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Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, 22, 38-48
RESEARCH ARTICLE
ISSN: 1871-5303
eISSN: 2212-3873

Dietary Intakes and Food Habits of Wheelchair Basketball Athletes Com- Impact
Factor:
2.895

pared to Gym Attendees and Individuals who do not Practice Sport Activ-
ity The official journal of the ITALIAN ASSOCIATION OF CLINICAL
ENDOCRINOLOGISTS, shortly defined AME
(Associazione Medici Endocrinologi)

Elisabetta Toti1, Valentina Cavedon2, Anna Raguzzini1, Anna Lucia Fedullo1, Chiara Milanese2,
Elisabetta Bernardi3, Sheila Bellito4, Marco Bernardi4,5, Tommaso Sciarra6 and Ilaria Peluso1,*
Endocrine, Metabolic & Immune Disorders -Drug Targets

1
Research Centre for Food and Nutrition, Council for Agricultural Research and Economics (CREA-AN), Rome, Italy;
2
Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; 3Depart-
ment of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari “Aldo Moro,” Bari, Italy; 4Feder-
azione Italiana Pallacanestro In Carrozzina (FIPIC), Rome, Italy; 5Department of Physiology and Pharmacology “V.
Erspamer”, Sapienza University of Rome, Italy; 6Joint Veteran Center, Scientific Department, Army Medical Center,
Rome, Italy

Abstract: Background: Mediterranean diet (Med-D) has been previously suggested for athletes,
but Paralympics usually have a low intake of plant foods. Orthorexia nervosa (ON) can drive die-
tary intake of both athletes and gym attendees.

Objective: We aimed to compare dietary intakes and food habits of elite wheelchair basketball ath-
letes (WBA) and able-bodied individuals who practice or not sport activity and with different fat
mass percentage (FM%).

ARTICLE HISTORY
Received: August 25, 2020
Revised: November 30, 2020
Accepted: December 11, 2020
DOI:
10.2174/1871530321666210208213046
Methods: We recruited 15 WBA from the Italian National team and 3 control groups (15 each
group): healthy individuals who do not practice any sports activity (NSA) and gym attendees with
low (GAL, FM%<17) and high (GAH, FM%>18) FM%. Food consumption was monitored by a 3-
d diary, while Med-D scores and ON score were evaluated through standardized questionnaires. In
WBA we also assessed Neurogenic Bowel Dysfunction (NBD), GastroEsophageal Reflux Disease
(GERD), allergy questionnaire for athletes (AQUA) and Starvation Symptoms Inventory (SSI).
Results: In WBA, ON correlated with GERD and SSI. WBA and GAH with eating behavior of ON
had higher adherence to Med-D, whereas NSA had less adherence to Med-D. Sub-score, including
fruits, vegetables and legumes, was higher in the GAL and GAH groups compared to the WBA and
NSA groups. Med-D was inversely related to animal protein intake (PRO-AN) in NSA and GAL.
FM% was inversely related to PRO-AN in WBA and GAH, and to ON only in GAH. In WBA,
PRO-AN and vegetable protein intake correlated with both carbohydrate and energy intakes.

Conclusion: In WBA, commitment to wellness (ON and Med-D adherence) could be a response to
gastrointestinal and starvation symptoms. WBA should be involved in setting their own individual-
ized dietary strategies.

Keywords: Body composition, dietary habit, Mediterranean diet, nutrition, paralympics, starvation symptoms, sport, spinal
cord injury, spina bifida, wheelchair sport.

1. INTRODUCTION behavioral dimensions of the drive for muscularity [2]. Al-

Strict control of food intake is a feature of orthorexia ner-
vosa (ON), which is common in gym attendees [1], and it is
associated with frequent exercising [1], exercise dependence
[2], dissatisfaction with their own body appearance [3] and
* Address correspondence to this author at the Research Centre for Food
and Nutrition, Council for Agricultural Research and Economics (CREA-
AN), Via Ardeatina 546, Rome, Italy; Tel/Fax: +39- 06 51494 426;
E-mail: ilaria.peluso@crea.gov.it
though ON emerged as a predictor of muscle dysmorphia
symptoms in bodybuilders [4], controversy in the field of
ON exists, especially when physical health status drives eat-
ing behavior (including food restriction to relieve constipa-
tion) [5].
Paralympic sports are practised by athletes with various
health conditions [6], including those with spinal cord injury
(SCI) and spina bifida (SB). Neurogenic bowel dysfunction
(NBD), which has a high prevalence in individuals with SCI

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Dietary Intakes and Food Habits Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 39
and SB, induces symptoms that affect dietary intake
(amount or type of food consumed) [7].
Although the Mediterranean diet (Med-D) has been
suggested as a natural supplemental resource [8] for able-
bodied athletes [9] and for veterans with injuries [10], Para-
lympic athletes have a low-quality diet, in terms of fruits,
vegetables, legumes and cereals [11]. However, a low-fibre
diet could be beneficial in managing NBD in SCI [12].
The study hypothesis was that the dietary habits of Para-
lympic athletes could be due to health conditions rather than
to ON.
In this comparative study, we aimed to compare the ad-
herence to Med-D, the occurrence of ON and the dietary in-
takes in elite wheelchair basketball athletes (WBA) with re-
spect to healthy individuals who do not practice sports activi-
ty and gym attendees with different fat mass percentage
(FM%).
2. MATERIALS AND METHODS
2.1. Recruitment of Volunteers and Inclusion Criteria
The sample included 15 male WBA of the Italian
National team, during a training camp before the 2019 Euro-
pean Championship. The International Wheelchair Basket-
ball Federation (IWBF) classification documents, ASIA
(American Spinal Injury Association Impairment Scale) and
health condition of each WBA were provided by the “Feder-
azione Italiana Pallacanestro in Carrozzina” (Rome, Italy).
We selected control healthy able-bodied individuals
(Body Mass Index: BMI range from 20 to 30 kg/m2), from a
no-profit study (Research Centre for Food and Nutrition,
Council for Agricultural Research and Economics, Rome,
Italy), according to the following exclusion criteria: any dis-
ease, allergy, food intolerance, special diets or dietary restric-
tion (including vegetarian diet).
Based on the FM%, determined by skinfold thickness
[13], three groups of controls (15 male each) were selected,
including inactive men not practicing any sports activity
(NSA) and gym attendees with FM% lower than 17%
(GAL) and higher than 18% (GAH).
2.2. Characteristics of Volunteers
Data characterizing the volunteers was collected through
questionnaires. Potential confounders, including smoking
habits, diseases and use of drugs, were determined. For
WBA, according to Krogh et al. [14], we calculated the per-
centages of athletes with severe (score ≥14), moderate
(score ranging between 10–13) and minor (score ranging be-
tween 7–9) NBD scores. The “gastroesophageal reflux dis-
ease” (GERD) score was calculated according to Ubaldi et
al. [15].
The “allergy questionnaire for athletes” (AQUA) was
used to evaluate the percentage of WBA with allergy
(score≥5) [16] and the reported upper respiratory tract infec-
tions and herpes labialis [17].
Starvation symptoms in the “starvation symptom invento-
ry” (SSI) questionnaire include preoccupation with food and
eating, impaired cognitive performance, poor emotional and
social functioning and physiological changes [18].
For all volunteers, the degree of adherence to the Med-D
diet was calculated with: the 14-item Mediterranean Diet
Score (MDS), the 11 items MEDScore and sub-scores (co-
herent - CO, incoherent - IC and different - D), as previously
described [19].
ORTO-15 was used for ON evaluation [20] and sub-
scores ORTO-12 (excluded items: 5, 6, 8) [21], ORTO-11
(excluded items: 5, 8, 14, 15) [22], ORTO-9 (excluded
items: 1, 2, 8, 9, 13, 14) [23], ORTO-7 (excluded items: 2,
5, 6, 8, 10, 12, 14, 15) [24] and ORTO-6 (excluded items:
1,2, 5, 6, 8, 9, 13, 14 and 15) [25] were calculated.
Habitual dietary intake was assessed by means of a vali-
dated 3-day recall record questionnaire, two consecutive
working days, and one-weekend day/holiday as described by
Willett [26] and additional information was acquired during
a nutritional interview performed by an experienced dieti-
tian. The nutritional composition of the diet was calculated
using the CREA-AN tables of the composition of foods [http-
s://www.crea.gov.it/-/tabella-di-composizione-degli-
alimenti] and the USDA Databases [https://ndb.nal.usda.gov-
/ndb/].
2.3. Statistical Analysis
Significance among groups for categorical variables
were assessed by χ2 probability test. Continuous variables
were expressed as means and standard error of the mean
(SEM).
Analysis of variance (ANOVA) (Normality Test Passed)
or ANOVA on Ranks (Normality Test Failed), followed by
Student-Newman-Keuls post hoc analysis, were used for
comparing the groups. Spearman correlations were assessed
between the parameters of interest.
The level of significance was set at P <0.05. All statisti-
cal tests were performed using Sigma plot software (Jandel
Scientific, Inc.).
3. RESULTS
3.1. Characteristics of Volunteers
Health condition of WBA is reported in Table 1.
According to the drugs used (Table 1): one WBA took in-
sulin (because of diabetes), one WBA took oxycodone (be-
cause affected by chronic pain) and three took oxybutynin
(because of the neurogenic bladder).
The IWBF class ranged between 1-4.5 and Spearman cor-
relation analysis revealed a significantly high correlation be-
tween IWBF class and NBD (-0.754, p<0.001). Being IWBF
class a reverse score, WBA with higher impairment had
more NBD symptoms. However, the major symptoms were
related to constipation and were not reported only in WBA
with SCI. Mean SSI of WBA (Table 1) was within the range
40 Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 Toti et al.

Table 1. Characteristics of WBA.

Amputation n=5: TF (L), TF (R), TF (L and R), TT (R), TF (L and R) plus TR (R).
SB n=1: ASIA A – Lum 2 (R and L).
SCI n=6: ASIA A - Lum 2 (R) T11 (L),
ASIA A - T1 (R) T2 (L),
Health condition/ ASIA A - T10 (R and L),
Impairment ASIA A - T12 (R and L),
ASIA A - T4 (R and L),
ASIA D – Lum 1 (R and L).
OHC n=3: different length plus extra-rotation (L), foot amelia/dismelia (R and L) and impaired strength and range of motion in the lower
limb (R).
Drugs
Insulin 1/15
Oxycodone 1/15
Oxybutynin 3/15
NBD score: 5.5±1.5
Severe ≥14 1/15
Moderate 4/15
Minor 7–9 2/15
GERD score: 3.9±0.1
SSI score: 8.5±1.6
> 20.1 1/15
AQUA score: 5.5±1.6
>5 7/15
WBA: wheelchair basketball athletes; SCI: spinal cord injury; SB: spina bifida; OHC: other health conditions; ASIA: American Spinal Injury Association Impairment Scale. Lum:
lumbar; T: thoracic; L: left; R: right; LLA: lower limb amputation; ULA: upper limb amputation; TF: transfemoral; TT: transtibial; TR: trans-radial; NBD: neurogenic bowel dysfunc-
tion; GERD: gastroesophageal reflux disease; SSI: starvation symptoms inventory; AQUA: allergy questionnaire for athletes.

Table 2. Comparison of WBA and control groups.

WBA NSA GAL GAH

Age (years) 28.5±1.5 31.5±2.2 30.1±2.2 31.8±2.0
BM (kg) 74.8±3.2 79.5±2.5 82.5±2.2 81.7±2.2
FM% 21.8±1.2 (a) 24.9±2.0 (a) 13.5±0.7 (b) 23.5±1.5 (a)
Training (h/week) 14.8±1.6 (a) 0 3.9±0.5 (b) 2.5±0.5 (b)
Sitting* (h/week) 78.6±3.9 (a) 40.1±3.9 (b) 33.1±3.2 (b) 36.4±3.3 (b)
Smokers 2/15 3/15 3/15 4/15
Occasionally 2/15 3/15 2/15 6/15
Alcohol drinkers 13/15 9/15 10/15 10/15
WBA: wheelchair basketball athletes; GAL: gym attendees with FM% below 17; GAH: gym attendees with FM% above 18; NSA: inactive men who do not practice sport activity.
NA: not applicable; BM: body mass; FM%: fat mass percentage; *for WBA meal and screen (television/PC) time. Continuous variables are expressed as means with SEM, Student-
Newman-Keuls.: (a) versus (b) p<0.05. Categorical variables χ2: (a) versus (b) p<0.05.

reported in healthy individuals (10.4 ± 9.7) and only one had
a score above the cutoff [18].
Other conditions were revealed by GERD impact scale
(reverse score, correlated with SSI -0.643, p<0.01) and
AQUA score (Table 1).
In the AQUA questionnaire, 5/15 WBA declared to have
Herpes labialis 1 to 3 times/year and 6/15 to give up training
or competitions for an infectious episode (1-3/year).
On the contrary, according to the exclusion criteria indi-
viduals of the control groups were free of any disease and
did not take any drug.
BMI did not differ significantly among the control
groups (kg/m2: 25.8±0.7, 25.7±0.5 and 25.6±0.6 for NSA,
GAL and GAH, respectively), whereas according to the in-
clusion criteria, FM% was lower in GAL compared to the
other control groups and to WBA (Table 2).
On the other hand, WBA spent more time in training and
in a sedentary state (Table 2). In both GAL and GAH
groups, 4 out of 15 gym attendees practised bodybuilding
and the others practised both strength and aerobic training.
WBA, GAL and GAH used protein supplements, with a
mean intake of 19.3±2.4, 27.3±6.5 and 29.3±12.2 g/d, re-
spectively. No differences were found for age and smoking
(Table 2). All volunteers were occasional drinkers and dur-
ing the 3d-food diary 9 WBA, 8 NSA, 3 GAL and 10 GAH
reported drinking alcoholic beverages with a mean alcohol
intake of: 4.1±1.2, 8.2±2.7, 15.8±4.4, 7.3±1.5 g/d, respective-
ly.
Habitual dietary intakes are reported in Table 3. Percent-
age of energy intake (En) from alcoholic beverages was high-
er in GAH compared to WBA.
En% from macronutrients (Table 3) did not comply with
the energy intake for habitual diet for sport characterized by
Dietary Intakes and Food Habits Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 41

Table 3. Energy, macronutrients and fiber intakes.

WBA NSA GAL GAH

En Kcal/kg BM/d 32.6±2.8 28.4±2.8 30.2±1.2 28.5±1.1
Fat % En 36.9±0.6 33.7±1.5 32.4±1.6 35.7±1.0
>35% 10/15 11/15 7/15 8/15
>25% 15/15 13/15 12/15 15/15
CHO % En 43.9±1.2 (a) 50.1±1.3 (b) 41.4±2.6 (a) 43.1±2.5 (a)
<45 * 8/15 1/15 9/15 6/15
<55 15/15 13/15 14/15 15/15
<57 15/15 13/15 14/15 15/15
Sugars %En 14.9±1.1 (a) 11.1±1.3 (a,b) 8.8±1.2 (b) 8.4±0.9 (b)
>15% En 7/15 2/15 1/15 0/15
CHO g/kg BM 3.6±0.3 3.6±0.2 3.1±0.3 3.0±0.2
<2g/kg BM 1/15 0/15 2/15 1/15
Proteins %En: 18.4±0.7 (a) 14.8±0.8 (b) 25.3±1.9 (c) 19.7±2.4 (a)
>20% ** 4/15 1/15 11/15 5/15
>18% ** 9/15 2/15 12/15 5/15
PROT-AN 65.8±1.9 62.1±1.4 65.3±2.4 62.9±2.3
PROT-VEG 30.4±1.8 (a) 37.8±1.4 (b) 23.3±2.5 (c) 32.2±3.2 (a)
PROT-SUP 3.7±1.7 (a) 0 11.0±2.9 (b) 4.8±2.5 (a)
Proteins g/kg BM 1.5±0.1 (a) 1.0±0.1 (b) 1.9±0.1 (c) 1.4±0.1 (a)
<0.9 g/kg 2/15 3/15 0/15 4/15
<1.2 g/k*** 6/15 13/15 0/15 8/15
>1.7 g/kg** 4/15 0/15 9/15 5/15
>2.0 g/kg* 3/15 0/15 7/15 4/15
PROT-AN 0.9±0.08 (a) 0.6±0.02 (b) 1.2±0.1 (c) 0.9±0.1 (a)
PROT-VEG 0.4±0.1 0.4±0.1 0.4±0.1 0.4±0.1
Alcohol %En 0.7±0.2 (a) 0.8±0.3 (a,b) 0.8±0.5 (a,b) 1.4±0.4 (b)
Fibre (gr/d) 17.4±1.3 (a) 19.1±1.3 (a) 20.2±2.1 (a,b) 23.4±1.1 (b)
<25g/d 14/15 13/15 12/15 13/15
WBA: wheelchair basketball athletes; GAL: gym attendees with FM% below 17; GAH: gym attendees with FM% above 18; NSA: inactive men who do not practice sport activity.
En: energy intake; CHO: carbohydrates; PROT-AN: proteins from animal sources; PROT-VEG: proteins from vegetable sources; PROT-SUP: proteins from supplements. Continu-
ous variables are expressed as means with SEM. Student-Newman-Keuls: multiple comparison (a), (b) and (c): p<0.05. Categorical variables, χ2: *p<0.05, **p<0.01, ***p<0.001.

a mixed (aerobic and anaerobic) metabolism, including bas-
ket (carbohydrates: CHO 57%, fat 25% and protein 18%)
and for power sport (CHO 55%, fat 25% and protein 20%),
suggested by the Federazione Medico Sportiva Italiana
(https://www.nutrizioneesalute.fmsi. it/images/img/pdf/opus-
colo_per_atleti_e_famiglie.pdf).
Furthermore, in some cases macronutrients’ intake did
not comply with the recommended intakes for the Italian
population [Livelli di Assunzione di Riferimento di Nutrien-
ti ed energia per la popolazione italiana (LARN), https://sin-
u.it/tabelle-larn-2014/] (CHO at least 45%, sugars below
15%, fat below 35%, proteins 0.9g/kgBM/d).
Means of fat% were higher compared to the suggested
values in all groups, whereas CHO % was higher in the
NSA compared to WBA, GAL and GAH (Table 3).
Although WBA had a higher percentage of sugars’ in-
take, in 7/15 above the suggested dietary target (<15%En),
one of them had a CHO intake below the LARN suggested
target in order to prevent ketosis (2g/kg BM/d).
GAL was the group with the highest intake of proteins
(g/kg BM/d), especially from animal and supplement
sources while in the WBA and in both the gym attendees’
groups, different percentages of volunteers had low or high
intakes compared to the recommendations (Table 3).
Despite mean intakes of micronutrients were in the
range of the LARN, many volunteers, in all groups, had in-
takes below the recommended values for calcium and vita-
mins D, A and B12 (Table 4). In particular, all WBA had vi-
tamin D intakes below the recommended values and the
mean intake was lower in WBA compared to the other
groups (Table 4). Furthermore, more WBA (9/15) than GAL
42 Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 Toti et al.

Table 4. Micronutrients intakes.

WBA NSA GAL GAH

Vitamin B1 mg 1.3±0.2 1.4±0.2 1.6±0.1 1.6±0.1
<1.2 9/15 6/15 3/15 4/15
Vitamin B2 mg 1.9±0.3 1.8±0.1 2.2±0.2 2.0±0.1
<1.6 * 9/15 6/15 2/15 3/15
Vitamin B6 mg 2.4±0.2 (a) 1.4±0.1 (b) 1.7±0.1 (b) 1.4±0.1 (b)
<1.3 0/15 5/15 4/15 5/15
Vitamin B12 µg 2.2±0.1 1.9±0.1 2.1±0.1 1.9±0.1
<2.4 12/15 13/15 12/15 13/15
Vitamin C mg 99±13 104±14 130±11 108±10
<105 10/15 7/15 5/15 6/15
Vitamin E mg 14.8±0.8 13.2±1.0 16.9±1.1 15.7±1.1
<13 4/15 7/15 3/15 3/15
Vitamin A (RE) µg 928±184 (a) 504±29 (b) 627±39 (b) 578±44 (b)
<700 * 9/15 15/15 10/15 12/15
Vitamin D µg 3.6±0.9 (a) 12.5±1.1 (b) 13.6±0.6 (b) 14.2±0.7 (b)
<15 15/15 11/15 11/15 11/15
Calcium mg 759±107 856±22 859±38 935±62
<1000 12/15 14/15 11/15 11/15
Iron mg 12.2±0.9 12.7±1.1 12.8±0.8 12.2±0.6
< 10 4/15 4/15 3/15 4/15
HEME-iron 3.7±0.3 4.2±0.4 4.1±0.2 4.1±0.2
Zinc mg 13.7±1.0 14.7±1.4 17.2±1.2 19.2±3.3
< 12 6/15 4/15 5/15 1/15
WBA: wheelchair basketball athletes; GAL: gym attendees with FM% below 17; GAH: gym attendees with FM% above 18; NSA: inactive men who do not practice sport activity.
RE: retinol equivalents. Continuous variables are expressed as means with SEM. Student-Newman-Keuls: multiple comparison (a) versus (b): p<0.05. Categorical variables, χ 2:
*p<0.05.

Table 5. ON and Med-D adherence.

Score WBA NSA GAL GAH

ORTO-15 36.9±1.1 34.7±1.1 37.4±1.0 37.3±0.5
ORTO-12 29.9±0.9 27.6±0.9 29.9±0.8 29.7±0.5
ORTO-11 27.2±0.9 25.8±0.8 27.5±0.8 27.8±0.6
ORTO-9 24.3±1.1 22.5±1.2 25.2±1.0 23.9±0.7
ORTO-7 19.2±0.8 18.3±0.5 19.7±0.4 20.4±0.5
ORTO-6 17.7±1.0 16.0±1.0 18.3±0.8 17.2±0.7
MDS 6.3±0.6 6.7±0.5 7.5 ± 0.5 7.6 ± 0.5
MEDScore 30.1±1.2 29.5±2.1 33.1±2.0 34.5±1.5
MDS-CO 2.3±0.4 2.6±0.3 3.2 ± 0.3 2.9 ± 0.3
MEDScore-CO 16.3±1.1 (a) 16 9±1.1 (a) 20.3±0.8 (b) 20.3±0.7 (b)
MDS-IC 0.7±0.1 0.7±0.1 0.8 ± 0.1 1.0 ± 0.2
MEDScore-IC 6.5±0.3 5.0±0.6 5.9±0.5 6.6±0.5
MDS-D 3.3±0.3 3.4±0.2 3.5 ± 0.2 3.7 ± 0.2
MEDScore-D 7.3±0.7 7.5±0.9 6.9±1.1 7.5 ± 0.8
WBA: wheelchair basketball athletes; GAL: gym attendees with FM% below 17; GAH: gym attendees with FM% above 18; NSA: inactive men who do not practice sport activity.
ORTO: score and sub-scores of orthorexia (*reverse scores: individuals with lower scores have more symptoms). Continuous variables are expressed as means with SEM. MEDS-
core and MDS: adherences to Mediterranean diet. Sub-scores CO: coherent, IC: incoherent, D: different. Data are expressed as means with SEM, Student-Newman-Keuls: (a) versus
(b) p<0.05.

(2/15) had vitamin B2 intake below the recommended val- No significant differences were found in ON (Table 5).
ues. On the other hand, the mean intakes of vitamin B6 and The mean MEDScore-CO, including fruits, vegetables
vitamin A were higher in WBA, compared to the other and legumes, was higher in the GAL and GAH groups com-
groups (Table 4).
Dietary Intakes and Food Habits Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 43

pared to the WBA and NSA groups (Table 5). The other
sub-scores were not different (Table 5).
Spearman correlations revealed that WBA with lower
ORTO-15 and ORTO-12 had higher MEDScore (Table 6).
MEDScore was related with ORTO-7 in GAH and NSA
(Table 6). However, GAH and NSA with eating behavior of
ON had more and less adherence to Med-D, respectively.
Correlations revealed that NSA (ORTO-15 versus vita-
min C: -0.540, p<0.05) and GAH (ORTO-11 and ORTO-7
versus vitamin C: -0.646, p<0.01 and -0.560, p<0.05, respec-
tively). with ON behaviour had lower intake of vitamin C.
In the GAH group, ON was also associated with low intake
of vitamin E (versus: ORTO-15: -0.781, p<0.001;
ORTO-12: -0.713, p<0.01; ORTO-11: -0.723, p<0.001;
ORTO-9: -0.611, p<0-05 and ORTO-6: -0.535, p<0.05) and
vitamin D versus: ORTO-15: -0.619, p<0.05; ORTO-12:
-0.639, p<0.01; ORTO-11: -0.566, p<0.05; ORTO-9: -0.525,
p<0.05 and ORTO-6: -0.528, p<0.05).
MEDScore was correlated with NBD (0.508 p=0.05).
On the contrary, MEDScore was inversely related to
PROT-AN in NSA and GAL (Table 6).

Table 6. Spearman correlations among WBA and control groups.

WBA NSA GAL GAH

IWBF class vs NA NA NA
MEDScore -0.569* - - -
NBD -0.754*** - - -
FM% -0.627* - - -
ORTO-15 vs
MEDScore -0.539* NS NS NS
GERD 0.543* NA NA NA
SSI -0.732** NA NA NA
Fat % En -0.652** NS NS NS
CHO % En 0.517* NS NS NS
PROT-AN NS -0.619* NS NS
ORTO-12 vs
MEDScore -0.539* NS NS NS
GERD 0.559* NA NA NA
SSI -0.732** NA NA NA
Fat % En -0.678** NS NS NS
ORTO-11 vs
Fat % En -0.649** NS NS NS
CHO % En 0.511* NS NS NS
PROT-AN NS -0.669** NS NS
ORTO-9 vs
GERD 0.584* NA NA NA
Fat % En -0.596* NS NS NS
PROT-AN NS -0.688** NS NS
ORTO-7 vs
MEDScore NS 0.526* NS -0.628*
SSI -0.517* NA NA NA
Fat % En -0.514* NS NS NS
PROT-AN NS -0.530* NS NS
FM% NS NS 0.548* 0.546*
ORTO-6 vs
Fat % En -0.543* NS NS NS
PROT-AN/kg NS -0.512* NS NS
FM% NS NS NS 0.510*
PROT-AN vs
MEDScore NS -0.608* -0.643** NS
CHO/kg 0.654** NS NS -0.571*
En 0.793*** NS NS NS
FM% -0.571* NS NS -0.611*
PROT-VEG vs
CHO/kg 0.950*** NS NS NS
Fibre 0.575* NS NS NS
En 0.900*** NS NS NS
NS: not significant; NA: not applicable; FM%: percentage of fat mass; IWBF: International Wheelchair Basketball Federation; ORTO: score and sub-scores of orthorexia (reverse
scores); MEDScore: adherence to Mediterranean diet. NBD: neurogenic bowel dysfunction; GERD: gastroesophageal reflux disease; SSI: starvation symptoms inventory; En: energy
intake; CHO/kg: carbohydrates’ intake g/kg BM/d; PROT-AN: proteins from animal sources (g/kg BM/d); PROT-VEG: proteins from vegetable sources (g/kg BM/d). †p=0.051;
*p<0.05, **p<0.01, ***p<0.001.
44 Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1
On the other hand, only in WBA both PROT-AN and
PROT-VEG correlated with both CHO and En (Table 6).
ON correlated with fat % En and CHO % En in WBA only
(Table 6).
FM% was inversely related to PROT-AN in WBA and
GAH, but to ON only in GAH (Table 6). Besides, WBA of
the lower IWBF class had more FM% and higher NBD
(Table 6). Moreover, ON was related to GERD (Table 6),
which was related to NBD (-0.520, p<0.05) and SSI (-0.643,
p<0.01). Being IWBF class, ORTO scores and GERD rev-
erse scores (lower scores correspond to higher impairment
or symptoms), WBA with eating behavior of ON had more
symptoms and adherence to Med-D.
4. DISCUSSION
In the present study, the mean FM% of the WBA (Table
2) was lower than those of WBA of the Great Britain Men's
Wheelchair Basketball World Class Performance Program
(26.6% ± 6.5%) [27] and of Swiss Elite Wheelchair Athletes
practicing various sports (25.2 ± 9.5%) [28], within whom
basketball game players showed the highest fat-free mass
[28]. However FM% of WBA was higher than GAL group
and not significantly different from the other two control
groups (Table 2). FM% was inversely related to ON in gym
atteendees and to IWBF class in WBA (Table 6). FM% was
inversely related to PROT-AN in WBA and GAH (Table 6).
Differences in % of proteins from animal, vegetable and sup-
plement sources were found among groups (Table 3).
Mean intake of proteins, expressed as g/kg BM/d (Table
3), was in the range (1.2-1.7 g/kg BM/d) suggested for Para-
lympic Athletes [29], however both lower and higher intakes
than those recommended were found in WBA, GAL and
GAH (Table 3). Only in WBA both PRO-AN and PRO-
VEG intake correlated with both CHO and En (Table 6).
The observed CHO intake (Table 3) near to the lower
limit of the recommendations (3.0–12.0 g/kg), was previous-
ly reported in wheelchair athletes [30]. Similar results were
found in male WBA of the Spanish National team [31] and
CHO intakes resulted lower than those recommended for ath-
letes as previously reported in the British wheelchair games
players [32]. An adequate CHO intake is essential to sustain
both general health and immune function [33, 34]. We in-
cluded AQUA among secondary outcomes for WBA, be-
cause clinical conditions of Paralympic athletes predispose
them to an increased risk of illness compared to able-bodied
athletes [35], with a high incidence rate of respiratory sys-
tem illness, but also of the digestive tract [35, 36]. However,
neither Med-D adherence nor ON were related to AQUA, as
well as macronutrient intake.
WBA and GAH with ON had higher adherence to Med-
D, whereas NSA had less adherence to Med-D. However,
MEDScore-CO was lower in WBA compared to GAH and
GAL. The MEDScore-CO includes fruits, vegetables and
legumes. Accordingly, Grams et al. [31] reported that
legumes were consumed in minimal amounts by WBA be-
longing to the Spanish National Team. Moreover, among
Toti et al.
players of the Turkish National Wheelchair Women’s Bas-
ketball Team (fibre intake 13.7-42.4g/d) only 36.4% met the
required fibre intake according to the Recommended Dietary
Allowances (RDA) [37].
Despite the need for nutrition education in relation to
consumption of whole grains, legumes, vegetables and
whole fruits [11, 31, 37], a high-fibre diet has been shown to
prolong constipation, increase colonic transit time and in-
crease NBD score in SCI patients [38]. Consumption of
about 15g/d of dietary fibre could be beneficial in managing
NBD in SCI, whereas an increase in fibre intake from 25g/d
to 31g/d may increase evacuation time [39]. Therefore, it
has been suggested that clinicians may recommend a low-fi-
bre diet [38]. NBD can cause significant pain and discom-
fort and is a source of emotional distress, negatively impact-
ing participation in social activities and travel [7]. It has
been reported that some individuals with SCI coped with
changes in bowel function by limiting how much they ate,
by skipping meals or by avoiding some foods [7].
It has been suggested that, among the British wheelchair
games players, low fiber intake could be related to individu-
alized bowel management strategies [32]. Low consumption
of fibre induces dysbiosis [12]. The latter has been found in
individuals with SCI [40, 41], particularly in those with bow-
el dysfunction [42], where butyrate-producing bacteria were
found to be specifically reduced compared to healthy con-
trols [42]. Dysbiosis was related to serum lipids in individu-
als with SCI [43, 44] and can lead to chronic low-grade in-
flammation after SCI [12]. From that, personalized nutrition-
al programs are recommended for wheelchair athletes with
SCI and NBD [12].
Bert et al. [45] observed that having a nutritional plan or
nutritional restriction seems to relate to ON and pointed out
that ON can have serious consequences on athletes’ health.
In able-bodied gym members ON was associated with
uneasiness with body image and frequent exercising [3] and
to the use of dietary supplements [46].
On the contrary, in WBA ON correlated with GERD and
SSI (Table 6). A clear overlap exists between ON and eating
disorders (ED) [5]. The “Australian Institute of Sport (AIS)
and National Eating Disorders Collaboration (NEDC) posi-
tion statement on disordered eating in high-performance
sport” pointed out the importance of the early identification
of ED and low energy availability in athletes [47]. Although
the control of body composition may contribute to an in-
creased prevalence of ED, body mass should not be the sole
focus of the multimodal assessment of ED and among risk
factors there are chronic disease (including diabetes) and gas-
trointestinal conditions [47]. The position statement suggest-
ed nutritional and body composition assessments, as well as
education sessions and individualized nutritional interven-
tions [47]. In male elite WBA, the macronutrient distribu-
tion improved, after advice during a precompetitive-period,
from 3.8 ± 1.3 g/kg to 4.2 ± 1.9 g/kg CHO, from 1.7 ± 0.6
g/kg to 1.5 ± 0.5 g/kg protein, and from 36 ± 5% to 32 ± 5%
of En derived from fat [48].
Dietary Intakes and Food Habits Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 45
The adequacy of the micronutrient intake by elite male
WBA, belonging to the Spanish National Team, was posi-
tively related to their total En and fruits and cereals were
within the food groups found to be predictors of adequate in-
take of most micronutrients [31]. In the present study many
volunteers did not meet the recommendations for some mi-
cronutrient (vitamin D, B1, B2, B12, C and calcium, Table
4), whereas iron intake was adequate in the majority of the
cases. Previously reported percentages of WBA who meet
the requirements according to the RDA were 63.6%, 100%,
72.7%, 81.8%, 95.5%, 86.4% and 27.3% for vitamin B1,
B2, B12, C, D, calcium and iron, respectively [37].
It has been suggested that supplements may be a possi-
ble solution for WBA, if adequate micronutrient intake can-
not be achieved through regular dietary intake alone [31]. Vi-
tamin D was among the commonly consumed supplements
by male rugby wheelchair athletes [49], whereas in our
study no WBA reported any vitamin D supplementation de-
spite the low intake (Table 4).
In mice, low Vitamin D dietary intake induced a lower
microbial diversity, neuronal hyperexcitability and altered
nociception mediated by the endocannabinoid system at the
spinal cord level [50]. In a study on osteoporotic patients
with SCI, the supplementation with calcium, vitamin D and
omega-3 polyunsaturated fatty acids for 4 months, did not
change significantly pro-inflammatory cytokines [51].
On the contrary, proinflammatory markers were negative-
ly correlated with dietary intake of anti-inflammatory nutri-
ents, such as omega-3 fatty acids, vitamin A, carotenoids,
and zinc, in individuals with SCI following an anti-inflam-
matory diet for 3 months [52]. This anti-inflammatory diet
excluding foods with high glycemic indices, common intoler-
ances (cow's milk), and foods that negatively influence car-
diovascular health such as hydrogenated oils; and introduc-
ing nutraceuticals with anti-inflammatory effects (omega-3,
chlorella, coenzyme Q10, n-acetyl-cysteine, mixed toco-
pherols, alpha lipoic acid, zinc, selenium, green tea extract,
curcumin and a vegetable-based protein powder), reduced in-
flammation [53, 54]. After this treatment, the decrease of in-
terleukin-2 and interferon-gamma correlated with the reduc-
tion of the sensory neuropathic pain [54].
AIS and NEDC found paucity of data in Paralympics,
with further research and understanding required in this pop-
ulation.
Therefore, the major strength of our study is that we
found that WBA had different eating habits compared to
gym attendees or to people who do not practice any sport ac-
tivity. Another point of strength is the suggestion that ON in
WBA is related more to physical rather than psychological
factors. In particular, ON was inversely related to FM% and
correlated with SSI in GAH and WBA, respectively.
The study has also several limitations. The major limita-
tion of our study is that the relatively limited sample size pre-
vented us from sub-grouping WBA with different types and
degree of severity of their impairment.
Although the world-class quality of the sample is among
the strengths of this study, we will need to further explore
and confirm the relationship between gastrointestinal symp-
toms and adherence to Med-D in a larger participant sample
that includes women, varying types of Paralympic sports
and athletes from both the pre-elite and elite levels. Howev-
er, among the elite British wheelchair games players, male
showed significantly higher daily energy, CHO and protein
intakes than female, but En derived from CHO, protein, and
fat were similar (53.6%, 16.9% and 29.3% for men and
53.3%, 19.0% and 26.8% for women) [32].
CONCLUSION
Although many volunteers in all groups did not follow
the National recommendations, Paralympic athletes require
specific nutritional guidelines, considering their specific
health conditions and possible related gastrointestinal symp-
toms. Personalized dietary and supplementation strategies to
cover nutritional demand and support WBA health and
longevity should consider self-regulation of food choice of
WBA, due to accumulated experience and exposure to vari-
ous tolerated foods. In WBA, eating behaviors seem to be
due to self-control of gastrointestinal symptoms and commit-
ment to well-being (including ON and Med-D adherence)
and could be a response to starvation symptoms. Our find-
ings suggest that athletes’ opinions and experience in self-
management of health conditions related to their impairment
should be included in the design of an integrated approach
to tailored education and dietary interventions, in order to
improve both compliance and efficacy.
LIST OF ABBREVIATIONS
AIS = Australian Institute of Sport
ANOVA = Analysis of Variance
AQUA = Allergy Questionnaire for Athletes
ASIA = American Spinal Injury Association Impair-
ment Scale
BM = Body Mass
CHO = Carbohydrates
ED = Eating Disorders
En = Energy Intake
FM% = Fat Mass Percentage
GAH = Gym Attendees with FM%>18
GAL = Gym Attendees with FM%<17
GERD = GastroEsophageal Reflux Disease
IWBF = International Wheelchair Basketball Feder-
ation
L = Left
Lum = Lumbar
46 Endocrine, Metabolic & Immune Disorders - Drug Targets, 2022, Vol. 22, No. 1 Toti et al.

LARN = Livelli di Assunzione di Riferimento di Nu- CONSENT FOR PUBLICATION

trienti ed Energia Per la Popolazione A written informed consent was obtained from all partici-
Italiana pants involved in the study.
LLA = Lower Limb Amputation AVAILABILITY OF DATA AND MATERIALS
MDS = Mediterranean Diet Score The datasets generated and analysed during the current
Med-D = Mediterranean Diet study are not publicly available (individuals’ data availabili-
ty is restricted by the Ethics Committee) but are available
NBD = Neurogenic Bowel Dysfunction from the corresponding autor, [IP], on reasonable request.
NEDC = National Eating Disorders Collaboration
FUNDING
NSA = healthy Individuals who do not Practice
Sport Activity The study was supported by FIPIC (Federazione Italiana
Pallacanestro In Carrozzina) and Ministero della Difesa (Pro-
OHC = Other Health Conditions ject AMAMP 2019-2021).
ON = Orthorexia Nervosa
CONFLICT OF INTEREST
ORTO = Orthorexia Score Research was funded by Federazione Italiana Pallacane-
PRO-AN = Animal Protein Intake stro in Carrozzina (FIPIC, Rome, Italy) and by Progetto
AMAMP (Ministero della Difesa). M.B. and S.B. were col-
PROT-AN = Proteins from Animal Sources laborators of FIPIC. M.B. is the Federal Doctor and S.B. col-
PROT-SUP = Proteins From Supplements laborated only in the impairment level and relative IWBF
class assessment. However, the funders had no role in the de-
PROT-VEG = Proteins from Vegetable Sources sign of the study; analyses, or interpretation of data. The
R = Right other authors declare no conflict of interest.
RDA = Recommended Dietary Allowances ACKNOWLEDGEMENTS
SB = Spina Bifida The authors would like to thank the volunteers who
SCI = Spinal Cord Injury willingly participated in this study, Fernando Zappile and
Alessia Ferri, President and General Secretary of the FIPIC,
SEM = Standard Error Mean respectively, who sponsored the project on the Italian Nation-
SSI = Starvation Symptom Inventory al WB teams, Bianca Maria Mariani (FIPIC, Rome, Italy)
for the recruitment of the athletes and Roberta Peluso for the
T = Thoracic photograph used in the graphical abstract. The authors ac-
TF = Transfemoral knowledge Dr. Claudio Andrew Gobbi for the English revi-
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TR = Transradial
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