CREATINE USAGE AND EDUCATION OF TRACK AND FIELD THROWERS AT NATIONAL COLLEGIATE ATHLETIC ASSOCIATION DIVISION I UNIVERSITIES LAWRENCE W. JUDGE,1 JEFFREY C. PETERSEN,2 BRUCE W. CRAIG,1 DONALD L. HOOVER,3 KARA A. HOLTZCLAW,1 BRIANNA N. LEITZELAR,1 REBECCA M.R. TYNER,4 AMY S. BLAKE,5 OMAR S. HINDAWI,6 AND DAVID M. BELLAR7 1
School of Physical Education, Sport, and Exercise Science, Ball State University, Muncie, Indiana; 2Department of Health, Human Performance, and Recreation, School of Education, Waco, Texas; 3Department of Physical Therapy, Western Kentucky University, Bowling Green, Kentucky; 4Advancing Knowledge in Health Care, Chicago, Illinois; 5New Castle School Corporation, New Castle, Indiana; 6Department of Sport Rehabilitation, Hashemite University, Zarqa, Jordan; and 7School of Kinesiology, University of Louisiana Lafayette, Lafayette, Louisiana ABSTRACT
Judge, LW, Petersen, JC, Craig, BW, Hoover, DL, Holtzclaw, KA, Leitzelar, BN, Tyner, RMR, Blake, AS, Hindawi, OS, and Bellar, DM. Creatine usage and education of track and field throwers at National Collegiate Athletic Association Division I universities. J Strength Cond Res 29(7): 2034–2040, 2015— The purpose of this study was to analyze the level of creatine use along with the perceived benefits and barriers of creatine use among collegiate athletes who participate in throwing events within the sport of track and field. A total of 258 throwers from National Collegiate Athletic Association Division I institutions completed an online survey regarding creatine. The results provided baseline levels of creatine use and allowed for the analysis of factors related to athletic conference affiliation. Results indicate that creatine use remains to be a common (32.7%) practice among throwers with significantly higher levels of use among Football Bowl Subdivision (FBS) conference athletes (44.6%) than Football Championship Subdivision (FCS) conference athletes (28.8%), x2 = 5.505, p = 0.019. The most common reasons for using creatine included a desire to improve/increase: strength (83.3%), recovery time (69.0%), and performance (60.7%). The most common perceived obstacles included contamination/quality control (39.5%), cost (33.3%), inconvenience (16.7%), and cramping (14.3%). A desire for additional education and training was noted through an expression of interest (55.6%) with significantly higher levels of interest from FBS athletes (65.6%) than FCS athletes (52.2%), x2 = 6.425, p = 0.039.
Address correspondence to Lawrence W. Judge, [email protected]. 29(7)/2034–2040 Journal of Strength and Conditioning Research Ó 2015 National Strength and Conditioning Association
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However, the athletic departments provide nutritional supplement counseling at only 26.6% of the schools. Although the access to full-time nutritionist counsel was available at 57.3% of the schools, there was a significant difference (x2 = 9.096, p = 0.003) between FBS schools (73.7%) and FCS schools (51.7%).
KEY WORDS supplements, ergogenic aids, performance INTRODUCTION
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hrowing events in track and field require maximal strength and power to be competitive and demand training regimens that are designed to maximize these qualities (16). These training regimens extended into nutritional content and insuring the optimal type and amount of intake for best performance (6). In an effort to further maximize strength and power, some athletes use creatine as a nutritional supplement; and documentation showed that creatine enhanced training of athletes in sports that require strength and power, such as track and field throwing events (3,26). Reports of creatine use in previous research of collegiate athletes has ranged between a low of 13.3% to a high of 78.0% (8,9,10,12,17,33). A variety of protocols have been used to assess the effects of creatine supplementation upon brief, intermittent, and high-intensity exercise. For example, creatine with resistance training has been shown to improve performance indices associated with muscular strength, muscular endurance, and anaerobic power production (1,2,14,15,19,31,32,36). However, no specific studies have detailed the use or knowledge of creatine in track and field throw athletes at the collegiate level. The efficacious use of creatine as a nutritional supplement for athletic performance is related to proper levels of use, and creatine dosing is generally broken up into a loading phase and maintenance phase. Recommended
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Journal of Strength and Conditioning Research loading doses include 0.3 g$kg21$d21 (approximately 20 g$d21) for 5–7 days or the maintenance dose of 3–5 g$d21 (6,38). Another study reported that a common method of beginning creatine supplementation included a 5- or 6-day loading period with the athlete consuming 20–25 grams of creatine per day, leading to a maintenance dose of 3–5 g$d21 (30). Side effects are a concern with any ergogenic aids; therefore, a discussion related to creatine supplementation is warranted. Weight gain is the only clinically significant side effect reported in the literature (5,20); however, creatine users commonly state that they experience dehydration, cramping, kidney damage, gastrointestinal distress, and musculoskeletal injury (5,27) in addition to the commonly reported weight gain. Although kidney damage would be the most concerning of the side effects mentioned, it should be noted that in the dosages most commonly used, studies have not shown creatine to have any negative effects on renal function, independent of duration (i.e., short term: 5 days, intermediate term: 14 days, or long term: 10 months to 5 years) (26–29,32), even though creatine concentration in the urine has been reported to be 90 times greater than normal (28). These increased levels of creatine in urinary output resulting from creatine supplementation have been linked to the production of false indicators for kidney dysfunction (38). Additionally, Buford et al. (5) stated that “creatine supplementation appears to be safe” when taken within recommended dosages (both short-term and longterm studies) in healthy populations (5,6). Creatine is not directly regulated by the U.S. Food and Drug Administration (FDA) (8), which means that its production is not held accountable to the same quality control standards of pharmaceutical products. Therefore, a more valid concern related to creatine usage in a collegiate athlete population is that of contaminated or impure creatine supplements. One particular review by Graham et al. (11) raised concerns relating to impurities or active ingredient concentrations resulting in doses that do not match the product labeling. One study discovered several distributors of creatine were selling creatine that did not contain the levels of ingredients that were printed on the labels (7). The lack of regulation and standards related to creatine may result in potentially dangerous outcomes given that the manufacturer is also the one responsible for insuring its purity and safety. In a similar manner, the National Collegiate Athletic Association (NCAA) ban on the distribution of creatine to student-athletes has resulted in concerns related to the oversight, safety, and supervision of creatine usage among collegiate athletes (25). As of August 2000, the NCAA Division I Bylaw 16.5.2.g has placed creatine and creatinecontaining compounds on the “nonpermissible” list of nutritional supplements, meaning that universities are prohibited from providing creatine to student-athletes (25). The bylaw does not ban the use of creatine, but it does place a ban on the distribution of the supplement by the university
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to its student-athletes. However, the passage of this bylaw does not yet appear to have made an impact on the rates of creatine supplementation among student-athletes. Despite the NCAA regulation, it seems that athletes continue to use creatine supplements in their efforts to improve overall performances (33). Both the training and competition for collegiate track and field throw athletes place a premium on power and strength as necessitated by the physical demands of the events contested. Based on these desired qualities, collegiate throwers would be likely consumers of supplements purported to enhance speed and power. Without university distribution, these athletes may seek alternative sources to obtain the supplement, which may create circumstances where the athlete may unknowingly settle for using contaminated or impure supplements (9). Additionally, studentathletes may receive little to no supervision regarding the appropriate quantity for effective and safe use of the supplement as creatine is no longer provided or controlled by university personnel. Based on these concerns, this study sought to examine both the use and knowledge of creatine among a sample of collegiate track and field throw athletes.
METHODS Experimental Approach to the Problem
The purpose of this study was to investigate the levels of use, perceived benefits and side effects, and knowledge of creatine supplementation of NCAA Division I track and field throwers in the United States. The use of a 36-item survey instrument allowed for the collection of data from both institutions and coaches across the NCAA Division I target population. Questions consisting of creatine use and creatine education were used to determine the frequency of use and the athlete’s depth of knowledge concerning appropriate use of the supplement. Individuals with a strong professional background in both throwing events of track and field and the usage of nutritional supplements constructed the survey instrument. In addition, a panel of experts in sport nutrition reviewed the survey to establish content and face validity. Minor revisions were made according the feedback from the expert review process. Subjects
The subjects (19.9 6 1.30 years) included both males (n = 137) and females (n = 121) who participated in resistance training to enhance athletic performance in collegiate field events. Age range of subjects was 18–24. Both the survey instrument and the data collection protocol were reviewed and approved by the appropriate Institutional Review Board of the primary investigator’s university to safeguard the rights of the participants. All participants signed an electronic informed consent prior to filling out the survey. When queried about total weightlifting experience inclusive of high school and college, the experience, in years, of resistance training was 5.5 6 0.90 for the male athletes VOLUME 29 | NUMBER 7 | JULY 2015 |
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Creatine Usage and Education
TABLE 1. Creatine use (FBS vs. FCS).*
Know others using Thought of using Used Currently use
FBS
FCS
Count (%)
Count (%)
51 38 29 6
(77.27) (57.58) (43.94) (20.00)
124 74 55 21
(64.9) (38.74) (28.80) (36.84)
x2
p
4.11 7.66 5.51 2.61
0.043† 0.006† 0.019† 0.107
*FBS = football bowl subdivision; FCS = football championship subdivision. †indicates significance difference between FBS and FCS.
and 3.6 6 0.94 for the female athletes. A total of 333 NCAA Division I universities were located through the NCAA directory; a total of 285 invitations to participate in the study were distributed by e-mail to all head NCAA Division I track and field coaches in the United States. The e-mail invitation included a hyperlink to the questionnaire and a request for informed consent from each participant. These coaches were instructed to share this invitation to participate directly with the current throw athletes in their track and field programs. Procedures
A 36-item survey instrument was developed to collect data regarding creatine usage patterns of collegiate track and field throwers. Questions related to sources of supplement information, perception of dosage, and perceived barriers to using creatine were added to the original survey. The creatine use and knowledge survey was developed by the researchers, reviewed by experts in the area of nutritional supplements for face and content validity. The final survey consisted of 30 items assessing demographics, creatine usage, knowledge of creatine, benefits/costs toward taking creatine, and sources for creatine information. Sample questions include (a) “What type of creatine do you take?” (b) “Please mark the benefits you have experienced with the use of creatine.” (c) “Would you be interested in an educational program to learn more about creatine?” The questionnaire was formatted for online completion and delivered using the inQsit system. A total of 285 questionnaires were distributed by e-mail to NCAA Division I head track and field coaches. The university head track and field coach was instructed to forward the e-mail, which included the hyperlink, directly to the throwers or through their assistant (throws) coach for distribution to the throwers. The survey required approximately 15–20 minutes to complete. Participants were provided with an explanation of the study through a letter that described the study and were required to provide their informed consent before beginning data collection. To improve response rates, a reminder was e-mailed 2 weeks
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after the initial contact. The results were tabulated and entered into a spreadsheet format for data analysis. Statistical Analyses
Face and content validity for the survey instrument were determined through an expert panel. Cronbach’s alpha analyses were not calculated due to the nominal and categorical nature of the survey questions (34). Descriptive statistics were calculated and examined to determine the basic information regarding the level of creatine use and knowledge in the studied population. Chi-square analyses were conducted to examine variations in use and knowledge regarding demographic classifications. All analyses were undertaken with SPSS version 21.0.
RESULTS The 285 surveys distributed to NCAA Division I college coaches yielded 258 completed surveys from athletes. The resulting data provided baseline levels of current creatine use
TABLE 2. Advice/counsel factor for creatine use and product selection (current and former users).*
Sport performance Speed Endurance Physical appearance Recovery Strength Other
FBS
FCS
Count (%)
Count (%)
15 6 9 4 21 23 3
36 12 10 9 37 47 5
(18.52) (7.41) (11.11) (4.93) (25.93) (28.40) (3.70)
(23.07) (7.69) (6.41) (5.76) (23.72) (30.13) (3.21)
*FBS = football bowl subdivision; FCS = football championship subdivision.
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TABLE 3. Results by classification of football subdivision.* FBS Variable Used creatine Student-athletes desire additional information about creatine
Response
Count (%)
Response
Count (%)
Yes No Yes
29 (43.94) 37 (56.06) 30 (46.15)
Yes No Yes
55 (28.80) 136 (71.20) 55 (29.57)
No May be Yes No
Access to full-time nutritionist
FCS
23 12 46 16
(35.38) (18.47) (74.19) (25.81)
No May be Yes No
89 42 93 87
(47.85) (22.58) (51.67) (48.33)
*FBS = football bowl subdivision; FCS = football championship subdivision.
and also allowed for further analysis of differences among factors related to athletic conference affiliation (Football Bowl Subdivision [FBS] vs. Football Championship Subdivision [FCS]). Results show that creatine use is common (32.7%) among throwers with significantly higher levels of use among FBS conference athletes (43.94%) in comparison with FCS conference athletes (28.8%), x2 = 5.505, p = 0.019 (Table 1). The most common reasons for using creatine included desire to improve strength (83.3%), recovery time (69.0%), and sport performance (60.7%) (Table 2). The most common obstacles for creatine use included concerns with contamination/quality control (39.5%), cost (33.3%), inconvenience (16.7%), and cramping (14.3%). When asked to indicate their likelihood of seeking advice or counsel from a variety of resources, results indicated that athletes were most likely to use a teammate (36.6% FBS and 32.1% FCS) followed by a coach (23.3% FBS and 23.2% FCS), with utilization of a nutritionist (20% FBS and 23.2% FCS) being the least likely source from which to seek creatine information. Cost (36.6% FBS and 21.4% FCS) was also a major factor in determining product selection. The throwers expressed an interest in additional
education (55.6%) regarding creatine with significantly more interest from FBS athletes (65.6%) than FCS athletes (52.2%), x2 = 6.425, p = 0.039. However, only 26.6% of the participating athletic departments provided nutritional supplement counseling (Table 2). Although the access to full-time nutritionist counsel was available at 57.3% of the schools, there was a significant difference (x2 = 9.096, p = 0.003) between FBS schools (74.19%) and FCS schools (51.7%) (Table 3). Male and female participants reported different perceptions regarding the beneficial nature of creatine use (x2 = 21.775, p = 0.001) with a greater percentage of male participants reporting creatine as beneficial (70.0% male vs. 23.5% female) (Table 4). Reported levels of creatine use were also related to perceptions regarding the beneficial nature of creatine (x2 = 37.002, p = 0.001) with participants who had a history of using creatine reporting higher levels of perceived benefit (76.1%) than those without a history of creatine use (17.9%) (Table 4). Furthermore, reported perceptions that creatine use was beneficial were related to greater perceptions that creatine would improve stamina (x2 = 8.172, p = 0.002), improve muscle endurance (x2 = 39.026, p = 0.001), enhance injury recovery (x2 = 9.918,
TABLE 4. Responses regarding the beneficial nature of creatine use. Variable Gender Male Female History of creatine use Used creatine No creatine use
Response
Count (%)
Response
Count (%)
Yes beneficial Yes beneficial
63 (70.00) 8 (23.53)
Not beneficial Not beneficial
27 (30.00) 26 (76.47)
Yes beneficial Yes beneficial
64 (76.19) 7 (17.95)
Not beneficial Not beneficial
20 (28.81) 32 (82.05)
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Creatine Usage and Education p = 0.002), improve exercise recovery (x2 = 48.093, p = 0.001), and improve the distance the athlete could throw (x2 = 23.375, p = 0.001).
DISCUSSION Despite the NCAA placement of creatine on the “nonpermissible” list of nutritional supplements (August 2000, NCAA Division I Bylaw 16.5.2.g change) that bans them from making creatine available to their athletes, research has shown an increase in creatine use among collegiate athletes (4). Creatine supplementation has been shown to increase athletic performance (1,2,15,19,32,36), which is one of the main reasons it was placed on the nonpermissible list, as it might give larger schools with a bigger budget an advantage over smaller schools. Although this may level the playing field from a competition point of view, it does not seem to discourage creatine usage. With the current NCAA ban on creatine distribution, one of the most significant concerns surrounding creatine use is that many student-athletes receive little education regarding the appropriate dosing and potential harmful effects of creatine supplementation. For these reasons, student-athletes may not fully understand the established practices regarding dosage and duration of creatine supplementation nor the concerns related to purity (7). In light of the results of the present investigation and past studies regarding use among collegiate athletes (4,10,12,37), universities should consider implementing an educational program that provides adequate information and support for student-athletes, which should assist with increasing student knowledge and safety and preventing overuse. Education regarding appropriate use of creatine can be distributed to NCAA student-athletes in a number of ways. One recommendation is that a professional dietician provides sufficient information regarding the potential side effects of the creatine supplement. Unfortunately, only 26.6% of the universities in this study provided nutritional counseling to the athletes. Universities are encouraged to provide mandatory nutritional counseling to all athletes to prevent any side effects that creatine, or other supplements, may cause. If every NCAA university would implement nutritional counseling, then all athletes would gain meaningful knowledge of the potential effects, and coaches would more easily be able to influence the use of creatine by their athletes. Overuse as a result of inadequate education may be related to noncompliance with recommended dosing. Research has shown that even low doses of creatine improve power in high-intensity training (4,14). When used properly, collegiate track and field throwers may use creatine in small or appropriate doses to improve their performance. The quickest method of increasing muscle creatine stores seems to be to consume ;0.3 g$kg21$d21 of creatine monohydrate for at least 3 days followed by 3–5 g$d21 thereafter to maintain elevated stores. Ingesting smaller amounts of creatine monohydrate (e.g., 2–3 g$d21) will increase muscle creatine stores over a 3- to 4-week period; however, the performance effects
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of this method of supplementation are less supported (6). Interestingly in this previous study, only 22.6% of the participants were compliant with the suggested doses, whereas 73.8% of the participants were noncompliant by using higher than suggested doses. Access to effective educational programs designed to increase knowledge of creatine supplementation should help student-athletes make more informed decisions about creatine use and perhaps reduce the incidence of overuse. Creatine is used as an aid in the strength and conditioning of power athletes (3,26). However, there are potential side effects that are important to note. Diarrhea, muscle cramps, weight gain, and dehydration levels were studied among NCAA Division I football players after they consumed creatine supplements. Results indicated that diarrhea was the most frequently reported side effect followed by muscle cramping, but 26.9% of the participants reported no perceived side effects (18). All of these side effects are temporary, and if the symptoms persist or become intense, the athlete is encouraged to discontinue using the supplement to eliminate the symptoms of these side effects (18). However, consuming dosages that exceed recommendations are likely to enhance these side effects and have not shown greater improvements in performance (18). The decision of the NCAA to ban universities from distribution of creatine to athletes implies that creatine is a harmful substance. However, there has been limited research that has evaluated potential side effects of the supplement. As previously stated, negative side effects that may occur have been noted as temporary, and athletes are likely to take the risk to gain temporary gains in strength throughout competition as demonstrated through responses from the 258 participants in this study. Health issues or signs of any negative side effect were not listed as major drawbacks to the usage of creatine. Indeed, only 14% of the current subjects reported “cramping” as a drawback, and this response was the only 1 involving health concerns. Because of the novelty of the creatine supplement, there is a concern for harmful side effects that may not occur with initial use but have the ability to occur over long-term that may become evident in the future. A 21-month study on NCAA Division I football players along with results of a study on effects of the liver and kidney after creatine use have indicated that long-term creatine supplementation does not have a significant negative health effect on athletes (20,21). Collegiate athletes typically compete in their sport for a maximum of 4 years, and these athletes are not likely to continue to use the supplement after the completion of their competitive career. Given the current reports of no long-term side effects with creatine, athletes may benefit from having open access to and knowledge of appropriate use of this supplement (6). However, not all sport budgets allow for the provision of supplements to their athletes, and this creates an unfair advantage to those teams who are able to purchase creatine and other supplements for their athletes (24).
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Journal of Strength and Conditioning Research Despite the discussion of short- and long-term effects regarding health, a greater majority of the participants in this study reported obstacles pertaining to contamination and quality control (39.5%), cost (33.3%), and inconvenience (16.7%). The results did not suggest any concerns of the athletes with their own health. These 3 reported obstacles may all be intertwined. Because cost is one of the driving factors in the selection of creatine supplements, athletes must have a complete understanding of what the underlying implications of a low-cost supplement, including impurities and contamination. The potential impurities and contaminants that are typically found in supplements in general (17) and specifically in creatine (22) are the highest risk factors associated with creatine use (9). Companies that produce dietary supplements “are responsible for evaluating the safety and labeling of their products before marketing to ensure that they meet all the requirements” determined by the FDA (35). However, the FDA does not directly test these products before companies sell their product. If the NCAA reverses its decision on creatine and permits universities to distribute creatine, athletes will have to depend on education to learn the proper usage of creatine. The results of this study indicate that these educational opportunities are not available in many schools and that it is not the first choice for gaining information in the usage of creatine. Allowing universities to exercise control over the distribution of the creatine supplement may create a competitive edge for teams who can afford supplementation, but banning distribution potentially creates more risk for athletes from the potentially harmful use of creatine. Hedrick (2000) examined the policies of strength and conditioning coaches at various universities in relating to the process in which they distributed creatine. Before the NCAA regulation, which bans distribution of creatine to student-athletes, strength coaches could determine which athletes needed creatine supplementation and maintained control regarding dosing, usage, and education (13). Under this previous framework, coaches and athletes worked together to ensure appropriate dosing, purity of the supplement, and education regarding benefits and side effects (13). Perhaps, the driving force behind the NCAA ban was intended to increase consistency across all universities as some universities did not have the funds to operate under a system where distributing creatine could be done in safe controlled environment.
PRACTICAL APPLICATIONS The NCAA recently changed its snack and food policy to allow schools to provide all student-athletes with unlimited fuel to sustain them (23). Perhaps, this recent change will pave the way for a re-examination of Bylaw 16.5.2.g’s ban on supplements. The results of this investigation may provide relevant data to support a recommendation that the NCAA create and implement a policy regarding creatine use, which may be used to shape future legislation. Such NCAA legislation could result in an increased awareness of the levels of
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use, improved education, and a reduction of negative effects of overuse. Given that creatine supplements, especially low quality supplements with unwanted contaminants, may produce unwanted side effects, close monitoring and supervision of student-athletes is warranted. To find the purest creatine products, institutions should purchase products from reputable sources that guarantee their products undergo a rigorous testing and certification process. However, current NCAA regulations ban the distribution of creatine to student-athletes and significantly hinder the ability of the strength coach to provide an adequate level of oversight. Nonetheless, strength coaches are strongly encouraged to identify and implement strategies to more closely monitor student-athletes. Coaches must take action to protect and serve their athletes who choose to use the supplement despite the ban by engaging in open and honest communications with their athletes regarding the use of creatine. Coaches are encouraged to (a) employ or consult with professionals such as Registered Dietitians with an interest in sport medicine or Masters Level Strength and Conditioning Coaches who have training in proper nutrition and supplement use; (b) be aware of the increasing trend of creatine supplementation amongst collegiate athletes; (c) develop and maintain open communication with each athlete regarding individual use; (d) review recent literature regarding the benefits and side effects of creatine use; and (e) keep their eyes and ears open to recognize signs that their athletes may be using creatine incorrectly.
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28. Poortmans, JR and Francaus, M. Long-term oral creatine supplementation does not impair rental function in healthy athletes. Med Sci Sports Exerc 31: 1108–1110, 1999. 29. Poortmans, JR, Kumps, A, Duez, P, Fofonka, A, Carpentier, A, and Francaux, M. Effects of oral creatine supplementation on urinary methylamine, formaldehyde, and formate. Med Sci Sports Exerc 37: 1717–1720, 2005. 30. Rawson, ES, Stec, MJ, Frederickson, SJ, and Miles, MP. Low-dose creatine supplementation enhances fatigue resistance in the absence of weight gain. 2011. Available at: http://easacademy.org/researchnews/article/low-dose-creatine-supplementation-enhances-fatigueresistance-in-the-absence-of-weight-gain-b. Accessed October 17, 2014. 31. Rawson, ES and Volek, JS. Effects of creatine supplementation and resistance training on muscle strength and weightlifting performance. J Strength Cond Res 17: 822–831, 2003. 32. Saremi, A, Gharakhanloo, R, Sharghi, S, Gharaati, MR, Larijani, B, and Omidfar, K. Effects of oral creatine and resistance training on serum myostatin and GASP-1. Mol Cell Endocrinol 317: 25–30, 2010. 33. Stuntz, CP, Edwards, JC, and Kaye, M. Individual and social predictors of performance-enhancing and dietary supplement use among male NCAA division III athletes. J Issues Intercol Athl 7: 187– 206, 2014. 34. Trobia, A. Cronbach’s alpha. In: Encyclopedia of Survey Research Methods. P.J. Lavakas, ed. Thousand Oaks, CA: Sage, 2008. 35. U.S. Food and Drug Administration. Dietary supplements. 2014. Available at: http://www.fda.gov/Food/Dietarysupplements/ default.htm. Accessed October 10, 2014. 36. Vandenberghe, KP, Goris, M, Van Hecke, P, Van Leemputte, M, Vanderven, D, and Hespel, P. Long-term creatine intake is beneficial to muscle performance during resistance training. J Appl Physiol (1985) 83: 2055–2063, 1997. 37. Wyss, M and Kaddurah-Daouk, R. Creatine and creatinine metabolism. Physiol Rev 80: 1107–1213, 2000. 38. Yoshizumi, WM and Tsourounis, C. Effects of creatine supplementation on renal function. J Herb Pharmacother 4: 1–7, 2004.
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School of Physical Education, Sport, and Exercise Science, Ball State University, Muncie, Indiana; 2Department of Health, Human Performance, and Recreation, School of Education, Waco, Texas; 3Department of Physical Therapy, Western Kentucky University, Bowling Green, Kentucky; 4Advancing Knowledge in Health Care, Chicago, Illinois; 5New Castle School Corporation, New Castle, Indiana; 6Department of Sport Rehabilitation, Hashemite University, Zarqa, Jordan; and 7School of Kinesiology, University of Louisiana Lafayette, Lafayette, Louisiana ABSTRACT
Judge, LW, Petersen, JC, Craig, BW, Hoover, DL, Holtzclaw, KA, Leitzelar, BN, Tyner, RMR, Blake, AS, Hindawi, OS, and Bellar, DM. Creatine usage and education of track and field throwers at National Collegiate Athletic Association Division I universities. J Strength Cond Res 29(7): 2034–2040, 2015— The purpose of this study was to analyze the level of creatine use along with the perceived benefits and barriers of creatine use among collegiate athletes who participate in throwing events within the sport of track and field. A total of 258 throwers from National Collegiate Athletic Association Division I institutions completed an online survey regarding creatine. The results provided baseline levels of creatine use and allowed for the analysis of factors related to athletic conference affiliation. Results indicate that creatine use remains to be a common (32.7%) practice among throwers with significantly higher levels of use among Football Bowl Subdivision (FBS) conference athletes (44.6%) than Football Championship Subdivision (FCS) conference athletes (28.8%), x2 = 5.505, p = 0.019. The most common reasons for using creatine included a desire to improve/increase: strength (83.3%), recovery time (69.0%), and performance (60.7%). The most common perceived obstacles included contamination/quality control (39.5%), cost (33.3%), inconvenience (16.7%), and cramping (14.3%). A desire for additional education and training was noted through an expression of interest (55.6%) with significantly higher levels of interest from FBS athletes (65.6%) than FCS athletes (52.2%), x2 = 6.425, p = 0.039.
Address correspondence to Lawrence W. Judge, [email protected]. 29(7)/2034–2040 Journal of Strength and Conditioning Research Ó 2015 National Strength and Conditioning Association
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However, the athletic departments provide nutritional supplement counseling at only 26.6% of the schools. Although the access to full-time nutritionist counsel was available at 57.3% of the schools, there was a significant difference (x2 = 9.096, p = 0.003) between FBS schools (73.7%) and FCS schools (51.7%).
KEY WORDS supplements, ergogenic aids, performance INTRODUCTION
T
hrowing events in track and field require maximal strength and power to be competitive and demand training regimens that are designed to maximize these qualities (16). These training regimens extended into nutritional content and insuring the optimal type and amount of intake for best performance (6). In an effort to further maximize strength and power, some athletes use creatine as a nutritional supplement; and documentation showed that creatine enhanced training of athletes in sports that require strength and power, such as track and field throwing events (3,26). Reports of creatine use in previous research of collegiate athletes has ranged between a low of 13.3% to a high of 78.0% (8,9,10,12,17,33). A variety of protocols have been used to assess the effects of creatine supplementation upon brief, intermittent, and high-intensity exercise. For example, creatine with resistance training has been shown to improve performance indices associated with muscular strength, muscular endurance, and anaerobic power production (1,2,14,15,19,31,32,36). However, no specific studies have detailed the use or knowledge of creatine in track and field throw athletes at the collegiate level. The efficacious use of creatine as a nutritional supplement for athletic performance is related to proper levels of use, and creatine dosing is generally broken up into a loading phase and maintenance phase. Recommended
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Journal of Strength and Conditioning Research loading doses include 0.3 g$kg21$d21 (approximately 20 g$d21) for 5–7 days or the maintenance dose of 3–5 g$d21 (6,38). Another study reported that a common method of beginning creatine supplementation included a 5- or 6-day loading period with the athlete consuming 20–25 grams of creatine per day, leading to a maintenance dose of 3–5 g$d21 (30). Side effects are a concern with any ergogenic aids; therefore, a discussion related to creatine supplementation is warranted. Weight gain is the only clinically significant side effect reported in the literature (5,20); however, creatine users commonly state that they experience dehydration, cramping, kidney damage, gastrointestinal distress, and musculoskeletal injury (5,27) in addition to the commonly reported weight gain. Although kidney damage would be the most concerning of the side effects mentioned, it should be noted that in the dosages most commonly used, studies have not shown creatine to have any negative effects on renal function, independent of duration (i.e., short term: 5 days, intermediate term: 14 days, or long term: 10 months to 5 years) (26–29,32), even though creatine concentration in the urine has been reported to be 90 times greater than normal (28). These increased levels of creatine in urinary output resulting from creatine supplementation have been linked to the production of false indicators for kidney dysfunction (38). Additionally, Buford et al. (5) stated that “creatine supplementation appears to be safe” when taken within recommended dosages (both short-term and longterm studies) in healthy populations (5,6). Creatine is not directly regulated by the U.S. Food and Drug Administration (FDA) (8), which means that its production is not held accountable to the same quality control standards of pharmaceutical products. Therefore, a more valid concern related to creatine usage in a collegiate athlete population is that of contaminated or impure creatine supplements. One particular review by Graham et al. (11) raised concerns relating to impurities or active ingredient concentrations resulting in doses that do not match the product labeling. One study discovered several distributors of creatine were selling creatine that did not contain the levels of ingredients that were printed on the labels (7). The lack of regulation and standards related to creatine may result in potentially dangerous outcomes given that the manufacturer is also the one responsible for insuring its purity and safety. In a similar manner, the National Collegiate Athletic Association (NCAA) ban on the distribution of creatine to student-athletes has resulted in concerns related to the oversight, safety, and supervision of creatine usage among collegiate athletes (25). As of August 2000, the NCAA Division I Bylaw 16.5.2.g has placed creatine and creatinecontaining compounds on the “nonpermissible” list of nutritional supplements, meaning that universities are prohibited from providing creatine to student-athletes (25). The bylaw does not ban the use of creatine, but it does place a ban on the distribution of the supplement by the university
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to its student-athletes. However, the passage of this bylaw does not yet appear to have made an impact on the rates of creatine supplementation among student-athletes. Despite the NCAA regulation, it seems that athletes continue to use creatine supplements in their efforts to improve overall performances (33). Both the training and competition for collegiate track and field throw athletes place a premium on power and strength as necessitated by the physical demands of the events contested. Based on these desired qualities, collegiate throwers would be likely consumers of supplements purported to enhance speed and power. Without university distribution, these athletes may seek alternative sources to obtain the supplement, which may create circumstances where the athlete may unknowingly settle for using contaminated or impure supplements (9). Additionally, studentathletes may receive little to no supervision regarding the appropriate quantity for effective and safe use of the supplement as creatine is no longer provided or controlled by university personnel. Based on these concerns, this study sought to examine both the use and knowledge of creatine among a sample of collegiate track and field throw athletes.
METHODS Experimental Approach to the Problem
The purpose of this study was to investigate the levels of use, perceived benefits and side effects, and knowledge of creatine supplementation of NCAA Division I track and field throwers in the United States. The use of a 36-item survey instrument allowed for the collection of data from both institutions and coaches across the NCAA Division I target population. Questions consisting of creatine use and creatine education were used to determine the frequency of use and the athlete’s depth of knowledge concerning appropriate use of the supplement. Individuals with a strong professional background in both throwing events of track and field and the usage of nutritional supplements constructed the survey instrument. In addition, a panel of experts in sport nutrition reviewed the survey to establish content and face validity. Minor revisions were made according the feedback from the expert review process. Subjects
The subjects (19.9 6 1.30 years) included both males (n = 137) and females (n = 121) who participated in resistance training to enhance athletic performance in collegiate field events. Age range of subjects was 18–24. Both the survey instrument and the data collection protocol were reviewed and approved by the appropriate Institutional Review Board of the primary investigator’s university to safeguard the rights of the participants. All participants signed an electronic informed consent prior to filling out the survey. When queried about total weightlifting experience inclusive of high school and college, the experience, in years, of resistance training was 5.5 6 0.90 for the male athletes VOLUME 29 | NUMBER 7 | JULY 2015 |
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Creatine Usage and Education
TABLE 1. Creatine use (FBS vs. FCS).*
Know others using Thought of using Used Currently use
FBS
FCS
Count (%)
Count (%)
51 38 29 6
(77.27) (57.58) (43.94) (20.00)
124 74 55 21
(64.9) (38.74) (28.80) (36.84)
x2
p
4.11 7.66 5.51 2.61
0.043† 0.006† 0.019† 0.107
*FBS = football bowl subdivision; FCS = football championship subdivision. †indicates significance difference between FBS and FCS.
and 3.6 6 0.94 for the female athletes. A total of 333 NCAA Division I universities were located through the NCAA directory; a total of 285 invitations to participate in the study were distributed by e-mail to all head NCAA Division I track and field coaches in the United States. The e-mail invitation included a hyperlink to the questionnaire and a request for informed consent from each participant. These coaches were instructed to share this invitation to participate directly with the current throw athletes in their track and field programs. Procedures
A 36-item survey instrument was developed to collect data regarding creatine usage patterns of collegiate track and field throwers. Questions related to sources of supplement information, perception of dosage, and perceived barriers to using creatine were added to the original survey. The creatine use and knowledge survey was developed by the researchers, reviewed by experts in the area of nutritional supplements for face and content validity. The final survey consisted of 30 items assessing demographics, creatine usage, knowledge of creatine, benefits/costs toward taking creatine, and sources for creatine information. Sample questions include (a) “What type of creatine do you take?” (b) “Please mark the benefits you have experienced with the use of creatine.” (c) “Would you be interested in an educational program to learn more about creatine?” The questionnaire was formatted for online completion and delivered using the inQsit system. A total of 285 questionnaires were distributed by e-mail to NCAA Division I head track and field coaches. The university head track and field coach was instructed to forward the e-mail, which included the hyperlink, directly to the throwers or through their assistant (throws) coach for distribution to the throwers. The survey required approximately 15–20 minutes to complete. Participants were provided with an explanation of the study through a letter that described the study and were required to provide their informed consent before beginning data collection. To improve response rates, a reminder was e-mailed 2 weeks
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after the initial contact. The results were tabulated and entered into a spreadsheet format for data analysis. Statistical Analyses
Face and content validity for the survey instrument were determined through an expert panel. Cronbach’s alpha analyses were not calculated due to the nominal and categorical nature of the survey questions (34). Descriptive statistics were calculated and examined to determine the basic information regarding the level of creatine use and knowledge in the studied population. Chi-square analyses were conducted to examine variations in use and knowledge regarding demographic classifications. All analyses were undertaken with SPSS version 21.0.
RESULTS The 285 surveys distributed to NCAA Division I college coaches yielded 258 completed surveys from athletes. The resulting data provided baseline levels of current creatine use
TABLE 2. Advice/counsel factor for creatine use and product selection (current and former users).*
Sport performance Speed Endurance Physical appearance Recovery Strength Other
FBS
FCS
Count (%)
Count (%)
15 6 9 4 21 23 3
36 12 10 9 37 47 5
(18.52) (7.41) (11.11) (4.93) (25.93) (28.40) (3.70)
(23.07) (7.69) (6.41) (5.76) (23.72) (30.13) (3.21)
*FBS = football bowl subdivision; FCS = football championship subdivision.
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TABLE 3. Results by classification of football subdivision.* FBS Variable Used creatine Student-athletes desire additional information about creatine
Response
Count (%)
Response
Count (%)
Yes No Yes
29 (43.94) 37 (56.06) 30 (46.15)
Yes No Yes
55 (28.80) 136 (71.20) 55 (29.57)
No May be Yes No
Access to full-time nutritionist
FCS
23 12 46 16
(35.38) (18.47) (74.19) (25.81)
No May be Yes No
89 42 93 87
(47.85) (22.58) (51.67) (48.33)
*FBS = football bowl subdivision; FCS = football championship subdivision.
and also allowed for further analysis of differences among factors related to athletic conference affiliation (Football Bowl Subdivision [FBS] vs. Football Championship Subdivision [FCS]). Results show that creatine use is common (32.7%) among throwers with significantly higher levels of use among FBS conference athletes (43.94%) in comparison with FCS conference athletes (28.8%), x2 = 5.505, p = 0.019 (Table 1). The most common reasons for using creatine included desire to improve strength (83.3%), recovery time (69.0%), and sport performance (60.7%) (Table 2). The most common obstacles for creatine use included concerns with contamination/quality control (39.5%), cost (33.3%), inconvenience (16.7%), and cramping (14.3%). When asked to indicate their likelihood of seeking advice or counsel from a variety of resources, results indicated that athletes were most likely to use a teammate (36.6% FBS and 32.1% FCS) followed by a coach (23.3% FBS and 23.2% FCS), with utilization of a nutritionist (20% FBS and 23.2% FCS) being the least likely source from which to seek creatine information. Cost (36.6% FBS and 21.4% FCS) was also a major factor in determining product selection. The throwers expressed an interest in additional
education (55.6%) regarding creatine with significantly more interest from FBS athletes (65.6%) than FCS athletes (52.2%), x2 = 6.425, p = 0.039. However, only 26.6% of the participating athletic departments provided nutritional supplement counseling (Table 2). Although the access to full-time nutritionist counsel was available at 57.3% of the schools, there was a significant difference (x2 = 9.096, p = 0.003) between FBS schools (74.19%) and FCS schools (51.7%) (Table 3). Male and female participants reported different perceptions regarding the beneficial nature of creatine use (x2 = 21.775, p = 0.001) with a greater percentage of male participants reporting creatine as beneficial (70.0% male vs. 23.5% female) (Table 4). Reported levels of creatine use were also related to perceptions regarding the beneficial nature of creatine (x2 = 37.002, p = 0.001) with participants who had a history of using creatine reporting higher levels of perceived benefit (76.1%) than those without a history of creatine use (17.9%) (Table 4). Furthermore, reported perceptions that creatine use was beneficial were related to greater perceptions that creatine would improve stamina (x2 = 8.172, p = 0.002), improve muscle endurance (x2 = 39.026, p = 0.001), enhance injury recovery (x2 = 9.918,
TABLE 4. Responses regarding the beneficial nature of creatine use. Variable Gender Male Female History of creatine use Used creatine No creatine use
Response
Count (%)
Response
Count (%)
Yes beneficial Yes beneficial
63 (70.00) 8 (23.53)
Not beneficial Not beneficial
27 (30.00) 26 (76.47)
Yes beneficial Yes beneficial
64 (76.19) 7 (17.95)
Not beneficial Not beneficial
20 (28.81) 32 (82.05)
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Creatine Usage and Education p = 0.002), improve exercise recovery (x2 = 48.093, p = 0.001), and improve the distance the athlete could throw (x2 = 23.375, p = 0.001).
DISCUSSION Despite the NCAA placement of creatine on the “nonpermissible” list of nutritional supplements (August 2000, NCAA Division I Bylaw 16.5.2.g change) that bans them from making creatine available to their athletes, research has shown an increase in creatine use among collegiate athletes (4). Creatine supplementation has been shown to increase athletic performance (1,2,15,19,32,36), which is one of the main reasons it was placed on the nonpermissible list, as it might give larger schools with a bigger budget an advantage over smaller schools. Although this may level the playing field from a competition point of view, it does not seem to discourage creatine usage. With the current NCAA ban on creatine distribution, one of the most significant concerns surrounding creatine use is that many student-athletes receive little education regarding the appropriate dosing and potential harmful effects of creatine supplementation. For these reasons, student-athletes may not fully understand the established practices regarding dosage and duration of creatine supplementation nor the concerns related to purity (7). In light of the results of the present investigation and past studies regarding use among collegiate athletes (4,10,12,37), universities should consider implementing an educational program that provides adequate information and support for student-athletes, which should assist with increasing student knowledge and safety and preventing overuse. Education regarding appropriate use of creatine can be distributed to NCAA student-athletes in a number of ways. One recommendation is that a professional dietician provides sufficient information regarding the potential side effects of the creatine supplement. Unfortunately, only 26.6% of the universities in this study provided nutritional counseling to the athletes. Universities are encouraged to provide mandatory nutritional counseling to all athletes to prevent any side effects that creatine, or other supplements, may cause. If every NCAA university would implement nutritional counseling, then all athletes would gain meaningful knowledge of the potential effects, and coaches would more easily be able to influence the use of creatine by their athletes. Overuse as a result of inadequate education may be related to noncompliance with recommended dosing. Research has shown that even low doses of creatine improve power in high-intensity training (4,14). When used properly, collegiate track and field throwers may use creatine in small or appropriate doses to improve their performance. The quickest method of increasing muscle creatine stores seems to be to consume ;0.3 g$kg21$d21 of creatine monohydrate for at least 3 days followed by 3–5 g$d21 thereafter to maintain elevated stores. Ingesting smaller amounts of creatine monohydrate (e.g., 2–3 g$d21) will increase muscle creatine stores over a 3- to 4-week period; however, the performance effects
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of this method of supplementation are less supported (6). Interestingly in this previous study, only 22.6% of the participants were compliant with the suggested doses, whereas 73.8% of the participants were noncompliant by using higher than suggested doses. Access to effective educational programs designed to increase knowledge of creatine supplementation should help student-athletes make more informed decisions about creatine use and perhaps reduce the incidence of overuse. Creatine is used as an aid in the strength and conditioning of power athletes (3,26). However, there are potential side effects that are important to note. Diarrhea, muscle cramps, weight gain, and dehydration levels were studied among NCAA Division I football players after they consumed creatine supplements. Results indicated that diarrhea was the most frequently reported side effect followed by muscle cramping, but 26.9% of the participants reported no perceived side effects (18). All of these side effects are temporary, and if the symptoms persist or become intense, the athlete is encouraged to discontinue using the supplement to eliminate the symptoms of these side effects (18). However, consuming dosages that exceed recommendations are likely to enhance these side effects and have not shown greater improvements in performance (18). The decision of the NCAA to ban universities from distribution of creatine to athletes implies that creatine is a harmful substance. However, there has been limited research that has evaluated potential side effects of the supplement. As previously stated, negative side effects that may occur have been noted as temporary, and athletes are likely to take the risk to gain temporary gains in strength throughout competition as demonstrated through responses from the 258 participants in this study. Health issues or signs of any negative side effect were not listed as major drawbacks to the usage of creatine. Indeed, only 14% of the current subjects reported “cramping” as a drawback, and this response was the only 1 involving health concerns. Because of the novelty of the creatine supplement, there is a concern for harmful side effects that may not occur with initial use but have the ability to occur over long-term that may become evident in the future. A 21-month study on NCAA Division I football players along with results of a study on effects of the liver and kidney after creatine use have indicated that long-term creatine supplementation does not have a significant negative health effect on athletes (20,21). Collegiate athletes typically compete in their sport for a maximum of 4 years, and these athletes are not likely to continue to use the supplement after the completion of their competitive career. Given the current reports of no long-term side effects with creatine, athletes may benefit from having open access to and knowledge of appropriate use of this supplement (6). However, not all sport budgets allow for the provision of supplements to their athletes, and this creates an unfair advantage to those teams who are able to purchase creatine and other supplements for their athletes (24).
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Journal of Strength and Conditioning Research Despite the discussion of short- and long-term effects regarding health, a greater majority of the participants in this study reported obstacles pertaining to contamination and quality control (39.5%), cost (33.3%), and inconvenience (16.7%). The results did not suggest any concerns of the athletes with their own health. These 3 reported obstacles may all be intertwined. Because cost is one of the driving factors in the selection of creatine supplements, athletes must have a complete understanding of what the underlying implications of a low-cost supplement, including impurities and contamination. The potential impurities and contaminants that are typically found in supplements in general (17) and specifically in creatine (22) are the highest risk factors associated with creatine use (9). Companies that produce dietary supplements “are responsible for evaluating the safety and labeling of their products before marketing to ensure that they meet all the requirements” determined by the FDA (35). However, the FDA does not directly test these products before companies sell their product. If the NCAA reverses its decision on creatine and permits universities to distribute creatine, athletes will have to depend on education to learn the proper usage of creatine. The results of this study indicate that these educational opportunities are not available in many schools and that it is not the first choice for gaining information in the usage of creatine. Allowing universities to exercise control over the distribution of the creatine supplement may create a competitive edge for teams who can afford supplementation, but banning distribution potentially creates more risk for athletes from the potentially harmful use of creatine. Hedrick (2000) examined the policies of strength and conditioning coaches at various universities in relating to the process in which they distributed creatine. Before the NCAA regulation, which bans distribution of creatine to student-athletes, strength coaches could determine which athletes needed creatine supplementation and maintained control regarding dosing, usage, and education (13). Under this previous framework, coaches and athletes worked together to ensure appropriate dosing, purity of the supplement, and education regarding benefits and side effects (13). Perhaps, the driving force behind the NCAA ban was intended to increase consistency across all universities as some universities did not have the funds to operate under a system where distributing creatine could be done in safe controlled environment.
PRACTICAL APPLICATIONS The NCAA recently changed its snack and food policy to allow schools to provide all student-athletes with unlimited fuel to sustain them (23). Perhaps, this recent change will pave the way for a re-examination of Bylaw 16.5.2.g’s ban on supplements. The results of this investigation may provide relevant data to support a recommendation that the NCAA create and implement a policy regarding creatine use, which may be used to shape future legislation. Such NCAA legislation could result in an increased awareness of the levels of
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use, improved education, and a reduction of negative effects of overuse. Given that creatine supplements, especially low quality supplements with unwanted contaminants, may produce unwanted side effects, close monitoring and supervision of student-athletes is warranted. To find the purest creatine products, institutions should purchase products from reputable sources that guarantee their products undergo a rigorous testing and certification process. However, current NCAA regulations ban the distribution of creatine to student-athletes and significantly hinder the ability of the strength coach to provide an adequate level of oversight. Nonetheless, strength coaches are strongly encouraged to identify and implement strategies to more closely monitor student-athletes. Coaches must take action to protect and serve their athletes who choose to use the supplement despite the ban by engaging in open and honest communications with their athletes regarding the use of creatine. Coaches are encouraged to (a) employ or consult with professionals such as Registered Dietitians with an interest in sport medicine or Masters Level Strength and Conditioning Coaches who have training in proper nutrition and supplement use; (b) be aware of the increasing trend of creatine supplementation amongst collegiate athletes; (c) develop and maintain open communication with each athlete regarding individual use; (d) review recent literature regarding the benefits and side effects of creatine use; and (e) keep their eyes and ears open to recognize signs that their athletes may be using creatine incorrectly.
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Creatine Usage and Education 10. Froiland, K, Koszewski, W, Hingst, J, and Kopecky, L. Nutritional supplement use among college athletes and their sources of information. Int J Sport Nutr Exerc Metab 14: 104–120, 2004.
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