The “Triad”: Are You at Risk?

Whenever you think about nutrition in the United States, chances are you wonder why Americans consume so much food.  When you read the government’s 2010 statistics, which shows that one in every three Americans is obese, the seriousness of the problem is quite obvious.¹  Dancers are generally not affected by this problem because of the frequency and intensity of the mere act of dancing.  From a young age, dancers have studied and learned the details of form and technique - they have slowly developed a unique, personal style that helps them express their deepest feelings and emotions.  A dancer’s body curls, lengthens and spins creating an illusion, becoming art.

That artistic instrument that is your body requires certain amounts of fuel, in the form of food that will be burned while taking classes, rehearsing and performing. There is a syndrome that alters the body’s functions when the amount of calories burned is more than the ones that you eat - this syndrome is called the Female Athlete Triad and it affects dancers and other athletes who are required to maintain a slim figure.²  This syndrome is referred to as a “triad” because it has three components:  1. decreased energy, 2. abnormal menstruation and 3. weak bones. The syndrome typically starts when your body burns more calories than the ones you consume. Some dancers aren't aware of the fact that they’re not eating an adequate amount yet others do it consciously because of fear of gaining weight. You can tell this is happening to you if you are losing weight, feeling constantly tired and there is a perpetual sensation of coldness in your hands and feet.³  If this happens for a long period of time, your menstrual cycle will become irregular or it could stop for a few months. An irregular or absent menstrual cycle will subsequently affect your bone health and this can eventually lead to osteoporosis (weak bones) and fractures.

"Some dancers aren't aware of the fact that they’re not eating an adequate amount yet others do it consciously because of fear of gaining weight."

The Female Athlete Triad affects adolescents and young adults who participate in sports like long distance running, diving, gymnastics and dance.  The components of the Triad can happen independently.  You could be eating well and still have absence of your menstrual cycle for several months.  This occurs to many athletes who participate in intense training and the cause is usually that their percent body fat is bellow 22%.⁴  If your menstruation is abnormal, contact your health care professional because you could be at risk of developing osteoporosis and other health problems.

For those of you who struggle with body weight, blame it on the culture of thinness.⁵   We currently live in a society that sees beauty in people who are slim and this dramatically influences the way we think and behave.  Being slim is fine, but in order to perform well as a dancer you need to maintain healthy eating habits. If you are unhappy with the way you look and would prefer to lose weight, a nutritionist can be of immense help. They can assist you at finding a balance between nutrition and a training intensity that will work for you. They will also assist you in establishing healthy and realistic short-term goals - goals that are achievable will make you feel good about the effort you are putting in.  A nutritionist will also discuss the possibility of using positive reinforcement.  Positive reinforcement is a reward for your accomplishments.  The reward can come from yourself, your parents, friends or your teacher.   When you are rewarded for your achievements, you are more likely to repeat healthy behaviors that helped you achieve them in the first place.

"In adolescents, the basic healing time for a fractured bone is approximately two months for fractures in the arms and three months for fractures in the legs. It can take anywhere from 2 to 5 years for anyone to heal 100%.⁷   It is ideal to prevent these problems rather than to have to deal with them in the future."

Besides a nutritionist, there are other professionals who are available to you. Psychological counseling is sometimes recommended for dancers whose body image dissatisfaction leads to disordered eating.  During a counseling session with a psychologist you will explore the reasons behind your behavior and will find ways to modify it. Most people feel good about sharing their feelings with someone who is there to listen, be impartial and offer advice. When talking to a psychologist you could create behavioral contracts - these are small agreements that you will determine and that you will try to stick to during a certain period of time.  You create the rules depending on what you want to accomplish. This type of open one-to-one conversation can be very rewarding.

In some instances your physician will be the best person to talk to. Your physician might ask you to answer a questionnaire called the Pre-Participation Exam.⁶  This exam contains 12 questions that can determine if you are at risk of developing one or more of the components of the Triad.  If you and your physician determine that you are at risk, they will guide you as to what to do next.  As long as you have a desire and willingness to change, negative effects on your health can be prevented.

I am a physiotherapist and, unfortunately, I meet dancers quite often when they have already suffered an injury caused by the "triad".  The most frequent injury that we see is a stress bone fracture but some dancers suffer muscle and ligament injuries as well.  The rehabilitation can be long and painful and you will not be unable to work and rehearse during that time period of healing.  In adolescents, the basic healing time for a fractured bone is approximately two months for fractures in the arms and three months for fractures in the legs. It can take anywhere from 2 to 5 years for anyone to heal 100%.⁷   It is ideal to prevent these problems rather than to have to deal with them in the future.  Think seriously about this information.  The first step to prevent and treat the Female Athlete Triad is by being aware of its existence, which is something you have done just by simply reading this article.  If you decide that there is a problem related to your weight and how it is affecting your dance career, talk to somebody about it.  It could be your fellow dancers, your friends or any health care provider with whom you feel comfortable speaking.

Hector Lozada, Physiotherapist, doctoral student at Boston University. Email: hlozada@bu.edu

References:

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity in the United States, 2009–2010. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.  NCHS Data Brief, 82;2012.

2. Barrack MT, Ackerman KE, Gibbs JC. Update on the female athlete triad. Curr Rev Musculoskelet Med. 2013;6(2): 195–204.

3.  Signs of the Triad. Female Athlete Triad Coalition. Available at: http://www.femaleathletetriad.org/for-athletes-coaches/signs-of-the-triad/.  Accessed October 15, 2013.

4. Rintala M, Mustajoki P. Could mannequins menstruate? BMJ.  1992;305:1575-1576.

5. Halliwell E.  The impact of thin idealized media images on body satisfaction: Does body appreciation protect women from negative effects? Body Image. 2013;10(4):509-514.

6. De La Torre DM, Snell BJ. Use of the preparticipation physical exam in screening for the female athlete triad among high school athletes.  J Sch Nurs.  2005;21(6):340-5.

7. Weerakkody Y, Schubert R. Fracture Healing. Radiopedia web site.  Available at: http://radiopaedia.org/articles/fracture-healing. Accessed October 15, 2013.

First Steps to Weight Loss

PART TWO: Eat Salad Every Day

THE BIG PICTURE Leafy green vegetables, especially dark green ones, are the most nutrient-dense foods on the planet. That makes the act of eating a salad one of the most important things you can do to improve your overall well being and maintain a healthy amount of body fat. As long as your salads are done right (see below), eating more of them will both decrease the calories you take in and increase the nutrients you get. This means salad consumption is very helpful for both weight loss and health gain.

NUTRIENT DENSITY Healthy foods are nutrient dense, meaning they have a lot of nutrients per calorie. Micronutrients are a class of nutrients that are crucial for having a long, healthy life. They keep your body in running order, including your bones, soft tissues, eyes, and immune system. Getting lots of them also significantly reduces your risk of many diseases, including certain types of cancer. Calories are what give you energy. Since you only need so much energy per day, you’re better off getting as much nutrition as you can along with those calories. Most people eating Western diets get too many calories and not enough micronutrients. This almost always leads to too much body fat and ill health. That means most Westerners need to eat more foods that are more nutrient dense, like greens.

Salad is high in many nutrients, including fiber. Eating fibrous foods such as vegetables, beans, and fruit fills the volume of your stomach and makes you feel full and satisfied. That leaves less room for food that is less healthy. And so, one easy step you can take to reduce the amount of calories you eat while increasing the amount of nutrients you get is to eat a salad every day, preferably before a big meal like lunch or dinner. Some people even base an entire meal on salad by adding other yummy ingredients, like the ones below.

WHAT MAKES A SALAD AWESOME? Aside from green leaves, there are many more tasty and health-promoting foods you can add to your salad. Here are some:

-greens: romaine lettuce, spinach, mixed greens, arugula -other vegetables: bell peppers, onions, tomatoes, carrots, sprouts, artichoke hearts -fruits: diced grapefruit, apples, figs, berries, and any dried fruits -nuts and seeds: pumpkin seeds, hemp seeds, sunflower seeds, walnuts, almonds, flaxseed -herbs, fresh or dried: cilantro, oregano, mint -legumes: black beans, red lentils, garbanzo beans, kidney beans, sweet peas -whole grains: brown rice, quinoa, barley, millet, wild rice, corn

The more ingredients you add from the vegetables, legumes, and fruits categories, the more nutrients your salad has per calorie. And when you include fruits, herbs, and other delicious foods, the tastier your salad becomes and the less dressing you might want to add.

WHAT MAKES A SALAD BACKFIRE? Adding foods that are low in nutrients but high in calories can destroy the health status of a salad in no time. Meat, cheese, and oil are common examples. If you add these foods, they should be in small amounts (the smallest amount you can muster). Croutons made from white bread are another example of a low-nutrient food often added to salads.

Many salad dressings are based on oil, which is one of the least nutrient dense foods around. Even olive oil, which has been heavily advertised as a health food, is actually very low in nutrients aside from fat, from which it gets 100% of its calories. That means that the more oil and oil-based dressings you add to your greens, the less health-promoting the salad becomes. And the harder it will be to maintain a healthy weight or to lose weight.

HOW DO I MAKE A HEALTHY SALAD DRESSING? If you are buying a salad dressing, one of the first ingredients in the ingredient list should be some kind of vinegar or water, not oil. One trick is to just buy vinegar on its own, such as balsamic, apple cider, etc. You can also use hummus, tahini, salsa, and hot sauce as great salad toppings that can be mixed in to add a lot of flavor.

There are lots of recipes for healthy salad dressings, but here’s a simple formula you can use to create your own: Pick a vinegar, a nut butter or seed butter, an herb or spice, and a citrus fruit. Put these ingredients into a blender and add enough water to blend. Keep adding water until you have the desired consistency and flavor power. Lots of vinegar will take lots of water and other ingredients to mellow out. The more nut or seed butter you add, the more calories the salad dressing will have. Athletes needing more calories can be generous with the amount of nuts and seeds their salads--and any meal--include.

Part 1: Stop Drinking Calories!

DISCLAIMER: The author is neither a nutritionist nor registered dietician. Information contained herein was gathered from many sources and can be found in the literature of such organizations as the World Health Organization, the American Dietetics Association, the American Council on Exercise, National Institutes of Health, and others. Consult with a physician before making changes to your diet or exercise program.

For more about the Author, Sebastian Grubb visit: SebastianGrubb.com

Catching Up With Sebastian Grubb

Enforced Arch 'Mover' and contributor, Sebastian Grubb takes life one step at a time but carries the world in his arms. Tackling fitness, nutrition and dance in one lifetime may seem overwhelming but for him, it's done with grace. He is thrilled to share his expertise with the world and has recently launched a website where you can get the best of all three worlds in one place. I had the opportunity to briefly interview him and here's what he had to say:

You have a very diverse background of expertise. Why did you choose to bring them together into one website? My life is organized around bridging my different interests. Movement, food, creativity: balancing these make up what I consider the foundation of a good life. In the end, my primary pursuits are health and happiness, and professionally that means working as an artist and trainer. I also don't see such a big divide between the categories; you need to eat well to move well (over the long-term), and dance certainly fits into the pursuit of fitness also.

What do you expect someone to get when they stumble upon SebastianGrubb.com (supposing they came for nutrition and they peruse the dance section)? I hope they might see the connection, see how different pursuits aid each other. Dance is an ancient, ancient human tradition; every culture has their own dance. That's strong evidence for the importance of everyone dancing. So someone can come to my site and think, "Hmmm, maybe I'll go out dancing this week or take a dance class." On another track, I notice that people who do pursue dance and/or fitness do not necessarily also pursue healthy eating, or have misinformation about what is actually healthy. That's why I have written and posted nutrition articles on the site.

Please tell me about Sebastian Grubb's philosophy of movement and lifestyle: My philosophy around healthy living is: to make time to move creatively and vigorously most days of the week, to eat almost exclusively whole plant foods, to sleep well and foster healthy social relationships. In more specific terms, exercise for at least 1 hour on 6-7 days per week; eat as many vegetables, fruits, legumes and whole grains as possible; sleep 7-10 hours a night, depending on need; practice sensitive, mature communication and healing psychological wounds.

What is a typical day in the life of Sebastian Grubb, what do you eat, what companies do you spend your time with? I have an unfortunately chaotic schedule, owing to shifting dance rehearsals, performances, and touring. That said, I generally dance 20-30 hours per week and train fitness clients 12-15 hours per week, in small groups and 1-on-1. I often train clients in the morning and evening, with a rehearsal in between. I work like this 6 days a week. And I perform about 20 weekends per year, with about 12 of those being outside California.

As you might have guessed, I eat a lot. Here's my basic structure: Breakfast based on fruit, lunch based on salad, dinner based on steamed vegetables. Add to that a lot of whole grains, nuts, seeds, and legumes. And add a snack mid-afternoon, and an additional meal, usually a second dinner. This past year I have been learning a lot about training less to avoid injury and burnout, and about eating denser calorie sources, like nuts and seeds. It's funny that part of my challenge has been moving less and eating more, but that's just how it is.

I also do fitness-specific training for myself, like circuit strength-training, running, etc. This totally depends on the intensity of my rehearsals, if I am doing a lot of lifting of other dancers, learning a new style, or getting ready for a performance weekend. In general I fit in 2 strength training sessions per week, usually right before a rest (or low-intensity) day. Again, it's about the whole picture and a long-term perspective of sustainability.

Here's who I'm currently working with in the dance world: AXIS Dance Company hired me in 2009 and it has been a phenomenal learning and growth opportunity for me. We work 12-20 hours per week, on average, and I do almost all my touring with AXIS. I have been performing with Scott Wells & Dancers since 2008, which is a project-based gig. And then I freelance and make my own work. Currently I'm rehearsing with Christine Bonansea on a dancetheatre piece inspired by Sartre's play, "No EXIT". I'm also choreographing "WORKOUT", a dancetheatre piece based on fitness training and fitness-specific subcultures. It's very entertaining, vigorous, and interesting for me. WORKOUT will premiere this December in San Francisco.

What legends in the dance community, or perhaps not in the dance community, inspire you? I have always been inspired by older dancers. This started when I was in college and looked to young professionals in their twenties. Now I am inspired by dancers in their thirties and beyond. I love watching someone dance who is in their fifties or sixties and has this whole body of experience and movement history. It really shows. I'm looking to cultivate that in myself, as an aesthetic choice and even as a subtle spiritual practice. In the Bay Area I've been most inspired by Joe Goode and Scott Wells, both of whom are remarkable dancers, but who've also attracted communities of dancers and audiences around their work, which continues to evolve.

Growing up I performed in musicals and also saw a lot of them performed, some live and some on video. I remember being particularly inspired by Gene Kelly. I also watched most of Charlie Chaplin's films and draw from them to this day.

I should add that I am inspired by watching athletes; I love the pure effort, and the grace that comes from finding efficient ways to move. In college I was really inspired by bodybuilders and strongmen, both of whom have taken this process of molding and changing their bodies to an extreme. It takes such diligence and belief in their own ability to shape their world. I really admire that, though I would say my own fitness practice is much more balanced today than it was when I first pursued fitness via bodybuilding.

What's coming up for you and how do we follow your inspirational work? Thanks for asking! I have a lot of upcoming projects. Earlier I mentioned "WORKOUT", which premieres in December. I am also about to begin making a commissioned work for AXIS Dance Company. And AXIS has two big projects this Fall, making long works with outside choreographers Amy Seiwert and Victoria Marks. We will basically have two rehearsal intensives back-to-back over three months. Those will all be more like 30-hour dance weeks. You can catch all this in video and social media on-line via facebook, twitter and youtube. Here are some specific websites to check:

http://www.axisdance.org http://www.sebastiangrubb.com/gallery http://www.youtube.com/sebastiangrubb http://www.youtube.com/user/axisdancecomp

Images of Sebastian Grubb from The Narrowing, for AXIS Dance Company. Photography by David Papas

Thank you Sebastian Grubb for taking time to share this information with the Enforced Arch community. We are looking forward to all your upcoming creative projects and celebrate your achievements thus far!

Be sure to check out his new website HERE!

SUPPLEMENTATION: Part 6 of 7

Photo courtesy of niaid.nih.gov

VITAMIN B-12

For those who only consume plant foods ("vegans") or those who have a hard time absorbing B-12 (generally, the older we get, the harder it is), taking a B-12 supplement is highly recommended by many medical practitioners and health organizations. B-12 is one of many B vitamins, but it is the only one not provided in plant foods. It is made by a bacteria that lives in many places, including dirt and animal intestines. For animals, B-12 stores up in their bodies; hence, if you eat another animal's body, you consume B-12 too. Humans also have this special bacteria living inside us, but we don't get enough B-12 from them. Since plants tend to have the dirt washed off them, if you only eat plants you will not get adequate B-12. If you are not sure about your own B-12 status, you can get a blood test done at a doctor's office; ask specifically for them to check your B-12 level. If you believe you could benefit from supplementing it, B-12 supplements are easy to find and painless to take.

SUPPLEMENTATION: Part 1 of 7 SUPPLEMENTATION: Part 2 of 7 SUPPLEMENTATION: Part 3 of 7 SUPPLEMENTATION: Part 4 of 7 SUPPLEMENTATION: Part 5 of 7

For more on the Author, Sebastian Grubb, visit his ‘Movers’ page!

SUPPLEMENTATION: Part 5 of 7

VITAMIN D DETAILS

Vitamin D is required by the body to absorb and utilize calcium. Without enough Vitamin D in the body, one will not be able to keep one's bones strong by maintaining their calcium balance. Vitamin D is available to us in three forms: synthesis via sun-exposure on one's skin, consuming certain foods, and supplementation/fortification. Most whole foods that contain Vitamin D are not otherwise the more nutritious of foods (e.g. cow liver, fish liver, cheese, and egg yolks). Hence most experts recommend obtaining adequate Vitamin D via the other two methods. Supplementation is relatively easy to do and is recommended for many categories of people: those living far away from the equator, the elderly, those with known difficulty in synthesizing Vitamin D via the skin, those living in a wintry climate, those who remain indoors, those with dark skin who get little sun exposure, and those who always cover themselves completely with clothes or sunscreen. Aside from people living on or near the equator, most people will for some part of the year be helped by Vitamin D supplementation. Near the equator and elsewhere in summer, most people can get enough Vitamin D by exposing the skin of their arms and face to sunlight for 15-20 minutes. For those with darker complexion, more time is required. Far from the equator or when it is no longer summer (i.e. the sun remains within 45 degrees of the horizon), consumption of foods fortified with Vitamin D or supplementation of this nutrient is recommended. It is of course possible to get too much of a good thing, so please check with a physician about your daily recommended intake (400-800 IUs is typical).

SUPPLEMENTATION: Part 1 of 7 SUPPLEMENTATION: Part 2 of 7 SUPPLEMENTATION: Part 3 of 7 SUPPLEMENTATION: Part 4 of 7 SUPPLEMENTATION: Part 6 of 7

For more on the Author, Sebastian Grubb, visit his ‘Movers’ page!

Fast BreakFast

Organic Bluberries Organic Rasberries Pistachio Apricot Granola Organic Silk LIVE! Soy Yogurt

Dancers stress about the cost of groceries and find themselves making trips to the nearest fast food chain in the morning, between classes or rehearsals, and even after performances. I understand the convenience of fast food but it's generally unhealthy and processed foods are full of sugar, salt, cholesterol and void of nourishment. It may seem like you're breaking a deal but the unforeseen costs are toward your overall health. Dancers need to be especially concerned with what they're putting into their bodies. It's our medium of expression and deserves our utmost care.

I manage to make myself a healthy breakfast, within budget, that is both quick and delicious! If you spend $5 on a fast food breakfast each day let's imagine this means you have a budget of $35 a week. With that money you can get a couple $4 boxes of organic berries, a $5 bag of organic granola and a tub of organic soy yogurt for $6. I suggest soy yogurt over animal yogurts because *2% dairy products contains 20mg of cholesterol while all soy products have none! Lastly don't forget a beverage which can be anything from fresh squeezed organic orange juice, organic soymilk or fair trade coffee. These items cost up to $5 for the half gallon or 1/2 lb bag of coffee grounds.

$4 Bluberries $4 Rasberries $5 Granola $6 Soy Yogurt $5 Beverage Total cost = $24 a week

*Dairy data from USDA National Nutrient Database for Standard Reference, Release 23 (2010). Data consistent with typical 2% milk.

SUPPLEMENTATION: Part 2 of 7

CALCIUM AND VITAMIN D

Two nutrients currently receiving a great deal of attention are calcium and Vitamin D. This is in part because inadequate levels of Vitamin D in the body have recently been linked to higher risk for a host of diseases (including multiple sclerosis, dementia, Alzheimer's, certain cancers, heart disease, and all-cause mortality). It is also because many populations living in wealthy areas such as the EU, UK and U.S. have been seeing a decrease in their bone-strength (e.g. osteoporosis). And it is calcium (with the help of Vitamin D, Magnesium, and other nutrients) that is the primary raw material for making and maintaining strong bones.

This increasing trend for weak bones has contributed to the popularity of calcium supplementation. Yet those populations around the globe that consume the most calcium (such as Americans in the U.S.) actually have the highest rate of osteoporosis. And often those in other populations (with different lifestyles) who consume much less have bones that are surprisingly stronger. In the end, it seems that calcium intake is not the most important factor for having strong bones. Rather it comes down to three others: 1) quantity and type of exercise, 2) dietary intake, aka food, and 3) Vitamin D via sun-exposure, certain foods or supplementation.

Safe, health-promoting exercise and strong bones are mutually dependent. Movement that is both vigorous and safe requires strong bones to support it. At the same time, maintaining an active, movement-based lifestyle is key to having strong bones. This, coupled with elevated rates of osteoporosis and people seeking healthy ways to treat it, is why bone health is an important sub-topic for the Axis Syllabus student and practitioner.

SUPPLEMENTATION: Part 1 of 7 SUPPLEMENTATION: Part 3 of 7 SUPPLEMENTATION: Part 4 of 7 SUPPLEMENTATION: Part 5 of 7 SUPPLEMENTATION: Part 6 of 7

For more on the Author, Sebastian Grubb, visit his ‘Movers’ page!

Dancers Are Also Athletes

Additional exercise outside your dance program should be chosen to complement what you are already doing. For many this means strength training for muscle groups not targeted by dance, and activities that are even more aerobically demanding, such as running. Dancers may also want to consider reducing the impact on their joints by selecting (non-dance) exercise forms such as bicycling and swimming. Drink 1-2 cups of water before activity, sip throughout, and generously replenish afterward.

If exercising strenuously, and to speed recovery, ensure adequate intake of foods high in carbohydrates within 30 minutes and foods high in protein within 60 minutes following activity. Healthy foods high in carbohydrates include fruit and whole grains. Plant foods high in protein include beans, lentils, nuts, and seeds.

Ensure adequate intake of carbohydrates and fluids before, during, and between dance sessions to improve energy levels and digestion. Dancers often dance many hours per day, with small breaks in-between rehearsals and classes. Focus on small snacks high in carbohydrates, fluid replacement, and save a larger meal for the beginning of a break of 2+ hours and after the day's activities are over. Under-eating is a surefire way to have inadequate energy during class or rehearsal.

Warm-up appropriately, starting with a low dynamic and keeping initial stretching light and in short duration (approximately 5 seconds). Take time to cool-down at the end of each activity session, gradually reducing activity intensity and finishing with deeper stretching, especially for muscles that worked extra hard or are excessively tight. Take at least 1 rest day per week from intense activity. Aim for 8-10 hours of sleep every 24 hours.

Ensure adequate intake of Vitamin D for optimal bone health. In some sunny climates nearer the equator, this can be accomplished with sun exposure on your own skin. In winter and in areas far North or South of the equator, supplementation is highly recommended by many health agencies. Vitamin D plays many important roles in the body, including the process of utilizing calcium to increase and maintain bone density. (Disclaimer)

For more on the Author, Sebastian Grubb, visit his 'Movers' page!