The Problem with Chalking it Up to Noncompliance

I struggled with disordered eating, body image, and over-exercising throughout my high school and college years. Healing my relationship with food, exercise, and my body was a lengthy process of therapy, reading books, listening to podcasts, and ultimately doing a lot of self-work to change my thought patterns. 

Something that played a big role in my healing journey was reading the book Health at Every Size by Linda Bacon. I read this book during my senior year of college as I was regaining the weight I had lost from strict dieting and overexercising; I oscillated between accepting the weight gain and the fuller, healthier life it lent me and completely loathing the weight gain and trying to fight it. I felt a strong sense of guilt and shame around gaining weight and considered myself a failure. I would read Health at Every Size before bed, and it was like a comforting hug from a friend telling me that everything would be okay. This book played a big role in healing my relationship with food and my body. More importantly, it shaped how I practice as a dietitian.

The Health at Every Size paradigm receives hefty criticism. I think people who are against it have a lot of good points. I also think that they don’t completely understand what it is about. Even if they do, that’s fine. Not everyone has to agree — this is simply my personal experience and viewpoint. 

Health at Every Size is a concept that focuses on health instead of weight and promotes intuitive eating. It is a weight-neutral approach to healthcare; weight is seen as another component of diversity and is not the focus of health interventions. Simply put: instead of treating someone’s ailment by prescribing weight loss, other interventions are used instead.

Weight-neutrality is the reason this movement gets so much criticism, which makes sense given the large body of research surrounding weight and its association with health outcomes. However, Health at Every Size is not anti-weight loss. Proponents of this concept understand that when health interventions are implemented, such as diet changes, weight loss may occur depending on the individual. Weight is simply not the focus of health interventions and is instead seen as an outcome.

When I read the book Health at Every Size, it opened my eyes to the fact that someone’s health is not simply about their behaviors and lifestyle (such as diet and exercise habits). Among other factors, our society, environment, socioeconomic status, and psychology play important roles as well.

Due to my personal experiences, I understand this best in terms of body image and disordered eating. My poor body image and disordered eating behaviors did not occur in a vacuum. They were influenced by a variety of things, and when I acknowledged this, it helped my healing immensely. The messages I received from a young age about how a woman’s body should look from magazines, movies, TV shows, and social media. The woo-woo promises perpetuated by social media influencers about how fad diets are somehow the answer to all of my problems. The comments I hear people make every day. People make jokes about how individuals in larger bodies eat an unhealthy diet and don’t exercise. People make assumptions that an individual eats an unhealthy diet and doesn’t exercise because they don’t care, instead of considering that perhaps they don’t have access to healthy foods, their neighborhood is not a safe place to go for a walk or a jog, or they don’t have the time to exercise because they are working three jobs. 

What frustrates me the most is how I see these assumptions in healthcare all the time. The eye-roll from the nurse as I ask about a patient and the insistence that this person just won’t listen. The snarky notes from the doctor implicating the patient doesn’t care about their health and will never change. It’s so easy to blame an individual for their noncompliance with medical advice instead of asking the deeper questions and understanding why they aren’t complying. People see a set of lab values, a list of medications, and a medical history typed up in the words of other healthcare professionals, and they create an idea in their head before even asking the individual themselves — “What’s going on? How can I help you?”

I’m not immune to this. I’ve done it myself. It’s a natural human response. I prepare to talk to a patient, and I think of what I’ll need to say and do to help them. But I ask questions. I listen. I do my best to try to understand where they’re coming from. I reflect on what I can do better.

In my first job as a supermarket dietitian, I worked with a person who came to me for general diet education and weight loss advice only to learn that they had lost their job and as a result, barely had enough food to get by for the month. They also did not have access to a refrigerator, freezer, stove, or oven. We spent our entire hour-long session looking up food pantries in the area and discussing ideas about eating a balanced diet of non-perishable food items. 

In my current job as a renal dietitian, I see medication noncompliance often; it’s usually not for a lack of trying. One person has trouble getting to their pharmacy because they can’t drive and have to rely on someone to take them. Another person’s pharmacy is out of stock when they go to pick up their prescription, and they have to wait to fill it. Another person was never educated about the importance of the medication and how it affects their health. Another person doesn’t like taking the medication because of the side effects. I see it as my job to help them instead of scolding them. Can you set up mail order for your prescriptions? Do you want a list of other pharmacies to go to? Can I explain to you why you are prescribed this medication? Is there another medication that has a similar mechanism that you may tolerate better? 

On the flip side, people who are compliant and do care for themselves are applauded. Let’s consider the privileges they’ve been granted. Having the money to buy healthy food. Having access to a store that sells healthy food. Having transportation to take them to the store, the pharmacy, the gym, the doctor. Having health insurance. Having a support system in their life. Not feeling discriminated against by healthcare professionals, thus allowing them to not dread going to the doctor, dentist, physical therapist, dietitian, etc. 

I’m not saying that some people don’t simply ignore medical advice and don’t care much for their health. I’m saying ignoring the fact that there are other factors at hand is just plain wrong. 

I’ve been reflecting on this a lot more lately with the current state of the world. The COVID-19 pandemic has a lot of people in tight financial situations, thus limiting their access to food and healthcare. The current resurgence of the Black Lives Matter movement has brought to light for many people the injustices in our society and how they affect peoples’ lives. These injustices are not new. In my opinion, to truly help the cause, it takes more than just donating money, volunteering, and/or posting to social media. It should be reflected in our everyday lives. 

Want to make fun of someone based on how they look? Don’t. Want to assume what someone’s lifestyle is like based on how they look? Don’t. Want to assume what someone values based on how they look? Don’t. Want to put all the blame on the individual for their health ailments or lack thereof? Don’t.

More importantly, for my fellow healthcare professionals: don’t put the people you are treating into a box. Don’t assume their noncompliance or lack thereof is all their fault. Dig deeper. Ask more questions. Adapt your interactions based on the person in front of you, not a story you’ve made up in your head. Realize that health is about more than the individual — it involves the world around them. Realize you cannot truly understand someone’s health just by looking at them.

Do the work of listening to every person you encounter and being kind. Do the work of understanding where someone is coming from — whether it be their culture, their mental health, their knowledge base, and so on. Do the work of reading books like Health at Every Size, even if you don’t totally agree with them, so you can understand the many factors that impact a person’s health. Do the work of keeping an open mind.

I feel obligated to do the work now and to continue to do the work after all of the hype dies down not because everyone is posting about it on social media, but because I care about helping people. As a healthcare professional, I feel obligated to help the people I serve, and helping them involves more than just giving them advice. It involves understanding the many factors that influence their health behaviors and finding solutions that work best for them. 

I acknowledge that I have many priveledges and will never fully understand the discrimination and hardship people I work with have encountered. But I will always do my best to understand where they are coming from and stop myself from allowing assumptions get in the way of me doing everything I can to help them.

Published by Talia Follador

Registered Dietitian Nutritionist (RDN) with a passion for holistic health, intuitive eating, psychology, and cooking. Proud Penn State alumnus, spiritual explorer, nutrition geek, baseball junkie. I like to have my cake and eat it, too . :)

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