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1.  Geographic Health's Way to Prevention of Diseases: A Case Study on Arsenic Spatial Dispersion and Dyspnea in Isfahan Province 
As geographic science discusses the analysis of environment, human beings and their mutual relations, thus the field of medical geography consists of being inspired from the relations between these two factors, analyzing environmental factors, their identification them and the state of their effects on human health, as well as determining the location of these factors. Some hazards that threat human health are the results of environmental factors and the relevant pollutions. Some important categories of diseases including (Shortness of Breath or, Dyspnea) have considerable differences in various places, as observed in their spatial prevalence and distribution maps.
The record of patients with Dyspnea diseases were prepared for this descriptive research, for the period of 2009-2011, from the provincial health center, with the questionnaires were excluded patients with a family history of disease and the spatial diagram for disease prevalence was drawn according to the prepared data. The arsenic geographical distribution diagram in Isfahan province was also prepared and then the relation between an element of Arsenic in the province and the Dyspnea diseases were analyzed.
The analyses showed that the highest rate of Arsenic is entered the soil via fertilizers to come eventually into the food cycle of humans. By analyzing the amount of used fertilizers in Isfahan province and the dispersion diagram of Arsenic in Isfahan province, it was found that the highest frequency of Arsenic is in places having agricultural base. The spatial dispersion of Dyspnea diseases also showed that the spreading of Dyspnea diseases is greater in places with higher scale of Arsenic.
This study is a logical justification between the two diagrams to confirm the hypothesis regarding the effect of arsenic on Dyspnea.
PMCID: PMC4274543  PMID: 25538832
Arsenic; dyspnea; Isfahan province; medical geography; spatial dispersion
2.  First report on the association of drinking water hardness and endothelial function in children and adolescents 
Archives of Medical Science : AMS  2014;10(4):746-751.
This study aims to investigate the relationship of water hardness and its calcium and magnesium content with endothelial function in a population-based sample of healthy children and adolescents.
Material and methods
This case-control study was conducted in 2012 among 90 individuals living in two areas with moderate and high water hardness in Isfahan County, Iran. The flow-mediated dilatation (FMD) of the brachial artery and the serum levels of soluble adhesion molecules (sICAM-1, sVCAM-1) were measured as surrogate markers of endothelial function, and high-sensitivity C-reactive protein (hs-CRP), as a marker of inflammation.
Data of 89 participants (51% boys, mean age 14.75 (2.9) years) were complete. Those participants living in the area with high water hardness had higher FMD, hs-CRP, and soluble adhesion molecules (sICAM-1, sVCAM-1) than their counterparts living in the area with moderate water hardness. Multiple linear regression analysis showed that after adjustment for confounding factors of age, gender, body mass index, healthy eating index and physical activity level, total water hardness, as well as water content of calcium and magnesium, had a significant positive relationship with FMD. The corresponding associations were inverse and significant with soluble adhesion molecules (p < 0.05).
This study, which to the best of our knowledge is the first of its kind in the pediatric age group, suggests that water hardness, as well as its calcium and magnesium content, may have a protective role against early stages of atherosclerosis in children and adolescents.
PMCID: PMC4175776  PMID: 25276160
water hardness; endothelial function; calcium; magnesium; children and adolescents
3.  Expression of cord blood cytochrome P450 1A1 gene according to the air pollution level of the maternal residence area 
This study aimed to compare the cytochrome P450 1A1 (CYP1A1) gene expression in the cord blood of infants born from mothers living in low- and high-air polluted areas.
Materials and Methods:
The study was conducted in Spring 2012 in Isfahan, the second large and air-polluted city in Iran. The study comprised 60 neonates, consisting of 30 infants born from mothers residing in areas with high levels of air pollution and an equal number of infants born in areas with a lower air pollution level. The umbilical cord blood sample was taken immediately after birth. The relative gene expression levels of CYP1A1 were examined using real time-polymerase chain reaction method.
CYP1A1 gene expression level was 3.3-fold higher in the group living in areas with higher pollution level than in the other group (P = 0.01). No significant difference existed in the mean values of maternal age, gestational age, the newborns’ birth weight, and the gender distribution between the two groups.
This study provides confirmatory evidence of prenatal health hazards of ambient air pollution and highlights the need for pollution prevention programs to protect women of childbearing age and their children. The clinical implications of this study finding should be confirmed in future longitudinal studies.
PMCID: PMC4235086  PMID: 25422651
Air pollution; CYP1A1 gene expression; fetus; prevention
4.  The Association between Depression and Climatic Conditions in the Iran Way to Preventive of Depression 
Neurotransmitters, such as dopamine and serotonin, play an undeniable role in the incidence of mental illnesses. Almost all humans will experience depression. Furthermore, most humans lack the ability to control and reduce depression, the disorder can lead to physical damage. The main goal of this study was to determine the association between distribution of depression and the climatic conditions in the Iran country.
Spatial distribution maps of depression were plotted by using data recorded during 2010 year in the Iran health center registry. The geographical mapping of depression and climatic conditions were then incorporated into a geographic information system to create a spatial distribution model and in this study we used neural network to model the trend of depression and climatic conditions.
The spatial distributions of depression diseases in the country, followed by were scattered based on climatic conditions. In fact, common depression was more prevalent in the parts of the country where cold and rainy weather was more abundant.
The findings of this study can be useful for psychologists and controlling of this disease, because lack the ability to control and reduce depression, the disorder can lead to physical damage. Data are also important to establish further effects modeling for depression. Moreover, psychologists and health professionals should consider the impact of environmental factors on their patients’ health.
PMCID: PMC4258674  PMID: 25489441
Climatic conditions; depression; Iran; spatial distribution
5.  Growth Disorders Among 6-Year-Old Iranian Children 
Sociodemographic factors are important determinants of weight disorders. National representative studies provide a view on this health problem at national and regional levels.
This study aimed to assess the distribution of growth disorders in terms of body mass index (BMI) and height in 6-year-old Iranian children using geographical information system (GIS).
Materials and Methods:
In this cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were examined in a mandatory national screening program in 2009. Descriptive analysis was used to calculate the prevalence of underweight, overweight, obesity, and short stature. Then, ArcGIS software was used to draw the figures.
The study population consisted of 955388 children (48.5% girls and 76.5% urban). Overall, 20% of children were underweight, and 14.3% had high BMI, consisted of 10.9% overweight and 3.4% obese. The corresponding figure for short stature was 6.6%; however, these growth disorders were not equally distributed across various provinces.
Our results confirmed unequal distribution of BMI and height of 6-year-old children in Iran generally and in most of its provinces particularly. The differences among provinces cannot be fully explained by the socioeconomic pattern. These findings necessitate a comprehensive national policy with provincial evidence-based programs.
PMCID: PMC4102995  PMID: 25068062
Body Mass Index; Child; Socioeconomic Factors
6.  Dual burden of body weight among Iranian children and adolescents in 2003 and 2010: the CASPIAN-III study 
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.
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.
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.
PMCID: PMC3953979  PMID: 24701221
obesity; underweight; waist circumference; body mass index; pediatric age
7.  Does Water Hardness Have Preventive Effect on Cardiovascular Disease? 
The aim of this study is to investigate the association of calcium and magnesium concentration of drinking water with cardiovascular disease (CVDs) in urban and rural areas of a city in Iran.
This case-control study was conducted in 2012 in Khansar County in Isfahan province, Iran. We used the official data of the Provincial health center regarding the chemical analysis data of urban and rural areas including the hardness, calcium and magnesium content of drinking water. Data of patients hospitalized for CVD in the only specialty hospital of the city was gathered for the years of 2010 and 2011.
In 2010, water calcium content above 72 mg/L was associated with reduced number of CVDs in 1000 population; whereas in 2011 this decrease in CVDs was observed for calcium levels of more than 75 mg/L. In 2010, the level of water Mg content ranged from 23 to 57 mg/L. By increasing Mg hardness level above 31 mg/L in 2010 and above 26 mg/L in 2011 were associated with decreased number of CVDs in 1000 people. decrease.
Our study suggests favorable protective effects of water hardness, mainly water magnesium content, on CVDs. Water hardness, as well as calcium and magnesium content of drinking water may have a protective role against CVDs. Further experimental studies are necessary to determine the underlying mechanisms and longitudinal studies are required to study the clinical impacts of the current findings.
PMCID: PMC3950737  PMID: 24627741
Calcium; cardiovascular disease; Iran; magnesium; water hardness
8.  Relation of air pollution with epidemiology of respiratory diseases in isfahan, Iran from 2005 to 2009 
National Institute of Environmental Health Sciences (NIEHS) scientists shows that long-term exposure to air pollutants increases the risk of respiratory diseases such as allergies, asthma, chronic obstructive pulmonary disease, and lung cancer. Children and the elderly are particularly vulnerable to the health effects of ozone, fine particles, and other airborne toxicants. Air pollution factors are considered as one of the underlying causes of respiratory diseases. This study aimed to determine the association of respiratory diseases documented in medical records and air pollution (Map distribution) of accumulation in Isfahan province, Iran. By plotting the prevalence and spatial distribution maps, important differences from different points can be observed.
Materials and Methods:
The geographic information system (GIS), pollutant standards index (PSI) measurements, and remote Sensing (RS) technology were used after entering data in the mapping information table; spatial distribution was mapped and distribution of Geographical Epidemiology of Respiratory Diseases in Isfahan province (Iran) was determined in this case study from 2005 to 2009.
Space with tracing the distribution of respiratory diseases was scattered based on the distribution of air pollution in the points is an important part of this type of diseases in Isfahan province where air pollution was more abundant.
The findings of this study emphasis on the importance of preventing the exposure to air pollution, and to control air pollution product industries, to improve work environmental health, and to increase the health professionals and public knowledge in this regard.
PMCID: PMC3908529  PMID: 24523799
Air pollution; Iran; Isfahan province; respiratory diseases; spatial distribution
9.  Pathologic Analysis of Control Plans for Air Pollution Management in Tehran Metropolis: A Qualitative Study 
Regarding the importance of air pollution issue for large cities, as Tehran metropolis, many plans, programs, projects and regulations have been developed to manage urban air pollution. However, most of them failed to decline the pollution. The purpose of this study is to pathologically analyze air-pollution control plans in order to offer effective solutions for Tehran metropolis.
A qualitative content analysis and a semi-structured interview with 14 practicing professionals were used to identify key causes and sources of Tehran's air pollution, to recognize challenges and obstacles towards effective performance of air-pollution control plans in this metropolitan area, and to suggest the most effective controlling solutions.
Challenges related to air-pollution control plans can be divided into two major categories: Firstly lack of integrated and organized stewardship and secondly those related to political, economical, social and technical environmental abbreviated as PEST, challenges. For effective control of the Tehran air pollution, the following eight controlling alternatives were identified: Systematization of plan preparation process, organizing the stewardship, standardization and utilization of new technologies and professional experts, cultural and infrastructural development, realization of social justice, developing coordination and controlling mechanisms, improving citizen's participatory capacity, and focusing on effective management of fuel and energy.
Controlling air pollution in Tehran should be considered as a priority for policymakers to make enforcements through applying a systemic cycle of preparation effective and comprehensive plans. Further, implement the enforcements and evaluate the environmental impact of the plans through involving all stakeholders.
PMCID: PMC3793499  PMID: 24130939
Air pollution management; control plan; pollutants; public health
10.  Determinants of Hypovitaminosis D in Pregnant Women and Their Newborns in a Sunny Region 
Introduction. This study aims to assess the factors associated with 25-hydroxy vitamin D (25(OH)D) levels in pregnant women and their newborns in a sunny region. Materials and Methods. This cross-sectional study was conducted in 2012 in Isfahan, Iran. It comprised 100 nulliparous singleton pregnant women, selected by random cluster sampling. Laboratory tests were assessed before delivery in mothers and after delivery in their infants' umbilical cord blood. The P for trend of variables was assessed across the air quality index (AQI) quartiles. The associations of AQI and 25(OH)D were assessed by multiple linear regression after adjustment for age, body mass index, and dietary intake. Results. Sera of 98 mothers and an equal number of newborns were analyzed. The median (interquartile range, IQR) of serum 25(OH)D of mothers and neonates was 15.1(12.6, 18.2) ng/mL in mothers and 15.7(12.0, 18.1) ng/mL in neonates, respectively. AQI had an inverse association with serum 25(OH)D (Beta = −0.58, P = 0.04). The corresponding figure was also inverse and significant for newborns (Beta (SE)= −0.51(0.04), P = 0.01). Conclusion. The independent inverse association of 25(OH)D with air quality can explain the high prevalence of hypovitaminosis D in pregnant women living in this sunny region.
PMCID: PMC3713371  PMID: 23935619
11.  Role of Environmental Chemicals in Obesity: A Systematic Review on the Current Evidence 
The purpose of this paper is to systematically review the experimental and human studies on obesogenic chemicals and their mechanisms of action to provide a comprehensive view on the multifactorial aspects of obesity. The literatures were searched in available databases. The relevant papers were selected in three phases. After quality assessment, two reviewers extracted the data while another checked their extracted data. In this review, we summarized information regarding environmental chemicals that can be associated with obesity. Most evidence comes from experimental and laboratory studies; however a growing number of human studies also support the role of obesogenic chemicals. The current evidence proposes that the systemic responses to exposure to environmental factors could potentially increase the risk of excess weight. The effects of exposure to these chemicals are of crucial importance during developmental phases of life, when preprogramming for an adipogenic outcome may occur. By considering the adverse transgenerational effects of obesogen chemicals on human health, the global obesity epidemic should be considered as a multifactorial complex disorder necessitating the emphasis of public health interventions for environmental protection.
PMCID: PMC3687513  PMID: 23840234
12.  Association of Blood Cadmium Level with Cardiometabolic Risk Factors and Liver Enzymes in a Nationally Representative Sample of Adolescents: The CASPIAN-III Study 
Introduction. This study aimed to determine the association of blood cadmium level with cardiometabolic risk factors and liver enzymes in adolescents. Methods. This case control study comprised 320 Iranian adolescents, 160 with metabolic syndrome and an equal number of controls. They were selected from participants of a nationwide survey entitled the CASPIAN-III study. Cadmium was measured by atomic absorption method. Results. The mean age of the case and control groups was not significantly different (15.3 ± 2.6 versus 14.63 ± 2.5 years, resp., P > 0.05). The mean cadmium level was near double-fold higher than the standards of the World Health Organization, without significant difference between the MetS and control groups (10.09 ± 2.21, 9.97 ± 2.38 μg/L, resp., P > 0.05). Cadmium level had positive but nonsignificant correlations with diastolic blood pressure, serum triglycerides, fasting blood glucose, LDL-C, and liver enzymes. Conclusion. Cadmium level had positive but nonsignificant association with some cardiometabolic risk factors and liver enzymes. The associations did not reach statistical significant level, and this may be because of the high levels of cadmium in both groups studied or because of the young age group of participants. Controlling environmental pollutants shall be a priority for the prevention of chronic diseases.
PMCID: PMC3671559  PMID: 23762083
13.  First report on body image and weight control in a nationally representative sample of a pediatric population in the Middle East and North Africa: the CASPIAN-III study 
This study explores the associations of weight perceptions with actual body mass index (BMI) and attempts to lose weight in a nationally representative sample of a pediatric population.
Material and methods
Data were collected from school students of 27 provinces in Iran, as part of “the national survey of school student high risk behaviors”. We used t-test for continuous data and chi square test for categorical data. The correlation between categorical variables was assessed by Cramer's phi test. A multiple nominal logistic regression model was fitted to data to assess the association between perceived body weight and gender by adjusting for potential confounding variables.
The study participants consisted of 5570 (2784 girls, 70% urban) students with mean age of 14.7 ±2.4 years. Overall, 17.3% of students were underweight, and 17.7% were overweight or obese. Nearly 25% and 50% of participants reported themselves as appropriate weight and very obese, respectively. In both genders, the strength of association between perceived weight and actual BMI was quite high (Cramer's phi coefficient = 0.5, p < 0.0001), and that of perceived body weight with trying to lose weight was moderate (Cramer's phi coefficient = 0.2, p < 0.0001). Overweight students were more likely than their obese peers to try to lose weight. After adjusting for possible confounders, the chance of perceiving oneself as very obese compared to perceiving oneself as very thin was 1.56-fold higher in girls than in boys, i.e. OR (95% CI): 1.56 (1.27-1.91).
This study revealed a considerably frequent “mismatch” between actual weight status and body shape dissatisfaction, which supports the necessity of increasing public awareness in this regard.
PMCID: PMC3648834  PMID: 23671430
perceived overweight; weight loss; body image; children and adolescents
14.  Association of Nitrate, Nitrite, and Total Organic Carbon (TOC) in Drinking Water and Gastrointestinal Disease 
Objective. We aimed to investigate the amounts of nitrate, nitrite, and total organic carbon (TOC) in two drinking water sources and their relationship with some gastrointestinal diseases. Methods. This cross-sectional study was conducted in 2012 in Iran. Two wells located in residential areas were selected for sampling and measuring the TOC, nitrate (NO3−), and nitrite (NO2−). This water is used for drinking as well as for industrial and agricultural consumption. Nitrate and nitrite concentrations of water samples were analyzed using DR 5000 spectrophotometer. The information of patients was collected from the records of the main referral hospital of the region for gastrointestinal diseases. Results. In both areas under study, the mean water nitrate and nitrite concentrations were higher in July than in other months. The mean TOC concentrations in areas 1 and 2 were 2.29 ± 0.012 and 2.03 ± 0.309, respectively. Pollutant concentration and gastrointestinal disease did not show any significant relationship (P > 0.05). Conclusion. Although we did not document significant association of nitrite, nitrate, and TOC content of water with gastrointestinal diseases, it should be considered that such health hazards may develop over time, and the quality of water content should be controlled to prevent different diseases.
PMCID: PMC3649361  PMID: 23690803
15.  Mortality Inequality in 1-59 Months Children Across Iranian Provinces: Referring System and Determinants of Death Based on Hospital Records 
To determine inequality in mortality in 1-59 months children across Iranian provinces focusing on referring system and determinants of death.
After designing and examining a national questionnaire for mortality data collection of children 1-59 months, 40 medical universities have been asked to fill in the questionnaires and return to the main researcher in the health ministry in 2009.
Mortality in 1-59 months children was unequally distributed across provinces (universities). The recommended refer was 3466 but only 1620 patients were referred. The first five important determinants of death were congenital (671 children or 20.9%), accident (547 children or 17.1%), pulmonary diseases (370 children or 11.5%), cardiovascular (266 children or less than 8.3%), central nervous system (263 children or 8.2%), and infectious and parasitic diseases (245 children or 7.6%), respectively.
Our results suggest that inequality in 1-59 months mortality based on the hospital records, and specially referring system, needs more attention in Iran. In addition, it is advisable to conduct provincially representative surveys to provide recent estimates of hospital access inequalities and to allow monitoring over time.
PMCID: PMC3634164  PMID: 23626882
Children mortality; hospital records; Iran; national mortality registration system; referring system
16.  Inequality in School Readiness and Autism among 6-Year-Old Children across Iranian Provinces: National Health Assessment Survey Results 
Iranian Journal of Pediatrics  2013;23(1):71-78.
To assess the national inequality of school readiness and autism among 6-year-old Iranian children before school entry using a national health assessment survey.
In a cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of screening and diagnostic levels.
The study population consisted of 955388 children (48.5% girls and 76.1% urban residents). Of the whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 7.6, 0.08, 10, 10.9, 56.7, 0.7, 0.8 and 0.6 percent had color blindness, hearing impaired, speech disorder, school readiness, autism, height to age retardation, body mass index extremes, decayed teeth, disease with special needs, spinal disorders, and hypertension, respectively. The distribution of these disorders was unequally distributed across provinces.
Our results confirmed that there is an inequality in distribution of school readiness and autism in 6-year-old children across Iranian provinces. The observed burden of these distributions among young children needs a comprehensive national policy with evidence-based province programs to identify the reason for different inequality among provinces.
PMCID: PMC3574995  PMID: 23550225
National Health Assessment Survey; School Readiness; Autism; Children; Inequality; Iran
17.  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.
By the current global obesogenic environment, non-alcoholic fatty liver disease is becoming an important health problem in the pediatric age group.
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.
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.
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.
PMCID: PMC3546518  PMID: 23346152
Aminotransferase; Child; Iran
19.  Development and Evaluation of a Questionnaire for Assessment of Determinants of Weight Disorders among Children and Adolescents: The Caspian-IV Study 
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.
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.
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.
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
20.  First growth curves based on the World Health Organization reference in a Nationally-Representative Sample of Pediatric Population in the Middle East and North Africa (MENA): the CASPIAN-III study 
BMC Pediatrics  2012;12:149.
The World Health Organization (WHO) is in the process of establishing a new global database on the growth of school children and adolescents. Limited national data exist from Asian children, notably those living in the Middle East and North Africa (MENA). This study aimed to generate the growth chart of a nationally representative sample of Iranian children aged 10–19 years, and to explore how well these anthropometric data match with international growth references.
In this nationwide study, the anthropometric data were recorded from Iranian students, aged 10–19 years, who were selected by multistage random cluster sampling from urban and rural areas. Prior to the analysis, outliers were excluded from the features height-for-age and body mass index (BMI)-for-age using the NCHS/WHO cut-offs. The Box-Cox power exponential (BCPE) method was used to calculate height-for-age and BMI-for-age Z-scores for our study participants. Then, children with overweight, obesity, thinness, and severe thinness were identified using the BMI-for-age z-scores. Moreover, stunted children were detected using the height-for-age z-scores. The growth curve of the Iranian children was then generated from the z-scores, smoothed by cubic S-plines.
The study population comprised 5430 school students consisting of 2312 (44%) participants aged 10–14 years , and 3118 (58%) with 15–19 years of age. Eight percent of the participants had low BMI (thinness: 6% and severe thinness: 2%), 20% had high BMI (overweight: 14% and obesity: 6%), and 7% were stunted. The prevalence rates of low and high BMI were greater in boys than in girls (P < 0.001). The mean BMI-for-age, and the average height-for-age of Iranian children aged 10–19 years were lower than the WHO 2007 and United states Centers for Disease Control and Prevention 2000 (USCDC2000) references.
The current growth curves generated from a national dataset may be included for establishing WHO global database on children’s growth. Similar to most low-and middle income populations, Iranian children aged 10–19 years are facing a double burden of weight disorders, notably under- and over- nutrition, which should be considered in public health policy-making.
PMCID: PMC3471000  PMID: 22985219
Growth; Iran; Reference curve; Weight disorder
21.  A study on lipid content and fatty acid of breast milk and its association with mother’s diet composition 
The aim of our study was to determine the content of fat and fatty acid composition of breast milk, and its association with the mother’s diet.
Materials and Methods:
This cross-sectional study was conducted among pregnant mothers who came to health care centers for last prenatal care in Isfahan, Iran. Eight to 72 hours after delivery, 2 to 5 ml of colostrum was collected by hand into tubes. They were kept in an ice box and sent within half an hour to the collaborating health centre for freezing at -20°C until analysis, which was performed at the laboratory of NNFTRI in Tehran. The milk samples were homogenized by Vortex (Heidolph Vortex Shaker REAX 1. 220 V. 30 W Germany) at 2400 rpm for 30 sec.
The data of 86 out of 91 samples were complete. The mean maternal age and gestational age was 28.37 ± 5.55 years old and 38.7 ± 1.2 weeks, respectively. The content of fat was 2.17 ± 1.22 g/100 ml breast milk. Arachidonic acid (AA, 20:4n-6) and docosohexaanoic acid DHA (22:6n-3) made 0.8 ± 0.4% and 0.3 ± 0.2% of total fatty acids. Although the AA/DHA ratio in our study is suitable, but the content of DHA is nearly low.
Dietary habits of women in reproductive age group should be improved, with special emphasis on the fatty acid content of breast milk. This may have long-term impact on health promotion and disease prevention.
PMCID: PMC3697205  PMID: 23826007
Breast milk; fatty acid; Iran; neonate; pregnancy
22.  Synergistic effects of genetic polymorphism and air pollution on markers of endothelial dysfunction in children 
This study aims to determine the association of some genetic polymorphisms in the relationship of air pollutants on the serum levels of thrombomodulin (TM) and tissue factor (TF) in a population-based sample of children and adolescents.
Materials and Methods:
This cross-sectional study was conducted among 110 participants (52.8% girls) with a mean age of 12.7 + 2.3 years, in Isfahan, Iran. Genotypes of TM G33-A and + 5466A > G polymorphisms were determined by the polymerase chain reaction – restriction length fragment polymorphism method (PCR-RFLP). The enzyme-linked immunosorbent assay (ELISA) was used for measurement of serum TM and TF.
The following genotypes were identified for TM: GG in 69.2%, GA in27.2%, and AA in 3.6% of the participants. Considering TF, 108 participants were homozygous for the + 5466A allele, and two subjects had + 5466AG genotype. The mean pollution standards index (PSI) value was at a moderate level; the mean particulate matter measured up to 10 μm (PM10); and ozone (O3), nitrogen dioxide, and sulfur dioxide were considerably high. The mean serum TF and TM levels were not significantly different among the participants with the aforementioned genotypes. Among participants exposed to high quartiles of O3, PM10, and PSI, the TM-33G / A polymorphism (GA + AA genotype) increased the Odds ratio (OR) of the low serum TM level. There was no statistically significant association in the areas of low pollution.
The findings of our study support the synergistic effect of the TM-33G / A polymorphism and air pollutants on factors associated with the onset of the atherosclerosis. This might be confirmatory evidence for gene-environment interaction, and related effects on atherogenesis from early life.
PMCID: PMC3687876  PMID: 23798936
Air pollution; atherosclerosis; children; genetics; prevention
23.  Prevalence study of clinical disorders in 6-year-old children across Iranian provinces: Findings of Iranian national health assessment survey 
To assess the national prevalence of clinical disorders in 6-year-old Iranian children before school entry using a national health assessment survey.
Materials and Methods:
In a cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of screening and diagnostic levels.
The study population consisted of 955388 children (48.5% girls and 76.1% urban). Of the whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 10, 10.9, 56.7, 0.7, 0.8 and 0.6% had color blindness, hearing impaired, speech disorder, height to age retardation, body mass index extremes, decayed teeth, having disease with special needs, spinal disorders, and hypertension, respectively. The distribution of these disorders was unequally distributed across provinces.
Our results confirmed that the prevalence of clinical disorders among 6-year-old children across Iranian provinces was not similar. The observed burden of these distributions among young children needs a comprehensive national policy with evidence-based province programs to identify the reason for different distribution among provinces.
PMCID: PMC3685772  PMID: 23798916
Children; clinical symptoms; Iran; national health assessment survey; prevalence
24.  Methodology and Early Findings of the Third Survey of CASPIAN Study: A National School-based Surveillance of Students’ High Risk Behaviors 
A school-based surveillance system entitled the childhood and adolescence surveillance and prevention of Adult Noncommunicable disease (CASPIAN) Study is implemented at national level in Iran. This paper presents the methods and primary findings of the third survey of this surveillance system.
This national survey was performed in 2009–2010 in 27 provinces of Iran among 5570 students and one of their parents. In addition to physical examination, fasting serum was obtained. Body mass index was categorized based on the World Health Organization growth charts.
Data of 5528 students (2726 girls, 69.37% urban, mean age 14.7 ± 2.4 years) were complete and are reported. Overall, 17.3% (17.3% of girls and 17.5% of boys) were underweight, and 17.7% (15.5% of girls and 19.9% of boys) were overweight or obese. Abdominal obesity was documented in 16.3% of students (17.8% of girls and 15% of boys). 57.6% of families consumed breads, the staple food for Iranians, prepared with white flour. Most families (43.8% in urban areas and 58.6% in rural areas) used solid hydrogenated fats. 22.7% of students did not add salt to the table food. 14.2% of students reported to have a regular daily physical activity for at least 30 min a day. Overall, 10.4% of students (11.7% in urban areas and 7.3% in rural areas) reported that they used tobacco products, often waterpipe. 32.8% of students experienced at least three times of bullying in the previous 3 months. During the year prior to the survey, 14.46% of students had an injury needing the interference by school health providers.
This survey is confirmatory evidence on the importance of establishing surveillance systems for risk behaviors to implement action-oriented interventions.
PMCID: PMC3389436  PMID: 22783465
Chronic diseases; prevention; risk behaviors; risk factors; school health; surveillance
25.  Association of particulate air pollution and secondhand smoke on endothelium-dependent brachial artery dilation in healthy children 
This study aimed to determine the association of particulate matters with endothelial function, measured by flow mediated dilation (FMD) of brachial artery, in children with or without exposure to secondhand smoke.
This cross-sectional study was conducted from January to March 2011 in Isfahan, which is the second large and air-polluted city in Iran. The areas of the city with lowest and highest air pollution were determined, and in each area, 25 prepubescent boys with or without exposure to daily tobacco smoke in home were selected, i.e. 100 children were studied in total.
FMD was significantly smaller in those living in high-polluted area and those exposed to secondhand smoke. Multiple linear regression analysis, adjusted for age and body mass index, showed that both passive smoking status and living area in terms of particulate air pollution were effective determinants of the brachial artery diameter. The standardized coefficient of passive smoking status was –0.36 (SD = 0.09, P < 0.0001) showing negative association with percent increase in FMD. Likewise, the percent increase in brachial artery diameter was lower in passive smoker children. Similar relationship was documented for PM10 concentration with a regression coefficient of –0.32 (SD = 0.04, P < 0.0001). Without considering passive smoking variable, PM10 concentration has significant independent effect on FMD level.
Our findings provide evidence on the association of environmental factors on endothelial dysfunction from early life. Studying such associations among healthy children may help identify the underlying mechanisms. The clinical implications of environmental factors on early stages of atherosclerosis should be confirmed in longitudinal studies.
PMCID: PMC3526122  PMID: 23267390
Air pollution; children; endothelium-dependent brachial artery; smoke

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