Defining the “dose” of altitude training: how high to live for optimal sea level performance enhancement

Effects of 10 days of separate heat and hypoxic exposure on heat acclimation and temperate exercise performance

Adaptations to heat and hypoxia are typically studied in isolation but are often encountered in combination. Whether the adaptive response to multiple stressors affords the same response as when examined in isolation is unclear. We examined 1) the influence of overnight moderate normobaric hypoxia on the time course and magnitude of adaptation to daily heat exposure and 2) whether heat acclimation (HA) was ergogenic and whether this was influenced by an additional hypoxic stimulus. Eight males [V̇o2max = 58.5 (8.3) ml·kg−1·min−1] undertook two 11-day HA programs (balanced-crossover design), once with overnight normobaric hypoxia (HAHyp): 8 (1) h per night for 10 nights [[Formula: see text] = 0.156; SpO2 = 91 (2)%] and once without (HACon). Days 1, 6, and 11 were exercise-heat stress tests [HST (40°C, 50% relative humidity, RH)]; days 2–5 and 7–10 were isothermal strain [target rectal temperature (Tre) ~38.5°C], exercise-heat sessions. A graded exercise test and 30-min cycle trial were undertaken pre-, post-, and 14 days after HA in temperate normoxia (22°C, 55% RH; FIO2 = 0.209). HA was evident on day 6 (e.g., reduced Tre, mean skin temperature (T̄sk), heart rate, and sweat [Na+], P < 0.05) with additional adaptations on day 11 (further reduced T̄sk and heart rate). HA increased plasma volume [+5.9 (7.3)%] and erythropoietin concentration [+1.8 (2.4) mIU/ml]; total hemoglobin mass was unchanged. Peak power output [+12 (20) W], lactate threshold [+15 (18) W] and work done [+12 (20) kJ] increased following HA. The additional hypoxic stressor did not affect these adaptations. In conclusion, a separate moderate overnight normobaric hypoxic stimulus does not affect the time course or magnitude of HA. Performance may be improved in temperate normoxia following HA, but this is unaffected by an additional hypoxic stressor.

Physiological Adaptations to Hypoxic vs. Normoxic Training during Intermittent Living High

In the setting of “living high,” it is unclear whether high-intensity interval training (HIIT) should be performed “low” or “high” to stimulate muscular and performance adaptations. Therefore, 10 physically active males participated in a 5-week “live high-train low or high” program (TR), whilst eight subjects were not engaged in any altitude or training intervention (CON). Five days per week (~15.5 h per day), TR was exposed to normobaric hypoxia simulating progressively increasing altitude of ~2,000–3,250 m. Three times per week, TR performed HIIT, administered as unilateral knee-extension training, with one leg in normobaric hypoxia (~4,300 m; TR_HYP) and with the other leg in normoxia (TR_NOR). “Living high” elicited a consistent elevation in serum erythropoietin concentrations which adequately predicted the increase in hemoglobin mass (r = 0.78, P < 0.05; TR: +2.6%, P < 0.05; CON: −0.7%, P > 0.05). Muscle oxygenation during training was lower in TR_HYP vs. TR_NOR (P < 0.05). Muscle homogenate buffering capacity and pH-regulating protein abundance were similar between pretest and posttest. Oscillations in muscle blood volume during repeated sprints, as estimated by oscillations in NIRS-derived tHb, increased from pretest to posttest in TR_HYP (~80%, P < 0.01) but not in TR_NOR (~50%, P = 0.08). Muscle capillarity (~15%) as well as repeated-sprint ability (~8%) and 3-min maximal performance (~10–15%) increased similarly in both legs (P < 0.05). Maximal isometric strength increased in TR_HYP (~8%, P < 0.05) but not in TR_NOR (~4%, P > 0.05). In conclusion, muscular and performance adaptations were largely similar following normoxic vs. hypoxic HIIT. However, hypoxic HIIT stimulated adaptations in isometric strength and muscle perfusion during intermittent sprinting.

A Clinician Guide to Altitude Training for Optimal Endurance Exercise Performance at Sea Level

Constantini, Keren, Daniel P. Wilhite, and Robert F. Chapman. A clinician guide to altitude training for optimal endurance exercise performance at sea level. High Alt Med Biol. 18:93-101, 2017.-For well over 50 years, endurance athletes have been utilizing altitude training in an effort to enhance performance in sea level competition. This brief review will offer the clinician a series of evidence-based best-practice guidelines on prealtitude and altitude training considerations, which can ultimately maximize performance improvement outcomes.

Athletes at High Altitude

CONTEXT

Athletes at different skill levels perform strenuous physical activity at high altitude for a variety of reasons. Multiple team and endurance events are held at high altitude and may place athletes at increased risk for developing acute high altitude illness (AHAI). Training at high altitude has been a routine part of preparation for some of the high level athletes for a long time. There is a general belief that altitude training improves athletic performance for competitive and recreational athletes.

EVIDENCE ACQUISITION

A review of relevant publications between 1980 and 2015 was completed using PubMed and Google Scholar.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

AHAI is a relatively uncommon and potentially serious condition among travelers to altitudes above 2500 m. The broad term AHAI includes several syndromes such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), and high altitude cerebral edema (HACE). Athletes may be at higher risk for developing AHAI due to faster ascent and more vigorous exertion compared with nonathletes. Evidence regarding the effects of altitude training on athletic performance is weak. The natural live high, train low altitude training strategy may provide the best protocol for enhancing endurance performance in elite and subelite athletes. High altitude sports are generally safe for recreational athletes, but they should be aware of their individual risks.

CONCLUSION

Individualized and appropriate acclimatization is an essential component of injury and illness prevention.

Biochemical and functional modifications in biathlon athletes at medium altitude training / Modificările biochimice și funcționale ale atleților biatloniști după antrenament la altitudine medie

Objective: The aim of our research was to identify physiological and biochemical changes induced by training at medium altitude.

Methods: Ten biathlon athletes underwent 28-day training camp at medium altitude in order to improve their aerobic effort, following the living high-base train high-interval train low (Hi-Hi-Lo) protocol. There were investigated three categories of functional and biochemical parameters, targeting the hematological changes (RBC, HCT, HGB), the oxidative (lipoperoxid, free malondialdehyde and total malondialdehyde) and antioxidative balance (the hydrogen donor capacity, ceruloplasmin and uric acid) and the capacity of effort (the maximum aerobic power, the cardiovascular economy in effort, the maximum O2 consumption).

Results: All the biochemical and functional evaluated parameters showed significant increases between the pre-training testing and post-training testing (5.13 ± 0.11 vs. 6.50 ± 0.09, p < 0.0001 for RBC; 44.80 ± 1.22 vs. 51.31 ± 2.31, p < 0.0001 for HCT; 15.06 ± 0.33 vs. 17.14 ± 0.25, p < 0.0001 for HGB; 1.32 ± 0.04 vs.1.62 ± 0.01, p < 0.0001 for LPx; 1.61 ± 0.01 vs. 1.73 ± 0.01, p < 0.0001 for free MDA; 2.98 ± 0.08 vs. 3.37 ± 0.03, p < 0.0001 for total MDA; 45.92 ± 0.13 vs. 57.98 ± 0.12, p < 0.0001 for HD; 25.95 ± 0.13 vs. 31.04 ± 0.06, p < 0.0001 for Crp; 3.47 ± 0.03 vs.7.69 ± 0.02, p < 0.0001 for UA; 63.91 ± 1.00 vs. 81.53 ± 1.97, p < 0.0001 for MAP; 33.13 ± 0.57 vs. 57.41 ± 0.63, p < 0.0001 for CVEE; 4190 ± 50.45 vs. 5945 ± 46.48, p < 0.0001 for VO2max).

Conclusions: Aerobic effort capacity of biathlon athletes has increased in the post-training period, using Hi-Hi-Lo protocol.

Similar Inflammatory Responses following Sprint Interval Training Performed in Hypoxia and Normoxia

Sprint interval training (SIT) is an efficient intervention capable of improving aerobic capacity and exercise performance. This experiment aimed to determine differences in training adaptations and the inflammatory responses following 2 weeks of SIT (30 s maximal work, 4 min recovery; 4-7 repetitions) performed in normoxia or hypoxia. Forty-two untrained participants [(mean ± SD), age 21 ±1 years, body mass 72.1 ±11.4 kg, and height 173 ±10 cm] were equally and randomly assigned to one of three groups; control (CONT; no training, n = 14), normoxic (NORM; SIT in FiO2: 0.21, n = 14), and normobaric hypoxic (HYP; SIT in FiO2: 0.15, n = 14). Participants completed a [Formula: see text] test, a time to exhaustion (TTE) trial (power = 80% [Formula: see text]) and had hematological [hemoglobin (Hb), haematocrit (Hct)] and inflammatory markers [interleukin-6 (IL-6), tumor necrosis factor-α (TNFα)] measured in a resting state, pre and post SIT. [Formula: see text] (mL.kg(-1).min(-1)) improved in HYP (+11.9%) and NORM (+9.8%), but not CON (+0.9%). Similarly TTE improved in HYP (+32.2%) and NORM (+33.0%), but not CON (+3.4%) whilst the power at the anaerobic threshold (AT; W.kg(-1)) also improved in HYP (+13.3%) and NORM (+8.0%), but not CON (-0.3%). AT (mL.kg(-1).min(-1)) improved in HYP (+9.5%), but not NORM (+5%) or CON (-0.3%). No between group change occurred in 30 s sprint performance or Hb and Hct. IL-6 increased in HYP (+17.4%) and NORM (+20.1%), but not CON (+1.2%), respectively. TNF-α increased in HYP (+10.8%) NORM (+12.9%) and CON (+3.4%). SIT in HYP and NORM increased [Formula: see text], power at AT and TTE performance in untrained individuals, improvements in AT occurred only when SIT was performed in HYP. Increases in IL-6 and TNFα reflect a training induced inflammatory response to SIT; hypoxic conditions do not exacerbate this.

Preparticipation Evaluation of the Young Athlete: What an Orthopaedic Surgeon Needs to Know

The preparticipation evaluation (PPE) is a widely used tool for detecting health conditions that may delay or disqualify athletic participation. The medical interview is the most valuable tool for identifying athletes who may be at increased risk for injury. Physical examination is tailored to identifying cardiac abnormalities or factors that may place an athlete at increased risk for injury. Although practiced in Europe, universal cardiac screening with electrocardiography is not currently recommended in the United States largely due to the high rate of false-positive results. Neuropsychological testing for management of concussion and laboratory testing for sickle cell trait may be indicated in select groups of athletes. Health care providers should view the PPE as a chance for anticipatory guidance and athlete-directed health counseling. Despite widespread acceptance of the PPE, the quality of such examinations varies significantly, which is an area for possible improvement and further research.

Living altitude influences endurance exercise performance change over time at altitude

For sea level based endurance athletes who compete at low and moderate altitudes, adequate time for acclimatization to altitude can mitigate performance declines. We asked whether it is better for the acclimatizing athlete to live at the specific altitude of competition or at a higher altitude, perhaps for an increased rate of physiological adaptation. After 4 wk of supervised sea level training and testing, 48 collegiate distance runners (32 men, 16 women) were randomly assigned to one of four living altitudes (1,780, 2,085, 2,454, or 2,800 m) where they resided for 4 wk. Daily training for all subjects was completed at a common altitude from 1,250 to 3,000 m. Subjects completed 3,000-m performance trials on the track at sea level, 28 and 6 days before departure, and at 1,780 m on days 5, 12, 19, and 26 of the altitude camp. Groups living at 2,454 and 2,800 m had a significantly larger slowing of performance vs. the 1,780-m group on day 5 at altitude. The 1,780-m group showed no significant change in performance across the 26 days at altitude, while the groups living at 2,085, 2,454, and 2,800 m showed improvements in performance from day 5 to day 19 at altitude but no further improvement at day 26. The data suggest that an endurance athlete competing acutely at 1,780 m should live at the altitude of the competition and not higher. Living ∼300-1,000 m higher than the competition altitude, acute altitude performance may be significantly worse and may require up to 19 days of acclimatization to minimize performance decrements.

Same Performance Changes after Live High-Train Low in Normobaric vs. Hypobaric Hypoxia

PURPOSE

We investigated the changes in physiological and performance parameters after a Live High-Train Low (LHTL) altitude camp in normobaric (NH) or hypobaric hypoxia (HH) to reproduce the actual training practices of endurance athletes using a crossover-designed study.

METHODS

Well-trained triathletes (n = 16) were split into two groups and completed two 18-day LTHL camps during which they trained at 1100-1200 m and lived at 2250 m (P i O2 = 111.9 ± 0.6 vs. 111.6 ± 0.6 mmHg) under NH (hypoxic chamber; FiO2 18.05 ± 0.03%) or HH (real altitude; barometric pressure 580.2 ± 2.9 mmHg) conditions. The subjects completed the NH and HH camps with a 1-year washout period. Measurements and protocol were identical for both phases of the crossover study. Oxygen saturation (S p O2) was constantly recorded nightly. P i O2 and training loads were matched daily. Blood samples and VO2max were measured before (Pre-) and 1 day after (Post-1) LHTL. A 3-km running-test was performed near sea level before and 1, 7, and 21 days after training camps.

RESULTS

Total hypoxic exposure was lower for NH than for HH during LHTL (230 vs. 310 h; P < 0.001). Nocturnal S p O2 was higher in NH than in HH (92.4 ± 1.2 vs. 91.3 ± 1.0%, P < 0.001). VO2max increased to the same extent for NH and HH (4.9 ± 5.6 vs. 3.2 ± 5.1%). No difference was found in hematological parameters. The 3-km run time was significantly faster in both conditions 21 days after LHTL (4.5 ± 5.0 vs. 6.2 ± 6.4% for NH and HH), and no difference between conditions was found at any time.

CONCLUSION

Increases in VO2max and performance enhancement were similar between NH and HH conditions.

Altitude training for elite endurance athletes: A review for the travel medicine practitioner

High altitude training is regarded as an integral component of modern athletic preparation, especially for endurance sports such as middle and long distance running. It has rapidly achieved popularity among elite endurance athletes and their coaches. Increased hypoxic stress at altitude facilitates key physiological adaptations within the athlete, which in turn may lead to improvements in sea-level athletic performance. Despite much research in this area to date, the exact mechanisms which underlie such improvements remain to be fully elucidated. This review describes the current understanding of physiological adaptation to high altitude training and its implications for athletic performance. It also discusses the rationale and main effects of different training models currently employed to maximise performance. Athletes who travel to altitude for training purposes are at risk of suffering the detrimental effects of altitude. Altitude illness, weight loss, immune suppression and sleep disturbance may serve to limit athletic performance. This review provides an overview of potential problems which an athlete may experience at altitude, and offers specific training recommendations so that these detrimental effects are minimised.

Hemoglobin mass and intravascular volume kinetics during and after exposure to 3,454-m altitude

High altitude (HA) exposure facilitates a rapid contraction of plasma volume (PV) and a slower occurring expansion of hemoglobin mass (Hbmass). The kinetics of the Hbmass expansion has never been examined by multiple repeated measurements, and this was our primary study aim. The second aim was to investigate the mechanisms mediating the PV contraction. Nine healthy, normally trained sea-level (SL) residents (8 males, 1 female) sojourned for 28 days at 3,454 m. Hbmass was measured and PV was estimated by carbon monoxide rebreathing at SL, on every 4th day at HA, and 1 and 2 wk upon return to SL. Four weeks at HA increased Hbmass by 5.26% (range 2.5-11.1%; P < 0.001). The individual Hbmass increases commenced with up to 12 days of delay and reached a maximal rate of 4.04 ± 1.02 g/day after 14.9 ± 5.2 days. The probability for Hbmass to plateau increased steeply after 20–24 days. Upon return to SL Hbmass decayed by −2.46 ± 2.3 g/day, reaching values similar to baseline after 2 wk. PV, aldosterone concentration, and renin activity were reduced at HA ( P < 0.001) while the total circulating protein mass remained unaffected. In summary, the Hbmass response to HA exposure followed a sigmoidal pattern with a delayed onset and a plateau after ∼3 wk. The decay rate of Hbmass upon descent to SL did not indicate major changes in the rate of erythrolysis. Moreover, our data support that PV contraction at HA is regulated by the renin-angiotensin-aldosterone axis and not by changes in oncotic pressure.

Prooxidant/Antioxidant Balance in Hypoxia: A Cross-Over Study on Normobaric vs. Hypobaric "Live High-Train Low"

"Live High-Train Low" (LHTL) training can alter oxidative status of athletes. This study compared prooxidant/antioxidant balance responses following two LHTL protocols of the same duration and at the same living altitude of 2250 m in either normobaric (NH) or hypobaric (HH) hypoxia. Twenty-four well-trained triathletes underwent the following two 18-day LHTL protocols in a cross-over and randomized manner: Living altitude (PIO2 = 111.9 ± 0.6 vs. 111.6 ± 0.6 mmHg in NH and HH, respectively); training "natural" altitude (~1000-1100 m) and training loads were precisely matched between both LHTL protocols. Plasma levels of oxidative stress [advanced oxidation protein products (AOPP) and nitrotyrosine] and antioxidant markers [ferric-reducing antioxidant power (FRAP), superoxide dismutase (SOD) and catalase], NO metabolism end-products (NOx) and uric acid (UA) were determined before (Pre) and after (Post) the LHTL. Cumulative hypoxic exposure was lower during the NH (229 ± 6 hrs.) compared to the HH (310 ± 4 hrs.; P<0.01) protocol. Following the LHTL, the concentration of AOPP decreased (-27%; P<0.01) and nitrotyrosine increased (+67%; P<0.05) in HH only. FRAP was decreased (-27%; P<0.05) after the NH while was SOD and UA were only increased following the HH (SOD: +54%; P<0.01 and UA: +15%; P<0.01). Catalase activity was increased in the NH only (+20%; P<0.05). These data suggest that 18-days of LHTL performed in either NH or HH differentially affect oxidative status of athletes. Higher oxidative stress levels following the HH LHTL might be explained by the higher overall hypoxic dose and different physiological responses between the NH and HH.

Hypoxic training: effect on mitochondrial function and aerobic performance in hypoxia

PURPOSE

The effects of hypoxic training on exercise performance remain controversial. Here, we tested the hypotheses that i) hypoxic training possesses ergogenic effects at sea level and altitude and ii) the benefits are primarily mediated by improved mitochondrial function of the skeletal muscle.

METHODS

We determined aerobic performance (incremental test to exhaustion and time trial for a set amount of work) in moderately trained subjects undergoing 6 wk of endurance training (3-4 times per week, 60 min per session) in normoxia (placebo, n = 8) or normobaric hypoxia (FIO2 = 0.15, n = 9) using a double-blind and randomized design. Exercise tests were performed in normoxia and acute hypoxia (FIO2 = 0.15). Skeletal muscle mitochondrial respiratory capacities and electron coupling efficiencies were measured via high-resolution respirometry. Total hemoglobin mass was assessed by carbon monoxide rebreathing.

RESULTS

Skeletal muscle respiratory capacity was not altered by training or hypoxia; however, electron coupling control respective to fat oxidation slightly diminished with hypoxic training. Hypoxic training did increase total hemoglobin mass more than the placebo (8.4% vs 3.3%, P = 0.02). In normoxia, hypoxic training had no additive effect on maximal measures of oxygen uptake or time trial performance. In acute hypoxia, hypoxic training conferred no advantage on maximal oxygen uptake but tended to enhance time trial performance more than normoxic training (52% vs 32%, P = 0.09).

CONCLUSIONS

Our data suggest that, in moderately trained subjects, 6 wk of hypoxic training possesses no ergogenic effect at sea level. It is not excluded that hypoxic training might facilitate endurance capacity at moderate altitude; however, this issue is still open and needs to be further examined.

Comparison of "Live High-Train Low" in normobaric versus hypobaric hypoxia

We investigated the changes in both performance and selected physiological parameters following a Live High-Train Low (LHTL) altitude camp in either normobaric hypoxia (NH) or hypobaric hypoxia (HH) replicating current "real" practices of endurance athletes. Well-trained triathletes were split into two groups (NH, n = 14 and HH, n = 13) and completed an 18-d LHTL camp during which they trained at 1100-1200 m and resided at an altitude of 2250 m (PiO2  = 121.7±1.2 vs. 121.4±0.9 mmHg) under either NH (hypoxic chamber; FiO2 15.8±0.8%) or HH (real altitude; barometric pressure 580±23 mmHg) conditions. Oxygen saturations (SpO2) were recorded continuously daily overnight. PiO2 and training loads were matched daily. Before (Pre-) and 1 day after (Post-) LHTL, blood samples, VO2max, and total haemoglobin mass (Hb(mass)) were measured. A 3-km running test was performed near sea level twice before, and 1, 7, and 21 days following LHTL. During LHTL, hypoxic exposure was lower for the NH group than for the HH group (220 vs. 300 h; P<0.001). Night SpO2 was higher (92.1±0.3 vs. 90.9±0.3%, P<0.001), and breathing frequency was lower in the NH group compared with the HH group (13.9±2.1 vs. 15.5±1.5 breath.min(-1), P<0.05). Immediately following LHTL, similar increases in VO2max (6.1±6.8 vs. 5.2±4.8%) and Hb(mass) (2.6±1.9 vs. 3.4±2.1%) were observed in NH and HH groups, respectively, while 3-km performance was not improved. However, 21 days following the LHTL intervention, 3-km run time was significantly faster in the HH (3.3±3.6%; P<0.05) versus the NH (1.2±2.9%; ns) group. In conclusion, the greater degree of race performance enhancement by day 21 after an 18-d LHTL camp in the HH group was likely induced by a larger hypoxic dose. However, one cannot rule out other factors including differences in sleeping desaturations and breathing patterns, thus suggesting higher hypoxic stimuli in the HH group.