Voluntary and involuntary risk of low energy availability (LEA): a narrative synthesis review of screening tools for athletes

Low energy availability (LEA) is resultant of insufficient dietary energy intake relative to exercise energy expenditure (EEE), compromising physiological function in athletes. Behaviours attributing to insufficient energy intakes and/or excessive EEE, and therefore risk of LEA, can be voluntary (“advertent”) or involuntary (“inadvertent”). Discriminating between and screening for voluntary and involuntary risk may prevent athletes from going undetected by traditional LEA and clinical eating disorder (ED) screening tools and facilitate more targeted support and interventions. A narrative synthesis review was conducted to assess the ability of current screening tools in discriminating between voluntary and involuntary risk of LEA. Studies were included if tools screened for contributors to LEA and had undergone validation research in athletes. Eighteen studies met eligibility criteria and were included in this study. Eleven tools were theoretically able to detect voluntary and involuntary LEA risk. Three were prominent in their potential to identify voluntary and involuntary risk (considering both eating and exercise behaviours), demonstrate validity across various athletic groups and provide a comprehensive screen across diverse samples of athletes (i.e., Eating Disorder Examination Questionnaire 6.0 [EDE-Q 6.0], Eating Disorders Screen for Athletes [EDSA], and Exercise Dependence and Elite Athletes Scale [EDEAS]). Although, it was apparent that different screening tools offer differing benefits for various groups and screening aims. Further validation is required to confirm the discriminatory ability of tools in distinguishing voluntary and involuntary risk of LEA.