For more than a decade, the live high - train low (LHTL) approach, developed by Levine & Stray-Gundersen has been widely used by elite endurance athletes. Originally, it was pointed out, that by living at moderate altitude, athletes should benefit from an increased red cell volume (RCV) and haemoglobin mass (Hbmass), while the training at low altitudes should prevent from the disadvantage of reduced training intensity at moderate altitude. In acute hypoxia, VO2max is reduced linearly by about 6-8% in elite athletes from sea level to 3000m, with corresponding higher relative training intensities for the same absolute work load. With two weeks of acclimatisation, this initial deficit can be reduced by about one half. It has been debated during the last years, whether sea-level training or exposure to moderate altitude increases RCV and Hbmass in elite endurance athletes. Studies which directly measured Hbmass with the optimized CO-rebreathing technique demonstrated that Hbmass in endurance athletes is not influenced by sea-level training. We actually documented that Hbmass is not increased even after three years of training in national team cross-country skiers. When athletes are exposed to moderate altitude, new studies support the argument that it is possible to increase Hbmass temporarily by 5-6%, provided that athletes spend more than 400 hours at altitudes above 2300-2500m. However, this effect size is smaller than the reported IG-14% higher Hbmass values of endurance athletes living permanently at 2600m. It remains to be investigated, whether endurance athletes reach these values with a series of LHTL camps.
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