Sep. 22, 2013 at 8:43 AM ET

Hear “anorexia” and you think bone-thin young women — scary-skinny runway models with emaciated figures. But an overlooked group of young people are also struggling with anorexia nervosa: overweight and even obese kids.

Adolescents with a history of obesity are at “significant risk” for developing anorexia, says Dr. Leslie A. Sim, clinical director of the Mayo Clinic’s eating disorders program, in a recent paper in Pediatrics. But because of their size, their symptoms often go unrecognized and untreated, Sim says.

“It’s harder to see that they have an eating disorder because we think they should be dieting; the physician told them to be dieting,” says Sim, who has gathered some not-yet-published data suggesting that about 35 percent of the Mayo Clinic’s anorexic patients have a history of obesity, and that on average, the eating disorders they have go unidentified for about 11 months longer than in their smaller-sized peers.

Most people will probably be surprised or even skeptical to hear that a kid struggling with obesity can also be anorexic, says Lynn Grefe, president of the National Eating Disorders Association. But they shouldn’t be: an estimated 30 million Americans will have an eating disorder sometime in their life, Grefe says.

Taken too far, the anti-obesity movement can mean focusing on thin versus fat, instead of healthy versus unhealthy, which can trigger disordered eating behaviors in some children, both Sim and Grefe agree. Teaching habits such as counting calories or avoiding carbs or calling this food “good” and that food “bad” can all too easily slip into the obsessive eating patterns associated with eating disorders in vulnerable kids, Grefe says.

And that can especially be true for obese or overweight children, who are likely being told implicitly or explicitly by almost every adult in their lives that they’re not OK the way they are. “So they’re just kind of doing what they were told to do, but it gets out of control,” Sim says. “I think these kids are almost more at risk, because of the messages they receive that a kid of normal weight doesn’t get.”

Ali Hougnou

Ali Hougnou
In this photo, taken during Ali Hougnou’s sophomore year, the teenager was around her heaviest weight.

When Ali Hougnou was a little kid, she was a normal weight. But after her parents divorced when she was 9, she used food to try to quiet her heartache. She steadily gained weight for years, and by age 15 she weighed 200 pounds. At 5’5”, that put her body mass index – a way of measuring body fat using height and weight — at 33. (A BMI of 30 or higher is considered obese.)

She tried diets and exercise, but nothing would make the weight come off, until the summer before 10th grade, when she spent some time with her godmother’s family in Spokane, Wash. It was like an accidental fat camp: she ate the same healthful, organic foods her hosts did, and was outdoors and active in the same the way they lived, and easily lost 15 pounds. Back home, her classmates finally stopped teasing her about her weight; they started complimenting her instead. “And the more people told her how great she looked, the more she stopped eating,” her mom, Tammy Carlisle of Long Island, N.Y., says.

Over her sophomore year, Hougnou lost nearly 40 percent of her body weight. She felt faint and lightheaded all day long, and at one point, all she ate were 80-calorie cups of nonfat yogurt: one for breakfast, one for lunch, and one for dinner. She was wasting away, but all anyone seemed to care about was that she wasn’t fat anymore.

“To everyone else, and even to myself, I was just dieting,” Hougnou says. “I was doing exactly what the doctor had wanted. The pediatricians were so pleased with my weight loss.”

Because we have the idea that “any weight loss is good for an obese person, no matter what – even if the person is not eating all day, or purging or vomiting,” Sim says. “I think, too, what happens is (pediatricians) are so distracted by their perceived responsibility to prevent obesity in their patients that they’re like, ‘Oh, this is great, you’re losing weight,’ and they don’t ask, ‘Well, how are you losing weight?’”

Hougnou’s therapist advised her mom that the teenager was showing some signs of disordered eating, though there were no outward signs — she was a healthy size 4. Around that same time, the girl’s best friend told the school principal, who then told Hougnou’s mom, that Hougnou kept her locker stocked with all kinds of diet stuff: diet pills, “juice cleanse” drinks, diuretics.

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