"Living High-Training Low" for Olympic Medal Performance: What Have We Learned 25 Years After Implementation?

BACKGROUND: Altitude training is often regarded as an indispensable tool for the success of elite endurance athletes. Historically, altitude training emerged as a key strategy to prepare for the 1968 Olympics, held at 2300 m in Mexico City, and was limited to the "Live High-Train High" method for endurance athletes aiming for performance gains through improved oxygen transport. This "classical" intervention was modified in 1997 by the "Live High-Train Low" (LHTL) model wherein athletes supplemented acclimatization to chronic hypoxia with high-intensity training at low altitude. PURPOSE: This review discusses important considerations for successful implementation of LHTL camps in elite athletes based on experiences, both published and unpublished, of the authors. APPROACH: The originality of our approach is to discuss 10 key "lessons learned," since the seminal work by Levine and Stray-Gundersen was published in 1997, and focusing on (1) optimal dose, (2) individual responses, (3) iron status, (4) training-load monitoring, (5) wellness and well-being monitoring, (6) timing of the intervention, (7) use of natural versus simulated hypoxia, (8) robustness of adaptative mechanisms versus performance benefits, (9) application for a broad range of athletes, and (10) combination of methods. Successful LHTL strategies implemented by Team USA athletes for podium performance at Olympic Games and/or World Championships are presented. CONCLUSIONS: The evolution of the LHTL model represents an essential framework for sport science, in which field-driven questions about performance led to critical scientific investigation and subsequent practical implementation of a unique approach to altitude training.

Medical Care for Swimmers.

Swimming is one of the most popular sports worldwide. Competitive swimming is one of the most watched sports during the Olympic Games. Swimming has unique medical challenges as a result of a variety of environmental and chemical exposures. Musculoskeletal overuse injuries, overtraining, respiratory problems, and dermatologic conditions are among the most common problems swimmers encounter. Although not unique to swimming, overtraining is a serious condition which can have significant negative impact on swimmers' health and performance. This review article is an attempt to discuss various issues that a medical team should consider when caring for swimmers.

Kenyan and Ethiopian distance runners: what makes them so good?

Since the 1968 Mexico City Olympics, Kenyan and Ethiopian runners have dominated the middle- and long-distance events in athletics and have exhibited comparable dominance in international cross-country and road-racing competition. Several factors have been proposed to explain the extraordinary success of the Kenyan and Ethiopian distance runners, including (1) genetic predisposition, (2) development of a high maximal oxygen uptake as a result of extensive walking and running at an early age, (3) relatively high hemoglobin and hematocrit, (4) development of good metabolic "economy/efficiency" based on somatotype and lower limb characteristics, (5) favorable skeletal-muscle-fiber composition and oxidative enzyme profile, (6) traditional Kenyan/Ethiopian diet, (7) living and training at altitude, and (8) motivation to achieve economic success. Some of these factors have been examined objectively in the laboratory and field, whereas others have been evaluated from an observational perspective. The purpose of this article is to present the current data relative to factors that potentially contribute to the unprecedented success of Kenyan and Ethiopian distance runners, including recent studies that examined potential links between Kenyan and Ethiopian genotype characteristics and elite running performance. In general, it appears that Kenyan and Ethiopian distance-running success is not based on a unique genetic or physiological characteristic. Rather, it appears to be the result of favorable somatotypical characteristics lending to exceptional biomechanical and metabolic economy/efficiency; chronic exposure to altitude in combination with moderate-volume, high-intensity training (live high + train high), and a strong psychological motivation to succeed athletically for the purpose of economic and social advancement.

The upper limit of aerobic power in humans.

Data on the upper limit of aerobic power in humans are scarce. Thus, here we demonstrate extraordinarily high V'O(2)max and submaximal exercise performance in a young elite cross country skier (22 years, 170 cm, 63 kg; hemoglobin: 16.8 g/dL) who was evaluated before winning an Olympic gold medal. The test was performed during progressive roller-ski exercise on an outdoor uphill track (7-10% incline). The athlete demonstrated a V'O(2)max of 90.6 mL/min/kg (45 s average; 26 METs; 5.7 L/min). But even more impressive than V'O(2)max was his ability to exercise at a V'O(2) of 65 mL/min/kg (71.4% V'O(2)max) at a lactate level of 1.6 mmol/L. At the self-selected maximal lactate steady state he consumed 78 mLO(2)/min/kg (85.7% V'O(2)max) with a corresponding lactate level of 4.4 mmol/L. These values rank among the highest ever demonstrated in human beings.

Hematological and physiological adaptations following 46 weeks of moderate altitude residence.

Although acclimatization to moderate altitude (MA) is thought to be unnecessary or to require minimal adaptation, retrospective data from the U.S. Air Force Academy (USAFA), a military college located at 2210 m, suggested otherwise. To further examine the utility of USAFA as a model for MA acclimatization, a longitudinal experimental design was prospectively utilized to determine the magnitude and time course of selected hematological and performance parameters following 46 weeks at this unique MA setting. Incoming USAFA male freshmen (n=55) were divided into experimental groups based on prior residence at sea level (SL) or MA. Hematological and performance parameters were repeatedly assessed during their entire first year at MA. Hematological data consisted of a complete blood count (CBC) with reticulocyte parameters, as well as determination of serum levels of ferritin, erythropoietin, and soluble transferrin receptor (sTfR). Performance testing included aerobic (1.5-mile run) and physical (push-ups, sit-ups, pull-ups, and standing long jump) fitness tests, maximal aerobic capacity, and running economy. Significant (p<0.05; main effect) hematological differences between SL and MA subjects were observed for the majority of the study. MA subjects had a significantly higher hemoglobin concentration ([Hb], +5.5%), hematocrit (+2.8%), and serum ferritin (+59.0%) and significantly lower sTfR (-11.4%) values than their SL peers. Although both serum ferritin and sTfR demonstrated a significant altitude group x time interaction, [Hb] and hematocrit did not. A significant main effect of altitude without interaction was also observed for performance parameters, with SL subjects having a significantly lower Vo2peak (-5.9%), slower 1.5- mile run time (+5.4%), poorer running economy (+6.6%), and lower composite physical fitness test score (-13.9%) than MA subjects. These results suggest that complete acclimatization to 2210 m by former SL residents may require lengthy physiological adaptations, as both hematological and physical performance differences persisted between groups. Further research at this uniquely well controlled MA setting is warranted.

Introduction to altitude/hypoxic training symposium.

Altitude/hypoxic training has traditionally been an intriguing and controversial area of research and sport performance. This controversial aspect was evident recently in the form of scholarly debates in highly regarded professional journals, as well as the World Anti-Doping Agency's (WADA) consideration of placing "artificially-induced hypoxic conditions" on the 2007 Prohibited List of Substances/Methods. In light of the ongoing controversy surrounding altitude/hypoxic training, this symposium was organized with the following objectives in mind: 1) to examine the primary physiological responses and underlying mechanisms associated with altitude/hypoxic training, including the influence of genetic predisposition; 2) to present evidence supporting the effect of altitude/hypoxic acclimatization on both hematological and nonhematological markers, including erythrocyte volume, skeletal muscle-buffering capacity, hypoxic ventilatory response, and physiological efficiency/economy; 3) to evaluate the efficacy of several contemporary simulated altitude modalities and training strategies, including hypoxic tents, nitrogen apartments, and intermittent hypoxic exposure (IHE) or training, and to address the legal and ethical issues associated with the use of simulated altitude; and 4) to describe different altitude/hypoxic training strategies used by elite-level athletes, including Olympians and military special forces. In addressing these objectives, papers will be presented on the topics of: 1) effect of hypoxic "dose" on physiological responses and sea-level performance (Drs. Benjamin Levine and James Stray-Gundersen), 2) nonhematological mechanisms of improved performance after hypoxic exposure (Dr. Christopher Gore), 3) application of altitude/hypoxic training by elite athletes (Dr. Randall Wilber), and 4) military applications of hypoxic training (Dr. Stephen Muza).

Effect of hypoxic "dose" on physiological responses and sea-level performance.

Live high-train low (LH+TL) altitude training was developed in the early 1990s in response to potential training limitations imposed on endurance athletes by traditional live high-train high (LH+TH) altitude training. The essence of LH+TL is that it allows athletes to "live high" for the purpose of facilitating altitude acclimatization, as manifest by a profound and sustained increase in endogenous erythropoietin (EPO) and ultimately an augmented erythrocyte volume, while simultaneously allowing athletes to "train low" for the purpose of replicating sea-level training intensity and oxygen flux, thereby inducing beneficial metabolic and neuromuscular adaptations. In addition to "natural/terrestrial" LH+TL, several simulated LH+TL devices have been developed to conveniently bring the mountain to the athlete, including nitrogen apartments, hypoxic tents, and hypoxicator devices. One of the key questions regarding the practical application of LH+TL is, what is the optimal hypoxic dose needed to facilitate altitude acclimatization and produce the expected beneficial physiological responses and sea-level performance effects? The purpose of this paper is to objectively answer that question, on the basis of an extensive body of research by our group in LH+TL altitude training. We will address three key questions: 1) What is the optimal altitude at which to live? 2) How many days are required at altitude? and 3) How many hours per day are required? On the basis of consistent findings from our research group, we recommend that for athletes to derive the physiological benefits of LH+TL, they need to live at a natural elevation of 2000-2500 m for >or=4 wk for >or=22 h.d(-1).

Application of altitude/hypoxic training by elite athletes.

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. The purpose of this paper is to describe the practical application of altitude/hypoxic training as used by elite athletes. Within the general framework of the paper, both anecdotal and scientific evidence will be presented 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. These include the three primary altitude/hypoxic training models: 1) live high+train high (LH+TH), 2) live high+train low (LH+TL), and 3) live low+train high (LL+TH). The LH+TL model will be examined in detail and will include its various modifications: natural/terrestrial altitude, simulated altitude via nitrogen dilution or oxygen filtration, and hypobaric normoxia via supplemental oxygen. A somewhat opposite approach to LH+TL is the altitude/hypoxic training strategy of LL+TH, and data regarding its efficacy will be presented. Recently, several of these altitude/hypoxic training strategies and devices underwent critical review by the World Anti-Doping Agency (WADA) for the purpose of potentially banning them as illegal performance-enhancing substances/methods. This paper will conclude with an update on the most recent statement from WADA regarding the use of simulated altitude devices.

Physical fitness and hematological changes during acclimatization to moderate altitude: a retrospective study.

While high altitude adaptations have been studied extensively, limited research has examined moderate altitude (MA: 1500 to 3000 m) adaptations and their time course, despite the fact that millions of people sojourn to or reside at MA. We retrospectively examined long-term MA acclimatization by analyzing recurring physical fitness test results and hematological data among 2147 college-age male cadets previously residing at either sea level (SL) or MA and currently attending the U.S. Air Force Academy (USAFA), a unique, regimented, and well-controlled military university located at 2210 m. Significant (p < 0.01) differences were found in aerobic and anaerobic fitness test scores between former SL and MA subjects, with MA subjects scoring 27 points (8%) higher during a 1.5-mile aerobic fitness run and 18 points (6%) higher than SL subjects in the anaerobic fitness test for 2 yr. These differences may be partly explained by the hematological differences observed. Hemoglobin concentration ([Hb]) was significantly (p < 0.001) higher (6.3%; approximately 1 g/dL) in MA subjects prior to arrival at USAFA and acutely, but the difference between altitude conditions was gone at the next retrospective blood draw (+17 months). After 2.5 yr at USAFA, former SL residents had significantly (p < 0.001) higher [Hb] by +10%, or 1.5 g/dL versus prearrival values. This study suggests that significant hematological acclimatization occurs with MA exposure and requires greater than 7 months to reach stability. The altitude-induced erythropoiesis may explain in part the improvements in aerobic performance, but altitude-related anaerobic differences still remain after hematological acclimatization.

Effect of a global alteration of running technique on kinematics and economy.

In this study, we examined the consequences of a global alteration in running technique on running kinematics and running economy in triathletes. Sixteen sub-elite triathletes were pre and post tested for running economy and running kinematics at 215 and 250 m.min-1. The members of the treatment group (n=8) were exposed to 12 weeks of instruction in the "pose method" of running, while the members of the control group (n=8) maintained their usual running technique. After the treatment period, the experimental group demonstrated a significant decrease in mean stride length (from 137.25+/-7.63 cm to 129.19+/-7.43 cm; P<0.05), a post-treatment difference in vertical oscillation compared with the control group (6.92+/-1.00 vs. 8.44+/-1.00 cm; P<0.05) and a mean increase in submaximal absolute oxygen cost (from 3.28+/-0.36 l.min-1 to 3.53+/-0.43 l.min-1; P<0.01). The control group exhibited no significant changes in either running kinematics or oxygen cost. The global change in running mechanics associated with 12 weeks of instruction in the pose method resulted in a decrease in stride length, a reduced vertical oscillation in comparison with the control group and a decrease of running economy in triathletes.

Effect of FIO2 on oxidative stress during interval training at moderate altitude.

PURPOSE: To evaluate the effect of different fractions of inspired oxygen (FIO2) on oxidative stress during a high-intensity interval workout in trained endurance athletes residing at altitude. METHODS: Subjects (N = 19) were trained male cyclists who were residents of moderate altitude (1800-1900 m). Testing was conducted at 1860 m (PB 610-612 torr, PIO2 approximately 128 torr). Subjects performed three randomized, single-blind trials consisting of a standardized interval workout (6 x 100 kJ) while inspiring a medical-grade gas with FIO2 0.21 (PIO2 approximately 128 torr), FIO2 0.26 (PIO2 approximately 159 torr), and FIO2 0.60 (PIO2 approximately 366 torr). Serum lipid hydroperoxides (LOOH) and whole-blood reduced glutathione (GSH) were measured 60 min preexercise and immediately postexercise, and analyzed using standard colorimetric assays. Urinary malondialdehyde (MDA) and 8-hydroxydeoxyguanosine (8-OHdG) were measured 24 h preexercise and 24 h postexercise, and analyzed via HPLC and ELISA, respectively. RESULTS: Compared with the control trial (FIO2 0.21), total time (min:s) for the 100-kJ work interval was faster (5% in FIO2 0.26; 8% in FIO2 0.60 (P < 0.05)) and power output (W) was higher (5% in FIO2 0.26, 8% in FIO2 0.60 (P < 0.05)) in the supplemental oxygen trials. There was a significant pre- versus postexercise main effect (P < 0.05) for LOOH and GSH; however, there were no significant differences in LOOH or GSH between the FIO2 trials. MDA and 8-OHdG were unaffected by either the interval training session or FIO2. CONCLUSION: Supplemental oxygen used in conjunction with high-intensity interval training at altitude ("live high + train low via supplemental O2" (LH + TLO2)) results in a significant improvement in exercise performance without inducing additional free radical oxidative stress as reflected in hematological and urinary biomarkers.

Intermittent normobaric hypoxia does not alter performance or erythropoietic markers in highly trained distance runners.

This study was designed to test the hypothesis that intermittent normobaric hypoxia at rest is a sufficient stimulus to elicit changes in physiological measures associated with improved performance in highly trained distance runners. Fourteen national-class distance runners completed a 4-wk regimen (5:5-min hypoxia-to-normoxia ratio for 70 min, 5 times/wk) of intermittent normobaric hypoxia (Hyp) or placebo control (Norm) at rest. The experimental group was exposed to a graded decline in fraction of inspired O2: 0.12 (week 1), 0.11 (week 2), and 0.10 (weeks 3 and 4). The placebo control group was exposed to the same temporal regimen but breathed fraction of inspired O2 of 0.209 for the entire 4 wk. Subjects were matched for training history, gender, and baseline measures of maximal O2 uptake and 3,000-m time-trial performance in a randomized, balanced, double-blind design. These parameters, along with submaximal treadmill performance (economy, heart rate, lactate, and ventilation), were measured in duplicate before, as well as 1 and 3 wk after, the intervention. Hematologic indexes, including serum concentrations of erythropoietin and soluble transferrin receptor and reticulocyte parameters (flow cytometry), were measured twice before the intervention, on days 1, 5, 10, and 19 of the intervention, and 10 and 25 days after the intervention. There were no significant differences in maximal O2 uptake, 3,000-m time-trial performance, erythropoietin, soluble transferrin receptor, or reticulocyte parameters between groups at any time. Four weeks of a 5:5-min normobaric hypoxia exposure at rest for 70 min, 5 days/wk, is not a sufficient stimulus to elicit improved performance or change the normal level of erythropoiesis in highly trained runners.

Effect of F(I)O(2) on physiological responses and cycling performance at moderate altitude.

PURPOSE: To evaluate physiological responses and exercise performance during a "live high-train low via supplemental oxygen" (LH + TLO(2)) interval workout in trained endurance athletes. METHODS: Subjects (N = 19) were trained male cyclists who were permanent residents of moderate altitude (1800-1900 m). Testing was conducted at 1860 m (P(B) 610-612 Torr, P(I)O(2) approximately 128 Torr). Subjects completed three randomized, single-blind trials in which they performed a standardized interval workout while inspiring a medical-grade gas with F(I)O(2) 0.21 (P(I)O(2) approximately 128 Torr), F(I)O(2) 0.26 (P(I)O(2) approximately 159 Torr), and F(I)O(2) 0.60 (P(I)O(2) approximately 366 Torr). The standardized interval workout consisted of 6 x 100 kJ performed on a dynamically calibrated cycle ergometer at a self-selected workload and pedaling cadence with a work:recovery ratio of 1:1.5. RESULTS: Compared with the control trial (21% O(2)), average total time (min:s) for the 100-kJ work interval was 5% and 8% (P < 0.05) faster in the 26% O(2) and 60% O(2) trials, respectively. Consistent with the improvements in total time were increments in power output (W) equivalent to 5% (26% O(2) trial) and 9% (60% O(2) trial; P < 0.05). Whole-body [VO](2) (L.min-1) was higher by 7% and 14% (P < 0.05) in the 26% O(2) and 60% O(2) trials, respectively, and was highly correlated to the improvement in power output (r = 0.85, P < 0.05). Arterial oxyhemoglobin saturation (S(p)O(2)) was significantly higher by 5% (26% O(2)) and 8% (60% O(2)) in the supplemental oxygen trials. CONCLUSION: We concluded that a typical LH + TLO(2) training session results in significant increases in arterial oxyhemoglobin saturation, [V02] and average power output contributing to a significant improvement in exercise performance.

Detection of DNA-recombinant human epoetin-alfa as a pharmacological ergogenic aid.

The use of DNA-recombinant human epoetin-alfa (rhEPO) as a pharmacological ergogenic aid for the enhancement of aerobic performance is estimated to be practised by at least 3 to 7% of elite endurance sport athletes. rhEPO is synthesised from Chinese hamster ovary cells, and is nearly identical biochemically and immunologically to endogenous epoetin-alfa (EPO). In a clinical setting, rhEPO is used to stimulate erythrocyte production in patients with end-stage renal disease and anaemia. A limited number of human studies have suggested that rhEPO provides a significant erythropoietic and ergogenic benefit in trained individuals as evidenced by increments in haemoglobin, haematocrit, maximal oxygen uptake (VO2max) and exercise endurance time. The purpose of this review is to summarise the various technologies and methodologies currently available for the detection of illicit use of rhEPO in athletes. The International Olympic Committee (IOC) banned the use of rhEPO as an ergogenic aid in 1990. Since then a number of methods have been proposed as potential techniques for detecting the illegal use of rhEPO. Most of these techniques use indirect markers to detect rhEPO in blood samples. These indirect markers include macrocytic hypochromatic erythrocytes and serum soluble transferrin receptor (sTfr) concentration. Another indirect technique uses a combination of 5 markers of enhanced erythropoiesis (haematocrit, reticulocyte haematocrit, percentage of macrocytic red blood cells, serum EPO, sTfr) to detect rhEPO. The electrophoretic mobility technique provides a direct measurement of urine and serum levels of rhEPO, and is based on the principle that the rhEPO molecule is less negatively charged versus the endogenous EPO molecule. Isoelectric patterning/focusing has emerged recently as a potential method for the direct analysis of rhEPO in urine. Among these various methodologies, the indirect technique that utilises multiple markers of enhanced erythropoiesis appears to be the most valid, reliable and feasible protocol currently available for the detection of rhEPO in athletes. In August 2000, the IOC Medical Commission approved this protocol known as the 'ON model', and it was subsequently used in combination with a second, confirmatory test (isoelectric patterning) to detect rhEPO abusers competing in the 2000 Sydney Summer Olympics. This combined blood and urine test was approved with modifications by the IOC in November 2001 for use in the 2002 Salt Lake City Winter Olympics.