ARTICLE INFO		ABSTRACT
ORIGINAL ARTICLE		Background: Substance abuse has significant impact on nutritional status. Due to the increased malnutrition during drug use and withdrawal, this study aimed at assessing the anthropometric indices in individuals referring to drug treatment centers in Qom. Methods: In this descriptive-analytical study, 329 addicted individuals referring to addiction centers in Qom were randomly selected. A questionnaire was used with three parts including demographic characteristics, drug abuse history, and anthropometric indices including measurement of height, weight, waist circumference, arm circumference, and skinfold thickness in triceps and calf muscles. Results: The participants consisted of 328 men and only one woman, 29% of whom were in detoxification. The participants' mean age was 39.0 ± 7.1 years. The first and most-frequently used drug was opium. All anthropometric indices were associated with the consumption of opium substances and drug use was associated significantly with some parameters. With the exception of skinfold thickness in the calf, all the indices were affected by the type of consumed substances. The opium addicts had a higher body mass index compared with other drug users. Conclusions: Due to the importance of nutrition status in drug abusers' health and their lack of self-care, careful monitoring and evaluation of dietary intake, as well as nutrition status can play important roles in the rehabilitation of these individuals and help to prevent from reappearance of these habits.   Keywords: Addiction; Anthropometric indices; Nutritional assessment; Heroin
Article history: Received: 5 Oct 2016 Revised: 22 Nov 2016 Accepted: 5 Dec 2016
*Corresponding author: jsyazdy@yahoo.com School of Public Health, Shahid Sadoughi University of Medical Sciences, Square Alem, Shohadaye Gomname Blvd, Yazd, Iran.   Postal code: 8915173160 Tel: +98 35 38209100

	Table 1. Anthropometric indices and living conditions and accommodation information and overnight resting place of participants
	Variables	n	Mean ± SD
Quantitative variables     Age (year)		329	39 ± 11
Weight (kg)		329	73 ± 16
Height (cm)		329	172 ± 10
Waist circumference (cm)		329	89 ± 15
Arm circumference (cm)		329	30 ± 4
Calf skinfold thickness (mm)		329	36 ± 22
Triceps skinfold thickness (mm)		329	35 ± 21
Addiction history (month)		329	13 ± 9
Qualitative variables		n	Percent
Education status         Illiterate         Elementary         Middle school         High school         Academic educated		9 35 42 32 11	7.0 27.1 32.6 24.8 8.5
Living conditions         Single         Married (live with wife)         Married (live without wife)         Divorced		59 250 8 12	18.0 76.0 2.5 3.5
Accommodation information         Tenanted         Live with parents         Home owner         Support centers for addicted people		123 107 92 4	37.8 32.8 28.2 1.2
Drugs withdrawal treatment stage         Detoxification         Psychotherapy         Group therapy         All three methods		37 1 2 89	28.7 7.7 15.6 70.0
Drugs used by participants         Opium         Heroin         Opium sap         Glass & Crack         Addiction to more than one drug		71 20 11 10 17	55.0 15.5 8.5 7.8 13.2

Table 2. Participants' eating behaviors and attitude to healthy eating
Eating behaviors and attitude to healthy eating	Totally agree		Agree		Disagree		Strongly disagree		No comments
	n	%	n	%	n	%	n	%	n	%
Nutrition has a significant impact on health and disease.	128	39.0	45	14.0	4	1.2	3	0.9	7	2.1
My body weight is appropriate.	64	19.4	51	15.5	38	11.5	24	7.3	10	3.0
Bottled mineral water is the healthiest type of available water.	96	29.1	31	9.4	12	3.6	17	5.2	31	9.4
Tea is a good substitute for water.	33	10	31	9.4	48	14.5	64	19.4	11	3.3
Food consumption in restaurants and outdoors is useful for health.	12	3.6	10	3.0	50	15.2	94	25.5	21	6.4
Vitamins and minerals supplements are useful for everyone.	16	4.8	28	8.5	36	10.9	74	22.4	33	10.0
Physical activity is essential for health promotion.	137	41.5	38	11.5	3	0.9	6	1.8	3	0.9
Frying of food is harmful for health.	84	25.5	46	13.9	16	4.8	18	5.5	23	7.0
Iodized salt can be harmful to health.	43	13.0	28	8.5	30	9.1	45	13.6	41	12.4

Table 3. The relation between treatment stage and methods of drugs abused with anthropometric indices
BMI (kg/m2)	TST (mm)	CST (mm)	AC (cm)	WC (cm)	WT (cm)	HT (cm)	n	Treatment stage and methods
25.7 ± 9.4 26.2 ± 4.6 23.0 ± 1.9 0.78	3.7 ± 2.2 5.5 ± 3.5 3.8 ± 2.3 0.23	3.9 ± 2.6 3.5 ± 0.7 4.2 ± 2.1 0.37	30.0  ± 3.7 31.5 ± 4.9 30.0 ± 2.0 0.93	90.5 ± 14.0 90.5 ± 13.4 84.3 ± 9.6 0.86	73.0 ± 15.0 75.5 ± 16.0 72.5 ± 10.7 0.99	170.0 ± 7.2 169.5 ± 3.5 177.0 ± 6.2 0.24	115 18	Treatment stage    Detoxification    Psychotherapy    Group therapy    P-valuea
25.0 ± 4.1 25.8 ± 14.9 21.5 ± 3.7 0.44	3.7 ± 2.2 3.5 ± 2.3 3.3 ± 0.5 0.72	3.9 ± 2.5 3.4 ± 1.9 3.0 ± 1.1 0.09	30.5 ± 3.8 30.0 ± 5.0 27.1 ± 3.5 0.45	92.3 ± 12.8 87.1 ± 15.5 84.0 ± 11.4 0.05	74.5 ± 14.2 71.8 ± 15.4 70.1 ± 13.4 0.60	172.3 ± 6.6 171.1 ± 13.0 180.0 ± 7.3 0.07	83 157	Type of drug abuse    Oral    Inhalation    Injection    P-valuea

Table 4. The relation between the types of used drugs with anthropometric indices
Anthropometric indices	Type of used drugs				P-valuea
	Opium (n=112)	The sap of opium (n=38)	Glass & Crack (n=19)	Hashish (n=42)
Height (cm)	170.2 ± 12.0	170.2 ± 12.3	171.8 ± 7.2	176 ± 9.9	0.081
Weight (kg)	73.0 ± 12.0	73.0 ± 16.6	73.3 ± 13.1	69.2 ± 13.0	0.022
Waist circumference (cm)	89.7 ± 16.0	89.7 ± 15.9	91.4 ± 12.3	84.6 ± 14.8	0.002
Arm circumference (cm)	30.0 ± 4.8	30.1 ± 4.8	29.8 ± 4.0	29.0 ± 3.7	0.006
Calf skinfold thickness (mm)	3.4 ± 2.1	3.4 ± 2.1	4.1 ± 3.0	2.8 ± 1.3	0.003
Triceps skinfold thickness (mm)	3.2 ± 1.7	3.2 ± 1.7	3.8 ± 1.8	2.6 ± 1.4	<0.01
Body mass index( kg/m²)	26.1 ± 14.0	26.6 ± 13.8	24.9 ± 4.5	22.5 ± 4.8	0.014

Table 5. The relation between first drug abuse and main drugs abused with anthropometric indices
BMI (kg/m2)	TST (mm)	CST (mm)	AC (cm)	WC (cm)	WT (cm)	HT (cm)	n	First and main drugs abused
25.6 ± 1.9 26.3 ± 2.1 25.7 ± 2.6 23.8 ± 2.7 22.1 ± 3.9 0.002	3.6 ± 2.3 4.0 ± 2.2 2.4 ± 8.9 3.0 ± 1.6 2.8 ± 1.2 0.544	3.8 ± 2.5 4.3 ± 2.6 2.6 ± 1.1 2.8 ± 1.4 2.5 ± 0.5 0.104	30.4 ± 4.5 31.9 ± 2.6 30.2 ± 2.3 28.4 ± 3.9 27.6 ± 3.7 0.052	90.7 ± 15.7 87.6 ± 22.0 92.4 ± 9.0 82.8 ± 13.3 79.6 ± 12.6 0.006	73.8 ± 15.0 82.3 ± 14.4 78.2 ± 7.8 66.2 ± 13.7 63.6 ± 13.7 0.013	171.6 ± 9.3 176.3 ± 10.7 147.4 ± 5.9 171.5 ± 8.5 169.4 ± 4.9 0.317	254 5 6 46 8	First drug abuse    Opium    The sap of opium    Glass & Crack    Hashish    Heroin    P-valuea
25.9 ± 2.1 25.7 ± 4.5 24.4 ± 4.3 21.1 ± 2.7 22.1 ± 4.5 0.009	3.4 ± 2.0 4.7 ± 2.7 3.2 ± 1.7 2.2 ± 0.4 3.3 ± 1.5 0.002	3.6 ± 2.2 4.6 ± 2.9 3.6 ± 2.8 2.2 ± 0.8 3.2 ± 1.6 0.08	30.3 ± 4.6 31.6 ± 3.6 29.8 ± 4.1 27.5 ± 4.0 28.1 ± 3.6 0.027	90.4 ± 15.7 93.7 ± 16.6 89.7 ± 13.0 77.3 ± 6.9 81.6 ± 13.6 0.05	73.4 ± 14.6 77.1 ± 16.3 71.8 ± 14.6 63.4 ± 11.5 66.1 ± 14.5 0.041	171.1 ± 11.5 172.9 ± 6.9 171.2 ± 6.2 172.7 ± 6.3 173.1 ± 7.6 0.572	223 23 33 6 37	Main drugs abused    Opium    The sap of opium    Glass & Crack    Hashish    Heroin    P-value

Discussion
The present study was designed to evaluate the anthropometric indices of addicted participants with history of drug abuse. The results showed that all anthropometric indices were associated with the consumption of opium substances. Regarding the relationship between drug consumption and anthropometric indices, with the exception of skin fold thickness in the calf, all the indices were affected by the type of consumed substances. Surprisingly, the opium addicts had a higher body mass index compared with other drug users.
Some habits and behaviors such as physical activity, dietary pattern, smoking, and drug abuse have strong effects on health and disease. Studies showed that half of deaths occurring in the U.S. per year are preventable by modifying some behaviors and habits. Furthermore, 40% of patients in U.S. hospitals were admitted for reasons related to drug or alcohol abuse (Tomba, 2011). Nowadays, addiction is known as one of the major health problems in the world (Abd El Gawad et al., 2011). Despite the accepted effects of nutrition on the health of addicted people (Neale et al., 2012, Stungo, 1945, Waters, 1977),  some nutritional problems such as underweight, malnutrition, as well as lack of essential nutrients and vitamins were mentioned for them (Neale et al., 2012). Results of the present study also agree with these outcomes. In addition to inadequate food consumption, irregular food intake, inadequate fruits, vegetables, and protein, rich food intake coupled with increased consumption of simple sugars and sweet foods are the most important nutritional problems of these people (Neale et al., 2012). The use of some types of drugs is associated with changes in appetite and desire for food (Gosnell and Krahn, 1993).  In one of the pioneer researches on nutritional status, Heathcote (1981), investigated 16 heroin addicted participants and found that although inadequate intake and nutritional deficiency were not observed,  the blood levels of vitamin C, vitamin B6, and albumin of them were significantly less than those in the control group (Heathcote and Taylor, 1981). In one of the rare available studies, 38 addicted participants were compared with compatible individuals in the community, Morabia found that although energy intake in both groups was similar, addicted people substituted the foods rich in protein and fat with those rich in simple sugar, which were poor sources of vitamins and minerals (Morabia et al., 1989a). However, this is not always true. For example, morphine increases the desire for fat intake and would tend to reduce carbohydrate intake (Gosnell and Krahn, 1993). Another study carried out by Alves et al., and entitled as "the effects of demographic and social indices on the BMI and eating habits of heroin addicted people under methadone treatment", nutritional assessments and anthropometric indices showed that BMI in drug addicts who lived with their spouses were significantly higher than the others. This finding is consistent with the results
of the current study. Because the majority of people who referred to addiction treatment centers (76%) lived with their wives. The study by
Alves also found that unemployed addicted participants consume more fat, while heroin addicted participants consume less rapid absorbed carbohydrate (Alves et al., 2010). In addition, the results of the study carried out by Naele et al. on heroin addicted participants showed that addicted people desire cheap foods, especially sweet foods (Neale et al., 2012). These findings are consistent with those of the study conducted by Morabia (Morabia et al., 1989b), but in contradiction with the results of Alves' study (Alves et al., 2010). With heroin withdrawal, the dietary pattern is improved and so is the body weight, especially in woman (Neale et al., 2012). As it was found in the current study (Table 3), all anthropometric indices linked to weight and body fat storage, could be affected by the type of drug abuse,
that is in controversy with the results of Alves (Alves et al., 2010), Naele (Neale et al., 2012), and Morabia (Morabia et al., 1989b). Thus, for better comprehension, further studies are recommended.
Saeland et al. studied 123 men and 72 women, addicted to drugs, and found that the sugar added to foods provided about 30% of their total daily calorie intake and 61% of participants preferred to consume sweet foods. Triglyceride and cholesterol concentrations in 32% and 35% of participants were respectively higher than the normal values. Interestingly, foods bought by drug addicted individuals contained less nutritional value than the food purchased by other family members (Saeland et al., 2011). The results achieved through this study confirmed that only 5% of participants purchased the required food themselves. Zador, in a study on methadone users in Australia found that the diet of participants lacked sufficient energy, while it included excessive consumption of simple sugars (122g daily), increased share of sugars in energy (31%), and reduced fiber (10.7g). This dietary pattern is associated with increased dental caries and incidence of constipation (Zador et al., 1996). The decrease in fruit and vegetable consumption in drug abusers is related to the reduction of antioxidants intake, which has been confirmed in previous studies (Abd El Gawad et al., 2011).
The results of another study revealed that weight and BMI in addicted people are similar to those of  the general populations; accordingly, the researcher has suggested that this index is not a good indicator of nutritional status in this population (Morabia et al., 1989b). These results are in controversy with those of the current study in which the relation between anthropometric indices and the type of abused drug was investigated (Table 4). Moreover, the first drug abuse is related to weight, arm and WC, as well as body mass. In addition, there is a significant difference between the types of drugs and BMI mean in participants. Also, in the current study, the methods of drug abuse were associated with WC (Table 3).
Cowan studied 103 drug addicts selected from 6 locations in New York city and found that after receiving the required education on nutrition, their fruits and vegetables consumption had increased by 42%, while their energy, desserts, and sweets consumption decreased. In these patients, WC was reduced significantly. These results demonstrate the beneficial impact of educational interventions on eating behaviors and anthropometric indices of addicted participants (Cowan and Devine, 2013). According to the results of Banitalebi's study et al., 40% of addicted participants are physically active for more than an hour in a week. They mentioned tiredness from the work as the main  reasons of their lack of physical activity (Banitalebi et al., 2010). Findings of this research are consistent with those of this study regarding the "motivation" item (Table 2). As it can be observed from Table 2, more than half of the participants agreed that physical activities are essential for health. This study comes with some limitations; the methodology applied in assessment of body composition might dispossess complete accuracy. For example, the studies conducted on wrestlers indicated that Standard Errors of Estimate (SEEs) in both skinfold thicknesses method and bioelectrical impedance analysis have been limited, i.e., 3% to 3.5% (Ackland TR, 2012). Therefore, application of more precise methods such as hydrostatic weighing for complementary evaluations is proposed.
Conclusions
Given the importance of nutrition and the prevalence of nutritional problems in addicted participants and their inaccuracy in self-care, educational programs are recommended to improve the quality and quantity of their diets. Moreover, due to the effect of food intake on improvement of cognitive function and brain, precise  monitoring over eating habits can play an important role in rehabilitation of drug addicts and prevent them from these misbehaviors and habits.
Acknowledgments
This study was funded by Nutritional Research Center Qom University of Medical Sciences. Researchers would like to tank all participants and Student Research Committee, Qom University of Medical Sciences.
Authors’ contributions
Hozoori M designed research; Ghanbari-Nekou N, Etminani A and Efati B conducted research; Arsang-Jang S analyzed data; and Hozoori M,  Sadeghizadeh Yazdi J and Marzban A wrote the paper. Sadeghizadeh Yazdi J had primary responsibility for the final content. All authors read and approved the final manuscript.  
Conflicts of interest
The authors declare no conflicts of interest.

 
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