173 | The Dancer Looks Healthy. But Is She?

I feel like every little girl I know has spent some time in a pink leotard, hair in a high bun, twirling around a dance floor. My daughter included. Some of those little girls grow into incredibly dedicated athletes. And sometimes, the very discipline we admire can hide a problem. Picture one of those dancers in your exam room. She looks strong, trains every day, and tells you she's eating really healthy. Would you think to ask about missed periods, frequent illnesses, or any stress fractures? Because underfueling doesn't always look the way we expect. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and dietitian, and today we're talking about relative energy deficiency in sports, or red S in dancers. My guest today is Mora Fowler, a registered dietitian and former ballet dancer who specializes in nutrition for young dancers. We talk about how the pressure to be strong and look a certain way can quietly push healthy habits into risky territory. And even if you don't work with teens, you probably know a young dancer personally. This conversation may help you recognize when something isn't quite right. So grab your coffee or drive safe and enjoy my conversation with Mara. Mara, I am so excited to have this conversation with you. Thank you so much for being on the podcast. Welcome to the show.

Yeah, thanks so much for having me. I'm super excited to talk about nutrition and all the fun things that go with it.

I know. And this is such a cool niche. I'm really excited to chat with you about ballerina specifically. And you know, that sport is really built around discipline, repetition, and just pushing through very uncomfortable things. And those are really qualities that normally we do praise. So I would love to start this talk with understanding when can those strengths actually start becoming a vulnerability around food, exercise, or that person's body image.

Yeah. So the component that is a little bit different is um what I call the aesthetic component. We're not only looking at all the things to make us strong and perform well, but we're also looking at a lot of times what we look like because there's certain exercises. There's certain, I mean, we look at mirrors all the time. How do we get to a certain size because we need to be lifted or turned? And so there's a lot of components that go into it. Just I have to be strong. I have to be flexible. And those are just a few.

Yeah. I I don't know if the literature's actually looked at this or if you've, you know, noticed something about this, specifically with this dance culture that increases uh the individual's risk for disordered eating, like compared with other sports, because it is so high in this sport.

Yeah, sports in general, you know, you have the higher risk of developed eating disorders or disordered eating. But it's also a component of like, once again, the culture of this sport in particular or this art. You know, sometimes we're falling into disordered eating without realizing we're falling into it because we're pushing so hard. And I think that's something that I like to talk to my dancer clients about because they they might be like, oh, I'm fine, but then they realize I'm starting to miss my period or I'm getting sick a lot. And then those are it starts turning into the disorder. But yeah, it happens more often than what we're realizing. And I think we need more education on it for sure.

And, you know, I'm sure you hear a lot, and we can hear this in clinic as a individual might say, Well, I'm not dieting, I'm just eating clean, or I'm just trying to perform better. And so I would love if you can tease out what are some of those early signs that maybe performance nutrition possibly has crossed over into like underfueling or even disordered eating signs.

Yeah. So the eating clean is probably the one that's like, you don't think it's going in that direction because you're like, I'm doing such a good job. Like I'm I'm eating healthy, all the whole fruits and vegetables, but it starts crossing over, you know, it's, I believe it's the turn orthorexia, you know, where you start becoming like obsessive about it, where you don't want to enjoy outings or you're being weird in social events, or you're even hiding food because you you feel ashamed that you're eating something that's not like clean or a whole food or something along those lines. So when you start feeling that guilt, that's as a person yourself, that's a good first sign. And also the other components about like the parents kind of looking out like, is your child stepping away or not wanting to go to an event or having those types of concerns? So yeah, that's definitely one of the first signs.

Yeah, it's interesting that you talked about like hiding food or eating differently in front of other people. In episode 166, I actually spoke with an eating disorder registered dietitian, and she shared a lot of ways that we can actually ask if that's happening, because unless you ask, they likely aren't going to tell you. And I feel like that's a really important sign to dig into further and ask for more information from them. And so this that would be a great podcast episode to listen to after this one. It's episode 166, and it's called, So you think you can spot an eating disorder? And I'll link down to it in the show notes. But Mara, I want to talk about something called Red S, I think Reds. And it used to be called the female athlete triad. So I learned about the female athlete triad when I was in college. And so some of my listeners might be like, What is it different? Is it the same? Like, can you give us, first of all, a refresher course on what this triad is and talk to me about this new name? Is there something that's different or anything that we should be aware of?

Female athlete triad is simply the connection of the menstrual cycle, bone health, and energy and how it all works together. So when that triangle is like a little skewed, one thing's gonna be affected. And that's where that triad reference comes in. Triad specific to females too. That's another thing. But reds, it's for both female and male. You have a lot of other components that you're looking at, you know, from gastrointestinal and metabolic, psychological, cardiovascular. There's so many other components that may be affected. I think that's where reds can be like a much better term for what's going on because it's not just the bone health, it's not just the menstrual cycle. There's other people, and we can't leave out the guys too, because there's guys in dance as well.

Yeah, exactly. Is it more of like a clinical practice guideline? Like, are there things that we should do in screen four as like a PCP? Let's say if a dancer is coming to see me, um, are there guidelines within that?

Yeah, so I would look at um, you know, how many times maybe they've their history of like having a bone fracture, some that would definitely be number one. Are they getting sick? Screening, how tired they are, asking questions about like their diet habits and what that looks like as well. Cause once again, a big component of all of this is going to be energy that's affecting all of this. And our food is our energy. So we want it to be checking that. Oh, and once again, if it's a female, we do have to make sure that we're not missing a period or having irregular periods, because that I think is one of the top signs.

Yeah, I agree. And honestly, it's probably not asked enough. And I think, you know, I'm I'm in general pediatrics and I ask about periods a lot, but often we ask more for like regularity and more like on top of our mind is like PCOS, which is now PMOS, kind of we're screening for if they're missing periods. But I think that's really important to pay attention to for any of your athletes. And so, what types of changes in menstruation would become a clinical red flag?

Yeah, the first one that would become a red flag is definitely like we're missing periods. We're skipping without any concerns, of course, of like pregnancy or anything like that. But light periods, you went from like a normal to a lighter one, those would also be other signs to kind of look into. As soon as I personally hear someone say that they're not eating enough, one of my first questions, especially when I'm talking to a female, is like, are you getting your period? Because I want to start cross-checking that off, especially if they're very active.

Yeah. How many missed periods? Like, what's that time frame of like, oh, this is a concern? Cause obviously, you know, sometimes hormones, sometimes stress can maybe shift it for like a month, or if they're not great at tracking and they don't realize you know it was like a shorter month. And so they might have skipped that month, but in reality it was like just 30 days. Um, so I'm curious, like, when are you like you your periods are actually very irregular or you're missing a lot of periods?

Yeah, I would say like once we're getting at like three, I would say that's whenever I definitely have concerns. And if, you know, I we should be taking enough information to kind of see the full clinical picture too. Like if I already know this person's active, this person is not eating well, potentially, I'm like, this is something we gotta watch, or I need to educate this family or this patient on breads and what that is so they become aware.

So besides missing menstruation, what are some other symptoms that maybe they the patient might say kind of off the cuff or just flippantly that might uh trigger us to think about low energy availability, especially if they're not like losing weight or maybe they don't look cacectic or frail at this point?

Yeah, getting sick a lot is one, you know, like I'm always sick. I don't like I'm missing classes, I like I don't know what's going on, or I've had a really sick year this year, like it was having three times, like those that's something that I'll be like, oh, okay, there's another, there's something else going on. And that leads me into like wanting to see what they're like, is there nutritional deficiencies? And it just kind of starts spiraling there generally. If they are talking about lightheadedness, are we checking their heart rate? Are we seeing what that looks like? If it's super fast, is their blood pressure low? You know, from you know, a clinical standpoint, if they have a checkup, like those are concerns from like telling families, like, if you see this, definitely let us know. And then bone health injuries, you know, I broke my ankle, like little things like that. It that could also be a sign where you don't necessarily have to look like a typical someone who is going through an eating disorder.

Yeah, let's let's linger here a little bit and talk a little bit more about some of those bone injuries. I'm curious, like if you can explain the nutrients and calories and why does underfueling really play a role in stress fractures and long-term bone health?

Mm-hmm. So, you know, long-term bone health, the things that we need to have strong bones, like vitamin D and calcium, of course, you know, the energy to go along with it, those are all components of phosphorus, like to help keep our bones strong. So when we're not eating enough, then we're most likely not getting those nutrients. And another thing to even take into consideration is dancers are inside like almost all the time. So they might not even be getting the vitamin D from the sun that we generally need. So we have to take into all those factors. Are we eating enough, getting the calcium? Are we having the right foods? Are we having enough fat? Like those, those are definitely things that we have to look at.

Are there any studies that look at retired dancers and risk of osteoporosis or osteopenia?

Has that been studied? You know, I'm gonna be completely honest with you. A lot of my research based off of my younger dancers. So that's where most of my research lies. I'm sure it's up there. Cause the research for the younger dancers is there's a already a risk out there that they're starting to have bone health that looks like you're older. So I can only imagine what it looks like for older dancers.

Yeah. Yeah, I'd be interested to see the rate of osteoporosis, osteopenia in dancers specifically. Just I think that would be really interesting correlation. And probably a good education piece, right? Because kids just so think about right here, right now. They might not consider the implications for their future. And sometimes, I mean, they're teens, so usually not, but sometimes a study, you know, they could say, hey, you know, this is putting you at risk for when you're older of a hip fracture or something like that. Sometimes that educational piece can be helpful.

Yeah. And you hit a good point too, where it's like these a lot of these teenagers, they they're in their heads. They think they kind of know what's going on and it's hard for them to look long term. So my hope is to make sure we're educating at least right on the nutrition, you know, the energy point. So they don't have to, even if they're not thinking about it, they don't have to worry about it.

Okay. So that actually brings me to my next question very nicely. And this is when we, as their clinician, think and know they need to eat more. They need more energy, they need more calories. But in a dancer's mind, this is very, very scary because they're worried that more energy means changing their body or possibly hurting their performance. Like you said, if they have to be lifted into the air, they don't want to gain weight. So I would love to hear how you counsel patients through this challenge.

Yeah, so that's one thing as a dance dietitian, I have to take into consideration is like we're not trying to make our patients get to a point where they don't feel like they can do those things because when you go on point, when you need to be lifted, the reality is we can't be too big, but you do have to approach that in a specific way. So I approach it as like we need to be strong and we need to be flexible and we need to make sure we're growing right. And whenever I go about the nutrition, and I say it's strategic how we have to go about it. So it's not about just throwing more calories on your plate, but it's about how we're fueling ourselves throughout the day. Before a rehearsal, I'm never gonna tell a dancer to like have a full meal. They're gonna feel heavy, they're gonna feel gross. They also have to realize though, like their energy needs are probably a lot higher than what they think they are, especially if they're having those signs. So it's very much individualized because we might have some dancers who actually need to work on some weight loss and get to like a stronger body. But then there's the dancers who might need the weight gain because they're at a much higher risk. And then there's dancers who just they're right here, they're kind of in a great spot. And it's more about perfecting that strategy so that way that they are not feeling like too tired or too full and those types of things.

What do you say to someone when they say, well, I don't want to eat more because I'm gonna gain weight? So a lot of times I just do the math with them.

It's sometimes better for them just to like see it. And I don't like to tell my dancers to like calorie count because I'm not trying to promote that future, but sometimes they need to see what the math that I'm using to in order to tell them what they're what they need. Um, so they come to a realization, they're like, oh, this is how many grams of protein I should be having per day, or this is how many calories I should be having. And they see that formula and it kind of makes like that black and white data kind of come together to their personal life. So that that's definitely like one approach. I like the education side of it more than anything.

I actually really like your approach of kind of bringing in the math and the science behind it that brings data to them and that can be something that they can hold on to. And I had a dietitian on previously, and we actually talked about nutrition for injury recovery. And injured athletes also feel like they don't need to eat a lot because they're just lying around, right? Like I'm not doing two a days anymore. Why do I still need to eat at all? I don't want to eat because I'm going to gain weight. And she had a very similar approach of kind of talking about the metabolism and the science behind why fuel is still important, especially through an injury. So if you're tracking with us and you wanted to learn more about specifically like injury nutrition and maybe having a cool technique for discussing this with patients, go listen to episode 158. It's titled The Nutrition Mistake Every Injured Athlete Makes. I think you'll love listening to that one after this episode. Okay, Mara, if a clinician suspects disordered eating or even red S in a dancer, what happens next? Because I promise you, as a PA, we kind of don't know what to do.

Oh, it's a really good question. If we're suspecting like an actual eating disorder, we need to make sure we have, you know, psychiatry and therapists starting to get involved at that point. Um, so having a list of people you can go to for that. And then of course, I'm, you know, advocating for the dietitian, getting them involved too. Dieticians, I feel like sometimes we're like kind of discovering like the nitty-gritties because we're going through the diet recalls and we're picking up on some nuances that's really hard for, you know, the physician has so much to look at as well. So I love being able to pull that out and be like, hey, I think I noticed this. And then I mean, it could go even deeper, like depending on like other symptoms that we're having. Like, do we get GI involved because we're having like slow movement in our gut because things aren't working right? But the that's kind of like the route that I would encourage to take.

Is there, and this could be countrywide, because obviously all my listeners are in different states. So even if you know of a place, is there like a one centralized hub for an individual? Cause even as I'm thinking, I'm like, wow, that's like four referrals that I have to generate for my patient and four different people that this person now has to see, which the likelihood of them actually doing that is highly unlikely. So I'm just curious if there's more comprehensive care available.

Yeah, that's a really good question. Well, my background actually comes working with Johns Hawkins. So we have like we have a pathway for our individuals who become inpatient. Um, and then they kind of handle like the referrals from there. Outpatient care. They specifically do have like a whole disordered eating clinic that they'll be able to go to to kind of walk through. And they have all their clinicians that meet with them. So there's definitely areas that have it all in kind of like one spot so that way it doesn't become stressful for the physician. But we we would have to know our sources like within where you live and maybe looking into the pediatrician hospitals that exist.

Yeah, I agree. And also like the eating disorder clinics, you know, I mean, they're not all just inpatient. There's a lot of outpatient counseling that's available and things like that. So I love that you ended that by saying to know your resources. Like it does take a little extra work on our part, but this does sound like an area of medicine that is really limited for our patients and an area that I really think a lot of work could be done because I think these patients deserve more care than what we're giving them. And so, Mara, thank you so much for the work that you're doing. I'm just really grateful that you're able to take your personal history with this and your professional expertise and button those together to help your clients. So I just wanted to thank you for what you do. And if people are online and they want to connect with you, where can they do so?

So you can find me on my Instagram at Mara.thedance dietitian. I'm also on TikTok, same name, Mara.thedance dietitian. You can also go to my website. It's beyond the barnutrition.com and bar spelled B-A-R-R-E, like the belly bar. So that's my dance program. If you want to work one-on-one with me, I have a three-month program that I have just launched.

That's amazing. I will link down to all of that down below. What an incredible resource. So if you work with dancers and you're just even not sure, or you feel like you really can't provide the care that that patient needs sitting in front of you, send them to Mara. She will absolutely give them the care that they deserve. Mara, thank you so much for the gift of your time today. It was so fun chatting with you. Thank you so much. I had a blast. And thank you guys for carving out some time for nutrition today. I will see you next week.