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Knowledge of healthy lifestyle in Iran: a systematic review

Introduction Lifestyle is a set of goals, plans, values, attitudes, behaviors, and beliefs manifested in the personal and family life of the individual and in her or his social interactions. It is an interdisciplinary concept that involves a health-oriented view of the physical, psychological, social, and spiritual domains of life. Despite their great importance, there is not much knowledge in Iran about healthy lifestyles. The present study is an attempt to address the knowledge of healthy lifestyle in Iran through a review of the literature on the subject. Methods The present systematic review searched Elsevier, SID, Pub Med, Magiran, IranMedex, and Google Scholar databases for relevant articles published between 2000 and 2014. We used various keywords for the searches, including knowledge, lifestyle, health, and Iran. As a result, 62 articles were included in the study. Results There has been a dramatic increase in the publication of articles on lifestyle in Iran over the past 10 years. The results obtained showed that 64% of the articles addressed physical health, 14% addressed psychological health, 10% addressed social health, and 12% addressed spiritual health. Most lifestyle studies conducted in Iran have focused on physical health, and a few have examined the psychological, social, and spiritual aspects of lifestyle. None of the studies has examined the knowledge map of healthy lifestyles in Iran. Conclusion Given the changes in the causes of mortality from infectious and chronic diseases that impose greater medication and treatment costs on the society, and since diseases caused by unhealthy lifestyles have become the leading cause of death, it is essential for health researchers to focus on the root cause of these diseases, i.e., lifestyle and human behaviors.


Background
Lifestyle is a set of goals, plans, values, attitudes, behaviors, and beliefs manifested in the personal and family life of the individual and in her or his social interactions. It is an interdisciplinary concept that involves a health-oriented view of the physical, psychological, social, and spiritual aspects of life; lifestyle is in interaction with the social structure and context and the cultural context and capital (1). Studies have shown that lifestyle changes could help Page 2200 prevent 90% of diabetes type II and 80% of cardiovascular disease (2). Metabolic syndrome is associated strongly with unhealthy lifestyle models (3,4). In addition, the metabolic syndrome is associated with increased risk of cardiovascular disease and type 2 diabetes (5,6). Lifestyle practices are relatively constant, and that is the way to achieve the objectives and specific lifestyle of a person, group, or society. The World Health Organization has indicated that lifestyle can be defined based on certain patterns and behaviors that result from the interaction between personal characteristics, social interactions, social-economic position, and the environment (7). The concept of lifestyle was proposed by Adler (8) and was further discussed by his followers and other scholars. Lifestyle is a relatively fixed way through which the individual seeks to achieve her or his goals; it is a way for achieving goals and is specific to every individual, group, or community. The World Health Organization views lifestyle in accordance with specific definable behavior patterns produced by the interaction between personal attributes, social interactions, and environmental and socioeconomic conditions (9). In the last few decades, the general concept of lifestyle has become extensively popular among the public, and healthy lifestyles have become the focus of research for social scholars, medical sociologists, and health researchers. Such lifestyles consist of behaviors through which individuals engage in proper diets, regular exercise, the avoidance of destructive behaviors and drugs, protection against accidents, the early detection of the physical symptoms of diseases, emotional and intellectual control, coping with stress and psychological problems, independence, adaptation, and the modification of interpersonal relationships at the social level (10). One of the objectives set by the World Health Organization is the promotion of healthy lifestyles in societies by 2020. Therefore, governments should develop and implement strategies that can help improve the personal and social lives of people on their agenda (11) with the goal of mitigating unhealthy lifestyle practices, such as poor physical activity, poor nutrition, and drug abuse (12). Thus, it is imperative for healthcare systems to focus on behavioral approaches and risk factors in addition to conducting clinical assessments.

Statement of the Problem
Given the multi-causal nature of healthy lifestyle practices, their definition targets a particular consistency in performing a set of health-related behaviors (13). A healthy lifestyle is a valuable source for reducing the spread and impact of health problems, promoting health, increasing adaptation to life stressors, and improving the quality of life. Having a life of quality and health with an acceptable longevity and free of disease and disability is a universal right for humans for which governments and health systems are responsible, and it is a prerequisite for sustainable development (14). For people, health is the product of the interaction between genetic heritage and the social, psychological, and ecological environment in which one lives. Each of these factors has its separate effects on the individual's health. In addition to the differences in her or his biological and genetic background, an individual is encircled by her or his habitat, consisting of the physical and ecological environment in which the person lives. People also are affected by their economic, social, and psychological environment. The habitat is constantly changing, and changes in the ways people work and their lifestyles affect their health dramatically, leading to changes in disease and mortality patterns. These changes are referred to as 'health transition. Considering the interactions between the physical, psychological, social, and spiritual dimensions of health, modern medicine perceives people as consisting merely of separate parts, and it overlooks the interactions between the existential dimensions. Also, it is less focused on the relationship between the physical and mental dimensions and the other factors that affect health. Thus, it tends to have similar prescriptions for different individuals and ignores the many side-effects of chemical drugs and the heavy medical costs and other financial burdens imposed on the government by hospital bed occupancy. Therefore, researchers are more interested in the prevention and promotion of health through improving lifestyles and eliminating the factors that have adverse health effects. Unhealthy lifestyles are one of the factors that affect the incidence of chronic diseases. Research has demonstrated that up to 90% of the cases of type 2 diabetes and 80% of cardiac diseases can be prevented by making lifestyle changes (1). With the changes in the causes of mortality from infectious to chronic diseases that impose great medication and treatment costs on the society, researchers have been drawn to the root cause of these diseases, i.e., lifestyle and human behaviors. The main causes of mortality include smoking, poor diets, and the lack of physical activity, and diseases caused by unhealthy lifestyle patterns have become the leading cause of mortality in the modern world (15). The World Health Organization has predicted that 70% to 80% of mortalities in developed countries and 40% to 50% in developing countries are caused by lifestyle-related diseases (16). This report identified five major globallyprevalent chronic diseases, i.e., obesity, cardiac arrest, diabetes, cancer, and osteoporosis. In Iran, chronic diseases, especially cardiovascular diseases and the metabolic syndrome index, are considered to be the main causes of mortality and disability, and they are related directly or indirectly to lifestyle and nutrition (17). Research has demonstrated that 90% of the cases of type 2 diabetes, 80% of cardiac diseases, and 33% of cancers could be prevented through lifestyle changes, including improved diets, weight control, physical activity, and abstinence from smoking (1). The World Health Organization has indicated that many of the major risk factors that lead to death can be overcome through lifestyle changes (18). Dean Ornish from the University of California in San Francisco and the Preventive Medicine Research Institute studied the effects of diet and lifestyle choices on health and disease, and they posited that our telomerase and genes do not necessarily dictate our fate and can be changed by making healthy lifestyle choices. The members of the study group that had changed their lifestyles had a spectacular 10% increase in their telomerase length. Therefore, it can be surmised that genetics, lifestyle, and the environment work together to predict our health and that health services contribute to a meager 25% of our health (19). According to the results of a study, issues such as the structural weaknesses of health policy-makers who should be planning improvements in people's lives, inadequate attention to general health education, insufficient educational content on health promotion and improved lifestyle in the students' textbooks and families' neglecting of the Islamic teachings and their fading attention to the Islamic doctrine have widened the gap between the community and the Islamic lifestyle (20). Cockerham and Williams emphasized that health research should not be focused on the individual as an independent member of the community; rather, it should account for collective behavior patterns within a social context (21). Many scholars believe that the Western lifestyles based on materialistic thinking and consumerism, which have now also affected Iranian society in spite of the rich Islamic school on which it is founded and its many lifestyle-related recommendations. Cockerham's assertion about political and religious ideologies' having a significant effect on healthy lifestyle choices leads to the conclusion that, as the main intervening factor, Islam can help improve people's lifestyles. Health professions, which formerly used to focus on the treatment of diseases, are now concerned with the prevention of disease and the provision of health through improved lifestyle choices and the elimination of factors that have adverse health effects (22). As much as 53% of the causes of death are lifestyle-related (23). Poor lifestyle choices form a major factor affecting the incidence of chronic diseases, such as colon cancer, hypertension, chronic obstructive pulmonary diseases, hepatic cirrhosis, HIV, and cardiovascular diseases (24). Non-communicable diseases, in particular, have a close relationship with lifestyle. In other words, lifestyle is considered a major determinant of each individual's health and disease (25). Inevitably, the failure to improve people's lifestyles has irreversible future consequences. Lifestyle improvement necessitates changes in behaviors that form a large part of the individual's daily habits. If the overall quality of life does not improve with lifestyle changes, the persistence of this motivation will be hindered. Several studies have examined the relationship between lifestyle and the quality of life and its various dimensions (26). Modern healthcare services have gradually turned their attention from the assessment of mortality rates as an indicator of health outcomes toward wider scopes, such as the promotion of health, lifestyle, and the quality of life; in fact, lifestyle currently is considered to be the main indicator of health, with its improvement leading to the promotion of health by helping people cope with stressors and improve the quality of life (27). The World Health Organization has concluded that making lifestyle changes and modifications can overcome many major mortality risk factors (18). The present review study identified numerous recent studies conducted on lifestyle; however, they were scattered in different centers. As a sociological term, lifestyle is directly linked to a set of concepts. Therefore, an official organization or institution should identify the main research priorities, examine the void in studies conducted on this subject, and advise concerned institutions. A review of the literature showed that studies on this subject have been conducted in a scattered manner and that their results have not been nationally proposed as a package by any one particular organization or institution.

Study Objectives
Problem identification is the key to leadership in human societies. Addressing the issue of lifestyle practices from both a material and a spiritual perspective is absolutely essential. Given the growth in chronic diseases in the recent decade in developing countries, such as Iran, which has led to increased health problems such as obesity, cardiovascular diseases and diabetes, modifying the various aspects of lifestyle in all the classes of the society are necessary (28).

Material and Methods
In our systematic review, we searched Elsevier, SID, Pub Med, Magiran, IranMedex, and Google Scholar databases for articles published between 2000 and 2014. We used various keywords, such as knowledge, lifestyle, health, and Iran. We identified 62 articles that ultimately were included in the study.

Inclusion and Exclusion Criteria
Given the extensive range of studies conducted on lifestyle, the selection criteria used for the articles were: 1) The research being set in Iran 2) The article being published in credible scientific and research journals 3) The research having focused on healthy lifestyle practices in Iran Page 2202 4) The article being published in Persian or English

Qualitative Assessment
In the qualitative assessment of each article, the title, abstract, methods, results, and discussion were fully reviewed. The search was conducted for articles published by 2014 using the noted keywords and standard search strategies, and 110 articles were identified. The title and abstract of the articles that involved the keywords were reviewed, and 70 articles were selected for inclusion in the next stage. Similar articles published on multiple websites were merged. Articles that did not meet the study's inclusion criteria were excluded, and the remaining 62 articles were studied extensively.

Results
We selected 62 articles for inclusion in the study. There has been a dramatic increase in the number of lifestylerelated articles published in Iran in the past decade. The results obtained showed that 64% of these articles discussed physical health, 14% discussed psychological health, 10% discussed social health, and 12% discussed spiritual health. As suggested by the numbers, most of the articles were concerned with physical health, and only a few were focused on the psychological, social, and spiritual aspects of the knowledge of lifestyle. Moreover, none of the studies examined the knowledge map of healthy lifestyles in Iran. The search began in the selected databases using the study's keywords. The article's abstracts were reviewed first, and, then, due to the large number of articles that were identified, only the titles related to healthy lifestyles were selected for inclusion in the study. Initially, we selected 150 relevant articles based on the study's inclusion and exclusion criteria. After excluding duplicate articles, 110 articles were included in the next stage, during which the full texts of the articles were examined, resulting in the selection of 70 articles. After some reassessments, 62 articles were chosen for the final analysis. Table 1 shows a summary of the most important results obtained from these articles.

Discussion
In this study, we fully reviewed 62 articles to provide a picture of the studies conducted on healthy lifestyle in Iran. Each of these articles addressed the subject from their own specialized perspective. Studies conducted on lifestyle and mental health have posited that the promotion of mental health and the implementation of prevention programs, as well as improving job security and transparency in promotional prospects, have led to enhanced mental health among workers and employees (29). In a study conducted by Ahmadi et al., interventions for changing lifestyle were shown to have reduced marital conflicts with respect to personal issues, financial management, conflict resolution, and sexual relationships. Family counseling is a method of intervention for conflict resolution and lifestyle modification that was found to be effective in reducing marital conflicts (30,31). In another study, Ghorbanalipour et al. concluded that providing group training on lifestyle changes was effective in increasing marital satisfaction (32). Most of the studies were concerned with lifestyle and physical health, some of which will be further examined in this section. The phenomena of modernization, technological advances, increased urban density, lifestyle changes, and the tendency toward bad habits have led to an unprecedented increase in the prevalence of non-communicable diseases, including cardiovascular diseases as the most common cause of mortality and disability throughout the world. In one study, the implementation of a family-oriented empowerment model was deemed practical for patients with myocardial infarction and was found to lead to lifestyle improvements or changes for both the patients and their families (33). In another study, Abedi et al. confirmed the effectiveness of lifestyle changes in reducing the risk factors associated with cardiovascular diseases in sedentary, postmenopausal women in Ahwaz (34). In a study conducted on the relationship between lifestyle and chronic obstructive pulmonary disease, Rouhafza et al. concluded that lifestyle was a factor that affected the health of these patients and found that managing and improving the patients' lifestyle and performing pulmonary rehabilitation comprised effective steps in the treatment of this condition and that lifestyle should be an integral part of treatment programs targeting these patients (35). In a study on the relationship between lifestyle and primary hypertension in Sabzevar, Najjar et al. found a significant relationship between this condition and diet, sleep patterns, smoking, physical activity, and Body mass index (36). In their study on nutrition, lifestyle and exercise in postmenopausal women in Sabzevar, Yousefzadeh et al. found that training women about the vital role of consuming dairy products, performing daily exercise and adhering to a healthy lifestyle is effective in preventing the incidence of many postmenopausal complications (37). In another study conducted on the relationship between lifestyle prior to the diagnosis of gastric cancer in patients admitted to Aras clinic of Ardabil in 2006, most of the patients were found to suffer from poor nutrition and a lack of physical activity and exercise (38). In another study conducted in 2005 in district 17 of Tehran municipality on the relationship between lifestyle in adolescent girls and the prevention of osteoporosis showed that 57.7% of them had a poor lifestyle (39). Studies conducted on lifestyle and social health have indicated that, in the course of achieving social capital and a healthy community, the empowerment of families and the modification of their lifestyle practices in accordance with religious teachings can be considered an appropriate solution to the challenges of leading a healthy life in the modern world. Muslims can use their religious teachings and advice as a factor affecting changes in their lifestyle (20). Self-care is a major dimension of a healthy lifestyle. Individuals with high self-care capabilities value their health and make an effort to avoid illness, and when they do get sick, they try to recover their health as quickly as possible. Self-care capabilities vary among members of a population depending on their marital status and social class and are significantly related to various parameters, such as social capital, cultural capital, economic capital, BMI, physical attractiveness, the value of health, feelings of powerlessness, and body management (40).
In his study on the role of spirituality and religion in health, Dabaqi posited that religious faith and spirituality are negatively related to poor health behaviors, such as smoking and drug abuse. Various aspects of faith are linked to reduced depression and suicide and mortality rates and increased longevity, marital satisfaction, well-being, and happiness and an improved immune system function (41). The results of a study by Azartal et al. showed that adopting a health-promoting lifestyle that enables "psychological growth" and "stress management" was significantly related to the overall quality of life, at least among students (42). The researchers' concept of a healthy lifestyle was comprised of physical, psychological, social, and spiritual dimensions (43). Sammie et al. found a significant relationship between students' general health and their lifestyles, including exercise, diet, smoking, compliance with the rules of safety, and stress management (44). In another study, family-oriented and individualoriented education had the effect of reducing BMI and improving lifestyles (45). In a study conducted on the relationship between lifestyle and health-related quality of life in female high school students in Mashhad, Naghibi et al. found that, of the 18 dimensions of quality of life, "psychological health" and "physical health" had the highest and "social acceptance" the lowest correlation with lifestyle. Moreover, a significant positive correlation was observed between all the dimensions of lifestyle and quality of life (46). In their study, Majdi et al. found a Page 2204 statistically significant relationship between the parents' cultural and economic capital and their adolescent children's lifestyle. Adolescents' lifestyle can therefore be argued to be affected by their cultural and economic backgrounds (47). The results obtained by Samimi et al. showed a significant relationship between general health and lifestyle with respect to exercise, smoking, diet, stress, and compliance with the rules of safety (48). In another study, Nour Bakhsh et al. compared lifestyle and mental health in female teachers and housewives in Bashiriyeh and concluded that greater happiness and mental health were related to an improved lifestyle (49). Rozmus et al. investigated health promotion and high risk behaviors in male college students in Southern Alabama and found that 32% of the participants were overweight, 25% had the experience of drunk driving, 12% smoked cigarettes, 27% smoked marijuana, and 34% were sexually active. They found a relationship between gender and health, between drinking and abstinence from drinking and between an exciting life and physical and mental health (50). In another study, Nasrin Barouq et al. found that exercise, physical activity, smoking, and obesity were among the factors contributing to hypertension, and they emphasized the need for performing interventions to change lifestyles in the region (51).
Despite the increasing number of publications on lifestyle over the past years, there are no scientific publications presenting concentrated policies and measures that can help address and resolve the existing health inequities. The results of studies conducted in Iran showed that the significance of this issue is well understood. However, only a few of the reviewed articles dealt with lifestyle and health components, and none addressed the knowledge of practices that help promote lifestyle, the application of the knowledge, its role, and the links it has to other fields of knowledge. Despite the large number of studies conducted on this subject, they have not discussed the issue from the perspective of sociologists and social scholars, as most have been conducted by researchers in health and medical sciences and therefore lack a discussion of all the lifestyle indicators that only sociological studies can fully cover (52). Future studies should therefore be focused on the knowledge of lifestyle and the lifestyle changes this knowledge can affect, and they should seek to identify and utilize the findings of cultural and psychological studies, and more particularly, of social psychology studies. Most studies conducted in Iran have focused on lifestyle, and only a few have examined the health components that affect lifestyle. The review of articles showed that each researcher had dealt with the subject of lifestyle from her or his own specialized perspective and that no organization or institution had addressed lifestyle as a multi-dimensional and multi-causal term in a multi-sect oral manner, which necessitates the conducting of further studies. This subject should be discussed and analyzed as a national and social problem. Given the highlighted role of underlying factors in the development of social inequalities and the differences between countries, there is a gap of knowledge and evidence on the matter in Iran. For instance, religion and ethnicity are factors that are considered important in some countries, such as Iran, but not in others (53). Studies should therefore be designed according to the structural features of each class of the society and health improvement plans should be devised accordingly. There should be a greater focus on the knowledge of lifestyle in different scientific and research institutions, especially in educational centers. Scientific institutions are expected to draw a knowledge map for lifestyle and extract all the components that affect health. Policy-makers are strictly recommended to not use obsolete methods for dealing with new phenomena, and to base their policies and plans and their implementation on modern techniques and studies in order to affect lifestyle components, because the process of lifestyle formation and change are by no means simple. Many factors can lead to the emergence of one style of living in the society and then change its direction and cause its gradual decline. These factors are extensively affected by social and cultural changes and changes in the motivations, intentions, and behavioral patterns of each individual in the society. Although, initially, lifestyle is based on personal choices and identities, once publicized, it cannot be analyzed out of its social and cultural context. At the micro level, the personality and biological and psychological characteristics of the individual, family, friends, school, and university affect the individual's daily life and lifestyle. At the macro level, the city and the larger world the individual inhabits, the media, the highly active social and political atmosphere in which the individual is involved and the cultural climate of the society in which he or she lives affect lifestyle and its changes. Politicians and governments should thus not be indifferent to lifestyle changes and should encourage researchers to conduct studies on the subject.

Conclusions
Health is a concept that necessitates the promotion of a healthy lifestyle. The significant role of lifestyle is in the effect it exerts on the quality of life and the prevention of diseases. Lifestyle modifications and improvements are essential for maintaining and promoting health. The promotion of community health is an important pillar of progress in all societies. Given the financial burden imposed by diseases, health problems take up a substantial part of families' income and ultimately the national income. It is therefore essential to pay a greater attention to healthpromoting lifestyles and their determinants.