Use of person-centered language in obesity-related publications across sports medicine journals: a systematic review of adherence to person-centered language guidelines in sports medicine

Search strategy

Our group conducted a PubMed (which encompasses MEDLINE) systematic search on September 20, 2022, utilizing an adapted and updated search string from Exercise for overweight or obesity [23] (Supplement 1).

Article inclusion

Our search included studies published from January 1, 2019, through September 20, 2022. The journals included were the top 10 journals listed utilizing Google Metrics data (scholar.google.com/citations?view_op=top_venues) under the subcategory of Physical Education and Sports Medicine within the Health and Medical Sciences genre (Table 1). The search returns were randomized and placed in a Google Sheet for screening and extraction. The inclusion criteria were: original research related to or commenting on publications related to obesity, English manuscripts, and involved human subjects. The process of exclusion of articles is shown in Figure 1. The study did not include editorials and opinion pieces because the focus was on research studies.

Figure 1:

Flow diagram of inclusion and exclusion of articles screened.

Data extraction

Data extraction was conducted by two investigators utilizing Google Sheets in a blinded, duplicate manner in accordance with the best practices of meta-epidemiologic research [24]. The investigators then met to resolve differences in answers. The senior author served as a third party to resolve disagreements.

Our primary outcome was looking at the adherence to guidelines established by AMAMS related to PCL [15], which are presented in the introduction and continued specifically for obesity within resolution H-440.821 [25]. Thus, we systematically included articles in our search for the terms, partial terms, and phrases, along with terms identified in other studies [14, 26, 27] included in Figure 2. Additional elements collected from the articles were the type of research, the type of intervention, the institution of the first and last authors, the funding source, and the continent of origin.

Figure 2:

Percentage usage of non-person-centered language among sports medicine journals.

Data analysis

We reported the number of articles returned from our initial search, how many articles were excluded (and the reason), and the number of articles included overall and from each journal. We then calculated the proportion of articles adhering to PCL guidelines (i.e., not including the stigmatizing words listed above) among the sample and by a journal. Next, we calculated the incidence of each predetermined term. We utilized bivariate logistic regression to measure associations between PCL adherence and article characteristics utilizing Stata 16.1. (StataCorp, LLC; College Station, TX).

Article inclusion

Our search yielded 715 studies across the top 10 sports medicine journals based on Google metric data from September 20, 2022. We then screened these articles to see if they were pertinent to our study. A total of 504 articles were excluded for not being focused on obesity, 3 were not included due to not being focused on humans, and 11 could not be accessed. A total of 198 articles based on the criteria were deemed pertinent to have word searches conducted. Among the 10 journals, only 82 bodies of work showed adherence to obesity-related guidelines.

Study characteristics

Of the 198 articles, 47.5 % were cross-sectional studies (94/198) and 68.2 % (135/198) did not include an intervention. Grants were the most commonly listed funded resources (127/198; 64.1 %), and most of the authors were from public universities (185/198; 93.4 %). Additional characteristics of the studies can be found in Table 2.

Adherence to person-centered language

Across the 198 articles included in the final screen, 116 (58.6 %) were not compliant with the AMAMS PCL guidelines. Throughout all 198 published bodies of work, we found 201 cases of non-PCL terms being utilized. Out of all of the selected screened terms, the most commonly utilized stigmas were “obese” (98/198; 49.5 %) and “overweight” (80/198; 40.4 %). Other stigmatizing terms, such as “fat” as a label, “morbid,” “diabetic,” and “heavy, heavier,” were less frequent but still appeared in published works.

Associations of person-centered language and article characteristics

We utilized binary logistic regression to determine associations of PCL adherence and type of intervention, funding source, type of research, first-author employment, and the study’s continent of origin. Among these models, the only statistically significant association was for the continent of origin from which comparisons were made to studies from North America, and those published in European countries were less likely to be PCL adherent (OR: 0.31; 95 % CI: 0.16–0.60).

Recommendations

Sports medicine journal adherence to PCL guidelines may be improved by increasing author, editor, and journal awareness to obesity-centered stigma on health outcomes. By educating authors on utilizing PCL, we could limit the stigmatizing language that is filtered into academic literature. Education throughout all levels of medical education (physicians, residents, and medical students) can aid in limiting the usage of non-PCL in medical academia. We recommend that researchers utilize a similar protocol that we utilized here by screening their own manuscripts for stigmatizing language. Utilizing terminology such as “individuals with obesity” can be easily done by utilizing the “search/find” feature available throughout all writing platforms, including Google Docs, Microsoft Word, and Adobe Acrobat Reader. We also advise that all institutions that produce medical research adopt PCL guidelines similar to the AMAMS and ICMJE. This will prevent the perception of stigmatizing language in their bodies of work. Along with literature adherence, we encourage educators, physicians, and researchers to be trained in person-first language to influence the adoption of nonstigmatizing language into health-related careers. This includes utilizing PCL in reference to patients who are overweight/obese in the clinical setting. Clinicians, medical students, and healthcare workers should be taught to avoid identifying patients based on their medical conditions to limit harmful outcomes and prioritize patient well-being. With these changes, we can more effectively target patient-centered weight loss while minimizing the barriers set forth by stigmatizing language in medical care.

Limitations

Limitations of this study include the potential of human error in screening for stigmatizing language, as defined by AMAMS. To mitigate this error, screeners were trained in data extraction procedures for non-PCL terms and followed a stepwise protocol for reviewing publications. Additionally, the list of predetermined non-PCL may not include all stigmatizing terminology. Finally, our study focused on the 10 top journals from the specified category within Google Metrics; therefore, other journals need to be evaluated. The strengths of our study include a publicly available protocol to ensure reproducibility and our focus on the top impactful journals. Studies in the future should focus on expanding the literature on PCL adherence in accordance with AMAMS guidelines in other medical specialties.