Anorexia at Any Size

Source: Gerd Altmann/Pixabay

The idea of someone not skinny—let alone “fat”—with anorexia nervosa goes directly against how the disorder is depicted in the media. For example, when you think of anorexia, what image comes to your mind? Is it the gaunt model on the runway? The back view of the ultra-thin female curled up so you can see her ribs and protruding spine? The tape measure around a tiny waist?

There are so many photos that get recycled in the media. No wonder we have strong ideas about what people with anorexia nervosa are supposed to look like. Yet science is showing us that it’s not true. Someone who isn't emaciated can have anorexia nervosa: It’s called atypical anorexia nervosa.

In 2013, the diagnosis was added to the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-5). Only recently has it been coming into the spotlight via the news and journal articles. For instance, in 2022, Tess Holiday went public about her atypical anorexia nervosa. And last week, another academic journal article—"Atypical anorexia nervosa: Implications of clinical features and BMI cutoffs” (Kim, An, & Treasure, 2023)—highlighted the alikeness of anorexia nervosa and atypical anorexia nervosa and the potential ineffectiveness of a strict body mass index (BMI) cutoff.

Atypical Anorexia Nervosa

Atypical anorexia nervosa is when a person, despite significant weight loss, can still be classified as normal weight, overweight, or obese and has all the other markers of anorexia nervosa. So, in nonclinical-speak, here those are:

• The person must restrict food (e.g., diet), which leads them to be at a weight significantly under what they’d otherwise be at.
• The person is super scared of gaining weight.

Also, at least one of the following needs to repeatedly occur:

• The person sees or evaluates their body in distorted ways.
• Their weight or perception of their body affects their mood or self-esteem (e.g., gaining half a pound may trigger a horrible mood and a sincere sense of worthlessness).
• The person discredits concern about their weight loss or the effects of undereating. It’s this kind of attitude: “So what if my hair’s falling out? You’re overreacting.”

Someone with atypical anorexia nervosa tends to think they're not sick and often believes they need to lose more weight. That could be partially because of the disorder’s effect and partly because of the many spaces that tell them they need to lose more weight or congratulate them on their weight loss (e.g., medical environments where the BMI governs ideas about wellness, media advertisements, and social settings).

Atypical Anorexia Nervosa Versus Anorexia Nervosa

The research by Kim and colleagues points out that mental illness burdens tend to be comparable between atypical anorexia nervosa and anorexia nervosa. Further, atypical anorexia nervosa carries similar physical risks and consequences as low-weight anorexia nervosa (Vo & Golden, 2022). Those effects can range from hair loss and dull skin to severe cardiac issues. In addition, anorexia nervosa has long been recognized as the most lethal of eating disorders. And of mental health disorders, eating disorders are among the deadliest, second only to opioid use disorders.

Nonetheless, when assigning a diagnosis, the cutoff of the BMI can wholly distinguish between anorexia nervosa and atypical anorexia nervosa. The BMI, however, does not take into consideration factors that can skew to a higher or lower BMI. Examples include genetics, gender, body build, country, race, and more.

Pressing Forward

Unlike with anorexia nervosa, minimization surrounds the categorization of and terminology currently attached to atypical anorexia nervosa. For example, the disorder falls under a catchall, seemingly-less-serious type of eating disorder, titled “other specified feeding or eating disorder,” instead of anorexia nervosa. This separation probably confuses the public and practitioners alike.

Also, “atypical” implies unusual. Logically, then, the other must be “typical” and usual anorexia nervosa, right? Well, maybe not. A review of existing literature shows that atypical anorexia nervosa is at least as common as typical anorexia nervosa (Harrop et al., 2021). Hopefully, research and time can clarify or correct these issues.

Diet Essential Reads

The Body Mass Index Fallacy

3 Psychological Barriers That Make It Hard to Go Vegan

Information about atypical anorexia nervosa continues to emerge. But between weight stigma and the continuing war on obesity, it’s really complicated. For example, the American Academy of Pediatrics (AAP) just released their “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity” (Hampl et al., 2023). The AAP suggests dieting, exercising, weight-loss pills, and bariatric surgery as viable long-term treatment options to treat obesity in minors. Yet how many of those children will develop atypical or typical anorexia nervosa? Another eating disorder? This is not to say that everyone who loses a lot of weight has atypical anorexia nervosa or anorexia nervosa. They must match the DSM criteria for either diagnosis.

Bottom Line

So yes, a person who is not thin can have anorexia nervosa, as can anyone in any BMI category: normal weight, overweight, obese, and underweight.

If you are concerned you might be experiencing a clinical eating disorder—or you’re “just” struggling with food and body image—support is out there. Eating disorders specialist therapists can be beneficial. And if one is not affordable, there are numerous free support groups. You are worthy of healing, hope, and help.

This blog is for informational purposes and does not provide therapy or professional advice.

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