Children’s, Parents’ and Healthcare Professionals’ Preferences for Weight-Based Terminology in Health Care

ABSTRACT

The current study explored the preferences for and knowledge of weight-based terminology used in healthcare-related conversations, and descriptively compared the preferences of children, parents and healthcare professionals. In total, 86 children with overweight or obesity, 90 parents of children with overweight or obesity and 572 healthcare professionals indicated their preferences for 22 terms. When applicable, children and parents could indicate unfamiliarity with a term. Many children were unfamiliar with terms such as “adiposity^{“adipositas”}” (93%), “BMI” (60%) and “morbid obesity” (53%). Children, parents and healthcare professionals disliked “fat^adjective”. All groups liked the terms “healthier weight” and “above a healthy weight”. To conclude, children’s, parents’ and healthcare professionals’ preferences for weight-based terminology are predominately congruent, except for “BMI”. “BMI” is a popular term among healthcare professionals. It is recommended that healthcare professionals use terms that can be perceived as neutral or positive, such as “healthier weight”, as this may contribute to a positive conversation which may lead to better compliance, and to avoid terms that can be perceived as judgmental, such as “fat^adjective”, as this may worsen the dialogue and relationship between families and healthcare professionals, and increase weight-based stigma. Healthcare professionals should be aware that children may be unfamiliar with some terms.

Introduction

Healthcare professionals (HCPs) are responsible for discussing bodyweight with children (0–19 years) with overweight or obesity and their parents (McPherson et al., 2017). This can be a sensitive topic (Farnesi et al., 2012) and requires use of terms that are not perceived as judgmental (i.e. pejorative, stigmatizing or blaming), as these terms can reinforce weight-based stigma (Dutton et al., 2010; McPherson et al., 2017), and negatively impact the dialogue and the relationship between the family and HCPs (Gray et al., 2011; Puhl et al., 2011; Tailor & Ogden, 2009). It is crucial that HCPs are aware of the preferences of children and their parents regarding weight-based terminology (WBT). Various studies have shown that adolescents and parents prefer terms such as “weight”, “BMI”, “gaining too much weight” or “too much weight for his/her health” and disfavor terms such as “fat”, “chubby” or “obese” (Dutton et al., 2010; Eneli et al., 2007; Gray et al., 2011; Knierim et al., 2015; Puhl et al., 2017; 2011; Volger et al., 2012). Nevertheless, research regarding children’s WBT preferences and knowledge of WBT is limited (McPherson et al., 2017; Puhl & Himmelstein, 2018). Additionally, the preferences of children, parents and HCPs with regard to WBT have not yet been compared. Therefore, this study aims to explore the preferences and knowledge of WBT used in health care and to descriptively compare the preferences of children, parents, and HCPs in the Netherlands.

Materials and methods

Participants and procedure

The sample consisted of 86 children with overweight or obesity aged 7–19 years, 90 parents or caregivers¹ of children with overweight or obesity aged 6–19 years and 572 HCPs from eight different professions (see Table 1). The children and parents were recruited through a variety of weight management programs and through HCPs in the researchers’ professional network. All children were receiving or had received treatment for their weight at the time of the study. The HCPs who participated were recruited through their professional associations and through public health services across the Netherlands. All participants signed an informed consent form and parents were required to provide consent for their participating child. The institutional review board of the VU Medical Center waived the requirement of full medical ethical approval.

Table 1. Participant characteristics

	Children*	Parents	Healthcare Professionals
Total N	86	90	572
Age, M (SD)	11.65 (2.55)	43.78 (6.56)	42.35 (11.83)
7–13 years, n (%)	54 (64.3)	-	-
13–19 years, n (%)	30 (35.7)
Gender, n (%)
Female	47 (56.6)	66 (75.9)	528 (92.3)
Ethnicity^**, n (%)
Dutch	52 (60.5)	71 (83.5)	-
Parents born in the Netherlands,** n (%)
Mother	57 (68.7)	-	-
Father	58 (69.9)	-	-
Recruitment, n (%)
Community care	37 (43)	29 (32.2)	-
Primary care	1 (1.2)	1 (1.1)	-
Secondary care	36 (41.9)	35 (38.9)	-
Tertiary care	7 (8.1)	15 (16.7)	-
Online questionnaire	5 (5.8)	10 (11.1)	-
Education, n (%)
Low (≤ high school)	-	14 (17.3)	-
Middle	-	47 (58)	-
High (≥higher professional education)	-	18 (22.2)	-
Profession, n (%)
Community workers	-	-	34 (5.9)
Primary care provider	-	-	21 (3.7)
Dieticians	-	-	77 (13.5)
Physical therapist	-	-	37 (6.5)
Mental health professionals	-	-	69 (12)
Youth healthcare physicians (YHCPs)***	-	-	85 (14.9)
Youth healthcare nurses (YHCNs)	-	-	222 (38.8)
Pediatricians	-	-	27 (4.7)
Years of practicing profession, M (SD)	-	-	12.9 (10.52)

*65.1% of the children who completed the questionnaire had a parent complete the parental version of the questionnaire and 68.9% of the parents who completed the questionnaire had their child complete the child version of the questionnaire. Both parents participated in the case of five children, and one child participated together with both parents and two caregivers.

**The majority of the non-Dutch participants originate from Turkey or Morocco. There was no striking language barrier present.

***In the Netherlands, a YHCP works in the primary care setting and plays a supporting role in the healthy development of children for patients and their families. A pediatrician is a specialist in pediatric medicine and works in a hospital setting.

Measurements

All participants completed a Dutch questionnaire consisting of demographic questions and 22 terms that can be used to refer to bodyweight. The list of terms was developed by the authors and adapted after consulting with HCPs, children and parents. Participants rated the terms on a five point Likert scale, containing colored emoticons ranging from: ‘1ʹ = Very nice (dark green), ‘2ʹ = Nice (green), ‘3ʹ = neutral (yellow), ‘4ʹ = Not nice (orange) and ‘5ʹ = Not nice at all (red). Children and parents could also indicate if they were unfamiliar with a term, and whether HCPs had ever used a term they did not like (yes/no). HCPs provided their three most frequently used terms in their conversations with children and parents. Participants completed the questionnaire online (Qualtrics) or on paper. Descriptive statistics were used to analyze the results.

Translation

Since this is a study about Dutch weight-related words, translation into English is complex. Therefore, a bilingual speaker translated all Dutch weight-related terms into English. The weight-related words were then translated back into Dutch by someone else to check the translation.

Results

In total, 44.6% of the children (N = 74 for this item), and 37.0% of the parents (N = 81 for this item) experienced a HCP using a term they did not like.

The preferences of children, parents and HCPs per term, as well as the percentage of children and parents that indicated they did not know terms, are shown in Table 2.

Table 2. Preferences per group

Note: the weight-based terms are sorted on the percentage of children who answered ‘don’t know term’.

* These Dutch words are both translated into English as “fat”, but they are different parts of speech. The Dutch word, “dik” is an adjective, meaning “fat” while the Dutch word “vet” is a noun, meaning “fat”.

** These Dutch words are both translated in to English as “adiposity”. The Dutch term, ”adipositas” is the formal medical term for adiposity, whereas “vetzucht” is the more informal term for adiposity. No such informal term exists in English.

Unfamiliar

The terms that the majority of the children were unfamiliar with were “adiposity^{”adipositas”}”, “BMI”, “curvy” and “morbid obesity”. Only six words were known by all children: “weight”, “big”, “unhealthy weight”, “stocky”, “fat^noun” and “heavy”. Furthermore, many parents were unfamiliar with the terms “adiposity^{”adipositas”}” and “curvy”. Six words were familiar to all parents: “big”, “unhealthy weight”, “fat^noun”, “heavy”, “overweight” and “healthier weight”. The HCPs scored most of the terms that at least a quarter of the children were unfamiliar with as not nice (at all), except for the terms “BMI” and “obesity”. Most HCPs scored “BMI” as (very) nice. HCPs scored the term “obesity” as (very) nice as frequently as they scored it as not nice or not nice at all.

Not nice (at all)

Of the remaining terms that most children did know, the opinions of children, parents and HCPs were in the same range. “Fat^adjective”, “fat^noun”, “adiposity^{”vetzucht”}” were most often scored as not nice at all, and “chubby” was scored most frequently as not nice at all by children, and as not nice or not nice at all by parents and HCPs.

(Very) nice

The term that was scored as very nice by most of the children and HCPs, and was scored as nice by most parents, was “healthier weight”. All groups scored the terms “weight”, “above a healthy weight”, “stocky” and “big” most often as nice or very nice.

Differences between children, parents and HCP’s

A few differences were found between the three groups, among the terms which most children (i.e. 96% of the children or more) were familiar with. First, almost half of the children scored the term “weight problem” as not nice (at all), while almost half of the HCPs scored this term as (very) nice. Second, more than one third of the children scored the terms “unhealthy weight” and “overweight” as not nice (at all), while the majority of the HCPs scored this term as (very) nice. Lastly, the term “full-figured” was scored as not nice (at all) by roughly 40% of the children, while the majority of the HCPs scored this term as not nice (at all).

Term use by HCPs

HCPs reported using the terms “overweight” (34.4%), “BMI” (30.7%) and “healthy weight” (21.6%) most often in their conversations with children and parents. A minority (8.8%) of the HCPs used “obesity” in conversations with children and parents.

Discussion

The main finding of this study is that the terms “adiposity”, “BMI”, “curvy”, “morbid obesity”, “sturdy”, “heavyset”, “obesity”, “adiposity^{”vetzucht”}” and “corpulent” are not familiar to children. Furthermore, most of the terms that were unfamiliar to children were scored as not nice (at all) by HCPs, except for the term “BMI”, which was scored as (very) nice by HCPs. Children, parents, and HCPs scored the terms “fat^adjective”, “fat^noun”, “adiposity^{”vetzucht”}” and “chubby”, as not nice (at all). Earlier research found that terms that are disliked are perceived as judgmental and may have a negative influence on the patient-provider relationship (Gray et al., 2011; Puhl et al., 2013; McPherson et al., 2017; Tailor & Ogden, 2009). This suggests that “fat^adjective”, “fat^noun”, “adiposity^{”vetzucht”}” and “chubby” should be avoided. Terms perceived as positive and neutral were “healthier weight”, “above a healthy weight”, “stocky”, “big” and “weight”.

In previous studies, medical terms such as “obesity” were disfavored by adults or adolescents with overweight or obesity. The present study showed that the majority of children were unfamiliar with this term, and only 8.8% of the HCPs reported using this term in their conversations with children. Interestingly, previous studies have shown that “BMI” is preferred by adults and adolescents with overweight or obesity and is considered a neutral term. The present research found that more than half of the children did not know this term. This is in line with the results of the study conducted by Oettinger et al. (2009), who found that only 30% of the parents who went to visit the clinic with their child (2–8 years old) could define the term “BMI”.“BMI” is an English abbreviation routinely used in the Netherlands in the medical literature. However, “BMI” is less frequently used by the general population and therefore this term may be unknown to Dutch-speaking children. Another possible explanation is the fact that in earlier research it was impossible for children to indicate if they did not know a term (Puhl & Himmelstein, 2018). Therefore, we recommend to use terms which are familiar to children.

Furthermore, it may be advisable for HCPs to make use of more positive or neutral terms, such as “healthier weight”, as is also suggested in a recent review by Puhl (2020). The use of motivational interviewing, in which positive wording is used, showed improvements in health behaviors, e.g., diet, in children and their parents (Borrelli et al., 2015). Earlier research also stimulated weight-related conversation by framing terms positively (e.g., “healthier weight” instead of “obese”) (Shue et al., 2016). Therefore, a positive wording might be useful for enhancing the weight-related conversations. Lastly, children and HCPs may attach different meanings to the terms “weight problem”, “unhealthy weight” and “overweight”, and this may explain the differences in scores between these groups. Earlier research conducted with adults, found that the beliefs and values associated with a disease differed between HCPs and their patients, and may lead to differing appreciations of the interactions between HCPs and their patients (Kennedy et al., 2017). In our study, children with obesity may have been more emotionally involved than the HCPs, and hearing for example, the term “overweight” may have triggered a negative emotion (Buchanan, 2007), while for HCPs this term may be more neutral as it is medically correct.

The present study provides insight into the differences in preferences of children, parents and a diverse group of HCPs regarding WBT used in health care. Other strengths are that this is the first study to include young children (age 7 years and older) and to assess whether or not children are familiar with WBT. However, there are also some limitations to this study, including the small sample size of children and parents, and a possible selection bias due to the recruitment of children and parents through a selection of HCPs. Because of the relative small sample size we cannot rule out that ethnicity and educational level may have had an impact on the results. Generalization of the results of our small sample to the general population of The Netherlands should be done with caution. Furthermore, apart from WBT, the tone and context of the conversation in which a weight-based term was used, may have influenced how the term was perceived by children with overweight or obesity, and by their parents. Attitude and non-verbal communication of the HCPs are equally important in creating a safe environment to discuss weight (Farnesi et al., 2012; Stuij et al., 2020).

To conclude, children’s, parents’ and HCPs’ preferences do not always correspond with each other when it comes to the use of WBT in health care. It is recommended that HCPs use terms that to children and parents are familiar with, and terms which are perceived as neutral or positive, such as “healthier weight”. Furthermore, it is recommended to avoid terms which were disliked, as these terms may worsen the dialogue and relationship between the family and HCP. Furthermore, when discussing bodyweight, the HCP should check for understanding of and preferences for WBT with the child and their family.

Disclosure of potential conflict of interest

The authors report no conflict of interest.

Acknowledgments

This work was supported by the Dutch Ministry of Health, Welfare and Sport [grant number VWS: 324043]. The funding party had no role in study design, in the collection, analysis, and interpretation of data, in the writing of the report, nor in the decision to submit the article for publication. We would like to thank Sanne Niemer for her valuable contributions to this manuscript. We would also like to thank all participants: children, parents and healthcare professionals. We would also like to thank the healthcare professionals who helped us to recruit children and parents for participation in this study.

Notes

1. In the remainder of this manuscript, we use “parents” to refer to both caregivers and parents.