- Case report
- Open Access
Nutritional strategies in an elite wheelchair marathoner at 3900 m altitude: a case report
Journal of the International Society of Sports Nutrition volume 16, Article number: 51 (2019)
Altitude training is a common practice among middle-distance and marathon runners. During acclimatization, sympathetic drive may increase resting metabolic rate (RMR), therefore implementation of targeted nutritional interventions based on training demands and environmental conditions becomes paramount. This single case study represents the first nutritional intervention performed under hypobaric hypoxic conditions (3900 m) in Paralympic sport. These results may elucidate the unique nutritional requirements of upper body endurance athletes training at altitude.
This case study examined the effects of a nutritional intervention on the body mass of a 36-year-old professional wheelchair athlete (silver medalist at the Paralympic Games and 106 victories in assorted road events) during a five-week altitude training camp, divided into pre-altitude at sea level (BN), acclimatization to altitude (Puno, 3860 m) (BH), specific training (W1,2,3,4) and return to sea level (Post) phases. Energy intake (kcal) and body mass (kg) were recorded daily. Results demonstrated significant decrease in body mass between BN and BH (52.6 ± 0.4 vs 50.7 ± 0.5 kg, P < 0.001) which returned to pre-altitude values, upon returning to sea level at Post (52.1 ± 0.5 kg). A greater daily intake was observed during BH (2899 ± 670 kcal) and W1,2,3 (3037 ± 490; 3116 ± 170; 3101 ± 385 kcal) compared to BN (2397 ± 242 kcal, P < 0.01) and Post (2411 ± 137 kcal, P < 0.01). No differences were reported between W4 (2786 ± 375 kcal), BN and Post. The amount of carbohydrates ingested (g · kg− 1) was greater in W1,2,3, (9.6 ± 2.1; 9.9 ± 1.2; 9.6 ± 1.2) than in BN (7.1 ± 1.2) and Post (6.3 ± 0.8, P < 0.001). Effect sizes (Cohen’s d) for all variables relative to BN (all time points) exceed a large effect (d > 0.80).
These results suggest an elite wheelchair marathoner training at 3860 m required increased nutrient requirements as well as the systematic control needed to re-adapt a nutritional program. Moreover, our findings highlight training and nutritional prescription optimization of elite wheelchair athletes, under challenging environmental conditions.
In recent years, there has been emerging interest in the optimization of nutritional strategies to help athletes reach their fitness goals during hypoxic training conditions . However, nutritional guidelines for athletes training at 4000 m altitude remain unclear as most nutritional and exercise metabolism studies have been completed at lower altitudes [1, 2], and the data reflects athletes participating in activities less than marathon distances [3,4,5,6,7,8,9]. For example, in distance running only one study has examined well-trained runners at an altitude of 4000 m  and, recently a case study reported physiological data on an elite wheelchair marathoner training at 3900 m altitude . Loss of body fat and fat free mass have been reported during high altitude sojourns in people eating ad libitum [12,13,14,15], suggesting that strict altitude imposed dietary controls can attenuate daily energy deficits and partially mitigate weight loss . Loss of fat free mass at high altitude increases the risk of illness and injury in extreme environments [5, 17,18,19]. During acclimatization there is a reduction of intra and extracellular water combined with a decrease in plasma volume [6, 20], which can result in body mass loss up to 2 kg . Furthermore, during acute phase exposure, total exogenous glucose oxidation appears to be lower than at sea level, and after 21 days of initial exposure at 4300 m not reaching sea level, suggesting oxidation rates under hypoxic conditions do not cover the energy demands of athletes at altitude . Alternatively, other studies suggest individuals have an increased dependence on glucose as a fuel source at high altitude, especially during exercise [3, 7, 8].
Increased resting metabolic rate (RMR) has also been observed at altitude, which could be due to increased sympathetic drive and subsequent rise in adrenaline levels . Recent research found that RMR in elite middle-distance runners increased by ≈ 19% at a moderate altitude (2100 m) compared to sea-level conditions  and 10% at high altitude (3800 m) . In contrast, a small decrease in RMR was reported in a group of Olympic rowers training at 1800 m . Moreover, RMR is more pronounced over the first 2–3 days after arrival [16, 24]. However, elevated RMR (≥ 17%) can persist for up to 21 d after initial high altitude exposure . Ultimately, energy expenditure which is elevated at altitude may be equivalent to high intensity exercise conducted at sea level .
Due to the aforementioned factors, one of the primary nutritional goals for managing a successful altitude training camp involves matching the energy intake to the daily expenditure in order to minimize body mass loss . In fact, it was reported that, a total of 7.6 g · kg− 1 body mass of carbohydrates (CHO) per day did not cover the energetic demands of cyclists living and training at 4300 m . Importantly, up to 70% of the chronic altitude exposure-related weight loss is said to be due to reductions in muscle mass itself . To consider, D’Hulst & Deldique  recently suggested that based on the hypoxic dose theory , an exposure of 5000 km · h− 1 is the cutoff point above which muscle loss starts to occur. However, at altitude the stimulation of protein synthesis after exercise might be blunted by hypoxia, as it was shown that increase in muscle protein synthesis following walking at 4559 m  was much lower than a comparable study with exercise performed at sea level . Interestingly, in a separate study, body mass was maintained in ski mountaineers following an isocaloric diet of 4000 kcal · d− 1, supplemented with 1.5 g or 2.5 g · kg body mass casein protein per day during seven days at 2500–3800 m . Moreover Bigard and colleagues examined the effects of branch chain amino acids (BCAA) (7.8 g leucine, 3.4 g isoleucine, 11.2 g valine; 1.44 g protein · kg · d) compared to carbohydrate supplementation on body composition following six days of ski mountaineering at 2500–3800 m. Body composition and muscular performance were unaffected by BCAA. However, significant weight loss only occurred in the carbohydrate-supplemented group (− 1.55 vs. -0.8 kg) .
The purpose of this study was to examine the effects of a nutritional intervention on the body mass of an elite wheelchair marathoner during a five-week training camp performed between sea level and 3900 m altitude. The intervention was designed to anticipate increases in RMR due to the combined effects of both environmentally induced hypoxia and the demands of marathon training.
The study athlete was a 36-year-old, elite wheelchair marathoner, functional class T52 (upper limb involvement category). Some of his accolades include winning a silver medal at the Paralympic Games and 106 victories in assorted road events, including a win at the 2016 Boston Marathon, ten weeks after returning to sea level from Los Andes (Peruvian Altiplano). Our participant’s height = 1.76 m; body mass = 52.6 ± 0.4 kg; power output at second ventilatory threshold = 62 W; training 8000 km per year; former world record holder in the T52 division in 800 m (1 min:56 s); 1500 m (3 min:36 s); world record holder in 5000 m (12 min:37 s); half marathon (50 min:28 s) and fourth best ever time in marathon (1 h:42 min:05 s). Additionally, he has more than ten years of altitude training experience, with training camps performed in Boulder, CO (1655 m), Navacerrada, Spain (1858 m), Flagstaff, AZ (2106 m), Sierra Nevada, Spain (2320 m), Keystone, CO (2796 m) and Breckenridge, CO (2926 m), performing both altitude models: Live-High-Train-High (LHTH) and Live-High-Train-Low (LHTL) and has been exposed to more than 8000 h of normobaric-hypoxia. For the last five seasons prior to the current study, the athletes trained at moderate altitudes (1655 up to 2926 m) for: 78, 82, 101, 79 and 62 days.
The athlete requested advice for the development of an individualized nutritional program based on training loads to prepare for his upcoming season. Therefore, after consultation with laboratory members a nutrition program was designed, according to his training load (Table 1).
The research participant provided written consent prior to participation in the current study and read the manuscript before submission. Research was approved by the Ethics Research Committee of the University Miguel Hernandez.
Both pre-altitude (BN), at 16 m and acclimatization (BH) at 3900 m incorporated identical training loads (128 km of mileage each). However, the first two days of BH incorporated no training to minimize the effects of jet-lag, and acute mountain symptoms (AMS), like headache . Two daily training sessions were performed from Wednesday to Friday under the first ventilatory threshold (<VT1). The morning session involved 20 km of distance training and the afternoon session 16 km. A 20 km workout was performed on Saturday <VT1. Sunday was a rest day. Specific training weeks “W1, W2, W3 & W4” were based on a day-to-day basis periodization, according to level of heart rate variability (HRV) . When the HRV reached a reference value (RV), the subject completed a specific session in the morning, followed by an evening off. If the RV was not reached, two workouts <VT1 were performed: 20 km in the morning and 16 km in the afternoon. On three days the training was fixed; On Mondays and Thursdays the AM sessions were 16 km < VT1, while the PM sessions involved resistance training and Sundays were off. The specific sessions were known as: A (20 × 400 m at ~ second ventilatory threshold (VT2) in a plateau at 4090 m altitude; recovery reps: 75 s); B (30 km ~ VT1) and C (6 × 2000 m ~ VT2 in a plateau at 4090 m altitude; recovery reps: 120 s).
As a way to induce muscle hypertrophy, resistance sessions were performed at 80% of 1 RM  with 4 sets of 8 reps with 150 s recovery, aimed at avoiding loss of muscle mass induced by chronic hypoxia. RM test was not performed under altitude conditions due to high risk of injury, so it was done four days before flying to Peru. More details on the experimental design have been reported previously .
Throughout the experiment, basal body mass was recorded in fasting conditions, naked, after waking up, with a digital scale (Tanita BC-601®, TANITA Corporation, Tokyo, Japan). Utilizing a food recording system previously reported , a nutritional diary was maintained by the subject to record daily intake, which included main meals (breakfast, lunch and dinner), two small snacks and all training activities that occurred post-intake (Figs. 1 and 2).
Total energy (kcal), carbohydrates, proteins and fats (g · kg− 1 body mass) were estimated according to nutritional composition database supported by the Spanish Ministry of Science and Innovation .
The athlete was instructed by a nutritionist to prepare all meals which included weighing both ingredients prior to cooking and left overs prior to disposal. On days when the athlete ate at restaurants, which occurred on four occasions, he was instructed to send pictures of these meals to the research team . A personal chef was contacted to buy and cook all foods/ingredients for the athlete on a daily basis according to athlete instructions while the weighing and cooking process occurred under the athlete’s supervision. Additionally, the athlete was instructed to prepare all training drinks and post-training recovery solutions. To prevent contamination, the athlete did not eat raw foods or unpeeled fruits or vegetables and no water from the tap was consumed . At sea level the athlete cooked all meals at home.
Daily energy intake was increased ~ 20% from pre-altitude (BN), to arrival at altitude (BH) to avoid body mass loss from increased RMR which is common while living and training at higher altitudes [2, 22]. Moreover, main meals were designed according to the type of training session performed (Fig. 2), as we have recently reported that during specific training weeks (W1,2,3,4) number of A,B,C, sessions differed between specific training weeks, according to a training program based in HRV , which explains why at W2 the greatest amount of CHO was ingested (9.9 ± 1.2 g · kg− 1 body mass), and why during BH and W4 the total amount of CHO tended to be lower than W1,2,3 ( Table 2). Moreover, main meals were accompanied by two rich-carbohydrate snacks, based on reports that the inclusion of several rich carbohydrate snacks, more optimally covers increased energy requirements than three standalone main meals . Furthermore, regarding proteins, a minimum intake of 2.4 g · kg− 1 body mass was targeted in the current nutritional design to avoid loss of lean mass . To avoid gastrointestinal issues (GI) and fullness , a low protein/fat intake was provided for breakfast and PM sessions, however the percentage of lipids at lunch was lower than dinner. Protein intake at lunch and dinner were ≈ 1 g · kg− 1, given that specific and, more demanding sessions (A,B,C) were performed in the morning, and muscle tissue repair is a main meal target. The ingestion of lipids was set at a minimum of 1 g · kg− 1 body mass throughout the sea level and altitude camps, as fat cells increase their sensitivity to hormonal stimulation after training, resulting in a greater mobilization of fatty acids . Moreover, an Iso-Lyn Isotonic (AMIX) sports drink was used for workouts < VT1 shorter than 65 min (20 and 16 km). The athlete was instructed to drink a solution with 750 ml of water and 56.4 g of CHO, while a solution of 1250 ml with 80 g of CHO was recommended for specific sessions. The CHO rate was 0.5 to 1 g · kg− 1 body mass per hour . Despite these recommendations, the athlete and team elected to preserve his natural drinking habits that involved consuming drinks every 10 min. This decision was made because fluid consumption for a wheelchair racer can be precarious during propulsion, as they must come out of their natural prone/kneeling body position to drink. This action can force loss of vision, which increases the risk of collision or crashing. Because our participant never experienced GI in his career with the use of carb gels , he drank a 42 g CHO (Glucose + Fructose) Iso-Gel carbo snack (AMIX) during specific sessions workouts . Gels were consumed in the A session after fourteen 400 m rep, in the B session 90 min after starting, and in the C session after four 2000 m rep. Both types of carbs used in the solution and gels were multiple transportable carbohydrates, as directed by Jeukendrup .
During gym sessions water was consumed ad libitum and immediately after gym sessions the athlete co-ingested a rich leucine whey protein (23.6 g) (Whey Fussion, AMIX) dissolved in 400 ml of water and a carbohydrate gel (Iso-Gel Recovery, AMIX) (37.6 g maltodextrin + fructose + Vitargo®) as directed for speeding up to 25% glycogen synthesis . For refueling purposes carbohydrate guidelines , suggest aiming for post-exercise rapid recovery of muscle glycogen deposits, with 1 g · kg− 1 body mass of CHO, repeated every 2–3 h. After specific sessions, a carbohydrate shake was taken with a carbohydrate gel, providing 1.4 g · kg− 1 body mass. In the hour immediately after 16 km and 20 km < VT1, the subject drank a carbohydrate solution (Carbojet Gain, AMIX) (34 g CHO, 7.5 g prot, 1.8 g fat) dissolved in 400 ml of water, and after specific sessions he ingested a combination of the same drink plus Iso-Gel Recovery. To consider, 2.4 g · kg− 1 body mass, CHO were consumed (Fig. 1) at lunch which occurred approximately two hours post-exercise meal, in order to achieve 3.1 g · kg− 1 body mass of CHO 3 h post-exercise for our athlete vs. 3 g · kg− 1 body mass as suggested by Burke and colleagues .
On specific session days, rest was provided in the evenings along with a snack at 5:30 PM, to meet increased energy requirements . This snack included two 30 g cereal bars (Tri-Fit Bar, AMIX) (34.9 g CHO, 3.9 g prot, and 10.1 g fat).
In a manner to avoid loss of body mass  and enhance muscle protein synthesis  the athlete consumed 2.5 g leucine, 1.5 g isoleucine, and 1.5 g valine) immediately after each session (BCAA Elite Rate, AMIX). Before bedtime, 30 g of casein protein (Micellar Casein, AMIX) (1.7 g CHO, 24 g prot, 0.6 g fat) was ingested as suggested by Snijders and colleagues .
Finally, the athlete maintained iron levels through a daily intake of 105 mg of ferrous sulphate (Ferogradumet®, Ross, Abbott Científica), as ferrous sulphate intake has been related to the production of Hemoglobin and red cells [49, 50]. To comply with World Anti-Doping Agency (WADA) regulations, none of the aforementioned supplements contain prohibited substance.
For a description of the macronutrients intake during main meals in each session see Fig. 1.
All data are presented as mean ± SD. A repeated-measures ANOVA was carried out for all the variables including the factor TIME with levels BN, BH, W1, W2, W3, W4 and Post. A post hoc least significance difference (LSD) multiple-range test was performed to determine differences between the factor levels. Effect size (d) associated with change in body mass was calculated using Cohen’s d (difference in mean scores over time divided by pooled SD) with its 95% confidence limits (CL)  and were interpreted as trivial (≤ 0.19), small (0.20–0.49), medium (0.50–0.79), and large (≥ 0.80) . An alpha level of 0.05 was stated for statistical significance. Statistical analyses were performed using the SPSS version 22.0 (SPSS, Inc., Chicago, IL, USA) software.
Our nutritional intervention results can be found in Table 2.
A significant decrease in body mass was observed from BN to BH [P < 0.001; d = 4.16, 95% CL (2.02; 5.71)] but returned to near baseline levels during Post. There were no significant effect for time during the W1,2,3 period, however we observed a significant increase in body mass from W1 to W4 [P < 0.001; d = 2.35, 95% CL (0.86; 3.51)].
Results show a greater amount of kcal in BH [P < 0.01; d = 0.96, 95% CL (− 0.25; 2.04)] and W1 [P < .01; d = 1.61, 95% CL (0.27; 2.73)], W2 (P < 0.01; d = 3.49, 95% CL (1.59; 4.91)], W3 [P < 0.01; d = 2.15, 95% CL (− 0.66; 3.33)] than in BN. Same differences were observed within BH [P < 0.01; d = 0.97, 95% CL (− 0.24; 2.05)], W1 [P < 0.01; d = 1.68, 95% CL (0.31; 2.80)], W2 [P < 0.01; d = 4.52, 95% CL (2.26; 6.16)], W3 [P < 0.01; d = 2.31, 95% CL (0.78; 3.51)] and Post. No differences were reported between W4, BN and Post.
The amount of CHO ingested (g · kg− 1 body mass) was greater in W1 [P < 0.001; d = 1.43, 95% CL (0.12; 2.53)], W2 [P < 0.001; d = 2.33, 95% CL (0.80; 3.54)], W3 [P < 0.001; d = 2.08, 95% CL (0.62; 3.26)] than in BN. Differences were observed within W1 [v0.01; d = 2.01, 95% CL (0.56; 3.17)], W2 [P < 0.01; d = 3.47, 95% CL (1.58; 4.88)], W3 [P < 0.01; d = 3.18, 95% CL (1.38; 4.53)] and Post.
Protein intake (g · kg− 1 body mass) was greater in BH (P < 0.001; d = 2.54, 95% CL (0.95; 3.79)] and W1 (P < 0.001; d = 2.03, 95% CL (0.58; 3.20)], W2 (P < 0.001; d = 2.16, 95% CL (0.67; 3.34)], W3 (P < 0.001; d = 2.03, 95% CL (0.58; 3.20)], W4 (P < 0.001; d = 2.31, 95% CL (0.78; 3.52)] than in BN. Same differences were found within BH (P < 0.01; d = 2.38, 95% CL (0.83; 3.59)], W1 (P < 0.01; d = 1.90, 95% CL (0.48; 3.05)], W2 (P < 0.01; d = 1.96, 95% CL (0.52; 3.11)], W3 (P < 0.01; d = 1.90, 95% CL (0.48; 3.05)], W4 (P < 0.01; d = 2.00, 95% CL (0.56; 3.16)] and Post.
No differences were found in lipids intake (g · kg− 1 body mass) within any period.
The aim of this case study was to assess the effectiveness of an evidence based individualized nutrition program applied to an elite wheelchair marathoner during a five-week altitude training camp, carried out in the Peruvian Altiplano (Puno, Peru) at 3900 m. The program was designed based on existing literature for its ability to sustain the athlete’s body mass and meet the energetic demands of intense training, while promoting substrate availability, nutrient recovery, and muscle tissue repair. Interestingly, the designed nutritional intervention helped to: 1) maintain the athlete’s body mass throughout the altitude camp, 2) minimize performance deficits during intense training at altitude compared to sea level (~ 20 to ~ 24% in 1609 m and 3218 m reps respectively) , as evidence by recently reported data demonstrating a ~ 3% reduction in reps (2000 m) , 3) facilitate intra-sessions recovery through faster glycogen restoration, helping the athlete to perform during physiological demanding sessions (~ VT2) when completed consecutively, or until two sessions of ~ 2 h at ~ VT1 at W2 , and 4) maintain quality training sessions at altitude as evidence by: a) improved power output, 11-d post-altitude compared to 4-d pre-altitude (44 W vs 50 W), b) time reductions during 3000 m races 12-d post-altitude compared to 3-d pre-altitude (472 s vs 456 s) .
At 4300 m there can be an increase in respiratory water loss, due to greater ventilation and an increase in urinary water loss that can increase up to 500 ml per day . This could explain the nearly 2 kg weight loss observed from baseline (BN) to acclimatization phase (BH) and the return to pre-altitude levels in post (Table 2). It should be noted that there was an increment of energy intake of ≈ 500 kcal in hypoxic conditions compared to normoxic conditions (P = 0.001) and same training was done in BN and BH (Fig. 2). Of note, all effect sizes associated with statistically significant changes in body mass far exceeded Cohen’s convention for a large effect.
Increased RMR has been reported in athletes who live and train at altitude . For this reason, to maintain body mass in the current study, there was a significant increase in the amount of carbohydrates per kilogram of body mass and proteins per kilogram of body mass provided at altitude compared to sea level. We suspect that the slight increase in body mass observed in W4 was induced by the different number of specific sessions performed from W1 to W4; 2 in W1, 3 in W2, 2 in W3 and 1 in W4 . To increase energy supply, as a result of a greater energy demands and to avoid GI, six meals (breakfast, post-training AM, lunch, snack or post-training PM, dinner and bedtime) were projected in an elapsed time within three hours each one (Fig. 1), as it has been recommended to include several rich carbohydrate snacks, rather than three main meals . We did not find differences in energy intake between acclimatization (BH) and specific training weeks (W1 to W4) however this could be due to the fact that when the athlete performed a specific session in the morning, a rest afternoon was followed, in spite of two sessions performed daily during acclimatization with 36 km volume (Fig. 2). Furthermore, we did not consider a slightly lower exogenous glucose oxidation rate during acclimatization and chronic altitude , as it has been reported that such observations should be contrasted with fully fed individuals, although evidence exists to the contrary [3, 8]. Three hours before training sessions, a rich CHO meal was consumed, as it has been shown to increase glycogen availability . We recommended that the athlete change from cereals to a lower fiber food like white bread to avoid GI distress however because of disability imposed manual dexterity deficits which prevent cutting bread slices and spreading fruit jam, he decided to use cereals. The research team also had to consider that the athlete ate breakfast by seven in the morning, which was nearly two and a half hours before training sessions. However, the athlete commonly practiced training in a fasted state like this during training sessions at home, to minimize GI. Despite the athlete’s comfortability with this practice, it was discarded in Puno because temperatures were extremely cold by 7 am (~ 0 °C) and he trained barefoot.
To avoid a loss of muscle mass, high-protein foods were spread out across all meals (Fig. 1), while whey and casein protein training products were consumed to ensure minimum requirements of 2.4 g · kg− 1 body mass were achieved . However, we have to consider that the hypoxic dose  of this training camp was 3300 km · h− 1, not reaching the cut off point, where muscle loss begins . Due to personal preferences, protein delivery by meat was introduced at lunch, while fish was eaten at dinner. No eggs were eaten while training however the athlete ate an omelet for lunch during rest days (Table 1).
Main limitations of this study are evident in the absence of outcomes like upper body skinfolds, and upper arm circumference measurements, which could help us to know if body fat percentage and loss of muscle mass occurred in our athlete which was reported previously in subjects eating ad libitum under hypoxic conditions [12,13,14,15]. Moreover, RMR was not assessed, as recently reported  in Olympic rowers training at 1800 m who did not show an increase in RMR. However, our athlete was exposed to more intense hypoxic conditions, so sympathoexcitation may have occurred  leading to elevated adrenaline levels and subsequent greater energetic demands. Another limitation was evident in the use of a self-reported intake diary conducted without supervision from a nutritionist, however the athlete was provide instructions for meal preparation as described previously. Importantly, similar self reported nutritional tools have been validated for estimating energy and nutrient intake . Also, the use of pictures on four occasions to record restaurant meal consumption must be considered as a limitation. However, this methodology has been supported by exercise nutritionists as a useful strategy, particularly when research teams are not present . Finally, the absence of muscular biopsies did not allow us to measure glycogen and protein muscle content.
The aim of the daily meal distributions (Fig. 1) was to cover the energetic demands of training sessions and to ensure substrate availability, nutrients recovery, and muscle tissue repair according to literature recommendations.
This paper can help us to better understand the unique nutritional requirements of upper body endurance athletes during altitude training conditions where nutritional strategies may differ from able-bodied athletes. Importantly, to confirm and expand on the current findings specific to the aforementioned differences between able bodied and upper limb athletes, more research is needed on both populations. However, analogous studies are scarce in able bodied athletes and nonexistent in upper limb athletes. For example, only one study, published in 1967 examined well-trained athletes at 4000 m , while others have investigated nutritional interventions or exercise metabolism at moderate altitudes only (2150 m) [1, 2]. To date, the only other studies conducted at altitudes similar to ours involved either dissimilar sports disciplines , lacked a nutritional component , or utilized none elite athletes . Ultimately, this study represents the first nutritional intervention conducted on an elite wheelchair marathoner under altitude conditions. Since no specific nutritional interventions have been performed on able-bodied marathon runners or wheelchair athletes at 4000 m altitude, all nutritional guidelines were reflective of the literature pertaining to able-bodied athletes training at lower altitudes.
Ultimately, our nutritional intervention targeted body mass maintenance to sufficiently anticipate increases in RMR due to the combined effects of environmentally induced hypoxia and the demands of marathon training. Moreover, the intervention helped minimize performance perturbations, facilitated overall recovery, and enhanced athlete performance post-altitude. Future related studies should be designed based on considerations from the current study, however with more specificity therefore utilizing deeper assessment tools like biological samples. For example biopsies could be applied to determine the protein and glycogen synthesis-breakdown cycle of athletes during periods of intense training.
Availability of data and materials
Please contact authors for data requests.
Acute mountain symptoms
Branch chain amino acids
- BH :
- BN :
Heart rate variability
Resting metabolic rate
First ventilatory threshold
Second ventilatory threshold
- W1,W2, W3, W4 :
Specific training weeks at altitude
Heikura IA, Burke LM, Bergland D, Uusitalo ALT, Mero AA, Stellingwerff T. Impact of energy availability, health and sex on hemoglobin-mass responses following live-high-train-high altitude training in elite female and male distance athletes. Int J Sports Physiol Perform. 2018;13:1090–6.
Woods AL, Sharma AP, Garvican-Lewis LA, Saunders P, Rice T, Thompson KG. Four weeks of classical altitude training increases resting metabolic rate in highly trained middle-distance runners. Int J Sport Nutr Exerc Metab. 2016;27:83–90.
Brooks GA, Butterfield GE, Wolfe RR, Groves BM, Mazzeo RS, Sutton JR, Wolfel EE, Reeves JT. Increased dependence on blood glucose after acclimatization to 4300 m. J Appl Physiol. 1991;70:919–27.
Fulco CS, Kambis KW, Friedlander AL, Rock PB, Muza SR, Cymerman A. Carbohydrate supplementation improves time-trial cycle performance during energy deficit at 4300-m altitude. J Appl Physiol. 2005;99:867–76.
Sergi G, Imoscopi A, Sarti S, Perissinotto E, Coin A, Inelmen EM, Zambon S, Busetto L, Seresin C, Manzato E. Changes in total body and limb composition and muscle strength after a 6-8 weeks sojourn at extreme altitude (5000-8000m). J Sports Med Phys Fitness. 2010;50:450–5.
Hoyt RW, Durkot MJ, Kamimori GH, Schoeller DA, Cymerman A. Chronic altitude exposure (4300 m) decreases intracellular and total body water in humans. In: Sutton JR, Coats G, Houston CS, editors. Hypoxia and mountain medicine. Burlington: Queen City printers; 1992. p. 306.
Roberts AC, Butterfield GE, Cymerman A, Reeves JT, Wolfel EE, Brooks GA. Acclimatization to 4300-m altitude decreases reliance on fat as a substrate. J Appl Physiol. 1996;81:1762–71.
Roberts AC, Reeves JT, Butterfield GE, Mazzeo RS, Sutton JR, Wolfel EE, Brooks GA. Altitude and beta-blockade augment glucose utilization during submaximal exercise. J Appl Physiol. 1996;80:605–15.
Young AJ, Berryman CE, Kenefick RW, Derosier EN, Margolis LM, Wilson MA, Carrigan CT, Murphy NE, Carbone JW, Rood JC, Pasiakos SM. Altitude acclimatization alleviates the hypoxia-induced suppression of exogenous glucose oxidation during steady-state aerobic exercise. Front Physiol. 2018;9:830.
Buskirk ER, Kollias J, Akers RF, Prokop EK, Reategui EP. Maximal performance at altitude and on return from altitude in conditioned runners. J Appl Physiol. 1967;23:259–66.
Sanz-Quinto S, López-Grueso R, Brizuela G, Flatt AA, Moya-Ramón M. Influence of training models at 3900 m altitude on the physiological response and performance of a professional wheelchair athlete: a case study. J Strength Cond Res. 2019;33:1714–22.
Boyer SJ, Blume FD. Weight loss and changes in body composition at high altitude. J Appl Physiol. 1984;57:1580–5.
Consolazio CF, Matoush LO, Johnson HL, Krzywicki HJ, Isaac GJ, Witt NF. Metabolic aspects of calorie restriction: Hypohydration effects on body weight and blood parameters. Am J Clin Nutr. 1968;21:793–802.
Kayser B, Acheson K, Decombaz J, Fern E, Cerretelli P. Protein absorption and energy digestibility at high altitude. J Appl Physiol. 1992;73:2425–31.
Surks MI, Chinn KS, Matoush LR. Alterations in body composition in man after acute exposure to high altitude. J Appl Physiol. 1966;21:1741–6.
Butterfield GE, Gates J, Fleming S, Brooks GA, Sutton JR, Reeves JT. Increased energy intake minimizes weight loss in men at high altitude. J Appl Physiol. 1992;72:1741–8.
Hoppeler H, Kleinert E, Schlegel C, Claassen H, Howald H, Kayar SR, Cerretelli P. Morphological adaptations of human skeletal muscle to chronic hypoxia. Int J Sports Med. 1990;11:S3–9.
Fulco CS, Rock PB, Cymerman A. Maximal and submaximal exercise performance at altitude. Aviat Space Environ Med. 1998;69:793–801.
Murdoch DR. Symptoms of infection and altitude illness among hikers in the Mount Everest region of Nepal. Aviat Space Environ Med. 1995;66:148–51.
Milledge JS. Salt and water control at altitude. Int J Sports Med. 1992;13:S61–3.
Calbet JA. Chronic hypoxia increases blood pressure and noradrenaline spillover in healthy humans. J Physiol. 2003;551:379–86.
Stock MJ, Norgan NG, Ferro-Luzzi A, Evans E. Effect of altitude on dietary-induced thermogenesis at rest and during light exercise in man. J Appl Physiol. 1978;45:345–9.
Woods AL, Garvican-Lewis LA, Rice A, Thompson KG. 12 days of altitude exposure at 1800 m does not increase resting metabolic rate in elite rowers. Appl Physiol Nutr Metab. 2017;42:672–6.
Grover RF. Basal oxygen uptake of man at high altitude. J Appl Physiol. 1963;18:909–12.
Westerterp KR, Kayser B, Brouns F, Herry JP, Saris WH. Energy expenditure climbing Mt. Everest J Appl Physiol. 1992;73:1815–9.
Kayser B, Narici MV, Cibella F. Fatigue and performance at high altitude. In: Sutton JR, Houston CS, Coates G, editors. Hypoxia and molecular medicine. Burlington, NJ: Queen City press; 1993. p. 222–34.
MacDougall JD, Green HJ, Sutton JR, Coates G, Cymerman A, Young P, Houston CS. Operation Everest II: structural adaptations in skeletal muscle in response to extreme simulated altitude. Acta Physiol Scand. 1991;142:421–7.
D’Hulst G, Deldicque L. Human skeletal muscle wasting in hypoxia: a matter of hypoxic dose? J Appl Physiol. 2017;122:406–8.
Garvican-Lewis LA, Sharpe K, Gore CJ. Time for a new metric for hypoxic dose? J Appl Physiol. 2016;121:352–5.
Imoberdorf R, Garlick PJ, McNurlan MA, Casella GA, Marini JC, Turgay M, Bärtsch P, Ballmer PE. Skeletal muscle protein synthesis after active or passive ascent to high altitude. Med Sci Sports Exerc. 2006;38:1082–7.
Sheffield-Moore M, Yeckel CW, Volpi E, Wolf SE, Morio B, Chinkes DL, Paddon-Jones D, Wolfe RR. Postexercise protein metabolism in older and younger men following moderate-intensity aerobic exercise. Am J Physiol Endocrinol Metab. 2004;287:E513–22.
Bigard AX, Satabin P, Lavier P, Canon F, Taillandier D, Guezennec CY. Effects of protein supplementation during prolonged exercise at moderate altitude on performance and plasma amino acid pattern. Eur J Appl Physiol Occup Physiol. 1993;66:5–10.
Schneider M, Bärtsch P. Characteristics of headache and relationship to acute mountain sickness at 4559 meters. High Alt Med Biol. 2018;19:321–8.
Vesterinen V, Nummela A, Heikura I, Laine T, Hynynen E, Botella J, Häkkinen K. Individual endurance training prescription with heart rate variability. Med Sci Sport Exer. 2016;48:1347–55.
Campos GE, Luecke TJ, Wendeln HK, Toma K, Hagerman FC, Murray TF, Ragg KE, Ratamess NA, Kraemer WJ, Staron RS. Muscular adaptations in response to three different resistance-training regimens: specificity of repetition maximum training zones. Eur J Appl Physiol. 2002;88:50–60.
Spanish Ministry of Science and Innovation. Base de Datos Española de Composición de Alimentos (BEDCA). http://www.bedca.net/bdpub/index.php. Accessed 20 Jan 2017.
Martin CK, Correa JB, Han H, Allen HR, Rood JC, Champagne CM, Gunturk BK, Bray GA. Validity of the remote food photography method (RFPM) for estimating energy and nutrient intake in near real-time. Obesity. 2012;20:891–9.
Burke L. Practical issues in nutrition for athletes. J Sports Sci. 1995;13:S83–90.
Morton RW, McGlory C, Phillips SM. Nutritional interventions to augment resistance training-induced skeletal muscle hypertrophy. Front Physiol. 2015;6:245.
Dhillon J, Craig BA, Leidy HJ, Amankwaah AF, Osei-Boadi Anguah K, Jacobs A, Jones BL, Jones JB, Keeler CL, McCrory MA, Rivera RL, Slebodnik M, Mattes RD, Tucker RM. The effects of increased protein intake on fullness: a meta-analysis and its limitations. J Acad Nutr Diet. 2016;116:968–83.
Bjorntorp P. Importance of fat as a support nutrient for energy: metabolism of athletes. J Sports Sci. 1991;9:71–6.
Burke LM, Cox GR, Cummings NK, Desbrow B. Guidelines for daily carbohydrate intake. Int J Sports Med. 2001;31:267–99.
Pfeiffer B, Cotterill A, Grathwohl D, Stellingwerff T, Jeukendrup AE. The effect of carbohydrate gels on gastrointestinal tolerance during a 16-km run. Int J Sport Nutr Exerc Metab. 2009;19:485–503.
Jentjens RL, Moseley L, Waring RH, Harding LK, Jeukendrup AE. Oxidation of combined ingestion of glucose and fructose during exercise. J Appl Physiol. 2004;96:1277–84.
Jeukendrup AE. Carbohydrate feeding during exercise. Eur J Sport Sci. 2008;8:77–86.
Burke LM, Hawley JA, Wong SH, Jeukendrup AE. Carbohydrates for training and competition. J Sports Sci. 2011;29:S17–27.
Norton LE, Wilson GJ, Layman DK, Moulton CJ, Garlick PJ. Leucine content of dietary proteins is a determinant of postpandrial skeletal muscle protein synthesis in adult rats. Nutr Metab (Lond). 2012;9:67.
Snijders T, Smeets JS, van Vliet S, van Kranenburg J, Maase K, Kies AK, Verdijk LB, van Loon LJ. Protein ingestion before sleep increases muscle mass and strength gains during prolonged resistance-type exercise training in healthy young men. J Nutr. 2015;145:1178–84.
Stray-Gundersen J, Mordecai N, Levine BD. O2 transport response to altitude training in runners. Med Sci Sports Exerc. 1995;27:S202.
Garvican-Lewis LA, Vuong VL, Govus AD, Peeling P, Jung G, Nemeth E, Hughes D, Lovell G, Eichner D, Gore CJ. Intravenous iron does not augment the hemoglobin mass response to simulated hypoxia. Med Sci Sports Exerc. 2018;50:1669–78.
Cumming G, Finch S. A primer on the understanding, use, and calculation of confidence intervals that are based on central and noncentral distributions. Educ Psychol Meas. 2001;61:530–72.
Cohen J. A power primer. Psychol Bull. 1992;112:155–9.
Pasiakos SM, Berryman CE, Carrigan CT, Young AJ, Carbone JW. Muscle protein turnover and the molecular regulation of muscle mass during hypoxia. Med Sci Sports Exerc. 2017;49:1340–50.
Hansen J, Sander M. Sympathetic neural overactivity in healthy humans after prolonged exposure to hypobaric hypoxia. J Physiol. 2003;546:921–9.
The authors wish to thank the athlete who volunteered for this case study.
No funding was received for this study.
Ethics approval and consent to participate
This investigation had prior ethical approval by the Ethics Research Committee of the University Miguel Hernandez.
Consent for publication
The athlete provided consent for publication, after reading the last version of the manuscript.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
About this article
Cite this article
Sanz-Quinto, S., Moya-Ramón, M., Brizuela, G. et al. Nutritional strategies in an elite wheelchair marathoner at 3900 m altitude: a case report. J Int Soc Sports Nutr 16, 51 (2019). https://doi.org/10.1186/s12970-019-0321-8
- Nutritional intervention
- Energy intake
- Body mass