Is the association of continuous metabolic syndrome risk score with body mass index independent of physical activity? The CASPIAN-III study

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.

Association of overweight and obesity with mental distress in Iranian adolescents: the CASPIAN-III study

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. This nationwide study was conducted in 2009-2010 among 5570 students, aged 10-18 years, living in 27provinces in Iran. Data were collected by using the translated and validated questionnaire of the World Health Organization Global School-based Health Survey. 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. 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

Frequency, causes, and places of unintentional injuries in a nationally representative sample of Iranian children and adolescents: the CASPIAN-IV study

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. 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. 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%]. Prevention of unintentional injuries should be considered as a health priority. Appropriate preventive strategies should be enhanced at homes and schools

nationwide survey on the daily screen time of Iranian children and adolescents: the Caspian - IV study

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. 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. The study participants were 13486 school students [participation rate of90.6%] with a mean age of12. 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. 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

Relationship of serum magnesium and vitamin D levels in a nationally-representative sample of Iranian adolescents: the CASPIAN-III study

This study aims to assess the relationship of serum Mg and vitamin D levels in a nationally-representative sample of Iranian adolescents. 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. 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 +/- 0.22mg/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]. 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

nationwide survey on some hygienic behaviors of iranian children and adolescents: the caspian-iv study

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. 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. 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. 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

Tooth brushing and cardiometabolic risk factors in adolescents: Is there an association? The CASPIAN-III study

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. 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. 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. 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

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

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. 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. 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. 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

Mental health problems of Iranian female adolescents and its association with pubertal development: a nationwide study

Mental health problems including emotional and behavioral problems during puberty may be under influence of different risk factors including cultures, living in urban or rural areas and ethnic factors which may vary between different countries. The main aim of this study is to investigate the profile of emotional and behavioral problems and the role of factors such as age, stage of puberty, ethnicity, rurality and living in urban area, as risk factors in Iranian girls. As a part of a large national study we evaluated the emotional and behavioral problems in different stages of puberty in a community sample of Iranian adolescent girls from public schools that were selected by clustered random sampling method. In all subjects, demographic characteristics, and pubertal stages were measured. Emotional and behavioral problems were evaluated using Strength and Difficulties Questionnaire [SDQ]. The associations of age, pubertal development indices, socioeconomic and demographic factors with the behavioral problems were assessed. A total number of 4576 students enrolled the study and responded to the questions. The mean age of participants was 13.83 +/- 2.19 years. The mean total score of difficulties in participants was 14.34 +/- 5.81. According to these results 813 [17.8%] adolescents had total problem scores higher than Goodman's cutoff points and the most frequent problem domain was conduct problems [20.5%]. According to the results the most related variable with the total difficulty score of SDQ were ethnicity, residency in urban areas and development of menstrual cycle respectively. The results of this study showed that the most correlated factors with mental health problems in Iranian girls during puberty are ethnicity, urbanity and development of menstrual cycle

Methodology and early findings of the third survey of CASPIAN study: a national school-based surveillance of students' high risk behaviors

A school-based surveillance system entitled the childhood and adolescence surveillance and prevention of Adult No communicable 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. 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. 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 water pipe. 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. This survey is confirmatory evidence on the importance of establishing surveillance systems for risk behaviors to implement action-oriented interventions

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 I-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

Development and evaluation of a questionnaire for assessment of determinants of weight disorders among children and adolescents: the caspian-IV study

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 wide-ranging questionnaire for assessment of these parameters in a nationwide sample of Iranian children and adolescents. 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 using a validated 168-item semi-quantitative food frequency questionnaire. A validated questionnaire for quality of life was filled in anonymously. 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 associated with the understanding of participants 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. 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

national experience on physical activity initiatives for adolescent girls and their mothers: CASPIAN study

To provide a low- cost and simple model of culturally-appropriate and low cost facilities for improvement of physical activity for girls and their mothers through an after-school program and to determine the changes in anthropometric indexes after this trial. This national study was conducted in 2006-2007 in 7 provinces with different socioeconomic situations in Iran. Female students who studied in the 7[th] through 10[th] grade and their mothers were selected by random cluster sampling. In each province, 24 sessions of after-school aerobic physical activity were held for 90 minutes, two days a week, and 3 months long at school sites in the afternoon. The study comprised 410 participants [204 mothers and 206 daughters], with a mean age of 15.86 +/- 1.01 and 40.71 +/- 6.3 years in girls and their mothers, respectively. The results of the focus group discussions showed that in general, both mothers and daughters of generalized and abdominal obesity improved significantly both in girls and in their mothers [P-value <0.0001 for weight, body mass index and waist circumference]. Our findings may provide a low-cost and simple effective model of motivation for physical activity with targeted interventions for girls and their mothers. We suggest that the success of this trial might be a result of bonding and accompaniment of mothers and daughters. Such model can be integrated in the existing health and education systems to increase the physical activity level

Assessment of pubertal development in Iranian girls

We estimated pubertal development of 7,493 normal Iranian girls aged 6 to 20 years in a cross-sectional study. Pubertal stages were assessed according to Tanner. The mean ages to achieve secondary sexual characteristics as well as the mean age at menarche were estimated. Weight and height were measured and body mass index [BMI] was calculated. Reference curves for different breast stages and menarche were constructed. The percentiles for attaining each stage were compared to data proposed by Tanner. The mean age at breast bud stage [B2] was 10.10, pubic hair stage [P2] was 9.83, and menarche age was 12.55 years. The anthropometric variables were interpreted in different maturity stages. The mean age at attainment of puberty was compared with those of other populations. Not only the onset of puberty in Iranian girls but also the duration of puberty is similar to data from most other countries. A lower age limit for the definition of precocious puberty than the traditional 8 years is documented for Iranian girls. However, it should be noted that considering the rate of evolution of pubertal findings is more important than the age of their appearance