BONE HEALTH, AND DIETITIANS IN IDAHO AND BEYOND: STRATEGIES FOR REDUCING THE RISK OF OSTEOPOROSIS IN FEMALE ATHLETES AND PREPARING ENTRY-LEVEL DIETITIANS TO EFFECTIVELY ADDRESS ISSUES RELATED TO VITAMINS AND MINERALS.

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: HATCH
• Reporting Frequency: Annual
• Accession No.: 1007348
• Project Start Date: Oct 6, 2015
• Project End Date: Jun 30, 2020
• Program Code: [(N/A)]- (N/A)

Recipient Organization
UNIV OF IDAHO
875 PERIMETER DRIVE
MOSCOW,ID 83844-9803

Performing Department
School of Family and Consumer Science

Non Technical Summary
OsteoporosisCurrent Issue or Problem: Fifty-two percent of adults over 50 years have osteoporosis, which can result in poor mobility and decreased quality of life. Young women and girls who experience the female athlete triad (Triad) are similarly at risk for bone loss because of the hormonal changes that occur with this syndrome. The Triad is a condition characterized by inadequate nutrition, menstrual irregularity, and bone loss. The Triad can increase risk for osteoporosis and stress fractures now and in the future. Osteoporosis at any age can increase medical costs.Basic methods and approaches to collect data and produce results: A study will be conducted to determine whether or not foods offered to athletes via "refueling stations" located inside university weight rooms improve dietary intake and decrease risk for osteoporosis. An educational video that highlights the detrimental effects of the Triad and includes testimonials from former athletes who have experienced these effectswill be developed. Nutrition/dietetic students and female athletes will complete pre- and post questionnaires to assess changes in their knowledge of the Triad and osteoporosis following the video education.Ultimate Goals/Impact: We hope to see an increased awareness/knowledge of the Triad, including its effect on risk for osteoporosis, among female athletes and nutrition/dietetic students who may work with female athletes in the future when they become dietitians. We also hope to see routine Triad and osteoporosis screening and education for athletes.Vitamins and MineralsCurrent issue or problem:Registered dietitians provide nutritional counseling and medical nutrition therapy to clients and patients.The state of Idaho has two dietetic programs (University of Idaho and Idaho State University) that prepare students to become dietitians, many of whom work in Idaho following graduation. The many numerous physiological effects of each vitamin/mineral can be difficult for students to remember. Further research is needed to determine the knowledge and skills related to vitamins and minerals that are required for an entry-level dietitian position. In addition, research is needed to determine effective strategies for teaching this information to dietetic students to best prepare dietetic students for the workforce.Basic methods to collect data and produce results: Nutrition/dietetic students will complete an online survey that will assess their knowledge about vitamins and minerals, as well as strategies they use to remember this information. Practicing dietitians will complete an online survey that will provide their perspective on which vitamins and minerals should be emphasized in dietetic education and in what contexts (i.e. dietary supplements, patient/client education, relation to biochemical lab values, etc.). Vitamin/mineral curriculum will be created based on the findings of this research. Students will complete surveys before and after receiving this revised curriculum to assess changes in vitamin/mineral knowledge.Ultimate Goals/Impact:Best prepare nutrition/dietetic students to be competent entry-level dietitians in respect to vitamins and mineral knowledge and competency. This will result in the citizens of Idaho receiving optimal nutrition services related to vitamins and minerals.

Animal Health Component

50%

Research Effort Categories

Basic

20%

Applied

50%

Developmental

30%

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6099	3020	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
3020 - Education;

Keywords

nutrition education

osteoporosis

health

Goals / Objectives
Decrease risk of osteoporosis from the Female Athlete Triad (Triad) in female athletes.1) Assess the impact of foods offered via the refueling station on athletes' overall dietary intake, energy availability, and risk for the Triad.2) Develop a screening tool to predict low energy availability based on statistical evaluation of Triad risk factors.3) Develop a Triad education video that includes perspectives of a researcher, former athletes, a coach, and a registered dietitian.4) Assess the impact of a Triad educational video on Triad knowledge of nutrition students and female athletes (college and high school).Improve methods for teaching nutrition and dietetic students about vitamins and minerals.1) Assess dietetic student knowledge of, and methods for remembering vitamin and mineral information.2) Assess practicing dietitians' views on which vitamins and minerals should be emphasized in dietetic education and in what contexts (i.e. dietary supplements, patient/client education, relation to biochemical lab values, etc.).3) Develop, implement, and assess an educational intervention/curriculum strategy based on the information gained from the two previously mentioned objectives.

Project Methods
OsteoporosisParticipants: Members of the University of Idaho Women's Soccer team will be invited to participate in this research (N=26). This sample size will provide >.80 power. The work by Reed, De Souza and Williams (2013) was used to calculate power for this study; EA of 35±3.7 kcals/kg LBM was considered the "known" mean for the sample. A change in 5 kcals/kg LBM is considered significant because changes in markers of menstrual health can occur if an athlete's EA falls below 30 kcals/kg LBM (Loucks, Verdun, & Heath, 1998).1. This research will quantify the athletes' exercise energy expenditure and dietary intake over the course of their competitive season and specifically noting which foods were obtained from the refueling station. This research will assess the magnitude of the contribution these foods make to the athletes' total caloric intake and energy availability (dietary caloric intake - exercise energy expenditure; reported in kcals/kg lean body mass).a. Energy intake: Researchers will conduct 3 multi-pass 24-hour diet recalls (spaced 3-10 days apart) at the beginning, middle, and end of the season for each athlete to collect dietary info for the days that the athletes wore accelerometers. Foods provided from the refueling station will be noted. Dietary info will be entered into ESHA Food Processor software for quantification and analysis.b. Energy Expenditure: Athletes will wear an accelerometer at all times including sleeping (except for when in water) for the entire 3-13 day span in which the dietary recalls will take place. Researchers will also conduct a physical activity recall for the 3 days that diet recalls were obtained. Accelerometer data will only be used for the days in which dietary intake was obtained. This will simplify the distribution of accelerometers.c. Body Composition: To allow for estimate of EA (which is reported per kg of lean body mass) athletes will be asked to have their body composition measured via the Bod Pod. IRB Protocol #15-7962. An education video will be developed with the help of the College of Agriculture and Life Sciences (CALS) Educational Communications team. This video will include individuals (researcher, former athletes, a coach, and a registered dietitian) who have important perspectives on the Triad.3. Pre/post Triad knowledge questionnaires will be administered to nutrition students as part of the online sports nutrition class. These results will be compared to the results of students who participated in the questionnaire during a semester in which the video was not included. This same pre/post questionnaire will be used to assess changes in Triad knowledge in athletes.?IRB Protocol #15-820References:Loucks, A. B., Verdun, M., & Heath, E. M. (1998). Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. Journal of Applied Physiology, 84(1), 37-46.Reed, J. L., De Souza, M. J., & Williams, N. I. (2013). Changes in energy availability across the season in division I female soccer players. Journal of Sports Sciences, 31, 314-324. doi:10.1080/02640414.2012.733019Vitamin and Minerals1. Nutrition and dietetic students from Utah State University, College of Easter Washington, and University will be asked to complete an online questionnaire that includes free response and multiple choice questions to assess their knowledge (food sources, function, deficiency, toxicity, etc.) of a representative sample of vitamins and minerals. Students will also be asked to describe how they remembered that information (mnemonic devices, etc.).IRB Protocol #14-3622. An online survey will be used to assess practicing dietitians' to determine which vitamins and minerals they most frequently encounter and in what contexts (i.e. dietary supplements, patient/client education, relation to biochemical lab values, etc.). They will also be asked to provide any additional comments about how best to prepare dietetic students to effectively utilize their vitamin/mineral knowledge in entry-level dietitian positions.IRB Protocol #14-4693. Based on the findings of the student and practicing dietitian research mentioned above, an educational intervention will be developed. Junior-level Dietetic Students will complete pre/post questionnaires to measure changes in their vitamin and mineral knowledge following the educational intervention.

Progress 10/01/17 to 09/30/18

Outputs
Target Audience:Target audiences included: University students Female high school athletes Extension faculty and educators Attendees of poster sessions at the annual meeting of the Academy of Nutrition and Dietetics Readers of the Journal of the Academy of Nutrition and Dietetics Attendees of the Idaho Dance Education Orgranization annual meeting (dance students and teachers from across the state of Idaho) Changes/Problems:An unexpected outcome was that from the variables available from the data collected, an effective screening tool to predict presence of the female athlete triad (Triad) could not be developed. There seems to be variation in manifestations of the Triad among different indivuals. What opportunities for training and professional development has the project provided?Mentoring and professional development (via conference attendance) was provided to two graduate students and fourundergraduate students. How have the results been disseminated to communities of interest?Results have been shared with Extension faculty and educators through a workshop. Results have been shared with female athletes and their coaches/mentors via workshops. Results have been shared with Registered Dietitians via published abstracts and poster presentations at conferences. What do you plan to do during the next reporting period to accomplish the goals?Finish developing the vitamin and mineral educational tools. Publish one or more article in a peer-reviewed journal. Analyze the data to determine if nutrition students gained knowledge from watching the Female Athlete Triad video.

Impacts
What was accomplished under these goals? Decrease risk of osteoporosis from the Female Athlete Triad (Triad) in female athletes. 1) Results suggested that athletes in this sample regulated their intake such that they consumed a similar amount of calories on days in which they did not consume university-provided foods, and that the university provided foods may support diet qualit among ahtletes. 2) Results indicated that with the variables available from the data collected, an effective screening tool could not be developed. 3) Accomplished previously. 4) Changes in knowledge among collegiate and high school athletes was reported previously. Data was collected for college students but has not yet been analyzed. Improve methods for teaching nutrition and dietetic students about vitamins and minerals. 1) Completed previoulsy 2) Results from 394 Registered Dietians in 44 US states and territories suggest that it may be beneficial to emphasize the following nutrients: sodium, calcium, vitamin D, potassium, iron, phosphorus, vitamin B12, and magnesium. Participants encountered these vitamins and minerals most frequently in the following contexts: Labs and Biochemical Markers, Supplements, and Education. Participants reported that following their dietetics program, they were least confident in using their knowledge of vitamins and minerals in the following applications:supplement recommendation and sigs and symptoms. 3) Portions of a vitamin/mineral education intervention was piloted with food and nutrition students at the University of Idaho.

Publications

• Type: Theses/Dissertations Status: Published Year Published: 2018 Citation: Krick, R. L. (2018). Changes in knowledge of the female athlete triad among female high school athletes following a brief nutrition education intervention (Order No. 10690489). Available From Dissertations & Theses @ University of Idaho; ProQuest Dissertations & Theses Global. (2115932036). Retrieved from http://ida.lib.uidaho.edu:2048/login?url=https://search.proquest.com/docview/2115932036?accountid=14551
• Type: Theses/Dissertations Status: Published Year Published: 2018 Citation: Dyckman, J. R. (2018). Associations between collegiate female athletes energy availability and various female athlete triad Components/Risk factors when using three different criteria to calculate exercise energy expenditure (Order No. 10790325). Available From Dissertations & Theses @ University of Idaho; ProQuest Dissertations & Theses Global. (2139792515). Retrieved from http://ida.lib.uidaho.edu:2048/login?url=https://search.proquest.com/docview/2139792515?accountid=14551
• Type: Conference Papers and Presentations Status: Published Year Published: 2018 Citation: Howard, JW. Brown K. Prevalence of Risk for the Female Athlete Triad and Risk for Eating Disorders among Female Athletes at the University of Idaho. Presented at the University of Idaho Undergraduate Research Symposium. April 2018.
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Brown AF, Little M, Brown KN, Meenan MJ. Prevalence and Knowledge of the Female Athlete Triad among Collegiate Dancers. Presented at the International Association for Dance Medicine and Science Annual Conference. Houston, TX. October 2017.
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Krick, R, Brown KN, Ramsay SA, Brown AF. Changes in Knowledge of the Female Athlete Triad among Female High School Athletes Following a Brief Nutrition Education Intervention. Presented at the Food and Nutrition Conference and Expo of the Academy of Nutrition and Dietetics. Chicago, IL. October 2017.

Progress 10/01/16 to 09/30/17

Outputs
Target Audience:1) Dancer Athletes at the University of Idaho, 2) A sampling of Registered Dietitians nationwide, 3) undergraduate students enrolled in nutrition and dietetics courses at the University of Idaho. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Two graduate students and four undergraduate students have been mentored one-on-one as they have taken part in these research activities. How have the results been disseminated to communities of interest?A report of findings of the dancer study were shared with the Movement Science department to inform their future educational practices. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Ultimate Goals/Impact:Decrease risk of osteoporosis from the Female Athlete Triad (Triad) in female athletes. 1) Data collection is complete. However, additional participants may be added if statistical power requires it. 2) Analysis is underway to work towards developing a screening tool. 3) Completed previously. The video is now housed on YouTube at the following linkhttps://www.youtube.com/watch?v=iEvlK1JeELU 4) Analysis revealed that among collegiate dancer athletes (N=26) there was a significant increase in knowledge of the female athlete triad and how inadequate nutrition may impact risk for osteoporosis (score increased from(5.8 to 8.5 out of 10, p<0.05). Improve methods for teaching nutrition and dietetic students about vitamins and minerals. 1) Completed previously. 2) Data collection is completed. Over 300 practicing Registered Dietitian Nutritionists from across the nation completed the survey. 3) Based on preliminary data of the two previous goals, micromineral assignments have been developed and beta tested.

Publications

• Type: Other Status: Published Year Published: 2016 Citation: Worden S, Brown K. Methodology for Assessing Female Collegiate Athletes Total Dietary Intake, and Intake of Food Provided by a University Athletic Department: A Pilot Study. J Acad Nutr Diet 2017; 116:9 Supp A24.
• Type: Other Status: Published Year Published: 2017 Citation: Little, M. Brown, K, Brown AF, Meenan, M. Dancers risk for the female athlete triad, disordered eating, and changes in triad knowledge following an educational intervention. J Acad Nutr Diet 2017; 117:9 Supp A85.

Progress 10/06/15 to 09/30/16

Outputs
Target Audience:1) Female athletes at the University of Idaho 2) Nutrition students at Utah State University, College of Eastern Washington, and University of Idaho 3) Dietitians in the western United States. Changes/Problems:The original plan for the Female Athlete Triad Study was for participants to be members of the women's soccer team. Despite a letter of support from the coach and continued communication with the assistant coach, the team opted not to participate. Consequently, the study was expanded to include athletes from a variety of sports. This has delayed our data collection, but the project is still progressing. Data collection is approximately 75% complete. I beleive the study will still acheive the desired objectives. What opportunities for training and professional development has the project provided?The Female Athlete Triad video was used as part of a continuing education sports nutrition symposium for coaches, fitness professionals, etc. Mentoring of student volunteers has also aided their professional development in terms of research, as well as community education and outreach. How have the results been disseminated to communities of interest?Female Athlete Triad video that includes perspectives of a researcher, former athletes, a coach, and a registered dietitian was produced. This video has been shown to over 40 nutrition students, 93 health professionals, over 41 university-level athletes and dancers, and 98 high school athletes. What do you plan to do during the next reporting period to accomplish the goals?1) Complete data collection and analysis of the Female Athlete Triad Study. 2) Complete data collection and analysis of the Registered Dietitian Vitamin and Mineral study. 3) Develop a vitamin and mineral curriculum for food and nutrition students. 4) Further dissemination of the video to high school and college athletes and their throughout the state.

Impacts
What was accomplished under these goals? Female Athlete Triad 1) Data collection is underway; approximately 75% of data has been collected. 2) This cannot be done until data collection is completed. 3) Female Athlete Triad video that includes perspectives of a researcher, former athletes, a coach, and a registered dietitian was produced. This video has been shown to over 40 nutrition students, 93 health professionals, over 41 university-level athletes and dancers, and 98 high school athletes. 4) Data collection/analysis is underway to assess changes in knowledge among university-level athletes and high school athletes. Results of a Wilcoxin Signed Ranks Test indicated that Triad knowledge increased significantly from pre to post intervention (5.8 ±1.9 to 8.5 ±1.2; p<0.001). Knowledge scores were out of ten. Vitamins and Minerals 1) Data was collected from 40 undergraduate food and nutrition students.Students' scores on multiple choice vitamin/mineral questions suggested that they had difficulty remembering details regarding vitamins and minerals; the average score was 64% (5/8 questions). The majority of participants(88.2%; n = 30) knew that blood clotting is the primary function of vitamin K. The lowest average number of correct responses was the result of vitamin E deficiency (38%; n = 13). Three themes were identified as common study strategies for learning vitamin and mineral content: repetition, mnemonic devices, and personal application. 2) The Registered Dietitian Vitamin and Mineral survey was designed to determine practicing dietitians' frequency of use of their knowledge of each vitamin and mineral, and in which context. The survey was developed by the investigator and a graduate student. Three expert reviewers (practicing dietitians) reviewed the surveys for content validity as well as format and wording. Data analysis for survey reliability is currently underway. Once the survey reliability has been verified, the survey will be sent out to a large number of practicing dietitians. 3) Pilot in-class student projects related to vitamin and mineral mnemonic device development are underway. Further curriculum development will occur when full data collection from practicing dietitians is complete.

Publications

• Type: Journal Articles Status: Published Year Published: 2016 Citation: Brown K, Ellis J, Ogan D, Wengreen H. Nutrition and Dietetic Students Vitamin and Mineral Knowledge and Concurrent Learning and Retention Strategies. International Journal for Innovation Education and Research. 2016; 4(10): 274-283.