Optimizing athletic performance at very high altitude: A narrative review of preparation strategies,health challenges,and practical solutions for competitions
Restricted accessReview articleFirst published online 2026
Optimizing athletic performance at very high altitude: A narrative review of preparation strategies,health challenges,and practical solutions for competitions
High-altitude environments present unique physiological challenges for athletes, particularly in endurance sports. This review synthesizes the current literature on acute and chronic adaptations to hypobaric hypoxia, which collectively influence aerobic exercise performance during competitions at very high altitude. The benefits of acclimatization for improving endurance performance are offset by risks, including altitude sickness, sleep disorders, and muscle loss, if the acclimatization strategy is not properly planned. We evaluate different strategies, highlighting their efficacy in optimizing performance while mitigating drawbacks. Nutritional interventions and psychological techniques can also affect the maintenance of physical performance at high altitudes. Despite individual variability in adaptation, gradual ascent and pre-acclimatization emerge as best practices for minimizing health risks and performance loss. The review highlights the need for tailored preparation protocols, particularly for competitions at very high altitudes, and identifies gaps in knowledge regarding preparation strategies and health effects. By integrating insights from physiology, nutrition, and psychology, this review aims to offer recommendations to help athletes and coaches navigate the complexities of adequate preparation for high-altitude sports competitions.
GattererHVillafuerteFCUlrichS, et al.Altitude illnesses. Nat Rev Dis Primers2024; 10: 43.
2.
SchobersbergerWLeichtfriedVMueck-WeymannM, et al.Austrian Moderate altitude studies (AMAS): benefits of exposure to moderate altitudes (1,500–2,500m). Sleep Breath2010; 14: 201–207.
3.
BergerMMLuksAM. High altitude. Semin Respir Crit Care Med2023; 44: 681–695.
4.
BurtscherMNiedermeierMBurtscherJ, et al.Preparation for endurance competitions at altitude: physiological, psychological, dietary and coaching aspects. A narrative review. Front Physiol2018; 9: 1504.
5.
RamchandaniRFloricaITZhouZ, et al.Review of athletic guidelines for high-altitude training and acclimatization. High Alt Med Biol2024; 25: 113–121.
6.
BärtschPSaltinB. General introduction to altitude adaptation and mountain sickness. Scand J Med Sci Sports2008; 18: 1–10.
7.
DengLLiuYChenB, et al.Impact of Altitude Training on Athletes’ Aerobic Capacity: A Systematic Review and Meta-Analysis. Life (Basel)2025; 15(2). https://doi.org/10.3390/life15020305
8.
ChapmanRFStickfordJLLevineBD. Altitude training considerations for the winter sport athlete. Exp Physiol2010; 95: 411–421.
9.
MaronBJZipesDP. Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. J Am Coll Cardiol2005; 45: 1318–1321.
10.
PellicciaAFagardRBjørnstadHH, et al.Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the study group of sports cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the European Society of Cardiology. Eur Heart J2005; 26: 1422–1445.
11.
McKinneyJVelgheJFeeJ, et al.Defining athletes and exercisers. Am J Cardiol2019; 123: 532–535.
12.
KoufakisTKarrasSNMustafaOG, et al.The effects of high altitude on glucose homeostasis, metabolic control, and other diabetes-related parameters: from animal studies to real life. High Alt Med Biol2019; 20: 1–11.
13.
PalubiskiLMO’HalloranKDO’NeillJ. Renal physiological adaptation to high altitude: a systematic review. Front Physiol2020; 11: 756.
14.
HooperTMellorA. Cardiovascular physiology at high altitude. J R Army Med Corps2011; 157: 23–28.
15.
SvedenhagJPiehl-AulinKSkogC, et al.Increased left ventricular muscle mass after long-term altitude training in athletes. Acta Physiol Scand1997; 161: 63–70.
16.
BaggishALWolfelEELevineBD. Cardiovascular system. In: SwensonEBartschP (eds) High Altitude. New York, NY: Springer, New York, 2014, pp.103–139.
17.
CogoA. The lung at high altitude. Multidiscip Respir Med2011; 6: 14–15.
18.
PenalozaDArias-StellaJ. The heart and pulmonary circulation at high altitudes: healthy highlanders and chronic mountain sickness. Circulation2007; 115: 1132–1146.
19.
SanTPolatSCingiC, et al.Effects of high altitude on sleep and respiratory system and theirs adaptations. ScientificWorldJournal2013; 2013: 241569.
20.
Lukanova-JakubowskaAPiechotaKGrzywaczT, et al.The Impact of Four High-Altitude Training Camps on the Aerobic Capacity of a Short Track PyeongChang 2018 Olympian: A Case Study. Int J Environ Res Public Health2022; 19, Epub ahead of print 23 March 2022. DOI: 10.3390/ijerph19073814.
21.
ChapmanRF. The individual response to training and competition at altitude. Br J Sports Med2013; 47: i40–i44.
22.
GattererHDünnwaldTTurnerR, et al.Practicing Sport in Cold Environments: Practical Recommendations to Improve Sport Performance and Reduce Negative Health Outcomes. Int J Environ Res Public Health2021; 18, Epub ahead of print 15 September 2021. DOI: 10.3390/ijerph18189700.
23.
SiebenmannCRocheJSchlittlerM, et al.Regulation of haemoglobin concentration at high altitude. J Physiol2024; 602: 5587–5600.
24.
SemenzaGL. Hypoxia-inducible factors in physiology and medicine. Cell2012; 148: 399–408.
25.
HaaseVH. Regulation of erythropoiesis by hypoxia-inducible factors. Blood Rev2013; 27: 41–53.
26.
SemenzaGL. Hydroxylation of HIF-1: oxygen sensing at the molecular level. Physiology (Bethesda)2004; 19: 176–182.
27.
SasakiRMasudaSNagaoM. Erythropoietin: multiple physiological functions and regulation of biosynthesis. Biosci Biotechnol Biochem2000; 64: 1775–1793.
28.
VillafuerteFCCoranteN. Chronic mountain sickness: clinical aspects, etiology, management, and treatment. High Alt Med Biol2016; 17: 61–69.
29.
YoungAJSawkaMNMuzaSR, et al.Effects of erythrocyte infusion on VO2max at high altitude. J Appl Physiol (1985)1996; 81: 252–259.
30.
PandolfKBYoungAJSawkaMN, et al.Does erythrocyte infusion improve 3.2-km run performance at high altitude?Eur J Appl Physiol Occup Physiol1998; 79: 1–6.
31.
MizunoMSavardGKAreskogN-H, et al.Skeletal muscle adaptations to prolonged exposure to extreme altitude: a role of physical activity?High Alt Med Biol2008; 9: 311–317.
32.
LemieuxPBirotO. Altitude, exercise, and skeletal muscle angio-adaptive responses to hypoxia: a Complex story. Front Physiol2021; 12: 735557.
JacobsRALundbyA-KMFenkS, et al.Twenty-eight days of exposure to 3454 m increases mitochondrial volume density in human skeletal muscle. J Physiol2016; 594: 1151–1166.
35.
ImrayCWrightASubudhiA, et al.Acute mountain sickness: pathophysiology, prevention, and treatment. Prog Cardiovasc Dis2010; 52: 467–484.
36.
SalgadoRMRyanBJSeeleyAD, et al.Improving endurance exercise performance at high altitude: traditional and nontraditional approaches. Exerc Sport Sci Rev2025; 53: 10–22.
37.
ZafrenKPunMRegmiN, et al.High altitude illness in pilgrims after rapid ascent to 4380 M. Travel Med Infect Dis2017; 16: 31–34.
38.
RashidHHashmiSNHussainT. Risk factors in high altitude pulmonary oedema. J Coll Physicians Surg Pak2005; 15: 96–99.
39.
HorstmanDWeiskopfRJacksonRE. Work capacity during 3-wk sojourn at 4,300 m: effects of relative polycythemia. J Appl Physiol Respir Environ Exerc Physiol1980; 49: 311–318.
40.
MaherJTJonesLGHartleyLH. Effects of high-altitude exposure on submaximal endurance capacity of men. J Appl Physiol1974; 37: 895–898.
41.
BuskirkERKolliasJAkersRF, et al.Maximal performance at altitude and on return from altitude in conditioned runners. J Appl Physiol1967; 23: 259–266.
42.
BurtscherMFaulhaberMFlatzM, et al.Effects of short-term acclimatization to altitude (3200 m) on aerobic and anaerobic exercise performance. Int J Sports Med2006; 27: 629–635.
43.
BeidlemanBAFulcoCSMuzaSR, et al.Effect of six days of staging on physiologic adjustments and acute mountain sickness during ascent to 4300 meters. High Alt Med Biol2009; 10: 253–260.
44.
KlausenKRobinsonSMicahelED, et al.Effect of high altitude on maximal working capacity. J Appl Physiol1966; 21: 1191–1194.
45.
HeinickeKHeinickeISchmidtW, et al.A three-week traditional altitude training increases hemoglobin mass and red cell volume in elite biathlon athletes. Int J Sports Med2005; 26: 350–355.
46.
WehrlinJPZuestPHallénJ, et al.Live high-train low for 24 days increases hemoglobin mass and red cell volume in elite endurance athletes. J Appl Physiol (1985)2006; 100: 1938–1945.
47.
MilletGPFaissRPialouxV. Point: hypobaric hypoxia induces different physiological responses from normobaric hypoxia. J Appl Physiol (1985)2012; 112: 1783–1784.
48.
CoppelJHennisPGilbert-KawaiE, et al.The physiological effects of hypobaric hypoxia versus normobaric hypoxia: a systematic review of crossover trials. Extrem Physiol Med2015; 4: 2.
49.
FaulhaberMGattererHHaiderT, et al.Intermittent hypoxia does not affect endurance performance at moderate altitude in well-trained athletes. J Sports Sci2010; 28: 513–519.
50.
BeidlemanBAMuzaSRFulcoCS, et al.Intermittent hypoxic exposure does not improve endurance performance at altitude. Med Sci Sports Exerc2009; 41: 1317–1325.
51.
BeidlemanBAMuzaSRFulcoCS, et al.Seven intermittent exposures to altitude improves exercise performance at 4300 m. Med Sci Sports Exerc2008; 40: 141–148.
52.
DufourSPPonsotEZollJ, et al.Exercise training in normobaric hypoxia in endurance runners. I. Improvement in aerobic performance capacity. J Appl Physiol (1985)2006; 100: 1238–1248.
53.
RoelsBBentleyDJCosteO, et al.Effects of intermittent hypoxic training on cycling performance in well-trained athletes. Eur J Appl Physiol2007; 101: 359–368.
54.
MilletGPRoelsBSchmittL, et al.Combining hypoxic methods for peak performance. Sports Med2010; 40: 1–25.
55.
RobachPSchmittLBrugniauxJV, et al.Living high-training low: effect on erythropoiesis and aerobic performance in highly-trained swimmers. Eur J Appl Physiol2006; 96: 423–433.
56.
BrugniauxJVSchmittLRobachP, et al.Eighteen days of ‘living high, training low’ stimulate erythropoiesis and enhance aerobic performance in elite middle-distance runners. J Appl Physiol (1985)2006; 100: 203–211.
57.
MujikaISharmaAPStellingwerffT. Contemporary periodization of altitude training for elite endurance athletes: a narrative review. Sports Med2019; 49: 1651–1669.
58.
GovusADGarvican-LewisLAAbbissCR, et al.Pre-Altitude Serum ferritin levels and daily oral iron supplement dose mediate iron parameter and hemoglobin mass responses to altitude exposure. PLoS One2015; 10: e0135120.
59.
StellingwerffTPeelingPGarvican-LewisLA, et al.Nutrition and altitude: strategies to enhance adaptation, improve performance and maintain health: a narrative review. Sports Med2019; 49: 169–184.
60.
RobachPCalbetJALThomsenJJ, et al.The ergogenic effect of recombinant human erythropoietin on VO2max depends on the severity of arterial hypoxemia. PLoS One2008; 3: e2996.
61.
SaundersPUTelfordRDPyneDB, et al.Improved running economy in elite runners after 20 days of simulated moderate-altitude exposure. J Appl Physiol (1985)2004; 96: 931–937.
62.
SchmittLMilletGRobachP, et al.Influence of ‘living high-training low’ on aerobic performance and economy of work in elite athletes. Eur J Appl Physiol2006; 97: 627–636.
63.
GoreCJHahnAGAugheyRJ, et al.Live high:train low increases muscle buffer capacity and submaximal cycling efficiency. Acta Physiol Scand2001; 173: 275–286.
64.
GoreCJClarkSASaundersPU. Nonhematological mechanisms of improved sea-level performance after hypoxic exposure. Med Sci Sports Exerc2007; 39: 1600–1609.
65.
TownsendNEGoreCJHahnAG, et al.Living high-training low increases hypoxic ventilatory response of well-trained endurance athletes. J Appl Physiol (1985)2002; 93: 1498–1505.
66.
VogtMPuntschartAGeiserJ, et al.Molecular adaptations in human skeletal muscle to endurance training under simulated hypoxic conditions. J Appl Physiol (1985)2001; 91: 173–182.
67.
WilberRL. Application of altitude/hypoxic training by elite athletes. Med Sci Sports Exerc2007; 39: 1610–1624.
68.
WilberRLStray-GundersenJLevineBD. Effect of hypoxic ‘dose’ on physiological responses and sea-level performance. Med Sci Sports Exerc2007; 39: 1590–1599.
69.
GirardOBrocherieFGoodsPSR, et al.An updated panorama of ‘living low-training high’ altitude/hypoxic methods. Front Sports Act Living2020; 2: 26.
70.
MilletGPJornetK. On top to the top-acclimatization strategy for the ‘fastest known time’ to Mount Everest. Int J Sports Physiol Perform2019; 14: 1438–1441.
71.
PirlotTMihailovicTGimenezP, et al.Effects of ‘living high-training low and high’ on sleep, heart rate variability, and psychological responses in elite female cyclists. Eur J Sport Sci2025; 25: e12320.
72.
PirlotTMihailovicTGimenezP, et al.Psychological, sleep, and heart rate variability responses during early- and middle-term acclimatization of ‘living high-training low and high’. High Alt Med Biol2025; 26: 291–300.
73.
RobertsACButterfieldGECymermanA, et al.Acclimatization to 4,300-m altitude decreases reliance on fat as a substrate. J Appl Physiol (1985)1996; 81: 1762–1771.
74.
BrooksGAButterfieldGEWolfeRR, et al.Increased dependence on blood glucose after acclimatization to 4,300 m. J Appl Physiol (1985)1991; 70: 919–927.
75.
RoelsBThomasCBentleyDJ, et al.Effects of intermittent hypoxic training on amino and fatty acid oxidative combustion in human permeabilized muscle fibers. J Appl Physiol (1985)2007; 102: 79–86.
76.
Koivisto-MørkAEPaurIPaulsenG, et al.Dietary adjustments to altitude training in elite endurance athletes; impact of a randomized clinical trial with antioxidant-rich foods. Front Sports Act Living2020; 2: 106.
77.
NiemanDCMitmesserSH. Potential Impact of Nutrition on Immune System Recovery from Heavy Exertion: A Metabolomics Perspective. Nutrients2017; 9, Epub ahead of print 18 May 2017. DOI: 10.3390/nu9050513.
78.
HoppelerHVogtMWeibelER, et al.Response of skeletal muscle mitochondria to hypoxia. Exp Physiol2003; 88: 109–119.
79.
DünnwaldTGattererHFaulhaberM, et al.Body composition and body weight changes at different altitude levels: a systematic review and meta-analysis. Front Physiol2019; 10: 430.
80.
WandragLSiervoMRileyHL, et al.Does hypoxia play a role in the development of sarcopenia in humans? Mechanistic insights from the caudwell Xtreme everest expedition. Redox Biol2017; 13: 60–68.
81.
PhillipsSMVan LoonLJC. Dietary protein for athletes: from requirements to optimum adaptation. J Sports Sci2011; 29: S29–S38.
82.
Wing-GaiaSLGershenoffDCDrummondMJ, et al.Effect of leucine supplementation on fat free mass with prolonged hypoxic exposure during a 13-day trek to everest base camp: a double-blind randomized study. Appl Physiol Nutr Metab2014; 39: 318–323.
83.
FriedlanderALBraunBMarquezJ. Making molehills out of mountains. ACSMS Health Fit J2008; 12: 15–21.
84.
WesterterpKR. Energy and water balance at high altitude. News Physiol Sci2001; 16: 134–137.
85.
MawsonJTBraunBRockPB, et al.Women at altitude: energy requirement at 4,300 m. J Appl Physiol (1985)2000; 88: 272–281.
86.
MeyerNLManoreMMHelleC. Nutrition for winter sports. J Sports Sci2011; 29: S127–S136.
87.
KenefickRWCheuvrontSN. Hydration for recreational sport and physical activity. Nutr Rev2012; 70: S137–S142.
PialouxVBrugniauxJVRockE, et al.Antioxidant status of elite athletes remains impaired 2 weeks after a simulated altitude training camp. Eur J Nutr2010; 49: 285–292.
90.
KoivistoAEPaulsenGPaurI, et al.Antioxidant-rich foods and response to altitude training: a randomized controlled trial in elite endurance athletes. Scand J Med Sci Sports2018; 28: 1982–1995.
91.
ColbeyCCoxAJPyneDB, et al.Upper respiratory symptoms, gut health and mucosal immunity in athletes. Sports Med2018; 48: 65–77.
92.
SmithEMTangprichaV. Vitamin D and anemia: insights into an emerging association. Curr Opin Endocrinol Diabetes Obes2015; 22: 432–438.
93.
ZughaierSMAlvarezJASloanJH, et al.The role of vitamin D in regulating the iron-hepcidin-ferroportin axis in monocytes. J Clin Transl Endocrinol2014; 1: 19–25.
94.
HuibertsLMSmoldersKCHJ. Effects of vitamin D on mood and sleep in the healthy population: interpretations from the serotonergic pathway. Sleep Med Rev2021; 55: 101379.
95.
HalsonSL. Sleep in elite athletes and nutritional interventions to enhance sleep. Sports Med2014; 44: S13–S23.
96.
SilberBYSchmittJAJ. Effects of tryptophan loading on human cognition, mood, and sleep. Neurosci Biobehav Rev2010; 34: 387–407.
WurtmanRJWurtmanJJReganMM, et al.Effects of normal meals rich in carbohydrates or proteins on plasma tryptophan and tyrosine ratios. Am J Clin Nutr2003; 77: 128–132.
99.
HowatsonGBellPGTallentJ, et al.Effect of tart cherry juice (Prunus cerasus) on melatonin levels and enhanced sleep quality. Eur J Nutr2012; 51: 909–916.
100.
ZouineNLhilaliIGodderisL, et al.The interplay between vitamin D deficiency, iron Status, and Anemia risk in Moroccan women of reproductive age: a cross-sectional analysis. Epidemiologia (Basel)2024; 5: 805–827.
101.
LuksAMAuerbachPSFreerL, et al.Wilderness medical society clinical practice guidelines for the prevention and treatment of acute altitude illness: 2019 update. Wilderness Environ Med2019; 30: S3–S18.
102.
LuksAMHackettPH. Medical conditions and high-altitude travel. N Engl J Med2022; 386: 364–373.
103.
FuehrerJMcGowanJHueckerMR. High Altitude Cardiopulmonary Diseases. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2023.
HüfnerKCaramazzaFStawinogaAE, et al.Assessment of psychotic symptoms in individuals exposed to very high or extreme altitude: a field study. High Alt Med Biol2021; 22: 369–378.
106.
BhandariSSKoiralaPRegmiN, et al.Retinal hemorrhage in a high-altitude aid post volunteer doctor: a case report. High Alt Med Biol2017; 18: 285–287.
107.
BlochKEBuenzliJCLatshangTD, et al.Sleep at high altitude: guesses and facts. J Appl Physiol (1985)2015; 119: 1466–1480.
108.
TsengC-HLinF-CChaoH-S, et al.Impact of rapid ascent to high altitude on sleep. Sleep Breath2015; 19: 819–826.
109.
AinsliePNLucasSJEBurgessKR. Breathing and sleep at high altitude. Respir Physiol Neurobiol2013; 188: 233–256.
110.
BurgessKRAinsliePN. Central sleep apnea at high altitude. Adv Exp Med Biol2016; 903: 275–283.
111.
HeinigerGRaemyFSolelhacG, et al.Altitude-induced central sleep apnea does not affect mean sleep oxygen saturation in young healthy males. J Appl Physiol (1985)2025; 138: 792–798.
112.
Nussbaumer-OchsnerYUrsprungJSiebenmannC, et al.Effect of short-term acclimatization to high altitude on sleep and nocturnal breathing. Sleep2012; 35: 419–423.
113.
AgostoniPCorràUEmdinM. Periodic breathing during incremental exercise. Ann Am Thorac Soc2017; 14: S116–S122.
114.
HermandEPichonALhuissierFJ, et al.Periodic breathing in healthy humans at exercise in hypoxia. J Appl Physiol (1985)2015; 118: 115–123.
115.
HermandELhuissierFJPichonA, et al.Exercising in Hypoxia and Other Stimuli: Heart Rate Variability and Ventilatory Oscillations. Life (Basel)2021; 11, Epub ahead of print 28 June 2021. DOI: 10.3390/life11070625.
AinsliePNWilsonMHImrayCHE. Cerebral circulation and brain. In: SwensonEBartschP (eds) High Altitude. New York, NY: Springer, New York, 2014, pp.141–170.
118.
Virués-OrtegaJBuela-CasalGGarridoE, et al.Neuropsychological functioning associated with high-altitude exposure. Neuropsychol Rev2004; 14: 197–224.
119.
MooreRDRomineMWO’connorPJ, et al.The influence of exercise-induced fatigue on cognitive function. J Sports Sci2012; 30: 841–850.
120.
PighinSBoniniNHadjichristidisC, et al.Decision making under stress: mild hypoxia leads to increased risk-taking. Stress2020; 23: 290–297.
121.
DavrancheKCasiniLArnalPJ, et al.Cognitive functions and cerebral oxygenation changes during acute and prolonged hypoxic exposure. Physiol Behav2016; 164: 189–197.
122.
HettingaFJKoningsMJPeppingG-J. The science of racing against opponents: affordance competition and the regulation of exercise intensity in head-to-head competition. Front Physiol2017; 8: 118.
123.
NiedermeierMWeisleitnerALammC, et al.Is decision making in hypoxia affected by pre-acclimatisation? A randomized controlled trial. Physiol Behav2017; 173: 236–242.
124.
RaglinJS. Psychological factors in sport performance: the mental health model revisited. Sports Med2001; 31: 875–890.
125.
HardyLParfittG. A catastrophe model of anxiety and performance. Br J Psychol1991; 82: 163–178.
126.
OliverSJSandersSJWilliamsCJ, et al.Physiological and psychological illness symptoms at high altitude and their relationship with acute mountain sickness: a prospective cohort study. J Travel Med2012; 19: 210–219.
127.
OliverSJGoljaPMacdonaldJH. Carbohydrate supplementation and exercise performance at high altitude: a randomized controlled trial. High Alt Med Biol2012; 13: 22–31.
128.
TuffeyS. Psychological preparation of endurance performers. In: ShephardRJAstrandP-O (eds) Endurance in sport. Hoboken, NJ: John Wiley & Sons, Ltd, 2008, pp.451–457.
129.
HatzigeorgiadisAZourbanosNGalanisE, et al.Self-Talk and sports performance: a meta-analysis. Perspect Psychol Sci2011; 6: 348–356.
130.
RaglinJSWilsonGS. Psychology in endurance performance. In: ShephardRJAstrandP-O (eds) Endurance in sport. Hoboken, NJ: John Wiley & Sons, Ltd, 2008, pp.211–219.
