Appendix H - Participant Healthy Eating Policy

Policy for the prevention, identification and action on disorder eating.

Written by Sanna Nordin in consultation with representatives from all CATs Approved September 2009 - edited by Annemarie Donoghue for Northern Ballet 2022.

Northern Ballet recognises that disordered eating is more common in dance than in the general population, and that the dance environment can sometimes be a high-risk one for individuals. Disordered eating may also be unrelated to dance, and a combination of factors is often the cause. Nevertheless, we see prevention, identification, and positive action around disordered eating as part of our remit because it is both unhealthy and dangerous to allow problems to go undetected, however they may have arisen. Overall, we know that dance training can, and should be, a positive and healthy experience for all. It is therefore our goal to work toward the promotion of healthy eating and positive body image alongside, and as a part of, our artistic and technical goals.

The aim of this policy is to:

• Make clear the stance that Northern Ballet take on disordered eating
• Aid prevention, so that disordered eating can be avoided wherever possible
• Facilitate identification, so that participants with disordered eating can be identified early and as accurately as possible
• Support positive action when disordered eating does occur

As part of our commitment to this policy, we work to ensure that:

• If a staff member, individual, or carer is concerned about the weight of a dancer this must be communicated to a DSL or DSO. Dancers will not be commented on as being over or underweight, we will focus on the aim of a classical physique. They will only be advised to adjust their weight or diet if it appears that their health is at risk or prior to audition to help them gain a contract of work or place in a school. Only nominated staff along with Designated Safeguarding Leads will directly discuss concerns about under or overeating directly with a participant and where applicable their carer. Advice will be within the framework of this policy and take place in an appropriate setting
• Any dancer seeking to adjust their weight will be given knowledgeable, evidence-based advice regarding healthy eating and weight change. Regular meets will be offered and if necessary, they will be referred to a nutritionist, doctor, or dietician. Changes should be closely monitored and recorded by the participant or carer
• All dancers training intensively with the Academy of Northern Ballet receive yearly guidance on healthy eating and lifestyle choices
• Dancers with a suspected eating disorder will not be blamed or punished. Instead, they will be supported both within the Company and in the seeking of outside help (e.g., GP referral)

Terminology

Many terms are related to this policy, including disordered eating, eating disorders, anorexia nervosa, bulimia nervosa, overeating, binge eating, eating problems, and others. We recognise that eating problems exist on a continuum from healthy eating to clinical eating disorders, with a broad range of more or less healthy/more or less disordered eating in between.

Eating disorders

Eating disorders (including anorexia nervosa, bulimia nervosa, and binge eating disorder) are clinical problems that only a trained professional (such as a psychologist or psychiatrist) can diagnose and treat.

Disordered eating

Disordered eating is a broader term, describing problems that may not qualify as clinical eating disorders. They are less serious, and more people will have disordered eating than full eating disorders. However, people will usually develop disordered eating before eating disorders. For example, a dancer who previously ate healthily may develop disordered eating as a result of an upsetting event or great stress and, unless this disordered eating is tackled, it may develop into an eating disorder. Many individuals also suffer from disordered eating even if they do not have a diagnosed eating disorder.

Disordered eating is therefore a warning sign that we want to take seriously and consequently, this policy deals with disordered eating rather than with eating disorders alone.

Prevention

The Company aim to help prevent disordered eating by:

• Encouraging an atmosphere of supportive openness where it is recognised that dancers sometimes struggle with food and eating, but dancers can feel sure that they will get support if problems do occur, and where people know where to find help if they have any concerns. The nominated staff & safeguarding staff have attended training in understanding eating disorders
• Providing all students with evidence-based information on healthier eating and lifestyles
• Promoting healthy eating through the provision of adequate breaks for re-fuelling and hydration; encouraging students to take onboard enough fluids before, during and after dancing; and, where possible, try to ensure that healthy foods are available to buy. Where this is not possible, students will be encouraged to bring their own healthy lunches, or similar
• Ensuring those students studying on the CAT & Graduate Programmes are given yearly guidance, talks & homework packages to raise awareness and give information about healthy eating, healthy lifestyles and where necessary related issues such as disordered eating and the importance of this for their fitness and injury prevention. This can be delivered by an outside professional with experience in the area and by the staff during study sessions and mentor meetings
• Having this disordered eating policy available to all students, their guardians and Northern Ballet staff
• Ensuring that all staff provide consistent messages about healthy eating, disordered eating, and related issues

Identification

All staff, students and guardians are important in helping with the identification of disordered eating. It is valuable for everyone to have a basic level of awareness of disordered eating and for them to feel confident that the reporting of any suspected problems will be dealt with sensitively and professionally.

All concerns should be written on a Cause for Concern form and handed to a Designated Safeguarding Lead.

Confidentiality

Because disordered eating is sometimes related to perceived performance pressures in dance, teachers/tutors will not be involved “by default”. Instead, it is the job of the Designated Safeguarding Leads to receive reports of any worries, referrals from staff and deal with the necessary one-to-one meetings with students and guardians (where appropriate). It may be appropriate to also involve a health professional. Although we will respect confidentiality as far as possible, the matter will need to be shared between the student, their guardian (if under 18), the Designated Safeguarding Lead and relevant staff (e.g. those teaching the dancer or Programme Manager) on a need-to-know basis so that they may support the dancer appropriately. This most likely extends only to those teachers/tutors who teach the dancer directly. The dancer will always be told if, when, and why staff feel that they need to inform others, before actually doing so.

The identification of disordered eating and dancers at risk will occur via a “flag system.” One or more red flags (more serious warning signs) and/or two or more yellow flags (slightly less serious warning signs) will identify students for positive action.

Red Flags

• Student seeks help for themselves
• A friend, staff member or family member has expressed major concern regarding weight change or eating behaviour
• Evidence of self-induced vomiting, pharmacological abuse, or compulsive over-eating
• Drastic or sudden weight change
• Missing three or more consecutive periods in post-menarchic people (secondary amenorrhea), or not having reached menarche by age 15 (primary amenorrhea)
• Fine hair growth (lanugo)
• Diagnosed with stress fracture(s)
• Experiences major physical symptoms or problems related to disordered eating (e.g., fainting, collapsing)
• Excessive exercising inside and outside their regular training without advice to do so, or exercising under abnormal circumstances (e.g., when injured; in secret in their room)

Yellow Flags

• Two or more friends or Northern Ballet staff members have expressed some concern regarding weight change or eating behaviour
• Experiences several minor physical symptoms or problems related to disordered eating (e.g., sleep problems, dizziness)
• Recurrent injury or illness
• Secretive or evasive around food (e.g., repeatedly saying they “have already eaten”)
• Sudden changes in eating behaviours and patterns (e.g., becoming vegetarian, vegan, fussier about which foods they eat, new intolerances)
• Covers body and wears baggy clothing wherever possible. The dancer may say that they are always cold, and perhaps has discoloured or swollen hands and feet
• Visits the toilet each time they have eaten
• Lack of growth and/or sexual maturation
• Dry, pale, and/or discoloured hair and skin
• Poor teeth and raw knuckles (a result of self-induced vomiting)
• Gets angry or distressed when asked about eating problems
• Repeatedly displays failing concentration and fatigue in class
• Avoids social interactions and/or otherwise changed in personality
• Avoids screening and/or other physical tests and assessments

These warning signs are especially pertinent for dancers who:

• Have low self-esteem
• Are highly perfectionist (especially dancers who never feel that what they do is good enough) and are seemingly unable to stop and rest
• Have a history of menstrual dysfunction
• Have important changes going on in their lives (e.g. parental divorce, exam pressure, moving schools, puberty)

Action

How Northern Ballet deals with problems when they arise.

Importantly, the Company is not responsible for diagnosing or treating disordered eating. Instead, positive action comprises:

• Initial conversation. One-to-one meeting between a Designated Safeguarding Lead and the student as soon as possible after concerns have been raised or a referral obtained. This is an informal conversation to reassure the student that the Company will help support the student in the best way possible.
• Second conversation. If the student is under 18 years of age or has given their consent for guardians to be involved, a second, separate conversation will be held with them involving the Designated Safeguarding Lead and the student. We believe that guardians to students under 18 years of age have a right to know if their child is facing these issues. However, we are aware that, legally speaking, persons under 18 who are considered mature enough to understand what an illness and treatment entail have a lawful right to consent to treatment on their own, without involving guardians. Note: if students are judged to be at immediate risk, guardians will be contacted whatever the students’ age, although their agreement will still be sought.
• Recommending Referral. However the student has been referred, recommendation of referring the student to a qualified professional is imperative. The professional will depend on the nature of the situation.
• Information provision. Information and advice will also be passed to the student so that they, and/or their guardian, can seek further help themselves.
• Follow-up meetings. Depending on progress, the Designated Safeguarding Lead may want to provide on-going support, for example by having the student meet with them and/or another staff member that the student feels happy to discuss with (e.g. personal tutor, health professional).

In case of refusal

Of course, we cannot force anyone to visit their GP or other professional, nor to undertake treatment where this is deemed necessary. If a dancer refuses to seek further help this will be documented within the dancer’s confidential file. A dancer may be required to obtain a letter from their GP, confirming whether they are fit to continue taking part in dance and other physical activity, before being allowed to continue with their training.

In case of rapid weight changes

As a related note, if a dancer is demonstrating rapid weight loss or gain, they may be asked to obtain a letter from their GP or other suitable health professional that can verify whether physical activity should stop. Additionally, this approach may be useful if a dancer who has been under or overweight, and therefore away from dancing for a time, needs to show staff that they are again fit for taking part.

When to stop a dancer from engaging in physical activity

It is difficult to establish at what point a dancer with disordered eating is putting themselves at risk by doing physical activity (including dance). Although this is a difficult task, it is important to have an open discussion about when dancing should cease or reduce, because at very low weights or as a result of drastic weight change, the dancer is at risk of a whole host of physical problems such as pain, cramp, dehydration, fainting, stress fractures, and even heart attacks if the body resorts to
breaking down heart muscle for energy.

Teachers who feel that a dancer is too weak (physically or mentally) to partake in classes have a right to limit participation but will clearly explain this in a meeting with the student and the Designated Safeguarding Lead. Because it is not our role as non-medical professionals to diagnose or treat, the best way to monitor participation may be to establish good lines of communication with a health professional (e.g. the GP involved in the student’s referral or staff from the clinic at which a student is undergoing treatment). This way appropriate, on-going advice may be obtained as to whether the student should be allowed to dance. A health professional could, for instance, be able to advise as to whether the dancer’s weight or weight change is so rapid as to put the person at risk.

Following a modified programme of dancing and other physical activity, much as in the rehab from an injury, is often best. Students should in most cases be encouraged to still attend class, although not necessarily be physically involved. This is potentially helpful for everyone involved:

1. For the student
   1. To understand that we take the issue seriously, while valuing them as people.
   2. To still gain some benefits from the classes: for instance, students will still be able to observe, practice via imagery based on the current exercises taught, and perhaps be involved in feedback.
   3. Allows inclusion, such as seeing friends and emotional support.
2. For staff
   1. To “keep an eye” on the student (e.g. to prevent excessive exercising outside of dance).
   2. To support their learning in whatever way is possible.
   3. To provide appropriate emotional support.
3. For other students
   1. Sends a strong message that we take the issue seriously, while valuing the affected student as a person and not “punishing them” by excluding them from dancing completely.
   2. Allows them to provide emotional support in the form of friendship.

Despite all these potentially positive reasons, attending class when not being able to take part physically can also be very stressful and may result in feelings of jealousy and anger. Therefore, the dancer will be told about the reasons as to why they are encouraged to attend, but will ultimately be given the choice (perhaps in consultation with their guardian).

Auditions for the Academy of Northern Ballet

The basic purpose of auditions is to admit students who not only appear talented/as having exceptional potential, but also for whom the training appears to be in their best interest at that time. This best interest is regarding enjoyment, performance and career goals but also health, safety and well-being. It is not the policy of the Academy to admit students into the scheme who appear to suffer from disordered eating or related problems. However, students being considered for the
scheme who display overt signs of disordered eating at audition will be approached and a conversation held. If the student and their guardian(s) are aware of the issue, treatment is already being sought, and an agreement can be reached regarding, for instance, weight and health targets, the student may be admitted into the scheme. If any of these are not in place, admission may be denied (possibly with a recommendation to re-audition in the subsequent year).

If a student is moving between programmes within the Academy and is known to have disordered eating/an eating disorder, this information will be passed to the relevant Programme Manager to ensure adequate continuation of care.

Resources

Resources used in the development of this policy. Various academic journal articles, as cited in the footnotes throughout.

• The eating disorder policies of the Music and Dance Scheme ballet boarding schools (2008) and of London Studio Center (2008).
• Welbourne, J. (2000). Points to Consider When Establishing Policies to Cope with Eating Disorders in Dance Schools and Companies. From the conference proceedings of Dance UK’s Healthier Dancer Conference Moving Matters.
• Eating Disorders Association. (2005). What you need to know when creating your eating disorders policy.
• Piran, N. (2005). The role of dance teachers in the prevention of eating disorders. In Solomon, R., Solomon, J., & Minton, S. C. (Eds.), Preventing dance injuries (2nd Ed.). Champaign, IL: Human Kinetics.
• Information from b-EAT training session Understanding Eating Disorders with Nikki Schuster in May 2009 and Kathryn Weaver in September 2009.

Resources For Information and Advice Around Disordered Eating

Helplines and websites

• B-EAT, the eating disorders charity
  • helpline: 0808 8010667
  • student line: 0808 801 0811
  • youth line: 0808 801 0711
  • This website has a wealth of information as well as a dedicated section for young people. In addition to the online information and two telephone helplines (one for young people, one for adults), there is a text message service, an email service, a youth forum, a help-finder (search feature where you can find out more about support in your area) and more
  • Information sheets
    • B-EAT also publish several information sheets about eating disorders, including one about eating disorders among men and boys, eating disorders during puberty, and more.

Books

Your Body Your Risk

(edited by Scilla Dyke and distributed by DanceUK). This is a small, spiral-bound book/booklet which uses accessible language to discuss nutrition, eating disorders, and related issues. The book may be bought from DanceUK for around £4.50, and they provide discounts for bulk orders.

Overcoming Anorexia Nervosa

By Christopher Freeman. This easy-read book is based on solid research evidence around cognitive behavioural therapy and is useful both for general information and as a self-help guide. It is affordable and available in online bookshops such as Amazon.

Overcoming...

There are several other books in the same series as Overcoming Anorexia Nervosa that may be useful, including one about binge eating.