CoChat
Sign Up
Cited by 171Sports Performance and TrainingCardiovascular and exercise physiologyExercise and Physiological Responses

Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities

Stellingwerff, Trent, Heikura, Ida A., Meeusen, Romain, Bermon, Stéphane, Seiler, Stephen, Mountjoy, Margo L., Burke, Louise M.·2021·Sports Medicine
DOI 10.1007/s40279-021-01491-0
Open this paper in CoChat — free account

Abstract

The symptom similarities between training-overload (with or without an Overtraining Syndrome (OTS) diagnosis) and Relative Energy Deficiency in Sport (RED-S) are significant, with both initiating from a hypothalamic-pituitary origin, that can be influenced by low carbohydrate (CHO) and energy availability (EA). In this narrative review we wish to showcase that many of the negative outcomes of training-overload (with, or without an OTS diagnosis) may be primarily due to misdiagnosed under-fueling, or RED-S, via low EA and/or low CHO availability. Accordingly, we undertook an analysis of training-overload/OTS type studies that have also collected and analyzed for energy intake (EI), CHO, exercise energy expenditure (EEE) and/or EA. Eighteen of the 21 studies (86%) that met our criteria showed indications of an EA decrease or difference between two cohorts within a given study (n = 14 studies) or CHO availability decrease (n = 4 studies) during the training-overload/OTS period, resulting in both training-overload/OTS and RED-S symptom outcomes compared to control conditions. Furthermore, we demonstrate significantly similar symptom overlaps across much of the OTS (n = 57 studies) and RED-S/Female Athlete Triad (n = 88 studies) literature. It is important to note that the prevention of under-recovery is multi-factorial, but many aspects are based around EA and CHO availability. Herein we have demonstrated that OTS and RED-S have many shared pathways, symptoms, and diagnostic complexities. Substantial attention is required to increase the knowledge and awareness of RED-S, and to enhance the diagnostic accuracy of both OTS and RED-S, to allow clinicians to more accurately exclude LEA/RED-S from OTS diagnoses.

Integrity signals

Registry

Crossref · 10.1007/s40279-021-01491-0

Cites

274 of 274 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Claims the paper makes

This paper’s full text isn’t openly available, so its claims and self-check weren’t run. The registry and citation checks still apply.

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Athletes are at a greater risk for LEA from sociocultural pressures, such as social media pressures, pressures from coaches/teammates/self to look a certain way, or from the prevailing belief that a lower body weight will result in greater performance outcomes.

    “Athletes are at a greater risk for LEA from sociocultural pressures, such as social media pressures, pressures from coaches/teammates/self to look a certain way, or from the prevailing belief that a lower body weight will result in greater performance outcomes [122–125].”

    From International society of sports nutrition position stand: nutritional concerns of the female athlete (2023) · cites this paper as [125]

  • Endurance sports (often more than 30 hours of training per week) can sometimes result in extreme exercise energy expenditure that exceeds the capacity of the human alimentary tract for sustained energy absorption.

    “This is especially the case in endurance sports (often >30 hours of training/week), 37 which can sometimes result in extreme EEE that exceeds the capacity of the human alimentary tract for sustained energy absorption.”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [37]

  • A recent narrative review found that 18 of 21 identified OTS-based studies showed indications of LEA and LCA and thus may have demonstrated REDs outcomes rather than OTS.

    “a recent narrative review found that 18 of 21 identified OTS-based studies showed indications of LEA and LCA due to large increases in training while failing to compensate with increased EI, and thus may have demonstrated REDs outcomes rather than OTS.37”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [37]

  • REDs and OTS are syndromes involving the hypothalamic-pituitary-adrenal axis and have no single validated diagnostic biomarker; they feature a complex overlap of symptoms that hinge on a diagnosis utilising exclusion criteria.

    “REDs and OTS are syndromes involving the hypothalamicpituitary-adrenal axis and have no single validated diagnostic biomarker; they feature a complex overlap of symptoms that hinge on a diagnosis utilising exclusion criteria.37 58”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [37]

  • LEA and/or LCA should be excluded from an OTS diagnosis as LEA is the underlying aetiology for a REDs diagnosis.

    “It is important to note that LEA and/or LCA, although challenging to assess, should be excluded from an OTS diagnosis as LEA is the underlying aetiology for a REDs diagnosis.37 59”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [37]

Cites

Flagged first, then by citations

3 of the 277 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Stellingwerff, T., Heikura, I. A., Meeusen, R., Bermon, S., Seiler, S., Mountjoy, M. L., & Burke, L. M.
Affiliations
  • University of Victoria (CA)
  • Vrije Universiteit Brussel (BE)
  • Université Côte d'Azur (FR)
  • University of Agder (NO)
  • International Olympic Committee (CH)
  • Australian Catholic University (AU)
Corresponding author
Stellingwerff, Trent
ORCID
Venue
Sports Medicine
Publisher
Springer Science and Business Media LLC
Published
2021-06-28
Volume
51
Issue
11
Pages
2251-2280
ISSN
  • 0112-1642 (ISSN-L)
  • 1179-2035
DOI
10.1007/s40279-021-01491-0
OpenAlex
W3173850147
Cited by
171
References
277
Citations by year
2026: 28 · 2025: 36 · 2024: 51 · 2023: 33 · 2022: 22 · 2021: 1
FWCI
5.70
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • Sports Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • VUBIR (Vrije Universiteit Brussel) (submittedVersion)
Topics
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
  • Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
  • Health Sciences › Medicine › Rehabilitation › Exercise and Physiological Responses
Keywords
overtraining syndrome, relative energy deficiency in sport, training overload, energy availability, carbohydrate availability, energy intake, exercise energy expenditure, hypothalamic-pituitary axis, female athlete triad, misdiagnosis, diagnostic accuracy
MeSH terms
Relative Energy Deficiency in Sport, Energy Intake, Energy Metabolism, Female, Humans, Female Athlete Triad Syndrome, Athletes

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review