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1.  First National Report on Aminotransaminases’ Percentiles in Children of the Middle East and North Africa (MENA): the CASPIAN-III Study 
Hepatitis Monthly  2012;12(11):e7711.
Background
By the current global obesogenic environment, non-alcoholic fatty liver disease is becoming an important health problem in the pediatric age group.
Objectives
This study aimed to determine the first age-and gender-specific percentiles and upper limit normal limit (ULN) of alanine aminotransaminase (ALT) and aspartate aminotransaminase (AST) among a nationally-representative sample of children and adolescents in the Middle East and North Africa (MENA). The second objective was to determine the linear association of obesity indexes and age with serum ALT and AST levels.
Patients and Methods
This nationwide study was conducted among a representative sample of 4078 students aged 10-18 years, who were selected by multistage random cluster sampling from 27 provinces of Iran. ALT and AST were measured on fresh sera. Body mass index (BMI) was calculated as an index of generalized obesity, and waist- to- height ratio (WHtR) as an index of abdominal obesity. The age- and gender-specific percentiles of ALT and AST were constructed, and the 95th percentile of each enzyme was considered as the ULN. Gender-specific linear regression analysis was employed to examine the association of BMI or WHtR with the levels of ALT and AST.
Results
Data of ALT and AST were available for 4078 (2038 girls) and 4150 (2061 girls),respectively. Participants had a mean (SD) age of 14.71 (2.41).The ULN of ALT for boys, girls,and the total individuals were 36.00; 38.00; and, 37.00 U/L, respectively. In both genders, ALT and AST had linear association with age. The association with BMI was significant for ALT in both genders and for AST only in boys, the association of ALT with WHtR was significant in both genders; the corresponding figures were not significant for AST.
Conclusions
The findings of the current study confirmed the current ULN value of 40 U/L commonly used for the pediatric age group. The linear association of indexes for generalized and abdominal obesity with ALT underscores the importance of timely prevention and control of childhood obesity.
doi:10.5812/hepatmon.7711
PMCID: PMC3546518  PMID: 23346152
Aminotransferase; Child; Iran
2.  Metabolic Syndrome and Cardiovascular Risk Factors in a National Sample of Adolescent Population in the Middle East and North Africa: The CASPIAN III Study 
Objective. The present study was designed to investigate the prevalence of different combinations of the metabolic syndrome (MetS) risk factors among a nationally representative sample of adolescents in the Middle East and North Africa (MENA). Methods. The study sample, obtained as part of the third study of the school-based surveillance system entitled CASPIAN III, was representative of the Iranian adolescent population aged from 10 to 18 years. The prevalence of different components of MetS was studied and their discriminative value was assessed by receiver operating characteristic (ROC) curve analysis. Results. The study participants consisted of 5738 students (2875 girls) with mean age of 14.7 ± 2.4 years) living in 23 provinces in Iran; 17.4% of participants were underweight and 17.7% were overweight or obese. Based on the criteria of the International Diabetes Federation for the adolescent age group, 24.2% of participants had one risk factor, 8.0% had two, 2.1% had three, and 0.3% had all the four components of MetS. Low HDL-C was the most common component (43.2% among the overweight/obese versus 34.9% of the normal-weight participants), whereas high blood pressure was the least common component. The prevalence of MetS was 15.4% in the overweight/obese participants, the corresponding figure was 1.8% for the normal-weight students, and 2.5% in the whole population studied. Overweight/obese subjects had a 9.68 increased odds of (95% CI: 6.65–14.09) the MetS compared to their normal-weight counterparts. For all the three risk factors, AUC ranged between 0.84 and 0.88, 0.83 and 0.87, and 0.86 and 0.89 in waist circumference, abdominal obesity, and BMI for boys and between 0.78 and 0.97, 0.67 and 0.93, and 0.82 and 0.96 for girls, respectively. Conclusion. The findings from this study provide alarming evidence-based data on the considerable prevalence of obesity, MetS, and CVD risk factors in the adolescent age group. These results are confirmatory evidence for the necessity of primordial/primary prevention of noncommunicable disease should be considered as a health priority in communities facing a double burden of nutritional disorders.
doi:10.1155/2013/702095
PMCID: PMC3580930  PMID: 23476647
3.  Development and Evaluation of a Questionnaire for Assessment of Determinants of Weight Disorders among Children and Adolescents: The Caspian-IV Study 
Background:
Little experience exists on valid and reliable tools for assessment of the determinants of underweight and overweight in children and adolescents living in the Middle-East and North Africa (MENA). This study aimed to develop a valid and wideranging questionnaire for assessment of these parameters in a nationwide sample of Iranian children and adolescents.
Methods:
This national study was conducted in 31 provinces in Iran. The first phase consisted of focus group discussion with 275 children and adolescents and their parents. After a qualitative content analysis, the initial items were extracted. In the next step, the face validity was assessed by expert panelists using the quantitative method of the Impact Score. To assess the content validity, the content validity rate (CVR) and the content validity index (CVI) were determined. The internal consistency was examined by Cronbach alpha, and its test-retest reliability was determined. The socio-demographic variables, perinatal factors, lifestyle factors, family history, knowledge and attitude were assessed. Dietary intakes were assessed by a validated 168-item semi-quantitative food frequency questionnaire. A validated questionnaire for quality of life was filled in anonymously.
Results:
A team of expert researchers conducted the data analysis of 576 interviews by using qualitative content analysis method. The analysis process began by determining the semantic units about the concepts studied. The initial questionnaire was developed in four domains by including Likert scale questions. In the face validity step, all questions of the primary questionnaire obtained a score of more than 1.5. In the phase of CVR assessment, 6 questions obtained a score of less than 0.62, and were omitted. The rest of questions were assessed for CVI, and got a score of more than 0.75. Cronbach's alpha coefficient of the whole questionnaire was 0.97, and the Pearson correlation coefficient of the test-retest phase was 0.94.
Conclusion:
The developed questionnaire is a valid and reliable tool for assessment of the determinants of weight disorders in a nationally representative sample of children and adolescents in the MENA.
PMCID: PMC3482997  PMID: 23112896
Children and adolescents; overweight; questionnaire validity; underweight
4.  Algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO Child Growth Standards 
BMC Pediatrics  2008;8:19.
Background
The child growth standards released by the World Health Organization (WHO) in 2006 have several technical advantages over the previous 1977 National Center for Health Statistics (NCHS)/WHO reference and are recommended for international comparisons and secular trend analysis of child malnutrition. To obtain comparable data over time, earlier surveys should be reanalyzed using the WHO standards; however, reanalysis is impossible for older surveys since the raw data are not available. This paper provides algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO standards.
Methods
Sixty-eight surveys from the WHO Global Database on Child Growth and Malnutrition were analyzed using the WHO standards to derive estimates of underweight, stunting, wasting and overweight. The prevalences based on the NCHS reference were taken directly from the database. National/regional estimates with a minimum sample size of 400 children were used to develop the algorithms. For each indicator, a simple linear regression model was fitted, using the logit of WHO and NCHS estimates as, respectively, dependent and independent variables. The resulting algorithms were validated using a different set of surveys, on the basis of which the point estimate and 95% confidence interval (CI) of the predicted WHO prevalence were compared to the observed prevalence.
Results
In total, 271 data points were used to develop the algorithms. The correlation coefficients (R2) were all greater than 0.90, indicating that most of the variability of the dependent variable is explained by the fitted model. The average difference between the predicted WHO estimate and the observed value was <0.5% for stunting, wasting and overweight. For underweight, the mean difference was 0.8%. The proportion of the 95% CI of the predicted estimate containing the observed prevalence was above 90% for all four indicators. The algorithms performed equally well for surveys without the entire age coverage 0 to 60 months.
Conclusion
To obtain comparable data concerning child malnutrition, individual survey data should be analyzed using the WHO standards. When the raw data are not available, the algorithms presented here provide a highly accurate tool for converting existing NCHS estimates into WHO estimates.
doi:10.1186/1471-2431-8-19
PMCID: PMC2390546  PMID: 18457590
5.  The emerging face of the HIV epidemic in the Middle East and North Africa 
Current Opinion in HIV and AIDS  2014;9(2):183-191.
Purpose of review
A volume of quality HIV data has materialized recently in the Middle East and North Africa (MENA). This review provides a thematic narrative of the patterns of HIV infection transmission in this region in light of these data.
Recent findings
Tens of integrated bio-behavioral surveillance surveys among hard-to-reach key populations at higher risk have been conducted in MENA in the recent years. Many of the studies reported appreciable and growing HIV prevalence. A few studies found alarming prevalence of as much as 87.2% HIV prevalence among people who inject drugs in Tripoli, Libya. The discovery of these hitherto hidden epidemics was unsettling to some authorities after years in which the importance of a focus on HIV prevention among key populations was not recognized.
Summary
The new data from MENA indicate growing HIV epidemics among key populations across the region. There is heterogeneity, however, as to which key populations are affected and in what proportions in different countries. In a few countries, HIV appears to affect only one key population and often there is substantial geographical heterogeneity in HIV transmission. Data are indicative of a growing HIV disease burden in this part of the globe, in contrast with the declining epidemics in most other regions.
doi:10.1097/COH.0000000000000038
PMCID: PMC3921267  PMID: 24445372
emerging epidemic; epidemiology; HIV; Middle East and North Africa
6.  HSV-2 serology can be predictive of HIV epidemic potential and hidden sexual-risk behavior in the Middle East and North Africa 
Epidemics  2010;2(4):173-182.
Background
HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA.
Methods
We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA.
Results
We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is high.
Conclusions
HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden risk behaviors in a region where quality behavioral data are limited.
doi:10.1016/j.epidem.2010.08.003
PMCID: PMC3722433  PMID: 21352788
Sexually transmitted infections; genital herpes; epidemiology; mathematical modeling; review; Middle East and North Africa
7.  Diet, Genetics, and Disease: A Focus on the Middle East and North Africa Region 
The Middle East and North Africa (MENA) region suffers a drastic change from a traditional diet to an industrialized diet. This has led to an unparalleled increase in the prevalence of chronic diseases. This review discusses the role of nutritional genomics, or the dietary signature, in these dietary and disease changes in the MENA. The diet-genetics-disease relation is discussed in detail. Selected disease categories in the MENA are discussed starting with a review of their epidemiology in the different MENA countries, followed by an examination of the known genetic factors that have been reported in the disease discussed, whether inside or outside the MENA. Several diet-genetics-disease relationships in the MENA may be contributing to the increased prevalence of civilization disorders of metabolism and micronutrient deficiencies. Future research in the field of nutritional genomics in the MENA is needed to better define these relationships.
doi:10.1155/2012/109037
PMCID: PMC3321453  PMID: 22536488
8.  Methodology and Early Findings of the Fourth Survey of Childhood and Adolescence Surveillance and Prevention of Adult Non-Communicable Disease in Iran: The CASPIAN-IV Study 
Background:
The fourth survey of the surveillance system named “childhood and adolescence surveillance and prevention of adult non-communicable disease” (CASPIAN-IV study), was conducted among a national representative sample of Iranian students. This paper describes the methods and early findings of this survey.
Methods:
This nationwide school-based study was conducted in 2011-2012 in 30 provinces of Iran among 13,486 students, 6-18 years (6640 girls, 75.6% from urban areas) and one of their parents.
Results:
Mean age of students was 12.5 years. Based on the World Health Organization growth curves, 12.2% were underweight, 9.7% overweight and 11.9% were obese. Abdominal obesity was observed in 19.1% of students. The dominant type of cooking oil in urban families was liquid oil and hydrogenated fat (39% and 32%), most rural families used hydrogenated fat (53%), respectively. A total of 18% of students had at least 30 min of daily physical activity; 41% of students used computer in weekdays and 44% used it in weekends. Almost 34.5% of students reported to have at least one cigarette smoker and 21.5% reported to have a waterpipe smoker in their relatives. Moreover, 20.3% of students reported that they had suffered an injury needing the help of school health providers during the year prior to the study.
Conclusions:
Current evidence on the health risky behaviors among Iranian children and adolescents confirms the importance of conducting comprehensive surveillance surveys to identify health risk behaviors. Data of this survey and the trend of variables provide necessary information for health policy makers to implement action-oriented interventions.
PMCID: PMC3898452  PMID: 24498502
Chronic diseases; prevention; risk behaviors; risk factors; school health; surveillance
9.  Comparison of the use of Tanner and Whitehouse, NCHS, and Cambridge standards in infancy. 
Archives of Disease in Childhood  1993;69(4):420-422.
The British (Tanner and Whitehouse) and American (National Center for Health Statistics, NCHS) growth standards are widely used internationally, although the data are now over 30 years old. Routine weight data was retrieved from the child health records of a complete annual cohort of 3418 children aged 18-30 months to test the validity of these standards for modern infants. Compared with the Tanner and Whitehouse standards, Newcastle children rose initially and then fell a mean of 0.7 SDs between 6 weeks and 18 months, resulting in a threefold difference in the proportion of children below the 3rd centile at different ages. NCHS standards showed a similar pattern. When compared with modern standards from the Cambridge growth study, there was a much closer match, although Newcastle children showed a slight gain by the age of 1 year. Existing standards for weight introduce inaccuracy into the estimation of centile position in the early months of life. As both standards show similar problems this probably represents a real secular change due to changes in infant nutrition. These findings support the need to develop new national growth reference standards.
PMCID: PMC1029547  PMID: 8259870
10.  Characterising the progress in HIV/AIDS research in the Middle East and North Africa 
Sexually Transmitted Infections  2013;89(Suppl 3):iii5-iii9.
Objectives
The Middle East and North Africa (MENA) region is perceived to have limited HIV data. The objective of this study was to quantitatively characterise the progress in HIV research in this region since the discovery of the epidemic.
Methods
Four indices were defined and implemented to measure the progress of HIV research using the PubMed, Embase, MENA HIV/AIDS Epidemiology Synthesis Project and US Census Bureau HIV/AIDS Surveillance databases. The four indices provide complementary measures to characterise different aspects of the progress of HIV research.
Results
A total of 2118, 2352, 683 and 4889 records were identified through the PubMed, the Embase, the Synthesis Project and the HIV Prevalence indices, respectively. The proportion of the total global HIV records that relate to MENA is 1.2%. Overall, the indices show steady progress in the number of new records every year, with an accelerated pace in the last few years. The rate of progress in MENA was also higher than the rate of progress in HIV records globally. There is no evidence so far of stabilisation or a peak in the number of new records year by year. About half of the records were produced after the year 2005. The number of records shows large heterogeneity across countries.
Conclusions
MENA has witnessed a rapid growth in HIV research over the last decade. However, there are still large gaps in HIV scientific evidence in the region, and the progress is far from being uniform across countries. Ongoing and future research needs to be geared towards academic standard and production of scientific publications.
doi:10.1136/sextrans-2012-050888
PMCID: PMC3841727  PMID: 23596206
EPIDEMIOLOGY (GENERAL); DEVELOPING WORLD; HIV; SEROPREVALENCE
11.  Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis 
PLoS Medicine  2011;8(8):e1000444.
A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.
Background
Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.
Methods and Findings
This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4–14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%–54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%–76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.
Conclusions
This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US. But, as the disease rapidly spread, it became clear that AIDS also affects heterosexual men and women. Now three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). In some countries, male-to-male sexual contact remains the most important transmission route. Moreover, although the global prevalence of HIV infection (the proportion the world's population infected with HIV) has stabilized, the prevalence of HIV infection among MSM seems to be increasing in multiple countries and new and resurgent HIV epidemics among MSM populations are being frequently reported.
Why Was This Study Done?
In the US and the UK, the MSM population is visible and has helped to raise awareness about the risks of HIV transmission through male-to-male sexual contact. In many other countries, MSM are much less visible, fearing discrimination, stigmatization (being considered socially unacceptable) or arrest. In the Middle East and North Africa (MENA, a geographical region that encompasses countries that share historical, socio-cultural, linguistic and religious characteristics), MSM are the most hidden HIV risk group. Consequently, very little is known about HIV transmission patterns among MSM in MENA. Indeed, it is widely thought that there is virtually no information available on the epidemiology (causes, distribution, and control) of HIV among MSM in this region. In this systematic review and data synthesis, the researchers use predefined search criteria to identify all the published and unpublished data on the epidemiology of HIV among MSM in MENA and combine (synthesize) these data to produce a coherent picture of the HIV epidemic in this potentially key group of people for HIV transmission in this region.
What Did the Researchers Do and Find?
The researchers identified 26 articles and 51 other country-level reports and sources of data that included data on the prevalence of male-to-male sexual contact, HIV transmission, levels of high-risk behavior, and the extent of knowledge about HIV among MSM in MENA. The prevalence of HIV infection among MSM was low in most countries but high in others. For example, the infection rate in Pakistan was 27.6% among one MSM group. Importantly, there was some evidence of increasing HIV prevalence and emerging epidemics among MSM in the region. Thus, by 2008, MSM transmission was responsible for more than a quarter of notified cases of HIV in several countries. Worryingly, MSM were involved in several types of HIV-related high risk behavior. For example, they had, on average, between 4 and 14 sexual partners in the past six months, their rates of consistent condom use were generally below 25% and, in some countries, MSM frequently reported injecting drug use, another common mode of HIV transmission. In addition, 20%–75.5% of MSM exchanged sex for money and contact between MSM and female sex workers and other female sexual partners was often common. Finally, although the level of basic knowledge about HIV/AIDS was high, the level of comprehensive knowledge was limited with a high proportion of MSM perceiving their risk of contracting HIV as low.
What Do These Findings Mean?
These findings indicate that there is considerable and increasing data about HIV transmission and risk behavior among MSM in MENA. However, the quality of this evidence varies greatly. Little has been collected over time in individual populations and, because only the visible part of the MSM populations in many MENA countries has been sampled, these findings may not be representative of all MSM in this region. Nevertheless, these findings suggest that HIV epidemics are emerging among MSM in several MENA countries. Importantly, the high levels of risk behaviors practiced by many MSM in MENA mean that MSM could become the pivotal risk group for HIV transmission in this region in the next decade. There is, therefore, an urgent need to expand HIV surveillance and access to HIV testing, prevention and treatment services among MSM in this region to limit the size of the HIV epidemic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000444.
Information about the status of the HIV epidemic in the Middle East and North Africa can be found in the World Bank/UNAIDS/WHO report Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for strategic action
Information about the global HIV epidemic among men who have sex with men can be found in the World Bank report The Global HIV Epidemics among Men Who Have Sex with Men
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM and on safer sex
Information is available from Avert, an international AIDS charity, on all aspects of HIV/AIDS, including information on HIV, AIDS and men who have sex with men and on HIV and AIDS prevention (in English and Spanish)
The US Centers for Disease Control and Prevention also have information about HIV/AIDS among men who have sex with men (in English and Spanish)
doi:10.1371/journal.pmed.1000444
PMCID: PMC3149074  PMID: 21829329
12.  Dual burden of body weight among Iranian children and adolescents in 2003 and 2010: the CASPIAN-III study 
Introduction
Our aim was to compare changes of body mass index (BMI) and waist circumference (WC) curves of Iranian children by comparing the results of two national surveys of a surveillance program, i.e. CASPIAN-I (2003–2004) and CASPIAN-III (2009–2010). The second objective was to evaluate the prevalence of obesity, overweight and underweight among 10–18-year-old Iranian children and adolescents.
Material and methods
This study was performed among students who were selected by multistage random cluster sampling from urban and rural areas of 27 provinces of Iran, as part of a national survey of school student high risk behavior entitled CASPIAN-III, conducted in 2009–2010.
Results
We evaluated 5088 school students (50.2% boys). In rural areas, underweight was more common in boys and overweight and obesity in girls. In urban areas underweight and obesity were more common in boys, whereas overweight was more common in girls. The highest prevalence of underweight (23.5%) was seen in students aged 13 years and the lowest (11.4%) in those aged 18 years. Underweight was significantly more common in rural than in urban areas (22.1% vs. 15.8%, respectively, p < 0.0001) and overweight/obesity was more common in urban than in rural areas. Compared with the findings in 2003–2004, the overall prevalence of elevated body mass index (16.6%) including obesity (9.1%) and overweight (7.5%) as well as underweight (17.5%) increased from 2003 to 2010.
Conclusions
In recent years, the double burden of nutritional disorders has increased among Iranian children and adolescents, especially in rural areas. This change may be related to epidemiologic transition, notably in terms of nutrition transition and rapid changes in lifestyle habits. This finding is an important issue for policy-makers for interventional preventive programs.
doi:10.5114/aoms.2014.40735
PMCID: PMC3953979
obesity; underweight; waist circumference; body mass index; pediatric age
13.  Silent Epidemic of Depression in Women in the Middle East and North Africa Region 
Background:
As the world is being gripped by economic depression, international psychological epidemiologists have amassed evidence to suggest that psychological depression and its variants are becoming leading contributors to the global burden of disease with the Middle East and North Africa (MENA) region being no exception.
Aim:
The main aim of the present discourse, based on a review of the available literature, is to discuss critically whether women in the MENA region have a higher rate of psychological depression than those in other parts of the globe.
Result:
From the present synthesis, it emerges that the rate of depression may not be necessarily unique to the region.
Conclusion:
Although no society has totally overcome the marginalisation and lack of empowerment of women, in order to come to grips to this complex issue more vigorously designed epidemiological studies, using taxonomies that are standardised for cross-cultural populations, are needed to quantify the psychological functioning of women.
PMCID: PMC3074757  PMID: 21509269
Depression in women; Gender Issue, Middle East and North Africa; Islam; Review
14.  Overweight according to geographical origin and time spent in France: a cross sectional study in the Paris metropolitan area 
BMC Public Health  2012;12:937.
Background
For the first time in France in a population-based survey, this study sought to investigate the potential impact of migration origin and the proportion of lifetime spent in mainland France on body mass index (BMI) and overweight in adults living in the Paris metropolitan area.
Methods
A representative, population-based, random sample of the adult, French speaking population of the Paris metropolitan area was interviewed in 2005. Self-reported BMI (BMI = weight/height2) and overweight (BMI ≥ 25) were our 2 outcomes of interest. Two variables were constructed to estimate individuals’ migration origin: parental nationality and the proportion of lifetime spent in mainland France, as declared by the participants. We performed multilevel regression models among different gender and age groups, adjusted for demographics and socioeconomic status.
Results
In women, a parental origin in the Middle East or North Africa (MENA) was associated with a higher risk of being overweight (especially before the age of 55) and a higher BMI (between 35 and 54 years of age), and so were women of Sub-Sahara African parental origin in the middle age category. Only in the youngest men (< 35 years of age) did we observe any association with parental nationality, with a higher BMI when having a MENA parentage. Regarding the association between the proportion of lifetime spent in France and overweight, we observed that, in women, a proportion of 50% to 99% appeared to be associated with overweight, especially after the age of 35. In men, having spent more than half of one’s lifetime in France was associated with a higher risk of overweight among oldest men.
Conclusions
Our results plea for potential cultural determinants of overweight in the migrant and migrants-born populations in the French context of the capital region. Taking into account the people’ family and personal migration histories may be an important issue in public health research and policies on overweight and obesity prevention.
doi:10.1186/1471-2458-12-937
PMCID: PMC3529117  PMID: 23113925
15.  Diabetes-Related Lower Extremities Amputations in Saudi Arabia: The Magnitude of the Problem 
Annals of Vascular Diseases  2012;5(2):151-156.
Background: Data on diabetes-related lower extremities amputations in the Kingdom of Saudi Arabia (KSA) and perhaps in all of Middle East and North African (MENA) countries are limited, in view of the absence of national registries.
Methods: This review aims to challenge media figures by review of data in the local database of the author, available published data, as well as by analysis of recent annual reports of the Saudi Ministry of Health to estimate the magnitude of the problem. Different methods of analysis are used based on the number of beds, operations and admissions in KSA to generate approximate figures of the annual expected numbers of amputations in KSA and MENA countries. The 2010 International Diabetes Federation IDF comparative prevalence rate of 16.8% was used to standardize the analysis methods.
Results: Findings of 2 previous studies and 3 analytical methods led me to the prediction that about 325 amputations are likely to occur annually in Jeddah compared to 741 in Riyadh and 3970 in KSA. When we applied the results of KSA to those of MENA countries, 44208 amputations were predicted annually.
Conclusion: Half a million diabetes-related amputations of the lower extremities are likely to occur in KSA and MENA countries over the coming decade. National registries are urgently needed.
doi:10.3400/avd.oa.11.00098
PMCID: PMC3595872  PMID: 23555503
diabetes mellitus; ulceration; amputation; ischemia
16.  The case for developing publicly-accessible datasets for health services research in the Middle East and North Africa (MENA) region 
Background
The existence of publicly-accessible datasets comprised a significant opportunity for health services research to evolve into a science that supports health policy making and evaluation, proper inter- and intra-organizational decisions and optimal clinical interventions. This paper investigated the role of publicly-accessible datasets in the enhancement of health care systems in the developed world and highlighted the importance of their wide existence and use in the Middle East and North Africa (MENA) region.
Discussion
A search was conducted to explore the availability of publicly-accessible datasets in the MENA region. Although datasets were found in most countries in the region, those were limited in terms of their relevance, quality and public-accessibility. With rare exceptions, publicly-accessible datasets - as present in the developed world - were absent. Based on this, we proposed a gradual approach and a set of recommendations to promote the development and use of publicly-accessible datasets in the region. These recommendations target potential actions by governments, researchers, policy makers and international organizations.
Summary
We argue that the limited number of publicly-accessible datasets in the MENA region represents a lost opportunity for the evidence-based advancement of health systems in the region. The availability and use of publicly-accessible datasets would encourage policy makers in this region to base their decisions on solid representative data and not on estimates or small-scale studies; researchers would be able to exercise their expertise in a meaningful manner to both, policy makers and the public. The population of the MENA countries would exercise the right to benefit from locally- or regionally-based studies, versus imported and in 'best cases' customized ones. Furthermore, on a macro scale, the availability of regionally comparable publicly-accessible datasets would allow for the exploration of regional variations and benchmarking studies.
doi:10.1186/1472-6963-9-197
PMCID: PMC2774680  PMID: 19874590
17.  Weight, Height and Body Mass Index Nomograms; Early Adiposity Rebound in a Sample of Children in Tehran, Iran 
Background:
Assessing growth is a useful tool for defining health and nutritional status of children. The objective of this study was to construct growth reference curves of Iranian infants and children (0-6 years old) and compare them with previous and international references.
Methods:
Weight, height or length of 2107 Iranian infants and children aged 0-6 years old were measured using a cross-sectional survey in Tehran in 2010. Standard smooth reference curves for Iranian population were constructed and compared to multinational World Health Organization 2006 reference standards as well as a previous study from two decades ago.
Results:
Growth index references for Iranian girls are increased in compare to data from two decades ago and are approximately close to the international references. In boys; however, the increment was considerably large as it passed the international references. Not only the values for indexes was changed during two decades, but also the age at adiposity rebound came near the age of 3, which is an important risk factor for later obesity.
Conclusions:
During two decades, growth indexes of Iranian children raised noticeable. Risk factors for later obesity are now apparent and demand immediate policy formulations. In addition, reference curves presented in this paper can be used as a diagnostic tool for monitoring growth of Iranian children.
PMCID: PMC3898447  PMID: 24498497
Body mass index; children; height; infant; weight
18.  HIV surveillance in MENA: recent developments and results 
Sexually Transmitted Infections  2013;89(Suppl 3):iii11-iii16.
Objectives
To provide an overview of the current level of development and results from the national HIV surveillance systems of the 23 countries of the Middle East and North Africa (MENA), and to assess the quality of HIV surveillance systems in the period 2007–2011.
Methods
A questionnaire was used to collect the information about the structure, activities and the results of HIV surveillance systems from the National AIDS Programmes. Assessment of the quality was based on four indicators: timeliness of data collection, appropriateness of populations under surveillance, consistency of the surveillance sites and groups measured over time, and coverage of the surveillance system.
Results
Only in four countries did surveillance systems enable assessment of epidemic trends in the same populations and locations over time, such as in pregnant women (Morocco, Iran), injecting drug users (Iran, Pakistan), female sex workers (Djibouti, Morocco) and male sex workers (Pakistan). There is increasing evidence of HIV infection being firmly established in at least one of the populations most at risk of HIV in nine MENA countries, while lower risk populations show elevated HIV prevalence in South Sudan, Djibouti and some parts of Somalia.
Conclusions
The performance of HIV surveillance systems in several of the MENA countries has improved in recent years. The extent of HIV epidemics in the populations most at risk of HIV is still largely unknown in 10 countries. Multiple data sources that most of the countries still lack would enable indirectly estimation not only of the patterns of HIV epidemics but also the effectiveness of HIV responses.
doi:10.1136/sextrans-2012-050849
PMCID: PMC3841745  PMID: 23434789
Surveillance; HIV; Epidemiology (Clinical); Injecting Drug Use; Sexual Behaviour
19.  Underweight, Overweight and Obesity Among Zaboli Adolescents: A Comparison Between International and Iranians’ National Criteria 
Background:
Obesity and overweight are the major health problems in Iran. The aim of this study was to determine the prevalence of overweight and obesity among adolescents living in Zabol settled in Sistan va Baluchistan, one of economically underprivileged provinces in South Eastern of Iran, based on four different definitions.
Methods:
This cross-sectional study was accomplished among a sample of 837 Zaboli adolescents (483 males; 354 females) aged 11-15 years. Anthropometric measurements including weight and height were measured and body mass index (BMI) was calculated. Sex-specific BMI-for-age reference data of the Iranian national data, Centers for Disease Control data (CDC 2000), International Obesity Task Force data (IOTF) and recent World Health Organization (WHO) data was used to define overweight and obesity.
Results:
Mean age of the studied population was 13.14 year. Underweight was prevalent among almost 18.7% and 18.4% of adolescents by the use of WHO 2007 and CDC 2000 cut-off points. The prevalence rates reached 25.8% and 27.2% by IOTF and Iranian national criteria, respectively. The highest prevalence of overweight was obtained by IOTF cut-points (10.8%) followed by CDC 2000 criteria (9.4%), WHO 2007 (8.8%) while national Iranian cut-points resulted in the lowest prevalence (2.4%). 7.5% of the studied population were found to be obese by WHO 2007 definition, while this rate was 2.2%, 3.4% and 1.5% by IOTF, CDC 2000 and national Iranian cut-points.
Conclusions:
Almost all definitions revealed coexistence of underweight, overweight, and obesity among Zaboli adolescents. Huge differences exist between different criteria. To understand the best appropriate criteria for Iranian adolescents, future studies should focus on the predictability of obesity-related co-morbidities by these criteria.
PMCID: PMC3733182  PMID: 23930162
Adolescents; body mass index; Iran; obesity; overweight; prevalence; Zabol
20.  Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2008;5(7):e141.
Background
Alcohol, tobacco, and illegal drug use cause considerable morbidity and mortality, but good cross-national epidemiological data are limited. This paper describes such data from the first 17 countries participating in the World Health Organization's (WHO's) World Mental Health (WMH) Survey Initiative.
Methods and Findings
Household surveys with a combined sample size of 85,052 were carried out in the Americas (Colombia, Mexico, United States), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), Middle East and Africa (Israel, Lebanon, Nigeria, South Africa), Asia (Japan, People's Republic of China), and Oceania (New Zealand). The WHO Composite International Diagnostic Interview (CIDI) was used to assess the prevalence and correlates of a wide variety of mental and substance disorders. This paper focuses on lifetime use and age of initiation of tobacco, alcohol, cannabis, and cocaine. Alcohol had been used by most in the Americas, Europe, Japan, and New Zealand, with smaller proportions in the Middle East, Africa, and China. Cannabis use in the US and New Zealand (both 42%) was far higher than in any other country. The US was also an outlier in cocaine use (16%). Males were more likely than females to have used drugs; and a sex–cohort interaction was observed, whereby not only were younger cohorts more likely to use all drugs, but the male–female gap was closing in more recent cohorts. The period of risk for drug initiation also appears to be lengthening longer into adulthood among more recent cohorts. Associations with sociodemographic variables were consistent across countries, as were the curves of incidence of lifetime use.
Conclusions
Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones. Sex differences were consistently documented, but are decreasing in more recent cohorts, who also have higher levels of illegal drug use and extensions in the period of risk for initiation.
Louisa Degenhardt and colleagues report an international survey of 17 countries that finds clear differences in drug use across different regions of the world.
Editors' Summary
Background.
Understanding how much disability and death a particular disease causes (known as the “burden of disease”) is important. Knowing the burden of a disease in a country contributes to the development of healthier nations by directing strategies and policies against the disease. Researchers' understanding of the burden of diseases across different countries was piecemeal until the 1990 launch of a special World Health Organization (WHO) project, the Global Burden of Disease Project. In 2002, on the basis of updated information from this ongoing project, the WHO estimated that 91 million people were affected by alcohol use disorders and 15 million by drug use disorders.
Why Was This Study Done?
It is widely accepted that alcohol, tobacco, and illegal drug use are linked with a considerable amount of illness, disability, and death. However, there are few high-quality data quantifying the amount across different countries, especially in less-developed countries. The researchers therefore set out to collect basic patterns of alcohol, tobacco, cannabis, and cocaine use in different countries. They documented lifetime use of these substances in each county, focusing on young adults. They also wanted to examine the age of onset of use and whether the type of drugs used was affected by one's social and economic status.
What Did the Researchers Do and Find?
Data on drug use were available from 54,069 survey participants in 17 countries. The 17 countries were determined by the availability of collaborators and on funding for the survey. Trained lay interviewers carried out face-to-face interviews (except in France where the interviews were done over the telephone) using a standardized, structured diagnostic interview for psychiatric conditions. Participants were asked if they had ever used (a) alcohol, (b) tobacco (cigarettes, cigars or pipes), (c) cannabis (marijuana, hashish), or (d) cocaine. If they had used any of these drugs, they were asked about the age they started using each type of drug. The age of first tobacco smoking was not assessed in New Zealand, Japan, France, Germany, Belgium, The Netherlands, Italy, or Spain. The interviewers also recorded the participants' sex, age, years of education, marital status, employment, and household income.
The researchers found that in the Americas, Europe, Japan, and New Zealand, alcohol had been used by the vast majority of survey participants, compared to smaller proportions in the Middle East, Africa, and China. The global distribution of drug use is unevenly distributed with the US having the highest levels of both legal and illegal drug use among all countries surveyed. There are differences in both legal and illegal drug use among different socioeconomic groups. For example, males were more likely than females to have used all drug types; younger adults were more likely than older adults to have used all drugs examined; and higher income was related to drug use of all kinds. Marital status was found to be linked only to illegal drug use—the use of cocaine and cannabis is more likely in people who have never been married or were previously married. Drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g., The Netherlands).
What Do These Findings Mean?
These findings present comprehensive and useful data on the patterns of drug use from national samples representing all regions of the world. The data will add to the understanding of the global burden of disease and should be useful to government and health organizations in developing policies to combat these problems. The study does have its limitations—for example, it surveyed only 17 of the world's countries, within these countries there were different rates of participation, and it is unclear whether people accurately report their drug use when interviewed. Nevertheless, the study did find clear differences in drug use across different regions of the world, with the US having among the highest levels of legal and illegal drug use of all the countries surveyed.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050141.
Facts and figures on alcohol are available from the World Health Organization, including information about the burden of disease worldwide as a result of alcohol
Information on the management of substance abuse is available from WHO
Information on the Global Burden of Disease Project is also available from WHO
Researchers from the University of New South Wales, Australia and the University of Queensland co-chair, sponsors the Global Burden of Disease Mental Disorders and Illicit Drug Use Expert Group, which examines illicit drug use and disorders
The UN World Drug Report is available from the UN Office on Drugs and Crime
The University of New South Wales also runs the Secretariat for the Reference Group to the United Nations on HIV and Injecting Drug Use
doi:10.1371/journal.pmed.0050141
PMCID: PMC2443200  PMID: 18597549
21.  Neglected Tropical Diseases of the Middle East and North Africa: Review of Their Prevalence, Distribution, and Opportunities for Control 
The neglected tropical diseases (NTDs) are highly endemic but patchily distributed among the 20 countries and almost 400 million people of the Middle East and North Africa (MENA) region, and disproportionately affect an estimated 65 million people living on less than US$2 per day. Egypt has the largest number of people living in poverty of any MENA nation, while Yemen has the highest prevalence of people living in poverty. These two nations stand out for having suffered the highest rates of many NTDs, including the soil-transmitted nematode infections, filarial infections, schistosomiasis, fascioliasis, leprosy, and trachoma, although they should be recognized for recent measures aimed at NTD control. Leishmaniasis, especially cutaneous leishmaniasis, is endemic in Syria, Iran, Iraq, Libya, Morocco, and elsewhere in the region. Both zoonotic (Leishmania major) and anthroponotic (Leishmania tropica) forms are endemic in MENA in rural arid regions and urban regions, respectively. Other endemic zoonotic NTDs include cystic echinococcosis, fascioliasis, and brucellosis. Dengue is endemic in Saudi Arabia, where Rift Valley fever and Alkhurma hemorrhagic fever have also emerged. Great strides have been made towards elimination of several endemic NTDs, including lymphatic filariasis in Egypt and Yemen; schistosomiasis in Iran, Morocco, and Oman; and trachoma in Morocco, Algeria, Iran, Libya, Oman, Saudi Arabia, Tunisia, and the United Arab Emirates. A particularly noteworthy achievement is the long battle waged against schistosomiasis in Egypt, where prevalence has been brought down by regular praziquantel treatment. Conflict and human and animal migrations are key social determinants in preventing the control or elimination of NTDs in the MENA, while local political will, strengthened international and intersectoral cooperative efforts for surveillance, mass drug administration, and vaccination are essential for elimination.
doi:10.1371/journal.pntd.0001475
PMCID: PMC3289601  PMID: 22389729
22.  Untreated severe dental decay: a neglected determinant of low Body Mass Index in 12-year-old Filipino children 
BMC Public Health  2011;11:558.
Background
Dental decay is the most common childhood disease worldwide and most of the decay remains untreated. In the Philippines caries levels are among the highest in the South East Asian region. Elementary school children suffer from high prevalence of stunting and underweight.
The present study aimed to investigate the association between untreated dental decay and Body Mass Index (BMI) among 12-year-old Filipino children.
Methods
Data collection was part of the National Oral Health Survey, a representative cross-sectional study of 1951 11-13-year-old school children using a modified, stratified cluster sampling design based on population classifications of the Philippine National Statistics Office. Caries was scored according to WHO criteria (1997) and odontogenic infections using the PUFA index. Anthropometric measures were performed by trained nurses. Some socio-economic determinants were included as potential confounding factors.
Results
The overall prevalence of caries (DMFT + dmft > 0) was 82.3% (95%CI; 80.6%-84.0%). The overall prevalence of odontogenic infections due to caries (PUFA + pufa > 0) was 55.7% (95% CI; 53.5%-57.9%) The BMI of 27.1% (95%CI; 25.1%-29.1%) of children was below normal, 1% (95%CI; 0.5%-1.4%) had a BMI above normal. The regression coefficient between BMI and caries was highly significant (p < 0.001). Children with odontogenic infections (PUFA + pufa > 0) as compared to those without odontogenic infections had an increased risk of a below normal BMI (OR: 1.47; 95% CI: 1.19-1.80).
Conclusions
This is the first-ever representative survey showing a significant association between caries and BMI and particularly between odontogenic infections and below normal BMI. An expanded model of hypothesised associations is presented that includes progressed forms of dental decay as a significant, yet largely neglected determinant of poor child development.
doi:10.1186/1471-2458-11-558
PMCID: PMC3160376  PMID: 21752286
23.  Polish 2012 growth references for preschool children 
European Journal of Pediatrics  2013;172(6):753-761.
Growth references are useful in monitoring a child's growth, which is an essential part of child care. The aim of this paper is to provide updated growth references for Polish preschool children and to assess how well children in Poland match or diverge from the World Health Organization (WHO) growth standards/references and recent German height-for-age references. The height-, weight-, body mass index-for-age, and weight-for-height references were constructed with the LMS method using data from a recent, large, population-representative sample of 4,941 preschool children aged 3 to 6 years (the OLA study). In the case of boys, the third, 50th, and 97th height percentiles of new Polish and German references overlap almost completely, whereas the WHO growth standards/references percentiles are systematically lower. In the case of girls, comparison between the new Polish and German height references showed conformity on the third and 50th percentile, whereas body height values of the WHO standards/references are shorter. Polish children aged 3 to 6 years from for the nation representative sample, had significantly greater than zero mean z scores of height-, weight-, and BMI-for-age and weight-for-height, relative to the WHO growth standards/references. The number of children in the sample with height-for-age below −2 SD was significantly lower than expected and number of children with height-for-age above +2 SD was significantly higher than expected. Conclusion: The OLA study growth references can be recommended as national references for preschool children in Poland.
doi:10.1007/s00431-013-1954-2
PMCID: PMC3663205  PMID: 23371392
Preschool children; Growth references; LMS method
24.  Anthropometry and body composition of school children in Bahrain 
Annals of Saudi Medicine  2009;29(4):258-269.
BACKGROUND AND OBJECTIVES:
This study was conducted because of the lack of a comprehensive nationwide assessment of data on the anthropometric status and related health problems in Bahraini school children aged 6 to 18 years.
SUBJECTS AND METHODS:
A cross-sectional survey was conducted on the anthropometric status of school children enrolled in the primary, intermediate and secondary government schools in all populated regions of Bahrain. The sample size included 2594 students (1326 girls and 1268 boys) representing 2.5% of the total student population. For sample selection, a multi-stage sampling design was chosen that combined multi-cluster and simple random sampling methods. Anthropometric measurements included height, weight, mid-arm circumference and skin fold thickness at two sites (triceps and subscapular). Anthropometric indices derived were body mass index (BMI) and arm muscle area. The WHO reference standards (2007) and the National Health and Nutrition Examination Survey (NHANES) II data were used for comparison.
RESULTS:
Compared to WHO reference standards, the median height of Bahraini children and adolescents in the age range of 6 to 18 years was close to the 25th percentile or lower, while the median BMI during adolescent years was comparable in boys, but higher than WHO standards in girls, reaching the 75th percentile. The cut-off values of BMI for overweight/obesity status (85th and 95th percentile) were higher by 3-6 kg/m2 compared to WHO standards. While skin fold thicknesses were also higher in Bahraini adolescents compared to their American counterparts (NHANES II), arm muscularity was substantially lower.
CONCLUSIONS:
Current study findings for BMI as well as skin fold thicknesses suggest an increased trend toward adiposity among Bahraini adolescents, especially in girls, which puts this age group at a high risk of adult obesity and its consequences. A need for urgent intervention programs is emphasized.
doi:10.4103/0256-4947.55309
PMCID: PMC2841452  PMID: 19584585
25.  Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia 
BMC Public Health  2009;9:167.
Background
The burden of non-communicable diseases is rising globally. This trend seems to be faster in developing countries of the Middle East. In this study, we presented the latest prevalence rates of a number of important non-communicable diseases and their risk factors in the Iranian population.
Methods
The results of this study are extracted from the third national Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007), conducted in 2007. A total of 5,287 Iranian citizens, aged 15–64 years, were included in this survey. Interviewer-administered questionnaires were applied to collect the data of participants including the demographics, diet, physical activity, smoking, history of hypertension, and history of diabetes. Anthropometric characteristics were measured and serum biochemistry profiles were determined on venous blood samples. Diabetes (fasting plasma glucose ≥ 126 mg/dl), hypertension (systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, or use of anti-hypertensive drugs), dyslipidemia (hypertriglyceridemia: triglycerides ≥ 150 mg/dl, hypercholesterolemia: total cholesterol ≥ 200 mg/dl), obesity (body mass index ≥ 30 kg/m2), and central obesity (waist circumference ≥ 80 cm in females and ≥ 94 cm in males) were identified and the national prevalence rates were estimated.
Results
The prevalence of diabetes, hypertension, obesity, and central obesity was 8.7% (95%CI = 7.4–10.2%), 26.6% (95%CI = 24.4–28.9%), 22.3% (95%CI = 20.2–24.5%), and 53.6% (95%CI = 50.4–56.8%), respectively. The prevalence of hypertriglyceridemia and hypercholesterolemia was 36.4% (95%CI = 34.1–38.9%) and 42.9% (95%CI = 40.4–45.4%), respectively. All of the mentioned prevalence rates were higher among females (except hypertriglyceridemia) and urban residents.
Conclusion
We documented a strikingly high prevalence of a number of chronic non-communicable diseases and their risk factors among Iranian adults. Urgent preventive interventions should be implemented to combat the growing public health problems in Iran.
doi:10.1186/1471-2458-9-167
PMCID: PMC2697989  PMID: 19480675

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