Prevalence of obesity and overweight in Iranian students: a systematic review and meta-analysis

Abstract

Background
Obesity and overweight are among the most common and serious health issues in many countries, leading to numerous medical consequences such as heart disease, hypertension, fatty liver etc.

Objective
This review article addressed the prevalence of obesity and overweight in Iranian students by using meta-analysis.

Methods
A number of domestic and international databases were searched, including IranMedex, Magiran, SID, Scopus, PubMed, IranDoc, Web of Science and Google Scholar. Eligible publications were 160 articles that addressed the prevalence of obesity or overweight. Data were combined using random effects model. Heterogeneity of the studies was examined by Q statistics and the I ² index. Data were analyzed using STATA version 11.1.

Results
In the 160 reviewed studies, a total of 481,070 individuals (6–20 years) were included. The prevalence of obesity among Iranian students based on body mass index (BMI) was 11% (95% confidence interval [CI]: 10%–12%) (in girls 8% [95% CI: 7%–10%] and in boys 11% [95% CI: 10%–13%]). The prevalence of overweight in students based on BMI was 12% (95% CI: 12%–13%) (in girls 13% [95% CI: 11%–14%] and in boys 11% [95% CI: 18%–30%]). The rate of obesity was 13% (95% CI: 11%–16%) in elementary school students, 10% (95% CI: 7%–14%) in secondary school students and 7% (95% CI: 6%–9%) in high school students.

Conclusions
The prevalence rate of overweight was more than that of obesity with a 1% difference. The prevalence of obesity was higher in boys, while the prevalence of overweight was higher in girls. The prevalence of obesity was higher in primary school students than in secondary school students. This prevalence was higher in secondary school students than in high school students.

Full text

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© 2019 Indian Journal of Medical Specialities | Published by Wolters Kluwer - Medknow 1
Abstract
Original Article
IntroductIon
The World Health Organization (WHO) has identied obesity
as a global issue and[1] referred to it as the most serious global
health issue that affects the quality of life and ends up in physical,
mental, and psychological disorders.[2,3] The prevalence of
childhood obesity has dramatically increased throughout the
world over the past decades. Obesity in adolescence is mostly
rooted in childhood.[4] According to international denitions, at
least 10% of children worldwide are overweight or obese.[5] In
other words, about 22 million children worldwide are involved
in obesity.[6] In 2010, overweight obesity led to the death of
3.4 million people, a loss of 3.9% of the length of their lives,
and 3.8% of disability.[7] It has been estimated that up to
one-third of the population of children in developed countries
are overweight.[8] The prevalence of obesity in Canadian
children in the age range of 7–13 years ranged from 5% to
15% between 1981 and 1996.[9] From 2011to 2012, 32.2% of
the US children were overweight and 17.3% were obese. In
addition, 5.9% of children with obesity had Grade 2 and 2.1%
had Grade 3 of obesity criteria. Although these rates were not
Background of the Study: Childhood obesity, in addition to the desire for continuity in adulthood, is associated with an increase in mortality
and various diseases. Purpose of the Study: This meta-analytic study aimed at determining the prevalence of obesity among Iranian children.
Methodology: Two researchers independently searched national and international databases using Mesh, Scopus, PubMed, Science Direct,
Web of Science, Springer, Magiran, Iranmedex, SID, Medlib, and the Google Scholar search engine. The heterogeneity between studies was
evaluated using the I2 index. Data were analyzed using STATA software. This study was conducted based on the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses statement. Results: Among 93 studies with a sample size of 3,845,768, the prevalence of obesity
in Iranian children was 7% (girls 8% and boys 10%), and the prevalence of overweight was 12% (girls 17% and boys 15%). The incidence
rate of obesity in children was 13% based on US centers for disease control and prevention (CDC) 2000 reference, 11% on international
obesity task force (IOTF) reference, 9% on World Health Organization reference, 9% on Iranian reference, 5% on CDC reference, and 3% on
national center for health statistics (NCHS) reference. Meta-regression diagram also showed that the prevalence of obesity in children was
not dependent on sample size. However, the prevalence of obesity declined during the years 1999–2016, which was statistically signicant.
Conclusion: The prevalence of obesity in Iranian children was less than of their overweight. On the other hand, the prevalence of childhood
obesity in girls was lower than that of boys, and the prevalence of child overweight among girls was higher than that of boys.
Keywords: Children, Iran, meta-analysis, obesity, prevalence, overweight
INJMS_2_19R3
Access this article online
Quick Response Code:
Website:
www.ijms.in
DOI:
10.4103/INJMS.INJMS_2_19
Prevalence of Obesity in Iranian Children: Systematic Review
and Meta‑Analysis
Moloud Fakhri1,2, Diana Sarokhani3, Mandana Sarokhani3, Ali Hasanpour Dehkordi4, Leila Jouybari5
1Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, 2Department of Reproductive Health and
Midwifery, Sexual and Reproductive Health Research Center, Mazandaran University of Medical Sciences, Sari, 3Psychosocial Injuries Research Center, Ilam University
of Medical Sciences, Ilam, 4Department of Medical-Surgical, Faculty of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, 5Nursing
Research Center, Golestan University of Medical Sciences, Gorgan, Iran
This is an open access journal, and arcles are distributed under the terms of the Creave
Commons Aribuon-NonCommercial-ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non-commercially, as long as appropriate credit
is given and the new creaons are licensed under the idencal terms.
For reprints contact: reprints@medknow.com
How to cite this article: Fakhri M, Sarokhani D, Sarokhani M, Dehkordi
AH, Jouybari L. Prevalence of obesity in Iranian children: Systematic review
and meta-analysis. Indian J Med Spec 2019;10:XX-XX.
Received : 08-01-2019
Accepted : 16-Apr-2019
Revised : 05-Mar-2019
Published Online : ???
Address for correspondence: Dr. Leila Jouybari,
Nursing Research Center, Golestan University of
Medical Sciences, Gorgan, Iran.
E-mail: jouybari@goums.ac.ir
Dr. Ali Hasanpour Dehkordi,
Department of Medical-Surgical, Faculty of Nursing and Midwifery,
Shahrekord University of Medical Sciences, Shahrekord, Iran.
E-mail: Alihassanpourdehkordi@gmail.com

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Fakhri, et al.: Prevalence of obesity in Iranian children
Indian Journal of Medical Specialities ¦ Volume 10 ¦ Issue 3 ¦ July-September 2019
2
Scopus, PubMed, Science Direct, Web of Science, Springer,
Magiran, Iranmedex, SID, Medlib, and the Google Scholar
search engine. For generalization of the research step, internal
and external keywords were used for general keywords and
in external databases, the combination of keywords was used
with the “AND” and “OR” operators. The search step was
unrestricted and updated by November 2017. In order to
complete the search process, manual search was also performed
through reviewing the sources of the articles found.
Research outcomes
The inclusion criteria included articles that reported the
prevalence of obesity among Iranian children. Exclusion
criteria involved studies that had nonrandom sampling, studies
that did not have sufcient data and information, studies with
inaccessible full texts, studies that did not have the required
quality, studies that were not of childhood age range, and
studies that were conducted outside Iran. The language of the
articles was Persian and English, but in the search phase, no
time and language restrictions were applied.
Quality appraisal
The researchers examined the quality of articles using the
STROBE checklist,[32] a well-known international standard
checklist for qualitative evaluation of articles. This checklist
consists of 22 different sections and covers different parts of
a report including sampling, variable measurement, statistical
analysis, confounding modications, validity, and reliability
of used tools and study objectives. The score range for this
checklist is between 0 and 44, and articles scoring <15.5 were
excluded from the study.
Data abstraction
Studies that conformed to the required criteria were nally
analyzed. To reduce the reporting bias and error in data
collection, two researchers independently extracted data
from articles. The researchers listed a checklist including the
name of the author, study title, age, the prevalence of obesity
(in general, the girl and the boy), the prevalence of weight gain
(in general, the girl and the boy), the prevalence of weight
loss, the year and place of the study, the total number, and the
number of girls and boys.
Synthesis
The variance of each study was calculated according to the
binomial distribution. Studies were combined according to
the sample number and variance. Regarding the heterogeneity
of the studies, the random effects model was used. In order
to evaluate the studies, Cochran method and I2 index were
utilized. The I2 <25% indicates a low heterogeneity, I2 between
25% and 75% indicates a moderate heterogeneity, and I2 >75%
indicates a high heterogeneity. The heterogeneity in our study
was 99.2%, which was categorized as high heterogeneity. To
investigate the relationship between the prevalence of obesity
and the quantitative variables of years, and the number of
signicantly different from those of 2009–2010, all obesity
classes have increased over the past 14 years.[10] Obesity in
Iran is a serious problem and is linked to the pandemic of
obesity in the world.[11] Lifestyle changes in many developing
countries including Iran have been accompanied by aftermaths
such as weight gain and obesity and now, childhood obesity
has become a global epidemic with domestic, psychological,
and economic complications.[12-16] Obesity is associated
with an increase in adult mortality and is also accompanied
with childhood problems such as insulin resistance, type 2
diabetes, dyslipidemia, polycystic ovary syndrome, pulmonary
disorders, orthopedics, psychiatric problems, chronic
cardiovascular diseases, and hypertension.[17] Obesity in
children is also accompanied by depression, confusion, low
self-esteem, and frustration.[18] The importance of obesity in
childhood and adolescence is not only due to early physical and
psychological complications, but also because of the increase
in adulthood obesity, the increased incidence of diseases and
mortality, and also heavy economic burdens on the society.[17]
Given the risks in health issues and the signicant rise in
obesity, it has become a major global health challenge. Obesity
has not only increased, but it has not been controlled over the
past 33 years. Therefore, international collaboration is needed
to help tackle this problem.[19-21] It is also necessary to have
information about the prevalence of obesity among children
because it can lead to the identication of subgroups at risk
to take preventive measures.[22] Prevention of obesity is very
important because effective treatments for this condition are
limited. Food management and increased physical activity
should be encouraged, promoted, and prioritized to protect
children.[4,12,23-30] Over the past few years, many studies have
been published on the prevalence of obesity in Iranian children,
which have reported different outcomes. This study aimed to
determine the prevalence of obesity among Iranian children
through a systematic review and meta-analysis.
LIterature revIew
Protocol of study
We registered the study protocol on the PROSPERO site (ID:
128049, Date: 09/03/2019).
Purpose of the study
This study aimed at determining the prevalence of obesity in
Iranian children through meta-analysis.
The design of the study
This research was based on the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses study of reporting
system.[31]
Methodology
All articles on the prevalence of obesity in Iranian children
have been studied. Two researchers independently used
the keywords “Prevalence, Obesity, Overweight, children,
Meta-analysis, and Iran” and their combinations and
scrutinized the national and international databases including

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Fakhri, et al.: Prevalence of obesity in Iranian children
Indian Journal of Medical Specialities ¦ Volume 10 ¦ Issue 3 ¦ July-September 2019 3
NOTE: Weights are from random effects analysis
Overall (I-squared = 99.2%, p = 0.000)
Akhavan-karbasi.S (2005)
Hajian-Tilaki.K (2012)
Ebrahim zade kor (2006)
Keykhaei.F (2012)
Veghari.Gh (2011)
Mahmoudpour.F (2012)
Vafa.MR (2008)
Nouri-Saeidlu.S (2009)
Khorramabadi.S (2011)
Taheri.F (2009)
Faghih.Sh (2015)
Dorosty.AR (2009)
Motlagh.ME (2007)
Zamani.M (2011)
Ghadimi.R (2011)
Study
Haeri Bebahani.B (2007)
Azarbayjani.A (2009)
Aminzadeh.M (2010)
Asna-Ashari.F (2015)
Nouri-Saeidlu.S (2011)
Yavari kia.AR (2012)
Dorosty.AR (2009)
Dorosty.AR (2009)
Veghari.Gh (1998)
Torabi.Z (2012)
Salaki.S (2010)
Salehinia.H (2012)
Khaji.A (2003)
Amanollahi.A (2011)
Kafhami-Khorasani.H (2013)
Ghadimi.R (2011)
Ayatollahi.S.M.T (2007)
Khatibi.M (2016)
Dorosty.AR (2005)
Mirzaei.M (2010)
Ziaei-Kajbaf.T (2009)
Asadi noughabi.F (2007)
Bayegi.F (2005)
Amanollahi.A (2011)
Tabatabaei.M (2002)
Sodaei-Zanuzagh.H (2010)
Nuh jah.S (2009)
Moradi.Gh (2015)
Musavi-Jazayeri.SMH (2005)
Hajian-Tilaki.K (2011)
Naderi-Bani.M (2011)
Khodaverdi.F (2007)
Nouri-Saeidlu.S (2010)
Zekavat.OR (2008)
Yepan-Gharavi.A (2012)
Taheri.F (2002)
Bayegi.F (2005)
Asna-Ashari.F (2015)
Mahmoudpour.F (2012)
Golestan.M (2006)
Tabesh.H (2012)
Mohammadian.S (2005)
Bayegi.F (2005)
Soheliefar.J (2003)
Karjibani.M (2002)
Soheliefar.J (2008)
Ebrahim zade kor.B (2011)
Abarghooei.A (2014)
Asna-Ashari.F (2015)
Rfat.R (2009)
Asna-Ashari.F (2015)
Veghari.Gh (2005)
Zarrati.M (2011)
Nasiri.A (2006)
Mottaghi.A (1999)
Shahqolian.N (2001)
Shapourimoghdam.A (2010)
Sedighi.E (2012)
Hasanzadeh-Rostami.Z (2012)
ID
Mirshekar.S (2015)
Ziaoddini.H (2007)
Musavi-Jazayeri.SMH (2005)
Agha Alinezhad.H (2013)
Nabavi.M (2010)
Talaei-Zanjani.A (2009)
Javedan.Gh.A (2015)
Tabatabaei.M (2002)
Shidfar.F (2011)
Gaeini.A (2007)
Esfaranjani.SV (2009)
Talaei-Zanjani.A (2009)
Dorosty.AR (2002)
Karam Soltani.Z (2005)
Veghari.Gh (2013)
Mirsoleimani.H (2012)
Taheri.F (2012)
Motlagh.ME (2008)
Hamidi.A (2004)
Maddah.M (2009)
Mozaffari.H (2002)
Kelishadi.R (2009)
Seyyedamini.B (2010)
Agha Alinezhad.H (2013)
Dorosty.AR (2009)
Tabatabaei.M (2002)
Gaeini.A (2010)
Golestan.M (2013)
Agha Alinezhad.H (2013)
Dorosty.AR (2009)
Ghanbari.H (2010)
Kalantari.N (2009)
Fesharakinia.A (2006)
Soheilipour.F (2012)
Dalili.S (2014)
Veghari.Gh (2004)
Kabir.K (2012)
0.07 (0.07, 0.08)
0.04 (0.02, 0.06)
0.15 (0.12, 0.18)
0.06 (0.04, 0.09)
0.22 (0.19, 0.26)
0.14 (0.13, 0.15)
0.12 (0.10, 0.13)
0.12 (0.09, 0.14)
0.02 (0.02, 0.02)
0.05 (0.03, 0.06)
0.08 (0.05, 0.10)
0.15 (0.10, 0.20)
0.14 (0.13, 0.14)
0.03 (0.03, 0.03)
0.10 (0.08, 0.12)
0.14 (0.13, 0.15)
0.05 (0.04, 0.06)
0.14 (0.11, 0.17)
0.18 (0.16, 0.20)
0.15 (0.13, 0.18)
0.03 (0.03, 0.03)
0.18 (0.09, 0.27)
0.05 (0.04, 0.06)
0.06 (0.06, 0.07)
0.05 (0.04, 0.05)
0.11 (0.09, 0.13)
0.07 (0.04, 0.10)
0.24 (0.22, 0.25)
0.06 (0.05, 0.07)
0.08 (0.07, 0.10)
0.22 (0.19, 0.25)
0.45 (0.38, 0.52)
0.05 (0.04, 0.05)
0.02 (0.01, 0.03)
0.13 (0.12, 0.14)
0.02 (0.02, 0.03)
0.09 (0.08, 0.11)
0.09 (0.07, 0.10)
0.09 (0.07, 0.10)
0.09 (0.07, 0.10)
0.11 (0.10, 0.12)
0.03 (0.03, 0.04)
0.07 (0.06, 0.09)
0.12 (0.10, 0.13)
0.08 (0.07, 0.09)
0.06 (0.04, 0.07)
0.02 (0.01, 0.04)
0.15 (0.10, 0.19)
0.03 (0.03, 0.03)
0.05 (0.04, 0.06)
0.07 (0.05, 0.10)
0.03 (0.02, 0.04)
0.05 (0.04, 0.06)
0.04 (0.03, 0.06)
0.04 (0.03, 0.04)
0.06 (0.05, 0.08)
0.05 (0.05, 0.06)
0.06 (0.05, 0.08)
0.07 (0.06, 0.09)
0.06 (0.04, 0.07)
0.01 (0.01, 0.02)
0.04 (0.03, 0.04)
0.06 (0.04, 0.08)
0.18 (0.15, 0.21)
0.06 (0.04, 0.07)
0.17 (0.12, 0.22)
0.10 (0.08, 0.12)
0.28 (0.25, 0.30)
0.05 (0.04, 0.07)
0.16 (0.07, 0.24)
0.05 (0.04, 0.07)
0.10 (0.09, 0.11)
0.05 (0.04, 0.07)
0.05 (0.04, 0.06)
0.05 (0.05, 0.06)
ES (95% CI)
0.05 (0.04, 0.05)
0.05 (0.05, 0.05)
0.02 (0.02, 0.03)
0.08 (0.05, 0.11)
0.14 (0.11, 0.18)
0.02 (0.01, 0.03)
0.07 (0.06, 0.07)
0.04 (0.03, 0.04)
0.53 (0.50, 0.56)
0.05 (0.03, 0.06)
0.06 (0.04, 0.08)
0.05 (0.03, 0.06)
0.07 (0.06, 0.08)
0.13 (0.12, 0.14)
0.04 (0.03, 0.04)
0.17 (0.14, 0.21)
0.09 (0.08, 0.11)
0.04 (0.03, 0.04)
0.03 (0.02, 0.03)
0.06 (0.05, 0.06)
0.08 (0.06, 0.09)
0.03 (0.03, 0.03)
0.06 (0.03, 0.09)
0.12 (0.09, 0.15)
0.05 (0.05, 0.06)
0.05 (0.04, 0.06)
0.05 (0.03, 0.07)
0.06 (0.05, 0.08)
0.08 (0.06, 0.11)
0.04 (0.03, 0.04)
0.07 (0.05, 0.09)
0.19 (0.15, 0.23)
0.02 (0.01, 0.03)
0.09 (0.08, 0.10)
0.12 (0.10, 0.14)
0.01 (0.01, 0.02)
0.05 (0.03, 0.07)
100.00
0.78
0.59
0.58
0.40
1.15
1.04
0.53
1.28
1.01
0.65
0.26
1.15
1.28
0.79
1.04
%
1.09
0.47
0.78
0.60
1.28
0.08
1.23
1.21
1.14
0.73
0.53
1.01
1.12
0.85
0.42
0.14
1.14
0.97
1.03
1.21
0.77
0.92
0.94
0.84
1.08
1.21
0.88
1.00
1.10
0.93
0.94
0.28
1.28
1.00
0.59
1.14
1.06
0.94
1.19
0.84
1.21
0.86
0.97
1.01
1.23
1.15
0.78
0.50
0.87
0.25
0.73
0.65
0.99
0.09
0.93
1.05
0.82
1.13
1.24
Weight
1.18
1.28
1.23
0.55
0.41
1.11
1.25
1.20
0.52
0.91
0.91
0.91
1.16
1.03
1.17
0.39
0.93
1.28
1.27
1.21
1.01
1.28
0.56
0.44
1.22
1.17
0.82
0.91
0.53
1.24
0.65
0.35
1.14
1.10
0.70
1.25
0.72
0.07 (0.07, 0.08)
0.04 (0.02, 0.06)
0.15 (0.12, 0.18)
0.06 (0.04, 0.09)
0.22 (0.19, 0.26)
0.14 (0.13, 0.15)
0.12 (0.10, 0.13)
0.12 (0.09, 0.14)
0.02 (0.02, 0.02)
0.05 (0.03, 0.06)
0.08 (0.05, 0.10)
0.15 (0.10, 0.20)
0.14 (0.13, 0.14)
0.03 (0.03, 0.03)
0.10 (0.08, 0.12)
0.14 (0.13, 0.15)
0.05 (0.04, 0.06)
0.14 (0.11, 0.17)
0.18 (0.16, 0.20)
0.15 (0.13, 0.18)
0.03 (0.03, 0.03)
0.18 (0.09, 0.27)
0.05 (0.04, 0.06)
0.06 (0.06, 0.07)
0.05 (0.04, 0.05)
0.11 (0.09, 0.13)
0.07 (0.04, 0.10)
0.24 (0.22, 0.25)
0.06 (0.05, 0.07)
0.08 (0.07, 0.10)
0.22 (0.19, 0.25)
0.45 (0.38, 0.52)
0.05 (0.04, 0.05)
0.02 (0.01, 0.03)
0.13 (0.12, 0.14)
0.02 (0.02, 0.03)
0.09 (0.08, 0.11)
0.09 (0.07, 0.10)
0.09 (0.07, 0.10)
0.09 (0.07, 0.10)
0.11 (0.10, 0.12)
0.03 (0.03, 0.04)
0.07 (0.06, 0.09)
0.12 (0.10, 0.13)
0.08 (0.07, 0.09)
0.06 (0.04, 0.07)
0.02 (0.01, 0.04)
0.15 (0.10, 0.19)
0.03 (0.03, 0.03)
0.05 (0.04, 0.06)
0.07 (0.05, 0.10)
0.03 (0.02, 0.04)
0.05 (0.04, 0.06)
0.04 (0.03, 0.06)
0.04 (0.03, 0.04)
0.06 (0.05, 0.08)
0.05 (0.05, 0.06)
0.06 (0.05, 0.08)
0.07 (0.06, 0.09)
0.06 (0.04, 0.07)
0.01 (0.01, 0.02)
0.04 (0.03, 0.04)
0.06 (0.04, 0.08)
0.18 (0.15, 0.21)
0.06 (0.04, 0.07)
0.17 (0.12, 0.22)
0.10 (0.08, 0.12)
0.28 (0.25, 0.30)
0.05 (0.04, 0.07)
0.16 (0.07, 0.24)
0.05 (0.04, 0.07)
0.10 (0.09, 0.11)
0.05 (0.04, 0.07)
0.05 (0.04, 0.06)
0.05 (0.05, 0.06)
ES (95% CI)
0.05 (0.04, 0.05)
0.05 (0.05, 0.05)
0.02 (0.02, 0.03)
0.08 (0.05, 0.11)
0.14 (0.11, 0.18)
0.02 (0.01, 0.03)
0.07 (0.06, 0.07)
0.04 (0.03, 0.04)
0.53 (0.50, 0.56)
0.05 (0.03, 0.06)
0.06 (0.04, 0.08)
0.05 (0.03, 0.06)
0.07 (0.06, 0.08)
0.13 (0.12, 0.14)
0.04 (0.03, 0.04)
0.17 (0.14, 0.21)
0.09 (0.08, 0.11)
0.04 (0.03, 0.04)
0.03 (0.02, 0.03)
0.06 (0.05, 0.06)
0.08 (0.06, 0.09)
0.03 (0.03, 0.03)
0.06 (0.03, 0.09)
0.12 (0.09, 0.15)
0.05 (0.05, 0.06)
0.05 (0.04, 0.06)
0.05 (0.03, 0.07)
0.06 (0.05, 0.08)
0.08 (0.06, 0.11)
0.04 (0.03, 0.04)
0.07 (0.05, 0.09)
0.19 (0.15, 0.23)
0.02 (0.01, 0.03)
0.09 (0.08, 0.10)
0.12 (0.10, 0.14)
0.01 (0.01, 0.02)
0.05 (0.03, 0.07)
100.00
0.78
0.59
0.58
0.40
1.15
1.04
0.53
1.28
1.01
0.65
0.26
1.15
1.28
0.79
1.04
%
1.09
0.47
0.78
0.60
1.28
0.08
1.23
1.21
1.14
0.73
0.53
1.01
1.12
0.85
0.42
0.14
1.14
0.97
1.03
1.21
0.77
0.92
0.94
0.84
1.08
1.21
0.88
1.00
1.10
0.93
0.94
0.28
1.28
1.00
0.59
1.14
1.06
0.94
1.19
0.84
1.21
0.86
0.97
1.01
1.23
1.15
0.78
0.50
0.87
0.25
0.73
0.65
0.99
0.09
0.93
1.05
0.82
1.13
1.24
Weight
1.18
1.28
1.23
0.55
0.41
1.11
1.25
1.20
0.52
0.91
0.91
0.91
1.16
1.03
1.17
0.39
0.93
1.28
1.27
1.21
1.01
1.28
0.56
0.44
1.22
1.17
0.82
0.91
0.53
1.24
0.65
0.35
1.14
1.10
0.70
1.25
0.72
0-.556 0 .556
Figure 1: The prevalence and 95% confidence intervals of obesity among Iranian children based on the authors’ name and years of research drawing
on the random effects model. The middle point of each section reveals the prevalence of obesity in children in each study. The lozenge shows the
prevalence of obesity in Iranian children for all studies

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Fakhri, et al.: Prevalence of obesity in Iranian children
Indian Journal of Medical Specialities ¦ Volume 10 ¦ Issue 3 ¦ July-September 2019
4
samples, the meta-regression model was used. Data were
analyzed using STATA version 11 (KitelyTech’s industry
leading custom software development services, Chicago). The
signicance level of the tests was considered to be P < 0.05.
resuLts
While conducting the study, 93 articles had entered the
meta-analysis process, which were in the period from 1998
to 2017.[41-58,60-123,125-129] The total number of participants in
the study was 3,845,768. As the selected studies had high
heterogeneity, the random effects model was used. The
meta-analysis of the prevalence of obesity in Iranian children
resulted from the combination of the results of studies
presented in Flowchart 1 and Table 1. The properties of the
studies are listed in Table 1.
The prevalence of obesity in Iranian children was 7%
(girls 8% and boys 10%) [Figure 1], of which, the weight
gain was 12% (girls 17% and boys 15%), and the incidence
of weight reduction was 13% [Table 2].
As shown in Figure 2, there was no signicant relationship
between the prevalence of obesity in Iranian children and the
number of research samples (P = 0.116). However, there was
a signicant relationship between the prevalence of obesity
and the year of study (P = 0.039) [Figure 3].
dIscussIon
Overall, 144 articles with the sample size of 377,858 people
(134,588 males and 164,858 females) were included in the
study. The prevalence of obesity in populations above the
age of 18 in Iran was estimated as 21.7% (95% condence
AQ13
interval [CI]: 18.5%–25%) and in population below 18, it was
6.1% (95% CI: 6.8%–5.4%).[33] Regarding 93 studies with
3,845,768 people, the prevalence of obesity among Iranian
children was 7% (girls 8% and boys 10%), and the prevalence
of weight gain was 12% (girls 17% and boys 15%). The results
of this study indicated that the prevalence of childhood obesity
in boys was higher than that of girls. In a study regarding 23
provinces in Iran in the years 2003–2004, the prevalence of
weight gain and obesity in schoolchildren was 9.8% and 4.4%,
respectively.[34] The ndings of these studies indicated that the
prevalence of weight gain was higher than that of obesity in
children, which was quite consistent with the current study. In
a study conducted in Canada by Veugelers and Fitzgerald, the
prevalence of obesity was 9% in girls and 10.9% in boys.[35] In
another study in Greece in 2007, the incidence rate of obesity
was 48.9% in girls and 51.1% in boys (aged 8–10 years old).[36]
In their study, which was similar to this research, the prevalence
of childhood obesity was higher in boys than girls. However, in
a study in Sweden in 2006, the prevalence of obesity was 5%
for girls and 10% for boys (10%),[37] which was inconsistent
with the current study`s ndings.
In the analysis, the prevalence of childhood obesity on the basis
of different references was examined. It was found that the
prevalence of obesity in children was 13% based on CDC 2000
reference, 11% on IOTF reference, 9% on WHO reference, 9%
on Iranian reference, 5% on CDC reference, and 3% on NCHS
reference. These results indicated that, according to the CDC
2000 reference, the prevalence of obesity in children was the
highest, and based on the NCHS reference, the prevalence of
obesity in children was the lowest. In China, the incidence rate
of obesity in children under 6 years of age was 3.2%, 3.5%, and
6.8%, using the WHO, IOTF, and CDC guidelines, respectively.
The corresponding values for children aged 6–9 years were
10%, 6.3%, and 10.4%, respectively.[38] In Sweden in 2006, the
prevalence of obesity was 3.4% and that of weight gain was 22%
for 10-year-old children using the WHO reference.[37] According
279 records were identified
through database searching
0 additional records were
identified through other sources
121 record duplicates were removed
158 records were screened 34 records were
excluded
124 full-text articles were
assessed for eligibility
29 full-text articles
were excluded,
for reasons
95 studies were included
in qualitative synthesis
93 studies were included
in quantitative synthesis
(meta-analysis)
Flowchart 1: Flowchart of including the studies in meta-analysis
0.1 .2 .3 .4 .5
Prevalence of Obesity in Iranian Children
0 200000 400000 600000 800000 1000000
Sample Size
Figure 2: The relationship between the prevalence of obesity in Iranian
children and the number of research samples using the meta-regression
model

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Contd...
Table 1: Information extracted from articles entered into the meta‑analysis process
Author Year of
Study
City of Study References Prevalence
of obesity
Prevalence of
Overweight
Sample
Size
[86]Veghari.Gh 1998 Golestan CDC 4.6 8.5 2339
[111]Mottaghi.A 1999 Tehran CDC 5.2 6.9 901
[50]Shahqolian.N 2001 choharmahal - 9.9 - 2772
[51]Hushiyar rad.A 2002 - CDC2000 - - 2505
[70]Tabatabaei.M 2002 Ahvaz CDC 10.9 - 3482
[70]Tabatabaei.M 2002 Ahvaz IOTF 5.2 - 3482
[70]Tabatabaei.M 2002 Ahvaz CDC2000 3.6 - 3482
[113]Dorosty.AR 2002 Guilan-Sistan WHO 7 23.3 4315
[127]Taheri.F 2002 Birjand NCHS 3.3 - 1772
[22]Karjibani.M 2002 Zahedan NCHS 1.4 - 2067
[66]Mozaffari.H 2002 Tehran - 7.7 13.3 1800
[60]Khaji.A 2003-2004 Tehran Iranian reference 6.3 0.10.7 2766
[63]Soheliefar.J 2003-2004 Hamedan WHO 5.7 6.4 1400
[82]Hamidi.A 2004 Tehran CDC 2.6 1.5 13086
[86]Veghari.Gh 2004 Golestan CDC 1.2 3.3 2749
[129]Baegi 2005 Neishabur WHO 7.3 - 1471
[43]Karamsoltani.Z 2005 Yazd - 13.3 - 3245
[129]Baegi.F 2005 Neishabur Iranian reference 8.5 - 1471
[44]Dorosty.AR 2005 Yazd - 13.3 - 3245
[129]Baegi 2005 Neishabur CDC 4.6 - 1471
[57]Veghari.Gh 2005 Gorgan Percentiles - - 1446
[117]Musavi-Jazayeri.SMH 2005 Tehran - - - 927
[117]Musavi-Jazayeri.SMH 2005 Tehran CDC - - 927
[74]Mohammadian.S 2005-2006 Gorgan - 6.4 14.7 844
[56]Akhavan-karbasi.S 2005-2006 Yazd - 3.8 4.3 400
[55]Golestan.M 2006 Yazd WHO 6.5 12.9 794
[75]Ebrahim zade kor 2006 Bandar torkman - 6.4 - 343
[21]Nasiri.A 2006 Birjand - 15.7 - 70
[119]Fesharakinia.A 2006 Korasan-Jonubi CDC2000 1.8 3.4 954
[110]Ziaoddini.H 2007 - IOTF 5 13.5 899035
[87]Khodaverdi.F 2007 Tehran CDC 14.6 13.8 240
[94]Ayatollahi.S.M.T 2007 Shiraz - - - 2397
[43]Haeri Bebahani.B 2007 Sabzevar CDC2000 4.8 7.9 1800
[123]Asadi nooghab.F 2007 Bandar abas CDC 8.5 11.4 1350
[106]Motlagh.ME 2007 - - 3.4 12.8 862433
[105]Gaeini.A 2007-2008 Tehran CDC - - 756
[106]Motlagh.ME 2008 - CDC 3.5 13.5 782244
[128]Soheliefar.J 2008 Hamedan - 3.5 - 2000
[46]Salem.Z 2008 Rafsanjan CDC - 9.4 1275
[64]Vafa.MR 2008 Tehran IOTF 11.7 8 513
[120]Zekavat.OR 2008-2009 Jahrom CDC - - 1158
[122]Esfaranjani.SV 2009 Ahvaz IOTF 6 11.9 960
[109]Nouri-Saeidlu.S 2009 West Azerbaijan - - 165740
[92]Ziaei-Kajbaf.T 2009 Ahvaz - 9.5 6.9 903
[78]Dorosty.AR 2009 Kazerun-Ahvaz-Urmia-Yazd IOTF 5.4 - 6818
[78]Dorosty.AR 2009 Kazerun-Ahvaz-Urmia-Yazd WHO 3.9 - 6818
[78]Dorosty.AR 2009 Kazerun-Ahvaz-Urmia-Yazd Iranian reference 6.3 - 6818
[78]Dorosty.AR 2009 Kazerun-Ahvaz-Urmia-Yazd - 13.6 - 6818
[97]Maddah.M 2009 Rasht WHO 5.9 5 6635
[101]Kelishadi.R 2009 - CDC 3.4 10.9 955388
[78]Dorosty.AR 2009 Kazerun-Ahvaz-Urmia-Yazd CDC 5 - 6818
[61]Talaei-Zanjani.A 2009 Arak CDC 4.5 8.7 742
[61]Talaei-Zanjani.A 2009 Arak - 1.7 4 742

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6
Contd...
Table 1: Contd...
Author Year of
study
City of study References Prevalence
of obesity
Prevalence of
overweight
Sample
size
[49]Rfat.R 2009 Eslam shahr (tehran) CDC2000 16.95 - 240
[47]Kalantari.N 2009 Shiraz - 19.25 0.4 400
[125]Nuh jah.S 2009 Ahvaz WHO 7.3 0.1.5 1035
[41]Azarbayjani.A 2009 Tehran CDC2000 14.1 189 488
[126]Aminzade.M 2010 Ahvaz CDC 17.7 18.8 1594
[42]Salaki.S 2010 Shahriar - 7.1 11 7 325
[52]Gaeini.A 2010 Tehran - 5.1 9.8 603
[54]Mirzaei.M 2010 Yazd WHO 2.4 6.3 2768
[73]Seyyedamini.B 2010 Tabriz - 5.9 12 300
[67]Nabavi.M 2010 Semnan - 14.3 18.8 400
[68]Sodaei-Zanuzagh.H 2010 Marand CDC 3.4 4.5 3513
[115]Shapourimoghdam.A 2010 Korasan-Razavi CDC 54 7.2 625
[108]Maddah.M 2010 Zahedan CDC - - 1079
[109]Nouri-Saeidlu.S 2010 West Azerbaijan CDC - - -
[118]Ghanbari.H 2010-2011 Shiraz WHO 7.1 11.9 478
[109]Nouri-Saeidlu.S 2011 West Azerbaijan CDC2000 - - -
[69]Amanollahi.A 2011 Tehran WHO 8.6 16.5 1040
[69]Amanollahi.A 2011 Tehran Iranian reference 8.2 21.8 1040
[122]Shidfar.F 2011 Tehran IOTF 52.8 21.92 1184
[125]Ebrahim zade kor.B 2011 Bandar torkman NCHS 6 - 616
[79]Zamani.M 2011 Jahrom - 9.7 14.1 984
[84]Ghadimi.R 2011 Babol CDC2000 4.5 36 206
[103]Hajian-Tilaki.K 2011 Babol CDC2000 5.8 12.3 1000
[114]Veghari.Gh 2011 - IOTF 14.1 8.4 7399
[85]Ghadimi.R 2011 Babol CDC 14.3 11.8 3649
[76]Naderi-Bani.M 2011 Chadegan CDC 2.2 - 403
[100]Zarrati.M 2011-2012 Tehran CDC 5.3 22 1184
[62]Khorramabadi.S 2011-2012 Khorram Abad - 4.7 15.5 1155
[91]Keykhaei.F 2012 Zahedan - 22.1 11.8 548
[16]Torabi.Z 2012 Zanjan CDC 10.9 12.9 890
[47]Yavari kia.AR 2012 Hamedan - 17.65 27.9 68
[52]Mirsoleimani.H 2012 Rasht - 17.2 11.3 426
[96]Salehinia.H 2012 Tehran - 23.7 12 4656
[99]Hajian-Tilaki.K 2012 Babol WHO 15 11.8 760
[71]Mahmoudpour.F 2012 Tabriz WHO 3.6 22.6 3103
[80]Yepan-Gharavi.A 2012 Gonbad kavoos CDC 7.2 - 400
[112]Soheilipour.F 2012 Zahedan 9.3 11.8 3582
[104]Taheri.F 2012 Birjand CDC 9.2 9.6 1541
[71]Mahmoudpour.F 2012 Tabriz - 11.6 20.8 3103
[81]Sedighi.E 2012-2013 Javanrood IOTF 4.8 7.7 2316
[72]Kabir.K 2012-2013 Karaj CDC 5.3 89 450
[88]Hasanzadeh-.Z 2012-2013 Fars CDC2000 5.2 5.7 8911
[98]Tabesh.H 2012-2013 Ahvaz CDC - - 5811
[86]Veghari.Gh 2013 Golestan 3.5 5.2 2487
[89]Kafhami-Khorasani.H 2013 Zahedan CDC 22.1 - 590
[90]Golestan.M 2013 Yazd CDC2000 6.3 4.3 1000
[65]Agha Alinezhad.H 2013 Tehran WHO 7.9 0.09.4 381
[65]Agha Alinezhad.H 2013 Tehran CDC 12.1 7.1 381
[65]Agha Alinezhad.H 2013 Tehran - 8.4 8.9 381
[102]Mohammadian.S 2013 Tehran CDC - - 215
[93]Dalili.S 2014 Rasht CDC 11.8 11.3 858
[95]Abarghooei.A 2014 Isfahan WHO 17.6 - 635
[83]Faghih.Sh 2015 Shiraz CDC2000 14.9 15.4 221

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0.1 .2 .3 .4 .5
Prevalence of Obesity in Iranian Children
2000 2005 2010 2015
Year
Figure 3: The relationship between the prevalence of obesity in Iranian
children and the year of research using the meta-regression model
to the WHO criteria, the prevalence of obesity in Iranian children
was about three times as much as Swedish children. In the
analysis adjusting for children’s age groups, the children were
divided into two groups of 6 and over 6 years old. It was found
that the prevalence of obesity was 8% for children under the age
of 6 years and 7% for children aged 6 years and above. It can
be said that the prevalence of obesity in Iranian children less
than 6 years old was higher than that of children over the age
of 6 years. According to the results of a study in Korea in 2005,
the prevalence of obesity and weight gain on 54,324 children
under the age of 6 years was 6.3% and 10%, and on 32,673
children aged 7–12 years was 8.6% and 12.3%, respectively.[39]
The ndings of that study were not consistent with the results
of the current study. In another study conducted by Armstrong
et al. in Scotland on 32,200 children aged 6–8 years, it was found
that the prevalence of obesity in children was 8.55%; 8.1% in
girls and 9% in boys.[40]
Table 2: The results of meta‑analysis on the prevalence of obesity in Iranian children
Name of Questionnaire Subgroups Number of study Prevalence (95% CI) P I2 (%)
Obesity Total 85 7 (7-8) <0.001 99.2
Girl 29 8 (7-9) <0.001 93.3
Boy 26 10 (9-11) <0.001 98.8
Overweight Total 68 12 (11-13) <0.001 99.7
Girl 7 17 (12-22) <0.001 96.9
Boy 7 15 (11-18) <0.001 93
Prevalence of underweight 17 13 (8-18) <0.001 99.8
Based on rural and urban population Urban 68 9 (8-9) <0.001 98.4
Rural and urban 11 6 (5-6) <0.001 99.8
Rural 3 9 (4-13) <0.001 99.3
Based on the reference IOTF 8 11 (7-14) <0.001 99.5
CDC 30 5 (5-6) <0.001 98.8
WHO 14 9 (7-11) <0.001 98.6
NCHS 3 3 (1-5) <0.001 93.7
Iranian reference 4 9 (6-13) <0.001 97.6
CDC2000 11 13 (10-16) <0.001 98.2
Based on age <6 22 8 (6-10) <0.001 98.8
≥6 71 7 (7-8) <0.001 98.8
WHO: World Health Organization, CI: Condence interval, IOTF: The International Obesity Task Force, CDC: US Centers for Disease Control and
Prevention, NCHS:National Center for Health Statistics
Table 1: Contd...
Author Year of
study
City of study References Prevalence
of obesity
Prevalence of
overweight
Sample
size
[58]Asna-Ashari.F 2015 Hamedan IOTF 4.4 - 795
[58]Asna-Ashari.F 2015 Hamedan CDC 5.7 - 795
[58]Asna-Ashari.F 2015 Hamedan WHO 9.7 - 795
[58]Asna-Ashari.F 2015 Hamedan - 15.4 - 795
[77]Mirshekar.S 2015 Zabol TSF 4.5 11 3443
[107]Moradi.Gh 2015 Sanandaj CDC 11.5 24.1 2506
[116]Javedan.Gh.A 2015 Tehran CDC 68 20 17484
[121]Khatibi.M 2016 Kerman IOTF 2.1 7.7 443

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Fakhri, et al.: Prevalence of obesity in Iranian children
Indian Journal of Medical Specialities ¦ Volume 10 ¦ Issue 3 ¦ July-September 2019
8
In Figure 2, the size of a large circle shows sample numbers. No
signicant relationship was observed between the prevalence
of obesity in Iranian children and the number of research
samples (P = 0.116). This means that the prevalence of obesity
in Iranian children will not increase with increasing number of
samples. According to Figure 3, there is a signicant relationship
between the prevalence of obesity in Iranian children and the
years of study (P = 0.039). Thus, during the years studied, the
incidence of obesity in Iranian children declined in the period
between 2008 and 2017. There was no difference between the
prevalence of obesity in urban and rural communities of Iran
and in both regions, the prevalence of obesity was 9%, which
may have resulted in the same results due to the unmatched
number of studies in each of these two groups. The results of
a review study on 144 children show that, in 2010, nearly 43
million infants were overweight or obese.[7] In the USA, during
1999–2000, 16% of children were overweight and 31% of
them were at the risk of becoming overweight or were actually
overweight. This signied an increase of almost 30% since 1960
and a rise of 45% since the last completed studies in the years
1996–1988.[130] A study on 6 to 11-year-old American children
showed that the prevalence of obesity ranged from 4.2% in 1970
to 18.8% in 2004.[131] As for girls living in California, 21.7%
were overweight.[132] In Sicily, the prevalence of weight gain
in children aged 11 years was 40% and in 15 year olds, it was
25%.[133] According to a study by Martin et al., in Sorocaba in
2010, the prevalence of weight gain and obesity in children aged
7–11 years was 13.1% and 9%, respectively.[134] In another report
from the USA, Figueroa-Colon et al. reported the prevalence
of obesity among young girls under the age of 5 years as 23%,
10% for White girls aged 5–11 years, 47% for Black girls,
and 27% for Whites.[135] The ndings of a study by Veugelers
and Fitzgerald in Canada in 2003 showed that the prevalence
of obesity and weight gain in children aged 10–11 years was
9.9% and 32.9%, respectively.[35] In a study by Valean et al., in
Romania, the prevalence of obesity and weight gain in children
aged 10 years was 13.31% and 15.95%, respectively.[136] It could
be said that the prevalence of obesity among Iranian children
was lower than those of many European countries.
Limitations of the study
The limitations of this study included the lack of access to the
full texts of some studies and the uneven distribution of studies
among urban and rural areas.
concLusIon
Given the high prevalence of obesity and the economic, social, and
socioeconomic consequences that ensue the society and families,
governments should opt for scientic and educational approaches
in devising plans to control and alleviate this phenomenon.
Fast foods should be limited or removed from the daily diet.
Health-care providers should check the child’s risk of obesity
and other health problems. Moreover, for children under the age
of 2 years, body mass index should be monitored regularly, and
electronic health record programs and anthropometric criteria
should be devised for children’s health control programs.
Financial support and sponsorship
None.
Conflicts of interest
There are no conicts of interest.
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Author Queries???
AQ13: Kindly provide 59 and 124 reference citation. And also reference citation for chronological order in text part
and table body.
Note: Please check the reviewer comments throughout the article