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The Bigger Picture

By July 12, 2022July 20th, 2022Feature Article, North&South

The Bigger Picture

Despite decades of alarm about rising rates of obesity, as a nation we’re getting fatter — clear evidence our approach so far simply isn’t working. What are the costs of getting things so wrong, and what do the experts say we need to do to tip the scales in the right direction once and for all?

By Mirjam Guesgen

In Owen Marshall’s short story “The Fat Boy”, a blond schoolboy with a “froglike” face and thick, flabby legs is seen watching every time a crime is committed in an unnamed small town. The fat boy is sly, evil, and imbued with a knack for being where he is least desired. Silent and staring, the fat boy is a “harbinger of trouble” and despised by the townspeople. He is eventually set upon violently, though his beaten body has mysteriously vanished by the time the mob retreats. Published in 1984 and considered among Marshall’s finest works, “The Fat Boy” plays on the social unease, even disgust, that fatness fosters: the boy’s body and appearance is central to his position as loathed outsider. “No one likes a fat kid staring at them”, one character says, and you can imagine him shuddering.

Though it was written nearly 40 years ago, the specific kind of distaste Marshall described then is instantly recognisable today. Fatness is still widely believed to be a personal — even moral — failing on the part of the fat individual. This judgement impacts all kinds of areas of fat people’s lives. Numerous studies have shown they are frequently regarded as less intelligent and lazier than thin people, and a person’s weight can impact both their ability to land a job and how much they get paid. At a glance, they are judged not only on their physical appearance, but on their health, competence and worth as a person. As the author Roxane Gay writes in her 2017 memoir, Hunger, shock registered at her appearance betrays “how little people think of fat people, how they assume we are neither smart nor capable if we have such unruly bodies”.

The prejudices held and expressed about fatness are also unique in that people comment on or ridicule people’s weight far more freely than they make other personal remarks.

Remember Winston Peters in 2018 telling the Speaker of the House to “throw fatty out” of Parliament during a disagreement with National MP Gerry Brownlee? Or Judith Collins saying we all need to “take personal responsibility” for our “little weaknesses”, while on the 2020 campaign trail — adding that fat people shouldn’t blame systems for personal choices.

Radio host Rachel Smalley will likely always be remembered for her 2014 on-air gaffe where a live microphone picked up her comments calling women weighing more than 72 kilograms “heifers” and “a bunch of lardos”. Smalley apologised profusely, saying she did not realise she was on air, but she is far from the only New Zealander to hold views like this — most just don’t get caught accidentally airing such comments on live radio.

New Zealanders are, on the whole, getting bigger. According to the latest Health Statistics, New Zealand is the eighth-fattest nation in the OECD, with about one in three New Zealanders aged 15 or older now classed as ‘obese’. That means 34.3 per cent of us — close to 1.4 million adults — have a body mass index (BMI) of more than 30 (anything above 25 is considered overweight and 30-plus is obese — though more on the usefulness of this measurement later). And that percentage has been slowly creeping up: in 2011, the number was around 29 per cent.

The annual Ministry of Health survey for 2020/21 also found that, among children, obesity rates had risen by a third since the previous year’s survey, from 9.5 to 12.7 per cent. The ministry noted on its website that prior to this childhood obesity rates had been relatively stable (some experts believe issues of food insecurity exacerbated by lockdowns and the pandemic may partially explain the jump).

At the population level, these numbers are cause for concern: obesity is likely to exacerbate or cause health problems including diabetes, fatty liver, arthritis and soft tissue problems. But the way we have tried to tackle obesity at the individual level has been counterproductive, and even harmful. This is because despite the fact that telling people to lose weight rarely works, we’re still stuck in a mode of thinking which favours individual personal responsibility — just try this new diet, just join a gym. Meanwhile, high-energy, high-sugar food is more abundant and affordable than ever, too many of us are stressed and time-poor, and initiatives to get more of us out of our cars on our daily commute are met with resistance every step of the way. We’ve spent decades focusing on the wrong things, hitting our heads against a brick wall and wondering why it won’t budge. And all the while we’ve kept getting bigger as the healthcare costs keep rising.

Obesity expert and retired endocrinologist Robyn Toomath says our approach to tackling obesity is like trying to reduce melanoma rates by telling people to change their skin colour — and just as ineffective. What’s worse, fat patients blame themselves for failing to lose weight, despite the fact that for most people doing so is a near-impossible ask. The way diet and exercise affect people’s bodies varies vastly, and numerous studies have found that the stigma associated with obesity can affect someone’s physical and psychological health just as negatively as the weight itself.

Pretty much any way you slice it, we’ve been tackling obesity all wrong. We have failed to reduce obesity rates, and we have failed to make fat people thin — though we have succeeded in making many people feel terrible about their bodies. But it’s not too late to change. It’s time to rethink everything you think you know about obesity.

You could call  Isoa Kavakimotu a fitness influencer. His Instagram account, which has more than 24,000 followers, is mainly workout videos, peppered with a few jokes and memes. One video shows him squatting while holding a sizable kettlebell; in another he swings a 20-kilogram weight plate up and over his head. In a video posted in February, he turns to the camera, his 30-plus-kilogram dog slung over his shoulders because he left the leash at home. “Ah well,” he says, jokingly. “It’s a free workout.”

Kavakimotu, a digital media specialist for a community group in east Auckland, sees himself as less #fitspo, and more like Boba Fett the Star Wars bounty hunter, just “a simple man making his way through the galaxy”. The Instagram account, the videos: they’re simply a way to keep track of his fitness journey. When Kavakimotu started posting his workouts online a year and a half ago, the then-28-year-old had reached a weight where he struggled to join in with mates for a friendly sports game, where every day meant doses of pain killers for his aching back. He couldn’t do life’s basics, he says: moving around his house was difficult; walking down the street was even harder. At 1.91 metres tall, his weight had topped out at 339 kilograms — even for a tall guy, that was an inhibiting amount to carry around.

Kavakimotu has always been big. At school, he wore the largest uniform they had. He was well aware, even as a teen, that if he got any bigger he wouldn’t have anything to wear at all. Fitting into chairs was a struggle, whether on public transport or at a barbecue — Kavakimotu describes the white plastic lawn chair ubiquitous to back gardens as the bane of his existence. “I think people look at it and go, ‘Oh, it’s just a chair’, but I don’t think you understand how embarrassing that is,” he says. “It’s already bad enough that I’m frickin’ huge.”

Kavakimotu describes the white plastic lawn chair ubiquitous to back gardens as the bane of his existence. “I think people look at it and go, ‘Oh, it’s just a chair’, but I don’t think you understand how embarrassing that is.”

He’s tried every diet under the sun, from keto to no-carb and juice fasting. At one point he was eating so much canned tuna he realised he was putting himself at risk of mercury poisoning. None of the diets stuck — they were too restrictive. It would be tough too when his family would ask him to get KFC for them, which he would, and then squirrel himself away in his room to eat his separate dinner in private.

Trips out of the house became an anxiety-inducing experience. Eventually, it was just easier to stay home than face the embarrassment, judging eyes, or his own self-defeating, critical thoughts. “I was always ready to beat myself up before anyone else could,” he says. “Beating people to the punch because hearing it from myself is better than hearing it from other people.” At times, he contemplated taking his own life.

Growing up, Kavakimotu moved house almost every year. When he did have a place to live, he’d be sharing a small two- or three-bedroom house with nine or 10 other family members. The family was time-poor, with parents working ridiculous hours trying to put food on the table. When he didn’t have a place to live, he’d be sleeping in a car, eating takeaways for dinner — after all, cars don’t have a kitchen. We may each make our own choices, but we don’t all have the same set of options to choose from.

It was when Collins made her remarks during the 2020 election campaign that Kavakimotu felt compelled to speak out. It bothered him too much; the situation just wasn’t as simple as “personal responsibility”. Collins was half right, he says, and he does bear some responsibility for his lifetime eating and exercise habits. But she was wrong, too. Appearing on TVNZ’s Breakfast with host Jenny-May Clarkson, Kavakimotu argued that obesity was a structural issue, calling for cheaper healthy food and fewer takeaway and liquor stores, especially in low-income areas.

Physician and Health Coalition Aotearoa chair Boyd Swinburn agrees with Kavakimotu’s assessment, blaming what he calls the “obesogenic environment” for New Zealand’s rising obesity levels. An obesogenic environment is one where high-calorie, low-nutrition foods are easily available and relatively cheap, where nutritious food comes with a big price tag, and where our work lives often involve long hours sitting and expending little energy. The government needs to address junk food in the same way that they’ve addressed other harmful substances, he says.

“The things that work for tobacco — the taxation, fiscal policies, banning advertising, labelling, having smoke-free environments — they’re all these parallels that a government will need to do. They’ve done well for tobacco and they’ve done appallingly for junk food.” The coalition is calling for regulations around unhealthy food marketing to children, schools to create policies encouraging healthy foods and making sure they’re available, and introducing a levy on soft drinks. Sugar taxes are somewhat controversial — while they are popular among campaigners and seem to have had some success overseas, including in the United Kingdom, Chile and Norway, previous health ministers in New Zealand have said they have found little evidence putting taxes on particular foods would lower obesity rates in New Zealand. Some advocates have also argued that such a method amounts to a tax on the poor, and say that making healthy food and drink more affordable is a better solution.

In June, the current government again ruled out a sugar tax in Aotearoa. Earlier this year, the government announced a proposal to ban fizzy and sugary drinks in primary schools (previously, policies banning soft drinks were widespread but voluntary) and it has signalled it’s considering setting voluntary targets for processed food manufacturers to reduce sugar and salt.

It is unlikely that Kavakimotu will ever be a skinny guy. Most people who lose a significant amount of weight end up regaining it, and researchers have found that less than 1 per cent of people classed as obese have a probability of attaining a “normal” body weight. What determines how much a person weighs is more complicated than the “calories in, calories out” mantra touted by fitness and diet gurus the world over.

The reason why is survival: it’s written in our biology for our bodies to keep our weight consistent. The body needs to be able to maintain its day-to-day activities — pumping your heart, powering your brain — without having to rely solely on the calories you’re consuming at any given moment. It needs to be able to ration, to store energy for later or to motivate you to find more food if times are tough. Our bodies evolved at a time when losing weight signalled food scarcity, and we developed brain and body signals (think the rumbling of tummies and the angst of feeling hangry) to motivate us to go in search of food if we became hungry. Now, that same biology is turned against us: it’s easy to find high-calorie food in our modern obesogenic society, but hard to lose weight.

Another thing we have struggled to understand in trying to deal with the obesity epidemic is that a person can improve their health while remaining fat. Even a relatively modest amount of weight loss can improve certain health conditions, Swinburn says. “You might still now be 110 kilograms, but your metabolic profile looks a lot better.” That’s because fat will leave the body from the last places it built up: the liver and muscles (which are also places that you’re unlikely to notice the fat loss externally).

To say that the link between health and weight is complex would be an understatement — a quick look at the numbers demonstrates this. Historically, health has been associated with a person’s likelihood to contract particular diseases or develop certain ailments. Based on this definition, it doesn’t appear as if the country is unhealthier now than we were a decade ago, despite a 19 per cent increase in obesity rates. Waistline measurements have remained fairly steady compared to 2011, rates of heart disease have dropped from 5.5 per cent to 4.2 per cent, high blood pressure rates have hovered at around 16 per cent and high cholesterol rates have held at around 10 per cent. Rates of diabetes too have gone up and down but are the same now as they were in 2011, 5.5 per cent.

Although there are some illnesses that seem to be directly caused by carrying extra kilos (obstructive sleep apnea, for example, is more often than not caused by having extra fat around the throat), many times, weight is just one of a slew of factors that contribute to a particular disease. For something like arthritis or in the case of some cancers, carrying extra fat can play a negative role, but so do other risk factors like family history, age, previous infections or injuries.

Delve deeper and the picture becomes even more complex. A 2014 review found that up to half of people classed as obese were healthy when it came to their blood pressure and cholesterol, body fat and blood sugar levels. On the flipside, a review from 2012 found that between 9 and 21 per cent of type 2 diabetics were classed as “normal” weight (that is, where their BMIs were between 18.5 and 25). Several studies have also linked being normal weight or underweight to dying earlier than people who are overweight or obese. Swinburn agrees the health impacts of weight can be confounding, with a lot of factors to tease out. A smoker or someone suffering from multiple health conditions might be thin but in poorer health and at higher risk of dying than someone fatter than them without those co-morbidities, he explains by way of example. The point is, you can’t tell how healthy a person is just by clocking their weight.

“Even in highly structured weight loss programmes the success rate is so low that if it was a pharmaceutical product it would get unlisted.”

One woman I spoke to, Mondelea Bezuidenhout, joked that despite a diligent diet of vegetables, salads, lean protein and low-calorie smoothie bowls she’s the kind of person who only has to breathe around chocolate in order to put on a few kilograms. “I’m not an angel with golden wings, I’m a person, I’m not perfect,” Bezuidenhout told me. “But in general, I make healthier choices than my friends, I just don’t lose weight like normal people.” At one point she restricted her eating so much that she rapidly lost 20 kilograms — but gained it all back, along with an additional 20 kilos.

Robyn Toomath would be unsurprised to hear Bezuidenhout describe her struggles with weight. She believes our genes play an enormous role in determining our weight, combined with the environment we live in. Our current obesogenic society has tipped many people with a predisposition to gain weight into obesity, she says. And we’re not getting any better at treating this, because we’re still stuck on the idea that people just need to make better choices.

She recalls the moment the penny dropped for her that losing weight couldn’t be as simple as going on a diet or joining a gym. She had seen friends — wealthy people, well-informed people, people with motivation and control over all aspects of their life, some of whom were even doctors — try and fail to become thinner. “They couldn’t do it! And I thought ‘Jeepers, if these people can’t do, it what’s the chance for the mass of people?’”

A doctor for 38 years, Toomath is the former clinical director of general medicine at Auckland City Hospital and the former president of the New Zealand Society for the Study of Diabetes. She has also written about obesity in the 2016 book Fat Science: Why Diets and Exercise Don’t Workand What Does. She believes the biggest mistake doctors make is telling obese patients to lose weight, something she stopped doing about six years into her career after realising it was essentially an ineffective treatment. “Even in highly structured weight loss programmes the success rate is so low that if it was a pharmaceutical product it would get unlisted because it doesn’t work,” she says.

Toomath used to give lectures to her medical colleagues describing how “prescribing” weight loss led to a curious role reversal between doctor and patient. “What normally happens when we prescribe something that doesn’t work is that the patient is pissed off with us and comes back and complains. But if we prescribe weight loss and it doesn’t work, the person who feels shame and guilt and remorse is the patient,” she says. “They internalise that failure to lose weight as their problem, not our problem.”

describe body size and particularly obesity as an issue of personal responsibility.” The key players are the junk food purveyors, who resist restrictions around selling and advertising their products, and the government, which doesn’t want to be seen to restrict people’s choices as consumers. Programmes like Jenny Craig or WeightWatchers and the exercise industry also have a vested interest in pushing a personal responsibility narrative, she says. The key thing we need to understand in Toomath’s view, is that to a large extent our body size is dictated by things beyond our control. “I think it’s the collusion, it’s this shared myth that it is something that we have control over,” she says.

Toomath differs from some campaigners in that while she acknowledges there are fat people who are extremely healthy, she believes that the odds are obesity either causes or exacerbates all manner of health problems — which is precisely why it’s so frustrating that we don’t seem to be making any progress. “You do have to talk to people about weight if they have a medical condition related to their weight,” she says. But she would tell patients — even those who were keen to lose weight — that it probably wasn’t going to work, so they should take another approach.

“We should be as active as we possibly can be and the great thing about being very heavy is that you will burn more calories and get more benefit from a small amount of walking because your body’s doing a lot of work.” She would also have the patient work to build up their self-esteem, and make them understand their weight was not their fault. She would then recommend medications or surgical interventions to deal with specific issues like heart disease or family predispositions to certain illnesses.

Toomath founded Fight the Obesity Epidemic in the early 2000s, and quit in 2015, saying the country had made no progress. Seven years later, we’re not doing any better. While she thinks the hospital sector has made some practical changes to try to accommodate obese patients — the derogatory language she’d hear at the start of her career, like calling someone a “whale” of a patient, is no longer seen as acceptable — there is still no tax on sugar, still no restrictions around junk food advertising, and we are still too reliant on our cars. Toomath would like to see public transport made free, as it is rarely door-to-door and thus incorporates some exercise into daily routines. “The key element is that we can describe population changes in lots of ways, that don’t have personal responsibility as the underlying issue. We can look at lots of issues collectively and say, ‘We need to change this.’”

Since being diagnosed with type 2 diabetes in December last year, journalist Megan Whelan has been trying to tease apart the difference between her health and her weight. Through speaking with medical professionals, and trawling academic literature, she’s come to realise how complicated the link truly is.

Type 2 diabetes often comes from the body storing fat in places it’s not supposed to be, such as the liver, leading to insulin resistance — that is, when cells in the body don’t respond to the hormone insulin and therefore have a hard time removing sugar from the blood, so it builds up. As Whelan writes in the first of a nuanced and thoughtful series of weekly columns for RNZ, “Diabetes and Me”, her weight has had an impact, but it’s not the only factor in her diagnosis. “For as long as I can remember, my body has been a thing that has been separate to me — I have always hated my body,” she writes. Spending years “unlearning” this on a journey of fat acceptance, Whelan describes how she may have missed the point by believing that instead of hating her body, she didn’t have to care about it at all.

“Maybe if I had cared about my body more I wouldn’t be here?” she says in her column. “Or maybe I would have, given diabetes has a genetic factor and runs in my family . . . Maybe if I had leaned more towards the ‘go to the doctor, eat the occasional vegetable’ school of self-care instead of the ‘bubble baths and lush facials’ one, I’d somehow have defeated the complex relationship between lifestyle, environment, genetics and hormones. Or maybe I needed to spend my 30s fixing my brain, so I’d have the resources to face this challenge?”

Whelan tells me that throughout her life doctors have been quick to recommend she lose weight — often when she hadn’t asked for advice on the topic — but never discussed realistic goals or how she could achieve them with changes to her diet and exercise, or discussed the other factors at play. “No doctor has ever said to me, ‘You can’t change your genetics. You can’t change your weight overly much over time. You can’t change particularly what’s going on in your gut bacteria or how your pancreas is.’”

She says we need to get over the notion that thin means healthy. “I fundamentally believe you can be healthy and fat at the same time. We know that from research. I also know that you can be fat and have some health difficulties.”

Being fat also doesn’t mean that you don’t deserve medical care and respect or to be treated with humanity and dignity. On the face of it this is obvious, but Whelan says that often the doctors and people around her have tried to shame her into action.

“People seem to think that shaming fat people or tough love will help. Guys, we know we’re fat. We really do. You don’t need to tell us.” In fact, shaming people for their weight can have the opposite effect: a 2013 study of adults published in a peer-reviewed journal by the Public Library of Science, found that people who had experienced weight discrimination were around 2.5 times more likely to become obese later on than those who hadn’t been shamed. This might be because fat-shaming leads to poorer mental health, people internalising those comments and then binge-eating as a result.

Whelan has spent a large portion of her life learning to love her body. She now concentrates on what her body can do — like the fact she can deadlift seven reps of a 55-kilogram bar — rather than what it looks like. “My body is incredible,” she says. “It can do so many more amazing things than I had got it into my head I could do.”

Silke Hartung remembers passing out in PE class as a 12-year-old. She’d been trying to stick to the then-popular low-carb Atkins diet, one of a string of fad diets recommended to her by adults in her life: her mother, the mothers of her friends, even her doctor. Hartung cannot remember a time in her life when her weight wasn’t an issue — not for her, but for others. Now based in Auckland, Hartung grew up in Germany on a street near a busy intersection. She recalls once, while she waited for the bus, a car stopping in the middle of traffic and its driver winding down the window to grunt at her, imitating a pig. At school, her teacher took it upon herself to stage a “fat intervention” where she had all the students tell Hartung what they thought of fat people. Her mother would say she had an “Arsch wie ein Brauereipferd” — the rear end of a working horse — and ask Hartung to walk several metres behind her so no one would suspect they were related.

“That was pretty devastating,” Hartung says. “I had years of therapy to get over that.” Hartung started therapy at age 14 to deal with depression partly brought on by fat-shaming (though she says there were other factors that contributed to her poor mental health, including a turbulent family life).

Instead of comfort, consolation or strategies to deal with hurtful comments from others, Hartung’s therapist blamed her weight for her issues. “They made the therapy about my food addiction,” she says. “Here’s someone with depression, ADHD and who has suffered abuse. And what you talk about is eating.” Through therapy, strong friendships and a lot of self-reflection, Hartung, now a magazine editor, came to realise people’s reaction to her body was more often than not about their own insecurities. “I know it’s a lot of women’s biggest fear, to be fat,” she says. Her mother was one such woman. “My mum struggled with weight and starved herself,” Hartung says. “Maybe she wanted to protect me and stop me from feeling about myself like she did about herself.” Her method for achieving this was unhelpful, to say the least.

Photo of Silke Hartung
Silke Hartung underwent bariatric surgery after an ankle injury caused her to gain a significant amount of weight. Photo: Cameron James McLaren.

For people like Hartung, who are fat and have been active their whole lives, life is a constant battle against the stigma associated with being a certain weight. When she was younger, Hartung’s free time would consist of heading to the local pool to swim laps, badminton games with her friends or wiling the weekend away on an ultralong walk or hike. In her native Germany, hiking is practically the national sport. “By nature, I’m just somebody who likes to move,” she says.

After sustaining a devastating ankle injury and a virus that led to chronic fatigue syndrome, which had years of knock-on effects on her health and weight, she was happy to get moving again and has been enjoying challenging uphill hikes with her daughter and becoming an accredited snorkel guide. When hiking she still gets stares and dirty looks from some passersby — the same looks she got when she was standing at the bus stop, the same ones her fellow pupils gave her at school.

While schoolchildren may be tactless, adults carry years of built-up judgement about fatness, and it can affect all areas of a fat person’s life. Studies show that obese people are less likely to be hired, particularly for customer-facing roles. When they are, they’re paid about 6 per cent less than their thinner counterparts. Other research has found that fat people are perceived as less ambitious, lacking in self-discipline and not cut out for leadership. The way stigma against fatness can be disguised as concerns about public health is stark in the case of Mondelea Bezuidenhout.

In 2018, South African-born Bezuidenhout moved with her husband, Donovan, and their two kids across oceans to New Zealand. The family wanted a fresh start and Donovan’s skillset as a lineman was desperately needed here. The family of four left their work, lives, friends and family behind to start their new life in Palmerston North. Then in November 2019, Bezuidenhout suffered a concussion that dislodged a shunt implanted in her brain years earlier. She began experiencing daily headaches, and couldn’t remember how to cook dishes she’d been making her whole life. Even if she did manage to cook, food didn’t taste the same. The active former netball player was suffering bouts of extreme fatigue that made walking to the end of the street a mission. She’d feel overwhelmed when her kids and husband talked to her all at once. “It completely changed my life,” she says. She felt depressed, and her weight crept up, hovering around 150 kilograms.

It was about the same time as her accident that the Bezuidenhout family began the process of applying for permanent residency to stay in New Zealand. They went through the usual process, collating years of documents, some of which were held up back in South Africa, and getting medical tests done.

Photo of Modelea Bezuidenhout
Modelea Bezuidenhout says everyone struggles with self-acceptance — and that she’s worked hard to love her body. Photo: Elizabeth Little.

Everything appeared to be progressing well until in July 2020, when Bezuidenhout received a message from immigration that surprised her. The medical assessment had determined her body mass index (BMI) put her in a “severe risk” category. She was given three months to lose weight or face being rejected for residency. When she asked her case manager how much to lose, the reply was vague. “In this case we cannot advise you how much weight to lose,” their message read. The whole thing was confusing, Bezuidenhout says. “All my blood results were 100 per cent normal. I don’t have high blood pressure, I don’t have diabetes, I don’t have any other illnesses.” Immigration didn’t seem to care about her shunt either — only her weight.

Bezuidenhout had already consulted a nutritionist about her eating, after having difficulty tolerating particular foods after her concussion. She now began a strict, twice-daily exercise routine. In three months, she lost 15 kilograms. “I was really proud of myself,” she says, having “worked her arse off” even through post-concussion symptoms. Her doctor backed her and wrote a letter to immigration outlining the work she’d done and corroborating her bill of health with blood tests.

But a few months later, Bezuidenhout’s application for residency was denied. She faced being sent back to South Africa with her husband and kids, who all applied under a joint application. According to the documents she received, she posed too much of a risk to the New Zealand healthcare system — a potential cost of about $41,000. “It’s so stressful and demeaning. You’ve tried your best and it’s not good enough,” she says. “If it’s the shunt, I understand. If it’s because I went for the surgery to fix my shunt, I understand.” But she says her immigration adviser told her it wasn’t that — it was her BMI that was the issue. “I’ve always been comfortable in my skin and that was the hardest part of it all. I had to make peace with myself all over again.”

New Zealand doesn’t have a specified BMI requirement for immigration but it does require a person to be in “good health”. In March this year Bezuidenhout and her family received their residency papers, after publicity about her case led to a crowdfunding campaign that raised more than $7,000 for an immigration lawyer. She considers herself privileged to be able to fight her case.

Bezuidenhout’s case raises the question of whether BMI can determine anything useful beyond the ratio between a person’s weight and height, despite being the measurement we base so much of our health response on when it comes to obesity. The index doesn’t distinguish between weight from muscle and weight from fat, and says nothing about where in the body fat is being stored. The oft-touted example of BMI’s limitations is that many All Blacks would be classed as overweight or obese. This is more than nit-picking. Where fat is stored can greatly influence a person’s risk of developing coronary heart disease, diabetes and gout, because carrying more fat in the upper part of the body increases that risk.

BMI has been well noted as a problematic measure for comparing across different ages and ethnic groups. In a 2018 paper published in the journal Public Health, “The Shame of Fat Shaming in Public Health: Moving Past Racism to Embrace Indigenous Solutions”, Auckland-based exercise physiologist Isaac Warbrick (Ngāti Te Ata, Te Arawa, Ngāpuhi) and his co-authors argue that the focus on BMI is too narrow when addressing poor health outcomes for Māori. “Within lifestyle health promotion, weight remains the primary outcome measure in interventions targeting Māori,” they write. “Physical health is the primary focus, with limited mention of psychological, spiritual, or whānau well-being.”

Warbrick, who is co-director of AUT’s Taupua Waiora research centre, worries BMI does more harm than good, and has questioned why we keep using weight as a measurement for health when it perpetuates stigma and shame. In an interview with Stuff, he was quoted as saying that despite focusing for years on weight loss when it comes to health interventions, obesity rates keep rising. “Why are we measuring it? If it does harm, drives all this anxiety, why measure it at all?” Warbrick told North & South that he’s since shifted his focus to using Māori knowledge to improve health and drive lifestyle change, rather than continuing to focus on the issue of a “weight-focused system”.

In defence of BMI, Boyd Swinburn argues that, in a doctor’s office, it isn’t used in isolation. “If they’re a good doctor then they should be taking lots of other things into account,” he says, citing measures like blood pressure or waist circumference. But as nearly any fat person would tell you, this is often wishful thinking. In fact, overweight or obese people are less likely to visit a doctor or access healthcare at all, based on a history of being judged or feeling embarrassed. Every fat person interviewed for this story had one, if not multiple, examples of when they’d been discriminated against by healthcare staff.

Kavakimotu says he just got sick of seeing doctors after countless encounters where doctors were rude or focused purely on his weight. “I just didn’t want to see any unless I absolutely had to.” He was constantly questioned about what he was doing to lose weight, at the expense of overlooking what he was there for in the first place. As someone who now works out two to three times a day, six days a week, with normal blood pressure and no diabetes, it can be tiresome. “There are some doctors out there who are amazing,” he says. “But others are just not willing to understand.”

Whelan agrees that unless your doctor is spectacular, they will usually try to treat your weight before anything else. She recalls seeing a doctor who wasn’t her regular GP for a repeat on her depression medication and being asked whether she’d ever considered losing weight to help with her mental health. In instances like this, going to the doctor felt like an exercise in shame.

In the worst-case scenario, it can be life-threatening. Earlier this year the New Zealand Herald reported on the case of a Tauranga woman suffering abdominal pain who spent years being brushed off by doctors telling her to lose weight before she was finally, by chance, referred for an ultrasound in 2020. The scan revealed a three-litre tumour growing around her organs — she had been suffering from ovarian cancer.

This case echoes an experience recounted to researcher Ashlea Gillon (Ngāti Awa, Ngāpuhi, Ngāiterangi), who has heard countless tales of discrimination through her role researching the experiences of fat Indigenous wāhine. One woman spent nine years trying to get a doctor to order her a scan which would eventually reveal she had a tumour. Another woman nearly died because she had blood clots in her lungs, but was told by her doctor that the reason she struggled to walk upstairs was because she needed to lose weight.

Worldwide, the medical focus on weight is shown to come at the expense of care, both emotional and diagnostic. Studies show doctors will use stigmatising language in obese patients’ medical records, questioning the patients’ credibility, expressing disapproval or emphasising their own authority. Doctors can fail to offer certain diagnostic tests or forms of treatment — for example, one study found that obese women are less likely to receive screening for cervical, breast and colorectal cancer than thinner women.

“People seem to think that shaming fat people or tough love will help. Guys, we know we’re fat. We really do.”

Gillon says that access to healthcare isn’t just a basic human right, it’s an indigenous one too. It’s about having agency and mana over one’s body — what she terms body sovereignty — and having that acknowledged and respected. “We are all entitled to healthcare, education, employment, meaningful relationships. We deserve to have that access.”

Racial stigma among fat people can be seen in the numbers for bariatric surgery in Aotearoa, too. Bariatric surgery is a last-ditch medical intervention, which shrinks the size of a person’s stomach and is used to assist weight loss in instances where a person’s weight is clearly causing negative health outcomes and they cannot achieve further weight loss through diet and exercise alone. Of those referred for the surgery, about half receive it. Nearly three-quarters of Pacific people and about half of Māori don’t make it to surgery day. “People from the hospital were saying we serve this big brown population, but I noticed the people coming into the clinic weren’t those people,” says surgical trainee Jamie-Lee Rahiri (Ngāti Porou, Ngāti Whātua, Te Āti Haunui a Pāpārangi).

Reasons for the dropout rate vary — some candidates for the surgery don’t meet pre-op weight loss requirements or the requirement to quit smoking — but some of it comes down to discrimination. To try to understand why the dropout rate was so high, Rahiri spoke to Māori who had completed the surgery about their experiences. It became startlingly clear to her that although they were grateful for the procedure, there were huge cultural issues with the process. “There was some racist stuff that went down in the educational seminars,” she says. “One participant told me that the doctor said ‘none of this tangi business’ and she looks around the room and everyone looks phenotypically white . . . so naturally she felt targeted. It was obvious to her that there was a preconception.” Participants in her survey described feeling like there was a hierarchy, where they were the “fat brown person” and doctors had control.

Pacific research fellow at the University of Auckland Tamasin Taylor heard similar accounts from Pasifika people. “They’re keenly aware of other’s attitudes of them,” she says. “The thought is, ‘Oh, I’m just this Pacific person who can’t manage my health.’” People described not being able to fit in the chairs provided or being weighed in the hallway in front of other patients, experiences they found profoundly embarrassing.

There is also still a prejudice among members of the public towards bariatric surgery — that it is the easy way out, a vain or selfish thing to do, Taylor says. This is something Toomath also found during her career. She recalls suggesting bariatric surgery to patients only for them to admit to her they had desperately wanted to request the procedure but were too ashamed to ask because they thought surgery was an admission of failure.

There is also a perception bariatric surgery is a waste of public health dollars, something Taylor refutes by pointing to studies that indicate that surgery pays for itself within a few years as people need fewer or no medications and are able to work and contribute to their community. The remarkable irony is that these are people doing what society and the medical profession had told them to do: lose weight. And yet, they still face judgement for it. There’s a certain moral onus on being the “right” weight, a prevalent idea that it’s something a person has to struggle for — that those people who “cheat” by getting surgery just didn’t try hard enough.

Of course, we save our harshest criticism for people who don’t see the need to try at all. Cat Pausé was a self-described “fatlicious feminist”, a sociologist who studied, wrote and spoke prolifically in academic journals, in the media and on podcasts about the stigma and dehumanisation fat people face.

An American living in New Zealand, where she was a Massey University academic, Pausé died in her sleep, aged 42, in March this year. Her cause of death was “medical”, though its exact cause has not been made public. On social media, among heartfelt tributes from friends and colleagues, ran an undercurrent of unpleasantness. “Please get healthy and don’t end up like her”, one of the tamer tweets about Pausé read. Others derided her using language tinged with disgust, with many implying that Pausé, who advocated for being fat and happy, had got what she deserved. It’s hard to square claims that the objection to obesity is simply about a population-wide concern for people’s health when an outspoken, unashamed fat person is not afforded basic dignity in the days after their death.

I spoke to Pausé for this story before she died. Our conversation had a profound impact on me. When she requested that we not publish dehumanising images of headless fat people alongside this article, she helped me understand just how insidious fat bias truly is. She was smart, self-assured and had seen and heard it all when it came to questions about weight. Pausé’s comments set the tone for what I was to learn over the coming months from the people I spoke to next and the countless academic papers I read.

Many people who have embraced fat acceptance talk about the struggle to unlearn a lifetime of messaging which tells them to hate their bodies. Robyn Toomath, the retired anti-obesity campaigner, thinks structural hatred and this internalised shame is part of why we haven’t seen a bigger push for the change we actually need to make a difference. “Where you might see other groups uniting behind a cause to change the status quo and improve things, we don’t see that [with obesity].” She still hopes she will live to see society mobilise, to say “Fuck, give us a decent environment — we can’t change our genes, for goodness’ sake. Get rid of all this junk food and advertising, make public transport free, get cycle lanes in the city, make it easier for us. Because we’re being harmed.”

Megan Whelan has found lifting weights has had a huge positive impact on the way she thinks about her body. Photo: Rebekah Parsons-King, RNZ.

Mirjam Guesgen is a freelance science journalist, formerly living in Wellington and now based in Canada.

This story appeared in the July 2022 issue of North & South.