How Medical Writers Can Write About Weight Without Causing Harm

How medical writers describe weight, weight loss, and weight maintenance shapes readers’ knowledge and attitudes. Growing research also shows that how we (and all media) write and portray individuals affected by overweight and obesity directly impacts their health. Learning to write empathetically and without bias about weight can prevent medical writers from inadvertently contributing to weight stigma.

What is weight stigma?

Weight stigma is discrimination or stereotyping based on a person’s weight (1). It is the same as weight bias or weight-based discrimination. People of all genders, ages, races, and backgrounds globally experience weight stigma. An example of weight stigma is the assumption that someone with obesity is lazy, lacks willpower, or has low levels of intelligence.

Weight stigma in medical writing came into play once the medical field defined obesity as a disease and a public health epidemic in the US in the 1990s (2). Weight stigma can play out in health writing and provider-patient interactions if writers or providers assume that a person’s excess weight necessarily causes a medical condition. While it is true that obesity causes some diseases such as diabetes, heart disease, or high blood pressure, there are many diagnoses for which dieting and weight loss are not the only treatments.

Weight stigma dehumanizes people living in larger bodies, changing how others treat them. People in larger bodies feel blamed and ignored by healthcare providers and the healthcare system that only addresses their health concerns or complaints as being weight-related. Dehumanization and stigmatization are harmful to mental and physical health (3,4).

Why is weight stigma a health hazard?

Weight stigma has been shown to increase a person’s chances of:

1. Receiving inadequate or dismissive healthcare (2).

2. Avoiding healthcare (emergency and routine preventative) (2).

3. Weight cycling and worsening obesity (3).

4. The development of binge-eating disorders and other eating disorders (1).

5. Depression, anxiety, substance abuse, and suicidality (4).

When individuals with obesity avoid or delay health care services, the development of obesity-related comorbidities may go unnoticed, progress in severity, and become more challenging to treat.

Why what and how you write about obesity matters

Since the rise of national obesity prevention campaigns and the use of language such as the “obesity epidemic,” the reports of weight-based discrimination have increased by about 66 percent, according to the National Eating Disorders Association (5). US adults reported weight bias as the fourth most common form of discrimination they experienced in 1995-1996, a frequency that has undoubtedly increased in subsequent years (5). How and what medical writers write about obesity contributes to:

●     Amplification or legitimization of potentially harmful obesity-related language, labels, or terminology.

●     The establishment of cultural norms surrounding dieting, weight loss, and body positivity.

●     Formation and maintenance of attitudes and implicit biases (such as being overweight is a choice).

●     The policies, structures, and types of care delivered by healthcare providers, insurance companies, and healthcare systems.

●     The framing of the causes of and solutions for obesity in ways that reinforce stigma (6,7).

●     Weight stigma that causes discrimination and anti-fat bias.

In their 2018 appeal to the media, Lancet contributors wrote, "The media portrayal of obesity – often stigmatizing and inaccurate – is influential and insidious to popular belief. Yet publishers and editors rarely challenge this media content, and so a stream of derogatory articles floods into mainstream media.”(6)

Tips for Writing About Obesity

In 2012, The Rudd Center for Food Policy and Obesity, The Obesity Society (TOS), Obesity Action Coalition (OAC), the Obesity Medicine Association (OMA), and the American Society for Metabolic and Bariatric Surgery (ASMBS) released their Guidelines for Media Portrayals of Individuals Affected by Obesity. Some tips it offers for medical writers are (7):

1. Avoid using weight-based stereotypes (such as people with obesity lack willpower.

2. Respect the diversity of people who are obese (men, women, old, young, all races and ethnicities.

3. Portray people with excess weight or obesity as persons with professions, expertise, authority, and skills in various activities and settings.

4. Do not use descriptions of a person’s body weight that imply negative assumptions about their character, intelligence, abilities, or lifestyle habits.

Others from the healthcare, anti-diet, and body-positive communities encourage medical and health writers to:

1. Ask interview subjects what term(s) they prefer to be used when describing their body weight (if they are a person in a larger-sized body), but only if their weight is relevant to your story (9).

2. Know your biases – you have them even if you don’t think you have any (1,8-9).

3. Do your research. Base your stories, articles, and reports about obesity on credible scientific findings and evidence-based research (9).

4. Identify the funding source of any science you cited and be aware of potential conflicts of interest related to the scientific research findings (9).

1. Don't assume anything about a person based on their body size (7).

2. Avoid implying that all people with overweight and obesity have a desire to lose weight (7).

3. Avoid combative language when referring to efforts to reduce the prevalence of overweight and obesity (e.g. “the war on obesity”’ or “the battle of the bulge”) (7).

4. Avoid judging people negatively because they’ve chosen to use medical tools like surgery or medication to treat obesity. No one method, treatment, or diet will be right for all (9).
   

New Terms to Add to Your Lexicon

●     People-first language- putting individuals before the disability or disease (people with obesity vs. obese people)(10).

●     Weight stigma- discrimination or stereotyping based on a person’s weight or size; the same as anti-fat bias, fat-phobia, and sizeism (3).

●     Body positivity- a social movement geared towards acceptance of bodies of all sizes and types rather than those that conform to societal ideals of beauty (10).

●     Body neutrality- a path individuals take to feel comfortable with their body, focusing on function rather than appearance, without the expectation of specific feelings toward the body, such as positivity. Considered a more realistic goal for those who have struggled with eating disorders or a history of trauma (11).

●     Anti-diet framework- (from Health At Every Size HAES). An approach that centers the whole person and their overall health, encourages intuitive eating, and removes the focus from body weight and prescriptive eating plans (10).

Do’s and Don’ts of Writing About Obesity and Overweight

Do Use/Write	Don’t Use/Write
Weight	Weight problem
Excess weight	Severely obese, Morbidly obese
Body Mass Index (BMI)	Fat, Morbidly obese
People in larger-sized bodies	Overweight or Obese People
People with overweight or obesity	Overweight or Obese People

A few words about fat-acceptance, BMI-backlash, why some writers use ob*sity, ob*se, and overw*ight

The recent controversy over the latest weight-loss drugs (GLP-1 agonists such as semaglutide) highlights our culture’s current disagreement as to whether or not obesity should be considered a disease. In 1998, at the height of the low-fat diet craze, the National Institutes of Health approved BMI as the standard measurement of health. Critics of BMI, obesity, and overweight assert that these terms were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness (11).

BMI is the default measure for obesity because it is the easiest and cheapest way to measure body fat. Using BMI, healthcare providers can easily put people into risk categories using the same measurement across a range of patients. However, BMI is not an accurate measure of individual health or body fat. At the same BMI, women have, on average, more body fat than men, and Asians have more body fat than whites (13, 14, 15). BMI scales do not take into account race or sex. Recent studies of BMI and health indicators (blood sugar, cholesterol, and blood pressure) found that more than half of people considered overweight by BMI were healthy by these other indicators (16).

Critics of BMI, with its clinical categories of obese and morbidly obese, choose not to write these terms and instead use a different spelling to indicate their objection to their continued use. This is where ob*sity, ob*se, and overw*ght spellings come in. They argue that seeing or reading these biased and racialized terms could re-traumatize readers with larger bodies or diverse races and ethnicities (8,10,11).

Choosing whether or not to use the word “fat” has similarly become divisive among health and medical writers. Fat activism began in the 1960s as a social justice movement to advance the rights of overweight individuals and eliminate the social stigma of being overweight. Some fat-activist writers may use fat as a neutral descriptor, but writers should do so cautiously. While using the words “fat” or “fatness” might be acceptable to individuals who identify with the Fat Acceptance movement, these terms can be offensive to others. Know your audience.

The same is true when deciding whether to use obese, obesity, obesity epidemic, and overweight. The World Obesity Foundation Media Guidelines advise, “While clinical terms to describe various degrees of obesity are appropriate when used in the scientific community, these terms may be viewed as pejorative to other public audiences.” Again, use clinical terms with caution and know your audience.

How can medical writers make a difference?

As journalists, reporters, and writers, we have an ethical and professional duty to write accurately and fairly about obesity and people impacted by obesity while not causing them more harm. You should aim to avoid further stereotyping or perpetuation of harmful stereotypes with the words you choose. Represent all persons equitably and accurately in your writing, regardless of their body weight. As scientific writers, use your training to identify biased research, your words to amplify inaccuracies in study findings or the way research is interpreted, and commit to presenting balanced coverage of health, body weight, size, and obesity.

Because obesity’s causes and solutions are complex. The media guidelines referenced below and Lancet’s editorial both challenge medical writers to seek multiple perspectives and commit to comprehensive reporting about obesity. Because of structural barriers to weight loss and health, such as food insecurity or increased stress related to racism, writers must remove the focus from individual-focused blaming and shaming. Focusing on the individual also prevents thinking about larger societal solutions at a structural and systemic level. As ethical writers, recognizing your biases around body weight, size, and health will help you better tell the complex story of obesity in our culture.

Sources

1. Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review. Prim Health Care Res Dev. 2019 Jul 22;20:e116. doi: 10.1017/S1463423619000227. PMID: 32800008; PMCID: PMC6650789. https://pubmed.ncbi.nlm.nih.gov/32800008/

2. Andreyeva, T, Puhl, R, and Brownell, K. Changes in perceived weight discrimination among Americans, 1995–1996 Through 2004–2006. Obesity. 2008;16: 1129-1134. https://doi.org/10.1038/oby.2008.35

3. Tomiyama A, Carr, D, Granberg, E. et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med. 2018 August 15;16:123.https://doi.org/10.1186/s12916-018-1116-5

4. Hatzenbuehler ML, Keyes KM, and Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity. 2012 September 10;17: 2033-2039. https://doi.org/10.1038/oby.2009.131

5. Weight stigma. National Eating Disorders Association (NEDA). Published 2022. Accessed May 8, 2023. https://www.nationaleatingdisorders.org/weight-stigma

6. Flint, SW, Nobles G, Gately P, et al. Weight stigma and discrimination: a call to the media. Lancet. 2018 March; 6(3):169-170. https://doi.org/10.1016/S2213-8587(18)30041-X

7. Guidelines for Media Portrayal of Individuals Affected by Obesity. Obesity Action Coalition (OAC), The Rudd Center for Food Policy and Obesity, The Obesity Society (TOS), Obesity Medicine Association (OMA), and American Society for Metabolic and Bariatric Surgery (ASMBS). Published 2012. Accessed May 2023. https://www.obesityaction.org/wp-content/uploads/Guidelines-for-Media-Portrayals-of-Individuals-Affected-by-Obesity-2016.pdf

8. Health At Every Size© Principles. Association for Size Diversity and Health (ASDAH). Accessed May 2023. https://asdah.org/health-at-every-size-haes-approach/

9. Media guidelines: Avoiding weight stigma and discrimination. World Obesity Foundation (WOF). Accessed May 2023. https://obesitycanada.ca/wp-content/uploads/2020/02/WOF_Media_guidelinesDev1-1.pdf

10. People first language. Obesity Action Coalition. Accessed May 2023. www.obesityaction.org/weight-bias-and-stigma/people-first-language-for-obesity.

11. Strings, S. Fearing the Black Body: The Racial Origins of Fat-Phobia. NY, NY:NYU Press; May 7, 2019. 296p.

12. What’s the difference between body positivity and body neutrality? The Cleveland Clinic. Published April 22, 2022. Accessed May 8, 2023. https://health.clevelandclinic.org/body-positivity-vs-body-neutrality/

13. Caleyachetty R, Barber TM, Mohammed NI, et al. Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England: a population-based cohort study. Lancet Diabetes Endocrinol. doi:10.1016/S2213-8587(21)00088-7

14. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 363(9403):157-163. doi:10.1016/S0140-6736(03)15268-3.

15. Karnes JH, Arora A, Feng J, et al. Racial, ethnic, and gender differences in obesity and body fat distribution: An All of Us Research Program demonstration project. PLoS One. 2021;16(8):e0255583. Published 2021 Aug 6. doi:10.1371/journal.pone.0255583.

16. Stefan N, Haring HU, Hu F, Schulze M. Metabolically healthy obesity: epidemiology, mechanisms, and clinical implications. Lancet: Diabetes and Endocrinology. 2013; 1(2): 152-162. DOI:https://doi.org/10.1016/S2213-8587(13)70062-7