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Journal of Clinical and Experimental Hepatology logoLink to Journal of Clinical and Experimental Hepatology
. 2023 Jun 29;14(1):101209. doi: 10.1016/j.jceh.2023.06.009

Prevalence of Non-alcoholic Fatty Liver Disease in Iran: A Systematic Review and Meta-analysis

Seidamir P Tabaeian ∗,§§, Aziz Rezapour †, Samad Azari ‡, Mariano Martini §, Maryam Saran , Meysam Behzadifar , Saeed Shahabi #, Abdollah Sayyad †, Ali Tahernejad ∗∗, NL Bragazzi ††, SJ Ehsanzadeh ‡‡, Masoud Behzadifar ¶,∗
PMCID: PMC10709132  PMID: 38076354

Abstract

Background

Non-alcoholic fatty liver disease (NAFLD) has a benign course in several patients; however, a serious form of this disease can turn into liver failure, liver cirrhosis, and hepatocellular carcinoma.

Aim

This study aims to estimate the prevalence of NAFLD in Iran.

Method

We searched the following databases from January 2000 to December 2022: Scopus, Pubmed/Medline, Embase, Web of Sciences, the Cochrane Library, and Google Scholar also a number of Iranian databases, namely MagIran, SID, and Elmnet. Additionally, the quality of the included studies was evaluated through the Newcastle-Ottawa Scale. We estimated heterogeneity between studies using the I2 statistic. Furthermore, we performed a synthesis of prevalence estimates through the random-effects DerSimonian and Laird model across the included studies with a 95% confidence interval. To assess the publication bias, we also used Egger's test.

Results

Thirty-one studies were eligible for inclusion. The overall number of participants in the present study was 41,971. The overall prevalence of NAFLD in Iran was 33% [CI: 27–37%], with I2 = 99.7% (P < 0.01). The prevalence was 35% [CI: 27–43%] and 37% [CI: 27–47%] in males and females, respectively. We used Egger's test, and no significant publication bias was identified in the overall prevalence (P = 0.45).

Conclusion

According to the results of this study, the prevalence of NAFLD in Iran is not only high but alsoa growing trend. Effective strategies for changing lifestyles, changing eating habits, and encouraging physical activities among Iranians are recommended. Also, providing screening tests, especially among high-risk groups, has a significant effect on early diagnosis and NAFLD control.

Keywords: non-alcoholic fatty liver disease, Iran, prevalence, met-analysis, systematic review

Non-alcoholic fatty liver disease (NAFLD) is a significant challenge for health systems worldwide and accounts for an important part of liver problems.1 NAFLD has a benign course in several patients; however, a serious form of this disease can turn into liver failure, liver cirrhosis, and hepatocellular carcinoma (HCC).2 Also, NAFLD is linked with extrahepatic conditions, namely type 2 diabetes mellitus, metabolic syndrome, dyslipidemia, chronic kidney diseases, cardiovascular diseases, and obesity.3,4 Recent data has revealed that NAFLD has been increasing worldwide over the past few years, which has subsequently led to increased economic costs for health systems.5 In this regard, research has demonstrated that poor lifestyle, inactivity, high carbohydrate and high fat intake, and poor diet are positively related to the prevalence of NAFLD.6

Despite the high rate of NAFLD worldwide, its prevalence seems to be heterogeneous from one country to another.7 The rate of NAFLD soared from about 391 million cases in 1990 to about 882 million cases in 2017, and its prevalence increased from 8.2 to 10.9, with North Africa and the Middle East having the highest prevalence.8 In the same vein, NAFLD has been a health challenge in Iran; in this regard, various studies have investigated the causes and prevalence of NAFLD in Iran. Having updated knowledge regarding the trend and epidemiological information of the disease might help Iranian health policy-makers and stakeholders understand the disease burden better and predict its process; this way, they would implement programs and policies needed to prevent and control NAFLD. Given the numerous challenges imposed by NAFLD on the Iranian health system, we conducted the present study to examine the prevalence of NAFLD in Iran. The purpose of this study is to investigate the prevalence based on the published studies conducted on the prevalence of NAFLD in Iran.

Main text

Methods

In the present systematic review, we followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement (Appendix).9 Also, we registered the protocol of this review in PROSPERO (CRD42022363598)10; the protocol was also approved by the Review Ethics Board of Iran University of Medical Sciences (IR.IUMS.REC.1401.383).

Search Strategy

Two authors of the present paper independently searched the following databases: Scopus, Pubmed/Medline, Embase, Web of Sciences, the Cochrane Library, and Google Scholar, as well as Iranian databases MagIran, SID, and Elmnet, from January 2000 to December 2022. Also, we used Boolean operators with the following related keywords: (Prevalence OR Epidemiology OR Frequency OR Incidence) AND (Non-alcoholic fatty liver OR Non-alcoholic fatty liver disease OR non-alcoholic fatty OR nonalcoholic fatty liver OR nonalcoholic fatty liver disease OR nonalcoholic steatohepatitis OR non-alcoholic steatohepatitis OR MAFLD OR NAFLD OR non-alcoholic) AND (Iran). In addition, two researchers (MaB and SS) from the present study independently reviewed the reference lists of articles to find more related studies. We resolved any discrepancy between the two researchers by consulting a third researcher (SPT) on our team.

Inclusion Criteria

The inclusion criteria in the present study are as follows:

  • 1.

    Observational studies that reported the prevalence of NAFLD in different populations.

  • 2.

    Studies published in Farsi and English.

  • 3.

    Studies that investigated patients who resided in Iran.

  • 4.

    Studies with sufficient data to calculate prevalence.

  • 5.

    Studies published in peer-reviewed journals.

  • 6.

    Studies that focused on patients who were diagnosed with serum-based indicators, imaging, liver biopsy, and ultrasound.

  • 7.

    Studies that had no gender or age restrictions.

Exclusion Criteria

Also, we followed the exclusion criteria below.

  • 1.

    Studies whose designs were controlled trials, case series, and case reports, as well as books, posters, oral presentations, letters to the editor, and opinion articles.

  • 2.

    Studies with alcoholic patients.

  • 3.

    Studies with patients who resided outside of Iran.

  • 4.

    Studies that had insufficient data.

  • 5.

    Studies whose data were replicated.

  • 6.

    Studies whose full texts were not available.

Data Extraction

We developed a data extraction form including the following information: the first author's name, publication year, mean or range age of participants, place where the study was conducted, study design, test used for diagnosing NAFLD, number of patients, reported prevalence, and the number of NAFLD patients according to their gender. In the next step, two researchers (SA and NLB) from the present study independently extracted the data from the selected studies and entered it into the data extraction form. We resolved discrepancies between the two reviewers by consensus or by consulting a third researcher (MM) from this study.

Quality Assessment of the Included Studies

The quality of included studies was evaluated through the Newcastle-Ottawa Scale (NOS),11 which has three domains: selection, comparability, and outcome. Based on the NOS scores, we classified the selected studies into three groups as follows: scores ranging from 7 to 9 were considered low risk of bias (high quality), scores of 4–6 were moderate risk of bias (fair quality), and scores of 1–3 were considered high risk of bias (low quality). Two authors (MeB and AR) of this study independently reviewed each study to assess the risk of bias. Any disputes among the reviewers are resolved by consensus or via consulting with a third author (SJE).

Statistical Analysis

We analyzed the data using Stata Software (version 12), with the statistical significance set at P < 0.05. Also, we estimated heterogeneity between studies using the I2 statistic. Meanwhile, we performed a synthesis of prevalence estimates using the random-effects DerSimonian and Laird model across the included studies with a 95% confidence interval (95% CI). Furthermore, we used Egger's test to assess for publication bias. We also performed a sensitivity analysis to ensure the stability of the results. In order to evaluate the causes of the heterogeneity of the included studies, we included the participants' gender, type of participants, sample size, year of publication, diagnostic test, setting, obese and non-obese populations, risk of bias, and geographic region of the subgroup. Also, we performed the meta-regression test according to the year of publication, sample size, and mean age.

Results

Study Selection

A total of 829 records were identified in the comprehensive search. After the exclusion of duplicates and non-relevant records, thirty-one studies were included in the review.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 Figure 1 gives more details regarding the selection process for the included studies.

Figure 1.

Figure 1

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PRISMA flow diagram.

Characteristics of the Included Studies

The overall number of participants in the included studies was 41,971, with a sample size ranging from 34 to 7723 participants. Also, all the studies had a cross-sectional design. In addition, an ultrasound test was used to diagnose the NAFLD patients. Table 1 presents the characteristics of the included studies.

Table 1.

The Main Characteristics of the Included Studies.

First author Year City Mean or range age Sample size Diagnostic test Prevalence (%) Conditions of participants Setting
Savadkoohi F 2003 Zahedan 43.6 ± 8.9 247 Ultrasound 32.8 Population based OPD visitors
Hosseinpanah F 2007 Tehran 60 ± 9 76 Ultrasound 82.9 Type 2 diabetes Hospital based
Alavian SM 2008 Tehran 41.61 ± 12.04 1120 Fatty liver index or hepatic steatosis index 9.5 School-aged children and adolescents Public health centers
Jamali R 2008 Golestan 40.59 ± 14.69 2049 Ultrasound 2.04 Population based OPD visitors
Merat S 2009 Tehran 56.56 ± 10.5 172 Ultrasound 55.8 Type 2 diabetes Hospital based
Adibi A 2009 Isfahan 12.59 ± 3.25 949 Ultrasound 16.9 Overweight and obese children Hospital based
Alavian SM 2009 Tehran 15 ± 2.3 966 Ultrasound 7.1 Hepatitis B patients Blood transfusion Center
Rafeey M 2009 Tabriz 6.53 ± 3.07 1500 Ultrasound 2.3 Children OPD visitors
Tazhibi M 2010 Isfahan 6–18 1107 Ultrasound 16.9 Children and adolescence Public health centers
Sohrabpour AA 2010 Tehran-Hormozgan-Golestan 36.1 ± 13.1 5589 Fatty liver index or hepatic steatosis index 2.9 Population based OPD visitors
Shahbazian HB 2011 Ahvvaz 51 ± 10 272 Ultrasound 70 Type 2 diabetes Hospital based
Hosseini SM 2011 Isfahan 12.57 ± 3.3 962 Ultrasound 16.8 Children and adolescence OPD visitors
Razavizade M 2012 Kashan 41.63 ± 11.46 245 Ultrasound 78.4 Population based OPD visitors
Lahsaee S 2012 Kerman 31.76 ± 11.31 1993 Fatty liver index or hepatic steatosis index 16 Population based Blood transfusion Center
Shiasi Arani K 2013 Kashan 9.55 ± 2.3 306 Ultrasound 55.3 Children and adolescence Public health centers
Bagheri Lankarani K 2013 Shiraz 43.1 ± 14.1 819 Ultrasound 21.5 Population based Hospital based
Eshraghian A 2013 Shiraz 48.20 ± 12.32 832 Ultrasound 15.3 Population based Public health centers
Montazerifar F 2014 Zahedan 16 ± 2 34 Ultrasound 44.11 Obese adolescant Public health centers
Saki F 2014 Shiraz 10.57 ± 3.04 102 Ultrasound 54.9 Obese Children OPD visitors
Jafarian A 2014 Tehran 33 116 Fatty liver index or hepatic steatosis index 12 Cadaveric Organ Donor Population Hospital based
Amirkalali B 2014 Amol 45.35 ± 15.87 5023 Ultrasound 43.8 Population based Public health centers
Karimi-Sari H 2015 Tehran 33.96 ± 9.92 114 Fatty liver index or hepatic steatosis index 16.7 Sleeve Bariatric Surgery Hospital based
Taghavi Ardakani A 2015 Kashan 9.07 ± 1.88 200 Ultrasound 59 Obese Children OPD visitors
Ostovaneh MR 2015 Amol-Zahedan 37.27 ± 0.40 7723 Ultrasound 35.2 Population based Public health centers
Adibi A 2017 Isfahan 45.53 ± 8.92 483 Ultrasound 39.3 Population based Public health centers
Rabiee B 2017 Amol 48.15 ± 13.41 5052 Ultrasound 21.4 Population based Public health centers
Heidari Z 2017 Zahedan 50.79 ± 10.49 255 Ultrasound 86.6 Type 2 diabetes Public health centers
Namakin K 2018 Birjand 12 to 18 200 Ultrasound 54 Overweight and obese children OPD visitors
Hosseini Ahangar B 2019 Tehran 43.28 ± 14.03 999 Ultrasound 19.6 Population based Hospital based
Etminani R 2020 Isfahan 45.5 ± 8.6 413 Ultrasound 39.3 Middle-Aged Public health centers
Amirkalali B 2021 Amol 16 to 65 2308 Ultrasound 46·7 Lean and non-lean populations Hospital based
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OPD, outpatient department.

Overall Prevalence of NAFLD

According to the random model, the overall prevalence of NAFLD in Iran was 33% [CI: 27–39%], with I2 = 99.7% (P < 0.01). The prevalence was 35% [CI: 27–43%] and 37% [CI: 27–47%] in males and females, respectively. Figure 2 shows the overall prevalence of NAFLD in Iran.

Figure 2.

Figure 2

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NAFLD prevalence in Iran.

Risk of Bias

Table 2 shows the NOS quality assessment scores of the included studies, with a mean score of 6.65. According to the results, 20 studies were considered high quality (low risk) and 11 were moderate (fair risk). The prevalence was 32% [CI: 24–40%] and 34% [CI: 24–44%] in high-quality (low risk) and moderate (fair risk) studies, respectively.

Table 2.

Newcastle–Ottawa Quality Assessment.

First author Year Representativeness (0,1,2) Sample size (0,1) Diagnostic tool (0,1,2) Comparability of study population (0,2) Outcome assessment (0,1) Statistical test (0,1) Total score (0–9)
Savadkoohi 2003 1 1 0 0 1 1 5
Hosseinpanah 2007 0 1 2 2 1 1 8
Alavian 2008 0 1 2 1 1 1 6
Jamali 2008 1 1 2 0 1 1 6
Merat 2009 1 1 2 2 1 1 8
Adibi 2009 1 1 2 2 1 1 8
Alavian 2009 1 1 2 2 1 1 8
Rafeey 2009 2 1 2 2 1 1 9
Tazhibi 2010 2 1 1 0 1 1 6
Sohrabpour 2010 2 1 2 0 1 1 7
Shahbazian 2011 1 1 2 0 1 1 6
Hosseini 2011 1 1 2 2 1 1 8
Razavizade 2012 1 1 2 2 1 1 9
Lahsaee 2012 1 1 2 0 1 1 6
Shiasi Arani 2013 2 1 2 2 1 1 9
Bagheri Lankarani 2013 1 1 1 1 1 1 6
Eshraghian 2013 1 1 2 2 1 1 8
Montazerifar 2014 1 1 2 0 1 1 6
Saki 2014 1 1 2 2 1 1 8
Jafarian 2014 1 1 2 2 1 1 8
Amirkalali 2014 2 1 1 0 1 1 6
Karimi-Sari 2015 2 1 2 2 1 1 9
Taghavi Ardakani 2015 2 1 2 2 1 1 9
Ostovaneh 2015 1 1 2 2 1 1 8
Adibi 2017 1 1 2 2 1 1 8
Rabiee 2017 1 1 2 2 1 1 8
Heidari 2017 1 1 2 0 1 1 6
Namakin 2018 2 1 2 2 1 1 9
Hosseini Ahangar 2019 2 1 2 2 1 1 9
Etminani 2020 2 1 2 2 1 1 9
Amirkalali 2021 2 1 2 2 1 1 9
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Also, Figure 3 shows the results of the sensitivity analysis, confirming that the findings were stable. In addition, we conducted a subgroup analysis. Table 3 shows the prevalence by obesity status, publication year, geographic region, setting, type of participants, diagnostic test, sex, and sample size in the included studies.

Figure 3.

Figure 3

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Sensitivity analysis.

Table 3.

Results of Subgroup Analysis.

Variables Prevalence (CI 95%) I2 (%) Number of studies
Obesity status (Total)
Overweight and obese 33 (15–51) 99.9 7
Non-obese 32 (27–38) 99.6 24
Year of publication
2000–2005 33 (27–39) 0 1
2006–2010 18 (14–22) 99.1 9
2011–2015 35 (27–43) 99.3 14
2016–2022 43 (28–58) 99.5 7
Regional
West 2 (2–3) 0 13
East 52 (30–73) 99.2 5
North 26 (17–34) 99.8 12
South 34 (27–42) 98.7 1
Participants
Children 28 (19–36) 99.6 22
Adults 35 (27–43) 99.7 9
Diagnostic test
Ultrasound 32 (25–38) 99.7 26
Others 39 (18–61) 99.6 5
Sex
Male 35 (27–43) 99.4 19
Female 37 (27–47) 99.6 19
Sample size
Sample size ≤1000 39 (30–48) 99.2 21
Sample size >1000 20 (11–30) 99.9 10
Health status
Without disease 28 (22–34) 99.7 27
Type 2 diabetes mellitus 65 (37–92) 98.8 4
Obesity status (Children)
Non obese 11 (3–18) 98.9 4
Overweight and obese 48 (26–69) 98.8 5
Obesity status (Adults)
Non obese 25 (10 61) 99.8 2
Overweight and obese 34 (26–43) 94 20
Level of quality of studies
Low risk of bias (high quality) 32 (24–40) 99.5 20
Moderate risk of bias (fair quality) 3424, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44 96.9 11
Setting
OPD visitors 57 (42–73) 99.7 9
Hospital based 61 (58–84) 99.8 9
Public health center 71 (60–82) 99.7 11
Blood transfusion Center 53 (44–97) 90 2
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OPD, outpatient department

The prevalence of NAFLD was found in both obese or overweight patients (33%), and non-obese individuals (32%). However, the prevalence varied based on the year of publication, with studies published between 2000 and 2005 reporting a prevalence of 33%, studies published between 2011 and 2015 reporting a prevalence of 18%, and studies published between 2016 and 2020 reporting a higher prevalence of 43%. When considering geographical regions, we observed that the prevalence of NAFLD in the west, east, north, and south of Iran was 2%, 52%, 26%, and 34%, respectively. Additionally, we found that the prevalence of NAFLD was higher in studies with smaller sample sizes (39% in studies with a sample size of ≤1000) compared to those with larger sample sizes (20% in studies with a sample size >1000). Furthermore, the prevalence of NAFLD varied based on the data collection method. Studies based on outpatient department (OPD) visitors reported a prevalence of 57%, while studies based on hospital-based data reported a prevalence of 61%. Studies based on public health centers reported the highest prevalence of NAFLD at 71%.

According to the publication year (P = 0.19) and age of participants (P = 0.25), meta-regression increased; however, it decreased based on the sample size (P = 0.21). But none of them was statistically significant. Also, the results of Egger's test show no significant publication bias in the overall prevalence (P = 0.45) (Figure 4).

Figure 4.

Figure 4

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Publication bias.

In some of the included studies, participants had comorbidities such as type 2 diabetes, hepatitis B, and other diseases. Additionally, some studies included children as participants, which limits the generalizability of the results to the overall population. To address this issue, we performed an analysis using population-based samples only. The overall prevalence was 43% [CI: 31–55%].

Discussion

We investigated the prevalence of NAFLD in Iran in the present study. Results revealed that the overall prevalence of this disease was 33%, with prevalences of 34% and 31% in adults and children, respectively. In this regard, the prevalence of NAFLD in Iran is lower than in Chile (39.4%),43 India (38.6%),44 South Korea (51.4%),45 and Turkey (48.3%).46 However, Younossi et al.47 reported a lower prevalence of NAFLD (25.24%). Also, compared to other studies conducted in Israel (30%)48 and Italy (20%),49 the prevalence of NAFLD in Iran was higher. We think that this difference in prevalence across countries might be because of lifestyle, demographic characteristics, and health services related to treatment, as well as the studied populations and methods for diagnosing fatty liver.50

Results also showed that ultrasound was used in 84% of studies for diagnosing NAFLD. Also, the prevalence of NAFLD based on the ultrasound test was 32%, and other methods were 39%. In addition, the ultrasound method has been reported to be non-invasive, accurate, detailed, painless, accessible, and safe for all patients.51 In Iran, the ultrasound diagnostic method is also commonly used because of its high sensitivity and specificity, easy access, and appropriate insurance coverage.52

In recent years, the lifestyle in Iran has changed, and people have become less active. Also, the consumption of carbonated drinks and sweets, the use of fatty foods, and fast foods have become common in Iran, leading to a dramatic increase in obesity that might justify the increasing trend of NAFLD in Iran in recent years.53 In this regard, about 29 million Iranians are suffering from obesity and overweight, and 85% of the population was sedentary at the time of writing this manuscript.54

Our findings showed that the prevalence of NAFLD was higher in obese and overweight people, which was consistent with the findings of other studies.46, 47, 48, 54 Also, various studies have shown that there is a positive correlation between obesity and NAFLD;55,56 therefore, controlling obesity through public education and lifestyle modification could be a sound measure.57

The findings of our study revealed that the highest prevalence of NAFLD was observed on the western side of the country, with a rate of 52%. The western provinces of Iran are the most important sources of livestock breeding and red meat production, and their consumption is also very high in these provinces. In this regard, Hashemian et al. argued that the prevalence of NAFLD is positively related to the amount of red meat consumption.58 Alongside, this several studies reported that red meat consumption is associated with an increased risk of NAFLD.59,60 Red meat can accelerate obesity, and as a result, people will be prone to various diseases, including NAFLD.61 Therefore, a change in eating habits and reducing the amount of red meat consumption might be effective in decreasing the prevalence of NAFLD.62,63

In the present study, the prevalence of NAFLD was higher in women than men which is consistent with the findings of Summart et al.64 The high prevalence of NAFLD in women can be attributed to fat distribution, their physiology, and sex hormones.65 In this regard, nutritionists argue that the hormonal changes in women after menopause and lack of estrogen and progesterone hormones increase the appetite in women that might lead to obesity.66,67 In the same vein, most Iranian women's obesity is due to eating habits as well as being inactive.68 Also, obesity after pregnancy is pervasive in Iran.42

Although NAFLD affects people of any age, even in children,69 the findings of the present study show that the prevalence of NAFLD in adults was higher than that in children, which is in alignment with the findings of precursory studies.70, 71, 72 In this regard, it has been argued that lack of proper physical activity, accumulation of fat in the body, smoking, and various diseases can increase the potential risk of NAFLD in adults, especially in the adults.73

Also, the findings of our study show that the prevalence of NAFLD in type 2 diabetic patients is 2.3 times higher compared to healthy people, which is consistent with the results of studies conducted in other countries.46,64 Due to the fact that the management of type 2 diabetes is very difficult when it coincides with NAFLD, we thus recommend screening type 2 diabetic patients for NAFLD thoroughly.74 It is noteworthy to mention that the prevalence of type 2 diabetes in Iran in people over 40 years old is about 24%, which might be a further cause of the prevalence of NAFLD.75

To reduce the prevalence of NAFLD in Iran, the following policies and programs have been implemented: raising taxes on fast foods, sugary foods, and soft drinks; food labeling; financial supports for factories that produce healthy food; and the establishment of a public sports federation to encourage people to be more physically active.76

Limitations and further research

The present study has two limitations. First, the included studies did not have a homogeneous population under investigation. Second, the diversity of diagnostic tests used, different age groups, and risk factors examined can also be the cause of the heterogeneity in the present study. As Iran has a variety of geographical regions and social classes and, in some provinces, no valid study on the prevalence of NAFLD has yet been conducted, we believe that more research is needed in this area.

The results of the present study demonstrated that the prevalence of NAFLD in Iran is not only high but also growing. Also, the cost of NAFLD epidemics might be very damaging to the health system; thus, we argue that a comprehensive NAFLD management program is required. In this regard, effective strategies for changing lifestyles, changing eating habits, and encouraging physical activities among Iranians are recommended. Also, providing screening tests, especially among high-risk groups, can play an important role in early diagnosis and NAFLD control.

Credit authorship contribution statement

SPT, MaB, MeB, MS, and SA: Conceptualiz and design. MaB, and SA: Data curation. MaB, SA and NLB: Formal analysis. AR, MM, SS, AS, AT and MaB: Investigation. SPT, NLB and MaB: Methodology. SPT, MaB: Project administration. MeB, AR, SA, MM, SS, AS, AT and MaB: Resources. MaB, and NLB: Software. SPT and MaB: Supervision. MeB, AR, SA, MM, SS, AS, AT and MaB: Validation. MeB and SPT: Visualization. MeB and SPT: Roles/Writing - original draft. MaB, AR, SJE and NLB: Writing - review & editing. None: Funding acquisition.

Conflicts of interest

The authors have none to declare.

Acknowledgments

Not applicable.

Funding

Not applicable.

Ethics approval and consent to participate

The protocol was also approved by the Review Ethics Board of the Iran University of Medical Sciences (IR.IUMS.REC.1401.383).

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Footnotes

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jceh.2023.06.009.

Supplementary data

The following is the Supplementary data to this article.

Multimedia component 1
mmc1.docx (25.8KB, docx)

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