Kath Read says people deserve to be treated with the same dignity and respect whatever their size. Credit:Paul Harris Other mundane bits of the built environment also cause anxiety among many on the eastern reaches of the body-mass- index spectrum: railway station turnstiles, elevators, staircases, door-frames, airport security scanners and so on. One of the most depressingly frequent matters for big people is the realisation that they live and work in a world that is simply not designed to accommodate them. And this is important, because, not to put too fine a point on it, there are a hell of a lot of them around. The formal definition of an obese person is one with a body mass index (BMI) of 30 or above. The BMI for people in the "normal" range is 18.5 to 25. The obese range is further subdivided, with BMI numbers above 40 being classified as "morbid". Collectively, the post-30 BMI cohort is not a fringe group. It comprises, in fact, roughly 27 per cent of adult Australians, or about 6 million people. That's more fat people than Catholics, or Australians born overseas.

Professor Stephen Simpson, of the Charles Perkins Centre, says society is heading down a 'slippery slope'. Credit:Louise Kennerley But although there exists a large and complex infrastructure of public and private resources to support and succour Catholics in their faith and immigrants in their introductions, there is little in the way of non-medical consideration for the bigger boned. In large part, this is because there is no consensus about what the body type actually signifies. Rebecca Donnelly demonstrates one of the larger beds available at Campbelltown Hospital. Credit:Brendon Thorne "I don't like the term 'people with obesity'," said Melbourne University academic and fat activist Dr Jenny Lee. "As far as I know it is used medically, it implies obesity is a disease, and that it's an added extra on top of a 'normal' body. It also disembodies fat people and encourages distance from our bodies."

It's a heated debate among people involved in the politics and policies of fat. The terminology is contested. To some, "obese" medicalises and depersonalises people; to others, "fat" is an insult. Some refer to obesity as a disability, or a disease; others disagree, citing genetic dispositions or social disadvantage as causes, and even – at the bolshie end of the scale – lifestyle choices. Rebecca Donnelly shows how chairs come in different sizes to cater for different patient needs at Campbelltown Hospital. Credit:Brendon Thorne We haven't as a population changed substantially genetically, nor have we become more slothful and gluttonous Professor Stephen Simpson However, there is at least one point of common experience. Everyone reacts cautiously when offered a seat. "I'm pretty lucky in most cases, even though I am at the larger end of the scale," said Read, "But I have friends who are smaller than me who really have problems with chairs.

A Canberra Hospital chair designed especially for obese patients. Credit:rohan.thomson.canberratimes@gmail.com "When you're talking about chairs in public spaces ... That's an area that is fraught. I have friends who really struggle with chairs. I have friends who have broken lots of chairs." This is unfortunate for more than one reason. In one significant aspect it is actually permissible to blame the chair for its own demise. This is a matter that design anthropologist Dr Dori Tunstall has often addressed. AusBig CEO Janet Hope says many people at the heavier end of the spectrum struggle with the limitations of domestic architecture. Credit:Simon Schluter Tunstall is dean of the design faculty at Canada's Ontario College of Art and Design, but used to lecture at Melbourne's Swinburne University so knows the Australian built environment well.

"Increasing obesity rates are the result of specific design decisions," she said. "Our sedentary lifestyle is by design, through the creation and promotion of chairs." AusBig's Janet Hope puts herself in the place of an obese person with a special suit. Credit:Simon Schluter Other contributing factors, such as large portion sizes at fast food outlets, she notes, also stem from design decisions. The fact that the design industry now largely ignores the problem that it had a hand in creating is a fundamental failing. "Everyone needs, for example, products made with durable materials, clothing that is flattering to all shapes, and environments that provide more space and reduce social anxiety," she said. Janet Hope is dedicated to educating health professionals who work with obese people. Credit:Simon Schluter

"The principles of universal design still apply when designing for the majority of society, which include people who are obese." This is undoubtedly true, but the sensitivities involved in making decisions specifically on the basis of BMI are delicate indeed. The line between inclusion and insult is sometimes extremely thin. In July this year, Canadian aircraft manufacturer Bombardier unveiled a new passenger plane with extra-wide middle seats to accommodate larger passengers. In October, however, when Hawaiian Airlines admitted that it was allocating seats according to passenger weight outrage ensued. The oft-raised contention that obese people should be required to purchase an extra seat on planes and trains reasonably raises cries of discrimination. Less often heard, if arguably more rational, are pleas for design fixes that make life less stressful for the one-in-four Australians who are defined as fat.

Janet Hope heads an organisation called AusBig, dedicated to education for health professionals in hospital and home-care settings about working with obese people. Many people at the heavier end of the spectrum, she said, struggle with the limitations of domestic architecture. "Sometimes they don't own their homes, they're only renting, so there are restrictions there," she said. "We have had a man in Melbourne who fell through the floorboards because he wasn't able to have the floor strengthened, because he was renting and his weight increased. "We've got to look at the flooring structure, and we also have to look at the doorways. If someone gets confined to a wheelchair, the chair can be 600, 700, even 800mm wide, and door openings are only 550mm. So there are issues there. These alterations are costly, and often landlords don't want their buildings touched." Hope referred to a case in Sydney in 2014 in which a man who weighed 300kg could not fit through the front door. A wall of his house had to be demolished in order to get him to hospital. In another case last year, she added, a critically ill woman who became house-bound and morbidly obese following an injury opted to die at home rather than endure the humiliation of being similarly extracted.

For the first time in history, we live in a world where there are more fat people than hungry people. So dramatic has been this shift – and so high the economic and health costs associated with it – that the World Health Organisation has set a global target aiming to reduce obesity rates to those of 2010 by 2025. It may well be a forlorn hope. In May this year, British medical journal The Lancet published an analysis of BMI trends in 200 countries, involving 19.2 million participants. It concluded that "if post-2000 trends continue, the probability of meeting the global obesity target is virtually zero". In other words, the fat cohort is not going away any time soon. Overwhelmingly, research and discussion is aimed (admirably enough) at finding ways to reduce obesity rates in future generations. Comparatively little of it focuses on facilitating useful and productive lives for fat people living now. And that's odd. Because in Australia that's more than a quarter of the adult population.

One of the big reasons for leaving fat people to cope unassisted with a built environment designed for an idealised thin everyperson, researchers agree, is the persistent tendency to see obesity as the result of personal choice. "If it was simply a matter of failure of will power then it's the largest failure in human history, because 63 per cent of us are now considered overweight or obese," said Professor Stephen Simpson, executive director of Obesity Australia and academic director of the University of Sydney's Charles Perkins Centre. "This isn't simple. We haven't as a population changed substantially genetically, nor have we become more slothful and gluttonous – neither of those things is true. "We are interacting with an environment that is encouraging us to go down this slippery slope. And once we're on it, it's very, very difficult to get off it." The Charles Perkins Centre is a dedicated facility for the research and treatment of non-communicable conditions such as diabetes and heart disease to which larger people are particularly susceptible. The centre, said Simpson, has been designed from the start to comfortably accommodate obese people even at the heaviest end of the spectrum.

"All the furniture is rated to 380kg," he said. "We have weighing platforms that allow a larger person to be weighed with dignity. We have interview rooms so the clinicians can meet with patients and their families which are bigger and more spacious, and have entryways that are wider. "Even lavatories have to be designed such that they are reinforced so that you don't have the terrible situation of the shattering of porcelain and the injuries that causes." In recent years, Australian hospitals have seen a significant increase in the number of high-weight people admitted to emergency departments. According to NSW Health, for instance, in 2013-14 there were 60,000 admissions due to issues associated with obesity. Ensuring that medical facilities and health workers are properly prepared to deal with obese patients in ways that ensure the safety and dignity of both is partly the responsibility of the Australian College of Emergency Medicine (ACEM), which publishes guidelines for emergency department design. The current guidelines state that the "planning of space and equipment … needs to consider the needs of patients of up to 400kg".

This includes making sure that ambulance bays, doorways, corridors and handrails are all big enough to deal with very large patients. There should also be at least one extra-large resuscitation bay, general cubicle and isolation room. Recognising that obesity often runs in families, at least one fifth of chairs in the waiting room should be big enough to accommodate very big visitors. ACEM's Dr Keith Joe was the chief author of the college's design guidelines. He said because new hospitals are built infrequently, and existing emergency departments upgraded slowly, facilities to handle ill or injured people at the higher end of the weight scale were at a premium. Most emergency departments, he said, at least had a resuscitation or trauma cubicle, which were larger than normal, into which obese patients could be put. Proper facilities for ward admissions – including extra-large MRI machines – tended to be limited to major hospitals. "For people who are under 250kg, or have a BMI less than 35, our equipment and facilities can accommodate for them, but often not for the morbidly obese," Joe said. It's a situation to which fat activist Kath Read can relate all too well. Over the years she's had two emergency department admissions.

The first time, she said, she was given a gown that was too small, leaving her embarrassed and exposed, and had a painful experience with a blood pressure cuff that wouldn't reach around her arm. The second time, both the gown and the cuff were designed for large people. "These sound like really small things, but they can have a dramatic effect on your health and wellbeing," she said. "Then there's the matter of the dignity of it. We are human beings and we deserve the dignity and respect that everyone else gets." The brute fact that healthcare equipment and facilities – much less the rest of the built environment – are not designed to accommodate the needs of more than one quarter of the adult population might be considered a scandal. And perhaps it is. Perhaps, too, though, it is a consequence that arises from the curious lack of cultural consensus regarding how fat people get fat, and what they represent when they do. For the fat themselves, such ambivalence sometimes exacerbates already significant health and social issues. Anecdotal evidence, at least, suggests that many delay seeking help for medical and economic problems because they fear the scorn and ridicule of the thin.

"They put off seeking treatment for much longer than people in regular size bodies would do," said Sarah Harry, a Melbourne psychotherapist, fat activist and yoga teacher. "I think the architecture of the world – and the architecture particularly of the health world – just continues to support the idea that people aren't coming for treatment because of the shame and stigma and moral judgment that they face with clinicians." Over in Ontario, Dori Tunstall thinks that this is an area in which design can make a corrective contribution. "There is a tremendous amount of stigma and shame culture surrounding obesity in many societies, but especially Western societies," she said. "Biases against people who are obese have negatively affected their employment levels and rates of promotion, and their psychological wellbeing through bullying and intimidation. It is crucial that designers work to promote positive images of people who are obese, as well as design inclusive products, environments and interfaces for people who are obese."

Keith Joe sees a need to change the whole approach. "We know there is a social way of thinking about obesity," he said "Some people don't see morbid obesity as a problem that needs to be addressed by surgery. That's where it falls down. "If you thought of morbid obesity in the same way that you thought of cancer or diabetes, and you put a guideline around it, then the funding would be taken much more seriously." Is it illegal? If fat people seem excluded from planning regulations, does that amount to discrimination (as it surely would, for instance, if public building design failed to accommodate for the blind or the chair-bound)? It's an awkward question with no clear answer, especially as many larger people neither expect nor demand special treatment.

The Australian Human Rights Commission holds that obesity "can be covered by the definition of disability in the Disability Discrimination Act". That provides a measure of legal protection, but only a partial one. The Commission notes that an employer can still discriminate against an obese person "if the person cannot perform the inherent requirements of a job after reasonable adjustments have been made". In terms of state law, only Victoria makes it an offence to discriminate against a person's physical attributes, which, according to several legal sources, arguably covers fatness. However, the only time this law has been tested was in 1992, in a case against the Public Transport Corporation. The court ruled that obesity did not constitute a disability unless it was accompanied by a secondary condition. In 2014, dairy corporation Parmalat sacked a forklift operator on the grounds that at 170kg he exceeded the safe weight limit for the vehicle. The company also said obesity-linked severe sleep apnoea meant his daytime drowsiness constituted a danger to other workers. The man sued for the right to return to work, but in 2015 the Fair Work Commission upheld the sacking.