The Female Athlete Triad: Health of Dancers in Professional Training

The Female Athlete Triad: The Health of Dancers in Professional Training

The Female Athlete Triad – Only an Athletic Concept?

Dance is the hidden language of the soul (Graham, M. 1953)

Professional dancers are unique because they are the only artists who never put aside the tool of their trade. For dancers, the whole body (physical and psychological) is their instrument, their means of artistic expression. Balance, strength, power, speed, endurance, flexibility and joint mobility are all called upon, making dancers some of the most proficient, all-around athletes.

Despite dancers dedicating a considerable amount of time to their bodies, many are plagued by one, or all three, of the following health conditions: premature reduction in bone density or osteoporosis, menstrual irregularities or amenorrhoea, and low energy availability (with or without disordered eating) (Doyle-Lucas, A.F., Akers, J.D. & Davy, B.M. 2010).

In 1992, these three interconnected health conditions relating specifically to female athletes became classified as the Female Athlete Triad. Associated with disordered eating and known to be connected to energy deficiency, these components play a causal role in the development of menstrual disturbances. Both energy deficiency and low oestrogen levels associated with amenorrhea play a role in initiating premature reduction of bone density.

There is much existing research into sports science, but dance science is an emerging discipline. A strong case has been made for dancers to be considered athletes, both by sports science and the practitioners of dance. The physical artistry of many dance forms necessitates extraordinary physical athleticism, flexibility and strength, to levels that can rival many other athletic sports. (Prof. Yiannis, K. 2004, as cited in Koutedakis, Y. & Jamurtas, A. 2004)

The Female Athlete Triad: Outline of my Investigation

I believe that the Female Athlete Triad is a particularly relevant health concern to dancer’s, as the triad is said to be predominantly prevalent amongst sports that place a heavy emphasis on an athlete’s physical appearance (Beals & Manore, 2002; Sundgot-Borgon & Torstveit, 2004 as cited in Bean, A. 2009).

My investigation explores the optimal nutritional, physical and psychological health of dancers in professional training with respect to the Female Athlete Triad.

My theoretical and investigative research on the Female Athlete Triad is as concise and as correct as possible. I have researched from a wide variety of resources including books, webpage’s, articles, journals, newspapers, biographies and autobiographies. I have ensured that all information used was from a reliable source; the majority of which has originated from doctors, scientists, and well-established dance artists.

I refer throughout this investigation to the facts and figures from Fit to Dance 2 (Laws, H. 2005), a follow-up publication of Fit to Dance? (Brinson, P. & Dick, F. 1996).

Fit to Dance 2 (Laws, H. 2005) is a report compiled to present a comprehensive picture of the health and injury status of UK dancers. The publication collected information from professional dancers, dance students and dance teachers from over 52 dance companies, 23 vocational schools, 10 West End shows, four South Asian training establishments, and National Dance agencies.

I specifically refer to Fit to Dance 2 (Laws, H. 2005) throughout this investigation, as it is the most extensive national dance survey of its kind. Compiled from over a thousand dancers, across multiple dance genres, I am confident the report will provide me with the most accurate and comprehensive results.

The Third-Year Survey

Alongside my research, I designed a questionnaire (see appendix) to investigate for myself if any of the health aspects, in respect to the Female Athlete Triad, are prevalent amongst my fellow dance students.

Divided into four parts, the first section of my questionnaire asks questions about general health and diet. The second asks questions about menstruation and bone health, and the third about dancers’ attitudes towards the dance aesthetic. The last section of the questionnaire asks dancers about their previous health knowledge and the support they may have received from their dance establishment. Questions required a yes/no, or tick the box only response, to ensure the questionnaire was quick, the answers concise, and that a maximum number of students took part.

I handed out 65 questionnaires to third-year Laban 2011 students and received 48 back. Throughout this essay, I will refer to this investigation as the ‘Third Year’ survey. I am aware that the Third Year survey cannot be talked about as if it were an accurate sample of all professional dancers. It is a sample of 48 third-year students aged 20-26, some of whom, may or may not, wish to work as a professional dancer in the future. The students are following a path of mainly contemporary, ballet and creative dance, under one school system, with that particular school’s pressures and regulations. I understand its limitations and believe that a ballet school, for example, would most likely produce very different responses.

What does the Female Athlete Triad mean today?

In 2007 the Female Athlete Triad was ‘remodelled’ by the American College of Sports Medicine.  The updated version of the Female Athlete Triad does not deal with the three components of the triad with such strict diagnostic criteria. But instead, considers the three corners of the interrelated issues of energy availability, menstrual function, and bone health.

The updated Female Athlete Triad notes that each of these health issues is a continuum ranging from optimal health to a diagnosed problem (Bean, A. 2009).  At the optimal end of the spectrum are optimal energy availability, regular ovulatory menstrual cycles and maximal bone health.

At the other end of the spectrum are the clinical outcomes associated with each triad component: energy deficiency (with or without disordered eating), abnormal menstrual cycles or amenorrhea, and a premature reduction in bone density or osteoporosis (ACSM, 2007).

Another aspect of the new Female Athlete Triad is that athletes may not present symptoms at the extreme end of the spectrum; but may instead, display ‘subclinical’ presentations of one or more of the conditions (ACSM, 2007). The new model for the Female Athlete Triad also allows for the different rates of decline that can occur along the three continuums.

Moreover, while each condition can occur independently, it is more likely that, because of the apparent associations between the three conditions, a person suffering from one condition is also suffering, or may suffer in the future, from the others. All three conditions can derive from a combination of extreme training, poor nutritional status, and lack of biomechanical and physiological knowledge (ACSM, 2007).

The 1992 version of the Female Athlete Triad might not be beneficial to dancers, because if a dancer were medically at the end of a spectrum, then they most likely, would not be fit to dance. Moreover, the diagnosis and treatment may have come too late, and irreparable damage might have occurred.

The 2007 classification of the Female Athlete Triad, and the use of continuums, means that dancers who are still maintaining their health to a level where they can dance/train, can be identified as unhealthy within the understanding of the triad. I believe that the 2007 model takes the Female Athlete Triad out of the realms of medical intervention. Now, dance teachers and establishments can use the Triad as a functional training tool to monitor elements of dancers’ health and wellbeing.

Negative Caloric Imbalance and the Female Athlete Triad

Caloric restriction and/or an extreme volume of exercise can cause a negative caloric imbalance (Berardi, G. 1991). A dancer may be able to train and perform while in a negative caloric imbalance by several physical and exaggerated psychological factors.

Physically, the body can adapt itself to become more energy efficient by reducing its metabolic rate from between ten and thirty percent (Bean, A. 2009). Within this state, a dancer can train and maintain their energy balance on fewer calories than expected.

Psychologically, dancers are very strong-willed, highly driven people, and have a strong desire to succeed (Mastin, Z. 2009). From my experience and research, these characteristics, along with the aid of stimulants such as caffeine, can allow dancers to temporarily mask any physical and/or emotional fatigue.

Nevertheless, as glycogen and nutrient stores become chronically depleted, dancers can become more susceptible to injury and infection, and ultimately their performance can suffer (Bean, A. 2009). It is suggested that amenorrhea (the absence of menstruation for three months or more) and oligomenorrhea (periods occurring at intervals greater than 35 days, with only four to nine periods in a year) are an energy conserving adaptation by the body. By ‘shutting down’ the normal menstrual function, the body tries to economise energy to cope with the chronic negative caloric balance (Bean, A. 2009).

If caloric intake and energy expenditure are within a dancer’s control, why are some dancers deteriorating into a negative caloric balance?

The Dance Aesthetic

Dance may be a form of physical exercise, but it is also an art form. While athletes have quantifiable performance results that can help them to optimise their performance weight, dancers do not.

Therefore, dancers can get into trouble when the optimal body composition for fitness, and the optimal body composition for an ‘accepted’ aesthetic, conflict with each other.

From the 1960’s to early 90’s dance saw the rise of the wraithlike, ethereal ballerina (Gordon, 1983 as cited in Dunning, J. 1997). From the romantic ballets of Marius Petipa to the neoclassical ballets of George Balanchine, thin was in, and ballet was in horror of the ‘civilian’ body-shape (Jennings, L. 2007).

“All dancers had to subscribe to this thin ideal, but it was never made clear how it was to be achieved. There was minimal nutritional advice or counselling, and little understanding of the effects of dieting on the adolescent body” Luke Jennings, dance critic for The Guardian, 2007.

Dancers struggling to meet the thin ideal fill the pages of past prima ballerina’s autobiographies such as Gelsey Kirkland’s ‘Dancing on my Grave’ (1992), Allegra Kent’s ‘Once a Dancer’ (2009) and Suzanne Farrell’s ‘Holding on to the Air’ (1990). For example:

“Not long after the watermelon feast, I had an encounter with Mr.B [George Balanchine] in class, in which he underscored his demand for starvation. With his knuckles, he [Balanchine] thumped my sternum and down my ribcage clucking his tongue and remarking “must see bones”. I was less than a hundred pounds even then.” (Kirkland, G & Lawrence, G. 1986. Pg, 62)

“[Balanchine] did not merely say “eat less”, he repeatedly said, “eat nothing”. (Kirkland, G & Lawrence, G. 1986. Pg, 63)

Allegra Kent’s autobiography Once a Dancer (2009), discusses the un-official, semi-secret trade in ‘slimming pills’ (actually amphetamines and cocaine), and her long-standing battle with food.

“I began slowly and systematically overeating. I went on eating long after the hunger was gone, and, in the throes of one of these eating episodes it didn’t matter what I ate.” (Kent, A. 2009, Pg. 134)

Many ballet directors and teachers perceive how thin a dancer becomes as a sign of dedication towards their art and is often at times rewarded with a soloist role, or an increase of rank within the company (Benn & Walters, 2001 as cited in Dunning, J. 1997).

Some professional companies also have “appearance clauses” in their contracts. These usually state that if the dancer gains any noticeable amount of weight, she is eligible to lose her position in the company (Jenning, L. 2007).

A wake-up call came in 1997 when the news broke of twenty-two-year-old Boston Ballet dancer Heidi Guenther who died from complications arising from an eating disorder (Itzac, P.B. 1997). Her death shook the dance world which has seen many changes in the past decade. Since Guenther’s passing, there has been an increase in nutritional counselling (Laws, H. 2005), an increase in the duty of care within dance schools and companies (Laws, H. 2005), and a shift in the desired aesthetic of dancer’s.

“If a girl or boy looks too thin or unhealthy, they are not allowed to perform. As performing is the main motivation for these young, talented people, it quickly has the desired effect.” Jane Hackett, director of the English National Ballet School in London, 2007.

“There was a time when very, very skinny dancers were fashionable, but we have a robust, holistic approach to the health and welfare of our students [the days when dancers lived on cigarettes and coffee are over].” Lucinda Sharp, resident psychologist at the Australian Ballet School in Melbourne, 2007.

Although a publicised shift in attitude, there is still contradictory evidence suggesting that dancers continue to be judged on their physicality, not on their artistic merit alone.

Jennifer Ringer, a Principle dancer with the New York City Ballet, who had a public battle with anorexia, was publically faulted on her weight, not her dancing in a recent review (Nov 28th, 2010) from New York Times critic Alastair Macaulay:

“Jennifer Ringer, as the Sugar Plum Fairy, looked as if she’d eaten one sugar plum too many.”

The comment sparked online fury against the critic by ballet enthusiasts, and support defending Ringer’s weight; some arguing that the body in ballet is irrelevant. However, Macaulay defended his criticism of the ballerina:

“If you want to make your appearance irrelevant to criticism, do not choose ballet as a career. The body in ballet becomes a subject of the keenest observation and the most intense discussion. I am severe — but ballet, as dancers know, is more so,” Macaulay wrote in a piece published Dec. 3rd 2010.

Although dancers now have access to nutritional counselling and more attention is being paid to a dancers’ welfare (Laws, H. 2005), how much can the desired aesthetic realistically change within the dance world?

Often considered as extra baggage to a dancer, excess body fat can adversely affect strength, speed, agility, flexibility and endurance (Berardi, G. 1991).

Moreover, when a dancers’ told that they are the wrong shape or have bad line, not enough extension or need to ‘suck in their stomach’, it can be a challenge to take this criticism as part of their art rather than of their body; or even as an objective, rather than subjective issue.

Furthermore, the training environment for professional dancers traditionally includes a mirrored wall, which, while a valuable teaching tool, also means that a dancer’s body image is always at the forefront of their mind.

The Fit to Dance 2 (Laws, H. 2005) survey reported that 40.6% of dancers surveyed were underweight by national guidelines, with the average female BMI at 20. Some critics argue, however, that BMI is not a good guideline of health for dancers as muscle and fat percentages can radically skew a BMI reading (Doyle-Lucas, A.F. & Akers, J.D. & Dary, B.M. 2010).

Moreover, Fit to Dance 2 (Laws, H. 2005) does not state that the recommended BMI for dancers is 18.5+ (Mastin, Z. 2009); therefore a statistical average BMI of 20 is perhaps a healthy medium.

Eating Disorders and the Female Athlete Triad

Dancers tend to lean towards a particular psychological profile with traits such as a desire to fit into the hierarchal dance world, a willingness to be told what to do, and an eagerness to accept and take on board corrections (Taper, B. 1996).

Researchers have found that the personality characteristics of élite sports professionals are very similar to those with eating disorders: obsession, competitiveness, perfectionism, compulsiveness and self-motivation (Bean, A. 2009).

The average incidence of eating disorders in the white middle-class population is 1 in 100, whereas in classical ballet the rate is increased to one in five (Dr Warren, M. 1997 as cited in Dunning, J. 1997).

This increase could be due to a number of factors including conformity to the desired aesthetic within the dance environment, the perhaps natural selection for thinner dancers who could either come with their own eating problems or cause further pressure on those who do not naturally conform to the perceived ideal, lack of nutritional education, and/or the physical demands of the work.

Within my Third Year study, I did not ask fellow dancers if they had an eating disorder as some dancers may be undiagnosed or possibly recovered. Secondly, some may be unaware that the disordered eating practices they may be engaging in are in fact unhealthy, or perhaps unaware of the clinical definition of an eating disorder. Furthermore, I am not qualified to give any such diagnosis myself.

I did, however, ask fellow dance students yes/no questions about their perception of the ideal dancers aesthetic. For example, the Third Year survey revealed that 54.3% of students felt that if they were thinner, they would be a more confident dancer; however, 62.9% students did not feel that if they were thinner, they would be a more successful dancer.

These results show that the students do not necessarily correlate thinness with success; however, it does seem to correspond to increased confidence. A total of 77.1% of dancers ticked yes (regardless of their current size) when asked if they ‘wished they were thinner’. This result shows a trend towards the thin aesthetic which could support Dr Warren’s research.

The Third Year survey also listed several disordered eating practices and asked dancers to tick if they had/or are engaging in any. Each question allowing further insight into their eating practice without attempting to label any disordered eating practice with a diagnosis.

The Third Year survey revealed that 17.1% of dancers dieted to lose weight daily, 8.6% once a month, 28.6% every few months, 5.7% once a year, and 40% had never dieted.

The Third Year survey also revealed that 54.3% of students had consumed large quantities of food in a short period of time whilst feeling out of control, 28.6% had fasted (abstaining from food for a day or more), 22.9% had self-induced vomited, 20% had excessively exercised, and 8.6% had abused laxatives. The survey did not tell me if a student had self-induced vomiting once, or if they were inducing vomiting after every meal which might suggest Bulimia.

Although my survey had its limitations, I feel it is essential to include aspects of eating disorders, and disordered eating in this investigation; as both can lead to adverse health effects which relate to the Female Athlete Triad.

What is an Eating Disorder?

Anorexia Nervosa and Bulimia Nervosa

Anorexia nervosa and bulimia nervosa are the two medically defined eating disorders that are most likely to affect dancers (Dyke, S. 2001). Anorexia nervosa is an eating disorder characterised by a body weight that is maintained at least 15% below that expected for a person’s height, and a strong, overwhelming fear of weight gain (Bean, A. 2009).

Bulimia nervosa is characterised by episodes of binging in which large, uncontrollable amounts of food are consumed within short periods of time, interspersed with purging which can take the form of excessive exercise, induced vomiting, starving for periods of time, or taking medicines such as laxatives or diuretics to counteract the bingeing (B-EAT, 2010).

Eating disorders can adversely affect an individual’s position on the spectra of the Female Athlete Triad, as well as cause numerous other health problems (see Appendix – Table 1).

The Statistics

Dance UK’s Healthy Dancer Programme (1991) which surveyed over a thousand working professional dancers in the UK, found that 25% of dancers interviewed had suffered from an eating disorder at some point in their career. Fit to Dance? (Brinson, P. & Dick, F. 1996) reported that 15% of respondents were on a diet and Fit to Dance 2 (Laws, H. 2005) reported that 23% of dancers were on a weight reducing diet.

Despite the suggestion that the attitudes towards a thin ideal are changing, and although there is more nutritional help and counselling readily available to dancers (Laws, H. 2005), these figures suggest that the percentage of dancers attempting to lose weight has in fact increased, and the rate of dancers with an eating problem or an eating disorder has stayed more or less the same.

Disordered Eating

More common than anorexia nervosa or bulimia nervosa is disordered eating (B-EAT, 2010). Disordered eating is not an eating disorder, and it is not necessarily dangerous towards health. However long term, disordered eating can lead to adverse health implications, and even towards a clinical eating disorder (Dyke, S. 2001).

Disordered eating means that the person is eating in a way that deliberately harms them psychologically and/or physically. It encompasses a range of eating patterns and attitudes towards food that can ultimately result in an unbalanced diet (Schullherr, S. 2008).

Signs of disordered eating can include: separating foods into good or bad, skipping meals, continually weighing food, fasting, dieting repetitively, using laxatives and/or diuretics, and intense guilt from eating the wrong food (Schullherr, S. 2008).

Physical harm may occur because of the restriction placed on some foods groups which may lead the diet to become unbalanced, with inadequate intake of vitamins, minerals or calories. Psychological harm may occur if the person uses food for reasons other than sustenance and pleasure (Schullherr, S. 2008).

The more disordered eating practices a person engages in, the more they are at risk for crossing the line into a formal eating disorder (Dyke, S. 2001).

Dancers are especially prone to disordered eating habits because of their schedules. Dancers’ schedules can encompass erratic, often unsociable hours, making it particularly difficult to eat regular nutritious meals throughout the day.

Fit to Dance 2 (Laws, H. 2005) investigated how much time per week dancers spent participating in physical activity. Their definition of physical activity included: class, rehearsal, performance, body conditioning, strength training, fitness training and other physical activity (mainly found to be Pilates, yoga etc.).

On average, professional dancers spent 36 hours per week dancing/training and dance students 27.1 hours. This high volume of activity could limit the time dancers have to eat and digest food before starting another physical activity. Dancers may also struggle to eat a substantial evening meal on performance days when shows usually begin around 7 pm. Within ballet, for example, corps de ballet members perform most nights of the week, for principles only a couple of nights per week due to the increased physicality of the role.

Both eating disorders, and some cases of disordered eating, can result in an energy deficit or negative caloric balance, the primary cause of problems associated with the Female Athlete Triad (ACSM, 2007).

As discussed previously, an energy deficit can give rise to health ailments such as a low body weight and/or body fat percentage, hormone disruption and poor nutritional status; all of which, can lead to the second two components of the Female Athlete Triad: irregular menstruation or amenorrhoea, and a premature reduction in bone health or osteoporosis. (ACSM, 2011)

The Female Athlete Triad: Menstrual Dysfunction and Amenorrhea

Amenorrhea (the absence of menstruation) has two classifications: primary or secondary. Primary amenorrhea may be diagnosed when a girl reaches the age of sixteen without yet having a period (Bean, A. 2009).

However, it is secondary amenorrhea (when a woman who has had regular menstrual cycles stops getting her monthly period for three months or more) and Oligomenorrhea (menstrual periods occurring at intervals greater than 35 days, with only four to nine periods in a year) that relate to the Female Athlete Triad (Bean, A. 2009).

Amenorrhea and Oligomenorrhea are typically triggered once fat levels drop below 17% of total body weight (Koutedakis, Y. & Sharp, C.N.C. 1999). Once fat levels reach a chronically low level, the hypothalamus in the brain decreases the production of the gonadotrophin-releasing hormone (GnRH). Reduced GnRH levels can adversely affect the pituitary gland, reducing its production of essential hormones that operate the ovaries (luteinising hormone and follicle stimulating hormone); a reduction of which, can cause the ovaries to produce less oestrogen and progesterone, and eventually lead to a cessation of menstrual periods (ACSM, 2007).

Menstrual Dysfunction and Its Affect on Dancer’s Performance

Menstrual dysfunction can adversely affect a dancer’s performance. Dancers who suffer from deficient oestrogen levels have an increased risk of soft tissue injuries, loss of suppleness within their ligaments, stress fractures, prolonged healing of injuries, and a reduced ability to recover from hard training sessions (Llyod et al., 1986 as cited in Bean, A. 2009).

Dancers suffering from menstrual dysfunction may also experience painful sexual intercourse, altered emotions, lowered sex drive, loss of bone density, osteoporosis and infertility (Bean, A. 2009).

Contraception and Menstrual Health

The Third Year survey asked students how often they menstruated before starting full-time dance training: 68.5% reported once a month, 8.6% once every three months, 22.9% had gaps of three months or more, and 0% had gaps of 6 months or more.

The survey also asked students how often they menstruated since starting full-time dance training: 80% reported once a month, 8.6% once every three months, 5.7% had had gaps of three months or more and 5.7% had experienced gaps of six months or more.

Since starting full-time dance training, the percentage of students having regular monthly periods increased, and the percentage that had gaps of three months or more decreased, which shows a trend towards healthy, regular monthly cycles.

However, those with gaps of six months or more increased from 0% to 5.7% which shows a trend away from regular monthly cycles. These results could mean that the physical demands of the dance training has affected their menstrual health, and may have caused a temporary cessation of menstruation.

The survey also asked if the students were currently/or had been, on any form of prescribed contraception. Of those that were/or had been, it asked ‘before starting on prescribed contraception were your periods regular?’ to which 45.5% of students said No. This result is worth noting because the contraceptive pill can give a false or to say fake period (Marks, L.V. 2010).

When a woman takes a hormonal method of birth control such as the common pill, which contains a combination of hormones such as progestin and oestrogen, the body no longer has a uterine cycle/menstrual period.

Ingestion of the common pill ensures that oestrogen and progesterone remain in balance, preventing any hormonal fluctuations, or build up in the lining of the uterus; a lack of which necessitates no periodic shedding/menstrual period. The pill also prevents the ovaries from releasing an egg each month (ovulation). This sequence of events is known as menstrual suppression (Marks, L.V. 2010).

With this in mind, the 45.5% of students that said they did not have regular periods before starting on prescribed contraception, may still have irregular menstrual cycles.

Conversely, the survey did not ask students which type of prescribed contraception they were/or had been taking. The pill is only one form of prescribed contraception, and an IUD, for example, would have a different effect on periods, as would contraceptive implants or injections which can stop periods altogether (Marks, L.V. 2010).

Though it may be beneficial to note that 45.5% of students did not have regular, monthly periods before starting prescribed contraception, I do not proceed to state why as my questionnaire and knowledge is somewhat limited and would require further research and education on my part.

However, the result I obtained was reflected in the Fit to Dance 2 (Laws, H. 2005) survey which reported that 36% of female dancers did not have regular, monthly periods when they were not on the pill. Irregular menstrual cycles could be a sign that these dancers are experiencing menstrual dysfunction; one of the health conditions within the Female Athlete Triad.

Can Amenorrhea be Reversed?

If a dancer has experienced amenorrhea for six months or longer, its recommended that they book a consultation with their local GP; from which, they may get referred to a specialist such as a gynaecologist, sports physician or endocrinologist.

If a dancer has some degree of disordered eating, they may also consider seeking advice from a sports nutritionist or sports psychologist, with a background in dance if possible. (Dyke, S. 2001).

Treatment would most likely focus on resuming a healthy body weight and body fat percentage, and either altering or reducing the dancers training programme. For example, the dancer may be required to reduce their number of classes and/or performances, or reduce the intensity to which she would typically train.

Studies on athletes show that when those suffering from amenorrhoea improve their diet and restructure their training to improve their energy balance, normal menstruation resumes within about three months (Dueck et al., 1996 as cited in Bean, A. 2009).

It is my experience, however, that dancers tend to avoid doctors for fear of having their training reduced, not wanting to admit they have a problem, or will push through an injury in the hope that it will disappear. I believe that, perhaps, the culture of the art can outweigh the concerns of the sport.

Amenorrhea and Bone Health

Dancers and athletes who suffer from amenorrhea could also suffer from a decrease in bone health, the third corner of the Female Athlete Triad. Low oestrogen levels are symptomatic of amenorrhea and can lower the absorption rate of calcium into the bones, leading to a loss of bone minerals and bone density (Doyle-Lucas, A.F. & Akers, J.D. & Davy, B.M. 2010).

A study by Victor Cross and Chris Boivin showed that professional ballet dancers with few or no periods, had significantly lower bone density in the lumber (lower) spine (Brinson, P. & Dick, F. 1996). A further study by Dr Nicola Keays on retired ballet dancers confirms these findings (Keays, N. 1998, as cited in Brinson, P. & Dick, F. 1996).

Dr Keays found that retired dancers who had the fewest periods, or those whose weight had dropped furthest below their ideal weight for height, also had the lowest spinal bone density. Despite the relatively young age of professional dancers (18-35 years-of-age), low oestrogen levels can severely weaken the skeleton resulting in brittle bones and premature osteoporosis.

Lowered bone density in younger, premenopausal women is called osteopenia (i.e. lower bone density than average for age). Similar to the osteoporosis that affects post-menopausal women, bones can become thinner, more porous and more fragile (Mastin, Z. 2009).

Thin, brittle bones can be prone to ‘fragility fractures’ where a minor bump or fall can cause a break. Therefore, it is vital that dancers maintain a healthy diet, healthy body weight for height, and have regular, monthly periods to ensure maximal bone health; particularly because of the intense physicality of their art.

Female Athlete Triad: A Premature Reduction in Bone Health

What is Bone?

Bone is a tissue made up of both living and non-living material (N.0.S, 2011). The living material consists of blood vessels, nerves, collagen, osteoblasts (cells that form bone), and osteoclasts (cells that remove bone). The non-living material encompasses osteocytes (mature osteoblasts that have ended their bone-forming careers), minerals, fibres and crystalline salts (niams.nhi, 2011).

Calcium is perhaps the most essential mineral in maintaining good bone health. Lack of calcium can cause the holes in the internal honeycomb structure of the bones to become larger and more porous which can lead to osteoporosis (Mastin, Z. 2009).

The body must continually maintain the thickness and strength of its bones through a process of ossification. Ossification is a process whereby osteoblasts continuously deposit bone and osteoclasts continually reabsorb it (AAOS, 2011). Calcium compounds must be present for ossification to take place.

Osteoblasts do not make calcium; therefore the body must obtain calcium through the diet ( For a list of common foods high in calcium, please see Table 2 in the Appendix.

Genes and Bone Health

A dancer’s diet, genes, age, gender and race, can play a role in the health of their bones and their risk of osteoporosis (NOS, 2011). The chances of developing osteoporosis in women increase if the following apply:

  • A family history of poor bone health
  • Over the age of 50
  • Are Post-menopause
  • Of Caucasian decent
  • Have a consistent BMI below 19
  • Had a previous bone fracture.

Osteoporosis can stay hidden until a bone fracture occurs (NOS, 2011).

Bone Health and Injury

The Third Year survey showed that 45.7% of students had incurred a bone injury since starting full-time dance training (the majority of which were shin splints or knee, ankle, or foot bone injuries).

A previous or reoccurring bone injury is only one indicator of a reduction in bone health. It could be representative of porous bones (depending how the bone injury occurred) and could be considered an indicative element of the Female Athlete Triad.

The questionnaire, however, does have its limitations, and this statistic alone cannot suggest any particular health diagnosis, but instead contribute to a broader picture of a dancer’s health in relation to the Female Athlete Triad.

I could research further into the relationship between dancers’ bone health and their injuries; however, these causalities are outside the realm of the Female Athlete Triad and may divert my investigation.

I have, however, researched and outlined ways that dancers can maintain their bone health; maintenance of which, may help to prevent the occurrence of some bone injuries, avoid a premature reduction in bone health or osteoporosis, and prevent a decline in the additional health ailments of the Female Athlete Triad.

Diet and The Female Athlete Triad


As mentioned previously, a poor diet can be detrimental to bone health. A high intake of caffeine, salt, heavy drinking and/or tobacco products can cause calcium to leach from the body (niams.nhi, 2011).

Caffeine is often consumed in the form of coffee, tea and energy drinks, with the desire to increase cognitive functioning and improve mood (Matin, V.2009). It is generally agreed that consuming up to 300 mg of caffeine per day is safe, which is about three cups of coffee (NHS, 2010).

Avoiding tea and coffee during and around mealtimes is essential for people at risk of anaemia (iron deficiency). Both coffee and tea contain polyphenols, a chemical compound whose structure can bind to iron making it more difficult for the body to absorb (Larson-Meyer, D.E. 2007).

The Third Year survey asked dancers how many portions of coffee/tea/energy drinks they drank a day; a glass (approximately 250ml) taken as one portion, and a standard bottle (500ml) accepted as two portions.

The survey reported that 22.9% did not drink any caffeinated beverages, 60% drank 1-2 portions, 14.3% drank 3-4 portions, and 2.8% drank five or more portions daily. With only 2.8% drinking 5 or more portions, the majority of students surveyed were within, or near, the suggested caffeine limit.

However, if I were to repeat the survey, I would separate the 3-4 portions. Considering that three portions are deemed safe, and four portions over the limit, it was not wise of me to join the two together.

Moreover, the questionnaire does not ask which specific caffeine drinks the dancers were drinking which could range from the lightly caffeinated Lucozade sport to the highly-caffeinated Red Bull or Monster energy drinks.

This information would allow my results to give a more accurate picture of the dancer’s caffeine intake. That said, the questionnaire might then become too focused on the student’s caffeine intake, and I would have to question its relevance within the Female Athlete Triad.


Smoking is detrimental to bone health as it can inhibit osteoblast activity and promote osteoclast activity (Cottam, S. 2005).

The Third Year survey reported that 31.4% of students smoked which is a comparatively high percentage in comparison to Fit to Dance 2 (Laws, H. 2005) which reported that 19% of dance students smoked.

Its worth noting that Fit to Dance 2 (Laws, H. 2005) had over a thousand recipients, whereas the Third Year survey had 48, which does limit the accuracy of its statistics.

There is, however, a direct, positive correlation between smoking and risk of injury (Laws, H. 2005). Fit to Dance 2’s (Laws, H. 2005) statistics showed that current smokers were more likely to have bone, neck, shoulder, lower back, groin and hip injuries than those who didn’t smoke. For that reason, it is imperative that dancers avoid tobacco products to reduce their chance of incurring an injury and allowing them to maintain peak physical condition.

Calcium Absorption

Other minerals such as magnesium and vitamin D are vital in aiding calcium absorption (Mastins, Z. 2009). Magnesium is present in foods such as nuts and seeds (particularly pumpkin seeds), fish, whole grains and beans, as well as fortified foods (Mastins, Z. 2009).

Levels of vitamin D in food are relatively low therefore dancers should look out for foods fortified with the vitamin. Vitamin D can, however, be produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis (Larson-Meyer, D.E 2007). Table 3 within the Appendix, displays the recommended daily allowance for calcium, magnesium and vitamin D for optimum bone health

Dancing can also prove beneficial to bone health. Weight-bearing activities (those which force the body to work against gravity) such as dance, are known to strengthen bone because of their high impact movements which can stimulate bone growth (niams.nih, 2009). That said, dancers in professional careers, or in preparation for them, are usually exercising more than twenty hours per week, which can, in fact, have adverse consequences for their bone and all-round health.

Female Athlete Triad: Physical and Psychological Stress

Dance is an art form that can challenge, strain and stress the human body. Dancers must overcome physical stress from years of intense training, competitive stress during countless auditions, stress associated with maintaining the necessary body shape, stress coping with an injury, and the stress to surpass oneself artistically and skilfully.

Performance nerves, job anxiety, low pay, late nights, immense fatigue, no pension scheme, and with no financial safety net should a dancer become injured; I believe it is a massive accomplishment for any dancer to succeed within this performing art.

The Fit to Dance 2 (Laws, H. 2005) survey found that psychological problems were experienced more often than physical injury, with 92% of dancers experiencing at least one psychological issue within the last 12 months, and 85% experiencing more than one.

The survey defined the following as a psychological problem: stress, tension and anxiety, depression, low self-confidence, performance pressures, eating problems, tiredness, and burnout (Laws, H. 2005).

The most frequently cited psychological issue was ‘tension with people’, followed closely by ‘constant tiredness’, ‘low self-confidence’ and ‘general anxiety’; all of which over 50% of dancers said they had experienced within the last 12 months (Laws, H. 2005).

Stress was also a significant concern amongst the third-year Laban students, with 17.2% of students feeling stressed every day, 31.4% every few days, 31.4% once a week, 20% once a month and 0% of students never feeling stressed (Third Year survey, 2011).

Stress and It’s Affect on the Body

When the body is stressed the adrenal glands release cortisol into the bloodstream, forcing the body into a state of heightened alertness, often referred to as the ‘fight or flight’ response (NHS, 2011). Dancers can find this response useful for performances; however, if the body is in a constant state of alertness for prolonged periods of time, cortisol can have a damaging effect on the body.

Prolonged levels of cortisol can lower the body’s immune system, increase blood pressure, alter thyroid function, disrupt menstrual function, and be detrimental to bone health (Wilson, J.L. 2002).

Cortisol activates nearly all biochemical pathways involved in bone re-absorption (Wilson, J.L. 2002). Specifically, it inhibits osteoblast activity by suppressing the production of androgens which are used to rebuild bone, thereby slowing the body’s natural repair response. Cortisol also increases the activity of osteoclasts, which complement the function of androgens by allowing the dead bone to be reabsorbed (Wilson, J.L. 2002).

Furthermore, cortisol decreases mineral absorption in the gut and increases the excretion of calcium from the kidneys, so the calcium and magnesium needed for bone formation will be less readily available, as are the mechanisms by which it occurs (Laker, M. 2008).

The Female Athlete Triad: Overtraining Syndrome

If dancers regularly push their body beyond its limits and do not receive adequate rest to compensate, the intense physical stress can lead to Overtraining Syndrome (training beyond the body’s ability to recover) (Quinn, E. 2010 as cited in Blakey, P. 2008).

Dancers are highly disciplined individuals, and it is exceptionally motivated overachievers that are most prone to overtraining and burnout (Mastin, Z. 2009). The idea that ‘the more you put in, the more you get out’ is not necessarily true. Lack of rest days, little sleep and an overloaded physical schedule can all cause Overtraining Syndrome leading to injuries and ill health (Brinson, P. 1991).

Overtraining Syndrome is characterised by fatigue, insomnia, decreased immunity, increased incidence of injuries, a sudden drop in performance and a decrease in training capacity/intensity (please see the Appendix – Table 4 for a full list of symptoms).

How Important is Sleep?

The optimum form of rest is sleep making it very significant to dancers’ all-round health and recovery (Mastin, V. 2009). Lack of rest days or relaxation from a busy working schedule, could increase cortisol levels and disrupt sleep (Koutedakis, S. 1999).

The Fit to Dance 2 (Laws, H. 2005) survey reported that on average dance students received 7.37 hours of sleep a night, but felt they needed 8.71. Professional dancers said they received 7.52 hours of sleep a night, but felt they needed 8.31.

It is recommended that the average population receive at least eight hours of sleep a night (NHS, 2011), with dancers and athletes more than eight, due to the increased physical demands on their bodies. With this in mind, I asked the third-year students how regularly they were sleeping for eight hours or more.

The Third-Year survey indicated that 14.3% of students received eight hours of sleep every day, 42.9% managed eight hours every few days, 28.5% slept eight hours once a week, 8.6% once a month and 5.7% never sleeping eight hours. This data means that 85% of third-year dance students surveyed are not receiving the recommended minimum of eight hours of sleep per night (NHS, 2011); or what the more extensive survey of dancers determined as the necessary amount.

Rest and Recovery

The adverse effects of a sleep deficit can exacerbate if too little time is taken out of training to recover. In the Fit to Dance 2 (Laws, H. 2005) survey, both students and professionals had an average of 1.3 days off per week, 44% only 0.5-1 day off, and 11% reporting no days off.

The Third-Year survey reported that 68.6% of students exercised outside of conservatory-scheduled dance classes, rehearsals or performances. Of those partaking in external physical activity, 58.3% participated in an extra three hours of exercise per week, 16.7% five hours per week, 8.3% ten hours per week, and 16.7% did more than ten hours of unscheduled physical activity per week that was unrelated to their course of study.

The human body needs time to rest, sleep, relax and recover. Training through injury, fatigue and illness can quickly lead to Overtraining Syndrome (Kouteedakis, Y. & Sharp, C.N.C 1999). The Fit to Dance 2 (Laws, H. 2005) survey backs up this research, reporting that dancers who had experienced stress due to external factors were more likely to have joint and shoulder injuries. The study also indicated that those who had suffered from constant tiredness were more likely to have muscle and lower back ailments.

Therefore, based on the findings from the Fit to Dance 2 (Laws, H. 2005) survey, the third-year dancer students who experience stress, could be more likely to suffer an injury.

Overtraining Syndrome can also lead to a negative caloric balance which, as we have seen, can cause low oestrogen levels, a decrease in bone health, and disruption to the menstrual cycle; the full spectrum of health conditions relating to the Female Athlete Triad.

Education and the Female Athlete Triad

Dance training usually, although not always, begins informally around the ages of 3-8 years. Acceptance into a professional dance company is also at a relatively young age, approximately 16-21 years-of-age (Taper, B. 1996).

The dance world has traditionally insisted on extreme dedication from its artists, requiring the pursuit of perfection to be the single focus activity in a young person’s life. A dancers day is usually very repetitive: wake up, class, lecture, class, theory, class, rehearsal, go home, sleep, wake up, and return to the dance school to start the day over again (Kent, A. 1984).

Socialising after school hours or staying out late can make an early morning class challenging, causing many dancers to become introverted or socialise only within their dance circle, and within training hours (Taper, B. 1996).

Dancers should consider developing other interests outside of dance, not only to further enrich their lives but for social, artistic and emotional growth. External interests are also valuable in case of injury which can jeopardise a dancer’s career and exclude them from their current social circle.

Due to the study of dance beginning at a relatively young age, dancers can be highly vulnerable during their training and artistic careers, therefore, dance teachers and choreographers have a responsibility to their students’ emotional wellbeing (Evens, J. 2010).

Dance teachers and choreographers are responsible for young people whose personalities are not yet fully formed, who are impressionable, and whose confidence and self-perception can be easily damaged (Itzac, P.B. 1997).

It is my opinion that education is a crucial factor in a dancer’s physical and psychological health. Educating dancers about nutrition could allow students to realise the importance of their own food choices and encourage them to make empowered, positive decisions. Furthermore, teaching dance students about health and fitness could inspire them to gain a sense of independence, self-sufficiency and control over their bodies (Evens, J. 2010).

Where do Dancers get their Dietary Advice?

Unfortunately, communication regarding health and nutrition in the dance world can be much like a game of Chinese whispers. Information can be communicated primarily through word of mouth, and much of it can get disordered (Mastin, Z. 2009).

The Fit to Dance 2 (Laws, H. 2005) survey asked dancers where they received their dietary advice. From the results they obtained: 40% of dancers took information from the media or literature, 34% from their dance company or school staff, 30% from friends, 14% from other sources (mainly parents and family), 14% from an accredited dietician and 11% from their GP.

With 70% of dancers taking advice from the media, literature or friends, those who put into practice the advice they receive can come into difficulty as the information has not come from a reliable source, i.e. an accredited dietician, nutritionist or doctor.

Many diet books, television programmes, and articles on weight loss diets are geared towards the general population, not towards dancers who need guidelines tailored specifically towards their unique needs and problems.

In fact, most weight loss diets are designed for those who are overweight (or more accurately those with a high body fat percentage) and who are actively trying to achieve a healthy body composition (Mastin, Z. 2009).

Misinformation could lead many dancers to exist on low-fat diets, in an attempt to achieve a low-fat body; but such restrictive diets can be devoid of essential fats which are necessary to assist with the absorption of specific nutrients (Larson-Meyer, D.E. 2007).

Fats and the Female Athlete Triad

Types of Body Fat

There are three types of body fat: essential fat, storage fat and sex-specific fat.

Essential fat makes up part of the bodies cell membranes, brain tissue, nerve sheaths, bone marrow and the fat surrounding the organs (Larson-Meyer, D.E. 2007). The primary purpose of essential fat is to provide insulation, protection and cushioning against physical damage. In a healthy person, essential fat should account for 3% of their total body weight (Bean, A. 2009).

The second component of body fat is storage fat which acts as an energy reserve. Storage fat takes the form of adipose (fat) cells under the skin (also called subcutaneous fat) and around the organs (intra-abdominal fat) which the body can burn during aerobic activity (Bean, A. 2009).

Women also have a third requirement for body fat called sex-specific fat. Stored mostly in the hips and breasts, this type of fat is involved in oestrogen production, as well as the conversion of inactive oestrogen into its active form to ensure healthy hormonal balance and menstrual function (Bean, A. 2009). Sex-specific fat can account for another 5-9% of a woman’s total body weight (Bean, A. 2009).

Fat Intake – Guidelines

The International Conference on Foods, Nutrition and Sports Performance (1991) recommends a fat intake of 15-30% of total caloric intake for sports people. This recommendation is in line with The World Health Organisation’s guidance of 30% total caloric intake, about 70g for women (as cited in Bean, A. 2009).

Consuming too much fat can create a build-up of non-essential, storage fat (Mastin, Z. 2009). Excess body weight in the form of non-essential fat is a distinct disadvantage to dancers as it can reduce the height of jumps, reduce speed, and reduce overall technical efficiency (Chmelar, R.D. & Fitt, S.S. 1990).

The optimum body fat percentage associated with optimal health for the average woman is between 18 and 25% (NHS, 2011). However, the individual dancer has an optimum fat range at which their performance improves yet their health does not suffer.

Dancers should listen carefully to their bodies when weighing up artistic needs against health imperatives. No less than 12% body fat is recommended for women because this can lead to many serious health complications (Bean, A. 2009).

What is Fat and Why Do We Need It?

Dancers need to be educated about their food choices so they can eat the right types of fat; as opposed to the perhaps traditional dieting attitude that sees all fat as bad. Types of beneficial fats include monounsaturated fats, polyunsaturated fats and essential fatty acids (Mastin, Z. 2009). Fats that are detrimental to health include saturated and trans fats (Mastin, Z. 2009).

Saturated fat is solid at room temperature and usually derived from animal sources, e.g. lard, and butter (Larson-Meyer, E.N. 2007). The NHS recommends that women eat no more than 20g of saturated fat a day, as the ingestion of which can inflate cholesterol levels and increase the risk of heart disease.

Monounsaturated fats are usually liquid at room temperature. The most abundant sources of monounsaturated fats include olive, rapeseed, groundnut, hazelnut and almond oils, avocados, olives, nuts and seeds (Mastin, Z. 2009). Monounsaturated fats are beneficial to the body in small amounts and can reduce low-density lipoprotein cholesterol (bad cholesterol) without affecting the high-density lipoprotein cholesterol (good cholesterol).

Polyunsaturated fat is also liquid at room temperature and usually found in vegetable, sunflower, corn and soy oils (Mastin, Z. 2009). Like monounsaturated fats, polyunsaturated fats can also decrease LDL (bad) cholesterol. However, as it does this, it also lowers HDL (good) cholesterol, and so it is not as beneficial to health as monounsaturated fats (Larson-Meyer, E.N. 2007).

What is Cholesterol?

Cholesterol is a type of lipid (fat) that is produced by the liver and found in certain foods (NHS, 2007). Cholesterol must travel through the bloodstream to get to the various parts of the body; however, it cannot move alone. Cholesterol has to combine with specific proteins to make lipoproteins which help to transport it through the circulatory system (Laker, M. 2008).

The two most important types of lipoproteins are low-density lipoproteins (bad cholesterol) and high-density lipoproteins (good cholesterol) (Larson-Meyer, E.N. 2007).

Found in foods from animal sources such as eggs, meats, and whole-fat dairy products, LDL cholesterol (otherwise known as bad cholesterol) can clog arteries and keep blood from flowing efficiently through the body (Laker, M. 2008).

HDL cholesterol, on the other hand, is a beneficial form of cholesterol as it can remove the LDL cholesterol from the blood vessels, and carry it back to the liver where it can be processed and removed from the body (Laker, M. 2008). HDL cholesterol is also needed to make vitamin D, create several hormones, build cell walls, and create bile salts that aid fat digestion. Therefore, it could be beneficial for dancers to minimise their intake of LDL cholesterol, and maximise their intake of HDL cholesterol to maintain the health of their circulatory system. Dancers can maximise their HDL cholesterol by maintaining a healthy and active lifestyle and increasing their intake of monounsaturated fatty acids.

Essential Fatty Acids

Essential fatty acids (EFAs) are long-chain polyunsaturated fatty acids. EFA’s are necessary fats that humans cannot synthesise, and therefore must obtain through their diet (Mastin, Z. 2009).

Derived from linolenic, linoleic, and oleic acids, there are two types of essential fatty acids: Omega-3 and Omega-6. Omega-9 is also necessary, yet classed as non-essential because the body can manufacture it on its own, provided the essential EFAs are present (Bean, A. 2009).

Rich sources of EFA’s include oily fish such as mackerel, salmon and sardines, linseeds (flaxseeds), linseed (flax) oil, pumpkin seeds, walnuts, almonds, rapeseed oil and soya beans (Mastin, Z. 2009).

Omega-3 fatty acids, in particular, can be extremely beneficial to dancers. Studies have shown that Omega-3 fatty acids can lead to improvements in strength and endurance by enhancing aerobic metabolism (Brilla and Landerholm, 1990; Bucci 1993 as cited in Larson-Meyer, D.E. 2007).

The benefits of Omega-3 fatty acids can include:

  • Improved delivery of oxygen and nutrients to cells because of reduced blood viscosity.
  • More flexibility in red blood cell membranes with improved oxygen delivery.
  • An increase in energy levels and stamina.
  • Anti-inflammatory properties.
  • A reduction of inflammation caused by over-training (Vegan Society, 2011).

Trans/Hydrogenated Fats

Both dancers and the general public should not consume trans fats, also labelled: hydrogenated fats, partially hydrogenated fats or shortenings (NHS, 2011). Minute amounts of trans fatty acids are found naturally in meat and dairy products, but most derive from processed fats and formed during a process called hydrogenation (American Heart Association, 2010).

Hydrogenation is a process whereby the chemical structure a fat is broken down and combined with hydrogen (American Heart Association, 2010).

Trans or hydrogenated fats can mainly be found in processed foods because they add bulk to products, have a neutral flavour, give products a long shelf life and are cheap to make (Lueck, T.J 2006).

These fats have no nutritional value, but have a large number negative attributes including significant and serious lowering of HDL cholesterol, with a substantial and severe increase in LDL cholesterol which can make arteries more rigid.

Trans fats can also cause significant clogging of arteries, insulin resistance, cause or contribute to type 2 diabetes, and can cause or contribute to other serious health problems (NHS, 2011). Therefore dancers should stay away from trans fats to maintain the health of their arteries and the overall health of their body.

The Female Athlete Triad: Vegetarians and Vegans

Dancers need an adequate intake of calories to absorb the optimum levels of nutrients, vitamins and minerals necessary for good health. Dancers should also make educated food choices. By eating foods that are rich in calcium, magnesium or fortified with vitamin D, dancer’s can help to improve or maintain their bone health. Dancers should also eat foods high in essential fatty acids which are necessary for a healthy hormone balance and a regular menstrual cycle.

It is also vital that dancers eat a wide variety of healthy foods to avoid ill health. Some dancers may remove whole food groups from their diet for either moral or religious reasons, or in an attempt to control caloric intake. Fit to Dance? (Dr Brinson, P & Dick, F. 1996) reported that 30-40% of dancers surveyed were vegetarian. A vegetarian diet is one that cuts out red meat, poultry and seafood.

Fit to Dance 2 (Laws, H. 2005) however, only found that 9% of dancers were vegetarian and a further 0.6% vegan (who also forgo dairy, eggs, honey and any product with animal derivatives). Albeit, one could argue that the survey was not detailed enough as it does not state the percentage of dancers who abstain from dairy and all grains (the popular paleo diet), or the percentage of dancers who abstain from red meat and poultry but still eat fish (Pescatarians).

Although the rate of vegetarian dancers has decreased since the ‘Fit to Dance?’ survey (Dr Brinson, P. & Dick, F. 1996), it is still above the national average. The 2006 Mintel Survey reported that 6% of the British population were vegetarian, and a further 10% of the population did not eat red meat. The Third-Year survey found that 14.2% of dancers were vegetarian, 5.7% vegan and 22.9% abstained from red meat.

As there is a relatively high percentage of dancers that are vegetarian, when compared with the national average, I believe it is essential that they have a basic understanding of good nutrition. Knowledge of key essential nutrients could help to ensure that their vegetarian or vegan diet can encompass the full range of nutrients needed for optimal health.

Iron Deficiency

Up to 80% of female athletes could be iron deficient (Bean, A. 2009). Reasons for the deficiency can include: existing on a low-calorie diet (fewer than 1500 kcal a day), a restrictive diet (e.g. vegetarian or vegan diets), or lack of nutritional knowledge (Bean, A. 2009).

Low levels of iron in the blood can lead to anaemia (NHS, 2011). The main symptoms of iron-deficiency anaemia are tiredness, fatigue, irritability, headaches, light-headedness, and above normal breathlessness during exercise. In extreme cases, the sufferers may also experience pale skin, brittle nails, chest pain, a coldness in the hands or feet, or an irregular heartbeat (Larson-Meyer, D.D. 2007).

Female dancers should aim to consume at least the recommended daily allowance (RDA) of 14.8mg of iron a day (NHS, 2007). If a dancer restricts to a vegetarian or vegan diet, please see the Appendix – Table 5 for plant foods with a high iron content.

Vitamin B12

Vegetarian and vegan dancers can be susceptible to a vitamin B12 deficiency because it is not found naturally in any plant-based sources (Larson-Meyer, D.E. 2007).

Vitamin B12 plays a vital role in our bodies’ cell function, blood formation and nervous system (Larson-Meyer, D.E. 2007). The only reliable vegan sources of vitamin B12, other than B12 supplements, are foods fortified with the vitamin. These can include plant milks, soy products and some breakfast cereals.

Symptoms of a vitamin B12 deficiency usually take five years or more to develop in adults (Office of Dietary Supplements, 2011). Symptoms can include:

  • Loss of energy
  • Tingling
  • Numbness
  • Reduced sensitivity to pain or pressure
  • Blurred vision
  • Abnormal gait
  • Sore tongue
  • Poor memory
  • Confusion
  • Hallucinations
  • Personality changes

An extremely low vitamin B12 intake can also cause anaemia, nervous system damage, heart disease or pregnancy complications (Wasserman, D. & Mangels, R. 2006). Although required in amounts smaller than any other known vitamin, adults should still aim to have at least the RDA of 2.4mcg of vitamin B12 in their diet. (Office of Dietary Supplements, 2011)

The best way to avoid a vitamin B12, iron, magnesium, vitamin D or calcium deficiency is to eat a well balanced, healthy diet which includes a wide variety of foods. Alongside a broad spectrum diet, dancers could also take nutritional supplements to ensure they are receiving the recommended daily allowance of necessary vitamins and minerals.

The Fit to Dance 2 (Laws, H. 2005) survey reported that 63% of dancers took nutritional supplements, of which: 56% consumed a multi-vitamin, 20% supplemented with iron tablets, 20% consumed calcium tablets, and 16% consumed other nutritional supplements.

The Third-Year survey reported that 60% of dancers took a nutritional supplement, of which: 33% consumed a supplement designed to support healthy bones, 11.4% consumed an iron supplement, and 55.6% ingested another form of vitamin/mineral supplement.

These results show that perhaps dancers are more health conscious, or more aware of the needs of their bodies when compared to the average population where only 54% of people take nutritional supplements regularly (Office of Dietary Supplements, 2011).

To understand these findings further, I would need to ask additional questions. However, I am hesitant to do this as it could lead to the topic of ‘dancers health in regards to supplementation’ rather than in relation to the Female Athlete Triad.

It is worth noting that some of the ailments associated with anaemia and a vitamin B12 deficiency, such as tiredness, fatigue and poor memory, can also be associated with stress and many other illnesses. If a dancer has overloaded their schedule or developed Overtraining Syndrome, they may also experience these symptoms.

Dancers work with their body day in, day out, and are often highly skilled at understanding when something is not right. If a dancer does feel an unexplained drop in their usual performance or feel excessively tired despite decreasing their training schedule, increasing their rest time, and adjusting their dietary intake, they should consider consulting their local GP who can advise on any relevant diagnosis and treatment (Mastin, V. 2009).

The Female Athlete Triad: Bone Health and the Body’s pH

A vegetarian diet, or one which limits red meat, may be beneficial to bone health because of its effect on the body’s pH balance (Young, R. 2009).

The potential of hydrogen, or pH, is a measure of the acidity or alkalinity of a solution, in this case, the body’s fluids and tissues. Measured on a scale of 0 to 14, the lower the pH, the more acidic the solution, while the higher the pH, the more alkaline (or base) the solution.

A pH of 7 is neither acidic nor alkaline and is known as neutral (Young, R. 2009). A healthy pH range for the human body ranges from around 6.8 – 7.8. However, a pH balance just above 7.35-7.5 (slightly alkaline) can be beneficial to our health as our enzymatic, immunologic, and repair mechanisms all function their best in a slightly alkaline environment (Young, R. 2009).

Exercise and pH

Despite our bodies preferring an alkaline pH, our biochemical functions such as the metabolism of food, and many other fundamental life processes such as immune and stress responses, all generate substantial amounts of acidic by-products (Brown, S.E. 2009). Anaerobic exercise can produce an acidic by-product known as lactic acid, or an excess of hydrogen ions to be precise (Brown, S.E. 2009).

Anaerobic exercise is short-lasting, high-intensity activity, where the body’s demand for oxygen exceeds the oxygen supply available. Anaerobic exercise relies on energy sources such as ATP that are stored within the muscles, and is not dependent on oxygen for energy. Dancing is a highly anaerobic exercise because it is a stop-start activity in which the muscles, particularly the core and legs, are required for short but very intense bursts of energy (Blakey, P. 2008).

Food and pH

Food has a significant role in determining the pH of the body (Vasey, C. 2006). Proteins are one of the highest acid-producing foods, especially red meats such as steak, bacon, sausage, hamburgers and beef. Other acid producing foods include:

  • Refined foods such as white flour
  • Corn syrup
  • Refined sugar
  • Caffeine
  • Food and beverages with a high sulphur content
  • Alcohol
  • Artificial chemical sweeteners (Vasey, C.N.D 2006).

The body relies on the kidneys to excrete any harmful acidic waste products and to maintain a neutral pH. If a poor diet increases acidity faster than the kidneys can neutralise it, they must compensate by utilising the body’s alkali reserves. Minerals from tissues such as the bones are used to offset the increasingly acidic environment, thereby robbing them of essential minerals such as calcium. This process can, in turn, cause the demineralisation of an otherwise healthy skeleton and lead to a reduction in bone health; which, once again, can pull dancers into one of the corners of the Female Athlete Triad (Brown, S.E. 2009).

A diet high in alkaline-forming foods such as fruits, vegetables, nuts and seeds can help to achieve a more alkaline pH balance. Alkaline forming foods can accept hydrogen ions and thus reduce the acidic load on the kidneys (Baroody, T.A. 2001).

It is worth noting that many foods which are highly acidic in their natural form such as lemons and limes, once digested, have end products that are alkaline. Likewise, meat will test alkaline before digestion, but it can leave a very acidic residue in the body (Young, R. 2009).

Maintaining a slightly alkaline pH could be beneficial for dancers as it can allow cells to discard waste and toxins easier (Young, R. 2009). The body’s tissues are also able to hold more oxygen when compared to an acidic environment, which could help to improve a dancer’s stamina. (Baroody, T.A. 2001).

Plus, the alkaline diet could also help to support strong bones and reduce a dancers chance of developing a premature reduction in bone density, an element of the Female Athlete Triad.

 Conclusion: Dancers & The Female Athlete Triad

Support Available to Dancers

To end my research, I thought it relevant to investigate the information and support available to dancers in three specific areas: health and nutrition, stress and other psychological problems, and injury prevention.

The Third-Year survey found that 54.3% of students felt they had not received sufficient information about nutrition, and 91.4% said they had not received adequate information about how to deal with stress while training at Laban.

Conversely, 60% of third-year students felt they had received sufficient information about injury prevention and treatment while training at Laban, however that still leaves 40% wanting.

Laban, as do many conservatoires, offers specialist health services within its’ school such as physiotherapists, acupuncturists, dieticians and massage therapists. However, these are generally outside services and are usually not free to access for dance students.

I believe it is important for dancers to receive specialist health care. A small health complaint that may prove an annoyance for a member of the public could potentially affect a dancer tenfold because of the exceptional demands they place upon their bodies.

Some professional dance companies do offer free health care with in-house dieticians and physiotherapists. (Laws, H. 2005). However, access to such help for dance students, or professional dancers within small-scale dance companies is unlikely to ever be a reality, especially with the recent government funding cuts to the arts council (Arts Council, 2011).

Nevertheless, dance establishments should perhaps acknowledge that stress is a particular concern for dancers (Laws, H. 2005). The Third-Year survey found that 80% of third-year Laban students felt stressed at least once a week and 17.2% of students felt stressed every day.

Stress can potentially cause many health concerns as it increases cortisol levels within the body which can affect hormones, menstruation and bone health. Dancers’ careers depend upon the health of their bodies, so it is particularly relevant for dancers to seek out further understanding of psychological health which may help them to maintain a long and healthy career.

Laban has now implemented a new 1st-year module called ‘Physical Awareness and Development’ which informs students about nutrition, stress, menstruation and overall health and wellbeing. It would be interesting to circulate the Third-Year survey again, once these first-year students reach their final year, to see if there is any difference in the data collected. The results could perhaps give some indication as to whether the ‘Physical Awareness and Development’ module has made a difference to students’ knowledge and understanding of their physical and psychological health.

Summary: how can Dancer’s avoid the Female Athlete Triad?

To perform professionally a dancer must not only possess the passion, drive, and determination to succeed, but they must train and rehearse tirelessly to perfect technique, skill and stamina.

Unlike athletes, who have specific seasons for which they must be in top physical condition, dancers have to maintain a peak level of fitness all year round. It is for this reason that dancers should maintain a sustainable fitness and diet regime.

All three health ailments of the Female Athlete Triad: amenorrhea, energy deficit and a premature reduction in bone health, can be significantly improved or prevented by achieving a balance in caloric intake and expenditure. More specifically, to avoid the ailments of Female Athlete Triad, dancers could consider the suggestions of healthy practice that I have outlined throughout this essay. To summarise:

To maintain or achieve optimal bone health dancers should:

  • Ensure an adequate intake of calories, taking care not to fall into a calorie deficit.
  • Ensure an adequate intake of calcium, vitamin D and magnesium.
  • Achieve moderate exposure to sunlight.
  • Ensure adequate sleep and rest periods to protect the body and mind from fatigue and over-training.
  • Eat a wide-spectrum, balanced diet full of plant-based foods to ensure a healthy pH balance.
  • Take steps to establish optimal menstrual health and positive psychological well-being.

To maintain or achieve optimal menstrual health dancers should:

  • Ensure an adequate intake of calories, taking care not to fall into a calorie deficit.
  • Ensure an adequate intake of essential fatty acids and minimal consumption of saturated and trans fat.
  • Vegetarian and vegan dancers should pay particular attention to achieving their RDA of iron and vitamin B12.
  • Ensure a healthy body fat percentage: 12% is vital, 18-25% is recommended.
  • Ensure adequate sleep and rest periods to protect the body and mind from fatigue and over-training.
  • Take steps to establish optimal bone health and positive psychological well-being.

To maintain or achieve a positive psychological well-being, dancer’s should:

  • Ensure adequate sleep and rest periods to protect the body and mind from fatigue and over-training.
  • Develop interests outside of dance.
  • Expand their social circle to encompass friends outside of their dance peers.
  • Read appropriate books to ensure healthy food choices.
  • Register with a well-informed GP

Ultimately dancers must find points of balance between body image and nutritional imperatives; between what is aesthetically pleasing and what is anatomically possible. Keeping the causal elements of the Female Athlete Triad in check could help to prevent a negative caloric intake, menstrual irregularities or amenorrhea, and a decline in bone health or osteoporosis.


Table 1

Symptoms of Anorexia Nervosa:

  • Extreme weight loss
  • Stunted growth in pre-adolescents
  • Constipation and abdominal pains
  • Dizzy spells and feeling faint
  • Bloated stomach, puffy face and ankles
  • Downy hair on the body
  • Hair loss
  • Poor blood circulation and feeling cold
  • Dry, rough, or discoloured skin
  • Absence of periods (amenorrhea)
  • Lack of interest in sex
  • Loss of bone mass and eventually osteoporosis (brittle bones)
  • Intense fear of gaining weight
  • An obsessive interest in what others are eating
  • Distorted perception of body shape or weight
  • Changes in personality and mood swings

Symptoms of Bulimia Nervosa:

  • Frequent weight changes
  • A sore throat, tooth decay and bad breath caused by excessive vomiting
  • Swollen salivary glands making the face rounder
  • Poor skin condition
  • Possible hair loss
  • Irregular periods (amenorrhea)
  • Loss of interest in sex
  • Lethargy and tiredness
  • Increased risk of heart problems and problems with other internal organs
  • Distorted perception of body weight and shape
  • Emotional behaviour and mood swings
  • Anxiety and depression; low self-esteem, shame and guilt
  • Isolation – feeling helpless and lonely

(Data from B-EAT, 2010.)

Table 2

Dancers can obtain calcium in their diet by eating foods with a high calcium content. These include:

Food Serving Size (average) Calcium (mg)
Milk, semi-skimmed glass, 200 ml 240
Milk skimmed glass, 200 ml 244
Soy drink, calcium enriched glass, 200 ml 178
Yoghurts and Cream    
Yoghurt, low-fat, fruit pot, 150 g 210
Yoghurt, low-fat, plain pot, 150 g 243
Commercial soy yogurt, plain* 170g 80-250
Edam portion, 40 g 318
Feta portion, 40 g 144
Cheddar medium chunk, 40 g 296
Cottage small pot, 112 g 142
Mozzarella, fresh portion, 56 g 203
Parmesan, fresh portion, 30 g 308
Curly Kale serving, 95 g 143
Collard greens, cooked* 1 cup 357
Turnip greens, cooked* 1 cup 249
Kale, cooked* 1 cup 179
Bok choy, cooked* 1 cup 158
Mustard greens, cooked* 1 cup 152
Broccoli, cooked* 1 cup   94
Green/French beans serving, 90 g 50
Tofu, soy bean, steamed 100 g 510
Tempeh* 1 cup 215
Soybeans, cooked* 1 cup 175
Haricot bean @ 100g 180
Almond butter* 2 Tbsp 86
Tahini* 2 Tbsp 128
Almonds 12 whole, 26 g 62
Sesame seeds 1 tablespoon, 12 g 80
Tahini Paste 1 heaped teaspoon, 19 g 129
Pasta, plain, cooked portion, 230 g 85
Sardines in oil, tinned portion, 100 g 500
Whitebait, fried portion, 80 g 688
Salmon, tinned average portion, 100 g 91
Fish paste small jar, 35 g 98
Apricots, raw, no stone 2 fruit, 80 g 58
Figs, ready to eat 2 fruit, 110 g 253
Orange peeled, 160 g 75

Data from the National Osteoporosis Society and the Vegan Society, 2011.

Table 3

The recommended daily allowance for calcium, magnesium and vitamin D for optimum bone health are displayed in the table below:


RDA (Per Day)

19-50 Yrs

>50 Yrs

19-50 Yrs

>50 Yrs

Vitamin D  #1

5* µg

10* µg

5* µg

10* µg


1000* mg


1000* mg








Vitamin D: 1 µg = 1 mcg = 1 microgram = 1/1,000,000 of a gram

Calcium & Magnesium: 1 mg = 1 milligram = 1/1,000 of a gram

#1 As cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D.

* indicate AI (Adequate Intake) figures taken from the Dietary Reference Intakes (DRI).

Data from the Office of Dietary Supplements, 2011.

Table 4

Symptoms of Overtraining Syndrome include:

    • Washed-out feeling, tired, drained, lack of energy
    • Mild leg soreness, general aches and pains
    • Pain in muscles and joints
    • Sudden drop in performance
    • Insomnia
    • Headaches
    • Decreased immunity (increased number of colds, and sore throats)
    • Decrease in training capacity / intensity
    • Moodiness and irritability
    • Depression
    • Loss of enthusiasm for the sport
    • Decreased appetite
    • Increased incidence of injuries.
  • A compulsive need to exercise

Data from Quinn, E. 2010 cited in Blakey, P. 2008.

Table 5

Plant foods with a high iron content include: 

Food Amount Iron (mg)
Soybeans, cooked 1 cup 8.8
Blackstrap molasses 2 Tbsp 7.2
Lentils, cooked 1 cup 6.6
Spinach, cooked 1 cup 6.4
Quinoa, cooked 1 cup 6.3
Tofu 4 ounces 6.0
Bagel, enriched 3 ounces 5.2
Tempeh 1 cup 4.8
Lima beans, cooked 1 cup 4.4
Swiss chard, cooked 1 cup 4.0
Black beans, cooked 1 cup 3.6
Pinto beans, cooked 1 cup 3.5
Turnip greens, cooked 1 cup 3.2
Chickpeas, cooked 1 cup 3.2
Potato 1 large 3.2
Kidney beans, cooked 1 cup 3.0
Prune juice 8 ounces 3.0

Data from the Vegan Society, 2011


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