7th June 2019, Volume 132 Number 1496

Caz Hales, Lesley Gray, Carol MacDonald, Gordon Purdie

Effective communication is essential in the relationship between a patient and healthcare professional (HCP) with terminology playing an important role. The terminology used by HCPs can impact on an individual’s perceptions of weight and experience of stigma,1 how people respond to public health directives,2 treatment seeking and utilisation of healthcare,3,4 how an individual feels about their health5 and the patient-practitioner relationship.4,6,7 The use of stigmatising terms when referring to people with excess weight adds to the existing discrimination and weight bias in healthcare settings,8 particularly when the terminology is associated with broader moral perceptions and judgments about the individual being described.2

As HCPs are increasingly being urged to talk with patients about health and weight,9,10 it is crucial to understand the power of language in providing bias-free healthcare.1 While there have been increasing calls for the use of people-first language (eg, person living with obesity) in the context of obesity,1,8,12 the terminology used by HCPs to describe a person with an excessive accumulation of body fat (adipose tissue) remains a contentious and interactionally delicate issue.7,13 The lack of a clear consensus on terminology in ‘fat/obesity’ research and practice and the need for common language to facilitate clear and respectful cross-disciplinary communication was highlighted by participants at the 2015 Weight Bias Summit in Canada.14

The ways in which terminology is used are complicated and often contradictory. For example,15 the terms ‘overweight’, ‘obese’, ‘morbidly obese’ and ‘obesity’ are predominantly used in biomedical literature, in which understandings of obesity are grounded in a language of disease, risk, prevention and treatment.13 In contrast, in the feminist and fat studies literature the term ‘fat’ is preferred over ‘obesity’.14,16 In this biopolitical sphere, understandings of excess weight are embedded in a language of power, oppression, stigma, prejudice and discrimination.13 In practice, excess adipose tissue terminology is further complicated by the nature of the health practitioner-patient interaction and the need for the language used to have clinical meaning for patients.7,17

Preferences for obesity-related terms have been described by primary-care patients with obesity18,19 community populations,4,20,21 weight-loss patients22,23 and candidates for weight-loss surgery.23

A Scottish study which explored men’s motivations in joining a weight loss intervention highlighted a tension between acceptable and motivating weight-related terminology.20 Although male participants reported finding terms like ‘fat’ hurtful, they felt that the use of such terms may be more motivating than terms such as ‘overweight’.20 An earlier study by Gray and colleagues24 found that men reported being diagnosed as ‘obese’ was a motivating factor. In contrast, participants in a large community sample of American adults rated the terms ‘unhealthy weight’ and ‘overweight’ as motivating to lose weight, whereas the terms ‘weight’ and ‘chubby’ were rated as the least motivating.4 Participants in that study rated ‘morbidly obese’, ‘fat’ and ‘obese’ to be most blaming, with ‘high BMI’ and ‘weight’ in particular, as least blaming.

A study which focused on male obesity in New Zealand further highlighted the tension between acceptable and motivating weight-related terminology and communication style preferences.25 In that study men reported that while they want the topic of their weight raised, they want sensitivity around the terminology used. In another qualitative study, Gray et al7 sought to identify approaches used by general practitioners and how the issue of overweight or obesity is raised with patients in general practice consultations. What appeared to be effective, whichever words were applied was linking the clinical relevance of the discussion.7 This aligns with work by MacKean and GermAnn26 who found that actual terminology used is generally of less importance to patients than the tone of the conversation.

There has been no quantitative research exploring issues around weight-related terminology in the New Zealand health service context. This study addresses that gap by exploring the perceptions and preferences of commonly used terms to describe adiposity among a convenience sample of New Zealand HCPs and lay adult population.

Method

Sampling and recruitment

Adults aged 18 years and over residing in New Zealand were recruited. Visitors to New Zealand were not eligible as the aim was to understand language preferences from the New Zealand context. Convenience sampling aimed to gather responses from a sample of HCPs attending seminars addressing quality care of higher-weight patients and from non-HCPs (lay population).

Between January to June in 2016, research survey stands were intermittently set up at various sites around New Zealand (Auckland, Wellington, Christchurch and Dunedin), including two supermarket entrances, two shopping malls, a tertiary hospital main atrium and two university campuses. The HCP-specific sites included four health professional research seminar events about quality care for larger patients, and two university health schools. HCPs could also complete a survey at a general survey stand. The survey stands were staffed by the first and second author and two research assistants recruited to this project.

Data collection

A self-report questionnaire was developed specifically for use in the study to assess perceptions and preferences of commonly used terms to describe adiposity. Questions relating to preferences of terms were adapted from questionnaires previously administered for similar purpose in other countries4,18,22,23,27 and the terms used in the questionnaire reflect terminology used in those previous studies assessing adult weight-related preferences. In addition, the term ‘bariatric’ was added to reflect a move towards the term ‘bariatric care’ used frequently in New Zealand health services and by HCP participants in other New Zealand research, to describe care of patients with a body mass index of 40kg/m2 and above.13,28

Perceptions of terms were assessed by asking participants to rate the degree to which listed terms were 1) stigmatising, 2) blaming of the person for their weight, and 3) motivating a person to lose weight. Participants rated each of the following terms using a four-point scale (eg, 1 = Not at all, 2 = Slightly stigmatising, 3 = Stigmatising, 4 = Very stigmatising). The terms presented were: fat, chubby, obese, high BMI, morbidly obese, bariatric, heavy, large, overweight and weight.

Participants were further asked to indicate their preference for terms (listed above) using a seven-point scale (1 = Very undesirable, 7 = Very desirable). They were first asked to rate the terms according to how desirable or undesirable they would find each of the terms “if someone you did not know used it to refer to your weight” and then “if someone you did know used it to refer to your weight”.

Demographic data collected included: occupation, age, gender, ethnicity and weight status. Ethnicity and weight status were self-reported by the category participants most closely aligned with.

Data analysis

The terms were compared with Friedman’s tests and when these were significant, pairs of terms were compared with Wilcoxon signed-rank tests. For each preference group (eg, stigma, blame) analysis was restricted to participants who had rated all of the terms. SPSS v24 (IBM Corp., Armonk, NY) was used for this analysis. Ratings of HCP and the lay population where compared with Wilcoxon rank-sum tests. SAS 9.4 (SAS Institute Inc., Cary, NC, USA) was used for this analysis and for Figures 1–6. The Holm-Bonferroni method for multiple comparisons and a significance level of 5% were used to assess statistical significance.

Ethical considerations

All participants gave implied consent by the decision to complete the questionnaire and ethical approval was given by the Victoria University of Wellington Human Ethics Committee (Approval Number 22185).

Results

Participants

In total,775 participants completed questionnaires for data analysis (HCP n=329, lay population n=446). The HCP group included students who identified they were studying a health professional qualification whereas the lay population group included students who were not studying a health professional qualification or did not specify their study area. The lay population convenience sample of participants were mainly female (62%), aged between 18–25 (56%) with 66% identifying as Pakeha/European, and is not generalisable to the New Zealand population. (See Table 1).

Table 1: Summary of sample characteristics (N=775).

 

Lay population N=440

% (n)

Health professionals (including health professional students) N=330

% (n)

Total N=775

% (n)

Gender

Female

Male

Other

62% (271)

37% (163)

1% (6)

91% (300)

9% (30)

0% (0)

74% (571)

26% (198)

1% (6)

Age

 18–25

26–35

36–45

46–60

Over 60

Not stated

56% (247)

14% (62)

9% (41)

9% (40)

11% (50)

23% (77)

21% (68)

23% (75)

29% (95)

4% (14)

(1)

42% (324)

17% (133)

15% (116)

18% (137)

8% (64)

(1)

Ethnicity

Pakeha/European

Māori

Pacific Peoples

Asian

Other

66% (291)

10% (42)

5% (23)

15% (65)

7% (32)

75% (248)

6% (20)

6% (21)

6% (21)

6% (21)

70% (539)

8% (63)

6% (46)

11% (88)

7% (53)

Self-estimated weight status

Underweight

Normal weight

Overweight

Very overweight

Extremely overweight

Not stated

5% (20)

67% (293)

24% (107)

4% (16)

1% (4)

3% (9)

59% (195)

30% (100)

6% (20)

2% (5)

(1)

4% (29)

64% (493)

27% (207)

5% (36)

1% (9)

(1)

Note: Occupational group was not stated for five participants. 

The HCP participants stated ethnicity was similar to the New Zealand nursing workforce.29

Preferences for weight-related terms

There were significant differences between participants’ perception of terms used to describe people of different body weight with respect to stigma, blame, motivation to lose weight and desirability, whether people were known or unknown to the participant (all p<0.0001 Friedman’s test).

Stigmatising terms

Participants rated ‘weight’ as the least stigmatising term, with 69% rating ‘weight’ as ‘not at all’ stigmatising. Contrary, morbidly obese and fat were rated as the most stigmatising terms, with 42% and 30% of participants rating ‘morbidly obese’ and ‘fat’ as ‘very stigmatising’, respectively (See Figure 1).

Figure 1: Least to most stigmatising terms.

c

Note: Participants rated each word on a 4-point Likert scale (from ‘Not at all’ to ‘Very stigmatising’). Numbers in circles are the percentage of participants.  
*Indicates groups of terms that are not statistically significantly different (using the Holm–Bonferroni method for multiple comparisons). N=693. 

Blaming terms

Participants rated ‘weight’ as the least blaming term, with 63% of participants rating this as ‘not at all blaming’ (see Figure 2). In contrast, participants rated the terms ‘morbidly obese’ (41%), ‘fat’ (26%) and ‘obese’ (25%) as ‘very blaming’ terms.

Figure 2: Least to most blaming terms.

c 

Note: Participants rated each word on a 4-point Likert scale (from ‘Not at all’ to ‘Very blaming’). Numbers in circles are the percentage of participants.
*Indicates groups of terms that are not statistically significantly different (using the Holm–Bonferroni method for multiple comparisons). N=683. 

Motivating terms

‘Weight’ was rated as the term least likely to motivate someone to lose weight, with 51% rating this term as ‘not at all’ motivating (see Figure 3). Whereas 42% and 26% of participants rated the terms ‘morbidly obese’ and ‘obese’, respectively, as ‘very motivating’ terms to encourage someone to lose weight.

Figure 3: Least to most motivating terms.

c

Note: Participants rated each word on a 4-point Likert scale (from ‘Not at all’ to ‘Very motivating’). Numbers in circles are the percentage of participants. 
*Indicates groups of terms that are not statistically significantly different (using the Holm–Bonferroni method for multiple comparisons). N=680. 

Terms used to describe participant’s weight by people known to the participant and people not known to the participant

Regardless of whether the person was known or unknown to participants, ‘weight’ was rated as the ‘most desirable’ term with 11% rating ‘weight’ as ‘very desirable’ by people known to the participant and 12% by people not known to the participant. The terms ‘morbidly obese’, ‘fat’ and ‘obese’ were rated as the most undesirable (for people known to participants, 50% rated ‘morbidly obese’; as more undesirable; 40% for ‘fat’ and 41% ‘obese’ as ‘very undesirable’) when used to describe participant’s weight irrespective of whether the person was known or not known to participants (See Figures 4 and 5).

Figure 4: Least to most desirable terms used by someone known to participant in relation to participant’s adiposity.

c

Note: Participants rated each word on a 7-point Likert scale (from ‘Very undesirable’ to ‘Very desirable’). Numbers in circles are the percentage of participants.
*Indicates groups of terms that are not statistically significantly different (using the Holm–Bonferroni method for multiple comparisons). N=674.
 

Figure 5: Least to most desirable terms used by someone not known to participant in relation to participant’s adiposity.

c

Note: Participants rated each word on a 7-point Likert scale (from ‘Very undesirable’ to ‘Very desirable’). Numbers in circles are the percentage of participants.
*Indicates groups of terms that are not statistically significantly different (using the Holm–Bonferroni method for multiple comparisons). N=666.
 

Differences between HCP and lay population participant responses

Participant responses were grouped as either HCP or lay population. The groups were compared with each other to identify any significant differences in responses between the two groups.

After adjusting for multiple comparisons there were three terms which presented statistically significant differences between the two groups. The terms ‘overweight’ and ‘obese’ were perceived to be more motivating by the lay population (both p<0.0001), and ‘chubby’ was more likely to be rated as an undesirable term to describe adiposity of someone not known to the participant by HCPs (p<0.0001). The lay population group rated ‘overweight’ as ‘motivating’ (40%) compared to the HCP group rating overweight as ‘slightly motivating’ (40%). For the lay population, 32% rated ‘obese’ as ‘very motivating’ and for HCP, 17% rated ‘obese’ as ‘very motivating’. While both groups rated ‘chubby’ in the undesirable range for use by someone not known to the participant, 38% of HCP and 28% of the lay population rated ‘chubby’ as ‘very undesirable’ (See Figure 6).

Figure 6: Statistically significant differences between HCP and lay population participant responses.

c 

Note: This figure shows the three terms that presented statistically significant differences between the HCP and lay population. Participants rated motivating terms on a 4-point Likert scale (from ‘Not at all’ to ‘Very motivating’. Participants rated the desirable term on a 7-point Likert scale (from ‘Very undesirable’ to ‘Very desirable’. Numbers in circles are the percentage of participants.  

Discussion

The present study examines perceptions and preferences of commonly used terms to describe adiposity in a sample of adults living in New Zealand. Generally, the findings are consistent with previous research with ‘weight’ considered to be the more desirable, least stigmatising and least blaming terms than other commonly used language to describe a person’s body size. ‘Weight’ has consistently been rated as a more desirable term for HCPs to use when discussing a patient’s size.4,20,22,23 The use of ‘high BMI’ by HCPs also tended to be rated as more acceptable than other terms (after ‘weight’), as has been found in a previous study.21 One reason for this acceptability could be that these terms are objective measurements.

The terms morbidly obese’, ‘fat’ and ‘obese’ were rated as more stigmatising, more blaming and more undesirable when used to describe participant’s adiposity, regardless of whether the person was known or unknown to participants; similar to findings in other studies.4,18,20–23 Due to the varied use and negative connotations of the terms ‘obese’, ‘morbidly obese’ and ‘fat’ in social media, these terms have greater social meaning beyond healthcare than other terms used during patient-HCP interactions. The use of stigmatising language by health professionals was highlighted in a recent study where 19% of participants indicating they would avoid contact with that health professional and 21% would seek a new doctor.4

The term ‘fat’ which is actively applied and promoted in the field of fat studies, to understand how fat people are portrayed, represented and treated over time, is a conscious choice to move away from terminology that medicalises obesity.18 Yet in this study participants rated the term ‘fat’ to be as stigmatising as ‘morbidly obese’ and ‘obese’. This contrasts with an earlier qualitative Australian study where 80% (N=76) said that they hated or disliked the word ‘obesity’ and would rather be called ‘fat’ or ‘overweight’.30 In America, a study exploring how university students use and react to fat-related terms15 found that in spite of the fact that most participants viewed terms such as ‘fat’ and ‘obese’ to be unacceptable, female participants were more likely to report using ‘fat’ and ‘obese’ in daily conversations and especially in self-descriptions. This suggests dissonance in application of terms.

Our research found that there was a dissonance in relation to terms identified as most blaming to those identified as most likely to motivate people to lose weight. ‘Weight’ was considered to be the least blaming yet was not considered to be a motivating term to lose weight. Similarly, ‘obese’, ‘morbidly obese’ and ‘fat’ were considered the most blaming terms but deemed to be most likely to motivate someone to lose weight. This supports the notion that weight stigma and the social meaning attached to terminology has a significant influence during patient-HCP interactions.6,7,17

One strategy adopted during HCP-patient interactions to minimise issues of weight stigma is the use of terms voiced by the patient. Hales13 found that HCPs felt more comfortable using terms deemed stigmatising and blaming such as ‘obese’ and ‘fat’ if the patient used these terms in their conversations. Likewise, other studies have reported that HCPs use terminology rated more favorably by patients and avoid terms that patients may find undesirable.19,22, In a study of pre-registration dietitians, nurses and doctors, the preferred terms when raising the issue of obesity with clients were ‘BMI’, followed by ‘weight’.19 Similarly, Dutton et al22 found that physicians were most likely to use the term ‘weight’ and least likely to use ‘fatness’, ‘excess fat’, ‘heaviness’ and ‘large size’ in discussions with overweight or obese patients.

Of concern for HCPs is the meaningful nature of terms used during weight-related conversations and care situations. The term ‘weight’ has been identified in this and other studies as the preferred term to use during patient-HCP interactions as it is less blaming and less stigmatising. However, this term may not convey the appropriate message in some clinical contexts. For example, weight is used as a measurement to assess fluid status in patients with end-stage kidney disease and congestive heart failure; often many of these patients have high levels of body fat. In this context the gaining and losing of weight does not relate to changes in actual adipose tissue and yet many of these patients are encouraged to lose ‘weight’ to promote better health and delay further complications of their disease states. Therefore, weight loss conversations using the preferred non-judgmental term of ‘weight’ can be highly problematic.

Similarly, being specific about what the care issue is during a conversation can add meaning to the conversation and portray less judgment. For example, weight is often not the issue when caring for patients of larger size as much of the equipment in use can accommodate patient weights of over 150kg. However, the person’s physical size and shape is the factor of concern in these care situations and discussing weight in this context can lead to further confusion and inappropriate use of terminology.17 Thus, the terms used during each clinical situation must be carefully considered to ensure conversations are respectful, appropriate and support meaningful dialogue.

The term ‘bariatric’, although increasingly utilised and promoted within healthcare,13 was identified as an issue during data collection for the lay population sample. Many participants in this study had not heard of the term at the time of completing the survey, despite increasing adoption of the term in New Zealand healthcare.28 This raises two important points; firstly, that people are generally not familiar with a term frequently used in healthcare practice to describe care services for larger-bodied people, and secondly that the data related to the term ‘bariatric’ may be misleading due to how participants interpreted the term.

Limitations

This was a convenience sample. While the samples are not representative of the lay or HCP populations, the participant demographics are similar to the HCP population in New Zealand. It is possible some health professional students or non-practising health professionals are included in the lay population group. This is an overview paper, as sub set analysis, eg, for gender and/or ethnicity has not yet been conducted. Finally, the term ‘bariatric’ was poorly understood by participants as reported by the data collection field workers, therefore data related to the term ‘bariatric’ may be misleading due to how participants interpreted the term.

Conclusion

Medicalised terminology has become stigmatising language in relation to weight stigma and HCPs are in a difficult position as there is no universal agreement on preferred non-stigmatising terms, particularly in clinical scenarios in which a person’s size, shape and weight are relevant to the care discussion. While ‘one term does not fit all’ HCPs should refer to weight or high BMI instead of ‘obesity’ terms and recognise that language has the ability to harm and must be applied with care, particularly in first encounters.

This study presents preferences for adiposity-related terms in New Zealand. The study highlights that HCPs and lay population samples may lack understanding about the impact of utilising blaming terms when attempting to motivate a person in relation to weight loss. Care must be taken to ensure HCPs do not contribute to weight stigma through inappropriate use of language.

Summary

This paper comprised 775 adult participants (330 health professionals, 440 non-health, five not specified) and is the first study of its kind in Aotearoa New Zealand to explore weight-related terminology. Communication has an essential role in the therapeutic relationship between patient and healthcare professionals (HCPs) where terminology used can significantly impact on an individual’s perceptions of weight and experience of stigma. ‘Weight’ or ‘high BMI’ were the most preferred terms for describing excess adiposity for participants. There was a conflict in responses relating to the terms considered most blaming and those considered to be motivating terms to lose weight, which is perhaps unsurprising given the level of bias and stigma in relation to people with excess adiposity (fatness). Whichever term is selected, HCP-patient conversations need to be respectful, appropriate and support meaningful non-stigmatising dialogue.

Abstract

Aim

Communication has an essential role in the therapeutic relationship between a patient and healthcare professionals (HCPs) with terminology playing an important role. The terminology used by HCPs can significantly impact on an individual’s perceptions of weight and experience of stigma. This is the first quantitative research study in Aotearoa New Zealand to explore weight-related terminology.

Method

A self-completion questionnaire was administered to a convenience sample of adults aged 18 years and over, residing in New Zealand across four different geographical regions (Auckland, Wellington, Christchurch and Dunedin) in 2016.

Results

Seven hundred and seventy-five participants completed questionnaires, with 330 identifying as HCPs or HCP students, 440 as lay persons and five not specified. ‘Weight’ or ‘high BMI’ were the most preferred terms for describing excess adiposity for participants. The term ‘bariatric’ is poorly understood in New Zealand. There was dissonance in responses relating to the terms considered most blaming and those considered to be motivating terms to lose weight.

Conclusion

The terms ‘weight’ or ‘high BMI’ are the terms most commonly preferred across this and other surveys, although neither term is meaningful in describing accurately the clinical relevance of the person’s size during the HCP-patient interaction. Whichever term is selected, HCP-patient conversations need to be respectful, appropriate and support meaningful non-stigmatising dialogue.

Author Information

Caz Hales, Senior Lecturer, Graduate School of Nursing and Midwifery, Victoria University of Wellington, Wellington; Lesley Gray, Senior Lecturer, Department of Primary Health Care and General Practice, University of Otago, Wellington; Carol MacDonald, Independent Researcher, Wairarapa; Gordon Purdie, Biostatistician, Dean’s Department, University of Otago, Wellington.

Acknowledgements

The authors would like to thank all the participants, the data collection sites for their permission to erect survey stands and to Sarah Nelson, Rebecca Bear and Julie Howe for their contribution to the data collection and data entry. 

Correspondence

Lesley Gray, Senior Lecturer, 23a Mein Street, Level F, Department of Primary Health Care and General Practice, University of Otago, Wellington 6242.

Correspondence Email

lesley.gray@otago.ac.nz

Competing Interests

Nil.

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