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1.  The impact of obesity on hypertension and diabetes control following healthy Lifestyle Intervention Program in a developing country setting 
BACKGROUND:
The aim of this study was to evaluate the impact of obesity and overweight on diabetes mellitus (DM) and hypertension (HTN) control in a healthy lifestyle intervention program in Iran.
METHODS:
Within the framework of the Isfahan Healthy Heart Program (IHHP), a community trial that was conducted to prevent and control cardiovascular disease and its risk factors, two intervention counties (Isfahan and Najafabad) and one reference county (Arak) were selected. Demographic information, medical history, anti-diabetic and anti-hypertensive medications use were asked by trained interviewers in addition to physical examination and laboratory tests for 12514 adults aged more than 19 years in 2001 and were repeated for 9572 adults in 2007.
RESULTS:
In women, the frequency of HTN control change significantly neither in normal weight nor in those with high body mass index (BMI), waist circumference (WC) or waist to hip ratio (WHR). In men, the frequency of HTN control was only significant among those with high WHR, whereas the interaction between changes in intervention compared to reference area from 2001 to 2007 was significant in men with normal or high WC or WHR. In intervention area, the number of women with high BMI who controlled their DM increased significantly from 2001 to 2007 (p = 0.008), however, this figure decreased in men. In reference area, obesity indices had no significant association with DM control. The percentage of diabetic subjects with high WC who controlled their DM decreased non-significantly in intervention area compared to reference area in 2007. A non-significant increase in controlled DM among men and women with high WHR was observed between intervention and reference areas.
CONCLUSIONS:
Our lifestyle interventions did not show any improving effect on HTN or DM control among obese subjects based on different obesity indices. Other lifestyle intervention strategies are suggested.
PMCID: PMC3252770  PMID: 22247721
Hypertension; Diabetes; Obesity; Control; Prevention; Iran
2.  Alteration in unhealthy nutrition behaviors in adolescents through community intervention: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2013;9(1):89-97.
BACKGROUND
Primary prevention of chronic diseases has been suggested to initiate health promotion activities from childhoods. The impact of Isfahan Healthy Heart Program (IHHP), a comprehensive community trial, on unhealthy snacks and fast food intake changes was evaluated in Iranian adolescents between 2001 and 2007.
METHODS
Healthy Heart Promotion from Childhood (HHPC) as one of the IHHP interventional projects was conducted in adolescents aged 11-18 years, selected randomly by multistage random sampling. Isfahan and Najafabad districts were intervention areas (IA) and Arak district was reference area (RA). The baseline and post-intervention surveys were conducted on 1941 and 1997 adolescents, respectively. Healthy lifestyle interventions were performed during the 2nd phase of the study targeting about 410000 students in urban and rural areas of the IA via education, environmental and legislation activities. Dietary intake was assessed annually using a fifty-item food frequency questionnaire in both communities.
RESULTS
The interaction of year×area demonstrated that the consumption of unhealthy snacks decreased significantly in middle school boys of RA compared to IA (P for interaction=0.01). However, middle school girls (P for interaction = 0.002) and both sexes of high school students in IA showed a significant reduction in fast food consumption against RA (P for interaction < 0.001).
CONCLUSION
The HHPC interventions made some improvement in fast food consumption. It did not show significant decrease regarding unhealthy snacks in adolescents. Proper and higher dose of interventions may be effective in achieving this goal.
PMCID: PMC3653262  PMID: 23696765
Nutrition; Dietary Behaviour; Adolescent; Lifestyle; Community Trial
3.  How does the impact of a community trial on cardio-metabolic risk factors differ in terms of gender and living area? Findings from the Isfahan healthy heart program 
Objective:
To assess the impact of gender and living area on cardiovascular risk factors in the context of a comprehensive lifestyle intervention program.
Design:
Data from independent sample surveys before (2000--2001) and after (2007) a community trial, entitled the Isfahan Healthy Heart Program (IHHP) were used to compare differences in the intervention area (IA) and reference area (RA) by gender and living area.
Setting:
The interventions targeted the population living in Isfahan and Najaf-Abad counties as IA and Arak as RA.
Participants:
Overall, 12 514 individuals who were more than 19 years of age were studied at baseline, and 9570 were studied in postintervention phase.
Interventions:
Multiple activities were conducted in connection with each of the four main strategies of healthy nutrition, increasing physical activity, tobacco control, and coping with stress.
Main Outcomes:
Comparing serum lipids levels, blood pressure, blood glucose and obesity indices changes between IA and RA based on sex and living areas during the study.
Results:
In IA, while the prevalence of hypertension declined in urban and rural females (P < 0.05). In IA, the prevalence of hypercholesterolemia and hypertriglyceridemia decreased in both females and males of urban and rural areas except for hypercholesterolemia in rural males (P < 0.01). In RA, the significant changes include both decrease in the hypercholesterolemia among rural males (P < 0.001) and hypertriglyceridemia in urban females (P < 0.01), while hypertriglyceridemia was significantly increased in rural females (P < 0.01).
Conclusions:
This comprehensive community trial was effective in controlling many risk factors in both sexes in urban and rural areas. These findings also reflect the transitional status of rural population in adopting urban lifestyle behaviors.
PMCID: PMC3687879  PMID: 23798939
Age; cardiovascular risk factor; community health program; health promotion; rural; sex; urban
4.  Effects of 5-Year Interventions on Cardiovascular Risk Factors of Factories and Offies Employees of Isfahan and Najafabad: Worksite Intervention Project-Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2010;6(3):94-101.
BACKGROUND
Effects of 5-year interventions of Worksite Intervention Project from Isfahan Healthy Heart Program on cardiovascular risk factors of factories and offices employees were studied in Isfahan and Najafabad (intervention area) compared to Arak (control area).
METHODS
We had especial interventions for nutrition, physical activity and smoking as well as hypertension and obesity screening systems in all offices and factories, and other risk factors screening systems whenever possible. Before and after the interventions, questionnaires containing demographic and other required data were completed for the two populations; height, weight and blood pressure (BP) were measured and a fasting and 2h blood sample was taken for the measurement of blood sugar (BS) and lipid levels.
RESULTS
The prevalence of hypercholesterolemia, hypertriglyceridemia and central obesity decreased, but low HDL increased in office staff (P < 0.01). Waist circumference, HDL and total cholesterol mean values decreased, and diastolic BP and fasting and 2h BS increased among the intervention group. In factory workers, the prevalence of hypertriglyceridemia and central obesity decreased, while low HDL prevalence increased in intervention group (P < 0.001). Mean values of waist circumference, HDL and total cholesterol, and triglyceride decreased significantly (P < 0.001), while diastolic BP and fasting BS increased.
CONCLUSION
It seems that Worksite Intervention Project has a protective effect on CVD risk factors in factories and offices employees. So, the modifiable project can be used as an applicable tool for health improvement in worksites which creates tangible changes in employees’ lifestyle.
PMCID: PMC3347823  PMID: 22577423
Risk Factors; Cardiovascular Disease; Workplace; Intervention
5.  White Rice Consumption and CVD Risk Factors among Iranian Population 
Association between white rice intake and risk factors of cardiovascular diseases remained uncertain. Most of the previous published studies have been done in western countries with different lifestyles, and scant data are available from the Middle East region, including Iran. This cross-sectional study was conducted in the structure of Isfahan Healthy Heart Program (IHHP) to assess the association between white rice consumption and risk factors of cardiovascular diseases. In the present study, 3,006 men were included from three counties of Isfahan, Najafabad, and Arak by multistage cluster random-sampling method. Dietary intake was assessed with a 49-item food frequency questionnaire (FFQ). Laboratory assessment was done in a standardized central laboratory. Outcome variables were fasting blood glucose, serum lipid levels, and anthropometric variables. Socioeconomic and demographic data, physical activity, and body mass index (BMI) were considered covariates and were adjusted in analysis. In this study, Student's t-test, chi-square test, and logistic regression were used for statistical analyses. Means of BMI among those subjects who consumed white rice less than 7 times per week and people who consumed 7-14 times per week were almost similar—24.8±4.3 vs 24.5±4.7 kg/m2. There was no significant association between white rice consumption and risk factors of cardiovascular diseases, such as fasting blood sugar and serum lipid profiles. Although whole grain consumption has undeniable effect on preventing cardiovascular disease risk, white rice consumption was not associated with cardiovascular risks among Iranian men in the present study. Further prospective studies with a semi-quantitative FFQ or dietary record questionnaire, representing type and portion-size of rice intake as well as cooking methods and other foods consumed with rice that affect glycaemic index (GI) of rice, are required to support our finding and to illustrate the probable mechanism.
PMCID: PMC3702347  PMID: 23930344
Cardiovascular diseases; Diet; Risk factors; White rice; Iran
6.  Improvement of dietary oil consumption following a community trial in a developing country: The role of translational research in health promotion 
ARYA Atherosclerosis  2013;9(1):29-37.
BACKGROUND
This study aimed to determine the effects of the interventions of Isfahan Healthy Heart Program (IHHP) on the type of oil consumed at the population level. It also tried to assess how this strategy has been effective as a health policy.
METHODS
The IHHP, a six-year community intervention program (2001-07), aimed at health promotion through the modification of cardiovascular disease risk factors. It was performed in Isfahan and Najafabad counties (intervention area) and Arak county (reference area), all in central Iran. This study targeted the whole population of over 2,000,000 in the intervention area. The findings of annual independent sample surveys were compared with the reference area. Dietary interventions were performed as educational, environmental, and/or legislative strategies.
RESULTS
From 2001 to 2007, the mean of changes for hydrogenated oil consumption was -3.2 and -3.6, and for liquid oil it was 3.6 and 2.8 times per week in the intervention and reference areas, respectively (P < 0.001). According to Commerce office record, the increase in liquid oil distribution during 2000-2007 was significantly higher in Isfahan than Arak (34% vs. 25%).
CONCLUSION
The effects of the simple, comprehensive, and integrated action-oriented interventions of our program could influence policy making and its results at the community level. It can be adopted by other developing countries.
PMCID: PMC3653266  PMID: 23696757
Oil Consumption; Hydrogenated Oil; Liquid Oil; Community Trial
7.  Is Friedewald formula a good estimation for low density lipoprotein level in Iranian population? 
Objective:
Serum low density lipoprotein (LDL) level is an important biomarker for coronary artery disease (CAD). As direct LDL measurement is expensive and not cost effective, especially in a large population, it is estimated by Friedewald formula. Therefore, we decided to compare the direct LDL measurement method with LDL measured by Friedewald formula in a large general population for the first time in Iran. Furthermore, we examined the association of total cholesterol (TCh), triglyceride (TG), and high density lipoprotein (HDL) with LDL.
Subjects and Methods:
This study was conducted on the subjects, aged 11–97 years, in the third phase of Isfahan Healthy Heart Program (IHHP) from three cities: Isfahan, Najafabad, and Arak. A fasting blood sample was taken from all subjects and referred to Isfahan Cardiovascular Research Center (ICRC) laboratory (central laboratory of IHHP) to assess TCh, TG, HDL, and LDL directly. Also, the LDL level was calculated by Friedewald formula, in addition.
Results:
The mean level of LDL by direct method was lower than that calculated by Friedewald formula. The mean difference between the two methods was significant, which was 6.6 ± 15.5 mg/dl difference (t = -42.925, P < 0.0001). There was strong correlation between direct and calculated LDL levels (adjusted R2 = 80.4%). Using regression model, a new formula was found for the estimation of LDL.
Conclusion:
It is concluded that the Friedewald formula overestimates the LDL level compared to the direct method in general Iranian population. It is suggested that LDL measurement be carried out directly, especially in high-risk people. If a formula is necessary for LDL estimation, it is better to obtain an especial formula for each population.
PMCID: PMC3634287  PMID: 23626626
Direct measurement; Friedewald formula; Iiran; low density lipoprotein
8.  Metabolic syndrome in menopausal transition: Isfahan Healthy Heart Program, a population based study 
Introduction
There is a remarkable increase in cardiovascular disease after menopause. On the other hand, metabolic syndrome as a collection of risk factors has a known effect on cardiovascular diseases. Hormone changes are considered as one of the main relevant factor regarding cardiovascular disease as well as some recognized relationship with metabolic syndrome's components. This study was carried out in order to search for prevalence of metabolic syndrome during menopausal transition.
Method
In a cross sectional study in urban and rural areas of Isfahan, Najafabad and Arak cities, 1596 women aged more than 45 years were investigated using Isfahan Healthy Heart Program's (IHHP) samples. Participants were categorized into three groups of pre-menopause, menopause and post-menopause. Leisure time physical activity and global dietary index were included as life style factors. The association of metabolic syndrome and its components with menopausal transition considering other factors such as age and life style was analyzed.
Results
there were 303, 233 and 987 women in premenopausal, early menopausal and postmenopausal groups respectively. Metabolic syndrome was found in 136(44.9%) premenopausal participants and significantly increased to 135(57.9%) and 634(64.3%) in early menopausal and postmenopausal participants respectively, when age was considered (P = 0.010). Except for hypertension and hypertriglyceridemia, there was no significant difference between three groups of menopausal transition when metabolic syndrome's components were considered.
Conclusion
In contrary to the claims regarding the role of waist circumference and blood glucose in increasing of metabolic syndrome during the menopausal transition, this study showed this phenomenon could be independence of them.
doi:10.1186/1758-5996-2-59
PMCID: PMC2958965  PMID: 20923542
9.  The effectiveness of stress management intervention in a community-based program: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2012;7(4):176-183.
BACKGROUND:
This study was designed to assess the effectiveness of stress management training in improving the ability of coping with stress in a large population.
METHODS:
Five cross-sectional studies using multistage cluster random sampling were performed on adults aged ≥ 19 years between 2000 to 2005 in Isfahan and Najafabad (Iran) as intervention cities and Arak, Iran as the control city within the context of Isfahan Healthy Heart Program. Stress management training was adapted according to age and education levels of the target groups. In a 45-minute home interview, demographic data, General Health Questionnaire (GHQ) and stress management questionnaires were collected. Data was analyzed by t-test, linear regression and general linear model.
RESULTS:
Trends of both adaptive and maladaptive coping skills and GHQ scores from baseline to the last survey were statistically significant in both intervention and reference areas (P < 0.001). While adaptive coping skills increased significantly, maladaptive coping skills decreased significantly in the intervention areas. Furthermore, stress levels decreased significantly in the intervention compared to the reference area.
CONCLUSION:
Stress management programs could improve coping strategies at the community level and can be considered in designing behavioral interventions
PMCID: PMC3413087  PMID: 23205052
Stress Management; Community; Intervention; Coping Strategies
10.  The relation between dietary intake of vegetable oils and serum lipids and apolipoprotein levels in central Iran 
ARYA Atherosclerosis  2012;7(4):168-175.
BACKGROUND:
The detrimental effects of partially hydrogenated vegetable oils (PHVOs) on apolipoproteins have been reported from several parts of the world. However, little data is available in this regard from the understudied region of the Middle East. The present study therefore tried to evaluate the association between type of vegetable oils and serum lipids and apolipoprotein levels among Iranians.
METHODS:
In this cross-sectional study, data from 1772 people (795 men and 977 women) aged 19–81 years, who were selected with multistage cluster random sampling method from three cities of Isfahan, Najafabad and Arak in “Isfahan Healthy Heart Program” (IHHP) (Iran), was used. To assess participants' usual dietary intakes, a validated food frequency questionnaire was used. Hydrogenated vegetable oil (commonly consumed for cooking in Iran) and margarine were considered as the category of PHVOs. Soy, sunflower, corn, olive and canola oils were considered as non-HVOs. After an overnight fasting, serum cholesterol (total, low density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol) and triglyceride as well as apolipoproteins A and B were measured using standard methods.
RESULTS:
Participants with the highest intakes of non-HVOs and PHVOs were younger and had lower weight than those with lowest intakes. High consumption of non-HVOs and PHVOs was associated with lower intakes of energy, carbohydrate, dietary fiber, and higher intakes of fruits, vegetables, meat, milk and grains. No overall significant differences were found in serum lipids and apolipoprotein levels across the quartiles of non-HVOs and PHVOs after controlling for potential confounding.
CONCLUSION:
We did not find any significant associations between hydrogenated or nonhydrogenated vegetable oil and serum lipid and apolipoprotein levels. Thus, further studies are needed in this region to explore this association.
PMCID: PMC3413086  PMID: 23205051
Vegetable Oils; Cardiovascular Risk Factors; Lipids; Apolipoproteins; Diet
11.  How effective are strategies for non-communicable disease prevention and control in a high risk population in a developing country? Isfahan Healthy Heart Programme 
Introduction
The Isfahan Healthy Heart Programme (IHHP) is a community-based programme for non-communicable diseases prevention and control using both a population and high risk approach in Iran. This study demonstrated the efficacy of IHHP interventional strategies to improve lifestyle behaviours in a population at risk for developing cardiovascular diseases.
Material and methods
Healthy Lifestyle for NCDs High Risk Population is one of ten projects of IHHP. High risk individuals were defined as those who have at least one risk factor for developing coronary artery disease (CAD). Changes of behavioural indicators have been compared between two areas with a survey after 5 years of intervention.
Results
Among high risk individuals in the intervention and reference areas, 77.8% and 82.5% had at least one major risk factor for CAD. The prevalence of major risk factors for CAD (except cigarette smoking) was decreased in both intervention and reference areas during 5 years of intervention and the pattern of diet and physical activity was improved.
Conclusions
Interventional activities in IHHP targeting the high risk population seem to be effective in improving lifestyle behaviour, increasing awareness and control of risk factors of the high risk population.
doi:10.5114/aoms.2010.13503
PMCID: PMC3278939  PMID: 22371716
coronary artery disease; risk factor; healthy lifestyle; community interventions; developing country; Iran
12.  Effects of a community-based healthy heart program on increasing healthy women's physical activity: a randomized controlled trial guided by Community-based Participatory Research (CBPR) 
BMC Public Health  2007;7:216.
Background
Cardiovascular disease remains the leading killer of women in most developed areas of the world. Rates of physical inactivity and poor nutrition, which are two of the most important modifiable risk factors for cardiovascular disease in women, are substantial. This study sought to examine the effectiveness of a community-based lifestyle-modification program on increasing women's physical activity in a randomized trial guided by community-based participatory research (CBPR) methods.
Methods
A total of 335 healthy, 25–64 years old women who had been selected by a multiple-stage stratified cluster random sampling method in Bushehr Port/I.R. Iran, were randomized into control and intervention groups. The intervention group completed an 8-week lifestyle modification program for increasing their physical activity, based on a revised form of Choose to Move program; an American Heart Association Physical Activity Program for Women. Audio-taped activity instructions with music and practical usage of the educational package were given to the intervention group in weekly home-visits by 53 volunteers from local non-governmental and community-based organizations.
Results
Among the participants, the percentage who reported being active (at lease 30 minutes of moderate intensity physical activity for at least 5 days a week, or at least 20 minutes of vigorous physical activity for at least three days a week) increased from 3% and 2.7% at baseline to 13.4% and 3% (p < 0.0001) at the ending of the program in the intervention and control groups, respectively. The participants in the intervention group reported more minutes of physical activity per week (mean = 139.81, SE = 23.35) than women in the control group (mean = 40.14, SE = 12.65) at week 8 (p < 0.0001). The intervention group subjects exhibited a significantly greater decrease in systolic blood pressure (-10.0 mmHg) than the control group women (+2.0. mmHg). The mean ranks for posttest healthy heart knowledge in the intervention and control groups were 198.91 and 135.77, respectively (P < 0.0001).
Conclusion
An intervention based on CBPR methods can be effective for the short-term adoption of physical activity behavior among women. The development of participatory process to support the adequate delivery of lifestyle-modification programs is feasible and an effective healthcare delivery strategy for cardiovascular community health promotion.
Trial Registration
ACTRNO12606000521527
doi:10.1186/1471-2458-7-216
PMCID: PMC2018720  PMID: 17716376
13.  Formative Research for a Community-Based Message-Framing Intervention 
Objective
To inform a community-based message framing intervention encouraging physical activity and fruit and vegetable consumption among medically underserved adults.
Method
Key informant interviews, focus groups, and a survey were conducted with limited-literacy Hispanics in the northeastern United States.
Results
Barriers to healthy lifestyle behaviors exist at individual, community, and policy levels. A strong degree of networking among local organizations and elected officials exists that can be used to encourage healthy lifestyle initiatives.
Conclusions
Community-based health communication interventions must address neighborhood realities, the literacy levels of the target population, and existing networks of providers and consumers.
doi:10.5993/AJHB.36.3.5
PMCID: PMC3294377  PMID: 22370435
formative research; social-ecological model; Hispanics; healthy lifestyle; message framing
14.  Body Mass Index, Waist-circumference and Cardiovascular Disease Risk Factors in Iranian Adults: Isfahan Healthy Heart Program 
Considering the main effect of obesity on chronic non-communicable diseases, this study was performed to assess the association between body mass index (BMI), waist-circumference (WC), cardiometabolic risk factors and to corroborate whether either or both BMI and WC are independently associated with the risk factors in a sample of Iranian adults. This cross-sectional study was performed on data from baseline survey of Isfahan Healthy Heart Program (IHHP). The study was done on 12,514 randomly-selected adults in Isfahan, Najafabad and Arak counties in 2000-2001. Ages of the subjects were recorded. Fasting blood glucose (FBG), 2-hour post-load glucose (2hpp), serum lipids, systolic and diastolic blood pressure (SBP and DBP), BMI, WC, smoking status, and total daily physical activity were determined. Increase in BMI and WC had a significant positive relation with the mean of FBG, 2hpp, SBP, DBP, serum lipids, except for HDL-C (p<0.001 for all). After adjustment for age, smoking, physical activity, socioeconomic status (SES), and BMI, the highest odds ratio (OR) (95% CI) for diabetes mellitus (DM) according to WC was 3.13 (1.93-5.08) and 1.99 (1.15-3.44) in women and men respectively. Moreover, the highest ORs based on BMI with adjustment for age, smoking, physical activity, SES, and WC were for dyslipidaemia (DLP) [1.97 (1.58-2.45) in women and 2.96 (2.41-3.63) in men]. The use of BMI or WC alone in the models caused to enhance all ORs. When both BMI and WC were entered in the model, the ORs for all risk factors, in men, according to BMI, were more compared to WC. However, in women, ORs for DM and hypertension (HTN) in WC quartiles were more than in BMI quartiles. BMI is the better predictor of DM, HTN, and DLP in men compared to WC. Conversely, in women, WC is a superior predictor than BMI, particularly for DM and HTN. Furthermore, the measurement of both WC and BMI in Iranian adults may be a better predictor of traditional risk factors of CVDs compared to BMI or WC alone.
PMCID: PMC3805889  PMID: 24288953
Body mass index; Diabetes mellitus; Dyslipidaemia; Hypertension; Obesity; Risk Factor; Waist-circumference; Iran
15.  Dietary Intakes and Physical Activity among Preschool Aged Children living in Rural American Indian Communities Prior to a Family-based Healthy Lifestyle Intervention 
Objective
To report dietary intake and physical activity among preschool-aged children living in rural American Indian (AI) communities prior to a family-based healthy lifestyle intervention and to compare data to current age-specific recommendations.
Subjects/Design
One hundred thirty-five preschool-aged children, living in rural AI communities, provided diet and physical activity data, prior to a two-year randomized healthy lifestyle intervention. Three 24-hour dietary recalls assessed nutrient and food and added sugar intake, which were compared to the National Academy of Science's Daily Reference Intakes, the United States Department of Agriculture's (USDA) MyPyramid, and the American Heart Association recommendations. Time watching television and moderate plus vigorous activity (MVA) was compared to the MyPyramid and the American Academy of Pediatrics recommendations.
Statistical analysis
Nutrient, food group, added sugar intake and time watching television and in MVA were compared to recommendations by computing the percent of recommendations met. Nonparametric tests identified differences in diet and physical activity among age groups and normal and overweight children (body mass index < 85th and ≥ 85th percentile).
Results
Average nutrient intakes met recommendations whereas food group intakes did not. Mean fruit and vegetable intakes for two to three year-olds were 0.36 cups/day fruit and 0.45 cups/day vegetables and, for four to five year-olds, 0.33 cups/day fruit and 0.48 cups/day vegetables. Both age groups reported consuming more than 50 grams of added sugar, exceeding the recommendation of 16 grams. Overweight versus normal weight children reported significantly more sweetened beverage intake (8.0 ± 0.10 vs. 5.28 ± 0.08 ounces/day, p < 0.01) On average, all children reported watching television 2.0 hours/day and significant differences were observed for total television viewing and non-viewing time between overweight and normal weight children (8.52 ± 0.6 vs. 6.54 ± 0.6 hours/day, p < 0.01). All children engaged in less than 20 minutes/day of MVA.
Conclusions
Overall, children in this sample did not meet MyPyramid recommendations for fruits or vegetables and exceed added sugar intake recommendations. Viewing and non-viewing television time was highly prevalent along with low levels of MVA. The HCSF intervention has the potential for improving nutrition and physical activity among preschool children living in rural AI communities.
doi:10.1016/j.jada.2010.04.009
PMCID: PMC2946329  PMID: 20630162
dietary intake; physical activity; preschool-aged American Indian children; USDA's MyPyramid
16.  Comparing health-related quality of life of employed women and housewives: a cross sectional study from southeast Iran 
BMC Women's Health  2012;12:41.
Background
Quality of life differs for different people in different situations and is related to one's self-satisfaction with life. Considering the role of women in family and social health and the specific cultural characteristics of our province, we aimed to compare the quality of life of employed women with housewives in Zahedan, Iran.
Methods
This cross-sectional study was carried out during 2009–2010 in Zahedan, Iran. The sample consisted of 110 housewives and 110 employed women selected randomly from ten health care centers. Health-related quality of life was assessed using the SF-36. Analysis of covariance (ANCOVA) was used to compare quality of life in housewives and employed women while controlling for age, education and income.
Results
The mean (±SD) age of participants was 33.87± 8.95 years. Eighty-eight women (40%) had a university degree with a mean (±SD) official education of 10.8 (±4.9) years. The results indicated that employed women scored higher than housewives in all measures except for physical functioning. The differences were found to be remarkable for vitality, mental health and role emotional. However, after controlling for age, education and family income, none of differences reached significant level.
Conclusion
After controlling for potential confounders, the findings from this study indicated that there were no significant differences in quality of life between employed women and housewives. However, employed women scored higher on the SF-36, especially on the role emotional, vitality, and mental health. The findings suggest that associations exist between some aspects of health-related quality of life and employment. Indeed improving health-related quality of life among housewives seems essential.
doi:10.1186/1472-6874-12-41
PMCID: PMC3559256  PMID: 23173572
17.  Short-term results of community-based interventions for improving physical activity: Isfahan Healthy Heart Programme 
Introduction
To assess the effect of a comprehensive community-based programme for increasing physical activity (PA) after 2 years of interventions.
Material and methods
A 6-year, action-oriented, comprehensive, and integrated community-based study, entitled the Isfahan Healthy Heart Programme, was conducted in Iran from the year 2000. The interventions targeted the whole population of nearly 2,180,000 living in two cities, and were compared with another city considered as a reference. Educational, environmental and legislative interventions were conducted at the community level. Annual evaluations were performed among 6,000 representative individuals. This paper presents the changes in PA habits after 2 years of interventions for increasing PA. The PA habits were assessed by using the Baecke questionnaire, and an energy expenditure of 150 kcal for daily leisure time physical activity was adopted as a cut-off for defining active and inactive lifestyle.
Results
In the intervention and reference areas, respectively 85 and 83% of the population were physically inactive. From 2000 to 2002, the daily PA among both genders decreased in both intervention and reference communities. Meanwhile, the leisure-time PA increased significantly in the intervention area, but decreased in the reference area. The transportation PA did not significantly change in the intervention area, but showed a remarkable decline in the reference area.
Conclusions
We suggest that the synergism resulting from community collaborations has been effective in improving some aspects of PA in our community. The ongoing changes in environmental factors and policies can help in increasing the worksite and transportation PA in later stages of this community-based programme.
doi:10.5114/aoms.2010.13504
PMCID: PMC3278940  PMID: 22371717
lifestyle; physical activity; community-based intervention; prevention; non-communicable diseases
18.  Impact of a community-based lifestyle intervention program on blood pressure and salt intake of normotensive adult population in a developing country 
Background:
Data on the effect of lifestyle intervention programs on salt intake and blood pressure in developing countries are scarce. This study aimed to assess the impact of a healthy lifestyle community-based trial on salt intake and blood pressure among a representative sample of normotensive Iranian adults.
Materials and Methods:
We compared the data for salt intake, urinary sodium levels and blood pressure from three cross-sectional surveys in time points of 1999, 2001-2002 (beginning of the community interventions), and 2007 (after the community trial) for normotensive adult population of Isfahan, Iran in the framework of Isfahan Healthy Heart Program. Using multi-stage cluster sampling method, one of the family members at each household was randomly selected with Iranian adult population as a target. Dietary salt intake was estimated based on 24 hour urinary sodium levels. Systolic and diastolic blood pressures were measured according to standard methods.
Results:
Dietary sodium intake and urinary sodium levels as well as systolic and diastolic blood pressure were significantly decreased during the 9-year study period. Unlike systolic and diastolic blood pressures that had a consistent decrement between 1999 and 2007, dietary sodium intake and urinary sodium levels were slightly raised from 1999 to 2000-2001 and then reduced between 2001-2 and 2007 evaluations. The same findings were reached when data were analyzed separately by gender or weight status.
Conclusions:
A lifestyle community trial was effective in controlling the escalating trend of blood pressure and salt intake in Iranian population. It can be considered as a model to be adopted in other developing countries.
PMCID: PMC3527040  PMID: 23267374
Blood Pressure; Salt; Adult; Urine; Lifestyle
19.  The Correlation Between Lipid Profile and Stress Levels in Central Iran: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2010;6(3):102-106.
BACKGROUND
Previous studies suggest that mental status may influence serum lipid levels. This study was conducted on adult population living in rural and urban areas in Central Iran to assess the correlation between stress level and lipid profile disorders.
METHODS
Data was extracted from final evaluation of Isfahan Healthy Heart Program (IHHP) in 2008. Multistage and random cluster methods were used for sampling. The study population consisted of 9752 adults aged ≥19 years living in three districts namely Isfahan, Arak and Najaf Abad. Demographic data, age and sex were recorded. Blood samples were taken to determine the lipid levels including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), low levels of high-density lipoprotein cholesterol (HDL-C) and triglycerides. Stress levels were assessed using the General Health Questionnaire. Logistic regression and chi-square tests were used for statistical analysis.
RESULTS
The odds ratios of high stress in individuals with high levels of TC, LDL-C and low levels of HDL-C compared to normal individuals after adjustment for age and sex were as follows respectively: 1.05 (1.02,1.15), 1.06 (1.02,1.18), 1.06 (1.01,1.17).
CONCLUSION
Intervention activities towards reduction of stress levels at the community level may be useful as part of the strategy for cardiovascular disease prevention.
PMCID: PMC3347824  PMID: 22577424
Cholesterol; Triglycerides; Stress; Adult
20.  SWITCH: rationale, design, and implementation of a community, school, and family-based intervention to modify behaviors related to childhood obesity 
BMC Public Health  2008;8:223.
Background
Although several previous projects have attempted to address the issue of child obesity through school-based interventions, the overall effectiveness of school-based programs on health-related outcomes in youth has been poor. Thus, it has been suggested that multi-level interventions that aim to influence healthy lifestyle behaviors at the community, school and family levels may prove more successful in the prevention of childhood obesity.
Methods/Design
This paper describes the rationale, design, and implementation of a community-, school-, and family-based intervention aimed at modifying key behaviors (physical activity, screen time (Internet, television, video games), and nutrition) related to childhood obesity among third through fifth graders in two mid-western cities. The intervention involves a randomized study of 10 schools (5 intervention and 5 control schools). The intervention is being conducted during the duration of the academic year – approximately 9 months – and includes baseline and post-intervention measurements of physical activity, dietary intake, screen time and body composition.
Discussion
We hope this report will be useful to researchers, public health professionals, and school administrators and health professionals (nurses and physical/health educators) seeking to develop similar prevention programs. It is obvious that more collaborative, inter-disciplinary, multi-level work is needed before a proven, effective intervention package to modify behaviors related to childhood obesity can be generally recommended. It is our hope that SWITCH is a step in that direction.
Trial Registration
ClinicalTrials.gov NCT00685555
doi:10.1186/1471-2458-8-223
PMCID: PMC2474862  PMID: 18588706
21.  Epidemiological differences of lower urinary tract symptoms among female subpopulations and group level interventions 
Objectives:
1) To study the risk factor profiles of lower urinary tract symptoms (LUTS) among adolescent girls, housewives and working women and its socioeconomic and quality of life losses. 2) To undertake risk factor modifications using the adolescent girls.
Design and Setting:
Cross-sectional descriptive study followed by educational intervention.
Statistical Methods:
Cluster sampling, Proportions, confidence intervals, Chi square and t-Tests and Logistic regression.
Materials and Methods:
House to house survey was done in two villages and one urban ward. Seventy-five housewives, 75 working women and 180 adolescent girls were asked about the risk factors and losses due to LUTS. Three teams of adolescent girls were utilized to bring about behavioral modifications. Impact was measured through user perspectives obtained from the participants.
Results:
Risk factors, social, economic and quality of life losses were different among the three female populations. Overall prevalence of LUTS among the three groups is 61(18.5%). Improper anal washing technique, malnutrition, presence of vaginal discharge, use of unsanitary menstrual pads, pinworm infestation and use of bad toilets were the significant causes among girls. Presence of sexually transmitted diseases was a contributing factor among housewives and working women. Prolonged sitting the posture was also contributing to LUTS among working women. Seventy-four per cent of beneficiaries expressed that intervention is useful.
Conclusions:
The causes for LUTS and their consequences were differing among the three female subpopulations. Specific group level interventions using trained girls were successful.
doi:10.4103/0970-1591.44256
PMCID: PMC2684399  PMID: 19468505
Karimnagar district; lower urinary tract symptoms; working women; socioeconomic and quality of life losses
22.  Effect of an individually tailored one-year energy balance programme on body weight, body composition and lifestyle in recent retirees: a cluster randomised controlled trial 
BMC Public Health  2010;10:110.
Background
The increased prevalence of overweight and obesity warrants preventive actions, particularly among people in transitional stages associated with lifestyle changes, such as occupational retirement. The purpose is to investigate the effect of a one year low-intensity computer-tailored energy balance programme among recent retirees on waist circumference, body weight and body composition, blood pressure, physical activity and dietary intake.
Methods
A randomised controlled trial was conducted among recent retirees (N = 413; mean age 59.5 years). Outcome measures were assessed using anthropometry, bio-impedance, blood pressure measurement and questionnaires.
Results
Waist circumference, body weight and blood pressure decreased significantly in men of the intervention and control group, but no significant between-group-differences were observed at 12 or at 24-months follow-up. A significant effect of the programme was only observed on waist circumference (-1.56 cm (95%CI: -2.91 to -0.21)) at 12 month follow up among men with low education (n = 85). Physical activity and dietary behaviours improved in both the intervention and control group during the intervention period. Although, these behaviours changed more favourably in the intervention group, these between-group-differences were not statistically significant.
Conclusions
The multifaceted computer-tailored programme for recent retirees did not appear to be effective. Apparently the transition to occupational retirement and/or participation in the study had a greater impact than the intervention programme.
Trial registration
Clinical Trials NCT00122213.
doi:10.1186/1471-2458-10-110
PMCID: PMC2845102  PMID: 20205704
23.  Factors Related to Cardiovascular Disease Risk Reduction in Midlife and Older Women: A Qualitative Study 
Preventing Chronic Disease  2007;5(1):A06.
Introduction
Cardiovascular disease (CVD) is the leading cause of death for women in the United States. A healthy diet and appropriate physical activity can help reduce the risk for CVD. However, many women do not follow recommendations for these behaviors. In this study, we used qualitative methods to better understand knowledge and awareness about CVD in women, perceived threat of CVD, barriers to heart-healthy eating and physical activity, and intervention strategies for behavior change.
Methods
We conducted four focus groups with 38 white women aged 40 years or older in Kansas and Arkansas. We also interviewed 25 Cooperative State Research, Education, and Extension Service agents in those states. Environmental audits of grocery stores and the physical environment were done in three communities.
Results
Most women were aware of the modifiable risk factors for CVD. Although they realized they were susceptible, they thought CVD was something they could overcome. Common barriers to achieving a heart-healthy diet included time and concern about wasting food. Most women had positive attitudes toward physical activity and reported exercising in the past, but found it difficult to resume when their routine was disrupted. The environmental audits suggested that there are opportunities to be physically active and that with the exception of fresh fish in Kansas, healthful foods are readily available in local food stores.
Conclusion
Interventions to change behavior should be hands-on, have a goal-setting component, and include opportunities for social interaction. It is especially important to offer interventions as awareness increases and women seek opportunities to build skills to change behavior.
PMCID: PMC2248795  PMID: 18081995
24.  Heart Healthy and Ethnically Relevant (HHER) Lifestyle Trial for Improving Diet and Physical Activity in Underserved African American Women 
Background
African American women are at increased risk for CVD morbidity and mortality relative to white women. Physical inactivity and poor dietary habits are modifiable health behaviors shown to reduce CVD risk. Community health centers have the potential to reach large numbers of African Americans to modify their risk for CVD, yet few lifestyle counseling interventions have been conducted in this setting.
Methods
The HHER Lifestyle trial is a randomized controlled trial to compare the effects of a standard care intervention (provider counseling, nurse goal setting, and educational materials) to a comprehensive intervention (standard care intervention plus 12 months of telephone counseling and tailored print materials) on changes in physical activity and dietary fat consumption in financially disadvantaged African American women at 6 and 12 months. Secondary outcomes are body mass index, central adiposity, and total cholesterol. Potential mediators of outcome are self-efficacy for overcoming barriers, social support, and decisional balance.
Results
African American women (N=266; 130 standard care, 136 comprehensive intervention) 35 years and older from nine clinics within two community health centers were enrolled. Most participants were overweight or obese with existing chronic health conditions.
Conclusion
The HHER Lifestyle trial is unique in that it targets financially disadvantaged African American women from community health centers, incorporates a standard care intervention into a routine clinical appointment, and includes a comprehensive process evaluation. The design will allow us to examine the added effect of regular telephone counseling and tailored print materials to a primary care provider and nurse intervention.
doi:10.1016/j.cct.2009.09.006
PMCID: PMC2818166  PMID: 19781665
lifestyle intervention; cardiovascular risk reduction; physical activity; exercise; diet; nutrition; underserved population; African American; women; health disparities; primary care
25.  Lifestyle Intervention Development Study to Improve Physical Function in Older Adults With Cancer: Outcomes From Project LEAD 
Purpose
Declines in physical functioning (PF) among elderly cancer patients threaten quality of life and the ability to maintain independence. Adherence to healthy lifestyle behaviors may prevent functional decline.
Patients and Methods
Project Leading the Way in Exercise and Diet (LEAD), an intervention development study of the Pepper Older Americans Independence Center, aimed to determine whether breast and prostate cancer survivors (age 65+ years) assigned to a 6-month home-based diet and exercise intervention experienced improvements in PF when compared with an attention control arm receiving general health information. An accrual target was set at 420, and PF (Short Form-36 subscale), physical activity (Community Healthy Activities Models Program for Seniors), and diet quality (index from 3-day recalls) were assessed at baseline and at 6 and 12 months (6 months after intervention).
Results
This developmental project did not achieve its accrual target (N = 182); however, PF change scores were in the direction and of the magnitude projected. Baseline to 6-month change scores in the intervention versus the control arms were as follows: PF, +3.1 v −0.5 (P = .23); physical activity energy expenditure, +111 kcal/wk v −400 kcal/wk (P = .13); and diet quality index, +2.2 v −2.9 (P = .003), respectively. Differences between arms diminished during the postintervention period.
Conclusion
These findings suggest that home-based diet and exercise interventions hold promise in improving lifestyle behaviors among older cancer survivors, changes that trend toward improved PF. Future studies should incorporate larger sample sizes and interventions that sustain long-term effects and also take into account secular trends; these efforts will require adequate planning and resources to overcome the numerous barriers to intervening in this difficult to reach yet vulnerable population.
doi:10.1200/JCO.2006.05.7224
PMCID: PMC1532928  PMID: 16849763

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