Humans can only survive the low barometric pressure of altitudes above 6000m by making a complex series of adaptations. The energetics of human survival at such extreme altitudes have not been widely studied. Objectives were to compare the doubly labelled water (DLW) and intake-balance (IB) methods to estimate daily energy expenditure while climbing between 6000 and 8046m and to investigate the putative metabolic cost involved with the process of acclimatization to extreme altitude. Reliability of the DLW method to provide an accurate and portable means to measure human energy expenditure depends upon a series of assumptions regarding the flux of tracer and tracee across the physiological compartments of measurement. Additional objectives were to review and examine the proficiency of these assumptions to account for perturbations experienced while using DLW while climbing at extreme altitude. Findings suggest that the use of DLW at extreme altitudes requires special consideration towards elevated rates of fractional isotope loss, inter-subject isotope transfer, alterations in total body water, changes in background isotopic abundance, and choice of sampling technique. Revised strategies directed at achieving these aims are calculated. Results from extreme altitude indicate that IB and DLW techniques each provide similar estimates of group mean energy expenditure despite substantial changes in body weight and composition and that the metabolic cost for the process of acclimatization accounts for roughly 12% of total daily energy expenditure. Problems associated with maintaining energy balance while climbing at extreme altitude are related to low energy intakes, approximately only 70% of energy demands, and energy expenditure values that are comparable to those of highly trained endurance athletes at sea-level.

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