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Anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) are serious conditions with significant adverse medical, psychological, social and economic effects on individuals, impairing quality of life.1 Eating disorders (EDs) are at least as common in Māori as in non-Māori, according to the New Zealand Mental Health Survey Te Rau Hinengaro (NZMHS).2 However, to date there is very limited research focused on EDs and Māori. This paper considers the existing evidence and identifies gaps in the literature, and briefly discusses other aspects that may have an impact on the experience of eating disorders in Māori.

Prevalence

The NZMHS used standardised diagnostic measures and conducted face-to-face interviews during 2003 and 2004 with 12,992 New Zealand adults over the age of 16 years. Of that number, 2,595 participants identified as being of Māori descent.2 The rates of EDs for Māori were similar to the general population and in some instances higher, with a prevalence of 0.7% for AN, 2.4% for BN and 3.1% for any eating disorder, compared to 0.6%, 1.3% and 1.3% respectively for the whole population.2 While the NZMHS findings are now limited by the age of the data, these results suggest that AN rates for Māori may be similar to the general New Zealand population, and in the case of BN and any eating disorder greater than the non-Māori prevalence.

Similar findings have been established in other countries. In Australia, the prevalence of EDs features in indigenous Aboriginal and Torres Strait Islander peoples is equal to that of non-indigenous Australians.3 Similarly, a study in New Mexico found eating disturbances among Hispanic and Native American youth were comparable to their European American counterparts.4 Further epidemiological data of EDs throughout Asia and the Pacific5 also suggests the prevalence of EDs within these regions have increased. These findings support the findings of the NZMHS that EDs exist in indigenous and non-westernised nations at a rate that is at least equal across population groups.

Pathways to eating disorders

If BN and potentially other EDs are as common among Māori than non-Māori,2 we must ask why, and examine the potential differential impacts on the pathways to the development of EDs for Māori. Māori are known to experience disproportionate exposure to risk factors for a number of health conditions, including mental illness. Much of the research in this area has centred on the influence of the social determinants of health and how as a consequence of colonisation, Māori experience higher levels of deprivation,6 reduced access to quality healthcare,7 and increased exposure to adversities such as racism.6,8 The applicability of this to Māori who experience EDs is unknown. The pathways to EDs are multifaceted and while some of the risk factors are shared with other mental disorders, some are more specific to EDs. The key determinants include; biological (including familial genetic predisposition),9 sociological (cultural/environmental influences)10 and psychological influences (including disturbance in a perceived body/weight image).11 The majority of this research has been conducted on dominant ethnic groups within populations and therefore its relevance to indigenous and ethnic minority groups is undetermined.

In terms of genetic predisposition, there is a growing agreement within the scientific community that sub-analysis within genetic studies by ethnic groups is problematic due to confounding variables. This includes race and ethnicity being a social construct and not an adequate marker of genetic diversity, as well as, the prevalence of admixture across populations.12 Instead, the trend has moved to focusing on the impact of racism and the determinants of health in the interpretation of ethnic differences.12 In the context of EDs, this is explored in the sociological and psychological pathways to EDs for ethnic minority groups.

Research on sociological pathways to EDs for other indigenous populations and ethnic minority groups has focused primarily on acculturation.13 Acculturation is the process of one culture adopting the values, norms and beliefs of another dominant culture.14 In the context of EDs this involves the adoption of Western-constructed beliefs regarding beauty, which includes body image ideals of ‘thinness’ for women, and a slim and muscular ideal for men.15 The research suggests that there is an association between EDs psychopathology and cultural change in some population groups, particularly in the context of Western culture adoption.13 However, research in this area is complicated by cross-cultural variation in both the conceptualisation and measurement of acculturation in that there is a lack of a uniformed definition of what acculturation actually is and therefore how it is measured.13 Consequently, studies have shown mixed results dependent on the groups studied and methods used.13 To date, there has been no research that has specifically investigated the association between acculturation and EDs in Māori. Therefore, the relevance of cultural change in the development of EDs among Māori remains unclear.

What is available is a small body of literature that focuses on body image ideals and dissatisfaction in Māori15 and other Polynesian peoples16—a well-established risk factor for the development of EDs.17,18 Durie, a Māori scholar has suggested (1994, cited by Talwar15) that Māori believe ‘slender body forms’ are not always valued over ‘well rounded’ body shapes and in Polynesian society obesity is not necessarily viewed negatively given larger body types have been associated with high status, power, authority and wealth.15 However, more recent empirical research suggests that these beliefs may have changed.15,16,19,20 Studies investigating body ideals in Pacific people indicate these groups may have a preference for smaller body types.16,20 These findings are reflected in New Zealand studies that have established no difference in body dissatisfaction and body ideals between Māori and New Zealand European female participants, including both groups identifying a desire for smaller figures.15,19 These studies are however limited by small sample sizes, differences in body mass index between measured groups, and in one study, non-standardised means of collecting ethnicity data. Despite these limitations, what they do offer is an alternative view to the expressed belief by Durie (1994, cited by Talwar15) that Māori are protected from EDs by different body image standards. It is possible that that cultural change has impacted on Māori developing EDs through the adoption of Western constructions of beauty and thin idealisation. However, further research in this area is clearly required to substantiate this.

Service utilisation

The level of specialist eating disorder service use for Māori in New Zealand is also uncertain. EDs treatment services have reported concerns about a low referral rate for Māori.21 Potential reasons for this apparent under-representation of Māori in EDs services include over-diagnosis of EDs in NZMHS, under-diagnosis of EDs in health services and barriers to access to quality healthcare for Māori with EDs. While we acknowledge these factors may affect all people with EDs, it is likely that Māori are disproportionally affected. For example, the findings of Metcalf22 demonstrate the widespread under-treatment for Māori across a range of conditions. BN and BED in particular are more likely to go undetected because routine screening is uncommon and the evidence that many do not seek help due to shame or secrecy related to the EDs.23 This may equate to a greater discrepancy in detection rates for BN and BED in primary care samples compared to the NZMHS prevalence data and a lower rate of referral to specialist EDs services. There is also evidence that Māori have reduced rates of contact with primary care comparative to need,7 further contributing to the potential for disparity. Nonetheless, the paucity of available research that is specific to EDs in Māori makes it difficult to gauge the level of specialist EDs service use and to be certain that Māori experience under-treatment of ED conditions.

Our lack of understanding of how Māori experience EDs is further compounded by a low rate of ethnicity data reporting in New Zealand based studies. This is observed in a number of studies that examine the level of engagement and effectiveness of eating disorder treatments for AN.24–26 A small rate of Māori participation (6–10%) is reported in BN and BED studies.27,28 Given the sample sizes, sub-analysis data concerning Māori participants may not have been statistically justifiable. Limited data in this area may also be a reflection of the inherent difficulties of researching rare disorders in a sub-population of a country with a small population size; however, research efforts are still required to avoid further marginalising an already vulnerable group. This lack of available evidence limits our understanding of how Māori might experience and respond to current treatments for eating disorders that are available.

Treatment journeys

The Meihana model describes a variety of factors that influence the Māori journey to hauora Māori (Māori wellbeing).29 A component of this model is Ngā Roma Moana (ocean currents), which describes four factors from Te Ao Māori (Māori world view) that may influence Māori patients and whānau in clinical settings. These factors include Ahua (personal indicators of the Māori world), whānau, whenua (land) and tikanga (customary practices).

The sharing of food is an essential part of tikanga, which guides both interpersonal and environmental behaviour. Food acts to consecrate both formal and informal occasions, and serves as a marker of noa or ‘neutrality’ in spaces otherwise considered tapu or ‘sacred’. Simply put, transitioning from tapu to noa happens most commonly through the consumption of food. The act of serving food to guests is also an important part of manaakitanga (hospitality) and contributes to the mana (prestige) of the hosts. The avoidance of food at these occasions has the potential to insult and be perceived as a breach of tikanga. How this affects Māori who have EDs, including how they navigate tikanga and whether current management approaches for Māori with EDs includes this challenge, warrants further exploration.

Conclusion

We suspect that Māori do not receive treatment in specialist ED services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with EDs is likely to be systemic bias. More specifically, differential access to health services due to an under-recognition of EDs in Māori by health services, alongside a low rate of referral for treatment. This would be consistent with what is already known regarding the extensive under-treatment of Māori for a range of other conditions.30 However, service utilisation data is currently lacking to be certain about this, which is further compounded by a lack of ethnicity reporting in published studies. Furthermore, there is a paucity of literature that has considered Māori-specific factors related to the development of EDs. Urgent attention to research in the area of EDs in Māori is required. This is especially important given the typical age of onset for EDs is in adolescence/young adulthood and the younger age of the Māori population. This suggests there may be increasing numbers of Māori youth developing EDs and therefore a corresponding need to ensure primary and secondary services are more accessible and responsive to this cohort. We call for research and quality improvement activities to examine and address the gaps in knowledge. This would involve primary and specialty care audits together with an investigation of national secondary mental health service data. An in-depth examination of Māori experiences of EDs to identify enablers and barriers to health care is also required.

Summary

Abstract

The New Zealand Mental Health Survey, Te Rau Hinengaro, indicated that eating disorders are at least as common in Māori as non-Māori, which is consistent with international findings that eating disorders exist in other indigenous and ethnic minority groups. Specific factors may be relevant to the development and treatment of eating disorders in the Māori population. We suggest this may include differential exposure to risk factors, the impact of acculturation, changing body image ideals and systemic bias reducing access to treatment and research participation. However, an absence of high-quality research regarding eating disorders in Māori makes it difficult to be certain about this. We suspect that Māori do not receive treatment in specialist eating disorders services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with eating disorders is likely to be systemic bias. Urgent attention to this area of research is required.

Aim

Method

Results

Conclusion

Author Information

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Department of Psychological Medicine, University of Otago, Christchurch; Mauterangimarie Clark, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Jenni Manuel, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Suzanne Pitama, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Ruth Cunningham, Department of Public Health, University of Otago, Wellington; Karen Keelan, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Vivienne Rijnberg, Department of Public Health, University of Otago, Wellington; Lana Cleland, Department of Psychological Medicine, University of Otago, Christchurch; Jennifer Jordan, Department of Psychological Medicine, University of Otago, Christchurch.

Acknowledgements

Correspondence

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch, PO Box 4345, Christchurch 8140.

Correspondence Email

cameron.lacey@otago.ac.nz

Competing Interests

All authors report grants from New Zealand Lottery Health Grant during the conduct of the study.

1. Striegel Weissman R, Rosselli F. Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness. Behaviour Research and Therapy. 2017; 88:49–64.

2. Baxter J, Kokaua J, Wells JE, McGee MA, Oakley Browne MA. Ethnic comparisons of the 12 month prevalence of mental disorders and treatment contact in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry. 2006; 40(10):905–13.

3. Hay PJ, Carriage C. Eating disorder features in indigenous Aboriginal and Torres Strait Islander Australian peoples. BioMed Central Public Health. 2012; 12:233.

4. Smith JE, Krejci J. Minorities join the majority: Eating disturbances among Hispanic and Native American youth. International Journal of Eating Disorders. 1991; 10(2):179–86.

5. Thomas JJ, Lee S, Becker AE. Updates in the epidemiology of eating disorders in Asia and the Pacific. Current Opinion in Psychiatry. 2016; 29(6):354–62.

6. Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015. 3rd ed. Wellington: Ministry of Health; 2015.

7. Schluter PJ, Bridgford P, Cook L, Hamilton G. Improving the evidence-base for access to primary health care in Canterbury: A panel study. Australian & New Zealand Journal of Public Health. 2014; 38(2):171–6.

8. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Social Science & Medicine. 2006; 63(6):1428–41.

9. Duncan L, Yilmaz Z, Gaspar H, Walters R, Goldstein J, Anttila V, et al. Significant locus and metabolic genetic correlations revealed in genome-wide association study of anorexia nervosa. American Journal of Psychiatry. 2017; 174(9):850–8.

10. Culbert KM, Racine SE, Klump KL. Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry. 2015; 56(11):1141–64.

11. Latner JD, Hildebrandt T, Rosewall JK, Chisholm AM, Hayashi K. Loss of control over eating reflects eating disturbances and general psychopathology. Behaviour Research & Therapy. 2007; 45(9):2203–11.

12. Yudell M, Roberts D, DeSalle R, Tishkoff S. Taking race out of human genetics. Science. 2016; 351(6273):564–5.

13. Doris E, Shekriladze I, Javakhishvili N, Jones R, Treasure J, Tchanturia K. Is cultural change associated with eating disorders? A systematic review of the literature. International journal of Eating and Weight Disorders. 2015; 20(2):149–60.

14. Ayala GX, Mickens L, Galindo P, Elder JP. Acculturation and body image perception among Latino youth. Ethnicity and Health. 2007; 12(1):21–41.

15. Talwar R, Carter JD, Gleaves DH. New Zealand female body image: what roles do ethnicity and body mass play?(Report). New Zealand Journal of Psychology. 2012; 41(1):69.

16. Brewis AA, McGarvey ST, Jones J, Swinburn BA. Perceptions of body size in Pacific Islanders. International Journal of Obesity. 1998; 22(2):185–9.

17. McGuinness S, Taylor JE. Understanding body image dissatisfaction and disordered eating in midlife adults. New Zealand Journal of Psychology. 2016; 45(1):4–12.

18. Stice E, Desjardins CD. Interactions between risk factors in the prediction of onset of eating disorders: Exploratory hypothesis generating analyses. Behaviour Research Therapy. 2018; 105:52–62.

19. Ngamanu RE. Body Image Attitudes Amongst Maori and Pakeha Females. Masters (Thesis). Hamilton: University of Waikato, New Zealand; 2006. Available from:  http://researchcommons.waikato.ac.nz/bitstream/handle/10289/2459/thesis.pdf?sequence=1&isAllowed=y

20. Craig PL, Swinburn BA, Matenga-Smith T, Matangi H, Vaughn G. Do Polynesians still believe that big is beautiful? Comparison of body size perceptions and preferences of Cook Islands, Maori and Australians. The New Zealand Medical Journal. 1996; 109(1023):200–3.

21. Lacey C, Leona L, Roberts D, Lawson R, Jordan J. Barriers to Māori participation in mainstream mental health services – proposed research. Presentation to Te Runaka ki Ōtautahi o Kai Tahu Trust, Christchurch. 2010.

22. Metcalf SL, G. Arnold, J. Variation in the use of medicines by ethnicity during 2006/07 in New Zealand: a preliminary analysis. The New Zealand Medical Journal. 2013; 126(1384):14:41.

23. Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent Health, Medicine and Therapeutics. 2018; 9:11–6.

24. Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial. International Journal of Eating Disorders. 2011; 44(7):647–54.

25. Jordan J, McIntosh VVW, Carter FA, Joyce PR, Frampton CMA, Luty SE, et al. Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa. European Eating Disorders Review. 2014; 22(4):278–84.

26. Surgenor LJ, Maguire S, Beumont PJV. Drop-out from inpatient treatment for anorexia nervosa: can risk factors be identified at point of admission? European Eating Disorders Review. 2004; 12(2):94–100.

27. Bulik CM, Sullivan PF, Carter FA, McIntosh VV, Joyce PR. The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine. 1998; 28(3):611–23.

28. McIntosh VVW, Jordan J, Carter JD, Frampton CMA, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Research. 2016; 240:412–20.

29. Pitama S, Huria T, Lacey C. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana The New Zealand Medical Journal. 2014; 127(1393):107–19.

30. Amanda C. Qualitative interviewing: encountering ethical issues and challenges. Nurse Researcher. 2006; 13(4):19.

Contact diana@nzma.org.nz
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Anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) are serious conditions with significant adverse medical, psychological, social and economic effects on individuals, impairing quality of life.1 Eating disorders (EDs) are at least as common in Māori as in non-Māori, according to the New Zealand Mental Health Survey Te Rau Hinengaro (NZMHS).2 However, to date there is very limited research focused on EDs and Māori. This paper considers the existing evidence and identifies gaps in the literature, and briefly discusses other aspects that may have an impact on the experience of eating disorders in Māori.

Prevalence

The NZMHS used standardised diagnostic measures and conducted face-to-face interviews during 2003 and 2004 with 12,992 New Zealand adults over the age of 16 years. Of that number, 2,595 participants identified as being of Māori descent.2 The rates of EDs for Māori were similar to the general population and in some instances higher, with a prevalence of 0.7% for AN, 2.4% for BN and 3.1% for any eating disorder, compared to 0.6%, 1.3% and 1.3% respectively for the whole population.2 While the NZMHS findings are now limited by the age of the data, these results suggest that AN rates for Māori may be similar to the general New Zealand population, and in the case of BN and any eating disorder greater than the non-Māori prevalence.

Similar findings have been established in other countries. In Australia, the prevalence of EDs features in indigenous Aboriginal and Torres Strait Islander peoples is equal to that of non-indigenous Australians.3 Similarly, a study in New Mexico found eating disturbances among Hispanic and Native American youth were comparable to their European American counterparts.4 Further epidemiological data of EDs throughout Asia and the Pacific5 also suggests the prevalence of EDs within these regions have increased. These findings support the findings of the NZMHS that EDs exist in indigenous and non-westernised nations at a rate that is at least equal across population groups.

Pathways to eating disorders

If BN and potentially other EDs are as common among Māori than non-Māori,2 we must ask why, and examine the potential differential impacts on the pathways to the development of EDs for Māori. Māori are known to experience disproportionate exposure to risk factors for a number of health conditions, including mental illness. Much of the research in this area has centred on the influence of the social determinants of health and how as a consequence of colonisation, Māori experience higher levels of deprivation,6 reduced access to quality healthcare,7 and increased exposure to adversities such as racism.6,8 The applicability of this to Māori who experience EDs is unknown. The pathways to EDs are multifaceted and while some of the risk factors are shared with other mental disorders, some are more specific to EDs. The key determinants include; biological (including familial genetic predisposition),9 sociological (cultural/environmental influences)10 and psychological influences (including disturbance in a perceived body/weight image).11 The majority of this research has been conducted on dominant ethnic groups within populations and therefore its relevance to indigenous and ethnic minority groups is undetermined.

In terms of genetic predisposition, there is a growing agreement within the scientific community that sub-analysis within genetic studies by ethnic groups is problematic due to confounding variables. This includes race and ethnicity being a social construct and not an adequate marker of genetic diversity, as well as, the prevalence of admixture across populations.12 Instead, the trend has moved to focusing on the impact of racism and the determinants of health in the interpretation of ethnic differences.12 In the context of EDs, this is explored in the sociological and psychological pathways to EDs for ethnic minority groups.

Research on sociological pathways to EDs for other indigenous populations and ethnic minority groups has focused primarily on acculturation.13 Acculturation is the process of one culture adopting the values, norms and beliefs of another dominant culture.14 In the context of EDs this involves the adoption of Western-constructed beliefs regarding beauty, which includes body image ideals of ‘thinness’ for women, and a slim and muscular ideal for men.15 The research suggests that there is an association between EDs psychopathology and cultural change in some population groups, particularly in the context of Western culture adoption.13 However, research in this area is complicated by cross-cultural variation in both the conceptualisation and measurement of acculturation in that there is a lack of a uniformed definition of what acculturation actually is and therefore how it is measured.13 Consequently, studies have shown mixed results dependent on the groups studied and methods used.13 To date, there has been no research that has specifically investigated the association between acculturation and EDs in Māori. Therefore, the relevance of cultural change in the development of EDs among Māori remains unclear.

What is available is a small body of literature that focuses on body image ideals and dissatisfaction in Māori15 and other Polynesian peoples16—a well-established risk factor for the development of EDs.17,18 Durie, a Māori scholar has suggested (1994, cited by Talwar15) that Māori believe ‘slender body forms’ are not always valued over ‘well rounded’ body shapes and in Polynesian society obesity is not necessarily viewed negatively given larger body types have been associated with high status, power, authority and wealth.15 However, more recent empirical research suggests that these beliefs may have changed.15,16,19,20 Studies investigating body ideals in Pacific people indicate these groups may have a preference for smaller body types.16,20 These findings are reflected in New Zealand studies that have established no difference in body dissatisfaction and body ideals between Māori and New Zealand European female participants, including both groups identifying a desire for smaller figures.15,19 These studies are however limited by small sample sizes, differences in body mass index between measured groups, and in one study, non-standardised means of collecting ethnicity data. Despite these limitations, what they do offer is an alternative view to the expressed belief by Durie (1994, cited by Talwar15) that Māori are protected from EDs by different body image standards. It is possible that that cultural change has impacted on Māori developing EDs through the adoption of Western constructions of beauty and thin idealisation. However, further research in this area is clearly required to substantiate this.

Service utilisation

The level of specialist eating disorder service use for Māori in New Zealand is also uncertain. EDs treatment services have reported concerns about a low referral rate for Māori.21 Potential reasons for this apparent under-representation of Māori in EDs services include over-diagnosis of EDs in NZMHS, under-diagnosis of EDs in health services and barriers to access to quality healthcare for Māori with EDs. While we acknowledge these factors may affect all people with EDs, it is likely that Māori are disproportionally affected. For example, the findings of Metcalf22 demonstrate the widespread under-treatment for Māori across a range of conditions. BN and BED in particular are more likely to go undetected because routine screening is uncommon and the evidence that many do not seek help due to shame or secrecy related to the EDs.23 This may equate to a greater discrepancy in detection rates for BN and BED in primary care samples compared to the NZMHS prevalence data and a lower rate of referral to specialist EDs services. There is also evidence that Māori have reduced rates of contact with primary care comparative to need,7 further contributing to the potential for disparity. Nonetheless, the paucity of available research that is specific to EDs in Māori makes it difficult to gauge the level of specialist EDs service use and to be certain that Māori experience under-treatment of ED conditions.

Our lack of understanding of how Māori experience EDs is further compounded by a low rate of ethnicity data reporting in New Zealand based studies. This is observed in a number of studies that examine the level of engagement and effectiveness of eating disorder treatments for AN.24–26 A small rate of Māori participation (6–10%) is reported in BN and BED studies.27,28 Given the sample sizes, sub-analysis data concerning Māori participants may not have been statistically justifiable. Limited data in this area may also be a reflection of the inherent difficulties of researching rare disorders in a sub-population of a country with a small population size; however, research efforts are still required to avoid further marginalising an already vulnerable group. This lack of available evidence limits our understanding of how Māori might experience and respond to current treatments for eating disorders that are available.

Treatment journeys

The Meihana model describes a variety of factors that influence the Māori journey to hauora Māori (Māori wellbeing).29 A component of this model is Ngā Roma Moana (ocean currents), which describes four factors from Te Ao Māori (Māori world view) that may influence Māori patients and whānau in clinical settings. These factors include Ahua (personal indicators of the Māori world), whānau, whenua (land) and tikanga (customary practices).

The sharing of food is an essential part of tikanga, which guides both interpersonal and environmental behaviour. Food acts to consecrate both formal and informal occasions, and serves as a marker of noa or ‘neutrality’ in spaces otherwise considered tapu or ‘sacred’. Simply put, transitioning from tapu to noa happens most commonly through the consumption of food. The act of serving food to guests is also an important part of manaakitanga (hospitality) and contributes to the mana (prestige) of the hosts. The avoidance of food at these occasions has the potential to insult and be perceived as a breach of tikanga. How this affects Māori who have EDs, including how they navigate tikanga and whether current management approaches for Māori with EDs includes this challenge, warrants further exploration.

Conclusion

We suspect that Māori do not receive treatment in specialist ED services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with EDs is likely to be systemic bias. More specifically, differential access to health services due to an under-recognition of EDs in Māori by health services, alongside a low rate of referral for treatment. This would be consistent with what is already known regarding the extensive under-treatment of Māori for a range of other conditions.30 However, service utilisation data is currently lacking to be certain about this, which is further compounded by a lack of ethnicity reporting in published studies. Furthermore, there is a paucity of literature that has considered Māori-specific factors related to the development of EDs. Urgent attention to research in the area of EDs in Māori is required. This is especially important given the typical age of onset for EDs is in adolescence/young adulthood and the younger age of the Māori population. This suggests there may be increasing numbers of Māori youth developing EDs and therefore a corresponding need to ensure primary and secondary services are more accessible and responsive to this cohort. We call for research and quality improvement activities to examine and address the gaps in knowledge. This would involve primary and specialty care audits together with an investigation of national secondary mental health service data. An in-depth examination of Māori experiences of EDs to identify enablers and barriers to health care is also required.

Summary

Abstract

The New Zealand Mental Health Survey, Te Rau Hinengaro, indicated that eating disorders are at least as common in Māori as non-Māori, which is consistent with international findings that eating disorders exist in other indigenous and ethnic minority groups. Specific factors may be relevant to the development and treatment of eating disorders in the Māori population. We suggest this may include differential exposure to risk factors, the impact of acculturation, changing body image ideals and systemic bias reducing access to treatment and research participation. However, an absence of high-quality research regarding eating disorders in Māori makes it difficult to be certain about this. We suspect that Māori do not receive treatment in specialist eating disorders services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with eating disorders is likely to be systemic bias. Urgent attention to this area of research is required.

Aim

Method

Results

Conclusion

Author Information

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Department of Psychological Medicine, University of Otago, Christchurch; Mauterangimarie Clark, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Jenni Manuel, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Suzanne Pitama, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Ruth Cunningham, Department of Public Health, University of Otago, Wellington; Karen Keelan, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Vivienne Rijnberg, Department of Public Health, University of Otago, Wellington; Lana Cleland, Department of Psychological Medicine, University of Otago, Christchurch; Jennifer Jordan, Department of Psychological Medicine, University of Otago, Christchurch.

Acknowledgements

Correspondence

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch, PO Box 4345, Christchurch 8140.

Correspondence Email

cameron.lacey@otago.ac.nz

Competing Interests

All authors report grants from New Zealand Lottery Health Grant during the conduct of the study.

1. Striegel Weissman R, Rosselli F. Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness. Behaviour Research and Therapy. 2017; 88:49–64.

2. Baxter J, Kokaua J, Wells JE, McGee MA, Oakley Browne MA. Ethnic comparisons of the 12 month prevalence of mental disorders and treatment contact in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry. 2006; 40(10):905–13.

3. Hay PJ, Carriage C. Eating disorder features in indigenous Aboriginal and Torres Strait Islander Australian peoples. BioMed Central Public Health. 2012; 12:233.

4. Smith JE, Krejci J. Minorities join the majority: Eating disturbances among Hispanic and Native American youth. International Journal of Eating Disorders. 1991; 10(2):179–86.

5. Thomas JJ, Lee S, Becker AE. Updates in the epidemiology of eating disorders in Asia and the Pacific. Current Opinion in Psychiatry. 2016; 29(6):354–62.

6. Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015. 3rd ed. Wellington: Ministry of Health; 2015.

7. Schluter PJ, Bridgford P, Cook L, Hamilton G. Improving the evidence-base for access to primary health care in Canterbury: A panel study. Australian & New Zealand Journal of Public Health. 2014; 38(2):171–6.

8. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Social Science & Medicine. 2006; 63(6):1428–41.

9. Duncan L, Yilmaz Z, Gaspar H, Walters R, Goldstein J, Anttila V, et al. Significant locus and metabolic genetic correlations revealed in genome-wide association study of anorexia nervosa. American Journal of Psychiatry. 2017; 174(9):850–8.

10. Culbert KM, Racine SE, Klump KL. Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry. 2015; 56(11):1141–64.

11. Latner JD, Hildebrandt T, Rosewall JK, Chisholm AM, Hayashi K. Loss of control over eating reflects eating disturbances and general psychopathology. Behaviour Research & Therapy. 2007; 45(9):2203–11.

12. Yudell M, Roberts D, DeSalle R, Tishkoff S. Taking race out of human genetics. Science. 2016; 351(6273):564–5.

13. Doris E, Shekriladze I, Javakhishvili N, Jones R, Treasure J, Tchanturia K. Is cultural change associated with eating disorders? A systematic review of the literature. International journal of Eating and Weight Disorders. 2015; 20(2):149–60.

14. Ayala GX, Mickens L, Galindo P, Elder JP. Acculturation and body image perception among Latino youth. Ethnicity and Health. 2007; 12(1):21–41.

15. Talwar R, Carter JD, Gleaves DH. New Zealand female body image: what roles do ethnicity and body mass play?(Report). New Zealand Journal of Psychology. 2012; 41(1):69.

16. Brewis AA, McGarvey ST, Jones J, Swinburn BA. Perceptions of body size in Pacific Islanders. International Journal of Obesity. 1998; 22(2):185–9.

17. McGuinness S, Taylor JE. Understanding body image dissatisfaction and disordered eating in midlife adults. New Zealand Journal of Psychology. 2016; 45(1):4–12.

18. Stice E, Desjardins CD. Interactions between risk factors in the prediction of onset of eating disorders: Exploratory hypothesis generating analyses. Behaviour Research Therapy. 2018; 105:52–62.

19. Ngamanu RE. Body Image Attitudes Amongst Maori and Pakeha Females. Masters (Thesis). Hamilton: University of Waikato, New Zealand; 2006. Available from:  http://researchcommons.waikato.ac.nz/bitstream/handle/10289/2459/thesis.pdf?sequence=1&isAllowed=y

20. Craig PL, Swinburn BA, Matenga-Smith T, Matangi H, Vaughn G. Do Polynesians still believe that big is beautiful? Comparison of body size perceptions and preferences of Cook Islands, Maori and Australians. The New Zealand Medical Journal. 1996; 109(1023):200–3.

21. Lacey C, Leona L, Roberts D, Lawson R, Jordan J. Barriers to Māori participation in mainstream mental health services – proposed research. Presentation to Te Runaka ki Ōtautahi o Kai Tahu Trust, Christchurch. 2010.

22. Metcalf SL, G. Arnold, J. Variation in the use of medicines by ethnicity during 2006/07 in New Zealand: a preliminary analysis. The New Zealand Medical Journal. 2013; 126(1384):14:41.

23. Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent Health, Medicine and Therapeutics. 2018; 9:11–6.

24. Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial. International Journal of Eating Disorders. 2011; 44(7):647–54.

25. Jordan J, McIntosh VVW, Carter FA, Joyce PR, Frampton CMA, Luty SE, et al. Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa. European Eating Disorders Review. 2014; 22(4):278–84.

26. Surgenor LJ, Maguire S, Beumont PJV. Drop-out from inpatient treatment for anorexia nervosa: can risk factors be identified at point of admission? European Eating Disorders Review. 2004; 12(2):94–100.

27. Bulik CM, Sullivan PF, Carter FA, McIntosh VV, Joyce PR. The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine. 1998; 28(3):611–23.

28. McIntosh VVW, Jordan J, Carter JD, Frampton CMA, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Research. 2016; 240:412–20.

29. Pitama S, Huria T, Lacey C. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana The New Zealand Medical Journal. 2014; 127(1393):107–19.

30. Amanda C. Qualitative interviewing: encountering ethical issues and challenges. Nurse Researcher. 2006; 13(4):19.

Contact diana@nzma.org.nz
for the PDF of this article

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Anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED) are serious conditions with significant adverse medical, psychological, social and economic effects on individuals, impairing quality of life.1 Eating disorders (EDs) are at least as common in Māori as in non-Māori, according to the New Zealand Mental Health Survey Te Rau Hinengaro (NZMHS).2 However, to date there is very limited research focused on EDs and Māori. This paper considers the existing evidence and identifies gaps in the literature, and briefly discusses other aspects that may have an impact on the experience of eating disorders in Māori.

Prevalence

The NZMHS used standardised diagnostic measures and conducted face-to-face interviews during 2003 and 2004 with 12,992 New Zealand adults over the age of 16 years. Of that number, 2,595 participants identified as being of Māori descent.2 The rates of EDs for Māori were similar to the general population and in some instances higher, with a prevalence of 0.7% for AN, 2.4% for BN and 3.1% for any eating disorder, compared to 0.6%, 1.3% and 1.3% respectively for the whole population.2 While the NZMHS findings are now limited by the age of the data, these results suggest that AN rates for Māori may be similar to the general New Zealand population, and in the case of BN and any eating disorder greater than the non-Māori prevalence.

Similar findings have been established in other countries. In Australia, the prevalence of EDs features in indigenous Aboriginal and Torres Strait Islander peoples is equal to that of non-indigenous Australians.3 Similarly, a study in New Mexico found eating disturbances among Hispanic and Native American youth were comparable to their European American counterparts.4 Further epidemiological data of EDs throughout Asia and the Pacific5 also suggests the prevalence of EDs within these regions have increased. These findings support the findings of the NZMHS that EDs exist in indigenous and non-westernised nations at a rate that is at least equal across population groups.

Pathways to eating disorders

If BN and potentially other EDs are as common among Māori than non-Māori,2 we must ask why, and examine the potential differential impacts on the pathways to the development of EDs for Māori. Māori are known to experience disproportionate exposure to risk factors for a number of health conditions, including mental illness. Much of the research in this area has centred on the influence of the social determinants of health and how as a consequence of colonisation, Māori experience higher levels of deprivation,6 reduced access to quality healthcare,7 and increased exposure to adversities such as racism.6,8 The applicability of this to Māori who experience EDs is unknown. The pathways to EDs are multifaceted and while some of the risk factors are shared with other mental disorders, some are more specific to EDs. The key determinants include; biological (including familial genetic predisposition),9 sociological (cultural/environmental influences)10 and psychological influences (including disturbance in a perceived body/weight image).11 The majority of this research has been conducted on dominant ethnic groups within populations and therefore its relevance to indigenous and ethnic minority groups is undetermined.

In terms of genetic predisposition, there is a growing agreement within the scientific community that sub-analysis within genetic studies by ethnic groups is problematic due to confounding variables. This includes race and ethnicity being a social construct and not an adequate marker of genetic diversity, as well as, the prevalence of admixture across populations.12 Instead, the trend has moved to focusing on the impact of racism and the determinants of health in the interpretation of ethnic differences.12 In the context of EDs, this is explored in the sociological and psychological pathways to EDs for ethnic minority groups.

Research on sociological pathways to EDs for other indigenous populations and ethnic minority groups has focused primarily on acculturation.13 Acculturation is the process of one culture adopting the values, norms and beliefs of another dominant culture.14 In the context of EDs this involves the adoption of Western-constructed beliefs regarding beauty, which includes body image ideals of ‘thinness’ for women, and a slim and muscular ideal for men.15 The research suggests that there is an association between EDs psychopathology and cultural change in some population groups, particularly in the context of Western culture adoption.13 However, research in this area is complicated by cross-cultural variation in both the conceptualisation and measurement of acculturation in that there is a lack of a uniformed definition of what acculturation actually is and therefore how it is measured.13 Consequently, studies have shown mixed results dependent on the groups studied and methods used.13 To date, there has been no research that has specifically investigated the association between acculturation and EDs in Māori. Therefore, the relevance of cultural change in the development of EDs among Māori remains unclear.

What is available is a small body of literature that focuses on body image ideals and dissatisfaction in Māori15 and other Polynesian peoples16—a well-established risk factor for the development of EDs.17,18 Durie, a Māori scholar has suggested (1994, cited by Talwar15) that Māori believe ‘slender body forms’ are not always valued over ‘well rounded’ body shapes and in Polynesian society obesity is not necessarily viewed negatively given larger body types have been associated with high status, power, authority and wealth.15 However, more recent empirical research suggests that these beliefs may have changed.15,16,19,20 Studies investigating body ideals in Pacific people indicate these groups may have a preference for smaller body types.16,20 These findings are reflected in New Zealand studies that have established no difference in body dissatisfaction and body ideals between Māori and New Zealand European female participants, including both groups identifying a desire for smaller figures.15,19 These studies are however limited by small sample sizes, differences in body mass index between measured groups, and in one study, non-standardised means of collecting ethnicity data. Despite these limitations, what they do offer is an alternative view to the expressed belief by Durie (1994, cited by Talwar15) that Māori are protected from EDs by different body image standards. It is possible that that cultural change has impacted on Māori developing EDs through the adoption of Western constructions of beauty and thin idealisation. However, further research in this area is clearly required to substantiate this.

Service utilisation

The level of specialist eating disorder service use for Māori in New Zealand is also uncertain. EDs treatment services have reported concerns about a low referral rate for Māori.21 Potential reasons for this apparent under-representation of Māori in EDs services include over-diagnosis of EDs in NZMHS, under-diagnosis of EDs in health services and barriers to access to quality healthcare for Māori with EDs. While we acknowledge these factors may affect all people with EDs, it is likely that Māori are disproportionally affected. For example, the findings of Metcalf22 demonstrate the widespread under-treatment for Māori across a range of conditions. BN and BED in particular are more likely to go undetected because routine screening is uncommon and the evidence that many do not seek help due to shame or secrecy related to the EDs.23 This may equate to a greater discrepancy in detection rates for BN and BED in primary care samples compared to the NZMHS prevalence data and a lower rate of referral to specialist EDs services. There is also evidence that Māori have reduced rates of contact with primary care comparative to need,7 further contributing to the potential for disparity. Nonetheless, the paucity of available research that is specific to EDs in Māori makes it difficult to gauge the level of specialist EDs service use and to be certain that Māori experience under-treatment of ED conditions.

Our lack of understanding of how Māori experience EDs is further compounded by a low rate of ethnicity data reporting in New Zealand based studies. This is observed in a number of studies that examine the level of engagement and effectiveness of eating disorder treatments for AN.24–26 A small rate of Māori participation (6–10%) is reported in BN and BED studies.27,28 Given the sample sizes, sub-analysis data concerning Māori participants may not have been statistically justifiable. Limited data in this area may also be a reflection of the inherent difficulties of researching rare disorders in a sub-population of a country with a small population size; however, research efforts are still required to avoid further marginalising an already vulnerable group. This lack of available evidence limits our understanding of how Māori might experience and respond to current treatments for eating disorders that are available.

Treatment journeys

The Meihana model describes a variety of factors that influence the Māori journey to hauora Māori (Māori wellbeing).29 A component of this model is Ngā Roma Moana (ocean currents), which describes four factors from Te Ao Māori (Māori world view) that may influence Māori patients and whānau in clinical settings. These factors include Ahua (personal indicators of the Māori world), whānau, whenua (land) and tikanga (customary practices).

The sharing of food is an essential part of tikanga, which guides both interpersonal and environmental behaviour. Food acts to consecrate both formal and informal occasions, and serves as a marker of noa or ‘neutrality’ in spaces otherwise considered tapu or ‘sacred’. Simply put, transitioning from tapu to noa happens most commonly through the consumption of food. The act of serving food to guests is also an important part of manaakitanga (hospitality) and contributes to the mana (prestige) of the hosts. The avoidance of food at these occasions has the potential to insult and be perceived as a breach of tikanga. How this affects Māori who have EDs, including how they navigate tikanga and whether current management approaches for Māori with EDs includes this challenge, warrants further exploration.

Conclusion

We suspect that Māori do not receive treatment in specialist ED services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with EDs is likely to be systemic bias. More specifically, differential access to health services due to an under-recognition of EDs in Māori by health services, alongside a low rate of referral for treatment. This would be consistent with what is already known regarding the extensive under-treatment of Māori for a range of other conditions.30 However, service utilisation data is currently lacking to be certain about this, which is further compounded by a lack of ethnicity reporting in published studies. Furthermore, there is a paucity of literature that has considered Māori-specific factors related to the development of EDs. Urgent attention to research in the area of EDs in Māori is required. This is especially important given the typical age of onset for EDs is in adolescence/young adulthood and the younger age of the Māori population. This suggests there may be increasing numbers of Māori youth developing EDs and therefore a corresponding need to ensure primary and secondary services are more accessible and responsive to this cohort. We call for research and quality improvement activities to examine and address the gaps in knowledge. This would involve primary and specialty care audits together with an investigation of national secondary mental health service data. An in-depth examination of Māori experiences of EDs to identify enablers and barriers to health care is also required.

Summary

Abstract

The New Zealand Mental Health Survey, Te Rau Hinengaro, indicated that eating disorders are at least as common in Māori as non-Māori, which is consistent with international findings that eating disorders exist in other indigenous and ethnic minority groups. Specific factors may be relevant to the development and treatment of eating disorders in the Māori population. We suggest this may include differential exposure to risk factors, the impact of acculturation, changing body image ideals and systemic bias reducing access to treatment and research participation. However, an absence of high-quality research regarding eating disorders in Māori makes it difficult to be certain about this. We suspect that Māori do not receive treatment in specialist eating disorders services at a level commensurate with comparable prevalence data in New Zealand and that a significant contributory factor to the apparent unmet need for Māori with eating disorders is likely to be systemic bias. Urgent attention to this area of research is required.

Aim

Method

Results

Conclusion

Author Information

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Department of Psychological Medicine, University of Otago, Christchurch; Mauterangimarie Clark, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Jenni Manuel, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Suzanne Pitama, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Ruth Cunningham, Department of Public Health, University of Otago, Wellington; Karen Keelan, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch; Vivienne Rijnberg, Department of Public Health, University of Otago, Wellington; Lana Cleland, Department of Psychological Medicine, University of Otago, Christchurch; Jennifer Jordan, Department of Psychological Medicine, University of Otago, Christchurch.

Acknowledgements

Correspondence

Cameron Lacey, Māori/Indigenous Health Institute (MIHI), University of Otago, Christchurch, PO Box 4345, Christchurch 8140.

Correspondence Email

cameron.lacey@otago.ac.nz

Competing Interests

All authors report grants from New Zealand Lottery Health Grant during the conduct of the study.

1. Striegel Weissman R, Rosselli F. Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness. Behaviour Research and Therapy. 2017; 88:49–64.

2. Baxter J, Kokaua J, Wells JE, McGee MA, Oakley Browne MA. Ethnic comparisons of the 12 month prevalence of mental disorders and treatment contact in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry. 2006; 40(10):905–13.

3. Hay PJ, Carriage C. Eating disorder features in indigenous Aboriginal and Torres Strait Islander Australian peoples. BioMed Central Public Health. 2012; 12:233.

4. Smith JE, Krejci J. Minorities join the majority: Eating disturbances among Hispanic and Native American youth. International Journal of Eating Disorders. 1991; 10(2):179–86.

5. Thomas JJ, Lee S, Becker AE. Updates in the epidemiology of eating disorders in Asia and the Pacific. Current Opinion in Psychiatry. 2016; 29(6):354–62.

6. Ministry of Health. Tatau Kahukura: Māori Health Chart Book 2015. 3rd ed. Wellington: Ministry of Health; 2015.

7. Schluter PJ, Bridgford P, Cook L, Hamilton G. Improving the evidence-base for access to primary health care in Canterbury: A panel study. Australian & New Zealand Journal of Public Health. 2014; 38(2):171–6.

8. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Social Science & Medicine. 2006; 63(6):1428–41.

9. Duncan L, Yilmaz Z, Gaspar H, Walters R, Goldstein J, Anttila V, et al. Significant locus and metabolic genetic correlations revealed in genome-wide association study of anorexia nervosa. American Journal of Psychiatry. 2017; 174(9):850–8.

10. Culbert KM, Racine SE, Klump KL. Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry. 2015; 56(11):1141–64.

11. Latner JD, Hildebrandt T, Rosewall JK, Chisholm AM, Hayashi K. Loss of control over eating reflects eating disturbances and general psychopathology. Behaviour Research & Therapy. 2007; 45(9):2203–11.

12. Yudell M, Roberts D, DeSalle R, Tishkoff S. Taking race out of human genetics. Science. 2016; 351(6273):564–5.

13. Doris E, Shekriladze I, Javakhishvili N, Jones R, Treasure J, Tchanturia K. Is cultural change associated with eating disorders? A systematic review of the literature. International journal of Eating and Weight Disorders. 2015; 20(2):149–60.

14. Ayala GX, Mickens L, Galindo P, Elder JP. Acculturation and body image perception among Latino youth. Ethnicity and Health. 2007; 12(1):21–41.

15. Talwar R, Carter JD, Gleaves DH. New Zealand female body image: what roles do ethnicity and body mass play?(Report). New Zealand Journal of Psychology. 2012; 41(1):69.

16. Brewis AA, McGarvey ST, Jones J, Swinburn BA. Perceptions of body size in Pacific Islanders. International Journal of Obesity. 1998; 22(2):185–9.

17. McGuinness S, Taylor JE. Understanding body image dissatisfaction and disordered eating in midlife adults. New Zealand Journal of Psychology. 2016; 45(1):4–12.

18. Stice E, Desjardins CD. Interactions between risk factors in the prediction of onset of eating disorders: Exploratory hypothesis generating analyses. Behaviour Research Therapy. 2018; 105:52–62.

19. Ngamanu RE. Body Image Attitudes Amongst Maori and Pakeha Females. Masters (Thesis). Hamilton: University of Waikato, New Zealand; 2006. Available from:  http://researchcommons.waikato.ac.nz/bitstream/handle/10289/2459/thesis.pdf?sequence=1&isAllowed=y

20. Craig PL, Swinburn BA, Matenga-Smith T, Matangi H, Vaughn G. Do Polynesians still believe that big is beautiful? Comparison of body size perceptions and preferences of Cook Islands, Maori and Australians. The New Zealand Medical Journal. 1996; 109(1023):200–3.

21. Lacey C, Leona L, Roberts D, Lawson R, Jordan J. Barriers to Māori participation in mainstream mental health services – proposed research. Presentation to Te Runaka ki Ōtautahi o Kai Tahu Trust, Christchurch. 2010.

22. Metcalf SL, G. Arnold, J. Variation in the use of medicines by ethnicity during 2006/07 in New Zealand: a preliminary analysis. The New Zealand Medical Journal. 2013; 126(1384):14:41.

23. Hail L, Le Grange D. Bulimia nervosa in adolescents: prevalence and treatment challenges. Adolescent Health, Medicine and Therapeutics. 2018; 9:11–6.

24. Carter FA, Jordan J, McIntosh VV, Luty SE, McKenzie JM, Frampton CM, et al. The long-term efficacy of three psychotherapies for anorexia nervosa: a randomized, controlled trial. International Journal of Eating Disorders. 2011; 44(7):647–54.

25. Jordan J, McIntosh VVW, Carter FA, Joyce PR, Frampton CMA, Luty SE, et al. Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa. European Eating Disorders Review. 2014; 22(4):278–84.

26. Surgenor LJ, Maguire S, Beumont PJV. Drop-out from inpatient treatment for anorexia nervosa: can risk factors be identified at point of admission? European Eating Disorders Review. 2004; 12(2):94–100.

27. Bulik CM, Sullivan PF, Carter FA, McIntosh VV, Joyce PR. The role of exposure with response prevention in the cognitive-behavioural therapy for bulimia nervosa. Psychological Medicine. 1998; 28(3):611–23.

28. McIntosh VVW, Jordan J, Carter JD, Frampton CMA, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Research. 2016; 240:412–20.

29. Pitama S, Huria T, Lacey C. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana The New Zealand Medical Journal. 2014; 127(1393):107–19.

30. Amanda C. Qualitative interviewing: encountering ethical issues and challenges. Nurse Researcher. 2006; 13(4):19.

Contact diana@nzma.org.nz
for the PDF of this article

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