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

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.

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

Organization	Definition
World health organization	WHO 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 prevention	In 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 force	Provides 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 Strategy	High 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 Science	Time 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.

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)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Aazami et al. (2012) ( 35 )	Kermanshah, local study	U	2010							CDC 2000		CDC 2000
				Both	NA	9.3 ± 1.5	1400	17.3 ± 3.1	17.14 - 17.46		10.9 (10.39 - 11.41)		13.4 (12.79 - 14.01)
				Male	NA	9.3 ± 1.5	756	17.44 ± 3.2	17.21 - 17.67		13.4 (12.57 - 14.23)		12.6 (11.81 - 13.39)
				Female	NA	9.3 ± 1.4	644	17.11 ± 3.1	16.87 - 17.35		8.1 (7.53 - 8.67)		14.3 (13.35 - 15.25)
Abdollahi et al. (2010) ( 36 )	Golestan, provencial study	U	2005							WHO		WHO
				Male	17 - 70	45.9 ± 14.76	2500	26.48 ± 4.44	26.31 - 26.65		20.3 (19.67 - 20.93)		42.3 (41.334 - 43.26)
				Female		43.4 ± 13.58	2500	27.63 ± 5.54	27.41 - 27.85		30.7 (29.87 - 31.53)		35 (34.11 - 35.8)
Ahmadi et al. (2010) ( 37 )	Kerman, local study	U	2009							>2SD of mean		>2SD of mean
				Both	7 - 11	9 ± 1.4	1566	16 ± 3	15.85 - 16.15		9.7 (9.27 - 10.13)		4.4 (4.19 - 4.61)
				Male		NA	770	16 ± 2.9	15.79 - 16.20		NA		NA
				Female		NA	796	16.1 ± 3.1	15.88 - 16.32		NA		NA
Akhavan-Karbasi et al. (2009) ( 38 )	Yazd, local study	U	2006							CDC 2000		CDC 2000
				Both	6 - 6.9	NA	400	NA	NA		3.8 (3.29 - 4.31)		4.3 (3.73 - 4.78)
				Male		NA	200	NA	NA		5.5 (4.78 - 6.22)		5 (4.34 - 5.66)
				Female		NA	200	NA	NA		2 (1.73 - 2.27)		3.5 (3.03 - 3.97)
Mirzazadeh et al. (2000) ( 9 )	Tehran, local study	U	2002							CDC 2000		CDC 2000
				Both	10 - 19	NA	421	NA	NA		3.8 (3.45 - 4.15)		NA
				Male			177	NA	NA		5.1 - (4.39 - 5.81)		NA
				Female			244	NA	NA		2.8 (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 10. [Part 8]

The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age	Sample Size, n	BMI	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Veghari et al. (2012) ( 84 )	Golestan, local study	Both	2008							CDC 2000		CDC 2000
				Both	15 - 65	39.6 ± 14.3	6489:	NA	NA		23 (22.39 - 23.61)		31.5 (30.76 - 32.2)
				Male		NA	3245	25 ± 4.8	24.88 - 25.12		14.1 (13.68 - 14.52)		32.4 (31.65 - 33.15)
				Female		NA	3244	27.5 ± 6.1	27.29 - 27.71		31.8 (31.27 - 32.33)		30.5 (29.98 - 31.02)
Kelishadi et al. ( 85 )	CASPIAN I, national study	Both	2004							CDC 2000		CDC 2000
				Both	6 - 18	12.27 ± 3.32	20,966	18.42 ± 3.87	18.42 - 3.8		3.42 (3.17 - 3.67)		10.96 (10.54 - 11.39)
				Male		12.27 ± 3.3	10,793	18.26 ± 3.83	18.26 ± 3.83		3.34 (3.00 - 3.69)		9.70 (9.14 - 10.27)
				Female		12.27 ± 3.34	10,173	18.60 ± 3.91	18.60 ± 3.91		3.50 (3.15 - 3.87)		12.30 (11.66 - 12.95)
Kelishadi et al. ( 30 )	CASPIAN III, national study	Both	2010							CDC 2000		CDC 2000
				Both	10 - 18	14.27 ± 24	5625	19.42 ± 4.09	19.31 - 19.53		8.91 (8.17 - 9.68)		8.02 (7.32 - 8.75)
				Male		14.68 ± 24	2824	19.61 ± 4.12	19.45 - 19.76		10.13 (9.03 - 11.29)		9.38 (8.33 - 10.51)
				Female		14.76 ± 23	2801	19.23 ± 4.06	19.08 - 19.38		7.68 (6.71 - 8.72)		6.64 (5.74 - 7.62)
Khashayar et al. (2013) ( 86 )	CASPIAN IV, national study	Both	2012							CDC 2000		CDC 2000
				Both	6 - 18	12.47 ± 3.36	13,350	18.85 ± 4.42	18.70 - 18.99		11.89 (11.22 - 12.59)		9.66 (9.13 - 10.21)
				Male		12.36 ± 3.39	6777	18.73 ± 4.42	18.53 - 18.94		13.58 (12.59 - 14.63)		9.27 (8.56 - 10.05)
				Female		12.58 ± 3.32	6573	18.97 ± 4.39	18.76 - 19.17		10.15 (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

Reference	Location	Urban/Rural	Year of Study	Gender	Age - group, y	Age[a]	Sample Size, n	WHR[a]	CI 95% WHR Mean	Prevalence of Abdominal Obesity, %	WC[a]	CI 95% WC mean	WHtR[a]	CI 95% WHtR Mean
Amini et al. (2007) ( 41 )	Tehran	U
			2001	Both	10 - 15	12.6 ± 0.9	395	0.8 ± 0.07	0.79 - 0.81	NA	NA	NA	NA	NA
			2001	Male		12.7 ± 0.9	197	0.83 ± 0.06	0.82 - 0.84	NA	NA	NA	NA	NA
			2001	Female		12.5 ± 0.9	198	0.77 ± 0.06	0.76 - 0.78	NA	NA	NA	NA	NA
Azimi-Nezhad et al. (2009) ( 44 )	Khorasan- Razavi	Both
			2004	Both	15 - 20	NA	540	NA	NA	NA	NA	NA	NA	NA
			2004	Male	NA	NA	280	NA	NA	NA	74.63 ± 12.54	73.16 - 76.1	0.43 ± 0.07	0.42 - 0.44
			2004	Female	NA	NA	260	NA	NA	NA	70.09 ± 10.6	68.80 - 71.38	0.47 ± 0.06	0.46 - 0.48
Gharakhanlou et al. (2012) ( 49 )	National study	U
			2011	Male	15 - 19	NA	139	0.82 ± 0.05	0.81 - 0.83	NA	-74.5 ± 8.9	73.02 - 75.98	0.43 ± 0.06	0.42 - 0.43
			2011	Female	NA	NA	145	0.78 ± 0.06	0.77 - 0.79	NA	7.2.7 ± 9.0	71.24 - 74.16	0.45 ± 0.07	0.44 - 0.46
Hosseini-Esfahani et al. (2011) ( 87 )	Tehran	U
			2001	Male	10 - 14	12.4 ± 1	688	NA	NA	NA	NA	64.9 ± 117	64.08 - 65.72	NA
			2001	Male	15 - 19	16.8 ± 1	734	NA	NA	NA	NA	3.9 ± 11	73.10 - 74.70	NA
			2005	Male	10 - 14	12.2 ± 1	190	NA	NA	NA	NA	72.6 ± 13	70.75 - 74.45	NA
			2005	Male	15 - 19	17.1 ± 1	346	NA	NA	NA	NA	80.4 ± 12	79.14 - 81.66	NA
			2008	Male	10 - 14	12.2 ± 1	230	NA	NA	NA	NA	71.3 ± 13	69.62 - 72.98	NA
			2008	Male	15 - 19	17.2 ± 1	287	NA	NA	NA	NA	81.5 ± 13	79.97 - 83.03	NA
			2001	Female	10 - 14	12.3 ± 1	675	NA	NA	NA	NA	66.9 ± 9	66.22 - 67.58	NA
			2001	Female	15 - 19	17.0 ± 1	913	NA	NA	NA	NA	72.5 ± 9	71.92 - 73.08	NA
			2005	Female	10 - 14	12.3 ± 1	214	NA	NA	NA	NA	68.5 ± 10	67.16 - 69.84	NA
			2005	Female	15 - 19	17.3 ± 1	357	NA	NA	NA	NA	73.3 ± 9	72.37 - 74.23	NA
			2008	Female	10 - 14	12.3 ± 1	231	NA	NA	NA	NA	66.9 ± 10	65.61 - 68.19	NA
			2008	Female	15 - 19	17.2 ± 1	351	NA	NA	NA	NA	71.3 ± 9	70.36 - 72.24	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 13. [Part 3]

The WHR, WC, and WHtR Mean and Abdominal Obesity in Population-Based Studies in Iranian Children and Adolescents

Reference	Location	Urban/Rural	Year of Study	Gender	Age - group, y	Age	Sample Size, n	WHR	CI 95% WHR Mean	Prevalence of Abdominal Obesity, %	WC	CI 95% WC mean	WHtR	CI 95% WHtR Mean
Kelishadi et al. (1997) ( 85 )	CASPIAN I, National study	Both
			2004	Both	6 - 18	12.27 ± 3.32	20,966	0.43 ± 0.06	0.429 - 0.431	9.27(8.87-9.67)	64.61 ± 10.91	64.46 - 64.76	0.80 ± 0.08	0.805 - 0.807
			2004	Male	NA	12.27 ± 3.3	10,793	0.43 ± 0.06	0.427 - 0.429	9.14(8.60-9.69)	64.99 ± 11.41	64.78 - 65.21	0.82 ± 0.09	0.817 - 0.821
			2004	Female	NA	12.27 ± 3.34	10,173	0.44 ± 0.06	0.431 - 0.433	9.41(8.84-9.99)	64.21 ± 10.34	64.01 - 64.41	0.79 ± 0.08	0.791 - 0.794
Kelishadi (2012) et al. ( 30 )	CASPIAN III, National study	Both
			2010	Both	10 - 18	14.27 ± 24	5625	0.44 ± 0.13	0.442 - 0.448	NA	68.72 ± 20.67	68.1 - 69.2	NA	NA
			2010	Male	NA	14.68 ± 24	2824	0.44 ± 0.14	0.439 - 0.449	NA	67.59 ± 22.16	66.7 - 68.4	NA	NA
			2010	Female	NA	14.76 ± 23	2801	0.44 ± 0.12	0.441 - 0.450	NA	69.86 ± 18.99	69.1 - 70.5	NA	NA
Khashayar (2013) et al. ( 86 )	CASPIAN IV, National study	Both
			2012	Both	6 - 18	12.47 ± 3.36	13,350	0.45 ± 0.06	0.454 - 0.458	19.12(18.22-20.06)	67.02 ± 11.96	66.57 - 67.48	0.18 ± 0.03	0.184 - 0.187
			2012	Male		12.36 ± 3.39	6777	0.46 ± 0.06	0.456 - 0.461	20.41(19.09-21.79)	67.83 ± 12.84	67.15 - 68.51	0.19 ± 0.03	0.189 - 0.192
			2012	Female		12.58 ± 3.32	6573	0.45 ± 0.06	0.452 - 0.457	17.79(16.56-19.09)	66.19 ± 10.92	65.62 - 66.76	0.18 ± 0.03	0.179 - 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.

Table 4. [Part 2]

The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Amanolahi et al. (2012) ( 39 )	Tehran, local study	U	NA	Female	NA	10.6 ± 0.71	1040	NA	NA	CDC 2000	NA	CDC 2000	8.65
Amidimazaheri et al. (2010) ( 40 )	Isfahan, local study	NA	NA	Female	14 - 18	NA	384	NA	NA	CDC 2000	1.03 (0.93 - 1.13)	CDC 2000	9.1 (8.27 - 9.93)
Amini et al. (2007) ( 41 )	Tehran, local study	U	2001							CDC 2000		CDC 2000
				Both	10 - 15	12.6 ± 0.9	396	19.8 ± 3.8	19.43 - 20.17		10 (9.11 - 10.88)		16 (14.68 - 17.32)
				Male		12.7 ± 0.9	199	19.7 ± 4	19.14 - 20.26		13 (11.43 - 14.57)		14 (12.33 - 15 - 67)
				Female		12.5 ± 0.9	197	19.9 ± 3.7	19.38 - 20.42		6.5 (5.65 - 7.35)		19 (16.85 - 21.15)
Aminzadeh et al. (2013) ( 42 )	Ahvaz, local study	U	2010							CDC 2000		CDC 2000
				Both	6 - 10	NA	1594	NA	NA		17.7 (16.98 - 18.41)		18.8 (18.05 - 19.55)
				Male			835	NA	NA		14.65 (13.80 - 15.50)		16.7 (15.76 - 17.64)
				Female			759	NA	NA		21.08 (19.90 - 22.26)		21.74 (20.53 - 22.95)
Asadi Noghabi et al. (2011) ( 43 )	Bandarabbas, local study	U	NA							CDC 2000		CDC 2000
				Male	7 - 11	NA	661	NA	NA		10.9 (10.16 - 11.64)		10 (9.31 - 10.69)
				Female		NA	689				6.2 (5.77 - 6.63)		12.8 (11.97 - 13.63)
Azimi-Nezhad et al. (2009) ( 44 )	Khorasan-Razavi, provencial study	Both	2004							WHO		WHO
				Male	15 - 20	NA	280	20.64 ± 3.45	20.24 - 21.04		NA		NA
				Female		NA	260	21.47 ± 3.34	21.06 - 21.88		NA		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 5. [Part 3]

The Prevalence of Obesity in Population-Based Studies in Iranian Children and Adolescents (Based on BMI Measure)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Bazhan et al. (2005) ( 45 )	Lahijan, local study	U	2001	Female	14 - 17	NA	400	21.9 ± 3.5	21.56 - 22.24	CDC 2000	5.3 (4.81 - 5.79)	CDC 2000	14.8 (13.56 - 16.04)
Bidad et al. (2008) ( 46 )	Tehran, local study	U	2005	Female	11 - 17	14 ± 1.8	400	20.61 ± 3.79	20.24 - 20.98	CDC 2000	6.7 (6.09 - 7.31)	CDC 2000	14.6 (13.38 - 15.82)
Baygi et al. (2010) ( 47 )	Neishabour, local study	U	2005							CDC 2000		CDC 2000
				Both	6 - 12	NA	1471	NA	NA		4.6 (4.38 - 4.82)		NA
				Male		NA	822	NA	NA		NA		NA
				Female		NA	649	NA	NA		NA		NA
Gargari et al. (2004) ( 48 )	Tabriz, local study	U	2001	Female	14 - 17.9	16 ± 1.4	1518	21.3 ± 3.6	21.12 - 21.48	CDC 2000	NA	CDC 2000	NA
Gharakhanlou et al. (2012) ( 49 )	National study	U	2011							WHO		WHO
				Male	15 - 19	NA	139	3.1 ± 21.4	20.88 - 21.92		2.8 (2.35 - 3.25)		9.3 (7.90 - 10.70)
				Female		NA	145	21.9 ± 3.8	21.28 - 22.52		2.7 (2.27 - 3.13)		12.4 (10.63 - 14.17)
Haeri Behbahani et al. (2009) ( 50 )	Sabzevar, local study	U	2007							CDC 2000		CDC 2000
				Both	6 - 11	NA	960	16.6 ± 2.8	16.42 - 16.78		6 (4.5 - 7.6)		8.4 (6.7 - 10.2)
						NA	840	16.3 ± 2.6	16.12 - 16.48		3.5 (2.2 - 4.7)		7.4 (5.6 - 9.2)
Hajian et al. (2008) ( 51 )	Babol, local study	U	2006	Both	7 - 12	NA	1000	NA		CDC 2000	5.8 (5.46 - 6.14)	CDC 2000	12.3 (11.63 - 12.97)
Hajian-Tilaki et al. (2011) ( 52 )	Babol, local study	U	2006							CDC 2000		CDC 2000
				Both	7 - 12	9.3 ± 1.5	1000	NA	NA		5.8 (5.46 - 6.14)F: 3.8		12.3 (11.63 - 12.96)M: 12.5F:
				Male		NA	450	16.8 ± 3.4	16.49 - 17.14		8.8 (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)
				Female		NA	550	16.7 ± 2.8	16.47 - 16.93		3.8 (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)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Hajian-Tilaki et al. (2012) ( 53 )	Babol, local study	U	NA							CDC 2000		CDC 2000
				Both	12 - 17	NA	1200	NA	NA		8.3 (7.87 - 8.73)		15.1 (14.37 - 15.82)
				Male			NA	NA			10.2		NA
				Female			NA	NA			6.5		NA
Janghorbani et al. (1998) ( 54 )	Kerman, local study	U	1995	Female	14 - 18	16.2 ± 1.3	1000	19.8 ± 2.9	19.62 - 19.98	WHO	5.3 (4.99 - 5.61)	WHO	21.9 (20.84 - 22.96)
Karandish et al. (2004) ( 55 )	Tehran, local study	U	2000							CDC 2000		CDC 2000
				Both	11 - 16	NA	2486	NA	NA		NA		NA
				Male		13.7 ± 1.54	1147	19.8 ± 3.95	19.57 - 20.03		7.3 (6.91 - 7.69)		23.3 (22.27 - 24.33)
				Female		13.4 ± 1.64	1339	20.63 ± 4.11	20.41 - 20.85		8.3 (7.89 - 8.71)		18.8 (17.98 - 19.62)
Kelishadi et al. (2003) ( 56 )	Isfahan, Markazi local study	Both	2001							CDC 2000		CDC 2000
				Both	11 - 18	NA	2000	U: 25.4 ± 5.2 R: 23.2 ± 7.1	U: 24.29 - 26.51R: 22.76 - 23.64		NA		NA
				Male		NA	1000				1.87 (1.79 - 1.95)		7.4 (7.10 - 7.70)
				Female		NA	1000				2.9 (2.73 - 3.07)		10.7 (10.11 - 11.29)
Khadivzadeh et al. (2002) ( 57 )	Mashad, local study	U	1998	Female	15 - 19	NA	440	NA	NA	CDC 2000	1.8 (1.63 - 1.97)	CDC 2000	5.8 (5.29 - 6.31)
Maddah (2007) ( 58 )	Guilan, local study	U	2005	Female	14 - 17	NA	1054	NA	NA		F: 5.2 (4.90 - 5.50)		18.6 (17.69 - 19.51)
Maddah et al. (2010) ( 59 )	Rasht, local study	U	2007							CDC 2000		CDC 2000
				Both	6 - 11	NA	6635	NA	NA		NA		NA
				Male			3551				5 (4.89 - 5.11)		11.5 (11.26 - 11.74)
				Female			3084				5.9 (5.72 - 6.08)		15 (14.58 - 15.42)
Maddah et al. (2010) ( 60 )	Zahedan, local study	U	NA							CDC 2000		CDC 2000
				Both	7 - 11	NA	1079	NA	NA		NA		M: 8.9 F: 10.3
				Male			500		NA		NA		8.9 (8.42 - 9.38)
				Female			579	NA	NA		NA		10.3 (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)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Mehrkash et al. (2010) ( 61 )	Gorgan, local study	U	NA							CDC 2000		CDC 2000
				Both	15 - 18	NA	450	NA	NA		NA		NA
				Male		15.66 ± 0.68	225	21.24 ± 3.45	20.79 - 21.69		NA		NA
				Female		16.34 ± 0.77	225	22.41 ± 4.32	21.85 - 22.97		NA		NA
Mirhosseini et al. (2009) ( 62 )	Mashhad, local study	U	NA	Female	15 - 17	16.4 ± 0.09	622	20.7 ± 3.6	13.5 - 36.9	NA	NA	NA	NA
Mirmiran et al. (2004) ( 63 )	Tehran, local study	U
			1999	Both	6 - 16	NA	732	NA	NA	CDC 2000	4.5 (4.19 - 4.81)	CDC 2000	NA
			1999	Male			339	NA			5.5 (4.95 - 6.05)		NA
			1999	Female			393	NA			3.7 (3.35 - 4.05)		NA
			2002	Both	6 - 16	NA	673	NA	NA	CDC 2000	5.7 (5.29 - 6.11)	CDC 2000	NA
			2002	Male		NA	312				6.3 (5.64 - 6.96)
			2002	Female		NA	361				5.2 (4.69 - 5.71)
Moayeri et al. (2006) ( 64 )	Tehran, local study	U	2005							CDC 2000		CDC 2000
				Both	11 - 18	NA	2880	NA	NA		7.1 (6.72 - 7.48)		17.9 (17.06 - 18.74)
						NA	1180	NA	NA		7.8 (7.54 - 8.06)		21.1 (20.49 - 21.71)
						NA	1700	NA	NA		6.4 (6.12 - 6.68)		14.7 (14.10 - 15.30)
Mohammadpour-Ahranjani et al. (2003) ( 65 )	Tehran, local study	U	2001							CDC 2000		CDC 2000
				Male	11 - 16	13.7 ± 1.54	1068	19.8 ± 3.95	19.56 - 20.04		7.3 (6.89 - 7.71)		18.8 (17.88 - 19.72)
				Female		13.4 ± 1.54	1253	20.6 ± 4.11	20.37 - 20.83		8.3 (7.88 - 8.72)		23.1 (22.12 - 24.08)
Mojibian et al. (2001) ( 66 )	Yazd, local study	U	2000	Female	15 - 65	NA	570	NA	NA	WHO	16.3 (15.18 - 17.42)	CDC 2000	11.8 (10.15 - 13.45)
Montazerifar et al. (2009) (67)	Sistan va Baluchistan, local study	U	2006							CDC 2000		CDC 2000
				Female	14 - 18	16.4 ± 1.3	752	20 ± 1.45	NA		1.5 (1.39 - 1.61)		F: 8.6 (8.04 - 9.16)
	Zahedan, local study		2007	Female	11 - 14	13 ± 0.89	687				1.7 (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)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Montazerifar et al. (1999) ( 68 )	Yazd, local study	U	1998							CDC 2000		CDC 2000
				Both	7 - 11	NA	463	NA	NA		3.9 (3.56 - 4.24)		NA
				Male		NA	230	NA	NA		4.3 (3.77 - 4.83)		NA
				Female		NA	223	NA	NA		3.4 (2.98 - 3.82)		NA
Mostafavi et al. (2005) ( 69 )	Shiraz, local study	U	2002							CDC 2000		CDC 2000
				Both	13 - 18	NA	803	NA			2.9 (2.51 - 3.29)		11.3 (9.91 - 12.69)
				Male		NA	NA	19.4 ± 3.4	18.93 - 19.87		NA		NA
				Female		NA	NA	20.6 ± 3.8	20.07 - 21.13		NA		NA
Mozaffari et al. (2007) ( 70 )	Tehran, local study	U	2002	Female	7 - 12	9.67 ± 3.5	1800	NA	NA	CDC 2000	7.7 (7.37 - 8.03)	CDC 2000	13.3 (12.77 - 13.83)
Mozaffari et al. (2004) ( 71 )	Yazd, local study	U	2003							NCHS		NCHS
				Both	6 - 12	NA	4755	NA	NA		3.5 (3.40 - 3.60)		NA
				Male		NA	2948	NA	NA		1.0 (0.96 - 1.04)		NA
				Female		NA	1807	NA	NA		7.6 (7.28 - 7.92)		NA
Pourghasem et al. (2002) ( 72 )	Tabriz, local study	U	NA	Female	14 - 18	NA	1518	NA	NA	CDC 2000	3.6 (3.43 - 3.77)	CDC 2000	11.1 (10.60 - 11.59)
Rafraf et al. (2010) ( 73 )	Tabriz, local study	U	2008	Female	14 - 17	15.67 ± 1.01	985	21.28 ± 3.5	21.06 - 21.50	CDC 2000	2. (2.63 - 2.97)	CDC 2000	16.4 (15.54 - 17.26)
Rashidi et al. (2007) ( 74 )	Tehran, local study	U	2001							CDC 2000		CDC 2000
				Male	11 - 16	13.7 ± 1.54	1068	19.8 ± 4	20.37 - 20.83		7.3 (6.89 - 7.70)		18.8 (17.88 - 19.72)
				Female		13.4 ± 1.64	1253	20.6 ± 4.1	17.75 - 18.05		8.3 (:7.87 - 8.72)		23.1 (22.12 - 24.08)
Sadeqipoor et al. (1999) ( 75 )	Tehran, local study	U	1996	Female	11 - 14	NA	350	NA	NA	CDC 2000	13.7 (12.46 - 14.94)	CDC 2000	NA
Salem et al. (2009) ( 76 )	Kerman, local study	U	2007							CDC 2000		CDC 2000
				Female	11 - 18	14.3 ± 1.7	1221	NA	NA		F: 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)

Reference	Location	Urban/Rural	Year of Study	Gender	Age-group, y	Age[a]	Sample Size, n	BMI[a]	CI 95% BMI Mean	Obesity Definition	Prevalence of Obesity/CI 95%	Over Weight Definition	Prevalence of Over Weight/CI 95%
Salem et al. (2011) ( 77 )	Kerman, local study	U	2009							CDC 2000		CDC 2000
				Male	NA	NA	500	16.78 ± 3.76	16.45 - 17.11		NA		10.2 (9.40 - 11.00)
				Female	NA	NA	775	17.25 ± 3.33	17.02 - 17.48		NA		8.9 (8.33 - 9.47)
Saffari et al. (2011) ( 78 )	Qazvin, local study	U	2010	Female	6 - 14	NA	2201	17.9 ± 3.7 (6 - 9 yo: 16.10) (10 - 14 yo: 19.1(5)	NA	CDC 2000	NA	CDC 2000	NA
Sohailifar et al. (2000) ( 79 )	Hamadan, local study	U	1998							NCHS		NCHS
				Both	11 - 16	NA	2000	NA	NA		3.5 (3.35 - 3.65)		NA
				Male		NA	1000	NA	NA		4 (3.76 - 4.24)		NA
				Female		NA	1000	NA	NA		7.2 (6.79 - 7.61)		NA
Sotoodeh et al. (1997) ( 80 )	Hassanabad Khaleseh of Eslamshahr, local study	R	1994	Female	15 - 19	NA	35	22.5	NA	CDC 2000	NA	CDC 2000	NA
Taheri et al. (2009) ( 81 )	Birjand, local study	U	2005							CDC 2000		CDC 2000
				Both	15 - 18	NA	2230	NA	NA		2.2 (2.11 - 2.29)		6.2 (5.96 - 6.44)
				Male		NA	1115	NA	NA		2.8 (2.64 - 2.96)		5 (4.72 - 5.28)
				Female		NA	1115	NA	NA		1.8 (1.70 - 1.90)		7.1 (6.71 - 7.49)
Taheri et al. (2013) ( 82 )	Birjand, local study	U	2012							CDC 2000		CDC 2000
				Both	6 - 11	NA	1541	NA	NA		9.2 (8.78 - 9.62)		9.6 (9.17 - 10.03)
						NA	690	16.9	NA		10.9 (10.18 - 11.62)		11 (10.27 - 11.73)
						NA	851	16.3	NA		7.9 (7.41 - 8.39)		8.3 (7.79 - 8.81)
Veghari et al. (2010) ( 83 )	Golestan, local study	Both	2006	Both	15 - 24	NA	499	22.8	22.3 - 23.4	CDC 2000	5.1 (4.67 - 5.52)	CDC 2000	24.2 (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 12. [Part 2]

The WHR, WC, and WHtR Mean and Abdominal Obesity in Population-Based Studies in Iranian Children and Adolescents

Reference	Location	Urban/Rural	Year of Study	Gender	Age - group, y	Age	Sample Size, n	WHR	CI 95% WHR Mean	Prevalence of Abdominal Obesity, %	WC	CI 95% WC mean	WHtR	CI 95% WHtR Mean
Janghorbani et al. (1998) ( 54 )	Kerman	U	1995	Female	14 - 18	16.2 ± 1.3	1000	0.8 ± 0.06	0.8 - 0.81	NA	NA	70.8 ± 8.0	70 - 71.0	NA
Janghorbani et al. (2007) ( 88 )	National	Both
			2005	Male	15 - 24	23.9 ± 0.15	v	NA	NA	3.2	NA	NA	NA	NA
			2005	Female	NA	24.9 ± 0.18	NA	NA	NA	18.1	-	-	-	-
Mehrkash et al. (2010) ( 61 )	National study	U
			NA	Both	15 - 18	15.66 ± 0.68	225	NA	NA	NA	NA	75.24 ± 8.76	74.43-76.05	NA
			NA	Both	NA	16.34 ± 0.77	225	NA	NA	NA	NA	79.85 ± 10.35	78.50-81.20	NA
Mirhosseini et al. (2009) ( 62 )	Mashhad, Local study	U	NA	Female	15 - 17	16.4 ± 0.09	622	0.7 ± 0.04	0.69 - 0.70	9.5	NA	69 ± 7.8	68.39 - 69.61	NA
Sotoodeh et al. ( 80 )	HassanabadKhaleseh of Eslamshahr, Local study	R
			1994	Female	15 - 19	NA	205	0.78	NA	NA	NA	NA	NA	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).