Can You Have an Eating Disorder Without Being Underweight?
One of the most harmful myths about eating disorders is that they are only serious when someone is underweight. In reality, eating disorders cause significant physical and emotional harm at any body size.
Someone may live in a smaller, mid-size, or larger body and still experience severe restriction, binge eating, purging, compulsive movement, food anxiety, or an overwhelming preoccupation with food and weight.
In fact, someone can appear “healthy” to the people around them while experiencing significant physical and emotional consequences. You cannot tell whether someone has an eating disorder simply by looking at them.
Your appearance doesn’t tell us whether you’re eating enough, how distressed you feel around food, or how much your eating disorder is interfering with your life.
Eating disorders are not defined by appearance
Eating disorders are serious mental and physical health conditions involving disturbances in eating behavior. They affect a person’s physical health, emotional well-being, relationships, and ability to function in daily life.
Eating disorder diagnoses include:
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Avoidant/restrictive food intake disorder, or ARFID
Other specified feeding or eating disorder, or OSFED
Unspecified feeding or eating disorder
Pica
Rumination disorder
What is “atypical” anorexia?
“Atypical” anorexia nervosa is an eating disorder diagnosis included within the OSFED category.
A person with “atypical” anorexia experiences all the same features of anorexia nervosa, such as significant dietary restriction, an intense fear of weight gain, and behaviors that interfere with adequate nourishment. However, their current weight is not classified as “significantly low.”
The word atypical is misleading, and it doesn’t mean the eating disorder is unusual, mild, or less deserving of treatment.
Someone with “atypical” anorexia may have:
Lost a significant amount of weight
Become intensely fearful of gaining weight
Cut out foods or entire food groups
Developed rigid rules about eating
Exercised despite exhaustion, pain, illness, or injury
Experienced intense guilt after eating
Become preoccupied with calories, weight, food, or body shape
Developed medical complications related to inadequate nourishment
Their body may still be average-sized or larger because people begin at different weights and bodies respond differently to restriction. Looking only at someone’s current weight can therefore conceal the extent of their malnutrition, weight loss, eating disorder behaviors, and medical risk.
You do not have to “look sick” to be medically unwell
People sometimes assume that eating disorder complications only occur at very low weights. Research does not support that assumption.
A 2023 systematic review and meta-analysis of medical instability in typical and atypical adolescent anorexia nervosa found that adolescents can experience medical instability even when they are not underweight. The review examined complications including slow heart rate, low blood pressure, low body temperature, and low phosphorus levels.
Another study comparing adolescents with anorexia nervosa and atypical anorexia found that atypical anorexia was associated with substantial physical and psychological health concerns, despite participants presenting at or above what was classified as a “normal” weight. The researchers found little evidence that atypical anorexia was less severe than full-threshold anorexia.
Possible consequences of restriction, purging, binge eating, or other eating disorder behaviors can include:
Dizziness or fainting
Fatigue and weakness
Difficulty concentrating
Heart rate or blood pressure changes
Electrolyte abnormalities
Digestive problems
Feeling cold frequently
Sleep disruption
Hormonal changes
Menstrual changes
Reduced bone density
Anxiety, irritability, or depression
Increased food preoccupation
Social withdrawal
Difficulty functioning at work, school, or home
Not everyone will experience the same symptoms. Normal lab results also do not automatically mean that a person is adequately nourished or that their eating disorder is not serious.
Weight loss is not proof that a behavior is healthy
One reason eating disorders in larger bodies are missed is that restrictive behaviors may be praised rather than recognized as concerning.
Friends, family members, and even healthcare providers may congratulate someone for losing weight without asking how that weight loss happened.
Behaviors may be described as “discipline,” “clean eating,” “wellness,” or “getting healthy,” even when the person is:
Skipping meals
Eating far too little
Feeling unable to rest
Avoiding social situations involving food
Experiencing constant anxiety about eating
Bingeing after periods of restriction
Vomiting, using laxatives, or engaging in other compensatory behaviors
Feeling that their self-worth depends on their weight
Behaviors should not be considered healthy in one body and dangerous in another, and eating disorder risk cannot be determined by whether a person’s weight loss is socially acceptable.
Higher-weight people often face delays in diagnosis and treatment
Weight stigma can make it more difficult for people in larger bodies to be recognized as having an eating disorder.
A study of college students found significant disparities in eating disorder diagnosis and treatment according to weight status, along with disparities related to race and ethnicity, socioeconomic background, and sex. Among students experiencing eating disorder symptoms, those with a history of higher weight were less likely to report receiving an eating disorder diagnosis.
Healthcare professionals may overlook concerning behaviors because a patient is not thin. In some cases, patients may even be encouraged to continue restricting or losing weight despite reporting symptoms of an eating disorder.
Eating disorders are serious conditions, and early identification can help someone access appropriate medical, psychological, and nutrition support sooner.
Eating disorders are about more than weight loss
Not every eating disorder involves a desire to become thinner.
For example, a person with ARFID may restrict their intake because of:
Sensory sensitivities
Low interest in food
Fear of choking
Fear of vomiting
Fear of having an allergic reaction
Fear of digestive discomfort or other consequences of eating
A person with binge eating disorder may experience episodes of eating accompanied by significant distress and a sense of being unable to stop. Someone with bulimia may binge and engage in compensatory behaviors while their body weight remains relatively stable. Others may alternate between restriction, binge eating, purging, and compulsive exercise without neatly meeting the criteria for one diagnosis.
Eating disorders are identified by the full pattern of behaviors, thoughts, physical symptoms, and impairment, not simply by a number on the scale.
Signs you may need support
You don’t need to diagnose yourself before asking for help.
It may be useful to speak with an eating-disorder-informed professional if you notice that:
Food takes up a significant amount of your mental energy
You frequently skip meals or delay eating
You have become increasingly rigid about what, when, or how much you eat
You feel guilty, ashamed, or anxious after eating
You binge or feel out of control around food
You vomit, use laxatives, fast, or exercise to compensate for eating
You avoid events because you do not know what food will be served
You are afraid of weight gain or body changes
You struggle to eat enough because of sensory needs, nausea, low appetite, or fear
Your eating habits are affecting your relationships, concentration, mood, or physical health
You feel like you are not “sick enough” to deserve care
Feeling that you are not sick enough is not evidence that you’re fine. It may be one of the ways the eating disorder discourages you from seeking support.
What if my provider is focused on my weight?
It can be difficult to describe eating disorder symptoms when you’re worried that your concerns will be dismissed or reframed as a need for weight loss.
You might say:
“I’m concerned about my eating behaviors and how much anxiety I experience around food. I’d like us to focus on those symptoms rather than assuming weight loss is appropriate for me.”
Or:
“My intake has become increasingly restrictive, and I’m experiencing dizziness, fatigue, and food preoccupation. I would like an eating disorder assessment.”
You can also ask:
“What evaluation or treatment would you recommend if a thinner patient reported these same symptoms?”
A thorough eating disorder assessment should look beyond BMI. It may include your eating patterns, recent and historical weight changes, compensatory behaviors, exercise, physical symptoms, mental health, medical history, and the degree to which food concerns are affecting your life.
You deserve care before things get worse
You don’t have to wait until you are underweight, medically unstable, or unable to function before seeking help.
You don’t have to prove that your relationship with food is “bad enough.” If eating feels frightening, chaotic, rigid, exhausting, or all-consuming, that is valid enough reason to seek help.
At CV Wellbeing, our dietitians provide compassionate, weight-inclusive nutrition counseling for people with eating disorders and disordered eating. We look at the whole picture rather than using body size as a measure of whether someone deserves support.
Eating disorders do not have a look, and recovery is not reserved for people in certain bodies. Reach out for help today.
References
Brennan, C., Illingworth, S., Cini, E., & Bhakta, D. (2023). Medical instability in typical and atypical adolescent anorexia nervosa: A systematic review and meta-analysis. Journal of Eating Disorders, 11, 58.
National Institute of Mental Health. Eating Disorders: What You Need to Know.
National Institute of Mental Health. Let’s Talk About Eating Disorders.
Sawyer, S. M., Whitelaw, M., Le Grange, D., Yeo, M., & Hughes, E. K. (2016). Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics, 137(4).
Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6), 518–526.