On language - first, do no harm.

We use specific medical language and terminology – it is common and necessary for the profession. Mostly we mean no harm, and we often do not even think twice about it – and it is so hard to change.

The ‘obese patient’, the 'severely,’ or ‘morbidly obese’ patient are now terms that are not only outdated, but have been identified as harmful to persons with the disease and obstacles to the successful treatment of obesity.

The adoption of person-centered language in medical specialties including anesthesiology is overdue for many disorders and diseases, obesity being one of them.

Let us think about it.

The terms ‘obese patient’ implies that the disease is a defining characteristic of the person and the person becomes the disease. This narrative deprives the person of the fact that the disease is only one aspect of their life and not what defines them. The expanded term ‘morbidly obese patient’ adds insult to injury with the implicit suggestion that there is a non-disease entity of the disease of obesity – absurd. The alternative person-centered framing – the patient with obesity or severe obesity – corroborates empathy, concern, and care for the affected individual and validates what science is telling us about obesity, it is a disease.

This latter insight is slow to progress in the minds of healthcare providers and society at large although the scientific literature is clear.[1] The physiology and pathophysiology of adipose tissues is fascinating and the multifactorial etiology of the disease of obesity is complex, hence effective treatment and sustained success have remained a challenge.[2]

In the case of obesity, negative attitudes and beliefs toward persons with the disease – implicit and sometimes explicit weight bias – continue to be wide spread in healthcare systems and society. One contributing factor is the misguided and prevailing perception that obesity is completely under the control of the individual affected by it.[3] This implies for the person to be thought of as making poor (nutritional) choices, being poorly behaved with a lack of self-control and discipline and worse. Simplifying obesity to an issue of personal behavior essentially dismisses the current scientific evidence for obesity.[4] This is not what we want to be known for.

Weight-biased and stigmatizing language in daily medical practice and the literature denies patients dignity and respect.[5] The obesity stigma unleashes grave consequences for our patients with the disease. Affected persons have a lesser likelihood of seeking care for their obesity, they may experience psychological trauma and their quality of life declines.

We are healthcare providers and therefore we should continue to listen to our patients. The perception of weight-based bias from physicians has been reported by 70% of patients with obesity.[6] The term ‘morbidly obese’ and its relatives have been identified as least desirable and most stigmatizing and blaming in the context of obesity in numerous studies with patients, the lay public and providers.[789] It is time to more thoughtfully use our language and replace injurious lingo. It is time to center our language around the lived experience of people with obesity and their identification without reinforcing labels, objectification, stigmatization, and marginalization.

Mostly outside of the specialty of anesthesiology, the discussion in the wider medical community regarding unintentionally disparaging language with respect to obesity has been ongoing for more than a decade. Eventually the American Medical Association released a position statement on person-first language for obesity known as H-440.821 in 2017.[10] A joint international consensus statement to end the stigma of obesity was published in 2020 and endorsed by many entities that included just one anesthesia society, the International Society for the Perioperative Care of Patients with Obesity (ISPCOP).[11] Within surgery, the subspecialty of bariatric surgery strongly supports person-centered language for obesity.[3] This is reflected by many of their journals which have specific instructions for authors to eliminate inappropriate terms to describe patients with obesity. In fact, the editor-in-chief of a major American scientific journal in the field of bariatric metabolic surgery provided further specific language instructions in an e-mail to reviewers and editors as late as March 2022 to assure an appropriate narrative for patients with obesity.

For the quest to rethink the way we think and to re-examine our narratives in medicine and society, the disease of obesity is just one example. It is embedded with the larger issue of health equity and justice, and the journey though still nascent, unmistakably continues.[12] It is important to understand our language and choice of words as a powerful instrument of equity and inclusion beyond healthcare, as so eloquently described in a recent Harvard Business Review article.[13]

Rethinking and consciously changing the way we describe patients with certain diseases will not immediately solve the problem, but it is a step in the right direction.

We may agree that medicine constantly evolves and changes over time – we diagnose what we know and not what we do not yet know. And with this evolution, medical language also must evolve and change based on deeper understanding and new knowledge about diseases, and integrate dignity and respect for our patients. But language, as Voltaire reminds us, is a very difficult thing to put into [the right] words. We must continue to try.

In this special issue of the journal, the authors and the editors have made every attempt to be mindful of the need for our patients to be addressed appropriately and with respect.

Financial support and sponsorship

Nil.

Conflicts of interest

Royalties for 2 obesity related chapters in UpToDate - Wolters Kluwer.

Past President of the International Society for the Perioperative Care of Patients with Obesity.