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Are Contact Sports Worth the Risk?
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To the Lakota, and other indigenous people on North America's Great Plains, the bison was an essential part of their culture ( expressed in the quote on the previous page). The bison provided meat for nutrition, a hide for clothing and shelter, bones for tools, and fat for soap. The bison was also central to their religious beliefs. So, when European settlers hunted the bison nearly to extinction, Lakota culture suffered. Culture is central to a society and the identity of its people, as well as its continued existence. Therefore, geographers study culture as a way to understand similarities and differences among societies across the world, and in some cases, to help preserve these societies. Analyzing Culture All of a group's learned behaviors, actions, beliefs, and objects are a part of culture. It is a visible force seen in a group's actions, possessions, and influence on the landscape. For example, in a large city you can see people working in offices, factories, and stores, and living in high-rise apartments or suburban homes. You might observe them attending movies, concerts, or sporting events. Culture is also an invisible force guiding people through shared belief systems, customs, and traditions. Culture is learned, in that it develops through experiences, and not merely transmitted through genetics. For example, many people in the United States have developed a strong sense of competitiveness in school and business, and believe that hard work is a key to success. These types of elements, visible and invisible, are cultural traits. A series of interrelated traits make up a cultural complex, such as the process of steps and acceptable behaviors related to greeting a person in different cultures. A single cultural artifact, such as an automobile, may represent many different values, beliefs, behaviors and traditions and be representative of a cultural complex. Since culture is learned there are many ways that one generation passes its culture to the next. Children and adults learn traits three ways: ⢠imitation, as when learning a language by repeating sounds or behaviors from a person or television ⢠informal instruction, as when a parent reminds a child to say "please" ⢠formal instruction, as when students learn history in school 132 HUMAN GEOGRAPHY: AP" EDITION CULTURAL COMPLEX OF THE AUTOMOBILE The automobile provides much more than just transportation, as it reflects many values that are central to American culture. Origins of Culture The area in which a unique culture or a specific trait develops is a culture hearth. Classical Greece was a culture hearth for democracy more than 2,000 years ago. New York City was a culture hearth for rap music in the 1970s. Geographers study how cultures develop in hearths and diffuse-or spread-to other places. Geographers also study taboos, behaviors heavily discouraged by a culture. For example, many cultures have taboos against eating certain foods, such as pork or insects. What is considered taboo changes over time. In the United States, marriages between Protestants and Catholics were once taboo, but they are not widely opposed now. Traditional, Folk, and Indigenous Cultures With the beginning of the Industrial Revolution in the late 18th century, modern transportation and communication connected people as never before and led to extensive cultural mixing, especially as cities have grown. The world prior to this time was very different; however, remnants of the past are still evident in our modern cultures. Traditional, folk, and indigenous cultures share some important characteristics and are often grouped together, but they do have some subtle differences. Traditional Culture Recently, the meanings of traditional, folk, and indigenous culture have begun to merge, causing geographers to debate when each should be used. Increasingly, the term traditional culture is used to encompass all three cultural designations. All three types share the function of passing down long-held beliefs, values, and practices and are generally resistant to rapid changes in their culture. Folk Culture The beliefs and practices of small, homogenous groups of people, often living in rural areas that are relatively isolated and slow to change, are known as folk cultures. Like all cultures, they demonstrate the diverse ways that people have adapted to a physical environment. For example, people around the world learned to make shelters out of available resources, whether 3.1: INTRODUCTION TO CULTURE 133 it was snow or mud bricks or wood. However, people used similar resources such as wood differently. In Scandinavia, people used trees to build cabins. In the American Midwest, people processed trees into boards, built a frame, and attached the boards to it. Many traits of folk culture continue today. Corn was first grown in Mexico around 10,000 years ago, and it is still grown there today. While many elements of folk culture exist side by side with modern culture, there are people whose societies have changed little, if at all, from long ago. These people practice traditional cultures, those which have not been affected by modern technology or influences. They often live in remote regions, such as some small tribes in the Amazon rainforest, and have scant knowledge of the outside world. As the lines continue blurring between cultural designations, the Amish of Pennsylvania are often referenced as both folk and traditional culture. Indigenous Culture When members of an ethnic group reside in their ancestral lands, and typically possess unique cultural traits, such as speaking their own exclusive language, they are considered an indigenous culture. Some indigenous peoples have been displaced from their native lands, but still practice their indigenous culture. Native Americans in the United States, such as the Navajo, have kept indigenous cultural practices. First Nations of Canada, such as the Inuit, have also retained their indigenous culture. Globalization and Popular Culture As a result of the Industrial Revolution, improvements in transportation and communication have shortened the time required for movement, trade, or other forms of interaction between two places. This development, known as space-time compression (see Topics 1.4 and 3.6), has accelerated culture change around the world. In 1817, a freight shipment from Cincinnati needed 52 days to reach New York City. By 1850, because of canals and railroads, it took half that long. And by 1852, it took only 7 days. Today, an airplane flight takes only a few hours, and digital information takes seconds or less. Similar change has occurred on the global scale. People travel freely across the world in a matter of hours, and communication has advanced to a point where people share information instantaneously across the globe. The increased global interaction has had a profound impact on cultures, from spreading English across the world to instant sharing of news, events and music. Globalization specifically refers to the increased integration of the world economy since the 1970s. The process of intensified interaction among peoples, governments, and companies of different countries around the globe has had profound impacts on culture. The culture of the United States is intertwined with globalization. Through the influence of its corporations, Hollywood movies, and government, the United States exerts widespread influence in other countries. But other countries also shape American culture. For example, in 2019, the National Basketball Association included players from 38 countries or territories. When cultural traits- such as clothing, music, movies, and types of 134 HUMAN GEOGRAPHY: AP. EDITION businesses-spread quickly over a large area and are adopted by various groups, they become part of popular culture. Elements of popular culture often begin in urban areas and diffuse quickly through globalization processes such as the media and Internet. These elements can quickly be adopted worldwide, making them part of global culture. People around the world follow European soccer, Indian Bollywood movies, and Japanese animation known as anime. With people in many nations wearing similar clothes, listening to similar music, and eating similar food, popular cultural traits often promote uniformity in beliefs, values, and the cultural landscape across many places The cultural landscape, also known as the built environment (see Topic 3.2), is the modification of the environment by a group and is a visible reflection of that group's cultural beliefs and values. Traditional Culture to Popular Culture Popular culture emphasizes trying what is new rather than preserving what is traditional. Many people, especially older generations or those who follow a folk culture, openly resist the adoption of popular cultural traits. They do this by preserving traditional languages, religions, values, and foods. While older generations often resist the adoption of popular culture, they seldom are successful in keeping their traditional cultures from changing, especially among the young people of their society. One clash between popular and traditional culture is occurring in Brazil. As the population expands to the interior of the rain forest, many indigenous cultures, like the Yanamamo tribe, have more contact with outside groups. Remaining isolated by the forest is becoming increasingly difficult as many young people from the indigenous cultures become exposed to popular culture and begin to integrate into the larger Brazilian society. As the young people leave their communities, they are more likely to accept popular culture at the expense of their indigenous cultural heritage, which threatens the very existence of their folk culture. Traditional culture typically exhibits horizontal diversity, meaning each traditional culture has its own customs and language that makes it distinct from other culture groups. Yet, people people within each group are usually homogeneous, or very similar to each other. By contrast, popular culture typically exhibits vertical diversity, meaning that modern urban societies are usually heterogeneous, or exhibiting differences, within the society and usually contain numerous multiethnic neighborhoods. However, on a global scale popular cultures are relatively similar with the same type of malls, shops, fast food, and clothing. Urban global culture centers are not identical, yet, global cities often do not have as much horizontal diversity across space as folk cultures. 3.1: INTRODUCTION TO CULTURE 135 COMPARING TRADITIONAL AND POPULAR CULTURE Trait Traditional Culture Popular or Global Culture Society ⢠Rural and isolated location ⢠Urban and connected location ⢠Homogeneous and ⢠Diverse and multiethnic indigenous population population ⢠Most people speak an ⢠Many people speak a global indigenous or ethnic local language such as English or language Arabic ⢠Horizontal diversity ⢠Vertical diversity Social ⢠Emphasis on community and ⢠Emphasis on individualism and Structure conformity making choices ⢠Families live close to each ⢠Dispersed families other ⢠Weakly defined gender roles ⢠Well-defined gender roles Diffusion ⢠Relatively slow and limited ⢠Relatively rapid and extensive ⢠Primarily through relocation ⢠Often hierarchical ⢠Oral traditions and stories ⢠Social media and mass media Buildings and ⢠Materials produced locally, ⢠Materials produced in distant Housing such as stone or grass factories, such as steel or glass ⢠Built by community or owner ⢠Built by a business ⢠Similar style for community ⢠Variety of architectural styles ⢠Different between cultures ⢠Similar between cities ⢠Traditional architecture ⢠Postmodern / contemporary architecture Food ⢠Locally produced ⢠Often imported ⢠Choices limited by tradition ⢠Wide range of choice ⢠Prepared by the family or ⢠Purchased in restaurants community Spatial Focus ⢠Local and regional ⢠National and global Artifacts, Mentifacts, and Sociofacts Whether a cultural attribute is considered traditional, folk, indigenous, or popular in nature, it is valuable to differentiate between elements of culture that can be seen and those that can not. There are artifacts that comprise the material culture, which consists of tangible things, or those that can be experienced by the senses. Art, clothing, food, music, sports, and housing types are all tangible elements of culture. Another element of the study of artifacts is understanding the techniques to use or build a specific artifact. Artifacts can be unique to a particular culture, or can be shared. For example, people of all cultures need to communicate through language, yet there are many groups that possess languages unique to their culture. The ability to read, write and understand the English language is an artifact of importance for much of popular global culture. 136 HUMAN GEOGRAPHY: AP" EDITION Mentifacts comprise a group's nonmaterial culture and consist ofintangible concepts, or those not having a physical presence. Beliefs, values, practices, and aesthetics (pleasing in appearance) determine what a cultural group views as acceptable and desirable. Mentifacts can also be unique or shared. People of many cultures possess an belief in one or many deities, and often the deities are unique to that culture. The belief in a god is a mentifact-the religious building or symbols are artifacts. Cultural groups also possess sociofacts, which are the ways people organize their society and relate to one another. Taken altogether, people tend to see the whole of their culture as greater than the sum of its individual parts. Sociofacts are embodied through families, governments, sports teams, religious organizations, education systems, and other social constructs. As with artifacts and mentifacts, sociofacts may also be unique or similar to other societies. Families are the foundations of most societies, yet what constitutes the structure of a family may vary widely between cultural groups. For example, Western cultures tend to view the nuclear family, consisting of the parents and their children as the basic family unit. By contrast, in many Western African cultures the norm is the extended family, consisting of several generations and other family members such as cousins living under one roof.The outdoor recreation industry represents a new economy. The leaders of this economy will need to have a deep understanding of our local natural resources and integrate the components of innovation, health, and wellness into a vision for what comes next. Everyone wins when you do the right things for the environment, the community, and the venture. We want to offer the young generation a chance to be part of the foundation we are building for adventure tourism in the emirates and the region. Adventure Tourism Is the Fastest-Growing Global Niche. What does this mean? It means that thereâs plenty of room for young experts to enter the field. Itâs not just the "guides" that the adventure tourism industry needs. Itâs everything that goes with it, from adventure tourism accommodations to trip planners, event managers, marketing and finance directors, advertising, public relations, and communications. We want to highlight that adventure tourism requires more than just guides, and various careers within adventure tourism play a big role in attracting high-value customers, supporting local economies, and encouraging sustainable practices. The continued growth of this sector creates net positive impacts not only for tourism, but also for destination economies, their people, and their environment. 1) Understanding Tourism Tourism is one of the worldâs fastest-growing industries and a major foreign exchange and employment generation for many countries. It is one of the most remarkable economic and social phenomena. 2) Understanding Adventure Tourism Adventure tourism is defined as the movement of the people from one to another place outside their comfort zone for exploration or travel to remote areas, exotic and possibly hostile areas. Adventure tourism is a type of tourism in which tourists engage in adventure activities such as trekking, climbing, rafting, scuba diving, or the likes. Adventure tourism gains much of its excitement by allowing the tourist to step outside their comfort zone. This may be from experiencing culture shock or through the performance of acts that required some degree of risk whether real or perceived. It is also about connecting with a new culture or a new landscape and being physically active at the same time. It is not only about being risky or pushing your boundaries. In fact, it is especially important to know and respect your limits while you are in an unfamiliar area. Adventure travel is a leisure activity that takes place in an unusual, exotic, remote, or wilderness destination. It tends to be associated with high levels of activity by the participant, most of it outdoors. Adventure tourists expect to experience various levels of risk, excitement, and tranquillity and be personally tested. In particular, they are explorers of unspoiled, exotic parts of the planet and also seek personal challenges. The main factor distinguishing adventure tourism from all other forms of tourism is the planning and preparation involved. 3) Definitions of Adventure Tourism Adventure tourism is a new concept in the tourism industry. The tourism industry adopted adventure tourism, but there is not any specific definition of adventure tourism. Most commentators concur that adventure tourism is a niche sector of the tourism industry, but there are many other niche sectors in tourism that have the same characteristics that overlap with adventure tourism such as ecotourism, activity tourism, or adventure travel. One of them can confuse. Adventure tourism is a complicated and ambiguous topic. Some important definitions of adventure tourism are as following: A) According to the Adventure Travel Trade Association (ATTA): âadventure tourism is a tourist activity that includes physical activity, cultural exchange, or activities in nature.â B) According to Muller and Cleaver: âAdventure tourism is characterized by its ability to provide the tourist with relatively high levels of sensory stimulation, usually achieved by including physically challenging experiential components with the tourist experience.â C) The Canadian Tourism Commission in 1995 defines adventure tourism as: âan outdoor leisure activity that takes place in an unusual, exotic, remote or wilderness destination, involves some form of unconventional means of transportation, and tends to be associated with low or high levels of activity.â D) According to Sung et al: âadventure tourism is the sum of the phenomena and relationships arising from the interactions of adventure touristic activities with the natural environment away from the participantâs usual place of residence area and containing elements of risk in which the outcome is influenced by the participation, setting, and the organizer of the touristâs experience.â E) According to UNWTO: â adventure tourism can be domestic or international, and like all travel, it must include an overnight stay, but not last longer than one year.â 4) Types of Adventure Tourism Adventure tourism has grown exponentially all over the world in recent years with tourists visiting destinations previously undiscovered. This allows for new destinations to market themselves as truly unique, appealing to those travellers looking for a rare, incomparable experience. Adventure tourism includes various activities like caving, hiking, sailing, trekking, etc. Adventure tourism is categorized into two categories: ⢠Hard Adventure ⢠Soft Adventure Hard Adventure Hard adventure refers to activities with high levels of risk, requiring intense commitment and advanced skills. Hard tourism includes the activities like climbing mountains/rock/ice, trekking, caving, etc. Hard adventure activities are highly risked in nature. Professional guides and advanced levels of skills are required to perform these activities. Many tourists died during climbing mountains, caving every day. Soft Adventure Soft adventure refers to activities with a perceived risk but low levels of risk, requiring minimal commitment and beginner skills; experienced guides lead most of these activities. Soft tourism includes the activities like backpacking, camping, hiking, kayaking, etc. Soft adventure activities are low-risk in nature. Professional guides lead these activities. Soft adventure is a popular category in adventure tourism as it caters to a wider audience. 5) Adventure Tourism Activities Adventure travellers are early adopters by nature, meaning they are generally more willing to try new destinations, activities, and travel products. Popular activities change rapidly, and it seems there is a new twist on an existing sport every year. Some activities have low risk and some have high. Adventure tourism activities are classified into two types: ⢠Hard Adventure Activities ⢠Soft Adventure Activities Hard Adventure Activities Hard adventure activities are highly risky and dangerous in nature. These activities are as the following: ⢠Caving ⢠Mountain Climbing ⢠Rock Climbing ⢠Ice Climbing ⢠Trekking ⢠Sky Diving Soft Adventure Activities These activities are less dangerous and risk as compared to hard adventure activities. These activities are mostly lead by professional guides. An example of these activities are: ⢠Backpacking ⢠Bird watching ⢠Camping ⢠Canoeing ⢠Eco-tourism ⢠Fishing ⢠Hiking ⢠Horseback riding ⢠Hunting ⢠Kayaking/sea/whitewater ⢠Orienteering ⢠Safaris ⢠Scuba Diving ⢠Snorkeling ⢠Skiing ⢠Snowboarding ⢠Surfing Adventure tourism activities sit well with the environment because the natural world provides us with the resources for many of the activities that provide risk, challenge, sensory stimulus, novelty, discovery, and so on. 6) Characteristics and Features of Adventure Tourism The threefold combination of activity, nature, and culture marks adventure travel as an all-around challenge. Some unique characteristics and features of adventure tourism are as the following: ⢠Physical activity, like involving physical exertion or psychomotor skills ⢠Contact with nature, activities bringing contact with the natural world in general, or with specific wildlife ⢠Contact with different cultures, i.e. people, faith, lifestyles ⢠Journeys for example vehicle, animal, or human power ⢠Uncertain outcomes ⢠Danger and risk ⢠Challenges ⢠Anticipated rewards ⢠Novelty ⢠Stimulation and excitement ⢠Exploration and discovery ⢠Contrasting emotions 7) Adventure Tourism Supplier A tourism supply chain is the system of people, products, activities, and materials that get a product or service from its raw state through production and distribution to the consumer. As with any sector, volume discounts drive the mass price point, so major retailers primarily market select trips that sell in high volume. The supply chain for these mass tourism products is often very simple, comprising only transportation and accommodation elements. The adventure tourism supply chain is more complex. Niche products often require specializes in knowledge and operations. Adventure tourismâs supply chain linkages go very deep, and this is one of the key reasons that adventure tourism delivers greater benefits at the local level. Supply chains vary from destination to destination. Without a proper supply chain, the tourism sector cannot survive. Tourism suppliers are the backbone of the tourism industry. Adventure tourism suppliers work at a different, different level like as domestic as well international level. 8) Adventure Tourism Importance and Benefits Adventure tourism is one of the fastest-growing sectors of the tourism sector, attracting high-value customers, supporting local economies, and encouraging sustainable practices. The continued growth of this sector creates net positive impacts not only for tourism, but also for destination economies, their people, and their environment. Some importance and benefits of adventure tourism are: A) Employment Generation Adventure tourism generates jobs. Adventure tourism generates directs jobs to accommodation, transportation sector, and travel agencies or tour operators. Adventure tourism also provides indirect jobs to tourism suppliers. Adventure tourism plays an important role in the generation of employment in the economy. B) Foreign Exchange Adventure tourism attracts foreign tourists on a large scale, as a result, it helps in foreign exchange generation. When tourists travel to another country, they spend a large amount of money on accommodation, transportation, and shopping. Adventure tourism generates foreign exchange and supports the economy of the host country. C) Economy Development Adventure tourism helps in the development of the host countryâs economy. Adventure tourism activities directly support the economy in various forms. The more tourists, the more economic growth. D) Support Local Communities Adventure tourism helps in the development of infrastructure and supports local communities. Adventure tourism activities directly contributed to the local economy of the communities and increase local people's living standards. E) Conservation of Natural Resources Adventure tourism activities are nature-based activities. Leaders in the adventure tourism industry are dedicated to making this tourism segment as sustainable as possible. They help in the conservation of natural resources as well as culture. F) Creating Business Opportunities Adventure tourism activities create new business opportunities. Several companies specialize in helping emerging adventure tourism operators market their products. Each new adventure tourism activity creates a new business opportunity. G) Local and Foreign Investment Adventure tourism creates business opportunities; as a result, it attracts local as well as international investors. Investors invest their money in accommodation, transportation, and travel trade organization. Adventure tourism plays an important role in the economy of the host country. Received: 26 November 2019 Revised: 10 January 2020 Accepted: 19 January 2020 DOI: 10.1111/obr.13005 PEDIATRICS/PHYSIOLOGY Adipokines: A gear shift in puberty DesirĂŠe Nieuwenhuis | NatĂ lia Pujol-Gualdo Amanda J. Kiliaan Department of Anatomy, Radboud university medical center, Donders Institute for Brain, Cognition and Behaviour, Preclinical Imaging Center PRIME, Nijmegen, The Netherlands Correspondence Amanda J. Kiliaan, PhD, Associate Professor, Department of Anatomy, Donders Institute for Brain, Cognition, and Behaviour, Preclinical Imaging Center PRIME, Radboud university medical center, 6500 HB Nijmegen, Geert Grooteplein 21N 6525 EZ Nijmegen, The Netherlands. Email: amanda.kiliaan@radboudumc.nl Funding information Europees Fonds voor Regionale Ontwikkeling (EFRO), Grant/Award Number: BriteN 2016 1 | INTRODUCTION The prevalence of obesity in adolescents and children is increasing in | Ilse A.C. Arnoldussen | Summary In this review, we discuss the role of adipokines in the onset of puberty in children with obesity during adrenarche and gonadarche and provide a clear and detailed overview of the biological processes of two major players, leptin and adiponectin. Adipokines, especially leptin and adiponectin, seem to induce an early onset of puberty in girls and boys with obesity by affecting the hypothalamic-pituitary- gonadal (HPG) axis. Moreover, adipokines and their receptors are expressed in the gonads, suggesting a role in sexual maturation and reproduction. All in all, adipokines may be a clue in understanding mechanisms underlying the onset of puberty in child- hood obesity and puberty onset variability. KEYWORDS adipokines, obesity, puberty 1,2 the age of 5 years were overweight or were with obesity in 2016, and 3 Obesity is defined by an excessive accumulation of white adipose tissue (WAT), and it is often indicated by a body mass index (BMI) 4 above 30. Two main types of adipose tissue were described: WAT and brown adipose tissue (BAT), which differ in morphology and func- 5-7 Ilse A.C. Arnoldussen and Amanda J. Kiliaan contributed equally to this work. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Š 2020 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation Obesity Reviews. 2020;21:e13005. wileyonlinelibrary.com/journal/obr 1 of 10 https://doi.org/10.1111/obr.13005 alarming rates. Specifically, worldwide, 41 million children below this number is expected to increase to 70 million in 2025. obesity is associated with various severe health complications, includ- ing increased risk of diabetes mellitus type 2, hypertension, heart dis- eases, and disturbances in sex hormone levels. 5,6 and mitochondria and plays a role in thermogenesis. Adipocytes in tion. BAT consists of adipocytes containing multiple lipid droplets WAT contain only a few mitochondria and a single lipid droplet. Adipose tissue has several functions including the storage of energy, thermogenesis, and the production and secretion of adipokines Generally, two physiological processes, adrenarche and gonadarche, 11,24 Childhood 5,7,8 a key role in puberty onset. Puberty is known as a period through which the body changes physically, being a physiological process resulting in the maturation of children, i.e. they develop sexual characteristics and obtain reproduc- 9,11 Adipokines are involved in a number of physiological processes including blood pressure, metabo- lism, glucose, and vascular homeostasis and may play amongst others 8-10 (hormones, cytokines, and peptides). tive functions. between obesity and puberty,2,12-23 the biological mechanisms under- lying obesity and puberty onset remain unclear. Hereafter, we review in detail the role of adipokines in the onset of puberty in childhood obesity. Although many studies have shown associations 2 | INITIATION OF PUBERTY PHYSIOLOGICAL PROCESSES IN THE interact to regulate the onset of puberty. During adrenarche, the adrenal cortex secretes steroid hormones (including 2 of 10 NIEUWENHUIS ET AL. androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, and cortisol), insulin-like growth factor, and growth hormone, which contribute to the pubertal insights on new genetic loci (e.g. melanocortin-4 receptor, mitochon- drial carrier 2, and mitogen-activated protein kinase 13) and on sev- eral pathways that regulate the timing of puberty; however, it partly 34 9,24,25 Both adrenarche and gonadarche are involved in the development growth spurt, body odor, skin oiliness, and skeletal maturation. explains puberty timing variation. Thereby, defining the role of 25 adipokines is of importance in elucidating the variability in puberty as the expression of adipokines is sex-specific and is altered with body composition, adiposity, and during growth spurts. Moreover, adipokines and their receptors are expressed in gonads and several brain regions suggesting involvement in the onset of puberty and sex- ual maturation. Lastly, adipokines interfere in processes regulating timing and duration of puberty, for instance in the HPA and HPG axes which are both key players during adrenarche and gonadarche. Involvement of adipokines in the onset of puberty and specifically in individuals with obesity will be further reviewed in the next 2,24 3 | Puberty onset in girls is assessed using different markers, such as thelarche (breast development), menarche (the start of of pubic hair. pituitary-gonadal (HPG) axis is activated,2,26 and several hormones have been identified to participate in the activation of the HPG axis During gonadarche (Figure 1), the hypothalamic- 2,27 Kisspeptin, neurokinin B, and dynorphin are released by specialized including kisspeptin, neurokinin B, dynorphin, leptin, and ghrelin. 28 key regulator of the pulsatile secretion of gonadotropin releasing neurons, the KNDy neurons in the hypothalamus. Kisspeptin is a 29,30 B stimulates, and dynorphin inhibits the release of kisspeptin, which hormone (GnRH) from the hypothalamus. In addition, neurokinin implies that both coordinate a pulsatile release of kisspeptin. 31 Sub- sections. sequently, the activated HPG axis induces the pituitary gland to secrete luteinising hormone (LH) and follicle stimulating hormone (FSH). As a result, gametogenesis occurs, and the gonads will release sex hormones. Consequently, secondary sex characteristics develop including breast development in girls and an increased testicular vol- 2,26,32 is possibly due to differences in levels of body fat, hypothalamic-pitui- THE ONSET OF PUBERTY IN GIRLS ume in boys. The age at puberty onset varies greatly among individuals, which 19 35 menstruation), and pubic hair development. 33 genome-wide association studies have provided important new tary-adrenal (HPA) axis activity, and genetic background. Recent The average age of However, this age differs between cultures and ethnicities, and since 1980, age at menarche is girls at start of menarche is 12.4 years. 36 significantly decreasing. 36-39 F I G U R E 1 Hormonal regulation in the initiation of puberty in boys and girls. The secretion of kisspeptin, neurokinin B, and dynorphin from KNDy neurons initiate the release of gonadotropin releasing hormone (GnRH) from the hypothalamus. This activates the pituitary gland to produce and secrete luteinising hormone (LH) and follicle stimulating hormone (FSH), which in turn stimulate the gonads to produce estrogen and testosterone in girls and boys, respectively 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 3 of 10 T A B L E 1 Summary of included studies Authors Year Country Study Design Primary Outcome Sex Sample Size (n) Age (y) Data Collection Lian et al21 2019 China Cross-sectional Puberty starts earlier in Chinese Han girls with obesity compared with Chinese Han girls with normal weight. Girls 2996 9-19 2012 and 2013 Biro et al12 Lazzeri et al20 2018 USA 2018 Italy Longitudinal Cross-sectional Body mass index had a greater effect on age at menarche than did race and ethnicity. Girls 946 6-16 2004-2014 Li et al23 2018 China Longitudinal For both, boys and girls, a higher BMI (ie, overweight and obese) is associated with earlier onset of puberty Girls Girls Boys Girls 542 Deng et al22 Flom et al15 2017 China Cross-sectional Increased BMI is associated with early timing spermarche and menarche. Boys Girls Girls 1278258 9-15 2005-2012 He et al24 Holmgren et al17 2017 China 2017 Sweden Cross-sectional Longitudinal Onset of puberty is not related to obesity in boys. Boys Boys Girls Girls 782 7-17 972 929 5839 Kelly et al19 2017 UK 2016 Brazil 2016 USA Longitudinal prospective cohort Higher BMI in girls is associated with the onset of menstruation at an earlier age. 11 10-18 11-17 Barcellos Gemelli et al25 Cross-sectional Longitudinal Excess weight is associated with early age of menarche. Girls 727 2014 2003-2009 Glass et al16 Lee et al26 In girls, but not in boys, greater adiposity is associated with the earlier onset of puberty. Boys Girls 135 Cabrera et al27 Leonibus et al14 2014 USA 2013 Italy Cross-sectional Longitudinal Thelarche occurred earlier than recently reported, while age of menarche remained unchanged. Girls 610 3-17.9 2007 2005-2012 Currie et al13 2012 Europe, USA, Canada Cross-sectional Overweight/obesity during childhood predicts the early onset of puberty in girls. Girls 20410 11, 13, 15 2005-2006 2017 USA Prospective birth cohort Overweight/obese status at the age of 7 ye was associated with increased risk of early menarche 788 From birth to menarche occurred Pregnancies 1959-1966 2016 USA Cross-sectional Boys with overweight enter puberty earlier compared with boys with normal weight or obesity, while puberty starts later in boys with obesity compared with boys with normal weight and overweight. Boys 3872 6-16 2005-2010 Overweight during childhood shows a relation with the early onset of puberty in girls. 6535 4259 695 11 15 5.8-12.2 2009/2010 2013/2014 2014-2017 Higher BMI during childhood is associated with early puberty. 2008 and 2009 2000-2002 Obesity during childhood is related to the earlier onset of puberty. Boys Girls 84 123 71 (Continues) 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4 of 10 NIEUWENHUIS ET AL. 3.1 | Fat storage For the initiation of puberty, the timing of stimulation and/or inhibi- tion of different hormones is important, and additionally, a certain amount and distribution of body fat is needed in order to start menar- che, which emphasizes the importance of body fat. From an evolution- ary point of view, body fat increases in mammalian females during puberty onset, and it highlights the need to guarantee a healthy preg- 40 women with anorexia nervosa. particularly body fat localized predominantly on the gluteofemoral fat depots, is profoundly associated with start of menarche, more than nancy, offspring, and maternal survival. fat, sex-hormones, and neuroendocrine alterations can evolve in men- strual dysfunction, for instance, in women with severe obesity or in 41-43 44-46 to gluteofemoral fat depots suggesting that leptin may convey infor- amount of total body fat. mation on body fat distribution to the hypothalamus during puberty. An improper level of body Importantly, body fat distribution, Blood leptin levels are strongly related 45 3.2 | HPG axis The HPG axis is activated by the release of kisspeptin resulting in the release of GnRH from the hypothalamus, and LH and FSH from the pituitary gland. In girls, FSH is involved in the development of the folli- cles in the ovaries, and it promotes the secretion of estrogen. LH stim- ulates the production of androgen hormones and induces ovulation 48 9,47 the release of kisspeptin and neurokinin B, and kisspeptin thereby (Figure 1). The secretion of estrogen has an inhibitory effect on inhibits the GnRH release from the hypothalamus. pattern of GnRH is important for the regulation of the menstrual cycle. This roughly 28-day-cycle comprises several phases, including the follicular phase and luteal phase. During the follicular phase, increasing levels of FSH stimulate the maturation of follicles and the production of estrogen from the ovaries. This in turn inhibits the release of FSH from the pituitary gland. A high level of estrogen will induce the production of LH by the pituitary gland, resulting in ovula- tion. The matured follicle secretes progesterone thereby inhibiting the release of GnRH. When the corpus luteum is demolished, there is less 48 3.3 | Adipokines According to results from studies reported in Table 1, girls with obe- sity enter puberty earlier compared with girls with normal higher leptin concentrations inhibit the intake of food and increases inhibition of GnRH. As a consequence, the cycle will start again. whole process, starting from the activated HPG axis, results in the development of the secondary sex characteristics in girls including 9,47 thelarche and menarche. 13,14,16-23,49-51 weight. these girls might be found in the secretion of adipokines. For instance, leptin is positively associated with the amount of body fat. Generally, energy expenditure. 9,52-54 An explanation for the early onset of puberty in The expression This TABLE 1 (Continued) Authors Year Country Study Design Primary Outcome Sample Sex Size (n) Age (y) Data Collection Herman-Giddens et al28 2012 USA Cross-sectional Observed mean ages of beginning genital and pubic hair growth and early testicular volumes were earlier than in past studies, depending on the characteristic and race/ethnicity. Boys 4131 6-16 2005-2010 Sorensen et al29 Aksglaede et al30 2010 2009 Denmark Denmark Cross-sectional/longitudinal Longitudinal Puberty onset at earlier ages was associated with an increased BMI in boys. Boys 1528 5.8-19.9 1991-1993/2006-2008 1930-1969 Juul et al31 Ribeiro et al32 2007 2006 Denmark Portugal Retrospective cohort Cross-sectional Higher BMI is associated with early voice break. 11-15 10-15 1990-1999 Kaplowitz et al18 Abbreviation: BMI, body mass USA Cross-sectional The early onset of puberty in Caucasian girls is likely related to an increased BMI. 5-12 1992-1993 2001 index. The higher BMI in boys and girls at 7 y of age, the earlier they enter puberty. Boys 21 612 Girls 135 223 Boys 463 Boys 382 Girls 437 Girls 10 750 Early sexual maturation in boys and girls is associated with overweight. 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 5 of 10 Leptin may possibly play a role in adrenarche as its plasma level increases with higher levels of body fat and as it can modulate both girls. 33 ing adrenarche. In coherence, in children with obesity, the androgen These findings suggested that lower reproductive status was associated with higher total adiponectin concentrations and that a higher reproductive status was related to higher HMW adiponectin the HPA and HPG axes. These axes are functionally integrated dur- DHEAS was positively associated with leptin levels. Nevertheless, concentrations in girls. In addition, individuals with obesity often another study showed that enhanced adrenal androgen secretion in girls with premature adrenarche was not explained by leptin or BMI 55 ated with androgen levels in girls ; however, it was not related to levels. and IL-6. TNF-Îą alters, and IL-6 inhibits the expression of 56 8 In addition, the adipokine adiponectin was negatively associ- 57 differences of adiponectin seem to develop during the progression of 56 adiponectin (Figure 2). Thereby, a low level of total adiponectin and/or high levels of inflammatory cytokines in individuals with obe- sity can promote the onset of puberty. Many more adipokines are secreted by WAT including omentin, 52,65-67 9,36,62,68 adrenarche in girls with Prader-Willi syndrome. Interestingly, sex puberty. adrenarche; however, both are not required factors. Thus, leptin and adiponectin might be able to influence In gonadarche, leptin can stimulate the secretion of kisspeptin, and subsequently activation of the HPG axis, which eventually increases the expression of estrogen and androstenedione in the ova- 58 2,60 65-67 The expression of these ries (Figure 2). Ob gene in WAT, resulting in the synthesis and secretion of leptin. Thus, high levels of leptin promote onset of puberty in girls via secre- tion of kisspeptin, and estrogen stimulates leptin secretion addition- ally. Moreover, adiponectin can affect the HPG axis due to the expression of adiponectin receptors in the hypothalamus, pituitary In return, estrogen stimulates the expression of the 59 gland, and gonads. onset as it inhibits the secretion of kisspeptin and GnRH in the hypo- thalamus and the release of GH and LH in the pituitary gland, and 2,60-62 52,60 63 girls with central precocious puberty (CPP). Moreover, total adiponectin had negative correlations with progression of puberty in girls (defined by Tanner stages), whereas HMW adiponectin had FIGURE 2 Adipokinesaffectingthe initiation of puberty in girls. Leptin stimulates the release of kisspeptin in KNDy neurons, which activates the hypothalamus to produce gonadotropin releasing hormone (GnRH). In response to the release of GnRH, the pituitary gland secretes follicle stimulating hormone (FSH) and luteinising hormone (LH), which stimulates the ovaries to release estrogen resulting in the formation of secondary sex characteristics in girls. Estrogen stimulates the production of leptin. Adiponectin inhibits GnRH release resulting in reduced levels of GnRH and thereby a delayed onset of puberty. TNF- Îą and IL-6 inhibit the production of adiponectin and therefore stimulate the onset of puberty In detail, adiponectin is a regulator of puberty thereby inhibiting the onset of puberty (Figure 2). with obesity often have low levels of adiponectin. et al. showed that total adiponectin was significantly lower, whereas high molecular weight (HMW) adiponectin was significantly higher in ment. 55 63 develop a chronic low-grade inflammatory state, which can be indi- cated by a high level of circulating inflammatory cytokines like TNF-Îą 64 Individuals Sitticharoon positive associations with LH levels and the progression of puberty in 63 visfatin, resistin, and chemerin. and visfatin are expressed in the ovaries. adipokines in the ovaries suggests a role within the reproductive sys- tem; however, the exact biological processes have to be examined. Thus, specifically leptin, adiponectin, and inflammatory cytokines pro- duced by WAT could be permissive key players during an early onset of puberty in girls with obesity. As an exception, HMW adiponectin seems to have a stimulatory effect on peripheral repro- ductive function as HMW is not able to cross the blood brain 63 barrier. 4 | Markers that are used to assess puberty onset in boys are THE ONSET OF PUBERTY IN BOYS spermarche, voice break, testicular volume, and pubic hair develop- 35 spermarche develop in the early stages of puberty onset, voice In women, omentin, chemerin, While pubic hair development, larger testicular volume, and 69 testicular volume increases, which occurs at an average age of break usually appears in later stages of puberty. Generally, first 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 6 of 10 NIEUWENHUIS ET AL. 11.9 years, followed by the development of pubic hair at 12.2 years of average, and lastly, boys experience spermarche around an aver- 55 related with leptin levels. Thereby, leptin plausibly has a minor impact in adrenarche in boys. Since leptin receptors are found in the hypothalamus, pituitary gland, and testes, they might be involved in the onset of puberty by affecting the HPG axis during gonadarche. Leptin stimulates the release of kisspeptin and GnRH, and as a consequence, it accelerates the onset of puberty (Table 1, Figure 3). In contrast, adiponectin inhibits the secretion of GnRH, GH, LH, and FSH therewith delaying the onset of puberty. However, adiponectin levels are generally lower in men compared with women and even lower in men with obe- age age of 13.4 years. 70 4.1 | Fat storage Many aspects of the reproductive physiology are energetically demanding,71 and therefore, an adequate energy level is necessary. In boys, a dynamic change in body composition occurs around the age of 10 to 13 years, in which they gain approximately 40% of sity. culating inflammatory cytokines. levels can stimulate the HPG axis and therewith an early onset of puberty in boys. Nevertheless, leptin can inhibit the production of tes- 72 mostly consisting of lean mass, which causes exhaustion of most of fat. Subsequently, a growth spurt follows in which they gain tissue 72 in boys, an adequate amount of body fat is important in the onset of their body fat. These alterations in amount of body fat indicate that 4.2 | Puberty in boys is initiated by the release of kisspeptin. As mentioned before, this activates the HPG axis, resulting in the release of GnRH from the hypothalamus, and consequently the release of LH and FSH 9,74 puberty. tosterone from the testes, to estrogen (Figure 3). of the development of secondary sex characteristics in boys. Additionally, leptin can affect fertility in men as it can modulate the nutritional support of spermatogenesis, and moreover, dysfunction of spermatogenesis is associated with an increased leptin level and 73 58 2,60-62 HPG axis from the pituitary gland (Figure 1). and LH stimulates the secretion of testosterone from the testes, which inhibits the release of kisspeptin from the KNDy neurons and 9,48 in men, the release of kisspeptin is more consistent, causing a con- 29,48 subsequently GnRH from the hypothalamus. receptors expressed on KNDy neurons. In humans, KNDy neurons Contrarily to women, LH-induced testosterone levels lead to the stant release of LH. development of secondary sex characteristics in boys. differences between sexes in kisspeptin release are related to a sex- specific and sex steroid-dependent kisspeptin system as estrogen and progesterone modulate kisspeptin activity through the sex-steroid 48 in the infundibular nucleus are involved in negative and positive sex- 48 tal exposure to sex steroids and result in sex-specific differences in steroid feedbacks. kisspeptin release. These sexual dimorphisms are induced by perina- 75,76 4.3 | Adipokines The association between obesity and puberty onset in boys is rather controversial compared with findings in girls. Most studies reported an early onset of puberty in boys associated with increased ate adipose tissue from actual breast tissue. stages are more difficult to assess than female stages as boys lack a more determined marker such as menarche. Thirdly, puberty onset can be indicated by the activation of the HPG axis, and the presence of these secondary sex characteristics is the result of hormonal 2 14,17,22,23,50,51,77,78 BMI, 20,49 all while others reported no associations at Current markers used 79 16,80 or a delayed onset of puberty (Table 1). The presence of excessive adipose tissue can be involved in puberty onset in boys as the secretion of adipokines can modulate both adrenarche and gonadarche. Leptin can affect adrenarche by modulating both the HPG and HPA axes,33 and moreover, androgen levels were positively 55 nal androgen secretion in boys with premature adrenarche was not associated with plasma leptin levels. Nevertheless, enhanced adre- 9 In more detail, 61,62 adiponectin, and individuals with obesity often have high levels of cir- Moreover, inflammatory cytokines, TNF-Îą, and IL-6, inhibit expression of the leptin receptor in the testis. FSH induces spermatogenesis, too. function and role still have to be examined. 64 High leptin and low adiponectin and fat tissue can convert testosterone Both processes might result in the delay 29,61,79 81,82 In men, other adipokines like chemerin are found in the gonads 65 Thus, particularly high leptin and low adiponectin levels stimulate the HPG axis and thereby accelerate the onset of puberty in boys. Additionally, leptin can dysregulate the development of secondary sex characteristics and spermatogenesis by affecting testosterone levels and nutritional sup- port of spermatogenesis. 5 | LIMITATIONS AND FUTURE RESEARCH DIRECTIONS Even though multiple epidemiological studies have shown the link between puberty onset and obesity, there are some important limita- tions. Firstly, determining both the onset and stage of puberty is rather difficult. For instance, assessing the stage of breast develop- ment in girls with obesity is complicated as clinicians should differenti- 2 changes in response to the activated HPG axis. to determine the onset of puberty refer to secondary sex characteris- tics, such as testicular volume in boys and breast development in girls. A more accurate measurement of puberty onset would be to combine secondary sex characteristics with plasma or serum hormone level measurements such as LH, FSH, adipokines, e.g. leptin. Thereby, differences in puberty measurements could explain variations in the age of puberty onset between boys and girls within different Thereby, resistin is expressed in the testes of rats, but its exact 83 Secondly, male pubertal 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License NIEUWENHUIS ET AL. 7 of 10 FIGURE 3 Adipokines affecting the initiation of puberty in boys. Leptin activates kisspeptin secretion in KNDy neurons, this activates the production of gonadotropin releasing hormone (GnRH) from the hypothalamus. GnRH stimulates the pituitary gland to secrete follicle stimulating hormone (FSH) and luteinising hormone (LH), activating the production of testosterone from the testes allowing the development of secondary sex characteristics. Leptin also inhibits the production of testosterone, which may cause a delayed onset of puberty. Adiponectin inhibits GnRH release. Low levels of adiponectin, as a result of TNF-Îą and IL-6 expression, lead to a reduced inhibition of GnRH. In response to GnRH release, the pituitary gland will secrete FSH and LH, and the testes will produce testosterone resulting in the development of secondary sex characteristics in boys countries, and In addition, the inclusion of a of puberty. ferent time points is complicated, as subjects examined several decades ago presented pronounced differences concerning lifestyle patterns such as nutrition and exercise habits. Lastly, obesity or over- weight is often determined by BMI, a classification based on weight and height measurements. Additionally, it is important that all studies studies or across continents, ethnicities proper age range (8-16 years) is important when assessing the onset (Figure 4). 12-15,17,20-23,49,77-79,84,85 30,47 Furthermore, comparison between studies from dif- 86 Specifically in children, BMI is often dependent on age and growth use the same anthropometric standards and sex-specific cut-offs. 13,14,16-23,49-51,77-80 fat and would represent a more accurate measurement in its regard. Based on this review, several suggestions can be made for further research. Firstly, the roles of adipokines like resistin, chemerin, visfatin, and omentin in puberty onset, fertility, and sexual maturation should be examined in detail. Secondly, future research examining the onset of puberty should combine indicators of puberty onset (e.g. breast development or testicular volume) with plasma or serum hor- mone measurements such as LH, FSH, sex-steroids, adipokines (e.g. spurts. ment in case of growth spurts. distribution of body fat should be taken into account in determining puberty and obesity in children. For instance, the body adiposity index (BAI), which was introduced in 2011 by Bergman et al.,87 uses hip cir- cumference and height in order to estimate the percentage of body 87 Thereby, BMI is a less accurate measure- F I G U R E 4 87,88 Therefore, both percentage and Average age of puberty onset in Europe, China, and the United States according to several studies from Table 1. Age of puberty onset ranges from 8.47 to 13.33 years in girls and from 8.63 leptin), and body fat distribution (e.g. BAI,87 waist-hip ratio's and/or dual-energy X-ray absorptiometry (DXA)2). Additionally, defining con- sistent and general measurements of puberty in both boys and girls, combined with a proper age range (8-16 years), would facilitate the comparisons between different studies and their results. 12-15, 17, 20-23, 25-29, 31 to 13.7 years in boys. included if average age of markers used to assess puberty was not reported. Pink: girls. Blue: boys Studies (Table 1) were not 39, 56 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 8 of 10 NIEUWENHUIS ET AL. 6 | CONCLUSION In conclusion, epidemiological data regarding obesity and puberty onset in girls show similar outcomes as adiposity results in the early onset of puberty in girls. The majority of the studies examining boys with obesity indicate an early onset of puberty, while not all reported an earlier onset of puberty. In detail, high leptin, TNF-Îą, and IL-6 levels combined with low adiponectin levels stimulate the activation of the HPG axis in girls and boys with obesity, and 5, 45, 50, 51 REFERENCES 1. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. May- o Clin Proc. 2017;92(2):251-265. 2. Reinehr T, Roth CL. Is there a causal relationship between obesity and puberty? The Lancet Child & adolescent health. 2019;3(1):44-54. 3. WorldHealthOrganization. Facts and figures on childhood obesity. 2017. 4. Guglielmi V, Sbraccia P. Obesity phenotypes: depot-differences in adipose tissue and their clinical implications. Eat Weight Disord. 2018; 23(1):3-14. 5. Gomez-Hernandez A, Beneit N, Diaz-Castroverde S. Escribano O. 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FUNDING INFORMATION This research was funded by Europees Fonds voor Regionale Ontwikkeling (EFRO), project BriteN 2016. ORCID Ilse A.C. Arnoldussen Amanda J. Kiliaan https://orcid.org/0000-0002-7395-5284 https://orcid.org/0000-0002-2158-6210 13, 14, 16-26, 29-32 Furthermore, several receptors Nevertheless, We conclude Search strategy We searched PubMed for articles published before Novem- ber 15th, 2019 using relevant keywords, including âonset of puberty and adiposity/obesityâ, âonset of pubertyâ, âchildren with obesityâ, âadipose tissueâ, âchildhood obesityâ, âadiposityâ, âobesityâ, âadipokine(s)â, âHPG axisâ, âadipokines ovary/ova- riesâ, or âadipokines testesâ, either alone or in combination. 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Associations between body mass, leptin, IGF-I and circulating adrenal androgens in children with obesity and premature adrenarche. Eur J Endocrinol. 2002;146(4):537-543. 56. BĂśttner A, Jr K, MĂźller G, et al. Gender Differences of adiponectin levels develop during the progression of puberty and are related to serum androgen levels. J Clin Endocrinol Metabol. 2004;89(8):4053- 4061. 57. Unanue N, Bazaes R, IĂąiguez G, Cortes F, Avila A, Mericq V. Adre- narche in Prader-Willi syndrome appears not related to insulin sensi- tivity and serum adiponectin. Horm Res. 2007;67(3):152-158. 58. Michalakis K, Mintziori G, Kaprara A, Tarlatzis BC, Goulis DG. The complex interaction between obesity, metabolic syndrome and repro- ductive axis: a narrative review. Metabolism: clinical and experimental. 2013;62(4):457-478. 59. Machinal-Quelin F, Dieudonne MN, Pecquery R, Leneveu MC, Giudicelli Y. Direct in vitro effects of androgens and estrogens on ob gene expression and leptin secretion in human adipose tissue. Endo- crine. 2002;18(2):179-184. 60. Dobrzyn K, Smolinska N, Kiezun M. Adiponectin: A new regulator of female reproductive system. Int J Endocrinol. 2018;2018:1-12, 7965071. 61. Martin LJ. Implications of adiponectin in linking metabolism to testic- ular function. Endocrine. 2014;46(1):16-28. 62. Mathew H, Castracane VD, Mantzoros C. Adipose tissue and repro- ductive health. Metabolism: clinical and experimental. 2018;86:18-32. 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 10 of 10 NIEUWENHUIS ET AL. 63. Sitticharoon C, Sukharomana M, Likitmaskul S, Churintaraphan M, Maikaew P. Corrigendum to: Increased high molecular weight adiponectin, but decreased total adiponectin and kisspeptin, in central precocious puberty compared with aged-matched prepubertal girls. Reprod Fertil Dev. 2017;29:2506-2517. 64. Das UN. Is obesity an inflammatory condition? Nutrition. 2001; 17(11-12):953-966. 65. Comninos AN, Jayasena CN, Dhillo WS. The relationship between gut and adipose hormones, and reproduction. Hum Reprod Update. 2014; 20(2):153-174. 66. Singh A, Choubey M, Bora P, Krishna A. Adiponectin and chemerin: contrary adipokines in regulating reproduction and metabolic disor- ders. Reproductive sciences (Thousand Oaks, Calif). 2018;25:1462- 1473. 67. Tsatsanis C, Dermitzaki E, Avgoustinaki P, Malliaraki N, Mytaras V, Margioris AN. The impact of adipose tissue-derived factors on the hypothalamic-pituitary-gonadal (HPG) axis. Hormones (Athens). 2015; 14:549-562. 68. Kang MJ, Oh YJ, Shim YS, Baek JW, Yang S. Hwang IT. The usefulness of circulating levels of leptin, kisspeptin, and neurokinin B in obese girls with precocious puberty. 2018;34:627-630. 69. Lee J, Song J, Hootman JM, et al. Obesity and other modifiable fac- tors for physical inactivity measured by accelerometer in adults with knee osteoarthritis: data from the osteoarthritis initiative (OAI). Arthritis Care Res (Hoboken). 2012;53-61. 70. Bramswig J, Dubbers A. Disorders of pubertal development. Deutsches Arzteblatt international. 2009;106:295-303. quiz 04 71. Elias CF, Purohit D. Leptin signaling and circuits in puberty and fertil- ity. Cell Mol Life Sci. 2013;70(5):841-862. 72. Riumallo J, Durnin JV. Changes in body composition in adolescent boys. Eur J Clin Nutr. 1988;42(2):107-112. 73. Siervogel RM, Demerath EW, Schubert C, et al. Puberty and body composition. Horm Res. 2003;60(Suppl 1):36-45. 74. Zhang J. Gong M. Andrologia: Review of the role of leptin in the regu- lation of male reproductive function; 2018. 75. Kauffman AS, Gottsch ML, Roa J, et al. Sexual differentiation of Kiss1 gene expression in the brain of the rat. Endocrinology. 2007;148(4): 1774-1783. 76. Zeydabadi Nejad S, Ramezani Tehrani F, Zadeh-Vakili A. The role of kisspeptin in female reproduction. Int J Endocrinol Metab. 2017;15:1- 11, e44337. 77. Sorensen K, Aksglaede L, Petersen JH, Juul A. Recent changes in pubertal timing in healthy Danish boys: associations with body mass index. J Clin Endocrinol Metab. 2010;95(1):263-270. 78. Juul A, Magnusdottir S, Scheike T, Prytz S, Skakkebaek NE. Age at voice break in Danish boys: effects of pre-pubertal body mass index and secular trend. Int J Androl. 2007;30(6):537-542. 79. Lee JM, Wasserman R, Kaciroti N, et al. Timing of puberty in overweight versus obese boys. Pediatrics. 2016;137(2):137-146, e20150164. 80. He F, Guan P, Liu Q, Crabtree D, Peng L, Wang H. The relationship between obesity and body compositions with respect to the timing of puberty in Chongqing adolescents: a cross-sectional study. BMC Pub- lic Health. 2017;17:664-673. 81. Ishikawa T, Fujioka H, Ishimura T, Takenaka A, Fujisawa M. Expres- sion of leptin and leptin receptor in the testis of fertile and infertile patients. Andrologia. 2007;39(1):22-27. 82. Martins AD, Moreira AC, Sa R, et al. Leptin modulates human Sertoli cells acetate production and glycolytic profile: a novel mechanism of obesity-induced male infertility? Biochim Biophys Acta. 1852;2015: 1824-1832. 83. Morash BA, Willkinson D, Ur E, Wilkinson M. Resistin expression and regulation in mouse pituitary. FEBS Lett. 2002;526(1-3):26-30. 84. Cabrera SM, Bright GM, Frane JW, Blethen SL, Lee PA. Age of thelarche and menarche in contemporary US females: a cross- sectional analysis. Journal of pediatric endocrinology & metabolism: JPEM. 2014;27(1-2):47-51. 85. Herman-Giddens ME, Steffes J, Harris D, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics. 2012;130(5):e1058-e1068. 86. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1-452. 87. Akin I, Tolg R, Hochadel M, et al. No evidence of âobesity paradoxâ after treatment with drug-eluting stents in a routine clinical practice: results from the prospective multicenter German DES.DE (German Drug-Eluting Stent) Registry. JACC Cardiovasc Interv. 2012;5(2): 162-169. 88. Marcovecchio ML, Chiarelli F. Obesity and growth during childhood and puberty. World Rev Nutr Diet. 2013;106:135-141. How to cite this article: Nieuwenhuis D, Pujol-Gualdo N, Arnoldussen IAC, Kiliaan AJ. Adipokines: A gear shift in puberty. Obesity Reviews. 2020;21:e13005. https://doi.org/ 10.1111/obr.13005 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are gover7.017 Fingernail Policy for ASC Personnel with Direct Patient Contact The surgical center applies this policy equitably and inclusively, and management expects staff to do so in good faith. Purpose: To prevent infection by ensuring proper hand and nail hygiene among ASC staff with direct patient contact. Policy: All ASC staff with direct patient contact must maintain clean and well-groomed fingernails and a healthy hand skin condition. Artificial Nails The ASC defines Artificial nails as press-on, extenders, studs, stones, or other objects positioned on top of the natural nail that are elevated and irregular. These are not allowed as they can be a potential source of infection and can also inhibit proper hand hygiene. Nail Enhancements The ASC defines Nail enhancements as nail paint, gel, and shellac. These are allowed, as evidence against them is weak/moderate and inconsistent, as long as they are undamaged, free of chipping, adequately maintained, and do not interfere with proper hand hygiene, job performance, or glove integrity. Staff must ensure that their nails are trimmed, clean, rounded, and at a length that does not inhibit them from performing their duties or putting themselves or their patient at risk for exposure. Staff must wash their hands with soap and water or use an alcohol-based hand rub before and after each patient encounter and after any activity that may contaminate the hands. Staff must report any cuts, sores, or other skin conditions that may prevent them from maintaining proper hand hygiene to the supervisor. Implementation: The infection Control Nurse or designee will educate staff on hand and nail hygiene, proper hand-washing techniques, and alcohol-based rubs. Supervisors will monitor staff compliance with the policy and provide corrective action as needed. The ASC will provide hand hygiene products and education materials for staff. Evaluation: The infection Control Nurse or designee will evaluate the effectiveness of this policy annually and through regular staff education and monitoring of staff compliance. Nurses are reminded of the standards of nursing practice specified in 22 Texas Administrative Code Rule 217.11 (B)(O), which includes Implementing measures to promote a safe environment for clients and others and Implementing measures to prevent exposure to infectious pathogens and communicable conditions. Reference: AORN INC. (2022). Guidelines for perioperative practice.Positive/Negative/Neutral Objects - How are they different? Positive: has fewer electrons than protons Negative: Has more electrons than protons Neutral: has equal numbers of protons and electrons Laws of Electric Charges - What are they? How are they applied? Like charges repel, opposites charges attract, charged AND neutral objects attract Induced Charge Separation - Explain this process. A shift of the position of electrons when a charged object is brought near it. If the charged object is positive, the electrons will move toward it. If the charged object is negative, the electrons will move away from it. Charging by Friction (What is happening with the charges? - Know electrostatic series examples) Process in which objects made from different materials rub against each other, producing a net static charge on each object. When charged by friction, one material will have a stronger attraction to electrons and will pull the electrons off the other material Charging by Conduction (Be able to explain what the electrons are doing) Charging by contact with a charged object. An object that becomes charged by contact always gets the same type of charge that is on the object that charges it. Grounding (Be able to explain how it happens) A method of removing static charges from an object. Electrons from the ground move up to the charged object. If the object is negative, electrons leave the object. If the object is positive, electrons enter the object. The ground always remains neutral Conductors/Insulators/Semiconductors (Know examples for each and characteristics) Conductor: A material that allows electrons to flow through it easily. GOOD CONDUCTORS: Silver, copper, gold, aluminium, magnesium, iron, usually metals Insulator: A material that prevents electrons from flowing through it. Plastic, wood and glass are examples. To prevent electric shocks, conductive wires are wrapped in insulators. Semiconductors: Have special properties that make them fair conductors, they are the foundation of modern electronics, including radios, computers and telephones. Charging by Induction (How do we induce a PERMANENT charge?) You can permanently charge an object using induction by attaching a conducting wire to the neutral object that goes to the ground Electric Discharge - What causes it? Know everyday examples. How is lightning formed? When two objects that have a charge imbalance are brought close together or come in contact with each other, electrons are transferred rapidly. Electrons move from the object with a more negative charge to the object with the less negative charge. Lightning occurs through an imbalance of charge between clouds and the ground. Negative charge at the bottom of a cloud repels the electrons at the earth's surface which move away, causing the ground to become positively charged Current Electricity: Refers to the electrons that flow in a controlled way through a conductor Forms of Current Electricity - Alternating Current (AC) vs Direct Current (DC) - How do they differ? AC: Electrons move back and forth, alternating their direction. produced in generating stations and is then distributed over long distances ex. Something plugged into a wall outletDifferentiate between communicable and chronic diseases. Communicable diseases are spread by pathogens (bacteria, viruses, fungi, and parasites). They may be spread through the air (Hantavirus, tuberculosis), food (salmonella, Ecoli), or water (SARS, polio). Some diseases are spread by insects. The bite of a tick may result in Lyme disease or Rocky Mountain Spotted Fever; mosquitoes spread malaria. The bite of a warm-blooded animal can cause rabies. Some communicable diseases are spread directly from person to person, such as the childhood illnesses: measles, mumps, and chicken pox. Sexually transmitted diseases are passed only through intimate contact. The most common STDs are caused by bacteria (Chlamydia, gonorrhea, syphilis) and viruses (herpes, HIV, human papilloma virus). Methods of preventing communicable diseases include avoiding pathogens, cleanliness, the use of barriers and prophylactics, abstinence from risky behaviors, and staying away from those infected. Chronic diseases involve the degeneration of body organs.Policy for Bloodborne Pathogen Exposure Incident as per OSHA regulation (29 CFR 1910.1030) Purpose: To ensure that ASC staff members are protected against potential exposure to bloodborne pathogens per OSHA regulations (29 CFR 1910.1030). Scope: This policy applies to all ASC staff members who may be exposed to blood or other potentially infectious materials during their duties. Policy: An exposure incident is defined as a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties. Any spill or accident that results in an exposure incident must be immediately reported to the Infection Control Nurse, first-line leader, or another responsible person. The employer shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure and post-exposure evaluation and follow-up to all employees who have had an exposure incident. The employer shall provide a confidential medical evaluation and follow-up for the exposed employee, which shall include at least the following elements: ⢠Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred. ⢠Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law. The source individual's blood shall be tested as soon as feasible and after consent is obtained to determine HBV and HIV infectivity. ⢠Collection and testing of blood for HBV and HIV serological status. ⢠If the employee consents to baseline blood collection but does not consent to HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible ⢠Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service. ⢠Counseling. ⢠Evaluation of reported illnesses. The employer shall ensure that the healthcare professional evaluating an employee after an exposure incident is provided with the following: A copy of OSHA regulation 1910.1030 A description of the exposed employee's duties as they relate to the exposure incident Documentation of the route(s) of exposure and circumstances under which exposure occurred Results of the source individual's blood testing, if available. All medical records are relevant to the appropriate treatment of the employee, including vaccination status, which is the employer's responsibility to maintain. The employer shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation. The healthcare professional's written opinion for Hepatitis B vaccination shall include the following: Whether it is indicated for the employee If the employee has received such a vaccination The healthcare professional's written opinion for post-exposure evaluation and follow-up shall include the following: That the employee has been informed of the results of the evaluation That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment All other findings or diagnoses shall remain confidential and not be included in the written report. An employer must establish and maintain accurate medical records for each employee with occupational exposure. Records should include the employee's Name, hepatitis B vaccination status and dates, results of medical testing and follow-up procedures, healthcare professional's written opinion, and information provided to the healthcare professional. Records must be kept confidential and not disclosed without the employee's written consent, except as required by law. Records must be kept for at least the duration of the employee's employment plus 30 years. Form 7.041 Employee Consent Form for Testing for HBV and HIV Serological Status Following Accidental Exposure I, __________________________, understand that I have been involved in an accidental exposure incident and may be at risk for contracting Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) under 29 CFR 1910.1030. Therefore, following OSHA standards, I am being offered the opportunity to be tested for these viruses. I understand that the testing will involve a blood sample and that the results will be kept confidential and will only be shared with authorized personnel. I also understand that testing is voluntary and that I have the right to refuse to test. By signing this form, I consent to be tested for HBV and HIV following the accidental exposure incident. Signed: __________________________ Patient's Name: __________________________ Form 7.042 Patient Consent Form for Testing for HBV and HIV Serological Status Following Accidental Exposure I, __________________________, understand that a staff member involved in an accidental exposure incident may be at risk for contracting Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) following 29 CFR 1910.1030. Therefore, by OSHA standards, the staff member may be offered the opportunity to be tested for these viruses. I also understand that testing of my blood is necessary to determine if I am infected with HBV and HIV. The results will be kept confidential and only shared with authorized personnel. I understand that testing is voluntary and that I have the right to refuse to test. By signing this form, I consent to the staff member being tested for HBV and HIV and to my blood testing following the accidental exposure incident. Signed: __________________________ Form7.043 Refusal of Testing Patient/Employee (Circle One) I,_____________________________________, understand that I have the right to refuse testing for Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) following an accidental exposure incident per 29 CFR 1910.1030. I understand that if I refuse to test, it may impact my ability to receive appropriate medical treatment and the healthcare facility's power to respond to the exposure incident. Following 29 CFR 1910.1030, The source individual's blood shall be tested as soon as feasible and after consent is obtained to determine HBV and HIV infectivity. The employer shall establish that legally required consent cannot be obtained if permission is not obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested, and the results documented. Signed: __________________________Stages in the Sale of a Property Stage 1 â Getting to Instruction ⢠Initial contact with the vendor: need to check the following: type of property, contact details of vendor, address of property/Eircode and purpose of the contact - sale or valuation? If a sale, does the vendor need a quick sale? Qualify the lead i.e. is the vendor buying another property? If an investment property, is the tenant in situ? Check if there is a folio number available and confirm the ownership of the property. Schedule the viewing. ⢠Pre-viewing: Set up a file & record all info from initial contact on CRM system. Check the Property Price Register to help get a general idea of property valuation (subject to viewing, helps to display knowledge of area/market and set expectations for the vendor). Nature of property may affect pricing e.g. starter home vs. larger property with vendor seeking to downsize. Consideration for comparables may include similar/same location, size and condition of property, availability and type of parking, layout of property, plot size, orientation of garden, extensions undertaken etc. Nature of market conditions, state of wider economy, cost of capital and availability of credit may also be factors. ⢠Appraisal/viewing: Bring an advertising pack/sales & marketing brochures. Walk through property with client, note nice features/selling points for the brochure, let the client talk about upgrades/specific features of the property. It is very important to listen to the vendor and build rapport. Confirm property details e.g. condition and layout, plot size, orientation of garden. Check for certificates of compliance for any extensions, planning permissions for conversions, right of way if applicable etc. Check if a BER available/provide details for approved assessors. Demonstrate your/the practiceâs professional expertise, justify why you should get the instruction, discuss recent local sales and give your potential valuation. Discuss the sales fee, marketing fee and any additional charges e.g. professional photography, drone footage, virtual tours (walkthrough video, Matterport etc.) Ask how the vendor heard about you/your practice and why are they considering you for the sale. Where appropriate offer advice to help vendor increase potential sales price. (If possible, leave with signed Property Services Agreement/Letter of Engagement.) Thank you, send/email market appraisal, any queries/questions do get in touch and let the vendor know that weâll be in touch in coming days. ⢠Post appraisal â letter sent that pm/next morning with market appraisal; diary note to follow up. Check that market appraisal letter received and check for questions. If did not get sale, find out why not/debrief. If get the sale, email confirmation of instruction. Once PSRA sent and LOE returned signed = stage 2. Other details required â ID, proof of address, proof of ownership/title, solicitor details, BER certificate (refer to assessor if not available). All these should be uploaded to CRM. Stage 2 â Getting to âSale Agreedâ Set up appointment to measure & photograph, note any special features e.g., upgraded kitchen, south-facing garden. Provide ideas for improving sales potential (declutter, painting, tidy garden etc. Check if has vendor potential buyers in mind already e.g., relations, friends, other parties interested. Seek vendor approval for photos/text of brochure. Check for access (tenants in situ/working from home etc) and confirm viewing times. If given a key for viewings â tag it! Check alarm codes & whether a sign is allowed on the property. Bring to market â upload to all websites e.g., daft/my home, in house websites and create window display. Match the property against your internal database of potential purchasers /CRM system. Set up appointments for viewings on CRM or arrange for open viewings. Confirm viewings with vendor & purchaser. Turn on lights, open windows, secure valuables, leave out brochures & business cards, bring viewings sheets to keep record of attendees. Introduce yourself and get attendee details. Let people view the property and address any questions. Point out key features. Record questions to be answered and any feedback from viewers. Ask are they selling property? Let viewers know of offers already received. Lock up/alarm property/close windows. Provide vendor with feedback on viewings - number of viewers / questions raised/overall reaction to property. Offers should be confirmed in writing & upload to on CRM/ offers will be input by bidders onto online bidding platforms âProof of fundsâ required for offers in some practices. Successful bidder will be chosen by vendor, who might want quick sale/no chain or prefer the highest bidder. Booking deposit will be sought from successful bidder. The amount varies by practice but must cover fees. Sales Advice Notice/letter should be sent to both solicitors (and may be ccâd to vendor/buyer or notify both that SAN have gone out). Booking deposit receipt should be issued. The BER certificate and report should go to the solicitor. Send requests for docs/info to successful bidder including steps they need to take to progress sale e.g., organise the bank valuation and/or schedule the survey. Once the deposit is paid the property is Sale Agreed, inform other bidders, and update all websites/sales board etc. Stage 3 â Getting to closing Access should be organised for the bank valuation/survey. Stay in touch with both solicitors âcontract-chasingâ i.e., check when contracts are issued, signed and queries answered. Legal searches undertaken by the solicitors may include checking boundaries, land registry, title, rights of way, compliance certs etc. When contracts are signed 10% purchase price/booking deposit should be sent to the vendorâs solicitor. Once all queries satisfied = drawdown of mortgage/funding, house/life insurance in place. Title deeds will be requested once contract is signed. Decide final closing date. Check that the property taxes have been paid. Check that vendor has vacated the property. When vacant, conduct the final walkthrough and take final readings (MPRNs ). Check with solicitor if the drawn down funds h, and once received the solicitor gives authorisation to the estate agent to release the keys. The agent will do up invoice, send the balance of funds to solicitor and provide gift to purchaser. Finally remove sign, mark as sold on CRM, seek testimonials, upload to social media and close a/c on CRM