Protocol Design for Large–Scale Cross–Sectional Studies of Surveillance of Risk Factors of Non–Communicable Diseases in Iran: STEPs 2016

INTRODUCTION: The rise in non-communicable diseases (NCDs) has gained increasing attention. There is a great need for reliable data to address such problems. Here, we describe the development of a comprehensive set of executive and scientific protocols and instructions of STEPs 2016. METHODS/DESIGN: This is a large-scale cross-sectional study of Surveillance of Risk Factors of NCDs in Iran. Through systematic proportional to size cluster random sampling, 31,050 participants enrolled in three sequential processes, of completing questionnaires; physical measurements, and lab assessment. RESULTS: Out of 429 districts, samples were taken from urban and rural areas of 389 districts. After applying sampling weight to the samples, comparing the distribution of population and samples, compared classification was determined in accordance with the age and sex groups. Out of 31,050 expected participants, 30,541 participant completed questionnaires (52.31% female). For physical measurements and lab assessment, the cases included 30,042 (52.38% female) and 19,778 (54.04% female), respectively. DISCUSSION: There is an urgent need to focus on reviewing trend analyses of NCDs.To the best of our knowledge, the present study is the first comprehensive experience on systematic electronic national survey. The results could be also used for future complementary studies

Geographical Disparities in Hypertension Incidence Rate in Iran 2004-2016: Bayesian Spatial Analysis

Introduction: Cardiovascular diseases such as coronary heart disease, heart failure, arrhythmia, and cardiomyopathy all include hypertension as a key risk factor. Research has shown that the early detection and treatment of hypertension and its risk factors, as well as public health policies to reduce behavioral risk factors, have led to a gradual reduction in mortality caused by heart disease and stroke in high-income countries in the past three decades. Trends in hypertension incidence have been monitored at the national level in Iran. The aim of this study examine province-level disparities in Hypertension incidence from 2004 to 2016. Methods: Use the Non-Communicable Diseases Risk-Factors Surveillance in the Islamic Republic of Iran STEPs registry data. to estimate the incidence rate of hypertension for all provinces in 2004, 2006-2009, 2011, and 2016 using a Bayesian spatial model with Markov chain Monte Carlo algorithm in OpenBUGS version 3.2.3 and R version 4.2.2. Results: The estimated Hypertension incidence rate in total increased from 19.87 per 1000 people (95% credible interval 14.28, 25.48) in 2004 to 193.02 (171.92, 220.48) in 2016. According to the estimates of 2016, we found that the provinces of Markazi, Ardabil, and Semnan had the highest rate of hypertension, and the provinces of Hormozgan, and Sistan-Baluchistan had the lowest rate. Our findings show that Khorasan, North, Alborz, and Semnan have the most significant percentage change in incidence rate from 2004-2016. Conclusion: To reduce the prevalence of hypertension in Iranian regions, it is crucial to develop regular hypertension screening programs, especially among the elderly

Physical activity pattern in Iran : Findings from STEPS 2021

AbstractBackground: Insufficient physical activity (IPA) is a significant risk factor for various non-communicable diseases. The Iran action plan is a 20% reduction in IPA. Therefore, we aimed to describe the age and sex pattern of physical activity domains, IPA, the intensity of physical activity, sedentary behavior, and their associates at Iran’s national and provincial levels in 2021.Methods: This study used the data of the STEPwise Approach to NCD Risk Factor Surveillance (STEPS) 2021 in Iran. The STEPS study used the Global Physical Activity Questionnaire (GPAQ) version two developed by WHO for the assessment of physical activity, which included work, transport, and recreational activities domains. We showed and compared demographic and clinical characteristics of participants between males and females, using t-test and Chi-square test. A logistic regression model adjusted for residential areas, years of schooling, wealth index, age, marital status, and occupation has also been implemented. The results were presented as percentages and 95% confidence intervals (CI).Results: We included 27,874 participants with a mean (SD) age of 45.69 (15.91), among whom 12,479 (44.77%) were male. The mean prevalence of IPA for the whole population for all ages was 51.3% (50.62–51.98%). By sex, 41.93% (40.88–42.98%) and 57.87% (56.99–58.75%) of men and women had IPA, respectively. According to the physical activity domains, the age-standardized prevalence of no recreational activity was 79.40% (78.80–79.99%), no activity at work was 66.66% (65.99–67.32%), and no activity at transport was 49.40% (48.68–50.11%) for both sexes combined. Also, the overall age-standardized prevalence of sedentary behaviors was 50.82% (50.11–51.53%). Yazd province represented the highest prevalence of IPA (63.45%), while West Azerbaijan province represented the lowest prevalence (39.53%). Among both sexes, living in the urban area vs. rural area [adjusted OR: 1.44; (1.31–1.58)], married vs. single status [adjusted OR: 1.33; (1.16–1.53)], and wealth index of class 3 vs. class 1 [adjusted OR: 1.15; (1.01–1.30)] were significantly associated with a higher rate of IPA.Conclusions: The prevalence of IPA was considerably high in Iran. To achieve the predefined goal of reducing IPA, the health system should prioritize increasing physical activity, especially in urban areas and among females.Abstract Background: Insufficient physical activity (IPA) is a significant risk factor for various non-communicable diseases. The Iran action plan is a 20% reduction in IPA. Therefore, we aimed to describe the age and sex pattern of physical activity domains, IPA, the intensity of physical activity, sedentary behavior, and their associates at Iran’s national and provincial levels in 2021. Methods: This study used the data of the STEPwise Approach to NCD Risk Factor Surveillance (STEPS) 2021 in Iran. The STEPS study used the Global Physical Activity Questionnaire (GPAQ) version two developed by WHO for the assessment of physical activity, which included work, transport, and recreational activities domains. We showed and compared demographic and clinical characteristics of participants between males and females, using t-test and Chi-square test. A logistic regression model adjusted for residential areas, years of schooling, wealth index, age, marital status, and occupation has also been implemented. The results were presented as percentages and 95% confidence intervals (CI). Results: We included 27,874 participants with a mean (SD) age of 45.69 (15.91), among whom 12,479 (44.77%) were male. The mean prevalence of IPA for the whole population for all ages was 51.3% (50.62–51.98%). By sex, 41.93% (40.88–42.98%) and 57.87% (56.99–58.75%) of men and women had IPA, respectively. According to the physical activity domains, the age-standardized prevalence of no recreational activity was 79.40% (78.80–79.99%), no activity at work was 66.66% (65.99–67.32%), and no activity at transport was 49.40% (48.68–50.11%) for both sexes combined. Also, the overall age-standardized prevalence of sedentary behaviors was 50.82% (50.11–51.53%). Yazd province represented the highest prevalence of IPA (63.45%), while West Azerbaijan province represented the lowest prevalence (39.53%). Among both sexes, living in the urban area vs. rural area [adjusted OR: 1.44; (1.31–1.58)], married vs. single status [adjusted OR: 1.33; (1.16–1.53)], and wealth index of class 3 vs. class 1 [adjusted OR: 1.15; (1.01–1.30)] were significantly associated with a higher rate of IPA. Conclusions: The prevalence of IPA was considerably high in Iran. To achieve the predefined goal of reducing IPA, the health system should prioritize increasing physical activity, especially in urban areas and among females

Insight into blood pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC 8 hypertension guidelines

BACKGROUND: We compared the prevalence, awareness, treatment, and control of hypertension in Iran based on two hypertension guidelines; the 2017 ACC/AHA -with an aggressive blood pressure target of 130/80 mmHg- and the commonly used JNC8 guideline cut-off of 140/90 mmHg. We shed light on the implications of the 2017 ACC/AHA for population subgroups and high-risk individuals who were eligible for non-pharmacologic and pharmacologic therapies. METHODS: Data was obtained from the Iran national STEPS 2016 study. Participants included 27,738 adults aged ≥25 years as a representative sample of Iranians. Regression models of survey design were used to examine the determinants of prevalence, awareness, treatment, and control of hypertension. RESULTS: The prevalence of hypertension based on JNC8 was 29.9% (95% CI: 29.2-30.6), which soared to 53.7% (52.9-54.4) based on the 2017 ACC/AHA. The percentage of awareness, treatment, and control were 59.2% (58.0-60.3), 80.2% (78.9-81.4), and 39.1% (37.4-40.7) based on JNC8, which dropped to 37.1% (36.2-38.0), 71.3% (69.9-72.7), and 19.6% (18.3-21.0), respectively, by applying the 2017 ACC/AHA. Based on the new guideline, adults aged 25-34 years had the largest increase in prevalence (from 7.3 to 30.7%). They also had the lowest awareness and treatment rate, contrary to the highest control rate (36.5%) between age groups. Compared with JNC8, based on the 2017 ACC/AHA, 24, 15, 17, and 11% more individuals with dyslipidaemia, high triglycerides, diabetes, and cardiovascular disease events, respectively, fell into the hypertensive category. Yet, based on the 2017 ACC/AHA, 68.2% of individuals falling into the hypertensive category were eligible for receiving pharmacologic therapy (versus 95.7% in JNC8). LDL cholesterol< 130 mg/dL, sufficient physical activity (Metabolic Equivalents≥600/week), and Body Mass Index were found to change blood pressure by - 3.56(- 4.38, - 2.74), - 2.04(- 2.58, - 1.50), and 0.48(0.42, 0.53) mmHg, respectively. CONCLUSIONS: Switching from JNC8 to 2017 ACC/AHA sharply increased the prevalence and drastically decreased the awareness, treatment, and control in Iran. Based on the 2017 ACC/AHA, more young adults and those with chronic comorbidities fell into the hypertensive category; these individuals might benefit from earlier interventions such as lifestyle modifications. The low control rate among individuals receiving treatment warrants a critical review of hypertension services

Evaluation of the hypercholesterolemia care cascade and compliance with NCEP-ATP III guidelines in Iran based on the WHO STEPS survey

Abstract Introduction Noncommunicable diseases (NCDs), particularly cardiovascular disease (CVD), are the leading cause of death worldwide, with hypercholesterolemia being a major risk factor for CVD. This study evaluated the hypercholesterolemia care cascade in Iran—including prevalence, diagnosis, treatment coverage, and effectiveness—using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines. Methods This cross-sectional study drew on data from the 2021 Iran STEPS survey, which employed a systematic cluster sampling of adults aged ≥ 18 years across all provinces in Iran. Hypercholesterolemia was defined per NCEP-ATP III thresholds (LDL ≥ 160 mg/dL, total cholesterol ≥ 240 mg/dL, HDL ≤ 40 mg/dL, or ongoing lipid-lowering therapy). Weighted descriptive statistics were calculated, and Poisson regression with robust variance estimated crude and adjusted prevalence ratios for optimal lipid control among those treated. The 10-year CVD risk was determined using the Framingham Risk Score, stratifying participants into low ( 20%) risk categories. Results Out of 18,074 participants, 10,582 (55.32%, 95% CI: 54.29–56.35) met NCEP-ATP III criteria for hypercholesterolemia. Among these, only 20.61% (19.55–21.72) were receiving pharmacological treatment. Treatment coverage was notably lower in males (13.15%, 11.98–14.40) than females (29.12%, 27.35–30.96). Statins were the most commonly used medication (11.43% of males, 25.87% of females). Of those receiving treatment, 52.85% (females) and 53.93% (males) achieved optimal LDL, while 76.98% (females) and 81.06% (males) attained total cholesterol  60 mg/dL goal. The 10-year CVD risk was  20% in 8.94%. Conclusion Despite a high prevalence of hypercholesterolemia in Iran, treatment coverage remains suboptimal, particularly among males and working-age adults. Although most treated individuals achieve favorable LDL and total cholesterol levels, gaps persist in achieving optimal HDL targets. These findings underscore the need for strengthened screening, treatment, and adherence strategies—alongside broader preventive measures—to reduce the burden of hypercholesterolemia and CVD in Iran.Abstract Introduction Noncommunicable diseases (NCDs), particularly cardiovascular disease (CVD), are the leading cause of death worldwide, with hypercholesterolemia being a major risk factor for CVD. This study evaluated the hypercholesterolemia care cascade in Iran—including prevalence, diagnosis, treatment coverage, and effectiveness—using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines. Methods This cross-sectional study drew on data from the 2021 Iran STEPS survey, which employed a systematic cluster sampling of adults aged ≥ 18 years across all provinces in Iran. Hypercholesterolemia was defined per NCEP-ATP III thresholds (LDL ≥ 160 mg/dL, total cholesterol ≥ 240 mg/dL, HDL ≤ 40 mg/dL, or ongoing lipid-lowering therapy). Weighted descriptive statistics were calculated, and Poisson regression with robust variance estimated crude and adjusted prevalence ratios for optimal lipid control among those treated. The 10-year CVD risk was determined using the Framingham Risk Score, stratifying participants into low ( 20%) risk categories. Results Out of 18,074 participants, 10,582 (55.32%, 95% CI: 54.29–56.35) met NCEP-ATP III criteria for hypercholesterolemia. Among these, only 20.61% (19.55–21.72) were receiving pharmacological treatment. Treatment coverage was notably lower in males (13.15%, 11.98–14.40) than females (29.12%, 27.35–30.96). Statins were the most commonly used medication (11.43% of males, 25.87% of females). Of those receiving treatment, 52.85% (females) and 53.93% (males) achieved optimal LDL, while 76.98% (females) and 81.06% (males) attained total cholesterol  60 mg/dL goal. The 10-year CVD risk was  20% in 8.94%. Conclusion Despite a high prevalence of hypercholesterolemia in Iran, treatment coverage remains suboptimal, particularly among males and working-age adults. Although most treated individuals achieve favorable LDL and total cholesterol levels, gaps persist in achieving optimal HDL targets. These findings underscore the need for strengthened screening, treatment, and adherence strategies—alongside broader preventive measures—to reduce the burden of hypercholesterolemia and CVD in Iran

“Current incidence of injuries in Iran; findings of STEPS survey 2021”

Abstract Background: The updated epidemiology of injuries at the national and sub-national levels are required for policymakers to effectively handle the burden of injuries. This paper aimed to assess the incidence and risk factors of different injuries in Iran based on a recent national survey. Methods: We used data from Iran Stepwise approach to surveillance (STEPS) Survey 2021, a population-based study in urban and rural areas of Iran's 31 provinces. A multistage clustered probability design and weighting adjustments were used to select eligible individuals and generate estimations. We estimated the incidence of injuries, assessed sociodemographic variables, and identified potential behavioral risk factors associated with injuries, and results were reported for sociodemographic and geographic stratifications. Result: Data from 27,874 participants of the STEPS survey were assessed, of which 1538 (5.5 %, 95 % CI: [5.2–5.8]) reported having an injury in the past 12 months. Falls (44.4 %) were the most common cause of injury, followed by road traffic injury (21.7 %) and exposure to mechanical forces (16.5 %). Except for falls and burns, males had a higher proportion of all types of injuries. Logistic regression analysis showed that being male (OR: 1.7, [1.5, 2.0]) and being an occasional or heavy alcohol drinker (OR: 2.0, [1.3, 3.0] and OR: 2.7, [1.7, 4.1] respectively) were significant risk factors associated with road traffic injuries. Seatbelt use was 90.0 % among both drivers and front-seat passengers, while the use of safety car seats for children was as low as 9.4 %. Injury incidence varied significantly among provinces, with the highest incidence among males observed in Razavi Khorasan (11.2 %) and among females observed in Tehran (12.0 %). Conclusion: This study investigated the updated epidemiology of injuries in Iran and revealed socioeconomic and geographic disparities across country. This epidemiological information can be used to modify injury prevention programs.Abstract Background: The updated epidemiology of injuries at the national and sub-national levels are required for policymakers to effectively handle the burden of injuries. This paper aimed to assess the incidence and risk factors of different injuries in Iran based on a recent national survey. Methods: We used data from Iran Stepwise approach to surveillance (STEPS) Survey 2021, a population-based study in urban and rural areas of Iran's 31 provinces. A multistage clustered probability design and weighting adjustments were used to select eligible individuals and generate estimations. We estimated the incidence of injuries, assessed sociodemographic variables, and identified potential behavioral risk factors associated with injuries, and results were reported for sociodemographic and geographic stratifications. Result: Data from 27,874 participants of the STEPS survey were assessed, of which 1538 (5.5 %, 95 % CI: [5.2–5.8]) reported having an injury in the past 12 months. Falls (44.4 %) were the most common cause of injury, followed by road traffic injury (21.7 %) and exposure to mechanical forces (16.5 %). Except for falls and burns, males had a higher proportion of all types of injuries. Logistic regression analysis showed that being male (OR: 1.7, [1.5, 2.0]) and being an occasional or heavy alcohol drinker (OR: 2.0, [1.3, 3.0] and OR: 2.7, [1.7, 4.1] respectively) were significant risk factors associated with road traffic injuries. Seatbelt use was 90.0 % among both drivers and front-seat passengers, while the use of safety car seats for children was as low as 9.4 %. Injury incidence varied significantly among provinces, with the highest incidence among males observed in Razavi Khorasan (11.2 %) and among females observed in Tehran (12.0 %). Conclusion: This study investigated the updated epidemiology of injuries in Iran and revealed socioeconomic and geographic disparities across country. This epidemiological information can be used to modify injury prevention programs

Prevalence of plasma lipid abnormalities and associated risk factors among Iranian adults based on the findings from STEPs survey 2021

AbstractThe study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (P Abstract The study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (< 50 mg/dL in women, < 40 mg/dL in men), or self-reported use of lipid-lowering medications. Mixed dyslipidemia was characterized as the coexistence of high LDL-C with at least one of the hypertriglyceridemia and low HDL-C. The prevalence of each lipid abnormality was determined by each population strata, and the determinants of abnormal lipid levels were identified using a multiple logistic regression model. The prevalence was 39.7% for hypertriglyceridemia, 21.2% for hypercholesterolemia, 16.4% for high LDL-C, 68.4% for low HDL-C, and 81.0% for dyslipidemia. Hypercholesterolemia and low HDL-C were more prevalent in women, and hypertriglyceridemia was more prevalent in men. The prevalence of dyslipidemia was higher in women (OR = 1.8), obese (OR = 2.8) and overweight (OR = 2.3) persons, those residents in urban areas (OR = 1.1), those with inappropriate physical activity (OR = 1.2), patients with diabetes (OR = 2.7) and hypertension (OR = 1.9), and participants with a history (OR = 1.6) or familial history of CVDs (OR = 1.2). Mixed dyslipidemia prevalence was 13.6% in women and 11.4% in men (P < 0.05). The prevalence of lipid abnormalities was highly heterogeneous among provinces, and East Azarbaijan with 85.3% (81.5–89.1) and Golestan with 68.5% (64.8–72.2) had the highest and lowest prevalence of dyslipidemia, respectively. Although the prevalence of high cholesterol and LDL-C had a descending trend in the 2016–2021 period, the prevalence of dyslipidemia remained unchanged. There are modifiable risk factors associated with dyslipidemia that can be targeted by the primary healthcare system. To modify these risk factors and promote metabolic health in the country, action plans should come to action through a multi-sectoral and collaborative approach

Age of tobacco smoking initiation among Iranian adults based on National and Subnational data from the 2021 STEPS survey : Short title: Tobacco Smoking Onset Age in Iran

Abstract Tobacco smoking is a significant global public health challenge, responsible for 8 million deaths annually. This study aimed to analyze the age of smoking initiation and its sociodemographic determinants among Iranian adults, based on data from the 2021 STEPwise approach to surveillance (STEPS) survey, to inform targeted public health interventions. The analysis of 27,874 adults revealed that the average initiation ages for cigarette and hookah smoking were 22.2 years and 24.9 years, respectively. Men typically began smoking earlier than women, with average ages of 21.9 years for males and 27.7 years for females. No significant differences were observed in smoking initiation ages between rural and urban areas. Education level and marital status were also influential, with the youngest initiators having 7–12 years of education and being single. This study highlights the significant roles of gender, education, and urban-rural differences in smoking initiation in Iran. The findings underscore the need for targeted public health strategies conforming to the WHO’s MPOWER initiatives and the Framework Convention on Tobacco Control (FCTC). Increased investment in public health, focusing on education and preventive measures, is crucial to reduce early smoking initiation and its associated health risks, ultimately supporting broader health policy goals.Abstract Tobacco smoking is a significant global public health challenge, responsible for 8 million deaths annually. This study aimed to analyze the age of smoking initiation and its sociodemographic determinants among Iranian adults, based on data from the 2021 STEPwise approach to surveillance (STEPS) survey, to inform targeted public health interventions. The analysis of 27,874 adults revealed that the average initiation ages for cigarette and hookah smoking were 22.2 years and 24.9 years, respectively. Men typically began smoking earlier than women, with average ages of 21.9 years for males and 27.7 years for females. No significant differences were observed in smoking initiation ages between rural and urban areas. Education level and marital status were also influential, with the youngest initiators having 7–12 years of education and being single. This study highlights the significant roles of gender, education, and urban-rural differences in smoking initiation in Iran. The findings underscore the need for targeted public health strategies conforming to the WHO’s MPOWER initiatives and the Framework Convention on Tobacco Control (FCTC). Increased investment in public health, focusing on education and preventive measures, is crucial to reduce early smoking initiation and its associated health risks, ultimately supporting broader health policy goals

Metabolomics profile and 10-year atherosclerotic cardiovascular disease (ASCVD) risk score

BackgroundThe intermediate metabolites associated with the development of atherosclerotic cardiovascular disease (ASCVD) remain largely unknown. Thus, we conducted a large panel of metabolomics profiling to identify the new candidate metabolites that were associated with 10-year ASCVD risk.MethodsThirty acylcarnitines and twenty amino acids were measured in the fasting plasma of 1,102 randomly selected individuals using a targeted FIA-MS/MS approach. The 10-year ASCVD risk score was calculated based on 2013 ACC/AHA guidelines. Accordingly, the subjects were stratified into four groups: low-risk (n = 620), borderline-risk (n = 110), intermediate-risk (n = 225), and high-risk (n = 147). 10 factors comprising collinear metabolites were extracted from principal component analysis.ResultsC4DC, C8:1, C16OH, citrulline, histidine, alanine, threonine, glycine, glutamine, tryptophan, phenylalanine, glutamic acid, arginine, and aspartic acid were significantly associated with the 10-year ASCVD risk score (p-values ≤ 0.044). The high-risk group had higher odds of factor 1 (12 long-chain acylcarnitines, OR = 1.103), factor 2 (5 medium-chain acylcarnitines, OR = 1.063), factor 3 (methionine, leucine, valine, tryptophan, tyrosine, phenylalanine, OR = 1.074), factor 5 (6 short-chain acylcarnitines, OR = 1.205), factor 6 (5 short-chain acylcarnitines, OR = 1.229), factor 7 (alanine, proline, OR = 1.343), factor 8 (C18:2OH, glutamic acid, aspartic acid, OR = 1.188), and factor 10 (ornithine, citrulline, OR = 1.570) compared to the low-risk ones; the odds of factor 9 (glycine, serine, threonine, OR = 0.741), however, were lower in the high-risk group. “D-glutamine and D-glutamate metabolism”, “phenylalanine, tyrosine, and tryptophan biosynthesis”, and “valine, leucine, and isoleucine biosynthesis” were metabolic pathways having the highest association with borderline/intermediate/high ASCVD events, respectively.ConclusionsAbundant metabolites were found to be associated with ASCVD events in this study. Utilization of this metabolic panel could be a promising strategy for early detection and prevention of ASCVD events