Anorexia Nervosa in Individuals of Higher Weights

Restrictive Eating Disorders in Normal and Higher Weight Individuals

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It has historically been assumed that individuals with Anorexia Nervosa look emaciated and have a very low weight. In fact, until the most recent edition of the diagnostic manual used to diagnose the illness, one necessary criterion was “weight less than 85% of that expected.” What is less widely recognized is that restrictive eating disorders, those characterized by dietary restriction or weight loss, can manifest in individuals at higher weights.

In my own clinical practice, I have seen individuals at weights that would usually be considered “normal” who have had restrictive eating disorders, complete with amenorrhea (missed menstrual periods), which can be a common side effect to a reduction from ideal body weight. According to my patients’ reports, their prior doctors never appeared to consider that the amenorrhea was due to dietary restriction. These doctors seemed to pursue numerous other potential causes for the patient’s lack of menstrual period and failed to diagnose them with an eating disorder.

In a society with shows such as “The Biggest Loser” that promote extreme weight loss (and eating disordered behaviors), the ramifications of this ignorance can be widespread. Kai Hibbard, a winner on “The Biggest Loser,” has come out about her disordered eating and the medical consequences that resulted from her extreme weight loss.

About her experience on “The Biggest Loser”, Kai Hibbard reported

So I got to a point where I was only eating about 1,000 calories a day and I was working out between 5 and 8 hours a day . . . And my hair started to fall out.  I was covered in bruises.  I had dark circles under my eyes.  Not to get too completely graphic, but my period stopped altogether and I was only sleeping 3 hours a night.

Her lowest BMI (at the end of the show) was 23.2, which is considered within the “normal” range of between 18.5 and 24.9.

Lebow and colleagues reviewed 179 intake evaluations for adolescents who presented for eating disorder evaluations at the Mayo Clinic. All adolescents were seeking help for a restrictive eating disorder, characterized by weight loss and/or dietary restriction. The findings revealed that those with a history of being overweight, when compared to individuals without this history:

  • Presented with a weight status in a range traditionally considered “healthy” (BMI between 18.5 and 24.9) at the time of seeking treatment;
  • Had experienced a greater drop in BMI;
  • Had been ill for about 10 months longer; and
  • Had eating disorders that were just as severe in terms of common symptoms, rates of amenorrhea, and number of reported physical symptoms.

Though some adolescents and children (and likely even adults too) may appear to be at healthy or normal weights, if they are experiencing an eating disorder or disordered eating, they can be significantly physically or emotionally impaired.

For example, other research has demonstrated that patients who lost a larger percentage of their baseline BMI had medical problems as serious as those of patients who presented at a lower BMI but who had lost less weight overall.

There are significant implications to these findings:

  • Many serious eating disorders may go undetected because we have become too focused on absolute weights as barometers for health.
  • Physical complications of semi-starvation and weight loss – red flags in a low-weight individual – are often overlooked in higher-weight patients.
  • A BMI that falls into the higher weight categories is normal for some individuals. These people may need support from professionals in learning to accept a body weight that is higher than the culture at large considers desirable.
  • Even in the absence of low weight, practitioners should remain attuned to physical consequences of malnutrition or eating-disordered thoughts and behavior.
  • When assessing an individual with eating symptoms and/or weight loss, providers should consider an adult’s weight history (or in the case of an adolescent, the full developmental growth curve) rather than a single data point.
  • Individuals with a history of being overweight can suffer from an eating disorder for longer before it is identified. Given that early identification is the best predictor of full recovery from an eating disorder, greater attention needs to be paid to this population.

Both in health care settings and society at large, an obese or overweight individual’s weight loss is often seen as a positive. However, it may place the person of higher weight at risk for developing a restrictive eating disorder. In general, science supports that extreme dieting should be discouraged. Furthermore and most fundamentally, it is important to remember that eating disorders can happen to a person at any weight.

Another recent article about this topic can be found here.


Lebow, J., Sim, L., & Kransdorf, L. (2014). Prevalence of a History of Overweight and Obesity in Adolescents With Restrictive Eating Disorders. Journal of Adolescent Health, 19-24.    

Neumark-Sztainer, D. (2015).  Higher Weight Status and Restrictive Eating Disorders:  An Overlooked Concern. Journal of Adolescent Health, 56, 1-2.

Peebles, R., Hardy, K., Wilson, J., and Lock, J. (2010) Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics, 1193–1201

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