Atypical Anorexia: You don't have to be underweight to have anorexia

Key Points

• Atypical anorexia is an eating disorder with all the symptoms of anorexia, except for extreme weight loss.
• Atypical anorexia is dangerous and leads to the same physical and mental health issues as anorexia nervosa.
• Early intervention is key, but treatment is possible at all stages.
• Licensed Registered Dietitians can help guide your recovery with a personalized nutrition plan.

What do you think of when you hear the term ‘anorexia’? The word is often associated with images of extremely skinny people. 

But anorexia has a lesser-known sibling—atypical anorexia. They both share the same symptoms, except for being underweight.

People with atypical anorexia experience disordered eating, but their weight can remain in the normal or overweight range. This difference can make it harder for them to get the right help for their disordered eating.

They may often hear comments like:

“You don't look anorexic.”

“You don't look sick; you can't have an eating disorder.”

"It's not real anorexia."

Making things worse, sometimes these words can even come from healthcare providers who are unaware of atypical anorexia.

However, according to the National Eating Disorder Association (NEDA), research shows no difference in the medical and psychological effects of atypical anorexia compared to anorexia nervosa.

Early intervention is key, and the first step to getting help is knowing what it is, the signs, dangers, risk factors, and treatment options.

What is atypical anorexia nervosa?

Atypical anorexia nervosa is an eating disorder that shares all the signs of anorexia except severe weight loss.

Despite its name, 'atypical' anorexia is two to three times more common than anorexia nervosa, but many may not even realize they have it because of their weight.

What are the signs of atypical anorexia nervosa?

Adults with atypical anorexia scored equally high on measures of eating disorder thoughts and behaviors as those with anorexia nervosa and bulimia nervosa.

Signs of atypical anorexia include:

• A preoccupation with food and weight loss
• Intense fear of weight gain or being "fat."
• Tying self-worth to body weight
• Low self-esteem and distorted body image
• Extreme calorie restriction: In the case of atypical anorexia, a person may eat more calories but not enough nutrients
• Stress about eating in public and may withdraw from eating socially to avoid weight stigma.
• Mental disorders related to anorexia, including anxiety, depression, substance use disorder, bipolar disorder, and others
• Brain fog or lack of concentration.

If you think you may have atypical anorexia and would like to talk to someone, Fay can help. Use Fay to find a Registered Dietitian experienced in eating disorder recovery, covered by your insurance.

Why is atypical anorexia nervosa hard to diagnose?

Having anorexia but being in a larger body makes atypical anorexia an eating disorder that is hard to detect. 

This is because while someone with atypical anorexia can exhibit all the behaviors and emotional distress as those with anorexia nervosa, their bodies can remain in the normal weight or overweight range.

People with atypical anorexia nervosa can even experience a higher number of mental health disorders compared to those with anorexia nervosa.

Diagnosis of atypical anorexia or higher-weight anorexia can be missed because:

• Busy healthcare providers may miss diagnosing atypical anorexia unless they correlate blood tests, vital signs, and physical examinations and question patients about their food intake.
• In a society obsessed with being thin, people may receive praise and social validation for a drop in weight, food restriction, and over-exercising, even if they are endangering their lives.
• If a person with atypical anorexia is overweight, doctors and loved ones may unknowingly encourage them to lose weight, further fueling the eating disorder.
• Many people may not seek help because of thoughts like, "I can't have anorexia. I need to lose weight."

How dangerous is atypical anorexia nervosa?

Atypical anorexia is officially classified as OSFED (Other Specified Feeding or Eating Disorders). NEDA notes that people with OSFED were just as likely to die from their eating disorder as those with anorexia or bulimia.

The physical health impact of atypical anorexia includes:

• Malnutrition (losing a large amount of weight in a short period of time can lead to malnutrition, even if the person is not underweight)
• Dehydration and electrolyte imbalance
• Gastrointestinal issues like constipation and bloating
• Very low heart rate (Bradycardia)
• Low blood pressure
• Hormonal changes
• Menstrual issues like missed periods
• Infertility later in life
• Stunted growth
• Low bone mineral density leading to fragile bones
• Brittle hair and nails, and more.

What are the risk factors of atypical anorexia?

According to NEDA, risk factors for an eating disorder include:

Psychological

• Perfectionism
• A high level of dissatisfaction with body image
• A history of anxiety disorder, obsessive compulsiveness, and stress
• Rigid rule-following or belief that there is always a 'right' way of doing things
• Being highly competitive with low self-esteem
• Past or current trauma.

Social

• Having a close relative with an eating disorder
• Anxiety, depression, and substance use disorder can run in families, which can increase the risk of eating disorders
• A history of dieting and obsession with weight
• Having type 1 diabetes (diabulimia)
• Diet culture and weight stigma (discrimination based on weight) can make mental health conditions like eating disorders worse.

FAQs about atypical anorexia nervosa

How can you be malnourished if you have a larger body?

Malnutrition is a condition where the body does not receive the proper nutrients to function correctly. It can occur at any size, even though the term is commonly associated with low body weight.

So, even if someone gets the calories they need (or more), they can be malnourished if their diet lacks essential nutrients for proper functioning. For example, a diet rich in highly processed foods like burgers and fries can provide immediate energy and fat reserves, but there is no nutritional value. Losing weight rapidly (5-10% of body weight) within 3-6 months is also considered malnourishment.

Being obese or overweight can also result in malnutrition when hormonal imbalances interfere with nutrient absorption from food.

Malnutrition can lead to vitamin deficiencies, extreme fatigue, dizziness, weakness, loss of muscle mass, dry skin, and more.

Why does treatment for atypical anorexia recommend gaining weight, even at an average weight?

The first step to recovery is to restore electrolyte balance and fix vital sign abnormalities.

Treatment for atypical anorexia may start with controlled weight gain or weight restoration. This may be surprising to some considering that people with atypical anorexia are often in a normal weight range or overweight.

It's natural to think, "Why would my doctor tell me to gain weight when I am not underweight?"

Weight restoration is a part of treatment because people with atypical anorexia often arrive at the doctor's office with malnutrition, regardless of the number on the weighing scale.

Malnutrition can result in severe electrolyte abnormalities, including low potassium, sodium, magnesium, and phosphorus (among others). The use of laxatives, diet pills, purging, and other methods to lose weight may have also wreaked havoc on electrolyte balance.

How do you know if you or a loved one has atypical anorexia?

It is difficult to detect a 'hidden illness' like atypical anorexia. But to help yourself and others, the first step is to shed misconceptions about eating disorders. Understand that anyone, at any weight, can have anorexia (or another eating disorder).

If you feel that you, a friend, or a loved one is increasingly hesitant about eating around others, there may be a risk of an eating disorder. You may watch out for early signs of malnutrition, like fatigue and dizziness.

If you suspect that a loved one is battling anorexia, avoid shaming them for their disordered eating. Also, it is essential to approach them with compassion, tell them they are loved, and listen to their story. Reach out to an expert and learn more.

How do you get treatment for atypical anorexia? Fay can help.

While recovery can be hard, breaking free from your eating disorder can be worth it.

Eating disorder recovery involves a multidisciplinary team of a healthcare provider, therapist, and Registered Dietitian.

You do not have to wait until your health deteriorates or others consider you "sick enough" to get help. If you would like to talk to someone about atypical anorexia, Fay can connect you to a Registered Dietitian who specializes in eating disorder recovery.

The views expressed by authors and contributors of such content are not endorsed or approved by Fay and are intended for informational purposes only. The content is reviewed by Fay only to confirm educational value and audience interest. You are encouraged to discuss any questions that you may have about your health with a healthcare provider.