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Jump to Key Points SAN DIEGO — A 13-year-old girl loses 30 lb in 9 months, but her weight is still in the 90th percentile for her age. A teen athlete has a slow heart rate accompanied by weight loss.
These scenarios may seem unlikely to trigger a physician to suspect an eating disorder and investigate further. But they’re both potential warning signs, a pair of pediatricians told colleagues in a presentation at the American Academy of Pediatrics (AAP) 2026 National Conference.
“If you’re noticing those red flags, you should screen [for an eating disorder],” said Michelle Odette, MD, assistant professor of pediatrics at the University of California, San Francisco.
Anorexia Nervosa Can Occur Without Low Weight
As Marissa Raymond-Flesch, MD, MPH, professor of pediatrics at the University of California, San Francisco, explained, anorexia nervosa often comes to mind when people think of eating disorders. “The hallmarks of anorexia are restriction of energy intake relative to requirements. That leads to significantly low body weight in the context of age, sex, developmental trajectory, and physical health.”
- Atypical anorexia nervosa can occur with BMI ≥5th percentile; low weight absent.
- Rapid wt loss or percentile drop from baseline = red flag, even if “normal” weight.
- Bradycardia + wt loss in athletes should not be assumed athletic heart syndrome.
- Early clues: fatigue, dizziness, poor concentration; menstrual changes also concerning.
- Family-based treatment has strongest evidence; anorexia and atypical anorexia respond similarly.
However, another form of the disease — known as atypical anorexia nervosa — may be harder to detect in patients.
Patients with this condition meet all the criteria for anorexia nervosa except low weight. Their BMI is ≥ the 5th percentile for their sex and age in the pediatric population or ≥ 18.5 in adults, Raymond-Flesch explained.
The 13-year-old girl who’d lost 30 lb over a fairly brief period turned out to have atypical anorexia nervosa. Questioning revealed that she had been fasting, reducing portions, and walking up to 2 hours a day. This was all to avoid bullying over weight gain, Raymond-Flesch said.
Disruptions in Weight, Height Trajectories Matter
Raymond-Flesch recommended focusing on irregularities in a patient’s own weight or growth trajectory. Alarm bells should go off if a patient, for example, falls from a stable 75th percentile to the 50th or 40th, she said. “That may still be normal, but it’s not normal for them.”
Both anorexia and atypical anorexia can lead to medical instability and hospitalization, Raymond-Flesch said. She noted that research has shown patients with the atypical form “do present much sicker when they are hospitalized because this gets missed.” Both forms of anorexia respond similarly to family-based treatment, she said.
According to her, this therapy for eating disorders in children and adolescents is backed by the most evidence.
Other Eating Disorder Warning Signs
Low heart rate. “If you’re noticing weight loss in an athlete, especially one who has bradycardia, I would not assume it’s athletic heart syndrome right off the bat,” Odette said.
Low heart rate (bradycardia) can be a sign of athletic heart syndrome, also known as athlete’s heart. This refers to “differences in your heart’s left ventricle and other changes that happen when you exert yourself for an hour a day on most days of the week,” according to the Cleveland Clinic. “A provider can pick up unusual heart sounds through a stethoscope or testing. However, this is a harmless condition with no symptoms.”
- Vague complaints. “Some of the earliest signs you’ll see are patients saying, ‘I feel tired, I feel dizzy, I’m having a hard time focusing in class,’” Odette said. For her part, Raymond-Flesch highlighted menstrual changes as another red flag.
- GLP-1 drugs in the home. Some patients use GLP-1 weight-loss drugs “diverted from other family members’ prescriptions to suppress appetite,” Odette said.
Her advice: “Ask about GLP-1s in the patient who has rapid weight loss or if you’re aware GLP-1s are in the home. Screen for disordered eating in any patient you are starting on a GLP-1 so you understand what behaviors are happening.”
Outside Expert: Weighing Is a ‘Golden Opportunity’
In an interview, Cynthia M. Bulik, PhD, professor of nutrition at University of North Carolina at Chapel Hill (UNC) Gillings School of Global Public Health who studies eating disorders, said clinicians “have a golden opportunity to ask children how they feel about their weight when they step on the scale.”
As she explained, “A simple question like ‘how do you feel about your weight?’ can open up the door to a conversation. Also, instead of just looking down and jotting down the number, watch the child’s reaction to the weight that they see. Do they seem distressed, embarrassed, or hesitant to step on the scale?”
Odette, Raymond-Flesch, and Bulik reported no disclosures.
