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ADULT ANTHROPOMETRIC MEASURES AND SOCIODEMOGRAPHIC FACTORS INFLUENCING AGE AT MENARCHE OF UNIVERSITY STUDENTS IN MALAYSIA
MD. GOLAM HOSSAIN, AISZE WEE, MAEIRAH ASHAIE and T. KAMARUL
Journal of Biosocial Science / FirstView Article / March 2013, pp 1 13DOI: 10.1017/S0021932013000060, Published online: 12 March 2013
Link to this article: http://journals.cambridge.org/abstract_S0021932013000060
How to cite this article:MD. GOLAM HOSSAIN, AISZE WEE, MAEIRAH ASHAIE and T. KAMARUL ADULT ANTHROPOMETRIC MEASURES AND SOCIODEMOGRAPHIC FACTORS INFLUENCING AGE AT MENARCHE OF UNIVERSITY STUDENTS IN MALAYSIA. Journal of Biosocial Science, Available on CJO 2013 doi:10.1017/S0021932013000060
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J. Biosoc. Sci., page 1 of 13, 6 Cambridge University Press, 2013doi:10.1017/S0021932013000060
ADULT ANTHROPOMETRIC MEASURES ANDSOCIO-DEMOGRAPHIC FACTORS INFLUENCING
AGE AT MENARCHE OF UNIVERSITYSTUDENTS IN MALAYSIA
MD. GOLAM HOSSAIN*1, AI-SZE WEE†, MAEIRAH ASHAIE† and
T. KAMARUL†
*Department of Statistics, University of Rajshahi, Bangladesh and †National Orthopaedic
Centre of Excellence for Research and Learning (NOCERAL), Department of
Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
Summary. Early onset of menarche has been shown to be associated with
breast cancer and ischaemic heart disease. Studies on age at menarche of the
Malaysian population are poorly documented. This study aimed to determine
the influence of anthropometric and socio-demographic factors on the age at
menarche of university students in Malaysia. Data were obtained in 2010–11from 961 students between the ages of 18 and 25 years from the University of
Malaya using stratified sampling, and multiple regression analysis was applied.
Sixty-three per cent of students reached menarche at the age of 12 or 13 years,
with the mean and median of age at menarche being 12.45e 1.17 and 12.01
years, respectively. Menarcheal age was positively associated with height
( p < 0.05) and negatively associated with BMI ( p < 0.001). Students from
urban areas attained menarche earlier than those from rural areas ( p < 0.05).
Students from small-sized families attained menarche earlier than those fromlarger families ( p < 0.05). First-born students experienced menarche earlier
than those who were seventh-born or later. Obese and overweight students
reached menarche earlier than students who were underweight or of normal
weight ( p < 0.01). The variations in age at menarche among the Malaysian
ethnic groups were statistically insignificant. The results suggest that heavier
and first-born students from small families are more likely to attain menarche
earlier than their counterparts.
Introduction
Menarche is the onset of menstruation and is considered to be the central event of
female puberty. Early onset of menarche has been reported to be a positive indicator
of breast cancer (Kelsey, 1993; Kotsopoulos et al., 2005; Shin et al., 2011; Dogan
1
1 Corresponding author. Email: [email protected]
et al., 2011), pelvic inflammatory disease and spontaneous abortion (Helm et al., 1996)
and cardiovascular disease (Cooper et al., 1999; Lakshman et al., 2009). Also, early
menarche may be a risk factor for lower lung function and asthma in adulthood (Macsaliet al., 2011). On the other hand, delayed menarche may be associated with an increased
risk of irregular menstrual cycles and low peak bone mass (Anai et al., 2001).
The age at menarche (menarcheal age) is defined as the occurrence of the first
menstrual cycle. The age at menarche varies from population to population and is
associated with several factors such as anthropometric measures, physiological strength
(ability of a person to exert force on physical objects using muscles), nutritional status,
ethnic group, geographical location, life-style (expressed as both work and leisure
behaviour patterns and activities, attitudes, interests, opinion, values and allocation ofincome of an individual) and other socioeconomic and demographic factors (Shangold
et al., 1989; Georgiadis et al., 1997; Bharati & Bharati, 1998; Laitinen et al., 2001;
Okasha et al., 2001; Padez, 2003; Ersoy et al., 2004; Chavarro et al., 2004; Wronka &
Pawlinska-Chmara, 2005; Gharravi et al., 2008; Hossain et al., 2010; Goon et al.,
2010; Cho et al., 2010; Adali & Koc, 2011). It is apparent that these factors have
undergone drastic changes over time, resulting in alteration in the age of menarche.
This is reflected by the gradual decline in the average age of menarche globally (Zegeye
et al., 2009; Cabanes et al., 2009).Okasha et al. (2001) suggested that the relationship between menarcheal age and
adult anthropometric measures may be important in understanding the significance of
the effects of menarcheal age on disease in later life. Special attention should be given
to university female students considering their potential influence on the family and
their contribution to the nation’s workforce and productivity. Due to their unique role
in the population, it is therefore important to investigate the relationship between the
age at menarche of university students and their anthropometric measures and socio-
economic and demographic factors.Some researchers have investigated the association of university students’ age at
menarche with anthropometric measures and socio-demographic factors for different
countries (Okasha et al., 2001; Padez, 2003; Chavarro, 2004; Gharravi et al., 2008;
Hossain et al., 2010). The multi-ethnic population of Malaysia, consisting mainly of
Malays, Chinese and Indians, is ideal to reflect the centralized geographical location
between the Far East and the Indian Peninsula. However, studies on this have not been
well documented and analysed (Tan et al., 1983; Lee et al., 2006). The aim of the present
study was to look at the association between age at menarche of university students inMalaysia and their anthropometric measures and socio-demographics profiles.
Methods
A total number of 961 healthy university female students were enrolled in the present
study. The participants were Malaysian citizens and aged from 18 to 25 years. The
samples were collected from the student’s residing hall of the University of Malaya,
Malaysia, from July 2010 to April 2011 using stratified random sampling with a pro-portional allocation technique.
The University of Malaya, being one of the largest universities in Malaysia, was a
good site to conduct this study since the students were of multi-ethnicity and originated
Md. G. Hossain et al.2
from all over the country. In addition, because the university is a government-owned
institution and therefore admissions to any degree course are based on government
agency selection criteria (which are based on pure merit, quota for the underprivilegedetc.), enrolled students represent Malaysian families of varying socioeconomic status.
Thus the study sample was representative of the average young women living in the
country. The subjects were from three major ethnic groups: Malays, 769 (80%); Chinese,
120 (12.5%); and Indians, 72 (7.5%).
The subjects were interviewed by a single interviewer. A standardized questionnaire
was used to collect socioeconomic and demographic information from each subject.
Age at menarche was estimated by the recall method and based on the age at menarche
given by the study subjects. Subjects reported their age at menarche on the basis oftheir last birthday. The same interviewer also took the anthropometric measurements.
Body height was measured as the distance from the highest point of the top of the head
in the mid-sagittal plane to the floor by anthropometer, and body weight was taken
with thin clothing using a weighing scale. Body mass index (BMI) was derived, defined
as the ratio of weight in kilograms to height squared in metres.
Statistical analysis
Descriptive statistics were used to calculate the mean and standard deviations for
age at menarche. The Probit model was used to estimate median age at menarche
(Table 2). Subjects were classified into three main ethnicities: Malays, Chinese and
Indians. Analysis of variance (ANOVA) was used to find the differences in age at
menarche among the ethnicities. The standard assumptions of ANOVA (normality
and homogeneity of group variances) were checked using the normal probability plot
and the Levene test, respectively. The post hoc compression (LSD) test was utilized to find
pair-wise differences among the group’s data.Multiple linear regression analysis was used to find the relationship between age at
menarche and several quantitative and ordinal variables such as height, BMI, parents’
education level and family income, as modelled below:
AAM ¼ b0 þ b1FE þ b2MEþ b3Htþ b4BMIþ b5FIþ e; ð1Þ
where AAM (age at menarche) is the response variable, and FE (father’s education),
ME (mother’s education), Ht (height), BMI (body mass index) and FI (family income)
are predictors.
The estimated regression model was:
AAM^¼ 11:90�0:037 FE�0:066 MEþ 0:014 Ht�0:064 BMI�0:004 FI: ð2Þ
The important assumption of multiple regression analysis is that the predictor variables
must be independent of each other to avoid multicollinearity problems. The multi-collinearity problems that would otherwise result in inaccuracies should first be re-
moved. A statistical tool (Variance Inflation Factors, VIF) can be used to detect the
multicollinearity caused by the predictor variables (Chatterjee & Hadi, 2006). In the
present study, the relationship between the predictor variables was examined using
VIF as follows: (1) if 0 < VIF < 5, there is no evidence of a multicollinearity problem;
Age at menarche in Malaysian university students 3
(2) if 5 a VIF a 10, there is a moderate multicollinearity problem; and (3) if VIF > 10,
there is a serious multicollinearity problem of variables. These showed no multicolli-
nearity problem among predictors (Table 3).To determine the relationship between menarcheal age and body size, the sample
was again subdivided into four groups according to the most widely used categories of
BMI for adults: underweight (BMI a 18.5 kg/m2), normal weight (18.5 < BMI < 25
kg/m2), overweight (25 a BMI < 30 kg/m2) and obese (BMI b 30 kg/m2) (Flegal et al.,
2005; Subramanian et al., 2009).
Finally, Student’s t-test was utilized for comparison of mean values between two
groups: residence (urban and rural), father’s occupation (professional and non-profes-
sional) and mother’s occupation (housewife and employed). Statistical analysis wascarried out using SPSS software (version 15.0). A value of p < 0.05 was regarded as
statistically significant in the analysis.
Results
The age at menarche of 961 healthy university students was investigated in this study.
The range of menarcheal age was 9 to 16 years. Most of the students (91.2%) reached
menarche between 11 and 14 years of age, with more than 63% of the students attain-ing menarche between 12 and 13 years of age. A minority of students (3.8%) experienced
menarche at the early age of between 9 and 10 years. Similarly, only a small number of
students (4.9%) experienced a delayed menarche (between 15 and 16 years) (Table 1).
The average and median age at menarche of university students in Malaysia was
12.45e 1.17 years (95% CI for mean: 12.38–12.53 years) and 12.01 years, respectively.
Individually, Malay female students experienced menarche at 12.45e 1.16 years (95%
CI for mean: 12.37–12.53 years) and a median at 11.99 years. Chinese female students
experienced menarche later than Malays and Indians (12.55e 1.29 years, 95% CIfor mean: 12.32–12.78 years, and median 12.74 years). On the other hand, Indian
female students attained menarche earlier than both Malays and Chinese students
(12.35e 1.19 years, 95% CI for mean: 12.07–12.63 years, and median 11.90 years)
(Table 2).
Table 1. Frequency distribution of age at menarche, Malaysian university students,
2010–11
Age at menarche (years) n %
9 4 0.4
10 33 3.4
11 139 14.5
12 356 37.0
13 257 26.7
14 125 13.0
15 42 4.4
16 5 0.5
Total 961 100.0
Md. G. Hossain et al.4
Analysis of variance (ANOVA)
One-way ANOVA was applied to find the variation of menarcheal age between the
ethnic groups. The normality and homogeneity of the ethnic group were checked using
the normal probability plot and the Levene test prior to the ANOVA analysis. Thenormal probability plot showed that the data followed a normal distribution. The Levene
test showed that the data were homogeneous. Therefore, the data satisfied the standard
assumption of the ANOVA model. The ANOVA results demonstrated that variation
in age at menarche among the ethnic groups was statistically insignificant ( p > 0.05).
Table 2. Descriptive statistics of age at menarche by ethnic group, Malaysian university
students, 2010–11
95% CI
Ethnic group n (%) Mean SD Lower bound Upper bound Min Max Median
Malay 769 (80) 12.45 1.16 12.37 12.53 9 16 11.99
Chinese 120 (12.5) 12.55 1.29 12.32 12.78 10 16 12.74
Indian 72 (7.5) 12.35 1.19 12.07 12.63 9 15 11.90
Total 961 12.45 1.17 12.38 12.53 9 16 12.01
Table 3. Multiple regression analysis of influence of body measurements and socio-
demographic factors on age at menarche, Malaysian university students, 2010–11
95% CI
Variable Coefficient p-value Lower bound Upper bound VIF
Constant 11.90 <0.001 9.569 14.206
Father’s education �0.037 ns �0.194 0.119 1.636
Mother’s education �0.066 ns �0.230 0.097 1.647
Height (cm) 0.014 <0.05 0.007 0.028 1.017
BMI (kg/m2) �0.064 <0.001 �0.088 �0.041 1.012
Family income �0.004 ns �0.108 0.100 1.376
Table 4. Difference in age at menarche by parents’ occupation and residence,
Malaysian university students, 2010–11
n (%) Mean SD Mean difference
Mother’s occupation Housewife 609 (69) 12.49 1.192
Employed 273 (31) 12.40 1.098 0.09
Father’s occupation Professional 433 (49.4) 12.51 1.173
Non-professional 444 (50.6) 12.42 1.185 0.09
Residence Rural 531 (57.3) 12.50 1.160
Urban 396 (42.7) 12.37 1.187 0.13*
**5% level of significance.
Age at menarche in Malaysian university students 5
Multiple regression analysis
The coefficients of the regression model showed that the age at menarche of students
was positively associated with their height ( p < 0.05) and negatively associated with their
BMI ( p < 0.001). There was neither significant association between menarcheal age of
students with their parents’ education nor family income. These results suggest that
heavier female students reached menarche earlier than those who were thinner.
Post hoc compression test
The post hoc compression (LSD) was used to find the pair-wise differences in age atmenarche among the family size (number of sibling groups) and birth order groups.
In this study, 49% of participants came from large families with five or more children
and 2.7% of students were from small families with one or two children. The LSD test
demonstrated that Malaysian university students from large families attained menarche
significantly later (12.54e 1.13 years) than those from smaller families (12.38e 1.13
years, p < 0.05, medium sized family with three or four children; 12.08e 1.13 years,
p < 0.01, small family with one to two children) (Fig. 1). In addition, students who
were born seventh or in later position (birth order) (6.2%) experienced a later menarche(12.88e 1.26 years) than those born in an earlier position (12.47e 1.19 years, p < 0.05,
for fourth to sixth birth order (25.4%); 12.47e 1.21 years, p < 0.05, for second to third
birth order (31.2%); and 12. 43e 1.10 years, p < 0.01, for first-born (37.1%)) (Fig. 1).
The respondents were classified into four groups according to their categorized
BMI. More than 68% of students were of normal weight, 20.1% underweight, 8.5%
overweight and only 3.1% obese. The pattern of age at menarche decreased along
with increased body size (Fig. 2). The LSD test indicated that the age at menarche of
overweight and obese students was significantly earlier than that of underweight and
Fig. 1. Trends in age at menarche with increasing family size and birth order.
Md. G. Hossain et al.6
normal weight students ( p < 0.001). These results suggest that heavier students attained
menarche earlier than thinner students.
The mean values of BMI and age at menarche by ethnic group are depicted graph-
ically in Fig. 3. Age at menarche showed a negative association with BMI by ethnic
Fig. 2. Trends in age at menarche with increasing body size.
Fig. 3. Association between age at menarche and BMI by ethnic group.
Age at menarche in Malaysian university students 7
group. Female Indian students’ BMI values were larger than those of Chinese and
Malays; and they reached menarche earlier. Conversely, Chinese female students reached
menarche later than Indians and Malays and they were thinner (Fig. 3).
Student’s t-test
Student’s t-test was used to test for significant differences in age at menarche between
two groups. It was interesting to note that the mothers of approximately 70% of univer-
sity students in Malaysia were housewives and that 57.3% of students were from rural
areas. Students from urban environments reached menarche earlier ( p < 0.05) than
their counterparts from rural areas. There was no significant relation between parents’occupations and their daughter’s menarcheal age.
Discussion
The data used in this study were collected from female university students covering
three major ethnic groups living in urban and rural areas of Malaysia. Tan et al.
(1983) investigated the association between age at menarche and socioeconomic and
demographic factors of adult females in Peninsular Malaysia. Their data were obtainedfrom the Malaysian Family Life Survey conducted in 1967–77. Their main focus was
on socioeconomic and demographic factors as predictors, and they found that age at
menarche was associated with age at first marriage and age at first birth. More recently,
Lee et al. (2006) studied menstrual disturbance among secondary school girls in Malaysia.
Although previous studies have looked into socioeconomic conditions and their influence
on menarche, as far as the authors of this paper are aware, the present study may be the
first to investigate the association of age at menarche with anthropometric measures and
socio-demographic factors of young females in modern-day Malaysia. Furthermore,while the data obtained during the era when Malaysia was an undeveloped nation may
be valid, the changes in the country’s economic prowess and socio-demographic condi-
tions have had a major impact on Malaysian society, thus rendering previous published
data obsolete.
In the present study, the average age at menarche of Malaysian female students was
found to be 12.45 years, and median 12.01 years. The range of menarcheal age was from
9 to 19 years, and more than 63% of female students reached menarche at between
12 and 13 years of age. This information is relatively consistent with other studies onMalaysian girls. A study on Malaysian adolescent females living in Negeri Sembilan,
Malaysia, reported their average menarcheal age to be 12.3 years (Lee et al., 2006),
close to the value of 12.5 years found for adolescent females in the USA by Anderson
et al. (2003). In other countries, age of menarche has been found to vary slightly: in
Canada, 12.72 years (Al-Sahab et al., 2010); in Portugal, 12.32 years (Padez, 2003); in
Iran, 12.20 years (Gharrravi et al., 2008); and in China, 12.76 years (Song et al., 2011).
Amongst the less developed countries, age of menarche appears to be later than in
Malaysian females: in Indonesia, 12.96 years (Batubara et al., 2010); in Bangladesh,13.12 years (Hossain et al., 2011); in Nigeria, 12.9 years (Lawan et al., 2010) and in
Ethiopia, 15.8 years (Zegeye et al., 2009).
Md. G. Hossain et al.8
The present study found no significant differences between ethnic groups, although
Indian students experienced menarche earlier. The subjects in the present study were
born and grew up in the same environment in Malaysia, in order to fit the hypothesisthat environment is an important factor for age at menarche. The study showed that
Malaysian Chinese females experienced menarche at a similar age (12.55 years) as
Chinese females in China (12.76 years, Song et al., 2011), but Malaysian Indian females
attained menarche earlier (12.35 years) than Indian females in India (12.80 years, Sanyal
& Ray, 2008).
Age at menarche and adult anthropometric measures
The coefficients of regression analysis showed that age at menarche increased with
increased height and decreased BMI, that is, heavier students attained earlier menarche
than thinner students. Also, the post hoc (LSD) test demonstrated that obese and over-
weight students reached menarche earlier than underweight and normal weight students.
Indian students were heavier than Chinese students, and had an earlier menarche (Fig. 3).
Adult body size was the best predictor of early onset of menarche. In a South Asian
study, Hossain et al. (2010) reported that taller and heavier university students in
Bangladesh attained menarche earlier than shorter and thinner females. Similar findingswere found by Ersoy et al. (2004), who reported an inverse relationship between age at
menarche and post-menarcheal weight and BMI of Turkish students. The present results
also corroborate the study of Okasha et al. (2001), who reported that age at menarche
of students at the University of Glasgow was positively associated with height and
negatively associated with weight and BMI. The results of the present study are also in
agreement with that of an Iranian study (Gharravi et al., 2008), which reported that age
at menarche of university students in Iran was positively associated with height.
Age at menarche and socioeconomic status
Regression coefficients in the present study demonstrated that there was no associa-
tion between menarcheal age of university students and their parents’ educational levels
and occupations. To the authors’ knowledge, there have been no comparable studies on
this in Malaysia to date. However, a similar study conducted on female university stu-
dents in Portugal (Padez, 2003) found no association between a student’s age at menarche
and their parents’ educational levels and occupations. However, in a similar study ata Bangladeshi University, the mother’s educational level and occupation (and not the
father’s) was found to have a significant influence on their daughter’s age at menarche
(Hossain et al., 2010). An American study also found that parents’ education was not a
predictor of early age at menarche amongst the American population, either Black or
White (Braithwaite et al., 2009). The present study found that economic status (family
income) did not have a significant effect on age at menarche. This result was in agree-
ment with an Iranian study, which reported that there was no significant difference in
menarche age in the different socioeconomic classes of Iranian university students(Gharravi et al., 2008). Most studies conducted in different nations have found that socio-
economic factors are important predictors of age at menarche. Females from families of
high socioeconomic status attained menarche earlier than those from families with lower
Age at menarche in Malaysian university students 9
socioeconomic status (Tan et al., 1983; Abioye-Kuteyi et al., 1997; Ersoy et al., 2004;
Chavarro et al., 2004; Wronka & Pawlinska, 2005; Wronka, 2010; Hossain et al., 2010).
The present study demonstrated that female university students from urban areas ofMalaysia experienced menarche earlier than those from rural locations. Similar find-
ings have been reported from Portugal (Padez, 2003), Spain (Marrodan et al., 2000),
Bangladesh (Hossain et al., 2010), Iran (Delavar & Hajian-Tilaki, 2008), China (Song
et al., 2011) and Turkey (Adalı & Koc, 2011).
Age at menarche and demographic factors
The present study demonstrated that family size (number of siblings) and birth orderwere important predictors of age at menarche amongst Malaysian female students. Stu-
dents from large families with five or more children attained menarche later than those
from small families. Moreover, students who were born earlier in the family had an
earlier menarche than those who were born in seventh or later position (birth order).
These results are in agreement with the findings of Padez (2003), who reported that
family size and birth order were important indicators for menarcheal age of university
students in Portugal. In addition, Chavarro et al. (2004) reported that age at menarche
was positively associated with family size in a study of students at the National Univer-sity of Colombia, USA. However, Hossain et al. (2010) found that there was no asso-
ciation between age at menarche and family size (number of siblings) and birth order
in Bangladeshi university students. These differences may be reflective of the disparity
in the socioeconomic backgrounds of these two countries. It could be that an increase in
the size of a family may result in lesser appropriation of wealth. However, this does not
explain why similar finding was not found in countries such as Bangladesh.
Conclusion
This study investigated the relationship between age at menarche and some selected
anthropometric measures and socio-demographic factors of 961 healthy university students
in Malaysia. It demonstrated that adult body size is an important indicator of age at
menarche. Also, family size and birth order are equally important demographic predic-
tors of menarcheal age. Other possible influences include birth weight (Silva et al., 2002;
Terry et al., 2009), mother’s BMI (Keim et al., 2009), childhood living conditions (Kac
et al., 2000), food habits in childhood (Windham et al., 2004), physical activity, life-style factors and nutrition (Merzenich et al., 1993), waist circumference and maternal
menarcheal age (Cho et al., 2010). However, bearing in mind that the sample popula-
tion may still be biased due to the demographics of the sample site, more research is
required to further investigate the relationship between age at menarche and anthro-
pometric measures and socio-demographic factors of Malaysians. This may include
recruitment from more universities and various parts of Malaysia.
Acknowledgments
The authors gratefully acknowledge the authority of Students’ Residence Hall (College),
University of Malaya, for giving permission to take data from female students. The
Md. G. Hossain et al.10
research is approved by the ethical committee of the institution. There was no grant,
technical or corporate support for this research project. All authors declared that there
were no conflicts of interests in relation to this study.
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