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Draft Recommendation Statement

Screening for Eating Disorders in Adolescents and Adults

October 19, 2021

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Recommendation Summary

Population Recommendation Grade
Asymptomatic adolescents and adults The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. I

Additional Information

Tools
Related Resources
  • Screening for Eating Disorders in Adolescents and Adults (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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Eating disorders (e.g., binge eating disorder [BED], bulimia nervosa [BN], and anorexia nervosa [AN]) are a group of psychiatric conditions defined as a disturbance in eating or eating-related behaviors that impairs physical or psychosocial functioning.1,2 The prevalence of eating disorders in the United States has not been well studied, thus current rates may underestimate the true burden. According to several large U.S. cohort studies, the lifetime prevalence of eating disorders ranges from 0.5% to 3.5% in women, 0.1% to 2.0% in men, 0.3% to 2.3% in adolescent girls, and 0.3% to 1.3% in adolescent boys.1,3 Eating disorders are associated with short-term and long-term adverse health outcomes, such as physical, psychological, and social problems.1

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The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. The evidence is lacking and the balance of benefits and harms cannot be determined.

See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4

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Patient Population Under Consideration

This recommendation applies to adolescents and adults (age 10 years or older) who have no signs or symptoms of eating disorders.

Definitions of Eating Disorders

Common eating disorders and their key diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders2 include the following:

  • AN: Restriction of energy intake relative to requirements, leading to significantly low weight for age, sex, and developmental trajectory; intense fear of gaining weight or becoming fat; disturbance in the way body weight or shape is experienced.
  • BN: Recurrent episodes of binge eating characterized by eating a larger amount of food than the amount that most persons would eat and a sense of lack of control of overeating during the episode; recurrent inappropriate compensatory behaviors to prevent weight gain (e.g., self-induced vomiting and laxative misuse); undue influence of body shape and weight on self-evaluation.
  • BED: Recurrent episodes of binge eating and marked distress about binge eating episodes.
  • Other specific feeding and eating disorder: Eating or feeding disturbance (e.g., atypical AN, BN, or BED of low frequency or limited duration; purging disorder; and night eating syndrome) that causes clinically significant distress or impairment but does not meet the full criteria for the disorders in this diagnostic class; in the published literature, persons meeting criteria for this disorder are often categorized as having a “subthreshold” diagnosis for another eating disorder based on endorsement of key behaviors (e.g., binge eating) that fall short of the required frequency and duration thresholds.

Assessment of Risk

Risk factors for eating disorders include various biological, psychological, social, and environmental factors, such as trauma, childhood adversity, perfectionism, rigidity, or social pressure related to appearance.1,5-7 Various populations are at increased risk for eating disorders, such as athletes, females, and younger adults (ages 18 to 29 years).1,8,9 Eating disorders also vary by race and ethnicity and sexual gender identity. White populations have higher rates of AN; BN is more prevalent among Latino, Asian, and Black persons than White persons.1,2,10 Transgender adolescents and young adults have higher rates of self-reported eating disorder diagnoses than cisgender heterosexual females.1,11 There is an increased incidence of eating disorders among persons with comorbid psychiatric conditions, including depression, obsessive compulsive disorder, substance use disorders, and anxiety disorders.1,12 Genetic heritability may also contribute to the risk of developing AN or BN.1,6,13,14

Screening Tests

Assessment of weight, height, and body mass index (BMI) is considered the standard of care in primary care settings, and changes in growth or weight may lead to detection of some eating disorders. For persons without obvious physical symptoms or signs of eating disorders, screening questionnaires are available that could be used in primary care settings, including the Eating Disorder Screen for Primary Care (EDS-PC), Screen for Disordered Eating, and the SCOFF.1,15

Treatment or Interventions

Persons suspected of having an eating disorder are typically referred to specialists for diagnostic evaluations and treatment.1 Treatment for eating disorders in symptomatic persons generally involves an interdisciplinary approach encompassing psychological/behavioral, medical, and nutritional components. Treatment may vary based on the severity of the disorder. Psychological approaches used include cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavior therapy. Two medications have U.S. Food and Drug Administration approval for treatment of an eating disorder, including lisdexamfetamine for BED treatment and fluoxetine for BN treatment. Other medications used to treat BED include topiramate and selective serotonin reuptake inhibitors (SSRIs). Medical management focuses on addressing physical and medical complications of eating disorders (e.g., cardiac instability, musculoskeletal injury, and endocrine function).1,16,17

Suggestions for Practice Regarding the I Statement 

Potential Preventable Burden

Eating disorders can lead to physical complications affecting many organ systems; complications differ by diagnosis. Complications from AN are ascribed to weight loss and malnutrition (e.g., low bone density/fractures, symptomatic bradycardia/hypotension, and gastroparesis).1,18 BED is associated with higher rates of obesity and related metabolic disorders than other eating disorders.1,19 BN is associated with complications due to purging, such as cardiovascular problems (e.g., arrhythmias and cardiac failure), electrolyte disturbances, pancreatitis, gastric erosions or perforations, dental erosion, and renal injury.19 Eating disorders have also been associated with disturbances in cognitive and emotional functioning and psychiatric conditions (i.e., mood, anxiety, and substance abuse disorders).12,20 Persons with eating disorders have higher mortality rates than the general population, particularly those with AN.21

Potential Harms

Potential harms of screening questionnaires include false-positive screening results that lead to unnecessary referrals (and associated time and economic burden), treatment, labeling, anxiety, and stigma. Pharmacologic interventions may result in adverse events such as dry mouth, headache, and insomnia (lisdexamfetamine); paresthesia and taste perversion (topiramate); or insomnia, nausea, and tremor (SSRIs). Psychological interventions are likely to have minimal harms.1

Current Practice

Assessing weight, height, and BMI is the standard of care in primary care settings. Various guidelines mention screening in the context of monitoring for potential signs and symptoms of eating disorders or to promote awareness of eating disorder symptoms in populations who may be at risk (e.g., adolescents and young female athletes). No recent estimates of screening rates have been found in the literature.1

Other Related USPSTF Recommendations

The USPSTF recommends screening for depression in adults, including pregnant and postpartum women (B recommendation).22 The USPSTF also recommends screening for depression in adolescents ages 12 to 18 years (B recommendation) and found insufficient evidence to recommend for or against screening in children age 11 years or younger (I statement).23 The USPSTF recommends counseling interventions for pregnant and postpartum persons who are at increased risk of perinatal depression (B recommendation).24

The USPSTF recommends offering or referring adults with a BMI of 30 or greater to intensive, multicomponent behavioral interventions to improve important health outcomes.25 The USPSTF also recommends that clinicians screen children and adolescents age 6 years or older for obesity and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.26

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Scope of Review

The USPSTF commissioned a systematic review1 to evaluate the benefits and harms of screening for eating disorders in adolescents and adults with a normal or high BMI. Evidence limited to populations who are underweight or have other physical signs or symptoms of eating disorders was not considered. The USPSTF has not previously made a recommendation on this topic.

Accuracy of Screening Tests and Risk Assessment

The USPSTF found no studies that directly evaluated the benefits of screening for eating disorders. Seventeen studies evaluated the accuracy of various screening questionnaires for detecting any eating disorder or specific eating disorders. Most studies assessed the SCOFF; two studies assessed the EDS-PC, and other questionnaires were assessed by one study each.1 Accuracy was compared with either a diagnostic clinical interview or a range of longer self-reported diagnostic questionnaires. Only two studies evaluated adolescents, and there was limited reporting on other populations of interest (e.g., populations of different races and ethnicities and sexual gender identities).1

For detecting any eating disorder among adults, the SCOFF (cut point ≥2) had a pooled sensitivity of 84% (95% confidence interval [CI], 74% to 90%) and a pooled specificity of 80% (95% CI, 65% to 89%) (10 trials; n=3,684 participants). At a higher cut point (≥3), the pooled sensitivity was lower (69% [95% CI, 56% to 80%]) and specificity was higher (80% [95% CI, 65% to 89%]) (7 trials; n=2,749 participants). Two studies assessed the EDS-PC among adults using a cut point of 2 or greater; sensitivity was similar (97% and 100%), and specificity varied (40% and 71%).1 The Adolescent Binge Eating Questionnaire had a sensitivity of 100% and specificity of 27% in a population of adolescents (ages 11 to 18 years) recruited from a pediatric obesity clinic. A single study evaluated the SCOFF in a sample of adolescent girls and boys and found a sensitivity of 73% and a specificity of 78%.1

Benefits of Early Detection and Treatment

The USPSTF found no studies that directly assessed the benefits of screening for eating disorders. Forty trials assessed interventions for adult populations with recently detected or previously untreated eating disorders. No trials were found that enrolled participants who were screen-detected in primary care. Many enrolled participants via advertisements for interventions for binge eating and obesity. Trials evaluated heterogeneous interventions. The majority of the trials enrolled mostly women and populations with BED or BN only. No eligible trials focused on populations with AN.1 There was limited evidence on populations of interest (e.g., by age, sex, race and ethnicity, gender identity, sexual orientation, and mental health comorbidity).1

Twenty-three trials assessed psychological interventions. Guided self-help improved eating disorder symptom severity more than inactive control (pooled standardized mean difference [SMD], -0.96 [95% CI, -1.26 to -0.67]) (5 trials; n=391 participants); pooled estimates for unguided self-help (6 trials; n=368 participants) also favored the intervention, but the difference between groups was not statistically significant (SMD, -0.18 [95% CI, -0.38 to 0.03]). Self-help interventions also reduced depression symptoms more than inactive control, including both guided self-help (pooled SMD, -0.73 [95% CI, -1.04 to -0.43]; 4 trials; n=324 participants) and unguided self-help (pooled SMD, 0.37 [95% CI, -0.68 to -0.05]; 3 trials; n=156 participants). Group therapy (7 trials; n=253 participants) was associated with larger reductions in depression scores from baseline than inactive control (pooled SMD, -0.48 [95% CI, -0.69 to 0.27]).1 Results were inconsistent in the two trials that assessed a combination of fluoxetine and self-help for BN or fluoxetine with individual cognitive behavioral therapy for BED.1 Three trials of individual therapy were assessed; however, the trials differed in type of therapy and measured outcomes.1

Four trials of lisdexamfetamine for the treatment of BED (n=900 participants) measured change in eating disorder symptom severity using the Yale–Brown Obsessive Compulsive Scale modified for binge eating (YBOCS-BE) and found larger reductions in changes from baseline scores associated with lisdexamfetamine (50 to 60 mg/day) than placebo (pooled mean difference, -5.75 [95% CI, -8.32 to -3.17]). Two trials compared topiramate with placebo for the treatment of BED and both found statistically significant reductions in YBOCS-BE scores from baseline among the topiramate group than the placebo group, from -6.40 (p<0.001) to -2.55 (p=0.004). Five trials assessed various SSRIs among persons with BED and reported on heterogeneous outcome measures; results were inconsistent. Three trials assessed fluoxetine for populations with BN and found inconsistent results for improvement in eating disorder and depression symptoms.1

The body of evidence has several limitations. Most studies of screening test accuracy assessed the SCOFF in adult women, but few studies evaluated screening tools in men, adolescents, or other populations (e.g., populations of different races and ethnicities and sexual gender identities).1 Intervention trials did not identify study participants from primary care clinics. Trials mostly recruited participants with advertisements for binge eating and obesity. As a result, intervention studies were limited by the lack of generalizability to populations who would be detected by routine screening in primary care settings. In addition, most treatment trials only included women with BED or BN; none focused on individuals with AN. Treatment trials assessed outcomes over a short duration (6 to 16 weeks) and there was limited evidence of effectiveness in specific populations of interest. Although treatment may help improve some outcomes in symptomatic persons, it is unclear whether screening and treatment of screen-detected persons can improve health outcomes in asymptomatic patients.

Harms of Screening and Treatment

The USPSTF found no studies that directly evaluated the harms of screening. None of the trials of psychological interventions reported on harms. Nine trials of pharmacotherapy reported on adverse events of four medications: lisdexamfetamine (4 trials), topiramate (2 trials), and one trial each on fluoxetine and escitalopram.1 Trials were of short duration (6 to 16 weeks). Lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia than placebo. Topiramate was associated with higher rates of paresthesia, taste perversion, and difficulty with concentration or confusion than placebo. SSRIs were associated with insomnia, nausea, and tremor.1

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There are several critical evidence gaps in understanding the potential net benefit of screening for eating disorders. More studies are needed that address the following areas:

  • Screening and early treatment trials that focus on health outcomes and that enroll screen-detected populations from general primary care settings
  • Studies on the potential harms of screening such as labeling and false-positive results
  • Trials addressing screening in adolescents, men, and different sexual/gender and racial/ethnic populations
  • Accuracy studies enrolling asymptomatic adults and adolescents from primary care settings that use consistent definitions and reference standards to define eating disorder conditions
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Several organizations recommend screening in the context of monitoring changes in weight and other vital signs or signs and symptoms to determine whether a patient might have an eating disorder. The American Academy of Pediatrics recommends that pediatricians include screening for eating disorders in their annual health supervision or sports examinations through longitudinal weight and height monitoring as well as looking for signs of disordered eating. All preteens and adolescents should be screened about eating patterns and body image issues.27 The Academy for Eating Disorders recommends that all high-risk patients should be monitored for symptoms of eating disorders.28 The American Academy of Child and Adolescent Psychiatry recommends that mental health providers screen all preteen and adolescent patients for eating disorders through height and weight assessments and screening questions about eating patterns and body image and to refer for further evaluation, if needed.29 The American College of Obstetricians and Gynecologists recommends that clinicians be able to identify signs of disordered eating and screen at-risk patients.30

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  1. Feltner C, Peat C, Reddy S, et al. Screening for Eating Disorders in Adolescents and Adults: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 212. AHRQ Publication No. 21-05284-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2021.
  2. American Psychiatric Association, DSM Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013.
  3. Udo T, Grilo CM. Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of U.S. adults. Biol Psychiatry. 2018;84(5):345-354. 
  4. U.S. Preventive Services Task Force. Procedure Manual. Published 2018. Accessed October 6, 2021. https://uspreventiveservicestaskforce.org/uspstf/procedure-manual.
  5. Treasure J, Duarte TA, Schmidt U. Eating disorders. Lancet. 2020;395(10227):899-911. 
  6. Mitchell KS, Mazzeo SE, Schlesinger MR, et al. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. Int J Eat Disord. 2012;45(3):307-315.
  7. Hudson JI, Hiripi E, Pope HG Jr, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358. 
  8. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14(1):25-32. 
  9. Marques L, Alegria M, Becker AE, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Disord. 2011;44(5):412-420. 
  10. Diemer EW, Grant JD, Munn-Chernoff MA, et al. Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. J Adolesc Health. 2015;57(2):144-149. 
  11. Udo T, Grilo CM. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int J Eat Disord. 2019;52(1):42-50. 
  12. Kaye WH, Bulik CM, Plotnicov K, et al. The genetics of anorexia nervosa collaborative study: methods and sample description. Int J Eat Disord. 2008;41(4):289-300.
  13. Watson HJ, Yilmaz Z, Thornton LM, et al. Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nat Genet. 2019;51(8):1207-1214.
  14. Maguen S, Hebenstreit C, Li Y, et al. Screen for disordered eating: improving the accuracy of eating disorder screening in primary care. Gen Hosp Psychiatry. 2018;50:20-25. 
  15. Berkman ND, Brownley KA, Peat CM, et al. Management and Outcomes of Binge-Eating Disorder. AHRQ Publication No. 15(16)-EHC030-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2015.
  16. Berkman ND, Bulik CM, Brownley KA, et al. Management of eating disorders. Evid Rep Technol Assess (Full Rep). 2006(135):1-166.
  17. Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. 2005;165(5):561-566.
  18. Forney KJ, Buchman-Schmitt JM, Keel PK, et al. The medical complications associated with purging. Int J Eat Disord. 2016;49(3):249-259.
  19. Zakzanis KK, Campbell Z, Polsinelli A. Quantitative evidence for distinct cognitive impairment in anorexia nervosa and bulimia nervosa. J Neuropsychol. 2010;4(Pt 1):89-106. 
  20. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13(2):153-60.
  21. Siu AL, Bibbins-Domingo K, Grossman DC, et al; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
  22. Siu AL; U.S. Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.
  23. Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(6):580-587.
  24. Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(11):1163-1171.
  25. Grossman DC, Bibbins-Domingo K, Curry SJ, et al; US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.
  26. Hornberger LL, Lane MA. Identification and management of eating disorders in children and adolescents. Pediatrics. 2020:e2020040279.
  27. Academy for Eating Disorders' Medical Care Standards Committee. Eating Disorders: A Guide to Medical Care. 3rd ed. Reston, VA: Academy for Eating Disorders; 2016.
  28. Lock J, La Via MC. Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(5):412-425.
  29. ACOG Committee Opinion No. 740: gynecologic care for adolescents and young women with eating disorders. Obstet Gynecol. 2018;131(6):e205-e213.
  30. Bakalar JL, Shank LM, Vannucci A, et al. Recent advances in developmental and risk factor research on eating disorders. Curr Psychiatry Rep. 2015;17(6):42. 
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Rationale Assessment
Detection
  • There is adequate evidence on the accuracy of the SCOFF questionnaire for screening for eating disorders in adult women; evidence is inadequate for adolescents, males, and other specific populations.
  • There is inadequate evidence about the accuracy of other screening tests in adults and adolescents.
Benefits of Early Detection and Intervention and Treatment (Based on Direct or Indirect Evidence)
  • There is no direct evidence that screening for eating disorders in adolescents and adults improves health outcomes.
  • There is inadequate evidence on the effectiveness of interventions for improving health outcomes in screen-detected adolescents and adults with eating disorders.
Harms of Early Detection and Intervention and Treatment
  • There is inadequate direct evidence on the harms of screening for eating disorders in adolescents and adults.
  • Overall, there is adequate evidence to bound the harms of screening for and treatment of eating disorders in adolescents and adults as no greater than small, based on noninvasive screening, the nature of therapy interventions, and the low likelihood of serious harms from pharmacotherapy.
USPSTF Assessment
  • The benefits and harms of screening for eating disorders in adolescents and adults are uncertain, and the balance of benefits and harms cannot be determined.
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