Application of altitude/hypoxic training by elite athletes

Randall L. Wilber


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 utilized 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 normobaric 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.


Hypobaric hypoxia; Intermittent hypoxic training; Live high-train low; Nitrogen dilution; Normobaric hypoxia; Supplemental oxygen


Abellan, R., Remacha, A.F., Ventura, R., Sarda, M.P., Segura, J., Rodriguez, F.A. Hematologic response to four weeks of intermittent hypobaric hypoxia in highly trained athletes. Haematologica. 2005; 90:126-127.

Ashenden, M.J., Gore, C.J., Dobson, G.P., Hahn, A.G. "Live high, train low" does not change the total haemoglobin mass of male endurance athletes sleeping at a simulated altitude of 3000 m for 23 nights. Eur J Appl Physiol. 1999a; 80:479-484.

Ashenden, M.J., Gore, C.J., Martin, D.T., Dobson, G.P., Hahn, A.G. Effects of a 12-day "live high, train low" camp on reticulocyte production and haemoglobin mass in elite female road cyclists. Eur. J. Appl. Physiol. 1999b; 80:472-478.

Ashenden, M.J., Gore, C.J., Dobson, G.P., Et Al. Simulated moderate altitude elevates serum erythropoietin but does not increase reticulocyte production in well-trained runners. Eur J Appl Physiol. 2000; 81:428-435.

Aughey, R.J., Gore, C.J., Hahn, A.G., Et Al. Chronic intermittent hypoxia and incremental cycling exercise independently depress muscle in vitro maximal Na+-K+-ATPase activity in well-trained athletes. J Appl Physiol. 2005; 98:186-192.

Aughey, R.J., Clark, S.A., Gore, C.J., Et Al. Interspersed normoxia during live high, train low interventions reverses an early reduction in muscle Na+-K+-ATPase activity in well-trained athletes. Eur J Appl Physiol. 2006; 98:299-309.

Bailey, D.M., Davies, B. Physiological implications of altitude training for endurance performance at sea level: A review. Br J Sports Med. 1997; 31:183-190.

Beidleman, B.A., Muza, S.R., Rock, P.B., Et Al. Exercise responses after altitude acclimatization are retained during reintroduction to altitude. Med Sci Sports Exerc. 1997; 29:1588-1595.

Bonetti, D.L., Hopkins, W.G., Kilding, A.E. High-intensity kayak performance after adaptation to intermittent hypoxia. Int J Sports Physiol. Perform. 2006; 1:246-260.

Brugniaux, J.V., Schmitt, L., Robach, P., Et Al. Eighteen days of "living high, training low" stimulate erythropoiesis and enhance aerobic performance in elite middle-distance runners. J Appl Physiol 2006; 100:203-211.

Brugniaux, J.V., Schmitt, L., Robach, P., Et Al. Living high-training low: tolerance and acclimatization in elite endurance athletes. Eur J Appl Physiol. 2006; 96:66-77.

Buskirk, E.R., Kollias, J., Akers, R.F., Prokop, E.K., Reategui, E.P. Maximal performance at altitude and on return from altitude in conditioned runners. J Appl Physiol. 1967; 23:259-266.

Chick, T.W., Stark, D.M., Murata, G.H. Hyperoxic training increases work capacity after maximal training at moderate altitude. Chest. 1993; 104:1759-1762.

Clark, S.A., Aughey, R.J., Gore, C.J., Et Al. Effects of live high, train low hypoxic exposure on lactate metabolism in trained humans. J Appl Physiol. 2004; 96:517-525.

Desplanches, D., Hoppeler, H. Effects of training in normoxia and normobaric hypoxia on human muscle ultrastructure. Pflugers Arch. 1993; 425:263-267.

Fulco, C.S., Rock, P.D., Cymerman, A. Maximal and submaximal exercise performance at altitude. Aviat Space Environ Med. 1998; 69:793-801.

Fulco, C.S., Rock, P.D., Cymerman, A. Improving athletic performance: Is altitude residence or altitude training helpful? Aviat Space Environ Med. 2000; 71:162-171.

Glyde-Julian, C.G., Gore, C.J., Wilber, R.L., Et Al. Intermittent normobaric hypoxia does not alter performance or erythropoietic markers in highly trained distance runners. J Appl Physiol. 2004; 96:1800-1807.

Gore, C.J., Hahn, A.G., Aughey, R.J., Et Al. Live high: train low increases muscle buffer capacity and submaximal cycling efficiency. Acta Physiol Scand. 2001; 173:275-286.

Gore, C.J., Rodriguez, F.A., Truijens, M.J., Townsend, N.E., Stray-Gundersen, J., Levine, B.D. Increased serum erythropoietin but not red cell production after 4 wk of intermittent hypobaric hypoxia (4,000-5,500 m). J Appl Physiol. 2006; 101:1386-1393.

Hahn, A.G., Telford, R.D., Tumilty, D.M., Et Al. Effect of supplemental hypoxic training on physiological characteristics and ergometer performance in elite rowers. Excel. 1992; 8:127-138.

Hamlin, M.J., Hellemans, J. Effects of intermittent normobaric hypoxia on blood parameters in multi-sport endurance athletes. Med Sci Sports Exerc. 2004; 36(5):S337.

Hendriksen, I.J.M., Meeuwsen, T. The effect of intermittent training in hypobaric hypoxia on sea-level exercise: A cross-over study in humans. Eur J Appl Physiol. 2003; 88:396-403.

Hinckson, E.A., Hopkins, W.G. Changes in running endurance performance following intermittent altitude exposure simulated with tents. Eur J Sport Sci. 2005; 5:15-24.

Hinckson, E.A., Hopkins, W.G., Fleming, J.S., Edwards, T., Pfitzinger, P., Hellemans, J. Sea-level performance in runners using altitude tents: A field study. J Sci Med Sport. 2005; 8:451-457.

Karlsen, T., Madsen, O., Rolf, S., Stray-Gundersen, J. Effects of 3 weeks hypoxic interval training on sea level cycling performance and hematological parameters. Med Sci Sports Exerc. 2002; 34(5):S224.

Katayama, K., Matsuo, H., Ishida, K., Mori, S., Miyamura, M. Intermittent hypoxia improves endurance performance and submaximal exercise efficiency. High Alt Med Biol. 2003; 4:291-304.

Katayama, K., Sato, K., Matsuo, H., Ishida, K., Iwasaki, K., Miyamura, M. Effect of intermittent hypoxia on oxygen uptake during submaximal exercise in endurance athletes. Eur J Appl Physiol. 2004; 92:75-83.

Katayama, K., Sato, Y., Morotome, Y, Et Al. Ventilatory chemosensitive adaptations to intermittent hypoxic exposure with endurance training and detraining. J. Appl Physiol. 1999; 86:1805-1811.

Kinsman, T.A., Gore, C.J., Hahn, A.G., Et Al. Sleep in athletes undertaking protocols of exposure to nocturnal simulated altitude at 2650 m. J Sci Med Sport. 2005; 8:222-232.

Kinsman, T.A., Townsend, N.E., Gore, C.J., Et Al. Sleep disturbance at simulated altitude indicated by stratified respiratory disturbance index but not hypoxic ventilatory response. Eur J Appl Physiol. 2005; 94:569-575.

Knaupp, W., Khilnani, S., Sherwood, J., Scharf, S., Steinberg, H. Erythropoietin response to acute normobaric hypoxia in humans. J Appl Physiol. 1992; 73:837-840.

Laitinen, H., Alopaeus, K., Heikkinen, R., Et Al. Acclimatization to living in normobaric hypoxia and training at sea level in runners. Med Sci Sports Exerc. 1995; 27(5):S109.

Levine, B.D. Intermittent hypoxic training: Fact and fancy. High Alt Med Biol. 2002; 3:177-193.

Levine, B.D. Should "artificial" high altitude environments be considered doping? Scand J Med Sci Sports. 2006; 16:297-301.

Levine, B.D., Stray-Gundersen, J. A practical approach to altitude training: Where to live and train for optimal performance enhancement. Int J Sports Med. 1992; 13(1):S209-S212.

Levine, B.D., 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.

Levine, B.D., Stray-Gundersen, J. Dose-response of altitude training: How much altitude is enough? In: RC Roach, PD Wagner, PH Hackett. Hypoxia and Exercise. New York: Springer; 2006.

Martin, D.T., Hahn, A.G., Lee, H., Roberts, A.D., Victor, J., Gore, C.J. Effects of a 12-day "live high, train low" cycling camp on 4-min and 30-min performance. Med Sci Sports Exerc. 2002; 34(5):S274.

Mattila, V., Rusko, H. Effect of living high and training low on sea level performance in cyclists. Med Sci Sports Exerc. 1996; 28(5):S157.

Mclean, S.R., Kolb, J.C., Norris, S.R., Smith, D.J. Diurnal normobaric moderate hypoxia raises serum erythropoietin concentration but does not stimulate accelerated erythrocyte production. Eur J Appl Physiol. 2006; 96:651-658.

Morris, D.M., Kearney, H.T., Burke, E.R. The effects of breathing supplemental oxygen during altitude training on cycling performance. J Sci Med Sport. 2000; 3:165-175.

Niess, A.M., Fehrenbach, E., Strobel, G., Et Al. Evaluation of stress response to interval training at low and moderate altitudes. Med Sci Sports Exerc. 2003; 35:263-269.

Nummela, A., Rusko, H. Acclimatization to altitude and normoxic training improve 400-m running performance at sea level. J Sports Sci. 2000; 18:411-419.

Pedlar, C., Whyte, G., Emegbo, S., Stanley, N., Hindmarch, I., Godfrey, R. Acute sleep responses in a normobaric hypoxic tent. Med Sci Sports Exerc. 2005; 37:1075-1079.

Piehl-Aulin, K., Svedenhag, J., Wide, L., Berglund, B., Saltin, B. Short-term intermittent normobaric hypoxia - haematological, physiological and mental effects. Scand J Med Sci Sports. 1998; 8:132-137.

Powell, F.L., Garcia, N. Physiological effects of intermittent hypoxia. High Alt Med Biol. 2000; 1:125-136.

Richalet, J.P., Bittel, J., Herry, J.P., Et Al. Use of a hypobaric chamber for pre-acclimatization before climbing Mount Everest. Int J Sports Med. 1992; 13(1):S216-S220.

Robach, P., Schmitt, L., Brugniaux, J.V., Et Al. Living high-training low: effect on erythropoiesis and aerobic performance in highly-trained swimmers. Eur J Appl Physiol. 2006; 96:423-433.

Roberts, A.D., Clark, S.A., Townsend, N.E., Anderson, M.E., Gore, C.J., Hahn, A.G. Changes in performance, maximal oxygen uptake and maximal accumulated oxygen deficit after 5, 10 and 15 days of live high:train low altitude exposure. Eur J Appl Physiol. 2003; 88:390-395.

Rodriguez, F.A., Truijens, M.J., Townsend, N.E., Et Al. Effects of four weeks of intermittent hypobaric hypoxia on sea level running and swimming performance. Med Sci Sports Exerc. 2004; 36(5):S338.

Roels, B., Millet, G.P., Marcoux, C.J.L., Coste, O., Bentley, D.J., Candau, R.B. Effects of hypoxic interval training on cycling performance. Med Sci Sports Exerc. 2005; 37:138-146.

Rusko, H.K., Leppavuori, A., Makela, P., Leppaluoto, L. Living high, training low: a new approach to altitude training at sea level in athletes. Med Sci Sports Exerc. 1995; 27(5):S6.

Rusko, H.K., Tikkanen, H., Paavolainen, L., Hamalainen, I., Kalliokoski, K., Puranen, A. Effect of living in hypoxia and training in normoxia on sea level VO2max and red cell mass. Med Sci Sports Exerc. 1999; 31(5):S86.

Saunders, P.U., Telford, R.D., Pyne, D.B., Et AL. Improved running economy in elite runners after 20 days of simulated moderate-altitude exposure. J Appl Physiol. 2004; 96:931-937.

Savourey, G., Garcia, N., Besnard, Y., Hanniquet, A.M., Fine, M.O., Bittel, J. Physiological changes induced by pre-adaptation to high altitude. Eur J Appl Physiol. 1994; 69:221-227.

Savourey, G., Garcia, N., Caravel, J.P., Et Al. Pre-adaptation, adaptation and de-adaptation to high altitude in humans: hormonal and biochemical changes at sea level. Eur J Appl Physiol. 1998; 77:37-43.

Schmidt, W. Effects of intermittent exposure to high altitude on blood volume and erythropoietic activity. High Alt Med Biol. 2002; 3:167-176.

Schmitt, L., Millet, G., Robach, P., Et Al. Influence of "living high-training low" on aerobic performance and economy of work in elite athletes. Eur J Appl Physiol. 2006; 97:627-636.

Stray-Gundersen, J., Chapman, R.F., Levine, B.D. "Living high-training low" altitude training improves sea level performance in male and female elite runners. J Appl Physiol. 2001; 91:1113-1120.

Terrados, N., Melichna, J., Sylven, C., Jansson, E., Kaijser, L. Effects of training at simulated altitude on performance and muscle metabolic capacity in competitive road cyclists. Eur J Appl Physiol. 1988; 57:203-209.

Tiollier, E., Schmitt, L., Burnat, P., Et Al. Living high-training low altitude training: Effects on mucosal immunity. Eur J Appl Physiol. 2005; 94:298-304.

Townsend, N.A., Gore, C.J., Hahn, A.G., Et Al. Living high-training low increases hypoxic ventilatory response of well-trained endurance athletes. J Appl Physiol. 2002; 93:1498-1505.

Truijens, M.J., Toussaint, H.M., Dow, J., Levine, B.D. Effect of high-intensity hypoxic training on sea-level swimming performances. J Appl Physiol. 2003; 94:733-743.

Ventura, N., Hoppeler, H., Seiler, R., Binggeli, A., Mullis, P., Vogt, M. The response of trained athletes to six weeks of endurance training in hypoxia or normoxia. Int J Sports Med. 2003; 24:166-172.

Vogt, M., Puntschart, A., Geiser, J., Zuleger, C., Billeter, R., Hoppeler, H. Molecular adaptations in human skeletal muscle to endurance training under simulated hypoxic conditions. J Appl Physiol. 2001; 91:173-182.

Wallechinsky, D. The Complete Book of the Winter Olympics (Turin 2006 Edition). Toronto: Sport Media Publishing, Inc.; 2006.

Wehrlin, J.P., Zuest, P., Hallen, J., Marti, B. Live high-train low for 24 days increases hemoglobin mass and red cell volume in elite endurance athletes. J Appl Physiol. 2006; 100:1938-1945.

Wilber, R.L. Current trends in altitude training. Sports Med. 2001; 31:249-265.

Wilber, R.L. Performance at sea level following altitude training. In: Altitude Training and Athletic Performance. Champaign: Human Kinetics; 2004.

Wilber, R.L. Current practices and trends in altitude training. In: Altitude Training and Athletic Performance. Champaign: Human Kinetics; 2004.

Wilber, R.L., Holm, P.L., Morris, D.M., Dallam, G.M., Callan, S.D. Effect of FIO2 on physiological responses and cycling performance at moderate altitude. Med Sci Sports Exerc. 2003; 35:1153-1159.

Wilber, R.L., Holm, P.L., Morris, D.M, Et Al. Effect of FIO2 on oxidative stress during interval training at moderate altitude. Med Sci Sports Exerc. 2004; 36:1888-1894.

Wilber, R.L., Im, J., Holm, P.L., Et Al. Effect of FIO2 on hemoglobin/myoglobin-deoxygenation during high-intensity exercise at moderate altitude. Med Sci Sports Exerc. 2005; 37(5):S297.