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The Perils of Person-First Language

By Carrie Dennett, MPH, RDN, CD

Most health professionals who seek to avoid contributing to weight stigma likely have adopted person-first language, a concept that first developed in the 1980s among disability activist groups. The idea was that using language that puts people before their disability or diagnosis enables them to reclaim their personhood in a society that often sees condition first, person second. For example, instead of using the term “diabetics,” it’s “people with diabetes.” Instead of “she’s disabled,” it’s “she has a disability.” Instead of “the obese,” it’s “people with obesity.”

On that last point, in 2014 the Rudd Center for Food Policy and Obesity, in partnership with the Obesity Society, the Obesity Action Coalition, the Obesity Medicine Association, and the American Society for Metabolic and Bariatric Surgery published Guidelines for Media Portrayals of Individuals Affected by Obesity. The latter two groups are no longer listed as contributors on the current version of the guidelines. The document offers suggestions for balanced and accurate media coverage that doesn’t contribute to stigma—useful for dietitians who work in print, broadcasting, or online media, or who write about weight-related issues in blog posts or newsletters. The guidelines also call for person-first language, as have the American Medical Association, the World Health Organization, and the Academy of Nutrition and Dietetics.

Semantics Don’t Erase Stigma
Trouble is, many people only use person-first language with characteristics that are considered negative. Some believe this should be changed if possible, as it implies judgment. After all, many don’t use person-first language with characteristics considered descriptive in a neutral or positive way. For example, many say “she’s a dietitian” or “he’s Canadian.” They don’t say “she’s a person who works in dietetics” or “he’s a person from Canada.”

Some experts believe person-first language can be particularly stigmatizing when the word in question is “obesity,” a word that’s loaded with stigma no matter how health care practitioners use it in a sentence. In their 2016 opinion piece in Frontiers in Psychology, psychologists Angela Meadows, PhD, MSc, and Sigrun Daníelsdóttir, MSc, suggest the word “obesity” be discarded, because it has become “mired in the medicalization of body state.”

Even though the term “obese” is a designation on the BMI chart that may or may not have an adverse affect on health, advocates for making obesity a medical diagnosis frequently claim that this will help remove its stigma. It hasn’t. If dietitians doubt that, they should look at the ever-present media coverage of “the war on obesity,” which in many minds is translated as “the war on people with obesity.” Furthermore, look at the comments sections of articles, blogs, and Instagram posts written by people in larger bodies. “Obese” is one of the words wielded as a weapon to shame and silence. It becomes dehumanizing, and could lead to poor physical and mental health outcomes. (See the article “The Health Impact of Weight Stigma” in the January issue of Today’s Dietitian.)

People-First Language Does Not Speak for All People
Most of the groups backing person-first language for obesity support weight loss diets or surgeries. Research in which people with weights in the overweight or obese BMI categories are asked how they prefer providers to refer to their bodies includes a high proportion of patients who are seeking weight loss treatment. They’re trying to change their bodies and so aren’t necessarily representative of people of similar weights outside of a weight loss setting.

Also of concern is the use of person-first language perceived in a way that affixes labels like “people who struggle with weight,” “people who suffer from excess weight,” or as seen in the title of the Rudd Center guidelines, “individuals affected by obesity.” Many may think these statements aren’t empathetic but stigmatizing. They may believe the speaker (or writer) is labeling someone’s weight as problematic, and making assumptions about how people in larger bodies feel about their weight. It’s noteworthy that the organizers of the annual Weight Stigma Conference ask presenters to avoid using person-first language.

Don’t Just Fake It Until You Make It
Unfortunately, like many efforts to be politically correct, person-first language can be more of an exercise in linguistics than a heartfelt move to put people first. It doesn’t matter how spot-on someone is with language “rules” if they still harbor bias against people based on their body shape or size.

Rather than checking off the “person-first language” box, it may be a good idea for health professionals to reflect on their own biases and assumptions about people in bodies that don’t meet the culture’s thin ideal. Patients are human beings, and human beings are inherently worthy of respect. Dietitians and other health care providers can do profound harm when they bring bias into patient appointments, no matter how much they think they’re exhibiting warmth and empathy by following the rules about “correct” wording for referring to their patient’s bodies.

Health First, For All Bodies
When working one-on-one with a patient who’s in a larger body, consider whether size is even something that needs to be discussed. If someone is seeking nutrition counseling for cholesterol or blood sugar management, why not focus on the same things you would in a patient in a smaller body who has the same condition: nutrition, physical activity, stress reduction, sleep, and so on? If body size is a necessary part of the discussion, ask the person how they refer to their body, and if they would like you to use the same language.

When I interviewed Julie Duffy Dillon, MS, RD, LDN, CEDRD, for the article on weight stigma in this month’s issue of Today’s Dietitian, she suggested that instead of referring to “normal,” “overweight,” or “obese” for body size, refer to sizes as follows:

  • high weight or low weight;
  • plus size or straight size; or
  • conventionally accepted or marginalized.

“I like to ask my clients which words they prefer we use in sessions to describe size, as some prefer these or ‘fat’ as a neutral descriptor,” Dillon says.

Just as “high” and “low” are relative terms, using “people in larger bodies” or “people in smaller bodies” are also good alternatives. When it’s necessary to be more technical, referring to “people with BMIs in the obese range” is an option. Meadows and Daníelsdóttir go further. They recommend doing away with the words “obese” and “obesity” altogether in research, publishing, and health care, and instead use neutral terms like “weight” and “higher weight.”

Australian dietitian Fiona Sutherland, APD, a leading specialist in mindful and intuitive eating and the Health at Every Size movement, has yet another suggestion: “Wondering how to describe the body of another person? Try this out: ‘human being.’”

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutrition-related topics. She also provides nutrition counseling via the Menu for Change program in Seattle.