Data Are Lacking for Eating Disorder Screening Recommendations

Karina W. Davidson, PhD, MASc

Experts are uncertain whether screening for eating disorders is beneficial among adults and adolescents without signs or symptoms of anorexia nervosa, binge-eating disorder or bulimia nervosa, according to the US Preventive Services Task Force (USPSTF).

In new recommendations set by the USPSTF, experts were non-committal on the significant benefits and harms of screening for eating disorder in adolescents aged ≥10 years old and adults with normal to above-normal body mass index (BMI) who had no signs of such disorders. In fact, the authors of the recommendation statement—a first of its kind for this population—emphasized the need for greater research into the effect of eating disorder screening for both adolescents and adults, at a time when such disorders are increasing in prevalence.

“Clinicians should be aware of the risk factors, signs, and symptoms of eating disorders, listen to any patient concerns about eating, and make sure that persons who need help get it,” they wrote. “The decision to screen should be based on each patient’s individual risk factors and circumstances.”

Led by Karina W. Davidson, PhD, MASc, of the Feinstein Institutes for Medical Research at Northwell Health, the USPSTF authors conducted a systematic review evaluating the benefits and harms of eating disorder screening in the defined population. They used MEDLINE, Cochrane Library, PsycINFO and trial registry data published through December 19, 2020 as part of their research.

Alongside benefits and harms, the team sought to define eating disorder test accuracy, the severity of tested patients’ symptoms, their quality of life and their state of depression. The review included 57 studies featuring 10,773 patients; 3 trials involving 1073 patients were limited to adolescents (mean/median age, 14-15 years).

Key screening tools observed in the review included the 5-item Sick, Control, One, Fat, Food (SCOFF) questionnaire and the Yale-Brown Obsessive Compulsive scale modified for binge eating (YBOCS-BE).

Across 10 trials evaluating screening test accuracy, SCOFF reported an 84% pooled sensitivity (95% CI, 74 – 90) and 80% pooled specificity (95% CI, 65 – 89) in adults. In the 40 randomized controlled trials evaluating interventions for eating disorders, none enrolled a population detected via screening.

A pair of drugs (lisdexamfetamine, topiramate for binge eating disorder) were associated with greater reductions in YCOS-BE compared to placebo. But 9 pharmacotherapy trials that reported treatment harms showed lisdexamfetamine was associated with greater rates of dry mouth, headache and insomnia, while topiramate was associated with greater rates of paresthesia, taste perversion, confusion and concentration difficulty.

Across 24 trials assessing for psychological interventions in patients with eating disorders, only guided self-help had enough evidence for review; it was shown to improve eating disorder severity versus control in patients with binge eating disorder.

Indeed, no observed trials relevant to the USPSTF recommendations directly observed the benefits and harms of eating disorder screening in patients without signs or symptoms. While SCOFF had “adequate accuracy” for detecting disorders—and lisdexamfetamine, topiramate and guided self-help showed benefit in reducing eating disorder symptom severity—the recommendation authors concluded more is needed.

They highlighted 4 areas in need of further assessment:

• Screening and early treatment trials that address health outcomes and can enroll screen-detected populations from primary care settings
• Trials focused on the potential harm of screening, including factors like labeling and false-positive results
• Trials focused on the benefits and harms of screening to treatment in adolescents, men, and across different patient demographics
• Trials assessing asymptomatic adults and adolescents for the accuracy of eating disorder condition definitions

As Davidson and colleagues noted, various institutions including the American Academy of Pediatrics, Academy for Eating Disorders, and American Academy of Child and Adolescent Psychiatry have recommendations supporting regular eating disorder screening in targeted populations.

In an editorial accompanying the recommendation statement, Evelyn Attia, MD, of the Department of Psychiatry at Columbia University College of Physicians and Angela S. Guarda, MD, of the Department of Psychiatry at Weill Cornell Medicine, advocated for improved processing from screening to treatment—particularly in younger patients with an eating disorder.

“Research on screening in primary care also should be paired with development and assessment of early brief intervention strategies for those individuals who screen positive, especially adolescents,” they wrote. “Increasingly, evidence supports the importance of early interventions aimed at avoiding the development of secondary neurobiological maintaining factors that may make eating disorders more treatment resistant, as well as interventions that target early behavior change.”

They supported the utility of the USPSTF recommendation statement; though it may not have provided a clear dictation on clinical practice, it highlighted how evidence may inform such a future recommendation.

“Directing attention to rigorous research to close this evidence gap will be important to find optimal approaches to identify patients with these complex disorders and improve their health outcomes,” Attia and Guarda wrote.

The statement, “Screening for Eating Disorders in Adolescents and Adults,” was published online in JAMA.