Ballet Business | You are what you eat, especially as ballet dancers
One issue remains in the headlines after the news was announced that Royal Ballet Principal Tamara Rojo had been appointed Artistic Director at English National Ballet (April 13th 2012) from September this year : eating disorders (ED) in ballet. A subject rarely discussed openly, if Rojo can speak out without recriminations, could others? Not necessarily : last year Mariafrancesca Garritano, a dancer at La Scala in Milan was sacked after she spoke of a “plague of anorexia” in her company and in 2003 The Bolshoi’s Anastasia Volochkova lost her job for being the wrong shape. An exception is the positive story of retired Birmingham Royal Ballet Principal Rachel Peppin Parker, who also danced with Atlanta Ballet and who has, and continues to speak, at the Royal College of Medicine and elsewhere about her own experiences.
In the ballet media spotlight
On 17th April 2012 the BBC published a video report entitled, Pledge to stop ballet eating disorders, which was filmed at the Northern Ballet Academy. Both the headline and the presenter say ‘eating disorder’ but eating disorders are diagnosed via clinical assessment and aren’t something you can see by looking at someone. For this reason, Disordered Eating (DE – also known as EDNOS or Eating Disorders Not Otherwise Specified) is perhaps a more accurate term as it encompasses a range of problems. It also more accurately describes, for the majority of dancers and dance students, where they find their relationship with food could most accurately be placed at certain times in their lives.
In The Sunday Times, Fatten up, girls, you’re tutu skinny by Richard Brooks on 15th April, Rojo is quoted as saying “audiences want to see beautiful and healthy-looking dancers yet there is still that pressure to be thin. Some comes from the fashion world and that in turn affects ballet. When you are in a ballet company, you often lose perspective of reality. So you go for extremes in order to stand out and be noticed. But I have preached and will continue to preach. I have never been thin and I want for myself and for others to have long and healthy careers. This also comes from what is in your head, as the mind rules the body.” It is important to point out that it’s not only females who are at risk; in males it can be harder to spot as exercise becomes part of everyday life and to some degree covers up the underlying issues.
The Mail Online quoted from The Sunday Times piece later the same day with a headline screaming English National Ballet chief orders dancers to put on weight, and continues within the text to say “Tamara Rojo … says she wants to stamp out anorexia in ballet.” They also picked up the findings of a study which found that 83% of ballet dancers had some form of eating disorder.
When I interviewed Rojo before her appointment was announced, her view on DE was, “you know, every profession has its difficulties. It’s obvious that in ballet we work with our bodies and that it may be that in some cases it’s taken to an extreme – a personal obsession with the body – but I am still not convinced that that happens more often [in ballet] than in society in general. But if that was to happen of course that has to be dealt with, with care and with all the help that whoever is going through a tough time can get.”
What are the facts about ballet & eating disorders?
According to Beat*, 1.6 million people in the UK are affected by ED’s and women aged 12-20 are most at risk with only 15-20% of cases in males. Anorexia is the rarest ED and Bulimia the most prevalent.
It is easy to extrapolate headline figures from the many studies that have been carried out across all areas of DE, but ignoring the detailed analysis and self-noted shortcomings of some of the research would render such activity inaccurate. What I want to do here is to highlight recurring themes in these studies as they relate to classical ballet (though caution must be maintained as each study had differing aims, small numbers of dancers, and the dancers used were sometimes dance students and sometimes professional ballet dancers – the term ‘ballet dancer’ isn’t definitive). In most studies, recognised criteria for measuring DE and ED’s were used, and this is where I’ve noted similarities in the conclusions. Where possible I refer to DE as opposed to ED’s because disordered eating is more of a ‘state’ than ED’s, which are each separate, recognised illnesses.
The risk factors for ballet students
Currently there has been no research conducted to give accurate figures as to whether ballet is more or less affected by DE than society in general, and this research would be very useful as a benchmark for the industry. What we can say is that the studies referenced here indicate that ballet dancers are a high risk group in terms of the development of ED’s. Indeed, this is acknowledged in The Royal Ballet School’s Eating Disorders Policy and it warns : “The likelihood of these conditions occurring amongst students at The Royal Ballet School is increased because of a common tendency amongst young aspiring dancers to conform to a perceived stereotype of the ‘perfect dancer’, despite the policies of the School which give clear guidance concerning appropriate dietary habits and expectations.” The School’s strategy is to monitor students closely for warning signs.
In some studies the prevalence of both full and sub-threshold anorexia nervosa (AN) was found to be 3 to 6 times higher among ballet dancers than in the general population.1-3 In a 20059 study ballet students were also found to be at higher risk of developing ED’s than their non-dancing peers. But it’s important to keep a balance here because the study found that within the higher risk group there are other factors to consider. Let’s keep perspective too; the majority of the ballet students did not exhibit ED’s. Schools with an emphasis on preparing students for a professional ballet career scored a significantly higher prevalence of AN than those studying at less competitive schools. Anecdotal (and non-scientific) evidence told to me suggests that for some professional dancers at least, vocational training was preferable from age 16 years as opposed to starting at the more traditional 11 years, where many attend highly competitive boarding schools and face annual assessments where they can be asked to leave the school if they fail to show progress or begin to develop a non-ideal body shape. The Dunning study in 1985 reported that at the School of American Ballet (one of the most elite in the US) only 5% of dancers who matriculate at 8 years graduated at 17 years.
There’s another risk to competitive sports, to which ballet training, with its aim of producing elite athletes has been linked : Anorexia athletica (AA). A study last year saw 52 pre-professional ballet dancers aged 13-20 years, who were tested for clinical eating disorders, anorexia athletica criteria, eating disorder related psychopathology and self-concept, and were compared with 52 patients with anorexia nervosa and 44 non-athletic controls of the same age. The results showed that a clinical eating disorder diagnosis was made in 1.9% of the ballet dancers versus 0% of the high school students; anorexia athletica was diagnosed in 5.8% of the dancers versus 2.3% of the students, and that ballet dancers scored lower than patients with anorexia nervosa with regard to eating disorder related psychopathology and higher than the patients with regard to self-concept. This remains an important area for further research as professional ballet dancers are no different from other elite athletes in terms of sports/science and they should be able to benefit from the findings of any further research.
It isn’t just ED’s though. According to one study, body dissatisfaction is present in up to 84% of ballet dancers.3
DE behaviours are more prevalent too – at 45% relative to non-dancers who were the control group in one study.4
In one study, 40% of ballet dancers were below 85% ideal body weight (IBW – the body weight criterion for a diagnosis of AN).5
Where does ballet training fit into this ?
Ballet dancers are considered athletes, and in line with other types of athletes, the prevalence of bulimic behaviours are thought to stem from intense training regimes and the perception that maintaining a lower weight will result in an enhanced performance. 6-7 The etiology of DE/ED’s -the environmental & genetic risk (the competitive nature of ballet training, especially in ballet schools that are attached to a professional company and where job contracts may be highly prized and rare, and the fact that professional ballet training as a career choice means paying considerable attention to control of body shape and weight) has been explained in several studies. Study2 found that in a group of 49 female ballet students the competitive pressure to achieve a slim body shape may be important in the etiology of ED’s. Again, I would say that it is very important to recognise that males can be susceptible to ED’s as well. Despite the findings, the study showed that all of the 6 students diagnosed with either AN or ‘partial syndrome’ AN completed their academic training year. The study results highlighted the fact that just over one half of the students were underweight and that 90% of the students reported feeling feint or dizzy and lacked energy daily.**
In the study8 referenced by the Mail Online earlier, though 83% of dancers presented with some form of ED, by far the most common was EDNOS, with approximately 55% of the dancers falling into this category.
Another factor reported in the study was that although ballet dancers routinely exercised for 6-8 hours per day in ballet training, 17.2% of the dancers also exercised for another 1-3 hours per day for weight control purposes. The study concluded that an alarmingly high number of dancers met criteria for a diagnosis of DE which included the whole range of disorders, and that they were phenotypically similar to individuals with eating disorders. The study also concluded that the true numbers around DE/ED’s is probably higher still because dancers with significant eating pathology may not have taken part in the study.
As the media plays an influential role in this subject (as confirmed by the following example) I’d like to explain what ED’s and EDNOS are. Prof. Anne Becker studied the culture in Fiji, a place where ideal body image is of a large size. Prof. Becker found that within 5 years of Fijians watching popular mainstream American TV channels, cases of ED’s were diagnosed. This does not mean that media reporting causes EF’s, rather Prof. Becker’s later research found that it was the number of people within social groups who watch and are influenced by TV.
Anorexia nervosa (AN) is an ED (eating disorder) where a person doesn’t stay at even the minimum healthy weight for their height. This can cause amenorrhea (lack of menstrual cycle), as can any of the ED’s/EDNOS, and poor nutrition due to low food intake can be a risk factor for developing stress fractures due to poor bone health, osteoporosis (thinning and weakening of the bones) loss of muscle mass, fatigue, injury and illness.
Anorexia Athletica (AA) sometimes known as compulsive exercise,is relevant here in the context of the dance population. I’ve highlighted already the use of excessive exercise to mask the signs of a problem. The results of too much exercise can sometimes seem favourable to dancers but this is not the recommended course of action.
Bulimia nervosa (BN) is an ED also linked to low self-esteem and stress and is defined by binge eating accompanied by a sense of a loss of control, often followed by purging to prevent weight gain. It is more common that AN and because bulimics usually stick to an average body weight it can often be hidden for a long time. Bulimics can also suffer from AN.
EDNOS – Eating Disorder Not Otherwise Specified
EDNOS describes a pattern of disordered eating that does not fit the criteria for other forms of ED. For example, those with ‘partial syndrome’ ED’s fall into this group, as do those with regular or normal periods, or infrequent bulimic episodes.
ED’s are often an expression of emotional distress and it is important to understand that this can be long-standing and may have developed before any involvement in ballet. None of the studies here have concluded that ballet in itself causes ED’s or EDNOS.
During ballet training it is widely recognised (but not so widely practiced) that only a person’s GP/physician or nutritionist should be involved in any discussions about weight. A small study10 with 13 ballet students from a professional dance school developed in Portugal investigated which specific characteristics of dance (and gymnastics) environments made them high risk in the context of participants developing ED’s. Unsurprisingly, teachers and coaches exerted significant influence on the young athletes, and it could be surmised that these influential people could benefit their students by taking extra care not to remark or have conversations around weight with them.
The side effects of any of these ED’s or EDNOS can be very serious and need to be treated. Please see your GP if you are concerned.
If there is one message you take away after reading this piece, I hope it will be that life isn’t always the ride we’d hoped for, and that there is no shame whatsoever in asking for help. NONE.
I would like to thank Derrick D. Brown M.Sc., Dance Scientist, Sport Nutritionist, for his advice and guidance in helping me to report on this subject sensitively and accurately.
*The UK’s only nationwide organisation supporting people affected by eating disorders, their family and friends, Beat, which is also the world’s largest eating disorders charity, states on its website : “Beat has several members of staff available 24hours a day for comment.” Unfortunately, over a two-week period, no-one was able to respond to my request.
**For information on nutritional advice please see the Ballet News facebook page note called ‘Nutrition for ballet dancers’ where you can also ask questions.
- Garner DM, Garfinkel PE. Socio-cultural factors in the development of anorexia nervosa 1980
- le Grange D, Tibbs J, Noakes TD. Implications of a diagnosis of anorexia nervosa in a ballet school 1994
- Szmuckler GI, Eisler I, Gillies C, Hayward ME. The implications of anorexia nervosa in a ballet school 1985
- Braisted JR, Mellin L, Gong EJ, Irwin CE Jr. The adolescent ballet dancer. Nutritional practices and characteristics associated with anorexia nervosa 1985
- Abraham S. Characteristics of eating disorders among young ballet dancers 1996
- Davis C, Strachan S. Elite female athletes with eating disorders: a study of psychopathological characteristics 2001
- Powers PS, Schocken DD, Boyd FR. Comparison of habitual runners and anorexia nervosa patients 1998
- Ringham R, Klump K, Kaye W, Stone D, Libman S, Stowe S, Marcus M. Eating Disorder Symptomatology Among Ballet Dancers 2006
- Thomas JJ, Keel PK, Heatherton TF. Disordered Eating Attitudes and Behaviors in Ballet Students : Examination of Environmental and Individual Risk Factors 2005
- Francisco R, Alarcao M, Narciso I. Aesthetic sports as high-risk contexts for eating disorders – young elite dancers and gymnasts perspectives 2012
- Herbrich L, Pfeiffer E, Lehmkuhl U, Schneider N. Anorexia athletica in pre-professional ballet dancers 2011