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A CORRELATION AMONG NUTRITION KNOWLEDGE, EATING HABITS, AND
EATING BEHAVIORS IN UNIVERSITY DANCERS

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
Sarah A. Florida

Research Advisor, Dr. Rebecca Hess
California, Pennsylvania
2013

ii

iii

ACKNOWLEDGEMENTS

I would to take the opportunity to acknowledge those
individuals who have made the following document a reality
for me during my time here at California University of
Pennsylvania.
First I would like to credit and appreciate Dr.
Rebecca Hess for serving as my thesis chairperson. If it
weren’t for her patience, guidance, and calming presence
I’m sure this process would have been a much tougher one.
With her help I was able to take just an idea and create an
entire thesis, and I am grateful for her part in my
Master’s program at Cal.
I would also like to thank the members of my
committee, Dr. Ayanna Lyles and Dr. Chris Harman for their
help with brainstorming and supporting me through edits
that only improved the quality of my thesis overall.
Dr. Tom West also deserves a huge thank you for acting
as thesis advisor for our entire class and also in
assisting me personally with the statistical analysis
portion of my thesis among others of course.
Lastly I would like to take a moment to show
appreciation for my supportive mother, family, friends, and
significant other for their endless encouragement
throughout this year. Through challenges and moments of
great achievement all were there to help me keep my chin up
or celebrate in the best ways possible. For all of their
love, I am grateful. Had it not also been for Tyler’s
encouragement specifically, I would have never applied to
Cal and thus, been accepted to study in this Master’s
program. I owe this experience to him and credit his
contribution each step along the way, at times quite
literally. I love you sweetheart.
My mother especially deserves all my gratitude for her
support with making college and grad school a reality. I
dedicate the following document to her, although it will
never compare to the amount of work she put into being my
parent. For all she’s taught me, the long phone calls, the
laughs, the cheers, and the moments of her being my hero—
words will never express my appreciation.
Here’s to graduation and the next adventure ahead.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES

. . . . . . . . . . . . . . . vii

LIST OF FIGURES .
INTRODUCTION
METHODS

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . 5

Research Design
Subjects

. . . . . . . . . . . . . . 5

. . . . . . . . . . . . . . . . . 6

Instruments . . . . . . . . . . . . . . . . 8
Procedures

. . . . . . . . . . . . . . . . 12

Hypotheses

. . . . . . . . . . . . . . . . 14

Data Analysis
RESULTS

. . . . . . . . . . . . . . . 14

. . . . . . . . . . . . . . . . . . 15

Demographic Information
Hypothesis Testing

. . . . . . . . . . . 15

. . . . . . . . . . . . . 19

Additional Findings . . . . . . . . . . . . . 20
DISCUSSION . . . . . . . . . . . . . . . . . 22
Discussion of Results . . . . . . . . . . . . 22
Conclusions . . . . . . . . . . . . . . . . 28
Recommendations. . . . . . . . . . . . . . . 29

v
REFERENCES . . . . . . . . . . . . . . . . . 32
APPENDICES . . . . . . . . . . . . . . . . . 35
APPENDIX A: Review of Literature

. . . . . . . . 36

Introduction . . . . . . . . . . . . . . . . 37
Sports Nutrition .

. . . . . . . . . . . . . 37

Carbohydrates for Energy . . . . . . . . . . 39
Proteins for Repair and Recovery . . . . . . . 40
Fats as Fuel . . . . . . . . . . . . . . . 40
Nutrition Knowledge, Eating Habits, and Eating
Attitudes in the Physically Active Population

. . 42

Association to Eating Disorders and
Disordered Eating

. . . . . . . . . . . . . . 45

Nutrition Education

. . . . . . . . . . . . . 47

APPENDIX B: The Problem . . . . . . . . . . . . 51
Statement of the Problem . . . . . . . . . . . 52
Definition of Terms . . . . . . . . . . . . . 53
Basic Assumptions . . . . . . . . . . . . . . 54
Limitations of the Study . . . . . . . . . . . 55
Significance of the Study

. . . . . . . . . . 55

APPENDIX C: Additional Methods .

. . . . . . . . 57

Cover Letter to Dance Instructors and
University Departments (C1) . . . . . . . . . . 58
Cover Letter in Email Sent to Participants
Prior to Participation (C2) . . . . . . . . . . 60

vi
Demographic Sheet (C3) . . . . . . . . . . . . 62
Revised Nutrition Knowledge and Eating Habits
Questionnaire & Scoring Key (C4).

. . . . . . . 65

Dutch Eating Behaviors Questionnaire &
Scoring Key(C5)

. . . . . . . . . . . . . . 73

IRB: California University of Pennsylvania (C6) . . 81
ABSTRACT

. . . . . . . . . . . . . . . . . 87

vii
LIST OF TABLES
Table

Title

1

Descriptive Statistics for Survey Scales

Page
. 17

1

INTRODUCTION

Nutrition has been studied for years in sport’s
settings due to its ability to optimize performance,1-6
reduce the likelihood of injury,3,5 and help the body
recover from exercise and stress. Athletes today strive to
gain the competitive advantage over their opponents, and in
many cases, proper nutrition plays a key role. Nutrients
work to supply active body systems with sufficient energy
stores to be used in physical activity, thus reducing
fatigue and allowing the athlete to perform longer. Proper
nutrition also aids in restoring muscle and blood nutrients
for the body to efficiently recover from physical exertion.
Nutrition can be considered an important component in any
athlete’s daily training and must be addressed properly,
meeting the specific needs of an individual athlete.
The needs for caloric and nutrient intake are higher
in the physically active population due to their high
energy expenditure.1-4,7,8 An athlete’s increased physical
activity requires their physiological systems to work at a
higher rate and for longer time periods, resulting in an
energy expenditure considerably higher than a sedentary

2
individual. A physically active population includes sport
athletes participating in power or endurance training, as
well as dancers.18 Although dancers may not compete in the
typical way a sport athlete does, they are just as active
physically trying to meet the demands of their environment
and performance/practice schedules.18 For the purposes of
the current study, dancers are considered both athletes and
addressed as being members of the physically active
population.
In order for a physically active population to remain
healthy and see positive gain in performance they must meet
their energy expenditure with proper energy intake.
According to research, athletes at the university level
fail to demonstrate proper nutrition practices.5,6,9 Time,
finances, and sufficient room to prepare nutritious meals
can be difficult in a school setting. Results of various
studies also conclude student athletes lack nutrition
knowledge and good eating behavior as a whole.5
Research has shown a higher trend in disordered eating
in female athletes over their male counterparts.11,12 Females
participating in sports or activities emphasizing physique
are significantly more likely to practice disordered eating
or improper nutrition habits according to past research.11,12
Dance is particularly targeted in the research for

3
participants being more likely to suffer from eating
disorders or disordered eating habits.14-18 Many studies have
been conducted on participant groups in only one form of
dance, are considered adolescents, or dancers in a strictly
professional track. There is limited research on dancers
participating at the university level who may not be on the
professional track or who perform multiple forms of dance.
Reportedly, dancers who perform mainly one form of dance
respond differently in regards to their nutrition knowledge
or eating behaviors.17 According to research, collegiate
ballet dancers have a higher risk of disordered eating than
their modern dance counter parts.17 Previous research
information provides an interesting starting point for the
current study done on dancers that perform multiple forms
of dance.
The goal of the current study was to examine an
experience level that had not been focused on extensively
in the literature, the typical university dancer, many of
whom may not pursue a professional dance career or a
specific form of dance. The current study sought to create
a nutritional profile of these dancers in order to
determine if anomalies lie in their nutrition knowledge,
eating habits, and eating behaviors. Since adolescent and
professional track dancers have shown to be at risk for

4
disordered eating and associated problems according to
previous literature, establishing a profile at the
university level could provide further insight into any
potentially similar or dissimilar issues occurring at this
level of participation.
By creating a nutritional profile, instructors and
clinicians will be able to identify areas of weakness in
the nutritional status of university dancers. Medical
personnel may then also determine the best way to provide
education, intervention, or offer help where there are
discrepancies. Nutrition habits of the dancers could then
be enhanced, injury could be reduced, and recovery from
physical activity could be at a more optimal level in the
student dancer.

5

METHODS

The primary purpose of this study was to examine the
nutritional profile of Division II university dancers. The
following sections are included: research design, subjects,
instruments, procedures, hypotheses, and data analysis.

Research Design

The current study used a correlational research design
to examine nutrition knowledge, eating habits, and eating
behaviors in a sample of university dancers.
 Nutritional
knowledge and eating habit scores were determined using a
revised, 32-item questionnaire. Reliability coefficients
for the nutritional knowledge section consisting of 22
questions was reported at 0.88, while the 10 questions
designed to measure eating habits had a reliability
coefficient of 0.81. Eating behavior scores were determined
using the Dutch Eating Behaviors Questionnaire.21 Cronbach’s
alpha coefficients of the scales for restrained eating,
emotional eating, and external eating contained in the DEBQ
are reported at or above .80.

6
The current study was designed to potentially expose
deficits in nutrition knowledge, habits, and behaviors in
university dancers resulting from disordered eating
tendencies.
Results were limited to university dancers that were
defined as being dance majors or dance minors at their
respective university, and having 5 or more years of
formalized dance instruction. Universities considered for
this study were all members of the Pennsylvania State
Athletic Conference (PSAC). All PSAC schools are considered
NCAA Division II universities with similar size in student
body. Formalized dance instruction was operationally
defined as having taken classes in private or
preprofessional studios, companies, and/or post secondary
schools, as well as be currently taking classes and
performing at their respective university.

Subjects

Subjects were university dancers from universities
within the same demographic in Pennsylvania, both in size
and location, and all a part of the Pennsylvania State
Athletic Conference (PSAC). Each university also offered
major or minor program tracks in dance. Subjects were

7
healthy, which was deemed as regularly participating in
dance, and had a specified amount of dance background.
Participants were required to have at least 5 or more years
of formalized dance training, currently taking classes and
performing, and be categorized as a dance major or minor at
their respective university. Only volunteer participants
were considered for this study.
Informed consent was waived but implied by completing
an electronic survey for the study.

Participation could be

ceased at any time without penalty to the participant by
not submitting the survey. The dance departments received
notice of the survey and information regarding the research
via a cover letter sent prior to email notification to the
dancers (APPENDIX C1).
Participants were made aware of the survey first
through notification from their instructors or dance
departments and then directly via their email addresses.
The departments and instructors however were unaware of the
dancers decision to participate in the survey. Participants
were also provided a cover letter before beginning the
online survey via Survey Monkey (APPENDIX C2). All
participants were required to complete a demographic
section (APPENDIX C3) and two surveys (APPENDIX C4-C5),
that took approximately 25 minutes total as reported in

8
previous research.20 Participant confidentiality was
maintained at all times and no identifying information was
asked of the participants. The study was approved by
California University of Pennsylvania’s Institutional
Review Board prior to taking place (APPENDIX C6).

Instruments

The study utilized a section for pertinent demographic
information and two surveys. The first survey was a twopart, 32-question Nutrition Knowledge and Eating Habits
Questionnaire developed by Marino19, and revised by Shepard20
(2007) (APENNDIX C4). The current study updated terminology
from www.mypyramid.gov to www.myplate.gov, however
reliability was believed to have been unaffected by the
changes as the two are used interchangeably. There were no
other changes to the questionnaire. Reliability
coefficients for the nutritional knowledge section
consisting of 22 questions was reported at 0.88, while the
10 questions designed to measure eating habits had a
reliability coefficient of 0.81. Any questions that
referenced the government nutritional guidelines were
updated with current terminology based on www.myplate.gov
rather than www.mypyramid.gov, which are still used

9
interchangeably and is believed to have no effect on
validity or reliably of the questionnaire.
The nutritional knowledge section of the questionnaire
consisted of the first 22 questions, asking each
participant to what degree they agreed with a specific
statement provided. Answers ranged from Strongly Disagree
(1) to Strongly Agree (4) on a four-point Likert scale, and
were developed by Marino originally. All questions were
scored according to their reported value. If a participant
selected 4 as an answer they were awarded 4 points toward
their end total. Scores on this 22-question section ranged
from 22-88. An overall percentage was found for each
participant by dividing his or her total point score by
88.20 Participant percentages were then categorized into a
range from poor to excellent nutrition knowledge. The
ranges for the categories were as follows: poor (54% or
below), fair (55-69%), good (70-84%), and excellent (85100%).20 Higher scores in this section indicated that a
participant had a higher knowledge of sports nutrition.20
The second section of the Nutrition Knowledge and
Eating Habits Questionnaire contained 10 questions intended
to test the quality of eating habits of each participant.
Participants were asked to indicate how often they consume
particular foods or engage in certain eating habits using a

10
four-point Likert scale, originally developed by Marino,
with answers ranging from always to never. Always indicated
that the participant did that eating habit 5-7 days a week,
Often indicated 3-4 days a week, Sometimes indicated 1-2
days per week, and Never indicated that the habit did not
occur at all. Questions numbering 2, 3, and 6 were reverse
scored.

Reverse scoring occurs when a participant answers

a question with a 4, but is awarded 1 point.

All other

questions were scored according to their value; if the
participant answered with a 4, they were awarded 4 points.
Scores on this section ranged from 10 – 40 points total.
Each participant’s total was divided by 40 and reported as:
excellent (85 - 100%), good (70 - 84%), fair (55 - 69%), or
poor (54% or below).

Higher scores on this section

indicated that a subject exhibited increased positive
eating habits.20
The second survey, and the third part of the nutrition
profile completed by the participants assessed their eating
behaviors as measured by the Dutch Eating Behavior
Questionnaire21 (DEBQ). The DEBQ developed by van Strien
(1986) is composed of three types of subscales: one
measures restrained eating, three measure emotional eating,
and one measures external eating. Cronbach’s alpha
coefficients of the scales for restrained eating, emotional

11
eating, and external eating contained in the DEBQ are
reported at or above .80. Restrained eating was found to
have a coefficient of .95 while the three measures of
emotional eating were .94, .93, and .86. External eating
was the lowest at .80.
Scoring for the DEBQ was calculated by finding two
numeric values for each subscale, one overall raw score and
one scale score. The DEBQ subscales are listed below:
Emotional Eating Diffuse Emotions (4 items): 3, 8, 10, 28
Emotional Eating Clearly Labeled Emotions (9 items): 1, 5,
13, 16, 20, 23, 25, 30, 32
Emotional Eating (13 items): 1, 3, 5, 8, 10, 13, 16, 20,
23, 25, 28, 30, 32
External Eating (10 items): 2, 6, 9, 12, 15, 18, 21, 24,
27, 33
Restrained Eating (10 items): 4, 7, 11, 14, 17, 19, 22, 26,
29, 31
Raw score totals are calculated by totaling up the
item scores for each DEBQ-scale.

Scale scores are obtained

by dividing the raw scale score by the total number of
items in that scale endorsed by the participant. For
example, the restrained scale contains ten items. If the
raw score was 36 and all ten items were endorsed the scale
score was calculated by 36/10= 3.6. If nine items were

12
endorsed it would then have been 36/9= 4. If less than nine
items were endorsed, scale scores were not to be computed
as validity was believed to be lost (as reported in the
DEBQ manual).21 For the purposes of the current study the
subscale scores of restrained eating were considered.
According to previous research on dancer participants,
often times disordered eating is prevalent. In order to
measure this in the current study the most closely related
subscale in the DEBQ was the one measuring restrained
eating. Thus, the restrained eating subscale was chosen to
represent the eating behavior portion of this study.
Restrained eating is defined as the intent to limit food
intake in order to prevent weight gain or promote weight
loss. In the current study, once a scale score for the
restrained eating subscale was calculated the scores were
categorized as being very high = >4.01, high = 3.51-4.00,
above average = 3.23-3.50, average = 2.78-3.22, below
average = 2.31-2.77, low = 1.30-2.30, or very low = <1.29
for being at risk of restrained eating.

Procedures

The researcher first notified the university program
directors and/or dance departments for email addresses of

13
potential participants through use of an electronic cover
letter. The cover letter explained the study and
demographic requirements of the participants. The letter
also asked for their participation in forwarding email
address lists of their dance majors and/or minors. However,
it became clear during this procedure privacy restrictions
resulted in limited access to the dancers and participants
in this study.
Each participant accessed Survey Monkey through a link
in his or her email, as directed by an email received from
the primary researcher. After having read a cover letter,
each participant was asked to fill out Marino’s Revised
Nutrition Knowledge and Eating Habits Questionnaire19 and
Dutch Eating Behaviors Questionnaire (DEBQ)20. The surveys,
along with the short demographic page, took approximately
25 minutes to complete based upon previous research.20
Results were kept confidentially on California
University of Pennsylvania’s server. Data was held on a
password-protected file in order to maintain its safety,
with access being limited to the researcher and chairperson
only. Scores for all three variables, nutritional
knowledge, eating habits, and the subscale of restrained
eating behavior from the DEBQ were compiled into SPSS and
analyzed according to the data analysis.

14

Hypotheses

The following hypotheses were based on previous
research and the researcher’s intuition after a review of
the literature.
1.

There will be no correlation among nutrition
knowledge scores and eating habits scores in
university dancers.

2.

There will be a positive correlation between the
restrained eating behavior subscale of the DEBQ
scores and eating habits scores in university
dancers.

3.

There will be an inverse correlation between
nutrition knowledge scores and the restrained
eating behavior subscale of the DEBQ scores in
university dancers.

Data Analysis

All data was analyzed using SPSS version 14.0 for
Windows at an alpha level of < 0.05.

The research

hypotheses were analyzed using a Pearson Product Moment
Correlation.

15

RESULTS

The purpose of the study was to examine the
nutritional profile of dancers at the university level.
This section will explain: Demographic Information,
Hypothesis Testing, and Additional Findings. Participants
were asked to fill out a Revised Nutrition Knowledge and
Eating Habits Questionnaire, a Dutch Eating Behaviors
Questionnaire, and a demographic section as a part of
participating in this study.

Demographic Information

Data includes information from 18 Division II
university dancers. Schools represented are PSAC
educational institutions with major or minor programs in
dance. Due to the nature of increased privacy laws, gaining
access to email addresses of potential participants was
more challenging than anticipated. The potential number of
participants of this study was no more than 40. Due to the
small number of universities willing to participate, along
with strict requirements of this study, the potential n was

16
smaller than predicted. In order to analyze results the
researcher was seeking at least a return rate of 40% in
order to justify the study. A total number of 18
participants volunteered their time for this study, which
was a return rate of 45%.
Of the 18 dancers, 17 completed demographic
information. All demographic questions were optional for
the privacy of the participants. The average age of
participants was 20 years old. The age range was 18-22,
with one outlier of age 26. The average height of the
dancers was 63.69 + 1.54 years, with an average weight of
140.31 + 25.25lbs. All academic years were represented with
a total of 3 seniors, 4 juniors, 6 sophomores, and 3
freshman; 2 dancers chose not to disclose which academic
class they were in. In order to participate in the current
study dancers must have had at least 5+ years of formalized
dance background. The majority of dancers (n=9) had 12+
years of dance background according to the demographic
response. Four dancers had 9-12 years experience and four
had 5-8 years experience. Each of the participants reported
themselves as dance minors at their respective university.
The majority of participants (n=12) indicated that a
medical professional had never talked to them about their
nutrition previously. Out of those who had (n=5), two had

17
said a Certified Athletic Trainer had spoken to them about
their nutrition, one had spoken to a Medical Doctor, one
had spoken to a Registered Dietician, and one failed to
respond to this question.

Only 2 out of the 17 dancers

answered yes when asked whether or not they have ever
consulted a medical professional about nutrition.
All participants completed the two surveys addressing
nutrition knowledge, eating habits, and eating behavior.
Their scores on the nutrition knowledge and eating habits
questionnaire overall were poor while their scores on the
restrained eating subscale of the Dutch Eating Behavior
Questionnaire (DEBQ) were categorized as being at average
risk of restrained eating (Table 1).

Table 1. Descriptive Statistics for Survey Scales
Test Name
Nutrition
Knowledge
Eating
Habits
Restrained
Eating
Subscale
of
DEBQ

Test Average
Score
42.68%

Standard
Deviation
0.077

Range of
Scores
27.27 - 59.09%

53.47%

0.074

37.50 – 67.50%

3.22

0.667

1.7 – 4.0

Classifications of the percentage scores on the
nutrition knowledge and eating habits portions of the

18
participants responses were categorized as excellent = 85100%, good = 70-84%, fair = 55-69%, and poor = 54% or
below.20 Of the 18 participants, only one was classified as
having fair nutrition knowledge, while the remainder were
in the poor category. Ten participants were in the fair
category for eating habits while the remainder was
categorized as poor. Overall, none of the participants were
categorized as having good or excellent nutrition knowledge
or eating habits.
The scores for the restrained eating subscale of the
DEBQ were categorized as being very high = >4.01, high =
3.51-4.00, above average = 3.23-3.50, average = 2.78-3.22,
below average = 2.31-2.77, low = 1.30-2.30, or very low =
<1.29 for being at risk of restrained eating.21 Five
participants were categorized as being in the high risk of
restrained eating category, 6 in the above average, 4 in
the average, and 3 in the low category. None of the
participants were categorized in the very high, below
average, or very low category of the restrained eating
subscale of the DEBQ portion of this study.

19
Hypothesis Testing

Testing was performed on the data using SPSS version
14.0 for Windows at an alpha level of < 0.05.

The research

hypotheses were analyzed using a Pearson Product Moment
Correlation.

Hypothesis 1: There will be no correlation among
nutrition knowledge scores and eating habits scores in
university dancers.
Hypothesis 2: There will be a positive correlation
between the restrained eating behavior subscale of the
DEBQ scores and eating habits scores in university
dancers.
Hypothesis 3: There will be an inverse correlation
between nutrition knowledge scores and the restrained
eating behavior subscale of the DEBQ scores in university
dancers.

Conclusion: A Pearson correlation was calculated for
the relationships between (1) participant’s nutrition
knowledge scores and eating habit scores, (2) participant’s
restrained eating behavior subscale scores of the DEBQ and
eating habit scores, and (3) participant’s nutrition

20
knowledge scores and restrained eating behavior subscale
scores of the DEBQ.
A weak positive correlation that was not significant was
found between nutrition knowledge and eating habits
(r(16)=.177, P>.05). Thus, this hypothesis was supported.

A weak positive correlation that was not significant was
found between restrained eating as measured by the DEBQ
subscale and eating habits(r(16)=.064, P>.05). Thus,
hypothesis 2 was not supported.

A weak positive correlation that was not significant was
found between restrained eating as measured by the DEBQ
subscale and eating habits in university
dancers(r(16)=.234, p>.05). Thus, hypothesis 3 was not
supported.

Additional Findings

Demographic data was analyzed against the
participant’s results scores for nutrition knowledge,
eating habits, and the restrained eating subscale of the
DEBQ. No statistically significant Pearson Product Moment
Correlations were found between participant’s weight, age,

21
year in school, or the fact that they had or had not taken
a nutrition course and their scores on the three survey
components.
It was interesting, however, that only 3 of the 17
participants had taken a nutrition course; 2 sophomores and
1 senior. When participants were asked if they had a
question about nutrition and whom would they first consult
the results were also interesting. Their answers in
descending order were as follows: parents (n=4), medical
doctor (n=4), registered dietician (n=3), dance instructor
(n=2), non-dance friend (n=2), and Certified Athletic
Trainer (n=2).

22

DISCUSSION

The following discussion is divided into three
sections: Discussion of Results, Conclusions, and
Recommendations.

Discussion of Results

This study was designed to establish a nutritional
profile of PSAC Division II university dancers by
collecting data about their nutrition knowledge, eating
habits, and their possible eating behavior risk of
restrained eating.
Gaining participants for such a study proved to be
more difficult than expected. Due to the nature of
increased privacy laws, research was negatively affected.
Gaining access to email addresses of potential participants
was challenging because of institutions not wanting to
release the information. While understandable, it then
reduced the potential number of participants of this study
to no more than 40 participants. In order to analyze
results the researcher was seeking at least a return rate

23
of 40% in order to justify the study. A total number of 18
participants volunteered their time for this study, which
was a return rate of 45%.
Nutrition plays a key role in athlete’s performance,
but can also reduce injury and fuel their bodies for
sustained physical activity.1-6 Dancers are no different in
that they too demand a lot physically from their bodies in
order to perform, and are also at risk to injury and
fatigue because of those demands. Thus, the caloric and
nutrient needs of athletes and dancers are higher due to
their high energy expenditure when compared to a sedentary
individual.1-4,7,8
In order for dancers to remain healthy and see
positive gain in performance they must meet their energy
expenditure with proper energy intake. According to
previous research however, athletes at the university level
fail to demonstrate proper nutrition practices.5,6,9 Results
of these various studies also conclude student athletes
lack nutrition knowledge and good eating behavior as a
whole.5 The results of this study support previous research
and provide an insight into the university dancer.
Based on previous research the current study
hypothesized that university dancers would have tendencies
of restrained eating and poor eating habits. It was also

24
hypothesized that university dancers’ nutrition knowledge
would be ambiguous to their habits and behaviors, again
according to previous research and the researchers
intuition.
Participants in the current study revealed poor
nutrition knowledge and eating habits as a whole and
individually. Only one dancer was categorized as having
fair nutrition knowledge while the remainder scored into
the poor category. Of the 18 participants, in regards to
eating habits, all scored into the fair or poor categories.
This could be the cause of many different contributing
factors, one being that all participants were dance minors.
In this study, dance minor programs have only dance class
requirements to fulfill the minor and lack coursework in
nutrition or physiology, which relates to the body’s
function or health. Without education requirements
addressing nutrition or body function dancers might not
have optimal opportunities to gain such information. Thus,
university dancers remain uneducated about their health as
seen by their lack of nutrition knowledge and proper eating
habits in the current study.
The individuals participating as dance minors in
college may have other passions, which allows them to pay
less attention to nutrition and their physique as a dancer.

25
If this is true, then profiles of similar university
dancers might also reflect a lack of nutrition knowledge
and proper eating habits as opposed to past research that
has shown dancers to have better knowledge about nutrition
than non-dancers.
Research has also shown a higher trend in disordered
eating in female athletes over their male counterparts.11,12
Females participating in sports or activities emphasizing
physique are significantly more likely to practice
disordered eating or improper nutrition habits according to
past research.11,12 Dance is particularly targeted in the
research for participants being more likely to suffer from
eating disorders or disordered eating habits.14-18 It was
because of this previous research that the current study
sought to discover what was occurring in the university
dancer in regards to eating behaviors and disordered
eating.
The current study considered risk of restrained eating
as a measure of eating behaviors occurring in the NCAA
Division II university dancer. Participants as a whole were
at average risk of restrained eating, however there were 11
out of the 18 participants who displayed above average risk
of restrained eating, 5 of which who were in the high risk
category. These findings support previous research of

26
disordered eating being present in a dance setting but not
to the extreme in research on professional dancers.
It is also interesting to note that the literature
suggests that dancers who perform mainly one form of dance
respond differently in regards to their nutrition knowledge
or eating behaviors.17 According to research, collegiate
dancers who study primarily ballet have a higher risk of
disordered eating than their counter parts who primarily
study modern or alternative types of dance.17 When asked in
the current study what the foundation of their dance minor
was, either ballet, modern or mixed, most dancers responded
mixed. Due to the majority of the dancers in the current
study having a mixed minor they are receiving classes and
influences from several types of dance. This supports the
previous research by examining a different aspect of the
collegiate dancer, one who fairs in the middle between
ballet and modern, which shows new information about
nutrition in this population.
Dancers at the university level often have a full
schedule of requirements to meet their dance major or minor
ranging from classical ballet to alternative or modern
dance. Since research has shown ballet to be more at risk
for disordered eating than modern it can be rationalized
that dancers at the university level will also show to have

27
varying nutritional profiles because of varying program
requirements.
By creating this nutritional profile, instructors and
medical professionals are able to identify areas of
weakness in the nutritional status of university dancers.
From this study medical professionals can also determine
the best way to provide education, intervention, or offer
help where there are discrepancies in the dancers they work
with now or in the future. There is plenty of room for
improvement in the nutrition habits of the dancers, which
will enhance performance, reduce injury, and overall
provide the dancers a healthier lifestyle.
Another important component to this research is the
discovery of the lack of utilization of ATC’s by dancers.
Education should also address the qualifications of
Certified Athletic Trainers and how they can assist dancers
health and well being. It also provides an insight for
medical professionals to approach the subject with
university dancers knowing they may need more direction for
their nutritional health.

28
Conclusions

Findings suggest that PSAC Division II university
dancers lack proper nutrition knowledge, eating habits, and
indicate that some are potentially at risk for restrained
eating behaviors. Results indicate that dancers require
education about nutrition and proper care for their active
bodies in general. If nutrition or physiology coursework
was added to their requirements for their dance minor, the
results of future studies like this may show positive
outcomes. Dance instructors, certified athletic trainers,
and any other personnel working with university dancers
should work to increase the nutrition knowledge of dancers
in hopes to positively affect their eating habits and
decrease their risk of restrained eating. With improved
nutrition knowledge and eating habits, restrained eating
risk may decrease, performance quality may increase, and
dancers may be healthier with less fatigue and potential
injury.

29

Recommendations

Future research is needed to look at different
divisions of university dancers, perhaps Division I where
dancers are more likely to be dance majors performing in
more competitive programs or considering dance as a career,
and/or receiving scholarship money for their education.
Future research should also consider education institutions
outside of the PSAC Division II schools. Results may differ
due to geographic location, or in competitive
conservatories.
Another key component to the current study was placing
the demographics section at the end of the online survey.
It was believed that data would better represent the dancer
if they did not first identify themselves as such. This was
believed to create less biased answers from the
participants and is suggested in replicating for future
studies. Lastly, in regards to the demographics section of
this study it is recommended to add the answer of “Internet
information” to the question regarding whom dancers would
consult if they had a nutrition question. Due to technology
and the use of smart phones increasing it would be

30
beneficial to see where the Internet falls in the opinion
of participants seeking information.
General recommendations however include adding
nutrition and/or physiology coursework to dance major and
minor program tracks at universities to educate dancers on
their personal nutrition habits. Also, educating
individuals who work closely with the university dance
population would be beneficial as they may assist in
optimizing dancer performance through encouraging proper
eating habits and behaviors.
Another useful tool typically under-utilized by the
dance community is the use of Certified Athletic Trainers.
Each of the schools asked to participate in this study have
traditional athletic programs staffed by ATC’s who could
also benefit the university dancer while providing
nutrition education within their scope of practice.
The visibility of Certified Athletic Trainer needs to
be increased in regards to the dance population if benefits
are to be gained. From this study the ATC can recognize a
need for nutrition education and the opportunity to
approach a sometimes elusive community through offering to
help. Historically dancers had avoided athletic training
rooms because they do not recognize themselves as athletes.
Ideally this would change so dancers may recognize that

31
they demand a lot from their bodies and on occasion need
treatment like any other type of athlete. Through
collaboration of university ATC’s, dance instructors, and
dancers nutrition education may be provided and the health
and wellbeing of the dancers’ improved.

32
REFERENCES

1.

Pramukova B, Szabadosova V, Soltesova A. Current
knowledge about sports nutrition. Australasian Medical
Journal[serial online]. March 2011;4(3):107-110.
Available from: Academic Search Complete, Ipswich, MA.
Accessed October 18, 2012.

2.

Kreider R, Wilborn C, Antonio J, et al. ISSN exercise
& sport nutrition review: Research &
recommendations. Journal Of The International Society
Of Sports Nutrition [serial online]. 2010;(1):7.
Available from: Directory of Open Access Journals,
Ipswich, MA. Accessed November 26, 2012.

3.

Karlsson M, Nordqvist A, Karlsson C. Physical activity
increases bone mass during growth. Food & Nutrition
Research[serial online]. March 2008;52:1-10. Available
from: SPORTDiscus with Full Text, Ipswich, MA.
Accessed November 26, 2012.

4.

Heaney S, O'Connor H, Michael S, Gifford J, Naughton
G. Nutrition knowledge in athletes: A systematic
review. International Journal Of Sport Nutrition &
Exercise Metabolism [serial online]. June 2011;
21(3):248-261. Available from: SPORTDiscus with Full
Text, Ipswich, MA. Accessed November 26, 2012.

5.

Ozdogan Y, Ozfer Ozcelik A. Evaluation of the
nutrition knowledge of sports department students of
universities. Journal Of The International Society Of
Sports Nutrition [serial online]. January
2011;8(1):11-17. Available from: SPORTDiscus with Full
Text, Ipswich, MA. Accessed September 14, 2012.

6.

Nazni P, Vimala S. Nutrition knowledge, attitude and
practice of college sportsmen. Asian Journal Of Sports
Medicine [serial online]. June 2010;1(2):93-100.
Available from: SPORTDiscus with Full Text, Ipswich,
MA. Accessed September 14, 2012.

7.

Heaney S, O'Connor H, Gifford J, Naughton G.
Comparison of strategies for assessing nutritional
adequacy in elite female athletes' dietary

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intake. International Journal Of Sport Nutrition &
Exercise Metabolism [serial online]. June
2010;20(3):245-256. Available from: SPORTDiscus with
Full Text, Ipswich, MA. Accessed November 26, 2012.
8.

American College of Sports Medicine, American Dietetic
Association, and Dieticians of Canada. Joint Position
Stand: Nutrition and Athletic Performance. Med Sci
Sports Exer. 2000:709-731

9.

Dunn D, Turner L, Denny G. Nutrition knowledge and
attitudes of college athletes. Sport Journal [serial
online]. October 2007;10(4):45-52. Available from:
SPORTDiscus with Full Text, Ipswich, MA. Accessed
September 14, 2012.

11.

Greenleaf C, Petrie T, Carter J, Reel J. Female
collegiate athletes: Prevalence of eating disorders
and disordered eating behaviors. Journal Of American
College Health [serial online]. March 2009;57(5):489496. Available from: SPORTDiscus with Full Text,
Ipswich, MA. Accessed September 14, 2012.

12.

Reinking M, Alexander L. Prevalence of disorderedeating behaviors in undergraduate female collegiate
athletes and nonathletes. Journal Of Athletic
Training [serial online]. January 2005;40(1):47-51.
Available from: Academic Search Complete, Ipswich, MA.
Accessed October 19, 2012.

14.

Anshel M. Sources of disordered eating patterns
between ballet dancers and non-dancers. Journal Of
Sport Behavior[serial online]. June 2004;27(2):115133. Available from: Academic Search Complete,
Ipswich, MA. Accessed September 12, 2012.

15.

Nordin-Bates S, Walker I, Redding E. Correlates of
disordered eating attitudes among male and female
young talented dancers: Findings from the UK centres
for advanced training. Eating Disorders [serial
online]. May 2011;19(3):211-233. Available from:
Academic Search Complete, Ipswich, MA. Accessed
September 12, 2012.

16.

Penniment K, Egan S. Perfectionism and learning
experiences in dance class as risk factors for eating
disorders in dancers. European Eating Disorders

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Review [serial online]. January 2012;20(1):13-22.
Available from: Academic Search Complete, Ipswich, MA.
Accessed September 12, 2012.
17.

Schluger A. Disordered eating attitudes and behaviors
in female college dance students: Comparison of modern
dance and ballet dance majors. North American Journal
Of Psychology [serial online]. March 2010;12(1):117128. Available from: Academic Search Complete,
Ipswich, MA. Accessed September 15, 2012.

18.

Hidayah G, Bariah A. Eating attitude, body image, body
composition and dieting behaviour among dancers. Asian
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19.

Marino SA. The Role Nutrition Plays in the Eating
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California, PA: California University of Pennsylvania;
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Shepard M. A Nutritional Profile of Female NCAA
Division II Swimmers. [master’s thesis]. California,
PA: California University of Pennsylvania; 2007.

21.

Van Strien T, Frijters J, Bergers G, Defares P. The
Dutch eating behavior questionnaire (DEBQ) for
assessment of restrained emotional, and external
eating behavior. International Journal Of Eating
Disorders [serial online]. February 1986;5(2):295-315.
Available from: Academic Search Complete, Ipswich, MA.
Accessed November 26, 2012.

35

APPENDICES

36

APPENDIX A
Review of Literature

37

REVIEW OF LITERATURE

The purpose of this literature review is to inform the
reader of the necessary background information regarding
nutrition in the physically active young adult population.
The literature review examines the influence of nutrition
as it relates to sport, nutrition knowledge and habits of
the physically active, disordered eating in the athlete
population, specifically dance, nutrition education, as
well as measurements for nutrition and eating behaviors.

Sports Nutrition

Adequate nutrition is a crucial component of optimal
sports performance in the physically active. In order to
keep one’s physiological systems running effectively, an
individual must have sufficient nutrient and caloric
intake.

1-8

In the athletic population these requirements

increase due to higher energy expenditure during physical
activity.

1-4

Although proper nutrition habits should be

promoted for every individual, it is even more important
for an athlete. Poor eating habits have the potential to

38
lead to compromised performance, decreased endurance, and
in some cases, injury.

3,5

Athletes’ physiological systems perform at a higher
rate than that of a sedentary population, thus their
nutritional needs are greater. Age and activity level play
an important role in the athlete’s energy consumption in
order to remain healthy. Energy input through caloric
intake is considered on an individual basis, taking into
account the variables of activity. While there are no fixed
number of calories an athlete should consume, it is
recommended they meet the energy expended from activities
in order to maintain a healthy body composition.8
Previous research has also indicated an importance of
diet and timing of nutrient ingestion for optimal athletic
performance.

1-3

According to a joint statement from the

American College of Sports Medicine, American Dietetic
Association, and the Dietitians of Canada, athletes
participating in high energy expenditure or prolonged
training need to consume adequate fuel for optimal
performance.

8

Failure to do so may result in loss of muscle

mass, menstrual dysfunction, loss or failure to gain bone
density, increased risk of fatigue, injury, or illness, and
a longer recovery process.

8

While all nutrients serve

important roles for a balanced diet, athletes specifically

39
need to concentrate on consuming enough carbohydrates,
proteins, fats and fluids in order to sustain peak
performance. The following are recommendations taken from
the position statement “Nutrition and Athletic
Performance”,8 “Current knowledge about sports nutrition”,1
and “ISSN exercise and sport nutrition review: research and
recommendations”.2

Carbohydrates for Energy
Carbohydrates are one of the most important
macronutrients for athletes to consider and supply their
working bodies. The main function of carbohydrates is to
provide energy for cellular metabolism by maintaining blood
glucose levels during exercise and replacing muscle
glycogen.

1,8

Carbohydrates must be of the type that supplies

glucose rather than fructose, which may upset the body and
work counteractively against the athlete.8 The consumption
guidelines vary based on the athletes gender, sport,
environmental condition and total energy expenditure.1,2,8
Typically though, it is recommended that athletes consume
6-10g/kg of body weight per day, with high endurance
athletes needing to consume on the higher end of that
range.

8

Carbohydrates are to be consumed before, during and

after exercise due to their powerhouse qualities of

40
igniting systems to perform and helping them recover after
physical activity has occured.1,8

Proteins for Repair and Recovery
An increased intake of protein is recommended for
athletes because it is effectively used for maintenance,
repair, and synthesis of muscles in response to training or
performance.1,2,8 Protein is most recommended after training
has occurred in order to facilitate this production in
skeletal muscle.

8

Athletes rarely have to supplement

protein into their diet as it is in many foods typically
consumed. The dietary guidelines for adults over the age of
18 is for protein to make up 10-35% of ones diet, with
athletes consuming more on the high end of that range.1,8
Endurance athletes are suggested to ingest approximately
1.2-1.4g/kg/day, higher than the typical 0.8g/kg/day for a
sedentary population.8 Some evidence about protein loading
is inconclusive because of how protein is used in the body
and not being stored like carbohydrates.

Fats as Fuel
The dietary guidelines of fat intake for athletes are
only slightly higher for athletes than it is for a
sedentary population.1,2,8 The recommended daily allowance

41
for total fat has not yet been established, however an
acceptable macronutrient distribution range for all adults
is 20-35% of daily energy intake.8 Intakes of healthily fats
assist physiologic processes in the body to function
properly. The body uses fats as a source of energy,
especially as exercise intensity decreases.8 Research has
shown a low fat diet, consisting of less than 15% total
calories as fat, does not have a positive effect on an
athlete’s performance.8 An exceptionally low fat diet can
also negatively affect hormonal secretions in female
athletes, creating menstrual cycle complications.8
Nutrients have the ability to assist with proper
physiologic functioning, which means it is important for
athletes to play an active role in eating correctly. Higher
energy expenditures require athletes to increase calorie
consumption to offset the loss from exercise or training.
Nutrition also plays a key role in injury prevention as
well as helping an athlete recover from activity.3,5
Sports nutrition is a key component to the health and
performance of athletes. Care should be given continually
to the nutrition needs of athletes on an individual basis
in order to meet the demands of their respective sport.

42
Nutrition Knowledge, Eating Habits, and Eating Attitudes in
the Physically Active Population

Although nutrition plays an important role in sports
performance it has been shown that the knowledge of a
proper diet eludes many athletes.

5-21

Dunn et al,9 performed

a study on college athletes’ nutritional knowledge and
attitudes and found they seemed to lack the ability to
translate their nutrition knowledge into good eating
habits.

9

Dunn reported overall, the eating attitudes of

athletes were positive with a low risk for having an eating
disorder, but there was much room for improvement when it
came to diet and disease relationships.

9

Dunn attributes

some of the knowledge and habit disconnect to the
collegiate environment itself, which creates a lack of time
and space to prepare proper meals.9
The research shows a lack of knowledge and poor eating
habits is not solely a problem in the United States (US),
but abroad as well. Yahya Ozdogan5 evaluated nutrition
knowledge of university students of sports departments in
three universities in Ankara, Turkey yielded similar
results to the research in the US. The students in the
study were first and fourth years at their university.
Results were significantly different between the two

43
classes. The fourth year students mean score was 13.460 +
3.703 while the first years mean score was only 11.150 +
2.962.5 The fourth year students had taken a nutrition class
so knowledge gained from the nutrition class may be the
reason for better scores on the nutrition scales used in
the study. Overall, however, the students only had fair
knowledge of proper nutrition knowledge and habits.
Ozdogan,5 similar to Dunn,9 attributes these discrepancies
in knowledge and habits to lack of information, disinterest
in making a change to ones diet, or barriers such as
finances, time, and food preference.5
Peerkhan Nazni et al6 studied knowledge, attitude and
practice of athletes participating in volleyball,
weightlifting and running in private colleges in India. He
found of the three disciplines, runners were the most
knowledgeable about nutrition but at only 29% scoring in
the “very good” category.6 Nazni concluded sportsman have
better than fair knowledge of nutrition but the statistics
show that less than half of them would fall into this
classification. Nazni completed research using the
Knowledge, Attitude, and Practice questionnaire6, which was
different from Dunn and Ozdogan, but had similar results.
They concluded a lack of knowledge is prevalent in the
collegiate age group as a whole.

44
Dancers eating attitudes have also been shown to be
less than optimal in the literature.14-18 Hidayah18 evaluated
the eating attitudes, body image, body composition and
dieting behavior among dancers and found dancers are at a
higher risk for disordered eating compared to a control
group. Hidayah reported that of the 23 dancers, 21.74% had
a high prevalence of risk of eating disorder while only
12.00% of the 50 lean subjects, which was the control
condition, were in the same category.18 The results were
statistically significant and suggest dancers have more
concerns in regards to gaining weight and overall body
image.18
Similarly, Schluger17 compared eating attitudes and
behaviors in female college dance students majoring in two
forms of dance, either modern or ballet. It was reported
out of the modern dance majors, 12.2% scored >20 on the
EAT26, a measure for disordered eating, indicating a high
level of risk for disordered eating. Ballet majors scored
24.4% on the same scale, found to be significantly higher,
indicating a higher risk for disordered eating.17
Although the research has offered opinions on why
athletes, dancers, or the physically active population are
displaying inadequate nutrition habits, further research is
needed to determine why this occurs. Schluger17 and

45
Penniment16 both evaluated perfectionism scales in order to
see the role it played on disordered eating in dancers.
According to Schluger and Penniment dancers as a population
have statistically significantly higher tendencies of
perfectionism, which could contribute to the prevalence of
disordered eating among dancers.

Association to Eating Disorders and Disordered Eating
Many researchers have established female athletes
having a higher risk of developing disordered eating habits
according to their findings.

11-18

Reportedly, sports with an

aesthetic component, such as gymnastics or dance, resulted
in an even higher risk.11,12 Reinking12 describes this higher
risk population as lean-sport athletes, or those in which a
larger body type is discouraged. One of the many issues of
improper nutrient intake in females is the female athlete
triad consisting of disordered eating, amenorrhea, and
osteoporosis.12 At the root of the triad is disordered
eating, according to Reinking; this may mean it is an issue
to be addressed with these lean-sport athletes. This study
concluded lean-sport athletes had a lower body weight and
desired body weight compared to their non-lean sport
athlete peers as well as higher scores on body
dissatisfaction scales.

12

46
Greenleaf11 also examined the prevalence of disordered
eating patterns in female collegiate athletes, which
provided similar results. According to Greenleaf, out of
204 athletes, 2% were classified as having an eating
disorder and 25.5% were symptomatic.

11

Greenleaf states

that there was a significant amount of the asymptomatic
athletes that fell below the clinical definition of
disordered eating,

11

which may mean the results could be

underestimating the problem. In this research study it was
reported about half of the female participant pool was
dissatisfied with their current weight and most believed
they were overweight.

11

It is believed in many cases,

appearance is considered more by females than males. This
may pose an increased risk for athletes who need a higher
energy intake to balance their expenditure.
Dancers have shown to be at high risk for improper
eating habits due to the nature of their environment.
Anshel14 looked at the dance environment to better define
these sources leading to a cultural issue according to
other research. Anshel found the scores for perfectionism,
decreased body satisfaction, and desire for thinness were
higher in the dancing group when compared to the nondancers. This was attributed to the significance placed on
thinness for success in the studio as well as the

47
performance time required of dancers.

14

Anshel described

the energy expenditure for dancers as being lower than
other female high intensity sports. This may be interpreted
as dancers would not decrease their weight from exercise
alone, making extreme dieting a viable option in this
population.

14

Both Anshel14 and Nordin-Bates15 noted that disordered
eating in the dance community traces back to a young age.
Nordin-Bates found in her study of 347 young talented
dancers aged 10-18 scores of perfectionism were quite high
in the young dancers, and 15% of the females were showed
symptoms of disordered eating and menstrual problems.

15

Besides perfectionism, Nordin-Bates discussed the influence
self-esteem can have on the development of disordered
eating. This study discovered self esteem to moderately
correlate with disordered eating, which may also be a
developing issue to emerge later in life.

15

Nutrition Education

Previous research has shown subjects respond
positively to nutrition education programs.

6-9

With

nutrition being so important to optimal performance it
should be a priority to provide education to athletes at

48
any level. Abood et al10 looked at how an education program
affected a collegiate population. The purpose of this
research was to evaluate the efficacy of a nutrition
education program for collegiate female athletes in order
to improve nutrition knowledge.

10

In this pretest-posttest

design, 30 athletes completed a nutrition knowledge test,
self-efficacy scale, and dietary practices questionnaire.
Results reflected a positive trend in habits and knowledge
following the intervention, concluding that those athletes
would be less at risk for the effects of poor nutrition.

10

If programs are shown to work on sport athletes than it
could have implications for also educating dancers.
Upon looking into previous research on nutrition
intervention, several studies supporting its application.
Torres-McGehee21 and a team of researchers conducted an
intervention program for Division I dancers on proper diet
and nutrition intake. This study was also a pretestposttest design that assessed the effectiveness of a
nutritional education program on the college dancer. After
a 4-week program, there was a significant increase in
nutrition knowledge.

21

Mean scores for depression, drive

for thinness, body dissatisfaction and maturity fears all
decreased in the intervention group, showing its success as
a program.

21

Yannakoulia20 looked at a similar intervention

49
but in younger pre-professional dancers. This study
examined professional dance students as opposed to
collegiate dancers. The aim of the study was to evaluate
the effectiveness of an intervention program that combined
nutrition education and prevention of disordered eating.

20

There were 32 dancers and the data was from a set of
questionnaires that were taken on three occasions.

20

Significant increase in knowledge and decreased in
disordered eating were seen in the intervention group even
six months after the intervention, demonstrating its
effectiveness.20
The development and evaluation of a nutrition
education program has also been documented in the
literature for adolescent dancers.

19

Through a pre-recorded

lecture series shown to youth ballet dancers at a summer
intensive program, the researchers sought to educate the
dancers on sports nutrition, healthier diets and the female
athlete triad.

19

Each participant completed demographic

information, a sports nutrition knowledge questionnaire,
and a food frequency questionnaire before and after the
nutrition education program. The program was shown to be
statistically significant in increasing knowledge and
perceived susceptibility to the female athlete triad.
Self-efficacy also improved along with better dietary

19

50
habits of the experimental group,

19

both of which are

important in reducing disordered eating in the dance
population as a whole.
Although much of the focus in this area is on eating
disorders, the greater problem is with disordered eating
itself. Many athletes and dancers stay clear of a diagnosed
eating disorder like anorexia nervosa or bulimia but are
not eating properly for their activity level. Nutrition
education programs would benefit dancers and clinicians
working with dancers to better address these issues.

51

APPENDIX B
The Problem

52
STATEMENT OF THE PROBLEM

The purpose of the study was to examine the
nutritional profile of dancers at the university level by
examining their nutrition knowledge, eating habits and
eating behavior in regards to tendency of restrained
eating. As disordered eating has frequently been associated
with the dance community, assessing nutrition knowledge and
eating behavior overall might shed more light on problem
areas. It was beneficial to see where anomalies lie in a
university population for the use of education provided by
instructors or medical personnel who work with the dancers.
If this study can identify levels of nutrition
knowledge, and expose possible deficits in nutrition habits
and eating behaviors in the dancers, perhaps the frequency
of disordered eating cases would decrease, benefiting the
performance and health of that dancer. Much of the research
focusing on an adolescent population, professional dancers,
or dancers performing only one specific form of dance,
there is a gap in information about the university level
dancer. It will also be beneficial to see if disordered
eating persists in a demographic that may or may not be on
the professional track to a dance career. Many of the
university dancers are serious about dance but perhaps have

53
other career ambitions, which could change the results from
past research, done on individuals whose livelihood was
dance.

Definition of Terms
The following definitions of terms were defined for
this study and are operational definitions within the
context of the study:
1)

Eating Behavior – reported as a score (%), used to
assess the behaviors each dancer has in regards to
restrained eating.

2)

Eating Disorder - Eating disorders are clinically
diagnosed syndromes characterized by significant
disturbances in eating behavior and by distress or
excessive concern about body shape or weight.

3)

Eating Habits – reported as a score (%), used to
assess the quality of eating habits for each dancer.

4)

Disordered Eating – a term used to describe less
severe forms of eating disorders, where the dancer may
reach just at or below the criteria for a diagnosed
eating disorder.

5)

Formal Dance Experience –in order to participate in
the current study, formal dance experience is defined
as those dancers enrolled as a dance major or minor

54
student at their university, or have had 5+ years of
formal experience. A setting appropriate for this
prerequisite is a dance studio where they paid for
lessons and trained with an educated instructor of
that form of dance. Multiple settings or studios are
acceptable but each must together total five or more
years experience.
6)

Nutrition Knowledge – reported as a score (%),
measuring the quality and background knowledge each
dancer has about pertinent sports related nutrition.

7)

Restrained Eating – a term used to describe the
restriction of food by way of dieting, absence of
eating, or eating in smaller quantities than needed by
the dancer.

Basic Assumptions
The following were basic assumptions of this study:
1)

The participants will be honest when they complete
their demographic sheets.

2)

The participants will be honest when they complete the
questionnaires assessing nutritional knowledge, eating
habits, and eating attitudes.

3)

All scales, measurements, and software used in this
study were considered valid and reliable.

55

Limitations of the Study
The following were possible limitations of the study:
1)

Results may be limited to Division II university
dancers that fit the operational definition for
participation.

2)

Results may be limited to schools that offered dance
major or minor programs.

3)

Results may be limited to schools by which email
addresses could be obtained.

Significance of the Study
The results of this study showed the basic nutrition
knowledge, eating habits, and eating behaviors of
university dancers. The clinician and instructor then saw
where the dancers needed to be educated for the purposes of
reaching optimal performance and minimize injury. A
nutritional profile was also beneficial to the dancers for
the purposes of self-assessment, so they became more aware
of inconsistency in their diets and could make changes
accordingly.
The literature for university dancers is limited. This
study sought to fill in a gap in the research, and give a
better understanding of what is occurring nutritionally in

56
the university dancer. A nutritional profile is a good
starting point to explore how this population differs or is
similar to other participants in previous studies.
Education programs on proper nutrition habits have been
shown in the literature to be beneficial in educating a
dance population, thus such an education program could be
implemented at the Division II university level.

Nutrition

plays a key role in a dancers health and performance.
Collecting data on what they know in regards to nutrition
will be an excellent initiative to correcting any
discrepancies.

57

APPENDIX C
Additional Methods

58

APPENDIX C1
Cover Letter to Dance Instructors and University
Departments

59
March 14, 2013
Dear dance educators and/or department chair:
My name is Sarah Florida and I am a certified athletic trainer who is currently a graduate
student at California University of Pennsylvania pursing a Master of Science in Athletic
Training. Part of the graduate study curriculum is to complete a research thesis through
conducting research. I am conducting survey research in order to examine the nutritional
profile of dancers at the university level. I will be studying any correlations among
nutritional knowledge, eating habits, and eating behavior in the participants. By creating
a general profile of the dancers nutrition, instructors and clinicians can see possible
discrepancies in order to address them properly through education or intervention.
Dancers from selected universities meeting the criteria of being dance majors or minors,
and having 5+ years formalized dance experience will be asked to participate in this
research. However, their participation is voluntary and they do have the right to choose
not to participate. They also have the right to discontinue participation at any time during
the survey completion process at which time their data will be discarded with no penalty.
The California University of Pennsylvania Institutional Review Board has reviewed and
approved this project. The approval is effective 03/11/2013 and expires 03/10/2014.
I would greatly appreciate it if you could forward email addresses for dance
majors/minors within your department or other students participating in dance classes
and/or productions that fit the criteria for participation. I ask that you inform the dancers
to please take this survey at their earliest convenience as it will take approximately 25
minutes to complete. All survey responses are anonymous and will be kept confidential,
an informed consent to use the data collected will be assumed upon return of the survey.
Aggregate survey responses will be housed in a password-protected file on the CalU
campus. Minimal risk is posed by participating in this study and might only involve selfreflection in the participant. The survey will take approximately 25 minutes to complete.
If you have any questions regarding this project, please feel free to contact the primary
researcher, Sarah Florida at FLO6062@calu.edu. You can also contact the faculty
advisor for this research, Dr. Rebecca Hess at 724-938-4356 or through email at
hess_ra@calu.edu. Dancers can use the following link to access the survey:
https://www.surveymonkey.com/s/WGRYBZT
Thank you for taking the time to take part in my thesis research. I greatly appreciate your
time and effort put into this task.
Sincerely,
Sarah Florida, ATC
Primary Researcher
California University of Pennsylvania
734.255.9764
FLO6062@calu.edu

60

APPENDIX C2
Cover Letter in Email Sent to Participants Prior to
Participation

61
March 14, 2013
Dear Participant:
My name is Sarah Florida and I am currently a graduate student at California University
of Pennsylvania pursing a Master of Science in Athletic Training. Part of the graduate
study curriculum is to complete a research thesis through conducting research. I am
conducting survey research in order to examine the nutritional profile of dancers at the
university level. I am studying any correlations among nutritional knowledge, eating
habits, and eating attitudes in university dancers. By creating a general profile of dancers
nutrition, instructors and clinicians can see possible discrepancies in order to address
them properly through education or intervention.
Dancers from selected universities meeting the criteria of being dance majors, dance
minors, and/or having 5+ years formalized dance experience have been asked to
participate in this research. However, your participation is voluntary and you do have the
right to choose not to participate. You also have the right to discontinue participation at
any time during the survey completion process at which time your data will be discarded
without penalty. The California University of Pennsylvania Institutional Review Board
has reviewed and approved this project. The approval is effective 03/11/2013 and expires
03/10/2014.
Please be honest as all survey responses are anonymous and will be kept confidential. An
informed consent to use the data collected will be assumed upon return of the survey.
Aggregate survey responses will be housed in a password-protected file on the CalU
campus. Minimal risk is posed by participating as a participant in this study. I ask that
take this survey at your earliest convenience as it will take approximately 25 minutes to
complete. If you have any questions regarding this project, please feel free to contact the
primary researcher, Sarah Florida at FLO6062@calu.edu. You can also contact the
faculty advisor for this research, Dr. Rebecca Hess at 724-938-4356 or through email at
hess_ra@calu.edu. Thanks in advance for your participation in my survey. The survey
can be accessed at the following link: https://www.surveymonkey.com/s/WGRYBZT
Thank you for taking the time to take part in my thesis research. I greatly appreciate your
time and effort put into this task.
Sincerely,
Sarah Florida, ATC
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
734.255.9764
FLO6062@calu.edu

62

APPENDIX C3
Demographic Sheet

63
Demographic Sheet
Please answer the following questions honestly and to the
best of your knowledge. All of your responses and the
results of this study will be kept strictly confidential.
Thank you for your time.
1.

Height________ Weight_________

2.

Age_______

3.

Academic year in college (Please select one)
____Freshman ____Sophomore ____Junior ____Senior

4.

How many years experience do you have dancing in a formal
setting combined? (For example paid instruction, classes,
studios, colleges/universities)
___5-8

5.

___9-12

___12+

Are you a dance major or minor at your university (please
select one)
___Dance Major

___Dance Minor

6.

Was there an audition for your dance major or minor?
__Yes __No

7.

Is your dance minor ballet based, modern based, mixed or
other?
___Ballet

___Modern

___Mixed

___Other, specify

8.

Have you ever taken a nutrition course? ____yes* ____no
*If yes, how many nutrition courses have you taken?____

9.

Has a medical professional ever talked to you about
nutritional habits?
____yes* ____no
yes, who? (Please check all that apply):

*If

____Certified Athletic Trainer
____Registered Dietician
____Medical Doctor
____Other(Please specify):____________
10. Have you ever consulted a medical professional about
nutrition/diet? ____yes* ____no
*If yes, who?
(Please check all that apply)

64
____Certified Athletic Trainer

____Registered Dietician

____Medical Doctor
____Other(Please specify):____________
*If yes, for what purpose? (Please check one):
____To lose weight
____Supplementation
____To gain weight
____Other(Please specify):_______
7. If you had a question about nutrition, whom would you
most likely consult? (Please check only one):
____Certified Athletic Trainer
____Teammate
____Coach
____Parents
____Friend
____Medical Doctor
____Counselor
____Registered Dietician
____Other (Please Specify):____________

65

APPENDIX C4
REVISED NUTRITIONAL KNOWLEDGE AND EATING HABITS
QUESTIONNAIRE & SCORING KEY

66
Revised Nutritional Knowledge and Eating Habits
Questionnaire
SECTION 1: Please choose the number for each statement
indicating to what extent you agree or disagree with each
of the following statements.
4 - Strongly Agree
3 - Agree Somewhat
2 - Disagree Somewhat
1 - Strongly Disagree
1. Skipping breakfast can negatively affect athletic
performance.
4

3

2

1

2. Nutrition affects mental performance.
4

3

2

1

3. Calcium excretion from the body increases with alcohol
consumption.
4

3

2

1

4. According to myplate.gov (previously mypyramid.gov), it
is recommended that females, age 18-25, who engage in
more than 60 min. of exercise per day, should consume 8
daily ounce equivalents from the grains group.
4

3

2

1

5. According to myplate.gov, females age 18-25, who engage
in more than 60 min. of exercise per day, should consume
2 cups of fruit daily.
4

3

2

1

6. According to myplate.gov, females age 18-25, who engage
in more than 60 min. of exercise per day, should consume
3 servings from the dairy group each day.
4

3

2

1

7. According to myplate.gov, females age 18-25, who engage

67
in more than 60 min. of exercise per day, should consume
6.5 ounce equivalents from the meat/bean group every
day.
4

3

2

1

8. Eating breakfast can improve concentration.
4

3

2

1

9. Excess vitamin consumption can be toxic.
4

3

2

1

10.Anemia is a deficiency of iron.
4

3

2

1

11.Average percentage of body fat in females is 20-25%.
4

3

2

1

12.Cereal, bread, bagels, and pasta are good sources of
carbohydrates.
4

3

2

1

13.Tofu, nuts, and beans are good sources of protein.
4

3

2

1

14.Athletes tend to consume twice as much protein as
recommended.
4

3

2

1

15.The best sources of iron come form animal products and
fish.
4

3

2

1

16.Eating cereals or breads enriched with iron should be
eaten with a source of vitamin C to enhance absorption of
iron.
4

3

2

1

17.Proteins act to repair and build muscle tissue and make
hormones to boost the immune system.

68
4

3

2

1

18.Fats are essential in all diets.
4

3

2

1

19.If a diet is lacking in carbohydrates, proteins are then
used for energy.
4

3

2

1

20.Oatmeal, legumes, and fruits are sources of soluble
fiber.
4

3

2

1

21.The recommended amount of iron for females is 18-23
milligrams per day.
4

3

2

1

22.Vitamin C is also known as ascorbic acid.
4

3

2

1

SECTION 2: Please choose the number that applies to each of
the following questions. Refer to the scale below to
determine the number of days per week defined in each
rating. All of the results will be strictly confidential.
Thank you for your cooperation.

1.

4
3
2
1
How
4

2.

2

1

3

2

1

How often do you take mineral supplements?
4

4.

3

How often do you take vitamin supplements?
4

3.

- Always: Occurs 5-7 days per week
- Often: Occurs 3-4 days per week
- Sometimes: Occurs 1-2 days per week
- Never: Does not occur at all
often do you eat breakfast in the morning?

3

2

1

How often do you eat three base meals per day?

69
4
5.

1

3

2

1

3

2

1

3

2

1

How often do you eat dairy products such as milk,
yogurt, or cheese?
4

10.

2

How often do you eat vegetables, such as broccoli,
tomatoes, carrots, or salad?
4

9.

3

How often do you eat fruits, such as apples, bananas,
or oranges?
4

8.

1

How often are you on a “diet”?
4

7.

2

How often do you record what you eat?
4

6.

3

3

2

1

How often do you seek out nutrition information?
4

3

2

1

70
Scoring Key: Revised Nutritional Knowledge and Eating
Habits Questionnaire
SECTION 1:
1. Skipping breakfast can negatively affect athletic
performance. 4
2.

Nutrition affects mental performance. 4

3.

Calcium excretion from the body increases with alcohol
consumption. 4

4.

According to myplate.gov (previously mypyramid.gov),
it is recommended that females, age 18-25, who engage
in more than 60 min. of exercise per day, should
consume 8 daily ounce equivalents from the grains
group. 4

5.

According to myplate.gov, females age 18-25, who
engage in more than 60 min. of exercise per day,
should consume 2 cups of fruit daily. 4

6.

According to myplate.gov, females age 18-25, who
engage in more than 60 min. of exercise per day,
should consume 3 servings from the dairy group each
day. 4

7.

According to myplate.gov, females age 18-25, who
engage in more than 60 min. of exercise per day,
should consume 6.5 ounce equivalents from the
meat/bean group every day. 4

8.

Eating breakfast can improve concentration. 4

9.

Excess vitamin consumption can be toxic. 4

10.

Anemia is a deficiency of iron. 4

11.

Average percentage of body fat in females is 20-25%.
4

12.

Cereal, bread, bagels, and pasta are good sources of
carbohydrates. 4

13.

Tofu, nuts, and beans are good sources of protein. 4

14.

Athletes tend to consume twice as much protein as
recommended. 4

71
15.

The best sources of iron come form animal products and
fish. 4

16.

Eating cereals or breads enriched with iron should be
eaten with a source of vitamin C to enhance absorption
of iron. 4

17.

Proteins act to repair and build muscle tissue and
make hormones to boost the immune system. 4

18.

Fats are essential in all diets. 4

19.

If a diet is lacking in carbohydrates, proteins are
then used for energy. 4

20.

Oatmeal, legumes, and fruits are sources of soluble
fiber. 4

21.

The recommended amount of iron for females is 18-23
milligrams per day. 4

22.

Vitamin C is also known as ascorbic acid. 4

RANGE OF SCORES: 22-88
SECTION 2:
1. How often do you eat breakfast in the morning? 4
2. How often do you take vitamin supplements? 1
3. How often do you take mineral supplements? 1
4. How often do you eat three base meals per day? 4
5. How often do you record what you eat? 4
6. How often are you on a “diet”? 1
7. How often do you eat fruits, such as apples, bananas, or

oranges? 4
8. How often do you eat vegetables, such as broccoli,

tomatoes, carrots, or salad? 4

9. How often do you eat dairy products such as milk, yogurt,

or cheese? 4

72
10. How often do you seek out nutrition information? 4

RANGE OF SCORES: 10-40
CLASSIFICATIONS:
*Excellent = 85-100%
*Good
= 70-84%
*Fair
= 55-69%
*Poor
= 54% or below

73

APPENDIX C5
DUTCH EATING BEHAVIORS QUESTIONNAIRE & SCORING PROCEDURE

74
Dutch Eating Behaviors Questionnaire
Please choose the number for each statement indicating to
what extent you act in the matter of the following
statements.
5 – Very Often
4 - Often
3 - Sometimes
2 - Seldom
1 - Never

1. If you have put on weight, do you eat less than you
usually do?
5

4

3

2

1

2. Do you try to eat less at mealtimes than you would
like to eat?
5

4

3

2

1

3. How often do you refuse food or drink offered because
you are concerned about your weight?
5

4

3

2

1

4. Do you watch exactly what you eat?
5

4

3

2

1

5. Do you deliberately eat foods that are slimming?
5

4

3

2

1

6. When you have eaten too much, do you eat less than
usual the following days?

75
5

4

3

2

1

7. Do you deliberately eat less in order not to become
heavier?
5

4

3

2

1

8. How often do you try not to eat between meals because
you are watching your weight?
5

4

3

2

1

9. How often in the evening do you try not to eat because
you are watching your weight?
5

4

3

2

1

10. Do you take into account your weight with what you
eat?
5

4

3

2

1

11. Do you have the desire to eat when you are irritated?
5

4

3

2

1

12. Do you have a desire to eat when you have nothing to
do?
5

4

3

2

1

13. Do you have a desire to eat when you are depressed or
discouraged?
5

4

3

2

1

14. Do you have a desire to eat when you are feeling
lonely?
5

4

3

2

1

76
15. Do you have a desire to eat when somebody lets you
down?
5

4

3

2

1

16. Do you have a desire to eat when you are mad?
5

4

3

2

1

17. Do you have a desire to eat when you are approaching
something unpleasant to happen?
5

4

3

2

1

18. Do you get the desire to eat when you are anxious,
worried, or tense?
5

4

3

2

1

19. Do you have a desire to eat when things are going
against you or when things have gone wrong?
5

4

3

2

1

20. Do you have a desire to eat when you are frightened?
5

4

3

2

1

21. Do you have a desire to eat when you are disappointed?
5

4

3

2

1

22. Do you have a desire to eat when you are emotionally
upset?
5

4

3

2

1

23. Do you have a desire to eat when you are bored or
restless?
5

4

3

2

1

77
24. If food tastes good to you, do you eat more than
usual?
5

4

3

2

1

25. If food smells and looks good, do you eat more than
usual?
5

4

3

2

1

26. If you see or smell something delicious, do you have a
desire to eat it?
5

4

3

2

1

27. If you have something delicious to eat, do you eat it
straight away?
5

4

3

2

1

28. If you walk past the bakery do you have the desire to
buy something delicious?
5

4

3

2

1

29. If you walk past a snackbar or café, do you have the
desire to buy something delicious?
5

4

3

2

1

30. If you see others eating, do you also have the desire
to eat?
5

4

3

2

1

31. Can you resist eating delicious foods?
5

4

3

2

1

32. Do you eat more than usual when you see others eating?

78
5

4

3

2

1

33. When preparing a meal are you inclined to eat
something?
5

4

3

2

1

79
Dutch Eating Behaviors Questionnaire Scoring Procedure

All scores for participants are transferred from
Survey Monkey to Microsoft Excel. For each participant two
scores are calculated: a raw score total for each scale and
an overall scale score for each scale. The DEBQ scales are
listed below:
Emotional Eating Diffuse Emotions (4 items): 3, 8, 10, 28
Emotional Eating Clearly Labeled Emotions (9 items): 1, 5,
13, 16, 20, 23, 25, 30, 32
Emotional Eating (13 items): 1, 3, 5, 8, 10, 13, 16, 20,
23, 25, 28, 30, 32
External Eating (10 items): 2, 6, 9, 12, 15, 18, 21, 24,
27, 33
Restrained Eating (10 items): 4, 7, 11, 14, 17, 19, 22, 26,
29, 31
Raw score totals are calculated by totaling up the
item scores for each DEBQ-scale.

Scale scores are obtained

by dividing the raw scale score by the total number of
items in that scale endorsed by the participant. For
example, the restrained scale contains ten items. If the
raw score is 36 and all ten items have been endorsed the
scale score is calculated by 36/10= 3.6. If nine items are
endorsed it would then be 36/9= 4. If less than nine items

80
are endorsed scale scores should not be computed because it
will no longer be valid. A participant’s classification of
scale score is then obtained by putting the score in the
norm site of Boom test uitgevers.

81

APPENDIX C6
Institutional Review Board –
California University of Pennsylvania

82
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair

Dear Ms. Sarah Florida:
Please consider this email as official notification that your proposal titled
"Correlation Among Nutrition Knowledge, Eating Habits and Eating Behaviors in
University Dancers” (Proposal #12-050) has been approved by the California
University of Pennsylvania Institutional Review Board as amended, with the
following stipulations:
--: In the consent form the text equivalent must be included: Discontinuation of
participation at any time will go without penalty.
Once you have add this to your consent form, 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 consent form for the Board’s
records.
The effective date of the approval is 3/11/13 and the expiration date is 3/10/14.
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:
(1) 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)
(2) Any events that affect the safety or well-being of subjects
(3) Any modifications of your study or other responses that are
necessitated by any events reported in (2).
(4) To continue your research beyond the approval expiration date of
3/10/14 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

83
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2011;112(3):711-725. Available from: SPORTDiscus with
Full Text, Ipswich, MA. Accessed September 15, 2012.

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ABSTRACT
TITLE:
Researcher:

A Correlation Among Nutrition Knowledge,
Eating Habits, and Eating Behaviors in
University Dancers
Sarah A. Florida

Advisor:

Dr. Rebecca Hess

Date:

April 2013

Research Type: Master’s Thesis
Context:

There is limited research comparing
nutritional knowledge, eating habits, and
eating behaviors of university dancers. The
current study considered dance major or
minors at neighboring Pennsylvania State
Athletic Conference (PSAC) schools that were
similar in size to California University of
Pennsylvania, also a member of the PSAC. The
potential n due to restricted access to the
dancers email addresses because of privacy
was 40. A total 45% return rate left the
current study’s n=18.

Objective:

The purpose of this study was to examine the
nutritional profile of dancers at the
university level and determine if
correlations existed between their nutrition
knowledge, eating habits, and eating
behaviors.

Design:

Correlational research design.

Setting:

Pennsylvania State Athletic Conference
(PSAC) schools with major or minor programs
in dance with total potential n of 40. All
participants completed the study through the
use of surveymonkey.com

Participants:

A total of 18 responses were collected. All
participants must have had 5+ years of
formalized dance experience, and either a
dance major or minor at their university.
All participants in this study, however,
were dance minors.

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Interventions: The researcher obtained email addresses of
the university dancers after receiving
permission from dance departments or dance
instructors. An electronic cover letter was
sent to the departments, instructors, and
participants. It was clearly explained in
the cover letter that participation was
voluntary and discontinuing the survey at
any time was without penalty. By completing
the survey on surveymonkey.com consent was
given for use of data in analysis.
Main Outcome
Measures:

Nutrition knowledge and eating habits were
obtained through the use of a two part
survey, the Revised Nutritional Knowledge
and Eating Habits Questionnaire. The
participant’s eating behaviors were measured
through the use of the Dutch Eating
Behaviors Questionnaire restrained eating
subscale.

Results:

There were no correlations between nutrition
knowledge scores and eating habit scores,
eating habit scores and restrained eating
subscale scores, or restrained eating
subscale scores and nutritional knowledge
scores in the university dancers.

Conclusion:

University dancers were found to have poor
nutrition knowledge, fair eating habits, and
to be at an average risk of restrained
eating according to data analysis. This
implicates a need for proper nutrition
education and a need for certified athletic
trainers to become involved in interacting
with dancers at this level to improve their
health and wellbeing.

Word Count:

415