IMPROVING ENDURANCE PERFORMANCE

WITH ‘LIVE HIGH - TRAIN LOW’ ALTITUDE

TRAINING
Relevance and limits
– Written by Paul Robach, France and Carsten Lundby, Switzerland

Historically, altitude training has been defined as the practice adopted by athletes who train for several
weeks in an oxygen-deprived environment (altitude training camp) in order to improve their endurance
performance. By extension, altitude training refers to the use of natural or simulated altitude conditions
during the course of the training process, at rest and/or during exercise. Whatever the altitude training
strategy, athletes exposed to altitude are facing low-oxygen pressure (hypoxia), resulting in a lower
blood and tissue oxygenation (hypoxemia).

Altitude training became popular at the time of the 1968 Olympic Games in Mexico (located at 2,400 m),
where endurance athletes not only failed to set new records (as opposed to sprinters) but also
decreased their performance (e.g. 3000 m steeplechase, 10,000 m and marathon disciplines). The main
reason for this was obviously altitude hypoxia, a condition known to decrease aerobic performance in
humans. This failure prompted athletes and coaches to implement altitude training camps with the
objective to acclimatise to competition at altitude. It soon became apparent, however, that alti-tude
training also could improve endurance performance upon return to sea level. The rationale was that on
the one hand, total red blood cell volume is a key factor for endurance performance, as highlighted by
experiments incorporating blood manipulations. The larger number of red blood cells an athlete has, the
faster he will probably be able to run a marathon. On the other hand, altitude exposure triggers the
secretion of the renal hormone erythropoietin (EPO), which in turn stimulates red blood cell synthesis
i.e. provided that the ‘altitude dose’ is sufficient. So, the original concept was that combining training
and altitude would boost total red blood cell volume and therefore endurance performance. The fact is
that over the years, this attractive hypothesis has led numerous sport federations to build a substantial
number of hypoxic facilities worldwide.

After several decades and the involvement of a large number of elite athletes who sometimes set new
world records after returning from altitude, the key question arises: does it really work?Unfortunately,
to date the majority of well-controlled scientific studies fail to demonstrate a systematic positive effect
of altitude training on endurance performance in athletes.

Nonetheless, a common observation is that some athletes do benefit from this method, while others do
not (reports of a reduction in exercise capacity also exist). So, the next question is: why does altitude
training fail to induce a consistent positive effect on performance?

Firstly, scientific literature indicates that the individual variation in the adaptive responses to altitude is
very large in humans, and the determinants of altitude tolerance exposure are poorly understood.

Secondly, at a practical level, exercising in hypoxia poses a major problem, which is the management of
training intensities. Because maximal exercise capacity is reduced under hypoxic conditions, training at
altitude at the same absolute intensity as at sea level represents a larger stimulus that could eventually
lead to overtraining. Conversely, conserving the same relative intensity at sea level (i.e. decreasing
running speed) has the potential to alter running skills or even induce detraining. Therefore, in such a
challenging environment, it is very difficult for the coaches to design the optimal training regimen
adapted to each athlete. As a consequence, the likelihood of obtaining the expected positive effect on
performance for all athletes is low. That said, numerous anecdotal reports showing that elite endurance
athletes have produced word-class records after a prolonged sojourn at altitude certainly explain why
classical altitude training (i.e. living and training at natural altitude for several weeks) remains a popular
method.

NEW METHODS
The various problems encountered with classical altitude training have prompted scientists and coaches
to investigate alternative methods, whereby the athletes are discontinuously exposed to hypoxia at rest
and/or during exercise sessions. The first of these methods is ‘live high - train low’ and consists of
sleeping at altitude to gain the haematologic adaptations (increased erythrocyte volume) but training
near sea level to maximise performance (preservation of sea level training intensity and oxygen flux).
Another method is the ‘live low - train high’ method including intermittent hypoxic exposure during
training sessions. However, given the relatively short duration of hypoxic exposure, muscular
adaptations (and not necessarily an improved oxygen carrying capacity) are thought to enhance exercise
performance after ‘live low-train high’. The present article focuses on performance improvements and
haematologic adapt-ations induced by the ‘live high - train low’ altitude training intervention.

‘LIVE HIGH - TRAIN LOW’ ALTITUDE TRAINING

Often considered as a variation of classic altitude training, the principle of ‘live high - train low’ is the
following: living/sleeping at altitude for several weeks enables total red blood cell volume to increase
(similarly to classic altitude training), while training at or near sea level allows the athletes to maintain
their training intensities within normal levels (contrary to classic altitude training, where absolute
training intensities are generally reduced). By doing so, training-related problems are overcome and one
may therefore expect more consistent adaptations than with classical altitude training. The approach
was allegedly first tested on an empirical basis by some athletes in the Italian Alps in the 1980s, but was
first shown to be beneficial for enhancing aerobic performance by American scientists in the late 1990s1.
Since then, several other studies have confirmed that ‘live high - train low’ might confer some
physiological advantages, such as an increase in total red blood cell volume and ultimately, an
improvement in maximal oxygen transport. Of note, there is no definitive consensus about the
mechanism(s) underlying the increase in performance. Some authors suggest, on a rather robust
evidence base, that haematological adaptation is the main factor. Others have rather proposed that
skeletal muscle function (but not red blood cell number) is improved after ‘live high - train low’, so that
muscle efficiency and therefore endurance performance are maximised2.

Beyond the concept’s attractiveness or any scientific evidence, it is important to acknowledge that
simplicity is certainly another reason behind the success of this approach. Breathing hypoxic air during
sleep is easy to implement everywhere on Earth and is by far much less expensive or complicated than
organising a long training camp in the mountains, even if the use of natural altitude (hypobaric hypoxia)
was proved efficient1. Indeed, building hypoxic rooms or even sleeping in hypoxic tents is technologically
affordable, since atmospheric pressure is not modified; only the fraction of oxygen has to be reduced
(with oxygen extraction or nitrogen enriching) in order to simulate altitude.
After 20 years of research on ‘live high - train low’, the general consensus is that this method may help
some, but not all, athletes in improving their performance. In this context, natural altitude seems to be
more efficient than artificial hypoxia, while sub-elite athletes might benefit more from ‘live high - train
low’ than elite athletes3. The observed improvements are nonetheless modest since endurance
performance is generally improved by 1 to 2%. It is, however, acknowledged that such a change in
performance is considered worthwhile by elite athletes. In any case, the advantages conferred by this
legal method are much less than those induced by illegal and potentially harmful blood manipulations
such as autologous blood transfusion or prolonged recombinant EPO treatment. Of note, even though
the legality of artificial hypoxia is today accepted, the ethical aspects are nonetheless controversial, as
illustrated by the recent World Anti-Doping Agency’s consideration of placing “artificially-induced
hypoxic conditions” on the Prohibited List of Substances/Methods4.

Recently, the view that ‘live high - train low’ improves performance has been challenged by a study
conducted on highly-trained cyclists, for the first time in a double blind manner, showing no change in
endurance performance5. In these athletes, neither total red blood cell volume nor skeletal muscle
function improved after ‘live high - train low’ intervention. Such findings clearly raise the question of the
actual ergogenic effects of ‘live high - train low’ in elite endurance athlete populations i.e. those already
possessing very high levels of total red blood cell volume and maximal oxygen uptake, therefore having
very little room for further improvement. A recent analysis showing an inverse linear relationship
between the initial levels of total haemoglobin mass (a parameter equivalent to total red blood cell
volume) and the response of total haemoglobin mass induced by ‘live high - train low’ (Figure 1),
suggests that the more red blood cells an athlete has before entering a ‘live high - train low’ camp, the
lower his likelihood of obtaining a substantial effect and vice versa6. Basically, the elite athletes
possessing the highest levels of total haemoglobin mass are the cross-country skiers, the distance
runners and the cyclists. Elite swimmers, although they are also engaged in highly aerobic activities,
usually have total haemoglobin mass levels lower than those measured in terrestrial endurance sports.
Elite team sports athletes whose performance level relies on both their aerobic and anaerobic
capacities, but are also highly dependent on technical and tactical skills usually possess a total
haemoglobin mass of 11 g.kg-1 within or slightly above the normal range (10 to 11 g.kg-1). For those
athletes it is reasonable to expect that ‘live high - train low’ may substantially increase their red blood
cell synthesis, therefore reinforcing their aerobic potential. Whether this translates into an elevated
exercise performance is questionable, as one would assume the organisms of elite athletes already to be
fully optimised, i.e. if a high haemoglobin mass and aerobic capacity would be a requirement in order to
become Olympic champion these values would be higher in the best athletes, but this is not the case.

A FEW RECOMMENDATIONS ON ‘LIVE HIGH - TRAIN LOW’ ALTITUDE TRAINING

Although the efficacy of ‘live high - train low’ in elite endurance athletes has been challenged recently7,
beneficial effects on aerobic performance may nonetheless exist in other athletes, such as team sports
players. Accordingly, some practical recommendations can be formulated.

Dose of hypoxia
Current recommendations indicate that daily exposure to hypoxia should be as long as possible, while
the total duration of the ‘live high - train low’ camp should be 3 to 4 weeks. Altitude should not exceed
2,500 to 3,000 m. Pending confirmatory research, it is believed that higher altitudes, which could
theoretically induce a stronger synthesis of red blood cells, are thought to impair the athletes’ recovery
process. Nevertheless, it is not excluded that adequate progressive acclimatisation may preserve sleep
quality at altitude >3,000 m.
Training
There are no evidence-based guidelines regarding the best training regimen for an optimal ‘live high
train low’ paradigm. Nevertheless, a precautionary principle would indicate that training load should be
lightened over the first 2 to 3 days to avoid overtraining, although no evidence supports this statement.

Illness
Inflammation or viral infection is associated with a blunted haematological response during ‘live high -
train low’. Even if a causal link has not been established, it seems important to carefully monitor health
status during the camp, especially when two or more athletes share the same room.

Supplementation
Since iron is required for red blood cell synthesis, athletes are often supplemented with iron prior to and
during a camp. While the role of iron on erythropoiesis is not debatable, systematic supplementation in
iron-replete individuals may induce oxidative stress in some cases. Case-by-case iron supplementation
should be preferred, by targeting the athletes with depleted iron stores prior to the altitude training
camp. Of note, absolute iron deficiency is characterised by ferritin levels <30 µg/L, and functional iron
deficiency is defined by ferritin cut-off value of 30 to 99 µg/L or even 100 to 299 µg/L if associated with a
transferrin saturation of <20%.

Natural or simulated altitude?

Hypobaric hypoxia (natural altitude) is suggested to be more efficient than normobaric hypoxia
(simulated altitude) for ‘live high - train low’. One reason is that hypobaric hypoxia is thought to induce
more pronounced adaptive responses than normobaric hypoxia, such as ventilation, fluid balance or
nitric oxide metabolism. This hypothesis is, however, debated and to date, no experimental evidence
exists to suggest that natural altitude is the best option. Nonetheless, the acute rise in plasma EPO is
similar with normobaric and hypobaric hypoxic exposure.

Competition at altitude
Even if evidence is lacking, it would seem prudent to recommend implementing ‘live high - train low’ or
even classical altitude training for preparing for a competition at moderate altitude. Indeed, endurance
performance is acutely reduced at moderate altitude but acclimatisation has the potential to restore, at
least in part, the athlete’s capacity for prolonged exercise. To this regard, a period of 1 to 2 weeks at
moderate altitude seems appropriate to maximise acclimatisation. However, it should be reminded that
even after prolonged acclimatisation (3 weeks or more), full restoration of performance at altitude is
virtually impossible.

IN SUMMARY
Among the various existing methods using hypoxia during the training process, ‘live high - train low’
altitude training appears the most relevant approach to improve endurance performance in athletes.
However, it should be emphasised that the improvements remain modest and that the method may
have limited or no impact at all when applied to elite endurance athlete populations. The large
individual variability in the response to hypoxia might explain, at least in part, why some athletes do
benefit from ‘live high - train low’ and others do not. Unfortunately, the predictive factors of altitude
tolerance remain unknown. Finally, the cost effectiveness of ‘live high - train low’ has to be considered.
On one hand, sleeping/living in altitude facilities or hypoxic rooms during 3 to 4 weeks represents a
significant effort for the athletes (indeed the logistic strain that may be experienced by athletes being
subjected to ‘live high - train low’ is often neglected. Also, if using hypoxic room exposure it should be
acknowledged that athletes may not find it very attractive to spend up to 16 hours per day in strict
confinement). On the other hand, the outcome, although potentially worthwhile, may be modest.
Consequently, to be relevant, this method requires a strong adherence of the athletes.

Paul Robach Ph.D.

Physiologist
Ecole Nationale des Sports de Montagne
Site de l’Ecole Nationale de Ski et d’Alpinisme
Chamonix, France

Carsten Lundby Ph.D.

Professor
Zurich Center for Integrative Human Physiology (ZIHP)
University of Zurich
Zurich, Switzerland
Contact: paul.robach@ensm.sports.gouv.fr

References
1. Levine BD, Stray-Gundersen J. “Living high-training low”: effect of moderate-altitude
acclimatization with low-altitude training on performance. J Appl Physiol 1997; 83:102-112.
2. Gore CJ, Hahn AG, Aughey RJ, Martin DT, Ashenden MJ, Clark SA et al. Live high:train low
increases muscle buffer capacity and submaximal cycling efficiency. Acta Physiol Scand 2001;
173:275-286.
3. Bonetti DL, Hopkins WG. Sea-level exercise performance following adaptation to hypoxia: a
meta-analysis. Sports Med 2009; 39:107-127.
4. Wilber RL. Application of altitude/hypoxic training by elite athletes. Med Sci Sports Exerc
2007;39:1610-1624.
5. Siebenmann C, Robach P, Jacobs RA, Rasmussen P, Nordsborg NB, Diaz V et al. “Live high - train
low” using normobaric hypoxia: a double-blinded, placebo-controlled study. J Appl Physiol 2012;
112:106-117.
6. Robach P, Lundby C. Is live high-train low altitude training relevant for elite athletes with already
high total hemoglobin mass? Scand J Med Sci Sports 2012; 22:303-305.
7. Lundby C, Millet GP, Calbet JA, Bartsch P, Subudhi AW. Does ‘altitude training’ increase exercise
performance in elite athletes? Br J Sports Med 2012; 46:792-795.

Back in 2011, Carsten Lundby and his colleagues at the University of Zurich published
an exhaustive, carefully double-blinded test of the standard approach to altitude
training, “live high, train low,” which involves living at a high elevation in thin air (or
simulating it with an altitude tent or altitude house) but doing hard workouts closer to
sea level. In contrast to previous studies and the accepted practice of elite athletes, they
found no benefits.

The next year, Lundby and several colleagues wrote a review titled “Does ‘altitude
training’ increase exercise performance in elite athletes?” in the British Journal of Sports
Medicine, pointing out flaws in the research used to support altitude training. Lots of
debate followed, but altitude training remained just as popular as ever among athletes.
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Now Lundby and a colleague, Paul Robach, have a new review with the same title, this
time published in Experimental Biology. Instead of rehashing the evidence for live high,
train low (LHTL), which hasn’t changed much since 2012, they turn their attention to
“live low, train high” (LLTH) protocols, which have received a lot of research interest in
the last few years.

Not to spoil the surprise, but they’re once again skeptical.

Some background: The idea that athletes who live near sea level might benefit from
doing certain workouts at high altitude (either by traveling up a mountain or by using an
altitude chamber) has been around for a while. Because your muscles can’t get enough
oxygen during an altitude workout, they’re put under greater-than-usual stress, which
might lead to greater-than-usual adaptations in the muscles themselves—for example,
more capillaries to distribute oxygen to the muscle.

The problem is that, with a lower VO2max at altitude, your training is compromised in
other ways: You can’t work as hard as you would at sea level, so there’s no net benefit
to training at altitude.

One way around that is to do a different kind of training: repeated sprint intervals, which
are short enough that the negative effects of altitude don’t kick in as much. While this
doesn’t seem to do much for sustained endurance, a series of studies in recent years
have suggested that it can help with repeated sprint performance—the type of ability
that matters in field sports, and may also be helpful in sports with intense surges, like
cycling and cross-country skiing.
Once again, Lundby and his colleagues are skeptical of the evidence, arguing that the
positive studies either weren’t appropriately blinded, or used tests of repeated sprinting
ability with poorly defined endpoints. The apparent improvements, they argue, may
simply reflect more even pacing of the sprints.

Lundby and David Montero, also of the University of Zurich, have their own study of
repeated sprint training in hypoxia (i.e., simulated altitude), just published in
the International Journal of Sports Physiology and Performance.

It’s a double-blinded crossover study with 15 cyclists who did four weeks of repeated
sprints (4 sets of 5 x 10 seconds all-out with 20 seconds of recovery between reps and
5:00 between sets) three times a week. They each did this protocol twice, in
randomized order with a six-week washout period, with normal air and with 13.8 percent
oxygen, which is equivalent to an altitude of 3,000 meters (~10,000 feet).

They did an exhaustive series of outcome tests: at altitude, at sea level, 3-5 days after
the training and again 10-12 days after, fresh or just after a time trial or progressive
exercise test. And the results? No difference in repeated sprint performance.

Interestingly, there was an apparent difference in blood flow to the thigh muscle, as
measured by near-infrared spectroscopy. This supports the idea that sprint training at
altitude forces the muscles to work with less oxygen, and thus triggers adaptations to
bring more oxygen to the muscles. It just doesn’t seem to translate into increased
performance.

So where does that leave us? In a way, it reminds me of the post I wrote earlier this
week about the controversial DNAFit study on the genetics of training. Once again, we
have a study that runs counter to previous results; in this case, though, it’s not a for-
profit company presenting the data, it’s an academic with no obvious vested interest.
The similarity is that, in both cases, we’re left to weigh for ourselves apparently
conflicting evidence, and to make decisions based on imperfect knowledge.

My feeling after Lundby’s 2011 study was that it didn’t necessarily prove that
LHTL never worked, but it suggested that the benefits were, at best, more fickle than
many suspected. Perhaps the same is true here.

Lundby’s conclusion, of course, is that altitude training shouldn’t be recommended to

elite athletes—but with this interesting and important caveat: “Unless there is a firm
belief by the given athlete that this may actually be beneficial when considering the pros
and cons of the various approaches—placebo may work wonders—which is unfortunate
for science but great for sport performance.”
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Home Pros and Cons 10 Advantages and Disadvantages of Altitude Training

10 Advantages and Disadvantages of Altitude

Training
 Pros and Cons

Altitude training as a way to improve the performance of athletes is a common

knowledge. Pro athletes such as runners as well as non-professional athletes undergo
this type of training to increase their capability to exercise. But before anyone decides if
this is the perfect training technique to use, it helps to know more about this method as
well as its advantages and disadvantages.

What is Altitude Training?

Altitude training is an extreme method of endurance training that athletes use to have
leverage over other athletes in terms of performance in competitions. People who
normally use this training are cyclists, football players and runners, among others. This
training is practiced by athletes by staying and training in high altitudes, at around 8,000
feet above sea level, for several weeks. This is because in high places, there is less
oxygen and the air is thinner and as a result, the body learns to adapt to the reduced
amount of oxygen.

However, to determine if this is the ideal training method for an individual, it helps to
learn about its positive and negative implications.
List of Advantages of Altitude Training
1. Higher Red Blood Cells Concentration
The kidneys are responsible in the release of the hormone known as erythropoietin.
This hormone stimulates the bone marrow to produce red blood cells that are important
in the supply of oxygen in the body. When a person trains at high altitudes, there is less
supply of oxygen. This causes the kidneys to increase the release of erythropoietin and
consequently, more oxygen is carried by the blood to the organs and tissues.

2. Aids in Endurance and Performance

The measure of the amount of oxygen in the body that can be converted into energy
from the food a person eats is known as VO2. This works through the conversion of the
eaten food into adenosine triphosphate. Conversely, in terms of measuring how much
an athlete has improved when it comes of performance, the term is known as VO2 max.
This condition is achieved by training at high altitudes and ensures improved
performance and endurance.

3. Healthier Respiratory System

The respiratory system is where the lungs are and is responsible for breathing. In higher
altitudes, there is a reduction in the percentage of oxygen molecules as the altitude
rises due to lesser barometric pressure. When an athlete trains for several weeks at
high altitudes, the body learns to adapt to the reduced oxygen supply and the
respiratory muscles are strengthened.

4. Effects Stay Longer

Proponents of altitude training posit that by spending weeks training in high altitudes,
muscle metabolism takes place and so does improved performance and endurance.
This is because there is an increase in the supply of red blood cells that are
instrumental to carrying oxygen to different parts of the body. What makes this effective
is that even if the athlete competes in lower altitudes, the concentration in red blood
cells remains high.

5. Comfortable
Supporters of altitude training say that the cool air present above sea level offers a level
of comfort for athletes. This is because exercising is mostly done in lower grounds while
the athlete can spend 12 hours sleeping and resting in higher grounds.

List of Disadvantages of Altitude Training

1. Affects Immunity
One of the drawbacks of training in high altitudes is in a person’s immunity to diseases.
With a weakened immune system, an athlete can be susceptible to pathogens that can
lead to ailments. It is important for the body to have proper nutrition while training since
it also increases the amount of nutrients needed.

2. Exposure to Stress
Another negative effect of this extreme training method is the increase in cortisol levels
in the body under stress. Training in high altitudes results to lesser oxygen supply.
Because of this, the lungs and the heart have to work harder. With lower oxygen supply
as elevation rises, the body needs to compensate this by increasing the production of
cortisol. This can lead to muscle breakdown.

3. Weakens Endurance
Critics of altitude training claim that even if the body increases the production of red
blood cells as oxygen is reduced, there is no assurance that the muscles will still have
the same amount of oxygen it needs for performance. This is also because different
people react differently to stressors and that not all can adapt to higher altitudes. That
said, it may affect the endurance of an athlete while it will not have an effect on another.

4. Negative Increase in Red Blood Cell Production

Opponents of high altitude trainings argue that lingering in places where air is thinner
might increase the production of red blood cells to supply the different organs and
tissues of the body. While it is helpful to familiarize the body with lower oxygen supply,
the red blood cell increase can also affect the viscosity of the blood or its concentration.
If this happens, flow of blood is restricted and it becomes slower, which is not also
healthy. This is on top of the concern that this type of training entails expenses and can
costly which might not be practical for some athletes considering that not all have
access to high altitudes.
5. Possible Dehydration
Skeptic individuals on applying this method of training say that a person undergoing this
extreme training is prone to dehydration. This is because as the elevation becomes
higher, breathing and heart rate increase. Increased respiratory rate can result to more
moisture loss. Moreover, since the athlete is exposed to cool and dry air, dehydration is
more likely to occur unless fluid intake is increased. Another possibility can be the
hastened evaporation of moisture from the skin since there is lowered air pressure.

Altitude training is not for everyone since our bodies react differently to the impacts of
training in elevated grounds. It also has benefits and drawbacks that need to be
considered. To ensure an athlete or any individual interested in altitude training gets the
most of this method, it is important to undergo tests and consult a medical practitioner
before subjecting the body to this type of training.

http://connectusfund.org/10-advantages-and-disadvantages-of-altitude-training