Anorexia patients of normal weight can be just as ill as patients who are severely underweight


Anorexia patients with normal body weights can be just as ill as patients who are severely underweight, doctors have warned. 

Despite looking a relatively healthy weight on the outside, such patients may have a a dangerously low heart rate and blood pressure.

Researchers have now said the rate at which anorexia patients lose weight is far more dangerous than how much weight they lose. 

They warned such patients may not be be spotted because their disorder is masked by their body weight, meaning they aren’t receiving crucial treatment.

And experts also said overweight patients may be praised for losing weight, without anyone knowing they are ill.  

Anorexia patients with normal body weights can be just as ill as patients who are severely underweight, doctors have warned. They have drastic and sudden weight loss, and restrict food, but are not dangerously low in weight (stock image)

Anorexia patients with normal body weights can be just as ill as patients who are severely underweight, doctors have warned. They have drastic and sudden weight loss, and restrict food, but are not dangerously low in weight (stock image)

The research, led by Stanford University School of Medicine, is the largest study of normal-weight adolescents with anorexia.

It compared 50 patients with atypical anorexia nervosa against 66 people who met the traditional diagnostic criteria.

Atypical anorexia nervosa was formally recognised in 2013 and is diagnosed in patients who don’t have the usual low body weight synonymous with the disorder. 

Participants were aged between 12 and 24 and almost all were female. They all got treatment for their eating disorder during the study. 

Patients in both groups lost the same amount of weight – 30lbs (13.6kg) – over a year and four months.  


When people think of anorexia, they normally think of a person of extremely low weight.

However, a person with atypical anorexia nervosa does not have this symptom of the disease.

In 2013, the American Psychiatric Association added atypical anorexia nervosa to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The DSM is used worldwide and contains sets of diagnostic criteria to help clinicians diagnose mental health problems. 

Atypical anorexia has all the criteria of anorexia met, except despite significant weight loss, the individual’s weight is within or above the normal range.

According to the DSM-5 criteria, to be diagnosed with either atypical anorexia or tradition anorexia, they must have:

  • Persistent restriction of energy intake (in the case of anorexia, leading to significantly low body weight)
  • Either an intense fear of gaining weight or of becoming fat or persistent behaviour that interferes with weight gain (even if significantly low weight)
  • Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the potentially low body weight

Sometimes atypical anorexia is considered an ‘other specified feeding or eating disorder’ (OSFED).

Like any other eating disorder, OSFED is a very serious mental illness that is not only about the way the person treats food but about underlying thoughts and feelings, the eating disorder charity Beat states. 

Dr Andrea Garber, study lead author from University of California-San Francisco, said more research is needed to identify a weight considered healthy for those patients recovering from atypical anorexia nervosa.

She said: ‘If a patient was obese, the goal is not to have them regain all the lost weight.

‘If someone gains a bit of weight, regains menses, and is doing well socially, emotionally and cognitively, that might indicate that they are in a place of recovery.’

However, those with atypical anorexia were still within a normal weight for their height.


The researchers found both groups had equally poor vital signs, including low heart rate. A slow heart rate can cause frequent fainting, heart failure and sudden cardiac arrest or death.

They equally had low electrolytes, chemicals in the blood which can drop due to a poor diet. 

An imbalance causes weakness and, if untreated, can lead to seizures and potentially fatal heart rhythm disturbances.

Equal numbers of patients in the two groups were no longer having periods, signalling a failure of normal hormonal functions which also causes fragile bones.

Dr Neville Golden, study senior author, said: ‘Our study showed they [patients with atypical anorexia] can be just as sick medically and psychologically as anorexia nervosa patients who are underweight.

‘This group of patients is underrecognised and undertreated.’

Some members of both groups also had very low blood pressure, although this was more common in the patients with typical anorexia. 

Atypical patients also had worse psychological symptoms, such as low self esteem and OCD, on average.

The researchers determined which factors best predicted illness severity by using a statistical model.

The amount, speed and duration of weight loss were linked with worse illness, while body weight at the time of diagnosis was not, they found. 

On the back of the findings, experts said GPs may fail to identify symptoms, such as dizziness and absent periods, as an eating disorder in patients who are not underweight.

Arti Dhokia, of Priory’s Woodbourne Hospital in Birmingham, told MailOnline: ‘Although awareness of eating disorders amongst doctors is increasing, the “markers” and “red flags” used are often associated with low weight.

‘When anorexia nervosa is mentioned, images of emaciated bodies, protruding bones and wasted muscles come to mind. 

‘Atypical presentations are varied, and aren’t as easily identified. Patients who were previously overweight or obese may have experienced extreme weight loss, but still have a healthy BMI for example.’ 

Leading UK charity Beat said: ‘We welcome these findings as it furthers a growing bank of evidence that weight, or BMI, should not dictate how ill someone is deemed to be.

‘You cannot tell whether someone is unwell simply by looking at them, and it is crucial to break the stigma that only very underweight people can have anorexia. 

‘Healthcare professionals sometimes fail to spot eating disorders and this is often exacerbated in patients who are not underweight.’  

Dr Andrea Garber, the study lead author from University of California-San Francisco, implied teenagers who are overweight or obese are vulnerable to adopting unhealthy ways of losing weight.

She added: ‘Teens are being told to lose weight without being given tools to do so in a healthy way.

‘By the time they get to see us, they’ve lost a tremendous amount of weight, their vital signs are unstable and they need to be hospitalized.’

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