RED-S in Gymnastics: What Parents and Coaches Need to Know

Most gymnastics parents have never heard of RED-S. Most gymnasts haven't either. But if your daughter pushes through exhaustion that sleep doesn't fix — if her periods stopped and someone told you that's just what happens with serious training — if she's had a stress fracture that didn't quite make sense given her age — you've probably been watching it happen. You just didn't have a name for it.

Relative Energy Deficiency in Sport — RED-S is not a fringe diagnosis or an elite-athlete problem. A 2024 review in Endocrine Reviews describes it as a spectrum of abnormalities caused by low energy availability, affecting exercising populations of either biological sex and producing consequences across nearly every organ system in the body.¹ It is not simply not eating enough. Its effects on bone, hormones, cardiovascular health, immune function, and long-term wellbeing can be serious and lasting, and in gymnastics specifically, it occurs at rates that should concern every parent and coach in the sport.

What RED-S Actually Is

RED-S was introduced by the International Olympic Committee (IOC) in 2014 as an expansion of the previously recognized Female Athlete Triad, a syndrome of three interconnected conditions: low energy availability, menstrual disruption, and compromised bone density. The IOC's expansion to RED-S recognized that low energy availability affects multiple physiological systems beyond those three, and that it affects athletes of all genders, not only females.²

At its core, RED-S is caused by low energy availability, a state where what the gymnast eats doesn't cover both the demands of exercise and the energy the body needs to run its basic functions. The body responds by rationing. It cuts back on bone maintenance, hormonal production, immune function, and growth — all the systems that aren't immediately essential for survival. A 2024 review in the European Journal of Sport Science defines it simply as impaired physiological functioning caused by low energy availability in athletes of either sex.³

According to a PMC systematic review, low energy availability may be one of the strongest indicators of injury risk for athletes.⁴ It is not always intentional. Athletes may have LEA because of inadequate nutritional knowledge, time constraints, logistical barriers to eating, or because training demands have increased faster than caloric intake has kept pace.

Why Gymnastics Is a High-Risk Sport

Gymnastics is consistently identified in the literature as one of the sports at highest risk for RED-S. A 2024 ScienceDirect review categorizes gymnastics as a "lean sport" — one in which a higher power-to-body-mass ratio is thought to contribute to performance, creating both explicit and implicit pressure around body composition.⁵ The review notes that the reported prevalence of LEA for female gymnasts is 44.8%, higher than in soccer (33.3%), ballet (22%), and volleyball (20%).

The 2024 Endocrine Reviews article notes that the diurnal pulsatility of salivary cortisol appears to be abolished in elite gymnasts, a finding that may indicate adaptation to prolonged periods of low energy availability.¹ This kind of physiological adaptation suggests that some elite gymnasts may be chronically underfueled in ways that have become normalized both within their own bodies and within the training environment.

Registered Sports Dietitian Christina Anderson RDN, who specializes in gymnast nutrition, notes that most gymnasts are convinced that if they eat more or enough to fuel their workouts, they will gain large amounts of weight. She explains that since there are not adequate amounts of energy going into the athlete, their bodies have turned many systems down to conserve energy, and that once adequate fueling is restored, the body's metabolism adapts to process the new fuel efficiently.⁶

Health Consequences of RED-S

The health consequences of RED-S extend across virtually every organ system. The PMC review on RED-S in female athletes identifies the following major consequences of longstanding low energy availability:⁴

The bone health consequences deserve particular emphasis in a gymnastics context. A PMC review on the Female Athlete Triad and RED-S explains that low energy availability leads to decreased bone formation and bone turnover, resulting in loss of normal repair mechanisms for minor and major lesions and a higher risk of fracture.⁷ Registered Dietitian Christina Anderson RDN states clearly: most stress fractures in gymnasts are due to RED-S, not overuse or a freak accident, the athlete does not have enough energy to build or maintain bone mass.⁶

Menstrual Health as a Warning Sign

In post-pubertal female athletes, menstrual irregularities are one of the most important and accessible warning signs of low energy availability. The PMC review notes that one sign of LEA in women can be menstrual irregularities, which reflects LEA-facilitated changes in reproductive hormone production.⁴

The Endocrine Reviews research notes that the prevalence of hypothalamic amenorrhea (absent periods caused by hormonal suppression rather than a structural problem) can be as high as 69% in gymnasts and runners — compared to 2–5% in the general population.¹ A higher rate of amenorrhea occurs in sports where a lean physique is imposed, with gymnastics specifically named.

The 2024 German Journal of Sports Medicine review notes that specific questions should always ask about the female cycle when RED-S is suspected, along with stress fractures, sleep patterns, and psychological changes such as depressive or aggressive mood and lack of motivation.⁸

Signs and Symptoms to Watch For

RED-S does not always present with visible signs. Many gymnasts with LEA appear healthy and continue to perform well — at least initially. The following signs and symptoms, from the published literature and clinical expertise cited above, warrant attention and, if multiple are present, professional evaluation:

• Fatigue that does not resolve with restunexplained chronic tiredness distinct from normal training tiredness
• Menstrual irregularitiesabsent, infrequent, or highly unpredictable cycles in post-pubertal females
• Stress fractures, particularly in a young athlete without a clear overuse explanation
• Mood changespersistent irritability, tearfulness, low mood, or anxiety; RDN Christina Anderson notes that gymnasts with RED-S often cry frequently during practices⁶
• Recurrent illnessfrequent colds or infections, slow recovery from illness
• Slowed growth or delayed pubertycompared to expected developmental timeline
• Dietary restriction patternsavoiding food groups, eating very small portions, or expressing significant anxiety around food
• Performance plateau or declinedespite continued training, performance stops improving or declines
• Hair loss, cold sensitivity, or poor circulationsigns of metabolic suppression

What RED-S Is Not

RED-S is not the same as an eating disorder, though the two can co-exist. The PMC review notes that disordered eating, a range of irregular eating behaviors that may not meet clinical criteria for a diagnosed eating disorder — is more prevalent among athletes than non-athletes, with a prevalence of 6–45% reported in female athletes.⁴ Athletes may participate in disordered eating behaviors purposefully for weight management, or unknowingly due to time constraints or lack of nutritional knowledge.

RED-S is also not exclusively a problem of intentional restriction. A gymnast who genuinely tries to eat well but does not understand the energy demands of 20+ hours of weekly training can have LEA without any disordered eating. The solution in those cases is nutritional education and support, not psychological treatment.

What to Do If You Are Concerned

If you are a parent, coach, or the athlete yourself and are concerned about possible RED-S, the following steps reflect the approach described in the published clinical literature:

• Consult a sports medicine physician or pediatrician familiar with youth athletic health. Request that RED-S be considered explicitly in the evaluation.
• Request a referral to a registered sports dietitian who specializes in youth athletes or gymnastics. General dietitians may not have the sport-specific context needed for accurate assessment.
• Do not address this through the coach alone. Coaches are not qualified to assess or treat RED-S. While coaches can create a supportive nutritional culture, clinical evaluation requires healthcare professionals.
• Do not normalize absent periods as a normal part of being a serious athlete. This framing is common in gymnastics culture and is medically incorrect.
• If an eating disorder is suspected, psychological support is an important part of the treatment alongside nutritional and medical management. The 2024 review states that early implementation of eating disorder-specific psychotherapy can significantly improve likelihood of successful outcome.⁸