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Objective Musculoskeletal pain conditions (MPs) are a widespread public problem that can affect 13.5% to 47% of the total population. Dietary changes can have strong effects on person’s health; for instance, Sulfur amino acids (SAAs) can act as a precursor of neurotransmitters, antioxidative metabolic intermediates, such as glutathione, impact inflammation, and play a role in severity and frequency of MPs. We evaluated the relationship between dietary SAAs intake with severity and frequency of pain in patients with MPs. Results This cross-sectional study consisted of 175 men and woman. Anthropometric measurements and pain assessments were conducted via questionnaires. Dietary data were collected using 7 days 24-h recall. ANOVA and Spearman correlation coefficients were used to examine the relationship and correlation, respectively, between exposure and outcome variables. There was a significant correlation between age, weight, waist circumference (WC), waist circumference to height (WHtR), body mass index (BMI), and severity and frequency of MPs among women. There was a correlation between age and severity of pain in men. The present study highlights a positive association between the dietary SAAs and severity of pain, even after adjusting for confounding variables.

Background Obesity, widely recognized as a serious health concern, is characterized by profoundly altered metabolism. However, the intermediate metabolites involved in this change remain largely unknown. Objective: We conducted targeted metabolomics profiling to identify moieties associated with adult obesity. Methods In this case-control study of Iranian adults, 200 obese patients were compared with 100 controls based on 104 metabolites profiled by a targeted metabolomic approach using liquid chromatography coupled to triple quadrupole mass spectrometry (LC-MS/MS). The analysis comprised acylcarnitines, diacyl-phosphatidylcholines (PCaa), acyl-alkyl-phosphatidylcholines (PCae), sphingomyelins (SM), lyso-phospholipids (LPC) and amino acids. We performed multivariable linear regression to identify metabolites associated with obesity, adjusting for age, sex, total energy intake, total physical activity, smoking, and alcohol consumption. The Bonferroni correction was used to adjust for multiple testing. Results A pattern of 19 metabolites was significantly associated with obesity. Branched chain amino acids, alanine, glutamic acid, proline, tyrosine LPCa C16:1, PCaa C32:1, PCaa C32:2 and PCaa C38:3 were positively, while serine, asparagine, LPCa C18:1, LPCa C18:2, LPCe C18:0, PCae C34:3, PCae C38:4 and PCae C40:6 were negatively associated with obesity (all p

Background The prevalence of obesity and its two important phenotypes, the metabolically healthy obese (MHO) and the metabolically unhealthy obese (MUO) are 10.9, 9.1, and 1.8%, respectively, among children and adolescents in Iran. Data on the link between diet quality indices and obesity phenotypes in children and adolescents is scarce. The present study aimed to assess the association of the Dietary Approaches to Stop Hypertension (DASH) score with MHO and MUO, as well as with cardiometabolic risk factors (RFs) in children and adolescents with excess weight. Methods This cross-sectional study was conducted on 341 children and adolescents with excess weight aged 6–13 years, selected from primary schools of Tehran. The DASH score was determined based on eight components using a valid and reliable food frequency questionnaire. Anthropometric measures, insulin, fasting plasma glucose, lipid profile, and physical activity levels were collected. MUO was classified based on two definitions: having 2 or more cardiometabolic RFs, or being insulin resistant determined by a homeostatic model assessment of insulin resistance (HOMA-IR) ≥ 3.16. Multivariable logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for MUO phenotypes and cardiometabolic RFs in each tertile of the DASH score after adjustment for confounders. Results The mean ± SD for age and DASH score was 9.3 ± 1.7 years and 24.0 ± 4.9, respectively. The prevalence of MUO was 62.2% based on RFs, and 43.4% based on HOMA-IR. Participants in the highest tertile of the DASH score had significantly decreased odds for MUO based on HOMA-IR (OR = 0.49; 95% CI: 0.28–0.87) compared with those in the lowest tertile, after adjustment for confounders. However, there were no associations between the DASH score and any of cardiometabolic RFs, or MUO based on RFs (OR = 0.68; 95% CI: 0.38–1.20). Conclusion The DASH score was inversely associated with MUO based on HOMA-IR, but not associated with MUO based on cardiometabolic RFs in this sample of children and adolescents. A DASH-style diet may have favourable effects on insulin sensitivity among children and adolescents with excess weight. Universal definitions for MHO/MUO are required, and longitudinal studies recommended to shed light upon this subject.

Background: Deficiency of vitamin D, an anti-inflammatory micronutrient with some favorable effects on lipid profiles, has been found to be highly prevalent in adolescents. We aimed to investigate the effect of a school-based vitamin D supplementation regimen on the correction of vitamin D deficiency as well as lipid and inflammatory profiles of healthy adolescent boys. Methods: In this randomized single-blind placebo-controlled trial, seventy-one healthy adolescent boys (age 17 years old) were recruited from one high school in Tehran, Iran, and randomly assigned to two groups. The supplement group received vitamin D pearls at a dose of 50,000 IU monthly for 6 months, this dose is indeed defined by the Ministry of Health in Iran for a potential national school-based vitamin D supplementation program. The other group was given placebo pearls for the same duration. Before and after the treatment, the serum levels of 25-hydroxy vitamin D (25(OH) D), parathyroid hormone (PTH), retinol, lead (Pb), the lipid profile and the inflammatory biomarkers were measured and compared. Results: Between-groups statistical analysis showed that a dose (50,000 IU/month) vitamin D significantly increased the serum levels of 25-hydroxyvitamin D (25 (OH) D) (p &lt, 0.001) and decreased serum levels of PTH (p = 0.003). No significant change was observed in serum levels of retinol and Pb. Between-group analysis revealed that the serum levels of TG (P = 0.001) decreased while an increase in serum levels of HDL (p = 0.021) was observed (p&thinsp, &lt, 0.05). Both the within- and between-group analysis showed that serum tumor necrosis factor receptor 2 (TNFR2) concentration declined while serum interleukin-10 (IL-10) increased in response to vitamin D supplementation (p&thinsp, 0.05). Conclusion: A supplementation regimen of (50,000 IU/month) vitamin D in a context with high rates of vitamin deficiency has shown positive impacts on the serum vitamin D, lipid profile and inflammatory biomarkers in healthy adolescent boys.

Objective The objective of this study was to investigate the association of serum levels of 25(OH)D3 (vitamin D), retinol (vitamin A) and zinc with stunting in a large sample of Iranian toddlers. Study design This was a cross-sectional study. Methods A total of 4261 children, aged 10–36 months, who had Iranian birth certificates were included in the present study. Weight and height were measured by experienced professionals in accordance with standard protocols. Stunting was defined as a height-for-age z-score of Results The mean age of the study participants was 19.2 ± 8.4 months. A significant inverse association was found between serum retinol concentrations and the odds of stunting such that after controlling for potential confounders, toddlers in the highest quartile of serum retinol levels had 29% lower odds of stunting than those in the lowest quartile (odds ratio [OR]: 0.71, 95% confidence interval [CI]: 0.53–0.97). Furthermore, a significant inverse association was found between serum levels of retinol and stunting in girls (OR: 0.57, 95% CI: 0.34–0.94), urban toddlers (OR: 0.66, 95% CI: 0.44–0.99) and those who did not use nutritional supplements (OR: 0.70, 95% CI: 0.52–0.95). Although serum 25(OH)D3 levels were not significantly associated with stunting in the overall study population, we found a positive association among toddlers who used nutritional supplements. No significant association was found between serum levels of zinc and stunting. Conclusion We found a significant inverse association between serum levels of retinol and stunting in toddlers aged 10–36 months.

Some studies have examined the association between micronutrient deficiencies and overweight in children, but data in this regard are conflicting. This study was done to investigate the association between serum levels of vitamin D, A and zinc with overweight in a large sample of Iranian toddlers.A total of 4261 toddlers, aged 15-23 months, who had an Iranian birth certificate and attended primary health care, were included in the current cross-sectional study. Weight and height were measured by experts based on standard protocols and body mass index (BMI) was calculated. Based on WHO criteria, overweight was defined as BMI-z-score of ≥1SD. Serum levels of 25(OH)D3 , retinol and zinc were measured for each toddler. Binary logistic regression was applied to assess the association of 25(OH)D3 , retinol and zinc levels with overweight.Mean age of study participants was 19.2 ± 8.4 months. After controlling for potential confounders, children in the highest quartile of serum 25(OH)D3 levels had lower odds of overweight compared with those in the lowest quartile (OR: 0.79, 95% CI: 0.63-0.99). Furthermore, a marginally significant inverse association was found between serum levels of 25(OH)D3 and overweight among urban toddlers (OR: 0.75, 95%CI: 0.56-1.00). Such a relationship was not seen for rural children. No other significant association was seen between serum levels of retinol and zinc and overweight either before or after controlling for covariates.In conclusion, we found a significant inverse association between serum levels of vitamin D and overweight among toddlers. Further studies, particularly of prospective nature, are required to confirm our findings.

A particular subgroup of obese adults, considered as metabolically healthy obese (MHO), has a reduced risk of metabolic complications. However, the molecular basis contributing to this healthy phenotype remains unclear. The objective of this work was to identify obesity-related metabolite patterns differed between MHO and metabolically unhealthy obese (MUHO) groups and examine whether these patterns are associated with the development of cardiometabolic disorders in a sample of Iranian adult population aged 18-50 years. Valid metabolites were defined as metabolites that passed the quality control analysis of the study. In this case-control study, 104 valid metabolites of 107 MHO and 100 MUHO patients were separately compared to those of 78 normal-weight metabolically healthy (NWMH) adults. Multivariable linear regression was used to investigate all potential relations in the study. A targeted metabolomic approach using liquid chromatography coupled to triple quadrupole mass spectrometry was employed to profile plasma metabolites. The study revealed that, after Bonferroni correction, branched-chain amino-acids, tyrosine, glutamic acid, diacyl-phosphatidylcholines C32:1 and C38:3 were directly and acyl-carnitine C18:2, acyl-lysophosphatidylcholines C18:1 and C18:2, and alkyl-lysophosphatidylcholines C18.0 were inversely associated with MHO phenotype. The same patterns were observed in MUHO patients except for the acyl-carnitine and lysophosphatidylcholine profiles where acyl-carnitine C3:0 and acyl-lysophosphatidylcholine C16:1 were higher and acyl-lysophosphatidylcholines C18:1, C18:2 were lower in this phenotype. Furthermore, proline, and diacyl-phosphatidylcholines C32:2 and C34:2 were directly and serine, asparagines, and acyl-alkyl-phosphatidylcholine C34:3 were negatively linked to MUHO group. Factors composed of amino acids were directly and those containing lysophosphatidylcholines were inversely related to cardiometabolic biomarkers in both phenotypes. Interestingly, the diacyl-phosphatidylcholines-containing factor was directly associated with cardiometabolic disorders in the MUHO group. A particular pattern of amino acids and choline-containing phospholipids may aid in the identification of metabolic health among obese patients.

The main objective of the Second National Integrated Micronutrient Survey (NIMS-II) was to assess the nutritional status of four micronutrients, namely iron, zinc, and vitamins A and D, and also to conduct an anthropometric assessment of selected groups of children, adolescents, pregnant women, and adults, disaggregated by sex and residential area in nationally representative samples. This paper reports the design of the study along with preliminary findings.In this study, 32 770 individuals were selected by using single-stage cluster sampling. Venous blood samples were collected on site for laboratory analysis; interviews were conducted, and anthropometric measurements were performed.The prevalence of anemia was highest (17.1%) among 15- to 23-month-old children; vitamin A deficiency was 18.3% in this age group. As regards iron deficiency anemia, the prevalence in all age/sex groups was less than 5%, ranging from 0.5% in 6-year-old children to 4.2% in 15- to 23-month-old children. Zinc and vitamin D deficiencies were highest among pregnant women (8% and 85.3%, respectively). Finally, the prevalence of overweight and obesity among adults was 40.3% and 29.2%, respectively.Results of this study can help in designing nutritional intervention programs for nationwide implementation. Of all micronutrient deficiencies, vitamin D deficiency was the most prevalent in all study groups. Thus, appropriate actions should be taken in our community.

It is reported that women in developing countries reach menopause earlier compared to developed countries. This seems to be due to underestimation of age at menopause as pre-menopause women who will reach menopause at older ages are commonly excluded in cross-sectional settings. In this study, we propose an estimation method which can deal with this bias. We also assessed major determinants of menopause.The second national integrated micronutrient survey in Iran completed in 2015 is a population-based study with a nationally representative sample of 4,898 Iranian women aged 50 to 60 years. We used data on menopause status and menopausal age (asked retrospectively) to estimate the median survival time. We also used Logistic regression to model menopausal status on the current age and to estimate the median age, at which 50% of women will experience menopause. Demographic, lifestyle, and anthropometric determinants were also examined.The estimated age at menopause was 51.2 (51.0-51.3) years in the logistic model and 50.5 (48.1, 53.7) years in survival analysis. In both models, the age at menopause was significantly lower among rural and underweight women. In addition, survival analysis showed that smokers and women with smaller family size had significantly lower age at menopause.While many studies stress a gap in age at menopause between developed and developing countries, this study with a reliable estimation method showed that such a gap might originate from an underestimation of age at menopause in developing countries rather than a real difference.

Background: Recent studies show that Iranians, especially women, do not have enough physical activity and if serious measures are not taken to resolve this problem, the consequences will be harmful to the society. The purpose of this advocacy paper was to determine and explain the responsibilities of all organizations and institutions responsible for promoting physical activity to root out the problem. Methods: After a thorough library search we conducted nine in-depth interviews with the relevant policymakers and government officials, managers, and practitioners in promoting physical activity. All interviews were recorded. To analyze, all of voice files were typed, saved as Word files, and exported to MAXQDA10 software by the research team. To find the main themes, all the files were read carefully several times. Then they were coded, categorized, and organized based on the main objectives of the study. In this way, themes and subthemes were emerged. Results: According to the participants in the study current state of physical activity in the country, especially among women, is not promising. The participants explained about the main obstacles for promotion of physical activity in the country and recommended practical strategies for its promotion. The strategies were suggested in three areas: Promoting culture, social protection, and adjusting current policies to overcome the existing barriers. Conclusion: Regarding the unfavorable state of physical activity in the country presentation of this advocacy document can be an effective step in promoting physical activity, thus reducing chronic diseases and improving general health in the country.

This study was carried out to investigate the effect of vitamins E and C on cognitive performance among the elderly in Iran.About 256 elderly with mild cognitive impairment, aged 60-75 years, received 300 mg of vitamin E plus 400 mg of vitamin C or placebo daily just for 1 year.Demographic characteristics, anthropometric variables food consumption, cognitive function by Mini-Mental State Examination (MMSE), and some of the oxidative stress biomarkers were examined.Antioxidant supplementation reduced malondialdehyde level (P0.001) and raised total antioxidant capacity (P0.001) and glutathione (P0.01). The serum 8-hydroxydeoxyguanosine remained unchanged (P0.4). After adjusting for the covariates effects, MMSE scores following 6- (25.88 ± 0.17) and 12-month antioxidant supplementation (26.8 ± 0.17) did not differ from control group (25.86 ± 0.18 and 26.59 ± 0.18, respectively).Despite significant improvement in most of the oxidative stress biomarkers, antioxidants' supplementation was not observed to enhance cognitive performance. A large number of kinetic and/or dynamic factors could be suspected.

In Iran, as in most countries, cardiovascular diseases are the leading cause of death (highest mortality rate), but rank third in terms of disease burden. On the other hand, the relationship between high salt intake, hypertension, and cardiovascular disease has been proven. Food consumption pattern in Iran shows that consumption of salt, pickled foods and salty snacks is common. Regarding the World Health Organization (WHO) target for salt intake (about 5 g per day), the evidence indicates that Iranian people consume 2-3 times more than the recommended amount of salt. Fortunately, serious attention has been paid to this matter since 2009 and along with arrangements for it, support of all relevant sectors (public and private) has been included in the agenda. At present, reduction of salt intake is among the major priorities of planners, policy makers, and experts of the Iranian health services system. On the other hand, many studies in EMRO have shown high levels of daily salt intake in these countries. In this review, the solutions used in the Islamic Republic of Iran at various levels were considered, including determination of salt intake measurement methods, revision in the amount of salt in processed food products, food labeling, promoting awareness of various social groups, gathering support from all relevant sectors, designing a regular public awareness campaign for reducing salt intake, and lessons learned in this regard, that can be helpful to countries in the region.

Background: This study evaluated the effect of an intervention for reducing excess weight gain in primary school-age children in Tehran. Methods: A cluster-randomized controlled trial was conducted in 12 primary schools in Tehran. Three hundred thirty-four pupils, 167 in the intervention and 167 in the comparison group, determined to be overweight or obese based on World Health Organization standards, were recruited for the study. The intervention included nutrition education and increased physical activity (PA) for the pupils, lifestyle modification for parents, and a change in food items sold at the schools’ canteens. The entire intervention lasted approximately 18 weeks. Measures were taken before and immediately after the intervention. Results: The intervention significantly reduced body mass index Z-score and hip circumference ( p = .003 and p < .001, respectively). Waist circumference increased in both groups, but the increase was higher in the comparison group ( p = .001). No significant difference was seen in time spent on TV viewing between groups ( p = .08). Vigorous PA increased in the intervention group ( p < .001), while the comparison group showed an increase in moderate activity only ( p < .001). Energy intake increased significantly in the intervention group ( p < .001). Neither triceps skinfold thickness nor time spent on the computer changed in the intervention group ( p = .51 and p = .1, respectively), while they increased in the comparison group ( p < .001 and p = .004, respectively). Conclusion: The study provides a successful model for the implementation of similar interventions throughout the country.

Background: Flour fortification with folic acid is one of the main strategies for improving folate status in women of childbearing age. No interventional trial on the efficacy of folic acid fortification has been conducted so far in Iran. Objectives: To study the effects of flour fortification with folic acid on any reduction in neural tube defects (NTDs) and folate status of women of childbearing age. Methods: In a longitudinal hospital-based study, 13,361 postpartum women were studied after admission for childbirth before and after fortification. In addition, two cross-sectional surveys were conducted before (2006) and after flour fortification (2008). The cluster sampling method was used and 580 women, 15–49 years old, were studied as a representative sample of Golestan province in the north of Iran. Fasting blood samples were collected to measure serum vitamin B12, folate and plasma homocysteine. Sociodemographic data, health characteristics and dietary intake were determined. Results: The mean daily intakes of folate from natural food before and after flour fortification were 198.3 and 200.8 µg/day, respectively. The total folate intake increased significantly from 198.3 to 413.7 µg/day after fortification (p < 0.001). Folate intake increased by an average of 226 µg/day from fortified bread. The mean serum folate level increased from 13.6 to 18.1 nmol/l; folate deficiency decreased from 14.3 to 2.3% (p < 0.001). The incidence rate of NTDs declined by 31% (p < 0.01) in the post-fortification period (2.19 per 1,000 births; December 2007 to December 2008) compared to the pre-fortification period (3.16 per 1,000 births; September 2006 to July 2007). Conclusions: Implementation of mandatory flour fortification with folic acid can lead to a significant increase in serum folate and a significant decrease in NTDs.

Iran has been active in human nutrition training for the past five decades, but the existing curricular programs do not equip the graduates with the knowledge and skills required for solving food security and nutritional problems of the country. Given this, the Nutrition Department (ND) of Iran’s Ministry of Health and Medical Education (MOHME) initiated a curricular reform to develop responsive graduate programs in key areas of nutrition that fill the existing gaps in nutrition training with the goal of improving nutrition policy-making and program development, implementation and evaluation. ND called for a request for proposals for a project entitled “Graduate Level Training in Nutrition”. Specifically, with technical assistance from leading academic institutions in Asia, North America and UK, seven new graduate programs were housed in three separate institutions, but coordinated so that together they form a broad multidisciplinary resource for graduate education and research. These seven-degree programs are MSc and PhD in Molecular/Cellular Nutrition, MSc and PhD in Nutritional Epidemiology, MSc and PhD in Food Policy and Nutrition Intervention, and MSc in Community Nutrition. The programs were prepared in collaboration and active participation of selected faculty members of the three Iranian universities, International Union of Nutritional Sciences and the University of Philippines at Los Baños. The development of these programs was made possible through a loan from the World Bank, under the Second Primary Health and Nutrition Project in the MOHME.

Objective: Several studies indicated that techniques to change body weight and appearance were prevalent and different among adolescents. The aim of the study, therefore, was to assess differences in frequency and type of body change techniques used among adolescents by sex and body weight status. Methods: A sample of 758 adolescents aged 12–18 years were recruited from private and public schools in Tehran. Information about socio-demographic background and body change techniques were collected via a self-administered questionnaire. Results: A high percentage of adolescents used body change techniques frequently to alter their body appearance. Girls changed normal eating pattern significantly (p = 0.007) to lose weight more frequently than boys while boys used this method significantly (p = 0.01) to gain weight more frequently than girls. Overweight/obese adolescents exercised significantly to change muscle size (p = 0.03) and changed normal diet to lose weight (p < 0.001) more frequently than normal weight adolescents. The relation between sex and body weight status with body change techniques (p < 0.0) implied that male and female adolescents especially overweight/obese adolescents were frequently trying to change their body appearance. Conclusion: Significant differences existed in using body change techniques according to sex and body weight status and these should be considered in obesity prevention programs for adolescents.

The correlation between body iron stores and inflammation with insulin resistance in type 2 diabetes is not thoroughly investigated, especially in the Persian population.A cross-sectional study was designed in Tehran, Iran. Fifty-four people with type 2 diabetes and 53 matched healthy participants were included. Serum ferritin, total iron binding capacity, insulin resistance, C-reactive protein and tumor necrosis factor-alpha were measured in both groups.Diabetic patients had higher insulin resistance, hemoglobin A(1)C and serum ferritin. Significant positive correlations were observed between insulin resistance with serum ferritin and tumor necrosis factor-alpha and between serum ferritin and tumor necrosis factor-alpha in diabetic patients.Inter-relationship between insulin resistance, serum ferritin and TNF-alpha was found in type 2 diabetic patients. Serum iron even in the normal range had positive correlation with insulin resistance. It may be because the normal ranges determined for serum ferritin are too wide and the criteria for iron overload are too high.

Iron intake and status were investigated in 471 mothers [age range: 16-53 years] from rural areas in Khorramabad, Islamic Republic of Iran. Although average total iron intake was acceptable, only 6.4% of women derived at least 4% of their total intake from animal iron. Average energy and protein intakes were inadequate. Low iron status was seen in 8.2%-28.7%, depending on the parameter used, with 28.3% experiencing iron-deficiency anaemia. Significantly higher animal iron intakes were found in literate or employed women, or those of family size fewer than six people. Increasing employment opportunities, income levels and literacy rates for women will result in better iron intake and status and should receive particular attention in national planning.

Objective: Investigation of the relationship between educational level, body mass index (BMI), waist-to-hip ratio (WHR), physical activity and parity in a group of Iranian men and women living in Tehran. Design: A cross-sectional study in a group of Iranian men and women. The subjects were classified into two educational levels: low education (≤12 y schooling) and high education (>12 y schooling); and BMI, WHR, physical activity and parity (in women) were compared in two groups in men and women, separately. Setting: Metabolic Unit of Tehran University of Medical Sciences in Tehran. Subjects: Three hundred and fifteen men aged 33.1 (22–46) and 403 women aged 27.9 (22–45). Results: After controlling for age and smoking, women with a higher level of education showed a significantly lower mean BMI than less educated women (24.8±4.2 vs 28.3±4.9, P

The nutritional assessment of pre-school children in rural areas of Mahabad Iran showed that about 75% had mild to severe protein-energy malnutrition (PEM) 8-17% of the total (802) being severely malnourished. The data reveal a decreasing trend for the % of "normal" cases from birth through the 3rd year of life regardless of whether malnutrition is expressed by the Gomez or McLaren and Reed classification. (These classifications measure weight with respect to age length and mid-arm circumference for determining malnutrition.) PEM was most prevalent in the 2nd and 3rd years of life severe PEM was twice as common among girls than boys and the survey showed that 83% of the normal children were those who were given breast milk only the rest being fed a mixture of mothers and artificial milk. The report recommends the discontinuation of bottle feeding because: 1) the milk is usually made too diluted at the time of reconstitution a fact confirmed by casual observations in the present study; and 2) previous investigations have revealed that contamination at the time of preparation results in diarrhea among bottle-fed children. A higher prevalence of intestinal infections have been reported among artificially fed infants even in more affluent societies. It is strongly recommended that in any intervention program nutrition education about the value of mothers milk as well as the importance of proper weaning patterns be included.

Iranian indigenous front-line health workers (FLHW) were locally trained to deliver environmental and primary health care services to mothers and children. After two years, there was a significant decline in crude birth and death rates and in infant and 1-5 year mortality rates in the test area as compared to a control area. One out of four encounters was referred to a health center physician, the remainder being handled by the FLHWs themselves. (Am J Public Health 1981;71:739-742.)

"nThe main aim of the Master of Public Health (MPH) program is to equip the participants with the knowledge and skills essen­tial for better service management and applied (including health system) research. The content of the program is re­vised and expanded in the last three decades and currently there are different MPH programs included the general MPH, Modu­lar MPH, Medical Ethics MPH and MD-MPH programs. General evaluation and feedback show that the MPH pro­gram has been reasonably successful. MPH program enables participants to perform their duties and functions more success­fully.&nbsp