Athletes’ and Coaches’ Perceptions of Nutritional Advice: Eating More Food for Health and Performance

ackground: Low energy availability results in physiological adaptations which contribute to unfavourable health outcomes. Little information exists on perceptions of nutritional advice to eat more food to maintain health and enhance performance. The aim of this study was to explore athletes' and coaches' perceptions towards advice to athletes to eat larger than their current quantities of food and to explore how nutritionists could deliver this advice. Methods: Semi-structured interviews (~20 min in length) were conducted using online communication technology, audio-recorded, and transcribed verbatim. The interview explored perceptions of the nutritional advice provided, its role in health and performance, and the challenges to eating larger amounts of food. Data were analysed using NVIVO 1.2 using an inductive thematic approach. Results: Nine elite athletes (female = 6; males = 3) and nine high-performance coaches (female = 3; male = 6) completed the semi-structured interviews. Athletes reported improved training consistency, fewer injuries

nutritional advice provided, its role in health and performance, and the challenges to eating larger amounts of food. Data were analysed using NVIVO 1.2 using an inductive thematic approach. Results: Nine elite athletes (female = 6; males = 3) and nine high-performance coaches (female = 3; male = 6) completed the semi-structured interviews. Athletes reported improved training consistency, fewer injuries and illnesses, and improved resilience when consuming adequate energy and nutrients to meet their needs. Lack of time and meal preparation dif culties were the main challenges faced to fuelling. Conclusions: Although education about under-fuelling is important, motivating, enabling, and supporting athletes to change behaviour is pivotal to increasing athlete self-awareness and to make long-term nutritional changes. Keywords:low energy availability; health; challenges; bene ts 1. Introduction Having suf cient energy available (energy availability, EA) for basic physiological functions can positively in uence health and performance [1–3]. In 2014, relative energy de ciency in sport (RED-S) was described by the International Olympic Committee (IOC). RED-S refers to low EA (LEA) and can occur in both male and female athletes [3]. LEA is de ned as having insuf cient energy for normal physiological function after the energy cost of exercise has been removed [1]. LEA/RED-S may have unfavourable health effects on body systems as well as negatively impacting on athletic performance [4–6]. Hence, it is vital to optimise both short- and long-term nutrition strategies to reduce risk of injury and illness, and to improve training adaptation and performance [3]. Adequate energy intake is essential for maintaining normal reproductive function and bone health [6,7]. LEA can arise from disordered eating behaviours, clinical eating disorders, the timing of training con icting with eating opportunities, or lack of educa- tion [2]. Independently or in combination, these can make taking suf cient energy to meet training and performance demands dif cult to achieve on a daily basis [8–10]. Fur- thermore, external pressures (body image, and family/sport culture) from others (family, Nutrients2021,13, 1925.

these can make taking suf cient energy to meet training and performance demands dif cult to achieve on a daily basis [8–10]. Fur- thermore, external pressures (body image, and family/sport culture) from others (family, Nutrients2021,13, 1925.

Nutrients2021,13, 1925 2 of 11 coaches, and fellow athletes) can be a contributory factor for LEA/RED-S. On the other hand, coaches and other sports professionals can positively in uence athlete wellbeing by reinforcing the message around fuelling and by facilitating regular screening for risk of LEA using an appropriate tool, for example, the Low Energy Availability in Females Questionnaire (LEAF-Q) in females [11]. Although LEA risk has been investigated in elite male cyclists [12], no agreed screening tool for males exists and the development of such a tool is warranted. To the best of our knowledge, there are no data available on the perceptions of athletes and their coaches towards advice to consume more energy to support health and train- ing/performance demands. The purpose of this study, therefore, was to explore athletes' and coaches' perceptions towards advice to eat more food to fuel health and performance as well as the challenges that athletes face in following this advice. A secondary aim of the study was to explore how nutritionists could deliver this advice to achieve greater impact. 2. Materials and Methods 2.1. Participants In order to determine the viability of the interview questions for use with athletes and coaches, interviews were conducted with two coaches who were not included in the nal project. Two questions were removed following this pilot as feedback from the two coaches was that the time taken to complete the interview needed to be reduced. The questions removed did not substantially impact on the information to be collected. The nal semi- structured interview included the following categories: (1) background information and participant characteristics; (2) bene ts and challenges of adequate fuelling; (3) application and delivery of message on fuelling; and (4) gaps in education. Using email, iers and video calls, elite athletes and high-performance coaches were invited to complete the semi- structured interview online during June and July 2020. Sporting organisations under the auspices of the Irish national sports governing organisation, Sport Ireland, were contacted and asked to inform athletes and coaches of the study. Participant inclusion criteria were as follows: (1) being advised to consume

iers and video calls, elite athletes and high-performance coaches were invited to complete the semi- structured interview online during June and July 2020. Sporting organisations under the auspices of the Irish national sports governing organisation, Sport Ireland, were contacted and asked to inform athletes and coaches of the study. Participant inclusion criteria were as follows: (1) being advised to consume more calories by performance nutritionist (athlete); and (2) working with athletes who were advised to consume more calories (coach). The interviewer (DL) was available by email to clarify any questions from participants about the interviews. The study was approved by the Human Research Ethics Committee of University College Dublin (LS-20-36-Corish). All subjects provided informed consent online before completing the interview. 2.2. Procedure All interviews were conducted by a research nutritionist (DL) using Zoom (Zoom Video Communications, California, USA) as a result of COVID-19 social-distancing re- quirements and were audio-recorded. Interviews lasted approximately 20 min. A semi- structured topic guide with open-ended questions designed to create discussion on topics relevant to the study was used. Prior to the interview, information was collected on: (1) participant demographics; (2) type of sport/coaching; (3) number of hours spent exercis- ing/coaching per week; (4) perceptions about increasing calorie consumption (i.e., under- standing, feelings, and advantages/disadvantages of eating more); and (5) behavioural change (i.e., how the advice has been perceived over time, what supports athletes/coaches need to implement recommended dietary changes, and advice for sports practitioners working with athletes at risk of LEA). 2.3. Data Analysis All interviews were transcribed using Rev (Rev transcription company, 2010, Austin, TX, USA), then analysed using NVivo 1.2 (QSR International, London, England). An inductive thematic analysis procedure was applied to the data to identify common themes. Transcripts were read repeatedly by a second author, L.M., who was blinded to the partici- pants, and initial trends within the data generated. Both D.L. and L.M. independently and

Nutrients2021,13, 1925 3 of 11 systematically coded the transcripts, and then discussed the codes to verify their applica- tion to the data. Overarching themes and sub-themes were identi ed, and quotations were extracted to illustrate typical views. 3. Results 3.1. Participant Characteristics Nine elite athletes (female = 6; male = 3) and nine high-performance coaches (female = 3; male = 6) completed the semi-structured interviews. All participants were engaged in sport at an elite level and had access to nutrition services through Sport Ireland Institute (Tables ). The mean number of hours athletes spent training each week was 27 ( 7). The mean number of hours coaching per week was 16 ( 10). The mean athlete age was 26 ( 3) years. Table 1.Athlete participant characteristics. Sports Elite Level Athletes (n) Age (Years) Training (Hours) Competition Level Athletics 1 30 18 International Boxing 1 23 20 International Judo 1 30 25 International Modern pentathlon 2 26–29 30 International Rowing 4 22–26 16–40 International Table 2.Coach participant characteristics. Sports Coaches (n) Coaching (Hours) Coaching Level Athletics 3 5–8 International Cricket 1 15 International Cycling 1 20 International Rowing 1 30 International Swimming 3 10–30 International 3.2. Bene ts and Challenges of Adequate Fuelling The sub-themes and representative quotes associated with the bene ts and challenges of adequate fuelling are presented in Table. 3.2.1. Bene ts Six coaches and two athletes identi ed an improvement in the consistency of training resulting in better performance as a major bene t of fuelling adequately. Participant 12 described how adequate fuel allows for consistency in training: “The big one is energy. With swimming, it's a huge load within a week. It's a lot of training, even at a club level. And I'm coaching teenagers, they do anywhere of up to 14 h, excluding gym work. So actually, they could do up to 16, 17 h training a week. So for me, it's just that they're able to give as much as they can at each session” (Participant 12—Coach). Four athletes and three coaches perceived that they had better immune function and were able to avoid

do anywhere of up to 14 h, excluding gym work. So actually, they could do up to 16, 17 h training a week. So for me, it's just that they're able to give as much as they can at each session” (Participant 12—Coach). Four athletes and three coaches perceived that they had better immune function and were able to avoid recurrent injuries/illnesses as another bene t of fuelling for performance: “Now I felt like, once I got my head around, I was way better, had way more energy. My mood was better. I was in better form. My immune system was much better. I wasn't getting sick as much. Yeah. It all had a huge impact obviously then on my performance as well. It was really good” (Participant 15—Athlete).

Nutrients2021,13, 1925 4 of 11 Table 3.Theme: The bene ts and challenges of adequate fuelling. Sub-Theme Representative Quotes Bene ts Energy “Energy, yes. De nitely being able to nish out the session at a high level, rather than nose-diving halfway through the session” (Participant 6—Athlete). “There is a lot more quality coming from each session. I wasn't going through the motions as much. It was more quality and focused, I guess, during each session. You just have the energy available” (Participant 18—Athlete). Consistency and better recovery “So, just kind of overall health being better and just getting more consistency out of training” (Participant 13—Athlete). “Having athletes who are healthy to train everyday consistently, is for me, the biggest bene cial part of this” (Participant 5—Coach). Overall health and performance “One of the key things we always try to get across to our athletes, is if you're not available to train due to illness or sickness then it doesn't matter if you're strong as an ox in the gym” (Participant 2—Coach). “I think a big part is that you don't end up getting little niggles and injuries. Because that kind of comes from when you're tired or whatever, and then it has a knock-on effect. So, overall health being better and just getting more consistent in training” (Participant 13—Athlete). Challenges Timing and preparation of food around training “Actual time to eat enough can be very dif cult, particularly for runners because the mechanical motion of running can make it uncomfortable to eat anywhere close to training. The windows to get food into the athlete are fairly small post training. If an athlete is running twice a day, the window is then reduced to this block just before training. It's dif cult to eat. And then if that's combined with a work or study schedule, that means there's not much time between training and in everyday life, that can be really dif cult” (Participant 1—Coach). “Huge challenge, trying to just even get the quantity into me and also food preparation was really dif cult” (Participant 14—Athlete). Budget “Cost for sure, yeah. That

to eat. And then if that's combined with a work or study schedule, that means there's not much time between training and in everyday life, that can be really dif cult” (Participant 1—Coach). “Huge challenge, trying to just even get the quantity into me and also food preparation was really dif cult” (Participant 14—Athlete). Budget “Cost for sure, yeah. That is de nitely a thing, because if you're eating well and healthy and you're trying to get adequate amounts in. There is a cost aspect to that. Good ingredients are going to be obviously more expensive than cheap food, and I think that cost element, depending on where the athlete is at, depending on what level of funds they have available to them” (Participant 9—Coach). “Obviously cost then as well. Your budget goes up as well because you're buying more and more food. And you want to get good quality food as well. So that's another factor” (Participant 15—Athlete). Volume of food “Just the volume, de nitely. It's a huge volume of food. Timing it. Yeah, the timing and the volume” (Participant 6—Athlete). Risk of weight gain “It can be tricky on the weight side. Because when people commit to that new way of eating, sometimes they can put weight on before they lose it, and it gets complex then at that point as to how they need to stick with it longer term. Because it is a change that you see bene t from in the more medium to longer term, it's not an overnight thing” (Participant 9—Coach). Participant 9 emphasised the importance of maintaining optimal health for consistent training and performance: “Health is the primary one. If someone is consistently falling ill, that's a big issue, and it will often manifest through upper respiratory type infections. Athletes present what may be cold or u-like symptoms, or just general getting stale, not progressing their training. They might just reach a bit of a brick wall before they can move on. With some others, there can be underlying health issues as well when it comes to bone density, bone health”

will often manifest through upper respiratory type infections. Athletes present what may be cold or u-like symptoms, or just general getting stale, not progressing their training. They might just reach a bit of a brick wall before they can move on. With some others, there can be underlying health issues as well when it comes to bone density, bone health” (Participant 9—Coach). Furthermore, a number of athletes reported having more energy available which improved training quality and resilience at training camps:

Nutrients2021,13, 1925 5 of 11 “Just my recovery, which is really nice. From then, I could feel the massively positive impact that had; my resilience on training camps” (Participant 3—Athlete). 3.2.2. Challenges Five coaches and ve athletes acknowledged that the main challenges to adequate fuelling were time management around training and food preparation in this study: “Time is a huge thing. I work 20 h a week in the school, but it's going to training, going to work, coming home. And that's for four or ve days in a week. It's driving all over the place. So timing is a huge thing. I have to be super prepared. If I'm not, I fall off the wagon. For me, the day before, I'd have to have everything prepared. The dinner is the only thing I'd prepare when I come in. You never get to relax, because all you're doing is cooking and eating and training and moving. And that is quite dif cult” (Participant 15—Athlete). The nancial burden and the volume of food required were identi ed as challenges to eating adequately to support training demands by coaches and athletes: “But I think us not having the capacity or budget in terms of providing meals, I think that is a barrier. Whether people like to admit it or not. Because you can say all the right things and provide athletes with all the right information but if they have to stop in a garage and get a sandwich or a wrap or whatever, you're still going to have a percentage of the time where they're not going to make the right choice” (Participant 2—Coach). “It's just very dif cult to eat that quantity of food. Even when I did the pre-prepared meals, but if I got one of those big ones that was like 900 calories, I'd have to eat half of it and then come back to half of it a little bit afterwards. It's just dif cult to eat a large quantity. And my stomach didn't feel that great eating a huge, huge amount” (Participant 14—Athlete). The participants also

meals, but if I got one of those big ones that was like 900 calories, I'd have to eat half of it and then come back to half of it a little bit afterwards. It's just dif cult to eat a large quantity. And my stomach didn't feel that great eating a huge, huge amount” (Participant 14—Athlete). The participants also identified the risk of gaining weight as a challenge to eating adequately: “I think I was just paranoid about gaining weight. It was my main thing that I struggled with. And even I weighed myself and I got heavier, but I thought I looked a lot leaner. I think I was a bit scared because I didn't think I needed to eat more. I thought that I was eating a lot and I was worried that I had put on weight” (Participant 10—Athlete). 3.3. Delivery and Application of Message The sub-themes and representative quotes associated with the delivery and application of nutrition-related advice are presented in Table. The athletes and coaches recognised that enabling and supporting athletes with clear and speci c messages to change behaviour is pivotal to increase athlete self-awareness and to make long-term nutrition-related changes. Participant 11 echoed that a speci c and prescriptive message on adequate fuelling for health and performance is warranted: “I'm not saying it has to be completely and utterly prescriptive, but I think sometimes when they're asked to eat more, they don't always know what that looks like. A little more explanation into how that might look and an actual visual would help and a little bit more prescription into what it is they need to put in their mouth” (Participant 11—Coach). Relating the advice on fuelling to athlete performance was also considered a key element in terms of athlete “buy-in”: “Always trying to bring it back to performance and wellbeing for me was creating myself being (a) more robust athlete. So, if you are more robust and you are healthier, you miss less training. And that comes from eating more. Eating less is just going to have the opposite effect. You

This study explores athletes' and coaches' perceptions of nutritional advice regarding increased food intake for health and performance.