatness. By contrast, the term weight received a mean rating of 1.1 ± 1.0, a value that was significantly more (all p ≤ 0.001) desirable than that for all other descriptors. Both excess weight (0.1 ± 1.1) and BMI (0.1 ± 1.1) were rated as neutral.
Obese Men's Ratings
Men's ratings were very similar to women's. As shown in Figure 2, they rated fatness (−1.4 ± 0.8), obesity (−1.1 ± 1.1), and excess fat (−1.0 ± 0.8) as undesirable to very undesirable. Fatness and obesity were rated as significantly more (all p ≤ 0.001) undesirable than all other terms, except excess fat and large size. Like women, men rated the term weight as significantly more (all p ≤ 0.001) desirable than all others descriptors and tended to view with favor the terms excess weight (0.4 ± 0.9) and BMI (0.2 ± 1.0).
Although women's and men's relative ratings of the terms were very similar, their absolute ratings of the descriptors differed significantly in several cases (as determined by ANOVA). Women rated as significantly more (all p ≤ 0.005) undesirable than men the terms fatness, excess fat, and large size. There were no other significant gender-related differences.
Extremely Obese Women's Ratings
The extremely obese women (i.e., applicants for bariatric surgery; Figure 3) rated as undesirable the terms fatness (−1.2 ± 1.4), excess fat (−1.0 ± 1.4), large size (−0.9 ± 1.4), obesity (−0.8 ± 1.4), and heaviness (−0.7 ± 1.2). These five descriptors were rated as significantly more (all p ≤ 0.001) undesirable than the remaining six terms. Fatness, excess fat, and large size were rated significantly more (all p ≤ 0.001) undesirable than obesity and heaviness. As in the moderately obese women and men, bariatric surgery candidates rated weight (1.1 ± 1.0) as significantly more (all p ≤ 0.001) desirable than all other terms and viewed the descriptors weight problem (0.4 ± 0.4), BMI (0.2 ± 1.2), excess weight (0.1 ± 1.2), and unhealthy body weight (0.1 ± 1.4) as neutral.
Differences Related to Degree of Obesity
ANOVA revealed that the obese women (N = 167) rated the terms obesity, fatness, and excess fat significantly more (all p ≤ 0.005) negatively than did the extremely obese women (N = 105). Thus, whereas both groups of women found the three terms undesirable, women with a BMI of 30 to 40 kg/m2 found the descriptors even more undesirable than did the extremely obese women. No other significant differences were observed between the two groups of women.
Differences Related to Ethnicity
Examining all women together (N = 272), only one statistically significant difference was found between white (N = 214) and African-American (N = 51) women's ratings of the descriptors. African-American women rated unhealthy body weight (−0.6 ± 1.1) as undesirable, whereas their white counterparts judged it essentially neutral (0.1 ± 1.3; p ≤ 0.005). Similarly, African-American women tended to rate unhealthy BMI as more undesirable than white women rated it (−0.9 ± 1.2 vs. −0.3 ± 1.2), although the difference was not significant at p ≤ 0.005, the criterion selected a priori. (The p value was < 0.01.)
Obese women and men in this study rated the terms fatness and obesity as undesirable to very undesirable descriptors for their doctors to use in discussing body weight. Such terms may well be hurtful or offensive to obese individuals because of their pejorative connotations in everyday use. Primary care practitioners’ use of such descriptors could bring to an abrupt halt a needed discussion of an important topic. The terms excess fat, large size, and heaviness also elicited undesirable ratings.
By contrast, women and men both rated the descriptors weight, excess weight, and BMI as neutral to desirable. Of these, weight was the clear winner, receiving a rating of desirable or better from both genders. We believe that this term was rated favorably because it is nonjudgmental and easily understood. BMI also would seem to be a nonjudgmental term but one that is not universally known. Its acceptability may increase further as more health care providers use the term.
Our group of extremely obese women, who were candidates for bariatric surgery, provided ratings that were similar to those of our women with BMIs of 30 to 40 kg/m2. Thus, they viewed as undesirable the terms fatness, excess fat, and obesity. Their ratings, however, were significantly less negative than those of women with BMIs of 30 to 40 kg/m2. The reasons for this difference are not clear but may reflect bariatric surgery patients’ having become inured to negative descriptors. These patients are routinely referred to as morbidly obese, which may render obesity or fatness less harsh by comparison.
Johnson (15) has noted that some size-acceptance activists prefer to be called fat or large (or even plus-sized). By embracing these terms, they strive to remove the stigma and negativity attached to them. Our sample, of extremely obese women, however, rated fatness, excess fat, and large size as their three most undesirable terms. These descriptors were similarly unpopular with women and men with BMIs of 30 to 40 kg/m2.
This study has several limitations. The first is its relatively small sample. The findings need to be replicated in additional samples to determine whether there are differences in patients’ preferred terms based on age, BMI, gender, socioeconomic status, geographic region, or ethnicity (i.e., African American, Hispanic American, Native American, etc.). This study revealed very similar responses among African-American and white women, but there were relatively few African-American respondents. Second, all participants in the present investigation sought treatment for their obesity. Studies are needed of obese individuals who do not seek weight reduction, because these are the very persons with whom primary care physicians may need to broach the topic of body weight. Third, additional methods, including open-ended questions, should be used to determine patients’ most and least preferred terms for describing their excess weight. There may well be descriptors that patients find more desirable than weight. Fourth, future studies also should assess the desirability of the term overweight, which is used to characterize individuals with a BMI of 25.0 to 29.9 kg/m2. This descriptor was not assessed in the present study because several pilot respondents thought that the sentence “I want to talk with you about your overweight” sounded awkward. Studies also will need to identify the terms that overweight individuals (i.e., BMI of 25.0 to 29.9 kg/m2) prefer to use to discuss their excess weight.
Given our nation's rapidly advancing epidemic of obesity (8), research is urgently needed on the role that primary care practitioners can play in the prevention and treatment of this disorder (4, 6, 22). Whatever the role, however narrow or broad, it will have to begin with the practitioner's initiating a conversation with the patient about weight. In the absence of empirical findings to guide practice, we believe that the discussion might best be broached in the following manner: “Mr. Jones, could we talk for a moment about your weight? Tell me your thoughts about your weight at this time.” With this approach, the practitioner seeks the patient's agreement to discuss this topic and then asks for his or her thoughts, rather than reciting the health hazards of obesity or pressing the need for weight reduction. If practitioners know that a patient has lost weight before, only to regain it, they could state, “Tell me your thoughts about your weight at this time. I know how hard you've worked in the past to control it. What are your goals now?” This approach, in addition to being open ended, seeks to convey empathy and respect for the patient's prior efforts.
Obese individuals do not feel that their practitioners fully understand how much they struggle with their weight (23, 24). In addition to inviting patients to discuss the challenges of weight management, health care providers can implicitly communicate their respect and concern for obese persons by ensuring that their offices meet the physical needs of larger individuals. This is facilitated by providing sturdy armless chairs, appropriately sized blood pressure cuffs and examination gowns, and a scale that can measure persons of all body weights (25). Perhaps most important, practitioners can communicate their respect by providing obese individuals the same medical care for hypertension, type 2 diabetes, hypercholesterolemia, and related conditions that they provide nonobese patients who present with these conditions.
Some practitioners, as well as laypersons, may believe that our concerns about the terminology of body weight tiptoe around the serious complications posed by obesity or do not confront patients with their failures to control their eating and activity habits. Why call obesity anything but obesity? In this view, similar to that for the treatment of addictions, patients need to hear and acknowledge that they are obese as a first step toward addressing their problem. There are, however, at least two limitations with this view. First, the “call-it-what-it-is” approach fails to recognize the offensive, derogatory manner in which the terms fatness and obesity are used by the public (15, 16, 17, 18, 19). It is difficult for patients to hear the medical implications of these terms, separate from their demeaning moral and esthetic connotations, as used by the public. Second, in our experience, the confrontational approach simply does not work; it is far more likely to result in hurt feelings than weight loss. We agree with Johnson (15) that, “Practitioners who insist that they are breaking through patients’ denial by calling them obese should realize that what they are more probably breaking is the patient's trust and desire to return for further care.” This is particularly likely when patients are told that they are obese, are exhorted to lose weight or face dire medical consequences, and then are provided minimal or no assistance with weight management. We believe that the use of motivational interviewing, rather than confrontation, will facilitate a more favorable discussion and outcome (26, 27).
Primary care practitioners currently may not know how best to help obese patients manage their weight. Results of this study, however, suggest steps that may be taken to at least reduce the likelihood of doing harm when broaching this topic.
This study was supported, in part, by Grants DK56114 and DK56124 from the National Institute of Diabetes Digestive and Kidney Disease and by an unrestricted educational grant from Abbott Laboratories. We thank Dr. Silas Halperin for statistical consultation and Vicki Clark, Leanne Magee, Rebecca Rothman, and Stephanie Sargent for assistance with data collection and management.