Dietary Information for Gut Endurance Sport Testing (DIGEST): Exploring the relationship between Gut Health, Sports Nutrition Knowledge and Nutritional Practices in Elite Sport

Dietary Information for Gut Endurance Sport Testing (DIGEST): Exploring the relationship between Gut Health, Sports Nutrition Knowledge and Nutritional Practices in Elite Sport | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dietary Information for Gut Endurance Sport Testing (DIGEST): Exploring the relationship between Gut Health, Sports Nutrition Knowledge and Nutritional Practices in Elite Sport Rowan Kearns, James Steven Gerard Dooley, Mark Matthews, Andrea McNeilly This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4476204/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Gastrointestinal (GI) complaints are prevalent among athletes and can have a significant impact on performance, particularly in endurance athletes. Possessing greater nutrition knowledge and effectively applying it may play an important role in optimising an athlete’s performance. Despite this, there is a paucity of research regarding GI experiences, sports nutritional knowledge (SNK) and any reciprocal relationship in elite sport. The aim of this study was to design a novel questionnaire to assess the relationship between common GI complaints, GI health, and SNK in elite athletes and coaches in the United Kingdom and Ireland. The study further explored attitudes and practices regarding diet, supplementation, and training practices to gain a comprehensive understanding of potential causative factors to GI distress. Main Body This study developed and administered a novel SNK questionnaire, the ‘Dietary Information for Gut Endurance Sport Testing’ (DIGEST) questionnaire to 400 elite athletes and their coaches from various sporting backgrounds. The cross-sectional questionnaire assessed GI complaints, SNK, probiotic usage, dietary practices, and exercise workload. Chi-square analyses and independent sample t-tests were employed to examine associations between variables. Results There were 211 reports of GI complaints, with the higher prevalence in individual sports, 161, compared to team sport participants, 50 complaints ( p = 0.04). Common GI complaints included stomach pain, bloating, constipation, diarrhoea, bloody diarrhoea, and nausea. The timing of GI complaints challenged conventional understanding with 45.5% of participants experiencing symptoms pre-exercise, 14% at the start of exercise, 35.1% after more than 30 minutes, and 38.7% immediately post exercise. While probiotic use was common ( p = 186), its benefits were inconclusive. Bloating and irritable bowel disease (IBD) were significantly correlated with probiotic use, which may indicate individuals with these conditions use probiotics for symptom management. The study found no significant correlation between SNK scores and GI complaints among elite athletes ( p = 0.13), suggesting SNK may not play a crucial role in preventing or contributing to these issues. However, it is noteworthy that a substantial number of participants, athletes (mean score of 59%) and coaches (mean score of 58%), demonstrated suboptimal SNK scores below the 65% threshold. Consequently, it remains unclear whether enhancing SNK levels could contribute to the reduction of GI complaints. Conclusion The results of this study suggest that both athletes and coaches have sub-optimal SNK, and it appears that SNK is not related to incidence of GI complaints. However, GI complaints remain common in elite sports, especially in individual sports. These complaints occur most frequently before and towards the end of exercise. Future studies should explore exercise intensity, training practices, stress levels, and psychological well-being alongside SNK to better understand GI complaints in this population. gastrointestinal complaints sports nutrition knowledge elite athletes probiotics dietary practices Key Points Prevalence of GI Complaints Among Athletes : The study found that gastrointestinal complaints are common among athletes, particularly in endurance sports such as running and triathlon. These complaints often occur both pre-exercise and post-exercise, affecting performance. Influence of Probiotics on GI Health : While probiotic usage was common among athletes, the study showed that the relationship between probiotic usage and the reduction of GI complaints was not conclusive. Suboptimal Sports Nutrition Knowledge (SNK) : Both athletes and coaches demonstrated low scores in sports nutrition knowledge, with many not reaching the knowledge threshold that could potentially help in mitigating GI issues. Impact of Nutrition on GI Complaints : Although the study did not find a direct correlation between SNK and the frequency of GI complaints, it highlighted the potential indirect benefits of improved nutrition knowledge, such as better dietary choices that could support gut health and possibly reduce GI symptoms. Timing and Severity of GI Symptoms : The findings indicate that the timing of GI complaints varies, with a significant number occurring before and immediately after exercise. This variability points to the complex relationship between exercise, diet, and GI symptoms, and suggests that timing of meals and types of food consumed could be crucial in managing GI distress. Background Gastrointestinal (GI) complaints are a prevalent factor leading to reduced performance in athletes 1 – 4 . Approximately 30–70% of athletes experience GI symptoms of varying severity, including bloating, cramping, diarrhoea, and vomiting whilst exercising 2 , 5 . These symptoms are particularly common among endurance-based athletes, with studies reporting occurrence in up to 96% in long distance runners 6 – 8 . The aetiology of GI complaints encompasses a multifaceted interplay of physiological, nutritional, and psychological factors 5 , 9 . Several mechanisms have been proposed to explain the occurrence of GI distress, including ischemia-reperfusion injury to the gut lining resulting in tight junction permeability 10 , prolonged motion causing injury to the gut lining 11 , and altered hormonal function involving the Gut Brain Axis (GBA) reducing overall gastrointestinal function capacity 12 . Furthermore, a dose-response relationship exists between exercise intensity and GI complaints, indicating an increased likelihood of experiencing symptoms as exercise intensity rises 13 , 14 . Efforts to mitigate GI symptoms in athletes have prompted the exploration of various preventative interventions. These include maintaining euhydration 15 , carbohydrate feeding protocols 8 , training the gut to tolerate and efficiently process nutrients 16 , dietary fermentable oligo- di- mono- saccharide and polyols (FODMAP) modifications 14 and dietary supplements, such as probiotics, pre-biotics and synbiotics 17 – 26 . One aspect which warrants further exploration is the concept of educational interventions, specifically targeting the enhancement of nutritional knowledge among athletes. Advanced nutritional knowledge and its effective application could significantly improve dietary decision-making, potentially reducing gastrointestinal complaints and optimising performance in endurance sports. Nevertheless, there remains a paucity of research investigating any correlation between GI experiences and sports nutritional knowledge (SNK) among elite athletes. Previous research suggests an athlete’s nutritional knowledge exhibits a positive (albeit weak) correlation with improved dietary habits and subsequent performance 27 – 30 . To this end, several questionnaires have been developed and utilised in elite sport to establish the SNK of athletes, including ‘The Nutritional Knowledge for Young and Adult Athletes (NUKYA)’, ‘Nutrition for Sport Knowledge Questionnaire (NSKQ)’ and an abridged version of the NSKQ (the A-NSKQ) 31 – 33 . However, there is a lack of consistency with regards to questionnaire design and factors such as participant literacy, socioeconomic status, and education 28 , 34 . Moreover, while the prevalence of GI complaints in the athletic population have been extensively documented, and the influence of nutrition on GI symptoms has been acknowledged, there is still a paucity of research pertaining to the assessment of GI health knowledge levels within this population 27 , 28 , 35 . Additionally, none of the existing questionnaires for athletes and their support staff incorporate aspects of GI health. Main Body The primary objective of this study was to introduce and evaluate a novel questionnaire for assessing GI complaints, GI health, and SNK relating to GI health in elite athletes and coaches. A secondary aim was to explore their attitudes and practices concerning diet, supplementation, exercise workload, and sport participation, with the goal of gaining a comprehensive understanding of potential causative factors contributing to GI complaints in this athlete population. This study was conducted in two distinct phases. Phase 1 was the development of a SNK questionnaire which incorporated a gut health element. Phase 2 involved the dissemination of the questionnaire to athletes and coaches in elite sport within the United Kingdom (UK) and Ireland. Phase One: Questionnaire Development A new SNK questionnaire, called the ‘Dietary Information for Gut Endurance Sport Testing’ (DIGEST) questionnaire, was developed following a scoping exercise of current nutritional knowledge screening tools used in sports nutrition professional practice and adapting previous SNK questionnaires, NSKQ 32 , ANSKQ 33 and probiotics questionnaires 36 , 37 . The questionnaire included questions on demographic information, exercise information, GI complaints and frequency of occurrence, nutrition knowledge, supplement knowledge, and probiotic knowledge. The questionnaire consisted of 59 questions across 6 sub-sections: demographic information (n = 5), exercise information (n = 13), GI complaints (n = 11), SNK (n = 9), supplements (n = 8) and probiotic knowledge (n = 13). The majority of questions were multiple-choice, with others requiring participant to type their answer. Demographic information consisted of questions regarding the participants sex, age, nationality, and education level. Exercise information contained questions on the participant’s sport, level they compete at (or coach), type and volume of training sessions and competition. The GI complaints section contained a series of questions on the participants GI health history, type and frequency of GI complaint and also the timing which GI complaints occur in relation to exercise. SNK and supplement questions were based on the sports nutrition sections of NSKQ 32 , ANSKQ 33 . Correct answers were given + 1 score, while incorrect or ‘unsure’ were given a score of 0. To establish a framework for interpreting the participants SNK results, scoring matrices from previously published questionnaires were used 32 , 38 – 41 . According to these matrices, a score below 65% was considered ‘low’ or ‘poor’ knowledge. The Probiotic knowledge section of the questionnaire was adapted from previously validated instruments used to assess health professionals' understanding of probiotics 36 , 37 . This section evaluated respondents' familiarity with the definition, properties, and practical application of probiotics. The questionnaire was designed to take about 15 minutes to complete. Ethics approval and Consent This study obtained ethical approval from the Research Ethics Committee of Ulster University (SESRI-22-038-A), and all participants provided electronically signed informed consent, under the ‘Declaration of Helsinki’ 42 . Phase 2: Recruitment: The study recruited 400 participants from the UK and Ireland. The population encompassed male and female elite endurance and/or high intensity athletes, their coaches, and sports nutritionists/dieticians in elite sport. Participants were required to be ‘healthy’ and of ‘elite’ status, meaning they were free from any long-term injury, disease, or condition that would render them as ‘non-elite’. Additionally, they had to be actively competing or striving to compete at the highest level in their respective sports 43 . E-mails which contained a consent form and link to the online questionnaire were sent to elite sport practitioners and athletes. Social platforms which enable direct messaging were also utilised, including Facebook, LinkedIn and Instagram. Individuals identifying themselves (via their bio) as elite athletes or coaches with sporting qualifications were considered for inclusion in the study's potential candidate pool. The direct message contained information on the study and a link to complete the questionnaire via the Redcap online survey platform (Redcap, NIH/NCATS UL1 TR000445). Data Analysis All statistical analyses were conducted with IBM SPSS Statistics for Windows, Version 24.0. The normal distribution of variables was assessed using the Shapiro–Wilk test. Parametric tests (independent t-test) were used for normal data, non-parametric tests (Mann-Whitney U test) were used when assumptions of normality were violated. Chi-square tests were used to compare categorical data in variables. The significance level was set at p ≤ 0.05. Results Demographic The present study recruited a diverse sample of participants ( n = 400), consisting of elite athletes ( n = 342) and sports nutritionists ( n = 58) from the UK and Ireland. These participants represented a variety of individual and team sports disciplines (Table 1 ). Among the participants, 75% were engaged in individual sports with the largest sporting groups being distance running ( n = 132) and triathlon ( n = 82), while the remaining 25% participated in team sports, with Gaelic football having most participants ( n = 38). The gender demographics consisted of male ( n = 231 / 58%), female ( n = 153 / 38%) and others ( n = 16 / 4%). The age range of the participants spanned from 18 to 65 years, with the majority of athletes ( n = 143 / 36%) aged between 18–31 years of age. GI Conditions and Complaints Among the 400 study participants, 142 (35.5%) reported a diagnosed GI condition. Stomach cramps were most prevalent, affecting 53.5% ( n = 76), followed by IBD, reported by 42.9% ( n = 61). Gastrointestinal reflux disease (GERD) and reflux were noted in 26.8% (n = 38), and constipation was present in 16.9% ( n = 24) of participants. During exercise, 213 athletes experienced GI complaints, with 45.5% ( n = 97) reporting symptoms pre-exercise and 38.7% ( n = 82) post-exercise (Table 1 ). Hurling/Camogie and basketball participants exhibited a 100% incidence of GI complaints, albeit these sports had the lowest participants in the cohort ( n = 4 and n = 2 respectively). Triathlons, distance running, and ‘other’ individual sports had highest participant numbers with more than half reporting some form of GI complaint (58.1%, 55.3% and 55% respectively). Stomach pain and diarrhoea were the most frequent symptoms. Notably, distance runners had a higher incidence of bloating, while triathletes reported a diverse range of symptoms, including bloating, bloody diarrhoea, and stomach pain. Overall, 54.7% ( n = 116) of athletes selected that they occasionally experience GI symptoms such as stomach pain, bloating, constipation, diarrhoea, bloody diarrhoea, and nausea. Symptoms were more frequently reported during longer ( n = 32 / 14.8%) and more intense ( n = 38 / 17.7%) exercise sessions. A weak positive correlation was observed between exercise duration and both bloating (correlation coefficient of 0.15) and diarrhoea (0.18), as well as between exercise intensity and both stomach pain (0.11) and diarrhoea (0.24). Additionally, 127 (31.75%) athletes sought professional advice for digestive issues (Table 2 ), with 142 (35.5%) diagnosed with conditions such as IBS, GERD, reflux, constipation, and cramps. Table 1 Total participants and the percentage of GI complaints in each sport. Sport Total Participants Stomach Pain Bloating Constipation Diarrhoea Bloody Diarrhoea Nausea None Triathlon 74 22.9% 18.92% 8.11% 31.08% 5.41% 9.46% 41.89% Distance Running 114 22.81% 42.11% 8.77% 31.58% 3.51% 6.4% 44.74% Distance Cycling 10 20% 50% 30% 20% 10% 10% 40% Combat Sport 11 18.18% 45.45% 9.09% 27.27% 0 18.18% 54.55% Other 80 26.25% 32.50% 17.5% 11.25% 2.5% 7.5% 45% Gaelic Football 37 32.43% 24.32% 5.41% 10.81% 2.7% 5.41% 51.35% Hurling/ Camogie 4 75% 50% 0 75% 0 25% 0 Soccer 13 23.08% 15.38% 0 0 0 0 69.23% Rugby 16 12.5% 12.5% 0 18.75% 0 0 68.75% Basketball 2 100% 0 0 100% 0 0 0 Other 26 34.62% 38.46% 11.54% 30.77% 11.54% 38.46% Individual vs Team Sport GI complaints A comparative analysis was conducted to investigate the differences in reported GI complaints between participants in "individual sports" and "team sports." The analysis included a total of 211 complaints, acknowledging that participants had the chance to report multiple symptoms. Among the participants, those involved in individual sports exhibited a significantly higher number of GI complaints (p = 0.04), with a total of 161 complaints, whereas those participating in team sports reported 50 complaints. Sports Nutrition Knowledge In accordance with the methodology described, we utilised scoring matrices from previously published studies to categorise SNK scores into four distinct classifications: very poor, poor, good, and very good 32 , 38 – 41 . The 400 participants consisted of 342 athletes and 58 coaches, of these, 242 participants scored below 65% in the SNK assessment, falling into the 'poor knowledge' category as per the scoring matrices (Table 2 ). Athletes had a mean score of 4.98 (SD = 1.56), while coaches scored slightly higher with a mean of 5.22 (SD = 1.61), indicating no significant difference in nutrition knowledge between athletes and coaches ( p - ≥ 0.05). The highest average SNK scores were noted in basketball, at 88.89, although there was a limited sample size of just two participants. Conversely, combat sports and other team sports exhibited the lowest average scores, 51.51 and 50.85 respectively. No significant difference was found when comparing SNK of athletes and coaches or between genders (p > 0.05). However, a consistent trend observed across the studied sports was the higher SNK scores achieved by coaches compared to athletes, especially pronounced in individual sports, with an overall average difference of approximately 14.24%. Gender-based analysis of the data revealed higher SNK scores among female athletes in several sports, including rugby, Gaelic football, and hurling, compared to their male counterparts (overall average approximately 20.28%). Table 2 Comparison of SNK scores between type of sport, athletes and coaches, gender and overall score for sport. Sport Total Participants Athlete SNK Score % Coach SNK Score% Male SNK Score % Female SNK Score % SNK Score % Individual Sports: Triathlon 82 54.26 ± 20.8 63.5 ± 12.9 57.73 ± 19.6 51.4 ± 19.5 55 ± 19.52 Distance Running 132 54.72 ± 16.64 56.95 ± 10.3 58.21 ± 15.6 56.31 ± 16.14 54.93 ± 16.19 Distance Cycling 15 61.48 ± 11.38 64.2 ± 10.18 57.4 ± 11.86 61.48 ± 11.38 Combat Sport 10 51.85 ± 18.15 50 ± 5.56 57.14 ± 12.5 37.04 ± 18.89 51.51 ± 16.6 Other 59 54.06 ± 15.94 69.44 ± 9.21 55.56 ± 16.44 56.16 ± 15.7 55.7 ± 16.08 Team Sports: Gaelic Football 38 50.84 ± 16.19 65.08 ± 22.56 51.51 ± 17.26 63.89 ± 26.5 53.33 ± 18.29 Hurling or Camogie 4 40.74 ± 18.89 8 44.45 ± 22.26 61.11 ± 27.78 52.78 ± 26.5 Soccer 12 52.78 ± 13.32 66.67 ± 25.34 55.56 ± 18.15 66.67± 22.22 55.56 ± 17.08 Rugby 18 59.83 ± 14.8 46.66 ± 10.89 54.32 ± 13.3 66.67 ± 15.7 56.17 ± 15.03 Basketball 2 88.89 88.89 88.89 Other 25 50.55± 13.82 51.85 ± 19.95 47 ± 12.45 54.7 ± 17.14 50.85 ± 15.46 Results presented as percentage mean ± standard deviation, unless otherwise indicated. Differences between athlete and coaches, and gender based on independent samples t-test (p < 0.05). Sports Nutrition Knowledge and GI Complaints Among the participants, 242 reported experiencing GI complaints and had low SNK scores (60.5%), while 158 with high SNK scores (39.5%) also reported such complaints. Statistical analysis revealed no significant difference in the incidence of GI complaints between the two groups. This suggests that SNK scores do not markedly influence the frequency or severity of GI complaints. Probiotic Usage and Knowledge 186 participants reported purchasing probiotics, while 204 participants indicated that they had not. The predominant reason for not purchasing probiotics, was their uncertainty about the potential benefits associated with probiotic usage. Out of the 204 participants who did not take probiotics, 115 did not experience any GI complaints while 89 reported experiencing GI symptoms. Conversely, of the 186 individuals who regularly consume probiotics, 70 reported no GI complaints and 116 individuals reported experiencing GI complaints. Sports with a higher incidence of GI symptoms, such as distance running and triathlons, also showed a higher rate of probiotic use (above 60% in both sports). However, the relationship between probiotic use and the reduction or exacerbation of GI symptoms was not clearly delineated in the results. The correlations between probiotic use and specific GI symptoms across different sports were not statistically significant at the p < 0.05 level. Interestingly, bloating and IBD were also significantly associated with probiotic use, suggesting that individuals with these conditions are more likely to resort to probiotics to manage symptoms. Discussion The pathophysiology of GI distress in athletes exhibits heterogeneity. While various hypotheses have been proposed, the exact cause remains elusive. Nonetheless, it is widely acknowledged that nutrition can serve both as a beneficial and detrimental factor in this context 2 , 11 , 16 , 44 – 47 . While previous research has indicated that SNK can influence an athletes' dietary habits 34 , there remains a paucity of research exploring any influence SNK may have on GI complaints. Therefore, the primary aim of this study was to introduce and evaluate a novel questionnaire for assessing prevalent GI complaints, GI health, and SNK in elite athletes and coaches. GI Complaints Our results indicate that GI complaints are prevalent among elite athletes with a total of 53% (213 complaints) reported during training and/or competition. Additionally, 142 participants disclosed a diagnosed GI condition relating to stomach cramps, IBD, GERD and reflux. Endurance sports, predominantly individual-based like running and cycling, have been well-documented for their association with GI complaints. Studies have consistently shown a high incidence of GI symptoms among endurance runners, with reports suggesting up to 90% of athletes experiencing severe symptoms during their activities 48 , 49 . Similarly, a significant proportion of other endurance athletes, including cyclists and triathletes, are affected, with the occurrence ranging from 30–90% 47 . Our observed incidence rate of 53% not only falls within this documented range but also serves to reinforce the established connection between endurance sports and GI distress. The heightened risk for endurance athletes may be attributed to several factors. The prolonged physical exertion inherent in these sports can lead to reduced blood flow to the GI tract, exacerbating symptoms like cramping and nausea 11 , 16 , 50 . Additionally, the physical jostling experienced during activities like running may contribute to the increased incidence of GI disturbances 11 . Sports Nutrition Knowledge To establish a benchmark for interpreting SNK scores and guide future research, several studies employed scoring matrices categorised into four categories: very poor, poor, good, and very good 32 , 38 – 41 . Among the participants in this study, 242 scored below 65% in the SNK section, indicating inadequate or poor SNK knowledge, with a mean SNK percentage of 55%. These results are consistent with previous studies that have investigated SNK. For instance, a previous study found that Division 1 college athletes had a mean score of 45.7% 51 , similarly, two other studies investigating Gaelic Footballers' nutritional knowledge reported mean scores of 44.3% and 54% 52,53 . Our data also highlighted interesting variations among different sports. Basketball players, albeit in a small sample size, showed the highest average SNK score of 88.89. In contrast, athletes in combat sports and team sports like rugby and Gaelic football scored lower, with averages of 51.51 and 50.85 respectively. This variation suggests that SNK may be influenced by the nature of the sport and the emphasis placed on nutrition in training. Moreover, the coaches had a higher mean score than athletes, particularly in individual sports. This disparity may reflect a gap in knowledge transfer and highlights the potential need for enhanced educational strategies targeting both athletes and coaches. Additionally, our gender-based analysis revealed higher SNK scores among female athletes in several sports. These consistent results across different athlete populations highlight the need for enhanced education in sports nutrition among athletes, coaches, and nutritionists. This is crucial not only for athletes but also for coaches and nutritionists, who play a pivotal role in disseminating this knowledge. GI Complaints and Association with SNK Score In terms of the potential association between SNK and GI complaints among the participants, we found that 242 individuals with low SNK scores reported experiencing GI complaints, while 158 with high SNK scores also reported such issues, indicating no significant difference between SNK score and the occurrence of GI complaints. These results suggest that sports nutrition knowledge alone may not have a direct association with the occurrence of GI complaints in elite athletes. This observation is consistent with the broader research landscape, which points to multiple factors influencing GI complaints in athletes, such as physiological stress, psychological factors, and lifestyle choices 12 , 16 , 50 , 54 , 55 . However, it's important to consider the potential indirect benefits of improved SNK 28 , 29 , 56 , 57 . For example, a study by Nascimento and colleagues 56 demonstrated that enhanced nutrition knowledge led to better food choices and dietary habits among athletes, which subsequently improved overall health markers. Similarly, Spronk and colleagues 28 found a positive correlation between high levels of SNK and improved dietary habits, suggesting a beneficial impact on athletes' health and performance. While our research did not find a direct link between SNK and GI complaints, our study differs from existing research by specifically focusing on the direct correlation between SNK and GI complaints, adding a unique perspective to the existing body of knowledge. Improved SNK, encompassing elements of GI health as highlighted in our questionnaire, could indirectly influence GI health through more informed dietary and lifestyle choices. For instance, better nutrition knowledge may lead athletes to adopt diets that support gut health, potentially mitigating some GI complaints. This indirect pathway suggests that while SNK may not directly reduce the incidence of GI complaints, it plays a crucial role in shaping behaviours and choices that contribute to overall GI and athletic health. However, exploring the specific mechanisms through which enhanced SNK might lead to improvements in GI health and determining the extent of these potential benefits was outside the scope of our current study. Individual vs Team Sport Our analysis revealed that athletes in individual sports, especially in endurance activities like triathlons and distance running, reported more GI complaints, such as diarrhoea and bloating, compared to those in team sports. This aligns with the current literature suggesting a higher susceptibility to GI symptoms among individual sports athletes 11 , 50 , 58 , 59 . The mechanism behind this increased vulnerability may be a result of the prolonged physical exertion and associated physiological changes in these sports, such as altered gut permeability and reduced blood flow to the GI tract 11 . However, while the existing literature has primarily focused on endurance-based activities, the understanding of GI complaints in the context of team sports remains limited. Possible factors that could be investigated include differences in training intensity, duration, dietary practices, psychological stressors, and the overall physiological demands of individual and team sports. Understanding these nuances may be crucial for developing targeted strategies to mitigate GI complaints in athletes. For example, if specific dietary practices or training regimens are identified as key contributors to GI distress in certain sports, interventions can be tailored accordingly. Factors Contributing to GI Complaints Most participants experienced GI complaints primarily before starting their exercise, as indicated by 45.5% of respondents, with the next most common timing being immediately post-exercise (38.7%). It should be noted that the questionnaire allowed for multiple responses regarding the timing of symptoms. The predominance of GI symptoms prior to exercise initiation underscores a more complex relationship between physical activity and GI distress than previously understood. This pattern challenges the popular belief of a temporal association between exercise and the onset of symptoms 11 . The varied timing of these complaints, as reported by participants, reflects the multifaceted nature of GI distress in the context of physical activity. The increased occurrence of symptoms like bloating and diarrhoea in longer and more intense exercise sessions might reflect the impact of prolonged physical strain and dehydration on GI function and inflammatory pathways 60 , 61 . The high prevalence of pre-exercise GI complaints observed in this study suggests other factors influence symptoms and perhaps further exploration of the relationship between GI distress and the gut-brain-axis is warranted 62 , 63 . Understanding the timing of GI complaints during exercise is crucial for developing targeted interventions and optimising athletes' performance and well-being. Probiotics This study represents an initial exploration of probiotic knowledge among elite athletes and their coaches, with no previous data available for comparison. However, findings from Soni and colleagues 36 on health professionals' attitudes and practices regarding probiotic use revealed that although participants were aware of the term "probiotic," only 54.7% knew about their reported benefits. Similarly, our study found many (69.2%) of the elite athletes and coaches expressed uncertainty regarding the potential benefits of probiotics, choosing the option ‘I’m not sure how probiotics would benefit me’. Interestingly, while a considerable number of participants reported using probiotics within the current study, GI symptoms continued to be a common concern across various sports disciplines. This suggests that athletes might be using probiotics as a self-directed approach to managing specific GI issues such as stomach pain, bloating, and IBD 19 , 20 , 22 , 60 , 64 . This aligns with existing literature, which indicates the frequent use of probiotics may alleviate symptoms of GI disorders 65 , 66 . Moreover, the survey primarily focused on whether participants were taking probiotics, without delving into the nuances of their usage, such as the duration, type, and perceived efficacy of these probiotics. Emerging research, however, points towards the potential benefits of probiotics in alleviating GI issues, particularly in endurance athletes. Studies suggest that probiotics may enhance gut health and contribute to maintaining gut barrier integrity, potentially reducing the occurrence or severity of GI symptoms 21 , 25 , 60 , 64 , 66 . Limitations Our study is not without limitations, firstly, the online administration of the questionnaire, while facilitating broad participation, introduces the possibility of non-authentic responses. However, this concern is unlikely given the low SNK scores, making it less likely that participants engaged in deliberate cheating. Furthermore, the inclusion of coaches in the study was relatively low compared to the athlete population. This discrepancy in sample size may affect the generalisability of the findings and therefore, consideration must be taken when interpreting the results related to coaches' perspectives. One of the key limitations of our study lies in the nature of the questionnaire used. The survey predominantly focused on whether participants were consuming probiotics without delving deeper into the specifics of their use, such as duration, type, dosage, and most crucially, the athletes’ subjective assessment of the effectiveness of probiotics on their symptoms and overall performance. This gap in data collection limits the scope of our understanding of the true impact of probiotics in managing GI health among athletes. Additionally, certain important aspects of athletes' dietary practices, such as meal timing, hydration status, and supplement intake, were not comprehensively examined in this study. The extent to which these factors contribute to the occurrence of GI complaints remains unclear and should be further investigated in future research. Conclusion Despite advancements in sports nutrition, the findings in this study confirm that GI complaints are still prevalent among athletes. Furthermore, the study reveals that both athletes and their coaches possess sub-optimal sports nutrition knowledge. The development of the DIGEST questionnaire, tailored specifically for athletes and coaches, offers potential as a tool for assessing gut health, GI complaints, and SNK during training and competition. By implementing the DIGEST questionnaire, nutritionists, dieticians, and coaches can identify athletes who are experiencing GI complaints and subsequently provide targeted interventions to effectively manage their symptoms. The findings underscore the importance of addressing nutrition education, optimising gut health, and considering individualised strategies to manage GI distress in athletes. Abbreviations DIGEST - Dietary Information for Gut Endurance Sport Testing GI - Gastrointestinal SNK - Sports Nutrition Knowledge IBD - Irritable Bowel Disease GERD - Gastroesophageal Reflux Disease GBA - Gut Brain Axis FODMAP - Fermentable Oligo-, Di-, Mono-saccharides and Polyols NUKYA - Nutritional Knowledge for Young and Adult Athletes NSKQ - Nutrition for Sport Knowledge Questionnaire A-NSKQ - Abridged Nutrition for Sport Knowledge Questionnaire UK - United Kingdom SESRI - Sports and Exercise Science Research Institute SD - Standard Deviation SPSS - Statistical Package for the Social Sciences NIH - National Institutes of Health NCATS - National Center for Advancing Translational Sciences VRI - Victorian Research Institute BMI - Body Mass Index NCAA - National Collegiate Athletic Association ANOVA - Analysis of Variance Declarations Author Information RP Kearns ORCID ID: 0000-0002-9428-8273 JSG Dooley ORCID ID: 0000-0002-9459-5572 M Matthews ORCID ID is: 0000-0002-3054-3466 AM McNeilly ORCID ID: 0000-0001-6050-6415 Ethics Approval and Consent to Participate This study obtained ethical approval from the Research Ethics Committee of Ulster University (SESRI-22-038-A). All participants provided electronically signed informed consent in accordance with the Declaration of Helsinki. Consent for Publication All authors have consented to publication. Availability of Data and Material The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding No financial support was received for the conduct of this study, or for the preparation or publication of this manuscript. Authors' Contributions RP Kearns: Conceived the study idea, designed the study, performed the analysis, and wrote the first draft of the manuscript. JSG Dooley, M Matthews, and AM McNeilly: Provided expertise and input on the study design, recruitment, and data collection process. All authors have read and approved the final version of this manuscript. Acknowledgements The authors would like to thank the athletes, coaches, and sports nutritionists/dieticians who participated in this study. We also acknowledge the support of Ulster University, particularly the School of Life and Health Sciences. References Jeukendrup AE, Vet-Joop K, Sturk A, Stegen JHJC, Senden J, Saris WHM et al. Relationship between gastro-intestinal complaints and endotoxaemia, cytokine release and the acute-phase reaction during and after a long-distance triathlon in highly trained men. Clin Sci 2000; 98 . doi:10.1042/cs0980047. De Oliveira EP, Burini RC, Jeukendrup A. Gastrointestinal complaints during exercise: Prevalence, etiology, and nutritional recommendations. Sports Medicine 2014; 44 . doi:10.1007/s40279-014-0153-2. Hoogervorst D, van der Burg N, Versteegen JJ, Lambrechtse KJ, Redegeld MI, Cornelissen LAJ et al. Gastrointestinal complaints and correlations with self-reported macronutrient intake in independent groups of (Ultra)marathon runners competing at different distances. Sports 2019; 7 . doi:10.3390/sports7060140. Marttinen M, Ala-Jaakkola R, Laitila A, Lehtinen MJ. Gut microbiota, probiotics and physical performance in athletes and physically active individuals. Nutrients 2020; 12 . doi:10.3390/nu12102936. Waterman JJ, Kapur R. Upper gastrointestinal issues in athletes. Curr Sports Med Rep 2012; 11 . doi:10.1249/JSR.0b013e318249c311. van Wijck K, Lenaerts K, Grootjans J, Wijnands KAP, Poeze M, van Loon LJC et al. Physiology and pathophysiology of splanchnic hypoperfusion and intestinal injury during exercise: Strategies for evaluation and prevention. Am J Physiol Gastrointest Liver Physiol. 2012; 303 . doi:10.1152/ajpgi.00066.2012. Schwellnus MP, Wright J. Gastrointestinal System and Exercise: A Clinical Approach to Gastrointestinal Problems Encountered in Athletes. In: Olympic Textbook of Medicine in Sport . 2009 doi:10.1002/9781444300635.ch11. Costa RJS, Snipe RMJ, Kitic CM, Gibson PR. Systematic review: exercise-induced gastrointestinal syndrome—implications for health and intestinal disease. Aliment Pharmacol Ther. 2017; 46 . doi:10.1111/apt.14157. De Oliveira EP, Burini RC. The impact of physical exercise on the gastrointestinal tract. Curr Opin Clin Nutr Metab Care. 2009; 12 . doi:10.1097/MCO.0b013e32832e6776. Ter Steege RWF, Kolkman JJ, Huisman AB, Geelkerken RH. Gastrointestinal ischaemia during physical exertion as a cause of gastrointestinal symptoms. Ned Tijdschr Geneeskd 2008; 152 . Smith KA, Pugh JN, Duca FA, Close GL, Ormsbee MJ. Gastrointestinal pathophysiology during endurance exercise: endocrine, microbiome, and nutritional influences. Eur J Appl Physiol. 2021; 121 . doi:10.1007/s00421-021-04737-x. Clark A, Mach N. Exercise-induced stress behavior, gut-microbiota-brain axis and diet: A systematic review for athletes. 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Probiotics, prebiotics and synbiotics: useful for athletes and active individuals? A systematic review. Benef Microbes 2020; 11 . doi:10.3920/BM2019.0076. Miles MP. Probiotics and Gut Health in Athletes. Curr Nutr Rep. 2020; 9 . doi:10.1007/s13668-020-00316-2. Roberts JD, Suckling CA, Peedle GY, Murphy JA, Dawkins TG, Roberts MG. An exploratory investigation of endotoxin levels in novice long distance triathletes,and the effects of a multi-strain probiotic/prebiotic,antioxidant intervention. Nutrients 2016; 8 . doi:10.3390/nu8110733. Lamprecht M, Frauwallner A. Exercise, intestinal barrier dysfunction and probiotic supplementation. Med Sport Sci 2013; 59 . doi:10.1159/000342169. Leite GSF, Resende Master Student AS, West NP, Lancha AH. Probiotics and sports: a new magic bullet? Nutrition. 2019; 60 . doi:10.1016/j.nut.2018.09.023. Pyne DB, West NP, Cox AJ, Cripps AW. Probiotics supplementation for athletes – Clinical and physiological effects. Eur J Sport Sci 2015; 15 . doi:10.1080/17461391.2014.971879. Adikari AMGCP, Adikari AMGCP, Appukutty M, Kuan G. Effects of Daily Probiotic Supplementation on Football Player’s Stress and Anxiety. 2019 doi:10.2991/acpes-19.2019.1. Wosinska L, Cotter PD, O’Sullivan O, Guinane C. The potential impact of probiotics on the gut microbiome of athletes. Nutrients. 2019; 11 . doi:10.3390/nu11102270. Pugh JN, Sparks AS, Doran DA, Fleming SC, Langan-Evans C, Kirk B et al. Four weeks of probiotic supplementation reduces GI symptoms during a marathon race. Eur J Appl Physiol 2019; 119 . doi:10.1007/s00421-019-04136-3. Díaz-Jiménez J, Sánchez-Sánchez E, Ordoñez FJ, Rosety I, Díaz AJ, Rosety-Rodriguez M et al. Impact of probiotics on the performance of endurance athletes: A systematic review. Int J Environ Res Public Health. 2021; 18 . doi:10.3390/ijerph182111576. Heaney S, O’Connor H, Michael S, Gifford J, Naughton G. Nutrition knowledge in athletes: A systematic review. Int J Sport Nutr Exerc Metab. 2011; 21 . doi:10.1123/ijsnem.21.3.248. Spronk I, Kullen C, Burdon C, O’Connor H. Relationship between nutrition knowledge and dietary intake. British Journal of Nutrition. 2014; 111 . doi:10.1017/S0007114514000087. Rossi FE, Landreth A, Beam S, Jones T, Norton L, Cholewa JM. The effects of a sports nutrition education intervention on nutritional status, sport nutrition knowledge, body composition, and performance during off season training in NCAA division I baseball players. J Sports Sci Med 2017; 16 . Renard M, Kelly DT, Chéilleachair NN, Catháin C. Evaluation of Nutrition Knowledge in Female Gaelic Games Players. Sports 2020; 8 . doi:10.3390/sports8120154. Tam R, Beck KL, Manore MM, Gifford J, Flood VM, O’Connor H. Effectiveness of Education Interventions Designed to Improve Nutrition Knowledge in Athletes: A Systematic Review. Sports Medicine. 2019; 49 . doi:10.1007/s40279-019-01157-y. Trakman GL, Forsyth A, Hoye R, Belski R. The nutrition for sport knowledge questionnaire (NSKQ): Development and validation using classical test theory and Rasch analysis. J Int Soc Sports Nutr 2017; 14 . doi:10.1186/s12970-017-0182-y. Trakman GL, Brown F, Forsyth A, Belski R. Modifications to the nutrition for sport knowledge questionnaire (NSQK) and abridged nutrition for sport knowledge questionnaire (ANSKQ). J Int Soc Sports Nutr 2019; 16 . doi:10.1186/s12970-019-0293-8. Trakman GL, Forsyth A, Devlin BL, Belski R. A systematic review of athletes’ and coaches’ nutrition knowledge and reflections on the quality of current nutrition knowledge measures. Nutrients. 2016; 8 . doi:10.3390/nu8090570. Spendlove JK, Heaney SE, Gifford JA, Prvan T, Denyer GS, O’Connor HT. Evaluation of general nutrition knowledge in elite Australian athletes. British Journal of Nutrition 2012; 107 . doi:10.1017/S0007114511005125. Soni R, Tank K, Jain N. Knowledge, attitude and practice of health professionals about probiotic use in Ahmedabad, India. Nutr Food Sci 2018; 48 . doi:10.1108/NFS-02-2017-0032. Fijan S, Frauwallner A, Varga L, Langerholc T, Rogelj I, Lorber M et al. Health professionals’ knowledge of probiotics: An international survey. Int J Environ Res Public Health 2019; 16 . doi:10.3390/ijerph16173128. Jagim AR, Fields JB, Magee M, Kerksick C, Luedke J, Erickson J et al. The influence of sport nutrition knowledge on body composition and perceptions of dietary requirements in collegiate athletes. Nutrients 2021; 13 . doi:10.3390/nu13072239. Klein DJ, Eck KM, Walker AJ, Pellegrino JK, Freidenreich DJ. Assessment of sport nutrition knowledge, dietary practices, and sources of nutrition information in ncaa division iii collegiate athletes. Nutrients 2021; 13 . doi:10.3390/nu13092962. Torres-McGehee TM, Pritchett KL, Zippel D, Minton DM, Cellamare A, Sibilia M. Sports nutrition knowledge among collegiate athletes, coaches, athletic trainers, and strength and conditioning specialists. J Athl Train 2012; 47 . doi:10.4085/1062-6050-47.2.205. Tam R, Gifford JA, Beck KL. Recent Developments in the Assessment of Nutrition Knowledge in Athletes. Curr Nutr Rep. 2022; 11 . doi:10.1007/s13668-022-00397-1. Pentz R. ES13.05 The Ethics of International Research. Journal of Thoracic Oncology 2021; 16 . doi:10.1016/j.jtho.2021.08.748. O’brien L, Collins K, Amirabdollhian F. Exploring sports nutrition knowledge in elite gaelic footballers. Nutrients 2021; 13 . doi:10.3390/nu13041081. Han M, Yang K, Yang P, Zhong C, Chen C, Wang S et al. Stratification of athletes’ gut microbiota: the multifaceted hubs associated with dietary factors, physical characteristics and performance. Gut Microbes 2020; 12 . doi:10.1080/19490976.2020.1842991. Stuempfle KJ, Hoffman MD, Hew-Butler T. Association of gastrointestinal distress in ultramarathoners with race diet. Int J Sport Nutr Exerc Metab 2013; 23 . doi:10.1123/ijsnem.23.2.103. Ten Haaf DSM, Van Der Worp MP, Groenewoud HMM, Leij-Halfwerk S, Nijhuis-van Der Sanden MWG, Verbeek ALM et al. Nutritional indicators for gastrointestinal symptoms in female runners: The ‘Marikenloop study’. BMJ Open 2014; 4 . doi:10.1136/bmjopen-2014-005780. Parnell JA, Wagner-Jones K, Madden RF, Erdman KA. Dietary restrictions in endurance runners to mitigate exercise-induced gastrointestinal symptoms. J Int Soc Sports Nutr 2020; 17 . doi:10.1186/s12970-020-00361-w. Stuempfle KJ, Hoffman MD. Gastrointestinal distress is common during a 161-km ultramarathon. J Sports Sci 2015; 33 . doi:10.1080/02640414.2015.1012104. Stuempfle KJ, Valentino T, Hew-Butler T, Hecht FM, Hoffman MD. Nausea is associated with endotoxemia during a 161-km ultramarathon. J Sports Sci 2016; 34 . doi:10.1080/02640414.2015.1130238. Mach N, Fuster-Botella D. Endurance exercise and gut microbiota: A review. J Sport Health Sci. 2017; 6 . doi:10.1016/j.jshs.2016.05.001. Werner EN, Guadagni AJ, Pivarnik JM. Assessment of nutrition knowledge in division I college athletes. Journal of American College Health 2022; 70 . doi:10.1080/07448481.2020.1740234. Mitchell L, Lehane P, McCarthy M, O’Shea K, Tracey M, Whyte T et al. Nutrition knowledge of elite and non-elite Gaelic footballers. Science and Medicine in Football 2022; 6 . doi:10.1080/24733938.2021.1906440. Renard M, Anton-Solanas A, Kelly DT, Ó Catháin C. Evaluation of nutrition knowledge in elite and sub-elite Gaelic football players. Science and Medicine in Football 2022; 6 . doi:10.1080/24733938.2021.1883195. Ribeiro FM, Petriz B, Marques G, Kamilla LH, Franco OL. Is There an Exercise-Intensity Threshold Capable of Avoiding the Leaky Gut? Front Nutr. 2021; 8 . doi:10.3389/fnut.2021.627289. Cronin O, Molloy MG, Shanahan F. Exercise, fitness, and the gut. Curr Opin Gastroenterol. 2016; 32 . doi:10.1097/MOG.0000000000000240. Nascimento M, Silva D, Ribeiro S, Nunes M, Almeida M, Mendes-Netto R. Effect of a nutritional intervention in athlete’s body composition, eating behaviour and nutritional knowledge: A comparison between adults and adolescents. Nutrients 2016; 8 . doi:10.3390/nu8090535. Worsley A. Nutrition knowledge and food consumption: can nutrition knowledge change food behaviour? Asia Pac J Clin Nutr. 2002; 11 Suppl 3 . doi:10.1046/j.1440-6047.11.supp3.7.x. Nikolaidis PT, Veniamakis E, Rosemann T, Knechtle B. Nutrition in ultra-endurance: State of the art. Nutrients. 2018; 10 . doi:10.3390/nu10121995. Morici G, Gruttad’Auria CI, Baiamonte P, Mazzuca E, Castrogiovanni A, Bonsignore MR. Endurance training: Is it bad for you? Breathe. 2016; 12 . doi:10.1183/20734735.007016. Huang WC, Wei CC, Huang CC, Chen WL, Huang HY. The beneficial effects of Lactobacillus plantarum PS128 on high-intensity, exercise-induced oxidative stress, inflammation, and performance in triathletes. Nutrients 2019; 11 . doi:10.3390/nu11020353. Shing CM, Peake JM, Lim CL, Briskey D, Walsh NP, Fortes MB et al. Effects of probiotics supplementation on gastrointestinal permeability, inflammation and exercise performance in the heat. Eur J Appl Physiol 2014; 114 . doi:10.1007/s00421-013-2748-y. Dinan TG, Cryan JF. Gut instincts: microbiota as a key regulator of brain development, ageing and neurodegeneration. Journal of Physiology 2017; 595 . doi:10.1113/JP273106. Wilson PB. Perceived life stress and anxiety correlate with chronic gastrointestinal symptoms in runners. J Sports Sci 2018; 36 . doi:10.1080/02640414.2017.1411175. Huang WC, Pan CH, Wei CC, Huang HY. Lactobacillus plantarum ps128 improves physiological adaptation and performance in triathletes through gut microbiota modulation. Nutrients 2020; 12 . doi:10.3390/nu12082315. Cox AJ, Pyne DB, Saunders PU, Fricker PA. Oral administration of the probiotic Lactobacillus fermentum VRI-003 and mucosal immunity in endurance athletes. Br J Sports Med 2010; 44 . doi:10.1136/bjsm.2007.044628. Schreiber C, Tamir S, Golan R, Weinstein A, Weinstein Y. The effect of probiotic supplementation on performance, inflammatory markers and gastro‐intestinal symptoms in elite road cyclists. J Int Soc Sports Nutr 2021; 18 . doi:10.1186/s12970-021-00432-6. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4476204","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":311184961,"identity":"9ec7fcf1-8eea-4904-81d5-d695d1d8f6ef","order_by":0,"name":"Rowan Kearns","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACCRiDn72B8QBC/ACmUgwtkj0HgOoSSNFiMCOBSC2S7c3PPhf8Ycg3kHxjcPDnD5t8BvbDD5h5zuDWIs1zzHj2zDYGy+3SOQaHeRLSLBt40gyYeW7g1iInkWDMzNvw38ByNlALQ8JhAwaGHAZmng94tMg//8zM84fBwODmGYODPxL+GzDwv8GvRVqCx5iZhw2o5QaPwQGehAMGDBIgW/A4TLInp5iZt43BQLInreAwT1qyAZvEM4ODc/B4X+L48c1gh/GzH9748IeNnQE/f/LDB2+O4daCCdgY8MbKKBgFo2AUjAJiAAAPeUn8vvoL9gAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-9428-8273","institution":"Ulster University","correspondingAuthor":true,"prefix":"","firstName":"Rowan","middleName":"","lastName":"Kearns","suffix":""},{"id":311184962,"identity":"7b143f0b-a627-4e12-9d37-7cd2101ae507","order_by":1,"name":"James Steven Gerard Dooley","email":"","orcid":"","institution":"Ulster University - Coleraine Campus: Ulster University","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"Steven Gerard","lastName":"Dooley","suffix":""},{"id":311184963,"identity":"7c10f9c5-3e1a-4db8-a7ef-99e6e5dea447","order_by":2,"name":"Mark Matthews","email":"","orcid":"","institution":"Ulster University","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Matthews","suffix":""},{"id":311184964,"identity":"b0629772-14b8-42c9-a61b-55f53e01ba64","order_by":3,"name":"Andrea McNeilly","email":"","orcid":"","institution":"Ulster University - Coleraine Campus: Ulster University","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"McNeilly","suffix":""}],"badges":[],"createdAt":"2024-05-25 09:36:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4476204/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4476204/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59364835,"identity":"973aa9b3-efb9-41ce-af69-8646c68bd446","added_by":"auto","created_at":"2024-06-30 22:51:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":914288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4476204/v1/8d21647b-4ebd-4536-bc7c-d4e796d4e8a4.pdf"}],"financialInterests":"","formattedTitle":"Dietary Information for Gut Endurance Sport Testing (DIGEST): Exploring the relationship between Gut Health, Sports Nutrition Knowledge and Nutritional Practices in Elite Sport","fulltext":[{"header":"Key Points","content":"\u003cp\u003e\u003cstrong\u003ePrevalence of GI Complaints Among Athletes\u003c/strong\u003e: The study found that gastrointestinal complaints are common among athletes, particularly in endurance sports such as running and triathlon. These complaints often occur both pre-exercise and post-exercise, affecting performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluence of Probiotics on GI Health\u003c/strong\u003e: While probiotic usage was common among athletes, the study showed that the relationship between probiotic usage and the reduction of GI complaints was not conclusive.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuboptimal Sports Nutrition Knowledge (SNK)\u003c/strong\u003e: Both athletes and coaches demonstrated low scores in sports nutrition knowledge, with many not reaching the knowledge threshold that could potentially help in mitigating GI issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of Nutrition on GI Complaints\u003c/strong\u003e: Although the study did not find a direct correlation between SNK and the frequency of GI complaints, it highlighted the potential indirect benefits of improved nutrition knowledge, such as better dietary choices that could support gut health and possibly reduce GI symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTiming and Severity of GI Symptoms\u003c/strong\u003e: The findings indicate that the timing of GI complaints varies, with a significant number occurring before and immediately after exercise. This variability points to the complex relationship between exercise, diet, and GI symptoms, and suggests that timing of meals and types of food consumed could be crucial in managing GI distress.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n"},{"header":"Background","content":"\u003cp\u003eGastrointestinal (GI) complaints are a prevalent factor leading to reduced performance in athletes\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Approximately 30\u0026ndash;70% of athletes experience GI symptoms of varying severity, including bloating, cramping, diarrhoea, and vomiting whilst exercising\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. These symptoms are particularly common among endurance-based athletes, with studies reporting occurrence in up to 96% in long distance runners \u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The aetiology of GI complaints encompasses a multifaceted interplay of physiological, nutritional, and psychological factors\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Several mechanisms have been proposed to explain the occurrence of GI distress, including ischemia-reperfusion injury to the gut lining resulting in tight junction permeability\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, prolonged motion causing injury to the gut lining\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, and altered hormonal function involving the Gut Brain Axis (GBA) reducing overall gastrointestinal function capacity\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Furthermore, a dose-response relationship exists between exercise intensity and GI complaints, indicating an increased likelihood of experiencing symptoms as exercise intensity rises\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEfforts to mitigate GI symptoms in athletes have prompted the exploration of various preventative interventions. These include maintaining euhydration\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, carbohydrate feeding protocols\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, training the gut to tolerate and efficiently process nutrients\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, dietary fermentable oligo- di- mono- saccharide and polyols (FODMAP) modifications\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and dietary supplements, such as probiotics, pre-biotics and synbiotics\u003csup\u003e\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. One aspect which warrants further exploration is the concept of educational interventions, specifically targeting the enhancement of nutritional knowledge among athletes. Advanced nutritional knowledge and its effective application could significantly improve dietary decision-making, potentially reducing gastrointestinal complaints and optimising performance in endurance sports. Nevertheless, there remains a paucity of research investigating any correlation between GI experiences and sports nutritional knowledge (SNK) among elite athletes.\u003c/p\u003e \u003cp\u003ePrevious research suggests an athlete\u0026rsquo;s nutritional knowledge exhibits a positive (albeit weak) correlation with improved dietary habits and subsequent performance\u003csup\u003e\u003cspan additionalcitationids=\"CR28 CR29\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. To this end, several questionnaires have been developed and utilised in elite sport to establish the SNK of athletes, including \u0026lsquo;The Nutritional Knowledge for Young and Adult Athletes (NUKYA)\u0026rsquo;, \u0026lsquo;Nutrition for Sport Knowledge Questionnaire (NSKQ)\u0026rsquo; and an abridged version of the NSKQ (the A-NSKQ) \u003csup\u003e\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. However, there is a lack of consistency with regards to questionnaire design and factors such as participant literacy, socioeconomic status, and education\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Moreover, while the prevalence of GI complaints in the athletic population have been extensively documented, and the influence of nutrition on GI symptoms has been acknowledged, there is still a paucity of research pertaining to the assessment of GI health knowledge levels within this population\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. Additionally, none of the existing questionnaires for athletes and their support staff incorporate aspects of GI health.\u003c/p\u003e"},{"header":"Main Body","content":"\u003cp\u003eThe primary objective of this study was to introduce and evaluate a novel questionnaire for assessing GI complaints, GI health, and SNK relating to GI health in elite athletes and coaches. A secondary aim was to explore their attitudes and practices concerning diet, supplementation, exercise workload, and sport participation, with the goal of gaining a comprehensive understanding of potential causative factors contributing to GI complaints in this athlete population.\u003c/p\u003e \u003cp\u003eThis study was conducted in two distinct phases. Phase 1 was the development of a SNK questionnaire which incorporated a gut health element. Phase 2 involved the dissemination of the questionnaire to athletes and coaches in elite sport within the United Kingdom (UK) and Ireland.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePhase One: Questionnaire Development\u003c/h2\u003e \u003cp\u003eA new SNK questionnaire, called the \u0026lsquo;Dietary Information for Gut Endurance Sport Testing\u0026rsquo; (DIGEST) questionnaire, was developed following a scoping exercise of current nutritional knowledge screening tools used in sports nutrition professional practice and adapting previous SNK questionnaires, NSKQ \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, ANSKQ\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e and probiotics questionnaires \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. The questionnaire included questions on demographic information, exercise information, GI complaints and frequency of occurrence, nutrition knowledge, supplement knowledge, and probiotic knowledge. The questionnaire consisted of 59 questions across 6 sub-sections: demographic information (n\u0026thinsp;=\u0026thinsp;5), exercise information (n\u0026thinsp;=\u0026thinsp;13), GI complaints (n\u0026thinsp;=\u0026thinsp;11), SNK (n\u0026thinsp;=\u0026thinsp;9), supplements (n\u0026thinsp;=\u0026thinsp;8) and probiotic knowledge (n\u0026thinsp;=\u0026thinsp;13). The majority of questions were multiple-choice, with others requiring participant to type their answer. Demographic information consisted of questions regarding the participants sex, age, nationality, and education level. Exercise information contained questions on the participant\u0026rsquo;s sport, level they compete at (or coach), type and volume of training sessions and competition. The \u003cspan refid=\"Sec15\" class=\"InternalRef\"\u003eGI complaints\u003c/span\u003e section contained a series of questions on the participants GI health history, type and frequency of GI complaint and also the timing which GI complaints occur in relation to exercise. SNK and supplement questions were based on the sports nutrition sections of NSKQ \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, ANSKQ \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Correct answers were given\u0026thinsp;+\u0026thinsp;1 score, while incorrect or \u0026lsquo;unsure\u0026rsquo; were given a score of 0. To establish a framework for interpreting the participants SNK results, scoring matrices from previously published questionnaires were used\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. According to these matrices, a score below 65% was considered \u0026lsquo;low\u0026rsquo; or \u0026lsquo;poor\u0026rsquo; knowledge. The Probiotic knowledge section of the questionnaire was adapted from previously validated instruments used to assess health professionals' understanding of probiotics \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. This section evaluated respondents' familiarity with the definition, properties, and practical application of probiotics. The questionnaire was designed to take about 15 minutes to complete.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEthics approval and Consent\u003c/h2\u003e \u003cp\u003eThis study obtained ethical approval from the Research Ethics Committee of Ulster University (SESRI-22-038-A), and all participants provided electronically signed informed consent, under the \u0026lsquo;Declaration of Helsinki\u0026rsquo; \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2: Recruitment:\u003c/h2\u003e \u003cp\u003eThe study recruited 400 participants from the UK and Ireland. The population encompassed male and female elite endurance and/or high intensity athletes, their coaches, and sports nutritionists/dieticians in elite sport. Participants were required to be \u0026lsquo;healthy\u0026rsquo; and of \u0026lsquo;elite\u0026rsquo; status, meaning they were free from any long-term injury, disease, or condition that would render them as \u0026lsquo;non-elite\u0026rsquo;. Additionally, they had to be actively competing or striving to compete at the highest level in their respective sports \u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. E-mails which contained a consent form and link to the online questionnaire were sent to elite sport practitioners and athletes. Social platforms which enable direct messaging were also utilised, including Facebook, LinkedIn and Instagram. Individuals identifying themselves (via their bio) as elite athletes or coaches with sporting qualifications were considered for inclusion in the study's potential candidate pool. The direct message contained information on the study and a link to complete the questionnaire via the Redcap online survey platform (Redcap, NIH/NCATS UL1 TR000445).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted with IBM SPSS Statistics for Windows, Version 24.0. The normal distribution of variables was assessed using the Shapiro\u0026ndash;Wilk test. Parametric tests (independent t-test) were used for normal data, non-parametric tests (Mann-Whitney U test) were used when assumptions of normality were violated. Chi-square tests were used to compare categorical data in variables. The significance level was set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic\u003c/h2\u003e \u003cp\u003eThe present study recruited a diverse sample of participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;400), consisting of elite athletes (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;342) and sports nutritionists (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;58) from the UK and Ireland. These participants represented a variety of individual and team sports disciplines (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the participants, 75% were engaged in individual sports with the largest sporting groups being distance running (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;132) and triathlon (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;82), while the remaining 25% participated in team sports, with Gaelic football having most participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38). The gender demographics consisted of male (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;231 / 58%), female (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;153 / 38%) and others (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16 / 4%). The age range of the participants spanned from 18 to 65 years, with the majority of athletes (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;143 / 36%) aged between 18\u0026ndash;31 years of age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGI Conditions and Complaints\u003c/h2\u003e \u003cp\u003eAmong the 400 study participants, 142 (35.5%) reported a diagnosed GI condition. Stomach cramps were most prevalent, affecting 53.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;76), followed by IBD, reported by 42.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;61). Gastrointestinal reflux disease (GERD) and reflux were noted in 26.8% (n\u0026thinsp;=\u0026thinsp;38), and constipation was present in 16.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;24) of participants. During exercise, 213 athletes experienced GI complaints, with 45.5% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;97) reporting symptoms pre-exercise and 38.7% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;82) post-exercise (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Hurling/Camogie and basketball participants exhibited a 100% incidence of GI complaints, albeit these sports had the lowest participants in the cohort (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4 and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2 respectively). Triathlons, distance running, and \u0026lsquo;other\u0026rsquo; individual sports had highest participant numbers with more than half reporting some form of GI complaint (58.1%, 55.3% and 55% respectively). Stomach pain and diarrhoea were the most frequent symptoms. Notably, distance runners had a higher incidence of bloating, while triathletes reported a diverse range of symptoms, including bloating, bloody diarrhoea, and stomach pain. Overall, 54.7% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;116) of athletes selected that they occasionally experience GI symptoms such as stomach pain, bloating, constipation, diarrhoea, bloody diarrhoea, and nausea. Symptoms were more frequently reported during longer (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32 / 14.8%) and more intense (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38 / 17.7%) exercise sessions. A weak positive correlation was observed between exercise duration and both bloating (correlation coefficient of 0.15) and diarrhoea (0.18), as well as between exercise intensity and both stomach pain (0.11) and diarrhoea (0.24). Additionally, 127 (31.75%) athletes sought professional advice for digestive issues (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with 142 (35.5%) diagnosed with conditions such as IBS, GERD, reflux, constipation, and cramps.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal participants and the percentage of GI complaints in each sport.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSport\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStomach\u003c/p\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBloating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConstipation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDiarrhoea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBloody\u003c/p\u003e \u003cp\u003eDiarrhoea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriathlon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e74\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.08%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e41.89%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance Running\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e114\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.81%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.51%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e44.74%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance Cycling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombat Sport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.45%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.09%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.27%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18.18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e54.55%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e80\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaelic Football\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e37\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.43%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.32%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.81%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e51.35%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHurling/ Camogie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoccer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.08%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e69.23%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRugby\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e68.75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasketball\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e26\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.54%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.54%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e38.46%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eIndividual vs Team Sport GI complaints\u003c/h2\u003e \u003cp\u003eA comparative analysis was conducted to investigate the differences in reported GI complaints between participants in \"individual sports\" and \"team sports.\" The analysis included a total of 211 complaints, acknowledging that participants had the chance to report multiple symptoms. Among the participants, those involved in individual sports exhibited a significantly higher number of GI complaints (p\u0026thinsp;=\u0026thinsp;0.04), with a total of 161 complaints, whereas those participating in team sports reported 50 complaints.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSports Nutrition Knowledge\u003c/h2\u003e \u003cp\u003eIn accordance with the methodology described, we utilised scoring matrices from previously published studies to categorise SNK scores into four distinct classifications: very poor, poor, good, and very good \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. The 400 participants consisted of 342 athletes and 58 coaches, of these, 242 participants scored below 65% in the SNK assessment, falling into the 'poor knowledge' category as per the scoring matrices (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Athletes had a mean score of 4.98 (SD\u0026thinsp;=\u0026thinsp;1.56), while coaches scored slightly higher with a mean of 5.22 (SD\u0026thinsp;=\u0026thinsp;1.61), indicating no significant difference in nutrition knowledge between athletes and coaches (\u003cem\u003ep\u003c/em\u003e- \u0026ge; 0.05). The highest average SNK scores were noted in basketball, at 88.89, although there was a limited sample size of just two participants. Conversely, combat sports and other team sports exhibited the lowest average scores, 51.51 and 50.85 respectively. No significant difference was found when comparing SNK of athletes and coaches or between genders (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, a consistent trend observed across the studied sports was the higher SNK scores achieved by coaches compared to athletes, especially pronounced in individual sports, with an overall average difference of approximately 14.24%. Gender-based analysis of the data revealed higher SNK scores among female athletes in several sports, including rugby, Gaelic football, and hurling, compared to their male counterparts (overall average approximately 20.28%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of SNK scores between type of sport, athletes and coaches, gender and overall score for sport.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSport\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAthlete\u003c/p\u003e \u003cp\u003eSNK Score %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCoach\u003c/p\u003e \u003cp\u003eSNK Score%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eSNK Score %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eSNK Score %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSNK Score\u003c/p\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual Sports:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTriathlon\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e54.26\u0026thinsp;\u0026plusmn;\u0026thinsp;20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e57.73\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55 \u0026plusmn; 19.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDistance Running\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e132\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e54.72\u0026thinsp;\u0026plusmn;\u0026thinsp;16.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56.95 \u0026plusmn; 10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e58.21 \u0026plusmn; 15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56.31\u0026thinsp;\u0026plusmn;\u0026thinsp;16.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54.93\u003c/p\u003e \u003cp\u003e\u0026plusmn; 16.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDistance Cycling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e61.48\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e64.2 \u0026plusmn; 10.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e61.48\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCombat Sport\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e51.85\u0026thinsp;\u0026plusmn;\u0026thinsp;18.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e57.14\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e37.04\u0026thinsp;\u0026plusmn;\u0026thinsp;18.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51.51\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e54.06\u0026thinsp;\u0026plusmn;\u0026thinsp;15.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69.44\u0026thinsp;\u0026plusmn;\u0026thinsp;9.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e55.56\u0026thinsp;\u0026plusmn;\u0026thinsp;16.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e56.16\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeam Sports:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGaelic Football\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e50.84\u0026thinsp;\u0026plusmn;\u0026thinsp;16.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.08 \u0026plusmn;\u003c/p\u003e \u003cp\u003e22.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e51.51\u0026thinsp;\u0026plusmn;\u0026thinsp;17.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63.89\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e53.33 \u0026plusmn; 18.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHurling or Camogie\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e40.74\u0026thinsp;\u0026plusmn;\u0026thinsp;18.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e44.45\u0026thinsp;\u0026plusmn;\u0026thinsp;22.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e61.11\u0026thinsp;\u0026plusmn;\u0026thinsp;27.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52.78 \u0026plusmn; 26.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSoccer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e52.78\u0026thinsp;\u0026plusmn;\u0026thinsp;13.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.67\u0026thinsp;\u0026plusmn;\u0026thinsp;25.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e55.56 \u0026plusmn; 18.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.67\u0026plusmn; 22.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55.56 \u0026plusmn; 17.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRugby\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e59.83\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.66 \u0026plusmn; 10.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e54.32 \u0026plusmn; 13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.67 \u0026plusmn; 15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e56.17 \u0026plusmn; 15.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBasketball\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e50.55\u0026plusmn; 13.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.85 \u0026plusmn; 19.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e47 \u0026plusmn; 12.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54.7 \u0026plusmn; 17.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50.85 \u0026plusmn; 15.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eResults presented as percentage mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, unless otherwise indicated. Differences between athlete and coaches, and gender based on independent samples t-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSports Nutrition Knowledge and GI Complaints\u003c/h2\u003e \u003cp\u003eAmong the participants, 242 reported experiencing GI complaints and had low SNK scores (60.5%), while 158 with high SNK scores (39.5%) also reported such complaints. Statistical analysis revealed no significant difference in the incidence of GI complaints between the two groups. This suggests that SNK scores do not markedly influence the frequency or severity of GI complaints.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProbiotic Usage and Knowledge\u003c/h2\u003e \u003cp\u003e186 participants reported purchasing probiotics, while 204 participants indicated that they had not. The predominant reason for not purchasing probiotics, was their uncertainty about the potential benefits associated with probiotic usage. Out of the 204 participants who did not take probiotics, 115 did not experience any GI complaints while 89 reported experiencing GI symptoms. Conversely, of the 186 individuals who regularly consume probiotics, 70 reported no GI complaints and 116 individuals reported experiencing GI complaints. Sports with a higher incidence of GI symptoms, such as distance running and triathlons, also showed a higher rate of probiotic use (above 60% in both sports). However, the relationship between probiotic use and the reduction or exacerbation of GI symptoms was not clearly delineated in the results. The correlations between probiotic use and specific GI symptoms across different sports were not statistically significant at the p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level. Interestingly, bloating and IBD were also significantly associated with probiotic use, suggesting that individuals with these conditions are more likely to resort to probiotics to manage symptoms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe pathophysiology of GI distress in athletes exhibits heterogeneity. While various hypotheses have been proposed, the exact cause remains elusive. Nonetheless, it is widely acknowledged that nutrition can serve both as a beneficial and detrimental factor in this context \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. While previous research has indicated that SNK can influence an athletes' dietary habits\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, there remains a paucity of research exploring any influence SNK may have on GI complaints. Therefore, the primary aim of this study was to introduce and evaluate a novel questionnaire for assessing prevalent GI complaints, GI health, and SNK in elite athletes and coaches.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eGI Complaints\u003c/h2\u003e \u003cp\u003eOur results indicate that GI complaints are prevalent among elite athletes with a total of 53% (213 complaints) reported during training and/or competition. Additionally, 142 participants disclosed a diagnosed GI condition relating to stomach cramps, IBD, GERD and reflux. Endurance sports, predominantly individual-based like running and cycling, have been well-documented for their association with GI complaints. Studies have consistently shown a high incidence of GI symptoms among endurance runners, with reports suggesting up to 90% of athletes experiencing severe symptoms during their activities \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. Similarly, a significant proportion of other endurance athletes, including cyclists and triathletes, are affected, with the occurrence ranging from 30\u0026ndash;90% \u003csup\u003e47\u003c/sup\u003e. Our observed incidence rate of 53% not only falls within this documented range but also serves to reinforce the established connection between endurance sports and GI distress.\u003c/p\u003e \u003cp\u003eThe heightened risk for endurance athletes may be attributed to several factors. The prolonged physical exertion inherent in these sports can lead to reduced blood flow to the GI tract, exacerbating symptoms like cramping and nausea\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. Additionally, the physical jostling experienced during activities like running may contribute to the increased incidence of GI disturbances\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSports Nutrition Knowledge\u003c/h2\u003e \u003cp\u003eTo establish a benchmark for interpreting SNK scores and guide future research, several studies employed scoring matrices categorised into four categories: very poor, poor, good, and very good\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Among the participants in this study, 242 scored below 65% in the SNK section, indicating inadequate or poor SNK knowledge, with a mean SNK percentage of 55%. These results are consistent with previous studies that have investigated SNK. For instance, a previous study found that Division 1 college athletes had a mean score of 45.7%\u003csup\u003e51\u003c/sup\u003e, similarly, two other studies investigating Gaelic Footballers' nutritional knowledge reported mean scores of 44.3% and 54% \u003csup\u003e52,53\u003c/sup\u003e. Our data also highlighted interesting variations among different sports. Basketball players, albeit in a small sample size, showed the highest average SNK score of 88.89. In contrast, athletes in combat sports and team sports like rugby and Gaelic football scored lower, with averages of 51.51 and 50.85 respectively. This variation suggests that SNK may be influenced by the nature of the sport and the emphasis placed on nutrition in training. Moreover, the coaches had a higher mean score than athletes, particularly in individual sports. This disparity may reflect a gap in knowledge transfer and highlights the potential need for enhanced educational strategies targeting both athletes and coaches. Additionally, our gender-based analysis revealed higher SNK scores among female athletes in several sports. These consistent results across different athlete populations highlight the need for enhanced education in sports nutrition among athletes, coaches, and nutritionists. This is crucial not only for athletes but also for coaches and nutritionists, who play a pivotal role in disseminating this knowledge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eGI Complaints and Association with SNK Score\u003c/h2\u003e \u003cp\u003eIn terms of the potential association between SNK and GI complaints among the participants, we found that 242 individuals with low SNK scores reported experiencing GI complaints, while 158 with high SNK scores also reported such issues, indicating no significant difference between SNK score and the occurrence of GI complaints. These results suggest that sports nutrition knowledge alone may not have a direct association with the occurrence of GI complaints in elite athletes. This observation is consistent with the broader research landscape, which points to multiple factors influencing GI complaints in athletes, such as physiological stress, psychological factors, and lifestyle choices\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e. However, it's important to consider the potential indirect benefits of improved SNK \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e,\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. For example, a study by Nascimento and colleagues\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e demonstrated that enhanced nutrition knowledge led to better food choices and dietary habits among athletes, which subsequently improved overall health markers. Similarly, Spronk and colleagues\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e found a positive correlation between high levels of SNK and improved dietary habits, suggesting a beneficial impact on athletes' health and performance. While our research did not find a direct link between SNK and GI complaints, our study differs from existing research by specifically focusing on the direct correlation between SNK and GI complaints, adding a unique perspective to the existing body of knowledge. Improved SNK, encompassing elements of GI health as highlighted in our questionnaire, could indirectly influence GI health through more informed dietary and lifestyle choices. For instance, better nutrition knowledge may lead athletes to adopt diets that support gut health, potentially mitigating some GI complaints. This indirect pathway suggests that while SNK may not directly reduce the incidence of GI complaints, it plays a crucial role in shaping behaviours and choices that contribute to overall GI and athletic health. However, exploring the specific mechanisms through which enhanced SNK might lead to improvements in GI health and determining the extent of these potential benefits was outside the scope of our current study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eIndividual vs Team Sport\u003c/h2\u003e \u003cp\u003eOur analysis revealed that athletes in individual sports, especially in endurance activities like triathlons and distance running, reported more GI complaints, such as diarrhoea and bloating, compared to those in team sports. This aligns with the current literature suggesting a higher susceptibility to GI symptoms among individual sports athletes\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e,\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e. The mechanism behind this increased vulnerability may be a result of the prolonged physical exertion and associated physiological changes in these sports, such as altered gut permeability and reduced blood flow to the GI tract\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, while the existing literature has primarily focused on endurance-based activities, the understanding of GI complaints in the context of team sports remains limited. Possible factors that could be investigated include differences in training intensity, duration, dietary practices, psychological stressors, and the overall physiological demands of individual and team sports. Understanding these nuances may be crucial for developing targeted strategies to mitigate GI complaints in athletes. For example, if specific dietary practices or training regimens are identified as key contributors to GI distress in certain sports, interventions can be tailored accordingly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFactors Contributing to GI Complaints\u003c/h2\u003e \u003cp\u003eMost participants experienced GI complaints primarily before starting their exercise, as indicated by 45.5% of respondents, with the next most common timing being immediately post-exercise (38.7%). It should be noted that the questionnaire allowed for multiple responses regarding the timing of symptoms. The predominance of GI symptoms prior to exercise initiation underscores a more complex relationship between physical activity and GI distress than previously understood. This pattern challenges the popular belief of a temporal association between exercise and the onset of symptoms\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The varied timing of these complaints, as reported by participants, reflects the multifaceted nature of GI distress in the context of physical activity. The increased occurrence of symptoms like bloating and diarrhoea in longer and more intense exercise sessions might reflect the impact of prolonged physical strain and dehydration on GI function and inflammatory pathways\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u003c/sup\u003e. The high prevalence of pre-exercise GI complaints observed in this study suggests other factors influence symptoms and perhaps further exploration of the relationship between GI distress and the gut-brain-axis is warranted\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e. Understanding the timing of GI complaints during exercise is crucial for developing targeted interventions and optimising athletes' performance and well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eProbiotics\u003c/h2\u003e \u003cp\u003eThis study represents an initial exploration of probiotic knowledge among elite athletes and their coaches, with no previous data available for comparison. However, findings from Soni and colleagues \u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e on health professionals' attitudes and practices regarding probiotic use revealed that although participants were aware of the term \"probiotic,\" only 54.7% knew about their reported benefits. Similarly, our study found many (69.2%) of the elite athletes and coaches expressed uncertainty regarding the potential benefits of probiotics, choosing the option \u0026lsquo;I\u0026rsquo;m not sure how probiotics would benefit me\u0026rsquo;. Interestingly, while a considerable number of participants reported using probiotics within the current study, GI symptoms continued to be a common concern across various sports disciplines. This suggests that athletes might be using probiotics as a self-directed approach to managing specific GI issues such as stomach pain, bloating, and IBD\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u003c/sup\u003e. This aligns with existing literature, which indicates the frequent use of probiotics may alleviate symptoms of GI disorders\u003csup\u003e\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. Moreover, the survey primarily focused on whether participants were taking probiotics, without delving into the nuances of their usage, such as the duration, type, and perceived efficacy of these probiotics. Emerging research, however, points towards the potential benefits of probiotics in alleviating GI issues, particularly in endurance athletes. Studies suggest that probiotics may enhance gut health and contribute to maintaining gut barrier integrity, potentially reducing the occurrence or severity of GI symptoms\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur study is not without limitations, firstly, the online administration of the questionnaire, while facilitating broad participation, introduces the possibility of non-authentic responses. However, this concern is unlikely given the low SNK scores, making it less likely that participants engaged in deliberate cheating. Furthermore, the inclusion of coaches in the study was relatively low compared to the athlete population. This discrepancy in sample size may affect the generalisability of the findings and therefore, consideration must be taken when interpreting the results related to coaches' perspectives. One of the key limitations of our study lies in the nature of the questionnaire used. The survey predominantly focused on whether participants were consuming probiotics without delving deeper into the specifics of their use, such as duration, type, dosage, and most crucially, the athletes\u0026rsquo; subjective assessment of the effectiveness of probiotics on their symptoms and overall performance. This gap in data collection limits the scope of our understanding of the true impact of probiotics in managing GI health among athletes. Additionally, certain important aspects of athletes' dietary practices, such as meal timing, hydration status, and supplement intake, were not comprehensively examined in this study. The extent to which these factors contribute to the occurrence of GI complaints remains unclear and should be further investigated in future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite advancements in sports nutrition, the findings in this study confirm that GI complaints are still prevalent among athletes. Furthermore, the study reveals that both athletes and their coaches possess sub-optimal sports nutrition knowledge. The development of the DIGEST questionnaire, tailored specifically for athletes and coaches, offers potential as a tool for assessing gut health, GI complaints, and SNK during training and competition. By implementing the DIGEST questionnaire, nutritionists, dieticians, and coaches can identify athletes who are experiencing GI complaints and subsequently provide targeted interventions to effectively manage their symptoms. The findings underscore the importance of addressing nutrition education, optimising gut health, and considering individualised strategies to manage GI distress in athletes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eDIGEST\u003c/strong\u003e - Dietary Information for Gut Endurance Sport Testing\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGI\u003c/strong\u003e - Gastrointestinal\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSNK\u003c/strong\u003e - Sports Nutrition Knowledge\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIBD\u003c/strong\u003e - Irritable Bowel Disease\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGERD\u003c/strong\u003e - Gastroesophageal Reflux Disease\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGBA\u003c/strong\u003e - Gut Brain Axis\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFODMAP\u003c/strong\u003e - Fermentable Oligo-, Di-, Mono-saccharides and Polyols\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNUKYA\u003c/strong\u003e - Nutritional Knowledge for Young and Adult Athletes\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNSKQ\u003c/strong\u003e - Nutrition for Sport Knowledge Questionnaire\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eA-NSKQ\u003c/strong\u003e - Abridged Nutrition for Sport Knowledge Questionnaire\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eUK\u003c/strong\u003e - United Kingdom\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSESRI\u003c/strong\u003e - Sports and Exercise Science Research Institute\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSD\u003c/strong\u003e - Standard Deviation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSPSS\u003c/strong\u003e - Statistical Package for the Social Sciences\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNIH\u003c/strong\u003e - National Institutes of Health\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNCATS\u003c/strong\u003e - National Center for Advancing Translational Sciences\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVRI\u003c/strong\u003e - Victorian Research Institute\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBMI\u003c/strong\u003e - Body Mass Index\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNCAA\u003c/strong\u003e - National Collegiate Athletic Association\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eANOVA\u003c/strong\u003e - Analysis of Variance\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRP Kearns ORCID ID: 0000-0002-9428-8273\u003c/p\u003e\n\u003cp\u003eJSG Dooley ORCID ID: 0000-0002-9459-5572\u003c/p\u003e\n\u003cp\u003eM Matthews ORCID ID is: 0000-0002-3054-3466\u003c/p\u003e\n\u003cp\u003eAM McNeilly ORCID ID: 0000-0001-6050-6415\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study obtained ethical approval from the Research Ethics Committee of Ulster University (SESRI-22-038-A). All participants provided electronically signed informed consent in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have consented to publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo financial support was received for the conduct of this study, or for the preparation or publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRP Kearns: Conceived the study idea, designed the study, performed the analysis, and wrote the first draft of the manuscript.\u003c/p\u003e\n\u003cp\u003eJSG Dooley, M Matthews, and AM McNeilly: Provided expertise and input on the study design, recruitment, and data collection process.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the athletes, coaches, and sports nutritionists/dieticians who participated in this study. We also acknowledge the support of Ulster University, particularly the School of Life and Health Sciences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJeukendrup AE, Vet-Joop K, Sturk A, Stegen JHJC, Senden J, Saris WHM \u003cem\u003eet al.\u003c/em\u003e Relationship between gastro-intestinal complaints and endotoxaemia, cytokine release and the acute-phase reaction during and after a long-distance triathlon in highly trained men. \u003cem\u003eClin Sci\u003c/em\u003e 2000; \u003cstrong\u003e98\u003c/strong\u003e. doi:10.1042/cs0980047.\u003c/li\u003e\n\u003cli\u003eDe Oliveira EP, Burini RC, Jeukendrup A. 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The effect of probiotic supplementation on performance, inflammatory markers and gastro‐intestinal symptoms in elite road cyclists. \u003cem\u003eJ Int Soc Sports Nutr\u003c/em\u003e 2021; \u003cstrong\u003e18\u003c/strong\u003e. doi:10.1186/s12970-021-00432-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"gastrointestinal complaints, sports nutrition knowledge, elite athletes, probiotics, dietary practices","lastPublishedDoi":"10.21203/rs.3.rs-4476204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4476204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGastrointestinal (GI) complaints are prevalent among athletes and can have a significant impact on performance, particularly in endurance athletes. Possessing greater nutrition knowledge and effectively applying it may play an important role in optimising an athlete\u0026rsquo;s performance. Despite this, there is a paucity of research regarding GI experiences, sports nutritional knowledge (SNK) and any reciprocal relationship in elite sport. The aim of this study was to design a novel questionnaire to assess the relationship between common GI complaints, GI health, and SNK in elite athletes and coaches in the United Kingdom and Ireland. The study further explored attitudes and practices regarding diet, supplementation, and training practices to gain a comprehensive understanding of potential causative factors to GI distress.\u003c/p\u003e\u003ch2\u003eMain Body\u003c/h2\u003e \u003cp\u003eThis study developed and administered a novel SNK questionnaire, the \u0026lsquo;Dietary Information for Gut Endurance Sport Testing\u0026rsquo; (DIGEST) questionnaire to 400 elite athletes and their coaches from various sporting backgrounds. The cross-sectional questionnaire assessed GI complaints, SNK, probiotic usage, dietary practices, and exercise workload. Chi-square analyses and independent sample t-tests were employed to examine associations between variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were 211 reports of GI complaints, with the higher prevalence in individual sports, 161, compared to team sport participants, 50 complaints (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04). Common GI complaints included stomach pain, bloating, constipation, diarrhoea, bloody diarrhoea, and nausea. The timing of GI complaints challenged conventional understanding with 45.5% of participants experiencing symptoms pre-exercise, 14% at the start of exercise, 35.1% after more than 30 minutes, and 38.7% immediately post exercise. While probiotic use was common (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;186), its benefits were inconclusive. Bloating and irritable bowel disease (IBD) were significantly correlated with probiotic use, which may indicate individuals with these conditions use probiotics for symptom management. The study found no significant correlation between SNK scores and GI complaints among elite athletes (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13), suggesting SNK may not play a crucial role in preventing or contributing to these issues. However, it is noteworthy that a substantial number of participants, athletes (mean score of 59%) and coaches (mean score of 58%), demonstrated suboptimal SNK scores below the 65% threshold. Consequently, it remains unclear whether enhancing SNK levels could contribute to the reduction of GI complaints.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results of this study suggest that both athletes and coaches have sub-optimal SNK, and it appears that SNK is not related to incidence of GI complaints. However, GI complaints remain common in elite sports, especially in individual sports. These complaints occur most frequently before and towards the end of exercise. Future studies should explore exercise intensity, training practices, stress levels, and psychological well-being alongside SNK to better understand GI complaints in this population.\u003c/p\u003e","manuscriptTitle":"Dietary Information for Gut Endurance Sport Testing (DIGEST): Exploring the relationship between Gut Health, Sports Nutrition Knowledge and Nutritional Practices in Elite Sport","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-19 10:45:23","doi":"10.21203/rs.3.rs-4476204/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cc9b12b8-e8da-4056-a2e2-11c1f161ba2e","owner":[],"postedDate":"June 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-30T22:43:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-19 10:45:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4476204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4476204","identity":"rs-4476204","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}