Athlete Eating Disorder: How to identify and get help

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Eating disorders are one of the biggest risks faced by dancers, particularly women. The focus on size, shape and weight can put extreme pressures on dancers. The aesthetic standards of the dance world favor lean physiques – from body revealing costumes and clothing to the demands of jumping, leaping, and partnering. Every day in the studio, a dancer is bombarded by direct comparisons with fellow performers in a competitive environment with occasional added subtle, or not so subtle comments (“you’d jump better if you were 5 pounds lighter”). Some of these environments can lead young people into destructive eating habits which may have long-term and even fatal consequences.

Dance instructors should always be careful when talking about body size and weight. What is said could be misunderstood or taken to extremes. Teachers of young dancers have a responsibility to be aware of the signs that might indicate problems, and to take steps towards early intervention.

Eating disorders commonly begin with normal dieting that gradually becomes more compulsive. Extreme weight control methods can develop, such as anorexia (lack of interest in food) or bulimia (combination of binge eating followed by purging, often as vomiting). Other examples of disordered relationships with food include fasting or overly restrictive eating, excessive exercise, and overusing diuretics and laxatives.

In some ways, the decisions behind these disorders give a dancer a sense of control in an environment where there are constant uncertainties about being selected for a troupe, cast for a particular role, having to wear certain costumes, or being able to meet the demands of the choreographer.

With initial weight loss, many dancers gain a boost of confidence with increased jumping and turning abilities. They often may hear approval and confirmation from colleagues and instructors. This definitely makes acknowledging early issues with energy intake more difficult, and often medical care is sought only when there is a later significant decrease in performance.

Issues with body self-image and food can also be connected with emotional issues such as anxiety or depression. Unique dance stressors such as a constant need to learn new routines combined with frequent sources of critique (instructors, earning a role, placing in a competition) can increase risk for many mental health concerns, including anorexia and bulimia.

What is Anorexia Nervosa?

Anorexia Nervosa is a psychological illness with devastating physical consequences. Anorexia is characterized by low body weight and body image distortion with an obsessive fear of gaining weight that manifests itself through depriving the body of food. It often coincides with increased levels of exercise and vomiting.

Anorexia is the most fatal of all psychiatric illnesses. Extreme food restriction can lead to starvation, malnutrition and a dangerously low body weight, and in some cases death. A typical anorexic person will severely restrict their food intake. They will maintaining very low calorie count, restrict the types of food eaten, eat only one meal a day, or follow obsessive and rigid rules such as only eating food of one color.

What is Bulimia?

Bulimia is an emotional disorder involving a disordered body image and an obsessive desire to lose weight. Bouts of almost out of control overeating are following with purging behavior, often in the form of vomiting.

Warning Signs

There are behavioral, physical and psychological signs or changes that often accompany an eating disorder. Warning signs may not be easy to detect. People with an eating disorder will generally experience great shame or guilt about their behavior, and will try to hide it. Some people do not realize they have a problem. Some will not want to give up their behavior, because it is their way of coping. 

Dancers, in particular, often deal from a particular sub-type termed “exercise anorexia” where there is insufficient caloric intake to match often excessive exercise energy demands. This might occur in part due to ignorance of the nearly 4,000-5,000 calories that can be burned a day by intense dance, or the energy deficiency could also be intentionally created by dancers who do additional exercise (treadmill, stair machines, elliptical above and beyond usual dance requirements. In working with dancers, it is best to ask about the amount and frequency of exercise, both inside and outside the dance studio. This extra exercise may represent a compulsive behavior that is a direct part of the anorexia nervosa illness.

Many young dancers have limited financial resources which often means making compromises on the amount or type of food intake that can lead to lower levels of calorie intake. As a physician, I often see reduced intake dairy and meat products, which are high calorie food sources that also have calcium and iron.

Female dancers often report higher levels of caffeine, nicotine or even illicit cocaine use both for stimulating energy levels and appetite suppression. In dealing with dancers, one must address these more common dance world issues to provide individualized and comprehensive care. Initially, a dancer may deny any problems with food intake, excessive exercise, or substance use, but as rapport and comfort are built with the medical team, such concerns may be more readily shared.

Disordered eating can be linked with poor bone health and irregular or absent menstrual periods. This is known as the female athlete/performer triad, which can lead not only to a higher risk of bone stress injuries, but also diminished overall dance performance and overall health.

Getting Help

For all patients dealing with eating disorders, one of the main issues is acknowledging and accepting that they suffer from the illness. Given that many dancers have a high sense of self-identity with their dance work, it can be even more challenging to come to this initial stage of acceptance. There is a fear not being able to dance, which then leads to a fear of not being identified as a dancer, and then ultimately a collapse of how they view themselves. In approaching treatment recommendations, one has to focus on the eventual performance enhancement goals, such as becoming a stronger, healthier, and more confident dancer.

Instructors that suspect a student may have an eating disorder should recommend an urgent medical evaluation with professionals who are familiar with eating issues in the dance world. Treatment may involve a combination of medical monitoring, dietary counseling and psychological help.

Students diagnosed with an eating disorder need medical clearance to take part in exercise. Even moderate levels of exercise can result in severe health risk and teachers share the responsibility for safety in these situations. A student may need to be limited or restricted from dance activities to protect their health until they recover.

One helpful thing about dancers is that they are used to working with multiple team members, from fellow dancers to multiple choreographers and instructors. Thus, once they understand that optimal treatment of their eating disorder requires an inter-disciplinary approach including physicians, nutritionists, and mental health providers, a dancer is more apt to accept this team-based treatment approach.

Dancers are used to tight, goal-oriented schedules, so setting short-term realistic goals definitely help in building confidence and compliance. Regular visits to modify goals and constant communication amongst providers (with appropriate privacy safeguards, of course) are also quite helpful.

Dancers in general will be more receptive to working with medical professionals that know the culture of the dance world and the expectations/demands. When an apprehensive dancer hears that he/she is not the first to seek treatment with a medical provider who has helped others get healthy, that dancer will feel less isolation and have more confidence in a treatment plan.

Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA.

Contributing Expert: Dr. Chris Koutures is a dual board-certified pediatric and sports medicine specialist who practices at ActiveKidMD in Anaheim Hills, CA. He is a team physician for USA Volleyball (including participating in the 2008 Beijing Olympics), the U.S. Figure Skating Sports Medicine Network, Cal State Fullerton Intercollegiate Athletics, Chapman University Dance Department, and Orange Lutheran High School. He offers a comprehensive blend of general pediatric and sport medicine care with an individualized approach to each patient and family. Please visit https://activekidmd.com/ or follow him on twitter (@dockoutures).

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