The Concept of “Non-Compliance” and Weight Loss Recommendations

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As a fat patient who often exercises my right of informed refusal when it comes to recommendations of weight loss, I have had to correct my chart multiple times when the healthcare provider who recommended the weight loss labeled me as “non-compliant.” I’ll tell you how I handle it, but first I want to dig into the whole concept of “compliance” and weight loss recommendations. I refuse weight loss recommendations whether they are behavior-based, pharmacotherapy, or surgical, but in this post I’m going to focus on behavioral interventions.

Content Note that this post includes discussion of dieting behaviors, so please take care of yourself.

Per the World Health Organization, compliance refers to the extent to which a patient’s behaviors, including medication-taking behavior, diet, and changes in lifestyle, coincides with health care providers’ recommendations.

In a piece for the New York Times Dr. Danielle Ofri explains it:

“Noncompliant” is doctor-shorthand for patients who don’t take their medications or follow medical recommendations. It’s one of those quasi-English-quasi-medical terms, loaded with implications and stereotypes.

As soon as a patient is described as noncompliant, it’s as though a black mark is branded on the chart. “This one’s trouble,” flashes into most doctors’ minds, even ones who don’t want to think that way about their patients. And like the child in school who is tagged early on as a troublemaker, the label can stick around forever.

When it comes to being higher-weight and labeled as non-compliant, I think that a lot of this issue can be framed by a response to a study by Sturgiss et al called “Challenging assumptions in ob*sity research.” The initial study, while still coming from the body-size-as-disease model, makes the point that “It is inaccurate to assume that weight loss always means an improvement in health, even for someone with ob*sity*” and suggested that it would be better to focus on health-supporting behaviors rather than using weight loss as a proxy for compliance or health.

The paper prompted a “rapid response” by Zhijie Xu, resident physician, Mi Yao; Lizheng Fang, Cadet Brigade, Naval Medical University of Chinese PLA #800, Xiangyin Road, Yangpu district, Shanghai, China that was published on bmj.com

Let’s dig in:

Sturgiss et al. suggested that ob*se patients can benefit from lifestyle interventions even if their weight remains stable. We doubt this because compliance rate will likely decrease with increasingly complex recommendations from health care providers. Ob*se patients who are unwilling to make efforts to lose weight are unlikely to comply with complex lifestyle interventions.

There’s a lot to unpack here.

First of all, they are trying to cast recommendations to engage in health-supporting behaviors as more complicated than intentional weight loss recommendations, but they offer no proof of that. Setting aside the weight-stigma driven assumption that fat people are either not smart enough or too lazy to follow the health advice given to thinner people, giving people a list of options for health-supporting behaviors from which they can choose doesn’t seem that complicated to me. (Now, to be clear, health by any definition is not an obligation, barometer of worthiness, or entirely within our control and the ways that experiences of privilege and oppression can limit access to these options is complicated, but the same can be said for weight loss interventions.)

Consider Matheson et al which looked at four behaviors: 5 or more servings of fruits and vegetables a day, exercising 12 times per month, up to 1 drink a day for cis-women and 2 drinks a day for cis-men (unfortunately, as is common, trans and non-binary people were not included,) and not smoking. When higher-weight people participated in just one of these habits their health hazard ratio dropped significantly, when they participated in all four, their health hazard ratio was essentially the same as “normal weight” people (see full details here.) That seems, to me, far less complicated than trying to figure out exactly how many calories there are in a restaurant meal or how many calories you burned walking from the car you parked extra far from the door, and then doing the math to make sure you are appropriately under-nourishing your body to create the recommended calorie deficit, plus when you’re attempting weight loss you’re trying to make these determinations and choices while chronically under-fed and desperately trying to over-ride your body’s famine response, making it that much harder, more on that in a moment.  

Back to the response. While they cited the original paper, they offer no citations for their “doubts” which appear to be a combination of weight stigma and lack of understanding of the reality of weight loss interventions.

The truth is that higher-weight people often make near-heroic efforts to comply with weight loss recommendations that a century of research makes clear are almost certain to fail.

Beyond that fact, characterizing this as a matter of higher-weight people being simply “unwilling to make efforts” does not account for the reality that following a healthcare practitioner’s recommendation for weight loss means giving one’s body less fuel than it needs in the hopes that the body will consume itself and become smaller. This goes against our body’s most primitive survival instincts and the body responds to this perceived famine in myriad ways including increasing ghrelin, the hormone that makes us hungry, and decreasing leptin, the hormone that tells us that we are full. The authors of this response are trying to rebrand being unable to override our body’s survival response as “unwillingness.” It is, at its root, a disingenuous way to blame fat people for the fact that starvation is not sustainable.

Further, many of us refuse to “comply” with weight loss recommendations because of the knowledge that they almost never produce significant long-term weight loss, and that they typically result in weight cycling which is independently linked to significant harm. Our decision to follow the research instead of our healthcare practitioners’ advice that is rooted in a failed paradigm then gets characterized (through the lens of practitioner’s weight bias) as laziness, lack of willpower, or “unwillingness” to follow recommendations.

Understand that the vast majority of fat patients have been (and continue to be) lied to by practitioners like the ones who wrote this paper. These practitioners don’t necessarily know/believe that they are lying but that’s the reality. They are telling their patients that behavioral interventions will succeed if they patient “does it right” or “tries hard enough.” Often these practitioners are fully aware that the vast majority of people (95+ percent) who attempt weight loss will lose weight short term and then gain it all back (with many regaining more than they lost,) but they have convinced themselves that 100 years of near 100% failure is the fault of the patients and not the interventions. (I’ll also point out that even if it was the fault of fat patients, the massive failure rate for one hundred years would still matter, and this intervention would still fail to meet the requirements of ethical evidence-based medicine.)

When an evidence-based recommendation like the one in the original paper to move just a smidge away from the weight-centric paradigm incites this kind of response wherein the authors try to substitute “everybody knows” for evidence, that’s weight stigma in action.

The fact that these authors (including the lead author who is a doctor) thought it was important to type this out and send it in tells us three important things about them:

1.       They believe that their assumptions about fat people are just as valid as actual evidence

2.       They have fundamental misunderstandings of the realities of attempted weight loss but they are forging ahead nonetheless

3.       They assume that fat people aren’t practicing health-supporting behaviors already

But don’t take my word for it, they prove it with their next statement:

In fact, measures coping with metabolic risk factors or other chronic conditions usually help ob*se patients lose weight (4). Weight loss may not always improve health, but its significance in compliance cannot be overlooked.

To “prove” their claim, they cite a CDC webpage that is giving the “you can’t do a diet, it has to be a lifestyle change” line (in fact, whatever you call it, the most likely outcome of weight loss attempts is short-term loss and long-term regain,) as well as peddling the 5-10% weight loss myth. This website, in turn, cites a 2013 report from the Department of Health and Human Services called “Managing Overw*ight and Ob*sity in Adults” which also doesn’t provide a single study where more than a tiny fraction of people succeed at significant, long-term weight loss with these behavior-based weight loss recommendations.

This is such a perfect microcosm of the state of weight science, citations of citations of citations that don’t, in any way, prove the original point, and researchers substituting their sincerely held beliefs for actual evidence-based conclusions. This is not good science - you can’t even see good science from here. They go on:

Also, clinicians can assess such patients’ compliance based on weight changes within a period of time so as to find ways to enhance compliance.

False. Even those who are fully enmeshed in the weight loss paradigm are typically aware that the body’s reaction to undernourishment is not nearly as linearly predictable as these authors seems to believe. In fact, patients can only control their behaviors, they have no control over how their body responds to undernourishment. This is exactly the misinformed attitude that leads to doctors calling their fat patients liars when those patients (completely predictably) “plateau” in their weight loss and then (almost inevitably) regain the weight.

On the other hand, with the thought that health may be affected by overw*ight, ob*se patients are likely to turn to health care providers for advice. These patients usually comply with tailored lifestyle interventions very well.

Said another way – if we lie to patients and tell them that these lifestyle interventions will lead to weight loss and make them healthier, they will “comply” with our recommendations in the short term.

Also, the fact that people who have been told that weight loss is the only path to health often ask healthcare practitioners to help them lose weight is not surprising – it’s also not (as these authors appear to think it is) a substitute for actual research showing that significant, long-term weight loss is actually attainable and, if attained, would actually improve health (an outcome almost never measured in weight loss research.)

It is common that, compliance rate usually decreases over time, and maintaining a healthy body weight requires patients’ long-term compliance.

Citation please? There is literally no research that backs up this statement. It’s something that people have made up because they are unwilling to say that intentional weight loss fails almost all the time, and are desperate to blame the 95% of fat people who are failed by intentional weight loss for the failure.

By observing weight changes, ob*se patients themselves can constantly monitor their compliance as well, thereby overcoming problems caused by noncompliance in lifestyle interventions over time. Weight loss may not always improve health, but its significance in compliance cannot be overlooked.”

Again I say, false. Again, the idea that calories in/calories creates predictable long-term weight loss such that you can tell whether or not you are following a diet based on how much weight you’ve lost is nothing more than an urban legend - it is not evidence-based. Clinging to this allows healthcare practitioners to maintain their sincerely held belief in the weight loss paradigm at the expense of the higher-weight patients to whom they are failing to give ethical, evidence-based care or informed consent. To be clear, many practitioners are not aware that this is what is happening, but it is happening nonetheless.

This needs to stop. In general, even among well-meaning healthcare practitioners, the idea of “compliance” in healthcare is problematic at best, and upholds not just weight-based oppression but also racism, ableism, and other marginalizations. Practitioners should offer evidence-based information in ways that the patient can understand, and then work with the patient based on the patient’s situation and priorities, rather than doling out edicts and expecting the patient to “comply” without question. And that’s before we take into account that, when it comes to weight loss interventions, non-compliance is the evidence-based response.

If you get labeled as “non-compliant” for refusing a weight loss intervention you can ask to have it removed from your chart. If it’s found to be a “disagreement” rather than an error (and thus they aren’t required to remove it) you can add a note to your chart. I add something like “Provider recommended intentional weight loss but was unable to meet request for evidence of long-term efficacy/safety. As the intervention suggested doesn’t meet the requirements for ethical, evidence-based medicine, I requested an evidence-based treatment path and the provider was not able to offer one.”

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.