The DOI matches its Crossref record; 274 of the 277 references it cites were found in a registry or an index.
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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In the citing paper
“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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Background
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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