The Overlooked Burden of Atypical Anorexia Nervosa: Commentary on Melville et al. (2025)

Abstract

Obesity and eating disorders (EDs) have historically been viewed as distinct conditions; however, emerging evidence suggests a significant overlap, particularly among individuals seeking obesity treatment. While binge-eating disorder (BED) is commonly identified in this population, restrictive EDs such as atypical anorexia nervosa (atypical AN) can go largely undetected. This paper comments on findings from Melville et al.'s systematic review of 85 studies assessing ED prevalence in adults with high Body Mass Index (BMI) seeking obesity treatment. We highlight the striking absence of atypical AN diagnoses despite substantial evidence supporting its prevalence in broader populations. We explore several reasons for this under-recognition, including the definitional ambiguities of atypical AN in the DSM-5, limitations of assessment tools that emphasize binge eating, and weight stigma that tends to mask restrictive eating as “normal” dieting. The implications are significant: failure to identify atypical AN may lead to delayed or inappropriate care and reinforce harmful stereotypes that restrictive EDs only affect underweight individuals. We argue for greater clinical vigilance, the refinement and clarification of diagnostic criteria and the development of validated tools for detecting atypical AN, particularly in higher-weight individuals. Clinicians, particularly those providing weight loss interventions, should be trained to identify restrictive eating irrespective of BMI and prioritize behaviors and psychological impairment over weight status. Recognizing atypical AN as a serious, underdiagnosed condition is critical to ensuring ethical, equitable and effective care across the weight spectrum, in both ED and weight-loss treatment settings.