Parent Article

Villamor E, Jansen EC. Nutritional determinants of the timing of puberty. Annual review of public health.
2016 Mar 18;37:33-46.

Nutritional Behavior and Obesity leading to Precocious

Puberty in Females of Karachi, Pakistan
INTRODUCTION:
Puberty is the transition from childhood to young adulthood, which includes modifications of body
composition, size, and shape that results in the development of secondary sex traits and the maturation
of the reproductive organ.6 The emergence of secondary sex traits in girls before the age of eight is
known as precocious puberty.1 Females are ten times more likely than boys to experience premature
puberty11. The timing of puberty has significant clinical, social, and public health effects. One of the most
significant variables influencing pubertal growth is thought to be nutritional status. 2 Children and
adolescents who are obese experience severe consequences. Positive energy balance brought on by
increased calorie intake and decreased energy expenditure, which is typical of sedentary lifestyles, is the
primary factor causing childhood obesity. 3

A school-based population research of 4058 adolescents in grades 1-3 in Zhongshan, Guangdong, China
found that premature puberty was more common among overweight (27.94%) and obese girls (48.00%)
than in girls who were normal weight (8.73%).(15).Similar to this, in a prospective study of 134 Iranian
girls, those who consumed 34 g of milk daily at age 9 had greater odds of menarche occurring at or
before the age of 12 than did those who consumed 34 g daily (18). Another research conducted at The
Institute of Child Health in Lahore over the course of a year found that out of 43 instances of precocious
puberty (PP), 26 cases were female and out of which central precocious puberty (CPP) were 55.8% and
peripheral precocious puberty were 44.1%.(17) In a small study of American girls, total animal protein
consumption between the ages of 3 and 8 was linked to an earlier menarche.19

Former research has depicted that significant changes in a mother's diet may have long-term metabolic
effects on her children, especially in the form of obesity, leptin resistance, and insulin resistance 10.
According to research, the beginning of puberty in girls only occurred when total body fat reached
roughly 17% (16). The studies have shown a close association between excessive weight gain and
precocious puberty, particularly in females. The timing of puberty can vary by up to 25%, which can be
explained by the nutritional state during infancy, which has a substantial impact on pubertal
development .A high-fat diet (HFD) has been linked, in particular, to altered biochemical and
neuroendocrine processes as well as a pro-inflammatory state. Studies have demonstrated that a meal
rich in fat and/or glycemic index can activate microglia and produce inflammation in the hypothalamus.
This microglial activation appears to create and activate prostaglandins, which in turn stimulate neurons
that express the gonadotropin-releasing hormone, causing precocious puberty.4 Leptin is a hormone
produce by Fat cells that affects eating metabolism and reproduction by acting on hypothalamus it may
trigger puberty by inducing kisspeptin(adipokine produce by adipose tissue) expression in the
hypothalamus. Studies in mice suggested that kisspeptin expression encourages vaginal opening and
 KISS1 knockout mice have abnormal puberty and do not initiate estrus(the opening of the vagina, the
secretion of mucus, and the crinkling and thickening of the mucous membrane wall) 5.

It's important to research how obesity is leading to precocious puberty because [Obese children are at
risk for associated consequences like metabolic changes, cardiovascular ailments, orthopedics issues,
and psychological abnormalities.] .It is important to understand the potential impact of these factors on
the health of young girls, as there has been no research conducted in Karachi, Pakistan. This is a
significant gap in the literature, as Karachi is a major urban center with a large population of young girls.
This research could provide valuable insights into the factors that contribute to precocious puberty in this
population and help to develop effective interventions to prevent this condition.

RATIONALE:
By determining the causes of precocious puberty and creating efficient therapies to treat it, this
research may be possible to improve the health of young girls in Karachi, Pakistan. This study
may also help parents and medical professionals in Karachi, to become more aware of this
issue. In addition to the specific health consequences of precocious puberty, it is also important
to consider the social and economic consequences of this condition. For example, girls with
precocious puberty may be more likely to drop out of school, to experience early pregnancy,
and to have lower levels of educational attainment. This research could help to prevent these
negative consequences and improve the overall well-being of young girls in Karachi, Pakistan.

OBJECTIVES:

 To investigate the relationship between nutritional behavior, obesity, and the onset of
precocious puberty in females in Karachi, Pakistan.
 To develop awareness and effective interventions to prevent precocious puberty in this
population.

OPERATIONAL DEFINITION:

Precocious puberty (PP):

It is the commencement of pubertal changes earlier than the generally acknowledge minimum
age( between the ages of 10 and 16, with an average age of onset of 12.4 years.13)for the onset
of puberty, i.e., before the age of 8 in girls.8

Obesity:
Abnormal fat buildup or excess adiposity in infancy i.e: (individuals whose body mass index
(BMI) is greater than or equal to 30 kg/m2.14)that influences early puberty is interpreted as
obesity.12

Nutritional Behavior:
The excessive consumption of processed and high fat-food are causing the girls to enter
puberty earlier which increase the risk of health issues9.

HYPOTHESIS:
There is a strong correlation between the variables and the possible hypothesis is that the type
of diet intake and the adiposity may contribute to inception of premature puberty (precocious
puberty) in young girls at the age of 8.

Material And Methods :

Study Design:
This research will be a cross sectional survey.

Study Setting :
Research work will be conducted at Secondary schools of Karachi.

Study Duration:
Time period of minimum 3-6 months will be required after approval of synopsis.

Study Population:
Young girls (Who have early onset of puberty) among 101.54 million females population of
Karachi of different ages.

Sample Size :
Sample Size for Frequency in a Population

Population size(for finite population correction factor or fpc)(N): 1000000

Hypothesized % frequency of outcome factor in the population (p):50%+/-5
Confidence limits as % of 100(absolute +/- %)(d): 5%
Design effect (for cluster surveys-DEFF): 1
Sample Size(n) for Various Confidence Levels

ConfidenceLevel(%) Sample Size

95% 384
Sample Technique :
Non- Probability Stratified Sampling will be followed.

Sample Selection:
Inclusion criteria:

1) Young girls who have reached puberty earlier than normal.

2) Girls who are obese in pre-pubertal phase.

3) Girls with disruptive eating pattern.

Exclusive criteria:

1) Girls who are diagnosed with PCOS.

2) Young girls who developed secondary sexual characteristics on time.

3) Girls who are genetically obese.

4) Young girls living active lifestyle.

Data Collection Procedure:

Will complete this after making questionnaire

Data Analysis Procedure:

All the data will be entered in SPSS version 20 for analysis. Qualitative variables like gender,
age group, eating pattern ,eating habits ,sedentary lifestyle will be measured in terms of
frequencies and will be presented through tables and charts. Chi-square tests will be applied; p
value less than 0.05 will be considered significant.

ETHICAL CONSIDERATION:
Written informed consent will be obtained from the participants before research. Data will be
kept highly confidential, and research will be conducted after obtaining ethical permission from
the institutional review board of JSMU.

Variables:

Dependent variable:
Precocious Puberty

Independent variable :

obesity and nutritional behavior.

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