Anorexia athletica in pre-professional ballet dancers

Journal Title (Medline/Pubmed accepted abbreviation): J. Sports Sci.
Year: 2011
Volume: 29
Issue: 11
Page numbers: 1115-1123
doi: 10.1080/02640414.2011.578147

Summary of background and research design:

Background: The prevalence of anorexia among young athletes involved in aesthetic sports (dance, figure skating, gymnastics, diving, etc) is increasing.  However, it is recognized that a subclinical form of anorexia among these athletes exists.  To try and describe this condition, “anorexia athletica” was coined describing athletes who lose weight, deliberately restrict calories, and are fearful of becoming obese.  However, diagnosis of this anorexia athletica is difficult.  Social (and professional) pressures are very high for some athletes, especially ballet dancers, and it is important for clinicians to distinguish between regimented yet healthful eating practices and clinical, dangerous anorexia nervosa.

Research question: What is the frequency of anorexia and other disordered eating habits of young, pre-professional ballet dancers?  How do their habits compare to patients diagnosed with anorexia nervosa or non-athlete high school students?

Subjects: The ballerina (experimental) group included girls age 13-20 who train at a high level at least 10 hrs per week.  The anorexia nervosa (AN) patient group consisted of 52 patients, age 15.8 ± 1.7.  The non-athlete group (control) group included 44 high school students, age 16.7 ± 2.1 not involved in competitive sports or being treated for eating disorders or psychiatric disorders.

Experimental design: cross-sectional (no intervention)

Protocol:  All participants completed demographic questionnaires.  Their height and weight were also measured.  The ballerinas and controls were screened for psychiatric disorders via face-to-face interviews.  Two types of questionnaires were used for all participants to assess eating disorders: one assessed prevalence and severity of eating habits, the other assessed eating attitudes as well as behaviors.  Lastly, the participants completed a multidimensional self-concept scale.

Summary of research findings:
  • The ballerinas had a significantly lower BMI than the control group (18.2 ± 1.6 for dancers, 20.0 ± 2.1 for controls) but significantly higher than the AN patients (15.2 ± 1.4).
  • One of the 52 dancers met the criteria for AN while 3 met the criteria for anorexia athletica.  In total, 73.1% displayed disordered eating habits.  Eleven of the AN patients met the criteria for anorexia athletica.  No one in the control group exhibited clinical signs of eating disorders, but 1 met the criteria for anorexia athletica.
  • More than half of the ballet dancers expressed the desire to lose weight, while 19.2% of the AN patients and 27.3% of the control group wanted to lose weight.
  • All of the AN patients displayed amenorrhea (menstrual dysfunction) while approximately 25% of the ballet dancers exhibited amenorrhea.  In the control group, 6.8% displayed menstrual dysfunction or were not yet menstruating.  One average, ballet dancers menstruated later than those in the other 2 groups (p < 0.005).
  • On the psychopathologic questionnaire (perfectionism, body dissatisfaction, etc.), the AN patients had significantly higher results in 7 of the 11 categories than the control group whereas the ballet dancers scored higher on 3 of the 11 Eating Disorder question categories than the control group (drive for thinness, interoceptive awareness, and asceticism).  These 3 categories indicated less severe issues than the patients with AN (and these categories are very closely associated with dance).

Key practice applications:

It appears that ballet dancers do not have an increased risk of clinical AN, despite the strong pressures to be thin.  However, it may be more difficult to recognize AN in this cohort due to their already slender size, so teammates, coaches, friends, and family members should carefully watch ballerina’s eating habits in case a sickness develops.  The investigations with anorexia athletica were inconclusive, indicating that this term needs to be better defined.
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