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Introduction 1. Relevance of the course 2. Key concepts and common competencies 3. Core competency in Entrepreneurship 4. Career opportunities for Grade 12 entrepreneurship
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Teaching English Introduction to the course: Language learning and teaching A 2 Characteristics of the language learners: Studying a system that aligns with international standards. A3 Cognitive factors in language learning: Addressing questions and obtaining necessary information regarding phenomena such as transfer, interference, and generalization; A4 Inductive and deductive language learning: ability and intelligence; and the phenomenon of systematic forgetting A5 Language learning methods and strategies: Familiarizing with foreign language learning methods, strategies for learning foreign languages, and communication strategies A6 International Assessment System of language skills in CEFR, IELTS, TOEFL: effective methods and strategies used to improve language skills (listening, reading, writing, speaking) A7 Psychological factors in language learning: Exploring various psychological factors such as self-esteem, shyness, risk-taking, anxiety, attitude, and motivation A8 The effectiveness of authentic materials during the learning process: The role of tasks and games in teaching foreign languages A9 Errors in language learning: Discussing types of errors, identifying and describing errors, causes of errors, and fossilized errors A10 Error correction or error analysis approaches: developing students' ability to apply their knowledge in practicing error correction A11 Age-related factors in language learning: Exploring types of comparisonand contrast, focusing on topics such as the age hypothesis and bilingualism, and providing a detailed explanation of these concepts A12 Teaching grammar: Studying grammar teaching methods; deductive and inductive approaches in grammar teaching; A13 Teaching grammar through context: linguistic intuition; language phenomena; using grammatical dictionaries; analyzing grammatical tasks; and designing exercises, tasks, and tests through completing grammarbased activities. A14 Teaching vocabulary. Seeking answers to questions such as 'What is a word?' and 'What does it mean to learn a word?' A15 Teaching vocabulary in context: teaching lexical units/phrases/collocations; introducing new vocabulary; using corpus data for pedagogical purposes; developing students' vocabulary learning strategies A16 Assessing vocabulary tasks: designing vocabulary tasks, exercises, and tests. In international assessment systems such as CEFR, IELTS, and TOEFL, grammar accuracy and lexical resource A 17 Teaching pronunciation: Understanding the importance of pronunciation for successful communication; teaching stress; teaching intonation A18 Modern technologies in teaching pronunciation A19 Error correction methods: watching to various experiences in this area and analyzing video lessons from international experts in the field A20 Analysis of skill integration in language learning: Understanding the stages of developing skill integration; integration of the four language skills; task-based integration; and project-based integration. A21 Teaching listening comprehension A22 Modern technologies in teaching listening comprehension A23 Teaching Speaking A24 Modern technologies in teaching Speaking A25 Teaching Reading A26 Modern technologies in teaching Reading A27 Teaching Writing A28 Modern technologies in teaching Writing A29 The role and importance of translation in teaching a foreign language A30 Module 2. International standards for teaching and assessment Classroom Language: The teacher's actions; the teacher's voice; the teacher's intonation; using the foreign language in the classroom A31 Foreign language environment: asking questions in the foreign language, giving instructions in the foreign language, providing oral explanations in the foreign language, and issues related to the use of the native language in the foreign language class. A 32 Designing curriculum: Studying, analyzing, and working with curricula designed for schools, lyceums, and colleges. A33 Planning lessons and the structure of lesson plans: determining thesequence of lessons, objectives, tasks, and expected outcomes; choosing the lesson structure for planning A34 Designing tasks for different stages of the lesson: Starting the lesson; concluding the lesson; connecting tasks within the lesson A35 Time management: allocating appropriate time for tasks during the lesson; and providing homework assignments A36 Educational materials and resources: Effective use of existing educational materials and resources; anticipating and addressing potential issues Planning and adapting materials: to the situation during teaching and working on lesson planning for groups of students with different abilities. A37 Classroom research: Stages of classroom research, data collection, analysis, and planning; creating/preparing the materials needed for data collection; distinguishing between the positive and negative aspects of the research A38 Data analysis: creating/preparing the materials needed for data collection; distinguishing between the positive and negative aspects of the research. A39 Peer lesson observation: Observing lessons; conducting interviews; questionnaires for teachers and students; maintaining a daily record; discussing problematic situations/events; notes and other aspects; the process of lesson observation: stages of observation; presenting observation results both orally and in writing. A40 Educational materials and national values: important tool for implementing and promoting educational standards, as well as national values. A41 Differences between methods of teaching foreign languages: practical application of modern methods in language teaching; foreign experiences in language teaching: the grammar-translation method; the method of conducting lessons entirely in the foreign language; the audio-linguistic method; and communicative methods. A42 Methods used in the local environment and their analysis: Discussion of the positive and negative aspects of various methods; language and culture; teaching/learning processes; the role of the native language in learning a foreign language; and the psychological foundations of foreign language teaching. A43 Teaching a foreign language through computer technologies A44 Types of independent work and its implementation A45 Principles of Assessment in foreign language teaching Đ46 Issues in Language Assessment Đ47 Alternatives in Assessment Đ48 Test methods. Methods and criteria for assessing language aspects: written expression, reading, listening comprehension, speaking, Đ49 integrating language skills: vocabulary; grammar; alternative forms of assessment; planning assessment; critical analysis; principles for designingtest tasks: scientific rigor, consistency, conciseness, clarity, informality, logical sequence, and systematic approach. Đ50 Foreign language for ESP. Studying and analyzing needs; setting objectives for teaching a foreign language in a specific field or professional area; defining teaching approaches in curriculum development; and discussing topics related to these areas. Đ51 Selecting textbooks, materials and resources Đ52 Content-based Instruction (CBI) Đ53 Strategies-based Instruction Đ54 Lifelong Learning: Teacher development, PreSETT, InSETT Đ55 The Role of Teaching Practice A56 Organization and implementation of compulsory and non-compulsory course process in foreign language teaching A57 Organization in and outclass activities A58 Defining the goals and content of foreign language teaching at various levels of the education system in the Republic of Uzbekistan: evaluating educational materials; adapting educational materials; creating educational materials; and discussing the role of the foreign language teacher in specialized fields to gain relevant information. A59 The role of independent study skills: foreign language focused on reading, research and study skills; make revision questions. incclude mcq question. answer the question. true false1.Which Part Of The Science Investigatory Project Report Provides A Concise Summary Of The Entire Study? A) Title Page B) Abstract C) Chapter 1: Introduction And Its Background D) Chapter II: Review Of Related Literature And Studies 2.In Which Chapter Of The Science Investigatory Project Report Is The Problem Being Investigated Stated? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter V: Summary, Conclusion, And Recommendation 3.Where Can You Find The Formulation Of Hypothesis In The Science Investigatory Project Report? A) Chapter 1: Introduction And Its Background B) Chapter III: Methodology C) Chapter IV: Presentation, Analysis, And Interpretation Of Data D) Chapter V: Summary, Conclusion, And Recommendation 4.Which Part Of The Science Investigatory Project Report Explains The Significance And Relevance Of The Study? A) Title Page B) Abstract C) Chapter 1: Introduction And Its Background D) Chapter V: Summary, Conclusion, And Recommendation 5.Which Chapter Of The Science Investigatory Project Report Presents The Scope And Limitations Of The Study? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter V: Summary, Conclusion, And Recommendation 6.Where Can You Find The Definition Of Terms Used In The Science Investigatory Project Report? A) Title Page B) Abstract C) Chapter 1: Introduction And Its Background D) Chapter III: Methodology 7.In Which Chapter Of The Science Investigatory Project Report Are The Related Literature And Studies Discussed? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter V: Summary, Conclusion, And Recommendation 8.Where Can You Find The Subject Of The Study In The Science Investigatory Project Report? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter IV: Presentation, Analysis, And Interpretation Of Data 9.Which Chapter Of The Science Investigatory Project Report Presents The Research Design And Procedure Used? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter IV: Presentation, Analysis, And Interpretation Of Data 10.In Which Chapter Of The Science Investigatory Project Report Are The Results And Analysis Of The Gathered Data Presented? A) Chapter 1: Introduction And Its Background B) Chapter II: Review Of Related Literature And Studies C) Chapter III: Methodology D) Chapter IV: Presentation, Analysis, And Interpretation Of DataTHE FIDE LAWS OF CHESS. Introduction FIDE Laws of Chess cover over-the-board play. The Laws of Chess have two parts: 1. Basic Rules of Play and 2. Competitive Rules of Play. The English text is the authentic version of the Laws of Chess (which were adopted at the 93rd FIDE Congress at Chennai, India) coming into force on 1 January 2023. Preface. The Laws of Chess cannot cover all possible situations that may arise during a game, nor can they regulate all administrative questions. Where cases are not precisely regulated by an Article of the Laws, it should be possible to reach a correct decision by studying analogous situations which are regulated in the Laws. The Laws assume that arbiters have the necessary competence, sound judgement and absolute objectivity. Too detailed a rule might deprive the arbiter of his/her freedom of judgement and thus prevent him/her from finding a solution to a problem dictated by fairness, logic and special factors. FIDE appeals to all chess players and federations to accept this view. A necessary condition for a game to be rated by FIDE is that it shall be played according to the FIDE Laws of Chess. It is recommended that competitive games not rated by FIDE be played according to the FIDE Laws of Chess. Member federations may ask FIDE to give a ruling on matters relating to the Laws of Chess. BASIC RULES OF PLAY. Article 1: The Nature and Objectives of the Game of Chess 1.1 1.2 1.3 1.4 The game of chess is played between two opponents who move their pieces on a square board called a âchessboardâ. The player with the light-coloured pieces (White) makes the first move, then the players move alternately, with the player with the dark-coloured pieces (Black) making the next move. A player is said to âhave the moveâ when his/her opponentâs move has been âmadeâ. The objective of each player is to place the opponentâs king âunder attackâ in such a way that the opponent has no legal move. 1.4.1 The player who achieves this goal is said to have âcheckmatedâ the opponentâs king and to have won the game. Leaving oneâs own king under attack, exposing oneâs own king to attack and also âcapturingâ the opponentâs king is not allowed. 1.4.2 The opponent whose king has been checkmated has lost the game. 1.5 If the position is such that neither player can possibly checkmate the opponentâs king, the game is drawn (see Article 5.2.2). Article 2: The Initial Position of the Pieces on the Chessboard 2.1 2.2 The chessboard is composed of an 8 x 8 grid of 64 equal squares alternately light (the âwhiteâ squares) and dark (the âblackâ squares). The chessboard is placed between the players in such a way that the near corner square to the right of the player is white. At the beginning of the game White has 16 light-coloured pieces (the âwhiteâ pieces); Black has 16 dark-coloured pieces (the âblackâ pieces). These pieces are as follows: A white king usually indicated by the symbol K A white queen Two white rooks Two white bishops Two white knights Eight white pawns A black king A black queen Two black rooks Two black bishops Two black knights Eight black pawns usually indicated by the symbol Q usually indicated by the symbol R usually indicated by the symbol B usually indicated by the symbol N usually indicated by the symbol usually indicated by the symbol K usually indicated by the symbol Q usually indicated by the symbol R usually indicated by the symbol B usually indicated by the symbol N usually indicated by the symbol Staunton Pieces p Q K B N R 9 2.3 The initial position of the pieces on the chessboard is as follows: 2.4 The eight vertical columns of squares are called âfilesâ. The eight horizontal rows of squares are called âranksâ. A straight line of squares of the same colour, running from one edge of the board to an adjacent edge, is called a âdiagonalâ. Article 3: The Moves of the Pieces 3.1 It is not permitted to move a piece to a square occupied by a piece of the same colour. 3.1.1 If a piece moves to a square occupied by an opponentâs piece the latter is captured and removed from the chessboard as part of the same move. 3.1.2 A piece is said to attack an opponentâs piece if the piece could make a capture on that square according to Articles 3.2 to 3.8. 3.1.3 A piece is considered to attack a square even if this piece is constrained from moving to that square because it would then leave or place the king of its own colour under attack. 3.2 The bishop may move to any square along a diagonal on which it stands. 3.3 The rook may move to any square along the file or the rank on which it stands. 3.4 The queen may move to any square along the file, the rank or a diagonal on which it stands. 3.5 3.6 3.7 When making these moves, the bishop, rook or queen may not move over any intervening pieces. The knight may move to one of the squares nearest to that on which it stands but not on the same rank, file or diagonal. 3.7 When making these moves, the bishop, rook or queen may not move over any intervening pieces. The knight may move to one of the squares nearest to that on which it stands but not on the same rank, file or diagonal. The pawn: 3.7.1 The pawn may move forward to the square immediately in front of it on the same file, provided that this square is unoccupied, or 3.7.2 on its first move the pawn may move as in 3.7.1 or alternatively it may advance two squares along the same file, provided that both squares are unoccupied, or 3.7.3 the pawn may move to a square occupied by an opponentâs piece diagonally in front of it on an adjacent file, capturing that piece. 3.7.3.1 A pawn occupying a square on the same rank as and on an adjacent file to an opponentâs pawn which has just advanced two squares in one move from its original square may capture this opponentâs pawn as though the latter had been moved only one square. 3.7.3.2 This capture is only legal on the move following this advance and is called an âen passantâ capture. 3.7.3.3 When a player, having the move, plays a pawn to the rank furthest from its starting position, he/she must exchange that pawn as part of the same move for a new queen, rook, bishop or knight of the same colour on the intended square of arrival. This is called the square of âpromotionâ. 3.7.3.4 The player's choice is not restricted to pieces that have been captured previously. 3.7.3.5 This exchange of a pawn for another piece is called promotion, and the effect of the new piece is immediate. 3.8 There are two different ways of moving the king: 3.8.1 by moving to an adjoining square. 3.8.2 by âcastlingâ. This is a move of the king and either rook of the same colour along the playerâs first rank, counting as a single move of the king and executed as follows: the king is transferred from its original square two squares towards the rook on its original square, then that rook is transferred to the square the king has just crossed. 3.8.2.1 The right to castle has been lost: 3.8.2.1.1 If the king has already moved, or 3.8.2.1.2 With a rook that has already moved. 3.8.2.2 Castling is prevented temporarily: 3.8.2.2.1 if the square on which the king stands, or the square which it must cross, or the square which it is to occupy, is attacked by one or more of the opponent's pieces, or 3.8.2.2.2 if there is any piece between the king and the rook with which castling is to be effected. 3.9 The king in check: 3.9.1 The king is said to be 'in check' if it is attacked by one or more of the opponent's pieces, even if such pieces are constrained from moving to the square occupied by the king because they would then leave or place their own king in check. 3.9.2 No piece can be moved that will either expose the king of the same colour to check or leave that king in check. 3.10 Legal and illegal moves; illegal positions: 3.10.1 A move is legal when all the relevant requirements of Articles 3.1 â 3.9 have been fulfilled. 3.10.2 A move is illegal when it fails to meet the relevant requirements of Articles 3.1 â3.9. 3.10.3 A position is illegal when it cannot have been reached by any series of legal moves. Article 4: The Act of Moving the Pieces 4.1 4.2 Each move must be played with one hand only. Adjusting the pieces or other physical contact with a piece: 4.2.1 Only the player having the move may adjust one or more pieces on their squares, provided that he/she first expresses his/her intention (for example by saying âjâadoubeâ or âI adjustâ). 4.2.2 Any other physical contact with a piece, except for clearly accidental contact, shall be considered to be intent. 4.3 Except as provided in Article 4.2.1, if the player having the move touches on the chessboard, with the intention of moving or capturing: 4.3.1 one or more of his/her own pieces, he/she must move the first piece touched that can be moved. 4.3.2 one or more of his/her opponentâs pieces, he/she must capture the first piece touched that can be captured. 4.3.3 one or more pieces of each colour, he/she must capture the first touched opponentâs piece with his/her first touched piece or, if this is illegal, move or capture the first piece touched that can be moved or captured. If it is unclear whether the playerâs own piece or his/her opponentâs was touched first, the playerâs own piece shall be considered to have been touched before his/her opponentâs. 4.4 If a player having the move: 4.4.1 touches his/her king and a rook he/she must castle on that side if it is legal to do so 4.4.2 deliberately touches a rook and then his/her king he/she is not allowed to castle on that side on that move and the situation shall be governed by Article 4.3.1. 4.4.3 intending to castle, touches the king and then a rook, but castling with this rook is illegal, the player must make another legal move with his/her king (which may include castling with the other rook). If the king has no legal move, the player is free to make any legal move. 4.4.4 promotes a pawn, the choice of the piece is finalised when the piece has touched the square of promotion. 4.5 4.6 If none of the pieces touched in accordance with Article 4.3 or Article 4.4 can be moved or captured, the player may make any legal move. The act of promotion may be performed in various ways: 4.6.1 the pawn does not have to be placed on the square of arrival. 4.6.2 removing the pawn and putting the new piece on the square of promotion may occur in any order. 4.6.3 If an opponentâs piece stands on the square of promotion, it must be captured. 4.7 When, as a legal move or part of a legal move, a piece has been released on a square, it cannot be moved to another square on this move. The move is considered to have been made in the case of: 4.7.1 A capture, when the captured piece has been removed from the chessboard and the player, having placed his/her own piece on its new square, has released this capturing piece from his/her hand. 4.7.2 Castling, when the player's hand has released the rook on the square previously crossed by the king. When the player has released the king from his/her hand, the move is not yet made, but the player no longer has the right to make any move other than castling on that side, if this is legal. If castling on this side is illegal, the player must make another legal move with his/her king (which may include castling with the other rook). If the king has no legal move, the player is free to make any legal move. 4.7.3 Promotion, when the player's hand has released the new piece on the square of promotion and the pawn has been removed from the board. 4.8 4.9 A player forfeits his/her right to claim against his/her opponentâs violation of Articles 4.1 â 4.7 once the player touches a piece with the intention of moving or capturing it. 4.8. A player forfeits his/her right to claim against his/her opponentâs violation of Articles 4.1 â 4.7 .4.9. If a player is unable to move the pieces, an assistant, who shall be acceptable to the arbiter, may be provided by the player to perform this operation. Article 5: The Completion of the Game 5.1.1 The game is won by the player who has checkmated his/her opponentâs king. This immediately ends the game, provided that the move producing the checkmate position was in accordance with Article 3 and Articles 4.2 â 4.7. 5.1.2 The game is lost by the player who declares he/she resigns (this immediately ends the game), unless the position is such that the opponent cannot checkmate the playerâs king by any possible series of legal moves. In this case the result of the game is a draw. 5.2.1 The game is drawn when the player to move has no legal move and his/her king is not in check. The game is said to end in âstalemateâ. This immediately ends the game, provided that the move producing the stalemate position was in accordance with Article 3 and Articles 4.2 â 4.7. 5.2.2 The game is drawn when a position has arisen in which neither player can checkmate the opponentâs king with any series of legal moves. The game is said to end in a âdead positionâ. This immediately ends the game, provided that the move producing the position was in accordance with Article 3 and Articles 4.2 â 4.7. 5.2.3 The game is drawn upon agreement between the two players during the game, provided both players have made at least one move. This immediately ends the game. COMPETITIVE RULES OF PLAY Article 6: The Chessclock 6.1 âChessclockâ means a clock with two time displays, connected to each other in such a way that only one of them can run at a time. âClockâ in the Laws of Chess means one of the two time displays. Each time display has a âflagâ. âFlag-fallâ means the expiration of the allotted time for a player. 6.2 Handling the chessclock: 6.2.1 During the game each player, having made his/her move on the chessboard, shall pause his/her own clock and start his/her opponentâs clock (that is to say, he/she shall press his/her clock). This âcompletesâ the move. A move is also completed if: 6.2.1.1 6.2.1.2 the move ends the game (see Articles 5.1.1, 5.2.1, 5.2.2, 9.2.1, 9.6.1 and 9.6.2), or the player has made his/her next move, when his/her previous move was not completed. 6.2.2 A player must be allowed to pause his/her clock after making his/her move, even after the opponent has made his/her next move. The time between making the move on the chessboard and pressing the clock is regarded as part of the time allotted to the player. 6.2.3 A player must press his/her clock with the same hand with which he/she made his/her move. It is forbidden for a player to keep his/her finger on the clock or to âhoverâ over it. 6.2.4 The players must handle the chessclock properly. It is forbidden to press it forcibly, to pick it up, to press the clock before moving or to knock it over. Improper clock handling shall be penalised in accordance with Article 12.9. 6.2.5 6.2.6 Only the player whose clock is running is allowed to adjust the pieces. If a player is unable to use the clock, an assistant, who must be acceptable to the arbiter, may be provided by the player to perform this operation. His/Her clock shall be adjusted by the arbiter in an equitable way. This adjustment of the clock shall not apply to the clock of a player with a disability. 6.3 Allotted time: 6.3.1 When using a chessclock, each player must complete a minimum number of moves or all moves in an allotted period of time including any additional amount of time added with each move. All these must be specified in advance. 6.3.2 The time saved by a player during one period is added to his/her time available for the next period, where applicable. In the time-delay mode both players receive an allotted âmain thinking timeâ. Each player also receives a âfixed extra timeâ with every move. The countdown of the main thinking time only commences after the fixed extra time has expired. Provided the player presses his/her clock before the expiration of the fixed extra time, the main thinking time does not change, irrespective of the proportion of the fixed extra time used. 6.4 Immediately after a flag falls, the requirements of Article 6.3.1 must be checked. 6.5 Before the start of the game the arbiter shall decide where the chessclock is placed. 6.6 At the time determined for the start of the game Whiteâs clock is started.6.7. Default time: 6.7.1 The regulations of an event shall specify a default time in advance. If the default time is not specified, then it is zero. Any player who arrives at the chessboard after the default time shall lose the game unless the arbiter decides otherwise. 6.7.2 If the regulations of an event specify that the default time is not zero and if neither player is present initially, White shall lose all the time that elapses until he/she arrives, unless the regulations of an event specify, or the arbiter decides otherwise. 6.8 A flag is considered to have fallen when the arbiter observes the fact or when either player has made a valid claim to that effect. 6.9 Except where one of Articles 5.1.1, 5.1.2, 5.2.1, 5.2.2, 5.2.3 applies, if a player does not complete the prescribed number of moves in the allotted time, the game is lost by that player. However, the game is drawn if the position is such that the opponent cannot checkmate the playerâs king by any possible series of legal moves. 6.10 Chessclock setting: 6.10.1 Every indication given by the chessclock is considered to be conclusive in the absence of any evident defect. A chessclock with an evident defect shall be replaced by the arbiter, who shall use his/her best judgement when determining the times to be shown on the replacement chessclock. 6.10.2 If during a game it is found that the setting of either or both clocks is incorrect, either player or the arbiter shall pause the chessclock immediately. The arbiter shall install the correct setting and adjust the times and move-counter, if necessary he/she shall use his/her best judgement when determining the clock settings. 6.11.1 If the game needs to be interrupted, the arbiter shall pause the chessclock. 6.11.2 A player may pause the chessclock only in order to seek the arbiterâs assistance, for example when promotion has taken place and the piece required is not available. 6.11.3 The arbiter shall decide when the game restarts. 6.11.4 If a player pauses the chessclock in order to seek the arbiterâs assistance, the arbiter shall determine whether the player had any valid reason for doing so. If the player has no valid reason for pausing the chessclock, the player shall be penalised in accordance with Article 12.9. 6.12.1 Screens, monitors, or demonstration boards showing the current position on the chessboard, the moves and the number of moves made/completed, and clocks which also show the number of moves, are allowed in the playing hall. 6.12.2 The player may not make a claim relying only on information shown in this manner. 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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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 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. 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, WidĂ©n 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) 1999â2004. 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. 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Associations between body mass, leptin, IGF-I and circulating adrenal androgens in children with obesity and premature adrenarche. Eur J Endocrinol. 2002;146(4):537-543. 56. Böttner A, Jr K, MĂŒller 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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The usefulness of circulating levels of leptin, kisspeptin, and neurokinin B in obese girls with precocious puberty. 2018;34:627-630. 69. Lee J, Song J, Hootman JM, et al. Obesity and other modifiable fac- tors for physical inactivity measured by accelerometer in adults with knee osteoarthritis: data from the osteoarthritis initiative (OAI). Arthritis Care Res (Hoboken). 2012;53-61. 70. Bramswig J, Dubbers A. Disorders of pubertal development. Deutsches Arzteblatt international. 2009;106:295-303. quiz 04 71. Elias CF, Purohit D. Leptin signaling and circuits in puberty and fertil- ity. Cell Mol Life Sci. 2013;70(5):841-862. 72. Riumallo J, Durnin JV. Changes in body composition in adolescent boys. Eur J Clin Nutr. 1988;42(2):107-112. 73. Siervogel RM, Demerath EW, Schubert C, et al. Puberty and body composition. Horm Res. 2003;60(Suppl 1):36-45. 74. Zhang J. Gong M. Andrologia: Review of the role of leptin in the regu- lation of male reproductive function; 2018. 75. 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The relationship between obesity and body compositions with respect to the timing of puberty in Chongqing adolescents: a cross-sectional study. BMC Pub- lic Health. 2017;17:664-673. 81. Ishikawa T, Fujioka H, Ishimura T, Takenaka A, Fujisawa M. Expres- sion of leptin and leptin receptor in the testis of fertile and infertile patients. Andrologia. 2007;39(1):22-27. 82. Martins AD, Moreira AC, Sa R, et al. Leptin modulates human Sertoli cells acetate production and glycolytic profile: a novel mechanism of obesity-induced male infertility? Biochim Biophys Acta. 1852;2015: 1824-1832. 83. Morash BA, Willkinson D, Ur E, Wilkinson M. Resistin expression and regulation in mouse pituitary. FEBS Lett. 2002;526(1-3):26-30. 84. Cabrera SM, Bright GM, Frane JW, Blethen SL, Lee PA. Age of thelarche and menarche in contemporary US females: a cross- sectional analysis. Journal of pediatric endocrinology & metabolism: JPEM. 2014;27(1-2):47-51. 85. Herman-Giddens ME, Steffes J, Harris D, et al. Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics. 2012;130(5):e1058-e1068. 86. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1-452. 87. Akin I, Tolg R, Hochadel M, et al. No evidence of âobesity paradoxâ after treatment with drug-eluting stents in a routine clinical practice: results from the prospective multicenter German DES.DE (German Drug-Eluting Stent) Registry. JACC Cardiovasc Interv. 2012;5(2): 162-169. 88. Marcovecchio ML, Chiarelli F. Obesity and growth during childhood and puberty. World Rev Nutr Diet. 2013;106:135-141. How to cite this article: Nieuwenhuis D, Pujol-Gualdo N, Arnoldussen IAC, Kiliaan AJ. Adipokines: A gear shift in puberty. Obesity Reviews. 2020;21:e13005. https://doi.org/ 10.1111/obr.13005 1467789x, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13005, Wiley Online Library on [10/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are gover What is an official invitation letter? The companies write a letter of invitation-business when they host business visitors from abroad or from the same region or country. The business visitors can be investors; potential buyers may be conference visitors, business partners, employees of any company, or mere individuals who come for training at the companyâs facilities. If a company is inviting any visitor, a representative of that company must write the letter. Also, the firms must have some specific people who would sign the invitation letters. These letters are very much precise, only containing the necessary information. The invitation letter should state the name of the business organization they represent and their relationship to the host (e.g., distributor, regional sales reps, etc.). The letter should articulate the planned dates of travel, and must be formatted professionally. What is a personal invitation letter? A Personal invitation letter is a letter one writes to invite people to a party or a social gathering at a very personal level. It is a formal request asking for the personâs presence at the event that is going to take place. All the relevant details regarding the event like the reason, date, time and venue and the dress code, if any, must be provided in the invitation letters. This will keep the guests informed, and they will feel happy to attend the event. The style and tone of the letter would depend upon the relationship between the sender and receiver. Through the letter, you should be able to make the receiver feel that you highly value his/her presence at the party or the event. A personal invitation letter can be written to invite a person to a birthday party, wedding, conference, meeting, dinner, etc. Before writing the letter, make sure you have a list of people whom you would like to invite to the party or the event. How to Write an Invitation Letter Writing an invitation letter becomes easy and swift once you get through the tips and the format of the invitation letter provided below. Usually block, semi-block or a modified block format is used for official invitation letters. The important aspects of any invitation letters are date, time, salutations and closing. For more advice refer to the tips provided. Tips for Invitation Letter Writing â Organize the Matter â Before you draft an invitation letter ensure that you have all the required material. This material refers to a list of the people to be invited, sequential order of the events, timings of the events, special guest, official documents, photocopies and any other required item. Some items may also need to be attached along with the letter, keep them alongside. Refer to these as and when required. All the relevant documents will help you in drafting the letter. â Drafting â You donât just write a letter straightway and post it. It has to be reviewed and finalized. One of these processes is drafting. Drafting ensures that your mistakes and their rectification arenât passed on to the invitation itself. Make all the mistakes in the draft itself. Drafting an invitation letter is important as sometimes we may make mistakes that we are not able to see but they are visible to others. One may require a draft to be approved by seniors before it is finalized. A second opinion from a friend or peer etc. may be required as well to determine certain things. â Politeness â You donât need to be told that you have to use polite language while writing an invitation letter, why would you be rude when sending an invitation? True, but you have to remind yourself of certain manners and etiquettes required of an invitation. Your invitation is your initiative, not the recipients so you need to be gracious. Always begin the letter with a welcome note instead of straightforward information of the invitation. Words of respect and gratitude are symbols of courtesy and politeness, always expressing your gratitude in the beginning and the end of the letter. â Positive Tone â The gesture of welcome and gratitude themselves are positive points of an invitation letter. Apart from these, gestures of appreciation and anticipation are other positive points which can persuade a guest to attend the event. When you show your appreciation and anticipation towards the recipient through your words, it is an acknowledgement of his importance and thereby a positive approach. Towards this effect two tenses are used within the invitation letter, the present and the future. The present tense conveys information about the event and the future tense conveys an anticipated presence of the guest. â Offer Assistance â An invitation being the responsibility of the sender, the assistance to the recipient by default becomes a responsibility of the host. The more facilities you provide the better the chances of someoneâs attendance. You can offer pick up and drop services, accommodation, meals, provide them contact numbers in case you are not present at the venue and other required assistance. Relevant facts like date, time and venue of the event in the beginning itself is itself assisting. These assistances encourage a positive response from the invitees. â Special Instructions â Some occasions require special instructions for the guests. These instructions can be: 1. Dress code 2. Road or route map 3. Purpose of the occasion â birthday, honor, anniversary etc. 4. Return gift 5. Response or confirmation to the invitation 6. Attire and items required for the guest to bring 7. No eatables allowed 8. Entrance only by invitation 9. 2 people per pass 10. No weapons allowed â Length of the Matter â A simple invitation letter will only contain only the relevant facts. A simple invitation letter features an introduction which allows the sender to introduce themselves and or the organization they represent. A simple background of the individual or company is enough. Though invitations are meant to be concise and straightforward, it isnât necessary. You can vary the length as per your need and requirement. Wedding and party invitation letters are not lengthy as compared to visit and certain personal invitation letters. â Using Letterhead â As a rule official Invitation letters require a letterhead. Letterhead represents the sender and its inclusion is authority established. If you have a pre printed letterhead then use that. Personal Invitation letters donât require letterheads and one can use it as per oneâs desire. â Gesture of Appreciation â Next, the appreciation for the guest to attend an activity or event must be shown. This can be completed with a formal note, stating that you look forward to seeing the individual at the event. â Donât forget the Enclosure â Some requests require certain documents to be attached; these can be the photocopies of documents like agreements, hard copies of email received, earlier correspondence, receipts, warranty etc. Keep original copies of all your letters, faxes, e-mails, and other related documents. â Closing the Letter â Start the letter with Gratitude and end it with the same. It is a professional and social courtesy. At the end of your last paragraph is written, a complimentary close of the likes of âSincerelyâ, âThank youâ, âTrulyâ is essential. Close the letter by restating your appreciation and gratitude. â Proofreading â Check for - awkward phrases, grammatical errors, incomplete sentences and spelling mistakes. Fix them with appropriate punctuation and remove dull or lifeless sentences and replace them with clever phrasing, poetry or a themed approach. This is the final step; the draft will be reviewed and revised before it acquires a proper form. Read it aloud to yourself to figure out mistakes which are missed out in writing. â Inform in Advance â Invitation letters need to be sent in advance. Try to send the invitation letter two weeks or more in advance. The recipient needs to know in advance so that they can adjust their schedules, book tickets or make other arrangements which are essential.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: âA 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 neededâ. 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 peopleâs 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.ۧ۳ۊÙŰ© ۧ۳ŰȘۧ۰ ŰčÙ
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