• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of jcardisresHomeCurrent issueInstructionsSubmit article
J Cardiovasc Dis Res. Mar 2013; 4(1): 30–33.
Published online Feb 27, 2013. doi:  10.1016/j.jcdr.2013.02.002
PMCID: PMC3758097

Influence of education in the prevalence of obesity in Iranian northern adults



The main aim of this study was to evaluate whether prevalence of obesity in educational levels is different and some related factors in Iranian northern adults.

Materials and methods

This was a cross-sectional descriptive study based on population and 2452 cases (1224 men and 1228 women) aged 15–65 years were chosen by cluster and stratify sampling. Subjects were randomly chosen from 125 clusters and each cluster included 20 cases. Interviewers recorded the data using a multidimensional questionnaire including socio-demographic indexes.


As a whole, the prevalence of obesity was seen in 24% of subjects (15.5% in male and 32.5% in female) and significantly was seen in 3.1% and 14.1% of uneducated people more than in 1–9 year schooling and in high school or college-educated people, respectively (P = 0.001). The risk of obesity was 2.294 (P = 0.001) in uneducated compared to high school or college-educated people, 1.668 (P = 0.001) in urban area compared to rural area, 2.619 (P = 0.001) in 40–65 year people compared to 15–40 year people, and 1.534 (P = 0.003) in good economic compared to poor economic groups. After adjusted for location area, gender, age, and economic stats, the risk of obesity was 2.044 (P = 0.001) in uneducated people compared to high school or college-educated subjects.


The obesity as a health problem in Iranian northern adults supported in this study and it was negatively associated with educational levels. Public health programs that aim to reduce obesity should primarily focus on the illiterate and low-educated people.

Keywords: Adults, Education, Northern Iran, Obesity

1. Introduction

Obesity is one of the greatest public health challenges in current century and the World Health Organization (WHO) warns the rising of it in some countries. In Eastern Mediterranean Regions (EMR), obesity becomes at an alarming level among children and adults.1 Obesity is a major risk factor for the coronary heart disease, dislipidemia, insulin resistance, hypertension, type 2 diabetes, cancer, musculoskeletal disorders, sleep apnea, and related to some hormones dependent on arteriosclerosis.2 The strong relationship between socio-demographic factors and obesity was seen in some regions.3 The association between education and obesity is controversial in EMR and several confounding factors such as age, gender, residential area, and income may hold up it. However, more investigations are needed to explore the role of socio-economic status in the prevalence of obesity in the EMR countries.4 The role of adult literacy skills as a mediating factor to the health education considered in recent study.5 The role of educational level as a multifaceted concept well known in some of the social and cognitive skills6 and the strong relationship between education and literacy skills with health knowledge approved in some of the studies.7

Data from NHANES (National Health and Nutrition Examination Survey) survey have shown a higher prevalence of obesity in low-educated men and women compared with high-educated people.8 In WHO study, there was a significantly negative association between years of schooling and body mass index (BMI) but in the USA, there was a gap between obesity and less or better educated subjects.9 Golestan province is in the north of Iran (south-east of Caspian Sea). Of 1.6 million populations in this area, 66.39% were 15–64 years, whereas 43.9% and 56.1% are living in urban and rural areas, respectively. Agriculture is the main occupation in rural area and different ethnic groups such as Fars (native), Turkman, and Sisstani are living in this region.10 Due to the restriction in executing epidemiological projects, there has not been any study on the relationship between obesity and socio-demographic factors in this area up till now; therefore, it was necessary to design a research project about it. The aim of this study was to evaluate whether prevalence of obesity in educational levels is different in Iranian northern adults in 2010. Some of the confounder factors such as location area, gender, age, and economic status are considered in this study.

2. Materials and methods

This is a cross-sectional descriptive study based on population and 2452 cases (1224 men and 1228 women) aged 15–65 years were chosen by cluster and stratify sampling. Subjects were randomly chosen from 125 clusters and each cluster included 20 cases. Family code of primary health center in rural areas and postal code in urban areas were used for classification with equal proportion of age and sex. From each district, one team had been trained to complete the questionnaire and measuring weight and height. Interviewers recorded the data using a multidimensional questionnaire including socio-demographic indexes. Pregnant women and unwillingness cases were excluded from this study. The reliability was assessed using Cronbach's alpha coefficient and found to be 0.83. This study approved by Ethical Research Committee in Golestan University of Medical Sciences and consent was received from all participants.

SPSS software (PASW statistics 16 version) was used for the statistical analysis and Chi-square and Pearson's tests used for comparing frequencies. Multivariate logistic regression analysis was applied to estimate the odds ratio (OR) of obesity considering the educational level at 95% significant level. The P value less than 0.05 was considered as statistical significant.

Weight was measured by removing heavy clothing and shoes. Height was measured in standing upright position. BMI was calculated as weight (kg)/height (m2). BMI of 25.0–29.9 kg/m2 was classified as overweight, BMI of 30.0 kg/m2 or over was classified as obese.11

Educational level classified in three groups: Uneducated, 1–9 year schooling, and high school or college. Economic status, with regard to Iranian social-economic, was categorized based on the facilities of six items: Separate bathroom, separate kitchen, vacuum cleaner, computer, separate freezer, and washing machine. Each of them is one score. According to this list, the scoring of the economic status of samples in this study was as follows: Poor ≤2 score, moderate = 3–4 score, and good ≥5 score.

3. Results

Mean and standard deviation of age and BMI were 39.21 ± 14.3 years and 26.35 ± 5.7 kg/m2, respectively. The characteristics of subjects and BMI distributions based on socio-demographic factors are shown in Table 1. Illiteracy, urbanization, and intermediate economic status were seen in 30.8%, 46.5%, and 53.7% of subjects, respectively. Obesity in uneducated, 1–9 year schooling, and high school or college-educated people was common in 29.6%, 26.4% and 15.4%, respectively. Statistical difference among three groups was significant (P = 0.001). Obesity was seen in 3.1% and 14.1% of uneducated people more than in 1–9 year schooling and in high school or college-educated groups, respectively (P = 0.001). The prevalence of obesity was seen in women (32.5%) more than men (15.5%), in urban (29.1%) more than in rural area (19.7%), and in 40–65 year (31.8%) more than 15–40 year (16.2%) and positively associated with economic status (P = 0.001). In high school or college-educated group, obesity was not significant among economic groups and in genders. Also, in uneducated groups, obesity in different age groups was not significant. The obesity was common in women more than men, in urban area more than rural area, in 40–65 year more than 15–45 year, and in good economic group more than other economic groups. Among uneducated subjects, the prevalence of obesity in 40–65 year people was 6.7% more than in 15–40 year people (P = 0.234). The obesity was not significant in genders in high school or college-educated people but statistical significant differences were seen both in 1–9 year schooling (P = 0.001) and uneducated people (P = 0.001). Obesity in wealth uneducated people was significantly prevalent 20.4% more than in those were high school or college-educated (P = 0.001). Statistical differences among three economic groups those who are in high school or college education level were not significant. Also, this situation was shown in age groups (15–40 year and 40–65 year) those who were uneducated. Obesity was common in uneducated people more than in 1–9 year schooling and in high school or college-educated people except in male and in 40–65 year age group. The outstanding result of this study was the lower obesity in high school or college-educated people in all exposure variables.

Table 1
Distribution of body mass index based on educational level and some socio-demographic-related factors.

The logistic regression analysis estimated the OR of obesity for varicose exposure. The risk of obesity was 2.294 (P = 0.001) and 1.962 (P = 0.001) in uneducated subjects compared to high school or college-educated and 1–9 year schooling subjects, respectively. The risk of obesity significantly remained in uneducated people after adjusted for location area, gender, age, and economic status (OR = 2.044, 95% confidence interval [CI], 1.570–2.660). Statistically, the association between risk of obesity and location area (OR = 1.668, 95% CI), gender (OR = 2.619, 95% CI), and age groups (OR = 2.343, 95% CI) was significant. Compare to poor subjects, the OR was 1.534 (P = 0.003) in good economic subjects. However, there was no significant association between intermediate economic groups with risk of obesity [Table 2].

Table 2
The estimated crude and adjusted odds ratio of obesity with different levels of socio-demographic factors with 95% confidential interval using multivariate logistic regression.

4. Discussion

In this study, the prevalence of overweight and obesity was seen in 30.9% and 24% of adults, respectively. Substantially, obesity varies worldwide and its current prevalence ranges from as low as ≤5% in China, Japan, and African nations to as high as ≥75% in urban Samoa.12 Obesity reported 22.9% in Spain13 and 40% in South Asians.14 The prevalence of obesity and overweight reported in Iran15 18.1% and 32.0%, respectively and in another study,16 the overweight, obesity, and pathological obesity was common in 28.6%, 10.8%, and 3.4% of adults, respectively. Comparing with other studies in Iran, in our area study, the obesity was seen higher, whereas compared to Spain and South Asian it was lower.

Notably, our study result shows that illiteracy is a risk factor for obesity and it is promoted after adjusted by economic status and location area. Gender (female) and aging were the other potential factors for weight gain. The relationship between educational level and obesity in different studies was not similar. Low education and aging were associated factors with obesity in northern Iran17 and urbanization, income, education, and gender posed were different relationships with overweight in Peruvian cities.18 During 1991–2008, a rising burden of overweight among low economic status and low educational level was shown in some low-income countries.19 Education inversely associated with obesity in the adult's Portuguese people from 1995 to 200520 and it has an attenuation trend with BMI in Indian people.21 In Turkish men, overweight was not thoroughly related to education while it was significantly increased among the high-wealth groups but in women, it was high in low-educated and middle-wealth groups.22 In a cohort study in European countries, a negative association was seen between higher BMI and lower education level23 and in Spain, the old women those who are low-educated and low-income were the most susceptible group to weight gain.24 The impact of obesity on the health-related quality of life was notable among low-educated groups in rural Spanish women.25 In Tunis, the metabolic syndrome was observed in illiterate women more than the college-educated women.26 The negative relationship between BMI and educational level was seen in Spanish adults with rising in men and older subject.27 As above-mentioned studies, illiteracy and rising income were the risk factors for obesity and overweight in our study. Low education may influence on some obesity-related factors as physical activity and diet.28 In our study, we did not see any statistical significance among three economic levels in high school or college-educated subjects but in uneducated and low-educated subjects, the difference was significant. The strong relationship between education and health knowledge7 and cardiovascular disease control rate29,30 is reported in previous studies.

Iran as a developing country located in the Middle-East Region is considered to be a country in nutrition transition31 and similar to the most countries that have undergone rapid economic and demographic changeover, non-communicable diseases, especially cardiovascular disease, are the major cause of death in Iran.32 It is necessary to design a preventive program for control of obesity and overweight, especially in illiterate and good economic people in northern Iran.

Similar to the other studies, urbanization,33 female gender,34 older age,35 and good economic status36 were found as the risk factors for obesity in our study. Socio-economic status influenced on obesity by changing lifestyle and food behaviors and resulted in low activities. They are well known as the underlying agents for weight gain.3

5. Conclusion

This study supports that obesity is a health problem in Iranian northern adults and illiteracy is a risk factor especially in wealth families. With regards to changing of lifestyle and booming economic status in Iran, it is expected to increase in this area. Thereby, strategic planning is necessary for preventing or reducing obesity. Public health programs that aim to reduce overweight and obesity should primarily focus on the low-educated population.

Conflicts of interest

All authors have none to declare.


1. Mehio Sibai A., Nasreddine L., Mokdad A.H., Adra N., Tabet M., Hwalla N. Nutrition transition and cardiovascular disease risk factors in Middle East and North Africa countries: reviewing the evidence. Ann Nutr Metab. 2010;57:193–203. [PubMed]
2. Calle E.E., Thun M.J., Petrelli J.M., Rodriguez C., Heath C.W. Body mass index and mortality in a prospective cohort of US adults. New Engl J Med. 1999;341:1097–1105. [PubMed]
3. McLaren L. Socioeconomic status and obesity. Epidemiol Rev. 2007;29:29–48. [PubMed]
4. Musaiger A.O. Overweight and obesity in the Eastern Mediterranean Region: can we control it? East Mediterr Health J. 2004;10:789–793. [PubMed]
5. Schillinger D., Barton L.R., Karter A.J., Wang F., Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep. 2006;121:245–254. [PMC free article] [PubMed]
6. Baker D.W. The meaning and the measure of health literacy. J Gen Intern Med. 2006;21:878–883. [PMC free article] [PubMed]
7. Gazmararian J.A., Williams M.V., Peel J., Baker D.W. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–275. [PubMed]
8. Zhang Q., Wang Y. Trends in the association between obesity and socioeconomic status in U.S. adults: 1971 to 2000. Obes Res. 2004;12:1622–1632. [PubMed]
9. Molarius A., Seidell J.C., Sans S., Tuomilehto J., Kuulasmaa K. Educational level, relative body weight, and changes in their association over 10 years: an international perspective from the WHO MONICA Project. Am J Public Health. 2000;90:1260–1268. [PMC free article] [PubMed]
10. Statistical Center of Iran . 2006. Population and Housing Census.http://www.sci.org.ir Available from: Accessed 18.11.12.
11. World Health Organization . WHO; Geneva: 2000. Obesity: Prevention and Managing the Global Epidemic.
12. World Health Organization . WHO; 2006. Global Strategies on Diet, Physical Activity and Health.http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/ Available from: Last updated 2006 Aug 26, cited; Accessed 12.06.11.
13. Gutiérrez-Fisac J.L., Guallar-Castillón P., León-Muñoz L.M., Graciani A., Banegas J.R., Rodríguez-Artalejo F. Prevalence of genera and abdominal obesity in the adult population of Spain, 2008–2010: The ENRICA study. Obes Rev. 2012;13:388–392. [PubMed]
14. Rao N., Eastwood S.V., Jain A. Cardiovascular risk assessment of South Asians in a religious setting: a feasibility study. Int J Clin Pract. 2012;66:262–269. [PubMed]
15. Janghorbani M., Amini M., Willett W.C. First nationwide survey of prevalence of overweight, underweight, and abdominal obesity in Iranian adults. Obesity (Silver Spring) 2007;15:2797–2808. [PubMed]
16. Kelishadi R., Alikhani S., Delavari A., Alaedini F., Safaie A., Hojatzadeh E. Obesity and associated lifestyle behaviours in Iran: findings from the First National Non-communicable Disease Risk Factor Surveillance Survey. Public Health Nutr. 2008;11:246–251. [PubMed]
17. Hajian-Tilaki K.O., Heidari B. Prevalence of obesity, central obesity and the associated factors in urban population aged 20–70 years, in the north of Iran: a population-based study and regression approach. Obes Rev. 2007;8:3–10. [PubMed]
18. Jacoby E., Goldstein J., López A., Núñez E., López T. Social class, family, and life-style factors associated with overweight and obesity among adults in Peruvian cities. Prev Med. 2003;37:396–405. [PubMed]
19. Jones-Smith J.C., Gordon-Larsen P., Siddiqi A., Popkin B.M. Is the burden of overweight shifting to the poor across the globe? Time trends among women in 39 low- and middle-income countries (1991–2008) Int J Obes (Lond) 2012;36:1114–1120. [PMC free article] [PubMed]
20. Marques-Vidal P., Paccaud F., Ravasco P. Ten-year trends in overweight and obesity in the adult Portuguese population, 1995 to 2005. BMC Public Health. 2011;11:772. [PMC free article] [PubMed]
21. Gupta R., Guptha S., Gupta V.P., Agrawal A., Gaur K., Deedwania P.C. Twenty-year trends in cardiovascular risk factors in India and influence of educational status. Eur J Cardiovasc Prev Rehabil. 2012;19(6):1258–1271. [PubMed]
22. Ergin I., Hassoy H., Kunst A. Socio-economic inequalities in overweight among adults in Turkey: a regional evaluation. Public Health Nutr. 2012;15(1):58–66. [PubMed]
23. Hermann S., Rohrmann S., Linseisen J. The association of education with body mass index and waist circumference in the EPIC-PANACEA study. BMC Public Health. 2011;11:169. [PMC free article] [PubMed]
24. Aranceta J., Perez-Rodrigo C., Serra-Majem L. Influence of sociodemographic factors in the prevalence of obesity in Spain. The SEEDO'97 Study. Eur J Clin Nutr. 2001;55:430–435. [PubMed]
25. García-Mendizábal M.J., Carrasco J.M., Pérez-Gómez B. Role of educational level in the relationship between body mass index (BMI) and health-related quality of life (HRQL) among rural Spanish women. BMC Public Health. 2009;9:120. [PMC free article] [PubMed]
26. Allal-Elasmi M., Haj Taieb S., Hsairi M. The metabolic syndrome: prevalence, main characteristics and association with socio-economic status in adults living in Great Tunis. Diabetes Metab. 2010;36:204–208. [PubMed]
27. Rodríguez-Martín A., Novalbos Ruiz J.P., Martínez Nieto J.M., Escobar Jiménez L. Life-style factors associated with overweight and obesity among Spanish adults. Nutr Hosp. 2009;24:144–151. [PubMed]
28. Ball K., Crawford D. Socioeconomic status and weight change in adults: a review. Soc Sci Med. 2005;60:1987–2010. [PubMed]
29. Erceg M., Ivicević-Uhernik A., Kern J., Vuletić S. Is there any association between blood pressure and education level? The CroHort study. Coll Antropol. 2012;36:125–129. [PubMed]
30. Lyra R., Silva Rdos S., Montenegro R.M., Jr. High prevalence of arterial hypertension in a Brazilian Northeast population of low education and income level, and its association with obesity and metabolic syndrome. Rev Assoc Med Bras. 2012;58:209–214. [PubMed]
31. Ghassemi H., Harrison G., Mohammad K. An accelerated nutrition transition in Iran. Public Health Nutr. 2002;5:149–155. [PubMed]
32. Hadaegh F., Harati H., Ghanbarian A., Azizi F. Prevalence of coronary heart disease among Tehran adults: Tehran Lipid and Glucose Study. East Mediterr Health J. 2009;15:157–166. [PubMed]
33. Musaiger A.O. Overweight and obesity in eastern Mediterranean region: prevalence and possible causes. J Obes. 2011 September;18:407237. [PMC free article] [PubMed]
34. Musaiger A.O., Al-Hazzaa H.M. Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. Int J Gen Med. 2012;5:199–217. [PMC free article] [PubMed]
35. Apostolopoulou M., Savopoulos C., Michalakis K., Coppack S., Dardavessis T., Hatzitolios A. Age, weight and obesity. Maturitas. 2012;71:115–119. [PubMed]
36. Zienczuk N., Egeland G.M. Association between socioeconomic status and overweight and obesity among Inuit adults: International Polar Year Inuit Health Survey, 2007–2008. Int J Circumpolar Health. 2012;71:1–7. [PMC free article] [PubMed]

Articles from Journal of Cardiovascular Disease Research are provided here courtesy of Elsevier
PubReader format: click here to try


Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...


  • PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...