Abstract
Objectives
People with hypertension are more susceptible to developing cardiometabolic risk factors including overweight, obesity, diabetes mellitus, dyslipidemia, and metabolic syndrome (MetS). We aim to determine the trends in the prevalence of these risk factors among Iranian adults with hypertension from 2007 to 2021.
Methods
We utilized data for adults from 25 to 64 years old from four rounds of the STEPwise approach to non-communicable diseases risk factor surveillance (STEPS) study conducted in Iran in 2007, 2011, 2016, and 2021. Direct standardization by age, sex, and residency area was conducted using the 2016 Iranian census population. Weighted least squares linear regression was performed to assess the statistical changes in the trends.
Results
Overall, 21,088 participants were included in this study. From 2007 to 2021, the standardized prevalence of hypertension among adults did not change significantly (from 24.5 to 22.8%). Dyslipidemia was the most prevalent comorbidity among adults with hypertension (from 83.7 to 85.5%). The standardized prevalence of overweight (39.3–40.4%) did not change significantly among adults with hypertension, while the standardized prevalence of obesity (34.3–38.4%), diabetes (10.3–13.5%), and MetS (64.4–78.3%) increased significantly, with MetS showing the highest annually change (0.9%). Considering changes in specific subgroups, significant increases in obesity were observed in males, the 45–54 age group, and rural subgroups. For MetS and diabetes, all subgroups showed a significant increase, except for diabetes in age groups, where significant increases were limited to the 55–64 age group.
Conclusions
There has been a significant increase in the prevalence of obesity, diabetes, and MetS among adults with hypertension in Iran. The observed disparities in these trends across different subgroups highlight the need for health policymakers to implement targeted strategies that account for age, sex, and area differences to effectively prevent and control these risk factors.
Supplementary Information
The online version contains supplementary material available at 10.1007/s40200-024-01498-0.
Keywords: Hypertension, Obesity, Diabetes mellitus, Dyslipidemia, Metabolic syndrome, Prevalence
Introduction
Over 8.5 million deaths globally are attributed to complications of hypertension (HTN), including stroke, ischemic heart disease, and end-stage renal disease [1]. In 2019, it was estimated that more than 1 billion people in the world suffered from HTN [2]. People with HTN are more susceptible to cardiovascular disorders because of their higher vulnerability to cardiometabolic risk factors. Overweight, obesity, type 2 diabetes mellitus (T2DM), dyslipidemia, and metabolic syndrome (MetS) are examples of cardiometabolic disorders that are more prevalent in hypertensive individuals. Several genetic, metabolic, behavioral, and socioeconomic factors have been identified as contributing to this causality. It has been demonstrated that several genes, such as FTO and GNDPA2, play a role in promoting obesity and T2DM by downregulating fat oxidation [3]. A low-grade inflammation secondary to HTN also upregulates these genes [3]. This inflammatory state leads to an increase in the production of reactive oxygen species besides the overactivity of the renin-angiotensin-aldosterone system [4]. Insulin resistance is another metabolic condition that contributes to the completion of this cascade [3]. Overeating and a decrease in physical activity are examples of behavioral changes contracting with the above-mentioned genetic-metabolic cascade [5]. Furthermore, the cultural factors, social class, level of income, and urbanization are environmental factors that associate these pathways together and make hypertensive people prone to suffering from these disorders [6, 7].
In Iran, a country in the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO), the prevalence of HTN increased from 1.8 million people in 1990 to 13.6 million in 2016 [8]. Beside the increase in the prevalence of HTN in Iranian adults, other non-communicable diseases (NCDs) prevalence has been increased simultaneously. The prevalence of MetS was estimated at 47.6% in 2016, which was higher than other EMRO countries [9]. Also, a crescendo trend has been detected from 2007 to 2021 in the prevalence of diabetes mellitus in Iranian adults, with a prevalence of 14.15% in 2021 [10]. This ongoing trend is also actual in the prevalence of obesity in Iranian adults since 2004 [11]. In addition, it is also documented that HTN and obesity are the two main components of the development of MetS in Iran as compared with other elements [12].
The integrated relationship between HTN and the promotion of cardiometabolic risk factors, coupled with the lack of reliable evidence on the changes in the prevalence of these disorders in this high-risk group in Iran and other EMRO countries, has prompted the conduct of the present research. The study aims to assess the time trend and prevalence of overweight, obesity, diabetes, dyslipidemia, and MetS in Iranian adults with HTN from 2007 to 2021.
Methods
Study design
In this retrospective study, data from four rounds of the WHO’s STEP-wise approach to NCD risk factor surveillance (STEPS) conducted in Iran in 2007, 2011, 2016, and 2021 were utilized [13–16]. These studies employed a cluster random sampling method to ensure national and subnational representativeness of the samples. The STEPS studies were performed in three steps: questionnaire-based data collection (step 1), anthropometry measurements (step 2), and laboratory measurements (step 3). Participants aged ≥ 18 were included in the STEPS studies, but laboratory measurements were performed only for those aged ≥ 25 years old. Thus, people under 25 were excluded from this study due to a lack of laboratory measurements necessary for defining some variables. To accurately estimate the prevalence trends over these 15 years, a comparison with matched age group structures seems essential. Therefore, the age group of ≥ 65 years old from the STEPS of 2016 and 2021 was not considered for analysis in the present study. All participants with hypertension were included in the analysis.
Data collection
As mentioned, the STEPS studies consisted of three steps. In the first step, participants’ socio-demographic characteristics, and history of known risk factors for NCDs were collected using questionnaires. For this study, we used data regarding age, sex, area of residency, province, and questions about currently taking any antidiabetic and antihypertensive medication prescribed by a doctor.
In the second step, anthropometry measurements were conducted using standardized and calibrated instruments. Blood pressure was measured in a sitting position, preferably from the right arm, after at least 5 min of rest. Three measurements were taken with approximately 5-minute intervals between them. The mean of the second and third blood pressure measurements was used as the blood pressure of participants. Height and waist circumference were assessed with a standard ruler, and weight was recorded in an upright position using a calibrated scale, with participants dressed in light clothing and barefoot.
In the third step, venous blood samples were collected following overnight fasting. Fasting blood sugar (FBS), total cholesterol, serum triglyceride, and high-density lipoprotein cholesterol (HDL-C) levels were measured.
Definition of variables
Participants were categorized in groups by sex (male and female), age (25–34, 35–44, 45–54, 55–64), area of residency (rural and urban), and province. We used the most recent administrative division of Iran, which has comprised 31 provinces since 2010, as our reference point to align the provinces in the STEPS 2007 study with those in subsequent studies. HTN was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg and/or taking hypertension medication [17]. The definition of being overweight and obese was considered as 25 ≤ body mass index (BMI) < 30 kg/m2 and BMI ≥ 30 kg/m2, respectively [18]. Diabetes was considered fasting blood sugar (FBS) ≥ 126 mg/dL and/or the current use of anti-diabetic agents [10]. dyslipidemia was considered as [19] serum triglyceride ≥ 150 mg/dL and/or total cholesterol ≥ 200 mg/dL and/or LDL-C ≥ 130 mg/dL (calculated by Friedwald formula) and/or non–HDL-C ≥ 160 mg/dL (subtraction of HDL-C from total cholesterol) and/or HDL-C < 40 mg/dL in men and < 50 mg/dL in women. With consideration that all of the included participants had hypertension, MetS was defined as the existence of at least two following criteria [12]: FBS ≥ 100 mg/dL or receiving anti-diabetic agents; waist circumference ≥ 90 cm for both sexes; TG ≥ 150 mg/dL; and HDL-C ≤ 40 mg/dL for men, and HDL-C ≤ 50 mg/dL for women.
Statistical analysis
After cleaning and defining the variables, the weighting of the 2007 and 2011 studies was done by post-stratification using the 2016 National Population and Housing Census conducted by Iran’s Statistical Center, while in the 2016 and 2021 studies, the non-responsiveness of participants was also considered [15, 16]. Then, the crude prevalence of variables was presented with percentages and a 95% confidence interval (95% CI). To make the comparison among years possible, direct standardization by age, sex, and residency area was conducted using the 2016 National Population and Housing Census [16], and 95% CIs were calculated using the BinomCI function in R with the Wald method. The trend of variables over time was assessed via weighted least squares linear regression, considering year, age group, sex, and area as the independent variables and the sex-age-area stratified prevalences as the outcome. We used weighted least squares linear regression to incorporate the different standard errors of each prevalence estimate in the model, aiming to achieve more robust conclusions about the significance of the changes. The coefficient of the year in each model was reported and considered as the annual change of the prevalences. A significance level of p < 0.05 was used. All data were analyzed through the R statistical package version 4.1.2 (https://cran.r-project.org/).
Ethics
The current study met all ethical criteria of the Helsinki 1966 Declaration. The proposal of the current study was approved by the Research Ethics Committee of Endocrinology and Metabolism Research Institute (EMRI), Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.EMRI.REC.1402.058). In addition, all participants volunteered to participate in the studies after fulfilling the written informed contest.
Results
Demographics and the prevalence of the HTN
From the 76,595 adult participants (aged 25–64) in the four STEPS surveys, a total of 21,088 individuals had HTN and were included in this study (Table 1). Among the included samples in all four STEPS studies, the main groups were females, the 55–64 age group, and urban residents, comprising approximately 54%, 42%, and 68% of the total sample, respectively.
Table 1.
The demographic data of included sample from different STEPS studies. The data are the number of persons (percent)
| STEPS year | 2007 | 2011 | 2016 | 2021 | Total | |
|---|---|---|---|---|---|---|
| Sex | Female | 3926 (53.61%) | 1399 (61.96%) | 2926 (54.92%) | 3580 (57.95%) | 11,831 (54.1%) |
| Male | 3398 (46.39%) | 859 (38.04%) | 2402 (45.08%) | 2598 (42.05%) | 9257 (43.9%) | |
| Age group | 25–34 | 643 (8.78%) | 234 (10.36%) | 511 (9.59%) | 458 (7.41%) | 1846 (8.8%) |
| 35–44 | 1250 (17.07%) | 317 (14.04%) | 1002 (18.81%) | 1159 (18.76%) | 3728 (17.7%) | |
| 45–54 | 2294 (31.32%) | 580 (25.69%) | 1746 (32.77%) | 2030 (32.86%) | 6650 (31.5%) | |
| 55–64 | 3137 (42.83%) | 1127 (49.91%) | 2069 (38.83%) | 2531 (40.97%) | 8864 (42.0%) | |
| Area | Urban | 4499 (61.43%) | 1652 (73.16%) | 3711 (69.65%) | 4510 (73.00%) | 14,372 (68.2%) |
| Rural | 2825 (38.57%) | 606 (26.83%) | 1617 (30.35%) | 1668 (27.00%) | 6716 (31.8%) | |
| Total | 7324 | 2258 | 5328 | 6178 | 21,088 | |
The crude prevalence of hypertension among adults in 2007, 2011, 2016, and 2021 were 23.17% (95% CI: 22.31–24.03), 23.10% (21.97–24.24), 22.89% (22.32–23.46), and 28.49% (27.82–29.17), respectively. Considering standardized prevalences of hypertension among adults in 2007, 2011, 2016, and 2021 were 24.49% (24.47–24.50), 23.95% (23.94–23.97), 19.89% (19.88–19.90), and 22.76% (22.75–22.77), respectively, without any significant change (p-value = 0.051). Regarding subgroups, only females showed a significant decrease over the study period, with standardized prevalence decreasing from 25.35% (25.33–25.37) to 22.82% (22.80-22.83), reflecting a yearly decrease of -0.19% (p-value = 0.002).
The ranking of different cardiometabolic risk factors did not change among adults with hypertension over the study period, with dyslipidemia being the most prevalent and diabetes the least prevalent (Fig. 1A). The changes in the standardized prevalence of hypertension among adults in different provinces showed varying patterns (Fig. 1B).
Fig. 1.
Changes in the trend of metabolic conditions including: overweight, obesity, diabetes, dyslipidemia and metabolic syndrom in adults with hypertension from 2007 to 2021 (A); the map demonstrates the changes in the prevalence of HTN from 2007 (left) to 2021 (right) in subnational level (B)
Prevalence of overweight and obesity in people with HTN from 2007 to 2021
The standardized prevalence of overweight among adults with hypertension varied from 39.31% (95% CI: 39.3-39.33) in 2007 to 40.43% (40.41–40.44) in 2021, without any significant change (p-value = 0.12). The changes in subgroups were all insignificant. The standardized prevalence of overweight was higher in males (from 44.71% [95% CI: 44.69–44.73] in 2007 to 43.18% [43.16–43.2] in 2021) compared to females (from 33.81% [33.79–33.83] in 2007 to 37.62% [37.6-37.64] in 2021) consistently over the study period. Among all age groups, the standardized prevalence was about 40% over the study period (Table 2). The pattern of overweight among adults with hypertension changed among provinces: while central provinces had a higher prevalence of overweight in 2007, northwestern and western provinces were more affected by overweight in 2021 (Fig. 2A).
Table 2.
The trend of prevalence of overweight in adults with hypertension from 2007 to 2021. Data demonstrate the prevalence in weighted percent (CI95%); the P value and the coefficient of trends also reported in the two last columns
| STEPS year | 2007 | 2011 | 2016 | 2021 | p value | Coefficient of trend (annual change (%)) | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of overweight | crude | standardized | crude | standardized | crude | standardized | crude | standardized | |||
| Total | 39.08 (37.09–41.07) | 39.31 (39.3-39.33) | 39.39 (36.7-42.08) | 38.66 (38.65–38.68) | 40.33 (38.94–41.72) | 41.93 (41.91–41.94) | 40.32 (38.95–41.7) | 40.43 (40.41–40.44) | 0.12 | 0.142 | |
| sex | Female | 34.07 (31.67–36.46) | 33.81 (33.79–33.83) | 35.33 (32.15–38.52) | 34.95 (34.93–34.97) | 35.09 (33.27–36.91) | 38.72 (38.7-38.74) | 35.89 (34.13–37.64) | 37.62 (37.6-37.64) | 0.215 | 0.13 |
| Male | 44.26 (41.15–47.38) | 44.71 (44.69–44.73) | 44.12 (39.66–48.58) | 42.3 (42.28–42.32) | 46.57 (44.45–48.7) | 45.07 (45.05–45.09) | 46.43 (44.27–48.59) | 43.18 (43.16–43.2) | 0.3 | 0.158 | |
| age group | 25–34 | 36.78 (31.51–42.05) | 37.68 (37.65–37.7) | 35.85 (28.48–43.21) | 35.88 (35.86–35.91) | 42.44 (37.94–46.94) | 43.2 (43.18–43.22) | 39.27 (34.19–44.36) | 40.68 (40.65–40.7) | 0.251 | 0.351 |
| 35–44 | 40.64 (36.18–45.11) | 41.08 (41.05–41.11) | 36.63 (30.56–42.7) | 38.39 (38.37–38.42) | 39.71 (36.45–42.96) | 41.31 (41.29–41.34) | 38.61 (35.46–41.76) | 38.57 (38.54–38.6) | 0.752 | -0.062 | |
| 45–54 | 39.7 (36.21–43.2) | 40.33 (40.3-40.37) | 41.23 (36.23–46.22) | 41.88 (41.85–41.92) | 38.97 (36.57–41.37) | 40.23 (40.2-40.26) | 39.88 (37.49–42.27) | 41.11 (41.08–41.15) | 0.532 | 0.11 | |
| 55–64 | 38.3 (35.18–41.42) | 38.68 (38.64–38.72) | 41.95 (38.42–45.48) | 42.36 (42.32–42.4) | 41.26 (39.04–43.47) | 42.14 (42.1-42.18) | 41.6 (39.45–43.75) | 42.65 (42.61–42.69) | 0.113 | 0.225 | |
| Area | Rural | 37.14 (34.36–39.92) | 36.57 (36.55–36.6) | 42.71 (36.57–48.85) | 42.01 (41.98–42.04) | 36.82 (34.36–39.28) | 36.28 (36.25–36.31) | 38.33 (35.7-40.96) | 38.33 (38.3-38.36) | 0.869 | 0.026 |
| Urban | 39.8 (37.28–42.33) | 40.16 (40.15–40.18) | 38.42 (35.46–41.38) | 37.62 (37.6-37.64) | 41.8 (40.12–43.47) | 43.68 (43.67–43.7) | 40.99 (39.38–42.59) | 41.08 (41.06–41.1) | 0.058 | 0.204 | |
Fig. 2.
Changes in the prevalence of overweight (A); obesity (B); diabetes (C); dyslipidemia (D) and Metabolic syndrome (E) among adults with hypertension from 2007 (the left map) to 2021 (the right map) at subnational level
The standardized prevalence of obesity among adults with hypertension increased significantly from 34.29% (95% CI: 34.28–34.31) in 2007 to 38.38% (38.36–38.39) in 2021 (p-value < 0.001), with an estimated annual change of 0.41%. While the standardized prevalence of obesity among females with hypertension was consistently higher than that among males over the study period, the trend changed significantly in males (p-value < 0.001), reducing the gap between the two sexes (from 44.71% in females and 24.08% in males in 2007 to 46.08% and 30.83% in 2021). Among age groups, only the 45–54 age group showed a significant increase in standardized prevalence, rising from 38.98 to 42.82% (p-value = 0.043), with an estimated yearly change of 0.48%. While the change in standardized prevalence in urban areas was not significant, it increased significantly in rural areas from 27.58 to 36.05% from 2007 to 2021 (p-value < 0.001), with an annual change of 0.87% (Table 3). Overall, obesity among people with hypertension increased in most provinces from 2007 to 2021 (Fig. 2B).
Table 3.
The trend of prevalence of obesity in adults with hypertension from 2007 to 2021; data demonstrate the prevalence in weighted percent (CI95%); the P value and the coefficient of trends also reported in the two last columns
| STEPS year | 2007 | 2011 | 2016 | 2021 | p value | Coefficient of trend (annual change (%)) | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of obesity | crude | standardized | crude | standardized | crude | standardized | crude | standardized | |||
| Total | 36.15 (34.21–38.09) | 34.29 (34.28–34.31) | 35.41 (32.88–37.94) | 33.79 (33.78–33.81) | 39.38 (37.99–40.78) | 34.2 (34.19–34.22) | 41.43 (40.05–42.82) | 38.38 (38.36–38.39) | < 0.001 | 0.414 | |
| sex | Female | 47.03 (44.43–49.62) | 44.71 (44.69–44.73) | 45.93 (42.66–49.21) | 44.29 (44.27–44.31) | 48.53 (46.63–50.43) | 39.54 (39.52–39.56) | 50.2 (48.36–52.04) | 46.08 (46.05–46.1) | 0.096 | 0.244 |
| male | 24.91 (22.22–27.61) | 24.08 (24.06–24.1) | 23.15 (19.45–26.84) | 23.5 (23.48–23.52) | 28.48 (26.53–30.43) | 28.97 (28.95–28.99) | 29.37 (27.39–31.36) | 30.83 (30.81–30.85) | < 0.001 | 0.543 | |
| age group | 25–34 | 28.65 (23.28–34.02) | 29.17 (29.14–29.19) | 31.09 (24.35–37.84) | 31.12 (31.1-31.14) | 26.72 (22.65–30.8) | 24.89 (24.87–24.91) | 35.81 (30.78–40.83) | 34.75 (34.72–34.77) | 0.144 | 0.543 |
| 35–44 | 37.6 (33.05–42.15) | 37.4 (37.37–37.43) | 40.54 (34.41–46.67) | 37.79 (37.77–37.82) | 41.37 (38.05–44.68) | 40.37 (40.34–40.4) | 42.19 (38.97–45.41) | 40.52 (40.49–40.54) | 0.063 | 0.349 | |
| 45–54 | 39.3 (36-42.59) | 38.98 (38.95–39.01) | 33.66 (29.2-38.12) | 32.39 (32.36–32.42) | 42.25 (39.8–44.7) | 40.49 (40.46–40.52) | 45.11 (42.67–47.54) | 42.82 (42.79–42.85) | 0.043 | 0.48 | |
| 55–64 | 35.69 (32.83–38.56) | 35.33 (35.29–35.37) | 35.95 (32.61–39.28) | 34.97 (34.93–35.01) | 39.13 (36.91–41.35) | 38.28 (38.24–38.32) | 39.14 (37.01–41.27) | 37.58 (37.54–37.62) | 0.096 | 0.322 | |
| area | Rural | 29.63 (26.95–32.31) | 27.58 (27.55–27.6) | 26.5 (21.65–31.34) | 25.61 (25.58–25.63) | 37.06 (34.56–39.56) | 34.87 (34.84–34.9) | 39.3 (36.64–41.96) | 36.05 (36.02–36.08) | < 0.001 | 0.868 |
| Urban | 38.57 (36.1-41.04) | 36.38 (36.36–36.4) | 38.02 (35.11–40.93) | 36.34 (36.32–36.35) | 40.35 (38.68–42.03) | 33.99 (33.98–34.01) | 42.14 (40.53–43.76) | 39.1 (39.09–39.12) | 0.439 | 0.108 | |
Diabetes time trend from 2007 to 2021 in hypertensive people
The standardized prevalence of diabetes among adults with hypertension increased significantly from 10.25% (95% CI: 10.24–10.26) in 2007 to 13.53% (13.52–13.54) in 2021 (p-value < 0.001), with an estimated annual change of 0.25%. Although the prevalence was consistently slightly higher in females compared to males, both sexes experienced significant increases from 2007 to 2021 (from 11.27 to 14.15% in females [p-value = 0.012] and from 9.25 to 12.92% in males [p-value = 0.01]), with a higher rate of change in males (0.28% compared to 0.24%). Similarly, both rural and urban areas showed significant increases, with rural areas rising from 8.55 to 10.69% (p-value = 0.021) and urban areas from 10.78 to 14.41% (p-value = 0.007). Although diabetes standardized prevalence among adults with hypertension increased with age throughout the study, the time trend was only significant in the 55–64 age group, rising from 18.59 to 31.05% (p-value < 0.001), with an annual change of 0.8% from 2007 to 2021 (Table 4). The standardized prevalence varied across provinces but similar to the national trend, most provinces showed an increasing pattern from 2007 to 2021 (Fig. 2C).
Table 4.
The trend of prevalence of diabetes in adults with hypertension from 2007 to 2021; data demonstrate the prevalence in weighted percent (CI95%); the P value and the coefficient of trends also reported in the two last columns
| STEPS year | 2007 | 2011 | 2016 | 2021 | p value | Coefficient of trend | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of T2DM | crude | standardized | crude | standardized | crude | standardized | crude | standardized | |||
| Total | 14.19 (12.65–15.74) | 10.25 (10.24–10.26) | 19.23 (16.76–21.7) | 12.05 (12.04–12.06) | 18.29 (16.85–19.73) | 9.81 (9.8–9.81) | 23.44 (21.66–25.23) | 13.53 (13.52–13.54) | < 0.001 | 0.248 | |
| sex | Female | 16.16 (14.2-18.11) | 11.27 (11.26–11.29) | 21.27 (18.13–24.41) | 14.5 (14.48–14.51) | 20.77 (18.75–22.78) | 11.21 (11.19–11.22) | 25.24 (22.89–27.59) | 14.15 (14.14–14.17) | 0.012 | 0.24 |
| Male | 12.01 (9.57–14.46) | 9.25 (9.23–9.26) | 16.5 (12.57–20.44) | 9.65 (9.63–9.66) | 15.13 (13.12–17.15) | 8.43 (8.42–8.45) | 21 (18.25–23.76) | 12.92 (12.91–12.94) | 0.01 | 0.279 | |
| age group | 25–34 | 3.43 (1.1–5.75) | 3.66 (3.65–3.67) | 0.81 (0-2.02) | 0.9 (0.9–0.91) | 2.96 (1.11–4.81) | 2.97 (2.96–2.98) | 5.64 (2.2–9.07) | 4.19 (4.18–4.19) | 0.123 | 0.119 |
| 35–44 | 9.85 (7.12–12.59) | 9.52 (9.5–9.53) | 12.64 (7.34–17.94) | 11.27 (11.25–11.28) | 6.83 (4.91–8.76) | 5.72 (5.71–5.73) | 12.56 (8.37–16.75) | 11.52 (11.5-11.53) | 0.4 | -0.107 | |
| 45–54 | 18.23 (14.9-21.55) | 18.33 (18.3-18.35) | 24.93 (19.75–30.12) | 24.48 (24.45–24.51) | 18.61 (16-21.21) | 17.62 (17.59–17.64) | 23.23 (20.23–26.22) | 22.57 (22.54–22.6) | 0.149 | 0.196 | |
| 55–64 | 18.91 (16.45–21.38) | 18.59 (18.56–18.62) | 27 (23.28–30.73) | 27.02 (26.99–27.06) | 26.51 (23.93–29.09) | 26.39 (26.35–26.42) | 32.09 (29.14–35.04) | 31.05 (31.01–31.08) | < 0.001 | 0.801 | |
| area | Rural | 12.54 (10.62–14.47) | 8.55 (8.54–8.57) | 13.08 (9.62–16.54) | 7.15 (7.13–7.16) | 13.92 (11.97–15.87) | 7.28 (7.26–7.3) | 17.98 (15.57–20.39) | 10.69 (10.68–10.71) | 0.021 | 0.192 |
| Urban | 14.87 (12.84–16.91) | 10.78 (10.77–10.79) | 21.5 (18.41–24.59) | 13.57 (13.56–13.58) | 20.15 (18.28–22.02) | 10.59 (10.58–10.6) | 25.2 (22.98–27.43) | 14.41 (14.4-14.43) | 0.007 | 0.303 | |
Prevalence of dyslipidemia in people with HTN from 2007 to 2021
The standardized prevalence of dyslipidemia among adults with hypertension changed from 83.74% (95% CI: 83.73–83.75) in 2007 to 85.47% (85.46–85.48) in 2021. However, the weighted least squares linear regression indicated a decreasing trend (p-value = 0.019) in the standardized prevalence of dyslipidemia, with an annual change of -0.18%. Most subgroups showed insignificant trends over the study period. However, females (p-value < 0.001 and annual change of -0.35%), the 55–64 age group (p-value = 0.003 and annual change of -0.39%), and urban areas (p-value = 0.009 and annual change of -0.30%) exhibited significant decreasing trends (Table 5). While some provinces showed decreasing patterns in the standardized prevalence of dyslipidemia among adults with hypertension from 2007 to 2021, the northwest, south, and southeast provinces were more affected by an increase in the prevalence of dyslipidemia (Fig. 2D).
Table 5.
The trend of prevalence of dyslipidemia in adults with hypertension from 2007 to 2021; data demonstrate the prevalence in weighted percent (CI95%); the P value and the coefficient of trends also reported in the two last columns
| STEPS year | 2007 | 2011 | 2016 | 2021 | p value | Coefficient of trend | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of DLP | crude | standardized | crude | standardized | crude | standardized | crude | standardized | |||
| total | 85.43 (83.74–87.12) | 83.74 (83.73–83.75) | 81.29 (78.57–84.01) | 77.41 (77.39–77.42) | 82.04 (80.59–83.5) | 81.22 (81.21–81.24) | 84.41 (82.92–85.9) | 85.47 (85.46–85.48) | 0.019 | -0.183 | |
| sex | Female | 89.95 (88.23–91.67) | 87.05 (87.04–87.06) | 86.18 (83.27–89.1) | 83.31 (83.3-83.33) | 83.97 (82.1-85.84) | 83.08 (83.07–83.1) | 86.2 (84.22–88.18) | 88.14 (88.13–88.16) | < 0.001 | -0.347 |
| Male | 80.39 (77.42–83.35) | 80.49 (80.47–80.51) | 74.71 (69.75–79.67) | 71.61 (71.6-71.63) | 79.58 (77.29–81.87) | 79.4 (79.38–79.42) | 81.97 (79.68–84.25) | 82.85 (82.83–82.87) | 0.482 | 0.081 | |
| age group | 25–34 | 79.54 (73.57–85.52) | 79.65 (79.63–79.67) | 74.44 (65.82–83.07) | 72.83 (72.81–72.85) | 77.67 (72.31–83.03) | 77.5 (77.48–77.52) | 85.61 (80.95–90.27) | 85.58 (85.57–85.6) | 0.363 | 0.216 |
| 35–44 | 85.68 (81.57–89.79) | 85.77 (85.75–85.79) | 78.14 (71.37–84.91) | 76.32 (76.3-76.34) | 85.65 (82.61–88.69) | 86.39 (86.38–86.41) | 88 (84.88–91.13) | 87.75 (87.73–87.77) | 0.548 | 0.103 | |
| 45–54 | 86.27 (83.75–88.78) | 86.26 (86.24–86.29) | 83.29 (78.6-87.98) | 82.96 (82.94–82.99) | 80.98 (78.3-83.66) | 80.31 (80.28–80.33) | 84.19 (81.86–86.53) | 84.06 (84.04–84.09) | 0.135 | -0.21 | |
| 55–64 | 87.42 (85.47–89.37) | 87.32 (87.29–87.34) | 84.86 (81.66–88.07) | 84.51 (84.48–84.54) | 82.12 (79.89–84.36) | 82.18 (82.15–82.21) | 82.64 (80.03–85.25) | 82.38 (82.35–82.41) | 0.003 | -0.392 | |
| area | Rural | 83.19 (81.07–85.31) | 82.5 (82.48–82.53) | 76.84 (70.94–82.74) | 75.16 (75.14–75.19) | 80.5 (78.3-82.71) | 78.14 (78.12–78.17) | 83.39 (81.17–85.62) | 80.63 (80.61–80.65) | 0.543 | -0.062 |
| Urban | 86.36 (84.12–88.6) | 84.12 (84.11–84.13) | 82.93 (79.93–85.93) | 78.1 (78.09–78.12) | 82.7 (80.85–84.55) | 82.18 (82.17–82.19) | 84.73 (82.9-86.57) | 86.97 (86.96–86.99) | 0.009 | -0.296 | |
Changes in the prevalence of MetS in hypertensive people
The standardized prevalence of MetS among adults with hypertension increased significantly from 64.36% (95% CI: 64.35–64.37) in 2007 to 78.29% (78.28–78.31) in 2021 (p-value < 0.001), with an estimated annual change of 0.88%, the highest annual change among the evaluated cardiometabolic risk factors in this study. All subgroups showed a significant increase in the trend. Among sexes, males had a higher standardized prevalence (80.36% [95% CI: 80.35–80.38] compared to 76.19% [76.17–76.20]) in 2021, as well as a higher annual change in trend (1.04% compared to 0.71%) compared to females. While the standardized prevalence of MetS was higher in older age groups, the annual change in trend was highest in the 25–34 age group at 1.32% per year. Regarding areas, the standardized prevalence was higher in urban than rural areas throughout the study, reaching 79.81% and 73.4% in 2021, respectively. However, the annual change in rural areas was almost twice that of urban areas (1.26% vs. 0.60%) (Table 6). Almost all provinces showed an increasing pattern of MetS from 2007 to 2021 (Fig. 2E).
Table 6.
The trend of prevalence of metabolic syndrom in adults with hypertension from 2007 to 2021; data demonstrate the prevalence in weighted percent (CI95%); the P value and the coefficient of trends
| STEPS year | 2007 | 2011 | 2016 | 2021 | p value | Coefficient of trend | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence of MetS | crude | standardized | crude | standardized | crude | standardized | crude | standardized | |||
| Total | 68.77 (66.72–70.82) | 64.36 (64.35–64.37) | 69.74 (66.59–72.89) | 63.66 (63.64–63.67) | 75.67 (74.07–77.27) | 68.1 (68.08–68.11) | 82.06 (80.57–83.56) | 78.29 (78.28–78.31) | < 0.001 | 0.884 | |
| sex | Female | 71.62 (69.13–74.11) | 64.68 (64.66–64.7) | 72.59 (68.98–76.2) | 66.1 (66.08–66.12) | 76.34 (74.21–78.46) | 64.08 (64.06–64.1) | 82.88 (80.92–84.84) | 76.19 (76.17–76.2) | < 0.001 | 0.71 |
| Male | 65.6 (62.28–68.92) | 64.05 (64.03–64.07) | 65.9 (60.38–71.43) | 61.26 (61.24–61.28) | 74.83 (72.4-77.25) | 72.03 (72.01–72.05) | 80.96 (78.65–83.27) | 80.36 (80.35–80.38) | < 0.001 | 1.035 | |
| age group | 25–34 | 53.15 (46.65–59.64) | 53.45 (53.42–53.47) | 53.13 (43.3-62.96) | 52.08 (52.05–52.1) | 56.93 (50.09–63.76) | 53.81 (53.79–53.83) | 75.28 (68.8-81.75) | 72.16 (72.14–72.18) | 0.007 | 1.324 |
| 35–44 | 69.16 (64.41–73.91) | 69.2 (69.17–69.22) | 67.6 (60.21–74.99) | 67.8 (67.78–67.83) | 75.39 (71.52–79.25) | 76.7 (76.68–76.73) | 82.91 (79.58–86.23) | 81.92 (81.89–81.94) | < 0.001 | 1.045 | |
| 45–54 | 71.65 (68.43–74.88) | 72.15 (72.12–72.18) | 70.65 (64.84–76.47) | 69.96 (69.93–69.99) | 76.34 (73.57–79.12) | 75.79 (75.76–75.82) | 81.77 (79.19–84.35) | 81.91 (81.88–81.93) | < 0.001 | 0.888 | |
| 55–64 | 73.27 (70.53–76.01) | 73.59 (73.56–73.63) | 78.73 (75.26–82.21) | 78.48 (78.44–78.51) | 78.89 (76.62–81.15) | 79.06 (79.02–79.09) | 83.16 (80.82–85.49) | 82.7 (82.67–82.73) | < 0.001 | 0.682 | |
| area | Rural | 62.16 (59.33-65) | 59.54 (59.51–59.57) | 58.52 (51.85–65.2) | 52.03 (52-52.06) | 70.33 (67.74–72.92) | 64.73 (64.71–64.76) | 79.1 (76.72–81.48) | 73.4 (73.38–73.43) | < 0.001 | 1.257 |
| Urban | 71.49 (68.83–74.14) | 65.86 (65.84–65.87) | 73.88 (70.43–77.32) | 67.27 (67.25–67.29) | 77.92 (75.92–79.91) | 69.14 (69.13–69.16) | 83.02 (81.2-84.84) | 79.81 (79.8-79.83) | < 0.001 | 0.601 | |
also reported in the two last columns
Discussion
The present study was designed to provide health policymakers with evidence regarding the time trend and changes in the prevalence of cardiometabolic risk factors among Iranian adults with hypertension from 2007 to 2021. Our findings demonstrated that the prevalence of hypertension remained relatively constant over these 15 years. However, the prevalence of obesity, diabetes, and MetS has significantly increased among adults with hypertension, and the highest change rate occurred in MetS with an annual change of 0.9%. Dyslipidemia, with a standardized prevalence of about 80%, was the most prevalent risk factor throughout the study period. Considering subgroups, different patterns of trends were observed for various risk factors, each with different rates of change. Similarly, disparities were seen in the trends of risk factors among provinces.\.
In our study, we observed no significant change in the trend of HTN over a 15-year period. This finding aligns with previous national studies in Iran, which also reported no changes in the time trend of HTN prevalence [20, 21]. Therefore, the status of HTN has not improved in Iran in these 15 years and does not fulfill the NCD framework global monitoring’s target of reducing its prevalence by 25% by 2025 policies to reduce the prevalence of HTN.
Our results illustrated different patterns of trend in the prevalence of cardiometabolic risk factors among adults with hypertension. Specifically, the prevalence of overweight and obesity among these adults reached similar levels in 2021, nearly 40%. While there was no improvement in the prevalence of overweight over the 15-year study period, the obesity situation among hypertensive individuals has worsened since 2007, with an annual increase of 0.41%. The literature also demonstrated an increasing tendency of obesity prevalence in the general population of Iran [11]. Our findings revealed that the prevalence of obesity in adult females with hypertension was higher than in males, a situation that has remained unchanged since 2007.In contrast, the trend of obesity among adult males with hypertension has increased significantly, with a rate change of 0.54%, narrowing the gap of difference among sexes. Previous studies on the general population also showed higher obesity prevalence among females [11, 18, 22]. Various factors, including differences in fat utilization, anatomical fat distribution, comorbidities, sex hormones, genetics, and molecular mechanisms, have been discussed as probable related factors [23, 24]. However, the increasing trend in males is alarming. One possible reason could be males tend to be less concerned about their health status than females [25], and the improvement of awareness among females [26] about obesity from either cosmetic or medical aspects could explain the plateau in females. Furthermore, our study revealed that while the prevalence of overweight among adults with hypertension remained almost unchanged, the trend of obesity prevalence increased in rural areas, reaching similar levels to urban areas by 2021. Previous national studies have shown a nonsignificant increase in the trend of obesity and overweight in both rural and urban areas among the general population [11]. Typically, the prevalence of obesity is higher in urban areas due to different lifestyles and occupations [28]. Thus, the significant increase in the prevalence of obesity in rural adults with hypertension observed in the present study could be due to lifestyle changes in rural areas, especially among individuals with hypertension. This alarming trend should prompt health policymakers to take immediate measures.
Our findings showed a significant increase in the national prevalence of diabetes (among adults with hypertension since 2007. This finding is consistent with previous national studies that have also depicted an ongoing trend in the prevalence of diabetes in the general population [10, 29]. Failure to meet the targets of the WHO global monitoring framework in Iran is presented in the current research by a meaningful increasing tendency in the prevalence of diabetes in all subgroups of sexes, ages, and areas since 2007. As with previous national studies, diabetes is more prevalent among Iranian females, older ages, and urban residents [10]. Females have a more significant risk factor burden than males and a higher BMI [30]. Additionally, women experience more hormonal fluctuations during their reproductive years, which can lead to more significant body changes [30]. Also, pregnancy discloses the pre-existing diabetes and leads to gestational diabetes as a primary risk factor for the progression of diabetes [31]. Menopausal alterations also make them susceptible to the effects of diabetes [30]. Exposure to more psychosocial stress also prone them to develop diabetes more than males [30]. In addition, an unhealthy lifestyle exemplified by higher fat intake, decrement of physical activity, and impaired glucose metabolism with aging leads to more development of diabetes in older ages and urban residents [30, 32].
Our study showed dyslipidemia was the most prevalent risk factor in adults with hypertension throughout the study period. and was nearly the same as its prevalence in the general population in 2021, about 80% [19]. Low awareness of Iranians about dyslipidemia might be the reason for its high prevalence [11, 33]. Like the high prevalence of diabetes and obesity in hypertensive people, we found that dyslipidemia is more prevalent in adult females with hypertension. From the pathophysiological aspect, increased insulin resistance, upregulation of release of free fatty acids from adipose tissue, and secretion of more ApoB protein from the liver secondary to more incidence of accumulation of visceral fat and conditions such as PCOS in women may cause this sex disparity in the development of these cardiometabolic risk factors [35].
An alarming increase in the prevalence of MetS in adults with hypertension since 2007 in both sexes and all subgroups was depicted by this report, the same trend as shown by previous national research [9, 12]. The annual changes in MetS have been the highest among the cardiometabolic risks in this study, with a rate change of about 0.9%. The prevalence of MetS in adult males with hypertension was more than in females in the present research, which is in contrast with the higher prevalence of diabetes and dyslipidemia in females in the present research and the findings of the previous studies [9]. Methodological differences should be noticed in interpreting this finding, as exemplified by the different definitions of obesity with BMI or waist circumference, which is more prevalent in males. Waist circumference was one of the main components of MetS prevalence in Iran [9]. In addition, excluding elderlies, the age group with the highest prevalence of MetS in Iran contributes to this discrepancy. It is also noteworthy that the annual change of MetS in the younger age group (25–34 years old) and rural areas showed the highest increase, with 1.32% and 1.26% annually, respectively. Based on previous studies, these two groups were expected to have lower risks of MetS [9, 12]. These intensive and alarming increases in subgroups must be considered very serious. Health policymakers should make more practical decisions to hinder the sequelae of the intensive worsening of MetS.
This study revealed significant disparities in the standardized prevalence of cardiometabolic risk factors among adults with hypertension across different provinces. While some provinces showed improvements in certain risk factors, others exhibited increasing trends. Previous studies have also highlighted provincial disparities in NCDs [37, 38], which may be attributed to variations in population characteristics [39, 40] such as ethnicity, culture, education, income, social class, and environmental factors like air pollution and lead exposure [41, 42]. Additionally, differences in healthcare system performance, infrastructures, and access may contribute to these disparities [43]. For instance, based on our study East Azerbaijan has maintained a constant prevalence of hypertension while reducing the prevalence of obesity, diabetes, dyslipidemia, and MetS among hypertensive adults. Guidelines such as IraPEN have been developed to address NCDs [38], and their effective implementation may explain improvements in some regions. Conversely, poor performance in other areas may result from challenges in implementing these guidelines. Future studies should investigate healthcare system performance at the provincial level, both in well-performing provinces like East Azerbaijan and in poorly performing ones, to understand the differences and, if necessary, develop more practical, region-specific guidelines based on local conditions.
After identifying the trends of risk factors, it is essential to design and implement suitable strategies and interventions or modify existing policies to address NCD risk factors [38]. The WHO provides “best-buy” interventions that are highly cost-effective and feasible, particularly for low- and middle-income countries [44]. Additionally, there are both national and international guidelines for managing hypertension and its comorbidities [45, 46]. Our study highlighted specific changes in the rates of metabolic risk factors among people with hypertension, indicating which subgroups policymakers should target in low-resource settings. The highest rates of change for obesity were in rural subgroups (0.87%), for diabetes in the older 55–64 age group (0.8%), and for MetS in the younger 25–34 age group (1.32%) and rural areas (1.25%). Health policymakers should focus resources on developing targeted strategies for these specific sex, age, and area subgroups by combining existing interventions and guidelines with real-world information to create more cost-effective programs. In particular, younger age groups and rural areas should be prioritized for strategy development.
The main strength of this research lies in its comprehensive assessment of changes in the prevalence of cardiometabolic risk factors among hypertensive individuals in Iran. This study is the first of its kind in the EMRO. Compared to similar studies outside the EMRO region, our research includes a large study population over an extended period, encompassing both rural and urban areas of the country. Additionally, our research provides a wide spectrum of sub-national data on these cardiometabolic risk factors among various subgroups, enabling health policymakers to develop more practical preventive programs. The publication of successful experiences in decreasing the prevalence of these risk factors in certain provinces can serve as a guide for other local authorities to implement similar approaches with necessary modifications based on local requirements.
The limitation of this study is its cross-sectional nature, which restricts our ability to establish causal relationships. Additionally, the exclusion of the elderly group means that our findings may not fully represent the entire population. Conducting further surveys that include all age groups across the country would enable more comprehensive research and more accurately estimate the prevalence of these cardiometabolic risk factors.
Conclusion
In this study, we investigated the prevalence of cardiometabolic risk factors among adults with hypertension from 2007 to 2021. Our findings indicated that while the prevalence of hypertension among adults remained relatively stable, the prevalence of obesity, diabetes, and MetS increased significantly. Notably, significant increases in obesity were observed in males, the 45–54 age group, and rural subgroups. For MetS and diabetes, all subgroups showed significant increases, except for diabetes, where significant changes were limited to the 55–64 age group. These disparities in trends across different subgroups underscore the need for health policymakers to implement targeted strategies that consider age, sex, and regional differences to effectively prevent and control these risk factors.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to express their gratitude for their partnership with the Deputy for Research and Technology, the Deputy of Health of the Ministry of Health and Medical Education, the National Institute for Health Research, the World Health Organization, and the Non-Communicable Diseases Research Center of Endocrinology and Metabolism Population Sciences Institute of Tehran University of Medical Sciences. This conducted study was an endocrinology and metabolism fellowship thesis project of Dr. Akbar Jafari.
Abbreviations
- 95% CI
95% confidence interval
- BMI
Body mass index
- DBP
Diastolic blood pressure
- EMRO
Eastern Mediterranean Regional Office
- FBS
Fasting blood sugar
- HTN
Hypertension
- MetS
Metabolic syndrome
- NCDs
Non-communicable diseases
- SBP
Systolic blood pressure
- STEPS
STEPwise approach to non-communicable diseases risk factor surveillance
- T2DM
Type 2 diabetes mellitus
- WHO
World Health Organization
Author contributions
Conceptualization: Akbar Jafari, Ozra Tabatabaei-Malazy, Bagher Larijani.
Data Curation: Seyed Hamidreza Mirbehbahani, Ali Golestani, Akbar Soltani, Sayed Mahmoud Sajjadi-Jazi, Sepehr Khosravi, Farshad Farzadfar.
Formal Analysis: Ali Golestani.
Investigation: Bagher Larijani and all of the co-authors.
Methodology: Akbar Jafari, Seyed Hamidreza, Ali Golestani, Ozra Tabatabaei-Malazy, Akbar Soltani, Sayed Mahmoud Sajjadi-Jazi, Sepehr Khosravi, Bagher Larijani.
Writing—Original Draft Preparation: Akbar Jafari, Seyed Hamidreza, Ali Golestani, Ozra Tabatabaei-Malazy.
All of the authors participated in rewriting and finalizing the article and approved it.
Funding
This study was funded by the Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran (Number: 66469-221-02-1402). It should be noted that the institute had no role in any part of the study, writing of the manuscript, or the decision to submit.
Data availability
The data supporting this study’s findings are available from the corresponding author upon reasonable request.
Declarations
Ethical considerations
All participants in the survey were entirely voluntary, and both verbal and written consent were obtained from each participant. The proposal of the current study was approved by the Research Ethics Committee of Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.EMRI.REC.1402.058).
Conflict of interest
The authors had no conflicts of interest.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Ozra Tabatabaei-Malazy and Bagher Larijani equally contributed as Correspondence.
Akbar Jafari, Seyed Hamidreza Mirbehbahani and Ali Golestani equally contributed as first author.
Contributor Information
Ozra Tabatabaei-Malazy, Email: tabatabaeiml@sina.tums.ac.ir.
Bagher Larijani, Email: emrc@tums.ac.ir.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data supporting this study’s findings are available from the corresponding author upon reasonable request.