The SCOFF questionnaire and clinical interview for eating disorders in general practice: Comparative study

Department of Psychiatry, St George's Hospital Medical School, University of London, London SW17 0RE.
BMJ (online) (Impact Factor: 17.45). 11/2002; 325(7367):755-6. DOI: 10.1136/bmj.325.7367.755
Source: PubMed


Standards 2 and 3 of the national service framework for mental health outline the need to improve health care for patients with anorexia nervosa and bulimia nervosa.1 Healthcare workers in primary care are at the forefront of screening and managing these disorders. Assessment tools available to primary healthcare professionals can take a long time to administer and may need to be interpretedby specialists2; this may limit improvements in care. A screening tool was developed, but only to facitate epidemiological research.3The SCOFF questionnaire is a brief and memorable tool designed to detect eating disorders and aid treatment (see figure). It showed excellent validity in a clinical population and reliability in a student population. 4 5 We assessed the SCOFF questionnaire in primary care.
Participants, methods, and results
We invited sequential women attenders (aged 18-50) at two general practices in southwest London to participate. We gave participants information sheets that described the study. Women who verbally consented to participate were asked the SCOFF questions in a separate room; this took about two minutes. A researcher blind to the woman's score on the SCOFF questionnaire conducted a clinical diagnostic interview lasting 10-15 minutes, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). Women identified by the interview as having an eating disorder were invited to discuss this and were offered the contact number for the Eating Disorders Association. The local research and ethics committee approved the study.
Of the 341 women who agreed to take participate, one (who had a body mass index of 17 (weight (kg)/height (m)2)) had anorexia nervosa, three had bulimia nervosa, and nine had an “eating disorder not otherwise specified.” A receiver operating curve set the optimal threshold for the questionnaire at two or more positive answers to the five questions. With this cut off, the SCOFF questionnaire detected all four cases of anorexia nervosa and bulimia nervosa and seven of nine cases of eating disorders not otherwise specified (figure). The questionnaire had a sensitivity of 84.6% (95% confidence interval 54.6% to 98.1%). In the 328 women confirmed not to have an eating disorder, the questionnaire indicated 34 false positives. It had a specificity of 89.6% (86.3% to 92.9%), positive predictive value of 24.4% (12.9% to 39.5%), and negative predictive value of 99.3% (97.6% to 99.9%).
View larger version:In a new windowDownload as PowerPoint SlideReceiver operating curve showing the effect of cut-off points (1 to 5) for the SCOFF questionnaire to detect cases and non-cases of eating disorders. 1 to 5=minimum number of positive responses to questionnaire

The SCOFF questionnaire detected all cases of anorexia and bulimia nervosa. It is an efficient screening tool for eating disorders.
Two missed cases of eating disorders not otherwise specified reflect the reality of clinical situations, in which denial or non-disclosure by patients may occur. One of the patients in whom the diagnosis was missed later disclosed disordered eating behaviour. It may be more difficult and perhaps less pertinent to detect patients who do not meet full criteria for anorexia nervosa or bulimia nervosa.
The positive predictive value of the questionnaire is low because of the low prevalence of eating disorders in this sample, which was consistent with the Western population as a whole. Overinclusion is acceptable for screening instruments designed for disorders with high mortality rates, particularly as the questionnaire is short and easy to administer. Positive results should be followed by further questioning rather than by automatic referral.
The SCOFF questionnaire is efficient at detecting cases of eating disorders in adult women in primary care. We recommend its use by healthcare professionals in primary care. Future work will assess the validity of the questionnaire in other populations, such as adolescents, in whom the prevalence may be higher.
Study to be attributed to the Department of Psychiatry at St George's Hospital Medical School, University of London, London. We thank K Kennett for her help with data collection. We also thank Wandle Valley Surgery and Brocklebank Group Practice, particularly T Coffey, who provided study patients. We thank the volunteers for their kind participation.
Contributors: All authors contributed to the conception and design of the study. AL, AO'B, JB, and CP were responsible for the collection and management of data. AL, FR, and JM analysed and interpreted data. AL wrote the paper and all other authors oversaw the writing and edited the paper. JM and HL will act as guarantors.

Funding None

Competing interests None declaredReferences1.↵Department of Health.A national service framework for mental health: modern standards and service models. London:Stationery Office,1999.2.↵Garner DM, Olmstead MA, Polivy J.Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia.Int J Eat Disord 1983; 2:15–34.3.↵Beglin SJ, Fairburn CG.Evaluation of a new instrument for the detection of eating disorders in community samples.Psychiatry Res 1992; 44:191–201.OpenUrlCrossRefMedlineWeb of Science4.↵Morgan JF, Reid F, Lacey JH.The SCOFF questionnaire: assessment of a new screening tool for eating disorders.BMJ 1999; 319:1467–1468.OpenUrlFREE Full Text5.↵Perry L, Morgan J, Reid F, O'Brien A, Brunton J, Luck A, et al.Oral versus written administration of the SCOFF.Int J Eating Disorders (in press).

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    • "In the present study, disordered eating is defined in terms of behaviours assessed by the SCOFF questionnaire, which is a short screening tool for EDs applied in clinical practice and research, allowing to identify adolescents at risk for EDs (Hill, Reid, Morgan, & Lacey, 2010; Luck et al., 2002; Morgan, Reid, & Lacey, 1999). The SCOFF questionnaire assesses core features of EDs including intentional vomiting, losing control over food, weight loss, body dissatisfaction and food intrusive thoughts. "
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    ABSTRACT: The objective of this study was to investigate the prevalence of eating disorder (ED) risk as well as associated psychopathology and health-related quality of life (HrQoL) in a large population sample of Austrian adolescents. A sample of 3610 adolescents aged 10-18 years was recruited from 261 schools representative for the Austrian population. The SCOFF questionnaire was used to identify participants at risk for EDs, and the Youth Self-Report and KIDSCREEN were used to assess general psychopathology and HrQoL. In total, 30.9% of girls and 14.6% of boys were screened at risk for EDs. SCOFF scores were significantly associated with internalising and externalising behavioural problems as well as HrQoL after controlling for sex, age and body mass index. The SCOFF score further turned out to be an independent predictor of HrQoL. The high prevalence of ED risk among Austrian adolescents points out the need for prevention in this field. Variables indicating eating pathology should be included in general mental health screenings. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
    European Eating Disorders Review 05/2015; DOI:10.1002/erv.2368 · 2.46 Impact Factor
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    • "EDE-Q). However, the SCOFF has been validated in the general population with good values of sensitivity and specificity [43, 44, 46, 75] and other studies have recently employed it to assess prevalence of disordered eating in large general population samples [15, 25]. Moreover, it captured a group of participants who showed strong associations with co-morbid behaviours which is consistent with evidence showing that that sub-threshold ED presentations might have a similar psychiatric burden to that of full diagnoses. "
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    ABSTRACT: Purpose Disordered eating has been shown to be more prevalent than full eating disorders diagnoses. However, research on its prevalence, socio-demographic, psychological correlates, and patterns of service use in multi-ethnic samples is still limited. This paper explores these associations in a South London-based (UK) sample. Methods The South East London Community Health (SELCoH) study is a general population survey (N = 1,698) of individuals aged 16+. Disordered eating was defined as ≥2 positive answers at the SCOFF questionnaire. Crude and adjusted logistic and multinomial logistic regression models were fit to investigate associations between socio-demographic characteristics, disordered eating, psychiatric comorbidity, and service use. Results A total of 164 (10 %) participants reported disordered eating and the majority were from ethnic minorities. In adjusted models, Asian ethnicity was associated with purging, loss of control eating and preoccupation with food. Individuals with disordered eating had higher odds of screening positive for post-traumatic stress disorder and personality disorders and of having anxiety/mood disorders, suicidal ideation/attempts, hazardous levels of drinking, and used drugs in the previous year. Only 36 % of individuals with disordered eating had sought professional help in the previous 12 months mostly through their general practitioner (27.4 %), followed by psychotherapists (12.8 %) and mental health specialists (5.5 %). Conclusion This study found a high prevalence of disordered eating, especially amongst ethnic minorities, and associations with a number of psychiatric conditions. Overall few participants accessed specialist services. These findings suggest that both disordered eating manifestations amongst ethnic minorities and access to care need better investigation.
    Social Psychiatry and Psychiatric Epidemiology 08/2014; 49(8). DOI:10.1007/s00127-014-0822-3 · 2.54 Impact Factor
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    • "This questionnaire has been designed and validated to screen ED in at-risk populations. In previous studies [31] [32] [33] [34] [35], it has been confirmed to be a highly effective screening instrument for detecting ED, with an excellent sensitivity and specificity for the presence of ED with a cutoff of at least two positive answers. Thus, we will later on refer in this study to a " positive SCOFF screening " when at least 2 positive answers were present. "
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    ABSTRACT: Objective: Traumatic life events are important risk factors for eating disorders (ED). War has been associated, in military populations, with an increased post-service incidence of ED and an increased mean body mass index. We hypothesize that a modification of eating behavior (EB) related to stress during wartime may increase the risk of developing an ED later on among civilians exposed to war stress during adulthood. Methods: This descriptive cross-sectional study was performed in a group of 303 undergraduate young adult students of both sexes from Lebanon, 6 months after the July 2006 war. Modification of EB during wartime, sociodemographic and other potential risk factors were assessed retrospectively. Students were then screened for ED using the SCOFF questionnaire. Results: SCOFF was positive in 31.4% of the students, with a mean value 41.6% higher among subjects who reported an altered EB during the war. Among subjects with a positive SCOFF screening, 71% had experienced a change of EB during wartime. Alteration of EB during war was related to an odds ratio for a positive SCOFF screening of 2.6 (95% CI 1.54-4.34) and 1.8 (95% CI 1.01-3.21) for non-adjusted and adjusted analysis, respectively. Conclusions: Modification of EB related to stress during wartime is associated with an increased risk of eating disorders. Early detection and treatment of eating disorders may be improved by routinely evaluation of EB modification in patients with a past history of war exposure.
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