Calls for better research after USPSTF issues recommendation statement against routine eating disorder screening

There’s no evidence to suggest that teenagers and adults with normal growth and weight should be routinely screened for eating disorders, according to a new recommendation statement from the United States Preventive Services Task Force (USPSTF),¹ but experts in identifying and treating eating disorders disagree.^2,3

The recommendation didn’t claim that patients of normal weight and growth can’t have an eating disorder—only that there is not enough evidence to support a broad screening recommendation for the general public. Advocates, however, say this illustrates a gap in research more than anything.

Almost 5% of women and more than 2% of men in the United States are faced with some variety of eating disorder including anorexia nervosa, bulimia nervosa, binge eating disorder, and more. The isolation and stress of the COVID-19 pandemic has only increased this problem in recent years, according to an editorial that accompanied the statement, causing a spike in the development of severe eating disorders and the need for hospitalization or other intensive treatments—especially in teenagers.³

“These disorders commonly begin during adolescence and young adulthood and appear prevalent among individuals who present for general clinical care… Because some individuals with eating disorders conceal core illness symptoms—and avoid or delay seeking specialist care—due to feelings of embarrassment, stigma, or ambivalence toward treatment, screening for these disorders in primary care settings is especially important, as most cases of eating disorders remain undetected and untreated,” writes Evelyn Attia, MD, of the NYS Psychiatric Institute in New York City, New York, in an editorial on the recommendations for the JAMA.³

Eating disorders are often recognized because of outward signs like weight loss and purging habits. Weight, height, and body mass index measurements are often used in the screening for eating disorders in primary care practice, but even the evidence report that accompanies the recommendation highlights the face that these disorders can also develop without any physical symptoms at all. Regardless of how a disorder presents itself, the evidence report published with the recommendation also notes that these disorders—whether obvious from weight measurements or not—can lead to a host of adverse effects like⁴:

• Malnutrition
• Dental erosion
• Obesity
• Electrolyte imbalances
• Mood disorders
• Substance abuse disorders

Routine screening could help identify atypical presentations of eating disorders earlier, leading to quicker intervention and reduced mortality, suggests the report. However, none of the studies reviewed in consideration for the recommendation looked closely enough at the benefits and harms of routine screening, and how effective current screening tools might be in the general population.⁴

Erin Harrop, LICSW, PhD, an assistant professor at the University of Denver in Colorado and a licensed medical social worker, called the agency’s decision against making a formal recommendation for screening “unfortunate.”

“We know that early identification is a key predictor of better outcomes long-term,” Harrop said. “Although much of the data supporting early intervention is for those in thinner bodies, I think this overall recommendation speaks much more to the lack of research about those in higher weight bodies rather than screening being not recommended.”

Harrop added that the lack of evidence to support a general screening recommendation also highlights the lack of data on effective interventions for eating disorders in higher weight populations overall. She continued that she is afraid the task force’s statement will be misinterpreted as an indication that eating disorder screenings in normal and higher weight populations are not important, rather than highlighting the need for more high-quality research.

“It is clear from our epidemiological studies that many people who are higher weight struggle with eating and body image issues; to not intervene and screen means these people could be struggling and hurting in silence, without professional supports to help facilitate recovery,” Harrop said.

Harrop shared that her clinical experience in treating patients with atypical anorexia has often uncovered a lack of screening—especially for teenagers—in the primary care setting. Symptoms like low blood pressure, weight loss, fainting, and menstrual cycle changes were overlooked by primary care providers and attributed to other causes like athleticism or anxiety, Harrop explained. Harrop and Attia both suggested that, in many cases, it takes a specialist who is trained in recognizing atypical presentations of eating disorders to identify and intervene in these cases.

“Although we do not have much information on treatment rates and timelines for people with atypical anorexia, the research that we do have speaks of people with atypical anorexia waiting longer for treatment than their thinner peers,” Harrop said. “This is problematic, because many are just as sick, physically, and early intervention is key to better outcomes. I worry that the suggestions about not explicitly recommending screening for higher weight folks will have many negative repercussions for people with atypical anorexia: longer treatment delay, more entrenched behaviors, increased feelings of hopelessness and suicidality, psychological distress, and a more difficult medical journey back to health.”

Harrop and other experts who have weighed in on the recommendation of the task force express hope that the obvious lack of data in this area will lead to new research instead of appearing as an endorsement for complacency.

Be sure to check out the May 2022 issue of Contemporary Pediatrics for more on eating disorders.