Normal weight, but still anorexic

When most people think of anorexia, they think of bone-thin people: But this is not always true. When overweight girls lose too much weight too quickly, it can be just as dangerous – despite a normal weight.

By Thomas Muller Published: 21.06.2016, 05:01 am

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A disturbed body perception is typical for patients with eating disorders

Disturbed body perception is typical for patients with eating disorders.

© RioPatuca Images /

MELBOURNE. When they think of anorexia, most people think of bone-thin people. But anorexia symptoms can be present even at relatively normal weights, when overweight and obese people suddenly lose weight dramatically.

If all criteria for anorexia are met except for underweight – for example, disturbed body schema, marked fear of gaining weight and fixation on calorie avoidance – then atypical anorexia is assumed according to the DSM 5.

This eating disorder is often considered less risky. According to the results of an Australian study, however, psychological and physical complaints hardly differ from those in classic anorexia.

Over 70 percent with overweight

Pediatricians around Dr. Susan Sawyer of the University of Melbourne looked at the examination results of 256 adolescents who had been transferred to specialists at the University Hospital Eating Disorders Program with suspected eating disorders (Pediatrics 2016, online 29. March).

Patients were thoroughly examined physically and psychologically using standardized questionnaires and examination protocols. Physicians diagnosed 118 patients (46 percent) with anorexia, and 42 (16 percent) with atypical anorexia.

Nine out of ten sufferers were girls in each case, and on average the adolescents were 15 to 16 years old.

The prerequisite for anorexia was a body weight of less than 89 percent of the age-specific median. Physicians assumed atypical anorexia if weight was above this threshold, but patients had lost more than 10 percent of their premorbid body weight.

The biggest difference between adolescents with atypical and classic anorexia was in body weight before the onset of the eating disorder. Of those with atypical anorexia, 71 percent had previously been overweight or obese, compared with only 12 percent of those with classic anorexia.

Low resting pulse

Unsurprisingly, the adolescents with the atypical form had lost significantly more weight (17.6 vs 11.0 kg) and also needed slightly more time to do so (13.3 vs 10.2 months).

In contrast, there were hardly any differences in the psychological and physical examination: the resting pulse was similarly low in atypical anorexia as in the classic form (60 vs 59 per minute), bradycardia (pulse below 50/min) occurred slightly less frequently (24 vs 33 percent), orthostatic instability, on the other hand, was found slightly more frequently (43 vs 38 percent), but the differences were not statistically significant.

Similar observations could be made for the proportion of patients with hypothermia (10 vs 13 percent). Only systolic blood pressure was significantly higher in adolescents with atypical anorexia (106 vs 99 mmHg) and the proportion affected with amenorrhea was significantly lower (32 vs 61 percent).

One-third are depressed

However, adolescents with the atypical form showed more severe eating disorder symptoms when questioned with the Eating Disorder Examination (EDE). They had a more negative body image and were even more dissatisfied with their weight than the significantly thinner adolescents with classic anorexia.

Psychiatric comorbidities (38 vs 45 percent), suicidal and self-harm thoughts (43 vs 39 percent) were similarly frequent in both course forms. The scores on obsessive-compulsive and depression scales did not differ significantly.

Depression was diagnosed in about one-third each, anxiety disorder in 17 and 24 percent, and obsessive-compulsive disorder in 5 and 6.

Researchers therefore rate atypical anorexia as a severe eating disorder with significant physical and psychological consequences. One-quarter had bradycardia and one-third had amenorrhea; 40 percent were hospitalized.

This is important to know, he said, because more and more patients with eating disorders are being admitted to hospitals who are not underweight.

In Melbourne, their proportion increased from 8 percent to nearly 50 percent within six years. Even in such patients a thorough physical (pulse, temperature, blood pressure) and psychological examination is necessary, especially when adolescents with normal weight have lost weight drastically in a short time.

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Correct colleague Schatzler! there is no black mold!

Of course there are known metabolic problems with FALSE "radical diets", which were stupidly introduced by psychologists (Giesener school) (optifast etc.) and with which unfortunately also today still money is earned.
This is known NOT to lead to the desired success.
The desire to have a normal weight is certainly not a mental illness, certainly not in overweight people and the anorexia patients lack this desire.
Psychologists have brought disaster into obesity therapy because they are either unaware of the metabolic effects of wrong diets or even accept them by setting wrong priorities.

Somehow it’s all anorexia?

If one reads the text of this Australian publication by S. M. Sawyer et al. not somehow fleeting "down under, but critically and accurately, one cannot get out of the amazement:

The authors define "atypical anorexia nervosa (AN)" In adolescents as significant weight loss o h n e underweight ["BACKGROUND AND OBJECTIVE: Adolescents with atypical anorexia nervosa (AN) have lost significant weight but are not underweight"].

In atypical AN, 71% were premorbidly overweight, in typical AN only 12% were overweight: But how, pray tell, does one get reliable "premorbid" overweight? Anthropometric data at growth age, before disease onset ever occurs? And how can one compare weight losses with primarily rather overweight (atypical AN) with additional weight losses with primarily rather underweight (typical AN) at all?? ["RESULTS: Compared with AN, more adolescents with atypical AN were premorbidly overweight or obese (71% vs 12%). They had lost more weight (17.6 kg vs 11.0 kg) over a longer period (13.3 vs 10.2 months)"].

Otherwise, both comparison groups showed the full program of the generally widespread bio-psycho-social adolescent development, maturation and personality crises: Cardiac rhythm, orthostasis and eating disorders, distress in eating behavior and body image. Apprehensions about food and weight, yo-yo effects ("bingeing"), purging, excessive physical training, or. psychiatric co-morbidity were about the same in atypical and typical AN. ["Psychological morbidity measures included eating and weight concerns, bingeing, purging, compulsive exercise, and psychiatric comorbidity" . "There was no significant difference in the frequency of bradycardia (24% vs 33%;) or orthostatic instability (43% vs 38%). We found no evidence of a difference in frequency of psychiatric comorbidities (38% vs 45%) or suicidal ideation (43% vs 39%). Distress related to eating and body image was more severe in atypical AN."].

The study’s crucial systematic flaw: A comparison group of adolescents without AN was completely missing! Not even the thought that overweight, symptomatic adolescent type 2 diabetics or adolescents with metabolic syndrome should also be encouraged and instructed in weight reduction, dietary changes, sports and exercise in accordance with guidelines occurred to the study authors! Because these have nevertheless k e i n e atypical anorexia nervosa, as described by Susan M. Sawyer et al. demanded, but only the most successful possible metabolic conversion and homeostasis as a treatment goal.

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