Nothing to SCOFF at: Screening for Eating Disorders in the Emergency Room

As many who have suffered from eating disorders know, these illnesses can often go unnoticed for years. Family members and friends might not be the only ones who don’t catch the signs and symptoms of EDs; doctors, too, may not identify the presence of an eating disorder. Whether or not sufferers desire to get help, the symptoms associated with eating disorders often lead many to present at doctors’ offices and emergency departments, suffering from “mysterious ailments.”

In a study by Dooley-Hash, Lipson, Walton & Cunningham (2012, 2013), 16% of youth 14-20 presenting to the emergency department screened positive for eating disorders. The researchers describe their study in two articles published in the International Journal of Eating Disorders in 2012 and 2013. For this post, I’ll focus on the 2013 article, which highlights the patterns of emergency department use of those who present with eating disorders.

Tetyana has previously written about common medical complications (and possible underlying causes) that eating disorders patients present with to the ER. In this post, I will focus on the reported reasons for which those with eating disorders present to emergency rooms and the potential screening implications.


For this study, the authors achieved a sample size of 1920 individuals aged 14-20 presenting to an emergency department, with an average age of 17.5. A small majority of the individuals (56.5%) were female, and 72.2% were White. Within this sample, 15.5% screened positive for an eating disorder (which would work out to about 298 individuals).

Eating disorder presentation was assessed using a scale of 5 yes/no questions, the SCOFF. This instrument (which stands for “sick, control, one stone, fat, food” based on the questions asked) is often used to screen for eating disorders in time-limited settings where non-specialists are assessing patients (Morgan, Reid & Lacey, 2000). Each “yes” is assigned a score of 1 and a total score of 2 or above suggests a possible case of anorexia or bulimia nervosa. (Click here to view the five questions.)

This easily administered questionnaire is also relatively basic; Morgan et al. (who developed the scale) note that it has a false-positive rate of up to 12.5%. (This means that up to 12.5% of individuals who would screen positive for an eating disorder wouldn’t actually have one). However, it may be an effective way to quickly screen for eating disorders in settings like the emergency department, where doctors might not necessarily have the time to administer and score the Eating Disorder Examination Questionnaire, for example.

The researchers were interested in determining how often patients had visited the emergency room during the previous year and the main reason for visiting the emergency room.


Of the 15.5% who screened positive for eating disorders (percentages rounded to the nearest whole number):

  • 78% were female
  • 25% were considered obese according to BMI
  • 68% were White
  • 29% also screened positive for depression
  • 42% engaged in risky drinking behaviour
  • 37% used drugs
  • 28% presented to the emergency department for gastrointestinal ailments

Prior emergency room visits were more frequent among those who screened positive for eating disorders; as the authors note, among those who frequently (i.e., more than 5 times in 12 months) presented to the emergency room, 43.3% screened positive for an eating disorder. Generally these visits were related to gastrointestinal issues, followed by genitourinary complaints, and almost always unrelated to the eating disorder itself.


These results have important implications for eating disorder screening. The majority of individuals presenting to the emergency room who screened positive for eating disorders were not actually presenting because of the eating disorder; if they had not been screened for the purposes of this study, it is possible that their disorders may have gone unnoticed.

As the authors suggest, this finding highlights the importance of increased understanding of and screening for eating disorder in emergency departments. Though they note that this is important particularly for those presenting with gastrointestinal or genitourinary complaints, I wonder if this finding might be good practice in general.

Perhaps using a screening tool such as the SCOFF might be an effective way to identify eating disorders among those presenting to the emergency department; despite its simplicity and the misgivings I identify above, it appears to do what it is supposed to–it identifies patients with eating disorders–in a reliable and valid way, and it is surprisingly sensitive for such a short scale (Hill, Reid, Morgan & Lacey, 2010).

It is important to note, of course, that when someone with an eating disorder presents to the emergency department with something “seemingly unrelated to the eating disorder,” they might just be physically sick. Alongside the need to improve screening for eating disorders is the need to acknowledge that not everything is related to the eating disorder. Just as we can’t discount individuals who “don’t seem like they have an eating disorder,” we equally can’t assume that the eating disorder is the only important health concern an individual might be facing.

An interesting finding that the authors only minimally commented on was that 24.4% of those who screened positive for eating disorders were obese. Given what we know about weight stigma and the stereotypes that surround individuals with eating disorders (i.e., that people might not suspect that someone with a larger body size might suffer from an eating disorder), I wouldn’t be surprised if these individuals would be especially likely to be missed when presenting to the emergency room. Of course, someone would need to test that in some sort of well-designed study, but an interesting observation that deserves a bit more attention, in my opinion!

Regardless of the instrument used, this study highlights that there is a need to improve screening for eating disorders in emergency department settings. The authors suggest that doing so would help to reduce costs and “burden” on the healthcare system by reducing re-visits by individuals with eating disorders, many of whom may be frequent visitors. Additionally, this could evidently have implications for intervening earlier in the course of the eating disorder and hopefully ultimately improving outcomes for sufferers.


Dooley-Hash, S., Lipson, S.K., Walton, M.A., & Cunningham, R.M. (2013). Increased emergency department use by adolescents and young adults with eating disorders International Journal of Eating Disorders, 46, 308-315 : 10.1002/eat.22070


Andrea is a PhD candidate focusing on individual, familial, and health care definitions and experiences of eating disorder recovery. She has an MSc in Family Relations and Human Development and a BA in Sociology. In her Masters research, she used qualitative and arts-based approaches (digital storytelling) to explore the experiences of young women in recovery from eating disorders. Andrea has recovered from EDNOS. She can be reached at andrea[at]scienceofeds[dot]org.