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Kevin Williams,1 Christian Askew,1 Christopher Mazoue,1 Jeffrey Guy,1 Toni M Torres-McGehee,2 J Benjamin Jackson III1 1University of South Carolina School of Medicine, Department of Orthopaedic Surgery, Columbia, SC, USA; 2University of South Carolina School of Public Health, Columbia, SC, USACorrespondence: Kevin WilliamsDepartment of Orthopaedic Surgery, University of South Carolina School of Medicine, 2 Medical Park, Suite 404, Columbia, SC 29203, USATel +1 317-946-9810Email kwillmd@gmail.comIntroduction: Vitamin D is paramount to bone health and little is known about vitamin D’s role in the prevention of stress fractures in high-risk athletes. This study consists of a prospective, cross-sectional analysis accompanied by a retrospective review for control comparison of vitamin D3 supplementation in high-risk athletes. Our hypothesis is that supplemental vitamin D3 treatment will decrease the occurrence of stress fractures in high-risk collegiate athletes.Materials and Methods: A total of 118 NCAA Division I athletes were recruited from 6 high-risk collegiate teams. Blood draws in August and February established baseline 25(OH)D levels. Subjects with serum 25(OH)D < 30 ng/mL were supplemented with 50,000 IU of vitamin D3/week for 8 weeks. Treated subjects were re-tested to ensure serum 25(OH)D levels rose to sufficient status. All enrolled subjects were monitored for the development of stress fractures. A 5-year retrospective chart review of athletes from the same sports teams was conducted to determine the incidence of any reported stress fractures in the past.Results: Prospective: 112 of the 118 enrolled subjects were tested in August. Sixty-one demonstrated vitamin D sufficiency (40.2 ng/mL ± 8.28) and 51 were either insufficient or deficient (22.7 ng/mL ± 4.89). Of the 118 enrolled subjects, 104 were tested in February. Fifty-six demonstrated vitamin D sufficiency (40.7 ng/mL ± 9.47) and 48 were insufficient or deficient (21.6 ng/mL ± 5.87). Two stress fractures were diagnosed amongst our cohort of 118 student athletes (1.69%). Retrospective: 34 stress fractures were diagnosed in 453 subjects from 01/2010-05/2015 (7.51%). Amongst our athletic teams, the cross-country team specifically demonstrated a statistically significant decrease in stress fracture incidence (p< 0.05). We also found a statistically significant reduction in stress fracture incidence amongst the current overall cohort compared to our retrospective cohort (p< 0.05).Conclusion: In our population, almost half of the tested athletes proved to be vitamin D deficient. Hypovitaminosis D was prevalent throughout the winter months compared with the summer. With vitamin D3 supplementation, the stress fracture rate in our overall cohort demonstrated a statistically significant decrease from 7.51% to 1.65% (p=0.009).Keywords: vitamin D, stress injuries, sports medicine, bone health

Exercise-associated hyponatremia (EAH) is commonly observed in endurance athletes, where prolonged physical exertion combined with being unaware of personal hydration needs can lead to excessive water consumption or inadequate sodium intake. Marching band (MB) is an emerging setting for sports medicine professionals. However, there is little research on non-musculoskeletal illnesses among these performing artists. This study is part of a larger cross-sectional study and seeks to examine whether MB artists have previously experienced EAH and the presence of known EAH risk factors (e.g., pre-existing medical conditions, medication use, nutritional behaviors). Active collegiate MB members (n = 1207; mean age = 19.6 ± 1.3 years) completed an online survey that characterized demographics, medical history, and nutrition behaviors. Statistical analyses included descriptives (mean, standard deviation) and frequencies for all data. Binomial logistic regressions analyzed the relationship and determined the odds ratio (OR) between previous EAH and EAH risk factors. Participants were from 23 different states, predominately White (82.9%), female (56.7%), and at NCAA Division I institutions (92%). A total of 74 (6.1%) participants reported previously experiencing EAH, 32 (43.2%) within the past year. Previous EAH occurrence was greatest among individuals who had kidney conditions (χ 2 (1) = 5.920, R 2 = 0.013, OR = 15.708, p = 0.015); mood/neurological conditions (χ 2 (1) = 7.508, R 2 = 0.017, OR = 2.154, p = 0.006), particularly anxiety (χ 2 (1) = 7.651, R 2 = 0.017, OR = 3.590, p = 0.006); used mental health medications (χ 2 (1) = 7.512, R 2 = 0.017, OR = 2.220, p = 0.006), particularly selective serotonin reuptake inhibitors (χ 2 (1) = 13.502, R 2 = 0.030, OR = 3.297, p < 0.001); and who dieted (χ 2 (1) = 6.121, R 2 = 0.014, OR = 1.913, p = 0.013) or perceived they had an eating disorder (χ 2 (1) = 9.502, R 2 = 0.021, OR = 2.729, p = 0.002). Healthcare providers should be aware that MB artists may have pre-existing medication conditions, use medication, and have inadequate nutrition. Targeted hydration and nutritional education for MB artists is essential for effective prevention and early EAH recognition, improving health and performance for MB artists within demanding environments.

Low energy availability (LEA) is common among female student-athletes and contributes to reduced bone mineral density and hormonal dysfunction. However, limited research exists on student-athletes of color, making it difficult to generalize results across populations, particularly Historically Black Colleges and Universities (HBCUs) student-athletes., Objectives: This study examined the energy needs and LEA prevalence, with or without eating disorder (ED) risk, among HBCU female student-athletes., Methods: Twenty-seven female student-athletes (age = 19 ± 1 year; height = 166.9 ± 7.6 cm; weight = 68.8 ± 11.3 kg) completed baseline measures, including the Eating Disorder Inventory-3 (EDI-3), EDI-3 symptom checklist (EDI-SC), anthropometric measures, and resting metabolic rate (RMR). Participants maintained a dietary log to measure energy intake and wore a heart rate monitor to estimate exercise energy expenditures for 7 days. LEA was defined as <30 kcal/kg of fat-free mass (FFM)/day., Results: The mean energy availability (15.9 ± 10.1 kcal/kg FFM/day) indicated 92.6% of participants ( n = 25) displayed LEA; of those, 60% ( n = 15) had LEA with ED risk. ED risk was identified in 59.3% of student-athletes ( n = 13; EDI-3: n = 2; SC: n = 3; Both: n = 11). Interestingly, of the two student-athletes without LEA, one was identified at risk for EDs using both the EDI-3 and SC., Conclusions: HBCU female student-athletes face high risks of LEA and EDs, with most showing signs of both. This underscores the need for culturally sensitive interventions to improve EA and support mental health in this underserved group. Clinicians should focus on nutrition education and early ED identification to enhance long-term health and athletic performance.

Background: This study investigated the effects of decreased energy availability (EA) and carbohydrate availability (CA) on reproductive and metabolic hormones in male endurance-trained athletes., Methods: Thirteen athletes (age: 26.08 ± 4.3 years; weight: 70.9 ± 6.5 kg; height: 179.9 ± 4.2 cm) participated in two training weeks with varying training volumes (low [LV] and high [HV]). The participants logged their diet and exercise for seven days and provided blood samples to measure hormone levels (Testosterone [T], insulin, leptin, cortisol, and interleukin-6 [IL-6])., Results: Results showed that 46.2% (HV) and 38.5% (LV) of participants were at risk for low EA (≤25 kcal/kg FFM·d-1), while 53.8% (HV) and 69.2% (LV) had low CA (<6 g/kg). Strong positive correlations were found between leptin and body fat percentage (DXABFP) in both weeks (HV: r(11) = 0.88, p < 0.001; LV: r(11) = 0.93, p < 0.001). Moderate correlations were observed between T and DXABFP (r(11) = 0.56, p = 0.05) and negative correlations between leptin and fat intake (r(11) = -0.60, p = 0.03). Regression analyses indicated significant relationships between DXABFP and T (F(1,11) = 4.91, p = 0.049), leptin (HV: F(1,11) = 40.56, p < 0.001; LV: F(1,11) = 74.67, p < 0.001), and cortisol (F(1,11) = 6.69, p = 0.025)., Conclusions: These findings suggest that monitoring body composition and macronutrients can be clinically useful for male athletes, especially those without access to blood testing. Ultimately, a greater understanding of health and performance outcomes for male athletes is needed.

Context: Marching band (MB) artists experience stressors influencing their physical, mental, and emotional health warranting medical support, and they face challenges similar to those of other college students and athletes. Mental health illnesses exist in collegiate and MB settings, but barriers affect access to treatment., Objectives: To examine MB artists' perceived barriers to and attitudes toward seeking care from mental health professionals. The secondary aim was to explore barriers to and attitudes about seeking mental health counseling between genders and history of pursuing mental health counseling., Design: Cross-sectional study., Setting: Online survey., Patients or Other Participants: A total of 534 MB artists (women = 312, men = 222; age = 19.7 ± 1.4 years)., Main Outcome Measure(s): Participants completed surveys on demographics and past medical history along with the Barriers to Help Seeking Checklist, the Attitudes Toward Seeking Professional Psychological Help-Short Form Scale (ATSPPH-SF), and the Mental Help Seeking Attitudes Scale (MHSAS). Descriptive statistics were calculated to assess demographic data. Cross-tabulations and χ2 statistics were used to evaluate individual barriers (Barriers to Help Seeking Checklist) between genders. Scales were scored 1 to 7 and 10 to 30 on the MHSAS and ATSPPH-SF, respectively. A 1-way analysis of variance measured differences in the total mean score on the ATSPPH-SF between genders., Results: The highest barrier reported was lack of time to seek services (69.1%; n = 369), followed by 47.6% (n = 254) for services not available during my free time. Average scores were 4.0 ± 0.4 on the MHSAS (indicating neutral attitudes toward seeking help) and 17.97 ± 5.48 on the ATSPPH-SF (indicating slightly positive attitudes to seeking help). No differences were seen for the total mean scores on the MHSAS and ATSPPH-SF between genders., Conclusions: Marching band artists' barriers to and attitudes toward mental health care influenced their ability to seek care in times of need and demonstrated some similarities to those of collegiate athletes. Awareness of the obstacles MB artists face in receiving mental health care will assist health care providers in advocating for improved care in this setting., (© by the National Athletic Trainers' Association, Inc.)

Context: For gender-diverse (GD) college marching band (MB) artists, the risks for anxiety and depression may be higher as they navigate the demands and stressors associated with MB, college, and their gender identity., Objectives: To examine the risks of anxiety and depression across GD MB artists and to explore their barriers and attitudes toward seeking mental health (MH) care., Design: Cross-sectional study., Setting: Online survey., Patients or Other Participants: Seventy-eight GD individuals (transgender = 12, nonbinary = 66, age = 19 ± 1 years)., Main Outcome Measure(s): A survey was used to assess demographics, anxiety risk using the State-Trait Anxiety Inventory, depression risk using the Center for Epidemiologic Studies Depression Scale, and barriers and attitudes using the Barriers Towards Seeking Help Checklist, the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form, and the Mental Help Seeking Attitudes Scale. We calculated descriptive statistics and univariate analyses to evaluate scores, risks, and differences between MH and receiving assistance., Results: Participants had high state anxiety (mean = 52.0 ± 112.1), trait anxiety (mean = 55.2 ± 10.0), and symptoms of depression (mean = 30.4 ± 12.0) based on the State-Trait Anxiety Inventory and the Center for Epidemiologic Studies Depression Scale. Overall, 78.2% (n = 61 of 78) of GD MB artists were considered at risk for both state and trait anxiety and depression, and 18% (n = 11 of 61) did not seek help from an MH professional. These GD MB artists cited a lack of time (82.1%; n = 64 of 78) as the primary barrier to seeking professional help. The mean score on the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form for all GD artists was 19.5 ± 5.0, and the total score for the Mental Help Seeking Attitudes Scale was 47.8 ± 9.2, which indicated more favorable attitudes toward seeking professional help., Conclusions: We identified high rates of clinical symptoms for depression and anxiety among GD MB artists. The data are consistent with those from other minority populations and above the normative values for cisgender students. The lack of help-seeking behaviors in nearly 15% of at-risk participants highlights the need for specialized resources for GD patients and those participating in MB., (© by the National Athletic Trainers’ Association, Inc.)

Marching band (MB) artists are often part of the general student population and not required to complete a pre-participation health screening to identify predisposing medical conditions or risks for injury/illness. Anecdotally, exertional heat illnesses (EHI) are a concern for MB artists. As more athletic trainers provide MB healthcare, research is needed on EHI occurrence and MB associated EHI risk factors. We utilized an exploratory cross-sectional study design to determine EHI risk factors, including previous EHI occurrence, among collegiate MB artists. MB artists ( n  ​= ​1 207; age ​= ​[19.6 ​± ​1.3] years) actively participating in their college/university's MB during the 2019 football season completed an online survey to characterize demographics, medical history, medication and supplement use, and nutrition behaviors. Chi-square and binomial logistical regressions assessed associations between categorical variables. Previous EHI was reported by 50.6% of MB artists, with 466 (76.3%) experiencing exertional heat exhaustion and 31 (5.1%) exertional heat stroke. More females reported exertional heat exhaustion overall (68.2%, p  ​< ​0.001) and in the previous year (73.3%, p  ​< ​0.001). Experiencing a previous EHI was significantly associated with having a mood/neurological condition (63.5%, p  ​< ​0.001), diagnosed (74.3%, p  ​= ​0.004) or perceived eating disorder (66.7%, p  ​< ​0.001), and taking prescription medications (59.4%, p  ​< ​0.001), over-the-counter medications (58.9%, p  ​= ​0.002), and supplements (55.4%, p  ​= ​0.037). Half of collegiate MB artists reported experiencing previous EHIs and engaged in behaviors known to increase EHI risk. MB artists should complete pre-participation examinations to identify pre-existing medical conditions and risks for adverse medical events. Healthcare providers working with MB artists should develop policies and procedures to mitigate EHI risks and occurrence., (© 2024 Chengdu Sport University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltdé.)

Context: Eating disorders (EDs) are a cluster of behavioral conditions characterized by uneasy thoughts and behaviors that grow into severe or persistent eating disturbances. The demands on student-athletes may create mental and physical stressors that increase the likelihood of EDs and disordered eating., Objective: To examine the ED risk through eating attitudes and behaviors in male and female student-athletes and across various sport types (endurance, aesthetic, power, ball or team, or technical sports)., Design: Cross-sectional study., Setting: Collegiate athletics., Patients or Other Participants: National Collegiate Athletic Association Division I and II student-athletes (n = 2054; males = 631; females = 1423) from 40 institutions., Main Outcome Measure(s): Participants completed a web-based demographic survey and the Eating Attitudes Test-26 (EAT-26). Multiple χ2 analyses examined participants classified as at risk for EDs. Independent-samples t tests and a 1-way analyses of variance compared sex and sport type across EAT-26 totals and subscale (Dieting, Bulimia, and Oral Control) scores., Results: Overall, 25.3% (n = 520/2054) of student-athletes were classified as at risk for EDs. Differences were found between sex and ED risk (χ21,2054 = 32.9, P ≤ .01; 17.3% [n = 109/631] males, 28.9% [n = 411/1423] females) and across ED risk and sport type (χ24,2054 = 13.4, P = .01). When examining females only, we observed differences across ED risk and sport type (χ24,1423 = 13.4, P ≤ .01). No differences were evident across ED risk and sport type for males. Differences were seen between sex and binge eating (χ21,2054 = 6.8, P = .009), sex and diet pill use (χ21,2054 = 19.6, P ≤ .01), and sport type and diet pill use (χ24,2054= 12.2, P = .016), excessive exercise (χ24,2054 = 32.1, P ≤ .01), and losing more than 20 lb (9 kg) in the last 6 months (χ24,2054 = 10.2, P ≤ .037)., Conclusions: Student-athletes in the collegiate setting are at risk for EDs. Medical professionals, such as athletic trainers, need to be educated on the potential risk factors that may lead to EDs. Protocols for prevention, screening and recognition, and referral should be developed for student-athletes at risk for EDs., (© by the National Athletic Trainers’ Association, Inc.)

Context: Exercise dependence (EXD) is a compulsive and addictive behavior that can negatively affect physical and mental health, leading to significant impairment or distress. Exercise dependence has been associated with symptoms of eating disorders (EDs). Student-athletes are an at-risk population for EXD and EDs given the physical and psychological demands of competitive sports., Objective: To examine the EXD and ED risks in student-athletes across sex and sport category and to determine the association between EXD and ED., Design: Cross-sectional study., Setting: Collegiate athletics., Patients or Other Participants: National Collegiate Athletic Association Division I and II student-athletes (n = 1885; age = 19.8 ± 1.4 years; females = 69.6%, n = 1312; males = 30.4%, n = 573)., Main Outcome Measure(s): A web-based survey including demographics, the Exercise Dependence Scale-21, the Eating Attitudes Test-26, and questions about pathogenic behaviors., Results: Overall, 4.9% (n = 92) of the student-athletes were categorized as at risk for EXD (females = 4.8%, n = 63/1312; males = 5.1%, n = 29/573), with differences across sex and sport categories (all: χ28,1885 = 99.1, P < .001). The ED risk in student-athletes (Eating Attitudes Test-2, pathogenic behavior use, or both) was 22.7% (n = 428; females = 25.5%, n = 334/1312; males = 16.4%, n = 94/573), with differences by sex (χ24,1885 = 10.1, P = .039). Multiple logistic regressions indicated a significant association between the risks of EXD and ED for all student-athletes; athletes at risk for EXD were also at greater risk for EDs (odds ratio = 5.104; 95% CI = 3.237, 8.046) than nondependent-asymptomatic athletes (odds ratio = 2.4068; 95% CI = 1.5618, 3.7089)., Conclusions: Although physical activity has become a public health intervention to improve overall health in populations, EXD can be considered a problem related to physical activity. Exercise dependence can negatively affect physical and mental health, whereas EDs may be psychiatric disorders influenced by EXD, as exercise can be a compensatory behavior to achieve weight loss. To minimize the overall risk of EDs in student-athletes, additional education and awareness are needed. Special attention should be given to any student-athletes, in particular females, who display signs of EXD., (© by the National Athletic Trainers’ Association, Inc.)

Context: Engaging in exercise and appropriate nutritional intake improves mental health by reducing anxiety, depression, and sleep disturbances. However, few researchers have examined energy availability (EA), mental health, and sleep patterns in athletic trainers (ATs)., Objective: To examine ATs' EA, mental health risk (ie, depression, anxiety), and sleep disturbances by sex (male, female), job status (part time [PT AT], full time [FT AT]), and occupational setting (college or university, high school, or nontraditional)., Design: Cross-sectional study., Setting: Free living in occupational settings., Patients or Other Participants: A total of 47 ATs (male PT ATs = 12, male FT ATs = 12; female PT ATs = 11, female FT ATs = 12) in the southeastern United States., Main Outcome Measure(s): Anthropometric measurements consisted of age, height, weight, and body composition. Energy availability was measured through energy intake and exercise energy expenditure. We used surveys to assess the depression risk, anxiety (state or trait) risk, and sleep quality., Results: Thirty-nine ATs engaged in exercise, and 8 did not exercise. Overall, 61.5% (n = 24/39) reported low EA (LEA); 14.9% (n = 7/47) displayed a risk for depression; 25.5% (n = 12/47) indicated a high risk for state anxiety; 25.5% (n = 12/47) were at high risk for trait anxiety, and 89.4% (n = 42/47) described sleep disturbances. No differences were found by sex and job status for LEA, depression risk, state or trait anxiety, or sleep disturbances. Those ATs not engaged in exercise had a greater risk for depression (risk ratio [RR] = 1.950), state anxiety (RR = 2.438), trait anxiety (RR = 1.625), and sleep disturbances (RR = 1.147), whereas ATs with LEA had an RR of 0.156 for depression, 0.375 for state anxiety, 0.500 for trait anxiety, and 1.146 for sleep disturbances., Conclusions: Although most ATs engaged in exercise, their dietary intake was inadequate, they were at increased risk for depression and anxiety, and they experienced sleep disturbances. Those who did not exercise were at an increased risk for depression and anxiety. Energy availability, mental health, and sleep affect overall quality of life and can affect ATs' ability to provide optimal health care., (© by the National Athletic Trainers’ Association, Inc.)

Context: Interest is growing in the association between repetitive concussions and mental health. However, studies on the relationship between concussion frequency and adverse mental health outcomes among female and male youth are lacking., Objectives: To examine the association between self-reported concussion frequency and nonfatal suicidal behaviors among youth and to explore the possible interaction of biological sex., Design: Retrospective cross-sectional survey., Setting: National Youth Risk Behavior Surveillance System., Patients or Other Participants: United States secondary school students (N = 28 442)., Main Outcome Measure(s): Exposure variables were the frequency of self-reported sport- or recreation-related concussion in the previous 12 months (0, 1, ≥2). Outcome variables were feelings of self-reported sadness or hopelessness and suicidal ideation, planning, and attempts. Covariates were age, sex, race and ethnicity, bullying victimization, sexual orientation, and physical activity., Results: Students who reported ≥2 concussions were at significantly greater odds of reporting suicidal attempts (adjusted odds ratio = 2.03; 95% CI = 1.43, 2.88) when compared with students reporting a single concussive event during the past 12 months. However, sex interactions revealed that this finding may have been driven by males; the strength of associations did not increase from single to multiple concussions among females., Conclusions: Our findings suggest that adolescents who reported concussion were at increased odds of reporting poor mental health and suicidal behaviors. Moreover, an increased number of concussive events may be associated with significantly greater odds of reporting suicidal attempts, particularly among males. Irrespective of sex, health care professionals should closely monitor mental health behaviors in adolescents with repetitive concussions, especially those that occur in close temporal proximity., (© by the National Athletic Trainers’ Association, Inc.)

Family-centered care (FCC) includes collaboration between families and healthcare providers, the creation of flexible policies, and the family taking an active role in the delivery of care. Secondary school athletic trainers provide care for underage patients in school-based health systems, making them responsible for maintaining communication with parents, guardians, and/or caregivers. This cross-sectional survey investigated the extent to which athletic trainers (n = 205) include aspects of FCC in their daily secondary school clinical practice (current practices = CP) and whether they believe that aspect of care is necessary for FCC to be provided in athletic training (perceived necessary = PN) in their everyday practice using the Family-Centered Care Questionnaire-Revised tool. The total mean score for the CP scale (mean = 26.83 ± 4.36) was significantly lower ( p ≤ 0.01) than the PN scale (mean = 35.33 ± 4.17). All FCC subscales compared between CP and PN were significantly different ( p ≤ 0.01), with each being of higher importance than CP in athletic training. Data analysis revealed four themes related to enhancing FCC in secondary schools: limited education and resources, staffing and space concerns, non-technical skills, and social determinants of health. Attention should be placed on developing resources and interventions for secondary school athletic trainers to collaboratively work with children and their support systems.

This study examined female collegiate ballet dancers' ( n = 28) Female Athlete Triad (Triad) risk via the Cumulative Risk Assessment (CRA) and nutritional profiles (macro- and micronutrients; n = 26). The CRA identified Triad return to play criteria (RTP: Full Clearance, Provisional Clearance, or Restricted/Medical Disqualified) by assessing eating disorder risk, low energy availability, menstrual cycle dysfunction, and low bone mineral density. Seven-day dietary assessments identified any energy imbalances of macro- and micronutrients. Ballet dancers were identified as low, within normal, or high for each of the 19 nutrients assessed. Basic descriptive statistics assessed CRA risk classification and dietary macro- and micronutrient levels. Dancers averaged 3.5 ± 1.6 total score on the CRA. Based on these scores, the RTP outcomes revealed Full Clearance 7.1%, n = 2; Provisional Clearance 82.1%, n = 23; and Restricted/Medical Disqualification 10.7%, n = 3. Dietary reports revealed that 96.2% ( n = 25) of ballet dancers were low in carbohydrates, 92.3% ( n = 24) low in protein, 19.2% ( n = 5) low in fat percent, 19.2% ( n = 5) exceeding saturated fats, 100% ( n = 26) low in Vitamin D, and 96.2% ( n = 25) low in calcium. Due to the variability in individual risks and nutrient requirements, a patient-centered approach is a critical part of early prevention, evaluation, intervention, and healthcare for the Triad and nutritional-based clinical evaluations.

Mental health research exists for student-athletes in the areas of depression, anxiety, and self-esteem prevalence. However, updated prevalence rates and assessment of risks across sports, academic status, and genders are needed. Filling the gaps in research assists in the creation of patient-centered mental health screening and interventions designed for student-athletes. Therefore, the purpose is to examine the prevalence of depression, anxiety, and self-esteem in collegiate student-athletes and differences between sex, academic status, and sport type, and identify associations for risks. Using a cross-sectional design, collegiate student-athletes were surveyed to assess for risks of depression, anxiety, and self-esteem. With the use of SPSS, Chi-square analyses and multinomial logistic regressions were used. Student-athletes (22.3%) were at risk for depression, anxiety (12.5%), and low self-esteem (8%). No significant differences were found for sex, academic status, and sport type for depression or self-esteem; however, significant differences occurred for state and trait anxiety by sex. A significant association for depression and anxiety risk was found with females at risk. Depression and anxiety are present within student-athletes, regardless of sport type. Females are at a higher risk; however, all student-athletes would benefit from the creation of validated, patient-centered mental health screenings and psychotherapeutic interventions.

Context: The COVID-19 pandemic led to an abrupt disruption in access to services and personnel for collegiate student-athletes in the spring and summer of 2020. We sought to identify the effects of this unprecedented change by examining the psychological well-being, changes to normal routines, and return-to-play considerations of current student-athletes in order to guide support for both current and future student-athletes who may face similar situations., Methods: We utilized a phenomenological approach to interview a purposeful sample of eighteen collegiate student-athletes (7 males, 11 females; mean age = 20 years) from across the United States. The participants were interviewed using a semi-structured interview protocol, which was audio recorded and transcribed verbatim using Zoom. The data were then analyzed and coded by a 3-person team via the consensual qualitative research tradition., Results: Four domains emerged after data analysis: 1) ambiguity, 2) perspective, 3) bonding and cohesion, and 4) resource utilization. Participants discussed ambiguity in terms of eligibility and participation questions, academic changes, and varying COVID-19 policies. Participants shared a wide range of perspectives, from apprehension at the onset of the pandemic, to excitement when returning to campus and competition. They shared how bonding and team development were affected due to a lack of socialization and that support system dynamics between family, coaches, and teammates were strengthened. When describing resource utilization, participants discussed the use of personnel and supplies to help them adjust to changes in facility and space availability. The identification and utilization of resources enabled them to establish a "new normal" for their academics, workouts, and hobbies during the pandemic., Conclusions: Collegiate student-athletes realized the seriousness of the pandemic and utilized their resources and support systems to adjust their routines and keep a positive attitude during COVID-19. At the same time, some student-athletes struggled with these changes. Personnel should be aware of these effects to provide care and prevent future negative effects., Competing Interests: Conflict of interest: All authors declare no conflicts of interest in this paper., (© 2022 the Author(s), licensee AIMS Press.)

Social agents associated with cheerleading environments are increasingly linked to body image dissatisfaction (BID) and eating disorders (ED). This study examined ED risk across team type, squad type, and position. An additional purpose determined BID in clothing type (daily clothing, midriff uniform, and full uniform), and meta-perceptions from the perspective of peers (MP peers), parents (MP parents), and coaches (MP coaches). Female cheerleaders ( n = 268) completed an online survey which included demographics, the Eating Attitudes Test-26, and pathogenic behavior questions. Body image perceptions were assessed by using the Sex-Specific Figural Stimuli Silhouettes. Overall, 34.4% of cheerleaders ( n = 268; mean age: 17.9 ± 2.7 years) exhibited an ED risk. Compared to All-Star cheerleaders, college cheerleaders demonstrated significant higher ED risk ( p = 0.021), dieting subscale scores ( p = 0.045), and laxative, diet pill, and diuretic use ( p = 0.008). Co-ed teams compared to all-girl teams revealed higher means for the total EAT-26 ( p = 0.018) and oral control subscale ( p = 0.002). The BID in clothing type revealed that cheerleaders wanted to be the smallest in the midriff option ( p < 0.0001, η2 = 0.332). The BID from meta-perception revealed that cheerleaders felt that their coaches wanted them to be the smallest ( p < 0.001, η2 = 0.106). Cheerleaders are at risk for EDs and BID at any level. Regarding the midriff uniform, MP from the perspective of coaches showed the greatest difference between perceived and desired body image.

The purpose of this study was to examine individual and combined Female Athlete Triad components within collegiate cheerleaders, an at-risk group. Cheerleaders ( n = 19; age: 20.3 ± 1.2 years) completed anthropometric measurements, health history questionnaires, resting metabolic rate, the eating disorder inventory-3 and symptom checklist, blood sample, and DXA scan. Participants completed dietary and exercise logs for 7 days and used heart rate monitors to track daily and exercise energy expenditure. Proportions were calculated for low energy availability (LEA) risk, disordered eating risk, and pathogenic behaviors. Chi-square analysis was used to determine the difference between cheerleaders who experience low EA with or without disordered eating risk. All cheerleaders demonstrated LEA for the days they participated in cheerleading practice, 52.6% demonstrated LEA with eating disorder risk and 47.4% demonstrated LEA without eating disorder risk, 52.6% self-reported menstrual dysfunction, 14% experienced menstrual dysfunction via hormonal assessment, and 0% demonstrated low bone mineral density. Overall, 47.7% presented with one Triad component, 52.6% demonstrated two Triad components using self-reported menstrual data, and 10.5% demonstrated two Triad components using hormonal assessments. All cheerleaders displayed LEA. These findings support the need for increased education on the individual components of the Triad and their potential consequences by qualified personal.

Background: Studies examining the physiological consequences associated with deficits in energy availability (EA) for male athletes are sparse. Purpose: To examine male athlete triad components; low energy availability (LEA) with or without an eating disorder risk (ED), reproductive hormone [testosterone (T)], and bone mineral density (BMD) in endurance-trained male athletes during different training periods. Methods: A cross-sectional design with 14 participants (age: 26.4 ± 4.2 years; weight: 70.6 ± 6.4 kg; height: 179.5 ± 4.3 cm; BMI: 21.9 ± 1.8 kg/m2) were recruited from the local community. Two separate training weeks [low (LV) and high (HV) training volumes] were used to collect the following: 7-day dietary and exercise logs, and blood concentration of T. Anthropometric measurements was taken prior to data collection. A one-time BMD measure (after the training weeks) and VO 2max -HR regressions were utilized to calculate EEE. Results: Overall, EA presented as 27.6 ± 10.7 kcal/kgFFM·d-1 with 35% ( n = 5) of participants demonstrating increased risk for ED. Examining male triad components, 64.3% presented with LEA (≤ 30 kcal/kgFFM·d-1) while participants presented with T (1780.6 ± 1672.6 ng/dl) and BMD (1.31 ±.09 g/cm 2 ) within normal reference ranges. No differences were found across the 2 training weeks for EI, with slight differences for EA and EEE. Twenty-five participants (89.3%) under-ingested CHO across both weeks, with no differences between weeks. Conclusion: Majority of endurance-trained male athletes presented with one compromised component of the triad (LEA with or without ED risk); however, long-term negative effects on T and BMD were not demonstrated. Over 60% of the participants presented with an EA ≤ 30 kcal/kgFFM·d-1, along with almost 90% not meeting CHO needs. These results suggest male endurance-trained athletes may be at risk to negative health outcomes similar to mechanistic behaviors related to EA with or without ED in female athletes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Moore, Drenowatz, Stodden, Pritchett, Brodrick, Williams, Goins and Torres-McGehee.)

Purpose: Orthorexia nervosa (Orthorexia) is an eating attitude and behavior associated with a fixation on healthy eating, while eating disorders (EDs) are clinically diagnosed psychiatric disorders associated with marked disturbances in eating that may cause impairment to psychosocial and physical health. The purpose of this study was to examine risk for Orthorexia and EDs in student-athletes across sex and sport type and determine the association between the two. Methods: Student-athletes ( n = 1,090; age: 19.6 ± 1.4 years; females = 756; males = 334) completed a survey including demographics, the ORTO-15 test (<40 and <35 threshold values), the Eating Attitudes Test-26 (EAT-26; >20 score), and additional questions about pathogenic behaviors to screen for EDs. Results: Using a <40 threshold value for the ORTO-15, 67.9% were at risk for Orthorexia, a more restrictive threshold value of <35 determined 17.7% prevalence across student-athletes with significant differences across sex [ <40: χ ( 1 , 1 , 090 ) 2 = 4.914, p = 0.027; <35: χ ( 1 , 1 , 090 ) 2 = 5.923, p = 0.015). Overall, ED risk (EAT-26 and/or pathogenic behavior use) resulted in a 20.9% prevalence, with significant differences across sex (χ 2 = 11.360, p < 0.001) and sport-type category (χ 2 = 10.312, p = 0.035). Multiple logistic regressions indicated a significant association between EAT-26 subscales scores and Orthorexia, and between Orthorexia positivity, ORTO-15 scores, and risk for EDs. Conclusions: Risk for Orthorexia and ED is present in collegiate student-athletes. While healthy and balanced eating is important, obsessive healthy eating fixations may increase the risk for EDs in athletes. More education and awareness are warranted to minimize the risk for Orthorexia and EDs in student-athletes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Uriegas, Winkelmann, Pritchett and Torres-McGehee.)

Non-steroidal anti-inflammatory drugs' anti-pyretic and anti-inflammatory effects has led some individuals to theorize these medications may blunt core body temperature (Tc) increases during exercise. We utilized a double-blind, randomized, and counterbalanced cross-over design to examine the effects of a 24-h naproxen dose (3-220 ​mg naproxen pills) and placebo (0 ​mg naproxen) on Tc and plasma interleukin-6 (IL-6) concentrations during cycling in a hot or ambient environment. Participants ( n  ​= ​11; 6 male, 5 female; age ​= ​27.8 ​± ​6.5 years, weight ​= ​79.1 ​± ​17.9 ​kg, height ​= ​177 ​± ​9.5 ​cm) completed 4 conditions: 1) placebo and ambient (Control); 2) placebo and heat (Heat); 3) naproxen and ambient (Npx); and 4) naproxen and heat (NpxHeat). Dependent measures were taken before, during, and immediately after 90 ​min of cycling and then 3 ​h after cycling. Overall, Tc significantly increased pre- (37.1 ​± ​0.4 ​°C) to post-cycling (38.2 ​± ​0.3 ​°C, F 1.7,67.3  ​= ​150.5, p  ​< ​0.001) and decreased during rest (37.0 ​± ​0.3 ​°C, F 2.0,81.5  ​= ​201.6, p  ​< ​0.001). Rate of change or maximum Tc were not significantly different between conditions. IL-6 increased pre- (0.54 ​± ​0.06 ​pg/ml) to post-exercise (2.46 ​± ​0.28 ​pg/ml, p  ​< ​0.001) and remained significantly higher than pre-at 3 ​h post- (1.17 ​± ​0.14 ​pg/ml, 95% CI  ​= ​-1.01 to -0.23, p  ​= ​0.001). No significant IL-6 differences occurred between conditions. A 24-h, over-the-counter naproxen dose did not significantly affect Tc or IL-6 among males and females cycling in hot or ambient environments., Competing Interests: Portions of the study were supported by funding from the American College of Sports Medicine Foundation and the National Athletic Trainers’ Association Research and Education Foundation. The agencies had no role in the study design, data collection or analysis, or the writing and submitting for publication. The authors have no other conflict of interests to disclose., (© 2021 The Authors.)

Context: Female athletes and performing artists can present with low energy availability (LEA) from either unintentional (eg, inadvertent undereating) or intentional (eg, eating disorder [ED]) methods. Whereas LEA and ED risk have been examined independently, few researchers have examined them simultaneously. Awareness of LEA with or without ED risk may provide clinicians with innovative prevention and intervention strategies., Objective: To examine LEA with or without ED risk (eg, eating attitudes, pathogenic behaviors) in female collegiate athletes and performing artists and compare sport type and LEA with the overall ED risk., Design: Cross-sectional study., Setting: Free living in sport-specific settings., Patients or Other Participants: A total of 121 collegiate female athletes and performing artists (age = 19.8 ± 2.0 years, height = 168.9 ± 7.7 cm, mass = 63.6 ± 9.3 kg) participating in equestrian (n = 28), soccer (n = 20), beach volleyball (n = 18), softball (n = 17), volleyball (n = 12), and ballet (n = 26)., Main Outcome Measure(s): Anthropometric measurements (height, mass, body composition), resting metabolic rate, energy intake, total daily energy expenditure, exercise energy expenditure, Eating Disorder Inventory-3 (EDI-3), and EDI-3 Symptom Checklist were assessed. Chi-square analysis was used to examine differences between LEA and sport type, LEA and ED risk, ED risk and sport type, and pathogenic behaviors and sport type., Results: Most (81%, n = 98) female athletes and performing artists displayed LEA and differences between LEA and sport type (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({\rm{\chi }}&#95;5^2\) = 43.8, P < .001). The majority (76.0%, n = 92) presented with an ED risk, but the ED risk did not differ by sport type (P = .94). The EDI-3 Symptom Checklist revealed that 61.2% (n = 74) engaged in pathogenic behaviors, with dieting being the most common (51.2%, n = 62). Most (76.0%, n = 92) displayed LEA with an ED risk. No differences were found in LEA by ED risk and sport type. Softball players reported the most LEA with an ED risk (82.4%, n = 14), followed by ballet dancers (76%, n = 19)., Conclusions: Our results suggested that a large proportion of collegiate female athletes and performing artists were at risk for LEA with an ED risk, thus warranting education, identification, prevention, and intervention strategies relative to fueling for performance., (© by the National Athletic Trainers' Association, Inc.)

There is a paucity of research examining hydration and nutrition behaviors in youth American football players. A potentially unique risk factor are league restrictions based on weight (WR) or age (AR). The purpose of this study was to examine hydration status between WR and AR leagues. The secondary purpose was to describe eating patterns in players. An observational cohort design with 63 youth football players (10 ± 1 yrs, 148.2 ± 9.4 cm, 44.9 ± 15.3 kg) was utilized. Independent variables were league (AR ( n = 36); WR ( n = 27)) and activity type (practice (PX = 8); game (GM = 3)). Dependent variables were hydration status (urine osmolality; percent change in body mass (%BM)), eating attitudes (Children's Eating Attitude Test (ChEAT-26)) and self-reported frequency of meals. On average, players arrived activity mildly hypohydrated (830 ± 296 mOsm/kg) and %BM was minimal (-0.1 ± 0.7%) during events. Players consumed 2 ± 1 meals and 1 ± 1 snack before events. The ChEAT-26 survey reported 21.6% ( n = 8) of players were at risk for abnormal eating attitudes. Among these players, eating binges, vomiting, excessive exercise and drastic weight loss were reported. Youth American football players arrived activity mildly hypohydrated and consumed enough fluid during activity to maintain euhydration. Abnormal eating attitudes and the use of unhealthy weight loss methods were reported by some youth American football players.

Background: Because of their anti-pyretic effects, some individuals prophylactically use non-steroidal anti-inflammatory drugs (NSAIDs) to blunt core temperature (Tc) increases during exercise, thus, potentially improving performance by preventing hyperthermia and/or exertional heat illness. However, NSAIDs induce gastrointestinal damage, alter renal function, and decrease cardiovascular function, which could compromise thermoregulation and increase Tc. The aim of this systematic review was to evaluate the effects of NSAIDs on Tc in exercising, adult humans., Methods: We conducted searches in MEDLINE, PubMed, Cochrane Reviews, and Google Scholar for literature published up to November 2020. We conducted a quality assessment review using the Physiotherapy Evidence Database scale. Nine articles achieved a score ≥ seven to be included in the review., Results: Seven studies found aspirin, ibuprofen, and naproxen had no effect (p > .05) on Tc during walking, running, or cycling for ≤ 90 min in moderate to hot environments. Two studies found significant Tc changes. In one investigation, 81 mg of aspirin for 7-10 days prior to exercise significantly increased Tc during cycling (p < .001); final Tc at the end of exercise = 38.3 ± 0.1 °C vs. control = 38.1 ± 0.1 °C. In contrast, participants administered 50 mg rofecoxib for 6 days experienced significantly lower Tc during 45 min of cycling compared to placebo (NSAID Tc range ≈ 36.7-37.2 °C vs control ≈ 37.3-37.8 °C, p < 0.05)., Conclusions: There are limited quality studies examining NSAID effects on Tc during exercise in humans. The majority suggest taking non-selective NSAIDs (e.g., aspirin) 1-14 days before exercise does not significantly affect Tc during exercise. However, it remains unclear whether Tc increases, decreases, or does not change during exercise with other NSAID drug types (e.g., naproxen), higher dosages, chronic use, greater exercise intensity, and/or greater environmental temperatures., Competing Interests: The authors have no other conflict of interests to disclose., (© 2021 The Society of Chinese Scholars on Exercise Physiology and Fitness. Published by Elsevier (Singapore) Pte Ltd.)

Background: Marching band artists are a physically active population, composed of approximately 27,000 people in the United States. University marching band artists face many of the same physically active demands and mental stressors as student athletes, potentially predisposing them to injury, illness, and risk for eating disorders (EDs). The purpose of this study was to examine ED risk across sex in university marching band artists, and to determine the type of risk based on the Eating Disorder Inventory-3 (EDI-3) and Eating Disorder Inventory-3 Symptom Check List (EDI-3 SC). A secondary aim examined marching band artists and pathogenic weight control behavior use across sex., Methods: This was a cross-sectional study. A total of 150 marching band artists (female: n = 84, male: n = 66, age = 19.9 ± 1.1 years) from three National Collegiate Athletic Association Division I university marching bands participated in the study. We screened for ED risk using the EDI-3, and the EDI-3 SC., Results: Overall, marching band artists were at risk for EDs, using only the EDI-3, 45.3% (n = 68) were at risk, with females at significant higher risk than males [χ 2  = 5.228, p = .022]; using only the EDI-3 SC, 54% (n = 81) were at risk and no significant differences were found across sex. Overall, 48% of all participants reported dieting and 20.7% engaged in excessive exercise to control weight. Significant differences were found between sex and purging to control weight [χ 2  = 3.94, p = .047] and laxative use [χ 2  = 4.064, p = .044], with females engaging in behavior more than males., Conclusions: Eating disorder risk was prevalent for both female and male marching band artists, with females displaying higher risk for EDs than males. Furthermore, marching band artists are engaging in pathogenic behaviors to control their weight. Healthcare providers (e.g., physicians, athletic trainers, physical therapist, dietitians, etc.) working in this setting should be aware of the risk factors displayed in marching band artists, and be able to provide education, prevention, and clinical interventions to this population. Additionally, marching band administrators should be aware of all medical risk factors and the benefit of having a healthcare provider (e.g., athletic trainer) to oversee the healthcare and wellness of marching band artists.

Context: To our knowledge, no researchers have investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures., Objective: To examine core temperature (Tc) and EHI risk factors in MB artists., Design: Descriptive epidemiology study., Setting: Three rehearsals and 2 football games for 2 National Collegiate Athletic Association Division I institution's MBs., Patients or Other Participants: Nineteen volunteers (females = 13, males = 6; age = 20.5 ± 0.9 years, height = 165.1 ± 7.1 cm, mass = 75.0 ± 19.1 kg) completed the study., Main Outcome Measure(s): We measured Tc, wet bulb globe temperature, and relative humidity preactivity, during activity, and postactivity. Other variables were activity time and intensity, body surface area, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percentage of body mass loss), and medical history (eg, previous EHI, medications). The statistical analysis consisted of descriptive information (mean ± standard deviation), comparative analyses that determined differences within days, and correlations that identified variables significantly associated with Tc., Results: The mean time for rehearsals was 102.8 ± 19.8 minutes and for games was 260.5 ± 47.7 minutes. Mean maximum Tc was 39.1 ± 1.1°C for games and 38.4 ± 0.7°C for rehearsals; the highest Tc (41.2°C) occurred during a game. Fluid consumption did not match sweat rates (P < .001). Participants reported to games in a hypohydrated state 63.6% of the time. The maximum Tc correlated with the maximum wet bulb globe temperature (r = 0.618, P < .001) and was higher in individuals using mental health medications (rpb = -0.254, P = .022) and females (rpb = 0.330, P = .002). Body surface area (r = -0.449, P < .001) and instrument mass (r = -0.479, P < .001) were negatively correlated with Tc., Conclusions: Marching band artists experienced high Tc during activity and should have access to athletic trainers who can implement EHI-prevention and -management strategies., (© by the National Athletic Trainers' Association, Inc.)

Context: Research exists on energy balances (EBs) and eating disorder (ED) risks in physically active populations and occupations by settings, but the EB and ED risk in athletic trainers (ATs) have not been investigated., Objective: To assess ATs' energy needs, including the macronutrient profile, and examine ED risk and pathogenic behavioral differences between sexes (men, women) and job statuses (part time or full time) and among settings (college or university, high school, nontraditional)., Design: Cross-sectional study., Setting: Free-living in job settings., Patients or Other Participants: Athletic trainers (n = 46; male part-time graduate assistant ATs = 12, male full-time ATs = 11, female part-time graduate assistant ATs = 11, female full-time ATs = 12) in the southeastern United States., Main Outcome Measure(s): Anthropometric measures (sex, age, height, weight, body composition), demographic characteristics (job status [full- or part-time AT], job setting [college/university, high school, nontraditional], years of AT experience, exercise background, alcohol use), resting metabolic rate, energy intake (EI), total daily energy expenditure (TDEE), exercise energy expenditure, EB, macronutrients (carbohydrates, protein, fats), the Eating Disorder Inventory-3, and the Eating Disorder Inventory-3 Symptom Checklist., Results: The majority of participants (84.8%, n = 39) had an ED risk, with 26.1% (n = 12) engaging in at least 1 pathogenic behavior, 50% (n = 23) in 2 pathogenic behaviors, and 10.8% (n = 5) in >2 pathogenic behaviors. Also, 82.6% of ATs (n = 38) presented in negative EB (EI < TDEE). Differences were found in resting metabolic rate for sex and job status (F1,45 = 16.48, P = .001), EI (F1,45 = 12.01, P = .001), TDEE (F1,45 = 40.36, P < .001), and exercise energy expenditure (F1,38 = 5.353, P = .026). No differences were present in EB for sex and job status (F1,45 = 1.751, P = .193); χ2 analysis revealed no significant relationship between ATs' sex and EB ({\rm{\chi }}&#95;{1,46}^2= 0.0, P = 1.00) and job status and EB ({\rm{\chi }}&#95;{1,46}^2 = 2.42, P = .120). No significant relationship existed between Daily Reference Intakes recommendations for all macronutrients and sex or job status., Conclusions: These athletic trainers experienced negative EB, similar to other professionals in high-demand occupations. Regardless of sex or job status, ATs had a high ED risk and participated in unhealthy pathogenic behaviors. The physical and mental concerns associated with these findings indicate a need for interventions targeted at ATs' health behaviors., (© by the National Athletic Trainers' Association, Inc.)

Objective: To determine which intrinsic and extrinsic exertional heat illness (EHI) risk factors exist in youth American football players and observe perceptual and physiological responses of players during events (games and practices)., Methods: Cross-sectional cohort study observing 63 youth football players, varying in position. Independent variables were league (weight-restricted (WR, n = 27) and age-restricted (AR, n = 36)) and event type. Dependent variables were anthropometrics, work-to-rest ratio, and wet bulb globe temperature. Descriptive variables included preparticipation examination and uniform configuration. A subset of 16 players participated in physiological variables (heart rate and gastrointestinal temperature). Data collection occurred on 7 AR and 8 WR nonconsecutive practices and the first 3 games of the season., Results: Mean values for anthropometric variables were higher (p < 0.05) in the AR league than the WR league. Work time (χ 2 (1,111) = 4.232; p = 0.039) and rest time (χ 2 (1,111) = 43.41; p < 0.001) were significantly greater for games, but ratios were significantly higher for practices (χ 2 (1,111) = 40.62; p < 0.001). The majority of events (77%) observed were in black and red flag wet bulb globe temperature risk categories. A total of 57% of the players had a preparticipation examination, and up to 82% of events observed were in full uniforms. Individual gastrointestinal temperature and heart rate responses ranged widely and no players reached critical thresholds., Conclusion: Extrinsic (disproportionate work ratios, environmental conditions) and intrinsic (higher body mass index) EHI risk factors exist in youth football. Certain risk factors may be influenced by event and league type. National youth football organizations need to create thorough guidelines that address EHI risk factors for local leagues to adopt., (Copyright © 2019. Production and hosting by Elsevier B.V.)

Context: No research has investigated thermoregulatory responses and exertional heat illness (EHI) risk factors in marching band (MB) artists performing physical activity in high environmental temperatures., Objective: Examine core temperature (Tc) and EHI risk factors in MB artists., Design: Descriptive epidemiology study., Setting: Three rehearsals and 2 football games for 2 NCAA Division I MBs., Participants: Nineteen volunteers completed the study (female = 13, males = 6; age = 20.5 ± 0.9 years; weight = 75.0 ± 19.1 kg; height = 165.1 ± 7.1 cm)., Main Outcome Measures: We measured Tc pre-, post-, and every 15 minutes during activity and recorded wet-bulb globe temperature (WBGT) and relative humidity (RH) every 15 minutes. Other variables included activity time and intensity, ground surface, hydration characteristics (fluid volume, sweat rate, urine specific gravity, percent body mass loss [%BM]), and medical history (eg, previous EHI, medications). Statistical analysis included descriptives (mean ± standard deviation), comparative analyses determined differences within and between days, and linear regression identified variables that significantly explained Tc., Results: Mean rehearsal time = 102.8 ± 19.8 minutes and game time = 260.5 ± 47.7 minutes. Max game Tc (39.1 ± 1.1°C) was significantly higher than rehearsal (38.4 ± 0.7°C, P = .003). The highest max game Tc = 41.2°C. Participants consumed significantly more fluid than their sweat rates (P < .003), which minimized %BM loss, particularly during rehearsals (-0.4 ± 0.6%). Mean game %BM loss = -0.9 ± 2.0%; however, 63.6% of the time, participants reported hypohydrated to game day. Max Tc was significantly predicted by max WBGT, max RH, ground surface, using mental health medications, and hours of sleep (adjusted R2 = 0.542, P < .001)., Conclusions: Marching band artists experience high Tc during activity and should have access to athletic trainers who can implement EHI prevention and management strategies., (© by the National Athletic Trainers' Association, Inc.)

Context: Research exists on energy balance (EB) and eating disorder (ED) risk in physically active populations and occupations by settings, but EB and ED in athletic trainers (ATs) has not been investigated., Objective: To assess ATs' energy needs, including macronutrient profile, and to examine ED risk and pathogenic behavior between sex (males, females), job status (part-time=PT-AT; full-time=FT-AT) and setting (college/university, high school, non-traditional)., Design: Cross-sectional and descriptive., Setting: Free-living in job settings., Participant: ATs (n=46; males PT-AT n=12, males FT-AT n=11; females PT-AT n=11, female FT-AT n=12) in Southeastern United States., Main Outcome Measures: Anthropometric measurements (age, height, weight, body composition), resting metabolic rate (RMR), energy intake (EI), total daily energy expenditure (TDEE), exercise energy expenditure (EEE), EB, macronutrients (carbohydrates, protein, fats), Eating Disorder Inventory-3, and the Eating Disorder Inventory-3 Symptom Checklist., Results: Majority (84.8%, n=39) had ED risk, with 26.1% (n=12) engaging in at least 1 pathogenic behavior, 50% (n=23) in 2 pathogenic behaviors, and 10.8% (n=5) in more than 2 pathogenic behaviors. 82.6% of ATs (n=38) presented in negative EB (EI

Using a double-blind, randomized and counterbalanced, cross-over design, we assessed naproxen's effects on gastrointestinal (GI) distress and performance in eleven volunteers (6 male, 5 female). Participants completed 4 trials: 1) placebo and ambient); 2) placebo and heat; 3) naproxen and ambient; and 4) naproxen and heat. Independent variables were one placebo or 220 mg naproxen pill every 8 h (h) for 24 h and ambient (22.7 ± 1.8°C) or thermal environment (35.7 ± 1.3°C). Participants cycled 80 min at a steady heart rate then 10 min for maximum distance. Perceived exertion was measured throughout cycling. Gastrointestinal distress was assessed pre-, during, post-, 3 h post-, and 24 h post-cycling using a GI index for upper, lower, and systemic symptoms. No statistically significant differences occurred between conditions at any time for GI symptoms or perceived exertion, distance, or heart rate during maximum effort. A 24 h naproxen dose did not significantly affect performance or cause more frequent or serious GI distress when participants were euhydrated and cycling at moderate intensity in a thermal environment., (© 2020 Chengdu Sport University. Production and hosting by Elsevier B.V. on behalf of KeAi.)

Background: In the US Army, soldiers' nutrition behaviors have a direct impact on their performance. The emphasis in basic combat training is on "soldierization" (transforming a civilian into a soldier), and drill sergeants are instrumental in this process. Limited information about how drill sergeants use their influence to have an impact on nutrition behaviors of new soldiers is available., Objective: This study aimed to determine nutrition attitudes, beliefs, and knowledge of drill sergeants; the ways drill sergeants instill new soldiers with an army identity (eg, warrior athlete, army strong); and how healthy eating is perceived to fit with this new identity., Design: This qualitative, phenomenological study used in-depth interviews conducted with army drill sergeants at two southeast US Army posts between July and August 2011 (n=30)., Main Outcome Measures: Interviews emphasized drill sergeants' perceptions of the eating environment during basic training, the drill sergeant role, and drill sergeants' main duties., Data Analysis: An iterative process of group coding using a constant comparative method was used to find distinct themes. Data were analyzed using qualitative data analysis software., Results: Drill sergeants described their main duty as training new soldiers. Drill sergeants identified the ideal soldier as lean and physically fit but did not identify training soldiers how to eat to become the ideal soldier as part of their duties. Confusion about nutrition concepts was common. Overall, drill sergeants recognized that what soldiers eat affects their physical performance and appearance, but they did not see helping soldiers establish healthy eating behaviors as one of their duties or responsibilities during basic combat training., Conclusions: Drill sergeants are key individuals in the process by which new recruits develop a soldier identity. Additional resources are necessary to help drill sergeants emphasize nutrition and health during basic combat training and help them guide soldiers toward adopting healthy eating as part of their soldier identity to improve weight management, health, and performance., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Introduction: Promoting healthy eating among Soldiers is a priority to the Army due to the link between nutrition and performance. The Army typically uses nutrition education to encourage Soldiers to make healthier food choices with low emphasis on other psychosocial determinants of food choice behaviors., Materials and Methods: Drill Sergeant Candidates (n = 575) completed surveys assessing nutrition knowledge, eating identity type, and food choice behaviors including fruit and vegetable intake, skipping meals, and eating out frequency. In multiple linear regression models using full-information maximum likelihood estimation while controlling for race/ethnicity, education, and marital status, we examined relationships between nutrition knowledge, a healthy eating identity, and Soldiers' food choice behaviors. The study was approved by the Department of Defense and University of South Carolina's Institutional Review Boards., Results: A healthy eating identity was positively associated with greater fruit and vegetable consumption (p < 0.05), and negatively associated with skipping meals and eating out frequency (p < 0.05). Nutrition knowledge was negatively associated with skipping meals (p < 0.05)., Conclusions: Findings suggest that fostering a healthy eating identity may be more effective for promoting healthy food choice behaviors than nutrition education alone. Determining if various points in a Soldier's career could be leveraged to influence a healthy eating identity and behaviors could be an important strategy to improve compliance with health promotion programs.

Background: Despite exercising in cool environments, ice hockey players exhibit several dehydration risk factors. Individualized fluid plans (IFPs) are designed to mitigate dehydration by matching an individual's sweat loss in order to optimize physiological systems and performance., Methods: A randomized control trial was used to examine IFP versus ad libitum fluid ingestion on hydration in 11 male minor professional ice hockey players (mean age = 24.4 ± 2.6 years, height = 183.0 ± 4.6 cm, weight = 92.9 ± 7.8 kg). Following baseline measures over 2 practices, participants were randomly assigned to either control (CON) or intervention (INT) for 10 additional practices. CON participants were provided water and/or carbohydrate electrolyte beverage to drink ad libitum. INT participants were instructed to consume water and an electrolyte-enhanced carbohydrate electrolyte beverage to match sweat and sodium losses. Urine specific gravity, urine color, and percent body mass change characterized hydration status. Total fluid consumed during practice was assessed., Results: INT consumed significantly more fluid than CON (1180.8 ± 579.0 ml vs. 788.6 ± 399.7 ml, p  = 0.002). However, CON participants replaced only 25.4 ± 12.9% of their fluid needs and INT 35.8 ± 17.5%. Mean percent body mass loss was not significantly different between groups and overall indicated minimal dehydration (<1.2% loss). Pre-practice urine specific gravity indicated CON and INT began hypohydrated (mean = 1.024 ± 0.007 and 1.024 ± 0.006, respectively) and experienced dehydration during practice (post = 1.026 ± 0.006 and 1.027 ± 0.005, respectively, p  < 0.001). Urine color increased pre- to post-practice for CON (5 ± 2 to 6 ± 1, p  < 0.001) and INT (5 ± 1 to 6 ± 1, p <  0.001)., Conclusions: Participants consistently reported to practice hypohydrated. Ad libitum fluid intake was not significantly different than IFP on hydration status. Based on urine measures, both methods were unsuccessful in preventing dehydration during practice, suggesting practice-only hydration is inadequate to maintain euhydration in this population when beginning hypohydrated.

Context: Urine specific gravity (Usg), measured by a handheld manual refractometer (MAN), has been recognized as a valid and practical means of assessing hydration status. Newer, digital refractometers are faster and more user friendly but have not been validated against the traditional MAN., Objective: To compare the reliability and validity of 2 digital refractometer models and a MAN., Design: Descriptive laboratory study., Setting: Research laboratory., Patients or Other Participants: Sample of convenience was recruited from the local university and surrounding community (n = 82)., Intervention(s): Participants provided multiple urine samples (n = 124) over a 5-month period under various hydration conditions., Main Outcome Measure(s): Urine specific gravity was compared among a MAN, a digital refractometer requiring the prism to be dipped (DIP) into a urine sample, and a digital refractometer that requires urine to be pipetted (PIP) onto its prism for analysis., Results: The MAN measurements were strongly correlated with the DIP (r = 0.99, P < .001) and PIP (r = 0.97, P < .001) measurements. Bland-Altman analyses revealed slight mean underestimation (95% upper and lower levels of agreement) between MAN and DIP (-0.0012 [0.0028] and PIP -0.0011 [0.0035], respectively) and trends toward increased underestimation at higher Usg. Measurement error ≥ .005 was greater for PIP (4/124, 3.2%) than for DIP (2/124, 1.6%)., Conclusions: Negligible differences were exhibited between PIP and DIP, with both displaying acceptable reliability and validity compared with the MAN. However, the Bland-Altman analysis suggests underestimation bias for the DIP and PIP as Usg increases, with the potential for rare but substantial underestimation when using PIP that should be recognized by clinicians, particularly when used as a screening measure in weight-class sports.

Context: With increased media coverage and competitive opportunities, cheerleaders may be facing an increase in eating disorder (ED) prevalence linked to clothing-related body image (BI)., Objective: To examine ED risk prevalence, pathogenic weight control behaviors, and variation in clothing-specific BI across position and academic status among collegiate cheerleaders., Design: Cross-sectional study., Setting: National Collegiate Athletic Association Division I and II institutions., Patients or Other Participants: Female collegiate cheerleaders (n = 136, age = 20.4 ± 1.3 years, height = 160.2 ± 8.1 cm, weight = 57.2 ± 8.3 kg)., Main Outcome Measure(s): Participants self-reported height, weight, and desired weight and completed the Eating Attitudes Test. Body image perceptions in 3 clothing types (daily clothing, midriff uniform, full uniform) were assessed using sexbased silhouettes (body mass index = 18.3 kg/m(2) for silhouette 1, 23.1 kg/m(2) for silhouette 4)., Results: The ED risk for cheerleaders was estimated at 33.1%. However, when body mass index was controlled using backward stepwise logistic regression, flyers had greater odds (odds ratio = 4.4, 95% confidence interval = 1.5, 13.2, P = .008) of being at risk compared with bases, but no difference was noted between the base and back-spot positions (odds ratio = 1.9, 95% confidence interval= 0.5, 6.6, P = .333). A main effect of BI perceptions was seen (P < .001), with a significant interaction by clothing type (F(2,133) = 22.5, P < .001, η(2) = 0.14). Cheerleaders desired to be smaller than their perceived BIs for each clothing type, with the largest difference for midriff uniform (2.6 ± 0.8 versus 3.7 ± 0.9), followed by full uniform (2.7 ± 0.8 versus 3.5 ± 0.9) and daily clothing (2.8 ± 0.8 versus 3.5 ± 0.9)., Conclusions: Cheerleaders, especially flyers, appear to be at risk for EDs, with greatest BI dissatisfaction when wearing their most revealing uniforms (ie, midriffs). Universities, colleges, and the national governing bodies of these squads need to focus on preventing eating disorders and BI dissatisfaction and promoting self-esteem.

Context: Coaches, athletic trainers (ATs), strength and conditioning specialists (SCSs), and registered dietitians are common nutrition resources for athletes, but coaches, ATs, and SCSs might offer only limited nutrition information. Little research exists about sports nutrition knowledge and current available resources for nutrition information for athletes, coaches, ATs, and SCSs., Objective: To identify resources of nutrition information that athletes, coaches, ATs, and SCSs use; to examine nutrition knowledge among athletes, coaches, ATs, and SCSs; and to determine confidence levels in the correctness of nutrition knowledge questions within all groups., Design: Cross-sectional study., Setting: National Collegiate Athletic Association Division I, II, and III institutions across the United States., Patients and Other Participants: The 579 participants consisted of athletes (n = 185), coaches (n = 131), ATs (n = 192), and SCSs (n = 71)., Main Outcome Measure(s): Participants answered questions about nutrition resources and domains regarding basic nutrition, supplements and performance, weight management, and hydration. Adequate sports nutrition knowledge was defined as an overall score of 75% in all domains (highest achievable score was 100%)., Results: Participants averaged 68.5% in all domains. The ATs (77.8%) and SCSs (81.6%) had the highest average scores. Adequate knowledge was found in 35.9% of coaches, 71.4% of ATs, 83.1% of SCSs, and only 9% of athletes. The most used nutrition resources for coaches, ATs, and SCSs were registered dietitians., Conclusions: Overall, we demonstrated that ATs and SCSs have adequate sports nutrition knowledge, whereas most coaches and athletes have inadequate knowledge. Athletes have frequent contact with ATs and SCSs; therefore, proper nutrition education among these staff members is critical. We suggest that proper nutrition programming should be provided for athletes, coaches, ATs, and SCSs. However, a separate nutrition program should be integrated for ATs and SCSs. This integrative approach is beneficial for the continuity of care, as both categories of professionals might be developing and integrating preventive or rehabilitative programs for athletes.

Context: Participation in appearance-based sports, particularly at the collegiate level, may place additional pressures on female athletes to be thin, which may increase the likelihood of their resorting to drastic weight control measures, such as disordered eating behaviors., Objectives: (1) To estimate the prevalence and sources of eating disorder risk classification by academic status (freshman, sophomore, junior, or senior) and riding discipline (English and Western), (2) to examine riding style and academic status variations in body mass index (BMI) and silhouette type, and (3) to examine these variations across eating disorder risk classification type (eg, body image disturbances)., Design: Cross-sectional study., Setting: Seven universities throughout the United States., Patients or Other Participants: A total of 138 participants volunteered (mean age = 19.88 ± 1.29 years). They represented 2 equestrian disciplines English riding (n = 91) and Western riding (n = 47)., Main Outcome Measure(s): Participants self-reported menstrual cycle history, height, and weight. We screened for eating disorder risk behaviors with the Eating Attitudes Test and for body disturbance with sex-specific BMI silhouettes., Results: Based on the Eating Attitudes Test, estimated eating disorder prevalence was 42.0% in the total sample, 38.5% among English riders, and 48.9% among Western riders. No BMI or silhouette differences were found across academic status or discipline in disordered eating risk. Overall, participants perceived their body images as significantly larger than their actual physical sizes (self-reported BMI) and wanted to be significantly smaller in both normal clothing and competitive uniforms., Conclusions: Disordered eating risk prevalence among equestrian athletes was similar to that reported in other aesthetic sports and lower than that in nonaesthetic sports. Athletic trainers working with these athletes should be sensitive to these risks and refer athletes as needed to clinicians knowledgeable about disordered eating. Professionals working with this population should avoid making negative comments about physical size and appearance.

Eating knowledge, nutritional knowledge, and psychological changes among female collegiate dancers were examined before and after a 4-wk. team-centered program on sport nutrition, exercise, and disordered eating consequences. Collegiate female dancers from two NCAA Division I institutions participated in a control (n = 19; M age = 19.1 yr., SD = 1.0) or intervention (n = 21; M age = 19.2 yr., SD = 1.2) group. Measures were administered to both groups before and after intervention to assess eating disorders, depression, and nutritional and disordered eating knowledge. There was a statistically significant increase in scores on nutritional and overall eating disorder knowledge in the intervention group compared to the control group. Mean scores on depression, drive for thinness, body dissatisfaction, and maturity fears decreased in the intervention group.

Knowledge of eating disorders, confidence in knowledge, and attendance of eating disorder educational programs were assessed among NCAA Division I and II university administrators (n = 61), coaches (n = 44), and dancers (n = 53). A questionnaire assessed knowledge in 5 domains: etiology, signs and symptoms, management and treatment, risk factors, and prevention and education. Overall, dancers' knowledge and previous attendance were significantly lower than administrators' and coaches'. There was inconsistency between participants' confidence in answers and the correctness of their answers. Education is necessary for improving knowledge and reducing risky behaviors in auxiliary dancers.

Context: Medical professionals have recognized eating disorders and related problems in competitive athletes. Auxiliary members (color guard, dance, majorettes) experience the same appearance-related pressures observed in sports commonly associated with eating disorders., Objective: To estimate eating-disorder prevalence based on associated eating-disorder characteristics and behaviors in female auxiliary members and to compare perceived and ideal body images and anthropometric measurements between at-risk and not-at-risk participants for eating-disorder characteristics and behaviors., Design: Cross-sectional design., Setting: Three universities in the southeastern United States., Patients or Other Participants: Participants (n = 101, mean age = 19.2 +/- 1.2 years) represented 3 auxiliary units, including color guard (n = 35), dance line (n = 47), and majorettes (n = 19)., Main Outcome Measure(s): Participants self-reported menstrual history, height, and weight. Anthropometric measurements included height, weight, body fat percentage, and waist and hip circumferences. We screened for eating-disorder risk behavior with the Eating Attitudes Test (EAT)-26 and for body dissatisfaction with the Figural Stimuli Survey., Results: Based on the EAT-26, we estimated eating-disorder prevalence among members to measure 29.7% (95% confidence interval = 20.8%, 38.6%). The EAT-26 results revealed that 21% of participants used purgatives and 14% vomited to control weight or shape. The at-risk group had higher scores on the EAT-26 total (P