Athletic Training and Sports Health Care

Original Research Supplemental Data

Development and Pilot Testing of the Runner's Health Choices Questionnaire

Laurie Stickler, PT, DHS, OCS; Alexandra Arnold, DPT; Shelby Myers, DPT; Madeleine Sampson, DPT; Barbara Hoogenboom, PT, EdD, ATC, SCS

Abstract

Purpose:

To use prior qualitative studies and pertinent research to develop and pilot a survey for female distance runners to assess their perspectives toward health as related to sport and the factors impacting their eating behaviors.

Methods:

The Runner's Health Choices Questionnaire (RHCQ) was developed using themes from prior research. A panel of experts reviewed the survey to determine validity. The RHCQ was then pilot tested by female cross-country runners at six colleges/universities.

Results:

Face and content validity were established. Twenty-six female cross-country runners completed the pilot study. Runners did not suggest changes to the survey. Minimal changes in wording were needed based on survey review and data analysis.

Conclusions:

A novel quantitative survey on health attitudes and dietary behaviors of the female distance runner was developed. The RHCQ is a valid, brief, and easily accessible tool that health care providers could incorporate into practice to assess the reasons behind athletes' dietary choices and perspectives of health behaviors.

[Athletic Training & Sports Health Care. 2020;12(2):74–80.]

Abstract

Purpose:

To use prior qualitative studies and pertinent research to develop and pilot a survey for female distance runners to assess their perspectives toward health as related to sport and the factors impacting their eating behaviors.

Methods:

The Runner's Health Choices Questionnaire (RHCQ) was developed using themes from prior research. A panel of experts reviewed the survey to determine validity. The RHCQ was then pilot tested by female cross-country runners at six colleges/universities.

Results:

Face and content validity were established. Twenty-six female cross-country runners completed the pilot study. Runners did not suggest changes to the survey. Minimal changes in wording were needed based on survey review and data analysis.

Conclusions:

A novel quantitative survey on health attitudes and dietary behaviors of the female distance runner was developed. The RHCQ is a valid, brief, and easily accessible tool that health care providers could incorporate into practice to assess the reasons behind athletes' dietary choices and perspectives of health behaviors.

[Athletic Training & Sports Health Care. 2020;12(2):74–80.]

The definition of health from the World Health Organization includes “complete physical, mental, and social well-being.”1 Athletes are often considered “healthy” because they exercise on a regular basis, but there are many determinants to consider when assessing their overall health. Von Rosen et al.2 suggested a biopsychosocial model be used to assess the health of athletes, highlighting the importance of factors other than training routine, including nutrition, stress, and sleep. The consequences of unhealthy behaviors or a lack of overall health in athletes are varied and numerous, ranging from increased injury risk2–4 to poor cardiovascular health.5,6

In two separate studies, von Rosen et al.2,3 studied numerous factors related to injury risk among adolescent athletes. In addition to training routines, nutrition, self-esteem, and sleep were identified as contributors to potential for injury. The authors suggested that a combination of these negative factors is often present,2 highlighting the need for a comprehensive look at health.

Nutrition, and specifically low energy availability, is highlighted to be at the crux of two defined syndromes: Relative Energy Deficiency in Sport (RED-S)7 and the Female Athlete Triad (hereafter referred to as the triad).6 Energy availability is defined as the dietary energy in-take minus the energy that is expended in exercise relative to fat-free mass.6,7 RED-S was defined in 2014 by the International Olympic Committee as a comprehensive term for the range of symptoms associated with low energy availability. RED-S may affect both males and females. Both short- and long-term consequences of RED-S have been described and include, but are not limited to: nutritional deficiencies, chronic fatigue, depression, illness, decreased performance, physiological implications affecting all systems, disrupted menses in females/fertility issues in males, and diminished bone health.7 The prevalence of RED-S has not yet been reported in the literature.

The triad is a more specific term than RED-S and refers to the relationship that exists between energy availability, menstrual function, and bone mineral density in female athletes.8 Low energy availability, whether intentional or unintentional, can result in menstrual dysfunction and low bone density in females.6 Although these three areas of dysfunction can be seen together, athletes can demonstrate a combination or only a single component of the triad. According to systematic reviews by Gibbs et al.9 and Hergenroeder et al.10 the prevalence of all three components in female high school, collegiate, and elite athletes ranges between 0% and 16%; the percentage of athletes demonstrating two components ranges between 2.7% and 27%; and the percentage of athletes having one component ranges between 16% and 60%.

Low energy availability is of concern in all athletes; however, female athletes, such as distance runners, who participate in sports where leanness is viewed as a critical performance factor are at a higher risk of developing poor nutritional habits or an eating disorder.11 The female collegiate cross-country runner faces intense training and high energy demands. The perceived performance benefits and the sociocultural pressure for an “ideal” body shape can play a role in female athletes' eating patterns.12 In all athletes, increasing energy availability is a key component in prevention and treatment of RED-S7 and the triad.4,13

Although a multidisciplinary approach is recommended to treat the triad and RED-S,4,13–15 the best method for improving energy availability in female athletes has not yet been identified. In several studies that attempted to improve menstrual status by increasing energy availability via a supplement or nutritional counseling, compliance of the athletes was an issue.16–19 In a study by Spronk et al.,20 nutritional knowledge was only weakly correlated with nutritional quality of dietary intake in both male and female athletes (average age: 18.6 years), suggesting knowledge does not always translate to action. Furthermore, in a small qualitative written portion of a survey distributed to female collegiate cross-country runners, Zawila et al.21 found themes in food selection choices (eg, food preference, health indication, body appearance, and weight issues), suggesting that multiple factors contribute to food choices.

On a broader scale, qualitative research has been used to understand the “why” behind female collegiate cross-country runners' health and eating behaviors.22,23 In one study,22 the main themes that emerged included nutritional knowledge, internal and external factors, and health attitudes. The runners reported varied intrinsic and extrinsic reasons for eating behaviors, including the desire to have a balanced diet, inexperience with cooking, and the lack of transportation or money to purchase food. This highlights the complexity of factors affecting runners' health attitudes and eating behaviors. This complexity is further illustrated by a narrative case report by Busanich et al.,24 who found that eating behaviors in elite male and female distance runners result from an array of social, cultural, and gender factors and experiences. Thus, the aforementioned factors and experiences need to be explored further to understand health and eating decisions in female athletes to help manage and prevent low energy availability and related health problems.

Nutrition, sleep, and stress may significantly affect the health of athletes, and understanding reasons for athletes' decisions regarding sport and nutrition may help optimize health. Female distance runners face intense training demands and may be subject to internal and external pressures to succeed. Although there are a variety of established valid screening tools for eating disorders,25 these tools do not assess why athletes make the decisions they do regarding health and eating and the potential impact of sport on these decisions. Therefore, the purpose of this study was to use prior qualitative studies and pertinent research to develop and pilot test a survey for female distance runners that can be used to assess their perspectives toward health as related to sport and the factors affecting their eating behaviors.

Methods

Survey Development

Prior qualitative studies have explored the health attitudes, perceptions, and eating behaviors of female runners.22,23 Qualitative research has many strengths, including “its attention to contexts in which behavior does/does not occur; examination of the differences between what informants say and what they actually do; and consideration of how the processes of social distinction and identity/image management affect behavior” (p. S44).26 Because of these characteristics, the information gathered in prior qualitative studies on health perspectives is extremely beneficial; however, qualitative results lack generalizability to a population. Thus, a quantitative survey, the Runner's Health Choices Questionnaire (RHCQ), was developed based on prior research. Explicit analysis of themes from existing research was used to develop and discern question content. The majority of questions were developed considering the themes found by Stickler et al.22; however, the researchers used relevant information and findings from other research encountered in the review of the topic.4–8,10,16,21,24,27–30

The RHCQ consists of 15 questions, ensuring that it can be taken in a 10- to 15-minute timeframe to help increase the response rate. When designing content and question order, recommendations by Bradburn et al.27 were used to avoid bias and appear non-threatening, including starting the survey with fact-based questions before moving into opinion-based questions. Questions that ask participants to rank factors use a Likert scale continuum of No Impact, Minimal Impact, Moderate Impact, High Impact, and Neutral/Don't Know.27 Participants are able to offer additional factors in open-ended sections. For the pilot survey, there was an opportunity at the conclusion of the survey to add any feedback regarding question wording, possible missed answers, and any additional comments that participants may have had.

Questions 1 to 5 were designed to gather demographic information about participants to accurately describe the population and allow for thorough analysis of the results. Following the basic demographic information, a general non-threatening question (Question 6) inquires about reasons for running. Understanding why an athlete runs may help to understand the athlete as a whole.

Questions 7 to 9 ask background questions regarding nutrition. Zawila et al.21 determined that many collegiate cross-country runners lack nutritional knowledge critical to making healthy eating decisions and preventing nutrition-related health disorders. Stickler et al.22 described a lack of access to nutritional knowledge as a factor in why athletes make certain eating decisions. Therefore, questions 7 and 8 were included to assess how much nutritional education these athletes had and what sources they had access to when making their diet and eating choices. A general question about the type of diet the athlete followed (Question 9) was included because the American College of Sports Medicine indicates that knowledge of dietary practices of the athlete can help determine whether the triad is present.8 Further, vegetarians specifically may have a difficult time meeting energy demands and are at risk for low energy availability.28

Question 10 inquires about the reasoning behind overall dietary choices of the athletes: “Please rate how much of an impact you feel the following factors have on your choice of overall diet specified in the question above.” The answer options offered were chosen based on a specific theme or factor found in previous literature to potentially have an affect on athletes' dietary choices. The first three options (enjoyment of food, makes you feel healthy, and health condition) were noted by both Zawila et al.21 and Turner-McGrievy et al.29 to be factors. The idea of general health promotion was addressed with the answer choice “makes you feel healthy” to use common language. Busanich et al.24 suggested that injury prevention, weight loss or maintenance, and athletic performance enhancement can play a role in dietary choice. The option of weight loss or maintenance was supported under the theme of health attitudes as described by Stickler et al.22 and Zawila et al.21 Eating a balanced diet was determined to be a key concept for athletes when determining their ideas of health. The response “athletic performance enhancement” was included as an answer option because Stickler et al.22 noted that training dictated eating behavior, a key concept in their qualitative study. Stickler et al.22 also determined that internal and external factors were a theme in the perspectives that female cross-country runners had on their health and eating behaviors; thus, “cost,” “family,” and “friends/peers” were included as possible responses encompassing external factors that could influence dietary decisions. Furthermore, Kroshus et al.30 determined that teammates can have a role in the decisions athletes make regarding their dietary choices. Finally, responses “cost,” “animal welfare,” “environmental concerns,” and “religious reasons” were included because they were included as responses in the study by Turner-McGrievy et al.29

Question 11 focuses on the factors that have an affect on the athlete's daily meal decisions: “Please rate how much of an impact you feel the following factors have on your daily meal decisions.” The answer options “time to prepare meals,” “cost,” and “transportation availability” were included because logistics were determined to be important in making dietary decisions according to Stickler et al.22 Kroshus et al.30 determined that teammates can have a profound affect on what the athlete chooses to eat and therefore the responses “presence of others” and “teammates” were included as potential factors for daily meal decisions. The answer options “experience with cooking” and “choices in cafeteria” were determined to be important possible factors based on the study by Stickler et al.,22 which found that “living/meal situation” was a subtheme. “Family” and “coaches” also were considered subthemes22; therefore, they were included as potential factors due to the large influence family and coaches may have on athletes' choices and behaviors, especially regarding their diet. The factors “health concerns,” “creating a balanced diet,” “cost,” and “practice/race that day” were included as potential reasons for dietary choice because Turner-McGrievy et al.29 and Busanich et al.24 suggested that these may strongly affect how athletes make their decisions about daily meals and overall diet. The answer options “creating a balanced diet” and “nutritional knowledge” were included because these were key concepts and a theme found in the perceptions of athletes on their health and eating behaviors.22

Question 12 shifts from eating behaviors to focusing on possible factors influencing running performance: “Please rate how much of an impact you feel the following factors have on your running performance.” Zawila et al.21 noted the key concepts of fuel in and out and hydration, so the answer options “caloric intake” and “hydration” were included. Caloric intake was also suggested by Busanich et al.,24 but as a negative influencing factor because runners may limit their food in-take to improve performance. Additionally, Busanich et al.24 emphasized the influence of emotional distress on performance in elite runners, so “daily mood” was included as an option. Because this term may be interpreted differently among participants, the simpler positive factors of “confidence” and “motivation,” as supported by Stickler et al.,22 were added. Stickler et al.22 also suggested “sleep” as a factor influencing running performance and injury risk2,3 so this was included as an answer option. To limit the number of responses, the ideas from Stickler et al.22 of eating to perform and fuel in/out and healthy body weight were combined to create the answer option “body weight” as a factor impacting running performance. Finally, “menstrual cycle” was included due to the fact that prior research on the triad indicates that menstrual status relates strongly to bone health, which could affect running performance.4–8,10,16

Question 13 asks participants to rate factors that they believe impact their overall health: “Please rate how much of an impact you feel the following factors have on your overall health.” This question was placed subsequent to the more specific dietary behavior questions rather than before to prevent participants from altering their answers to what they believed was expected from the researchers. All answer options for question 13 were taken in some form from Stickler et al.,22 with general eating habits and body weight also being modified from Turner-McGrievy et al.29 Sleep was not only reported by runners as important to health,22,23 but, as noted previously, may be a risk factor for injury.2,3 Energy balance, body weight, training routine, and daily mood were themes noted by Busanich et al.24 to be perceived by runners as influencing overall health.

Question 14 continues to look at the athlete's beliefs on what factors impact her desire to run: “Please rate how much of an impact you feel the following factors have on your desire to perform well in running.” Stickler et al.22 supported “self-motivation,” “coach,” and “wanting to help team” through several themes, including psychological factors and health behaviors, as some of the desire to perform well. Stickler et al.22 and Busanich et al.24 both recognized that self-motivation has an influence because runners may take care of themselves to perform better. In addition, runners value their identity as a runner who performs in a certain manner or performs well.24,30 There may also be external factors that affect their desire to run, including their coach and family, so these were also included as possible answers.

Finally, Stickler et al.,22 Zawila et al.,21 and Kroshus et al.30 found that athletes often used unreliable sources of health information; thus, it was necessary to ask the athletes about where they received their nutritional information (Question 15). Previous authors have shown that individuals and athletes may receive their information from a variety of sources, including those easily accessible through their team, such as coach, teammates, sports nutritionist, or primary care physician. The findings of Kroshus et al.30 indicate that athletes may use their coach and teammates as a source of nutritional information. Stickler et al.22 and Zawila et al.21 both found that runners received information from these sources, as well as their parents and other external sources (eg, social media, Internet sources, magazines, and a book or textbook).

Establishment of Validity

Validity refers to the degree that an instrument measures what it is intended to measure, and more specifically content validity indicates the adequacy with which the universe is sampled by a test.31 To establish face and content validity, a panel of experts reviewed the instrument and assisted with determining whether the questions satisfied the appropriate domains. The panel consisted of three individuals, a registered dietician and two experts in the realm of the triad (both board certified sports physical therapists, each with more than 20 years of experience performing research on, treating, and engaging with female runners). Validity also was enhanced by the process of using prior qualitative data and other research to formulate both questions and answers. In addition, two former female collegiate cross-country runners and one current female marathon runner reviewed the survey questions for understandability, ease of reading, flow, and the time required to take the survey.

Pilot Study

Sampling included several colleges in Michigan with a proposed minimum of one school per Division (I, II, and III) and the National Association of Intercollegiate Athletics (NAIA). Survey participation was voluntary. The goal was to have 30 participants take this pilot survey. To be included in the study, the participant had to be female, a member of the collegiate cross-country team, and between the ages of 18 and 25 years. All others were excluded from the study. All participants read and agreed to an online informed consent prior to beginning the survey. The pilot study was approved by the institution's Human Research Review Committee.

The survey was distributed through the online Qualtrics platform (Qualtrics, Provo, UT). An introduction to the survey was e-mailed to coaches of female collegiate cross-country teams in Michigan across Divisions I, II, III, and the NAIA. After an acceptance from the coach to send out the survey to their athletes, coaches were asked to contact the researchers with the number of runners to whom he or she sent the survey to allow tracking of the response rate. Coaches who agreed then received another e-mail with instructions for distribution of the survey to the athletes via an e-mail with a link to the survey. With an online platform, researchers aimed to reach a larger number of collegiate female runners. Participants were provided with an incentive of winning one of two $20 gift cards that were drawn randomly if they chose to provide an e-mail address at the end of the survey.

Results

Face and content validity were successfully established following review from the panel of experts and current and/or former cross-country runners. The panel of experts reviewed the RHCQ and agreed the questions satisfied the appropriate domains. Former and current cross-country runners reported the survey taking them between 11 and 18 minutes to complete; this included time to evaluate questions and wording choices and to provide feedback. The survey was adjusted after consideration of the feedback from the panel of experts and runners. These adjustments included updating diet types and definitions and small wording changes.

Twenty-one schools were contacted and coaches from six schools agreed to send out the survey. From those six schools, 26 of 94 possible cross-country runners completed the survey for a 27.7% response rate. The ages of the runners ranged from 18 to 23 years, with an average age of 20 ± 1.3 years. Descriptive statistics were calculated for all questions solely for identification of any additional changes that may have been needed in question structure or responses. Only responses for question 6 are presented in Figure 1 because a change to the structure of this question is recommended, based on the results of this pilot study. Responses to all other questions are not reported herein because this pilot study focused only on survey development. No additional factors were reported in the “other” boxes present at the end of several questions, suggesting that answer choices sufficiently represented an array of answers for runners. Furthermore, runners who completed the survey did not have any further wording suggestions.

Response to question 6: why do you run?

Figure 1.

Response to question 6: why do you run?

Discussion

In establishing face and content validity of the RHCQ, a few minor changes were made following expert review. The pilot study provided the opportunity for a comprehensive look at the responses of runners to the questions that guided further development or modification of the tool, with the goal of eventual deployment on a larger scale. There was no additional feedback given by pilot respondents on ways to improve this pilot survey. It was reported (Question 16) to be “well written, easy to use and understand.”

Total distribution of responses for each of the 15 questions of the pilot study was assessed to ensure usability of the questions and responses as written. Only one question was identified through this as needing alteration. The structure of question 6 (“Why do you run?”) should be changed to use a ranking system because the runners valued a majority of listed factors as reasons why they run (Figure 1), but were not given the opportunity to identify which factors might be more valued than others. By changing this question to a ranking system, it may be easier to discern which factors participants perceive as the most impactful.

For future use of the tool, the researchers suggest adding a question looking at willingness to make dietary changes to see how rooted athletes are in their health behaviors. This question could be: “If provided or given access to new or additional information from a health care professional, how likely would you be to make dietary changes?” This additional question is related to literature demonstrating a gap between knowledge and behavior20 and low compliance by athletes with interventions designed to improve health in studies looking at the effects of increasing energy availability.16–19

The researchers believe that the RHCQ (Table A, available in the online version of this article) could be used for group analysis or for individual use with distance runners for both prevention and treatment of low energy availability. Table 1 identifies what topics the questions address to aid in the analysis of results. This may be of particular use for those health care providers or coaches who distribute the survey on an individual basis. For example, health care providers may be able to address specific intrinsic and extrinsic factors noted by an athlete that are negatively influencing eating behaviors. Those identifying unreliable sources of information could receive education on reliable sources. Athletes who are vegetarian or vegan may need targeted nutritional education on how to successfully meet dietary needs. Individualized and targeted education, whether to a team or a single athlete, has the potential to improve the health of athletes.

Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)Proposed Survey After Pilot StudyRunner's Health Choices Questionnaire (RHCQ)

Table A:

Proposed Survey After Pilot Study

Runner's Health Choices Questionnaire (RHCQ)

Distribution of Survey Topics

Table 1:

Distribution of Survey Topics

Limitations and Future Research

Because we are unaware of any survey with similar constructs, concurrent validity cannot be established. Furthermore, the sample of schools for the pilot was one of convenience. Cross-country runners within the sample were not required to complete the survey; thus, those with more interest in health may have chosen to take the survey. Also, the response rate was limited due to the survey being administered via the Internet versus in person.

In future research, we plan to distribute this survey to greater numbers of female cross-country runners across collegiate divisions in the United States to gain better insight into female athletes' perspectives on health and what affects their eating behaviors. Data gained from this survey will be analyzed to compare female cross-country runners between different collegiate divisions for education and care to be tailored appropriately. With minimal adaptations, this survey could be administered to female athletes in other sports rather than solely distance runners.

Implications for Clinical Practice

The RHCQ may be used on an individual basis with female runners as part of pre-participation screening on the presence of injury or disability to help discern the specific factors that may be influencing a runner's health and nutrition-related decisions. Additionally, the RHCQ may be distributed to a team of athletes at a university. The distribution of answers throughout the team may help guide general education regarding eating behaviors and health decisions.

Conclusion

The RHCQ is a valid, brief, and easily accessible tool that coaches, physicians, physical therapists, athletic trainers, and other health care providers could incorporate into their practice to assess the reasons behind athletes' dietary choices and perspectives of health behaviors.

References

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Distribution of Survey Topics

Survey QuestionsTopic
1 to 9Background/demographics
10 to 11Intrinsic and extrinsic factors that influence dietary choices
12 to 14Perception of impact of biopsychosocial factors on overall health and running
15Sources of nutritional and health information

Proposed Survey After Pilot Study

Runner's Health Choices Questionnaire (RHCQ)

What is your age? _______

Please specify your ethnicity (choose all that apply):

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian/Pacific Islander

Other/prefer not to answer

What is the division of the college you attend?

Division I

Division II

Division III

NAIA

How many years have you been a competitive runner as part of a team?

Less than 1 year

1–3 years

4–5 years

6–7 years

8–9 years

10+ years

During the competitive season, on average, what is your running mileage/week?____________

Why do you run? Please rank the following reasons from most important to least important:

Enjoyment

To stay healthy

Competition

To be part of a team

Sense of accomplishment

It's a way of life

____

____

____

____

____

____

Have you taken a nutrition course?

Never

Once in high-school

Once in college

More than once

Does the team/college provide you with access to a nutritionist/clinical dietitian?

Yes

No

Not sure

How would you classify your diet?

Regular (including foods from all food groups)

Vegan (excludes all animal products; including dairy, eggs, fish, poultry, and meat)

Vegetarian (excludes fish, poultry, and meat)

Pesco-vegetarian (A branch of vegetarianism that includes fish in the diet)

Paleo (A diet consisting mostly of naturally raised animal products and plants, focusing on high protein and fiber)

Other (Please specify): _________________________________________

For the following questions, please rate how much each factor impacts you personally. Please mark your answer.

Please rate how much of an impact you feel the following factors have on your choice of overall diet specified in the above question.

No ImpactMinimal ImpactModerate ImpactHigh ImpactNeutral/Don't Know
Enjoyment of food          
Makes you feel healthy          
Health condition          
Injury prevention          
Weight loss or maintenance          
Athletic performance enhancement          
Cost          
Family          
Friends/Peers          
Coaches          
Animal welfare          
Environmental concerns          
Religious reason          

Please comment on any additional factors here:

______________________________________________________________________________

__________________________________________________________________

Please rate how much of an impact you feel the following factors have on your daily meal decisions.

No ImpactMinimal ImpactModerate ImpactHigh ImpactNeutral/Don't know
Health concerns          
Creating a balanced diet          
Nutritional knowledge          
Experience with cooking          
Time to prepare meals          
Presence of others          
Family          
Teammates          
Coaches          
Cost          
Practice/Race that day          
Choices in cafeteria          
Transportation availability          

Please comment on any additional factors here:

______________________________________________________________________________

__________________________________________________________________

Please rate how much of an impact you feel the following factors have on your running performance.

No ImpactMinimal ImpactModerate ImpactHigh ImpactNeutral/Don't Know
Motivation          
Confidence          
Daily mood          
Sleep          
Hydration          
Caloric intake          
Menstrual cycle          
Body weight          

Please rate how much of an impact you feel the following factors have on your overall health.

No ImpactMinimal ImpactModerate ImpactHigh ImpactNeutral/Don't Know
Energy balance (energy intake vs. expenditure)          
General eating habits          
Body weight          
Training routine          
Sleep          
Daily mood          

Please rate how much of an impact you feel the following factors have on your desire to perform well in running.

No ImpactMinimal ImpactModerate ImpactHigh ImpactNeutral/Don't Know
Self motivation          
Family          
Coach          
Want to help team          

Please mark the frequency of your use of the following sources for nutritional knowledge.

NeverRarelyOccasionallyOften
Coach        
Teammates        
Parents        
Social media (i.e.Facebook, Twitter, etc.)        
Internet sources        
Magazines        
Book/textbook        
Nutritional course        
Sports nutritionist        
Primary care physician        
Athletic trainer        

Please comment on additional sources here:

______________________________________________________________________________

__________________________________________________________________

If provided or given access to new or additional information from a healthcare professional, how likely would you be to make dietary or health changes?

Very likely

Somewhat likely

Unsure

Somewhat unlikely

Very Unlikely

Authors

From the Physical Therapy Department, Grand Valley State University, Grand Rapids, Michigan.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Laurie Stickler, PT, DHS, OCS, Grand Valley State University, Cook Devos Center for Health Sciences, 301 Michigan Street, NE, Suite 278, Grand Rapids, MI 49503. E-mail: sticklel@gvsu.edu

Received: July 18, 2018
Accepted: December 21, 2018
Posted Online: May 08, 2019

10.3928/19425864-20190315-01

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