Nutritional Supplement Use Among College Athletes and Their Sources of Information

104 International / Froiland, Journal Koszewski, of Sport Nutrition Hingst, and and Exercise Kopecky Metabolism, 2004, 14, 104-120 2004 Human Kinetics Publishers, Inc. Nutritional Supplement Use Among College Athletes and Their Sources of Information Kathryn Froiland, Wanda Koszewski, Joshua Hingst, and Lisa Kopecky A survey was conducted to examine the source of information and usage of nutritional supplements in 115 male and 88 female varsity athletes at a Division I university. The survey asked each athlete to define supplement, and report supplement use and type, source of information, and reasons for use. Supplement use frequencies were determined, and comparisons were made between gender and sport. Eighty-nine percent of the subjects had or were currently using nutritional supplements. Many athletes did not consider sports drinks and calorie replacement products as supplements. Females were more likely to take calcium and multivitamins, and males had significant intake for ginseng, amino acids, glutamine, hydroxy-methyl-buterate (HMB), weight gainers, whey protein, and Juven. The most frequently used supplements overall were energy drinks (73%), calorie replacement products of all types (61.4%), multivitamin (47.3%), creatine (37.2%), and vitamin C (32.4%). There was also significant supplement use noted per sport. Females were more likely to obtain information from family members regarding supplementation, and males from a store nutritionist, fellow athletes, friends, or a coach. Female athletes were more likely to take supplements for their health or because of an inadequate diet, while men reported taking supplements to improve speed and agility, strength and power, or for weight/muscle gain. Key Words: dietary supplements, sport, ergogenic aids, gender Introduction The expanding dietary supplement industry dramatically impacts athletes who are continually seeking a competitive edge. In 1999, Krumbach, Ellis, and Driskell (9) reported that almost 57% of collegiate athletes surveyed reported taking vitamin and mineral supplements. In addition to vitamins and minerals, athletes are experimenting with the latest supplemental trends such as creatine, hydroxy-methyl-butyrate (HMB), Ephedrine, and Androstendione. Massad et al. (12) reported that high school students are also using a wide variety of supplements such as fluid replacement drinks, multivitamins and minerals, The authors are with the Department of Nutritional Science and Dietetics at the University of Nebraska Lincoln, Lincoln, NE 68583-0806. 104

Supplement Information and Usage / 105 vitamin C, protein drinks, and carbohydrate loading drinks. Swirzinksi et al. (21) reported that 31% of high school football athletes surveyed were using supplements. The majority was taking creatine, but others were taking vitamin and mineral supplements, or weight gain products such as HMB and Mega Mass (21). Jacobson et al. (5) reported that 79% of male athletes and 65% of female athletes have indicated that they used some type of nutritional supplement during their college athletic career. Few other studies have surveyed usage of dietary supplements among advanced or collegiate athletes, who may be more prone to the use of nutritional supplements for a competitive edge. Learning more about the types and variety of supplements high school, collegiate, and elite athletes are using, sources of information and recommendations, as well as reasons athletes choose to use particular supplements would help to enable athletic personnel to properly educate and counsel. Most male collegiate athletes report taking supplements to improve athletic performance and build muscle, while female collegiate athletes report taking supplements because they were recommended by family members and to prevent illness (9, 10). Athletes have reported that they rely on themselves, family members, and friends for information and recommendations regarding supplements (9, 10). Unfortunately athletes seldom seek information from informed sources such as registered dietitians, strength coaches, athletic trainers, or physicians (9, 10). This leaves the competitive athlete vulnerable to misinformation and inappropriate recommendations, which may lead to health and performance problems or National Collegiate Athletic Association (NCAA) eligibility concerns. The objectives of this study were to (a) determine the prevalence of supplement use among athletes of all sports and genders at a NCAA Division I university, (b) determine the knowledge level athletes have about the supplements they take and their reasons for taking them, (c) determine where athletes receive information regarding supplements, and (d) identify trends or differences between genders, sport type, and metabolic category. Survey Development Methods The University of Nebraska s Institutional Review Board for the Protection of Human Subjects approved the study and questionnaire. The survey was made up of six parts: (a) definition of a supplement; (b) use of nutritional supplements, if and how often; (c) source of information and recommendation regarding use, and reasons for choosing to take a nutritional supplement; (d) supplement frequency of use, which was presented in categories (energy supplements, protein supplements/weight gainers, vitamin supplements, mineral supplements, herbals, and other supplements); (e) explanation for taking a supplement and what it does to enhance performance or improve health; and (f) demographics. The survey was reviewed by a certified athletic trainer, a registered dietitian, a licensed medical nutrition therapist who specializes in sports nutrition, an exercise physiologist, and several strength coaches. The survey was pre- and post-pilot tested (n = 15) for validity and reliability (Spearman rank correlation = 0.85), using collegiate athletes varying in gender, ethnicity, and sport, from institutions that would not be participating in the study.

106 / Froiland, Koszewski, Hingst, and Kopecky Figure 1 Frequency distribution for sports. Reflects the number of athletes from each sport who participated in the survey. Subjects and Statistical Analysis Athletes were 19 years of age and older. Twelve female and 9 male varsity sports were recruited. Sports surveyed were baseball, softball, women s (W) volleyball, men s and women s (M/W) tennis, football, wrestling, W bowling, M/W yell squad and dance team, M/W basketball, W soccer, M/W gymnastics, M/W golf, M/W track and field, W swimming and diving, and W rifle. For sport distribution, see Figure 1. Three hundred and seventy athletes were surveyed, and 207 responded (55.8%): 88 female, 115 male, and 4 gender unknown. At least one athlete responded from every sport. Subjects were Caucasian (66.7%, n = 138), African American (10%, n = 20), Asian (3%, n = 6), Hispanic (3%, n = 7), Native American (1.5%, n = 3), other (2.5%, n = 5), and unknown (14%, n = 28). Classification was evenly distributed among freshman, sophomores, juniors, and seniors and above. Athletes voluntarily completed the written questionnaire at team meetings or on an individual basis. Data were collected during October and November of 2001. Data were entered into the Windows-based SAS analysis STAT View program. Descriptive data were calculated as frequencies. Data were evaluated by gender and sport using chi-square (χ 2 ) analyses. Significance was determined at p <.05. For further analysis, sports were placed into four groups (A, B, C, and D) according to metabolic demand, based on information provided by the National Strength and Conditioning Association (9). Due to the small number of participants in category D, this group was excluded from chi-square analysis. See Table 1 for group descriptions and sport distribution.

Supplement Information and Usage / 107 Table 1 Sport Grouping According to Metabolic Demand Group Sports Metabolic demand A Basketball, yell, swimming and Sports that predominately rely on the diving, volleyball, gymnastics phosphagen system but also frequently use anaerobic glycolysis B Golf, tennis, baseball, softball Sports that almost solely rely on the phosphagen system C Track and field, football, Mix sports that rely on a combination wrestling, soccer of the phosphagen system, anaerobic glycolysis, and aerobic metabolism D Bowling and rifle Other did not categorize well with the above groups Results Definition of a Supplement Athletes were asked to write their own definition of a supplement. Thirty-four (34) percent responded with all or parts of the following: that a supplement is a product that helps to increase performance, strength, muscle, and enhance recovery. Other popular definitions included; a multivitamin, something that improves health or the body, additional nutrition added to the diet, pills, anything other than food, or something that helps you gain or lose weight. Frequency of Supplement Use Twenty-three percent of the athletes surveyed regularly (>5 times per week), 16% reported that they occasionally (2 4 times per week), and 22% seldom (<2 times per week) used a nutritional supplement. Thirty-nine percent reported that they were not currently using a nutritional supplement. However, many athletes did not consider calorie and fluid replacement products, such as Recovery Mix, Energy Mix, Personal Edge Bars, Boost, or Gatorade as nutritional supplements, because when asked if they were using these products, less than 6% reported that they never did. And 45.5% reported regularly, 34% reported occasionally, and 14.5% reported seldom using calorie replacement products. Twenty-three athletes (11%) reported that they had never, nor were currently, taking any form of a nutritional supplement. Supplements were categorized as energy supplements; protein supplements/ weight gainers, vitamin supplements, mineral supplements, herbals, and other supplements. Athletes could check all that applied under each category. Frequencies were determined for each category and for individual items within those categories. Eighty-six percent of the athletes reported using an energy-type supplement. Almost 73% of the athletes reported using energy drinks (Gatorade, Powerade, All

108 / Froiland, Koszewski, Hingst, and Kopecky Sport, Red Bull), and 61.4% reported using calorie replacement products that included drinks or powders (Boost- and Slim Fast-type products) and bars (Personal Edge- and Power Bar-type products). Additionally, 37.2% reported taking creatine. The most popular protein supplement/weight gainer was protein powders (21.7%). Almost 67% of athletes reported use of vitamins. Forty-seven percent (47.3%) reported taking a multivitamin, and 32.4% reported taking vitamin C. Other popular vitamin supplements were vitamin E (15%) and vitamin A or beta-carotene (10.1%). Twenty-six percent of surveyed athletes reported use of herbal supplements. Ginseng and echinacea were the most popular herbal supplements at 13% and 9.7%, respectively. Calcium (18.8%) and iron (10.6%) were the mineral supplements most frequently used, and 15 athletes (2 females and 13 males) reported using nicotine, which was listed under other supplements. Complete data, given as frequency percents, are presented in Table 2 by gender and in Table 3 by metabolic group categories. Two male athletes reported taking steroids, 5 males reported taking dehydroepiandrosterone (DHEA), and 10 males reported taking Androstendione. Six (1 female and 5 males) reported taking products containing Ma Huang (Ephedra); however, 7 different athletes self-listed products under fat-burners or other supplements that contain Ma Huang, such as Ripped Fuel. These data were combined to conclude that 13 (3 female and 10 male, 6.3%) athletes reported taking Ma Huang. Products that were self-listed under other energy supplements (5.3%) were Spark, Advocare POS 1, 2, 3, and 4, Calcium, Barley Green, Ripped Fuel, Hydroxycut, vitamins, cod liver oil pills, and conjugated linoleic acid (CLA). Products self-listed under other protein supplements (2.4%) were protein bars, lysine, and Advocare. Products that were listed under other herbal supplements (<2.0%) included synephrine, herbal lite, ginger root, homeopathic remedies, and apple cider vinegar. Listed under other supplements (<2.0%) were Advocare, fiber, and Procasa II. Specifically listed under type of fat burner (4.8%) were Fat Grabbers, Ma Huang, Hydroxy Cut, Ripped Fuel, Wt. 2001 G, Xenadrine, Metabolic, Shape, and 2 subjects reported unknown. Including past and present use, 5 athletes reported experience with 20 or more supplements, 18 reported experience with 11 19 supplements, and 27 reported experience with 6 10 supplements. Comparisons By Gender and Sport By supplement category, males were significantly (p <.05) more likely to use energy and protein supplements, and females were significantly (p <.05) more likely to use vitamins and minerals. Males were significantly (p <.05) more likely to use Ginseng, DHEA, androstendione, nicotine, energy drinks, calorie replacement products, creatine, pyruvate, amino acids, glutamine, HMB, weight gainers, whey protein, and Juven (Table 2). Multivitamin and calcium supplement usage was reportedly more significant (p <.05) to female athletes. Baseball players and wrestlers were significantly more (p <.05) likely to use calorie-replacement products (drinks, powders, or bars) and vitamin C than other athletes. Baseball and football athletes were significantly more (p <.0001) likely to use creatine. Wrestlers were significantly more (p <.05) likely to use caffeine,

Supplement Information and Usage / 109 Table 2 Dietary Supplement Usage By Division I Athletes and Comparison By Gender Total Female Male Supplement (%) (%) (%) p value Total energy 86.0 32.5 54.2 <.0001 Energy drinks 72.9 26.6 47.8.0002 Calorie replacement 61.4 20.2 41.9 <.0001 Creatine 37.2 3.4 34.5 <.0001 Caffeine 11.1 3.9 7.4 ns Other energy 5.3 2.0 3.4 ns Pyruvate 2.4 0.0 2.5.05 Total protein 48.3 8.4 40.9 <.0001 Protein powders 21.7 2.5 19.7.001 Whey protein 12.6 0.5 12.3 <.0001 Amino acids 11.6 0.5 1.3 <.0001 Weight gainers 10.6 0.5 10.3.0001 Glutamine 9.7 1.0 8.9.002 HMB 7.7 0.5 7.4.002 CIB 6.8 2.9 3.9 ns Soy protein 6.3 1.4 3.9 ns Metr-X 5.8 0.8 5.05 Juven 5.8 0.0 5.9.002 Arginine 2.9 0.0 2.9 ns Other protein 2.4 1.0 2.4 ns Total vitamins 66.7 34.0 32.5.002 Multivitamin 47.3 26.1 21.7.002 Vitamin C 32.4 14.8 18.2 ns Vitamin E 15 5.9 9.4 ns Beta carotene/vit A 10.1 1.0 2 ns Vitamin D 8.2 4.9 3.4 ns Vitamin B-12 5.3 1.0 4.4 ns B-complex 4.8 2.5 2.5 ns Folic acid 3.9 1.5 1.5 ns Vitamin B-6 3.9 1.5 2.5 ns Niacin 3.9 1.5 2.5 ns Total herbals 26.5 10.3 16.7 ns Ginseng 13.0 3.4 9.9.05 Echinacea 9.7 5.4 4.4 ns Ginkgo, biloba 3.9 1.0 3 ns St. John s wort 3.4 1.0 2.5 ns MaHuang 6.3 1.5 4.9 ns (continued)

110 / Froiland, Koszewski, Hingst, and Kopecky Table 2 (continued) Total Female Male Supplement (%) (%) (%) p value Total minerals 39.1 21.2 18.2.02 Calcium 18.8 12.3 6.9.004 Iron 10.6 8.4 2.5.007 Zinc 7.7 3.9 3.9 ns Potassium 4.8 1.5 3.4 ns Total other 27.5 7.9 20.2.05 Nicotine 7.2 1.0 6.4 ns Androstendione 4.8 0.0 4.9.005 Fat burner 4.8 1.0 3.4 ns Glucosomine 3.9 0.5 3.4 ns DHEA 2.4 0.0 2.5.05 Caffeine/aspirin 2.4 1.5 1 ns Note. Subjects could check all that applied. Significance: p <.05; ns: nonsignificant. HMB: Hydroxy-methyl-buterate; CIB: Carnation Instant Breakfast; Beta carotene/vit A: beta carotene and vitamin A; B-complex: a multivitamin containing only the B vitamins; DHEA: dehydroepiandrosterone. Total n was 207, and gender n was 203. Less than 2.0% reported taking MCT oils, ATP, branched chain amino acids, biotin, pantothenic acid, vitamin K, green tea, wheat grass, other herbals, herbal mix, saw palmeto, yohimbe, garlic, L-carnitine, melatonin, diuretics, steroids, oxygenated water, glycerol, magnesium, phosphorus, selenium, chromium picolinate, copper, other minerals. There were no responses to vanadium, sodium bicarbonate, boron, and aspartic acid. caffeine mixed with aspirin, and amino acids. Football athletes were significantly more (p <.05) likely to use HMB, Juven, zinc, glucosamine, and DHEA. Division by metabolic demand showed that group C used more glutamine, HMB, Juven, multivitamins, and combined caffeine and aspirin (p <.05). Group B reported significantly more (p <.05) nicotine use than other groups. Considering supplement categories, group C was significantly more likely to use energy and protein supplements (p <.05). Source of Nutrition Information Subjects could select as many information sources as applied. The majority of athletes reported that they obtained information regarding supplements from family members (32.4%), fellow athletes (31.9%), their strength coach (28.0%), athletic trainer (30.0%), registered dietitian (28.5%), friend (28.5%), and coach (28.0%) (Table 4). Less than 10% reported using a pharmacist or professional athlete, or television, radio, or the Internet as a source of information regarding supplements.

Supplement Information and Usage / 111 Table 3 Dietary Supplement Usage Comparison By Metabolic Demand A B C Supplement (%) (%) (%) p value Total energy 29.0 22.7 33.8.0003 Energy drinks 24.3 19.3 30.2 ns Calorie replacement 19.3 18.8 24.8 ns Creatine 9.9 10.4 17.8 ns Caffeine 2.0 2.5 6.9 ns Other energy 1.5 1.0 3.0 ns Pyruvate 0.0 0.5 2.0 ns Total protein 14.0 13.5 20.8.05 Protein powders 5.9 7.4 8.9 ns Whey protein 3.0 4.5 5.4 ns Amino acids 2.0 3.5 6.4 ns Weight gainers 2.5 4.5 4.0 ns Glutamine 1.0 1.0 7.9.0004 HMB 1.0 0.5 6.4.002 CIB 2.0 1.5 3.5 ns Soy protein 1.5 1.0 4.0 ns Metr-X 2.5 1.0 2.5 ns Juven 1.0 0.5 4.5 ns Arginine 0.0 0.5 2.5 ns Other protein 1.0 0.5 1.0 ns Total vitamins 22.2 15.5 26.5 ns Multivitamin 17.3 8.4 20.8.05 Vitamin C 8.4 9.4 14.4 ns Vitamin E 4.5 4.5 6.4 ns Beta carotene/vit A 1.0 1.0 1.0 ns Vitamin D 1.5 2.5 4.5 ns Vitamin B-12 0.5 2.0 3.0 ns B-complex 2.5 1.5 1.0 ns Folic acid 1.0 1.0 2.0 ns Vitamin B-6 1.0 1.0 2.0 ns Niacin 0.5 1.5 2.0 ns Total herbals 8.2 5.3 12.6 ns Ginseng 4.5 3.0 5.9 ns Echinacea 4.5 2.0 3.5 ns Ginkgo, biloba 1.5 1.0 1.5 ns St. John s wort 1.5 0.5 1.5 ns MaHuang 1.9 1.0 3.4 ns (continued)

112 / Froiland, Koszewski, Hingst, and Kopecky Table 3 (continued) A B C Supplement (%) (%) (%) p value Total minerals 11.6 7.7 18.8 ns Calcium 5.4 3.5 9.4 ns Iron 4.5 2.5 3.5 ns Zinc 2.5 1.0 4.5 ns Potassium 1.5 1.0 2.5 ns Total other 7.7 8.2 11.6 ns Nicotine 1.5 4.0 2.0.05 Androstendione 1.0 0.5 3.5 ns Fat burner 1.0 1.0 2.5 ns Glucosomine 0.0 1.0 3.0 ns DHEA 0.0 0.0 2.5.04 Caffeine/aspirin 0.0 0.5 1.5.03 Note. Subjects could check all that applied. Significance: p <.05; ns: nonsignificant. CIB: Carnation Instant Breakfast; HMB: hydroxy-methyl-buterate; B-complex: a multivitamin containing only the B vitamins; Beta carotene/vit A: beta carotene and vitamin A; DHEA: dehydroepiandrosterone.groups A, B, and C are defined in Table 1. Total N for groups A, B, and C was 202. Males were significantly more (p <.05) likely to obtain information or recommendations from a store nutritionist, fellow athletes, friends, coach, television, or a magazine. Female athletes were significantly more (p <.05) likely to obtain information or recommendations from family members. Comparison by sport showed that wrestlers were significantly more (p <.0005) likely to obtain information from their coach. Division by metabolic demands showed that group C was significantly more (p <.05) likely to use professional athletes or television as a source of information or recommendation (Table 4). Reasons for Taking Supplements The reasons the athletes gave for taking supplements are given in Table 5; athletes could select all and any area that applied to them. Over 40% of the athletes reported that they took supplements for their health (43.5%), to improve strength and power (42.5%), to increase energy (42.5%), or for weight or muscle gain (41.5%). Female athletes were significantly (p <.05) more likely to take supplements because of an inadequate diet or for their health. Males were significantly more (p <.05) likely to take supplements to improve speed and agility, strength and power, or for weight/ muscle gain. When divided into metabolic demand groups, group C was significantly more (p <.05) likely to take supplements to improve speed and agility, and for weight/muscle gain.

Supplement Information and Usage / 113 Table 4 Source of Dietary Supplement Information Total Female Male A B C Reason (%) (%) (%) p value (%) (%) (%) p value For my health 43.5 17.2 26.6 <.0001 15.3 8.4 19.3 ns Strength/power 42.5 37.9 5.4 <.0001 9.9 12.9 20.8.003 Increase energy 42.5 16.2 27.1 ns 13.4 10.4 18.8 ns Weight/ muscle gain 41.5 36.9 4.9 <.0001 10.4 14.4 17.8.02 Prevent injury/illness 28.5 14.7 14.2 ns 8.9 6.9 12.4 ns Speed/agility 25.1 22.7 3.0 <.0001 5.4 5.4 14.9.005 I felt I needed to 18.4 6.4 12.0 ns 6.4 3.0 8.9 ns Inadequate diet 17.9 6.4 11.3 <.0001 8.9 3.0 5.4.07 Weight/ fat loss 17.4 5.4 12.3 ns 5.9 3.5 7.9 ns Help heal injury/illness 16.4 6.8 9.8 ns 5.4 2.5 8.4 ns It makes me feel better 14.5 4.9 9.8 ns 5.0 3.0 6.9 ns Note. Subjects could check all that applied. Significance: p <.05; ns = nonsignificant. Groups A, B, and C defined in Table 1. Total n = 207; gender n = 203; n for groups A, B, and C = 202.

114 / Froiland, Koszewski, Hingst, and Kopecky Table 5 Reason for Taking Supplements Total Female Male A B C Reason (%) (%) (%) p value (%) (%) (%) p value For my health 43.5 17.2 26.6 <.0001 15.3 8.4 19.3 ns Strength/power 42.5 37.9 5.4 <.0001 9.9 12.9 20.8.003 Increase energy 42.5 16.2 27.1 ns 13.4 10.4 18.8 ns Weight/ muscle gain 41.5 36.9 4.9 <.0001 10.4 14.4 17.8.02 Prevent injury/illness 28.5 14.7 14.2 ns 8.9 6.9 12.4 ns Speed/agility 25.1 22.7 3.0 <.0001 5.4 5.4 14.9.005 I felt I needed to 18.4 6.4 12.0 ns 6.4 3.0 8.9 ns Inadequate diet 17.9 6.4 11.3 <.0001 8.9 3.0 5.4.07 Weight/ fat loss 17.4 5.4 12.3 ns 5.9 3.5 7.9 ns Help heal injury/illness 16.4 6.8 9.8 ns 5.4 2.5 8.4 ns It makes me feel better 14.5 4.9 9.8 ns 5.0 3.0 6.9 ns Note. Subjects could check all that applied. Significance: p <.05; ns: nonsignificant. Groups A, B, and C defined in Table 1. Total n = 207; gender n = 203; n for groups A, B, and C = 202.

Supplement Information and Usage / 115 Explanation for Supplement Use Surveyed athletes were asked to write in reasons for choosing the supplements that they took. Self-written reasons for taking creatine included: for muscle or weight gain, energy to lift more weight thereby leading to increased strength and power, to become bigger-faster-stronger, to flush nutrients into the muscle, and to help burn fat. Athletes reported taking calcium supplements for bone health, lactose intolerance, and low dietary calcium intake. Echinacea and vitamins E and C were used to enhance the immune system and to prevent illness. Reasons for multivitamin use included, for health and immune system, low dietary intake, energy, registered dietitian s recommendation, or habit from childhood. Caffeine use was for energy, alertness, and weight loss. Fat burners were used to reduce body fat, speed up metabolism, energy, and to control calorie intake. Reported reasons for use of energy drinks were fluid replacement, thirst quencher, and for energy during practice. Use of recovery mix, calorie replacement products, or protein shakes was to replace missed meals, increase energy, replenish nutrients after workouts, weight gain, increased performance, and recovery and muscle repair. Reasons for taking glutamine, HMB, or Juven was to enhance athletic ability or for faster recovery. Steroids and androstendione were used to boost testosterone levels and increase energy, strength, and size. Seventy-five athletes (36%) did not respond to this particular question. Discussion The definition of a dietary supplement, according to the 1994 Dietary Supplement Health and Education Act (2), is a product taken orally that contains a dietary ingredient intended to supplement the diet. The dietary ingredients may include: vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glandular, and metabolites. They can also be extracts or concentrates. Dietary supplements may be found in many forms such as tablets, capsules, softgels, gelcaps, liquids, or powders. They can also be in other forms, such as a bar (2). Ergogenic aids are defined as substances and procedures believed to improve physical work capacity, physiologic function, or athletic performance (13). Thirty-four (34) percent of the athletes surveyed in the present study defined a dietary supplement as a product that helps to increase performance, strength, muscle, and enhance recovery. Other frequently reported definitions included simply a multivitamin or pills, something that improves health or the body, anything other than food, or something that helps you gain or lose weight. In addition, 39% of the athletes reported that they were not currently using a nutritional supplement. However, less than 6% reported that they never used Recovery Mix, Energy Mix, Boost, or Gatorade, which they had relatively unlimited access to on a daily basis because it was provided by the athletic department. This demonstrates that almost one third (33%) of athletes surveyed did not consider fluid and calorie replacement products as dietary supplements. It is evident that many athletes do not have a clear or complete understanding of what qualifies as a dietary supplement. Regarding education and supplements, Jacobson et al. (5) found that only 37% of athletes surveyed correctly identified the appropriate function of vitamins, and that 30.3% thought that vitamins provided a direct source of energy. Parr et al.

116 / Froiland, Koszewski, Hingst, and Kopecky (15) concluded that those who are competitively active in sports have been found to be uneducated regarding proper nutrition. Twenty-three athletes (11%) reported that they never took, nor were currently taking, any form of nutritional supplements. This leaves 89% that were currently or previously taking nutritional supplements. Kruskall and Johnson (10) reported that 52% of female athletes surveyed and 63% of male athletes used at least 1 supplement. Jonnalgadda (6) found that 42% of Division I freshman football players reported use of some form of a dietary supplement. Jacobson et al. (5) reported that 79% of men and 65% of women indicated that they had used nutritional supplements during their college athletic career. And in the current study, including past and present use, almost 25% of the athletes surveyed reported experience with 6 or more supplements. The variety of supplements taken by subjects in the present study is generally similar to what has been reported in previous studies. Seventy-three percent of the athletes reported using energy drinks, 61.4% reported using calorie replacement products that would include drinks, bars, and powders, and 47.3% reported taking a multivitamin. The use of multivitamins by athletes is nothing new; in 1999, Krumbach et al. (9) found that 56.7% of athletes reported taking a multivitamin supplement, which was higher than the 47% found in a 1997 review by Sobal and Marquart (20). In contrast, Jonnalgadda (6) found that only 23% of collegiate freshman football players used vitamins, and Jacobson et al. (5) found that only 18.9% of college varsity athletes used vitamin and mineral supplements. In the current study, we found that women were significantly more likely to use a multivitamin supplement than men, which is supported by Krumbach et al. (9) and Jacobson et al. (5). And though there is high use of multivitamins within the athletic population, Weight et al. (22) found that 3 months of vitamin and mineral supplementation exerted no ergogenic effects. They had no discernible effect on the measured physiological variables, including maximal oxygen consumption, blood lactate turning point, or peak treadmill running speed (22). Creatine is another popular supplement and has been the topic of several studies much beyond what is mentioned here (6, 10, 11, 17, and 19). Jonnalagadda et al. (6) reports that 36% of freshman collegiate football players were using creatine, and LaBotz et al. (11) similarly reported that 28% of athletes were using creatine. The present study found that 37.2% of athletes had or were currently taking creatine. However, it should be taken into consideration that before August 2000, creatine was provided to many athletes by the university s athletic department. Kruskall and Johnson (10) found that men most commonly used protein, creatine, and multivitamins. In the present study, male athletes were similarly significant compared to females, for creatine and protein products, such as weight gainers and whey protein, but also energy drinks and calorie replacement products. LaBotz et al. (11) also found that male athletes were significantly more likely than female athletes to use creatine. Awareness and use of creatine is also significant for males when compared to females at the high school level, where it was also concluded that use of creatine increases with age and grade (17). In addition, Smith and Dahm (19) reported that creatine users were more likely to use other supplements. Kruskall and Johnson (10) and Jacobson et al. (5) found that energy bars or shakes (calorie replacement products) were most popular with women. Similar to Krumbach et al. (9), we found that female athletes were more likely to take calcium,

Supplement Information and Usage / 117 which is reflective of advice given by the registered dietitians on the athletic department staff regarding bone health and the lack of calcium in many of the female athlete s diets. Two females and 13 males reported using nicotine, which is not considered a dietary supplement (2), but was included because some athletes use it in cigarette and smokeless form to help maintain or lose weight. Group B was significant for nicotine use, but this most likely reflects the use that was reported by the baseball athletes who participated in the study. Regarding the use of banned substances, 2 male athletes reported the use of steroids, 10 males and 3 females reported use of Ma Huang (Ephedra) containing products, 5 males reported use of DHEA and 10 males reported use of androstendione. These products are found on the NCAA list of banned substances (14). This means a 14.5% self-reported use of banned substances. It must be considered that some athletes may have chosen not to report use out of fear of being caught using a banned substance. Many steroid users start as adolescents (1). In fact, Ray et al. (17) reported an 11% use of steroids in high school athletes, as well as androstendione, and Scott et al. (18) reported that 4.5% of male and 0.8% of female high school athletes were using steroids. Interestingly, only 6 athletes directly reported using ephedra; however, several others self-listed products that would contain ephedra under fatburners or other-supplements. These were combined to determine total use (6.3%). This may indicate that the athletes using these fat-burners or other supplements were unaware that they were taking products that contained Ma Huang. Interestingly, Jonnalagadda et al. (6) found that 48% of freshman Division I college football players reported that they were not aware of the NCAA banned and restricted substances. The most popular source of information regarding nutritional supplements was family members (32.4%) and then fellow athletes (31.9%). Other frequently checked sources were strength coach, athletic trainer, registered dietitian, friend, and coach. Krumbach et al. (9) reported that athletes most frequently listed self (40.6%), then nutritionist/dietitian (32.1%), and then family member or friend (31.1%). Hoefer and Silagyi-Rebovich (3) found that parents and physicians were the most influential and that parental use of supplements was related to the athlete s use. Jacobson et al. (5) found that the strength coach was the most popular, followed by athletic trainer, university classes, coach, and family (5.5%). Where Jacobson and Gemmell (4) indicated that magazines were the primary source of information, the previously mentioned studies found that magazines were not a significant source (3, 5, 9). Division I baseball and football players from Juhn et al. (7) reported that their primary source of information was their strength and conditioning coach (94%), and the present study showed that wrestlers were more likely than any other athlete to receive information from their coach. Dietitians/nutritionists were most frequently consulted by the athletes in Krumbach et al. (9) (32.1%), and the current study (28.5%), followed by Jacobson et al. at 10%. Kruskall and Johnson (10) reported that no men and only 1 female athlete referred to a dietitian, and Juhn et al. (7) similarly reported that only 1 athlete referred to a dietitian for information. In this study and Krumbach et al. (9), the athletic department provided a dietitian specializing in sports nutrition at no charge to the athletes and athletic department staff. There was no dietitian readily available to the athletes involved in the Kruskall and Johnson study, and the status of an

118 / Froiland, Koszewski, Hingst, and Kopecky athletic department dietitian is unknown in the other studies and unlikely at the high school level. This leads to the conclusion that if a qualified dietitian/nutritionist is available to athletes, they will consult them for information but, if not readily available, athletes will not seek them out. It is quite evident that the supporting staffs of an athletic program, and the family and peers of the athletes themselves, play an important role in providing information to athletes regarding nutritional supplements, which is supported by Sobal and Marquart (20). It is also evident that resources for information may change from high school to college (17, 19, 21). The question is: How accurate is the information they are providing? Jacobson and Gemmel (4) and Jacobson et al. (5) report that, by accredited certification standards, most athletic trainers and strength and conditioning coordinators have some nutrition training; however, most coaches, parents, and friends have no such training, depending on profession and education. The primary reasons for taking supplements given by the athletes in the present study were for their health, to improve strength and power, to increase energy, or for weight or muscle gain. Similar responses were reported by Hoefer and Silagyi-Rebovich (3), Kruskall and Johnson (10), and Sobal and Marquart (20). Female athletes were more likely to report using supplements because of an inadequate diet or for their health, and males were more likely to respond with speed and agility, weight gain, or strength and power; these responses were reflected in the findings of Kruskall and Johnson (10). It is evident that female and male athletes are, in general, making choices for different reasons but which, in the end, hopefully lead to enhanced performance. In their review of literature, Sobal and Marquart (20) found that there is variation in supplement use between types of sports when considering only the use of vitamins and minerals. Both Sobal and Marquart (20) and Krumbach et al. (9) observed that basketball players took less vitamin and mineral supplements than other athletes. Jacobson et al. (5) found that creatine use was significant for baseball and football athletes, which the current results reflect. Those athletes participating in contact sports such as football, wrestling, and boxing were significantly more likely to use supplements in general, as well as supplements specifically designed for anabolic purposes (12). Group C was significant for use of glutamine, HMB, Juven, and multivitamins. Significant use of multivitamins for this group may be attributed to that fact that both the football and wrestling programs provided their athletes with a daily multivitamin. Athletes are clearly using a wide variety of supplements to fuel the competitive edge, and they are relying on the people around them, particularly athletic program support staff, for information and recommendations. The advice given by these staff members clearly has an effect on the choices the athlete makes regarding supplementation. Family members contribute greatly to the source of information regarding supplementation in the current study and others (3, 9, 10). It may be that parents are worried about the athletic success of their children or simply their health; they may also find that something works for them (vitamins or herbals in particular) and recommend it to their child to help battle the physical stress of athletic training. Not all athletic programs currently have the funding to support the addition of a full time registered dietitian to their program; however, it is imperative that the athletes have reliable sources of information to turn to, particularly to counterbalance the many misconceptions found in the various forms of advertisements.

Supplement Information and Usage / 119 Registered dietitians working with athletes, athletic trainers, strength coaches, and coaches must be able and willing to provide accurate and appropriate information regarding the wide array of supplements being utilized by collegiate athletes. Accurate and appropriate information provided by athletic staff may also influence the information and advice regarding nutritional supplements that is frequently transferred from friend to friend or between teammates. References 1. Blue, J.G., and J.A. Lombardo. Steroids and steroid-like compounds. Clinics in Sports Med. 18:666-689, 1999. 2. Dietary Supplement Health and Education Act of 1994. Pub L No. 103-417, 108 Stat 4325. 3. Hoefer, B.A., and J. Silagyi-Rebovich. Nutrition supplementation use among college athletes in soccer, track, and field events. J. Amer. Diet. Assoc. (Abstract). 101(S):A-85, 2001. 4. Jacobson, B.H., and H.A. Gemmell. Nutrition information sources of college varsity athletes. J. Appl. Sport Sci. Res. 5:204-207, 1991. 5. Jacobson, B.H., C. Sobonya, and J. Ransone. Nutrition practices and knowledge of college varsity athletes: a follow-up. J. Strength Cond. Res. 15:63-68, 2001. 6. Jonnalagadda, S.S., C.A. Rosenbloom, and R. Skinner. Dietary practices, attitudes, and physiological status of collegiate freshman football players; J. Strength Cond. Res.15:507-513, 2001. 7. Juhn, M.S., J.W. O Kane, and D.M. Vinci. Oral creatine supplementation in male collegiate athletes: a survey of dosing habits and side effects. J. Am. Diet. Assoc. 99:593-594, 1999. 8. Kraemer, W.J. Physiological adaptations to resistance and aerobic endurance training programs. In The Essentials of Strength and Conditioning, Beahles, T.R. and R.W. Earle (Eds.). National Strength and Conditioning Association:USA, 2000, pp.142. 9. Krumbach, C.J., D.R. Ellis, and J.A. Driskell. A report of vitamin and mineral supplement use among university athletes in a Division I Institution. Int. J. Sport Nutr. 9:416-425, 1999. 10. Kruskall, L.J. and L.J. Johnson. Perceived benefits, sources of information, and patterns of current and past supplement usage reported by male and female collegiate athletes. J. Am. Diet. Assoc. (Abstract). 101(S):A-45, 2001. 11. LaBotz, M., and B.W. Smith. Creatine supplement use in an NCAA Division I athletic program. Clin. J. Sport Med. 9:167-169, 1999. 12. Massad, S.J., N.W. Shier, D.M. Koceja, and N.T. Ellis. High school athletes and nutritional supplements: a study of knowledge and use. Int. J. Sport Nutr. 5:232-245, 1995. 13. McArdle, W.D., F.I. Katch, and V.L. Katch. Sports and Exercise Nutrition. Baltimore; Lippincott Williams and Wilkins, 1999. 14. National Collegiate Athletic Association. 2001-02 NCAA banned-drug classes. <http:// www.ncaa.org/sports_sciences/drugtesting/banned_list.html#3>. 2001 15. Parr, R.B., M.A. Porter, and S.C. Hodgson. Nutrition knowledge and practice of coaches, trainers, and athletes. Physician Sports Med. 12:127-138, 1984. 16. Perko, M.A., J. Cowdery, and M.Q. Wang. Associations between academic performance of Division I college athletes and their perceptions of the effects of anabolic steroids. Percep. Mot. Skills. 80:284-286, 1995.

120 / Froiland, Koszewski, Hingst, and Kopecky 17. Ray, T.R., J.C. Eck, L.A. Covington, R.B. Murphy, R. Williams, and J. Knudtson. Use of oral creatine as an ergogenic aid for increased sports performance: perceptions of adolescent athletes. Southern Medical Journal. 94:608-612, 2001. 18. Scott, D.M., J.C. Wagner, and T.W. Barlow. Anabolic steroid use among adolescents in Nebraska schools. Am J. Health Syst. Pharm. 53:2068-2072, 1996. 19. Smith, J., and D.L. Dahm. Creatine use among a select population of high school athletes. Mayo Clin Proc. 75:1257-1263, 2000. 20. Sobal, J., and L.F. Marquart. Vitamin/mineral supplement use among athletes: A review of literature. Int. J. Sport Nutr. 4:320-334, 1994. 21. Swirzinski, L., R.W. Latin, K. Berg, and A. Grandjean. A survey of sport nutrition supplements in high school football players. J. Strength Cond. Res. 14:464-469, 2000. 22. Weight L.M., K.H. Myburgh, and T.D. Noakes. Vitamin and mineral supplementation: effect on the running performance of trained athletes. Am. J. Clin. Nutr. 47:192-195, 1988.