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Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities
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.
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“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“Emerging definitions highlight short-term LEA as a few days to weeks, mediumterm as weeks to months and long-term as months to years.37 40”
From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [37]
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“The authors 1) concluded that OTS and RED-S share many overlapping symptoms, 2) proposed that trainingoverload/OTS studies may be confounded by unrecognized inadequate energy intake (e.g., low dietary carbohydrates) coupled with high training loads, 3) cautioned that low energy availability leading to RED-S may be mis…”
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Melin, A., Areta, J. L., Heikura, I. A., Stellingwerff, T., Torstveit, M. K., & Hackney, A. C. (2023) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.14327 · Cited by 116
“47”
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“The recognition that overreaching and low energy availability often co-occur, 11,12 but have separate etiologies, is an important distinction that should be made in the field.”
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“This lack of change could be attributed to the relatively short duration of the LEA state, which may not have been sufficient to induce symptoms associated with Relative Energy Deficiency in Sport (RED-S) [47].”
Wyatt, P. M., Drager, K., Groves, E. M., Stellingwerff, T., Billington, E., Boyd, S., & Burt, L. (2023) · Calcified Tissue International · doi:10.1007/s00223-023-01120-0 · Cited by 12
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“…intake have demonstrated effects on reductions in both HRV 21,24,25 and RMR. 26,27 As well, a high and consistent training load coupled with ED has been theorized to exacerbate overtraining effects 13,28 on autonomic nervous system function in endurance athletes 13 that may present as low HRV.”
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“…eating behaviours is low energy availability (defined as: EI – energy expenditure/FFM), which can occur without disordered eating behaviours (especially in high energy expenditure athletes) [32], but is often underpinned by disordered eating behaviours in female [28, 33] and male athletes [28, 34].”
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A Comprehensive Analysis of Overtraining Syndrome in Athletes and Recreational Exercisers
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“In extreme cases, it can lead to non-functional over-reaching or overtraining that can take many months to resolve [30, 31].”
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Relative energy deficiency in military (RED-M)
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Self-citationGeiger, S., Esser, A. J., Marsall, M., Muehlbauer, T., Skoda, E., Teufel, M., & Bäuerle, A. (2024) · BMC Sports Science Medicine and Rehabilitation · doi:10.1186/s13102-024-00902-9 · Cited by 6
“However, an imbalance between training intensity and the appropriate recovery periods may lead to various impairments, such as overtraining syndrome or relative energy deficiency [3, 4].”
BackgroundTsukahara, Y., Kamada, H., Torii, S., & Yamasawa, F. (2022) · International Journal of Sports Medicine · doi:10.1055/a-1954-9239 · Cited by 5
“reported a possible overlap between OTS and RED-S, although both conditions are challenging to diagnose as they are based on exclusions [10].”
BackgroundInfluentialMicrorobots Based on Stimulus‐Responsive Hydrogels: Development Status and Prospects
Wang, X., Gao, Y., Liu, C., Wang, Y., Liu, A., & Yang, W. (2025) · ChemNanoMat · doi:10.1002/cnma.202500017 · Cited by 4
Exploring the presentation of REDs in ultra endurance sport: a review
Colangelo, J., Smith, A. J., Henninger, K., Buadze, A., & Liebrenz, M. (2025) · Journal of Eating Disorders · doi:10.1186/s40337-025-01381-0 · Cited by 4
“…[60], not professional or elite, and might not have access to the recommended cadre of healthcare practitioners suggested in the REDs treatment guidelines [17]; discussion of the successful application of REDs protocols was not explicitly explored in any studies represented in our results [17, 61].”
Qu, J., Wang, Q., Wang, R., Ma, X., Ji, F., Qian, Y., Bao, J. Q., & Lu, Y. (2025) · Injury · doi:10.1016/j.injury.2024.112134 · Cited by 4
Gowers, C. R., McManus, C., Chung, H. C., Jones, B., Tallent, J., & Waterworth, S. (2025) · Journal of the International Society of Sports Nutrition · doi:10.1080/15502783.2025.2496448 · Cited by 4
“The high energy demands and unique physiological adaptations associated with endurance training necessitate adequate energy intake for optimal performance, recovery, and overall health [1–3].”
Recommendations for Advancing the Resistance Exercise Overtraining Research
Bell, L., Ruddock, A. D., Maden‐Wilkinson, T., & Rogerson, D. (2022) · Applied Sciences · doi:10.3390/app122412509 · Cited by 4
How much sport is too much? A focus on musculoskeletal health of the adult
Bruyère, O., & Kaux, J. (2023) · Aging Clinical and Experimental Research · doi:10.1007/s40520-023-02448-1 · Cited by 4
“Also, in recent years, there has been more discussion of relative energy deficiency in sport (RED-S), a complex syndrome caused by low energy availability that leads to impaired physiological function and negatively affects aspects of health and performance [26].”
BackgroundAgudo-Ortega, A., Talsnes, R. K., Eid, H., Sandbakk, Ø. B., & Solli, G. S. (2024) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2024-0131 · Cited by 4
Stewart, D. G., Allen, J. B., & Kirkland, A. (2023) · International Journal of Sports Science & Coaching · doi:10.1177/17479541231179301 · Cited by 6
“The challenges in de fi nition, diagnosis of and delineation between similarly complex conditions such as LEA, OTS, and RED-S 7,9,10 are likely to remain elusive unless there is greater recognition of the ontologies used to construct knowledge of complex aetiologies.”
BackgroundInfluentialEat well to the best performance: calorie intake and eating behavior among athlete: a review
Wati, I. D. P., Kusnanik, N. W., Wahjuni, E. S., Samodra, Y. T. J., Gandasari, M. F., & Sofyan, D. (2023) · International Journal of Public Health Science (IJPHS) · doi:10.11591/ijphs.v13i1.23336 · Cited by 4
“The availability of sufficient energy will help athlete performance but will hinder performance if it is not sufficient [17], [29], [30].”
BackgroundTenan, M. S., & Alejo, B. (2024) · Journal of Athletic Training · doi:10.4085/1062-6050-0580.23 · Cited by 4
Why low-intensity endurance training for athletes?
Matomäki, P. (2025) · European Journal of Applied Physiology · doi:10.1007/s00421-025-05843-w · Cited by 4
“While overtraining syndrome may be witnessed in the field, very little objective scientific data exists on it (Weakley et al. 2022), and even that limited data may be confounded by insufficient energy intake (Stellingwerff et al. 2021).”
Alterations in glycemic control and glucose tolerance following overtraining in endurance athletes
Ranahan, A. M., Pignanelli, C., Thompson, K. M. A., Burr, J. F., & Coates, A. M. (2025) · Applied Physiology, Nutrition, and Metabolism · doi:10.1139/apnm-2025-0278 · Cited by 3
Impact of Equation Choice on Resting Metabolic Rate Ratio in High-Level Men and Women Athletes
Alcántara, J. M. A., Hausen, M., Itaborahy, A. D. S., & Freire, R. (2024) · Journal of the American Nutrition Association · doi:10.1080/27697061.2023.2301405 · Cited by 3
Bernacikovà, M., Kumstát, M., Burešová, I., Kapounková, K., Struhár, I., Sebera, M., & Paludo, A. C. (2022) · Frontiers in Physiology · doi:10.3389/fphys.2022.919982 · Cited by 3
“RED-S, however, is explicitly caused by chronically poor energy availability (Stellingwerff et al., 2021).”
BackgroundThe Prevalence of Low Energy Availability in Cross-Country Skiers during the Annual Cycle
Андреевна, Б. Е., Lyudinina, A. Y., & Bojko, E. R. (2024) · Nutrients · doi:10.3390/nu16142279 · Cited by 3
“TEE was estimated with an equation rather than determined with the reference method (i.e., doubly-labeled water), which probably led to an overestimation of TEE in this study.”
MethodГаврилова, Е. А., Анатольевич, Ч. О., Pavlova, O. Y., Владимировна, Б. Е., Rasskazova, A. V., Gorkin, M. V., Sarkisov, A. K., Didora, A. B., & Shitova, V. I. (2024) · Human Physiology · doi:10.1134/s036211972470110x · Cited by 3
“These include eating disorders, mental stress not associated with sports activities, and a decrease in the quality and/or quantity of sleep, as evidenced by many scientific publications [20, 23, 77, 79, 80], etc., as well as developed and generally accepted OTS diagnostic EROS scales [3, 4].”
Heikura, I. A., Tsai, M., Sesbreno, E., McCluskey, W. T. P., Johnson, L. J., Murray, H. J., & Stellingwerff, T. (2025) · International Journal of Sport Nutrition and Exercise Metabolism · doi:10.1123/ijsnem.2024-0254 · Cited by 3
Self-citationKeay, N., Lanfear, M., & Francis, G. (2022) · International Journal of Sports Medicine and Rehabilitation · doi:10.28933/ijsmr-2022-04-2205 · Cited by 3
Esser, A. J., Geiger, S., Paslakis, G., Muehlbauer, T., Gradl-Dietsch, G., Seitz, J., Giel, K. E., Striegel, H., Bäuerle, A., & Teufel, M. (2025) · Zeitschrift für psychosomatische Medizin und Psychotherapie · doi:10.13109/zptm.2025.71.2.189 · Cited by 2
Considerations of Fertility in Elite Sportswomen: A Narrative Review
L’Heveder, A., Roberts, R. E., Hassan, A. A., Kasaven, L. S., Saso, S., Bracewell‐Milnes, T., Nicopoullos, J. D. M., Thum, M., O’Neill, H. C., Pollock, N., et al. (2025) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.18283 · Cited by 3
Delaney, D., McGuire, A., Warrington, G. D., & Doyle, L. (2025) · International Journal of Sports Science & Coaching · doi:10.1177/17479541251362409 · Cited by 2
Hanss, K. E., Denning, D. M., Flatt, R. E., Sanzari, C. M., Murray, S. B., Lavender, J. M., Compte, E. J., Blashill, A. J., Nagata, J. M., Keel, P. K., et al. (2025) · Eating Behaviors · doi:10.1016/j.eatbeh.2025.102022 · Cited by 2
Hooren, B. V., Rietjens, G. J., & Plasqui, G. (2025) · Current Biology · doi:10.1016/j.cub.2025.11.038 · Cited by 2
Wood, A. N., & Soundy, A. (2025) · Sports · doi:10.3390/sports13120453 · Cited by 2
“In addition, tertiary prevention strategies centered around individualized nutritional interventions are critical and show promising effects [11], focusing on increasing overall energy intake to restore energy balance and support physiological recovery [12].”
From Biological Foundations to Optimizing Performance and Health in Elite Female Winter Olympians
Sandbakk, Ø. B., Spörri, J., Fridén, C., Melin, A., Zoppirolli, C., Sperlich, B., Skattebo, Ø., Fornasiero, A., Ørtenblad, N., & Holmberg, H. (2026) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.70263 · Cited by 2
“The inclusion of menstrual and hormonal health markers in monitoring helps identify issues such as cycle irregularities or signs of low energy availability early [80].”
In‐Field Validity and Inter‐Unit Variability of Metabolic Carts During Simulated Exercise
Hooren, B. V., Souren, T., & Bongers, B. C. (2026) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.70297 · Cited by 2
“Accurate assessment of respiratory gases is critical because they are used to make clinical decisions [1–3], guide exercise prescription [5, 6], and support a wide range of research applications [7–16].”
Portugal, G. B., Machado, L. D. P., Marinho, B., de Faria, V. C., de Souza, L. M. L., Viana, B. F., Bunn, P. D. S., & da Silva, E. B. (2026) · Military Medicine · doi:10.1093/milmed/usag185 · Cited by 2
Adolescent athletes’ sleep problems and overtraining
Cho, U., & Im, K. B. (2024) · Sports Psychiatry · doi:10.1024/2674-0052/a000070 · Cited by 2
da Silva, J. L. D. Q. (2024) · Editora Pascal LTDA eBooks · doi:10.29327/5403830.1-5 · Cited by 1
Rationalising a spectrum of problematic exercise: A qualitative study
Nicholls, K., & Ogden, J. (2024) · Journal of Health Psychology · doi:10.1177/13591053241274471 · Cited by 2
“…a behavioural addiction, can have negative consequences for work or study, social and personal relationships, and tends to lead to increased risk of injury and potentially overtraining syndrome or RED-S (Griffiths, 1997; Kreher and Schwartz, 2012; Langbein et al., 2021; Stellingwerff et al., 2021).”
Síndrome de estrés tibial medial en deportistas: una mirada global en diagnóstico y tratamiento
Guzman, J. M., Rodríguez, J. P., & Sanhueza, A. N. (2023) · Archivos de la Sociedad Chilena de Medicina del Deporte · doi:10.59856/arch.soc.chil.med.deporte.v68i2.69 · Cited by 1
“En esta evaluación se debe estimar la disponibilidad de energía y buscar activamente la presencia del síndrome de déficit de energía relativo en el deporte (RED-S), ya que una lesión por sobrecarga puede ser una oportunidad de pesquisar esta compleja situación en un deportista (55).”
BackgroundArnold, J. I., Mawji, A., Stene, K., Taylor, D. C., & Koehle, M. S. (2024) · Sports Medicine · doi:10.1007/s40279-024-02105-1 · Cited by 1
Гаврилова, Е. А., Анатольевич, Ч. О., Pavlova, O. Y., Владимировна, Б. Е., Rasskazova, A. V., Gorkin, M. V., Sarkisov, A. K., Didora, A. B., & Shitova, V. I. (2024) · Human Physiology · doi:10.31857/s0131164624060095 · Cited by 1
Results of a 100-Year Study of the Problem of Overtraining
Гаврилова, Е. А., & Анатольевич, Ч. О. (2024) · Human Physiology · doi:10.1134/s0362119724700889 · Cited by 1
“In his review T. Stellingwerff et al. [9], demonstrated that many of the negative consequences of OTS may be primarily related to the deficiency of energy and carbohydrate availability.”
Spécificités gynécologiques de la sportive de haut niveau
Maître, C. (2025) · Bulletin de l Académie Nationale de Médecine · doi:10.1016/j.banm.2025.02.003 · Cited by 1
Rowan, M. R., Koob, G., Varzeas, K. A., Stewart, T. M., & Becker, C. B. (2025) · Springer eBooks · doi:10.1007/978-3-032-03228-7_198 · Cited by 1
Energy, carbohydrates and fats in clinical sports nutrition
Kozjek, A. K., Knap, K., Tonin, G., Kozjek, N. R., & Gleeson, M. (2026) · Clinical Nutrition ESPEN · doi:10.1016/j.clnesp.2025.102900 · Cited by 3
Nguyen, V. T. M., Esser, A. J., Lalgi, T. J., Geiger, S., Paslakis, G., Muehlbauer, T., Teufel, M., & Bäuerle, A. (2026) · Performance Enhancement & Health · doi:10.1016/j.peh.2025.100407 · Cited by 1
Jing, S., Awang, M. M., Pa, W. A. M. W., Wei, Z., Pan, P., Chen, Y., & Wang, M. (2026) · International Journal of Sport and Exercise Psychology · doi:10.1080/1612197x.2026.2645205 · Cited by 1
Orlov, O. I., & Gunina-Orlova, L. M. (2026) · Scientific Journal of National Pedagogical Dragomanov University Series 15 Scientific and pedagogical problems of physical culture (physical culture and sports) · doi:10.31392/udu-nc.series15.2026.03k(203).58 · Cited by 1
McDonald, C. V., McSorley, E. M., McNeilly, A., & Magee, P. J. (2026) · Nutrition Reviews · doi:10.1093/nutrit/nuag042 · Cited by 1
Metadata
- 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
- Published
- 2021-06-28
- Volume
- 51
- Issue
- 11
- Pages
- 2251-2280
- ISSN
- 0112-1642 (ISSN-L)
- 1179-2035
- 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
- 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 › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Physiology (medical) › 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
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