PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Am J Prev Med. Author manuscript; available in PMC Jun 1, 2008.
Published in final edited form as:
PMCID: PMC1986842
NIHMSID: NIHMS25375
Cancer Screening in Women: BMI and Adherence to Physician Recommendations
Jeanne M. Ferrante, MD,1,2 Ping-Hsin Chen, PhD,1 Benjamin F. Crabtree, PhD,2,3 and Daniel Wartenberg, PhD2,4
1 Department of Family Medicine, UMDNJ-New Jersey Medical School, Newark, NJ
2 The Cancer Institute of New Jersey, New Brunswick, NJ
3 Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
4 Department of Environmental and Occupational Medicine, UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ
Correspondence and reprint requests: Jeanne M. Ferrante, MD, Department of Family Medicine, UMDNJ-New Jersey Medical School, MSB-B648, P.O. Box 1709, Newark, NJ 07101-1709, Phone: 973-972-6481, Fax: 973-972-7997, E-mail: ferranjm/at/umdnj.edu
Objectives
Reasons obese women are less likely to obtain mammograms and Pap smears are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear.
Methods
Data from the 2000 National Health Interview Survey (8289 women aged 40-74 years) were analyzed in 2006 using logistic regression. Women with prior hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear.
Results
After adjusting for sociodemographic variables, health care access, health behaviors, and comorbidity, severely obese women (BMI ≥ 40 kg/m2) were less likely to have mammography within 2 years (OR 0.50; 95% CI 0.37, 0.68) and Pap smear within 3 years (OR, 0.43; 95% CI, 0.27,0.70). Obese women were as likely as normal weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendation for mammography (OR 0.49; 95% CI, 0.32-0.76). Women in all obese categories (BMI ≥ 30 kg/m2) were less likely to adhere to physician recommendation for Pap smear (OR's ranged 0.17-0.28; p<0.001).
Conclusions
Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.
The prevalence of obesity, defined as body mass index (BMI) ≥ 30 kg/m2, among US adults has increased from 23% during 1988-1994 to 32% during 2003-2004. In addition, the prevalence of severe obesity (BMI ≥ 40 kg/m2) increased from about 1 in 35 adult Americans to 1 in 20.1, 2 Obesity is associated with increased incidence of breast and cervical cancer,3, 4 later stage breast cancer diagnosis,5-8 and higher breast and cervical cancer mortality rates.9, 10
Obese women, particularly those with BMI > 35-40, have lower rates of mammograms and Pap smears.11-18 One of the strongest and most consistent predictors of cancer screening is a physician's recommendation. 19-21 It is unclear if the lower rates of cancer screening in obese women are due to lack of physician recommendations or patients not adhering to physician recommendations. Factors associated with physician recommendations for mammography include having private insurance, higher income, higher education, younger age, greater number of visits, a regular physician, greater number of physicians seen, personal history of breast problems, a recent Pap smear, and taking medications.22-24 Factors associated with physician recommendations for Pap smear include younger age, being born in the US, and having contact with a specialist or general doctor in the past year.25 It is unknown if physicians are less likely to recommend mammogram or Pap smears to obese women. Obese patients are stereotyped to have less willpower and be less concerned about their health than non-obese patients.26, 27 Physicians may subconsciously feel obese patients are less interested in preventive care, and thus be less likely to suggest cancer screening. Increasing BMI is associated with a greater number of different physicians seen, 28 so that physicians may assume that someone else will order cancer screening. In addition, physicians may be less likely to pursue pelvic examinations in severely obese patients due to technical difficulties or increased comorbidity. 29, 30
The degree to which obese women adhere to physician's recommendations for breast and cervical cancer screening is also unknown. Factors associated with adherence to mammography recommendation are having private insurance, being seen in family practice, and having a recent Pap smear. 22 There are no studies exploring the relationship between BMI and adherence to doctors' recommendations for mammography or Pap smear. The purpose of this study is to determine if BMI is associated with receipt of and adherence to physician recommendations for mammography and Pap smear.
Study Population
This study, conducted in 2006, analyzed data collected from the 2000 National Health Interview Survey (NHIS), a cross-sectional in-person health survey conducted annually by the National Center for Health Statistics, Centers of Disease Control and Prevention (CDC). 31 It uses a multistage, stratified, clustered sampling design to obtain health-related information of the U.S. population. In 2000, one adult, randomly selected from each of 43,437 households, answered a supplemental Cancer Control Module that fielded a number of questions relating to cancer screening (n=32,374). The response rate was 72% to the supplement and core surveys.31
Women age 40–74 years who responded to the Cancer Control supplement (n=8289) were included in this analysis. Women under the age of 40 were excluded because breast cancer screening is not recommended in women under age 40, and women under 40 tend to get Pap smear screening as part of their reproductive care, so obesity may not be as great a barrier to Pap smear screening in those younger than age 40. Women age 75 and over were excluded because physician agreement of screening tests in those over 74 years is not universal.32 Women who had hysterectomies were excluded from Pap smear outcomes. The Institutional Review Board of the University of Medicine and Dentistry of New Jersey-New Jersey Medical School approved the use of the NHIS database.
Outcome Measures
The outcome measures were: up-to-date in screening, physician recommendation, and patient adherence to physician recommendations. Up-to-date in screening was defined as the proportion of all respondents who had a clinical breast exam (CBE) within 2 years, mammogram within 2 years, or Pap smear within 3 years. 33, 34 Physician recommendation was defined as the proportion of all women who received a recommendation to have mammogram or Pap smear. All women who received screening were assumed to have physician recommendations.22, 35 Women who didn't receive mammogram or Pap smears were asked the primary reason for not having the test. Women reporting a primary reason other than “doctor didn't recommend it” were asked whether their doctor recommended a mammogram or Pap smear in the last 12 months. Women were classified as not receiving a physician recommendation if they reported their “doctor didn't recommend it” as the primary reason, or they answered the follow-up question that they did not have a physician recommendation. Women who did not see a physician in the past year were excluded from the outcome of physician recommendation. Patient adherence to physician recommendations was defined as the proportion of women receiving physician recommendations who had a mammogram within 2 years or Pap smear within 3 years.
Independent Variables
The main independent variable of interest was BMI, defined as self-reported body weight (in kilograms) divided by self-reported height (in meters squared) at NHIS interview. Underweight women (BMI < 18.5) were excluded because they have lower rates of mammography and Pap smears, perhaps due to severe illness (n=505).13 Potential confounding variables included sociodemographics (age, race/ethnicity, marital status, educational level, region of country, income), access to care (health insurance, contact with primary care doctor, number of visits), health behaviors (smoking, exercise, alcohol use, vitamin use), and health risks (family history of breast or cervical cancer, comorbidity). Comorbidity was determined using the Charlson comorbidity index, a weighted index of 19 selected categories of disease that are associated with mortality and other important health outcomes.36
Statistical Analysis
Using descriptive statistics and bivariable analyses, the sample was characterized based on published definitions of BMI categories: normal weight (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2), obese class I (30 to < 35 kg/m2), obese class II (35 to < 40 kg/m2), and obese class III (≥ 40 kg/m2). 37 Prevalence of being up-to-date in screening, physician recommendation, and patient adherence to physician recommendation by BMI were compared using the chi-square test. A series of multivariable logistic regression models were built for each separate outcome: up-to-date in CBE, mammography, and Pap smear; physician recommendation for mammography and Pap smear; and patient adherence to mammography and Pap smear recommendations. First, an unadjusted model was developed that included only categories of BMI as the independent variable. Then, a fully adjusted model controlled for potential confounders. This full model was compared to a reduced model that used a backwards elimination variable selection procedure. Variables significantly associated with each outcome at the p<0.10 level were retained in this reduced model. Indicator variables for BMI were forced into the reduced model. Since there was no significant difference in the full and reduced models, the reduced models are presented for greater parsimony. Because authorities now recommend stopping Pap smears at age 65 if consistently normal, 34 analyses for all Pap models were repeated with only age group 40-64. Results were similar, so results for the whole sample are presented.
All analyses used SAS-callable SUDAAN (version 9.0, Research Triangle Institute, Research Triangle Park, North Carolina, 2005) to adjust for the complex sampling design. Results were weighted to reflect the oversampling of African-Americans and Hispanics, the nonresponse rate, and population estimates from the U.S. Census. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated. Statistical significance was set at p<0.05.
Table 1 shows the characteristics of women in the study sample by BMI categories. Overall, 42% were normal weight, 32% were overweight, and 26% were obese. Increasing BMI was significantly associated with age, Black race, lower education, lower incomes, Medicaid insurance, contact with a primary care doctor, greater number of visits, and higher number of comorbidities.
Table 1
Table 1
Characteristics of women in the study sample by BMI categories
Table 2 shows unadjusted associations among BMI categories and each outcome. There were significant differences across BMI categories for all outcomes except physician recommendation for Pap smear. Rates were lowest for severely obese women for all outcomes. Compared with normal weight women, severely obese women had 9% to 10% lower prevalence of being up-to-date in clinical breast exams (69% vs. 78%), mammography (62% vs. 72%), and Pap smears (77% vs. 86%).
Table 2
Table 2
Unadjusted prevalence of screening, physician recommendation, and patient adherence to physician recommendation by BMI category
Table 3 shows adjusted results for each primary outcome by BMI categories from the reduced multivariate models. Compared with normal weight women, women in all obese categories were less likely to be up-to-date with CBE. Women in the severely obese category had 50% decreased odds of being up-to-date with mammogram and 57% decreased odds of being up-to-date with Pap smear. Although there was a significant difference across BMI categories for physician recommendation for mammograms in the unadjusted model, controlling for sociodemographics, insurance, health behaviors, and comorbidity eliminated this difference. Likewise, BMI was not statistically associated with physician recommendations for Pap smear. Severely obese women had 51% decreased odds of adhering to physician recommendations for mammogram. Women in all obese categories were less likely to adhere to physician recommendations for Pap smear.
Table 3
Table 3
Adjusted odds ratios (OR) for screening, physician recommendation, and patient adherence to physician recommendation by BMI*
This study suggests that patient barriers are more important than physician barriers for decreased rates of Pap smears and mammograms in obese women, particularly severely obese women. Since physician recommendation is the strongest predictor of cancer screening in women, it is reassuring that physicians are as likely to recommend mammograms and Pap smears to obese as well as non-obese women. The lower prevalence of breast and cervical cancer screening in severely obese women is not due to lack of physician recommendations, but rather to lower adherence to physician recommendations.
Despite the success of the CDC's Breast and Cervical Cancer Early Detection Program in increasing screening in poor and minority women,38 screening disparities still exist for another high-risk group: severely obese women. The reasons for this are unclear. Cancer screening may be a low priority for an obese woman in the context of other personal and family health priorities. 39 Obese women have greater economic and health burdens due to higher poverty, greater number of comorbid conditions, and greater need for physician visits. 40, 41 However, after adjustment for income, comorbidity, and number of physician visits, associations between BMI, screening, and adherence to physician recommendations did not alter. Obese women have greater number of physician visits so they should have more opportunities for cancer screening. Instead, this study shows that despite obese patients having more visits to the physician, they were less likely to have mammograms and Pap smears. Obese persons have more contacts with primary care physicians and see physicians more frequently, presumably to manage chronic conditions, but they might postpone preventive exams that do not address specific symptoms or present illnesses.
Another cause for disparities in cancer screening in obese women may be patient and clinician attitudes. Increasing weight has been associated with having negative opinions about one's appearance and reluctance to obtain pelvic examinations. 29, 42 Obese women may have higher anxiety regarding physical privacy, embarrassment regarding weight, and perceptions of increased pain and discomfort from the procedures.43-45 In addition, obese women may delay preventive exams because they encounter negative attitudes or judgmental behavior from health professionals, they do not want to be weighed, or they do not want to receive lectures regarding weight.42, 46-48 Improving patient-physician relationships and interactions are needed to overcome these barriers.
There appears to be a “threshold effect” in the association of BMI with being up-to-date on mammography and adherence to physician recommendation for mammography. Only the most severely obese women had decreased odds of being up-to-date and adhering to physician recommendations for mammograms, while women in all obese categories were less likely to be up-to-date in CBE and adherent to recommendations for Pap smear. Clinical breast exams and Pap smears require disrobing in physician offices and being physically examined by physicians, so they may be considered to be more personally invasive and uncomfortable than obtaining a mammogram. Prior experience of pain and discomfort with procedures may dissuade obese women from obtaining cancer screenings. 42 In addition, health care facilities may not be equipped for examining severely obese patients. Small size gowns, exam tables, and small speculums are barriers for obese women in receiving preventive health care.42
Although rates for mammography and Pap smears for normal weight and less obese women are near Healthy People 2010 targets of 70% for mammograms and 90% for Pap smears, 49 rates for severely obese women lag behind (62.3% and 76.9%, respectively). While absolute differences of 9% to 10% in proportion of women receiving screening between severely obese and normal weight women may appear small, these findings are concerning given the increasing epidemic of severe obesity in the US 1, 2 and the higher mortality rates for breast and cervical cancer in obese women.9, 10 To reach Healthy People 2010 objectives of reducing death rates from breast and cervical cancer, and increasing proportions of women receiving mammograms and Pap smears, targeting high-risk severely obese women to increase adherence to physician recommendations is needed.
This study has several limitations. All information were derived from self-report data. Concordance between self-reported data on cancer screening and medical record documentation has been found to be satisfactory for purposes of monitoring national level and trends in usage. 50-53 A woman's recall of physician recommendation may be biased, but it is unlikely that reporting errors would differ across BMI categories. Additionally, patients may be subject to recall bias when reporting weight and height, with obese women overestimating height and underestimating weight more than thinner women.54 This would decrease the ability to detect differences across BMI, so these results may underestimate true associations. Women who were up-to-date on screening were assumed to have received recommendations from their physicians, so women who self-referred for screening may have been misclassified. However, few women get mammograms without a recommendation.55, 56 Self-referral is more common at mobile mammography facilities and in women under age 40.55 This sample population consisted of women over age 40, and only 2.29% (n=153) reported receiving screening in a mammogram van. Finally, it was not possible to control for all confounders or explanatory factors such as patients' health beliefs or attitudes, physician characteristics, or the nature of patient-physician relationships, which may influence cancer screening and adherence to screening recommendations.
In summary, this study shows physicians are as likely to recommend breast and cervical cancer screening to obese women as to non-obese women, but obese women are less likely to adhere to physician recommendations. Despite the critical role of physician recommendations in increasing cancer screening, interventions focusing solely on increasing physician recommendations of mammography and Pap smears will probably be insufficient for obese women. Qualitative studies are needed to examine specific barriers encountered by obese women to understand their reluctance to adhere to physician recommendations for mammograms and Pap smears. Research is needed on strategies to improve the clinician-patient interaction, how this dialogue can be modified when discussing cancer screening in obese women, and how medical facilities can be enhanced to better accommodate severely obese patients. In addition, follow-up is needed with patients once they are given advice to undergo cancer screening to ensure compliance. Since obese women are more likely to develop and die from breast and cervical cancer, additional strategies are needed to make cancer screening more acceptable for this high-risk group.
Acknowledgments
Dr. Ferrante is the recipient of a career development award (1K07CA101780-01-A2) from the National Cancer Institute, which supported this study. We thank the National Center for Health Statistics for providing the NHIS database. The analyses, interpretations, and conclusions are those of the authors and do not reflect those of the National Center for Health Statistics.
Footnotes
No financial conflict of interest was reported by the authors of this paper.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288(14):1723–27. [PubMed]
2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549–55. [PubMed]
3. Harvard report on cancer prevention. Causes of human cancer. Obesity Cancer Causes Control. 1996;7 1:S11–3. Anonymous.
4. Field AE, Coakley EH, Must A, et al. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med. 2001;161(13):1581–6. [PubMed]
5. Jones BA, Kasi SV, Curnen MG, Owens PH, Dubrow R. Severe obesity as an explanatory factor for the black/white difference in stage at diagnosis of breast cancer. Am J Epidemiol. 1997;146(5):394–404. [PubMed]
6. Hall HI, Coates RJ, Uhler RJ, et al. Stage of breast cancer in relation to body mass index and bra cup size. Intl J Cancer. 1999;82(1):23–7.
7. Moorman P, Jones B, Millikan R, Hall I, Newman B. Race, anthropometric factors, and stage at diagnosis of breast cancer. Am J Epidemiol. 2001;153(3):284–91. [PubMed]
8. Cui YD, Whiteman MK, Landenberg P, et al. Can obesity explain the racial difference in stage of breast cancer at diagnosis between black and white women? J Womens Health Gend Based Med. 2002;11(6):527–36. [PubMed]
9. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348(17):1625–38. [PubMed]
10. Garfinkel L. Overweight and cancer. Ann Intern Med. 1985;103(6 Pt 2):1034–6. [PubMed]
11. Fontaine KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med. 1998;7(4):381–4. [PubMed]
12. Wee CC, McCarthy EP, Davis RB, Phillips RS. Screening for cervical and breast cancer: is obesity an unrecognized barrier to preventive care? Ann Intern Med. 2000;132(9):697–704. [PubMed]
13. Fontaine KR, Heo M, Allison DB. Body weight and cancer screening among women. J Womens Health Gend Based Med. 2001;10(5):463–70. [PubMed]
14. Amonkar MM, Madhavan S. Compliance rates and predictors of cancer screening recommendations among Appalachian women. J Health Care Poor Underserved. 2002;13(4):443–60. [PubMed]
15. Wee CC, McCarthy EP, Davis RB, Phillips RS. Obesity and breast cancer screening. The influence of race, illness burden, and other factors. J Gen Intern Med. 2004;19:324–31. [PMC free article] [PubMed]
16. Wee CC, Phillips RS, McCarthy EP. BMI and cervical cancer screening among White, African-American, and Hispanic women in the United States. Obes Res. 2005;13(7):1275–80. [PubMed]
17. Ostbye T, Taylor DH, Jr, Yancy WS, Jr, Krause KM. Associations between obesity and receipt of screening mammography, Papanicolaou tests, and influenza vaccination: results from the Health and Retirement Study (HRS) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study. Am J Public Health. 2005;95(9):1623–30. [PubMed]
18. Ferrante JM, Chen P, Jacobs A. Breast and cervical cancer screening in obese minority women. J Womens Health. 2006;15(5):512–22.
19. Fox SA, Murata PJ, Stein JA. The impact of physician compliance on screening mammography for older women. Arch Intern Med. 1991;151(1):50–6. [PubMed]
20. Grady KE, Lemkau JP, McVay JM, Reisine ST. The importance of physician encouragement in breast cancer screening of older women. Prev Med. 1992;21:766–80. [PubMed]
21. Love RR, Brown RL, Davis JE, Baumann LJ, Fontana SA, Sanner LA. Frequency and determinants of screening for breast cancer in primary care group practice. Arch Intern Med. 1993;153:2113–7. [PubMed]
22. May DS, Kiefe CI, Funkhouser E, Fouad MN. Compliance with mammography guidelines: physician recommendation and patient adherence. Prev Med. 1999;28(4):386–94. [PubMed]
23. Lane DS, Zapka J, Breen N, Messina CR, Fotheringham DJ. A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium. Prev Med. 2000;31(5):481–93. [PubMed]
24. O'Malley MS, Earp JA, Hawley ST, Schell MJ, Mathews HF, Mitchell J. The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening? Am J Public Health. 2001;91(1):49–54. [PubMed]
25. Coughlin SS, Breslau ES, Thompson T, Benard VB. Physician recommendation for Papanicolaou testing among U.S women, 2000. Cancer Epidemiol Biomarkers Prev. 2005;14(5):1143–8. [PubMed]
26. Price JH, Desmond SM, Krol RA, Snyder FF, O'Connell JK. Family practice physicians' beliefs, attitudes, and practices regarding obesity. Am J Prev Med. 1987;3(6):339–45. [PubMed]
27. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9(12):788–805. [PubMed]
28. Sansone RA, Sansone LA, Wiederman MW. The relationship between obesity and medical utilization among women in a primary care setting. Int J Eating Disord. 1998;23:161–7.
29. Adams CH, Smith NJ, Wilbur DC, Grady KE. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health. 1993;20(2):45–57. [PubMed]
30. Lubitz RM, Litzelman DK, Dittus RS, Tierney WM. Is obesity a barrier to physician screening for cervical cancer? Am J Med. 1995;98(5):491–6. [PubMed]
31. National Center for Health Statistics. Data File Documentation, National Health Interview Survey, 2000. Hyattsville, Maryland: National Center for Health Statistics; 2002. machine readable data file and documentation.
32. Humphrey LL, Helfand M, Chan BKS, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(5):347–60. [PubMed]
33. U.S. Preventive Services Task Force. Screening for Breast Cancer. Recommendations and Rationale. Agency for Healthcare Research and Quality; Rockville, MD: 2002. February 2002. Accessed April 28, 2006, at http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm.
34. U.S. Preventive Services Task Force. Cervical Cancer- Screening. Agency for Healthcare Research and Quality; Rockville, MD: 2003. [Accessed April 28, 2006, at]. http://www.ahrq.gov/clinic/uspstf/uspscerv.htm.
35. Wee CC, McCarthy EP, Phillips RS. Factors associated with colon cancer screening: the role of patient factors and physician counseling. Prev Med. 2005;41(1):23–9. [PubMed]
36. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. [PubMed]
37. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998;158(17):1855–67. Anonymous. [PubMed]
38. Division of Cancer Prevention and Control; [Accessed 12/12/06, at]. The National Breast and Cervical Cancer Early Detection Program: Saving Lives Through Screening – 2006 Program Fact Sheet. http://www.cdc.gov/cancer/nbccedp/about.htm.
39. Hoffman-Goetz L, Mills SL. Cultural barriers to cancer screening among African American women: a critical review of the qualitative literature. Womens Health. 1997;3(34):183–201. [PubMed]
40. Seidell JC. Societal and personal costs of obesity. Exp Clin Endocrinol Diabetes. 1998;106 2:7–9. [PubMed]
41. Quesenberry CP, Jr, Caan B, Jacobson A. Obesity, health services use, and health care costs among members of a health maintenance organization. Arch Intern Med. 1998;158(5):466–72. [PubMed]
42. Amy NK, Aalborg A, Lyons P, Keranen L. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obes. 2005;30(1):147.
43. Glasgow RE, Whitlock EP, Valanis BG, Vogt TM. Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening. Ann Behav Med. 2000;22(3):223–8. [PubMed]
44. Jennings KM. Getting a Pap smear: focus group responses of African American and Latina women. Oncol Nurs Forum. 1997;24(5):827–35. [PubMed]
45. Miller D, Martin I, Herbison P. Interventions for relieving the pain and discomfort of screening mammography. Cochrane Database of Systematic Reviews. 2002;(4):CD002942.
46. Olson CL, Schumaker HD, Yawn BP. Overweight women delay medical care. Arch Fam Med. 1994;3(10):888–92. [PubMed]
47. Wadden TA, Anderson DA, Foster GD, Bennett A, Steinberg C, Sarwer DB. Obese women's perceptions of their physicians' weight management attitudes and practices. Arch Fam Med. 2000;9:854–60. [PubMed]
48. Schoenberg NE, Hopenhayn C, Christian A, Knight EA, Rubio A. An in-depth and updated perspective on determinants of cervical cancer screening among central Appalachian women. Women Health. 2005;42(2):89–105. [PubMed]
49. U.S. Department of Health and Human Services. With Understanding and Improving Health and Objectives for Improving Health. 2. Washington, DC: U.S. Government Printing Office; 2000. Healthy People 2010.
50. Gordon NP, Hiatt RA, Lampert DI. Concordance of self-reported data and medical record audit for six cancer screening procedures. J Natl Cancer Inst. 1993;85:566–70. [PubMed]
51. McGovern PG, Lurie N, Margolis KL, Slater JS. Accuracy of self-report of mammography and Pap smear in a low-income urban population. Am J Prev Med. 1998;14(3):201–8. [PubMed]
52. Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey, and chart audit. Am J Public Health. 1995;85:795–800. [PubMed]
53. Zapka JG, Bigelow C, Hurley T, et al. Mammography use among sociodemographically diverse women: the accuracy of self-report. Am J Public Health. 1996;86(7):1016–21. [PubMed]
54. Rowland ML. Self-reported weight and height. Am J Clin Nutr. 1990;52:1125–33. [PubMed]
55. Suter LG, Elmore JG. Self-referral for screening mammography. J Gen Intern Med. 1998;13(10):710–3. [PMC free article] [PubMed]
56. Zapka JG, L SC. Interventions for patients, providers, and health care organizations. Cancer. 2004;101(S5):1165–87. [PubMed]