225: Is There a Benefit to Altitude Training? - with Dr. Peter Hackett and Jon Jonis

[Music] Hello and welcome to Fast Talk, your source for the science of endurance performance. I'm your host Rob Pickles, here with Trevor Conner. Perhaps nothing in endurance sports carries the sort of mystique that altitude camps have. It's a marker of the seriousness with which we take our training when we go to altitude for a few weeks, build up that natural EPO, and return home to crush our friends and rivals. But, is it really that simple? Do we see those mythical gains promised us from time in the high mountains? The answer is a definitive no. Followed by a maybe, followed by a clear yes if you do it right. The truth is that there are responders and non-responders to altitude. To take it a step further, many adaptations to altitude take time, take very high altitudes, and not all of those adaptations are positive. Doing an altitude camp right takes careful planning and monitoring. Here to help us navigate through the many landmines of altitude training is one of the top experts on the subject, Dr. Peter Hackett, who is the director of the Institute for Altitude Medicine. Dr. Hackett has spent decades researching altitude in the Himalayas, Denali, South America, and Colorado. Joining him is John Jonas, the founder of Mount Air Cardio, here in Boulder, a company that is trying to help athletes get the benefit of hypoxic exposure without having to deal with the negative consequences of training at high altitude. Along with our two experts, we'll hear from a host of coaches, athletes, and physiologists, including two top coaches, Turk Freel, who's the founder of Training Peaks and Tim Kusik, who developed the WKO+ training software. Jim Miller, the head of high performance at USA Cycling, will talk about running altitude training camps. Paisen McElvin, host of the popular Adventure/Stash podcast, will talk about living at altitude as an athlete. Dr. Robert Kennefick, senior vice president of research and development at intrinsic health solutions, will share his thoughts on supplemental oxygen. And finally, Dr. Andy Pruitt, Colby Pierce, and Todd Carver, will discuss the downsides of training at altitude. So, dial up your altitude tends to 11, and let's make you fast. For many of us in North America, the road racing season is winding down. You can test your end of season fitness with fast talk labs, just schedule an inside advance test with us. Your inside test results will reveal your VO2 max, up to date training zones, anaerobic threshold, carb max, fat max, VLA max, then it'll suggest a path forward for better training and fitness. Learn more at fasttalklabs.com. Well, welcome everybody to the show. I'm actually really excited about this one because altitude was something that I was always interested in when I was actually studying exercise science at CSU. I took every opportunity I could to get involved in studies on it, to write paper on it, which means I probably know about 100th of what the two of you know, but it's an exciting subject. And I, we haven't covered it yet in the show, so I'm really going to be interested in going into how does altitude affect you, whether training at altitude has benefits or not. Because I think a lot of people involved in endurance sports think, "Oh, I'm going to go out to altitude." I'll get to spike that EPO and I'm going to come back and crush everybody. And my guess is, as we go through this conversation, it's not so black and white, it's not so clear cut. So I think it's going to be an interesting conversation and I hope both of you are looking forward to this. Yeah, Trevor, I'm really interested in, you know, in we're focusing today on how altitude affects training itself, right? And I think it's really important that we are focusing on more of that narrow sort of track so that we can understand with a little bit more depth exactly what's happening physiologically within the body. You know, I think everybody should listen. Maybe we'll follow this up at some point in the future with a, how does it affect performance, right? Which is a totally different topic, you know, the decrement in performance in VO2 max. In the acute sense, when you say, "Come up to Boulder to do an Iron Man up here," you know, when you otherwise live at sea level. So why don't we start instead of going into right away the physiology of what happens when you go to altitude? I want to answer that big question, is it always beneficial? Is it always a positive thing? Are you going to see gains if you go and sign up for that big altitude camp? Yes, sir, is it always positive? No. Next question. So this could be a really short pause tonight. So it's a very simple topic and we're done. That was another episode of Fast Talk. The whole idea of altitude training is to strike a balance between the beneficial effects of a climatization and the effects that aren't so good. And you want to come out predominantly with the beneficial effects. So that requires some planning and some smarts, but it can be accomplished, you know, for a lot of people. But then there's also this issue of some people just don't respond in terms of performance. Now, when we say responders and non-responders, you can talk about performance, which is what coaches and athletes want to know about, or you can talk about the change in human global mass as a responder or non-responder. But there is certainly related, but I think for cyclists and athletes, it's about performance. So, you know, there are some people that don't get any benefit. And there are those that do get a benefit. And there's quite a search going on right now to nail down what the mechanism is that differentiates the responders and the non-responders. And it's not solid yet, but clearly the hiff pathway, the hypoxia inducible factor pathway, which is what's responsible for the EPO effect that rise in EPO and the rising human global mass is the key factor. And there has to be genetic polymorphisms that explain why some people respond and others don't. In other words, it's most likely in your genes, although there can be external factors as well. But that search continues a paper by Ben Levine and they looked at responders and non-responders in a large population of subjects they had studied over the years. But this was about 10 years ago before it was really advanced methodology and snip testing and whole genome sequencing, looking at these specific areas. And they did find a mutation that was associated with non-responders, but it wasn't very robust. In other words, it didn't have any kind of predictive value. And it was in the hiff pathway. But I think that's where the money is and the science just isn't quite there yet to figure out the genetic basis of responders versus non-responders. Whether you're a responder or not a responder is just one of the factors you have to consider when going to altitude. Here, Dirk Ferel describes several of the other factors that make going to altitude tricky. It's tricky to do it right and to come out of it in a positive way. There's many ways you can mess it up. And if you go in to altitude and you push too hard, too many days, you just come out of it in a state that you can't really come back from in the right amount of time. So I mean, to do it properly, you're going in with blood work, where's your blood work before you even get to altitude? You know, tracking hemoglobin in what mass I think is what it was. Tracking that throughout your stay and seeing how your body is adapting and adjusts from there. So certainly it can help. There's plenty of examples of where it's done all the time, you know, but there's many more examples probably where it didn't help people just because they pushed it too hard. So it's an area of caution. If you go to altitude, you know, I tend to think like really you need to hold back more than what you think you can do and kind of just let altitude kind of take care of itself, but don't expect to do really high quality training at altitude and don't but then that can't affect your mental state too much either. So you know, yes, you could be of great benefit, but it's tricky to manage. Is there a way to know ahead of time if somebody is going to be a responder or a non-responder before somebody goes through or do they just have to try the camp, try altitude and see what happens? Yeah, the answer is not yet. There's no way yet. If we can nail down the polymorphism that is responsible for this, like if it's E-PASS 1, for example, or EGLN, one of the genes that codes for the hip pathway, I'm sure that's what it's we're going to find, but no, that's eventually what it might take. As soon enough, it'll be on 23 and me. And I love those said, we'll hit you with the physiology later. We'll start with the big picture. Yeah, I can't wait to see what we're going to talk about later if we're not in the physiology yet, but I'm glad you brought that up because something we're going to talk a lot about is this HIF1 alpha, the hypoxia inducible factor, which seems to be the master regulator. And as you pointed out, there's different polymorphisms. It seems to have different impacts on different people. So before we start to really dive into that, something I wanted to bring up, again, that gross overview is it seems like the research is really mixed. Some studies show big benefits, some studies show no benefits, and it's hard to kind of chase this down. And as some of that, because of this huge individual variation, variability and who they get into their studies that they might just get responders, they might get more non-responders. And as a result, you're going to get different study results. Well, certainly that's a factor. No question about it. But then there's also the dose of hypoxia or the dose of altitude and the duration. And don't forget that there's pretty good consensus that there's no benefit of training at altitude for C-11 performance. If you can't include low altitude training that is intense training as part of that program. But the ones that really show the benefit and remarkable benefit are the ones that combine living at a high altitude and then intensive training at low altitude, at least three times a week during that training camp at altitude. Yeah. And to clarify that point, right, there's kind of three different scenarios that we can have. But live low and they train low. We can have people that live high and train high. Older is kind of moderate, but I'll throw us in that category. But then there is also kind of what a lot of the positive research has been around, which is living high and training low. And oftentimes, you know, a way to do that is to say to live in Park City, Utah, kind of at a high elevation in the mountains and then drive back down to Salt Lake, which is, if I remember, I kind of just underneath sort of the threshold to be considered low. And really being purposeful about your living situation. Another way to do it right is to not necessarily move your physical location, but then you can also change your living quarters at home, right? And this is where things like altitude tends to come in and then you can be sleeping sort of overnight in a hypoxic environment. So there's sort of multiple ways for people to achieve this live high train low, but it definitely seems to be the clearest. You know, us people living at altitude all the time, maybe we're not getting the benefits for seal of a performance or at least not all of them. There's a number of ways to do it. So if you agree that what seems to be the most effective paradigm is sleep high and train low, that is live high and train low, then you, as you pointed out, you know, the classic studies of the Venus Ray Gunterson, where Park City and Salt Lake. So you can do that. You can do that between mammoth and bishops, for example, but it's hard like in Western Colorado here, you can't do that very well because you can't get down below 5,000 feet very easily. To get any effect, you have to be between 2,000 to 2,500 meters. So that's 6,600 and 8,000 feet to trigger the Epo response. However, if those altitudes, your VO2 max is impaired, acutely your submax endurance is impaired and you get a detraining effect that has to be counteracted with intensive training in a greater oxygen environment. So you can either move to a lower altitude to do that training, you know, during the week or whatever. Or you can do it like the US Olympic Training Center in Colorado Springs and you can actually give oxygen, which is the same as going down a lower altitude and that will tremendously increase your training intensity while you're living at high altitude. That's another approach. So that really brings us to what I was hoping to talk about next because we'll dive deeper into the different training methods later on. What is the minimum in terms of both the altitude and the length of time you need to be at altitude in order to see an effect? And I think a lot of people are going to be surprised by this because you just talked about I think you said 6,800 feet. And for example, a lot of people kind of boulder going, "Well, I'm going to go and get all that altitude training." Well, boulder is only at 5,400 feet. Yeah, I think the data are pretty clear, 2,000 meters. That's 6,600 feet. Would be the minimum and 2,500 meters is considered kind of the maximum for being able to live at altitude comfortably without some of the detrimental effects. And the duration, the classic study show four weeks, ideal. Four weeks is better than three weeks and three weeks is better than two weeks and less than two weeks doesn't do much at all. So I think people, if you're going to consider a two to three week camp, you want to go for the three week training camp rather than the two week. And I'm not saying this is all 100% consensus, but this is my take on the literature and talking to experts. So that's duration. So why can't you go to 5,500 meters, like 18,000 feet for a few days and get the same effect? If it's the altitude stimulus or hypoxic stimulus times time, you would think if you went a lot higher for a shorter time, it'd be just as good. The problem is that to get a beneficial effect. You have to have a sustained, equal response. You cannot run up to 6,000 meters, get a huge, equal response and come back down because as soon as you come back down, there's a very strong off response. And you have to have be able to maintain a high, equal level. Clearly the studies showed one big difference between the responders and non responders at two weeks into the altitude training camp. The responders all had 20 times the normal Epo level at sea level and the non responders had not. It had turned off or it was turning off and on. You know, they didn't follow it every single day, but it was not sustained. So you need a sustained response of Epo. And how many hours a day does it take? Well, clearly, there's been a lot of studies now looking at one hour a day, four hours a day, six hours a day, and none of them work. What I call the classic study showed you have to have a minimum of eight hours a day. And ideally, 16 hours a day, really, to get the beneficial effect. So that means not just sleeping at altitude, but living at altitude and then going down to low altitude to train or putting on an oxygen system to train. As a national team coach, Jim Miller has a lot of experience with the commitment it takes to get benefits out of an altitude camp. Let's hear his thoughts, including alternate ways to get the same gains. I think it helps most athletes. I can only think of through the years only one, maybe two athletes that don't respond super well at altitude. So I think in general, I'm a huge fan of it. I build it into everybody's training program, but for this one athlete, I didn't. And he could come to, he could come to altitude. He could race, provided wasn't five, seven day stage race. But if he brought the altitude, he didn't have great adaptations and his training, typically it was just, it's just volume and everything for him, it didn't work. So what do you find are the benefits of training at altitude? What, what effects do you see it having on your athletes? Everything, you know, I mean, I mean, this is not a secret. It's red blood cells. It's oxygen carrying capacity. If you have a little bit of heat, then you get some, some plasma expansion, which is also nice. Anything less than seven days is waste of time. And then up to 21 days, up to three weeks, I think is ideal. If you can do three weeks and you have the means to do that and then the time and everything works out that you can do with that's my preference. If it's a quick hit, you just don't get that much out of it. I've actually used heat stress training. In some cases, I think as effectively as I do training in terms of red blood cell increase, hemoglobin, hematocritic, etc. And how do you do heat training with your athletes? I do it at the end of training sessions. So it's for the first week, we'll do primarily just volume. And then they come, when they come in from training, they immediately go into a sauna, initially starts with 10 minutes. And then we build up to 20 minutes. But over the first week, we do it every day and you just add two minutes each day. The last hour of the ride, you don't hydrate in the sauna, you don't hydrate. But then when you get out, you hydrate like crazy. And then once you've built up to the 20 minutes, 22 minutes, then it's just every other day as a maintenance. But if you take blood draws during the course of that, you can see the evolution of those profiles. Like a year ago, Joe Dombrovsky is one of these guys who doesn't acclimate great altitude. He wasn't the guy who was in particular speaking up. But we tried it last year with Joe. Out to didn't really see any benefits. He didn't raise better. He didn't produce more power. He was just isolated and mountain by himself. And that's what came out of it. So before the G-Rod, then we just did heat stress training. And he had bumps in red blood cells. He had bumps in a man of crib. He had good plasma expansion. And I think it actually worked better for him than altitude would. And he actually wrote really well, right? I mean, he was 12th at the G-Rod. He had a shot at top 10. He was more of a tactical air that he wasn't top 10 than it was his capacitor, fitness, as brutal. And he had a lot of fatigue that it generates and not just fatigue like we're thinking of, oh my god, I'm tired. But that autonomic stress is huge. It's a few track HRV, resting heart rate, et cetera, et cetera. You'll see everything kank. So it is a big stress on the body. And we do it at those moderate altitude. So again, we're talking that over 2,000 meters. The length of time that you need exposure is actually quite long. So I'm actually looking at a study that was led by Dr. Brothers. And this was a study conducted not too far away from here at the US Air Force Base at about 2,200 meters. And it took over seven months to see an acclimation. So this isn't, even at that altitude, if you go there and go, I'm going to do a one week training camp and get all these gains. Well, no, you're not. Sorry. You know, what's interesting though is I think that listeners are saying, hey, you know what, I took a vacation in Breckenridge last year. And man, I felt terrible on the first day. But once I was three or four days in, I was starting to feel a lot better. I must have been acclimatizing to altitude. But it doesn't sound like that's the case. What's happening in that situation when we're just talking about the first three or four days that somebody has gotten to altitude? That process is called a climatization. And when we were talking about the Epo response, which is different than a climatization. So the anecdote you relate is entirely true. People go to Breckenridge and day one is the worst. The first night is often pretty bad. And where they get up there late in the day and then they sleep the next morning, they'll have mountain sickness. And then it takes two or three days to pass. That process is called a climatization to altitude. But it's a little different than what we're talking about. And that has nothing to do with the increase in Epo or red cells. That has to do with the increase in ventilation, which eventually raises the oxygen saturation over the course of two to three days. So the moment you arrive in Breckenridge, your oxygen saturation might be 88, 87, 89%. The next day, it'll be 90%. The day after that will be 92%, and then maybe 93, 94, that's about as high as you can get at that altitude. And that has to do with a reset of your peripheral and central chemoreceptors so that the peripheral chemoreceptors are jacked up and you start breathing more. And the central chemoreceptors allow the CO2 to drop without causing apnea so that your carbon dioxide level at Breckenridge after four or five days is going to be your CO2 content would be maybe 33 instead of 40, like it would be a sea level. And that's because you're breathing so much more. But the Epo response, people confuse us all the time. They think that, oh, if I'm a climatizing altitude because I went out of trekked in a pile, because my increase in red blood cells, no, it takes weeks for an increase in red blood cells to cause an increase in red cell mass. As you all know, most of our listeners will know, that doesn't happen in a few days. What does happen is that you lose plasma volume in the first 24 hours to 48 hours at altitude. And as a result, your hemoglobin concentration is higher. So actually, your hemoglobin level is higher, but it's not because of new red cells, it's because you're physiologically dehydrated. So we're diving into the physiology here. And yeah, I think this is a really important thing to point out. And a little bit of research that I was involved in with altitude and what I read, this was probably the thing that surprised me the most, which is that short term adaptation. And you just mentioned some of it, but the best summary I ever heard of it is your body's immediate adaptation is actually making a little bit more of an anaerobic animal. So that you can handle anaerobic metabolism. You can handle acid production better than you normally do when you're at sea level. And actually, in the short run, some of those aerobic adaptations get brought down. So something else that happens in a relatively short period of time is you might see a bit of a decrease in mitochondrial function or mitochondrial mass. Because if you're not handling the aerobic side very well, well, mitochondria produce a lot of reactive oxygen species, which are damaging to your body. So if you come up to altitude and your body's not good at handling, it goes, I don't want all this Ross produced. So I'm going to bring that down and actually rely a little more on anaerobic metabolism. So it's actually the exact opposite of what you think. Trevor, can I ask you a follow-up to that? Was there an altitude component in there? I know that as high altitude mountaineers, right, they tend to have very high anaerobic sort of energy contribution to exercise as opposed to aerobic. And so I'm wondering, is that happening at this 5,500, 5,600 feet, 2,000 meters? Or are we talking, you know, kind of when we're in the Himalayas and where at many thousands of meters at that point? I get a bit too. I always struggled with this because when we were talking about altitude and studying it, I think, well, boulder for Collins because I'm a cyclist. That's where I train. But normally when people are talking about altitude and Dr. Hackett, you could talk to us better than I can, but frankly, boulders not even considered practically moderate altitude. Exactly. When you're talking high altitude training, you're up over 10,000 feet well over. Yeah. I mean, everybody in the mountain medicine community and high altitude community uses 2,500 meters or 8,000 feet as the definition of high altitude. But from an athletic point of view, I mean, you all know that Biotumac starts to drop at a lower altitude than that. It's here for Pace and Mechelvin who lives at high altitude and here is his experience of whether he finds it beneficial for training. If you're a professional world cup racer, I think living at altitude is a negative. If you are a marathon racer, I think it's a positive. That said, I still do sea level training camps for sure. And I know that I can't be at my best or my fittest and less. I do some sea level training camps. You can just handle more training load. You can put your muscles through more. It just creates different physiological adaptations. So I think the Holy Grail is both if you're doing the Leadville 100 and you're really trying to cross all your teeth and dot all your eyes. You absolutely need time at elevation. If you're getting ready for the sea otter classic or the Iceman come with something like that, I don't think an elevation training camp is going to help you that much. So why do we go into the basic adaptations of what happens when you're exposed to altitude? So for example, if you went to a training camp at a thousand feet, how does your body respond? What are the major adaptations that we see? And is it set science on what the impact is and how our bodies respond? Dr. Hackett, would you like to take this first? So I'm glad you used the words both adaptations and how our body responds because they're like two different things. Just think of adaptations as useful, but the way our body responds at altitude is not always useful and positive. So there's the hematologic adaptation, which is within two hours of going to high altitude, the kidney senses the drop in partial pressure of oxygen in the blood and stimulates the release of a hormone called Irithropoetin or EPO, which then acts on the bone marrow and a few other places to produce red blood cells. The blood cells take a few days to produce and it takes a few weeks to actually get an appreciable increase in what we call red cell mass or hemoglobin mass, hemoglobin being the molecule in the red cell that's so important for carrying the oxygen. So the hematologic response takes time. To have a good hematologic response, you have to have adequate iron stores. It's very important for any athlete considering altitude training to make sure that they have adequate iron stores. This is particularly true of women, but men athletes as well, serum ferrored and should be 50 or higher to get beneficial effects of the EPO stimulation. And then secondly, not all beings are created equal and genetically speaking and some are going to have a good EPO response and some aren't. But on average, there is an increase in EPO and an increase in red cell mass and an hemoglobin mass. In other areas, there's a change in cerebral blood flow, which is responsible for the headache that people get when they first go up. And after four or five days at altitude, that returns back towards normal. That cerebral vasodilation is associated with mountain sickness and its resolution is associated with getting over mountain sickness, although the cause in effect is entirely clear. There's a cardiovascular adjustment. There's an increase in resting heart rate and an increase in basal metabolic rate so that heart rate at 8,000 feet will be slightly elevated over sea level at rest. And with exercise, it'll be elevated even more. And cardiac output is slightly diminished despite the increased heart rate. And that is because of the decrease in plasma volume. Plasma volume changes are finally starting to get the attention they deserve. And altitude studies. For example, there's this big argument about who's better adapted high altitude to the Tibetans or the Ketua in South America. And it turns out they both may have some hemoglobin masses, but their plasma volume regulation is different. And so they have different hemoglobin concentrations. So to be clear, you go to wrecking ridge or 8,000 feet to say you go to Dylan. And you may or may not notice an increase in urination. But there's a fluid shift within your body from the extroversicular space so that plasma volume goes down. In essence, your body is dehydrating. And it doesn't matter how much you drink to overcome that because it's a reset of the Osmo Center of the brain. And the more water you drink, the more you're going to pee after a certain point. And I've been trying for 45 years to figure out why the body would do that at high altitude. And the only thing I can come up with is that when you have lower plasma volume, you do have more oxygen carrying capacity because for every 100 ml of blood, you've got more red cells in there than you would without the loss of plasma volume. So if plasma volume goes down, then by definition, the percentage of red cells goes up. But it's not because there's new red cells. It's because there's less plasma. So that's an important adaptation. And that doesn't really change over a period of time. Your plasma volume will always be lower at high altitude until you get maybe get an increase in total blood volume, which can take months. And then of course, there's the changes in muscle, which is not my specialty. But unless you're doing high velocity training, high intensity training at a lower altitude in between, you develop muscle atrophy at altitude. You get a detraining effect. muscle fibers are thinner. As a result, capillary density and mitochondrial density look higher, but it could be artificial only because the muscle fibers are thinner. There's debate about that. There's a change in metabolism that George Brooks can tell you all about. And there's changes in anaerobic capacity. There's also an increase in oxidative enzymes. So, you know, there's metabolic changes that take place that I'm not the best one to speak about that. As Dr. Hackett explained, not all of our changes are beneficial. Let's hear from Dr. Andy Pruitt, Colby Pierce, and Todd Carver as they discuss the downsides of altitude training. I don't believe it's always beneficial. It depends on the context of the athlete, what their goals are. Who's the athlete, how they're presenting and what are the demands of their event? What do you gain when you go to altitude, baseline aerobic conditioning, most likely, assuming the adaptation curve is dealt with and you recover properly. And you hydro-properly, and you're eating enough probably red meat to offset the impact on blood chemistry. So, you're up regulating aerobic capacity, we'll say, or maybe we'll say a aerobic metabolic conditioning. That would be our baseline expectation for going to altitude. But there's several ways that can go afoul. And if you're a rider who, who, you know, I'll disagree with Coggin here for a minute, he'll like to say, it's an aerobic sport, dammit. And that's so easy to emphasize that aspect of conditioning. And I think that's a default the way a lot of people think. But the reality is there are a lot of bichresses that are highly neuromuscular or biomechanical or torque oriented in their demands. And so, if you're training for an event that has a big torque demand and also, if you go to altitude camp and you're already a rider who is, we'll say, you're not expressing a high ability to deliver a lot of glycolytic power, then you're just going to make your strength stronger, but it's going to get you further from the goal you're trying to achieve. So, practical example for American riders, if you're training for Joe Martin and you're already a climber who's lacking a lot of explosive power and you went, did three altitude camps all summer to get ready for Joe Martin in the hypothetical fall scenario where it's in COVID year. You might do really well be one of the strongest riders, but never be able to express a good placing because those races are so explosive. Right? That's a good, hopefully that's a practical example that people can figure out. It's a four-day stageer, so a lot of poppy hills. So, for those of you who aren't familiar with it. I mean, I don't know if you, that room, but when Chris Carmichael was the national team coach, they would go to Winner Park for their altitude camps, but he also had trucked in huge tanks of oxygen. So, they would do an endurance ride or altitude and then they would do their intervals with O2 self-pimentation. So, it's like they were doing altitude endurance and then their quality at sea level or below. So, they could do the huge amounts of work because they were self-pimenting their oxygen. So, that's the best case scenario. That's a great idea. That's a great idea. That's a semi-load of oxygen tanks to self-pimenture. Sure, everyone has access to that. Sure, sure, sure. But now, the point was that you have to have that balance. Yeah. You should train it altitude if you're going to race it altitude. Right? The adaptation to our specific, totally. I think, Colby's saying, if you're going to race in the Midwest at Joe Martin or something, it's like, do you really need altitude training? It might help you it might not. Yeah, it depends on your content. Yeah, if you're training for Mount Evans Hill climber, I can speak. Yeah. And you should probably train it altitude regardless of who you are if that's your goal. That's right. So, some of the data would actually contradict the altitude training for sea level performance. No. altitude training makes you slow. If you don't do something about the counteract. Hi, everyone. This is Coach Conner. FASTAG Labs just released a newest module from the Craft of Coaching with Joe Frale, which we're really excited about here at FASTAG Labs. We all know that it takes plenty of analysis, critical thinking, and decision-making to create performance. Joe Frale unpacks the complexity of this topic with a guide to the common training metrics and tools for the data analysis. We'll learn more about balancing training load over a season, how to get athletes race ready, and best practices for post-race analysis. Here from Pros, to master coaches, Ben Day of Day-to-Day coaching, who talks about how to best measure and cultivate performance. And Julie Gibbons, who describes how to help your athletes grow from failure and disappointment. If you are a results driven, this module is not to be missed. Contact us to learn more at FASTAG Labs.com. Let's now dive into that more practical side. So, we have an athlete who's decided to do a couple of week training camp at altitude. Let's talk about how to get the most out of that. Dr. Hackett, I know you wanted to talk about sleep, which can be a big factor in something that a lot of people don't think about when they're going to altitude. Absolutely. And the first thing I would advise the athletes to do is try to extend the camp to three weeks instead of two weeks. But not an adaptation, but a response of the body when they go to high altitude is trouble with sleep. And this has been identified and studied for many decades. There appears to be a direct effect of hypoxia at his low oxygen levels on sleep centers of the brain. That's all it seems to be. I mean, direct effect of hypoxia. So that sleep is a little more superficial. It's a little more interrupted. Subjectively, people feel like I can get a good night's rest even though physiologically you can actually measure their total sleep time might be okay. But to sleep, architecture does change a bit between the stages and between REM sleep. Starting probably at about 8,000 feet, although some people are more sensitive than others. And it generally improves with a climatization, but sometimes it doesn't. And people can have terrible nights sleep for years. I can tell you right where I practice medicine. It's at Mountain Village is 9,500 feet. I have clients there that have what's called sleep periodic breathing, which wakes them up during the night all the time. I mean, for years. And this periodic breathing is worth mentioning because it's a physiologic problem that can be very frightening, but it's not really dangerous. And what happens is that during the night, after going to sleep, a strange respiratory pattern takes over where there's big breaths, four or five big breaths followed by a period of apnea for six to 12 seconds with no breathing at all. And then the body senses that your blood oxygen level has dropped. Your crowded body does a little kind of a gland in your crowded artery that senses oxygen. And it senses the signal of the brain to take a breath. And that next breath can be a big one. And it can often wake a person up with a feeling of suffocation. And then you take four or five big breaths. And then you stop breathing again because you've dropped your CO2 too low. So the bottom line is that's only one reason for why you might might not sleep well at high altitude. And the other has to do with these direct effects on sleep architecture. But some people have trouble falling asleep. Some people have trouble staying asleep and wake up. And it can impair recovery. It can interfere with recovery and it can interfere with general sense of well-being. So one of the problems with altitude tense, for example, if you're preparing for a boundary and ex-position, if you go up a little too quickly, like 8,000, 10,000, 12,000, 14,000, your sleep will start to become a problem. And then your recovery time can suffer as well or your recovery process. So that's kind of the bottom line of sleep. How can you improve it for somebody going to an altitude camp? You just want to be aware it can be a problem. You want to make sure you get a good night's sleep, no caffeine after 4 p.m. and good sleep hygiene as we call it, not being on your screen for an hour before going to bed. That sort of thing that people know about. And so that brings up the question of recovery. And John, I know you wanted to discuss heart rate variability and the impact of altitude on that. Yeah. Yeah. It's just such a common metric that most athletes are tracking these days with either an aura of rain or a whoop band. One of the things that we encourage people to do is this is a lot easier to do with simulated altitude than real altitude is to go up very, very slowly. And for an athlete who's training really hard and their and their body's already in a stress state, we only have them go up 500 feet per night even. And some of the metrics that they can look at when they're during this ascent phase is heart rate variability, REM sleep and deep sleep. And oftentimes if any of those three metrics start to drop, then you've gone too high too fast and you need to let your body catch up. And one thing that's a little bit counterintuitive with like the live high train low as it relates to recovery is that you initially see your heart rate variability go down as you as you go to altitude. As you acclimatize, it will come back up. But then if you're living low, you're now sort of in this super saturated oxygen state during the day. And so recovery scores actually improve compared to if you were living low, training low. So we see sort of across the board with all of our athletes that the recovery scores initially they drop because their physiology has not caught up with them yet. But then after you know, say like four weeks of being at altitude and training low and living low, their recovery scores are actually improved compared to baseline. And do you feel that's legitimate or is it overestimating their recovery because of that effect? I mean, it's just as measured by whatever device they're wearing. So we've definitely identified some difficulties with going up to altitude. We've said, "Hey, it's not always positive." We've said that you need to balance the adaptation from the deleterious effects, and we know that now going to altitude is going to affect recovery and sleepability. How do we design an altitude camp that is the most likely to get these positive adaptations without causing anything negative? How do we design something that an athlete can use to improve their performance in subsequent events after that? Dr. Hackett, you had mentioned three weeks. Yeah, there's two components here. One is designing the right program for the person. The second is, whatever the program is, maximizing your chances that you're going to benefit from it. So for example, I think the first thing you need to tell athletes is that altitude training is not magic. I agree. What's the idea of that? But altitude training isn't? The second thing is that in terms of narrow response to your question, I think you want to shoot for ideally three to four weeks, but even two weeks would be minimum. In terms of the dose, you want to be ideally around 8,000 feet, and you want to incorporate lower altitude, intensive interval training, or intensive training into that program. So that's the basics of the program. You also want to pay good attention to nutrition. And you want to maximize your sea level training first. I mean, if you really want to get the benefit of high altitude training, it's not for the weekend warrior that is not part of a training program. And he's going to go to high altitude to do, this is for people that are serious about their training, to take out the time and money and time away from work, or maybe they're working remotely. It's not an issue, time away from spouse, which may be an advantage, I don't know. But you want to maximize your sea level training first. So you want a good solid base of training, you want your nutrition to be in place, you want to know where you are, your training cycle, and incorporate the altitude into that. And you want to come up with a comfortable place to train. You don't want to be sleeping in a chicken coop at 8,000 feet and some friends backyard. I mean, you want to be comfortable, you want to eat right, you want good sleeping space, you want to hydrate, etc. So I think those are the basics. And then if you're also serious about it, you might check your serum ferritin and make sure that we generally recommend 50, a level of 50 or higher, make sure you got adequate iron. If you don't, you want to get your ironed up to normal levels before you go on the altitude you can. And you also want to be careful. There's other things that will block the EPO response. For example, infections. And one of the studies Levine did, the guy that actually had a drop in EPO on a central altitude was the only one that had a respiratory infection. And he didn't make a study out of it. But anecdotal experience suggests that any kind of cold influenza or infectious problem, oh, actually, you know what? He had a subject that had a dental infection and had a negative EPO response on a central altitude. And then when you went back without the infection, he had a normal EPO response. So in terms of maximizing the benefit of a training program, you want to make sure that you don't have any current medical problems, even simple things like a tooth infection, a skin infection, a sore throat, any kind of infection turns on an inflammatory cascade that can actually bunch your EPO response. So you want to be good health. You want an aware you are in your training program. You want to have a comfortable place. And you want to avoid overtraining. It's very easy to overtrain with altitude training, especially when you come down to a low altitude to do high intensity or put on an oxygen mask to do a high intensity. You want to make sure you don't train hard during your recovery time. And I think if somebody is serious about a competition, a big competition coming up and they want to do an altitude training program, I mean, don't make this your first altitude training experience. You should try to get one under your belt first before you train for the competition of your life, to make sure that you understand how it works, whether it's going to work for you. And I like this term competitive acclimatization. I forget who came up with that. One of the authors in the exercise science, which is the concept that it's a learning process. A climatization to altitude, like in mountaineers, they always say, oh, yeah, my body remembers how to climb to it. Your body does not remember how to acclimatize. You remember how to improve your climatization. You learn the right rate of ascent for going up to altitude. You learn what to eat and what to drink, what to avoid. You learn to stay healthy, not get diarrhea and the ball. Same thing with an altitude training camp. You learn what works for you. You learn how to sleep well. You learn what foods you might like. You learn what climates you might like, what temperatures you like to ride at, whatever. There's a learning process that allows you to maximize the experience if that makes sense. Dim Kusik has a lot of experience running altitude camps for his athletes. Let's hear his thoughts on how to maximize one of those camps. So the first question is, is the athlete an adapter to altitude training? So the reality is you need to know that before you spend a fair amount of time. For me, the main measurement, you need to do some, I mean, and again, I work with professional athletes. So they have access to things that the average person might not have, but still have to explain it this way. Himoglobin testing probably is the best answer. A lot of focus on hematocrit, but hemoglobin will probably give you some better insight into their adaptability to altitude. If we know they're adaptable to altitude, the second thing is diet and they're nutrient. They need to have a certain amount of iron in them before they go to altitude training. I see this mistake all the time. People aren't ready. They're nutrient content. They don't have enough iron in their body. I have a number I look for. I'm sure others have their own. If my athlete is below that, I would delay altitude training till they get above it. If they're an adapter and if their body is ready for altitude training, altitude training can have a benefit, but it's touching. Meaning, the hardest thing about going to altitude and altitude training is you are introducing a lot of overall stress to the system. You have to be there long enough to actually not only acclimatize, but to adapt to that overall stress, be able to train in that overall stress, and then adapt. I see a lot of people go through altitude training too short. They might have some blood markers. They might know their athletes and adaptor. They might even figure out the iron and the nutrients and the blood. Make sure that's all right. But then they go to altitude training for seven to ten days. So altitude training takes longer than most people think to really make it a measurable effect in adaptation. And then unfortunately, it doesn't last all that long. So one of the key things that you have to do is time your training really well at altitude. When you get out of altitude, what you do with all that, enhanced performance is super important, whether it's race and sometimes it is race and sometimes it's train. And people who figure out how to use altitude camps as then training boosters, not necessarily, you know, I'm doing an altitude camp, but I'm not going to a race right after. You're going to altitude camp and then you're doing some super training post altitude camp. We go back down to sea level. We have extra watts to spare. You train at those extra watts. You take advantage of that while you have it to do some really super strong training. Those two methods work well, meaning one method one, you do altitude training. Come down with your body. Adapt to sea level for a little bit. Race or come down with your body. Adapt to sea level for a day or two and train really hard for a short walk. Those two combinations can all work well. But you got to do those things right. You got to know the athletes and adaptor. You got to have the body set up to adapt to altitude. You got to be there long enough to actually have the adaptation and then how you leverage the post altitude timeframe, which probably is 14 days, 17 days, that's super important. I think you raised a really important thing earlier on, which is this is something you do after you've already maximized your training. This is truly marginal gains. I mean, I'm looking at the results of one study looking at a three week training camp and said they saw an average of one to three percent improvements. That's a huge improvement for an elite athlete. It is, but I think that listeners need to understand it. Comes at a great cost of relocating, which is a physical, a monetary, an emotional, a relationship cost and everything else. We can see one to three percent improvement by maximizing other aspects of training that might not. But for the elite athlete who is doing everything right, then yes, this one to three percent can be really important and they're the ones that can maybe afford this. The other side too is maybe it's worthwhile. Is it worthwhile for people who are going to train or to compete at altitude? We're talking a lot about sea level performance, but what if somebody's coming up to Leadville 100? Should that person be coming up and taking time out of their life to help themselves? I was wondering if you're going to get around to that. That's an area of great debate about what's the best way to prepare for competing at altitude. There's a good paper by Bob Chapman and Ben Levine in High Altitude Medicine Biology 2013 titled Something Like How to Prepare or When to Arrive and How to Prepare for Performing at Altitude. They review the data. The data from the scientists is a little different than what a lot of the coaches and trainers do. The science suggests that the worst thing you can possibly do is go up to altitude and immediately compete. The second second worst thing you can do is compete in the first 48 hours. And the best thing you can do is compete after three or four days of a climatization because then you're over your mountain sickness. You've had your plasma volume decrease. You're starting to sleep a little better. You know, there's a number of factors, but I know there's coaches out there that say, oh, no, we want to just show up and play, you know, like football, pro football teams, for example. We'll just want to say some of the coaches just want to play immediately on arrival. The science doesn't support that at all. And I don't think the anecdotal experience does either, but, but I still hear that in some circles. Ideally, if you had two weeks, we know that submax endurance increases remarkably at about 10 days, between 10 and 14 days with a climatization to altitude. So ideal scenario would be to arrive for an event 10 to 14 days beforehand. And before you get a detraining effect, so it's tricky. And you want to avoid detraining. You want to maximize your submax endurance improvement at high altitude. I guess the final question to kind of round this out and maybe John, this is more a question for you is what about simulated altitude for those people who can't take three weeks off work and come up here to Colorado and enjoy the mountains. What are the benefits of that? Yeah, I guess, I guess the main benefit is that you can dial in exactly what you want elevation wise. And you can go up, like I mentioned earlier, very, very slowly. So for weekend warriors, you know, we ascend at one to 2000 feet per night, pretty easily, but for the more elite athlete who's training very hard, it's a much slower rate of ascent. And, and you can monitor that and you, you know, you can dial it in and even pause your ascent. So that's really the main benefit other than, you know, not having to displace yourself is that you control your rate of ascent. And a lot of people, they'll go up, say, even like around six, 7,000 feet is where oftentimes you see sleep quality start to dip a little bit. So you just pause there, you know, you wait like two, three nights, then you continue your, your ascent. So yeah, that's, that's really the main benefit there. When utilizing something like an altitude 10 is there a maximal altitude, simulated altitude that begins to have the, the deleterious effects on recovery performance, you know, and you've maximized everything you're going to get on the stimulus side of things like you mentioned six to 7,000 feet, maybe pausing, do you sleep at 10,000? Do you sleep at 20,000? Where do you stop? Yeah, the sky is not the limit, I am sure. Yeah. And and we actually used to like in the old days, say even 10 years ago, many people were trying to really push where they were sleeping at, you know, 14, 16, 18,000 feet. But really once you're over 10,000 or really even 8,000, you're just not getting additional benefit. And you could, you start going the other way because, yeah, start impacting recovery, sleep. Yeah. Your sleep just falls off really quickly once you're above 12,000 feet. And so you're not recovering and, you know, everything suffers at that point. So we always recommend people stay in that eight to 10,000 foot band. It's tough to do, especially with a lot of elite athletes who think, well, I'm super fit and I can take it, but you can't. And so, yeah, eight to 10,000 feet is really sort of that sweet spot where you're triggering all the physiological responses, but you're still able to get the good sleep quality and the good recovery that comes with that. Now, is there still a time component with this? We're talking about altitude camps, you know, three weeks being ideal, two weeks being minimum, maybe even longer than three weeks being ideal. When we talk about the altitude 10 or simulated altitude, we don't have to upend our life at this point. Do you still just go for the three weeks, the four weeks before the event or is this something that should be 12 months out of the year? Well, we have a lot of athletes even just here in Boulder who do sleep at altitude every single night. And when they travel, they take their system with them pretty portable. You can just put it in as checked as checked baggage. You know, they just don't want to lose it. But for the average person, if you're training for a specific event or for a specific track, are you going to Kilimanjaro, wherever you're heading to? Yeah, four to six weeks. That's sort of an ideal amount of time before the event to be sleeping at altitude. I think the listeners need to, you know, they need to have a clear idea of the science in terms of the simulated altitude that they've been shown to be useful for preclimization to high altitude trekking and mountaineering. And people getting ready for a trip like that will often use these hypoxic tents at devices to sleep up to as high as 14 or 16,000 feet in preparation for a concaugur Kilimanjaro, for example, and they can be a useful. There's also really interesting data on weight loss at the use of high, hypoxia to induce weight loss, which is an area of active investigation. In terms of getting an EPO response and increasing red cell mass and improving performance for sea level, there's a lot more studying that needs to be done. The data aren't clear that a nighttime exposure, which would be only eight to 10 hours, maximum is of any use for that particular purpose. I think what has never been studied and I think would be really interesting. And maybe John, you could take this up or get some people to look into this is to do have athlete do an altitude training camp for say three weeks and then come down and use the altitude tent every night and see if that is enough of a stimulus to maintain the consistent EPO response and consistent performance response. The US military tried this one time where they went to Pike speak and acclimatized everybody improved their exercise performance and then they went down to low altitude and they put them in a hypobaric chamber intermittently during the week for a couple weeks to see if they would maintain their acclimatization and they didn't. But they also only used a few hours a few times a week and that's not enough. But it might be that a nighttime exposure would be enough. I mean, I would love to see that study done because then you could really extend the benefits of an altitude training camp. I just want to move that out there desperately looking for it. But there a review that I read last night was a one I'm going to try to pronounce that name PHOS ZCZYCA. But the review of the effect of altitude training on Rithpoliatic. I can never pronounce that response and hematological variables and adult athletes. And they did mention a study in there where they did something similar where they had athletes trained at an altitude training camp and then had daily exposure to altitude attempts. And I can't find it. But I remember them saying that they were able to maintain those adaptations. So I think that would be a great use for the altitude attempt. It was going get your training camp and then come back and make sure because we do match this in the show, but the typical length of those adaptations after you do a training camp, once you come back to sea lover or short, we're talking two weeks. That's right. Two, about two weeks. You should mention that at some point. Finally, we just heard about simulating altitude, but what about going the other way and using supplemental oxygen? Let's hear from Dr. Robert Cannefick on the subject. So that concept of live higher train low became very popular. There's some some counter work out there. Say that might not be the case, but the idea for individuals who are living at altitude because the partial pressure there is lower, the idea is that because of that, they're never really going to be able to exercise or train at the intensity they would if they were at sea level or the partial pressure is going to be greater. And so that idea, everybody knows that you go to altitude, forms, you get a decrement, then that translates to if I'm living in altitude and I'm training, I can't train either at that. You know, a big threshold that I have when I'm at sea level, but I want to be able to maintain or get that high intensity training at altitude. So breathing supplemental oxygen in that circumstance would be a way of doing that of overcoming the idea that you're still at altitude, but you know, your performance may not be degraded because you're overcoming the fact that partial pressure is lower. So I can see in that circumstance why it would be beneficial and why it could be a practice that would help sort of actually getting in a car and driving down to sea level and doing that higher intensity work there. So that leads to a second question, which is do you think for somebody who live in at sea level, there's any benefits I've seen this to training with the supplemental oxygen when they're doing, say, their interval work. Again, you know, for the most part, individuals are almost 100% saturated when they're at sea level. And even though we're doing high intensity work, people might think, well, you know, I'm there's some degree of desaturation that's occurring and I can't saturate fast enough. And that's not, that is not the case. So I wouldn't really have to look at the literature in this area to see whether or not that's a benefit from a physiological point of view and the simple fact that you are almost 100% saturated at sea level. It's possible, you know, pushing that up a tiny bit, which is we might just get a little bit more, but there's not a whole lot of change that you can get there by breathing 100%. percent might give you a tiny bit of edge, but I can see more of a benefit if you're living out to the limit. See level. So both of you are new to the show. We always finish out with our one minute take homes, which is each of you will get one minute to offer what you think is the most important thing for the listeners to take away from the show. So we've got four of us here who would like to go first. John, do you want to, you're going to be a look? Sure. Sure. I would just caution the listeners that not all altitude tents are created equally. The majority of the ones that are available in the market are fully sealed systems. And so you have a big temperature, humidity and CO2 spike when you go into them. So if it's something that you're considering, you know, getting into an altitude tent, make sure you have one that has the sensors inside of it and is continuously ventilated. It makes it cooler, much more comfortable for sleeping. And it allows you to accurately control your altitude, which is really important, especially during that a climatization phase. So just shop carefully when you're in the market for that. Rob, you want to go next? Yeah, you know, for me, it's these debates, you know, Trevor, they always spark a little something in me. Kind of like you said before, when you think of altitude, do you think of Boulder and Fort Collins in these places that we live in, right? And I'm always reminded during these conversations that Boulder as much as we wish it was, we're just not quite there in terms of altitude. And my short forays up into the mountains or a long ride up to the peak to peak is probably not enough, you know, for me to be getting any altitude benefit as much as I wish and fool myself into thinking that it does. So, you know, if somebody is going to do this, then, you know, take time, plan, do it right, follow all of the advice of making sure that your body is in a great place, that you're healthy, that you're maximizing your training, because there is a big cost, you know, to doing an altitude camp. And it's not something that you want to just go about willy nilly and set yourself up for failure. Dr. Beckett, would you like to go next? Well, I think in summary, anybody considering an altitude training camp needs to understand it's not magic, that it needs to be part of an overall training strategy that the person needs to really maximize sea level training first before going up and to try it at least one time if you're considering a major competition. And obviously learn about it quite a bit. I mean, there's a lot of advice out there now, not all of it sound. There are still some areas of debate, but I think it's fairly clear that not everyone is going to respond. And there's right now there's no way to predict who's going to be a responder and who is in. So, taking a three-week camp, which is probably what you need to get the maximum benefit. I mean, you may get no benefit at all. So it's a bit of a crapshoot and a lot of it appears to depend like so many things in life on how well you chose your parents. Fair point, so all of this finished it out by saying kind of echoing what you're saying, which is when I first moved to Colorado, I was so excited about going to what I thought was altitude and all the benefits I was going to get from it. And as it turns out, I am a non-responder. So I've lived here for years and I'm not sure I've seen that much improvement at all at altitude, so I'm still waiting at some point, maybe I'll respond. But I'm one of those people that very limited benefits and what we didn't discuss too much of what a lot of people don't talk about is a lot of the consequences you feel from it. So for me, talking from experience, it's a push if not something that hurts me a little. So it's really important to know this isn't black and white. You're not going to go to altitude and suddenly be a much better athlete, so take it with caution. I think you have the great recommendation of don't try this for the first time right before a key event. Go and experiment and try and find out if you are somebody who responds really well or if you're more like me. Don't be like Trevor. Never. That's the lesson of every episode. All right. Thank you both. It was a pleasure having you on the show. Thank you. It was a pleasure. Thanks for having me. 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