Why are women with excess body weight more likely to get cervical cancer? There are plenty of studies that clearly show that many cancers are related to obesity (1,2), partially due to hormonal changes and increased inflammation. Cervical cancer, however, is not one of these obesity-related cancers. Rather, it is associated with changes brought on by a virus (HPV). Weight should have nothing to do with it. What, then, is the explanation?
One explanation, I think, is fat-shaming.
Traditionally, most physicians think that obesity is basically a behavioral problem related to nothing more complicated than eating too much and exercising too little (3). Just like other members of our society, doctors and medical students are biased toward obese people (2, 4) and characterize them as “noncompliant, lacking in motivation and self-indulgent” (2). In Roxane Gay’s memoir, "Hunger," she makes an observation that unfortunately applies to many doctors: "...when people use the word 'obese,' they aren't merely being literal. They are offering forth an accusation" (5).
Instead of addressing the patient’s needs and concerns, physicians are all too willing to blame every problem on weight and to blame the patient for being in this predicament. Here’s what Jae has to say about this:
Before I lost weight, when I was in high school and weighed 270 pounds, I was so embarrassed to go to the doctor — the only thing she saw was my fat. I felt dehumanized. She automatically saw my obesity as an explanation for any and all symptoms I had. Then she would lecture me on the importance of diet and exercise.
Of course I knew I was fat — I'm not stupid. I knew my weight was a significant problem because I was the one living with it. I knew how crappy I felt, how sluggish and tired I always was. She didn't have to tell me that. It's so demoralizing and hurtful when you go in to see someone who has sworn to heal you; and instead, she makes you feel as if you are being judged or viewed as "lesser" just for your weight status. All I wanted was for her to see beyond my fat, to not devalue me as a human being, and to genuinely try to help me.
Women who avoid medical visits and, as a result, do not get regular Pap testing, are at much, much greater risk for developing cervical cancer. And studies have confirmed that overweight women are less likely to seek preventive care and opportunities for early diagnosis and treatment (6,7), even after controlling for socioeconomic status (8). Why is that? I think it’s because they feel so much shame about their bodies and because we doctors often add to that shame by saying stupid things, like, “you really need to lose weight.” So these women are likely to just stay home.
Doctor, Heal Thyself
Until I struggled with weight myself, I was as clueless and even judgmental as so many other physicians. If your doctor tells you to eat less and exercise more, that implies that you don’t already know that; it implies that you don’t care; it implies that you just need to try harder. Are you ever again going to trust that doctor as a person who might be able to really help you with your challenges? Why should you, when all she has done is to pile on even more shame?
Eventually, I learned that support and encouragement regarding healthy foods and physical activity were useful — but, more importantly, my patients and I needed to enter into a pact o avoid judgment, blame, or failure. There were only difficulties that could be followed by new opportunities. It all had to be positive.
Being obese may be unhealthy, but it’s not a moral failing, and we all share in the responsibility to detach shame from body size in other people and ourselves. It is up to all of us to stop viewing heavy people as undisciplined or unmotivated (2, 9,10). We need to teach our children, and we need to teach ourselves. I want to take back every word I said to patients about there being “a simple equation of calories in and calories out.” Here’s what I finally learned to tell my patients:
I don’t care what you weigh. I care that you eat healthy food and that you incorporate movement into your life. I care that you don’t hate yourself. I care that you don’t view your body as enemy territory. I care that you get enough sleep. I care that you spend time with people you love. I care that you go to the dentist twice a year and practice safe sex. The rest is up to you.
(1)Sung H et al. Global patterns in excess body weight and the associated cancer burden. CA Cancer J Clin 2018;0:1–25.
(2)Zheng Y et al. Associations of weight gain from early to middle adulthood with major health outcomes later in life. JAMA 2017; 318(3):255-69.
(3)Wang SS et al. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord 2004; 28:1333‐7.
(4)Puhl RM et al. Obesity bias in training attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity 2014; 22(4):1008-15.
(5)Gay Roxane. Hunger. New York: Harper Collins, 2017.
(6)Poorolajal J; Jenabi E. The association between BMI and cervical cancer risk: a meta-analysis. Eur J Ca Prev 2016; 25(3):232-8.
(7) Wee, CC et al. Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Annals of Internal Medicine. 2000; 132(9):697-704.
(8)Gu W et al. Obesity-associated endometrial and cervical cancers. Front Biosci 2013; 5:109.
(9) Lindeman, M et al. The effects of messages about the causes of obesity on disciplinary action decisions for overweight employees. J Psychol 2017; 151(4):345-58.
(10)Puhl RM, Heuer CA. The Stigma of Obesity: A Review and Update. Obesity 2009;17(5):941-64.