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1.  Comparison of effects of soft margarine, blended, ghee, and unhydrogenated oil with hydrogenated oil on serum lipids: A randomized clinical trail 
ARYA Atherosclerosis  2013;9(6):363-371.
BACKGROUND
Trans fatty acids (TFAs) are known as the most harmful type of dietary fats. Therefore, this study was done to compare the effects of some different oils including unhydrogenated, blended, ghee, and soft magazine with hydrogenated oil on serum lipid profile of healthy adults.
METHODS
This study was a randomized clinical trial conducted on 206 healthy participants of 20 to 60 years of age. Subjects were randomly divided into 5 groups and each of them was treated with a diet containing unhydrogenated oil, ghee, blended oil, soft margarine, or hydrogenated oil for 40 days. Fasting serum lipids were measured before and after the study.
RESULTS
Compared to hydrogenated oil, total cholesterol (TC) and triglyceride (TG) had a significant reduction in all groups, LDL-C declined in unhydrogenated oil and soft margarine groups, and apolipoprotein (Apo) B only in unhydrogenated oil group (all P < 0.05). However, there was a significant enhancement in ApoA of ghee oil (P < 0.001).
CONCLUSION
Consuming unhydrogenated oil, ghee, soft margarine, and blended oil had some beneficial effects on serum lipids.
PMCID: PMC3933054  PMID: 24575140
Clinical Trial; Dietary Fat; Commercial Oil; Lipid
2.  Body Mass Index, Waist-circumference and Cardiovascular Disease Risk Factors in Iranian Adults: Isfahan Healthy Heart Program 
Considering the main effect of obesity on chronic non-communicable diseases, this study was performed to assess the association between body mass index (BMI), waist-circumference (WC), cardiometabolic risk factors and to corroborate whether either or both BMI and WC are independently associated with the risk factors in a sample of Iranian adults. This cross-sectional study was performed on data from baseline survey of Isfahan Healthy Heart Program (IHHP). The study was done on 12,514 randomly-selected adults in Isfahan, Najafabad and Arak counties in 2000-2001. Ages of the subjects were recorded. Fasting blood glucose (FBG), 2-hour post-load glucose (2hpp), serum lipids, systolic and diastolic blood pressure (SBP and DBP), BMI, WC, smoking status, and total daily physical activity were determined. Increase in BMI and WC had a significant positive relation with the mean of FBG, 2hpp, SBP, DBP, serum lipids, except for HDL-C (p<0.001 for all). After adjustment for age, smoking, physical activity, socioeconomic status (SES), and BMI, the highest odds ratio (OR) (95% CI) for diabetes mellitus (DM) according to WC was 3.13 (1.93-5.08) and 1.99 (1.15-3.44) in women and men respectively. Moreover, the highest ORs based on BMI with adjustment for age, smoking, physical activity, SES, and WC were for dyslipidaemia (DLP) [1.97 (1.58-2.45) in women and 2.96 (2.41-3.63) in men]. The use of BMI or WC alone in the models caused to enhance all ORs. When both BMI and WC were entered in the model, the ORs for all risk factors, in men, according to BMI, were more compared to WC. However, in women, ORs for DM and hypertension (HTN) in WC quartiles were more than in BMI quartiles. BMI is the better predictor of DM, HTN, and DLP in men compared to WC. Conversely, in women, WC is a superior predictor than BMI, particularly for DM and HTN. Furthermore, the measurement of both WC and BMI in Iranian adults may be a better predictor of traditional risk factors of CVDs compared to BMI or WC alone.
PMCID: PMC3805889  PMID: 24288953
Body mass index; Diabetes mellitus; Dyslipidaemia; Hypertension; Obesity; Risk Factor; Waist-circumference; Iran
3.  White Rice Consumption and CVD Risk Factors among Iranian Population 
Association between white rice intake and risk factors of cardiovascular diseases remained uncertain. Most of the previous published studies have been done in western countries with different lifestyles, and scant data are available from the Middle East region, including Iran. This cross-sectional study was conducted in the structure of Isfahan Healthy Heart Program (IHHP) to assess the association between white rice consumption and risk factors of cardiovascular diseases. In the present study, 3,006 men were included from three counties of Isfahan, Najafabad, and Arak by multistage cluster random-sampling method. Dietary intake was assessed with a 49-item food frequency questionnaire (FFQ). Laboratory assessment was done in a standardized central laboratory. Outcome variables were fasting blood glucose, serum lipid levels, and anthropometric variables. Socioeconomic and demographic data, physical activity, and body mass index (BMI) were considered covariates and were adjusted in analysis. In this study, Student's t-test, chi-square test, and logistic regression were used for statistical analyses. Means of BMI among those subjects who consumed white rice less than 7 times per week and people who consumed 7-14 times per week were almost similar—24.8±4.3 vs 24.5±4.7 kg/m2. There was no significant association between white rice consumption and risk factors of cardiovascular diseases, such as fasting blood sugar and serum lipid profiles. Although whole grain consumption has undeniable effect on preventing cardiovascular disease risk, white rice consumption was not associated with cardiovascular risks among Iranian men in the present study. Further prospective studies with a semi-quantitative FFQ or dietary record questionnaire, representing type and portion-size of rice intake as well as cooking methods and other foods consumed with rice that affect glycaemic index (GI) of rice, are required to support our finding and to illustrate the probable mechanism.
PMCID: PMC3702347  PMID: 23930344
Cardiovascular diseases; Diet; Risk factors; White rice; Iran
4.  Healthy Bread Initiative: Methods, Findings, and Theories—Isfahan Healthy Heart Program 
The scientific evidences show that the content, baking methods, and types of bread can make health impacts. Bread, as a major part of Iranian diet, demonstrates a significant potential to be targeted as health promotion subject. Healthy Food for Healthy Communities (HFHC) was a project of Isfahan Healthy Heart Program (IHHP), consisting of a wide variety of strategies, like Healthy Bread (HB) Initiative. The HB Initiative was designed to improve the behaviour of both producers and consumers, mainly aiming at making high-fibre, low-salt bread, eliminating the use of baking soda, providing enough rest time for dough before baking (at least one hour), and enough baking time (at least one minute in oven). A workshop was held for volunteer bakers, and a baker-to-baker training protocol under direct supervision was designed for future volunteers. Cereal Organization was persuaded to provide less refined flour that contained more bran. Health messages in support of new breads were disseminated by media and at bakeries by health professionals. Evaluation of the HB Initiative was done using before-after assessments and population surveys. While HB was baked in 1 (0.01%) bakery at baseline, 402 (41%) bakeries in the intervention area joined the HB Initiative in 2009. Soda was completely eliminated and fibre significantly increased from 4±0.4 g% before study to 12±0.6 g% after the intervention (p<0.001). The preparation and baking times remarkably increased. Wastage of bread decreased from 13±1.8 g% to 2±0.5 g% and was expressed as the most important advantage of this initiative by consumers. People who lived in Isfahan city consumed whole bread 6 times more than those who lived in reference area Arak (p<0.001). The HB Initiative managed to add new breads as a healthy choice that were compatible with local dishes and made a model to solve the long-standing problems of bread. It used various health promotion approaches but was best consistent with Beattie's model.
PMCID: PMC3702358  PMID: 23617204
Bread; Community trial; Health promotion; Nutrition; Iran
5.  Parental perceptions of weight status of their children 
ARYA Atherosclerosis  2013;9(1):61-69.
BACKGROUND
Understanding the knowledge, attitudes, and beliefs of parents is important for planning appropriately to control their children’s weight. We aimed to study these variables in parents of normal, underweight, overweight, and obese children.
METHODS
This cross-sectional study targeted the parents of normal, underweight, overweight, and obese children, who were selected using multistage random sampling method. The parents’ knowledge, attitudes, beliefs, and behaviors about the weight status of their children, weight management, obesity, diet, lifestyle, and related psychosocial factors were evaluated using a validated questionnaire. The questionnaire, which had been validated, consisted of 12 demographic, 8 knowledge, 19 attitude and beliefs, and 25 behavior questions. Mean knowledge, attitude and beliefs, and behavior scores were compared across three subgroups of parents. Student’s independent t-test, ANOVA, and Kruskal-Wallis test were used to study the correlation between different demographic and socioeconomic factors, and the studied variables.
RESULTS
90% of parents were aware that obesity is a disease, and 92% knew that eating too much fast food would lead to obesity in children. Only 5% assumed that obese children are healthier than non-obese children. The mean scores of the three subgroups showed no significant difference in knowledge, attitude and beliefs, and behavior. Families with fathers, whose education level was higher than high school diploma, rated their children’s weight status as overweight or obese significantly less than families with fathers, whose education level was high school diploma or lower (8.5% vs. 16.5%, respectively, P = 0.014). Only 12% of parents tried to help their children lose weight at least once, and only 6% arranged sport activities for the family members. In 57% and 41% of families, the child, respectively, decided how much time was enough to watch TV, and how much chocolates and sweets to eat. 46% of children watched TV for more than 2 hours/day, and 49% of children watched TV while eating meals. The mean total score of boys’ parents was significantly lower than that of girls’ parents (P < 0.05). Families with low income, with no medical insurance, or not owning a house thought that the cost of registration in sport activities for children was too high (P < 0.03).
CONCLUSION
Some parents unreasonably rated the weight status of their children as overweight/obese. It is suggested that further studies be carried out to evaluate and improve parents’ knowledge, attitudes, and behaviors regarding their children’s weight.
PMCID: PMC3653261  PMID: 23696761
Children; Obesity; Overweight; Knowledge; Attitude; Belief; Behavior
6.  Alteration in unhealthy nutrition behaviors in adolescents through community intervention: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2013;9(1):89-97.
BACKGROUND
Primary prevention of chronic diseases has been suggested to initiate health promotion activities from childhoods. The impact of Isfahan Healthy Heart Program (IHHP), a comprehensive community trial, on unhealthy snacks and fast food intake changes was evaluated in Iranian adolescents between 2001 and 2007.
METHODS
Healthy Heart Promotion from Childhood (HHPC) as one of the IHHP interventional projects was conducted in adolescents aged 11-18 years, selected randomly by multistage random sampling. Isfahan and Najafabad districts were intervention areas (IA) and Arak district was reference area (RA). The baseline and post-intervention surveys were conducted on 1941 and 1997 adolescents, respectively. Healthy lifestyle interventions were performed during the 2nd phase of the study targeting about 410000 students in urban and rural areas of the IA via education, environmental and legislation activities. Dietary intake was assessed annually using a fifty-item food frequency questionnaire in both communities.
RESULTS
The interaction of year×area demonstrated that the consumption of unhealthy snacks decreased significantly in middle school boys of RA compared to IA (P for interaction=0.01). However, middle school girls (P for interaction = 0.002) and both sexes of high school students in IA showed a significant reduction in fast food consumption against RA (P for interaction < 0.001).
CONCLUSION
The HHPC interventions made some improvement in fast food consumption. It did not show significant decrease regarding unhealthy snacks in adolescents. Proper and higher dose of interventions may be effective in achieving this goal.
PMCID: PMC3653262  PMID: 23696765
Nutrition; Dietary Behaviour; Adolescent; Lifestyle; Community Trial
7.  Improvement of dietary oil consumption following a community trial in a developing country: The role of translational research in health promotion 
ARYA Atherosclerosis  2013;9(1):29-37.
BACKGROUND
This study aimed to determine the effects of the interventions of Isfahan Healthy Heart Program (IHHP) on the type of oil consumed at the population level. It also tried to assess how this strategy has been effective as a health policy.
METHODS
The IHHP, a six-year community intervention program (2001-07), aimed at health promotion through the modification of cardiovascular disease risk factors. It was performed in Isfahan and Najafabad counties (intervention area) and Arak county (reference area), all in central Iran. This study targeted the whole population of over 2,000,000 in the intervention area. The findings of annual independent sample surveys were compared with the reference area. Dietary interventions were performed as educational, environmental, and/or legislative strategies.
RESULTS
From 2001 to 2007, the mean of changes for hydrogenated oil consumption was -3.2 and -3.6, and for liquid oil it was 3.6 and 2.8 times per week in the intervention and reference areas, respectively (P < 0.001). According to Commerce office record, the increase in liquid oil distribution during 2000-2007 was significantly higher in Isfahan than Arak (34% vs. 25%).
CONCLUSION
The effects of the simple, comprehensive, and integrated action-oriented interventions of our program could influence policy making and its results at the community level. It can be adopted by other developing countries.
PMCID: PMC3653266  PMID: 23696757
Oil Consumption; Hydrogenated Oil; Liquid Oil; Community Trial
8.  The effects of a comprehensive community trial on cardiometabolic risk factors in adolescents: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2012;7(4):184-190.
BACKGROUND:
This study aimed to assess the effects of a 6-year-long community-participatory program including school-based interventions on mean values and prevalence of cardiometabolic risk factors among adolescents.
METHODS:
The interventions of this community trial, conducted from 2000 to 2007 in Iran, targeted the whole population (of nearly two millions) living in two cities considered as the intervention area (IA) in comparison with a reference area (RA). Data from surveys conducted before and after interventions was used to compare the differences between the secondary school students of the IA and RA.
RESULTS:
The prevalence of hypercholesterolemia and hypertriglyceridemia declined significantly in girls and boys in the IA (P < 0.01). The prevalence of high LDL-C decreased significantly in the girls in the RA (P = 0.002). Among both sexes in the IA, the prevalence of low HDL-C increased significantly (P < 0.001), whereas it decreased in the girls and boys in the RA (P = 0.04). Although in the IA, the prevalence of overweight and obesity decreased significantly in girls (P = 0.001), it increased in boys (P = 0.001) as well as in the girls of the RA (P = 0.01).
CONCLUSION:
By performing school-based interventions, our study was successful, at least in part, in controlling some cardiometabolic risk factors in adolescents. Such modifications may have long-term impacts on non-communicable diseases prevention in adulthood.
PMCID: PMC3413088  PMID: 23205053
Prevention; Adolescents; Lifestyle; Community Trial; Iran
9.  How does the impact of a community trial on cardio-metabolic risk factors differ in terms of gender and living area? Findings from the Isfahan healthy heart program 
Objective:
To assess the impact of gender and living area on cardiovascular risk factors in the context of a comprehensive lifestyle intervention program.
Design:
Data from independent sample surveys before (2000--2001) and after (2007) a community trial, entitled the Isfahan Healthy Heart Program (IHHP) were used to compare differences in the intervention area (IA) and reference area (RA) by gender and living area.
Setting:
The interventions targeted the population living in Isfahan and Najaf-Abad counties as IA and Arak as RA.
Participants:
Overall, 12 514 individuals who were more than 19 years of age were studied at baseline, and 9570 were studied in postintervention phase.
Interventions:
Multiple activities were conducted in connection with each of the four main strategies of healthy nutrition, increasing physical activity, tobacco control, and coping with stress.
Main Outcomes:
Comparing serum lipids levels, blood pressure, blood glucose and obesity indices changes between IA and RA based on sex and living areas during the study.
Results:
In IA, while the prevalence of hypertension declined in urban and rural females (P < 0.05). In IA, the prevalence of hypercholesterolemia and hypertriglyceridemia decreased in both females and males of urban and rural areas except for hypercholesterolemia in rural males (P < 0.01). In RA, the significant changes include both decrease in the hypercholesterolemia among rural males (P < 0.001) and hypertriglyceridemia in urban females (P < 0.01), while hypertriglyceridemia was significantly increased in rural females (P < 0.01).
Conclusions:
This comprehensive community trial was effective in controlling many risk factors in both sexes in urban and rural areas. These findings also reflect the transitional status of rural population in adopting urban lifestyle behaviors.
PMCID: PMC3687879  PMID: 23798939
Age; cardiovascular risk factor; community health program; health promotion; rural; sex; urban
10.  Barriers and facilitators of weight management in overweight and obese people: Qualitative findings of TABASSOM project 
Introduction:
Since weight management is affected by various factors, including social and behavioral ones, this study aimed to explore the peoples’ experience of barriers and facilitators of weight management.
Materials and Methods:
This qualitative content analysis was conducted as the initial step of TABASSOM Study. Participants, who tried to reduce their weight at least once, were selected by purposeful sampling method from aerobic fitness clubs, parks, and public offices in Isfahan in 2010. Data saturation was reached after indepth unstructured interviews with 11 participants. Data analysis was done by conventional content analysis method.
Findings:
The participants have intermittently followed weight loss program. Barriers such as physical problems, lack of motivation, lack of work and family support and lack of time have resulted in their failures and outages. The main facilitator to start or restart after stopping such programs for a while was positive psychologic effect.
Discussion and Conclusion:
Findings showed that many problems could prevent weight loss. It is important to identify obstacles that hinder weight management and regimen programs and to discuss them with people before planning for their weight management.
PMCID: PMC3696212  PMID: 23833613
Obesity; overweight; qualitative study
11.  Validity and reproducibility of a food frequency questionnaire for assessment of fruit and vegetable intake in Iranian adults* 
BACKGROUND:
This study's aim was to design and validate a semi-quantitative food frequency questionnaire (FFQ) for assessment of fruits and vegetables (FV) consumption in adults of Isfahan by comparing the FFQ with dietary reference method and blood plasma levels of beta-carotene, vitamin C, and retinol.
METHODS:
This validation study was performed on 123 healthy adults of Isfahan. FV intake was assessed using a 110-item FFQ. Data collection was performed during two different time periods to control for seasonal effects, fall/winter (cold season) and spring/summer (warm season). In each phase a FFQ and 1 day recall, and 2 days of food records as the dietary reference method were completed and plasma vitamin C, beta-carotene and retinol were measured. Data was analyzed by Pearson or Spearman and intraclass correlations.
RESULTS:
Serum Lipids, sex, age, body mass index (BMI) and educational level adjusted Pearson correlation coefficient of FV with plasma vitamin C, beta-carotene and retinol were 0.55, 0.47 and 0.28 in the cold season (p < 0.05) and 0.52, 0.45 and 0.35 in the warm season (p < 0.001), respectively. Energy and fat intake, sex, age, BMI and educational level adjusted Pearson correlation coefficient for FV with dietary reference method in the cold and warm seasons were 0.62 and 0.60, respectively (p < 0.001). Intraclass correlation for reproducibility of FFQ in FV was 0.65 (p<0.001).
CONCLUSIONS:
The designed FFQ had a good criterion validity and reproducibility for assessment of FV intake. Thus, it can serve as a valid tool in epidemiological studies to assess fruit and vegetable intake.
PMCID: PMC3430018  PMID: 22973322
Semi-quantitative Food Frequency Questionnaire; Criterion Validity; Reproducibility; Sensitivity; Specificity; Fruits and Vegetable
12.  Association between sleep duration and metabolic syndrome in a population-based study: Isfahan Healthy Heart Program 
BACKGROUND:
Recent epidemiologic studies have found that self-reported sleep duration is associated with components of metabolic syndrome (MS) such as obesity, diabetes and hypertension. This relation may be under influence of regional factors in different regions of the world. The association of sleep duration and MS in a sample of Iranian people in the central region of Iran was investigated in this study.
METHODS:
This cross-sectional study was conducted as a part of the Isfahan Healthy Heart Program (IHHP). A total of 12492 individuals aged over 19 years, 6110 men and 6382 women entered the study. Definition of National Cholesterol Education Program was used to define MS. Sleep duration was reported by participants. Relation between sleep duration with MS was examined using categorical logistic regression in two models; unadjusted and adjusted for age and sex.
RESULTS:
In our study, 23.5 % of participants had MS. Compared with sleep duration of 7-8 hours per night; sleep duration of less than 5 hours was associated with a higher odds ratio for MS. This association remained significant even after adjustment for age and sex (OR: 1.52; 95%CI: 1.33-1.74). However, sleep duration of 9 hours or more showed a protective association with MS (OR: 0.79; 95%CI: 0.68-0.94).
CONCLUSIONS:
There was a positive relation between sleep deprivation and MS and its components. This relation was slightly affected by sex and age.
PMCID: PMC3214399  PMID: 22091310
Sleep; Metabolic Syndrome; Heart; Population
13.  Metabolic syndrome in menopausal transition: Isfahan Healthy Heart Program, a population based study 
Introduction
There is a remarkable increase in cardiovascular disease after menopause. On the other hand, metabolic syndrome as a collection of risk factors has a known effect on cardiovascular diseases. Hormone changes are considered as one of the main relevant factor regarding cardiovascular disease as well as some recognized relationship with metabolic syndrome's components. This study was carried out in order to search for prevalence of metabolic syndrome during menopausal transition.
Method
In a cross sectional study in urban and rural areas of Isfahan, Najafabad and Arak cities, 1596 women aged more than 45 years were investigated using Isfahan Healthy Heart Program's (IHHP) samples. Participants were categorized into three groups of pre-menopause, menopause and post-menopause. Leisure time physical activity and global dietary index were included as life style factors. The association of metabolic syndrome and its components with menopausal transition considering other factors such as age and life style was analyzed.
Results
there were 303, 233 and 987 women in premenopausal, early menopausal and postmenopausal groups respectively. Metabolic syndrome was found in 136(44.9%) premenopausal participants and significantly increased to 135(57.9%) and 634(64.3%) in early menopausal and postmenopausal participants respectively, when age was considered (P = 0.010). Except for hypertension and hypertriglyceridemia, there was no significant difference between three groups of menopausal transition when metabolic syndrome's components were considered.
Conclusion
In contrary to the claims regarding the role of waist circumference and blood glucose in increasing of metabolic syndrome during the menopausal transition, this study showed this phenomenon could be independence of them.
doi:10.1186/1758-5996-2-59
PMCID: PMC2958965  PMID: 20923542
14.  Effect of Hydrogenated, Liquid and Ghee Oils on Serum Lipids Profile 
ARYA Atherosclerosis  2010;6(1):16-22.
BACKGROUND
Trans fatty acids are known as the most harmful type of dietary fats, so this study was done to compare the effects of hydrogenated, liquid and ghee oils on serum lipids profile of healthy adults.
METHODS
This study was a randomized clinical trial conducted on 129 healthy participants aged from 20 to 60 years old who were beneficiaries of Imam-e-Zaman charitable organization. Subjects were randomly divided into 3 groups and each group was treated with a diet containing cooking and frying liquid, ghee, or hydrogenated for 40 days. Fasting serum lipids, including total cholesterol (TC), triglyceride (TG), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), apoprotein A (Apo A), and apoprotein B (Apo B) were measured before and after the study.
RESULTS
TC, TG and Apo B had a significant reduction in the liquid oil group compared to the hydrogenated oil group. In the ghee group TG declined and Apo A increased significantly (P < 0.01). Liquid oil group had a significant reduction in HDL-C, compared to the ghee oil group (P < 0.05).
CONCLUSION
It was concluded that consuming liquid oil along with frying oil caused to reduce all serum lipid levels. However, ghee oil only reduced TG and increased HDL-C levels.
PMCID: PMC3347809  PMID: 22577408
Serum lipids; Apoproteins; Liquid oil; Hydrogenated oil; Ghee; Clinical trial

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