Perfluorooctanoate and changes in anthropometric parameters with age in young girls in the Greater Cincinnati and San Francisco Bay Area.

METHODS: We conducted a study of per- and polyfluoroalkyl substance biomarkers, including PFOA, in girls from Greater Cincinnati (CIN, N = 353) and the San Francisco Bay Area (SFBA, N = 351). PFOA was measured in the baseline serum sample collected in 2004-2007 of 704 girls at age 6-8 years. Mixed effects models were used to derive the effect of PFOA on BMI, waist-to-height and waist-to-hip ratios over increasing age in this longitudinal cohort. RESULTS: Median PFOA serum concentrations were 7.3 (CIN) and 5.8 (SFBA) ng/mL, above the U.S. population median for children 12-19 years in 2005-2006 (3.8 ng/mL). Log-transformed serum PFOA had a strong inverse association with BMIz in the CIN girls (p = 0.0002) and the combined two-site data (p = 0.0008); the joint inverse effect of PFOA and Age*PFOA weakened at age at 10-11 years. However, in the SFBA group alone, the relationship was not significant (p = 0.1641) with no evidence of changing effect with age. The effect of PFOA on waist:height ratio was similar to BMIz at both sites, but we did not find a significant effect of PFOA on waist:hip ratio in either the CIN or SFBA girls. CONCLUSIONS: PFOA is associated with decreased BMI and waist:height ratio in young girls, but the strength of the relationship decreases with age. Site heterogeneity may be due to greater early life exposure in Cincinnati. DISCLAIMER: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Use of trade names is for identification only and does not imply endorsement by the CDC, the Public Health Service, or the US Department of Health and Human Services.

Romantic, sexual, and sexual risk behaviours of adolescent females with severe obesity.

BACKGROUND: There is an increasing adolescent population with severe obesity with impairments in social and romantic relationships that are seeking clinical weight management, including weight loss surgery (WLS). OBJECTIVE: To document romantic, sexual and sexual risk behaviours in a clinical sample of adolescent females with severe obesity (BMI > 40 kg/m2 ) compared to those of healthy weight (HW). METHODS: This multi-site study-an ancillary to a prospective longitudinal observational study documenting health in adolescents having WLS-presents pre-operative/baseline data from 108 females undergoing WLS, 68 severely obese seeking lifestyle intervention and 118 of HW. Romantic and sexual risk behaviour and birth control information sources were assessed using the Sexual Activities and Attitudes Questionnaire (SAAQ). RESULTS: Severely obese females reported engaging in fewer romantic and sexual behaviours compared to HW. Similar to HW, a subgroup (25%) of severely females were engaging in higher rates of sexual risk behaviours and reported pregnancies and sexually transmitted infections (STIs). A considerable number (28-44%) reported receiving no birth control information from physicians. CONCLUSIONS: Discussion topics with the adolescent patient should extend beyond reproductive health needs (e.g. contraception, unintended pregnancies) to include guidance around navigating romantic and sexual health behaviours that are precursors to these outcomes.

Phthalate exposure and pubertal development in a longitudinal study of US girls.

STUDY QUESTION: Does phthalate exposure during early childhood alter the timing of pubertal development in girls? SUMMARY ANSWER: Urinary concentrations of high-molecular weight phthalate (high-MWP) metabolites are associated with later pubarche. WHAT IS KNOWN ALREADY: Phthalates are anti-androgenic environmental agents known to alter early development, with possible effects on pubertal onset. STUDY DESIGN, SIZE, AND DURATION: This multi-ethnic study included 1239 girls from New York City, greater Cincinnati, and the San Francisco Bay Area who were 6-8 years old at enrollment (2004-2007) and who were followed until 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS Phthalate metabolites were measured in urine collected at enrollment from 1170 girls; concentrations ranged from <1 to >10,000 µg/l. Breast and pubic hair stages and body size were assessed one to two times annually to determine the age at transition from stage 1 to 2 for breast and pubic hair development. Associations between exposures and pubertal ages were estimated using Cox proportional hazard ratios (HR) with 95% confidence intervals (CI) and survival analyses. Associations were examined with respect to age-specific body mass-index percentile, one of the strongest predictors of pubertal onset. MAIN RESULTS AND THE ROLE OF CHANCE: Urinary concentrations of high-MWP including di(2-ethylhexyl) phthalate (ΣDEHP) metabolites were associated with later pubic hair development during 7 years of observation. The relationship was linear and was stronger among normal-weight girls. Among normal-weight girls, age at pubic hair stage 2 (PH2) was 9.5 months older for girls in the fifth compared with the first quintile of urinary ΣDEHP (medians: 510 and 59 µg/g creatinine, respectively; adjusted HR 0.70, CI 0.53-0.93, P-trend 0.005. Age at first breast development was older for fifth quintile of mono-benzyl phthalate versus first (HR 0.83, CI 0.68-1.02; P-trend 0.018). No associations were observed between low-molecular weight phthalate urinary metabolite concentrations and age at pubertal transition in adjusted analyses. LIMITATIONS, REASONS FOR CAUTION: While there is evidence that phthalate exposures are fairly consistent over time, the exposure measure in this study may not reflect an earlier, more susceptible window of exposure. We investigated alternative explanations that might arise from exposure misclassification or confounding. WIDER IMPLICATIONS OF THE FINDINGS: Phthalates are widespread, hormonally active pollutants that may alter pubertal timing. Whether exposures delay or accelerate pubertal development may depend on age at exposure as well as other factors such as obesity and exposures earlier in life. Whether exposures act independently or as part of real life mixtures may also change their effects on maturation from birth through childhood. STUDY FUNDING/COMPETING INTEREST(S): This project was supported by the US National Institutes of Health, Environmental Protection Agency, New York State Empire Clinical Research Investigator Program and the Avon Foundation. L.H.K. is employed by Kaiser Permanente. The remaining authors declare they have no actual or potential competing financial interests.

Exploring the relationship between timing of menarche and eating disorder symptoms in Black and White adolescent girls.

OBJECTIVE: This study examined the relationship between timing of sexual maturation and eating disorders symptoms in adolescent girls. METHOD: Data were collected over 10 years for a cohort of 1,213 Black girls and 1,166 White girls who were either 9 or 10 years old at study entry. Annually, girls' height and weight were measured and, biannually, girls completed self-report measures of eating disorders symptoms. RESULTS: Early-onset menarche is a risk factor for the development of body image and dieting concerns, but the effect of timing is due to the impact of early and late maturation on body weight. DISCUSSION: Findings underscore the importance of adiposity as a risk factor for poor mental health.

A preliminary examination of adolescent girls' perceptions of the parental knowledge of their boyfriends.

STUDY OBJECTIVE: The purpose of this study was to describe adolescent girls' perceptions of their parents' contact with and knowledge of the girls' boyfriends. A second objective was to determine if knowledge was related to demographic characteristics of the girls or aspects of the relationship with their boyfriend. DESIGN: Cross-sectional analysis of data from an interview with adolescent girls enrolled in a longitudinal study. SETTING: Urban adolescent medicine clinic. PARTICIPANTS: Adolescent girls (n = 109) with a mean age of 17.6 (range 14.9-19.3 yr). Eighty percent were African-American and 20% were Caucasian. RESULTS: Most girls reported that their parents had some contact (either in person or on the phone) with their boyfriends. Thirteen girls reported that their parents did not know their boyfriends well, 40 reported that their parents knew their boyfriends somewhat, and 56 reported that their parents knew their boyfriends well. Age, race, and sexual experience were not related to how well the parents knew the boyfriend. Girls who had been involved with their boyfriends longer, believed that their relationship would last longer, were more satisfied, were more likely to tell their boyfriends private information and were more likely to describe their parents as knowing their boyfriends well. CONCLUSIONS: These results provide an initial description of girls' perceptions of their parents' relationships with their boyfriends. It would be important to understand how to utilize the information regarding these parental-boyfriend relationships to further adolescent girls' development of healthy (both psychologically and physically) relationships.

Drug treatment of nonviral sexually transmitted diseases: specific issues in adolescents.

Sexually transmitted diseases (STDs) are common and happen more frequently in younger patients. These adolescents have unique risks of acquiring infection because of developing psychosocial skills, biological factors and sociocultural barriers. The clinician must be adept at identifying and modifying these risks through knowledge of the adolescent stages of development and biology, with good history and examination skills that make teens comfortable during their evaluation, and with patient education and treatment. Whereas patient compliance and partner notification can be problematic in any population, teenagers may be more prone not to follow through on these issues. While compliance may notbe as important as previously thought, there is a dearth of studies of patient compliance and STD treatment in adolescents. Guidelines for the treatment of STDs were published by the Centers for Disease Control and Prevention (CDC) in 1998 and the Medical Society for the Study of Venereal Diseases in 1999. Most of the data obtained to formulate these guidelines were not necessarily adolescent specific and few studies, if any, have included adolescent patients since the CDC document was published. In the treatment of chlamydia, it appears that even with relative noncompliance with the 7-day regimen of doxycycline, it is as effective as single dose azithromycin. This has implications in cost control, important for centres with limited funds for treatment. While fluoroquinolone-resistant gonorrhoea has been reported for some time, the number of reports in the US is increasing, with a recent report of decreased susceptibility to azithromycin. As many studies have shown efficacy with single agent therapy with azithromycin in combined gonococcal and chlamydial infection, one must view these new resistance data with concern and give serious consideration to dual agent treatment, especially in the locale of the practitioner. Also, fluoroquinolone use is not advised in patients under the age of 18 years at present because of concerns of adverse effects on cartilage. While not much has changed from the 1998 guidelines for most of the other STDs, there seems to be a general trend in treating pelvic inflammatory disease (PID) on an outpatient basis if good follow-up is assured, even in the adolescent population. There is still debate on whether anaerobe coverage is needed in PID without tubo-ovarian abscess or other complications. One other update includes the use of daily metronidazole gel instead of twice daily usage in the treatment of bacterial vaginosis. With the lack of studies specific to adolescents, it is left up to the clinician to tailor the treatment of adolescents on the basis of current guidelines and patient preferences.

Sexual initiation: predictors and developmental trends.

BACKGROUND: Early initiation of sexual intercourse is associated with increased risk for acquiring sexually transmitted diseases. GOAL: To examine variables related to sexual initiation and developmental changes in the reasons why adolescent girls have sexual intercourse. STUDY DESIGN: A longitudinal study of girls recruited from an adolescent medicine clinic was performed. RESULTS: Logistic regression showed that girls who described their families as being expressive, having a moral-religious emphasis, providing supervision, and having greater maternal education, and who experienced menarche at an older age were older at sexual initiation. On the basis of contingency analyses, younger girls were less likely to report attraction or love, and more likely to report peers having sex as a reason for sexual intercourse at initiation. A generalized estimating equation analysis indicated that girls at younger ages are more likely to report curiosity, a grown-up feeling, partner pressure, and friends having sexual intercourse as reasons for intercourse. Girls at older ages are more likely to report a feeling of being in love, physical attraction, too excited to stop, drunk or high partner, and feeling romantic as reasons for having sexual intercourse. CONCLUSIONS: Prevention programs should include a focus on familial characteristics and susceptibility to peer norms. They should be conducted with sensitivity to the developmental changes in intimate relationships that occur during adolescence.

Adolescent girl's coping with an STD. Not enough problem solving and too much self-blame.

STUDY OBJECTIVE: Approximately three million teenagers are infected with an STD each year. The ways in which an adolescent girl copes with an STD may have implications for future risk and for psychological adjustment. The purpose of the current study was to compare whether coping with an STD was similar to coping with other stressors. SETTING: Urban, hospital-based adolescent medicine clinic. DESIGN AND PARTICIPANTS: Sixty-seven girls with a mean age of 15.9 (sexual debut was 13.8) yr completed the KIDCOPE in response to both an STD acquisition and an interpersonal stressor within the previous 6 months. RESULTS: Problem solving was used less often, and self-blame was used more often, in response to an STD acquisition. Frequency of use of self-blame was not correlated with perceived helpfulness. CONCLUSIONS: These findings suggest that clinicians need to help adolescent girls manage STD acquisition from the perspective of problem solving rather than self-blame.

Impact of timing of pubertal maturation on growth in black and white female adolescents: The National Heart, Lung, and Blood Institute Growth and Health Study.

OBJECTIVES: To evaluate the impact of early, mid-onset, and late maturation, as assessed by timing of menarche, on height, height velocity, weight, body mass index, and sum of skinfolds in a group of white and black girls. STUDY DESIGN: The Growth and Health Study recruited 9- and 10-year-old girls from Richmond, California, Cincinnati, Ohio, and Washington, DC. There were 616 white and 539 black participants recruited at age 9 and 550 white and 674 black participants recruited at age 10. Participants were seen annually for 10 visits. Longitudinal regression models were used to test for differences in each growth measure by timing of menarche across all ages and to determine whether these differences change with age. RESULTS: Mean age at menarche among white participants was 12.7 years, and among black participants, 12.0 years. According to race-specific 20th and 80th percentiles, early maturers were tallest at early ages and shortest after adult stature had been attained. Peak height velocity and post-menarche increment in stature were greatest in early maturers and least in late maturers. Weight was greatest in early and least in late maturers, as was body mass index. Sum of skinfolds was also greatest in early and least in late maturers. There was no impact of timing of maturation on two common measures of regional fat distribution. CONCLUSIONS: Girls who matured early were shorter in early adulthood, despite having greater peak height velocity and post-menarchal increment in height. Throughout puberty, early maturers had greater ponderosity and adiposity, although there was no association with regional distribution of fat.

The prevalence of upper lip hair in black and white girls during puberty: a new standard.

In order to develop standards for upper lip hair in adolescent girls, 4693 observations in 856 black and white subjects were made over 9 years. Up to 2 years after menarche, 90% of girls had no upper lip hair. More than 2 years after menarche, 48.8% of black girls and 9.0% of white girls had small amounts of upper lip hair. This may be more significant in adolescent girls than in older women.

Techniques of testing for sexually transmitted diseases.

Adolescent and young adult women are the highest-risk group for nearly all sexually transmitted infections. This article reviews diagnostic methods for the most common bacterial and viral sexually transmitted infections, with special attention to the use of nucleic acid amplification methods, as well as the utilization of nontraditional clinical specimens. These new modalities should help the care provider identify and manage the large asymptomatic pool of infected patients, and further lower the prevalence and burden of infection.

Estradiol and testosterone effects on lipids in black and white boys aged 10 to 15 years.

Previous studies of lipids in adolescent males have shown greater increases in triglycerides and decreases in high-density lipoprotein cholesterol (HDL-C) in white boys compared with black boys, significant correlations between sex hormones and lipids, and complex body mass index (BMI) hormone-lipid associations. Within this frame of reference, we assessed race, BMI, and sex hormones as predictors of lipid parameters in 536 black and white boys recruited from area schools. Black boys were more advanced in puberty than white boys. After adjusting for pubertal stage, estradiol (E2) levels were higher in black boys but free testosterone (T) levels did not differ. Age, pubertal stage, race, BMI, free T, and E2 were entered as explanatory variables for lipids in backward stepwise regression analyses. The BMI and race were retained in every model. Black boys had lower triglycerides and apolipoprotein B (apo B) and higher HDL-C. E2 was inversely associated with total cholesterol (TC), triglycerides, low-density lipoprotein cholesterol (LDL-C), apo B, and the LDL-C/HDL-C ratio. Free T was inversely associated with HDL-C and positively associated with apo B. Given the increases in free T and E2 during adolescence and the association of these hormones with both atherogenic and protective lipid parameters, racial differences in E2 could contribute to the more atherogenic lipid profile found in white boys after puberty.

New developments in diagnosis and management of adolescents with sexually transmitted disease.

The battle against the epidemic of sexually transmitted infections continues but the clinician has new diagnostic and therapeutic weapons. This manuscript reviews new technologies, as well as novel applications of newer methodologies, such as utilization of amplified DNA techniques for urine specimens or patient-collected specimens. Newest treatment recommendations are also reviewed.

Overweight, fat patterning, and cardiovascular disease risk factors in black and white boys.

PURPOSE: To evaluate the relationships of overweight and fat patterning with cardiovascular disease (CVD) risk factors in black and white boys. DESIGN: Cross-sectional analysis of CVD risk factors by weight and central adiposity groups in black and white boys, aged 10 to 15 years. Mean adiposity, lipid, and blood pressure variables were compared between weight and central adiposity groups within race by using linear regression models. Observed clustering of risk factors within weight and adiposity groups was compared with the expected clustering under an assumption of no association. RESULTS: Within each racial group, overweight boys had greater skinfolds, lower high-density lipoprotein cholesterol levels, higher low-density lipoprotein cholesterol and triglyceride levels, and higher systolic and diastolic blood pressure than non-overweight boys. Among overweight boys, greater central adiposity was associated with higher risk factor levels and increased clustering of risk factors. CONCLUSION: Overweight and central adiposity together profoundly affect CVD risk factor levels and risk factor clustering in black and white boys.

Locus of control for general health and STD acquisition among adolescent girls.

PURPOSE: To examine adolescent girls' perception of control over general health and sexually transmitted disease (STD) acquisition. METHODS: Adolescents participating in a longitudinal study were asked questions regarding their perception of their locus of control. These questions, adopted from a previous measure, focused on six loci: internal control, control by parents, partners, peers, and health care providers, and chance. RESULTS: There were 128 girls (mean age, 17 years; range, 14.5 to 18.8); 82% were black and 18% white. Statistically significant associations were found between control of general health and STD acquisition for each locus of control subscale, with the exception of partner control. However, the girls reported significantly less control over STD acquisition than over general health for health care providers, parents, and by chance, and significantly more partner and internal control over STD acquisition than general health. The correlations between parental control over general health and over STD acquisition were inversely correlated with age. Partner control was positively related to current condom use, but internal control was not. CONCLUSIONS: The degree of the locus of control was specific for STD acquisition. Girls who believe they should be able to control STD acquisition may not be using condoms. The view of partners as having control over STD acquisition may represent joint communication or coercion. However, in general these findings support the development of female-controlled methods for STD prevention, such as topical microbicides.

Adolescents and sexually transmitted diseases.

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

Adolescents' views regarding sexual history taking.

To address the health needs of adolescents, health care providers need to understand adolescent perceptions of the sexual history taking process. Adolescents (n = 113) were recruited from two sources of health care to complete a questionnaire regarding sexual history taking issues. The results revealed that there were differences in demographics, practice characteristics, and communication strategies between the private office and the hospital clinic. Attitudes and beliefs related to the discussion of sensitive issues were similar. Most adolescents would like health care providers to discuss sensitive topics directly. It is important for health care providers to feel comfortable initiating discussion of sensitive issues directly.

PIP: This study described adolescents' perception of their sexual history taken by health care providers. There were two stages of data collection. The first included focus group discussion, while the second was the administration of a sexual history-taking questionnaire. Adolescents were recruited from three locations (private pediatric practice, adolescent clinic setting, or a Job Corps Center) and were of a mean age of 16 years. Findings revealed differences in demographics and practice characteristics, as well as in strategies used when communicating with the care provider. However, there were similarities in attitudes and beliefs related to the discussion of sensitive issues. The majority of the adolescents believed that issues related to sexuality were important for their health care provider to discuss. Moreover, they preferred that their care provider address sexuality issues within a generally caring context; however, they also favored a direct approach.

Relationship between perceived parental monitoring and young adolescent girls' sexual and substance use behaviors.

STUDY OBJECTIVE: The purpose of the study was to examine the independent effects of perceived parental monitoring on sexual experience, contraceptive, and substance use. DESIGN, SETTING, AND PARTICIPANTS: Adolescent females at an urban-based adolescent clinic (N = 174; 41% sexually experienced) rated the extent to which they were directly and indirectly monitored by their parents. MAIN OUTCOME MEASURES: These perceptions were compared with reported contraceptive use as well as substance use. Direct parental monitoring was best described using two dimensions: direct monitoring and direct monitoring when with peers. RESULTS: Direct monitoring was found to be associated with the use of hormonal birth control methods at last intercourse. Direct parental monitoring when with peers was found to be associated with less use of alcohol and cigarettes. CONCLUSIONS: These data suggest that parental monitoring is a relevant factor for primary care physicians to explore during treatment.

Perceived and measured weight changes during adolescent pregnancy.

STUDY OBJECTIVES: This study examines the accuracy of recalled gestational weight gain and maximum weight gain during pregnancy and evaluates which factors have an impact on those estimates. DESIGN: Cross-sectional survey. SETTING: Adolescent pregnancy clinic in an urban hospital. SUBJECTS: Forty postpartum adolescents were recruited. Half the subjects were evaluated within 6 months postpartum, and half were seen over the next 9 months. MAIN OUTCOME MEASURES: Months postpartum, intrapartum weight gain documented in chart, maximum weight documented in chart, recalled intrapartum weight gain, recalled maximum weight; differences between chart-documented and recalled weight gain and maximum weight. RESULTS: Self-documented and documented weight gain and maximum intrapartum weights were highly correlated (Pearson r = .99), although those at highest weight tended to underestimate their weight gain and maximum weight. CONCLUSIONS: Adolescents are able to reliably recall weight gain and maximum weight during pregnancy.

Sex hormones and lipoproteins in adolescent male offspring of parents with premature coronary heart disease and a control group.

OBJECTIVE: To compare pubertal maturation, sex steroid hormones, and lipoproteins and their interrelationships in male offspring of parents with premature coronary heart disease (cases) and a control group. DESIGN: This was a cross-sectional comparison of cases and members of a control group 10 to 15 years of age. SUBJECTS AND METHODS: Offspring were recruited from patient lists of area physicians. Members of the control group were recruited from area schools. Body mass (kg/m2), serum lipids, lipoproteins, apolipoproteins, estradiol, and free testosterone were measured. RESULTS: Differences in age were not significant, but offspring were taller, heavier, and more mature. Offspring had higher total and low density lipoprotein cholesterol. Offspring had lower estradiol levels in early puberty but higher levels in late puberty. With family history and body mass in the regression models for lipid parameters, free testosterone was a significant explanatory factor for total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein, and estradiol was a significant predictor for apolipoprotein B. The percent of the variance in the lipid parameters explained by testosterone and estradiol was small. CONCLUSION: Sex hormone concentrations appear to be modest but significant predictors of lipoprotein and apolipoprotein concentrations in offspring and a control group in cross-sectional analysis. After controlling for pubertal maturation, hormone and lipid concentrations differed in offspring and the control group.