you can't tell if someone has an eating disorder just by looking at them
atypical anorexia is pretty typical
When I was first diagnosed with an eating disorder, I laughed. Loudly and defiantly.
“No, you don’t understand. That’s not what is going on here,” I said to my therapist.
“Why don’t you tell me what you think is going on?” she asked in an irritatingly calm voice.
So, less calmly, I explained: I couldn’t have an eating disorder because I definitely was not underweight. In fact, I thought my body was bigger than it ‘should be.’ I just wanted to be told what to eat and what to do in order to get to my ideal body size.
I can now see how flawed my argument was, but it took a while for me to see the truth: I had an eating disorder.
I am in recovery for atypical anorexia. It is classified under Otherwise Specified Feeding and Eating Disorders (OSFED) in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). To be diagnosed with atypical anorexia, a person must meet all of the criteria for anorexia nervosa, *except* for a low body weight. Those other criteria include:
Dr. Jennifer Gaudiani writes in her book “Sick Enough: A Guide to the Medical Complications of Eating Disorders,” that atypical anorexia is actually pretty typical.
“Atypical anorexia is by far more prevalent than anorexia nervosa, occurring in up to 3 percent of the population in one large study” Gaudiani writes.
“Less than 6 percent of people with eating disorders are medically diagnosed as ‘underweight,’” said the Eating Disorder Center in a recent Instagram post.
Other eating disorder diagnoses include Bulimia Nervosa, Binge Eating Disorder, and Avoidant Restrictive Food Intake Disorder.
Q: if it’s so common, why is it called “atypical” anorexia?
A: weight stigma
Gaudiani says that, in her experience, “many individuals with atypical anorexia nervosa don’t believe they have an eating disorder because they aren’t stereotypically emaciated.” That is then perpetuated by society and medical providers who praise patients for weight loss, “when, in fact, the behaviors being used are the opposite of healthy.”
In my case, this was true. My argument with my therapist that day was completely warped by the lies my eating disorder told me and the confirmation from society it was all true. Throughout my life, my disordered eating behaviors were normalized and sometimes even praised. When I lost a little bit of weight, I was told I looked good. When I gained weight, I was ridiculed and critiqued by strangers, doctors, classmates, and loved ones, though it was often the silence from those who had previously praised me that felt unbearably loud.
Because I was curvy and never clinically underweight, I (and those around me) failed to see the early signs that I was actually struggling. I obsessed over my body and body-checked often. I meticulously counted calories, points, steps and pounds. I avoided eating until I couldn’t stand it anymore, then binged on whatever was in my kitchen cabinet. I over-exercised. I tied my worth to my appearance.
Eventually, I developed serious physical symptoms, without ever having a “significantly low body weight.” My hair fell out. I had vitamin deficiencies. I had no energy. I had digestive problems. I was irritable. My bones ached. My period stopped.
how can that be?
In her book, Dr. Gaudiani explains this phenomenon as an evolutionary survival mechanism. She argues our bodies cannot tell the difference between a famine and intentional restriction, and it does whatever it can to protect us. Sometimes that means maintaining our weight.
“When a person consumes too few calories, the cave person brain decreases their metabolic rate so that fewer calories are burned. It does this by slowing down our heart rate, lowering our blood pressure, slowing our digestion, reducing blood flow to our hands and feet, and decreasing our feeling of energy to get things done, in order to make us hold still and conserve energy. This increases the likelihood that the person will survive until food is again available. In addition, the cave person brain fiercely strives to maintain our body weight,” Gaudiani writes.
This can also be applied to dieting or binging. Your body doesn’t know when it is on an intentionally restrictive diet. So when you stop dieting or restricting, your body may gain back the weight you lost, plus some, in order to protect itself from a future famine.
“After prolonged deprivation, feeling ravenous and eating more calories than the body needs for energy is biological, not a lapse of willpower,” says Gaudiani.
Gaudiani says that when people don’t immediately experience weight loss or other physical symptoms from starvation, they have ‘survivor’ genes; their bodies are “remarkably effective at defending their bodies from starvation.”
I was told I had ‘survivor genes’ quite a bit in residential treatment. At the time, I resented it and would get really angry over it. Now, in my recovery, I feel so much gratitude for the strength and resilience of my body. Despite all of my restriction, my body did everything in its power to keep me alive.
where do we go from here?
Anorexia nervosa in the only eating disorder in the DSM-5 that has a criterium of low body weight. Eating disorder experts have advocated for the removal of any mention of body size or weight in diagnostic criteria. There has also been a push to merge anorexia nervosa and atypical anorexia into one eating disorder diagnosis, since bodies can react so differently to the same set of circumstances. Separating the diagnoses reinforces weight stigma. It can perpetuate the idea that 1) one diagnosis is worse than the other or 2) you are not “sick enough” if you have a higher body weight. Which, as I can tell you from my own experience, is not true.
I think it is important to learn the philosophy of Health At Every Size® or HAES®. Medical and mental health providers should especially understand that health can look differently on every body, and weight should not be a sole determinant of health. You can find HAES-informed providers here.
If you want to learn more about eating disorders in people of all shapes and sizes, or about the negative impacts of diet culture and weight stigma, here are some books and articles I recommend:
Empty: A Memoir by Susan Burton
Hunger: A Memoir of (My) Body by Roxane Gay
Tess Holliday Reveals She’s ‘Anorexic and in Recovery’ by Carolyn L. Todd in SELF
You Have the Right to Remain Fat by Virgie Tovar
Fat shaming, BMI and alienation: COVID-19 brought new stigma to large-sized people by Maria L. La Ganga in the Los Angeles Times
Fat-Shaming People Won’t Improve Their Health by Christine Byrne in Outside Magazine
The Millennial Vernacular of Getting Swole by Anne Helen Petersen
The Body Is Not an Apology: The Power of Radical Self-Love by Sonya Renee Taylor
Anti-Diet: Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating by Christy Harrison
The F*ck It Diet: Eating Should Be Easy by Caroline Dooner
what nourished me this past week
what nourished my soul: I got into grad school for clinical mental health counseling. It feels scary to consider a different life path (or detour), but I am so heartened by how supportive my friends and family have been. Something a friend told me recently has stuck with me: “No matter what choice you make, it will be the right one, because you are making it.”
what nourished my soul (pt. 2): Last weekend I tweeted about how painful it is when you and a friend “break-up” or outgrow each other. The response was overwhelming and made me feel so understood. Side note: If you find yourself trying to navigate a friendship break-up or you are really missing a friend you faded away from, especially now that we are re-emerging from the isolation of the pandemic, I want to talk to you (for journalism!) Email me: juliegall95@gmail.com.
what nourished my mind: I’m reading People We Meet on Vacation by Emily Henry. A good book for, well, vacation.
what nourished my body: I started working in-person again, and I forgot how good it feels to do the little movements that go along with being in the office: walking to the Metro, grabbing a coffee, taking a mid-day stretch, walking past a coworker’s desk to say hi.
what nourished my belly: My friend Teresita’s birthday was last week. We celebrated her this weekend with a BBQ! She made chicken and veggie skewers and the viral TikTok drink of half Blue Moon/half Angry Orchard (10/10 recommend!)
