REDs in Gymnasts: What Changed in the 2023 Update (Ep 219)

REDs in gymnasts is one of the most important things I talk about as a gymnastics sports dietitian, and back in 2022 our very first episode on it became one of the most downloaded episodes of this podcast. Four years later, a lot has changed. The research has changed, the name has changed, and the way doctors are supposed to screen for it has changed.

And most gymnastics parents, and honestly a lot of coaches and doctors, haven’t caught up yet. So this is the update. If your gymnast is heading into comp season injured, tired, banged up, moody or just not herself, this one is for you.

What is REDs in gymnasts?

REDs stands for relative energy deficiency in sport. In plain English, your gymnast is NOT getting enough energy (enough food) to cover everything her body is trying to do. And for a gymnast, that is a lot. She’s training, she’s growing, she might be going through puberty, she’s sitting through a full day of school and half a day at the gym, and she’s trying to recover from the last practice while getting ready for the next one.

When there isn’t enough energy to go around, her body doesn’t just stop. It starts cutting corners, or what I call going into low power mode. The first things to go are the ones it considers optional in the short term: bone building, hormones and periods, growth and development, her immune system, her mood and, eventually, her performance.

I want to be really clear about one thing. REDs is not the same as an eating disorder. They absolutely can overlap, but most of the underfueled gymnasts my team works with are not trying to restrict. This is why I often call it unintentional underfueling. A lot of gymnasts just aren’t hungry enough for what they need, when they need it. They focus more on “healthy eating” than adequate fueling. Or they are so busy that managing their fueling around a full school day and a gym schedule is really hard.

How REDs affects every system in your gymnast’s body

Here’s the thing most people don’t realize. REDs isn’t one symptom. It can touch just about every system in the body, because when there aren’t enough calories coming in, the body turns down anything it doesn’t need to survive today.

• Hormones. This is usually the first hit. The body turns down the hormones that run growth, metabolism and puberty, and everything else flows from there.
• Periods. Periods that come late, become irregular or stop altogether. Missing periods are common in gymnastics, but they are NOT normal. Her period is one of the best signs we have that her body is getting enough to grow, develop and stay healthy.
• Bones. Without enough energy and proper hormone production, bones don’t build the way they should, and the teen years are when she builds the most bone she will ever have. This is where stress reactions and stress fractures come from. It only takes missing about 300 calories a day to cause bone loss. That is basically a snack.
• Growth and development. Falling off her height and weight curves, or puberty that isn’t happening on time.
• Metabolism. Her body gets really good at running on less. That sounds efficient, but it means she’s in survival mode, not performance mode.
• Blood and iron. Low iron and iron deficiency anemia often show up alongside underfueling. They wreck energy and endurance, and iron issues usually take three to six months to fully resolve.
• Heart. In the most severe cases we see an abnormally low resting heart rate or low blood pressure, which can show up as dizziness or lightheadedness and can be really dangerous.
• Gut. Bloating, constipation, stomach pain and feeling full really fast. Then it becomes a vicious cycle, because the gymnast who feels bloated doesn’t want to eat, and she starts cutting out random foods thinking it’s a food problem when it’s really a lack of food problem.
• Immune system. Sick all the time, sick longer than she used to be, catching every bug that goes around the gym.
• Sleep. Trouble falling asleep, staying asleep or waking up in the middle of the night.
• Mental health. More irritability, more anxiety, low mood and trouble focusing. This one runs both ways, because stress and anxiety can make it harder to eat, which makes the underfueling (and the mood) worse.

So when a parent tells me their gymnast is always sick, she’s moody, she can’t sleep and now she has a stress reaction, I’m not hearing four separate problems. I’m hearing one.

How does REDs show up in the gym?

Now let’s talk about the part gymnasts actually care about the most.

• Strength and power. She’s training hard and not getting stronger, or she’s losing strength. Floor and vault feel heavy, slow and sluggish.
• Endurance. She’s great for the first hour or two of practice and then she fades. Her last rotations and turns are the sloppy ones.
• Response to training. She can do all the conditioning in the world, but without enough nutrition her body can’t build and adapt to it.
• Recovery. Her body keeps repairing for up to 48 hours after a workout. If she’s sore for days, wrecked by the end of the week and barely hanging on by the end of comp season, that screams what I call the recovery gap: the space between what she needs to grow, repair and adapt and what she’s actually eating.
• Coordination and focus. Missed connections, falls on beam that shouldn’t have happened, trouble holding body positions and getting lost in the middle of a routine.
• Judgment and safety. That split-second awareness in the air is affected when the brain is low on energy, and that means more injuries that take longer to heal.
• Motivation. So many upper level gymnasts lose the love of the sport. Parents read it as attitude, when a lot of the time her tank is just empty.

Speaking as a nationally rated NCAA/USAG judge for 18+ years, so many of the deductions I see at meets aren’t skill problems. They’re energy problems. Short landings, bent arms and legs, wobbles, form breaks at the end of a routine. That is what running on empty looks like on the competition floor, and those little tenths are what keep a gymnast from the 38 or 39 all-around she’s working for.

What changed in the 2023 REDs update?

In 2023, the International Olympic Committee put out an updated consensus statement on REDs. It’s basically the big official paper where the top researchers in the world agree on what we know, and it replaced the earlier versions from 2014 and 2018. Here are the six changes I want gymnastics parents to know.

Change #1: the name

It used to be written RED-S. Now it’s just REDs, with no hyphen. I actually prefer it. It’s a small thing, but it’s a really quick tell: if the article or advice you’re reading still says RED-S or talks about the female athlete triad, there’s a good chance it’s working off older information.

Change #2: low energy is a spectrum, not an on/off switch

This one takes some of the fear out of it. The update describes low energy availability as a spectrum, from “adaptable” to “problematic.” Adaptable is short-term and mild: she had a longer workout than normal and ran a little low that day, or she was sick for a few days and didn’t eat much. Her body can handle that, and it is NOT a REDs diagnosis.

Problematic is when she doesn’t eat enough for weeks, months or years. That is where REDs develops. One rough practice isn’t REDs. Months of five to six hour workouts on a granola bar, a skipped breakfast and not enough after practice is where we get into trouble. If you want to go deeper, our post on acute vs chronic underfueling in gymnasts pairs really well with this one.

And here’s why “too long” matters so much in our sport: missing only about 300 calories a day is enough to cause bone loss, and gymnastics has a very high rate of bone stress injuries. A small gap day after day turns into a full-blown injury that takes weeks, if not months, to heal.

Change #3: carbs matter on their own

Parents, this is the one I really want you to hear. The update calls out low carbohydrate availability as a threat to your gymnast’s bone health, even when her total calories don’t look terrible. So when a parent tells me “she eats so healthy, lots of protein, lots of veggies,” I’m not celebrating. Protein and veggies are great, but they are not what fuels a three-hour bars and beam practice. Carbohydrate is.

• Before practice, we look at about 1 gram of carbs per kilogram of body weight.
• For practices that are 3.5 hours or longer, she should start getting carbs in about two hours into practice. During, not at the end.
• For the whole day, we usually start around 5 to 7 grams of carbs per kilogram and adjust for growth and how hard she’s training.

For a 40 kg (about 88 pound) gymnast, that’s roughly 200 to 280 grams of carbs a day. Most parents are shocked by that number, because it’s probably more carbs than you eat. And that’s OK. You’re probably not training 20 hours a week while growing and developing at the same time.

Change #4: REDs can look like overtraining or a mood problem

The update talks about how REDs overlaps with overtraining syndrome and how it’s connected to mental health. At home, that looks like mood swings, crying in the car after practice, burnout, losing skills she had a month ago, mental blocks, “she’s just tired,” “she’s being lazy” or “she doesn’t want it anymore.” Sometimes those things are real. But a lot of the time, part of what’s going on is underfueling, and that is fixable. If this hits home, read does your gymnast have REDs or overtraining syndrome and our post on underfueling and mood swings in gymnasts.

Change #5: doctors have a better screening tool

Along with the update, the IOC released an updated clinical tool called the REDs CAT2 (Clinical Assessment Tool, version 2). It helps doctors look at the whole picture, including bone injuries, periods, labs and growth, and figure out how at risk an athlete really is. Your pediatrician probably isn’t using it, and that’s OK. You can still walk into that appointment with better questions.

Change #6: boys get REDs too

As a boy mom, I take this one personally. The signs in male gymnasts look a lot the same: injuries that keep coming back, stress fractures and stress reactions, not growing, not developing and not getting stronger even though they’re training a ton. There are some differences (low testosterone is one), but energy, performance, soreness and recovery are all affected the same way.

What should you ask your gymnast’s doctor about REDs?

• If she has a stress reaction or stress fracture, where is she on her growth curve, and is she eating enough?
• If there are no signs of puberty (breast development) by 13, or no period by 15, that’s a red flag for underfueling. And it’s reassuring, because underfueling is something we can fix.
• Can we look at her growth chart? I want gymnasts plotted three to four times a year, because it’s a whole lot easier to catch a problem at the lower levels than after years of it and three stress fractures in a row. (This is why growth matters so much in gymnastics.)
• Should we check labs? Iron and vitamin D are a good place to start.

You might hear “she’s fine, she’s just small” or “that’s normal for gymnasts.” Missing periods and not growing are never normal for a gymnast. Being a gymnast does not exempt her from biology.

What one growth chart showed us

Let me tell you about a Level 9/HOPES gymnast we worked with. By every outside measure, she seemed “fine.” She was training hard, competing and eating what her family thought was plenty.

She came to us coming off a wrist fracture that everyone had chalked up to overuse or a freak accident. Then we pulled up her growth chart.

For years, she had grown very steadily along the 85th to 90th percentile. When we saw her, she had dropped to the 35th percentile. That is NOT normal, and it was a huge “aha” moment for her parents. That wrist fracture had a lot more to do with underfueling than bad luck.

Here’s the hard part. A few months after we started working on her fueling, she was diagnosed with elbow OCD, because she was still underfueled and her body was still trying to catch up. Underfueling doesn’t reverse overnight.

She looked fine. Her growth chart told a very different story. That is exactly why I want every gymnast plotted three to four times a year.

Why REDs matters right before comp season

Comp season stacks long practices, travel, early sessions and nerves on top of everything her body is already doing to grow, develop, repair and recover. That’s exactly when a small fueling gap turns into a big injury, or the mid-season implosion I talk about every year. The time to catch underfueling is now, not in February when she’s in a boot and you’re hoping she can petition to regionals.

4 things to check this week

1. Pick one practice day and look at it honestly. Did she have carbs at every meal? If practice was 3.5 hours or longer, did she have one or two carb snacks during? Did she have a real meal after?
2. Pull up her growth chart, or ask her doctor to look at it with you. This is often the “aha” moment for parents whose gymnast seemed fine.
3. Write down anything you’ve noticed: injuries, missing or irregular periods, poor growth, mood changes, getting sick all the time, struggling with strength, skills or power.
4. If you noticed any of those, it’s time to get help from a pediatric/adolescent sports dietitian who knows gymnasts. Not a general nutritionist, and not a meal plan off the internet.

Ready to get support?

Not sure if your gymnast is underfueled? Start with my free masterclass, Is Your Gymnast Underfueled!?, where I walk you through the signs and how to read a growth chart. You can also take the free Gymnast Fueling Quiz.

When you’re ready for 1:1 support, The Balanced Gymnast® Program is how our team of pediatric/adolescent sports dietitians helps gymnasts close the gap before comp season. Have a male gymnast? Check out our men’s gymnastics nutrition program.

And if you haven’t heard the original episode, go back and listen to Episode 4 on relative energy deficiency in sport and gymnastics.