Being classified as ‘underweight’ is one of the requirements of an anorexia nervosa diagnosis, which means many people with disordered eating are slipping through the cracks
If you’re worried about your own or someone else’s health, you can contact Beat, the UK’s eating disorder charity, on 0808 801 0677 or beateatingdisorders.org.uk
Adam, 27, first showed signs of an eating disorder at 12. His weight remained stable despite other overt signs that his body was in crisis – he had early-stage kidney and bowel problems and was not developing testosterone. “No one ever worried,” he says, because he was never underweight and so his eating disorder slipped under the radar. His body has been permanently damaged in the process.
At 23, Adam was diagnosed with ‘atypical anorexia’. It is characterised by all the same behaviours as anorexia nervosa: caloric restriction, disordered eating and psychological markers such as an intense fear of gaining weight, and body image distortion and preoccupation. However, to receive a ‘typical’ anorexia diagnosis, you must have a body mass index (BMI) that classifies you as ‘underweight’. Never mind that BMI is famously a deeply flawed indicator that fails to account for differences in race, gender, age, or muscle mass – the size of the body is diagnosed instead of the behaviour.
With atypical anorexia, although what you do, think and feel is the same, you may not have lost weight, or not enough weight to present as emaciated. The ‘atypical’ label declassifies the disorder as not yet dangerous, pushing the patient down the risk matrix. The premise of treatment is therefore the worst-case scenario: waiting until the patient’s BMI drops to a threatening level for action to be taken.
This course of action would be harmful for any medical condition, but is particularly damaging when it comes to eating disorders. “Your mind is already constantly telling you that you are not sick enough – perhaps not even sick at all. So telling someone that they have to be skinnier in order to be taken seriously and to receive help encourages them to get sicker. It makes them want to prove that they are struggling,” says Taylor*, 21, who has been diagnosed with atypical anorexia. “Eating disorders, especially anorexia, are so competitive. You constantly compare yourself to others who are struggling. As if the one who gets the sickest wins. It would be incredibly helpful if doctors would not participate in this ’competition’ by only treating the one who has the lowest BMI.”
15-year-old Aurora had a similar experience to Taylor* after receiving a diagnosis at 12. “Having a weight requirement for anorexia only fuels the motive to lose weight even further,” she says. “It’s very damaging, especially because the disorder is so focused on the sufferer’s perception of their body.”
In our culture, where thinness has long been idealised, disordered eating becomes uniquely permissible for those who are not already thin. From friends and family to medical professionals, when a person with a larger body loses weight it is rewarded as a universal moral good – no matter the price. “Someone in a fat body could lose half their body weight before people even think it’s a concern,” says Erin Harrop, a researcher and clinical social worker with personal experience of atypical anorexia, on the podcast Maintenance Phase. “For most of that time, people are going to be congratulating them.”
Fatphobia is rife in our society – we live in a country where fat-shaming is actively encouraged in newspapers as the only fix for the so-called ‘obesity crisis’. The medical sphere is not immune to this – anti-fat bias has been a recorded preoccupation of NHS doctors as recently as last year. “Weight stigma makes reaching out for help even more difficult, as people can worry they won’t be taken seriously if they haven’t lost weight as part of their eating disorder,” says Tom Quinn, the director of external affairs at eating disorder charity Beat.
According to Quinn, despite NICE guidelines stating that an eating disorder cannot be defined by BMI alone, Beat knows plenty of people who have been turned away from treatment because of their weight. “This stigma can worsen eating disorder thoughts and behaviours and make it much more difficult to recover.” As a result, people with atypical anorexia report more severe psychological symptoms than those without an elevated BMI.
Amidst this backdrop, the term ‘atypical’ is alienating and exclusionary. Taylor* describes receiving the diagnosis as “humiliating”. Adam finds the wording similarly unhelpful. “Every single eating disorder diagnosis is atypical because there is no typical,” he says. The idea that there is only one profile of anorexia flattens the “melting pot of what influences someone’s risk factors and receptiveness to treatment.” For Adam, who has ADHD and autism, his co-occurring disabilities are an important part of the picture of his eating disorder that is not considered by BMI alone.
“Eating disorders are mental illnesses, not physical conditions, and it’s crucial that GPs can spot the behavioural and psychological signs” – Tom Quinn
Meanwhile, LGBTQ+ people also suffer from eating disorders at a proportionally higher rate. For trans and non-binary people, who are two to four times more likely to experience an eating disorder, this can be a way of coping with body and gender dysphoria.
Looking beyond the reductive and binary categorisation that currently exists, many advocate for an anorexia spectrum diagnosis to better accommodate the diverse contexts and needs of different people. Speaking to Dazed, Harrop says they are in favour of this approach, arguing that a diagnosis should not rely on “arbitrary” and “ever-changing” weight classifications. Instead, the best course of action is to make sure “weight is only one part of the picture, alongside other physical markers of starvation (such as losing a period) and psychological and behavioural markers: how much a person is restricting and their rate of weight loss, as well as other factors that hugely increase risk, such as purging.”
Beat’s Quinn affirms this: “Eating disorders are mental illnesses, not physical conditions, and it’s crucial that GPs can spot the behavioural and psychological signs in their patients.” For this to work, he says, believing patient testimony is tantamount. “It’s crucial that eating disorder professionals ensure people feel validated in their illness regardless of their weight or shape.”
Ultimately, we should be looking at any self-deprivation or self-starvation as a medical concern, regardless of what the body of the person suffering looks like. And treating everyone who presents the symptoms with respect and equal importance. As Taylor* says, “it’s absolutely essential to validate the patient’s feelings and reassure them that they are in fact sick enough and deserve to receive help.”
