Publications by authors named "Ali Rafei"

26 Publications

  • Page 1 of 1

Discriminatory Accuracy of the Gail Model for Breast Cancer Risk Assessment among Iranian Women.

Iran J Public Health 2020 Nov;49(11):2205-2213

Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran.

Background: The Gail model is the most well-known tool for breast cancer risk assessment worldwide. Although it was validated in various Western populations, inconsistent results were reported from Asian populations. We used data from a large case-control study and evaluated the discriminatory accuracy of the Gail model for breast cancer risk assessment among the Iranian female population.

Methods: We used data from 942 breast cancer patients and 975 healthy controls at the Cancer Institute of Iran, Tehran, Iran, in 2016. We refitted the Gail model to our case-control data (the IR-Gail model). We compared the discriminatory power of the IR-Gail with the original Gail model, using ROC curve analyses and estimation of the area under the ROC curve (AUC).

Results: Except for the history of biopsies that showed an extremely high relative risk (OR=9.1), the observed ORs were similar to the estimates observed in Gail's study. Incidence rates of breast cancer were extremely lower in Iran than in the USA, leading to a lower average absolute risk among the Iranian population (2.78, ±SD 2.45). The AUC was significantly improved after refitting the model, but it remained modest (0.636 vs. 0.627, ΔAUC = 0.009, bootstrapped =0.008). We reported that the cut-point of 1.67 suggested in the Gail study did not discriminate between breast cancer patients and controls among the Iranian female population.

Conclusion: Although the coefficients from the local study improved the discriminatory accuracy of the model, it remained modest. Cohort studies are warranted to evaluate the validity of the model for Iranian women.
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http://dx.doi.org/10.18502/ijph.v49i11.4739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917489PMC
November 2020

Age, Period and Cohort Analysis of Smoking Prevalence in Iranian Population over a 25-Year Period.

Arch Iran Med 2021 01 1;24(1):7-14. Epub 2021 Jan 1.

Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Current and daily smoking prevalence rates have been have investigated in several cross-sectional studies. However, analyses in terms of age-period-cohort (APC) have not been carried out. We assessed daily smoking dynamics over a 25-year period using the APC model.

Methods: In our analyses, we used data from 214,652 people aged 15 to 64 years, collected by national health surveys conducted in 1990-1991, 1999, 2005, 2007, 2011 and 2016. The Intrinsic Estimator model was used to analyze the impact of APC on daily smoking prevalence.

Results: Males were found to exhibit a higher prevalence of smoking compared to females (26.0% against 2.7%). Prevalence of smoking increased by age, peaking at the age groups of 40-44 in men and 45-49 in women, followed by a decreasing trend. The 1990 period had the highest prevalence in both genders, and the 2016 period had the lowest. The coefficients of birth cohort effects showed different patter19s of fluctuations in the two genders with the maximum and minimum coefficients for men calculated in the 1966-1970 and 1991-95 birth cohorts, and for females the 1931-1935 and 1971-1975 birth cohorts, respectively.

Conclusion: We showed the impact of APC on daily tobacco smoking prevalence, and these factors should be considered when dealing with smoking.
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http://dx.doi.org/10.34172/aim.2021.02DOI Listing
January 2021

Age, period and cohort analysis of high cholesterol levels in Iranian adults over a 20-year period.

J Diabetes Metab Disord 2019 Dec 25;18(2):289-299. Epub 2019 Jun 25.

1Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Poursina Ave, Tehran, Iran.

Purpose: Hypercholesterolemia is one of the most important modifiable risk factors of non-communicable diseases and data on their values in different societies and their trend of changes should be updated every couple of years. Many studies have focused on assessing the prevalence of high cholesterol. We must emphasise that most of these studies were cross-sectional and did not directly investigate the temporal trends of change for age, period and birth cohort (APC). The aim of this study is to evaluate the effect of age, period and birth cohort on the prevalence of borderline to high cholesterol levels in Iranian adult population.

Methods: The data were collected from 110,302 subjects between 25 and 69 years of age over the period of 1990-2011. Data from these subjects were collected by using five national cross-sectional surveys conducted in 1990-91, 1999, 2003, 2007 and 2011. The APC effect on the prevalence of borderline and high cholesterol levels was assessed using the Intrinsic Estimator model.

Results: The overall prevalence of borderline cholesterol level among male subjects was found to be lower than that of females (39.8% vs. 46.3%). Similarly, the prevalence of high cholesterol level in men was reported to be 13.1%, which was lower than the 18.0% calculated in women. The prevalence of borderline and high cholesterol levels increased with age in men between the ages of 45-49. Then it stayed quite steady and eventually declined. Then it stayed quite steady and eventually declined. The prevalence in women also increased with age, with its maximum rise after the ages of menopause and a slight decline at the ages of 65-69. As for the birth cohorts, the prevalence of borderline and high cholesterol levels followed a declining trend by going from earlier birth cohorts to the later ones.

Conclusion: The present study provides evidence that age, period and birth cohort affect the prevalence of borderline and high cholesterol levels. Thus, these factors should be considered when developing and implementing care plans for people with hypercholesterolemia.
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http://dx.doi.org/10.1007/s40200-019-00410-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6915163PMC
December 2019

Prevalence of high blood pressure in Iranian adults based on the 2017 ACC/AHA guideline.

Med J Islam Repub Iran 2019 2;33:26. Epub 2019 Apr 2.

Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran.

: In 2017, American College of Cardiology (ACC) and the American Heart Association (AHA) presented a new guideline for assessing blood pressure in adults. This study aimed to assess the prevalence of hypertension in Iranian adults based on ACC/AHA 2017 guideline. Data from 9801 Iranian adults (59.2% women) aged between 20-69 years were obtained from the sixth round of National Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD) performed in 2011. Blood pressure was classified as normal, elevated blood pressure, and stage 1 and 2 hypertension using a weighted analysis and 2017 ACC/AHA guidelines. Data were presented as prevalence and 95% confidence interval (95% CI). All analyses were performed in Stata/SE 14.0. Overall prevalence of hypertension in Iranian men was 52.0%. Also, 32.9% (95% CI: 29.9-36.0) and 19.1% (95% CI: 16.9-21.6) of men had stage 1 and 2 hypertension, respectively. In addition, 44.3% of women had hypertension, of whom 26.3% (95% CI: 24.5 - 28.2) had stage 1 and 18.0% (95% CI: 16.1-20.1) stage 2 hypertension. Furthermore, 16.5% (95% CI: 14.4-18.9) and 9.6% (95% CI: 7.86-11.7) of men and women had elevated blood pressure, respectively. The findings of this study indicated that adopting the 2017 ACC/AHA guidelines showed a higher prevalence of adult hypertension (48.2%) in Iran. In this study, the prevalence of hypertension in men was higher than in women, which was steadily increased by age in older adults in both sexes.
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http://dx.doi.org/10.34171/mjiri.33.26DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6662534PMC
April 2019

Validation of Diet History Questionnaire in Assessing Energy and Nutrient Intakes of Iranian Population.

Iran J Public Health 2019 Jun;48(6):1074-1081

Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran.

Background: This study described validity of Diet History Questionnaire (DHQ) for assessing energy and nutrient intake among Iranian population.

Methods: A group of experienced nutritionists translated the DHQ to Farsi language and modified it based on Iranian food habits and cooking methods. We recruited 244 healthy adults with a mean age of 42.83 ± 0.75 yrs. from healthy individuals who were friends or relatives of patients in the Cancer Institute of Iran from April 2011 to February 2012. We used the DHQ to assess dietary intakes through interviews as well as at least four 24-h recalls one in every season. Reliability was estimated by comparing data of DHQ with mean intake from 24-hour recalls using deattenuated and energy-adjusted Spearman correlation coefficients. We classified dietary intakes of two methods into three groups to probe if DHQ correctly allocates subjects into different intake groups compared to reference method. The results are reported as percent of disagreement, adjacent agreement, and complete agreement.

Results: Deattenuated spearman correlation ranged from 0.18 for vitamin B and fat to 0.60 for sugar. It ranged from 0.13 for pantothenic acid to 0.60 for sugar in men and from 0.07 for fat to 0.58 for sugar in females. The complete agreement of methods ranged from 51% for selenium to 36% for carotene in the entire sample, from 50% for energy to 31% for niacin in males and from 49% for sugar to 27% for vitamin B in females.

Conclusion: The DHQ is a valid tool for assessing most nutrients intake among Iranian population. In addition, it is a proper instrument in categorizing individuals based on their dietary intakes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635338PMC
June 2019

Response to the Letter on the Gap of Cigarette and Hookah Smoking between Socioeconomic Groups in Iran: Effect of Inequalities in Socioeconomic Position.

Arch Iran Med 2019 03 1;22(3):166-167. Epub 2019 Mar 1.

Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

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March 2019

The Gap of Cigarette and Hookah Smoking Between Socioeconomic Groups in Iran: Effect of Inequalities on Socioeconomic Position.

Arch Iran Med 2018 09 1;21(9):418-424. Epub 2018 Sep 1.

Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: Hookah and cigarette smoking have adverse effects on individuals' health and therefore place a great burden on public health. The aim of this study was to measure inequalities in socioeconomic position to determine contributing factors on cigarette and hookah smoking in Iran.

Methods: In this study, secondary analysis of the Iran's sixth national Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2011) was conducted for 10,572 individuals aged 15 to 70 years old. Subjects were categorized into three groups according to their socioeconomic status (low, middle and high) in order to assess their inequalities using principal component analysis. At the end, the gap between the low and high socioeconomic groups was decomposed using Blinder-Oaxaca decomposition technique.

Results: The prevalence of cigarette and hookah smoking in high, middle, and low socioeconomic groups was 11.8%, 13.2%, and 13.1% (P=0.158), and 2.6%, 3.3% and 4.3%, (P<0.001), respectively. Blinder-Oaxaca decomposition technique showed a lower prevalence of hookah smoking in high socioeconomic group compared to low socioeconomic group (P<0.001). The gap between the two mentioned groups was measured to be 1.7%. However, this gap for cigarette smoking (1.5%) was not significant (P=0.093).

Conclusion: The finding indicates the importance of socioeconomic status in hookah smoking. After decomposition of the gap between the 2 socioeconomic groups, age, gender and education level were reported to be the major contributors to the differences observed between the 2 groups.
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September 2018

Diseases and Health Outcomes Registry Systems in I.R. Iran: Successful Initiative to Improve Public Health Programs, Quality of Care, and Biomedical Research.

Arch Iran Med 2017 Nov 1;20(11):696-703. Epub 2017 Nov 1.

Deputy of Research, Ministry of Health and Medical Education, I.R. Iran.

Registration systems for diseases and other health outcomes provide important resource for biomedical research, as well as tools for public health surveillance and improvement of quality of care. The Ministry of Health and Medical Education (MOHME) of Iran launched a national program to establish registration systems for different diseases and health outcomes. Based on the national program, we organized several workshops and training programs and disseminated the concepts and knowledge of the registration systems. Following a call for proposals, we received 100 applications and after thorough evaluation and corrections by the principal investigators, we approved and granted about 80 registries for three years. Having strong steering committee, committed executive and scientific group, establishing national and international collaboration, stating clear objectives, applying feasible software, and considering stable financing were key components for a successful registry and were considered in the evaluation processes. We paid particulate attention to non-communicable diseases, which constitute an emerging public health problem. We prioritized establishment of regional population-based cancer registries (PBCRs) in 10 provinces in collaboration with the International Agency for Research on Cancer. This initiative was successful and registry programs became popular among researchers and research centers and created several national and international collaborations in different areas to answer important public health and clinical questions. In this paper, we report the details of the program and list of registries that were granted in the first round.
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November 2017

National Prevalence of Self-Reported Coronary Heart Disease and Chronic Stable Angina Pectoris: Factor Analysis of the Underlying Cardiometabolic Risk Factors in the SuRFNCD-2011.

Glob Heart 2018 06 9;13(2):73-82.e1. Epub 2018 Feb 9.

Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Background: Coronary heart disease (CHD) is one of the most common causes of mortality worldwide. The national prevalence remains unclear in most of the developing countries.

Objective: This study sought to estimate national prevalence of self-reported CHD and chronic stable angina pectoris in the general adult population of Iran using data from the fourth round of the Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2011) survey.

Methods: The analysis comprised data of 11,867 civilian, nonhospitalized and noninstitutionalized residents ages 6 to 70 years of age. The calculated prevalence of self-reported CHD and chronic stable angina pectoris were extrapolated to the Iranian adult population who were >20 years old using the complex sample analysis. The factor analysis was performed for clustering of the associated cardiometabolic risk factors among people ages >40 years of age.

Results: The estimated national prevalence of self-reported CHD and chronic stable angina pectoris were 5.3% (95% confidence interval: 4.6 to 5.9) and 7.7% (95% confidence interval: 4.6 to 8.7), respectively. Higher prevalence of these conditions were observed among the older people, urban residents, and women. Factor analysis generated 4 distinct factors that were mainly indicators of dyslipidemia, hypertension, central obesity, hyperglycemia, and tobacco smoking. The factor incorporating hypertension was a significant correlate of self-reported CHD.

Conclusions: We report concerning prevalence of self-reported CHD and chronic stable angina pectoris in the adult population of Iran. The constellation of raised systolic and diastolic blood pressures was significantly predictive of the presence of self-reported CHD.
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http://dx.doi.org/10.1016/j.gheart.2018.01.001DOI Listing
June 2018

Zero and Five End-Digit Preference and Blood Pressure Quality of Care Revisited.

Arch Iran Med 2017 Oct;20(10):633-639

3)Pediatric Chronic Kidney Disease Research Center, The Childrens Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran. 9)Department of Pediatric Nephrology, The Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran.

Background: To determine the rate of zero and five end-digit preference (EDP) for systolic and diastolic blood pressures (SBP and DBP, respectively) and risk factors amongst a representative sample of Iranian adults in the year 2011.

Methods: Data gathered from 7997 Iranian adults aged 25-70 were extracted from the database of the sixth Survey of Surveillance of Risk Factors of Non-communicable Diseases, which surveyed a total of 11,864 individuals aged 6 to 70 years. Multilevel multiple logistic regression was used to identify the independent factors associated with zero or five EDP.

Results: The prevalence of three serial zero or five EDP for SBP and DBP were 18.5% (95% CI: 11.3%-25.7%). SBP ≥140 mmHg (OR = 0.78; 95% CI: 0.65-0.95), DBP ≥90 mmHg (OR = 0.71; 95% CI: 0.58-0.88), and a positive family history of diabetes (OR = 0.77; 95% CI: 0.66-0.9) were found as protective factors against zero or five EDP in blood pressure recording the male gender (OR = 1.18; 95% CI: 1.04-1.35) was found to be its independent risk factor.

Conclusion: Sex, SBP, DBP and family history of diabetes were found to be the main independent determinants of EDP in our country which underscores the importance of assessing the many patient-related factors in the studies involving EDP as part of BP monitoring in public health care.
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October 2017

Cigarette and Water-Pipe Use in Iran: Geographical Distribution and Time Trends among the Adult Population; A Pooled Analysis of National STEPS Surveys, 2006-2009.

Arch Iran Med 2017 May;20(5):295-301

Cancer Research Center, Cancer Institute of Iran, Tehran University Medical of Sciences, Tehran, I. R. of Iran, Cancer Biology Research Center, Cancer Institute of Iran, Tehran University Medical of Sciences, I. R. of Iran.

Objective: To assess the geographical distribution and time trends of manufactured cigarette and water-pipe use among Iranian adult population.

Method: Pooled data from four consecutive nationally and provincially representative STEPS surveys, 2006-2009, were analyzed. Prevalence of current daily manufactured cigarette smokers, current daily water-pipe and current daily dual users and associated 95%CIs were estimated using complex sample analysis techniques.

Results: Overall, the prevalence of current daily tobacco use, including cigarette and water-pipe, was estimated 23.7% for men and 3.0% for women, in which 20.2% of men and 0.8% of women were exclusively cigarette smokers, 2.7% and 2.2% were exclusively water-pipe users, and 0.6% and 0.01% smoked both cigarettes and water-pipes. The prevalence of cigarette smoking ranged from 12.3% to 27.7% in men and 0.1% to 1.8% in women, and was generally highest in the northwest of the country. Conversely, the prevalence of water-pipe smoking ranged from 1.7% to 10.9% in men and 0% to 16.8% in women, and was highest in the south and southeast. No secular trends were observed for daily cigarette smoking in either men (P = 0.637) or women (P = 0.308) from 2006 to 2009. However, the prevalence of water-pipe decreased slightly in women (P = 0.012) and men (P = 0.055), though the later was not statistically significant.

Conclusion: In Iran, widespread geographical variation in the use of different types of tobacco products should be taken into account when planning for tobacco prevention policies and programs. Iran may serve as an important setting for etiological studies to examine the effects of long-term water pipe use on diseases.
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http://dx.doi.org/0172005/AIM.007DOI Listing
May 2017

Awareness, Treatment and Control of Pre-hypertension and Hypertension among Adults in Iran.

Arch Iran Med 2016 Jul;19(7):456-64

Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Background: Hypertension is a major risk factor for non-communicable diseases. Yet, Nation-wide prevalence and trend reports in developing countries are sparsely available.

Methods: Data from three cycles of Survey of Risk Factors of Non-communicable Diseases (SuRFNCD) 2005 - 2011 were aggregated. In 2011, 8218 adults aged 25 - 70 years were enrolled. For trend analysis 68850, 4184, and 7416 adults aged 25 - 64 years were included from 2005, 2007, and 2011 surveys, respectively. Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg, diastolic blood pressure (DBP) ≥ 90 mmHg, or receiving anti-hypertensive medication. Pre-hypertension was defined as SBP between 120 - 139 or DBP between 80 - 89 mmHg. The status of awareness, non-pharmacologic treatment (management), pharmacologic treatment, and control (SBP < 140 mmHg, and DBP < 90 mmHg) among hypertensive individuals were also determined.

Results: 25.6% (95%CI: 23.5 - 27.5) of the adults aged 25 - 70 years had hypertension and 39.8% (95%CI: 37.8 - 41.9) had pre-hypertension. The prevalence of hypertension was greater among older adults (P < 0.001), women (P = 0.013), and urban-dwellers (P = 0.027). In 2005 - 2011, the proportion of adults with hypertension (25.7% to 24.1%) and pre-hypertension (45.5% to 40.4%) significantly decreased. In 2011, rates for awareness, management, treatment, and control among hypertensives were 43.2% (95%CI: 40.0 - 46.4), 40.3% (95%CI: 37.0 - 43.6), 34.8% (95%CI: 31.5 - 38.2), and 38.6% (95%CI: 33.1 - 44.2), respectively. Over time, status of awareness, management, treatment and control was significantly improved and was more salient among men (P < 0.05 for all analyses).

Conclusions: The prevalence of hypertension and pre-hypertension is gradually declining. Despite improvements in awareness, management, treatment and control, these decline rates are still low and initiative strategies need to be implemented to further improve the current status.
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http://dx.doi.org/0161907/AIM.003DOI Listing
July 2016

Prevalence of metabolic syndrome in Iran: A 2011 update.

J Diabetes 2017 May 20;9(5):518-525. Epub 2016 Jul 20.

Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, Tehran, Iran.

Background: The aim of the present study was to determine the prevalence of metabolic syndrome and its individual components among the Iranian adult population in 2011 and to investigate changes between 2007 and 2011.

Methods: Data from two rounds of the Surveillance of Risk Factors of Non-communicable Diseases national surveys conducted in 2007 and 2011 were pooled. Metabolic syndrome was defined according to International Diabetes Federation criteria.

Results: In 2007, the prevalence of metabolic syndrome among adults aged 25-64 years was 35.95 (95% confidence interval [CI] 34.27-37.63), which decreased to 32.96 (95% CI 30.73-35.18) in 2011 (P = 0.0108). Despite this overall decline, the prevalence of central obesity (P = 0.1383), raised triglycerides (P = 0.3058), and reduced high-density lipoprotein cholesterol (HDL-C; P = 0.5595) remained constant. There was a trend towards a decline in the proportion of individuals with increased blood pressure (P = 0.0978), and the proportion of adults with increased fasting plasma glucose (FPG) increased (P < 0.0001). In 2011, the prevalence of central obesity, raised triglycerides, reduced HDL-C, increased blood pressure and increased FPG was 51.88 (95% CI 48.97-54.79), 36.99 (95% CI 34.52-39.45), 54.72 (95% CI 50.87-58.57), 38.92 (95% CI 36.19-41.64), and 24.97 (95% CI 22.02-27.93) respectively.

Conclusions: Over the period 2007-11, the prevalence of metabolic syndrome has decreased slightly in Iran, although prevalence of increased FPG has increased significantly. One-third of the Iranian adult population is diagnosed with metabolic syndrome.
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http://dx.doi.org/10.1111/1753-0407.12438DOI Listing
May 2017

Prevalence of Chronic Neck Pain, Low Back Pain, and Knee Pain and Their Related Factors in Community-Dwelling Adults in Iran: A Population-based National Study.

Clin J Pain 2017 02;33(2):181-187

*Sports Medicine Research Center, Neuroscience Institute †Department of Sports and Exercise Medicine, School of Medicine §Department of Epidemiology and Biostatistics, School of Public Health #Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences ‡Spine Division, Noorafshar Rehabilitation & Sports Medicine Hospital ∥Department of Community Medicine, Iran University of Medical Sciences ¶Centre for Disease Control and Management, Tehran, Iran.

Background: Chronic musculoskeletal pain (CMP) is increasing in prevalence rapidly. Over the past 2 decades low back pain has been ranked globally as the primary cause of years lived with disability. The primary objective of this study was to investigate the prevalence of chronic neck pain (CNP), chronic low back pain (CLBP), and chronic knee pain (CKP) and their related risk factors in the national Iranian population.

Methods: We analyzed data obtained through a cross-sectional, population-based survey of 7889 Iranians who were aged between 30 and 70 years.

Results: The prevalence of CNP, CLBP, and CKP was 15.34%, 27.18%, and 29.97%, respectively. Female sex, aging, body mass index≥25, Lur or Arab ethnicity, illiteracy, passive smoking, positive osteoporosis history, and low or high physical activity levels were risk factors for CLBP, CNP, and CKP after adjustment for potential confounders. For example, in participants with a body mass index≥30, odds ratios for CNP, CLBP, and CKP adjusted for age, sex, ethnicity, living area, education, employment status, smoking, and physical activity levels were 1.26 (95% confidence interval [CI], 1.04-1.52), 1.37 (95% CI, 1.17-1.59), and 1.64 (95% CI, 1.41-1.91), respectively.

Conclusions: This is the first study investigating the prevalence of CNP, CLBP, and CKP in the national population of Iran. It shows some modifiable risk factors for CMP, and suggests that affordable planning for these risk factors can be valuable in preventing CMP globally. However, this is a cross-sectional study and future longitudinal studies in this field are necessary.
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http://dx.doi.org/10.1097/AJP.0000000000000396DOI Listing
February 2017

Assessing factors related to waist circumference and obesity: application of a latent variable model.

J Environ Public Health 2015 3;2015:893198. Epub 2015 Dec 3.

Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran 1985713834, Iran.

Background: Because the use of BMI (Body Mass Index) alone as a measure of adiposity has been criticized, in the present study our aim was to fit a latent variable model to simultaneously examine the factors that affect waist circumference (continuous outcome) and obesity (binary outcome) among Iranian adults.

Methods: Data included 18,990 Iranian individuals aged 20-65 years that are derived from the third National Survey of Noncommunicable Diseases Risk Factors in Iran. Using latent variable model, we estimated the relation of two correlated responses (waist circumference and obesity) with independent variables including age, gender, PR (Place of Residence), PA (physical activity), smoking status, SBP (Systolic Blood Pressure), DBP (Diastolic Blood Pressure), CHOL (cholesterol), FBG (Fasting Blood Glucose), diabetes, and FHD (family history of diabetes).

Results: All variables were related to both obesity and waist circumference (WC). Older age, female sex, being an urban resident, physical inactivity, nonsmoking, hypertension, hypercholesterolemia, hyperglycemia, diabetes, and having family history of diabetes were significant risk factors that increased WC and obesity.

Conclusions: Findings from this study of Iranian adult settings offer more insights into factors associated with high WC and high prevalence of obesity in this population.
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http://dx.doi.org/10.1155/2015/893198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4681816PMC
August 2016

Twenty-year dynamics of hypertension in Iranian adults: age, period, and cohort analysis.

J Am Soc Hypertens 2015 Dec 16;9(12):925-34. Epub 2015 Sep 16.

Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Hypertension is a well-known health problem all over the world. Many studies have assessed its prevalence and associated risk factors, but all were cross-sectional and did not evaluate the trend of hypertension through all three different temporal dimensions including age, period, and cohort. So, we aimed to assess the 20-year dynamics of hypertension via the age-period-cohort model. Data from 74,155 subjects aged 25-60 years gathered through five national health surveys (1990-91, 1999, 2003, 2007, and 2011) were used in this study. The age-period-cohort effect on hypertension was analyzed using the intrinsic estimator model. The prevalence of hypertension increased with age for both genders except for males in 2003 and 2011 periods with drops of 3.5% for ages 55-60 and 8.1% for ages 50-60, respectively. As for the period effect, the prevalence of hypertension was almost constant in all age groups for both genders from 1990-1999. The cohort-based prevalence of hypertension showed a declining trend in all cohorts for females except for 2011 in birth cohort of 1950-1955 which remains stationary. The trend of prevalence for males also follows a decreasing trend except for periods of 2003, 2007, and 2011; birth cohorts of 1945-1949, 1975-1980, and 1950-1960 increase by 3.5%, 1.9%, and 8.1%, respectively. The age effect on the prevalence of hypertension showed an almost monotonic increasing trend. The period effect increased the total prevalence of hypertension from 1992 to 1997. The cohort effect also showed a monotonic decrease in hypertension prevalence except for a few discrepancies.
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http://dx.doi.org/10.1016/j.jash.2015.09.005DOI Listing
December 2015

Blood pressure percentiles by age and body mass index for adults.

EXCLI J 2015 24;14:465-77. Epub 2015 Mar 24.

Saveh Medical University, Saveh, Iran.

Since no comprehensive study has been conducted on blood pressure (BP) percentiles established upon nationally representative sample population of adults, the present study aimed to construct the blood pressure percentiles by age, sex and body mass index (BMI) of the subjects. Analyses were based on data collected in 2011 from 8,425 adults aged 25 to 69 years old. Data on demographic characteristics, anthropometric measurements, and blood pressure was recorded for each subject. Linear Regression analysis was used to assess the adjusted relationship of age-sex-specific standard deviation scores of BMI, height, and weight with blood pressure. Four separate models for systolic blood pressure (SBP) and diastolic blood pressure (DBP) of men and women were constructed for BP percentiles according to age and BMI. Blood pressure increased with the rise in BMI and weight, but showed a negative correlation with height. SBP and DBP rose steadily with increasing age, but the rise in SBP was greater than DBP. Overweight and obese population, seem to fall into the category of hypertensive. The findings of present study show that BP percentiles are steadily increased by age and BMI. In addition, most obese or overweight adults are hypertensive.
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http://dx.doi.org/10.17179/excli2014-635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553889PMC
September 2015

Obesity and Related Factors in Iran: The STEPS Survey, 2011.

Iran Red Crescent Med J 2015 Jun 23;17(6):e22479. Epub 2015 Jun 23.

Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran.

Background: To date, no study has addressed the association between race/ethnicity and obesity considering other sociodemographic and lifestyle factors in Iran.

Objectives: The current study aimed to study lifestyle and the environmental factors affecting obesity in the Iranian subjects of the STEPS Survey, 2011.

Patients And Methods: The study was conducted on 8639 subjects (aged ≥ 20 years) in the STEPS Survey 2011 in Iran under supervision of the World Health Organization (WHO). Height and body weight were measured following the standardized procedures. Generalized Estimating Equations (GEE) method was used to examine factors associated with obesity. The examined variables were age, gender, race/ethnicity, place of residence, employment status, physical activity, smoking status, and educational level.

Results: Overall, 22.3% of the subjects were obese. In a GEE model, a healthy weight status among adults was associated with being younger, male, in a rural residence, employees, spending more time engaged in physical activity, being a smoker and having a moderate or high level of education. These associations were statistically significant after adjusting for other variables.

Conclusions: The study results suggest a need for targeted interventions and continued surveillance for the Iranian adults.
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http://dx.doi.org/10.5812/ircmj.17(6)2015.22479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552963PMC
June 2015

Oral hygiene status in a general population of Iran, 2011: a key lifestyle marker in relation to common risk factors of non-communicable diseases.

Int J Health Policy Manag 2015 Jan 30;4(6):343-52. Epub 2015 Jan 30.

National Program for Disease Registries and Health Outcomes, Deputy for Research, Ministry of Health and Medical Education, Tehran, Iran.

Background: To estimate Oral Hygiene (OH) status in the Iranian population in 2011, and to determine the influence of socio-economic characteristics on OH, and its interrelation with common risk factors of Non-Communicable Diseases (NCDs).

Methods: Data including a total of 12,105 individuals aged 6-70 years were obtained from the sixth round of the surveys of NCDs risk factors in Iran. OH was recorded through a structured questionnaire measuring daily frequencies of tooth brushing and dental flossing. Descriptive analyses were performed on demographic characteristics in the complex sample survey setting. We also employed weighted binary logistic regression to compute Odds Ratio (OR) as a measure of association between the response and explanatory factors. Furthermore, to construct an asset index, we utilized Principal Component Analysis (PCA).

Results: The percentage with minimum recommended daily OH practices was 3.7% among men and 7.7% among women (OR= 2.3; P<0.001). Urban citizens were more likely to have their teeth cleaned compared to rural people (OR= 2.8; P<0.001). For both genders, a relatively better condition was observed in the 25-34 age group (male: 5.6%; female: 10.3%). In addition, OH status improved significantly by increase in both level of education (P<0.001) and economic status (P<0.001). There were also apparent associations between self-care practices and specific behavioral risk factors, though the correlation with dietary habits and tobacco use could be largely explained by socio-economic factors.

Conclusion: OH situation in Iran calls for urgent need to assign proper interventions and strategies toward raising public awareness and reducing disparities in access to health facilities.
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http://dx.doi.org/10.15171/ijhpm.2015.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450729PMC
January 2015

A warning threshold for monitoring tuberculosis surveillance data: an alternative to hidden Markov model.

Trop Med Int Health 2015 Jul 24;20(7):919-29. Epub 2015 Mar 24.

Iran University of Medical Sciences, Tehran, Iran.

Objectives: Although hidden Markov model (HMM) is known as a powerful tool for the detection of epidemics based on the historical data, the frequent use of such a model poses some limitation especially when decision-making is required for new observations. This study was aimed to address a warning threshold for monitoring the weekly incidences of tuberculosis as an alternative to HMM.

Methods: We extracted the weekly counts of newly diagnosed patients with sputum smear-positive pulmonary TB from 2005 to 2011 nationwide. To detect unexpected incidences of the disease, two approaches: Serfling and HMM, were applied in presence/absence of linear, seasonal and autoregressive components. Models were subsequently evaluated in terms of goodness of fit, and their results were compared in detection of the disease phases. Then, multiple hypothetical thresholds were constructed based on the estimate of models and the optimal one was revealed through ROC curve analysis.

Results: Findings from both adjusted R-square (R~2) and Bayesian information criterion (BIC) presented a higher goodness of fit for periodic autoregressive HMM (BIC = -1323.6; R~2=0.74) than other models. According to ROC analysis, better values for both Youden's index and area under curve (0. 96 and 0. 98 respectively) were obtained by the threshold based on the estimate of periodic autoregressive model.

Conclusions: As the optimal threshold presented in this study is simple in concept and has no limitation in practice, especially for monitoring new observations, we would recommend such a threshold to be used for monitoring of TB incidence data in the surveillance system.
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http://dx.doi.org/10.1111/tmi.12494DOI Listing
July 2015

Serum HDL-C level of Iranian adults: results from sixth national Surveillance of Risk Factors of Non-Communicable Disease.

J Diabetes Metab Disord 2014 16;13:67. Epub 2014 Jun 16.

Center for Disease Control, Ministry of Health and Medical Education, Tehran, Iran.

Background: Reduced level of high-density lipoprotein-cholesterol (HDL-C) is shown to be in association with the risk of coronary artery disease (CAD), metabolic syndrome, and chronic renal disease. Lack of a national representative research for assessing the level of HDL-C among Iranian adults, which is essential for health policy makers, was the motivation for this study.

Methods: HDL-C levels of 4,803 Iranian adults aged 25-64 years old were measured by sixth national Surveillance of Risk Factors of Non-Communicable Disease (SuRFNCD) in 2011. Data were entered into STATA 12 software and were analyzed using fractional polynomial model and other statistical methods.

Results: In average, Iranian adult women had 5.8 ± 0.3 mg/dL higher HDL-C level than men. The analysis showed that the HDL-C levels will be changed at most 3 mg/dL from the age of 25 to 64 years. Furthermore, it was shown that approximately half of the men and one third of the women had HDL-C level less than 40 mg/DL. Also HDL-C level of more than 60% of the women was less than 50 mg/dL.

Conclusions: High level of HDL-C among Iranian adults was shown in this study which can be a major reason of increasing incidence of heart diseases in Iran. Hence, formulating policy regulations and interventions in Iranian lifestyle to reduce HDL-C levels should be among top priorities for health politicians.
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http://dx.doi.org/10.1186/2251-6581-13-67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4099153PMC
July 2014

Trends in the prevalence of diabetes and impaired fasting glucose in association with obesity in Iran: 2005-2011.

Diabetes Res Clin Pract 2014 Feb 3;103(2):319-27. Epub 2014 Jan 3.

Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Aims: To estimate the prevalence and trends of diabetes mellitus (DM) and impaired fasting glucose (IFG), 2005-2011, and to determine the contribution of obesity to DM prevalence.

Patients And Methods: Data from Surveillance of Risk Factors of Non-communicable Diseases (SuRFNCD) conducted in 2005, 2007, and 2011 were gathered. DM was defined as presence of self-reported previous diagnosis or a fasting plasma glucose (FPG)≥7 mmol/L. IFG was diagnosed with FPG levels between 5.6 and 6.9 mmol/L. Prevalence rates for 2011 and trends for 2005-2011 were determined by extrapolating survey results to Iran's adult population. Population attributable fraction (PAF) of obesity was also calculated.

Results: In 2011, IFG and total DM prevalence rates were 14.60% (95%CI: 12.41-16.78) and 11.37% (95%CI: 9.86-12.89) among 25-70 years, respectively. DM was more common in older age (p < 0.0001), in women (p = 0.0216), and in urban-dwellers (p = 0.0001). In 2005-2011, trend analysis revealed a 35.1% increase in DM prevalence (OR: 1.04, 95%CI: 1.01-1.07, p = 0.011); albeit, IFG prevalence remained relatively unchanged (OR: 0.98, 95%CI: 0.95-1.00, p = 0.167). In this period, DM awareness improved; undiagnosed DM prevalence decreased from 45.7% to 24.7% (p < 0.001). PAF analysis demonstrated that 33.78%, 10.25%, and 30.56% of the prevalent DM can be attributed to overweight (BMI≥25kg/m(2)), general obesity (BMI≥30 kg/m(2)), and central obesity (waist circumference≥90 cm), respectively. Additionally, the DM increase rate in 2005-2011, was 20 times higher in morbidly obese compared with lean individuals.

Conclusion: More than four million Iranian adults have DM which has increased by 35% over the past seven years, owing in large part, to expanding obesity epidemic.
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http://dx.doi.org/10.1016/j.diabres.2013.12.034DOI Listing
February 2014

Gender-specific changes in physical activity pattern in Iran: national surveillance of risk factors of non-communicable diseases (2007-2011).

Int J Public Health 2014 Apr 18;59(2):231-41. Epub 2013 Dec 18.

Center for Disease Control, Tehran, Iran,

Objectives: This study describes the gender-specific pattern of physical activity (PA) in Iran 2011. The 4-year changes in PA levels (domains) are also determined according to the Iran's national surveys conducted on 2007 and 2011.

Methods: Physical activity assessed based on the global physical activity questionnaire. In all, 4,121 (2007), and 7,436 (2011) adults were analyzed.

Results: Based on 2011 survey, 56.4 %, 39.2 %, and 74.4 % of participants were physically inactive at work, commuting and recreation, respectively. In all domains of PA, males showed a higher degree of activity (min/day) than females (P value <0.001). The overall prevalence of physical inactivity was increased from 15 % (2007) to 21.5 % (2011) (P value <0.001). Over the 4 years, a significant decline in total physical activity (MET × min/week) and the duration of commuting activity were noted in both genders. Work-related activity was dramatically decreased in females. However, the time spent in recreational activity remained relatively constant.

Conclusions: This report indicating that the Iranian population, particularly females, have become less active during the survey period. Physical inactivity should receive more attention as a public health issue.
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http://dx.doi.org/10.1007/s00038-013-0529-3DOI Listing
April 2014

Trend of blood cholesterol level in Iran: results of four national surveys during 1991-2008.

Acta Med Iran 2013 ;51(9):642-51

Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran.

Trends in cholesterol level of different populations have been investigated in several studies. This study is conducted to determine the trend of cholesterol level of Iranian adults from 1990 to 2007. Data on cholesterol measurements of four national health surveys that have been carried out in Iran used in this study. Cholesterol level of 12728 adults aged 25-64 were measured in 1990-1 survey. Also in 1999, 2005, and 2007 surveys, blood cholesterol level of 18398, 52344 and 19630 have been sampled, respectively. The median of cholesterol were modeled with age for men and women separately for the four surveys using fractional polynomials. Then, trends in the median of cholesterol across these four surveys were studied. The analysis of cholesterol data over four national health surveys showed that the change in males' cholesterol level had a decreasing trend. This decreasing trend was more pronounced in ages younger than 45 years. However, the medians of cholesterol of females during 16 years of four national surveys had a varying trend. It was decreasing in ages younger than 45; but increasing in ages over 45 years. The median of the cholesterol level of males and females in 2005 survey was on average about 10 mg/dl higher in comparison with the other surveys. Our findings showed that the pattern of trend in cholesterol level of Iranian men and women adults have a considerable difference with those of the other developing and developed countries.
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July 2014

Comparing effects of ketamine and thiopental administration during electroconvulsive therapy in patients with major depressive disorder: a randomized, double-blind study.

J ECT 2014 Mar;30(1):15-21

From the *Department of Anesthesiology, Amir Alam Hospital, †Department of Clinical Pharmacy, Faculty of Pharmacy, ‡Research Center for Rational Use of Drugs, Department of Clinical Pharmacy, §Psychiatric and Psychology Research Centre, Roozbeh Hospital, ∥Department of Psychiatry, Roozbeh Hospital, and ¶Department of Statistics and Mathematics, Tehran University of Medical Sciences; #Department of Psychology, University of Applied Science and Technology; **Faculty of Pharmacy and Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.

Objectives: Recently, ketamine has attracted attention for induction of anesthesia during electroconvulsive therapy (ECT). This study compared the effects of thiopental and ketamine in patients undergoing this procedure.

Method: This randomized, double-blind clinical trial included inpatients, with major depressive disorder, undergoing ECT. Subjects were randomly allocated to receive either ketamine or thiopental. Mini-Mental State Examination and Hamilton Depression Rating Scale were used to assess memory and depression, respectively, before the first and second ECT sessions as well as a few days and 1 month after the sixth session. The electrical charge, seizure duration, blood pressure, and heart rate were also recorded.

Results: Of the 31 patients, 17 met the criteria for the ketamine group but 2 dropped out of the study. Therefore, 15 patients received ketamine and 14 received thiopental. Each patient underwent 6 ECT sessions. At the end of the study, depression improved significantly in both groups. However, a significant difference in depression improvement was noted only before the second ECT with ketamine compared with thiopental. Despite a significant decline in Mini-Mental State Examination scores in both groups after the first ECT, cognitive function improved afterward but was only significant in ketamine group. Seizure duration was found to be significantly longer with ketamine. Stimulus intensity used for each ECT increased gradually and linearly with a greater increase observed in thiopental group.

Conclusions: Ketamine administration during ECT is well tolerated and patients may experience earlier improvement in depressive symptoms, longer seizure duration, and better cognitive performance when compared with thiopental.
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http://dx.doi.org/10.1097/YCT.0b013e3182a4b4c6DOI Listing
March 2014

Serum cholesterol level nomograms for Iranian population; suggestion for national cut-offs.

Iran J Public Health 2013 1;42(2):164-71. Epub 2013 Feb 1.

Dept. of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.

Background: High cholesterol levels are associated with increased risk of coronary heart disease and stroke. Understanding the distribution of serum cholesterol levels in each country is valuable index for use in public health planning. This study aimed to construct nomograms of total cholesterol (TC) levels and establish the cut-points specific to Iranian population.

Methods: Data on serum TC levels of 19,630 non-institutionalized individuals aged 25-64 years from third national survey on non-communicable diseases (SuRFNCD) in 2007 were used to construct cholesterol nomograms. We proposed cutoff values for borderline and high TC levels based on rounded 75th and 90th percentiles in three age groups (25-34, 35-44 and 45-64) respectively.

Results: Average yearly increase of TC for males up to the age of 45 and females up to 64 were 1.15 and 1.03 mg/dl, respectively. TC levels were higher in females. In males, cutoff values for "borderline and high" TC levels were 195 and 220 mg/dl in 25-34, 210 and 240 mg/d in 35-44 and 215 and 245 mg/dl in 45-64 years old individuals. In women, these values were 200 and 225 mg/dl in 25-34,215 and 240 mg/dl in 35-44 and 235 and 265 mg/dl in 45-64 years old individuals respectively.

Conclusion: Since TC levels are different in two sexes and change with age, we proposed different cutoffs for sex and age group. We think these cutoffs could be used in national public health planning.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3595653PMC
March 2013
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