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Abbasalizad-Farhangi M, Barzegari M. Nutrition Transition in Iran: An Analytical Study of the Factors Related to Life-Style Regarding Non-Communicable Diseases in Recent Decades. JNFS 2023; 8 (4) :553-564
URL: http://jnfs.ssu.ac.ir/article-1-584-en.html
URL: http://jnfs.ssu.ac.ir/article-1-584-en.html
Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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1 Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; 2 Department of Community Nutrition, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran.
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Nutrition Transition in Iran: An Analytical Study of the Factors Related to Life-Style Regarding Non-Communicable Diseases in Recent Decades
Mahdieh Abbasalizad-Farhangi; PhD*1 & Maliheh Barzegari; MSc2
Mahdieh Abbasalizad-Farhangi; PhD*1 & Maliheh Barzegari; MSc2
1 Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; 2 Department of Community Nutrition, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Background: In the current scoping review, nutrition transition and its consequences in Iran have been reviewed, and relevant health improvement policies have been described. Methods: This was an analytical study which concerned demographic, economic and socio-political context, nutrition, dietary patterns and related metabolic syndrome, or their consequences among Iranian population in recent decades. Results: In the last decades, socio-economic problems increased food insecurity, and unhealthy diet has been common. The prevalence of obesity was higher in urban areas compared with rural areas. There was also a high prevalence of nutritional risk factors; food choices tended to be less healthy; high-fat food choices has been increased, and there was lower physical activity. The prevalence of non-communicable diseases and metabolic syndrome including hypertension and type 2 diabetes mellitus are progressively elevated. Conclusions: Urgent preventive strategies and policies by the government and healthcare community are essential. These strategies are necessary for promoting national health, increasing life expectancy, and decreasing metabolic syndrome, diet-related and lethal diseases including cardiovascular diseases, and diabetes. Keywords: Nutrition transition; Obesity; Iran; Health; Chronic diseases |
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| Article history: Received: 24 Feb 2022 Revised: 18 May 2022 Accepted: 28 Jun 2022 |
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| *Corresponding author: abbasalizad_m@yahoo.com Attar Neyshabouri Street, Daneshgah Avenue, Tabriz University of Medical Sciences, Tabriz, Iran. Postal code: 5166614711 Tel: +98 4133357580 |
Introduction
The nutrition transition definition is basically according to changes in the quality and quantity of dietary patterns and behaviors in a population. These changes also involve some lifestyle-related factors including general health, work environments, physical activity and socioeconomic situation, all of which ultimately influence energy consumption (Rouhani-Tonekaboni et al., 2018). The current status of nutrition transition in Iran is characterized by high consumption of energy categorized as fat, fast foods and sugary foods, less physical activity and low fiber intakes (Popkin, 1993). In the current study, the authors evaluated the aspects of nutrition transition and its related changeable and unchangeable risk factors that contribute to higher burden of non-communicable diseases (NCDs) among the Iranian population.
Population and mortality changes
Population and mortality changes
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Improving global and regional public health is possible via improving in nutrition, vaccination, and perfect sanitation which leads to lowering infant mortality and increasing life expectancy. After the Islamic Revolution of 1979, Iran developed some policies to decrease birth rate, and after the Iraq war against Iran, some plans changed and led to an increased growth rate. Based on the data obtained from Iran Statistics Center (ISC), Iran’s total population is 83 million people, while it is estimated that the total population size will reach to 92 million people in 2050 and then be reduced to 70 million in 2100. Accordingly, Iran has a large population size ranking 19th to 26th between 2050 and 2100 (United Nations, 2015b) . Over the last few decades, the fertility rate has reduced due to some preventive strategies like family planning programs which were administered by the government, increased women’s literacy, increased marriage age, reduced child mortality rate, increased life costs, and pregnancy control by women (Abbasi-Shavazi, 2001, Abbasi Shavazi and Hosseini-Chavoshi, 2011, Ghobadi, 2010, Mirzaie, 2005, World Bank, 2010). Furthermore, it is demonstrated that the growth rate in Iran has been reduced in the last three decades and reached to about 1.2% in 2015-2020. It has been estimated that the growth rate would reach 0% by 2050, and after that, it will be negative (Figure 1) (United Nations, 2015b) . Since 2000, the Total Fertility Rate (TFR) of Iran was less than 2.1; however, it is estimated to be positive by 2050 (Figure 1) (United Nations, 2015b). The age range of the majority of population (̴ 70%) by the year 2020 will be 15–64 years old, and the median age about 32.4; the median age will be continuously increasing to 44.7 in 2050 (United Nations, 2015b) . In 2010–2015, the life expectancy of the Iranian population was about 75, and based on the World Population Prospects (WPP), it will be approximately 80 years in 2050 (United Nations, 2015b) .
Economic and socio-political context
There are considerable disparities of wealth and income in Iran; previous studies have shown great economic inequalities in Iran, particularly between rural and urban areas (Heslot, 2014). The total unemployment rate is 12%, while 30-40% of the youth are unemployed (Heslot, 2014). There are some accumulated resources, in old age, regarding socio-economic security and welfare, including income from work, family support, employers' comfort, owning pension savings, and other benefits such as health coverage and insurance (Mehri et al., 2020). On the contrary, the Iranian old-age economic situation is different in comparison with the above sources, and there is not a citizen-based pension like western countries such as the United States and Europe. Therefore, rich people are relying on their origins, but middle and low-income groups rely on their family and government supports (Mehri et al., 2020). However, there is some support and pensions for specific employees who worked in certain private or government organizations. Some of them are Boniyad Shahid Foundation, Komiteh Emdad Emam, and Astan Qods Razavi. Furthermore, low-income groups receive a monthly cash transfer of 450,000 rials (3 USD) (Mehri et al., 2020). Likewise, the income of the top decile of the population is 15-20 times higher than the bottom one, showing a great inequality of income distribution among the Iranian population (Ghassemi et al., 2002). Other studies revealed that Iran has acceptable industrial equipment in the field of animal protein, milk, cheese and wheat with self-sufficiency threshold (Alamdarlo et al., 2019, Soltani et al., 2020).
Nutritional status of Iranian population
Among countries, the variety of food consumption patterns is different and relies on cultures and social levels (Jessri et al., 2011). In recent decades, there have been considerable lifestyle modifications in Iran, especially in food consumption behaviors. Besides, several policies has been administered to improve nutrition statues and prevent malnutrition or obesity (Abdi et al., 2016, Baranowski et al., 2003, Legg et al., 2000). In 2005, a nationwide program was devised to reduce malnutrition in children under five years old. This program had two phases; first phase, was a collaborative phase, that covered all the mothers and their under six-year-old children in rural/urban health centers. The coverage included health planning, breastfeeding education, growth monitoring, illiteracy elimination, and also increasing access to food stores. The Second phase was a supportive phase focusing on low-income families who suffered from nutrition deficiencies and had growth-retarded or malnourished children. Previous studies have suggested that after ten years of administration, this program had some positive effects on children and reached an adequate extent; but, some aspects remained unclear, and there were some gaps that need more work (Ghodsi et al., 2018). Moreover, some vitamin and mineral deficiencies were prevalent in Iran including iodine, iron, zinc, vitamin B2 and vitamin A. In the case of vitamin B2, the most affected community were rural people, and non-standard food and dairy products were recognized as the most important factors (Ghassemi et al., 2002). A study in 2016 reported that in children under 5, there were 7.6%, 4.5% and 13.1% prevalence of underweight, wasted and stunted in Iran which were globally 16%, 8% and 26% (Abdi et al., 2016).
Food consumption
In Iran, the primary source of food production is agriculture, and due to several difficulties in marketing and production system it does not have an acceptable efficiency (Ardakani et al., 2017, Ardakani et al., 2009, Heslot, 2014). Moreover, about 35% of agricultural products, feeding 15 to 20 million people, are wasted and lost (Pirmoradi et al., 2013). To determine the changing trend in delivering food and nutrition security, an index for each dimension has been calculated by Ardakani et al. in five-year period, including accessibility, availability, stability and utilization; it has been indicated that in this period, accessibility and availability dimensions were steadily reduced (Table 1). Also, nutrition and food security in Iran from 2007 to 2011 sharply declined (Figure 2) (Ardakani et al., 2017). However, there have been great changes in Iranian dietary context and habits over time. The Iranian dietary pattern generally includes three categories of traditional, healthy, and western dietary patterns; the traditional dietary pattern is semi-healthy and mainly consists of rice, vegetables, red meat, fruits, soy, pickles, animal fat, and poultry. Healthy dietary pattern comprises fish, olive and vegetable oil, and little amounts of bread and animal fat; finally, western dietary patterns includes fast foods, soft drinks, sweets, cream, and high-fat meats (Zaribaf et al., 2019). Furthermore, Iranian food security has been affected by international sanctions, with greatest impact on the middle-class and poorer households. The sanctions caused great inflation in the price of food products; while people showed tendency to buy food products with lower price and less nutritional values (Heslot, 2014). Nowadays, the majority of population in Iran are not able to prepare foods with high nutritional quality, and they tend to buy cheap foods with high energy and less micronutrients, leading to more diet-related disease like obesity, type two diabetes mellitus (T2DM )and cardiovascular disorders (Pouraram et al., 2018).
Dietary changes
Besides nutrition transition, considerable dietary changes have also occurred, and fatty food consumption has increased. In traditional countries, fat consumption increased as well (Popkin, 1993, Umanath et al., 2016). Despite unhealthy food consumption, some lifestyle habits such as smoking and low physical activity contribute to adiposity and cardiovascular disease (CVD) (Sadeghi et al., 2017). Khatibi et al. demonstrated that high-fat and high-salt foods' led to the high prevalence of hypertension and CVD (Khatibi et al., 2018). Other studies showed that there was a higher prevalence of obesity in lower socio-economic levels of society, and also obesity increased through urbanization of big cities such as Tehran (Emamian et al., 2017). Based on the previous studies, people have more tendency toward fatty and fast foods (Mansouri-Tehrani et al., 2019, Mohammadbeigi et al., 2018, Rouhani-Tonekaboni et al., 2018). The prevalence of food insecurity among different groups in Iran is 49% in households, 49% in adolescents, 61% in mothers, 65% in the elderly, and 6% among children (Behzadifar et al., 2016, Shahraki et al., 2016). Traditional food patterns containing high amount of vegetable, wheat, and fruit is replaced with sugars and high fatty foods with less amounts of iron, iodine and other micronutrient deficiencies (Ardakani et al., 2017). Furthermore, 30% of households consume 80% of per capita energy- 3000 kcal per person- and this diet provides less than 80% of the essential micronutrients such as vitamin A, calcium, and riboflavin (Ghassemi, 2000, Rastegar, 2016).
Sedentary lifestyle and obesity
Obesity has a high prevalence worldwide, and a sedentary lifestyle is one of its main contributing factors, responsible for 5% of total deaths (Xie et al., 2014). A sedentary lifestyle is a health-related risk factor and leads to obesity and related co-morbidities (Smith et al., 2015). In Iran, evidence shows that obesity has been increased in recent years (Emamian et al., 2017), with a high prevalence in children and adolescents (Esmaili et al., 2015). Esmaili et al. in a nationwide study, demonstrated that the prevalence of overweight, obesity, and abdominal obesity among Iranian children and adults was higher in urban areas than in rural areas (Figure 3) (Esmaili et al., 2015). The cause of obesity is screen addiction including watching TV, cell phones, and tablets, and personal computers. Screen addiction such as TV watching is associated with lower metabolic rate in comparison with reading and writing which also sedentary activities (Hu et al., 2001, Sisson et al., 2012), and the risk of CVD increases by prolonged TV watching (Grøntved and Hu, 2011). Currently, the epidemiological transition in Iran led to nutritional problems among primary-school children and watching TV aggravated their food habits, which resulted in developing obesity independent of physical activity (Ghobadi et al., 2018). Also, according to a nationwide cross‐sectional survey, the leisure-time physical activity in men and women was 35.4% and 20.3%, respectively (Janghorbani et al., 2007). Iran is a developing country that has experienced urbanization, cultural, social, and economic transitions (Kelishadi et al., 2008). Over the past years, the prevalence of obesity among Iranian people significantly increased (Esteghamati et al., 2010). Interestingly, as described before, obesity in Iran for males and females was 3.34% and 3.50% in 2004 and 13.58% and 10.15% in 2012. However, the prevalence of abdominal obesity was 47.9% in 1999 and 71.1% in 2011 (Barzin et al., 2015, Djalalinia et al., 2016). Moreover, the prevalence of obesity has increased in children and adolescents (Djalalinia et al., 2016). The highest rates of obesity belonged to women of 40 and men of 20 ; higher waist circumference (WC) and lower education were also related to higher risk of obesity (Barzin et al., 2015). Sedentary behaviors and changes in diet could be the most important contributing factors to the increased prevalence.
Blood cholesterol and dyslipidemia
Dyslipidemia and high cholesterol levels in plasma are the most common problems leading to CVD. Dyslipidemia is defined with lower levels of high-density lipoprotein cholesterol (HDL-C), and higher values of triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) in the blood (Hedayatnia et al., 2020). Among the Iranian population, the prevalence of low HDL-C, hypertriglyceridemia, high levels of LDL-C, and hypercholesterolemia in both genders are 43.9, 46.0, 35.5, and 41.6 %, respectively (Hedayatnia et al., 2020). Recently, Hedayatnia et al. assessed the prevalence of dyslipidemia and related components among 8698 participants aged 35–65 with experience of heart attack in Mashahd (Table 2) (Hedayatnia et al., 2020). Moreover, it has been indicated that among Iranian adult patients with CVD, the prevalence of dyslipidemia was 87% (Darroudi et al., 2018, Hedayatnia et al., 2020). CVD is the major cause of mortality in Iran; among the cause-specific death rates, 79% of deaths are from chronic diseases, and 50% are related to CVD (Sadeghi et al., 2017). It has also been estimated that until 2025, CVD mortality will be increased (Figure 4); obesity, unhealthy diet, high-fat diet, and dyslipidemia are the most common causes of CVD (Després and Lemieux, 2006, Mathers and Loncar, 2006, Ordovas, 2006, Tveden-Nyborg et al., 2016). In a study on Iranian adults over 20 in 2019, it was demonstrated that from 1990 to 2011 the borderline increase in the blood cholesterol level in males was 39.8% and in females was 46.3% (Hosseini et al., 2019). Hosseini et al. reported that the prevalence of borderline increase in blood cholesterol nationwide had had an increasing
trend with the prevalence of 46.3%, while hypercholesterolemia’s prevalence rate was 18.0% in 1990-2011 (Hosseini et al., 2019). In the study conducted by Alimohammadi et al., the total cholesterol levels in females and males was reduced in the period of 1980 to 1990 and increased in 1990-2010; whereas, the figure for females had increased constantly from 1980 to 2010 (Alimohammadi et al., 2018).
Hypertension, T2DM and metabolic syndrome
Hypertension is one of the five global causes of mortality among children and adults, when obesity, hypertension, and other CVD risk factors are combined, the likelihood of adverse CVD significantly increases, and there is a need for aggressive treatment (Natsis et al., 2019). Based on the meta-analysis of 42 studies in Iran between 1980 and 2012, the total prevalence of hypertension was 22%, 23.6% in men and 23.5% in women. In addition, the prevalence of hypertension was higher in women ≥ 40 (Figure 5) (Mirzaei et al., 2016). In a study with 402,282 subjects, the prevalence of hypertension in urban and rural areas was 22.1% and 18.6% respectively (Mirzaei et al., 2016). Moreover, Mirzaei et al. showed that from 1980 to 2010, there was an increased prevalence of hypertension which increased with age; at the age range of over 40, the prevalence of hypertension in women was more than men (Mirzaei et al., 2016). It has also been indicated that Iranian people had higher daily consumption of salt compared with the National Training Program of United States guidelines, and people with lower socio-economic status had higher salt intake compared with people with higher socio-economic status (Mazloomy Mahmoodabad et al., 2016). There was a strong relationship between T2DM, and obesity, both of which are the most dangerous diseases among metabolic disorders (Verma and Hussain, 2017). In a study among 728 Iranian patients with T2DM, the relationship between obesity and dietary patterns was evaluated, and the results showed that there was a negative and positive association between healthy and unhealthy dietary habits, and the prevalence of general obesity (Basiri et al., 2015). Every year, T2DM imposes a huge financial burden on society and healthcare systems (Bakker et al., 2016). Previous studies demonstrated that there was a 35% increase in the prevalence of T2DM among the Iranian adult population between 2005 to 2011, contributing to the total prevalence of 11.4% (Esteghamati et al., 2014). Furthermore, Esteghamati et al. indicated that all kinds of diabetes showed a 85.5% prevalence of T2DM (Esteghamati et al., 2017). In a study in Tehran city, the prevalence of T2DM among people with low socio-economic status was higher than the other regions; they had a higher rate of T2DM (Asadi-Lari et al., 2016). Metabolic syndrome (MetS), is also a prominent disorder contributing to T2DM, hypertension, obesity, and dyslipidemia. A nationwide survey showed that the prevalence of MetS among the urban population, older adults, low educated people, postmenopausal women, and people with unhealthy diets and low physical activity was higher than the other groups (Hajian-Tilaki, 2015). Since one of the significant factors of MetS is obesity, and obesity directly relates to lifestyle, some studies revealed that the rate of obesity among Iranian adults has increased in the last decades (Azimi-Nezhad et al., 2012, Hajian-Tilaki and Heidari, 2007, Jouyandeh et al., 2013, Shahini et al., 2013); this rate was almost higher in women (Azimi-Nezhad et al., 2012, Delavari
et al., 2009).
Economic and socio-political context
There are considerable disparities of wealth and income in Iran; previous studies have shown great economic inequalities in Iran, particularly between rural and urban areas (Heslot, 2014). The total unemployment rate is 12%, while 30-40% of the youth are unemployed (Heslot, 2014). There are some accumulated resources, in old age, regarding socio-economic security and welfare, including income from work, family support, employers' comfort, owning pension savings, and other benefits such as health coverage and insurance (Mehri et al., 2020). On the contrary, the Iranian old-age economic situation is different in comparison with the above sources, and there is not a citizen-based pension like western countries such as the United States and Europe. Therefore, rich people are relying on their origins, but middle and low-income groups rely on their family and government supports (Mehri et al., 2020). However, there is some support and pensions for specific employees who worked in certain private or government organizations. Some of them are Boniyad Shahid Foundation, Komiteh Emdad Emam, and Astan Qods Razavi. Furthermore, low-income groups receive a monthly cash transfer of 450,000 rials (3 USD) (Mehri et al., 2020). Likewise, the income of the top decile of the population is 15-20 times higher than the bottom one, showing a great inequality of income distribution among the Iranian population (Ghassemi et al., 2002). Other studies revealed that Iran has acceptable industrial equipment in the field of animal protein, milk, cheese and wheat with self-sufficiency threshold (Alamdarlo et al., 2019, Soltani et al., 2020).
Nutritional status of Iranian population
Among countries, the variety of food consumption patterns is different and relies on cultures and social levels (Jessri et al., 2011). In recent decades, there have been considerable lifestyle modifications in Iran, especially in food consumption behaviors. Besides, several policies has been administered to improve nutrition statues and prevent malnutrition or obesity (Abdi et al., 2016, Baranowski et al., 2003, Legg et al., 2000). In 2005, a nationwide program was devised to reduce malnutrition in children under five years old. This program had two phases; first phase, was a collaborative phase, that covered all the mothers and their under six-year-old children in rural/urban health centers. The coverage included health planning, breastfeeding education, growth monitoring, illiteracy elimination, and also increasing access to food stores. The Second phase was a supportive phase focusing on low-income families who suffered from nutrition deficiencies and had growth-retarded or malnourished children. Previous studies have suggested that after ten years of administration, this program had some positive effects on children and reached an adequate extent; but, some aspects remained unclear, and there were some gaps that need more work (Ghodsi et al., 2018). Moreover, some vitamin and mineral deficiencies were prevalent in Iran including iodine, iron, zinc, vitamin B2 and vitamin A. In the case of vitamin B2, the most affected community were rural people, and non-standard food and dairy products were recognized as the most important factors (Ghassemi et al., 2002). A study in 2016 reported that in children under 5, there were 7.6%, 4.5% and 13.1% prevalence of underweight, wasted and stunted in Iran which were globally 16%, 8% and 26% (Abdi et al., 2016).
Food consumption
In Iran, the primary source of food production is agriculture, and due to several difficulties in marketing and production system it does not have an acceptable efficiency (Ardakani et al., 2017, Ardakani et al., 2009, Heslot, 2014). Moreover, about 35% of agricultural products, feeding 15 to 20 million people, are wasted and lost (Pirmoradi et al., 2013). To determine the changing trend in delivering food and nutrition security, an index for each dimension has been calculated by Ardakani et al. in five-year period, including accessibility, availability, stability and utilization; it has been indicated that in this period, accessibility and availability dimensions were steadily reduced (Table 1). Also, nutrition and food security in Iran from 2007 to 2011 sharply declined (Figure 2) (Ardakani et al., 2017). However, there have been great changes in Iranian dietary context and habits over time. The Iranian dietary pattern generally includes three categories of traditional, healthy, and western dietary patterns; the traditional dietary pattern is semi-healthy and mainly consists of rice, vegetables, red meat, fruits, soy, pickles, animal fat, and poultry. Healthy dietary pattern comprises fish, olive and vegetable oil, and little amounts of bread and animal fat; finally, western dietary patterns includes fast foods, soft drinks, sweets, cream, and high-fat meats (Zaribaf et al., 2019). Furthermore, Iranian food security has been affected by international sanctions, with greatest impact on the middle-class and poorer households. The sanctions caused great inflation in the price of food products; while people showed tendency to buy food products with lower price and less nutritional values (Heslot, 2014). Nowadays, the majority of population in Iran are not able to prepare foods with high nutritional quality, and they tend to buy cheap foods with high energy and less micronutrients, leading to more diet-related disease like obesity, type two diabetes mellitus (T2DM )and cardiovascular disorders (Pouraram et al., 2018).
Dietary changes
Besides nutrition transition, considerable dietary changes have also occurred, and fatty food consumption has increased. In traditional countries, fat consumption increased as well (Popkin, 1993, Umanath et al., 2016). Despite unhealthy food consumption, some lifestyle habits such as smoking and low physical activity contribute to adiposity and cardiovascular disease (CVD) (Sadeghi et al., 2017). Khatibi et al. demonstrated that high-fat and high-salt foods' led to the high prevalence of hypertension and CVD (Khatibi et al., 2018). Other studies showed that there was a higher prevalence of obesity in lower socio-economic levels of society, and also obesity increased through urbanization of big cities such as Tehran (Emamian et al., 2017). Based on the previous studies, people have more tendency toward fatty and fast foods (Mansouri-Tehrani et al., 2019, Mohammadbeigi et al., 2018, Rouhani-Tonekaboni et al., 2018). The prevalence of food insecurity among different groups in Iran is 49% in households, 49% in adolescents, 61% in mothers, 65% in the elderly, and 6% among children (Behzadifar et al., 2016, Shahraki et al., 2016). Traditional food patterns containing high amount of vegetable, wheat, and fruit is replaced with sugars and high fatty foods with less amounts of iron, iodine and other micronutrient deficiencies (Ardakani et al., 2017). Furthermore, 30% of households consume 80% of per capita energy- 3000 kcal per person- and this diet provides less than 80% of the essential micronutrients such as vitamin A, calcium, and riboflavin (Ghassemi, 2000, Rastegar, 2016).
Sedentary lifestyle and obesity
Obesity has a high prevalence worldwide, and a sedentary lifestyle is one of its main contributing factors, responsible for 5% of total deaths (Xie et al., 2014). A sedentary lifestyle is a health-related risk factor and leads to obesity and related co-morbidities (Smith et al., 2015). In Iran, evidence shows that obesity has been increased in recent years (Emamian et al., 2017), with a high prevalence in children and adolescents (Esmaili et al., 2015). Esmaili et al. in a nationwide study, demonstrated that the prevalence of overweight, obesity, and abdominal obesity among Iranian children and adults was higher in urban areas than in rural areas (Figure 3) (Esmaili et al., 2015). The cause of obesity is screen addiction including watching TV, cell phones, and tablets, and personal computers. Screen addiction such as TV watching is associated with lower metabolic rate in comparison with reading and writing which also sedentary activities (Hu et al., 2001, Sisson et al., 2012), and the risk of CVD increases by prolonged TV watching (Grøntved and Hu, 2011). Currently, the epidemiological transition in Iran led to nutritional problems among primary-school children and watching TV aggravated their food habits, which resulted in developing obesity independent of physical activity (Ghobadi et al., 2018). Also, according to a nationwide cross‐sectional survey, the leisure-time physical activity in men and women was 35.4% and 20.3%, respectively (Janghorbani et al., 2007). Iran is a developing country that has experienced urbanization, cultural, social, and economic transitions (Kelishadi et al., 2008). Over the past years, the prevalence of obesity among Iranian people significantly increased (Esteghamati et al., 2010). Interestingly, as described before, obesity in Iran for males and females was 3.34% and 3.50% in 2004 and 13.58% and 10.15% in 2012. However, the prevalence of abdominal obesity was 47.9% in 1999 and 71.1% in 2011 (Barzin et al., 2015, Djalalinia et al., 2016). Moreover, the prevalence of obesity has increased in children and adolescents (Djalalinia et al., 2016). The highest rates of obesity belonged to women of 40 and men of 20 ; higher waist circumference (WC) and lower education were also related to higher risk of obesity (Barzin et al., 2015). Sedentary behaviors and changes in diet could be the most important contributing factors to the increased prevalence.
Blood cholesterol and dyslipidemia
Dyslipidemia and high cholesterol levels in plasma are the most common problems leading to CVD. Dyslipidemia is defined with lower levels of high-density lipoprotein cholesterol (HDL-C), and higher values of triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) in the blood (Hedayatnia et al., 2020). Among the Iranian population, the prevalence of low HDL-C, hypertriglyceridemia, high levels of LDL-C, and hypercholesterolemia in both genders are 43.9, 46.0, 35.5, and 41.6 %, respectively (Hedayatnia et al., 2020). Recently, Hedayatnia et al. assessed the prevalence of dyslipidemia and related components among 8698 participants aged 35–65 with experience of heart attack in Mashahd (Table 2) (Hedayatnia et al., 2020). Moreover, it has been indicated that among Iranian adult patients with CVD, the prevalence of dyslipidemia was 87% (Darroudi et al., 2018, Hedayatnia et al., 2020). CVD is the major cause of mortality in Iran; among the cause-specific death rates, 79% of deaths are from chronic diseases, and 50% are related to CVD (Sadeghi et al., 2017). It has also been estimated that until 2025, CVD mortality will be increased (Figure 4); obesity, unhealthy diet, high-fat diet, and dyslipidemia are the most common causes of CVD (Després and Lemieux, 2006, Mathers and Loncar, 2006, Ordovas, 2006, Tveden-Nyborg et al., 2016). In a study on Iranian adults over 20 in 2019, it was demonstrated that from 1990 to 2011 the borderline increase in the blood cholesterol level in males was 39.8% and in females was 46.3% (Hosseini et al., 2019). Hosseini et al. reported that the prevalence of borderline increase in blood cholesterol nationwide had had an increasing
trend with the prevalence of 46.3%, while hypercholesterolemia’s prevalence rate was 18.0% in 1990-2011 (Hosseini et al., 2019). In the study conducted by Alimohammadi et al., the total cholesterol levels in females and males was reduced in the period of 1980 to 1990 and increased in 1990-2010; whereas, the figure for females had increased constantly from 1980 to 2010 (Alimohammadi et al., 2018).
Hypertension, T2DM and metabolic syndrome
Hypertension is one of the five global causes of mortality among children and adults, when obesity, hypertension, and other CVD risk factors are combined, the likelihood of adverse CVD significantly increases, and there is a need for aggressive treatment (Natsis et al., 2019). Based on the meta-analysis of 42 studies in Iran between 1980 and 2012, the total prevalence of hypertension was 22%, 23.6% in men and 23.5% in women. In addition, the prevalence of hypertension was higher in women ≥ 40 (Figure 5) (Mirzaei et al., 2016). In a study with 402,282 subjects, the prevalence of hypertension in urban and rural areas was 22.1% and 18.6% respectively (Mirzaei et al., 2016). Moreover, Mirzaei et al. showed that from 1980 to 2010, there was an increased prevalence of hypertension which increased with age; at the age range of over 40, the prevalence of hypertension in women was more than men (Mirzaei et al., 2016). It has also been indicated that Iranian people had higher daily consumption of salt compared with the National Training Program of United States guidelines, and people with lower socio-economic status had higher salt intake compared with people with higher socio-economic status (Mazloomy Mahmoodabad et al., 2016). There was a strong relationship between T2DM, and obesity, both of which are the most dangerous diseases among metabolic disorders (Verma and Hussain, 2017). In a study among 728 Iranian patients with T2DM, the relationship between obesity and dietary patterns was evaluated, and the results showed that there was a negative and positive association between healthy and unhealthy dietary habits, and the prevalence of general obesity (Basiri et al., 2015). Every year, T2DM imposes a huge financial burden on society and healthcare systems (Bakker et al., 2016). Previous studies demonstrated that there was a 35% increase in the prevalence of T2DM among the Iranian adult population between 2005 to 2011, contributing to the total prevalence of 11.4% (Esteghamati et al., 2014). Furthermore, Esteghamati et al. indicated that all kinds of diabetes showed a 85.5% prevalence of T2DM (Esteghamati et al., 2017). In a study in Tehran city, the prevalence of T2DM among people with low socio-economic status was higher than the other regions; they had a higher rate of T2DM (Asadi-Lari et al., 2016). Metabolic syndrome (MetS), is also a prominent disorder contributing to T2DM, hypertension, obesity, and dyslipidemia. A nationwide survey showed that the prevalence of MetS among the urban population, older adults, low educated people, postmenopausal women, and people with unhealthy diets and low physical activity was higher than the other groups (Hajian-Tilaki, 2015). Since one of the significant factors of MetS is obesity, and obesity directly relates to lifestyle, some studies revealed that the rate of obesity among Iranian adults has increased in the last decades (Azimi-Nezhad et al., 2012, Hajian-Tilaki and Heidari, 2007, Jouyandeh et al., 2013, Shahini et al., 2013); this rate was almost higher in women (Azimi-Nezhad et al., 2012, Delavari
et al., 2009).
| Table 1. Change in nutrition and food security dimensions in Iran (Ardakani et al., 2017, Ardakani et al., 2009). | |||
| Dimension | 1992-96 to 1997-01 | 1997-01 to 2002-06 | 2002-06 to 2007-11 |
| Availability | -8.1 | -14.6 | -1.11 |
| Accessibility | -3.9 | -0.93 | -9.8 |
| Stability | +7.8 | -2.05 | -5.2 |
| Utilization | -12.9 | +16.11 | -5.03 |
| Table 2. Prevalence of dyslipidemia and related components (Hedayatnia et al., 2020). | |||||
| The population | Dyslipidemia | High LDL-C | High TC | High TG | Low HDL-C |
| Total population (n = 8698) | 85.40 (7424) | 32.30 (2811) | 38 (3309) | 33.90 (2947) | 65.80 (57.19) |
| Men (n = 3582) | 80.30 (2877) | 29.80 (1067) | 34.10 (1223) | 36.90 (1321) | 55.60 (1990) |
| Women (n = 5116) | 88.90 (4547) a | 34.10 (1744) a | 40.80 (2086) a | 31.80 (1626) a | 72.90 (3729) a |
| LDL-C: Low density lipoprotein cholesterol; TC: Total cholesterol; TG: Triglycerides; HDL-C: High density lipoprotein cholesterol; a: P < 0.001 for comparison between men and women. | |||||
| Figure 1. Continued natural growth rate and fertility change intersection from 1950-1955 to 2045 2050 (United Nations, 2015a). |
| Figure 2. Food and nutrition security trend in Iran from 1992 to 2011 (Ardakani et al., 2017, Ardakani et al., 2009). |
| Figure 3. Prevalence of overweight, general, and abdominal obesity (Esmaili et al., 2015). |
| Figure 4. Predicted annual CVD burden by age in Iranian adults (2005-2025) (Sadeghi et al., 2017). |
| Figure 5. Prevalence of hypertension in 1980–2012 based on age and gender (Mirzaei et al., 2016). |
Conclusion
Nutritional transition in Iran is ongoing alongside with increased prevalence of several health-related changeable and unchangeable risk factors; they include unhealthy diet, low physical activity, and age which leads to increased prevalence of NCDs like hypertension, T2DM, and metabolic syndrome. The reasons for such change are increased urbanization, fast food and fatty food consumption, increased unhealthy and western dietary habits, lower intakes of micronutrients, and increased sedentary lifestyle. In recent years, the socio-economic status of the majority of population has become worse in Iran, leading to great tendency of low-income population to choose insufficient and unhealthy food items. Moreover, in contrast to increased general knowledge about the beneficial aspects of regular physical activity, most of the people particularly in urban areas have a sedentary lifestyle possibly due to increased use of personal cars, TV watching, smart gadgets and social media. Although maternal morbidity and infant mortality rate has decreased, the rate of obesity, hypertension, T2DM and related metabolic compliances such as metabolic syndrome have increased to an alarming point. Iran’s government has made great policies to reduce mother and child’s mortality rate and increase life expectancy. However, further preventive policies and integrated strategies are required to develop vital habits in general population, such as physical activity, dietary patterns, financial support, decreasing urbanization and lowering stress. Although industrial communities encourage people to use unhealthy foodstuff, healthcare system and government could apply health policies to population, in small or great communities, workplaces, schools, universities, and social media.
Conflict of interest
The authors declared no conflict of interest.
Authors’ contributions
All authors read and approved the manuscript; Barzegari M, collected data collection and wrote the first draft of the manuscript. Abbasalizad-Farhangi M designed the project, revised the manuscript, and supervised the project.
Ethical considerations
The current work has been approved by research undersecretary of Tabriz University of Medical Sciences (IR.TBZMED.REC.1401.087).
References
Abbasi-Shavazi MJ 2001. Fertility revolution in Iran. Popul Soc. 373 (1): 4.
Abbasi Shavazi M & Hosseini-Chavoshi M 2011. Evolution of fertility, family planning and population policies in Iran.
Abdi F, Atarodi Z, Mirmiran P & Esteki T 2016. Review of nutritional status in Iranian population. Focus on sciences. 2 (3): 1-4.
Alamdarlo HN, Riyahi F & Vakilpoor MH 2019. Wheat Self-Sufficiency, Water Restriction and Virtual Water Trade in Iran. Networks and spatial economics. 19 (2): 503-520.
Alimohammadi M, et al. 2018. The trend of changes in the risk factors of coronory heart disease from 1980 to 2010 in Iran. Shiraz e-medical journal. 19 (4).
Ardakani Z, Bartolini F & Brunori G 2017. Food and nutrition security in Iran: Application of TOPSIS technique. New Medit. 16 (1): 18-28.
Ardakani Z, Yazdani S & Gilanpour O 2009. Studying the effects of Non-Tariff Barriers on the export of the main agricultural products of Iran. American journal of applied sciences. 6 (7): 1321-1326.
Asadi-Lari M, et al. 2016. Socioeconomic status and prevalence of self-reported diabetes among adults in Tehran: results from a large population-based cross-sectional study (Urban HEART-2). Journal of endocrinological investigation. 39 (5): 515-522.
Azimi-Nezhad M, et al. 2012. High prevalence of metabolic syndrome in Iran in comparison with France: what are the components that explain this? Metabolic syndrome and related disorders. 10 (3): 181-188.
Bakker K, et al. 2016. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence‐based global consensus. Diabetes/metabolism research and reviews. 32: 2-6.
Baranowski T, Cullen KW, Nicklas T, Thompson D & Baranowski J 2003. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity research. 11 (S10): 23S-43S.
Barzin M, et al. 2015. Rising trends of obesity and abdominal obesity in 10 years of follow-up among Tehranian adults: Tehran Lipid and Glucose Study (TLGS). Public health nutrition. 18 (16): 2981-2989.
Basiri MG, et al. 2015. Association of major dietary patterns with general and abdominal obesity in Iranian patients with type 2 diabetes mellitus. International journal for vitamin and nutrition research. 85 (3-4): 145-155.
Behzadifar M, et al. 2016. Prevalence of Food Insecurity in Iran: A Systematic Review and Meta-analysis. Prevalence of food insecurity in Iran. 19 (4): 288-294.
Darroudi S, et al. 2018. Prevalence of combined and noncombined dyslipidemia in an Iranian population. Journal of clinical laboratory analysis. 32 (8): e22579.
Delavari A, Forouzanfar MH, Alikhani S, Sharifian A & Kelishadi R 2009. First nationwide study of the prevalence of the metabolic syndrome and optimal cutoff points of waist circumference in the Middle East: the national survey of risk factors for noncommunicable diseases of Iran. Diabetes care. 32 (6): 1092-1097.
Després J-P & Lemieux I 2006. Abdominal obesity and metabolic syndrome. Nature. 444 (7121): 881-887.
Djalalinia S, et al. 2016. A systematic review on the prevalence of overweight and obesity, in iranian children and adolescents. Iranian journal of pediatrics. 26 (3): e2599.
Emamian MH, Fateh M, Hosseinpoor AR, Alami A & Fotouhi A 2017. Obesity and its socioeconomic determinants in Iran. Economics & human biology. 26: 144-150.
Esmaili H, et al. 2015. Prevalence of general and abdominal obesity in a nationally representative sample of Iranian children and adolescents: the CASPIAN-IV study. Iranian journal of pediatrics. 25 (3): e401.
Esteghamati A, et al. 2014. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: 2005–2011. Diabetes research and clinical practice. 103 (2): 319-327.
Esteghamati A, et al. 2010. Secular trends of obesity in Iran between 1999 and 2007: National Surveys of Risk Factors of Non-communicable Diseases. Metabolic syndrome and related disorders. 8 (3): 209-213.
Esteghamati A, et al. 2017. Diabetes in Iran: prospective analysis from first nationwide diabetes report of National Program for Prevention and Control of Diabetes (NPPCD-2016). Scientific reports. 7 (1): 1-10.
Ghassemi H 2000. National food and nutrition security: A note on planning and administration. Tehran: Food and Agriculture Organization of the United Nations, representation in the Islamic Republic of Iran.
Ghassemi H, Harrison G & Mohammad K 2002. An accelerated nutrition transition in Iran. Public health nutrition. 5 (1a): 149-155.
Ghobadi N 2010. Essays on Fertility, Gender Preference and Family Planning in Iran. UC Berkeley.
Ghobadi S, et al. 2018. Association between overweight/obesity and eating habits while watching television among primary-school children in the city of Shiraz, Iran. Public health nutrition. 21 (3): 571-579.
Ghodsi D, et al. 2018. Effectiveness of the national food supplementary program on children growth and nutritional status in Iran. Maternal & child nutrition. 14 (3): e12591.
Grøntved A & Hu FB 2011. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. Journal of the American medical association. 305 (23): 2448-2455.
Hajian-Tilaki K 2015. Metabolic syndrome and its associated risk factors in Iranian adults: A systematic review. Caspian journal of internal medicine. 6 (2): 51.
Hajian-Tilaki K & Heidari B 2007. Prevalence of obesity, central obesity and the associated factors in urban population aged 20–70 years, in the north of Iran: a population-based study and regression approach. Obesity reviews. 8 (1): 3-10.
Hedayatnia M, et al. 2020. Dyslipidemia and cardiovascular disease risk among the Mashad study population. Lipids in health and disease. 19 (1): 1-11.
Heslot S 2014. Iran’s food security, https://apo.org.au/node/40764.
Hosseini M, et al. 2019. Age, period and cohort analysis of high cholesterol levels in Iranian adults over a 20-year period. Journal of diabetes & metabolic disorders. 18 (2): 289-299.
Hu FB, et al. 2001. Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Archives of internal medicine. 161 (12): 1542-1548.
Janghorbani M, et al. 2007. First nationwide survey of prevalence of overweight, underweight, and abdominal obesity in Iranian adults. Obesity. 15 (11): 2797-2808.
Jessri M, et al. 2011. Comparison of trends in dietary pattern in Iran, Middle Eastern and North African countries from 1961 to 2005. Pajoohandeh Journal. 16 (1): 1-10.
Jouyandeh Z, Nayebzadeh F, Qorbani M & Asadi M 2013. Metabolic syndrome and menopause. Journal of diabetes & metabolic disorders. 12 (1): 1.
Kelishadi R, et al. 2008. Obesity and associated lifestyle behaviours in Iran: findings from the first national non-communicable disease risk factor surveillance survey. Public health nutrition. 11 (3): 246-251.
Khatibi M, Bagherzadeh S, Aghamolaey H & Najafipour H 2018. Prevalence and Risk Factors of Hypertension in the Urban Population of Iran. Journal of hypertension. 7 (253): 2167-1095.1000253.
Legg C, Puri A & Thomas N 2000. Dietary restraint and self-reported meal sizes: diary studies with differentially informed consent. Appetite. 34 (3): 235-243.
Mansouri-Tehrani MM, Hashemi-rad S, Hajiha T, Mousavian S & Rezazadeh A 2019. Association of junk food consumption with overweight-obesity among preclinical medical students of Shahid Beheshti University of Medical Sciences. Social determinants of health. 5 (1): 2-10.
Mathers CD & Loncar D 2006. Projections of global mortality and burden of disease from 2002 to 2030. Plos med. 3 (11): e442.
Mazloomy Mahmoodabad SS, Tehrani H, Gholian-aval M, Gholami H & Nematy M 2016. The effect of social class on the amount of salt intake in patients with hypertension. Blood pressure. 25 (6): 360-363.
Mehri N, Messkoub M & Kunkel S 2020. Trends, determinants and the implications of population aging in Iran. Ageing international. 45 (4): 1-17.
Mirzaei M, Moayedallaie S, Jabbari L & Mohammadi M 2016. Prevalence of hypertension in Iran 1980–2012: a systematic review. Journal of Tehran University heart center. 11 (4): 159.
Mirzaie M 2005. Swings in fertility limitation in Iran. Critique: critical Middle Eastern studies. 14 (1): 25-33.
Mohammadbeigi A, et al. 2018. Fast food consumption and overweight/obesity prevalence in students and its association with general and abdominal obesity. Journal of preventive medicine and hygiene. 59 (3): E236.
Natsis M, Antza C, Doundoulakis I, Stabouli S & Kotsis V 2019. Hypertension in obesity: novel insights. Current hypertension reviews. 16 (1): 30-36.
Ordovas JM 2006. Genetic interactions with diet influence the risk of cardiovascular disease. American journal of clinical nutrition. 83 (2): 443S-446S.
Pirmoradi A, Latifi S & Sey Mohammadi S 2013. Waste reduction strategy for food security crops. Global journal of scientific researches. 1 (2): 48-51.
Popkin BM 1993. Nutritional patterns and transitions. Population and development review. 19 (1): 138-157.
Pouraram H, Sharif S, Abtahi M & Djazayery A 2018. Cost estimation of desirable food basket in Iran as an important component of sustainable development. Iranian journal of nutrition sciences & food technology. 13 (1): 147-152.
Rastegar F 2016. A Study on Trends in Iran: A Closer Look at Democracy, Education, Fertility, Divorce, Nutrition Transition, and HIV/AIDS. International journal of information and education technology. 6 (9): 679.
Rouhani-Tonekaboni N, Seyedi-Andi SJ & Haghi M 2018. Factors affecting fast food consumption behaviors of female students in North of Iran: Application of theory of planned behavior. Caspian journal of health research. 3 (3): 75-79.
Sadeghi M, Haghdoost AA, Bahrampour A & Dehghani M 2017. Modeling the burden of cardiovascular diseases in Iran from 2005 to 2025: The impact of demographic changes. Iranian journal of public health. 46 (4): 506.
Shahini N, Shahini I & Marjani A 2013. Prevalence of metabolic syndrome in Turkmen ethnic groups in Gorgan. Journal of clinical and diagnostic research. 7 (9): 1849.
Shahraki SH, Amirkhizi F, Amirkhizi B & Hamedi S 2016. Household food insecurity is associated with nutritional status among Iranian children. Ecology of food and nutrition. 55 (5): 473-490.
Sisson SB, Shay CM, Broyles ST & Leyva M 2012. Television-viewing time and dietary quality among US children and adults. American journal of preventive medicine. 43 (2): 196-200.
Smith L, Gardner B & Hamer M 2015. Childhood correlates of adult TV viewing time: a 32-year follow-up of the 1970 British Cohort Study. Journal of epidemiology and community health. 69 (4): 309-313.
Soltani A, et al. 2020. Future food self-sufficiency in Iran: A model-based analysis. Global food security. 24: 100351.
Tveden-Nyborg P, et al. 2016. Diet-induced dyslipidemia leads to nonalcoholic fatty liver disease and oxidative stress in guinea pigs. Translational research. 168: 146-160.
Umanath M, Chengappa P & Vijayasarathy K 2016. Consumption pattern and nutritional intake of pulses by segregated income groups in India. Agricultural economics research review. 29 (347-2016-17244): 53-64.
United Nations 2015a. Department of Economic and Social Affairs, population division. Trends in contraceptive use worldwide [Internet].
United Nations 2015b. Trends in contraceptive use worldwide, Department of Economic and Social Affairs, population division.
Verma S & Hussain ME 2017. Obesity and diabetes: an update: Diabetes & metabolic syndrome. Clinical research & reviews. 11 (1): 73-79.
World Bank 2010. Fertility decline in the Islamic Republic of Iran 1980–2006: A case study.
Xie YJ, Stewart SM, Lam TH, Viswanath K & Chan SS 2014. Television viewing time in Hong Kong adult population: associations with body mass index and obesity. PLoS One. 9 (1).
Zaribaf F, et al. 2019. Dietary patterns in relation to lipid profiles among Iranian adults. Journal of cardiovascular and thoracic research. 11 (1): 19.
Nutritional transition in Iran is ongoing alongside with increased prevalence of several health-related changeable and unchangeable risk factors; they include unhealthy diet, low physical activity, and age which leads to increased prevalence of NCDs like hypertension, T2DM, and metabolic syndrome. The reasons for such change are increased urbanization, fast food and fatty food consumption, increased unhealthy and western dietary habits, lower intakes of micronutrients, and increased sedentary lifestyle. In recent years, the socio-economic status of the majority of population has become worse in Iran, leading to great tendency of low-income population to choose insufficient and unhealthy food items. Moreover, in contrast to increased general knowledge about the beneficial aspects of regular physical activity, most of the people particularly in urban areas have a sedentary lifestyle possibly due to increased use of personal cars, TV watching, smart gadgets and social media. Although maternal morbidity and infant mortality rate has decreased, the rate of obesity, hypertension, T2DM and related metabolic compliances such as metabolic syndrome have increased to an alarming point. Iran’s government has made great policies to reduce mother and child’s mortality rate and increase life expectancy. However, further preventive policies and integrated strategies are required to develop vital habits in general population, such as physical activity, dietary patterns, financial support, decreasing urbanization and lowering stress. Although industrial communities encourage people to use unhealthy foodstuff, healthcare system and government could apply health policies to population, in small or great communities, workplaces, schools, universities, and social media.
Conflict of interest
The authors declared no conflict of interest.
Authors’ contributions
All authors read and approved the manuscript; Barzegari M, collected data collection and wrote the first draft of the manuscript. Abbasalizad-Farhangi M designed the project, revised the manuscript, and supervised the project.
Ethical considerations
The current work has been approved by research undersecretary of Tabriz University of Medical Sciences (IR.TBZMED.REC.1401.087).
References
Abbasi-Shavazi MJ 2001. Fertility revolution in Iran. Popul Soc. 373 (1): 4.
Abbasi Shavazi M & Hosseini-Chavoshi M 2011. Evolution of fertility, family planning and population policies in Iran.
Abdi F, Atarodi Z, Mirmiran P & Esteki T 2016. Review of nutritional status in Iranian population. Focus on sciences. 2 (3): 1-4.
Alamdarlo HN, Riyahi F & Vakilpoor MH 2019. Wheat Self-Sufficiency, Water Restriction and Virtual Water Trade in Iran. Networks and spatial economics. 19 (2): 503-520.
Alimohammadi M, et al. 2018. The trend of changes in the risk factors of coronory heart disease from 1980 to 2010 in Iran. Shiraz e-medical journal. 19 (4).
Ardakani Z, Bartolini F & Brunori G 2017. Food and nutrition security in Iran: Application of TOPSIS technique. New Medit. 16 (1): 18-28.
Ardakani Z, Yazdani S & Gilanpour O 2009. Studying the effects of Non-Tariff Barriers on the export of the main agricultural products of Iran. American journal of applied sciences. 6 (7): 1321-1326.
Asadi-Lari M, et al. 2016. Socioeconomic status and prevalence of self-reported diabetes among adults in Tehran: results from a large population-based cross-sectional study (Urban HEART-2). Journal of endocrinological investigation. 39 (5): 515-522.
Azimi-Nezhad M, et al. 2012. High prevalence of metabolic syndrome in Iran in comparison with France: what are the components that explain this? Metabolic syndrome and related disorders. 10 (3): 181-188.
Bakker K, et al. 2016. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence‐based global consensus. Diabetes/metabolism research and reviews. 32: 2-6.
Baranowski T, Cullen KW, Nicklas T, Thompson D & Baranowski J 2003. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity research. 11 (S10): 23S-43S.
Barzin M, et al. 2015. Rising trends of obesity and abdominal obesity in 10 years of follow-up among Tehranian adults: Tehran Lipid and Glucose Study (TLGS). Public health nutrition. 18 (16): 2981-2989.
Basiri MG, et al. 2015. Association of major dietary patterns with general and abdominal obesity in Iranian patients with type 2 diabetes mellitus. International journal for vitamin and nutrition research. 85 (3-4): 145-155.
Behzadifar M, et al. 2016. Prevalence of Food Insecurity in Iran: A Systematic Review and Meta-analysis. Prevalence of food insecurity in Iran. 19 (4): 288-294.
Darroudi S, et al. 2018. Prevalence of combined and noncombined dyslipidemia in an Iranian population. Journal of clinical laboratory analysis. 32 (8): e22579.
Delavari A, Forouzanfar MH, Alikhani S, Sharifian A & Kelishadi R 2009. First nationwide study of the prevalence of the metabolic syndrome and optimal cutoff points of waist circumference in the Middle East: the national survey of risk factors for noncommunicable diseases of Iran. Diabetes care. 32 (6): 1092-1097.
Després J-P & Lemieux I 2006. Abdominal obesity and metabolic syndrome. Nature. 444 (7121): 881-887.
Djalalinia S, et al. 2016. A systematic review on the prevalence of overweight and obesity, in iranian children and adolescents. Iranian journal of pediatrics. 26 (3): e2599.
Emamian MH, Fateh M, Hosseinpoor AR, Alami A & Fotouhi A 2017. Obesity and its socioeconomic determinants in Iran. Economics & human biology. 26: 144-150.
Esmaili H, et al. 2015. Prevalence of general and abdominal obesity in a nationally representative sample of Iranian children and adolescents: the CASPIAN-IV study. Iranian journal of pediatrics. 25 (3): e401.
Esteghamati A, et al. 2014. Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: 2005–2011. Diabetes research and clinical practice. 103 (2): 319-327.
Esteghamati A, et al. 2010. Secular trends of obesity in Iran between 1999 and 2007: National Surveys of Risk Factors of Non-communicable Diseases. Metabolic syndrome and related disorders. 8 (3): 209-213.
Esteghamati A, et al. 2017. Diabetes in Iran: prospective analysis from first nationwide diabetes report of National Program for Prevention and Control of Diabetes (NPPCD-2016). Scientific reports. 7 (1): 1-10.
Ghassemi H 2000. National food and nutrition security: A note on planning and administration. Tehran: Food and Agriculture Organization of the United Nations, representation in the Islamic Republic of Iran.
Ghassemi H, Harrison G & Mohammad K 2002. An accelerated nutrition transition in Iran. Public health nutrition. 5 (1a): 149-155.
Ghobadi N 2010. Essays on Fertility, Gender Preference and Family Planning in Iran. UC Berkeley.
Ghobadi S, et al. 2018. Association between overweight/obesity and eating habits while watching television among primary-school children in the city of Shiraz, Iran. Public health nutrition. 21 (3): 571-579.
Ghodsi D, et al. 2018. Effectiveness of the national food supplementary program on children growth and nutritional status in Iran. Maternal & child nutrition. 14 (3): e12591.
Grøntved A & Hu FB 2011. Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. Journal of the American medical association. 305 (23): 2448-2455.
Hajian-Tilaki K 2015. Metabolic syndrome and its associated risk factors in Iranian adults: A systematic review. Caspian journal of internal medicine. 6 (2): 51.
Hajian-Tilaki K & Heidari B 2007. Prevalence of obesity, central obesity and the associated factors in urban population aged 20–70 years, in the north of Iran: a population-based study and regression approach. Obesity reviews. 8 (1): 3-10.
Hedayatnia M, et al. 2020. Dyslipidemia and cardiovascular disease risk among the Mashad study population. Lipids in health and disease. 19 (1): 1-11.
Heslot S 2014. Iran’s food security, https://apo.org.au/node/40764.
Hosseini M, et al. 2019. Age, period and cohort analysis of high cholesterol levels in Iranian adults over a 20-year period. Journal of diabetes & metabolic disorders. 18 (2): 289-299.
Hu FB, et al. 2001. Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Archives of internal medicine. 161 (12): 1542-1548.
Janghorbani M, et al. 2007. First nationwide survey of prevalence of overweight, underweight, and abdominal obesity in Iranian adults. Obesity. 15 (11): 2797-2808.
Jessri M, et al. 2011. Comparison of trends in dietary pattern in Iran, Middle Eastern and North African countries from 1961 to 2005. Pajoohandeh Journal. 16 (1): 1-10.
Jouyandeh Z, Nayebzadeh F, Qorbani M & Asadi M 2013. Metabolic syndrome and menopause. Journal of diabetes & metabolic disorders. 12 (1): 1.
Kelishadi R, et al. 2008. Obesity and associated lifestyle behaviours in Iran: findings from the first national non-communicable disease risk factor surveillance survey. Public health nutrition. 11 (3): 246-251.
Khatibi M, Bagherzadeh S, Aghamolaey H & Najafipour H 2018. Prevalence and Risk Factors of Hypertension in the Urban Population of Iran. Journal of hypertension. 7 (253): 2167-1095.1000253.
Legg C, Puri A & Thomas N 2000. Dietary restraint and self-reported meal sizes: diary studies with differentially informed consent. Appetite. 34 (3): 235-243.
Mansouri-Tehrani MM, Hashemi-rad S, Hajiha T, Mousavian S & Rezazadeh A 2019. Association of junk food consumption with overweight-obesity among preclinical medical students of Shahid Beheshti University of Medical Sciences. Social determinants of health. 5 (1): 2-10.
Mathers CD & Loncar D 2006. Projections of global mortality and burden of disease from 2002 to 2030. Plos med. 3 (11): e442.
Mazloomy Mahmoodabad SS, Tehrani H, Gholian-aval M, Gholami H & Nematy M 2016. The effect of social class on the amount of salt intake in patients with hypertension. Blood pressure. 25 (6): 360-363.
Mehri N, Messkoub M & Kunkel S 2020. Trends, determinants and the implications of population aging in Iran. Ageing international. 45 (4): 1-17.
Mirzaei M, Moayedallaie S, Jabbari L & Mohammadi M 2016. Prevalence of hypertension in Iran 1980–2012: a systematic review. Journal of Tehran University heart center. 11 (4): 159.
Mirzaie M 2005. Swings in fertility limitation in Iran. Critique: critical Middle Eastern studies. 14 (1): 25-33.
Mohammadbeigi A, et al. 2018. Fast food consumption and overweight/obesity prevalence in students and its association with general and abdominal obesity. Journal of preventive medicine and hygiene. 59 (3): E236.
Natsis M, Antza C, Doundoulakis I, Stabouli S & Kotsis V 2019. Hypertension in obesity: novel insights. Current hypertension reviews. 16 (1): 30-36.
Ordovas JM 2006. Genetic interactions with diet influence the risk of cardiovascular disease. American journal of clinical nutrition. 83 (2): 443S-446S.
Pirmoradi A, Latifi S & Sey Mohammadi S 2013. Waste reduction strategy for food security crops. Global journal of scientific researches. 1 (2): 48-51.
Popkin BM 1993. Nutritional patterns and transitions. Population and development review. 19 (1): 138-157.
Pouraram H, Sharif S, Abtahi M & Djazayery A 2018. Cost estimation of desirable food basket in Iran as an important component of sustainable development. Iranian journal of nutrition sciences & food technology. 13 (1): 147-152.
Rastegar F 2016. A Study on Trends in Iran: A Closer Look at Democracy, Education, Fertility, Divorce, Nutrition Transition, and HIV/AIDS. International journal of information and education technology. 6 (9): 679.
Rouhani-Tonekaboni N, Seyedi-Andi SJ & Haghi M 2018. Factors affecting fast food consumption behaviors of female students in North of Iran: Application of theory of planned behavior. Caspian journal of health research. 3 (3): 75-79.
Sadeghi M, Haghdoost AA, Bahrampour A & Dehghani M 2017. Modeling the burden of cardiovascular diseases in Iran from 2005 to 2025: The impact of demographic changes. Iranian journal of public health. 46 (4): 506.
Shahini N, Shahini I & Marjani A 2013. Prevalence of metabolic syndrome in Turkmen ethnic groups in Gorgan. Journal of clinical and diagnostic research. 7 (9): 1849.
Shahraki SH, Amirkhizi F, Amirkhizi B & Hamedi S 2016. Household food insecurity is associated with nutritional status among Iranian children. Ecology of food and nutrition. 55 (5): 473-490.
Sisson SB, Shay CM, Broyles ST & Leyva M 2012. Television-viewing time and dietary quality among US children and adults. American journal of preventive medicine. 43 (2): 196-200.
Smith L, Gardner B & Hamer M 2015. Childhood correlates of adult TV viewing time: a 32-year follow-up of the 1970 British Cohort Study. Journal of epidemiology and community health. 69 (4): 309-313.
Soltani A, et al. 2020. Future food self-sufficiency in Iran: A model-based analysis. Global food security. 24: 100351.
Tveden-Nyborg P, et al. 2016. Diet-induced dyslipidemia leads to nonalcoholic fatty liver disease and oxidative stress in guinea pigs. Translational research. 168: 146-160.
Umanath M, Chengappa P & Vijayasarathy K 2016. Consumption pattern and nutritional intake of pulses by segregated income groups in India. Agricultural economics research review. 29 (347-2016-17244): 53-64.
United Nations 2015a. Department of Economic and Social Affairs, population division. Trends in contraceptive use worldwide [Internet].
United Nations 2015b. Trends in contraceptive use worldwide, Department of Economic and Social Affairs, population division.
Verma S & Hussain ME 2017. Obesity and diabetes: an update: Diabetes & metabolic syndrome. Clinical research & reviews. 11 (1): 73-79.
World Bank 2010. Fertility decline in the Islamic Republic of Iran 1980–2006: A case study.
Xie YJ, Stewart SM, Lam TH, Viswanath K & Chan SS 2014. Television viewing time in Hong Kong adult population: associations with body mass index and obesity. PLoS One. 9 (1).
Zaribaf F, et al. 2019. Dietary patterns in relation to lipid profiles among Iranian adults. Journal of cardiovascular and thoracic research. 11 (1): 19.
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Received: 2022/02/24 | Published: 2023/11/20 | ePublished: 2023/11/20
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