Enacting policy: mapping Kaupapa Māori aspirations onto the New Zealand Eating Issues and Eating Disorders Strategy

Ngā māuiui kai, or eating disorders (hereafter NMK), is a te reo Māori term coined by Te Tira Wānanga Māuiui Kai, the Māori eating disorders network, to describe Māori understandings and experiences of disordered eating. Te Tira Wānanga Māuiui Kai is comprised of te reo Māori experts, clinicians, researchers, people with lived experience and their whānau (support network).¹ The term NMK is grounded within Te Ao Māori framework and reflects a Māori conceptualisation of eating and disordered eating as illustrated in this quote:

“Māuiui is to be tired, sick, unwell, out of sorts, or out of balance. Kai is food. So, ngā māuiui kai is to be out of balance or out of sorts in relation to food. We use māuiui often throughout our glossary of terms, because it is not a permanent state; but is recoverable. We avoid use of the term “mate” often used in te reo Māori to describe ill health. Although used to mean “sick”, mate is also used to mean “dead” or to indicate a permanent state.”¹

Understanding Te Ao Māori conceptualisations of health is critical to addressing persistent equity gaps in the identification and treatment of NMK. Under Te Tiriti o Waitangi, the health system holds obligations to achieve equitable outcomes for Māori and to uphold Māori leadership, knowledge and authority in the design and delivery of services that affect Māori wellbeing.² In practice, however, Māori knowledge and Kaupapa Māori service (KMS) expertise have been inconsistently recognised and under-utilised within policy development, commissioning and service pathways, including in the NMK sector.

Evidence from population-level data indicates that Māori experience at least comparable—and in some cases higher—prevalence of specific non-underweight eating disorders, such as pukuruaki (bulimia nervosa), compared with non-Māori,³ yet are significantly less likely to receive specialist treatment, highlighting systemic barriers to care.⁴ These barriers include discrimination within health services, geographic inaccessibility, culturally biased assessment and eligibility criteria and experiences of shame and stigma associated with NMK diagnosis.⁵ Health policies and service protocols that incorporate weight-centric assessment can also contribute to both under-diagnosis of NMK for Māori as well as the unhelpful promotion of weight-loss interventions (e.g., for comorbidities like diabetes), which may exacerbate disordered eating.^5,6

This evidence of structural inequities for Māori is particularly noteworthy in the context of the Government’s refreshed New Zealand Eating Issues and Eating Disorders Strategy (NZEIEDS),⁷ released in September 2025. This strategy represented a much-needed update, almost two decades after the first comprehensive national strategy, entitled Future Directions for Eating Disorders in New Zealand.⁸ While Future Directions was an important first step given the fragmented and under resourced nature of NMK support at the time, the “future” it envisioned has been a long time coming. Nearly 20 years later, the persistent inequities identified in recent Māori-led research suggest that there is still much work to do.

The NZEIEDS has outlined a new future for eating issues and eating disorders support in New Zealand, including explicit recognition of KMS as a key area for future investment. This is significant as no previous government strategies have recognised or resourced Māori-led approaches to these conditions. This project contributes to that next step by exploring kaimahi (workforce) perspectives of NMK presentations within KMS and aligning their insights within NZEIEDS priorities to inform practical and responsive steps for strategy implementation.

Method

Kaupapa Māori methodologies (KMM) and participatory action research (PAR)

The project was informed by KMM,⁹ which respond to Māori-identified research needs and support Māori health research workforce development.⁹ We also drew on PAR,¹⁰ emphasising collaboration between researchers and participants to address real-world problems, prioritising cultural safety and empowerment. This design intentionally foregrounded practice-based knowledge from Kaupapa Māori kaimahi that is often under-recognised in mainstream evidence.¹¹ Together, KMM and PAR prioritise the voices of Māori to ensure that the research outcomes are practical, systems-focussed and strengths-based, with meaningful benefits for Māori. Framing the results within the NZEIEDS therefore reflects a deliberate intention to make the findings actionable and create real-world change.

Purapura Whetu and University of Otago, Christchurch campus

This research project is based on a research partnership between Purapura Whetu and the University of Otago, Christchurch campus. Purapura Whetu is a Kaupapa Māori mental health organisation located in Christchurch. Purapura Whetu employs seven health coaches under their Te Tumu Waiora model. Those health coaches are based within five primary healthcare organisations across Christchurch. Through this collaboration, kaimahi identified concerns about the increasing number of whānau with disordered eating and the lack of available support.

Participants

Initially, 11 kaimahi agreed to participate. Three were unable to attend due to urgent clinical demands, resulting in eight kaimahi participating. Participant roles included health coach, registered nutritionist, team leads across services, social workers, counsellors and support staff, with some staff holding multiple roles.

Focus group questions

Participants were asked three questions relating to NMK presentations with KMS:

• What are the presenting challenges?
• What supports are needed?
• What are KMS doing well?

Thematic analysis and coding

Participant responses during the wānanga (traditional process of sharing knowledge) were recorded in real time on a whiteboard in bullet point form by a designated transcriber (author 3). This approach was taken following ethics committee guidance that audio recording had the potential to identify participants by voice. It was agreed by the research team that sufficient capacity existed to support real-time transcription in lieu of audio recording. Transcribing kōrero (talk/communication) visibly also enabled participants to view, clarify, amend or expand their contributions as they were documented, supporting collective ownership and accuracy of the data. Throughout the wānanga, the transcriber checked these summaries with participants to confirm accuracy and meaning. However, detailed notes (author 2) also captured verbatim quotes, which are included in speech marks where used.

Analysis followed a reflexive thematic approach informed by Braun and Clarke.¹² First, two members of the research team (authors 1 and 3) independently reviewed the transcribed whiteboard notes to familiarise themselves with the data and generate the initial codes. Author 2 coded their notes independently. All codes were then discussed with the full research team and iteratively clustered into candidate themes that reflected patterned meanings relevant to the research aims.¹³ Themes were actively constructed through team discussion rather than assumed to have “emerged” from the data, acknowledging the positionality and expertise of the research team.¹⁴

Following this inductive phase, a deductive¹⁵ analytic step was undertaken in which the agreed themes and associated actionable points were mapped onto the NZEIDS framework to support policy- and service-level relevance. The preliminary thematic report was then emailed to focus group participants for feedback and approval, and the final report was returned to participants to confirm accuracy and resonance.

Ethics

This project received ethical approval from the University of Otago’s ethics committee (H25/0386).

Health Research Council funded project

This project was funded through a Health Research Council of New Zealand Māori Health Research Development Grant (HRC25/142).

NZEIEDS

Content for Table 1 was extracted from the NZEIEDS “roadmap of initial actions and further opportunities”. This roadmap outlines four priority areas for investment: prevention and early intervention, access, effectiveness and workforce. Proposed actions toward government priorities are categorised as “initial action areas” (short term) or “future opportunities” (medium to long term), with short term defined as 6–18 months and future opportunities intended to be progressed over the next 5 years.

View Table 1–8.

Results

Findings are presented sequentially by research question. For each question, we describe emergent themes, supported by an illustrative kaimahi quote and description of the theme. Actionable steps derived from the focus groups are then mapped directly onto relevant NZEIEDS domains, demonstrating how findings inform the practical implementation of strategic priorities.

Question 1: what are the challenges faced today?

Theme 1: food insecurity

“Binge eating is related to pay cycles, previously known as DPB [previous name for a single parent benefit] eating. Benefits are paid in weekly or fortnightly instalments resulting in times with food and times with less or no food. Eating behaviours reflected this pay cycle. Some parents restrict their food intake to ensure their children are fed.” – Kaimahi

Kaimahi identified food insecurity as a pressing concern, reporting economic deprivation often created significant barriers to whānau accessing nutritious kai. Kaimahi described distressing scenarios where whānau, particularly mothers, resorted to inadequate diets when financial resources were scarce, such as consuming dripping (animal fat) on toast or going without food. Kaimahi also coined the term “DPB eating”, describing a pattern of binge eating when food becomes available after periods of prolonged hunger. In discussion, kaimahi agreed that urbanisation has further exacerbated this issue by distancing many Māori from traditional food practices and communal gardening, reducing available food sources. To address these challenges, kaimahi suggested targeted initiatives, including the expansion of community food gardens and food banks, alongside efforts to reintegrate Kaupapa Māori approaches to support food security.

Theme 2: the impact of comorbidities

“Services operate in isolation, unable to treat interconnected needs. Weight-loss demands (e.g., for diabetes) clash with disordered eating recovery, risking harm.” – Kaimahi

Kaimahi critiqued current mainstream approaches to related health issues, such as diabetes, for prioritising weight-loss interventions, such as dieting, new weight loss medications or bariatric surgery, while neglecting the psychological and emotional needs of tāngata whai ora (person seeking wellness/patient) who may have not disclosed their disordered eating. Kaimahi described how health service providers continue to recommend dieting as a weight loss strategy for knee or hip surgery, despite poor efficacy as a long-term strategy to improve health outcomes.¹⁶ Concerningly, such a weight-centric focus can worsen outcomes, particularly for tangata whai ora whose disordered eating may have a coping function.¹⁷ For example, kaimahi reported that trauma histories were common, and trauma-related symptoms often influenced eating behaviours among tāngata whai ora presenting with disordered eating.

Kaimahi reported that whānau would often be supported by general practitioners (GP) without sufficient trauma-informed care training, leading to misaligned messaging and unhelpful recommendations that could undermine whai ora wellbeing. To address these issues, integrated care models that combine physical health interventions with mental health support are required, alongside comprehensive training for healthcare providers in weight-neutral and trauma-informed approaches.¹⁸

Question 2: what do KMS do well?

Theme 3: whānau ora (healthy families) model of practice

“Tāngata whai ora are experts in their lives; Kaupapa Māori services’ role is to walk alongside (not ‘fix’), using strengths-based, needs-focused approaches. Kaupapa Māori services celebrate autonomy, cultural identity (wairua, whakapapa), and promote community involvement.” – Kaimahi

Kaimahi agreed that a fundamental priority for KMS is whakawhanaungatanga (the process of building relationship/kinship), taking the time to build new relationships with tāngata whai ora and their whānau. Kaimahi said that often an NMK is only disclosed after several sessions once tāngata whai ora felt listened to and trust that a therapeutic alliance has been built. Kaimahi therefore emphasised the importance of a whānau ora model of practice, which empowered tāngata whai ora as the experts in their own journeys, recognising their cultural identity and connecting them to community to support overall wellbeing.

While whānau involvement is central within this model, kaimahi emphasised whānau as being defined by tāngata whai ora themselves, and the requirement for a flexible approach to whānau involvement to accommodate diverse whānau dynamics. As a response, kaimahi tailored their healthcare approaches to whānau dynamics, acknowledging that individualised care may be necessary in cases of conflict or where tāngata whai ora desired privacy, and options for separate support for whānau were required. Resourcing Māori providers to deliver whānau ora–aligned services, tailored to diverse whānau experiences, is identified as a key step towards equitable care.⁷ Kaimahi suggested that this could include investment in respite services.

Question 3: what supports are needed?

Theme 4: access to secondary services

“Kaupapa Māori services often absorb cases deemed ‘too severe’ by mainstream services, with poor handover.” – Kaimahi

Strict eligibility criteria for specialist NMK services were viewed by kaimahi as unhelpfully excluding complex cases with co-occurring challenges such as substance use or other mental health conditions, or atypical presentations, leaving many without adequate support. Siloed, diagnoses-specific treatment approaches were seen as ineffective for complex realities, highlighting the need for coordinated shared care instead of repeated referral. Kaimahi reported frequent redirection of “severe” cases from mainstream to KMS without adequate communication, disrupting continuity of care.

To bridge this disconnect, kaimahi recommended training mainstream services about Kaupapa Māori providers’ roles and scopes. They also cited short consultation times and overstretched teams as barriers to therapeutic relationships. Solutions included revising entry/exit criteria to include Māori who need support but don’t meet strict thresholds. For KMS, kaimahi emphasised the need for better-resourced multidisciplinary teams, and flexible, wraparound care that respects both whānau involvement and individual autonomy, ensuring an intersectional approach responsive to diverse Māori realities.

Theme 5: workforce development

“Paid professional development in eating disorders is required for kaimahi, including CBT [cognitive behavioural therapy] and cultural competency. There is a lack of awareness among GPs, teachers and whānau about avoidant restrictive food intake disorder and non-purging NMK like binge eating disorder and [this] leads to misdiagnosis.” – Kaimahi

Kaimahi suggested that colleagues across mainstream healthcare settings had limited NMK knowledge, contributing to difficulties recognising conditions such as avoidant restrictive food intake disorder (ARFID) and binge eating disorder (BED), and to inappropriate responses when concerns were identified. Lack of adequate knowledge resulted in misdiagnosis or delayed intervention. Kaimahi also raised diagnostic overshadowing as a key issue—for example they described takiwātanga (autism) tāngata whai ora with ARFID being overlooked or not offered support, due to their autism spectrum disorder diagnosis. This was described as distressing and harmful for whānau whose concerns were minimised or dismissed.

Kaimahi agreed peer support programmes, especially for adolescents, are a critical need. There is some evidence among high-acuity inpatients living with NMK that aspects of treatment can be very stressful, indeed traumatic at times, and associating with unwell peers can have unhelpful impacts in undermining treatment and recovery through negative comparisons, competitive aspects or learning new NMK behaviours.¹⁹ However, preliminary evidence suggests considerable additional benefit of peer support for recovery.²⁰ Kaimahi also emphasised the importance of anti-stigma campaigns to challenge weight-centric narratives in healthcare and developing accessible psychoeducation resources for whānau with NMK, which is essential to counter reliance on unvetted and potentially harmful online information.

Theme 6: culturally informed screening and assessment tools

“Develop appropriate screening tools. Kaimahi are currently using SCOFF/DSM 5. However, these are not relevant to Kaupapa Māori service, and not culturally safe for Māori.” – Kaimahi

Kaimahi considered the current screening tools, such as the SCOFF²¹ and diagnostic criteria (e.g., DSM-5),²² were not fit for purpose due to their symptom-focussed approach, failure to account for the impact of trauma and emotional drivers of eating issues and insensitivity to cultural contexts. Kamahi called for the co-development of trauma-informed, emotion-centred assessment tools in collaboration with Māori stakeholders. Kaimahi agreed that piloting and evaluating these tools within KMS are necessary to ensure they align with Māori wellbeing frameworks and improve diagnostic accuracy.

The development of revised diagnostic criteria or screening tools for Māori must be grounded in the provisions of Te Tiriti o Waitangi, with the explicit aim of enabling equitable access to health services under article 3.²

Discussion

This study sought to centre the perspectives of Kaupapa Māori kaimahi in understanding NMK presentations, with the dual aim of identifying systemic challenges and strengths and translating these insights into actionable policy and practice steps aligned with the NZEIEDS. Through a wānanga with eight kaimahi, six key themes were identified, reflecting both barriers and enablers in NMK support for Māori. These themes were further developed into 24 actionable points, which were then mapped onto the NZEIEDS framework to demonstrate how Kaupapa Māori knowledge can directly inform strategy implementation.

Food insecurity represents a critical lever for prevention and early intervention, aligning with emerging evidence identifying it as a causal factor for NMK.²³ Resourcing primary healthcare services, including KMS, to support early intervention is therefore critical for improving outcomes. This urgency is underscored by the substantial psychosocial and economic burden borne by carers, alongside the common delay of over a year before tāngata whai ora seek help for NMK.^24,25 Furthermore, kaimahi described discrimination and diagnostic overshadowing within mainstream services as significant barriers to diagnosis and support,⁵ an inequity that mirrors broader patterns experienced by Māori within mental health system.²⁶ Together, these factors highlight the necessity for accessible, responsive and trustworthy early intervention pathways.

In this context, kaimahi identified insufficient time for relationship building in mainstream services erodes the trust necessary for early disclosure and help-seeking. They emphasised whanaungatanga (relationship/kinship) as foundational, not merely an adjunct to clinical assessment, to effective NMK support. The hui (meeting) process exemplifies this approach, using a culturally grounded format to strengthen clinician–whānau relationships and foster holistic understanding.²⁷ Kaimahi further critiqued current NMK referral pathways for their symptom and weight-centric focus, which can overlook trauma-related symptoms, emotional distress and wider social drivers for NMK. They consistently called for assessment and treatment frameworks that account for the cumulative impacts of trauma, deprivation and cultural disconnection. Assessment frameworks such as the Meihana model,²⁸ which integrates social, cultural and clinical domains, were identified as better aligned with this holistic approach; however, kaimahi emphasised that all NMK screening and assessment tools require validation for Māori with NMK to ensure cultural safety and clinical relevance.

Kaimahi envisage holistic NMK support involving co-ordinated cross-sector responses to address housing, food insecurity, education, income support and culturally grounded care and support. This approach, embedded in whānau ora principles and relational funding models, enables sustained, holistic support for tāngata whai ora and their whānau. While international scholars increasingly advocate for such intersectional and multidisciplinary models,²⁹ this study demonstrates that Māori practitioners are already articulating these solutions within their own practice contexts. Elevating kaimahi knowledge confirms that interdisciplinary, culturally responsive NMK support is not a novel import, but an approach already embedded within Māori ways of working.

Workforce development was also identified as essential to improving NMK outcomes for Māori. Kaimahi emphasised the need for training across primary and specialist care in trauma-informed, weight-neutral and culturally safe practice, particularly given the high burden of physical comorbidities for Māori.³⁰ This includes shifting primary care policy away from emphasising weight-loss advice towards evidence-based and holistic health approaches, alongside strengthening pre- and post-bariatric surgery supports to prevent relapse of pre-existing NMK. Investment in culturally appropriate peer support (particularly for rangatahi [youth/young people]) and public health campaigns addressing lesser-known NMK presentations such as ARFID and non-purging disorders were also identified as priorities.

Conclusion

Government recognition of KMS as an investment priority creates an opportunity to shift from strategy to delivery; equity for Māori with NMK will depend on whether Kaupapa Māori expertise is treated as core implementation evidence and resourced accordingly through commissioning, workforce and integrated pathways across the health system.