Preventive Medicine 49 (2009) 402–406

Contents lists available at ScienceDirect

Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

Association between physical activity and insulin resistance in Iranian adults: National
Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2007)
Alireza Esteghamati a,⁎, Omid Khalilzadeh a, Armin Rashidi a, Alipasha Meysamie b, Mehrdad Haghazali c,
Fereshteh Asgari c, Mehrshad Abbasi a, Shadab Rastad a, Mohammad Mehdi Gouya c
a
Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences P.O. Box 13145-784, Tehran, Iran
b
Department of Community Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
c
Center for Disease Control, Ministry of Health and Medical Education, Tehran, Iran

a r t i c l e i n f o a b s t r a c t

Available online 8 September 2009 Background. Insulin resistance is an underlying mechanism of metabolic syndrome. We attempted to
determine the association between physical activity and insulin resistance in Iranian adults.
Keywords: Methods. The data of the third national Surveillance of Risk Factors of Non-Communicable Diseases
Physical activity (SuRFNCD-2007) in Iran were used. We ran the Global Physical Activity Questionnaire (GPAQ) over a
Insulin resistance
nationally representative sample of 3101 adults. Total physical activity (TPA) was calculated using metabolic
Homeostasis model assessment
Sedentary
equivalents (MET) for intensity of physical activities. Insulin resistance was measured by the homeostasis
model assessment of insulin resistance (HOMA-IR).
Results. When physical activity was classified into high, moderate, and low categories, HOMA-IR values
significantly increased from the high category to the moderate and low categories (p b 0.01). After
adjustment for age, area of residence, smoking, and body mass index (BMI), TPA (r = −0.26, p b 0.01 in males
and r = −0.21, p b 0.01 in females), duration of vigorous-intensity activity (r = −0.28, p b 0.01 in males and
r = −0.18, p = 0.01 in females), duration of moderate-intensity activity (r = −0.16, p = 0.01 in males and
r = −0.17, p b 0.01 in females), and the time spent on sedentary behaviors (r = 0.16, p = 0.01 in males and
r = −0.22, p b 0.01 in females) were significantly correlated to HOMA-IR. The prevalence of physical
inactivity increased linearly with increasing HOMA-IR quintiles.
Conclusions. Our findings indicate a significant relationship between physical inactivity and insulin
resistance. For communities in a transition phase of lifestyle, encouraging physical activity may help prevent
insulin resistance and its adverse consequences.
© 2009 Elsevier Inc. All rights reserved.

Introduction 2002). These changes in lifestyle seem to be making obesity an

Insulin resistance has an important role in the pathogenesis of
several conditions including obesity (Esteghamati et al., 2008d),
hypertension (Esteghamati et al., 2008c), type 2 diabetes (Meigs et al.,
2007), dyslipidemia (Semenkovich, 2006; Chapman & Sposito, 2008),
and cardiovascular disease (Bonora et al., 2007, 2002). We and others
have recently shown that the prevalence of such conditions is rather
high in the Iranian population (Esteghamati et al., 2008a, 2008b;
Janghorbani et al., 2007). As a result of progressive urbanization and
industrialization, adults tend to experience a decline in their level of
physical activity and replacement of their comparatively healthier
traditional diets by calorie-dense, high-fat foods (Ghassemi et al.,
⁎ Corresponding author. Fax: +98 21 64432466.
E-mail addresses: esteghamati@tums.ac.ir (A. Esteghamati),
khalilzadeh@razi.tums.ac.ir (O. Khalilzadeh), rasidiarmin@yahoo.com (A. Rashidi),
meysamie@tums.ac.ir (A. Meysamie), haghmehr@yahoo.com (M. Haghazali),
asgarifcdc@yahoo.com (F. Asgari), mehrshad_abbasi@yahoo.com (M. Abbasi),
shadabrastad@yahoo.com (S. Rastad), mgoya57@yahoo.com (M.M. Gouya).
increasingly common problem in the country, and may subsequently
lead to insulin resistance and its adverse metabolic consequences.
Physical activity has been suggested to improve insulin sensitivity
(Bradley et al., 2008; Balkau et al., 2008; Nowak et al., 2008; Kavouras
et al., 2007). However, the association between different levels of
physical activity, defined by an international standard questionnaire,
and insulin resistance is yet to be explored in large scale population-
based studies. Furthermore, it is interesting to explore this association
in different domains of physical activity (i.e., work, commuting, and
leisure time) and evaluate the independent association of sedentary
lifestyle behaviors with insulin resistance. It is particularly important
to discover ways to improve health conditions in populations under-
going socio-cultural phase transitions. The homeostasis model
assessment of insulin resistance (HOMA-IR) is a practical method
for estimating insulin resistance in epidemiologic studies (Wallace
et al., 2004). For the first time in Iran, we investigated in this study the
association between HOMA-IR and physical activity, assessed by the
Global Physical Activity Questionnaire (GPAQ) (WHO, 2008), in a
large national-representative sample of Iranian adults.

0091-7435/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2009.09.005
 A. Esteghamati et al. / Preventive Medicine 49 (2009) 402–406 403

Materials and methods Physical examination and biochemical measurements

Participants Weight and height of participants were determined in light clothing and
without shoes. Portable calibrated electronic weighing scale and portable
This study was based on the data of the third SuRFNCD in Iran carried measuring inflexible bars were used. Waist circumference was measured using
out in 2007. Details of the survey are reported elsewhere (CDC of Iran, constant tension tape at the end of a normal expiration, with arms relaxed at the
2008). In brief, a cluster sampling scheme was applied to randomly select a sides, at the midpoint between the lower part of the lowest rib and the highest
representative sample of Iranian adults aged 25–64 years. Addresses were point of the hip on the mid-axillary line. Blood pressure was measured with a
randomly selected from the postal codes across the country. Two males calibrated Omron M7 sphygmomanometer (HEM-780-E). The average of three
and two females were assigned to each age category (15–24, 25–34, measurements, made at intervals of 5 min, was used for analysis. The body mass
35–44, 45–54, and 55–64 years). The sample taken from each province was index (BMI; kg/m2) was calculated according to the Quetelet formula.
proportional in size to the total population of the province. For instance, 51 Venous blood (10 ml) was taken in sitting position, collected in four tubes,
(1020 participants) and 2 (40 participants) clusters were taken from centrifuged immediately, and transferred under cold chain condition to the
Tehran and Ilam, the largest and smallest provinces in Iran, respectively. Central Reference Laboratory of Ministry of Health of Iran (Tehran, Iran).
Trained healthcare professionals conducted household interviews and Fasting plasma glucose (FPG) was measured by the enzymatic colorimetric
physical examinations. Interviewers were instructed on details of the method using glucose oxidize test (intra- and inter-assay coefficients of
survey and how to conduct the interviews in a 1-day workshop in Tehran variation of 2.1% and 2.6%, respectively). One tube was treated with 2 μg
prior to the commencement of the survey. All interviews were in Persian. sodium fluoride for glucose preservation to enhance the accuracy of glucose
The data were recorded in standardized questionnaires and were measurement. The two remaining tubes were transferred to the endocrine
rechecked based on a predetermined schedule. Blood sampling was done laboratory of Vali-Asr Hospital (Tehran University of Medical Sciences,
within a few days of the interview. The survey received ethics approval Tehran, Iran) for fasting plasma insulin (FPI) measurement. Plasma insulin
from the Center for Disease Control (CDC) of Iran and all participants gave was measured by the radioimmunoassay method (Immunotech, Prague,
informed consent. Czech Republic). Sensitivity was 0.5 mU/ml, and the upper limits of intra- and
inter-assay coefficients of variation were 4.3 and 3.4, respectively.
Physical activity assessment
Statistical analysis
The second version of the GPAQ was employed in the survey (WHO,
HOMA-IR was calculated as FPG (mmol/l) × FPI (mU/l)/22.5 (Matthews
2008). This questionnaire, which has been developed by WHO, is composed
et al., 1985). Complex sample survey analysis was performed using SPSS 16
of 16 questions about physical activity in a typical week and assesses physical
for Windows (Chicago, IL). Data were weighted for sex, age, and residential
activity in three domains, namely, work, transportation, and recreational
area (urban/rural) strata, according to the population of Iran (national
activities. The evaluation of physical activity in three domains is one of the
census, 2006). The method of general linear modeling was used to adjust the
factors that make GPAQ distinct from other questionnaires including the less
variables of interest for factors such as age, sex, area of residence, BMI, and
sophisticated, short version of the international physical activity question-
smoking, and to compare the adjusted variables across quintiles of HOMA-IR
naire IPAQ (available at: http://www.ipaq.ki.se). It also determines the
(1.237, 1.556, 1.947, and 2.822) and categories of physical activity.
intensity of activity (i.e., vigorous or moderate) in each domain as well as the
Multivariate regression analysis was used to find independent correlates of
time spent on sedentary behaviors such as watching TV. Sedentary behavior
HOMA-IR. p b 0.05 was considered statistically significant.
was defined as activities such as sitting at a desk, traveling in car/bus/train,
reading, working with computer, and watching television.
Results
In order to measure energy expenditure, the concept of metabolic equi-
valents (MET) was used. MET is the ratio of a person's working metabolic rate
relative to the resting metabolic rate. One MET is defined as the energy cost of After excluding participants with missing data in questionnaires
sitting quietly, and is equivalent to a caloric consumption of 1 kcal/kg/h. It is (n = 113), analyses were performed in the remaining 3101 individuals.
estimated that a person's caloric consumption is four times as high when
being moderately active, and eight times as high when being vigorously Table 1
active. Therefore, when calculating a person's overall energy expenditure Characteristics of study participants in groups with low, moderate, and high levels of
using the GPAQ data, four METs are assigned to the time spent on moderate physical activity (SuRFNCD-2007, Iran).
activities, and eight METs to the time spent on vigorous activities. The total
Low Moderate High P
physical activity score (TPA) was calculated as the sum of all MET × minutes
for moderate- or vigorous-intensity physical activity performed in work, n (total = 3101) 1239 (40.0%) 765 (24.7%) 1097 (35.4%) —
commuting, and recreation. Burden (n)a 12.5 7.7 11.1 —
b
Age (year) 44.5 (0.3) 44.3 (0.4) 43.4 (0.3) 0.05
Participants were classified into the following three categories, as defined
Males (%) 468 (37.8) 350 (45.7) 680 (62.0) b0.01
by the GPAQ analysis framework:
Area of residence b0.01
Urban (%) 862 (69.6) 542 (70.6) 668 (60.9)
1) High: a person reaching any of the following criteria is classified in this Rural (%) 377 (30.4) 223 (29.4) 429 (39.1)
category: BMI (kg/m2)b 27.2 (0.2) 26.6 (0.2) 25.9 (0.2) b0.01
Waist circumference (cm)b 90.3 (0.4) 89.1 (0.4) 87.4 (0.4) b0.01
• Vigorous-intensity activity on at least 3 days a week achieving a
Systolic blood pressure 123.9 (0.7) 122.9 (0.8) 121.4 (0.6) 0.02
minimum of at least 1500 MET-minutes per week, or (mmHg) b

• Seven or more days of any combination of walking and moderate- or Diastolic blood pressure 81.0 (0.5) 80.3 (0.5) 80.2 (0.5) 0.35
vigorous-intensity activities achieving a minimum of at least 3000 MET- (mmHg)b
minutes per week. Smoking statusc b0.01
2) Moderate: a person not meeting the criteria for the “high” category, but Never smoker 83.8 (1.7) 83.3 (1.7) 76.2 (1.7)
meeting any of the following criteria is classified in this category: Ex-smoker 3.9 (0.5) 4.6 (0.7) 6.2 (0.8)
Current smoker 12.3 (1.5) 12.1 (1.4) 17.6 (1.5)
• Three or more days of vigorous-intensity activity of at least 20 min per
Fasting plasma glucose 5.30 (0.08) 5.12 (0.06) 5.03 (0.05) b0.01
day, or (mmol/l)b
• Five or more days of moderate-intensity activity or walking of at least Fasting plasma insulin (mU/l)b 9.78 (0.24) 9.74 (0.27) 9.24 (0.21) 0.13
30 min per day, or HOMA-IRb 2.71 (0.08) 2.32 (0.07) 1.99 (0.06) b0.01
• Five or more days of any combination of walking and moderate- or
Variables (except age, sex, and area of residence) are standardized for age, sex, and
vigorous-intensity activities achieving a minimum of at least 600 MET-
residential area of the 2006 population of Iran.
minutes per week. a
National estimate rounded to the nearest million.
3) Low: a person not meeting any of the above mentioned criteria falls in this b
Mean (SE).
c
category. % (SE).
404 A. Esteghamati et al. / Preventive Medicine 49 (2009) 402–406

Table 2 and HOMA-IR (p b 0.01) significantly increased across categories of

Association between several features of physical activity with HOMA-IR after decreasing physical activity.
adjustment for potential confounders (SuRFNCD-2007, Iran).
In both genders (and after adjustment for age, area of residence,
Males Females BMI, and smoking), HOMA-IR was significantly associated with TPA,
Standardized P Standardized P the duration of vigorous- and moderate-intensity activity, and
beta beta sedentary behaviors. The association between HOMA-IR and TPA
Total physical activity (TPA) was independent of the duration of sedentary behaviors. Similarly, the
Adjustment for association between HOMA-IR and both vigorous and moderate types
Age and area of residence −0.28 b 0.01 −0.23 b0.01 of activity was independent of the duration of sedentary behaviors
Age, area of residence, BMI, −0.26 b 0.01 −0.21 b0.01 (Table 2).
and smoking
Age, area of residence, BMI, −0.24 b 0.01 −0.20 b0.01
TPA and MET-minutes of activity at work and at commuting were
smoking, and duration of significantly lower at higher HOMA-IR quintiles after adjustment for
sedentary behaviors age, sex, area of residence, BMI, and smoking (p b 0.01). The same
pattern was seen for the duration of vigorous- or moderate-intensity
Duration of vigorous activity
physical activity (p b 0.01), whereas the duration of sedentary
Adjustment for
Age and area of residence −0.30 b 0.01 −0.19 0.01 behaviors was significantly (p b 0.01) higher at higher HOMA-IR
Age, area of residence, BMI, −0.28 b 0.01 −0.18 0.01 values (Fig. 1). As shown in Fig. 2, the percentage of individuals with
and smoking vigorous-intensity activity was significantly lower while that of
Age, area of residence, BMI, −0.25 b 0.01 −0.15 0.02 inactive individuals was significantly higher at higher HOMA-IR
smoking, duration of
moderate activity,
quintiles (p b 0.01). The percentage of individuals in high (low)
and sedentary behaviors category activity was negatively (positively) correlated with HOMA-
IR quintiles (p b 0.01).
Duration of moderate activity In order to evaluate the situation in postmenopausal women, we
Adjustment for
restricted the analysis to this subset of participants (n = 545). HOMA-
Age and area of residence −0.15 0.01 −0.18 0.01
Age, area of residence, BMI, −0.16 0.01 −0.17 0.01 IR was significantly associated with TPA (r = −0.17, p b 0.01), duration
and smoking of vigorous-intensity activity (r = −0.15, p = 0.02), duration of
Age, area of residence, BMI, −0.13 0.03 −0.14 0.02 moderate-intensity activity (r = −0.13, p = 0.01), and duration of
smoking, duration of sedentary behaviors (r = 0.27, p b 0.01). The associations remained
vigorous activity, and
significant after additional adjustment for BMI and smoking.
sedentary behaviors

Duration of sedentary behaviors Discussion

Adjustment for
Age and area of residence 0.17 0.01 0.25 b0.01
Our study population represents the adult population of Iran. The
Age, area of residence, BMI, 0.16 0.01 0.22 b0.01
and smoking duration and intensity (vigorous vs. moderate) of physical activity in
Age, area of residence, BMI, 0.12 0.03 0.17 b0.01 three domains of work, commuting, and recreation were assessed
smoking, and TPA using the GPAQ questionnaire. Considering that most physical
activities in developing countries take place while working and
commuting, separating these domains from recreational activities is a
Anthropometric characteristics of participants are presented in Table 1. logical approach recommended by WHO in GPAQ, in order to yield a
The body mass index (BMI; p b 0.01), waist circumference (p b 0.01), more comprehensive estimate of overall physical activity. In addition,
systolic blood pressure (p = 0.02), fasting plasma glucose (p b 0.01), through controlling the potential confounding effects of work and

Fig. 1. The association between HOMA-IR and TPA, activity at work, activity at commuting, and activity at recreation after adjustment for age, sex, residential area, BMI, and smoking
(A). The association between HOMA-IR and the duration of sedentary behaviors, moderate activity, and vigorous activity after adjustment for age, sex, residential area, BMI, and
smoking (B) (SuRFNCD-2007, Iran). ⁎p b 0.05, ⁎⁎p b 0.01, ⁎⁎⁎p b 0.001. Handles represent SE.
 A. Esteghamati et al. / Preventive Medicine 49 (2009) 402–406
Fig. 2. The percentage of individuals with vigorous, non-vigorous, and without activity across quintiles of HOMA-IR (A). The percentage of individuals in different categories of
activity across quintiles of HOMA-IR (B). Sufficient activity is defined as high or moderate categories of physical activity (B). The number in each box refers to the percentage of
individuals that correspond to the given activity category/intensity. Variables are adjusted for age, sex, and area of residence (SuRFNCD-2007, Iran).
commuting activities, this approach assesses the association between
physical inactivity and metabolic abnormalities more precisely than
traditional questionnaires which focus mainly on evaluating recrea-
tional activities.
To estimate physical activity energy expenditure, MET-minutes of
activities in different domains were calculated and summed up to yield
TPA. After adjustments for age, gender, residential area, smoking, and
BMI, we demonstrated a significant association between TPA and
HOMA-IR. Furthermore, both moderate- and vigorous-intensity
activities were independently correlated with lower HOMA-IR values.
The time spent on sedentary behaviors was also associated with
HOMA-IR independent of physical activity at other domains. We
demonstrated a significant linear association between HOMA-IR
quintiles and various aspects of physical activity. As shown in Fig. 1A,
work-time physical activity had a higher (compared to commuting and
recreation) contribution to the association between TPA and HOMA-IR.
The advantages of this study include a large sample size
representative of the nation, using a standardized international
questionnaire (WHO, 2008) and the concept of metabolic equivalents,
exploring the association in different domains of physical activity (i.e.,
work, commuting, and recreation) and evaluation of the association
between some of the less studied aspects of physical activity and
insulin resistance. For example, the association between sedentary
behavior and insulin resistance has not been evaluated in previous
works. The association between insulin resistance and physical activity
or exercise has been the topic of many recent studies (Balkau et al.,
2008; Nowak et al., 2008; Bradley et al., 2008; Kavouras et al., 2007;
Franks et al., 2007; Foy et al., 2006; Mohan et al., 2005; Brage et al.,
2004; Kriska et al., 2001; Mayer-Davis et al., 1998). The results of the
available reports, however, have sometimes been inconsistent, mainly
due to differences in the study design, sampling protocol, age range of
participants, method for assessing physical activity (e.g., different
questionnaires), and insulin resistance estimation methods. Mayer-
Davis et al. (1998) showed in a study on 1467 individuals aged 40–69
years that physical activity (total, vigorous-intensity, and moderate-
intensity) has a direct relationship with insulin sensitivity measured
by the frequently sampled intravenous glucose test (FSIGT). Using the
405
clamp technique and accelerometer to measure insulin resistance and
physical activity, respectively, Balkau et al. (2008) showed in 801
adults that the duration of physical activity and total physical activity is
significantly related to insulin sensitivity in both genders. After
adjusting for total activity, however, the relationship between the
duration of activity and insulin sensitivity lost its significance. In
another study on 1262 adults aged 20 years or older in south India,
physical activity was measured in three domains: job-related activity,
leisure-time activity, and exercise. Subjects were then categorized into
three groups: light-, moderate-, and heavy-grade activity. HOMA-IR
was significantly higher in subjects with light-grade activity compared
to those with heavy-grade activity (Mohan et al., 2005).
Different mechanisms have been proposed to explain the effect of
physical activity on insulin sensitivity. One theory points out that
physical activity enhances glucose transport into the muscle cells,
possibly by up-regulating the expression of glucose transporter 4
(Goodyear & Kahn, 1998; Perseghin et al., 1996; O'Gorman et al.,
2006; Holloszy, 2005). Moreover, regular physical activity decreases
the fat mass and replaces it with lean mass, such that the amount of
muscle available for glucose absorption increases (Perseghin et al.,
1996). Obesity stimulates the production of inflammatory cytokines
which result in insulin resistance (Bradley et al., 2008). Indeed,
lowering the body weight may be a mechanism through which
physical activity increases insulin sensitivity (Balkau et al., 2008).
Enhanced blood perfusion of muscles during physical activity is
another mechanism (Baron et al., 1995).
Our study is the first attempt of its kind in Iran and one of the
largest studies on the subject. A recent study on 3600 adults (age:
20–70 years) living in urban areas of northern Iran showed that job-
related activity was low in 64.3% of individuals, and leisure-time
activity was very low or low in 81.3% of subjects. Furthermore, 79.2%
of subjects had less than 2 h of exercise per week (Hajian-Tilaki &
Heidari, 2007). A study in Tehran indicated that 45% of women aged
40–60 years have low levels of physical activity, as assessed by the
IPAQ questionnaire (Azadbakht & Esmaillzadeh, 2008). Together with
our results, one can conclude that the level of physical activity among
Iranian adults is low in several dimensions.
406 A. Esteghamati et al. / Preventive Medicine 49 (2009) 402–406
Conclusions
The findings of our study indicate a significant, inverse relationship
between physical activity and insulin resistance. This relationship is
manifested in terms of the intensity and level of activity as well as
energy expenditure during activity. Our results have important
implications for healthcare professionals and policymakers. In partic-
ular, encouraging physical activity needs to be the focus of more
attention in order to help prevent insulin resistance and its adverse
consequences. Community-based lifestyle intervention programs have
been recently tried in our country and have been associated with
promising success. For example, a recent 4-year lifestyle intervention
program in two Iranian communities in central Iran led to an increase
in leisure-time activity. Energy expenditure for total daily physical
activities showed a decreasing trend over the study period, but the
mean drop from baseline was significantly smaller in the intervention
areas than in the control area (Sarrafzadegan et al., 2009).
The main limitation with our study is its cross-sectional nature
which does not allow us to assess causal relationships. The other
limitation concerns recall bias related to the use of questionnaires.
Insulin resistance is best assessed by the hyperinsulinemic euglycemic
clamp technique (DeFronzo et al., 1979). Because of its costs and
invasiveness, however, we preferred to use the HOMA-IR index to
estimate insulin resistance. HOMA-IR is probably the most suitable
method for measuring insulin resistance in large epidemiological
studies such as the present study (Bonora et al., 2007; Wallace et al.,
2004). Finally, we used a Persian translation of GPAQ. The authors are
currently trying to determine the validity and reliability of this
translation for future use in Iran.
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgments
This study was supported by the Ministry of Health and Medical
Education, Tehran, Iran.
Authors' contributions: A.E. provided clinical expertise throughout
the project. O.K. performed statistical analysis and contributed to
writing. A.R. edited manuscript drafts and helped with data
presentation. A.M. supervised data analysis and controlled data
quality. M.H. and M.M.G. participated in the design and coordinated
different stages of the survey. F.A. supervised the flow of the survey.
M.A. designed the manuscript structure. S.R. helped with the first draft
of the manuscript. All authors read and approved the final manuscript.
References
Azadbakht, L., Esmaillzadeh, A., 2008. Dietary and non-dietary determinants of central
adiposity among Tehrani women. Public Health Nutr. 11, 528–534.
Balkau, B., Mhamdi, L., Oppert, J.M., et al., 2008. Physical activity and insulin sensitivity:
the RISC study. Diabetes 57, 2613–2618.
Baron, A.D., Steinberg, H.O., Chaker, H., Leaming, R., Johnson, A., Brechtel, G., 1995.
Insulin-mediated skeletal muscle vasodilation contributes to both insulin sensi-
tivity and responsiveness in lean humans. J. Clin. Invest. 96, 786–792.
Bonora, E., Formentini, G., Calcaterra, F., et al., 2002. HOMA-estimated insulin resistance
is an independent predictor of cardiovascular disease in type 2 diabetic subjects:
prospective data from the Verona Diabetes Complications Study. Diabetes Care 25,
1135–1141.
Bonora, E., Kiechl, S., Willeit, J., et al., 2007. Insulin resistance as estimated by homeostasis
model assessment predicts incident symptomatic cardiovascular disease in
Caucasian subjects from the general population: the Bruneck study. Diabetes Care
30, 318–324.
Bradley, R.L., Jeon, J.Y., Liu, F.F., Maratos-Flier, E., 2008. Voluntary exercise improves
insulin sensitivity and adipose tissue inflammation in diet-induced obese mice.
Am. J. Physiol. Endocrinol. Metab. 295, E586–E594.
Brage, S., Wedderkopp, N., Ekelund, U., et al., 2004. Objectively measured physical
activity correlates with indices of insulin resistance in Danish children. The
European Youth Heart Study (EYHS). Int. J. Obes. Relat. Metab. Disord. 28,
1503–1508.
CDC of Iran, 2008. The profile of the third National Surveillance of Non-Communicable
Disease Risk Factors in the I.R. of Iran. Center for Disease Control, Ministry of Health
& Medical Education, Tehran, Iran.
Chapman, M.J., Sposito, A.C., 2008. Hypertension and dyslipidaemia in obesity and
insulin resistance: pathophysiology, impact on atherosclerotic disease and
pharmacotherapy. Pharmacol. Ther. 117, 354–373.
DeFronzo, R.A., Tobin, J.D., Andres, R., 1979. Glucose clamp technique: a method for
quantifying insulin secretion and resistance. Am. J. Physiol. 237, E214–223.
Esteghamati, A., Abbasi, M., Alikhani, S., et al., 2008a. Prevalence, awareness, treatment,
and risk factors associated with hypertension in the Iranian population: the
national survey of risk factors for noncommunicable diseases of Iran. Am. J.
Hypertens. 21, 620–626.
Esteghamati, A., Gouya, M.M., Abbasi, M., et al., 2008b. Prevalence of diabetes and
impaired fasting glucose in the adult population of Iran: National Survey of Risk
Factors for Non-Communicable Diseases of Iran. Diabetes Care 31, 96–98.
Esteghamati, A., Khalilzadeh, O., Abbasi, M., Nakhjavani, M., Novin, L., Esteghamati, A.R.,
2008c. HOMA-estimated insulin resistance is associated with hypertension in
Iranian diabetic and non-diabetic subjects. Clin. Exp. Hypertens. 30, 297–307.
Esteghamati, A., Khalilzadeh, O., Anvari, M., Ahadi, M.S., Abbasi, M., Rashidi, A., 2008d.
Metabolic syndrome and insulin resistance significantly correlate with body mass
index. Arch. Med. Res. 39, 803–808.
Foy, C.G., Foley, K.L., D'Agostino Jr., R.B., Goff Jr., D.C., Mayer-Davis, E., Wagenknecht, L.E.,
2006. Physical activity, insulin sensitivity, and hypertension among US adults:
findings from the Insulin Resistance Atherosclerosis Study. Am. J. Epidemiol. 163,
921–928.
Franks, P.W., Loos, R.J., Brage, S., O'Rahilly, S., Wareham, N.J., Ekelund, U., 2007. Physical
activity energy expenditure may mediate the relationship between plasma leptin
levels and worsening insulin resistance independently of adiposity. J. Appl. Physiol.
102, 1921–1926.
Ghassemi, H., Harrison, G., Mohammad, K., 2002. An accelerated nutrition transition in
Iran. Public Health Nutr. 5, 149–155.
Goodyear, L.J., Kahn, B.B., 1998. Exercise, glucose transport, and insulin sensitivity.
Annu. Rev. Med. 49, 235–261.
Hajian-Tilaki, K.O., Heidari, B., 2007. 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. 8, 3–10.
Holloszy, J.O., 2005. Exercise-induced increase in muscle insulin sensitivity. J. Appl.
Physiol. 99, 338–343.
Janghorbani, M., Amini, M., Willett, W.C., et al., 2007. First nationwide survey of
prevalence of overweight, underweight, and abdominal obesity in Iranian adults.
Obesity (Silver Spring) 15, 2797–2808.
Kavouras, S.A., Panagiotakos, D.B., Pitsavos, C., et al., 2007. Physical activity, obesity
status, and glycemic control: the ATTICA study. Med. Sci. Sports Exerc. 39, 606–611.
Kriska, A.M., Hanley, A.J., Harris, S.B., Zinman, B., 2001. Physical activity, physical fitness,
and insulin and glucose concentrations in an isolated Native Canadian population
experiencing rapid lifestyle change. Diabetes Care 24, 1787–1792.
Matthews, D.R., Hosker, J.P., Rudenski, A.S., Naylor, B.A., Treacher, D.F., Turner, R.C.,
1985. Homeostasis model assessment: insulin resistance and beta-cell function
from fasting plasma glucose and insulin concentrations in man. Diabetologia 28,
412–419.
Mayer-Davis, E.J., D'Agostino Jr., R., Karter, A.J., et al., 1998. Intensity and amount of
physical activity in relation to insulin sensitivity: the Insulin Resistance
Atherosclerosis Study. Jama 279, 669–674.
Meigs, J.B., Rutter, M.K., Sullivan, L.M., Fox, C.S., D'Agostino Sr., R.B., Wilson, P.W., 2007.
Impact of insulin resistance on risk of type 2 diabetes and cardiovascular disease in
people with metabolic syndrome. Diabetes Care 30, 1219–1225.
Mohan, V., Gokulakrishnan, K., Deepa, R., Shanthirani, C.S., Datta, M., 2005. Association
of physical inactivity with components of metabolic syndrome and coronary artery
disease—the Chennai Urban Population Study (CUPS no. 15). Diabet Med. 22,
1206–1211.
Nowak, A., Pilaczynska-Szczesniak, L., Sliwicka, E., Deskur-Smielecka, E., Karolkiewicz,
J., Piechowiak, A., 2008. Insulin resistance and glucose tolerance in obese women:
the effects of a recreational training program. J. Sports Med. Phys. Fitness 48,
252–258.
O'Gorman, D.J., Karlsson, H.K., McQuaid, S., et al., 2006. Exercise training increases
insulin-stimulated glucose disposal and GLUT4 (SLC2A4) protein content in
patients with type 2 diabetes. Diabetologia 49, 2983–2992.
Perseghin, G., Price, T.B., Petersen, K.F., et al., 1996. Increased glucose transport-
phosphorylation and muscle glycogen synthesis after exercise training in insulin-
resistant subjects. N. Engl. J. Med. 335, 1357–1362.
Sarrafzadegan, N., Kelishadi, R., Esmaillzadeh, A., et al., 2009. Do lifestyle interventions
work in developing countries? Findings from the Isfahan Healthy Heart Program in
the Islamic Republic of Iran. Bull. World Health Organ. 87, 39–50.
Semenkovich, C.F., 2006. Insulin resistance and atherosclerosis. J. Clin. Invest. 116,
1813–1822.
Wallace, T.M., Levy, J.C., Matthews, D.R., 2004. Use and abuse of HOMA modeling.
Diabetes Care 27, 1487–1495.
WHO, 2008. Global physical activity questionnaire (GPAQ). World Health Organization,
Geneva, Switzerland. Accessed December 1 Available from: www.who.int/entity/
chp/steps/resources/GPAQ_Analysis_Guide.pdf.