A Patient and Public Involvement Investigation to Inform a Study Exploring the Impact of Low Energy Availability on Cardiovascular Health in Physically Active Females, 2022-2023

Low energy availability (LEA) has gained substantial research attention in recent years, yet many studies overlook the importance of patient and public involvement (PPI) at the design stage. PPI enhances the relevance, acceptability, recruitment, retention, and overall integrity of research by ensuring collaboration between researchers and members of the public. This PPI investigation aimed to inform the design of a proposed study examining cardiovascular (CV) health and LEA in physically active females. A qualitative descriptive design was adopted, involving semi-structured interviews with ten physically active females aged 19–29 years, representing a range of sports and competitive levels. Interviews were conducted online or in person, and data were analysed using reflexive thematic analysis. Three themes were developed: (i) Piecing It Together: Making Sense of LEA; (ii) Weighing Up the Study: Motivations and Concerns; and (iii) Making It Work: Practical Needs and Preferences. Participants initially demonstrated limited awareness of LEA but identified personal experiences once informed. They emphasised the study’s relevance for athlete health and recognised the importance of raising awareness of LEA. Key concerns included time demands of the proposed study and the sensitive nature of discussing eating behaviours. Participants also recommended several adjustments to improve feasibility and comfort, including simplifying procedures, reducing laboratory burden, offering flexible scheduling, maintaining clear communication, screening for eating disorders, providing support resources, ensuring access to a female tester, and offering financial incentives. These insights directly informed refinements to the proposed research study design, including reducing the number of laboratory tests, streamlining procedures, shortening the tracking period, and enhancing participant communication strategies. Overall, this PPI investigation ensured that the proposed study is more participant-centred, acceptable, and likely to have meaningful impact on CV health and LEA research in physically active females.