Adolescents Nutritional Association (Micronutrients) with Menarche: Role of Health Schemes and Services in India

Menarcheal age in adolescent girls marks an important health concern in women's biology. The timing of menarche is an important determinant of Population size, Reproductive health and is an important factor of Health planning. The paper aimed to nd the current mean age at menarche in India and its Nutritional association with micronutrients (given the role of government schemes and services). To ning out about the same the Menarcheal age group of (10-19 years) in India are examined. Binary logistic regression model is used to to estimate the association in the Menarcheal age among the Adolescent using the Comprehensive National Nutritional Survey. The mean age at menarche among adolescents stands at 9.07 years (95% C.I.: 8.990,9.166), including the non menstruating girls within the concerned age group,the mean age was 12.815 years (95% C.I.: 12.837,12.793). Girls with anemia are more likely to have their menarche 0.364 years higher than girls who are non amenic. The mean age at menarche is 0.72 years more likely to occur among those who have multivitamin tables/ syrup. The study concludes that over the time the age at menarche has declined rapidly with economic growth, urbanisation, Improvements in the Nutritional intake ( addition of Micronutrients also seen a contributing factor). The area of concern with regard to Micronutrients supplementation is that, it is done so to provide proper nutritional factors but on the other hand is also causing early Mnearche that most of the Health scientists warned and seen it as a cause for ovarian, breat cancers and other diseases amongst girls in future. Hence its imprtant to keep a proper check on the dietary intake among girls at early stages of life.


Background
Menarcheal age in adolescent girls marks an important health concern in women's biology. It affects the reproductive health of a woman, other physical health problems, and mental health. A de cohort study revealed that early puberty is associated with increased risk of type 2 diabetes and Obesity, NHS cohort study revealed that young age at Menarche is associated with T2DM in adulthood (1).Multiple studies con rmed that early Menarche is a risk indicator for breast cancer. (2). It is not just a physical health concern but also affects socio-economic factors such as Education, Marriage, Early Motherhood, Early pregnancy, and other consequences. Determining age at menarche helps to detect all the possible health and socio-economic factors related to it in women. Women in India have been Regarded as the neglected sex in comparison to men. Gender discrimination plays a major role in terms of health with boys and men given nutritious food than girls. The health consciousness over women's health that has been improving day by day with various health schemes and health programs implemented like Janani Suraksha Yojana Menarche is considered a milestone in women's reproductive life. (16). The timing of menarche is an important determinant of population size, reproductive health and is an important factor of health planning. (17). Menarche is affected by several factors including genetic, race, environmental, nutrition, geographical location, BMI, psychological factors, family size, socioeconomic status, physical stress, socioeconomic status, and more as cited in Tehrani, F.et al (2014) (16). The age at menarche demonstrated a secular declining trend over the past two centuries across the globe as pointed out by Tanner JM (1955) and others as cited in Pathak, Tripathi & Subramanian (2014) (12).
In the 19th century factors that affected menarche particularly were climate, ethnic origin, social status, physical activity, education, sexual stimulation, housing, and health status; and 20th century documented other factors namely the birth, physique, family income, occupation, and education of parents, family size, etc, these new developments in the 20th century is observed due to the dramatic improvement of socioeconomic conditions, general health of the population in the industrialized countries that resulted in the early onset of puberty in children as argued by Karapanou & Papadimitriou (2010) (11). Improvements in living standards, hygiene, nutrition, and healthcare, which are also considered to result in earlier sexual maturation in developing countries. (1). where it was 13.76 years in 2005. (12). A very recent study conducted in Goa witnessed young girls reaching menarche at an early age of 8 and 9 years compared to 12-14 years decades ago. (3) Nutrition as an important lifestyle factor, in the timing of puberty, has been acknowledged increasingly.
"Micronutrients play an important role in the proper growth and development of the human body and its de ciencies affects the health contributing to low productivity and a vicious cycle of malnutrition" (Toteja, 2014). Micronutrients help in the health and development of children and adolescents during their time of growth. Micronutrient de ciency is an important cause of morbidity and mortality, especially in infants and preschool children. The microenvironment de ciency in children and adolescents includes Iron, iodine, vitamin A and Zinc. (MoHFW, 2019). Goyal, Mehta & Kaur (2017) found out through their study conducted in Punjab to nd out the Nutritional status and Menarche in Adolescents of Punjab reveals that menarche is delayed due to undernutrition and as the Nutrition improves, the attainment of menarche is lowered. (13) Several studies conducted before this research tried to nd out the Association of Micronutrients with Puberty in girls have marked signi cant results in other countries excluding India. Villamor and Jansen, (2016) states the Role of iron, zinc, and other micronutrients in reproductive functioning and offering development and estimates the status of these nutrients during childhood may be related to the timing of sexual maturation (22). Further points out about the evolutionary theory that predicts the de ciencies in the nutrients could be related to the delayed onset of sexual maturation on the other hand children having su cient nutrients earlier in life would develop it sooner. Citing the results of various researches in funding the association of Micronutrients reveal: Intake of calcium, magnesium, and phosphorus by girls in the upper median in Iran showed higher odds of experiencing menarche before 12 years of age compared to others.
Swiss girls supplemented with calcium from ages 7.9-8.9 reached menarche earlier than the placebo group.
A positive association between iron intake and age at menarche among 230 girls from the US is observed.
Vitamin A intake was strongly associated with earlier menarche in a study conducted by Maclure.
Studies on Micronutrients reported the intake of Vitamin A, B12, C, and thiamine were related to earlier age at Menarche; Vitamin C intake showed a positive association with Menarche among girls of 10-13 years of age group in Quebec City area as cited in Liu, (2017) (8). Dietary intake of Zinc was associated with earlier menarche in Girls in Britain among 3298 British girls who participated in ALSPAC. (18). One other study conducted in Columbia assessing the status of Micronutrients in middle childhood with their association at an age at menarche revealed that the association of ferritin was stronger in girls aged 9-10 years and HB concentration in middle childhood resulted in early menarche and is opposite in the case of ferritin. (23). Two prospective observational studies in girls have reported a delayed menarcheal age with its association of higher ber intakes in childhood (1).
The prevalence of Anaemia is more than 60% among adolescent girls a study indicates that examined the Prevalence of Anaemia among pregnant women and Adolescent girls. (20). The results revealed that the overall prevalence of Anaemia in adolescent girls was 90.1%, with 7.1% of the population being severely Anemic. Union government. The Comprehensive National Nutritional Survey 2016-2018 survey reveals Female adolescents have a high prevalence of Anemia at 40% than in males having 18%. The survey indicates that Anaemia has decreased steadily over time with an increase in the household wealth in all three age groups (0-5 years) Preschool, (5-14years) school-going/early adolescents, (15-19 years). Anemia has remained a major health issue in India decades for now and continues to be until today. Iron The iron supplementation scheme so far improved the status of Anaemia, reducing 16% from 74.3% among preschool children during 1998-1999 to 58.5% during 2015-2016. In 2013, weekly iron and folic acid supplementation were launched subsequently to reduce Nutritional Anaemia among adolescents covering the age group of 6 months to women of reproductive age. (4).
With the iron supplementations programs, successfully the rate of Anaemia has come down but surprisingly risks of other micronutrient de ciencies detected caught attention. Gonmei & Toteja (2018) (4) shows a recent study conducted in Telangana among women aged 15-35years lower prevalence of Anaemia to be 28.4%, other hand prevalence of other micronutrient de ciencies reported as 46.3% ferritin de ciency, folate to be 56.8%, Vitamin B12 to be 44%, etc. which shows the need for policies and schemes to also direct the provisions to reduce other micronutrient de ciencies.
The existing literature suggests that there is an association of Micronutrients and Menarche proved by studies taken place in different countries but in India, since micronutrient supplementation to adolescent girls had begun only in 2013 in India, an all India pooled research related to micronutrition and its association with menarche has not been studded yet, whereas this was not the case with other countries like Korea, US, Mexico unlike in India, the micronutrient supplementation programs had begun in late 19th century. The strength of the current research study is assessing the role of micronutrients concerning Menarche for the Indian adolescent population belonging to the age group 10-19. The age group marks important criteria for the study since 10-19 represents the younger population and recent developments can be observed, 15-45 or other age groups that capture all menstruating women do not yield beer results for the study since it coincides with the generational gap and a wide range of factors like In uence of Marriage and other socio-economic factors.

Methods
The cross-sectional data for the present study comes from the Comprehensive National Nutritional Survey (2016-18) which was conducted under the Ministry of Health and Family Welfare (MoHFW), Government of India in collaboration with the United Nations Children's Fund (UNICEF). The CNNS is nationally representative of a multi-stage survey which is also considered as the largest micronutrient survey where 11,2316 children and adolescents were interviewed and 51,029 blood and stool samples were drawn across 30 states and union territories. 35,830 Out of the total 112,316 are from 10-19 age groups. It provides various dimensions of nutrition including Anemia and hemoglobinopathies, In ammatory biomarkers, Protein, Micronutrients, Non-communicable diseases, and socio-economic and demographic dimensions as well. The survey questionnaire was translated into 20 state-speci c Indian languages and administered through trained local eld interviewers.
The CNNS asked all the girls in-between the age group 10-19, 'At what age have you had your rst menstrual period?' during the face-to-face interview with the presence of a parent or guardian. Out of a total 35,830 respondents, about 23,510 girls (66%) have yet to get their menarche. Hence the nal analytical sample was reduced to 12,320 girls between the ages 10-19.
Outcome variable: for the present study, the age at which the subject has got her rst period is considered as a dependent variable as the questionnaire has asked to report about the age at menarche.
Exposure variables: In this study, a set of demographics, socioeconomic, micronutrient as well as anemia has been used for analysis. The mean age of menarche has been calculated for two groups. Since our data set consists of 10-19 adolescent girls, many girls have not got their period till the date of the interview. We used bivariate analysis to present the age at menarche for different regions and salient socioeconomic, demographic, anemia, and micronutrients among girl children during the study period. We have used One-way analysis of variance (ANOVA) to test the statistical differences in age at menarche across different risk factors. To nd the possible association between anemia, and micronutrients, we have categorized our dependent variable into dichotomous. By using logistic The above model is used for the bivariate logistic regression and multivariate logistic regression. Considering the place of resident, the mean age is higher in urban in the inclusion of those who did not get menarche but in case of exclusion, rural people are showing higher results. In case of caste, 'SC' showing the higher result for the former one and in the later one 'other' showing the higher value. For religion 'Sikh' is showing higher value in both the cases. In wealth index, 'poorest' shows the lowest value in former one and 'richest' shows the lower value in later one.

Results
The result regarding the geographical region re ects variation in the contribution of mean age at menarche for both including and excluding girls who did not get their period at the time of survey. In case of inclusion Jammu and Kashmir got the highest and Nagaland got the lowest age at menarche. Exclusion shows that Gujarat has the highest value and Assam has the lowest age at menarche.  3 shows the signi cance among the micronutrients and the mean age at menarche. Girls with anaemia are more likely to have their menarche 0.364 years higher than those girls who don't have anaemia. Zinc de cient plays a highly signi cant role in menarche. Girls without iron de ciency are likely to have 0.668 years less than those who have iron de ciency. Table no. 4 re ects that in both cases, the mean age at menarche is greater for those who did not consume multivitamin as compare to those consume. The mean age at menarche has been found to be 8.3 years in case of Consumption of iron and folic supplement with the inclusion and 12.7 years in case of exclusion.

Discussion
There are some limitations that need to be considered while interpreting the results. The present study gives the cross-sectional nature of the data, we could not identify any causal relationship between outcome and exposure variables. Rather, we only identify the association between the micronutrients and presence of anaemia with the menarche age of adolescent girls.
The study is based on the retrospective or recall method for the measurement of menarche age. There are some studies which criticize the recall method for over-reporting the menarche age, while certain studies have accused it of under-reporting the menarche age. Some have compared recall data with other sources of information and noted that the recall method provides fairly consistent estimates.
Sampling and sample size was designed to present results at the state level. The analysis below the state level will not be statistically representative. Disaggregated analysis, at the state level, cannot be done due to limitations in sample size. Therefore, we suggest that further studies take up the longitudinal surveys to evaluate the present scenario and identify the casual risk factors of menarche age among adolescent girls and adolescent pregnant girls and also to conduct a comparative study in pre-menarche and postmenarche nutrition.

Conclusion
The study concludes that over time the age at menarche has declined rapidly with economic growth, urbanization, Improvements in the Nutritional intake and others. The current mean at menarche stands at 8.2 years for India, which is an alarming factor for future health consequences of adolescent health and other social implications. The study also found that there is a signi cant association of micronutrients and menarche, with girls who are anemic tend to have menarche at 0.36 years later to the non -anemic girls. The government schemes did play a major role in adolescent health in terms of improved nutrition and micronutrient de ciencies where adolescents who are supplemented with idol and folic acid consumption noticed early age at menarche with a mean age at. 8.3 and 12.7 otherwise.
The area of concern here in the case of Micronutrients is that adolescents provided with multivitamins in addition to the dietary regime are seeing early age at recharge and vice versa. Multivitamin supplementation is implemented in the rst place to improve vitamin de ciency but probably because the adolescents are supplemented with more than enough nutrients, the hormones might be kicking in soon causing menarche. Hence, the micronutrients supplementation should be closely Monitored and adolescent health should be the major priority in detecting early Brest cancer symptoms and other possible diseases since girls with early menarche are more prone to health problems. Early menarche is also closely with early marriages, and early reproductive signs, hence, more health and other schemes should target these issues for adolescents for their physical, mental and other issues.
More studies in the eld of science to cater to the preventive measures for possible health risks of adolescents to be conducted. More studies are needed in order to predict which girls may develop metabolic or psychological disturbances due to early menarche and whether they can be bene ted by The new scheme focused on the overall development of the Adolescents in addition the Micronutrients supplementation began. Under the scheme, each AG is given supplementary nutrition of 600 calories, 18-20 grams of protein, and micronutrients. National nutritional Anaemia control program includes the schoolgirls (6-10 years) and adolescents of (11-18) years under the National Rural Health Mission have been included. The review of the scheme revealed that the scheme adhered to the Adolescent girl's Anemia control program. (14). A study was conducted to understand the e cacy not Twice Weekly Iron Supplementation in Anaemic Adolescent Girls by Shoba, S & Sharada. (2003) among 244 subjects revealed that the Haemoglobin level increased steadily in all subjects who are supplemented with iron and folic tablets and as the supplementation period increased. The Programmes have been successful, one of the studies reviewed the SABLA scheme in Bikaner dist. revealed that 73.5% of the girls reported that they are aware of the Adolescent Girl's scheme while 26.5% reported that they were not aware, majority of the respondents are aware of the welfare schemes yet do not have knowledge on how to avail those bene ts. Although awareness is present, the functioning of the scheme noticed certain backdrops, the problem of irregular supply of food of 12%, irregular supply of drugs 12%. A study conducted by Joshi, M & Gumashta, R. 2013 (6) assessing the weekly iron folate supplementation in Adolescent girls reveals that the overall prevalence of Anemia was brought down by 25% in the 'Daily Iron Folic Acid Supplementation' group after the supplementation for nearly 3 months while it was brought down by 31.67% in the group provided with weekly supplementation.

Declarations
Ethics approval and consent to participate (Not Applicable)

Consent for publication (Not Applicable)
Availability of data and materials: The datasets generated and/or analysed during the current study is publically available only on request.

Funding (Not applicable)
Authors' contribution: Aparna and I wrote the main manuscript text. Shriya edited the manuscript. I participated in the data analysis. All the authors reviewed the manuscript.