Synopsis
Recognise eating disorders and low energy availability beyond stereotyped presentations, use inclusive and culturally responsive assessment, identify sport-related medical harm, and remove weight, sex, gender, ethnicity, age or disability barriers to specialist care.
- Eating disorders occur in every sex, gender, age, ethnicity, socioeconomic group and body size; ask about behaviour and consequences rather than waiting for a stereotyped appearance.
- Atypical anorexia can cause serious starvation physiology after substantial loss while weight remains above the low range; BMI is neither a referral gate nor a severity score.
- In men and boys, enquire about muscularity concerns, leanness, supplements, anabolic-androgenic steroids, bulking and cutting, body checking and compulsive resistance or endurance exercise.
- Relative energy deficiency in sport is impaired physiological functioning from problematic low energy availability; it affects male and female participants at any ability level and may be intentional or unintentional.
- RED-S and an eating disorder overlap but are not synonyms: an athlete can be underfuelled without weight or shape psychopathology, and an eating disorder can exist without organised sport.
- Trans and gender-diverse people need respectful names, pronouns and anatomy-specific care; explore dysphoria or weight manipulation without treating identity as pathology or a reason to withhold affirming care.
- Cultural food practices, religious fasting and shared meals require curious assessment in context; use an independent professional interpreter for sensitive history when language support is needed.
- Autistic and otherwise neurodivergent people may need sensory, predictability, interoception and communication adaptations, but these needs do not exclude concurrent anorexia, bulimia or binge-eating disorder.
- Older adults may have new illness or recurrence alongside frailty, isolation, swallowing difficulty, medication effects or medical disease, requiring parallel differential diagnosis and timely specialist treatment.
Key red flags
Rapid weight loss, very low intake or recurrent collapse is dangerous at any starting weight; normal-range or high BMI must not delay medical assessment or referral.
Syncope during exercise, chest pain, unexplained bradycardia, reduced performance, recurrent stress injury or impaired recovery may signal low energy availability rather than healthy athletic adaptation.
Men and boys may describe pursuit of leanness or muscularity, rigid protein or supplement rules, bulking and cutting cycles, compensatory training or steroid use rather than fear of fatness.
Purging, insulin restriction, stimulant or laxative use and deliberate dehydration can produce lethal metabolic harm that a routine weight check will miss.
Food insecurity, coercive weight control, abuse, minority stress and unsafe housing may constrain eating or disclosure and require practical and safeguarding intervention alongside treatment.
Bone pain or focal tenderness in an underfuelled athlete requires exercise restriction and assessment for stress injury; training through symptoms can progress an incomplete fracture.
Investigation priorities
Elicit restriction, bingeing, purging, muscularity, dysphoria, sensory needs, food access and cultural meaning.
Management branches
Eating, weight, body, exercise or unexplained physiological symptoms raise concern in any patient.
- Use neutral questions about intake, rules, bingeing, compensation, exercise, supplements, body goals, trajectory and function without presuming sex, identity or motive.
- Complete physical and psychiatric risk assessment, including postural observations, ECG or bloods when indicated and same-day escalation for medical or suicide danger.
- Refer promptly to an age-appropriate eating-disorder service when suspected; do not wait for a low BMI or a culturally familiar presentation.