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Iran J Pediatr. 2015 June; 25(3):e401. DOI: 10.5812/ijp.25(3)2015.401
Published online 2015 June 27. Research Article
Prevalence of General and Abdominal Obesity in a Nationally Representative
Sample of Iranian Children and Adolescents: The CASPIAN-IV Study
Haleh Esmaili 1; Maryam Bahreynian 1; Mostafa Qorbani 2,3; Mohammad Esmaeel Motlagh 4;
Gelayol Ardalan 5; Ramin Heshmat 6; Roya Kelishadi 5,*
1Department of Nutrition, Child Growth, Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of
Medical Sciences, Isfahan, IR Iran
2Department of Public Health, Alborz University of Medical Sciences, Karaj, IR Iran
3Department of Epidemiology, Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences,
Tehran, IR Iran
4Department of Pediatrics, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
5Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Diseases, Isfahan University of
Medical Sciences, Isfahan, IR Iran
6Chronic Diseases Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
*Corresponding author: Roya Kelishadi, Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-
communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran. Tel: +98-3137923077, Fax: +98-3136687898, E-mail: kelishadi@med.mui.ac.ir
Received: December 23, 2014; Revised: May 26, 2015; Accepted: May 29, 2015
Background: Pediatric obesity is one of the predisposing risk factors for many non-communicable diseases.
Objectives: The purpose of this study was to estimate the national prevalence of general and abdominal obesity among Iranian children
and adolescents.
Patients and Methods: This cross-sectional nation-wide study was performed in 30 provinces in Iran among 14880 school students aged
6 – 18 years, selected by multistage random cluster sampling. The World Health Organization growth curve was used to categorize Body
Mass Index (BMI). Obesity was defined as BMI equal to or higher than the age- and gender-specific 95th percentile; abdominal obesity was
considered as waist-to-height ratio of more than 0.5.
Results: Data of 13486 out of 14880 invited students were complete (response rate of 90.6%). They consisted of 6543 girls and 75.6% urban
residents, and had a mean age of 12.45 (95% CI: 12.40 - 12.51) years. The prevalence rate of general and abdominal obesity was 11.89% (13.58% of
boys vs. 10.15% of girls) and 19.12% (20.41% of boys vs. 17.79% of girls), respectively. The highest frequency of obesity was found in the middle
school students (13.87% general and 20.84% abdominal obesity). The highest prevalence of general obesity was found in Boushehr (19%)
followed by Guilan and Mazandaran (18.3%, 18.3%), while the lowest prevalence was observed in Hormozgan (2.6%). The highest frequency
of abdominal obesity was found in Mazandaran (30.2%), Ardabil (29.2%) and Tehran (27.9%). Provinces such as Sistan-Baloochestan (8.4%),
Hormozagan (7.4%), and Kerman (11.4%) had the lowest prevalence of abdominal obesity. The Southern and South Eastern provinces had
the lowest prevalence of general obesity (2.6% and 5.6%) and abdominal obesity (7.4% and 8.8%). Moreover, the highest prevalence of obesity
was found in North and North West Iran by maximum frequency of 18.3% general obesity and 30.2% of abdominal obesity.
Conclusions: The results showed a high prevalence of general and abdominal obesity among boys living in the Northern provinces of
Iran. The present study provides insights that policy makers should consider action-oriented interventions for prevention and control of
childhood obesity at national and sub-national level.
Keywords: Overweight; Obesity; Prevalence; Child; Adolescent; Iran
Copyright © 2015, Growth & Development Research Center. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-
Commercial 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. Background
Obesity and being overweight are increasing rapidly
in the developed and developing countries (1, 2). It is es-
timated that by 2030 up to 57.8% of the world’s adults
would suffer from being overweight or obese (2). Along
with adulthood obesity, childhood obesity has also
emerged as an epidemic health problem in both devel-
oped and developing countries (3, 4). Increase in popu-
lation size and age and urbanization and a noticeable
change in lifestyle had led to an elevated overweight and
obesity, especially in developing countries (2). Iran, as a
developing country, has been undergoing a rapid phase
of urbanization and lifestyle changing especially vis-a-vis
nutrition transition in the past few decades, contribut-
ing to increasing prevalence of obesity (5, 6). The prob-
lem of obesity has not only effected the adults’ life, but
the health condition of children. Childhood abdominal
obesity would lead not to only obstructive sleep apnea
with subsequent increase in the accumulation of carbon
dioxide, but an increase in the prevalence of high blood
pressure and fatty liver (7, 8). Central obesity could serve
as a leading cause of type 1 diabetes and higher levels of
LDL-cholesterol (7, 9, 10). Moreover, it can be associated
with a low bone mass especially among adolescents and
increased risk of allergic diseases in childhood (11-13).
It can be argued that obesity in children and adolescents
connects with adiposity in adulthood and consequently
Esmaili H et al.
Iran J Pediatr. 2015;25(3):e4012
might increase the prevalence of several non-communi-
cable chronic diseases (NCDs) including type 2 diabetes
and cardiovascular diseases at much earlier stage of life
(1, 14). Therefore, it is important to track the prevalence of
obesity among children and adolescents, as this informa-
tion is essential for local and public health programming
and health policies.
2. Objectives
This study aimed to present the national estimation of
general and abdominal obesity among a nationally rep-
resentative sample of Iranian children and adolescents.
3. Patients and Methods
The data of this study were collected as a part of the “na-
tional survey of school student high risk behaviors” (2011
- 2012), as the fourth survey of the school-based surveil-
lance system entitled Childhood and Adolescence Sur-
veillance and PreventIon of Adult Non-communicable
Disease (CASPIAN-IV) study. This school-based nationwide
health survey was conducted in 30 provinces of Iran. De-
tails on the study protocol have been defined before (15),
and herein we report it in brief.
3.1. Study Population and Sampling Framework
The study population consisted of 14,880 school stu-
dents, aged 6 - 18. They were selected by multistage, clus-
ter sampling method from urban and rural areas of dif-
ferent cities in 30 provinces of the country (48 clusters
of 10 students in each province). Stratification was ex-
ecuted in each province according to the residence area
(urban/rural) and school grade (elementary/intermedi-
ate/high school). The sampling was proportional to size
with equal sex ratio, namely, a selection of boys and girls
from each province in equal numbers, and the ratios in
urban and rural areas corresponded to the population of
students in those related sites. In this way, the number
of samples in rural/urban areas and in each school grade
was divided equally to the population of students in each
grade. Cluster sampling with equal clusters was used in
each province to scope the required sample size. Clusters
concluded the level of schools, including 10 sample units
(students and their parents) in each cluster. The maxi-
mum sample size that could provide a proper estimate
of all risk factors of interest was selected resulting in the
sample size of 480 students in each province. Therefore, a
total of 48 clusters of 10 subjects in each of the provinces,
and a total of 14,880 students were selected.
3.2. Assessment of Anthropometric Measures
Information about weight, height, and waist circumfer-
ence was recorded by trained health care professionals un-
der standard protocol and by using zero-calibrated instru-
ments. Weight was measured to the nearest 200 g shoeless
and lightly dressed condition. Height was measured in
standing position, barefoot and shoulders touching the
wall and recorded to the nearest 0.2 cm (16). Body Mass In-
dex (BMI) was calculated as weight (Kg) divided by height
squared (m²). Waist Circumference (WC) was measured
by a non-elastic tape and recorded to the nearest 0.2 cm
at the end of expiration at the midpoint between the top
of iliac crest and the lowest rib in standing position. The
World Health Organization (WHO) growth curve was used
to categorize BMI [15]. In the current study, overweight and
obesity were defined as the age- and gender-specific BMI
of 85th -94th percentiles and equal or higher than the 95th
percentile, respectively; whereas, abdominal obesity was
considered as waist circumference to height ratio (WHtR)
to be more than 0.5 (15)
3.3. Statistical Analysis
We used survey data analysis methods in the STATA
Corp. 2011, STATA Statistical Software (Release 12. College
Station, TX: STATA Corp LP. Package). Moreover, descrip-
tive analysis was used to determine the percentage of ab-
dominal obesity, overweight and general obesity among
children and adolescents.
4. Results
The population of this survey consisted of 14,880 chil-
dren and adolescents (participation rate 90.6%) includ-
ing 49.2% girls and 75.6% urban inhabitants. Mean ±
Standard Deviation (SD) of the age was 12.47 ± 3.36 years,
without significant difference between boys (12.36 ± 3.40
years) and girls (12.58 ± 3.32 years). Anthropometric char-
acteristics of children and adolescents are presented in
Table 1. The Mean ± SD of WHtR and BMI of participants
was 0.46 ± 0.06 and 18.85 ± 4.41 (Kg/m²) respectively.
Table 1. Anthropometric Characteristics of a Nationally Representative Sample of Iranian Children and Adolescents: the CASPIAN-IV Study a
Characteristics Total bBoys cGirls cP Value
Age, y 12.47 (3.36) 12.3 (12.1-12.6) 12.5 (12.3-12.8) 0.2
Weight, kg 42.4 (17.06) 43.07 (41.9-44.2) 41.7 (40.7-42.6) 0.06
Height, cm 146.99 (18.10) 148.1 (146.8 - 149.5) 145.7 (144.6 - 146.8) 0.005 d
Waist circumference, cm 67.02 (11.96) 67.8 (67.1 - 68.5) 66.1 (65.6 - 66.7) < 0.001 d
Waist/height 0.46 ( 0.06) 0.46 (0.45 - 0.46) 0.45 (0.45 - 0.45) 0.03 d
BMI, kg/m² 18.85 (4.41) 18.7 (18.5 - 18.9) 18.9 (18.7 - 19.1) 0.1
a Abbreviations: BMI; Body Mass Index, CI; Confidence Interval, SD; Standard Deviation.
b Values are presented as Mean (SD).
c Values are presented as (Mean, CI).
d P value < 0.05 was considered as significant.
Esmaili H et al.
3
Iran J Pediatr. 2015;25(3):e401
%25.00
%10.70
%13.21
%21.15
%6.44
Urban areas
overweight obese
%18.19
%11.77
%20.84
%13.87 %10.29
%10.72
%8.02
Primary school
%9.28
%20.41
Boys Girls
%10.06
%17.79
Middle school High school
%11.35
%19.06
abdominal obesity
overweight obese abdominal obesity
overweight obese abdominal obesity
Rural areas
%7.79
%12.84
%20.00
%15.00
%10.00
%5.00
%0.00
%25.00
%20.00
%15.00
%10.00
%5.00
%0.00
Figure 1. Prevalence of Overweight, General and Abdominal Obesity
Among a Nationally Representative Sample of Iranian Children and Ado-
lescents: the CASPIAN-IV Study
In terms of gender, the mean (95% CI) of WHtR of girls was
(0.45, CI: 0.45 - 0.45) without significant difference with
boys. The mean (95% CI) of BMI in girls (18.9 Kg/m², CI: 18.7 -
19.1) was higher than in boys (18.7 Kg/m², CI: 18.5 - 18.9), but
this difference was not significant (P = 0.1).
The prevalence of overweight, general and abdominal
obesity was 9.66%, 11.89, and 19.12%, respectively. Based on
gender difference, however, the prevalence of general
and abdominal obesity was significantly higher among
boys than girls [13.58% of boys vs. 10.15% of girls for gener-
al obesity (P < 0.001) and 20.41% vs. 17.79% for abdominal
obesity (P = 0.006) (Figure 1).
Overall, 10.7% of students in urban areas were over-
weight, 13.21% were generally obese and 21.15% were ab-
dominally obese. The prevalence of overweight and ab-
dominal obesity was higher among students in urban
areas than in rural areas (P < 0.001) (Figure 1).
The prevalence of overweight among children ranged
from 8.02% in Primordial school to 11.35% in high school
students (P < 0.001). The obesity prevalence increased
from Primordial to intermediate school (11.77 to 13.87%)
followed by a descending trend up to 10.29% among high
school students (P < 0.001). Among the three school lev-
els, the prevalence of general obesity was higher in mid-
dle school students. The prevalence of abdominal obesity
increased from 18.19% in Primordial school to 20.84% in
middle school; and then, it showed a decreasing trend up
to 19.06% in high school students (P = 0.07) (Figure 1).
Figure 2. Prevalence of General Obesity Among a Nationally Representa-
tive of Iranian Children and Adolescents in Different Provinces of Iran,
2012: the CASPIAN- IV Study
Figure 3. Prevalence of Abdominal Obesity Among a Nationally Represen-
tative of Iranian Children and Adolescents in Different Provinces of Iran,
2012: the CASPIAN-IV Study
Considerable variations were documented in the preva-
lence of obesity across the country, the highest preva-
lence of general obesity was found in Boushehr (19%)
followed by Guilan and Mazandaran (18.3%, 18.3%), while
the lowest prevalence was observed in Hormozgan (2.6%).
The highest frequency of abdominal obesity was found in
Mazandaran (30.2%), Ardabil (29.2%) and Tehran (27.9%).
Provinces such as Hormozagan (7.4%), Sistan-Balooches-
tan (8.4%) and Kerman (11.4%), however, showed the low-
est prevalence of central adiposity. Across the country,
the Southern and South Eastern provinces had the low-
Esmaili H et al.
Iran J Pediatr. 2015;25(3):e4014
est prevalence of general obesity (2.6% and 5.6%) and ab-
dominal adiposity (7.4% and 8.8%). Moreover, the highest
prevalence of obesity was found in North and North West
of Iran by maximum frequency of 18.3% general obesity
and 30.2% of abdominal adiposity (Figures 2 and 3).
5. Discussion
This national, cross-sectional study presents data on
different BMI categories and waist circumference in a
large sample of Iranian children and adolescents aged
6 – 18. The prevalence of general and abdominal obe-
sity was 11.89% and 19.12%. The result of the first national
study on obesity in 2008, indicated that based on the
Center for Disease Control (CDC), International Obesity
Task Force (IOTF) and national cut-offs the prevalence of
obesity among 6 -18 year old students was 4.5%, 2.9% and
4.79%, respectively (17). The obesity prevalence in a study
conducted by Ziaoddini et al. (18) illustrated that about
3.5% of 6-year-old children were affected by obesity. In the
current study, the prevalence of general and abdominal
obesity was higher among boys (13.58% and 20.41%, re-
spectively) than girls (10.15% and 17.79%, respectively). In
the present study the prevalence of abdominal and gen-
eral adiposity in three levels of education was 19.36% and
11.97%, respectively with higher frequency of abdominal
and general obesity in middle school students. The first
national study on the obesity prevalence has illustrated
the higher frequency of general obesity among boys than
girls (national cut offs: 2.4% vs. 2.39%; CDC: 2.5% vs. 2% and
IOTF criteria: 1.6% vs. 1.3%) and the rate of general obesity
in three levels of Primordial, middle and high school was
4.4%, 3.1% and 2.6%, respectively with the higher preva-
lence among Primordial school students (17).
Current results illustrated that the Southern and South
Eastern provinces had the lowest prevalence of general
and abdominal obesity, while the highest prevalence of
obesity was found in Northern provinces with 18.3% of
general and 30.2% of abdominal obesity. The results of this
study correspond with Ziaoddini et al. (2010) who found
the lowest prevalence of obesity among young children
of this area (18). In disease mapping study among Iranian
population aged 15 - 64, the greatest prevalence of obesity
was found in Mazandaran for males 17.8% and 29.8% for fe-
males whereas the lowest prevalence was documented
in Sistan-Baloochestan and Hormozgan provinces (19).
Compared with children and adolescents in the current
study, the prevalence of obesity was 22.5% among adults
in North Iran and the prevalence of obesity was similarly
higher among females than males [30.3% vs. 15.4% (P <
0.01)] (20). Although the frequency of obesity was lower
than 10% among children in South Iran, among adults
living in this region it has a high frequency of about 50%
(58.2% of females vs. 45.3% of males) (21).
The increasing rate in the percentage general obesity
among Iranian children and adolescents compared to
2008, provides alarming evidence for health care system
in order to pay considerable attention to education, pre-
vention, screening, and control of general and abdomi-
nal adiposity from early life. In this regard, Primordial
care providers can help preventing the obesity-associ-
ated disorders through comprehensive assessment and
management of weight disorders among children at na-
tional level.
The latest national data from the Middle-East region
revealed that the obesity is epidemic in several Middle
Eastern countries such as Kuwait, Saudi Arabia, Lebanon,
Oman, Turkey, Bahrain and Jordan. Moreover, the results
showed that the obesity-associated co-morbidities in
these countries are growing as well (22). A report from
the United States published in 2012 highlighted that
the prevalence of obesity among 2 - 19 year-old boys and
girls was 18.6% and 15.0% respectively. In addition, the re-
port also illustrated the dramatic increment in the obe-
sity prevalence from 14.0% to 18.6% among boys, and from
13.8% to 15.0% among girls in 1999 - 2000 and from 2000 to
2009 (23). Among Canadian adolescents aged 12 - 19, the
rate of central obesity increased from 1.8% to 12.8% during
1981 – 2009 (24). Similarly a review study by de Moraes et
al. (2011) demonstrated that more than 10% of 10 - 19 year-
old adolescents suffered from abdominal obesity with its
highest prevalence rate among boys (25). Furthermore,
findings of a recent systematic review and meta-analysis
study among Iranian children and adolescents revealed
a lower prevalence of obesity and a higher frequency of
overweight among girls with a higher rate of excess body
weight among children aged 2 to11 compared to their old-
er counterparts (26). According to the above-mentioned
studies, along with the growing prevalence of general
and abdominal obesity among Iranian children and ado-
lescents, the similar results have also been observed in
other parts of the world in recent years such as the USA,
Canada and Middle-Eastern countries (22-24).
The vicious cycle of obesity and metabolic disease
could negatively affect the health of the coming genera-
tions (27). The most important cause of the higher prev-
alence of obesity among children and adolescents is re-
lated to the lifestyle alterations including rapid changes
in food pattern consumption, extra energy intake from
fast food and fatty snacks, as well as lower energy expen-
diture and sedentary lifestyle, family history of obesity,
psychological health problems, screen time and sleep
patterns (27-31).
Hence, lifestyle modifications and regular physical ac-
tivities, social education, and nutrition interventions
are considered as the most important urgent action
strategies to cope with childhood obesity. Furthermore,
it is necessary to evaluate the community recourses and
identify useful strategies for preventing the obesity epi-
demic. We need through and helpful information regard-
ing general and central obesity collected by health care
professionals, researchers, school health coaches, com-
munity organizations, food industries, and government
should we aim to modify the environmental inappropri-
Esmaili H et al.
5
Iran J Pediatr. 2015;25(3):e401
ate contributors to extra weight gain. In addition, obesity
mapping is a valuable tool that enables us to evaluate and
recognize the high-risk regions of abdominal and gener-
al obesity, conduct therapeutics, intervention, and finally
provide extra educational programs.
One of the limitations of this study is its cross-sectional
design, which cannot determine any cause and effect
relationship. However, it is possible to generalize the re-
sults of this study to rural/urban Iranian students due to
the study design and proportional to population sample
size calculation and sampling.
In conclusion, findings of this national study empha-
sizes the significance of the general and abdominal obe-
sity prevalence among Iranian children and adolescents
who live in different regions of the country. The results
also indicated that the highest frequency of obesity was
found in the Northern parts of the country. The high rate
of obesity was documented in both genders. The findings
of the present study provide insights for policy makers
to consider action-oriented interventions for prevention
and control of childhood obesity at national and sub-na-
tional levels.
Acknowledgements
The authors would like to thank the large team working
with this national project, as well as the students, their
parents and school principals who participated in this
study.
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