ATHLETE KNOWLEDGE AND USE OF POST-EXERCISE REHYDRATION DRINKS A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Joshua Gregoire Research Advisor, Dr. Robert Kane California, Pennsylvania 2011 ii iii ACKNOWLEDGEMENTS I would like to thank my committee members, Dr. Robert Kane, EdD, PT, ATC, Chris T. Harman, EdD, ATC, and Thomas F. West, PhD, ATC, for all of their assistance in the various aspects involved in this research. I would also like to thank Nancy Groh, EdD LAT, ATC for her help in formulating the early parts of this thesis. Lastly, I would like to thank Dan Tarara, MS, ATC, LAT for his unwavering support in helping me from the time I was a junior in undergraduate up until the present. I would not have done this thesis if not for your help in selecting this topic for your class my junior year. iv TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . . ii AKNOWLEDGEMENTS . . . . . . . . . . . . . . . . iii TABLE OF CONTENTS LIST OF TABLES INTRODUCTION METHODS . . . . . . . . . . . . . . . iv . . . . . . . . . . . . . . . . vii . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . 5 Research Design Subjects . . . . . . . . . . . . . . . 5 . . . . . . . . . . . . . . . . . . 6 Preliminary Research . . . . . . . . . . . . . 6 Instruments . . . . . . . . . . . . . . . . . 7 Procedure . . . . . . . . . . . . . . . . . . 8 Hypotheses. . . . . . . . . . . . . . . . . . 8 Data Analysis RESULTS . . . . . . . . . . . . . . . . 9 . . . . . . . . . . . . . . . . . . . 10 Demographic Information Hypothesis Testing . . . . . . . . . . . . 10 . . . . . . . . . . . . . . 11 Additional Findings . . . . . . . . . . . . . . 15 DISCUSSION . . . . . . . . . . . . . . . . . . 17 Discussion Results . . . . . . . . . . . . . . 17 Conclusions . . . . . . . . . . . . . . . . . 24 Recommendations . . . . . . . . . . . . . . . 26 v REFERENCES . . . . . . . . . . . . . . . . . . 27 APPENDICES . . . . . . . . . . . . . . . . . . 29 APPENDIX A: Review of Literature . . . . . . . . . 30 Benefits of Post-exercise Rehydration Drinks . . . . 32 Dehydration. . . . . . . . . . . . . . . . 32 Starting Exercise Hypohydrated . . . . . . . 34 Returning to Fluid Balance . . . . . . . . . 34 Nutritional Needs of Athletes . . . . . . . . . 35 Nutrients in Sweat . . . . . . . . . . . . . 36 Current Post -Exercise Rehydration Drinks Fluid-Replacement Drinks . . . . . . . . . . 37 Carbohydrate -Protein drinks Milk . . . 37 . . . . . . . . . 38 . . . . . . . . . . . . . . . . . . . 39 Research Trials of Current Rehyd ration Drinks . 39 Athlete Knowledge Summary . . . . . . . . . . . . . . 47 . . . . . . . . . . . . . . . . . . . 48 APPENDIX B: The Problem . . . . . . . . . . . . . 49 Statement of the Problem . . . . . . . . . . . 50 Definition of Terms . . . . . . . . . . . . . . 50 Basic Assumptions . . . . . . . . . . . . . . . 51 Limitations of the Study . . . . . . . . . . . . 51 Significance of the Study. . . . . . . . . . . . 52 APPENDIX C: Additional Methods . . . . . . . . . . 53 IRB: California University of Pennsylvania (C1) . . . 54 vi Cover Letter to Participant (C2) . . . . . . . . . 66 Cover Letter to Athletic Director(C3) . . . . . . . 68 Response Letter from Athletic Director (C4) . . . . 70 High Point University Liaison Letter (C5) . . . . . 72 Survey (C6) . . . . . . . . . . . . . . . . . 74 REFERENCES . . . . . . . . . . . . . . . . . . 86 ABSTRACT . . . . . . . . . . . . . . . . . . 91 vii LIST OF TABLES Table Title Page 1 Participants per Team . . . . . . . . . 11 2 Age of Participants . . . . . . . . . . 11 3 One-Way ANOVA between Knowledge Score and Sport Played. . . . . . . . . . . . 12 4 T-Test Between Drink Knowledge and Gender . 13 5 Chi-Square Comparison of PERD Usage and Sport . . . . . . . . . . . . . . 13 6 Chi-Square Comparing PERD Usage and Gender. 14 7 Times Per Week PERD is Consumed. . . . . . 15 8 Types of PERD Used 9 Post-Exercise Rehydration Drink Category. . 16 10 Post-Exercise Rehydration Use by Team . . . 18 11 Dehydration’s Impact on Performance. . . . 21 12 Which of these does NOT dehydrate you . . . . . . . . . . 15 faster? . . . . . . . . . . . . . . . 21 13 Water is NOT Effective PERD . . . . . . . 22 14 What is considered an electrolyte? . . . . 22 15 Questions Answered Correctly >90.0%. . . . 23 1 INTRODUCTION It is imperative for athletes to rehydrate as efficiently as possible after strenuous exercise. Many athletes participate in multiple practices per day; some of these practices are spaced within three hours of each other. Due to energy demands, the proper rehydration drink is critical when athletes need to recover for another session. There has been a plethora of research done in recent years, which aim to test the efficiency of recovery utilizing many types of drinks. Since the creation of fluid replacement drinks, they have been the standard for all athletes; however, the post-exercise rehydration market is burgeoning. Currently, post-exercise rehydration drinks include: carbohydrate-electrolyte replacement drinks (fluid replacement), carbohydrate-protein replacement, milk, and even pickle juice. Before attempting to evaluate athlete knowledge concerning these drinks, it is important to establish a base of knowledge from which clinicians can draw answers. Due to their inclusion in every study of rehydration drinks, it can be concluded that fluid replacement drinks are among the first choices of rehydration drinks. Fluid- 2 replacement drinks typically consist of: 0g fat, 0g protein, 15g carbohydrate, 115mg sodium, and 31mg potassium.1,2 The electrolytes contained in fluid replacement drinks have led to it being called a better post-exercise rehydration drink than plain water.1 As a result, many companies have created rehydration drinks (ie. Gatorade, Powerade, Vitamin Water, FRS, etc…). Most drinks, however, contain a near identical chemical make-up. As a result, preferences for taste and school affiliation will often determine what is consumed. Recently, fluid replacement drink companies have churned out new “additive” products for their drinks. These are packets of nutrient powders that can be added to any drink. Used in climates of intense heat, these are becoming more commonplace as they gain widespread acceptance. The electrolytes often added are Sodium, Potassium, Calcium, and Magnesium. The theory behind these new additives is that simple fluid replacement drinks may not always be enough to fulfill hydration needs. Due to athletic demands, new rehydration drinks are always being produced. One newer type of drink is a carbohydrate-protein drink. These drinks have a very different nutrient makeup than fluid-replacement drinks: 4g protein, 1g fat, 16g carbohydrate, 127mg sodium, and 16mg 3 potassium per serving. However, clinical trials have shown no increased effects (muscle protein synthesis, strength gains, cycle time to exhaustion, etc…) over fluidreplacement drinks.2 The ideology behind infusing protein into these drinks is to increase muscle recovery after exercise. The typical protein type found in these drinks is whey protein. Support for this theory has been provided by research.3 In one clinical trial, weight-lifters had an increase in muscle protein uptake at a higher level with 10g whey protein and 21g carbohydrate than a drink with carbohydrate only. The positive protein balance observed among the participants in the whey protein group was hypothesized to lead to greater hypertrophy and, in effect, strength gains. Recently, milk has entered the discussion of postexercise rehydration drinks. The reason for this is that milk contains all the nutrients thought to be important in a post-exercise rehydration drink.4 Milk can be processed and altered in many different ways. For example, there is whole milk, 2% milk, skim milk, chocolate milk, strawberry milk, and soy milk; all of these contain different nutrients. In a direct comparison, chocolate 2% milk appears to show the greatest benefit to athletes.3 The nutrient makeup of typical chocolate 2% milk is: 8g 4 protein, 5g fat, 27g carbohydrate, 159mg sodium, 446mg potassium. However, the reasons for the positive results have not been thoroughly studied. Common theories accounting for this include: slower digestion of proteins, increased circulation of fatty acids within the blood, less urine production post-exercise, and increased amount of protein.2-5 While researching post-exercise rehydration drinks, it is important not to lose sight of the main objective: general health of the athlete. Athletes need to be educated on basic nutrition concepts and rehydration drinks so they may make informed decisions on what they are ingesting. While numerous studies have examined athlete knowledge concerning basic nutrition, none have examined knowledge solely based on rehydration.7-12 Therefore; there is a gap in knowledge that needs to be explored. Athletes must be tested on knowledge and usage of post-exercise rehydration drinks. This study will attempt to answer the following questions: 1) What do athletes know about post-exercise rehydration and 2) Does post-exercise rehydration drink consumption and knowledge vary between gender and sport? 5 METHODS The primary purpose of this study is to: review current literature on post-exercise rehydration drinks, test athlete knowledge of post exercise rehydration drinks, and evaluate the usage of post exercise rehydration drinks. The following section will include the following subsections: research design, subjects, instruments, procedures, hypotheses, and data analysis. Research Design This research is a descriptive research design. The independent variables will be: gender, division of institute, and sport played. The dependent variables will be the knowledge score as measured by the number of questions answered correctly in that section of the survey and the type of drink used. The knowledge score will be a numerical value ranging from 0 to 19, 19 being a perfect score. 6 Subjects The subjects that will be used for this study will be volunteer male and female athletes from California University of Pennsylvania and High Point University. All athletes 18 years of age and older at these institutions will be provided the opportunity to participate. The study will be approved by the Institutional Review Board at California University of Pennsylvania (Appendix C1) prior to any data collection. The cover letter to the athlete (Appendix C2) and survey (Appendix C6) will be distributed electronically. Each participant’s identity will remain confidential and will not be included in the study. Preliminary Research The survey was created by the primary researcher in consultation with thesis committee members. After review by the committee, a pilot study of the survey was given to a random group of athletes in order to determine reliability. 7 Instruments The survey (Appendix C6) was created and distributed using Survey Monkey. The survey consisted of demographic questions and a knowledge assessment section. Questions were created using established rehydration protocols from the American College of Sports Medicine and National Athletic Trainers’ Association. The survey was broken up into three sections: demographic information, use of postexercise rehydration, and athlete knowledge. If athletes do not regularly consume a post-exercise rehydration drink, defined as a drink consumed within an hour of physical activity in order to aid in recovery, they will skip the section dealing with use of post-exercise rehydration drinks and proceed from demographic information to knowledge. The knowledge questions were developed by the researcher. All questions include answers which are backed by empirical evidence. The questions test knowledge in the following areas: nutrients in sweat, nutrients considered electrolytes, types of post-exercise rehydration drinks, dehydration, and fluid-replacement protocols. 8 Procedure The athletic director at each institution will be emailed a cover page outlining the research. They will then be asked to return a letter of permission to use their school’s athletes as test subjects. Following approval by the California University of Pennsylvania’s Institutional Review Board, the athletic director will be forwarded an email which will contain a cover letter and link to the survey, created on www.surveymonkey.com. A follow-up email will be sent out with four days remaining of data collection. Hypotheses The following hypotheses were based on previous research and the researcher’s intuition based on a review of the literature: Hypothesis 1: Post-exercise rehydration drink knowledge will vary significantly based on sport. Hypothesis 2: Post-exercise rehydration drink knowledge will not vary based on gender. Hypothesis 3: Post-exercise rehydration drink usage will vary significantly between sports. 9 Hypothesis 4: Post-exercise rehydration drink usage will differ significantly between genders. Data Analysis All data will be analyzed by PASW Statistics 18 for Windows at an alpha level of 0.05. An ANOVA was used to test post-exercise rehydration drink knowledge and sport. A chi-square was used to test: post-exercise rehydration drink usage and sport, post-exercise rehydration drink usage and gender. A T-Test was used to test post-exercise rehydration drink knowledge and gender. 10 RESULTS The purpose of this study was to review the literature of post-exercise rehydration drinks and determine athlete knowledge and use of post-exercise rehydration drinks. The following section contains the data collected through the study and is divided into three subsections: Demographic Information, Hypotheses Testing, and Additional Findings. Demographic Information The participants were collegiate athletes at High Point University (n = 41) and California University of Pennsylvania (n = 58). Out of the 109 returned surveys, 99 were usable for data collection. Of the 99, there were 29 males and 70 females. The breakdown of respondents for each sport is indicated in Table 1. Ages of the participants ranged from 18 to 23 (Table 2). 11 Table 1. Participants per Team Sport Frequency Volleyball 5 Tennis 3 Golf 9 Soccer 20 Swimming 12 Track and Field 33 Cross Country 17 Total 99 Table 2. Age of Participants Age Frequency 18 16 19 32 20 25 21 17 22 8 23 1 Total 99 Percentage 5.1 3.0 9.1 20.2 12.1 33.3 17.2 100 Percentage 16.2 32.3 25.3 17.2 8.1 1.00 100.0 Hypothesis Testing The following hypotheses were tested in this study. All hypotheses were tested with a level of significance set at α ≤ 0.05. An ANOVA was used to test for differences between post-exercise rehydration drink knowledge and sport. A chi-square was used to test for a relationship between post-exercise rehydration drink usage and sport as well as post-exercise rehydration drink usage and gender. A T-test was used to test for a significant difference in 12 post-exercise rehydration drink knowledge depending upon gender. Hypothesis 1: Post-exercise rehydration drink knowledge will vary significantly based on sport. Conclusion: A one-way ANOVA was used to compare knowledge score means and sport, no significant difference was found (F(6,92) = 1.934, p > .05), shown below in Table 3.The overall mean score for all participants was MEAN (SD). Table 3. One-Way ANOVA between Knowledge Score and Sport Played Variables Sum of df Mean F P Squares Square Between Groups 47.568 6 7.928 1.934 .084 Within Groups 377.180 92 4.100 Total 424.747 98 Hypothesis 2: Post-exercise rehydration drink knowledge will not vary based on gender. Conclusion: Findings supported the hypothesis as no significance difference between drink knowledge and gender. An independent-samples T-test was calculated comparing the mean score on the knowledge based portion of the study and the gender of the participant. No significant difference was found (t(29) = .268, p > .05). The mean of the males (m 13 = 14.14, sd = 2.133) was not significantly different from the mean of the females (m = 14.01, sd = 2.075), as shown in Table 4. Table 4. T-Test between Drink Knowledge and Gender Gender N Mean Standard Standard t P Deviation Error Mean Male 29 14.14 2.133 .396 .268 .790 Female 70 14.01 2.075 .248 Hypothesis 3: Post-exercise rehydration drink usage will vary significantly between sports. Conclusion: Participants usage of post-exercise rehydration drinks by sport can be found in Table 10. A chi-square test of independence was calculated comparing post-exercise rehydration drink usage and sport played; no significant relationship was found (X2(6) = 7.786, p >.05), as shown in Table 5. Table 5. Chi-square Comparison of PERD Usage and Sport Variable N df Chi-square value Sig Sport and PERD 99 6 7.786 .254 Usage Hypothesis 4: Post-exercise rehydration drink usage 14 will differ significantly between genders. Conclusion: Rehydration drink usage by gender can be found in Table 6. Findings did not support the hypothesis as no significance difference between drink knowledge and gender. A chi-square test of independence was calculated comparing gender and PERD use, (X2(1) = .357, p >.05), as shown in Table 6. Table 6. Chi-Square Comparing PERD Usage and Gender Variable N df Chi-square value Gender and PERD 99 1 .357 Usage Sig .567 15 Additional Findings Additional tests were conducted to determine PERD usage. Of the 99 surveyed, 82 reported they consumed a PERD. Usage amount is shown in Table 7. Table 7. Times Per Week PERD is Consumed Days Per Week Frequency Percentage 1 10 12.2 2 6 7.3 3 19 23.2 4 11 13.4 5 17 20.7 6 19 23.2 Total 82 100.0 When asked what they consumed for a PERD, ten types were reported, as seen in Table 8. The most commonly used drink was water, followed by Gatorade and chocolate milk Table 8. Types of PERDs Used Type Frequency Gatorade 37 Powerade 20 Accelerade 1 Muscle Milk 8 Chocolate Milk 36 Water 61 Propel 1 Protein Shake 2 GENr8 1 16 It is interesting to note water came in as the number one drink when it is not considered a PERD. This will be discussed in the discussion section. The responses can be divided into four categories, as shown in Table 9. Table 9. Post-Exercise Rehydration Drink Category Type Frequency Fluid-replacement 58 Carbohydrate-protein 12 Water 61 Milk 36 Total 167 17 DISCUSSION The purpose of this study was to determine athlete knowledge and use of post-exercise rehydration drinks. It is hoped that these findings will help guide athletic trainers as they provide nutritional counseling and advice to their patients. The following section is divided into three subsections: Discussion of Results, Conclusions, and Recommendations. Discussion of Results The primary purpose of this study was two-pronged: to evaluate the effect of several factors on athlete knowledge of post-exercise rehydration drinks and to determine if athletes consumed a post-exercise rehydration drink. Based on the review of literature, the researcher concluded that usage would differ between sports; however, no significance difference in PERD usage was found between sports. This could be due to a number of factors. A possibility for the findings could be due to the sports that returned the survey. The amount of PERD usage by team is shown in Table 10. 18 Table 10. Post-Exercise Rehydration Use by Team Team Number Yes (%) Number No (%) Total (%) Volleyball 5 (100%) 0 (0%) 5 (100.0%) Tennis 1 (33.3%) 2 (66%.7%) 3 (100.0%) Golf 8 (88.9%) 1 (11.1%) 9 (100.0%) Soccer 16 (80.0%) 4 (20.0%) 20 (100.0%) Swimming 11 (91.7%) 1 (8.3%) 12 (100.0%) Track & Field 28 (84.8%) 5 (15.2%) 33 (100.0%) Cross Country 13 (76.5%) 4 (23.5%) 17 (100.0%) Total 82 (82.8%) 17 (17.2%) 99 (100.0%) As the table shows, volleyball reported the highest amount of PERD usage, 100.0%, while tennis reported the lowest, 33.3%. The results show a trend toward using PERDs as all teams except tennis reported higher than 50% usage. Had there been more respondents in volleyball or tennis, significant differences may have been found. While no significant differences were found between teams and knowledge score, interesting trends were noticed. The highest individual score was a 19, or perfect, belonging to a cross country athlete. The lowest score was a 9 which belonged to both a tennis and swimming athlete. The lowest overall team score belonged to tennis (m = 19 12.00, sd = 2.648), while the highest was cross country (m = 15.18, sd = 2.215). Interestingly, the second lowest score was volleyball (m = 12.80, sd = 2.168) who also reported the highest amount of PERD usage. While it is important to note the two lowest scores also had the lowest responses, it can be inferred that PERD usage is not dependent on knowledge. The researcher also hypothesized that usage would differ between gender. Rationale for this was based on prior research which indicated males used protein drinks and other muscle enhancing products more than females.8,13,14 While both studies found dietary supplement use to be similar, it was thought that only protein drink use would be a strong predictor for PERD use. Research has found significant differences in knowledge between genders when testing overall nutritional knowledge.9 In the study, females scored higher on areas dealing with vitamins, minerals, and health related disorders. When it came to protein and carbohydrates for strength gains, however, males scored higher than females. As a result the researcher hypothesized that nutritional knowledge would not have significant difference between genders. Support for this was found as there was no significant difference. Interestingly, males scored higher 20 (though not significantly) than females, (m = 14.14, sd = 2.133) and (m = 14.01, sd = 2.075), respectively. These findings are not consistent with other research.9,11 Reasons for this could be due to this survey only looking at PERD knowledge and not overall health knowledge. To this researcher’s knowledge, post-exercise rehydration drink knowledge has not been studied across multiple sports. When hypothesizing that PERD knowledge would have significant difference between sports, studies using general nutrition knowledge was used.9 Support for this argument was not found as there were no significant differences between sport played and knowledge score. Possible explanations for this are: the sports who returned surveys were not varied enough (all focusing on aerobic exercises rather than anaerobic activity) or that nutritional knowledge does not translate well to PERD knowledge. While team means for knowledge score were all above 50%, some questions were answered incorrectly more than 50% of the time. The question answered correctly the least was question 7. Question 7 asked, “At what percent body weight loss does dehydration START to impact performance, A) 1-2% B) 3-4%, C) 5-6%, D) 7-8%, E) Greater than 8%”? The correct 21 answer, 1-2%, was selected 30.3% of the time, as shown in Table 11. Table 11. Dehydration’s Impact on Performance Choice Frequency Percentage 1-2% 30 30.3 3-4% 33 33.3 5-6% 18 18.2 7-8% 13 13.1 >8% 5 5.1 Total 99 100.0 It is unclear why the second choice, 3-4%, was selected more often than the correct choice, 1-2%. Another question participants scored poorly on was question 13. Question 13 asked, “Which of these does NOT dehydrate you faster than normal, A) Caffeine B) Alcohol C) Ephedra D) Sugar”? The correct answer, sugar, was selected only 39.4%, as seen Table 12. Table 12. Which of these does NOT dehydrate you faster? Choice Frequency Percentage Caffeine 6 6.1 Alcohol 7 7.1 Ephedra 47 47.5 Sugar 39 39.4 Total 99 100.0 These results are interesting in that they show a lack of nutritional knowledge among athletes. A reason for this could be due to the negative press ephedra has garnered. It 22 is possible that athletes assumed ephedra was the answer because it is illegal in sports. Whatever the reason, it shows a lack of knowledge by the participants. When asked if water was an effective PERD, participants reported it was at a rate of 67.7%, as shown in Table 13. Table 13. Water is NOT an Effective PERD. Answer Frequency Percentage True 20 20.2 False 67 67.7 I don’t know 12 12.1 Total 82 100.0 Recently, it has been reported that water alone is not enough for athletes to get back into positive fluid balance and may lead to further dehydration by decreasing blood osmolality.1,16,17 Participants also had trouble selecting the correct electrolyte out of four possibilities, as shown in Table 14. Table 14. What is considered an electrolyte? Nutrient Frequency Percentage Calcium 40 40.4 Hydrogen 24 24.2 Oxygen 13 13.1 Lithium 22 22.2 Total 99 100.0 23 The correct answer, calcium, was answered correctly just 40.4% of the time (n = 40). This shows a lack in both general nutrition and PERD knowledge. While the aforementioned questions showed a lack of PERD knowledge, there were some which were answered correctly almost universally. Only one question was answered correctly 100.0% of the time, question 14. Question 14 was, “If I am not thirsty, I shouldn’t drink anything, A) True, B) False, C) I don’t know”. All participants answered false. This is an important finding as it shows the athlete’s awareness of needing to regularly consume fluids while exercising. Four other questions yielded a correct response rate greater than 90.0%, questions 4, 5, 10 and 12, shown in Table 15. Table 15. Questions Question Question 4 Question 5 Question 10 Question 12 Answered Correctly >90.0% Frequency of Yes Percentage of Yes 94 94.9 96 97.0 97 98.0 98 99.0 a. Question 4, “Which of these is NOT a symptom of heat illness?” b. Question 5, “When should a PERD drink be consumed after exercise?” c. Question 10, What determines if a drink is a good PERD?” d. Question 12, “Everyone sweats at the same rate.” 24 Conclusions While certain questions showed a lack in athlete knowledge concerning PERDs, it was encouraging to see all teams and gender scoring above 50%, in fact, the lowest team score was a 63% (Tennis) while the highest was an 80% (Cross country). This study did not find significant differences between knowledge and gender or knowledge and sport. Furthermore, no significant differences were found between PERD use and gender or PERD use and sport played. This research is important for athletic trainers specifically for a number of reasons. With the high percentage of athletes using PERDs, it is important for athletic trainers to keep up-to-date on PERD information. Athletic trainers see athletes more than dieticians, doctors, and most other medical professionals. Therefore, they are in the optimal position to educate athletes as to their needs and the effect PERDs can have. This provides an opportunity to be the focal point toward helping athletes stay hydrated, reducing the risk of heat illness. Athletic trainers are also at most, if not all, practices for their assigned sports. This is most important during the summer when the heat index climbs and athletes are at a greater risk for heat illness. Athletic trainers up-to-date with 25 current PRED research will be able to better serve their athletes as to what to drink, when to drink, and why to drink, possibly saving lives every year. Also of note, particularly for an athletic trainer is that many athletes considered water to be an effective PERD. With this logic, if athletic trainers are not conscientious, athletes may be drinking only water while exercising in hot climates. This causes a problem due to water lowering sodium levels in the body, causing more harm than good.17 Athletes need to know: what they should be drinking, the proper amount to drink and the right time to drink the rehydration drink. As mentioned, athletic trainers are in the best position to help athletes with these decisions. This study provides a basis for which other research can draw upon. The results of this research are a benefit to the medical community in that it shows athletes are consuming PERDs at a high rate, (82%). However, the data also shows that athletes consider water to be an effective PERD; as more evidence points to the contrary, it is important to make sure the athletes know this. 26 Recommendations While athletes continue to consume PERDs, more research should be performed to discern what is the optimal PERD as well as how to pass that knowledge onto the athletes. One possibility to help in this effort would be a study comparing the effectiveness of the top five PERDs used by athletes today on anaerobic and aerobic capacity. Athletes could be divided up into two groups, aerobic or anaerobic based activities. Those groups can then have subgroups of: control, fluid-replacement, carbohydrate-protein replacement, 2% chocolate milk. A 12-week clinical study could then be undertaken to ascertain which drink provides the most benefit for each group of athletes. This study showed that while athletes have a general sense of PERDs, their knowledge is still limited. A study should be conducted to assess the optimal way to distribute information to athletes. A pre-test survey could be administered to a group of athletes. After which, they could be put into one of several groups that distribute knowledge a different way (brochure, meeting, podcast, etc…). A month later, a post-test would be administered to see which group scores better post-test. 27 REFERENCES 1. Casa D, Hillman S. National Athletic Trainers' Association Position Statement: Fluid Replacement for Athletes. J Athl Training. April 2000;35(2):212. 2. Watson P, Love T, Maughan R, Shirreffs S. A comparison of the effects of milk and a carbohydrate-electrolyte drink on the restoration of fluid balance and exercise capacity in a hot, humid environment. Eur J Appl Physiol. November 2008;104(4):633-642. 3. Roy BD. Milk: the new sports drink? a review. J Int Soc Sports Nutr. 2008 Oct 2;5:15. 4. Karp J, Johnston J, Tecklenburg S, Mickleborough T, Fly A, Stager J. Chocolate Milk as a Post-Exercise Recovery Aid. Int J Sports Nutr. February 2006;16(1):78-91. 5. Tang J, Manolakos J, Kujbida G, Lysecki P, Moore D, Phillips S. Minimal whey protein with carbohydrate stimulates muscle protein synthesis following resistance exercise in trained young men. Appl Physiol Nutr Metab. December 2007;32(6):1132-1138. 6. Shirreffs S, Casa D, Carter R. Fluid needs for training and competition in athletics. J of Sports Sci. December 2, 2007;25:83-91. 7. Hartman JW, Tang JE, Wilkinson SB, Tarnopolsky MA, Lawrence RL, Fullerton AV Phillips SM. Consumption of fat-free fluid milk after resistance exercise promotes greater lean mass accretion than does consumption of soy or carbohydrate in young, novice, male weightlifters. Am J Clin Nutr 86: 373–381, 2007. 8. Jackson J, Lyons T, Roberts J, Geary C, Williams J. Use of Nutritional Supplementation Among University Recreation Users. Rec Sports J. April 2010;34(1):2-8. 9. Dunn D, Turner L, Denny G. Nutrition Knowledge and Attitudes of College Athletes. Sport Journal. October 2007;10(4):45-52. 28 10. Kunkel M, Bell L, Luccia B. Peer nutrition education program to improve nutrition knowledge of female collegiate athletes. J Nutr Educ. March 2001;33(2):114-115. 11. Jessri M, Jessri M, RashidKhani B, Zinn C. Evaluation of Iranian College Athletes' Sport Nutrition Knowledge. Int J Sport Nutr. June 2010;20(3):257-263. 12. Abood D, Black D, Birnbaum R. Nutrition Education Intervention for College Female Athletes. J Nutr Educ. May 2004;36(3):135-139. 13. Braun H, Koehler K, Geyer H, Kleinert J, Mester J, Schänzer W. Dietary Supplement Use Among Elite Young German Athletes. Int J Sport Nutr. February 2009;19(1):97-109. 14. Froiland K, Koszewski W, Hingst J, Kopecky L. Nutritional supplement use among college athletes and their sources of information Int J Sport Nutr. February 2004;14(1):104-120. 15. Coso J, Estevez E, Baquero R, Mora-Rodriguez R. Anaerobic performance when rehydrating with water or commercially available sports drinks during prolonged exercise in the heat. Appl Physiol Nutr Metab. April 2008;33(2):290-298. 16. Costill D. Carbohydrate for athletic training and performance. Boletín De La Asociación Médica De Puerto Rico. August 1991;83(8):350-353. 17. Merson S, Maughan R, Shirreffs S. Rehydration with drinks differing in sodium concentration and recovery from moderate exercise-induced hypohydration in man. Eur J Appl Physiol. July 2008;103(5):585-594. 29 APPENDICES 30 APPENDIX A Review of Literature 31 REVIEW OF LITERATURE Athletes lose more than just water when they sweat while working out. Therefore, it is imperative for them to replenish with more than simply water after working out. The choice of what to drink post-exercise can have profound effects on an athlete’s well-being and ability to perform later in the day. With all the conflicting messages about rehydration drinks, athletes can make drink choices on partial or false information. As a result, athletes may be under-performing. Also, many athletes participate in multiple practices per day; some of these practices are spaced within mere hours of each other. Due to energy demands, proper rehydration is critical when athletes need to recover for another session, and often, water alone is not enough.1,2 There has been a plethora of research done in recent years which aims to test the efficiency of recovery in many types of drinks. 1-14 This literature review aims to explain the benefits of various drinks and why some may be better than others. The topics for this literature review will be discussed in the following sections: why a post-exercise rehydration drink is needed, nutritional demands of athletes, current 32 rehydration drinks on the market, and athlete knowledge of post-exercise rehydration drinks. Benefits of Post-exercise Rehydration Drinks Sweating is a natural body function in response to the increase in core temperature that accompanies exercise. Athletes are no exception; quite the contrary, they sweat more than the average person15,16. As such, they must off-set this loss of water and nutrients utilized by exercise by taking in more than the average person17. This sweat loss can lead to heat illness and dehydration18,19. Therein lies the need for a post-exercise rehydration drink. Athletes need a post-exercise rehydration drink in order to: prevent dehydration, get back the nutrients they lose in sweat, return to positive fluid balance, and perform to their optimal capacity. Dehydration Dehydration is a rampant problem plaguing athletes, especially during double sessions in late summer. There are two (2) types of dehydration: exercise-induced dehydration (dehydration brought on by exercise) and hypohydration (dehydration before exercising). 20 It has been reported 33 that athlete performance is negatively affected when they lose ~2% body mass due to perspiration 19, 20, 3, 8, 21, 22, 13, 23, 14, 24, 25 . Dehydration is defined as: a urine specific gravity of >1.02018, 19 . Dehydration can be combated with proper pre- hydration; however, during multiple bouts of exercise per day, practices start early and, as a result, it may not always be feasible to properly pre-hydrate. As a result, athletes must rehydrate after exercise. This need exponentially increases when another bout of exercise is to follow in a short time. Athletes are suggested to consume enough fluid as to ensure not more than 2% body mass is lost 18, 19 . It has been reported that properly rehydrating is possible without the use of a post-exercise rehydration drink for athletes who do not have another session of exercise within 12 hours because that athlete will be back in positive fluid balance after eating regular meals.23 However, for those with another bout in the same day, this is not the case. Starting a session of exercise dehydrated and negative fluid balance leads to an outset of decreased performance in addition to making the dehydration worse26. Furthermore, the more dehydrated an athlete gets, the more their performance decreases.27 34 Starting Exercise Hypohydrated It has been reported that up to 66% of athletes appear hypohydrated at the outset of exercise.2 Hypohydration can have a significant impact on exercise capability. Some of these factors are: increase heart rate, increase blood pressure, and core temperature.28-29 The ability of athletes to return to positive fluid balance between multiple exercise periods is critical to maintaining a high intensity of activity during a second session. As a result, finding the right post-exercise rehydration drink is mandatory for proper care of athletes. Furthermore, research indicates that additional strain is put on the cardiovascular system to maintain exercise ability while hypohydrated.42 Returning to Fluid Balance In a study to determine the effectiveness of multiple post-exercise rehydration drinks on returning athletes to positive fluid balance was comprised of seven physically active males who completed a max VO2 test, familiarization test, and two experimental tests. Sweat was collected from the athletes and measured for electrolyte content. The first experimental test ended when participants lost 1.8% body mass. The participants were given 30 minutes rest 35 before drinking the selected beverage (1% milk or fluidreplacement drink) in an amount that was 150% their sweat loss. After three hours of rest, the participant’s fluid levels were measured and then put through a second test to test time to exhaustion. At the end of the three hour recovery it was found that the athletes ingesting the carbohydrate-electrolyte drink were euhydrated (neutral fluid balance) while the patients consuming milk were in positive fluid balance when compared to water alone.3,21,22,30 This is an important study because it could help in providing a basis for post-exercise drink volume. However, without being in a laboratory setting, knowing the amount of sweat loss MAY prove difficult. Nutritional Needs of Athletes Nutritional needs of athletes are far greater than those of the general population. Athlete must consume more fat, carbohydrates, proteins, vitamins, and minerals than typical guidelines stipulate.17 A general population diet consists of: 45-55% carbohydrate (or 3-5 grams/kg/day, 1015% protein, and 25-35% fat.18 For carbohydrate recommendations, athletes involved on high volume of exercise, defined as 2-3 hours per day, 5-6 times per week, 36 have a diet that should consist of: 55-65% carbohydrate (58 grams/kg/day).18 These levels of carbohydrates should be sufficient to restore muscle and liver glycogen stores. For protein, needs of athletes increase from .8-1.0 kg/body weight/day to 1.5-2.0 kg/body weight/day.17 The additional nutrient needs of athletes extends to hydration as well. Nutrients in Sweat As athletes sweat, they lose valuable electrolytes along with water. The most important nutrients to exercise hydration are Sodium (Na+), Potassium (K+), and Chloride (Cl-).16, 22 These electrolytes must also be supplemented with water while rehydrating. Along with the previously mentioned electrolytes, Calcium (Ca2+), Magnesium (Mg2+), and Iron (Fe) are also lost in sweat.22 Sodium is of most importance as it has been show to impact exercise capacity along with dehydration.1 Current research indicates that sweat rates are correlated with body mass, sport, and environmental conditions.16 It is important to note the differences when forming hydration protocols and strategies for athletes.22 37 Current Post-Exercise Rehydration Drinks The market for post-exercise rehydration drinks is ever-expanding. New companies and new products are constantly entering the field of post-exercise rehydration drinks. Fluid-Replacement Drinks The use of fluid replacement drinks has become commonplace due to the relationship between fatigue and carbohydrate availability.3 Fluid replacement drinks appear in commercials, magazines, on billboards, and sponsor athletic events. As a result, it may be concluded that fluid replacement drinks are the most popular form of postexercise rehydration drinks. Fluid-replacement drinks typically consist of: 0g fat and protein, 15g carbohydrate, 115mg sodium, and 31mg potassium.11 The electrolytes contained in fluid replacement drinks have led to it being called a better post-exercise rehydration drink than plain water.18 As a result, many companies have created their own drinks to compete in the market. Most, however, are nearly identical in terms of nutrient make-up. This makes taste preference and school affiliation the determining factor in what is consumed. Recently, fluid replacement drink 38 companies have churned out new “additive” products for their drinks. These are packets of nutrient powders that can be added to any drink. The electrolytes often added are Sodium, Potassium, Calcium, and Magnesium. Carbohydrate-Protein Drinks Due to athlete demands, new rehydration drinks are always being produced. One newer type of drink is a carbohydrate-protein drink. These drinks have a very different nutrient makeup than fluid-replacement drinks: 4g protein, 1g fat, 16g carbohydrate, 127mg sodium, and 16mg potassium. However, clinical trials have shown no increased effects over fluid-replacement dinks.4 The ideology behind infusing protein into these drinks is to increase muscle recovery after exercise. The typical protein type found in these drinks is whey protein. Support for this theory was provided in a study of weight-lifters. The study found an increase in muscle protein uptake at a higher level with 10g whey protein and 21g carbohydrate when compared to carbohydrate only.12 The addition of protein hypothesized to lead to greater hypertrophy and, in effect, strength gains. 39 Milk Recently, milk has entered the discussion of postexercise rehydration drinks. Milk is nutrient dense in all areas athletes demand.8 Milk can be processed and altered in many different ways. For example, there is whole milk, 2%, skim, chocolate, and strawberry; all of these contain different nutrients. In a direct comparison, chocolate 2% milk appears to show the greatest benefit to athletes due to its nutrient makeup: 8g protein, 5g fat, 27g carbohydrate, 159mg sodium, 446mg potassium. However, the reasons for the positive results have not been thoroughly studied. Common theories accounting for this include: slower digestion of proteins, increased circulation of fatty acids within the blood, less urine production postexercise, and increased amount of protein.3,4,11,31 Research Trials of Current Rehydration Drinks Clinical trials were performed to test time to exhaustion, fat-free soft tissue mass, fluid balance, and nutrient balance. Among these trials, milk performed on par or better than leading fluid-replacement drinks as well as carbohydrate-protein drinks. On average, milk and fluid-replacement drinks performed equally on time to exhaustion tests. Milk performed the best among fat-free 40 soft tissue mass increase, fluid balance, and nutrient balance. Because of the recent success, imitators are trying to recreate the nutrients found in milk. However, a key component taken out is lactose. The reason for this subtraction is to allow these beverages to be consumed by even those who are lactose intolerant. A study to determine milk’s effectiveness on lean mass tissue gains from progressive resistive exercise was undertaken. In this study, 56 novice weightlifters participated in a weight-lifting program which lasted 12 weeks and resulted in 20 sessions of: pushing exercises, pulling exercises, and leg exercises.31 The drinks tested were: commercially available carbohydrate drink, soy beverage, and skim milk. The quantity taken of each was 500mL directly after finishing the workout and 1 hour postexercise. One repetition max was determined pre-workout and compared to post-exercise at 12 weeks. Milk showed better results in all categories tested, which were: Body weight, Fat mass, fat- and bone- free mass, and bone mineral content. Type II muscle fiber cross-sectional area gains were significantly higher in milk than both other drinks while type I muscle fiber was not statistically different between soy and milk, but both were significantly higher than the carbohydrate beverage. Lean mass tissue 41 showed greatest improvement within those who ingested milk. Also, in 1 repetition maximal leg strength, milk provided greater gains in leg press, knee extension, and hamstring curls by a significantly higher margin. The study provided by Hartman gives support to the effects milk has in promoting maximal strength and lean mass tissue increases. Many athletes participate in multiple exercise bouts per day for part of their season. As a result, it is hard for many to become adequately rehydrated before the second stint of exercise. Therefore, the ability to perform at an optimal level decreases. Due to the strong support in other areas, milk (1% chocolate milk in this study) was tested against other leading drinks (carbohydrate-protein and fluid-replacement) in endurance tests. The study being examined, conducted by Karp et al., quantifies endurance as time to voluntary exhaustion while maintaining a cycling speed congruent with 70% VO2 max. This study had nine male cyclists undergo a glycogen depleting trial consisting of alternating 2-min periods of high intensity followed by low intensity work followed 4 hours later by a stint of cycling at 70% VO2 max until exhaustion. This protocol was completed by all nine athletes on 3 occasions which were spaced a week apart. After the data was compared, milk was shown to produce significantly superior numbers in time to 42 exhaustion and total work produced than a leading carbohydrate-replacement drink. There was no significant difference in both categories between milk and a fluidreplacement drink. The amount of work produced by the cyclists after ingesting the chocolate milk was 57% higher than after consuming the carbohydrate-replacement drink while there was a 48% increase in work produced after the consumption of a fluid-replacement drink when compared to a carbohydrate-replacement drink.4 Sweat loss rate is important because athletes lose both water and nutrients. On average, milk can have ten times the amount of sodium and potassium as fluidreplacement and carbohydrate-replacement drinks, respectively. In a study comparing five types of milk (whole, 2%, 1%, skim, and 2% chocolate), two types of fluid-replacement drinks (Gatorade Thirst Quencher and Gatorade Endurance), and a carbohydrate-replacement drink (Accelerade), chocolate milk was shown to hold more nutrients.11 This nutrient density becomes beneficial for the athlete due to the ability to replenish nutrients inbetween workouts. The ways in which milk helps exercise are immense. However, it is the why which often alludes researchers. There is no one reason why milk has so many properties 43 conducive to exercise. Some of the reasons include: fat content, amino acid type, carbohydrates, and vitamins. No other drink compares to milk’s wide range of nutrients. It is within this area further research is required to ascertain the wide range of benefits milk provides. A possible obstacle in getting athletes to drink milk is the fear they (the athletes) will gain weight. Other hydration drinks do not contain the lipid component of milk. However, it could be this lipid component that makes milk such a good drink. The lipid composition in milk ranges from milk to milk depending if it’s whole, skim, or in-between. However, regardless of type, the main lipid is saturated fatty acid. Two of these fatty acids are capric and lauric acid. In clinical research, these two fatty acids have been shown to inhibit the Cyclooxygenase enzyme.32 Cyclooxygenase creates prostanoids that aid in the inflammatory process and cause pain. Therefore, capric and lauric acid act as Cox I and Cox II inhibitors. This can delay or even negate minor pains associated with exercise. Because they (capric and lauric acid) do not have a strong effect, this pain masking is not deemed detrimental. Addressing the issue of milk causing an increase in body fat among athletes, a study was done to examine the effects of dairy products on weight management33. Their 44 results found that a diet high in calcium increased lipolysis and led to 26-39% reductions in body weight than diets with suboptimal calcium intake. Furthering research in this realm found significant increases in body weight loss among diets high in dairy products.33 In a 24-week study of obese individuals, participants in the control group (low-calcium diet) lost 6.4% of their body weight while participants in the high dairy product group lost 10.88%, diets high in calcium but not from dairy reported an 8% loss. Furthermore, fat loss from the participants went up by 38% in high calcium diets and 64% in diets high in dairy. These findings indicate that there are other nutrients in milk that attribute to fat loss than just calcium. Another nutrient milk has that not all sport drinks have is protein. Recently, companies have mimicked milk’s ratio of proteins to fats (Muscle Milk). The main types of proteins in milk are casien (80%) and whey (20%). Whey protein receives the commercial coverage and has appeared in many drinks and powders for increase strength gains. However, casein protein may be just as valuable to the body as whey protein. While whey protein is lauded as the most important type, research has been found that amino acid uptake was 45 only significantly affected when both proteins were consumed.34 The reasons for these findings were the amino acid levels found within muscles after a rest period of four hours. Whey protein led to higher levels of leucine while casein protein led to higher levels of phenylalanine. Leucine is an essential amino acid that increases the synthesis of muscle protein. Phenylalanine is also an essential acid needed to create proteins in the body. Milk has many nutrients not found in other drinks. Some nutrients may not seem important at first glance; however, after delving further into the physiology of them, there may be a place in athletics. Two such nutrients are Folate and B12. Folate, or folic acid, plays a key role in the metabolism of amino acids.35 As amino acids are the building blocks for cells, and especially muscles, an increase folate consumption due to milk may help athletes recover faster. Vitamin B12 plays an essential role in the body as it helps with folate metabolism.36 As previously stated, folate aids in amino acid metabolism, however, without being metabolized itself, folate can do very little to help the body. Therefore, vitamin B12 is an essential component in amino acid metabolism as a result of its impact on folate. 46 A major worry for athletes, and especially studentathletes, is coming down with a cold or other illness. Due to the intense strain put on their bodies, and occasionally the climate they play in, athletes are more susceptible to illness than the general public. One nutrient responsible for immune system function is Zinc.37 Milk can commonly have 18-25% of daily requirements of zinc. This is vastly different from other sport drinks which generally have none. It can thus be hypothesized that milk will help athletes stay healthy during their times of intense exercise.38 The thyroid gland plays a pivotal role in regulating metabolic rate and growth. To do this, the thyroid gland needs Iodine to create triiodothyronine and thyroxine.38 If the thyroid gland has sufficient amount of Iodine, it functions properly and regulates a healthy metabolic rate. This is imperative for athletes because a stable metabolism can increase fat loss and stimulate nutrient absorption. A common complaint and possible obstacle with milk is the prevalence of lactose intolerant individuals. Lactose is a disaccharide formed by galactose and glucose.39 It plays an essential role in the digestion and absorption of other sugars. Lactose is not found in every type of milk. As a result, different types of milk can be experimented 47 with to determine if there is a suitable kind. Furthermore, with the advances in modern science, lactose can be taken out of bovine milk and replaced with other sugars. If mass production of a milk with lactose taken out, it could solve the problem for lactose intolerant individuals. Athlete Knowledge Athlete knowledge of nutrition is an essential component to their ability to perform optimally. However, as seen in previous research, their knowledge is inadequate and often comes from unreliable sources.40-43 Fad diets, nutritional recommendations on nutrition labels, and most articles on common literature do not translate to athlete nutritional needs. This knowledge base needs to be addressed in order to provide comprehensive care to athletes. Athletes who perform multiple bouts of exercise per day are at an increased rate of nutritional deficit.43 These athletes need special recommendations concerning their nutritional intake. Athletes who perform multiple bouts per day constitute a wide range of athletic teams, especially with sports with extensive pre-season work, including: soccer, football, basketball, baseball. Most of these sessions occur under conditions of elevated heat.44 As 48 a result, many athletes begin workouts hypohydrated.43,45 Current research into the field of athlete knowledge of nutrition focuses mostly on general nutrition guidelines and needs. As such, there is a lack of research work in athlete knowledge specific to rehydration drinks. Summary While there may be an adequate amount of research examining the effects of hydration, little is known about what athletes do with this knowledge. Research indicates that milk may be the optimal rehydration drink, although not by a margin significant enough to dissuade the use of any other type of drink. In conclusion, there potentially is still a gap between what the medical community knows and what athletes know. In an attempt to help bridge this gap, this thesis was performed. 49 APPENDIX B The Problem 50 The Problem Statement of the Problem The purpose of this study is to determine athlete knowledge concerning post-exercise rehydration drinks. This is important because athletes’ consumption of post-exercise drinks is on the rise. By evaluating athlete knowledge and use, recommendations can be made in regards to future education of athletes. If athletes are educated in postexercise rehydration drinks, they will be able to make educated decisions when someone else is not around to facilitate their decision of what to drink. Lastly, it is beneficial for athletes to know what the best post-exercise rehydration drink is. Definition of Terms The following definitions of terms will be defined for this study: 1) Post-exercise Rehydration Drink – A drink consumed after exercise that is a meant to facilitate rehydration.48 2) Athlete – A person who is trained or skilled in exercises, sports, or games requiring physical strength, agility, or stamina.49 51 3) Carbohydrate-Protein Drink – A drink consumed after exercise that contains carbohydrates and protein, usually in a 4:1 ratio.1 4) Fluid Replacement Drink/Carbohydrate-Electrolyte Drink – A drink consumed after exercise that contains carbohydrates and electrolytes.1 5) Hypohydration – Dehydration at the onset of physical activity.5 6) Euhydration – Neutral fluid-balance.5 Basic Assumptions The following are basic assumptions of this study: 1) The subjects will be honest when they complete their demographic sheets. 2) The subjects will answer the knowledge questions to the best of their ability. Limitations of the Study The following are basic assumptions of this study: 1) Only athletes older than 18 were used as participants. 2) A true sample was not received due to only surveying two schools. 3) Low response rate could have skewed the data 52 Significance of the Study With the recent push by coaches and healthcare professionals alike to have athletes use post-exercise rehydration drinks, athlete knowledge is often overlooked. Rather than handing athletes a specific drink, athletes should be instructed on proper rehydration drinks. This way, they can make educated decisions on their own. 53 APPENDIX C Additional Methods 54 APPENDIX C1 Institutional Review Board – California University of Pennsylvania 55 56 57 58 59 60 61 62 63 64 65 Institutional Review Board California University of Pennsylvania Psychology Department LRC, Room 310 250 University Avenue California, PA 15419 instreviewboard@cup.edu instreviewboard@calu.edu Robert Skwarecki, Ph.D., CCC-SLP,Chair Mr. Gregoire, - - Please consider this email as official notification that your proposal titled “Athlete Knowledge of Post Exercise Rehydration Drinks” (Proposal #10-047) has been approved by the California University of Pennsylvania Institutional Review Board as submitted, with the following stipulations: A screening question or statement indicating that participants must be 18 years of age or older must be present in the consent form and/or questionnaire. A statement indicating where the results will be housed and maintained must be added to the consent form. Once you have made this revision, you may immediately begin data collection. You do not need to wait for further IRB approval. [At your earliest convenience, you must forward a copy of the revised consent form for the Board’s records]. (1) (2) (3) (4) The effective date of the approval is 02-23-2011 and the expiration date is 02-22-2012. These dates must appear on the consent form . Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) Any events that affect the safety or well-being of subjects Any modifications of your study or other responses that are necessitated by any events reported in (2). To continue your research beyond the approval expiration date of 02-222012 you must file additional information to be considered for continuing review. Please contact instreviewboard@cup.edu Please notify the Board when data collection is complete. Regards, Robert Skwarecki, Ph.D., CCC-SLP, Chair, Institutional Review Board 66 APPENDIX C2 Cover Letter to Participant 67 Dear Participants: My name is Joshua Gregoire and I am a master’s degree candidate at California University of Pennsylvania. One of the requirements for a master’s degree is the completion of a thesis and for this I am requesting your help. As of late, the beverage industry has expended numerous funds in the area of post-exercise rehydration drinks (PERDs for short). Information about various PERDs is on television, in magazines, and talked about among coaches. I am conducting this study to find out what you, the athletes, know about PERDs as well as how frequently you use them. Your responses will be anonymous, but it is hoped that the results of this study will be published for the medical community to see, in an effort to expand upon the research. Your responses will be housed in a secure location by surveymonkey.com, accessible only to the researcher. The survey should not take longer than 10 minutes for you to complete. The effective date of the approval is 02-23-2011 and the expiration date is 02-22-2012. If you wish to participate in the study, please follow the link https://www.surveymonkey.com/s/G5TCF97 Thank you, Joshua Gregoire, ATC, NASM-PES Graduate Assistant Athletic Trainer California University of Pennsylvania 68 APPENDIX C3 Cover Letter to Athletic Director 69 70 APPENDIX C4 Response Letter from Athletic Director 71 72 APPENDIX C5 Liaison Letter 73 74 APPENDIX C6 Survey 75 76 77 78 79 80 81 82 83 84 85 86 REFERENCES 1. Coso J, Estevez E, Baquero R, Mora-Rodriguez R. 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Finn J, Wood R. Incidence of pre-game dehydration in athletes competing at an international event in dry tropical conditions. Nutrition & Dietetics. December 2004;61(4):221-225. 48. Shirreffs, SM (2003) The optimal sports drink. Sportmed Sporttraumatol. 51, 25–29. 49. WEBSTER’S NINTH NEW COLLEGIATE DICTIONARY. SPRINGFIELD, MA: MERRIAM-WEBSTER INC. 1988. 91 ABSTRACT TITLE: ATHLETE KNOWLEDGE AND USE OF POST-EXERCISE REHYDRATION DRINKS RESEARCHER: Joshua P. Gregoire ADVISOR: Robert Kane, EdD, PT, ATC DATE: April 2011 RESEARCH TYPE: Master’s Thesis CONTEXT: Current research indicates that athletes use supplements at a high rate. Literature has not examined if this trend correlates to post-exercise rehydration drink knowledge. OBJECTIVE: The purpose of this study was to: test athlete knowledge of post exercise rehydration drinks and evaluate the usage of post exercise rehydration drinks. The study was a descriptive design survey. SETTING: The survey was distributed via email and taken online at the participants’ convenience on www.surveymonkey.com. PARTICIPANTS: The convenient sample of 99 athletes out of a possible 311 took the online survey at their convenience after being sent a link and cover letter. The response rate was 31.8%. INTERVENTIONS: The independent variables used were sport played and gender of participants. After obtaining consent from the athletic director, athletes were sent the survey and asked to respond at their leisure. At the end of the survey window, each response was given a knowledge score based on the number of questions answered correctly MAIN OUTCOME: The dependent variable used was the knowledge score given based on the number of 92 questions answered correctly on the survey. PSAW 19.0 for Windows was used for all data statistics with an alpha level of <.05. one-way ANOVA was used to compare knowledge score means and sport. An independentsamples T-test was calculated comparing the mean score on the knowledge based portion of the study and the gender of the participant. A chi-square test of independence was calculated comparing post-exercise rehydration drink usage and sport played. A chi-square test of independence was calculated comparing gender and PERD use. RESULTS: The research found: no significant differences between athlete knowledge sport played, (F(6,92) = 1.934, p = .084), no significant differences found between PERD knowledge and gender (t(29) = .268, p =.790), no significant relationship between PERD usage and sport played (X2(6) = 7.786, p =.254), and no significant differences between gender and PERD usage (X2(1) = .357, p=.567). CONCLUSIONS: Of note was the findings of athlete knowledge based on gender as males scored higher than did females, but not significantly better (m = 14.14, sd = 2.133) and (m = 14.01, sd = 2.075), respectively. This research indicates that 80% of athletes use post-exercise rehydration drinks on a regular basis.