Simple Eating Disorder Screen Reveals Hidden Risks in Young Substance Users

A five-question questionnaire that takes less than a minute to complete may be one of the most efficient tools available for spotting hidden eating disorder risk among young people who come into clinics for entirely different reasons. New research published in the Journal of Eating Disorders suggests that the Eating Disorder Screen for Primary Care, a brief instrument originally designed for busy primary care settings, can reliably flag eating disorder risk in adolescents and young adults recruited through substance use research programs. The study, led by Emily Giddens of Monash University together with colleagues at the Medical University of South Carolina and the University of Melbourne, also reveals a striking psychological signature among the young people who screen positive: they struggle far more with regulating their emotions, experience more depression and anxiety, and use cannabis more frequently than their peers who do not endorse eating disorder concerns.

The relationship between eating disorders and substance use disorders has long puzzled clinicians. Epidemiological studies consistently show that these conditions co-occur at rates far higher than chance would predict, yet eating disorder symptoms are rarely measured in substance use research. This gap matters because the two disorders may share underlying mechanisms, particularly difficulties in emotional regulation and impulsive behavior when distressed. If researchers studying youth substance use ignore eating pathology, they may be missing a crucial piece of the puzzle that explains why some young people develop severe substance-related problems while others do not. The new study set out to determine whether a brief screener could close that gap without adding meaningful burden to research participants or clinical staff.

The research team analyzed data from 682 young people between the ages of 15 and 25, assessed across 722 visits through a standardized intake process. Each participant completed the Eating Disorder Screen for Primary Care, known as the ESP, along with a comprehensive battery of psychological measures. These included the Difficulties in Emotion Regulation Scale Short Form for emotional dysregulation, the UPPS-P Revised Child Impulsivity Scale for impulsive personality traits including negative urgency, the Patient Health Questionnaire for depression, the General Anxiety Disorder seven-item questionnaire for anxiety, and validated instruments for problems related to cannabis and electronic cigarette or nicotine use. Participants also reported their substance use over the previous thirty days using timeline follow-back methods, a well-established calendar-based approach for reconstructing recent consumption patterns.

The ESP itself is remarkably simple. It asks respondents to rate, on a scale from zero to two, how often they experience concerns such as feeling terrified of being overweight, avoiding eating when hungry, going on eating binges, vomiting after eating, or exercising excessively to control weight. In primary care, a score of two or higher is traditionally used as the clinical cut-off indicating possible eating disorder. But the researchers wanted to know whether that threshold, developed for general medical patients, would perform well in a population of young people recruited specifically for substance use research, where the presentation of eating pathology may differ from typical clinical samples.

To answer that question, the team applied receiver operating characteristic analysis, a statistical technique that evaluates how well a screening tool discriminates between people who have a condition and those who do not across all possible cut-off scores. Clinical diagnoses were established using the Mini International Neuropsychiatric Interview, a structured diagnostic instrument. The analysis examined sensitivity, the proportion of true cases correctly identified; specificity, the proportion of non-cases correctly cleared; and positive and negative predictive values across a range of possible thresholds from two to five. The results showed that the traditional clinical cut-off of two or higher yielded high sensitivity but poor specificity, meaning it caught most true cases but also flagged many young people who did not meet diagnostic criteria.

The receiver operating characteristic curves pointed to a better balance at a score of three or higher. At this revised threshold, the ESP achieved acceptable diagnostic accuracy for detecting eating disorder diagnoses within this particular population, trading a small loss in sensitivity for a meaningful gain in specificity. The finding carries practical significance: screening tools embedded in substance use research protocols and clinical intakes can be tuned to the population being assessed rather than relying on thresholds imported from different settings. For researchers, the tailored cut-off means that a two-minute questionnaire can now yield interpretable eating disorder risk data in studies that were never designed with eating pathology in mind.

Having established the optimal threshold, the researchers then compared young people who screened at risk with those who did not, using Wilcoxon rank sum tests to account for the non-normal distribution of the psychological and substance use measures. The differences were substantial and consistent. Youth who endorsed eating disorder risk reported significantly higher emotional dysregulation, meaning greater difficulty identifying, tolerating, and modulating their emotional states. They also scored higher on negative urgency, a specific facet of impulsivity that describes the tendency to act rashly when experiencing intense negative emotions. This trait has been implicated in both binge eating and substance use, and the new findings suggest it may be a common pathway connecting the two classes of disorders.

The psychiatric burden among those at risk extended to mood and anxiety. Participants flagged by the revised ESP cut-off reported significantly more depressive symptoms on the PHQ and more anxiety symptoms on the GAD-7 than their non-risk peers. Their substance use profiles were equally distinctive. Although they reported lower quantity and frequency of alcohol consumption, they used cannabis more frequently and reported greater problems related to both cannabis, measured with the Marijuana Adolescent Problem Inventory, and nicotine, measured with the Penn State Electronic Cigarette Dependence Index. This pattern suggests that eating disorder risk in youth does not simply generalize to all substance use; instead, it clusters with specific substances, particularly cannabis and nicotine, while alcohol use may actually be reduced.

The authors argue that these findings point to emotional dysregulation as a central risk factor for the co-occurrence of eating disorder symptoms and substance use in young people. When the capacity to manage distressing emotions is compromised, multiple maladaptive behaviors, from restrictive eating and bingeing to cannabis and nicotine use, may emerge as alternative strategies for emotional relief. This transdiagnostic perspective has implications for treatment: interventions that build emotion regulation skills, such as dialectical behavior therapy approaches, could potentially address both conditions simultaneously rather than treating them in isolation. It also suggests that substance use treatment programs should consider screening for eating pathology, since young people with co-occurring eating disorder risk may require tailored support to achieve better outcomes.

For clinicians and researchers alike, the study offers a pragmatic message. Brief, low-effort screening tools like the ESP can be incorporated into substance use research and clinical intake processes with minimal burden, yet they capture clinically meaningful information that would otherwise be lost. The tailored cut-off of three or higher demonstrated acceptable diagnostic accuracy in this youth sample, and the psychological profile it identifies, marked by emotional dysregulation, negative urgency, depression, anxiety, and heavier cannabis and nicotine involvement, provides researchers with concrete targets for understanding why eating disorders and substance use disorders so often travel together. As youth mental health services grapple with rising rates of both conditions, a one-minute questionnaire may prove to be an unexpectedly powerful window into the shared roots of these intertwined disorders.

Subject of Research: Eating disorder risk screening and its mental health and substance use correlates in adolescents and young adults

Article Title: Distinct mental health and substance use patterns in youth who endorse eating disorder risk using the eating disorder screen for primary care

Article References: Giddens, E., Kirkland, A. E., Mahlberg, J., Ferguson, P. L., Steward, T., Verdejo-Garcia, A., Tomko, R. L., & Squeglia, L. M. (2026). Distinct mental health and substance use patterns in youth who endorse eating disorder risk using the eating disorder screen for primary care. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01792-7

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01792-7

Keywords: eating disorders, substance use, screening tools, youth, emotional dysregulation, impulsivity, cannabis, nicotine, depression, anxiety, primary care, diagnostic accuracy