Should Weight Be a Factor in Diagnosing Anorexia Nervosa?

When you picture someone struggling with anorexia, who do you see? For most of us, our mind conjures up the image of an emaciated white teenage girl. This is the depiction that we have seen over and over again in movies, television shows, textbooks, and almost all forms of media. Anorexia has long been characterized by thinness. But despite what we have been taught, anorexia occurs across the weight spectrum.

Atypical anorexia nervosa (AAN), also called “higher weight anorexia,” is currently included in the DSM-V under the Other Feeding and Eating Disorder (OSFED) diagnosis. It is used to diagnose people who meet all the criteria for anorexia nervosa (AN) but are not underweight. A recent research review by Harrop et al (2021) published in the International Journal of Eating Disorders suggests that atypical anorexia is two to three times more common than “typical” anorexia nervosa. Despite the fact that AAN is far more common than AN, people with AAN are far less likely to receive treatment for their eating disorder (between 1.5 to 17 times less likely than people with AN). This discrepancy is not due to differences in illness severity because research suggests that people with AAN and AN have similar medical concerns, cognitive symptoms, eating disorder behaviors, clinical impairment, symptom presentation, symptom severity, and require similar care.

Why are people with “atypical anorexia” so much less likely to receive eating disorder treatment than their thinner peers, despite being equally sick? And why differentiate the two groups in the first place?

In my opinion, it has a lot to do with the systemic weight biases that are woven into our culture. Let’s start with some common assumptions that people tend to make (and just to be clear, these assumptions are steeped in fatphobia and are not true):

1. Being fat is the result of eating too much.
2. If people ate less, they would be thin.
3. If people starved themselves (as is characteristic of anorexia) they would be very thin.
4. Therefore, if you are fat, you must not really have anorexia.

This line of thinking (which is completely unsupported by science) leads to the conclusion that only low-weight anorexia warrants treatment while people in larger bodies who have the same exact symptoms are told that they aren’t sick enough—or even worse, their weight loss efforts are encouraged and applauded. This compromises recovery for people in larger bodies with anorexia because the illness is often more progressed and more difficult to treat by the time that they finally do get help, if they get treatment at all. The different diagnoses also lead to more weight-based discrimination in the medical system, as insurance may not cover treatment costs for an OSFED diagnosis or only cover shorter durations of treatment.

“Atypical anorexia nervosa” is a diagnosis steeped in fatphobia. I really hope that when the next team of experts convenes to create the 6th edition of the DSM, they will examine their own fatphobia (we all have it!) and consider dropping the weight criteria from the anorexia diagnosis completely.