National Eating Disorders Strategy Q&A

The National Strategy can be a really helpful tool for understanding what should be available to you in the system of care, and to understand what you should be able to expect in terms of standards when interacting with the different components of the system of care. So in that sense, it is an information piece and a guide; it could be used as a navigation tool to help understand what the system looks like and what you should be able to expect.

If you're in a good place in your own journey, you might also want to use the Strategy to have conversations in your region about what's needed - and get involved in local initiatives. Having lived experience representation and advice embedded within project or service design, delivery and evaluation is essential for getting the best outcomes for people with lived experience, and lived experience leadership and guidance is the first principle of the National Strategy. You could connect up with your local Primary Health Network and other local services, or state-based and national eating disorder organisations to find out about opportunities.

The role and varied contributions of the Lived Experience workforce to the system of care is also extremely important. This includes people in designated Lived Experience roles, including  consultancy, leadership, policy, peer support, training and advocacy, to name a few roles, and there are actions in the Strategy related to the Lived Experience workforce (see the Workforce section). There are also many people working in the system of care in non-designated roles who have their own lived experience, who can bring a valuable lived experience-informed lens to their work, while being guided by the standards and actions within the Strategy relevant to their role's context or setting.

For adult community mental health services, Specialist Supportive Clinical Management (SSCM) is often the treatment approach adopted. There are a number of NEDC approved SSCM training providers that you can seek out for this. 

The other thing to consider is the type of presentations that your service sees. For example, CBT-Guided Self-Help could also be considered for people experiencing binge eating disorder, bulimia nervosa or disordered eating. 

For some case managers, their role might not be to provide the eating disorder-specific treatment, but ensuring that they are trained in other functions within the stepped system of care, such as identification and initial response, is really important. This will support early identification and intervention. 

Other approaches that your service could consider are early and/or brief interventions (see page 57 of the National Strategy). This can include single session interventions and manualised lower intensity treatments. 

There are multiple aspects to consider for the evaluation of the National Strategy. Firstly, there is evaluating the implementation and impact of the National Strategy itself, and then there is also services evaluating their own initiatives. NEDC is currently developing a detailed evaluation plan to support evaluation of the implementation and impact of the Strategy, which will build on the key progress indicators identified on p.74 of the Strategy. This evaluation plan will be available in the new year.

We have already developed an evaluation tool that clinicians and services can use to evaluate their own initiatives. 

While access to affordable eating disorder care has improved in recent years (through a range of initiatives including the introduction of the MBS Eating Disorder items, and service development activities to increase eating disorder service provision within public mental health services), there is still much more work to be done to ensure that eating disorder treatment and support is available to all. A key aim of the National Strategy is to ensure equitable access to services. Achieving this will predominately require top-down initiatives and change. Treatment Standard 8 (see page 55 of the National Strategy) states "Treatment if affordable". The actions that sit under this involve government and health services ensuring that public mental health services provide eating disorder services consistent with the needs of their region, that regional planners ensure that there are low-cost treatment options in their region for those who require them, and that training providers and relevant professional organisations ensure that GPs, mental health professionals, dietitians, psychiatrists and paediatricians are equipped to utilise the Medicare Eating Disorder Treatment and Management Plan items. There are also a range of workforce development actions in the Strategy to support the workforce in these settings to be able to deliver these services. NEDC, in our coordinative function, will be working with these stakeholders to implement these actions across jurisdictions. 

NEDC will be forming a range of implementation groups to support Strategy implementation by particular stakeholder groups. If you would be interesting in participating in an implementation group, please email nationalstrategy@nedc.com.au and include a description of your service setting. Stakeholders are also welcome to contact NEDC to seek specific guidance and consultation support.

In addition, NEDC has a workstream dedicated to supporting Primary Health Networks to build on their eating disorders response - please contact nationalstrategy@nedc.com.au for more information. 

Navigating the system of care is one of the biggest challenges identified by people with lived experience and their families/supports and communities, with many people experiencing a fragmented system with a lack of connection and coordination across services. These challenges can be even greater in regional, rural and remote areas, where there may be a lack of services and providers with eating disorder-specific knowledge and skills.

The Stategy's vision is for eating disorder care to be embedded in the health systems of all states/territories and regions, and for people all across Australia experiencing or at risk of eating disorders and their families/supports and communities to be able to access an effective, equitable and coordinated system of care. To achieve this, services need to be available to people when and where they need them, they need to be staffed by people with appropriate skills and knowledge, and operate in a way which helps people understand their options and navigate/connect to other services as needed.

There are a range of Standards and Actions within the Strategy to help achieve this, including a mix of 'top-down' and 'bottom-up' actions. 'Top-down' approaches include actions by national, state/territory, and regional planners to identify and address system gaps, and ensure adequate access to treatment services in every region, as well as a range of workforce development actions. 'Bottom-up' approaches within the Strategy include standards and actions related to transitions between services, tailored care navigation, and the provision of information about the system of care at every service entry point. There are a range of stakeholders with a role in these 'top-down' and 'bottom-up' actions, including but not limited to government, service planners, treatment services and clinicians, initial responders, and psychosocial and recovery support providers.  NEDC will be supporting these stakeholders to implement the actions outlined in the National Strategy. 

NEDC recognises the challenges faced by services in responding to and meeting the needs of people within their local region, often with limited resources. However, it is highly likely that mental health and drug and alcohol services are already seeing clients experiencing or at risk of eating disorders, due to the high rates of co-occurence of eating disorders and other mental health conditions.

There are a range of initiatives that mental health and drug and alcohol services can undertake to build capacity within their service to better meet the needs of people experiencing or at risk of eating disorders, which have only a small cost (time or direct cost). These include encouraging staff to complete free online training to develop skills in identification and initial response, such as NEDC's free Eating Disorder Core Skills: eLearning for Mental Health Professionals, designed to equip mental health professionals with the knowledge and skills needed to identify when a person is experiencing an eating disorder, complete a comprehensive eating disorder assessment, refer to appropriate services in the stepped system of care, and understand the components of eating disorder treatment and recovery.

Other strategies may include providing training to staff on brief treatment interventions, such as CBT-Guided Self Help, as a first step, with a view to staff completing additional training in other treatment modalities over the longer term. These actions will assist services to work towards Workforce Action 2.2 (Health and mental health services to routinly include consideration of eating disorder-specific skills in workforce planning to match the scope of the service) and 2.3 (Health and mental health servcies to ensure sufficient eating disorder expertise for their team to meet the needs of people presenting with eating disorders).

The National Strategy is a 10-year strategy. Sustainable change will take time, and the process of National Strategy implementation will occur across three main phases - activation (years 1-4), integration (years 5-7), and sustainability (years 8-10). NEDC has developed an implementation timeline which identifies key priority targets within the activation phase of National Strategy implementation. Taking action towards these key priority targets will help to achieve early change towards the Strategy’s desired outcomes for people with lived experience and their families/supports and communities, and will lay the foundation for effective action across the subsequent phases of National Strategy implementation. Some actions have already commenced. NEDC has discussed the implementation timeline with key stakeholders, and will make this timeline publicly available in the new year. 

Within the stepped system of care, there are three levels of treatment: community-based, community-based intensive, and hospital and residential. The National Strategy includes five Standards related to hospital and residential care (see pages 62-64). 
Funding for the state and territory residential care facilities sits separately to the National Strategy and each state and territory is at different stages of development of their facilities. For more information on progress within your state/territory, we suggest contacting your state/territory government.

The concurrent development of the National Eating Disorders Strategy 2023-2033 and the Victorian Eating Disorders Strategy presented a valuable opportunity for national and state collaboration. NEDC has been involved in the development of the Victorian Eating Disorder Strategy and both strategies are underpinned by the NEDC stepped system of care for eating disorders. The National Eating Disorders Strategy provides national standards and priority actions which are to be met with local knowledge in the creation of context-sensitive, practical solutions. In this way, the Victorian Strategy provides an example of how national standards and actions may be applied to a state/territory context. NEDC will continue to support alignment and implementation of the two Strategies.  

NEDC was also asked: 

How are you ensuring the strategy is neurodiversity-affirming and considers the access needs of neurodivergent people with eating disorders? Additionally, is NEDC working with the National Autism Strategy working group that is developing the National Roadmap for Autistic health and wellbeing? If not, will they?

NEDC has ensured representation of neurodivergent people, including neurodivergent people with lived and living experience of eating disorders, as well as neurodivergent clinicians and researchers, throughout the development of the National Eating Disorders Strategy. We particularly acknowledge the expertise of Eating Disorders Neurodiversity Australia (EDNA), who provided extensive and valuable input throughout the development of the National Strategy. The key principles underpinning the National Strategy are informed by these and further intersectional perspectives. These principles should underpin all actions undertaken to implement the Strategy. In addition, several standards and actions aim specifically to address the needs of neurodivergent people as well as other underserved and higher risk populations (see for example Identification Standard 3 Action 3.3, and Treatment Standard 5 and associated actions). The Strategy emphasises the need to better understand and meet the needs of underserved and higher risk population groups, as a key enabler to drive needed change across the system of care. 

To date, we have not been involved in the development of the National Autism Strategy, but would welcome the opportunity to provide input as appropriate to support alignment with the National Eating Disorders Strategy and related initiatives. Our current work to develop 'eating disorder-safe' principles (relevant to 14 actions across the National Strategy) will result in practical guidance on eating disorder prevention and harm minimisation across a range of settings, including within public policy. We have neurodivergent perspectives represented (lived experience, clinical and academic) on the Eating Disorder Safe Principles Expert Advisory Group as well as on the project team. Due to be published in June 2024, these principles could usefully inform key policy developments and strategies across a range of areas, such as health, education and social and community services. This could include the National Roadmap for Autistic Health and Wellbeing. 

We are committed as a team to continuing to learn and develop in this space and welcome ongoing feedback.

Thank you for the feedback that this is a useful resource. We have created a short clip which can be accessed via our website or via YouTube.

NEDC recognises the challenges associated with accessing care in regional areas, and calls for people to be able to access timely, affordable care, as close to home as possible. The National Strategy contains standards and actions to address a range of these challenges, including ensuring that community-based public mental health services (including child and adolescent/youth mental health services) provide evidence-based eating disorder treatment, and that regional planners address service gaps.

To ensure these actions can be met, NEDC will be supporting stakeholders with activation, planning, and implementation. In the interim, while these shifts are occuring, resource gaps may be able to be addressed through access to digital resources, telehealth options, case consultation, and supervision. 

The National Strategy is a system-building strategy. The focus is on defining what is needed in an effective, equitable and coordinated system of care for eating disorders, and on feasible, grounded steps for building it. It is not a clinical guideline and does not provide recommendations or information about specific models of clinical care. Links to clinical guidelines for eating disorders can be found here.

From a system-building perspective, the National Strategy identifies the settings where treatment should be delivered, as well as the competencies required for the workforce to be able to deliver this treatment.  Regional planners and individual services should ensure that workforce planning considers a range of treatment modalities to meet local needs across eating disorder presentations and population groups, and that workforce development activities support the workforce to be able to deliver these treatment modalities.

The National Strategy also emphasises the need for new models of care to be developed to better meet the needs of people across the full range of eating disorder presentations and population groups, and for emerging and new models of care to be evaluated. 

There are many stakeholders who have a role in implementation of the National Strategy. Some of these stakeholders are actively involved in eating disorder system-building activities and implementation of the National Strategy, and others are at different stages of recognising and understanding their role. NEDC are utilising a range of Implementation Science-informed mechanisms to enhance engagement and uptake, such as working with stakeholders to identify barriers and enablers, developing targeted stakeholder implementation resources, identifying champions to help drive regional implementation, and providing targeted consultation.

There is no direct equivalent program for adults. However, a range of other services offer psychoeducation and support for individuals and families/supports, including while waiting to engage with treatment. Some examples of initiatives which are available to adults include: Butterfly Foundation’s ‘Emerging’ program, Eating Disorders Families Australia’s ‘Fill the Gap’ carer counselling program, Eating Disorder Victoria’s workshops and group programs and peer mentoring program, and Eating Disorder Queensland’s peer support sessions. For treatment services for adults in Queensland, contact the Queensland Eating Disorder Service (QuEDS) or Eating Disorders Queensland.

You can find your local Primary Health Network via the following link: https://www.health.gov.au/our-work/phn/your-local-PHN/find-your-local-PHN

Q: Why does the Next Steps Program [run by Butterfly Foundation] not provide support to people with ARFID?

A: We [Butterfly Foundation] know that there is a significant gap in the area of providing tailored support for ARFID - this is certainly something that Butterfly is passionate about, and will be a focus in our future endeavours/new support options to ensure that there is more adequate support available.

Prior to launching Next Steps we underwent a significant evaluation process, including a literature review examining the evidence-based practice for all eating disorders - and found that there were important differences in the management of ARFID, and that it would be more suitable to have a tailored approach specifically for individuals and their carers impacted by ARFID.

We are hoping that our program can pave the way in increasing the scope and delivery of virtual intensive outpatient programs in the future, and that our learnings will support the development of a structured program particularly targeted at managing ARFID.

Response provided by Grace Collison, Clinical Program Manager for Butterfly Foundation’s Next Steps program. For more information, please contact nextsteps@butterfly.org.au.

Q: Why is BMI included in eligibility criteria for Butterfly's Next Steps program?

A: To clarify, we [Butterfly Foundation] do not have BMI requirements in terms of eligibility to the program - we know that the BMI does not adequately capture the severity of an individual’s experience, and are firm believers that this is a largely problematic and outdated model. In saying that, we are asking the primary referrer/medical professional responsible for medical monitoring in the community to monitor the participant’s weight, to ensure that there is no significant changes that indicate deterioration or medical de-stabilisation.

It is important to note that this would not result in an automatic discharge/ineligibility from our program. However, it provides an indication to us that we might need to provide some more wrap-around support/explore medical risk, to ensure that the participant is safe and able to continue engaging in a virtual program.

Response provided by Grace Collison, Clinical Program Manager for Butterfly Foundation’s Next Steps program. For more information, please contact nextsteps@butterfly.org.au.

Q: In relation to the Tasmanian Eating Disorders Service, how many beds are available and is there an age limit?

A: The beds available are for adults (18+) as TEDS is an adult service. The service will work with young people aged 16 yr+ on a case-by-case basis. TEDS does not have a dedicated number of beds as people are admitted according to medical acuity and priority. For the preferred ward, TEDS have found that no more than 4 inpatients at one time is best for optimal management.  A backup ward is also available if required. If consumers have medical complications that require specialist care (e.g. cardiac, health comorbidities), they are admitted to the specific speciality ward and once stabilised, are transferred back to the preferred ward. 

for example, telling a client with ED to go on a more restrictive diet without consulting with GPs or dietitians.

Supervision (individual and group), mentoring, and communities of practice can be helpful tools here, and ensuring that people are seeking support from an eating disorders-informed clinician. Some people may not know about the National Strategy and evidence-based guidelines. We highly encourage you to help others to engage in best practice, and access resources to support them to do so where you feel you can. You might also support your colleagues to upskill in this area by promoting key resources and training, or bringing this topic to any group/peer supervision or team meetings that are held. If you feel that there is potential harm to the client, we recommend following your professional guidelines.

The Federal Government Department of Health and Aged care has extended NEDC's funding for 2024/25 to continue to support the implementation of the National Strategy. NEDC will work closely with all states and territories to implement the National Strategy and ensure its Standards and Actions are embedded across existing health and mental health services. We can't say at this time whether further funding will be committed to the implementation.

We would recommend being guided by eating disorder safe principles specifically for individuals in higher weights. This can reduce the potential harm for the person. It is important for the service (and clinicians) to have a clear understanding of the rationale for weighing and by who (medical monitoring, experiential challenge, cognitive restructurings) and the impact this may have with disorder eating/ eating disorder presentation and weight stigmatising beliefs.

Services (and clinicians) should also allow the individual to have choice in how treatment should proceed including declining aspects of the treatment, choosing not to see the number nor discussing numbers in the session (blind weighing).

The National Strategy helps to articulate the specific roles that clinicians can hold across the Stepped System of Care, and what needs to happen in those roles. For example, within Initial Response, clinicians should be able to complete a comprehensive assessment, provide psychoeducation, ensure the person is safe (physically and psychologically), engage families and supports, and make a referral to or support a person to access treatment appropriate to their needs.

We recommend reading the Identification (pages 41-44) and Initial Response (pages 45-48) which articulates these specific roles and actions.

There are some great resources to help clinicians upskill to be an 'Identifier' and Initial Responder' - see NEDC's Eating Disorder Core Skills: eLearning for Mental Health Professionals for free introductory training and supporting resources.

Over the 24/25 year, NEDC will be developing a suite of resources to continue to help with workforce planning, development and implementing change.

NEDC will also be working closely with all states and territories to support them with implementation of the National Strategy. This will include exploring workforce and service development for public funded mental health services.

Your local statewide services (for example, CEED, InsideOut, QuEDS) can provide support with this work. Similarly, connecting with your Primary Health Network can be a good place to start. Please reach out to our team if we can provide more specific guidance on your specific target.

If you are ready to start exploring and planning for workforce development, you can check out NEDC's new national Training & Workforce Development database. This will help you to identify professional development opportunities available for your target workforce.

NEDC will be launching Eating Disorder Safe principles on 24 July 2024. The Eating Disorder Safe principles will underpin ongoing work to drive positive culture change in the ways that people talk about and respond to health, food, minds and bodies across a wide range of settings. The development of these principles arose from National Eating Disorders Strategy: there are 14 Standards and Actions spanning prevention, identification, treatment, psychosocial and recovery support and workforce which all call for the establishment of eating disorder safe principles so that social and environmental risks and harms can be eliminated as far as possible.  

NEDC will be developing and launching a Workforce Development Hub, an online suite of evidence-based tailorable workforce development resources to help organisations and individuals to plan and implement workforce initiatives in line with the National Strategy standards and actions.

We will continue to be responsive to the sector and develop resources and eLearning programs that we know clinicians and services need, including implementation resources. Let us know if there is something that you need to support your National Strategy Action Plan.

'There are many alternative ways of describing foods which avoid using dichotomies such as healthy/unhealthy or good/bad. To some extent, the word choices you make will depend on your context and the people you are communicating with (having regard to their age, culture, socioeconomic position and other factors). 

• As a general rule, it can be helpful to focus on using descriptive names for foods without conferring positive or negative attributes, e.g. calling foods what they are, such as "pizza", "broccoli", "chocolate", "eggs", "cherries." 
• If your role involves helping people to learn about foods, you could also focus on experiential terms, such as "crunchy," "green", "sweet", "cold", "filling."  
• If your role involves nutrition counselling, you could help a person to understand the different effects that foods have on their health, such as "fibre helps you feel full and helps your digestive system move everything through," or "sharing a bowl of chips with friends helps you feel included which is great for your social and emotional wellbeing," or "eating a variety of foods helps to meet our health needs."

We can also talk about people's relationship with food, and ways to support this relationship in a positive way. This might include having a flexible relationship with food that is not bound by rules, being able to eat without stress and in ways that feel supportive, or practicing intuitive eating (if appropriate). 

Protective factors refer to those parts of a person's inner or outer world that we can nourish and nurture as part of helping to lower their risk of developing an eating disorder. This includes a broad range of factors such as bodily attunement, high self-esteem, positive self-image, the ability to practice self-compassion, media literacy skills, appreciation of body diversity, positive family connectedness, regular positive family mealtimes, experiences of weight inclusive healthcare, involvement in sport, and food security. You can read more about protective factors on our Risk & Protective factors webpage.

Bolstering protective factors through professional practice involves finding ways to help a person or a group to build on what they already have, or to develop new skills or attitudes. This might be done in the context of therapy for psychological factors such as body image, self-esteem, self-compassion and self-concept. Several evidence-based group programs exist for building media literacy and appreciation of body diversity. Professionals who work with families could focus on building family systems that can support positive mealtimes and overall connectedness. Some workers may also be able to assist clients to access food relief and/or financial counselling as part of improving their food security. 

All health professionals can play a role in providing weight inclusive healthcare as a key protective factor against eating disorders. For more information and practice tips, see the NEDC page on weight stigma.

Full question: I’m a lived experience worker at a youth mental health facility in Victoria. I'm noticing a gap between eating disorder support and co-morbid mental health treatment. Some colleagues are hesitant to address this, as the service hasn't traditionally supported eating disorders. Can you share your views on the importance of early intervention and holistic care in this space?

Response

As answered in session, it is really important that the general mental health and eating disorders services are working together and providing holistic care.  Identification and initial response of eating disorders is essential to be provided by all health and mental health care systems. This can take time to shift.  Resources on the NEDC website can support the upskilling of practitioners. This includes free elearning for GPs and mental health professionals.

EDV is funded by the Victorian Government, through the Department of Health.

EDV’s Early Help Seeking services such as telehealth nurse and counselling are only eligible for Victorians.

EDV does have written resources on our website and an online learning portal which is accessible across Australia. 

Find these at https://learn.eatingdisorders.org.au/

The BHN Health Promotion team host a Community of Practice to support the health promotion sector to apply a size inclusive lens to their practice.

We also host workshops with health promotion teams who are interested in learning more.

If you are interested in joining the community of practice or want to work with us to support your team to apply a size inclusive lens to your work, contact us at healthpromotion@bhn.org.au

Young children aged 2-7 years best understand concrete information. Nutrition concepts are abstract, we cannot see, touch, or taste the nutrients in food so like algebra, nutrition is harder to conceptualise.

Young children benefit from activities that allow them to explore food with their five senses - sight, smell, hearing, touch and taste (without pressure to eat it or learning about what the food does in our bodies!). Activities like gardening, cooking or sensory play with food are great ways for children to explore food.

Children aged 7-12 years, can begin to grasp the concept of food groups, such as dairy, grains, vegetables and fruit. It is not necessary to focus on specific nutrients (such as, calcium) in food. They still benefit from activities that allow them to explore food with their five senses.

Teenagers are able to think abstractly and reason logically. They can learn about health and nutrition in a way that is empowering and non-judgmental, for example, 'fibre is in wholegrains, vegetables and fruit and aids digestion'. Teenagers also benefit from learning to plan and cook meals.

Full question: How have you supported your lived experience workforce as your service has expanded? What have been your key successes or challenges in supporting employee professional development and wellbeing?

Response: 

As the team expanded, we appointed a Team Leader to ensure appropriate training and support of all new staff. Work instructions were developed for training purposes and there is a bi-weekly 'team huddle' to assist with communication and support needs. Each staff member working with the BEP, has a monthly meeting with the Team Leader as well as quarterly with Management. This is in addition to external Professional supervision, specialised group supervision, monthly peer review for group programs and opportunities for debrief and shared care. The BEP staff also work within a wider multi-disciplinary team where emphasis is placed on upskilling and Professional Development.

Our key successes include the successful establishment of the new suite of services, recruitment of four additional peer workers (including a carer peer), and opportunities for networking across the sector. Staff have also been supported in completing mandatory training such as Gatekeeper Suicide Prevention  and Mental Health First Aid.

Challenges have included the need for additional promotion as a service which provides support, to young people, males and gender-diverse individuals as this has not been something that we have previously been known for. This process can sometimes be frustrating for staff and so we work to manage expectations and provide support wherever we can. Another challenge for peer workers is getting the balance right between the purposeful disclosure expected within a peer work role and maintaining professional boundaries. We address this through our training and ongoing support supervision mechanisms.

Whilst a Certified Health and Wellness Coach is not an area that we are very familiar with, we encourage participants to get as much support on board as possible, that is going to work for them. All types of services and supports can compliment each other and it is important that people find the right fit for them.

The National Strategy Action Hub serves a few different functions:

1. It helps NEDC to be aware of initiatives that are happening across Australia that are aligned with the National Strategy. This helps us to understand what is working with Strategy implementation, and also what gaps exist
2. Promoting existing services, frameworks, and models helps to reduce duplication. If something effective already exists, we don't need to invent something new. This helps to create quality, consistency, and accessibility of services
3. We need more opportunities to showcase the wonderful work that is being done across Australia. Whilst we recognise there are many gaps in the system of care, we have also achieved a lot in the last 20 years. The Action Hub helps us to recognise this work to others across the country