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

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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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Author notes

  1. Trent Stellingwerff and Ida A. Heikura shared lead co-authors.

Authors and Affiliations

  1. Pacific Institute for Sport Excellence, Canadian Sport Institute-Pacific, 4371 Interurban Road, Victoria, BC, V9E 2C5, Canada

    Trent Stellingwerff & Ida A. Heikura

  2. Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada

    Trent Stellingwerff & Ida A. Heikura

  3. Human Physiology and Sports Physiotherapy Research Group, Vrije Universiteit Brussel, Brussels, Belgium

    Romain Meeusen

  4. Université Côte d’Azur, LAMHESS Nice, Nice, France

    Stéphane Bermon

  5. World Athletics, Health and Science Department, Monte Carlo, Monaco

    Stéphane Bermon

  6. Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway

    Stephen Seiler

  7. Department of Family Medicine, McMaster University, Hamilton, ON, Canada

    Margo L. Mountjoy

  8. IOC Medical Commission Games Group, Lausanne, Switzerland

    Margo L. Mountjoy

  9. Australian Institute of Sport, Bruce, ACT, Australia

    Louise M. Burke

  10. Mary Mackillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia

    Louise M. Burke

Authors
  1. Trent Stellingwerff
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  2. Ida A. Heikura
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  4. Stéphane Bermon
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  5. Stephen Seiler
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Correspondence to Trent Stellingwerff.

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All authors declare that they have no conflict of interest as it relates to the material associated with this review.

Author contributions

Development and formulation of concept and primary authors: TS and IH; Original draft authors: TS, IH, MM and LB; Critical feedback and revisions: RM, SB, SS. All authors have read and approved the final version.

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Stellingwerff, T., Heikura, I.A., Meeusen, R. et al. Overtraining Syndrome (OTS) and Relative Energy Deficiency in Sport (RED-S): Shared Pathways, Symptoms and Complexities. Sports Med 51, 2251–2280 (2021). https://doi.org/10.1007/s40279-021-01491-0

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