High-altitude environments are advantageous for addressing the question of evolutionary adaptation not only because of the pervasive nature of hypoxia but also due to the variation present among world populations in the generational duration of high-altitude habitation. Research efforts focusing on human adaptation to high altitude have been concentrated in the Andes and the Himalayas due primarily to the antiquity and relative isolation of human settlements in these regions, as well as the recent migration of lowland populations to the Andean or Tibetan Plateaus. In southern Peru and northern Bolivia extensive exploitation of major highland obsidian deposits and dental morphology suggest that humans moved from the coastline of Peru into the Andean Plateau approximately 10,000 years ago (
Burger, et al. 2000;
Piperno and Dillehay 2008). Today, nearly seven million persons reside on the
Altiplano, where some communities can be found up to 5000m (
Aldenderfer 2003),(
West 2002). Likewise, archaeological artifacts indicate that hominids lived along the fringes of the Tibetan Plateau at least 2 million years ago (
Brown 1999;
Dennell, et al. 1988;
Etler 1996), visited the Plateau’s higher steppes 25,000 – 50,000 years ago (
Sensui 1981;
Zhimin 1982) and lived, at least temporarily, on the Plateau 18,000 - 20,000 years ago (
Aldenderfer and Zhang 2004;
Huang 1994;
Zhang and Li 2002). Clearly, the duration of human residence in the Andean and Himalayan highlands is extensive and therefore likely sufficient for natural selection to have occurred in response to the pressures exerted by the high-altitude environment. The largely European-derived inhabitants of the high-altitude regions of Colorado and Utah, the European or other nationalities that settled in the Andean Plateau of South America, and the Han (“Chinese”) populations immigrating recently to the Tibetan Plateau of western China provide a natural group for comparison with high-altitude derived populations.
As mentioned above, we consider that pregnancy and the prenatal period should be particularly sensitive periods for examining selective advantage given that the reproductive fitness of three individuals may be diminished as a result of an unsuccessful pregnancy. For this reason, numerous comparative studies of maternal physiology during pregnancy and/or perinatal health outcome between migrant and native high-altitude populations have been used to illustrate human adaptation to high altitudes. Moreover, the potent effect of high-altitude on birth weight and perinatal health outcome provides an easily identifiable phenotype that presumably decreases reproductive success.
Residence at high altitude exerts one of the most powerful effects on fetal growth, reducing birth weight more than 100 g per 1000 m elevation gain as a result of slowed fetal growth rather than shortened gestation (
Jensen and Moore 1997;
Krampl, et al. 2000;
Lichty, et al. 1957;
Unger, et al. 1988). As a result, gestation at high altitude increases the number of infants born small-for-gestational age (SGA) three-fold (
Julian, et al. 2007). The effect of altitude to reduce birth weight is apparent in all high-altitude populations that have been studied to date, however infants born to women of highland origin are less affected than those born to women of lowland origin (
Julian, et al. 2007;
Vargas, et al. 2007;
Zamudio, et al. 2007). For example, at altitudes ranging between 3600 – 4100 m in Bolivia Andean infants weigh ~ 300g more than Europeans at birth and are born SGA one-third as often, whereas there is no birth weight difference between ancestry groups at 400 m (
Julian, et al. 2007). After accounting for the birth-weight influences of maternal hypertensive complications of pregnancy, parity, maternal body weight and the number of prenatal visits, European relative to Andean ancestry increased the risk of being born SGA at high altitude nearly five-fold (
Julian, et al. 2007).
Tibetans, a geographically and genetically distinct high-altitude population, are also protected from reduced birth weight with altitude. Tibetans weighed more than Han newborns in Lhasa, Tibet, (
Moore 2001a) and experienced only one-third the altitude-associated reduction in birth weight compared with Han (“Chinese”) infants living across the same 2700–4800 m altitude gradient in the Tibetan Autonomous Region of southwestern China (
Moore, et al. 2004). Similar results have been reported by Tripathy et al. who found that Tibetan infants born at high altitude (Leh, India; 3521 m) weighed more than populations of low-altitude origin, but nearly 300 g less than at lower altitudes (Bylakuppe; 800m or Chandragiri, India; 970m). As a result, Tibetans were less often of low birth weight (< 2500 g) at both low and high altitude compared with other groups (
Tripathy and Gupta 2005). Likewise Yangzom et al. reported that Tibetan infants weighed more and were less often SGA than non-Tibetan (i.e. Han [Chinese] or Hui [Muslim]) infants born in Lhasa (
Yangzom, et al. 2008).
It is important to acknowledge that while factors commonly associated with low birth weight (e.g., poor nutrition, low socioeconomic status, primiparity, short maternal stature or limited health care access) likely contribute to birth-weight variation within each population, they do not appear responsible for these ancestry-related differences in fetal growth at high altitude. In fact, differences in such maternal body size or socioeconomic factors likely operate to minimize, not exaggerate, birth-weight differences among these groups. In other words, short maternal stature, poor nutritional status, and limited health care availability are more characteristic of the indigenous compared with the newcomer populations in the higher-altitude regions of Bolivia or Tibet and thus, Andean and Tibetan infants would be expected to weigh
less, not more, than their European or Han counterparts (
Julian, et al. 2007;
Vargas, et al. 2007;
Wilson, et al. 2007),(
Larrea and Freire 2002;
Pimental and García 1995),(
Moore, et al. 2001b). However the data, as summarized above, suggest the opposite. In fact when ancestry-group differences in maternal body size or socioeconomic factors variables are taken into account using multiple regression analysis, the birth-weight differences between European and Andean groups enlarges (
Haas 1981;
Julian, et al. 2007). Moreover, the protection of birth weight at high altitude is intermediate in infants born to women of mixed European-Andean ancestry and demonstrates a dose-dependent relationship with ancestry such that women with greater Amerindian ancestry deliver infants of greater birth weight at high altitude. This is true whether ancestry was assessed via surnames or gene markers (
Bennett, et al. 2008;
Julian, et al. 2008b;
Julian, et al. 2007;
Wilson, et al. 2007;
Zamudio, et al. 2007).
That the Andean and Tibetan populations demonstrate protection from altitude-associated reductions in fetal growth even after other factors influencing birth weight are taken into account as well as the “dose-dependent” nature of this protective effect suggests that genetic factors are likely involved. Additional support for genetic involvement comes from the observation that developmental factors are not able to account for altitude-associated variation in fetal growth at high altitude. Our studies in Colorado and our as well as Jere Haas’ observations in Bolivia demonstrate that birth-weight reductions are similar among infants born to European newcomers as those born to women of European ancestry who were born and raised at high altitude of 1-2 generations’ high-altitude residence (
Moore, et al. 1982a;
Moore, et al. 2001a;
Weinstein and Haas 1977; Hageman, personal communication).
In order for high altitude to be considered a selective pressure, it must be clearly associated with lower reproductive fitness as evidenced by greater infant mortality rates and/or morbidity, and not only a reduction in birth weight. Historical accounts at the time of Spanish movement into South America during the 16
th century illustrate the potent challenge that high altitude posed to reproductive success. Father Cobo, a 16
th century missionary, noted that in Jauja, Peru (3400 m) the indigenous high-altitude populations were “…healthiest and where they [reproduce] the most prolifically is in these same cold air-tempers, which is quite the reverse of what happens to the children of the Spaniards, most of whom when born in such regions do not survive” (
Cobo 1897). Scientific inquiries conducted within the last 60 years reveal similar, albeit less dramatic findings. In Colorado, neonatal mortality rates were nearly twice as high (≥2740 m) relative to lower altitudes (<2130 m) during the 1960s and 1970s (
McCullough, et al. 1977) (). Suggesting that low birth weight is not advantageous at high altitude, infants of low birth weight born above 2730 m had higher mortality rates relative to infants of normal birth weight (
McCullough, et al. 1977). In Peru Mazess demonstrated that the neonatal mortality rate was nearly two-fold greater for infants born at high (Nuñoa, 3030 m) relative to low altitude (338 m) (
Mazess 1965) (). In contrast, Beall found that low birth-weight infants born at 3860 m (Puño, Peru) had lower infant mortality rates than low birth-weight infants born at 600 m (Tacna) (
Beall 1981). However, infant mortality was lower at high than low altitude across all birth weights, not just in the low birth-weight group, suggesting that some factor such as access to health care was likely responsible. In Bolivia, intrauterine and infant mortality increases with altitude (
Giussani 2002;
Keyes, et al. 2003); altitude increased infant mortality in both rural and urban areas, although rates were higher in the former. Likewise, available data indicate that neonatal mortality is higher in highland compared with lowland Himalayan regions. Neonatal mortality rates were reported to be 144 or 42.1/1000 live births in Ladakh, India (3500m) or Lhasa, Tibet (3658m), respectively; these figures are more than double the rate seen in lower-altitude areas of China (
Wiley 1994;
Yangzom, et al. 2008) (). As judged by maternal reproductive history, Tibetan infants also had lower pre and postnatal mortality than did Han infants in remote regions of Tibet where health care is equally limited for both ethnic groups (
Moore, et al. 1998). Other studies in the more urban setting of Lhasa have found equivalent infant mortality rates between Tibetan and non-Tibetan babies (
Yangzom, et al. 2008).
| Table 1Effect of high altitude on neonatal or infant mortality |
The interpretation of these mortality data is complicated by the fact that, outside of Colorado, all studies examining the effect of high altitude on infant mortality have been conducted in developing countries where access to health care and the quality of health care are often limited. In addition, the lack of comprehensive vital statistics means that births and infant deaths occurring outside of a hospital setting are likely not recorded and the contribution of factors such as prematurity, maternal complications of pregnancy or neonatal complications cannot be assessed. The effect of high altitude on infant mortality in areas such as Colorado may also be obscured by recent improvements in access to health care in the higher-altitude regions. For these reasons, it is difficult to assess the impact of reduced birth weight on reproductive fitness at high altitude. Given the clear elevation in mortality risk accompanying reduced birth weight or intrauterine growth restriction at low altitudes (
Bartels, et al. 2005;
Gilbert 2003) and the absence of any convincing evidence that this is not the case at high altitude, we consider it likely that reduced birth weight at high altitude diminishes reproductive fitness.
Concerning morbidity, infants born at high altitude have lower arterial oxygen saturations (SaO
2) and higher pulmonary artery pressure (Ppa) relative to their low-altitude counterparts. As was the case with birth weight, the effect of altitude to reduce SaO
2 and increase Ppa is diminished in infants of native high-altitude ancestry. In Lhasa, SaO
2 in the first two days of life was higher in Tibetans (90-94%) than in Han (90-94% vs. 86-92%) and while SaO
2 stabilized in Tibetans shortly after delivery, in Han infants the decline persisted over the 1
st four months of life (
Niermeyer 2003). Yangzom et al. also reported that non-Tibetan infants were more often cyanotic at birth and required post-delivery oxygen supplementation at high altitudes (
Yangzom, et al. 2008). Along similar lines, the two- to three-fold increase in intrauterine growth restriction at high altitudes in Bolivia is accompanied by an increased risk of respiratory disorders in neonatal life (
Keyes, et al. 2003). Reduced SaO
2 and higher Ppa (
Niermeyer, et al. 1993) increase disease severity and mortality in neonatal and childhood acute respiratory infection, highlighting the likelihood that genetic characteristics associated with a higher incidence of these phenotypic attributes should be subject to intense selective pressure.
Maternal physiological studies conducted over the past 25 years have revealed that likely candidates for the protection of fetal growth afforded by high-altitude ancestry include factors that influence the availability of oxygen and/or other nutrients to the fetus including maternal arterial oxygenation (e.g., ventilation, SaO
2, hemoglobin concentration), uteroplacental blood flow, nutrient availability, placental transport and/or feto-placental nutrient uptake. Our studies indicate that maternal arterial oxygenation probably is not the factor responsible for Andeans’ or Tibetans’ relative protection from hypoxia-associated reductions in birth weight. Specifically, ventilatory sensitivity to hypoxia, resting ventilation, SaO
2, total blood volume and plasma volume increased with pregnancy to a similar extent in Andean and European women residing at high altitude in Bolivia (
Vargas, et al. 2007). The pregnancy-related increase in ventilation raised SaO
2 and effectively offset the hemodilutional effect of plasma volume expansion such that arterial O
2 content (CaO
2) remained close to non-pregnant levels in both groups. Similarly, in Lhasa (3658 m) hypoxic ventilatory response and resting ventilations were equivalent between Tibetans and Han during pregnancy and in the non-pregnant state, and CaO
2 was lower, not higher, during pregnancy in the Tibetan compared to the Han women likely as the result of greater plasma volume expansion (
Moore, et al. 2001b).
Because uteroplacental blood flow is the primary factor responsible for increasing oxygen delivery to the uteroplacental circulation, we have extensively investigated the relationship between ancestry, variations in uteroplacental blood flow and reduced fetal growth at high altitudes (
Julian, et al. 2008a;
Julian, et al. 2008b;
Moore, et al. 1982b;
Wilson, et al. 2007;
Zamudio, et al. 1995). In general, these investigations overwhelmingly support the hypothesis that greater uterine artery blood flow contributes to the protective effect of high-altitude ancestry on fetal growth. In particular, our recent studies of uterine artery blood flow during pregnancy at high (3600-4100 m) altitude in Bolivia have revealed that Andeans have profoundly different uterine vascular adjustments to pregnancy relative to Europeans (
Wilson, et al. 2007). Uterine artery (UA) blood flow and O
2 delivery were 1.6-fold greater in Andean than European women as the result of greater lower body blood flow in general and a larger pregnancy-associated increase in UA diameter and UA blood flow in particular (
Wilson, et al. 2007). Further, these higher levels of UA blood flow were entirely responsible for raising UA oxygen delivery and were related to the heavier birth weights seen in the Andeans vs. Europeans. A recent cross-sectional study also demonstrated that Andeans had greater UA diameters late in pregnancy relative to Europeans residing at high (3600m; La Paz, Bolivia) but also at low altitude (400m; Santa Cruz, Bolivia) (
Zamudio, et al. 2007). These observations agreed with our previous observations in Tibet, showing that Tibetans had greater UA blood flow velocity and a larger redistribution of lower extremity flow to favor the UA than Han (“Chinese”) women in the third trimester of pregnancy at high altitude (
Moore, et al. 2001b). While these studies support the important role played by Andean and Tibetan populations’ ability to maintain higher levels of UA blood flow during pregnancy at high altitude, it is not clear whether the higher levels of UA blood flow and oxygen delivery in multigenerational vs. shorter-term residents of high altitude
per se are responsible for conferring protection from altitude-associated reductions in fetal growth, whether such protection is due to greater delivery of other nutrients such as glucose, or whether increased delivery of oxygen, glucose as well as other nutrients are responsible.
Several factors support an evolutionary explanation for the protection of fetal growth in Andeans and Tibetans at high altitude. First, as reviewed above, both populations have resided at high altitudes for a sufficient duration of time for natural selection to have occurred. Secondly, the protection of fetal growth at high altitude is not due to other factors known to influence fetal growth (e.g., socioeconomic or nutritional status, maternal stature or income) and thus, is likely due to inherent biological variation(s) between ancestry groups. Moreover, neither being born and raised at high altitude nor relatively short generational duration of high-altitude residence (e.g., 1-2 generations) are sufficient for such protection of fetal growth, giving credence to the likelihood that genetic rather than developmental mechanisms are involved. Finally, reductions in fetal growth increase infant morbidity and mortality, and thus genotypes protecting fetal growth in the face of hypoxia presumably would be strongly selected for over generations of high-altitude residence. Given that the relative “advantage” of Andean ancestry for fetal growth is apparent exclusively at high altitude, we suggest that the Andean-specific phenotype is reliant on some combination of genetic and environmental factors or, in other words, that maternal genotype modifies the effect of an environmental attribute (chronic hypoxia) on a particular phenotype, namely birth weight. Other examples of such gene by environment interaction include reports that maternal genotype influences the reduction in birth weight due to passive smoke exposure during pregnancy (
Wu, et al. 2007). Possible targets for investigation into the genetic factors involved include variations in genes involved in implantation, angiogenic, inflammatory or vasoactive processes, the expression of antioxidant enzymes or other factors influencing the pregnancy-associated rise in UA blood flow, placental transporters or other factors influencing fetal nutrient uptake. Differences in birth weight between ancestry groups may also arise from epigenetic modification, consisting of mitotically and transgenerationally heritable changes in gene expression that are not the result of altered DNA sequence (
Anway, et al. 2005;
Rakyan, et al. 2002;
Rakyan, et al. 2003). Thus changes that result from exposure to endogenous or exogenous factors such as hypoxia during such as gestation and neonatal life may be manifested in future generations. Our recent data -- demonstrating that parent-of-origin influences the effect of high altitude on birth weight (
Bennett, et al. 2008) -- suggests that epigenetic factors or other extracellular signals modifying gene expression may indeed be involved. Similar to constitutional genetic variation, epigenetic modifications can convey the effects of environmental exposure across generations.
In summary, we consider that the challenge of demonstrating whether or not humans have adapted genetically to high altitude has been met. Differences in maternal physiological characteristics clearly exist between migrant and native high-altitude populations, such physiological characteristics are influenced by genetic origin, and these physiological as well as genetic attributes in turn influence reproductive fitness. The new challenge is to determine how such differences in physiological response to pregnancy arise, what specific genes are involved, and how such physiological and genetic factors interact to influence evolutionary process.