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Atypical anorexia may not even be a term you’ve heard before. But Erin Harrop, an assistant professor at the University of Denver Graduate School of Social Work and one of the only atypical anorexia researchers in Colorado, believes it needs more attention—and a new label, to boot. In time for National Eating Disorders Awareness Week February 27 through March 5, here’s what you need to know about the not-so-atypical disorder, how Colorado culture may play into it, and how you can support those affected.
What is atypical anorexia?
According to Harrop, atypical anorexia (AAN) is essentially the same as anorexia nervosa (AN)—the official medical term for the eating disorder characterized by restricted energy intake, fear of weight gain, and body image disturbance. But atypical patients don’t have low body weight, barring them from a diagnosis of “typical” AN.
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In almost all other senses, AAN is not “atypical:” AAN may affect up to 2.8% of American women by the age of 20, and multiple studies suggest that AAN is two to three times more common than AN. Moreover, the number of Coloradans diagnosed with AAN is rising, with the state’s exercise-oriented culture, the COVID-19 pandemic, and increasing medical awareness of the disorder all potentially playing a part.
Still, the DSM-5, the official diagnostic manual for mental disorders in the United States, defines anorexia’s first criterion as a “restriction of energy intake relative to requirements, leading to a significant low body weight.” While there is no strict definition for what counts as low body weight, the DSM does use body mass index (BMI) to indicate the severity of an individual’s anorexia, from mild (BMI ≥ 17) to extreme (BMI < 15). The system means that people with higher BMIs are excluded from a diagnosis of AN, and Harrop, who has personally suffered from both AN and AAN, believes that this causes more harm than good.
“AAN and AN are the only diagnoses in the DSM where we are actually using a biomarker [rather than exclusively behavioral and psychological symptoms] to tell the difference between what is happening with a [mental disorder],” they say. The professor also notes that decades of research have shown that BMI is not always an accurate measure of fatness or healthy weight.
While providing pediatric mental health care as a medical social worker at Seattle’s Children Hospital, Harrop became motivated to pursue AAN research after routinely seeing heavier patients with severe eating disorders being denied care because of their weight. “Basically we would send them home and be like, ‘Come back when you’re thinner,’ ” Harrop says. “Obviously if you have an eating disorder, that is the exact opposite of the message that you need to be receiving.”
The numbers back up the anecdote. Despite AAN having similar physical risks as AN (such as slow heart rate, bone loss, and absent menstruation), Harrop found in their 2020 dissertation work that AAN patients wait an average of 11.6 years after symptom onset to receive treatment versus two to three years for AN patients. And when they receive treatment, AAN patients often report medical providers making their eating disorder worse—sometimes going as far as encouraging further caloric restriction or calling AAN patients “lazy” or “noncompliant,” Harrop says.
Harrop believes the term “atypical” itself is partially to blame for the differential treatment, both in the medical sense and in that it invalidates and otherizes those with the disorder. In addition, the DSM currently labels AAN as an “other specified feeding or eating disorder,” which in Harrop’s words is a “garbage bucket” diagnosis that encompasses a wide range of disordered eating experiences that don’t fit into any clinical definitions. This not only makes receiving specialized care more difficult, but also limits insurance coverage.
With AAN diagnoses rising in Colorado, it’s all the more important for the general public to understand that the true difference between AAN and AN isn’t in how severe the disorder is, but in how difficult it is to access the tools to get better.
Colorado culture plays into higher-weight eating disorders
Patrick Devenny, a former Colorado Buffaloes football player who has struggled with binge eating and bulimia and is now a mental health advocate, knows that weight stigma is not new for Colorado, and that it especially harms those suffering with eating disorders.
“If I go out in Boulder, and I’m super strict on my diet, and I’m running 27 miles a day, and I have four percent body fat, people will look at me and say, ‘Wow, I wish I had your discipline,’ ” Devenny says. “What’s really happening [is that I’m] getting applauded, but at the same time living in mental hell.”
Colorado has a strong culture of performance and athleticism, and Devenny says that, as a hotbed for endurance sports and outdoor activities, this creates a “slippery slope [into] disordered eating.” Indeed, Harrop says that a Boulder-based participant in their ANN research spoke at length about how focused residents of the Denver and Boulder areas are on fitness, nutrition, and weight loss. When this focus becomes an unhealthy obsession, it’s called orthorexia, and it can drive disordered eating and poor body image.
Orthorexic tendencies were part of Devenny’s former football days. He says that athletes often maintain strict diet regimens in the name of better performance—but it might not be for the best. “I genuinely think, in the locker room, more than half [of people] have disordered eating,” he says.
While there is conflicting evidence on whether AAN is more prevalent than AN in males (most AAN studies’ test populations are over 90 percent female), one 2019 study found that, unlike in female patients, AAN disproportionately affects younger male patients. This could be influenced by male body image standards, which Devenny describes as an “unrealistic reality” that encourages not only disordered dieting, but also HGH (Human Growth Hormone) or steroid usage to increase muscle mass.
In the end, weight stigma in America’s slimmest state not only impacts eating disorders, but also how larger-bodied people participate in fitness. Harrops says that they often don’t feel safe in traditional fitness spaces, leading to the development of local fat activity groups like Fat Aces and Fat Babes in the Wild to provide a comfortable community for members to exercise with. “It’s wonderful to have an emphasis on health and fitness. That’s great,” they say. “When it goes over to that orthorexia place or when it becomes exclusionary…[it can send the message that] maybe you’re less welcome in those spaces.”
How to help atypical anorexia patients
Harrop believes there’s a number of tenets that people should implement to support AAN patients. First, acknowledge that anorexia happens in all body sizes. Don’t assume that weight loss or dietary restriction is necessarily a good thing for higher-weight people, and keep an eye on the health of your loved ones, no matter their size.
Second, don’t congratulate others on weight loss, since it could be caused by an eating disorder (or other mental and/or physical condition). Harrop personally asserts that when they were in the throes of their eating disorder, receiving compliments on their weight loss did not help in their recovery. Focus your compliments on others’ emotional or interpersonal strengths, rather than their appearance.
Third, take the blame of eating disorders off of the individual. Numerous social factors—fitness and diet culture, beauty standards, racial and ethnic stigma—influence eating disorders, so don’t be hard on those suffering and double down by assuming it’s their fault.
Lastly, both Harrop and Devenny say that it’s important for eating disorder patients and those around them to understand that recovery takes time, and that symptoms often do not improve linearly. “It’s a marathon, not a sprint,” Devenny says.