See

discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/257649567

Altitude exposure in sports: the Athlete

Biological Passport standpoint
ARTICLE in DRUG TESTING AND ANALYSIS MARCH 2014
Impact Factor: 2.82 DOI: 10.1002/dta.1539 Source: PubMed

CITATIONS

5 AUTHORS, INCLUDING:
Fabian Sanchis-Gomar

Helios Pareja-Galeano

Hospital Universitario 12 de Octubre, Madri

European University of Madrid

153 PUBLICATIONS 657 CITATIONS

67 PUBLICATIONS 167 CITATIONS

SEE PROFILE

SEE PROFILE

Thomas Brioche

Giuseppe Lippi

French National Institute for Agricultural R

University Hospital of Parma

12 PUBLICATIONS 29 CITATIONS

1,210 PUBLICATIONS 12,778 CITATIONS

SEE PROFILE

SEE PROFILE

Available from: Helios Pareja-Galeano

Retrieved on: 26 August 2015

Drug Testing
and Analysis

Perspective
Received: 26 June 2013

Revised: 14 August 2013

Accepted: 14 August 2013

Published online in Wiley Online Library

(www.drugtestinganalysis.com) DOI 10.1002/dta.1539

Altitude exposure in sports: the Athlete

Biological Passport standpoint
Fabian Sanchis-Gomar,a,b* Helios Pareja Galeano,a,b Thomas Brioche,a,b,c
Vladimir Martinez-Bellod and Giuseppe Lippie
The Athlete Biological Passport (ABP) is principally founded on monitoring an athletes biological variables over time, to identify abnormal biases on a longitudinal basis. Several factors are known to inuence the results of these markers. However, the
manner in which the altitude factor is taken into account still needs to be standardized. Causal relationships between
haematological variables should be correctly integrated into ABP software. In particular, modications of haematological
parameters during and after exposure to different altitudes/hypoxic protocols need to be properly included within detection
models. Copyright 2013 John Wiley & Sons, Ltd.
Keywords: haemoglobin; haematocrit; reticulocytes; hypoxia exposure; blood doping

Introduction
Rather than using direct techniques to detect illicit drugs or substances, the Athlete Biological Passport (ABP) is founded on monitoring an athletes biological variables over time to identify
abnormal biases on a longitudinal basis[1] and, more specically,
in Bayesian networks through a mathematical formalism based
on probabilities shown on a graph.[2] The blood variables used
to dene the ABP include haematocrit, haemoglobin (Hb), red
blood cell count, mean corpuscular volume, mean corpuscular
Hb, mean corpuscular Hb concentration, reticulocyte count, and
percentage of reticulocytes.[3] In addition, the multiparametric
markers OFF-Hr score (index of stimulation) and ABPS (abnormal
blood prole score) are calculated from this set of parameters.[4,5]
Several and heterogeneous factors are known to inuence the
result of these markers, including ethnic origin, age, gender, the
analyzer used for measurement, the sport discipline, the seasonal
changes of the haematological parameters and exposure to altitude.[2,68] This information can be easily recorded during blood
analysis, with the possible exception of altitude. The manner in
which the altitude factor is taken into account still needs to be
standardized.[6] Recent publications reect concern about how
hypoxic environment (natural or articially induced exposure)
may be misinterpreted by the ABP software as heterogeneous
and confounding factors,[9] since altitude exposure and training
are not adequately weighted within the ABP software/algorithm.
The time course for normalization of parameters after exposure
to different altitudes/hypoxia protocols needs to be properly
addressed in detection models. Intermittent hypoxia training or
exposure consists of brief periods of daily exposure to severe natural or articial hypoxia (e.g. altitude exposure, nitrogen houses,
hypoxia tents, breathing apparatuses for inspiratory hypoxia).[10]
The living high, training low method (LHTL) is another approach
which entails living at a high/moderate altitude (2500 m) and
training at a low altitude (1250 m).[11,12] Other alternatives exist,
such as the so-called living high, training high (LHTH) and living
low, training high (LLTH).[13,14] Therefore, all these different hypoxic exposure protocols, with potential heterogeneous effects

Drug Test. Analysis (2013)

on the components of the ABP, should be accurately considered,

along with hypoxic stimulation in combination with training.
Sottas et al. concluded that athletes exposition to altitude was
identied using the whereabouts forms as determined in the
three-week pre-competition prole of each athlete tested during
the 2005 and 2007 World Athletics Championships (3444 entries).[15] Although the whereabouts forms currently consider altitude simulation systems, devices, and protocols,[3] it is
noteworthy that the whereabouts forms at that time (between
2005 and 2007) had some drawbacks since: (1) they did not consider the possibility of an athlete using altitude simulation systems, or the type of device or protocol applied; (2) they did not
contain accurate information about training sessions and/or competitions before sample collection; (3) they did not take into account other confounding factors listed in the operating
guidelines.[3] Even today the whereabouts forms do not properly
consider these last two points. It is also assumed that the effect of
altitude exposure is appropriately interpreted according to the
recommendations of the World Health Organization (WHO) for
diagnosis of anaemia. [16] These recommendations are based on
a paper published in 1945 and are mostly related to normal increases of haemoglobin and haematocrit values related to longterm altitude exposure (Table 1).
* Correspondence to: Fabian Sanchis-Gomar, Department of Physiology, Faculty
of Medicine, University of Valencia, Av. Blasco Ibaez, 15, Valencia 46010
Spain. E-mail: fabian.sanchis@uv.es
a Faculty of Medicine, Department of Physiology, University of Valencia, Spain
b Fundacin Investigacin Hospital Clnico Universitario/INCLIVA, Spain
c Laboratory M2S (Movement, Sport and Health Sciences), UFR-APS, Rennes
Cedex, France
d Faculty of Teaching, Department of Teaching of Musical, Visual and Corporal
Expression, University of Valencia, Spain
e Clinical Chemistry and Hematology Laboratory, Department of Pathology and
Laboratory Medicine, Academic Hospital of Parma, Italy

Copyright 2013 John Wiley & Sons, Ltd.

Drug Testing
and Analysis

F. Sanchis-Gomar et al.

Table 1. Normal increases of haemoglobin and haematocrit values

16
related to long-term altitude exposure. (Extracted from WHO. )
Altitude (metres)

Increase in
haemoglobin (g/l)

Increase in
haematocrit (l/l)

0
+2
+5
+8
+13
+19
+27
+35
+45

0
+0.005
+0.015
+0.025
+0.040
+0.060
+0.085
+0.110
+0.140

<1000
1000
1500
2000
2500
3000
3500
4000
4500

New ndings in this eld

Recent scientic ndings show broad heterogeneity and different
responses when subjects are exposed to natural altitude vs articial hypoxia, also displaying rather different and controversial
haematological results.[12,1719] In an excellent review published
recently by Lundby et al., the authors focused on altitude training
and the increase of performance in elite athletes. Interestingly,
after a careful review and despite the lack of rigorous scientic
studies, these authors concluded that LHTH and LHTL may increase exercise performance in some, but not all, athletes. However, LLTH and intermittent hypoxic breathing at rest do not
improve endurance capacity more than normoxic training. Thus,
the use of intermittent hypoxic exposure was not recommended
since it would not increase sea-level performance.[20] Moreover,
Robach and Lundby recently reported that LHTL may only increase Hbmass, and possibly VO2max, in athletes with an initial
low Hbmass value, and that the potential response seems to be
reduced in athletes with an already high Hbmass or red blood
cell volume (RCV).[21] Therefore, although individual studies support the hypothesis that exposure to hypoxia induces improved
endurance performance, the current literature does not support
this common notion for athletes with an already high Hbmass.
Neither the postulated hypoxia-induced effects nor its putatively
underlying mechanisms have yet been convincingly proven.
Unfortunately, some of the current literature suffers from various
methodological shortcomings including a small number of
subjects, non-randomized study designs, neither single nor
double-blinded design, heterogeneous populations, and various hypoxic methods or training modalities within as well as
between studies.[22]

The function of the Expert Panel

An expert is someone with knowledge in a particular eld, is
chosen by the Anti-Doping Organization (ADO), and is
responsible for providing an evaluation of the ABP. For the
haematological module, experts will have knowledge in one or
more of the elds of clinical haematology, sports medicine, or
exercise physiology.[23]
The Expert Panel is responsible for (1) reviewing ABP data and
results from the adaptive model provided by the ADO in order to
identify any possible pathological or confounding conditions; (2)
recommending any follow-up testing or suggesting possible clinical testing that may be required to conrm assessment or to collect further evidence to support or conrm possible pathologies;

wileyonlinelibrary.com/journal/dta

(3) reviewing any athletes explanations and providing opinions

on whether any atypical nding was highly probable given that
a prohibited substance or method had been used; (4) working
with the relevant ADO as required and providing evidentiary
support as necessary throughout any results management
process.[23] A nal report of the ABP containing data with a high
chance of being attributable to the use of one or more prohibited
substances or methods is typically dened as an adverse
passport nding.[23]
Nevertheless, the haematological system of an athlete is
subjected to potential changes induced by unusual environmental conditions such as the hypoxia of altitude.[24] Therefore, altitude is a confounding factor for blood variables, because
hypoxia might affect both red blood cell production and vascular
volumes. The time of exposure and the degree of hypoxia
(altitude) must be evaluated on an individual basis, also considering specic information about the time of collection in relation to
the sojourn at high altitude. Two leading experts in this eld,
Schumacher and dOnofrio, both recognize that any abnormality
in a prole should be scrutinized in view of the question Can the
abnormal result of the prole be explained by the environmental
conditions to which the athlete was exposed prior to providing
the sample?[24] Thus, the expert evaluation is broadly dependent
on the right timing of blood tests.[24] In fact, times of blood drawings are also important for a correct evaluation and interpretation. The effect of altitude, if present, shows a typical delay
from exposure to increase of Hb. In addition, the experts point
out that specic issues with the schedule of each athlete such
as altitude exposure must be considered. [24] The evaluation of
the athletes personal prole could aid the experts in considering
them a responder or a non-responder.[25]
Yet the altitude factor has not been standardized in the adaptive model/algorithm so far. All these variables should be included in the anti-doping model, considering the large number
of athletes that are currently being screened. A crucial point for
interpreting ABP blood prole is the use of special tents or chambers, where hypoxia can be articially reproduced. It is noteworthy that the use of articial hypoxia could be reproduced either
at home or at sea level. The registration of athletes data with ADAMS software only includes permanence at natural altitude, but
not the use of articial hypoxia and the corresponding degree
of articial altitude. Moreover, in the case of an adverse passport
nding, the alleged use of this method is subject to the arbitrary
interpretation of the experts.
Concluding remarks
The precision of the ABP could be improved by intensifying
the direct participation of laboratory experts in (1) creating
and validating algorithms; (2) recognizing biologically valid
thresholds for the different sports, training regimens, and environmental conditions; and (3) identifying reliable laboratory
instrumentation, protocols, and quality assurance programmes
for haematological testing.[26]
The chance of obtaining false-positive and false-negative test
results is crucial in an anti-doping context, wherein this special diagnostic area carries important forensic implications and a large
number of disqualications are now taken to court. Athletes
who live or train regularly at high altitudes may be unfairly not
penalized or even unjustly sanctioned. Thus, athletes could eventually use the altitude exposure explanation to elude elevated
results in haematological abnormalities. The cut-off limit is in fact

Copyright 2013 John Wiley & Sons, Ltd.

Drug Test. Analysis (2013)

Drug Testing
and Analysis

Altitude and ABP

lower when an altitude model was explicitly considered, i.e. a
higher sensitivity to blood doping.[27] A model that is based on
the distribution of altitudes during the two weeks before the test
may offer a reasonable alternative.[2] Likewise, thresholds are
higher when the athlete is tested at a high altitude, i.e. a lower
probability of a false-positive.[27] To date, ABP software classied
the altitude exposure taking into account the total meters of
altitude as follow: <1000 m; 10001500 m; 15002000 m;
20002500 m; 25003000 m; >3000 m. Moreover, prior to blood
collection, the athlete must answer the following questions:[2] (1)
Have they spent any time at high altitudes (>1000 m) during the
previous two weeks? If yes, when and at what altitude? (2) Have
they used a hypoxia tent (>1000 m) during the previous two
weeks? If yes, when and what PiO2 was used? However, the
impact of altitude or hypoxia exposure is still overlooked in the
current ABP model. All the variables should be transparently
characterized and describe how they inuence the calculation
of the likelihood percentage of abnormal variation of data in
the Bayesian/adaptive model. Altitude is the most commonly
modied variable over time in an athletes prole and must
always be correctly considered in the calculation, but also by
experts who interpret the ABP data.[24]
Causal relationships between different altitudes/hypoxic protocols and the variation of haematological variables should be appropriately integrated in ABP software, as follows:
1) Type of altitude exposure protocol: LLTH, LHTL, LHTH, or intermittent hypoxic breathing at rest since LHTH and LHTL may
induce higher haematological adaptations than LLTH or intermittent hypoxic breathing at rest.
2) Even though Hbmass has some drawbacks (i.e. problems in
standardization), it could be included in the procedure to obtain baseline values before altitude exposure. Members of the
Athlete Passport Management Unit (APMU) could benet
from this additional information. Consequently, it is crucial
to establish an initial or basal Hbmass and Hb concentration
before altitude exposure since the potential response is severely reduced in athletes with an already high Hbmass, Hb
concentration, or RCV. For this purpose, screening for Hb
levels and Hbmass in athletes before engaging in hypoxic exposure protocols may be a potential and innovative perspective, for example including a baseline Hb level obtained with
three determinations off-season and at least one month
before and after altitude/hypoxic exposure. As previously
mentioned, Hbmass for anti-doping purposes should be
assessed always in combination with haemoglobin and blood
volume.[28]
3) The Expert Panel should be aware of the athletes baseline
haematological values (before hypoxic exposure) for accurate
interpretation of blood prole uctuations due to hypoxic
exposure. For example, an increase of 10 g/L of Hb can be
achievable after an exposure to altitude or hypoxia (LHTL,
2500m/21 days) in a male athlete with a baseline Hb level of
130 g/L, whereas the same extent of increase is virtually
unachievable by another male athlete with a baseline Hb
level of 155 g/L. Surprisingly, this aspect is embarrassingly
overlooked in the complex algorithm of the ABP software,
which has been developed according to WHO recommendations (Figure 1).[16]
Finally, it has recently been demonstrated that it is possible to
abuse recombinant human erythropoietin (rHuEpo) without
triggering ABP thresholds.[29] Accordingly, additional and more

Drug Test. Analysis (2013)

sensitive markers are needed to detect rHuEpo abuse by means

of the ABP model. For this purpose, several markers such as total
haemoglobin mass (Hbmass), bilirubin, ferritin, Hbmr, RBCHb/
RetHb ratio, and/or Serum Epo concentration should be considered for integration.[2,3034]

References
[1] S. Gilbert. The biological passport. Hastings Cent. Rep. 2010, 40, 18.
[2] P.E. Sottas, N. Robinson, M. Saugy. The athletes biological passport and
indirect markers of blood doping. Handb. Exp. Pharmacol. 2010, 195,
305.
[3] WADA. The World Anti-Doping Code. Athlete Biological Passport Operating Guidelines and Compilation of Required Elements, Version
3.1, 2012, pp 152. Available at: www.wada-ama.org [5 August 2013]
[4] C.J. Gore, R. Parisotto, M.J. Ashenden, J. Stray-Gundersen, K. Sharpe,
W. Hopkins, et al. Second-generation blood tests to detect erythropoietin abuse by athletes. Haematologica 2003, 88, 333.
[5] P.E. Sottas, N. Robinson, S. Giraud, F. Taroni, M. Kamber, P. Mangin,
et al. Statistical classication of abnormal blood proles in athletes.
Int. J. Biostat. 2006, 2, 3.
[6] P.E. Sottas, N. Robinson, M. Saugy. A forensic approach to the interpretation of blood doping markers. Law Probab. Risk 2008, 7, 191.
[7] G. Ban. Limits and pitfalls of athletes biological passport. Clin.
Chem. Lab. Med. 2011, 49, 1417.
[8] G. Lippi, C. Mattiuzzi, G. Ban. Controlling sources of preanalytical
variability in doping samples: Challenges and solutions. Bioanalysis
2013, 5, 1571.
[9] F. Sanchis-Gomar, V.E. Martinez-Bello, M.C. Gomez-Cabrera, J. Vina.
Current limitations of the athletes biological passport use in sports.
Clin. Chem. Lab. Med. 2011, 49, 1413.
[10] E.A. Hinckson, W.G. Hopkins, J.S. Edwards, P. Ptzinger, J. Hellemans.
Sea-level performance in runners using altitude tents: A eld study.
J. Sci. Med. Sport 2005, 8, 451.
[11] J. Stray-Gundersen, R.F. Chapman, B.D. Levine. Living high-training
low altitude training improves sea level performance in male and
female elite runners. J. Appl. Physiol. 2001, 91, 1113.
[12] J. Stray-Gundersen, B.D. Levine. Live high, train low at natural altitude. Scand. J. Med. Sci. Spor. 2008, 18, 21.
[13] B.D. Levine, J. Stray-Gundersen. Living high-training low: Effect of
moderate-altitude acclimatization with low-altitude training on performance. J. Appl. Physiol. 1997, 83, 102.
[14] J.P. Wehrlin, P. Zuest, J. Hallen, B. Marti. Live high-train low for 24
days increases hemoglobin mass and red cell volume in elite endurance athletes. J. Appl. Physiol. 2006, 100, 1938.
[15] P.E. Sottas, N. Robinson, G. Fischetto, G. Dolle, J.M. Alonso, M. Saugy.
Prevalence of blood doping in samples collected from elite track and
eld athletes. Clin. Chem. 2011, 57, 762.
[16] World Health Organisation. Iron Deciency Anemia: Assessment, prevention and control, a guide for programme managers. WHO Publications, Geneva, 2001.
[17] J.P. Richalet, C.J. Gore. Live and/or sleep high:train low, using
normobaric hypoxia. Scand. J. Med. Sci. Spor. 2008, 18, 29.
[18] P. Bartsch, C. Dehnert, B. Friedmann-Bette, V. Tadibi. Intermittent
hypoxia at rest for improvement of athletic performance. Scand. J.
Med. Sci. Spor. 2008, 18, 50.
[19] G.P. Millet, B. Roels, L. Schmitt, X. Woorons, J.P. Richalet. Combining
hypoxic methods for peak performance. Sports Med. 2010, 40, 1.
[20] C. Lundby, G.P. Millet, J.A. Calbet, P. Bartsch, A.W. Subudhi. Does altitude training increase exercise performance in elite athletes? Brit.
J. Sports Med. 2012, 46, 792.
[21] P. Robach, C. Lundby. Is live high-train low altitude training relevant
for elite athletes with already high total hemoglobin mass? Scand. J.
Med. Sci. Spor. 2012, 22, 303.
[22] P. de Paula, J. Niebauer. Effects of high altitude training on exercise
capacity: Fact or myth. Sleep Breath. 2010, 16, 233.
[23] WADA. The World Anti-Doping Code. Athlete Biological Passport
Operating Guidelines and Compilation of Required Elements.
2012, pp. 152. Available at: www.wada-ama.org [20 May 2013]
[24] Y.O. Schumacher, G. dOnofrio. Scientic expertise and the athlete
biological passport: 3 years of experience. Clin. Chem. 2012, 58, 979.
[25] R.F. Chapman, J. Stray-Gundersen, B.D. Levine. Individual variation in
response to altitude training. J. Appl. Physiol. 1998, 85, 1448.

Copyright 2013 John Wiley & Sons, Ltd.

wileyonlinelibrary.com/journal/dta

Drug Testing
and Analysis

F. Sanchis-Gomar et al.

[26] G. Lippi, M. Plebani, F. Sanchis-Gomar, G. Ban. Current limitations

and future perspectives of the athlete blood passport. Eur. J. Appl.
Physiol. 2012, 112, 3693.
[27] N. Robinson, P.E. Sottas, P. Mangin, M. Saugy. Bayesian detection
of abnormal hematological values to introduce a no-start rule
for heterogeneous populations of athletes. Haematologica 2007, 92, 1143.
[28] F. Sanchis-Gomar, G. Lippi. Hb(mass) for anti-doping purposes
should be assessed in combination with hemoglobin and blood
volume. Int. J. Sport Med. 2012, 33, 502.
[29] M. Ashenden, C.E. Gough, A. Garnham, C.J. Gore, K. Sharpe. Current
markers of the athlete blood passport do not ag microdose EPO
doping. Eur. J. Appl. Physiol. 2011, 111, 2307.
[30] J. Morkeberg, K. Sharpe, B. Belhage, R. Damsgaard, W. Schmidt,
N. Prommer, et al. Detecting autologous blood transfusions: A

wileyonlinelibrary.com/journal/dta

[31]
[32]

[33]
[34]

comparison of three passport approaches and four blood

markers. Scand. J. Med. Sci. Spor. 2009, 21, 235.
W. Jelkmann, C. Lundby. Blood doping and its detection. Blood 2011,
118, 2395.
T. Pottgiesser, T. Echteler, P.E. Sottas, M. Umhau, Y.O. Schumacher.
Hemoglobin mass and biological passport for the detection of autologous blood doping. Med. Sci. Sport Exer.
2012, 44, 835.
J. Morkeberg. Detection of autologous blood transfusions in
athletes: A historical perspective. Transfus. Med. Rev. 2012, 26, 199.
F. Sanchis-Gomar, V.E. Martinez-Bello, M.C. Gomez-Cabrera,
J. Vina. The hybrid algorithm (Hbmr) to ght against blood
doping in sports. Scand. J. Med. Sci. Spor. 2010, 20, 789,
author reply 792.

Copyright 2013 John Wiley & Sons, Ltd.

Drug Test. Analysis (2013)