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Despite the well-documented role of carbohydrate (CHO) in promoting endurance exercise performance, endurance athletes typically fail to meet current recommendations in competition. Adequate nutrition knowledge is key to drive athletes’ behaviour, but the current level of knowledge in this population is not known. The present study assessed knowledge of CHO for competition in an international cohort of endurance athletes using the Carbohydrates for Endurance Athletes in Competition Questionnaire (CEAC-Q). The CEAC-Q was completed by 1016 individuals (45 % female), from the United Kingdom (40 %), Australia/New Zealand (22 %), the United States of America/Canada (18 %) and other countries (21 %). Total CEAC-Q scores were 50 ± 20 % (mean ± sd), with no differences in scores between the five subsections (10 ± 5 points, P < 0⋅001). Based on typical knowledge and frequency of correct answers, we defined questions with low (0–39 %), moderate (40–69 %) and high (70–100 %) knowledge at a population level. Knowledge deficiencies were identified in questions related to CHO metabolism (Low: 2 out of 5 questions (2/5), Moderate: 3/5), CHO-loading (Low: 2/5, Moderate: 1/5), pre-event CHO (Low: 2/5, Moderate: 2/5), CHO during exercise (Moderate: 4/5) and CHO for recovery (Low: 3/5, Moderate: 1/5). Current CHO amounts recommendations were identified correctly for CHO-loading, pre-competition meal, during competition >2⋅5 h) and post-competition recovery by 28% (Low), 45 % (Moderate), 48 % (Moderate), and 29 % (Low), respectively. Our findings indicate that endurance athletes typically have limited knowledge of carbohydrate guidelines for competition, and we identify specific knowledge gaps that can guide targeted nutrition education to improve knowledge as an initial step towards optimal dietary practice.

A key role of a practicing sports dietitian working with competitive endurance athletes is to translate complex information, educate and support athletes to make nutritional changes to their dietary behaviour for improved performance outcomes. Current carbohydrate (CHO) guidelines based upon a wealth of literature demonstrate clear performance benefits when endurance athletes compete with optimal CHO availability. Despite this strong scientific evidence and sports nutrition guidelines recommending CHO intakes to enhance endurance sports performance, a clear mismatch still exists between current guidelines and practice amongst endurance athletes as evidenced in the Literature Review (Chapter 2). With this in mind, the aim of this Professional Doctorate thesis was to investigate whether athletes fail to consume optimal CHO in competition because they were unaware and lack knowledge of the current CHO guidelines, have difficulties with translating knowledge into practice, have personal beliefs or are exposed to external factors which influence their dietary intake within competition.To systematically assess CHO knowledge, we first needed to develop a tool and methodology to do so. Thus, the aim of Study 1 (Chapter 3) was to develop and validate a CHO specific nutrition knowledge assessment tool, based upon contemporary carbohydrate guidelines. The Carbohydrate for Endurance Athletes in Competition Questionnaire (CEAC-Q) consists of 25 questions divided into 5 subsections: CHO metabolism, loading, pre-race meal, during race and recovery with each subsection worth 20 points resulting in a total maximum possible score of 100. A between-groups analysis of variance assessed construct validity between the general population (GenP; n = 67), endurance athletes (EA; n = 145), and registered sports dietitians/nutritionists (SDN; n = 60) with expected increasing levels of knowledge respectively. As expected, there was increasing level of knowledge between populations with a significant difference in CEAC-Q total and subsection scores (mean ±SD) observed between all pairwise comparisons; GenP (17 ±20 %, 3 ±5), EA (46 ±19 %, 9 ±5) and SDN (76 ±10 %, p = < 0.001, 15 ±4 %, p = 0.001), respectively. The CEAC-Q took athletes an average 10:36 ±07:45 minutes to complete online. These data demonstrate that CEAC-Q is a new psychometrically valid, practical and time-efficient tool for practitioners to assess athletes’knowledge of CHO for competition in less than 10 minutes, allowing for quick and accurate identification of knowledge gaps to nutrition strategies to optimise performance.Having developed a suitable CHO knowledge assessment tool in Study 1 (Chapter 3), the aim of Study 2 (Chapter 4) was to assess current knowledge levels and identify knowledge gaps on an international cohort of EA. The CEAC-Q was completed online by EA (n = 1016) actively competing in endurance sporting events (cycling, triathlon and running) with mean CEAC-Q total and subsection scores of 50 ±20% and 10 ±5, respectively. Multiple regression determined that years of competitive experience, competitive level and a sports nutritionist influence were positively related to CEAC-Q scores. Clear knowledge gaps transpired where correct knowledge of current CHO guidelines was shown by 28% (n = 284) for CHO loading, 45% (n = 457) for the pre-competition meal, 48% (n = 487) for during competition lasting >2.5 h and 29% (n = 296) for post-competition recovery. The CEAC-Q identified common gaps in knowledge of CHO guidelines that require further education that may partially explain why athletes fail to meet them within competition.

This article forms part of a series looking at the relationship between diet and good health, and the role of the dietician in the primary health care team. This review highlights some of the physical, social and medical factors that can indicate compromised nutritional status in the elderly, the screening tools available to detect malnutrition, and when to involve a dietician.

Endurance athletes fail to meet carbohydrate (CHO) guidelines for competition, which may be due to limited knowledge. However, the relationship between knowledge and practice in this population is unknown. To investigate this, we assessed the dietary intake in 50 athletes (37 females) who completed endurance events ≥2.5 h in duration and compared CHO intake against the carbohydrates for endurance athletes in competition questionnaire validated nutrition knowledge questionnaire, with specific questions related to CHO loading, pre‐competition meal and during‐competition intake. CHO‐loading guidelines (10–12 g · kg−1 · day−1) were met in practice by n = 5 (10%), but there was no relationship between identified requirements (range 0–12 g · kg−1 · day−1) and actual intake (rs = 0.133, p = 0.358), with the n = 18 (36%) who correctly identified requirements, ingesting 6.1 ± 1.9 g · kg−1 · day−1. CHO intake for pre‐competition meal guidelines (1–4 g · kg−1) was met in practice by n = 40 (80%), but there was no relationship between identified requirements (range 0 to >4 g · kg−1) and actual intake (rs = 0.101, p = 0.487), with n = 19 (38%) who correctly identified guidelines requirements, ingesting 1.4 ± 0.6 g · kg−1. CHO intake during‐competition guidelines (60–90 g · h−1) was met in practice by n = 18 (36%), but there was no relationship between the amounts of CHO required (range 30 to >90 g/h) and actual intake (rs = 0.028, p = 0.849), with n = 32 (64%) who correctly identified guidelines requirements, ingesting 56 ± 20 g · h−1. Results show no relationship between the knowledge of CHO recommendations and practice, suggesting that theoretical knowledge does not guarantee the achievement of best practice and other important factors may ultimately determine practice. Highlights The carbohydrates for endurance athletes in competition questionnaire (CEAC‐Q) score did not show any association between theoretical knowledge and actual intake for carbohydrate (CHO) loading, pre‐competition, or during competition scenarios, indicating that athletes do not necessarily apply what they know. Despite 30% of athletes meeting the guidelines for CHO loading, and CHO intake during competition, there was no clear relationship between practice and their knowledge of these guidelines as measured by the CEAC‐Q. The discrepancy between theoretical knowledge and actual intake within real‐world competition highlights that other factors may be important barriers and facilitators to translate scientific knowledge and bridge the gap into optimal dietary practices of endurance athletes.

The Nutritional Support for Africans Starting Antiretroviral Therapy (NUSTART) trial was designed to determine whether nutritional support for malnourished HIV-infected adults starting antiretroviral therapy (ART) can improve early survival. Appetite is related to health outcomes in this population, but the optimal appetite metric for field use is uncertain. We evaluated two measures of appetite with the goal of improving understanding and treatment of malnutrition in HIV-infected adults. Longitudinal cohort study embedded in a clinical trial of vitamin and mineral-fortified, v. unfortified, lipid-based nutritional supplements. HIV clinics in Mwanza, Tanzania and Lusaka, Zambia. Malnourished (BMI<18.5 kg/m2) HIV-infected adults starting ART. Appetite measurements, by short questionnaire and by weight of maize porridge consumed in a standardized test, were compared across time and correlated with changes in weight. Appetite questionnaire scores, from polychoric correlation, and porridge test results were normally distributed for Tanzanians (n 187) but clustered and unreliable for Zambians (n 297). Among Tanzanian patients, the appetite score increased rapidly from referral for ART, plateaued at the start of ART and then increased slowly during the 12-week follow-up. Change in appetite questionnaire score, but not porridge test, correlated with weight change in the corresponding two-week intervals (P=0.002) or over the whole study (P=0.05) but a point estimate of hunger did not predict weight change (P=0.4). In Tanzania change in appetite score correlated with weight change, but single point measurements did not. Appetite increases several weeks after the start of ART, which may be an appropriate time for nutritional interventions for malnourished HIV-infected adults.

Although non-suicidal self-injury (NSSI) is an issue of major concern to colleges worldwide, we lack detailed information about the epidemiology of NSSI among college students. The objectives of this study were to present the first cross-national data on the prevalence of NSSI and NSSI disorder among first-year college students and its association with mental disorders. Data come from a survey of the entering class in 24 colleges across nine countries participating in the World Mental Health International College Student (WMH-ICS) initiative assessed in web-based self-report surveys (20 842 first-year students). Using retrospective age-of-onset reports, we investigated time-ordered associations between NSSI and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV) mood (major depressive and bipolar disorder), anxiety (generalized anxiety and panic disorder), and substance use disorders (alcohol and drug use disorder). NSSI lifetime and 12-month prevalence were 17.7% and 8.4%. A positive screen of 12-month DSM-5 NSSI disorder was 2.3%. Of those with lifetime NSSI, 59.6% met the criteria for at least one mental disorder. Temporally primary lifetime mental disorders predicted subsequent onset of NSSI [median odds ratio (OR) 2.4], but these primary lifetime disorders did not consistently predict 12-month NSSI among respondents with lifetime NSSI. Conversely, even after controlling for pre-existing mental disorders, NSSI consistently predicted later onset of mental disorders (median OR 1.8) as well as 12-month persistence of mental disorders among students with a generalized anxiety disorder (OR 1.6) and bipolar disorder (OR 4.6). NSSI is common among first-year college students and is a behavioral marker of various common mental disorders.

To assess the accuracy of WMH-ICS online screening scales for evaluating four common mental disorders (Major Depressive Episode[MDE], Mania/Hypomania[M/H], Panic Disorder[PD], Generalized Anxiety Disorder[GAD]) and suicidal thoughts and behaviors[STB] used in the UNIVERSAL project. Clinical diagnostic reappraisal was carried out on a subsample of the UNIVERSAL project, a longitudinal online survey of first year Spanish students (18-24 years old), part of the WHO World Mental Health-International College Student (WMH-ICS) initiative. Lifetime and 12-month prevalence of MDE, M/H, PD, GAD and STB were assessed with the Composite International Diagnostic Interview-Screening Scales [CIDI-SC], the Self-Injurious Thoughts and Behaviors Interview [SITBI] and the Columbia-Suicide Severity Rating Scale [C-SSRS]. Trained clinical psychologists, blinded to responses in the initial survey, administered via telephone the Mini-International Neuropsychiatric Interview [MINI]. Measures of diagnostic accuracy and McNemar χ2 test were calculated. Sensitivity analyses were conducted to maximize diagnostic capacity. A total of 287 students were included in the clinical reappraisal study. For 12-month and lifetime mood disorders, sensitivity/specificity were 67%/88.6% and 65%/73.3%, respectively. For 12-month and lifetime anxiety disorders, these were 76.8%/86.5% and 59.6%/71.1%, and for 12-month and lifetime STB, 75.9%/94.8% and 87.2%/86.3%. For 12-month and lifetime mood disorders, anxiety disorders and STB, positive predictive values were in the range of 18.1-55.1% and negative predictive values 90.2-99.0%; likelihood ratios positive were in the range of 2.1-14.6 and likelihood ratios negative 0.1-0.6. All outcomes showed adequate areas under the curve [AUCs] (AUC>0.7), except M/H and PD (AUC = 0.6). Post hoc analyses to select optimal diagnostic thresholds led to improved concordance for all diagnoses (AUCs>0.8). The WMS-ICS survey showed reasonable concordance with the MINI telephone interviews performed by mental health professionals, when utilizing optimized cut-off scores. The current study provides initial evidence that the WMS-ICS survey might be useful for screening purposes.

Purpose Age and body mass index (BMI) are critical considerations when assessing individual breast cancer risk, particularly for women with dense breasts. However, age- and BMI-standardized estimates of breast density are not available for screen-aged women, and little is known about the distribution of breast density in women aged < 40. This cross-sectional study uses three different modalities: optical breast spectroscopy (OBS), dual-energy X-ray absorptiometry (DXA), and mammography, to describe the distributions of breast density across categories of age and BMI. Methods Breast density measures were estimated for 1,961 Australian women aged 18–97 years using OBS (%water and %water + %collagen). Of these, 935 women had DXA measures (percent and absolute fibroglandular dense volume, %FGV and FGV, respectively) and 354 had conventional mammographic measures (percent and absolute dense area). The distributions for each breast density measure were described across categories of age and BMI. Results The mean age was 38 years (standard deviation = 15). Median breast density measures decreased with age and BMI for all three modalities, except for DXA-FGV, which increased with BMI and decreased after age 30. The variation in breast density measures was largest for younger women and decreased with increasing age and BMI. Conclusion This unique study describes the distribution of breast density measures for women aged 18–97 using alternative and conventional modalities of measurement. While this study is the largest of its kind, larger sample sizes are needed to provide clinically useful age-standardized measures to identify women with high breast density for their age or BMI.

BackgroundBreast density is a strong and potentially modifiable breast cancer risk factor. Almost everything we know about breast density has been derived from mammography, and therefore, very little is known about breast density in younger women aged <40. This study examines the acceptability and performance of two alternative breast density measures, Optical Breast Spectroscopy (OBS) and Dual X-ray Absorptiometry (DXA), in women aged 18–40.MethodsBreast tissue composition (percent water, collagen, and lipid content) was measured in 539 women aged 18–40 using OBS. For a subset of 169 women, breast density was also measured via DXA (percent fibroglandular dense volume (%FGV), absolute dense volume (FGV), and non-dense volume (NFGV)). Acceptability of the measurement procedures was assessed using an adapted validated questionnaire. Performance was assessed by examining the correlation and agreement between the measures and their associations with known determinants of mammographic breast density.ResultsOver 93% of participants deemed OBS and DXA to be acceptable. The correlation between OBS-%water + collagen and %FGV was 0.48. Age and BMI were inversely associated with OBS-%water + collagen and %FGV and positively associated with OBS-%lipid and NFGV.ConclusionsOBS and DXA provide acceptable and viable alternative methods to measure breast density in younger women aged 18–40 years.