Our study shows that many patients felt it to be appropriate for the doctor to initiate a conversation on overweight and obesity. At the same time, the patients were sensitive to a number of terms that describe obesity. Many respondents claimed that a wrong choice of words has a negative impact on their relationship to the doctor. As noted above, women had the highest sensitivity to expressions, as well as those who developed overweight early in life, those who had higher education and those who were dissatisfied with their weight.
One in every three patients reported that the doctor had taken the initiative to talk about obesity. Taking the patients’ considerable weight into account, this is a low figure. Another study has shown that weight was a topic in only 17 % of consultations with overweight patients (21). Moreover, notions may vary among patients and doctors as to whether the topic of weight has been raised at all during the consultation. One study found that patients far more rarely than doctors thought that weight had been referred to. The largest discrepancy in opinion was found among patients who had made little effort to lose weight by themselves (22), which emphasises the complexity involved in conversations about this topic.
GPs are reluctant to discuss overweight with their patients because they are apprehensive of causing offence (5, 23). This is especially challenging when the doctor is unfamiliar with the patient (4). In order to succeed with prevention, this topic must be raised at an early stage. Assuming that patients who are overweight, but otherwise healthy, visit their GP more rarely than obese patients with co-morbidity, this means that the conversation on weight must be held with unfamiliar patients. This should also happen in cases where the patients themselves fail to take such an initiative. Findings indicating that co-morbidity rather than body mass index is decisive for the doctor to raise the issue of obesity (4) – (6) highlight the need for prevention. Nine out of ten patients in our study believed that the doctor was correct in taking such an initiative.
The higher sensitivity to expressions among women may be related to gender differences in terms of self-image and bodily awareness. Women tend to be more critical of their own bodies (8, 9), whereas men have a greater tendency to underestimate their own weight (24). It has also been shown that men prefer a more frank language than women do (25).
A contributory factor to the higher sensitivity among people with higher education could be that in contrast to those with less education, they have a lower tendency to underestimate their own weight (24). Therefore, certain expressions may to a greater extent be perceived as confronting. In a sociolinguistic perspective, frank usage may be more prevalent in communities with less education and those with more education may be less hardened to it. A third explanation as to why people with higher education relatively speaking find overweight more stressful could be the perception of falling outside of socially acceptable norms (26).
Somewhat unexpectedly, we found no predictive value of anxiety symptoms measured on the HADS scale. The same applied to the ability to function socially, age and marital status.
There was a clear correlation between having been overweight early in life and being sensitive to expressions. Most likely, this can be traced back to experiences of stigmatisation because of overweight (27), something that thereby may have exerted a decisive influence on identity development. People who develop overweight in adulthood will hardly internalise social norms as strongly.
The data were collected at the one-year follow-up of treatment for obesity. On this occasion the patients reported their degree of satisfaction with their own body/weight loss at that time. Initial weight losses may serve as encouragement and strengthen the patient’s self-image, which may partly explain why those who were dissatisfied with their weight were also more sensitive to expressions.
Traditionally, doctors have actively overseen the development of professional terminology (28), and clinicians tend to seek linguistic precision. Our findings show, however, that expressions which to clinicians ought to clearly denote BMI > 30 kg/m² in fact give rise to negative reactions in patients.
While «overweight» is a precise expression for a body mass index score of 25 – 30 kg/m², it would be correct to use designations such as «obesity/obese/fat», «adipositas/adipose» and «obesitas» for a BMI > 30 kg/m². Most likely, clinicians tend to avoid the expressions «adipositas/obesitas» because they are unknown to people in general. They may also avoid «obesity/obese/fat» because of apprehension about causing offence. They tend to use incorrect terms such as «overweight» and «morbid overweight» including for a BMI > 30 kg/m². Is it correct to let the patients’ perceptions of these terms govern the language usage of health personnel?
This question can be regarded in light of protection motivation theory, in which personal health concerns may be seen as having a positive value (29). A key element of this theory is the individual’s assessment of threat – the perception of a health risk (vulnerability) and the degree of seriousness of the consequences (severity). Health concerns are seen as a resource for changing harmful behaviour. It is conceivable that more specific terms have a greater potential for enhancing such concerns.
However, this theory rests on an important assumption: One should at the same time guide and support new behaviour. Thus, the theory does not legitimise uncritical use of terms when the therapeutic relationship is about to cease or otherwise does not emphasise any change in health-related behaviour. In isolation, offensive terms may produce the reverse of their intended effect (30). At the same time, there are studies showing that obesity patients perceive frank expressions as more motivating than euphemisms for promoting change (31, 32). In this way, it may be more appropriate to use a more frank, perhaps even confrontational, language to patients, at least as far as men are concerned.
Seen in isolation, the choice of terms will hardly have a direct impact on the degree of weight loss, although they may help influence mental processes that are helpful in bringing about changes in behaviour. Hearing the doctor say that they are fat may help patients realise the seriousness of the situation. Such notions also accord with what we know about relative risk of disease (33).
We already know that men and young people in general prefer more frank modes of expression (31). Our study confirms the gender difference, but also points to other significant factors. It is difficult to know where to draw a line between what will have a motivational effect and what would only be seen as offensive. If the patients perceive this as stigmatisation, they may react by avoiding consultations or changing their GP. In this way, unfortunate use of terms may at worst have negative health consequences (32).
This study is based on patients suffering from morbid obesity. The findings cannot be directly generalised to the far larger population of overweight people who are not seeking treatment. In addition, we need to take into account that one of the questions was associated with issues somewhat in the past, and this may have had an effect on the responses. The selection of variables for the regression analysis was restricted to data that had been collected before this sub-study was initiated. Other variables that were unavailable to us may possibly have had an effect on the sensitivity to expressions and thus on the results.
In our opinion, the findings are relevant – especially for GPs. They often observe their patients’ weight increase and one of their tasks is prevention. Knowledge about the perception of language usage may lower the threshold for raising the issue of body weight at an early stage, thus increasing the effectiveness of prevention.