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Bonne TC, Jeppesen JS, Bejder J, Breenfeldt Andersen A, Olsen NV, Huertas JR, Nordsborg NB. Moderate hypoxic exposure for 4 weeks reduces body fat percentage and increases fat-free mass in trained individuals: a randomized crossover study. Sleep Breath 2023; 27:1611-1618. [PMID: 36178574 DOI: 10.1007/s11325-022-02713-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/29/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE We evaluated whether or not changes in body composition following moderate hypoxic exposure for 4 weeks were different compared to sea level exposure. METHODS In a randomized crossover design, nine trained participants were exposed to 2320 m of altitude or sea level for 4 weeks, separated by > 3 months. Body fat percentage (BF%), fat mass (FM), and fat-free mass (FFM) were determined before and after each condition by dual X-ray absorptiometry (DXA) and weekly by a bioelectrical impedance scanner to determine changes with a high resolution. Training volume was quantified during both interventions. RESULTS Hypoxic exposure reduced (P < 0.01) BF% by 2 ± 1 percentage points and increased (P < 0.01) FFM by 2 ± 2% determined by DXA. A tending time × treatment effect existed for FM determined by DXA (P = 0.06), indicating a reduced FM in hypoxia by 8 ± 7% (P < 0.01). Regional body analysis revealed reduced (P < 0.01) BF% and FFM and an increased (P < 0.01) FFM in the truncus area. No changes were observed following sea level. Bioelectrical impedance determined that BF%, FM, and FFM did not reveal any differences between interventions. Urine specific gravity measured simultaneously as body composition was identical. Training volume was similar between interventions (509 ± 70 min/week vs. 432 ± 70 min/week, respectively). CONCLUSIONS Four weeks of altitude exposure reduced BF% and increased FFM in trained individuals as opposed to sea level exposure. The results also indicate that a decrease in FM is greater at altitude compared to sea level. Changes were specifically observed in the truncus area.
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Affiliation(s)
- Thomas Christian Bonne
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Jan Sommer Jeppesen
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Jacob Bejder
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
| | - Andreas Breenfeldt Andersen
- Department of Nutrition, Exercise and Sports (NEXS), University of Copenhagen, Copenhagen, Denmark
- Section of Sport Science, Department of Public Health, Arhus University, Aarhus, Denmark
| | - Niels Vidiendal Olsen
- Department of Neuroscience and Pharmacology, University of Copenhagen, Universitetsparken 13, 2100, Copenhagen, Denmark
| | - Jesús Rodríguez Huertas
- Department of Physiology, Faculty of Sport Sciences, Institute of Nutrition and Food Technology, Biomedical Research Centre, University of Granada, Armilla, Granada, Spain
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Park Y, Jang I, Park HY, Kim J, Lim K. Hypoxic exposure can improve blood glycemic control in high-fat diet-induced obese mice. Phys Act Nutr 2020; 24:19-23. [PMID: 32408410 PMCID: PMC7451840 DOI: 10.20463/pan.2020.0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Blood glucose and insulin resistance were lower following hypoxic exposure in previous studies. However, the effect of hypoxia as therapy in obese model has not been unknown. METHODS Six-week-old mice were randomly divided into chow diet (n=10) and high-fat diet (HFD) groups (n=20). The chow diet group received a non-purified commercial diet (65 % carbohydrate, 21 % protein, and 14 % fat) and water ad libitum. The HFD group was fed an HFD (Research Diet, #D12492; 60% kcal from fat, 5.24 kcal/g). Both groups consumed their respective diet for 7 weeks. Subsequently, HFD-induced mice (12-weeks-old) were randomly divided into two treatment groups : HFD-Normoxia (HFD; n=10) and HFD-Hypoxia (HYP; n=10, fraction of inspired=14.6%). After treatment for 4 weeks, serum glucose, insulin and oral glucose tolerance tests (OGTT) were performed. RESULTS Homeostatic model assessment values for insulin resistance (HOMA-IR) of the HYP group tended to be lower than the HFD group. Regarding the OGTT, the area under the curve was 13% lower for the HYP group than the HFD group. CONCLUSION Insulin resistance tended to be lower and glucose uptake capacity was significantly augmented under hypoxia. From a clinical perspective, exposure to hypoxia may be a practical method of treating obesity.
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Affiliation(s)
- Yeram Park
- Department of Physical Education in Graduated school, Konkuk University, SeoulRepublic of Korea
| | - Inkwon Jang
- Department of Sports Medicine and Science in Graduated School, Konkuk University, SeoulRepublic of Korea
| | - Hun-Young Park
- Department of Sports Medicine and Science in Graduated School, Konkuk University, SeoulRepublic of Korea
| | - Jisu Kim
- Department of Sports Medicine and Science in Graduated School, Konkuk University, SeoulRepublic of Korea
| | - Kiwon Lim
- Department of Physical Education in Graduated school, Konkuk University, SeoulRepublic of Korea
- Department of Sports Medicine and Science in Graduated School, Konkuk University, SeoulRepublic of Korea
- Physical Activity and Performance Institute (PAPI), Konkuk University, SeoulRepublic of Korea
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Effects of Living High-Training Low and High on Body Composition and Metabolic Risk Markers in Overweight and Obese Females. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3279710. [PMID: 32104687 PMCID: PMC7036094 DOI: 10.1155/2020/3279710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
This study examined the effects of 4 weeks of living high-training low and high (LHTLH) under moderate hypoxia on body weight, body composition, and metabolic risk markers of overweight and obese females. Nineteen healthy overweight or obese females participated in this study. Participants were assigned to the normoxic training group (NG) or the LHTLH group (HG). The NG participants lived and trained at sea level. The HG participants stayed for approximately 10 hours in a simulated 2300 m normobaric state of hypoxia for six days a week and trained for 2 hours 3 times a week under the same simulated hypoxia. The interventions lasted for 4 weeks. All groups underwent dietary restriction based on resting metabolic rate. The heart rate of the participants was monitored every ten minutes during exercise to ensure that the intensity was in the aerobic range. Compared with the preintervention values, body weight decreased significantly in both the NG and the HG (−8.81 ± 2.09% and −9.09 ± 1.15%, respectively). The fat mass of the arm, leg, trunk, and whole body showed significant reductions in both the NG and the HG, but no significant interaction effect was observed. The percentage of lean soft tissue mass loss in the total body weight loss tended to be lower in the HG (27.61% versus 15.94%, P=0.085). Between the NG and the HG, significant interaction effects of serum total cholesterol (−12.66 ± 9.09% versus −0.05 ± 13.36%,) and apolipoprotein A1 (−13.66 ± 3.61% versus −5.32 ± 11.07%, P=0.042) were observed. A slight increase in serum high-density lipoprotein cholesterol (HDL-C) was observed in the HG (1.12 ± 12.34%) but a decrease was observed in the NG (−11.36 ± 18.91%). The interaction effect of HDL-C between NG and HG exhibited a significant trend (P=0.055). No added effects on serum triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), or APO-B were observed after 4 weeks of LHTLH. In conclusion, 4 weeks of LHTLH combined with dietary restriction could effectively reduce the body weight and body fat mass of overweight and obese females. Compared with training and sleeping under normoxia, no additive benefit of LHTLH on the loss of body weight and body fat mass was exhibited. However, LHTLH may help to relieve the loss of lean soft tissue mass and serum HDL-C.
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Dünnwald T, Gatterer H, Faulhaber M, Arvandi M, Schobersberger W. Body Composition and Body Weight Changes at Different Altitude Levels: A Systematic Review and Meta-Analysis. Front Physiol 2019; 10:430. [PMID: 31057421 PMCID: PMC6477059 DOI: 10.3389/fphys.2019.00430] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 03/28/2019] [Indexed: 12/12/2022] Open
Abstract
Changes in body composition and weight loss frequently occur when humans are exposed to hypoxic environments. The mechanisms thought to be responsible for these changes are increased energy expenditure resulting from increased basal metabolic rate and/or high levels of physical activity, inadequate energy intake, fluid loss as well as gastrointestinal malabsorption. The severity of hypoxia, the duration of exposure as well as the level of physical activity also seem to play crucial roles in the final outcome. On one hand, excessive weight loss in mountaineers exercising at high altitudes may affect performance and climbing success. On the other, hypoxic conditioning is presumed to have an important therapeutic potential in weight management programs in overweight/obese people, especially in combination with exercise. In this regard, it is important to define the hypoxia effect on both body composition and weight change. The purpose of this study is to define, through the use of meta-analysis, the extent of bodyweight -and body composition changes within the three internationally classified altitude levels (moderate altitude: 1500–3500 m; high altitude: 3500–5300 m; extreme altitude: >5300 m), with emphasis on physical activity, nutrition, duration of stay and type of exposure.
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Affiliation(s)
- Tobias Dünnwald
- Institute for Sports Medicine, Alpine Medicine & Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Hannes Gatterer
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Martin Faulhaber
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Marjan Arvandi
- Institute of Public Health, Medical Decision Making and HTA, Department for Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Wolfgang Schobersberger
- Institute for Sports Medicine, Alpine Medicine & Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,Tirol Kliniken GmbH Innsbruck, Innsbruck, Austria
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Rodríguez FA, Iglesias X, Feriche B, Calderón-Soto C, Chaverri D, Wachsmuth NB, Schmidt W, Levine BD. Altitude Training in Elite Swimmers for Sea Level Performance (Altitude Project). Med Sci Sports Exerc 2016; 47:1965-78. [PMID: 25628173 DOI: 10.1249/mss.0000000000000626] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION This controlled, nonrandomized, parallel-groups trial investigated the effects on performance, V˙O2 and hemoglobin mass (tHbmass) of four preparatory in-season training interventions: living and training at moderate altitude for 3 and 4 wk (Hi-Hi3, Hi-Hi), living high and training high and low (Hi-HiLo, 4 wk), and living and training at sea level (SL) (Lo-Lo, 4 wk). METHODS From 61 elite swimmers, 54 met all inclusion criteria and completed time trials over 50- and 400-m crawl (TT50, TT400), and 100 (sprinters) or 200 m (nonsprinters) at best stroke (TT100/TT200). Maximal oxygen uptake (V˙O2max) and HR were measured with an incremental 4 × 200 m test. Training load was estimated using cumulative training impulse method and session RPE. Initial measures (PRE) were repeated immediately (POST) and once weekly on return to SL (PostW1 to PostW4). tHbmass was measured in duplicate at PRE and once weekly during the camp with CO rebreathing. Effects were analyzed using mixed linear modeling. RESULTS TT100 or TT200 was worse or unchanged immediately at POST, but improved by approximately 3.5% regardless of living or training at SL or altitude after at least 1 wk of SL recovery. Hi-HiLo achieved greater improvement 2 (5.3%) and 4 wk (6.3%) after the camp. Hi-HiLo also improved more in TT400 and TT50 2 (4.2% and 5.2%, respectively) and 4 wk (4.7% and 5.5%) from return. This performance improvement was not linked linearly to changes in V˙O2max or tHbmass. CONCLUSIONS A well-implemented 3- or 4-wk training camp may impair performance immediately but clearly improves performance even in elite swimmers after a period of SL recovery. Hi-HiLo for 4 wk improves performance in swimming above and beyond altitude and SL controls through complex mechanisms involving altitude living and SL training effects.
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Affiliation(s)
- Ferran A Rodríguez
- 1INEFC-Barcelona Sport Sciences Research Group, National Institute of Physical Education of Catalonia, University of Barcelona, Barcelona, SPAIN; 2Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, Granada, SPAIN; 3Altitude Training Center of Sierra Nevada, Consejo Superior de Deportes, Granada, SPAIN; 4Department of Sports Medicine and Physiology, University of Bayreuth, Bayreuth, GERMANY; and 5Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Dallas, and University of Texas Southwestern Medical Center at Dallas, Dallas, TX
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Woolcott OO, Ader M, Bergman RN. Glucose homeostasis during short-term and prolonged exposure to high altitudes. Endocr Rev 2015; 36:149-73. [PMID: 25675133 PMCID: PMC4399271 DOI: 10.1210/er.2014-1063] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Most of the literature related to high altitude medicine is devoted to the short-term effects of high-altitude exposure on human physiology. However, long-term effects of living at high altitudes may be more important in relation to human disease because more than 400 million people worldwide reside above 1500 m. Interestingly, individuals living at higher altitudes have a lower fasting glycemia and better glucose tolerance compared with those who live near sea level. There is also emerging evidence of the lower prevalence of both obesity and diabetes at higher altitudes. The mechanisms underlying improved glucose control at higher altitudes remain unclear. In this review, we present the most current evidence about glucose homeostasis in residents living above 1500 m and discuss possible mechanisms that could explain the lower fasting glycemia and lower prevalence of obesity and diabetes in this population. Understanding the mechanisms that regulate and maintain the lower fasting glycemia in individuals who live at higher altitudes could lead to new therapeutics for impaired glucose homeostasis.
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Affiliation(s)
- Orison O Woolcott
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, California 90048
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Siervo M, Riley HL, Fernandez BO, Leckstrom CA, Martin DS, Mitchell K, Levett DZH, Montgomery HE, Mythen MG, Grocott MPW, Feelisch M. Effects of prolonged exposure to hypobaric hypoxia on oxidative stress, inflammation and gluco-insular regulation: the not-so-sweet price for good regulation. PLoS One 2014; 9:e94915. [PMID: 24733551 PMCID: PMC3986261 DOI: 10.1371/journal.pone.0094915] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 03/21/2014] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES The mechanisms by which low oxygen availability are associated with the development of insulin resistance remain obscure. We thus investigated the relationship between such gluco-insular derangements in response to sustained (hypobaric) hypoxemia, and changes in biomarkers of oxidative stress, inflammation and counter-regulatory hormone responses. METHODS After baseline testing in London (75 m), 24 subjects ascended from Kathmandu (1,300 m) to Everest Base Camp (EBC;5,300 m) over 13 days. Of these, 14 ascended higher, with 8 reaching the summit (8,848 m). Assessments were conducted at baseline, during ascent to EBC, and 1, 6 and 8 week(s) thereafter. Changes in body weight and indices of gluco-insular control were measured (glucose, insulin, C-Peptide, homeostasis model assessment of insulin resistance [HOMA-IR]) along with biomarkers of oxidative stress (4-hydroxy-2-nonenal-HNE), inflammation (Interleukin-6 [IL-6]) and counter-regulatory hormones (glucagon, adrenalin, noradrenalin). In addition, peripheral oxygen saturation (SpO2) and venous blood lactate concentrations were determined. RESULTS SpO2 fell significantly from 98.0% at sea level to 82.0% on arrival at 5,300 m. Whilst glucose levels remained stable, insulin and C-Peptide concentrations increased by >200% during the last 2 weeks. Increases in fasting insulin, HOMA-IR and glucagon correlated with increases in markers of oxidative stress (4-HNE) and inflammation (IL-6). Lactate levels progressively increased during ascent and remained significantly elevated until week 8. Subjects lost on average 7.3 kg in body weight. CONCLUSIONS Sustained hypoxemia is associated with insulin resistance, whose magnitude correlates with the degree of oxidative stress and inflammation. The role of 4-HNE and IL-6 as key players in modifying the association between sustained hypoxia and insulin resistance merits further investigation.
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Affiliation(s)
- Mario Siervo
- Human Nutrition Research Centre, Institute for Ageing and Health, Newcastle University, Newcastle on Tyne, United Kingdom
| | - Heather L. Riley
- Warwick Systems Biology Centre, University of Warwick, Coventry, United Kingdom
| | - Bernadette O. Fernandez
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- University of Southampton, Clinical & Experimental Sciences, Faculty of Medicine, Southampton General Hospital, Southampton, United Kingdom
| | - Carl A. Leckstrom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel S. Martin
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, United Kingdom
| | - Kay Mitchell
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, United Kingdom
| | - Denny Z. H. Levett
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, United Kingdom
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
| | - Hugh E. Montgomery
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
| | - Monty G. Mythen
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
| | - Michael P. W. Grocott
- University of Southampton, Clinical & Experimental Sciences, Faculty of Medicine, Southampton General Hospital, Southampton, United Kingdom
- Centre for Altitude Space and Extreme Environment Medicine, Portex Unit, UCL Institute of Child Health, London, United Kingdom
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, United Kingdom
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
| | - Martin Feelisch
- Warwick Systems Biology Centre, University of Warwick, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- University of Southampton, Clinical & Experimental Sciences, Faculty of Medicine, Southampton General Hospital, Southampton, United Kingdom
- Southampton NIHR Respiratory Biomedical Research Unit, Southampton, United Kingdom
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Hessien M. Improved glycemic control in moderate altitude type II diabetic residents. High Alt Med Biol 2013; 14:27-30. [PMID: 23537257 DOI: 10.1089/ham.2012.1033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Exposure to altitude hypoxia may elicit changes in glucose homeostasis. This work is designated to investigate the glycemic control in type II diabetic patients (DMII) permanently resident at moderately high altitude (2400 m), and to investigate whether the arterial oxygen-related parameters are different in DMII patients living at altitude compared to those living at low altitude. Blood glucose, HbA1c, hemoglobin concentration, and hematocrit (HCT) were measured in moderate altitude type II diabetics and compared with both altitude nondiabetics and diabetic patients living at normoxic and normobaric conditions. The data revealed that fasting blood glucose was lower in altitude diabetic patients compared to diabetics living at low altitude (157±33 mg/dL and 176.81±15.98 mg/dL, respectively, p<0.01). Also, glycemic control was improved in altitude diabetic patients, where their HbA1c was lower than the corresponding low altitude diabetic patients (8.68±0.79% and 9.30±1.02% respectively, p<0.01). Low oxygen tension at altitude was compensated in both diabetics and nondiabetics by a significant increase in both hemoglobin and HCT (17.33±0.72 mg/dL and 50.7±2.20%, respectively) compared to the corresponding groups living at low levels (15.53±0.55 mg/dL and 45.8±1.64%, respectively). The underlying disease neither affected the arterial oxygen tension (PaO2) nor oxygen saturation (SaO2), where insignificant correlations were observed between glucose, PaO2 (r=-0.06) and SaO2 (r=-0.2). These results suggest that moderate altitude may improve the glycemic control in type II diabetic patients compared to diabetics living at sea level.
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Affiliation(s)
- Mohamed Hessien
- Department of Chemistry, Section of Biochemistry, Faculty of Science, Tanta University, Cairo, Egypt.
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Abstract
Altitude physiology began with Paul Bert in 1878. Chronic mountain sickness (CMS) was defined by Carlos Monge in the 1940s in the Peruvian Andes as consisting of excess polycythemia. Hurtado et al performed studies in the Peruvian Andes in the 1950s to 1960s which defined acclimatization in healthy altitude natives, including polycythemia, moderate pulmonary hypertension, and low systemic blood pressure (BP). Electrocardiographic changes of right ventricular hypertrophy (RVH) were noted. Acclimatization of newcomers to altitude involves hyperventilation stimulated by hypoxia and is usually benign. Acute mountain sickness (AMS) in travelers to altitude is characterized by hypoxia-induced anorexia, dyspnea, headache, insomnia, and nausea. The extremes of AMS are high-altitude cerebral edema and high-altitude pulmonary edema. The susceptible high-altitude resident can lose their tolerance to altitude and develop CMS, also referred to as Monge disease. The CMS includes extreme polycythemia, severe RVH, excess pulmonary hypertension, low systemic BP, arterial oxygen desaturation, and hypoventilation.
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Affiliation(s)
- Thomas F Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
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Wu MC, Tsai YL, Huang CY, Kao CL, Hou CW, Chen CY, Korivi M, Jean WH, Lee SD, Kuo CH. Hyperinsulinemia and overweight in obese Zucker rats effectively suppressed by exercise training with hypoxia recovery. Eur J Sport Sci 2013. [DOI: 10.1080/17461391.2011.606839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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