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

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.

[Amenorrhea in athletic adolescents : the tip of the iceberg]

The female athletic triad refers to the interaction between menstrual function, energy availability and bone density. When an imbalance appears between energy input and output, the global health of the athletic teenager is at risk of somatic and/or psychological complications as defined by the RED-S (Relative Energy Deficiency in Sports). In athletic girls menstrual disorder should be seen as an alert. It may be difficult to distinguish it from menstrual irregularity due to immature hypothalamic-hyphophysic-gonadal axis, which can be physiological at that age. A multidisciplinary approach is needed. The challenge is to find a balance between sport practice and prevention of complications due to lack of estrogens.

Collegiate coaches' knowledge of the female athlete triad in relation to sport type

BACKGROUND

The purpose of this study was to determine what coaches of female athletes know about the three components of the female athlete triad with regard to type of sport coached and the characteristics of the coach.

METHODS

The sample consisted of 309 NCAA Division I coaches of female athletes in the sports of: sports with subjective scoring of performance (gymnastics and diving), low body weight sports (cross country and rowing), revealing or fitted clothing (volleyball and swimming), and other (soccer and basketball). An original, self-report questionnaire, and a 4-point Likert scale to measure confidence in answer was used. The variables were: knowledge, confidence, and coach's characteristics (coach's gender, degree held, years of experience in coaching females, continuing education participation specific to the triad and triad components, and type of sport coached).

RESULTS

Coaches of low body weight sports scored significantly higher than both coaches of sports requiring fitted clothing and "other" sports in the overall score. They further had significantly more confidence in their answers than coaches of "other" sports. No significant differences in the overall score in any of the types of sport or total values were found regarding gender, experience, and degree. Coaches who had received training about the triad or its components scored significantly higher than coaches who did not receive training.

CONCLUSIONS

The results demonstrated a lack of information among coaches and that participating in formative training can help to reduce this problem. The results found can help in the design of continuing education for coaches.

Energy deficiency, menstrual disturbances, and low bone mass: what do exercising Australian women know about the female athlete triad?

PURPOSE

Prevention of the female athlete triad is essential to protect female athletes' health. The aim of this study was to investigate the knowledge, attitudes, and behaviors of regularly exercising adult women in Australia toward eating patterns, menstrual cycles, and bone health.

METHODS

A total of 191 female exercisers, age 18-40 yr, engaging in ≥2 hr/wk of strenuous activity, completed a survey. After 11 surveys were excluded (due to incomplete answers), the 180 participants were categorized into lean-build sports (n = 82; running/athletics, triathlon, swimming, cycling, dancing, rowing), non-lean-build sports (n = 94; basketball, netball, soccer, hockey, volleyball, tennis, trampoline, squash, Australian football), or gym/fitness activities (n = 4).

RESULTS

Mean (± SD) training volume was 9.0 ± 5.5 hr/wk, with participants competing from local up to international level. Only 10% of respondents could name the 3 components of the female athlete triad. Regardless of reported history of stress fracture, 45% of the respondents did not think that amenorrhea (absence of menses for ≥3 months) could affect bone health, and 22% of those involved in lean-build sports would do nothing if experiencing amenorrhea (vs. 3.2% in non-lean-build sports, p = .005). Lean-build sports, history of amenorrhea, and history of stress fracture were all significantly associated with not taking action in the presence of amenorrhea (all p < .005).

CONCLUSIONS

Few active Australian women are aware of the detrimental effects of menstrual dysfunction on bone health. Education programs are needed to prevent the female athlete triad and ensure that appropriate actions are taken by athletes when experiencing amenorrhea.

National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes

OBJECTIVE

To present recommendations for the prevention, detection, and comprehensive management of disordered eating (DE) in athletes.

BACKGROUND

Athletes with DE rarely self-report their symptoms. They tend to deny the condition and are often resistant to referral and treatment. Thus, screenings and interventions must be handled skillfully by knowledgeable professionals to obtain desired outcomes. Certified athletic trainers have the capacity and responsibility to play active roles as integral members of the health care team. Their frequent daily interactions with athletes help to facilitate the level of medical surveillance necessary for early detection, timely referrals, treatment follow-through, and compliance.

RECOMMENDATIONS

These recommendations are intended to provide certified athletic trainers and others participating in the health maintenance and performance enhancement of athletes with specific knowledge and problem-solving skills to better prevent, detect, and manage DE. The individual biological, psychological, sociocultural, and familial factors for each athlete with DE result in widely different responses to intervention strategies, challenging the best that athletics programs have to offer in terms of resources and expertise. The complexity, time intensiveness, and expense of managing DE necessitate an interdisciplinary approach representing medicine, nutrition, mental health, athletic training, and athletics administration in order to facilitate early detection and treatment, make it easier for symptomatic athletes to ask for help, enhance the potential for full recovery, and satisfy medicolegal requirements. Of equal importance is establishing educational initiatives for preventing DE.

The relationship between perfectionism, eating disorders and athletes: a review

Perfectionism is a potentially maladaptive personality trait implicated in a number of psychopathologies. As our understanding of the construct perfectionism has shifted from more unidimensionally focused conceptualizations to multidimensional ones, our ability to assess its bearing on various disorders has grown. One particular area in which perfectionism appears to play an important role is among eating disorder patients. The personalities of both those with anorexia nervosa (AN) and bulimia nervosa (BN) are thought to be intrinsically perfectionistic, which suggests a need to understand the role perfectionism plays in the development, course and outcome of these disorders. There is also an increased focus on perfectionism among athletes and its relationship to the higher prevalence of eating disorders in this group. With the institution of Title IX in the United States (which prohibited sex discrimination in higher educational settings) the participation of women in various sports has increased exponentially and with it concerns about their well-being in a milieu where a risk for menstrual irregularities, osteoporosis and eating disorders (the female athlete triad) are common. However, conflicting data suggests that athletics may be a protective factor in the development of eating disorders on the one hand, or it may be a risk factor on the other. Thus, it has become important to examine other variables, such as perfectionism, that may influence the outcome, one way or another. This review examines the current evidence about the relations between perfectionism, athletics and eating disorders.