Relative Energy Deficiency in Dance 

Nick Allen and Matthew Wyon

Dance, like sport, is a generic term that encompasses a wide variety of movements forms and is carried out by a wide variety of people of all shapes and sizes. In a few dance genres, some dancers might be more prone to a negative health effect referred to as relative energy deficit syndrome (REDs). This had previously been called Female Athlete Triad but with the recognition that males can also meet the criteria, the International Olympic Committee in 2014 provided a new definition as  an energy deficiency relative to the balance between dietary energy intake and energy availability required to support homeostasis, health and activities of daily living, growth and sporting activities.” They also recognized it had an effect on more than just menstruation and bone health with multiple systems being affected including decreases in energy metabolism, reproductive function, musculoskeletal health, immunity, glycogen synthesis and cardiovascular and hematological health. This can be accompanied by either an eating disorder or disordered eating, the prevalence of which is greater in some genres more than others. The dance environment is different to the sporting one, especially with certain genres promoting a high emphasis on body aesthetics and high workloads that can be accompanied by under-fuelling and skipping meals.  There is a duty of care within the dance sector to investigate this further and support dancers affected by Relative Energy Deficiency in Dance (RED-D). Furthermore, it is important to establish clear pathways for the prevention, identification, and management of RED-D. The purpose of this study was to reach a consensus on the clinical guidelines for identifying and managing RED-D. 

Figure 1: Consensus Process

The full paper, explains the consensus process and outcomes in detail, but in summary an expert panel (EP) was formed that consisted of participants' recognised for their involvement and expertise in REDs and a range of dance genres. These included Sports and Exercise Medicine (4), Endocrinology (2), Rheumatology (1), Psychiatry (1), Psychology (3), Physiology (1), Dietetics (2), and Physiotherapy (6). Through a series of focus groups and voting a consensus (70+% agreement) was achieved for a definition, identification and management plan (Figure 1). This was then distributed to a wide range of stakeholders that included national dance advocacy bodies, national and international dance medicine and science associations and large dance companies for their support and agreement with the outcomes.

Results

Questionnaires: These can play a key role to help identify early identification in asymptomatic or unreported RED-D patients such as Low Energy Availability in Females Questionnaire (LEAF Q) (81%), Low Energy Availability in Males Questionnaire (LEAM Q) (75%) and Dance-specific Energy Availability Questionnaire (DEAQ) (75%)

Diagnosis: Functional hypothalamic amenorrhoea is present in REDs females; blood tests are key in routine screening (e.g., once or twice a year) of asymptomatic dancers and should include (FBC, Ferritin, B12, Folate, ESR, Renal function and bone biochemistry [25-Hydroxy-Vitamin D, calcium, phosphorus, alkaline phosphatase and albumin]; bone mineral density (BMD) assessment is important after 1-2 bone stress injury; dental assessment can be a helpful indicator of an eating disorder in RED-D.

Management: Individual assessment nutritional intake is one of the primary considerations of RED-D management alongside evaluating and modifying dance workload;  a liquid meal supplement is not superior to real food when attempting to address energy deficit. For females, increasing energy availability is fundamental to restoring a normal menstrual cycle in RED-D;  the oral contraceptive pill should not be considered in the management of RED-D; in some cases, transdermal oestradiol therapy with cyclic oral progestin is an efficacious management strategy for restoring normal bone health.

Risk Stratification and Return-to-Dance Pathways are proposed to support decision-making in the dance. A typical professional dancer in ballet will be contracted to 30 hours of dance-related activity a week without accounting for additional strength or fitness training. Furthermore, the variability in workload with different intensities experienced with different roles within the same repertoire can make appropriate energy intake relative to workload challenging. An individualised approach to patient management working within the framework will allow dancers to be supported. It was important to acknowledge the importance of load management in RED-D while balancing the psychological impact of withdrawal (or inclusion) in dance-related activities

Conclusions

RED-D, like REDs, represents a complex, multi-system disorder. The need for early identification and clear management strategies is evident. The diagnosis pathway recognises primary criteria within the diagnosis process but also acknowledges where secondary criteria that lack sensitivity may be used to support a decision to investigate RED-D. The management pathway reflects the wide physiological and psychological impact of RED-D and demonstrates the need for a multidisciplinary approach in its management, importantly including psychological input.

To read the full Open Access paper click here

Allen N, Kelly S, Lanfear M, et al. Relative energy deficiency in dance (RED-D): a consensus method approach to REDs in dance. BMJ Open Sport & Exercise Medicine 2024;10:e001858. doi:10.1136/ bmjsem-2023-001858