Patient and Family Perspectives on Terms for Obesity

The study was composed of 2 separate, United States-based, English-speaking samples: (1) parents (at least 18 years of age) with children aged 10 to 17 years old, and (2) youth between the ages of 10 and 17. Participants in both samples were recruited during the fall of 2021 via Qualtrics Panel Services, a national, Web-based survey platform that provides online samples for survey research. Qualtrics advertised the study using a variety of online platforms including customer loyalty Web portals, targeted e-mail lists, social media advertisement, member referrals, and messages in mobile applications. To ensure diversity within the samples, quotas were set on the basis of sex (female/male), race/ethnicity (ie, Black or African American, Latinx or Hispanic, white), and weight status, to align similarly with national averages. Informed consent and assent, as appropriate, was provided by all participants (parents of youth aged 10–12 provided their consent), and study procedures were approved by the institutional review board at the University of Connecticut.

The parent sample was composed of 1936 adults (48% male; mean age of 39.8 years). The overall racial/ethnic composition of parents included 33% Black or African American; 31% Latinx, Hispanic, or Mexican-American; 32% white, non-Hispanic, non-Latinx; and 4% multiethnic or another race/ethnicity. The youth sample was composed of 2032 participants (41% male, mean age of 14.6 years) and self-identified as 25% Black or African American; 23% Latinx, Hispanic, or Mexican-American; 40% white, non-Hispanic, non-Latinx; and 12% multiethnic or another race/ethnicity. Further methodological details pertaining to recruitment, data collection, and sample composition are reported elsewhere.¹⁰ 

Youth reported their age (year and month born), race/ethnicity, sex they were born as, sexual orientation (straight [heterosexual], gay or lesbian [homosexual], bisexual, other [please specify], or not sure, questioning), and their current height (in feet/inches) and body weight (in pounds). Parents reported their sex, age, and race/ethnicity, and provided their child’s demographic information and current height/weight. BMI percentiles for age and sex were calculated and categorized using the Centers for Disease Control and Prevention growth charts.¹⁸ 

To assess youth perceptions of parental use of words to describe adolescents’ body weight, youth were provided with a list of 27 words and phrases describing body weight (see Table 1 for all terms and phrases). From this list, 18 words (and accompanying question prompts and response options described below) have been tested previously with adolescent and parent samples^5–7,19 ; an additional 9 terms were added to this list identified from more-recent literature.¹¹  Participants were first prompted with, “Which words do your parents use to describe your weight?” and asked to rate the frequency that their parent(s) used each word on the list using a 5-point Likert scale (1 = never–5 = very often). Next, participants were provided with the same list of words but asked, “If your parent(s) use any of the following words or phrases to talk about your weight, how does it make you feel?” For each word, youth indicated whether it made them feel sad, embarrassed, ashamed, fine/not bothered by it, not sure, or not applicable if their parent doesn’t use the word. Each negative emotion (sadness, embarrassment, shame) was assigned a value of 1 and summed to create a score ranging from 0 to 3 for each word, with 0 indicating no negative emotions and 3 reflecting all 3 negative emotions.⁶  Finally, participants were provided with the same list a third time and asked, “Which words would you most want your family to use to talk about your weight?” Using a 4-point scale, adolescents rated each word (1 = “No, my parent(s) should never use this word,” 2 = “This word bothers me,” 3 = “This word is okay, I don’t mind,” 4 = “Yes, I prefer them to use this word/phrase”; an additional “Not sure” response option was excluded when examining this variable continuously).

To assess parental usage of weight terminology to describe their child’s weight, parents were provided with the same list of 27 words and asked, “What words or phrases do you use to talk about your child’s weight?” Parents rated the frequency that they used each word on the list using a 5 point Likert scale (1 = never–5 = very often).

Data analysis was conducted using SPSS version 28.0. Descriptive information based on the overall youth sample is provided to show their perceptions of, and preferences for, parents’ use of body weight terminology, and their emotional reactions to parental body weight terminology. Individual differences are examined as a function of participants’ sex (ie, boys, girls), race/ethnicity (ie, White, Black/African American, Hispanic/Latinx, with multiethnic/another race/ethnicity excluded in comparisons because of low prevalence), weight status (ie, BMI <fifth percentile, BMI 5–84.9th percentile, BMI 85–94.9^th percentile, BMI ≥95th percentile), and sexual orientation (ie, heterosexual, sexual minority) using 1 way analysis of variance. Subsequently, descriptive information regarding parent-reported use of body weight terminology is provided for the overall parent sample, followed by comparisons based on parent sex (ie, fathers, mothers, with individuals identifying as another sex excluded in sex comparisons because of low prevalence), parent race/ethnicity, and child weight status (same race/ethnicity and weight status comparisons as described above). Listwise deletion was used for missing data and statistical significance was set at P < .01 because of the multitude of comparisons.

Table 1 displays youth-reported frequency of the words their parents use to describe their body weight. Overall, the terms “normal weight,” “healthy weight, and “weight were reported to be used most frequent, whereas the terms “extremely obese,” “high BMI,” “obese,” and “BMI” were reported to be least frequent. Differences in terminology used by parents emerged inconsistently across each of the weight-related terms on the basis of sex, race/ethnicity, and sexual orientation. In general, frequency with which parents use the weight-related terms was higher among adolescents with BMI ≥95^th percentile, with the exception of terms specifically referencing low weight (eg, “skinny,” “thin”).

Prevalence of negative emotional reactions in response to parental use of words to talk about youth body weight is displayed in Table 2. Overall, the terms “overweight”, fat and extremely obese elicited the most negative emotions. For example, 43% of youth reported feeling embarrassed when their parents used the word overweight. In addition, 37% of youth indicated feeling ashamed in response to their parents using the terms “gaining too much weight,” “fat,” and “overweight” to describe their weight. Additionally, sadness was reported by at least a third of youth when their parents describe their weight using the terms “large,” “extremely obese,” “fat,” and “overweight.”

Emotional reactions to parental body weight terminology did not differ on the basis of youth weight status. Similar consistency was documented as a function of race/ethnicity, with a few exceptions; for example, the term “fat” elicited more negative emotions for white compared with Black/African American youth, and the term “underweight” evoked more negative emotions for Hispanic/Latinx youth relative to their white and Black/African American peers. Differences between girls and boys in emotional reactions emerged for just over a third of the weight-related terms, with more negative reactions reported by girls compared with boys. Finally, when considering differences as a function of sexual orientation, half of the weight-related terms elicited more negative reactions from sexual minority, relative to heterosexual, youth.

Table 3 presents preferences for parental use of body weight terminology among the full youth sample. Overall, more than half of youth prefer that their parents never use the terms “obese,” “fat,” “extremely obese,” “plus-size,” and “high BMI” to describe their weight. The most preferred terms overall were “healthy weight” and “normal weight.”

Demographic and weight-related differences in youth preferences for weight-related terminology use by parents are displayed in Table 4. When sex and sexual orientation differences were present, boys and heterosexual youth indicated a greater preference for parents to use each weight-related term compared with girls and sexual minority youth, with the exception of the term “curvy,” which was more preferred by girls than boys, and more preferred by sexual minority youth than those identifying as heterosexual. Preference for the term “curvy” was also higher among Hispanic/Latinx youth as compared with their white peers. Youth with a BMI ≥85th percentile, Black/African American, and Hispanic Latinx youth indicated a greater preference for their parents using the term “thick” to describe their body weight compared with those with lower body weight and/or identifying as white.

Table 5 displays parents’ reported frequency of using specific words and phrases to talk about their child’s weight. Overall, parents indicated using the terms “healthy weight,” “normal weight,” and “weight” most frequently, whereas the terms “extremely obese,” “fat,” “obese,” and “plus-size” were reported to be used least frequently. Fathers reported using each of the body weight terms more often than mothers. In addition, Hispanic/Latinx parents indicated higher usage of all of the weight terms compared with white and Black/African American parents, with the exception of the terms “normal weight” and “healthy weight,” in which no differences emerged between Hispanic/Latinx and white parents. Differences in parents’ use of each weight term varied as a function of child weight status; for example, parents with youth with BMI ≥95^th percentile reported using the terms “heavy,” “chubby,” and “fat” more often than parents of youth with lower weight.

Our study offers important insights about perceptions of weight terminology among racially/ethnically diverse youth. There was consistency in youth and parental reports regarding terms that parents use most frequently (eg, “weight,” “healthy weight,” “normal weight”) and least frequently (eg, “obese,” “extremely obese”). These findings suggest that parents appear to be defaulting to more neutral words when talking about their child’s weight, which align with adolescent-reported preferences for parental use of these words. However, parental use of terminology varied across sex, race/ethnicity, and child weight status, showing that, in some cases, parents are using terminology that adolescents do not feel comfortable with. For example, parental use of words such as “heavy,” “chubby,” and “fat” were more frequent among those with a child with BMI ≥95^th percentile compared with parents of youth with lower weight; yet, overall, 48% to 58% of adolescents indicated that they never want their parents to use these words. Further, parent-reported use of almost all weight terms was higher among fathers compared with mothers, and by Hispanic/Latinx parents compared with white and Black/African American parents. This parallels recent evidence documenting more frequent, youth-focused weight conversations reported by fathers and/or Hispanic/Latinx parents,^10,20  but suggests that these conversations may include weight terminology that induces negative emotional reactions in youth.

Our findings indicate that the terms “overweight,” “fat,” and “extremely obese” elicited the most negative emotions in youth, with more than one-third reporting embarrassment, shame, and sadness when their parents used these words to talk about their weight. Girls reported more negative emotions in response to weight terminology (including more neutral terms) than boys, consistent with previous evidence.^6,7  Notably, emotional reactions to parental weight terminology were generally consistent across weight status and race/ethnicity of youth. Several exceptions emerged, including more negative emotions to the term “fat” by white compared with Black/African American youth, and the term “underweight” among Hispanic/Latinx youth versus white and Black/African American peers. Our findings further indicated that half of the weight-related terms elicited more negative reactions from sexual minority, relative to heterosexual, youth. These data reflect the first assessment of weight terminology among sexual minority youth. With evidence documenting considerable weight-based victimization²¹  and higher body dissatisfaction²²  among sexual minority youth, more comprehensive examination of preferences for weight communication is needed in this population.

Finally, our findings point to several similarities and differences in youth preferences for weight terminology. Overall, youth’s most preferred terms were “healthy weight” and “normal weight,” whereas at least half of participants indicated that they never want their parents to use the terms “obese,” “fat,” “extremely obese,” “plus-size,” “big,” “weight problem,” “large,” and “high BMI” to describe their weight. These findings are similar to limited previous evidence in youth documenting a general dislike of words such as “obese” and “fat.”^11,17  However, differences in youth preferences for certain terminology emerged across several characteristics. Although girls expressed a higher preference for the term “curvy” than boys, they expressed lower preferences than boys for 19 of the remaining 26 items, including words such as “fat,” “obese,” “large,” and “heavy,” as well as more neutral words such as “weight.” Given girls’ more negative emotional reactions to weight terminology than boys in our sample and previous studies,^6,7  it may be that most weight terminology triggers lower preferences for weight communication in girls. Similarly, sexual minority youth expressed lower preferences for 17 of the 27 terms compared with heterosexual youth. Whether this finding reflects a broader discomfort in weight communication or a lack of options of preferred weight terminology among sexual minority youth will be important to investigate in future work. Differences also emerged for the word “thick,” which received higher preference ratings by youth with a BMI ≥85^th percentile and Black/African American and Hispanic/Latinx youth compared with their lower-weight and white peers. Overall, most youth preferred “thick over words and phrases such as “BMI, “higher body weight, “big,” “obese,” “fat,” and “gaining too much weight.” Preference for the word “curvy” was also higher among Hispanic/Latinx youth, sexual minority youth, and those with a BMI ≥95^th percentile compared with their white, heterosexual, and lower-weight peers. These findings reiterate the importance of appreciating sociocultural contexts²³  that contribute to youth’s assigned meanings and use of weight communication. For example, labels provide a meaningful sense of identity for denoting sexual and gender identity, and preferred terminology used by youth to describe their body size may provide an additional sense of self-awareness, empowerment, and acceptance, particularly for youth with multiple stigmatized identities (eg, because of their weight, sexual or gender identity, and/or their race/ethnicity).

Collectively, these findings highlight the need to recognize diversity in youth preferences for weight terminology, which may differ according to sex, sexual orientation, race/ethnicity, and weight status. By using youth’s preferred weight terminology when discussing weight-related health, parents can promote a more sensitive dialogue to help increase youth comfort levels and encourage their engagement in these conversations. Given that parental usage of weight terminology may not always align with their child’s preferences, and that many youth never want their parents to talk about their weight,¹⁰  pediatric providers have an opportunity to educate parents about the importance of using supportive, nonstigmatizing communication in parent–child interactions about weight-related health.

Limitations of this study should be noted. Our data reflect independent participant samples; future research should examine parent–child dyads to determine patterns of weight communication within families. Additionally, youth preferences for weight terminology may differ across familial and health care contexts, indicating a need to identify which terminology is most acceptable to youth in different settings. Our reliance on self-report and cross-sectional data limits any conclusions about changes in terminology preferences over time, and may be susceptible to socially desirable response patterns among parents who do not want to admit to using negative weight terminology. Future research should expand assessment of terminology preferences to youth with more diverse sexual and gender identities, including youth who identify as transgender. It will also be informative to examine parental characteristics associated with their use of specific weight terminology, such as previous experiences of weight stigma, weight status, and body image. Finally, study measures were only offered in English, and additional research is needed to understand the cultural nuances in the meanings of weight terminology in other languages and cultures. Our study also has several key strengths, including adolescent and parent samples of diverse racial/ethnic backgrounds, different weight categories, and both males and females. We also assessed a broader range of weight-related terms and phrases than previous research, allowing for comparison of word preferences that may have more salience in different cultural or racial/ethnic contexts. Our examination of youth emotional reactions to weight terminology provides additional insights that can inform weight-related communication between parents and youth.

Our findings show some consistencies in weight terminology that youth most prefer, dislike, and respond to with negative emotions, but also differences in their perceptions across sex, sexual orientation, race/ethnicity, and weight status. This individual variation can create challenges for communicating about weight with youth, especially in the absence of a single word or phrase that is universally accepted. However, by asking youth their preferred terms when discussing weight-related health, parents can promote more supportive and less stigmatizing communication with their children.