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Overtraining syndrome, Low Energy Availability and Relative Energy Deficiency in Sport (RED-S)

Whether you are an elite athlete or a weekend warrior, is not uncommon to experience periods of time where you feel that your performance in the gym, on the pitch or on the trails is not quite your best. However, if this becomes a long term problem, this can be a sign of something more significant that needs addressing.

What is overtraining syndrome?

Overtraining syndrome (OTS) is a condition where there is a drop in athletic performance or no improvement despite a progressive training load. It is often referred to as “burnout”, and essentially occurs from an imbalance between training load and recovery. Psychological stressors are also an important factor.

Low energy availability (LEA) is very similar in a sense, and there is likely to be a lot of overlap. LEA is specifically referring to a situation where there is under-fuelling for activity demands, i.e. not eating enough food (intentionally or not) to give you adequate energy for both your training AND recovery.

All of these conditions occur on a spectrum, and if LEA is not addressed, in can progress to RED-S, which is a condition where the body’s metabolic and hormonal functions are struggling to operate normally due to long term lack of adequate fuel. This can be more obvious in the female athlete, as there is often new irregularity of periods, or stopping of periods altogether. It is crucial to recognise and address LEA to prevent RED-S from occurring, as it can lead to serious complications such as low bone mineral density and the potential for serious injuries such as stress fractures.

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Who can be affected?

These conditions can affect both men and women, and although these problems are more commonly thought of as issues of elite athletes, in theory anyone who is engaging in fitness related activity can be at risk.

Commonly, people who are at greater risk of these conditions tend to be endurance athletes, dancers and anyone with a heavy training load throughout the week. However we do also see a lot of people, particularly women, who engage in extreme “body transformation” type personal training programs that involve inappropriately low calorie restriction starting to slide into low energy availability and experience problems.


What are the symptoms?

OTS often presents primarily with feeling very tired. Your muscles may feel more sore than you would expect from your training, you may not be getting the results you are looking for, and you may feel it is harder to push yourself during your sessions. It can also impact your mental health, causing low mood, irritability and poor concentration.

Low energy availability can present in a very similar way. You may also notice weight loss or loss of muscle mass / negative body composition changes.

Sadly due to lack of awareness, progression to RED-S sometimes isn’t picked up until a complication such as a stress fracture or loss of the menstrual cycle occurs. Losing your period is never normal or an expected sequalae, and it is not a “badge” of high fitness and leanness


When should I be worried?

It is important to note that there is a lot of overlap with the symptoms of these conditions and other medical conditions, so a thorough assessment of your complete history, training and diet is crucial to make sure there aren’t other things going on that need treatment.

If you are experiencing any of the above symptoms, it is important to see a doctor as soon as possible, ideally with an interest in Sport and Exercise Medicine


What can I do?

Prevention is better than cure! If you are serious about your training or sport, it is a good idea to get guidance from appropriate professionals.

  • Make sure you are eating enough to support your exercise and recovery, and get help from a qualified dietician or sports nutritionist if you are unsure.
  • Track your menstrual cycle and be vigilant for any changes.
  • If you are a female athlete in your late 40s or above, consider to get a DEXA scan to gain insight into your bone density and your risk of osteoporosis, as your diet and exercise regime may need to be adjusted based on this.
  • Make sure your training is focused, appropriately progressive and specific to your current fitness level and goals and seek help from a reputable personal trainer, strength and conditioning or running coach etc if you are unsure.
  • Make sure that you are taking a proper rest day each week.
  • Get help for managing stress.
  • See your physiotherapist early for any injuries and be sure to get a thorough check up with a doctor with experience in Sport and Exercise medicine if you don’t feel better after a week of relative rest.

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Topics: General Practice / Family Medicine

Dr Emma Warner

Dr Emma Warner

Family Medicine, General Practice



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