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Life course epidemiology: recognising the importance of puberty
  1. C Mary Schooling
  1. School of Urban Public Health at Hunter College and City University of New York School of Public Health, New York, USA
  1. Correspondence to Professor C Mary Schooling, 2180 Third Avenue, New York, NY 10035, USA; mschooli{at}

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Given the emphasis within the developmental origins of adult health and disease paradigm on the first 1000 days, Viner et al 1 are to be applauded for drawing attention to adolescence as a key developmental stage for brain development, psychosocial development, health behaviour, obesity and mental health, with ramifications throughout the life course. Viner et al 1 also highlight the importance of adolescence as a critical or sensitive period for adult health and disease, including cardiovascular disease and cardiometabolic outcomes, with the risk perhaps mediated by programming of metabolic factors, such as insulin-like growth factor 1, or by obesity.

One further aspect of adolescence that might also deserve mention, concerning major adult chronic diseases, is the peak level of sex hormones achieved in adolescence through pubertal development. Experimental evidence, although not always observational evidence, indicates that oestrogens cause breast cancer and possibly cardiovascular disease but protect against diabetes.2 Similarly, androgens play a role in prostate cancer. More importantly, the cardiovascular risk of testosterone has recently been highlighted by regulators, most recently by the Food and Drug Administration in the United States,3 although testosterone, similar to oestrogen, may also have some positive effects on glucose metabolism,4 perhaps via muscle mass, which provides a sink for glucose disposal. As such, the peak sex hormone levels achieved in late adolescence may well be an additional consideration as regards the role of development during adolescence in adult health. For example, sex differences in key cardiovascular risk factors, such as lower high-density lipoprotein-cholesterol levels in men than those in women, emerge in adolescence and could be relevant to the higher rates of cardiovascular disease in men than in women.5 Moreover, given our biological imperative to get our genes into the next generation, of which chronic disease may just be a byproduct,6 it would seem plausible that adolescents, having survived infancy and childhood, would be designed to be sensitive to environmental factors that promote sexual development and thereby reproductive success.

Specifically, living conditions that allow higher levels of sex hormones in adolescence would be expected to protect against diabetes, but increase vulnerability to hormonally related cancers and, among men, to ischaemic cardiovascular disease.5 Understandably, these adolescent drives and their consequences might be least evident for the commonly studied western population, where reasonably high living standards have been enjoyed for generations and the range of adolescent living conditions is not as wide as in the rest of the world. Nevertheless, relevance to the majority of the global population in low-income and middle-income countries might exist, for example, perhaps contributing to the greater vulnerability to diabetes in populations exposed to very low living standards in adolescence.7 Viner et al have importantly drawn attention to a key developmental stage of which puberty is the central drama. Greater consideration of the role of pubertal development and sex hormones might not only inform interventions in adolescence, for example, development of muscle mass to protect against diabetes, but also provide aetiological clues concerning interventions in adults to tackle leading causes of morbidity and mortality.


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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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