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. 2026 Jul 27;38(7):e70317. doi: 10.1002/ajhb.70317

Secular Trends in Height, Weight, and Body Mass Index Among Tibetan Children and Adolescents in the Tibet Autonomous Region, China, From 2005 to 2019

Chen Zhang 1,2, Meng Yuan 1, Bin Li 1,2, Zhihong Chen 1,2, Xiaokun Mu 1,2, Yi Sun 1,2,✉
PMCID: PMC13407213  PMID: 42509193

ABSTRACT

Objective

This study aimed to characterize growth and development patterns among children and adolescents in the Tibet Autonomous Region and to interpret their human biological significance through the interaction between hypoxic exposure and improvements in nutrition, healthcare, and socioeconomic conditions.

Methods

Data were drawn from the 2005, 2010, 2014, and 2019 Chinese National Survey on Students' Constitution and Health. The study included Tibetan school students aged 7–18 years from testing sites in and around Lhasa, Tibet Autonomous Region, China, at an altitude of approximately 3600 m. Height and weight were measured using standardized protocols, and BMI was calculated. Sex‐specific and age‐specific means and standard deviations were reported by survey year. Differences across years were assessed using one‐way analysis of variance, with temporal trend tests also performed.

Results

From 2005 to 2019, Tibetan children and adolescents showed an overall upward trend in height, weight, and BMI. For height, significant differences across survey years were observed in most age groups among both boys and girls, except for the group aged 16 years (p < 0.05). The greatest height gains occurred among boys aged 13 years and girls aged 10 years, indicating age‐specific heterogeneity in secular growth changes. Weight followed a broadly similar pattern: mean body weight in 2019 exceeded that in 2005 in most sex and age‐specific groups, with particularly marked increases among boys aged 13 years and girls aged 10 years. BMI increased gradually, with more evident gains in some age groups after 2010, although the magnitude of BMI change was smaller than that observed for height and weight. Concurrently, the number of participants classified as having height‐related growth retardation declined from 150 in 2005 to 35 in 2019, suggesting a substantial reduction in the burden of low stature and an overall improvement in population‐level growth status.

Conclusion

Despite continuous exposure to high altitude hypoxia, Tibetan children and adolescents experienced measurable improvements in physical growth between 2005 and 2019. These findings indicate that although hypoxia remains a key ecological constraint on growth at high altitude, its adverse effects may be partly buffered by enhanced nutritional security, school‐based dietary support, improved healthcare resources, and broader socioeconomic development.

Keywords: children and adolescents, growth and development, secular trends, Tibetan

1. Introduction

Growth and development among children and adolescents living at high altitude have long been central concerns in human biology. Early studies emphasized chronic hypobaric hypoxia as a major ecological stressor affecting linear growth, weight gain, and maturational tempo in high altitude populations (Greksa 1990; Yang et al. 2020). More recent research, however, has moved beyond a single factor hypoxia model toward a more integrative framework (Stinson 1982; Bustamante et al. 2025). Current evidence indicates that growth outcomes in high altitude children and adolescents are shaped by the combined influence of ecological stress, nutritional resources, access to healthcare, household socioeconomic conditions, and long‐term adaptive processes (Ulijaszek and Kadetz 2008; Leonard 1989; Harris et al. 2001).

In China, research on Tibetan children and adolescents in the Tibet Autonomous Region has mainly used cross‐sectional data to compare height, weight, body mass index (BMI), and nutritional status across populations or regions (Nie et al. 2025). These studies indicate that Tibetan children and adolescents exhibit distinct high altitude growth characteristics, with growth status influenced by hypoxic exposure, dietary patterns, healthcare accessibility, and regional socioeconomic development (Argnani et al. 2008; Xi et al. 2016; Weitz et al. 2000). Evidence from the Andes, the Ethiopian Highlands, and other high altitude regions has reached a similar conclusion, showing that even under comparable hypoxic conditions, physical growth among children and adolescents remains strongly conditioned by nutrition, household socioeconomic status, disease burden, and access to medical services (Artiningrum et al. 2014; Pawson et al. 2001; Gonzales et al. 1984; Mohammed et al. 2020). Taken together, these findings suggest that growth and development in high altitude children and adolescents should be understood within an interactional framework that integrates hypoxia, nutrition, healthcare, and socioeconomic conditions.

The Tibet Autonomous Region is a major high‐altitude inhabited region in China, where Tibetans constitute the principal long‐established ethnic population. Tibetan children and adolescents grow up in a cold, hypoxic environment with distinctive dietary and cultural characteristics. Between 2005 and 2019, nutritional security, healthcare resources, and socioeconomic conditions in the Tibet Autonomous Region improved continuously, creating a more favorable external environment for child and adolescent growth (Tables S10 and S11). Regarding nutrition, the education “Three Guarantees” policy and the Student Nutrition Improvement Program strengthened dietary and living support for school‐aged children and adolescents (People's Government of the Tibet Autonomous Region 2025). In terms of healthcare, the primary healthcare system expanded and service accessibility improved progressively. Socioeconomically, regional economic growth substantially increased and living conditions continued to improve (Tibet Autonomous Region Bureau of Statistics, Tibet Survey Team of the National Bureau of Statistics 2020). These changes provide a valuable empirical context for examining how improvements in nutrition, healthcare, and socioeconomic conditions may relate to growth and development under persistent high‐altitude hypoxia.

Nevertheless, important gaps remain in research on the growth and development of Tibetan children and adolescents in the Tibet Autonomous Region. Most previous studies have focused on cross‐sectional comparisons of physical growth across ethnic groups, regions, or altitude gradients. Although these studies have provided useful evidence on population differences in height, weight, BMI, and nutritional status, they have not systematically examined secular changes in height, weight, and BMI among Tibetan children and adolescents across an extended period. More critically, few studies have incorporated nutritional security, healthcare resources, and socioeconomic development into a unified analytical framework. This limitation restricts the ability of existing research to explain the social and environmental foundations of changing growth patterns among children and adolescents living under high altitude hypoxia.

To address these gaps, the present study proposes the following hypothesis: under persistent high‐altitude hypoxic stress, improvements in nutritional security, healthcare resources, and socioeconomic conditions may contribute to increases in height, weight, and BMI among Tibetan children and adolescents, and may partly buffer or offset the adverse effects of hypoxia on growth and development.

2. Materials and Methods

2.1. Data Source

Data were derived from the original anthropometric measurements of Tibetan primary and secondary school students aged 7–18 years in the Tibet Autonomous Region, collected during four waves of the Chinese National Survey on Students' Constitution and Health (CNSSCH) in 2005, 2010, 2014, and 2019. The included Tibetan student data were obtained from nationally designated survey sites in and around Lhasa, located at approximately 3600 m above sea level. All four survey waves were conducted in fixed urban schools, and the same urban school‐based survey setting was maintained in 2005, 2010, 2014, and 2019. Han students were not included in the present analysis. During data screening, only students recorded as Tibetan in the CNSSCH dataset were retained, and students recorded as Han or other ethnic groups were excluded. Tibetan ethnicity was determined according to the ethnicity information recorded in the original student survey records. According to the field quality control requirements specified in the CNSSCH testing protocol, the pooled dataset was screened and cleaned using the following exclusion criteria: (1) missing height or weight data that precluded BMI calculation; (2) incorrect measurement units or obvious data entry errors for height or weight; (3) values identified as implausible according to the quality control rules; and (4) duplicate records for the same participant, in which case only the record with complete information and internal logical consistency was retained. After screening, the final analytic sample included 2240 participants in 2005, of whom 1111 were boys and 1129 were girls; 2512 participants in 2010, of whom 1234 were boys and 1278 were girls; 2259 participants in 2014, of whom 1109 were boys and 1150 were girls; and 2038 participants in 2019, of whom 999 were boys and 1039 were girls. The process of participant inclusion and exclusion is shown in Figure 1.

FIGURE 1.

FIGURE 1

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Flowchart of participant inclusion and exclusion.

2.2. Methods for Measuring Height and Weight

The study indicators included height (cm), weight (kg), and BMI. Height was measured to the nearest 0.1 cm using a calibrated mechanical or electronic stadiometer. Participants were measured barefoot in an upright standing position, with heels together, the heels, sacral region, and scapular area positioned as close as possible to the vertical board, the head maintained in the Frankfurt horizontal plane, and the arms hanging naturally at the sides. Weight was measured to the nearest 0.1 kg using an electronic scale or beam balance. The scale was calibrated daily with standard weights before measurement. Participants were measured without shoes and wearing light clothing, standing steadily at the center of the platform; the value was recorded after the reading had stabilized. BMI was calculated as weight in kilograms divided by height in meters squared, and values were retained to one decimal place (Dong et al. 2019). Stunting was identified according to WS/T 456‐2014, the Chinese health industry standard for screening malnutrition among school aged children and adolescents (National Health and Family Planning Commission of the People's Republic of China 2014). Participants whose height was less than or equal to the sex‐specific and age‐specific screening cutoff for stunting were classified as having stunting. Overweight and obesity were classified according to WS/T 586‐2018 (National Health and Family Planning Commission of the People's Republic of China 2018). Overweight was defined as BMI greater than or equal to the sex‐specific and age‐specific overweight cutoff and lower than the obesity cutoff, whereas obesity was defined as BMI greater than or equal to the sex‐specific and age‐specific obesity cutoff. Because the dataset contained integer ages only, the corresponding whole year cutoffs were applied.

2.3. Statistical Analysis

This study used a repeated cross‐sectional design. Participants were stratified by sex and single‐year age groups from 7 to 18 years. For each survey year 2005, 2010, 2014, and 2019 the means and standard deviations of height, weight, and BMI were calculated separately within each sex and age‐specific group. Continuous variables were assessed for normality and are presented as mean ± standard deviation (mean ± SD). Survey year was treated as the grouping variable. Within each sex and age‐specific group, differences in height, weight, and BMI across survey years were examined using one‐way analysis of variance (ANOVA), with the test statistic reported as the F value. Tests for temporal trends were also performed. The significance level was set at α = 0.05. Data management and statistical analyses were conducted using IBM SPSS Statistics version 27.0.

3. Results

3.1. Secular Trends in Height Among Tibetan Children and Adolescents

Among boys, except for the 16 year old group, significant differences in height were observed across survey years in all age groups from 2005 to 2019 (p < 0.05). In terms of the magnitude of change, mean height in 2019 was generally higher than that in 2005 among participants aged 7–15 years. The most pronounced increase was observed in the 13 year old group, with mean height rising from 145.81 cm in 2005 to 159.53 cm in 2019. Clear increases were also observed among participants aged 10, 12, and 14 years. In contrast, changes were relatively small among those aged 16 years and older, and some older age groups showed fluctuations after 2014.

Among girls, except for the 16 year old group, height generally increased from 2005 to 2019, and differences across survey years were statistically significant in most age groups (p < 0.05). Mean height in 2019 was generally higher than that in 2005 among participants aged 7–15 years. The largest increase was observed in the 10 year old group, with mean height increasing from 134.15 cm in 2005 to 143.12 cm in 2019. Substantial increases were also observed among participants aged 12 and 13 years. Height changes were relatively gradual among those aged 16 years and older, and the mean values for the 17 and 18 year old groups declined slightly after 2014. Changes in height by age and sex from 2005 to 2019 are presented in Table 1 and Figure 2.

TABLE 1.

Height by sex and age among Tibetan children and adolescents from 2005 to 2019.

Gender Age 2005 2010 2014 2019 F p p trend
Male 7 118.43 ± 5.50 123.11 ± 5.39 122.53 ± 5.04 122.47 ± 4.96 16.319 < 0.001 < 0.001
8 125.57 ± 6.02 126.85 ± 5.52 127.84 ± 4.92 130.19 ± 5.75 8.266 < 0.001 < 0.001
9 132.21 ± 6.41 132.52 ± 6.00 136.43 ± 4.70 135.20 ± 4.51 12.377 < 0.001 < 0.001
10 133.25 ± 4.96 137.36 ± 5.06 138.12 ± 5.34 140.48 ± 4.78 33.715 < 0.001 < 0.001
11 138.93 ± 6.47 141.96 ± 6.12 144.59 ± 7.54 144.77 ± 6.56 15.102 < 0.001 < 0.001
12 143.25 ± 7.92 145.22 ± 8.61 147.99 ± 7.34 150.81 ± 8.36 16.843 < 0.001 < 0.001
13 145.81 ± 8.38 153.55 ± 8.48 156.27 ± 7.21 159.53 ± 8.12 43.032 < 0.001 < 0.001
14 157.73 ± 7.88 162.81 ± 8.07 159.69 ± 8.83 162.99 ± 6.57 9.348 < 0.001 < 0.001
15 161.56 ± 7.13 166.90 ± 6.67 167.45 ± 7.29 165.81 ± 5.92 14.692 < 0.001 < 0.001
16 166.81 ± 5.30 167.55 ± 5.84 168.96 ± 5.71 167.49 ± 6.09 2.280 0.079 0.089
17 168.67 ± 5.10 169.43 ± 5.65 170.67 ± 5.38 168.60 ± 5.51 2.970 0.032 0.540
18 168.76 ± 5.03 169.30 ± 5.74 172.31 ± 5.63 169.58 ± 5.14 7.783 < 0.001 0.005
Female 7 116.69 ± 6.68 122.50 ± 5.76 121.52 ± 4.47 122.71 ± 5.41 22.892 < 0.001 < 0.001
8 125.57 ± 6.56 125.67 ± 5.38 128.36 ± 5.66 128.79 ± 5.49 7.199 < < 0.001 < 0.001
9 131.17 ± 7.31 132.75 ± 6.29 136.12 ± 5.53 137.18 ± 5.97 15.615 < 0.001 < 0.001
10 134.15 ± 5.66 138.12 ± 7.22 137.97 ± 6.64 143.12 ± 6.88 31.614 < 0.001 < 0.001
11 141.61 ± 6.09 143.34 ± 6.88 147.03 ± 7.30 146.28 ± 7.09 12.846 < 0.001 < 0.001
12 144.91 ± 6.35 144.83 ± 8.05 149.93 ± 7.27 151.32 ± 6.93 21.201 < 0.001 < 0.001
13 147.42 ± 6.89 152.02 ± 6.10 152.92 ± 5.25 154.06 ± 4.95 22.476 < 0.001 < 0.001
14 152.88 ± 7.31 156.93 ± 4.93 154.80 ± 5.23 157.57 ± 5.10 13.812 < 0.001 < 0.001
15 155.44 ± 4.99 157.63 ± 5.08 157.59 ± 4.90 156.91 ± 5.04 3.976 0.008 0.002
16 157.76 ± 5.67 157.23 ± 4.73 157.71 ± 5.27 156.61 ± 4.92 1.040 0.375 0.139
17 157.51 ± 4.73 157.61 ± 5.38 158.85 ± 4.66 156.65 ± 5.27 3.255 0.022 0.542
18 157.51 ± 4.82 158.25 ± 4.61 159.41 ± 5.33 156.60 ± 4.32 5.907 < 0.001 0.720
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Note: Values are presented as mean ± standard deviation (cm). F and p values were obtained from one‐way analysis of variance comparing height across survey years within each sex‐ and age‐specific group. p trend was calculated using a linear trend test with survey year treated as an ordinal variable. A two‐sided p < 0.05 was considered statistically significant.

FIGURE 2.

FIGURE 2

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Height development levels of males and females aged 7–18 years, 2005–2019.

3.2. Secular Trends in Weight Among Tibetan Children and Adolescents in the Tibet Autonomous Region

From 2005 to 2019, body weight showed an overall increasing trend among Tibetan children and adolescents in the Tibet Autonomous Region. Among boys, except for the 17 year‐old group, significant differences in weight across survey years were observed in all age groups (p < 0.05). Mean weight in 2019 was generally higher than that in 2005 among boys aged 7 to 16 years. The most pronounced increase was observed in the 13 year‐old group, with mean weight rising from 38.04 kg in 2005 to 46.47 kg in 2019. Substantial increases were also observed among boys aged 12, 14, and 15 years. The difference was not statistically significant in the 17 year‐old group. Although the 18 year‐old group showed a statistically significant difference across survey years, the mean value in 2019 was lower than that in 2014, indicating some fluctuation in body weight among older boys.

Among girls, except for the 17 year old group, significant differences in weight across survey years were observed in all age groups (p < 0.05). Mean weight in 2019 was generally higher than that in 2005 among girls aged 7–16 years. The largest increase was observed in the 10 year old group, with mean weight increasing from 28.69 kg in 2005 to 34.96 kg in 2019. Clear increases were also observed among girls aged 12 and 14 years. The difference was not statistically significant in the 17 year old group. Although the 18 year old group showed differences across survey years, the mean value in 2019 was slightly lower than that in 2014. Changes in weight by age and sex from 2005 to 2019 are presented in Table 2 and Figure 3.

TABLE 2.

Weight by sex and age among Tibetan children and adolescents from 2005 to 2019.

Gender Age 2005 2010 2014 2019 F p p trend
Male 7 21.93 ± 2.97 23.50 ± 3.18 23.73 ± 3.78 23.86 ± 3.46 6.770 < 0.001 < 0.001
8 25.23 ± 3.52 25.04 ± 4.69 25.42 ± 4.17 27.47 ± 4.18 4.386 0.005 0.006
9 28.72 ± 4.28 28.61 ± 5.51 32.29 ± 5.87 31.28 ± 5.16 11.392 < 0.001 < 0.001
10 29.14 ± 4.33 30.60 ± 5.36 32.12 ± 5.45 34.23 ± 5.41 16.836 < 0.001 < 0.001
11 32.11 ± 5.02 33.69 ± 6.24 35.30 ± 6.98 36.72 ± 6.28 8.808 < 0.001 < 0.001
12 35.17 ± 5.69 35.01 ± 7.11 36.55 ± 6.44 41.29 ± 6.81 21.089 < 0.001 < 0.001
13 38.04 ± 7.48 42.10 ± 8.69 43.78 ± 7.41 46.47 ± 7.54 16.514 < 0.001 < 0.001
14 44.51 ± 6.64 48.89 ± 8.44 46.01 ± 7.88 50.23 ± 7.48 10.252 < 0.001 < 0.001
15 47.99 ± 7.03 52.41 ± 8.92 53.82 ± 8.33 53.26 ± 6.70 10.727 < 0.001 < 0.001
16 53.18 ± 5.80 53.04 ± 6.51 54.75 ± 5.82 55.06 ± 5.53 2.856 0.037 0.003
17 55.37 ± 4.97 55.38 ± 6.93 57.02 ± 5.31 55.90 ± 5.04 1.792 0.148 0.145
18 56.30 ± 6.00 57.72 ± 6.17 59.61 ± 5.79 57.17 ± 5.42 5.155 < 0.001 0.005
Female 7 20.81 ± 3.23 22.77 ± 3.13 22.01 ± 2.84 23.40 ± 3.07 12.021 < 0.001 < 0.001
8 24.14 ± 3.71 23.78 ± 3.68 25.03 ± 3.91 26.07 ± 3.39 5.449 0.001 0.001
9 27.73 ± 5.29 26.75 ± 4.92 29.43 ± 5.19 31.99 ± 5.80 13.278 < 0.001 < 0.001
10 28.69 ± 3.90 29.44 ± 5.39 31.07 ± 5.06 34.96 ± 6.59 28.876 < 0.001 < 0.001
11 33.66 ± 4.83 34.03 ± 6.55 36.33 ± 7.20 36.66 ± 6.71 5.389 0.001 < 0.001
12 35.75 ± 6.72 34.46 ± 7.31 39.99 ± 6.92 40.68 ± 6.37 19.556 < 0.001 < 0.001
13 40.90 ± 7.22 42.06 ± 7.14 43.21 ± 8.23 45.16 ± 6.36 5.594 < 0.001 < 0.001
14 45.45 ± 8.38 46.84 ± 6.46 45.21 ± 5.41 49.77 ± 6.01 9.380 < 0.001 < 0.001
15 47.91 ± 6.07 48.49 ± 6.50 49.30 ± 6.71 50.79 ± 6.81 3.232 0.022 < 0.001
16 50.89 ± 5.32 49.68 ± 5.99 51.44 ± 5.49 52.12 ± 5.90 3.273 0.021 0.063
17 51.39 ± 5.89 49.99 ± 6.14 51.86 ± 5.40 51.97 ± 5.98 2.425 0.065 0.287
18 50.80 ± 4.98 50.24 ± 6.15 52.93 ± 6.00 52.00 ± 4.94 4.550 0.004 0.006
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Note: Values are presented as mean ± standard deviation (cm). F and p values were obtained from one‐way analysis of variance comparing height across survey years within each sex‐ and age‐specific group. p trend was calculated using a linear trend test with survey year treated as an ordinal variable. A two‐sided p < 0.05 was considered statistically significant.

FIGURE 3.

FIGURE 3

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Weight development levels of males and females aged 7–18 years, 2005–2019.

3.3. Secular Trends in BMI Among Tibetan Children and Adolescents in the Tibet Autonomous Region

From 2005 to 2019, BMI showed an overall increasing trend among Tibetan children and adolescents in the Tibet Autonomous Region, although the magnitude of change was smaller than that observed for height and weight. Among boys, significant differences in BMI across survey years were observed in the age groups of 8–12 years and 14–16 years (p < 0.05), whereas no statistically significant differences were found in the 7, 13, 17, and 18 year old groups. The most evident changes occurred among boys aged 10, 12, 14, and 15 years. Specifically, BMI in the 12 year old group increased from 17.05 kg/m2 in 2005 to 18.06 kg/m2 in 2019, while BMI in the 15 year old group increased from 18.31 to 19.35 kg/m2.

Among girls, significant differences in BMI across survey years were observed in the 7, 9, 10, and 12 year old groups and in the age groups of 14 to 18 years (p < 0.05). No statistically significant differences were observed in the 8, 11, and 13 year old groups. BMI in 2019 was higher than that in 2005 in most age groups, with more evident changes among girls aged 10, 12, 15, 16, and 18 years. Compared with boys, girls showed a more sustained upward trend in BMI in the older age groups. Changes in BMI by age and sex from 2005 to 2019 are presented in Table 3 and Figure 4.

TABLE 3.

Body mass index by sex and age among Tibetan children and adolescents from 2005 to 2019.

Gender Age 2005 2010 2014 2019 F p p trend
Male 7 15.59 ± 1.25 15.47 ± 1.48 15.73 ± 1.67 15.84 ± 1.47 1.201 0.309 < 0.001
8 15.98 ± 1.60 15.47 ± 2.00 15.49 ± 1.88 16.15 ± 1.69 2.706 0.045 0.709
9 16.37 ± 1.57 16.20 ± 2.33 17.29 ± 2.60 17.05 ± 2.19 5.170 0.002 < 0.001
10 16.35 ± 1.69 16.14 ± 2.12 16.78 ± 2.31 17.28 ± 2.10 5.827 < 0.001 < 0.001
11 16.57 ± 1.69 16.63 ± 2.28 16.76 ± 2.19 17.42 ± 2.04 2.796 0.040 0.002
12 17.05 ± 1.61 16.46 ± 2.01 16.59 ± 1.89 18.06 ± 1.86 15.998 < 0.001 < 0.001
13 17.83 ± 2.72 17.72 ± 2.55 17.90 ± 2.64 18.17 ± 1.98 0.498 0.684 0.336
14 17.81 ± 1.65 18.33 ± 2.13 17.91 ± 1.69 18.83 ± 1.91 5.426 0.001 < 0.001
15 18.31 ± 1.72 18.75 ± 2.58 19.14 ± 2.34 19.35 ± 2.01 4.034 0.008 < 0.001
16 19.10 ± 1.83 18.86 ± 1.81 19.16 ± 1.70 19.60 ± 1.40 3.027 0.030 0.024
17 19.48 ± 1.69 19.27 ± 1.96 19.57 ± 1.57 19.66 ± 1.48 1.007 0.390 0.261
18 19.76 ± 1.78 20.14 ± 1.96 20.07 ± 1.62 19.87 ± 1.56 0.947 0.418 0.214
Female 7 15.21 ± 1.07 15.13 ± 1.42 14.86 ± 1.25 15.50 ± 1.28 3.951 0.009 < 0.001
8 15.24 ± 1.47 14.99 ± 1.52 15.13 ± 1.70 15.68 ± 1.33 2.478 0.061 0.150
9 16.00 ± 1.79 15.08 ± 1.84 15.81 ± 2.11 16.90 ± 2.13 10.656 < 0.001 0.555
10 15.89 ± 1.46 15.35 ± 1.93 16.25 ± 1.90 16.96 ± 2.29 13.502 < 0.001 < 0.001
11 16.74 ± 1.83 16.45 ± 2.32 16.68 ± 2.22 17.03 ± 2.23 1.086 0.355 0.438
12 16.91 ± 2.20 16.26 ± 2.09 17.68 ± 2.06 17.69 ± 1.98 10.683 < 0.001 < 0.001
13 18.80 ± 3.01 18.10 ± 2.22 18.40 ± 2.85 19.01 ± 2.44 2.263 0.081 0.895
14 19.37 ± 2.92 19.02 ± 2.50 18.85 ± 1.89 20.05 ± 2.30 4.659 0.003 0.216
15 19.82 ± 2.21 19.51 ± 2.33 19.83 ± 2.42 20.59 ± 2.30 3.633 0.013 0.016
16 20.50 ± 2.36 20.09 ± 2.19 20.70 ± 2.18 21.24 ± 2.07 4.724 0.003 0.009
17 20.71 ± 2.12 20.13 ± 2.31 20.56 ± 2.06 21.17 ± 2.16 3.920 0.009 0.115
18 20.50 ± 2.02 20.04 ± 2.10 20.85 ± 2.34 21.20 ± 1.83 5.461 0.001 0.002
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Note: Values are presented as mean ± standard deviation (cm). F and p values were obtained from one‐way analysis of variance comparing height across survey years within each sex‐ and age‐specific group. p trend was calculated using a linear trend test with survey year treated as an ordinal variable. A two‐sided p < 0.05 was considered statistically significant.

FIGURE 4.

FIGURE 4

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BMI levels of males and females aged 7–18 years, 2005–2019.

3.4. Changes in Stunting and Excess Body Weight Among Tibetan Children and Adolescents

The prevalence of stunting declined from 4.42% in 2005 to 0.88% in 2019. In contrast, the prevalence of overweight increased from 5.54% to 9.81%, while the prevalence of obesity increased from 0.98% to 1.67% and reached its highest level in 2014 at 1.81%. From 2005 to 2019, the overall increase in overweight prevalence was greater among boys than among girls (4.14%–9.01% vs. 6.91%–10.59%). The largest age and sex‐specific increase in overweight prevalence occurred among 11‐year‐old boys, rising from 5.21% to 15.71%, an increase of 10.51 percentage points. The largest increase in obesity prevalence occurred among 10‐year‐old girls, rising from 0.00% to 5.50%, an increase of 5.50 percentage points. The corresponding results are presented in Tables 4 and S9.

TABLE 4.

Changes in stunting, overweight, and obesity among Tibetan children and adolescents, 2005 to 2019.

Year Stunted children, n (%) Overweight children, n (%) Obese children, n (%)
2005 99 (4.42) 124 (5.54) 22 (0.98)
2010 49 (1.95) 153 (6.09) 35 (1.39)
2014 15 (0.66) 164 (7.26) 41 (1.81)
2019 18 (0.88) 200 (9.81) 34 (1.67)
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4. Discussion

Based on four waves of the Chinese National Survey on Students' Constitution and Health, this study found that height, weight, and BMI among Tibetan children and adolescents in the Tibet Autonomous Region increased overall from 2005 to 2019, while the number of participants with stunting decreased markedly. The findings show that growth among Tibetan children and adolescents did not remain static under high altitude hypoxia but instead demonstrated observable improvement over time. The age distribution of these changes is also biologically meaningful. The largest secular increases in height and weight were concentrated mainly between 10 and 15 years of age. This pattern may reflect a population level shift toward an earlier onset of the adolescent growth spurt and a greater magnitude of growth during this period. However, because the present study used repeated cross‐sectional data rather than individual longitudinal growth records, this interpretation should be regarded as an inference about population level growth patterns rather than direct evidence of individual pubertal timing.

This finding should be interpreted from the perspective of the joint influence of high altitude ecology and the social environment. High altitude hypoxia remains an important ecological stressor affecting growth and development among children and adolescents living on plateaus. However, international evidence has shown that hypoxia is not the sole determinant of growth outcomes (World Health Organization 2016; UNICEF 2025; Marini and Gragnolati 2006; Shively 2021). Leonard's (1989) study of children in Nuñoa in the Peruvian Andes found that children from families with higher socioeconomic status had greater energy intake and better dietary quality, and had significantly greater height and weight than children from families with lower socioeconomic status. This evidence suggests that nutrition and household economic conditions can substantially influence physical growth among high altitude children (Leonard 1989). Obert et al. (1994) further showed, in a study of boys from the Andean highlands, that socioeconomic and nutritional conditions provided a more direct explanation for differences in child physical growth than altitude itself. Huicho et al. (2020) analyzed nutritional improvement among Peruvian children and showed that, under the combined influence of multisectoral policies, economic growth, and improved health services, including the CRECER multisectoral nutrition strategy, the Juntos conditional cash transfer program, primary healthcare services, and child nutrition monitoring, the prevalence of stunting among children younger than 5 years declined from 31.3% in 2000 to 13.1% in 2016. This indicates that nutritional policies, medical services, and social protection measures can effectively improve child growth outcomes. Mohammed et al. (2020), using data from children in the Ethiopian highlands, found that children living above 2500 m had a 41% higher risk of stunting than those living at lower altitudes. Importantly, their findings also indicated that diet, disease burden, household resources, and healthcare conditions were important determinants of child growth.

The present findings are broadly consistent with this international high altitude literature. Changes in height are particularly informative. Height is a sensitive indicator of the long term growth environment, nutritional status, and disease burden, and is generally less affected by short term fluctuations. In this study, mean height increased in most age groups, while the number of participants with stunting decreased markedly, suggesting that long term growth conditions may have improved during the observation period (Dang et al. 2008). Under a relatively stable altitude environment, the systematic increase in population height indicates that changes in the growth and development of Tibetan children and adolescents cannot be explained by hypoxia alone. Therefore, the present findings support the view that although high altitude hypoxia has persistent adverse effects on child and adolescent growth, improvements in nutrition, healthcare, and socioeconomic conditions may partly buffer or offset these effects (Leonard et al. 1990; Shao et al. 2025). From 2005 to 2019, socioeconomic and public service conditions in the Tibet Autonomous Region improved continuously. Per capita GDP increased from 8884 to 48 961 yuan (Table S11). The number of health professionals increased from 8569 to 19 077, the number of licensed physicians and assistant physicians increased from 4356 to 8322, and the number of health professionals per 1000 population increased from 3.13 to 5.55 (Table S12). In addition, the education “Three Guarantees” policy and the Student Nutrition Improvement Program provided more stable dietary and living support for school aged children and adolescents (People's Government of the Tibet Autonomous Region 2025). Accordingly, the observed improvement in physical growth may reflect the contribution of enhanced nutritional security, healthcare resources, and socioeconomic conditions to the growth potential of high altitude children and adolescents, while also partly buffering the adverse effects of high altitude hypoxia on growth and development.

The joint analysis of weight and BMI showed that body weight among Tibetan children and adolescents increased overall from 2005 to 2019. Further cross‐sectional comparisons indicated that, in most age groups and survey years, Tibetan children and adolescents had lower weight and BMI than Han children and adolescents of the same age who were measured at lower altitude survey sites in the CNSSCH reference data (Tables S1–S8). This comparison was used only to provide a contextual reference for population differences, rather than to infer the independent effect of altitude. These findings suggest that the overall physical growth level of Tibetan children and adolescents remained relatively low in comparative terms (Zhang et al. 2021). However, when these cross‐sectional differences were interpreted within a longitudinal framework, the rate of BMI increase among Tibetan children and adolescents accelerated after 2010, and the gap between Tibetan and Han groups narrowed in some age groups (Tables S3–S8). This suggests that the weight to height relationship in this population is undergoing a structural shift. Taken together, the longitudinal and cross‐sectional findings indicate a dual pattern in weight and BMI among urban Tibetan children and adolescents: on the one hand, their overall levels remain lower than those of Han children and adolescents; on the other hand, their growth trajectory has shifted from relative stability toward accelerated increase (Dong et al. 2018). At the same time, overweight and obesity among children and adolescents have become increasingly prominent public health problems worldwide (NCD Risk Factor Collaboration [NCD‐RisC] 2017). Ogden et al. (2014) reported that the prevalence of obesity among children and adolescents aged 2–19 years in the United States reached 17%, with rates of 20.5% among those aged 6–11 years and 12–19 years, and that the prevalence had doubled over nearly three decades, making obesity a leading child public health concern. Wang and Taerken (2023) showed that the obesity prevalence among Han individuals aged 7–18 years reached 21.5% in 2019 and increased rapidly from 2000 to 2019. Against this background, overnutrition has also begun to emerge among children and adolescents in the Tibet Autonomous Region, and its prevalence has shown an overall year increase over time (Peng et al. 2022). This population is therefore at a critical transition from a low BMI profile toward a higher risk range. With rising income and increasingly diversified food consumption, the combined effects of traditional high‐energy foods such as butter tea, fast food, and ultraprocessed foods, together with the common perception that greater body fatness represents better health, may contribute to the continued increase in BMI (Dickerson et al. 2008). The analysis of overweight and obesity further supports this nutritional transition. Although stunting declined over time, the combined prevalence of overweight or obesity increased from 6.52% in 2005 to 11.48% in 2019, suggesting that Tibetan children and adolescents are gradually shifting from undernutrition related growth constraints toward emerging risks of excess body weight. This trend underscores an emerging public health concern for Tibetan children and adolescents: the public health challenge is rapidly shifting from undernutrition toward overnutrition.

Overall, although high altitude hypoxia continues to impose ecological pressure on the growth and development of Tibetan children and adolescents, it is not the only determinant. Improvements in nutritional supply, school meals, healthcare resources, and socioeconomic conditions may partly buffer or reduce the adverse effects of high altitude hypoxia on growth and development by increasing food availability, reducing disease burden, and improving access to health services.

5. Strengths and Limitations

A major strength of this study is the representativeness of the data source. The study was based on four waves of the Chinese National Survey on Students' Constitution and Health conducted in 2005, 2010, 2014, and 2019. The broad sample coverage and large sample size enabled a reliable characterization of the physical growth status of Tibetan children and adolescents in the Tibet Autonomous Region. In addition, all survey waves used standardized measurement protocols and quality control procedures, which ensured the comparability of height, weight, and BMI data across different survey years. Nevertheless, this study has several limitations. First, the available data were collected from Lhasa and surrounding areas, where altitude was approximately 3600 m; therefore, altitude‐stratified analysis could not be performed. Second, the repeated cross‐sectional design could only capture differences in population mean values across survey years and could not substitute for individual longitudinal growth trajectories. Future studies should incorporate data on altitude gradients, family background, dietary patterns, and healthcare service utilization to further clarify the joint mechanisms through which high altitude hypoxia and improvements in nutrition, healthcare, and socioeconomic conditions shape child and adolescent growth and development.

6. Conclusion

From 2005 to 2019, Tibetan children and adolescents in the Tibet Autonomous Region showed overall upward trends in height, weight, and BMI, accompanied by a marked decline in the number of participants with stunting. These findings indicate that, under persistent high altitude hypoxia, child and adolescent growth is not determined by hypoxia alone. Improvements in nutrition, expansion of healthcare resources, and socioeconomic development may jointly shape the growth process and partly buffer or offset the adverse effects of hypoxic exposure.

Author Contributions

Chen Zhang and Yi Sun: conceptualization. Yi Sun: data curation. Chen Zhang: formal analysis. Yi Sun, Chen Zhang, Bin Li, Meng Yuan, Zhihong Chen, and Xiaokun Mu: investigation. Yi Sun: supervision, project administration. Chen Zhang: visualization. Chen Zhang: writing – original draft preparation. Yi Sun: writing – review and editing. All authors have read and agreed to the published version of the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This study was supported by the 2023 Key Project of the Shandong Provincial Education Science Planning Program, “Research on the Construction of a Supervision System for Promoting Students, Physical Fitness and Health Standards” (Grant No. 2023ZD027).

Ethics Statement

Before participating in the study, both the children and their parents signed written informed consent forms. The study was approved by the Human Subjects Protection Committee at East China Normal University (Ethics Review Number: HR 077‐2020).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2005).

Table S2: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2005).

Table S3: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2010).

Table S4: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2010).

Table S5: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2014).

Table S6: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2014).

Table S7: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2019).

Table S8: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2019).

Table S9: Prevalence of stunting by year, sex, and age among Tibetan children and adolescents.

Table S10: Prevalence of overweight or obesity by year, sex, and age among Tibetan children and adolescents.

Table S11: Socioeconomic indicators.

Table S12: Healthcare indicators.

AJHB-38-e70317-s001.docx (715.5KB, docx)

Acknowledgments

We thank all participants, investigators, and staff members who contributed to this study. During the preparation and revision of this manuscript, the authors used ChatGPT (GPT 5, OpenAI) from July 14 to July 18, 2026, to assist with translating selected text from Chinese into English, improving English grammar and readability, and preparing and refining figures. All AI‐assisted translations were carefully checked against the original Chinese text and revised by the authors to ensure scientific and linguistic accuracy. All AI‐assisted figure content, including numerical values, labels, legends, and visual presentation, was independently verified against the original data and manuscript. No personally identifiable information, sensitive participant data, confidential information, or proprietary material was entered into the tool. The authors reviewed and approved all resulting content and take full responsibility for the accuracy, integrity, and originality of the manuscript.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2005).

Table S2: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2005).

Table S3: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2010).

Table S4: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2010).

Table S5: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2014).

Table S6: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2014).

Table S7: Differences in height, weight, and body mass index between Tibetan and Han male children and adolescents (2019).

Table S8: Differences in height, weight, and body mass index between Tibetan and Han female children and adolescents (2019).

Table S9: Prevalence of stunting by year, sex, and age among Tibetan children and adolescents.

Table S10: Prevalence of overweight or obesity by year, sex, and age among Tibetan children and adolescents.

Table S11: Socioeconomic indicators.

Table S12: Healthcare indicators.

AJHB-38-e70317-s001.docx (715.5KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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