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Vol. 62, No. 3, 2013
Issue release date: May 2013
Ann Nutr Metab 2013;62:257-265

First Report on Path Analysis for Cardiometabolic Components in a Nationally Representative Sample of Pediatric Population in the Middle East and North Africa (MENA): The CASPIAN-III Study

Kelishadi R. · Motlagh M.E. · Roomizadeh P. · Abtahi S.-H. · Qorbani M. · Taslimi M. · Heshmat R. · Aminaee T. · Ardalan G. · Poursafa P. · Karimi M.
aPediatrics Department, Faculty of Medicine and Child Growth and Development Research Center, bMedical Students Research Center, and cEnvironment Department, Environment Research Center, Isfahan University of Medical Sciences, Isfahan, dPediatrics Department, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, eBureau of Population, Family, and School Health, and fOffice of School Health, Ministry of Health and Medical Education, and gBureau of Health and Fitness, Ministry of Education, Tehran and hDepartment of Public Health, Alborz University of Medical Sciences, Karaj, and iEpidemiology Department, Chronic Diseases Research Center, and jEpidemiology Department, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran

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Background/Aims: This study aimed to test a potential model of the relationship between various cardiometabolic risk factors including obesity, unhealthy diet, low physical activity, dyslipidemia, and high blood pressure in a large population-based sample of children and adolescents. Methods: In this nationwide study, a representative sample of 5,528 students aged 10-18 years was selected by multistage random cluster sampling from 27 provinces of Iran. Demographic, anthropometric, biological, and biochemical factors were determined. Structural equation modeling (path analysis) was applied to evaluate the causal relationship between these variables. Results: The mean age of study participants was 14.7 ± 2.41 years and the mean body mass index (BMI) was 19.4 ± 4.1. Higher socioeconomic status was directly associated with unhealthy diet, low physical activity and BMI in both sexes. Age had a positive direct effect on low physical activity in both sexes. BMI showed the greatest direct effect on total cholesterol, triglyceride, low-density lipoprotein cholesterol, and mean arterial pressure in comparison with the direct effects of unhealthy diet and low physical activity. BMI was associated negatively with high-density lipoprotein cholesterol in both groups. Conclusions: No previous study has used path analysis for determining the interactions examined in this study among a nationally representative sample of children in the Middle East and North Africa (MENA). The results of this study underline the imperative need for the weight loss and lifestyle change from childhood as the first-line preventive strategy for metabolic syndrome and noncommunicable diseases.

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  1. Yusuf S, Reddy S, Ounpuu S, Anand S: Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001;104:2746-2753.
  2. Raymond SU, Leeder S, Greenberg HM: Obesity and cardiovascular disease in developing countries: a growing problem and an economic threat. Curr Opin Clin Nutr Metab Care 2006;9:111-116.
  3. World Health Organization. Global strategy for non-communicable disease prevention and control (Draft). Geneva: WHO; 1997. WHO document WHO/NCD/GS/97.1.
  4. Galal O: Nutrition-related health patterns in the Middle East. Asia Pac J Clin Nutr 2003;12:337-343.
  5. Popkin BM: The nutrition transition: an overview of world patterns of change. Nutr Rev 2004;62:S140-S143.
  6. Afkhami-Ardekani M, Zahedi-Asl S, Rashidi M, Atifah M, Hosseinpanah F, et al: Incidence and trend of a metabolic syndrome phenotype among Tehranian adolescents: findings from the Tehran Lipid and Glucose Study, 1998-2001 to 2003-2006. Diabetes Care 2010;33:2110-2112.
  7. Eckel RH, Grundy SM, Zimmet PZ: The metabolic syndrome. Lancet 2005;365:1415-1428.
  8. Morrison JA, Friedman LA, Wang P, Glueck CJ: Metabolic syndrome in childhood predicts adult metabolic syndrome and type 2 diabetes mellitus 25 to 30 years later. J Pediatr 2008;152:201-206.
  9. Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ: Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev 2008;9:474-488.
  10. Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, et al: American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. J Pediatr 2003;142:368-372.
  11. Koivistoinen T, Hutri-Kähönen N, Juonala M, Aatola H, Kööbi T, et al: Metabolic syndrome in childhood and increased arterial stiffness in adulthood: the Cardiovascular Risk In Young Finns Study. Ann Med 2011;43:312-319.
  12. Personen E, Liuba P: Footprints of atherosclerotic coronary heart disease in children. Rev Port Cardiol 2004:23:127-131.

    External Resources

  13. McGill HC Jr, McMahan CA, Herderick EE, Zieske AW, Malcom GT, et al: Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation 2002;105:2712-2718.
  14. Kelishadi R, Ardalan G, Gheiratmand R, Gouya MM, Razaghi EM, et al: Association of physical activity and dietary behaviors in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study. Bull World Health Organ 2007;85:19e26.

    External Resources

  15. Kelishadi R, Heshmat R, Motlagh ME, Majdzadeh R, Keramatian K, Qorbani M, et al: Methodology and early findings of the third survey of CASPIAN study: a national school-based surveillance of students' high risk behaviors. Int J Prev Med 2012;3:394-401.
  16. Abdi H, Williams LJ: Principal component analysis. WIREs Comp Stat 2010;2:433-459.

    External Resources

  17. Streiner DL: Finding our way: an introduction to path analysis. Can J Psychiatry 2005;50:115-122.
  18. Chen W, Srinivasan SR, Berenson GS: Path analysis of metabolic syndrome components in black versus white children, adolescents, and adults: the Bogalusa Heart Study. Ann Epidemiol 2008;18:85-91.
  19. Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, et al: Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 2004;350:2362-2374.
  20. Chan JC, Cheung JC, Lau EM, Wooà J, Chan AY, et al: The metabolic syndrome in Hong Kong Chinese. The interrelationships among its components analyzed by structural equation modeling. Diabetes Care 1996;19:953-959.
  21. Kelishadi R, Poursafa P: Obesity and air pollution: global risk factors for pediatric non-alcoholic fatty liver disease. Hepat Mon 2011;11:794-802.
  22. Kivimäki M, Lawlor DA, Smith GD, Keltikangas-Järvinen L, Elovainio M, et al: Early socioeconomic position and blood pressure in childhood and adulthood: the Cardiovascular Risk in Young Finns Study. Hypertension 2006;47:39-44.
  23. Lawlor DA, Ebrahim S, Davey Smith G: Socioeconomic position in childhood and adulthood and insulin resistance: cross sectional survey using data from British women's heart and health study. BMJ 2002;325:805.
  24. Must A, Tybor DJ: Physical activity and sedentary behavior: a review of longitudinal studies of weight and adiposity in youth. Int J Obes (Lond) 2005;29(suppl 2):S84-S96.
  25. Prentice-Dunn H, Prentice-Dunn S: Physical activity, sedentary behavior, and childhood obesity: a review of cross-sectional studies. Psychol Health Med 2012;17:255-273.
  26. Srinivasan SR, Freedman DS, Sundaram GS, Webber LS, Berenson GS: Racial (black-white) comparisons of the relationship of levels of endogenous sex hormones to serum lipoproteins during male adolescence: the Bogalusa Heart Study. Circulation 1986;74:1226-1234.
  27. Kelishadi R, Razaghi EM, Gouya MM, Ardalan G, Gheiratmand R, et al: Association of physical activity and the metabolic syndrome in children and adolescents: CASPIAN Study. Horm Res 2007;67:46-52.
  28. Feskens EJ, Virtanen SM, Räsänen L, Tuomilehto J, Stengård J, et al: Dietary factors determining diabetes and impaired glucose tolerance. A 20-year follow-up of the Finnish and Dutch cohorts of the Seven Countries Study. Diabetes Care 1995;18:1104-1112.
  29. Freire RD, Cardoso MA, Gimeno SG, Ferreira SR: Dietary fat is associated with metabolic syndrome in Japanese Brazilians. Diabetes Care 2005;28:1779-1785.
  30. Ferreira SR, Lerario DD, Gimeno SG, Sanudo A, Franco LJ: Obesity and central adiposity in Japanese immigrants: role of the Western dietary pattern. J Epidemiol 2002;12:431-438.
  31. Grundy SM: Metabolic syndrome scientific statement by the American Heart Association and the National Heart, Lung, and Blood Institute. Arterioscler Thromb Vasc Biol 2005;25:2243-2244.
  32. Licata G, Argano C, Di Chiara T, Parrinello G, Scaglione R: Obesity: a main factor of metabolic syndrome? Panminerva Med 2006;48:77-85.
  33. Scaglione R, Di Chiara T, Cariello T, Licata G: Visceral obesity and metabolic syndrome: two faces of the same medal? Intern Emerg Med 2010;5:111-119.
  34. Wang Y: Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int J Epidemiol 2001;30:1129-1136.
  35. Kaplan GA, Salonen JT: Socioeconomic conditions in childhood and ischaemic heart disease during middle age. BMJ 1990;301:1121-1123.
  36. Smith GD, McCarron P, Okasha M, McEwen J: Social circumstances in childhood and cardiovascular disease mortality: prospective observational study of Glasgow University students. J Epidemiol Community Health 2001;55:340-341.
  37. Golzarand M, Mirmiran P, Jessri M, Toolabi K, Mojarrad M, et al: Dietary trends in the Middle East and North Africa: an ecological study (1961 to 2007). Public Health Nutr 2012;9:1-10.

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