Global Alliance for the Promotion of Physical Activity: the Hamburg Declaration.

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the 'Hamburg Declaration'. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the 'Global Alliance for the Promotion of Physical Activity' to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The 'Hamburg Declaration' calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings.

Iron Deficiency and Anemia in Male and Female Adolescent Athletes Who Engage in Ball Games.

The aim of this study was to assess the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) among male adolescent athletes who participate in non-calorie-restricting sports, and to compare the results with female athletes of the same age and sports. Data of the hemoglobin concentration (Hb) and serum ferritin (sFer) levels of male (n = 350) and female (n = 126) basketball and football players, aged 11-18, from two sport medicine centers in Israel were gathered and analyzed. Mild ID was defined as sFer ≤ 30 µg/L, moderate as sFer ≤ 20 µg/L, and severe as sFer ≤ 10 µg/L. IDA was defined as sFer ≤ 20 µg/L and Hb < 13 g/dL for males and sFer ≤ 20 µg/L and Hb < 12 g/dL for females. The prevalence of mild ID was 41.1% and 53.2%, moderate was 17.4% and 27.8%, and severe was 2% and 4.8% in males and females, respectively. The prevalence of IDA was 2.6% in males and 4% in females. Mild and moderate ID was significantly higher among females. In conclusion, non-anemic ID, which is known to be common among female athletes, especially in sports requiring leanness, is also highly prevalent among adolescent males playing ball games. Therefore, screening for hemoglobin and sFer is recommended for young athletes of both genders and in all sports.

[RECOMMENDATIONS FOR CHANGING CARDIOVASCULAR SCREENING OF ATHLETES WHO ARE REQUIRED FOR PRE-PARTICIPATION SCREENING UNDER THE SPORTS LAW - A POSITION PAPER ON BEHALF OF THE ISRAEL HEART SOCIETY].

INTRODUCTION: For many years routine screening of athletes in Israel includes frequently performed ECGs and exercise tests that overload the system with questionable benefits. The purpose of the current document is to reevaluate the need for pre-participation testing and establish new evidence-based guidelines. It should be noted that our proposal for a change of approach relates only to subjects whose health questionnaire is normal, who do not have a family history of sudden and unexpected death at an early age, or a family history of hereditary heart disease and whose physical examination from a cardiovascular point of view is normal.

Activity Tracking After Surgery: Does It Correlate With Postoperative Complications?

BACKGROUND: Postoperative ambulation is an important tenet in enhanced recovery programs. We quantitatively assessed the correlation of decreased postoperative ambulation with postoperative complications and delays in gastrointestinal function. METHODS: Patients undergoing major abdominal surgery were fitted with digital ankle pedometers yielding continuous measurements of their ambulation. Primary endpoints were the overall and system-specific complication rates, with secondary endpoints being the time to first passage of flatus and stool, the length of hospital stay, and the rate of readmission. RESULTS: 100 patients were enrolled. We found a significant, independent inverse correlation between the number of steps on the first and second postoperative days (POD1/2) and the incidence of complications as well as the recovery of GI function and the likelihood of readmission (P < .05). POD2 step count was an independent risk factor for severe complications (P = .026). DISCUSSION: Digitally quantified ambulation data may be a prognostic biomarker for the likelihood of severe postoperative complications.

Walking to a better future? Postoperative ambulation after cesarean delivery and complications: A prospective study.

OBJECTIVE: To assess the correlation between maternal mobility after cesarean delivery and postoperative morbidity. METHODS: A prospective study was conducted in a tertiary hospital among patients after cesarean delivery. The women were recruited after surgery and before ambulation. Each participant received an accelerometer and routine instructions for mobilization. The patients were asked to wear the accelerometer constantly. It was collected at discharge. Electronic files were reviewed and patients' outcomes were analyzed. The Mann-Whitney U test was used to compare groups and a receiver operating characteristic curve was calculated for the threshold of number of steps. RESULTS: Data were analyzed for 199 patients, among which 107 (54.4%) deliveries were urgent and 90 (45.6%) were elective. The median number of steps was higher for multiparous women compared to nulliparous women (P = 0.035). Patients who developed complications after discharge walked significantly less during their hospitalization compared to those who did not. There was a trend toward increased risk for in-hospitalization complications among patients who walked less while hospitalized. A threshold of more than 9716 steps per hospitalization was found to be associated with fewer post-discharge complications. CONCLUSION: There is a significant correlation between the extent of ambulation after cesarean delivery and fewer postoperative complications.

Physical activity and maximal oxygen uptake in adults with Prader-Willi syndrome.

BACKGROUND: Prader-Willi Syndrome (PWS) is the most common genetic syndrome causing life-threatening obesity. Strict adherence to a low-calorie diet and regular physical activity are needed to prevent weight gain. Direct measurement of maximal oxygen uptake (VO2 max), the "gold standard" for assessing aerobic exercise capacity, has not been previously described in PWS. OBJECTIVES: Assess aerobic capacity by direct measurement of VO2 max in adults with PWS, and in age and BMI-matched controls (OC), and compare the results with values obtained by indirect prediction methods. METHODS AND PATIENTS: Seventeen individuals (12 males) age: 19-35 (28.6 ± 4.9) years, BMI: 19.4-38.1 (27.8 ± 5) kg/m2 with genetically confirmed PWS who exercise daily, and 32 matched OC (22 males) age: 19-36 (29.3 ± 5.2) years, BMI: 21.1-48.1 (26.3 ± 4.9) kg/m2. All completed a medical questionnaire and performed strength and flexibility tests. VO2 max was determined by measuring oxygen consumption during a graded exercise test on a treadmill. RESULTS: VO2 max (24.6 ± 3.4 vs 46.5 ± 12.2 ml/kg/min, p < 0.001) and ventilatory threshold (20 ± 2 and 36.2 ± 10.5 ml/kg/min, p < 0.001), maximal strength of both hands (36 ± 4 vs 91.4 ± 21.2 kg, p < 0.001), and flexibility (15.2 ± 9.5 vs 26 ± 11.1 cm, p = 0.001) were all significantly lower for PWS compared to OC. Predicted estimates and direct measurements of VO2 max were almost identical for the OC group (p = 0.995), for the PWS group, both methods for estimating VO2 max gave values which were significantly greater (p < 0.001) than results obtained by direct measurements. CONCLUSIONS: Aerobic capacity, assessed by direct measurement of VO2 max, is significantly lower in PWS adults, even in those who exercise daily, compared to OCs. Indirect estimates of VO2 max are accurate for OC, but unreliable in PWS. Direct measurement of VO2 should be used for designing personal training programs and in clinical studies of exercise in PWS.

Medical students as health coaches: Implementation of a student-initiated Lifestyle Medicine curriculum.

BACKGROUND: By 2020, the World Health Organization predicts that two-thirds of all diseases worldwide will be the result of lifestyle choices. Physicians often do not counsel patients about healthy behaviors, and lack of training has been identified as one of the barriers. Between 2010 and 2014, Hebrew University developed and implemented a 58-h Lifestyle Medicine curriculum spanning five of the 6 years of medical school. Content includes nutrition, exercise, smoking cessation, and behavior change, as well as health coaching practice with friends/relatives (preclinical years) and patients (clinical years). This report describes this development and diffusion process, and it also presents findings related to the level of acceptance of this student-initiated Lifestyle Medicine (LM) curriculum. METHODS: Students completed an online semi-structured questionnaire after the first coaching session (coaching questionnaire) and the last coaching session (follow-up questionnaire). RESULTS: Nine hundred and twenty-three students completed the coaching questionnaire (296 practices were with patients, 627 with friends /relatives); and 784 students completed the follow-up questionnaire (208 practices were with patients, 576 with friends /relatives). They reported overall that health coaching domains included smoking cessation (263 students), nutrition (79), and exercise (117); 464 students reported on combined topics. Students consistently described a high acceptance of the curriculum and their active role in coaching. Further, most students reported that they were eager to address their own health behaviors. CONCLUSIONS: We described the development and acceptance of a student-initiated comprehensive LM curriculum. Students perceived LM as an important component of physicians' professional role and were ready to explore it both as coaches and in their personal lives. Thus, medical school deans might consider developing similar initiatives in order to position medical schools as key players within a preventive strategy in healthcare policy.

[EXERCISE CAPACITY AND AEROBIC PHYSICAL FITNESS ASSESSMENT AMONG ADOLESCENTS AND ADULTS WITH CYSTIC FIBROSIS BY A QUESTIONNAIRE AND EXERCISE TESTS].

BACKGROUND: Physical exercise has been shown to improve lung condition or to slow deterioration in patients with cystic fibrosis (CF) and improves their quality of life. This study analyzes the physical exercise capacity and the level of aerobic fitness of adolescents and adults with CF who are patients at the CF Center at Hadassah Medical Center Mount Scopus in Jerusalem, Israel. OBJECTIVES: To assess physical exercise capacity and aerobic capacity levels among CF patients by a physical activity questionnaire in comparison to assessment by exercise tests. METHODS: The participants completed a physical activity questionnaire, performed the "6 minute walk test" and a cardio-pulmonary test on a treadmill. RESULTS: The study group included 36 patients, ages 12-43 years, who completed a physical activity questionnaire. Most patients (92%) reported engaging in physical exercise. Most of those who exercised (61%) did so at a low intensity, as described in CF research literature. The average weekly exercise time was 177 minutes; 35 patients completed a cardio-pulmonary exercise test and a "6 minute walk test". The cardio-pulmonary exercise tests showed that 34% of the participants had 'good to excellent' aerobic fitness, 26% had 'moderate' aerobic fitness and 40% had "poor to very poor" fitness. Males achieved significantly higher maximal oxygen uptake than females, even when there were no differences in the severity of disease. Similar to the differences in the general population, these differences showed that male patients had higher aerobic fitness and exercise capacities than female CF patients. A significant correlation was found between self-reported exercise time and exercise intensity in the questionnaire and maximal oxygen uptake in the cardio-pulmonary test (r = 0.5, P < 0.01). The physical activity questionnaire had 85% sensitivity for the identification of patients with low aerobic exercise capacity and specificity of only 50%. CONCLUSION: The physical activity questionnaire showed a good correlation with the exercise tests results. This questionnaire should be used as a health promotion tool to adapt exercise programs for each patient.

[A PARADIGM SHIFT IN THE PERCEPTION OF HEALTH MAINTENANCE FROM INCREASING PHYSICAL ACTIVITY TO DECREASING PHYSICAL INACTIVITY].

Modern man spends most of his waking hours (50-70%) in one form or another of sedentary behavior, defined as activity conducted in a sitting or reclining position involving low energy expenditure. The remaining waking hours are spent performing low intensity physical activity (25-45%) and medium-high intensity physical activity (less than 5%): Despite this distribution, medical research has focused on the impact of increasing medium-high intensity physical activity and many health organizations' recommendations are in accordance. In recent years, research conducted has begun to examine the effect inactivity has on health and has shown that excess sedentary behaviour is an independent risk factor for a wide range of medical problems such as obesity, metabolic syndrome, poor cardiovascular health profile, diabetes mellitus, and possibly cancer. Although the higher risk brought on by sedentary behaviour is partially reduced by increasing medium-high intensity physical activity, it is not completely neutralized. One way to diminish the harm caused by long hours of sitting is to take short breaks during periods of prolonged sitting in order to walk. According to these findings, it is worthwhile to recommend reducing the hours spent in sedentary behaviour, or at least to take frequent short breaks ("activity snacks") during periods of prolonged sitting to get up and walk around.

Changes in fitness are associated with changes in body composition and bone health in children after cancer.

AIM: This study examined the effects of physical activity on the fitness, body composition and mental health of children after cancer or bone marrow transplantation. METHODS: We focused on 22 children aged from seven to 14 years who had received chemotherapy and/or bone marrow transplantation in our medical centre. Ten children took part in a six-month exercise programme, and 12 children who did not exercise formed the control group. At baseline and at the end of the trial, we measured aerobic fitness, body composition, bone density and assessed the child's mood and quality of life. We pooled all participants together post hoc to compare changes in fitness with the various study outcomes. RESULTS: We found no differences between groups in changes in fitness, body composition or mental health indices. Significant correlations were found between changes in aerobic fitness and changes in lean body mass (r = 0.74, p = 0.002), bone mineral content (r = 0.57, p = 0.026) and femoral neck bone mineral density (r = 0.59, p = 0.027) in all participants. CONCLUSION: Group-based exercise training did not improve aerobic fitness in children after cancer or bone marrow transplantation. However, changes in fitness throughout the study period were associated with changes in body composition and bone health in all participants.

Baseline abdominal lipid partitioning is associated with the metabolic response to bariatric surgery.

BACKGROUND: The purpose of this study was to compare the effects of two bariatric procedures on abdominal lipid partitioning and metabolic response. METHODS: Fifty-one patients (RYGB 31(11 M/20 F); (SG) 20(8 M/12 F)) who met the criteria of metabolic syndrome before the operation were followed following Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Visceral and subcutaneous abdominal fat depots were assessed by CT before, 6 months, and 12 months following the operation. RESULTS: Patients undergoing both procedures did not differ in baseline body mass index (BMI) (42.84 ± 4.65 vs. 41.70 ± 4.68 kg/m(2)) or abdominal lipid depots. BMI at 12 months post-op was similar (29.44 ± 3.35 vs 30.86 ± 4.31 kg/m(2) for RYGB and SG, respectively). Both procedures led to a significant reduction in visceral and subcutaneous fat at 6 months (p < 0.001 for both). The visceral-to-subcutaneous fat ratio was comparable at 6 months vs. baseline yet was lower at 12 months vs. baseline for both procedures (p < 0.01). In patients who lost the diagnosis of metabolic syndrome, baseline visceral/subcutaneous fat was the only predictor of recovery (p < 0.005). No difference was detected between procedures in dynamics of abdominal fat depots or remission of cardiovascular risk factors. CONCLUSIONS: RYGB and SG induce a similar effect on abdominal fat mobilization. The metabolic effects in individual patients are mostly determined by their baseline abdominal lipid partitioning.

Nutrition knowledge, attitudes, and behaviors of israeli female combat recruits participating in a nutrition education program.

The objective of this study was to assess the impact of a pilot nutrition intervention program on knowledge, attitudes, and behaviors of female combat soldiers in basic training serving in the Israeli army and to determine changes in nutrient intake. Seventy recruits participated in the intervention. Anthropometric measurements and food frequency questionnaires were completed at 3 time points: at enlistment, at 2 months, and at 4 months. Additional questionnaires to assess nutrition knowledge, attitudes, and behaviors were administered preintervention and postintervention. Baseline results indicated that intakes of calcium, vitamin E, and vitamin D were below recommended levels. After 2 months (8 weeks), suboptimal consumption of many nutrients was observed. At this time point, a nutrition education program was initiated and activities were carried out for the final 2 months of basic training. Following completion of the intervention, a marked improvement in nutrient intake was reported, accompanied by significant changes in attitudes toward healthy eating and increased nutrition knowledge. One-year follow-up evaluation indicated that approximately 20% of participants had made long-term dietary changes. In conclusion, nutrition education increased knowledge, modified attitudes, and led to dietary changes in female recruits. Programs of this type should be considered for implementation in the military.

[Aerobic fitness and cardiorespiratory function of pediatric cancer survivors].

INTRODUCTION: Overall, more than 80% of children diagnosed with cancer will survive their immediate disease. This growing group of childhood cancer survivors is at an increased risk for several chronic diseases and increased mortality. Physical activity is a well-known and powerful means to reduce such complications, yet many children are not active as recommended. Furthermore, the complex treatments might adversely affect the heart and lungs, possibly limiting physical performance. AIM: To measure aerobic fitness among childhood cancer survivors, while assessing maximal cardiac and respiratory functions. METHODS: Eighteen children (mean age 11.5 +/- 2.1 years, 50% males) who had completed medical treatment for cancer, and 16 healthy children, performed a cardiorespiratory exercise test on a bicycle ergometer until exhaustion. Peak oxygen uptake, O2 pulse and several ventilatory parameters were measured and compared between the groups. RESULTS: The mean maximal load obtained by the cancer survivor group was lower than expected, compared with controls (89% +/- 19 vs. 101/% +/- 18, p = 0.055). Peak oxygen consumption was also lower, with a marginal statistical significance (33.3 +/- 7.5 vs. 38.9 +/- 9.7 ml O2/kg/min, p = 0.075), yet was significantly lower when expressed as a percent of age- and sex- appropriate norms [78% +/- 15 vs. 94% +/- 16, p = 0.0081. Cardiac and respiratory functions were normal in all children, with no between-group differences. CONCLUSIONS: We conclude that aerobic fitness is lower in children who have survived cancer, with no evidence of significant cardiac or lung damage. Given the importance of regular physical activity for this at-risk population, it should be continuously encouraged, while administering a personally tailored exercise prescription.

[Who will take care of the caretaker? Lifestyle recommendations for physicians].

A healthy lifestyle is the mainstay of preventive medicine. HeaLthcare personnel might disregard keeping a healthy diet and exercise habits, perhaps due to feeling protected by their own knowledge. Physicians might under-diagnose their own overweight status, and have been shown in some studies to display lower rates of healthy behaviors compared with the general population. This review presents the availabLe data on physicians' own lifestyle habits, and discusses the importance of these for both their own health, and for the benefit of their patients. We supply several healthy lifestyle recommendations based on national and international guidelines, and adapt them to the clinic and hospital settings. Eating a healthy diet, and performing at least 150 minutes of aerobic exercise a week, with additional resistance exercises 2-3 times a week, will benefit all caretakers--both personally and professionally.

Short-term dynamics and metabolic impact of abdominal fat depots after bariatric surgery.

OBJECTIVE: Bariatric surgery is gaining acceptance as an efficient treatment modality for obese patients. Mechanistic explanations regarding the effects of bariatric surgery on body composition and fat distribution are still limited. RESEARCH DESIGN AND METHODS: Intra-abdominal and subcutaneous fat depots were evaluated using computed tomography in 27 obese patients prior to and 6 months following bariatric surgery. Associations with anthropometric and clinical changes were evaluated. RESULTS: Excess weight loss 6 months following surgery was 47% in male and 42.6% in female subjects. Visceral fat and subcutaneous fat were reduced by 35% and 32%, respectively, in both sexes, thus the visceral-to-subcutaneous fat ratio remained stable. The strongest relation between absolute and relative changes in visceral and subcutaneous fat was demonstrated for the excess weight loss following the operations (r approximately 0.6-0.7), and these relations were strengthened further following adjustments for sex, baseline BMI, and fat mass. Changes in waist circumference and fat mass had no relation to changes in abdominal fat depots. All participants met the criteria of the metabolic syndrome at baseline, and 18 lost the diagnosis on follow-up. A lower baseline visceral-to-subcutaneous fat ratio (0.43 +/- 0.15 vs. 0.61 +/- 0.21, P = 0.02) was associated with clinical resolution of metabolic syndrome parameters. CONCLUSIONS: The ratio between visceral and subcutaneous abdominal fat remains fairly constant 6 months following bariatric procedures regardless of sex, procedure performed, or presence of metabolic complications. A lower baseline visceral-to-abdominal fat ratio is associated with improvement in metabolic parameters.

[Childhood obesity--assessment, prevention and treatment].

As in other parts of the western world, the rates of pediatric overweight and obesity are also rising in Israel. This fact warrants immediate action by several government offices and health care providers, and also by the trinity of physician, parent(s) and child. An overweight child is likely to remain undiagnosed if relying on observation alone, unless height and weight are objectively measured by the caring medical staff. This review is based on recommendations on the assessment, prevention, and treatment of children and youth who are overweight and obese, recently published on behalf of the American Medical Association and additional health organizations. In general, preventing and treating pediatric obesity is fairly similar: adhering to a healthy lifestyle which emphasizes healthy food choices and habits, regular physical activity, and limiting screen time. Treating and preventing obesity is a timely, but extremely difficult task. Medical personnel and parents should be continuously educated in this field, while supplied with practical tools for childhood lifestyle modification.

Iron deficiency and the role of nutrition among female military recruits.

UNLABELLED: The impact of iron deficiency is considerable when enhanced physical fitness is required. Female military recruits represent a unique population faced with intense physical and cognitive demands. PURPOSE: To examine the prevalence of iron deficiency and the impact of dietary habits among female recruits in the Israel Defense Forces. METHODS: Three hundred and forty-eight recruits completed the study (188 female combatants, 58 male combatants, and 92 noncombat females). Dietary intake was assessed using a Food Frequency Questionnaire. Blood samples were collected for complete blood cell count, iron indices, and vitamin B12. The common definitions for anemia and iron store deficiency were used as follows: hemoglobin <12 g x dL for females and <14 g x dL for males; serum ferritin <12 mg x dL. RESULTS: The prevalence of iron deficiency and iron deficiency anemia was 29.8% and 12.8%, respectively, among female combatants. Similar data were found among noncombat females (27.2% and 17.4%, respectively) as compared with 5.2% and 0% among males. No significant difference in iron or total calorie intake was detected between subjects with iron deficiency (with or without anemia) when compared with subjects with normal iron status in the same study group. Plant sources constituted 85% of dietary iron source for females, in comparison to 73% for males. The contribution of red meat to the daily iron intake was 2% for females and 20% for males. CONCLUSIONS: A high prevalence of iron deficiency was found among female recruits. Coupled with the iron loss during menstruation, inadequate iron intake may have a permissive role for iron deficiency in female recruits and is an important issue facing females in the military.

High prevalence of iron deficiency and anemia in female military recruits.

Iron deficiency anemia has long been known to impair physical and mental performance. Iron deficiency itself, even without anemia, may also cause such an effect. Similar to female athletes, women in active military units may have increased risks for iron deficiency and its detrimental effects. Female recruits were screened for anemia and iron store status, and a questionnaire on lifestyle habits and menstruation was completed. Iron depletion (serum ferritin level of <20 microg/L) was found for 77% of study participants. Iron deficiency (ferritin level of <12 microg/L and transferrin saturation of <15%) was found for 15% of study participants. Anemia was found for 24% of subjects, and iron deficiency anemia was found for 10% of subjects. High prevalence of iron depletion, iron deficiency, anemia, and iron deficiency anemia was found among female recruits intended for active military duty. Therefore, a recommendation can be made to screen such female recruits for anemia and iron stores.

Prevalence of iron depletion and anemia in top-level basketball players.

Iron depletion, with or without anemia, may have a negative effect on physical and mental performance. Even with current recognition of the problem, its incidence among athletes remains high. Most studies describe iron status in endurance athletes. This study examined the prevalence of iron depletion and anemia among male and female top-level basketball players. Adolescents and adults (N = 103) from 8 national basketball teams were screened for anemia and iron stores status, which included a complete blood count and levels of plasma ferritin, transferrin, and serum iron. Iron depletion, defined by a ferritin level below 20 microg/L, was found among 22% of study participants (15% in males vs. 35% in females, p = .019). Anemia was found among 25% of athletes (18% in males vs. 38% in females, p = .028). Iron deficiency anemia, defined by the presence of anemia, ferritin levels below 12 microg/L, and transferrin saturation below 16%, was found among 7% of players (3% in males vs. 14% in females, p = .043). In summary, a high prevalence of iron depletion, anemia, and iron deficiency anemia was found among basketball players of both genders. We recommend screening ballgame players for blood count and iron store status, and providing nutritional counseling and iron supplementation when necessary.

[Physical activity and training at high altitude].

In recent years there has been a growing interest in the effects of high altitudes on the human body. High altitudes are being frequented by more and more people for sport and leisure pursuits, and are increasingly being used both as a training environment and for investigating the healthy body in hypoxic conditions. During the ascent from sea level, atmospheric pressure and partial oxygen pressure decrease, humidity and temperature decrease, and radiation is elevated. The altitudes at which physiological changes and clinical symptoms occur are not constant, but variations may usually appear above 2300-2800 meters. There is a wide variability of reactions to low oxygen in the air inhaled. The physiological parameters during both rest and physical activity at high altitudes are different from those at sea level, and the differences are reflected in concomitant changes in attitude and behavior. Research into altitude as a training environment that could improve athletic endurance and performance has grown in the last decade, with the development of a number of new training methods, such as "Living High--Training Low" and "Training High--Living Low". These have contributed to an improvement of performance in a significant number of athletes. This article will demonstrate the impact and possible dangers of physical activity at high altitude, and will present the current knowledge and methods of altitude training. This article reviews the influence of low air and oxygen pressure on athletic performance. Recommendations are presented regarding physical activity at high altitude and nutritional support.