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Episode 5: Going Under the Knife

Updated: Dec 4

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*Editorial note: This article was originally published in the NZ Herald and follows New Zealand English conventions.


Bariatric surgery is frequently sold as the answer to the ‘o*esity epidemic,’ yet it’s risky, complicated, and often inaccessible. Episode 5 of Chewing the Facts digs into the truth behind weight-loss surgery.


Are Māori and Pasifika people being excluded from weight loss surgery by a racist qualification system that’s designed to save money?


That’s the challenge posed by critics in episode 5 of Chewing the Facts, a podcast that busts many popular myths about fatness.


In Aotearoa, access to publicly-funded bariatric or weight loss surgery, which changes the digestive and hormonal system to decrease appetite, is controlled by a number of factors including a patient’s body mass index (BMI) - weight in kilograms divided by height in meters squared.


Auckland University indigenous health lecturer Ash Gillon told Chewing the Facts host Sasha Borissenko she believed the controversial measurement tool had been weaponised by the medical community to restrict access to the operation.


“If your BMI is too high, you’re a bad type of fat person, you don’t get access to this ‘fix the fat’ treatment that inherently would make you a good person. So it’s like a double punishment, right?”


According to the BMI, which doesn’t allow for factors such as gender or ethnicity, a score of 25 or more is overweight and 30 or more is obese.


Te Whatu Ora planned care clinical lead Derek Sherwood and hospital and specialist services planned care group manager Duncan Bliss said patients generally must be within a BMI range of 35-55 to qualify for bariatric surgery.


The prioritisation tool dated back to 2012 and selected patients who would benefit most, Sherwood said.


Sherwood and Bliss said Te Whatu Ora wasn’t aware of any ethnicity-specific thresholds for bariatric surgery.


An Auckland University study in 2020 found Pākehā were more likely to gain access to publicly funded bariatric surgery.


Of the 1051 bariatric surgeries completed at Counties Manukau, 68 per cent identified as other European, 63 per cent identified as New Zealand European, compared with 41 per cent of Māori, and 28 per cent of Pacific people (numbers add up to more than 100 per cent because people can identify with more than one ethnicity).


Compare this to the latest New Zealand Health Survey, where one in three adults aged 15 and over are classified as obese using the body mass index.


This rises sharply to 71 per cent among Pacific people and almost 51 per cent for Māori.


In June, the American Medical Association released a new policy that urged doctors to use the BMI with more caution, saying the tool was “imperfect” and had been used for racist exclusion.


In a statement, a Te Whatu Ora spokesperson said Manatū Hauora (the Ministry of Health) was yet to reconcile the BMI with different cultural perspectives of body size.


The risks of surgery increased for people with a BMI of more than 50, the spokesperson said. The cut-off point of 55 varied depending on health issues and the general fitness of the patient.


Budget 2023 had allocated $118 million to increase surgical capacity and to improve equitable access.


While a proportion of the funding would be allocated to improve bariatric pathways and increase the number of surgeries, Te Whatu Ora couldn’t provide any further detail.


General Practice NZ chair Bryan Betty told Chewing the Facts although there could be genuine medical reasons for BMI caps, weight was used as a tool for restricting access because of capacity issues.


Certain regions restricted access to people below 165kg, whereas private surgery could be completed on people weighing 220-230kg, he said.


“I think this is particularly tragic when this occurs.”


“I’ve had one patient who’s got to 167 [kg] and missed out by two kilos. They felt like an abject, absolute failure.”


With the majority of his patients being Māori and Pacific people, he found the caps “really destructive and difficult”.


Te Whatu Ora population health director Gary Jackson said the business case to publicly fund bariatric surgery in 2008 used BMI because of financial constraints.


More than 100,000 people were eligible for the 150 surgeries available in Counties Manukau in 2018, for example.


“You’re almost testing people to make sure that they’re going to be motivated enough that, if it’s worth the public system spending $25,000 on doing their operation or whatever it costs, then they’re going to be able to follow through and make meaningful change in their life.”


Pacific Peoples Minister Barbara Edmonds, who was also associate health minister until July, told Chewing the Facts discrimination of any form was not acceptable.


If direct or indirect discrimination prevented people from accessing particular help, “that’s something that I’d be willing to definitely look at”.


Chewing the Facts: produced with the NZ Herald, with support from NZ On Air.


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