A Gymnast Losing Weight Before Trials: RED-S and the Limits of Coaching
A 15-year-old gymnast, 152 cm tall and 38 kg (BMI 16.4), has lost 3 kg in two months before the state trials. She eats only fruit and salad before school, has cut out milk and paneer to stay light, and trains five hours a day. She complains of constant fatigue and cold hands, and imaging has shown a stress fracture of the second metatarsal. Her periods, regular since menarche at 13, stopped four months ago. Her mother praises her discipline and says the coach told her to lose weight for a better score. The coach now asks you to recommend a protein powder and a fat burner so she can compete at the trials in three weeks. She is quiet in the interview, says she is fine, and asks whether she can at least keep training on the injured foot.
1. Identify the likely condition and the evidence for it, and explain why simply telling her to eat more is inadequate.
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Low BMI, rapid weight loss, restrictive eating, fatigue, cold intolerance, a metatarsal stress fracture and secondary amenorrhoea together indicate relative energy deficiency in sport, with features of anorexia athletica. No single sign proves it: amenorrhoea has other causes, and a stress fracture can come from loading alone. But the cluster plus documented weight loss is enough to act on.
Eating more is inadequate because the problem is energy availability relative to training demands, not calories alone. Low availability suppresses oestrogen and bone formation, which explains the fracture and the stopped periods, and the eating pattern is maintained by fear of weight gain reinforced by adults around her. A food lecture misses the psychology and the hormonal consequences. She needs a physician, dietitian and psychologist working with the coach, with bone health and menstrual function monitored.
2. Set out your immediate two-week plan, naming who is involved and what you will not do.
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- Tell her plainly and without blame that she is unwell, that this is not a discipline problem, and that training on the injured foot stops now. The stress fracture dictates restricted weight-bearing and a physician's review.
- Refer to a sports physician and a registered dietitian; involve a psychologist for the eating behaviour and a gynaecologist for bone and hormonal assessment.
- Inform the parents factually, including that praising weight loss is now harmful, and that the coach's weight advice contributed.
- Agree a written plan with school and coach: no public weighing, no body-composition targets, no fat burners or supplements, and no training until medical clearance.
- Set goals on behaviour and health (regular meals, sleep, mood, energy), not on weight.
What I will not do: prescribe a diet myself, promise a quick return, or use the trials as motivation.
3. The coach wants a supplement and the mother wants weight loss. How do you handle both, and what would a safe return-to-training diet look like?
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Give the coach a clear, non-negotiable no on the fat burner: stimulants are unsafe and banned, and in an underweight adolescent they are dangerous. A supplement is justified only when a deficiency is documented, such as iron or vitamin D, prescribed after testing.
With the mother, avoid confrontation but be specific: her daughter has a bone injury and has stopped menstruating at 15, both linked to low energy availability, and the weight advice is contributing. Ask for her help with regular meals, not with weight.
The diet itself is adequate energy first: three meals plus snacks, carbohydrate at each meal to fuel training, protein spread across the day, dairy or fortified alternatives for calcium, iron-rich foods with a vitamin C source, and vitamin D. Weight restoration is a medical goal, not a coaching one, and should be gradual. Return to training is staged after medical clearance.