Nutrition Knowledge, Eating Practices, and Health of Adolescent Female Runners: A 3-Year Longitudinal Study

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1 lnternationaljournal of Sport Nutrition, 1996,6, Human Kinetics Publishers. Inc. Nutrition Knowledge, Eating Practices, and Health of Adolescent Female Runners: A 3-Year Longitudinal Study Barbara G. Wiita and Isabelle A. Stombaugh The purpose of this study was to examine changes in nutrition knowledge, intakes, attitudes, and behaviors as well as health status of 22 female adolescent runners. Subjects completed questionnaires, interviews, and dietary analyses twice over a 3-year period. Overthis time they experienced physical growth and improved athletic performance. Although their mean score on a test of basic and sports nutrition knowledge remained stable at 67%, after 3 years more runners correctly responded to statements about carbohydrate and fat. However, fewer responded correctly to statements regarding fluid intake and skipping meals. --. Although runners increased the percentage of calories consumed as carbohydrates, they significantly decreased their mean energy intake, thus lowering carbohydrate intake. They significantly lowered protein, calcium, potassium, and sodium intakes. The incidence of possible eating disorders increased, as did stress fractures. Over 3 years, nutrition knowledge did not improve, the quality of dietary intakes decreased, incidence of eating disorders and stress fractures increased, and menstrual irregularities remained high. Key Words: carbohydrate, dietary intake, eating disorders Many endurance athletes and their coaches believe that lower body weights will produce faster times. For female athletes, who have higher levels of body fat than their male counterparts, attempting to control weight without knowledge about nutrition can result in poor or insufficient dietary intakes, disordered eating, amenorrhea, and future health problems such as osteoporosis. Although many health and fitness professionals presume that the nutrition and health problems of endurance female athletes may worsen the longer the women participate in their sport, no studies have documented the progression of these problems over time. Acquiring nutrition knowledge is a cumulative process. Individuals may receive information, but they only internalize what is important to them (25). In previous studies, when high school and college women participating in competitive sports were given comparable tests of nutrition knowledge, mean scores ranged from45% to 76% correct (1,8,19,29). With increases in age, educational level, and The authors are with the School of Home Economics, University of Akron, Akron, OH

2 Nutrition Knowledge / 41 5 time in a sport, scores also increased (1,8, 19,29). Whether knowledge is carried over into eating practices is unclear. It is believed that people who have basic knowledge of nutritional principles apply them when choosing food (19,28). Eating disorders are a special problem for athletes. The emphasis on thinness in our culture can be further reinforced by a sport environment that often stresses the effect of body size on peak performance. Runners may feel that they should be very lean to be successful. Many begin dieting during adolescence (12, 24). However, research on elite female runners has not shown a relationship between race time and body mass index or body weight (32). In order to control weight, female athletes may resort to bulimic or anorexic behavior (2,10,24). Disordered eating patterns, once established, are difficult to relinquish. Quality and quantity of food intake, as well as levels of physical activity during training and competition, affect adolescent female bone formation. Dietary calcium level is one factor that affects bone strength (4,8,13). Insufficient calcium has implications not only for osteoporosis in the future but also for stress fractures during the athlete's career (2, 4). Strenuous exercise, particularly long-distance running, has been associated with menstrual irregularities, including delayed onset of menarche, hormonal decreases, and amenorrhea (2,14,27,31). Other variables that may contribute to amenorrhea in the female athlete include body composition changes, nutritional deficiencies, weight loss, and psychological stress (1 7,27,3 1). Amenorrhea, in turn, has a negative impact on bone density and strength (2). Athletes are susceptible to the influence of others. When questioned about whom they would ask for information, female runners in a previous study stated that their coach was their primary source (29). The coach's assessment of ability is an important factor in the young competitor's development. The athlete respects the coach and is eager to receive the benefits of the coach's expertise, including such areas as optimal dietary habits and weight control. However, the coach is not always knowledgeable about nutrition and may dispense incorrect information (1 1). There have been no longitudinal studies of young female athletes' eating behaviors, health, and performance. Because the stress of sports participation is added to the normal concerns of growth and development, potential problems may be magnified for these athletes. Although studies have highlighted specific concerns of athletes at certain points in time, no researchers have noted if these concerns carry over from early to late adolescence. The purpose of this study was to examine and compare female runners over a 3-year period for changes in nutrition knowledge, eating attitudes, and physical status, and to learn about outside influences on female adolescents. Methods This descriptive, qualitative, and quantitative study examined a purposive sample of female runners. The subjects were adolescents from across the United States who participated in a summer camp for elite runners (Time 1). The top 2% of high school runners at state meets were invited to attend the camp. Of those invited, 37 initially took part in the study. Three years later (Time 2) the same runners were contacted by mail and telephone and asked to participate again, whether or not they were still running. Twenty-two of the original runners agreed. The subjects in this study include the 22 runners who completed both phases. Information regarding nutrition knowledge, attitudes, and eating behaviors was gathered using questionnaires, tests, and interviews. The same questions were

3 41 6 / Wiita and Stombaugh asked at Time 1 and Time 2. The runners were given apersonal dietary analysis with suggestions for improvement at the end of each research period. After their completed forms were received at Time 2, the participants were sent a gift to acknowledge their contribution. Subjects completed a nutrition knowledge test, which was a modified version of a standard Werblow test, a well-documented, well-reputed inventory that assesses basic nutrition knowledge (28). The original test includes a spectrum of statements regarding general nutrition knowledge and nutrition for the athlete. For this study, an updated version modified by Perron and Endres (19) was used. A composite test score was formulated from the percentage of correct responses. Nutrient intake was measured by a self-reported 3-day food record. Intakes were analyzed using the Computrition (5) software program. Actual intakes, percentages of the Recommended Dietary Allowance (RDA), and nutrient density (per 1,000 kcal consumed) were evaluated for several nutrients. Each subject was asked to complete the Eating Attitudes Test (EAT), an instrument often used to predict disordered eating based on responses to questions dealing with eating behaviors, attitudes toward food and diet, and perceived body image (9, 12). This 26-item test, with a Likert scale response, is a general index of anorexic characteristics, especially those concerned with fear of weight gain, drive for thinness, and restrictive eating patterns. It is a useful screening device to predict or identify likely cases of eating disorders such as anorexia nervosa and bulimia. However, a high score does not invariably reflect an eating disorder and a low score does not rule it out. The EAT is considered to be a useful guide for monitoring change in eating behaviors (12). Each subject completed a training questionnaire designed to collect demographic data and information regarding training, eating practices, and health concerns. Later, an interview was conducted to clarify information given on the 3- day food record. Open-ended questions were also asked in order to identify the individual's regarding food and sport. At Time 1, the interview was held at the running camp. At Time 2, it was conducted by telephone. Data were coded and analyzed with the Statistical Package for Social Sciences (SPSS) (18). The significance level for statistical analysis wasp <.05. Data were analyzed by comparing means for the group at Time 1 and Time 2 with t tests, cross-tabular analysis, and analyses of variance (ANOVA). The nutrition knowledge test, nutrient intakes, and EAT scores were examined in this manner. We qualitatively analyzed the data by examining them for patterns and trends. Results The subjects were 22 elite female adolescent runners who completed the tests and questionnaires during both phases of the study. Of the 22 athletes who participated, 73% were still running at Time 2, and 87% had been offered college athletic scholarships. Physical characteristics of the runners reflected growth over 3 years. At Time 1, mean age was 16, weight was Ib, and height was 63.6 in. At Time 2, when the mean age was 19 years, weight was lb and height was 65 in., both significantly greater than at Time 1 (Table 1). For a 5,000-m race, the standard distance in cross-country racing, the mean personal record at Time 1 was min. At Time 2, this time dropped to min, a significant diffe~nce (Table 1).

4 Nutrition Knowledge / 41 7 Table 1 Physical Characteristics of Female Adolescent Runners (N = 22) Characteristic Time 1 Time 2 Age (years) Mean Range Weight (lb) Mean SEM Range Height (in.) Mean SEM Range Personal record time (min), 5,000-m race Mean SEM Running Stress fractures Menstrual status Amenorrheic (0-3 cycleslyear) Oligomenorrheic (4-9 cycleslyear) Eumenorrheic (10-14 cycleslyear) On medication to regulate menses ***p c.001, significant differences between means on paired t tests. The mean score for the nutrition knowledge test did not change from Time 1 (66.2% f 3.1) to Time 2 (66.9% rtr 2.5). The incidence of correct responses was tabulated. At Time 1, less than 50% of the runners responded correctly to 10 of the statements on the nutritional knowledge test. At Time 2, less than 50% of the runners responded correctly to 6 of the statements. The statements with the fewest correct responses are listed in Table 2. The difference in responses at the two times to 10 questions was statistically significant O, <.05). After 3 years, more runners correctly responded to statements about carbohydrate and fat. Fewer responded correctly to statements regarding fluid intake and skipping meals (Table 3). The runners' nutrient intakes were determined from the 3-day food records. The average daily caloric intake decreased significantly (p =.02) from 2,150 kcal (1,134 from carbohydrate) at Time 1 to 1,647 kcal (1,011 from carbohydrate) at Time 2. Mean caloric intake dropped significantly (p =.01) from 42.1 f 3.0 kcall kg at Time 1 to 31.2 & 2.4 kcallkg at Time 2. Mean carbohydrate intake also decreased from 5.5 If: 0.35 glkg at Time 1 to 4.7 k 0.45 gkg at Time 2. The drop in protein intake (from 80.8 to 57.0 glday) significantly decreased (p =.001) the grams of protein consumed per kilogram of body weight (i.e., 1.6 f 0.11 at Time 1 versus 1.1 f 0.08 at Time 2; Table 4).

5 41 8 / Wiita and Stombaugh Table 2 Correct Responses by Less Than 50% of Female Runners to Statements on Nutrition Statement Percentage correct Time 1 Time 2 Equivalent weights of carbohydrate and protein have approximately the same caloric value. (True) Protein is the primary source of muscular energy for the athlete. (False) Increasing protein in the diet is necessary in order to increase muscle mass in the body. (False) Certain foods, such as grapefruit, are of special value in reducing diets because they bum fat. (False) A diet with little or no fat is the best diet for an athlete. (False) Adults may be overweight because they were taught to clean their plates as children. (True) It is important for the athlete to take nutrient supplements. (False) Athletes may require higher sodium levels than less active people. (True) An athlete should drink no water during practice but rather rinse out her mouth or suck on ice cubes. (False) The proportion of total calories from each of the energy-containing nutrients was calculated. Significant changes were seen in fat and carbohydrate intakes. The average percentage of total calories from carbohydrate was 53.1% at Time 1 and 59.6% at Time 2 (p =.02). The average percentage of calories from fat was 3 1.7% at Time 1 and 26.4% at Time 2 (p =.01). (Table 4). The mean absolute daily intake, percentage of the RDA, andnutrient density for selected nutrients are given in Table 4. Calcium, potassium, and sodium intakes were significantly lower at Time 2 (p <.05). The subjects reported the foods that they avoided. Significantly more runners limited fried foods at Time 2 than they had at Time 1 (p =.02). More runners also limited milk, cheese, and beef at Time 2, although these differences were not significant. Thirteen subjects reported that they had changed their diets since they started running; changes included eating less fat, meat, cola, and junk food and more vegetables. Eating behavior and attitudes were measured by means of the Eating Attitudes Test (EAT). At Time 1, none of the runners had scores indicative of disordered eating. At Time 2, 27% had high scores. ANOVA showed a notable difference in mean caloric intake and nutrition knowledge between the two groups. Those individuals with acceptable EAT scores consumed an average of

6 Nutrition Knowledge / 419 Table 3 Significant Differences in Subjects' (N = 22) Responses to Statements on Nutrition Between Time 1 and Time 2 Correct responses (%) Statement Time 1 Time 2 More correct responses at Time 2 Equivalent weights of carbohydrate and protein have approximately the same caloric value. (True) Carbohydrates are not as easily and rapidly digested as proteins and fat. (False) Protein is the primary source of muscular energy for athletes. (False) A reducing diet should not contain bread or potatoes. (False) Food advertisements are a very reliable source of nuhition information. (False) A diet low in cholesterol and saturated fat will aid in prevention of heart disease. (True) Adults may be overweight because they were taught to clean their plates as children. (True) More correct responses at Time 1 An athlete should drink no water during practice but rather rinse out her mouth or suck on ice cubes. (False) Skipping meals is justifiable if you need to lose weight quickly. (False) Carbohydrate loading increases glycogen in muscle and may improve performance in endurance events. (True) Note. Significance was calculated in paired t tests. *p <.05. **p <.01. 1,781 kcal, while those with high EAT scores consumed an average of 1,295 kcal daily (p =.04). Runners with acceptable EAT scores had a mean of 70% on the nutrition knowiedge test, whiie those with high EAT scores had a mean of 57% (p =.05). The subjects expressed health concerns about menstrual status and about injuries. Approximately half (56%) of the subjects had begun running before menarche. All subjects had begun menstruating by Time 1, when 9% were amenonheic, 3 1% oligomenorrheic, and 60% eumenorrheic. At Time 2,9% were amenonheic, 18% oligomenorrheic, and 73% eumenonheic. None were taking hormones to regulate menses at Time 1. At Time 2, however, 27% were taking such medication. These were reported as eumenorrheic (Table 1). At Time 1, 3 runners (13%) reported that they had experienced stress fractures. At Time 2,4 additional runners stated that they had experienced stress

7 420 / Wiita and Stombaugh Table 4 Dietary Intake of Runners (N = 22) Nutrients Time 1 Time 2 Energy intake Average daily total energy intake (kcal)** Calories per kilogram body weight Calories from carbohydrate Carbohydrate per kilogram body weight (g) Average daily protein intake (g)** Protein per kilogram body weight (g)*** Percent calories as carbohydrate*" Percent calories as protein Percent calories as fat** Mineral intake Average daily calcium (mg)* * Average daily phosphorus (mg)** ** Average daily iron (mg) Average daily zinc (mg) Average daily sodium (mg)* Average daily potassium (mg)* Vitamin intake Average daily vitamin A (IU) Average daily thiamin (mg) Average daily riboflavin (mg) Average daily folacin (mg) Average daily vitamin C (mg) Fiber intake Average daily fiber (g) Density of fiber (g) (per 1,000 kcal) consumed)* Note. Significant differences based on paired t tests. *p <.05. **p <.01. ***p <.001.

8 Nutrition Knowledge / 421 fractures. Thus, 7 (3 1 %) of the runners reported stress fractures by Time 2. Analysis of variance of calcium intake with menstrual status and with stress fractures did not show significant differences. As shown in Table 4, calcium intake was low for all the runners. Other injuries reported by 17 of the runners at Time 2 included hip, thigh, foot, and muscle injuries. Three subjects reported more than four injuries. At Time 1, 40% of the group reported that they had asked for advice concerning diet and health, and of these, 55% had received such advice. At Time 2, 70% had asked for advice, and of these, 90% had received it. The most frequent source of this advice was the coach (n = 15 at Time 2). Other sources of advice included parents, doctors, and teammates. At Times 1 and 2, 25% of the runners reported dissatisfaction with their weight. At Time 2,41% of the respondents stated that they had felt pressure about their weight. Sources of pressure were coaches, parents, friends, fashion models, and self. The interviewees stated that the nutrition advice from coaches was to eat carbohydrate foods, to avoid fat, to not eat too much, to eat enough, to eat at the end of a race, and to pay attention to what works. Six runners stated that their coach did not know or provide any nutritional advice. Discussion As one would expect, the runners changed over the 3 years: They were taller, heavier, and faster at Time 2. Overall scores on a test of nutrition knowledge did not change significantly over time but were comparable to those reported by other researchers (8, 19). Analysis showed patterns of continued misinformation. Few runners understood that equivalent weights of carbohydrate and protein have approximately the same caloric value. The runners thought that a diet with little or no fat is best for an athlete. Most stated that protein is the primary source for muscular energy and that increasing dietary protein is necessary to increase muscle mass. Many thought that athletes required no more sodium than other people. These misconceptions, if used to make food choices, could negatively affect the athletes' performance. Positive trends in nutrition knowledge were seen. There were significant increases in knowledge regarding caloric value and digestion of complex carbohydrates and protein. More runners knew that a diet low in cholesterol and saturated fat may reduce the risk of heart disease. There were also negative trends in knowledge. After 3 years, more runners agreed with the false statement that an athlete should drink no water during practice, a technique which could have negative consequences such as dehydration and nervous system dysfunction (30). More runners also believed erroneously that skipping meals is justified if an individual needs to lose weight quickly. The runners' nutrient intakes decreased from Time 1 to Time 2. Average daily caloric intake was significantly lowered from 2,150 to 1,647 kcal (p =.02). The RDA is 2,200 kcal for healthy, sedentary females (7), and runners need additional calories to fuel their activities. Their low consumption may have limited the energy available for physical activity and also essential nutrients needed for growth, repair, and sports performance. The proportion of carbohydrate calories in the diet increased from 53% (Time 1) to 61 % (Time 2). This shift is in line with current dietary recommendations (27). Carbohydrate is the primary energy source, and it is suggested that endurance

9 422 / Wiita and Stombaugh athletes consume at least 60% of calories from carbohydrate (23, 30). However, although the percentage of calories as carbohydrate increased, total caloric intake decreased. As a result, the mean carbohydrate intake actually decreased from 1,134 to 1,011 kcal. Intake per kilogram of body weight decreased from 5.5 to 4.7 g. A high-carbohydrate diet of 6 to 9 g per kilogram body weight is recommended for athletes such as runners, since carbohydrate is the primary fuel for endurance activity (3, 22, 23, 26). These runners had carbohydrate intakes lower than recommended level. The runners' protein intake decreased significantly from 1.6 to 1.1 g per kilogram body weight over the 3-year period. Although these values are higher than the RDA (7), after 3 years the runners' intakes were lower than recent recommendations, which range from 1.2 to 1.7 g per kilogram for endurance athletes (15,30). Adequate dietary protein is necessary to maintain nitrogen balance and prevent sports anemia. Female endurance athletes such as these runners may also need higher values because their energy intakes are usually low (30). Daily intakes of calcium, potassium, and sodium were significantly decreased. Many runners stated that they limited milk and cheese at Time 2. These foods are important sources of calcium and potassium, but they are sometimes associated with fat, and this may account for their decrease in the subjects' diets. This trend of decreased calcium intake is a concern, because the RDA for calcium is 1,200 mg for this age group and the mean intake for the runners was 623 mg, well below the recommendation (7). Lack of calcium contributes to weak, porous bones and is associated with stress fractures, a common problem for runners (4,8). The menstrual irregularities seen in these runners could further compromise bone density. Average daily fiber intake increasedfrom9.7 to 11.9 g but was still well below the recommended level of 25 g. Although the runners increased fiber, their intake needed to be augmented for optimum functioning of the digestive system. As the adolescent female athletes grew older there was more indication of disordered eating. Other researchers have also shown that the incidence of disordered eating tends to rise through adolescence (10, 12). Runners with high EAT scores consumed significantly fewer calories. Strenuous exercise, especially distance running, is associated with menstrual irregularities. At Time 2, 27% of the subjects were being medically treated to regulate their cycles and were classified as eumenorrheic. Before treatment, however, they would have been classified as amenorrheic or oligomenorrheic, thus increasing the percentage of menstrual irregularities in the group from 40% to 67%. A high percentage (56%) of the subjects reached menarche after becoming athletes. Other researchers have reported that 12% to 54% of runners begin running prior to menarche (16,21). Women who begin athletic training before menarche may delay onset of menses or may be at greater risk for amenorrhea (2, 16,21,27). Athletic amenorrhea is a multifactorial problem that may be associated with genetic propensity, hormonal status, nutritional adequacy, eating behavior, body composition, and amount of exercise as well as participation in sports before menarche (2, 14, 16,20,21,27). A number of these factors were seen in this population of elite runners. The reproductive hormones influence bone density because they positively affect the deposition of calcium. Athletes with menstrual irregularities may have decreased bone density. Researchers have reported a high prevalence of stress

10 Nutrition Knowledge / 423 fractures among runners, especially among those with amenorrhea (2,6,21). The incidence of stress fractures increased during this study even though a number of the runners had received treatment for menstrual irregularities. Their low calcium and phosphorus intakes may have contributed to decreased bone density. The impact of running upon a body with fragile bones may increase the risk of stress fractures (4, 6,27). Many runners reported that they felt pressure about their weight. At both times in the study, 25% were dissatisfied with their weight. The ideal body for a runner is perceived as lean, and the cultural ideal for young women is slender. Thus, runners feel pressure to be thin from their sport as well as from society. The subjects experienced pressure from coaches in the form of comments or weighing sessions. Parents and friends were also sources of pressure. Advice from coaches varied. Coaches recommended carbohydrates, the best energy source for exercise. Some coaches told their runners to avoid fat. While excessive fat intake may be a concern in the general population, it is less of a problem for runners, whose fat intakes are usually within recommended levels. Dietary fat is a concentrated form of energy that can provide runners with needed calories in a compact form. Some coaches reminded their runners to eat at the end of a race, a wise practice, since delaying carbohydrate intake for too long after exercise impairs recovery (3,22,26). Summary and Implications In this study, young female runners were followed over a 3-year period. Although there were individual differences, patterns were evident: Physical growth occurred, problems associated with food increased, and the incidence of eating disorders increased. Eating disorders, which are often hidden, can be difficult to change and carry serious health consequences. University athletic departments may need to develop programs to help identify athletes with eating disorders as well as a referral system for treatment. The percentage of energy nutrients consumed as carbohydrate increased over time. However, the decrease in total carbohydrate consumption and significant decrease in total energy intake were unexpected. The runners did not eat enough to meet the caloric needs of sedentary individuals. These runners need to receive nutrition education so they understand that their low caloric intakes could have negative consequences for performance and health. The runners' knowledge of long-term health implications of excessive fat intake combined with food choices that reduced fat in their diets were evidence of positive change. However, the pendulum may have swung too far, as some runners made excessive efforts to reduce fat and were unaware of its role in the body and its value to the athlete. The trend toward lower protein intake shown by these runners is a concern, since protein is so important for an endurance athlete. Protein, which is needed for nitrogen balance, may be used to meet energy needs when there is low caloric consumption. The very low amount of calcium as well as other nutrients consumed by the runners is a concern. Perhaps in their efforts to lower fat, runners eliminated good sources of calcium and other minerals. Calcium and phosphorus intakes are important during the years of competition to provide bone strength.

11 424 / Wiita and Stornbaugh Runners in this study did not have suboptimal iron intakes. Perhaps they were aware of the importance of iron and consumed iron-fortified foods. Analysis of their food intake showed that they consumed amounts of iron close to the RDA. Knowledge of nutrition is important for runners but it must be meaningful for them. They want a slender body that conforms to society's ideal. They want the winning edge. They want approval of their coaches and the sense of identity that running provides. As adolescents they are less concerned about the long-term health consequences of poor nutrition and more concerned with its effects on their appearance and their immediate performance. In our society, where there is so much freedom and adolescents have so many opportunities to make their own choices, it is important that they have the information to make wise decisions. Much misinformation related to sport nutrition is evident from this study. A better understanding of nutrition principles and application of this knowledge would have a positive impact on young athletes' food choices, performance, and health. Improving athletic performance may be the motivation that female runners need to implement sound nutritional strategies. A nutrition education program should also emphasize the short-term health benefits of a nutritional diet, such as reduction of stress fractures, rather than long-term benefits like the prevention of osteoporosis, since high-school and college-aged runners tend be concerned with their present performance rather than future consequences. References 1. Barr, S. Nutrition knowledge of female varsity athletes and university students. J. Am. Diet. Assoc. 87: , Barrow, G.W., and S. Saha. Menstrual irregularity and stress fractures in collegiate female distance runners. Am. J. Sports Med. 16: , Coleman, E. Carbohydrates: The master fuel. In Sports Nutrition for the 90s, J. Berning and S. Steen (Eds.). Gaithersburg, MD: Aspen, 1991, pp Dalsky, G. Effect of exercise on bone: Permissive influence of estrogen and calcium. Med. Sci. Sports Exerc. 22: , Computrition. Chatsworth, CA: Computrition, DeSouza, M.J., and D.H. Metzger. Reproductive dysfunction in arnenorrheic athletes and anorexic patients: A review. Med. Sci. Sports Exerc. 23: , Food and Nutrition Board, Commission on Life Sciences, National Research Council. Recommended Dietary Allowances (10th ed.). Washington, DC: National Academy Press, Frederick, L., and S. Hawkins. A comparison of nutrition knowledge and attitudes, dietary practices, and bone densities of postmenopausal women, female college athletes, and nonathletic women. J. Am. Diet. Assoc. 92: , Garner, D., and P. Garfinkel. The Eating Attitudes Test: Psychometric features and clinical correlates. Psychol. Med. 9: , Garner, D.M., and L.W. Rosen. Eating disorders among athletes: Research and recommendations. J. Appl. Sport Sci. Res. 2: , Graves, K., M. Farthing, S. Smith, and J. Turchi. Nutrition training, attitudes, knowledge, recommendations, responsibility, and resource utilization of high school coaches and trainers. J. Am. Diet. Assoc. 91: , Hsu, L.K. Eating Disorders. New York: Guilford Press, 1990.

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