It’s hard to avoid news about the “obesity epidemic”. Depending on who you talk to, obesity may be the number one killer of Americans or completely irrelevant to health. Alternative med boosters love to focus on obesity and other supposedly behavior-related illness. They use this to simultaneously blame the patient for their own ill-health, blame society for enabling them, and blame real doctors for not fixing it right.
The truth is that obesity is a real threat to health. The causes are protean. Societal problems, individual genetics, and politics can all contribute to obesity, as can personal choice and behavior.
In medicine we have a concept of “compliance”; when a patient fails to follow our recommendations, we often label them as “non-compliant”. This serves a few purposes: it communicates a certain impression about the patient (one that may or may not be accurate) and it helps immunize us against legal shenanigans. The idea is that if you clearly document that you tried to help the patient and that through no fault of your own they didn’t follow through, you shouldn’t be held responsible for a bad outcome.
There has been for several years a trend to use the term “non-adherence” rather than “non-compliance”. It’s thought that this has fewer paternalistic connotations than “compliance”, although I’m not sure simply changing the word can do this. Also, I’m not so sure that we should be so quick to absolve ourselves as doctors of a more active role in our patients’ health. While it’s certainly true that we can’t make people do what we think they should, we should make sure we understand what barriers they have to compliance. This is especially true of addictive behaviors.
When one of my residents tells me a patient is non-compliant (or “non-adherent”–whatever) my first question is always, “why?” Did we fail to communicate well? Did we give bad advice? Is the patient depressed? If we understand why the patient didn’t follow our advice, we’ve got something to work with. If we simply say “non-compliant” all we’ve done is immunize ourselves from a feeling of guilt. We haven’t done a thing for the patient.
Obesity is a tough problem. For most people, simply telling them to eat less and exercise more will not work. But it’s especially important to know what barriers patients face independent of their own mental health.
Affordable fresh foods are very difficult to find in some areas, especially inner cities. If you don’t have a car, you can’t schlepp out to the burbs to pick up broccoli. And if you’re raising kids and trying to eke out a living, anything that saves time is more likely to happen. If you’re living on a Bridge Card and half a minimum wage job, and you’re trying to keep the heat on and the kids tummies full, you’re going to be more likely to butter up some Wonder Bread and open a can of Chef Boyardee then whip up a fresh salad, chicken breast, and pasta primavera. And if you live in a lousy neighborhood, even if you find someone to watch the kids, you’re probably not going out for a run.
And you don’t have to be poor and living in the inner city to have problems eating right and exercising. There are plenty of other people working hard and/or raising families who simply feel unable to find the time to eat well, sleep right, and exercise. We haven’t built a society around these behaviors and we don’t encourage them.
While excuses are no substitute for action, you can’t take care of people properly if you don’t try to understand what makes them tick. I can tell someone over and over to lose weight and exercise more, but if they can’t pull it off, I can’t wash my hands of them and watch them rot. It’s easy to lose sight of the struggles of others, especially the subtle, silent ones. While I’m counseling them to exercise, they may be worried about how the gas company will get paid. I have to treat the person in front of me, not the patient I want them to be.