Effects of LHTH Training at 1600 m on Exercise Performance, Complete Blood Count and Erythropoietin: A Case Study of South Korean Elite Male Cross-Country Skiers

Background: In altitude training for elite athletes, altitudes below 1700 m are generally known to have low physiological stimulation and training effects. Therefore, the purpose of this study is to investigate the effect of live high train high (LHTH) altitude training at an altitude of 1600 m on athletic performance, complete blood count (CBC), and erythropoietin (EPO) in cross-country skiers. Methods: In this study, South Korean Six male cross-country skiers participated. Exercise performance, CBC, and EPO were measured 3 days before altitude training and 4 days after the end of altitude training. The training program in this study was the LHTH altitude training method, and the polarized (POL) training program was applied. For exercise performance analysis the Bruce protocol was applied using a treadmill and gas analyzer. Blood variables CBC (red blood cell; RBC, white blood cell; WBC, hemoglobin; Hb, hematocrit; Hct, platelets) and EPO were measured at rest and immediately after exercise. Results: The effect of 3 weeks of LHTH altitude training on male cross-country skiers was as follows. There were no differences in body weight, muscle mass, body fat mass, or body fat percentage (p $>$ 0.05). Although maximal oxygen uptake (VO2${}_2$max) increased (p $<$ 0.05), there was no significant difference in exercise time and maximum heart rate (HRmax) (p $>$ 0.05). The heart rate measured at 2 minutes after the end of exercise decreased rapidly (p $<$ 0.05). At rest, RBC, Hb, and Hct were increased (p $<$ 0.001), but there was no significant difference between WBC and platelets (p $>$ 0.05). Immediately after exercise, there was no significant difference in RBC and Hb (p $>$ 0.05), but WBC (p $<$ 0.001), platelets (p $<$ 0.01), and Hct (p $<$ 0.05) were significantly decreased. EPO was significantly decreased after training compared to before altitude training at rest and immediately after exercise (p $<$ 0.001). Conclusions: The results of this study suggested that 3 weeks of LHTH training at an altitude of 1600 m could stimulate RBC, Hb, and Hct. Also, improved VO2${}_2$max and recovery capacity along with increases in RBC and Hb mean that LHTH training at an altitude of 1600 m could induce a positive effect on physiological and performance changes in male cross-country skiers. We did not have a control group, and we do admit some limitations, including height adjustment, length of altitude training, and training program (intensity and volume). Nevertheless, LHTH training at an altitude of 1600 m can be a desirable intervention program when planning short-term altitude training for technical and physiological improvement in male cross-country skiers. In addition, it is suggested that exercise and living at high altitude stimulate blood variables and cardiopulmonary function, which will have a positive effect on exercise performance and health promotion not only for athletes but also for men in general.

altitude training; LHTH; exercise performance; complete blood count; erythropoietin

[1] Holmberg HC. The elite cross‐country skier provides unique in-sights into human exercise physiology. Scandinavian Journal of Medicine & Science in Sports. 2015; 25: 100–109.

[2] Holmberg HC. Integrative biomechanics and physiology in cc skiing. Materials for Tomorrow 2014. Chalmers: Göteborg. 2014.

[3] Sandbakk Ø, Hegge AM, Losnegard T, Skattebo Ø, Tønnessen E, Holmberg H. The Physiological Capacity of the World’s Highest Ranked Female Cross-country Skiers. Medicine & Sci-ence in Sports & Exercise. 2016; 48: 1091–1100.

[4] Mahood NV, Kenefick RW, Kertzer R, Quinn TJ. Physiological determinants of cross-country ski racing performance. Medicine and Science in Sports and Exercise. 2001; 33: 1379–1384.

[5] Alsobrook NG, Heil DP. Upper body power as a determinant of classical cross-country ski performance. European Journal of Applied Physiology. 2009; 105: 633–641.

[6] Sandbakk Ø, Holmberg H. A Reappraisal of Success Factors for Olympic Cross-Country Skiing. International Journal of Sports Physiology and Performance. 2014; 9: 117–121.

[7] Stray-Gundersen J, Chapman RF, Levine BD. “Living high-training low” altitude training improves sea level performance in male and female elite runners. Journal of Applied Physiology. 2001; 91: 1113–1120.

[8] Chapman RF, Stickford JL, Levine BD. Altitude training consid-erations for the winter sport athlete. Experimental Physiology. 2010; 95: 411–421.

[9] Sandbakk Ø, Holmberg H-, Leirdal S, Ettema G. The physiology of world-class sprint skiers. Scandinavian Journal of Medicine & Science in Sports. 2011; 21: e9–e16.

[10] Lee JY, Han TY, Choi YC. Effects of 3 Week High Altitude Training on Aerobic and Anaerobic Exercise Performance and Recovery Capability in Cross-country Skier. The Korea Journal of Sports Science. 2014; 23: 1171–1186.

[11] Flaherty G, O’Connor R, Johnston N. Altitude training for elite endurance athletes: a review for the travel medicine practitioner. Travel Medicine and Infectious Disease. 2016; 14: 200–211.

[12] Carroll S. The Making of the Fittest: The DNA Record of Evo-lution. Darwin. 2010; 23: 121–126.

[13] Lundby C, Robach P. Does ‘altitude training’ increase exercise performance in elite athletes? Experimental Physiology. 2016; 101: 783–788.

[14] Levine BD, Friedman DB, Engfred K, Hanel B, Kjaer M, Clif-ford PS, et al. The effect of normoxic or hypobaric hypoxic en-durance training on the hypoxic ventilatory response. Medicine & Science in Sports & Exercise. 1992; 24: 769–775.

[15] Levine BD, Stray-Gundersen J. “Living high-training low”: ef-fect of moderate-altitude acclimatization with low-altitude train-ing on performance. Journal of Applied Physiology. 1997; 83: 102–112.

[16] Levine BD. Intermittent Hypoxic Training: Fact and Fancy. High Altitude Medicine & Biology. 2002; 3: 177–193.

[17] Zheng K. Research on the Physiological Monitoring and Eval-uation of Pre-Competition Altitude Training for Zhejiang Elite Swimmers. Physical Activity and Health. 2021; 5: 64–70.

[18] Nummela A, Eronen T, Koponen A, Tikkanen H, Peltonen JE. Variability in hemoglobin mass response to altitude training camps. Scandinavian Journal of Medicine & Science in Sports. 2021; 31: 44–51.

[19] Lukanova-Jakubowska A, Piechota K, Grzywacz T, Ambroży T, Rydzik Ł, Ozimek M. The Impact of Four High-Altitude Training Camps on the Aerobic Capacity of a Short Track PyeongChang 2018 Olympian: A Case Study. International Journal of Environmental Research and Public Health. 2022; 19: 3814.

[20] Solli GS, Tønnessen E, Sandbakk Ø. The Training Character-istics of the World’s Most Successful Female Cross-Country Skier. Frontiers in Physiology. 2017; 8: 1069.

[21] Svedenhag J, Piehl-Aulin K, Skog C, Saltin B. Increased left ventricular muscle mass after long-term altitude training in ath-letes. Acta Physiologica Scandinavica. 1997; 161: 63–70.

[22] Gore CJ, Hahn AG, Aughey RJ, Martin DT, Ashenden MJ, Clark SA, et al. Live high:train low increases muscle buffer capacity and submaximal cycling efficiency. Acta Physiologica Scandi-navica. 2001; 173: 275–286.

[23] Gough CE, Saunders PU, Fowlie J, Savage B, Pyne DB, Anson JM, et al. Influence of altitude training modality on performance and total haemoglobin mass in elite swimmers. European Jour-nal of Applied Physiology. 2012; 112: 3275–3285.

[24] Saunders PU, Ahlgrim C, Vallance B, Green DJ, Robertson EY, Clark SA, et al. An Attempt to Quantify the Placebo Effect from a Three-Week Simulated Altitude Training Camp in Elite Race Walkers. International Journal of Sports Physiology and Perfor-mance. 2010; 5: 521–534.

[25] Garvican-Lewis LA, Halliday I, Abbiss CR, Saunders PU, Gore CJ. Altitude Exposure at 1800 m Increases Haemoglobin Mass in Distance Runners. Journal of Sports Science and Medicine. 2015; 14 :413–417.

[26] Friedmann-Bette B. Classical altitude training. Scandinavian Journal of Medicine & Science in Sports. 2008; 18: 11–20.

[27] Burtscher M, Nachbauer W, Baumgartl P, Philadelphy M. Ben-efits of training at moderate altitude versus sea level training in amateur runners. European Journal of Applied Physiology and Occupational Physiology. 1996; 74: 558–563.

[28] Yong-Chul C. The effect of 3 weeks high altitude skiing training on isokinetic muscle function of cross-country skierst. Journal of the Korea Convergence Society. 2018; 9: 465–477.

[29] Pugliese L, Serpiello FR, Millet GP, La Torre A. Training Di-aries during Altitude Training Camp in Two Olympic Champi-ons: An Observational Case Study. Journal of Sports Science and MedicineJournal of Sports Science and Medicine. 2014; 13: 666–672.

[30] Lee BH, Kim JK, Kwon HJ, Choi YC. Effects of Living Low and Training High on Body Composition, Exercise Performance, Blood CK, Lactate and Oxidative Stress Makers Responses in Cross Country Skiers. Journal of Sport and Leisure Studies. 2013; 53: 695–710.

[31] Sandbakk Ø, Solli GS, Talsnes RK, Holmberg H. Preparing for the Nordic Skiing Events at the Beijing Olympics in 2022: Evidence-Based Recommendations and Unanswered Questions. Journal of Science in Sport and Exercise. 2021; 3: 257–269.

[32] Kim JK, Choi YC. The effect of short-term off-season cross-country ski training on body composition, physical fitness, and isokinetic muscle functions of cross-country skiers. Journal of Men’s Health. 2019; 16: 63–74.

[33] Kim JK, Lee BW, Kim NJ, Choi YC. Effects of High Altitude Training on Maximal Exercise Capacity, RBC, and Hb Concen-tration in Cross-country Skier. The Korea Journal of Sports Sci-ence. 2013; 22: 1313–1324.

[34] Stöggl T, Sperlich B. Polarized training has greater impact on key endurance variables than threshold, high intensity, or high volume training. Frontiers in Physiology. 2014; 5: 33.

[35] Rønnestad BR, Hansen J, Thyli V, Bakken TA, Sandbakk Ø. 5-week block periodization increases aerobic power in elite cross-country skiers. Scandinavian Journal of Medicine & Science in Sports. 2016; 26: 140–146.

[36] Mujika I, Sharma AP, Stellingwerff T. Contemporary Periodiza-tion of Altitude Training for Elite Endurance Athletes: a Narra-tive Review. Sports Medicine. 2019; 49: 1651–1669.

[37] Sharma AP, Saunders PU, Garvican-Lewis LA, Périard JD, Clark B, Gore CJ, et al. Training Quantification and Periodiza-tion during Live High Train High at 2100 M in Elite Runners: An Observational Cohort Case Study. Journal of Sports Science and Medicine. 2018; 17: 607–616.

[38] George JD, Paul SL, Hyde A, Bradshaw DI, Vehrs PR, Hager RL, et al. Prediction of Maximum Oxygen Uptake Using both Exercise and Non-Exercise Data. Measurement in Physical Ed-ucation and Exercise Science. 2009; 13: 1–12.

[39] Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. American Heart Journal. 1973; 85: 546–562.

[40] Will PM, Walter JD. Exercise testing: Improving performance with a ramped Bruce protocol. American Heart Journal. 1999; 138: 1033–1037.

[41] Mikkola J, Laaksonen M, Holmberg H, Vesterinen V, Nummela A. Determinants of a Simulated Cross-Country Skiing Sprint Competition using V2 Skating Technique on Roller Skis. Journal of Strength and Conditioning Research. 2010; 24: 920–928.

[42] Rusko H. The Handbooks of Sports Medicine and Science: Cross Country Skiing. John Wiley & Sons. Jyväskylä. 2008.

[43] Martin SA, Hadmaș RM. Individual Adaptation in Cross-Country Skiing Based on Tracking during Training Conditions. Sports. 2019; 7: 211.

[44] Loucks AB. Energy balance and body composition in sports and exercise. Journal of Sports Sciences. 2004; 22: 1–14.

[45] American Dietetic Association; Dietitians of Canada; American College of Sports Medicine, Rodriguez NR, Di Marco NM, Lan-gley S. American College of Sports Medicine position stand. Nu-trition and athletic performance. Medicine & Science in Sports & Exercise. 2009; 41: 709–731.

[46] Lee J, Zhang XL. Physiological determinants of VO2max and the methods to evaluate it: a critical review. Science & Sports. 2021; 36: 259–271.

[47] Losnegard T, Mikkelsen K, Rønnestad BR, Hallén J, Rud B, Raastad T. The effect of heavy strength training on muscle mass and physical performance in elite cross country skiers. Scandi-navian Journal of Medicine & Science in Sports. 2011; 21: 389–401.

[48] Stöggl T, Enqvist J, Müller E, Holmberg H. Relationships be-tween body composition, body dimensions, and peak speed in cross-country sprint skiing. Journal of Sports Sciences. 2010; 28: 161–169.

[49] Kim TH, Han JK, Lee JY, Choi YC. The Effect of Polarized Training on the Athletic Performance of Male and Female Cross-Country Skiers during the General Preparation Period. Health-care. 2021; 9: 851.

[50] Bertoli A, Di Daniele N, Ceccobelli M, Ficara A, Girasoli C, De Lorenzo A. Lipid profile, BMI, body fat distribution, and aero-bic fitness in men with metabolic syndrome. Acta Diabetologica. 2003; 40: s130–s133.

[51] Singh SJ, Morgan MD, Hardman AE, Rowe C, Bardsley PA. Comparison of oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. European Respiratory Journal. 1994; 7: 2016–2020.

[52] Bonne TC, Lundby C, Jørgensen S, Johansen L, Mrgan M, Bech SR, et al. “Live High–Train High” increases hemoglobin mass in Olympic swimmers. European Journal of Applied Physiology. 2014; 114: 1439–1449.

[53] Truijens MJ, Toussaint HM, Dow J, Levine BD. Effect of high-intensity hypoxic training on sea-level swimming performances. Journal of Applied Physiology. 2003; 94: 733–743.

[54] Choi YC, Khuyagbaatar B, Cheon M, Batbayar T, Lee S, Kim YH. Kinematic Comparison of Double Poling Techniques be-tween National and College Level Cross-Country Skiers Us-ing Wearable Inertial Measurement Unit Sensors. International Journal of Precision Engineering and Manufacturing. 2021; 22: 1105–1112.

[55] Fellin RE, Rose WC, Royer TD, Davis IS. Comparison of meth-ods for kinematic identification of footstrike and toe-off dur-ing overground and treadmill running. Journal of Science and Medicine in Sport. 2010; 13: 646–650.

[56] Jeukendrup A, Diemen AV. Heart rate monitoring during training and competition in cyclists. Journal of Sports Sciences. 1998; 16: 91–99.

[57] Benson R, Connolly D. Heart Rate Training. Human Kinetics. Champaign, IL. 2019.

[58] Nieuwland W, Berkhuysen MA, Van Veldhuisen DJ, Rispens P. Individual assessment of intensity-level for exercise training in patients with coronary artery disease is necessary. International Journal of Cardiology. 2002; 84: 15–20.

[59] Sylta O, Tønnessen E, Seiler S. From Heart-Rate Data to Train-ing Quantification: a Comparison of 3 Methods of Training-Intensity Analysis. International Journal of Sports Physiology and Performance. 2014; 9: 100–107.

[60] Basset F. Effects of Short-term normobaric hypoxia on anaero-bic and aerobic performance in highly trained athletes. 14th In-ternational Hypoxia Symposium. 2005; 91: 391–402.

[61] Bailey DM, Davies B. Physiological implications of altitude training for endurance performance at sea level: a review. British Journal of Sports Medicine. 1997; 31: 183–190.

[62] Larsson P, Olofsson P, Jakobsson E, Burlin L, Henriksson-Larsén K. Physiological predictors of performance in cross-country skiing from treadmill tests in male and female subjects. Scandinavian Journal of Medicine & Science in Sports. 2002; 12: 347–353.

[63] Bergh U. Physiology of cross-country ski racing. Human Kinet-ics. Champaign: Ill. 1982.

[64] Choi Y. The Study of Sprint Cardiorespiratory Index and Body Composition according to Period in National and Reserve Cross-country Skier. Korean Journal of Sports Science. 2018; 27: 993–1005.

[65] Breda FL, Manchado-Gobatto FB, de Barros Sousa FA, Beck WR, Pinto A, Papoti M, et al. Complex networks analysis rein-forces centrality hematological role on aerobic–anaerobic per-formances of the Brazilian Paralympic endurance team after al-titude training. Scientific Reports. 2022; 12: 1148.

[66] Rusko H, Tikkanen H, Peltonen J. Altitude and endurance train-ing. Journal of Sports Sciences. 2004; 22: 928–945.

[67] Baranauskas MN, Fulton TJ, Fly AD, Martin BJ, Mickleborough TD, Chapman RF. High Intraindividual Variability in the Re-sponse of Serum Erythropoietin to Multiple Simulated Altitude Exposures. High Altitude Medicine & Biology. 2022; 23: 85–89.

[68] Friedmann B. Individual variation in the erythropoietic response to altitude training in elite junior swimmers. British Journal of Sports Medicine. 2005; 39: 148–153.

[69] Wachsmuth NB, Völzke C, Prommer N, Schmidt-Trucksäss A, Frese F, Spahl O, et al. The effects of classic altitude training on hemoglobin mass in swimmers. European Journal of Applied Physiology. 2013; 113: 1199–1211.

[70] Manh PH, Viet DH, Van Linh NT, Van Thal L. The effects of simulated altitude training on physiological and biochemi-cal functions in national male cyclists. Science Technology for Sports Performance Enhancement. 2018; 28–35.

[71] Volkan Gürses V, Şakir Akgül M. The Effects of Low Altitude Training on Erythropoietin Response and Hematological Vari-ables in Elite Female Fencers. Universal Journal of Educational Research. 2018; 6: 2169–2174.

[72] Chapman RF, Karlsen T, Resaland GK, Ge RL, Harber MP, Witkowski S, et al. Defining the “dose” of altitude training: how high to live for optimal sea level performance enhancement. Journal of Applied Physiology. 2014; 116: 595–603.

[73] Pottgiesser T, Garvican LA, Martin DT, Featonby JM, Gore CJ, Schumacher YO. Short-Term Hematological Effects upon Com-pletion of a Four-Week Simulated Altitude Camp. International Journal of Sports Physiology and Performance. 2012; 7: 79–83.

[74] Wehrlin JP, Steiner T. Is Hemoglobin Mass at Age 16 a Predic-tor for National Team Membership at Age 25 in Cross-Country Skiers and Triathletes? Frontiers in Sports and Active Living. 2021; 3: 580486.

[75] Baart AM, Klein Gunnewiek JMT, Balvers MGJ, Zwerver J, Vergouwen PCJ. Pitfalls in interpreting red blood cell param-eters in elite high‐altitude and sea‐level athletes: a unique case series. Physiological Reports. 2021; 9: e14891.

[76] Weng X, Chen H, Yu Q, Xu G, Meng Y, Yan X, McConell G, et al. Intermittent Hypoxia Exposure Can Prevent Reductions in Hemoglobin Concentration After Intense Exercise Training in Rats. Frontiers in Physiology. 2021; 12: 627708.

[77] Hu M, Lin W. Effects of Exercise Training on Red Blood Cell Production: Implications for Anemia. Acta Haematologica. 2012; 127: 156–164.

[78] Wehrlin JP, Zuest P, Hallén J, Marti B. Live high-train low for 24 days increases hemoglobin mass and red cell volume in elite endurance athletes. Journal of Applied Physiology. 2006; 100: 1938–1945.

[79] Tilahun Muche Z, Haile Wondimu D, Bayissa Midekssa M, Chekol Abebe E, Mengie Ayele T, Abebe Zewdie E. A Compar-ative Study of Hematological Parameters of Endurance Runners at Guna Athletics Sport Club (3100 Meters above Sea Level) and Ethiopian Youth Sport Academy (2400 Meters above Sea Level), Ethiopia. Journal of Sports Medicine. 2021; 2021: 1–9.

[80] Pyne DB, Smith JA, Baker MS, Telford RD, Weidemann MJ. Neutrophil oxidative activity is differentially affected by exer-cise intensity and type. Journal of Science and Medicine in Sport. 2000; 3: 44–54.

[81] Thake CD, Mian T, Garnham AW, Mian R. Leukocyte counts and neutrophil activity during 4 h of hypocapnic hypoxia equiv-alent to 4000 m. Aviation, Space, and Environmental Medicine. 2004; 75: 811–817.

[82] Yalcin O, Bor-Kucukatay M, Senturk UK, Baskurt OK. Effects of swimming exercise on red blood cell rheology in trained and untrained rats. Journal of Applied Physiology. 2000; 88: 2074–2080.

[83] Al-Sweedan SA, Alhaj M. The effect of low altitude on blood count parameters. Hematology/Oncology and Stem Cell Ther-apy. 2012; 5: 158–161.

[84] Glotov AS, Zelenkova IE, Vashukova ES, Shuvalova AR, Zolotareva AD, Polev DE, et al. RNA Sequencing of Whole Blood Defines the Signature of High Intensity Exercise at Al-titude in Elite Speed Skaters. Genes. 2022; 13: 574.

[85] Wang Y, Huang X, Yang W, Zeng Q. Platelets and High-Altitude Exposure: a Meta-Analysis. High Altitude Medicine & Biology. 2022; 23: 43–56.

[86] Ke JB, Li JB, Zhang JH, Bian SZ, Yang J, Liu C, et al. Influence of acute high altitude exposure and short-term acclimation on platelet-associated parameters in healthy young man. Medical Journal of Chinese People’s Liberation Army. 2018; 43: 251–256.

[87] Wang J, Jen CJ, Chen H. Effects of Exercise Training and Decon-ditioning on Platelet Function in Men. Arteriosclerosis, Throm-bosis, and Vascular Biology. 1995; 15: 1668–1674.

[88] Wang JS, Jen CJ, Chen HI. Effects of chronic exercise and de-conditioning on platelet function in women. Journal of Applied Physiology. 1997; 83: 2080–2085.

[89] Wang JS, Jen CJ, Kung HC, Lin LJ, Hsiue TR, Chen HI. Dif-ferent effects of strenuous exercise and moderate exercise on platelet function in men. Circulation. 1994; 90: 2877–2885.