Article
Bone Mineral Density in Collegiate Dance Majors
Compared to Healthy Controls
Gregory S. Farnell, PhD, Valerie J. Williams, PhD, DPT, and Kristin Bogda, PhD
INTRODUCTION: The bone mineral density (BMD) status
of dancers is currently unknown. Some research indicates
that female dancers have no difference or higher BMD
than non-dancers. Other evidence indicates they have
lower BMD, predisposing them to osteoporosis and frac-
tures later in life. These differences among studies may be
due to differences in dancer type, age, level, and lack of
control of confounding variables. Few studies have been
completed on college-level dancers.
PURPOSE: To evaluate BMD in female college-level dance
majors.
METHODS: 20 female multi-genre collegiate dance
majors and 12 female non-dancer control subjects partic-
ipated in the study. Each participant underwent three
consecutive dual energy x-ray absorptiometry scans to
determine BMD of the total body, dual femurs, and
lumbar spine. Statistical analysis was completed by an
independent samples t-test.
RESULTS: The lumbar spine demonstrated a significant
difference between groups (p=0.011), with dancers show-
ing greater BMD (1.32±0.10 vs 1.21±0.12 g/cm2). There was
no significant difference between groups for total body or
dual femur BMD (p=0.104 and 0.175, respectively).
CONCLUSION: College-level dancers may have higher BMD
of their lumbar spine than non-dancers, but not in other
areas. This area may have increased BMD due to loading
from dance activity and warrants further investigation.
Med Probl Perform Art 2018; 33(2):90–94.
Dr. Farnell is at Department of Exercise Science and Sports
Studies, College of Arts and Sciences, John Carroll Univer-
sity, University Heights, OH, USA; Dr. Williams is at College
of Health and Life Sciences, Clinical Sciences Physiother-
apy, Brunel University London, Uxbridge, UK; and Dr.
Bogda is at Department of Health and Exercise Science,
College of Arts and Sciences, University of Oklahoma,
Norman, OK, USA.
Abstract presented at the annual American College of
Sports Medicine conference, May 28−June 1, 2013, Indi-
anapolis, IN.
The authors declare no funding or conflicts of interest
related to this study.
Address for correspondence: Dr. Gregory S. Farnell, Dep.
of Exercise Science and Sports Studies, John Carroll Uni-
versity, 1 John Carroll Blvd., University Heights, OH 44118-
4581, USA. Tel 216-397-1681. gfarnell@jcu.edu.
https://doi.org/10.21091/mppa.2018.2015
© 2018 Science & Medicine. www.sciandmed.com/mppa
90 Medical Problems of Performing Artists
O steoporosis is a disease diagnosed when an individual
has too low bone mineral density (BMD). More
specifically, the World Health Organization (WHO)
defines osteoporosis as a BMD that is 2.5 standard devia-
tions (SD) or more below the mean peak bone mass rela-
tive to an average young, healthy adult as measured by
dual-energy x-ray absorptiometry (DXA). A closely related
condition, osteopenia, is considered pre-osteoporosis,
where BMD is 1.0 to 2.5 SD below peak bone mass.1 Osteo-
porosis generally manifests in older adults, but prevention
early on in life may help prevent fractures and other seri-
ous comorbidities.2 It is often difficult to distinguish the
benefits of prevention versus specific interventions for
osteoporosis; prevention measures and clinical interven-
tions practices both have the same goal: to increase bone
mass and reduce fractures.2 Intervening, however, specifi-
cally with physical activity during the early years of peak
bone accrual (late puberty), may result in significantly
more bone growth than less active child.3
Dancers present with several factors that would indi-
cate they may have lower than average BMD, but also pos-
sess other characteristics that would suggest they have a
higher than average BMD. A dancer’s lifestyle may predis-
pose them to reduced BMD from some potential risk fac-
tors, such as disordered eating, low weight, low energy, cal-
cium and/or vitamin D intake, cigarette smoking,
excessive physical activity, and amenorrhea.4–6 In some
studies, young (age unspecified) dancers and professional
ballet students were found to have decreased BMD, poten-
tially due to low energy intake, low weight, and high phys-
ical activity, which may predispose them to osteoporosis
later in life.7,8 However, the fact that they are engaged in
high impact activity associated with dance would suggest
they may have a higher than average BMD.
Karlsson et al.9 studied the effect of physical training on
BMD in 42 professional ballet dancers. In their sample, the
dancers were, on average, 9 kg lighter but the same height
as their control group. After analyzing the absolute data,
they found no significant difference in BMD between the
dancers and controls. However, once they corrected for the
difference in the body mass index (BMI) of the two groups,
they found that the professional ballet dancers had higher
BMD in the lower extremity.9 Other studies have also
shown increased BMD in both young non-elite (age 10–12
yrs) and professional dance students (age 18–26 yrs).3,10 A
recent systematic review concluded that no universal agree-
ment on the BMD status of dancers can be found.11 The
authors suggest that future work should focus on develop-
ment of high-quality research studies which address risk
factors associated with low BMD as well as clearly defining
dancers’ training level, age, and ethnicity.11
Within the existing literature on BMD in multi-genre
dancers, professional dancers or young dancers are almost
exclusively the research participants, with very little litera-
ture examining college-aged, university-level dancers. A
few studies have investigated BMD in collegiate dancers
and did not find them to be different from controls.12-16
These studies included relatively small samples sizes rang-
ing from 10 to 36 subjects. Two studies were conducted in
the United States and two in Asia. There may be differ-
ences in BMD status related to ethnicity, and therefore it is
unknown if studies on dancers from different ethnic back-
grounds should be considered together when generalizing
to one population to another.11 Different genres of dance
may also affect BMD differently, depending on the absolute
load placed on the axial and appendicular skeleton.
Purpose: Dancers are a unique category of athletes where
their sport involves a high level of conditioning and impact;
however, collegiate dance majors may also engage in behav-
iors that may decrease BMD, or potentially increase BMD.
The current BMD status of collegiate dance majors is
unclear. The purpose of this study was to investigate the
BMD in multi-genre college-level dance majors in the
United States. It was hypothesized that dancers would have
a significantly different BMD than control subjects. Poten-
tial factors which could influence BMD including non-
dance exercise activity and menstrual irregularities were col-
lected, but not controlled, in order to describe the dancers
being studied and aide in generalizing to similar subjects.
METHODS
Thirty-two female participants (20 dancers, mean age
19.9±1.1 yrs [SD]; 12 controls, 20.6±2.9 yrs) were recruited
from a public university in the central United States. The
study was approved by the University of Central Okla-
homa Institutional Review Board (#11007 FB) prior to sub-
ject recruitment. This sample size is reflective of the largest
number possible to recruit at the time of the study at the
university where the study was carried out.
Participants were recruited during planned group meet-
ings with all dance majors. Subjects in the dance groups
were required to be dance majors enrolled in the univer-
sity. The undergraduate dance program included training
in advanced levels of ballet, modern, jazz, and tap. The
control group was also enrolled at the university and
recruited from a university-wide required core wellness
class. Initial voluntary consent was obtained following
informational meetings about the study; the students’
dance or health class instructors were not present at these
meetings. All subjects were between the ages of 18 and 24
yrs, female, considered low-risk for activity participation
using American College of Sports Medicine (ACSM)
guidelines, and not currently pregnant.17
Upon arrival at the lab, each participant completed an
informed consent form. Height and weight were measured,
and body mass index (BMI) was calculated as mass
(kg)/height (m)2. Self-reported questionnaires were admin-
istered to gain descriptive information regarding the dance
history/training of the dance group, the non-dance exer-
cise activity of all subjects, menstrual health, and nutri-
tion. Each participant underwent a standard DXA scan
(GE Lunar iDXA, GE Healthcare, Madison, WI) to deter-
mine BMD for the total body (BMD total), femoral neck
(BMD femur), and anteroposterior lumbar spine (BMD
lumbar). The lumbar score was from levels L1–L4. Body fat
percentage was also determined via the DXA scan. All
scans were done on the same day.
All data were assessed for normality and homogeneity
of variance with the Shapiro Wilk and Levene’s tests. An
independent t-test (two-sided) was performed to assess for
differences between groups. A Mann-Whitney U-test was
used to compare any non-normally distributed data. A
Fisher’s exact test was used to determine differences in sub-
ject responses to menstrual health and exercise questions
that were categorical in nature. All analyses were per-
a=0.05 set a priori. Because multiple comparisons were
formed using SPSS (ver. 24, IBM-SPSS, Armonk, NY) with
was applied (adjusted a=0.05 ÷ 3). The adjusted a to deter-
made for the primary hypothesis, a Bonferroni correction
mine significance was 0.017.
RESULTS
The purpose of this study was to describe BMD in college
dance majors and determine if there was a difference in
BMD compared to non-dance majors. All subjects identi-
fied as Caucasian or African American. There was no dif-
ference in proportion of self-reported race between groups
(c2=2.743, p=0.136). In the dancer group, 95% of the sub-
jects identified as Caucasian and 5% as African American.
In the control group, 75% identified as Caucasian and 25%
as African American. No subjects identified as Hispanic
or Asian. No differences were found between groups for
any demographic variables (Table 1). Within the dance
group 20% reported ballet, 20% modern/contemporary,
55% jazz, and 5.0% tap as their dance specialty.
Self-reported responses to questions regarding men-
strual health and exercise habits are presented in Tables 2
and 3, respectively. Members of the control group self-
reported to regularly exercise (non-dance) on more days
per week than the dance group: 4.3 (range 3.3–6.0) vs 1.0
(0.3–2.9) days/week, p=0.005. The difference in hours per
day spent exercising (non-dance) was not significant
between groups: dancers 1.0 (0.0–1.5) vs control 1.5 (1.0–
2.0) hrs/day, p=0.115).
Results of between-group comparisons in BMD are
shown in Table 1. The independent t-test identified a sig-
nificant difference between groups for BMD lumbar
June 2018    91
 TABLE 1. Descriptive Data and Differences in BMD of Collegiate Dancers and Controls
Dancers
___________________________ Control
___________________________
Mean ± SD n Mean ± SD n p-Value*
Age (yrs) 19.9 ± 1.1 20 20.6 ± 2.9 12 0.774
Height (cm) 162.8 ± 5.5 20 163.4 ± 6.0  12 0.786†
Weight (kg) 60.0 ± 7.5 20 60.9 ± 6.7 12 0.719
BMI (kg/m2) 22.6 ± 2.5 20 22.8 ± 2.2 12 0.826
Body fat (%) 28.79 ± 5.0 20 32.82 ± 6.7 12 0.061
BMD total (g/cm2) 1.16 ± 0.08 20 1.11 ± 0.08 12 0.104
BMD femur (g/cm2) 1.15 ± 0.11 17 1.08 ± 0.13 6 0.175
BMD lumbar (g/cm2) 1.32 ± 0.10 16 1.21 ± 0.12 11 0.011
*p-Values from two-sided t-tests with equal variances assumed, adjusted a=0.017.
† p-value from Mann-Whitney U.

(p=0.011). There was not a significant difference between
groups for BMD total (p=0.104) or BMD femur (p=0.175).
DISCUSSION
The goal of this study was to add to the body of literature
specific to collegiate-level dancers, providing insight to
determine if they have normal BMD status. The BMD
total for all subjects in the current study appeared to be
similar to the average for American females. The US Cen-
ters for Disease Control and Prevention published total
BMD (in g/cm2) for age groups from 8 to 80 yrs and over
from the National Health and Nutrition Examination
Survey (NHANES).18 The subjects in the current study fell
in the middle of two age categories from this report, 16–19
yrs and 20–29 yrs. The average BMD total of women aged
16–19 years was 1.092 ± 0.090 g/cm2 and the average of
those aged 20–29 years was 1.119 ± 0.087 g/cm2.18 The
average of the dancers was 1.16 ± 0.08 g/cm2 and control
subjects was 1.11 ± 0.08 g/cm2, placing both groups
between the 50th and 85th percentiles depending on the
age category.18 The subjects in this study, both dancers and
controls, appeared to have normal BMD.
The dancer group showed a significantly greater BMD
in the lumbar spine compared to the control group, and no
difference in BMD of the total body or femur. This sug-
gests that collegiate dancers do not have decreased BMD
compared to controls. When comparing the present study
with others on college-level dancers, the BMD total and
lack of difference in BMD total compared to control sub-
jects were consistent with Lim et al.,13 who found BMD
total to be 1.1 ± 0.06 in dancers (Korean dance, ballet, and
contemporary) and 1.1 ± 0.09 in non-dancers (p=0.20) with
an age range of 18–20 years.13 Another study on collegiate
female dancers (18–25 yrs) in the US was completed by
Friesen et al.,16 who found similar BMD for the total body.
In their study, BMD total was 1.147 ± 0.069 g/cm2 in colle-
giate dancers and was not significantly different from their
control subjects (p>0.05).16
When looking at BMD of specific sites (femur and
lumbar spine), Wong and To14 reported on the BMD of the
lumbar spine and femur of dance students at a Chinese
collegiate academy for performing arts (ballet, Chinese
dance, modern) and found no differences between dancers
and control subjects, as in the present study. The BMD
femur of both dancers and controls were lower than found
in the present study. The BMD of the femoral neck was
0.909 ± 0.074 g/cm2 for the dancers and 0.867 ± 0.138
g/cm2 for controls.14 The subjects in this study may be dif-
ferent from those in the present study because Wong et
al.’s subjects were younger, ranging from 17–22 years old.14
Also, women of Asian descent may differ from women in
the US, who included those of Caucasian and African
American decent in this study.19
In contrast to our study where no difference was found
for BMD femur, Friesen et al.,16 found BMD femur to be
significantly higher in college dancers than control sub-
jects: 1.163 ± 0.111 vs 1.099 ± 0.106 g/cm2 for the right hip,
and 1.160 ± 0.114 vs 1.101 ± 0.104 g/cm2 for the left hip,
p≤0.05.16 The values for controls were not reported in

TABLE 2. Self-Reported Menstrual Characteristics of Collegiate Dancers and Controls

Dancers
_______________________ Control
_______________________
n % n % p-Value
Age of menarche (yrs) n/a 12.85 ± 1.57* n/a 13.13 ± 1.73* 0.678
Using hormonal contraception 8 40.0% 4 33.3% 1.000†
Regular menstrual cycles (even when not using hormonal contraception) 13 65.0% 11 91.7% 0.204†
Ever skips period 7 35.0% 4 33.3% 1.000†
Extended length without period (amenorrhea) 4 20.0% 1 8.3% 0.626†
Currently without period (absent) 0 0.0% 1 8.3% 0.375†
* Values presented as mean ± SD. Dancers n=20, control n=12 for all questions.
† p-Value from Fischer’s exact test.

92 Medical Problems of Performing Artists

 TABLE 3. Self-Reported Dance and Exercise Habits of Participants
Dancers
___________________________
Mean ± SD
Age began dancing (yrs) 6.34 ± 4.61
Hours/day dancing 5.28 ± 2.45
Days/week dancing 5.38 ± 0.65
Hours/day spent exercising (non-dance) 1.0 (0.0–1.5)*
Days/week exercising (non-dance) 1.0 (0.3–2.9)*
Participates in resistance training 45.0%
Values presented as mean ± SD or * median (interquartile range).
†p-Value from Mann-Whitney U-test. Boldface indicates a significant difference.
numeric form, only via graphical representation, and
therefore cannot be presented for direct comparison.
The findings in the present study that BMD lumbar was
significantly higher in collegiate dancers than control sub-
jects are consistent with those of Wong and To.14 They
found that collegiate-level dancers in China had BMD
lumbar of 0.924 ± 0.089 g/cm2 vs controls of 0.971 ± 0.147
g/cm2 (p=0.14).14 There seems to be beneficial effects of
dance training on the skeletal health of the spine. The
higher magnitude of multi-planar ground reaction forces
encountered by dancers (compared to controls) may be great
enough to increase BMD in the lumbar spine. Gannon and
Hind20 demonstrated higher lumbar BMD in elite male gym-
nasts compared to swimmers and controls, but such a com-
parison did not exist for total BMD.20 This may in part be
explained by the multi-plane lumbar vertebrae loading
during activities such as dance and gymnastics compared to
non- or lesser lumbar-loading sports and should be further
explored in other types of athletes and in females.
There were some differences found in the reported exer-
cise habits of the dancer and control subjects in this study
that may support the difference in BMD lumbar. The
dancers participated in dance approximately 5 days/wk
and non-dance activity an additional 1 day/wk. The con-
trol subjects reported exercising (non-dance activity)
approximately 4 days/wk, whereas the dancers partici-
pated in non-dance exercise significantly less, averaging 1
day/wk. Both groups reported participating in resistance
training, although no information was collected on
number of days or load. The greatest difference in exercise
activity was likely due to dance. No differences in the men-
strual health questionnaire were identified.
Our study is not without limitations. While we
attempted to compare the subjects in this study only to
other collegiate-level dancers, they are not necessarily
training exclusively in the same types of dance. We made
what we consider to be the best available comparisons.
Due to the lack of random sampling and differences in
genre of training within different studies/institutions, the
generalizability of our findings is limited to a similar popu-
lation. Furthermore, although no differences were found
in the menstrual health questionnaire, it would have been
better if we were able to match subjects on potential risk
factors such as amenorrhea and menstrual irregularities.
Control
___________________________
n Mean ± SD n p-Value†
20 n/a
20 n/a
20 n/a
20 1.5 (1.0–2.0)* 8 0.115
20 4.3 (3.3–6.0)* 8 0.005
20 50.0% 10 1.000
This study had a small sample size, with unequal groups,
which may mean that it is under-powered to find true sig-
nificance. Future studies should include larger sample sizes
to increase confidence in results found from between-
group comparisons and also allow for subgroup analysis
based on menstrual health. Future work with larger sample
sizes should also consider regression analyses where poten-
tial factors influencing BMD (menstrual health, BMI, etc.)
could be included as covariates.
Conclusion
It is important for young dancers to maximize peak bone
mass and to minimize any loss of BMD. Maximizing peak
bone mass in dancers can be attained by making sure they
are not excessively losing weight and are careful of delayed
menarche.21 Peak bone mass in young adults is a major
predictor for bone mass later in life. The risk of developing
osteoporosis as an older adult may be profoundly affected
by early childhood behaviors and actions.22 In light of the
limitations of this study, our conclusions are non-defini-
tive regarding the BMD status of multi-genre collegiate
dancers compared to controls, and this remains an area
where additional research is needed. However, the current
study does provide some preliminary evidence that multi-
genre collegiate-level dance majors are not at increased
risk compared to control subjects and that they may have
better BMD status at the lumbar spine.
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Received 2-May-2017, accepted 22-Jan-2018
Published online 1-June-2018
https://doi.org/10.21091/mppa.2018.2015