Priority strategic directions in adolescent health in Iran based on the WHO's Global Accelerated Action for the Health of Adolescents.

OBJECTIVES: In line with the World Health Organization's Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, the goal of the current research was to identify critical strategies for adolescents' health and to determine the role and distribution of responsibilities among the leading players in the field of adolescent health in Iran. METHODS: The current qualitative and applied study is part of the Ministry of Health and Medical Education's "Adolescent, Youth and School Health" plan to develop the "National Adolescent Health Plan Document" in 2020. First, stakeholder analysis was done, then a pool of nationally appropriate strategies was selected from the list of priority strategies recommended by the WHO in the AA-HA! through several group sessions. After that, the experts selected priority strategies based on the criteria of feasibility, acceptability, effectiveness, guaranteed resources, coordination with other plans and temporal priority, scoring, and executive priorities. Eventually, the priority strategies were assigned to different players/stakeholders in the field over several sessions bearing in mind the methods of implementation and the target groups. RESULTS: The experts identified 58 priority strategies/actions for adolescent health under the seven priority areas of positive development, sexual protection, reproductive health, mental health, substance abuse, self-harm, violence, unintentional injury, communicable and non-communicable diseases, nutrition, and physical activity. CONCLUSIONS: The highest identified priority areas were in the areas of vaccination; special health care package for service providers; training and education to promote health literacy and self-care, life skills, sexual awareness, and prevention/protection against violence; community-based mental health services, planning for adolescents' spare time, substance use prevention.

Determinants of taking dietary supplements in Iranian children and adolescents: the CASPIAN-V study.

AIM: Tendency for taking dietary supplements is dramatically increasing. However, limited studies exist in this regard. We aimed to assess the frequency and determinants of dietary supplement use among a nationally-representative sample of Iranian children and adolescents. METHODS: This population-based cross-sectional study (the CASPIAN V) was conducted in students aged 7 to 18 years old in 2015. Multistage, stratified cluster sampling method was used to select participants from thirty provinces in Iran. Data regarding taking vitamin and mineral supplements were collected. Demographic information, anthropometric indices, physical activity, screen time and body image were also evaluated. Multivariate logistic regression model was used for analyses. RESULTS: The prevalence of dietary supplements use was 34.1% and the most popular dietary supplement was Iron (12.9%). Multivariate logistic regression showed that boys (0.84, 95%CI: 0.78, 0.91) and body image perception (OR: 0.84, 95%CI: 0.75, 0.94) used less dietary supplements compared to others. Children aged 11 to 14 years (OR: 1.15, 95%CI: 1.06, 1.26) and those with moderate family socioeconomic status (OR: 1.12, 95%CI: 1.007, 1.25) used more supplement compared to other groups. Moreover, those with higher paternal educational level (OR: 0.77, 95%CI: 0.64, 0.93) used less supplements. However, living area, family size, paternal occupation, children BMI, Intended weight loss, and body image by student did not indicate any significant association. CONCLUSION: Our findings indicated that about one-third of Iranian children and adolescents used dietary supplements; iron supplements were the most frequent ones. Children aged 11 to 14 years, those with higher educated mothers and moderate family socioeconomic status used more supplements compared to others. However, boys, children with excess weight and those with high-educated parents used less supplements compared to others. More studies are needed to clarify the efficacy and safety of dietary supplements in different age groups in various societies.

Association of alanine aminotransferase concentration with cardiometabolic risk factors in children and adolescents: the CASPIAN-V cross-sectional study

ABSTRACT BACKGROUND: It has been suggested that the levels of some liver enzymes, and especially alanine aminotransferase (ALT), might be correlatable with cardiometabolic risk factors. We investigated the relationship between ALT concentration and cardiometabolic risk factors among children and adolescents. DESIGN AND SETTING: This nationwide study in Iran was conducted within the framework of the fifth survey of a national surveillance program known as the Childhood and Adolescence Surveillance and PreventIon of Adult Non-communicable disease study (CASPIAN-V). METHODS: The participants comprised 4200 students aged 7-18 years, who were recruited through multi-stage random cluster sampling in 30 provinces in Iran. Physical examinations and laboratory tests were conducted in accordance with standard protocols. RESULTS: Overall, 3843 students (participation rate: 91.5%) completed the survey. Mean ALT levels were significantly higher in individuals with dyslipidemia, in terms of elevated total cholesterol (TC) or LDL-cholesterol or triglycerides (TG), excess weight and dyslipidemia. Some cardiometabolic risk factors were associated with higher levels of ALT, with the following odds ratio (OR) and 95% confidence interval (CI):metabolic syndrome (OR: 1.013; 95% CI: 1.001-1.025); elevated TC (OR: 1.060; 95% CI: 1.039-1.081), elevated LDL (OR: 1.031; 95% CI: 1.016-1.046), elevated TG (OR: 1.056; 95% CI: 1.040-1.072) and dyslipidemia (OR: 1.051; 95% CI: 1.034-1.068). CONCLUSION: This large population-based study revealed that some cardiometabolic risk factors were significantly associated with ALT levels. These findings suggest that an association with fatty liver is an underlying mechanism for development of cardiometabolic risk factors.

Association of sleep duration with metabolic syndrome and its components in children and adolescents; a propensity score-matched analysis: the CASPIAN-V study.

OBJECTIVE: This study aims to evaluate the association of sleep duration with metabolic syndrome (MetS) and its components in a pediatric population. METHODS: This multi-centric cross-sectional study was conducted in 2015 in 30 provinces of Iran. Participants consisted of 4200 school students aged 7-18 years, studied in a national school-based surveillance program (CASPIAN-V). Physical examinations and laboratory tests were performed using standard protocols. The analysis was conducted based on the propensity score matching and conditional logistic regression was used to evaluate the association of short sleep (less than 8 h a day) and the onset of sleep with MetS and its components. Results of conditional logistic regression was reported as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Overall, 3843 of participants completed the survey (response rate: 91.5%). Their mean (SD) age was 12.3 (3.2) years and 50.6% were boys. In the multivariate model, individuals who slept less than 8 h a day had significantly higher odds of MetS (OR 2.05, 95% CI 1.19-3.63) and high blood pressure (BP) (OR 1.46, 95% CI 1.04-2.06). Association between short sleep duration with other MetS components (including abdominal obesity, hypertriglyceridemia, hyperglycemia, and low levels of high-density lipoprotein-cholesterol was not statistically significant (P > 0.05). Moreover, association between the onset of sleep with MetS and its components was not statistically significant (P > 0.05). CONCLUSION: Short sleep duration is associated with increased risk of MetS and high BP in children and adolescents. The clinical impact of current findings should be assessed in future longitudinal studies.

Prevalence of cardiometabolic risk factors in a nationally representative sample of Iranian children and adolescents: the CASPIAN-V Study.

Introduction: This study presents the prevalence of cardiometabolic risk factors in a nationally representative sample of Iranian children and adolescents. Methods: This multi-centric study was conducted in 2015 among 4200 students aged 7-18 years. They were selected by multistage cluster sampling from 30 provinces of Iran. Anthropometric indices, biochemical and clinical parameters were measured. Results: The mean of weight, height, waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting blood glucose (FBG) was higher in boys than in girls (P < 0.05). The mean of triglyceride (TG), total cholesterol (TC) and low-density lipoprotein (LDL) levels were higher in girls than in boys (P < 0.05). The mean of weight, height, WC, SBP, DBP, alanine transaminase (ALT) and body mass index (BMI) was higher in urban than in rural residents (P < 0.05). Overall, 16.1%, 9.4% and 11.4% were underweight, overweight and obese. Abdominal obesity was documented in 21.6% of boys and 20.5% of girls. Low HDL-C was the most prevalent abnormality of lipid profile (29.5%) followed by high serum TGs (27.7%). Low HDL-C was more prevalent in boys than in girls (32.7% vs. 26%, respectively, P < 0.05). Prevalence of obesity and overweight were higher in girls than in boys (P < 0.05). The prevalence of obesity and overweight, abdominal obesity, and low HDL-C were higher in urban than in rural residents (P < 0.05). Conclusion: We found considerably high prevalence of some cardiometabolic risk factors including overweight and obesity, low HDL-C and hypertriglyceridemia in Iranian children and adolescents. The current findings underscore the necessity of intensifying health interventions for primordial and primary prevention of non-communicable diseases from early life.

The association of parental obesity with physical activity and sedentary behaviors of their children: the CASPIAN-V study / Associação da obesidade parental a atividade física e comportamentos sedentários deseus filhos: o estudo CASPIAN-V

Abstract Objective: Low physical activity and sedentary behaviors, two important determinants of childhood obesity, may be influenced by parental lifestyle and weight status. This study aims to determine the association of parental weight status with children's physical activity and screen time. Methods: This study was conducted on 14,440 Iranian schools students, aged 7-18 years, and one of their parents, who participated in the large national school-based surveillance program. The children's screen-based and physical activities were evaluated based on the World Health Organization's Global School Student Health Survey. Children and parental height, weight, and waist circumference were measured using standardized methods. Results: Overall, 14,274 students and one of their parents completed the survey (participation rate: 99%). Mean (standard deviation) age of students was 12.3 (3.2) years, and the prevalence of low physical activity and high screen time was 58.2% and 17.7%, respectively. In multivariate model, the parental general obesity and abdominal obesity increased the odds of children having low physical activity, by 21% and 13%, respectively. Parental overweight, general obesity, and abdominal obesity increased the odds of the combination of low physical activity/high screen time in children by 33%, 26%, and 20%, respectively. Conclusions: This study showed that parental obesity was associated with increased screen-based activities and low physical activity in children. Focus on parental weight status, as an important factor influenced by their lifestyle, can be helpful for preventing sedentary behaviors in their children.

Resumo Objetivo: A baixa atividade física e comportamentos sedentários, dois importantes fatores determinantes de obesidade infantil, podem ser influenciados pelo estilo de vida e o status do peso dos pais. Este estudo visa a determinar a associação do status do peso dos pais no nível de atividade física e ao tempo de tela das crianças. Métodos: Este estudo foi feito em 14.440 estudantes de escolas iranianas, com idades entre 7-18 anos e um de seus pais inscritos no grande programa nacional de vigilância escolar. As atividades físicas e em tela das crianças foram avaliadas com base no questionário da Pesquisa Global de Saúde do Escolar da Organização Mundial de Saúde. A estatura, o peso e a circunferência da cintura das crianças e dos pais foram medidos com métodos padronizados. Resultados: De modo geral, 14.274 estudantes e um de seus pais concluíram a pesquisa (taxa de participação: 99%). A idade média (desvio padrão) dos estudantes foi 12,3 (3,2) anos e a prevalência de baixa atividade física e alto tempo de tela foi de 58,2% e 17,7%, respectivamente. Em um modelo multivariado, a obesidade geral dos pais e a obesidade abdominal aumentaram as chances de as crianças com baixo nível de atividade física em 21% e 13%, respectivamente. Sobrepeso dos pais, obesidade geral e obesidade abdominal aumentaram as chances de combinação de baixo nível de atividade física/alto tempo de tela nas crianças em 33%, 26% e 20%, respectivamente. Conclusões: Este estudo mostrou que a obesidade dos pais foi associada ao aumento nas atividades de tela e ao baixo nível de atividade física nas crianças. O foco no status do peso dos pais, como um importante fator influenciado por seu estilo de vida, pode ser útil na prevenção de comportamentos sedentários em seus filhos.

Association of dietary patterns with continuous metabolic syndrome in children and adolescents; a nationwide propensity score-matched analysis: the CASPIAN-V study.

OBJECTIVE: This study aims to determine the association of dietary patterns with metabolic syndrome (MetS) and its components in children and adolescents. METHODS: This nationwide study was conducted in 2015 among 4200 students aged 7-18 years, who lived in 30 provinces in Iran. The analysis was conducted based on the propensity score using a matched case-control study design. Three dietary patterns were obtained conducting a principal component analysis with a varimax rotation on 16 dietary groups. Continuous MetS score was computed by standardizing the residuals (z-scores) of MetS components by regressing them according to age and sex. The gold standard diagnosis of MetS was considered based on the International Diabetes Federation criteria. Moreover, for the purpose of data analysis, matched logistics analysis was used. RESULTS: The study participants consisted of 3843 children and adolescents (response rate 91.5%) with mean (SD) age of 12.45 (3.04) years. Totally 49.4% of students were girls and 71.4% lived in urban areas. Three dietary patterns were obtained: Healthy, Western, and Sweet. Prevalence of MetS was 5% (boy 5.5 and girl 4.5%). Results of multivariate analysis show that students with Sweet dietary patterns were at higher risk for abdominal obesity (OR 1.29; 95% CI 1.01-1.66), elevated blood pressure (OR 1.35; 95% CI 1.01-1.81) and MetS (OR 1.33; 95% CI 1.02-1.74). The two other dietary patterns were not associated with MetS and its components. CONCLUSION: Sweet dietary pattern increase the risk of MetS and some its components in Iranian children and adolescents. This finding provides valuable information for effective preventive strategies of MetS based on diet rather than medication to maintain healthy lifestyle habits.

Association of parental obesity with cardiometabolic risk factors in their children: The CASPIAN-V study.

BACKGROUND: The family environment has a crucial role in the development of childhood obesity and related cardiometabolic disorders. This study aims to investigate the association of parental obesity and cardiometabolic risk factors in their children. METHODS: This multicentric cross-sectional study was performed on 14400 students (aged 7-18 years) and one of their parents. Students were recruited by multistage, stratified cluster sampling from urban and rural areas of 30 provinces of Iran. Fasting venous blood was obtained from a random sample of 4200 students. Demographic, anthropometric and clinical variables were collected. RESULTS: Data of 14002 students and results of blood samples of 3483 of them were complete and included in the current study. The prevalence of obesity in children, fathers, and mothers was 11.4%, 10.6%, and 24.2%, respectively. In students, the most commonly observed metabolic abnormality was low HDL-C (29.5%); the prevalence of metabolic syndrome and dyslipidemia was 5% and 55.7%, respectively. Significant correlations were observed between the body mass index (BMI) and waist circumference of parents and weight, height, BMI, and waist circumference, as well as systolic and diastolic blood pressure (BP) of their children (P< 0.05). In the multivariate model, the risk of excess weight (OR: 1.30, 95%CI: 1.17-1.44), obesity (OR: 1.36, 95%CI: 1.18-1.59), abdominal obesity (OR: 1.16, 95%CI: 1.05-1.29) and elevated BP (OR: 1.17, 95%CI: 1.04-1.31) were higher in those students whose parents had excess weight compared with other students. Parental obesity did not have significant association with metabolic syndrome and dyslipidemia in their children. CONCLUSIONS: Parental history of obesity could be used as a practical approach for the early preventive measures and identification of children at risk of cardiometabolic complications.

Validity of triglyceride-glucose index as an indicator for metabolic syndrome in children and adolescents: the CASPIAN-V study.

PURPOSE: The purpose of this study was to determine the cut-off values of triglycerides and glucose (TyG) index as one of the indirect indices for metabolic syndrome (MetS) in a pediatric population. METHODS: This national study was conducted in 2015 on 14400 students, aged 7-18 years. They were selected by random cluster sampling from 30 provinces of our country during the fifth survey of a national school-based surveillance program. MetS was defined based on the Adult Treatment Panel III (ATP III) criteria modified for the pediatric age group. The cut-off values of TyG index for MetS were obtained using the receiver operation characteristic (ROC) curve analysis by gender and age groups. RESULTS: Totally, 3843 students (52.3% boys) with mean (SD) age of 12.45 (3.04) years were assessed. The area under the ROC curve of TyG index for MetS was 0.83 in total participants. According to the ATP III criteria the cut-off values of the TyG index were 8.33 (8.21-8.45) in total students, 8.47 (8.36-8.58) in boys, and 8.33 (8.18-8.48) in girls. In the 7-12 and 13-18 years' age groups, these values were 8.47 (8.32-8.63) and 8.34 (8.22-8.45) in total, 8.39 (8.26-8.52) and 8.47 (8.33-8.61) in boys, 8.33 (8.11-8.55) and 8.35 (8.22-8.47) in girls, respectively. CONCLUSION: The findings of this study can be clinically helpful for screening MetS in children and adolescents but the effectiveness of these criteria needs to be evaluated by further longitudinal surveys. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study (National surveillance study).

Association of alanine aminotransferase concentration with cardiometabolic risk factors in children and adolescents: the CASPIAN-V cross-sectional study.

BACKGROUND: It has been suggested that the levels of some liver enzymes, and especially alanine aminotransferase (ALT), might be correlatable with cardiometabolic risk factors. We investigated the relationship between ALT concentration and cardiometabolic risk factors among children and adolescents. DESIGN AND SETTING: This nationwide study in Iran was conducted within the framework of the fifth survey of a national surveillance program known as the Childhood and Adolescence Surveillance and PreventIon of Adult Non-communicable disease study (CASPIAN-V). METHODS: The participants comprised 4200 students aged 7-18 years, who were recruited through multi-stage random cluster sampling in 30 provinces in Iran. Physical examinations and laboratory tests were conducted in accordance with standard protocols. RESULTS: Overall, 3843 students (participation rate: 91.5%) completed the survey. Mean ALT levels were significantly higher in individuals with dyslipidemia, in terms of elevated total cholesterol (TC) or LDL-cholesterol or triglycerides (TG), excess weight and dyslipidemia. Some cardiometabolic risk factors were associated with higher levels of ALT, with the following odds ratio (OR) and 95% confidence interval (CI):metabolic syndrome (OR: 1.013; 95% CI: 1.001-1.025); elevated TC (OR: 1.060; 95% CI: 1.039-1.081), elevated LDL (OR: 1.031; 95% CI: 1.016-1.046), elevated TG (OR: 1.056; 95% CI: 1.040-1.072) and dyslipidemia (OR: 1.051; 95% CI: 1.034-1.068). CONCLUSION: This large population-based study revealed that some cardiometabolic risk factors were significantly associated with ALT levels. These findings suggest that an association with fatty liver is an underlying mechanism for development of cardiometabolic risk factors.

The association of parental obesity with physical activity and sedentary behaviors of their children: the CASPIAN-V study.

OBJECTIVE: Low physical activity and sedentary behaviors, two important determinants of childhood obesity, may be influenced by parental lifestyle and weight status. This study aims to determine the association of parental weight status with children's physical activity and screen time. METHODS: This study was conducted on 14,440 Iranian schools students, aged 7-18 years, and one of their parents, who participated in the large national school-based surveillance program. The children's screen-based and physical activities were evaluated based on the World Health Organization's Global School Student Health Survey. Children and parental height, weight, and waist circumference were measured using standardized methods. RESULTS: Overall, 14,274 students and one of their parents completed the survey (participation rate: 99%). Mean (standard deviation) age of students was 12.3 (3.2) years, and the prevalence of low physical activity and high screen time was 58.2% and 17.7%, respectively. In multivariate model, the parental general obesity and abdominal obesity increased the odds of children having low physical activity, by 21% and 13%, respectively. Parental overweight, general obesity, and abdominal obesity increased the odds of the combination of low physical activity/high screen time in children by 33%, 26%, and 20%, respectively. CONCLUSIONS: This study showed that parental obesity was associated with increased screen-based activities and low physical activity in children. Focus on parental weight status, as an important factor influenced by their lifestyle, can be helpful for preventing sedentary behaviors in their children.

Association of anthropometric indices with continuous metabolic syndrome in children and adolescents: the CASPIAN-V study.

PURPOSE: This study aims to examine the association of anthropometric indices with continuous metabolic syndrome (cMetS) among Iranian children and adolescents. METHODS: This multicentric study was conducted on 14138 students aged 7-18 years, who participated in a national surveillance program. Fasting blood sample was obtained from a subsample of 3843 randomly selected students. Physical examination including the measurement of anthropometric indices and blood pressure was conducted; fasting blood glucose and lipid profile were measured; and cMetS score was computed. Standardized residuals (z-scores) were calculated for MetS components. A higher cMetS score indicates a less favorable metabolic profile. Linear regression models were applied to determine the association between cMetS and anthropometric indices. RESULTS: The study participants consisted of 3843 children and adolescents (52.3% boys) with mean (SD) age of 12.45 ± 3.04 years. All anthropometric indices had positive correlation with standardized scores of mean arterial pressure, waist circumference and cMetS (P < 0.05). Standardized scores of triglycerides were positively correlated with weight and body mass index (P < 0.05). In multivariate model, general and abdominal obesity, as well as high circumferences of neck, wrist, and hip circumferences increased the standardized cMetS risk score to 1.8, 1.9, 1.6, 1.5 and 1.5, respectively (P < 0.05 for all variables). CONCLUSION: The results demonstrated that higher anthropometric indices are associated with higher cMetS risk score in children and adolescents. This information could be valuable for screening and prevention of MetS at population level. LEVEL OF EVIDENCE: V, cross-sectional descriptive study (National surveillance study).

Association between neck and wrist circumferences and cardiometabolic risk in children and adolescents: The CASPIAN-V study.

OBJECTIVE: The predictive potentials of neck and wrist circumferences for cardiometabolic risks in children and adolescents remain to be determined. The aim of this study was to evaluate the association of neck and wrist circumferences with some cardiometabolic risk factors in children and adolescents. METHODS: This multicenter study was conducted during the 2014 to 2015 school year with 4200 children and adolescents ages 7 to 18 y. The children were selected by multistage cluster sampling from 30 provinces of Iran. Anthropometric indices (neck, wrist and waist circumference, and body mass index), biochemical and clinical parameters were measured. Metabolic syndrome was defined based on the Adult Treatment Panel III criteria modified for the pediatric age group. High total cholesterol, high low-density lipoprotein cholesterol, and obesity were included as other cardiometabolic risk factors. RESULTS: The participation rate for blood sampling was 91.5% (n = 3843). The mean (standard deviation) age of participants was 12.3 y (3.2 y). In a multivariate model, neck and wrist circumferences had significant association with elevated blood pressure, low high-density lipoprotein cholesterol, increased body mass index (overweight, excess weight, and generalized obesity), abdominal obesity, and metabolic syndrome. Additionally, obesity had the strongest associations with neck (odds ratio, 1.48; 95% confidence interval, 1.45-1.51) and wrist circumference (odds ratio, 2.25; 95% confidence interval, 2.15-2.36). CONCLUSION: Neck and wrist circumferences are associated with some cardiometabolic risk factors. They could be used as alternative clinical tools and easy-to-use indicators of cardiometabolic risk in children and adolescents.

Body weight misperception and health-related factors among Iranian children and adolescents: the CASPIAN-V study.

BACKGROUND: Along with increased prevalence of obesity, body weight misperception has also increased among adolescents. This study aims to evaluate the proportion of weight misperception among Iranian children and adolescents and its association with some health-related factors. METHODS: Data were collected from 14,440 Iranian students, aged 7-18 years, who participated in the national school-based surveillance program (CASPIAN-V). The students' anthropometric indices and blood pressure were measured using standardized methods, and valid questionnaires were used to assess their weight perception, eating patterns, physical activity and sedentary behaviors. According to agreements between the real weight and self-perceived weight status, participants were classified as underestimated, accurate and overestimated weight. RESULTS: The rates of underestimated, accurate and overestimated weight were 30.8%, 40.8% and 28.4%, respectively. In comparison with the accurate-weight group, both the underestimated- and overestimated-weight groups were less likely to have daily consumption of sugar-sweetened beverages (OR: 0.83, 95% CI: 0.74-0.93 and OR: 0.39, 95% CI: 0.34-0.44, respectively), sweets (OR: 0.81, 95% CI: 0.73-0.90 and OR: 0.68, 95% CI: 0.61-0.76, respectively) and salty snacks (OR: 0.78, 95% CI: 0.66-0.92 and OR: 0.30, 95% CI: 0.24-0.38, respectively). In the overestimated-weight group, the odds of daily intake of fast food decreased by 67% and the odds of low physical activity declined by 38% in comparison with the accurate-weight group. CONCLUSIONS: Weight misperception had a high prevalence among Iranian children and adolescents and is associated with their dietary patterns and physical activity behaviors. Suitable education programs need to be developed to correct the children and adolescents' insight about their weight status.

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.

First report on the validity of a continuous Metabolic syndrome score as an indicator for Metabolic syndrome in a national sample of paediatric population - the CASPIAN-III study.

INTRODUCTION: The aim of this study was to assess the validity of a continuous Metabolic Syndrome score (cMetS) in a nationally representativesample of Iranian children and to identify sex and age-specific optimal cut-off points of cMetS that are associated with MetS. MATERIAL AND METHODS: This study was conducted among 3,254 schoolchildren aged 10-18 years. cMetS was derived by aggregating ageand sex-standardised residuals of waist circumference (WC), mean arterial pressure (MAP), glucose, high density lipoprotein-cholesterol(HDL-C) and triglycerides (TG). To determine the optimal cut-off points of cMetS for predicting MetS, receiver operator characteristic(ROC) curve analysis was used with an estimation of the variables' sensitivity and specificity. RESULTS: A graded relationship was documented between cMetS and the number of risk factors. Increasing mean values of cMetS with increasingnumbers of components were apparent for both genders. The overall optimal cMetS cut-off point for predicting the presence of MetS was 2.93 [sensitivity= 92%, specificity = 91%, area of the curve = 0.96 (0.95-0.97)]. The values for boys and girls were 2.97 and 3.26 respectively in the total study. CONCLUSION: This nationwide study confirmed the validity of the cMetS score in a population-based sample of Iranian children. cMetSappears to be an appropriate index for investigating the association between potential risk factors and MetS in epidemiological researchin Iran.

First report on path analysis for cardiometabolic components in a nationally representative sample of pediatric population in the Middle East and North Africa (MENA): the CASPIAN-III Study.

BACKGROUND/AIMS: This study aimed to test a potential model of the relationship between various cardiometabolic risk factors including obesity, unhealthy diet, low physical activity, dyslipidemia, and high blood pressure in a large population-based sample of children and adolescents. METHODS: In this nationwide study, a representative sample of 5,528 students aged 10-18 years was selected by multistage random cluster sampling from 27 provinces of Iran. Demographic, anthropometric, biological, and biochemical factors were determined. Structural equation modeling (path analysis) was applied to evaluate the causal relationship between these variables. RESULTS: The mean age of study participants was 14.7 ± 2.41 years and the mean body mass index (BMI) was 19.4 ± 4.1. Higher socioeconomic status was directly associated with unhealthy diet, low physical activity and BMI in both sexes. Age had a positive direct effect on low physical activity in both sexes. BMI showed the greatest direct effect on total cholesterol, triglyceride, low-density lipoprotein cholesterol, and mean arterial pressure in comparison with the direct effects of unhealthy diet and low physical activity. BMI was associated negatively with high-density lipoprotein cholesterol in both groups. CONCLUSIONS: No previous study has used path analysis for determining the interactions examined in this study among a nationally representative sample of children in the Middle East and North Africa (MENA). The results of this study underline the imperative need for the weight loss and lifestyle change from childhood as the first-line preventive strategy for metabolic syndrome and noncommunicable diseases.

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.

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.

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.

Methodology and Early Findings of the Third Survey of CASPIAN Study: A National School-based Surveillance of Students' High Risk Behaviors.

BACKGROUND: A school-based surveillance system entitled the childhood and adolescence surveillance and prevention of Adult Noncommunicable disease (CASPIAN) Study is implemented at national level in Iran. This paper presents the methods and primary findings of the third survey of this surveillance system. METHODS: This national survey was performed in 2009-2010 in 27 provinces of Iran among 5570 students and one of their parents. In addition to physical examination, fasting serum was obtained. Body mass index was categorized based on the World Health Organization growth charts. FINDINGS: Data of 5528 students (2726 girls, 69.37% urban, mean age 14.7 ± 2.4 years) were complete and are reported. Overall, 17.3% (17.3% of girls and 17.5% of boys) were underweight, and 17.7% (15.5% of girls and 19.9% of boys) were overweight or obese. Abdominal obesity was documented in 16.3% of students (17.8% of girls and 15% of boys). 57.6% of families consumed breads, the staple food for Iranians, prepared with white flour. Most families (43.8% in urban areas and 58.6% in rural areas) used solid hydrogenated fats. 22.7% of students did not add salt to the table food. 14.2% of students reported to have a regular daily physical activity for at least 30 min a day. Overall, 10.4% of students (11.7% in urban areas and 7.3% in rural areas) reported that they used tobacco products, often waterpipe. 32.8% of students experienced at least three times of bullying in the previous 3 months. During the year prior to the survey, 14.46% of students had an injury needing the interference by school health providers. CONCLUSION: This survey is confirmatory evidence on the importance of establishing surveillance systems for risk behaviors to implement action-oriented interventions.