Eating disorders are a group of psychological conditions characterized by persistent disturbances in eating patterns and a preoccupation with body shape and weight.1 Early detection of eating disorders is critical to their outcomes. Primary care providers play an important role in this. Through proper screening, the primary care provider has the ability to recognize eating disorders or minimize the associated psychological and physical consequences. Nearly half of all eating disorders may go undetected.2 This underscores the importance of screening for eating disorders as a part of routine assessment in primary care.3 The SCOFF (Sick, Control, One, Fat, Food) questionnaire is a screening tool that can be used to detect eating disorders in the primary care setting.4
What are Eating Disorders?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V)5 classifies eating disorders into three subtypes: anorexia nervosa, bulimia nervosa and binge-eating disorder. Anorexia nervosa is characterized by a refusal to maintain a minimally acceptable body weight by harshly restricting food intake. Patients with anorexia have an intense fear of weight gain and present with excessive weight loss. Bulimia nervosa is characterized by episodes of binge eating with compensatory mechanisms to prevent weight gain, such as vomiting or taking laxatives. Binge eating disorder is characterized by excessive intake of food and a sense of a lack of control. Binge eating is often associated with obesity because affected patients do not use compensatory mechanisms after binging.4
Incidence and Prevalence
Approximately 10 million people in the United States are affected by an eating disorder annually.6 Ninety percent of affected patients are female and 75% are adolescents.7 Most eating disorders develop among young women between the ages of 15 and 25.4 Approximately 1 in 10 young men is affected by eating disorders.4
In young women, the prevalence of anorexia nervosa is approximately 0.3% and the prevalence of bulimia nervosa is 1%.4 The prevalence of binge eating disorder is between 0.7% and 4.3% in the general population, and women are affected 1 to 2 times more often than men.8
A multitude of contributing factors lead to the development of eating disorders, including personal and social factors. Common characteristics include highly self-critical, perfectionism, low self-esteem and a desire to control things.4
Participating in activities that promote thinness, such as ballet, modeling and gymnastics, place people at risk for developing an eating disorder.2 Obsession with body image, high focus on appearance and excessive dieting often contribute to eating disorders.4
A thorough history and use of the SCOFF are the most valuable tools for diagnosis. High-risk populations may be asymptomatic or present with mild symptoms such as fatigue or dizziness. Absence of symptoms does not rule out an eating disorder diagnosis.2 The key to diagnosing eating disorders is a thorough clinical interview that reveals pertinent history. The physical examination and laboratory test findings may be normal and therefore are not diagnostic.9 Signs and symptoms of eating disorders include the following:10
Abdominal pain/discomfort, bloating, abnormal bowel sounds
Apathy, anxiety, depression, irritable mood
Change in hair (i.e loss, dry, brittle)
Chest pain, bradycardia, arrhythmias
Enlarged salivary glands
Heartburn, acid reflux, abdominal distention
Loss of libido, cease in menstruation, fertility problems
Poor concentration, cognitive impairment
Scarring on dorsum of hand used to induce vomiting (Russell's sign)
Slowed development of secondary sexual characteristics
Sore throat, erythema of pharynx
Weak irregular pulse
Weight loss or low body weight (or weight fluctuation)
Yellowing of skin, lanugo.
Screening tools can help facilitate further investigation of a potential eating disorder in high-risk populations that may otherwise not seek treatment or deny the presence of an eating disorder. An estimated 10% of the population reports symptoms of an eating disorder but do not meet the full DSM-V criteria5 to diagnose it. This at-risk group is especially important to screen properly to prevent the development of an eating disorder.11
More than half of all adults diagnosed with an eating disorder were first diagnosed by their primary care provider.12 Screening for eating disorders in the primary care setting leads to early detection and prompt referrals for treatment. Adequate screening and recognition of eating disorders can prevent serious, often life-threatening consequences and preserve mental and physical health while improving the quality and lifespan of patients.3
It is important to use a screening tool because eating disorders are difficult to recognize in a quick primary care visit. Patients with eating disorders are often embarrassed and do not want to admit to themselves or a provider that they need help. Screening tools are also helpful because they negate the need for specialized experience or training in eating disorders. In addition, screening tools allow for earlier detection because signs evident in a physical exam may not appear until later stages.4
Aside from the physical complications, eating disorders can have an impact on emotional and social development.4
The SCOFF Screening Tool
The SCOFF is a five-question screening tool that focuses on detecting patients at high risk for an eating disorder. SCOFF is an acronym for Sick, Control, One, Fat, Food.9 The SCOFF Questionnaire is not diagnostic; it should be used as a tool to prompt further investigation of a patient with a positive score of two or more of five questions.4
- Do you make yourself Sick when you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone in a 3-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
*One point for every "yes"; a score of 2 or higher indicates a likely case of anorexia or bulimia
*One British stone = 6.4 kg or 14 pounds
The SCOFF questionnaire is considered the most promising screening tool to detect eating disorders in primary care. Each positive result needs to be followed up with further questioning and assessment. Further questioning should focus on weight loss; anxiety about weight gain; menstrual abnormalities; purging behaviors; binge eating; restrictive eating; obsession with food; use of laxatives, diuretics or weight loss pills; excessive exercise, personal or family history of behavioral problems; and how their weight correlates with self-image.9 Affirmative findings with these associated questions should aid screening and determine which patients to refer to specialists.
Numerous studies have examined the efficacy of the SCOFF. The original research, conducted in London, England, found that the SCOFF had 100% sensitivity and 87.5% specificity for detecting eating disorders.13 Another research study used the SCOFF to detect eating disorders and found it to have a sensitivity of 84.6% and a specificity of 89.6%.14 A more recent study performed in the United States documented the SCOFF's ability to be used effectively in the primary care setting, with a sensitivity of 72%.15 Recently, the SCOFF was further validated by detecting all true cases of eating disorders, indicating a sensitivity of 100%. In this study, the SCOFF detected 34 false positives and resulted in a specificity of 89.6%.16 In another U.S. study, the SCOFF's ability to detect an eating disorder was demonstrated by 93.2% specificity and 53.3% sensitivity.17
Other existing screening tools are extensive, difficult to interpret, and are specific to one subtype of an eating disorder. The SCOFF was developed for nonspecialists due to the lack of simple, memorable screening tools.13 A screening tool for the primary care setting needs to be brief, efficient and lead to prompt diagnosis and referrals.
A prompt referral for treatment can prevent some of the more severe consequences of eating disorders, such as osteoporosis, organ damage and death.2 Malnutrition and starvation associated with eating disorders can lead to medical complications that can affect nearly all organs.9
Most patients are treated as outpatients by a multidisciplinary team including a primary care provider, psychiatrist and dietitian. The primary care provider is responsible for close and frequent follow-up including accurate height and weight measurements. Treatment is dependent on the stage of the illness, which is based on the severity of physical and psychological complications.
Initial treatment focuses on achieving a healthy weight based on age and height.9 Family is encouraged to participate in treatment and support especially for children and adolescents. Psychotherapy such as cognitive behavior therapy (CBT) and interpersonal therapy are commonly used. Selective serotonin reuptake inhibitors (SSRIs) have such as fluoxetine (Prozac) and sertraline (Zoloft) can be used to help decrease binge eating episodes.9
Implications for Practice
The SCOFF is a reliable tool for the primary care provider to determine the presence of a possible eating disorder. For many patients with a positive SCOFF score, a comprehensive clinical interview by a clinical psychiatrist would be the next step.2
The SCOFF is more practical for the primary care setting than other screening tools because it encompasses multiple eating disorders and is easily memorized. Initiating different screening tools for each eating disorder would be unrealistic in the primary care setting. Providers should screen all female adolescents and young adults for eating disorders as part of routine care.9
Rebecca Castleberry is a family nurse practitioner in Florida.
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