Tadej Debevec

Exercise training during normobaric hypoxic confinement does not alter hormonal appetite regulation.

Background Both exposure to hypoxia and exercise training have the potential to modulate appetite and induce beneficial metabolic adaptations. The purpose of this study was to determine whether daily moderate exercise training performed during a 10-day exposure to normobaric hypoxia alters hormonal appetite regulation and augments metabolic health. Methods Fourteen healthy, male participants underwent a 10-day hypoxic confinement at ∼4000 m simulated altitude (FIO2 = 0.139±0.003%) either combined with daily moderate intensity exercise (Exercise group; N = 8, Age = 25.8±2.4 yrs, BMI = 22.9±1.2 kg·m−2) or without any exercise (Sedentary group; N = 6 Age = 24.8±3.1 yrs, BMI = 22.3±2.5 kg·m−2). A meal tolerance test was performed before (Pre) and after the confinement (Post) to quantify fasting and postprandial concentrations of selected appetite-related hormones and metabolic risk markers. 13C-Glucose was dissolved in the test meal and 13CO2 determined in breath samples. Perceived appetite ratings were obtained throughout the meal tolerance tests. Results While body mass decreased in both groups (−1.4 kg; p = 0.01) following the confinement, whole body fat mass was only reduced in the Exercise group (−1.5 kg; p = 0.01). At Post, postprandial serum insulin was reduced in the Sedentary group (−49%; p = 0.01) and postprandial plasma glucose in the Exercise group (−19%; p = 0.03). Fasting serum total cholesterol levels were reduced (−12%; p = 0.01) at Post in the Exercise group only, secondary to low-density lipoprotein cholesterol reduction (−16%; p = 0.01). No differences between groups or testing periods were noted in fasting and/or postprandial concentrations of total ghrelin, peptide YY, and glucagon-like peptide-1, leptin, adiponectin, expired 13CO2 as well as perceived appetite ratings (p>0.05). Conclusion These findings suggest that performing daily moderate intensity exercise training during continuous hypoxic exposure does not alter hormonal appetite regulation but can improve the lipid profile in healthy young males.

Moderate Exercise Blunts Oxidative Stress Induced by Normobaric Hypoxic Confinement.

PURPOSE Both acute hypoxia and physical exercise are known to increase oxidative stress. This randomized prospective trial investigated whether the addition of moderate exercise can alter oxidative stress induced by continuous hypoxic exposure. METHODS Fourteen male participants were confined to 10-d continuous normobaric hypoxia (FIO2 = 0.139 ± 0.003, PIO2 = 88.2 ± 0.6 mm Hg, ∼4000-m simulated altitude) either with (HCE, n = 8, two training sessions per day at 50% of hypoxic maximal aerobic power) or without exercise (HCS, n = 6). Plasma levels of oxidative stress markers (advanced oxidation protein products [AOPP], nitrotyrosine, and malondialdehyde), antioxidant markers (ferric-reducing antioxidant power, superoxide dismutase, glutathione peroxidase, and catalase), nitric oxide end-products, and erythropoietin were measured before the exposure (Pre), after the first 24 h of exposure (D1), after the exposure (Post) and after the 24-h reoxygenation (Post + 1). In addition, graded exercise test in hypoxia was performed before and after the protocol. RESULTS Maximal aerobic power increased after the protocol in HCE only (+6.8%, P < 0.05). Compared with baseline, AOPP was higher at Post + 1 (+28%, P < 0.05) and nitrotyrosine at Post (+81%, P < 0.05) in HCS only. Superoxide dismutase (+30%, P < 0.05) and catalase (+53%, P < 0.05) increased at Post in HCE only. Higher levels of ferric-reducing antioxidant power (+41%, P < 0.05) at Post and lower levels of AOPP (-47%, P < 0.01) at Post + 1 were measured in HCE versus HCS. Glutathione peroxidase (+31%, P < 0.01) increased in both groups at Post + 1. Similar erythropoietin kinetics was noted in both groups with an increase at D1 (+143%, P < 0.01), a return to baseline at Post, and a decrease at Post + 1 (-56%, P < 0.05). CONCLUSIONS These data provide evidence that 2 h of moderate daily exercise training can attenuate the oxidative stress induced by continuous hypoxic exposure.

Therapeutic Use of Exercising in Hypoxia: Promises and Limitations

It is well-established that different altitude training modalities can improve convective oxygen (O2) transport capacity and physical fitness of athletes (Millet et al., 2010). Exercising in hypoxia also induces specific muscular adaptations including increased oxidative enzymes (e.g., citrate synthase) activity, mitochondrial density, capillary-to-fiber ratio, and fiber cross-sectional area (Hoppeler et al., 2008). These changes with hypoxic training are mostly modulated via hypoxia-inducible factor 1α (HIF-1α) signaling cascade, which is not activated to the same extent when training is performed in normoxia or by passive hypoxic exposure. Indeed, large body of literature shows that, compared to hypoxic exercise, passive exposure to hypoxia does not provoke similar acute responses. In healthy individuals, both systemic (e.g., performance enhancement), cardiovascular (e.g., maximal O2 uptake, VO2max) or transcriptional muscular responses are minimal with intermittent passive exposures at moderate altitude. On the other hand, there are clear evidences that when hypoxia is combined with exercise, it triggers specific responses, not observed following similar exercise in normoxia (Bartsch et al., 2008; Lundby et al., 2009). In addition, greater specific adaptations have been reported in high-intensity vs. moderate-intensity hypoxic intervention (Faiss et al., 2013) (e.g., improvements in muscle O2 homeostasis and tissue perfusion induced by enhanced mitochondrial efficiency, control of mitochondrial respiration, angiogenesis, and muscle buffering capacity). It seems that the main underlying mechanism is the larger hypoxemia resulting from the combination of muscle deoxygenation (high-intensity exercise) and systemic desaturation (moderate hypoxia). In patients or elderly individuals, altitude is generally associated with increased health risks through enhanced sympathetic vasoconstrictor activation (Blitzer et al., 1996), obstructive sleep apneas (Nespoulet et al., 2012), hypoxemia (Levine et al., 1997), pulmonary hypertension (Valencia-Flores et al., 2004), arrhythmias (Kujanik et al., 2000), and alterations of postural control (Degache et al., 2012). However, several studies have investigated the therapeutic benefits of exercising in mild hypoxia on the blood pressure regulation and the influence of different hypoxic modalities in healthy individuals (Bailey et al., 2001; Wang et al., 2007; Haufe et al., 2008; Nishiwaki et al., 2011; Morishima et al., 2014; Shi et al., 2014) or in patients with different cardiovascular and respiratory risk factors such as chronic obstructive pulmonary disease (COPD) (Haider et al., 2009), obesity (Wiesner et al., 2010), coronary artery disease (Burtscher et al., 2004). Recent studies (Haufe et al., 2008; Wiesner et al., 2010) have also reported that sustained hypoxia may be of benefit to weight management programs of obese patients (Urdampilleta et al., 2012; Kayser and Verges, 2013). Both exercise (Williams et al., 2002) and/or intermittent hypoxia (Burtscher et al., 2004; Shatilo et al., 2008) have been suggested to positively influence age-related alterations in elderly individuals. Finally, living at altitude seems to have contradictory effects on different mortality risk factors. Therefore, this essay summarizes recent evidences suggesting that exercising in hypoxia might be a valuable and viable “therapeutic strategy.” We discuss the benefits and risks/limitations in (i) hypertensive (ii) obese, (iii) elderly individuals. Since the benefits of being active have been extensively investigated in these three groups of individuals (see respective reviews on the effects of physical activity in Cherubini et al., 1998; Baillot et al., 2014; Borjesson et al., 2016), the present article focus on the potential additional health benefits provided by hypoxic exercise, when compared to normoxic exercise. For safety and practical reasons, patients cannot access high altitude (even by using hypoxic devices) and preferably stay at moderate altitude (1800–3000 m). In this setting, exercise is used to increase the overall hypoxia-induced metabolic stress and thereby provide benefits beyond those achievable by normoxic therapeutic training modalities.

Whole body and regional body composition changes following 10-day hypoxic confinement and unloading-inactivity.

Future planetary habitats will expose inhabitants to both reduced gravity and hypoxia. This study investigated the effects of short-term unloading and normobaric hypoxia on whole body and regional body composition (BC). Eleven healthy, recreationally active, male participants with a mean (SD) age of 24 (2) years and body mass index of 22.4 (3.2) kg·m(-2) completed the following 3 10-day campaigns in a randomised, cross-over designed protocol: (i) hypoxic ambulatory confinement (HAMB; FIO2 = 0.147 (0.008); PIO2 = 93.8 (0.9) mm Hg), (ii) hypoxic bed rest (HBR; FIO2 = 0.147 (0.008); PIO2 = 93.8 (0.9) mm Hg), and (iii) normoxic bed rest (NBR; FIO2 = 0.209; PIO2 = 133.5 (0.7) mm Hg). Nutritional requirements were individually precalculated and the actual intake was monitored throughout the study protocol. Body mass, whole body, and regional BC were assessed before and after the campaigns using dual-energy X-ray absorptiometry. The calculated daily targeted energy intake values were 2071 (170) kcal for HBR and NBR and 2417 (200) kcal for HAMB. In both HBR and NBR campaigns the actual energy intake was within the targeted level, whereas in the HAMB the intake was lower than targeted (-8%, p < 0.05). Body mass significantly decreased in all 3 campaigns (-2.1%, -2.8%, and -2.0% for HAMB, HBR, and NBR, respectively; p < 0.05), secondary to a significant decrease in lean mass (-3.8%, -3.8%, -4.3% for HAMB, HBR, and NBR, respectively; p < 0.05) along with a slight, albeit not significant, increase in fat mass. The same trend was observed in the regional BC regardless of the region and the campaign. These results demonstrate that, hypoxia per se, does not seem to alter whole body and regional BC during short-term bed rest.

PlanHab: the combined and separate effects of 16 days of bed rest and normobaric hypoxic confinement on circulating lipids and indices of insulin sensitivity in healthy men.

PlanHab is a planetary habitat simulation study. The atmosphere within future space habitats is anticipated to have reduced Po2, but information is scarce as to how physiological systems may respond to combined exposure to moderate hypoxia and reduced gravity. This study investigated, using a randomized-crossover design, how insulin sensitivity, glucose tolerance, and circulating lipids were affected by 16 days of horizontal bed rest in normobaric normoxia [NBR: FiO2 = 0.209; PiO2 = 133.1 (0.3) mmHg], horizontal bed rest in normobaric hypoxia [HBR: FiO2 = 0.141 (0.004); PiO2 = 90.0 (0.4) mmHg], and confinement in normobaric hypoxia combined with daily moderate intensity exercise (HAMB). A mixed-meal tolerance test, with arterialized-venous blood sampling, was performed in 11 healthy, nonobese men (25-45 yr) before (V1) and on the morning ofday 17of each intervention (V2). Postprandial glucose and c-peptide response were increased at V2 of both bed rest interventions (P< 0.05 in each case), with c-peptide:insulin ratio higher at V2 in HAMB and HBR, both in the fed and fasted state (P< 0.005 in each case). Fasting total cholesterol was reduced at V2 in HAMB [-0.47 (0.36) mmol/l;P< 0.005] and HBR [-0.55 (0.41) mmol/l;P< 0.005]. Fasting HDL was lower at V2 in all interventions, with the reduction observed in HBR [-0.30 (0.21) mmol/l] greater than that measured in HAMB [-0.13 (0.14) mmol/l;P< 0.005] and NBR [-0.17 (0.15) mmol/l;P< 0.05]. Hypoxia did not alter the adverse effects of bed rest on insulin sensitivity and glucose tolerance but appeared to increase insulin clearance. The negative effect of bed rest on HDL was compounded in hypoxia, which may have implications for long-term health of those living in future space habitats.

Hypoxia-Induced Oxidative Stress Modulation with Physical Activity

Increased oxidative stress, defined as an imbalance between prooxidants and antioxidants, resulting in molecular damage and disruption of redox signaling, is associated with numerous pathophysiological processes and known to exacerbate chronic diseases. Prolonged systemic hypoxia, induced either by exposure to terrestrial altitude or a reduction in ambient O2 availability is known to elicit oxidative stress and thereby alter redox balance in healthy humans. The redox balance modulation is also highly dependent on the level of physical activity. For example, both high-intensity exercise and inactivity, representing the two ends of the physical activity spectrum, are known to promote oxidative stress. Numerous to-date studies indicate that hypoxia and exercise can exert additive influence upon redox balance alterations. However, recent evidence suggests that moderate physical activity can attenuate altitude/hypoxia-induced oxidative stress during long-term hypoxic exposure. The purpose of this review is to summarize recent findings on hypoxia-related oxidative stress modulation by different activity levels during prolonged hypoxic exposures and examine the potential mechanisms underlying the observed redox balance changes. The paper also explores the applicability of moderate activity as a strategy for attenuating hypoxia-related oxidative stress. Moreover, the potential of such moderate intensity activities used to counteract inactivity-related oxidative stress, often encountered in pathological, elderly and obese populations is also discussed. Finally, future research directions for investigating interactive effects of altitude/hypoxia and exercise on oxidative stress are proposed.

Exposure to hypobaric hypoxia results in higher oxidative stress compared to normobaric hypoxia

Sixteen healthy exercise trained participants underwent the following three, 10-h exposures in a randomized manner: (1) Hypobaric hypoxia (HH; 3450m terrestrial altitude) (2) Normobaric hypoxia (NH; 3450m simulated altitude) and (3) Normobaric normoxia (NN). Plasma oxidative stress (malondialdehyde, MDA; advanced oxidation protein products, AOPP) and antioxidant markers (superoxide dismutase, SOD; glutathione peroxidase, GPX; catalase; ferric reducing antioxidant power, FRAP) were measured before and after each exposure. MDA was significantly higher after HH compared to NN condition (+24%). SOD and GPX activities were increased (vs. before; +29% and +54%) while FRAP was decreased (vs. before; -34%) only after 10h of HH. AOPP significantly increased after 10h for NH (vs. before; +83%), and HH (vs. before; +99%) whereas it remained stable in NN. These results provide evidence that prooxidant/antioxidant balance was impaired to a greater degree following acute exposure to terrestrial (HH) vs. simulated altitude (NH) and that the chamber confinement (NN) did likely not explain these differences.

Prooxidant/Antioxidant Balance in Hypoxia: A Cross-Over Study on Normobaric vs. Hypobaric "Live High-Train Low".

“Live High-Train Low” (LHTL) training can alter oxidative status of athletes. This study compared prooxidant/antioxidant balance responses following two LHTL protocols of the same duration and at the same living altitude of 2250 m in either normobaric (NH) or hypobaric (HH) hypoxia. Twenty-four well-trained triathletes underwent the following two 18-day LHTL protocols in a cross-over and randomized manner: Living altitude (PIO2 = 111.9 ± 0.6 vs. 111.6 ± 0.6 mmHg in NH and HH, respectively); training “natural” altitude (~1000–1100 m) and training loads were precisely matched between both LHTL protocols. Plasma levels of oxidative stress [advanced oxidation protein products (AOPP) and nitrotyrosine] and antioxidant markers [ferric-reducing antioxidant power (FRAP), superoxide dismutase (SOD) and catalase], NO metabolism end-products (NOx) and uric acid (UA) were determined before (Pre) and after (Post) the LHTL. Cumulative hypoxic exposure was lower during the NH (229 ± 6 hrs.) compared to the HH (310 ± 4 hrs.; P<0.01) protocol. Following the LHTL, the concentration of AOPP decreased (-27%; P<0.01) and nitrotyrosine increased (+67%; P<0.05) in HH only. FRAP was decreased (-27%; P<0.05) after the NH while was SOD and UA were only increased following the HH (SOD: +54%; P<0.01 and UA: +15%; P<0.01). Catalase activity was increased in the NH only (+20%; P<0.05). These data suggest that 18-days of LHTL performed in either NH or HH differentially affect oxidative status of athletes. Higher oxidative stress levels following the HH LHTL might be explained by the higher overall hypoxic dose and different physiological responses between the NH and HH.

On the combined effects of normobaric hypoxia and bed rest upon bone and mineral metabolism: Results from the PlanHab study

Bone losses are common as a consequence of unloading and also in patients with chronic obstructive pulmonary disease (COPD). Although hypoxia has been implicated as an important factor to drive bone loss, its interaction with unloading remains unresolved. The objective therefore was to assess whether human bone loss caused by unloading could be aggravated by chronic hypoxia. In a cross-over designed study, 14 healthy young men underwent 21-day interventions of bed rest in normoxia (NBR), bed rest in hypoxia (HBR), and hypoxic ambulatory confinement (HAmb). Hypoxic conditions were equivalent to 4000m altitude. Bone metabolism (NTX, P1NP, sclerostin, DKK1) and phospho-calcic homeostasis (calcium and phosphate serum levels and urinary excretion, PTH) were assessed from regular blood samples and 24-hour urine collections, and tibia and femur bone mineral content was assessed by peripheral quantitative computed tomography (pQCT). Urinary NTX excretion increased (P<0.001) to a similar extent in NBR and HBR (P=0.69) and P1NP serum levels decreased (P=0.0035) with likewise no difference between NBR and HBR (P=0.88). Serum total calcium was increased during bed rest by 0.059 (day D05, SE 0.05mM) to 0.091mM (day D21, P<0.001), with no additional effect by hypoxia during bed rest (P=0.199). HAmb led, at least temporally, to increased total serum calcium, to reduced serum phosphate, and to reduced phosphate and calcium excretion. In conclusion, hypoxia did not aggravate bed rest-induced bone resorption, but led to changes in phospho-calcic homeostasis likely caused by hyperventilation. Whether hyperventilation could have mitigated the effects of hypoxia in this study remains to be established.

Short intermittent hypoxic exposures augment ventilation but do not alter regional cerebral and muscle oxygenation during hypoxic exercise

This study investigated the effects of four exposures to normobaric hypoxia (SIH group; FIO₂ = 0.120, N=10) or placebo-control normoxia (Control group; FIO₂ = 0.209, N=9) on cardio-respiratory responses to hypoxic exercise. Before and after the exposures all subjects performed a constant power test (CP) to exhaustion in hypoxia FIO₂ = 0.120 at a work load corresponding to 75% of previously determined normoxic VO₂ peak. Arterial oxygen saturation (SPO₂) and minute ventilation (V(E)) were measured continuously. NIRS was used to monitor regional changes in oxygenated, de-oxygenated and total hemoglobin concentrations of the frontal cortex, vastus lateralis and serratus anterior. Although neither group improved CP time, the SIH group exhibited increases in both V(E) (+15%; P<0.05) and SPO₂ (+4%; P<0.05) after intermittent hypoxia. No physiologically significant differences were observed during exercise in vastus lateralis, serratus anterior and cerebral oxygenation between groups and testing periods. These data suggest that normobaric SIH enhances hypoxic exercise V(E) and SPO₂ without affecting regional oxygenation or time to exhaustion.