Championing the use of people‐first language in childhood overweight and obesity to address weight bias and stigma: A joint statement from the<scp>European‐Childhood‐Obesity‐Group</scp>(<scp>ECOG</scp>), the<scp>European‐Coalition‐for‐People‐Living‐with‐Obesity</scp>(<scp>ECPO</scp>), the<scp>International‐Paediatric‐Association</scp>(<scp>IPA</scp>),<scp>Obesity‐Canada</scp>, the<scp>European‐Association‐for‐the‐Study‐of‐Obesity Childhood‐Obesity‐Task‐Force</scp>(<scp>EASO‐COTF</scp>), Obesity Action Coalition (<scp>OAC</scp>), The Obesity Society (<scp>TOS</scp>) and the<scp>World‐Obesity‐Federation</scp>(<scp>WOF</scp>)

Abstract

Leading voices in the field of obesity research and clinical practice have called for the use of person-first and patient-first language in overweight and obesity clinical practice, research, education, and advocacy communications. While this has been a clear and consistent message in the context of adult obesity,1-7 we here aim to highlight the importance of people-first language for childhood obesity. Obesity is a chronic, complex, neurometabolic disease whereby an abnormal or excessive accumulation of body fat results in risk to health. People-first terminology appropriately acknowledges individuals first and avoids defining them by their disease,8 for example, using the term ‘people with obesity’ instead of ‘obese people’. By extension, respectful person-first communication uses this patient-centred over euphemistic terms or emotional labels that suggest victimization or helplessness.9 In contrast, identity-first or disease-first language puts the illness or disability before the noun referring to the person.10 The use of compassionate, patient-centred language and imagery is considered a core strategy for addressing weight bias and obesity-related stigma.11, 12 Weight biases are the negative stereotypes, attitudes and beliefs about a person based on their body weight or body size.13 Biases are largely based on misconceptions of obesity being the result of individual weakness and consequently being an individual's responsibility to address, that fail to consider it is a disease with complex biological, genetic, psychosocial and environmental drivers.12 Weight biases manifest into actions and behaviours, such as weight-related stigmatization, teasing, bullying, social rejection, and discrimination in education, employment, and health care.14 Weight bias, stigma and weight-based discrimination create health, social and economic inequities, and therefore preventing bias and stigma should be prioritized.15 While all individuals are today prone to weight biases, children are particularly predisposed.16 Children's perceptions of discrimination can develop early in life,17 with some authors identifying expressions of weight-stigma and bias from the age of 3.18 Regardless of the time of exposure of stigma during the child's life, its impact has serious lifelong consequences including psychological distress, poorer social and academic outcomes, and adverse physical consequences impacting personality development, self-image, self-esteem and confidence, and overall quality of life.11 Children may experience stigmatizing language and behaviours in a variety of settings – from peers and educators in the school environment, to parents and family members at home.16 Social media platforms and movies and television shows targeted at children often reinforce weight biases.19-22 Stigmatizing language and behaviours are not restricted to social domains, but have also been extensively documented in healthcare settings and among staff in the clinical management of obesity.16 One study found that among adolescents living with obesity, the use of stigmatizing language triggered responses, such as sadness, embarrassment or shame.23 Parents and children who experience weight stigma in healthcare settings may delay or avoid seeking care, which can have serious consequences for their health and well-being.23 Weight stigma is also associated with poorer weight management outcomes for patients with obesity who are less likely to access care or adhere to treatment. The use of respectful, and non-stigmatizing language is important for the effective prevention, treatment and management of obesity. The American Academy of Pediatrics and The Obesity Society have published a policy statement on ‘Stigma Experienced by Children and Adolescents with Obesity24’ and the Canadian Obesity Clinical Practice Guidelines recommend that healthcare providers avoid using judgmental words, images and practices when working with patients living with obesity.25 However, despite multiple calls to academic institutions, public health-authorities, professional organizations including healthcare, media, public health services and governing bodies, to adopt a public narrative about childhood obesity that reflects the current scientific knowledge of the disease, progress remains slow. Indeed, a recently published study found very low adherence to patient-centred language in childhood obesity-related academic research published between 2018 and 2020 and available on PubMed, with a majority of the articles including stigmatizing non-patient-centred labels.26 However, among pediatric obesity articles indexed in PubMed over the last 20 years, we see a sharp decline in the use of non-patient-centred language in the titles of peer-reviewed papers from 2014 onward (Figure 1). Interestingly, 2019 represents the first time that a higher number of publications used people-first language in their titles than those that did not. These encouraging trends could be attributed to the decisions of the main obesity journals to enforce in their editorial policies the use of people-first language, altogether with the intensive campaigned advocating for its use by the main international organizations and societies (as during the 2019 European Congress of Obesity in Glasgow). However, there are still a substantial number of journals publishing articles that do not use people-first language in studies of children and adolescents with overweight and obesity. For instance, as of July 4th, 2022 32 papers were published on PubMed that did not use people-first language in their title and/ or abstract. While most obesity-oriented journals have person-first language policies, this does not extend to all journals. Also, implementation of these policies is inconsistent between journals. Indeed, all scientific journals that publish on the prevention, treatment or care of obesity must adopt and enforce people-first language policies, when publishing about patients with any disease, inclusive of obesity. This use of people-first language should also concern any conference presentation, spoken conversation, media articles or interviews (among other domains and context) in order to avoid the previously cited perception of discrimination and potentially increase this stigmatizing and reduce the positive impact and efficacy of educational, scientific or clinical actions. A recent analysis of the impact of Obesity Canada's (OC) strategic focus to reduce weight bias and obesity stigma through the adoption of a people-first-language policy in its obesity conferences, showed that over time, research abstracts had more mentions of weight bias, and a decrease in the use of disease-first terminology.27 This analysis also showed that adopting people-first language as a standard practice takes time and that clearly communicating and enforcing language policy changes is imperative for widespread adoption.27 It is imperative to continue to engage with children and adolescents with overweight and obesity, to ensure that they are central to the decisions around the use of person-first language, and that the linguistic framing of their condition reflects their preference.28 At the individual level, people-first-language is a sensitive discussion. Individuals living with obesity may have their own preferences about the terms or language they would prefer to use when discussing obesity with their healthcare provider. Some patients may prefer to use disease-first language (versus people-first language, e.g., I am a person living in a large body or I am a person living with obesity). Interestingly, Puhl and colleagues recently conducted a large online survey among US American adolescents and parents and highlighting the diversity of youth preferences and the need for individualized approaches that support effective parent and youth communication by using their preferred terms when discussing weight-related health.29 However, in research, education, clinical and policy/advocacy documents and presentations related to obesity prevention and management, people-first language should be a standard practice. Additionally, whether presentations, documents or having healthcare provider–patient conversations related to obesity, it is also important to be accurate with definitions, terms and language. For example, the term obesity and not ‘weight’ or ‘Body Mass Index’ (that are indicators used for the screening and diagnosis), should only be used when describing the disease of obesity. There is a need for extensive and continued education of all individuals who interact with children and adolescents with obesity across multiple settings, to minimize bias and stigma in their interactions. These individuals include healthcare staff, caregivers, teachers, coaches, peers, siblings, parents and families, who may, either directly or indirectly, contribute to stigmatization. In many instances, decision-making around food, activities, daily routines or social interactions is made by parents, legal representatives or other adults; therefore, supporting youth with overweight or obesity must involve multiple individuals who are educated well. Health professionals, caregivers and teachers should be educated on how best to support children with obesity at an individual and group level. Schools should include weight-based teasing in their anti-bullying policies. Teachers should also ensure that all children can be included and welcomed in school activities. This is particularly true for physical education teachers and sports/leisure instructors and coaches, whose classes potentially may inadvertently create stigmatizing situations. Such situations may include the targeting of children with overweight and obesity by asking them to perform extract drills or tasks, the exclusion rather than inclusion of children who may face physical, social and psychological barriers to participate in certain physical education or sports activities, biased teammate selection by peers or teasing and victimization based on weight, appearance30 or performance.31 Parents, siblings and families should also be provided with the skills needed to support young people in a way that is respectful (not only weight, also race, ethnicity, gender identity, age, religion etc.) inclusive and non-stigmatizing. In line with the United Nation Convention on the Rights of the Child,32 we believe that children and young people should not suffer bias or ‘discrimination of any kind, irrespective of the child's or his or her parent's or legal guardian's race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status’. Following the statements already initiated in adults,6 and facing the urgent need to end stigma surrounding obesity, particularly among children and adolescents, the European Childhood Obesity Group (ECOG), as the only international society entirely dedicated to Pediatric Obesity, invited the European Association for the Study of Obesity, the Childhood Obesity Task Force, the International Pediatric Association (IPA), Obesity Canada, the Obesity Action Coalition (OAC), The Obesity Society (TOS), and the World Obesity Federation (WOF)—to unite in their call for the use of person-first and people-first language and actions to minimize weight bias, stigma and discrimination by all individuals directly or indirectly engaged with children and adolescents with obesity. Obesity is a complex, systemic and chronic relapsing disease with many contributing factors that are beyond individual control.33 We collectively believe that ending the expression of weight bias and stigma in the form of pejorative language, coupled with positive action will contribute to the design, delivery and effectiveness of obesity interventions and management and will enhance social outcomes for all children regardless of their weight or disease status, while improving their health and well-being, growth and quality of life. The authors have no conflict of interest.

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