**Background:** Ballet dancers face unique pressures from aesthetic demands and rigorous training that increase risk for the Female Athlete Triad (Triad)—a spectrum of low energy availability (LEA) with or without eating disorders (ED), menstrual dysfunction, and impaired bone health. Despite known risks, Triad assessment and nutritional profiling remain understudied in collegiate dance populations. This study aimed to examine Triad risk using the Cumulative Risk Assessment (CRA) tool, determine return-to-play (RTP) recommendations, and evaluate macronutrient and micronutrient intake among female collegiate ballet dancers.
**Methods:** A retrospective cross-sectional design was used, drawing on data from a larger study of ED risk in collegiate female athletes. Twenty-eight female dancers (weight: 56.4 ± 7.0 kg; height: 165.3 ± 6.9 cm; age: 20.5 ± 3.6 years) from the University of South Carolina Dance Company were included; 26 completed dietary logs. The CRA tool assessed LEA with/without ED, low BMI, delayed menarche, oligomenorrhea/amenorrhea, low bone mineral density (BMD), and stress fracture history. Each category was scored 0 (low risk), 1 (moderate risk), or 2 (high risk). Total scores determined RTP: Full Clearance (0–1 points), Provisional Clearance (2–5 points), or Restricted/Medical Disqualification (≥6 points). Energy availability was calculated as EA = (energy intake − exercise energy expenditure) / fat-free mass (kcal/kg FFM/day); LEA was defined as <30 kcal/kg FFM/day. Eating disorder risk was assessed via the Eating Disorder Inventory-3 (EDI-3) and EDI-3 Symptom Checklist. Seven-day food logs were analyzed using ESHA software; nutrient intake was categorized as low, within normal, or high relative to DRI for women 18–35 years. BMD was measured by DEXA scan. Basic descriptive statistics were used.
**Key Results:** Dancers averaged a CRA total score of 3.5 ± 1.6. RTP outcomes were: Full Clearance 7.1% (n=2), Provisional Clearance 82.1% (n=23), and Restricted/Medical Disqualification 10.7% (n=3). Mean EA was 12.2 ± 11.3 kcal/kg FFM/day; 69.2% (n=18) were below the LEA threshold. Dancers were at risk for LEA a mean of 5.1 ± 1.2 days per week, with 84.6% (n=22) at risk 75–100% of the week. Overall ED risk was 76.9% (n=20); 69.2% (n=18) were identified as at risk by the symptom checklist, and 38.5% (n=10) by the EDI-3 questionnaire. Dieting was the most reported pathogenic behavior. Dietary analysis revealed: 96.2% (n=25) low in carbohydrates, 92.3% (n=24) low in protein, 19.2% (n=5) low in fat percent, 19.2% (n=5) exceeding saturated fats, 100% (n=26) low in Vitamin D, and 96.2% (n=25) low in calcium. Mean BMD was normal overall, but three dancers had negative Z-scores and were also at risk for LEA. Only four dancers reported a history of stress fracture.
**Clinical Implications:** The vast majority of collegiate ballet dancers in this study exhibited moderate Triad risk with profound energy and nutrient deficiencies. The CRA tool proved useful for stratifying risk and guiding RTP decisions, though the authors emphasize that RTP guidelines should be flexible and patient-centered. The near-universal deficiencies in carbohydrates, protein, Vitamin D, and calcium highlight critical nutritional gaps that could impair performance, bone health, and long-term well-being. The high prevalence of ED risk (76.9%) underscores the need for early screening and intervention. The authors advocate for multidisciplinary care teams—including athletic trainers, physicians, dietitians, and mental health professionals—to address the Triad and nutritional deficiencies in performing artists. Limitations include the small sample size, inability to wear armbands during performances, and retrospective design. Future research should compare dance styles, include male dancers, and explore environmental and cultural factors influencing nutrition and Triad risk.