Can you have Anorexia Nervosa even if you are not underweight?
Firstly, it is worth saying that if you are reading this because you are worried about yourself, or about someone you care about, then that is worth taking seriously.
Whilst Anorexia Nervosa has specific criteria for diagnosis, anyone struggling with restricting their food intake, fears around eating, weight or body image deserves assessment and support. Whether or not they have a diagnosis or meet particular diagnostic criteria.
What is Anorexia Nervosa?
Diagnostic manuals set out psychiatric conditions and their diagnostic criteria. This includes the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11). The DSM-5 criteria for a diagnosis of Anorexia Nervosa include (1):
- Restriction of energy intake relative to requirements, resulting in significantly low body weight for age, sex, developmental trajectory and physical health.
- Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain.
- Disturbance in the way body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or a lack of recognition of the seriousness of current low body weight.
So, under DSM-5 criteria, a diagnosis of Anorexia Nervosa does include significantly low body weight.
But does that mean that someone who isn’t at a low body weight is “fine”? No, not necessarily.
In fact, the other diagnostic manual commonly used, the ICD-11 (2), states that rapid weight loss – for example, more than 20% of total body weight within six months – may replace the low body weight guideline. This is provided someone also meets other diagnostic requirements.
This means that someone who started at a higher body weight and has lost a significant amount of weight, but remains within what might be considered a “healthy” weight range, may still meet the ICD-11 criteria for Anorexia Nervosa.
And, MOST importantly, someone’s current weight alone tells us very little about how much they may be struggling with restrictive eating. Or how much it may be affecting their physical and psychological health.
Sub-types within Anorexia Nervosa
Within a diagnosis of Anorexia Nervosa, it is also worth noting that there are two sub-types: restricting and binge-eating/purging.
Restricting sub-type: During the relevant period, someone achieves weight loss primarily through restriction of food intake, fasting and/or excessive exercise. Rather than recurrent episodes of binge eating or purging.
Binge-eating/purging sub-type: Alongside restriction, there have also been recurrent episodes of binge eating and/or purging behaviours.
Both are recognised presentations of Anorexia Nervosa but in the real-world things don’t always fit neatly into a certain box. Behaviours can change over time, people may move between different presentations, and what someone is experiencing may not be immediately obvious from the outside.
Which brings me back to something that I think is really important: listen to the person who is struggling.
Diagnostic criteria can be useful, but people don’t always fit neatly into them. What matters is understanding what is actually happening for that individual; their eating, their thoughts and behaviours around food and weight, and the impact all of this is having on their physical and psychological health. A diagnosis can help to describe what someone is experiencing. However it should never determine whether or not their difficulties are worthy of being taken seriously.
What about other eating disorder diagnoses?
Other eating disorders can of course, significantly affect someone’s quality of life and their physical and mental health. These have their own diagnostic criteria. We won’t go into all of those in detail here. However, one that is particularly relevant when answering the question of whether you need to be underweight to have anorexia is atypical anorexia.
Atypical anorexia sits within the category of Other Specified Feeding or Eating Disorder (OSFED). Someone with atypical anorexia can meet the other criteria associated with Anorexia Nervosa. However despite significant weight loss their body weight is not considered
significantly low.
Despite the name, atypical anorexia isn’t necessarily particularly “atypical”. Community studies have estimated its prevalence at around 2.5–2.9%, and research suggests that it may be at least as common as Anorexia Nervosa (3).
Perhaps more importantly, research increasingly shows we shouldn’t think of atypical anorexia as a less serious version of Anorexia Nervosa. People with atypical anorexia often experience many of the same physical complications seen in Anorexia Nervosa (4).
So the absence of a significantly low body weight does not mean that someone’s restrictive eating is less important. Or that they are less deserving of treatment and support.
Why does this distinction matter?
Why does this distinction matter?In clinic over the last 20 years, I have worked with people experiencing a wide range of eating disorders and disordered eating.
And do you know what makes me very sad? Seeing someone with atypical anorexia feeling as though they have somehow “failed” because they don’t have a “real” Anorexia Nervosa diagnosis.
Not only is that incredibly upsetting, it can also be really dangerous.
Restrictive eating disorders often go hand-in-hand with perfectionism and, for some people, a sense of comparison or competitiveness. Feeling that you aren’t yet “unwell enough” can therefore become another reason to continue restricting or attempting to lose weight. Sadly, services can sometimes reinforce this when someone seeks help but doesn’t meet the threshold for an overstretched service.
You do not need to become more unwell in order for your difficulties with food to matter.
So, can you have Anorexia Nervosa without being underweight?
Depending on the diagnostic criteria being used, someone may meet the criteria for Anorexia Nervosa without having a low body weight. For example, under ICD-11 criteria where there has been substantial rapid weight loss and the other diagnostic requirements are met.
More frequently, however, I see people who have been given a diagnosis of atypical anorexia. Or who may not have received a formal eating disorder diagnosis at all.
The diagnostic label matters in some contexts, particularly when accessing particular services or treatment. But it does not determine whether your difficulties are real, whether this is affecting your health, or whether you deserve help.
If eating less, restricting certain foods, trying to control your weight, worrying about eating more, or thoughts about food and your body are taking up far too much space in your life, you’re not alone. You don’t need to wait until you meet a particular diagnosis or weight threshold before asking for support.
If you recognise yourself in some of what I’ve written here, you are very welcome to get in touch or book a breakthrough appointment with me. We can look at what is happening for you now and what you might need to begin moving forward. Regardless of the diagnosis written (or not written) in your medical notes.
References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. 5th ed., text rev. Washington, DC: American Psychiatric Association Publishing; 2022.
2. World Health Organization. ICD-11 for Mortality and Morbidity Statistics: Feeding or Eating Disorders. Geneva: World Health Organization; 2026. Accessed 18 September 2026.
3. Hay P. Current approaches in the recognition and management of eating disorders. Medical Journal of Australia.2023;219(3 Suppl):S6–S12. doi:10.5694/mja2.52008.
4. Johnson-Munguia S, Negi S, Chen Y, Thomeczek ML, Forbush KT. Eating disorder psychopathology, psychiatric impairment, and symptom frequency of atypical anorexia nervosa versus anorexia nervosa: A systematic review and meta-analysis. International Journal of Eating Disorders. 2024;57(4):761–779. doi:10.1002/eat.23989.