Recent studies have shown that the cytochrome P450 (CYP) 3A phenotype marker 4β‐hydroxycholesterol/cholesterol (4βOHC/C) ratio is negatively correlated with body weight in healthy volunteers, and that obese patients have lower 4βOHC levels than healthy controls. However, 4βOHC/C ratio in underweight patients has yet to be reported. The aim of this study was to examine potential differences in CYP3A activity between underweight patients with anorexia nervosa and normal‐weight volunteers by measuring plasma 4βOHC/C ratio. Furthermore, we wished to describe any association between body mass index (BMI) and 4βOHC/C ratio in underweight patients. A total of 20 underweight patients and 16 normal‐weight volunteers were included in the study, all females. Underweight patients had a median 4βOHC/C ratio (molar ratio × 10−5) of 2.52 (range, 0.90–11.3) compared to 1.29 (0.56–2.09) in normal‐weight subjects (Mann‐Whitney P = 0.0005). 4βOHC/C ratio was negatively correlated with BMI in underweight patients (r = −0.56, P = 0.011), and in the whole study population (r = −0.67, P < 0.0001). This suggests that the negative correlation between 4βOHC/C and BMI, which has previously been reported between 4βOHC/C and body weight in healthy volunteers, extends to underweight patients. The findings indicate that CYP3A activity increases with decreasing BMI, resulting in higher CYP3A activity in underweight patients compared to normal‐weight subjects. The potential clinical relevance of this needs to be studied further by comparing pharmacokinetics of drugs subjected to CYP3A‐mediated metabolism in underweight vs. normal‐weight individuals.