This study presents the first SNKQ developed in Sri Lanka, specifically tailored for track and field athletes. To ensure an extensive, locally acceptable tool, we employed four comprehensive strategies that combined cultural acceptance and the latest evidence. Consequently, the development of the A-SNKQ in this study addresses a significant gap in the existing literature and offers a valuable instrument for assessing SNK within the local athletic context.
Fuber and colleagues (2017) listed Weetabix, chocolate spread, whole meal bread, and jelly beans as food items for participants to choose between high or low carbohydrates (26). However, in the Sri Lankan context, during our in-depth interviews and literature review, these food items did not emerge. Hence, we incorporated bread, cooked rice, string hoppers, and sweet potatoes as examples of carbohydrate-rich foods in our study. Similarly, while they listed kidney beans and tuna as foods rich in proteins, we have included chickpeas and fish as corresponding items in our SNKQ (26). Similarly, we substituted canola margarine, cottage cheese, and sunflower seeds with coconut oil and coconut sambal as sources of dietary fats (27). This replacement was implemented based on the prevalent use of coconut oil as the primary fat source in Sri Lanka (8).
It has been well established that athletes require a well-planned protein distribution to support their training as well as post-exercise recovery and adaptation, especially in skeletal muscles (28). According to current research, the recommended dietary protein intake to facilitate metabolic adaptation, repair, remodeling, and overall protein turnover typically ranges from 1.2 to 2.0 g/kg/d (29). Ingesting approximately 20 g to 30 g of total protein during exercise or the subsequent recovery period has been shown to enhance whole-body and muscle protein synthesis and improve nitrogen balance (29). Trakman and colleagues utilized a specific question within the SNK section to evaluate the approximate daily protein requirements of well-trained resistance athletes (30). In general, Sri Lankans have a low daily protein intake (30). Besides, another questionnaire assessed the athletes' knowledge regarding foods with high or low protein content, thereby highlighting the significance of understanding protein sources (31). The nutrition knowledge questionnaire for ultra-endurance athletes, developed by Blennerhassett and colleagues, includes a set of questions about foods categorized as low, medium, and high in protein content, providing a comprehensive assessment of participants' understanding in this area (27). In line with these findings, the current SNKQ includes a dedicated question focusing on the significance of protein distribution as well.
Fuber and his team (26) employed a separate question to assess the participant’s knowledge regarding vitamins B, C, calcium, and iron. However, in order to prevent excessive length, we have chosen to consolidate the various subcategories of vitamins into two questions. This approach enables a more concise and efficient evaluation of participants' knowledge of micronutrients. According to a review, it has been determined that reactive oxygen species play a crucial role in the processes of training adaptation resulting from resistance training. This adaptation is achieved by reducing the levels of inflammatory mediators and oxidative stress. The effects of antioxidants on recovery and sports performance have also been well evaluated in the above study (32). Blueberries are often considered to have one of the highest antioxidant contents among fruits. They are rich in various antioxidants and a large number of phytochemicals, including abundant anthocyanin pigments, vitamin C, and vitamin E, which contribute to their high antioxidant capacity (33). In Sri Lanka, antioxidant-rich fruits such as berry varieties, pomegranates, and grapes are neither cultivated nor easily accessible due to their high cost (34). Nevertheless, a study undertaken by Rupasinghe et al. suggests that local sour fruits like mandarins (Citrus reticulata) contain antioxidants (10).
Engaging in intense training while maintaining a low energy intake can present substantial health risks, including the potential development of adverse conditions such as low energy availability (LEA) (35). To address this concern and alleviate any misconceptions regarding the energy-producing components of sports, we included a separate topic on "energy balance" consisting of five questions. This allowed us to specifically focus on the issue of energy balance and provide clarity on its importance. During the in-depth interviews, it came to our attention that some athletes were utilizing intravenous (IV) vitamin B12 for energy enhancement, while others were considering the use of IV Iron during events, both of which were deemed as illegal practices and can be harmful (36).
Proper hydration for sports is an essential area to access in any questionnaire related to sports nutrition. Previous studies have primarily concentrated on various aspects of hydration, including the determination of optimal fluid intake during exercise sessions (27), the composition of sports drinks (27, 31), the myths and importance of hydration for sports performance (30), and the identification of dehydration signs (26). Hence, the subtopic 'hydration' was subsequently employed in our work to evaluate various aspects, including the identification of dehydration symptoms, the recognition of salt-rich sources, and the recommended post-training fluid intake for athletes. Our previous studies have also identified limitations in knowledge regarding hydration within a similar population (24).
In order to optimize metabolism and subsequent endurance performance, careful consideration must be given to the composition of pre-exercise meals (37). Athletes employ various dietary strategies to maximize glycogen stores during training sessions and improve performance (22). The post-exercise period is often recognized as the most critical phase for the timing of dietary intake (38). Therefore, to underscore the importance of athletes' knowledge regarding pre-training, during, and post-training meals, we have dedicated the first three subsections to these topics. Consistent with other SNKQs (26, 30), these three areas have also been addressed in their respective versions.
Supplements were reported to be consumed by a significant proportion (91.5%) of Sri Lankan athletes, without a scientific basis (11). Remarkably, the intake of multiple supplements (polypharmacy) in high doses for extended durations raises serious concerns with regard to their safety. Potential side effects of excessive supplement use consist of kidney injury, gastrointestinal discomfort, hypercalcemia, and an increased risk of cardiovascular diseases (39). Furthermore, a significant percentage of European and American dietary supplements, from 10–25%, may pose a potential risk of doping (40), while more recent data suggest an even higher rate of 38% (41). Given this grave situation, our questionnaire aims to shed light on the appropriate consumption of sports supplements to enhance the knowledge and understanding of athletes in this area. We incorporated a specific question into our A-SNKQ using a grid format, which was adopted from a sports nutrition position statement (2). The purpose of this evaluation was to assess participants' knowledge concerning supplements that have the potential to enhance performance in track and field athletes by relying on the most current guidelines and recommendations.
LEA, in turn, can lead to the manifestation of detrimental syndromes like RED-S, which can have adverse effects on an athlete's performance and overall well-being (22). In a study conducted in 2022, the objective was to develop and validate a questionnaire specifically designed to assess the knowledge of athletes regarding the signs and symptoms of RED-S (42). Despite the limited number of existing questions on RED-S, we found it essential to include this topic in our questionnaire to further explore this important aspect.
Limitations
The A-SNKQ developed in the current study has some limitations to consider. While it is a comprehensive tool, it contains knowledge items that may not be equally important for every athlete. As well, the length and technical nature of the questionnaire might pose challenges for athletes who lack motivation or have lower literacy levels. By implementing evidence-based interventions based on the findings of the SNK assessment tool, national athletic programs can optimize their athletes' nutrition knowledge and practices, leading to improved performance and overall success in the sporting arena. However, it is crucial to emphasize the need for proper validation of the current A-SNKQ, followed by the process of development, to ensure its relevance and significance in future research and practical applications.
Strengths
The current tool has undergone substantial enhancements, resulting in improved organization, precision, and effectiveness. These advancements were accomplished by adopting a comprehensive multi-modal approach that encompassed several key elements. This comprises aligning with existing literature, incorporating the latest review of sports nutrition guidelines and position statements, leveraging the expertise of sports nutritionists, and drawing insights from a qualitative study involving relevant stakeholders within the athletic community. The questionnaire was initially developed based on up-to-date evidence-based findings, ensuring its relevance and accuracy. Furthermore, it was carefully adopted to match the local context, taking into consideration the national food and supplement landscape. This process resulted in the modification of the A-SNKQ into a culturally specific and athlete-tailored assessment tool, further enhancing its applicability to track and field athletes in Sri Lanka. The qualitative review of the categories and sub-categories derived from experts' comments facilitated a clear item review process for subsequent rounds. Additionally, a notable strength of this study is the wide-ranging coverage of the A-SNKQ, which encompasses five in GNK and seven sub-sections in SNK. European questionnaires did not align closely with our context in Sri Lanka, and during our in-depth interviews and literature review, these options did not emerge. Therefore, we included the most commonly consumed local foods, beverages, and supplements. Furthermore, we incorporated a separate sub-section on RED-S within the sports nutrition section to assess this emerging issue observed among athletes.