Submitted by Allisha M. Weeden, Janette Olsen, John M. Batacan, Teri Peterson
Allisha M. Weeden is an Assistant Professor in the Dietetic Programs at Idaho State University. Janette Olsen is an Assistant Professor in Health Education at Idaho State University. John M. Batacan is an Assistant Professor in Health Education at Idaho State University. Teri Peterson is an Assistant Professor in the College of Business at Idaho State University.
PURPOSE: To identify nutrition knowledge based on collegiate sport, where nutrition knowledge was lacking, and specific nutrition related concerns of collegiate athletes.
METHODS: The cross-sectional study evaluated responses to a 65-item written questionnaire. Participants (n=174; female=88, male=86) competed in 13 different NCAA sanctioned sports. Nutrition knowledge scores calculated from the number of nutrition knowledge questions correct then converted to a percent from the number of questions correctly answered. Frequencies, Chi-square, and t-tests were used to report and compare nutrition knowledge scores.
RESULTS: The mean nutrition knowledge score of participants was 56.4% ± 13.4%. Higher nutrition knowledge scores were associated with completion of a collegiate nutrition course (p = 0.015), participation in individual sports (p = 0.043), and citation of healthcare professionals as the primary source of nutrition information (p = 0.008). Forty-two percent reported nutrition concerns related to what and how to eat healthy.
CONCLUSIONS: Collegiate athletes lacked nutrition knowledge and expressed concerns surrounding what and how to eat healthy. Completion of a collegiate level nutrition course may benefit collegiate athletes, especially those that do not have access to a Registered Dietitian (RD).
APPLICATIONS IN SPORT: Collegiate athletes, athletic departments, and even universities all benefit from successful sports teams. Nutrition can be a big part of success and the use of a RD to educate athletes ensures appropriate nutrition knowledge is provided. For universities with financial constraints collegiate level nutrition courses and small group cooking classes taught by an RD may still benefit collegiate athletes.
Collegiate athletes are a diverse and unique population requiring sufficient knowledge to ensure nutritional needs are met while positively impacting training capacity and performance (12,17,18). In addition to the academic, financial, and social challenges of the collegiate environment, collegiate athletes must aim to meet nutrition needs with rigorous training regimens. Despite the greater need for nutrition knowledge, athletes tend to score in the 50% range on nutrition knowledge tests (1,6,15) which is similar to that of non-athlete peers (6). Athletes may be confused about the need and use of protein, vitamins, and minerals (6,18) but have adequate knowledge about the need for carbohydrates (15,18)and the importance of fluid status on performance (18). Appropriate timing of food intake, especially carbohydrates, before, during, and after training may help improve athletic performance (17). However, without exposure to evidence-based nutrition information, collegiate athletes may adopt unhealthy eating habits from misinformation or information from unreliable sources (12). Collegiate athletes need quality sources to ensure accurate and appropriate nutrition information is received and implemented (18,21-22).
Previous reports of collegiate athlete nutrition knowledge focused on the athlete population as a whole (4,18,21). While appropriate to report in many cases, there is a lack of information regarding the nutrition knowledge of athletes from specific sports. Athletes from different sports have diverse nutrient needs and may hold varied levels of nutrition knowledge (4,7,19)For example, distance runners require a higher percentage of calories from carbohydrates (8) than power athletes participating in teams sports like American football. Likewise, athletes participating in power sports need a more modest intake of carbohydrate allowing for a higher intake of fat and protein (7). Thus, it is important to determine the specific nutrition-related concerns of athletes to enable universities to develop resources that address the unique needs of each sport.
Therefore, the purpose of this study was to determine differences in nutrition knowledge between collegiate athletes participating in different types of sports, identify areas where nutrition knowledge was lacking and investigate nutrition-related concerns athletes would like to have addressed.
This cross-sectional study administered a questionnaire to collegiate athletes (n = 174) at a National Collegiate Athletic Association (NCAA) Division I member institution in the western United States. The NCAA is a member association of higher education institutions in the United States founded in 1906 with the goal of protecting student-athletes (13). Member institutions at the Division I level provide more athletic related financial aid to student-athletes compared to Division II and Division III member institutions (13). The participating university had approximately 300 student-athletes competing in 13 recognized NCAA sports: men’s basketball, cross country, American football, tennis, and track & field; and women’s basketball, cross country, golf, soccer (football), softball, tennis, track & field, and volleyball. The athletic department at the participating university did not provide any structured nutrition information to athletes, employ a sports dietitian, or require athletes to complete a nutrition course. The inclusion criteria were athletes currently participating in team practices and at least 18 years of age. Only those athletes present on the day of administration completed the questionnaire (n = 192).
The questionnaire was administered, by 1 or more of the researchers, to each team separately and at a time convenient for the team during the semester that started in January. The participants completed the questionnaire within 15-25 minutes using a paper and pencil format with answers being written on a hard copy of the questionnaire. The data collected were part of a larger program planning and development process. The Institutional Review Board (IRB) was consulted at several stages before and after data collection. The IRB concluded that the larger program and analysis of this pre-existing data set did not constitute the federal definition of research involving human subjects. However, all participants provided informed written consent and were given the opportunity to exclude individual data from analysis. All participants were assigned a number and no identifying information was connected to the data set.
A 65-item Nutrition Knowledge and Behavior Questionnaire was developed by the research team that consisted of a dietitian, two health education specialists, and a statistician. The questionnaire was designed to obtain a baseline of athlete nutrition knowledge that would assist in the development and tailoring of nutrition education sessions for individual student athletes and each sport team. In order to establish content validity, the nutrition knowledge questions were derived from a basic nutrition textbook combined with the knowledge of the dietitian and health education specialists on the research team. The variety of questions were chosen to assure content validity of the knowledge instrument, that is the questions were designed to represent all relevant facets of nutrition knowledge for athletes. The 24 fact-based nutrition questions covered macronutrients (8 questions), micronutrients (5 questions), hydration (4 questions), dietary supplements (2 questions), and weight management (5 questions). The knowledge questions mirrored questions from a basic nutrition course offered at the university and were selected to illustrate the student athlete’s basic nutrition knowledge. Athletes answered all fact-based questions with ‘yes’, ‘no’, or ‘unsure’. The participants were verbally instructed not to guess and answer ‘unsure’ if the information was unfamiliar. One question asked if the athlete had “completed a college level nutrition course.” The possible answers for these questions were ‘yes’, ‘no’, and ‘unsure’. The athletes were asked “what is your primary or main source for nutrition information”. Pre-selected sources included ‘peers’, ‘athletic trainer’, ‘coach’, ‘health care professional’, ‘internet’, and ‘other’. The ‘other’ option had space available for write-in answers. Another question asked “What concerns do you have about nutrition?” This open-ended question allowed the athlete to express any concern related to nutrition without researcher-influenced wording or topics. The remaining questions addressed demographic information, usual dietary intake, body satisfaction, supplement use, dietary rituals, and participation in risky behaviors such as alcohol consumption.
The questionnaire was piloted in a sophomore level, undergraduate introductory health education course to assess the questionnaire for appropriate reading level and question clarity. No student athletes were enrolled in the course and students that were in attendance on the day of administration completed the pilot questionnaire (n = 14). The original format consisted of 63 questions with students recording multiple choice answers on an accompanying sheet and the answers to the open-ended questions written directly on the questionnaire. Students were given the opportunity to complete the questionnaire and give written feedback on any question. From the questionnaire results and written feedback, the researchers refined the wording to clarify specific questions. The method of administration was changed to eliminate the recording sheet to facilitate ease of administration and decrease completion time. Following these changes, the questionnaire was again evaluated by the four member research team for content validity.
Data were entered from the paper questionnaires into a Microsoft Excel spreadsheet then imported for statistical analyses into IBM SPSS Statistics for Windows (version 19.0, 2010, Armonk, NY: IBM Corp). Questionnaires (n=18) were excluded from analysis if the nutrition knowledge section was incomplete or if missing key pieces of information such as sport, gender, etc. No participant requested their data be excluded from analysis. Descriptive statistics were calculated for all the data. For categorical variables, frequencies and percentages were reported; for quantitative variables, means and standard deviations were reported. Nutrition knowledge scores were calculated as the number correct then converted to a percent correct. The Shapiro-Wilk test indicated a violation of normality (P = .027). However, tests of normality can be sensitive to large sample sizes. The data did not demonstrate significant skewness (P = .574) or kurtosis (P = .202). ANOVA and t-tests are both robust to violations of normality (14). In addition no outliers were detected based on both Z-scores and quartile analysis.
Levene’s test was performed on all comparison of means to assess homogeneity of variance and to determine whether to use an equal variances t-test or an unequal variances t-test. An independent samples t-test assessed the differences in mean knowledge score between groups: participants who had a previous nutrition course vs. those who did not and males vs. females. For each individual question, a Fisher’s Exact test compared the percentage of athletes who answered correctly between those who had or had not completed a nutrition course.
For analysis, cross country and track & field athletes were combined because the two sports had significant athlete crossover, were coached by the same staff, and practiced at the same time. One-way Analysis of Variance (ANOVA) compared mean knowledge scores among four sports for males and seven sports for females (Table 1), and among six primary sources of information (Table 2). Subsample knowledge score comparisons between genders were conducted for sports where males and females were both represented (basketball, tennis, and track & field). Significant ANOVAs were followed by post-hoc mean comparisons using Tukey’s adjustment. A Bonferroni correction was applied to p-values from t-tests and ANOVA to protect family wise errors. The corrected p-values are listed alongside the uncorrected p-values. The Chi-square test of independence assessed the relationship between type of sport (team vs. individual) and primary source of information. The Marascuilo procedure at an alpha level of 0.05 was used for post hoc comparisons on proportions of sources of information across multiple groups (3). For all statistical analyses, p <0.05 was considered statistically significant.
Nutrition-related concerns were self-reported by the athletes in an open-ended question. Multiple readings of the raw data were used to identify themes (20). Responses were then coded according to theme for analysis (20).
Complete demographic information of all participants (n = 174; female = 88, male = 86) and mean nutrition knowledge score for each category can be found in Table 1. Most athletes were white, non-Hispanic (n = 132, 86%), and the mean age was 20.0 ± 1.4 years (males = 20.3 years, females = 19.7 years). The mean nutrition knowledge score for all participants was 56.4% ± 13.4% (range 20.8%-83.3%). White athletes had significantly higher nutrition knowledge scores than non-white athletes (P= 0.043). There were no significant differences among athletes participating in different sports or between male and female (males p = 0.370, and females p = 0.501) collegiate athlete nutrition knowledge scores.
Overall, athletes were most likely to answer questions correctly regarding hydration (80%) and least likely to answer questions correctly on weight management (32%) and dietary supplements (36%). Specifically, athletes were correctly able to identify the benefits of fiber (83%), benefit of high protein foods on fullness (89%), importance of water in body temperature regulation (92%), and sources of electrolytes (97%). Athletes were least likely to identify that the consumption of certain foods does not promote weight loss (8%), function of carbohydrates (13%), difference between fat-soluble and water-soluble vitamins (17%), low-fat diets can be healthy (19%), and dietary supplement safety (21%).
Only 19% of participating collegiate athletes reported taking a college level nutrition course. Previous completion of a nutrition course was associated with higher nutrition mean knowledge scores (p= 0.015), indicating that students retained the knowledge gained. Athletes who reported completing a college level nutrition course had better knowledge of simple carbohydrates (with course = 73%, without course = 53%, P= 0.032), vitamins (with course = 36%, without course = 12%, p= 0.002), food sources of sodium (with course = 76%, without course = 58%, p= 0.048), function of protein with regard to muscle growth (with course = 64%, without course = 44%, p= 0.032), and dietary supplements (with course = 70%, without course = 47%, p= 0.017) than peers not completing a nutrition course.
When athletes were recoded to reflect participation in type of sport, team (basketball, American football, soccer, softball, volleyball) vs. individual (golf, tennis, track & field), athletes participating as individuals had higher nutrition knowledge scores (59.0 ± 14.1) than those participating in teams (54.8 ± 12.7, p= 0.043). Individual sport athletes were more aware of the impact of iron deficiency on performance (individual = 85%, team = 72%, p= 0.036), need for vitamins (individual = 86%, team = 74%, p= 0.047), low-fat diets (individual = 26%, team = 15%, p= 0.049), and recognition that greater protein intake will not build more muscle (individual = 59%, team = 42%, p= 0.027). Athletes participating in team sports were better able to identify protein needs (team = 67%, individual = 81%, p= 0.025) and indicators of dehydration (team = 71%, individual = 54%, p= 0.019).
Athletes were asked to report their primary source of nutrition information (Table 2). The most frequently chosen sources of information for all athletes were ‘other’ sources (n = 34, 19%), peers (n = 32, 18%), athletic trainer (n = 28, 16%), and “multiple sources” (n = 28, 16%). Any athlete selecting more than one source was classified as a “multiple sources” responder. For athletes listing ‘other’ as the primary source of nutrition information, parents/family (n = 16) were most commonly cited.
After elimination of athletes who cited multiple sources (contrary to the instructions to indicate their primary source of information) a significant relationship was found between type of sport (team [n = 90] vs. individual [n = 54]) and source of information (c2 = 13.108, p = 0.022). The three top sources for team sport athletes were athletic trainers (n = 23, 26%), other (n = 20, 22%), and peers (n = 19, 21%). The top three sources for athletes in individual sports were peers (n = 13, 24%), other (n = 14, 26%), and health care professionals (n = 11, 20%). The Marascuilo procedure demonstrated a significant difference between health care professionals and athletic trainers, with team athletes choosing athletic trainers more frequently than health care professionals for their information.
A one-way ANOVA detected at least one difference in mean knowledge scores among the different sources of information (p= 0.012). Tukey’s post hoc tests revealed athletes who cited health care professionals (e.g. physician, dietitian) as their primary source of information had higher nutrition knowledge scores than those that cited athletic trainers (p= 0.008). No other sources of information demonstrated significant differences among sources in mean nutrition knowledge score.
Athletes were also asked to report any nutrition-related concerns. There was no difference in nutrition knowledge score among those who reported some form of nutrition concern (53%) versus those who did not (47%). Of those reporting a concern, 42% were concerned with “what and how to eat healthy.” All other concerns were reported by less than 10% of participants and included topics like “how much to eat,” “how to eat in campus dining facilities,” “how to eat on a budget,” and “eating for weight gain/loss.”
Even though the nutrition knowledge scores of athletes can vary depending on the type of questions asked, the overall nutrition knowledge scores obtained in the current study are consistent with previous findings (4,15,24). A unique finding of the current study was lower nutrition knowledge scores among minority athletes compared to white athletes. While the current questionnaire did not address where athletes resided prior to arrival at the university or use of healthcare services, the lower nutrition knowledge scores could indicate a lack of access to healthcare and nutrition-related services both before their arrival at the university. Research indicated knowledge and other individual-level psychosocial factors could be influenced by environmental behavioral settings (5).
Nutrition education interventions improved nutrition knowledge and dietary behaviors of collegiate athletes (1,22). The current study indicated significantly higher nutrition knowledge scores for collegiate athletes who completed a nutrition course. The university at which athletes in this study were enrolled offered three introductory nutrition courses: a basic nutrition course designed for non-science majors, a basic nutrition course designed for nutrition majors and other science majors, and a basic nutrition course designed for (non-nutrition) health professions, primarily nursing students. Students completing any of these courses received information from a registered dietitian (RD) (all university nutrition courses are taught by an RD) and were exposed to information found on the questionnaire. While a collegiate level nutrition course was not an athlete-focused intervention, the findings suggested an increase in knowledge for student athletes completing a nutrition course, confirming previous research (27).
Indications by the current study that collegiate athletes completing a collegiate level nutrition course had better nutrition knowledge may benefit smaller universities with limited resources. Inclusion of a nutrition course could be more cost effective in improving the nutrient status of their athletes rather than maintaining a sports dietitian on staff (10). Many universities teach an introductory nutrition course and first-year student athletes could be required to take the course for academic credit. Participation by student athletes in an interactive Internet-based nutrition education program could be another viable option (28). Other options could include small group cooking and nutrition classes designed by an RD to address the individual needs of various sports. The cooking classes could also help address reported student-athlete concerns of how and what to eat. Regardless of how the information is presented, collegiate athletes need expertise and guidance to understand their nutritional needs.
Another unique finding of the current study was higher nutrition knowledge scores among athletes participating as individuals versus teams. This result is similar to a previous study that reported cross country and track athletes had higher nutrition knowledge scores than athletes from other sports (25). The differences observed in the current study may reflect the wide range of nutrient needs found in individual sports like track & field. Additionally, the greater nutrition knowledge held by individual sport athletes may reflect greater access to a nutrition professional (25) or encouragement from coaching staff to seek information from reputable sources (16). Individual sport athletes may also practice more self-regulatory skills and processes (26) to seek out sound nutrition advice than team sport athletes (9).
Recognition by athletic programs that different types of athletes have different nutrient needs (7-8) and different levels of understanding of nutrition may be useful in addressing the needs of specific athletes. Appropriate information needs to be disseminated to each type of athlete as the general day-to-day dietary consumption of athletes has the ability to impact performance (11) and, for some athletes, could result in long-lasting effects such as bone loss in female athletes (2).
Athletes in the current study were found to be the most knowledgeable regarding the function of fiber, hydration status, and replenishment of fluid and electrolytes. Previous findings indicate that college athletes are knowledgeable in the area of fluids and dehydration (18). Specific areas where nutrition knowledge was lacking included carbohydrate use in the body, vitamin storage, diets (low-fat and weight loss), and the impact of protein on muscle gain. These misconceptions are consistent with previous analyses indicating athletes often misunderstand the role of macronutrients, vitamins, and the benefits of dietary supplements (6). There was significant improvement in energy, carbohydrate, and protein intake when nutrition intervention was provided by an RD to student athletes (22).
Among the variety of nutrition information sources cited by athletes, in the current study, peers and athletic trainers were among the most common. Similarly, a previous study of collegiate volleyball players reported the media/internet/coach/trainer as the most common source of nutrition information (22). When available, coaches and athletic trainers are likely to utilize the services of an RD (16). However, NCAA athletes, even those with access to an RD, reported feeling most comfortable seeking nutrition advice from strength and conditioning specialists, parents, and athletic trainers (21). Despite less comfort in seeking the skills of an RD, collegiate athletes enrolled at universities with a Board Certified Specialist in Sports Dietetics (CSSD) have better nutrition knowledge and greater confidence in their abilities to make good nutrition-based decisions (25). While athletic trainers and strength and conditioning specialists can be good sources of nutrition information and score higher in nutrition knowledge than coaches, athletic trainers remain very confident in quality of information provided even when their knowledge is incorrect (21). Though athletic trainers may have a high level of nutrition knowledge and can be a positive source of information for collegiate athletes, there is the potential that athletic trainers are confidently passing on incorrect information to athletes.
Additional research is needed to fully understand factors contributing to nutrition knowledge,and how best to address the nutrition needs,of collegiate athletes. The extent to which differences in nutrition knowledge scores, the reason for these differences, and on-campus access to healthcare providers warrants further investigation. Future research should also focus on the development of a tool that can capture nutrition knowledge as well as measure behavior of collegiate athletes.
Limitations of the current study include reliance on self-reported data by student athletes. Questionnaires were administered in spring semester, so seniors competing in fall sports were excluded, which possibly altered overall team nutrition knowledge scores. Also, the questionnaire did not ask athletes to disclose their academic major which may have had an impact on the completion of a nutrition course. The questionnaire included all healthcare professionals together rather than isolating dietitian as an answer option, so any athlete already accessing a dietitian could not be reported. The open-ended nature of the survey question addressing athlete nutrition concerns and the context under which the questionnaire was administered prevents a conclusive determination as to whether concerns were performance based concerns, general nutrition based concerns, or both. Furthermore, the current measure may not have captured all aspects of nutrition knowledge nor did the questionnaire measure actual behavior. Additionally, since the study included a nonprobability sample of athletes at a single university, findings may not be applicable to all collegiate athletic programs.
The results of the current study indicate that collegiate athletes need and want nutritional advice. The current study also indicates that athletes participating in team sports may have a different level of nutrition knowledge than those participating in individual sports. Collegiate athletes and athletic departments could benefit from the provision of nutrition education in that proper nutrition can help athletes perform better, reduce injuries, and in general, stay in better health. Many collegiate athletic departments may not have the financial means to provide individualized nutrition support to their athletes, but the current study indicates that completion of a collegiate level nutrition course can have a positive benefit on nutrition knowledge and provide athletes with the information to make better nutrition choices.
APPLICATIONS IN SPORT
Nutrition can play a pivotal role in the performance of collegiate athletes and athletic departments should emphasize proper nutrition in combination with appropriate sport related training. Smaller universities that have greater financial constraints will need to be more creative, but collegiate level nutrition courses and small group cooking classes designed by a Registered Dietitian would be low budget options that can provide basic information to athletes that could improve performance and overall health. Universities with successful athletic teams also benefit from increased notoriety, recruitment abilities, and ultimately increased attendance at sporting events leading monetary increases.
The authors thank Sarah Carson Brunelle, RD, LD for her assistance with data collection.
No grant money or other financial support was received during the course of this study.
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Table 1. Characteristics of responding collegiate athletes and corresponding mean knowledge scoreab
Table 2. Comparison of mean knowledge scores of collegiate athletes across primary source of nutrition information