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Bianca Arnold

Correlation Between Rising Childhood Obesity Rates and Decrease


in Age of Onset of Puberty in Girls
Abstract
Childhood obesity has been on the rise since the 80s. Both the center
for disease control and the International Obesity Task Force have different
standards for what defines a child as obese, causing an obstacle for data
consistency. As a result, most data is derived of individual studies using
comparative body mass index (body mass index) rates. As the rate of
childhood obesity has increased the age of menarche in girls has decreased.
This phenomenon has been occurring since the industrial revolution, where
better access to nutrition has played a role in the bodys ability to begin
menses. This may have a direct link to the level of leptin, a hormone
produced by fat, present in the body. Girls with a higher BMIs are more likely
to enter puberty at a younger age than their peers of a lower BMI. The recent
occurrence of the lowering of the age of puberty may have many long term
health consequences.

Key Words: Menarche, Obesity, Cross Sectional, Longitudinal, Body Mass


Index (BMI), Leptin

Defining Obesity

One of the greatest struggles the fight on childhood obesity has seen is
the inability to agree on when a child is to be declared obese and how best
to measure obesity. The two most common practices for determining obesity
are the measuring of skinfold thickness and the calculation of BMI. BMI (body
mass index) is derived using height and weight. A BMI test will provide
consistent results for the same patient as they progress through life. A
skinfold test is usually done at the bicep and gives a more accurate measure
of adiposity in a child. However, there is more room for inconsistency using
this method. While the cutoff for obesity in adults is a BMI of 30 or greater,
there is debate about whether or not it is appropriate to use the same scale
for children because of the immaturity of their bodies (Pediatr, 2003). The
average BMI at birth is 13, it then rises to 17 at age 1 and drops again by
age 6 to around 15.5. Because children go through varying growth cycles, it
is not appropriate to use the same cutoffs as are used on adults. Preferably
there would be a standard table established that could correlate BMI to very
specific ages (Cole, 2000).
Because of the varying cutoffs for which children may be considered
obese, most studies will use BMI in relation to other study participants. This
is why population also plays a role in many studies and why many have
chosen to take participants from across the country as well as multinational
studies. For example, the average BMI in America would be higher than an
impoverished country, making it hard to use the same defining brackets. In a
population that is generally more obese to begin with, the data would show

that early onset of puberty has little to do with BMI, whereas in a community
featuring more extremes the age difference will be more noticeable (Cole,
2000).

History of Rising Obesity Rates in US Children


Obesity has become an epidemic. Obesity rates range from 10%-25%
of adults (defined in this journal as weighing in >85th%) in most Western
European countries up to 20%-25% in some parts of the United States. 20%
of children and adolescents are estimated to be overweight or obese. While
obesity is not restricted to any one social class, age group, or gender, women
are more likely to be obese. While obesity can sometimes be heavily related
to genetics, most causes are environmental. There is an increase in the
consumption of fast and ready-made foods and more time is spent in front of
a screen each day. Obese parents pose a huge threat to their children due to
genetics and sharing of lifestyle (diet, housing, food preferences) (Shalitin,
Philips, 2003).
There is little to no data collected prior to 1963 (when the first national
survey was conducted) on childhood obesity rates. Therefore, it is not known
exactly how long childhood obesity has been on the rise. The Fels
Longitudinal Study (FLS) has been studying rising obesity rates since 1929,
making it an important asset. Beginning in 1930 they took 7 cohorts of
children, beginning at age 3, and tracked their progress until age 18 (a total
of 16 measurements of height and weight per subject; one measurement

each year). This went on at regular intervals until 1993 (See table 1).
Participants were taken out of three counties near the Dayton, Ohio
metropolitan area.
In this study the IOTF (International Obesity Task Force) standards of
obesity were used in addition to those of the CDC (Center for Disease
Control). The two differ slightly, with the IOTF standards focusing more on
appropriate cutoffs for childhood obesity. The IOTF has higher standards of
obesity, while the CDC has lower ones. A child may be considered normal by
the CDC, but overweight by the IOTF. What was found was that indeed, over
time, the FLS research subjects had become more obese. Between the birth
cohorts of 1930 and 1993, the prevalence of obesity rose from 0% to 14%
among FLS boys and from 2% to 12% among FLS girls. The prevalence of
overweight children rose from 10% to 28% among boys and from 9% to 21%
among girls. The trend towards obesity began starting in birth year 1970 for
boys and 1980 for girls (Hippel, Nahhas 2013). The study did find issues with
consistency of ethnicity of the cohorts because there was a large influx of
children of Hispanic heritage beginning in the 60s, where there was almost
none prior to that. Because of this, data of 20 Hispanic children was omitted.
Also omitted were 7 pairs of twins and 9 girls who became pregnant during
throughout the study. The ultimate conclusion of the study was that
childhood obesity is a fairly recent phenomenon. (where BMI was stable
throughout the 60s and 70s and began to rise steadily in the 80s, until the
present) The data of this study is consistent with national data.

Another more recent study showed similar results, in 2009-2010, 9.7%


of infants and toddlers had a high weight-for-recumbent length and 16.9% of
children and adolescents 2 through 19 years of age were obese. There was
no difference in obesity prevalence among males or females between 20072008 and 2009-2010. However, trend analyses over a 12-year period
indicated a significant increase in obesity prevalence between 1999-2000
and 2009-2010 in males aged 2 through 19 years but not in females per 2year survey cycle. There was a significant increase in BMI among adolescent
males aged 12 through 19 years, but not among any other age group or
among females (Ogden 2012). The study suggests that female obesity rates
have not been as severe as male ones, but are still on the incline (See table
2). This particular study included 4111 participants (72 were omitted due to
missing data) of mixed races. 1376 non-Hispanic white, 792 non-Hispanic
black, and 1660 Hispanic children and adolescents. The smallest samples
were non-Hispanic black infants and toddlers (51 males and 59 females)
(Ogden, 2012). 31.8% of all participants aged 2-19 were overweight or obese
in 2010. Compare this to the rate of overweight children of the FLS study,
which had an average rate of 9.5% for overweight children in 1930. An
increase of overweight children of more than 20% in the past 80 years. Since
none of the participants in either study were malnourished, none of the data
can be attributed to better nutrition, however there is more ready access to
food now than ever before, which contributes to obesity.

Decrease in the Age of Menarche in Girls

In addition to the rise of childhood obesity in the past 30 years, there


has been a drop in age at which girls typically experience menarche.
Menarche is the first menstrual cycle a female undergoes and is strong
indicator of the beginning of puberty. Historically it has been proven that this
age is not purely genetic, meaning that while genetics influence does affect
the age of menses, environmental factors can easily override them. Data
from Europe, specifically Finland, Denmark, and Norway, documents that a
there was a drop in the average age of menarche from the age of 16/17 to
about the age of 13; beginning in the mid-19th century and ending in the
beginning of the 20th century. A similar phenomenon was recorded in the
United States, where the average age of menarche decreased from 14.75
years to just under 13; beginning in 1877 and going till the 1950s. This is
accredited almost entirely to the industrial revolution and better access to
nutrition. It seems that since the 1960s, the age of menarche has leveled off
significantly, though recent decreases of 2.5-4 months have been observed
in the past 25 years (Mouritsen, Aksglaede, Hagen, Mogensen, Juul, 2012).
It has also been observed that girls who are more physically active
during childhood enter puberty later than their less active peers. This may
have directly to do with the fact that as children tend to be more active, they
are less likely to be overweight or obese (Kaplowitz, 2008).
One study that was conducted looked at the critical weight a female
must be at in in order to enter and maintain puberty, directly effecting the
age of menarche. This study, conducted by researchers Frisch and Revelle,

concluded that in order for puberty to begin, a critical mass of ~42 kg must
be reached. An even higher ~46 kg must be reached in order for puberty to
be maintained. After reviewing longitudinal (a study that looks at continuous
data over time, versus single points of data) growth data for 181 normal
girls, Frisch and Revelle observed that the average weight at menarche was
consistently at 48 kg for girls who reached menarche before age 12,
between 12 and 13, between 13 and 14, and after age 14; however, average
height at menarche increased progressively the older the girls were at the
time of menarche. This data may imply that when a young girl reaches the
critical weight or ~48 kg, she is more likely to enter puberty than her peers.
The study also shows that height has very little to do with the onset of
menarche and that rather overall weight and fat percentage plays a larger
role (Kaplowitz, 2008).
Another study looked directly at the relationship between BMI and
skinfold thickness and timing of puberty. The National Heart, Blood, and Lung
Association did its National Growth and Health study using a cohort of 2379
girls. The cohort was equally black and white girls. They were recruited at
age 9, from Richmond, California, Washington, D.C. and Cincinnati, Ohio.
Each year the girls were measured for height, weight, skinfold thickness,
BMI, and stage of puberty. The average of menarche in white girls was 12.7
and the average age for black girls was 12. Upon completion of the study the
girls were divided into three groupings, based on age of menarche as
recorded. It was found that the girls who first entered menarche had, on

average, a higher BMI than others in the study. Subsequently those in the
mid-range group also had higher BMIs than those who were last to get their
periods (Biro, 2001).
Interestingly enough, a study conducted by the Girls-Health
Enrichment Multi-Site Study, found that amongst 147 black girls, those in
>95th% were found to develop breasts far before pubic hair and having their
first period (Himes, 2004). In the Bogalusa Heart Study, cross-sectional
studies (studies that compare single data points taken at different times)
were done; one in 1973-1974 and another in 1992-1993. The study consisted
of girls ages 5-17 who lived in a somewhat rural area of Louisiana. What the
study found was that over the course of 20 years the average age menarche
decreased ~9.5 months for black girls and ~2 months for white girls. Greater
than this though, is that it was found that girls in the >75th% were 1.79 times
more likely to experience menarche early, which was defined in this study as
before age 11 (Freedman et. al, 2002). This study specifically highlights that
while childhood obesity has been on the steady incline for the past 30 years,
the age of menarche has been decreasing. The timing of this study was also
fortunate because the first cross sectional was done before the 1980s, where
childhood obesity first began to spike. The second cross sectional shows a
more recent data set that accurately reflects how the rise in obesity has
decreased the age of menarche.
Another study also concluded that the age at which girls develop
breasts has decreased significantly. Before the 1980s, the average age of

which girls developed breasts was ~11. A follow up study in 1988-1994,


showed that the average age had dropped well below 10. Non- Hispanic
black girls were the most effected in this change. Similar, yet not as drastic
results were found in Denmark. There, a 12-month decline was observed
over a course of 15 years, using school and public medical records. In 2010,
approximately 5% of Danish girls had breast development before age 8
(Mouritsen, et. al, 2012).
Some studies may argue that for some, obesity may be the result of
early onset puberty, not the other way around. It has been found that
estrogen, and possibly progesterone, are responsible for working together to
retain excess calories as fat. Prolonged exposure to these hormones during a
growth period could cause an increase in BMI (Rosenbaum, 1999).

The Role of Leptin in Puberty


One hormone in particular has been linked between obesity and the
early onset of puberty. This hormone is leptin. Leptin is released by fat cells
as a way to communicate their presence to the brain. An increased level of
leptin as a triglyceride is meant to serve as a negative feedback loop to tell
the brain to decrease consumption of food in order to slow obesity. In
essence it is the bodys own fat-level regulator. It has also been discovered
to be linked with multiple reproductive matters, including the onset of
puberty. Low levels of leptin have been linked to obesity and lack of sex drive
in rats. Chronic leptin treatment of the mice not only helped them to regain a

healthy weight, but puberty and fertility were restored. In female rats that
had not yet undergone puberty, leptin helped lower the age of puberty as
well as accelerate it. Those rats that had higher initial body weights
responded even better to the leptin treatments because they already had a
high level of leptin being produced by their own adipose (fat) cells. The rats
eating a higher fat diet tended to enter puberty sooner than those on a low
fat diet (Ahima, Dushay, Flier, Prabakaran, J. Flier, 1997).
In females, levels of leptin rise throughout puberty, in correlation with
estrogen. In general, this is due to the increase of fat that occurs in the
female body during puberty. Women also have less leptin-binding proteins
than men, which means there is more free leptin within the body at any
given time. Patients with chronically low levels of leptin are unable to enter
puberty due to leptins association with the hypothalamus. Leptin may be the
messenger that tells the hypothalamus that fat store is adequate to enter
puberty. Therefore, if that level of fat is achieved at a younger age, the
hypothalamus engages pubertal hormones at a younger age. It was found
that girls with precocious puberty had twofold the amount of plasma leptin,
and higher rates of obesity, as compared to their peers. Consequences of
this include functional ovarian hyperandrogenism and polycystic ovary
syndrome due to an even higher increase of fat on top of the already existing
obesity (Shalitin, Phillip, 2003).

Health Implications of Childhood Obesity and Premature Puberty

The Newcastle thousand family study was able to find a link between
obesity rates in children and adulthood. 1147 children were in the initial
cohort, however only 529 were able to be followed until past the age of 50. It
was noted that the socioeconomic situation of the remaining participants
was slightly better than the average of the collective group in the beginning.
However, since all socioeconomic classes are equally susceptible towards
obesity, this made no difference in the final data. What was found was that,
at age 50, those who had been in the >90th% at ages between 9-13 were
between 5 and 9 times as likely to be obese. As is standard for adults,
obesity is defined as having a BMI of 30 or more. Similarly, children in the top
10% of their weight class at the age of 13 were twice as likely to be
overweight or obese. Interestingly enough, it is around age 13 that children
enter puberty, implying that especially the ages 9-13 are critical for setting
weight for the rest of adulthood. The journal mentions that thin or children of
average weight are no less susceptible to become overweight or obese
adults (Wright, Parker, Lamont, & Craft, 2001).
Precocious puberty (puberty beginning before age 8 in girls and age 9
in boys) has been linked to multiple health risks (Mayo Clinic Staff, 2014). In
the past 50 years the age of the onset of breasts has decreased even more
than the onset of menarche. Breast development is enough to diagnose a
patient with PP (precocious puberty). In the Pediatric Research in Office
Settings study (PROS) it was found that 6.7% of all white girls and 27.7% of
all black girls could be diagnosed with PP. What differentiated this study from

several similar ones, is that all subjects in the study had their breasts
palpitated, rather than just observed. This has been an issue faced by other
studies, because it is difficult to differentiate between simple fat distribution
and development of breast tissue. Parents were also asked to rate the
developmental stage of the childs body.

Conclusion:
The age of menarche and onset of puberty has decreased over past
200 years. As humans have better access to nutrition, the rate of obesity,
and childhood obesity, has increased. Overweight children have long been
observed to develop faster than children of a normal weight. Specifically, in
girls, a higher BMI between the ages of 9 and 13 has been linked to an
increased likelihood of entering puberty at a younger age than that of her
peers. Multiple studies have concluded that girls in the >85th% for weight
mature sooner. This may be due to the increased levels of leptin in the body,
which has been linked to triggering an early puberty in rats. Other than early
puberty, being overweight as a child has health implications for the entire
adult life. Obesity leads to heart disease, hypertension, arthritis, joint
damage, and diabetes.

Tables
Table 1:
Participation in the Fels Longitudinal Study
a. Boys
Birth Year

Participant
s

Measurements

Mean

Minimum

Maximum

1930 to 1934

34

799

10.48

3.00

18.08

1935 to 1944

76

1612

10.37

3.00

18.30

1945 to 1954

88

1856

10.47

3.00

18.65

1955 to 1964

113

1874

10.36

3.00

18.70

1965 to 1974

106

1544

10.25

3.00

18.57

1975 to 1984

65

979

11.67

3.00

18.64

1985 to 1993

88

956

10.73

3.00

18.89

Birth Year

Participant
s

Measurements

Mean

Minimum

Maximum

1930 to 1934

42

956

10.30

3.00

18.15

1935 to 1944

73

1477

10.40

3.00

18.99

1945 to 1954

66

1283

10.47

3.00

18.60

1955 to 1964

132

2168

10.19

3.00

18.91

1965 to 1974

90

1345

10.03

3.00

18.80

1975 to 1984

60

890

11.03

3.01

18.85

1985 to 1993

83

992

9.91

3.00

18.97

b. Girls

Table 2:

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