Pro: Live High+Train Low Does Improve Sea Level Performance Beyond that Achieved with the Equivalent Living and Training at Sea Level

Abstract

Altitude training has been used by elite endurance athletes for many years based on the belief that it serves to enhance sea level performance. The original model of altitude training was one in which athletes lived and trained in a natural/terrestrial hypobaric hypoxic environment at moderate altitude (1500–3000 m). This method of altitude training came to be known as “live high–train high” (LH+TH) altitude training and is still used today by many elite athletes, including the Ethiopian and Kenyan distance runners.

One of the potential limitations of LH+TH altitude training is that many elite athletes are unable to produce the level of training “intensity” (e.g., running velocity) and oxygen flux necessary to bring about or preserve the physiological changes that have a positive impact on performance. It is not uncommon to hear athletes remark that they seem to lose “speed” or “turnover” as a result of LH+TH altitude training, which ultimately has a negative impact on their sea level performance. In response to this potential limitation of LH+TH altitude training, the “live high–train low” (LH+TL) altitude training model was developed in the early 1990s. The essence of LH+TL allows athletes to “live high” in a natural/terrestrial, hypobaric hypoxic environment for the purpose of facilitating altitude acclimatization (e.g., an increase in endogenous erythropoietin [EPO] and resultant increase in erythrocyte volume, and other non-erythropoietic adaptations), while simultaneously allowing athletes to “train low” to induce beneficial metabolic and neuromuscular adaptations. Based on promising findings of the initial investigations of natural/terrestrial LH+TL (Chapman et al., 1998; Levine and Stray-Gundersen, 1997; Stray-Gundersen et al., 2001), several modifications to natural/terrestrial LH+TL have occurred over the past decade and are currently used by athletes. These include:

• Nitrogen apartment—a normobaric hypoxic (2500–3000 m) living/sleeping environment created via nitrogen dilution (Rusko et al., 2004; Wilber, 2004, 2007a).

• Hypoxic tent—a normobaric hypoxic (2000–4000 m) sleeping environment based on oxygen filtration technology (Wilber, 2004, 2007a).

• Supplemental oxygen—a temporary (1–3 h) hypobaric normoxic training environment created by inhalation of a medical grade gas with the appropriate fraction of inspired oxygen (F_IO₂) to simulate sea level conditions (partial pressure of inspired oxygen [P_IO₂] ∼150 Torr) (Morris et al., 2000; Wilber et al., 2003, 2004).

Within the context of this paper, the term LH+TL will refer to all four types of LH+TL altitude training.

Based on approximately 15 years of research, it appears that LH+TL is an effective method of training for the enhancement of sea level performance among endurance athletes, including elite/Olympic level athletes. Following the initial investigation by Levine and Stray-Gundersen (1997) that demonstrated the efficacy of LH+TL on sea level 5000 m run performance, several other studies have shown that LH+TL can have a positive impact on sea level endurance performance. “Performance” is defined here as one or more of the following parameters measured post-altitude at sea level (or near sea level) either in the laboratory or field: time trial, power output, economy/efficiency, or Vo₂ max. Investigations that have shown positive and significant improvements in post-altitude sea level endurance performance include:

• LH+TL via natural/terrestrial altitude (Chapman et al., 1998; Levine and Stray-Gundersen, 1997; Stray-Gundersen et al., 2001; Wehrlin and Marti, 2006; Wehrlin et al., 2006).

• LH+TL via nitrogen dilution (Garvican et al., 2011; Gore et al., 2001; Martin et al., 2002; Nummela and Rusko, 2000; Roberts et al., 2003; Robertson et al., 2010a, 2010b; Saunders et al., 2004, 2009).

• LH+TL via oxygen filtration (Brugniaux et al. 2006; Schmitt et al., 2006).

• LH+TL via supplemental oxygen (Morris et al., 2000).

Note that all of these studies were conducted in reputable laboratories with experience in altitude/hypoxic research. Studies cited here showing sea level performance enhancement subsequent to LH+TL were based on a sound research design, with all but one including a fitness-matched control group. It is also important to note that all of these studies were conducted on well-trained or elite (National Team) athletes, including runners (Brugniaux et al., 2006; Chapman et al., 1998; Levine and Stray-Gundersen, 1997; Nummela and Rusko, 2000; Robertson et al., 2010a, 2010b; Stray-Gundersen et al., 2001; Saunders et al., 2004, 2009; Schmitt et al., 2006; Wehrlin and Marti, 2006; Wehrlin et al., 2006;), cyclists (Garvican et al., 2011; Gore et al., 2001; Martin et al., 2002; Morris et al., 2000; Roberts et al., 2003), swimmers (Brugniaux et al., 2006; Schmitt et al., 2006), and Nordic skiers (Brugniaux et al., 2006; Gore et al., 2001; Schmitt et al., 2006).

Further evidence in support of the efficacy of LH+TL altitude training on sea level performance was recently provided in a meta-analysis by Bonetti and Hopkins (2009). They reported that for elite athletes, natural/terrestrial LH+TL has the potential to enhance endurance performance by 4.0% (±3.7%). This is markedly greater than the reported “smallest worthwhile change” (SWC) of ∼0.5% for 800 m through 5000 m track races, and ∼1.0% for 10,000 m through marathon races (Hopkins and Hewson, 2001). Indeed, given that medals in objectively-timed Olympic sports (e.g., athletics, swimming, speedskating) are typically determined by less than 0.5%, the potential benefit of LH+TL altitude training for elite athletes is clear and convincing. Based on their meta-analysis, Bonetti and Hopkins (2009) concluded that “natural LH+TL currently provides the best protocol for enhancing endurance performance in elite and subelite athletes” among all available altitude/hypoxic training strategies.

There is controversy regarding the primary physiological mechanism that influences sea level endurance performance following LH+TL altitude training (Gore and Hopkins, 2005; Levine and Stray-Gundersen, 2005). Whereas some have argued that the performance-enhancing effects of LH+TL are due to accelerated erythropoiesis (Levine and Stray-Gundersen, 2005), other authors believe that performance benefits are related to changes in running economy (Gore and Hopkins, 2005; Saunders et al., 2004), skeletal muscle buffering capacity (Gore et al., 2001; Gore and Hopkins, 2005), hypoxic ventilatory response (Gore and Hopkins, 2005; Townsend et al., 2002), and/or skeletal muscle Na⁺-K⁺-ATPase activity (Aughey et al., 2005; 2006; Gore and Hopkins, 2005). Currently, the majority of research on LH+TL altitude training among endurance athletes has included direct and/or indirect markers of accelerated erythropoiesis, with the most-robust parameter being the measurement of total hemoglobin mass via the carbon monoxide re-breathing technique (Schmidt and Prommer, 2005).

Finally, it is important to note that for LH+TL to be effective in inducing beneficial hematological and/or nonhematological effects in most individuals and ultimately influence sea level performance in a positive manner, a sufficient altitude/hypoxic “dose” must be attained (Wilber at al., 2007b). Sufficient altitude/hypoxic dose is determined based on the following considerations: 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? Although research regarding effective altitude/hypoxic dose is still evolving, some general guidelines have emerged for athletes and coaches to use in designing LH+TL training blocks. When using natural/terrestrial LH+TL, it appears that an effective altitude/hypoxic dose consists of living at 1800 m to 2500 m, for a period of 3 to 4 weeks, to include a daily hypoxic exposure of ≥22 hours (Wilber et al., 2007b). When using simulated LH+TL, it appears that fewer hours of hypoxic exposure may be necessary (12–16 h), but a higher elevation (2500–3000 m) is required to achieve similar erythropoietic effects (Wilber et al., 2007b). There is marked individual variability in physiological responses (Hb mass, Vo₂ max, etc.) to LH+TL altitude training (Chapman et al., 1998; Levine and Stray-Gundersen, 2005; Wehrlin et al., 2006). Although it is unclear as to the precise mechanism(s) for this individual variability, it is purported to be linked to inherent differences in hypoxia sensitivity (Caro, 2001).

In conclusion, evidence from several well-designed investigations over the past 15 years suggest that LH+TL altitude training is an effective method for enhancing sea level performance in endurance athletes, including athletes at the elite/Olympic level, provided a sufficient altitude/hypoxic “dose” is attained. At present, it appears that one of the major mechanisms affecting sea level endurance performance following LH+TL is an increase in total hemoglobin mass and oxygen-carrying capacity, although there is emerging evidence that other non-hematological mechanisms may be involved. LH+TL continues to evolve for the purpose of identifying optimal training protocols for use by athletes from a variety of endurance sports.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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