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Received: 2 September 2022    Revised: 19 October 2022    Accepted: 19 October 2022

DOI: 10.1111/sms.14268

SPECIAL ISSUE ARTICLE

High or hot—­Perspectives on altitude camps and heat-­

acclimation training as preparation for prolonged stage
races

Lars Nybo1   | Bent Rønnestad2   | Carsten Lundby2

1
Department of Nutrition, Exercise
and Sport, University of Copenhagen,
Copenhagen, Denmark
2
Inland Norway University of Applied
Sciences, Lillehammer, Norway
Correspondence
Lars Nybo, Universitetsparken 13,
second floor, DK-­2100 Copenhagen Ø,
Denmark.
Email: nybo@nexs.ku.dk
Abstract
Adaptation to heat stress and hypoxia are relevant for athletes participating in
Tour de France or similar cycling races taking place during the summertime in
landscapes with varying altitude. Both to minimize detrimental performance ef-
fects associated with arterial desaturation occurring at moderate altitudes in elite
athletes, respectively, reduce the risk of hyperthermia on hot days, but also as a
pre-­competition acclimatization strategy to boost blood volume in already highly
adapted athletes. The hematological adaptations require weeks of exposure to
manifest, but are attractive as an augmented hemoglobin mass may improve ar-
terial oxygen delivery and hence benefit prolonged performances. Altitude train-
ing camps have in this context a long history in exercise physiology and are still
common practice in elite cycling. However, heat-­acclimation training provides
an attractive alternative for some athletes either as a stand-­alone approach or in
combination with altitude. The present paper provides an update and practical
perspectives on the potential to utilize hypoxia and heat exposure to optimize
hematological adaptations. Furthermore, we will consider temporal aspects both
in terms of onset and decay of the adaptations relevant for improved thermoreg-
ulatory capacity and respiratory adaptations to abate arterial desaturation dur-
ing altitude exposure. From focus on involved physiological mechanisms, time
course, and responsiveness in elite athletes, we will provide guidance based on
our experience from practical implementation in cyclists preparing for prolonged
stage races such as the Tour de France.

KEYWORDS
altitude, acclimatization, cycling, heat, performance, training

1  |  I N T RO DU CT ION “acclimation training” or natural acclimatization to ei-

ther hypoxia induced via altitude training camps or ad-
The present perspective will focus on the potential aptation to hyperthermia via exposure to environmental
performance benefits derived from pre-­ competition heat stress. Acclimatization here defined as the integrated
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
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© 2022 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.

Scand J Med Sci Sports. 2022;00:1–10.  wileyonlinelibrary.com/journal/sms  |  1

 |
2       NYBO et al.
adaptation occurring during natural exposure to the envi-
ronment, while “acclimation training” is considered as ex-
posure that may induce similar physiological adaptation
via specific exposure to heat stress or hypoxia, typically su-
perimposed in artificial settings (e.g., climatic chambers,
training with increased isolation/clothing or by breath-
ing air with a reduced oxygen fraction). We will consider
physiological aspects related to the two environmental
stressors and how associated adaptations may benefit per-
formance in prolonged cycling stage races such as Tour de
France, Giro di Italia and Vuelta a España. Similar to sev-
eral other stage races or single day competitions, the route
in the 3  week grand tours typically implies that athletes
are exposed to altitudes varying from sea level to moun-
tain passages or stage finishes 2000 m above sea level and
riders will furthermore be challenged by thermal stress on
days with profound heat stress. It will, therefore, be rele-
vant to consider pre-­event acclimatization both as a strat-
egy to minimize the marked fatigue that occurs with acute
exposure to heat or altitude and the potential “transfer
effect”—­that is the hematological adaptations that with
sufficient stress (time and intensity-­wise) may increase
the athlete's hemoglobin mass (Hb-­mass) and potentially
improve aerobic performance. In addition to considering
if the stress is adequate (altitude/level of hypoxia or hy-
perthermia) and time course required to induce acclima-
tion, it is also relevant to consider the decay and ability
to maintain the achieved adaptation. Thus, for prolonged
stage races the first mountains, decisive stages or days
with heat stress may not take place in the immediate pe-
riod after acclimatizing, but mainly be relevant during the
second or third week of racing. In opposition to single day
competitions, this may complicate the timing of acclima-
tization and how much a pre-­competition acclimation
camp benefits performance in the later stages, when the
environmental heat or altitude exposure is most relevant.
2   |   H E M ATOLOG ICAL AN D “NON-­
H E M ATO LO GICAL” ADAPTAT IO NS
Acute exposure as well as the subsequent adaptation
to both hypoxia and heat stress includes a plethora of
physiological responses and for comprehensive over-
view of mechanisms involved, we refer to recent reviews
dedicated to provide insight in mechanisms involved in
acclimatization to hypoxia/altitude1,2 and for heat/hyper-
thermia.3,4 For brevity, we will in this perspective paper
make a coarser classification and divide into attention on
the hematological responses (mainly focused on changes
in Hb-­mass, total blood and plasma volume), respectively,
“non-­hematological” adaptations. For heat acclimatiza-
tion, the latter will mainly involve considerations on the
increased thermoregulatory capacity associated with im-
proved sweat gland function (the sudomotor response),
while for hypoxia, we will focus on the increased respira-
tory drive that may minimize arterial desaturation for a
given environmental oxygen pressure.
Elite endurance exercise performances are undoubt-
edly complex in nature involving a multitude of facets and
with several physiological factors still to be elucidated.
Nonetheless, the importance of a highly developed car-
diovascular system that allows for high aerobic energy
turnover as influenced arterial oxygen delivery (product
of maximal cardiac output and arterial oxygen content)
and skeletal muscle efficiency has been highlighted for
decades. Of these, arterial oxygen delivery and the asso-
ciated superior maximal oxygen uptake (V̇o2max) is largely
ensured by the interplay of a highly adapted myocardium
allowing for enhanced diastolic filling, a high Hb-­mass
and the skeletal muscle capability to extract and utilize
the majority of the delivered oxygen.5 Of particular inter-
est and importance for the present review, enhancing Hb-­
mass is very attractive as it may both elevate the oxygen
carrying capacity per liter blood and promote the pump-
ing capacity of the heart, secondary to the Frank-­Starling
mechanism.6
3  |   HEMATOLOGIC AL
ADAPTATIONS DURING ALTIT U D E
EX POSURE
It has been recognized for more than a century, that the
blood hemoglobin concentration [Hb] increases rapidly
during exposure to high altitude and returns to baseline
(pre exposure) levels during the first weeks upon return
to sea level. This hematological response to altitude re-
lates to hypoxia-­induced erythropoietin (EPO) secretion
from the kidneys and the associated potential to stimulate
erythropoiesis has attracted attention from cycling teams
and coaches as well as the classical exercise physiology
studies focused on utilizing “altitude training camps”
as an approach to improve endurance performances.7,8
However, elevated [Hb] is not necessarily indicative of
increased Hb-­mass as altitude exposure already within
the first hours upon ascent is associated with a diuretic
response that reduces the plasma volume and lower the
total blood volume1. Although, the increased hematocrit
and higher [Hb] increase the arterial oxygen carrying ca-
pacity, it will not benefit arterial oxygen delivery as it oc-
curs on the expense of a reduced maximal cardiac output.9
It is, therefore, important to emphasize that [Hb] or hema-
tocrit measures are insufficient to track or verify effects
of an altitude training camp in terms of boosting blood
volume. Rather, we recommend assessment of the total
NYBO et al.
Hb-­mass, for example, with CO-­breathing or other appro-
priate methodologies10 and such measures have revealed
that at least 3 weeks exposure is required to assure that
the elevated EPO and enhanced erythropoiesis translate
into significant higher Hb-­mass.11,12 In addition to suffi-
cient duration, altitude acclimatization also depends on
sufficient intensity of the stimuli (level of hypoxia) and
consistency of the exposure (hours per day). While “live
high—­train low” or acclimation via accommodation in
hypoxic chambers for some athletes may be an attractive
alternative and may allow for higher power output dur-
ing training compared to “live and train high”, it may not
be recommended as it increases the risk for insufficient
hourly exposure per day. For example, 4 weeks exposure
to hypoxia equivalent to 2160 m above sea level for 17 h/
day or 4 weeks at 3000 m for 16 h/day did not translate into
consistent elevation of Hb-­mass in RCT-­controlled stud-
ies.13,14 In contrast, continuous exposure to 3450 m, which
is higher than most coaches and athletes practice (but as
discussed below, worthy of consideration) are associated
with systematic elevations in Hb-­mass in recreationally
active participants.11,15 The risk of “loosing training in-
tensity” as reflected in lower power output during train-
ing at altitude has been considered as an argument for
“live-­high train-­low”.16 However, recent evidence from
training intervention studies with superimposed hypoxia
suggest that although power output (in particular dur-
ing intense aerobic intervals) will be lower at altitude,
the training will still provide a physiological stimuli suf-
ficient or as discussed below perhaps superior in terms of
stimulating some peripheral/muscular adaptations.17,18
In terms of optimizing the hematological adaptation the
“live high and train high-­approach” is, therefore, recom-
mended. However, in terms of achieving higher power
output and hence broader muscle fiber activation in some
training session, it may be considered to include short
repeated exercise intervals (30/15 s intervals or similar)
to allow for race pace relevant power output. This could
especially be relevant for athletes such as track and field
distance runners, where a lower intensity could imply
a marked change in the movement pattern and biome-
chanical load. Humans ascending to high altitude experi-
ence an immediate reduction in arterial oxyhemoglobin
saturation and consequently lower arterial O2 content and
reduced V̇o2max. If the exposure to altitude is extended,
the reduction in V̇o2max is partly counteracted by an in-
crease in arterial hemoglobin concentration. Initially, this
hemoconcentration is exclusively related to a reduction in
plasma volume (PV), whereas after several weeks a pro-
gressive expansion in total red blood cell volume (RCV)
contributes, although often to a modest extent. Since the
decrease in PV is more rapid and usually more pronounced
than the expansion in RCV, at least during the first weeks
   |
   3
of exposure, a reduction in the total circulating blood vol-
ume is commonly observed at high altitude.7,9 Although,
the hematological responses to altitude exposure has been
investigated for decades, its regulation remains to be com-
pletely understood. It is clear that many mechanisms are
involved, but the complexity of their interplay is not well
described. This may both relate to difficulties in complet-
ing well-­controlled comprehensive experiments and to di-
vergent individual responses that remains to be revealed.
In this review, we present our understanding of the kinet-
ics, the mechanisms and in particular the physiological
(performance) relevance of the hypoxia-­induced reduc-
tion in PV, respectively, and the expansion in RCV.7
From a practical point of view, residing for 3 weeks
(or longer) in ~2500 m above sea level, staying and com-
pleting most training session at this altitude may fulfill
the exposure criteria in terms of “intensity” (the level
of hypoxia), duration and consistency of exposure. The
daily training routes may naturally take riders to lower
altitudes for briefer periods without compromising the
abovementioned importance of consistent exposure.
Going higher or staying longer either as permanent res-
idence or as practiced by mountaineers with intermittent
-­shorter exposures (from one to few hours) to higher al-
titudes on top of the basecamp residence—­would from
a physiological point of view provide a superior stimuli
and given the knowledge that a short intense/initial drop
in arterial oxygen pressure will stimulate EPO, it could
be used as strategy to further enhance the erythropoietic
response. Indeed, in national team XC-­ski members the
live high—­train even-­higher approach has been shown
to facilitate Hb-­mass expansion; currently only with ev-
idence from a one-­armed study design without control
group,19 but the approach awaiting further scientific vali-
dation and it should also be realized that such “burst” in
EPO when residing at sea level have not translated into
performance gains.7 If athletes are compelled to reside at
lower altitudes for better training opportunities or ease of
logistics, it could be considered to apply the “mountain-
eering approach” by superimposing night time hypoxia
(e.g., sleeping in hypoxic tents or chambers) aiming at fa-
cilitating worthwhile adaptations. Here it is important to
note that hypoxic generators do not monitor barometric
pressure and that a given reduction in the inspired O2 per-
centage has larger effect when used at altitude compared
to sea level.
In addition to sufficient time for altitude acclimati-
zation to translate into elevated Hb-­mass, it is also very
relevant to consider the time course for the decay upon
return to sea level. Observations, both from a one-­year ex-
posure study associated with a marked elevation in Hb-­
mass (18% on average; Lundby et al. unpublished data)
and from the abovementioned 3–­4  week acclimatization
 |
4       NYBO et al.
studies,11,15 which increased Hb-­mass by 3%–­5%, signifies
that half of gained Hb-­mass is gone already 7 days upon
return to normoxia and completely returned to baseline
14 days after the altitude exposure.11,15 Thus, it is very im-
portant to stress that an altitude training camp should be
completed in close proximity to the competitive period.
Altitude camps conducted in the winter or pre-­season are
in contrast unlikely to have any direct effects on perfor-
mance several months later unless something is done to
prevent the decay.
4   |   N O N -­H E MATOLOG ICAL
A DA P TAT I ON TO HY POXIA
Besides facilitating erythropoiesis, hypoxia may also stim-
ulate mitochondrial biogenesis as indicated by a 11.5%
increase in volume density of intermyofibrillar mitochon-
dria following 4 weeks at 3450 m in non-­athlete partici-
pants.20 It is often speculated that such adaptation may
benefit V̇o2max, but since the capacity for mitochondrial
respiration is reported to vastly surpasses the ability of
O2 supply to the exercising skeletal muscle21 this is prob-
ably of minor importance for athletic performance at least
in terms of increasing aerobic power. Improved electron
transport efficiency, but reduced skeletal muscle mito-
chondria enzyme concentrations have been reported fol-
lowing both short (~2 weeks) and longer (4 weeks) altitude
exposure,22,23 but overall it appears that the respiratory
chain function remain unaltered22,23 and the potential per-
formance consequences of these mitochondrial changes
remain unclear.
While altitude training camps often focus on improving
performance upon return to lower altitudes (normoxia), it
is also relevant to consider that acclimatization is highly
relevant for minimizing performance deterioration during
races at altitude. Especially for highly trained athletes sus-
ceptibly to exercise-­induced arterial hypoxemia as it may
impact performance already at low to moderate altitudes.24
The benefits from acclimatization are in this context faster
than for the hematological responses as indicated by 3%
increase in V̇o2max already following 1  week of acclima-
tization to 2350 m altitude and 7.5% after 2 weeks when
V̇o2max in the trained athletes was tested at that altitude
and compared to the decline during acute exposure.25
These early improvements are likely a consequence of a
lower degree of arterial desaturation with acclimatiza-
tion,26 although saturation for a given oxygen pressure re-
mains below that of high altitude natives. The later could
explain why athletes born and raised at high altitude may
have more permanent physiological advantage in this en-
vironment. Also, native lowlanders may experience a fast
decay of this adaptation, which complicates the ability to
prepare for the altitude exposure taking place during the
second or third week of a grand tour.
To summarize the above, both hematological and non-­
hematological adaptations associated with high altitude
exposure may develop following weeks of such contin-
uous exposure. It should be emphasized that at least he-
matological adaptations are only short lived upon return
to sea level and that altitude training camps should be
planned accordingly.
5  |   HEAT ACC LIMATIZATION—­
THE “ NON-­H EMATOLOGICAL”
ADAPTATIONS
Heat acclimatization or acclimation protocols may be
categorized into short (≤7 days/exposures), medium (8–­
14 exposures) and long-­term (with more than 15 days
of exposure)27 with the majority of studies and in par-
ticular experiments with elite athletes focused on the
adaptations occurring during the first 1–­ 2 weeks. For
endurance-­trained athletes (adapting faster to heat than
untrained participants; see3,4 for overview) this period
of time is sufficient to increase the maximal sweat rate,
lower the resting core temperature as well as the thresh-
old for onset of sweating.28 Adaptations we consider as
three of the main “non-­hematological factors” of impor-
tance for increasing the thermoregulatory capacity and
allowing for increased exercise capacity in setting where
the environmental heat stress is high and the ability to
dissipate heat may limit exercise performance (i.e., ther-
mal balance rather than the athletes aerobic capacity be-
comes limiting). As an example of relevance for cycling
and the very fast onset of sudomotor adaptations occur-
ring in athletes, we followed the time course of physi-
ological and performance adaptations to heat exposure
during a two-­week intervention study (training camp
with acute transfer from cold to heat).29,30 Acute expo-
sure provoked a 16% drop in power output (TT on first
day in the 36°C environment) compared to performance
in cool settings, but following acclimatization this was
reduced to less than 2% and no difference in time to
complete the 43 km time trial used as the performance
measure in that study (lower air density and hence resist-
ance fully compensated for the slight reduction in power
output).29 Indicators of sudomotor adaptation was ob-
served after only 2 days of exposure and sweat rate both
in a standardized heat-­exposure test and during peak
performance significantly increased on day 5–­6 with no
further increase during the second week. This signifies
a very fast (completed in less than 1 week) improvement
in sweat gland function and associated increase in cool-
ing capacity, but also how vulnerable the non-­prepared/
NYBO et al.
unacclimatized rider will be during the first days of a
heat-­wave compared to a competitor that have acclima-
tized ahead of the race.
Thermal adaptation requires a series of sufficient ther-
mal impulses, which for heat acclimation in practice may
be achieved by a variety of different approaches as long as
the heat stress exceed the required threshold and facili-
tates adaptation.4,27 The abovementioned study by Karlsen
et al.29 exemplifying natural acclimatization achieved via
ecological exposure was completed as an intervention
study where the HEAT-­group for 2 week transferred from
habitual cool training environment to training in dry heat
(~35°C with 2–­4  h exposure per day). However, similar
physiological adaptations may be induced with shorter
(~1  h/day) training in climatic chambers31,32 or training
with increased clothing33,34 (so-­called sweat suit training
that hampers heat-­dissipation to provoke hyperthermia).
From a practical point of view and discussed below the
later may be attractive for some athletes as it may induce
physiological adaptations comparable to natural expo-
sure and allow the athlete to complete the remaining of
the weekly training in cooler conditions. As discussed in
recent consensus recommendation3 the natural exposure
may be preferred to allow athlete to familiarize with the
perception of the environment. For cyclists, for example,
test how much the specific settings (integrated effects of
air temperature, humidity, solar radiation and wind) af-
fects performance and hence may influence their pacing
strategy and hydration requirement. This may be more
important in the early phases of a career, while it for expe-
rienced athletes that may be less of an issue and they will
benefit from the physiological preparation independent of
the acclimatization/acclimation mode.
6   |   H E M ATOLOG ICAL
A DA P TAT I ON S TO PROLON G E D
H E AT ACC L IM AT ION
While short to medium duration acclimation protocols
are adequate for athletes to improve/maximize sweat
gland function and increase the resilience to environ-
mental heat stress, the duration required for completion
of the hematological adaptations makes long-­term heat-­
acclimation relevant. Although, acting via quite differ-
ent mechanisms than hypoxic exposure35 the two modes
are similar in terms of requiring sufficient time (weeks
of exposure) to allow for red blood cell formation. Short-­
duration heat acclimatization may markedly increase the
plasma volume (also in highly trained athletes), but pro-
longed heat-­acclimation protocols with several weeks of
exposure are required before the plasma volume expan-
sion (plateauing within the first week) is accompanied by
  
   5|
an increase in Hb-­mass. As illustrated by Figure 1 derived
from a point-­counter point discussion in 2016 in Journal
of Physiology36,37 both 10 days heat-­acclimation32,38 and
14 days with natural heat acclimatization30 can induce a
marked increase in plasma volume, but the PV-­expansion
in those studies was not associated with a change in peak
power or time trial performance in trained cyclists. In op-
position to our opponents in the abovementioned point-­
counter point discussion30 and their acclimation study,33
we found no evidence for short to medium duration heat
acclimatization to translate into improved performance
in cooler settings, although the athletes had massive im-
provements in exercise performance tested in the heat.
The evidence for “cool performance” transfer effects de-
rived from plasma volume expansion or other acclimation
effects achieved via short-­medium duration acclimatiza-
tion protocols are in our opinion still weak (see36,37 for
discussion or this paper27 for meta-­analysis). The point-­
counter point discussion did, however, prompt us to com-
plete a series of prolonged heat-­acclimation studies31,33–­35
with durations of 5 weeks or more to test the idea that
allowing sufficient time for adaptation, heat-­acclimation
and the associated plasma volume expansion would trans-
late into an increased RBC-­volume.
Utilizing the prolonged heat-­ acclimation approach,
accomplished either as part of the training (~1 h per day
and at least five times per week) completed in hot cli-
matic chambers31,34 or via training with superimposed
heat stress with increased clothing insulation,33 we ob-
serve systematic increases in Hb-­mass both in elite in-
ternational and national level competitive cyclists (see
Figure  2 for individual Hb-­mass gains across the range
of trained to highly trained athletes in the studies). On
average the 5 week heat-­training interventions, we have
completed elicit a ~3% effect (30 g gain) on total Hb-­mass,
which is significantly different from matched controls
and translate into elevated peak peak-­powerpower during
incremental testing (delta gain of 18 watt in heat-­exposed
groups compared to 6 watt in control; p < 0.05 both for the
Hb-­mass and peak power response). We also observe in-
creased average power output during time trials (pre-­post
increase of 20 watt for medium duration [15–­30 min] time
trials completed in the lab on stationary bikes), but for
this performance measure with no difference compared
to the control groups (as they also improve their time
trial power output). The later exemplifying the complex-
ity of completing interventions studies with competitive
cyclists, but also that the heat-­interventions (substitut-
ing ~5 h of the weekly training volume with training in
heat with matched rating of perceived exertion, but lower
power output) has the potential to improve all measures
of performance in the heat, induce a meaningful increase
in Hb-­mass (even in highly trained athlete) and with no
 |
6       NYBO et al.

F I G U R E 1   Changes in physiological performance capacity evaluated in cool conditions (triangles representing average power
output during time trials [TT] and squares representing peak aerobic power during incremental exercise testing) versus the percentage
change in plasma volume following acute plasma volume expansion (filled symbols; albumin infusion) or 2 weeks of natural outdoor heat
acclimatization (open symbols). The symbols represent individual values from Karlsen et al.30 and Keiser et al.32 with the delta changes
calculated as the percentage increase from control. Both for peak power in incremental testing and for TT performance in cool setting there
was no effect following the medium-­range (10–­14 days) heat acclimatization or acclimation protocols despite marked elevation in plasma
volume.37

negative consequences for simultaneous improvements
of TT performance in cool settings. Also, it appears that
the loss of adaptation (return of Hb-­mass to baseline)
can be prevented for a prolonged period via relatively few
(3 weekly) maintenance training sessions,39 which may
make the heat-­training approach more attractive than
altitude training, where the decay is fast and difficult to
prevent.
7   |   P R ACT ICAL
RECO M M E NDAT ION S AN D
P E RS P ECT I VE S FOR FU RT HE R
I M P ROV E M EN T S
The above studies serve as proof of principle that the
interventions can induce physiological meaningful
improvements in highly trained cyclists and that su-
perimposed environmental stress in practice can be im-
plemented in elite athletes training program. To allow
for a very systematic approach with “clean interventions”
and matched control groups, the scientific research in-
cluding the prolonged heat-­acclimation studies that we
have completed are usually completed during the pre-­or
off-­season. However, from case observations including
Hb-­mass evaluations from professional cyclists,40 it is our
experience that both heat-­training and altitude camps
can induce similar responses in cyclists during the com-
petitive season—­if the interventions comply with previ-
ously mentioned guidelines on duration and intensity.
The ability to complete controlled in-­season studies is dif-
ficult (if not impossible) and evaluation of performance
effects are not straight forward to use for systematic
evaluation as changes in race schedule, mental stressors,
sickness or fatigue following races may interfere with the
performance effects. For practical in-­season purposes we,
therefore, advocate for monitoring the physiological fac-
tors of relevance (e.g., sweat rate, respiratory-­or blood
lactate-­responses to a standard exercise bout and Hb-­
mass changes) either to supplement or substitute for per-
formance testing as tracer of adaptation. This approach
may be suitable both in terms of monitoring the onset and
NYBO et al.
F I G U R E 2   Delta changes (post–­pre)
in total Hb-­mass following prolonged
heat-­acclimation studies (5 weeks or
more) completes in heated room (climatic
Delta change in Hb-mass (g)
chambers—­open symbols) or training
in “sweat suit” (closed symbols) plotted
against the participants initial maximal
aerobic power (peak oxygen uptake/
kg body weight). Data are derived from
Mikkelsen et al.31 and two studies by
Rønnestad and coworkers.34,39
decay of acclimation, but should consider adequate re-
covery prior to testing to minimize influence from train-
ing or travel fatigue. How the overall stress experienced
by the elite athlete is affected by the additional stress su-
perimposed by undertaking heat-­training or going on an
altitude camp, should also be considered and the athletes
guided to account for example, dietary needs (to secure
iron status, water-­and electrolyte balance.41,42 In prac-
tice this is feasible to implement, if coaches and athletes
for heat-­acclimation use the approach of substituting/al-
locating part of the less intense part of the weekly/daily
training to induce heat stress (see our practical guidelines
below) and for altitude accept that power output in gen-
eral is lower when exposed to hypoxia. However, with
minor adjustments the physiological training stimuli may
be maintained as discussed above.
8   |   S H O UL D T H E CYCLIST G O
H I G H , G O H OT OR COMB IN E ?
Considering that the non-­hematological adaptations are
specific to the environmental stressor, the choice between
heat-­or altitude acclimation may eventually depend on
the specific exposure scenario for the given stage race.
For example, if several stages with mountain finishes
are located in the first part of the race and the risk of
profound heat is low, an altitude camp in the last lead-
­in phase may be prioritized. Reversely, if high heat stress
is expected and flatter stages scheduled in week-­one. The
non-­hematological effects (sudomotor adaptation to heat-­
acclimation and the respiratory response to hypoxia) are
targeting different organs and although there may be
some interference, it is possible for athletes to be adapted
  |
   7
Heated room
160 Sweat Suit
140
120
100
80
60
40
20
-20
-40
50 60 70 80 90
-1 -1
Maximal Oxygen Uptake (ml min kg )
to both stressors at the same time.43–­45 In contrast, it is not
straight forward to combine the two acclimation modes
in terms of the hematological adaptations. Although, it is
clearly attractive to gain both the hypoxia-­related stimu-
lation of erythropoiesis and the plasma volume expan-
sion with associated Hb-­mass gain from heat-­training, it
appears that the two may clash if imposed in combina-
tion.8,46 As mentioned previously, altitude exposure typi-
cally induce an acute reduction in plasma volume, while
the opposite response is a significant and presumable
important part of the heat-­acclimation required to drive
the prolonged hematological response. However, well-­
controlled studies with sufficient duration are lacking to
test if the two stressors can be combined (concomitantly
or one subsequent to the other).
Another aspect relevant to considerer for the individ-
ual athlete is whether acclimatization to heat or hypoxia
provide the best stimulus in terms of the Hb-­mass gain.
As exemplified for prolonged heat-­training by the vari-
ation across athletes in Figure  2 (but not dependent on
the initial blood/plasma volume or training status) and
observed individual variation across a large number of
heat and altitude camps,2,47 there may be some individ-
uals responding with a large gain in blood volume, while
others may have very limited benefit and no change in
Hb-­mass. Without, going into a complex discussion on
responders/non-­responders (that from a scientific robust
point of view would require replication of the individual
responses across several camps and/or testing of sufficient
exposure [e.g., longer time or increased intensity required
for that athlete]), it is obvious that some athletes benefit
more than others from a given intervention. Monitoring
individual responses during the first heat or altitude camp
are from our point of view relevant, both to identify how
 |
8       NYBO et al.
a given athlete adapts and for subsequent individualized
optimization.
Finally, it is very relevant to consider the decay of ac-
climation, both for the non-­hematological adaptations
and the ability to maintain the elevated blood volume
in the period after the acclimation/training camp. The
fast decay of Hb-­mass following return from altitude to
sea level is indeed a large challenge (and physiological
puzzle15) and the ability to maintain a sufficient hy-
poxic stimuli may be more difficult that for heat, where
we observe that “maintenance training” with as little
as 3 weekly session (1  h exposures) may be sufficient
to preserve the Hb-­mass gain induced by a proceed-
ing 5  week intervention.39 The latter implies that heat-­
training may be integrated in a competition period or
performed in close proximity to the start of a Grand Tour
without compromising tapering and peaking of perfor-
mance. Furthermore, during the stage race the combined
environmental-­ exercise heat stress may even on days
with moderate temperatures be sufficient to prevent or
minimize the decay of adaptation.39
9   |   A LT I T UDE AN D HE AT-­
ACC L I M AT I O N T R AIN IN G IN
P R ACT I C E AN D POT E N T IALS FOR
I MP ROV E M EN T
Both for altitude and as discussed for heat acclimatization,
the adequate intensity, duration and consistence of expo-
sure to elicit the acclimation may be achieved by various
approaches. For specific examples and descriptions on
how the level of hypoxia or hyperthermia was controlled,
we refer to the original studies referenced. Here we will
provide our best guidance on the parameters of impor-
tance and how they from our experience in work with
cyclists (scientific studies and advice of athletes) may be
implemented in practice.
1 0   |   FO R ALT IT U DE W E
E M P H A S I Z E T HE IM PORTAN CE OF
Sufficient duration: at least 3 weeks, but preferably longer
as the Hb-­mass response seems to be more consistent and
keeps increasing with longer exposure.
Consistency of the exposure: To secure sufficient
hours/day the cyclists should live and complete the pre-
dominant part of the training at altitude. The training
routes may naturally take riders to lower altitudes (for
shorter periods), but no need to deliberately go low for
training. The lower power output and energy turnover at
altitude, seems to be compensated for by elevated heart
rate at given exercise intensity and the hypoxia-­induced
stress on muscle metabolism.
Staying high enough: preferably above 2500 m as
residence at lower altitudes may increase the risk of
the intensity (level of hypoxia) being too low for some
individuals.
11  |   FOR HEAT ACC LIMATIO N
WE RECOMMEND
Sufficient duration: While the non-­hematological adapta-
tions may be achieved with short-­term protocols (within
days) the full potential and Hb-­mass elevation require
prolonged acclimation. We have used ~5 weeks (with at
least 5 weekly sessions) to secure enough time. It remains
to be tested if 3–­4 weeks with more consistent exposure is
sufficient (one study suggest so), but 2 weeks are appar-
ently not adequate.
Moderate intensity and duration of the heat stress/
level of hyperthermia: In the studies where we have
aimed at core temperatures between 38.5 and 39°C at
the end of ~1 h cycling in heated room or via sweat suit
training, we observe Hb-­mass adaptations and eleva-
tions in sweat rate that are comparable to studies with
longer session or more intense heat stress (end core of
~40°C). There thus seems no need to go for longer or
maximal sessions. Sweat rates of 1.5 L/h or above, main-
tain RPE (perceived exertion) to moderately hard and
core temperature during the latter part of the session in
the range of 38.5°C will provide sufficient stimulus and
not “overstress” the athletes.
Consistent exposure and maintenance afterward:
Frequent exposure over a consecutive period is most
likely advantageous, but once heat-­acclimation has been
achieved athletes may prevent the decay via combining
few heat-­ training sessions (e.g., 3 per week—­ or some
exposures substituted with passive exposure if reduced
training/tapering exclude high volume) with the exercise-­
induced more modest heat stress that most athletes expe-
rience during normal training/competition.
FUNDING INFORMATION
Lars Nybo and Carsten Lundby are supported by The
Novo Nordisk Foundation grant to Team Danmark.
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data
were created or analyzed in this study.
ORCID
Lars Nybo  https://orcid.org/0000-0002-9090-1958
Bent Rønnestad  https://orcid.org/0000-0002-6907-1347
NYBO et al.
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How to cite this article: Nybo L, Rønnestad B,
Lundby C. High or hot—­Perspectives on altitude
camps and heat-acclimation training as preparation
for prolonged stage races. Scand J Med Sci Sports.
2022;00:1-10. doi: 10.1111/sms.14268