Can you tell us a little bit about your career?
My career had an interesting start I guess in that I didn’t complete my placement at university.
I’ll share a little bit about how I got into eating disorders. I had two clinical placements: the first placement I did really well and the second placement I didn’t do really well with.
I like to think it was a bit of a personality clash more than my clinical work. At the time, I wasn’t a typical eating disorder dietitian.
I ended up having to do an extra couple of weeks work at the Gold Coast Hospital to try and demonstrate my competencies, and out of that I passed the course and then I was offered a locum job—and out of that, I got offered a permanent job.
I was covering mental health, but also the renal and urology ward and a few other bits and pieces. After doing that for a little while, I became disillusioned with dietetics I suppose in that real traditional model of being the educator.
So, I started studying law because I was going to transition my career over into that and I did that for a couple of years while I kept working as a dietitian.
In 1995, I saw my first eating disorder patient on the mental health ward and it just totally changed my perception of things because I was no longer in a position where I was educating people on what to do. I was in a position where it was more about trying to understand a person’s relationship with food and what was working for them and what was getting in the way of them nourishing themselves in a healthy way to support their wellbeing.
After I saw her, the penny really dropped for me and I kept working in eating disorders and mental health.
Six months later, I was approached by a private hospital to come and work with them part-time to see eating disorder patients. From there, I’ve never really left the eating disorder space, which has been really good for me.
I sometimes think about it in the way that when I didn’t pass university I was really disappointed, but these things all happen for a reason and it led me to a career path that I’ve been able to build over 20 years or so, which has been really exciting.
That first eating disorder case that sparked the interest, what was that experience like for you as a dietitian?
For me, it was like a breath of fresh air to be honest because the way that I was taught was that, as nutrition experts, we guide people on what to do and we give them the education, whereas with her it was really around.
It was about trying to understand a little bit more around why she was choosing not to nourish her body, why she wanted to restrict and why she wanted to lose weight.
The other thing I felt was it was more about a personal connection because I was seeing her on a regular basis over a more extended time frame than a lot of patients I was seeing, so that was something I really enjoyed because when they were discharged they would be linked in with outpatient care so you get to follow their journey a little bit more as well.
From a purely dietetic point of view, I certainly felt out of my depth. We had no training in eating disorders when I went through, but at the same time, we had a really good team around us.
We had a great psychiatrist, some good nursing staff and so they were really helpful in giving me some guidance in terms of how to manage it. But I found that I picked it up quite quickly because I was very client-centric and client-focused in my work, and so that I think was quite helpful as well.
Are there any things that you think people need to avoid when they’re working with someone with an eating disorder? I’d be afraid of saying the wrong thing that might do more harm than good.
The point you make there is a really good one because it’s something that comes up a lot. From time to time, we have dietitians who come in and sit in on some of my clinics or we do some training with them, and that question comes up probably 80–90% of the time.
The interesting thing with a lot of the people that we work with is sometimes you can say the right thing, but they’ll interpret it the wrong way because they might have some perceived beliefs around food, weight issues, or whatever it may be.
I had a job back in the early 2000s with a group called the Bronte Foundation and the person who was leading that gave me a piece of advice which I continue to share with other people today.
We were doing some training with some counsellors that were new to the field and that question came up and she said, “Look, when you’re talking to them, as long as what you’re saying is coming from the heart, you’re probably not going to say the wrong thing.”
If you have a genuine belief that what you’re saying isn’t harmful to that person, it’s unlikely that it’s going to be the wrong thing. Sometimes even if it is on the right track, they might perceive it as being the wrong thing. So, you’ve just got to trust your instinct I think.
The other point I would say to that is what I’ve learned most about eating disorders has been through the interactions with my clients; it hasn’t been from a textbook or it hasn’t been through some training—it’s been through my clients.
They’ll let me know if I’m saying the wrong thing because they give me that feedback. It’s a really good question, but I guess my advice would be as long as it’s coming from a good place and it’s coming from your heart then you’re probably going to be on the right track.
What are the most common types of eating disorder cases you see? Is it mostly anorexia nervosa or is there a mix of other forms?
It’s a real mix. In our practice, we largely see anorexia nervosa and that’s the eating disorder that most people identify with when you say the words eating disorder. What we know is anorexia nervosa is probably one of the least prevalent or if not the least prevalent eating disorder.
There’s also bulimia nervosa, binge eating disorder and a couple of others which are more dominating in terms of prevalence.
While anorexia is the most stereotypical one that comes to mind, it’s the least prevalent, but in our practice, we would see predominantly presentations for anorexia and restrictive types of eating.
I read that 40% or more of people with type II diabetes have some form of disordered eating. What would that typically involve if that’s correct?
I’m not too sure of that particular statistic, but one of the ways that we understand it is that once food becomes a focus and it has to be measured and calculated, you start then moving away from any sort of intuitive eating process.
The way I think about it is that when we exit the womb, we’re essentially born to eat intuitively, and we do that for a little bit of time until society starts having its influence around weight and body image and health and things like that.
With diabetes, I think what happens is the focus becomes on food and, depending on the education that’s received and how much people engage with the myths that are out there, food starts getting compartmentalised into foods I can have and foods I can’t have, and foods that are good for me and foods that aren’t good for me.
Once that dynamic starts, I guess it’s hard to practice intuitive eating because you’ve got this conscious process that’s guiding you as well.
Throughout that process, whether it be type I or type II diabetes, for example, the increased focus on food gets you questioning your choices. And as you question your choices, it starts to pollute the relationship that you have with food that makes it more troublesome.
One of my thoughts is the more we analyse what we eat and the more we focus on that investigative nature with food then the more complicated our relationship gets. I think that’s probably one of the things that influences eating behaviour and disordered eating in people with diabetes for example.
The other issue that comes up for people with diabetes is the issue of insulin manipulation and trying to practice strategies which impair the absorption of the carbohydrate and therefore minimise calorie intake. That’s a subsection of the population we see with eating disorders.
Then there’s the term called diabulimia, which in some way relates to that.
Diabulimia isn’t a formal eating disorder diagnosis, but it’s more representative of a term that’s used when people manipulate their insulin, manipulate their diabetes treatment in a way that is associated with eating disorder behaviour.
What are some of the key things you focus on generally working with people with eating disorders on the whole? Is intuitive eating one of the main focuses or are there other things that you look at?
For me, it depends on the presentation. Intuitive eating is always the goal of treatment, but from the way I practice, it fits in different spaces.
If somebody presents with anorexia nervosa, their ability to eat intuitively is very much negatively impacted by the eating disorder itself because they’re largely going through extended periods without food.
There may be a suppressed metabolic factor, they may be acknowledging appetite but suppressing it because they don’t want to eat. The whole relationship for people with eating disorders in relationship with their appetite and hunger becomes very polluted.
What we do at our practice is we use the RAVES model, which is a model I developed back in the early 2000s to guide people on their way to get to a place where they could practice intuitive eating.
We generally start by engaging people to eat fairly Regularly, and once they’ve got that structure to their eating, we then try and work on Adequate nutrition.
We’ll then start working on Variety—people might eat carbohydrates, but they might only eat the low GI or they might only eat the sweet potato rather than having a broader span of foods.
And then we work on Eating in a social context, and then Spontaneity and flexibility.
We tend to find that once we’ve worked through those processes, we’ve really engaged the body’s ability to listen to and also trust hunger and fullness, and then they can continue developing that as they embody themselves in that intuitive eating process.
For people that are able to do that, they find that it a really liberating experience. But I think the goal for all the people we see from an eating disorder perspective is definitely trying to reconnect with that intuitive eating. ‘
The way we frame it is that we want you to eat with your body rather than eating with your head.
Eating with your head is all of the rules: the do’s, the don’ts, the good, the bad, the healthy, the unhealthy. Whereas eating with your body is listening to your body, eating intuitively and then just rolling with that.
What part of that process do you find that people tend to resist the most? What’s generally the biggest barrier you find with most clients?
It’s generally adequacy and variety. Initially, people can also struggle with regularity.
They think, “Why do I need to be eating four or five or six times a day?” But once they get that in place, to eat adequately if you’ve got an eating disorder, there’s generally an element of restriction there so people become conditioned to that restriction being adequate.
If someone’s following a meal plan that’s only meeting 50% of their needs and we start talking about the adequacy and encourage them to double their intake, that will seem like an excessive amount of food to them.
That then escalates any concerns they have around weight change, body image and emotional connection.
We try and explore that with them. Even then, when you get to the point where adequate nutrition is being taken on board, we then start trying to work on this issue of variety and identifying that.
When it comes to carbohydrate-based foods, our approach is to identify that there is no good and bad.
People might have brown rice, they might have quinoa, they might have sweet potato; but they might avoid pasta, white rice and bread.
Then you’ve got to try and support that person to build those other foods into their eating pattern and get their own evidence that it’s safe to do so. If people have adequacy but they don’t have a lot of variety, then the ability to engage with food socially remains limited as well.
If you go to an Italian restaurant or if you go to a friend’s place for dinner or if you have a family function, some of those foods that you’re avoiding, if they’re present and you’re not eating them, the only option really is to not have them. This means you’re dipping back into some degree of restriction and inadequacy with your diet.
It’s trying to support people through that adequacy and variety part of it which I tend to find the most challenging, especially for those people with eating disorders.
Another area of interest is more severe cases of anorexia nervosa when they first get into the hospital. Is there any kind of standard method that you know of that is used in those cases for refeeding or anything like that?
To my knowledge, there’s no standard method that’s used universally. The Royal Australian College of Psychiatry published some guidelines in 2014 that looks at the management of eating disorders.
In there, they propose that when you’re working with adults, starting at 1500 calories is a reasonable place to start—that’s their recommendation.
But what we tend to find is that the way eating disorders are treated in an in-patient setting is largely to do with the philosophy of that practice or service.
Some services will predominantly use nasogastric feeds; other services will try and avoid nasogastric feeds. Some services, when people are first admitted, do overnight feeds and food throughout the day.
There are different models that are used in terms of how nutrition is provided, and then you’ve also got different models that are used for how much nutrition to provide.
Some services are very aggressive and assertive with their refeeding, so they might start at 2000–2500 calories a day from day one of admission. Then you have other services, which are more conservative in their approach to refeeding and they might start at 1000 calories a day, for example, or sometimes less.
It’s influenced by the philosophy of the service, the resources available, the expertise of the practitioners.
The fact that there’s such a variance is incredible. I’m assuming one of the big factors in why people are starting so conservative is the fear of refeeding syndrome. Is that a legitimate concern that happens often that you know of?
Kylie Matthews and I published on this recently. In 2013 there were a series of studies published and, back in 2010, one of the dietitians from Melbourne, Melissa Whitelaw, who really got this ball rolling in refeeding and looking at it in eating disorders throughout those studies, identified that these eating disorder patients—and this largely relates to adolescence—were being fed 2000–2500 calories from the start of feeding with no meaningful drop in phosphate and no increased risk of refeeding syndrome.
In the adolescent world now, it’s largely identified that you can be fairly aggressive with refeeding. As I say, services feeding anywhere between 2000–3000 calories a day is not uncommon.
From an adult point of view, the evidence is much more limited. The study that we did at the Royal Brisbane Hospital was, to our knowledge, one of the first that’s been done looking at refeeding in adults.
We were feeding at 1500 calories a day via nasogastric feed; so we were looking at people who were admitted to a medical ward, over 18 years old with anorexia nervosa. And we were feeding at 1500 calories a day, and what we found is that there was no increased risk of refeeding syndrome feeding at that rate.
There were no cases of refeeding syndrome; there were no marked electrolyte disturbances in response to feeding at that rate.
What we don’t know is what the mechanisms are that make eating disorder populations different from refeeding syndromes.
We can’t say that refeeding syndrome doesn’t happen, we still need to be cautious of it, but there’s certainly a growing body of literature and evidence to suggest that people with an eating disorder potentially aren’t at as great a risk of refeeding syndrome as was previously thought.
The interesting part about that is when you look at refeeding guidelines specifically is that eating disorders are generally always put in a high-risk category—so if you’ve got an eating disorder, you’re at high risk of developing refeeding syndrome. And that’s one of the things that as dietitians we are cautious about.
My perspective is that dietetics is a pretty conservative profession anyway, and so we’re probably going to take a more conservative, cautious approach than an aggressive, risk-taking approach; but I think there’s more and more evidence demonstrating that we can be more assertive with refeeding in this particular population.
Having said that, it still definitely needs to be monitored, so we would still recommend a thiamine supplement, a multivitamin, daily blood reviews and supplementation as necessary.
We’re not saying it can’t happen and we’re not saying it doesn’t happen, but we are saying is we can refeed more aggressively as long as those monitoring processes are in place.
Is there anything you wanted to add to wrap up the interview?
I would just say that if anyone’s interested in working in the eating disorder space, it’s a very challenging area, but it’s also a very rewarding area.
I think it offers you things that some of your traditional dietetic cases don’t offer, and for me, I’m certainly grateful that I’ve had the ability to work in this space for such a period of time. If you’re interested in it, get out there and enjoy yourself!