Overweight, obese and other words relating to weight

[sarawilcox]

We've had feedback from a hospital trust, asking us to add the following words or phrases to the content style guide:

• bariatric
• obese
• obesity
• overweight
• weight loss

Does anyone have any user research insight into the language around weight loss?

See also Weights and measures, e.g. kg, lb, oz

[sarawilcox]

The NHS website team has received a complaint about the language used on the website about obesity. The individual has referred us to Obesity: Language Matters.

[sarawilcox]

See also Obesity UK's The Responsible Reporting of Obesity: Media Guidelines
It includes the following points:
1 Language matters: try to use words that are non-stigmatising and free from negative connotations. ‘Obesity’ and ‘overweight’ work well. But if you’re interviewing someone with obesity, and they use different terminology, go with their preference.
2 People first: put the person before a disease they are living with e.g. ‘people with obesity’. The other way around can be dehumanising.
3 You don’t say: certain sayings have become part of the accepted lexicon. Phrases like ‘eat less, move more’ can be demoralising and erroneously suggest there’s a onesize-fits-all approach to weight loss.

[oh68]

People with obesity or people living with obesity

At NICE, we use 'people with X' to describe conditions. At the moment, we say 'people with obesity', which is also used in Obesity: Language Matters. We do not say 'obese people' or 'overweight people', because our style is to not label people with their condition. In the past, we have used 'people who are obese' or 'people who are overweight'.

Public Health England and the Department of Health and Social care have both used 'people living with obesity' in recent policy papers, blogs and reports. See Excess weight and COVID-19 (PDF, page 5), Supporting weight management and wellbeing approaches during the COVID-19 pandemic and the Tackling obesity policy.

We are keen to see if there is any user research on the terms 'people with obesity' and 'people living with obesity'. We are interested in how people (including healthcare professionals) interpret the meaning. It would also be useful to see how well 'people who are obese' tests too.

BMI

We have had feedback asking if we should use BMI instead of using the categories 'obese' and 'overweight'. For example, '21% had a BMI of over 30' instead of '21% were obese'.

But, some research has questioned if BMI is the best way to measure overweight. For example, among many others, a recent BMJ opinion article has encouraged using 'other measures of health, such as waist circumference, blood pressure, and blood sugar'.

So, we would also be interested in seeing any user research on how obesity and overweight are measured.

[sarawilcox]

Thanks @oh68. I'll see if we have any research or views on this before the next Style Council meeting and we can open it up for discussion then too.

[sarawilcox]

Discussed at Content Style Council, December 2021.

Some comments

• BMI is being discredited as an imperfect measure. Waist-to-hip ratio is a measure that some people find more useful but it’s harder to define. One option might be to say “seriously overweight” when you mean obese, but in secondary care, people would hear the term “obese”.
• It’s only useful to use the term obese if there’s a clinical need e.g. with indications for weight-loss surgery. “Overweight” could be better for non-clinical examples, e.g. dietary and exercise advice.
• “Obese” and “obesity” feel like common language so looking at analytics and search terms could be useful. What are people searching for?
• With people-first definitions, you get opposite views depending on who you speak to. Some people like a person-first approach because they feel the condition is secondary but some people identify with their condition – it’s a primary factor in their lived experience so they like to front-load it when they express themselves. No consensus on this. Speak to audiences on case-by-case basis.
• Autism is an area where person-first language isn’t generally preferred. “Autistic” is usually preferred to “person with autism”.

Also a comment (not at the meeting) from the NHS.UK Campaigns team.

• We've not done any testing around specific language/phrasing, but from recent UR we did on childhood obesity content, it's obviously a very sensitive subject for parents.
  There were comments around the perceived "judgmental" and accusatory language on the live site content, and there were positive reactions to the work we did to soften and reframe the language and tone of voice to be more understanding and supportive – for example, renaming the page from "Your child's weight" to a more passive "Children's weight". See the Children's weight page.

Our content is tied into the National Child Measurement Programme so the terms have to mirror what's used on the letters (and the BMI calculator). That means we use "children/child who is overweight/very overweight". Obesity isn't used. The same goes for Better Health, where the language is around being overweight or wanting to lose weight if you're overweight, but again no specific mention of obesity.

PHE/OHID (their new name) is doing some work on childhood obesity, so it might be worth asking if they have any more specific research in relation to this.

[sarawilcox]

Return to To Do column for now. Needs more research.

[sarawilcox]

LiveWell content now uses "living with obesity" rather than "obese".

[sarawilcox]

Discussion on the NHS.UK Slack #content channel about the use of "overweight" as a noun. "Living with overweight".

https://nhsuk.slack.com/archives/C01E2DKQB8X/p1693837538115599

The Language matters guidance uses overweight as a noun, even though it sounds odd. (The guide isn't consistent - sometimes it talks about being overweight.)

NICE guidance on assessing overweight or obesity also uses "overweight" as a noun.

The policy steer is that "being overweight" is best avoided for the same reasons as "being obese".

But some content designers feel it's unnatural and not easy to read (and could be seen as a typo).

[sarawilcox]

"Living with obesity" may not be appropriate in a context where the patient may not know they are obese. Or where we cannot be sure they are obese. E.g. in the BMI calculator.

[steph-w-nhs]

"Living with obesity" may not be appropriate in a context where the patient may not know they are obese. Or where we cannot be sure they are obese. E.g. in the BMI calculator.

• 'Obese' and 'overweight' are terms defined in NICE guidance on which the BMI tool is based.
• The BMI tool uses height and weight to estimate a person's weight classification, as we know there are lots of things the BMI calculation doesn't account for (age over 18 and body composition).
• In the flow of using a BMI tool, it could be confusing to tell a user that their classification is ‘living with obesity’ or ‘a person with obesity’.
• The tool addresses ‘you’ be be consistent with all classifications and give a clear result.
• We try and fulfil the language matters advice in the context of the results page itself. With additional wording around the classification, such as:

A BMI of 27.5 or more is classed as obese.
An obese result suggests you are carrying too much weight and you would benefit from making some healthy changes.

We believe we can also monitor feedback on the underweight classification, and could consider alternate terms such as 'low weight'.

[steph-w-nhs]

The NHS health assessment tools team completed a review of language around overweight and obesity.
We created a new Github issue detailing the findings and advice around "talking to users about weight"
#540