What do you do if your gymnast is “underweight” or has been diagnosed with an eating disorder, lost her period, or has what’s called “relative energy deficiency in sport”?

Or, what if your pediatrician tells you your gymnast is not growing, and you need to start Pediasure or Orgain and see an endocrinologist?

Physicians will often provide some sort of “oral nutrition supplement” like Pediasure, but is this enough? Unlikely for the high-level gymnast, and this can get expensive.

While there definitely could be endocrine (hormonal) issues at play that need to be investigated, most gymnasts who are not growing and developing are suffering from “inadequate energy availability.” This mean they aren’t eating enough to support their basic energy needs, growth/development, or the high levels of exercise expenditure from 20+ hours of practice a week.

A lesson on growth charts

Growth charts tell a story. What is “normal” for one gymnast may look totally different for another, but what’s important is that the athlete is tracking consistently along their own “curve”. Growth charts are separated into percentiles, from the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th. We can also look at “Z-scores” which correlate to -3, -2, -1, 0, 1, 2, and 3 in a statistical sense. The CDC 2-20 year chart should be used above age 2. The 50%tile is considered “average” but doesn’t mean it’s wrong to be above or below. 

From a clinical standpoint, we evaluate nutrition status based on growth history, percentiles, growth velocity, and z scores.  

If your gymnast’s weight has always been at the 10-25%tile, that could be normal for her. If her weight has always been at the 80%tile, that could also be totally normal.

If her weight goes from the 10-25%tile and then to the 50-75%tile (or higher) after puberty, this could also be totally normal (or evidence that a long-standing energy deficiency was resolved).

What is abnormal is when major percentiles are crossed. For instance, a gymnast may have tracked around the 50%tile for both weight and height from ages 7 to 10 years, but then as practice hours ramped up and nutrition needs weren’t met, both weight and height fall to the 10%tile by ages 14-15. This is not normal and considered “failure to thrive”, would meet criteria for moderate to severe malnutrition, and certainly represents long-term undernutrition.

If her weight has always been at the 75%tile and height at the 25%tile, that could still be normal, though it may signal something medical is going on. This mismatch in height is something we would likely catch in the early toddler years if something medical was at play, but still could happen in the pre-teen/teen gymnast.

Inadequate increases in height is a long-term effect of undernutrition, something we see more in third-world malnutrition but is often seen in gymnasts who have been underfueling for years. If your gymnast’s height is faltering, that is a bad sign. Though there could be a hormonal or medical issue at play (growth hormone deficiency, thyroid deficiency, celiac disease), if you have a high level gymnast it’s more than likely that she’s been in an energy deficit for a while. If height falls below a z-score of -2, this can be considered “stunting” and needs an endocrine evaluation.

Adult height is determined by what is called the “genetic height potential” which is an equation used based on mom and dad’s height to predict where someone will end up after puberty. It is not normal for a gymnast to not reach her predicted height just because “she’s a gymnast”. This is the same concept as not getting a period by 16 years just because “she’s a gymnast”. Stunting, delayed sexual maturation, and poor weight gain are all signs of underfueling which have long-reaching effects across multiple organ systems (neurological, cardiovascular, endocrine, reproductive, musculoskeletal).

Normal Growth
Normal Growth
Growth Overshoot

Why do we worry about a gymnast being “Underweight”?

In a sport that has idolized the small, thin, “little girl body”, why do we care about ensuring these bodies (even if some are naturally small) have adequate nutrition? Isn’t it a good thing that a gymnast’s growth may be stunted, and she remains abnormally small for her age and genetics? No, this is not a good thing at all and comes with significant long-term consequences that will threaten their health and longevity in the sport.

Relative Energy Deficiency in Sport (or RED-S) is a constellation of health issues that are all tied to inadequate nutrition to support normal bodily functions, growth/development, and optimal performance/recovery.

Relative Energy Deficiency in Sport

Can your gymnast be “normal weight” and “look fine”, yet be suffering from underfueling? Absolutely

Though many doctors and professionals will use BMI as a cut off for “weight status”, this does not consider body composition. You cannot tell if an athlete is underfueled by just looking at their weight or BMI in isolation.

You must look at the growth charts and determine what normal growth appears to be for the athlete, though sometimes this is difficult with athletes that have been chronically underfueled aka “unintentional underfueling”.

Does every gymnast that is “small” need to gain weight?

RED-S is more about inadequate energy availability than a “look”. Some individuals are genetically smaller, and that may be normal for them. But some are only smaller during gymnastics because they are underfueled and growth is suppressed, which is not normal and will keep them from optimal performance and longevity in the sport.
Sometimes resolving RED-S results in needed weight gain, but not always. Just because an athlete starts fueling properly does not mean they are going to gain “a million pounds”, but often it’s needed and normal.

Meeting with a registered dietitian sports nutritionist can help you determine if your gymnast is underfueled or if she is meeting her needs. And, if not meeting needs, they can help you plan and implement appropriate nutrition to resolve the issue.

How do you help a gymnast meet her nutritional needs?

  1. Plan Ahead
    • A gymnast’s schedule is often jam-packed with training, therapies, additional privates, or conditioning sessions, etc. especially when we get into high-level gymnastics with 4+ hour practices that span main meals and snacks. Additionally, two-a-day practices leave the gymnast needing to bring all her meals and snacks to gym if she cannot go home in between which can also be a logistical challenge.
    • Utilize leftovers for lunches, etc.
    • Do some meal prep- Making breakfast sandwiches and freezing them, mixing up some yogurt parfaits, etc. for easy breakfasts during the week can really help. I am not saying your gymnast needs to live out of a Tupperware but lessen the barrier to making solid fueling choices by having foods easily accessible.
    • Coordinate with the Carpool-See if you can collaborate with the carpool to bring healthy pre-workout snacks to be sure the gymnast gets solid nutrition even when you are not there.
  2. Increase meal and snack frequency
    • Aiming for some sort of nutrition every 2.5-3 hours is a good place to start. Essentially this looks like 3 meals and 3+ snacks with appropriate Performance Nutrition in there.
    • Sleeping in too late or delaying a meal past the 4+ hour mark will make it difficult to fit in adequate nutrition without your athlete getting “too full”. Try to get breakfast in by 8AM to start the day ahead.
  3. Optimize the nutrient and caloric density
    • Use the high-intensity performance plate (1/2 carbohydrate, ¼ color, ¼ protein + Fa and dairy). The high-intensity plate does not guarantee weight gain just because it is higher carbohydrate, but carbohydrate and fat are what can be increased in the diet once protein is met in terms of healthy weight gain.
    • Add Healthy fats like nuts, nut butters, olive oil, walnut, ground flax, chia seeds, hemp seeds
    • Swap bagel for breads (denser)
    • Add a dense breakfast cereal instead of just light weight Chex, cheerios, etc.
    • Add sliced avocado to sandwiches, soups, eggs, smoothies
    • Skip the light, diet, sugar free, and low-fat foods (honestly everyone can skip these, not just those needing to gain weight)
  4. Watch out for the “bulk”
    • Often gymnasts are eating “too healthfully” in the sense that they’re getting so many bulk and fiber from fruits, veggies, and whole grains that they are “full” before they meet their energy needs.
    • Save liquids at meals for halfway through or the end. It is easy to “fill up” on a glass of milk, etc. at the start of the meal and then be too full to finish.

In Summary

Hopefully you found this article helpful! Unintentional underfueling is so common in gymnastics, and had major consequences when it counts (recruiting, high level competition years, etc). If you have questions, feel free to drop me a line here.

If you think your gymnast may not be getting what she needs, I encourage you to start with a visit to the pediatrician or sports medicine physician who is familiar with RED-S and can review growth and health history.

You can also hop on the waitlist for my online gymnast nutrition course for parents of competitive gymnasts where you will learn all about fueling the gymnast, RED-S, and much more!

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