How to Increase Erythropoietin (EPO) Naturally
Erythropoietin (EPO) is a hormone produced mainly by the kidneys in response to low oxygen levels. It stimulates the bone marrow to produce and mature red blood cells, increasing the blood's oxygen-carrying capacity.
Research shows that repeated breath holds can cause a short-term rise in EPO of around 24%, with no drugs, no injections, and no risk of disqualification. Whether this leads to lasting increases in red blood cells is less clear, and the evidence is mixed.
What Is Erythropoietin (EPO) and What Does It Do?
- Erythropoietin (EPO) is a naturally occurring hormone
- About 90% of EPO is secreted by the kidneys
- EPO stimulates production and maturation of red blood cells in the bone marrow
- This increases the oxygen-carrying capacity of the blood
Erythropoietin, or EPO, is produced when oxygen levels in the body are low. This occurs naturally at high altitude. Like any hormone, imbalance can also be caused by sickness or overtraining.
Raised EPO and red blood cell levels can be seen in some sleep apnea patients. These people stop breathing periodically during sleep, and their blood oxygen saturation can drop substantially.
Low blood oxygen stimulates the production of erythropoietin. It is one of the body's protective mechanisms. When tissues are short of oxygen, the body releases and matures new red blood cells to compensate.
EPO: Natural Benefits, Blood Doping Risks and Safe Alternatives
EPO is essential for the production of red blood cells. A healthy red blood cell count supports aerobic power and oxygen-carrying capacity. For the athlete, this can mean greater stamina and less breathlessness.
Synthetic EPO is available as a pharmaceutical. It regulates the concentration of red blood cells and hemoglobin in the blood. It is used to treat anemia.
It is also used in blood doping, when athletes inject EPO to boost their aerobic capacity.
Blood doping is banned. It can result in long bans from competition. It has tainted events like the Tour de France. Since the Sydney Olympics in 2000, EPO testing has been commonplace.
Even worse, blood doping can be fatal. When EPO concentration is too high, the bone marrow produces too many red blood cells. This causes the blood to thicken. Thick blood is difficult for the heart to pump, slowing blood flow and affecting blood pressure.
The full long-term effects of unregulated synthetic EPO use are not known. But young athletes have suffered clotting and strokes. Some have died from heart attacks. It is possible to support your body's natural EPO response ethically and without these risks.
How to Increase EPO Naturally
If you want to support healthy red blood cell production, you first need to look at your diet. Your body needs certain nutrients to make red blood cells, especially when it is under endurance exercise stress.
Key nutrients include:
- Iron
- Vitamin B12
- Folate (vitamin B9)
- Vitamin C, which helps your body absorb iron
If you suspect your iron or red blood cell count is low, get a blood test and talk to your doctor before taking iron supplements, as too much iron can be harmful.
You can also boost EPO in the sauna, according to research cited by Men's Health.
Does Exercise Increase EPO?
EPO production increases when the body is low in oxygen. In one study, EPO rose after exercise that caused arterial oxygen saturation to drop below about 91% (Roberts et al., 2000).
At sea level, most people will not reach this level of desaturation during normal training. Breath holding after an exhalation is a more controlled way to create a temporary drop in blood oxygen.
How Breath Holding Can Increase EPO Naturally
Breath holding to simulate training at high altitude can cause a short-term increase in EPO production. When the body releases its own EPO, it is legal.
Injected synthetic EPO keeps levels elevated far longer and at far higher concentrations, which is what creates the serious risks for the heart and blood.
When you use breath holding, one study found a 24% increase in EPO, with levels staying raised for around 5 hours. The effect is real but short-lived.
Potential Benefits of Higher EPO for Athletic Performance
Stimulating your natural EPO response through breath holding exercises may have benefits for athletes, but the research is still developing.
- Breath holding to create hypoxia can trigger an acute rise of EPO in the blood. New red blood cells take several days to mature and enter the blood, but a single short-lived rise in EPO is unlikely on its own to meaningfully increase red blood cell mass.
- Whether regular breath holding produces lasting increases in red blood cells is uncertain. Experienced breath-hold divers tend to have higher red blood cell and hemoglobin levels than untrained people, but a controlled 2022 study found that six weeks of daily static breath holds did not raise EPO, hemoglobin mass or VO2 peak (Bouten et al., 2022). More intense protocols, such as breath holds during movement, may be needed.
Breath holding has other potential benefits beyond EPO production. It can help strengthen the breathing muscles, provide controlled exposure to air hunger, and create an altitude-like training stimulus without leaving sea level. See our guides on aerobic capacity and altitude training to learn more.
For healthy athletes, breath holding can be a practical, legal addition to training, without the risks of doping to your career, your health or your life.
You can track your breathing by measuring your BOLT score. BOLT measures how quickly you feel the first clear urge to breathe during a comfortable breath hold. It is a useful personal baseline for tracking progress, but it does not measure EPO, red blood cells or performance.
Research: How Much Can You Increase EPO Naturally?
Study 1: Breath Holds Increase EPO by 24%
Results showed that EPO concentration increased by 24%, peaking at three hours after the final breath hold and returning to baseline two hours later.
Exercise protocol: Three sets of five maximum duration breath holds, with each set separated by ten minutes of rest.
de Bruijn R, Richardson M, Schagatay E. "Increased erythropoietin concentration after repeated apneas in humans." Eur J Appl Physiol 2008; 102:609-13.
Study 2: Lowering Blood Oxygen Saturation Increases EPO by 24 to 36%
Researchers from the Human Performance Laboratory, University of Calgary, Canada, investigated the relationship between decreased oxygen concentration during exercise and erythropoietin production. This study involved hard exercise at altitude, not breath holding.
Five athletes cycled for three minutes at supramaximal intensity at two different elevations: 1,000m and 2,100m. Oxygen saturation of hemoglobin dropped below 91% for approximately 24 seconds at 1,000m and for 136 seconds at 2,100m. EPO levels increased by 24% and 36% respectively following the exercise.
Roberts D, Smith DJ, Donnelly S, Simard S. Plasma-volume contraction and exercise-induced hypoxaemia modulate erythropoietin production in healthy humans. Clinical Science. 2000.
Study 3: Low Blood Oxygen in Sleep Apnea and Hematocrit Levels
Korean researchers Choi et al. carried out a study on 263 subjects to determine the relationship between hematocrit levels and obstructive sleep apnea.
Patients with severe sleep apnea had significantly higher hematocrit levels than those with mild and moderate OSA. Hematocrit levels were significantly correlated with the percentage of time spent at oxygen saturation below 90%, which is consistent with low blood oxygen stimulating red blood cell production over time.
Jong Bae Choi, et al. Does obstructive sleep apnea increase haematocrit? Sleep and Breathing. 2006.
Study 4: Six Weeks of Static Breath Holds Did Not Change Hemoglobin Mass
Twenty-two men were randomly assigned to a control group or to six weeks of daily static breath holds (five maximal breath holds per day). The breath-hold sessions did not produce an acute rise in EPO, and after six weeks there was no change in resting EPO, hemoglobin mass, VO2 peak or 3 km cycling time trial performance. The researchers concluded that longer or more intense sessions with a stronger hypoxic stimulus are probably needed.
Bouten J, Debusschere J, Lootens L, et al. Six weeks of static apnea training does not affect Hbmass and exercise performance. J Appl Physiol. 2022;132(3):673-681.
If you are interested in trying the OA method for yourself, why not try our online course, become a certified breathwork instructor, or find an Oxygen Advantage® instructor near you.
FAQs
Q: How can breathing exercises increase EPO naturally?
A: Performing strong breath holds after an exhalation causes blood oxygen to drop. The kidneys detect this hypoxia and can release erythropoietin (EPO), which stimulates the production of new red blood cells. The rise in EPO is short-lived, and whether it leads to lasting changes in red blood cells depends on how intense and frequent the training is.
Q: Is natural EPO production from breathing safe?
A: Breath holds are legal and can be practised safely by healthy athletes on dry land. They should never be practised in or under water. Avoid strong breath holds if you are pregnant or have a heart condition, high or low blood pressure, epilepsy, diabetes, pulmonary hypertension or another serious medical condition, unless cleared by your doctor.
Q: How much can breathing exercises increase red blood cell count?
A: Some studies report short-term rises in EPO and immature red blood cells after intense breath-hold sessions. Evidence for lasting increases in red blood cell mass is mixed: one controlled study of six weeks of static breath holds found no change in hemoglobin mass.
Q: Does nasal breathing affect EPO production?
A: Nasal breathing alone does not trigger EPO production. To stimulate an EPO response, you must perform strong breath holds after an exhalation to induce a significant drop in blood oxygen.
Q: Can simulated altitude from breath holds replace real altitude training?
A: No. Breath hold training creates a brief hypoxic stimulus, while living or training at altitude provides a sustained one. After breath holds, EPO returns to baseline within hours, which is likely too short a signal to match the red blood cell changes seen with altitude exposure.