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1.  Frequency, Causes, and Places of Unintentional Injuries in a Nationally Representative Sample of Iranian Children and Adolescents: The CASPIAN-IV Study 
Background:
This study aims to assess the frequency, causes, and places of injuries in a nationally representative sample of Iranian children and adolescents, as well as the referral, places allocated for injured individuals.
Methods:
This nationwide study was conducted in 2011-2012 among 13486 elementary, secondary and high-school students who were selected by random cluster stratified multistage sampling from 30 provinces in Iran. The Global School-based Health Survey questionnaire of the World Health Organization was used.
Results:
The study participants consisted of 50.8% boys, 75.6% urban resident with a mean age of 12.5 years. Overall, 20.25% of participants reported that they were minimally injured once in the last 12 months; this prevalence was higher in boys than in girls (25.74% vs. 14.58%, respectively, P < 0.001), without significant difference in urban (20.11%) and rural (20.69%) areas. Most of them (39.92%) were injured at homes or house yards with higher prevalence in girls than in boys (48.61% vs. 35.17%, respectively, P < 0.001) and in rural than in urban areas (27.30% vs. 20.89%, respectively, P < 0.001). Schools were reported as the second prevalent site of injury occurrence (22.50%). Emergency departments and physician offices were the most prevalent referral places for injured individuals (32.31% and 22.38%, respectively). Most of the school injuries occurred during play or sport activities (45.92%).
Conclusions:
Prevention of unintentional injuries should be considered as a health priority. Appropriate preventive strategies should be enhanced at homes and schools.
PMCID: PMC4223940  PMID: 25400879
Adolescents; children; injuries; Iran; prevention
2.  A Nationwide Survey on Some Hygienic Behaviors of Iranian Children and Adolescents: The CASPIAN-IV Study 
Background:
This study aims to assess the frequency of some hygienic behaviors that is, tooth brushing and hand-washing, in Iranian school students at national level.
Methods:
This nationwide study was conducted in 2011-2012 among 14,880 elementary, secondary and high school students who were selected by random cluster stratified multistage sampling from 30 provinces in Iran. We used the global school-based health survey questionnaire of the World Health Organization.
Results:
The population of this survey consisted of 13,486 children and adolescents (participation rate of 90.6%) including 49.2% girls and 75.6% urban inhabitants. The mean age of participants was 12.5 years (12.3-12.6, 95% confidence interval) According to the self-report of students, 26.9% of them (20.2% of boys and 33.9% of girls) brushed their teeth more than once a day, 37.8% of boys and 42.1% of girls brushed their teeth once a day. In general, girls brushed their teeth more than boys. The frequency of those students who never brushed their teeth was twice in rural than in urban students (11.4% vs. 6.2%, respectively). In total, 3.4% of the students stated that their school had not an appropriate place for washing hands after toilet, with three-fold higher frequency in rural than in urban schools (6.8% vs. 2.3%, respectively). 85% of students (87% of girls vs. 83% of boys) reported that they had always washed their hands after toilet, 10.1% did it occasionally and 4.1% did not.
Conclusions:
This nationwide survey revealed that Iranian students have an acceptable level of hygienic behaviors both in urban and rural areas; however, still it is necessary to improve school health facilities and hygienic habits in Iranian students.
PMCID: PMC4192768  PMID: 25317289
Children and adolescents; hygiene; Iran; school
3.  Reference curves of anthropometric indices in two national studies conducted among Iranian children in 2003-2004 and 2009-2010: The Caspian study 
Background:
Reference percentile curves are usually used as a screening tool to determine growth disorders. Anthropometric indices are population-dependent and may differ according to ethnicity, dietary pattern and lifestyle habits. This study aims to compare the curves of anthropometric measures obtained in two national studies conducted among Iranian children and adolescents in 2003-2004 and 2009-2010.
Materials and Methods:
Anthropometric measures obtained in two nationwide surveys conducted in 10-18-year-old Iranian students were compared. Lambda-mu-sigma (LMS) Chart Maker Pro program was used to develop age- and gender-specific percentiles and to smooth and fit the model.
Results:
In 2003-2004, the mean and standard deviation (SD) of body mass index (BMI) and waist circumference (WC) were 18.98 ± 3.81 kg/m2 and 67.50 ± 11.05 cm in boys; and 19.44 ± 3.78 kg/m2 and 66.55 ± 9.89 cm in girls, respectively. In 2009-2010, the corresponding figures were 19.16 ± 4.07 kg/m2, 69.42 ± 11.43 cm, 19.63 ± 4.11 kg/m2, and 67.29 ± 9.69 cm, respectively. Height curves did not show considerable changes in two studies. Comparison of two series of studies showed that the weight, BMI, WC, and waist-to-height ratio were lower in adolescent girls than boys especially in higher percentiles. Moreover, in both genders, weight, BMI, and WC percentiles decreased.
Conclusion:
The growth charts of Iranian children and adolescents aged 10-18 years have changed over 5 years. The reference growth curves change over time in the pediatric age group, repeated surveys should be conducted to update the age- and gender-specific reference curves in different populations.
PMCID: PMC4235089  PMID: 25422654
Anthropometric indices; children and adolescents; Iran; reference curve
4.  Growth Disorders Among 6-Year-Old Iranian Children 
Background:
Sociodemographic factors are important determinants of weight disorders. National representative studies provide a view on this health problem at national and regional levels.
Objectives:
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.
Results:
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.
Conclusions:
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.
doi:10.5812/ircmj.6761
PMCID: PMC4102995  PMID: 25068062
Body Mass Index; Child; Socioeconomic Factors
5.  Insulin and leptin levels in overweight and normal-weight Iranian adolescents: The CASPIAN-III study 
Background:
In this study, we aim to compare insulin and leptin levels in adolescents with or without excess weight and in those with or without abdominal obesity.
Materials and Methods:
This case-control study was conducted among 486 samples. We randomly selected 243 overweight and an equal number of normal-weight adolescents from among participants of the third survey of a national surveillance program entitled Childhood and Adolescence Surveillance and PreventIon of Adult Non-communicable diseases study. Serum insulin and leptin were compared between two groups and their correlation was determined with other variables.
Results:
The mean age and body mass index (BMI) of participants were 14.10 ± 2.82 years and 22.12 ± 6.49 kg/m2, respectively. Leptin and insulin levels were higher in overweight than in normal-weight adolescents (P < 0.05). Leptin level was higher in children with abdominal obesity than in their other counterparts (P < 0.001). Leptin level was correlated with age, fasting blood glucose, BMI, and insulin level.
Conclusion:
Insulin and leptin levels were higher among overweight and obese children, which may reflect insulin and leptin-resistance. Given the complications of excess weight from early life, prevention and controlling childhood obesity should be considered as a health priority.
PMCID: PMC4116567  PMID: 25097618
Children; insulin; leptin; obesity; overweight
6.  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
7.  Prevalence of Prehypertension and Hypertension in a Nationally Representative Sample of Iranian Children and Adolescents: The CASPIAN-IV Study 
Background:
The global health burden has faced toward non-communicable diseases (NCDs). It is suggested that adulthood blood pressure (BP) is tracked from childhood. This study aims to evaluate the mean BP and the prevalence of prehypertension and hypertension in the Iranian pediatric population.
Methods:
In a national survey as the 4th phase of Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable diseases study and through random multistage cluster sampling, a national sample of Iranian school students, aged 6-18 years, were recruited. Data gathered by means of modified World Health Organization Global school-based student health survey questionnaire, a weight disorders determinants questionnaire and anthropometric and BP measurements. Prehypertension (HTN) was defined as BP equal or greater than 90th age and sex specific percentile or ≥120/80 mmHg and HTN was defined as BP ≥95th percentile.
Results:
A total of 13486 students entered the study (49.2% girls, 75.6% urban). Mean age of participants was 11.47 ± 3.36 years. A total rate of 4.17% (3.84-4.52 95% CI) for high systolic BP (SBP), 4.33% (3.99-4.68) for high diastolic BP (DBP) and 6.88% (6.45-7.32) for high SBP and/or DBP was depicted.
Conclusions:
The prevalence rate of high BP (pre-HTN together with HTN) is substantially high in this population. It is needed to study the causative situations and implement relevant interventions.
PMCID: PMC3990919  PMID: 24791193
Adolescent; blood pressure; child; hypertension; Iran; pre-hypertension
8.  Association of Overweight and Obesity with Mental Distress in Iranian Adolescents: The CASPIAN-III Study 
Background:
Excess weight may be associated with mental distress and this relationship varies according to the socio-cultural background of different populations. This study aims to assess the relationship of overweight and obesity with some psychological disorders in a nationally representative sample of Iranian adolescents.
Methods:
This nationwide study was conducted in 2009-2010 among 5570 students, aged 10-18 years, living in 27 provinces in Iran. Data were collected by using the translated and validated questionnaire of the World Health Organization Global School-based Health Survey.
Results:
Data of 5528 students (49.7% girls) were complete for this study. Their mean age was 14.7 (2.4) years. Overall 7.9% of participants were overweight and 8.8% were obese. 58.7% of students had anxiety, without significant association of overweight (odds ratio [OR]: 0.86, 95% confidence interval [CI]: 0.68-1.09) and obesity (OR: 1.11, 95% CI: 0.88-1.40) with an anxiety. Nearly 62.6% of students reported to have depression, there was no significant relationship between overweight (OR: 1.11, 95% CI: 0.86-1.43) obesity and (OR: 1.01, 95% CI: 0.79-1.29) with the depression. About 49.4% of students had insomnia, without significant association of overweight (OR: 1.17, 95% CI:, 0.91-1.51) and obesity (OR: 0.91, 95% CI: 0.71-1.17) with the insomnia.
Conclusions:
In Iranian adolescents, excess weight did not increase the risk of psychological distress. This finding might be due to the positive attitude of family and peers to fatness in adolescence.
PMCID: PMC4018633  PMID: 24829708
Adolescents; anxiety; depression; Iran; obesity; psychological disorders
9.  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  PMID: 24701221
obesity; underweight; waist circumference; body mass index; pediatric age
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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