Eating disorder rates increased exponentially following the initial COVID-19 lockdown, with studies showing a doubling of hospitalization rates for eating disorders among children and teens; patients are also presenting at younger ages and with more severe symptoms. Management of eating disorders is complex and, while early identification is essential to improving outcomes, recognizing disordered eating can be challenging as many patients with these conditions are overweight or normal weight.

However, the US Preventive Services Task Force (Task Force) recently determined that there is not enough research to make a recommendation for or against screening for eating disorders in patients with no signs or symptoms of these conditions.

“There is not enough evidence about the potential benefits and harms of screening for eating disorders, particularly in the primary care setting with people who do not have signs, symptoms, or concerns,” said coauthor and Task Force member Lori Pbert, PhD. “While evidence is limited in all people, certain groups need to be better represented in studies on eating disorders, including men, people of color, and the LGBTQ+ community,” said coauthor and Task Force vice chair Carol Mangione, MD, MSPH. This is the first-ever recommendation statement by the USPSTF on this topic.


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“While the USPSTF review provides important information about the current status of screening research, its conclusions risk possibly being misconstrued as suggesting that screening may not be necessary for early identification and referral of high-risk individuals,” Evelyn Attia, MD, and Angela S. Guarda, MD, commented in an editorial in JAMA.

Updates on Screening Tools, Medications for Eating Disorders

An accompanying systematic review by the USPSTF provides guidance on accurate screening tools and medications for eating disorders (eg, anorexia nervosa, bulimia nervosa, binge eating disorder). The SCOFF questionnaire was considered to have adequate accuracy for detecting eating disorders among adults and had a pooled sensitivity of 84% (95% CI, 74%-90%) and pooled specificity of 80% (95% CI, 65%-89%) in adults (10 studies, n=3684). The Task Force called for studies of screening test accuracy among adolescents and in primary care populations.

a ≥2 abnormal responses are considered a positive screen

A review of treatment trials indicated that guided self-help interventions, lisdexamfetamine, and topiramate were effective for reducing eating disorder symptom severity among referred populations with binge eating disorder. Guided self-help interventions were associated with greater reductions in eating disorder severity compared with control interventions over 12 to 24 weeks (pooled standardized mean difference [SMD], -0.96 [95% CI, -1.26-0.67]; 5 studies; n=391). Group and individual psychological interventions showed mixed results.

For pharmacotherapy, most randomized controlled trials were limited to adult women with binge eating disorder or bulimia nervosa and had a relatively short duration of follow-up. Lisdexamfetamine and topiramate demonstrated efficacy in reducing symptom severity in binge eating disorder, according to the Task Force. Lisdexamfetamine is approved for the treatment of moderate to severe binge eating disorder in adults, and topiramate is used off-label in the treatment of eating disorders.

Table. Pooled Outcomes for Lisdexamfetamine and Topiramate in the Treatment of Binge Eating Disorder

MedicationMean difference in YBOCS-BE vs Placebo
Lisdexamfetamine (4 RCTs; n=900)Pooled data: -5.75 (95% CI, -8.32-3.17)
Topiramate (2 RCTs; n=465)Study 1: -6.40 (95% CI, -8.16-4.64) Study 2: -2.55 (95% CI, -4.22-0.88)

YBOCS-BE, Yale-Brown Obsessive Compulsive Scale modified for binge eating; RCTs, randomized clinical trials

These pharmacotherapies were also associated with harms: lisdexamfetamine was associated with higher rates of dry mouth, headache, and insomnia, and topiramate was associated with higher rates of paresthesia, taste perversion, confusion, and concentration difficulty.

Fluoxetine is the only SSRI indicated for acute and maintenance treatment of bulimia nervosa in adults. Three trials in which fluoxetine was used in the treatment of bulimia nervosa found inconsistent effects for eating disorder symptom severity and depression. Five RCTs examined SSRIs (including fluoxetine) in the treatment of binge eating disorders; of the 2 trials that measured eating disorder severity, both found reduced symptoms scores favoring SSRIs but the results were considered imprecise by the Task Force. Change in depression symptom scores was greater with SSRIs than placebo.

Need for More Research in Black, Hispanic, and LGBTQ+ Individuals

The Task Force emphasized the lack of data on eating disorders among underrepresented groups, including boys and men, adolescents, people of color, and LGBTQ+ individuals.

“This is of particular concern given data suggesting that prevalence rates for eating disorders vary for different ethnic and racial groups,” Drs Attia and Guarda noted. “For example, bulimia nervosa is more common among Black and Hispanic individuals than among non-Latinx White individuals. Transgender youth have higher rates of self-reported eating disorders than cisgender heterosexual female.”

Sources

1. US Preventive Services Task Force. Screening for eating disorders in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2022;327(11):1061–1067. doi:10.1001/jama.2022.1806

2. Feltner C, Peat C, Reddy S, et al. Screening for eating disorders in adolescents and adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2022;327(11):1068–1082. doi:10.1001/jama.2022.1807

3. Attia E, Guarda AS. Prevention and early identification of eating disorders. JAMA. 2022;327(11):1029–1031. doi:10.1001/jama.2022.2458