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First Nationwide Survey of Prevalence of
Overweight, Underweight, and Abdominal
Obesity in Iranian Adults
Mohsen Janghorbani,* Masoud Amini,† Walter C. Willett,‡ Mohammad Mehdi Gouya,‡ Alireza Delavari,§
Siamak Alikhani,§ and Alireza Mahdavi§
Abstract
JANGHORBANI, MOHSEN, MASOUD AMINI,
WALTER C. WILLETT, MOHAMMAD MEHDI
GOUYA, ALIREZA DELAVARI, SIAMAK ALIKHANI,
AND ALIREZA MAHDAVI. First nationwide survey of
prevalence of overweight, underweight, and abdominal
obesity in Iranian adults. Obesity. 2007;15:2797–2808.
Objective: The goal was to estimate the prevalence of
overweight, obesity, underweight, and abdominal obesity
among the adult population of Iran.
Research Methods and Procedures: A nationwide cross-
sectional survey was conducted from December 2004 to
February 2005. The selection was conducted by stratified
probability cluster sampling through household family
members in Iran. Weight, height, and waist circumference
(WC) of 89,404 men and women 15 to 65 years of age
(mean, 39.2 years) were measured. The criteria for under-
weight, normal-weight, overweight, and Class I, II, and III
obesity were BMI ⬍18.5, 18.5 to 24.9, 25 to 29.9, 30 to
34.9, 35 to 39.9, and ⱖ40 (kg/m
2
), respectively. Abdominal
obesity was defined as WC ⱖ102 cm in men and ⱖ88 cm
in women.
Results: The age-adjusted means for BMI and WC were
24.6 kg/m
2
in men and 26.5 kg/m
2
in women and 86.6 cm
in men and 89.6 cm in women, respectively. The age-
adjusted prevalence of overweight or obesity (BMI ⱖ25)
was 42.8% in men and 57.0% in women; 11.1% of men and
25.2% of women were obese (BMI ⱖ30), while 6.3% of
men and 5.2% of women were underweight. Age, low
physical activity, low educational attainment, marriage, and
residence in urban areas were strongly associated with obe-
sity. Abdominal obesity was more common among women
than men (54.5% vs. 12.9%) and greater with older age.
Discussion: Excess body weight appears to be common in
Iran. More women than men present with overweight and
abdominal obesity. Prevention and treatment strategies are
urgently needed to address the health burden of obesity.
Key words: abdominal obesity, adiposity, adults, BMI,
epidemiology
Introduction
Obesity is an important public health problem worldwide,
and its prevalence is increasing in both developed and
developing nations with changes in dietary habits and ac-
tivity level (1–11). Individuals who are overweight are at
higher risk for a variety of disabling and life-threatening
chronic conditions, including high blood pressure, men-
strual abnormalities, psychosocial dysfunction, cardiovas-
cular disease, diabetes mellitus, arthritis, Pickwickian syn-
drome, gout, gallbladder disease, digestive disease, cancer,
respiratory dysfunction, diverticular disease, various skin
conditions, and overall mortality (4,12–20). Of these con-
ditions, diabetes may be the most closely linked to obesity,
and its prevalence appears to increase as the prevalence of
obesity increases. Abdominal obesity is considered an in-
dependent predictor of cardiovascular risk factors, morbid-
ity, and mortality (21).
The prevalence and pattern of obesity vary substantially
from nation to nation (3,22,23), and its current prevalence
(BMI ⱖ30 kg/m
2
) ranges from as low as ⬍5% in China,
Japan, and certain African nations to as high as ⬎75% in
urban Samoa (23). But even in relatively low-prevalence
countries, such as China, rates are almost 20% in some
Received for review October 16, 2006.
Accepted in final form March 6, 2007.
*School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran; †Isfahan
Endocrinology and Metabolism Research Center, Isfahan University of Medical Sciences,
Isfahan, Iran; ‡Department of Nutrition, Harvard School of Public Health, Boston, Massa-
chusetts; and §Ministry of Health and Medical Education, Health Deputy, Center for Disease
Control, Tehran, Iran.
Address correspondence to Mohsen Janghorbani, Department of Epidemiology and Biosta-
tistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran.
E-mail: janghorbani@yahoo.com
Copyright © 2007 NAASO
OBESITY Vol. 15 No. 11 November 2007 2797
cities (23). Although, the nationwide data on the prevalence
of overweight are available for some developing countries
(5,6,9,24 –26), they have not been reported for Iran. Accu-
rate information regarding the prevalence of overweight and
thinness is important for appropriate public health re-
sponses.
The rapid social and economic transition of Iran has been
accompanied by cultural changes, reduction of communica-
ble diseases, increased life expectancy, changes in nutri-
tional habits and physical activity, and increases in non-
communicable diseases, such as hypertension, diabetes, and
their risk factors. In Iran, only limited information exists on
the local prevalence of overweight in adulthood (27–29),
and there are no studies on the prevalence of underweight.
The objectives of this population-based survey were to
estimate the prevalence of overweight, underweight, and
abdominal obesity among adults 15 to 65 years of age in
Iran, and to conduct a preliminary investigation of the
determinants of overweight. These data will also serve as
the baseline for future examination of secular trends.
Research Methods and Procedures
Data Source
From December 2004 to February 2005, we conducted a
population-based cross-sectional survey among 89,404 Ira-
nian men and women studied for non-communicable dis-
ease risk factors. The survey was designed to provide in-
formation about a wide range of behaviors that affect
Iranians’ health at a provincial level so that provincial
health authorities can adjust national policies and programs
and respond to their local needs. By accumulating the pro-
vincial data, an estimate of the national figures can be
obtained. The study protocol is based on the World Health
Organization (WHO)
1
STEPwise approach to Surveillance
of risk factors for non-communicable disease (30). STEP-
wise approach to Surveillance uses different levels of risk
factor assessment, including collecting information using
questionnaires (Step 1), taking physical measurements (Step
2), and taking blood samples for biochemical assessment
(Step 3).
Subjects
A stratified, multistage probability cluster sample, with a
probability in proportion to size procedure, was used to
obtain a nationally representative sample of the population.
The frame for the selection of the sampling units was based
on the Iranian national zip code databank. The postal ad-
dresses of the starting points for the survey in each cluster
were determined centrally, using Iranian national zip code
databank. A counterclockwise movement from this point
was used to ensure a representative sample of households. A
total of 45,082 men and 44,322 women 15 to 65 years of
age, free from any physical handicaps, were weighed, and
their height and waist circumference (WC) were measured.
Of the 89,404 participants in the study, 1920 (2.1%) partic-
ipants had missing data on education, 1821 (2.0%) on
marital status, and 2414 (2.7%) on physical activity. These
individuals were excluded from subgroup analyses. The
subjects had a mean age of 39.2 years. All of the women
were post-menarche. Women who reported they were preg-
nant at the time of the survey, homeless people, and subjects
living in institutions or in the armed forces were excluded
from the analysis.
Data Collection
Subjects were contacted to schedule an interview in their
homes at their convenience. Pairs of trained staff members
of local medical universities/schools served as interviewers,
and a trained supervisor monitored the process in each
district. Before the data collection began, the interviewers
thoroughly explained to subjects the purpose and procedure
of the study and sought their consent. Interviews and an-
thropometric measurements were performed at the subjects’
homes with standard techniques and equipment (31), and
subjects 25 to 64 years of age were then invited to a referral
laboratory for blood testing, and 25,511 men and 27,574
women provided blood samples.
Height and weight were measured with subjects in light
clothes and without shoes using standard apparatus. Weight
was measured to the nearest 0.1 kg on a calibrated beam
scale. Height and WC were measured to the nearest 0.5 cm
with a measuring tape. To measure height, a measuring tape
was fixed to the wall and the subject stood with heels,
buttocks, shoulders, and occiput touching the vertical tape.
The head was held erect with the external auditory meatus
and the lower border of the orbit in one horizontal plane.
Waist was measured midway between the lower rib margin
and the iliac-crest at the end of a gentle expiration.
Overnight fasting blood samples were taken, and plasma
was separated and analyzed on the same day. Total choles-
terol and fasting blood glucose were assessed by standard-
ized procedures. Blood pressure was measured with a stan-
dard mercury sphygmomanometer and a cuff of suitable
size on the right arm after an adequate rest period of at least
15 minutes. Korotkoff Phases I and V were used for systolic
and diastolic blood pressure, respectively. Two measure-
ments were taken for each subject with a 30-second interval
between measurements. In addition to measurements, all
participants completed a set of interviewer-administered
questionnaires on sociodemography, smoking habits, diet,
physical activity, diabetes mellitus, and hypertension. The
Medical Ethics Committee of the Ministry of Health and
Medical Education approved the study protocol, and all
1
Nonstandard abbreviations: WHO, World Health Organization; WC, waist circumference;
SE, standard error.
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
2798 OBESITY Vol. 15 No. 11 November 2007
subjects gave their written consent. The study complied
with the current version of the Declaration of Helsinki.
Definitions
BMI is recognized as the measure of overall obesity. The
criteria for underweight, normal-weight, overweight, and
Classes I, II, and III obesity used in the present study were
based on BMI (weight/height
2
) [kg/m
2
]) and were consis-
tent with the definitions set forth by the WHO and the
National Heart, Lung, and Blood Institute as follows: un-
derweight ⬍18.5, normal-weight 18.5 to 24.9, overweight
25 to 29.9, Class I obesity 30 to 34.9, Class II obesity 35 to
39.9, and Class III obesity ⱖ40 kg/m
2
(4,12). WC was used
as a measure of abdominal obesity, defined as WC ⱖ102 cm
in men and ⱖ88 cm in women to distinguish subjects at
increased cardiovascular risk (21,32). A daily smoker was
defined as one who smoked at least 1 cigarette per day (at
least 7 cigarettes per week). Those who smoked fewer than
1 cigarette per day or 7 cigarettes per week were designated
as occasional smokers. Current smokers included daily and
occasional smokers. Those who had smoked at least 1
cigarette per day for at least 6 months but had quit were
designated as ex-smokers, and those who had never smoked
at all were designated as never smokers. The leisure time
physical activity variable was based on a detailed interview
about activity at work and leisure time. Interviewers had a
codebook that listed an activity level beside common occu-
pations and also probed participants about the nature of their
activity outside of working hours. When a participant re-
peatedly spent at least 30 minutes/wk of their leisure time
performing physical activity, this was considered as “regu-
lar physical exercise.”
Analysis
Data were entered on a computer in each medical uni-
versity/school, with EPI info software (Centers for Disease
Control and Prevention, Atlanta, GA). Datasets were trans-
fer into SPSS-compatible (SPSS, Inc., Chicago, IL) format
to calculate means and standard errors (SEs), ttest, and
2
tests. All analyses were stratified by gender. The mean (SE)
and 95% confidence interval were calculated for weight,
BMI, and WC. Robust SEs were calculated to minimize the
effect of cluster sampling on the test statistics. Multivariate
logistic regression was performed with the SPSS for Win-
dows (SPSS, Inc.) computer package to assess associations
between underweight, overweight, and obesity and age,
marital status, educational level, leisure time physical ac-
tivity, smoking habits, and area of residence. Prevalence
rates of overweight, underweight, and abdominal obesity
were age-adjusted, using the direct method of adjustment,
within the WHO European standard population (33). All
tests for statistical significance were two tailed and per-
formed at
␣
⬍0.05.
Results
Characteristics
Distributions of selected characteristics among 45,082
men and 44,322 women are shown in Table 1. Women had
lower educational level, physical activity, age-adjusted
weight, height, and systolic and diastolic blood pressure and
were more likely never to have smoked than men. Men had
lower age-adjusted BMI, WC, cholesterol, and fasting blood
glucose than women. The age-adjusted mean (SE) BMI was
24.6 (0.02) kg/m
2
in men, and 26.5 (0.02) kg/m
2
in women.
The age-adjusted mean (SE) WC was 86.6 (0.06) cm in men
and 89.6 (0.06) cm in women.
Prevalence
Table 2 presents the gender-specific crude and age-
adjusted prevalences of underweight, overweight, and
Classes I, II, and III obesity; 50.8% of the men and 37.8%
of women were normal-weight. Nearly half of adults 15 to
65 years of age were overweight or obese (49.9%). Overall,
42.9% men and 56.9% women were overweight or obese
(BMI ⱖ25), and 10.9% men and 24.5% women were obese
(BMI ⱖ30); 6.3% of men and 5.2% of women were under-
weight. When age was adjusted to the WHO European
standard population, the age-adjusted prevalence rates of
underweight and obesity were 6.4% and 11.1% in men, and
5.3% and 25.2% in women, respectively. The age-adjusted
prevalence rates of high WC (ⱖ102 cm in men and ⱖ88 cm
in women) were 12.5% among men and 53.5% among
women. As expected, WC increased with age and BMI;
1.1% of men and 21.5% of women who were normal-weight
(BMI, 18.5 to 24.9) had high WC, and 55.2% of men and
94.1% women with Class III obesity had high WC. The
prevalence of overweight, obesity, and abdominal obesity
was greater in women than in men, among married persons
compared with singles, among older compared with
younger people, and among residents of urban compared
with rural areas (Table 3). The prevalence of underweight
was greater in men than in women, among singles compared
with married, among younger compared with older people,
and among residents of rural compared with urban areas
(Table 3). There was an increasing prevalence of over-
weight or obesity (BMI ⱖ25) with increasing age, from
22.3% in the 15- to 24-year age group to 84.7% in the 55-
to 64-year age group ((p⬍0.001). Marital status was
significantly associated with overweight and Classes I, II,
and III obesity in both genders. Married men were 4.0 times
and married women were 3.7 times more likely to be obese
(BMI ⱖ30) than never married subjects. In both men and
women, overweight and Classes I, II, and III obesity and
abdominal obesity were more common with low educa-
tional attainment. The prevalence rates of overweight or
obesity (BMI ⱖ25) among men and women in rural areas
were 34.0% and 49.0%, whereas these rates in urban areas
were 47.7% and 61.3%, respectively. The prevalence rates
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
OBESITY Vol. 15 No. 11 November 2007 2799
of obesity (BMI ⱖ30) among men and women living in
rural areas were 8.1% and 19.8%, which were lower than
the rates in urban areas, 12.4% and 27.1%, respectively. The
prevalence rates of underweight (BMI ⬍18.5) among men
and women living in rural areas were 8.0% and 6.4%, which
were higher than the rates in urban areas, 5.4% and 4.6%,
respectively.
In both genders, BMI was strongly correlated with weight
(r⫽0.83 men, 0.89 women), WC (r⫽0.71 men, 0.74
women), age (r⫽0.25 men, 0.31 women), systolic blood
pressure (r⫽0.28 men, 0.30 women), diastolic blood
pressure (r⫽0.25 men, 0.28 women), cholesterol (r⫽0.21
men, 0.20 women), and fasting blood glucose (r⫽0.14
men, 0.12 women).
Risk Factors
Table 4 shows the mean (SE) of age, systolic and dia-
stolic blood pressure, cholesterol, fasting blood glucose,
height, weight, and WC by BMI class. As expected, all of
the variables increased with increasing BMI class in both
men and women, except height, which decreased with in-
creasing BMI class.
The prevalence of overweight, obesity, and underweight
was also analyzed with multivariate logistic regression. A
total of 231 men and 223 women were excluded from these
analyses because of missing risk factor information. Multi-
variate logistic regression analyses of underweight, over-
weight, and obesity in relation to age, physical activity,
smoking, education, marital status, and residence are shown
Table 1. Age-adjusted means and proportions of selected characteristics among 45,082 men and 44,322 women
Characteristic
Age-adjusted 关mean (SE)兴
Men Women
Age (yrs) 39.1 (0.07) 39.0 (0.07)
Weight (kg) 70.8 (0.06) 64.7 (0.07)
Height (cm) 169.7 (0.04) 156.5 (0.04)
Waist circumference (cm) 86.6 (0.06) 89.6 (0.06)
BMI (kg/m
2
)24.6 (0.02) 26.5 (0.02)
Systolic BP (mmHg) 123.3 (0.08) 121.3 (0.08)
Diastolic BP (mmHg) 78.4 (0.06) 76.5 (0.06)
Cholesterol (mg/dL) 196.6 (0.26) 206.4 (0.25)
Fasting blood glucose (mg/dL) 96.2 (0.21) 98.4 (0.20)
Education (%)
Primary or below 44.1 59.7
Secondary 44.3 33.0
Matriculation or above 11.6 7.3
Marital status (%)
Married 76.0 73.5
Single 23.3 19.9
Divorced/widowed 0.7 6.6
Smoking (%)
Never-smoker 64.4 91.5
Current-smoker 28.1 5.8
Ex-smoker 7.5 2.7
Leisure time physical activity (%)
Yes 35.4 20.3
No 64.6 79.7
Residential area (%)
Urban 73.5 71.3
Rural 26.5 28.7
SE, standard error; BP, blood pressure. Age-adjusted means were calculated using general linear models.
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
2800 OBESITY Vol. 15 No. 11 November 2007
in Table 5. Older age, non-smoking, married, low level of
education, and living in urban areas were positively associ-
ated with overweight and obesity in both men and women.
Low physical activity was positively associated with over-
weight and obesity in women but not men. Underweight
adults were more likely than those of desirable weight to be
younger, to smoke, to be physically active, and to live in
rural areas. Low level of education was positively associ-
ated with underweight in men but not women.
Discussion
In this nationwide cross-sectional study of 89,404 adults
15 to 65 years of age, we found that overweight and obesity
Table 2. Prevalence rates (%) of underweight, overweight, Classes I, II, and III obesity, and abdominal obesity
in Iran
Weight category*
Prevalence rate (95% confidence interval)
Cases Crude Age-adjusted†
Underweight
Men 2739 6.3 (6.1, 6.5) 6.4 (6.2, 6.6)
Women 2266 5.2 (5.0, 5.5) 5.3 (5.2, 5.5)
Overall 5005 5.8 (5.6, 5.9) 5.9 (5.7, 6.1)
Overweight
Men 13,926 32.0 (31.5, 32.4) 31.7 (31.4, 32.1)
Women 14,009 32.4 (32.0, 32.9) 32.3 (31.9, 32.7)
Overall 27,935 32.2 (31.9, 32.5) 32.0 (31.7, 32.4)
Class I obesity
Men 3913 9.0 (8.7, 9.3) 8.9 (8.7, 9.1)
Women 7711 17.9 (17.5, 18.2) 17.7 (17.4, 17.9)
Overall 11,624 13.4 (13.2, 13.6) 13.2 (13.0, 13.5)
Class II obesity
Men 631 1.4 (1.3, 1.6) 1.4 (1.3, 1.5)
Women 2182 5.1 (4.9, 5.3) 5.0 (4.8, 5.2)
Overall 2813 3.2 (3.1, 3.4) 3.2 (3.1, 3.3)
Class III obesity
Men 212 0.5 (0.4, 0.6) 0.5 (0.4, 0.5)
Women 699 1.6 (1.5, 1.7) 1.2 (1.1, 1.3)
Overall 911 1.0 (0.9, 1.1) 1.0 (0.9, 1.1)
Obesity (BMI ⱖ30)
Men 4756 10.9 (10.5, 11.0) 11.1 (10.9, 11.4)
Women 10,592 24.5 (24.0, 24.8) 25.2 (24.9, 25.6)
Overall 15,348 17.6 (17.3, 17.8) 18.1 (17.9, 18.4)
Abdominal obesity
Men 5599 12.9 (12.6, 13.2) 12.5 (12.2, 12.7)
Women 13,147 54.5 (54.1, 55.0) 53.5 (53.1, 53.8)
Overall 18,746 33.5 (33.1 33.8) 32.7 (32.4, 33.1)
WHO, World Health Organization; NHLBI, National Heart, Lung, and Blood Institute.
* Category definitions are based on WHO and NHLBI cutoffs (4,12). Underweight ⫽BMI ⬍18.5 kg/m
2
; overweight ⫽BMI 25 to 29.9
kg/m
2
; Class I obesity ⫽BMI 30 to 34.9 kg/m
2
; Class II obesity ⫽BMI 35–39.9 kg/m
2
; Class III obesity ⫽BMI ⱖ40 kg/m
2
. Abdominal
obesity was defined as waist circumference ⱖ102 cm in men and ⱖ88 cm in women (26,27).
† Adjustments for age have been performed to the WHO European standard population.
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
OBESITY Vol. 15 No. 11 November 2007 2801
are common in Iran, as 42.9% of men and 56.9% of women
had excess body weight (BMI ⱖ25). In contrast, under-
weight has a low prevalence (6.3% men and 5.2% women
present BMI values ⬍18.5). The obesity prevalence (BMI
Table 3. Age-adjusted mean* (SE) BMI and prevalence (%) of underweight, normal-weight, overweight,
obesity, and abdominal obesity in 45,082 men and 44,322 women according to selected characteristics in Iran
Variable
Mean
(SE)
Weight category†
Abdominal
obesity‡Underweight
Normal-
weight Overweight Obesity
Men
Age (yrs)
15 to 24 23.9 (0.15) 15.3 65.8 14.8 3.8 3.2
25 to 34 25.3 (0.09) 4.8 55.2 31.0 9.0 7.4
35 to 44 25.3 (0.05) 4.1 45.7 37.3 12.9 13.4
45 to 54 24.9 (0.09) 3.4 42.6 39.4 14.7 19.1
55 to 64 23.6 (0.15) 3.9 45.1 37.2 13.8 21.1
Education
Primary or below 24.2 (0.04) 5.1 49.7 32.9 12.2 15.6
Secondary 24.9 (0.04) 8.0 52.8 29.4 9.9 10.5
Matriculation or above 25.4 (0.06) 4.1 47.6 38.3 10.0 11.7
Marital status
Married 25.0 (0.03) 4.1 46.6 36.4 18.4 15.6
Single 23.3 (0.06) 13.3 64.6 17.5 4.6 4.0
Others 24.0 (0.25) 8.1 53.1 26.4 12.4 15.4
Smoking
Non-smokers 24.7 (0.03) 6.3 49.7 32.7 11.3 12.9
Current-smokers 24.1 (0.04) 6.9 55.1 29.1 8.9 11.4
Ex-smokers 25.5 (0.08) 4.0 44.5 36.5 15.0 18.1
Physical activity
No 24.7 (0.04) 5.8 49.7 32.7 11.8 14.2
Yes 24.6 (0.03) 7.2 52.8 30.7 9.3 10.4
Residential area
Urban 25.1 (0.03) 5.4 47.0 35.3 12.4 14.8
Rural 23.8 (0.04) 8.0 58.0 25.9 8.1 9.2
Women
Age (yrs)
15 to 24 24.9 (0.18) 14.0 60.4 19.3 6.3 18.1
25 to 34 26.9 (0.10) 4.8 42.8 33.6 18.9 44.5
35 to 44 27.8 (0.06) 2.3 29.1 37.0 31.6 64.2
45 to 54 27.2 (0.10) 2.3 26.3 36.4 35.0 71.5
55 to 64 25.6 (0.18) 2.8 30.0 36.0 31.1 73.3
Education
Primary or below 26.5 (0.04) 3.7 33.2 34.0 28.1 64.4
Secondary 26.6 (0.05) 7.7 43.3 30.2 18.7 41.3
Matriculation or above 25.8 (0.10) 6.9 50.0 30.2 13.0 33.5
Marital status
Married 27.1 (0.03) 3.1 32.6 35.8 28.5 62.5
Single 24.3 (0.07) 13.9 58.9 19.4 7.8 21.2
Others 26.2 (0.10) 3.6 32.5 33.9 30.0 66.7
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
2802 OBESITY Vol. 15 No. 11 November 2007
ⱖ30) was 10.9% in men and 24.5% in women. These data
are consistent with local reports of the high prevalence of
overweight and obesity in Iran (27–29) and other countries
in the Middle East (34 – 41). As in other studies in devel-
oping countries, obesity tends to increase with age and is
more common in women and people with low educational
attainment.
Prevalence rates in various studies from around the world
show considerable variation. Estimates of prevalence of
overweight and obesity will depend on methodological fac-
tors, the definition of obesity used, and the composition of
the community examined by age, ethnicity, and social class,
making comparisons among studies of limited value. One
study from Thailand among Thai adults 20 to 59 years of
age, found 28.3% and 6.8% were overweight and obese,
respectively (24). Another study from Singapore of ages 18
to 69 found 8.5% of women and 5.9% of men were obese
(25). A study from China, which has a low prevalence of
coronary heart disease in the general population, found the
prevalence of overweight in men and women 20 to 45 years
of age was 13.6% and 19.2% and for obesity 0.5% and
1.5%, respectively (5). The prevalence of obesity among
Turkish women and men was 32.4% and 14.1%, whereas
the prevalence of overweight among men and women was
65.9% and 50.4%, respectively (34,35). In Saudi Arabia, the
prevalence of obesity is estimated to be 17% to 44% in
women and 12% to 26% in men (36 –38), and in Egypt, the
prevalence of obesity ranges from 40.6% among women
living in urban areas to 6% among men living in rural areas
(39). The current prevalence of obesity (BMI ⱖ30) is
⬃20% to 25% in the United States and 10% to 24% in most
countries in Western Europe (3,4,22). The prevalence of
overweight and obesity in Iran is higher than the values
reported in China (5), Thailand (24), and Singapore (25),
but lower than the prevalence in Turkey, Saudi Arabia,
Kuwait, Persian Gulf countries, and the United States. Our
prevalence rate in the age group 20 to 65 years was com-
parable to those of developed nations such as Finland,
Australia, and the United Kingdom, in the same age group,
whose obesity prevalence ranges from 12% to 22% (4).
Consistent with prior studies (27–29,34,35,40,41), prev-
alence of overweight and Classes I, II, and III obesity and
abdominal obesity was found to be higher among women
than men, and the difference was more evident in abdominal
obesity where the rate for women was more than four times
that for men. These results may be explained by differences
in physical activity or caloric intake. Iranian women may
have less physical activity than men because of limited
outdoor activities due to specific climatic and/or social
conditions. Smoking is shown to be associated with lower
BMI. Current smoking rates among men and women were
28.1% and 5.8%, respectively, and these may contribute to
the differences in prevalence of overweight between men
and women.
Table 3. Continued
Variable
Mean
(SE)
Weight category†
Abdominal
obesity‡Underweight
Normal-
weight Overweight Obesity
Smoking
Non-smokers 26.5 (0.03) 5.1 37.9 32.6 24.4 54.0
Current-smokers 26.2 (0.11) 7.8 38.8 29.7 23.7 57.4
Ex-smokers 27.6 (0.17) 3.3 32.2 33.6 30.9 66.5
Physical activity
No 26.7 (0.06) 5.1 37.2 32.5 25.1 56.3
Yes 26.4 (0.03) 5.6 39.7 32.3 22.3 47.9
Residential area
Urban 26.9 (0.03) 4.6 34.1 34.2 27.1 57.5
Rural 25.6 (0.04) 6.4 44.5 29.2 19.8 49.0
SE, standard error; WHO, World Health Organization; NHLBI, National Heart, Lung, and Blood Institute.
* Age-adjusted means were calculated using general linear models.
† Category definitions are based on WHO and NHLBI cutoffs (4,12). Underweight ⫽BMI ⬍18.5 kg/m
2
; normal-weight ⫽BMI 18.5 to
24.9 kg/m
2
; overweight ⫽BMI 25 to 29.9 kg/m
2
; obese ⫽BMI ⱖ30 kg/m
2
.
‡ Abdominal obesity was defined as waist circumference ⱖ102 cm in men and ⱖ88 cm in women (26,27).
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
OBESITY Vol. 15 No. 11 November 2007 2803
Another finding that requires further elaboration is the
high prevalence of abdominal obesity in Iranian women.
Whereas age-adjusted mean WC in 19 populations studied
in the WHO MONICA project (42) was 83 to 98 cm in men
and 78 to 91 cm in women, the age-adjusted mean WCs
among men and women in our study were 86.6 and 89.6 cm,
respectively. Therefore, Iranian women have considerably
higher WC than women in other countries, and a large
proportion of women in our study population had high WC
even with normal weight. This may be due to genetic
predisposition of Iranian women, low levels of physical
activity, low smoking rates, high fertility rates, high illiter-
acy rates, or differences in epigenetic programming of Ira-
nian women. In some developed countries, such as France,
the percentage of obese subjects was similar in both gen-
ders. This is not the case for other developed countries, for
example, Hungary, where it is substantially higher in men
than in women, and in Greece and Portugal, where obesity
is higher in women than in men (43,44).
Urban residents generally have a higher BMI and abdom-
inal obesity than those living in rural areas. Urban residents
are more likely to eat more Western-style food and less
likely to be physically active. In most countries, urban
residents consume a greater proportion of protein and fat
and a smaller proportion of carbohydrates (26) and have
generally higher availability of calories.
Overweight and obesity were found to be higher among
ever married individuals than among never married persons
after adjustment for other confounders, which suggests that
people, particularly men, after marriage have less physical
activity, change their dietary pattern, may be less focused on
being attractive, or may be exposed to other environmental
factors. Unfortunately, the data used here do not allow for
an empirical test of these speculations. Further research
Table 4. Comparison of selected age-adjusted cardiovascular risk factors among underweight, normal-weight,
overweight, and Classes I, II, and III obesity by gender in Iran
Variable
Age-adjusted 关mean (SE)兴
Underweight
Normal-
weight Overweight
Class I
obesity
Class II
obesity
Class III
obesity
Men
Age (yrs) 30.9 (0.30) 37.2 (0.10) 42.9 (0.11) 44.4 (0.20) 43.0 (0.50) 41.0 (0.95)
Systolic BP (mm Hg) 117.8 (0.29) 121.2 (0.10) 125.5 (0.13) 129.7 (0.24) 131.7 (0.60) 132.0 (1.03)
Diastolic BP (mm Hg) 74.7 (0.21) 77.0 (0.07) 80.2 (0.09) 82.4 (0.17) 83.3 (0.43) 82.3 (0.73)
Cholesterol (mg/dL) 180.4 (1.28) 189.9 (0.38) 203.8 (0.43) 208.8 (0.79) 211.5 (2.03) 204.6 (3.48)
Fasting blood glucose (mg/dL) 92.5 (0.98) 93.6 (0.29) 98.5 (0.33) 101.1 (0.60) 106.5 (1.55) 100.9 (2.66)
Height (cm) 169.6 (0.15) 170.0 (0.05) 169.9 (0.07) 168.9 (0.12) 166.7 (0.31) 142.8 (0.53)
Weight (kg) 49.9 (0.16) 63.9 (0.05) 78.4 (0.07) 90.4 (0.13) 102.1 (0.32) 101.6 (0.55)
BMI (kg/m
2
)17.4 (0.04) 22.1 (0.01) 27.1 (0.02) 31.7 (0.03) 36.7 (0.07) 50.5 (0.12)
Waist circumference (cm) 72.2 (0.18) 80.9 (0.06) 92.8 (0.08) 102.5 (0.15) 111.0 (0.37) 104.1 (0.63)
Women
Age (yrs) 29.3 (0.30) 35.0 (0.12) 41.5 (0.11) 44.3 (0.13) 45.5 (0.24) 45.0 (0.42)
Systolic BP (mm Hg) 116.2 (0.37) 118.4 (0.14) 121.8 (0.15) 124.9 (0.20) 128.3 (0.37) 128.7 (0.66)
Diastolic BP (mm Hg) 72.8 (0.25) 74.4 (0.09) 76.9 (0.10) 79.1 (0.14) 81.1 (0.25) 81.4 (0.45)
Cholesterol (mg/dL) 187.2 (1.44) 197.9 (0.45) 208.8 (0.42) 213.3 (0.54) 213.9 (1.02) 219.2 (1.83)
Fasting blood glucose (mg/dL) 92.2 (1.21) 94.5 (0.38) 99.0 (0.35) 100.9 (0.46) 103.4 (0.86) 110.0 (1.54)
Height (cm) 158.2 (0.15) 157.0 (0.06) 156.6 (0.06) 155.9 (0.08) 154.9 (0.15) 149.5 (0.26)
Weight (kg) 43.2 (0.15) 54.7 (0.06) 67.2 (0.06) 77.8 (0.08) 88.2 (0.15) 99.8 (0.27)
BMI (kg/m
2
)17.3 (0.04) 22.2 (0.01) 27.4 (0.02) 32.0 (0.02) 36.8 (0.04) 45.0 (0.07)
Waist circumference (cm) 71.9 (0.21) 80.9 (0.08) 92.0 (0.08) 101.0 (0.11) 109.0 (0.21) 115.5 (0.37)
SE, standard error; BP, blood pressure; WHO, World Health Organization; NHLBI, National Heart, Lung, and Blood Institute. Category
definitions are based on WHO and NHLBI cut-offs (4,12). Underweight ⫽BMI ⬍18.5 kg/m
2
; normal-weight ⫽BMI 18.5 to 24.9 kg/m
2
;
overweight ⫽BMI 25 to 29.4 kg/m
2
; Class I obesity ⫽BMI 30 to 34.9 kg/m
2
; Class II obesity ⫽BMI 35 to 39.9 kg/m
2
; Class III obesity ⫽
BMI ⱖ40 kg/m
2
.
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
2804 OBESITY Vol. 15 No. 11 November 2007
Table 5. Factors related to prevalence of underweight (BMI ⬍18.5 kg/m
2
), overweight (BMI 25 to 29.9 kg/m
2
), and obesity (BMI ⱖ30 kg/m
2
)
(stepwise binary logistic regression model)
Variable
Men Women
Overweight Obesity Underweight Overweight Obesity Underweight
Age (yrs)
15 to 24 1.0 1.0 1.0 1.0 1.0 1.0
25 to 34 2.09 (1.91,2.29)‡ 1.99 (1.70,2.33)‡ 0.41 (0.35,0.47)‡ 1.94 (1.78,2.10)‡ 3.00 (2.67,3.37)† 0.59 (0.52,0.67)‡
35 to 44 3.02 (2.73,3.35)‡ 3.34 (2.83,3.95)‡ 0.40 (0.34,0.48)‡ 2.94 (2.68,3.22)‡ 6.54 (5.80,7.37)‡ 0.44 (0.37,0.53)‡
45 to 54 3.52 (3.17,3.92)‡ 4.04 (3.41,4.78)‡ 0.37 (0.31,0.44)‡ 3.21 (2.92,3.53)‡ 7.69 (6.80,8.69)‡ 0.49 (0.41,0.59)‡
55 to 64 3.15 (2.82,3.51)† 3.47 (2.92,4.13)‡ 0.41 (0.34,0.49)‡ 2.83 (2.57,3.12)‡ 5.90 (5.21,6.70)‡ 0.51 (0.43,0.61)‡
Physical activity
Yes — 1.0 1.0 1.0 1.0 1.0
No — 0.91 (0.85,0.98)* 0.90 (0.82,0.98)* 1.13 (1.06,1.20)‡ 1.14 (1.06,1.22)‡ 0.83 (0.74,0.92)‡
Smoking
Non-smokers 1.0 1.0 1.0 1.0 1.0 1.0
Current smokers 0.62 (0.59,0.65)‡ 0.51 (0.47,0.55)‡ 1.51 (1.37,1.67)‡ 0.69 (0.62,0.77)‡ 0.65 (0.58,0.73)‡ 2.28 (1.92,2.71)‡
Ex-smokers 1.01 (0.93,1.10) 1.14 (1.01,1.27)* 0.97 (0.80,1.18) 0.97 (0.83,1.12) 1.07 (0.91,1.25) 1.06 (0.75,1.49)
Education
Matriculation or above 1.0 1.0 1.0 1.0 1.0 —
Secondary 0.73 (0.68,0.79)‡ 1.04 (0.92,1.17) 1.45 (1.22,1.73)‡ 1.21 (1.09,1.33)‡ 2.09 (1.83,2.38)‡ —
Primary or below 0.89 (0.83,0.96)† 1.23 (1.09,1.37)‡ 1.36 (1.17,1.60)‡ 1.26 (1.15,1.39)‡ 1.92 (1.69,2.19)‡ —
Marital status
Married 1.0 1.0 1.0 1.0 1.0 1.0
Single 0.60 (0.55,0.65)‡ 0.50 (0.44,0.58)‡ 1.45 (1.27,1.66)‡ 0.52 (0.48,0.56)‡ 0.41 (0.37,0.45)‡ 1.82 (1.62,2.04)‡
Residential area
Urban 1.0 1.0 1.0 1.0 1.0 1.0
Rural 0.62 (0.59,0.65)‡ 0.52 (0.48,0.56)‡ 1.22 (1.12,1.33)‡ 0.63 (0.60,0.67)‡ 0.49 (0.46,0.52)‡ 1.12 (1.02,1.23)*
Values are significant adjusted odds ratios (95% confidence interval).
*p⬍0.05; † p⬍0.01; ‡ p⬍0.00.
Prevalence of Overweight and Underweight in Iran, Janghorbani et al.
OBESITY Vol. 15 No. 11 November 2007 2805
would be useful to examine which factors play a role in the
weight gain of married individuals in our society.
A high proportion of the men in this study smoked, and
smoking was inversely related to weight. The negative
association between smoking and overweight and obesity
might be partly due to its effects on metabolic rate, energy
intake and storage, and energy expenditure (45,46). In one
study, however, weight gain was observed in current smok-
ers as well as ex-smokers and non-smokers, suggesting
that the factors promoting weight gain were overcoming
the inverse effect of smoking (47). Although a greater
risk of excess weight is found among non-smokers, many
studies have shown that smoking has a larger impact on
morbidity and mortality than any small increase in BMI
(48,49).
Consistent with many prior studies (44,50,51), over-
weight and abdominal obesity were higher among low ed-
ucated individuals, after adjustment for other confounders.
Women who were overweight or obese exercised less than
those of normal weight. This relationship could not be seen
for overweight men in this survey. Conflicting results have
been observed in different studies (44,52).
Our study has several strengths and limitations. The
strengths include the large sample consisting of both urban
and rural populations, sound representativeness of the na-
tional population, and information on potential determinants
of obesity. One limitation of our study was the possibility
that BMI cut-off points used in this study may understate
health risk. The cut-off points are those recommended by
the WHO and National Heart, Lung, and Blood Institute
(4,12). Although they have proven to be fairly robust for
classifying obesity across populations, they are based pri-
marily on the association between BMI and mortality in
European and North American populations (53,54). As a
cross-sectional study, the present analysis is limited in its
ability to elucidate causal relationships between risk factors
and overweight. BMI can overestimate body fat in individ-
uals who are very muscular and underestimate body fat in
individuals who have lost muscle mass, such as many el-
derly (55). However, estimates from these potentially mis-
classified groups likely had little overall impact on the
analysis. Although we have not carried out any special
studies of the validity or reliability of data for this analysis,
a clerk was employed to check consistency and, where
possible, to ensure completeness of data. Our experience
with other parts of the dataset gives us some confidence that
data quality is sufficient for this type of study and that our
results provide useful additional evidence on the prevalence
of and risk factors for underweight, overweight, and obesity.
Despite the above limitations, the findings here add to our
understanding of the epidemiology of overweight and obe-
sity in Iran. Furthermore, this study provides new nation-
wide data from Iran, a developing country that has been
under-represented in past studies.
In summary, excess body weight appears to be quite
common in Iran. More women than men present with over-
weight and abdominal obesity. Preventive and treatment
strategies are urgently needed to prevent overweight and
obesity and promote weight maintenance and weight loss
and address the health burden of obesity.
Acknowledgments
The authors thank the agencies that organized and sup-
port the Iranian non-communicable disease risk factor sur-
veillance system, including the Ministry of Health, Treat-
ment and Medical Education, participating households, and
subjects who have given their full cooperation and sup-
port to the study and Majid Abyar for computer technical
assistance. There was no funding/outside support for this
study.
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