Introduction

Nutrition education interventions are specific programs designed to help a target population gain relevant knowledge or adopt improved eating behaviors [1, 2]. In athletic settings, these general exercise/nutrition interventions are designed to maintain or improve health and enhance athletic performance. Food choices are influenced by a range of factors, including taste, cost, convenience, and knowledge [3]. An athlete’s food choices may be influenced by factors such as time constraints, financial insecurity, and the frequency of travel associated with athletic commitments [4, 5]. According to the Centers for Disease Control and Prevention, childhood and adolescent obesity has tripled over the past generation, and nearly 20% of youth are currently overweight. There was a significant increase in obesity in the United States from 1990 to 2010. More than one-third (36%) of U.S. adults are obese [6]. Division I female collegiate athletes are no exception [7]. The optimal body fat for female collegiate athletes is 10–22% [8]. The National Strength and Conditioning Association recommends that female athletes should reduce their body fat to between 15% and 25% [9].

The Female Athlete Triad (the Triad) is a combination of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density. It is relatively common among young women participating in sports. The “female athlete triad” (amenorrhea, eating disorder, and low bone density) is another common problem in female athletes that negatively impacts performance, affecting up to 66% of women compared to 2–5% in the general female population [8]. Measuring body composition is much more valuable than measuring body weight. It is superior to simply measuring weight. Lean tissue versus fat mass Instead of being in the optimal range for body composition performance, many top-tier female athletes find themselves either dangerously thin, affected by the female triad, or have a high percentage of fat [10]. Both extremes can lead to injury, a less efficient cardiovascular system, illness, burnout, fatigue, inability to recover from intense training, and ultimately poor performance [9].

Female athletes are more likely to develop complications or injuries related to nutritional advice or inadequate information relative to their level of exercise [11]. Research findings have documented the benefits of nutrition related to athletic performance. Physical activity, athletic performance, and post-exercise recovery are enhanced by optimal nutrition [12]. Nutritional knowledge is linked to eating behavior [13]. In a recent study, athletes had difficulty translating their knowledge into food choices [14]. Only 50% of the survey questions about food choices were answered correctly. Unfortunately, athletes’ nutritional knowledge is poor [7]. Eating behaviors contribute to poor health and therefore hinder athletic performance. Current research suggests that as athletes’ knowledge increases, the nutritional quality of food choices improves [15]. Much of the nutritional information and guidance that athletes receive is provided by athletic trainers, strength and conditioning coordinators, coaches, or sports nutritionists, if available at their institution [7, 8, 16].

Collegiate female athletes also receive most of their energy balance education from their parents, friends, or teammates. Unfortunately, these resources often lack the latest and greatest information, and as a result, athletes may not receive the optimal energy balance education that can help them excel and stay healthy. Energy balance information should include the following: energy needs, body composition, macronutrient and micronutrient requirements, hydration, in-season and off-season training regimens, supplements, energy aids, sleep and recovery, weight management and eating disorders, and motivational techniques [7].

Athletes also find themselves under incredible amounts of stress and anxiety [17]. This stress can be caused by pressures from parents and coaches to perform at a certain level, trying to balance a large number of activities, or the increased level of competition in amateur sports [18]. According to Gallucci [19], stress can have physical effects on the body that are detrimental to athletic performance. Some of the symptoms of a stressed athlete include: upset stomach, headache, sweaty palms, nervous habits, lack of energy, insomnia, anxiety, boredom, anger, irritability [Gallucci, 2014]. Athletes must be able to effectively cope with performance stress and anxiety in order to be successful in their sport [19, 20]. Coping is defined as individuals’ conscious efforts to manage situations that they perceive as stressful and that threaten their well-being [21].

Although stress and poor nutritional practices are common in female athletes, few intervention studies have been designed to improve both of these outcomes in this high-risk population [22]. Therefore, the researcher sought to answer the question of whether an energy balance training and cognitive behavioral therapy intervention has an effect on perceived stress, generalized anxiety disorder, and body mass index in deaf athletes in Semnan province?

Materials and Methods: This research is a semi-experimental study with a pre-test and post-test research design with experimental and control groups. The statistical population of the research was formed by deaf athletes of Semnan province. The sampling method was purposeful, based on the criteria for entering the research, 24 people were selected and divided into 2 groups by simple random. The research questionnaires included Cohen's perceived stress (1983), Spitzer et al.'s (2006) generalized anxiety disorder questionnaire. Analysis of covariance test was used to analyze the research data. All statistical operations of the research were considered using SPSS version 25 software with a significance level of P<0.05.

Results: The results showed that after controlling for the effect of the pre-test, the difference between the pre-test and post-test scores of the two groups was significant for the variables of perceived stress, general anxiety and body mass index, and the mean scores of the energy balance and cognitive behavioral therapy group in the variables of perceived stress, general anxiety and The body mass index is also significantly lower than the energy balance group (p<0.001).

Conclusion: Therefore, it can be said that there is a significant difference between the effect of energy balance intervention combined with cognitive behavioral therapy with energy balance on perceived stress, general anxiety and body mass index of deaf athletes in Semnan province, and combined cognitive-behavioral therapy with energy balance is more effective than treatment It has energy balance. In explaining the results of this hypothesis, it can be said that in cognitive behavioral therapy, a great and special emphasis is placed on the role of emotions and specific techniques are used to manage emotions. The main assumption of this therapeutic approach is that a person with an emotional disorder uses maladaptive styles to regulate emotions, often trying to avoid unpleasant emotions or reduce their intensity, which leads to the opposite result and the continuation of their symptoms. As a result, transdiagnostic therapy is a therapeutic approach that teaches the patient how to deal with unpleasant emotions, as well as how to respond to their emotions in an adaptive way. In addition to modifying emotional regulation habits, the goal of treatment is to reduce the intensity and expression of maladaptive emotional experience and, as a result, improve functioning [30]. In transdiagnostic therapy, the goal is not to eliminate unpleasant emotions, but to restore emotions to a functional level so that unpleasant emotions become adaptive. This therapeutic approach attempts to reduce the intensity and severity of emotional habits by regulating them, thereby reducing the amount of damage and improving the individual's functioning. In this integrated approach, thoughts, behavior, and emotions are in constant communication with each other, and each affects the experience of emotion [31]. This therapeutic approach helps the patient to gain a better understanding of the relationship and role of thoughts, emotions, and behaviors in the formation of internal emotional experiences, including triggers and behavioral consequences, and to identify and modify emotional-derived behaviors through negative cognitive exploration of emotions and physical states, to learn insight and tolerance for physical emotions during internal exposure, and to face their emotional experiences in the context of the situation and the environment [32]. All of the above skills, by rebuilding emotional regulation habits, reduce the intensity of maladaptive emotional experiences and return emotions to a functionally desirable level. In this study, the techniques and skills of the integrated protocol therapy were able to improve anxiety symptoms by indirectly targeting these common factors.

Keywords: energy balance, cognitive behavioral therapy, perceived stress, generalized anxiety disorder, body mass index, athlete's deaf.

Ethical Considerations

Compliance with ethical guidelines

The ethical principles observed in the article, such as the informed consent of the participants, the confidentiality of information, the permission of the participants to cancel their participation in the research. Ethical approval was obtained from the Research Ethics Committee of the University of Shahrood Branch, Islamic Azad University, Shahrood, Iran.

Funding

This study was extracted from the M.A thesis of first author at Department of Sport Sciences of University of Shahrood Branch, Islamic Azad University, Shahrood, Iran..

Authors' contribution

Authors contributed equally in preparing this article.

Conflict of interest

The authors declared no conflict of interest