High altitude training can provide benefits to endurance athletes by exposing the body to hypoxic conditions which stimulate erythropoietin production and increase red blood cell count. The live high train low method, where athletes live at moderate altitudes of 2000-2500m and train at lower altitudes, has been shown to improve sea level performance for events lasting 8-20 minutes. Artificial methods like nitrogen houses and hypoxic tents can simulate these altitude effects for training. Repeated high intensity interval training in hypoxia may also provide benefits like improved time to fatigue. Care must be taken to avoid potential problems from altitude like weight loss, immune suppression or illness.

1. HIGH ALTITUDE TRAINING – KEY
TO EXCELLENCE IN
AEROBIC/ENDURANCE SPORTS
DR NIKHIL KUMAR,
DM (CARDIOLOGY)
DIRECTOR, CARDIOLOGY
FORTIS MEMORIAL RESEARCH INSTITUTE
GURGAON

2. Hypoxia
• The word hypoxia has its roots in the Greek language and describes the state of oxygen
deficiency compared to normal conditions
• This state is caused by lowering the oxygen partial pressure (pO2) at sea level of about 212 hPa or
by reducing the oxygen content of 20.94% in the air
• With increasing natural height, the air’s density declines–the oxygen partial pressure in
the air decreases proportionately
• Now a days, artificially generated climate conditions achieve the same effects on the
organism in the lowlands if the relation of oxygen and nitrogen is changed equivalently
under air pressure conditions that remain the same
• Lowering the oxygen concentration in the air to 13.9vol.% in the lowlands corresponds to
similar atmospheric conditions that exist in a natural height of 3000m

3. 4.000 m
air pressure
(hPa)
oxygen in relation
to sea level
altitude
3.000 m
2.000 m
1.000 m
sea level
898 89 %
1.013 100 %
795 78 %
701 69 %
616 61 %
Physical Background of HighAltitude Climate

4. Chronic Physiological Effects – HIF-α
 Hypoxia-inducible factors (HIFs) are transcription
factors that respond to changes in available oxygen in
the cellular environment, specifically, to decreases in
oxygen, or hypoxia
• Increase of erythropoietin (EPO) – development of
erythrocytes
• Upregulation of several genes to promote survival in
low-oxygen conditions, incl. glycolysis enzymes
(anaerobic glycolysis, glucose absorption)
• Angiogenesis (growth of new blood vessels from pre-
existing vessels) – improvement in oxygen transport
4

5. Physiological Adaptation of Training and Rest
in Altitude
• Increase in erythrocytes and reticulocytes in response to greater
release of the hormone erythropoietin (EPO) by the kidneys
• Production of new capillaries
• Oxygen absorption and transportation capacity increases
• Increase in oxygen utilization
• Increased economy of the cardiovascular system
• Optimization of heart rate at rest
• Improved aerobic and anaerobic endurance performance
• Exercising at altitude has been shown to cause muscular
adjustments of selected gene transcripts, and improvement of
mitochondrial properties in skeletal muscle 5

6. What is Altitude Training?
 Altitude training is the practice by some endurance athletes of
training for several weeks at high altitude
 At this altitude the air still contains approximately 20.9% oxygen,
but the barometric pressure and thus the partial pressure of oxygen
is reduced
 Depending very much on the protocols used, the body may adapt to
the relative lack of oxygen hypoxia
 When the athletes travel to competitions at lower altitudes they will
still have a higher concentration of red blood cells for 10-14 days,
and this gives them a competitive advantage
 The increase in red blood cells can mean 3% - 5% more speed,
endurance, and power

7. Oxygen Saturation - SaO2
We receive the best results if the training takes place
in an hypoxic environment where an arterial oxygen
saturation (SpO2) of 82 - 88% SpO2 is present.
Above 90% the stimulus for an effective
adaptation is too low
Below 80% the extreme reduction of the movement
influences the performance results

8. HISTORY
 The study of altitude training was stimulated during and after the 1968
Olympics in Mexico City, Mexico at an elevation of 2,240 metres (7349 ft)
 It was during these Olympic Games that endurance events saw significant
below-record finishes and anaerobic and sprint events broke all types of
records
 These games inspired investigations into altitude training from which
unique training principles were developed with the aim of avoiding
underperformance

9.  Kenyans tend to medal time after time in the Olympic track and
field events (2012 medal count : 14)
 Why the athletes who train there often cross the finish line first
in major marathons?
 The answer may have far less to do with drive and
determination—and everything to do with elevation!
 It’s possibly due to the fact that winning athletes often live or
train at altitude
 That effect only lasts around 10 days to two weeks, but that’s
long enough to give most athletes the competitive edge in
competition

10. Doping
 Injections of synthetic EPO are illegal in athletic competition
because they cause an increase in red blood cells beyond the
individual athlete's natural limits
 This increase, unlike the increase caused by altitude training,
can be dangerous to an athlete's health as the blood may
become too thick and cause heart failure
 The natural secretion of EPO by the human kidneys can be
increased by altitude training, but the body has limits on the
amount of natural EPO that it will secrete, thus avoiding the
harmful side effects of the illegal doping procedures

11. Training Regimens
 Athletes or individuals who wish to gain a competitive edge for
endurance events can take advantage of exercising at high
altitude
 Scientific studies on high-altitude training regimes were carried
out on elite athletes close to their ultimate performance
potential: these same training regimens are expected to be
effective on ordinary athletes further from their peak potential

12. Altitude Exposure Techniques
 Various techniques have been devised in order to expose
the athlete to the beneficial effects of high altitude whilst
not reducing their ability to train effectively
 Live High – Train High
 Live Low – Train High
 Live High – Train Low
 The typical altitudes used are around 2000-2500m, which in
itself reduces the risk of some of the unhelpful effects of
altitude exposure

13. Live-high, Train-high
 In the live-high, train-high regime, an athlete lives and trains at a desired
altitude
 The stimulus on the body is constant because the athlete is continuously in a
hypoxic environment
 Maximum exposure to altitude
 Evidence of a positive effect at sea level is controversial
 Less support for this method amongst experts
 After long periods of training at altitude, highly trained athletes returning to
sea level do not exhibit increased red blood cell count or improved
performance on 4000m cycling tests

14. Live-low, Train-high
 The athlete is exercising in a low oxygen environment,
whilst resting in a normal oxygen environment
 Some interesting findings suggesting that this technique
might work
 No good studies showing that the technique makes any
difference to the ultimate competitive performance of the
athlete at sea-level
 Training intensity is reduced so some athletes may find that
they actually lose fitness using this regime.

15. Live-high, Train-low
 The body will acclimatise to altitude by living there, whilst training
intensity can be maintained by training at (or near) sea level
 The beneficial effects of altitude exposure are harnessed whilst some of the
negative ones are avoided
 The residence at altitude must be for more than 12 hours per day and for at
least 3 weeks
 Improvements in sea-level performance have been shown in events lasting
between 8 and 20 minutes
 Athletes of all abilities are thought to benefit
 A non-training elevation of 2,100–2,500 metres (6,900–8,200 ft) and
training at 1,250 metres (4,100 ft) or less has shown to be the optimal
approach for altitude training

16.  The US Olympic speed skating team successfully integrated several LH+TL
altitude-training methods in preparation for the 2002 Salt Lake City
Winter Olympics
 In recent years, the US speed skaters have worked out an agreement with
several of the Scandinavian speed skating teams to use nitrogen apartments
and dormitories located in those countries
 As they did at the 2002 Winter Olympics, US speed skaters performed very
well in the 2006 Torino Olympics, capturing three gold, three silver, and
one bronze medal
.

17. Live-high, Train-low
 2,000m-2,500m: The optimum altitude for acclimatisation
 28 days: Number of days required for noticeable increase in
red blood cell count
 22 hours: Daily exposure sufficient to boost performance
 Good venues for live-high train-low
– Mammoth Lakes, California
– Flagstaff, Arizona
– Sierra Nevada
– Near Granada in Spain
– Rift Valley in Kenya

18. Repeated sprints in hypoxia
 In repeated sprints in hypoxia (RSH), athletes run short sprints under 30 seconds
as fast as they can
They experience incomplete recoveries in hypoxic conditions.
The exercise to rest time ratio is less than 1:4, which means for every 30 second
all out sprint, there is less than 120 seconds of rest
 When comparing RSH and repreated sprints in normoxia (RSN), studies show
that RSH improved time to fatigue and power output
 Possible physiological advantages from RSH include
compensatory vasodilatation and regeneration of Phosphocreatine (PCr)
 RSH is still a relatively new training method. For it to be fully understood and
trusted, more double blind studies must be conducted

19. Problems of Altitude Exposure
 Acclimatisation to high altitude is not simple
 There are a number of other effects that could cancel out the above
benefits
– Too many blood cells may make the blood thicker and can make blood flow sluggish
– Can actually decrease the amount of oxygen getting to where it is needed
 At very high altitudes (>5000m) weight loss is unavoidable because your
body actually consumes your muscles in order to provide energy
 Risk that the body’s immune system will become weakened - an
increased risk of infections
 The body cannot exercise as intensely at altitude - reduced training
intensity - which can reduce performance in some sports

20. Problems of Altitude Exposure
 Adverse changes in the chemical make-up of the muscles
 Loss of appetite, inhibition of muscle repair processes and excessive work of
breathing
 Altitude illnesses can dramatically reduce the capacity to be active at altitude, or
foreshorten the exposure to high altitude altogether
– Acute mountain sickness (AMS) is caused by acute exposure to low air pressure (usually
outdoors at high altitudes). It commonly occurs above 2,400 metres
– Acute mountain sickness can progress to high altitude pulmonary edema or high altitude
cerebral edema
 Dehydration, often confused with altitude sickness, occurs due to the higher rate of
water vapor lost from the lungs at higher altitudes
 Tremendous expense and logistical problems

21. Artificial altitude
 In an effort to reduce the financial and logistical challenges of traveling to
altitude training sites, scientists and manufactures have developed artificial
altitude environments that simulate the hypoxic conditions of moderate
altitude
 Altitude simulation systems have enabled protocols that do not suffer from
the tension between better altitude physiology and more intense workouts
 Such simulated altitude systems can be utilized closer to competition if
necessary

22. Methods used for training in hypoxia
• Supplemental Oxygen
• Hypoxic Sleeping Devices
• CAT Hatch
• Hypoxic Tent System
• Intermittent Hypoxic Exposure (IHE)
• IHE at Rest
• IHE During Exercise

23. Supplemental Oxygen
•It is a modification of the ‘live high – train low’
•Is used by athletes that live in a natural terrestrial altitude environment
but train at ‘sea level’ with the aid of supplemental oxygen
•Scientific data regarding the efficacy of hyperoxic training suggest that
high-intensity workouts at moderate altitude (1860m/6100ft) and
endurance performance at sea level, may be enhanced through the use of
supplemental oxygen

24. Hypoxic Sleeping Devices
• This systems are designed to allow athletes to sleep
high and train low
CAT Hatch
• It is a cylindrical hypobaric chamber
• Can simulate altitudes up to approximately 4575m
Hypoxico Tent System
• This modality can be installed over a standard
double or queen-sized bed.
• simulates elevations up to approximately
4270m

25. Intermittent Hypoxic Exposure (IHE)
•Is based on the fact that brief exposures to hypoxia (1.5 to 2.0 hours)
stimulate the release of EPO
•Athletes typically use IHE while at rest or in conjunction with a training
session
•The IHE allows the athlete to ‘live low-train high’
•Athletes typically use IHE while at rest, or in conjunction with a training
session
•Data regarding the effect of IHE on hematological indices and athletic
performance are minimal and inconclusive

26. Application of Altitude/Hypoxic Training by Elite Athletes
RANDALL L. WILBER Athlete Performance Laboratory, United States Olympic Committee,
Colorado Springs, CO
Med. Sci. Sports Exerc., Vol. 39, No. 9, pp. 1610–1624, 2007.
 At the Olympic level, differences in performance are typically less than 0.5%. This
helps explain why many contemporary elite endurance athletes in summer and winter
sport incorporate some form of altitude/hypoxic training within their year-round
training plan, believing that it will provide the competitive edge to succeed at the
Olympic level.
 This paper has presented both anecdotal and scientific evidence relative to the
efficacy of several contemporary altitude/hypoxic training models and devices
currently used by Olympic-level athletes for the purpose of legally enhancing
performance.
 Live high + train low altitude training is employed by elite athletes using:
– Natural/terrestrial altitude
– Normobaric hypoxia via nitrogen dilution (e.g., nitrogen apartment) or oxygen
filtration (e.g., hypoxic tent)
– Hypobaric normoxia via supplemental oxygen

27. High Altitude or Nitrogen House
 In Finland, a Finnish sport physiologist Heikki Rusko had designed a "high-altitude
house"
The air inside the house, which is situated at sea level, is at normal pressure but
modified to have a low concentration of oxygen, about 15.3% (below the 20.9%
at sea level) - roughly equivalent to the amount of oxygen available at 2,500 m
(8,200 ft) altitude
Athletes live and sleep inside the house, but perform their training outside (at
normal oxygen concentrations at 20.9%)
Research conducted by Heikki Rusko on six elite cross-country skiers suggests
that training in the nitrogen house is just as effective as training at altitude
He found that changes in critical blood markers and submaximal heart rate
Lactate were similar among athletes who trained in the nitrogen house compared
to athletes who trained at an altitude camp

28. Sea level
normobaric hypoxia
Sea level
~ 13,9 Vol% O2
normobaric hypoxia
Mountain
low pressure chamber –
3.000 altitude hypobaric
hypoxia
20,9 %
78,1 %
0,96 %
0,03 %
(40-60% rel. steam)
1.013 hPa
212 hPa
791 hPa
Oxygen
Nitrogen
noble gas
carbondioxide
steam
air pressure
O2 - partial press.
N2 - partial press.
13,9 %
84,4 %
0,96 %
< 0,07 %
(40-60% rel. steam)
1.013 hPa
141 hPa
855 hPa
Oxygen
Nitrogen
noble gas
carbondioxide
steam
air pressure
O2 - partial press.
N2 - partial press.
Oxygen
Nitrogen
noble gase
carbondioxid
steam
air pressure
O2 - partial press.
N2 - partial press.
20,9 %
78,1 %
0,96 %
0,03 %
(reduced)
701 hPa
141 hPa
553 hPa
Physical Background of HighAltitude Climate

29.  Artificial altitude can also be used for hypoxic exercise, where athletes train in
an altitude simulator which mimics the conditions a high altitude environment
 Athletes are able to perform high intensity training at lower velocities and
thus produce less stress on the musculoskeletal system
 Beneficial to an athlete who suffered a musculoskeletal injury and is unable to
apply large amounts of stress during exercise which would normally be needed
to generate high intensity cardiovascular training
 Hypoxia exposure for the time of exercise alone is not sufficient to induce
changes in hematologic parameters
 Hypoxico Inc pioneered the artificial altitude training systems in the mid
1990s

30. Innovation High Altitude
LOXYMED® Concept

31.  This system is based on the technology that
enables the creation of small high altitude
training areas as room-in-room solution for
active training and passive stay
 Contain all the key technology
 Excels by its compatibility and flexibility in
terms of setup and utilization
 The quality of the atmosphere generated by
this technology is unmatched and has set a
new standard in simulated altitude training

32.  The athlete is confronted with the same anoxic effect (hypoxia) as
is usually prevailing in natural heights
 The training and stay in this system results in the same
performance enhancing physical adaptations known from natural
heights
 Additional technical features present in the systems can raise the
altitude limit stepwise to a training height of 4500m

33.  Specially designed software ensures the effective use of high altitude climate
 Assisted by the software and several sensors within the hypoxic training
room a full automatic control panel processes the climate-data collected and
ensures a consistent atmosphere in the cabin
 The hypoxic training is fully acclimatized
 The temperature within the hypoxic training room can be altered before and
during the stay or training
 The system also automatically controls the carbon dioxide level in the room
keeping the concentration below 0.5 vol % at all times

34.  Very user friendly for the athletes
 Establishing a pre-selected height in the hypoxic room takes about 30-40
min (for altitudinal levels above 3000m it may take longer but not more than
1 hour)
 At any point of time 6-8 athletes can undergo altitude training within the
room
 Within the hypoxia room all types of training equipment can be placed
 A group of athletes with similar physical, physiological & performance
parameters can be subjected to altitude training and the response can be
compared

35. Sport Science Research Center - Shanghai / China
High Altitude Center
Training Area Room
Area 90 m2
Room Volume 320 m3
Max. Altitude 6.000 m
Max. Number of User 12
Realised 07/2004
6 Sleeping Areas Rooms
Area á 12 m2
Room Volume á 30 m3
Max. Altitude 4.000 m
Max. Number of User á 4
Realised 07/2004

36. Installation Plan
Sport Science Research Center - Shanghai / China

37. LOXYMED® - Centre for High-End Medical Care - Berlin / Germany
Rehabilitation Area
Cardio-Training Area incl.
Multivision
Alpin Area

38. Sport University - Beijing / China
21 Sleeping Areas Rooms
Area á 13 m2
Room Volume á 40 m3
Max. Altitude 4.000 m
Max. Number of User á 2
Test Laboratory Room
Area 45 m2
Room Volume 135 m3
Max. Altitude 6.000 m
Max. Number of User 4
Training Area Room
Area 90 m2
Room Volume 270 m3
Max. Altitude 6.000 m
Max. Number of User 10

39. Army Sports Institute - Pune / India
Training Area Room
Area 43 m2
Room Volume 175 m3
Max. Altitude 6.000 m
Max. Number of User 6
Realised 10/2008

40. Training under artificial altitude conditions
Compared to the training in natural high-altitude settings, training
in low-lands brings along the following advantages:
 The habitual day-to-day life can be maintained
 An optimal nutrition can be kept up
 Medical and psychological assistance can be secured
 Independance of weather and climatical conditions
 Avoiding all physical complaints that are being related to low air
pressure and extremely dry mountain air

41.  Avoidance of long travels and high travel costs
 Providing innovative, methodological solutions for training
 While endurance training can be performed under hypoxia, intensive
training can be performed just the same day under normal conditions
 Prior to high-altitutde travels, the training provides the possibility to
specifically adapt to the respective atmospherical conditions
SLEEP HIGH, TRAIN LOW EVERYWHERE!
Training under artificial altitude conditions

42.  The altitude house or nitrogen house can be used to simulate moderate
altitude living atmosphere at sea level and to stimulate EPO at sea level in
athletes, and the living high and training low approach seems to give all the
benefits of altitude acclimatization and seems to have the potential to avoid
the problems related to normal altitude training
 It seems to provide the best approach for the enhancement of the sea-level
performance in athletes
 Can be built almost anywhere as a fixed or mobile facility
 It may be the most cost-effective way to deal with teams of athletes - they
offer the athlete a fair, safe and cost effective altitude training system

43.  So, optimizing the altitude training formula of how high
to go and how long to stay there could be the difference
between ”Raising the Cup” or going home early