Most commonly asked nutritional questions for athletic trainers

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1 The University of Toledo The University of Toledo Digital Repository Theses and Dissertations 2017 Most commonly asked nutritional questions for athletic trainers Michael Uzelac University of Toledo Follow this and additional works at: Recommended Citation Uzelac, Michael, "Most commonly asked nutritional questions for athletic trainers" (2017). Theses and Dissertations This Thesis is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 A Thesis entitled Most Commonly Asked Nutritional Questions for Athletic Trainers by Michael Uzelac, ATC Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Masters of Science Degree in Exercise Science Luke Donovan, PhD, Committee Chair Sarah Long, Committee Member Janet Simon, PhD, Committee Member Patricia R. Komuniecki, PhD, Dean College of Graduate Studies The University of Toledo May 2016

3 Copyright 2016, Michael John Uzelac II This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author.

4 An Abstract of Most Commonly Asked Nutritional Questions for Athletic Trainers by Michael Uzelac, ATC Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Masters of Science Degree in Exercise Science The University of Toledo May 2016 Context: Athletic trainers (ATC s) are commonly asked nutritional questions from athletes and coaches. Since ATC s are commonly the primary source of health care related topics for athletes, it is important that ATC s are comfortable and confident in being able to respond to these questions. A list of competencies has been developed by the Commission on Accreditation of Athletic Training Education (CAATE) as a minimum of what needs to be taught in an accredited program. There is yet to be research on if the educational competencies completely prepare ATC s for these situations. Objective: To determine what nutritional questions ATC s are most commonly and determine how confident ATs are in answering these questions or knowing when to refer. Design: Descriptive Study Setting: Online survey. Patients or Other Participants: 1,000 certified athletic trainers. Intervention(s): The survey contained 93 questions (9 history/background, 84 assessment). The history/background questions were multiple choice with the ability to write in answers. The assessment questions were designed with a 5 point Likert scale. Main Outcome Measures: Frequency of, and confidence in answering questions about dietary recommendation, iii

5 meal plans, weight management, eating disorders, supplements, body composition, and fluid replacement. Results were viewed as exploratory due to a low response rate leaving the study with not enough power to produce significant findings. Results: Within the category of general nutrition 24% ± 18% reported they never receive the questions asked, 38% ± 10% reported yearly, 31% ± 14% reported monthly, 7% ± 6% reported weekly, and 0% ± 1% reported daily. Weight management and body composition category found that 23% ± 7% reported never, 47% ± 8% reported yearly, 25% ± 7% reported Monthly, 4% ± 3% reported weekly, and 0% ± 0% reported daily. Eating disorders and disordered eating category found 48% ± 16% reported never, 48% ± 13% reported yearly, 5% ± 2% reported monthly, 0% ± 0% reported weekly, and 0% ± 0% reported daily. Performance enhancing and recreational supplements and drugs category found 29% ± 12% reported never, 46% ± 7% reported yearly, 24% ± 8% reported monthly, 1% ± 2% reported weekly, and 0% ± 0% reported daily. The category of general nutrition as a whole had a reported confidence of 3.03±0.76. Within general nutrition, dietary recommendations/general nutrition had a reported confidence of 3.01±0.79, meal plans had a reported confidence of 3.35±0.66, and fluid had a reported confidence of 3.55±0.93. The category of weight management and body composition had a reported confidence of 3.17±0.86. Within weight management and body composition, weight management had a reported confidence of 3.18±0.82, and body composition had a reported confidence of 3.16±0.90. The category of eating disorders and disordered eating had a reported confidence of 3.1±0.8. The category of performance enhancing and recreational supplements and drugs had a reported confidence of 2.60±0.92. Conclusion: The findings indicate that ATC s are asked a wide spectrum of questions on a monthly iv

6 basis. Moving forward in the transition to the Professional Master s Degree, nutrition courses should remain a requirement and taught in a wide range other than just general nutrition. There should also be an emphasis properly identifying issues that need to be referred to other medical professionals. In order to determine if there is any true significance between the categories more research is necessary. v

7 Table of Contents Abstract... iii Table of Contents... vi List of Tables... vii List of Abbreviations... viii 1 Introduction Operational Definitions Statement of the Problem Research Hypotheses Literature Review Methods Study Design Participants Instruments Qualtrics Survey Survey Development Pilot Testing Procedures Statistical Analysis Results Discussion & Conclusion...22 v

8 5.1 Discussion Limitations Future Research Conclusion...26 References...27 A Additional Methods...29 A.1 Survey Building...29 A.2 Survey Distribution...31 A.2.1 Full Survey...31 A.2.2 IRB Form...62 A.2.3 Distribution Letter...63 B Additional Results...65 vi

9 List of Tables 3.1 CAATE Nutrition Competencies Participant Demographics General questions Frequency Totals of All Categories Confidence Scores of All Categories...21 B.1 Frequency of General Nutrition Concepts Questions...65 B.2 Frequency of Wight Management and Body Composition...68 B.3 Frequency of Eating Disorders and Disordered Eating...69 B.4 Frequency of Performance Enhancing and Recreational...70 B.5 Confidence of General Nutrition Concepts Questions...71 B.6 Confidence of Wight Management and Body Composition...73 B.7 Confidence of Eating Disorders and Disordered Eating...73 B.8 Confidence of Performance Enhancing and Recreational...74 B.9 Sports Covered by Participants...75 vii

10 List of Abbreviations ATC...Athletic Trainer Certified BOC...Board of Certification CAATE...Commission on Accreditation of Athletic Training Education FDA...US Food and Drug Administration NATA...National Athletic Trainers Association viii

11 Chapter 1 Introduction Athletics is constantly evolving with teams and athletes looking for something to give them the edge. This has led to advances in both equipment and training. In recent years many athletes have turned to nutrition. As a result of that, 49.6% of athletes have reported their universities have a registered dietitian on staff (1). This also means that half of all college athletes do not have a registered dietitian to turn to for proper nutritional guidance. Athletes then need to turn to someone else, which has commonly been reported as Athletic Trainers (ATCs)(1-3). The relationship between nutrition, health, and fitness can be important components for overall health in all populations. Proper nutritional practices are able to reduce the likelihood of illness and injury due to a higher standard of healthy living (2). Although the goals may be different when compared to the general population, proper nutrition is essential for individuals that participate in competitive athletics to maintain strength, flexibility, and endurance (2). There are many common trends and misbeliefs around nutrition that can make it hard for athletes to get the proper nutritional information (2). Since ATCs are commonly a source of information, it is important that 1

12 ATCs are knowledgeable in the questions they receive as well as confident in being able to give correct information or referring to a proper source (1-3). The AT Strategic Alliance has recently announced the decision to change the athletic training degree to a master s level (4). With programs changing over to the new format it will require a change in the curriculum. Currently, there are specific expectations that all athletic training students are supposed to meet, known as competencies. These competencies, which can be found in table 3.1, have been developed by the National Athletic Trainer s Association (NATA) and are used by the Commission on Accreditation of Athletic Training Education (CAATE). As part of accreditation, each program must meet these competencies in their athletic training program curriculum (5). Even though there are several different specific competences, there are no regulations that state how much attention should be paid to each one or how they should be taught. This may be due to the lack of previous research into which questions ATCs are most commonly faced with. With that information it would allow programs to be better aimed at to reflect more real life situations of the day to day responsibilities of ATCs. It has been found that the majority of ATCs have adequate knowledge of nutrition (3). They have also shown that coaches and athletes have a lack of adequate knowledge in nutrition (3). In one previous study, coaches identified ATCs as their most frequently used source of nutritional information while athletes identified them as their second most common resource used (3). A different study stated that collegiate athletes reported they chose ATCs as their primary source of nutritional information (1). The reason why they are commonly chosen as a top source of nutritional information may be because only 2

13 49.6% of athletes report having a nutritionist available at their university (1). Regardless of the reason, these studies demonstrate the importance of nutritional knowledge in ATCs and why there is a necessity for them to have appropriate confidence in the information they are giving their athletes. It is important that ATCs are not only knowledgeable of nutritional concepts, but they are confident in addressing nutritional questions, and if necessary, know when to refer to a registered dietitian and/or physician. The purpose of this study is to determine what nutritional questions ATCs are most commonly asked as well as determine how confident ATCs are in answering these questions and knowing when to refer. If we are able to identify what question they are approached with the most, future educational programs can use that information to assure they are preparing their students for the problems they are more likely to face in their careers. We hypothesize that the most common questions asked will be about supplements and the least common questions will be about eating disorders. We also hypothesize that ATCs will feel the most confident about answering questions about fluid replacement and the least confident in answering questions about supplements. Secondary analysis will also be done to determine if there are any relationships between specific populations and specific types of questions. 1.1 Operational Definitions Athletic Trainer (ATC): Any time athletic trainer is references it will be in reference to a current BOC certified athletic trainer. Nutritionist: Any time nutritionist is referenced it will be in reference to a registered detrition. 3

14 Board of Certification (BOC): Body responsible for certification of athletic trainers (2). National Athletic Trainers Association (NATA): The national association representing athletic trainers in the United States (2). NATA Competencies: Set of knowledge skills that must be included in athletic training education programs set by the national athletic trainers association (2). Commission on Accreditation of Athletic Training Education (CAATE): The committee responsible for accrediting athletic training education programs (2). 1.2 Statement of the Problem ATCs are commonly asked nutritional questions from athletes and coaches. It is important that ATCs are comfortable and confident in being able to respond to these questions (1-3). It is also important to ensure that through the educational competencies, athletic training students are being taught how to deal with the questions they will most commonly receive. The purpose of this study is to determine what nutritional questions ATCs are most commonly asked as well as determine how confident ATCs are in answering these questions and knowing when to refer. 1.3 Research Hypotheses 1. The most common questions asked will be about supplements and the least common questions will be about eating disorders. 4

15 2. Athletic Trainers will feel the most confident about answering questions about fluid replacement and eating disorders and the least confident in answering questions about supplements. 5

16 Chapter 2 Literature Review Nutrition plays an essential role in athletics and a healthy lifestyle (6). Optimal energy availability and proper training are key parts in maximizing both health and performance of an athlete (7). According to Hawley et al.(8), other than heredity and training, no single factor plays a greater role in optimizing performance than diet. Benefits of proper nutrition include greater level of athletic performance and decreased in healing time (9). Healing rate is important when 93% of male and 86% of female collegiate athletes report injuries from sports participation at some point (10). It also helps to assure proper physical development of young athletes (9). It is important that dietary intake is matched with energy expenditure to account for the increased demands on the body associated with competition and training(11). Unsafe weight management can negatively affect both performance and health (12). The American college of Sports Medicine, American Dietetic Association, and Dietitians of Canada released a position statement that identified the key areas of nutrition for athletes as: energy needs, body composition, macronutrient requirements, vitamins and minerals, hydration, training diet, and supplements and ergogenic aids. In the position statement they reported physical activity, athletic performance, and recovery from exercise are enhanced by optimal 6

17 nutrition (13). Athletic Trainers are commonly one if the main sources of nutritional information for athletes and also have an opportunity to be the first line of defense of nutritional problems since they work with them on such a consistent basis (1, 3, 11, 12). With athletes turning to Athletic Trainers for all of this information it is important that they have a proper knowledge of nutrition, weight management, and methods of changing body composition (12). As stated before, athletic training programs have a list of competencies that they must meet in order to be accredited. These competencies are set forth by CAATE to be used as a minimal requirement for a student s education. Of the 49 prevention and health promotion competencies, 18 of them are directly related to nutrition. These 18 competencies then fall into four categories. The four categories are: general nutrition concepts, weight management and body composition, disordered eating and eating disorders, and performance enhancing and recreational supplements and drugs (5). It also is a representation of what CAATE believes are the issues that athletic trainers are faced with. This study will identify which competencies based on nutrition are the most prevalent. Multiple studies have been done to assess the nutritional knowledge of Athletic Trainers as well as coaches, athletes, and Strength and Conditioning Specialists (3, 6, 14). In all of the studies, Athletic Trainers had greater nutritional knowledge than coaches and athletes (3, 6, 14). It should also be noted that the studies before CAATE updated their competencies, Rockwell et al. (14) (66%) and Shifflett et al.(6) (74%), found a lower percentage of Athletic Trainers with adequate nutritional knowledge than did Torres- McGehee et al.(3) (77.8%) which was done after the competencies had been updated. In 7

18 the study done by Torres-McGehee et al.(3), they found that Strength and Conditioning Specialists had the highest level of adequate knowledge at 81.6%, followed by Athletic Trainers at 77.8%, coaches at 35.9% and athletes at 9%. This shows that Athletic Trainers and Strength and Conditioning Specialist do have adequate knowledge while coaches and athletes do not. The lack of knowledge between coaches and athletes emphasizes the importance of Athletic Trainer s knowledge in the subject. The amount of nutritional courses taken varies greatly between Athletic Trainers, coaches, and athletes (6). According to Shifflett et al.(6), 96% of male and 97% of female Athletic Trainers had taken at least one nutritional course with 10-21% of them having taken three of more courses. This does not make them an expert in the field but does indicate that they have more nutritional knowledge than coaches which reported that 73% of males and 46% of females had taken one or more nutritional course. The study also found that only 27% of male and 24% of female athletes had taken at least one nutritional course. Shifflett et al.(6), also stated that Athletic Trainers were more familiar with sports related nutrition than both coaches and athletes. It is interesting that in the study done by Rockwell et al.(14), participants that worked with female athletes tended to score higher than the participants working with male athletes. Little research has been done on the confidence of ATCs when responding to nutritional questions. One study that assessed ATCs knowledge of nutrition did also ask their confidence in their answer to specific nutritional questions(3). This study found that ATCs had higher than normal confidence in their answers when comparing them to coaches, athletes, and strength and conditioning specialists. In this study they used a 4 point Likert scale for confidence(3). 8

19 It is important to understand the different credentials when talking about nutritional experts. A registered dietitian (RD) usually has at least a bachelor s degree and hours in a dietetic internship through an accredited program. They must also pass a dietetic registration exam. A certified nutritionist (CN) must have a two-year college level or distance learning six-course program. They must also pass a proctored exam. The term nutritionist alone does not imply that there is any form of certification (15). For this study we will be referring to registered dietitians. With only around half of universities having registered dietitians on staff it is important to look at where athletes are getting their nutritional information from (1, 3). While it may vary from study to study what the number one resource of nutritional information is, most agree that Athletic Trainers are among the top (1, 3, 6). Strength and Conditioning Specialists and Athletic Trainers were more likely to recommend or use more credible references such as academic journals, Registered Dietitians and Physicians, whereas coaches and athletes turned to magazines, Athletic Trainer s, and Strength and Conditioning Specialists (1, 3, 6). Athletes also commonly reported parents as a source of nutritional information (6). It is important that athletes are being referred to, or given information by credible sources. Supplements have become a hot topic when it comes to nutrition in athletics. It has been found that anywhere from 45% to 88% of have used supplements (1, 14). Burns et al. (1) reported that as many as 58% of athletes used more than one supplement. In 2010, it was reported that there was a 9% sales growth in sports nutrition and weight loss products which results in 22.7 billion dollars in total sales (16). Athletic Trainers have been reported to be the top source of supplement information for athletes followed by 9

20 coaches, Physicians, and Strength and Conditioning Specialist s, in that order (10). Misinformation about supplements can be a risk to safety, legality, and efficacy of dietary supplements for athletes (16). This is why it is important for Athletic Trainers to be able to properly educate athletes on proper and safe uses of nutritional supplements (16). Eating disorders is a hot topic when it comes to athletes and nutrition. They have been seen in as many as 2-40% of college athletes (14). Athletes have a greater possibility of developing eating disorders because of the demands placed upon them (17). Since title IX, participation in female sports has increased by 600% (11). Female athletes are not the only ones that face problems with eating disorders. Weight manipulation through either rapid weight gain or loss has been associated with sports such as wrestling and football (17). It is important that Athletic Trainers be able to identify possible eating disorders for the safety of the athletes since they are in position to be the first to observe the issue (11). With all that is known about common sources of nutritional information and the education level of these sources not much is known about what specific questions are the most frequently asked. It is important that our education programs address the issues that will be faced by student when they work clinically. If we were to know what issues were the most prevalent in athletics we could tailor the programs to address them. Misasi et al. (18) found that 83% of athletic training students believed more emphasis should be placed nutrition in the academic program. Not only is it important to make sure that nutrition is being taught in athletic training programs, but that the issues students will face will be proper taught so that as clinicians they may be confident in answer them correctly or knowing when to refer the situation if needed. 10

21 Chapter 3 Methods 3.1 Study Design We performed a descriptive study using a survey we created to assess what athletic trainers believed were the most frequently asked nutritional based questions they received and their confidence in giving a correct answer. The independent variable was Certified Athletic Trainers. The dependent variables were the frequency and confidence in the following question groups: dietary recommendation, meal plans, weight management, eating disorders, supplements, body composition, and fluid replacement. 3.2 Participants One thousand participants were contacted at random through the NATA. In order for a participant to be included they had to be currently certified through the Board of Certification (BOC). One thousand participants were chosen because it was the allotted amount for student surveys through the NATA. 3.3 Instruments Qualtrics The survey was built using an online survey based platform called Qualtrics. It is used both by businesses and universities around the world. It provides a wide variety of 11

22 tools to customize surveys built with the online software. Qualtrics also provides multiple ways to view, export, and analyze data Survey The survey contained 93 questions which can all be found in Appendix A. The survey consisted of two sections, demographic and assessment. The demographic portion of the survey was made up of multiple choice questions with the opportunity to choose all that applied and an open ended other choice in order to get a detailed background. The background questions included: primary source of nutrition, access to a registered dietitian, gender, work setting, sport coverage, other certifications, number of nutrition courses taken, and years of certified experience. This background information was used in order to discover if there are trends into questions that are being asked of different populations. This was measured during our secondary analysis that will be discussed later in the data analysis section. The assessment portion of the survey was made up of two types of questions, frequency and confidence. Both types of questions were answered on a 5 point Likert scale. The frequency questions scale was made up of never, yearly, monthly, weekly, and daily. The confidence scale ranged from no confidence to extremely confident. We chose to use a 5 point scale instead of a 4 point scale like used in previous studies so there would be the option of a neutral response. The questions of the assessment section were all stated in the same fashion to prevent any variables that may affect our results Survey development The survey was created based off of the NATA Competencies. The competences were broken up into the following smaller categories; dietary recommendations, meal 12

23 plans, weight management, eating disorders, supplements, body composition, and fluid replacement. Questions were then written to make sure all each portion of the NATA competencies was represented within the survey. These competencies can be found in table 3.1. Questions were also developed by recommendation made by eight certified ATCs in the collegiate from their personal experiences. The survey was constructed through Qualtrics for ease of distribution. Table 3.1 CAATE Nutrition Competencies General Nutrition Concepts PHP-32. Describe the role of nutrition in enhancing performance, preventing injury or illness, and maintaining a healthy lifestyle. PHP-33. Educate clients/patients on the importance of healthy eating, regular exercise, and general preventative strategies for improving or maintaining health and quality of life. PHP-34. Describe contemporary nutritional intake recommendations and explain how these recommendations can be used in performing a basic dietary analysis and providing appropriate general dietary recommendations. PHP-35. Describe the proper intake, sources of, and effects of micro- and macronutrients on performance, health, and disease. PHP-36. Describe current guidelines for proper hydration and explain the consequences of improper fluid/electrolyte replacement. PHP-37. Identify, analyze, and utilize the essential components of food labels to determine the content, quality, and appropriateness of food products. PHP-38. Describe nutritional principles that apply to tissue growth and repair. PHP-39. Describe changes in dietary requirements that occur as a result of changes in an individual s health, age, and activity level. PHP-40. Explain the physiologic principles and time factors associated with the design and planning of pre-activity and recovery meals/snacks and hydration practices. PHP-41. Identify the foods and fluids that are most appropriate for pre-activity, activity, and recovery meals/snacks. Weight Management and Body Composition PHP-42. Explain how changes in the type and intensity of physical activity influence the energy and nutritional demands placed on the client/patient National Athletic Trainers Association 15 PHP-43. Describe the principles and methods of body composition assessment to assess a client s/patient s health status and to monitor changes related to weight management, 13

24 strength training, injury, disordered eating, menstrual status, and/or bone density status. PHP-44. Assess body composition by validated techniques. PHP-45. Describe contemporary weight management methods and strategies needed to support activities of daily life and physical activity. Disordered Eating and Eating Disorders PHP-46. Identify and describe the signs, symptoms, physiological, and psychological responses of clients/patients with disordered eating or eating disorders. PHP-47. Describe the method of appropriate management and referral for clients/patients with disordered eating or eating disorders in a manner consistent with current practice guidelines. Performance Enhancing and Recreational Supplements and Drugs PHP-48. Explain the known usage patterns, general effects, and short- and long-term adverse effects for the commonly used dietary supplements, performance enhancing drugs, and recreational drugs. PHP-49. Identify which therapeutic drugs, supplements, and performance-enhancing substances are banned by sport and/or workplace organizations in order to properly advise clients/patients about possible disqualification and other consequences. (5) Pilot Testing After the initial survey was created it was then distributed to 25 ATC s in the North Eastern Ohio area. A total of 18 completed responses were collected. Of the respondents 39% were male (61% female). Experience spanned from 0 to 1 years of experience to 16 to 20 years of experience. Collegiate setting was identified by 61% and high school was identified by 33%. Participants had the opportunity to provide feedback as well at the end of the survey. The results were then examined for consistency. One Question was added following piloting. 3.4 Procedures: Each participant was randomly selected by the NATA and asked through to go to the link and fill out the survey. The was generated from a generic template 14

25 that NATA provided with spaces for information specific to the study. Following the initial , a second was distributed after two weeks as a reminder to complete the survey. The survey was open for one month. The participants were blinded from the researchers, and only contacted by the NATA. The study was exempt from needing a consent form, but in the general , it was clear that individuals did not need to complete the study and could stop at any time. At the end of the one month period the survey was closed and the data was analyzed. 3.5 Statistical analysis Due to being underpowered as a result of not having enough responses we used the data we received as exploratory data. We established count totals for each question and the percentages can be found in Appendix B. Due to the interval nature, or even distance between choices, of the confidence scale, we denoted for confidence values as follows; 1 for an answer of no confidence, 2 for very little confidence, 3 for moderately confident, 4 for moderately confident, and 5 for extremely confident. Questions from each category were grouped together and the mean and standard deviation of those mean scores was calculated and can be found in table 4.4. Frequency questions were ordinal, or followed an order, and not interval in nature but there was consistency seen through the results so totals were lumped together in each category to be viewed as exploratory data and can be seen on table

26 Chapter 4 Results The survey was distributed to 1,000 participants and we had a response rate of 8.2%, or 82. Of the 82 responses, only 69 were complete. Of the 69 that replied, one was not a certified athletic trainer so their responses were dropped leaving 68 total responses. The demographic results of the 68 responses can be found in table 4.1. Responses for each question can be found in the Appendix B. Table 4.1 Participant Demographics n=68 Gender Male Female 25% (17) 75% (51) Professional certification ATC PT NSCA-CSC Other* 100% (68) 1% (1) 7% (5) 25% (17) Nutritional courses taken % (1) 40% (27) 41% (28) 10% (7) 7% (5) Years as ATC 0 to 1 2 to 5 6 to % (0) 21% (14) 79% (54) 0% Work Setting D1 D2 D3 High school Professional Clinic Hospital Other # 16% (11) 3% (2) 6% (4) 46% (31) 3% (2) 13% (9) 3%(2) 10% (7) * Other certifications included; MPH, ITAT, ROT,Chiropractic Assistnat, NASM-PES, LMT, OCS, NASM- CES, CHES, and teacher certification, ACSM-EP-C, OTC, OT-SC # Other Work Settings included; Chiropractic Clinic, Education, national team, University student clinic, Health & Fitness Organization, Junior College, Community College Of the participants a total of 51 (75%) were females and 17 (25%) were males. When asked how many nutritional courses they had taken 1 (1%) said 0, 27 (40%) said 1, 28 (41%) said 2, 7 (10%) said 3, and 5 (7%) said 4 or more. The majority of participants 16

27 report having been an ATC for 6 to 10 years (79%). The rest (21%) have been an ATC for 2 to 5 years. Almost half of the participants (46%) work in the high school setting. The collegiate setting was accounted for by 25% of the participants. Table 4.2 provides more demographic as well as some more general questions. The most common source of nutrition was academic journals (66%), followed by physicians (32%), nutritionist (25%), and 29% said they use other sources. Of all of the participants, 35% said they had access to a nutritionist. When asked to choose all that apply with reporting types of nutritional questions they most commonly receive 76% reported supplements, 75% reported dietary recommendations, 67% reported weight loss/gain, 61% reported fluid replacement, 42% reported meal plans, 25% presented body composition, 13% reported eating disorders, and 3% reported other. The most common source of nutritional questions were from athletes (94%), followed by coaches (51%), other (21%), and 1% strength and conditioning specialist. When asked how often they presented with nutritional questions 49% reported monthly, 29% reported weekly, 19% reported yearly, 1% reported daily, and 1% reported daily. The confidence about their knowledge of nutrition was reported at 3.13±0.06 at the beginning of the survey and 3.18±0.06 at the end of the survey. A confidence of 3.5±0.70 was reported with knowing when to refer to a nutritionist. 17

28 Table 4.2 General questions What are your primary sources of nutritional information in your work setting? (choose all that apply) Academic Nutritionist Journal Physician Other* 25% 66% 32% 29% Do you have access to a nutritionist in your work setting? Yes No 35% 65% What types of nutrition questions do Dietary you most commonly recieve? Recommen dations Meal Plans Weight loss/gain Eating disorders Body Supplements Composition Fluid Replacement Other 75% 42% 67% 13% 76% 25% 61% 3% Who do you commonly get asked nutritional questions from? Athlete Coach Strength and conditioning specialist Other # 94% 51% 1% 21% How often are you presented with nutritional questions? Never Yearly Monthly Weekly Daily 1% 19% 49% 29% 1% How confident are you in knowing when to refer to see a nutritionist? No confidence Very little confidence Moderately confident Very confident Extremely confident Mean Standard Deviation 0% 4% 49% 40% 7% How confident do you No Very little Moderately Very Extremely Mean Standard 0% 10% 68% 21% 1% How confident do you feel about your knowledge of nutrition? (End of survey) No Very little Very confidence confidence Moderately confident Extremely Standard (1) (2) confident (3) (4) confident (5) Mean Deviation 1% 6% 66% 27% 0% How often are you asked about addressing nutritional problems with athletes? Never Yearly Monthly Weekly Daily Mean Standard Deviation 7% 44% 40% 9% 0% How comfortable do you feel addressing nutritional problems with athletes? No confidence Very little confidence Moderately confident Very confident Extremely confident Mean Standard Deviation 1% 13% 69% 16% 0% *Other nutritional sources include; other health care professionals, internet, books, ISSN group, strength coach, continuing education, drug free sport # Other common source of nutritional questions includes; parents, students, and patients 18

29 As previously stated, frequency was scored by totals. Following adding the totals together from all of the questions within the category of general nutrition 24% ± 18% reported they never receive the questions asked, 38% ± 10% reported yearly, 31% ± 14% reported monthly, 7% ± 6% reported weekly, and 0% ± 1% reported daily. Totals of the scores of the weight management and body composition category indicated that 23% ± 7% reported never, 47% ± 8% reported yearly, 25% ± 7% reported Monthly, 4% ± 3% reported weekly, and 0% ± 0% reported daily. For questions in the category of eating disorders and eating disorders 48% ± 16% reported never, 48% ± 13% reported yearly, 5% ± 2% reported monthly, 0% ± 0% reported weekly, and 0% ± 0% reported daily. When adding the responses for the questions that fell within the performance enhancing and recreational supplements and drugs 29% ± 12% reported never, 46% ± 7% reported yearly, 24% ± 8% reported monthly, 1% ± 2% reported weekly, and 0% ± 0% reported daily. All Total percentages for frequency can be found on table

30 Table 4.3 Frequency Totals of All Categories Category Never (1) Yearly (2) Monthly (3) Weekly (4) Daily (5) General Nutrition 24% ± 18% 38% ± 10% 31% ± 14% 7% ± 6% 0% ± 1% Dietary Recommendations/ General Nutrition 35% ± 19% 41% ± 11% 21% ± 10% 3% ± 2% 0% ± 0% Meals Plans 12% ± 10% 40% ± 7% 39% ± 12% 9% ± 3% 0% ± 1% Fluid Consumption 17% ± 11% 30% ± 5% 40% ± 9% 12% ± 9% 0% ± 1% Weight Management and Body Composition 23% ± 7% 47% ± 8% 25% ± 7% 4% ± 3% 0% ± 0% Weight Management 18% ± 6% 47% ± 4% 28% ± 2% 7% ± 0% 1% ± 1% Body Composition 27% ± 4% 47% ± 11% 24% ± 10% 2% ± 2% 0% ± 0% Eating Disorders and Disordered Eating 48% ± 16% 48% ± 13% 5% ± 2% 0% ± 0% 0% ± 0% Eating Disorders 48% ± 16% 48% ± 13% 5% ± 2% 0% ± 0% 0% ± 0% Performance Enhancing and Rereational Supplements and Drugs 29% ± 12% 46% ± 7% 24% ± 8% 1% ± 2% 0% ± 0% Supplements 29% ± 12% 46% ± 7% 24% ± 8% 1% ± 2% 0% ± 0% As stated before we denoted for confidence values as follows; 1 for an answer of no confidence, 2 for very little confidence, 3 for moderately confident, 4 for very confident, and 5 for extremely confident. The category of general nutrition as a whole had a reported confidence of 3.03±0.76. Within general nutrition, dietary recommendations/general nutrition had a reported confidence of 3.01±0.79, meal plans had a reported confidence of 3.35±0.66, and fluid had a reported confidence of 3.55±0.93. The category of weight management and body composition had a reported confidence of 3.17±0.86. Within weight management and body composition, weight management had a reported frequency of 3.18±0.82, and body composition had a reported confidence of 3.16±0.90. The category of eating disorders and disordered eating had a reported confidence of 3.1±0.8. The category of performance enhancing and 20

31 recreational supplements and drugs had a reported confidence of 2.60±0.92. All category totals can be found on table 4.4. Table 4.4 Confidence Scores of All Categories Confidence Category Confidenc e Mean Standard Deviation General Nutrition Dietary Recommendations/ General Nutrition Meals Plans Fluid Consumption Weight Management and Body Composition Weight Management Body Composition Eating Disorders and Disordered Eating Eating Disorders Performance Enhancing and Rereational Supplements and Drugs Supplements

32 Chapter 5 Discussion & Conclusion 5.1 Discussion The majority of the original research questions were unable to be answered due to the lack of total responses. We received a total of 83 responses. Of those 83 responses, 14 were not complete and one was not a certified athletic trainer so those responses were taken out leaving is with a total of n=68. Due to the lack of power we were unable to produce any meaningful data analysis and have decided to use the data as exploratory. It is recommended that the survey be re-administered at a later time with a larger sample size in order to produce significant results. The majority of the ATC s surveyed reported they receive nutritional questions between yearly and monthly. The highest concentration of the most frequently asked questions fell into the category of general nutrition (31%±14%) and the smaller category of fluid consumption (40%±9%). That falls in line with the most confident from ATC s (3.30±0.76 general nutrition, and 3.55±0.83 fluid consumption) likely due ATC s being more experienced in receiving those questions. Only one sub-category and no large category had a frequency of 1% or greater (1% ± 1%). This indicates that ATC s do need 22

33 to have an adequate knowledge or nutrition and more importantly when to refer but are not anticipated to be experts in the field. In general, ATC s felt moderately confident about their overall knowledge of nutrition, 3.13±0.60 at the beginning of the survey and 3.18±0.60 at the end of the survey. This was as expected as athletic trainers are not nutritional specialist but do need to have a solid base knowledge of nutrition as it is something they commonly faced with being they are often reported as one of the first source of nutrition (1, 3, 6). Also as expected, confidence was the lowest (2.6±0.92) when asked about supplements. This is likely due to lack of regulation by the FDA. More importantly, 96% felt moderately confident or greater when asked about their confidence of knowing when to refer a nutritional concern to a nutritionist. That indicates that most nutritional concerns will be properly addressed if the athlete complies with the ATC s suggestions. One are of concern is that on 35% of the respondents indicated that they have access to a nutritionist. This may be due to the large number of responses from high school ATC s (46%). As previously stated our first hypothesis was that the most common questions asked will be about supplements and the least common questions will be about eating disorders. In the general question of which types of questions ATC s we were correct in our hypothesis as 76% reported they frequently receive questions about supplements and 13% reported eating disorders. Our second hypothesis Athletic Trainers will feel the most confident about answering questions about fluid replacement and eating disorders and the least confident in answering questions about supplements. We were correct in this hypothesis as well as fluid consumption was the highest with a score of 3.55±0.83 (between moderately confident and very confident) and supplements was the lowest 23

34 confidence with a score of 2.60±0.92 (between very little confidence and moderately confident). 5.2 Limitations Originally the intent was to perform a cross sectional study with the independent variables being the following groups: gender (male vs. female), work setting (division I vs. division II vs. division III vs. secondary/clinical outreach vs. professional vs. hospital vs. clinic), primary sport coverage (baseball vs. basketball vs. bowling vs. cross country vs. fencing vs. field hockey vs. football vs. golf vs. gymnastics vs. ice hockey vs. lacrosse vs. rowing vs. skiing vs. soccer vs. softball vs. swimming and diving vs. tennis vs. track and field vs. volleyball vs. water polo vs. wrestling), number of nutritional courses taken (0 vs. 1 vs. 2 vs. 3 vs. 4 or more), and years of certification (0 to 5 vs. 6 to 10 vs. 11to15 vs. 16 to 20 vs. 21 to 25 vs. 26+). We were unable to do this because the power was not strong enough to run data analysis. As stated by Torres McGehee et al. (3), to establish a power of approximately 60% would require 100 participants per group. Another limitation was the survey was only distributed to 1000 participants due to limited funds. Of the 1000 requests, we received fewer responses than anticipated along with a high dropout rate of 16.9%. This may be due to the length of the survey. There was a total usable response rate of 6.8%. We were also limited by the lack of diversity in the response population. As seen in table 4.1, 75% of the population was female, 79% have been certified for 6 to 10 years, and only 25% were in the collegiate setting. Due to such a high number of high school athletic trainers many of the participants work the majority 24

35 of the common sports and would not provide us proper representation of if athletic trainers that work with specific sports receive different questions. When looking at the survey itself some of the categories did not have many questions. This was done because it was believed the questions provided were enough to encompass the category but it may have been limiting because the questions were too direct. Another limitation we had was that confidence does not always relate to actual knowledge. Studies in the past such as the study done by Torres-McGehee(3) indicate that Athletic Trainers may be over confident compared to their actual knowledge. One way to account for this could be to ask knowledge questions in the survey but this would length the survey as well. The likert scales we used may have also been a limitation. The first limitation in the scales was the non-interval scale used for frequency. The gap between yearly and monthly may have been too large to give us a true understanding of the frequency. The confidence scale may need to be adjusted for future research as well. Creating a new scale with an even number of choices will eliminate participants choosing from a middle neutral choice. 5.3 Future Research Although we did not get the response rate we had hoped, we do believe we were able to gather valuable data. Following this study, we believe we could create a shorter and better survey that could be distributed to a large sample size in order to gather enough responses to determine statistical significance. 25

36 5.4 Conclusion In conclusion we were unable to run data analysis due to the lack of responses. We decided to look at the data we have received as exploratory data. Through observation of the data some trends are noticeable. Athletic Trainers are faced with nutritional questions somewhere between monthly and yearly when looking at specific questions. In the broad sense, athletic trainers reported being asked nutritional questions more between monthly and weekly. ATCs appear to be asked the most about general nutritional information and the least about eating disorders. For most questions athletic trainers felt moderately confident addressing. As expected, the least confident appeared to be supplements. The findings in this study as well as previous studies such as Burns et al. (1), Shifflett et al.(6), and Torres-McGehee et al.(3) indicate that moving forward in the Professional Master s Degree nutrition courses should remain a requirement and taught in a wide range other than just general nutrition. There should also be an emphasis properly identifying issues that need to be referred to other medical professionals. In order to determine if there is any true significance between the categories more research is necessary. 26

37 References 1 Burns RD, Schiller MR, Merrick MA, Wolf KN. Intercollegiate student athlete use of nutritional supplements and the role of athletic trainers and dietitians in nutrition counseling. Journal of the American Dietetic Association Feb;104(2): Prentice WE. Arnheim's principles of athletic training: A competency-based approach: McGraw-Hill; Torres-McGehee TM, Pritchett KL, Zippel D, Minton DM, Cellamare A, Sibilia M. Sports nutrition knowledge among collegiate athletes, coaches, athletic trainers, and strength and conditioning specialists. Journal of athletic training Mar-Apr;47(2): Strategic Alliance Degree Statement After 2.5 Years of Diligent Analysis, Leaders of the Key Athletic Training Organizations Have Decided to Change the AT Degree Level to a Master s [cited; Available from: 5 Athletic Training Education Competencies Shifflett B, Timm C, Kahanov L. Understanding of athletes' nutritional needs among athletes, coaches, and athletic trainers. Research quarterly for exercise and sport Sep;73(3): Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Medicine and science in sports and exercise Oct;39(10): Hawley JA, Dennis SC, Lindsay FH, Noakes TD. Nutritional practices of athletes: are they suboptimal? Journal of sports sciences Summer;13 Spec No:S Hackman RM, Katra JE, Geertsen SM. The Athletic Trainer's Role in Modifying Nutritional Behaviors of Adolescent Athletes: Putting Theory into Practice. Journal of athletic training. 1992;27(3): Malinauskas BM, Overton RF, Carraway VG, Cash BC. Supplements of interest for sportrelated injury and sources of supplement information among college athletes. Advances in medical sciences. 2007;52: Zawila LG, Steib CS, Hoogenboom B. The Female Collegiate Cross-Country Runner: Nutritional Knowledge and Attitudes. Journal of athletic training Mar;38(1): Turocy PS, DePalma BF, Horswill CA, et al. National Athletic Trainers' Association position statement: safe weight loss and maintenance practices in sport and exercise. Journal of athletic training May-Jun;46(3):

38 13 Rodriguez NR, DiMarco NM, Langley S, et al. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. Journal of the American Dietetic Association Mar;109(3): Rockwell MS, Nickols-Richardson SM, Thye FW. Nutrition knowledge, opinions, and practices of coaches and athletic trainers at a division I university. International Journal of Sport Nutrition and Exercise Metabolism. 2001;11: Description of Degrees/Credentials Buell JL, Franks R, Ransone J, et al. National Athletic Trainers' Association position statement: evaluation of dietary supplements for performance nutrition. Journal of athletic training Jan-Feb;48(1): Ajzen I, Fishbein M. Understanding attitudes and predicting social behaviour Misasi SP, Davis CF, Morin GE, Stockman D. Academic preparation of athletic trainers as counselors. Journal of athletic training Jan;31(1):

39 Appendix A Additional Methods 1. Survey Building on Qualtrics I. Create account at qualtrics.com II. Under create survey select quick Survey Bulider III. Individually type in each question from Table 4. 29

40 IV. Activate survey i. Under the distribute survey tab select Activate your survey to collect responses 30

41 2. Survey distribution A.2.1 Full survey Most Commonly Asked Nutritional Questions For Athletic Trainers Q8 What best describes your work setting? D1 D2 D3 High school Professional Clinic Hospital Other Q3 Gender? Male Female Q7 How many years have you been certified Athletic Trainer? 0 to 1 2 to 5 6 to 10 31

42 11 to to to 25 More than 25 years Q4 What is your primary sport(s) coverage? (Choose all that apply) Baseball Basketball Bowling Cross Country Fencing Field Hockey Football Golf Gymnastics Ice Hockey Lacrosse Rifle Rowing Skiing Soccer Softball Swimming & Diving 32

43 Tennis Track & Field Volleyball Water Polo Wrestling Other Q5 What professional certifications do you currently hold? (Choose all that apply) ATC RD PT PTA NSCA-CPT NSCA-CSCS EMT PA RNP None Other Q1 What are your primary sources of nutritional information in your work setting? (choose all that apply) 33

44 Nutritionist Academic Journal Physician Other Q6 How many nutritional courses have you taken? or more Q2 Do you have access to a nutritionist in your work setting? Yes No Q9 What types of nutrition questions do you most commonly recieve? (choose all that apply) Dietary recommendations Meal plans Weight loss/gain Eating disorders Supplements 34

45 Body composition Fluid replacement Other Q10 Who do you commonly get asked nutritional questions from? (Choose all that apply) Athlete Coach Strength and condition specialist Other Q13 How often are you presented with nutritional questions? Never Yearly Monthly Weekly Daily Q11 How confident are you in knowing when to refer to see a nutritionist? No confidence Very little confidence Moderately confident Very confident 35

46 Extremely confident Q12 How confident do you feel about your knowledge of nutrition? No confidence Very little confidence Moderately confident Very confident Extremely confident Q14 How often are you asked about addressing nutritional problems with athletes? Never Yearly Monthly Weekly Daily Q15 How comfortable do you feel addressing nutritional problems with athletes? No confidence Very little confidence Moderately confident Very confident Extremely confident 36

47 Q16 How often are you asked about what to eat before practice/game? Never Yearly Monthly Weekly Daily Q17 How confident do you feel answering questions about what to eat before practice/game? No confidence Very little confidence Moderately confident Very confident Extremely confident Q18 How often are you asked about what to eat after practice/game? Never Yearly Monthly Weekly Daily 37

48 Q19 How confident do you feel answering questions about what to eat after practice/game? No confidence Very little confidence Moderately confident Very confident Extremely confident Q20 How often are you asked about what to eat before a workout (weight lifting)? Never Yearly Monthly Weekly Daily Q21 How confident do you feel answering questions about what to eat before a workout (weight lifting)? No confidence Very little confidence Moderately confident Very confident Extremely confident 38

49 Q22 How often are you asked about what to eat after workout (weight lifting)? Never Yearly Monthly Weekly Daily Q23 How confident do you feel answering questions about what to eat after a workout (weight lifting)? No confidence Very little confidence Moderately confident Very confident Extremely confident Q24 How often are you asked about how long before a game to eat? Never Yearly Monthly Weekly Daily 39

50 Q25 How confident do you feel answering questions about how long before a game to eat? No confidence Very little confidence Moderately confident Very confident Extremely confident Q26 How often are you asked about snacks during activity? Never Yearly Monthly Weekly Daily Q27 How confident do you feel answering questions about snacks during activity? No confidence Very little confidence Moderately confident Very confident Extremely confident Q30 How often are you asked about making meal plans? 40

51 Never Yearly Monthly Weekly Daily Q31 How confident do you feel answering questions about making meal plans? No confidence Very little confidence Moderately confident Very confident Extremely confident Q28 How often are you asked about not feeling well during or after competitions? Never Yearly Monthly Weekly Daily Q29 How confident do you feel answering questions about not feeling well during or after competitions? No confidence 41

52 Very little confidence Moderately confident Very confident Extremely confident Q32 How often are you asked about diet for performance enhancement? Never Yearly Monthly Weekly Daily Q33 How confident do you feel answering questions about diet for performance enhancement? No confidence Very little confidence Moderately confident Very confident Extremely confident Q34 How often are you asked about diet for a healthy lifestyle after athletics? Never 42

53 Yearly Monthly Weekly Daily Q35 How confident do you feel answering questions about diet for a healthy lifestyle after athletics? No confidence Very little confidence Moderately confident Very confident Extremely confident Q36 How often are you asked about reading food labels? Never Yearly Monthly Weekly Daily Q37 How confident do you feel answering questions about reading food labels? No confidence Very little confidence 43

54 Moderately confident Very confident Extremely confident Q38 How often are you asked about vegetarian/vegan alternatives for proper nutrition? Never Yearly Monthly Weekly Daily Q39 How confident do you feel answering questions about vegetarian/vegan alternatives for proper nutrition? No confidence Very little confidence Moderately confident Very confident Extremely confident Q40 How often are you asked about diet and injury prevention? Never Yearly Monthly 44

55 Weekly Daily Q41 How confident do you feel answering questions about diet and injury prevention? No confidence Very little confidence Moderately confident Very confident Extremely confident Q42 How often are you asked about caloric intake? Never Yearly Monthly Weekly Daily Q43 How confident do you feel answering questions about caloric intake? No confidence Very little confidence Moderately confident Very confident Extremely confident 45

56 Q44 How often are you asked about how many carbohydrates, fats or proteins to consume? Never Yearly Monthly Weekly Daily Q45 How confident do you feel answering questions about how many carbohydrates, fats, or proteins to consume? No confidence Very little confidence Moderately confident Very confident Extremely confident Q46 How often are you asked about sources of carbohydrates, fats, or proteins? Never Yearly Monthly Weekly Daily 46

57 Q47 How confident do you feel answering questions about sources of carbohydrates, fats, or proteins? No confidence Very little confidence Moderately confident Very confident Extremely confident Q48 How often are you asked about vitamins and minerals? Never Yearly Monthly Weekly Daily Q49 How confident do you feel answering questions about vitamins and minerals? No confidence Very little confidence Moderately confident Very confident Extremely confident 47

58 Q50 How often are you asked about trending diets (gluten free, paleo, etc.)? Never Yearly Monthly Weekly Daily Q51 How confident do you feel answering questions about trending diets (gluten free, paleo, etc.)? No confidence Very little confidence Moderately confident Very confident Extremely confident Q86 How often are you asked about what to eat during the menstrual cycle? Never Yearly Monthly Weekly Daily Q87 How confident do you feel answering questions about during the menstrual cycle? 48

59 No confidence Very little confidence Moderately confident Very confident Extremely confident Q72 How often are you asked about how much fluid to consume? Never Yearly Monthly Weekly Daily Q73 How confident do you feel answering questions about how much fluid to consume? No confidence Very little confidence Moderately confident Very confident Extremely confident Q74 How often are you asked about sports drinks? Never 49

60 Yearly Monthly Weekly Daily Q75 How confident do you feel answering questions about sports drinks? No confidence Very little confidence Moderately confident Very confident Extremely confident Q76 How often are you asked about sports drinks vs. water? Never Yearly Monthly Weekly Daily Q77 How confident do you feel answering questions about sports drinks vs. water? No confidence Very little confidence Moderately confident 50

61 Very confident Extremely confident Q78 How often are you asked about energy drinks? Never Yearly Monthly Weekly Daily Q79 How confident do you feel answering questions about energy drinks? No confidence Very little confidence Moderately confident Very confident Extremely confident Q80 How often are you asked about coffee consumption? Never Yearly Monthly Weekly Daily 51

62 Q81 How confident do you feel answering questions about coffee consumption? No confidence Very little confidence Moderately confident Very confident Extremely confident Q52 How often are you asked about how to lose weight? Never Yearly Monthly Weekly Daily Q53 How confident do you feel answering questions about how to lose weight? No confidence Very little confidence Moderately confident Very confident Extremely confident 52

63 Q54 How often are you asked about how to gain weight? Never Yearly Monthly Weekly Daily Q55 How confident do you feel answering questions about gain weight? No confidence Very little confidence Moderately confident Very confident Extremely confident Q82 How often are you asked about eating disorders? Never Yearly Monthly Weekly Daily Q83 How confident do you feel answering questions about eating disorders? 53

64 No confidence Very little confidence Moderately confident Very confident Extremely confident Q84 How often are you asked about the female athlete triad? Never Yearly Monthly Weekly Daily Q85 How confident do you feel answering questions about the female athlete triad? No confidence Very little confidence Moderately confident Very confident Extremely confident Q88 How often are you asked about measuring body composition? Never 54

65 Yearly Monthly Weekly Daily Q89 How confident do you feel answering questions about measuring body composition? No confidence Very little confidence Moderately confident Very confident Extremely confident Q90 How often are you asked about normal body composition ranges? Never Yearly Monthly Weekly Daily Q91 How confident do you feel answering questions about normal body composition ranges? No confidence Very little confidence 55

66 Moderately confident Very confident Extremely confident Q56 How often are you asked about how to build muscle? Never Yearly Monthly Weekly Daily Q57 How confident do you feel answering questions about how to build muscle? No confidence Very little confidence Moderately confident Very confident Extremely confident Q58 How often are you asked about supplements? Never Yearly Monthly 56

67 Weekly Daily Q59 How confident do you feel answering questions about supplements? No confidence Very little confidence Moderately confident Very confident Extremely confident Q60 How often are you asked about what supplements are good for weight loss? Never Yearly Monthly Weekly Daily Q61 How confident do you feel answering questions about what supplements are good for weight loss? No confidence Very little confidence Moderately confident Very confident 57

68 Extremely confident Q62 How often are you asked about supplements for weight gain? Never Yearly Monthly Weekly Daily Q63 How confident do you feel answering questions about supplements for weight gain? No confidence Very little confidence Moderately confident Very confident Extremely confident Q64 How often are you asked about supplements for performance enhancement? Never Yearly Monthly Weekly Daily 58

69 Q65 How confident do you feel answering questions about supplements for performance enhancement? No confidence Very little confidence Moderately confident Very confident Extremely confident Q66 How often are you asked about supplements for building muscle? Never Yearly Monthly Weekly Daily Q67 How confident do you feel answering questions about supplements for building muscle? No confidence Very little confidence Moderately confident Very confident Extremely confident 59

70 Q68 How often are you asked about when to take supplements? Never Yearly Monthly Weekly Daily Q69 How confident do you feel answering questions about when to take supplements? No confidence Very little confidence Moderately confident Very confident Extremely confident Q70 How often are you asked about if certain supplements are legal? Never Yearly Monthly Weekly Daily Q71 How confident do you feel answering questions about if certain supplements are legal? 60

71 No confidence Very little confidence Moderately confident Very confident Extremely confident Q92 How confident do you feel about your knowledge of nutrition? No confidence Very little confidence Moderately confident Very confident Extremely confident Q93 Please list other questions you have received about nutrition that were not listed. Q95 Thank you for helping with my thesis. Please use the space below to provide feedback such as any questions you have, or areas that were confusing or redundant. 61

72 A.2.2 IRB Form II. Acquired IRB exemption 62