Talk to users about weight

[juliaspiess-bjss]

What

How we talk to people about their weight or describe people's weight sensitively and inclusively

Context:

• The following recommendations are based on user research and a comms guide review done by the Tools Team in Q2/2024. The research was part of the transformation of adult BMI and child BMI tools, and Live Well content pages. Initiated by our clinical team, to review how we use the word obese and obesity and avoid weight stigma.
• This is intended as a starting point to adopt a more sensitive and inclusive language and could benefit from additional input from other teams that tested and transformed weight content recently.
• All terms marked with * are verified and the evidence can be found here. These terms passed a content crit and were tested with users. User feedback was collected in the context of an NHS.UK service. This can be a qualitative or quantitative user test, an analysis of service desk tickets or internal search words.
• The labels BMI, CBMI, LW = mean this copy is used in adult BMI, child BMI, or Live Well and has been approved by content designers, clinicians and policy.

Disclaimer:
The most appropriate language is personal, political and context-dependent. Some examples: While Healthcare Professionals (HCPs) regard ‘obesity’ as a neutral term, people with higher weights do not seem to like it and associate it with increased societal disapproval. While WHO classed obesity as a chronic disease and highlighted the need for sensitivity, some fat activists view the terms 'obese' and 'overweight' as problematic, because overweight is treated as something that needs to be prevented and cured. While the terms 'plus size', 'full size' or 'curvy' are often used in the fashion industry; in other contexts, they may be seen as euphemisms and should be avoided.

When to mention weight

We mention weight only when it’s relevant to our content. Discussing someone’s health does not necessarily mean weight needs to be addressed. Also, discussions of weight can harm people with eating disorders.

How to mention weight

Our priority is health. We don't talk about appearance and looks, and avoid terms that focus too much on physical appearance. We try not to label people and instead of 'You are overweight' we prefer to say

Your result suggests you are in the overweight range. BMI

Terms to use when talking to or describing people with low weight

• underweight*
• gain weight healthily/ safely, healthy ways to gain weight *
• Children who have low weight , low birth weight - is used for children
• people who are underweight
• people with/who have low weight

We don't say

• below a healthy weight*
• low BMI* - this is only used in the context of BMI results
• unhealthy weight
• people with less weight, people who have/with lower weight - unclear, compared to what?
• smaller-bodied people, people with small/smaller bodies
• people who lost too much weight
• living with underweight - 'living with' is only used for conditions

Terms to use when talking to or describing people with high weight

• overweight*
• people with high weight
• people living with obesity
• gained too much weight, too much weight for his/her age - is used for children

We don't say

• above a healthy weight, unhealthy weight*
• high body mass index, high BMI* - are used only in the context of the BMI calculator
• fat people, heavy people, and obese people - are commonly used terms, but not recommended on NHS.uk
• weight problem
• plus-size, curvy and full-size
• higher-weight people, people with higher weight
• excess weight
• larger-bodied people, people in larger bodies, larger-size people, people of size

Terms to use when talking to or describing people with very high weight
This topic has not been researched yet

How to use the term 'obese'

• We don't use the word obese or obesity in the first paragraph. If we need to use it, we mention it later, e.g. after calculating a BMI:

Your result suggests you are living with obesity. BMI

• We use the words obesity or obese only when people have searched for this content, classified themselves as obese or given us information to suggest they fall into this weight range.
• We balance a direct, serious tone with encouragement and motivation. We try to remain constructive while delivering 'bad news'.

How to talk about weight loss or weight gain

Set the scene with health.

• We prioritise long-term health benefits, over weight loss or weight gain:

Working towards a healthier weight range could strengthen your immune system.

• We focus on healthy habits and quality of life:

You can help the child reach a healthy weight by: Exploring healthy recipe ideas, food swaps, and activity ideas on NHS Healthier Families. CBMI

• Weight is not a behaviour and should not be a target for behaviour change – weight gain may or may not happen when people eat food high in calories and build muscle mass.
• When talking about weight gain, underweight people typically use the words 'gain weight healthily/ safely' or 'healthy ways to gain weight' *

Be extra sensitive when talking about children's weight

• We avoid increasing the focus on 'the result' among children. We focus on the parents who have the biggest impact on their lifestyles - and stay empathetic.

It can be hard to encourage young people to live a healthy lifestyle. CBMI

• Telling children they are overweight needs to be handled with care and teaching parents how to have a conversation with their child about healthy living is crucial.
• We focus on healthy growth and acknowledge that weight might still fluctuate a lot.

It's not always easy to tell if toddlers and young children are gaining weight too quickly. Checking their BMI every year can help you understand how they're growing. CBMI

• We emphasize the journey - a measurement result is a snapshot of the child 'right now' - with plenty of opportunity to change things.
• Reframe the 'bad news' into an opportunity to manage weight early. The RedBook is a good example as parents associate it with measuring progress - a snapshot in time rather than a verdict.

Identify people who might feel offended or excluded

• Parents of children who are overweight or underweight: When they receive the weight result, parents show strong emotional reactions ranging from anger to disbelief, denial and hurt. They tend to take it personally and feel judged as a parent. They receive the result with an air of finality, rarely perceived to offer hope or positivity. Their interpretation is highly subjective and prone to error. Some parents can potentially give their children a complex about their weight too.
• People with underweight: Gaining weight is as much of a concern to underweight users as losing weight is to others. If possible, we stay neutral and talk about both, until we know which journey people are on. We try to be inclusive of underweight people who are only 1-2% of the population.
• People with conditions that can cause weight changes: These could be mental health conditions, digestion problems, an overactive thyroid, type 2 diabetes, or heart failure. Or life stages like puberty or menopause.
• People with eating disorders: Some people might be triggered by content about body size, weight and calories. It might worsen their anxiety or make recovery more difficult.
• People from low socio-economic backgrounds: this topic has not been researched yet

Why

• We need a more sensitive and inclusive approach when talking to or describing people's weight
• Weight is a sensitive topic and especially people with overweight often experience weight stigma and discrimination.

Other information to support your proposal

Summary Reports - Start here

• Weight Language Evidence - Summary all below-mentioned research reports 08/2024
• Obesity and Language Literature Review - Summary of all below-mentioned literature review sources

Research Reports

• Empowering Users Living with Obesity - Clinician's recommendations on how to use the term obese
• NCMP and Change4Life. Qualitative Research Debrief - Parents's Experience of NCMP, May 2016
• Discovery 1 - User interviews Round 1 - Planning, Guides and results - NHS.UK BJSS Projects - CDT Confluence (digital.nhs.uk) - CBMI tool, As-Is version, Dec 2023/ Jan 2024
• Discovery 2 - Insights and recommendations - NHS.UK BJSS Projects - CDT Confluence (digital.nhs.uk) - CBMI tool, Prototype 1, February 2024
• Discovery 3 - User interviews round 2 - Results - NHS.UK BJSS Projects - CDT Confluence (digital.nhs.uk) - CBMI tool, Prototype 2, May 2024
• Discovery 3 - Analysis Mural Bord

Literature Review

• COP (squarespace.com)​
• Department of Health and Social Care ​
• http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf ​
• Palad CJ, Stanford FC. Use of people-first language with regard to obesity. Am J Clin Nutr. 2018;108(1):201–203.
• European Practical and Patient-Centred Guidelines for Adult Obesity Management in Primary Care (karger.com)
• Swiss Consensus for Obesity Management. 2016, http//:www.sgedssed.ch/consensus-obesité (in French and German, accessed Dec. 2017).​
• Australian National Health and Medical Research Council, Summary Guide for the Management of Overweight and Obesity in Primary Care, Dec 2013. https://nhmrc.gov.au/sites/default/files/documents/reports/ clinical%20guidelines/n57b-obesity-guidelines-summary.pdf (accessed December 18, 2018)​
• (PDF) Obesity stigma: Prevalence and impact in healthcare (researchgate.net)​
• Puhl R, The stigma of obesity: a review and update, Obesity journal, May 2009, vol. 17, issue 5, p 941-964
• Flint S. Obesity stigma: prevalence and impact in healthcare. British Journal of Obesity. 2015;1:14–8.
• ucher Della Torre S, Courvoisier DS, Saldarriaga A, Martin XE, Farpour-LambertNJ. Knowledge, attitudes, representations and declared practices of nurses and physicians about obesity in a university hospital: training is essential. Clin Obes. 2018Apr;8(2):122–30.
• Obesity, Stigma... in Publications – Dimensions​
• obesity stigma in Publications – Dimensions​
• patient centred... in Publications – Dimensions​
• https://www.bda.uk.com/news-campaigns/campaigns/managing-and-preventing-obesity/eliminating-weight-stigma-comms-guidelines.html​
• Weight Stigma in Youth: Prevalence, Consequences, and Considerations for Clinical Practice | Current Obesity Reports (springer.com)
• Puhl_et_al-2009-Obesity-libre.pdf (d1wqtxts1xzle7.cloudfront.net)​
• The Use of Effective Language and Communication in the Management of Obesity: the Challenge for Healthcare Professionals - PMC (nih.gov)​
• The impact of obesity on perceived patient‐centred communication (wiley.com)​
• MAC01741_NN_UK_HCP_Obesity_Guidelines_FA1a (easo.org)​
• Frontiers | Communicating Risk for Obesity in Early Life: Engaging Parents Using Human-Centered Design Methodologies (frontiersin.org)
• User Interviews - Planning, Guides and results - NHS.UK BJSS Projects - CDT Confluence (digital.nhs.uk)​
• “Fat is really a four‐letter word”: Exploring weight‐related communication best practices in children with and without disabilities and their caregivers - McPherson - 2018 - Child: Care, Health and Development - Wiley Online Library
• Barriers to and facilitators of nurse-parent interaction intended to promote healthy weight gain and prevent childhood obesity at Swedish child health centers | BMC Nursing | Full Text (biomedcentral.com)
• Parental support in childhood overweight and obesity: the More and Less study - Uppsala University (uu.se)
• Health First: Communicating about health and obesity (publichealthscotland.scot)
• Change the story. Change the world. - FrameWorks UK
• Eliminating weight stigma - guidelines for BDA communications - British Dietetic Association (BDA)
• Managing and Preventing Obesity - British Dietetic Association (BDA)
• HV_Language_guidelines.pdf (worldobesity.org)#
• European Commission classifies obesity as a chronic disease - The Lancet Diabetes & Endocrinology
• 3 Palad CJ, Stanford FC. Use of people-first language with regard to obesity. Am J Clin Nutr. 2018;108(1):201–203.
• Children's, Parents' and Healthcare Professionals' Preferences for Weight-Based Terminology in Health Care - PubMed (nih.gov)​
• Toward Sensitive Treatment of Obese Patients | AAFP
• Preferences and emotional response to weight‐related terminology used by healthcare professionals to describe body weight in people living with overweight and obesity (wiley.com)
• Physicians build less rapport with obese patients - PMC (nih.gov)
• local consensus process making use of focus groups to enhance the implementation of a national integrated health care standard on obesity care | Family Practice | Oxford Academic
• General practitioners' and district nurses' conceptions of the encounter with obese patients in primary health care - PubMed (nih.gov)
• A Practical Guide to Engaging Individuals with Obesity - PMC (nih.gov)
• Physicians' Beliefs about Discussing Obesity: Results from Focus Groups - Stewart C. Alexander, Truls Østbye, Kathryn I. Pollak, Margaret Gradison, Lori A. Bastian, Rebecca J. Namenek Brouwer, 2007 (sagepub.com)
• Barriers and enablers to managing obesity in general practice: a practical approach for use in implementation activities - PubMed (nih.gov)
• Communicating with children and families about obesity and weight‐related topics: a scoping review of best practices - McPherson - 2017 - Obesity Reviews - Wiley Online Library
• Communicating with children and families about obesity and weight‐related topics: a scoping review of best practices - McPherson - 2017 - Obesity Reviews - Wiley Online Library
• A systematic review of motivational interviewing for weight loss among adults in primary care - PMC (nih.gov)
• Do weight perceptions among obese adults in Great Britain match clinical definitions? Analysis of cross-sectional surveys from 2007 and 2012 | BMJ Open
• https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=Overview,deposits%20that%20can%20impair%20health.​​ Children's, Parents' and Healthcare Professionals' Preferences for Weight-Based Terminology in Health Care - PubMed (nih.gov)​ Toward Sensitive Treatment of Obese Patients | AAFP​Physicians build less rapport with obese patients - PMC (nih.gov)