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1.  Comparison of the Prevalence and Risk Factors of Hepatitis A in 10 to 18-Year-Old Adolescents of Sixteen Iranian Provinces: The CASPIAN-III Study 
Hepatitis Monthly  2016;16(9):e36437.
Background
Hepatitis A is a common health concern both in developing and developed countries. Hygienic and socioeconomic parameters deeply impact the prevalence and transmission of this disease. Evaluating the epidemiological distribution and risk factors for Hepatitis A virus (HAV) is necessary for policy makers to improve local and national preventive measures.
Objectives
The aim of this study was to compare the prevalence of hepatitis A infection in a sample of Iranian adolescents living in different provinces of Iran and to assess its family- and community-related risk factors.
Methods
In this cross-sectional study, serum samples of 10 to 18-year-old adolescents, who were studied in a national health survey, were examined for anti-HAV antibodies. A total of 2,494 subjects were included from 16 provinces by multistage random cluster sampling. Demographic and socioeconomic factors related to HAV transmission were extracted by valid questionnaires. A multilevel analysis using mixed-effects logistic regression (melogit) was used to evaluate the association of risk factors with HAV infection.
Results
The weighted prevalence of HAV varied significantly across the studied provinces (P = 0.001), ranging from 50.43% in the Fars province to 78.81% in Markazi province. HAV was significantly more prevalent in children whose mothers worked outside of the home (OR, 1.73; 95% CI, 1.14-2.62; P = 0.009).
Conclusions
The risk of symptomatic HAV infection is considerable in adolescents of all studied provinces; thus, universal HAV vaccination is recommended for all adolescents, regardless of their socioeconomic level. However, the risk is higher in some provinces, which seem to be transitioning from intermediate to low endemicity.
doi:10.5812/hepatmon.36437
PMCID: PMC5091029  PMID: 27822259
Hepatitis A; Prevalence; Risk Factors; Socioeconomic Status; Iran
2.  Exposure to Hookah and Cigarette Smoke in Children and Adolescents According to Their Socio-Economic Status: The CASPIAN-IV Study 
Iranian Journal of Pediatrics  2016;26(4):e3036.
Background
Exposure to smoking or passive smoking is one of serious health problems especially in the pediatric age group.
Objectives
To compare the prevalence and determinants of passive smoking in a nationally representative sample of Iranian children and adolescents according to their socioeconomic status (SES).
Materials and Methods
This nationwide study was conducted in 2011 - 2012 among 14880 students aged 6 - 18 years, living in 30 provinces in Iran. Exposure to the smoke of hookah or cigarette was documented by using validated questionnaires. Possible influencing factors were determined and the frequency of passive smoking was compared according to the regional and familial SES.
Results
Participants consisted of 13,486 children and adolescents including 49.2% girls and 75.6% urban inhabitants (90.6% participation rate). The mean age of participants was 12.47 ± 3.36 years. Overall, 43.87% of them (44.07% of boys and 43.66% of girls) were exposed to second hand smoke at home. Exposures to hookah or cigarette smoke at home were respectively reported in 21.46% and 34.49% of participants. The prevalence of passive smoking was lower in children of families with higher SES level, but higher in high SES regions of the country than in low SES ones, and ranged from 39.2% in the region with lowest SES to 49.05% in the highest SES region. Higher education levels of fathers and mothers were significantly associated with lower frequency of passive smoking.
Conclusions
Exposure to second hand smoke is a major problem among Iranian children and adolescents. Low family SES and low parental education increased the frequency of passive smoking. Appropriate public health education and legislation for smoke free home as well as family-centered counseling should be strengthened.
doi:10.5812/ijp.3036
PMCID: PMC5065706  PMID: 27781078
Passive Smoking; Determinants; Children and Adolescents; Socio-Economic Status
3.  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
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.  Mortality Inequality in 1-59 Months Children Across Iranian Provinces: Referring System and Determinants of Death Based on Hospital Records 
Background:
To determine inequality in mortality in 1-59 months children across Iranian provinces focusing on referring system and determinants of death.
Methods:
After designing and examining a national questionnaire for mortality data collection of children 1-59 months, 40 medical universities have been asked to fill in the questionnaires and return to the main researcher in the health ministry in 2009.
Results:
Mortality in 1-59 months children was unequally distributed across provinces (universities). The recommended refer was 3466 but only 1620 patients were referred. The first five important determinants of death were congenital (671 children or 20.9%), accident (547 children or 17.1%), pulmonary diseases (370 children or 11.5%), cardiovascular (266 children or less than 8.3%), central nervous system (263 children or 8.2%), and infectious and parasitic diseases (245 children or 7.6%), respectively.
Conclusions:
Our results suggest that inequality in 1-59 months mortality based on the hospital records, and specially referring system, needs more attention in Iran. In addition, it is advisable to conduct provincially representative surveys to provide recent estimates of hospital access inequalities and to allow monitoring over time.
PMCID: PMC3634164  PMID: 23626882
Children mortality; hospital records; Iran; national mortality registration system; referring system
7.  Socioeconomic inequality in oral health behavior in Iranian children and adolescents by the Oaxaca-Blinder decomposition method: the CASPIAN- IV study 
Background
The present study set to describe the socioeconomic inequality associated with oral hygiene behavior among Iranian pediatric population.
Methods
A representative sample of 13486 school students aged 6–18 years was selected through multistage random cluster sampling method from urban and rural areas of 30 provinces in Iran. Principle Component Analyses (PCA) correlated variables summarized as socioeconomic status (SES). Association of independent variables with tooth brushing was assessed through logistic regression analysis. Decomposition of the gap in tooth brushing between the first and fifth SES quintiles was assessed using the counterfactual decomposition technique. To assess the relation between tooth brushing and each socioeconomic category, Concentration Index (C) and the slope index of inequality (SII) were used, representing the linear regression coefficient.
Results
The participation rate was 90.6 % (50.7 % boys and 75.6 % urban inhabitants). The mean age of participants was 12.47 ± 3.36 years. The frequency of tooth brushing increased across SES quintiles, prevalence of tooth brushing between the first and fifth quintile, under 20 % difference, increased from 58.22 (95 % CI: 56.24,60.20) to 78.61 (95 % CI: 77.00,80.24). Only 3 % of the difference is explained by the factors considered in the study, and 17 % remained unknown. Residence area, family size, and smoking status made a significant contribution to the gap between the first and last SE groups. Residence area [ −2.01 (95 % CI: −3.46, −0.55)] was along the maximum levels of gaps between SE categories.
Conclusions
The findings revealed a socio-economic inequality in oral health behavior in Iranian children and adolescents. Also, factors influencing oral health are addressed to develop and implement complementary public health actions.
doi:10.1186/s12939-016-0423-8
PMCID: PMC5024445  PMID: 27628496
Adolescents; Children; Iran; Inequality; Oaxaca-Blinder decomposition; Oral health
8.  Association of socioeconomic status with psychiatric problems and violent behaviours in a nationally representative sample of Iranian children and adolescents: the CASPIAN-IV study 
BMJ Open  2016;6(8):e011615.
Objectives
The aim of the present study was to evaluate the association between socioeconomic status (SES) and psychiatric problems and violent behaviours in a nationally representative sample of Iranian children and adolescents, based on nationwide surveillance programme data, 2011–2012.
Methods
Overall, 14 880 students, aged 6–18 years, were selected using a multistage cluster sampling method from rural and urban areas of 30 provinces in Iran. SES was estimated based on a main summarised component, extracted from principle component analysis of family assets and parents' jobs and education. For statistical analysis, SES was classified as ‘low’, ‘middle’ and ‘high’. The WHO-Global School Based Student Health Survey (WHO-GSHS) questionnaire was used to assess psychiatric problems and violent behaviours.
Results
In total, 13 486 students (participation rate 90.6%) completed the study: 50.8% were boys and 75.6% were urban residents, with a mean age of 12.47±3.36 years. In the multivariate model, the ORs of depression, anxiety, feeling worthless, anger, insomnia, confusion and physical fights were lower in students with high SES compared with those with low SES (p<0.05) but physical fights was lower in the high SES group than in the low SES group (p<0.05). No significant relationship was documented between SES and other variables, including getting worried, history of bullying and being victimised.
Conclusions
Children and adolescents with low SES were at higher risk for psychiatric problems and violent behaviours. Mental health policies and public interventional strategies should be considered at the public level, notably for low SES families.
doi:10.1136/bmjopen-2016-011615
PMCID: PMC5013516  PMID: 27531729
socioeconomic status; psychiatric distress; violent behaviors; EPIDEMIOLOGY
9.  Determinants of Tobacco and Hookah Smoking in a Nationally Representative Sample of Iranian Children and Adolescents: The CASPIAN-IV Study 
Background
The consumption of tobacco through a hookah is growing in popularity, especially among children and adolescents, but little is known about the determinants of hookah smoking.
Objectives
The current study aimed to assess the determinants of tobacco smoking and hookah smoking in a nationally representative sample of Iranian children and adolescents.
Patients and Methods
This study was conducted as part of the fourth cross-sectional survey of a national school-based program. Using a cluster random sampling method, a validated questionnaire was completed anonymously by 14,880 students who were aged 6 - 18 years and living in urban and rural areas of 30 provinces in Iran.
Results
The final study group consisted of 13,486 children and adolescents (participation rate of 90.6%), of whom 49.2% were girls and 75.6% were urban residents. The mean age was 12.47 ± 3.36 years. According to the self-reports of the students, 2.6% (3.5% of boys and 1.7% of girls) were current tobacco smokers, 5.9% (7.5% of boys and 4.2% of girls) were ever tobacco smokers, and 1.8% (2.49% of boys and 1.14% of girls) were current hookah smokers. Based on a multiple logistic regression (MLR) model, the following factors increased the risk of current smoking: age, number of days spent with friends per week, hookah smoking or cigarette smoking by the father, hookah smoking by siblings, hookah smoking by other members of the family, and screen time. The age, number of days spent with friends, hookah or cigarette smoking by the father, hookah smoking by siblings, and screen time increased the risk of hookah smoking. Female gender and living in rural areas decreased the risk of current tobacco and hookah smoking.
Conclusions
Preventive measures against tobacco use should be underscored for Iranian families. The preparation of strategies on the promotion of a healthy lifestyle should be considered a health priority.
doi:10.5812/ircmj.31099
PMCID: PMC5065714  PMID: 27781117
Smoking; Hookah; Children; Adolescents; Iran
10.  Seroprevalence and Risk Factors of Varicella Zoster Infection in Iranian Adolescents: A Multilevel Analysis; The CASPIAN-III Study 
PLoS ONE  2016;11(6):e0158398.
The objective of this study was to evaluate the varicella zoster virus (VZV) immunity in Iranian adolescents. It was conducted as a primary study for vaccine implementation, and to investigate the association of climatic and socioeconomic factors with the epidemiology of this infection. In this cross- sectional study, anti VZV antibodies were measured in serum samples obtained in a national school-based health survey (CASPIAN- III). Association of demographic, socio-economic, and climate of the living region with the frequency of VZV was investigated by multivariate multilevel analysis. Overall, sera of 2753 individuals aged 10–18 were tested for VZV antibodies, from those 87.4% were positive. The prevalence was statistically different in four socio-geographic regions (P<0.001), varying between 85.24% in West region (mostly mountainous areas with cold climate) to 94.59% in Southeast region (subtropical climate). Among variables studied, only age and mean daily temperature of the living area were positively associated with the VZV seroprevalence. Our findings show that most Iranians develop immunity to VZV before the age of 10, but a substantial proportion of them are yet susceptible to the infection. Therefore, it seems that the best strategy to reduce the burden of the disease is to vaccinate high- risk adults, i.e. those without a history of varicella infection. The regional temperature might be the only determinant of VZV epidemiology in Iran.
doi:10.1371/journal.pone.0158398
PMCID: PMC4927171  PMID: 27355931
11.  Association of some psychosocial factors with anthropometric measures in nationally representative sample of Iranian adolescents: the CASPIAN-III study 
Background
During the last two decades, adolescent obesity has increased in western countries. In Iran-as a developing country- the prevalence of obesity is raised among youngsters as well. This study conducted to identify an association of adolescents’ loneliness, self-confidence and relationship with others in home and school environment with their weight status.
Methods
In this cross-sectional national survey, 5682 students aged 10–18 years from urban and rural districts of 27 provinces of Iran were selected via stratified multi-stage sampling method. Data on psychological problems of students was gathered through a questionnaire. Height, weight, and waist circumferences were measured according to standard protocols. Body mass index (BMI) and waist- to-height ratio was calculated.
Results
Boys which did not have best friends, spend time with their friends after school or get acceptance from them, had higher BMI than others. Only girls who did not spend time with their friends had higher BMI (19.48 ± 4.28) vs. (19.09 ± 3.92) and WC (71.04 ± 21.29) vs. (69.15 ± 17.43) than others, P < 0.05. In both sexes, adolescents who had sense of pressure about doing homework or had difficulties in relationship with their parents had higher BMI and WC values. Girls who reported being victim of violent behaviors (being bullied), had lower BMI compared to others. Risk of being overweight and obese, but not abdominal obese was statistically higher in adolescents not having close friends (OR = 1.81, CI: 1.11–2.95). Lack of self-confidence increased only the risk of obesity in teens (OR = 1033, CI: 1.09–1.64).
Conclusions
Our findings suggest that strategies for prevention of overweight and obesity in adolescent should be taking into account a deeper knowledge of psychosocial issues due to be able to design more effective programs for treating overweight teens.
doi:10.1186/s40200-016-0237-7
PMCID: PMC4888475  PMID: 27252934
Overweight; Obesity; Adolescent; Psychosocial factors
12.  Joint Association of Screen Time and Physical Activity with Cardiometabolic Risk Factors in a National Sample of Iranian Adolescents: The CASPIANIII Study 
PLoS ONE  2016;11(5):e0154502.
Metabolic syndrome (MetS) and its contributing factors are considered important health problems in the pediatric age group. This study was designed to assess the joint association of ST and PA with cardiometabolic risk factors among Iranian adolescents. A representative sample of 5625 (50.2% boys) school students with a mean age of 14.73 (SD: 2.41) were selected through multistage random cluster sampling method from urban and rural areas of 27 provinces in Iran. ST and PA were assessed by self-administered validated questionnaires. Anthropometric measures (height, weight and waist circumference (WC)) and MetS components (abdominal obesity, elevated blood pressure (BP), low high-density lipoprotein cholesterol (HDL-C), elevated triglycerides (TG) and high fasting blood sugar (FBG)) were measured according to standardized protocols. MetS was defined according to the Adult Treatment Panel III criteria modified for the pediatric age group. Moreover, elevated total cholesterol (TC), elevated low-density lipoprotein cholesterol (LDL-C), and generalized obesity were considered as other cardiometabolic risk factors. Students with high ST levels had significantly higher body mass index z-score (BMI z-score), WC, TG, LDL-C, and BP as well as lower HDL-C level; whereas those with high PA levels had significantly higher HDL-C levels as well as lower BMI z-score, TC, and BP. Adolescents with low PA/ high ST levels had significantly higher BMI, WC, LDL-C levels, as well as higher SBP and DBP compared to their other counterparts. In Multivariate model, joint effect of low PA/ high ST (compared to the high PA/low ST group) increased the odds of overweight, abdominal obesity and low HDL-C and decreased the odds of elevated TC. The findings of this study showed that joint association of high ST and low PA have direct association with abdominal obesity, overweight and low HDL-C and indirect association with elevated TC.
doi:10.1371/journal.pone.0154502
PMCID: PMC4864273  PMID: 27167372
13.  Association of Mental Disorders and Consultation with Family Members and Friends in Children and Adolescents: The CASPIAN-IV Study 
Background:
Behavioral disorders are common in the pediatric age group. This study aims to assess the relationship between the frequency of behavioral and mental disorders and counseling with family members and friends in a representative sample of Iranian children and adolescents.
Methods:
In this nationwide study, 14880 school students, aged 6–18 years, were selected by cluster and stratified multi-stage sampling method from 30 provinces in Iran. The World Health Organization Global School-based Health Survey questionnaire was used.
Results:
Overall, 13486 students (49.2% girls) with the mean (standard deviation) age of 12.47 (3.36) years completed the study. According to the students’ self-report, 56.1% of boys and 42.2% of girls shared their problems with their fathers. All behavioral disorders were less prevalent in children and adolescents who consulted with their father compared with those who did not (P < 0.001). In addition, 84.6% of boys and 84.0% of girls shared their problem with their mother. All behavioral disorders were less prevalent in children and adolescents who consulted with their mother compared with those who did not (P < 0.001). 45.6% of boys and 44.8% of girls shared their problem with their brother or sister. Some behavioral disorders were less prevalent in children and adolescents who consulted with their brother or sister (P < 0.01); however, the prevalence was not statistically different for most disorders (P > 0.05). Moreover, 60.4% of boys and 66.0% of girls shared their problems with their friends. The prevalence of most behavioral disorders was lower in those who consulted with their friends (P < 0.001).
Conclusions:
Children and adolescents should be encouraged to consult with their parents and friends about their problems. Parents should offer their children an opportunity to express their views and wishes about their problems.
doi:10.4103/2008-7802.176165
PMCID: PMC4785779  PMID: 27014431
Children and adolescents; consultation; mental health
14.  Methodology and Early Findings of the Assessment of Determinants of Weight Disorders among Iranian Children and Adolescents: The Childhood and Adolescence Surveillance and PreventIon of Adult Noncommunicable Disease-IV Study 
Background:
This paper presents the methodology and primary findings of a national project on determinants of weight disorders among Iranian children and adolescents at national and sub-national levels.
Methods:
This nationwide study was conducted in 2011–2012 in Iran as part of the fourth phase of a national surveillance program entitled Childhood and Adolescence Surveillance and PreventIon of Adult Noncommunicable disease-IV study. It had two phases of qualitative and quantitative study. This multicentric study was conducted among 25,000 students aged 6–18 years, living in urban and rural areas of 30 provinces of Iran. Students were selected by multistage cluster sampling method. Data regarding weight disorders including sociodemographic variables, perinatal factors, lifestyle factors, family and student dietary habits, quality of life, and family history of chronic diseases as well as body image were gathered via validated questionnaires.
Results:
Overall, 23043 students completed the survey (participation rate: 92.17%). The mean age of participants was 12.55 ± 3.31 years; 50.8% were boys, and 73.4% were from urban areas. Underweight was found in 10.4% of boys and 9.2% of girls, the corresponding figure for overweight and obesity was 21% and 18.3%. Abdominal obesity was found in 17.6% of students. Among parents, obesity was more frequent than other weight disorders, with higher prevalence in parents of girls than boys (24.5% vs. 21.5%, respectively, P < 0.001). Overweight and obesity were more prevalent in urban than in rural parents (66.7% vs. 59.7%, respectively, P < 0.001).
Conclusions:
This survey serves as confirmatory evidence on the prevalence of dual burden of weight disorders in Iran. Its findings on determinants of weight disorders would help policymakers to implement relevant programs at national and sub-national levels.
doi:10.4103/2008-7802.162953
PMCID: PMC4564901  PMID: 26425332
Adolescents; children; determinants; Iran; overweight; underweight
15.  Is the association of continuous metabolic syndrome risk score with body mass index independent of physical activity? The CASPIAN-III study 
Nutrition Research and Practice  2015;9(4):404-410.
BACKGROUND/OBJECTIVES
Although the association of body mass index (BMI) with metabolic syndrome (MetS) is well documented, there is little knowledge on the independent and joint associations of BMI and physical activity with MetS risk based on a continuous scoring system. This study was designed to explore the effect of physical activity on interactions between excess body weight and continuous metabolic syndrome (cMetS) in a nationwide survey of Iranian children and adolescents.
SUBJECTS/METHODS
Data on 5,625 school students between 10 and 18 years of age were analyzed. BMI percentiles, screen time activity (STA), leisure time physical activity (LTPA) levels, and components of cMetS risk score were extracted. Standardized residuals (z-scores) were calculated for MetS components. Linear regression models were used to study the interactions between different combinations of cMetS, LTPA, and BMI percentiles.
RESULTS
Overall, 984 (17.5%) subjects were underweight, whereas 501 (8.9%) and 451 (8%) participants were overweight and obese, respectively. All standardized values for cMetS components, except fasting blood glucose level, were directly correlated with BMI percentiles in all models (P-trend < 0.001); these associations were independent of STA and LTPA levels. Linear associations were also observed among LTPA and standardized residuals for blood pressure, high-density lipoprotein, and waist circumference (P-trend < 0.01).
CONCLUSIONS
Our findings suggest that BMI percentiles are associated with cMetS risk score independent of LTPA and STA levels.
doi:10.4162/nrp.2015.9.4.404
PMCID: PMC4523485  PMID: 26244080
BMI; metabolic syndrome; physical activity
16.  The association of vitamin D deficiency with psychiatric distress and violence behaviors in Iranian adolescents: the CASPIAN-III study 
Background
Subtle effects of vitamin D deficiency on behavior have been suggested. We investigated the association of vitamin D status with mental health and violence behaviors in a sample of Iranian adolescents.
Methods
This nationwide study was conducted in 2009–2010 in 1095 Iranian school students with mean age 14.7 ± 2.6 years. Items were adapted from the Global School-based Student Health Survey (GSHS). Psychiatric distress was considered as the self-reported anger, anxiety, poor quality sleep, confusion, sadness/depression, worry, and violence-related behaviors (physical fight, having bully, or getting bullied).
Results
Forty percent had serum 25(OH)D values below 10 ng/mL (vitamin D deficient), and 39 % had levels 10-30 ng/mL (vitamin D insufficient). The prevalence of self-reported anger, anxiety, poor quality sleep, sadness/depression, and worry was significantly lower (P < 0.05) in vitamin D sufficient participants compared with their other counterparts. The odds of reporting anger, anxiety, poor quality sleep, and worry, increased approximately 1.5 to 1.8 times in vitamin D insufficient compared with normal children and adolescents (P < 0.05). Risk estimates indicated that vitamin D insufficient and deficient subjects had higher odds of reporting worry compared to normal vitamin D group [OR = 2.417 (95 % CI: 1.483-3.940) for vitamin D insufficient students, and OR = 2.209 (95 % CI: 1.351-3.611) for vitamin D deficient students] (P-trend = 0.001). Violence behaviors did not show any association with vitamin D status (P > 0.05).
Conclusion
Some psychiatric distress such as anger, anxiety, poor quality sleep, depression, and worry are associated with hypovitaminosis D in adolescents. The clinical significance of the current findings should be determined in future longitudinal studies.
doi:10.1186/s40200-015-0191-9
PMCID: PMC4511535  PMID: 26203431
Mental health; Violence behaviors; Anger; Anxiety; Depression; Vitamin D; Adolescents
17.  A nationwide report on blood pressure of children and adolescents according to socioeconomic status: The CASPIAN-IV study 
Background:
Hypertension is a major leading factor for global burden of diseases. Blood pressure (BP) tracks from childhood to adulthood. So, it is important to investigate its aff ecting factors. In this study we aimed to compare the BP status in the Iranian pediatric population according to the socioeconomic status (SES) of their living area.
Materials and Methods:
In this nationwide study, a representative sample of 14,880 students, aged 6-18 years was chosen by multistage random cluster sampling from 30 provinces in Iran. Anthropometric indices and BP were measured. A validated questionnaire, including the questions of the World Health Organization Global School-based Student Health Survey was completed. Findings were compared across the four regions of the country, categorized based on their elevating SES: Southeast, north-northeast, west, and central.
Results:
Participants consisted of 13,486 children and adolescents, that is, a participation rate of 90.6%, composed of 49.2% girls and 75.6% urban residents. The mean (standard deviation) age of participants was 12.47 (3.36) years. The region with highest SES (central) had the lowest rate of high BP (HBP), that is, 3.0% (95% of confidence interval [CI]: 2.4-3.9), and the region with lowest SES (southeast) had the highest rate, that is, 7.4% (4.4-12.2). The mean (95% CI) values of systolic BP for the four regions from lowest to highest SES were 100.5 (99.6-101.3), 100.9 (100.3-101.4), 101.7 (101.3-102), and 101.7 (101.2-102.1) mmHg. The corresponding mean Diastolic BP values were as follows: 65.4 (64.6-66.1), 63.4 (62.9-63.8), 65.6 (65.3-65.8), and 64.4 (64.0-64.7) mmHg.
Conclusion:
We found significant differences in mean BP and the frequency of HBP according to the SES of the living area. Further studies are necessary to find the underlying factors resulting in such differences.
doi:10.4103/1735-1995.166210
PMCID: PMC4638066  PMID: 26622253
Adolescent; blood pressure; child; high blood pressure; socioeconomic status
18.  Weight disorders and anthropometric indices according to socioeconomic status of living place in Iranian children and adolescents: The CASPIAN-IV study 
Background:
Excess weight in children and adolescents is a multi-factorial phenomenon and associated with earlier risk of obesity-related diseases. This study aims to assess the prevalence of weight disorders and the mean values of anthropometric indices according to regional, socioeconomic, and urban-rural variations among Iranian children and adolescents.
Materials and Methods:
This nationwide study was performed in 2011-2012 among a representative multi-stage cluster sample of 14,880 Iranian students aged 6-8 years. The World Health Organization (WHO) reference curves were used to define weight disorders. Abdominal obesity was defined as the waist-to-height ratio (WHtR) of more than 0.5. Iran was classified into four regions according to the socioeconomic status (SES).
Results:
The mean (95% confidence interval) of body mass index (BMI), waist circumference (WC), and hip circumference (HC) was 18.8 (18.7, 18.9) kg/m2, 67.0 (66.7, 67.3) cm, and 80.8 (80.3, 81.2) cm, respectively. The prevalence of underweight was 12.2%. A total of 9.7%, 11.9%, and 19.1% of students overweight, obese, and abdominally obese, respectively. The highest mean of BMI, WC, wrist circumference, HC, and WHtR were related to the second high SES (North-northeast) area (19.2 [18.8, 19.5], 68.3 [67.3, 69.4], 14.8 [14.7, 15.0], 82.6 [81.1, 84.0], and 0.464 [0.460, 0.468]). In contrast, the lowest SES (Southeast) region had the lowest mean of these anthropometric indices (17.6 [17.1, 18.2], 63.2 [61.7, 64.8], 14.5 [14.2, 14.8], 76.9 [74.9, 79.0], and 0.439 [0.434, 0.444]).
Conclusion:
We found considerable differences in the prevalence of anthropometric measures throughout the country by SES of the region. Health policy making and implementing health strategies should consider SES of regions.
PMCID: PMC4590198  PMID: 26487872
Anthropometric measures; obesity; socioeconomic status; underweight
19.  Association of 25-hydroxy Vitamin D levels with indexes of general and abdominal obesity in Iranian adolescents: The CASPIAN-III study 
Background:
This study aimed to determine the association of serum 25-hydroxy Vitamin D (25(OH)D) levels with measures of general and abdominal obesity in Iranian adolescents.
Materials and Methods:
This nationwide cross-sectional study was conducted among 1090 students, aged 10-18 years, living in 27 provinces in Iran. Serum concentration of 25(OH)D was analyzed quantitatively by direct competitive immunoassay chemiluminescence method. Body mass index (BMI) and waist-to-height ratio (WHtR) were considered as measures of generalized and abdominal obesity, respectively.
Results:
Study participants consisted of 1090 adolescents (51.9% boy and 67.1% urban residents) with mean age, BMI, and waist circumference of 14.7 (2.6) years, 19.3 (4.2) kg/m2, and 67.82 (12.23) cm, respectively. The median serum 25(OH)D was 13.0 ng/mL (interquartile range: 20.6). Overall, 40% of participants were Vitamin D deficient, and 39% were Vitamin D insufficient. Serum 25(OH)D level was not associated with BMI and WHtR.
Conclusion:
We did not document any significant association between serum 25(OH)D level and anthropometric measures in adolescents. This finding may be because of considerably high prevalence of hypovitaminosis D in the study population.
PMCID: PMC4400704  PMID: 25983762
25-Hydroxy Vitamin D; adolescents; obesity
20.  Frequency of Aggressive Behaviors in a Nationally Representative Sample of Iranian Children and Adolescents: The CASPIAN-IV Study 
Background:
This study aims to explore the frequency of aggressive behaviors among a nationally representative sample of Iranian children and adolescents.
Methods:
This nationwide study was performed on a multi-stage sample of 6–18 years students, living in 30 provinces in Iran. Students were asked to confidentially report the frequency of aggressive behaviors including physical fighting, bullying and being bullied in the previous 12 months, using the questionnaire of the World Health Organization Global School Health Survey.
Results:
In this cross-sectional study, 13,486 students completed the study (90.6% participation rate); they consisted of 49.2% girls and 75.6% urban residents. The mean age of participants was 12.47 years (95% confidence interval: 12.29, 12.65). In total, physical fight was more prevalent among boys than girls (48% vs. 31%, P < 0.001). Higher rates of involvement in two other behaviors namely being bullied and bulling to other classmates had a higher frequency among boys compared to girls (29% vs. 25%, P < 0.001 for being bullied) and (20% vs. 14%, P < 0.001 for bulling to others). Physical fighting was more prevalent among rural residents (40% vs. 39%, respectively, P = 0.61), while being bullied was more common among urban students (27% vs. 26%, respectively, P = 0.69).
Conclusions:
Although in this study the frequency of aggressive behaviors was lower than many other populations, still these findings emphasize on the importance of designing preventive interventions that target the students, especially in early adolescence, and to increase their awareness toward aggressive behaviors. Implications for future research and aggression prevention programming are recommended.
doi:10.4103/2008-7802.151436
PMCID: PMC4362279  PMID: 25789141
Bullying; children and adolescents; Iran; physical fight; prevalence; violence
21.  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
22.  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
23.  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
24.  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
25.  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

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