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Age at menarche and cardiovascular health: results from the NHANES 1999-2016

Zheng, Yi MPH1; Wen, Tony S. MD2; Shen, Yun MPH3; Hu, Hui PhD1

Author Information
doi: 10.1097/GME.0000000000001653

Abstract

Cardiovascular disease (CVD) is the leading cause of death both nationwide and worldwide, accounting for one-fifth of women's deaths in the US in 2017.1 Efforts for CVD prevention usually focus on optimizing the outcome of classical health factors such as hypertension and diabetes. The American Heart Association (AHA) proposed the concept, cardiovascular health (CVH), to reframe the focus from the disease to health. Life's Simple 7 (LS7) was then developed as a tool to characterize CVH,2 which contains three health factors including blood pressure, total cholesterol, and glucose, and four behavioral factors including cigarette smoking, body mass index (BMI), physical activity, and diet. The more ideal metrics an individual possesses lead to a more favorable CVH. To date, the lifestyle factors incorporated by LS7 have been associated with CVD risk,3,4 and life expectancies,5 and ideal CVH has been associated with a lower risk of CVD,6,7 as well as other outcomes such as cancer,8 cognitive impairment,9 and depression.10 Currently, ideal CVH is estimated to be prevalent among 50% of the US population at 10 years of age and declines to less than 10% by 50 years of age.11,12 Thus, decelerating the loss of ideal CVH before middle age is the key to achieve the goal of “50×50×50,”13 a new strategy proposed by AHA targeting on “≥50% segments of the population ≤50 years old by 2050 or sooner.”

Early menarche is generally defined as the occurrence of the first menstruation before 12 years old.14 It is widely acknowledged that many CVDs have their origins during childhood.2 Previous studies have associated early menarche with CVD15-18 and individual CVH metrics such as hypertension,19 diabetes,20 and obesity21,22 in the general population. However, to our knowledge, only one study has examined the association between age at menarche and overall CVH. Cao et al23 found that early menarche is associated with worse CVH among postmenopausal women. However, several limitations exist in this study,23 including the use of a convenience sample and the focus on only postmenopausal women. To address these limitations, in this study, we aim to investigate whether age at menarche is associated with CVH among female adults in the US using nationally representative data from the National Health and Nutrition Examinations Survey (NHANES).

METHODS

Study population

The NHANES collects a wide range of data among a nationally representative sample of noninstitutionalized individuals through interviews, examinations, and laboratory tests in the US using a multistage probability sampling design. We obtained data from the 1999-2016 NHANES to investigate the associations between age at menarche and CVH. Among the 46,726 women in the 1999-2016 NHANES, a total of 20,447 women aged 18 years and older with nonmissing information on age at menarche and ideal CVH were included in this study. Specifically, out of the 20,447 included women, 19,771 (96.7%), 20,438 (99.9%), and 20,024 (97.9%) of them completed interviews on smoking, physical activity, and diet, respectively. A total of 19,987 (97.8%) and 20,230 (98.9%) women completed examinations on blood pressure and BMI, respectively. In addition, a total of 19,643 (96.1%) and 10,405 (50.9%) women completed laboratory tests on total cholesterol and glucose, respectively. A total of 9,406 participants had complete information on all the 7 CVH metrics.

Assessment of CVH

CVH was determined based on LS7,2 which includes the following metrics: blood pressure, glucose, total cholesterol, smoking, body mass index (BMI), physical activity, and diet.

Specifically, systolic (SBP) and diastolic (DBP) blood pressures were measured three times consecutively by certified examiners, with participants having a rest for at least 5 minutes between measurements. The average of all available blood pressure measures for each woman was calculated. Total cholesterol (mg/dL) and glucose (mg/dL) were assessed using fasting blood samples.24 Self-reported history of medications on hypertension, diabetes, and high cholesterol were also obtained to determine whether women received treatments for the conditions above, based on the questions “are you now taking prescribed medicines for high blood pressure/cholesterol/blood sugar.” Cigarette smoking was determined based on self-reports and categorized into three groups: 1) current smoker: smoked at least 100 cigarettes lifetime and currently smoking every day or some days, 2) former smoker: smoked at least 100 cigarettes lifetime but currently not smoking at all and had quit smoking no more than 12 months, and 3) nonsmoker: smoked less than 100 cigarettes or had already quit smoking more than 12 months. BMI (kg/m2) was calculated based on objectively measured weight and height. Physical activity was assessed by self-reported frequency and duration of moderate- and vigorous-intensity recreational activities.25 Total time of physical activity per week was calculated by converting each 1 minute of vigorous activity to 2 minutes of moderate activity. Dietary information was collected by 24-hour dietary recall interviews, and the Food Patterns Equivalents Database26 was used to assess the five dietary goals in LS7, including: 1) ≥ 4.5 cups per day of fruits and vegetables intake, 2) ≥7 oz per week of fish consumption, 3) ≥3 oz per day of whole grains intake, 4) <1,500 mg per day of sodium, and 5) <450 kcal (36 oz) per week of added sugar. A 2,000-kcal diet scale was used to express fruit, vegetables, fish, and whole grains intakes.

Each of the seven CVH metrics was categorized into three levels: poor (0 point), intermediate (1 point), and ideal (2 points) following LS7 (see Table, Supplemental Digital Content 1, http://links.lww.com/MENO/A644). Women with more than four ideal metrics were determined as having ideal CVH.27 For women with complete information on all 7 metrics (n = 9,406), total CVH score was calculated using the weighted sum, ranging from 0 to 14, with higher score indicating better CVH.

Assessment of age at menarche

Participants were asked “how old were you when you had your first menstrual period?” Consistent with previous studies,28,29 we categorized age at menarche into 3 groups: normal (12-13 y old), early (6-11 y old), and late (≥14 y old) menarche. In addition, age at menarche was also treated as a continuous variable in the analyses.

Covariates

Participants’ sociodemographic status was obtained, including age (<25, 25-34, 35-44, 45-54, 55-64, 65-74, and ≥75 y old), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and others), education (< high school, high school or equivalent, some college, college/graduate or above), marital status (never married, married or living with partner, and previously married), family poverty income ratio (PIR: <1, 1-2, and ≥2),30 and birth year (1915-1929, 1930-1939, 1940-1949, 1950-1959, 1960-1969, 1970-1979, 1980-1989, and 1990-1998).

Statistical analysis

Distributions of sociodemographic status were assessed between women with and without ideal CVH. Weighted linear and logistic regression models were performed to investigate the associations between age at menarche and CVH. Three sets of models were used, including unadjusted models, crude-adjusted models controlling for age and race/ethnicity, and fully adjusted models additionally controlling for education, marital status, PIR, and birth year. In addition, for each individual CVH metric, we performed similar analyses to examine its association with age at menarche using unadjusted models, crude-adjusted models controlling for sociodemographic factors, and fully adjusted models additionally controlling for the other six CVH metrics. Furthermore, we assessed the interactions between age at menarche and age as well as race/ethnicity to investigate whether age or race/ethnicity may modify the associations between age at menarche and CVH. Point estimates (beta coefficients for linear models and odds ratios [ORs] for logistic models) and 95% confidence intervals (CIs) were calculated. To account for the complex survey design of the NHANES, an 18-year weight was calculated by dividing the original 2-year weight by 9 for each woman, according to the NHANES analytic guidelines.31 All analyses were conducted using the “survey” package under R 3.5.1 (Vienna, Austria). The study was approved by the Institutional Review Board at the University of Florida (IRB202001477).

RESULTS

Among the 20,447 women included in this study, 2,292 (11.2%) women were identified as having ideal CVH. Among the 9,406 women who had complete information on all the 7 CVH metrics thus allowing for the calculation of CVH score, the average CVH score was 8.21 (95% CI: 8.19-8.25).

Table 1 shows the distribution of sociodemographic characteristics by CVH status. Women with nonideal CVH were more likely to have early menarche (21.6% vs 16.3%) compared with those with ideal CVH. In addition, compared with women with nonideal CVH, those with ideal CVH were younger (<25: 24.2% vs 8.0%, 25-34: 29.8% vs 13.9%, 35-44: 23.7% vs 17.2%), had higher educational levels (college/graduate level education or above: 46.3% vs 21.8%) and higher PIR (PIR≥2: 69.7% vs 56.6%). Furthermore, women with ideal CVH were less likely to be non-Hispanic Blacks (7.0% vs 12.6%) or previously married (8.4% vs 26.7%) than those with nonideal CVH.

TABLE 1 - Sociodemographic characteristics by cardiovascular health (CVH) status and distribution of average CVH score (N = 20,447)
Ideal CVH (n = 2,292) Nonideal CVH (n = 18,155) Total (N = 20,447)
Characteristics n (%) a n (%) a n (%) a
Age at menarche
 Early (<12) 415 (16.3) 3,993 (21.6) 4,408 (20.9)
 Normal (12-13) 1,199 (52.2) 9,089 (52.3) 10,288 (52.3)
 Late (≥14) 678 (31.5) 5,073 (26.1) 5,751 (26.8)
Age (y)
 18-25 699 (24.2) 1,855 (8.0) 2,554 (10.3)
 25-34 691 (29.8) 2,484 (13.9) 3,175 (16.1)
 35-44 472 (23.7) 2,707 (17.2) 3,179 (18.1)
 45-54 235 (14.1) 3,065 (20.8) 3,300 (19.9)
 55-64 97 (4.5) 3,171 (17.4) 3,268 (15.6)
 65-74 65 (2.7) 2,636 (12.8) 2,701 (11.4)
 ≥ 75 33 (1.0) 2,237 (9.9) 2,270 (8.7)
Race/ethnicity
 Non-Hispanic White 1,139 (73.6) 8,034 (69.0) 9,173 (69.6)
 Non-Hispanic Black 314 (7.0) 4,012 (12.6) 4,326 (11.8)
 Hispanic 572 (12.1) 4,981 (12.8) 5,553 (12.7)
 Others 267 (7.4) 1,128 (5.6) 1,395 (5.8)
Education
 Less than high school 215 (6.0) 5,099 (19.3) 5,314 (17.4)
 High school 307 (13.4) 4,164 (24.7) 4,471 (23.1)
 Some college 674 (30.3) 5,226 (32.7) 5,900 (32.4)
 College/Graduate or above 867 (46.3) 3,009 (21.8) 3,876 (25.2)
 Missing 229 (4.1) 657 (1.5) 886 (1.9)
Poverty income ratio
 <1 363 (11.1) 3,932 (15.2) 4,295 (14.7)
 1-2 416 (13.7) 4,664 (21.5) 5,080 (20.5)
 ≥2 1,348 (69.7) 8,058 (56.6) 9,406 (58.4)
 Missing 165 (5.5) 1,501 (6.6) 1,666 (6.5)
Marital status
 Married/living with partner 1,240 (61.1) 9,479 (58.4) 10,719 (58.8)
 Previously married 216 (8.4) 5,523 (26.7) 5,739 (24.2)
 Never married 699 (26.6) 2,681 (13.0) 3,380 (14.9)
 Missing 137 (3.9) 472 (1.9) 609 (2.2)
Birth year
 1915-1929 25 (0.6) 1,252 (5.0) 1,277 (4.4)
 1930-1939 63 (2.0) 2,471 (11.3) 2,534 (10.0)
 1940-1949 82 (4.4) 2,888 (15.4) 2,970 (13.9)
 1950-1959 182 (10.9) 3,049 (20.1) 3,231 (18.8)
 1960-1969 356 (19.4) 2,968 (19.5) 3,324 (19.5)
 1970-1979 614 (27.1) 2,732 (15.0) 3,346 (16.7)
 1980-1989 692 (26.2) 2,160 (10.5) 2,852 (12.6)
 1990-1998 278 (9.3) 635 (3.2) 913 (4.1)
aNumber of participants with weighted percentage.

Table 2 shows the average CVH scores by sociodemographic characteristics. Women with early menarche had lower CVH scores (mean: 7.89, 95% CI: 7.83-7.94), while those with late menarche had higher CVH score (mean: 8.40, 95% CI: 8.35-8.45). Lower CVH scores were also observed among women who were older, less educated, with lower income, and those who were non-Hispanic Black or previously married.

TABLE 2 - Distribution of average cardiovascular health (CVH) score by sociodemographic characteristics (n = 9,406)
Characteristics n Average CVH score a 95% CI a
Total 9,406 8.22 8.19-8.25
Age at menarche
 Early (<12) 1,987 7.89 7.83-7.94
 Normal (12-13) 4,834 8.26 8.22-8.30
 Late (≥14) 2,585 8.40 8.35-8.45
Age
 18-24 984 9.83 9.77-9.89
 25-34 1,629 9.34 9.29-9.40
 35-44 1,496 8.64 8.57-8.70
 45-54 1,536 7.99 7.93-8.06
 55-64 1,529 7.20 7.14-7.26
 65-74 1,237 7.10 7.03-7.16
 ≥ 75 995 7.08 7.01-7.14
Race/ethnicity
 Non-Hispanic White 4,402 8.24 8.20-8.28
 Non-Hispanic Black 1,847 7.68 7.62-7.74
 Hispanic 2,511 8.34 8.30-8.39
 Others 646 8.74 8.64-8.83
Education
 Less than high school 2,417 7.21 7.16-7.25
 High school 2,079 7.58 7.53-7.63
 Some college 2,787 8.23 8.18-8.27
 College/Graduate or above 2,003 9.34 9.29-9.39
 Missing 120 9.97 9.81-10.13
Poverty income ratio
 <1 1,845 7.68 7.63-7.74
 1-2 2,280 7.68 7.63-7.73
 ≥2 4,521 8.53 8.49-8.57
 Missing 760 8.12 8.03-8.21
Marital status
 Married/living with partner 5,175 8.35 8.31-8.38
 Previously married 2,547 7.30 7.26-7.35
 Never married 1,460 8.91 8.84-8.98
 Missing 224 9.57 9.41-9.72
Birth year
 1915-1929 562 7.35 7.27-7.43
 1930-1939 1,144 7.06 7.00-7.12
 1940-1949 1,383 7.35 7.29-7.41
 1950-1959 1,503 7.73 7.67-7.80
 1960-1969 1,549 8.26 8.19-8.32
 1970-1979 1,660 8.98 8.92-9.04
 1980-1989 1,198 9.51 9.45-9.58
 1990-1998 407 9.62 9.52-9.72
aWeighted average CVH score with 95% confidence interval.

Table 3 shows the associations between age at menarche and CVH. In all the three models, significantly lower odds of ideal CVH were observed for women with early menarche (fully adjusted OR: 0.70, 95% CI: 0.60-0.82), and significantly higher odds of ideal CVH were observed for those with late menarche (fully adjusted OR: 1.40, 95% CI: 1.21-1.62). Consistent results were observed when age at menarche was treated as a continuous variable, with each 1-year increase in age at menarche associated with a 17% increase in the odds of having ideal CVH (fully adjusted OR: 1.17, 95% CI: 1.13-1.21). In addition, similar results were observed when analyzing CVH as a continuous outcome. In the fully adjusted model, women with early menarche had lower CVH scores (fully adjusted β: −0.40, 95% CI: −0.55 to −0.25), while women with late menarche had higher CVH scores (fully adjusted β: 0.27, 95% CI: 0.13-0.42). Each 1-year increase in age at menarche was associated with a 0.14 (95% CI: 0.10-0.17) increase in CVH score. Supplemental Digital Content 2, http://links.lww.com/MENO/A645 shows the point estimates and 95% CIs for all the variables in the models.

TABLE 3 - Associations between age at menarche and ideal cardiovascular health (CVH) or CVH score among women in the 1999-2016 National Health and Nutrition Examination Survey
Ideal CVH (n = 20,447)Odds ratio (95% CI) a CVH score (n = 9,406)β (95% CI) a
Age at menarche Unadjusted Crude-adjusted b Fully adjusted c Unadjusted Crude-adjusted b Fully adjusted c
Categorical
 Normal Reference Reference Reference Reference Reference Reference
 Early 0.76 (0.66-0.87) 0.70 (0.61-0.81) 0.70 (0.60-0.82) −0.37 (−0.54 to −0.21) −0.44 (−0.59 to −0.28) −0.40 (−0.55 to −0.25)
 Late 1.21 (1.06-1.38) 1.34 (1.16-1.53) 1.40 (1.22-1.62) 0.14 (−0.04 to 0.31) 0.20 (0.04-0.35) 0.27 (0.13-0.41)
Continuous 1.10 (1.07-1.13) 1.15 (1.12-1.19) 1.17 (1.13-1.21) 0.10 (0.06-0.14) 0.13 (0.09-0.17) 0.14 (0.10-0.17)
aWeighted odds ratio and β coefficient with 95% confidence interval.
bModels adjusted for age, race/ethnicity.
cModels adjusted for age, race/ethnicity, education, poverty income ratio, marital status and birth year.

Table 4 shows the associations between age at menarche and individual CVH metrics. In the fully adjusted models, increases in age at menarche were associated with increases in the odds of having ideal status on smoking (OR: 1.04, 95% CI: 1.00-1.09) and BMI (OR: 1.19, 95% CI: 1.15-1.23) metrics, while no significant associations were observed for the other CVH metrics. When treating age at menarche as a categorical variable, significant associations were found between early menarche and BMI (OR: 0.65, 95% CI: 0.56-0.76) as well as glucose (OR: 0.82, 95%: 0.71-0.96).

TABLE 4 - Associations between age at menarche and each cardiovascular health (CVH) metric among women in the 1999-2016 NHANES
Ideal statusOdds ratio (95% CI) a
CVH metrics Age at menarche n (%) b Unadjusted Crude-adjusted c Fully adjusted d
Blood pressure (n = 19,987) Categorical
 Normal 4,276 (44.4) Reference Reference Reference
 Early 1,872 (43.9) 0.98 (0.89-1.09) 0.84 (0.74-0.95) 0.98 (0.82-1.17)
 Late 2,196 (42.9) 0.94 (0.87-1.02) 1.05 (0.95-1.17) 1.06 (0.90-1.24)
Continuous 8,344 (43.9) 0.98 (0.96-1.01) 1.05 (1.02-1.08) 1.01 (0.97-1.05)
Total cholesterol (n = 19,643) Categorical
 Normal 4,161 (42.4) Reference Reference Reference
 Early 1,860 (43.6) 1.05 (0.95-1.16) 0.94 (0.83-1.05) 1.04 (0.90-1.19)
 Late 2,204 (42.8) 1.02 (0.93-1.11) 1.08 (0.98-1.19) 1.04 (0.91-1.19)
Continuous 8,225 (42.7) 0.99 (0.97-1.01) 1.03 (1.01-1.06) 1.00 (0.97-1.03)
Glucose (n = 10,405) Categorical
 Normal 3,267 (63.6) Reference Reference Reference
 Early 1,290 (59.3) 0.83 (0.73-0.95) 0.76 (0.66-0.88) 0.83 (0.71-0.96)
 Late 1,652 (62.8) 0.97 (0.86-1.08) 1.06 (0.93-1.20) 0.97 (0.85-1.11)
Continuous 6,209 (62.5) 1.02 (0.99-1.06) 1.07 (1.03-1.10) 1.03 (0.99-1.07)
Smoking (n = 19,771) Categorical
 Normal 7,796 (76.4) Reference Reference Reference
 Early 3,191 (74.5) 0.90 (0.81-1.01) 0.95 (0.84-1.08) 0.98 (0.82-1.17)
 Late 4,518 (77.5) 1.07 (0.97-1.18) 1.06 (0.95-1.18) 1.16 (0.99-1.36)
Continuous 15,505 (76.3) 1.04 (1.02-1.07) 1.03 (1.00-1.06) 1.04 (1.00-1.09)
Body mass index (n = 20,230) Categorical
 Normal 2,910 (32.0) Reference Reference Reference
 Early 898 (22.8) 0.63 (0.57-0.69) 0.63 (0.56-0.70) 0.65 (0.56-0.76)
 Late 1,871 (38.6) 1.33 (1.21-1.47) 1.41 (1.28-1.56) 1.42 (1.22-1.65)
Continuous 5,679 (31.8) 1.18 (1.15-1.20) 1.19 (1.17-1.22) 1.18 (1.15-1.22)
Physical activity (n = 20,438) Categorical
 Normal 2,805 (32.2) Reference Reference Reference
 Early 1,176 (30.8) 0.94 (0.85-1.03) 0.94 (0.85-1.04) 0.97 (0.84-1.12)
 Late 1,504 (32.5) 1.02 (0.92-1.11) 1.12 (1.01-1.23) 1.07 (0.93-1.23)
Continuous 5,485 (32.0) 1.01 (0.99-1.03) 1.03 (1.01-1.06) 1.02 (0.99-1.06)
Healthy diet (n = 20,024) Categorical
 Normal 666 (5.7) Reference Reference Reference
 Early 244 (5.3) 0.93 (0.77-1.13) 1.00 (0.82-1.21) 0.98 (0.76-1.26)
 Late 376 (5.4) 0.94 (0.78-1.15) 0.92 (0.75-1.13) 0.74 (0.54-1.04)
Continuous 1,286 (5.6) 1.01 (0.97-1.05) 0.98 (0.93-1.02) 0.95 (0.89-1.01)
NHANES, National Health and Nutrition Examinations Survey.
aWeighted odds ratio with 95% confidence interval.
bNumber of participants with ideal status and its weighted percentage.
cModels adjusted for age, race/ethnicity, education, poverty income ratio, marital status, and birth year.
dModels adjusted for age, race/ethnicity, education, poverty income ratio, marital status, birth year, and the other six CVH metrics.

Potential interactions between age at menarche and age as well as race/ethnicity were also examined. Significant interactions between age at menarche and age were observed. Figure 1 shows the ORs and 95% CIs of the associations between age at menarche and ideal CVH by age groups. Significant associations between late menarche and ideal CVH were observed among those aged 25-34 (OR: 1.63, 95% CI: 1.26-2.10) or 35-44 (OR: 1.74, 95% CI: 1.31-2.30), and significant associations between early menarche and ideal CVH were observed among those aged 25-34 years (OR: 0.72, 95% CI: 0.53-0.97). No statistically significant interaction was found when assessing the interactions between age at menarche and race/ethnicity (see Figure, Supplemental Digital Content 3, http://links.lww.com/MENO/A646) or treating age at menarche as a continuous variable (see Figure, Supplemental Digital Content 4, http://links.lww.com/MENO/A647).

FIG. 1
FIG. 1:
Associations between age at menarche (reference group: normal menarche) and ideal cardiovascular health by age at interview.

DISCUSSION

To our knowledge, this is the first study investigating the associations between age at menarche and CVH using a nationally representative sample. We found that increases in age at menarche are significantly associated with increases in CVH among women. In addition, results from the interaction analyses showed that there are significant age differences in the associations between age at menarche and CVH. Significant associations between age at menarche and ideal CVH were only observed among young women.

The observed association between age at menarche and CVH is consistent with the literature. Previous studies showed that women with early menarche had higher odds of developing CVD, which might be mediated by impaired CVH.15,32 In a study among postmenopausal women in China, Cao et al23 found that early menarche is associated with worse CVH. While we found a similar association between early menarche and CVH, results from our interaction analyses showed that the observed associations between age at menarche and CVH differed by age. We found that age at menarche is predictive of CVH among young women, while the associations are nonsignificant among older women. These findings are consistent with previous studies. Yang et al33 found age differences in the association between age at menarche and CVD risk, with the association being insignificant among older women and positive among the younger. Another study found that the association of later menarche with lower mortality was attenuated by age.34 These findings suggest that age at menarche may become less important over time as a risk factor for CVH as there might be other competing factors among older women which can mitigate the associations. Interestingly, we also found that the protective effects of late menarche on CVH were apparent among women aged 25 to 44 years, while the detrimental effects of early menarche on CVH were only observed among those aged 25-34 years. Further studies are needed to confirm these findings and understand the underlying mechanisms.

Consistent with our findings for individual CVH metrics, early menarche has been associated with increases in BMI and higher incidence of type 2 diabetes in previous studies.20,35,36 Different from previous evidence on the associations between early menarche and other individual CVH metrics,19,37,38 no significant association was found between early menarche and blood pressure or total cholesterol in the fully adjusted model adjusting for both sociodemographic factors and the other six CVH metrics, although early menarche was significantly associated with blood pressure in the crude-adjusted model that only controlled for sociodemographic factors. In addition, smoking, physical activity, and diet were not significantly associated with early menarche in the fully adjusted model. These findings suggested that the associations between early menarche and CVH might be mainly driven by its associations with BMI. Future studies with longitudinal data are warranted to understand the causal relationships between age at menarche and BMI, and whether there exist risk factors that predispose individuals to early menarche and obesity, such as genetic factors39 and childhood lifestyle.40-44

Along with previous evidence linking age at menarche to adverse pregnancy and birth outcomes such as gestational diabetes mellitus28 and preterm birth,15,45 and subsequently increased risk of maternal CVD,15 our findings further highlighted that age at menarche may be used to identify high-risk population and to guide targeted preventions to maintain and improve CVH.46,47

Our study has several strengths. First, we used nationally representative data which ensures the generalizability of the findings. Second, we examined the interactions between age at menarche and age as well as race/ethnicity. The potential age differences in the associations between age at menarche and CVH identified in this study may provide important insights in improving CVH among women. However, several limitations should be noted. First, potential misclassification bias may exist since age at menarche was determined based on self-reports. Second, residual confounding may exist as the NHANES did not collect information on potential confounders such as urbanity. Third, although LS7 has been widely used to measure CVH in the field,2,11 it can only be regarded as a surrogate construct, and future efforts are needed to better characterize CVH. Future studies with longitudinal information are needed to further understand how age at menarche may impact the trajectory of CVH among women.

CONCLUSIONS

We found that age at menarche is associated with CVH among women. We also observed significant age differences, with significant associations observed among women aged 25-44 years. Age at menarche may play an important role in maintaining and improving CVH, especially among young women. Further studies are warranted to confirm these findings in longitudinal settings to better understand how age at menarche may impact CVH trajectory among women.

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Keywords:

Age at menarche; Cardiovascular disease risk factors; Cardiovascular health

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