Voluntary and involuntary risk of low energy availability: screening, prevalence, treatment and differences in anthropometric, physiological & psychological outcomes

Chesters, Rachel Louise ORCID: 0009-0008-8245-1329 (2026). Voluntary and involuntary risk of low energy availability: screening, prevalence, treatment and differences in anthropometric, physiological & psychological outcomes. University of Birmingham. Ph.D.

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Abstract

This thesis defines voluntary (‘advertent’) and involuntary (‘inadvertent’) risk of Low Energy Availability (LEA), evaluates whether existing screening tools can theoretically distinguish between the two, estimates their prevalences and investigates anthropometric, demographic, anthropometric, psychological and/or physiological differences between athletes at voluntary versus involuntary risk, and documents a successful multidisciplinary team (MDT) approach to Relative Energy Deficiency in Sport (REDs recovery) in a high-performance athlete who developed REDs through voluntary behaviour in a real-world setting.

A narrative synthesis review identified existing screening tools with theoretical capacity to discriminate between voluntary and involuntary risk and concluded that the development of a new tool was not necessary. The Eating Disorders Examinations Questionnaire (EDE-Q 6.0) was the preferred tool due to its comprehensiveness and higher sensitivity. Pilot work supported usability and suggested meaningful prevalence. A following cross-sectional study in high-performance male and female athletes reported that 54% were at voluntary risk and 46% at involuntary risk. Between-group comparisons were feasible in females only. Voluntary risk of LEA was associated with higher plasma cortisol (441 ± 138 vs. 300 ± 64 nmol/L) (P=0.002), greater menstrual dysfunction (P≤0.001), and higher EDE-Q 6.0 total and global scores (P=0.009; P=0.005). There were no other significant differences between groups. Eighty-four percent of athletes at voluntary risk of LEA went undetected by traditional eating disorder (ED) screening tools.

A case study of a female combat-sport athlete documented a successful MDT approach to REDs recovery resulting in improved menstrual function, strength, fitness, and body composition (including a 2.2kg [+4%] increase in body mass and a 10.2mm [-9%] reduction in sum of eight skinfolds), and highlighted practical considerations for weight-class sports.

Collectively, the work in this thesis builds a conceptual and applied case for distinguishing voluntary from involuntary LEA risk. Across chapters, this distinction is shown to be theoretically relevant, empirically observable in some contexts, and practically important in tailoring LEA and REDs support interventions. This thesis has contributed defined terminology, potential development of existing spectrums and screening methods, insight into the aetiology of voluntary risk of LEA in high-performing male and female athletes, data on prevalences of voluntary and involuntary risk, and guidance on REDs recovery interventions in high-performance, applied settings. This work has also shed light on many areas for future research needed to confirm its findings and continue to advance research and applied practice in this area.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):