Abstract
INTRODUCTION:
Over the past decades, the pattern of diseases in human societies had changed from infectious diseases to noncommunicable diseases (NCDs), and according to the report by the World Health Organization, the highest burden of disease is attributed to NCDs. The study was conducted to determine the status of hypertension, type-2 diabetes, lipid disorders, and body mass index (BMI) among the patients aged over 30 years admitted to health centers of Karaj, Iran.
MATERIALS AND METHODS:
In this cross-sectional study, the population included 2947 men and women aged 30 years and above admitted to six health-care centers in Karaj. The questionnaire includes demographic characteristics and had the questions on hypertension, diabetes and their risk factors, like lipid disorders and BMI was administered. The data were analyzed in SPSS, version 23, software using descriptive (frequency, percentage, mean, and standard deviation) and analytical (Chi-square and analysis of variance) tests (P < 0.01).
RESULTS:
About 10% of the participants had diabetes and 15% of the participants had hypertension. About 32% of the participants had dyslipidemia and 87% of the participants were overweight or obese and over 35% were obese. Furthermore, with the increase in BMI, the prevalence of lipid disorder, hypertension, and type-2 diabetes increased in the studied population (P < 0.01).
CONCLUSION:
According to the results, a high percentage of people had hypertension, type-2 diabetes, hyperlipidemia, and BMI in the population. Gender segregation showed that lipid disorders, overweight, and obesity in women were more than in men and percentage of people with hypertension among male were significantly higher than in females. In the case of type-2 diabetes, the results showed no statistically significant differences between men and women. The results may be helpful in developing educational strategies and prevention and control of these diseases.
Keywords: Blood pressure, body mass index, health status, lipid disorder, type-2 diabetes
Introduction
Over the past decades, the pattern of diseases in human societies has altered from infectious diseases to noncommunicable diseases (NCDs).[1,2] According to the report by the World Health Organization (WHO), the highest burden of diseases is attributed to NCDs[3] like diabetes mellitus (DM). The prevalence of type-2 diabetes is reported to be on the rise worldwide, and the number of people with type-2 diabetes in the world is estimated to reach 330 million in 2025, and by 2030, at least 366 million people are expected to live with DM.[4,5,6,7,8,9,10] In Iran, more than 3 million people are affected by DM, with an average of 500,000 people added to this statistic annually.[11] In a study conducted in Babol, 23.4% of people had DM.[12]
Hypertension is among the NCDs that are easy to identify and treat concomitantly. Given its high prevalence and associated cardiovascular diseases, hypertension is a health problem in industrialized and developing countries. In industrialized countries, 25% of adults and 60% of the elderly suffer hypertension.[13] In the Middle East, hypertension is one of the NCDs that increased dramatically in recent years.[14] Studies in Iran showed a high prevalence of hypertension so that the latest studies showed a 23.3% prevalence of the disease.[15] In a study conducted in Babol, 23.9% of people had high blood pressure.[12]
In the literature, obesity and overweight are associated with many chronic diseases such as hyper lipidemia,[15,16,17] hypertension,[13,16] type-2 diabetes,[18,19] cardiovascular diseases and their risk factors,[16] gallstone,[20] hormonal disorders,[21,22] cancer,[23] and metabolic syndrome.[24] The prevalence of overweight and obesity in the world has increased by 27.5% from 1980 to 2013 among the adults and 47.1% among the children, and the number of obese and overweight people has increased from 857 million in 1980 to 2.1 billion people in 2013.[25] Previous studies had shown that lipid disorders are the most important factors in the pathogenesis of cardiovascular diseases and type-2 diabetes.[26,27,28] Blood lipid disorders are defined as increased total cholesterol and low-density lipoprotein (LDL), high levels of triglycerides (TGs) and the reduction in high-density lipoprotein (HDL) concentrations alone or in combination.[29] The global prevalence of hyperlipidemia is 15.2%. According to a study conducted in Iran, the prevalence of hypercholesterolemia in individuals over 15 years had been reported to be 11.1%.[30]
With age, the risk of morbidity one or more chronic diseases increases.[12,31] In Iran, due to the population structure that is aging and also given the significance of hypertension, type-2 diabetes, lipid disorders, and body mass index (BMI), especially among adults, this study aims to determine the status of hypertension, type-2 diabetes, lipid disorders, and BMI among the patients aged over 30 years admitted to health centers of Karaj, Iran.
Materials and Methods
Participants and setting
In this cross-sectional study, the population included participants aged 30 years and above admitted to health-care centers in Karaj. Six health centers were randomly selected from among 12 health-care centers in the Mahdasht region of Karaj. Then, all the participants admitted to the health-care centers (3040 people) who gave consent for the study were included in the study. Of these, 93 people had incomplete information leaving a total of 2947 participants.
The study tool was a comprehensive questionnaire made by the Ministry of Health and completed by the health-care providers in health-care centers for screening blood pressure, lipids, type-2 diabetes, and BMI. Prior to the administration of the questionnaire, participants were given informed consent letters and informed about the purpose of the study. Furthermore, they were also instructed that decision to participate or withdraw from the study was optional at any time.
The questionnaire included demographic characteristics like the age, gender, marital status, education level, and occupation. The other part of the questionnaire had questions on hypertension and diabetes and their risk factors, such as lipid disorder and BMI. In the demographic information section, age was classified as 30–39, 40–49, 50–60, 60–69, and 70 and over years of age. Marital status was as follows: single, married, divorced, and widow. Educational status was coded as illiterate, elementary, guidance, high school, and university, while occupation was classified as unemployed, housekeeper, worker, self-employed, employee, and retired.
Blood pressure for all patients was recorded using the mercury sphygmomanometer. Blood pressure was measured after 5 min of resting and from the right arm at least twice. The following criteria were met: patients had not smoked, drunken tea, and did not have severe physical activity for at least half an hour before measuring blood pressure. Thus, those with a blood pressure equal to or >140/90 mmHg were considered to have hypertension.
The weight of the participants was measured by health-care provider with a precision of 100 g and height by a tape measure with an accuracy of 0.5 CM. Using BMI, the person's status was checked to be normal, overweight, and obese. In this questionnaire, BMI was defined as BMI <25 (normal), BMI <30 ≥25 (overweight), and BMI ≥30 (obese).
To measure blood glucose and lipids, individuals were referred to the nearest laboratory and were advised to be on fasting to the laboratory. Fasting blood sugar (FBS) was classified as FBS <100 (healthy), FBS <126 ≥100 (pre-diabetic), and FBS ≥126 (diabetic). Dyslipidemia (fat disorder) was classified as cholesterol ≥200, LDL ≥150, HDL ≤40 (in males), HDL ≤50 (in women), and TG ≥200.
Statistical analysis
The data were analyzed using the SPSS Statistics software (version 23.0, SPSS Inc., Chicago, IL, USA), software using descriptive (frequency, percentage, mean, and standard deviation) and analytical (Chi-square and analysis of variance) tests.
Results
The results of the analysis of the collected data from 2947 samples were such that 2240 participants were women (76%) and 707 were men (24%), with 61% of the participants under 50 years of age [Table 1].
Table 1.
Frequency distribution of variables of educational level, occupation, age, and marital status in the studied subjects
| Variable | Gender, frequency (%) | Total, frequency (%) | |
|---|---|---|---|
| Women | Male | ||
| Education level | |||
| Illiterate | 506 (22.6) | 267 (37.8) | 773 (26.2) |
| Elementary | 1297 (57.9) | 55 (7.8) | 1352 (45.9) |
| Guidance | 325 (14.5) | 171 (24.2) | 496 (16.8) |
| High school | 89 (4.0) | 174 (24.6) | 263 (8.9) |
| University | 23 (1.0) | 40 (5.7) | 63 (2.1) |
| Occupation | |||
| Unemployed | 0 (0) | 43 (6.1) | 43 (1.5) |
| Housekeeper | 2213 (98.8) | 0 (0) | 2213 (75.1) |
| Worker | 7 (0.3) | 59 (8.3) | 66 (2.2) |
| Self-employed | 4 (0.2) | 406 (57.4) | 410 (13.9) |
| Retired | 9 (0.4) | 153 (21.6) | 162 (5.5) |
| Employee | 7 (0.3) | 46 (6.5) | 53 (1.8) |
| Marital status | |||
| Single | 21 (0.9) | 7 (1.0) | 28 (1.0) |
| Married | 2177 (97.2) | 687 (97.2) | 2864 (97.2) |
| Divorced | 14 (0.6) | 0 (0) | 14 (0.5) |
| Widow-widower | 28 (1.3) | 13 (1.8) | 41 (1.4) |
| Age | |||
| 30-39 | 756 (33.8) | 112 (15.8) | 868 (29.5) |
| 40-49 | 700 (31.3) | 231 (32.7) | 931 (31.6) |
| 50-59 | 483 (21.6) | 161 (22.8) | 644 (21.9) |
| 60-69 | 210 (9.4) | 126 (17.8) | 336 (11.4) |
| ≥70 | 91 (4.0) | 77 (10.9) | 168 (5.7) |
| Total | 2240 (100) | 707 (100) | 2947 (100) |
According to Table 1, more than half of the females had elementary education and only 1% of them had a university education. Nearly 6% of the males had a university education and most of them were illiterate. About 6% of the unemployed were men and more than 50% were self-employed, while the majority of females (nearly 99%) were housekeepers. According to the marital status, 97% of the participants were married.
Table 2 shows that 87% of the participants were overweight and obese and over 35% were obese. Gender separation showed that the percentage of overweight and obesity among women was significantly higher than males (P = 0.000) and nearly 10% of the total studied population had a blood glucose level above FBS <126 (unit); however, Chi-square test showed no statistically significant differences between men and women (P = 0.357). Furthermore, 15% of the participants were hypertensive. The results of Fisher's exact test showed that the percentage of people with hypertension among male was significantly higher than in females (P = 0.000). Concerning lipid disorders, data from the table showed that 32% of the subjects had dyslipidemia. Gender segregation showed that lipid disorders in women were more prevalent than in men (P = 0.010).
Table 2.
Frequency distribution of body mass index, fasting blood sugar, lipid disorders, and hypertension among the participants
| Variable | Gender, frequency (%) | Total, frequency (%) | |
|---|---|---|---|
| Women | Male | ||
| BMI | |||
| BMI <25 | 195 (8.7) | 185 (26.2) | 380 (12.9) |
| 25≤ BMI <30 | 1189 (53.1) | 336 (47.5) | 1525 (51.7) |
| BMI ≥30 | 856 (38.2) | 186 (26.3) | 1042 (35.4) |
| Chi-square test (P) | 0.000 | ||
| FBS | |||
| FBS <100 | 1859 (83.0) | 594 (84.0) | 2453 (83.2) |
| 100≤ FBS <126 | 168 (7.5) | 42 (5.9) | 210 (7.1) |
| FBS ≥126 | 213 (9.5) | 71 (10.0) | 284 (9.6) |
| Chi-square test (P) | 0.357 | ||
| Hypertension | |||
| Have | 308 (13.8) | 140 (19.8) | 446 (15.2) |
| Have not | 1931 (86.2) | 567 (80.2) | 2501 (84.8) |
| Fisher’s exact test (P) | 0.000 | ||
| Lipid disorder | |||
| Have | 745 (33.3) | 198 (28.0) | 943 (32.0) |
| Have not | 1495 (66.7) | 509 (72.0) | 2004 (68.0) |
| Fisher’s exact test (P) | 0.010 | ||
| Total | 2240 (100) | 707 (100) | 2947 (100) |
FBS=Fasting blood sugar, BMI=Body mass index
Table 3 shows that 25% of the people with a BMI more than BMI <30 (unit) were diabetic, and the percentage for individuals with overweight and normal BMI was 1.5% and 0%, respectively. The Chi-square test showed that this difference was statistically significant (P < 0.000). In addition, the data from the table showed that with an increase in BMI, the prevalence of lipid disorder increased in the studied population. The Chi-square test showed that this increase was statistically significant (P < 0.000). In the case of hypertension, the table showed that with an increase in BMI, the prevalence of hypertension increased, which was confirmed by the Chi-square test, as well (P < 0.000).
Table 3.
Frequency distribution of the study participants according to blood glucose levels, lipid disorder, and blood pressure in relation to BMI status
| Variable | BMI, frequency (%) | Total, frequency (%) | |||
|---|---|---|---|---|---|
| BMI <25 | 25 ≤BMI<30 | BMI ≥30 | |||
| FBS | |||||
| FBS <100 | 380 (100) | 1396 (91.5) | 677 (65.0) | 2453 (83.2) | |
| 100 ≤ FBS <126 | 0 (0) | 106 (7.0) | 104 (10.0) | 210 (7.1) | |
| FBS ≥126 | 0 (0) | 23 (1.5) | 261 (25.0) | 284 (9.6) | |
| Chi-square test (P) | 0.000 | ||||
| Lipid disorder | |||||
| Have | 11 (2.9) | 360 (23.6) | 572 (54.9) | 943 (32.0) | |
| Have not | 369 (97.1) | 1165 (76.4) | 470 (45.1) | 2004 (68.0) | |
| Chi-square test (P) | 0.000 | ||||
| Hypertension | |||||
| Have | 9 (2.4) | 168 (11.0) | 271 (26.0) | 448 (15.2) | |
| Have not | 371 (97.6) | 1357 (89.0) | 770 (74.0) | 2498 (84.8) | |
| Chi-square test (P) | 0.000 | ||||
| Total | 380 (12.9) | 1525 (51.7) | 1042 (35.4) | 2947 (100) | |
FBS=Fasting blood sugar, BMI=Body mass index
Discussion
According to the results of the study, 15% of the participants in the study were hypertensive. The results of the Fisher's exact test showed that the percentage of hypertensive patients in men was significantly higher than that in women. In the study by Jamshidi and Seif in Hamadan, the prevalence of hypertension in men was higher than that of women.[32] Lower hypertension in women than in men in the present study can be due to sex hormones, as well as lower control of blood pressure by men and less adherence to treatment in men than women. In a cross-sectional study on people over 19 years of age in the city of Isfahan in Iran, Sadeghi et al. found that 15.6% of men were hypertensive.[33] In the study by Chaman et al., the prevalence of hypertension was reported to be 18.4%, and women were more affected than men.[34] In developing countries, the prevalence of hypertension has been reported in adults to be 10%–20%.[35]
The results showed that nearly 10% of the total population had a blood glucose level equal to or over 126 mg/dl. The Chi-square test showed no statistically significant differences between men and women. In the study by Meraci et al. in Isfahan, 6.6% of the population was diabetic, with a significant relationship between gender and diabetes.[36] In a population-based study in Germany, the prevalence of known diabetes was 8.4% in the population aged 74–75 years and diabetes was 8.2%.[37] Overall, the incidence of diabetes in adults in the world is about 4.7% to 8.5%.[38]
Concerning lipid disorders, data from the study showed that 32% of the participants had dyslipidemia. In a meta-analysis study in Portugal, the prevalence of hypercholesterolemia was more than or equal to 240% and 31.7%, respectively.[39] In some European countries, such as England and Portugal, the incidence of hypercholesterolemia was more than 240 mg/dl (35.2% and 23.4%, respectively).[40,41] According to the sex, lipid disorders in women were more prevalent than in males, which was similar to findings in Bushehr that reported higher rates of high blood fats in women more than males.[42] Our finding is also in line with those of Jamshidi and Seif in Hamadan, showing that LDL and TG levels in women are more prevalent than in males.[32] In the study by Moghaddas and Khamnian, the prevalence of high blood lipid in women was higher than in men.[43] Perhaps, the reason for the high blood lipids in women compared to men in these studies is the inactivity and the presence of more adipose tissue in women.
Our study showed that 87% of the population were overweight and obese, and over 35% of obese people said that the reason for them being overweight or obese was due to the lack of knowledge, inadequate nutrition, and sedentary lifestyle. Furthermore, because the study was performed on adults, they were more sedentary. In the study by Moghaddas and Khamnian in 2018, the prevalence of overweight and obesity was estimated to be 73%,[43] with the results close to the present study. In a national study conducted by Janghorbani et al., the prevalence of overweight in men and women was 57% and 42.8%, respectively.[44] Golestan cohort study was a population-based study of 8998 men and women, aged 35–81 years, from urban and rural areas. In this cohort study, the prevalence of overweight was 62.6%.[45] In the study by Ayatollahi and Ghoreshizadeh in Shiraz, the prevalence of overweight and obesity in men and women was 63.9% and 49.7%, respectively.[46] Overall, the prevalence of obesity in the world varies from 2% to 80%.[47] According to the sex, the percentage of overweight and obese women was significantly higher than that of men, which was in line with the study by Moghaddas et al.,[48] Cohort study,[45] Healthy Heart Program,[49] and the studies in Saudi Arabia.[50,51] However, in developed countries like America and many European countries, the prevalence of overweight and obesity in men was more than women, which was opposed to the results of this study.[52,53] The results showed that with the increase in BMI, the prevalence of diabetes increased as well, which was in line with the results of the study by Meraci et al.[36] and the study of Odegaard et al.[54] Moreover, the results showed that with an increase in BMI, the prevalence of hypertension among the studied population increased, which was in line with the study by Meraci et al. in Isfahan and Azizi et al. in Kermanshah,[13] similar to the results obtained by Wilson in the United States. Wilson found that BMI ≥25 was associated with a high risk of hypertension in both genders.[55] The results showed that the increase in BMI increased the prevalence of lipid disorders, which was in line with the study of lipid and glucose in Tehran, showing that overweight or obesity increases the likelihood of lipid disorders. According to the study of lipid and glucose, high levels of serum cholesterol and TG and low HDL were related to high BMI.[56]
The limitations of this study are the lack of cooperation of some people. There was also a lack of easy access to the laboratory for blood tests. Overall, the results showed that the prevalence and incidence of overweight and obesity in Karaj were significant. As obesity and overweight are related to hypertension, blood lipid disorder, and DM, precise planning should be done for changing this trend throughout the community, especially for adults. It is recommended that more studies should be conducted on the underlying causes and methods of controlling this process as well as the prevention of related diseases.
Conclusion
According to the results, a high percentage of people had hypertension, type-2 diabetes, hyperlipidemia, and BMI in the population. Gender segregation showed that lipid disorders, overweight, and obesity in women were more than in men, and percentage of people with hypertension among male was significantly higher than in females. In the case of type-2 diabetes, the results showed no statistically significant differences between men and women. Furthermore, the results showed that with an increase in BMI, the lipid disorder, hypertension, and type-2 diabetes increased in the studied population. Thus, more efforts are needed to raise the awareness about the clinical and economic consequences of these diseases at the community level. The results may be helpful in developing educational strategies and prevention and control of these diseases.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
This study was drawn from a research Project No. IR.KUMS.REC.1398.159, and the ethics code of IR.IUMS.REC 1395.9321108003 and ID code of IRCT20170814035698N2 were sponsored by the department of research and technology, Kermanshah University of Medical Sciences. The research fund was spent on the design and implementation of the study. Furthermore, we appreciate all the employees of the health centers of Karaj and all the participants in the study, who helped us with their kind cooperation.
References
- 1.Chandrasiri A, Dissanayake A, de Silva V. Health promotion in workplaces as a strategy for modification of risk factors for Non Communicable Diseases (NCDs): A practical example from Sri Lanka. Work. 2016;55:281–4. doi: 10.3233/WOR-162413. [DOI] [PubMed] [Google Scholar]
- 2.Farahmand M, Akbarzadeh M, Hejazi N, Almasi-Hashiani A. Dietary and physical activity pattern in fars province, national plan of chronic disease risk factor surveillance. Zahedan J Res Med Sci. 2013;15:46–50. [Google Scholar]
- 3.Murray CJ, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari M, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396:1223–49. doi: 10.1016/S0140-6736(20)30752-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Aksu H, Pala K, Aksu H. Prevalence and associated risk factors of type 2 diabetes mellitus in Nilufer district, Bursa, Turkey. Int J Diabet Metabol. 2006;14:98–104. [Google Scholar]
- 5.Bonakdaran S, Taghavi M. Cardiovascular risk factors in type 2 diabetic patients in Mashhad city. Iran J Endocrin Metabol. 2010;12:1–6. [Google Scholar]
- 6.Ebadifard Azar F, Sarabi Asiabar A. Does leadership effectiveness correlates with leadership styles in healthcare executives of Iran University of Medical Sciences. Med J Islam Repub Iran. 2015;29:166. [PMC free article] [PubMed] [Google Scholar]
- 7.Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047–53. doi: 10.2337/diacare.27.5.1047. [DOI] [PubMed] [Google Scholar]
- 8.Afkhami Ardekani M, Zare H, Alipor A, Poursharifi H, Arab Sheibani K. Correlation between self efficacy, type D personality and health locus of control with control of blood sugar in patients with diabetes type II. J Shahid Sadoughi Univer Med Sci. 2013;20:805–13. [Google Scholar]
- 9.Azar FE, Solhi M, Darabi F, Rohban A, Abolfathi M, Nejhaddadgar N. Effect of educational intervention based on PRECEDE-PROCEED model combined with self-management theory on self-care behaviors in type 2 diabetic patients. Diabetes Metab Syndr. 2018;12:1075–8. doi: 10.1016/j.dsx.2018.06.028. [DOI] [PubMed] [Google Scholar]
- 10.Kaboudi M, Dehghan F, Ziapour A. The effect of acceptance and commitment therapy on the mental health of women patients with type II diabetes. Ann Trop Med Public Health. 2017;10:1709–13. [Google Scholar]
- 11.Azizi F, Hatami H, Janghorbani M. Epidemiology and Control of Common Diseases in Iran. Tehran: Khosravi Publisher; 2004. [Google Scholar]
- 12.Rezapour A, Azar FE, Aghdash SA, Tanoomand A, Shokouh SM, Yousefzadeh N, et al. Measuring equity in household's health care payments (Tehran-Iran 2013): Technical points for health policy decision makers. Med J Islamic Republic Iran. 2015;29:246. [PMC free article] [PubMed] [Google Scholar]
- 13.Mojahedi MJ, Hami M, Shakeri MT, Hasani MH, Ahadi M. The prevalence and related risk factors of hypertension in young adults in Mashhad hypertension in young adults. Med J Mashhad Univer Med Sci. 2015;58:252–7. [Google Scholar]
- 14.Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: A systematic review. J Hypertens. 2004;22:11–9. doi: 10.1097/00004872-200401000-00003. [DOI] [PubMed] [Google Scholar]
- 15.Azizi F, Hatami H, Jonghorbani M. Epidemiology and Control Disease in Iran. Tehran: Eshtiagh Publication; 2010. [Google Scholar]
- 16.Rezapour A, Ebadifard Azar F, Azami Aghdash S, Tanoomand A, Ahmadzadeh N, Sarabi Asiabar A. Inequity in household's capacity to pay and health payments in Tehran-Iran-2013. Med J Islam Repub Iran. 2015;29:245. [PMC free article] [PubMed] [Google Scholar]
- 17.Rezaee J, Davoodpour B, Ariannejad J, Afzal Aghaei M, Mirsadraei M. The amount of serum lipids in over weighted patients with BMI over than 40. J Med Sci. 2008;4:23–7. [Google Scholar]
- 18.Aghahe-Meibody H, Azizi F. Relationship between body weight change and fat distribution with incidence of diabetes among people living in the area 13 of Tehran. Pajouhesh Dar Pezeshki. 2008;32:105–13. [Google Scholar]
- 19.Shafiee G, Hadaegh F, Azizi F. Comparison of waist-to-height ratio and body mass index for prediction of type 2 diabetes mellitus risk in women: Tehran lipid and glucose study. Iran J Endocrin Metabol. 2009;11:1–9. [Google Scholar]
- 20.Semnani V, Malek M, Khaniporshokooh S. Survey of the frequency of the types of gall stones and it's related risk factors in cholecystectomized patients in Semnan (2002-2003) Koomesh. 2004;6:15–20. [Google Scholar]
- 21.Maddah M, Jazayery A, Mirdamadi R, Eshraghiyan MR, Jalali M. Sex hormones, leptin and anthropometric indices in men. J Reproduct Infert. 2001;2:19–25. [Google Scholar]
- 22.Azar FE, Aghdash AS, Azar PF, Mazdaki A, Rezapour A, Ebrahimi P, et al. Cost-effectiveness of lung cancer screening and treatment methods: A systematic review of systematic reviews. BMC Health Serv Res. 2017;17:413. doi: 10.1186/s12913-017-2374-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Mansourian M, Ziapour A, Kazemian M, Damanabad Z, Rastegarimehr B, Mirzaei A, et al. Assessment of educational performance of nurses in neonatal intensive care unit from parents’ perspective. J Educ Health Promot. 2020;9:1–6. doi: 10.4103/jehp.jehp_371_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Sadeghi M, Golshadi I, Roohafza H, Aghdak P. Evaluation the relation between coronary risk factors, metabolic syndrome and 10 year ischemic event according to BMI in women above 19 years in central part of Iran. J Guilan Univer Med Sci. 2008;17:16–23. [Google Scholar]
- 25.Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–81. doi: 10.1016/S0140-6736(14)60460-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Nabilou B, Yusefzadeh H, Rezapour A, Azar FE, Safi PS, Asiabar AS, et al. The productivity and its barriers in public hospitals: Case study of Iran. Med J Islamic Republic Iran. 2016;30:316. [PMC free article] [PubMed] [Google Scholar]
- 27.Fesharakinia A, Zarban A, Sharifzadeh GR. Lipid profiles and prevalence of dyslipidemia in schoolchildren in south Khorasan Province, eastern Iran. Arch Iran Med. 2008;11:598–601. [PubMed] [Google Scholar]
- 28.Ferdosi M, Vatankhah S, Khalesi N, Ebadi Fard Azar F, Ayoobian A. Designing a referral system management model for direct treatment in social security organization. J Mil Med. 2012;14:129–35. [Google Scholar]
- 29.Vega GL. Management of atherogenic dyslipidemia of the metabolic syndrome: Evolving rationale for combined drug therapy. Endocrinol Metab Clin North Am. 2004;33:525–44, vi. doi: 10.1016/j.ecl.2004.03.013. [DOI] [PubMed] [Google Scholar]
- 30.Marrie RA, Yu BN, Leung S, Elliott L, Caetano P, Warren S, et al. Rising prevalence of vascular comorbidities in multiple sclerosis: Validation of administrative definitions for diabetes, hypertension, and hyperlipidemia. Mult Scler. 2012;18:1310–9. doi: 10.1177/1352458512437814. [DOI] [PubMed] [Google Scholar]
- 31.Aldrich N, Benson WF. Disaster Preparedness and The Chronic Disease Nedds of Vulnerable Older Adults. Preventing Chronic Disease: Public Health Res, Pract, Policy. 2008;5:1–7. [PMC free article] [PubMed] [Google Scholar]
- 32.Jamshidi L, Seif A. Comparison of cardiovascular diseases risk factors in male and female older adults of Hamadan City 2014. J Gerontol. 2016;1:1–10. [Google Scholar]
- 33.Sadeghi M, Roohafza HR, Kelishadi R. Blood pressure and associated cardiovascular risk factors in Iran: Isfahan Healthy Heart Programme. Med J Malaysia. 2004;59:460–7. [PubMed] [Google Scholar]
- 34.Chaman R, Yunesian M, Hajimohamadi A, Taramsari MG. Investigating hypertension prevalence and some of its influential factors in an ethnically variant rural sample. Knowledge Health. 2008;39:42–3. [Google Scholar]
- 35.Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22. doi: 10.1016/S0140-6736(20)30925-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Meraci M, Feizi A, Bagher NM. Investigating The Prevalence of High Blood Pressure, Type 2 Diabetes Mellitus and Related Risk Factors According to a Large General Study. Isfahan-Using Multivariate Logistic Regression Model. 2012 [Google Scholar]
- 37.Rathmann W, Haastert B, Icks A, Löwel H, Meisinger C, Holle R, et al. High prevalence of undiagnosed diabetes mellitus in Southern Germany: Target populations for efficient screening. The KORA survey 2000. Diabetologia. 2003;46:182–9. doi: 10.1007/s00125-002-1025-0. [DOI] [PubMed] [Google Scholar]
- 38.Moradi F, Toghroli R, Abbas J, Ziapour A, Lebni J, Aghili A, et al. Hospital managers’ skills required and onward challenges: A qualitative study. J Educ Health Promot. 2020;9:228. doi: 10.4103/jehp.jehp_171_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Costa J, Borges M, Oliveira E, Gouveia M, Carneiro AV. Incidence and prevalence of hypercholesterolemia in Portugal: A systemic review. Part II. Rev Port Cardiol. 2003;22:683–702. [PubMed] [Google Scholar]
- 40.Costa J, Oliveira E, David C, Borges M, Gouveia M, Carneiro A. Prevalence Of hypercholesterolemia in Portugal and Europe: The same reality? Rev Portuguesa Cardiol. 2003;22:967–74. [PubMed] [Google Scholar]
- 41.Roth GA, Fihn SD, Mokdad AH, Aekplakorn W, Hasegawa T, Lim SS. High total serum cholesterol, medication coverage and therapeutic control: An analysis of national health examination survey data from eight countries. Bull World Health Organ. 2011;89:92–101. doi: 10.2471/BLT.10.079947. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Saku K, Zhang B, Shirai K, Jimi S, Yoshinaga K, Arakawa K. Hyperinsulinemic hypoalphalipoproteinemia as a new indicator for coronary heart disease. J Am Coll Cardiol. 1999;34:1443–51. doi: 10.1016/s0735-1097(99)00372-1. [DOI] [PubMed] [Google Scholar]
- 43.Moghaddas F, Khamnian Z. The prevalence of obesity, hypertension, diabetes and hyperlipidemia among elderlies over 60 years of age of Sahlan area in Tabriz. Depict Health. 2018;9:206–13. [Google Scholar]
- 44.Janghorbani M, Amini M, Willett WC, Mehdi Gouya M, Delavari A, Alikhani S, et al. First nationwide survey of prevalence of overweight, underweight, and abdominal obesity in Iranian adults. Obesity (Silver Spring) 2007;15:2797–808. doi: 10.1038/oby.2007.332. [DOI] [PubMed] [Google Scholar]
- 45.Bahrami H, Sadatsafavi M, Pourshams A, Kamangar F, Nouraei M, Semnani S, et al. Obesity and hypertension in an Iranian cohort study; Iranian women experience higher rates of obesity and hypertension than American women. BMC Public Health. 2006;6:158. doi: 10.1186/1471-2458-6-158. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Ayatollahi SM, Ghoreshizadeh Z. Prevalence of obesity and overweight among adults in Iran. Obes Rev. 2010;11:335–7. doi: 10.1111/j.1467-789X.2010.00725.x. [DOI] [PubMed] [Google Scholar]
- 47.Erem C, Arslan C, Hacihasanoglu A, Deger O, Topbas M, Ukinc K, et al. Prevalence of obesity and associated risk factors in a Turkish population (trabzon city, Turkey) Obes Res. 2004;12:1117–27. doi: 10.1038/oby.2004.140. [DOI] [PubMed] [Google Scholar]
- 48.Moghaddas F, Khamnian Z. The prevalence of obesity, hypertension, diabetes and hyperlipidemia among elderlies over 60 years of age of Sahlan area in Tabriz. Depict Health. 2019;9:206–13. [Google Scholar]
- 49.Yahai M, Samadanian F, Hosseini M, Azadbakht L. Prevalence of overweight, obesity and central obesity among students of school of medicine in Isfahan University of Medical Sciences, Isfahan, Iran. J Health Syst Res. 2013;9:421–9. [Google Scholar]
- 50.Al-Rethaiaa AS, Fahmy AE, Al-Shwaiyat NM. Obesity and eating habits among college students in Saudi Arabia: A cross sectional study. Nutr J. 2010;9:39. doi: 10.1186/1475-2891-9-39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Musaiger AO. Overweight and obesity in Eastern Mediterranean region: Prevalence and possible causes. J Obes. 2011;2011:407237. doi: 10.1155/2011/407237. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Azadbakht L, Esmaillzadeh A. Dietary and non-dietary determinants of central adiposity among Tehrani women. Public Health Nutr. 2008;11:528–34. doi: 10.1017/S1368980007000882. [DOI] [PubMed] [Google Scholar]
- 53.Paeratakul S, Lovejoy JC, Ryan DH, Bray GA. The relation of gender, race and socioeconomic status to obesity and obesity comorbidities in a sample of US adults. Int J Obes Relat Metab Disord. 2002;26:1205–10. doi: 10.1038/sj.ijo.0802026. [DOI] [PubMed] [Google Scholar]
- 54.Odegaard AO, Koh WP, Vazquez G, Arakawa K, Lee HP, Yu MC, et al. BMI and diabetes risk in Singaporean Chinese. Diabetes Care. 2009;32:1104–6. doi: 10.2337/dc08-1674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Wilson PW, D'Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: The Framingham experience. Arch Intern Med. 2002;162:1867–72. doi: 10.1001/archinte.162.16.1867. [DOI] [PubMed] [Google Scholar]
- 56.Yeganeh M, Shakersain B, Azizi F, Yngve A, Hedayati M. Central obesity as a reliable predictor for hypertension and dyslipidemia: Tehran lipid glucose study. Iran J Endocrin Metabol. 2010;12:251–314. [Google Scholar]