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1.  Association between psychosocial distress with cardio metabolic risk factors and liver enzymes in a nationally-representative sample of Iranian children and adolescents: the CASPIAN-III study 
Background
The present study was designed to evaluate association of psychosocial distress with cardio metabolic risk factors and liver enzymes in Iranian children and adolescents.
Method
This nationwide study was conducted as the third survey of the school-based surveillance system that was conducted among 5593 school students, 10–18 years in Iran. High triglyceride (TG), high fasting blood sugar (FBS), high total cholesterol (TC), high low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), hypertension (HTN), generalized obesity and abdominal obesity were considered as cardio metabolic risk factors and alanine transaminase (ALT) and aspartate aminotransferase (AST) were considered as liver enzymes. Data were analyzed using multiple logistic regression (MLR) analysis.
Result
Psychosocial distress was detected in2027 (71.2%) of boys and 1759 (63.3%) of girls. Among boys, the mean of LDL, AST and DBP were higher and the mean FBS and HDL were lowering those with psychiatric distress than their other counterparts. Girls with psychosocial distress had significantly higher mean of HDL and FBS than those without psychiatric distress. Psychosocial distress significantly increased the odds of high LDL (OR = 2.36, 95%CI 1.53, 3.64), high FBS (OR = 1.23, 95%CI 1.02, 1.49) and low HDL (OR = 1.65, 95%CI 1.41, 1.95).
Conclusion
Psychosocial distress in adolescents is associated with increased risk of some cardio metabolic risk factors.
doi:10.1186/2251-6581-13-44
PMCID: PMC3975638  PMID: 24602504
Psychosocial distress; Cardio metabolic risk factor; Adolescents
2.  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
3.  A Nationwide Survey on the Daily Screen Time of Iranian Children and Adolescents: The CASPIAN - IV Study 
Background:
Leisure time activity is an important life-style habit. This study aims to determine the screen time of a nationally representative sample of Iranian children and adolescents.
Methods:
This nationwide cross-sectional study was conducted as part of the fourth survey of a surveillance system. The participants consisted of 14880 students, with aged range from 6 to 18 years, living in 30 provinces in Iran. Screen time, i.e. the time spent on watching television (TV)/video and computer games during leisure time, was assessed by using the questionnaire of the Globasl Student Health Survey of the World Health Organization.
Results:
The study participants were 13486 school students (participation rate of 90.6%) with a mean age of 12. 47 (3.36) years. Overall, 75.6% of students were from urban and 24.4% from rural areas and 50.8% were boys respectively. Overall, 33.4% and 53% of students watched TV/video more than 2 h a day in their leisure time during school days and holidays, respectively. Likewise, 6.3% and 10.9% of students used computer more than 2 h a day in their leisure time during the school days and holidays, respectively. Overall, 47.1% of urban students and 24.2% of rural students used personal computer in their leisure time during the school days. The corresponding figures were 50.8% and 27.2% in weekends and holidays, respectively.
Conclusions:
The time spent on screen activities is long in a considerably high number of Iranian children and adolescents. It should be reduced by increasing the public awareness and by providing facilities for regular daily physic activity for students’ leisure times.
PMCID: PMC3950747  PMID: 24627751
Children and adolescents; computer; Iran; television watching
4.  Prevalence of genitalia malformation in Iranian children: findings of a nationwide screening survey at school entry 
Background:
Ambiguous genitalia is a hereditary disorder that usually requires early attention and detection. The discovery of ambiguous genitalia in a neonate is situation that could be difficult to manage, not only because of complications such as salt-losing, but also due to the importance of sex determination before psychological gender could be established. Awareness of the prevalence of ambiguous genitalia can affect the attitude and consideration of physicians and related medical personnel about disease in different communities. So in this study, the prevalence of ambiguous genitalia and undescended testes (UDT) in Iran was reported.
Materials and Methods:
This national study was conducted in 2009-2010 as part of the routine screening examinations at school entry in Iran. The physical examinations were performed for students at entry to three school levels by physicians and medical personnel. Execution and conduction of this program was the duty of the University of Medical Sciences in each province.
Results:
On average, the prevalence of ambiguous genitalia was 0.04% at national level (0.03%, 0.05%, and 0.03% at 6, 12, and 15 year olds, respectively). The prevalence of ambiguous genitalia was not significantly different according to age group and living area. The average of UDT) prevalence in the whole country was 0.13%. The prevalence of UDT was higher at elementary school level than in the other two levels.
Conclusion:
Although the prevalence of genitalia abnormalities was not high in the school students in Iran, given the importance of the issue and in order to find the ambiguous genitalia or UDT, medical examinations and parental notification should be taken seriously at an earlier age.
doi:10.4103/2277-9175.125648
PMCID: PMC3949344  PMID: 24627844
Ambiguous genitalia; screening examinations; undescended testes
5.  Relationship of Serum Magnesium and Vitamin D Levels in a Nationally-Representative Sample of Iranian Adolescents: The CASPIAN-III Study 
Background:
This study aims to assess the relationship of serum Mg and vitamin D levels in a nationally-representative sample of Iranian adolescents.
Methods:
The study participants consisted of 330 students, aged range from 10 to 18 years, consisting of an equal number of individuals with and without hypovitaminosis D. The correlation between serum 25 hydroxy vitamin D (25(OH) D) and magnesium (Mg) concentrations was determined.
Results:
The mean age of participants was 14.74 ± 2.587 years, without significant difference between those with hypovitaminosis D and those without it. The mean 25(OH) D level was 6.34 ± 1.47 ng/ml in the group with hypovitaminosis D and 39.27 ± 6.42 ng/ml in the group without it. The mean Mg level was 0.80 ± 0.23 mg/dl with lower level in the group with hypovitaminosis D than in others (0.73 ± 0.22 mg/dl vs. 0.87 ± 0.22 mg/dl, respectively) and according to t-test analysis, significant lower levels in the deficient group was observed (P = 0.0001). The linear regression analysis showed the meaningful relationship between Mg and 25(OH) D serum levels (P = 0.0001).
Conclusions:
Our study revealed significant associations between serum Mg and 25(OH) D levels. This finding may be of use for further studies on the prevention and management of hypovitaminosis D in children and adolescents. Further longitudinal studies shall evaluate the underlying mechanisms and the clinical significance of the current findings.
PMCID: PMC3915480  PMID: 24554998
Adolescents; iran; magnesium; vitamin D
6.  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
7.  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.
doi:10.1155/2013/142856
PMCID: PMC3671559  PMID: 23762083
8.  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 
Introduction
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.
Results
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).
Conclusions
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.
doi:10.5114/aoms.2013.34558
PMCID: PMC3648834  PMID: 23671430
perceived overweight; weight loss; body image; children and adolescents
9.  Tooth brushing and cardiometabolic risk factors in adolescents: Is there an association? The CASPIAN-III study 
Background:
A growing body of evidence supports an association between oral health and cardiovascular diseases and diabetes in adults. This study aimed to investigate the relationship between tooth brushing frequency and cardiometabolic risk factors in adolescents.
Methods:
This nationwide population-based study was conducted among 5258 Iranian students, aged 10-18 years, living in urban and rural areas of 27 provinces in Iran. The association of tooth brushing frequency was assessed with anthropometric indexes and cardiometabolic risk factors after adjustment for potential confounders.
Results:
Higher frequency of tooth brushing was associated with lower mean levels of low-density lipoprotein cholesterol (LDL-C) in both genders (P < 0.0001) and lower frequency of elevated LDL-C in girls (P = 0.03). The frequency of elevated blood pressure decreased with higher tooth brushing frequency in boys (P = 0.03). After adjustment for many potential cofounders such as age, gender, anthropometric indexes, screen time, socioeconomic status, and family history of non-communicable diseases, participants who washed their teeth at least once a day had lower risk of high LDL-C and low high-density lipoprotein cholesterol (HDL-C) levels in comparison to those who reported lower frequency of tooth brushing; some different associations were observed among girls and boys.
Conclusions:
Our findings suggest an independent and protective role of teeth brushing frequency for some cardiometabolic risk factors in adolescents. Increasing both the general health awareness and improving oral health should be considered in primordial and primary prevention of non-communicable diseases.
PMCID: PMC3634165  PMID: 23626883
Blood pressure; cardiometabolic risk factors; lipid profile; obesity; prevention; tooth brushing
10.  Kidney function in obese adolescents with or without metabolic syndrome in a nationally-representative sample of pediatric population: First report from the Middle East and North Africa: The CASPIAN-III Study: A Case-Control Study 
Background:
Obesity in accordance with metabolic syndrome (MetS) confronts populations at the higher risk of morbidity and mortality of chronic diseases including, chronic kidney diseases (CKD). The renal complication of obesity and MetS has been less debated in young adolescents. The objective of this study was to assess the kidney function in obese adolescents with or without MetS.
Materials and Methods:
The data used in this study were collected as part of a national study entitled Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable disease Study. The present study was conducted on a sub-sample of 113 obese adolescents (body mass index >95th percentile) aged between 10 years and 16 years selected by convenient sampling from the whole population studied. Anthropometric indexes and blood pressure were examined. A 12-h fasting serum was obtained for each participant to measure blood glucose, lipid profile, quantitative C-reactive protein (hs-CRP), Cystatin-c, urea, and creatinine. Fasting spot urine was collected to determine microalbumin and creatinine. Based on the study findings, participants were assigned into two groups with and without MetS.
Results:
The mean of microalbuminuria was in similar ranges in two groups and while the mean glomerular filtration rate (GFR) calculated by Bokenkamp's, updated and combined Schwartz's formulas were significantly lower in MetS + obese group in comparison with obese group. The similar result was not achieved by Filler's formula. Among MetS components, waist circumference had a correlation with hs-CRP (P = 0.04; r = 0.15). GFR was calculated based on the Schwartz formula and Cystatin-c formulas had no significant correlation with any MetS components.
Conclusion:
Our findings suggest that MetS can increase the risk of kidney dysfunction in obese adolescents. More studies are suggested in this regard in the pediatric population.
PMCID: PMC3732895  PMID: 23930111
Kidney function; obesity; pediatric metabolic syndrome
11.  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
12.  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.
Objective
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.
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.
Findings
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.
Conclusion
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
13.  First Report on Self-Rated Health in a Nationally-Representative Sample of Iranian Adolescents: The CASPIAN-iii study 
Objective:
To evaluate predictive factors of adolescents’ appraisal of their health.
Methods:
The nationwide study, entitled “Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable Diseases (CASPIAN) study”, was conducted in 2010 among Iranian school students, aged 10-18. In addition to demographic factors and physical examination, variables as family structure, nutrition habits, physical activity, smoking, hygienic habits, violence, school attachment, family smoking, and family history of chronic diseases were assessed. The dependent variable is the self-rated health (SRH) and it was measured by 12 items, which had already been combined through latent class analysis. We had taken a dichotomous variable, i.e. the higher values indicate better SRH. The dependent variable was regressed on all predictors by generalized additive models.
Results:
75% of adolescents had a good SRH. The linear and smooth effects of independent variables on SRH were observed. Among all the variables, physical activity had a positive linear effect on SRH (β = 0.08, P value = 0.003). Smoking, violence, and family history of disease associated to SRH non-linearly (P value < 0.05). Family smoking (β = −0.01) and hygienic habits (β = 0.27) related to SRH both linearly and non-linearly.
Conclusions:
Physical health and high risk behavior, either of linear or non-linear effect, are factors, which seem to shape the adolescents’ perception of health.
PMCID: PMC3604845  PMID: 23543891
Adolescents; health status; health status indicator; logistic models; non-parametric statistics; school; self-report
14.  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
15.  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
16.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2431-12-149
PMCID: PMC3471000  PMID: 22985219
Growth; Iran; Reference curve; Weight disorder
17.  Policy Brief on Promoting Physical Activity Among Adolescents 
Regular physical activity (PA) is an underlying factor since childhood and adolescence for having a healthy and active future for life. The aim of this stud y was to review the evidence on increasing the youth PA to develop the national program at country level. At first, the databases were searched using the sensitive keywords, and systematic reviews of the relevant databases were extracted. The studies were evaluated in terms of relevance and methodological quality for effective interventions that were detected. These cases were also identified in the effective interventions: disadvantages, benefits, costs, methods, and limitations of early studies, which were based on systematic review of the studies. Three interventions were identified as physical education curriculum reform, the creation of extra-curricular activities, as well as approaches to environmental and social support. Evidences showed that the relative impact of these interventions were not high. Thus, a combination of all three options of integrated approach is recommended for reducing the sedentary lifestyle of youths.
PMCID: PMC3445274  PMID: 23024847
Behavioral change; evidence informed; life style; policy
18.  Prevalence study of clinical disorders in 6-year-old children across Iranian provinces: Findings of Iranian national health assessment survey 
Objective:
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.
Results:
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.
Conclusions:
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
19.  Methodology and Early Findings of the Third Survey of CASPIAN Study: A National School-based Surveillance of Students’ High Risk Behaviors 
Background:
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.
Methods:
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.
Findings:
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.
Conclusion:
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
20.  Secular trends in the national prevalence of overweight and obesity during 2007-2009 in 6-year-old Iranian children 
BACKGROUND:
This study aimed to determine the secular trends in the national prevalence of overweight and obesity among 6-year-old Iranian children, and to compare the results in Northern, Central and Southern parts of the country.
METHODS:
The data were collected as part of a routine and mandatory national screening program on children entering elementary schools in 2007, 2008 and 2009.
RESULTS:
The study population comprised 2,600,065 children including 862,433 in 2007, 782,244 in 2008 and 955,388 in 2009. Of total children 12.8%, 13.5% and 10.9% were overweight in 2007, 2008 and 2009, respectively (P > 0.05). The corresponding figures for obesity were 3.4%, 3.5% and 3.4%, respectively (P > 0.05). In all surveys, the prevalence of overweight was higher in Southern region than in the other two regions. P for trend was not significant for prevalence rates of overweight and obesity in any of the regions.
CONCLUSIONS:
To the best of our knowledge, this study was the first of its kind in presenting the nationwide trend of overweight and obesity in young children living in a developing country. It showed a considerably high prevalence of overweight and obesity, but with a constant rate in three years. The higher prevalence of overweight in Southern region than in Central and Northern regions might be related to the lower socioeconomic position of this population. At a very young age, children's lifestyle is more under control of parents. Primordial and primary prevention efforts against the overweight epidemic can be effective and shall be further strengthened.
PMCID: PMC3263092  PMID: 22279471
Prevalence; Trend; Overweight; Children; National Study; Iran
21.  Gender Differences in Healthy Ranges for Serum Alanine Aminotransferase Levels in Adolescence 
PLoS ONE  2011;6(6):e21178.
Background & Aims
There is a worldwide epidemic of obesity among adolescents who subsequently are at increased risk for the development of non alcoholic fatty liver disease (NAFLD). The serum alanine aminotransferase (ALT) is the most frequently used test for screening these individuals, but no age and gender-specific upper limits of normal (ULN) based on healthy population data in children are available. The objective of the present study was to define ULN for ALT in healthy children in order to use this as a tool for case finding.
Methods
A total of 975 school children (aged 7–18 years) were included in the study cohort. Highly significant correlations (all p<0.001) were noted between ALT values and measures of BMI, systolic and diastolic blood pressure, insulin levels, HOMA-IR, total cholesterol and triglyceride concentrations. In order to define the population with no risk factors, we excluded subjects having abnormal values for factors that correlated with ALT. This population comprised 186 boys and 185 girls.
Results
In boys, median serum ALT levels were 16 IU/L and 9, 11, 18, and 30 IU/L for the 5th, 25th, 75th, and 95th percentiles. In girls, median serum ALT was 13, and 7, 9, 16, and 21 IU/L for the 5th, 25th, 75th, and 95th percentiles, respectively. The ULNs for ALT were 30 IU/L and 21 IU/L for boys and girls respectively. We found a linear relationship between age and ALT in females (p<0.001) but not in males. By multiple logistic regression, independent predictors of an elevated ALT included the BMI, waist hip ratio and levels of serum total cholesterol. In females, age was an additional inverse predictor.
Conclusions
In children and adolescents, these normal limits for ALT should be applied. Those with persistent elevations should be investigated further.
doi:10.1371/journal.pone.0021178
PMCID: PMC3124486  PMID: 21738618
22.  Timing of puberty in Iranian girls according to their living area: a national study 
BACKGROUND:
This study aimed to compare the timing of puberty between various geographic locations and different ethnicities.
METHODS:
This national survey was conducted in 20 provinces in Iran. Healthy Iranian girls were selected from public schools using cluster random sampling. A total number of 30 clusters including 7493 girls, aged 6.0–20 years, were selected. In order to compare different areas, the national classification of the provinces based on climate, ethnicity, geographic locations, and socioeconomic variables were used. Accordingly, there are 11 regions in Iran. Analysis of variance was used to compare the mean ages of menarche, pubarche, and thelarche in different regions.
RESULTS:
Tehranian girls, with 11.99 ± 1.35 years (mean ± SD), had the lowest age of menarche which was statistically significantly. The second region with lowest age at menarche was Fars (12.40 ± 1.27 years). The mean age at breast bud stage (B2) was significantly lower in Ghazvin-Zanjan region (8.97 ± 1.45 years). In Fars region, the mean age at B2 stage of breast development (11.01 ± 1.88 years) was higher than other regions except for Mazendran-Guilan and Tehran-related cities. The mean age at public hair development at Tanner stage 2 (PH2) in Kordestan-Lorestan-Ilam region (10.70 ± 1.23 years) was significantly higher than other regions.
CONCLUSIONS:
We found significant differences in the age of pubertal stages of girls living in various regions with different ethnicity and geographic characteristics. Considering the impact of pubertal age on general health, more studies should be done about the lifestyle and environmental factors affecting the onset of puberty.
PMCID: PMC3214333  PMID: 22091244
Puberty; Girls; Living area; Iran
23.  A National Experience on Physical Activity Initiatives for Adolescent Girls and their Mothers: CASPIAN Study 
Iranian Journal of Pediatrics  2010;20(4):420-426.
Objective
To provide a low-cost and simple model of culturally-appropriate and low cost facilities for improvement of physical activity for girls and their mothers through an after-school program and to determine the changes in anthropometric indexes after this trial.
Methods
This national study was conducted in 2006-2007 in 7 provinces with different socioeconomic situations in Iran. Female students who studied in the 7th through 10th grade and their mothers were selected by random cluster sampling. In each province, 24 sessions of after-school aerobic physical activity were held for 90 minutes, two days a week, and 3 months long at school sites in the afternoon.
Findings
The study comprised 410 participants (204 mothers and 206 daughters), with a mean age of 15.86±1.01 and 40.71±6.3 years in girls and their mothers, respectively. The results of the focus group discussions showed that in general, both mothers and daughters were satisfied from the program and found it feasible and successful. After the trial, the indexes of generalized and abdominal obesity improved significantly both in girls and in their mothers (P-value <0.0001 for weight, body mass index and waist circumference).
Conclusion
Our findings may provide a low-cost and simple effective model of motivation for physical activity with targeted interventions for girls and their mothers. We suggest that the success of this trial might be a result of bonding and accompaniment of mothers and daughters. Such model can be integrated in the existing health and education systems to increase the physical activity level.
PMCID: PMC3446096  PMID: 23056741
Physical Activity; Female; Overweight; Public Health; Adolescent
24.  Assessment of Pubertal Development in Iranian Girls 
Iranian Journal of Pediatrics  2010;20(2):160-166.
Objective
We estimated pubertal development of 7,493 normal Iranian girls aged 6 to 20 years in a cross-sectional study.
Methods
Pubertal stages were assessed according to Tanner. The mean ages to achieve secondary sexual characteristics as well as the mean age at menarche were estimated. Weight and height were measured and body mass index (BMI) was calculated. Reference curves for different breast stages and menarche were constructed. The percentiles for attaining each stage were compared to data proposed by Tanner.
Findings
The mean age at breast bud stage (B2) was 10.10, pubic hair stage (P2) was 9.83, and menarche age was 12.55 years. The anthropometric variables were interpreted in different maturity stages. The mean age at attainment of puberty was compared with those of other populations.
Conclusion
Not only the onset of puberty in Iranian girls but also the duration of puberty is similar to data from most other countries. A lower age limit for the definition of precocious puberty than the traditional 8 years is documented for Iranian girls. However, it should be noted that considering the rate of evolution of pubertal findings is more important than the age of their appearance.
PMCID: PMC3446028  PMID: 23056698
Puberty; Adolescent Development; Sex Maturation; Iran

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