This paper is the first to examine the associations between physician BMI and patient trust as well as physician BMI and weight-related stigma. With respect to overall trust, our results suggest that overweight and obese patients trust their PCPs, regardless of their body weight. With respect to trust in weight-related advice, we found that patients more strongly trusted diet advice from overweight PCPs as compared to normal BMI PCPs which is consistent with our hypotheses. Inconsistent with our study hypotheses was the finding that patient perceptions of weight-related stigma increased with physician BMI. Patients seeing obese PCPs, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight. In our sample of overweight and obese patients, a fifth of all respondents reported feeling judged by their physician because of their weight.
These results suggest that physician BMI impacts patient trust in their PCP. Interestingly, these results are contrary to our early study looking at the impact of physician BMI and obesity care. In that study we found that normal weight doctors are more likely to provide recommended obesity care and feel comfortable doing so as compared to overweight and obese physicians (Bleich et al., 2012
). High levels of trust in weight-related advice from PCPs, particularly heavier PCPs, could be due to the fact that concordance between patient and PCP body weight improves the relationship from the patient perspective. In particular, the shared weight identity between an overweight/obese patient and an overweight/obese PCP may improve their interaction and communication about weight-related behaviors (Bissell et al., 2004
; Burgess et al., 2004
; Street et al., 2008
). However, patients’ high levels of trust in weight-related advice may be inappropriate as prior studies of PCPs show lack of knowledge and low self-efficacy regarding obesity care (Block et al., 2003
; Eriksen and Ujam, 1992; Forman-Hoffman et al., 2006
; Jay et al., 2008
; Vetter et al., 2008
While weight-related stigma has been documented among health professionals for decades (Puhl and Heuer, 2009
) as well as lowers physician respect towards patients with a higher BMI (Huizinga et al., 2009
), our finding that weight-related stigma increases with physician BMI is puzzling. One potential reason could be that physicians with a higher BMI have been stigmatized themselves and internalization of these negative attitudes could, in turn, lead to perpetration of the same behavior among patients (García et al., 2004
). Recent research among adolescents suggests that obese teens are more likely to be recipients and perpetrators of weight-related teasing (Kukaswadia et al., 2012
). Another explanation could be that heavier physicians simply do not perceive themselves as overweight or obese. The misclassification of weight status has increased among heavier individuals with overweight and obese individuals becoming increasingly less likely to self-identify as overweight (Johnson et al., 2008
). Therefore, our finding of high rates of weight-related stigma may be a reflection of general physician stigma towards obesity (Kristeller and Hoerr, 1997
Improving rates of weight related counseling in primary care settings is an important strategy to promote behavior change in obese patients, particularly due to the recent expansions of Medicare and Medicaid coverage for obesity care. There is a growing body of evidence suggesting that patients who are told by their physician that they are overweight are more likely to lose weight relative to those who are not told (Kant and Miner, 2007
; Levy and Williamson, 1988
), that patients who are counseled about their weight or weight-related behaviors are more likely to report working on those areas (Calfas et al., 1997
; Galuska et al., 1999
; Loureiro and Nayga, 2006
; Sciamanna et al., 2000
), and that patients who are advised by their physician to modify their behavior are generally more confident and motivated to engage in lifestyle modifications (e.g., dietary changes, increased physical activity) (Galuska et al., 1999
; Huang et al., 2004
; Kreuter et al., 2000
However, effective screening and counseling from PCPs is necessary but not sufficient to solve the problem of obesity. The relative success of these new public insurance obesity benefits may largely hinge on whether knowledge, self-efficacy, and stigma-related barriers faced by PCPs can be addressed. It is reassuring to know that overweight and obese patients generally trust their PCPs. This may help enhance the impact of intensive behavioral counseling even if patient-, physician- and health-system barriers to obesity care persist.
Future research should further examine the impact of physician BMI on obesity care. In particular, why patient perceived physician stigma is higher among heavier PCPS and why the patterns we observed between physician BMI and trust in weight-related counseling differ by the type of counseling. More research is also needed to understand the mechanisms driving higher trust among heavier PCPs as well as whether particular physician practices related to obesity care engender higher levels of trust in patients. It will also be interesting to examine why patient trust in diet advice was significantly higher among overweight (but not obese) PCPs as compared to normal BMI PCPs. Finally, it is puzzling that we observed relationships between patient trust in diet advice and physician BMI but not between patient trust in weight control/physical activity advice and physician BMI. Going forward, it will be important to better understand these relationships.
There are several limitations to this analysis. First, it is cross-sectional which only allows us to address associations rather than causal inferences. Second, we relied on respondents’ self-reported height and weight which typically underestimate BMI (Ezzati et al., 2006
). Third, unmeasured patient or physician factors may have affected our findings. Examples include patient familiarity with their physician and patient and physician attitudes towards obesity and preferred communication styles. Fourth, even though the survey was reviewed by experts in the fields of obesity and primary care as well as pilot tested for comprehensibility, it is possible that respondents differentially interpreted some of the questions. Fifth, the study population is restricted to those individuals who reported having a primary care visit in the past year, so findings are not generalizable to those individuals who lack this level of access to health care. Sixth, trust may mean different things for survey respondents (e.g., technical competency, interpersonal competency etc.) which could lead the survey question to capture different components of the trust concept. Seventh, the pictures of body images have not been have previously validated against observed BMI. Therefore, it is unknowable whether patients are more likely to misclassify the body weight of their physicians in some categories but not others. Patient reports of physician weight need to be validated against actual physician weight to fully understand the validity of the pictogram and whether misclassification – if any – exists. Eighth, it is possible that patient trust influenced their memory of PCP weight since PCP visits occurred prior to data collection. To address this potential recall bias, we did adjust for the length of time since the patients’ last visit with their PCP. Ninth, given that the use of web-based surveys is relatively new, potential sources of biases are not entirely understood. Finally, all PCP characteristics are reported by patients, which could misrepresent some of the physicians in the sample.