An Internship “Down Under”

Kiora! (NZ native greeting)

My name is Lauren Elder, and I am a recent graduate from the combined Masters in Public Health/Registered Dietetics Program at the UNC Gillings School of Global Public Health in the Department of Nutrition. This past fall, I was fortunate enough to have the opportunity to complete my clinical fieldwork at the South Island Eating Disorders Service (SIEDS) in Christchurch, New Zealand! SIEDS began under the efforts of Profs. Cynthia Bulik and Peter Joyce (currently Dean of University of Otago in Christchurch) in the early 90s. It is located at Princess Margaret Hospital (PMH) and functions as the expert regional service for NZ’s south island. While working at SIEDS, I trained under a team of fabulous dietitians and consequently had some very enriching professional experiences. While working primarily as an inpatient dietitian (occasionally cross-covering in the outpatient arena), my dietetic responsibilities included, but were not limited to, individual and group nutritional counseling, meal supervision/exposure tasks, meal planning, and nutrition support. All dietitians working with eating disorder populations share similar roles, but the overall approach to eating disorder treatment in NZ was fundamentally different from my experiences here in the States. These differences may be summarized by 3 T’s: time, team, and technique.

“Home Sweet Home”: SIEDS at PMH

Firstly, time. On the whole, Kiwis are incredibly generous with their time. It’s safe to make the generalization that New Zealanders work to live, not live to work, as is so common within most overworked western cultures. This principle was manifested in the daily morning and afternoon teatime that hospital employees enjoyed for a short break, the occasional outside walks with other dietitians, psychologists, and MDs, and the overall enthusiasm of staff to engage you in a more-than-ten-minute lunch conversation in their office. This priority shift is certainly not indicative of an unproductive service. Conversely, this treatment team handled the most complex eating disorder cases I have ever seen and had an extremely full caseload. Yet, they are able to step back from their work (literally and figuratively) and focus on one of life’s more important features: human interaction. Time was also evident in the length of stay for NZ inpatients. While patients in the States stay on average 26 days, NZ inpatients typically remain hospitalized for 72 days.1 This shorter stay in the US is a result of privatized health insurance, which typically does not cover sufficiently long hospital stays to allow patients to reach and stabilize at a healthy body weight. It was certainly a nice change to have more time with patients to work on improving nutritional parameters.

Secondly, team. Shadow staff at SIEDS for a day, and you will understand how a multi-disciplinary team should function. A team approach is, in my humble opinion, one of the most critical components in the treatment of eating disorders. Coordinating care from psychologists, nurses, dietitians, physicians, etc. allows for a completely detailed, integrated, and well-formulated treatment plan for the individual. Unless engaged with a patient, SIEDS staff had an informal open door policy, which made communication across all disciplines extremely easy and welcomed. Dietitians were also able to easily relay changes to diet prescriptions because they shared one office. Besides excellent and unhindered communication, this team was like a family. As cheesy as it may sound, happy hours, team netball games, and birthday celebrations were far from sporadic. It was great to feel so connected when living so far away! I also think that the personal connections within our team created an overall ambiance of positive energy that filtered down to the patients. This energy helped to create an uplifting experience for the inpatients even during the challenging stages of recovery.

Abel Tasman Hike

“The Fueled and the Furious”: Our SIEDS netball team!

Lastly, technique (I thought about inserting ‘travel’ instead because I thoroughly enjoyed exploring the natural beauty of the south island as well….see picture of Abel Tasman National Park). At SIEDS, probably due to the increased time allotted to each patient, nutritional counseling strategies and employed techniques were far above average. Dietitians established great rapport with patients and really made an effort to know each patient well. That being said, I did notice clear differences between nutritional counseling in NZ and the US. To start, the US has been using standardized chart writing for a while, while NZ is just now beginning to write using International Dietetics & Nutrition Terminology (IDNT). Another obvious difference is the units of measurement (English vs. metric). Additionally, the menu planning looks slightly different. US dietitians commonly utilize the ‘exchange system’ to ensure that patients obtain nutrition from all food groups, whereas NZ dietitians use a standard eating disorders menu and allow the patients to choose from a few different options at each meal. Thus, the US menu planning allows for more patient autonomy and menu flexibility, but the more rigid NZ method may enable patients to more routinely meet their estimated energy/protein/fluid needs. Nevertheless, both refeeding systems still have a long way to go as far as addressing unsolved issues like, “At what calorie range do we initiate refeeding?”, “At what rate do we increase calories to avoid refeeding syndrome?”, and “Is the current diet prescription of energy dense foods really best practice, or can we encourage a more healthy weight gain using foods from all food groups vs. primarily carbohydrate and fats?”

My fabulous team at SIEDS

Dr. Bulik said it best, “No matter where I go in the world, I can step onto an eating disorders service and feel ‘at home’.” It’s so true. The passion of dietitians and clinicians to treat eating disorders in an evidence-based way and to make breakthroughs in eating disorder research is universal. I am so grateful for my time in NZ. A big thanks to Rachel Lawson, Jane Elmslie, and the entire SIEDS team, as they not only sharpened my clinical skills and judgment, but more importantly they taught me to never shy away from human interaction, to value a team approach rather than an individual one, and to remain passionate about solving nutrition-related research questions in the field of eating disorders. I hope each of you can one day experience the beauty of NZ’s terrain and people—you too will undoubtedly have a similar enriching experience.

1. McKenzie J, Joyce P. Hospitalization for anorexia nervosa. International Journal of Eating Disorders. 1992; 11: 235-41.

By: Lauren Elder