Greater maximal O2 uptakes and vital capacities in Tibetan than Han residents of Lhasa

Comparing integrative ventilatory and renal acid-base acclimatization in lowlanders and Tibetan highlanders during ascent to 4,300 m

With over 14 million people living above 3,500 m, the study of acclimatization and adaptation to high altitude in human populations is of increasing importance, where exposure to high altitude (HA) imposes a blood oxygenation and acid-base challenge. A sustained and augmented hypoxic ventilatory response protects oxygenation through ventilatory acclimatization, but elicits hypocapnia and respiratory alkalosis. A subsequent renally mediated compensatory metabolic acidosis corrects pH toward baseline values, with a high degree of interindividual variability. Differential renal compensation between acclimatizing lowlanders (LL) and Tibetan highlanders (TH; Sherpa) with ascent was previously unknown. We assessed ventilatory and renal acclimatization between unacclimatized LL and TH during incremental ascent from 1,400 m to 4,300 m in age- and sex-matched groups of 15-LL (8F) and 14-TH (7F) of confirmed Tibetan ancestry. We compared respiratory and renally mediated blood acid-base acclimatization (PCO2, [HCO3-], pH) in both groups before (1,400 m) and following day 8 to 9 of incremental ascent to 4,300 m. We found that following ascent to 4,300 m, LL had significantly lower PCO2 (P <0.0001) and [HCO3-] (P <0.0001), and higher pH (P = 0.0037) than 1,400 m, suggesting respiratory alkalosis and only partial renal compensation. Conversely, TH had significantly lower PCO2 (P < 0.0001) and [HCO3-] (P < 0.0001), but unchanged pH (P = 0.1), suggesting full renal compensation, with significantly lower PCO2 (P = 0.01), [HCO3-] (P < 0.0001) and pH (P = 0.005) than LL at 4,300 m. This demonstration of differential integrative respiratory-renal responses between acclimatizing LL and TH may indicate selective pressure on TH, and highlights the important role of the kidneys in acclimatization.

Large-scale genome sequencing redefines the genetic footprints of high-altitude adaptation in Tibetans

BACKGROUND

Tibetans are genetically adapted to high-altitude environments. Though many studies have been conducted, the genetic basis of the adaptation remains elusive due to the poor reproducibility for detecting selective signatures in the Tibetan genomes.

RESULTS

Here, we present whole-genome sequencing (WGS) data of 1001 indigenous Tibetans, covering the major populated areas of the Qinghai-Tibetan Plateau in China. We identify 35 million variants, and more than one-third of them are novel variants. Utilizing the large-scale WGS data, we construct a comprehensive map of allele frequency and linkage disequilibrium and provide a population-specific genome reference panel, referred to as 1KTGP. Moreover, with the use of a combined approach, we redefine the signatures of Darwinian-positive selection in the Tibetan genomes, and we characterize a high-confidence list of 4320 variants and 192 genes that have undergone selection in Tibetans. In particular, we discover four new genes, TMEM132C, ATP13A3, SANBR, and KHDRBS2, with strong signals of selection, and they may account for the adaptation of cardio-pulmonary functions in Tibetans. Functional annotation and enrichment analysis indicate that the 192 genes with selective signatures are likely involved in multiple organs and physiological systems, suggesting polygenic and pleiotropic effects.

CONCLUSIONS

Overall, the large-scale Tibetan WGS data and the identified adaptive variants/genes can serve as a valuable resource for future genetic and medical studies of high-altitude populations.

A pleiotropic hypoxia-sensitive EPAS1 enhancer is disrupted by adaptive alleles in Tibetans

In Tibetans, noncoding alleles in EPAS1-whose protein product hypoxia-inducible factor 2α (HIF-2α) drives the response to hypoxia-carry strong signatures of positive selection; however, their functional mechanism has not been systematically examined. Here, we report that high-altitude alleles disrupt the activity of four EPAS1 enhancers in one or more cell types. We further characterize one enhancer (ENH5) whose activity is both allele specific and hypoxia dependent. Deletion of ENH5 results in down-regulation of EPAS1 and HIF-2α targets in acute hypoxia and in a blunting of the transcriptional response to sustained hypoxia. Deletion of ENH5 in mice results in dysregulation of gene expression across multiple tissues. We propose that pleiotropic adaptive effects of the Tibetan alleles in EPAS1 underlie the strong selective signal at this gene.

Physiology and Proteomic Basis of Lung Adaptation to High-Altitude Hypoxia in Tibetan Sheep

Simple Summary

As an indigenous animal living in the Tibetan plateau, the Tibetan sheep is well adapted to high-altitude hypoxia, and the lungs play an important role in overcoming the hypoxic environment. To reveal the physiological and proteomic basis of Tibetan sheep lungs during their adaptation to hypoxia, we studied the lungs of Tibetan sheep at different altitudes using light and electron microscopy and proteome sequencing. The results showed that in the lungs of Tibetan sheep occurred a series of physiological changes with increasing altitude, and some important proteins and pathways identified by proteome sequencing further support these physiology findings. These changes at the physiological and molecular levels may facilitate the adaptation of Tibetan sheep to high-altitude hypoxia. In conclusion, these findings may provide a reference for the prevention of altitude sickness in humans.

Abstract

The Tibetan sheep is an indigenous animal of the Tibetan plateau, and after a long period of adaptation have adapted to high-altitude hypoxia. Many physiological changes occur in Tibetan sheep as they adapt to high-altitude hypoxia, especially in the lungs. To reveal the physiological changes and their molecular mechanisms in the lungs of Tibetan sheep during adaptation to high altitudes, we selected Tibetan sheep from three altitudes (2500 m, 3500 m, and 4500 m) and measured blood-gas indicators, observed lung structures, and compared lung proteome changes. The results showed that the Tibetan sheep increased their O₂-carrying capacity by increasing the hemoglobin (Hb) concentration and Hematocrit (Hct) at an altitude of 3500 m. While at altitude of 4500 m, Tibetan sheep decreased their Hb concentration and Hct to avoid pulmonary hypertension and increased the efficiency of air-blood exchange and O₂ transfer by increasing the surface area of gas exchange and half-saturation oxygen partial pressure. Besides these, some important proteins and pathways related to gas transport, oxidative stress, and angiogenesis identified by proteome sequencing further support these physiology findings, including HBB, PRDX2, GPX1, GSTA1, COL14A1, and LTBP4, etc. In conclusion, the lungs of Tibetan sheep are adapted to different altitudes by different strategies; these findings are valuable for understanding the basis of hypoxic adaptation in Tibetan sheep.

Time Domains of Hypoxia Responses and -Omics Insights

The ability to respond rapidly to changes in oxygen tension is critical for many forms of life. Challenges to oxygen homeostasis, specifically in the contexts of evolutionary biology and biomedicine, provide important insights into mechanisms of hypoxia adaptation and tolerance. Here we synthesize findings across varying time domains of hypoxia in terms of oxygen delivery, ranging from early animal to modern human evolution and examine the potential impacts of environmental and clinical challenges through emerging multi-omics approaches. We discuss how diverse animal species have adapted to hypoxic environments, how humans vary in their responses to hypoxia (i.e., in the context of high-altitude exposure, cardiopulmonary disease, and sleep apnea), and how findings from each of these fields inform the other and lead to promising new directions in basic and clinical hypoxia research.

Altitude-Induced Sleep Apnea Is Highly Dependent on Ethnic Background (Sherpa Vs. Tamang)

Heiniger, Grégory, Simon Walbaum, Claudio Sartori, Alban Lovis, Marco Sazzini, Andrew Wellman, and Raphael Heinzer. Altitude-Induced Sleep Apnea Is Highly Dependent on Ethnic Background (Sherpa Vs. Tamang). High Alt Med Biol. 23:165-172, 2022. Rationale: High altitude-induced hypocapnic alkalosis generates central sleep apnea (CSA). In Nepal, two ethnic groups live at medium-to-high altitude: Tamangs originate from low-altitude Tibeto-Burman populations, whereas Sherpas descend from high-altitude Tibetans. Objective: To compare apnea severity at low and high altitude between Sherpas and Tamangs. Methods: Polygraphy recordings, including airflow and oxygen saturation, were performed in Nepal at "low" (2,030 m) and "high" (4,380 m) altitudes. Resting ventilation (V̇E) and mixed-exhaled CO₂ (F_ECO₂) were also measured at the same altitudes. Differences in apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and % of nocturnal periodic breathing (NPB) at the two altitudes were compared between ethnicities. Measurements and Main Results: Twenty Sherpas and 20 Tamangs were included (males, median [interquartile range] age: 24.5 [21.5-27.8] years vs. 26.0 [21.5-39.8] years, body mass index: 23.9 [22.1-26.1] kg/m² vs. 25.21 [20.6-27.6] kg/m²). Compared with Tamangs, Sherpas showed a lower increase in AHI (+7.5 [2.6-17.2]/h vs. +31.5 [18.2-57.3]/h, p < 0.001), ODI (+13.8 [5.5-28.2]/h vs. +42.0 [22.6-77.6]/h, p < 0.001), and NPB proportion (+0.9 [0-3.5]% vs. +12.8 [3.1-27.4]%, p < 0.001) from low to high altitude. Resting V̇E was higher in Sherpas versus Tamangs at both low (8.45 [6.89-10.70] l/min vs. 6.3 [4.9-8.3] l/min, p = 0.005) and high (9.7 [8.5-11] l/min vs. 8.74 [7.39-9.73] l/min, p = 0.020) altitudes, whereas the mean ± standard deviation F_ECO₂ decrease between low and high altitude was greater in Tamangs versus Sherpas (-0.50% ± 0.44% vs. -0.80% ± 0.33%, p < 0.023). Conclusion: Overall, altitude-adapted Sherpas showed a 3.2-times smaller increase in sleep-disordered breathing between low and high altitude compared with Tamangs, and higher ventilation and a smaller drop in F_ECO₂ at high altitude. These data suggest that genetic differences in breathing control can be protective against CSA.

Neuromuscular fatigability at high altitude: Lowlanders with acute and chronic exposure, and native highlanders

Ascent to high altitude is accompanied by a reduction in partial pressure of inspired oxygen, which leads to interconnected adjustments within the neuromuscular system. This review describes the unique challenge that such an environment poses to neuromuscular fatigability (peripheral, central and supraspinal) for individuals who normally reside near to sea level (SL) (<1000 m; ie, lowlanders) and for native highlanders, who represent the manifestation of high altitude-related heritable adaptations across millennia. Firstly, the effect of acute exposure to high altitude-related hypoxia on neuromuscular fatigability will be examined. Under these conditions, both supraspinal and peripheral fatigability are increased compared with SL. The specific mechanisms contributing to impaired performance are dependent on the exercise paradigm and amount of muscle mass involved. Next, the effect of chronic exposure to high altitude (ie, acclimatization of ~7-28 days) will be considered. With acclimatization, supraspinal fatigability is restored to SL values, regardless of the amount of muscle mass involved, whereas peripheral fatigability remains greater than SL except when exercise involves a small amount of muscle mass (eg, knee extensors). Indeed, when whole-body exercise is involved, peripheral fatigability is not different to acute high-altitude exposure, due to competing positive (haematological and muscle metabolic) and negative (respiratory-mediated) effects of acclimatization on neuromuscular performance. In the final section, we consider evolutionary adaptations of native highlanders (primarily Himalayans of Tibet and Nepal) that may account for their superior performance at altitude and lesser degree of neuromuscular fatigability compared with acclimatized lowlanders, for both single-joint and whole-body exercise.

The Characteristics of Sleep Apnea in Tibetans and Han Long-Term High Altitude Residents

PURPOSE

Obstructive sleep apnea (OSA) is common both at low and high altitude. Since adaptations to high altitude and respiratory control may differ among Tibetans and Hans, we compared characteristics of sleep-disordered breathing in the two ethnic groups at high altitude.

MATERIALS AND METHODS

This was a prospective observational study including 86 Tibetan and Han long-term (>5 years) high altitude residents with chief complaints of snoring and/or witnessed apnea underwent clinical evaluation and polysomnography at 3200 meters in Shangri-La, China.

RESULTS

In 42 Tibetans, 38 men, median (quartiles) age was 50.0 (41.0; 56.0)y, total apnea/hypopnea index (AHI) 53.9 (32.0; 77.5)/h, obstructive AHI 51.0 (28.0; 72.2)/h and central AHI 1.5 (0.2; 3.1)/h. In 44 Hans, 32 men, median (quartiles) age was 47.0 (43.5; 51.0)y, total AHI 22.2 (12.8; 39.2)/h, obstructive AHI 17.7 (12.0; 33.0)/h and central AHI 2.4 (0.5; 3.4)/h (p < 0.001 total and obstructive AHI vs Tibetans). In Tibetans, mean nocturnal oxygen saturation was lower [median 85.0 (83.0; 88.0)% vs 88.5 (87.0; 90.0)%] and obstructive apnea and hypopnea duration was longer [22.0 (19.6; 24.8) sec vs 18.3 (16.7; 20.6) sec] than in Hans (all p < 0.001). In regression analysis, Tibetan ethnicity, neck circumference and high-altitude living duration were the predictors of total AHI. We also found that with every 10/h increase in total AHI, there were an approximately 0.9 beat/min and 0.8 beat/min increase in mean heart rate during rapid eye movement (REM) and non-REM sleep and 1.9 mmHg and 2.0 mmHg increase in evening and morning systolic blood pressure.

CONCLUSION

Our data suggest that Tibetans presented more severe obstructive sleep apnea, hypoxemia and longer apnea duration compared to Hans at 3200 meters, which was correlated with higher heart rate and blood pressure suggesting a greater cardiovascular risk.

Distinct Mechanisms Underlie Developmental Plasticity and Adult Acclimation of Thermogenic Capacity in High-Altitude Deer Mice

Developmental plasticity can elicit phenotypic adjustments that help organisms cope with environmental change, but the relationship between developmental plasticity and plasticity in adult life (e.g., acclimation) remains unresolved. We sought to examine developmental plasticity and adult acclimation in response to hypoxia of aerobic capacity (V̇O_2max) for thermogenesis in deer mice (Peromyscus maniculatus) native to high altitude. Deer mice were bred in captivity and exposed to normoxia or one of four hypoxia treatments (12 kPa O₂) across life stages: adult hypoxia (6–8 weeks), post-natal hypoxia (birth to adulthood), life-long hypoxia (before conception to adulthood), and parental hypoxia (mice conceived and raised in normoxia, but parents previously exposed to hypoxia). Hypoxia during perinatal development increased V̇O_2max by a much greater magnitude than adult hypoxia. The amplified effect of developmental hypoxia resulted from physiological plasticity that did not occur with adult hypoxia – namely, increases in lung ventilation and volume. Evolved characteristics of deer mice enabled developmental plasticity, because white-footed mice (P. leucopus; a congener restricted to low altitudes) could not raise pups in hypoxia. Parental hypoxia had no persistent effects on V̇O_2max. Therefore, developmental plasticity can have much stronger phenotypic effects and can manifest from distinct physiological mechanisms from adult acclimation.

Exercise Performance in Central Asian Highlanders: A Cross-Sectional Study

Forrer, Aglaia, Philipp M. Scheiwiller, Maamed Mademilov, Mona Lichtblau, Ulan Sheraliev, Nuriddin H. Marazhapov, Stéphanie Saxer, Patrick Bader, Paula Appenzeller, Shoira Aydaralieva, Aybermet Muratbekova, Talant M. Sooronbaev, Silvia Ulrich, Konrad E. Bloch, and Michael Furian. Exercise performance in central Asian highlanders: A cross-sectional study. High Alt Med Biol. 00:000-000, 2021. Introduction: Life-long exposure to hypobaric hypoxia induces physiologic adaptations in highlanders that may modify exercise performance; however, reference data for altitude populations are scant. Methods: Life-long residents of the Tien Shan mountain range, 2,500 - 3,500 m, Kyrgyzstan, free of cardiopulmonary disease, underwent cardiopulmonary cycle exercise tests with a progressive ramp protocol to exhaustion at 3,250 m. ECG, breath-by-breath pulmonary gas exchange, and oxygen saturation by pulse oximetry (SpO₂) were measured. Results: Among 81 highlanders, age (mean ± SD) 48 ± 10 years, 46% women, SpO₂ at rest was 88% ± 2%, peak oxygen uptake (V'O₂peak) was 21.6 ± 5.9 mL/kg/min (76% ± 15% predicted for a low-altitude reference population); peak work rate (Wpeak) was 117 ± 37 W (77% ± 17% predicted), SpO₂ at peak was 84% ± 5%, heart rate reserve (220 - age - maximal heart rate) was 28 ± 17/min, ventilatory reserve (maximal voluntary ventilation - maximal minute ventilation) was 68 ± 32 l/min, and respiratory exchange ratio was 1.03 ± 0.09. Peak BORG-CR10 dyspnea and leg fatigue scores were 5.1 ± 2.0 and 6.3 ± 2.1. In multivariable linear regression analyses, age and sex were robust determinants of Wpeak, V'O₂peak, and metabolic equivalent (MET) at peak, whereas body mass index, resting systolic blood pressure, and mean pulmonary artery pressure were not. Conclusions: The current study shows that V'O₂peak and Wpeak of highlanders studied at 3,250 m, near their altitude of residence, were reduced by about one quarter compared with mean predicted values for lowlanders. The provided prediction models for V'O₂peak, Wpeak, and METs in central Asian highlanders might be valuable for comparisons with other high altitude populations.

High-Altitude Adaptation: Mechanistic Insights from Integrated Genomics and Physiology

Population genomic analyses of high-altitude humans and other vertebrates have identified numerous candidate genes for hypoxia adaptation, and the physiological pathways implicated by such analyses suggest testable hypotheses about underlying mechanisms. Studies of highland natives that integrate genomic data with experimental measures of physiological performance capacities and subordinate traits are revealing associations between genotypes (e.g., hypoxia-inducible factor gene variants) and hypoxia-responsive phenotypes. The subsequent search for causal mechanisms is complicated by the fact that observed genotypic associations with hypoxia-induced phenotypes may reflect second-order consequences of selection-mediated changes in other (unmeasured) traits that are coupled with the focal trait via feedback regulation. Manipulative experiments to decipher circuits of feedback control and patterns of phenotypic integration can help identify causal relationships that underlie observed genotype–phenotype associations. Such experiments are critical for correct inferences about phenotypic targets of selection and mechanisms of adaptation.

UBC-Nepal Expedition: Cerebrovascular Responses to Exercise in Sherpa Children Residing at High Altitude

Understanding the process of successful adaptation to high altitude provides valuable insight into the pathogenesis of conditions associated with impaired oxygen uptake and utilization. Prepubertal children residing at low altitude show a reduced cerebrovascular response to exercise in comparison to adults, and a transient uncoupling of cerebral blood flow to changes in the partial pressure of end-tidal CO₂ (P_ETCO₂); however, little is known about the cerebrovascular response to exercise in high-altitude native children. We sought to compare the cerebral hemodynamic response to acute exercise between prepubertal children residing at high and low altitude. Prepubertal children (n = 32; 17 female) of Sherpa descent (Sherpa children [SC]) at high altitude (3800 m, Nepal) and maturational-matched (n = 32; 20 female) children (lowland children [LLC]) residing at low altitude (342 m, Canada). Ventilation, peripheral oxygen saturation (S_pO₂), P_ETCO_2, and blood velocity in the middle and posterior cerebral arteries (MCA_v and PCA_v) were continuously measured during a graded cycling exercise test to exhaustion. At baseline (BL), P_ETCO₂ (-19 ± 4 mmHg, p < 0.001), S_pO₂ (-6.0% ± 2.1%, p < 0.001), MCA_v (-12% ± 5%, p = 0.02), and PCA_v (-12% ± 6%, p = 0.04) were lower in SC when compared with LLC. Despite this, the relative change in MCA_v and PCA_v during exercise was similar between the two groups (p = 0.99). Linear regression analysis demonstrated a positive relationship between changes in P_ETCO₂ with MCA_v in SC (R² = 0.13, p > 0.001), but not in LLC (R² = 0.03, p = 0.10). Our findings demonstrate a similar increase in intra-cranial perfusion during exercise in prepubertal SC, despite differential BL values and changes in P_ETCO₂ and S_pO₂.

Sea-level haemoglobin concentration is associated with greater exercise capacity in Tibetan males at 4200 m

NEW FINDINGS

What is the topic of this review? Recent developments link relatively lower hemoglobin concentration in Tibetans at high altitude to exercise capacity and components of oxygen transport. What advances does it highlight? Haemoglobin concentration (ranging from 15.2 to 22.9 g dl(-1) ) in Tibetan males was negatively associated with peak oxygen (O2 ) uptake per kilogram, cardiac output and muscle O2 diffusion conductance. Most variance in the peak O2 uptake per kilogram of Tibetan males was attributed to cardiac output, muscle diffusional conductance and arterial partial pressure of CO2 . The mechanisms underlying these differences in oxygen transport in Tibetans require additional analyses. Despite residence at >4000 m above sea level, many Tibetan highlanders, unlike Andean counterparts and lowlanders at altitude, exhibit haemoglobin concentration ([Hb]) within the typical sea-level range. Genetic adaptations in Tibetans are associated with this relatively low [Hb], yet the functional relevance of the lower [Hb] remains unknown. To address this, we examined each major step of the oxygen transport cascade [ventilation (VE), cardiac output (QT) and diffusional conductance in lung (DL) and muscle (DM)] in Tibetan males at maximal exercise on a cycle ergometer. Ranging from 15.2 to 22.9 g dl(-1) , [Hb] was negatively associated with peak O2 uptake per kilogram (r = -0.45, P < 0.05) and both cardiac output (QT/kg: r = -0.54, P < 0.02) and muscle O2 diffusion conductance (DM/kg: r = -0.44, P < 0.05) but not ventilation, arterial partial pressure of O2 or pulmonary diffusing capacity. Most variance in peak O2 uptake per kilogram was attributed to QT, DM and arterial partial pressure of CO2 (r(2)  = 0.90). In summary, lack of polycythaemia in Tibetans is associated with increased exercise capacity, which is explained by elevated cardiac, muscle and, to a small extent, ventilatory responses rather than pulmonary gas exchange. Whether lower [Hb] is the cause or result of these changes in O2 transport or is causally unrelated will require additional study.

Altitude Adaptation: A Glimpse Through Various Lenses

Simonson, Tatum S. Altitude adaptation: A glimpse through various lenses. High Alt Med Biol 16:125-137, 2015.--Recent availability of genome-wide data from highland populations has enabled the identification of adaptive genomic signals. Some of the genomic signals reported thus far among Tibetan, Andean, and Ethiopian are the same, while others appear unique to each population. These genomic findings parallel observations conveyed by decades of physiological research: different continental populations, resident at high altitude for hundreds of generations, exhibit a distinct composite of traits at altitude. The most commonly reported signatures of selection emanate from genomic segments containing hypoxia-inducible factor (HIF) pathway genes. Corroborative evidence for adaptive significance stems from associations between putatively adaptive gene copies and sea-level ranges of hemoglobin concentration in Tibetan and Amhara Ethiopians, birth weights and metabolic factors in Andeans and Tibetans, maternal uterine artery diameter in Andeans, and protection from chronic mountain sickness in Andean males at altitude. While limited reports provide mechanistic insights thus far, efforts to identify and link precise genetic variants to molecular, physiological, and developmental functions are underway, and progress on the genomics front continues to provide unprecedented movement towards these goals. This combination of multiple perspectives is necessary to maximize our understanding of orchestrated biological and evolutionary processes in native highland populations, which will advance our understanding of both adaptive and non-adaptive responses to hypoxia.

Why Are High Altitude Natives So Strong at High Altitude? Nature vs. Nurture: Genetic Factors vs. Growth and Development

Among high-altitude natives there is evidence of a general hypoxia tolerance leading to enhanced performance and/or increased capacity in several important domains. These domains likely include an enhanced physical work capacity, an enhanced reproductive capacity, and an ability to resist several common pathologies of chronic high-altitude exposure. The "strength" of the high-altitude native in this regard may have both a developmental and a genetic basis, although there is better evidence for the former (developmental effects) than for the latter. For example, early-life hypoxia exposure clearly results in lung growth and remodeling leading to an increased O2 diffusing capacity in adulthood. Genetic research has yet to reveal a population genetic basis for enhanced capacity in high-altitude natives, but several traits are clearly under genetic control in Andean and Tibetan populations e.g., resting and exercise arterial O2 saturation (SaO2). This chapter reviews the effects of nature and nurture on traits that are relevant to the process of gas exchange, including pulmonary volumes and diffusion capacity, the maximal oxygen consumption (VO2max), the SaO2, and the alveolar-arterial oxygen partial pressure difference (A-aDO2) during exercise.

Larger FVC and FEV1 among Tibetans compared to Han born and raised at high altitude

OBJECTIVES

This study compares forced vital capacity (FVC) and Forced Expiratory Volume at 1 Second (FEV1 ) of Tibetans with those of Han who were born and raised at high altitude.

MATERIALS AND METHODS

FVC and FEV1 tests were conducted among 1,063 children and adolescents between the ages of 6 and 20 years, and 184 adults between the ages of 21 and 39 years who had lived their entire lives at 3200 m, 3800 m and 4300 m in Qinghai Provence, Peoples Republic of China.

RESULTS

Even though FVC and FEV1 values of Han born and raised at high altitude are generally lower than those of Tibetans through age 15 in girls and age 16 in boys, differences are largely explained by variation in stature (height-squared) and chest circumference. Among older adolescents and adults, the FVC and FEV1 values of Tibetans are significantly larger than those of Han born and raised at high altitude; and are much larger than would be predicted, based on stature and chest circumference.

DISCUSSION

These results indicate that the large FVC and FEV1 values of Tibetan adults develop primarily from an accelerated pattern of lung growth that begins during mid-to-late adolescence and possibly extends into young adulthood. This developmental pattern is not only distinct from that of Han born and raised at high altitude, but also from those of Andean Quechua and Aymara. The pace of lung function growth may therefore represent another feature distinguishing the Tibetan from the Andean pattern of adaptation to high altitude hypoxia. Because of this, a search for features in the Tibetan genome related to this lung function growth phenotype might be productive and important.

Low haemoglobin concentration in Tibetan males is associated with greater high-altitude exercise capacity

Tibetans living at high altitude have adapted genetically such that many display a low erythropoietic response, resulting in near sea-level haemoglobin (Hb) concentration. We hypothesized that absence of the erythropoietic response would be associated with greater exercise capacity compared to those with high [Hb] as a result of beneficial changes in oxygen transport. We measured, in 21 Tibetan males with [Hb] ranging from 15.2 g dl(-1) to 22.9 g dl(-1) (9.4 mmol l(-1) to 14.2 mmol l(-1) ), [Hb], ventilation, volumes of O2 and CO2 utilized at peak exercise (V̇O2 and V̇CO2), heart rate, cardiac output and arterial blood gas variables at peak exercise on a cycle ergometer at ∼4200 m. Lung and muscle O2 diffusional conductances were computed from these measurements. [Hb] was related (negatively) to V̇O2 kg(-1) (r = -0.45, P< 0.05), cardiac output kg(-1) (QT kg(-1) , r = -0.54, P < 0.02), and O2 diffusion capacity in muscle (DM kg(-1) , r = -0.44, P<0.05), but was unrelated to ventilation, arterial partial pressure of O2 (PaO2) or pulmonary diffusing capacity. Using multiple linear regression, variance in peak V̇O2 kg(-1) was primarily attributed to QT, DM, and PCO2 (R(2) = 0.88). However, variance in pulmonary gas exchange played essentially no role in determining peak V̇O2. These results (1) show higher exercise capacity in Tibetans without the erythropoietic response, supported mostly by cardiac and muscle O2 transport capacity and ventilation rather than pulmonary adaptations, and (2) support the emerging hypothesis that the polycythaemia of altitude, normally a beneficial response to low cellular PO2, may become maladaptive if excessively elevated under chronic hypoxia. The cause and effect relationships among [Hb], QT, DM, and PCO2 remain to be elucidated.

Developmental Effects Determine Submaximal Arterial Oxygen Saturation in Peruvian Quechua

Kiyamu, Melisa, Fabiola León-Velarde, María Rivera-Chira, Gianpietro Elías, and Tom D. Brutsaert. Developmental effects determine submaximal arterial oxygen saturation in Peruvian Quechua. High Alt Med Biol 16, 138-146, 2015.--Andean high altitude natives show higher arterial oxygen saturation (Sao(2)) during exercise in hypoxia, compared to acclimatized sojourners. In order to evaluate the effects of life-long exposure to high altitude on Sao(2), we studied two groups of well-matched, self-identified Peruvian Quechua natives who differed in their developmental exposure to hypoxia before and after a 2-month training period. Male and female volunteers (18-35 years) were recruited in Lima, Peru (150 m). The two groups were: a) Individuals who were born and raised at sea-level (BSL, n=34) and b) Individuals who were born and raised at high altitude (BHA, n=32), but who migrated to sea-level as adults (>16 years old). Exercise testing was conducted using a submaximal exercise protocol in normobaric hypoxia in Lima (BP=750 mmHg, Fio(2)=0.12), in order to measure Sao(2) (%), ventilation (VE L/min) and oxygen consumption (Vo(2), L/min). Repeated-measures ANOVA, controlling for VE/VO(2) (L/min) and sex during the submaximal protocol showed that BHA maintained higher Sao(2) (%) compared to BSL at all workloads before (p=0.005) and after training (p=0.017). As expected, both groups showed a decrease in Sao(2) (%) (p<0.001), as workload increased. Resting Sao(2) levels were not found to be different between groups. The results suggest that developmental exposure to altitude contributes to the maintenance of higher Sao(2) levels during submaximal exercise at hypoxia.

Aerobic capacity of Peruvian Quechua: a test of the developmental adaptation hypothesis

High altitude natives are reported to have outstanding work capacity in spite of the challenge of oxygen transport and delivery in hypoxia. To evaluate the developmental effect of lifelong exposure to hypoxia on aerobic capacity, VO2peak was measured on two groups of Peruvian Quechua subjects (18-35 years), who differed in their developmental exposure to altitude. Male and female volunteers were recruited in Lima, Peru (150 m), and were divided in two groups, based on their developmental exposure to hypoxia, those: a) Born at sea-level individuals (BSL), with no developmental exposure to hypoxia (n = 34) and b) Born at high-altitude individuals (BHA) with full developmental exposure to hypoxia (n = 32), but who migrated to sea-level as adults (>16-years-old). Tests were conducted both in normoxia (BP = 750 mm Hg) and normobaric hypoxia at sea-level (BP = 750 mm Hg, FiO2  = 0.12, equivalent to 4,449 m), after a 2-month training period (in order to control for initial differences in physical fitness) at sea-level. BHA had a significantly higher VO2peak at hypoxia (40.31 ± 1.0 ml/min/kg) as compared to BSL (35.78 ± 0.96 ml/min/kg, P = 0.001), adjusting for sex. The decrease of VO2peak at HA relative to SL (ΔVO2peak ) was not different between groups, controlling for baseline levels (VO2peak at sea-level) and sex (BHA = 0.35 ± 0.04 l/min, BSL = 0.44 ± 0.04 l/min; P = 0.12). Forced vital capacity (controlling for height) and the residuals of VO2peak (controlling for weight) had a significant association in the BHA group only (r = 0.155; P = 0.031). In sum, results indicate that developmental exposure to altitude constitutes an important factor to determine superior exercise performance.

King of the Mountains: Tibetan and Sherpa Physiological Adaptations for Life at High Altitude

Anecdotal evidence surrounding Tibetans' and Sherpas' exceptional tolerance to hypobaric hypoxia has been recorded since the beginning of high-altitude exploration. These populations have successfully lived and reproduced at high altitude for hundreds of generations with hypoxia as a constant evolutionary pressure. Consequently, they are likely to have undergone natural selection toward a genotype (and phenotype) tending to offer beneficial adaptation to sustained hypoxia. With the advent of translational human hypoxic research, in which genotype/phenotype studies of healthy individuals at high altitude may be of benefit to hypoxemic critically ill patients in a hospital setting, high-altitude natives may provide a valuable and intriguing model. The aim of this review is to provide a comprehensive summary of the scientific literature encompassing Tibetan and Sherpa physiological adaptations to a high-altitude residence. The review demonstrates the extent to which evolutionary pressure has refined the physiology of this high-altitude population. Furthermore, although many physiological differences between highlanders and lowlanders have been found, it also suggests many more potential avenues of investigation.

Increased blood-oxygen binding affinity in Tibetan and Han Chinese residents at 4200 m

High-altitude natives are challenged by hypoxia, and a potential compensatory mechanism could be reduced blood oxygen-binding affinity (P50), as seen in several high-altitude mammalian species. In 21 Qinghai Tibetan and nine Han Chinese men, all resident at 4200 m, standard P50 was calculated from measurements of arterial PO2 and forehead oximeter oxygen saturation, which was validated in a separate examination of 13 healthy subjects residing at sea level. In both Tibetans and Han Chinese, standard P50 was 24.5 ± 1.4 and 24.5 ± 2.0 mmHg, respectively, and was lower than in the sea-level subjects (26.2 ± 0.6 mmHg, P < 0.01). There was no relationship between P50 and haemoglobin concentration (the latter ranging from 15.2 to 22.9 g dl(-1) in Tibetans). During peak exercise, P50 was not associated with alveolar-arterial PO2 difference or peak O2 uptake per kilogram. There appears to be no apparent benefit of a lower P50 in this adult high-altitude Tibetan population.

Exercise capacity and selected physiological factors by ancestry and residential altitude: cross-sectional studies of 9-10-year-old children in Tibet

AIM

Several physiological compensatory mechanisms have enabled Tibetans to live and work at high altitude, including increased ventilation and pulmonary diffusion capacity, both of which serve to increase oxygen transport in the blood. The aim of the present study was to compare exercise capacity (maximal power output) and selected physiological factors (arterial oxygen saturation and heart rate at rest and during maximal exercise, resting hemoglobin concentration, and forced vital capacity) in groups of native Tibetan children living at different residential altitudes (3700 vs. 4300 m above sea level) and across ancestry (native Tibetan vs. Han Chinese children living at the same altitude of 3700 m).

METHODS

A total of 430 9-10-year-old native Tibetan children from Tingri (4300 m) and 406 native Tibetan- and 406 Han Chinese immigrants (77% lowland-born and 33% highland-born) from Lhasa (3700 m) participated in two cross-sectional studies. The maximal power output (W max) was assessed using an ergometer cycle.

RESULTS

Lhasa Tibetan children had a 20% higher maximal power output (watts/kg) than Tingri Tibetan and 4% higher than Lhasa Han Chinese. Maximal heart rate, arterial oxygen saturation at rest, lung volume, and arterial oxygen saturation were significantly associated with exercise capacity at a given altitude, but could not fully account for the differences in exercise capacity observed between ancestry groups or altitudes.

CONCLUSIONS

The superior exercise capacity in native Tibetans vs. Han Chinese may reflect a better adaptation to life at high altitude. Tibetans at the lower residential altitude of 3700 m demonstrated a better exercise capacity than residents at a higher altitude of 4300 m when measured at their respective residential altitudes. Such altitude- or ancestry-related difference could not be fully attributed to the physiological factors measured.

Developmental and genetic components explain enhanced pulmonary volumes of female Peruvian Quechua

High altitude natives have enlarged vital capacities and residual volumes (RV). Because pulmonary volumes are an indication of functionally relevant traits, such as diffusion capacity, the understanding of the factors (genetic/developmental) that influence lung volumes provides insight into the adaptive responses of highlanders. In order to test for the effect of growth and development at high altitude on lung volumes, we obtained forced vital capacities (FVC), RV, and total lung capacities (TLC) for a sample of 65 Peruvian females of mostly Quechua origins (18-34 years) who were sub-divided into two well-matched groups: 1) sea-level born and raised females (BSL, n = 34) from Lima, Peru (150 m), and 2) high-altitude born and raised females (BHA, n = 31) from Cerro de Pasco, Peru (4,338 m). To determine Quechua origins, Native American ancestry proportion (NAAP) for each individual was assessed using a panel of 70 ancestry informative markers. NAAP was similar between groups (BSL = 91.71%; BHA = 89.93%; P = 0.240), and the analysis confirmed predominantly Quechua origins. After adjusting for body size and NAAP, BHA females had significantly higher FVC (3.79 ± 0.06 l; P < 0.001), RV (0.98 ± 0.03 l; P < 0.001) and TLC (4.80 ± 0.07 l; P < 0.001) compared to BSL females (FVC = 3.33 ± 0.05 l; RV = 0.69 ± 0.03 l; TLC = 4.02 ± 0.06 l). NAAP was not associated with FVC (P = 0.352) or TLC (P = 0.506). However, NAAP was positively associated with RV (P = 0.004). In summary, results indicate that developmental exposure to high altitude in females constitutes an important factor for all lung volumes, whereas both genetic and developmental factors seem to be important for RV.

Natural selection on EPAS1 (HIF2alpha) associated with low hemoglobin concentration in Tibetan highlanders

By impairing both function and survival, the severe reduction in oxygen availability associated with high-altitude environments is likely to act as an agent of natural selection. We used genomic and candidate gene approaches to search for evidence of such genetic selection. First, a genome-wide allelic differentiation scan (GWADS) comparing indigenous highlanders of the Tibetan Plateau (3,200-3,500 m) with closely related lowland Han revealed a genome-wide significant divergence across eight SNPs located near EPAS1. This gene encodes the transcription factor HIF2alpha, which stimulates production of red blood cells and thus increases the concentration of hemoglobin in blood. Second, in a separate cohort of Tibetans residing at 4,200 m, we identified 31 EPAS1 SNPs in high linkage disequilibrium that correlated significantly with hemoglobin concentration. The sex-adjusted hemoglobin concentration was, on average, 0.8 g/dL lower in the major allele homozygotes compared with the heterozygotes. These findings were replicated in a third cohort of Tibetans residing at 4,300 m. The alleles associating with lower hemoglobin concentrations were correlated with the signal from the GWADS study and were observed at greatly elevated frequencies in the Tibetan cohorts compared with the Han. High hemoglobin concentrations are a cardinal feature of chronic mountain sickness offering one plausible mechanism for selection. Alternatively, as EPAS1 is pleiotropic in its effects, selection may have operated on some other aspect of the phenotype. Whichever of these explanations is correct, the evidence for genetic selection at the EPAS1 locus from the GWADS study is supported by the replicated studies associating function with the allelic variants.

Do high-altitude natives have enhanced exercise performance at altitude?

Natives of high altitude (HA) may have enhanced physical work capacity in hypoxia due to growth and development at altitude or, in the case of indigenous Andean and Himalayan residents, due to population genetic factors that determine higher limits to exercise performance. There is a growing scientific literature in support of both hypotheses, although the specific developmental vs. genetic origins of putative population trait differences remain obscure. Considering whole-body measures of exercise performance, a review of the literature suggests that indigenous HA natives have higher mean maximal oxygen consumption (VO(2) (max)) in hypoxia and smaller VO(2) (max) decrement with increasing hypoxia. At present, there is insufficient information to conclude that HA natives have enhanced work economy or greater endurance capacity, although for the former a number of studies indicate that this may be the case for Tibetans. At the physiological level, supporting the hypothesis of enhanced pulmonary gas exchange efficiency, HA natives have smaller alveolar-arterial oxygen partial pressure difference ((A-a)DO(2)), lower pulmonary ventilation (VE), and likely higher arterial O(2) saturation (SaO(2)) during exercise. At the muscle level, a handful of studies show no differences in fiber-type distributions, capillarity, oxidative enzymes, or the muscle response to training. At the metabolic level, a few studies suggest differences in lactate production/removal and (or) lactate buffering capacity, but more work is needed in this area.

High-altitude physiology and pathophysiology: implications and relevance for intensive care medicine

Cellular hypoxia is a fundamental mechanism of injury in the critically ill. The study of human responses to hypoxia occurring as a consequence of hypobaria defines the fields of high-altitude medicine and physiology. A new paradigm suggests that the physiological and pathophysiological responses to extreme environmental challenges (for example, hypobaric hypoxia, hyper-baria, microgravity, cold, heat) may be similar to responses seen in critical illness. The present review explores the idea that human responses to the hypoxia of high altitude may be used as a means of exploring elements of the pathophysiology of critical illness.

Population genetic aspects and phenotypic plasticity of ventilatory responses in high altitude natives

Highland natives show unique breathing patterns and ventilatory responses at altitude, both at rest and during exercise. For many ventilatory traits, there is also significant variation between highland native groups, including indigenous populations in the Andes and Himalaya, and more recent altitude arrivals in places like Colorado. This review summarizes the literature in this area with some focus on partitioning putative population genetic differences from differences acquired through lifelong exposure to hypoxia. Current studies suggest that Tibetans have high resting ventilation (V (E)), and a high hypoxic ventilatory response (HVR), similar to altitude acclimatized lowlanders. Andeans, in contrast, show low resting V (E) and a low or "blunted" HVR, with little evidence that these traits are acquired via lifelong exposure. Resting V (E) of non-indigenous altitude natives is not well documented, but lifelong hypoxic exposure almost certainly blunts HVR in these groups through decreased chemosensitivity to hypoxia in a process known as hypoxic desensitization (HD). Together, these studies suggest that the time course of ventilatory response, and in particular the origin or absence of HD, depends on population genetic background i.e., the allele or haplotype frequencies that characterize a particular population. During exercise, altitude natives have lower V (E) compared to acclimatized lowland controls. Altitude natives also have smaller alveolar-arterial partial pressure differences P(AO2) - P(aO2) during exercise suggesting differences in gas exchange efficiency. Small P(AO2) - P(aO2) in highland natives of Colorado underscores the likely importance of developmental adaptation to hypoxia affecting structural/functional aspects of gas exchange with resultant changes in breathing pattern. However, in Andeans, at least, there is also evidence that low exercise V (E) is determined by genetic background affecting ventilatory control independent of gas exchange. Additional studies are needed to elucidate the effects of gene, environment, and gene-environment interaction on these traits, and these effects are likely to differ widely between altitude native populations.

A Comparative Analysis of Arterial Oxygen Saturation among Tibetans And Han Born And Raised at High Altitude

This study compares resting arterial oxygen saturation as measured by pulse oximetry (Sp(O2)) among 818 Tibetans and 668 Han who were born and raised at altitudes between 3200 and 4300 m in Qinghai Province, Western China. Both Tibetans and Han show an increase in Sp(O2) values between the ages of 5 and 19 yr, and both groups show a decline after the third decade. However, mean, age-adjusted Sp(O2) values at rest do not differ significantly among growing Tibetans and Han aged 5 through 19 yr or among Tibetans and Han aged 20 through 51 yr. Therefore, the results of this study do not support the hypothesis that indigenous groups possess a superior arterial saturation while awake and at rest compared to lowlanders who have been born and raised at high altitude. Differences between adult Tibetan males and females approach statistical significance (females show higher values than males), while differences between adult Han males and females are not statistically significant. A review of the literature indicates that substantial interstudy variation exists in resting Sp(O2) values among Tibetans residing at high altitudes (between 2% and 4%, depending on the age of individuals measured) and may reflect differences in sample size, health of participants, instruments, probe location, and measurement protocols.

Work capacity of permanent residents of high altitude

Tibetan and Andean natives at altitude have allegedly a greater work capacity and stand fatigue better than acclimatized lowlanders. The principal aim of the present review is to establish whether convincing experimental evidence supports this belief and, should this be the case, to analyze the possible underlying mechanisms. The superior work capacity of high altitude natives is not based on differences in maximum aerobic power (V(O2 peak)), mL kg(-1)min(-1)). In fact, average V (O2 peak) of both Tibetan and Andean natives at altitude is only slightly, although not significantly, higher than that of Asian or Caucasian lowlanders resident for more than 1 yr between 3400 and 4700 m (Tibetans, n = 152, vs. Chinese Hans, n = 116: 42.4 +/- 3.4 vs. 39.2 +/- 2.6 mL kg(-1)min(-1), mean +/- SE; Andeans, n = 116, vs. Caucasians, n = 70: 47.1 +/- 1.7 vs. 41.6 +/- 1.2 mL kg(-1)min(-1)). However, compared to acclimatized lowlanders, Tibetans appear to be characterized by a better economy of cycling, walking, and running on a treadmill. This is possibly due to metabolic adaptations, such as increased muscle myoglobin content and antioxidant defense. All together, the latter changes may enhance the efficiency of the muscle oxidative metabolic machinery, thereby supporting a better prolonged submaximal performance capacity compared to lowlanders, despite equal V(O2 peak). With regard to Andeans, data on exercise efficiency is scanty and controversial and, at present, no conclusion can be drawn as to the origin of their superior performance.

High Altitude Adaptation in Tibetans

Since the beginning of the Himalayan climbing era, the anecdotal extraordinary physical performance at high altitude of Sherpas and Tibetans has intrigued scientists interested in altitude adaptation. These ethnic groups may have been living at high altitude for longer than any other population, and the hypothesis of a possible evolutionary genetic adaptation to altitude makes sense. Reviewed here is the evidence as to whether Tibetans are indeed better adapted for life and work at high altitude as compared to other populations and, if so, whether this better adaptation might be inborn. Tibetans, compared to lowlanders, maintain higher arterial oxygen saturation at rest and during exercise and show less loss of aerobic performance with increasing altitude. Tibetans have greater hypoxic and hypercapnic ventilatory responsiveness, larger lungs, better lung function, and greater lung diffusing capacity than lowlanders. Blood hemoglobin concentration is lower in Tibetans than in lowlanders or Andeans living at similar altitudes. Tibetans develop only minimal hypoxic pulmonary hypertension and have higher levels of exhaled nitric oxide than lowlanders or Andeans. Tibetans' sleep quality at altitude is better and they desaturate less at night. Several of these findings are also found in Tibetans born at low altitude when exposed for the first time to high altitude once adult. In conclusion, Tibetans indeed seem better adapted to life and work at high altitude, and this superior adaptation may very well be inborn, even though its exact genetic basis remains to be elucidated.

Jack Reeves and his science

John T. (Jack) Reeves' science is reviewed across the 37 years of his research career at the University of Colorado Health Sciences Center, a period which occupied approximately half his remarkable life. His contributions centered on understanding the inter-relatedness as well as the underlying mechanisms controlling the various components of the O(2) transport system. We review here his studies on exercise performance; these encompassed about half his scientific output with the other half being devoted to the study of hypoxic pulmonary hypertension. Early studies concerned cardiac output, showing how it was a balance between O(2) uptake and O(2) extraction, and that cardiac output during exercise at high altitude was reduced, most likely because of decreased plasma volume and left ventricular filling. Jack's many studies addressed virtually every aspect of the O(2) transport system -- adding significantly to our understanding of the syndromes of altitude illness, the mechanisms by which ventilatory sensitivity to hypoxia and hypercapnia influenced ventilatory acclimatization, and the contributions of the various limbs of the autonomic nervous system on systemic blood pressure, vascular resistance and substrate utilization. His scientific career ended abruptly in 2004 when struck by a car while biking to work, but his legacy remains in his more than 385+ research articles or chapters, the 40+ fellows he trained, and the countless number of younger (and older) scientists for whom he served as a role model for learning how to scrutinize their data and present their findings in clear and sometimes bold prose. An integral man, he is sorely missed.

Economy of locomotion in high-altitude Tibetan migrants exposed to normoxia

High-altitude Tibetans undergo a pattern of adaptations to chronic hypoxia characterized, among others, by a more efficient aerobic performance compared with acclimatized lowlanders. To test whether such changes may persist upon descent to moderate altitude, oxygen uptake of 17 male Tibetan natives lifelong residents at 3500-4500 m was assessed within 1 month upon migration to 1300 m. Exercise protocols were: 5 min treadmill walking at 6 km h(-1) on increasing inclines from +5 to +15% and 5 min running at 10 km h(-1) on a +5% grade. The data (mean +/- S.E.M.) were compared with those obtained on Nepali lowlanders. When walking on +10, +12.5 and +15% inclines, net V(O2) of Tibetans was 25.2 +/- 0.7, 29.1 +/- 1.1 and 31.3 +/- 0.9 ml kg(-1) min(-1), respectively, i.e. 8, 10 and 13% less (P < 0.05) than that of Nepali. At the end of the heaviest load, blood lactate concentration was lower in Tibetans than in Nepali (6.0 +/- 0.9 versus 8.9 +/- 0.6 mM; P < 0.05). During running, V(O2) of Tibetans was 35.1 +/- 0.8 versus 39.3 +/- 0.7 ml kg(-1) min(-1) (i.e. 11% less; P < 0.01). In conclusion, during submaximal walking and running at 1300 m, Tibetans are still characterized by lower aerobic energy expenditure than control subjects that is not accounted for by differences in mechanical power output and/or compensated for by anaerobic glycolysis. These findings indicate that chronic hypoxia induces metabolic adaptations whose underlying mechanisms still need to be elucidated, that persist for at least 1 month upon descent to moderate altitude.

The Maximum Expiratory Flow-Volume Loop in Natives of Ladakh and Acclimatized Lowlanders

Differences in static and dynamic volumes may exist between high altitude residents of Indian Himalayas and their South American counterparts, as well as with acclimatized lowlander sojourners. Maximum expiratory flow-volume loops were recorded in healthy native highlanders of Ladakh (NH, N = 75) and in healthy acclimatized lowlanders (AL, N = 32) at an altitude of 3450 m in the western Indian Himalayas. The forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), both corrected for a height of 168 cm, were significantly higher in NH [FVC: 5.02 (0.51) vs. 3.89 (0.45) L, p < 0.0001; FEV1: 4.27 (0.47) vs. 3.44 (0.37) L, p < 0.0001]. The flow rates at larger lung volumes (PEFR, FEF25, and FEF50) were similar in the two groups. The NH showed significantly higher flow rates at low lung volumes, that is, FEF75 and FEF75-85% [FEF75: 2.03 (0.69) vs. 1.70 (0.52) L/s, p = 0.0092; FEF75-85%: 1.42 (0.54) vs. 1.06 (0.35) L/s, p = 0.0001]. The exact mechanisms allowing the higher flow rates at low lung volumes remain to be elucidated, but it is possible that these findings may indicate an inherited adaptive response in the Ladakhi highlander.

Tibetans at Extreme Altitude

Between 1960 and 2003, 13 Chinese expeditions successfully reached the summit of Chomolungma (Mt Everest or Sagarmatha). Forty-five of the 80 summiteers were Tibetan highlanders. During these and other high-altitude expeditions in Tibet, a series of medical and physiological investigations were carried out on the Tibetan mountaineers. The results suggest that these individuals are better adapted to high altitude and that, at altitude, they have a greater physical capacity than Han (ethnic Chinese) lowland newcomers. They have higher maximal oxygen uptake, greater ventilation, more brisk hypoxic ventilatory responses, larger lung volumes, greater diffusing capacities, and a better quality of sleep. Tibetans also have a lower incidence of acute mountain sickness and less body weight loss. These differences appear to represent genetic adaptations and are obviously significant for humans at extreme altitude. This paper reviews what is known about the physiologic responses of Tibetans at extreme altitudes.

Morphological growth and thorax dimensions among Tibetan compared to Han children, adolescents and young adults born and raised at high altitude

BACKGROUND

Studies comparing the growth of indigenous high-altitude Aymara children and children of low-altitude European descent who have been born and raised at high altitude in the Andes have provided evidence for genetically-determined differences in thorax growth, as well as for population differences in height, weight and other measures of overall size. Comparable studies now can be undertaken in Asia because of the growing number of Han Chinese who have been born and raised at high altitude on the Qinghai-Tibetan Plateau.

AIM

The study compares the growth of indigenous Tibetan children and children of Han descent who have been born and raised at the same high altitudes, and under similar socio-economic conditions.

SUBJECTS AND METHODS

Measurements of stature, sitting height, weight, triceps and subscapular skinfolds, upper arm muscle area, transverse chest diameter, anterio-posterior chest diameter, and chest circumference were taken on 1439 Tibetan and Han males and females between the ages of 6 and 29 years who were born and raised 3200 m, 3800 m or at 4300 m in the high altitude province of Qinghai in western China.

RESULTS

Han-Tibetan differences in body size do not occur systematically for any measurement, for any age group, or for either gender; nor is there a systematic pattern of body size differences between 3200 m and 4300 m. This indicates that there are no differences in general growth between the two groups at high altitude in Qinghai, although both groups grow more slowly than urban children at low altitude in China. On the other hand, Tibetan males possess significantly deeper chests than Han males, and Tibetan females possess significantly wider chests than Han females. Tibetans of both sexes possess significantly larger chest circumferences than Han males and females.

CONCLUSIONS

Although genetic similarities cannot be ruled out, comparable dietary stress is a likely explanation for the similar and slow morphological growth of Han and Tibetans at high altitude. However, Han-Tibetan differences in thorax dimensions are likely a consequence of population (genetic) differences in the response to hypoxia during growth.

Second generation Tibetan lowlanders acclimatize to high altitude more quickly than Caucasians

Tibetan highlanders develop at altitude peak aerobic power levels close to those of Caucasians at sea level. In order to establish whether this feature is genetic and, as a consequence, retained by Tibetan lowlanders, altitude-induced changes of peak aerobic performance were assessed in four groups of volunteers with different ethnic, altitude exposure and fitness characteristics, i.e. eight untrained second-generation Tibetans (Tib 2) born and living at 1300 m; seven altitude Sherpas living at approximately 2800-3500 m; and 10 untrained and five trained Caucasians. Measurements were carried out at sea level or at Kathmandu (1300 m, Nepal) (PRE), and after 2-4 (ALT1), 14-16 (ALT2), and 26-28 (ALT3) days at 5050 m. At ALT3, of untrained and trained Caucasians was -31% and -46%, respectively. By contrast, of Tib 2 and Sherpas was -8% and -15%, respectively. At ALT3, peak heart rate (HR(peak)) of untrained and trained Caucasians was 148 +/- 11 and 149 +/- 7 beats min(-1), respectively; blood oxygen saturation at peak exercise was 76 +/- 6% and 73 +/- 6%, and haemoglobin concentration ([Hb]) was 19.4 +/- 1.0 and 18.6 +/- 1.2 g dl(-1), respectively. Compared to Caucasians, Tib 2 and Sherpas exhibited at ALT3 higher HR(peak) (179 +/- 9 and 171 +/- 4 beats min(-1), P < 0.001), lower [Hb] (16.6 +/- 0.6 and 17.4 +/- 0.9 g dl(-1), respectively, P < 0.001), and slightly but non-significantly greater average values (82 +/- 6 and 80 +/- 7%). The above findings and the time course of adjustment of the investigated variables suggest that Tibetan lowlanders acclimatize to chronic hypoxia more quickly than Caucasians, independent of the degree of fitness of the latter.

Absence of Work Efficiency Differences During Cycle Ergometry Exercise in Bolivian Aymara

This study tested the hypothesis that Andean natives are adapted to high altitude (HA) via high work efficiency during exercise in hypoxia. A total of 186 young males and females were tested in Bolivia, comprising eight different subject groups. Groups were identified based on gender, ancestry (Aymara vs. European), altitude of birth (highlands vs. lowlands), and the altitude where tested (420, 3600, 3850 m). This design allows partitioning of ancestral (i.e., genetic) and developmental effects. To minimize measurement error, subjects were given two submaximal exercise tests on a cycle ergometer (on separate days). Each test consisted of four 5-min work bouts (levels), each separated by a 5-min rest period. For all groups, the oxygen consumption (V(O2))-work rate relationship was not different from the sea-level reference. Gross and net efficiencies (GE and NE) were not different between groups at any work level, with the exception of European men born in the lowlands and acclimatized and tested at 3600 m. These men showed slightly lower V(O2) at high work output, but this may be due to a nonsteady-state V(O2) kinetic, rather than to an altered steady-state V(O2)-work rate relationship per se. There were no significant group differences in delta efficiency (DE). In sum, these results provide no support for the hypothesis of energetic advantage during submaximal work in Andean HA natives. A review and analysis of the literature suggest that the same is true for HA natives in the Himalayas.

Sleep structure and periodic breathing in Tibetans and Han at simulated altitude of 5000 m

Tibetans are the oldest population living permanently at high altitude. They possess several adaptations to low oxygen pressure that improve oxygen transport. We hypothesised that native Tibetans have mechanisms allowing them to maintain a better sleep structure and oxygenation during sleep at high altitude than newcomers from lower altitudes acclimatised to living at high altitude. We studied eight healthy young Tibetans, aged 26+/-7 years, and six healthy young Han aged 30.5+/-4 years. All subjects were living on the Tibetan plateau at an altitude of around 4000 m. Investigations were performed in Xining at an altitude of 2261 m, PB=581 mmHg. Two full polysomnographies (PSG) were performed in a hypobaric chamber, one at the ambient altitude, the second during acute exposure to the simulated altitude of 5000 m (PB=405 mmHg). Both PSG were done on the same night using split night design. At 2261 m no differences in sleep structure, breathing pattern during sleep or oxygenation were found, except a higher number of arousals and awakenings in Han (P<0.002). At 5000 m Tibetans had a longer sleep time (P=0.002), shorter stage 1 non-REM sleep (P<0.001) and longer stage 2 non-REM sleep than Han (P<0.001). Tibetans showed a trend to have more periodic breathing (PB) and higher mean arterial blood saturation than Han (NS). Our data suggest that Tibetans preserved better sleep structure and arterial blood oxygenation than Han during acute exposure to the simulated altitude of 5000 m.

Spirometry values in Himalayan high altitude residents (Sherpas)

We compared the spirometric values of the isolated racial group of Himalayan Sherpas with those predicted for the European Coal and Steel Community (EC&S). 146 normal adult Sherpas (64 males, 82 females) and 103 adolescents (37 females and 66 males, age 10-18 years) resident at an altitude of 3,840 m were studied. Predicted values for each adult individual were calculated using the EC&S reference equations and separate Caucasian values for children were used, and new predictive equations for the Sherpa population derived. The FEV(1) of boys, adult male and female Sherpas are all significantly greater than predicted (% Predicted (PP) (95% Confidence Interval (CI)), 113% (110-116), 110% (107-114) and 116% (112-121), P < 0.0001 for all groups) as is forced vital capacity (FVC) (112% (111-119), 113% (109-117) and 121% (117-125) respectively, P < 0.0001 for all groups). Sherpa girls displayed a smaller difference in FEV(1) and FVC (PP(CI), 104% (99-109) P<0.1 and 108% (103-114) P = 0.005, respectively). We conclude that the Sherpa race has significantly larger spirometric values than Caucasians. We speculate that this is an adaptation in response to chronic hypoxia and high levels of habitual exercise.

Genetic and environmental adaptation in high altitude natives. Conceptual, methodological, and statistical concerns

A great number of physiological and anthropological studies have investigated Andean and Himalayan populations native to high altitude (HA). A non-scientific survey of the extant literature reveals a relatively liberal tradition of inferring genetic (evolutionary) adaptation to HA in these groups, often based on limited evidence and/or based on study designs insufficient to fully address the issue. Rather than review the evidence for or against genetic adaptation, and in order to provide some perspective, this paper will review relevant conceptual, methodological, and statistical issues that are germane to the study of HA native human groups. In particular, focus will be on the limitations of the most common research approach which bases evolutionary inference on the comparison of phenotypic mean differences between highland and lowland native populations. The migrant study approach is discussed, as is a relatively new approach based on genetic admixture in hybrid populations.