What’s the deal with overtraining?
What is Overtraining Syndrome (OTS)? Cleveland Clinic defines it as “a sports-specific decrease in performance together with disturbances in mood state.” For an athlete truly experiencing OTS, underperformance can persist in spite of a period of recovery lasting weeks or months. While the prevalence of OTS has not been adequately studied, and it is notoriously difficult to diagnose, it’s more prevalent than you think.
Here are some numbers on how common OTS really is: survey research suggests that up to 64% of elite distance runners report experiencing OTS at least once in their careers (and that number is between 7-21% for the number of endurance athletes experiencing it annually). Athletes who have a history of OTS appear to be at greater risk of developing OTS again, with one study demonstrating a 91% chance of return within 3 years.1
If you are an endurance athlete looking to achieve a body recomposition goal, RED-S (Relative Energy Deficiency in Sports) is an additional risk factor. RED-S is a consequence of underfueling workouts repeatedly. RED-S has long been associated primarily with female athletes and the “female athlete triad” (think gymnasts who no longer get their period), but it is not uncommon in men as well.
RED-S can lead to the following:
- higher risk of injury
- reduced concentration
- lack of response to training
- reduced strength
- decreased endurance
Prolonged RED-S or OTS can lead to thyroid or cardiovascular issues as well in addition to problems with training, so this is a very real and serious risk to anyone who is serious about making changes to body composition and intentionally in an energy deficit while training for a sport or aesthetics.
RED-S and OTS both originate from hypothalamic-pituitary and are incredibly similar conditions. The focus of OTS is moving too quickly through a training overload schedule with underrecovery, whereas RED-S is more focused on energy deficit. The causes and diagnoses of both are vague and incredibly complex, and overlap significantly. See the below diagram from a recent review on RED-S showing the complex spectrum of symptoms and causes2
REDS and OTS symptom wheel image
For the purposes of the BODYSIM program, we focus on OTS, but with awareness that RED-S is just as likely a diagnosis for our at-risk users. We use all information available to us to highlight red flags and, if necessary, refer our users to a healthcare provider who can help them determine a more detailed diagnosis and plan forward.
Our BODYSIM indicator puts you on a scale of 0-13, based on a combination of both blood lab biomarkers and the mental health self assessment:
Biomarker Diagnosis
Hormonal biomarkers are a primary red flag we identify with our users, and our at-home monthly blood test allows us to focus on the presence and evolution of those biomarkers for all of our users. Prolactin3 and the Testosterone/E24 ratios are measures of overtraining when the safe range is exceeded. While it is difficult to study the effects of OTS in a controlled manner given the danger of inducing OTS in athletes, observational studies have shown these markers to be present5, so we consider them to be an initial indicator that something should be brought to attention. However, these indicators are only useful for male users, since female hormonal fluctuations make the Testosterone/E2 ratios incredibly unstable.
Additionally, we have found anecdotally that a serious athlete will be more likely to blame their own fitness or training program on symptoms like difficulties with sleep or underperformance, so the support of biomarker evidence is a powerful sign that it might be time to reassess both diet and training together.
Mental Health Diagnosis
In addition to a biomarker diagnosis, it is absolutely crucial to pay attention to the rest of the spectrum of risk factors for OTS. As in the diagram above depicting the complexities around low energy availability and causes of RED-S, It is important to monitor mental recovery and stress. We’ve implemented the POMS questionnaire (Profile of Mood States), which is a self assessment of mental health stress and recovery in BODYSIM, as it is a generally accepted tool for monitoring progress of the stress contribution to OTS, but it needs to be taken in the context of all other symptoms.
Making a Diagnosis With Context
You can see in the image below, that the POMS scores are taken along with calories, protein, and carbohydrate intake, so we can take the context of how well you are fueling along with your POMS scores, biomarkers, and overall diet together to know how likely you are to be at risk.
What happens when you have OTS?
We’ve established that OTS and RED-S are surprisingly prevalent. Of course, it is important to manage treatment with a healthcare provider, but in most cases it can be reversed by becoming aware of and managing the impact of your load. This recent German study6 shared the diagram below of the Olympic committee’s view of the spectrum of OTS causes and manifestations. As an athlete, it is important to think about the balance between load and recovery, and increase recovery if OTS is a risk.
Our goal as an athlete or engaging in a resistance training program is to stay in the window of “Functional Overreaching”, and our BODYSIM OTS likelihood score can give you an indication of whether you are slipping into “Non-functional overreaching” even before OTS is a real possibility. It’s helpful to think about the “Load” and “Recovery” as holistic descriptions of your day to day. Too much load without enough sleep, hydration, mental recovery, etc. is just as risky as not taking a rest day.