Not there yet: needs and development for ngā māuiui kai (eating disorder) services in New Zealand

There have been major advances in the field of eating disorders in the past three decades with national strategies for service development and care in Aotearoa New Zealand as well as Australia.¹ However, despite progress, challenges remain. Two papers in this issue^2,3 highlight areas of under-service for people experiencing eating disorders in New Zealand. Solutions are offered that also inform similar challenges in Australia and elsewhere.

The first paper² discusses the inadequacies in care for young people with eating disorders admitted to general medical adult services. The paper was stimulated by the experience of two young people with an eating disorder whose ages of 16 and 17 years respectively put them outside the paediatric service and thus into an (it was argued) already overloaded adult service. It resonates with the recent call for age-appropriate services for all young people in the recently released Royal Australasian College of Physicians position paper. Among several key recommendations, this states that “Healthcare services must ensure young people receive health care in environments that are developmentally appropriate and delivered by staff trained in youth-specific health care”⁴.

Unfortunately, and not only in New Zealand, too many people with eating disorders requiring high-intensity care may be admitted to services lacking requisite environments or milieu and expertise. There are some encouraging developments, however. For example, while imperfect and yet small in number, the introduction of residential eating disorder care in 2021 in Australia is providing an alternate to inpatient hospitals. These programmes aim to provide holistic care incorporating a workforce with lived experience expertise. They have demonstrated effectiveness both for residents and their carers^5,6 and are now to be found in almost every state of Australia and within the public health services. It is difficult to say more about this first paper,² except to agree with the position of the authors and hope that it encourages development of age-appropriate eating disorder residential and similar services within New Zealand.

Continuing a theme of context-appropriate eating disorder services, the second paper used Kaupapa Māori methodologies applied to an analysis of Māori experiences in seeking help for ngā māuiui kai (eating disorders) and perceived service needs. This was followed by a deductive mapping of insights and themes onto the New Zealand Eating Issues and Eating Disorders Strategy.³ This was an interesting paper in many ways, not least its use of a novel participatory action research method. Instead of the usual audio recording and data transcription of interviews or focus groups, an argued more ethical approach was taken to data gathering. This was where there was real-time whiteboard bullet form transcriptions and member checking with participants.

The paper demonstrated notably that an understanding of ngā māuiui kai in Indigenous populations is one area where there has been a major shift in research and understanding over the past two to three decades. I am of an age to remember being asked the question “Do Aboriginal and Torres Strait Islander people develop eating disorders?” and being unable to answer except to refer to vague accounts from anthropology to suggest they might. We now have a body of literature, albeit still very small, that has found that Indigenous people across the globe do experience eating disorders, and indeed may be more likely to than the stereotypical high-income white person.⁷ However, as highlighted here,^3,8 there are deficiencies in identification, assessment and culturally appropriate treatment services.

This study of ngā māuiui kai in Māori³ identified important issues for Māori but also other Indigenous peoples. In particular, food insecurity and “cultural dispossession” of traditional methods of food preparation and choices are a significant and shared experience. I recall very well my colleague’s reflection that such dispossession was the likely explanation for our early finding of a moderate prevalence of eating disorder behaviours in First Australians.⁹ Common colonisation experiences alongside fiscal impoverishment, which exacerbates food insecurity, are known risk factors for developing eating disorders. However, each culture is unique. Some proposals, e.g., to increase or expand community food gardens and food banks and thus reintegrate Kaupapa Māori approaches to support food security, may not be directly translated into the other contexts. However, they yet may give impetus to changes in food practices and return to traditional foods, which have been found to be associated with improved physical health in Indigenous people in Canada.¹⁰

The importance of having a trauma-informed and less weight-centric approach to care services for people with eating disorders is also an area where others may be able to learn from the development of such integrated approaches within Māori healthcare services. The approach to walk alongside people using a strengths-based and personalised needs focus I would argue should be emulated in all services and particularly in the Australian context in culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander peoples. Workforce development and the utilisation of peer support similarly give benefits for outcomes. It is notable that the residential programmes in Australia fully integrate lived experience expertise in the workforce and this is highly regarded by people attending these programmes.¹¹ Finally, the need for culturally appropriate and informed screening tools and assessment is a major priority across the Tasman¹² and beyond.

In closing, these two papers make a strong argument for the development of ngā māuiui kai services in New Zealand. They synergise with international research and experiences and point a way to a better future. There is much to share and learn from each other.