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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 Desirée Nieuwenhuis | Natàlia 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. © 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-α 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- α 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-α 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-α, 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-α 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. 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Ann Epidemiol. 2017;27(3):187-93.e2. 16. Glass NA, Torner JC, Letuchy EM, et al. The relationship between greater prepubertal adiposity, subsequent age of maturation, and bone strength during adolescence. Journal of bone and mineral research: the official journal of the American Society for Bone and Min- eral Research. 2016;31(7):1455-1465. 17. Holmgren A, Niklasson A, Nierop AF, et al. Pubertal height gain is inversely related to peak BMI in childhood. Pediatr Res. 2017;81(3): 448-454. 18. Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman- Giddens ME. Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics. 2001;108(2):347-353. 19. Kelly Y, Zilanawala A, Sacker A, Hiatt R, Viner R. Early puberty in 11-year-old girls: Millennium Cohort Study findings. Arch Dis Child. 2017;102(3):232-237. 20. Lazzeri G, Tosti C, Pammolli A, et al. Overweight and lower age at menarche: evidence from the Italian HBSC cross-sectional survey. BMC Womens Health. 2018;18(1):168-174. thereby an early onset of obesity. leptin can inhibit the production of testosterone in boys and subse- quently inhibit the development of secondary sex characteristics affecting spermatogenesis. for other adipokines, like resistin and omentin, are present in the testes and ovaries suggesting a role in puberty or reproduction; 58, 71 however, their plausible function is still unknown. that adipokines may be key regulators in an early onset of puberty in both girls and boys with obesity, specifically by affecting the HPG axis during gonadarche. Future research should focus on assessing puberty onset by measuring consistent puberty markers and determine the percentage of body fat and its distribution and adipokines and hormone serum levels particularly involved in the HPG axis. CONFLICTS OF INTEREST The authors declare no conflict of interest. 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 ‘onset of puberty and adiposity/obesity’, ‘onset of puberty’, ‘children with obesity’, ‘adipose tissue’, ‘childhood obesity’, ‘adiposity’, ‘obesity’, ‘adipokine(s)’, ‘HPG axis’, ‘adipokines ovary/ova- ries’, or ‘adipokines testes’, either alone or in combination. Selection criteria used were English language, longitudinal or cross-sectional studies assessing the onset of puberty, including menarche, thelarche, spermarche, or voice break, combined with high BMI or obesity/adiposity, and articles assessing or reviewing adipokines and its effects on the reproductive system. 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. 9 of 10 21. Lian Q, Mao Y, Luo S, et al. Puberty timing associated with obesity and central obesity in Chinese Han girls. BMC Pediatr. 2019; 19(1):1-7. 22. Deng Y, Liang J, Zong Y, et al. Timing of spermarche and menarche among urban students in Guangzhou, China: trends from 2005 to 2012 and association with Obesity. Sci Rep. 2018;8(1):263-270. 23. Li W, Liu Q. Association of prepubertal obesity with pubertal devel- opment in Chinese girls and boys: a longitudinal study. 2018;30: e23195. 24. Mendle J, Beltz AM, Carter R, Dorn LD. Understanding puberty and its measurement: ideas for research in a new generation. Journal of research on adolescence: the official journal of the Society for Research on Adolescence. 2019;29(1):82-95. 25. Pagani S, Meazza C, Gertosio C, Bozzola E, Bozzola M. Growth hor- mone receptor gene expression in puberty. Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme. 2015;47:581-584. 26. Abreu AP, Kaiser UB. Pubertal development and regulation. Lancet Diabetes Endocrinol. 2016;4(3):254-264. 27. Aguirre RS, Eugster EA. Central precocious puberty: from genetics to treatment. Best Pract Res Clin Endocrinol Metab. 2018;32(4): 343-354. 28. Sultan C, Gaspari L, Maimoun L, Kalfa N, Paris F. Disorders of puberty. Best Pract Res Clin Obstet Gynaecol. 2018;48:62-89. 29. Skorupskaite K, George JT, Anderson RA. The kisspeptin-GnRH path- way in human reproductive health and disease. Hum Reprod Update. 2014;20(4):485-500. 30. Dahl SK, Amstalden M, Coolen L, Fitzgerald M, Lehman M. Dynorphin immunoreactive fibers contact GnRH neurons in the human hypothal- amus. Reprod Sci. 2009;16(8):781-787. 31. Navarro VM, Gottsch ML, Chavkin C, Okamura H, Clifton DK, Steiner RA. Regulation of gonadotropin-releasing hormone secretion by kisspeptin/dynorphin/neurokinin B neurons in the arcuate nucleus of the mouse. J Neurosci. 2009;29(38):11859-11866. 32. Zhai L, Liu J, Zhao J, et al. Association of obesity with onset of puberty and sex hormones in chinese girls: a 4-year longitudinal study. PLoS ONE. 2015;10(8):1-12, e0134656. 33. Cizza G, Dorn LD, Lotsikas A, Sereika S, Rotenstein D, Chrousos GP. Circulating plasma leptin and IGF-1 levels in girls with premature adrenarche: potential implications of a preliminary study. Horm Metab Res. 2001;33(3):138-143. 34. Cousminer DL, Widén E, Palmert MR. The genetics of pubertal timing in the general population: recent advances and evidence for sex-spec- ificity. Curr Opin Endocrinol Diabetes Obes. 2016;23(1):57-65. 35. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44(235):291-303. 36. Lacroix AE, Whitten R. Physiology. Treasure Island (FL): Menarche. StatPearls. StatPearls Publishing; 2018. 37. McDowell MA, Brody DJ, Hughes JP. Has Age at Menarche Chan- ged? Results from the National Health and Nutrition Examination Sur- vey (NHANES) 1999–2004. J Adolesc Health. 2007;40(3):227-231. 38. de Muinich Keizer SM, Mul D. Trends in pubertal development in Europe. Hum Reprod Update. 2001;7(3):287-291. 39. Talma H, Schönbeck Y, van Dommelen P, Bakker B, van Buuren S, Hirasing RA. Trends in menarcheal age between 1955 and 2009 in the Netherlands. PLoS ONE. 2013;8:e60056-e60056. 40. Kaplan HS, Lancaster JB. An evolutionary and ecological analysis of human fertility, mating patterns, and parental investment. Off- spring: Human fertility behavior in biodemographic perspective. 2003;1: 170-223. 41. Mitan LA. Menstrual dysfunction in anorexia nervosa. J Pediatr Adolesc Gynecol. 2004;17(2):81-85. 42. Xu H, Li P-H, Barrow TM, et al. Obesity as an effect modifier of the association between menstrual abnormalities and hypertension in young adult women: Results from Project ELEFANT. PLoS ONE. 2018; 13(11):e0207929-e0207929. 43. Tauqeer Z, Gomez G, Stanford FC. Obesity in women: insights for the clinician. J Womens Health (Larchmt). 2018;27(4):444-457. 44. de Ridder CM, Thijssen JH, Bruning PF, Van den Brande JL, Zonderland ML, Erich WB. Body fat mass, body fat distribution, and pubertal development: a longitudinal study of physical and hormonal sexual maturation of girls. J Clin Endocrinol Metab. 1992;75(2): 442-446. 45. Lassek W, Gaulin S. Brief communication: menarche is related to fat distribution. Am J Phys Anthropol. 2007;133(4):1147-1151. 46. Loomba-Albrecht LA, Styne DM. Effect of puberty on body composi- tion. Curr Opin Endocrinol Diabetes Obes. 2009;16:10-15. 47. Simonneaux V, Bahougne T. A multi-oscillatory circadian system times female reproduction. Front Endocrinol. 2015;6:1-15. 48. Marques P, Skorupskaite K, George JT, Anderson RA. Physiology of GNRH and gonadotropin secretion. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. Endotext.org: South Dartmouth (MA); 2000. 49. Barcellos Gemelli IF, Farias EDS, Souza OF. Age at menarche and its association with excess weight and body fat percentage in girls in the Southwestern Region of the Brazilian Amazon. J Pediatr Adolesc Gynecol. 2016;29(5):482-488. 50. Aksglaede L, Juul A, Olsen LW, Sorensen TI. Age at puberty and the emerging obesity epidemic. PLoS ONE. 2009;4:1-6, e8450. 51. Ribeiro J, Santos P, Duarte J, Mota J. Association between over- weight and early sexual maturation in Portuguese boys and girls. Ann Hum Biol. 2006;33(1):55-63. 52. Budak E, Fernandez Sanchez M, Bellver J, Cervero A, Simon C, Pellicer A. Interactions of the hormones leptin, ghrelin, adiponectin, resistin, and PYY3-36 with the reproductive system. Fertil Steril. 2006;85(6):1563-1581. 53. Castellano JM, Tena-Sempere M. Metabolic control of female puberty: potential therapeutic targets. Expert Opin Ther Targets. 2016; 20(10):1181-1193. 54. Venancio JC, Margatho LO, Rorato R, et al. Short-term high-fat diet increases leptin activation of CART neurons and advances puberty in female mice. Endocrinology. 2017;158(11):3929-3942. 55. l'Allemand D, Schmidt S, Rousson V, Brabant G, Gasser T, Gruters A. 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. Böttner A, Jr K, Müller 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, Iñiguez 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. 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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 “obesity paradox” 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 goverPersonality development means developing positive characteristics among individuals. Positive characteristics of an individual include: Obedience – Learn how to follow family as well as school regulations and decisions made for your own good. If young children like Something to read: Home Economics and Livelihood Education 7 Seibo College 5 you, can learn how to obey your elders then there will always be peaceful and happy relationship around. CourtesyBeing courteous means to be respectful. Polite behavior must be something you must observe anywhere, every time. Cleanliness and Orderliness – It means practicing good health and good grooming habits everyday. Understanding – To be in another’s shoes is to be in the same place as what others are experiencing through life. One must be very careful about what others may feel so be tactful and develop sensitivity towards their needs. Friendly – It is necessary that growing child like you to possess a good attitude in dealing with others. Develop a fine character and talk in such a manner that others will realize what admirable qualities you do possess. Home Economics and Livelihood Education 7 Seibo College 6 Becoming friendly means getting along well with each other. As you grow up, it is important to be able to meet and be acquainted other people. Sometimes. you will meet people who for some reason won’t like you. Understanding other’s feeling and emotion will make it possible to become the kind of person whom most people enjoy being with. It will help you become good natured and considerate to others. The following are guidelines for you to follow in order to develop your positive characteristics. be sensitive of other’s need. be genuinely concern with others. be thoughtful and pleasant. listen when others are talking. make them feel important. More effective way of being likeable can be summed up by the Golden Rule which says “Do unto others as you would have others do unto you” Do you want to be treated kindly? Then, follow the golden rule so that your relationship with others will be at its best. Your personality is influenced by many factors; however the most influential are heredity and environment. What is heredity? Heredity is the transmission of physical and mental traits from parents to offspring. The table below will identify your inherited traits and abilities: Home Economics and Livelihood Education 7 Seibo College 7 Here are some inherited physical features and traits from your mother and father. Physical Features Intelligence and mental ability Personal disposition - blood type - power to think - manner of thinking - body structure - power to learn - manner of feeling - color of skin/eyes - power to understand - manner of acting - color and texture of hair - power to do something What is environment? Home Economics and Livelihood Education 7 Seibo College 8 Your environment provides you with experiences, conditions, and influences that mold your personality. These are the people around you, your school, community, as well as the things that surround you that affect your personality. The people who will most likely affect your personality ,are your friends or peers, their manner of thinking and behaving will be sooner or later, the same as your manner and behavior as well. The things you use everyday like your personal computer, cell phone will also have an impact on your personality. Always remember to be yourself and do not pretend to be somebody you are not. Act according to your age and do not copy the identity of other person. Otherwise, you may become an individual that you and other person may not like. Understand yourself and do something to improve your personality. It is always necessary to practice good health habits as follows: eat the right kind of food. have a regular exercise. have enough sleep and rest. Observe good grooming habits as well: maintain cleanliness and neatness. wear appropriate clothes. observe good posture. Home Economics and Livelihood Education 7 Seibo College 9 If you understand our lesson well, you can now proceed to the next activities But if you have any questions, you can ask your leMake mcq quiz with 4 option in which one is correct -'10 Basis of Material Science • .....;;;";;;"~~;;,,;;,,,,;.;.,,;;,,,;,,;.;,.,------------ 6. Temporary materials: Some materials are meant to be placed in the oral cavity for a short period of time for different reasons. • Temporary crowns: While a permanent crown is prepared in the dental laboratory, the patient must wait for few days before it can be fabricated and cemented into place. Does patient experience any problems during this time period? If the tooth is vital (the pulp is alive), the patient is likely to experience pain and sensitivity while eating and drinking, also it looks unesthetic. What can be done to solve this problem? A temporary crown is placed before the patient leaves the clinic. It is constructed and luted in the same appointment in which the crown preparation is done. Temporary crowns are not very strong or esthetic but they serve adequately till the permanent crown is ready to be cemented. • Temporary restorations: Sometimes it is difficult to decide immediately the best line of treatment for a particular tooth. The exact condition of the pulp may not be obvious to the dentist from the patient's symptoms. A dentist removes all or part of the decay and then places a temporary restoration to have time to observe the behaviour of the pulp or to give the pilip time to heal before deciding the further treatment required. Classification based on Location of Fabrication 4,9 Materials can be classified based on the location of fabrication into: • Direct restorative materials. • Indirect restorative materials Direct restorative materials: They include those materials which are used to restore cavity preparations directly in the oral cavity (Box 1.5). Box 1.5: Examples of direct restorative materials Amalgam, composites, glass ionomer and other materials, which set by chemical reactions in the mouth. Indirect restorative materials: It includes those restorations which must be fabricated outside the mouth, indirectly on a cast/ model/ die, because their processing condition would harm oral tissues. Materials used in the construction of such prosthesis are called indirect restorative materials (Box 1.6). Box 1.6: Examples of indirect restorative materials Gold inlays, crowns of metal, ceramic and polymers, which are processed at elevated temperatures. Some indirect composite restorations can be processed under specific wavelength of light, e.g. Ceramage. Classification based on Longevity of Use 1. Permanent restorations: These restorations are not planned to be replaced for a particular time period. Though they are referred to as permanent, actually they are not, e.g. fillings, crowns, bridges and dentures do not last forever (Fig. 1.5). 2. Temporary restorations: These restorations are planned to be replaced in a short period of time, such as few days to weeks. For ~ Permanent C/) c c -.2 0 c- :;::; Cll co Interim ~ Q; 0 .8ll::1iJ C/) o~ Cll a:: c:=:J Temporary Time period Fig. 1.5: Diagram depicting the time period of use of a restoration. (Arrow in permanent restoration depicts that such restorations are not planned to be replaced for a long period of time.) Introducton to Dental Materials Dental materials Box 1.7: Characteristics of metals 1. High thermal and electrical conductivity 2. Ductility (pure metals are very soft and they can be bent without breaking) 3. Opacity (they do not transmit light) 4. Luster (they have a surface that strongly reflects light and appears bright and shiny) 5. They tend to dissolve to some extent in water or other aqueous solutions, producing cations. 6. All metals are white (actually gray) except for gold, which is yellow, and copper, which is reddish. 7. All metals are solid at room temperature except mercury, which is liquid at room temperature and is used with silver alloys as amalgam. 8. All metals have high melting temperatures because of high strength of the metallic bond that holds the atoms together. 3. Polymers 4. Composites Composites are mixtures of two or more of the first three classes in which the different components remain distinct from one another in the final structure. A common example is composite resin. Fig. 1.7a: Three-dimensional structure of iron (metal) Metals Metals are the oldest of the three classes of materials that have been used as dental materials. Metals are characterized by metallic bonds (Box 1.7) which will be discussed in the next chapter. Metals solidify with their atoms in a regular or crystalline arrangement (see Chapter 2), often in the form of a cube (Fig. 1.7a). example, temporary fillings done in a tooth during root canal treatment, which have to be replaced within 2-4 days during subsequent visits. They are used to protect the tooth and provide function till the final restoration is done. 3. Interim restoration: At times, dental treatment requires "long-term" definite temporary restorations or "interim" restorations. For examle, a 7-year-old child, met with trauma and fractured one of his central incisors. A large composite build- up may serve his immediate requirement until the root formation is completed and a permanent crown is placed. 5 Classification based on the Chemical Nature of the Material These are the atoms that make up a material and the way they are bonded together determine the properties of that materiaLS Weak bonds make for weak materials and vice versa (Table 1.4). Materials can be classified into different categories based on their primary atomic bonds (Fig. 1.6): 1. Metals 2. Ceramics Fig. 1.6: Classification of dental materials based on chemical nature 12 Basis of Material Science Box 1.9: Benefits of ceramics in dentistry 1. Many ceramic oxides are used as pigmenting agents. These oxides produce good range of colors. Due to this characteristic, we are able to match almost any tooth color with good esthetic results. 2. They are inert, i.e. not chemically reactive. This quality provides ceramics with good bio- compatibility. 3. Ceramic materials are translucent, like natural teeth. This translucency gives the ceramic crown a more natural appearance than any other dental material. Fig. 1.7b: Internal arrangement of tetrahedral structure of ceramic (silica) four large oxygen atoms surround smaller silicon atom Ceramics A ceramic is a compound formed by the union of a metallic and a non-metallic element (Box 1.8). Most of these materials are oxides, formed by the union of oxygen with metals such as silicon, aluminum, calcium and magnesium (Fig.1.7b). Ceramics may be simple or complex. Examples of simple ceramics are alumina and silica. Examples of complex ceramics are feldspar (potassium aluminum silicate) and kaolin (hydrated aluminum silicate). Ceramics may be crystalline or non- crystalline (i.e. amorphous). Porcelain is a specific type of ceramic used extensively in dentistry (Box 1.9). Box 1.8: Characteristics of ceramics 1. High melting points. 2. Brittleness, which means they cannot be bent or deformed (no sliding) to any extent without actually cracking and breaking. 3. They are poor conductor of heat and electricity. 4. They are chemically inert. 5. They have excellent esthetic result in terms of matching natural teeth. Fig. 1.8: Stucture of synthetic polymer Polymers They are the latest addition (early to mid- 1900s) to dental materials. Most of the polymers are nowadays synthesized by humans. Polymers are giant, long-chain organic molecules (Fig. 1.8). Polymers are characterized by covalent bonds within each molecule, giving them tremendous strength in a single direction. Try to break a nylon rope by pulling it! They are poor conductors of heat and electri- city. Most polymers have a structure containing thousands of carbon atoms linked together like beads on a string. Others, such as silicone polymers are formed with silicon-oxygen bonds. Introducton to Dental Materials Table 1.4: Characteristics of different materials 13 Characteristics Bond Properties Crystal structure Metals Metallic bonding High strength and hardness, high electrical and thermal conductivity BCC, FCC, or HCP unit cells Ceramics Ionic or covalent bonding, or both High hardness and stiffness, electrically insulating, refractory, and chemically inert Crystalline or amorphous Polymers Covalent bonding Low sensitivity, high electrical resistivity, and low thermal conductivity, strength and stiffness vary widely Amorphous and crystalline Composites Composites are combinations of any of the basic ceramic, metallic and polymeric materials (Box 1.10). Each material that makes up composites is called a phase. Their properties tend to be somewhere between those of their basic constituents and are used to enhance their performance, longevity and handling chracterstics. Box 1.10: Types of composites in dentistry 1. Ceramic - metallic composite: Tungsten carbide bur. 2. Metal - polymer composite: Die materials in dental laboratory. 3. Ceramic - polymer composite: Enamel, dentin, bone and restorative composites. A composite is a kind of "combination" of materials, which compliment each other. The properties lacking in one material are compensated by those of the other material. For example, restorative composite has two phases, namely resin and fillers. Teeth and bones are examples of natural composites. Enamel is a composite of hydroxyapatite (which is a ceramic material) and protein (which is a polymer). EVALUATION OF DENTAL MATERIALS Most manufacturers of dental materials maintain a quality assurance programme (As per international standard like ADA specifications) and materials are thoroughly tested before being released into the market for dental practitioner (Fig. 1.9). Laboratory Evaluations Most ADA/ ANSI specifications involve laboratory tests. The tests performed as per these specifications are useful but they all are performed in vitro, (carried out in the laboratory away from the clinical conditions) which have a lot of limitations in clinical practice.lO Clinical Notes 1. For example, most of the direct restorative materials are tested for their compressive strength but ultimately the material is subjected to a combination of compressive, tensile and shear stresses, which may decide the final success or failure of the material under masticatory load. 2. Similarly upper dentures mostly fracture along the midline because of bending. Hence a bending or transverse strength ~B-a-s-is-o-f-M-a-t-e-ria-I-S~c-ie-n-c-e-------------- ---------. test is far more meaningful for denture base materials than a compression test. Clinical Trials The majority of new materials are subjected to extensive clinical trials normally in co-operation with a dental college or hospital departments prior to their release. CONCLUSION As the number of available materials is going up, it is important that the dentist remains more aware about new products so that their judgement about the selection of material remains successful. Materials which have not been thoroughly evaluated should be avoided, specially with clinical dentistry falling under Consumer Protection Act (CPA). I Research and development I iI Manufacturer/analysis Ideal requirements for clinical use: Thermal, optical, mechanical, chemical, biological Available materials and their properties are evaluated Launch of new I product Choice and selection of material by the dentist Critical assessment based on clinical performance I I H feedback to IBy the late 1800s, the Spanish were losing control of Cuba. Concerned about insurrection in the countryside, they moved rural Cubans to “reconcentration” camps where the Spanish claimed they would be better able to protect them. U.S. Consul-General Fitzhugh Lee forwarded the following account of the conditions of the camps to the U.S. Assistant Secretary of State on November 27, 1897. Lee said the author of the note was “a man of integrity and character.” “[W]e will relate to you what we saw with our own eyes: “Four hundred and sixty women and children thrown on the ground, heaped pellet-mell as animals, some in a dying condition, others sick and others dead. . . . “There is still alive the only living witness, a young girl of 18 years, whom we found seemingly lifeless on the ground; on her right-hand side was the body of a young mother, cold and rigid, but with her young child still alive clinging to her dead body; on her left-hand side was also the corpse of a dead woman holding her son in a dead embrace. . . . “The circumstances are the following: complete accumulation of bodies dead and alive, so that it was impossible to take one step without walking over them; the greatest want of cleanliness, want of light, air, and water; the food lacking in quality and quantity what was necessary to sustain life. . . . From all this we deduct that the number of deaths among the reconcentrados has amounted to 77 per cent.” Source: Unsigned note that was included in a telegram sent by Fitzhugh Lee, U.S. Consul-General in Cuba, to the U.S. Assistant Secretary of State November 27, 1897. consul-general: a government official living in a foreign country charged with overseeing the protection of U.S. citizens and promoting trade pell-mell: state of disorder accumulation: pile want: lack reconcentrados: the reconcentration camp prisoners; The following is an excerpt from Albert J. Beveridge’s speech, delivered September 16, 1898. Beveridge gave this speech while he was campaigning to become a senator for Indiana. The speech helped him win the election and made him one of the leading advocates of American expansion. “Fellow citizens, it is a noble land that God has given us; a land that can feed and clothe the world;. . . . It is a mighty people that he has planted on this soil . . . It is a glorious history our God has bestowed upon his chosen people; . . .a history of soldiers who carried the flag across the blazing deserts and through the ranks of hostile mountains, even to the gates of sunset. . . . “The Opposition tells us that we ought not to govern a people without their consent. I answer: The rule of liberty that all just government derives its authority from the consent of the governed, applies only to those who are capable of self-government. I answer, We govern the Indians without their consent, we govern our territories without their consent, we govern our children without their consent. “They ask us how we will govern these new possessions. I answer: If England can govern foreign lands, so can America. If Germany can govern foreign lands, so can America. . . . “What does all this mean for every one of us? It means opportunity for all the glorious young manhood of the republic, the most virile, ambitious, impatient, militant manhood the world has ever seen. It means that the resources and the commerce of these immensely rich dominions will be increased. . . . “In Cuba, alone, there are 15,000,000 acres of forest unacquainted with the axe. There are exhaustless mines of iron. . . . There are millions of acres yet unexplored. . . . It means new employment and better wages for every laboring man in the Union. . . . Tobruk, a small town on the Libyan coast, was central to much of the fighting that took place in the Western Desert during the Second World War. It had originally been developed by the Italians during their colonisation of eastern Libya during the early decades of the 20th century. With a sheltered deep water harbour it became a key naval outpost. It was fortified during the 1930s with both coastal defence batteries and a 50 kilometre-long perimeter of reinforced concrete platoon posts, and other supporting infrastructure such as gun positions, headquarters bunkers, underground supply dumps, and observation towers. When British and Commonwealth forces advanced out of Egypt and into Libya in January 1941, Tobruk was their second objective. The Italian defence perimeter was attacked by the 6th Australian Division on the morning of 22 January and the town fell the next morning. The operation resulted in approximately 27,000 Italian prisoners and the capture of over 200 artillery pieces, but cost 49 Australian lives. The 6th Division's advance pressed on beyond Tobruk and eventually they were withdrawn from Libya to be deployed to Greece.The 9th Australian Division was moved in to Libya in February 1941 to garrison the territory captured by the 6th. By this time, however, German troops had arrived in Libya to reinforce their Italian allies and they launched an offensive that the British Commonwealth forces were ill-disposed to hold back. A retreat towards Egypt commenced. The 9th Division was ordered to fall back upon Tobruk, hold it in order deny its port facilities to the Germans, and delay their advance so as to provide time for defences on the Egyptian frontier to be prepared. Tobruk and the 9th Division were subsequently encircled, beginning what became known as "the siege of Tobruk". Reinforced by the 18th Brigade of the 7th Australian Division and other British and Commonwealth troops, and resupplied by the sea, the 9th Division held Tobruk from April to September 1941. During this period it repelled two major German attacks. In September and October the 9th Division, its condition steadily declining, was relieved by the British 70th Division, which continued to defend Tobruk until the siege was finally lifted by Operation Crusader in December. The defence of Tobruk resulted in 749 Australian deaths, and another 604 became prisoners of war. Tobruk was the scene of further heavy fighting in June 1942 when the fortunes of war again saw a British Commonwealth force seeking to deny the port to the enemy. The Axis forces, however, were in no mood for another siege and launched a massive attack to capture it on 20 June. It remained in their hands until their final retreat from Libya in November 1942.John Hurst Edmondson (1914-1941), soldier, was born on 8 October 1914 at Wagga Wagga, New South Wales, only child of native-born parents Joseph William Edmondson, farmer, and his wife Maude Elizabeth, née Hurst. The family moved to a farm near Liverpool when Jack was a child. Educated at Hurlstone Agricultural High School, he worked with his father and became a champion rifle-shooter. He was a council-member of the Liverpool Agricultural Society and acted as a steward at its shows. Having served (from March 1939) in the 4th Battalion, Militia, he enlisted in the Australian Imperial Force on 20 May 1940 and was posted to the 2nd/17th Battalion. Later that month he was promoted acting corporal (substantive in November). Well built and about 5 ft 9 ins (175 cm) tall, Edmondson settled easily into army life and was known as a quiet but efficient soldier. His battalion embarked for the Middle East in October and trained in Palestine. In March 1941 the 2nd/17th moved with other components of the 9th Division to Libya and reached Marsa Brega before an Axis counter-attack forced them to retreat to Tobruk. The siege of the fortress began on 11 April. Two days later the Germans probed the perimeter, targeting a section of the line west of the El Adem Road near Post R33. This strong-point was garrisoned by the 2nd/17th's No.16 Platoon in which Edmondson was a section leader. The enemy intended to clear the post as a bridgehead for an armoured assault on Tobruk.Under cover of darkness thirty Germans infiltrated the barbed wire defences, bringing machine-guns, mortars and two light field-guns. Lieutenant Austin Mackell, commanding No.16 Platoon, led Edmondson's five-man section in an attempt to repel the intruders. Armed with rifles, fixed bayonets and grenades, the party of seven tried to outflank the Germans, but were spotted by the enemy who turned their machine-guns on them. Unknown to his mates, Edmondson was severely wounded in the neck and stomach. Covering fire from R33 ceased at the pre-arranged time of 11.45 p.m. and Mackell ordered his men to charge. Despite his wounds, Edmondson accounted for several enemy soldiers and saved Mackell's life. When the remaining Germans fled, the Australians returned to their lines. Although Edmondson was treated for his wounds, he died before dawn on 14 April 1941. The Germans' armoured attack that morning was thwarted, partly due to the earlier disruption of their plans. Edmondson was buried in Tobruk war cemetery. He had not married. His Victoria Cross, gazetted on 4 July, was the first awarded to a member of Australia's armed forces in World War II. In April 1960 Mrs Edmondson gave her son's medals to the Australian War Memorial, Canberra, where they are displayed alongside his portrait (1958) by Joshua Smith. At Liverpool a public clock commemorates Edmondson, as do the clubrooms used by the sub-branch of the Returned Services League of Australia.Perhaps my nerves will be more under control when I am by myself. There were no entries in the diary until Friday April 18 when she wrote: Fighting terrific in Greece and North Africa…. I dread the casualty list also the heaviest air raid over London to date. Account …. of heavy fighting and much use of bayonet at Tobruk. Also gives an account of a charge in which a Lieutenant and a Corporal took prominent parts on Easter Sunday night. Of course, no names. When I read it …. I was sure the Corporal was Jack…. It said no casualties but …. I know … that all is not well with Jack. ….. (and) Stuffy ….has not come home yet. On Wednesday April 23 she received a letter from Jack dated March 30 and for the first time he said the conditions were bad. The food short, water one bottle for 48 hours. It worried me terribly so I posted a parcel (of) milk tablets, chocolate milk, biscuits (and) cigarettes.Tuesday April 15 I was feeling afraid of something while I was working and packing the cake (and) had a couple of brandys to (keep going).April 26 Received the following telegram in the mail, the bus man brought it in. “It is with deep regret that I have to inform you that Corporal John Hurst Edmondson was killed in action on the 14th April and desire to convey the profound sympathy of the Ministry for the Army and the Military Board.”Her final entryHealth 11/12 Review for Final Exam Core Concepts - Mental and Emotional Health, Substance Abuse Prevention, Safety and Violence Prevention, Family Life and Human Sexuality, Disease Prevention and Control, Healthy Eating Health Education Skills - goal setting, decision making, accessing information/resources, analyzing influences, communication, self-management, advocacy DIMENSIONS of Wellness - social, spiritual, emotional/mental, environmental, financial, intellectual, multicultural, occupational, physical, sexual RISK factors - anything that increases the risk of disease, injury, or illness. PROTECTIVE factors - anything that decreases the risk of disease, injury, or illness. INTERNAL health factors - health factors that can be either hereditary and genetic or acquired elements -- include smoking and personal diet or eating habits. Example – a genetic predisposition to an illness. EXTERNAL health factors - health factors that are part of the direct outer environment, the geographical location, micro-organisms, socio-economic elements that could affect an individual's health. Example – being unable to afford mental health services. Unit 1- Managing Personal and Community Wellness Explain Maslow’s Hierarchy of Needs in your own words using the image provided. Explain how each Social Determinant of Health may impact a person’s health. Levels of Disease Prevention • PRIMARY The goal is to avoid conditions altogether. • SECONDARY The goal is early detection. • TERTIARY The goal is to minimize the damage (manage). Define the following terms. Fads/Trends Sleep hygiene Driver safety Unit 2- Investigating Social Ecological Factors on Well-Being Socio-Ecological Model – The SEM examines how health behaviors form based on characteristics of individuals, communities, nations and levels in between. Each level overlaps with other levels signifying how the best public health strategies are those that encompass and target a wide range of perspectives. Interpersonal (personal) health vs. intrapersonal (relationship) health Health INEQUITY - systemic, ingrained and unjust barriers that prevent segments of the population from having the opportunity of health leading to health disparity. IMPLICIT BIAS - a form of bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors. Research has shown implicit bias can contribute to unequal access to quality healthcare, negative patient-provider relationships and interactions; and create mistrust in the healthcare system and practitioners among patients. This can contribute to health disparities. Health DISPARITY - represents a difference in health between populations. It is often used to describe disease burden and other negative health outcomes socially disadvantaged groups may face. Health EQUITY - The opposite of health inequity. It describes a system that supports a high standard of health and healthcare for all people. Racism - Beliefs, attitudes, institutional arrangements, and acts that tend to denigrate individuals or groups because of phenotypic characteristics or ethnic group affiliation. DISCRIMINATION - An unjust differential treatment of a person or a group. PRIVILEGE- The unearned access to resources and social power that are only available to some because of their membership within certain social groups. OPPRESSION is the act of taking away choices from others and can be defined as a system that maintains advantage and disadvantage based on social identities and that acts on multiple levels from interpersonal to institutional and societal. (internalized, interpersonal, institutional, structural) Systematic Oppression - Intentional disadvantage of groups of people based on their identity while advantaging members of dominant group (race, gender, sexual orientation, language, size, ability, etc.). Intersectionality - The complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups Unit 3- Accessing Resources and Communicating to Support Mental and Emotional Health What is anger? What is anxiety? What is stress? STRESSORS are the things that cause stress. Stressors can be internal and external. A stressor may be a one-time or short-term occurrence, or it can happen repeatedly over a long time. INTERNAL Stressors - are made by your belief system and the way you evaluate yourself. Examples include pessimistic attitude, negative self-talk, deep need to be perfect, low self-esteem or body image, unhealthy standards for self. EXTERNAL Stressors - are stressful things that happen in your surroundings and/or in your environment. Examples include busy schedules, work problems, family issues, financial trouble, social problems, injury, unforeseen circumstances. Socio-economic issues are also a part of external stressors such as poverty, violence, and racism. Define the following mental health conditions. Depression Eating disorders NSSI Non-suicidal self-injury Grief/Loss Suicide prevention A.C.T. • ACKNOWLEDGE- Tell them in a caring way that you recognize that they are having a problem • CARE- You can show you care by actively listening - put away anything else you are doing, make eye contact, sit down, ask questions. • TELL-(call 988 for additional help and support) - Tell them it is important that they speak with a trusted adult. Help them figure out who this may be and offer to go with your friend. A social norm is an unwritten, informal rule meant to guide behavior among the of society. It distinguishes between acceptable and unacceptable, good and bad, and so on. Social norms can influence a person with emotional or mental health disorders, access to care and stigmatize their situation. STIGMA- a mark of disgrace associated with a particular circumstance, quality, or person. • Self-stigma - This describes the internalized stigma that people with mental health conditions feel about themselves. • Public stigma - This refers to the negative attitudes around mental health from people in society. • Institutional stigma - This is a type of systemic stigma that arises from corporations, governments, and other institutions. Unit 4- Evaluating Risks of Substance Use and Abuse Harm Reduction - a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Explain how each level of the Social Ecological Model is impacted by addiction. Individual Relationship Community Society SEM Level Contributing/Risk Factors to substance use Preventative/Protective Factors for substance use Individual Interpersonal/Relationship Community Society Unit 5- Analyzing Influences to Examine Ways to Increase Safety and Reduce Violence HATE CRIME - a crime, usually violent, motivated by prejudice or intolerance toward an individual’s national origin, ethnicity, color, religion, gender, gender identity, sexual orientation, or disability. Explain how the media influences violence in society. The Pyramid of Hate Explain the escalation of hate using the Pyramid of Hate visual. List several hate crime motivators. Example: age HEALTHY Relationship Signs - comfortable pace, trust, honesty, independence, respect, equality, kindness, taking responsibility, healthy conflict, fun UNHEALTHY Relationship Signs - intensity, possessiveness, manipulation, isolation, sabotage, belittling, guilting, volatility, deflecting responsibility, betrayal Sexual Assault is a sexual behavior WITHOUT consent. Human trafficking - the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, using force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Sex trafficking - commercial sex act induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age. Trafficking happens using… • Force - using violence to control someone. • Fraud - using lies to control someone. • Coercion - using threats to control someone. Unit 6- Family Life and Human Sexuality Agency - A belief about yourself and the extent to which you can act on that belief. • The ability to choose freely one’s own narrative. • To embrace the idea that I am the cause (or agent) of my own thoughts and actions. • Personal agency is a personal responsibility for who we are, what we experience, what we do about that experience, and how we shape our world to give us more of the experiences we want. SEXUAL Agency • The ability to choose your own interests and desires vs. what we see in the media or others’ perceptions • The ability to identify, communicate, and negotiate one’s sexual needs • The ability to initiate behaviors that allow for the satisfaction of those needs Sexually Explicit Material - photographs, videos, films, magazines, and books whose primary themes, topics, or depictions involve sexuality that may cause sexual arousal. Sexual scripts - thoughts, patterns, or behavior that a person has about themselves in a romantic or sexual context. It is how people picture themselves or want to project themselves in front of others. Reproductive Rights of Teens - In Maryland, teens have the right to an abortion, keep their child, obtain and use birth control, paternity tests, adoption, give up custody of their child within 10 days of birth (Safe Haven Law). • REPRODUCTIVE RIGHTS- legal rights and the freedom of the individual to control decisions regarding contraception, abortion, sterilization and childbirth. • SAFE HAVEN LAW- a distressed parent who is unable or unwilling to care for their infant can safely give up custody of their baby, no questions asked. CONSENT is an agreement between participants to engage in sexual activity. • It is clearly and freely communicated, verbal, and affirmative. Consent CANNOT be given if… • A person is underage, one or both partners is intoxicated or incapacitated by drugs or alcohol, one partner is asleep or unconscious, one partner feels pressured, threatened or intimidated, or one partner holds a position of power or authority over the other. Unit 7- Advocating for Enhanced Nutrition, Food Systems, and Health Outcomes Dietary Guidelines for Americans Guideline 1: Follow a Healthy Dietary Pattern at Every Life Stage Guideline 2: Customize and Enjoy Food and Beverage Choices to Reflect Personal Preferences, Cultural Traditions, and Budgetary Considerations Guideline 3: Focus on Meeting Food Group Needs with Nutrient-Dense Foods and Beverages, and Stay Within Calorie Limits Guideline 4: Limit Foods and Beverages Higher in Added Sugars, Saturated Fat, and Sodium, and Limit Alcoholic Beverages FOOD DESERT- a neighborhood where there is little or limited access to healthy and affordable food such as fruits, vegetables, whole grains, low-fat milk and other foods that make up the full range of a healthy diet. FOOD INSEQURITY lack of access to a sufficient amount of food because of limited funds. More than 49 million American households are considered food insecure and are vulnerable to poor health as a result. PROCCESED FOODS- any raw agricultural commodities that have been washed, cleaned, milled, cut, chopped, heated, pasteurized, blanched, cooked, canned, frozen, dried, dehydrated, mixed or packaged — anything done to them that alters their natural state.Management and Globalization Global Management Why companies go global How companies for global Global Business environments Global Business Types of global business Pros and cons of global businesses Ethnic Challenges for global business Culture and Global Diversity Cultural intelligence Silent language of culture Tight and loose cultures Values and national cultures Global Management Learning Are management theories universal? Intercultural competencies Global learning goals Key concepts of the challenges of globalisation: Global economy Resources, markets and competition are worldwide in scope Internationalisation The process of increasing involvement in international operations Globalization/Deglobalization Glob- the growing interdependence among elements in the global economy The worldwide interdependence of resource flows, product markets and business competition World 3.0 Different views: World flat vs. round Distance is a metaphor that represents the degree of dissimilarities between countries Balancing cooperation in the global Global Management Global management - managing things in different countries Managing business and organizations with interests in more than one country What do we expect from global Managers Knowing how to adapt Knowing the language Global Manager Is culturally aware and informed on international affairs International Business Conducting for-profit transactions of goods and services across national boundaries International Motive Why do firms internatioalize their activities Cheaper labour Labour tax Natural resources Enrolments to do business Clientele Exclusive materials Personal benefits: Taxes Reasons why businesses go global Customers Suppluers Capital During (1993) - 4 motive 1. Market seeking 2. Efficiency Seeking 3. Resource seeking 4. Strategic Asset Seeking Cuervo Cazurra, Narula and un (2015) - 4 motive s Internationalization Motives A company may also explore the opportunities in different markets in order to take advantage and in some cases extend the product life cycle What is a Market Entry Strategy Involves the sale of goods or services to foreign markets but do not require expensive investments Franchising Exporting and importing Involve the sale of goods or services to foreign markets but do Types of market entry strategies Global sourcing Exporting Importing Licensing agreement Franchising Types of Foreign Direct Investment (FDI) strategies: Joint venture Strategic alliance Owned Subsidiary (sometimes called WOS) How to go abroad What conditions will affect the decisions of firms on how to internationalize their activities? During (1978)- Eclectic paradigm OLI model OLI- Ownership, Location and Internalization Advantages Ownership advantages Resources owned by the organization that can be transferred across locations include trademarks, production techniques and processes, managerial skills and other resources not available to the competitors Location Advantages Represent the implications of choosing to produce or to perform activities in a specific location (country or region) Internalization Advantages: The ability to internalize or to incorporate activities that add value to its business Evolution of Concepts- New Elements Although economic factors are certainly important to explain the formation, growth and expansion of firms within and across national borders, they are not sufficient to explain the additional complexity when a firm decides to expand its activities across national borders Economic factors Investigate the economic elements that affect the internationalization of firms Behavioural Elements Explaining the additional challenges (and perhaps opportunities) a firm faces in foreign host countries when compared to indigenous (local) firms Behavioural theories Johanson and Wiedersheim-Paul (1975) and Johanson and Vahlne (1977) Included the psychic Distance concept (beckerman,1956) to explain the internationalization behaviour of firms The Uppsala internationalization model Psychic distance is: the sum of factors preventing the flow of infomatio from and to the market Psychic Distance is a broad concept that includes several elements such as: language, culture, political systems, level of education, level of industrial development Firms behave in a “Risk Averse” manner It means that when the perceived risk goes down, the firm increase its commitment to the foreign market \ The Haier Group Data Strategy Big DATA and Small DATA The use of small data to satisfy individual customers’ needs, however, the book mentions a huge cultural shock at the plant in Camden, south caroline Ex: top down, hard hat colors and hierarchy Culutral Differnces can have a huge impact on the internationalization of firms Kogut and Singh (1988)- Cultural Distance Index First statsical study on the implication of ciltiral distance to the selection of entry mode When investigating in culturally distant countries, foreign firms can choose to partner with foreign firms in order to gain local knowledge and share the risk associated to the investment (higher commitment = higher risk) How Companies Go Global Global sourcing The process of purchasing materials or services around teh world for local use Exporting Selling locally made products in foreign markets Importing Buying foreign made products and selling them domestically Exports correspond to what percentage of Candain GDP What countries are the major trending partners of Canada Management and Globalization How Companies Go Global Licensing Agreement One firm pays a fee for rights to make or sell another company’s products What are the potential risks associated to licesning The case of new balance in China Franchising A fee is paid for the rights to use another firms name, branding and methods Insourcing Insourcing: refers to local job creation that results from foreign direct investment Types of insourcing Joint ventures: operate in a foreign country through co-ownership by foreign and local partners Strategic alliances: A partnership in which foreign and domestic firms share resources and knowledge for mutual gains Foreign subsidiaries: local operation completely owned by a foreign firm Criteria for choosing a joint venture partner: Familiarity with your firm’s major business String local workforce Values its customers Future expansion possibilities Strong local market for partner’s own products Good Profit potential Sound financial standing Global business environments Legal and poliical systems Trade agreements and trade barriers Regional economic alliances Legal and political systems Differing laws and practices regards Business ownership Negotiation and implementation of contracts Foreign currency exchange Protection of intellectual property rights Counterfeit merchandise Political risk Potential loss in value of foreign investment due to instability and political changes in the host country Political risk analysis (expertise/experience) Forecast political disruptions that threaten the value of a foreign investment Changes in the rules of the game Brexit US Trade Wars-mexico-China Other examples Bolivia, Venezuela, China De-globalization The process of weakening interdependence among nations Trade Agreements and trade Barriers World trade organization Most favourd nation status Tariffs Nontariss barriers (quotes, restrictions, etc.) Protectionism Regional Economic Alliances USMCA (replacment for the NAFTA-North American Free trade Agreement) EU- European Union APEC- Aisa Pacific Economic Copperation ASEAN - Association of Southeast Asian Nationas SADC - Southern Africa Development Community MERCOSUR- Chapter 5- Global Management and Cultural Diversity (part 2) Review Types of global business Global corporation MNE (multinational enterprise) or MNC (multinational corporation) with extensive business operations in more than one foreign country Transnational corporation A global corporation that operates worldwide on borderless basis Some host country complaints about MNCs Host Country companits about MNCs: Excessive profits Interference with local government Domination of local economy Interference with local government Hiring the best local talent Limited technology transfer Disrespect for local customers Examples - War in Ukraine Disruption in global -value chains and increased pressure and interference of MNCs with local government Fertilizer imports in Brazil (one of the major producers of agricultural commodities) We must consider the triple bottom line and the impact in society, the environment and the economy $2.5 billion invest in potash mine in Brazill What about Globalization gap Large multinationals adn industrilizednaitons gaining disporoportinonally form globalization Globalization gap: Large multinational and industrialized nations gaining disproportionally from Globalization Some MNC complaints about host countries MNC Complaints about host countries: Profiit limitations Laws and regulations Overpirce resources Exploitative rules Foreign exchange restriction Failure to uphold contracts Mutual benefits for host countries and multinational companies Mutual benefits for host country and global corporation of MNC: Shared growth opportunities Shared income opportunities Shared learning opportunities Share development opportunities Develop projects together What are some of the ethical challenges for global business Ethincal challenges for global business Child labour Employmnet of children for worl otherwise done by adults Sweatshops Employment of workers at very low wages for long hours in poor working conditions Ex: Nike bad labour prices Unsafe working conditions Corruption Illegal practices that further one’s business interests Corrupiotn of froeign public officials Act makes it illegal for Candain firms and their representatives to engage in corrupt practices overseas Bribes to foreign officials Excessive commissions Non-monetary gifts Sweatshops Conflict materials What is culture Culture : The shared set of beliefs, values, and patterns of behvaiourr common to a group of people Food preferences Values and traditions Language and beliefs Religion Art music Life style Hofstede defines culture as: “The collectiv programing of teh mind distinguishing the members of one group or category of people from others” What is culture shock Culture Shock: Confusion and discoumfert a person experiences in an unfaamiliar culture Stages to adjusting to a new culture Confusion Small vitorires The honeymoon Irritation and anger Reality Cultural Intelligence The ability to adapt and adjust to new cultures What is Ethnocentrism Tendency to consider one’s own culture as superior others Slinet languages of culture Contect Low context High context Space Proxemics Ex: personal space Time Monochronic Polychronic High and low contexts cultures Edward T.Hall (1959) Def: Part of a discourse that surround a word or passage and can throw on its meaning Low context cultures Emphizes communication via spoken or written words Countries like United States, Canada and Germany High context cultures Rely on nonverbal and situational cues as well as on spoken or written works Thailand Malaysia Time Monochronic cultures People tend to do one thing at a time Canda Polychronic cultures Time is used to accomplish many different things at once Egypt Space Proxemics Study of how people use space to communicate In North American people value “personal space’ Many Latin and Asian cultures expect much less personal space Tight and Loose Cultures Cultural tightness-looseness Tight = Strength of norms that govern social behvaviour Japan, Korea, Malaysia Loose = tolerance for any deviation from norms Australia, Brazil, Hungary Values and national cultures (Hofstede) Power distance Uncertainty avoidance Individalism-collectivism Masculinity-femininty Time Orientation Indulgence vs. Restraint Comparative management How management pratices systematically differ among countries and /or cultures Intercultural competencies Skills and personal characteristics that help us be successful in cross cultural situations Global Managers (know how to adapt) Need to successfully apply management functions across interantional boundaries Global Learning goals Not universal Engage critical thinking Look everywhere for new management ideas Always consider culture HEALTH EDUCATION 3. SPECIFIC OBJECTIVES: Students should able to know about_______ 1. definition of health education 2. aims of health education 3. objectives of health education 4. principles of health education 5. scope of health education 6. planning of health education 7. steps in planning health education 8. levels of health education 9. doctors s responsibility 4. INTRODUCTION: Health education is a term frequently used by health care professional. its aims at individual and community health. Health education is the translation of what is known about health into desirable individual and community behaviour pattern by means of an education process. Definition: “A process aimed at encouraging people to want to be healthy , to know how to stay healthy, to do what they can individually and collectively to maintain health And seek help when needed”. OBJECTIVES - To inform people or disseminate scientific knowledge about prevention of disease and promotion of health - To motivate people to change their habits and lifestyle that are harmful to their health also motivate people to adopt habits and ways of living conducive to healthy living. - To guide the people who need help to adapt and maintain healthy practices and lifestyle by showing proper community resources. --- PRINCIPLES OF HEALTH EDUCATION - Credibility Of Message: It is the degree to which the message to be communicated is perceived as trustworthy by the receiver. - Creating interest among participants: It is a psychological principle that people are unlikely to listen to things that are not of their interest. If a health programme is based on the felt needs, people will participate in the programme willingly. - Motivating the participants: Motivation is like a petrol engine that drives the mental engine. It is the fundamental desire in every person to learn. Motivation is contagious; one motivated person may spread motivation throughout the group. 13. - Enhance comprehension of content: It means health education should be based on the level of understanding, education and literacy of people at whom the teaching is directed. Teaching should be within the mental capacity of the audience. - Ensure reinforcement: Repetition at intervals is necessary to promote learning. Without reinforcement and feedback, students can go back to the pre-awareness stage. - Encourage active participation: Health education should aim at encouraging people to work actively with health workers and others in identifying their own health problems and also in developing solutions. 14. - Learning by doing: Teaching is effective when individuals actively participate in health education. Learning becomes active and quicker if the individuals are made active physically as well as psychologically. - Known to unknown: The people in a community know something and the health educator enlarges this knowledge. If the health educator links new knowledge with the old knowledge, it can enhance learning. - Maintaining good human relations: Sharing of information, ideas and feelings happens most easily between people who have a good relationship. 15. - Setting an example: The health educators should set a good example in the topic they are dealing with as it fosters better understanding. - Regular feedback: Feedback is one of the key concepts of the system approach. The health educator can modify the elements of the system in light of the feedback from his audience. For effective communication, feedback is of paramount importance - Efficient leadership: Leaders are agents of change and they can be made use of in health education work. Psychologists have shown and established that we learn best from people we respect and regard. 16. The essential attributes of a leader are as follows - Understands the needs of the community. - Provides proper guidance. - Takes initiative. - Is receptive to the views and suggestions of people. - Identifies himself with the community. Is selfless, honest, impartial, considerate and sincere. - Is easily accessible to people. 17. SCOPE OF HEALTH EDUCATION 1. Nutrition 2. Hygiene 3. Family health 4. Disease prevention and cantrol 5. Psychological health 6. Prevention of accident 7. Use of health services 8. Human biology 19. - Nutrition: The aim of nutrition education is to guide people to choose optimum and balanced diets, remove prejudices and promote good dietary habits. nutrition education is a major intervention for the prevention of malnutrition, promotion of health and improving the quality of life. 20. - Hygiene: This has two aspects: personal and environmental. Personal: The aim of personal hygiene is to promote standards of personal cleanliness . Environmental: Has two aspects: Domestic and community. All environmental sanitation programmes should include health education 21. - Family health: The family is the first defence as well as the chief reliance for the well-being of its members. One of the main tasks of health education is to promote family self-reliance, especially regarding the family's responsibilities in child bearing, child rearing, self-care and in influencing their children to adopt a healthy lifestyle. 22. - Disease prevention and control: Drugs alone will not solve health problems. Without health education, a person may fall sick again and again from the same disease. Educating the people about the prevention and control of locally endemic diseases is the first of the eight essential activities in primary health care. 23. - Psychological health: Psychological health problem can occur everywhere. There is a tendency to an increase in the prevalence of psychological diseases when there is a change in society from agriculture to an industrial economy and when people move from the warm intimacy of a village. 24. - Prevention of accidents: Accidents are a feature of the complexity of modern life. Accidents can occur in home, road and place of work. The predominant factor in accidents is carelessness that can be tackled by health education. 25. - Use of health services: Many people, particularly in rural areas, do not know what health services are available and many more do not know. There is a communication gap between the public and state health administration in the form of feedback for further improvement of health services. One of the declared aims of health education is to inform people about the health services available in their community. 26. PLANNING FOR HEALTH EDUCATION planning: is the process of making thoughtful and systemic decision about what needs to be done , how it has to be done, by whom And with what sources. 27. Principles of planning health education 1) Focus on actual current needs and context of community: It is important that plans are made with the needs and context of the community in mind. Health education should try to understand what is currently happening in the community one works in. 2) Plan for basic needs and interest of the community: Consider the basic needs and interests of the community. If the local needs and interests are not kept under consideration, the plans may not be effective. 28. 3) Planning with actual beneficiaries of health education: Plan with the people involved in the implementation of an activity. If people are included in planning, they will be more likely to participate and the plan will be more likely to succeed. 4) Identify and use all relevant community resources: It is essential that the health educator identify all the relevant resources that are locally available which could be used for benefit of people receiving the health education. 29. 5) Follow principle of flexibility: Planning should be flexible, not rigid. One should be able to modify the plans when necessary. For example, you would have to change your priorities if a new problem needing an urgent response arose. 6) A realistic plan not hypothetical: The planned activity should be achievable and take into consideration the financial, personal resources available and time constraints. Planning must be realistic; do not plan unachievable activities. 30. Steps in planning health education Planning is a continuous process. It does not just happen at the start of project . Health education must be well planned to actually improve and promote individual, family and community health 31. - Needs assessment: Conducting needs assessment is the first and probably the most important step in any successful planning process. assessment is the process of identifying and understanding the health problems of the community and their possible causes. - Identify priorities: After identifying the needs and resources of the community, the next is to identify their priorities because each community may have several problems but the urgent have to be given top priority in health education. For example: goitre 32. - Set the goals and objectives: In planning the process of health education, setting goals and objectives is the third and most essential step because these goals and objectives serve as consciously thought baseline parameters to be achieved during health education. - Develop strategies: Prior to the implementation of the health education intervention one must plan, develop and evaluate the several alternative strategies to achieve the set goals and objectives of health education because each problem and target community is quite unique. 33. - Implementation: This is the core phase of the health education process which includes carrying out the planned strategies so that the set goals and objectives of health education may be achieved. - Monitor and evaluation: This is the final step of the planning process of health education where continuous monitoring as well as end evaluation is carried out to ensure the degree to which stated goals and objectives have been achieved. 34. LEVELS/APPROACH OF HEALTH EDUCATION 35. INDIVIDUAL LEVEL - Individual Approach: The health education must first create an atmosphere of friendship and allow the individual to talk as much as possible. In this individual teaching we can discuss, argue and persuade the individual to change his behaviour. But by this we can reach to a small population and who come in contact with us. Methods of individual health education 1) Home visit 2) Personal contact/ counselling 3) Personnel letters 36. 1) Home visit: A home visit is one of the best approaches for individual health education because it can become one of the best opportunities for health education with individuals and their families. Home visits are important to understand the real background of families, their living conditions and the environment in which they live. 37. 2) Personal contact/counseling : Personal contacts or counselling (one-to-one communication) is a helping process where one person explicitly and purposefully gives his or her time to assist people explore their situations and act on a solution. After this the counsellor needs to work together with the person to find solutions that are appropriate to their situation. 38. 3) personal letters: Personal letters may also be used for individual health education, where health educators may get an opportunity to dispatch letters or printed education material to the people in a target community. 39. GROUP LEVEL Group health education may be useful way to deliver health education massages in efficient manner. A well organized group permits sharing of experiences and skills so that people are able to learn from each other. 40. Methods of group discussion 1)Lecture method: (Chalk & Talk ) A lecture may be defined as carefully prepared oral presentation of facts organized thoughts and ideas by a qualified person. The group should not be more than 30 and talk should not exceed 15-20 minutes. By using suitable audiovisual aids. 2) Group discussion: A group is an aggregation of people interacting in a face to face situation. It is a very effective method of health communication. 41. 3) Demonstration: A demonstration is a carefully prepared presentation to show how to perform a skill. This procedure is carried out step by step before an audience. 4) Panel discussion: In a panel discussion 4-8 qualified persons talk about the topic. Sit and discuss a given topic in front of a large group/audience. The chairman opens the meeting. Panel comprises of a chair person and 4-8 speakers. After the main aspect of the subject are explored, the audience is invited to take part. 42. 5) Symposium: It is a series of speeches on a selected subject. Each expert person present it briefly and at the end of session the chair person make a comprehensive summary. Audience are allowed to raise question. 6) Workshops : It consists of series of meetings usually 4 or more with emphasis on an individual work, within the group and with the help of consultants and response personnel. 7) Role play: This is a brief acting out of an actual situation for the benefit of the audience for better understanding. 43. 8) Conference and seminars: This programmes are usually held on a regional, state/national level. Where several experts from different disciplines meet to deliberate on a particular theme, to appraise others of latest knowledge and research in a particular field. 9) Open forum: It refers to the public meeting which are held for various purposes in the community, for example: gram sabha 44. COMMUNITY LEVEL It is meant for a defined community and is not only to create awareness but also to help people understand their health problems and needs, find alternatives solutions to their problems and needs , implement them, evaluate and get feedback and accordingly do the needful. For health education at the community level, it is better to approach local leaders who are influential and who have the people’s confidence. These may include local officers such as gramsevak, panchayat sarpanch ,police officer or block development officer etc . 45. HOSPITAL LEVEL 1) Health Education in OPD/Outdoor: The patient and his attendants have to spend a lot of time in the outpatient department for health check-up, treatment, registration, diagnosis, admission procedure etc. This period can be utilised for health education. For this, the following means/devices can be used: - Exhibiting pictures, posters, charts, bulletin board and models in the waiting hall. - Arranging group discussion, slide show, or documentary film in a proper place and on a proper topic. - Giving health education on a personal level in the consulting room. This mainly includes nutrition clinic, family planning clinic, psychiatric clinic etc. 46. - Distributing pamphlets. - Arranging street plays or nukkad naatak in the outpatient department or its neighbourhood. 47. 2) Health Education in wards/ IPD: While taking care of the patients the indoor patients, doctors s have the opportunities to educate them. This period can be fully utilised to give health education to the patients. For this the following methods can be effective: - Conversation with the patient and motivating him for change in his behaviour. - Imparting health education by arranging live demonstration for nutrition, treatment, diagnosis etc. - Providing clinical or bedside teaching. - Providing incidental teaching to patient and his attendants. 48. - Presenting examples. To describe the gains of health education in an individual suffering from the same health education in an individual suffering from the same disease and arranging a meeting between the patient and the cured old patients.