2.5. Pubertal Maturation

Trained clinicians used both observation and breast palpation to determine pubertal maturation stage at each study visit. Thelarche was defined by the onset of breast development, and pubarche as the first appearance of pubic hair (both sexual maturation rating stage 2, based on Marshall and Tanner criteria) (Marshall and Tanner, 1969). The methods for determining maturation have been defined elsewhere (Biro et al., 2010a). For the structural equation analysis, we considered the ‘puberty’ modifier variable to be present with reaching sexual maturation rating Stage 2 or greater for either thelarche and/or pubarche.