Screening for eating disorders (EDs) in adolescent females with type 1 diabetes (T1D) is recommended by national guidelines because of the increased risk of EDs in this population and the premature morbidity and mortality associated with this dual diagnosis (1). Currently, no ED screening tool has been validated and accepted for clinical use in T1D. We modified the SCOFF ED screening questionnaire for this population (mSCOFF) and compared it with the Eating Disorder Inventory-3 (EDI-3) in 43 adolescent females with T1D (mean ± SD age 15.8 ± 1.7 years, diabetes duration 7.6 ± 3.9 years, BMI 25.5 ± 3.5 kg/m2, A1C 8.4 ± 1.4% [68 mmol/mol]). Patients with known ED were excluded. This study had institutional ethics board approval.
The EDI-3 is a reliable, valid, 91-item self-report measure for screening ED risk (2). A modified form of the EDI (mEDI) eliminates questions related to diabetes-imposed dietary restrictions and has been validated for use in T1D (3). The mEDI was completed by participants and scored by a psychologist using the EDI subscale cutoffs proposed by Jones et al. (3).
The SCOFF is a reliable and valid screening instrument (4) consisting of the following questions:
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost >14 lbs (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?
The mSCOFF replaces the final question with, “Do you ever take less insulin than you should?” (5). Diabetes physicians administered and scored the mSCOFF according to the number of positive responses (positive screen is two or more in the general population).
On the mEDI, 10 (23.2%) participants were identified as being at high risk for an ED. On the mSCOFF, 12 participants answered positively to one or more questions and 3 answered positively to two questions. With the cutoffs set at one or more and two or more positive answers, respectively, the mSCOFF sensitivity was 80% (95% CI 44–97%) and 30% (7–65%), specificity 90% (76–98%) and 100% (89–100%), positive predictive value 75% (37–94%) and 100% (30–100%), and negative predictive value 97% (76–100%) and 83% (67–93%) compared with the mEDI. Agreement between the mSCOFF and mEDI was significant by the one or more positive mSCOFF responses criterion (κ = 0.68 [95% CI 0.43–0.94]) and moderate by the two or more positive mSCOFF responses criterion (κ = 0.40 [0.07–0.72]).
We observed strong agreement between the mSCOFF and the mEDI. Although the mEDI is a validated tool for the screening of ED in adolescent females with T1D, it is not practical to administer given its length, cost, and scoring requirements. This is true of many other questionnaires studied for this purpose. The mSCOFF is a five-item questionnaire that can be quickly administered during a routine clinic visit. This tool shows great potential for screening ED risk in adolescent females with T1D and requires validation against a gold standard.
Acknowledgments. The authors thank Cheryl Crummel and Jackie Fiander, Janeway Children’s Health and Rehabilitation Centre, for patient recruitment and study coordination.
Funding. The Health Care Foundation and the Eating Disorder Foundation of Newfoundland and Labrador funded this project.
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Author Contributions. C.S.Z. contributed to the intellectual conception and design of the study, funding application, data collection and supervision, analysis, and manuscript preparation. S.A.P. contributed to the scoring of the mEDI and writing of the manuscript. J.J.D. contributed to the statistical analysis. A.M.D. and T.B. contributed to the study design and interpretation and writing of the manuscript. L.A.N. contributed to the funding application, approvals, and manuscript preparation as senior author. All authors contributed to and approved the final manuscript for submission. C.S.Z. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Prior Presentation. Parts of this study were presented in abstract form at the 39th International Society for Pediatric and Adolescent Diabetes Annual Conference, Gothenburg, Sweden, 16–19 October 2013.