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Anorexia and Dance. Looking for the perfect body in dance!

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Anorexia and Dance. Looking for the perfect body in dance!

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dance&education. (2018). Anorexia and Dance. Looking for the perfect body in dance!. [online] Available at: https://danceandeducation.com/anorexia-and-dance-looking-for-the-perfect-body-in-dance/ [Accessed 14 Dec. 2018].

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by Lauren O'Sullivan

As dancers we are constantly judging ourselves: spending hours day after day in tight-fitting clothing in front of a mirror and scrutinising how we look. Dancers are expected to have slim and toned bodies. It is seen as particularly important for females to be of a slight stature for the ease of pas de deux and partnering work. But what is the impact? "The average incidence of eating disorders in the white middle-class population is 1 in 100. In classical ballet, it is one in five" says Dr Michelle Warren, an eating disorder specialist.

However, the ideal dancer's physique hasn't always favoured the slim. A century ago, the ballets and dance works of the time were biased towards the story-telling and dramatic elements of dance and therefore softer, rounder, and more delicate features were desired. Yet as the 1920s brought with them the flapper dress, the 'androgynous body' became fashionable often describing females as 'waifs': with skinny, willowy limbs. Soon abstraction and a focus towards favouring line and shape, spear-headed by the choreographer George Balanchine, took hold and dancers with a slim physique were favoured. Previously lavish costumes became minimal leotards and therefore an aesthetic towards little or no body fat became the norm.

A dancer's world is one of control. "People attracted to dance may be looking for that kind of structure," says Marijeanne Liederbach, director of research and education at the Harkness Center for Dance Injuries in Manhattan. "Achieving a triple pirouette or 105 on the scale are tangible goals in a difficult world." Anorexia, or Anorexia Nervosa, is defined (by BEAT) as: "a serious mental illness where people keep their body weight low by dieting, vomiting, using laxatives or excessively exercising". This definition is characterised mainly by symptoms of the disease. However, what is interesting is that the dictionary definition for 'perfect' seems to draw eerily close parallels to how sufferers have described that they feel. Perfect is defined as: "conforming absolutely to the description or definition of an ideal type; excellent or complete beyond practical or theoretical improvement". Perfection is a term often used in dance and many dancers strive for the 'perfect physique', but this can quickly become destructive. Sufferers of Anorexia have a distorted image of themselves; they look in the mirror and see a fat person, when in actual fact the opposite is true.

The feeling of control, or rather loss of control, was one of the main concerns for Margherita Barbieri, a young dancer who battled with Anorexia for four years. She says, "my eating disorder had become my identity". She was moody, aggressive, verbally and physically violent, and obsessed over calorie counting and exercise: behaviours that surprised even her. Talking to Margi it is clear that the tough environment of the dance world was the trigger in allowing Anorexia to take hold: she describes it as, "your genetics load the eating disorder gun, but the environment pulls the trigger".

Unfortunately, after failing to be accepted into Senior Associates at The Royal Ballet School, she was 'reassured' that it was because of her physique rather than lack of technique. According to Margherita she was given remarks such as 'too muscular' and 'oversized' to describe her physique. To be told that your body is too muscular seems contradictory in a profession that demands an athlete's strength and muscular power. It leads us to the wrong way of thinking when it comes to a dancer's physique. Still, the trigger of the loaded gun had been pulled and it was quick-fire from then on. Just 4-5 weeks later on her 14th birthday Margi had already lost 5kg and had eaten only a 'handful of times'. Despite this she was accepted into Elmhurst School of Ballet and placed into an even more intense dance environment where she (or namely Anorexia) had total control over her eating habits.

For 3 years she simply 'went along' to therapy sessions. It was only when as a new 18 year old and an adult, that she really embraced therapy. She wanted to recover. Margherita realised that Anorexia had stopped her developing into a woman: she was an adult trapped in a 12 year old's body. Unable to complete her GCSE's and having to leave Elmhurst School of Ballet, she had no femininity, social life, dance career or independence to speak of. "When I remembered all those things of why I needed to recover, the process of recovery became something I wanted and it became a million times easier".

Margherita speaks of 'making the split' as one of the most important moments of realisation in her recovery. "Identify 'Ana' as being separate from you and discover yourself." In this way you make your own decisions, including the decision to recover and wave goodbye to 'Ana'. In recovery and when therapy ends, Margi says that finding a community on Instagram and creating the hashtag #margisarmy has helped with maintaining her healthy outlook. But how can we help? It is important, especially for dance companies and institutions, to be aware of a dancer's background so that appropriate support and safeguarding can be put in place. Mental health is a complicated homeostasis: any other things a sufferer is experiencing can exacerbate or improve their condition. It is important to conceptualise what is maintaining their eating disorder and work from there. What is underlying? Is it self-esteem, anxiety, depression? Preferably, prevention methods should be sought and applied before Anorexia can even take hold.

Rachel Bar, manager of Health and Research Initiatives at Canada's National Ballet School has conducted research specific to eating disorder prevention in athletes. She explains that recovery practices such as CBT have no more than a 50% success rate for Anorexia; it is a difficult disease to treat and so instead she urges the focus on prevention. Anorexia is often seen as the individuals' problem, but by instead implementing systematic changes to an environment as a whole it removes the trigger aspect of the loaded eating disorder gun. Examples of this: don't weigh the students; don't deliver personal corrections and comments.

Rachel has noticed evolution in a positive direction at Canada's National Ballet School since the time she was a student there, particularly by looking at the messaging and modelling for the students. It is paramount that dancers are getting proper nutrition education (at the calibre of professional athletes) and are ultimately living well so that long term health issues are minimised and sustainability of the body is maximised. Being a dancer has huge health benefits and it is often taken for granted. It is a positive thing that dancers are thoughtful about what they put into their bodies and how they use their bodies. Being so active and able can have great positive effects on body image and should be celebrated. Changing the mind-set is the key to prevention. "Eating disorders is still not a 'safe word', but it is in our interests to talk about mental health with our dancers" says Rachel. Dance is a stressful and competitive environment and we can't afford a world where it is still taboo to talk about eating disorders.
With thanks to:
Rachel Bar - her review paper is published in The European Journal of Sports Science, titled: Eating disorder prevention initiatives for athletes: A review

Margherita Barbieri has appeared on:

BBC Berkshire radio for 'Mental Health Awareness Week' (October 2016)

BBC South today morning news (20th October 2016) with a short video clip of herself talking about the dangers of anorexia

Daily Mail News online (14th October 2016): described her story and how self-esteem is the lead cause of anorexia

Follow her on Instagram: @alwaysmargi https://www.instagram.com/alwaysmargi/

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Anorexia and Dance. Looking for the perfect body in dance!

# data[].attributes.attachment_link.description
As dancers we are constantly judging ourselves: spending hours day after day in tight-fitting clothing in front of a mirror and scrutinising how we look. Dancers are expected to have slim and toned bodies. It is seen as particularly important for females to be of a slight stature for the ease of pas de deux and partnering work.

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Energy intake and energy expenditure of pre-professional female contemporary dancers

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Energy intake and energy expenditure of pre-professional female contemporary dancers

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Brown, M. (2017). Energy intake and energy expenditure of pre-professional female contemporary dancers. PLOS ONE, 12(2), p.e0171998.

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Meghan A. Brown,

Glyn Howatson,

Edel Quin,

Emma Redding,

Emma J. Stevenson

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Abstract

Many athletes in aesthetic and weight dependent sports are at risk of energy imbalance. However little is known about the exercise and eating behaviours of highly trained dance populations. This investigation sought to determine the energy intake and energy expenditure of pre-professional female contemporary dancers. Twenty-five female contemporary dance students completed the study. Over a 7-day period, including five week days (with scheduled dance training at a conservatoire) and two weekend days (with no scheduled dance training at the conservatoire), energy intake (self-reported weighed food diary and 24 h dietary recall) and expenditure (tri-axial accelerometry) were recorded. Mean daily energy intake and expenditure were different over the 7-day period ( P = 0.014) equating to an energy deficit of -356 ± 668 kcal·day⁻¹ (or -1.5 ± 2.8 MJ·day⁻¹). Energy expenditure was not different when comparing week and weekend days ( P = 0.297). However daily energy intake ( P = 0.002), energy availability ( P = 0.003), and energy balance ( P = 0.004) were lower during the week compared to the weekend, where energy balance became positive. The percentage contribution of macronutrients to total energy intake also differed; with higher fat ( P = 0.022) and alcohol ( P = 0.020), and lower carbohydrate ( P = 0.001) and a trend for lower protein ( P = 0.051) at the weekend. Energy balance and appropriate macronutrient intake are essential for maintaining the demands of training, performance and recovery. Whilst aesthetics are important, female contemporary dancers may be at risk of the numerous health and performance impairments associated with negative energy balance, particularly during periods of scheduled training.

Citation: Brown MA, Howatson G, Quin E, Redding E, Stevenson EJ (2017) Energy intake and energy expenditure of pre-professional female contemporary dancers. PLoS ONE 12(2): e0171998. https://doi.org/10.1371/journal.pone.0171998

Editor: Shin Yamazaki, University of Texas Southwestern Medical Center, UNITED STATES

Received: April 14, 2016; Accepted: January 30, 2017; Published: February 17, 2017

Copyright: © 2017 Brown et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are reported in the manuscript and in the supporting information (supplemental file S1 Dataset).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Dance is characterised as a moderate-high intensity, high skill, and predominantly intermittent activity [ 1]. These characteristics can vary, largely dependent on the style of dance and the capacity in which it is performed. The daily training schedule of a dancer is difficult to define but typically includes multiple training sessions, consisting of technique classes, rehearsals, and/or performances. The intensity and volume of exercise previously reported [ 2] can often be comparable to that of many elite athletes. In addition, since dance is principally an art form, it demands artistry and expression as well as physical and technical skill. As with many comparable aesthetic sports, while extremely low body mass and fat mass are known to negatively influence performance potential, low levels are nevertheless often considered to be advantageous for movement efficacy and artistic expression [ 3]. Indeed, maintaining a lean physique is thought to be an important aspect of dance fitness and a pre-requisite for success in the profession [ 4, 5]. As a result, a dichotomous issue arises in dance, whereby attaining the desired body composition can be a conflicting component in the pursuit of optimal performance.

The typical energy intake and energy expenditure of athletes has been explored in a number of sports, for instance in football [ 6, 7], taekwondo [ 8], and gymnastics [ 9]. However little is known about the nutritional intake and energy requirements of a dance population. This is surprising given that many athletes in aesthetic or weight dependent sports fail to compensate high energy demands with an adequate energy intake, and are at risk of numerous health and performance impairments associated with energy imbalance [ 10]. A recent review [ 1] has summarised the research investigating the energy demands of dance; largely through measurement of heart rate and oxygen cost. Though the authors conclude that the majority of investigations describe the energy demand to be moderate-high and intermittent, they noted a number of methodological limitations. Additionally, while these studies have identified energy demands in regards to a single movement, class, or performance, few have investigated these in nutritional contexts (i.e. kcal) or investigated the longer-term energy demands. Similarly, while a number of studies have sought to identify the dietary intakes of dancers, only a handful have looked at this in parallel with their physical activity or energy expenditure. The majority of these studies determined that dancers were (for the most part) in negative energy balance or very low energy availability [ 11- 19]. However, these investigations used a range of measurement techniques to estimate energy intake and energy expenditure, and whilst these techniques provide an indication of energy balance, their validity has been questioned; thus limiting the strength of their findings. For instance, heart rate monitoring is not a reliable indicator for estimations of energy demand given the intermittent nature of dance [ 20], and self-reported dietary records are limited by under/over eating and/or reporting [ 21]. Indeed, a study in female ballet dancers reported a mean bias to under-reporting of 667 kcal·day⁻¹ or 21% of energy intake when comparing four-day weighed food recording and energy expenditure via doubly labelled water [ 22].

Although the low body mass index and body fat levels frequently reported in dancers [ 23- 25] suggest that exercise and/or eating behaviours may be suboptimal, the inherent limitations in study designs render previous conclusions of poor nutritional intake and energy balance questionable. Moreover, the majority of research has been conducted in ballet and little has been published in modern/contemporary equivalents. Research has demonstrated differences in artistic and physical demands of ballet and contemporary styles [ 26] and body composition data reveal that ballet dancers tend to be the leanest [ 27]. Thus it is not appropriate to assume that the literature regarding one dance style is relevant and directly transferable to the other.

Whilst aesthetics are important, dancers are subject to similar physiological stressors as other athletes, and dietary habits can affect dance performance [ 28]. Consequently, dancers would benefit from a greater understanding of their energy requirements to support their training schedules. Therefore this investigation sought to determine the energy and macronutrient intake and energy expenditure of pre-professional female contemporary dancers during a 7-day period of full time training at a conservatoire. A secondary objective was to compare exercise and dietary behaviours during week days (Monday-Friday; where there was scheduled dance training), and during the weekend (Saturday and Sunday; where there was no scheduled dance training).

Materials and methods

Participants

Twenty-five pre-professional female undergraduate contemporary dance students attending a conservatoire volunteered for the study (mean ± SD age 21 ± 2 y; stature 167.4 ± 5.9 cm; mass 63.4 ± 6.9 kg; and BMI 22.6 ± 2.0 kg·m ²). Prior to recruitment, institutional ethical approval was granted by the Faculty of Health and Life Sciences Ethics Committee of Northumbria University in Newcastle upon Tyne, UK, and written informed consent obtained. Participants were free from injury and currently participating fully in all scheduled dance training ( n = 14, n = 8 and n = 3 in 1 st, 2 nd and 3 rd years, respectively of a three-year full-time undergraduate dance degree). All participants were instructed to maintain their typical dietary and physical activity behaviours throughout the study.

Questionnaires.

Participants completed the Healthier Dance Practice National Survey (also referred to as the Fit to Dance 2 national survey) [ 24] to provide a range of information including dance background as well as dietary history. A menstrual cycle questionnaire was completed to assess menstrual cycle history and, where possible, to identify menstrual cycle phase. In addition an 18 item, Three Factor, Eating Questionnaire (TFEQ-R18) [ 29] was used to assess three eating behaviours; restrained eating (conscious restriction of food intake in order to control body weight or to promote weight loss), uncontrolled eating (tendency to eat more than usual due to a loss of control over intake accompanied by subjective feelings of hunger), and emotional eating (inability to resist emotional cues). The degree of expression (0-100%) of each eating behaviour was determined by comparing absolute scores relative to the proportion of the highest possible scores; with higher values indicating more of the behaviour [ 30].

Body composition

Stature was measured to the nearest 1 mm (Seca, Birmingham, UK) and body mass to the nearest 0.1 kg (Seca, Birmingham, UK). As per the standard techniques of the International Society for the Advancement of Kinanthropometry (ISAK) [ 31], calibrated Harpenden calipers (CMS Weighing Equipment Ltd, London, UK) were used for skinfold measurement at 7 sites (biceps, triceps, subscapular, suprailiac, abdominal, front thigh and medial calf) and waist and hip circumference was measured to determine waist to hip ratio (W:H). All measurements were taken on the right side of the body and measured in duplicate and the mean of these was used for analysis. Participants were fasted for ≥ 2 hours prior to measurement and all measurements were taken by the same investigator who demonstrated good intra-rater reliability (TEM 4% and 2% for skinfold and circumference respectively). Percentage body fat (%BF) was estimated [ 32] from predicted body density [ 33]. This then allowed for estimation of fat and fat free mass (FFM).

Energy intake

Participants were asked to complete a 7-day weighed food diary to provide a detailed description of their food and fluid intake as well as supplement use if applicable. Participants were given comprehensive verbal and written instructions to report time of consumption, how food/fluid was cooked or prepared, brand names, and quantities; electronic portable scales were provided.

In addition each participant engaged in a 24-hour recall interview using the two-pass method [ 34] on each day of the data collection period to be cross-referenced with the food diary. This allowed the researcher to clarify ambiguous information and complete diary entries with missing data. Commercially available dietary analysis software (Nutritics Ltd, Ireland) was used to calculate total energy intake (TEI). A single researcher analysed the dietary data in order to avoid variability in interpretation of these data [ 35]. Where foods were not listed in the dietary database, the product label was consulted and the nutrient composition entered manually. All testing was conducted in free living conditions and no attempts were made to influence the diet of participants.

Energy expenditure

A tri-axial accelerometer (ActiGraph GT3X+, Florida, USA) was secured under clothing on the right hip. These were worn continuously (except during activities which would submerge the accelerometer in water) throughout the same 7-day period that was analysed for dietary intake. Sixty second sampling epochs were collected at a 30 Hz sample rate. The Freedson VM3 combination algorithm [ 36] was used to estimate physical activity energy expenditure from the vector magnitude counts per minute of the three axis.

While participants were asked to wear the accelerometer at all times (except for washing and swimming), accelerometers were removed periodically for legitimate reasons; for example discomfort during sleep or when it was prohibited during performances. To account for missing data during these times, participants were required to register all non-wear periods (the activity, time and duration) in a diary [ 37]. Appropriate Metabolic Equivalent (MET) values from the Compendium of Physical Activities [ 38] were assigned to these reported activities, and were subsequently corrected to account for individual variation [ 39]. Corrected METs were used to estimate non-wear energy expenditure [ 38].

Individual basal metabolic rate (BMR) [ 40] was also estimated as well as the thermic effect of food (TEF). The TEF varies among macronutrients and as applied in previous research [ 6], the following values were used to calculate the total TEF in the present study; 2.5, 7, and 27.5% of intake for lipids, carbohydrate and protein, respectively.

Statistical analysis

The physical activity energy expenditure estimated from the accelerometer and from non-wear activity, BMR, and TEF were combined to estimate individual total energy expenditure (TEE). The average TEE (kcal, MJ), TEI (kcal, MJ), energy balance (kcal, MJ), energy availability (kcal·kg FFM), and macronutrient contributions (% of TEI, g and g·kg⁻¹) were determined for three periods; the total 7-day data collection period, an average day of the week (scheduled dance training), and an average weekend day (no scheduled dance training). Three separate paired sample t-tests were used to compare energy intake and energy expenditure during each of the three periods (7-day period, day of the week, and weekend day) in order to assess energy balance. Paired sample t-tests were also conducted on all variables to compare an average week day and an average weekend day. Unless otherwise stated, 95% confidence intervals (95% CI) are presented for mean differences between an average week day and an average weekend day. Statistical software (IBM SPSS v22, IBM, USA) was used and significance accepted at the P ≤ 0.05 a priori.

Results

Participant demographics

Participant characteristics are presented in Table 1. The Healthier Dance Practice National Survey determined that 7 participants were either vegan, vegetarian or actively avoided red meat, 6 reported to not drink alcohol, 2 were following weight-reducing diets, and 9 reported past and/or current eating problems. Despite this, participants demonstrated average levels of cognitive restraint (49 ± 20%), uncontrolled eating (44 ± 14%), and emotional eating (47 ± 22%), as evidenced by the TFEQ-R18. Self-reported menstrual function determined that 14 were eumenorrheic, 9 were oligomenorrheic, and 2 could not be determined due to contraceptive hormone use. Contraceptive use varied; 16 were naturally menstruating, 6 were using combination pill/vaginal ring/contraceptive patch, 2 were using progesterone only pills/implant, 1 used an oestrogen replacement. There was difficulty in identifying the menstrual cycle phase in 7 participants (due to irregular cycles or particular contraceptive hormone use) and were therefore undetermined, while 9 were in the follicular phase, 4 in the luteal phase, and 5 in late luteal and early follicular phases during the 7-day data collection period.

Energy intake and energy expenditure

Total energy expenditure, and energy and macronutrient intakes are summarised in Table 2. Fig 1 illustrates the daily energy intake and expenditure of each individual across the 7-day period. Average energy intake was lower than energy expenditure during the 7-day period (2428 ± 458 kcal or 10.2 ± 1.9 MJ vs 2784 ± 569 kcal or 11.6 ± 2.4 MJ, P = 0.014, [95% CI: -632, -80]) equating to an energy deficit of -356 ± 668 kcal·day⁻¹ or -1.5 ± 2.8 MJ·day⁻¹. Energy expenditure did not differ when comparing week and weekend days (2719 ± 407 vs 2633 ± 574 kcal, P = 0.297, [95% CI: -80, 252]). However daily energy intake (2297 ± 492 vs 2756 ± 669 kcal, P = 0.002, [95% CI: -735, -183]) ( Fig 2A), energy availability (24 ± 10 vs 36 ± 21, kcal·kg FFM⁻¹, P = 0.003, [95% CI: -20, -4]), and energy balance (-422± 513 vs 123 ± 1007 kcal P = 0.004, [95% CI: -902, -187]) ( Fig 2B) were lower during the week (during scheduled dance training) compared to the weekend, where energy balance in fact became positive. Percentage contributions to TEI of carbohydrate, fat and alcohol differed between an average week day and an average weekend day; where carbohydrate was lower ( P = 0.001, [95% CI: -7, -2%]) but alcohol and fat intake was highest at the weekend ( P = 0.022, [95% CI: 1, 6%]; and P = 0.020 [95% CI: 1, 5%] respectively). There was a strong trend for a lower percentage of TEI derived from protein at the weekend ( P = 0.051, [95% CI: -1, 3%]) as illustrated in Fig 3.

*denotes group mean significant difference ( P < 0.05).

Energy intake (A) and energy balance (B) of participants (n = 25) during an average week day, and an average weekend day. The dashed line represents group mean over the total 7-day data collection period. Values presented as mean ± SD. *denotes group mean significant difference between week and weekend ( P < 0.05).

Values presented as mean ± SD. *denotes group mean significant difference ( P < 0.05) and †denotes a trend ( P = 0.051) towards significant difference between week and weekend.

Discussion

This study aimed to investigate the energy intake and expenditure of female contemporary dancers during a week of full-time, pre-professional dance training. The present investigation was the first to utilise accelerometry and the combined method of self-report weighed food diaries and dietary recall interview techniques. In agreement with the literature [ 11- 19], we found that on average dancers were in negative energy balance (17 of 25 participants) with a daily deficit of -356 ± 668 kcal (-1.5 ± 2.8 MJ).

While the average energy deficit observed in the present study is less than previously reported in some dance populations (recently a deficit of -2.35 ± 2.14 MJ·day⁻¹ in female ballet dancers [ 13]), chronic energy deficiency in athletes can lead to detriments in performance and subsequent recovery, and could compromise growth, maturation and health [ 10]. For instance potential issues arising from inadequate nutrition in dancers include insufficient peak bone mass and menstrual dysfunction [ 19, 41]. Female dancers (as with other athletic females) are recommended to maintain an energy availability above 30 kcal·kg FFM⁻¹·day⁻¹ to reduce the risk of disorders associated with energy imbalance [ 42]; the present study demonstrated this to be only 26 ± 13 kcal·kg FFM⁻¹·day⁻¹. Accordingly, contemporary dancers would benefit from a greater understanding of their energy requirements and certainly more education regarding appropriate nutritional strategies to support their training demands.

Carbohydrates play an essential role in exercise metabolism and the delay of fatigue, as well as contributing to the replenishment of glycogen stores during recovery. We observed intakes of 5.0 ± 1.0 g·kg⁻¹·day⁻¹ over the 7-day period, which narrowly achieve the 5-7 g·kg⁻¹·day⁻¹ recommended for athletic populations [ 43], and the average 4.8 g·kg⁻¹·day⁻¹ during the academic training week falls short of these guidelines. Given that much of contemporary training is typically of low-moderate intensity [ 26] conducive to beta-oxidation, this is likely sufficient. However during more high-intensity training and/or performance periods, dancers may consider increasing carbohydrate intake in order to meet the higher physiological demands [ 1]. Similarly, adequate protein intake and amino acid availability are necessary for the repair and remodelling of skeletal muscle and connective tissue after exercise [ 44], which is critical given that dance has been shown to induce muscle damage [ 45]. The average intakes of 1.3 ± 0.3 g·kg⁻¹·day⁻¹ in the current investigation meet recommendations of 1.2-1.7 g·kg⁻¹·day⁻¹ [ 46]. However, recent research demonstrates that muscle protein synthesis is down-regulated when in energy deficiency and as a result energy deficient individuals should consume high protein diets (1.6-2.4 g·kg⁻¹·day⁻¹) to restore muscle protein synthesis and attenuate proteolysis and skeletal muscle loss [ 47, 48]. This evidence suggests that intakes in this population are likely below optimal, particularly given that 7 of the 25 participants were vegan, vegetarian or actively avoided red meat. Therefore the protein sources they consume may be of predominantly low biological value, for instance in vegetables, legumes, nuts, and grains. While fat plays a role in many physiological processes, fat intake represented 34 ± 5% of TEI (1.5 ± 0.4 g·kg⁻¹·day⁻¹) and was higher still at the weekend (1.8 ± 0.1 g·kg⁻¹·day⁻¹; representing 36 ± 6% of TEI); above recommended levels of <30%. Similarly, alcohol intakes were relatively high, contributing 3 ± 4% and 5 ± 5% of TEI across the 7-day period and on an average weekend day respectively. This is concerning given the evidence which suggests that alcohol intake is associated with reduced muscle protein synthesis [ 49], impaired glycogen restoration [ 50], and exacerbated losses in muscle function [ 51]. Certainly the dancers would benefit from a reduction in alcohol intake, specifically limiting intake to 0.5 g·kg⁻¹ in any post-exercise period in order to avoid interference with recovery processes [ 52].

Interestingly, the eating behaviours of these dancers are somewhat different during scheduled dance training (during the week) compared to when there is no scheduled dance training at the conservatoire (during the weekend). While we have demonstrated energy deficits throughout the week, the maintenance of similar energy demands (as a result of many of the dancers seeking extra-curricular classes and/or training) and increased energy intake contributed to a positive energy balance during the weekend (123 ± 1007 kcal·day⁻¹ or 0.5 ± 4.2 MJ·day⁻¹). Perhaps the dancers perceived that while they were not in training they could indulge in arguably less desirable nutritional behaviours. In contrast, during periods of academic dance training the participants appeared to respond with below optimal energy and macronutrient intakes for their training demands. Though restrictive, uncontrolled, and emotional eating behaviours appeared not to be elevated, a relatively high proportion of participants reported past and/or current eating problems (9 of 25 participants), which may be responsible for the erratic eating behaviours. In addition, the typical training schedule of a dancer offers unpredictable and/or limited opportunities for food and drink consumption, likely exacerbating these issues. Indeed an early investigation suggested that binge eating, particularly at the weekend, might explain why dancers do not experience reductions in weight [ 53]. Moreover, it is possible that the fluctuations in energy balance and macronutrient contributions we have observed from day-to-day (week day/weekend) are occurring in the long term (term time/off-season). This may explain why the dancers' body composition reported in the present investigation were healthy, despite an average negative energy balance indicative of weight loss. Indeed, the body mass index and percentage body fat of the participants were higher than typically reported in ballet populations (for instance 18.9 ± 1.0 kg·m ² and 17.4 ± 3.4% respectively in female ballet dancers [ 25]). However, given the differences in physiological demands as well as discrete skills between these dance genres (not least the gender roles in ballet requiring females to be lifted more frequently) [ 26], this is perhaps unsurprising. Collectively, these data suggest that the dancers are unable to effectively regulate their energy and macronutrient intakes to accommodate for their energy expenditure; essential for maintaining the demands of training, performance, recovery and physiological adaptation.

Accurately quantifying energy intake and energy expenditure is limited by indirect measurement techniques typically relied upon in research studies. In the present study, a 7-day period was chosen as it is thought to best represent the variety of dietary and physical activity practices and are associated with the most valid nutritional information [ 54]. However, it has been suggested that reasons for low energy intakes reported by dietary records in dance populations include deliberate under-reporting and/or under-eating due to the desire for weight loss [ 11, 18]. As observed in many populations, it is thought that not only is it possible that dancers fail to record portions of food correctly, but they may also omit foods eaten or restrict their food intake during the study period [ 12]. This should be considered when interpreting the present findings. However, in order to minimise the errors of measurement associated with participant compliance and motivation, we combined self-reported weighed food diaries with 24-hour recall interviews. This method has been found to result in good agreement with the gold standard observed food intake technique [ 55, 56]. Moreover, though accelerometry has been shown to be strongly correlated with indirect calorimetry [ 57, 58], some show an underestimation of physical activity levels using the devices [ 59- 61]. Notwithstanding, the loss of data associated with removal of the accelerometer evidently influences the estimation of physical activity [ 62]. Though efforts were made to account for missing data using non-wear activity logs, the accuracy of these is nevertheless limited by the possibility that 1) not all activities were reported and accounted for, and 2) the information provided was lacking detail. It is also important to note that demanding exercise and energy expenditure may alter BMR; particularly during energy deficit. Future research should consider more accurate estimation of BMR to determine its contribution to TEE. Finally, energy balance may differ across the menstrual cycle, for instance energy intake and expenditure appear to be elevated during the luteal phase [ 63]. In the present investigation, the menstrual cycle phase of participants during the study differed and in some cases was not identifiable, and therefore the findings should be interpreted with this in mind. Despite the aforementioned limitations, the present study offers a high degree of ecological validity in its free-living experimental design, which may not have been possible with other experimental techniques.

Conclusions

To conclude this research demonstrates that, as with many athletes in aesthetic or weight dependent sports, female contemporary dancers are at risk of energy deficiency, particularly during periods of scheduled dance training. As a result, this population could be susceptible to the numerous health and performance impairments associated with energy imbalance. In addition appropriate macronutrient intakes are essential for maintaining the demands of training, performance and recovery. The suboptimal macronutrient intakes observed in this study suggest a lack of knowledge regarding appropriate nutrition for sport and exercise performance. It is evident that dance populations would benefit from further research in order to develop current understanding of dance specific nutrition. For instance the variability of nutritional intakes and energy expenditures between term time and off-season remain to be investigated, and whether the negative energy balance reported in the current study is maintained in the long-term. Moreover it may be prudent to investigate nutritional strategies and the use of ergogenic aids which may provide practical solutions to improve energy balance and perhaps contribute to enhancing performance and recovery.

Author Contributions

1. Conceptualization: MAB GH EJS.

2. Formal analysis: MAB.

3. Methodology: MAB GH EQ ER EJS.

4. Resources: MAB GH EQ ER EJS.

5. Supervision: GH EJS.

6. Writing - original draft: MAB.

7. Writing - review & editing: MAB GH EQ ER EJS.

References

1. 24. Laws H. Fit to Dance 2-Report of the second national inquiry into dancers' health and injury in the UK. London: Newgate Press; 2005.

2. 31. Marfell-Jones M, Olds T, Stewart E. International Standards for anthropometric assessment. South Africa: ISAK; 2011.

3. 32. Siri WE. Body composition from fluid space and density. In: Brozek J, Hanschel A, editors. Techniques for measuring body composition Washington DC: National Academy of Science; 1961. p. 223-44.

4. 34. Ashley JM, Bovee VH. Dietary intake: Recording and analyzing. In: Andersen RE, editor. Obesity: Etiology, Assessment, Treatment and Prevention. Champaign, IL, USA: Human Kinetics; 2007. p. 99-110.

5. 35. Deakin V. Measuring nutritional status of athletes: clinical and research perspectives. In: Burke LD, V, editor. Clinical sports nutrition. Australia: McGraw Hill; 2000. p. 30-68.

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Energy intake and energy expenditure of pre-professional female contemporary dancers

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Many athletes in aesthetic and weight dependent sports are at risk of energy imbalance. However little is known about the exercise and eating behaviours of highly trained dance populations. This investigation sought to determine the energy intake and energy expenditure of pre-professional female contemporary dancers. Twenty-five female contemporary dance students completed the study.

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schnitt, d. (2013). Psychological Issues in Dancers—An Overview. [online] Tandfonline.com. Available at: https://www.tandfonline.com/doi/abs/10.1080/07303084.1990.10604624?src=recsys [Accessed 14 Dec. 2018].

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Danceconsortium.com. (2018). Dancers as Athletes | Dance Consortium. [online] Available at: http://www.danceconsortium.com/features/article/dancers-as-athletes/ [Accessed 14 Dec. 2018].

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As knowledge about the body increases, dance training improves and the competition for excellence paired with innovation is greater, dancers bodies are pushed to the limits. The physical ability and disciplines expected of a dancer can be easily related to those of an athlete and increasingly, dance critics are describing dancers as athletic.

So, can we consider dancers as athletes? Why might some people in the dance profession and in sport be unwillingly to accept this concept?

Firstly, let us consider the definition of athlete; a person trained or gifted in exercises or contests involving physical agility, stamina, or strength; a participant in a sport, exercise, or game requiring physical skill. A dancer must certainly achieve physical agility, stamina and strength in their profession and physical skill must be mastered. Daily training involves repetition of exercises to achieve the physical attributes necessary to execute movements required of a dancer, however the focus is not on sport or games. Whilst many dancers will compete in contests and will audition against other dancers for a place in a company the real emphasis in dance is on the performance itself. There is an element of competition across the dance profession but the reward is a particular role in a company or a promotion from chorus to soloist rather than a gold medal.

Dance critics have described dancers of Rambert Dance Company as 'elegant and athletic', Alvin Ailey's dancers as having 'athletic beauty' and the moves of Company Kafig as 'athletic feats'. Each company mentioned is known for their very different styles however the common thread here is athleticism which in these instances is seen to refer to physical skill and fitness. The term athletic when associated with a company will always form an image alongside other adjectives used, as well as the company's past history. For example Rambert's Dancers as elegant and athletic reflects their classical ballet past but still indicates their extreme physical ability.

One might compare the life styles of athletes and dancers and the similarities may be surprising to some. Due to the physical demands placed on the body health, diet and self-discipline are all crucial to both dance and athletics.

The careers of both dancers and athletes are threatened by injury and therefore the conditioning and care for the body are similar. Exercise models such as Pilates are designed to complement the needs of athletes and dancers alike without making a distinction. A career in either profession is likely to begin at a young age and end by the time they are 40 due to the extreme physical nature.

The thrust of dance as fitness into mainstream media has made dance popular as a means of keeping in shape. When an audience member who has experienced dance goes to see a professional company they may appreciate better the skill and physical fitness required to achieve such feats. When dance critics describe companies as athletic readers may relate to the concept through experience of athleticism at the gym or on the football field. Dance companies who promote themselves as athletic such as Australian Dance Theatre may find that this connects then to their target market and they draw in new audiences.

With hip hop dance hitting the major theatres it becomes apparent that the 'athletic feats' referred to are what make this dance so popular. It could be argues that the moves that receive cheers from the audience are all about physical virtuoso and little to do with artistry. However, the hip hop culture demands a certain confidence and flair alongside the physical skill and it is these qualities that make the movements impressive.

Often dancers described as athletic such as Australian Dance Theatre have trained in many different genres giving them powerful muscular physiques and an element of attack in their movement. In the case of ADT the Artistic Director encourages his dancers to train in capoeira and martial arts alongside dance in order to increase their physical strength and breadth of movement to accomplish the daring physical feats prevalent in the choreography.

Whilst it is clear that the physical attributes of a dancer are similar to those of an athlete, dance is considered an art form and there is much more to the art than physical skill and virtuosity. Musicality, expression and creativity are often included in the criteria of what makes a good dancer. In auditions and competitions the technical skill of a dancer can be near to perfect but if they do not have the ability to evoke the viewers and dance with the music then they will not necessarily fulfil the criteria. Dancers may be feel that if they are described as athletic their ability is being reduced to their physical skill alone whereas it is the joy of dance that will drive a dancer to continue their training at such a pace for so many years.

In many respects dancers are athletes but they are also artists and it is this combination that makes for a stunning emotional and physical performance.

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Touring the best international dance around the UK

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BBC News. (2018). Dancers urge action on anorexia. [online] Available at: https://www.bbc.co.uk/news/entertainment-arts-17937330 [Accessed 14 Dec. 2018].

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The director of the Royal Ballet has said that any dance company director who claims never to have worked with an anorexic performer is "lying".

Dame Monica Mason made the comments at Dance UK's conference on nutrition and eating disorders within the industry.

"Perhaps in the past we were more in denial. We are now in a situation where we can recognise it and really try to help these young people," she said.

Dame Monica is due to retire from her role at the Royal Ballet in July.

Speakers at the Nutrition and Disordered Eating Conference, which was attended by more than 100 delegates, included dance and medical experts, with former dancer Kenneth Tharpe chairing the proceedings.

The conference took place earlier this week, after dance professionals demanded a public forum for discussion.

Tharpe, now chief executive of contemporary dance centre The Place, urged greater transparency on the issue, opening the conference with the words: 'Let's talk about it'."

Dame Monica, who has been with the Royal Ballet for 54 years, backed his comments: "I think it is great that we are now talking about it more and more."

"Any director of a company who said they have never had an anorexic dancer would have to have been lying.
'Sausage machine'
"What we are looking for is a healthy, talented, gifted individual, and even in a company like the Royal Ballet the sizes and shapes of people vary enormously," said Dame Monica.

"I never wanted people to come out looking like they have been produced by a sausage machine."

David Bintley, director of Birmingham Royal Ballet, agreed, adding that he was not looking for a set physical "type" but would "run a mile away from somebody I suspect has an eating disorder" because they were difficult to solve.

David Nixon, artistic director of Northern Ballet added that his productions required "real, human shapes".

Delegates discussed how some dance companies promoted competition and egocentric behaviour. These "negative environments" were "closely linked to the propensity of eating disorders".

Medical experts stressed the need for dance organisations to identify staff to whom students could turn, and to familiarise themselves with support bodies that help people tackle eating disorders.

Following the conference, Dance UK launched the National Institute of Dance Medicine and Science (NIDMS), a joint initiative with Birmingham Royal Ballet, Trinity Laban, the Royal National Orthopaedic Hospital and the Universities of Wolverhampton and Birmingham.

It has also announced the opening of the first specialist dancers' health clinic at the Royal National Orthopaedic Hospital in London, which aims to give all top level dancers access to the comprehensive, dance-specific healthcare.

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The director of the Royal Ballet has said that any dance company director who claims never to have worked with an anorexic performer is "lying". Dame Monica Mason made the comments at Dance UK's conference on nutrition and eating disorders within the industry. "Perhaps in the past we were more in denial.

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The pursuit of developing dancers who can achieve high levels of proficiency and artistry is a great challenge. Dedicated and skillful guidance is required by teachers and choreographers to help develop future dancers with the capacity to make their mark in a demanding industry. In order to meet the artistic and technical demands of a highly competitive dance industry, dancers are working long hours and pushing their bodies in the studio and onstage, sometimes in addition to training outside of dance. But how much is too much and how do we know when a dancer has had enough?

The risk of doing too much is a condition known as burnout. Burnout is a state of consistent or unexplained tiredness, poor performance in spite of normal training, negative mood state and increased incident of illness or injury. Burnout is often seen in dancers where training, rehearsing and performing schedules do not give them sufficient time to rest and recover.

What causes burnout
Factors contributing to burnout are complex, interrelated and individually distinct. Some of the more common causes include; emotional and physical stress, poor nutrition, low levels of physical fitness, and inadequate rest and recovery. Busy class, rehearsal and performing schedules can also result in burnout, fatigue and injury, and although dancers are not generally in control of these schedules directly, it's important for them to understand how scheduling can affect their performance, health and well-being.

Identifying the warning signs of burnout
When a dancer does too much and ignores early warning signs (see list below), they risk the serious and lasting effects of burnout. However, identifying burnout is difficult as there are no simple tests and the signs and symptoms are nonspecific, subjective and can vary from dancer to dancer. Warning signs may include;
* A constant feeling of fatigue
* Excessive sweating
* Inability to recover optimally following intensive dancing
* Loss of desire and enthusiasm for dance (feeling of helplessness)
* Breakdown of technique
* Poor concentration
* Loss of appetite and loss of body weight
* Disturbed sleep often with nightmares or vivid dreams
* Increased need to visit the toilet at night
* Increased susceptibility to injuries
* Increased susceptibility to illness such as colds and chest infections
* Increased anxiety and irritability
* Signs of depression

Prevention
Prevention is more effective than treatment and education is an important prevention strategy. Teachers, choreographers and the dancers themselves need to be educated about the risks associated with burnout and the early signs to help them identify those who may be at risk.

Effective time management is an important way to help prevent burnout. For example, choreographers can utilize the dancers' time more efficiently by releasing them from rehearsal when not needed or schedule a video feedback session instead of additional gruelling rehearsals. Periodization is another model that can be utilized to manage dancers' workload and is a systematic approach to the entire training/rehearsal/performance preparation. Periodization develops skills, along with physical and psychological condition in a logical and sequential way to ensure dancers reach the highest levels of performance. Dancers working in periodized environments (where rest has been considered and structured) perform better and have fewer injuries (Wyon, 2010).

Treatments
Rest, reduced training volumes and 'active resting' (or change of activity patterns e.g. cross training - pilates, yin yoga) are the most effective treatments. Other regeneration techniques may be useful such as stress reduction through counseling, sleep, saunas, massage, aromatherapy, hydrotherapy and good nutrition (Koutedakis and Sharp, 1999).

Rest
Rest is not only an important physiological process which aids recovery and reduces fatigue, it is also an important time for the brain to integrate and store movement patterns. This not only improves movement memory, it also improves how movement is performed (Batson, 2009). Scheduling time for structured rest like meditation or a Yoga Nidra (deep relaxation exercises) can help equip dancers with another skill to help them manage their own physical and mental stress. For example, following the same schedule for an end of day release/relaxation ritual creates a routine for the dancer to de-stress.

Tips for identifying and avoiding burnout
Due to the complex nature of burnout, there is no one best way to identify the signs and avoid the condition. It is important to remember that each dancer and situation is unique, so awareness is the most important tool of prevention. Here are some tips to help identify the risks and avoid burnout.

1. Rest, rest, rest! This is probably the most important way to optimize performance.

2. Eat well! Eating well does not have to mean eating boring food. Make sure dancers have lots of delicious, healthy and nutritious food in their diets. Also, ensure healthy food is easy to find - so they don't spend their breaks times hunting down nutritious snacks. This may require dancers bringing their healthy food with them to class and rehearsal.

3. Don't forget food should also be fun! Make eating social and encourage dancers to share a delicious meal with friends, this is not only good for their bodies; it's also great for their mental wellbeing.

4. Manage high expectations and unnecessary pressure by setting appropriate and realistic goals.

5. Return to dancing when the dancer's body is ready. This includes a gradual return to dancing after breaks or injuries.

6. The health and wellbeing of a dancer is the most important consideration, so keep everything in perspective and remember dancers are just people who have stress in their non-dance lives. Some may also need to talk to a counselor about the stress they are experiencing.

7. The old adage "no pain, no gain" and "more is better" needs to be understood and in most cases discouraged.

8. Focus on quality of training, not quantity.

9. Learn relaxation techniques! Learning how to rest is often a skill overlooked in the pursuit of excellence (Batson, 2007). Meditation or a Yoga Nidra can help equip dancers with another skill to help them manage their own physical and mental stress.

10. Mental practice is another great tool to not only beat the burnout, but also optimize performance. Reviewing choreography mentally as well as practicing physically has been found to be more effective than physical rehearsal alone (Batson, 2009).

11. Make sure there is a life beyond the dance studio. It's important for dancers (and teachers/choreographers) to do something different (not more dancing or dance related training) and have FUN!!

12.Ensure dancers are getting sufficient quality sleep.

13. Be aware and monitor how dancers are feeling. The longer it takes to acknowledge or become aware of fatigue and burnout, the longer it will take to recover. If dancers report feeling tired, ill, or pain, give them a break and don't just work through it!

Final Thoughts
It is important to remember that dancers respond individually to the stresses of training, rehearsal and performance. Whilst one may be experiencing burnout another may find the same workload easy. For this reason, it's important to monitor individual dancers and make specific adjustments to workload as necessary to ensure optimal health and performance.

References
Batson, G. (2009) Somatic Studies and Dance, IADMS Resource Paper
Koutedakis, Y., (2000) "Burnout" in dance, the physiological viewpoint, Journal of Dance Medicine & Science, 4(4).
Koutedakis, Y., & Sharp, N., (1999) The fit and healthy dancer, John Wiley, Chichester.
Wyon, M. (2010) Preparing to perform periodization and dance. Journal of Dance Medicine & Science, 14(2).
About the authors:
Brenton Surgenor (BPhEd, MA, MSc) has a broad knowledge of human movement, somatic practices and dance science and has presented workshops and seminars in Australia, New Zealand, Hong Kong and the United Kingdom - he is currently Senior Lecturer (Academic Studies in Dance) at The Hong Kong Academy for Performing Arts.
www.brentonsurgenor.com
https://hkapa.academia.edu/BrentonSurgenor
https://hk.linkedin.com/in/brenton-surgenor-6ab52a9

Jaime Redfern (Dip, MFA, MEd) has worked in the performing arts sector for over 30 years as a performer, educator, choreographer and manager - he is currently Head of Contemporary Dance at The Hong Kong Academy for Performing Arts.
https://www.linkedin.com/in/jaime-d-redfern-4b43a6a

Photo credits:
Photographer Felix Chan
Dancers Selina Hack and Eric Kwong

Do you want to be the next guest blogger on DO ? Contact us at dancingopportunities@gmail.com

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How Much Is Too Much: Dancers And The Risks Of Burnout

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The pursuit of developing dancers who can achieve high levels of proficiency and artistry is a great challenge. Dedicated and skillful guidance is required by teachers and choreographers to help develop future dancers with the capacity to make their mark in a demanding industry.

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prezi.com. (2018). Coping mechanisms for anxiety in the sport of dance. [online] Available at: https://prezi.com/8r4xkxtulxo2/coping-mechanisms-for-anxiety-in-the-sport-of-dance/ [Accessed 14 Dec. 2018].

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Coping mechanisms for anxiety in the sport of dance