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Decomposition of socioeconomic inequality in growth disorders to its determinants in pediatric population: the CASPIAN IV study

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The current study aims to evaluate socioeconomic inequality in growth disorders and its determinants in Iranian children and adolescents.


In this nationwide cross-sectional survey, 14,880 students aged 6–18 years were selected through multistage cluster sampling method from urban and rural areas of 30 provinces of Iran in 2011. Socioeconomic status (SES) was calculated using principle component analysis. Socioeconomic inequality in growth disorders (including; underweight, excess weight, overweight, general obesity, abdominal obesity, and short stature) was assessed using concentration index (C) and slope index of inequality (SII). The Oaxaca Blinder decomposition method was used to determine determinants of this inequality.


Totally, 13,486 students participated in this study (participation rate: 90.6%), comprising 50.8% boys and 75.6% urban inhabitants. Their mean age was 12.47 ± 3.36 years with no significant gender difference. The prevalence of excess weight, overweight, and general and abdominal obesity increased linearly as SES increased, and the prevalence of underweight and short stature decreased linearly as SES increased. The C index for underweight and short stature was negative, which suggests that inequality was in favor of high SES groups, and regarding overweight, excess weight, general and abdominal obesity, the index was positive, indicating that inequality was in favor of in low SES groups.


Our findings show a considerable inequality in prevalence of growth disorders in Iranian children and adolescents. These findings provide practical information for health policies and programs.

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Socio Economic Status


Concentration Index


Slope Index of Inequality

CASPIAN study:

Childhood and Adolescence Surveillance and Prevention of Adult Non-Communicable Disease study


Progress in the International Reading Literacy Study


Screen Time


Electronic Games


Physical Activity


Body Mass Index


Waist Circumference


Family History


  1. Group WMGRS. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatrica Suppl. 2006;450:76.

    Google Scholar 

  2. Mohammadi Y, Parsaeian M, Farzadfar F, Kasaeian A, Mehdipour P, Sheidaei A, et al. Levels and trends of child and adult mortality rates in the Islamic Republic of Iran, 1990–2013; protocol of the NASBOD Study. Arch Iran Med. 2014;17(3):176–81.

  3. Freitas D, Maia J, Beunen G, Claessens A, Thomis M, Marques A, et al. Socio-economic status, growth, physical activity and fitness: the Madeira growth study. Ann Hum Biol. 2007;34(1):107–22.

  4. Djalalinia S, Kelishadi R, Qorbani M, Peykari N, Kasaeian A, Esfahani EN, et al. A systematic review on the prevalence of overweight and obesity, in Iranian children and adolescents. Iran J Pediatr. 2016;26(3):e2599.

    PubMed  PubMed Central  Google Scholar 

  5. Wit J, Clayton P, Rogol A, Savage M, Saenger P, Cohen P. Idiopathic short stature: definition, epidemiology, and diagnostic evaluation. Growth Hormon IGF Res. 2008;18(2):89–110.

    Article  CAS  Google Scholar 

  6. Kelishadi R, Qorbani M, Heshmat R, Djalalinia S, Sheidaei A, Safiri S, et al. Socioeconomic inequality in childhood obesity and its determinants: a blinder-Oaxaca decomposition. J Pediatr. 2018;94:131–9.

  7. Hoddinott J, Behrman J, Maluccio J, Melgar P, Quisumbing A, Ramirez-Zea M, et al. Adult consequences of growth failure in early childhood. Am J Clin Nutr. 2013;98(5):1170–8.

    Article  CAS  Google Scholar 

  8. Black R, Victora C, Walker S, Bhutta Z, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51.

    Article  Google Scholar 

  9. Kliegman RM. Nelson textbook of pediatrics. 2012.

  10. Katz D, O’Connell M, Yeh M, Nawaz H, Njike V, Anderson L, et al. Public health strategies for preventing and controlling overweight and obesity in school and worksite settings: a report on recommendations of the Task Force on Community Preventive Services. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2005;54(RR-10):1.

  11. Peykari N, Tehrani F, Eftekhari M, Malekafzali H, Dejman M, Neot R, et al. A peer-based study on adolescence nutritional health: a lesson learned from Iran. J Pak Med Assoc. 2011;61(6):549–54.

  12. Pensola TH, Valkonen T. Effect of parental social class, own education and social class on mortality among young men. Eur J Public Health. 2002;12(1):29–36.

    Article  Google Scholar 

  13. Bahreynian M, Motlagh ME, Qorbani M, Heshmat R, Ardalan G, Kelishadi R. Prevalence of growth disorders in a nationally representative sample of Iranian adolescents according to socioeconomic status: the CASPIAN-III Study. Pediatrics & Neonatology. 2015;56(4):242–7.

  14. Emamian M, Fateh M, Gorgani N, Fotouhi A. Mother's education is the most important factor in socio-economic inequality of child stunting in Iran. Public Health Nutr. 2014;17(9):2010–5.

    Article  Google Scholar 

  15. Xiao Y, Zhao N, Wang H, Zhang J, He Q, Su D, et al. Association between socioeconomic status and obesity in a Chinese adult population. BMC Public Health. 2013;13:355.

  16. Kelishadi R. Childhood overweight, obesity, and the metabolic syndrome in developing countries. Epidemiol Rev. 2007;29(1):62–76.

    Article  Google Scholar 

  17. Elder TE, Goddeeris JH, Haider SJ. Unexplained gaps and Oaxaca–blinder decompositions. Labour Econ. 2010;17(1):284–90.

    Article  Google Scholar 

  18. Jahangiri Noudeh Y, Hadaegh F, Vatankhah N, Momenan AA, Saadat N, Khalili D, et al. Wrist circumference as a novel predictor of diabetes and prediabetes: results of cross-sectional and 8.8-year follow-up studies. J Clin Endocrinol Metab. 2013;98(2):777–84.

  19. The World Bank. The World Bank In Islamic Republic of Iran [Available from:

  20. Larijani B, Majdzadeh R, Delavari A, Rajabi F, Khatibzadeh S, Esmailzadeh H, et al. Iran’s health innovation and science development plan by 2025. Iran J Public Health. 2009;38(1):13–6.

    Google Scholar 

  21. Motlagh M, Kelishadi R, Amirkhani M, Ziaoddini H, Dashti M, Aminaee T, et al. Double burden of nutritional disorders in young Iranian children: findings of a nationwide screening survey. Public Health Nutr. 2011;14(4):605–10.

    Article  Google Scholar 

  22. Ejtahed HS, Kelishadi R, Qorbani M, Motlagh ME, Hasani-Ranjbar S, Angoorani P, et al. Utility of waist circumference-to-height ratio as a screening tool for generalized and central obesity among Iranian children and adolescents: the CASPIAN-V study. Pediatr Diabetes. 2019 Aug;20(5):530–7.

  23. Kelishadi R, Majdzadeh R, Motlagh M-E, Heshmat R, Aminaee T, Ardalan G, et al. Development and evaluation of a questionnaire for assessment of determinants of weight disorders among children and adolescents: the Caspian-IV study. Int J Prev Med. 2012;3(10):699–705.

  24. Kelishadi R, Hovsepian S, Qorbani M, Jamshidi F, Fallah Z, Djalalinia S, et al. National and sub-national prevalence, trend, and burden of cardiometabolic risk factors in Iranian children and adolescents, 1990-2013. Arch Iran Med. 2014;17(1):71–80.

  25. Djalalinia S, Qorbani M, Peykari N, Kelishadi R. Health impacts of obesity. Pak J Med Sci. 2015;31(1):239–42.

    PubMed  PubMed Central  Google Scholar 

  26. Djalalinia S, Peykari N, Qorbani M, Moghaddam SS, Larijani B, Farzadfar F. Obesity researches over the past 24 years: a scientometrics study in middle east countries. Int J Prev Med. 2015;6.

  27. 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(6):394–401.

  28. Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et al. Methodology and early findings of the fourth survey of childhood and adolescence surveillance and Prevention of adult non-communicable disease in Iran: the CASPIAN-IV study. Int J Prev Med. 2013;4(12):1451–60.

  29. Wilson SL, Gallivan A, Kratzke C, Amatya A. Nutritional status and socio-ecological factors associated with overweight/obesity at a rural-serving US–Mexico border university. Rural Remote Health. 2012;12:2228.

    PubMed  Google Scholar 

  30. The Global school-based student health survey (GSHS).World Health Organization. [Available from:].

  31. Abdi H, Williams LJ. Principal component analysis. Wiley interdisciplinary reviews: computational statistics. 2010;2(4):433–59.

    Article  Google Scholar 

  32. Pediatrics AAo. American Academy of Pediatrics: children, adolescents, and television. Pediatrics. 2001;107(2):423–6.

    Article  Google Scholar 

  33. Kelishadi R, Ardalan G, Gheiratmand R, Gouya MM, Razaghi EM, Delavari A, et al. Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN study. Bull World Health Organ. 2007;85(1):19–26.

  34. Kelishadi R, Qorbani M, Djalalinia S, Sheidaei A, Rezaei F, Arefirad T, et al. Physical inactivity and associated factors in Iranian children and adolescents: the weight disorders survey of the CASPIAN-IV study. J Cardiovasc Thorac Res. 2017;91(1):41–8.

  35. Heshmat R, Qorbani M, Shahr Babaki AE, Djalalinia S, Ataei-Jafari A, Motlagh ME, et al. Joint Association of Screen Time and Physical Activity with Cardiometabolic risk factors in a National Sample of Iranian adolescents: the CASPIANIII study. PLoS One. 2016;11(5):e0154502.

  36. Bahreynian M, Qorbani M, Heshmat R, Motlagh ME, Djalalinia S, Ardalan G, et al. Snack Consumption among Iranian Children and Adolescents: The CASPIAN-IV Study. Iran J Public Health.2015;44 (Supple. No. 1): 62–75.

  37. Koolman X, van Doorslaer E. On the interpretation of a concentration index of inequality. Health Econ. 2004;13(7):649–56.

    Article  Google Scholar 

  38. Shaw M, Galobardes B, Lawlor D, Lynch J, Wheeler B, Davey-Smith G. The handbook of inequality and socioeconomic position: conceptes and measures. Bristol: The Policy Press; 2007.

    Book  Google Scholar 

  39. Emamian M, Zeraati H, Majdzadeh R, Shariati M, Hashemi H, Jafarzadehpur E, et al. Economic inequality in presenting near vision acuity in a middle-aged population: a blinder-Oaxaca decomposition. Br J Ophthalmol. 2013;97(9):1100–3.

    Article  Google Scholar 

  40. Emamian M, Zeraati H, Majdzadeh R, Shariati M, Hashemi H, Fotouhi A. The gap of visual impairment between economic groups in Shahroud, Iran: a blinder-Oaxaca decomposition. Am J Epidemiol. 2011;173(12):1463–7.

    Article  Google Scholar 

  41. Borooah VK, Iyer S. The decomposition of inter-group differences in a logit model: extending the Oaxaca-blinder approach with an application to school enrolment in India. J Econ Soc Meas. 2005;30(4):279–93.

    Article  Google Scholar 

  42. Najman J, Bor W, Morrison J, Andersen M, Williams G. Child developmental delay and socio-economic disadvantage in Australia: a longitudinal study. Soc Sci Med. 1992;34(8):829.

    Article  CAS  Google Scholar 

  43. Van De Mheen H, Stronks K, Van Den Bos J, Mackenbach JP. The contribution of childhood environment to the explanation of socio-economic inequalities in health in adult life: a retrospective study. Soc Sci Med. 1997;44(1):13–24.

    Article  Google Scholar 

  44. Roobiati NF, Bor W, Poncorini E, Murti B. Multilevel analysis: the effect of socioeconomic, birth weight, and nutrition intake with wasting in Boyolali, Central Java. J Matern Child Health. 2019;4(1):9–16.

    Article  Google Scholar 

  45. Larrea C, Kawachi I. Does economic inequality affect child malnutrition? The case of Ecuador. Soc Sci Med. 2005;60(1):165–78.

    Article  Google Scholar 

  46. De La Croix D, Doepke M. Inequality and growth: why differential fertility matters. Am Econ Rev. 2003;93(4):1091–113.

    Article  Google Scholar 

  47. Bryant-Waugh R. Feeding and eating disorders in children. Curr Opin Psychiatry. 2013;26(6):537–42.

    Article  Google Scholar 

  48. Tharkar S, Viswanathan V. Impact of socioeconomic status on prevalence of overweight and obesity among children and adolescents in urban India. The open obesity Journal. 2009;1:9–14.

    Article  Google Scholar 

  49. Julia M, van Weissenbruch MM, de Waal HA, Surjono A. Influence of socioeconomic status on the prevalence of stunted growth and obesity in prepubertal Indonesian children. Food Nutr Bull. 2004;25:354–60.

    Article  CAS  Google Scholar 

  50. Al-Hazzaa HM, Abahussain NA, Al-Sobayel HI, Qahwaji DM, Musaiger AO. Physical activity, sedentary behaviors and dietary habits among Saudi adolescents relative to age, gender and region. Int J Behav Nutr Phys Act. 2011;8:140.

    Article  Google Scholar 

  51. Hodges E. A primer on early childhood obesity and parental influence. Pediatr Nurs. 2003;29(1):13–6.

    PubMed  Google Scholar 

  52. Heshmat R, Qorbani M, Mozafarian N, Djalalinia S, Sheidaei A, Mansourian M. Economic inequality in prevalence of underweight and short stature in children and adolescents: the weight disorders survey of the CASPIAN-IV study. Arch Endocrinol Metab. 2020;64(5).

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The authors would like to thank all participants who contributed to this nationwide project.


This study was funded by Alborz University of Medical sciences.

Author information

Authors and Affiliations



Study concept and design: SD, RH, MQ, MEM, GA and RK; drafting of the manuscript, and critical revision of the manuscript: SD, MQ, AS, MHE, SS, HA and RK; Statistical Analysis: SD, MQ and AS. All of the authors have given final approval of the version to be published.

Corresponding authors

Correspondence to Mostafa Qorbani or Ramin Heshmat.

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Ethics approval and consent to participate

The study was conducted according to the Declaration of Helsinki (Seoul, 2008). Ethical approval was given by the Isfahan University of Medical Sciences ethics committee and other relevant national and provincial regulatory organizations. Each participant, after complete explanation of the objectives and protocols, was assured that his/her responses would remain anonymous and confidential. Participation was voluntary, and all potential participants had the right to withdraw from the study at any time. Written informed consent and oral assent were obtained from the parents and students, respectively.

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Not applicable.

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The authors declare that they have no competing interests.

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Djalalinia, S., Kelishadi, R., Qorbani, M. et al. Decomposition of socioeconomic inequality in growth disorders to its determinants in pediatric population: the CASPIAN IV study. J Diabetes Metab Disord 20, 467–476 (2021).

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