JRHS Journal of Research in Health Sciences

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1 JRHS Journl of Reserch in Helth Sciences journl homepge: Originl Article Dietry Intke nd Its Reltionship to Different Body Mss Index Ctegories: A Popultion-Bsed Study Ali Asghr Rshidi (Msc) 1, Ali Rez Heidri Bkvoli (PhD) 2, Amir Avn (PhD) 3,Mlihe Aghsizde (MsC) 4, Hmideh Ghzizdeh (PhD) 3, Mrym Tyefi (PhD) 5, Syyed Seid Khyytzdeh (PhD) 6, 7, Mhmoud Ebrhimi (PhD) 2, Mohsen Moohebti (PhD) 2, Mohmmd Sfrin (MD, PhD) 1, Mohsen Nemty(MD, PhD) 1, Mostf Sdr-Bzzz (MD) 3, Gordon A. Ferns (PhD) 8, nd Mjid Ghyour Mobrhn (MD, PhD) 3 * 1 Deprtment of Nutrition, School of Medicine, Mshhd University of Medicl Sciences, Mshhd, Irn 2 Crdiovsculr Reserch Center, School of Medicine, Mshhd University of Medicl Sciences, Mshhd, Irn 3 Metbolic Syndrome Reserch Center, Mshhd University of Medicl Sciences, Mshhd, Irn 4 Deprtment of Modern Sciences nd Technologies, School of Medicine, Mshhd University of Medicl Sciences, Mshhd, Irn 5 Clinicl Reserch Unit, Mshhd University of Medicl Sciences, Mshhd, Irn 6 Nutrition nd Food Security Reserch Center, Shhid Sdoughi University of Medicl Sciences, Yzd, Irn 7 Deprtment of Nutrition, Fculty of Helth, Shhid Sdoughi University of Medicl Sciences, Yzd, Irn 8 Brighton & Sussex Medicl School, Division of Medicl Eduction, Flmer, Brighton, UK ARTICLE INFORMATION ABSTRACT Article history: Received: 28 My 2018 Revised: 07 July 2018 Accepted: 27 August 2018 Avilble online: 08 September 2018 Keywords: Dietry intke Body mss index Nutrient Obesity * Correspondence: Mjid Ghyour-Mobrhn (MD, PhD) Tel: Fx: E-mil: ghyourm@mums.c.ir Bckground: Obesity is mjor public helth problem becuse of its ssocited dibetes mellitus nd crdiovsculr disese. We imed to explore the reltionship between dietry mcronutrients nd diposity in cohort study, representtive of the city of Mshhd in northestern Irn. Study design: A cross-sectionl study. Methods: The popultion smple (9847) derived from Mshhd stroke nd hert therosclerotic disorders (MASHAD: ) nd ws obtined using strtified-cluster method. The subjects were seprted into 4 groups by body mss index sttus: norml weight, underweight, overweight nd obese individuls. Individuls with men ge of ±8.26 yr were recruited nd nthropometric nd biochemicl fctors were mesured in ll the subjects. Individul dietry intkes were ssessed using 24-h dietry recll Dietpln6. Univrite nd multivrite nlyses were conducted before nd fter djustment for ge, gender nd energy intke. Results: individuls were significntly less physiclly ctive. They hd higher levels of serum fsted lipid profile, hs-crp, uric cid, nd glucose, nd blood pressures compred to norml weight individuls (P=). There ws significnt difference in the dietry intkes of the groups ctegorized by obese before djustment for energy intke in the obese compred to the norml weight group. These differences remined sttisticlly significnt for Trns ftty cid (P=0.033), lctose (P=0.009), fructose (P=0.025), glucose (P=0.017), sucrose (P=0.021) nd mltose (P=0.015) fter djustment for energy intke. Conclusion: Our findings demonstrte significnt ssocition between dietry Trns ftty cid nd totl sugr intke with diposity in representtive popultion smple from northestern Irn. Cittion: Rshidi AA, Heidri Bkvoli AR, Avn A, Aghsizde M, Ghzizdeh H, Tyefi M, Khyytzdeh SS, Ebrhimi M, Moohebti M, Sfrin M, Nemty M, Sdr-Bzzz M, Ferns GA, Ghyour Mobrhn M. Dietry Intke nd Its Reltionship to Different Body Mss Index Ctegories: A Popultion-Bsed Study. J Res Helth Sci. 2018; 18(4): e Introduction Obesity is incresing globlly nd ssocited with severl other co-morbidities, including dibetes mellitus nd crdiovsculr disese. These ltter ssocitions my be ttributble in prt to the higher prevlence of micronutrient deficiencies in obese people is higher compred to norml weight individuls 1-4, whilst weight gin is due to n imblnce between energy intke nd expenditure 5. It is not cler whether weight gin is relted to the mcronutrient source of the incresed energy intke, or merely relted to the totl energy consumption from whichever source. Obesity my be reduced by reducing dietry ft 6 lthough this is not consistent finding 7,8. Becuse of enormous public helth impct of obesity, identifying the dietry fctors ssocited with its custion is importnt if the globl trend for incresing dibetes nd crdiovsculr disese re to be contined. Moreover, whilst there is high prevlence of obesity in the Irnin popultion, the reltionship between the mcronutrient intke nd obesity hs not been extensively studied in this popultion. We imed to explore the reltionship between dietry mcronutrients nd diposity in cohort study, representtive of the city of Mshhd in northestern Irn.

2 2 / 7 Assocition of nutrient intke nd BMI sttus Methods Study Popultion The popultion smple derived from Mshhd stroke nd hert therosclerotic disorders (MASHAD: ) nd ws obtined using strtified-cluster method. The study design, smple selection, chrcteristics of study prticipnts s well s detils on dt collection methods hve been published 9. Demogrphic informtion such s ge, eduction level, mrrige sttus, current smoking nd job sttus ws obtined by fce to fce interview 9,10. The subjects (n=9809) were of men ge of 48.33±8.26 yer. Pregnnt nd brestfeeding women, ptients who hd systemic disese, nd ptients tking ny drug (including lipid-lowering drugs) were excluded from the study. They lso hd no known history of infectious diseses, fmily history of stroke, myocrdil infrction, nd dibetes mellitus. Informed consent ws obtined from ll prticipnts using protocols pproved by the Ethics Committee of the Mshhd University of Medicl Sciences, Mshhd, Irn. Anthropometric nd Biochemicl Mesurements Anthropometric prmeters including body weight, height, wist nd hip circumference were mesured using stndrd protocol. Body mss index (BMI) ws clculted s weight (kg) divided by height squred (m 2 ) nd BMI of <18.5, , nd 30 kg/m2 were considered s underweight, norml, overweight nd obese, respectively 11. The systolic nd distolic blood pressure ws mesured using stndrd mercury sphygmomnometer three times with n intervl of 30 min in prticipnts nd the verge of the three mesurements ws tken s the blood pressure. High blood pressure ws defined s BP 140/ Serum totl cholesterol, HDL, LDL nd TAG, nd fsting blood glucose concentrtions were determined fter 12 h fst. Fsting blood glucose concentrtions nd serum lipids were mesured enzymticlly using commercil kits, while serum CRP levels were determined by polyethylene glycol-enhnced immunoturbidimetry 13. Totl energy expenditure (TEE) ws mesured s the sum of bsl energy expenditure (BEE), the energy expenditure of physicl ctivity (EEPA) nd the thermic effect of food (TEF) 14. BEE clculted from the bsic Hrris-Benedict equtions 15. Overll, 10% to 20%, 25% to 40% nd 45% to 60% of BEE were dded for miniml, moderte nd strenuous ctivity, respectively. TEF ws mesured s the 10% of BEE nd EEPA. Assessment of Dietry Intke Dietry informtion ws collected using questionnire for 24-h dietry recll, dministered by trined dietry interviewers in fce-to-fce interview in Mshhd Helth Centers 16,17. This questionnire ws completed by mster students of nutrition. Individul dietry intke ws ssessed using Dietpln6 softwre (Forest field Softwre Ltd., UK). The selected vribles were crbohydrtes (totl crbohydrte, strch, sucrose, glucose, fructose, totl sugr, mltose, lctose), totl protein, fts (totl ft, sturted ftty cid, MUFA, PUFA, trns ftty cid nd cholesterol). Energy density ws clculted by (totl energy intke in dy (kcl)/ weight of food intke (gr)). Physicl ctivity level Physicl ctivity level (PAL) ws evluted using stndrd questionnire, nd prticipnts divided into 5 groups s followed: 1- extremely inctive (<1.40), 2- sedentry ( ), 3- modertely ctive ( ), 4- vigorously ctive ( ), or 5-extremely ctive (>2.40) 18. Sttisticl Anlysis Dt were clculted using SPSS-20 softwre (SPSS Inc., IL, USA). Kolmogorov-Smirnov test ws used to check the normlity of dt. Descriptive sttistics including men ±stndrd devition (SD) were determined for vribles with norml distribution or dt were expressed s medin± IQR for not normlly distributed vribles. For normlly distributed vribles, t-student test ws used, while Bonferonni correction ws used for multiple comprisons. The Mnn-Whitney U test ws used for continuous vribles. For ctegoricl prmeters, Chi-squre or Fisher exct tests were used. Logistic regression nlysis ws used to clculte ssocition of micro/mcronutrients with clinicl dt. All the nlyses were two-sided nd sttisticl significnce ws set t P<0.05. Results Chrcteristics of the popultion The prevlence of underweight, overweight nd obese individuls ws 1.4%, 42.3%, nd 30.3%, respectively. group hd significntly (P<0.05) lower physicl ctivity level nd totl energy expenditure. Not surprisingly the levels of LDL, TC, hs-crp, TG, uric cid, SBP/DBP, nd glucose were significntly higher, while the HDL level ws lower in the obese group, compred to the non-obese controls (P<). Similr results were observed for the other groups compred norml weight group (Tbles 1 nd 2). Assocition of mcronutrients intkes with obesity nd Wist circumference We then sought to investigte the reltionship between mcronutrient intkes in our popultion chrcterized by norml weight, underweight, overweight, obesity s well s with wist circumference. As shown in Tble 3, there were significntly different levels of energy, energy density, protein, totl ft, sturted ftty cid (SFA), mono-unsturted ftty cid (MUFA), polyunsturted ftty cid (PUFAs), trns ftty cid, cholesterol, totl crbohydrte, sucrose nd strch between the obese nd norml weight group (P<). These differences remined sttisticlly significnt for Trns ftty cid (P=0.033), lctose (P=0.009), fructose (P=0.025), glucose (P=0.017), sucrose (P=0.021) nd mltose (P=0.015) fter djustment for energy intke. Moreover, the levels of protein, sturted Ftty cid, lctose, mltose, strch, fructose, glucose, nd fiber were significntly different in subjects with high wist circumference (Tble 4) (P<0.01). The ssocition of mcronutrient intke with different ctegories of obesity ws investigted using logistic regression model before nd fter djustment bsed on 2 models [Model I: djusted for ge, sex nd energy intke; I: djusted for ge, sex, energy intke, current smoking nd physicl ctivity levels] (Tbles 5, 6). SFAs (P=0.031), PUFAs (P<), sucrose (P<) nd strch (P= 0.045) were relted to obesity, while in model 2, this ssocition remined only for sucrose (P<). A significnt reltionship ws detected for ft in model 1 nd 2 in the overweight group, compred to norml weight subjects (P=0.034 nd P=0.031, respectively).

3 Ali Asghr Rshidi et l 3 / 7 Tble 1: Generl chrcteristics of the study popultion ctegorized by body mss index nd derived from the Mshhd stroke nd hert therosclerotic disorders (MASHAD) study ( ) Vribles Norml weight (n: 2552) (n:139) (n: 4154) (n:2964) P vlue P vlue b P vlue c Gender Femle Mle Current smoker No Yes Mritl sttus Single Mrried Eduction Illiterte Elementry High school College Job sttus Student Employed Unemployed Retired versus norml weight b versus norml weight c versus norml weight Tble 2: Clinicl nd biochemicl chrcteristics of popultion ctegorized by body mss index nd derived from the Mshhd stroke nd hert therosclerotic disorders (MASHAD) study ( ) Norml weight Vribles Men SD Men SD Men SD Men SD P vlue P vlue b P vlue c Age (yr) Weight(kg) Height (meter) Totl energy expenditure Wist circumference (cm) Systolic blood pressure (mmhg) Distolic blood pressure (mmhg) LDL(mg/dl) HDL(mg/dl) Glucose(mg/dl) Uric cid(mg/dl) Totl cholesterol (mg/dl) Triglyceride (mg/dl) HSCRP (mg/dl) versus norml weight b versus norml weight c versus norml weight Discussion To the best of our knowledge, this study is the first to explore the impct of mcronutrients intke in lrge popultion contining 9809 subjects divided into 4 groups, norml weight, nd overweight, underweight nd obese individuls s well s with respect to centrl obesity. Our findings demonstrte the ssocition of Trns ftty cids, lctose, fructose, glucose, sucrose, nd mltose, fter djustment for energy intke, with obesity nd diposity. Additionlly, this ssocition ws lso observed for lctose, fructose, nd glucose in overweight group, compred to norml weight group, suggesting the importnt role of energy intke for incresing BMI, ctegorized by diposity. In this regrd, public helth experts believe tht dietry chnge is effective in the prevention nd tretment of obesity 19,20. Food intke of Irnin popultion is 40% higher thn required mount (40% more crbohydrtes nd 30% more fts) 21 nd similr results re reported in Mlysin study 22. Crbohydrte, protein, nd ft re the mjor sources of energy, nd their excess consumption will led to positive energy blnce. Our dt suggest tht there ws no significnt difference in totl crbohydrte, protein nd ft intke between norml weight, overweight nd obese individuls from Irn. Furthermore, energy intke in norml weight ws higher thn overweight nd obese individuls. Hence weight differences re likely to be due to the increse in energy expenditure such s physicl ctivity nd not energy intke, which is in greement with other studies 23,24. However, vrious fctors re relted to obesity such s genetic, environmentl (dietry nutrient intke, smoking) nd metbolic fctors 25,20. Moreover, the results of Ntionl Helth nd Nutrition Exmintion Survey in the USA showed tht the replcement of dietry ft with dietry crbohydrte did not lter the incidence of obesity in the popultion 26. High totl energy intke is usully relted to high totl sugr intke while severl other studies reveled inverse reltionship between sugr intke nd BMI In line with these observtions, our dt showed n ssocition of lctose, fructose, glucose, sucrose, nd mltose fter djustment for energy intke with respect to obesity. BMI is relted to dily sugr intke, but no significnt reltionship with totl clories, protein, ft or crbohydrtes intke 32. On

4 4 / 7 Assocition of nutrient intke nd BMI sttus the other hnd, there is incresing evidence showing the ssocition of protein intke nd BMI 33,34. However, lck of this reltionship ws showed with BMI 35,36 which re in greement with our dt. Tble 3: Energy nd mcronutrient intkes in subjects ctegorized by body mss index nd derived from the Mshhd stroke nd hert therosclerotic disorders (MASHAD) study ( ) Norml weight Men (SD) Men (SD) Men (SD) Men (SD) Vribles Men SD Men SD Men SD Men SD P vlue P vlue b P vlue c Energy (Kcl) Energy density Protein(gr) Adjusted Ft (gr) Adjusted SFA (gr) Adjusted MUSFA (gr) Adjusted PUSFA (gr) Adjusted TFA (gr) Adjusted Cholesterol Adjusted Crbohydrte Adjusted Sucrose(gr) Adjusted Lctose(gr) Adjusted Mltose(gr) Adjusted Strch(gr) ) Adjusted Fructose(gr) Adjusted Glucose(gr) Adjusted Fiber(gr) Adjusted versus norml weight b versus norml weight c versus norml weight We evluted the correltion between ft consumption with weight. We observed the significnt reduction of monosturted ftty cid nd Trns ftty cid in obese subjects fter djustment with energy intke. Severl studies hve been shown positive ssocition between ft intke nd obesity 38 lthough this is not consistent finding 38,39. The low incidence of obesity ws reported in n Eskimo popultion with highft diet in their diet 40. On the other hnd, nother study hs reported the ssocition of obesity with consuming oil-rich diets in some Arbic countries including United Arb Emirtes, Sudi Arbi nd Kuwit 41. Totl ft hs reltion to BMI while these reltions were inverse for monounsturted ft nd polyunsturted ft 42. This conflicting dt supports the need for further investigtion of the role of ft consumption with obesity. A mjor strength of the present study ws tht it ws crried out in lrge number, while the min limittion is ge nd gender differences between groups. Another limittion ws using 24-h dietry recll becuse it cnnot cover ll dietry intke (weekly, monthly nd yerly) lthough these vribles were djusted in logistic regression model.

5 Ali Asghr Rshidi et l 5 / 7 Tble 4: Energy nd mcronutrient intkes in subjects ctegorized by body mss index nd derived from the Mshhd stroke nd hert therosclerotic disorders (MASHAD) study ( ) energy (Kcl) Adjusted energy density Norml Centrl obese Norml Centrl obese Vribles Men SD Men SD P vlue Men SD Men SD P vlue Energy (Kcl) Protein (gr) Ft (gr) SFA (gr) MUSFA (gr) PUSFA (gr) TFA (gr) Cholesterol (mg) Sucrose (gr) Lctose (gr) Mltose (gr) Strch (gr) Fructose (gr) Glucose (gr) Fiber (gr) Crbohydrte (gr) Nutrient intkes were djusted for totl energy intke by the residul method of liner regression Centrl obese: >80cm for women nd >100cm for men; SFA: Sturted Ftty cid; MUSFA: Mono Unsturted Ftty cid; PUSFA: Poly Unsturted Ftty cid; TFA: Trns Ftty cid Tble 5: Assocition of mcronutrient intkes of protein, ft & energy with obesity compred to norml weight Vribles Odds rtio (95% CI) P vlue Odds rtio (95% CI) P vlue Odds rtio (95% CI) P vlue Energy density I Protein (gr) I Ft(gr) I SFA (gr) I MUFA (gr) I PUFA (gr) I TFA (gr) I Cholesterol (mg) I 1.52 (0.86, 2.62) 1.57 (0.91, 2.71) 1.56 (0.95, 2.61) 0.98 (0.96, 1.01) 0.99 (0.95, 1.02) 0.98 (0.95, 1.02) 0.99 (0.97, 1.02) 1.01 (0.98, 1.05) 1.02 (0.98, 1.05) 1.00 (0.99, 1.02) 1.02 (1.00, 1.03) 1.02 (1.00, 1.04) 0.76 (0.51, 1.13) 0.85 (0.57, 1.27) 0.78 (0.51, 1.19) (1.09, 1.51) 1.26 (1.06, 1.48) 1.17 (0.98, 1.39) 0.99 (0.98, 1.00) 0.99 (0.98, 1.00) 0.94 (0.87, 1.02) 0.94 (0.86, 1.03) 0.96 (0.87, 1.05) (1.26, 1.78) 1.31 (1.09, 1.57) 1.13 (0.91, 1.41) 0.98 (0.97, 0.98) 0.98 (0.97, 0.99) 0.98 (0.97, 0.99) 0.99 (0.98, 1.00) 0.99 (0.98, 0.99) 1.01 (1.00, 1.02) 0.81 (0.74, 0.89) 0.89 (0.80, 1.00) 1.00 (0.88, 1.15)

6 6 / 7 Assocition of nutrient intke nd BMI sttus Tble 6: Assocition of mcronutrient intkes of crbohydrte with obesity compred to norml weight Odds rtio (95% CI) Odds rtio (95% CI) Odds rtio (95% CI) Vribles P vlue P vlue P vlue Crbohydrte (gr) I Sucrose (gr) I Lctose (gr) I Mltose (gr) 0.85 (0.75, 0.96) (0.97, 1.01) (0.95, 1.00) (0.79, 0.99) (0.98, 1.02) (0.98, 1.03) I 0.86 (0.77, 0.97) (0.98, 1.03) (0.96, 1.03) Strch (gr) I Fructose (gr) 0.97 ( ) ( ) I 0.98 ( ) Glucose (gr) 0.97 (0.95,0.99) (0.96,1.00) I 0.98 (0.96,1.00) Fiber(gr) 0.98 (0.96,1.01) (0.98, 0.99) (0.97,1.02) (0.98, 1.00) I 1.00 (0.97,1.02) (0.98, 1.00) Conclusion Vrious genetic nd environmentl fctors re relted to obesity. On the other hnd, environmentl fctors like dietry nutrient intke ply n importnt role in the progression of the obesity. We demonstrted the ssocition of ftty cid, lctose, fructose, glucose, sucrose, nd mltose with obesity fter djustment for energy intke, suggesting the importnt role of sugr with body mss index. Further studies re wrrnted to investigte the ssocition of crbohydrte, protein nd ft intke with obesity. Conflict of interest sttement The uthors hve no conflict of interest to disclose. Funding This work ws supported by grnt from in Mshhd University of Medicl Sciences. Highlights subjects hd higher serum LDL-cholesterol, totl cholesterol, triglycerides, nd glucose compred to norml group. subjects hd high levels of serum hs-crp, uric cid, nd blood pressures compred to norml group. There ws significnt difference in the dietry intkes of the groups ctegorized by BMI. subjects hd high dietry intkes of protein, ft & crbohydrtes. References 1. Abdell M, le Roux CW, Docherty NG. Morbidity nd mortlity ssocited with obesity. Ann Trnsl Med. 2017; 5(7): Ch YS. Mcronutrient Intke nd Obesity. Food Sci Nutr. 2000; 5: Hssnzdeh-Rostmi Z, Kvosi E, Nsihtkon A. nd obesity mong preschool children from Frs province of Irn: prevlence nd ssocited fctors. J Res Helth Sci. 2016; 16(1): Hjin-Tilki K, Heidri B, Hjin-Tilki A, Firouzjhi A, Bgherzdeh M. The discrimintory performnce of body mss index, wist circumference, wist-to-hip rtio nd wist-to-height rtio for detection of metbolic syndrome nd their optiml cutoffs mong Irnin dults. J Res Helth Sci. 2014; 14(4): Rocndio A, Ansotegui L, Arroyo M. Comprison of dietry intke mong overweight nd non-overweight schoolchildren. Int J Obes Relt Metb Disord. 2001; 25(11): Winkvist A, Hultén B, Kim JL, Johnsson I, Torén K, Brismn J, et l. Dietry intke, leisure time ctivities nd obesity mong dolescents in Western Sweden: cross-sectionl study. Nutr J. 2015; 15(1): Astrup, A. The role of dietry ft in the prevention nd tretment of obesity. Efficcy nd sfety of low-ft diets. Int J Obes Relt Metb Disord. 2001; 25(1): Snchez C, Lopez-Jurdo M, Arnd P, Llopis J. Plsm levels of copper, mngnese nd selenium in n dult popultion in southern Spin: influence of ge, obesity nd lifestyle fctors. Sci Totl Environ. 2010; 408: Ghyour-Mobrhn M, Moohebti M, Esmily H, Ebrhimi M, Prizdeh SM, Heidri-Bkvoli AR, et l. Mshhd stroke nd hert therosclerotic disorder (MASHAD) study: design, bseline

7 Ali Asghr Rshidi et l 7 / 7 chrcteristics nd 10-yer crdiovsculr risk estimtion. Int J Public Helth. 2015; 60: Esmily H, Tyefi M, Doosti H, Nezmi H, Amirbdizdeh A. A Comprison between Decision Tree nd Rndom Forest in Determining the Risk Fctors Associted with Type 2 Dibetes. J Res Helth Sci. 2018; 18(2): e World Helth Orgniztion. Obesity: preventing nd mnging the globl epidemic. Report of WHO consulttion. Genev: WHO; Ghzizdeh H, Avn A, Fzilti M, Azimi-Nezhd M, Tyefi M, Ghsemi F, et l. Assocition of rs A<G with serum vsculr endothelil growth fctor concentrtions in ptients with metbolic syndrome. Gene. 2018; 667: Mirhfez SR, Zrifin A, Ebrhimi M, Ali RF, Avn A, Tjfrd M, et l. Reltionship between serum cytokine nd growth fctor concentrtions nd coronry rtery disese. Clin Biochem. 2015; 48: Poehlmn ET. A review: exercise nd its influence on resting energy metbolism in mn. Med Sci Sports Exerc.1989; 21(5): Hrris JA. And Benedict FG, A biometric study of bsl metbolism in mn. Wshington: Crnegie Institution of Wshington; Jmes WPT, Schofield EC. Humn energy requirements. A mnul for plnners nd nutritionists: Oxford University Press; Ahmdnezhd M, Asdi Z, Miri HH, Ferns GA, Ghyour- Mobrhn M, Ebrhimi-Mmghni M. Vlidtion of Short Semi-Quntittive Food Frequency Questionnire for Adults: Pilot study. J Nutr Sci Diet. 2017; 3(2): In press. 18. Vsconcellos MT, Anjos LA. A simplified method for ssessing physicl ctivity level vlues for country or study popultion. Eur J Clin Nutr. 2003; 57(8): Willett WC. Overview nd perspective in humn nutrition. Asi Pc J Clin Nutr. 2008; 17(S1): Shrm AM, Pdwl R. Obesity is sign over-eting is symptom: n etiologicl frmework for the ssessment nd mngement of obesity. Obes Rev. 2010; 11: Mlekzdeh RM, Mohmdnejd SH, Mert A. Pourshms nd A. Etemdi. Obesity pndemic: n Irnin perspective. Arc Irn Med. 2005; 8: Bry GA, Popkin BM. Dietry ft intke does ffect obesity! Am J Clin Nutr. 1998; 68(6): Reven GM. Do high crbohydrte diets prevent the development or ttenute the mnifesttions (or both) of syndrome X? A viewpoint strongly ginst. Curr Opin Lipidol. 1997; 8(1): Goly A, Eigenheer C, Morel Y, Kujwski P, Lehmnn T, De Tonnc N. Weight-loss with low or high crbohydrte diet? Int J Obes Relt Metb Disord. 1996; 20(12): Bgherniy M, Mostfvi FD, Shrm M, Mrcy MR, Allipour RB, Rnjbr G, et l. Assessment of the Efficcy of Physicl Activity Level nd Lifestyle Behvior Interventions Applying Socil Cognitive Theory for nd Girl Adolescents. J Res Helth Sci. 2018: 18(2); e Germn JB, Dillrd CJ. Sturted fts: wht dietry intke? Am J Clin Nutr. 2004; 80(3): Willims P. Sugr: is there need for dietry guideline? Nutr Diet. 2001; 58(1): Gibson SA. Consumption nd sources of sugrs in the diets of British schoolchildren: re high sugr diets nutritionlly inferior? Journl of Humn Nutrition nd Dietetics. 1993; 6(4): Lewis C, Prk Y, Dexter PB, Yetley E. Nutrient intkes nd body weights of persons consuming high nd moderte levels of dded sugrs. J Am Diet Assoc. 1992; 92(6): Nismith DJ, Nelson M, Burley V, Gtenby S. Does high sugr diet promote overweight in children nd led to nutrient deficiencies? J Hum Nutr Diet. 1995; 8(4): Bellisle F, Rollnd-Ccher MF. How sugr-contining drinks might increse obesity in children. The Lncet. 2001; 357(9255): Dong M, Pwloski L, & Sun Y. An Exmintion of BMI nd Dily Nutritionl Intke, compring Chinese Senior Immigrnts in North Virgini nd Chinese Senior residents in Chin. FASEB J. 2016; 30(Suppl): Weigle DS, Breen PA, Mtthys CC, Cllhn HS, Meeuws KE, Burden VR, et l. A high-protein diet induces sustined reductions in ppetite, d libitum cloric intke, nd body weight despite compenstory chnges in diurnl plsm leptin nd ghrelin concentrtions. Am J Clin Nutr. 2005; 82(1): Trichopoulou A, Gnrdellis C, Benetou V, Lgiou P, Bmi C, Trichopoulos D. Lipid, protein nd crbohydrte intke in reltion to body mss index. Eur J Clin Nutr. 2002; 56(1): Rndi G, Pelucchi C, Gllus S, Prpinel M, Dl Mso L, Tlmini R, et l. Lipid, protein nd crbohydrte intke in reltion to body mss index: n Itlin study. Public Helth Nutr. 2007; 10(03): Lee C, Norimh A, Ismil M. Assocition of energy intke nd mcronutrient composition with overweight nd obesity in Mly women from Klng Vlley. Ml J Nutr. 2010; 16: Seidell JC. Dietry ft nd obesity: n epidemiologic perspective. Am J Clin Nutr.1998; 67(3): 546S-50S. 38. Willett WC. Is dietry ft mjor determinnt of body ft? Am J Clin Nutr. 1998; 67(3): 556S-62S. 39. Lissner L, Heitmnn BL. Dietry ft nd obesity: evidence from epidemiology. Eur J Clin Nutr. 1995;49(2): Nobmnn ED, Ebbesson SO, White RG, Bulkow LR, Schrer CD. Associtions between dietry fctors nd plsm lipids relted to crdiovsculr disese mong Siberin Yupiks of Alsk. Int J Circumpolr Helth. 1999; 58: Veghri G, Sedght M, Joshghni H, Hoseini A, Niknezhd F, Angizeh A, et l.. The prevlence of obesity nd its relted risk fctor in the north of Irn in J Res Helth Sci. 2010; 10(2), Vv Den Ende c, Twisk JWR, Monyeki KD. The Reltionship Between BMI nd Dietry Intke of Primry School Children From Rurl re of South Afric: The Ellisrs Longitudinl Study. Am J Hum Biol. 2014; 26: