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A Systematic Review on the Prevalence of Overweight and Obesity, in Iranian Children and Adolescents

AUTHORS

Shirin Djalalinia 1 , 2 , Roya Kelishadi 3 , Mostafa Qorbani 4 , Niloofar Peykari 1 , 2 , Amir Kasaeian 1 , 5 , Ensieh Nasli-Esfahani 6 , Shohreh Naderimagham 1 , Bagher Larijani 7 , Farshad Farzadfar 1 , 7 , *

1 Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, IR Iran

2 Development of Research and Technology Center, Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, IR Iran

3 Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran

4 Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, IR Iran

5 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran

6 Diabetes Researcher Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran

7 Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, IR Iran

How to Cite: Djalalinia S, Kelishadi R, Qorbani M, Peykari N, Kasaeian A, et al. A Systematic Review on the Prevalence of Overweight and Obesity, in Iranian Children and Adolescents, Iran J Pediatr. 2016 ; 26(3):e2599. doi: 10.5812/ijp.2599.

ARTICLE INFORMATION

Iranian Journal of Pediatrics: 26 (3); e2599
Published Online: May 10, 2016
Article Type: Review Article
Received: May 27, 2015
Accepted: November 29, 2015
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Abstract

Context: Obesity has now become a common health problem worldwide. To gain insight into the epidemiology of the problem in Iran, we systematically reviewed all available studies on the prevalence of overweight and obesity in the Iranian pediatric population.

Evidence Acquisition: We systematically searched PubMed, ISI, SCOPUS, as well as Iranmedex, Irandoc, and Scientific Information Database (SID) databases.All studies on mean and standard deviation or percentile categories of BMI, WC, WHR, or WHtR or prevalence of obesity/overweight in Iranian child and adolescence, were performed from January 1990 to the end of December 2013. Refining processes were conducted by two independent reviewers. Quality assessment and data extraction followed based on validated form. As, these data were heterogeneous, meta-analysis was not performed.

Results: From 3253 records, through three refining steps, 129 articles were found related to our study. In Iran, national studies are limited and nearly there is no comprehensive study for sub-national trends. Different age and sex groups had large variations in the prevalence of obesity and overweight (from 1% up to 16.1% and from 4.4% up to 42.3% respectively for obesity and overweight).

Conclusions: Related data are very scattered or limited to some specific subgroups in some living areas. For comparing, aggregating, and imputing the information we need more modern practical statistical methods.

Keywords

Obesity Overweight Pediatrics Systematic Review

Copyright © 2016, Growth & Development Research Center. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Context

The global burden of disease (GBD) studies in 1990, 2000, and 2013 showed that metabolic risk factors (MRFs) are the most important determinants of emerging non-communicable diseases all over the world (1-8). Obesity has now become a common health problem and its prevalence continues to increase in both developed and developing countries (9-11). The increasing incidence of childhood obesity and its attributed socioeconomic and public health burden is a real threat for developing countries (12). Recent studies reveal the increasing rates of overweight and obesity and their attributed ranges of adverse health outcomes in children and adolescents (13, 14). Most obese children and adolescents already are at high risk for metabolic complications, and for a wide range of morbidities (15, 16). Moreover, there are some evidence on long-term premature mortality and physical morbidity in their adulthood (16, 17).

Despite priority of the problem, there is an evident gap in the related literature on these topics (11, 18). Even though there are a few studies on trend and point estimations of BMI trend and prevalence of obesity in Iranian pediatric population, there are little information about their exposure distribution at sub-national level and no information about their trends and their effects on the health (7, 12, 19). Most of available reports are scattered or limited to specific sub groups of population (9, 12).

Remarkably, the reported basal information on prevalence of overweight and obesity varies considerably from one study to another. They are recruited based on different measures from different target groups of different scopes with quite different age and sex distributions (9, 18), so that there is a growing need to prepare primary data to bridge health research to policy recommendations (18, 20). To address this issue, we need to provide comprehensive scientific evidence for triggering policy actions, controlling the programs, and measuring the effect of interventions (21).

Considering these, the main objective of our study was to systematically review of all available studies on the means and standard deviations of anthropometric measures including body mass index (BMI); waist circumference (WC); waist-hip ratio (WHR); and waist-to-height ratio (WHtR), or reported prevalence of obesity or overweight by sex, age, and year at national and sub-national levels from 1990 to 2013 in Iranian children and adolescents.

2. Evidence Acquisition

The design and protocol of the study have been described in more detail earlier (22, 23). Here we refer to some essential points in brief.

2.1. Outcomes Definition

The world health organization (WHO), U.S. centers for disease control and prevention, and international obesity task force each have presented different definitions of overweight and obesity in children and adolescents (24-27) (Table 1).

Table 1. Definitions of Overweight and Obesity in Children and Adolescents
OrganizationDefinition
World health organizationWHO child growth standards (birth to age 5); obesity: body mass index (BMI) > 3 standard deviations above the WHO growth standard median; overweight: BMI > 2 standard deviations above the WHO growth standard median; underweight: BMI < 2 standard deviations below the WHO growth standard median; WHO reference 2007 (ages 5 to 19); obesity: body mass index (BMI) > 2 standard deviations above the WHO growth standard median; overweight: BMI > 1 standard deviation above the WHO growth standard median; underweight: BMI < 2 standard deviations below the WHO growth standard median.
U.S. centers for disease control and preventionIn children ages 2 to 19, BMI is assessed by age- and sex-specific percentiles; obesity: BMI 95th percentile ≤; Overweight: BMI 85th < and ≤ 95th percentile; normal weight: BMI 5th < and ≤ 85th percentile; underweight: BMI < 5th percentile.
International obesity task forceProvides international BMI cut points by age and sex for overweight and obesity for children age 2 to 18. The cut points correspond to an adult BMI of 25 (overweight) or 30 (obesity).

2.2. Measures Definition

We have included studies that reported mean and standard deviation or percentile categories of BMI, WC, WHR, or WHtR or prevalence of obesity or overweight by sex, age, and year at national and sub-national levels in Iran, based on anthropometric measures. For each measure, the standardized protocols, definition and cut off were considered.

2.3. Search Strategy

To assess papers on obesity and/or overweight of Iranian children and adolescents, we searched PubMed and NLM Gateway (for MEDLINE), Institute of Scientific Information (ISI), and SCOPUS as the main international electronic data sources. Moreover Iranmedex, Irandoc, and scientific information database (SID), considered to the main domestic databases that have systematic search capability and the most coverage of national indexed or even non indexed Iranian scientific journals (Table 2). All Iranian scientific journals of medical universities that are not listed in the domestic electronic databases, governmental reports, projects reports, conferences and reference lists, were reviewed by hand searching. The Endnote version 11 reference manager software was used to manage the data.

Table 2. The Search Strategy
Search StrategyHigh Body Mass Index (BMI)/Waist Circumference/Waist-Hip Ratio Waist-to-Height Ratio
Search strategy in PubMed/Medline(“Body mass index” [Mesh] OR “Body Mass Index” [All Fields] OR “Overweight”[Mesh]) OR “Overweight” [All Fields] OR “Obesity” [Mesh] OR “Obesity” [All Fields] OR “Quetelet* Index” [All Fields] OR “Waist circumference “[Mesh] OR “Waist circumference” [All Fields] OR “Waist-hip ratio” [MeSH Terms] OR waist hip ratio [All Fields] OR “Waist to hip ratio” [MeSH Terms] OR waist to hip ratio [All Fields] OR waist to height ratio [All Fields]) AND (“Iran” [Mesh] OR “Iran” [All Fields]) OR Iranian [All Fields] OR I.R.Iran [All Fields] OR “I.R Iran” [All Fields] OR (“Persia” [MeSH Terms] OR “Persia” [All Fields])) AND ((“1985/01/01”[PDAT]: “2013/12/31”[PDAT]) AND “Humans”[MeSH Terms])
Search strategy in ISI Web of ScienceTime span = 1990 - 2013. Databases = SCI-EXPANDED, SSCI, CPCI-S, CPCI-SSH.Topic = (“Body Mass Index” OR “Overweight” OR “Obesity” OR “Quetelet* Index” OR “Waist Circumference” OR “Waist hip ratio” OR “Waist to hip ratio” OR “Waist-hip ratio” OR “Waist to height ratio”) AND (“Iran” OR Iranian OR I.R.Iran OR “persia”) OR Address= (Iran))
Search strategy in Scopus(TITLE-ABS-KEY (“Body Mass Index” OR “Overweight” OR “Obesity” OR “Quetelet* Index” OR “ Waist Circumference “ OR “Waist hip ratio “ OR “Waist to hip ratio” OR “Waist-hip ratio” OR “Waist to height ratio” OR “Waist-to- height ratio”)) AND (TITLE-ABS-KEY (Iran OR Iranian OR I.R.Iran OR Persia) OR (AFFIL (Iran)) AND PUBYEAR > 1989 AND PUBYEAR < 2013
IranMedex, SID and Irandoc“Body Mass Index”, “BMI”, “Overweight”, “Obesity”, “Quetelet* Index”, “Waist-hip ratio”, “Waist to ratio”, “Chaghi”, “Shakhesetudeh e badani”, “Ezafevazn”, “Dore kamar” , “Dore kamar be lagan”, “Dore kamar be basan”, “Dore kamar be ghad”, in combination with terms pediatr* OR child* OR adolescent OR student OR teenager OR boys OR girls koodak , atfal , nowjavan, daneshamooz, madreseh, madares, dokhtar, pesar in Persian language search.

We limited the search to national, provincial, district, community population based studies in Iranian children and adolescents (ages 6 - 18 years) and there was no restriction on language. Databases were searched from January 1990 to the end of December 2013.

2.4. National Data Source

We used the aggregated data of childhood and adolescence surveillance and prevention of adult non-communicable disease (CASPIAN) study as the main available national data source for the cardio metabolic risk factors of children and adolescents in Iran (28). Data were collected in four different surveys during 2003 to 2012 at the national and sub-national levels in Iran (20, 29-34).We assessed first, third, and fourth rounds data since second rounds of data were not available.

2.5. Study Selection and Eligibility Criteria

We excluded papers on non-population-based studies, or those with duplicate citations. The studies that focused on specific populations (such as school-based studies) were excluded. When there were multiple publications on the same population, only the largest study or the main source of data was included. We used GBD (global burden of diseases) validated quality assessment. Papers that had poor ratings were excluded and data were extracted from moderate and high quality studies. The quality assessment has been followed independently by two research experts and probable discrepancy between them resolved based on third expert opinion. Agreement was assessed using Cohen’s kappa statistic. The kappa statistic for agreement on quality assessment was 0.92.

2.6. Data Extraction

The data extraction sheet contained the following items: general information of study and its citation; population detailed characteristics; methodological information of designing and conduction of study (the study region, scope of study (local study or survey), total sample size, age and sex groups, urban/rural areas, cut-off point of prevalence, reported prevalence and its 95% confidence interval), and study outcomes indicators (age specific prevalence of overweight and/or obesity; body mass index mean; waist circumference mean; waist to hip ratio mean).

3. Results

We refined data for prevalence of obesity and overweight by sex, age, province, and year (n = 22972). Based on our search strategy we found 3253 records; of these 1875 were from international data bases and the remaining 1378 were obtained from national data bases. After removing duplicates, via the refining steps, only 129 articles were found related to our study domain. Figure 1 is a flowchart for the data collection and selection process.

Flowchart for the Data Collection and Selection Process
Figure 1. Flowchart for the Data Collection and Selection Process

Considering the inclusion and exclusion criteria, 62 articles that met our eligibility criteria were selected. From these, the extracted results of 53 papers are reported in Tables 3 - 10 and the others are shown with related information in Tables 11 - 13.

Table 3. [Part 1] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Aazami et al. (2012) (35)Kermanshah, local studyU2010CDC 2000CDC 2000
BothNA 9.3 ± 1.5140017.3 ± 3.117.14 - 17.4610.9 (10.39 - 11.41)13.4 (12.79 - 14.01)
MaleNA9.3 ± 1.575617.44 ± 3.217.21 - 17.6713.4 (12.57 - 14.23)12.6 (11.81 - 13.39)
FemaleNA9.3 ± 1.464417.11 ± 3.116.87 - 17.358.1 (7.53 - 8.67)14.3 (13.35 - 15.25)
Abdollahi et al. (2010) (36)Golestan, provencial studyU2005WHOWHO
Male17 - 7045.9 ± 14.76250026.48 ± 4.4426.31 - 26.6520.3 (19.67 - 20.93)42.3 (41.334 - 43.26)
Female43.4 ± 13.58250027.63 ± 5.5427.41 - 27.8530.7 (29.87 - 31.53)35 (34.11 - 35.8)
Ahmadi et al. (2010) (37)Kerman, local studyU2009>2SD of mean>2SD of mean
Both7 - 119 ± 1.4156616 ± 315.85 - 16.159.7 (9.27 - 10.13)4.4 (4.19 - 4.61)
MaleNA77016 ± 2.915.79 - 16.20NANA
FemaleNA79616.1 ± 3.115.88 - 16.32NANA
Akhavan-Karbasi et al. (2009) (38)Yazd, local studyU2006CDC 2000CDC 2000
Both6 - 6.9NA400NANA3.8 (3.29 - 4.31)4.3 (3.73 - 4.78)
MaleNA200NANA5.5 (4.78 - 6.22)5 (4.34 - 5.66)
FemaleNA200NANA2 (1.73 - 2.27)3.5 (3.03 - 3.97)
Mirzazadeh et al. (2000) (9)Tehran, local studyU2002CDC 2000CDC 2000
Both10 - 19NA421NANA3.8 (3.45 - 4.15)NA
Male177NANA5.1 - (4.39 - 5.81)NA
Female244NANA2.8 (2.46 - 3.14)NA

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 4. [Part 2] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Amanolahi et al. (2012) (39)Tehran, local studyUNAFemaleNA10.6 ± 0.711040NANACDC 2000NACDC 20008.65
Amidimazaheri et al. (2010) (40)Isfahan, local studyNANAFemale14 - 18NA384NANACDC 20001.03 (0.93 - 1.13)CDC 20009.1 (8.27 - 9.93)
Amini et al. (2007) (41)Tehran, local studyU2001CDC 2000CDC 2000
Both10 - 1512.6 ± 0.939619.8 ± 3.819.43 - 20.1710 (9.11 - 10.88)16 (14.68 - 17.32)
Male12.7 ± 0.919919.7 ± 419.14 - 20.2613 (11.43 - 14.57)14 (12.33 - 15 - 67)
Female12.5 ± 0.919719.9 ± 3.719.38 - 20.426.5 (5.65 - 7.35)19 (16.85 - 21.15)
Aminzadeh et al. (2013) (42)Ahvaz, local studyU2010CDC 2000CDC 2000
Both6 - 10NA1594NANA17.7 (16.98 - 18.41)18.8 (18.05 - 19.55)
Male835NANA14.65 (13.80 - 15.50)16.7 (15.76 - 17.64)
Female759NANA 21.08 (19.90 - 22.26)21.74 (20.53 - 22.95)
Asadi Noghabi et al. (2011) (43)Bandarabbas, local studyUNACDC 2000CDC 2000
Male7 - 11NA661NANA10.9 (10.16 - 11.64)10 (9.31 - 10.69)
FemaleNA6896.2 (5.77 - 6.63)12.8 (11.97 - 13.63)
Azimi-Nezhad et al. (2009) (44)Khorasan-Razavi, provencial studyBoth2004WHOWHO
Male15 - 20NA28020.64 ± 3.4520.24 - 21.04NANA
FemaleNA26021.47 ± 3.3421.06 - 21.88NANA

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 5. [Part 3] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Bazhan et al. (2005) (45)Lahijan, local studyU2001Female14 - 17NA40021.9 ± 3.521.56 - 22.24CDC 20005.3 (4.81 - 5.79)CDC 200014.8 (13.56 - 16.04)
Bidad et al. (2008) (46)Tehran, local studyU2005Female11 - 1714 ± 1.840020.61 ± 3.7920.24 - 20.98CDC 20006.7 (6.09 - 7.31)CDC 200014.6 (13.38 - 15.82)
Baygi et al. (2010) (47)Neishabour, local studyU2005CDC 2000CDC 2000
Both6 - 12NA1471NANA4.6 (4.38 - 4.82)NA
MaleNA822NANANANA
FemaleNA649NANANANA
Gargari et al. (2004) (48)Tabriz, local studyU2001Female14 - 17.916 ± 1.4151821.3 ± 3.621.12 - 21.48CDC 2000NACDC 2000NA
Gharakhanlou et al. (2012) (49)National studyU2011WHOWHO
Male15 - 19NA1393.1 ± 21.420.88 - 21.922.8 (2.35 - 3.25)9.3 (7.90 - 10.70)
FemaleNA14521.9 ± 3.821.28 - 22.522.7 (2.27 - 3.13)12.4 (10.63 - 14.17)
Haeri Behbahani et al. (2009) (50)Sabzevar, local studyU2007CDC 2000CDC 2000
Both6 - 11NA96016.6 ± 2.816.42 - 16.786 (4.5 - 7.6)8.4 (6.7 - 10.2)
NA84016.3 ± 2.616.12 - 16.483.5 (2.2 - 4.7)7.4 (5.6 - 9.2)
Hajian et al. (2008) (51)Babol, local studyU2006Both7 - 12NA1000NACDC 20005.8 (5.46 - 6.14)CDC 200012.3 (11.63 - 12.97)
Hajian-Tilaki et al. (2011) (52)Babol, local studyU2006CDC 2000CDC 2000
Both7 - 129.3 ± 1.51000NANA5.8 (5.46 - 6.14)F: 3.812.3 (11.63 - 12.96)M: 12.5F:
MaleNA45016.8 ± 3.416.49 - 17.148.8 (8.06 - 9.54) (7 - 9 yo: 8.77) (10 - 12 yo: 10.43)12.5 (11.49 - 13.51) (7 - 9 yo: 12.23) (10 - 12 yo: 11.15)
FemaleNA55016.7 ± 2.816.47 - 16.933.8 (3.46 - 4.11) (7 – 9 yo:5.02) (10 - 12 yo: 2.99)12.2 (11.30 - 13.09) (7 - 9 yo: 9.9) (10 - 12 yo: 16.54)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 6. [Part 4] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Hajian-Tilaki et al. (2012) (53)Babol, local studyUNACDC 2000CDC 2000
Both12 - 17NA1200NANA8.3 (7.87 - 8.73)15.1 (14.37 - 15.82)
MaleNANA10.2NA
FemaleNANA6.5NA
Janghorbani et al. (1998) (54)Kerman, local studyU1995Female14 - 1816.2 ± 1.3100019.8 ± 2.919.62 - 19.98WHO5.3 (4.99 - 5.61)WHO21.9 (20.84 - 22.96)
Karandish et al. (2004) (55)Tehran, local studyU2000CDC 2000CDC 2000
Both11 - 16NA2486NANANANA
Male13.7 ± 1.54114719.8 ± 3.9519.57 - 20.037.3 (6.91 - 7.69)23.3 (22.27 - 24.33)
Female13.4 ± 1.64133920.63 ± 4.1120.41 - 20.858.3 (7.89 - 8.71)18.8 (17.98 - 19.62)
Kelishadi et al. (2003) (56)Isfahan, Markazi local studyBoth2001CDC 2000CDC 2000
Both11 - 18NA2000U: 25.4 ± 5.2 R: 23.2 ± 7.1U: 24.29 - 26.51R: 22.76 - 23.64NANA
MaleNA10001.87 (1.79 - 1.95)7.4 (7.10 - 7.70)
FemaleNA10002.9 (2.73 - 3.07)10.7 (10.11 - 11.29)
Khadivzadeh et al. (2002) (57)Mashad, local studyU1998Female15 - 19NA440NANACDC 20001.8 (1.63 - 1.97)CDC 20005.8 (5.29 - 6.31)
Maddah (2007) (58)Guilan, local studyU2005Female14 - 17NA1054NANAF: 5.2 (4.90 - 5.50)18.6 (17.69 - 19.51)
Maddah et al. (2010) (59)Rasht, local studyU2007CDC 2000CDC 2000
Both6 - 11NA6635NANANANA
Male35515 (4.89 - 5.11)11.5 (11.26 - 11.74)
Female30845.9 (5.72 - 6.08)15 (14.58 - 15.42)
Maddah et al. (2010) (60)Zahedan, local studyUNACDC 2000CDC 2000
Both7 - 11NA1079NANANAM: 8.9 F: 10.3
Male500NANA8.9 (8.42 - 9.38)
Female579NANANA10.3 (9.49 - 11.11)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 7. [Part 5] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Mehrkash et al. (2010) (61)Gorgan, local studyUNACDC 2000CDC 2000
Both15 - 18NA450NANANANA
Male15.66 ± 0.6822521.24 ± 3.4520.79 - 21.69NANA
Female16.34 ± 0.7722522.41 ± 4.3221.85 - 22.97NANA
Mirhosseini et al. (2009) (62)Mashhad, local studyUNAFemale15 - 1716.4 ± 0.0962220.7 ± 3.613.5 - 36.9NANANANA
Mirmiran et al. (2004) (63)Tehran, local studyU
1999Both6 - 16NA732NANACDC 20004.5 (4.19 - 4.81)CDC 2000NA
1999Male339NA5.5 (4.95 - 6.05)NA
1999Female393NA3.7 (3.35 - 4.05)NA
2002Both6 - 16NA673NANACDC 20005.7 (5.29 - 6.11)CDC 2000NA
2002MaleNA3126.3 (5.64 - 6.96)
2002FemaleNA3615.2 (4.69 - 5.71)
Moayeri et al. (2006) (64)Tehran, local studyU2005CDC 2000CDC 2000
Both11 - 18NA2880NANA7.1 (6.72 - 7.48)17.9 (17.06 - 18.74)
NA1180NANA7.8 (7.54 - 8.06)21.1 (20.49 - 21.71)
NA1700NANA6.4 (6.12 - 6.68)14.7 (14.10 - 15.30)
Mohammadpour-Ahranjani et al. (2003) (65)Tehran, local studyU2001CDC 2000CDC 2000
Male11 - 1613.7 ± 1.54106819.8 ± 3.9519.56 - 20.047.3 (6.89 - 7.71)18.8 (17.88 - 19.72)
Female13.4 ± 1.54125320.6 ± 4.1120.37 - 20.838.3 (7.88 - 8.72)23.1 (22.12 - 24.08)
Mojibian et al. (2001) (66)Yazd, local studyU2000Female15 - 65NA570NANAWHO16.3 (15.18 - 17.42)CDC 200011.8 (10.15 - 13.45)
Montazerifar et al. (2009)(67)Sistan va Baluchistan, local studyU2006CDC 2000CDC 2000
Female14 - 1816.4 ± 1.375220 ± 1.45NA1.5 (1.39 - 1.61)F: 8.6 (8.04 - 9.16)
Zahedan, local study2007Female11 - 1413 ± 0.896871.7 (1.58 - 1.82)8.7 (8.11 - 9.29)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 8. [Part 6] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Montazerifar et al. (1999) (68)Yazd, local studyU1998CDC 2000CDC 2000
Both7 - 11NA463NANA3.9 (3.56 - 4.24)NA
MaleNA230NANA4.3 (3.77 - 4.83)NA
FemaleNA223NANA3.4 (2.98 - 3.82)NA
Mostafavi et al. (2005) (69)Shiraz, local studyU2002CDC 2000CDC 2000
Both13 - 18NA803NA2.9 (2.51 - 3.29)11.3 (9.91 - 12.69)
MaleNANA19.4 ± 3.418.93 - 19.87NANA
FemaleNANA20.6 ± 3.820.07 - 21.13NANA
Mozaffari et al. (2007) (70)Tehran, local studyU2002Female7 - 129.67 ± 3.51800NANACDC 20007.7 (7.37 - 8.03)CDC 200013.3 (12.77 - 13.83)
Mozaffari et al. (2004) (71)Yazd, local studyU2003NCHSNCHS
Both6 - 12NA4755NANA3.5 (3.40 - 3.60)NA
MaleNA2948NANA1.0 (0.96 - 1.04)NA
FemaleNA1807NANA7.6 (7.28 - 7.92)NA
Pourghasem et al. (2002) (72)Tabriz, local studyUNAFemale14 - 18NA1518NANACDC 20003.6 (3.43 - 3.77)CDC 200011.1 (10.60 - 11.59)
Rafraf et al. (2010) (73)Tabriz, local studyU2008Female14 - 1715.67 ± 1.0198521.28 ± 3.521.06 - 21.50CDC 20002. (2.63 - 2.97)CDC 200016.4 (15.54 - 17.26)
Rashidi et al. (2007) (74)Tehran, local studyU2001CDC 2000CDC 2000
Male11 - 1613.7 ± 1.54106819.8 ± 420.37 - 20.837.3 (6.89 - 7.70)18.8 (17.88 - 19.72)
Female13.4 ± 1.64125320.6 ± 4.117.75 - 18.058.3 (:7.87 - 8.72)23.1 (22.12 - 24.08)
Sadeqipoor et al. (1999) (75)Tehran, local studyU1996Female11 - 14NA350NANACDC 200013.7 (12.46 - 14.94)CDC 2000NA
Salem et al. (2009) (76)Kerman, local studyU2007CDC 2000CDC 2000
Female11 - 1814.3 ± 1.71221NANAF: 2.4(2.27 - 2.53)(11 - 14 yo: 3.3)(15 - 18 yo: 1.3)F: 11.2 (10.64 - 11.76) (11 - 14 yo: 11.9)(15 - 18 yo: 10.8)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 9. [Part 7] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeaSample Size, nBMIaCI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Salem et al. (2011) (77)Kerman, local studyU2009CDC 2000CDC 2000
MaleNANA50016.78 ± 3.7616.45 - 17.11NA10.2 (9.40 - 11.00)
FemaleNANA77517.25 ± 3.3317.02 - 17.48NA8.9 (8.33 - 9.47)
Saffari et al. (2011) (78)Qazvin, local studyU2010Female6 - 14NA220117.9 ± 3.7 (6 - 9 yo: 16.10) (10 - 14 yo: 19.1(5)NACDC 2000NACDC 2000NA
Sohailifar et al. (2000) (79)Hamadan, local studyU1998NCHSNCHS
Both11 - 16NA2000NANA3.5 (3.35 - 3.65)NA
MaleNA1000NANA4 (3.76 - 4.24)NA
FemaleNA1000NANA7.2 (6.79 - 7.61)NA
Sotoodeh et al. (1997) (80)Hassanabad Khaleseh of Eslamshahr, local studyR1994Female15 - 19NA3522.5NACDC 2000NACDC 2000NA
Taheri et al. (2009) (81)Birjand, local studyU2005CDC 2000CDC 2000
Both15 - 18NA2230NANA2.2 (2.11 - 2.29)6.2 (5.96 - 6.44)
MaleNA1115NANA2.8 (2.64 - 2.96)5 (4.72 - 5.28)
FemaleNA1115NANA1.8 (1.70 - 1.90)7.1 (6.71 - 7.49)
Taheri et al. (2013) (82)Birjand, local studyU2012CDC 2000CDC 2000
Both6 - 11NA1541NANA9.2 (8.78 - 9.62)9.6 (9.17 - 10.03)
NA69016.9NA10.9 (10.18 - 11.62)11 (10.27 - 11.73)
NA85116.3NA7.9 (7.41 - 8.39)8.3 (7.79 - 8.81)
Veghari et al. (2010) (83)Golestan, local studyBoth2006Both15 - 24NA49922.822.3 - 23.4CDC 20005.1 (4.67 - 5.52)CDC 200024.2 (22.59 - 25.81)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 10. [Part 8] The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)
ReferenceLocationUrban/RuralYear of StudyGenderAge-group, yAgeSample Size, nBMICI 95% BMI MeanObesity DefinitionPrevalence of Obesity/CI 95%Over Weight DefinitionPrevalence of Over Weight/CI 95%
Veghari et al. (2012) (84)Golestan, local studyBoth2008CDC 2000CDC 2000
Both15 - 6539.6 ± 14.36489:NANA23 (22.39 - 23.61)31.5 (30.76 - 32.2)
MaleNA324525 ± 4.824.88 - 25.1214.1 (13.68 - 14.52)32.4 (31.65 - 33.15)
FemaleNA324427.5 ± 6.127.29 - 27.7131.8 (31.27 - 32.33)30.5 (29.98 - 31.02)
Kelishadi et al. (85)CASPIAN I, national studyBoth2004CDC 2000CDC 2000
Both6 - 1812.27 ± 3.3220,96618.42 ± 3.8718.42 - 3.83.42 (3.17 - 3.67)10.96 (10.54 - 11.39)
Male12.27 ± 3.310,79318.26 ± 3.8318.26 ± 3.833.34 (3.00 - 3.69)9.70 (9.14 - 10.27)
Female12.27 ± 3.3410,17318.60 ± 3.9118.60 ± 3.913.50 (3.15 - 3.87)12.30 (11.66 - 12.95)
Kelishadi et al. (30)CASPIAN III, national studyBoth2010CDC 2000CDC 2000
Both10 - 1814.27 ± 24562519.42 ± 4.0919.31 - 19.538.91 (8.17 - 9.68)8.02 (7.32 - 8.75)
Male14.68 ± 24282419.61 ± 4.1219.45 - 19.7610.13 (9.03 - 11.29)9.38 (8.33 - 10.51)
Female14.76 ± 23280119.23 ± 4.0619.08 - 19.387.68 (6.71 - 8.72)6.64 (5.74 - 7.62)
Khashayar et al. (2013) (86)CASPIAN IV, national studyBoth2012CDC 2000CDC 2000
Both6 - 1812.47 ± 3.3613,35018.85 ± 4.4218.70 - 18.9911.89 (11.22 - 12.59)9.66 (9.13 - 10.21)
Male12.36 ± 3.39677718.73 ± 4.4218.53 - 18.9413.58 (12.59 - 14.63)9.27 (8.56 - 10.05)
Female12.58 ± 3.32657318.97 ± 4.3918.76 - 19.1710.15 (9.27 - 11.09)10.06 (9.30 - 10.86)

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 11. [Part 1] The WHR, WC, and WHtR Mean and Abdominal Obesity in Population-Based Studies in Iranian Children and Adolescents
ReferenceLocationUrban/RuralYear of StudyGenderAge - group, yAgeaSample Size, nWHRaCI 95% WHR MeanPrevalence of Abdominal Obesity, %WCaCI 95% WC meanWHtRaCI 95% WHtR Mean
Amini et al. (2007) (41)TehranU
2001Both10 - 1512.6 ± 0.93950.8 ± 0.070.79 - 0.81NANANANANA
2001Male12.7 ± 0.91970.83 ± 0.060.82 - 0.84NANANANANA
2001Female12.5 ± 0.91980.77 ± 0.060.76 - 0.78NANANANANA
Azimi-Nezhad et al. (2009) (44)Khorasan- RazaviBoth
2004Both15 - 20NA540NANANANANANANA
2004MaleNANA280NANANA74.63 ± 12.5473.16 - 76.10.43 ± 0.070.42 - 0.44
2004FemaleNANA260NANANA70.09 ± 10.668.80 - 71.380.47 ± 0.060.46 - 0.48
Gharakhanlou et al. (2012) (49)National studyU
2011Male15 - 19NA1390.82 ± 0.050.81 - 0.83NA-74.5 ± 8.973.02 - 75.980.43 ± 0.060.42 - 0.43
2011FemaleNANA1450.78 ± 0.060.77 - 0.79NA7.2.7 ± 9.071.24 - 74.160.45 ± 0.070.44 - 0.46
Hosseini-Esfahani et al. (2011) (87)TehranU
2001Male10 - 1412.4 ± 1688NANANANA64.9 ± 11764.08 - 65.72NA
2001Male15 - 1916.8 ± 1734NANANANA3.9 ± 1173.10 - 74.70NA
2005Male10 - 1412.2 ± 1190NANANANA72.6 ± 1370.75 - 74.45NA
2005Male15 - 1917.1 ± 1346NANANANA80.4 ± 1279.14 - 81.66NA
2008Male10 - 1412.2 ± 1230NANANANA71.3 ± 1369.62 - 72.98NA
2008Male15 - 1917.2 ± 1287NANANANA81.5 ± 1379.97 - 83.03NA
2001Female10 - 1412.3 ± 1675NANANANA66.9 ± 966.22 - 67.58NA
2001Female15 - 1917.0 ± 1913NANANANA72.5 ± 971.92 - 73.08NA
2005Female10 - 1412.3 ± 1214NANANANA68.5 ± 1067.16 - 69.84NA
2005Female15 - 1917.3 ± 1357NANANANA73.3 ± 972.37 - 74.23NA
2008Female10 - 1412.3 ± 1231NANANANA66.9 ± 1065.61 - 68.19NA
2008Female15 - 1917.2 ± 1351NANANANA71.3 ± 970.36 - 72.24NA

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 12. [Part 2] The WHR, WC, and WHtR Mean and Abdominal Obesity in Population-Based Studies in Iranian Children and Adolescents
ReferenceLocationUrban/RuralYear of StudyGenderAge - group, yAgeSample Size, nWHRCI 95% WHR MeanPrevalence of Abdominal Obesity, %WCCI 95% WC meanWHtRCI 95% WHtR Mean
Janghorbani et al. (1998) (54)KermanU1995Female14 - 1816.2 ± 1.310000.8 ± 0.060.8 - 0.81NANA70.8 ± 8.070 - 71.0NA
Janghorbani et al. (2007) (88)NationalBoth
2005Male15 - 2423.9 ± 0.15vNANA3.2NANANANA
2005FemaleNA24.9 ± 0.18NANANA18.1- - - -
Mehrkash et al. (2010) (61)National studyU
NABoth15 - 1815.66 ± 0.68225NANANANA75.24 ± 8.7674.43-76.05NA
NABothNA16.34 ± 0.77225NANANANA79.85 ± 10.3578.50-81.20NA
Mirhosseini et al. (2009) (62)Mashhad, Local studyUNAFemale15 - 1716.4 ± 0.096220.7 ± 0.040.69 - 0.709.5NA69 ± 7.868.39 - 69.61NA
Sotoodeh et al. (80)HassanabadKhaleseh of Eslamshahr, Local studyR
1994Female15 - 19NA2050.78NANANANANANA

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Table 13. [Part 3] The WHR, WC, and WHtR Mean and Abdominal Obesity in Population-Based Studies in Iranian Children and Adolescents
ReferenceLocationUrban/RuralYear of StudyGenderAge - group, yAgeSample Size, nWHRCI 95% WHR MeanPrevalence of Abdominal Obesity, %WCCI 95% WC meanWHtRCI 95% WHtR Mean
Kelishadi et al. (1997) (85)CASPIAN I, National studyBoth
2004Both6 - 1812.27 ± 3.3220,9660.43 ± 0.060.429 - 0.4319.27(8.87-9.67)64.61 ± 10.9164.46 - 64.760.80 ± 0.080.805 - 0.807
2004MaleNA12.27 ± 3.310,7930.43 ± 0.060.427 - 0.4299.14(8.60-9.69)64.99 ± 11.4164.78 - 65.210.82 ± 0.090.817 - 0.821
2004FemaleNA12.27 ± 3.3410,1730.44 ± 0.060.431 - 0.4339.41(8.84-9.99)64.21 ± 10.3464.01 - 64.410.79 ± 0.080.791 - 0.794
Kelishadi (2012) et al. (30)CASPIAN III, National studyBoth
2010Both10 - 1814.27 ± 2456250.44 ± 0.130.442 - 0.448NA68.72 ± 20.6768.1 - 69.2NANA
2010MaleNA14.68 ± 2428240.44 ± 0.140.439 - 0.449NA67.59 ± 22.1666.7 - 68.4NANA
2010FemaleNA14.76 ± 2328010.44 ± 0.120.441 - 0.450NA69.86 ± 18.9969.1 - 70.5NANA
Khashayar (2013) et al. (86)CASPIAN IV, National studyBoth
2012Both6 - 1812.47 ± 3.3613,3500.45 ± 0.060.454 - 0.45819.12(18.22-20.06)67.02 ± 11.9666.57 - 67.480.18 ± 0.030.184 - 0.187
2012Male12.36 ± 3.3967770.46 ± 0.060.456 - 0.46120.41(19.09-21.79)67.83 ± 12.8467.15 - 68.510.19 ± 0.030.189 - 0.192
2012Female12.58 ± 3.3265730.45 ± 0.060.452 - 0.45717.79(16.56-19.09)66.19 ± 10.9265.62 - 66.760.18 ± 0.030.179 - 0.183

Abbreviation: CI, confidence interval; F, female; M, male; NA, not available; R, rural; R, rural total; T, total; U, urban; UT, urban total; y, year.

aValues are expressed as mean (SD).

Tables 3 - 10 shows the prevalence of obesity based on BMI, in eligible population-based studies in Iranian children and adolescents. Also for more precise comparison, the confidence interval for 95% significance level (CI 95%) was calculated for possible cases. We have also included each study designed.

Considering the systematic review results; the number of total population and points of data were 22972 and 29, 38985 and 47 respectively for boys and girls. There were 5 studies that did not report BMI separately for boys and girls. As well as regarding the geographically distribution we found, 9 national, 14 provincial , and 58 district level points of data.

The findings are scattered, with very wide ranges of values for BMI and for rates of obesity and overweight. On the other hand, non-standard classifications of age groups led to greater complexity in estimation of values. For instance, information about elementary school students was provided with at least 6 different age categories including: 6 - 10, 6 - 11, 6 - 12, 6 - 14, 7 - 11, and 7 - 12. The lowest rate of obesity in this age group was 3.5% which was reported in Yazd and Sabzevar (9, 38, 50) and the highest rate of 17.7% was in Ahvaz (42). Similarly there were different reports for 10 - 15 year olds; based on one of them 13% of boys and 6.5% of girls in Tehran province were obese (41), in another study via the refining steps, only 129 articles were found related to our study domain in the same province reported 7.5% and 7.3% respectively for boys and girls (55). In 15 - 19 year old group, the prevalence of obesity was 2.8% for boys and 1.7% for girls (49, 57).

In Tables 11 - 13, the WHR, WC, and WHtR mean in population-based studies in Iranian children and adolescents reported based on papers data availability.

Tables 11 - 13 include only 9 papers with information on WHR, WC, or WHtR that met the study eligible criteria. The aggregated data CASPIAN studies are presented as the main source of national data.

Based on the first CASPIAN study in 2004, the national prevalence of abdominal obesity was 9.27 (8.87% - 9.67%) for both sexes, 9.14 (8.60% - 9.69%) for males, and 9.41 (8.84% - 9.99%) for females. In the last estimation for 2012 these were increased respectively to 19.12 (18.22% - 20.02%), 20.41 (19.09% - 23.05%), and 17.79 (16.56% - 19.02%). In similar time period, the national mean of WC from 64.61 (64.46 cm - 64.76 cm) rose to 67.02 (66.57 cm - 67.48 cm).

4. Discussion

This review of our finding, similar to some regional and global studies, provides alarming evidence-based data on the considerable prevalence of childhood and adolescents overweight (9, 12, 16, 17). In Iran national studies, especially in pediatric groups, are limited and nearly there is no comprehensive study for sub-national trends. Considering the results of CASPIAN, as the only valid national study; in 2004, the national prevalence of obesity for 6 - 18 year olds male and female was respectively 3.34 (3% - 3.69%) and 3.50 (3.15% - 3.87%). In 2010 these estimations respectively rose to 13.58 (12.59% - 14.63%), and 7.68 (6.71% -8.72%). In the last estimation for 2012 these were increased to; 13.58 (12.59% - 14.63%), and 10.15 (9.27% - 11.09%).

Different age and sex groups had large variations in the prevalence of obesity and overweight. As a considerable point; there are also a lot of missing data for different sub groups which is leading from the misclassification or other limitation of research papers’ data presentation (89, 90). Some of these diversities are attributed to the geographical scopes of studies; some estimations belong to local level studies, some others estimate district level and others are designed for national estimations. Moreover, the quality of presented data, and some methodological problems, in designing and conducting the related researches, were other sources of diversity (30, 32, 85). There are also some visible data lags in some areas of country or for different target groups that should be more considered for future studies’ plan. For all measures however the reports have significant missing in reporting the confidence intervals for both measures values’ and obesity/overweight rates, which limited our ability to compare and analyze results. On the other hand, most of our efforts to contact study authors for requesting more data and information failed.

In Iran there are few national studies and nearly no comprehensive study for sub-national trends (91-93). In comparison with other related studies, compared with the GBD studies with overall 102 points of data, we benefit from more data driven estimations rather than the model driven results. We will provide more data points that lead to higher quality of estimation (1, 4-8, 19). This is the first comprehensive systematic approach to search and data gathering, during which we benefited from the highest level of access to the published, available unpublished and grey literature through the comprehensive hand searching process. We had access to main national sources of CASPIAN study (30, 32, 85).

Considering previous studies, the present study has several achievements. This study presents the most scientific evidences for the prevalence and trends of obesity and overweight in pediatric population from 1990 to 2013. We benefited from all available sources of data alongside the advanced comprehensive search strategies. All of domestic data bases were searched exactly with all of English/Persian equivalent search terms.

Because of scarcity of data, variations in groups studied, differences in living areas (urban/rural), discrepancy of the measures, for comparing and aggregating the information, we need more modern practical statistical methods (9, 12). These methods are advanced regression models, using existing data, benefit from models for age, hierarchical pattern of data, spatial and temporal pattern of data, and covariates (94, 95).

The present study summarized the information of studies on mean and standard deviation of different measures including BMI, WC, WHR, or WHtR and reported prevalence of obesity or overweight by sex, age, and year at national and sub-national levels from 1990 to 2013 in Iranian children and adolescents.

Obesity seems to be one of the major public health problems. Considering that, several methods have been proposed in the field of medical and surgical treatments. In this context, recent promising approaches emphasize on the population based interventions impacts (96). Aiming that, we call for a sustained valid data sources to monitor, prevent, and control of pediatric overweight and obesity. These processes should be followed through ongoing community-based lifestyle intervention on diet, physical activity promotion, and other local and national experiences (31, 56, 87, 97). Evidences reveal that for more effectiveness, these interventions should be started and exactly followed from the adolescence (12, 23, 96).

Health researchers, professionals and policy-makers should focus on more evidence based policies which require more reliable data. Aiming that, all processes of designing; conducting; monitoring; and distribution of data should be managed based on advanced scientific methods (18, 98).

4. Conclusions

In conclusion, the present findings could provide practical information on children and adolescents’ overweight and obesity for better health policy and more detailed design studies in this area. Because of the importance of application of researches’ data more policy attention should be considered for more efficient papers’ data presentation. The presented results also could be used for future complementary sub-national, national or even global related studies.

Acknowledgements

Footnote

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