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J Athl Train. 2007 Jan–Mar; 42(1): 99–105. | PMCID: PMC1896079 |
Copyright National Athletic Trainers' Association, Inc. Nutritional Knowledge and Attitudes in Athletes With Physical Disabilities Reza Rastmanesh, PhD,* Furugh Azam Taleban, PhD,* Masood Kimiagar, PhD,* Yadolah Mehrabi,* and Moosa Salehi, PhD† *Shaheed Beheshti University of Medical Sciences, Tehran, Iran; †Shiraz Medical University, Shiraz, Iran Context: Little is known about sport nutritional problems and requirements of athletes with physical disabilities. Objective: To compare the nutritional knowledge and attitudes of Iranian athletes with physical disabilities (APDs) after nutrition education. Because proper nutrition is important for both performance and injury healing, learning about the nutritional areas in which APDs are deficient may assist professionals in educating them. Design: Nested case-control study. Setting: Sport camp. Patients or Other Participants: Seventy-two APDs (42 APDs in the intervention group and 30 age-matched and sex-matched control APDs) and 10 coaches completed the study. Intervention(s): The APDs in the intervention group and their coaches were given nutrition education, which included a booklet with a simplified food guide pyramid, simple concepts about nutrition and weight loss, and four 3-hour courses. The APDs in the control group and their coaches were not given nutrition education. Main Outcome Measure(s): Subjects completed 2 nutritional questionnaires with both quantitative and qualitative components. Nutritional questionnaires were administered at 2 consecutive camps, 30 days apart, before and after nutrition education. Our questionnaires included a demographics section; 88 Likert scale and true-false questions; and 18 open-ended questions, 13 of which were specifically designed for APDs. Each APD completed two 3-day food records. Results: The APDs in the intervention group scored significantly higher after nutrition education and higher than the control group on the knowledge subscales and interest in nutrition. Although the nutrition knowledge score in this study was moderate, several specific areas of deficient nutritional knowledge were identified that are critical for the health of APDs. Our model of nutrition education was more effective than the usual instructions presented irregularly by coaches. Conclusions: Our findings suggest that Iranian APDs lack nutritional knowledge in areas critical to preventing nutrition-related health problems, especially components related to nutrition for athletes with disabilities. Keywords: nutrition education, diet Key Points
- Athletes with physical disabilities would benefit from nutritional education and counseling to improve health and athletic performance.
- It is important for athletes with disabilities to consume the correct percentages of carbohydrates, protein, and fats in their daily meals, but the caloric intake should be adjusted based on the physical disability and activity level of the individual.
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Sport participation by persons with disabilities has increased dramatically over the past 50 years. Physiologic differences in athletes with physical disabilities (APDs), combined with the internal demands and external pressures during events such as the Paralympic Games, may led to health problems. In the Paralympic Games, APDs often focus not only on skill and endurance but also on national ambition and professional competing. Hence, athletes with spinal injury, blindness or visual impairment, or cerebral palsy; amputees; and those with developmental disabilities are at risk for certain injuries because of their specific impairments. 1 Persons with mental retardation and other developmental disabilities also encounter significant disparities and unmet health care needs. Contributing factors include deinstitutionalization, increased survival of individuals with these conditions, lack of appropriately trained providers, inadequate financing of dental services, 2 range-of-motion limitations, shoulder pain and low back pain after physical stress, and muscle fasciculation in athletes with polio and bilateral carpal tunnel syndrome. 3Despite pre-existing medical conditions and physical limitations of Special Olympians, most of the medical demands encountered during athletic competition are acute, minor injuries. 4 However, little is known about sport nutritional problems and demands in APDs. Proper nutrition may serve as a key component in preventing many health problems specific to athletes with disabilities, who are slightly more vulnerable to stress, fatigue, and poor performance than able-bodied athletes. 5,6 Despite the importance of good nutrition, APDs appear to lack nutritional knowledge or fail to comply with recommendations for other unknown reasons. Athletes appear to have positive attitudes toward nutrition. 7–9 Nutrition education (NE) significantly improved nutrition knowledge, self-efficacy, and the overall number of positive dietary changes in female athletes. 10Successful pilot projects including nutrition, blood pressure, and flexibility screening, such as the “Wellness Park” experience, provide not only an effective vehicle to improve access to health care for mentally retarded athletes but also involvement of health professionals and students in working and communicating with this special-needs population. 11 These results suggest that if the areas of knowledge deficits or reasons for nutritional choices can be identified, APDs will be receptive to NE. At the same time, it is important to recognize differences in nutrition knowledge 12 and nutrition attitudes 12–14 among different racial and cultural groups and between males and females. 15–17According to the Statistical Center of Iran, 18 the total number of physically disabled Iranians is about 450  000 persons; two thirds of these disabilities are related to war. Taking into account natural disasters, mine explosions, and vehicle accidents, it is estimated that by the year 2015, this number will double. 19Because little is known about the nutritional knowledge and attitudes in Iranian APDs and coaches, we decided to assess the nutritional knowledge and attitudes of these groups before and after NE. Coaches, APDs, and health care professionals, including athletic trainers, can then identify the areas in which APDs lack the nutritional knowledge important to optimal performance and healing. Instrument The instrument was a self-administered questionnaire designed to assess nutritional knowledge and attitudes of APDs and coaches before and after NE intervention. The questionnaire included a demographics section, 88 Likert scale and true-false questions, and 18 open-ended questions, 13 of which were specifically designed for APDs. We adopted the instrument from Zawila et al 9 using carefully selected questions from questionnaires originally created by Barr 20 and Werblow et al. 7 The questionnaire was translated from English into Persian and then translated back from Persian into English by a researcher fluent in both languages. Because of Islamic-Iranian food habits, items about alcohol and caffeine were deleted, and variables thought to be most relevant to the APDs were included. Thus, 23 new items were added, 13 items were modified, and 11 items were deleted. Items were carefully mixed so that the likelihood of guessing the right answer was substantially reduced. Reliability ( r = 0.85) and construct validity (Cronbach alpha > 0.7) had been determined in our pilot study with 41 APDs. The test-retest reliability was satisfactory (Pearson r = 0.61 to 0.93 for individual items and 0.85 for total score). The research team, several university faculty members, and a physician reviewed the pilot questionnaire to establish face validity and trustworthiness. The questionnaire was revised appropriately based on their feedback. We applied the World Health Organization criteria to identify APDs as normal weight (18.5 to <25 kg/m 2) or overweight (25 to <30 kg/ m 2). 213-Day Food Record Each APD completed two 3-day food records, each including 2 weekdays and 1 weekend day, at days 0 and 30. A dietitian provided 15 minutes of instructions to each APD on how to complete the food records. Also, APDs were encouraged to consume their usual amounts of typical foods and drinks on the days of the food records. The APDs were not required to weigh foods but were asked to measure the volume of foods consumed with household measurements (cups, tablespoons) or to indicate the weight of commercial products when it was possible to assess portion sizes. The Nutritionist (version IV; N-Squared Computing, San Bruno, CA) computer program was used to determine mean daily nutrient intakes. Subjects A total of 72 APDs (42 APDs in the intervention group and 30 age-matched and sex-matched control APDs) completed the study. The study was carried out between March and May 2004. All subjects had spinal cord injury or amputation(s). The APDs were randomized to the intervention or control group using a random number table. The study was single blinded. Ninety-seven percent (70 out of 72) of the APDs had the experience of participating in at least 1 of the Seoul, Barcelona, Atlanta, or Sydney Paralympic Games, except for the archery team, which first participated in Sydney in 2000. We contacted team coaches to explain the research purpose, methods, and benefits. The same directions were read to all participants. All athletes gave their informed consent to take part in the study, which was conducted in accordance with the Declaration of Helsinki. The APDs and their coaches in the intervention group were given NE (a booklet about a simplified food guide pyramid, simple concepts about nutrition and weight loss, and four 3-hour nutrition courses). The APDs in the control group were not given NE, but they were receiving regular instructions from the same coaches. For the control group, coaches were asked to continue with their usual training methods. Our booklet was a combination of the Persian translation of “Exchange Lists for Meal Planning” 22 (American Dietetic Association, revised 1995) and the Glycaemic Index of Iranian Foods.23 A dietitian instructed all APDs in the intervention group and their coaches once a week, for a total of four 3-hour nutrition courses. All APDs and coaches completed the study. Data for the control group were only collected before NE. Statistical Analysis The true-false questions were divided into the subscales of 3 or more questions based on the following topics: carbohydrates, protein, fats, calcium, iron, vitamins and minerals, functional foods, vegetables, health benefits of foods, hydration, nutrition for the athlete, nutrition for APDs, and weight loss. The remaining 18 true-false questions addressed the participants' attitudes toward nutrition; 13 of these questions were specifically designed for APDs. We divided the knowledge portion into nutrition for the athlete, nutrition for APDs, and general nutrition sections. Frequencies were calculated for all demographic data and for knowledge and attitudes questions. For analysis of questions using the Likert scale, strongly agree and agree were combined as positive responses and strongly disagree and disagree as negative responses. For 2-group comparisons, we calculated independent t tests to identify significant differences. All tests were 2-tailed, and P < .05 were considered significant. Significance levels were adjusted for multiple comparisons by using the Bonferroni method. Dichotomous variables were analyzed using the McNemar test when 2 time points were compared. Chi-square tests were used for categoric variables. General characteristics were compared using Fisher exact tests. The correlations between variables were examined by Spearman correlations. We also performed qualitative analysis on the open-ended questions, identifying themes to describe the reasons for food choices and selection. Statistical analyses were performed using SPSS for Windows (version 11.5; SPSS Inc, Chicago, IL). Subjects' general characteristics are summarized in Table 1. Mean age of the APDs was 30 ± 7.6 years. After NE, APDs in the intervention group scored significantly higher than both before education and the control group on the knowledge subscales ( Table 2). No differences were seen in knowledge about different topics between the intervention and control groups at baseline, although the control group scored marginally higher. The coaches' total score on the questionnaire was significantly higher than those of the APDs in both groups at baseline (66.6% versus 43.1% and 42.3%, respectively, P < .05), but interestingly, after NE, APDs in the intervention group scored significantly higher than coaches (81.3% versus 66.6%, P < .05). | Table 1General Characteristics of Iranian Athletes With Physical Disabilities (n = 72). |
| Table 2Knowledge Subscales: Correct Items Selected by Iranian Athletes With Physical Disabilities (n = 72). |
The APDs were asked to classify their body weights into 1 of 3 categories: below ideal weight, ideal weight, or above ideal weight. After NE, a significant improvement in the ability to recognize true body weight classification was seen in the intervention group. Only 1 of 42 APDs (2.4%) could not classify his or her weight correctly after NE, compared with 25 of 42 (59.5%) before NE ( P < .01) ( Table 3). None of the APDs classified their weights as below ideal weight. | Table 3Iranian Athletes with Physical Disabilities (No., %) Who Correctly Categorized Themselves as Having Ideal Body Weight (N = 72)*. |
The APDs were asked to classify their eating situation according to the following choices: (1) I buy or prepare most of my own food; thus, I generally control what I eat, or (2) my food is normally prepared by a family member, food service of federation, etc; thus, I am somewhat limited in my food selection. A total of 97.6% (41 of 42) of the APDs stated that their food is usually prepared by a family member. At baseline, APDs in both groups stated that they obtain nutritional information from limited sources. The top 3 reported sources were coaches, family members, and dietitians ( Table 4). The APDs showed a trend to communicate more with the dietitian. After NE, 50% (21 of 42) of APDs in the intervention group stated that they prefer to receive nutritional information from a dietitian, compared with 14.3% (6 out of 42) before NE and 16.6% (5 out of 30) in the control group ( P < .05). No correlation was noted between the number of nutritional sources used by the APDs and total scores on the questionnaire. No significant differences were observed between the knowledge for the athlete component plus the APD component and general knowledge component among the 3 groups. | Table 4Top 3 Reported Nutrition Information Sources by Iranian Athletes with Physical Disabilities (N = 72) (No., %). |
The mean of the APDs' total positive responses for the attitudes component after NE was 83.3% in the intervention group, compared with 55.5% before NE and 61.1% in the control group ( P < .05). Table 5 shows the percentage of positive answers to 13 open-ended questions. After NE, 83.3% (35 of 42) of the APDs had an increased interest in nutrition, which was significantly higher than before NE (20 of 42, 47.6%) and the control group (16 of 30, 53.3%; P < .01). | Table 5Yes Answers to Selected Knowledge and Attitude Questions in Iranian Athletes With Physical Disabilities (No., %). |
Qualitative analysis revealed several themes for food selection and choices. Before NE, coaches' recommendations, food availability, and food habits were the top 3 reported themes. Food availability and food habits remained the top 2 reported themes after NE, with a nonsignificant trend toward dietitians' recommendations. An example of a APD's written statement was, “Even if I know about good choices, I am somewhat limited in my food selection.” Other examples were “I feel the more you eat, the stronger you are,” “I feel the less you weigh, the faster you run,” “If your waist-to-hip ratio is high, you will not be able to have a good reflex,” and “If you know more about nutrition, you are more likely to make more healthy food choices.” The relationship between nutritional knowledge and attitude was significant in all 3 groups (P < .01). Dietary analysis showed a significant improvement in nutrient intakes and a nonsignificant improvement in body mass index (BMI) and waist-to-hip ratios ( Table 6). After NE, mean calcium intake of less than 800 mg (recommended dietary allowance) was seen in 47% (20 of 42), significantly less than before NE (71%, 30 of 42) and the control group (70%, 21 out of 30; P < .05). Similar patterns were seen for dietary intakes of vitamin C, vitamin D, and fiber (data not shown). | Table 6Nutritional and Anthropometric Data of Iranian Athletes With Physical Disabilities (N = 72) (Mean ± SD). |
Compared with the results of other recent surveys, 9,24–26 the APDs in our study displayed more knowledge about nutrition. However, analyzing the questions about calcium (items 17– 21), fiber (items 46, 47, and 70), and vitamin D (items 38 and 39) and topics related to energy and heart disease revealed multiple questions in which most of the APDs could not respond correctly. Although we expected APDs to correctly answer several quite simple questions related directly to health and nutrition, they failed to do so. This lack of knowledge becomes especially important when we note that most of our subjects were suffering from medical problems such as bone diseases (particularly those APDs who were taking anticonvulsant drugs due to war-related issues), constipation, and obesity (particularly in wheelchair users). For example, about 60% had a misconception about their body weight before NE, not realizing that they were overweight. The APDs failed to respond correctly to several questions regarding proteins. In fact, protein requirement was a debate among their coaches, which may explain the confusion in these areas. The protein intake of all APDs was almost 2 times higher than the recommended daily allowance requirement for athletes, and it was 4 times higher in power-lifting athletes. The high protein intake was accompanied by critically lower liquid intake. Athletes should be well hydrated before beginning exercise; they should also drink enough fluid during and after exercise to balance fluid losses. 27,28It is likely that the low intake of calcium, vitamin C, vitamin D, and fiber was due to lack of awareness about the recommended daily amounts and the number of servings necessary to achieve the benefits of these nutrients. Disabled individuals are already prone to vitamin D and calcium deficiency owing to their confined style of living, but consensus is lacking on recommended daily intakes of these nutrients for this population. No differences were seen between the knowledge for the athlete component plus the APD component and the general knowledge component, although APDs' scores for the athlete component plus the APD component were higher. Both areas related to nutrition for the athletes may need to be targeted in education, especially topics directly relevant to existing medical problems. Before NE, APDs in both groups obtained their nutritional information mostly from their coaches ( Table 4), with a significant shift to receiving information from a dietitian after NE in the intervention group. This finding is consistent with changes in APDs' attitudes about nutrition (open questions, Table 5) and especially their improved attitudes after NE regarding the necessity for different nutrition (question 84), special need for NE (question 85), and nutrition counseling for family members (question 86). Although coaches may have poor nutrition knowledge, 25 in our study, coaches' knowledge about various nutrition topics after NE could be interpreted as impressive. It seems that due to the special psychological and emotional relationships that exist between APDs and their coaches, it may be necessary to target team athletic trainers as a bridge between the medical and nutritional staffs and the athletes. Depending on the training regimen, athletes need to consume at least 50% but ideally 60% to 70% of their total calories from carbohydrates. The remaining calories should be obtained from protein (10% to 15%) and fat (20% to 30%). 29 It has been generally established that caloric intake should be increased in athletes. This attitude was dominant in coaches and APDs. The high BMI of APDs indicates that they may need modified caloric recommendations. Although our findings about higher BMI and waist-to-hip ratios were not surprising, such data are not usually available in the literature, particularly regarding the quality of life of people with increased health risks because of intra-abdominal fat accumulation reflected by a large waist circumference. 30According to the findings of Cotugna and Vickery, 11 67.8% of athletes with mental retardation were overweight or obese with the same BMI standards 21 that we applied. Of the males, 24.6% had a high-risk waist circumference; of females, 73.3%. 11 Before NE, only about one fourth (12 of 42, Table 3) of APDs in our intervention group classified their weight as above ideal. According to the National Institutes of Health, 21 about 60% of the APDs who considered themselves as having ideal body weight were, in fact, overweight, which is in agreement with the results of Cotugna and Vickery 11 on athletes with mental retardation. Quality of life may include many dimensions—psychological health being one example— and its association with overweight and fat distribution has been extensively studied. Negative attitudes toward overweight people, 31 peer pressure, and social discrimination put stress on those who are overweight. 32,33 In our study, being overweight was more pronounced in athletes who were wheelchair users (data not shown), the group that will be at increased health risks in later life, perhaps with less capacity or motivation to learn about healthy life and proper nutrition. So it is reasonable to target these groups while they are motivated. Although several countries have established reference ranges for the BMI of children 34 and adults, 35 and growth charts exist for certain groups of persons with disabilities, such as those with Down syndrome and cerebral palsy, 36 BMI standards have not been identified for most individuals with mental and physical disabilities. Energy overestimation because of wider wrist circumference and less activity due to wheelchair use may have contributed to the overweight situation. In our study, wider wrists were quite common in wheelchair users and in people with disabilities who use walking aids. With advancing age, people with disabilities will be more likely to develop serious limitations in performing basic daily activities. Thus, proper attention to calculating energy requirements and appropriate NE should be stressed in these athletes. The APDs appeared knowledgeable about starches, sugars, and body requirements for carbohydrates and replenishing muscle reserves after heavy training. Their protein intake was high and carbohydrate intake was reasonable, but oily foods, fats, and dairy products had been restricted, which had worsened their calcium intake status. Our results regarding lower fat intake in athletes are in accord with other studies. 9,37 However, as mentioned earlier, in our sample, APDs tended to eat more meat and other types of protein but not because of the fear of fat or concern with body appearance and weight issues as seen by Zawila et al. 9 Athletic trainers need to emphasize the roles of fat in the body. Food availability and food habits remained the top 2 reported themes even after NE. A total of 97.4% of the APDs stated that their food is usually prepared by a family member. However, statements such as “Even if I know about good choices, I am somewhat limited in my food selection,” were quite common in the qualitative analysis. Although nutritional knowledge and attitudes may have an effect on APDs' eating habits, offering NE to family members may also be important because disabled people are, most of the time, highly dependent on a family member or other caregivers to make food choices. Food choice decisions at the family level may lessen APDs' motivation to seek additional nutrition information. Zawila et al 9 and Barr 38 found that collegiate athletes who completed a nutrition course demonstrated greater nutritional knowledge than those who did not complete a nutrition course. Our study's data support this finding, suggesting that APDs may benefit from taking short nutrition courses. Zawila et al 9 and Barr 20 found a weak positive correlation between the athletes' reported number of nutritional information sources and nutritional knowledge. In the current study, we found a positive correlation between the same factors. Previous authors 7,9,20,38 disagree on whether collegiate athletes scored higher in general nutrition knowledge or in nutrition for the athlete. In our study, no differences between the knowledge for the athlete component plus the APD component and the general knowledge component were seen among the 3 groups. Higher scores on nutrition for the athlete may suggest an increased focus on knowledge related to the athlete without a foundation of general nutritional knowledge. 9 However, analysis of individual questions, as discussed previously, revealed specific areas in which APDs lack knowledge. A positive relationship between nutritional knowledge and attitudes in this study agrees with previous findings. 7,9After NE, coaches scored significantly lower than APDs. Higher scores by APDs after NE may indicate further interest and commitment. Endevelt et al 39 examined the knowledge and attitudes of gynecologists, pediatricians, and nurses who work in mother and child health clinics concerning infants' and pregnant women's nutrition and compared these findings to the public's general knowledge, noting that the mothers displayed higher levels of knowledge. However, the physicians showed a higher level of knowledge in the questions related to their specialties. Although a similar finding was seen in our study, in which coaches achieved significantly higher scores for the athlete component, registered dietitians or qualified sports nutrition professionals may complement the nutrition-related education and counseling of athletes. The nutritional questionnaire was a variation of 3 previous surveys by Zawila et al, 9 Barr, 20 and Werblow et al, 7 with additional questions developed by us. The questionnaire was pilot tested to establish construct validity, but the questionnaire cannot be declared reliable without test-retest analysis in other studies. We included the coaches as a third reference group in the sample. However, with only 10 coaches participating, statistical analysis was limited to the APDs and 1 comparison in terms of nutrition knowledge in coaches. The effect of a coach's knowledge on the athletes could not be exactly determined due to the small sample size. Consequently, the standard for “acceptable” nutritional knowledge could not be accurately defined. The control group had a higher score for nutrition knowledge and attitudes. In settings such as sport camps, it would be somewhat difficult to keep a control group completely blinded. Although the nutrition knowledge and attitude score of APDs in this study was moderate and reasonable, we recommend that the Iranian Federation of War-Disabled and Disabled Sports determine its coaches' nutrition knowledge and the nutrition knowledge needs of APDs in particular areas of practice. Further work is required to determine the validity and reliability of an Iranian knowledge instrument in other settings. The use of weight-making nutritional behaviors is of significant importance in APDs. Nutritional counseling at the family level is probably as important as training team coaches for APDs. Our findings suggest that Iranian APDs lack nutritional knowledge in areas critical to preventing nutrition-related health problems. Coaches and athletic trainers are knowledgeable about some appropriate nutritional recommendations, but registered dietitians or qualified sports nutrition professionals may complement the nutrition-related education and counseling of APDs. Because most of the APDs in our study did exhibit positive attitudes toward nutrition, they may benefit more from nutritional education presented by dietitians in collaboration with their coaches. We emphasize addressing all aspects of health and hygiene, but due to critically lower scores reflecting nutrition knowledge, it may be reasonable to focus more on this component in NE for APDs. SUGGESTIONS FOR FURTHER RESEARCH We assessed the nutritional knowledge and attitudes of Iranian APDs. Future researchers may include athletes with mental retardation. To assess the nutritional knowledge of broader Iranian populations, including healthy athletes, athletes with mental retardation, coaches, and athletic trainers, we suggest that authors use our modified nutritional knowledge and attitude questionnaire. We thank our committee members for their contributions to our research practicum at the Iranian Federation of War-Disabled and Disabled Sports; Parniyan Gholfam, MD, for assistance in conception of our research project, literature review, and data collection; and Mehrdad Shoa-Kazemi, MSc, for advice and assistance in the research process. We also thank our APDs and coaches for their time spent in completing the nutritional questionnaires. - Bergeron JW. Athletes with disabilities. Phys Med Rehabil Clin North Am. 1999;10:213–228.
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