Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Design,methods and initial experience

The Isfahan Healthy Heart Programme (IHHP) is a five to six year comprehensive integrated community-based programme for cardiovascular diseases (CVD) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviour in a target population. IHHP started late in 1999 and will be finished in 2005-2006. A primary survey was done to collect baseline data from interventional (Isfahan and Najaf-Abad) and reference (Arak) communities. In a two-stage sampling method, we randomly selected 5 to 10 percent of households from randomly selected clusters. Then individuals aged > or = 19 years were selected for the survey. This way, data from 12,600 individuals (6300 in interventional counties and 6300 in the reference county) was collected and stratified according to living area (urban vs. rural) and different age and sex groups. The samples underwent a 30-minute interview to complete validated questionnaires containing questions on demography, socioeconomic status, smoking behaviour, physical activity, nutritional habits and other behaviour regarding CVD. Blood pressure and body mass index (BMI) measurements were done and fasting blood samples were taken for two hours post load plasma glucose (2 hpp), serum (total, HDL and LDL) cholesterol and triglyceride levels. A twelve-lead electrocardiogram was recorded in all persons above 35 years of age. Community-wide surveillance of deaths, hospital discharges, myocardial infarction and stroke registry was carried out in the intervention and control areas. Four to five years of interventions based on different categories such as mass media, community partnerships, health system involvement and policy and legislation have started in the intervention area while Arak will be followed without intervention. Considering the results of the baseline surveys, (assessments needed, the objectives, existing resources and the possibility of national implementation) the interventions were planned. They were set based on specific target groups like school children, women, work-site, health personnel, high-risk persons, and community leaders were actively engaged as decision makers. A series of teams was arranged for planning and implementation of the intervention strategies. Monitoring will be done on small samples to assess the effect of different interventions in the intervention area. While four periodic surveys will be conducted on independent samples to assess health behaviours related to CVD risk factors in the intervention and reference areas, the original pre-intervention subjects aged more than 35 years will be followed in both areas to assess the individual effect of interventions and outcomes like sudden death, fatal and nonfatal MI and stroke. The whole baseline survey will be repeated on the original and an independent sample in both communities at the end of the study.     

The associations between noise annoyance and psychological distress with blood pressure in children and adolescents: The CASPIAN‐V Study

Although blood pressure (BP) tracks from childhood to adulthood, and the prevalence of pediatric primary hypertension is increasing, related determinants are not well understood. The role of noise pollution and psychological distress in increasing BP is well documented in adults, but it remains elusive in children. This study aims to investigate the association of noise annoyance and psychological distress with BP in a pediatric population. This national cross‐sectional study was conducted in 2015 on a sample of 14400 Iranian students, aged 7‐18 years. Information regarding noise annoyance and psychological distress were assessed using questionnaires, and BP values were measured. Levels of noise annoyance and psychological distress were classified based on tertiles to no/low, moderate, and high. Data of 14274 students were completed. The mean age of participants was 12.28 (0.05), with 51% boys and 71.4% urban inhabitant. Diastolic BP and mean arterial BP (MAP) had positive correlations with noise annoyance (regression coefficient: 0.028, 95 % CI: 0.005 ‐ 0.05 and 0.025, 95 % CI: 0.002 – 0.04, respectively). Participants with higher psychological distress were 15 % more likely to experience abnormally high BP compared to those with normal psychological status or mild distresses (OR: 1.15, 95 % CI: 1.003 – 1.34). Here, we found significant positive relationships between the level of noise annoyance and values of diastolic BP and MAP. Moreover, high psychological distress showed to increase the chance of abnormally high BP. The clinical impact of these findings should be assessed in further longitudinal studies.     

Oxidized LDL metabolites with high family risk for premature cardiovascular disease

Objective: Considering the importance of primary prevention of Cardiovascular Disease (CVD) from childhood, especially in children with high family risk for premature atherosclerosis, and also the importance of oxidized LDL in the process of atherosclerosis, the main metabolites of ox-LDL i.e. Malondialdehyde (MDA) and Conjugated diene (CDE) have been measured in children of high risk families and compared with a control group.Methods: Children and adolescents (6–18 years) of parents with premature myocardial infarction (Ml ≤ 55y in men and ≤ 65y in women), were selected as the case group. The control group included neighbors of the case group matched for age and socioeconomic status. All samples have been selected by simple random sampling. Both the case and control groups were divided in two subgroups : those with a total cholesterol and/or LDL-C ≥95th centile and those with normal lipid levels. Each subgroup consisted of 32 subjects, so 128 subjects were studied (64 in the case and 64 in the control group). MDA and CDE were measured by spectrophotometry using molar absorbivity. Data were analyzed by SPSS_v10/Win software using ANOVA, Bon-ferroni, Scheffe-Duncan, Tukey-HSD, and the Student’s t-test.Result: The mean MDA value in the case and control groups was significantly different (1.84 ± 0.43 vs. 1.67 ± 0.41 Μmol/L, p=0.03), but this difference was not significant regarding the mean CDE level (0.50 ± 0.05 vs. 0.47 ± 0.04 Μmol/ L, p>0.05). The mean MDA level in the case group with hyperlipidemia was significantly higher than that in the case group without hyperlipidemia (1.985 ± 0.516 vs. 1.690 ± 0.366, Μmol/L, P=0.02) and also higher than control group with or without hyperiipidemia (1.985 ± 0.516 vs. 1.720 ± 0.389,1.615 ± 0.429 Μmol/L respectivety, P<0.05). The mean CDE level in the case group with hyperiipidemia was significantly higher than the case group without hyperlipidemia (0.542 ± 0.034 vs. 0.494 ± 0.049 Μmol/L, P=0.04) and higher than the control group with or without hyperiipidemia (0.542 ± 0.034 vs. 0.464 ± 0.051, 0.484 ±0.048 Μmol/L respectively, p<0.05). In case boys with hyperiipidemia, the mean MDA (2.03 ± 0.2 Μmol/L) and the mean of CDE (0.56 ± 0.04 Μmol/L) was significantly higher than other subgroups (P<0.05).Conclusion: Considering the increased susceptibility of LDL to oxidation in children with high family risk for premature CVD, special attention should be paid to consumption of foods and seasoning containing antioxidants from childhood especially in high risk families.     

Vitamin D deficiency among pregnant women and their newborns in Isfahan, Iran

BACKGROUND AND AIMS: Vitamin D deficiency is one of the major health problems and unexpectedly has a high prevalence in sunny countries (e.g. Middle East). In this study we determined the prevalence of vitamin D deficiency in pregnant women and their newborns in Isfahan, a sunny city in Iran. METHODS: In a cross-sectional study, 88 newborns born in Beheshty hospital, affiliated to Isfahan University of Medical Sciences (August-September, 2005) and their mothers were studied. Their data were collected by questionnaires and blood sampling was done to measure serum alkaline phosphatase (ALP), calcium, phosphorus, 25 (OH) vitamin D and parathormone (PTH). Vitamin D deficiency defined as levels of 25 (OH) D < 20 and < 12.5 ng/ml for mothers and newborns, respectively and local cut-offs defined as levels in which mean serum PTH started to increase. RESULTS: The prevalence of vitamin D deficiency according to 25 (OH) D < 20 ng/ml in mothers and < 12.5 ng/ml in newborns was 5.7% and 4.5%, respectively. According to local cut-offs (35 ng/ml for mothers and 26 ng/ml for newborns) 26.1% of mothers and 53.4% of newborns were vitamin D deficient. CONCLUSION: According to local definition, vitamin D deficiency is a health problem in pregnant women and their newborns in this sunny city.     

Association of changes in oxidative and proinflammatory states with changes in vascular function after a lifestyle modification trial among obese children

BACKGROUND: The association of changes in oxidative and proinflammatory states with vascular function after diet and exercise intervention among obese children has not been previously explored. METHODS: In this 6-week diet and exercise intervention study in 35 obese children, age 12 to 18 years, we evaluated the relationship between changes in anthropometric indices, measures of insulin resistance, C-reactive protein (CRP), oxidized LDL (ox-LDL), and oxidative stress markers with changes in carotid intima-media thickness (C-IMT) and flow mediated dilation (FMD) of the brachial artery. RESULTS: At the end of the study, body mass index (BMI), waist circumference, and percentage body fat were decreased (P <0.05), but participants remained overweight (BMI > or = 95th percentile). Although FMD improved (P <0.05), the improvement in C-IMT did not reach statistical significance. The changes in BMI, waist circumference, fat mass, ox-LDL, malondialdehyde (MDA), CRP, insulin, and homeostasis model assessment for insulin resistance (HOMA-IR) had an inverse correlation with the changes in mean FMD after adjustment for age and sex, with the highest correlations documented for ox-LDL, CRP, and WC. The age- and sex-adjusted changes in ox-LDL, waist circumference, CRP, MDA, and body fat mass had the highest correlations with changes in C-IMT. CONCLUSIONS: Our findings suggest that a common inflammatory stress condition associated with childhood obesity, notably with abdominal fat deposition, may play a role in the development of the earliest stages of proatherosclerotic inflammatory processes and subsequent vascular dysfunction. These changes might be partially reversible by short-term diet and exercise intervention, even if patients do not reach ideal body weight.     

High prevalence of goiter in an iodine replete area: do thyroid auto-antibodies play a role?

INTRODUCTION: Despite long standing iodine supplementation in Iran the prevalence of goiter remains high in some areas. This may suggest that causes other than iodine deficiency, such as autoimmune thyroid diseases, should also be considered. We therefore assessed the prevalence of anti-thyroid antibodies in children living in an inland area in Iran and correlated these findings with prevalence of goiter within this region. METHODS: In a cross-sectional study, 1948 students were selected by multistage random cluster sampling from the 108 primary schools (age, 7-13 year-old) of the urban and rural areas of Semirom. After obtaining written consent from their parents, the children were examined by endocrinologists for goiter grading. Grade 2 goitrous children (108 cases) were compared with non-goitrous children (111 children as control group) for anti-thyroid antibodies. RESULTS: Overall, 36.7% of 1948 students had goiter. The mean urinary iodine excretion level was 1.49+/-0.7 micromol/L. This was within normal limits. Of 219 children studied, 4.3% presented with subclinical hypothyroidism, and 7.3% had positive anti-thyroid antibodies. There was non-significant difference of positive thyroperoxidase antibody (anti-TPO) (Odds Ratio= 3.2, p= 0.13) but significant difference of anti Tg between goitrous and non goitrous children (Odds Ratio: 5.6, 95% CI: 1.18-26.0, p: 0.015). CONCLUSION: This study suggests that autoimmunity may be one of the mechanisms responsible for goiter persistence after iodine replenishment in this iodine deficient region, but the role of other factors should also be considered.     

Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study

OBJECTIVE: To examine the relation of dietary and physical activity (PA) patterns with the body mass index (BMI), and the associations between these patterns among children. METHODS: A representative sample of 21 111 school students aged 6-18 years was selected by multistage random cluster sampling from 23 provinces in the Islamic Republic of Iran. PA and dietary pattern were assessed by self-administered validated questionnaires. FINDINGS: Fruit and vegetables, dairy products and snacks (salty, fatty or sweet) had a similar consumption frequency of approximately twice a day. The type of fat most frequently consumed was hydrogenated solid fat (consumed by 73.8% of families). The PA level was significantly higher among boys than girls, in rural than in urban residents, and in intermediate students than high-school students. Among boys, the frequency of consumption of vegetables and plant proteins (R(2) = 0.46); and among girls, the frequency of consumption of dairy products and fruits, as well as high PA level had a significant inverse association with BMI (R(2) = 0.57). Among boys, the low frequency of consumption of fruits, the time spent on PA and the energy expenditure; and among girls, the time spent on PA and the energy expenditure, had significant relationships with overweight. When controlling for covariates, PA levels had significant relationships with the frequency of consumption of all food groups. CONCLUSION: Unhealthy lifestyles make Iranian young people prone to chronic diseases later in life. When examining their health benefits, the interrelationship of dietary and PA behaviours should be considered.     

Blood pressure and its influencing factors in a national representative sample of Iranian children and adolescents: the CASPIAN Study.

BACKGROUND: This study was performed to determine the blood pressure (BP) percentile curves by height, as well as to assess the prevalence of high BP and its influencing factors among children in the first national survey in this field in Iran. DESIGN: A multicentre national cross-sectional survey. METHODS: This study was performed in 23 provinces among a representative sample of 21,111 students aged 6-18 years. RESULTS: Age and sex-specific percentile curves of systolic and diastolic BP were obtained by height. A comparison of the values obtained corresponding to the 90th percentiles with the Second Task Force cut-offs showed that the BP values and trends were relatively similar in both studies. The overall prevalence of systolic, diastolic as well as systolic or diastolic hypertension according to the Second Task Force study 95th percentile cut-off points were 4.2, 5.4 and 7.7%, respectively, without a significant sex difference. A history of low birthweight, overweight, taller height, the consumption of solid hydrogenated fat, as well as the frequency of fast food consumption increased the risk of both systolic and diastolic hypertension. Male sex, large waist, and low education of the mother were the risks for systolic hypertension, whereas the risk of diastolic hypertension rose with living in an urban area, attending public school, low physical activity level, having a housewife mother, and a positive family history of obesity, especially in the parents. CONCLUSION: Considering the effect of modifiable environmental factors on the childrens' BP, encouraging breast feeding and a healthy lifestyle may have an important effect on public health.