Sex disparity in non-communicable disease burden in Iran from 1990 to 2021 based on the global burden of disease study

Abstract

Non-communicable diseases (NCDs) pose a major health challenge worldwide, especially in low- and middle-income countries like Iran. Understanding sex disparities in NCDs is crucial for tailoring public health strategies to address unique risks and outcomes for different sexes. This study focused on 11 major NCD categories, estimating incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Age-standardized rates were calculated, values were presented with 95% uncertainty intervals (95% UI). Decomposition analysis assessed the impact of population growth, age structure, and incidence rates on incidence and death rates. In 2021, Iran had 80.2 million prevalent NCD cases, with slightly higher age-standardized prevalence in females. The age-standardized incidence rate was higher in females across all age groups, reaching 181,264.4 (95% UI: 165,696.5 to 200,091.3) in females and 131,900.5 (95% UI: 120,657.2 to 145,496.4) in males. Although the age-standardized death rate decreased more in males, it remained higher in males (477.6 (456.7 to 497.2)) than females (438.1 (420.3 to 455.5)). DALYs were moderately higher in females (19,983.4 (16,884.3 to 23,410.1)). In all provinces, YLLs were higher than YLDs for females, while the reverse was true for males in most provinces. These findings underscore the need for targeted public health interventions to address NCDs in females and males. While in males deaths are higher, in females DALYs are slightly higher which calls for tailored intervention to prevent death and disability.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-94015-z.

Introduction

Non-communicable diseases (NCDs) are chronic conditions characterized by a prolonged and slow progression. With the advent of the epidemiological transition, NCDs have emerged as a global epidemic. These diseases have profound health implications, as they exacerbate health-related suffering among affected individuals. Moreover, management of NCDs impose a high economic burden on countries.

Approximately 71% of all deaths and 43% of the global Disability adjusted life years(DALYs) are attributed to NCDs¹. DALY, a metric combining years of life lost to premature death and years lived with disability, highlights the dual burden of mortality and morbidity caused by NCDs^2,3.

NCDs are not merely health challenges; they are societal crises that disproportionately impact low- and middle-income countries⁴. In Iran, the epidemiological transition has escalated the prevalence of NCDs, driven by urbanization, lifestyle shifts, and an aging population⁵. As the nation grapples with these chronic conditions, understanding the role of sex disparities becomes crucial for crafting effective public health strategies Sex differences in NCDs are well-documented globally^6,7 but remain underexplored in Iran’s unique sociocultural and demographic context⁸.

Biological factors, such as hormonal and genetic differences, contribute to varying susceptibility and disease progression between men and women. Psychosocial dynamics, including societal roles and health-seeking behaviors, further deepen these disparities. In many communities across Iran, cultural norms often prioritize men’s health, leaving women at higher risk of undiagnosed and untreated chronic conditions. Conversely, men frequently engage in high-risk behaviors such as smoking and alcohol use, leading to higher mortality from certain NCDs⁹.

Iran’s diverse provinces present additional layers of complexity, with socioeconomic status, access to healthcare, and regional dietary and lifestyle practices influencing NCD outcomes. For instance, rural and economically disadvantaged areas often lack sufficient healthcare infrastructure, intensifying the burden of NCDs for both sexes in different ways. Despite these disparities, public health interventions often fail to consider the nuanced needs of men and women, missing opportunities for targeted and equitable solutions¹⁰.

This study uses the comprehensive estimates of the Global Burden of Disease (GBD) 2021 project to examine sex-specific patterns in NCDs across Iran. By investigating these disparities, this research aims to provide actionable insights for addressing the unequal impacts of NCDs and advancing health equity in the country.

Methods

Overview

GBD 2021 study evaluates the impact of 371 diseases and injuries across seven super-regions, 21 regions, and 204 countries and territories from 1990 to 2021, considering incidence, prevalence, mortality, years of life lost (YLL), years lived with disability (YLD), and DALYs¹¹. It also examines the burden of diseases attributable to 88 behavioral, environmental, metabolic, and occupational risk factors^11,12. This observational, population-based study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER)¹³. The data on burden metrics of Iranian population from 1990 to 2021 was obtained from the https://ghdx.healthdata.org/ website.

Data sources

Systematic reviews, population surveys, and hospital administrative data were utilized, with network meta-analysis conducted using meta-regression—Bayesian, regularized, trimmed (MR-BRT) to adjust for study-level differences in case definition or measurement methods. Data sources displaying implausibly low or high values, which could lead to unrealistic time trends, were identified as outliers^11,14.

Burden estimation framework

In GBD 2021, diseases and injuries are categorized into a hierarchical structure of cause categories with four levels, from the broadest groupings at Level 1 to the most detailed at Level 4. In our current analysis, we have concentrated on Level 2 causes as they represent our main outcomes of interest and selected the top 11 causes along with other causes¹¹. These causes are as follows: cardiovascular diseases (CVD), chronic respiratory diseases, diabetes and kidney diseases, digestive diseases, mental disorders, musculoskeletal diseases, neoplasms, neurological disorders, Sense organ diseases, skin and subcutaneous diseases, substance use disorders, and other NCDs.

Decomposition analysis

To analyze the factors contributing to the incidence of NCDs, two scenarios were developed. In the first scenario, the age-specific incidence rates from 1990 were applied to the 2021 population. The difference between the estimated cases in this scenario and the actual cases in 1990 was attributed to population growth. In the second scenario, the age-specific rates from 1990 were applied to the 2021 population, accounting for its size, age structure, and sex distribution. The difference between the estimated cases in this scenario and the actual cases in 2021 was attributed to changes in age-specific rates. Finally, the difference between the results of the two scenarios was used to estimate the contribution of population aging to the changes in NCD incidence¹⁵. The same approach was applied to death. To estimate the 95% uncertainty interval (UI) for the different components of the decomposition analysis, all calculations were performed using 1,000 random samples drawn from the distributions.

Sociodemographic index

Sociodemographic index (SDI) is a compound indicator calculated from the geometric mean of three measures: average years of educational attainment among individuals aged over 15 years, income per capita, and total fertility rate among women under 25 years in a country¹¹. It is reported on a scale from zero to one, where one indicates lower fertility rates, higher income, and educational levels.

Statistical analysis

We estimated the incidence, mortality, and DALYs to evaluate the burden of NCDs. YLLs were estimated by multiplying each NCD-related death by the standard life expectancy at the age of death. YLDs were calculated by multiplying the prevalence of each sequela by its specific disability weight. The combined measure of disease burden, incorporating both non-fatal health losses and premature deaths, was reported as DALYs, which is the sum of YLLs and YLDs. To account for variations in age structure and population size, age-standardized rates for incidence, mortality, and DALYs were calculated using the GBD standard population. This standard population is derived from the population structure of all national locations with populations exceeding 5 million people. The 95% uncertainty interval (UI) of all measures were determined using the 2.5th and 97.5th percentile of sorted 500 draws of posterior distribution¹¹.

Software

Python 3.12.13 used to perform statistical analysis and visualization.

Results

Incidence and prevalence

In 2021, there were about 80.2 million (95% UI: 79.7 to 80.7) prevalent cases of NCDs in Iran, which had a nearly equal contribution from females and males, 39.9 million (39.6 to 40.3) cases and 40.3 million (40.1 to 40.5) cases respectively. The age-standardized prevalence rate (ASPR) was slightly higher in females, at 94,972.4 (94,420.9 to 95,469.4) per 100,000, compared to 90,444.7 (89,507.6 to 91,302.0) per 100,000 in males (Table 1; Fig. 1). The highest ASPR belonged to other NCDs in both sexes (females: 94972.4 (94420.9 to 95469.4) per 100,000, males: 90444.7 (89507.6 to 91302.0) per 100,000). In females the second common group was neurological disorders (41976.0 (39126.3 to 44750.5) per 100,000) while in males it was digestive diseases (38803.0 (36873.2 to 40932.0) per 100,000). The least prevalent diseases in both sexes were substance use disorders which was significantly higher in males (1478.3 (1332.6 to 1646.5) per 100,000) compared to females (574.5 (518.8 to 636.1) per 100,000) (Fig. 2, Supplementary Material 1).

Table 1.

Overall burden of NCDs in females and males in 1990 and 2021.

	1990 Both	1990 Male	1990 Female	2021 Both	2021 Male	2021 Female	Change Both	Change Male	Change Female
Deaths all ages numbers	168,979.58 (156,506.49 to 177,564.98)	95,050.46 (85,956.73 to 101,603.54)	73,929.12 (66,471.16 to 78,533.7)	309,865.1 (300,497.35 to 319,594.03)	168,024.06 (160,370.09 to 175,253.15)	141,841.04 (135,819.14 to 147,730.93)	83.37 (72.37 to 99.59)	76.77 (63.39 to 96.29)	91.86 (78.8 to 116.81)
Deaths age standardized rate (per 100000)	713.66 (689.89 to 737.64)	751.88 (709.92 to 791.03)	667.18 (635.47 to 696.46)	455.79 (442.7 to 469.59)	477.58 (456.71 to 497.25)	438.11 (420.3 to 455.49)	− 36.13 (− 38.8 to − 33.15)	− 36.48 (− 40.26 to − 32.02)	− 34.33 (− 37.88 to − 29.74)
YLDs (years lived with disability) all ages numbers	4,129,572.57 (3,050,463.15 to 5,401,345.97)	1,795,806.53 (1,327,018.43 to 2,351,611.08)	2,333,766.04 (1,718,111.2 to 3,045,302.51)	9,003,874.05 (6,688,289.72 to 11,710,654.21)	3,795,719.12 (2,827,351.6 to 4,942,041.96)	5,208,154.93 (3,857,453.03 to 6,772,892.52)	118.03 (112.87 to 122.92)	111.37 (106.08 to 116.82)	123.17 (117.78 to 128.63)
YLDs (years lived with disability) age standardized rate (per 100000)	9606.29 (7152.47 to 12,504.75)	8154.79 (6099.31 to 10,628.56)	11,114.93 (8234.68 to 14,450.09)	10,211.21 (7614.07 to 13,263.58)	8657.84 (6464.27 to 11,282.69)	11,806.59 (8766.61 to 15,303.39)	6.3 (4.84 to 7.6)	6.17 (4.51 to 7.85)	6.22 (4.82 to 7.48)
YLLs (years of life lost) all ages numbers	6,757,663.19 (5,693,130.97 to 7,403,579.53)	3,846,797.86 (3,184,488.1 to 4,246,628.14)	2,910,865.34 (2,279,474.22 to 3,231,947.21)	6,928,721.68 (6,708,075.43 to 7,160,379.56)	3,954,019.71 (3,767,818.48 to 4,139,101.17)	2,974,701.97 (2,834,018.53 to 3,110,089.8)	2.53 (− 7.04 to 22.73)	2.79 (− 8.55 to 25.55)	2.19 (− 8.08 to 31.91)
YLLs (years of life lost) age standardized rate (per 100000)	17,502.57 (16,071.85 to 18,444.42)	19,174.74 (17,190.91 to 20,545.45)	15,621.03 (13,911.84 to 16,630.6)	9164.3 (8873.44 to 9458.28)	10,182.01 (9738.39 to 10,649.98)	8176.85 (7806.36 to 8534.41)	− 47.64 (− 50.89 to − 42.29)	− 46.9 (− 51.22 to − 40.11)	− 47.65 (− 51.33 to − 39.81)
Prevalence all ages numbers	50,997,301.63 (50,274,977.15 to 51,659,613.24)	25,415,172.15 (25,004,728.32 to 25,784,958.92)	25,582,129.48 (25,275,634.53 to 25,853,715.63)	80,245,502.15 (79,709,696.05 to 80,741,120.32)	39,917,852.36 (39,555,295.89 to 40,250,413.98)	40,327,649.78 (40,134,946.71 to 40,504,837.59)	57.35 (56.3 to 58.6)	57.06 (55.87 to 58.38)	57.64 (56.55 to 58.82)
Prevalence age standardized rate (per 100000)	9,2457.14 (91612.83 to 93,182.3)	90,775.8 (89,818.47 to 91,635.55)	94,186.65 (93,488.62 to 94,808.01)	92,652.64 (91,903.24 to 93,335.16)	90,444.71 (89,507.57 to 91,302.04)	94,972.36 (94,420.94 to 95,469.44)	0.21 (0.03 to 0.39)	− 0.36 (− 0.6 to − 0.15)	0.83 (0.63 to 1.05)
Incidence all ages numbers	83,568,495.19 (82,929,508.51 to 84,207,481.86)	37,777,773.17 (37,470,345.92 to 38,085,200.42)	45,790,722.02 (45,459,162.59 to 46,122,281.44)	131,067,862.54 (130,314,841.46 to 131,820,883.62)	55,998,493.04 (55,659,371.42 to 56,337,614.66)	75,069,369.5 (74,655,470.05 to 75,483,268.96)	69.22 (62.28 to 75.59)	62.57 (55.96 to 69.23)	74.9 (68.06 to 81.37)
Incidence age standardized rate (per 100000)	153,369.86 (142,435.7 to 167,130.13)	137,323.67 (127,601.18 to 149,563.57)	16,9991.87 (157,802.57 to 185,327.07)	156,107.21 (142,743.28 to 172,268.26)	131,900.5 (120,657.25 to 145,496.4)	181,264.35 (165,696.49 to 200,091.27)	3.4 (2.52 to 4.27)	3.11 (1.94 to 4.2)	3.63 (2.78 to 4.51)
DALYs (disability-adjusted life years) all ages numbers	1,0887,235.76 (9,412,620.72 to 12,316,893.41)	5,642,604.39 (4,837,276.95 to 6,372,771.28)	5,244,631.37 (4,386,685.89 to 6,075,202.02)	15,932,595.73 (13,621,058.3 to 18,638,188.15)	7,749,738.83 (6,776,582.92 to 8,918,413.17)	8,182,856.9 (6,819,277.02 to 9,722,316.73)	46.34 (33.72 to 64.37)	37.34 (23.79 to 58.26)	56.02 (42.59 to 78.56)
DALYs (disability-adjusted life years) age standardized rate (per 100000)	27,108.86 (24,323.19 to 30,120.99)	27,329.53 (24,489.54 to 30,236.37)	26,735.95 (23,363.65 to 30,233.02)	19,375.5 (16,768.39 to 22,378.22)	18,839.86 (16,576.62 to 21,499.32)	19,983.43 (16,884.25 to 23,410.05)	− 28.53 (− 33.25 to − 22.93)	− 31.06 (− 36.42 to − 24.14)	− 25.26 (− 30.39 to − 18.59)

Fig. 1.

Trend of burden metrics of non-communicable diseases (NCDs) in males and females in Iran from 1990 to 2021.

Fig. 2.

The proportion of each level 2 non-communicable diseases (NCDs) burden in males and females in Iran from 1990 to 2021.

By 2021, the incidence number had risen by 62.6% (56.0 to 69.2) in males and 74.9% (68.1 to 81.4) in females reaching 56.0 million (55.7 to 56.3) and 75.1 million (74.7 to 75.5) respectively. The age-standardized incidence rate (ASIR) increased by 3.4% (2.5 to 4.3), resulting in an ASIR of 152,028.8 (144,769.6 to 160,731.4) per 100,000. The percentage changes in females (3.6% (2.8 to 4.5)) were slightly higher than males (3.1% (1.9 to 4.2) per 100,000), although not significant.

The incidence of NCDs was consistently higher in women across all age groups. The gender gap progressively widened from the 5–9 years age group, peaking in the 35–39 age group, before narrowing thereafter. Notably, the pattern of NCDs varied by age group for each sex. In males, incidence peaked in the 5–9 years and 80 + years age groups. In females, three peaks were observed: in the 5–9 years, 35–39 years, and 80 + years age groups (Fig. 3).

Fig. 3.

The comparison of burden metrics of non-communicable diseases (NCDs) in different age groups in Iran between 1990 and 2021.

The ASIR increased in all provinces. Based on decomposition analysis, population growth was the main cause of this increase in females and males of all provinces except in females of Hamedan(Table 2). In 2021, Fars reported the highest ASIR for males, with a value of 136,388 (127,367 to 146,360) per 100,000, whereas West Azarbayejan had the highest ASIR among females at 178,012 (168,369 to 188,023) per 100,000. In contrast, Hamadan exhibited the lowest ASIR for both at 124,301 (115,955 to 132,794) per 100,000 in males, and 167,217 (158,635 to 176,543) per 100,000 in females, respectively (Supplementary Material 1, Fig. 4). Moreover, regarding the SDI, there were no notable differences in ASIR of provinces in different SDI quintiles with regards to sex (Fig. 5).

Table 2.

Decomposition analysis of incidence of NCDs in provinces.

Location	Sex	New cases		Expected new cases in 2021		1990–2021 new cases change cause (%)			Overall change (%)
		1990	2021	Population growth	Population growth + aging	Population growth (%)	Age Structure change (%)	Incidence rate change (%)
Iran (Islamic Republic of)	Both	84,231,608 (77,989,138 to 90,866,552)	131,543,301 (125,772,216 to 138,810,781)	126,035,036 (119,521,209 to 131,842,615)	129,909,690 (125,755,743 to 133,725,221)	49.6 (36.7 to 63.6)	4.6 (1.5 to 8.1)	2.3 (− 6.6 to 10.6)	56.5 (43.6 to 70.6)
Iran (Islamic Republic of)	Male	38,047,920 (34,889,202 to 41,582,393)	56,163,509 (53,149,884 to 59,494,320)	56,757,542 (52,436,235 to 61,095,772)	55,576,533 (52,891,545 to 58,210,478)	49.4 (34.1 to 66.5)	− 3.1 (− 8.0 to 1.9)	1.3 (− 9.5 to 11.8)	47.9 (33.8 to 64.4)
Iran (Islamic Republic of)	Female	46,183,688 (42,975,495 to 49,531,817)	75,379,791 (71,828,789 to 79,206,626)	69,156,359 (64,896,613 to 73,516,705)	74,267,066 (71,102,501 to 77,022,048)	50.0 (35.9 to 65.1)	11.1 (6.5 to 15.4)	2.7 (− 8.2 to 13.4)	63.5 (49.9 to 78.6)
Alborz	Both	2,201,025 (2,037,281 to 2,377,749)	4,674,933 (4,452,215 to 4,944,900)	4,513,739 (4,287,145 to 4,744,420)	4,621,473 (4,491,884 to 4,754,094)	105.3 (85.3 to 125.1)	4.9 (− 0.8 to 10.5)	2.3 (− 10.8 to 15.3)	112.4 (94.2 to 132.9)
Alborz	Male	1,011,132 (930,381 to 1,108,355)	1,994,710 (1,881,700 to 2,128,214)	2,045,866 (1,875,543 to 2,206,129)	1,977,590 (1,880,897 to 2,072,622)	101.9 (79.1 to 126.3)	− 6.9 (− 14.8 to 2.0)	2.2 (− 13.8 to 16.4)	96.7 (77.9 to 118.3)
Alborz	Female	1,189,893 (1,108,883 to 1,283,197)	2,680,223 (2,531,603 to 2,827,491)	2,478,003 (2,320,944 to 2,638,390)	2,645,032 (2,539,498 to 2,747,115)	108.4 (89.3 to 130.0)	14.2 (6.8 to 21.5)	3.2 (− 12.6 to 16.9)	125.7 (107.1 to 148.1)
Ardebil	Both	1,689,026 (1,548,692 to 1,847,615)	1,986,267 (1,880,068 to 2,104,020)	1,883,182 (1,775,505 to 1,981,894)	1,949,938 (1,883,732 to 2,011,963)	11.4 (0.0 to 23.5)	3.9 (0.9 to 7.1)	2.2 (− 5.4 to 10.3)	17.4 (6.0 to 30.3)
Ardebil	Male	771,493 (697,354 to 859,228)	855,930 (802,569 to 917,137)	864,310 (792,225 to 938,560)	840,897 (798,425 to 880,718)	12.0 (− 2.5 to 28.3)	− 3.1 (− 8.1 to 1.7)	2.0 (− 7.1 to 11.4)	11.3 (− 2.7 to 26.4)
Ardebil	Female	917,533 (847,298 to 994,337)	1,130,337 (1,068,589 to 1,199,681)	1,022,359 (948,855 to 1,094,438)	1,112,194 (1,066,416 to 1,155,674)	11.3 (0.4 to 24.2)	9.8 (5.6 to 14.2)	2.0 (− 5.9 to 11.3)	23.2 (11.5 to 36.4)
Bushehr	Both	1,053,625 (976,152 to 1,146,589)	1,976,363 (1,868,880 to 2,103,457)	1,907,531 (1,811,179 to 2,011,975)	1,943,714 (1,871,583 to 2,012,946)	81.4 (65.2 to 99.7)	3.1 (− 0.5 to 6.8)	3.2 (− 8.8 to 17.0)	87.5 (69.9 to 107.2)
Bushehr	Male	476,821 (434,327 to 524,103)	884,245 (826,478 to 954,113)	895,182 (818,701 to 968,990)	871,921 (822,187 to 920,613)	88.4 (66.2 to 112.8)	− 4.9 (− 11.1 to 1.6)	2.3 (− 14.5 to 19.7)	85.5 (64.2 to 109.0)
Bushehr	Female	576,804 (538,418 to 632,722)	1,092,118 (1,034,911 to 1,154,409)	1,011,181 (940,515 to 1,082,355)	1,072,671 (1,021,378 to 1,123,944)	75.2 (57.0 to 95.0)	10.7 (6.0 to 15.7)	3.3 (− 11.6 to 17.6)	89.7 (71.6 to 108.6)
Chahar Mahaal and Bakhtiari	Both	1,046,224 (955,164 to 1,146,381)	1,543,429 (1,455,772 to 1,653,471)	1,474,029 (1,389,422 to 1,559,667)	1,522,221 (1,466,541 to 1,577,651)	40.6 (27.2 to 57.0)	4.6 (1.1 to 8.2)	2.1 (− 8.7 to 12.1)	47.4 (32.7 to 64.9)
Chahar Mahaal and Bakhtiari	Male	478,008 (432,377 to 529,856)	661,611 (614,800 to 720,887)	671,278 (609,506 to 731,102)	655,840 (616,555 to 692,049)	40.3 (23.7 to 61.4)	− 3.5 (− 9.0 to 2.1)	1.1 (− 12.1 to 15.2)	39.1 (21.1 to 58.7)
Chahar Mahaal and Bakhtiari	Female	568,216 (519,478 to 617,244)	881,818 (836,528 to 937,627)	801,933 (742,946 to 860,903)	865,239 (825,882 to 903,919)	41.5 (25.1 to 58.3)	11.2 (6.4 to 16.0)	3.0 (− 8.7 to 13.7)	55.4 (40.3 to 71.9)
East Azarbayejan	Both	5,074,318 (4,705,413 to 5,526,420)	6,338,634 (6,017,107 to 6,722,034)	6,089,343 (5,778,726 to 6,430,753)	6,268,889 (6,066,264 to 6,493,493)	19.7 (9.6 to 33.1)	3.4 (0.6 to 6.3)	1.5 (− 6.4 to 9.2)	24.5 (12.6 to 38.5)
East Azarbayejan	Male	2,304,382 (2,109,222 to 2,530,608)	2,746,671 (2,588,555 to 2,947,533)	2,775,042 (2,571,423 to 2,995,678)	2,720,871 (2,589,035 to 2,863,478)	20.1 (7.3 to 35.2)	− 2.4 (− 6.7 to 1.7)	1.1 (− 8.6 to 10.3)	19.0 (6.9 to 32.6)
East Azarbayejan	Female	2,769,936 (2,562,716 to 2,995,009)	3,591,963 (3,399,237 to 3,785,308)	3,319,153 (3,107,792 to 3,538,748)	3,552,463 (3,400,910 to 3,705,869)	20.3 (8.8 to 33.9)	8.4 (4.3 to 12.2)	1.6 (− 6.7 to 10.5)	30.2 (18.6 to 43.3)
Fars	Both	5,485,459 (5,039,622 to 5,961,868)	8,104,628 (7,664,384 to 8,575,627)	7,726,786 (7,303,387 to 8,109,638)	7,951,334 (7,708,438 to 8,180,434)	40.6 (27.7 to 54.6)	4.1 (0.2 to 8.1)	3.0 (− 6.0 to 12.2)	47.7 (34.0 to 64.4)
Fars	Male	2,506,245 (2,278,949 to 2,745,163)	3,520,822 (3,293,230 to 3,754,405)	3,523,939 (3,254,622 to 3,793,420)	3,437,385 (3,288,021 to 3,577,321)	40.7 (25.3 to 60.4)	− 3.6 (− 9.5 to 1.8)	3.3 (− 8.3 to 14.3)	40.2 (25.4 to 57.5)
Fars	Female	2,979,214 (2,745,270 to 3,248,546)	4,583,806 (4,328,583 to 4,845,038)	4,190,727 (3,891,671 to 4,505,566)	4,506,174 (4,332,435 to 4,697,300)	40.0 (26.4 to 56.1)	10.8 (5.5 to 16.3)	2.6 (− 8.4 to 12.9)	53.6 (38.8 to 69.5)
Gilan	Both	3,343,238 (3,086,976 to 3,639,358)	3,928,189 (3,747,595 to 4,131,773)	3,834,034 (3,655,700 to 4,014,622)	3,948,242 (3,840,150 to 4,066,816)	14.4 (4.7 to 26.3)	3.5 (0.7 to 6.4)	− 0.6 (− 7.6 to 5.8)	17.3 (7.1 to 29.3)
Gilan	Male	1,472,166 (1,338,512 to 1,618,562)	1,646,882 (1,555,593 to 1,740,793)	1,694,641 (1,561,532 to 1,831,029)	1,661,415 (1,590,609 to 1,739,313)	14.8 (1.4 to 31.3)	− 2.3 (− 7.0 to 2.4)	− 0.7 (− 9.4 to 6.5)	11.8 (− 0.3 to 26.2)
Gilan	Female	1,871,072 (1,746,079 to 2,024,991)	2,281,307 (2,175,172 to 2,402,607)	2,137,380 (2,010,128 to 2,272,094)	2,286,955 (2,204,738 to 2,369,001)	14.2 (3.6 to 26.3)	8.0 (3.9 to 12.2)	− 0.3 (− 8.2 to 7.5)	22.1 (11.5 to 33.6)
Golestan	Both	1,996,071 (1,853,848 to 2,173,250)	3,048,919 (2,880,657 to 3,242,477)	2,939,127 (2,775,407 to 3,098,046)	3,028,698 (2,919,214 to 3,137,882)	47.4 (34.3 to 63.2)	4.5 (1.3 to 7.9)	1.2 (− 10.3 to 11.8)	53.2 (38.7 to 69.0)
Golestan	Male	898,342 (824,662 to 992,171)	1,301,511 (1,219,271 to 1,391,997)	1,320,283 (1,201,535 to 1,429,888)	1,293,304 (1,220,840 to 1,369,292)	46.4 (28.4 to 65.6)	− 3.0 (− 7.6 to 2.3)	1.0 (− 11.1 to 13.3)	44.6 (30.4 to 61.9)
Golestan	Female	1,097,729 (1,024,439 to 1,201,683)	1,747,408 (1,647,465 to 1,852,068)	1,618,547 (1,504,157 to 1,733,725)	1,733,103 (1,657,538 to 1,817,391)	46.8 (33.1 to 63.8)	10.4 (6.3 to 14.7)	1.0 (− 10.4 to 12.8)	58.3 (44.4 to 76.3)
Hamadan	Both	2,415,229 (2,221,259 to 2,633,256)	2,591,294 (2,462,960 to 2,736,383)	2,510,502 (2,385,709 to 2,641,405)	2,611,276 (2,533,635 to 2,692,643)	4.0 (− 5.8 to 14.7)	4.1 (1.5 to 6.8)	− 1.0 (− 7.1 to 5.6)	6.9 (− 2.9 to 18.7)
Hamadan	Male	1,104,790 (1,005,533 to 1,231,699)	1,106,116 (1,036,273 to 1,179,421)	1,138,929 (1,041,465 to 1,239,654)	1,122,748 (1,065,183 to 1,182,936)	3.3 (− 9.3 to 18.1)	− 1.6 (− 5.8 to 2.6)	− 1.5 (− 10.0 to 7.2)	− 0.2 (− 10.3 to 13.3)
Hamadan	Female	1,310,439 (1,211,529 to 1,414,013)	1,485,178 (1,413,751 to 1,565,775)	1,376,960 (1,286,123 to 1,467,766)	1,490,007 (1,430,155 to 1,544,231)	4.8 (− 5.1 to 16.9)	8.5 (5.0 to 12.3)	− 0.5 (− 7.4 to 7.1)	13.0 (3.3 to 24.8)
Hormozgan	Both	1,361,344 (1,261,771 to 1,476,303)	3,066,958 (2,891,796 to 3,273,000)	2,944,649 (2,790,535 to 3,102,528)	3,026,492 (2,917,374 to 3,140,070)	115.8 (95.9 to 138.9)	6.1 (2.1 to 10.6)	3.1 (− 14.4 to 19.7)	125.3 (103.9 to 149.8)
Hormozgan	Male	624,401 (572,733 to 682,605)	1,341,296 (1,255,335 to 1,447,506)	1,356,098 (1,244,844 to 1,463,651)	1,328,231 (1,251,301 to 1,403,094)	117.3 (93.7 to 145.3)	− 4.3 (− 10.8 to 2.2)	1.4 (− 17.9 to 21.7)	115.2 (90.9 to 140.3)
Hormozgan	Female	736,944 (684,522 to 795,553)	1,725,663 (1,621,477 to 1,831,510)	1,590,450 (1,475,327 to 1,694,801)	1,700,887 (1,616,880 to 1,777,980)	115.5 (94.5 to 139.4)	14.9 (9.3 to 20.8)	3.6 (− 15.4 to 22.4)	134.4 (112.9 to 158.3)
Ilam	Both	641,917 (585,746 to 700,766)	940,122 (888,607 to 1,000,052)	886,093 (840,237 to 936,737)	923,476 (893,977 to 952,636)	38.1 (25.9 to 54.1)	5.8 (1.8 to 9.8)	2.4 (− 7.8 to 13.1)	46.5 (31.9 to 63.3)
Ilam	Male	294,750 (266,549 to 325,735)	395,712 (368,860 to 425,654)	402,919 (367,564 to 439,104)	389,241 (369,871 to 409,912)	36.2 (19.8 to 55.0)	− 4.7 (− 11.0 to 2.2)	2.0 (− 9.6 to 14.0)	33.9 (18.7 to 51.5)
Ilam	Female	347,167 (318,289 to 378,079)	544,410 (515,480 to 580,691)	487,032 (450,241 to 519,005)	534,870 (513,488 to 554,662)	40.7 (25.8 to 57.4)	14.0 (8.3 to 19.9)	3.0 (− 7.3 to 13.2)	57.6 (41.0 to 74.5)
Isfahan	Both	5,689,611 (5,251,723 to 6,181,940)	8,448,925 (8,008,627 to 8,911,966)	8,127,168 (7,725,667 to 8,502,102)	8,357,654 (8,099,439 to 8,609,353)	42.9 (29.7 to 57.6)	4.1 (0.9 to 7.5)	1.7 (− 6.7 to 10.7)	48.7 (35.4 to 65.5)
Isfahan	Male	2,598,118 (2,367,068 to 2,869,467)	3,579,101 (3,374,685 to 3,806,321)	3,648,483 (3,367,620 to 3,928,948)	3,555,277 (3,383,433 to 3,724,918)	41.0 (23.1 to 60.9)	− 3.7 (− 9.0 to 1.7)	0.9 (− 10.2 to 10.8)	37.7 (23.7 to 57.8)
Isfahan	Female	3,091,493 (2,877,369 to 3,325,155)	4,869,825 (4,611,576 to 5,129,879)	4,485,832 (4,234,617 to 4,777,152)	4,799,087 (4,631,971 to 5,000,192)	45.4 (31.7 to 59.3)	10.1 (5.4 to 14.7)	1.8 (− 8.8 to 11.7)	57.1 (43.8 to 72.7)
Kerman	Both	2,742,370 (2,518,034 to 2,993,272)	5,130,990 (4,837,902 to 5,422,555)	5,063,592 (4,759,752 to 5,346,362)	5,208,529 (5,004,786 to 5,389,060)	84.6 (68.2 to 105.1)	5.3 (0.9 to 9.7)	− 2.8 (− 16.3 to 9.8)	87.4 (68.5 to 108.0)
Kerman	Male	1,240,970 (1,127,632 to 1,365,966)	2,244,604 (2,091,623 to 2,395,893)	2,332,087 (2,145,759 to 2,513,050)	2,288,448 (2,168,647 to 2,411,158)	87.9 (66.5 to 113.4)	− 3.4 (− 9.7 to 2.5)	− 3.6 (− 19.4 to 12.5)	80.5 (61.3 to 104.3)
Kerman	Female	1,501,400 (1,377,532 to 1,630,554)	2,886,386 (2,725,764 to 3,056,773)	2,720,074 (2,520,965 to 2,907,280)	2,921,904 (2,790,810 to 3,056,327)	81.8 (63.8 to 100.9)	13.5 (8.5 to 19.0)	− 2.1 (− 16.1 to 12.6)	92.8 (75.4 to 112.3)
Kermanshah	Both	2,466,119 (2,262,251 to 2,705,621)	3,079,770 (2,917,969 to 3,274,891)	2,921,469 (2,762,651 to 3,079,426)	3,035,804 (2,938,816 to 3,128,232)	18.3 (6.7 to 32.2)	4.7 (1.4 to 8.1)	1.7 (− 6.2 to 9.9)	24.7 (12.1 to 39.4)
Kermanshah	Male	1,135,436 (1,028,706 to 1,264,471)	1,311,535 (1,224,130 to 1,411,169)	1,318,330 (1,209,762 to 1,423,441)	1,294,476 (1,228,483 to 1,353,537)	15.8 (1.1 to 32.6)	− 2.2 (− 6.7 to 2.6)	1.5 (− 7.4 to 11.5)	15.4 (2.5 to 30.6)
Kermanshah	Female	1,330,683 (1,232,010 to 1,438,084)	1,768,235 (1,672,575 to 1,872,962)	1,602,175 (1,501,504 to 1,711,008)	1,740,015 (1,674,781 to 1,809,585)	20.8 (9.5 to 33.5)	10.3 (5.6 to 14.3)	2.1 (− 6.5 to 11.0)	33.0 (21.4 to 45.9)
Khorasan− e− Razavi	Both	6,843,538 (6,246,030 to 7,506,757)	10,411,334 (9,800,074 to 11,106,448)	9,997,106 (9,432,933 to 10,569,008)	10,270,263 (9,886,654 to 10,648,569)	46.0 (31.5 to 62.9)	4.0 (0.7 to 7.5)	2.3 (− 8.9 to 13.9)	52.4 (36.4 to 70.5)
Khorasan-e-Razavi	Male	3,081,239 (2,774,071 to 3,425,819)	4,445,585 (4,143,669 to 4,792,819)	4,498,604 (4,088,583 to 4,919,930)	4,392,699 (4,122,936 to 4,660,682)	46.0 (27.7 to 70.2)	− 3.5 (− 9.3 to 2.0)	1.3 (− 11.6 to 15.7)	44.4 (28.6 to 65.2)
Khorasan-e-Razavi	Female	3,762,298 (3,464,925 to 4,073,724)	5,965,748 (5,625,344 to 6,331,395)	5,484,222 (5,102,938 to 5,857,204)	5,875,278 (5,602,450 to 6,143,770)	45.6 (30.5 to 61.9)	10.5 (6.1 to 15.0)	2.1 (− 9.9 to 15.0)	58.3 (42.7 to 76.6)
Khuzestan	Both	4,648,716 (4,284,507 to 5,089,742)	7,686,245 (7,238,445 to 8,256,597)	7,278,402 (6,902,783 to 7,668,504)	7,525,980 (7,261,865 to 7,789,142)	56.6 (41.4 to 73.9)	5.3 (2.0 to 8.8)	3.8 (− 9.0 to 15.8)	65.2 (48.7 to 85.8)
Khuzestan	Male	2,115,355 (1,918,492 to 2,333,346)	3,310,382 (3,065,880 to 3,591,002)	3,310,491 (3,041,594 to 3,575,003)	3,239,249 (3,055,268 to 3,419,964)	56.4 (37.5 to 77.9)	− 3.0 (− 8.7 to 2.3)	3.9 (− 11.5 to 19.7)	57.3 (38.2 to 78.7)
Khuzestan	Female	2,533,361 (2,348,463 to 2,747,061)	4,375,863 (4,128,270 to 4,666,180)	3,970,696 (3,709,694 to 4,231,415)	4,284,710 (4,100,171 to 4,469,077)	56.2 (42.4 to 74.2)	12.5 (8.1 to 17.2)	3.4 (− 9.5 to 17.1)	73.0 (56.9 to 91.8)
Kohgiluyeh and Boyer− Ahmad	Both	700,108 (638,064 to 766,261)	1,178,013 (1,108,736 to 1,252,325)	1,122,798 (1,063,886 to 1,186,377)	1,162,057 (1,122,466 to 1,202,366)	60.2 (44.0 to 79.4)	5.5 (1.1 to 9.8)	1.9 (− 10.1 to 14.0)	68.2 (50.9 to 87.3)
Kohgiluyeh and Boyer-Ahmad	Male	320,339 (289,506 to 355,232)	508,695 (471,879 to 546,809)	515,127 (472,706 to 562,125)	503,621 (476,928 to 532,369)	61.0 (42.4 to 84.1)	− 3.7 (− 10.7 to 2.6)	1.4 (− 13.5 to 16.5)	59.0 (39.4 to 80.1)
Kohgiluyeh and Boyer-Ahmad	Female	379,769 (347,125 to 414,785)	669,318 (631,746 to 711,114)	604,505 (560,998 to 649,630)	656,526 (627,470 to 685,386)	58.4 (42.3 to 77.9)	13.9 (8.5 to 19.7)	3.3 (− 10.3 to 16.3)	76.1 (59.3 to 96.0)
Kurdistan	Both	1,807,925 (1,656,523 to 1,985,517)	2,620,470 (2,484,376 to 2,779,831)	2,499,079 (2,358,868 to 2,642,399)	2,579,150 (2,493,733 to 2,659,478)	38.3 (24.1 to 52.8)	4.3 (0.2 to 8.5)	2.5 (− 7.2 to 11.6)	45.1 (30.5 to 61.1)
Kurdistan	Male	819,518 (740,577 to 910,265)	1,118,263 (1,041,296 to 1,194,723)	1,135,923 (1,037,154 to 1,234,676)	1,101,820 (1,043,539 to 1,159,565)	38.5 (19.0 to 58.8)	− 4.3 (− 10.6 to 1.9)	1.7 (− 9.5 to 13.5)	36.1 (20.4 to 54.9)
Kurdistan	Female	988,407 (911,547 to 1,077,305)	1,502,206 (1,422,720 to 1,598,926)	1,367,486 (1,273,518 to 1,465,720)	1,476,385 (1,417,669 to 1,540,778)	38.3 (23.4 to 55.2)	11.2 (6.0 to 16.6)	2.7 (− 8.3 to 13.4)	52.1 (37.0 to 68.1)
Lorestan	Both	2,216,727 (2,034,053 to 2,417,656)	2,693,784 (2,543,787 to 2,885,358)	2,554,119 (2,422,218 to 2,692,216)	2,649,055 (2,567,227 to 2,734,799)	15.4 (3.8 to 27.7)	4.3 (1.1 to 7.3)	2.0 (− 6.7 to 10.2)	21.7 (8.6 to 36.0)
Lorestan	Male	1,014,583 (926,059 to 1,124,738)	1,141,610 (1,062,951 to 1,228,901)	1,156,091 (1,054,243 to 1,256,421)	1,127,157 (1,066,049 to 1,185,611)	13.8 (0.0 to 28.6)	− 2.9 (− 7.3 to 1.7)	1.3 (− 8.6 to 11.5)	12.5 (− 0.3 to 26.5)
Lorestan	Female	1,202,143 (1,108,447 to 1,301,148)	1,552,174 (1,459,630 to 1,651,565)	1,402,809 (1,298,867 to 1,504,606)	1,523,001 (1,452,638 to 1,590,954)	16.5 (5.2 to 31.0)	10.1 (6.0 to 14.4)	2.0 (-6.6 to 11.9)	29.1 (17.3 to 43.7)
Markazi	Both	1,762,824 (1,615,379 to 1,928,162)	2,244,192 (2,129,383 to 2,387,917)	2,141,816 (2,028,338 to 2,258,075)	2,213,571 (2,144,481 to 2,284,183)	21.3 (9.7 to 34.6)	4.1 (0.5 to 7.4)	1.8 (− 6.4 to 10.6)	27.4 (15.2 to 42.3)
Markazi	Male	787,536 (714,252 to 878,950)	955,868 (893,557 to 1,024,451)	959,857 (888,763 to 1,042,566)	942,619 (899,214 to 988,030)	22.6 (7.3 to 39.5)	− 2.4 (− 7.7 to 2.5)	1.6 (− 8.3 to 11.6)	21.2 (7.7 to 38.9)
Markazi	Female	975,288 (900,900 to 1,053,974)	1,288,324 (1,219,631 to 1,367,329)	1,174,721 (1,102,765 to 1,251,098)	1,269,158 (1,219,620 to 1,316,061)	20.4 (9.3 to 32.9)	9.7 (5.2 to 13.5)	1.9 (− 7.5 to 10.8)	31.7 (19.8 to 45.6)
Mazandaran	Both	3,803,552 (3,520,579 to 4,127,347)	5,485,445 (5,221,153 to 5,820,681)	5,226,929 (4,962,146 to 5,488,724)	5,407,996 (5,242,315 to 5,557,784)	37.8 (25.2 to 50.8)	4.8 (1.0 to 8.5)	2.0 (− 6.7 to 11.4)	44.7 (31.4 to 58.1)
Mazandaran	Male	1,662,610 (1,506,387 to 1,845,738)	2,281,226 (2,142,356 to 2,445,646)	2,301,464 (2,123,724 to 2,487,120)	2,251,701 (2,152,285 to 2,362,879)	38.1 (21.1 to 58.4)	− 2.8 (− 8.9 to 2.8)	1.8 (− 9.2 to 12.4)	36.9 (21.0 to 55.4)
Mazandaran	Female	2,140,941 (1,992,214 to 2,311,508)	3,204,219 (3,048,650 to 3,398,047)	2,926,046 (2,762,707 to 3,086,010)	3,162,606 (3,040,993 to 3,272,997)	36.7 (24.2 to 50.4)	10.9 (6.8 to 15.3)	1.4 (− 8.6 to 11.7)	49.3 (36.2 to 64.4)
North Khorasan	Both	905,187 (837,256 to 985,648)	1,333,150 (1,254,426 to 1,418,567)	1,263,117 (1,197,702 to 1,322,216)	1,314,265 (1,268,137 to 1,360,340)	39.8 (27.1 to 52.9)	5.7 (3.4 to 8.4)	2.2 (− 8.7 to 13.0)	47.7 (32.7 to 62.9)
North Khorasan	Male	404,319 (370,960 to 443,808)	572,394 (532,780 to 617,908)	566,288 (520,556 to 608,237)	566,700 (533,054 to 599,203)	40.6 (24.4 to 58.2)	0.1 (− 3.6 to 3.8)	1.0 (− 11.8 to 15.2)	41.7 (26.4 to 58.9)
North Khorasan	Female	500,869 (464,258 to 541,246)	760,756 (716,681 to 807,717)	693,673 (650,007 to 740,434)	744,941 (712,839 to 782,272)	38.7 (26.3 to 53.4)	10.4 (7.0 to 13.7)	3.2 (− 8.9 to 14.6)	51.9 (38.7 to 68.7)
Qazvin	Both	1,382,638 (1,263,833 to 1,507,716)	2,039,506 (1,933,402 to 2,165,724)	1,949,308 (1,848,370 to 2,055,491)	2,000,770 (1,934,502 to 2,063,555)	40.6 (27.0 to 56.6)	3.8 (− 0.6 to 7.7)	2.6 (− 7.0 to 12.4)	47.3 (32.7 to 62.5)
Qazvin	Male	626,876 (566,023 to 691,441)	870,002 (813,814 to 933,259)	888,278 (811,769 to 962,854)	855,166 (810,450 to 895,388)	41.4 (24.2 to 62.3)	− 5.4 (− 12.0 to 0.7)	2.5 (− 8.9 to 14.4)	38.9 (22.9 to 56.2)
Qazvin	Female	755,762 (695,492 to 815,442)	1,169,504 (1,110,870 to 1,237,083)	1,067,046 (993,332 to 1,134,693)	1,149,614 (1,102,660 to 1,196,230)	41.0 (26.5 to 56.5)	11.0 (6.0 to 16.1)	2.9 (− 6.7 to 13.1)	54.9 (40.1 to 70.9)
Qom	Both	1,076,870 (990,938 to 1,180,685)	2,192,054 (2,074,402 to 2,331,435)	2,096,579 (1,977,473 to 2,209,315)	2,161,467 (2,087,176 to 2,240,943)	93.7 (75.3 to 116.4)	6.0 (1.6 to 11.0)	2.7 (− 11.0 to 15.8)	102.9 (84.1 to 124.4)
Qom	Male	490,836 (443,518 to 544,605)	941,019 (877,203 to 1,012,441)	947,630 (867,001 to 1,034,054)	928,544 (874,615 to 982,299)	92.2 (68.1 to 121.0)	− 4.0 (− 10.8 to 3.0)	2.6 (− 16.2 to 20.6)	91.1 (68.5 to 117.1)
Qom	Female	586,034 (544,344 to 639,358)	1,251,035 (1,188,148 to 1,323,857)	1,151,004 (1,067,770 to 1,234,207)	1,234,205 (1,178,356 to 1,288,079)	96.5 (76.2 to 119.7)	14.4 (8.1 to 20.6)	3.0 (− 12.1 to 18.1)	113.3 (95.4 to 135.3)
Semnan	Both	690,099 (636,729 to 749,440)	1,181,598 (1,123,855 to 1,251,929)	1,142,752 (1,082,664 to 1,200,514)	1,166,686 (1,129,003 to 1,201,568)	66.1 (51.5 to 82.2)	3.5 (− 1.0 to 7.6)	2.5 (− 8.6 to 12.9)	72.0 (56.1 to 89.6)
Semnan	Male	313,494 (285,319 to 345,417)	505,230 (475,863 to 540,562)	515,384 (473,296 to 557,610)	498,722 (473,688 to 524,085)	65.2 (45.2 to 86.5)	− 5.2 (− 11.5 to 1.2)	1.8 (− 11.2 to 15.4)	61.6 (43.8 to 81.9)
Semnan	Female	376,604 (348,632 to 407,691)	676,368 (641,426 to 716,092)	629,172 (586,616 to 670,804)	667,324 (640,065 to 696,349)	67.2 (49.9 to 84.6)	10.0 (4.8 to 15.6)	2.4 (− 9.0 to 14.9)	79.5 (63.5 to 98.1)
Sistan and Baluchistan	Both	2,109,369 (1,926,980 to 2,335,089)	4,725,305 (4,375,338 to 5,160,667)	4,555,880 (4,286,179 to 4,852,160)	4,651,400 (4,419,111 to 4,899,500)	116.2 (94.9 to 143.0)	4.4 (1.7 to 7.1)	2.9 (− 18.6 to 24.0)	124.3 (97.4 to 153.8)
Sistan and Baluchistan	Male	961,409 (866,589 to 1,081,917)	2,087,911 (1,913,597 to 2,319,004)	2,087,450 (1,880,370 to 2,290,785)	2,067,764 (1,892,930 to 2,238,286)	117.4 (88.8 to 152.5)	− 2.2 (− 5.8 to 1.7)	2.3 (− 28.5 to 30.1)	117.1 (86.5 to 154.1)
Sistan and Baluchistan	Female	1,147,960 (1,053,470 to 1,262,192)	2,637,394 (2,450,767 to 2,865,859)	2,469,178 (2,280,263 to 2,674,835)	2,583,566 (2,428,495 to 2,749,920)	115.9 (93.9 to 142.7)	9.9 (6.1 to 13.5)	4.6 (− 17.5 to 30.4)	130.0 (106.6 to 160.3)
South Khorasan	Both	974,793 (894,791 to 1,072,109)	1,355,595 (1,271,644 to 1,451,715)	1,299,147 (1,231,751 to 1,367,810)	1,335,593 (1,288,272 to 1,385,951)	32.7 (19.1 to 47.9)	3.8 (1.3 to 6.5)	2.3 (− 8.2 to 12.2)	38.9 (23.7 to 55.7)
South Khorasan	Male	440,640 (399,424 to 489,787)	588,619 (543,586 to 637,793)	589,707 (533,211 to 643,668)	580,460 (542,188 to 617,449)	33.4 (16.6 to 54.9)	− 2.0 (− 6.6 to 2.7)	2.1 (− 11.7 to 16.3)	33.6 (17.3 to 52.4)
South Khorasan	Female	534,153 (494,355 to 581,445)	766,976 (722,280 to 817,376)	706,612 (658,988 to 750,522)	754,409 (719,408 to 787,219)	32.3 (19.3 to 46.4)	9.1 (5.8 to 12.6)	2.1 (− 8.5 to 13.4)	43.4 (30.3 to 59.2)
Tehran	Both	12,286,337 (11,363,342 to 13,213,640)	22,549,400 (21,431,298 to 23,861,822)	21,466,795 (20,506,532 to 22,427,032)	22,228,347 (21,566,009 to 22,868,215)	74.6 (59.6 to 91.2)	6.3 (2.3 to 10.4)	2.8 (− 8.8 to 14.3)	83.8 (67.4 to 101.4)
Tehran	Male	5,470,938 (5,010,137 to 5,932,312)	9,390,990 (8,821,698 to 9,972,296)	9,387,975 (8,735,772 to 10,031,270)	9,307,944 (8,897,791 to 9,726,114)	71.4 (53.0 to 92.7)	− 1.4 (− 7.1 to 3.9)	1.7 (− 11.4 to 15.4)	71.6 (54.2 to 90.5)
Tehran	Female	6,815,399 (6,358,062 to 7,295,994)	13,158,410 (12,492,086 to 13,945,765)	12,111,939 (11,451,256 to 12,796,850)	12,911,914 (12,466,527 to 13,422,730)	78.0 (62.0 to 95.3)	11.6 (6.3 to 16.9)	3.3 (− 9.7 to 16.3)	93.2 (76.8 to 111.2)
West Azarbayejan	Both	3,484,472 (3,235,186 to 3,800,490)	5,469,801 (5,169,353 to 5,808,686)	5,245,960 (4,970,852 to 5,512,297)	5,394,188 (5,211,025 to 5,579,860)	50.8 (37.7 to 66.3)	4.2 (1.1 to 7.5)	1.9 (− 8.4 to 13.9)	57.6 (43.7 to 74.2)
West Azarbayejan	Male	1,557,858 (1,424,891 to 1,696,446)	2,335,296 (2,186,008 to 2,501,286)	2,356,478 (2,172,346 to 2,561,087)	2,303,902 (2,175,851 to 2,436,211)	51.5 (35.2 to 70.9)	− 3.4 (− 8.4 to 1.0)	2.1 (− 10.7 to 14.9)	49.6 (34.5 to 67.1)
West Azarbayejan	Female	1,926,614 (1,794,264 to 2,091,417)	3,134,505 (2,967,779 to 3,310,365)	2,892,462 (2,696,005 to 3,086,625)	3,091,203 (2,958,311 to 3,228,936)	50.3 (36.3 to 65.5)	10.4 (6.2 to 14.8)	2.3 (− 9.3 to 12.5)	62.7 (48.3 to 78.7)
Yazd	Both	1,014,053 (940,065 to 1,102,912)	1,842,111 (1,743,418 to 1,961,952)	1,778,405 (1,691,363 to 1,876,131)	1,820,620 (1,761,863 to 1,888,689)	75.0 (60.0 to 93.2)	4.1 (0.5 to 7.5)	2.0 (− 11.0 to 14.6)	81.8 (65.5 to 100.7)
Yazd	Male	466,083 (426,976 to 512,695)	805,547 (750,818 to 865,618)	817,311 (745,034 to 886,581)	796,977 (749,188 to 841,937)	75.8 (53.8 to 98.4)	− 4.5 (− 9.8 to 1.6)	2.3 (− 14.0 to 18.6)	73.6 (54.2 to 94.7)
Yazd	Female	547,970 (511,274 to 596,687)	1,036,564 (978,925 to 1,104,710)	961,543 (898,860 to 1,028,166)	1,022,948 (976,395 to 1,071,855)	75.3 (58.8 to 94.6)	11.3 (6.8 to 16.0)	2.0 (− 10.9 to 16.3)	89.1 (71.4 to 109.1)
Zanjan	Both	1,318,816 (1,208,032 to 1,450,048)	1,675,868 (1,587,735 to 1,773,325)	1,596,688 (1,501,230 to 1,682,550)	1,653,193 (1,595,912 to 1,706,040)	21.0 (8.7 to 35.5)	4.2 (0.7 to 7.9)	1.7 (− 6.2 to 10.0)	26.7 (14.3 to 41.8)
Zanjan	Male	597,226 (541,391 to 668,017)	714,115 (669,023 to 766,068)	726,651 (656,012 to 793,809)	706,119 (668,142 to 743,549)	21.3 (5.4 to 40.8)	− 3.4 (− 9.3 to 2.5)	1.4 (− 8.8 to 12.5)	19.7 (5.0 to 37.5)
Zanjan	Female	721,590 (665,354 to 784,197)	961,752 (910,450 to 1,021,569)	875,716 (812,146 to 932,415)	949,328 (909,820 to 988,069)	21.1 (8.4 to 34.6)	10.3 (5.9 to 14.9)	1.6 (− 7.6 to 11.0)	33.3 (20.3 to 47.1)

Fig. 4.

Percentage change of each burden metric of non− communicable diseases (NCDs) by sex and province in Iran during 1990 to 2021.

Fig. 5.

Comparison of age− standardized rates of burden metrics for non− communicable diseases (NCDs) in Iran by socio− demographic index (SDI) and province between 1990 and 2021.

Deaths

The all− age death number nearly doubled in both sexes reaching 141841.0 (95% UI: 135819.1 to 147730.9) in females and 168024.1 (160370.1 to 175253.2) in males with a higher increase percentage in females (91.9 (78.8 to 116.8)). While the ASDR decreased more in males (-36.5% (-40.3 to -32.0)) compared to females (-34.3% (-37.9 to -29.7)) in the studied period, males exhibited a higher ASDR (477.6 (456.7 to 497.2) per 100,000) in comparison to females (438.1 (420.3 to 455.5)) in 2021 (Table 1; Fig. 1).

In 2021 CVDs was the NCD with the highest death in both sexes combined with 169581.89 (154573.58 to 180461.01) deaths, moreover it caused the highest mortality in both sexes compared to other groups of diseases (males: 258.8 (235.7 to 276.8), females: 253.7 (223.2 to 274.3)). followed by neoplasms (both: 57938.62 (50058.81 to 62706.81), males: 91.8 (77.0 to 100.4), females: 64.3 (56.4 to 70.0)) and diabetes and kidney diseases (both: 28145.3 (24935.24 to 30673.37), males: 39.4 (33.1 to 44.3), females: 43.5 (37.4 to 47.8)) (Fig. 2, Supplementary Material 1).

In contrast to incidence, deaths exhibited a different trend, with a single peak in the 80 + years age group. Deaths increased gradually until the 80 + age group and were higher in males compared to females across all age groups, except in the 80 + age group (Fig. 3).

From a subnational perspective, all provinces showed decreased ASDR for both males and females from 1990 to 2021 (Fig. 4). In most provinces the absolute contribution of the death rate change is the highest. For example, for both sexes nationwide, the death rate component in Iran as a whole is - 103.6%, compared with an 82.8% contribution from age structure change. However, there are notable exceptions. In provinces such as Alborz, Gilan, Golestan, Isfahan, Mazandaran, and Tehran the age structure component is dominant; for instance, in Tehran the age structure change reaches 174.1%, which exceeds the death rate change of − 121.2%. In contrast, in Sistan and Baluchistan population growth is the main contributor, with a contribution of 115.6%—higher than both the death rate change (–109.1%) and the age structure change (55.5%). These patterns hold consistently when analyzing the data separately for males and females (Table 3).

Table 3.

Decomposition analysis of deaths attributed to NCDs in provinces.

Location	Sex	New cases		Expected new cases in 2021		1990–2021 new cases change cause (%)			Overall change (%)
		1990	2021	Population growth	Population growth + aging	Population growth (%)	Age structure change (%)	Incidence rate change (%)
Iran (Islamic Republic of)	Both	168,980 (156,506 to 177,565)	309,865 (300,497 to 319,594)	252,557 (242,134 to 263,383)	485,069 (477,963 to 492,009)	49.3 (39.3 to 61.3)	137.4 (129.2 to 146.8)	− 103.6 (− 113.6 to − 94.9)	82.8 (71.8 to 96.7)
Iran (Islamic Republic of)	Male	95,050 (85,957 to 101,604)	168,024 (160,370 to 175,253)	141,733 (133,495 to 150,409)	264,510 (258,928 to 269,817)	48.8 (35.8 to 63.6)	128.9 (118.4 to 142.3)	− 101.1 (− 114.5 to − 89.9)	76.6 (61.8 to 94.4)
Iran (Islamic Republic of)	Female	73,929 (66,471 to 78,534)	141,841 (135,819 to 147,731)	110,834 (103,192 to 118,573)	220,295 (216,028 to 224,640)	49.7 (35.6 to 67.1)	148.1 (135.2 to 162.3)	− 106.4 (− 119.2 to − 94.4)	91.9 (75.5 to 111.0)
Alborz	Both	3354 (2877 to 3802)	9388 (8198 to 10,826)	6877 (6471 to 7290)	13,664 (13,033 to 14,342)	104.7 (76.4 to 137.3)	201.4 (175.5 to 235.5)	− 127.8 (− 178.9 to − 82.6)	180.0 (128.4 to 240.3)
Alborz	Male	1817 (1424 to 2215)	5229 (4233 to 6386)	3686 (3353 to 3996)	7529 (6994 to 8074)	102.9 (62.3 to 158.2)	212.2 (168.5 to 271.2)	− 127.2 (− 208.3 to − 60.2)	189.7 (110.2 to 293.2)
Alborz	Female	1538 (1274 to 1819)	4160 (3435 to 4958)	3195 (2966 to 3412)	6153 (5782 to 6479)	107.1 (71.5 to 154.9)	191.2 (159.2 to 236.0)	− 126.1 (− 192.0 to − 70.8)	172.8 (106.1 to 251.9)
Ardebil	Both	4103 (3525 to 4703)	5780 (5256 to 6333)	4572 (4150 to 5013)	7961 (7609 to 8300)	11.3 (− 6.2 to 33.2)	82.4 (69.2 to 99.1)	− 52.9 (− 73.0 to − 37.2)	40.1 (19.8 to 68.7)
Ardebil	Male	2293 (1840 to 2713)	3187 (2814 to 3590)	2556 (2274 to 2851)	3941 (3712 to 4198)	11.8 (− 9.4 to 42.7)	60.9 (47.7 to 76.1)	− 32.9 (− 55.3 to − 13.4)	39.5 (9.5 to 74.7)
Ardebil	Female	1810 (1406 to 2110)	2593 (2286 to 2870)	2019 (1736 to 2309)	4015 (3795 to 4226)	11.4 (− 12.2 to 40.5)	110.2 (90.0 to 136.9)	− 78.2 (− 107.9 to − 55.0)	43.5 (15.3 to 80.5)
Bushehr	Both	1665 (1464 to 1882)	3331 (3009 to 3747)	3027 (2833 to 3239)	5068 (4861 to 5277)	81.6 (58.5 to 109.2)	122.4 (106.5 to 142.5)	− 104.0 (− 134.4 to − 76.4)	100.7 (69.9 to 136.3)
Bushehr	Male	918 (768 to 1108)	1837 (1582 to 2114)	1716 (1553 to 1875)	2749 (2571 to 2928)	86.7 (54.9 to 131.3)	112.2 (93.1 to 140.8)	− 98.6 (− 140.6 to − 62.5)	99.6 (62.2 to 155.4)
Bushehr	Female	747 (617 to 866)	1494 (1305 to 1669)	1313 (1185 to 1425)	2309 (2184 to 2435)	76.3 (46.2 to 113.2)	133.1 (112.3 to 162.8)	− 110.1 (− 147.0 to − 75.9)	99.5 (64.3 to 145.4)
Chahar Mahaal and Bakhtiari	Both	1960 (1658 to 2185)	3100 (2781 to 3456)	2754 (2560 to 2958)	5335 (5118 to 5556)	40.0 (21.7 to 64.6)	130.7 (115.1 to 152.7)	− 113.5 (− 139.9 to − 89.5)	57.6 (33.3 to 86.5)
Chahar Mahaal and Bakhtiari	Male	1121 (916 to 1339)	1761 (1500 to 2034)	1577 (1408 to 1736)	2792 (2614 to 2976)	41.7 (16.6 to 83.3)	108.7 (90.7 to 140.7)	− 91.9 (− 130.7 to − 62.0)	58.2 (23.6 to 107.4)
Chahar Mahaal and Bakhtiari	Female	839 (678 to 982)	1339 (1151 to 1583)	1179 (1059 to 1305)	2544 (2417 to 2678)	39.6 (13.5 to 75.1)	160.7 (135.3 to 199.7)	− 142.0 (− 194.4 to − 106.7)	58.1 (24.7 to 100.9)
East Azarbayejan	Both	11,825 (10,376 to 13,440)	18,140 (16,156 to 20,308)	14,219 (13,267 to 15,176)	27,555 (26,293 to 28,682)	20.1 (4.3 to 41.3)	112.8 (98.3 to 130.7)	− 79.8 (− 103.2 to − 56.7)	53.2 (30.0 to 83.9)
East Azarbayejan	Male	6677 (5443 to 8041)	9562 (8082 to 11,235)	8050 (7309 to 8862)	14,498 (13,601 to 15,490)	20.6 (− 1.1 to 52.0)	96.7 (78.3 to 122.7)	− 74.4 (− 110.7 to − 45.1)	43.2 (12.4 to 89.2)
East Azarbayejan	Female	5147 (4246 to 6042)	8578 (7374 to 9879)	6169 (5573 to 6793)	13,025 (12,298 to 13,792)	19.8 (− 0.2 to 47.0)	133.6 (111.7 to 161.8)	− 86.3 (− 120.8 to − 57.9)	66.7 (35.0 to 109.0)
Fars	Both	10,058 (8829 to 11,460)	19,555 (16,988 to 22,193)	14,148 (13,328 to 14,943)	30,052 (28,688 to 31,440)	40.8 (22.6 to 64.7)	158.5 (138.5 to 184.6)	− 105.1 (− 140.0 to − 74.2)	94.4 (62.8 to 136.0)
Fars	Male	5814 (4732 to 7133)	10,577 (8739 to 12,639)	8168 (7540 to 8821)	16,633 (15,518 to 17,673)	40.5 (14.6 to 80.0)	144.8 (118.9 to 184.4)	− 103.2 (− 155.3 to − 66.2)	80.5 (37.6 to 140.4)
Fars	Female	4245 (3569 to 5010)	8978 (7613 to 10,478)	5971 (5520 to 6430)	13,423 (12,676 to 14,215)	41.8 (17.7 to 71.1)	176.6 (148.6 to 213.7)	− 107.1 (− 150.6 to − 65.1)	111.7 (65.2 to 166.7)
Gilan	Both	7376 (6538 to 8256)	13,756 (12,184 to 15,317)	8442 (7990 to 8879)	20,095 (19,291 to 20,929)	14.2 (1.7 to 31.9)	157.8 (140.0 to 182.6)	− 85.8 (− 113.7 to − 62.4)	86.0 (60.1 to 121.2)
Gilan	Male	3857 (3169 to 4632)	7172 (6025 to 8422)	4439 (4070 to 4783)	10,843 (10,177 to 11,548)	14.5 (− 4.6 to 43.4)	165.9 (138.4 to 206.3)	− 94.5 (− 138.7 to − 58.1)	86.2 (45.4 to 141.8)
Gilan	Female	3518 (2954 to 4113)	6585 (5643 to 7659)	4015 (3771 to 4255)	9253 (8808 to 9760)	13.9 (− 2.6 to 37.4)	148.0 (127.2 to 177.6)	− 74.9 (− 114.0 to − 45.6)	86.3 (47.2 to 132.7)
Golestan	Both	4279 (3742 to 4887)	8060 (7396 to 8717)	6306 (5865 to 6770)	11,013 (10,583 to 11,480)	47.7 (27.1 to 71.6)	110.3 (96.4 to 127.4)	− 69.4 (− 92.6 to − 50.3)	88.8 (62.3 to 119.0)
Golestan	Male	2368 (1932 to 2840)	4345 (3742 to 4992)	3482 (3181 to 3849)	5751 (5411 to 6118)	47.3 (19.3 to 88.6)	96.1 (78.6 to 121.9)	− 59.8 (− 95.2 to − 27.4)	83.8 (43.3 to 135.7)
Golestan	Female	1911 (1563 to 2211)	3715 (3317 to 4144)	2821 (2539 to 3133)	5271 (4999 to 5548)	47.9 (20.8 to 82.4)	127.9 (106.8 to 158.2)	− 81.9 (− 115.1 to − 52.8)	94.7 (59.9 to 137.0)
Hamadan	Both	5642 (4803 to 6375)	7982 (7175 to 8872)	5859 (5473 to 6279)	12,423 (11,912 to 12,919)	3.6 (− 10.4 to 22.1)	116.4 (102.0 to 134.8)	− 78.9 (− 102.3 to − 59.2)	40.6 (20.1 to 67.9)
Hamadan	Male	3230 (2630 to 3910)	4294 (3625 to 5030)	3323 (3005 to 3635)	6842 (6443 to 7242)	2.7 (− 15.7 to 31.1)	109.4 (90.3 to 137.4)	− 78.5 (− 111.9 to − 54.0)	33.8 (3.9 to 76.2)
Hamadan	Female	2412 (1973 to 2840)	3688 (3214 to 4198)	2541 (2277 to 2813)	5593 (5330 to 5873)	5.4 (− 13.6 to 32.2)	127.1 (105.1 to 154.2)	− 78.6 (− 110.4 to − 55.2)	53.5 (22.2 to 95.0)
Hormozgan	Both	3016 (2597 to 3458)	5011 (4406 to 5627)	6534 (6032 to 6972)	8831 (8419 to 9221)	116.0 (87.0 to 154.1)	76.1 (63.7 to 90.6)	− 125.8 (− 159.6 to − 97.7)	66.7 (37.5 to 99.7)
Hormozgan	Male	1750 (1406 to 2091)	2831 (2388 to 3359)	3812 (3405 to 4241)	4944 (4618 to 5293)	118.0 (76.9 to 175.9)	65.1 (51.5 to 85.1)	− 121.5 (− 162.9 to − 83.4)	62.7 (25.0 to 110.5)
Hormozgan	Female	1266 (1055 to 1479)	2179 (1843 to 2490)	2745 (2466 to 3002)	3891 (3679 to 4086)	116.6 (81.2 to 165.8)	90.9 (74.6 to 111.8)	− 136.5 (− 178.1 to − 100.8)	72.7 (38.9 to 115.6)
Ilam	Both	1259 (1116 to 1399)	2174 (1954 to 2407)	1740 (1633 to 1855)	3165 (3045 to 3296)	38.3 (22.3 to 56.6)	113.2 (100.1 to 129.8)	− 79.1 (− 102.7 to − 57.9)	72.4 (49.9 to 103.3)
Ilam	Male	745 (626 to 871)	1186 (1008 to 1371)	1016 (927 to 1100)	1686 (1589 to 1790)	36.4 (13.9 to 65.0)	89.9 (74.6 to 108.9)	− 67.4 (− 98.0 to − 37.2)	58.9 (26.2 to 101.7)
Ilam	Female	514 (432 to 592)	988 (848 to 1140)	721 (640 to 791)	1475 (1400 to 1554)	39.3 (17.5 to 68.3)	146.3 (123.4 to 174.3)	− 94.9 (− 131.6 to − 61.8)	90.8 (53.3 to 135.0)
Isfahan	Both	9803 (8570 to 11,175)	20,029 (17,703 to 22,531)	14,001 (13,203 to 14,808)	29,809 (28,534 to 31,162)	42.4 (25.2 to 65.9)	160.7 (141.5 to 187.2)	− 99.4 (− 131.1 to − 72.0)	103.7 (72.3 to 145.0)
Isfahan	Male	5276 (4286 to 6379)	10,611 (8810 to 12,568)	7410 (6835 to 7999)	15,908 (14,926 to 16,947)	39.9 (14.5 to 77.1)	160.4 (129.6 to 202.3)	− 100.3 (− 148.9 to − 60.2)	100.2 (54.6 to 161.9)
Isfahan	Female	4527 (3763 to 5352)	9418 (8059 to 10,997)	6568 (6100 to 7046)	13,904 (13,134 to 14,729)	45.1 (22.2 to 76.6)	161.9 (136.1 to 199.3)	− 99.7 (− 144.1 to − 59.9)	108.8 (63.2 to 166.8)
Kerman	Both	5902 (5204 to 6662)	10,987 (9647 to 12,271)	10,890 (10,221 to 11,545)	17,972 (17,219 to 18,739)	85.1 (60.2 to 111.3)	120.1 (105.8 to 139.1)	− 118.2 (− 149.6 to − 88.9)	87.4 (56.4 to 122.3)
Kerman	Male	3475 (2881 to 4206)	5999 (5037 to 7069)	6521 (5935 to 7085)	10,289 (9672 to 10,984)	87.5 (54.2 to 134.2)	109.0 (89.9 to 136.2)	− 123.4 (− 169.6 to − 84.2)	73.0 (33.7 to 123.7)
Kerman	Female	2427 (2046 to 2847)	4988 (4257 to 5787)	4394 (4019 to 4732)	7673 (7236 to 8058)	81.5 (50.6 to 125.1)	135.1 (112.6 to 163.1)	− 110.0 (− 153.4 to − 72.8)	105.4 (62.0 to 160.9)
Kermanshah	Both	5899 (5069 to 6717)	8700 (7622 to 9775)	6986 (6499 to 7467)	14,853 (14,196 to 15,481)	18.5 (2.1 to 40.0)	133.3 (115.2 to 156.2)	− 104.0 (− 133.4 to − 80.1)	47.3 (23.6 to 77.3)
Kermanshah	Male	3604 (2954 to 4269)	4660 (3918 to 5508)	4196 (3804 to 4589)	8412 (7900 to 8927)	16.2 (− 4.6 to 44.0)	116.9 (98.4 to 142.9)	− 104.6 (− 139.9 to − 77.6)	28.0 (1.4 to 65.9)
Kermanshah	Female	2295 (1868 to 2728)	4039 (3455 to 4695)	2761 (2483 to 3057)	6431 (6093 to 6757)	20.7 (− 2.2 to 49.6)	159.3 (133.6 to 196.4)	− 104.3 (− 142.4 to − 71.0)	76.5 (39.0 to 121.9)
Khorasan-e-Razavi	Both	16,347 (14,212 to 18,714)	24,346 (21,741 to 27,258)	23,864 (21,988 to 25,472)	41,007 (39,156 to 42,736)	46.2 (24.9 to 71.8)	104.8 (90.8 to 123.2)	− 101.4 (− 127.1 to − 78.9)	49.2 (24.8 to 79.3)
Khorasan-e-Razavi	Male	9273 (7546 to 11,123)	12,896 (10,947 to 15,207)	13,578 (12,245 to 14,952)	21,681 (20,283 to 23,107)	46.7 (20.1 to 83.0)	87.5 (71.5 to 109.3)	− 94.2 (− 129.5 to − 64.1)	38.9 (6.7 to 80.2)
Khorasan-e-Razavi	Female	7075 (5710 to 8315)	11,451 (9832 to 13,292)	10,305 (9150 to 11,561)	19,285 (18,062 to 20,507)	46.1 (19.4 to 84.7)	126.9 (105.6 to 157.7)	− 111.8 (− 152.6 to − 78.4)	62.8 (29.3 to 107.5)
Khuzestan	Both	9383 (8372 to 10,517)	16,657 (15,046 to 18,316)	14,698 (13,944 to 15,455)	24,418 (23,439 to 25,376)	56.1 (39.0 to 76.6)	103.1 (92.0 to 117.6)	− 82.1 (− 106.2 to − 60.2)	77.0 (52.8 to 105.5)
Khuzestan	Male	5067 (4264 to 5980)	8874 (7679 to 10,202)	7923 (7280 to 8520)	13,040 (12,303 to 13,795)	57.9 (31.6 to 90.0)	101.6 (85.3 to 124.2)	− 83.5 (− 116.7 to − 52.5)	76.1 (42.3 to 116.7)
Khuzestan	Female	4316 (3697 to 5010)	7784 (6786 to 8897)	6768 (6302 to 7192)	11,355 (10,836 to 11,907)	56.0 (35.2 to 86.7)	106.1 (91.2 to 128.0)	− 82.7 (− 113.3 to − 55.4)	79.6 (48.5 to 122.0)
Kohgiluyeh and Boyer-Ahmad	Both	1221 (1064 to 1396)	2087 (1840 to 2373)	1953 (1773 to 2110)	3425 (3274 to 3581)	59.3 (38.0 to 89.5)	120.3 (104.0 to 140.7)	− 109.4 (− 139.3 to − 80.9)	70.8 (43.0 to 109.0)
Kohgiluyeh and Boyer-Ahmad	Male	673 (556 to 790)	1126 (942 to 1337)	1087 (959 to 1209)	1849 (1729 to 1958)	61.9 (32.3 to 101.9)	113.3 (92.3 to 139.7)	− 107.6 (− 149.0 to − 68.1)	67.5 (30.4 to 116.3)
Kohgiluyeh and Boyer-Ahmad	Female	548 (447 to 637)	961 (815 to 1124)	868 (775 to 970)	1574 (1491 to 1670)	57.5 (30.0 to 99.6)	128.4 (105.5 to 158.3)	− 111.7 (− 153.1 to − 78.8)	74.6 (38.5 to 123.2)
Kurdistan	Both	4488 (3799 to 5083)	6067 (5435 to 6760)	6208 (5608 to 6774)	10,997 (10,519 to 11,458)	38.2 (17.5 to 64.5)	106.4 (91.5 to 126.6)	− 109.9 (− 133.9 to − 89.1)	34.5 (14.0 to 62.7)
Kurdistan	Male	2632 (2105 to 3159)	3249 (2754 to 3787)	3647 (3208 to 4071)	6174 (5748 to 6558)	38.2 (10.4 to 76.6)	95.8 (75.9 to 123.0)	− 110.5 (− 149.2 to − 80.7)	23.5 (− 6.1 to 60.2)
Kurdistan	Female	1855 (1460 to 2171)	2818 (2451 to 3203)	2566 (2170 to 2932)	4824 (4539 to 5086)	39.2 (9.5 to 73.6)	122.3 (98.8 to 154.6)	− 108.2 (− 142.2 to − 79.7)	51.7 (20.3 to 93.9)
Lorestan	Both	4565 (3974 to 5162)	6244 (5562 to 6887)	5256 (4888 to 5633)	9910 (9474 to 10,339)	15.0 (0.5 to 33.8)	101.9 (88.8 to 117.9)	− 80.0 (− 100.2 to − 61.5)	36.4 (16.8 to 63.6)
Lorestan	Male	2696 (2162 to 3222)	3592 (3165 to 4098)	3072 (2753 to 3346)	5112 (4783 to 5447)	13.2 (− 8.3 to 44.8)	75.8 (61.8 to 94.6)	− 56.5 (− 84.2 to − 34.6)	33.3 (3.4 to 69.5)
Lorestan	Female	1869 (1551 to 2149)	2652 (2155 to 3080)	2176 (1968 to 2401)	4793 (4568 to 5029)	16.3 (− 1.2 to 43.5)	140.1 (120.2 to 169.9)	− 114.8 (− 151.5 to − 84.7)	42.4 (12.4 to 82.5)
Markazi	Both	3793 (3282 to 4259)	6130 (5438 to 6822)	4609 (4359 to 4875)	10,878 (10,474 to 11,295)	21.7 (6.5 to 40.0)	165.5 (145.2 to 189.7)	− 125.6 (− 153.4 to − 100.7)	61.3 (34.9 to 93.1)
Markazi	Male	2155 (1731 to 2588)	3067 (2584 to 3618)	2627 (2409 to 2853)	5608 (5289 to 5956)	22.2 (− 0.9 to 54.4)	138.5 (112.8 to 171.9)	− 117.7 (− 161.6 to − 85.0)	42.0 (10.0 to 80.9)
Markazi	Female	1638 (1369 to 1905)	3063 (2664 to 3518)	1982 (1837 to 2122)	5263 (5029 to 5505)	20.9 (1.3 to 46.9)	199.6 (168.9 to 239.5)	− 133.0 (− 174.4 to − 100.8)	86.1 (52.9 to 132.6)
Mazandaran	Both	6392 (5585 to 7276)	14,751 (12,959 to 16,486)	8763 (8309 to 9267)	20,998 (20,081 to 21,965)	37.5 (20.0 to 62.3)	191.5 (166.1 to 224.9)	− 98.5 (− 137.4 to − 66.3)	130.4 (94.9 to 175.1)
Mazandaran	Male	3359 (2704 to 4084)	7513 (6270 to 8848)	4639 (4260 to 5006)	10,606 (9933 to 11,291)	37.3 (11.0 to 70.4)	177.1 (142.3 to 219.5)	− 93.1 (− 143.8 to − 47.0)	121.5 (70.9 to 188.7)
Mazandaran	Female	3033 (2504 to 3580)	7238 (6178 to 8446)	4134 (3847 to 4412)	10,377 (9806 to 10,942)	36.7 (15.0 to 66.2)	206.1 (173.1 to 250.4)	− 103.4 (− 150.0 to − 57.8)	138.7 (90.1 to 202.4)
North Khorasan	Both	2174 (1840 to 2507)	3207 (2859 to 3544)	3019 (2810 to 3268)	5374 (5165 to 5590)	39.3 (18.3 to 66.0)	108.6 (92.2 to 130.0)	− 99.8 (− 126.4 to − 78.3)	47.6 (24.2 to 78.1)
North Khorasan	Male	1227 (993 to 1473)	1685 (1447 to 1939)	1714 (1514 to 1906)	2925 (2744 to 3108)	40.0 (12.9 to 80.9)	99.0 (80.4 to 123.5)	− 101.0 (− 138.3 to − 71.6)	37.7 (9.0 to 77.1)
North Khorasan	Female	947 (750 to 1108)	1522 (1315 to 1746)	1317 (1165 to 1460)	2451 (2326 to 2579)	39.3 (12.3 to 73.1)	121.0 (98.8 to 150.3)	− 98.8 (− 137.8 to − 69.6)	60.9 (25.7 to 105.6)
Qazvin	Both	2757 (2404 to 3128)	4753 (4258 to 5325)	3888 (3652 to 4135)	7151 (6862 to 7407)	41.8 (22.5 to 65.6)	118.4 (102.3 to 138.2)	− 87.3 (− 115.5 to − 63.8)	72.7 (44.8 to 106.9)
Qazvin	Male	1501 (1210 to 1833)	2752 (2370 to 3134)	2133 (1929 to 2330)	3749 (3495 to 3994)	41.2 (14.7 to 85.6)	107.1 (87.1 to 138.1)	− 65.9 (− 102.9 to − 34.3)	82.6 (46.9 to 141.6)
Qazvin	Female	1256 (1068 to 1446)	2001 (1717 to 2347)	1769 (1621 to 1909)	3409 (3249 to 3558)	40.5 (20.4 to 66.4)	130.4 (111.9 to 154.7)	− 112.0 (− 145.1 to − 83.6)	59.0 (29.1 to 95.6)
Qom	Both	1988 (1732 to 2223)	4137 (3694 to 4602)	3868 (3666 to 4078)	7134 (6846 to 7410)	95.3 (72.3 to 121.9)	165.3 (146.2 to 188.1)	− 151.0 (− 185.1 to − 121.9)	108.2 (76.6 to 149.1)
Qom	Male	1079 (886 to 1299)	2112 (1784 to 2468)	2083 (1930 to 2257)	3802 (3572 to 4025)	92.0 (59.8 to 137.7)	158.9 (131.2 to 198.1)	− 155.1 (− 210.8 to − 113.7)	94.5 (52.2 to 154.1)
Qom	Female	909 (773 to 1067)	2025 (1765 to 2313)	1785 (1657 to 1911)	3342 (3186 to 3496)	96.0 (66.5 to 135.4)	171.6 (147.2 to 205.3)	− 144.9 (− 191.5 to − 106.7)	123.2 (81.5 to 176.5)
Semnan	Both	1577 (1405 to 1768)	2595 (2302 to 2971)	2611 (2484 to 2742)	4296 (4131 to 4470)	65.1 (47.1 to 89.0)	107.0 (94.4 to 122.2)	− 108.2 (− 135.8 to − 82.2)	64.2 (37.0 to 95.6)
Semnan	Male	888 (731 to 1056)	1432 (1200 to 1672)	1457 (1358 to 1571)	2360 (2238 to 2516)	64.8 (37.3 to 105.2)	102.4 (85.2 to 126.6)	− 105.7 (− 145.8 to − 71.3)	62.2 (29.2 to 108.1)
Semnan	Female	689 (588 to 793)	1163 (977 to 1362)	1152 (1079 to 1221)	1940 (1848 to 2033)	66.7 (44.1 to 97.5)	114.2 (98.7 to 136.0)	− 112.7 (− 150.7 to − 79.3)	69.7 (34.0 to 111.2)
Sistan and Baluchistan	Both	4629 (3829 to 5394)	7211 (6293 to 8312)	10,006 (9064 to 10,960)	12,274 (11,498 to 13,039)	115.6 (77.2 to 165.9)	48.8 (39.0 to 60.9)	− 109.1 (− 148.3 to − 77.6)	55.5 (24.2 to 95.1)
Sistan and Baluchistan	Male	2756 (2118 to 3324)	3925 (3235 to 4709)	5971 (5134 to 6844)	6868 (6224 to 7533)	117.0 (68.0 to 187.5)	32.4 (22.0 to 45.6)	− 106.7 (− 151.4 to − 68.0)	42.0 (7.3 to 95.3)
Sistan and Baluchistan	Female	1873 (1440 to 2236)	3287 (2743 to 3893)	4026 (3431 to 4657)	5391 (4940 to 5882)	113.5 (69.2 to 177.8)	71.7 (57.1 to 92.3)	− 112.0 (− 164.6 to − 70.9)	74.8 (32.7 to 128.5)
South Khorasan	Both	2083 (1778 to 2382)	2838 (2576 to 3123)	2774 (2524 to 3027)	4573 (4365 to 4768)	33.8 (12.7 to 56.9)	86.4 (73.7 to 102.0)	− 83.4 (− 104.9 to − 65.2)	36.3 (16.3 to 62.8)
South Khorasan	Male	1205 (962 to 1448)	1458 (1268 to 1661)	1613 (1424 to 1791)	2388 (2230 to 2533)	34.7 (8.8 to 71.9)	65.0 (50.6 to 84.2)	− 78.0 (− 107.5 to − 53.2)	21.6 (− 2.5 to 56.5)
South Khorasan	Female	878 (721 to 1039)	1380 (1206 to 1572)	1160 (1010 to 1310)	2189 (2072 to 2307)	32.2 (5.9 to 65.7)	117.5 (97.5 to 147.5)	− 92.9 (− 124.8 to − 62.9)	57.0 (27.7 to 97.4)
Tehran	Both	19,053 (16,194 to 22,028)	52,516 (46,124 to 60,861)	33,264 (31,436 to 35,054)	75,357 (71,844 to 78,620)	74.1 (51.5 to 103.3)	220.3 (189.9 to 259.0)	− 121.2 (− 171.3 to − 74.5)	174.1 (121.9 to 237.8)
Tehran	Male	10,605 (8484 to 12,963)	30,324 (25,264 to 36,057)	18,207 (16,735 to 19,495)	42,866 (40,072 to 45,488)	70.9 (40.7 to 121.1)	232.2 (191.1 to 299.3)	− 117.3 (− 188.5 to − 58.1)	184.7 (115.2 to 283.0)
Tehran	Female	8448 (6837 to 10,137)	22,192 (18,319 to 26,618)	15,031 (14,038 to 16,031)	32,528 (30,559 to 34,447)	76.9 (47.5 to 122.9)	206.5 (172.8 to 260.9)	− 122.6 (− 190.7 to − 62.9)	162.4 (98.2 to 243.4)
West Azarbayejan	Both	7768 (6768 to 8720)	12,562 (11,194 to 14,033)	11,727 (10,867 to 12,536)	20,441 (19,447 to 21,298)	51.0 (31.5 to 76.4)	112.6 (98.2 to 128.9)	− 101.2 (− 126.9 to − 76.2)	62.4 (36.8 to 92.0)
West Azarbayejan	Male	4446 (3717 to 5362)	6534 (5564 to 7592)	6741 (6102 to 7349)	10,883 (10,176 to 11,585)	51.0 (24.6 to 88.1)	93.0 (76.1 to 115.9)	− 97.2 (− 134.0 to − 67.3)	47.9 (16.2 to 89.8)
West Azarbayejan	Female	3322 (2741 to 3898)	6028 (5214 to 6905)	4996 (4428 to 5543)	9557 (9007 to 10,131)	51.0 (24.1 to 86.1)	137.7 (115.0 to 172.5)	− 106.2 (− 145.3 to − 72.7)	82.1 (48.3 to 127.6)
Yazd	Both	2052 (1797 to 2293)	3741 (3291 to 4216)	3595 (3385 to 3788)	6034 (5760 to 6294)	74.9 (55.1 to 102.3)	118.5 (104.5 to 137.7)	− 111.0 (− 143.6 to − 82.5)	83.7 (53.0 to 118.2)
Yazd	Male	1078 (888 to 1319)	1959 (1611 to 2363)	1891 (1733 to 2045)	3256 (3039 to 3473)	74.8 (43.7 to 125.2)	126.3 (103.5 to 159.0)	− 119.9 (− 177.6 to − 76.8)	81.7 (38.1 to 143.0)
Yazd	Female	974 (819 to 1117)	1781 (1510 to 2090)	1708 (1595 to 1819)	2774 (2643 to 2909)	75.7 (49.9 to 108.9)	109.6 (94.3 to 130.3)	− 101.8 (− 141.4 to − 67.8)	82.2 (46.7 to 129.5)
Zanjan	Both	2570 (2196 to 2917)	4031 (3667 to 4408)	3120 (2856 to 3365)	6219 (5935 to 6472)	21.5 (2.6 to 42.6)	120.3 (104.5 to 141.6)	− 84.9 (− 108.4 to − 65.1)	56.7 (32.9 to 86.7)
Zanjan	Male	1466 (1173 to 1773)	2277 (1990 to 2586)	1780 (1581 to 1991)	3396 (3194 to 3609)	21.4 (− 4.4 to 57.3)	109.9 (88.7 to 139.6)	− 76.3 (− 107.2 to − 50.0)	55.5 (20.9 to 101.3)
Zanjan	Female	1103 (900 to 1304)	1753 (1535 to 1991)	1341 (1176 to 1503)	2808 (2663 to 2951)	21.9 (− 0.4 to 53.6)	133.2 (111.5 to 165.9)	− 95.5 (− 131.3 to − 69.1)	59.8 (29.4 to 100.1)

In 2021, Golestan had the highest ASDR for males at 656.8 (571.4 to 747.0) per 100,000. Meanwhile, West Azerbaijan reported the highest ASDR for females at 571.4 (500.8 to 646.2) per 100,000. Kohgiluyeh and Boyer-Ahmad exhibited the lowest ASDR in males (386.9 (323.0 to 460.7) per 100,000), and Chahar Mahaal and Bakhtiari had the lowest death rates for females (327.7 (283.0 to 386.0) per 100,000) (Supplementary Material 1). With regards to SDI, it is notable that provinces with lower death rates were high and high-middle SDI provinces, while the higher mortalities were in low SDI provinces for both sexes (Fig. 5).

DALYs, YLLs, and YLDs

Similar to deaths, despite the increase in all age numbers during 1990–2021, age-standardized rates (ASR) of DALYs also saw a decrease in both males (-31.1% -36.4 to -24.1) and females (-25.3% (-30.4 to -18.6)), reaching 18,839.9 (16,576.6 to 21,499.3) and 19,983.4 (16,884.3 to 23,410.1), respectively in 2021 (Table 1; Fig. 1).

In both males (5,524.4 [5,118.5 to 5,882.9]) and females (4,455.2 [4,057.5 to 4,796.9]), CVD caused the most ASR DALYs. Following CVD, mental disorders exhibited the highest ASR DALY in females (3,162.8 (2,315.7 to 4,146.0) per 100,000) and males (2396.4 (1784.1 to 3085.4) per 100,000). The third highest DALY contributor for females was musculoskeletal disorders (2,621.3 (1,909.6 to 3,478.7) per 100,000), while neoplasms ranked as the third highest DALY-causing disease in males (2,263.6 (1,894.8 to 2,482.8) per 100,000) during the studies period (Fig. 2, Supplementary Material 1).

Similar to mortality trends, DALYs exhibited a single peak in the 80 + years age group, increasing gradually until this age group. DALYs were consistently higher in males in people aging 50–79 years while in other age groups females had higher DALY rates in 2021 (Fig. 3).

Regarding the provinces, they all saw a decrease in DALY rates (Fig. 4). Golestan led for both sexes, with DALYs at 22,225.8 (18,937.9 to 25,658.7) for females and 22,962.4 (19,958.8 to 26,749.9) for males. Conversely, Chaharmahal and Bakhtiari exhibited the lowest ASR DALYs for females at 17,306.4 (14,248.5 to 20,934.7) while Tehran reported the lowest ASR DALYs for males at 17,017.0 (14,259.1 to 20,107.2). Moreover, provinces in the middle SDI quintile generally had lower DALYs, while those in low SDI quintiles had higher DALYs (Supplementary Fig. 1). It is noteworthy that in females, YLLs were higher compared to YLDs in all provinces, whereas in males, except for Tehran and South Khorasan, YLDs were more prevalent than YLLs (Supplementary Fig. 4). Moreover, YLLs decreased in all provinces while the YLDs increased in all provinces in the study period (Fig. 4).

Discussion

The findings of this study highlight significant sex disparities in the burden of NCDs in Iran across prevalence, incidence, deaths, and DALYs. In 2021, NCD prevalence was nearly equal between females (39.9 million) and males (40.3 milion), but the ASPR was higher in females (94,972) than in males (90,445). The crude number of deaths nearly doubled for both sexes compared to 1990, with a higher percentage increase in females (91.9%) than males, while the ASDR was higher in males (477.6) than females (438.1). DALYs were slightly higher in males (18,840) than females (19,983), driven primarily by CVDs in both sexes. YLLs accounted for a larger portion of DALYs in females, while YLDs were more prominent in males, except in provinces like Tehran and South Khorasan. Moreover, females consistently showed a higher burden across most age groups, particularly between 35 and 39 years, while males experienced higher mortality and DALYs in specific provinces such as Golestan and West Azerbaijan. Subnational trends revealed that provinces like Fars for males and West Azerbaijan for females reported the highest ASIRs, whereas Tehran and Chaharmahal and Bakhtiari had the lowest DALYs for males and females, respectively. Provinces in lower SDI quintiles consistently bore a greater burden.

Based on our findings, NCDs in women had a slightly higher ASPR at 94,972 (94,421 to 95,469), compared to males with an ASPR of 90,445 (89,508 to 91,302). These results were in line with findings of previous studies which showed that NCDs such a major depressive disorder have higher prevalence in¹⁶. These results can be explained by multiple reasons. First the increased prevalence of risk factors for NCDs among women, such as unhealthy diets, physical inactivity, and exposure to harmful substances. Additionally, women generally have a longer life expectancy in comparison to men, which leads to an older age structure among women¹⁷, which makes them more prone to the cumulative effects of these risk factors¹⁸.

Neurological disorders were the most prevalent NCDs in women while digestive diseases were the most prevalent in men. A potential explanation for this finding is that men are more likely to engage in risky behaviors, such as excessive alcohol consumption and smoking, which are prominent risk factors for digestive diseases. These habits increase their susceptibility to developing digestive diseases¹⁹. On the contrary, women are generally more vulnerable to neurological disorders. For instance, growing evidence indicates that women have a higher likelihood of developing Alzheimer’s Disease, mostly due to sex-specific distinctions in the production and structure of neurofibrillary tangles²⁰. Furthermore, while the least prevalent NCD in both sexes was substance use disorder, it was significantly higher in men. A similar pattern has been observed historically in the U.S., where the gender gap in substance use prevalence has significantly narrowed over the past three decades. This trend indicates that most of the earlier disparities observed in substance use may have been due to social and cultural factors rather than inherent biological differences between sexes²¹. This finding may also apply to our results from Iran, where substance use is significantly more stigmatized for women compared to men. Interestingly, while such stigma can sometimes lead to higher prevalence by discouraging women from seeking help, in the case of Iran, it appears to have resulted in lower substance use among women as a result of avoidance²².

The COVID-19 pandemic has had a significant impact on NCD trends and sex disparities. The disruption of healthcare services, delayed diagnoses, and reduced access to preventive care led to a rise in disease burden, particularly among vulnerable populations. Studies indicate that women faced greater barriers in accessing healthcare during the pandemic due to caregiving responsibilities and economic instability, exacerbating existing sex disparities in NCDs²³. Additionally, the indirect effects of COVID-19, such as increased sedentary lifestyles and mental health issues, disproportionately affected women, contributing to higher rates of anxiety, depression, and metabolic disorders²⁴. On the other hand, men experienced higher COVID-19 mortality rates, which may have influenced the overall NCD burden by disproportionately reducing older male populations²⁵. These factors highlight the complex interplay between infectious disease outbreaks and chronic disease trends, reinforcing the need for resilient healthcare systems that address sex-specific vulnerabilities.

Moreover, incidence rate increased in total and in 2021 ASIR was 156,107 (142,743 to 172,268) of note, the major contributor to this increase was population growth in both sexes, not an inherent increase in the incidence rate. The incidence was also higher in females and it is noteworthy that females consistently had a higher incidence in all age groups. Risk factors associated with NCDs, such as obesity and physical inactivity, have been found to be more prevalent among women than men in Iran. As a result, the higher prevalence of these risk factors contributes to a greater incidence of NCDs in women. This pattern highlights the substantial role of lifestyle factors in shaping disease prevalence across sexes^1,26. Moreover, the hormonal fluctuations experienced by females, which differ from those of males, makes them more prone to certain NCDs such as autoimmune disorders²⁷.

Tehran had the highest incidence for both sexes while Ilam had the lowest. These differences in incidence rates of NCDs among provinces and between sexes could be due to variations in socioeconomic status, culture, lifestyle, dietary habits, access to healthcare, and health literacy²⁸. Notably, provinces classified as high and high-middle in the SDI had lower death rates and there were no notable difference regarding sex. This can be explained by better access to healthcare facilities, which ensures timely medical intervention, and a higher quality of care, including more advanced medical technologies and well-trained healthcare professionals. Additionally, these regions often have better public health infrastructure and higher health literacy, contributing to overall lower mortality rates²⁹.

In contrast to incidence and prevalence, death rates were consistently higher in males across all age groups, except for those aged 80 and above. Over the study period, males experienced a more substantial decline in ASDR compared to females. The most common causes of death comprised of CVDs, neoplasms, diabetes, and kidney diseases. The higher deaths rates in men can be attributed to the earlier manifestation of these conditions in men. For instance, CVDs, which are the leading causes of death in each sex, manifest earlier in men. This earlier onset can be attributed to various health behaviors, including higher rates of smoking, alcohol consumption, and drug use among men. Additionally, men are often exposed to greater occupational risks, which further contribute to the increased mortality rates. These combined factors lead to a higher overall death rate for males compared to females^28,30–32. Moreover, it might be attributed to lower healthcare utilization and reduced medication adherence among men. Males are often less likely to seek medical attention or engage in regular health check-ups, which may delay the diagnosis and treatment of chronic conditions³³. Additionally, lower adherence to prescribed medications can result in poor management of health conditions, further contributing to increased mortality rates in this demographic. These factors combined may help explain the disparity in death rates between males and females³⁴.

While the death rates were higher in males, the DALYs are slightly higher in females with a ASR DALY of 19,983 (16,884 to 23,410). These results are also in accordance with the global results³⁵. CVDs caused the highest DALY in both sexes, while for females mental disorders and musculoskeletal disorders ranked second and third; for males they were mental disorders and neoplasms. Historically, women’s health has predominantly focused on sexual and reproductive issues. While these are important, they do not cover the full range of health concerns women face throughout their lives³⁶. Patwardhan et al. analysis shows that females experience a higher burden of morbidity-driven conditions, especially mental and musculoskeletal disorders which further verify our results. NCDs that are more prevalent in women continue to receive less attention in research funding³⁷, planning of health systems and scientific literature³⁸.

Notably, YLLs were higher for females, while YLDs were higher for males. The paradox of higher death rates in males but higher YLLs in females may be explained by the fact that a larger proportion of females die at a younger age compared to males.

The findings of our paper have significant policy implications. Policymakers should address sex-specific factors contributing to health inequalities, such as socioeconomic determinants, differential healthcare access, and differences in health-seeking behavior and medication adherence among sexes. To reduce the burden of NCDs, public health interventions should incorporate gender-sensitive approaches, including targeted health education campaigns to encourage greater healthcare utilization among men and programs that promote appropriate access to preventive care for women. Furthermore, policies targeted at improving adherence to treatment protocols, especially in men, should be prioritized. By implementing such strategies, healthcare systems can more effectively improve the unequal distribution of disease burden between sexes.

This study demonstrates numerous strengths, such as systematic use of data and methods, enabling potential comparisons of NCDs across various countries in the Iran from 1990 to 2021, thereby potentially enhancing the generalizability of the findings. The data used in the analysis were derived from the GBD report, which may have some biases, particularly in low-income provinces since data collection is less robust in these regions. Missing data may result in an underestimation of the true burden of NCDs in these areas. Furthermore, the UIs for DALYs might be underestimated due to assumptions made in the GBD methodology that YLLs and YLDs are independent of one another. Future studies should aim to address these gaps by improving data collection in low-income regions and refining statistical models to better capture the complex interplay of mortality and morbidity³⁹.

Conclusion

This study highlights the growing sex-based disparities in the burden of NCDs in Iran, in line with global trends since 1990. Despite advancements in medical technologies and treatment options, improvement in reducing the overall NCD burden remains limited, in particular in the effective management of chronic conditions and equitable healthcare access. The findings reveal that females experience higher morbidity from mental and musculoskeletal disorders, while males face higher mortality rates. This highlights the need for health strategies that go beyond reproductive health, focusing on chronic conditions that disproportionately affect women. Priorities should include integrating mental health services into primary care and improving the management of musculoskeletal disorders. Regional disparities in NCD burden highlight inequities in healthcare access and quality, with higher SDI regions benefiting from better infrastructure and lower disease rates. Addressing these inequities requires targeted policies, resource allocation to high-burden areas, and strategies tailored to diverse demographic and socioeconomic needs.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

MHF and HJ wrote the manuscript and took part in conception and study design.MSH and AG did the analysis and prepared the figures.MMR helped with editing the draft and conception.MM helped with the methods.OT, NR and SGH supervised the research and helped with the conception.

Data availability

All data can be accessed from: https://ghdx.healthdata.org/.

Declarations

Ethics approval and consent to participate

Ethical approval was not applicable as this study was based on data that are publicly available and without nominal identification of individual data, this study was approved by the ethical committee of Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1401.160).

Competing interests

The authors declare no competing interests.