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The outdoor recreation industry represents a new economy. The leaders of this economy will need to have a deep understanding of our local natural resources and integrate the components of innovation, health, and wellness into a vision for what comes next. Everyone wins when you do the right things for the environment, the community, and the venture. We want to offer the young generation a chance to be part of the foundation we are building for adventure tourism in the emirates and the region. Adventure Tourism Is the Fastest-Growing Global Niche. What does this mean? It means that thereâs plenty of room for young experts to enter the field. Itâs not just the "guides" that the adventure tourism industry needs. Itâs everything that goes with it, from adventure tourism accommodations to trip planners, event managers, marketing and finance directors, advertising, public relations, and communications. We want to highlight that adventure tourism requires more than just guides, and various careers within adventure tourism play a big role in attracting high-value customers, supporting local economies, and encouraging sustainable practices. The continued growth of this sector creates net positive impacts not only for tourism, but also for destination economies, their people, and their environment. 1) Understanding Tourism Tourism is one of the worldâs fastest-growing industries and a major foreign exchange and employment generation for many countries. It is one of the most remarkable economic and social phenomena. 2) Understanding Adventure Tourism Adventure tourism is defined as the movement of the people from one to another place outside their comfort zone for exploration or travel to remote areas, exotic and possibly hostile areas. Adventure tourism is a type of tourism in which tourists engage in adventure activities such as trekking, climbing, rafting, scuba diving, or the likes. Adventure tourism gains much of its excitement by allowing the tourist to step outside their comfort zone. This may be from experiencing culture shock or through the performance of acts that required some degree of risk whether real or perceived. It is also about connecting with a new culture or a new landscape and being physically active at the same time. It is not only about being risky or pushing your boundaries. In fact, it is especially important to know and respect your limits while you are in an unfamiliar area. Adventure travel is a leisure activity that takes place in an unusual, exotic, remote, or wilderness destination. It tends to be associated with high levels of activity by the participant, most of it outdoors. Adventure tourists expect to experience various levels of risk, excitement, and tranquillity and be personally tested. In particular, they are explorers of unspoiled, exotic parts of the planet and also seek personal challenges. The main factor distinguishing adventure tourism from all other forms of tourism is the planning and preparation involved. 3) Definitions of Adventure Tourism Adventure tourism is a new concept in the tourism industry. The tourism industry adopted adventure tourism, but there is not any specific definition of adventure tourism. Most commentators concur that adventure tourism is a niche sector of the tourism industry, but there are many other niche sectors in tourism that have the same characteristics that overlap with adventure tourism such as ecotourism, activity tourism, or adventure travel. One of them can confuse. Adventure tourism is a complicated and ambiguous topic. Some important definitions of adventure tourism are as following: A) According to the Adventure Travel Trade Association (ATTA): âadventure tourism is a tourist activity that includes physical activity, cultural exchange, or activities in nature.â B) According to Muller and Cleaver: âAdventure tourism is characterized by its ability to provide the tourist with relatively high levels of sensory stimulation, usually achieved by including physically challenging experiential components with the tourist experience.â C) The Canadian Tourism Commission in 1995 defines adventure tourism as: âan outdoor leisure activity that takes place in an unusual, exotic, remote or wilderness destination, involves some form of unconventional means of transportation, and tends to be associated with low or high levels of activity.â D) According to Sung et al: âadventure tourism is the sum of the phenomena and relationships arising from the interactions of adventure touristic activities with the natural environment away from the participantâs usual place of residence area and containing elements of risk in which the outcome is influenced by the participation, setting, and the organizer of the touristâs experience.â E) According to UNWTO: â adventure tourism can be domestic or international, and like all travel, it must include an overnight stay, but not last longer than one year.â 4) Types of Adventure Tourism Adventure tourism has grown exponentially all over the world in recent years with tourists visiting destinations previously undiscovered. This allows for new destinations to market themselves as truly unique, appealing to those travellers looking for a rare, incomparable experience. Adventure tourism includes various activities like caving, hiking, sailing, trekking, etc. Adventure tourism is categorized into two categories: âą Hard Adventure âą Soft Adventure Hard Adventure Hard adventure refers to activities with high levels of risk, requiring intense commitment and advanced skills. Hard tourism includes the activities like climbing mountains/rock/ice, trekking, caving, etc. Hard adventure activities are highly risked in nature. Professional guides and advanced levels of skills are required to perform these activities. Many tourists died during climbing mountains, caving every day. Soft Adventure Soft adventure refers to activities with a perceived risk but low levels of risk, requiring minimal commitment and beginner skills; experienced guides lead most of these activities. Soft tourism includes the activities like backpacking, camping, hiking, kayaking, etc. Soft adventure activities are low-risk in nature. Professional guides lead these activities. Soft adventure is a popular category in adventure tourism as it caters to a wider audience. 5) Adventure Tourism Activities Adventure travellers are early adopters by nature, meaning they are generally more willing to try new destinations, activities, and travel products. Popular activities change rapidly, and it seems there is a new twist on an existing sport every year. Some activities have low risk and some have high. Adventure tourism activities are classified into two types: âą Hard Adventure Activities âą Soft Adventure Activities Hard Adventure Activities Hard adventure activities are highly risky and dangerous in nature. These activities are as the following: âą Caving âą Mountain Climbing âą Rock Climbing âą Ice Climbing âą Trekking âą Sky Diving Soft Adventure Activities These activities are less dangerous and risk as compared to hard adventure activities. These activities are mostly lead by professional guides. An example of these activities are: âą Backpacking âą Bird watching âą Camping âą Canoeing âą Eco-tourism âą Fishing âą Hiking âą Horseback riding âą Hunting âą Kayaking/sea/whitewater âą Orienteering âą Safaris âą Scuba Diving âą Snorkeling âą Skiing âą Snowboarding âą Surfing Adventure tourism activities sit well with the environment because the natural world provides us with the resources for many of the activities that provide risk, challenge, sensory stimulus, novelty, discovery, and so on. 6) Characteristics and Features of Adventure Tourism The threefold combination of activity, nature, and culture marks adventure travel as an all-around challenge. Some unique characteristics and features of adventure tourism are as the following: âą Physical activity, like involving physical exertion or psychomotor skills âą Contact with nature, activities bringing contact with the natural world in general, or with specific wildlife âą Contact with different cultures, i.e. people, faith, lifestyles âą Journeys for example vehicle, animal, or human power âą Uncertain outcomes âą Danger and risk âą Challenges âą Anticipated rewards âą Novelty âą Stimulation and excitement âą Exploration and discovery âą Contrasting emotions 7) Adventure Tourism Supplier A tourism supply chain is the system of people, products, activities, and materials that get a product or service from its raw state through production and distribution to the consumer. As with any sector, volume discounts drive the mass price point, so major retailers primarily market select trips that sell in high volume. The supply chain for these mass tourism products is often very simple, comprising only transportation and accommodation elements. The adventure tourism supply chain is more complex. Niche products often require specializes in knowledge and operations. Adventure tourismâs supply chain linkages go very deep, and this is one of the key reasons that adventure tourism delivers greater benefits at the local level. Supply chains vary from destination to destination. Without a proper supply chain, the tourism sector cannot survive. Tourism suppliers are the backbone of the tourism industry. Adventure tourism suppliers work at a different, different level like as domestic as well international level. 8) Adventure Tourism Importance and Benefits Adventure tourism is one of the fastest-growing sectors of the tourism sector, attracting high-value customers, supporting local economies, and encouraging sustainable practices. The continued growth of this sector creates net positive impacts not only for tourism, but also for destination economies, their people, and their environment. Some importance and benefits of adventure tourism are: A) Employment Generation Adventure tourism generates jobs. Adventure tourism generates directs jobs to accommodation, transportation sector, and travel agencies or tour operators. Adventure tourism also provides indirect jobs to tourism suppliers. Adventure tourism plays an important role in the generation of employment in the economy. B) Foreign Exchange Adventure tourism attracts foreign tourists on a large scale, as a result, it helps in foreign exchange generation. When tourists travel to another country, they spend a large amount of money on accommodation, transportation, and shopping. Adventure tourism generates foreign exchange and supports the economy of the host country. C) Economy Development Adventure tourism helps in the development of the host countryâs economy. Adventure tourism activities directly support the economy in various forms. The more tourists, the more economic growth. D) Support Local Communities Adventure tourism helps in the development of infrastructure and supports local communities. Adventure tourism activities directly contributed to the local economy of the communities and increase local people's living standards. E) Conservation of Natural Resources Adventure tourism activities are nature-based activities. Leaders in the adventure tourism industry are dedicated to making this tourism segment as sustainable as possible. They help in the conservation of natural resources as well as culture. F) Creating Business Opportunities Adventure tourism activities create new business opportunities. Several companies specialize in helping emerging adventure tourism operators market their products. Each new adventure tourism activity creates a new business opportunity. G) Local and Foreign Investment Adventure tourism creates business opportunities; as a result, it attracts local as well as international investors. Investors invest their money in accommodation, transportation, and travel trade organization. Adventure tourism plays an important role in the economy of the host country.'Create a quiz based on this lesson: . Tenali Rama was known for his sense of humour. In fact, King Krishnadevaraya used to enjoy his witty remarks even when they were targeted at him. Here is one such story. Scene 1 One day, an Arab horse trader visited the court of King Krishnadevaraya. He had a fine horse for the king. The (Greek/Chinese/Arab/ British) trader visited the court of King Krishnadevaraya King: All of you know that I am very fond of horses. The horses in my stable are the finest indeed! Send the trader in! I always want some rare breeds of horses from across the world to add to my man collection. Trader: Good day, Your Majesty! I have brought one of the finest horses from ArabiaI request you to see the horse. I am sure you will want him for your royal stable. King: This is indeed a magnificent creature! I wish to buy this fine horse. Trader: Your Majesty, I have two more such horses with me in Arabia and it would be my pleasure to bring them to you. Trader: You are really kind and I am sure you will like ader merchant magnificent splendid/superb King: I am so happy to hear that. I agree to buy the other two horses as well Into Trader: l am grateful for your offer and I promise to return with the other two horses within a week's time. Scene 2 Months passed, but there was no sign of the trader. Worried and anxious, the king decided to take a stroll in the garden. There, he spotted Tenali Rama sitting under a tree and scribbling something on a piece of paper. King: What are you writing on this sheet of paper, Rama? Rama: Here is the paper. You can see for yourself. It is the list of names of people who can be called 'very foolish!. Rama showed the paper to the king. It was a list of names with the king's name at the top. King: My name is always on top of the list. I do know that you respect me. On the top of the list was writtenâ 'List of the Biggest Fools in the World! He became furious. King: How can you call your King, 'a fool?' You will have to explain it to me. Rama: lam really sorry that I had to add you as well in the list of fools. How could your Highness trust an unknown Arab horse trader, give him a huge advance, and expect him to return? ' King: What if he really comes back? Rama: If he returns with his horses after taking so much money from you, then I will put his name as the first one. So, he will be on top of the list of fools. The king realized his mistake. His anger slowly gives way to laughter. King: You are really funny, Rama. I was very unhappy, but with your witty remark, you have defused my anger and anxiety. I love your sense of humour. Rama: Dear King, you are so good to everyone! You fail to understand that you should be good to people, but should never trust strangers. The king agreed and they walked back to the palace. 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 DesirĂ©e Nieuwenhuis | NatĂ lia Pujol-Gualdo Amanda J. Kiliaan Department of Anatomy, Radboud university medical center, Donders Institute for Brain, Cognition and Behaviour, Preclinical Imaging Center PRIME, Nijmegen, The Netherlands Correspondence Amanda J. Kiliaan, PhD, Associate Professor, Department of Anatomy, Donders Institute for Brain, Cognition, and Behaviour, Preclinical Imaging Center PRIME, Radboud university medical center, 6500 HB Nijmegen, Geert Grooteplein 21N 6525 EZ Nijmegen, The Netherlands. Email: amanda.kiliaan@radboudumc.nl Funding information Europees Fonds voor Regionale Ontwikkeling (EFRO), Grant/Award Number: BriteN 2016 1 | INTRODUCTION The prevalence of obesity in adolescents and children is increasing in | Ilse A.C. Arnoldussen | Summary In this review, we discuss the role of adipokines in the onset of puberty in children with obesity during adrenarche and gonadarche and provide a clear and detailed overview of the biological processes of two major players, leptin and adiponectin. Adipokines, especially leptin and adiponectin, seem to induce an early onset of puberty in girls and boys with obesity by affecting the hypothalamic-pituitary- gonadal (HPG) axis. Moreover, adipokines and their receptors are expressed in the gonads, suggesting a role in sexual maturation and reproduction. All in all, adipokines may be a clue in understanding mechanisms underlying the onset of puberty in child- hood obesity and puberty onset variability. KEYWORDS adipokines, obesity, puberty 1,2 the age of 5 years were overweight or were with obesity in 2016, and 3 Obesity is defined by an excessive accumulation of white adipose tissue (WAT), and it is often indicated by a body mass index (BMI) 4 above 30. Two main types of adipose tissue were described: WAT and brown adipose tissue (BAT), which differ in morphology and func- 5-7 Ilse A.C. Arnoldussen and Amanda J. Kiliaan contributed equally to this work. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 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. The majority of the studies examining boys with obesity indicate an early onset of puberty, while not all reported an earlier onset of puberty. In detail, high leptin, TNF-α, and IL-6 levels combined with low adiponectin levels stimulate the activation of the HPG axis in girls and boys with obesity, and 5, 45, 50, 51 REFERENCES 1. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. May- o Clin Proc. 2017;92(2):251-265. 2. Reinehr T, Roth CL. Is there a causal relationship between obesity and puberty? The Lancet Child & adolescent health. 2019;3(1):44-54. 3. WorldHealthOrganization. Facts and figures on childhood obesity. 2017. 4. Guglielmi V, Sbraccia P. Obesity phenotypes: depot-differences in adipose tissue and their clinical implications. Eat Weight Disord. 2018; 23(1):3-14. 5. Gomez-Hernandez A, Beneit N, Diaz-Castroverde S. Escribano O. 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FUNDING INFORMATION This research was funded by Europees Fonds voor Regionale Ontwikkeling (EFRO), project BriteN 2016. ORCID Ilse A.C. Arnoldussen Amanda J. Kiliaan https://orcid.org/0000-0002-7395-5284 https://orcid.org/0000-0002-2158-6210 13, 14, 16-26, 29-32 Furthermore, several receptors Nevertheless, We conclude Search strategy We searched PubMed for articles published before Novem- ber 15th, 2019 using relevant keywords, including âonset of puberty and adiposity/obesityâ, âonset of pubertyâ, âchildren with obesityâ, âadipose tissueâ, âchildhood obesityâ, âadiposityâ, âobesityâ, âadipokine(s)â, âHPG axisâ, âadipokines ovary/ova- riesâ, or âadipokines testesâ, either alone or in combination. 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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 goverEarlier in 2019 there was a lot of femicide uh girls being killed by their boyfriends because they did one or two things there are also cultures of if there is violence in terms of a marital relationship that that is fine if there's a marital rape that that is fine so you find such situations being normalized and it being also a taboo to speak about those issues the 2030 agenda for sustainable development is grounded in respect for human rights and the power of people to change the world every individual on the planet has the right to health and well-being in all aspects of their sexuality their body and their reproductive choices ensuring these rights is integral to addressing poverty education violence against women and gender equality sexual and reproductive health rights are agreed in international law they were fought for by courageous women's rights activists and advocates across a broad range of professional fields and frontline experiences by movements of all ages levels and backgrounds they are still being fought for while progress has been made globally many barriers remain especially for those most marginalized excluded or discriminated against human rights are central to delivering the 17 sustainable development goals in the sustainable development agenda indeed each sdg target is simultaneously a metric and a claim for human rights the interplay between these political commitments and human rights obligations is particularly important when it comes to achieving sexual and reproductive health rights for decades human rights-based tactics have been used to drive progress in this episode of right to a better world experts share challenges they have faced and tactics they have used to address them the challenges they describe occur in settings all around the world the strategies used are ones that they have found to be successful in their own settings viewers are encouraged to learn from these experiences and consider how tactics could be adapted to their own context when sexual and reproductive health begins with equality the discussions decisions programs and policies which follow can build towards a future where every individual is not only born free but lives free and equal in dignity and rights without violence or discrimination the time to take action is now violence against women is any act that results in or is likely to result in physical sexual or psychological harm or suffering to women this includes threats of such acts coercion or arbitrary deprivation of liberty in public or private life it happens everywhere in every country in the home in communities at work and at school crises including health and humanitarian crises frequently contribute to higher rates of violence against women violence against women is directed at women because of their status as women the consequences are dire jeopardizing women's health including sexual and reproductive health and mental health hampering their ability to participate fully in society causing tremendous physical and psychological suffering for both women and their children the majority of women survivors of violence do not disclose or seek any type of services efforts to address violence against women must recognize the many different contexts in which it occurs and the many different forms it can take the majority of violence against women is committed by an intimate partner her current or previous boyfriend or husband globally around 30 of women have experienced physical and or sexual violence by an intimate partner in their lifetime this increases the risk of acquiring an sti or in some regions hiv by 1.5 fold when a woman is experiencing violence especially from her partner she's really unable to keep safe from hiv men have power to decide how when and where sex should be done and the woman is at risk of being infected because she cannot say no schools are another setting where violence against girls can take place assault and harassment during their commute bullying sexual harassment and mental or physical abuse on school property are all challenges across various country contexts this has a direct impact on girls access to inclusive quality education a target of sdg4 and an indirect impact on many of their other human rights young girls are taking advantage of at a very young age and they do not understand the choices and the avenues whereby they can exercise their rights when it comes to sexual productive health and rights and so you find a lot of dropouts and a lot of girls also going through a lot of traumatic experiences that would be avoided if they had guidance promoting a safe and secure working environment for all is a cornerstone of sdg 8. this includes a workplace free from sexual harassment and violence but for many women especially women migrant workers and others in precarious employment this is far from reality so we went to naivasha which is a flower farm and we've met the informal workers the casual liberals working for the flower farms when for example the sexual violence cases are reported companies don't take them very seriously a wide range of tactics have been used to prevent and address violence against women and girls and to recognize it as a fundamental violation of human rights prevention of intimate partner violence is possible when interventions are informed by evidence of what works we started out by describing the problem we've now moved to research on what works what are the kinds of interventions that are successful both for preventing the problem from happening in the first place and also from interventions to respond the respect women framework on preventing violence against women developed by the who un women ohchr and other international agencies promotes seven strategies which focus on relationship skills strengthening empowerment of women services for health justice police and social sector poverty reduction environments made safer including schools workplaces and public spaces child and adolescence abuse prevented and transformation of gender attitudes beliefs and norms this action-oriented framework can enable policy makers and health implementers to design plan implement monitor and evaluate interventions and programs to prevent violence against women we have come a long way for sure we still have some ways to go and we need to do more to stop this violence from happening in the first place this involves addressing the social norms that still prevail in many settings that make this form of violence acceptable women are not exposed to gender-based violence by accident all because of an inbuilt vulnerability violence against women is rooted in discriminatory social norms and power dynamics dismantling these underlying causes of violence against women and girls is at the heart of achieving gender equality and empowering all women and girls as set out in the targets and indicators of sdg 5 ensuring healthy lives in sdg3 and reducing inequalities in sdg 10. women and men are valued differently society has heap privileges on the men while the women are looked at as subordinate power is not only the problem but also the solution to preventing violence against women we are making it personal everyone connects with power every day people living with power or grappling with power they find themselves within this whole conversation if you're working to create gnome change there has to be change at all levels strategies to raise awareness in communities about violence against women and girls are critical as there is still a lot of stigma and shame which inhibits many women and girls from talking about it intervention is like a big complicated word sometimes it's just about talking about dialogue i mean the fact that we went into schools and just began a conversation with parents um bringing them together in the school along with the school personnel and then having the conversation start from there and we also sort of train providers within schools to appropriately refer children to health facilities for care what we found was that this dialogue began to spark other conversations in the community and i guess they just felt that oh it's actually okay to talk about this openly rather than pretend that nothing is going on sassa is a community mobilization approach to prevent violence against women and hiv and aids it is activist led it's not workshop heavy based it comes away from the traditional programming of organizations going to do things themselves instead they support activists who do the activities with their friends and neighbors health systems play a critical role in responding to violence wherever it occurs supporting health workers to respond appropriately to violence as well as ensuring their work environment enables them to provide safe effective and quality survivor centred care are important strategies for better addressing violence against women and girls um we came to learn not to ask direct questions not to give our opinion or our judgment on them and let her speak and once with that flow starts once that connection is established that doctor-patient relationship emotionally is established she will actually tell you the whole history legal frameworks to promote enforce and monitor equality and non-discrimination on the basis of sex are an important sdg 5 indicator but putting laws in place does not automatically make them effective there are existing protections for women in the workplace or for individuals in the workplace in relation to harassment but we know from our call for evidence that they are not actually addressing the problem the recommendations that we developed included government implementing a mandatory duty for employers to take preventative steps to address harassment in the workplace so what we would like to see is government implement a much stronger legislative duty it has taken decades of struggle by the women's rights movement to persuade the international community to view violence against women as a human rights concern and a sustainable development priority not a private matter governments have obligations to respect protect and fulfill the right to a life free of violence and to provide for sanctions when they fail when seeking accountability the priority consideration must always be the safety and well-being of survivors respecting their wishes and autonomy and supporting them to make informed choices about the type of justice they want context is vitally important there are many strategies to hold perpetrators accountable including strategic litigation and public campaigns when the teachers impregnate the girls that means the system has failed and okay what they do is they blacklist the teachers and they are always removed from the payroll but we think that is not enough the case that was quite interesting is where one of the judges she did find a ruling against the teacher service commission the commission that is responsible for hiring teachers asking them that they must take responsibility and they were ordered to pay compensation to the girls who had gotten pregnant while in school the justice police issue came about a few years back when a young girl was raped and the punishment for her being ripped was that harappa she was gang-ripped and therapists were told to slash grass feminist organizations and young women organizations came back to the police and the police commissioner to ask and request that the people who are found to be perpetrators should be punished according to our constitution and according to the laws of the land and those are very big campaigns to get better justice so consequently they were jailed but also it was a sign that the system the police system had to be checked in terms of when someone reports a case any case of violence what happens and how is it followed through the maria pedra is another example of litigation that became a political mobilizer so this was a case from the inter-american commission that really galvanized a change in public policy a huge change because it was a case that addressed gender-based violence intimate partner violence it called on responsibility of brazil also for not having prevented this kind of violence the reality of a case that says you have the right to not be bruised you have the right to be free of physical psychological violence it's powerful it can change women's lives investing in autonomous women's movements has been one of the most important drivers of changes in laws and policies to address violence against women over the past 40 years according to data from over 70 countries women organizing to advance women's status define the very concept of violence against women raised awareness of the issue and put it on national and global policy agendas often we thought that it takes generations or centuries to change working intensely with the communities we can actually see change coming violence against women and girls is a violation of fundamental human rights to life and to physical and psychological integrity not to be tortured or treated in an inhuman and degrading way to respect for private and family life and the right not to be discriminated against this understanding is more than theoretical human rights-based tactics can offer a practical route to addressing systemic challenges across all the circumstances where violence against women and girls occurs including but not limited to at the hands of their partners at school and in the workplace by using evidence-informed prevention strategies addressing power relations and social norms community mobilizing and dialogue supporting health systems and professionals putting in place strong legal frameworks accessing justice and ending impunity feminist organizing and mobilizing every individual can help to deliver the 2030 agenda for sustainable development building a world in which women and girls are free from all forms of violence and discrimination [Music] youDAY 1Day-1Day-1-Basic question typesDay 1-3 Review