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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 3  |  Page : 156-161

The impact of obesity and nutrition habits on gynecomastia among Turkish adolescent males


Department of Plastic, Reconstructive and Aesthetic Surgery, Marmara University School of Medicine, Istanbul, Turkey

Date of Submission24-Nov-2020
Date of Acceptance13-Jan-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Melekber Cavus Ozkan
Department of Plastic, Reconstructive and Aesthetic Surgery, Marmara University Medical Faculty, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_118_20

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  Abstract 


Introduction: Gynecomastia (GM) during adolescence is quite common and represents a serious psychological challenge among young males. Obesity is also one of the major public health problems affecting an important proportion of the population. We studied the relationship between nutritional habits, body mass index (BMI), and GM of adolescent males. Materials and Methods: In this study, we report an analysis of the incidence of GM and its relationship with nutrition habits and BMI among 511 randomly selected high-school students between 16 and 18 years of age from schools located in Pendik municipality of Istanbul. Results: We found the incidence of GM of 33.3% (n = 170) in 511 high-school boys of whom 24.8% (n = 127) were classified overweight or obese. Although the mean BMI for the entire group was within the normal range (22.8 ± 4.4), it was significantly higher in boys with GM compared to the boys without GM, 26.8 ± 4.5 vs. 20.7 ± 2.5, respectively (P < 0.001). In addition, boys with stage 2 and higher degree GM had higher BMI compared to those with stage 1 GM, 29.2 ± 4.5 vs. 24.8 ± 3.3, respectively (P < 0.001). We, thereby, observed a clear positive correlation between BMI and GM. Conclusion: GM in high-school boys is closely correlated with overweight and obesity. Precautions should be taken to increase awareness of this global health concern to develop comprehensive public health strategies to improve the prevention and management of obesity and related complications like GM.

Keywords: Adolescent, gynecomastia, nutrition habits, obesity


How to cite this article:
Ozkan MC, Oluklu MT. The impact of obesity and nutrition habits on gynecomastia among Turkish adolescent males. Turk J Plast Surg 2021;29:156-61

How to cite this URL:
Ozkan MC, Oluklu MT. The impact of obesity and nutrition habits on gynecomastia among Turkish adolescent males. Turk J Plast Surg [serial online] 2021 [cited 2021 Sep 17];29:156-61. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/3/156/322671




  Introduction Top


Gynecomastia (GM) is a condition of abnormal development of dense subareolar tissue found in the breast of men. This benign proliferation of mammary glands mostly occurs during times of hormonal imbalance such as birth, puberty, and men older than 50 years. During adolescence, one-half of them experience GM due to hormonal transition and growth changes within the body, with typical onset at 13 and 14 years of age.[1],[2],[3] Within 1–3 years, up to 90% of boys have regression of their abnormal breast enlargement.[4],[5] If the symptoms/signs persist after 3 years or post 18 years of age, GM may be nonphysiologic and further evaluation should be performed.

Although the exact mechanism underlying the development of GM is not well understood yet, an increased estradiol concentration, lagging free testosterone production, and increased tissue sensitivity to normal male levels of estrogen are thought to be the main causes of GM in young boys.[5],[6],[7] Free testosterone levels in boys with GM have also been shown to be lower than those of without GM.[6] The possibility of finding an underlying cause of GM seems to increase with aging. The evidence of a higher prevalence of GM in men with overweight suggests a probable relation between adipose tissue and GM.[8],[9],[10]

Fat tissue leads to increased aromatization, in other words, conversion of androgen precursors to estrogen. Hence, obesity could pose an increased estrogen-to-androgen ratio, and lower free testosterone levels.[11] However, in recent years, there is a growing body of evidence that the adipose tissue-derived hormone, leptin, may influence the pathogenesis of pubertal GM even in nonobese young boys. Leptin was suggested to directly stimulate mammary epithelial cells, promote estrogen secretion by increasing aromatase activity, and/or induce breast tissue sensitivity to estrogen.[12] The prevalence of obesity among young adults and children in Turkey was shown to be increased 11, 6-fold between the periods 1990–1995 and 2011–2015.[13] The food habits of females were better than males; consequently, males were found to be more likely to be obese than females.[14]

The aim of this study was to evaluate whether a relation between GM, obesity, and food habits exists in among high-school boys in among high-school boys in Istanbul/Turkey.


  Materials and Methods Top


A questionnaire-based survey was carried among 511 randomly selected high-school students between 16 and 18 years of age from schools located in Pendik municipality of Istanbul. The study protocol was approved by the Ethical Committee for Clinical Research, Medical Faculty of Marmara University and permissions were obtained from the Directorate of National Education (No. 39090411-44-E.13998704, Dated December 12, 2016) of Istanbul Governorship.

The questionnaire

The school principals, assistant principals, and school counselors were provided information regarding the nature of the investigation and the questionnaire to be used. The permission documents from the Provincial Directorate of National Education and Ethics Committee of Marmara University were submitted. Appropriate periods for implementation of the questionnaire were learned from the school administrations and classrooms were visited while being accompanied by the attendant teacher.

After the information was provided that the study was based on voluntary participation, the nature of the investigation and the questionnaire were explained. Subjects were asked not to write personal or contact information on the questionnaire forms. Furthermore, information was provided that height and weight, as well as male GMgynecomastia assessments, would be performed in a private room allocated by the school administration. Furthermore, it was explained that the data would contribute to scientific literature and could be published in scientific journals.

On the first page of the questionnaire, information on the educational and employment status of the parents was obtained, while the second page included the Adolescent Food Habits Checklist (AFHC).

AFHC was developed by Johnson et al.[15] and the validity and reliability of the Turkish version were shown by Arıkan et al.[16] This is a self-rated questionnaire. The original AFHC consists of 24 items, while the Turkish version includes a total of 19 items for sugar consumption (4 items), fat consumption (6 items), fruit and vegetable consumption (6 items), carbohydrate and fast-food consumption (2 items), and general diet status (1 item), with a total score ranging between 0 and 19. A score of 0 reflects unhealthy eating habits, while the highest possible score of 19 reflects healthiest eating habits.

Examination for gynecomastia

After completion of questionnaires, height and weight measurements and GM assessments were performed among participants showing willingness for the study participation. All assessments for GM were performed by the same plastic surgeon. The breast tissue examination was performed by squeezing the breast tissue behind the nipple-areola complex between the thumb and index finger. A tissue thickness >2 cm was considered to show the presence of GM and recorded according to the GM classification proposed by Simon et al. [Table 1].[17]
Table 1: Simon et al.[17] classification of gynecomastia

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Height and weight measurements were performed using a weighing machine (Çomak, Turkey) with an electronic height measurer. Measurements were performed with the shoes removed, and trousers and underwear on. The chest circumference was measured at the level of the areola and the waist circumference was measured at the level of the umbilicus using a measurement tape.

Participants were excluded if they were on chronic drug treatment, had no development of secondary sex characteristics (body hair, beard, pubic hair, etc.), or had previous breast surgery.

Body mass index

Body mass index (BMI) was calculated on the basis of the formula: BMI = kg/m2. A BMI of <18.5 kg/m2, between 18.5 and 25 kg/m2, between 25 and 30 kg/m2, and >30 kg/m2 was considered to signify underweight, normal, overweight, and obese weight status.

Statistical assessments

The Statistical Package for the Social Sciences (SPSS) for Windows 20 (IBM SPSS Inc., Chicago, IL, USA) was used for statistical evaluations. The normal distribution of the data was examined with Kolmogorov–Smirnov test. Numerical variables with normal distribution were expressed as mean ± standard deviation, while those without normal distribution were expressed as median (minimum, maximum). Categorical variables were described as number and percentage. Numerical variables with normal distribution were compared between the two groups with Student's t-test, while those without normal distribution were compared using Mann–Whitney U test. ANOVA test was used for comparison of numerical variables with normal distribution between three or more groups (with post hoc Bonferroni correction), while Kruskal–Wallis H test was used for those without normal distribution (with post hoc Dun's correction). Categorical data were compared with Chi-square and Fisher's exact Chi-square tests. A P < 0.05 (*) was considered statistically significant.


  Results Top


The overall study population of 511 participants consistent of 84 subjects aged 15 years, 273 subjects aged 16 years, 145 participants aged 17 years, and 9 participants aged 18 years. The AFHC was administered to all study participants. The overall mean BMI was 22.8 ± 4.4 kg/m2, and the distribution of underweight, normal weight, overweight, and obese participants was 13.3% (n = 68), 61.8% (n = 316), 17.2% (n = 88), and 7.6% (n = 39), respectively. GM was identified in 33.3% (n = 170) of the study population, with 17.8% (n = 91), 9.6% (n = 49), 2.9% (n = 15), and 2.9% (n = 15) having Grade 1, 2A, 2B, and 3 GM, respectively. The median AFHC score was 8 (range: 1–19), with 44.6% (n = 146) of the participants having an AFHC score greater than the median [Table 2].
Table 2: Distribution of demographic and clinical findings

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A comparison of those with or without GM showed significantly higher mean waist circumference (91.9 ± 11.9 vs. 75.3 ± 7.8 cm; P < 0.001), mean chest circumference, (97.2 ± 9.6 vs. 84.4 ± 5.9 cm; P < 0.001), BMI (26.8 ± 4.5 vs. 20.7 ± 2.5 kg/m2; P < 0.001), percentage of overweight participants (%41.2 vs. %5.3; P < 0.001), and percentage of obese participants (%21.8 vs. %0.8; P < 0.001). Furthermore, as compared to those without GM, there were more mothers with a university degree among those with GM (6.5% vs. 11.2%, P = 0.001). The median AFHC score (8.5 vs. 7, P = 0.011) was also higher in those with GM than without it. No other associations between the presence of GM and other demographic characteristics could be detected [Table 3].
Table 3: Distribution of demographic and clinical findings according to gynecomastia in adolescents

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  Discussion Top


In the present study, we found the incidence of GM of 33.3% (n = 170) in 511 high-school boys of whom 24.8% (n = 127) were classified overweight or obese. Although in our study, the mean BMI for the entire group was within the normal range (22.8 ± 4.4), it was significantly higher in boys with GM compared to the boys without GM, 26.8 ± 4.5 versus 20.7 ± 2.5 respectively (P < 0.001). In addition, boys with stage 2 and higher degree GM had higher BMI compared to those with stage 1 GM, 29.2 ± 4.5 versus 24.8 ± 3.3 respectively (P < 0.001). We, thereby, observed a clear positive correlation between BMI and GM.

The reported prevalence of GM during puberty ranges from 48% to 69%.[1],[2],[4],[5],[6] In general, roughly, one-half of the adolescents will experience the development of GM. However, recent work by Kumanov et al.[18] in one of the largest cross-sectional studies done on GM to date demonstrated a prevalence of 3.9% of boys between the ages 10–19 years. In a previous study of Neyzi et al.,[19] the prevalence of GM has been reported to be 7% in Turkish schoolboys. This huge reported variance is largely affected by variability in the study population, due to the lack of uniform breast size criteria defined for diagnosis and differences in observer technique.[5],[20] The characteristics of the study population can also influence the prevalence of GM. Because, the incidence of GM typically peaks between the ages of 13 and 14, followed by a decline between the ages in 14 and 19 years old boys.[5],[18] In this present study, the prevalence of GM among high-school boys with a median age of 16 (range 15–18) was 33.3%. We did not find the relation between the age of the participant and the presence of GM. Relatively lower prevalence of GM that we found might be due to the higher median age of the study population compared to the expected peak age of GM among adolescents in the literature.

A rapid increase in the prevalence of obesity among children and adolescents across the world in both developed and developing countries has become an important health issue.[21],[22],[23],[24],[25] According to Alper et al.,[13] who conducted meta-analysis study, the prevalence of obesity among young adults and children increased from 0.6% to 7.3% with an 11-fold increase between the periods 1990–1995 and 2011–2015. Males were more likely to be obese than females. Diabetes, hypertension, and coronary heart disease are well-known long-term complications of obesity and they are correlated with increased morbidity and mortality.[26] Although it is not a life-threatening disorder, GN is another consequence attributed to obesity and overweight. Moreover, men with GM can experience significant psychosocial distress, especially if it occurs in the puberty period.

Although the exact mechanism of GM in pubertal boys has not been clearly elucidated yet, the imbalance between estrogen androgen activity was considered to be the main factor associated with the development of GM.[5],[27] An increase in estradiol concentration, increased breast tissue sensitivity to normal male levels of estrogen and relatively lower free-testosterone levels are possible causes of GM in puberty.[5],[6],[7] Elevated weight due to excessive adipose tissue is also associated with GM which suggested to be due to increased aromatase activity leading to increased conversion of testosterone to estrogen in obese men.[11],[12],[28]

In our study, we also observed a positive correlation between BMI and GM. Although the mean BMI of all participants was within the normal range (22.8 ± 4.4), the mean BMI was significantly higher in boys with GM compared to the boys without GM, 26.8 ± 4.5 versus 20.7 ± 2.5, respectively (P < 0.001). Moreover, boys with stage 2 and higher degree GM had higher BMI compared to those with stage 1 GM, 29.2 ± 4.5 versus 24.8 ± 3.3 respectively (P < 0.001). However, in the literature, there are conflicting data on whether the presence of GM positively correlates with that of obesity. Ersöz et al.[8] demonstrated that a meaningful increase in BMI in the young boys with GM compared with healthy controls (25.2 ± 4.0 vs. 21.5 ± 2.7, P = 0.0001). A study by Georgiadis et al.[29] in which 954 healthy males between the ages of 18–26 years reported that those with GM were significantly more likely to be overweight than those without. In a more recent study from India evaluated clinical profile, biochemical and hormonal parameters in 94 patients who had an onset of GM between age 10 and 20 years. They found that majority of the patients in the idiopathic GM group were obese (63%) and they had an early onset of GM as compared to lean patients (12.5 years vs. 14.9 years).[30]

Contrary to these reports, both Kumanov et al.[18] and Biro et al.[6] reported a negative relationship between GM and BMI. The reasons as to why only subset of boys either obese or not develop GM during the period of puberty are not well understood. No difference in sex hormone levels decreased free-testosterone levels and slightly higher estradiol concentrations have all been reported in boys with GM compared to nonaffected boys. However, apart from altered estrogen-androgen ratio, insulin-like growth factor 1 (IGF-1) levels, growth hormone concentrations, and leptin have also been implicated for the development of GM in the pubertal period.[31],[32],[33],[34],[35] Both growth hormone and IGF-1 are responsible for linear growth and they also stimulate mammary gland proliferation through their receptors located in breast tissue.[35] Leptin receptors have been found on mammary epithelial cells. Its level was found to be significantly higher in healthy, nonobese boys with pubertal GM compared with controls. Leptin is believed to be have a role on the development of pubertal GM by the direct stimulatory effect on breast tissue and by enhancing aromatase activity leading to altered estrogen-androgen ratio, and by amplifying the estrogen signal on breast tissue.[12]

Another aim of our work was to investigate the relationship between food habits, BMI and the possible factors associated with the development of pubertal GM. The food habits via AFHC and degree of family education of the participants were also evaluated to assess whether there was a correlation with the presence of GM. Although it was not statistically significant, we found that boys with GM had a mother's with a lower education degree compared to mothers of normal and lean boys (P = 0.064). However, we observed negative relation between GM and AFHC score among participants. Boys with GM had a higher median AFHC score of 8.5 (range 1–19) compared to the boys without GM who's median AFHC score was 7 (1–17) (P = 0.011). This unexpected result was a bite difficult to explain because AFHC has been studied for the assessment of food habits and its reliability and validity of measure of healthy eating behavior in adolescents were also confirmed.[15] A recent cross-sectional descriptive study aimed to measure the nutrition literacy level and to evaluate food habits using AFHC of randomly selected 276 university students demonstrated that the mean AFHC score acquired by males were 9.26 ± 4.18 and 10.37 ± 3.4 for females being significantly higher than males (P = 0.007). Nutritional literacy scores acquired by females were also significantly higher than males (P < 0.001). As a result, the proportions of individuals with BMI >25 were found to be significantly higher in males (13.05%) as compared to females (5.07%). In this study by Kalkan,[14] 85.1% of the university students were between the age of 18 and 21 years. The median age of 511 high-school boys in our study was 16 (15–18 age) being much younger than those of Kalkan et al. Social circumstances and reservations like being embarrassed with their socioeconomic status or bad food habits may influence the answers of participants, especially if they were at very sensitive age period like puberty. One of the disadvantages of test like AFHC might be being particularly a subjective test that their results entirely depends on the answers of the participants to the questionnaires rather than being an observational data. Another interesting finding of our work, although not statistically significant, was that 51.2% of boys whose mother's education level was primary school or below had GM, whereas 48.8% of boys whose mother's education level was secondary school or above had GM (P = 0.064). There was no relation between father's education degree and GM.


  Conclusion Top


GM in high-school boys is closely correlated with overweight and obesity. Precautions should be taken to increase awareness of this global health concern to develop comprehensive public health strategies to improve the prevention and management of obesity and related complications like GM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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