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Author: Sell, Laura, M. Title: Dietary Supplement Use in High School Athletes in Wisconsin The accompanying research report is submitted to the University of Wisconsin-Stout, Graduate School in partial

completion of the requirements for the

Graduate Degree/ Major: MS Food and Nutritional Sciences

Research Adviser: Kerry Peterson, Ph.D., R.D.

Submission Term/Year: Summer, 2013

Number of Pages: 69

Style Manual Used: American Psychological Association, 6th edition

I understand that this research report must be officially approved by the Graduate School and that an electronic copy of the approved version will be made available through the University Library website

I attest that the research report is my original work (that any copyrightable materials have been used with the permission of the original authors), and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office.

STUDENT’S NAME: Laura Sell

STUDENT’S SIGNATURE: ____Laura Sell______DATE: 7/25/2013

ADVISER’S NAME: Kerry Peterson, PhD, RD

ADVISER’S SIGNATURE: ________________________________DATE:

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Sell, Laura, M. Dietary Supplement Use in High School Athletes in Wisconsin

Abstract

Dietary supplements (DS) include a variety of products that are intended to supplement

the diet. Use of DS is well-documented in college, elite, and professional athletes. Limited data

suggest DS use in high school athletes is on the rise as more focus and pressure is put on these

athletes to compete and excel in their sport. The purpose of this study was to identify the

different legal DS consumed and frequency of their use by young athletes in Western Wisconsin,

analyze athlete’s behavioral intentions, attitudes toward the behavior, subjective norms, and

sources of information about DS. Winter and spring coaches at Eau Claire Memorial High

School were contacted and a preliminary meeting with the athletes to discuss the study and

distribute the consent forms was arranged. After obtaining informed consent, athletes completed

a 50 question survey assessing their perceptions and use of DS. Data were obtained from men’s

and women’s track and field, men’s hockey, and baseball, as well as women’s gymnastics,

soccer, and softball. Results indicated that most athletes previously or currently consumed a

variety of DS primarily for health promotion and to gain muscle size. Athletes believed that

supplements are safe, and most information was obtained from parents. Based on these data and

the increase in number of athletes choosing to consume DS, education regarding use in high

school athletes is warranted and regulation of DS from the Food and Drug Administration is

recommended.

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Acknowledgments

I would like to acknowledge a couple educators that have spent a great deal of time and

effort to help me grow as a graduate student. First and foremost, I would like to thank my

research advisor, Dr. Kerry Peterson who sparked my interest in the topic of dietary supplement

use. She has been a wonderful mentor for myself as a student and contributed greatly to the

success of my thesis project. I would also like to thank Dr. Carol Seaborn for her leadership and

guidance throughout my education. Thank you to Dr. Michael Perko at the University of North

Carolina-Greensboro who granted permission to utilize the Survey to Predict Adolescent

Athletes Dietary Supplement Use (SPAADSU, 1996) which he developed. Last, but not least, I

would like to thank the coaches and athletes at Eau Claire Memorial High School for facilitating

and participating in my study because without them this research would not be possible.

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Table of Contents

Abstract ...................................................................................................................................... 2

List of Tables .............................................................................................................................. 6

Chapter I: Introduction ............................................................................................................... 7

Statement of the Problem ................................................................................................. 9

Purpose of the Study ........................................................................................................ 9

Assumptions of the Study .............................................................................................. 10

Definition of Terms ....................................................................................................... 10

Limitations of the Study ............................................................................................... 11

Methodology ................................................................................................................. 12

Chapter II: Literature Review .................................................................................................... 14

Regulation of Dietary Supplements ……………………………………………………..14

Safety ……………………………………………………………………………………15

Dietary Supplement Use in United States.........................................................................16

Dietary Supplement Use in Young Adults and Adolescents ……………………………17

Dietary Supplement Use in High School Athletes ………………………………………18

Common Supplements Athletes are Consuming …………...…………………………...20

Creatine ………………………………………...…...…………………………...20

Caffeine…………………………………………………………………………..21

Multivitamin……………………………………………………………………..23

Sports Drinks ……………………………………………………………………25

Athlete’s Sources of Information about Dietary Supplements ………………………….26

Theory of Planned Behavior and Reasoned Action ……………………………………..27

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Chapter III: Methodology .......................................................................................................... 30

Subject Selection ........................................................................................................... 30

Data Collection Procedures ........................................................................................... 31

Instrumentation.............................................................................................................. 31

Data Analysis ................................................................................................................ 32

Limitations .................................................................................................................... 32

Chapter IV: Results ................................................................................................................... 34

Subject Description ……………………………………………………………………..34

Prevalence and Types of Dietary Supplements Consumed by High School Athletes…..35

Athlete’s Sources of Information ………………………………………………………..38

Athlete’s Motives for Dietary Supplement Use …………………………………………39

Factors That Are Better Predictors of Behavioral Intentions ……………………………40

Figure 1: Path Analysis of Influence of Significant Others, Attitudes towards the

Behavior and Subjective Norms on Behavioral Intentions ……………………………...42

Athlete’s Level of Knowledge and Safety about Dietary Supplement Use …..................42

Chapter V: Discussion ............................................................................................................... 45

Limitations ................................................................................................................... 45

Conclusions ................................................................................................................... 46

Recommendations ......................................................................................................... 50

References ................................................................................................................................ 53

Appendix A: Consent Form for Athletes ................................................................................... 60

Appendix B: Dietary Supplement Use in High School Athletes Survey (SPAADSU, 1996) ...... 62

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List of Tables

Table 1: Caffeine Content in Different Products….……………………………………………. 21

Table 2: Frequency of Athlete Participation……………………………………………………..35

Table 3: Types of Dietary Supplements Consumed …………………………………………….37

Table 4: Sources of Information about Dietary Supplements……………………………………38

Table 5: Reasons for Taking Dietary Supplements ……………………………………………..39

Table 6: Means and Standard Deviations for Three Subgroups and Corresponding Question

Numbers………………………………………………………………………………………….41

Table 7: Athlete’s Reported Knowledge Regarding the Safety of Dietary Supplement Use and

the Desire for an Educational Session from a Registered Dietitian ……………………………..43

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Chapter I: Introduction

Regulation of Dietary Supplements

In 1994, President Clinton passed a new law that altered the regulation of dietary

supplements (DS) prior to marketing (Hill, 2006). This law, known as the Dietary Supplement

Health and Education Act (DSHEA) of 1994, intended to balance oversight of dietary

supplements between the U.S. Federal Food and Drug Administration (FDA), the DS

manufacturers, and the consumers. Creating DSHEA allowed the dietary supplement industry to

expand into a booming, multi-billion dollar business and provided more freedom, access, and

variety of DS to consumers. However, the law also created skepticism amongst the FDA,

healthcare professionals, and lobbyists regarding the new regulations about labeling and safety

issues.

The FDA serves as an advocate to protect consumers from adulterated, misbranded, and

dangerous food and drug products. The agency regulates the safety of DS and their ingredients

after market. The new regulations set-forth by DSHEA replaced the existing policies about DS

and removed the regulatory barriers that limited the dissemination of information to the

consumer (Hill, 2006). This benefited the manufacturers by allowing them to create and promote

their products with less regulation, but it created consequences as well. These consequences are

highlighted below.

Before DSHEA, DS were treated with the same parameters as other foods, under the

Federal Food, Drug, and Cosmetics Act (FDCA) of 1938 (Hill, 2006). The FDCA determined

that vitamins and minerals had certain dietary properties, and at certain levels could pose

potential health risks; therefore, under FDCA, the FDA had the authority to conduct pre-market

approval processes and to remove any DS on the market if it posed a threat to the safety of the

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human consumer (Kaiser, 2000). Also under FDCA, a DS could be classified by the nature of

the product and its intended use which was determined by the manufacturers which allowed the

supplement industry to classify DS as a “food product” instead of a drug. Classifying

supplements as a food product does not require pre-market approval from the FDA or clinical

testing that a potential new drug would have to endure. This food classification saves the

manufacturers significant time and money and has increased the voice of the DS in industry

regulatory methods (McCann, 2005).

The interests of the DS industry are profit maximization, market growth, and creating

products that are safe and effective enough to encourage consumers to continuously purchase

products, while also avoiding expensive lawsuits (Kaiser, 2000). The creation of DSHEA failed

to give the FDA enough control over DS to protect the consumer by allowing products to reach

consumers with no pre-market evaluation, which brings to the attention of safety issues regarding

supplements.

DSHEA created ambiguity in regards to safety parameters. Considering DS fall under

the “food” category, many presume that DS are safe and will not cause adverse health effects.

Unfortunately in 1976, the Proxmire Amendment was created which prohibited the FDA from

using potency levels to classify DS as drugs (Pray, 2008). However, not only do DS have the

potential to be poisonous, they can also interfere with certain medications if taken

simultaneously.

Prior to marketing a DS, manufacturers are not required to obtain FDA approval unless

the DS contains a new ingredient that has not been evaluated for its safety (Hill, 2006).

However, the manufacturer does not need to provide the FDA with this evidence; they are

required to provide minimal evidence that the new ingredient is “reasonably safe” only 75 days

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prior to market (Hill, 2006). The FDA or the Drug Enforcement Administration can only

remove a product already in the market if it is tainted or otherwise hazardous to consumers.

These agencies must provide the evidence that it is unsafe, contains a controlled substance, or

does not include ingredients listed on the label. Unfortunately, this triggers a recall after it has

already been sold and injuries may have occurred.

Use and Safety of DS in Younger Populations

The safety and efficacy of all DS in individuals under the age of 18 remains unclear

because there are limited data in this population regarding the effects of long-term use of DS.

An investigation of young athletes revealed that many are either currently using or considering

the use of DS (Bell, Dorsch, McCreary, & Hovey, 2004). This leads to the importance of

including or changing requirements within DSHEA, as well as determining education or

intervention strategies as it pertains to young athletes and their parents or coaches.

Statement of the Problem

The term ‘dietary supplement’ has a broad definition and there is minimal regulation

prior to marketing. Furthermore, although DS are typically intended for adult consumption

consumers of all ages are able to purchase and consume DS. There is a lack of evidence

regarding safety and use of DS in individuals under the age of 18 years of age. With little

regulation from DSHEA, an increase in high school athletes are choosing to consume DS for

numerous reasons; however, the use, motives, and sources of information have not been clearly

documented.

Purpose of the Study

The present study aimed to determine the prevalence of DS use in high school athletes,

identify the different DS used, analyze motives for using DS, and determine the sources of

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information, level of knowledge and safety about DS. Secondary objectives aimed to determine

predictors of intentions for using DS and assess the influence that others have on attitudes,

subjective norms and behavioral intentions. This study also aimed to establish reasons to

implement changes in regulations of DSHEA for this population and decide if education or

intervention regarding supplement use is warranted. The following research questions were

addressed:

1. What types of DS are high school athletes consuming?

2. What are the athlete’s sources of information about using DS?

3. What are the athlete’s motives for using DS?

4. What factors are better predictors of behavioral intentions?

5. Do the athletes believe that DS are safe?

Assumptions of the Study

Several assumptions inherent to this research warrant comment. First, it was assumed

that the participants understood the survey and answered the questions truthfully. Second, it was

also assumed that the survey participants could reliably recall which DS they currently consume

or previously consumed. In addition, certain survey questions aimed at measuring behavioral

intentions, attitudes towards behavior, and subjective norms were assumed to indicate intentions

of DS use.

Definition of Terms

Attitudes towards the behavior. A contributing factor to an individual’s rationale

towards executing his or her behavioral intention.

Behavioral intentions. An individual’s cognitive readiness to perform a given behavior

or action.

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Dietary supplement (DS). A product taken by mouth in a tablet, capsule, softgel,

gelcap, liquid, powder, or bar form that contains one or more of the following dietary

ingredients: vitamins, minerals, herbs or other botanicals, amino acids, enzymes, organ tissues,

glandulars, and metabolites and is intended to supplement the diet (United States Food and Drug

Administration, 2006).

Dietary Supplement Health and Education Act of 1994. The law that provides

minimal regulation, grants manufacturers the ability to ensure the DS is safe before market and

allows the FDA to take action against unsafe DS after it reaches market (United States Food and

Drug Administration, 2013a).

Dietary substance. A product sold such as melatonin, Echinacea, glucosamine, or

Coenzyme Q10 as a dietary supplement but does not supplement the diet by increasing total

dietary intake.

Ergogenic aids. A substance that claims to enhance sports performance by improving

strength, speed, power, and endurance.

New dietary ingredient. Meets the above definition for dietary ingredients and was not

sold in the United States in a DS before October 15, 1994 (United States Food and Drug

Administration, 2013b).

Subjective norms. The beliefs about how significant others will view an individual’s

behavioral intention.

Limitations of the Study

Several limitations inherent to this study deserve comment. First, there was no control

group of non-athletes for data comparison. Second, only one high school was asked to

participate; therefore, the data are not comprehensive with regards to all athletes. Subsequently,

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the conclusions cannot be generalized to all high school athletes across the nation. Third, the

data were self-reported and collected using a survey instead of interviewing the athletes in

regards to their supplement use. Due to the broad nature of the definition of DS, the participants

may not have identified all possible supplements. In order to minimize the effects of this

limitation, a list of common DS was provided with the survey; however, the list was not

comprehensive. Furthermore, the study included minors so parental consent was required in

order to participate. Participation in this survey may have been limited due to lack of parental

consent because the parents may not have been so inclined to allow their child to participate in

the study.

Methodology

This research was approved by the University of Wisconsin-Stout Institutional Review

Board. Winter and spring sport coaches at Memorial High School in Eau Claire, Wisconsin were

contacted via email to participate in this study. Approval was obtained via email from the

school’s athletic director as well. Two teams from winter sports: men’s hockey and women’s

gymnastics, and six teams from spring sports: men’s and women’s track and field, men’s golf,

and freshman baseball, and women’s soccer and softball agreed to participate. From the eight

teams that agreed to participate, there were approximately 150 potential athletes that were

eligible to complete the survey. There were no exclusions to participate in this study.

Two meetings were coordinated with the coaches and the athletes. At the first meeting,

the nature of the study was discussed and the consent forms were disseminated. Coaches were

informed to invite the parents to the first meeting in order for them to address any questions or

concerns they might have in person. The second meeting was conducted to collect the consent

forms and to distribute the survey. In hopes to increase response rate, the athletes were informed

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that if they participated they would be entered into a drawing for a $15 iTunes gift card. The

instrument used was the Survey to Predict Adolescent Athletes Dietary Supplement Use

(SPAADSU, 1996) with a total of 50 questions.

Overall frequencies and percentages were obtained for demographic information

(questions 1 – 10) and to answer the research questions. The second section of the SPAADSU

(questions 11 – 46) was divided into the three respective sub-scores for analysis. Descriptive

statistics for mean, median, standard deviation (SD), minimum and maximum levels were

determined for each sub-score. An independent samples t-test was conducted to determine

comparisons by gender for each sub-score. Linear regression tests were also conducted to

determine whether attitudes were better predictors of intentions than subjective norms, and to

assess the degree to which parents, coaches, and physicians influence intentions, attitudes, and

subjective norms in the athletes. The Statistical Program for Social Sciences version 21 (SPSS,

2012) was used to analyze the data.

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Chapter II: Literature Review

The primary objectives of this study were to determine the prevalence of DS use in high

school athletes, identify the different DS used, analyze motives for using DS, and determine the

sources of information, level of knowledge, and level of safety about DS. Secondary objectives

aimed to assess the influence that significant others have on attitudes, subjective norms, and

ultimately behavioral intentions. It will also establish reasons to make changes in regulations of

DSHEA for this population and decide if education or intervention regarding supplement use in

high school athletes is necessary. The purpose of this literature review is to highlight the

regulation surrounding DS, the safety issues as related to the regulation of DS, the use of DS in

the general adult population and adult athletes, and the use of DS in adolescents, especially

athletes.

Regulation of Dietary Supplements

In 1994, President Clinton passed a new law that altered the regulation of dietary

supplements (DS) prior to marketing (Hill, 2006). This law, known as the Dietary Supplement

Health and Education Act (DSHEA) of 1994, intended to balance oversight of dietary

supplements between the United States Federal Food and Drug Administration (FDA), the DS

manufacturers, and the consumers. Creating DSHEA allowed the dietary supplement industry to

expand into a booming, multi-billion dollar business and provided more freedom, access, and

variety of DS to consumers. However, the law also created skepticism amongst the FDA,

healthcare professionals, and lobbyists regarding the new regulations about labeling and safety

issues.

The problems within DSHEA regarding regulation and monitoring deserve discussion.

The FDA regulates DS and their ingredients once they have entered the market and only after the

15

DS are placed on the shelves, will the FDA take action against any unsafe DS. The FDA has

very minimal control with DS prior to marketing, as this process is monitored according to

DSHEA. This law treats supplements as food which means they are regulated and tested much

differently than drugs. DS do not need to undergo the research and clinical testing that a drug

would need in order to provide safety and efficacy. Under DSHEA, the manufacturer needs to

ensure that the DS is safe before it is marketed and that it complies with the Dietary Supplement

Current Good Manufacturing Practices for quality control (United States Food and Drug

Administration, 2013a). However, there are numerous labeling and toxicity issues regarding

DS. Due to the minimal regulation of DS, consumers have complete access to over-the-counter

DS and the new law has allowed the DS industry to grow and develop into a thriving business.

DSHEA has created loopholes, especially in regards to the definition of a DS. The term

is incredibly broad because the definition allows a DS to include multiple different ingredients

such as vitamins, minerals, herbs, amino acids, enzymes, organ tissues, glandular, and their

constituents. The definition of a DS has great ambiguity which has prevented consumers from

identifying and understanding the supplements on the market (Shames, 2009). This broad

definition raises concerns regarding the safety and efficacy of the supplements.

Safety

Under DSHEA, the DS label cannot claim to treat, prevent, or cure specific diseases;

however, DSHEA allows flexibility with the information that manufacturers can place on the

label and manufacturers are allowed to state health claims regarding the effect of products on the

body structure or function (Kauflin, 2003). In 2009, a GAO report suggested that the general

consumer is not well-informed about the safety and efficacy of DS and may not be able to

correctly interpret the label information (Shames, 2009).

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Manufacturers are required to state the safety of the product and cannot include false or

misleading statements on the label (Hill, 2006). The label must include a descriptive name

stating that it is a supplement, the name and place of the manufacturer, packer, or distributor, the

ingredients, net contents of the package, and in most cases, a “Supplement Facts” panel that

includes each dietary ingredient in the product (Hill, 2006). Interesting enough, a United States

GAO study investigated 40 single-ingredient DS for the presence of lead, arsenic, mercury,

cadmium, and assorted pesticides and discovered trace amounts of at least one contaminant in 37

out of the 40 products analyzed (Kutz, 2010). Another study showed that contamination occurs

in about 25% of all DS (Petroczi, Taylor, & Naughton, 2001). These studies suggest that

supplement label does not reflect the true contents of the DS.

Healthy individuals under the age of 18 typically tend to have a lower Recommended

Dietary Allowance (RDA) for micronutrients, meaning their bodies do not require the same

amounts of vitamins and minerals that an adult would in order to function properly. Upper

Levels (UL) have been set for certain nutrients that may cause harm when consumed in excess.

Realistically, it is difficult to consume toxic amounts of micronutrients through the diet;

however, these vitamins and minerals are commonly found in multivitamin-mineral DS and

usually meet 75 - 100%, sometimes even more, of the daily values for adults. Therefore, use of

multivitamin-mineral DS in children may necessitate safety concerns.

Dietary Supplement Use in United States

The use of DS has increased over the last few decades, with approximately 150 million

U.S. residents using one or more of the over 35,000 different supplements available (Denham,

2011; Perko, 2012). The industry has witnessed an annual growth of about 12% each year

(Muth, Domanico, Anderson, Siegal, & Bloch, 1999). The most common DS used are

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multivitamin-mineral, weight loss supplements, sports performance supplements, calcium, B-

vitamins, vitamin C, glucosamine and chondroitin, vitamin D and fish oils/omega 3s (Bailey,

Gahche, Miller, Thomas, & Dwyer, 2013). In 2010, DS for sport-specific and weight loss usage

accounted for $22.7 billion in supplement company profits (Nutrition Business Journal, 2012).

DS users share similar characteristics. They tend to be older, have a lower body mass index, are

more physically active, are less likely to smoke, and have higher educational attainment and

socioeconomic status compared to nonusers (Bailey et al., 2013). The most recent National

Health and Nutrition Examination Survey (NHANES) determined that 49% of adults surveyed

consumed one or more DS daily and females were more frequent users than males (Bailey et al.,

2013). Contrary to these findings, more adolescents and young adults are becoming frequent

consumers, with an estimated 70% of adolescents under the age of 18 having consumed DS

(Herbold, Vazquez, Goodman, & Emans, 2004).

Dietary Supplement Use in Young Adults and Adolescents

Consumption of DS in the United States has been growing over the last three decades and

there is an increased amount of young adults and adolescents that are partaking in dietary

supplement use as well. Picciano, et al. (2007) reported 32% of DS use in children from birth to

18 years old in NHANES 1999 – 2002, with the lowest use reported among teenagers 14 – 18

years old (26%) and highest use among 4 – 8 year old children (49%). With less regulation,

consumers of all ages have gained more access to a variety of DS and consume them for

different purposes. A 2007 National Health Interview Survey reported that 94.5% of children

and adolescents surveyed used DS, with most consuming multivitamin-mineral, fish oil, creatine,

and fiber (Evans, Ndetan, Perko, Williams, & Walker, 2012). This report determined that males

consumed more than females, which differs from the data in adults (Bailey et al., 2013).

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Motives for consuming DS vary among this population and need to be recognized. The

motives for the behavior will determine what type of supplement the individual is using. For

example, an individual looking to enhance his or her overall general health will most likely chose

a DS such as a multivitamin, which will deliver different vitamins and minerals to supplement

the nutrients they may not receive from the diet. An athlete, on the other hand, who is interested

in building muscle, may choose a protein or creatine supplement to increase muscle size and

strength. However, types of DS used, reasons for using DS, and sources of information are not

as clear in this young population, especially in young athletes, and there is a need for further

identification and research.

Dietary Supplement Use in High School Athletes

DS use has been well-documented in college (Froiland, Koszewski, Hingst, & Kopecky,

2004), elite (Huang, Johnson, & Pipe, 2006), and professional athletes (Mader, 2012), but has

not been clearly documented in young athletes. The few studies investigating high school

athletes suggest that DS use is widespread (McDowall, 2007) and on the rise as more focus and

pressure is placed on the athletes to compete and excel in their sport and to give them the

competitive edge and compete at a higher level (Godo, Graves, O’Kroy, & Hecht, 2006). Young

athletes and their parents and/or coaches are putting performance and the number of wins ahead

of health. Multisport athletes tended to use DS more so than single-sport athletes, which

suggests that the competitiveness of the multisport athlete drives their intentions more than

athletes who only play one sport (Scofield & Unruh, 2006). The frequency of use of DS among

young adult and adolescent athletes determined from the literature ranged from 22.3% to 71%

(McDowall, 2007). The high prevalence and increase in use suggests that young athletes are

uninformed about the risks and proposed benefits of DS consumption. Approximately only 10%

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of adolescent athletes report good or very good knowledge about DS (Slater, Tan, & Teh, 2003),

suggesting that further education from credible sources is needed.

There is a large range of motives for DS consumption with the most frequently reported

reasons including: growth, illness prevention and treatment, enhanced performance, tiredness,

and muscle development (Scobal & Marquart, 1994). These motivations could be influenced by

reasons such as the desire to play at the collegiate and professional level after high school

(Calfee & Fadale, 2006). More often than not, athletes consume DS that will improve their sport

performance. Approximately 40 – 60% of high school athletes have used DS for this reason

alone (Scofield & Unruh, 2006), and according to a recent National Health Interview Survey

(NHIS), and over 1.2 million American adolescents are taking supplements for sports

performance (Evans et al. 2012). Males typically consume more frequently than females

(Scofield & Unruh, 2006) because males put more emphasis on the athletic performance-

enhancing effects, whereas females tend to be more concerned with health benefits (Slater et al.,

2003). The primary reason males consumed DS was to improve performance (36%) and 45% of

them consumed ergogenic aids, only 11% of females reported using ergogenic aids (Neiper,

2005).

Most young athletes reported consuming a range of supplements with the most common

including: multivitamin, protein, energizers, creatine (Bell et al., 2004), as well as sports drinks

and energy drinks (O’Dea, 2003). Some supplements have shown to be beneficial by improving

health and sports performance in small subgroups of adults (Applegate, 1999; Dodge, 2003;

Froiland et al., 2004; Perko, 1999); however, the long-term effects of use have not been

significantly studied in children and adolescents. Further investigating DS use in this population

will lead to a better understanding of their incentives for use, development of strategies for

20

prevention, and determination of recommendations for changes to DSHEA. Furthermore, it is

imperative to investigate use in this population because of the seriousness of the potential

adverse health effects that may arise from consuming certain DS.

Common Supplements Athletes Are Consuming

Creatine. Creatine is a substance synthesized in the body and is mostly found in muscle

tissues. It can be obtained from dietary sources such as meats and fish and from supplements as

well. This is the most commonly used ergogenic aid and widely marketed for its effects on

muscle and sports enhancement and recovery, as well as a therapeutic agent for certain medical

conditions such as Alzheimer’s and Parkinson’s (Buford et al., 2007). Creatine supplementation

has increased in adolescents in grades 11 and 12 who are close to the levels of collegiate athletes

(Metzl, Small, Levine, & Gershel, 2001).

Evidence shows that creatine supplementation can be beneficial depending on the age,

person, type of sport and dosage though it is not a “one size fits all.” The majority of research

surrounding creatine involves adult males; the effect of supplementation in a younger population

is minimal. Studies show that it is considered relatively safe in small doses, yet has the potential

to cause stomach pain, nausea, diarrhea, and muscle cramping (Ostojic & Ahmetovic, 2008;

Francaux & Poortmans, 2006). Little research has been conducted regarding large doses and its

effects; therefore, large doses are considered possibly unsafe due to the potential create kidney,

liver or heart troubles. Large doses of creatine may also cause dehydration because it draws

water from tissues (National Institute of Medicine, 2012). This is especially important in athletes

because of the increased requirement of fluids before, during and after activity.

Regardless of evidence that demonstrates creatine supplementation is relatively safe, the

high school athlete does not necessarily need it. Optimizing the effects of training and aiding in

21

muscle recovery after exercise with creatine is reasonable; however, the athlete should not rely

solely on it. The athlete should be consuming a proper, nutrient-dense diet to reap the benefits of

training.

Caffeine. Caffeine is a known central nervous system stimulant that increases alertness,

reduces fine motor coordination, can cause anxiety, insomnia, headaches, nervousness, and

dizziness and has mild addictive properties (National Institute of Medicine, 2011). As shown in

Table 1, caffeine is found in an abundant of products such as coffee, tea, several soft drinks,

chocolate and medications.

Table 1

Caffeine Content in Different Products

Product Serving Size Caffeine Content

Ground coffee 6 fl oz 71 mg

Black tea 6 fl oz 36 mg

Pepsi® 12 oz 37 mg

5-Hour Energy® 2 oz (60 mL) 207 mg

Hershey’s Kisses® 9 pieces 9 mg

Excedrin Migraine® 1 tablet 65 mg

Monster Energy® 16 fl oz 172 mg

(Adapted from the United States Department of Agriculture Nutrient Database for Standard

References, 2013; the Hershey Company, 2013; 5-hour Energy; 2013; United States Food and

Drug Administration, 2010)

22

There are benefits and consequences regarding caffeine consumption. Research shows

that natural caffeine-containing foods and beverages offer cognitive and performance-related

benefits, and potentially provides a source of antioxidants (Gardner, Ruxton, & Leeds, 2007).

Furthermore, research shows that it may even reduce the risk of stroke, certain cancers, and

cardiovascular disease which could be attributed to the antioxidant properties of caffeine

(Gardner et al., 2007). Athletes may opt to try caffeine prior to their workout or game because of

caffeine’s ability to increase stamina and endurance and reduce their level of fatigue and muscle

pain.

Energy drinks are different than sports drinks, and therefore, should not be used

interchangeably. The reason behind this is these beverages contain high amounts of stimulants

such as caffeine and guarana. They include other vitamins and minerals as well as

macronutrients: carbohydrates, fats, and proteins. One report found that 42.3% of children and

adolescents surveyed consumed energy drinks within two weeks prior to the survey (O’Dea,

2003). These should be avoided by individuals under the age of 18 because of their high

concentration of caffeine. The American Association of Poison Control Center (2012) reported

that from January 1, 2012 through December 31, 2012, poison centers received 1870 reports of

toxic exposure from energy drinks from those 18 years of age and younger.

The suggested caffeine intake for an adult is no more than 300 mg each day, which is the

equivalent to approximately three cups of coffee a day (National Institute of Medicine, 2011).

The American Academy of Pediatrics (2012) states that adolescents should consume less than

100 mg of caffeine a day and that younger children should not drink caffeinated beverages

regularly. A study conducted by Ellison, Singer, & Moore (1995) discovered that children and

adolescents age 5 – 18 years were consuming on average 37.4 mg each day. The average

23

consumer can tolerate caffeine in sensible doses; however, some are more sensitive to

stimulation than others and there are consequences. Side effects include symptoms of

withdrawal, increased heart rate and blood pressure, abdominal cramping, and dehydration,

increased risk of ulcers, increased insulin sensitivity, weight gain, tooth decay, and neurological

and cardiovascular repercussions (Ellison et al., 1995). Too much caffeine can be deadly as it

has toxic properties and a caffeine overdose is approximately 10 g ingested in a day (Seifert,

2011). However, in individuals with underlying health conditions lesser amounts of caffeine

could be fatal.

These supplements are detrimental to the athletes’ health and the benefits do not

outweigh the consequences. There have been several deaths citing popular energy drinks.

Federal officials reported 13 deaths over the last four years regarding energy drinks, including a

14-year-old girl from Maryland who died from a heart arrhythmia after she consumed two

Monster Energy® drinks on consecutive days (Meier, 2012). Other fatalities have similar reports,

however it is not clear if the drinks are the root cause or if there were other factors, such as

alcohol, involved.

Under DSHEA, there is no regulation for energy drinks. An FDA spokeswoman recently

stated that the manufacturers are responsible for investigating the adverse effects associated with

energy drinks (Hamburg, 2010). However, the reports that are filed with the FDA are minimal

and do not include all the adverse events and findings and therefore may not be completely

accurate. Additionally, the caffeine content may not be disclosed on the label, and even though

the label states that it is not recommended for those under 18, this is not regulated or monitored.

Multivitamin (MV). Vitamins and minerals are micronutrients and are required for

normal body functions and processes. They help release energy for synthesis and movement and

24

they function as coenzymes, co-catalysts, and buffers. They are essential for growth and

development and the requirements may be increased during certain developmental periods such

as childhood or early adolescence. However, it can be difficult to receive the recommended

dietary allowances of vitamins and minerals every day through the diet. Multivitamin

supplements are meant to be “insurance” for the diet; they should not be solely depended on for

substituting a poor diet. Even though taking multivitamins is controversial amongst healthcare

professionals, most agree that one daily multivitamin catered to the age of the individual is

acceptable. Due to the minimal regulations regarding labeling within DSHEA, what constitutes

a MV is not standardized (Yetley, 2007). Therefore, Radimer et al. (2004) declared that a MV is

a DS that contains three or more vitamins with or without minerals.

Although athletes typically tend to consume a balanced diet it can be difficult for athletes

in weight-regulated sports, such as wrestling and gymnastics, to meet micronutrient

requirements. Furthermore, strenuous exercise will increase the needs of nutrients; therefore,

athletes may have a greater need for a MV supplement. There is evidence that taking a MV after

exercise can help with recovery process (Louis, Hausswirth, Bleuzen, & Brisswalter, 2010).

Thus, consuming a daily multivitamin may prove to be beneficial in athletes.

The supplements discussed above are relatively safe; however, in certain conditions they

have the potential to be hazardous. Most MV are fortified with iron, which can be toxic in high

doses and can cause deficiencies of other vitamins or minerals because of its binding properties.

Toxicity and deficiency levels of any vitamin or mineral are undesirable and can be detrimental

to the individual’s health. Before choosing a MV, the individual should read the label and make

sure that the values of the micronutrients do not exceed 100% of the Daily Reference Intakes

25

(DRIs). A registered dietitian or physician is an excellent source of information regarding MV

and which supplement should be considered.

Sports drinks. As stated previously, sports drinks are different than energy drinks and

these beverages should not be used interchangeably. These are flavored beverages such as

Gatorade® and Powerade® that contain primarily carbohydrates and electrolytes, yet certain

brands might contain other vitamins or minerals. Potassium and sodium are the electrolytes in

sports drinks and are important for athletes, as they are excreted through the skin via sweat.

Sports drinks are designed to help to replace these nutrients and water that are lost during

exercise.

Sports drinks are beneficial for the high school athlete during or after a practice or game

because of the increased intensity and duration of the sport. Water is fine for activity under one

hour; whereas, sports drinks are recommended for sessions lasting over one hour (Academy of

Nutrition and Dietetics, 2013). Fluid is imperative for all individuals, but it is extremely

important in athletes. Many young athletes are inadequately hydrated (Bonci, 2010). Fluid

needs for this population are 0.5 – 1 L/day above baseline requirements (Petrie, Stover, &

Horswill, 2004). Fluid will help prevent muscle tears and fatigue and it makes the athlete feel

better during the exercise. One way to measure the fluid that was lost through sweat is to weigh

the athlete before and consume 16 – 24 fl oz for each pound lost during exercise (Bonci, 2010).

Ultimately, the athlete should be drinking throughout the day, but most importantly before,

during, and after exercise.

The only concern regarding sports drinks is that they can cause weight gain from the

calories in the drinks; also they contain sugars so there is the possibility of tooth decay. These

26

beverages should only be consumed during or after exercise, not throughout the day. This will

prevent ingesting hidden calories and excessive sugars.

Athlete’s Sources of Information about Dietary Supplements

Studies have determined that parents, coaches, athletic trainers and physicians tend to be

the leading sources of information for the athletes (Dunn, Eddy, Wang, Nagy, Perko, & Bartee,

2001; Godo et al., 2006; Bailey et al., 2011; Scofield & Unruh, 2006; Bailey et al., 2013).

Coaches are purported to be the most influential (Godo et al., 2006) yet studies have shown that

the majority of them have no formal training in nutrition (Graves, Farthing, Smith, & Turchi,

1991). When athletes were asked if they would take supplements if their coaches said they were

safe, 82.6% reported they strongly agreed or agreed (Godo et al., 2006); however, one study

determined that 49% of the surveyed coaches did not know there were side effects of supplement

use (Graves et al., 1991). Fitness clubs (24.5%), health store clerks (10.8%), and books and

magazines (10.1%) have been cited as sources as well (Scofield & Unruh, 2006). The reliability

and credibility of these sources is scarce and marketing efforts include using elite and

professional to promote certain supplements. This evidence shows that there is a need for

supplement education; not only for the athletes, but the coaches as well.

Physicians can be credible sources, yet they are still not experts in nutrition. Even though

DS do not require a prescription, physicians have the ability to prescribe them such as calcium

pills for bone health or fish oils for heart health. A sports dietitian would be the most beneficial

for the athletes regarding supplementation. Scofield and Unruh (2006) found that 28.5% of the

surveyed athletes reported their information came from a registered dietitian. Parents are also

very influential. Dunn et al. (2001) determined that parents were among the most likely to have

recommended a sport supplement to an adolescent athlete. Assessing whether parents, coaches,

27

and physicians are knowledgeable about supplements and nutrition and determining their

credibility is warranted.

Theory of Planned Behavior and Reasoned Action

The present study is based on the theory of planned behavior and reasoned action which

aims to comprehend human behavior and determine influential factors that motivate individuals

to complete an action or behavior (University of Twente, 2013). The theory of planned behavior

and reasoned action has the ability to predict deliberate behavior, suggesting that an individual’s

behavior is determined by his or her intention to perform the action; therefore, is a function of a

person’s attitude toward the behavior and subjective norms (University of Twente, 2013). The

Survey to Predict Adolescent Athlete’s Dietary Supplement Use (SPAADSU) was developed

based upon this theory. Under most circumstances, intention is greatest leverage of the

executing of a behavior. The theory of planned behavior and reasoned action will be utilized to

establish intervention strategies targeting high school athletes and their use of DS. This theory

also serves as the foundation for suggestions and recommendations for improving the

effectiveness of DSHEA.

The use of supplements seems to be influenced by beliefs, attitudes, and significant

others. An early study conducted by Dunn et al. (2001) investigated whether beliefs or attitudes

had a larger influence on supplement use in high school athletes and if parents, coaches, or

trainers encouraged more supplement use. After analysis, the data determined that trainers were

a better predictor than coaches or parents, which conflicts with other published research that

indicated coaches and parents have more influence on use of DS in athletes (Marquart and Sobal,

1993; Graves et al., 1991). This could be the result of the schools utilized for the study had

28

access to athletic trainers, whereas other studies used schools that did not employee athletic

trainers.

The behavioral intention is the most direct determinant of an athlete’s intent to use or not

to use DS. Godo et al. (2006) determined that 37.5% of the athletes surveyed stated they either

strongly agreed or agreed to use DS to improve their sports performance. This illustrates that

many athletes will try supplements as a means of improving performance. It is important to

understand the motivations behind athletes using supplements. Adolescents make choices based

on the positive or negative effects of the behavior. Dunn et al. (2001) also determined that

attitudes were better predictors of intentions to use supplements than subjective norms. This

suggests that attitudes about the positive aspects of DS use, such as enhanced sports

performance, are likely motivators for the athletes to use DS.

Under DSHEA, the regulation of DS is minimal. Little regulation has allowed consumers

to gain greater access to a wide variety of supplements. Now more than ever, the industry has

experienced a major increase in young adults purchasing DS, especially high school athletes.

These athletes are choosing a multitude of supplements with the most common supplements

including sports drinks, creatine, multivitamins, and caffeine. While sports drinks, creatine, and

multivitamins show minimal safety concerns, caffeine consumption can be potentially fatal.

The athletes are influenced by many factors and individuals. It is determined that

attitudes toward the behavior are greater motives to use supplements rather than subjective

norms. The athlete may choose to use supplements for many reasons which can range from

enhancing sports performance to overall general health promotion. Individuals who seem to

promote use tend to be parents, coaches, and athletic trainers. Therefore, there is a need to

understand the level of knowledge about DS of both the athlete and their sources of information

29

(coach, parent, or athletic trainer) and to determine if educational sessions and a change in

DSHEA’s regulations are necessary.

30

Chapter III: Methodology

The primary objectives of this study were to determine the prevalence of DS use in high

school athletes, identify the different DS used, analyze motives for using DS, and determine the

sources of information, and level of knowledge about DS and their safety. Secondary objectives

aimed to assess the influence that significant others have on attitudes, subjective norms, and

behavioral intentions. This chapter describes the methods for the subject selection, the instrument

that was used, data collection procedures, as well as limitations of the study.

Subject Selection

Prior to any data collection, this study was approved by the University of Wisconsin-

Stout Institutional Review Board. Coaches of winter and spring sports at Memorial High School

in Eau Claire, Wisconsin were contacted via email and asked to invite their athletes to participate

in a research study investigating the use of DS in high school athletes. Approval was obtained

via email from the school’s athletic director as well. The following athletic teams were invited

to participate: men’s and women’s track and field, basketball, and hockey, and men’s swim and

dive, wrestling, baseball, golf, and tennis, and women’s cheer and stunt, dance, gymnastics,

soccer, and softball. Additionally, the coach for men’s football volunteered to recruit some of

his athletes to participate in the study. All athletes involved in winter and spring sports were

eligible to participate and there were no exclusion criteria.

An initial meeting was coordinated with the coaches and athletes to discuss the nature of

the study. Coaches were informed to invite the parents to this meeting in order for them to

address any questions or concerns they might have in person; however, no parents attended the

initial meeting. At the meeting the informed consent forms were dispersed and discussed with

the athletes (Appendix A). The athletes were instructed to read and sign the form if they were

31

interested in participating. If the athlete was a minor then their parent’s signature was required

as well. Following distribution of the consent forms, a second meeting was coordinated for a

later date to collect the consent forms and administer the survey. Athletes who participated in

the study were entered into a drawing for a $15 iTunes gift card.

Data Collection Procedures

At the second meeting, the consent forms were collected and placed in a separate

envelope from the surveys. Once informed consent was obtained, a paper survey was

administered to the participating athletes who completed it at that time. Athletes had

approximately 15 minutes to complete the survey. Only the researcher and the athletes were in

the room during this period. After the athletes had completed the surveys they were placed in

their respective envelope. Consent forms and surveys were filed separately from each other in

order to preserve confidentiality.

Instrumentation

The instrument used was a 50-question survey (Appendix B). The Survey to Predict

Adolescent Athletes Dietary Supplement Use (SPAADSU, 1996) developed by Dr. Michael

Perko from the University of North Carolina-Greensboro represented questions 1-46 and

questions 47-50 were developed for the present research project to assess the athlete’s

knowledge of DS and their safety and to determine if the athletes believe they would benefit

from an educational session about DS presented by a registered dietitian. The last page of the

survey included a list of example DS to aid athletes with determining their use of DS.

The SPAADSU (questions 11-46) had undergone an item retest by Dr. Todd Bartee at the

University of Wyoming (Perko, 2013). Original reliability was 0.9049 when tested on 400

athletes and when tested on over 4000 athletes, the reliability was determined to be 0.89. The

32

survey is divided into two sections. The first section assesses demographics of the athletes,

athletic participation, DS use, and sources of information. The second section is separated into

three sections that assess: behavioral intentions (questions 11-23), attitudes towards the behavior

(questions 24-33), and subjective norms (questions 34-46). Each question was scored on the 5-

point Likert scale with: strongly agree = 1, agree = 2, neutral/no comment = 3, disagree = 4, and

strongly disagree = 5. Questions 47-50, which asked about the athlete’s knowledge of DS and

their safety, had the option of selecting “yes” or “no.”

Data Analysis

The Statistical Program for Social Sciences version 21 (SPSS, 2012) was used to analyze

the data. Overall frequencies and percentages were obtained for demographic information and to

answer the research questions. The second section of the SPAADSU (Q’s 11 – 46) was divided

into the three respective sub-scores for analysis as described previously. Descriptive statistics for

mean, median, standard deviation (SD), minimum and maximum levels were determined for

each sub-score. An independent samples t-test was conducted to determine comparisons by

gender for each sub-score. Linear regression tests were also conducted to determine whether

attitudes were better predictors of intentions than subjective norms, and to assess the degree to

which parents, coaches, and athletic trainers influence intentions, attitudes, and subjective norms

in the athletes. The beta-coefficient was used to determine this information. A larger beta-

coefficient number indicates that the predictor variable had more of an influence on the outcome

variable. A p-value of <0.05 was considered significant.

Limitations

There were a few limitations regarding the methodology and subject selection. First,

there was no control group of non-athletes for comparison. Originally the winter sports were

33

only going to be included in the study; however, due to minimal participation from those teams

spring sport coaches were contacted to participate in order to gain a greater data base and

response rate. Second, only one high school was asked to participate; therefore, the data are not

comprehensive with regards to all athletes across the nation. Subsequently, the conclusions

cannot be generalized to all high school athletes. Third, the data were self-reported and collected

using a survey instead of interviewing the athletes in regards to their supplement use. Due to the

broad nature of the definition of DS, the participants may not have identified all possible

supplements. In order to minimize the effects of this limitation, a list of common DS was

provided with the survey; however, the list was not comprehensive. Another limitation is that

minors were included in this study and required parental permission. The athletes were required

to take the consent form home for their parents to sign and then they were responsible for

returning the consent form. This potentially could have contributed to a low response rate due to

a variety of factors including, the athlete may have failed to remember to discuss it with their

parents, they may have misplaced it, or the parents may not have wanted their child to

participate. Additionally, if an athlete did not consume DS he or she would be less likely to

participate in this study. Therefore, athletes who do not use DS are likely under-represented in

the current study.

34

Chapter IV: Results

The primary objectives of this study were to determine the prevalence of DS use in high

school athletes, identify the different DS used, analyze motives for using DS, and determine the

sources of information, level of knowledge about DS and their safety. Secondary objectives

aimed to assess the influence that significant others have on attitudes, subjective norms, and

intentions of using DS. This information was determined by administering the SPAADSU to

athletes participating in winter and spring sports at Eau Claire Memorial High School in Eau

Claire, Wisconsin. This chapter reports the results of the study as related to the research

questions.

Subject Description

Athletes involved in winter sports were members of the men’s hockey and women’s

gymnastics teams; athletes in spring sports were recruited from men’s and women’s track and

field, men’s golf, and freshman baseball, and women’s soccer and softball (Table 2). From the

eight teams that agreed to participate, there were approximately 150 potential athletes that were

eligible to complete the survey. There were 54 returned surveys for data analysis representing a

36% response rate. Of the 54 participating athletes, 25 were males (46.3%) and 28 were females

(51.9%). There was one transgender athlete who indicated themselves as biologically male but

was included in a separate “transgender” category (1.9%) and was excluded from gender

comparison data analysis. The athletes were between the ages of 14 and 19 years old, accounting

for grades 9th – 12th. The median age of the athletes was 16 years old and the median grade level

was 11th. Most of the athletes were white or Caucasian (92.6%), one Hispanic or Mexican-

American (1.9%), one Oriental or Asian-American (1.9%), and two that listed other ethnicities

35

(3.7%). The frequency of respondents representing each sport is categorized in Table 2.

Women’s softball and track and field accounts for the majority of the surveys.

Table 2

Frequency of Athlete Participation

Winter Sports Frequency (N = 54) Percentage

Men’s hockey 7 13.0%

Women’s gymnastics 1 1.9%

Spring Sports

Men’s track and field 9 16.7%

Women’s track and field 10 18.5%

Men’s baseball 5 9.3%

Women’s softball 10 18.5%

Men’s football 5 9.3%

Women’s soccer 7 13.0%

Prevalence and Types of Dietary Supplements Consumed by High School Athletes

The survey inquired about the different supplements that the athletes consumed or had

consumed in the past in order to understand the types of DS athletes choose. Frequency tests

concluded that 27 of the 54 athletes who participated in the study had reported consuming at

least one or more dietary supplements on a daily basis, which accounted for 50% of the total

athletes. In addition, a total of 17 athletes reported they did not consume DS on a daily basis but

indicated they had and stopped (13%) or they tried a type of DS once or twice in the past

(18.5%). Only 9 athletes (16.7%) said they had never consumed DS. There was one missing

36

value which could be assumed that the athlete never consumed DS. There were no significant

differences between the use of DS in males and females.

Frequencies determined there were 25 different types of DS used by the athletes. Each

athlete listed all of the supplements they were taking at the time of the study or had tried in the

past. The most common DS reported was sports drinks (37.0%). These include beverages from

companies such as Gatorade®. The second most common type DS reported was muscle building

supplements, such as creatine and whey protein, with 26.0% of the athletes reporting they had

consumed these type of DS. The third most common supplement consumed was sports bars

(27.8%) and includes bars from companies such as Clif Bar® and Power Bar®. Other common

supplements were multivitamins (24.1%), fish oils and omega-3 fatty acids and energy drinks,

which reported equal consumption at 9.3%. Table 3 illustrates each of the different supplements

that were reported.

37

Table 3

Types of Dietary Supplements Consumed

Dietary Supplement Frequency (N = 54) Percentage

Sport drinks 20 37.0%

Protein/whey powders 16 29.6%

Sports bars 15 27.8%

Multivitamin 13 24.1%

Fish oils or Omega 3 fats 5 9.3%

Energy drinks 5 9.3%

Vitamin C 4 7.4%

Calcium 3 5.6%

Caffeine 3 5.6%

Zinc 3 5.6%

Vitamin B12 2 3.7%

Iron 2 3.7%

Glucosamine 2 3.7%

Vitamins 2 3.7%

O2 Gold 2 3.7%

Multivitamin + Iron 1 1.9%

Green tea extract 1 1.9%

Vitamin B complex 1 1.9%

Airborne™ 1 1.9%

Arbonne Teen Vitamins 1 1.9%

Flaxseed 1 1.9%

Magnesium 1 1.9%

Melatonin 1 1.9%

Vitamin B3 1 1.9%

SlimFast 1 1.9%

38

Athlete’s Sources of Information

The survey investigated the different sources of information to determine the knowledge

base of the sources and the credibility of the sources. The athletes were allowed to select

multiple sources of information. Frequency tests reported that out of the 54 athletes, the primary

source of information came from the athlete’s parents (46.3%). Additionally, physicians

(24.1%), coaches (20.4%), and friends (16.7%) were the other popular sources of information.

Less than 4% received information about DS from a registered dietitian, and 11% receive

information from other sources such as their chiropractor, therapist, or stores such as General

Nutrition Corporation (GNC) or Vitamin World. Table 4 shows all of the different sources of

information reported from the athletes.

Table 4

Sources of Information about Dietary Supplements

Sources of Information Frequency (N = 54) Percentage

Parents or guardians 25 46.3%

Physician 13 24.1%

Coaches 11 20.4%

Friends 9 16.7%

Reported receiving no information 8 14.8%

Teammates 7 13.0%

Other (ie: GNC, Chiropractor) 6 11.1%

Other family member 4 7.4%

Registered Dietitian 2 3.7%

Media 2 3.7%

39

Athlete’s Motives for Dietary Supplement Use

The survey inquired about several motives behind using supplements. The athletes were

able to select multiple motives. Out of the 54 athletes surveyed, 41 athletes reported their

motives for using supplements on the survey. Therefore, frequency tests determined that out of

the 41 athletes who reported their motives for using supplements, the most common reason they

consumed them was to promote and enhance their general health (44.0%). Other reasons

included: to gain muscle size (34.1%) and increase energy (24.4%), followed by to gain strength

and improve performance, both at 22.0%. Only 3 athletes (7.3%) reported they were unsure

about their motives for consuming DS. Table 5 depicts the different motives for consuming

supplements that were reported by the athletes.

Table 5

Reasons for Taking Dietary Supplements

Motive Frequency (N = 41) Percentage

General health reasons 18 44.0%

Gain muscle size 14 34.1%

For energy 10 24.4%

Gain strength 9 22.0%

Play sports better 9 22.0%

Look better 7 17.1%

Gain weight 6 14.6%

Not sure 3 7.3%

Other 3 7.3%

Lose weight 2 4.9%

Lose body fat 2 4.9%

40

When asked if they would use DS to improve their sports performance, 47.1% (n = 24) of

51 athletes that provided an answer “agreed” or “strongly agreed” with that statement. Due to

the fact that all of the participants could answer the second section of the SPAADSU survey,

there was a larger response for this section compared to the athletes that only use DS; both

consumers and non-consumers responded to this section of the survey.

Factors That are Better Predictors of Behavioral Intentions

All of the 54 participants completed the second section of the survey, which evaluated the

behavioral intentions, attitudes towards the behavior, and the subjective norms using a 5 point

Likert scale. This information helped elucidate if attitudes are better predictors compared to

subjective norms regarding the intention of the athlete to use DS. It further assessed the

influence that significant others such as parents, coaches, and physicians have on attitudes,

subjective norms, and intentions.

Descriptive statistics were conducted to analyze the means and standard deviations for

three subgroups of the second part of the SPAADSU. Table 6 indicates the three different

subgroups along with the corresponding survey question numbers and the means and DS for

each. According to the Likert scale, athletes tended to be in agreement with regards to their

behavioral intentions of using DS. The second subgroup, attitudes towards the behavior, the

respondents reported close to neutral with little variation. Furthermore, the data for the third

subgroup, subjective norms, indicated the athletes agreed with the statements.

41

Table 6

Means and Standard Deviations for Three Subgroups and Corresponding Question Numbers

Subgroups of the SPAADSU Survey Question Numbers Mean ± SD

1) Behavioral Intentions 11 – 23 2.47 ±, 1.28

2) Attitudes Towards the Behavior 24 – 33 3.35 ± 0.45

3) Subjective Norms 34 – 46 2.60 ± 0.45

An independent samples t-test determined there was a significant difference between

males and females in regards to their attitudes towards using supplements. In this sample, males

(M = 3.18, SD ± 0.38) expressed a more positive agreement regarding their attitudes towards

intentions of supplement use than females (M = 3.5, SD ± .46), t (51) = -2.84, p < 0.05. There

were no significant differences found between genders with regards to subjective norms or

behavioral intentions.

Simple linear regression was used to test which groups of significant others (parents,

coaches, or athletic trainers) had a stronger influence on the athlete’s behavioral intentions. It

also tested if subjective norms or attitudes had more of an influence on intentions. The results of

the regression indicated that the sources of information showed significant difference on

behavioral intentions.

According to the beta-coefficients, it determined that athletic trainers (b = 2.111) had

more of an influence and were better predictors of intentions than coaches (b = 1.451) and

parents (b = 1.045). It also showed that attitudes (b = 1.072) on the intentions were greater

predictors than subjective norms (b = 0.248). Figure 1 illustrates the path analysis for the beta-

coefficients from the linear regression analysis.

42

Figure 1. Path analysis of influence of significant others, attitudes towards the behavior and

subjective norms on behavioral intentions

Athlete’s Level of Knowledge and Safety about Dietary Supplement Use

The athletes were aware that DS have the potential to cause adverse side effects. Almost

all of the athletes (94.4%) believed there are side effects or risks in taking supplements. There

were only 3 athletes (5.6%) that stated otherwise. Furthermore, the majority of athletes (64.8%)

believed they were well-informed about the supplements, yet 16 of the athletes (29.6%) believed

they were not knowledgeable or educated enough regarding DS. Even though most of athletes

believed they were well-informed about DS, when asked if they would like more information

about supplements or supplements they were taking, 35 athletes (64.8%) indicated “yes”. The

majority of athletes (81.5%) also believed that they would benefit from an educational session

43

about DS conducted by a registered dietitian. Table 7 illustrates the results of questions 47-50

of the survey.

Table 7

Athlete’s Reported Knowledge Regarding the Safety of Dietary Supplement Use and the Desire

for an Educational Session from a Registered Dietitian

Survey Question Frequency

(N = 54)

Percentage

I believe there are no side effects or risks in taking DS Yes (3)

No (51)

5.6%

94.4%

I feel that I am well-informed about the supplements that I am

taking

Yes (35)

No (16)

Missing (3)

64.8%

29.6%

5.6%

I would like more information regarding different DS that I am

taking or would like to take

Yes (35)

No (18)

Missing (1)

64.8%

33.3%

1.9%

I believe I would benefit from an educational session about DS

conducted by a registered dietitian

Yes (44)

No (9)

Missing (1)

81.5%

16.7%

1.9%

Additionally, a series of questions was asked to evaluate the level of knowledge about DS

and their safety. When asked if taking DS is safe because they are tested by scientists, 24 out of

the 51 athletes (47.1%) disagreed or strongly disagreed to that statement. However, 19 reported

44

no opinion and 9 agreed. When asked if DS are safe because professional athletes take them, 40

athletes disagreed or strongly disagreed, but 11 of athletes had either no opinion or agreed. The

majority of the athletes, 88.2% (n = 45), disagreed or strongly disagreed to the statement that DS

work because professional athletes take them. These data concur with the previous results

discussed about the athlete’s knowledge and awareness of safety issues with DS consumption.

45

Chapter V: Discussion

The present study aimed to determine the prevalence of DS use in high school athletes.

The data collected identified the different DS used, analyzed motives for using DS, determined

the sources of information, and the athletes’ perceived level of knowledge about the safety of

DS. This information was determined by administering the SPAADSU to high school athletes at

Memorial High School in Eau Claire, Wisconsin. This chapter includes a discussion of the

findings and limitations within the study followed by recommendations for DSHEA and for

education or intervention strategies in this population.

Limitations

There were several limitations in this study that warrant comment. First, the winter

coaches were hesitant to participate in the study, and therefore athletes in winter sports are not

well-represented in the present study. More interest and participation came from the spring

sports and allowed for a larger sample population. Nonetheless, the small sample size limited

statistical comparisons and power.

Another factor potentially limiting subject participation and data collection was the

requirement for parental consent. To obtain parental consent, the consent forms were sent home

with the athletes, which likely reduced the rate of return and participation in the study.

Furthermore, it is possible that some of the parents were not inclined to allow their child to

participate for the reason that they were fearful of possible consequences if the athlete was

consuming a supplement that was banned or discouraged from the Wisconsin Interscholastic

Athletic Association (WIAA) athletic code. However, the consent form clearly indicated that the

survey inquired only about legal supplements. Lastly, the initial meeting with the girl’s track

46

and field team occurred a few days prior to the school’s spring break; the extended time between

the initial meeting and the follow-up meeting likely reduced the rate of response.

Another limitation was that the data were self-reported. Individual interviews may have

allowed for more accurate data collection. Due to the fact that the DS definition is incredibly

broad, the participants may not have realized all of the supplements that they were taking or had

consumed in the past. This stresses the importance of creating a more sound and concise

definition of what constitutes a DS. In order to minimize this limitation, a list of DS examples

was provided with the survey; however, the list was not comprehensive.

Conclusions

Of the 54 participating athletes, 25 were males, 28 females, and one was transgender that

chose to participate. The transgender athlete indicated themselves as biologically male but was

included in a separate “transgender” category and was excluded only from gender comparison

data analysis. This individual was excluded from analyses for the reason that they are

biologically male, but would associate and generalize with female attributes and mentalities.

This would have provided inaccurate data between males and females. There was no significant

difference between males and females with regards to supplement use. Most of the athletes were

under the age of 18 years old (81.5%) which is imperative to recognize because the effects of

short and long term supplementation has not been thoroughly studied in minors and most DS are

not intended for this young population. Half (50%) of the athletes surveyed were consuming DS

daily, (31.5%) of them had tried DS in the past but stopped, or had tried DS once or twice. This

determined that the majority of the athletes (81.5%) surveyed currently consume or have

consumed supplements. These data support existing literature (Bell et al., 2004), which suggests

DS use in this population is on the rise.

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Even though the athletes reported consuming relatively safe supplements such as sports

drinks, protein powders, fish oils, or multivitamins, there is still the possibility that the athlete

might be inclined to seek other supplements that could pose more of a health threat or

supplements that are illegal. Caffeine and energy drinks are correlated with heart attacks or

arrhythmias in young adults (Meier, 2012). These supplements were determined to be the most

harmful DS reported in the study. A total of only eight athletes (14.8%) listed they were

consuming caffeine (n = 3) and energy drinks (n = 5), yet one of the main reasons for consuming

supplements was for energy (24.4%). The present study did not evaluate if those athletes who

reported consuming caffeine and energy drinks were consuming them for specifically for energy

purposes. The motives for consuming caffeine or energy drinks would be pertinent to

understand in order to design intervention strategies targeting the use of caffeine consumption in

young athletes. The potential serious side effects related to excess caffeine consumption in

teenagers and the lack of requirement for companies to list the amount of caffeine in a product

(United States Federal Food and Drug Administration, 2013a) raises serious concerns and

suggests that stricter regulations are needed within DSHEA and the FDA regarding caffeinated

beverages and energy drinks.

The motives behind supplement use in the study were different than previously reported

in the literature. This study determined that the athletes chose to consume DS to improve their

general health (n = 18), with only nine of the athletes reporting use of DS to enhance sport

performance. Other studies discuss that athletes tend to enhance their sports performance as

their primary reason for using DS (Froiland et al., 2004). Due to the fact that all of the

participants could answer the second section of the SPAADSU survey, there was a larger

response for this section compared to the athletes that only use DS; both consumers and non-

48

consumers responded to this section of the survey. When asked if the athletes would use

supplements to enhance their sports performance, almost half (47.1%) of athletes said they

would, which concurs with previous studies (Scofield & Unruh, 2006; Godo et al., 2006).

Scofield & Unruh (2006) found that 83.3% of athletes currently using supplements consumed

them for the purpose of enhancing sports performance. Godo et al., (2006) determined that

37.7% of the athletes would use supplements to improve their sports performance. Gaining

muscle size (n = 14) and increasing energy (n = 10) were other popular motives for taking DS.

Froiland et al. 2004; Scofield and Unruh, 2006; and Godo et al. 2006 determined that

athletes tend to choose supplements that enhance their sports performance; however, considering

that this current study determined general health promotion to be the main motive behind using

supplements, it would be beneficial to investigate the connection of DS and enhancing general

health in high school athletes. Data generated by the present study suggest that athletes are more

interested in maintaining general health versus building muscle or enhancing sports performance

with the assistance of DS.

The athletes were receiving information from sources that agreed with current literature.

Parents were the primary source of information (46.3%). Questions were asked to assess

whether the athletes believe the parents and coaches are credible sources. When the athletes

were asked if they would ask their parents and/or coaches if DS were safe or if they work, over

half of the athletes said they would. These findings are similar to what others have reported in

the literature. Dunn et al. (2001) found that these data are concerning because parents may not

have a background in nutrition and health and it is unclear where the parents receive their

information regarding DS. A reliable source of accurate and up-to-date information about DS

and athletic performance is a certified sports dietitian which can be found on the Academy of

49

Nutrition and Dietetics: Sports, Cardiovascular, and Wellness Nutrition (SCAN) dietetic practice

group’s website. Only two athletes received their information from a registered dietitian.

Physicians (24.1%) were the second most commonly reported source, followed by coaches

(20.4%).

Additionally, some athletes (11.1%) indicated they received their information from stores

such as GNC™ or Vitamin World®. These are for-profit retailers and are therefore less likely to

provide information about the negative aspects of their products. Furthermore, the employees

are minimally trained by the company and likely lack the appropriate education and knowledge

needed to provide sound information regarding the safety of DS (Madison, 2013). When

working with high school athletes, emphasis should be placed on the appropriate channels for

receiving the most accurate advice about DS.

To determine the factors having the largest influence on an athlete’s use of dietary

supplements, three subgroups, behavioral intentions, attitudes towards the behavior, and

subjective norms, were investigated. There were significant differences between parents,

coaches, and athletic trainers and their influence on behavioral intentions. Approximately 63%

(n = 32) of the athletes who completed the second section (n = 51) of the survey indicated they

would use DS if their parents purchased them. These data indicate that parents, coaches, and

athletic trainers should be well-informed about the risks and benefits of DS use in high school

athletes. Due to the influence that trainers and coaches have on their athletes, both should be

required to complete nutrition courses to provide more accurate information for their athletes.

They should also be informed and knowledgeable about the consequences of supplement use.

This will allow trainers and coaches to be more credible and knowledgeable about supplement

use and can inform their athletes accurately. Surprisingly, this group of high school athletes

50

reported that they know there are safety issues and potential hazards regarding use of DS.

Almost all (94.4%) of the athletes indicated they were aware of risks. The data also indicated the

majority of high school athletes surveyed were aware that use of DS by professional athletes

does not indicate safety. However, there is likely still a need for education because some athletes

did report they would consume supplements because they are tested by scientists and

professional athletes take them. This also corresponds with the media targeting this young

population and their influence on the athlete’s intention to use DS (Scofield & Unrah, 2006).

Fortunately, over half (64.8%) of the athletes would appreciate more information about

supplements and 81.5% of the athletes said they would benefit from an educational session with

a registered dietitian.

Recommendations

After obtaining and analyzing these data, recommendations should be set-forth and taken

into consideration for future research, DSHEA, and for athletes, parents, and coaches.

Recommendations for future research include studying a larger sample population. The small

number of participants in the study made it difficult to run multiple comparison data analysis and

the small sample size limited the portrayal of overall supplement use in high school athletes.

The larger sample size would better represent the general population of high school athletes and

would allow for more statistical analyses to be conducted and could possibly find more

significant differences between groups. Furthermore, future research should identify supplement

use in high school non-athletes and compare the results to athletes. Comparing the two groups

would allow for a greater representation of the entire high school population which would

determine if non-athletes are targets of the supplement industry as well.

51

The current study discovered one transgender individual and was excluded from gender

comparison data analysis because they identified themselves as biologically male, but would

have behaviors and characteristics of a female. Due to the fact the study inquired about motives

and behavioral intentions for use of DS, representation from the transgender may have provided

inaccurate data. Therefore, future studies could include transgender individuals or design a study

using just a transgender population and compare it to non-transgender males and females.

When parents and coaches are discussing a training program with their athletes, they

should first promote the importance of consuming a well-balanced diet to maintain health and to

build their sports performance instead of DS. If the athletes choose to apply a DS regimen,

healthcare professionals should discuss supplement use with athletes, trainers, coaches, and

parents, before athletes begin a regimen. More importantly, a registered dietitian, preferably a

certified sports dietitian, should speak with the team regarding consumption of a healthy diet to

promote health and sports performance first, followed by a discussion of the use of supplements,

their risks and benefits, and how to properly use them if the athlete chooses. The registered

dietitian can provide brochures or credible website sources such as The Academy of Nutrition

and Dietetics, FDA, and The Office of Dietary Supplements for further information. This will

allow for more accurate information to be provided to the athletes which will help ensure safe

use of the DS as well as design an educational session regarding DS use for the athletes.

Regardless, due to the fact that parents and coaches were reported as sources of information for

the athletes, it should be recommended that future research assess and measure the credibility

and knowledge of supplements of these sources. Ultimately, health professionals, coaches, and

parents need to recognize this growing epidemic and be proactive by reinforcing the benefits of

consuming a balanced diet before turning to dietary supplements.

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The supplements of most concern in this population were the caffeine and energy drinks

and because consumption of these products was identified, it is recommended that DSHEA

implement new and stricter regulations regarding the ability of manufacturers to market these

products and limit their access to minors under the age of 18 years. The potential serious side

effects related to excess caffeine consumption in this population raises concerns and warrants

further research and, subsequently, intervention. As previously discussed, DS are accessible to

all ages and therefore, legislative efforts regarding the selling and purchasing of DS to minors

would be beneficial.

53

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Appendix A: Consent Form for Athletes

Consent to Participate in UW-Stout Approved Research Parent/Guardian/Athlete’s Form

Title: Dietary Supplement Use in High School Athletes in Wisconsin Investigator: Research Advisor: Laura Sell Dr. Kerry Peterson University of Wisconsin-Stout University of Wisconsin-Stout Graduate Student Advisor Human Nutritional Sciences Food and Nutrition Department Email: selll@my.uwstout.edu Email: petersonke@uwstout.edu Description: The primary objective of this study is to determine the prevalence of dietary supplement use in high school athletes at Memorial High School located in Eau Claire, Wisconsin. It will also aim to identify the different supplements used, analyze perceptions of and motives for using dietary supplements, and determine the sources of information and level of knowledge about dietary supplements in these athletes. This study only asks about use of legal dietary supplements. If you decide to participate in this study, you will be asked to complete a survey about dietary supplements. By completing this survey, you will help us to understand the prevelance and perceptions of dietarty supplement use in athletes your age. Information regarding dietary supplements can be found at the National Institutes of Health: Office of Dietary Supplements webpage: http://ods.od.nih.gov/ Risks and Benefits: There are no foreseeable risks to participating in this research. There are no direct benefits. However, by completing this survey you are helping researchers assess the use of dietary supplements in athletes your age. Your participation in entirely voluntary, and if you feel uncomfortable with any of the questions, or wish to stop the survey, you may do so at any time without consequence. Special Populations: If you are under the age of 18, you and your parent or guardian must sign this informed consent form before you complete the survey. Time Commitment and Payment: This survey should take no more than 15 minutes to complete. In return for your time and effort associated with completing this survey your name will be entered into a drawing for a $15 iTunes Gift Card.

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Confidentiality: Your name will not be included on any documents. Your responses cannot be identified from any of this information. This informed consent will not be kept with any of the other documents completed with this project. Right to Withdraw: Your participation in this study is completely voluntary. You may choose not to participate without any adverse consequences to you. Should you choose to participate and later wish to withdraw from the study, you may discontinue your participation at this time, or at any time during the study, without incurring adverse consequences. IRB Approval: This study has been reviewed and approved by The University of Wisconsin-Stout’s Institutional Review Board (IRB). The IRB has determined that this study meets the ethical obligations required by federal law and University policies. If you have questions or concerns regarding this study please contact the Investigator or Advisor. If you have any questions, concerns, or reports regarding your rights as a research subject, please contact the IRB Administrator. Investigator: IRB Administrator: Laura Sell Sue Foxwell, Director, Research Services University of Wisconsin-Stout 152 Vocational Rehabilitation Bldg. Graduate Student University of Wisconsin-Stout Human Nutritional Sciences Menomonie, WI 54751 Email: selll@my.uwstout.edu 715-232-2477 Email: foxwells@uwstout.edu Statement of Consent: By signing this consent form you agree to participate in the project entitled, “Dietary Supplement Use in High School Athletes in Wisconsin.” _____________________________________________________________ Signature (athlete) Date _____________________________________________________________ Signature of parent or guardian Date (Must sign if child is under 18 years of age)

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Appendix B: Dietary Supplement Use in High School Athletes Survey (SPAADSU, 1996)

Athletes and Dietary Supplement Survey

This is a survey that will look at what you and other athletes your age think about dietary supplements.

Section 1 Please answer the following questions about yourself. Check your answer directly on the survey. Answer all the questions. Do NOT put your name on the survey. Your answers will not be shared with anyone. 1. _____ Male _____ Female 2. What is your age today? (Circle one) 13 14 15 16 17 18 19 3. What grade are you in? (Circle one) 9th 10th 11th 12th 4. Which of the following best describes your ethnic background? _____ American Indian _____ Black or African-American _____ White or Caucasian _____ Hispanic or Mexican-America _____Oriental or Asian-American _____ Other: ____________________ 5. What sport(s) do you play for your school? Please list below -

_________________ _________________

_________________ _________________

_________________ _________________ 6. What types of sports and recreational activities do you participate in either inside or

outside of school? Please list below -

_________________ _________________

_________________ _________________

_________________ _________________

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7. Do you take one or more dietary supplements? (Please check only one below - A list of supplements can be found on page 7)

_____ Yes, I currently take them on a regular basis. _____ No, I used to take them but stopped. _____ No, but I have tried them once or twice. _____ No, I have never tried them. 8. If you answered yes to question 7, what is your reason for taking Dietary Supplements?

(Please check all that apply) _____ Gain weight _____ Lose weight _____ Gain strength _____ Gain muscle size _____ Play sports better _____ Look better _____ For energy _____ Lose body fat (get cut) _____ Not sure _____ General health reasons _____ Other _____________ 9. Please list the different dietary supplements you are currently taking or have taken in the

past. Also, please identify if you take it regularly (how often) or if it was a supplement that you had consumed in the past.

10. Where do you get information and advice regarding dietary supplement use?

_____ Parents/guardian ____ Other family member (specify): ___________ _____ Teammates ____ Media (specify): _______________________ _____ Coaches ____ Friends _____ Physician ____ Dietitian _____ I have not received any information or advice about dietary supplements _____ Other (specify): ______________________

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Section 2 The following questions are to be answered using a scale with 5 choices. You are to put an "X" after the choice that best describes how you feel about the statement. There are no right or wrong answers to these questions. Be honest with your answers. Remember, no one will see your answers.

11. I would use dietary supplements to improve my sports performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 12. I would use dietary supplements to improve my general health rather than for

better sports performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 13. I would use dietary supplements if my coach gave them to me. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 14. I would use dietary supplements if my parent(s) or guardian were taking them. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 15. I would use dietary supplements if an athletic trainer gave them to me. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 16. I would ask my coach if dietary supplements are safe. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 17. I would ask my coach if dietary supplements work. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

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18. I would ask my parent(s) or guardian if dietary supplements are safe. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 19. I would ask my parent(s) or guardian if dietary supplement work. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 20. I would use dietary supplements that I know work. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 21. I would use dietary supplements that I know were tested and safe. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 22. I would use dietary supplements if I could afford to buy them. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 23. I would use dietary supplements if my parent(s) or guardian bought then for me. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 24. Taking dietary supplements is safe because they are tested by scientists. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 25. Taking dietary supplements would give me more energy. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 26. Taking dietary supplements would help prevent my getting a cold or the flu. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

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27. Taking dietary supplements would help all athletes do better in sports. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 28. Taking dietary supplements is a safe way for athletes to improve sports

performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 29. Taking dietary supplements is a good way to build muscles. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 30. Athletes my age need dietary supplements to improve sports performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

31. Athletes my age need dietary supplements for general health reasons. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

32. Dietary supplements are safe because professional athletes take them. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 33. Dietary supplements work because professional athletes take them. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 34. My coach would support my using dietary supplements to improve sports

performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 35. My coach would support my using dietary supplements for general health reasons. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

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36. My parent(s) or guardian would support my using dietary supplements for general

health reasons. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 37. My parent(s) or guardian would support my using dietary supplements for better

sports performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 38. My teammates would support my using dietary supplements for better sports

performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 39. My teammates would support my using dietary supplements for general health

reasons. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 40. My doctor would support my using dietary supplements to improve sports

performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 41. My doctor would support my using dietary supplements for general health reasons. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 42. My team’s athletic trainer would support my using dietary supplements to improve

sports performance. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___

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43. My team’s athletic trainer would support my using dietary supplements for general health reasons.

Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 44. Generally speaking, I want to do what my parent(s) or guardian want me to do. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 45. Generally speaking, I want to do what my coach wants me to do. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 46. Generally speaking, I want to do what my doctor wants me to do. Strongly agree___ Agree___ No opinion___ Disagree___ Strongly disagree___ 47. I believe there are no side effects or risks in taking dietary supplements.

____ Yes ____ No

48. I feel that I am well-informed about the supplements that I am taking.

____ Yes ____ No

49. I would like more information regarding different dietary supplements that I am taking or would like to take. ____ Yes ____ No

50. I believe I would benefit from an educational session about dietary supplements

conducted by a Registered Dietitian. ____ Yes ____ No

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List of Possible Dietary Supplements

This sheet should be used to help complete question 9

Supplements

1. Carnitine

2. Chondroitin

3. Coenzyme Q-10

4. Conjugated Linolenic Acid (CAL)

5. Creatine

6. Echinacea

7. Fiber or Psyllium (pills or powder)

8. Fish Oil

9. Flaxseed

10. Garlic pills

11. Ginger pills

12. Ginkgo biloba

13. Ginseng

14. Glucosimine

15. Lecithin

16. Lutein

17. Lycopene

18. Melatonin

19. Prebiotics or probiotics

20. SAM-e

21. Soy or soy isoflavones

*Please include any other supplement(s) you

are taking if it is not on this sheet. These are

examples of dietary supplements; therefore,

does not include every supplement.*

22. Multivitamin

23. Calcium

24. Chromium

25. Folic acid/folate

26. Iron

27. Magnesium

28. Niacin

29. Potassium

30. Selenium

31. Vitamin A

32. Vitamin B complex

33. Vitamin B6

34. Vitamin B12

35. Vitamin C

36. Vitamin D

37. Vitamin E

38. Vitamin K

39. Zinc

Other

40. Sport drinks (example: Powerade)

41. Energy drinks (example: Rockstar)

42. Power bars

43. Protein/whey powders

44. Caffeine

45. Meal replacement (example:

SlimFast