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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Effects of nutritional and socioeconomic status on puberty
Omosalewa A Oyewole1, Adekunle S Adediran1, Abiola O Oduwole2
1 Department of Paediatrics, Federal Medical Centre Abeokuta, Abeokuta, Ogun State, Nigeria
2 Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
| Date of Submission | 30-Jun-2022 |
| Date of Decision | 08-Nov-2022 |
| Date of Acceptance | 01-Feb-2023 |
| Date of Web Publication | 10-Apr-2023 |
Correspondence Address:
Omosalewa A Oyewole,
Department of Paediatrics, Federal Medical Centre, Idi Aba Abeokuta, Ogun State
Nigeria
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/njbcs.njbcs_39_22
Context: The onset of puberty is determined by genetic and environmental factors like socioeconomic and nutritional status. Previous studies have shown a disparity in the effect of socioeconomic factors on menarche and sexual maturation. Aim: This study was carried out to determine the effect of nutrition and socioeconomic status (SES) on puberty. Settings and Design: It is a descriptive, cross-sectional study among adolescent female secondary school students in Abeokuta, Nigeria. Materials and Methods: Subjects selected responded to questions on the proforma. Body mass index (BMI) was calculated from weight and height that were measured. Statistical Analysis: The data were analyzed using Microsoft ExcelR (Microsoft Corporation SP2 software microsoft office 2010 professional plus (PC) Intel Corporation's 386 microprocessor Redmond, Washington, USA) 2010 and SPSS 22.0 (SPSS Inc., Illinois, USA). Results: Participants' mean age and BMI were 14.4 ± 1.9 years and 19.1 ± 2.9 kg/m2, respectively. Subjects from high socioeconomic class (SEC) attained puberty and menarche earlier (12.0 ± 1.5 and 12.9 ± 1.5 years) than those from low SEC (13.5 ± 1.3 and 13.7 ± 1.1 years). These were statistically significant for breast development and menarche. Nutritional status had a negative correlation (r = -0.098) with menarcheal age but positive with pubic hair (r = 0.702) and breast development (r = 0.306). Conclusion: The mean age of menarche occurred earlier in this study when compared to most previous studies in Nigeria. Improved SES and nutritional status influenced the early age of onset of puberty and attainment of menarche.
Keywords: Body mass index, nutritional status, puberty, socioeconomic status
| Introduction | |  |
Pubertal development is determined by genetics and environmental factors (nutrition and socioeconomic status).[1],[2] Adequate and balanced diet from infancy through childhood are prerequisite to physical growth and onset and progression of puberty.[1] Leptin and ghrelin are nutritional signals that modulate complex cascade of hormones that trigger puberty.[2] Intake of processed, high-fat foods accounted for early puberty likewise overweight and obesity.[1] In addition, the improved general health around the world play significant role in decreasing age for the onset of puberty.[2] In the past, the age at which girls in developing countries began puberty had been found to be later than those from developed countries.[3],[4],[5] Marshall and Tanner showed that onset of menarche occurred at age 17 years in nineteenth century, declined to 13 years in mid-twentieth century in European girls[3] while study by Ellis who compared Nigerian girls with British observed that menarche occurred later in Nigerian girls after 14 years.[5] Recently, it appears this disparity has been nullified due to improved nutritional and stable socioeconomic status (SES) except where there is undernutrition.[4],[6] It was observed that children who migrated from developing countries to developed societies entered puberty at earlier age.[4] There have been conflicting observations on the effect of SES on menarche and sexual maturation in previous studies.[7],[8],[9],[10],[11],[12] A study done in South-West Nigeria among undergraduates did not show any relationship between the age at menarche and SES.[7] A study done in Sokoto, northern Nigeria showed no difference in menarcheal age between rural and urban school girls,[8] likewise another study reported that there is no association between height, weight, and menstrual characteristics.[9] However, some studies observed that girls from families with high SES attained puberty earlier than their counterparts from families with middle and low SES.[10],[11],[12] Girls from families with high SES attained menarche 8.0 and 9.0 months earlier than their counterparts from families with middle and low SES, respectively.[10] Nwokocha and Okoro[12] found that socioeconomic class (SEC) of the parent influenced the age of pubertal development.
Most previous studies were done on age at menarche only; nutritional status and SES were also studied separately. This study aims to study the relationship and determine the effect of both parents' SES and the subject's nutritional status on the attainment of puberty. Higher nutritional status and SES positively influenced the overall general health including growth and puberty and reduction of diseases.
| Materials and Methods | | |
Study design and setting
A descriptive cross-sectional study was done in randomly selected secondary schools and local governments in Abeokuta Ogun state, Nigeria. Participants are apparently healthy adolescent girls (aged 10–20 years) from private and public secondary schools in Abeokuta.
Sample size determination
The sample size used was 711 participants. Sample size was calculated using N = Z[2] PQ/D[2].
Here N = Minimum sample size,
Z = Critical value in a two-tailed test (1.96),
P = Proportion of healthy adolescent girls, and
Q = (1-P).
Calculated sample size was 661 and attrition error of 10% was added. 727 participants were enrolled but 711 completed the study, 16 were excluded due to incomplete data.
A power of 80% and a confidence interval (CI) of 99% were used to calculate the sample size.
Ethics
Ethical approval of the study was obtained on March 14, 2014, renewed on May 7, 2015 from the Hospital Research Ethics Committee of Federal Medical Centre Abeokuta (FMCA/238/HREC/05/2014), and permission from the state ministry of education, zonal education offices, and the principals of the participating schools were obtained. Subjects were recruited after parental consent and verbal assent from the students.
Sampling procedure
A multistage randomized sampling technique was used.
Procedure for data collection: Information on demography, ethnic and parental occupation, and educational qualification were recorded to determine the family's SES as recommended by Olusanya.[13] The family size and birth order of the subjects were recorded. Physical examination and anthropometric measurements (weight and height) were done in privacy. In the presence of a female teacher, breast stages (stages 1–5) were assessed by visual inspection and palpation using the rating scales of Marshall and Tanner. Pubic hair stages (stages 1–5) were assessed by visual inspection using the same rating scales. Stage 1 represents immaturity, stage 2 marks the onset of breast development or pubic hair development, and stage 5 indicates full maturity.
Body mass index (BMI) was computed from the formula [weight/height[2]] (kg/m2) and each student was classified using the Centers for Disease Control (CDC) appropriate age and sex gender chart.[14] Students were classified based on their age using the appropriate CDC BMI growth chart into underweight, normal weight, overweight, and obese.
Data analysis
The data were analyzed using Microsoft ExcelR 2010 (Microsoft Corporation SP2 software microsoft office 2010 professional plus (PC) Intel Corporation's 386 microprocessor Redmond, Washington, USA) and IBM Statistical Package software version SPSS 22.0 (Statistical Package for Social Sciences Inc., Illinois, USA). Continuous data were described in terms of range, means, standard deviation, median, and modes. Categorical data were described in proportions. Mean values were compared using the Student t-test, while proportions were compared using the Chi-square test. The correlation was also done using Pearson's correlation test. Statistical significance was determined by a P value less than 0.05 and a CI of 95%.
| Results | | |
A total of 711 subjects completed the study at the mean age of 14.4 ± 1.9 years. [Table 1] shows the sociodemographic characteristics of the subjects. The majority of the subjects belonged to monogamous families [528 (74.3%)], most common among their siblings was first position [200 (28.1%)], and about two-thirds of them [467 (65.8%)] belonged to the upper SEC.
[Table 2] shows the distribution of the subjects by their BMI. The majority of the subjects had normal nutritional status. All the obese participants were mid-adolescents. The mean weight of all the subjects was 46.5 ± 9.4 kg, the mean height was 1.6 ± 0.1 m, and the mean BMI was 19.1 ± 2.9 kg/m2.
[Table 3] shows the distribution of the mean age of onset of puberty by SEC. The mean age of onset of thelarche (B2 - Tanner stage 2 for breast development) and pubarche (PH 2 - Tanner stage 2 for pubic hair development) occurred earlier in subjects from higher SEC compared with those from lower SEC. The difference is statistically significant at B2 (F = 4.20, P = 0.018).
[Table 4] shows the distribution of the mean age at completion of puberty by SEC. None of the subjects from the lower SEC had completed pubic hair development. However, this difference in mean age was not statistically significant (for Breast5, F = 0.63, P = 0.694; for Pubic Hair5, F = 0.57, P = 0.815, respectively).
[Table 5] shows the distribution of the mean age at menarche by SEC. Menarche occurred earlier in subjects from higher SEC compared with other SEC. The difference was not statistically significant (F = 1.45, P = 0.238).
[Table 6] shows the distribution of the mean age of onset of puberty by nutritional status. The subjects who were underweight have the lowest mean age of PH 2 and B2 which was only statistically significant for PH 2 (F = 4.7 2, P = 0.010). Only three subjects were overweight at PH 2 while none was obese. At Tanner stage 2 for breast development (B2), none of the subjects was neither overweight nor obese.
[Table 7] shows the distribution of the mean age of completion of puberty by nutritional status. At the completion of pubic hair development, none was obese. There was no significant statistical difference at the completion of puberty between the nutritional statuses.
[Table 8] shows the distribution of the mean age of attainment of menarche by nutritional status. There was a statistically significant difference in the mean ages of menarche among the various nutritional status group (F = 3.16, P = 0.024).
[Figure 1] is a scatter graph illustrating the correlation between nutritional status (BMI) and age of onset of thelarche of the subjects. There was a weak positive correlation between the nutritional status and age of the subjects. This association was statistically significant (r = 0.306, P = 0.02). | Figure 1: Scatter graph showing the correlation between nutritional status and age at onset of thelarche (r = 0.306)
Click here to view |
[Figure 2] is a scatter graph showing the correlation between nutritional status and age of onset of pubarche. There was a strong positive correlation between nutritional status and the age of onset of pubarche. This was found to be statistically significant (r = 0.702, P = 0.00). | Figure 2: Scatter graph showing the correlation between nutritional status and age at the onset of pubarche (r = 0.702)
Click here to view |
[Figure 3] is a scatter graph showing the correlation between nutritional status and age of menarche. There was a weak negative correlation between nutritional status and age of menarche which was found to be statistically significant (r = -0.098, P = 0.03). | Figure 3: Scatter graph showing the correlation between body mass index and age at menarche (r = -0.098)
Click here to view |
| Discussion | | |
This study showed that nutritional status influenced the age of pubertal maturation. Obese and overweight subjects in this study attained puberty and menarche earlier than subjects who have normal weight. The difference in age at pubertal maturation in this study was more significant between those that were overweight/obese and those with normal weight. The early puberty in the subjects who were overweight or obese may result from increased body fat percentage which was observed in previous studies.[9],[10],[11],[15] In an Indonesian study, BMI was moderately associated with the menstrual period, but body fat was found to be strongly influenced by menstruation.[9] A study done in Nigeria reported that girls who have attained menarche are significantly heavier, taller, and with higher BMI than their counterparts who are yet to attain menarche.[10] Subjects who were underweight were also observed to attain puberty at an earlier age than those with normal weight in this study. This may have occurred as a result of other factors like genetics and exposure to endocrine disruptor chemicals.[1],[16] It had been previously reported that low SES is a risk to early puberty in addition to psychosocial stress and the absence of a biologic father.[16]
The association between nutritional status and pubertal maturation varies. Pubic hair development showed a strong positive correlation, breast development has a weak positive correlation while a weak negative correlation was found with menarche. As the nutritional status increases, the age at pubertal maturation (breast and pubic hair development) increases but the reverse was observed for menarche. As documented in the literature, being overweight or obese is associated with early puberty while being underweight is associated with delayed puberty.[17],[18],[19],[20] In a multicenter study in China, obesity was found to be positively associated with sexual maturation in both boys and girls, and the association does not differ by gender, but the association is stronger in girls than in boys.[17] Childhood obesity, including both overweight/obesity and central obesity, was associated with earlier attainment of puberty in Chinese Han schoolgirls.[18] Our small subset confirms previous work showing that Hispanic girls on average enter puberty earlier than Caucasian girls and that ethnicity was found to be a stronger influence on pubertal onset than weight status as Hispanic girls attained puberty at an age earlier than Caucasians in a study done in California.[19] They also discovered the subtle changes in hormonal variables before breast development, as well as the pattern of advanced bone maturation in girls with higher BMI in the peripubertal years.[19] Biro et al.[21] reported that childhood obesity not only influenced adult obesity but also predisposes to early pubertal maturation.
This study showed that SEC influences the mean age of onset of breast and pubic hair development. There was a statistically significant difference among the SECs for breast development. As the SEC increased, the mean age of attainment of puberty decreased. This result was in keeping with previous studies which showed that the onset of puberty occurred earlier in subjects from higher SEC.[12],[22],[23] Babar et al.[22] found that subjects from parents of high SEC have higher BMI or nutritional status. A study reported access to higher education for women and family planning programs, and improvement of sanitary facilities and socioeconomic conditions are major factors that enhanced the child nutritional status of children in Sri Lanka.[23]
At the completion of pubertal development, there was no statistically significant difference in pubertal development among the SECs in this study. This same observation was also found in previous studies[10],[24] but Nwokocha and Okoro[12] found that the SEC of the parent influenced the age of completing puberty.
Menarche occurred earlier in subjects from higher SEC compared with middle and lower SECs in this study. This is in keeping with previous studies[8],[10] that demonstrated a relationship between SEC and menarcheal age among enrolled secondary students as subjects but the study by Raji et al.[7] in South Western Nigeria (Ogbomosho and Oshogbo) showed no such relationship. Participants were undergraduates and they might not have given a reliable picture of their parent's SEC.
| Conclusion | | |
The pubertal development and attainment of menarche occurred earlier in subjects from high SEC and overweight/obese subjects. This is in agreement with the global trend.
Strength
1. This study showed that SEC inversely influenced the mean age at the onset of breast and pubic hair development. 2. In this study, being overweight or obese is associated with early puberty.
Weakness
However, subjects who were underweight attained puberty at an earlier age in this study. Variations observed between nutritional status and pubertal development may be due to the involvement of other environmental factors (exposure to endocrine disruptor chemicals, social stimulation/exposure, physical exertion, and psychological effects).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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