To say that there is an obesity epidemic is an understatement. The conditions of overweight (body mass index [BMI], 25-29.9 kg/m ² ) and obesity (BMI, >30 kg/m ² ) are becoming the norm in the United States and other countries. In the United States, almost 30% of adult women are overweight, and 36% are obese. These data are comparable with the proportion of women who are overweight in Canada (30%) and England (32%). Increased rates of all-cause mortality, increased rates of cancer incidence, and increased risks of death from cancer have all been attributed to increasing BMI. There are many challenges to addressing the issue of obesity and the role that it plays in women’s health. By highlighting the article by Jernigan et al published in this issue, we can begin to address some of the physician practices and attitudes that are related to obesity management in gynecologic oncology in an attempt to further this discussion with our patients and our colleagues, and ultimately to move toward a more comprehensive policy on this issue.

In gynecologic oncology, endometrial cancer has been tied most closely to excess weight. Although it is clear that there is an increased incidence of endometrial cancer in the obese woman, the data are conflicting with regards to the impact of obesity on cancer-related outcomes. In a population-based cohort study, Calle et al have reported a 6.25 increase in relative risk of death in obese women (BMI, >40 kg/m ² ) with endometrial cancer. However, in a retrospective analysis of a prospective trial (Medical Research Council: a study in the treatment of endometrial cancer [ASTEC]), Crosbie et al did not find an association between BMI and posttreatment survival in women with early-stage endometrial cancer. However, this may not be a fair comparison because that trial was primarily comprised of women with early-stage, early-grade endometrial cancer who have a relatively low rate of recurrence. Therefore, this low baseline recurrence risk may limit the ability to determine any increased recurrence risks based on patient weight.

If we do not consider disease-specific death rates, but look at all-cause deaths, the situation continues to be confusing. In a recently published systematic review and metaanalysis, all-cause death hazard ratios for overweight and the various obesity grades were calculated relative to normal weight. Although overweight was not associated with an increased risk of all cause death (hazard ratio, 0.94; 95% confidence interval, 0.91–0.96), obesity had a hazard ratio of 1.18 (95% confidence interval, 1.122–1.25). Could some of the inconsistencies in the literature be due to study methods? Some studies have used self-reported measures for height and weight; other studies have used measured data points. In a survey of adult men and women, only 22.2% of obese women and 6.7% of obese men were able to classify themselves correctly as obese. In fact, obese women believed that they would be obese if they had a BMI of 38.2 kg/m ² as opposed to a BMI of 30 kg/m ² . The inability of an obese adult to appreciate accurately that they are obese may result in them potentially ignoring health messages about obesity and may hinder their motivation to lose weight. Interestingly, this study found that the adults were able to report their height and weight accurately but were not able to put an accurate “label on their weight.” The term obesity can be associated with many negative connotations that may discourage an individual from using this term to describe him- or herself. In the Thesaurus, obesity is synonymous with “fatness, grossness, and flab.” Why would anyone want to characterize him- or herself in this way? We need to get away from the negative cosmetic connotations and personal attacks that are associated with the weight epidemic, and begin to treat obesity like the medical condition that it really is.

Why not make BMI another vital sign? As health care providers, we would not have any difficulty telling a patient that her blood pressure is high. Why should we react differently about her weight? Is it that we think that this is a taboo subject? Is it that we ourselves are overweight or obese? Is it that, if they want our help, we do not know what to do? It is most likely a combination of all of these concerns. In the article published in this issue by Jernigan et al, 42.7% of respondents to the survey self-reported being overweight/obese. Interestingly, not only did most of the gynecologic oncologists (82%) who were surveyed believe that discussing weight would not harm the doctor-patient relationship, but 85.1% of them believed that they are responsible for addressing obesity. However, there did appear to be a bias based on the age of the provider, with younger providers responding that gynecologic cancer survivors would benefit from obesity education. I submit that both providers and patients would benefit from obesity education. We should acknowledge a responsibility for addressing the issue, providing resource information, and referring our patients if we do not believe that we are equipped to provide the educational materials ourselves. The time to pass the buck and to be passive about this issue must come to an end.

As providers, if we address the issue of obesity with our patients, do we have the tools necessary to help them make changes, and are our patients motivated to make the necessary dietary and lifestyle modifications that are required? In a recent prospective study of endometrial cancer survivors, the authors were able to show that behavior change and weight loss are achievable in overweight and obese survivors and that, with a 1-year of follow-up evaluation, the modifications were sustainable in the intervention group. Longer follow-up periods will be required to assess longer term outcomes, such as disease-specific and overall deaths, which is a study being planned by the authors.

If we are able to show that lifestyle interventions are feasible, successful, and associated with improved outcomes for cancer patients, who will pay for the interventions? Who will pay for primary prevention strategies to try to decrease overweight and obese conditions initially in an effort to decrease the risk of cardiovascular disease, diabetes mellitus, and cancer? Is an ounce of prevention truly worth a pound of cure? When local governments have tried to tax sugared beverages, limit the size of sugared beverages, or required posting of nutritional information at fast-food franchises or restaurants, this has been met with mixed reactions. Some have advocated for the posting of nutritional information in the belief that, if the public were aware and informed, they may make different choices; others (food industry) have lobbied that increased “fat or sugar” taxes may infringe on personal freedoms and that ultimately the individual has to take greater responsibility for their food choices.

As stated by Brownwell et al, “The challenge is to combine personal and collective responsibility approaches in ways that best serve the public good.” Combating the obesity pandemic will take a comprehensive approach, and we should all bear this responsibility. Governments have been proactive in other public health arenas such as vaccination programs and drug approvals, and this is no different. Parents, pediatricians, and schools ensure that children receive the required vaccinations. Can we also demand that our children receive healthy meals at home and at school? Are food choices and the health effects of obesity any less important than the effects of preventable infections? Again to quote Brownwell et al in their call to action, “Creating conditions that foster and support personal responsibility is central to public health. Default conditions now contribute to obesity, a reality that no amount of education or imploring of individuals can reverse. Government has a wide variety of options at its command to address the obesity problem. Judicious use of this authority can increase responsibility, help individuals meet personal goals, and reduce the nation’s healthcare costs.”