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Relative Energy Deficiency in Gymnasts (RED-S)

Gymnasts, do you ever find yourself feeling under-recovered, fatigued, sore and/or injured more often than not? Oftentimes, these symptoms are written off as “normal” for competitive gymnasts; however, even though these symptoms are common, they do not have to be “normal” and there may be an underlying cause for these symptoms.

A gymnast's demanding schedule introduces challenges that can span beyond their capabilities inside the gym. One of these challenges can be fueling enough to keep up with the high energy needs of a gymnast. Commonly, gymnasts underestimate their energy needs, do not build their meals and snacks strategically, or may even intentionally restrict how much fuel they take in while continuing to push their bodies to the extreme making them fall into a state of “low energy availability”.

What is low energy availability?

Energy availability is the difference between the energy (aka calories) you take in (through eating) and the energy you use through everyday activities and daily exercise.

The energy that's left (available) is what your body can use for all of its essential functions: like breathing, digestion, reproduction and transportation of oxygen and nutrients in the blood.

When your energy availability is low, your body does not have enough energy to support exercise and everyday activities causing your body to make compromises.

Causes of low energy availability

There are many different reasons a gymnast may have low energy availability.

1. Underestimating their energy requirements needed to thrive:

The energy needs of gymnasts are much higher than the average child their age. So it’s important that they are fueling with more food and are eating more frequently throughout the day than their peers or even what is shown in mainstream media.

Since gymnastics is a very body conscious sport, some athletes may feel the need to purposely restrict their food intake with hopes of increasing their performance or reaching a certain body standard goal. This can be very dangerous and never actually achieves the desired result. If this is the case, please reach out to a dietitian for fueling guidance.

3. Influence of diet culture:

Diet culture, or the way food and body is portrayed coming from places like family, friends, mainstream media, social media, even schools and of course within the sport - can influence gymnasts to eat a certain way or try to eat “too healthy”. The fixation and obsession with an unrealistic standard of “healthy” and “clean” eating (often referred to as orthorexia) can become problematic and can also lead to low energy availability. While a small salad for lunch might sound "healthy" and be okay for an adult who doesn’t have high energy needs, a salad is simply not going to be enough food for a gymnast at meal time. Sometimes “healthy” or "clean" options are not the best option for gymnasts who need tons of energy.

4. Unintentional under-fueling due to a busy schedule:

As a gymnast who is balancing 4-5 hour practices with school, fueling can be forgotten about. This is why it is important to get into a routine of eating meals and snacks frequently throughout the day.

No matter the cause, low energy availability in gymnasts will affect their wellbeing. When gymnasts don't eat enough to provide energy for exercise AND basic functions, they can develop what's called Relative Energy Deficiency in Sport (RED-S).

Relative Energy Deficiency in Sport (RED-S)

RED-S is a low energy availability state that can affect every system in the body. This condition occurs when you are expending more energy than you are taking in which leads to negative side effects such as stress injuries, reproductive dysfunction, decreased muscle strength, decreased concentration, decreased balance/coordination and increased risk for depression. The body will actually slow or even shut down many functions to save energy to make sure it has enough for absolutely essential functions (like breathing and digestion).

Signs and symptoms:


One of the most commonly discussed symptoms of RED-S is the body down-regulating hormones (aka the body's signal system) and shutting down the reproductive system. In females, it often shows up as a missing or irregular menstrual cycle. This is called amenorrhea which is far from “normal” and is most likely occurring due to the body barely having enough energy to keep your body functioning correctly and therefore “shuts off” this system. Since the reproductive system is not a necessary function to keep you alive, it's one of the first systems your body shuts down.

There are two main types of amenorrhea:

Primary amenorrhea is when the menstrual cycle has not started by age 15.

Secondary amenorrhea refers to the absence of three or more periods in a row by someone who has had periods in the past.

While both are common in the sport of gymnastics, neither condition is normal or healthy. If you suspect you or your gymnast is dealing with amenorrhea, it's time to talk to your doctor.

Amenorrhea and Hormonal Contraceptives

Gymnasts who suffer from amenorrhea may be advised by a doctor to take an oral contraceptive pill as a means of establishing a "regular" cycle. It’s important to understand that this is NOT actually going to fix the underlying problem of “low energy availability” and will only mask the symptom of menstrual dysfunction. If a gymnast chooses to be on an oral contraceptive pill, it is important that this is an informed decision taking into account their risk factors for RED-S and requirement for bone protection.

Bone Injuries

Another commonly discussed symptom that arises from hormonal imbalances is bone stress injuries which can arise more easily when the body is in a constant state of low energy availability.

Although amenorrhea and bone stress injuries are the two sure warning signs of RED-S, those types of symptoms usually present after underfueling has been an issue for a longer period of time.

There are many signs and symptoms of low energy availability that a gymnast may notice first, when low energy availability is still at it's beginning stages.

As a gymnast, RED-S can look like:

  • Poor energy in the gym

  • Frequent illness

  • Decreased strength and endurance

  • Frequent or poorly healing Injuries

  • Excessive soreness

  • Mental blocks on skills

  • Mood swings and irritability/ un-coachable behavior

If you are noticing negative differences in energy, strength, endurance, focus, coordination and mental health, these could all be due to low energy availability and it may be time to seek out help from your dietitian or physician to prevent more long term side effects from a constant state of low energy availability.

How can gymnasts reduce their risk for developing RED-S? fueling adequately and frequently throughout the day...

To help a gymnast build meals and snacks that are adequate in energy and nutritions, encourage them to follow the athletes plate (pictured below) for three to four meals a day along with 2 to 4 snacks or more per day. Since gymnasts are burning SO much energy, they should be eating every 2-3 hours to keep up with their body's high energy demands. If you feel like you are eating enough but are still experiencing symptoms of RED-S, it might be beneficial to reach out to your dietitian or physician for extra help.

Luckily, RED-S can be prevented! The best way to do so is through fueling properly to ensure that you get the energy you need in AND out of the gym!


Kerry Bair, RD, LDN, MPH

The Gymnast RD

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