Energy Availability, Mental Health, and Sleep Patterns of Athletic Trainers

Study Procedures

The study was part of a larger study conducted by our research team.¹ It is important to note that data were collected before the start of the 2020 COVID-19 pandemic, and the initial findings were published in 2021,¹ with a secondary analysis occurring in 2022. We began the initial study by sending out an inquiry-for-participation email to all ATs in the surrounding area of the southeastern US region. This email included a short survey to determine if interested volunteers met the inclusion criteria. Then individual meetings were scheduled to review the study details and obtain signed consent. After consent was obtained, participants underwent anthropometric and resting metabolic rate (RMR) measurements, scheduled a dual-energy x-ray absorptiometry (DXA) scan, and completed ED surveys along with the Center for Epidemiological Studies Depression Scale Revised (CESD-R), Spielberger State-Trait Anxiety Inventory (STAI), and Pittsburgh Sleep Quality Index (PSQI) surveys. Participants were given a written and oral overview of the weekly procedures, including detailed instructions for the food and exercise logs and armband. They began self-reporting 7 consecutive days of foods, fluids, and planned and intentional exercise in the online log at the end of the information session. We emphasized that participants should continue their normal food and fluid consumption, PA, and exercise during data collection. After the 7 days, participants emailed food and exercise logs to us and returned the armband. The Instruments and Protocols section describes only the instruments and protocols used for the secondary analysis.

Participants

A convenience sample of ATs (males = 23, age = 29.8 ± 8.5 years; females = 24, age = 28.9 ± 7.9 years) from the southeastern United States were recruited from local colleges or universities (CUs), high schools (HSs), and nontraditional (NT) settings (eg, clinics, recreation centers, outreach programs). The inclusion criterion was being an AT certified by the Board of Certification. The exclusion criterion was working primarily under a different credential (eg, an individual working under both certified AT and PT credentials). Institutional review board approval was acquired, and all participants provided consent before data collection.

Instruments and Protocols

Energy Needs

The ATs’ energy needs are presented in Table 2. Eight ATs reported they did not engage in planned and intentional exercise; thus, we could not calculate EA for those participants. Overall, 61.5% (n = 24/39) of ATs indicated LEA. No differences were observed between EA and sex–job status and sex–job setting. Low EA was identified in both sexes (male: 68.4% [13/19]. females: 55% [11/20]), job status (PT ATs = 65% [13/20], FT ATs = 57.9% [11/19]), and across all settings (CU = 46.2% [6/13], HS = 68.8% [11/16], and NT = 70.0% [7/10]). Differences were noted between sex–job status and sex–job setting for RMR (F_1,45 = 17.162, P = .001), EI (F_1,45 = 13.032, P = .001), TDEE (F_1,45 = 42.514, P < .001), and EEE (F_1,38 = 5.353, P = .026). No differences were seen within job status or job setting for EA.

Table 2 Energy Needs Assessment of Athletic Trainers^a,b

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Mental Health and Sleep

All mental health and sleep data are provided in Table 3. The overall prevalence of ATs at risk for depression was 14.9% (n = 7), 16.7% (n = 4) of males and 13.0% (n = 3) of females. No differences were evident for the depression risk by sex and job status. The overall prevalence of high state anxiety was 25.5% (n = 12), 25% of males (n = 6) and 26.1% of females (n = 6). Similarly, the overall prevalence of high trait anxiety was 25.5% (n = 12), 25% of males (n = 6) and 26.1% of females (n = 6). The overall prevalence of sleep disturbances was 89.4% (n = 42), 91.7% of males (n = 22) and 87% of females (n = 20). No differences were demonstrated for sleep and sex and job status.

Table 3 Depression, State and Trait Anxiety, and Sleep Disturbance Scores and Risks^a

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Exercise and Mental Health

Of the 39 ATs who engaged in exercise, 12.8% (n = 5) were at risk for depression compared with 25.0% (n = 2) of nonexercising ATs. The RR of depression if ATs did not exercise was 1.950 (95% CI = 0.456, 8.336). Of those who exercised, 20.5% (n = 8) were at risk for state anxiety compared with 50.0% (n = 4) of nonexercising ATs (RR = 2.438, 95% CI = 0.963, 6.168). Of those who exercised, 23.1% (n = 9) were at risk for trait anxiety compared with 37.5% (n = 3) of nonexercising ATs (RR = 1.625, 95% CI = 0.562, 4.701), and 87.2% (n = 34) were at risk for sleep disturbances compared with 100.0% (n = 8) of nonexercising ATs (RR = 1.147, 95% CI = 1.017, 1.294).

Energy Availability and Depression

Among the ATs classified with optimal EA (n = 15), 26.7% (n = 4) were at risk for depression compared with 4.2% (n = 1) with LEA. The RR of depression if ATs had LEA was 0.156 (95% CI = 0.019, 1.269). Of those with optimal EA, 33.3% (n = 5) were at risk for state anxiety compared with 12.5% (n = 3) with LEA (RR = 0.375, 95% CI = 0.104, 1.346), and 33.3% (n = 5) were at risk for trait anxiety compared with 16.7% (n = 4) with LEA (RR = 0.500, 95% CI = 0.159, 1.572). Among those with optimal EA, 80.0% (n = 12) were at risk for sleep disturbances compared with 91.7% (n = 22) with LEA (RR = 1.146, 95% CI = 0.866, 1.517).

Energy Needs

Differences were found by sex for RMR, TDEE, and EEE and addressed in a previous publication.¹ In the present study, males and females, on average, had LEA and consumed fewer calories than they expended. Despite differences in EI and TDEE, no differences were observed between EA and sex. Although the research on LEA in females is extensive, only recently did researchers³⁰ report LEA in males. Due to the potentially permanent implications of chronic LEA, our identification of similar LEA prevalence between sex reinforces the need for more research on the effects of LEA in males.

Regarding job status, FT ATs often have irregular schedules and long work hours. Arguably, a PT AT who works fewer hours may have more time to eat, yet this was not shown in our data. More than half of the ATs, regardless of job status or setting, had LEA. This percentage (61.5%) was higher than the prevalence range among athletes (up to 58%).³¹ Underreporting and differences in EI methods account for possible inaccuracies in determining population prevalence. Regardless, understanding nutrition is a competency set forth by the Board of Certification for ATs; 71.4% of ATs had adequate nutrition knowledge and were as confident in their incorrect answers on nutrition knowledge as they were in their correct answers.³² This confidence in their nutritional knowledge, although inaccurate, could explain their poor dietary habits. Those ATs with correct nutritional knowledge may knowingly not be practicing appropriate behaviors.

Mental Health

Although individuals in this study were only analyzed for the risk of depression and not diagnosed, 16.7% of males and 13% of females were at risk, values that were similar to those in the US general population (approximately 16%).⁶ Depression may be exacerbated by job duties, burnout, or other external pressures. Athletic trainers often work long hours, providing patient care in a fast-paced environment, and may neglect their own needs. Depending on the setting, an AT’s specific job duties may also influence his or her own mental health (eg, emergency response versus rehabilitative care). In a survey of 34 240 emergency medical service professionals, 6.8% (n = 1589) were classified as depressed.³³ Arguably, nurses have similar job responsibilities to ATs; in 1 investigation, 13% tested positive for depression and 16% for anxiety.³⁴ In the same study, 87% had symptoms of anxiety, depression, or posttraumatic stress disorder.³⁴ The prevalence of anxiety among health care professionals was greater than in the general US population (9.0%).³⁵ Anxiety was identified in 6.0% to 23.7% of emergency medical service providers,^33,36 which was comparable with approximately 25% of our ATs. Among a combined group of physicians, nurses, and emergency medical service providers, approximately 62% reported mild to severe anxiety symptoms.³⁶ For ATs, increased anxiety may be due to a high patient load, emergency situations, and pressures to return athletes to play.

Consideration for mental health conditions among ATs is important to combat the widespread professional concern of burnout.² Causes and symptoms of burnout resemble those of clinical depression,²¹ though individuals suffering from burnout experienced more depressive symptoms.² Wurm et al³⁷ found that physicians with mild, moderate, or severe burnout were 2.99, 10.14, or 46.84 times, respectively, more likely to suffer from clinical depression. Depression can proceed or precede burnout onset.² We did not examine burnout, yet given the concern for burnout among ATs² and the depression risk we identified, we suggest that future researchers consider the link between burnout and depression.

Sleep and Mental Health

Sleep disturbances in our study were higher (91.7% of males and 87.0% of females) than those in primary care male (25.3%) and female (40%) physicians³⁸ and nursing staff (61.0%).³⁹ In contrast, our results were consistent with those of shift-work resident physicians, of whom 90% reported poor sleep quality.⁴⁰ This similarity may be attributed to the irregular working hours of shift workers and some ATs. For ATs, poor sleep quality may be related to job responsibilities at different times of year (eg, in-season versus off-season). Low-quality sleep was associated with adverse psychological changes, including anxiety and depression.²³ Inadequate sleep may influence state anxiety levels throughout the workday. Not only was poor sleep related to decreased quality of life,²⁴ inadequate sleep, particularly when combined with anxiety and depression, negatively affects the quality of care provided.

Exercise and Mental Health

Exercise and even minimal PA may improve overall physical health and the physiological response to stress, perhaps via a mechanism whereby exercise facilitates endorphin release. Endorphins create a sense of well-being, subsequently reducing depression and anxiety levels. Unsurprisingly, physical inactivity contributes to mental health disorders. The benefits of exercise and PA on depressive symptoms may also be independent of age, sex, and geographic region. In this sample of ATs, 83% exercised but still exhibited a higher depression risk than the general population. Most researchers¹⁶ have reported a decreased relative risk of depression in exercisers. When comparing ATs who exercised with those who did not, our results agree with those of others¹⁶ who have shown a lower relative risk for depression with exercise.

Similarly, ATs who did not exercise displayed increased risks for both state and trait anxiety. The job responsibilities of ATs can include high-stress situations that require quick decision-making, potentially predisposing them to state or trait anxiety or both. Unfortunately, the cause of anxiety as both a symptom and a syndrome is not yet understood.⁴¹ Exercise has been identified as a protective factor against anxiety disorders, but much of the research lacks methodologic congruity, and therefore, concrete conclusions cannot be drawn.^18,19 However, authors^18,19 have demonstrated that individuals who exercise regularly had a lower risk of experiencing symptoms of and being diagnosed with anxiety than their physically inactive colleagues. In interventional studies, state anxiety decreased immediately after a single bout of exercise.¹⁹ Given the multidimensional context, we cannot yet conclude how exercise affected anxiety in the ATs studied. The effect of exercise on anxiety (and anxiety on exercise) may be clinically relevant to an AT only as a protective factor and as an influencer in the decision to exercise. Although exercise has been beneficial in reducing state anxiety, an AT cannot stop providing patient care and exercise when he or she feels anxious. Regular exercise decreases the anxiety risk and anxiety symptoms compared with physically inactive individuals. For ATs, exercise may be beneficial in reducing or protecting against anxiety.

Exercise and Sleep

Exercise is suggested to improve sleep quality.²⁴ As little as 30 minutes of yoga improved sleep quality in health care professionals.²³ Despite most of our participants exercising, 87% still experienced sleep disturbances. The dose threshold for exercise to improve sleep is unknown²⁴ and is influenced by exercise duration, intensity, type, and time of day. For example, exercising > 3 hours before bedtime is related to less sleep disturbance than exercising < 3 hours before bedtime.²⁴ The variability in PA and exercise levels among participants may have accounted for the high prevalence of poor sleep quality despite exercising. Another consideration is that exercise alone may not be enough to improve sleep quality. Numerous other factors, such as comfort in the environment, the stress level, prioritizing coursework or continuing education, or nutrition (eg, supplements, caffeine), can affect sleep quality.

Energy Availability and Mental Health

Dietary intake, a main factor in assessing EA, may be influenced by psychosocial stress and mental health conditions. However, no evidence indicates that a mental health condition in ATs is a direct cause or result of LEA. Although we hypothesized that ATs with LEA would have greater risks for mental health conditions, the results, based on RRs, were not supportive. This may reflect that, in our participants, LEA did not have a large effect on mental health. One factor is the role of exercise. An individual who exercises more expends more energy, increasing the chance for LEA. Exercise improves overall physical health and the physiological response to stress.¹⁷ Unsurprisingly, physical inactivity and poor diet have been recognized as contributors to noncommunicable chronic diseases and mental health disorders.¹⁷ Individuals can benefit from the protective factor of exercise against mental health disorders such as depression and anxiety, even with minimal amounts of PA.¹⁶ Exercise facilitates the release of endorphins; endorphins create a sense of wellbeing, which is why exercise is believed to reduce depression and anxiety levels.⁴² Therefore, the same exercising individual may also obtain the protective benefits of exercise on mental health, thereby experiencing a decreased risk. Another consideration is the combination of exercise and prolonged inadequate dietary intake leading to weight loss. Weight loss is associated with decreased depression and anxiety symptoms.¹⁰

Energy Availability and Sleep

Consistent with our hypothesis, most individuals with LEA experienced sleep disturbances. Nonetheless, and although they were at statistically lower risk, most of those with optimal EA had sleep disturbances. Although ATs with LEA were at statistically higher risk for sleep disturbances, the clinical relevance of this result must be determined. It is challenging to identify which variables are directly associated with sleep disturbances. As alluded to previously, an AT’s job requirements may create barriers to meeting dietary requirements and obtaining optimal sleep. Athletic trainers often work long hours and do not have a specific time allotted for eating. They may value exercise, sleep, and eating differently, choosing one over the other for personal reasons.