UB expert advocates for better screening for eating disorders, discusses atypical anorexia nervosa and how to spot it

BUFFALO, N.Y. – Better screening for eating disorders is needed, according to Lisa Ranzenhofer, PhD, assistant professor of psychiatry in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo. She is raising the issue during National Eating Disorders Awareness Week, Feb. 23 to March 1, a national campaign run by the National Eating Disorders Association.

Ranzenhofer conducts research and treats patients who have, or are at risk for, eating disorders and associated health concerns. One of her goals is improving screening for eating disorders in children, adolescents and adults, especially in general mental health and weight management settings, where the reason the patient is being seen is not directly related to eating disorders. Ranzenhofer’s past work has focused on understanding what leads to disordered eating in patients’ natural environments. Her work has highlighted different factors, like social problems and physical signs of stress (i.e., higher heart rate), that can indicate risk for disordered eating later in the day, offering opportunities to intervene in the real world. 

Eating disorders can go on for months or years before detection

Ranzenhofer says that eating disorders can be hard to identify in the community for many reasons, especially because weight ranges considered “healthy” are broad, so it can take closer examination of an individual’s growth history to recognize when a child or teen might no longer be growing as expected. And some eating disorders, such as bulimia nervosa or binge eating disorder, don’t involve low weight at all.

“Especially for athletes, but for many teens in general, eating habits may appear normal but still be insufficient to support growth or maintain weight,” Ranzenhofer says. “And misconceptions about who gets eating disorders often means boys, youth from racial/ethnic minority groups, and those who aren’t underweight may be less likely to be asked about symptoms.”

Ranzenhofer notes that contrary to conventional assumptions, disordered eating behaviors are not limited to people who are underweight. “Screening is especially important in settings focused on weight management, since cyclical dietary restriction and binge eating, as well as extreme weight control behaviors like fad diets or fasting, are actually more common in youth at higher weights,” she says. “The goal is inclusive screening that identifies eating disorders regardless of body weight.”

What is atypical anorexia nervosa?

Ranzenhofer wants clinicians to be aware of a condition called atypical anorexia nervosa (AAN), which was only recently added to the Diagnostic and Statistical Manual, the handbook used to define mental health diagnoses and guide medical billing.

“AAN is an eating disorder in which a person has all the core symptoms of anorexia nervosa — such as restrictive eating, intense fear of weight gain and body image concerns — but their body weight does not fall into what is traditionally labeled as ‘underweight,’” Ranzenhofer says.

She adds that weight and body mass index (BMI) are population-level tools, so they aren’t necessarily applicable to a specific individual.

“Just as people naturally vary in height or shoe size, each person has a weight range that is normal for their own body,” Ranzenhofer says. “Someone can experience significant weight loss and medical effects of starvation even if their weight still appears ‘normal’ or even above average.”

Symptoms of AAN that parents and pediatricians should look out for are rigid, inflexible or rule-based eating; significant weight loss; and often, personality shifts or withdrawal from activities and socializing.

She says research increasingly shows that the medical complications of AAN are nearly identical to anorexia nervosa and include cardiac abnormalities like low heart rate and low blood pressure, often warranting hospitalization.  

The first steps in treatment for AAN are generally thought to be the same as for anorexia nervosa and include renourishment, normalization of eating and, in many cases, weight restoration. This is often best accomplished through family-based approaches or structured programs.

“If you have concerns about atypical anorexia nervosa, a good starting point — just like for any eating disorder — is consulting the child’s pediatrician or pursuing an eating disorder evaluation with a specialist,” says Ranzenhofer. “A thorough evaluation can help determine whether an eating disorder (or subthreshold symptoms) is present and identify the best next steps.”