Eating disorders in New Zealand: Implications for Māori and health service delivery

Eating Disorder and Other Psychiatric Hospitalizations in New Zealand During the COVID-19 Pandemic

OBJECTIVE

An unprecedented rise in eating disorder presentations has been documented in several countries during the COVID-19 pandemic. We explored this phenomenon by analyzing nationwide psychiatric admissions over 5 years, controlling for demographic variables.

METHODS

We retrospectively analyzed all hospitalizations in New Zealand with a primary psychiatric diagnosis from 2017 to 2021, using Poisson regression to calculate admission rates by diagnosis, before and during the pandemic. Using Fisher's exact test and Poisson modeling, national data were validated against a manually collected sample of eating disorder admissions.

RESULTS

Eating disorder admissions rose significantly during the pandemic (RR 1.48, p < 0.0001), while other diagnoses remained unchanged or decreased slightly. Anorexia nervosa in 10 to 19-year-old females drove increases, with persistent elevations noted in the 10-14 age group. Pandemic-associated increases were more striking for Māori (RR 2.55), the indigenous Polynesian population, compared with non-Māori (RR 1.43).

CONCLUSIONS

Eating disorder hospital presentations increased during the COVID-19 pandemic, while other psychiatric presentations to hospital remained relatively unchanged. Possible drivers include disrupted routines, barriers to healthcare access, altered social networks, and increased social media use. Clinical services require additional resources to manage the increased disease burden, especially in vulnerable pediatric and indigenous populations. Ongoing monitoring will be required to establish the time-course of pandemic-related clinical demand.

'E koekoe te Tūī, e ketekete te Kākā, e kuku te Kererū, The Tūī chatters, the Kākā cackles, and the Kererū coos': Insights into explanatory factors, treatment experiences and recovery for Māori with eating disorders - A qualitative study

BACKGROUND

Eating disorders are as common in Māori, the Indigenous people of Aotearoa-New Zealand, as they are in non-Māori; however, research has focused on the experiences of non-Māori. This paper will describe explanatory factors, treatment experiences and what helps with recovery for Māori.

METHODS

Kaupapa Māori research methodology informed the methods and analysis. Fifteen semi-structured interviews comprised thirteen Māori participants with eating disorders (anorexia nervosa, bulimia nervosa and binge eating disorder) and two whānau (support network) members. A thematic analysis was undertaken by a first cycle of coding that used deductive structural coding to identify data describing participants' perceived causes of eating disorders, their experience of treatment and recovery. A second cycle of coding used inductive analysis with descriptive and pattern coding.

RESULTS

Three overarching themes were antecedents (cumulative exposure), treatment (a system of complexities) and recovery (resource empowerment). Antecedents comprised cumulative exposure to body and sporting ideals and adversity as causal factors of eating disorders. In the treatment theme, a system of complexities critiqued rural settings for generalised mental health services, allocation of Māori cultural support, the economic burden of treatment, culturally incongruent treatment (methods, values) and a weight-focused discharge criterion. Recovery (resource empowerment) found appropriate health information, self-determination and connection to Māori culture and whānau aspirations helped with recovery.

CONCLUSION

The diversity of birdcalls reminds us of the individuality of eating disorders. Health practitioners are reminded that just as the Tūī, Kākā and Kererū possess their own unique birdcalls, so do Māori with eating disorders and their whānau have their own experiences, needs and required treatment responses.

Avoidant/restrictive food intake disorder (ARFID) in New Zealand and Australia: a scoping review

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves restrictive or avoidant eating behaviour not related to weight or body image concerns. It was first included in the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) in 2013. ARFID frequently begins in childhood and can have serious psychosocial impacts and detrimental health consequences when nutritional and energy needs are persistently unmet. This systematic scoping review focuses on Australasia, synthesizing the current literature landscape on ARFID, and offering recommendations for targeted, actionable research directions for both funders and researchers.

METHODS

Online databases and university thesis repositories were systematically searched for studies examining ARFID in the New Zealand or Australian population since 2013. Database search results were exported to Rayyan software, and two independent reviewers screened all identified sources, prior to extraction of key data.

RESULTS

Twenty-nine studies and one thesis from 138 screened sources were eligible for inclusion. Frequent study types were treatment interventions and cross-sectional studies, with populations including individuals with ARFID, ED service populations, parents/caregivers, health professionals, and non-clinical populations. ARFID presents in a range of settings and is associated with poorer quality of life and significant functional impairment. Assessment of ARFID was varied, and no specific treatment guidelines for ARFID have been written as yet.

CONCLUSION

This review calls for more accurate prevalence estimates of ARFID in children and larger-scale studies in all ages using validated measures. It emphasizes the need for education and training of healthcare professionals, and interdisciplinary collaboration. Established interventions like behaviour analytics should be considered, and more comprehensive research is needed on interventions for ARFID, including controlled trials and longitudinal studies. Urgent research is needed to improve outcomes for those affected by ARFID.

Research into Psychedelic-Assisted Psychotherapy for Anorexia Nervosa Should be Funded

Eating disorders are debilitating diseases that have twin impacts on the body and mind and are associated with a number of physiological and psychological comorbidities (Blinder, Cumella, and Sanathara 2006; Casiero and Frishman 2006), including increased suicide risk (Arcelus et al. 2011; Lipson and Sonneville 2020). In addition, eating disorders are growing in prevalence (Gilmache et al. 2019) and impact women at much higher rates than men (Bearman, Martinez, and Stice 2006), especially in adolescence (Spriggs, Kettner, and Carhart-Harris 2021). Anorexia nervosa (AN) is a particularly devastating eating disorder, with one of the highest mortality rates of any psychiatric disorder (Sullivan 1995). Despite the severity of the condition, current treatments for AN are limited in their efficacy (Khalsa et al. 2017). Based on the growing body of evidence demonstrating the short-term and long-term efficacy of psychedelic-assisted psychotherapy for the treatment of other mental illnesses, I argue that research into psychedelic-assisted psychotherapy for AN should be funded.

Reimagining eating disorder spaces: a qualitative study exploring Māori experiences of accessing treatment for eating disorders in Aotearoa New Zealand

BACKGROUND

Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Māori with eating disorders and their whānau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand.

METHOD

Kaupapa Māori research methodology was used to ensure the research supported Māori health advancement. Fifteen semi-structured interviews were completed with Māori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whānau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings.

RESULTS

Two overarching themes identified systemic and social barriers to accessing treatment for Māori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Māori experiences, and how this makes a place and space of exclusion for Māori and their whānau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy.

CONCLUSION

More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whānau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Māori. Attention given to these findings will ensure a place for Māori in specialist eating disorder services in New Zealand.

Eating disorders, disordered eating, and body image research in New Zealand: a scoping review

BACKGROUND

The prevention and treatment of eating disorders relies on an extensive body of research that includes various foci and methodologies. This scoping review identified relevant studies of eating disorders, body image, and disordered eating with New Zealand samples; charted the methodologies, sample characteristics, and findings reported; and identified several gaps that should be addressed by further research.

METHODS

Using scoping review methodology, two databases were searched for studies examining eating disorders, disordered eating, or body image with New Zealand samples. Snowball methods were further used to identify additional relevant articles that did not appear in initial searches. Two independent reviewers screened the titles and abstracts of 473 records. Full text assessment of the remaining 251 records resulted in 148 peer-reviewed articles being identified as eligible for the final review. A search of institutional databases yielded 106 Masters and Doctoral theses for assessment, with a total of 47 theses being identified as eligible for the final review. The included studies were classified by methodology, and the extracted information included the study foci, data collected, sample size, demographic information, and key findings.

RESULTS

The eligible studies examined a variety of eating disorder categories including binge-eating disorder, bulimia nervosa, and anorexia nervosa, in addition to disordered eating behaviours and body image in nonclinical or community samples. Methodologies included treatment trials, secondary analysis of existing datasets, non-treatment experimental interventions, cross-sectional observation, case-control studies, qualitative and mixed-methods studies, and case studies or series. Across all of the studies, questionnaire and interview data were most commonly utilised. A wide range of sample sizes were evident, and studies often reported all-female or mostly-female participants, with minimal inclusion of males and gender minorities. There was also an underrepresentation of minority ethnicities in many studies, highlighting the need for future research to increase diversity within samples.

CONCLUSION

This study provides a comprehensive and detailed overview of research into eating disorders and body image in New Zealand, while highlighting important considerations for both local and international research.

A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope

The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as 'terminal' in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as 'futile'. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.

Intuitive Eating Scale-2: psychometric properties and clinical norms among individuals seeking treatment for an eating disorder in private practice

PURPOSE

Intuitive Eating (IE) is an approach to eating designed to facilitate a positive relationship with food. Its use in clinical settings and in the community is rapidly growing in popularity. The Intuitive Eating Scale 2 (IES-2) is a widely used measure that indexes intuitive eating motivations and behaviour, however evidence of its validity in populations with clinical eating disorders remains scarce. The objective of the proposed study was thus to evaluate the factor structure of the IES-2 in a large sample of individuals seeking treatment for eating disorders in private practice.

METHODS

Data collected from 569 women and men aged 12-68 years seeking treatment for an eating disorder in one of eight specialist private outpatient eating disorder clinics were examined using confirmatory factor analysis (CFA). Relationships between IES-2 scores and measures of psychopathology were also examined.

RESULTS

Results were relatively consistent with the purported four-factor structure of the IES-2. The measure displayed strong construct validity and good internal consistency. Scores on the IES-2 were inversely associated with scores of depression, anxiety, and disordered eating, providing evidence for divergent validity of the measure. Clinical norms are provided for anorexia nervosa (AN) spectrum disorders and bulimia nervosa (BN) spectrum disorders, as well as for the clinical sample as a whole.

CONCLUSION

Findings suggest that the IES-2 may be an appropriate measure for evaluating behaviours relating to IE in community outpatient eating disorder settings, and provide further evidence for the association between IE and positive health outcomes.

LEVEL OF EVIDENCE

III, evidence obtained from well-designed cohort or case-control analytic studies.

Psychosocial and financial impacts for carers of those with eating disorders in New Zealand

BACKGROUND

Eating disorders (ED) can have profound effects on family members and carers. These impacts can be experienced across multiple domains and may contribute to the maintenance of ED symptoms. In the absence of any New Zealand studies quantifying this, and given country-specific differences in access to care and treatment, this study explores the psychosocial and economic impacts on those caring for someone with an ED in New Zealand.

METHODS

Carers (N = 121) of those who had, or still had, a self-reported ED (82.6% anorexia nervosa) completed an online survey open between December 2016 and October 2020, adapted to the New Zealand context. Questions addressed ED recency and recovery status of the individual cared for, treatment access, and the financial and psychosocial impact on the carer. Data analysis included descriptive statistics, with financial cost data converted to the equivalent of 2020 New Zealand dollars.

RESULTS

Most (88.6%) recruited carers reported still caring for someone with ED symptoms of varying severity. A majority reported difficulty accessing treatment for the person they cared for, with a sizable minority (45%) paying for private treatment, despite few having private insurance. Carer losses typically included reduced income and productivity, travel costs, and other miscellaneous costs. Carers reported significant psychosocial impacts across a range of dimensions including family life, interpersonal relationships, and their own personal well-being.

CONCLUSIONS

Carers in New Zealand report impacts which are far reaching and longstanding, covering their own personal and interpersonal well-being and that of those around them. While most of those they care for get access to public (free) treatment at some time or another, the wider financial and economic impacts on carers are significant, and likely to take years to recoup. Though not unique to EDs, interventions and supports for carers are much needed in New Zealand, alongside more comprehensive research methodology to further determine positive and other impacts of EDs over the long course of the caregiving role.

HIGHLIGHTS

A majority reported difficulty accessing treatment for the person they cared for 45% paid for private treatment, despite few having private insurance Carers reported reduced income and productivity, travel costs, and other costs. Carers reported significant psychosocial impacts on family life, interpersonal relationships, and their own personal well-being. Carers provide a pivotal role in supporting treatment and recovery in their family member with the These findings will be relevant for funders and service providers in developing further approaches to address barriers and gaps in service provision to reduce impacts on carers, and as a result, those with eating disorders.

Teeth are for chewing: a critical review of the conceptualisation and ethics of a controversial intraoral weight-loss device

We are a diverse collective of researchers who are committed to improving the health and wellbeing of marginalised individuals. This article is a response to, and critique of, the DentalSlim Diet Control research. This device revises a controversial 1970s weight-loss technology connected to poor health outcomes, which is indicative of a culture that consistently promotes harm to fat and other marginalised communities.We address the historical context in which unruly bodies, particularly fat, and Indigenous bodies have been the site of unethical investigation conducted under the auspices of medical research. Existence outside the normative white, male, cis physical ideal demands regulation, and disciplinary measures. We demonstrate how Brunton et al.'s research is underpinned by anti-fat attitudes and assumptions which impose this punitive physical intervention onto healthy people in a way that should not be acceptable in medical research.Further, we address a range of harms, giving attention to Māori and to individuals with eating disorders, along with issues of research integrity. We argue that no ethics committee should have approved this research, no academic journal should have published it, and no member of the dental and medical community should promote or prescribe this device.

[Eating and feeding disorders : New developments]

An overview of eating and feeding disorders according to the future criteria of the International Classification of Diseases (ICD-11) is presented, including information on differential diagnosis, epidemiology, etiology, pathogenesis as well as therapy. Binge-eating disorder is new and the most frequent eating disorder. While anorexia nervosa and bulimia nervosa mostly affect women, the gender ratio in binge-eating disorder is more balanced. Concerning etiology, socio-cultural, biological and psychological factors are discussed. Cognitive behavioral psychotherapy is the best-validated treatment for all three eating disorders. According to the German guidelines for treatment (2019), focal psychodynamic psychotherapy is also a treatment option for anorexia nervosa. Evidence for the positive effect of psychopharmacologic drugs in the treatment of anorexia nervosa is still lacking. Fluoxetine has been shown to have a limited effect in the treatment of bulimia nervosa.

The impact of COVID-19 on eating disorder referrals and admissions in Waikato, New Zealand

BACKGROUND

Several countries have reported increased demand for eating disorder services during the COVID-19 pandemic, particularly for adolescents. Within New Zealand, anecdotal and media reports suggest similar changes but are limited in scope and detail. We assessed eating disorder service demand in the Waikato district in relation to the COVID-19 pandemic.

METHODS

We retrospectively analysed records of eating disorder admissions and referrals for both children (< 18 years) and adults (≥ 18 years) during 2019 and 2020 in the Waikato, a mixed urban-rural province in northern New Zealand (population 435,000). We analysed medical admission and outpatient referral rates, and referral acuity, in relation to the COVID-19 pandemic using Welch's t- and chi-square tests.

RESULTS

106 medical admissions met inclusion criteria (n = 37 in 2019; 69 in 2020). Admissions for eating disorders increased markedly following nationwide lockdown in March 2020 (RR = 1.7, p = 0.01), largely driven by increases in adult admissions (RR 2.0, p = 0.005). The proportion of 'new patient' admissions showed comparable increases for both children (RR = 2.0, p = 0.02) and adults (RR = 2.3, p = 0.03). Following lockdown, outpatient referrals increased in acuity (RR = 1.8, p = 0.047) and volume (RR = 1.6, p = 0.076) for children but not for adults.

CONCLUSIONS

Our study confirms a pandemic-related increase in demand for eating disorder services in the Waikato region of New Zealand, consistent with findings reported overseas. We observed contrasting increases in admissions for adults and outpatient referrals for children, exacerbating resource constraints for already stretched services and compromising provision of timely care. The COVID-19 pandemic has been linked to increased numbers and worsening severity of eating disorders in several settings. In New Zealand, similar trends have been noted anecdotally. We assessed clinical records to calculate rates of eating disorder-related hospital admissions and outpatient referrals during 2019 and 2020. We found significant increases in hospital admissions related to COVID-19, particularly for adults, and greater proportions of both children and adults having a first-ever eating disorder-related admission. In outpatient services, young people were referred more frequently during the pandemic and were more physically unwell when referred. These results indicate increased demand for eating disorder services as a result of the pandemic and complement findings reported overseas.

Eating disorders amongst Aboriginal and Torres Strait Islander Australians: a scoping review

BACKGROUND

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) have poorer mental health compared to other Australians. Yet, there is a lack of research into mental disorders among this population, especially for eating disorders (ED), which are amongst the most lethal and debilitating mental disorders.

AIM

We aimed to answer 2 questions: 1. What is the volume and content of literature on ED among Indigenous Australians? 2. Has a screening or diagnostic tool/instrument been developed for the assessment of ED amongst Indigenous Australians?

METHOD

We conducted a scoping review of electronic databases (Pubmeb, Embase, PsychInfo, Proquest, Cochrane Library, Indigenous HealtInfoNet and Scopus), for studies addressing ED, body image, muscle dysmorphia, weight and shape concern among Indigenous Australians, as well as diagnostic and screening tools. All relevant studies were reviewed in full by 2 researchers. Narrative synthesis of the data was performed.

RESULTS

There is limited evidence for ED among Indigenous Australians, however, the evidence available strongly suggests that ED are more common among Indigenous Australians compared to other Australians. Eating disorders among Indigenous Australians are also associated with high levels of overvaluation of weight and shape. The increased risk of ED among Indigenous Australians was largely explained by factors such as poorer psychosocial wellbeing. No evidence was found for the existence of validated diagnostic or screening tools for ED in Indigenous Australians.

CONCLUSION

The evidence suggests ED are common among Indigenous Australians, and there are no diagnostic or screening tools available to assist clinicians in assessing them. More research is required in this field, especially towards the development of a validated and culturally specific screening or diagnostic tool for ED among Indigenous Australians.