The prevalence, awareness, and treatment of lipid abnormalities in Iranian adults: Surveillance of risk factors of noncommunicable diseases in Iran 2016

The association between dietary intake of fats and transient global amnesia (TGA)

BACKGROUND

Different types of dietary fat may influence memory and cognitive functions. This study aimed to investigate the association between dietary fat intake and transient global amnesia (TGA).

METHODS

This case-control study was conducted using Persian Sabzevar cohort data on 258 individuals with TGA and 520 individuals without amnesia in Sabzevar Iran. The food frequency questionnaire (FFQ) was used to assess the intake of dietary fats of the participants. All study participants were screened for TGA by a neurologist and their status was determined based on the diagnostic symptoms defined by the Kaplan and Hodges criteria.

RESULTS

There was an inverse association between the risk of TGA and dietary intake of alpha-linolenic acid (ALA) (OR = 0.94, CI95%:0.88-0.99, P = 0.01). Also, a positive association was observed between TGA and dietary intake of n-6 fatty acids (OR = 1.18, CI 95%: 1.04-1.33, P = 0.01). The results remained significant after adjustment for age, sex, education, job, marital status, physical activity, BMI, and calorie intake.

CONCLUSION

Omega-3 fatty acids may have beneficial effects; however, omega-6 fatty acids may have adverse effects on the risk of amnesia. Further longitudinal studies are warranted.

Plasma acylcarnitines and amino acids in dyslipidemia: An integrated metabolomics and machine learning approach

Purpose

The Discovery of underlying intermediates associated with the development of dyslipidemia results in a better understanding of pathophysiology of dyslipidemia and their modification will be a promising preventive and therapeutic strategy for the management of dyslipidemia.

Methods

The entire dataset was selected from the Surveillance of Risk Factors of Noncommunicable Diseases (NCDs) in 30 provinces of Iran (STEPs 2016 Country report in Iran) that included 1200 subjects and was stratified into four binary classes with normal and abnormal cases based on their levels of triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and non-HDL-C.Plasma concentrations of 20 amino acids and 30 acylcarnitines in each class of dyslipidemia were evaluated using Tandem mass spectrometry. Then, these attributes, along with baseline characteristics data, were used to check whether machine learning (ML) algorithms could classify cases and controls.

Results

Our ML framework accurately predicts TG binary classes. Among the models tested, the SVM model stood out, performing slightly better with an AUC of 0.81 and a standard deviation of test accuracy at 0.04. Consequently, it was chosen as the optimal model for TG classification. Moreover, the findings showed that alanine, phenylalanine, methionine, C3, C14:2, and C16 had great power in differentiating patients with high TG from normal TG controls. Conclusions: The comprehensive output of this work, along with sex-specific attributes, will improve our understanding of the underlying intermediates involved in dyslipidemia.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01384-9.

Metabolomics Signature in Prediabetes and Diabetes: Insights From Tandem Mass Spectrometry Analysis

OBJECTIVE

This study investigates the metabolic differences between normal, prediabetic and diabetic patients with good and poor glycaemic control (GGC and PGC).

DESIGN

In this study, 1102 individuals were included, and 50 metabolites were analysed using tandem mass spectrometry. The diabetes diagnosis and treatment standards of the American Diabetes Association (ADA) were used to classify patients.

METHODS

The nearest neighbour method was used to match controls and cases in each group on the basis of age, sex and BMI. Factor analysis was used to reduce the number of variables and find influential underlying factors. Finally, Pearson's correlation coefficient was used to check the correlation between both glucose and HbAc1 as independent factors with binary classes.

RESULTS

Amino acids such as glycine, serine and proline, and acylcarnitines (AcylCs) such as C16 and C18 showed significant differences between the prediabetes and normal groups. Additionally, several metabolites, including C0, C5, C8 and C16, showed significant differences between the diabetes and normal groups. Moreover, the study found that several metabolites significantly differed between the GGC and PGC diabetes groups, such as C2, C6, C10, C16 and C18. The correlation analysis revealed that glucose and HbA1c levels significantly correlated with several metabolites, including glycine, serine and C16, in both the prediabetes and diabetes groups. Additionally, the correlation analysis showed that HbA1c significantly correlated with several metabolites, such as C2, C5 and C18, in the controlled and uncontrolled diabetes groups.

CONCLUSIONS

These findings could help identify new biomarkers or underlying markers for the early detection and management of diabetes.

The synergistic effect of obesity and dyslipidemia on hypertension: results from the STEPS survey

BACKGROUND

Obesity and dyslipidemia are important risk factors for hypertension (HTN). When these two conditions coexist, they may interact in a synergistic manner and increase the risk of developing HTN and its associated complications. The aim of this study was to investigate the synergistic effect of general and central obesity with dyslipidemia on the risk of HTN.

METHOD

Data from 40,387 individuals aged 25 to 64 years were obtained from a repeated cross-sectional study examining risk factors for non-communicable diseases (STEPS) in 2007, 2011 and 2016. Body mass index (BMI) was calculated as a measure of general obesity and waist circumference (WC) as a measure of central obesity. Dyslipidemia was defined as the presence of at least one of the lipid abnormalities. Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or current use of antihypertensive medication. To analyze the synergistic effect between obesity and dyslipidemia and HTN, the relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP), and synergy index (SI) were calculated. A weighted logistic regression model was performed to estimate the odds ratios (ORs) for the risk of HTN.

RESULTS

The results showed an association between obesity, dyslipidemia and hypertension. The interaction between obesity and dyslipidemia significantly influences the risk of hypertension. In hypertensive patients, the presence of general obesity increased from 14.55% without dyslipidemia to 64.36% with dyslipidemia, while central obesity increased from 13.27 to 58.88%. This interaction is quantified by RERI and AP values of 0.15 and 0.06 for general obesity and 0.24 and 0.09 for central obesity, respectively. The corresponding SI of 1.11 and 1.16 indicate a synergistic effect. The OR also show that the risk of hypertension is increased in the presence of obesity and dyslipidemia.

CONCLUSION

Obesity and dyslipidemia are risk factors for HTN. In addition, dyslipidemia with central obesity increases the risk of HTN and has a synergistic interaction effect on HTN. Therefore, the coexistence of obesity and lipid abnormalities has many clinical implications and should be appropriately monitored and evaluated in the management of HTN.

Exploring the burden of mixed dyslipidemia in patients with type 2 diabetes mellitus: A cross-sectional study in Kashmir, India

BACKGROUND

Diabetes-related dyslipidemia is a multifaceted, complicated disorder characterized by an abnormal lipid profile in individuals with diabetes. The incidence of different types of dyslipidemia, however, was not a focus of prior investigations. The patients were characterized into three categories of dyslipidemia. Different patterns of dyslipidemia were combined into single dyslipidemia (7 patterns), mixed dyslipidemia (16 patterns), and triple dyslipidemia (4 patterns).

METHODS

In this cross-sectional study, 586 people suffering from type 2 diabetes mellitus (T2DM) were included. We assessed the serum lipid profile and used log (TG/HDL-C) to determine the atherogenic index of plasma (AIP). Dyslipidemia was examined as a categorical variable, and the findings were presented as percentages and numbers. To compare categorical variables, we either utilized Fisher exact tests or Chi square tests.

RESULTS

The study comprised of 586 T2DM patients, with 310 (52.9%) women and 276 (47.1%) men. Women have significantly higher hypertension (33.6%) as compared to men (23.2%). 18.94% (111) of patients were having coronary artery disease (CAD) history consisting of 12.28% (72) females and 6.66% (39) males, a difference which is statistically significant. 98.12% of total individuals had as a minimum of one lipid abnormality. 4.61% (27) of study subjects were having isolated dyslipidemia and 93.51% (548) had dual or triple pattern of dyslipidemia (mixed dyslipidemia). High AIP >0.24 (94.8%) was the most predominant trend of dyslipidemia. The dual combination of AIP (>0.24) and HDL (<50 mg/dL in Females and <40 mg/dL in Males) was found to be the most common pattern of mixed dyslipidemia (68.08%). The most prevalent trend of isolated dyslipidemia was found to be high AIP (>0.24), In patients with CAD history. Among the mixed dyslipidemia, the common pattern of dyslipidemia (71.17%) was the dual combination of high AIP (>0.24) and low HDL (<50 mg/dL women and <40 mg/dL males). The triple combination of TG (≥200 mg/dL) and HDL (<40 and <50 mg/dL) and LDL (≥100 mg/dL) was only found in females.

CONCLUSION

In conclusion, dyslipidemia is highly prevalent in T2DM patients, with mixed dyslipidemia being the most common type observed in the community of Kashmir valley, India. High AIP was the most prevalent pattern in the current investigation.

Correlates of normal and decreased HDL cholesterol levels in type 2 diabetes: a cohort-based cross-sectional study

BACKGROUND

The literature describes an inverse association between the values of triglyceride (TG) and high-density lipoprotein cholesterol (HDL-C). This survey was designed to exhibit the features of people with type 2 diabetes (T2D) who display this inverse association and identify potential contributing factors to having normal HDL-C values.

METHODS

A total of 6127 persons with T2D were assigned to the present survey. Demographic features and clinical status data were compared between subjects with a substantial inverse association of TG and HDL-C and those without. Logistic regressions were performed to ascertain the role of different factors related to normal HDL-C. Moreover, the restricted cubic spline (RCS) functions were conducted to scrutinize the underlying relationships between the studied variables and low HDL-C levels.

RESULTS

Patients with high TG (150 ≤ TG < 400) compared to patients with normal TG (TG < 150) were less likely to have normal HDL-C. Younger age, narrow hip, lower levels of blood pressure, two-hour postprandial glucose (2hPP), fasting blood sugar (FBS), hemoglobinA1C (HbA1C), low-density lipoprotein cholesterol (LDL-C), total cholesterol, and non-HDL-C, higher atherogenic index of plasma (AIP), and TG/HDL-C ratio correlate with an inverse connection between the values of HDL-C and TG (all P < 0.05). Age greater than 65 years (odds ratio (OR) 1.260, 95% confidence intervals (CI) 1.124-1.413) had a positive association, whereas female sex (OR 0.467, CI 0.416-0.523) , 25 kg/m2 < body mass index (BMI) (OR 0.786, CI 0.691-0.894), and higher serum creatinine levels (OR 0.481, CI 0.372-0.621) had an inverse association with having normal HDL-C.

CONCLUSIONS

Patients with an inverse connection between TG and HDL-C values had considerably different anthropometric features, lipid profiles, and glucose indices compared to those without this relationship. Furthermore, patients who aged less than 65 years, had female gender, BMI more than 25 kg/m2, and higher serum creatinine levels were less likely to exhibit normal HDL-C levels.

Burden of Ischemic Heart Disease and Its Attributable Risk Factors in North Africa and the Middle East, 1990 to 2019: Results From the GBD Study 2019

BACKGROUND

The North Africa and Middle East (NAME) region has one of the highest burdens of ischemic heart disease (IHD) worldwide. This study reports the contemporary epidemiology of IHD in NAME.

METHODS AND RESULTS

We estimated the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs), and premature mortality of IHD, and its attributable risk factors in NAME from 1990 to 2019 using the results of the GBD (Global Burden of Disease study 2019). In 2019, 0.8 million lives and 18.0 million DALYs were lost due to IHD in NAME. From 1990 to 2019, the age-standardized DALY rate of IHD significantly decreased by 33.3%, mostly due to the reduction of years of life lost rather than years lived with disability. In 2019, the proportion of premature death attributable to IHD was higher in NAME compared with global measures: 26.8% versus 16.9% for women and 18.4% versus 14.8% for men, respectively. The age-standardized DALY rate of IHD attributed to metabolic risks, behavioral risks, and environmental/occupational risks significantly decreased by 28.7%, 37.8%, and 36.4%, respectively. Dietary risk factors, high systolic blood pressure, and high low-density lipoprotein cholesterol were the top 3 risks contributing to the IHD burden in most countries of NAME in 2019.

CONCLUSIONS

In 2019, IHD was the leading cause of death and lost DALYs in NAME, where premature death due to IHD was greater than the global average. Despite the great reduction in the age-standardized DALYs of IHD in NAME from 1990 to 2019, this region still had the second-highest burden of IHD in 2019 globally.

Association Between HDL2-C and HDL3-C with Cardiovascular Disease: A Nested Case-Control Study in an Iranian Population

Background

The contribution of high-density lipoprotein cholesterol (HDL-C) subclasses to incident cardiovascular disease (CVD) and coronary heart disease (CHD) remains a subject of debate.

Objectives

The objective of this study was to investigate these associations in a population with a high prevalence of dyslipidemia and CVD.

Methods

In a nested case-control study, HDL-C and its subclasses (HDL2-C and HDL3-C) in 370 age and gender-matched case and control subjects were determined. This study employed multivariable-adjusted conditional logistic regression to calculate the odds ratios (ORs) for the associations between HDL-C, HDL2-C, HDL3-C, and HDL2-C/HDL3-C (both as continuous and categorical variables) with incident CVD and CHD. The present study models were adjusted for a comprehensive set of confounders, including body mass index, current smoking, hypertension, type 2 diabetes mellitus, use of lipid-lowering drugs, family history of premature CVD, non-HDL-C, and triglycerides.

Results

In multivariate analysis, when considering lipoprotein parameters as continuous variables, a 1-unit increase in HDL-C and HDL3-C was associated with a reduced risk of incident CVD and CHD. For CVD, the ORs (95% confidence intervals [CI]) were 0.95 (0.92 - 0.98) and 0.95 (0.93 - 0.98) for HDL-C and HDL3-C, respectively. The corresponding values for CHD were 0.94 (0.91 - 0.97) and 0.94 (0.91 - 0.97). In the categorical approach to lipoprotein parameters, higher quartiles of HDL-C and HDL3-C, compared to the first quartile, were significantly associated with a lower risk of incident CVD and CHD. The ORs (95% CI) for the fourth quartiles were 0.43 (0.25 - 0.74, P for trend = 0.003) and 0.46 (0.27 - 0.78, P for trend = 0.005) for HDL-C and HDL3-C regarding CVD and 0.32 (0.17 - 0.59) and 0.32 (0.18 - 0.59) (all P for trend = 0.001) regarding CHD, respectively. Paradoxically, across quartiles of HDL2-C/HDL3-C, this lipid ratio was associated with a higher risk of CHD (92% higher risk in the fourth quartile).

Conclusions

The results showed that HDL3-C, but not HDL2-C, was primarily responsible for the protective effect of HDL-C against CVD, particularly CHD, in Iranian adults.

Prevalence of dyslipidemias in the Middle East region: A systematic review & meta-analysis study

BACKGROUND AND AIMS

Dyslipidemia is a known main risk factor for cardiovascular diseases, and it can be controlled to reduce the incidence of cardiovascular diseases. This meta-analysis aimed to estimate the prevalence of dyslipidemias in the Middle East.

METHODS

The relevant published articles between 2000 and 2021 that investigated the prevalence of dyslipidaemias in the Middle East were found through international data sources such as Medline, PubMed, and Google Scholar. The random-effects model was used to estimate the pooled prevalence with 95% confidence intervals.

RESULTS

The pooled prevalence of dyslipidemias, hypertriglyceridemia, hypercholesterolemia, high levels of low-density lipoprotein cholesterol and low levels of high-density lipoprotein cholesterol in the Middle East were 54.08% (95% CI: 43.83-66.71), 32.51% (95% CI: 28.59-36.43), 29.44% (95% CI: 18.74-40.13), 32.09% (95% CI: 22.17-42.01), 44.71% (95% CI: 37.86-51.57), respectively. During the last two decades, an increasing trend in the prevalence of dyslipidemias was observed overall and in both sexes. Also, the age groups over 30 significantly had the highest prevalence of hypercholesterolemia, high levels of low-density lipoprotein cholesterol, and low levels of high-density lipoprotein cholesterol (p < 0.05).

CONCLUSIONS

The increasing trend in the prevalence of dyslipidemias during the last two decades is an alarming and significant concern in the Middle East. Therefore, special measures are needed to deal with dyslipidemias as a health priority in the Middle East.

Prevalence of non-alcoholic fatty liver and its related factors in Iran: Systematic review and meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is a systemic disorder with a complex multifactorial and heterogeneous pathogenesis and has become the most common cause of chronic liver disease in many countries around the world. Numerous studies in Iran have presented different results on the prevalence and risk factors of NAFLD, in this study, which has been done in a systematic review and meta-analysis, provides a good estimate of the prevalence and risk factors of the disease in Iran. Following the peer review of electronic search strategies (PRESS and the preferred reporting items for systematic reviews and meta-analyses [PRISMA] statement, we searched Web of Science, PubMed, Embase, Scopus, and Persian scientific searcher (Elmnet) from inception to September 19, 2022. In the present study, 71 articles were reviewed for qualitative and meta-analysis. The overall mean prevalence of NAFLD in children studies was 22.4% (95% confidence interval [CI]: 10.9% to 33.9%). The prevalence was notably higher in adult studies 40.5% (95% CI: 35.1% to 46%). In 24 studies, the association between NAFLD and sex was reported, 10 of which showed significant relationships. Out of 46 studies observed that NAFLD prevalence increased significantly with body mass index (BMI). Eight out of 14 studies reported significant associations between FBS and NAFLD in children's studies. Though Iran has a high NAFLD prevalence compared to most areas, and due to the unfavorable situation of risk factors contributing to the NAFLD, it is necessary to take the necessary interventions to control these risk factors and prevent NAFLD.

Decreasing trend of blood lipid profile in type 2 diabetes: Not a promising change in HDL-C, a serial cross-sectional study

BACKGROUND

The prevalence of dyslipidemia in patients with type 2 diabetes (T2D) has been reported to be relatively high. The current study aimed to investigate the trend of serum lipid levels and the prevalence of dyslipidemia in patients with T2D.

METHODS

Data were extracted from a cohort of patients with T2D who had regular follow-ups every year for three years. TG, TC, LDL-C, HDL-C, and non-HDL-C were analyzed. The atherogenic index of plasma (AIP) was calculated using log (TG/HDL-C).

RESULTS

A total of 747 patients with T2D were included in this study, consisting of 469 (62.8%) women and 278 (37.2%) men. There was a significant downward trend in mean TG, TC, LDL-C, non-HDL-C, and AIP levels. The trend of mean HDL-C levels showed no significant change. The prevalence of high TG, high TC, high LDL-C, and high non-HDL-C significantly decreased from the first to the last visit. There was no significant change in the trend of prevalence of low HDL-C. The prevalence of high AIP significantly decreased in women and showed no significant changes in men.

CONCLUSIONS

A decreasing trend was observed in the mean levels and prevalence of TG, TC, LDL-C, non-HDL-C, and AIP. HDL-C did not change significantly. The success rate in achieving a complete normal lipid profile during follow-up years was not promising and continues to be challenging.

Prevalence of plasma lipid abnormalities and associated risk factors among Iranian adults based on the findings from STEPs survey 2021

The study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (< 50 mg/dL in women, < 40 mg/dL in men), or self-reported use of lipid-lowering medications. Mixed dyslipidemia was characterized as the coexistence of high LDL-C with at least one of the hypertriglyceridemia and low HDL-C. The prevalence of each lipid abnormality was determined by each population strata, and the determinants of abnormal lipid levels were identified using a multiple logistic regression model. The prevalence was 39.7% for hypertriglyceridemia, 21.2% for hypercholesterolemia, 16.4% for high LDL-C, 68.4% for low HDL-C, and 81.0% for dyslipidemia. Hypercholesterolemia and low HDL-C were more prevalent in women, and hypertriglyceridemia was more prevalent in men. The prevalence of dyslipidemia was higher in women (OR = 1.8), obese (OR = 2.8) and overweight (OR = 2.3) persons, those residents in urban areas (OR = 1.1), those with inappropriate physical activity (OR = 1.2), patients with diabetes (OR = 2.7) and hypertension (OR = 1.9), and participants with a history (OR = 1.6) or familial history of CVDs (OR = 1.2). Mixed dyslipidemia prevalence was 13.6% in women and 11.4% in men (P < 0.05). The prevalence of lipid abnormalities was highly heterogeneous among provinces, and East Azarbaijan with 85.3% (81.5-89.1) and Golestan with 68.5% (64.8-72.2) had the highest and lowest prevalence of dyslipidemia, respectively. Although the prevalence of high cholesterol and LDL-C had a descending trend in the 2016-2021 period, the prevalence of dyslipidemia remained unchanged. There are modifiable risk factors associated with dyslipidemia that can be targeted by the primary healthcare system. To modify these risk factors and promote metabolic health in the country, action plans should come to action through a multi-sectoral and collaborative approach.

Prevalence and sociodemographic determinants of selected noncommunicable diseases among the general population of Cyprus: A large population-based cross-sectional study

Background

Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide. The aim of this study was to determine the prevalence of NCDs among the population of Cyprus and to identify the distribution of the socioeconomic and demographic determinants among individuals with the most frequent NCDs.

Methods

A cross-sectional study was conducted using stratified sampling. Socioeconomic and demographic characteristics and the presence of NCDs were collected through a standardized questionnaire. The diseases were classified using the 10th revision of the International Classification of Diseases (ICD-10).

Results

In total, 1140 individuals participated in the study, among whom 590 (51.7%) had at least one chronic disease. The most prevalent NCDs were hyperlipidemia (17.4%), hypertension (12.9%), and thyroid diseases (8.4%). We identified more males than females with hyperlipidemia aged 25-44 years old and >65 years old (p = 0.024), more males compared to females with hypertension (p = 0.001) and more females compared to males with thyroid diseases (p < 0.001). Individuals with hypertension and hyperlipidemia were more likely to be married, to have completed a higher education, and to have a high annual income.

Discussion

In Cyprus, the majority of the general population had at least one NCD. Hyperlipidemia, hypertension, and thyroid disease are relatively common, even at younger ages, highlighting the need for the development of public health programs aimed at addressing and preventing NCDs.

The Pandemic of Coronary Heart Disease in the Middle East and North Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Coronary heart disease (CHD) is the leading cause of morbidity, mortality, and disability in the Middle East and North Africa (MENA). While the prevention, diagnosis, and management of CHD have been detailed in international guidelines, we aimed in this review to quantify the pandemic of CHD in the MENA region and highlight regional patient characteristics, clinical challenges, and future directions to optimize CHD care in the region.

RECENT FINDINGS

Patients with CHD in the MENA feature younger age at presentation and worse prognosis in women. Despite the high burden of CHD risk factors, many of these factors remain underrecognized, undertreated, and uncontrolled. Additionally, CHD care is hampered by poor patient awareness, inefficient preventive strategies, and limited access to guideline-recommended therapeutics. All stakeholders involved in healthcare should work together to develop and execute strategies aimed at tackling the burden of CHD in the MENA.

Risk of incident cardiovascular diseases at national and subnational levels in Iran from 2000 to 2016 and projection through 2030: Insights from Iran STEPS surveys

BACKGROUND

Cardiovascular Disease (CVD) is the leading cause of death in developing countries. CVD risk stratification guides the health policy to make evidence-based decisions.

AIM

To provide current picture and future trend of CVD risk in the adult Iranian population.

METHODS

Nationally representative datasets of 2005, 2006, 2007, 2008, 2009, 2011, and 2016 STEPwise approach to non-communicable diseases risk factor surveillance (STEPS) studies were used to generate the 10-year and 30-year risks of CVD based on Framingham, Globorisk, and World Health Organization (WHO) risk estimation models. Trend of CVD risk was calculated from 2000 until 2016 and projected to 2030.

RESULTS

In 2016, based on Framingham model, 14.0% of the Iranian, aged 30 to 74, were at great risk (≥20%) of CVD in the next 10 years (8.0% among females, 20.7% among males). Among those aged 25 to 59, 12.7% had ≥45% risk of CVD in the coming 30 years (9.2% among females, 16.6 among males). In 2016, CVD risk was higher among urban area inhabitants. Age-standardized Framingham 10-year CVD risk will increase 32.2% and 19%, from 2000 to 2030, in females and males, respectively. Eastern provinces had the lowest and northern provinces had the greatest risk.

CONCLUSIONS

This study projected that CVD risk has increased from 2000 to 2016 in Iran. Without further risk factor modification, this trend will continue until 2030. We have identified populations at higher risks of CVD to guide future intervention.

Prediction of hypercholesterolemia using machine learning techniques

Purpose

Hypercholesterolemia is a major risk factor for a wide range of cardiovascular diseases. Developing countries are more susceptible to hypercholesterolemia and its complications due to the increasing prevalence and the lack of adequate resources for conducting screening and/or prevention programs. Using machine learning techniques to identify factors contributing to hypercholesterolemia and developing predictive models can help early detection of hypercholesterolemia, especially in developing countries.

Methods

Data from the nationwide 2016 STEPs study in Iran were used to identify socioeconomic, lifestyle, and metabolic risk factors associated with hypercholesterolemia. Furthermore, the predictive power of the identified risk factors was assessed using five commonly used machine learning algorithms (random forest; gradient boosting; support vector machine; logistic regression; artificial neural network) and 10-fold cross validation in terms of specificity, sensitivity, and the area under the receiver operating characteristic curve.

Results

A total of 14,667 individuals were included in this study, of those 12.8% (n = 1879) had (undiagnosed) hypercholesterolemia. Based on multivariate logistic regression analysis the five most important risk factors for hypercholesterolemia were: older age (for the elderly group: OR = 2.243; for the middle-aged group: OR = 1.869), obesity-related factors including high BMI status (morbidly obese: OR = 1.884; obese: OR = 1.499; overweight: OR = 1.426) and AO (OR = 1.339), raised BP (hypertension: OR = 1.729; prehypertension: OR = 1.577), consuming fish once or twice per week (OR = 1.261), and having risky diet (OR = 1.163). Furthermore, all the five hypercholesterolemia prediction models achieved AUC around 0.62, and models based on random forest (AUC = 0.6282; specificity = 65.14%; sensitivity = 60.51%) and gradient boosting (AUC = 0.6263; specificity = 64.11%; sensitivity = 61.15%) had the optimal performance.

Conclusion

The study shows that socioeconomic inequalities, unhealthy lifestyle, and metabolic syndrome (including obesity and hypertension) are significant predictors of hypercholesterolemia. Therefore controlling these factors is necessary to reduce the burden of hypercholesterolemia. Furthermore, machine learning algorithms such as random forest and gradient boosting can be employed for hypercholesterolemia screening and its timely diagnosis. Applying deep learning algorithms as well as techniques for handling the class overlap problem seems necessary to improve the performance of the models.

Metabolic risk factors attributed burden in Iran at national and subnational levels, 1990 to 2019

Introduction

Metabolic risk factors (MRFs) predispose populations to a variety of chronic diseases with a huge burden globally. With the increasing burden of these risk factors in Iran, in this study, we aimed to report the estimated burden attributed to MRFs at national and subnational scales in Iran, from 1990 to 2019.

Methods

Based on the comparative risk assessment method of the Global Burden of Disease (GBD) Study 2019, data of deaths and disability-adjusted life years (DALYs) attributable to four top MRFs in Iran including high systolic blood pressure (SBP), high fasting plasma glucose (FPG), high body mass index (BMI), and high low-density lipoprotein (LDL) for the 1990-2019 period, were extracted. The socio-demographic index (SDI) was used to report the data based on the corresponding socio-economic stratifications. The results were reported in national and subnational 31 provinces of Iran to discover disparities regarding the attributable burden to MRFs. Furthermore, we reported the causes of diseases to which the attributable burden to MRFs was related.

Results

Overall, the age-standardized high LDL, high SBP, high BMI, and high FPG-attributed death rate changed by -45.1, -35.6, +2.8, and +19.9% from 1990 to 2019, respectively. High SBP was the leading risk factor regarding attributed age-standardized death rates reaching 157.8 (95% uncertainty interval: 135.3-179.1) and DALY rates reaching 2973.4 (2652.2-3280.2) per 100,000 person-years, in 2019. All rates increased with aging, and men had higher rates except for the +70 years age group. At the subnational level, provinces in the middle SDI quintile had the highest death and DALY rates regarding all four MRFs. Total deaths, DALYs, YLLs and YLDs number by the causes of diseases linked to MRFs increased over the study period. Cardiovascular diseases, diabetes mellitus, and kidney diseases were the main causes of burden of disease attributable to MRFs.

Conclusion

Herein, we found divergent patterns regarding the burden of MRFs as well as disparities in different regions, sex, and age groups for each risk factor and related causes. This could provide policymakers with a clearer vision toward more appropriate decision-making and resource allocation to prevent the burden of MRFs in Iran.

The burden of metabolic risk factors in North Africa and the Middle East, 1990-2019: findings from the Global Burden of Disease Study

Background

The objective of this study is to investigate the trends of exposure and burden attributable to the four main metabolic risk factors, including high systolic blood pressure (SBP), high fasting plasma glucose (FPG), high body-mass index (BMI), and high low-density lipoproteins cholesterol (LDL) in North Africa and the Middle East from 1990 to 2019.

Methods

The data were retrieved from Global Burden of Disease Study 2019. Summary exposure value (SEV) was used for risk factor exposure. Burden attributable to each risk factor was incorporated in the population attributable fraction to estimate the total attributable deaths and disability-adjusted life-years (DALYs).

Findings

While age-standardized death rate (ASDR) attributable to high-LDL and high-SBP decreased by 26.5% (18.6-35.2) and 23.4% (15.9-31.5) over 1990-2019, respectively, high-BMI with 5.1% (-9.0-25.9) and high-FPG with 21.4% (7.0-37.4) change, grew in ASDR. Moreover, age-standardized DALY rate attributed to high-LDL and high-SBP declined by 30.2% (20.9-39.0) and 25.2% (16.8-33.9), respectively. The attributable age-standardized DALY rate of high-BMI with 8.3% (-6.5-28.8) and high-FPG with 27.0% (14.3-40.8) increase, had a growing trend. Age-standardized SEVs of high-FPG, high-BMI, high-SBP, and high-LDL increased by 92.4% (82.8-103.3), 76.0% (58.9-99.3), 10.4% (3.8-18.0), and 5.5% (4.3-7.1), respectively.

Interpretation

The burden attributed to high-SBP and high-LDL decreased during the 1990-2019 period in the region, while the attributable burden of high-FPG and high-BMI increased. Alarmingly, exposure to all four risk factors increased in the past three decades. There has been significant heterogeneity among the countries in the region regarding the trends of exposure and attributable burden. Urgent action is required at the individual, community, and national levels in terms of introducing effective strategies for prevention and treatment that account for local and socioeconomic factors.

Funding

Bill & Melinda Gates Foundation.

Association between ultra-processed foods intake with lipid profile: a cross-sectional study

The purpose of this cross-sectional study was to examine the association between ultra-processed foods (UPFs) intake and lipid profile in Iranian people. The study was performed on 236 individuals with the age range of 20-50 years in Shiraz, Iran. Food intakes of the participants were evaluated using a 168-item food frequency questionnaire (FFQ) which was previously validated in Iranian populations. In order to estimate the ultra-processed foods intake, classification of NOVA food group was used. Serum lipids including total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) were measured. The results showed that mean of age and body mass index (BMI) of the participants were 45.98 years and 28.28 kg/m², respectively. Logistic regression was used to evaluation the relation between UPFs intake and lipid profile. Higher UPFs intake was associated with increased OR of TG and HDL abnormality in both crude (OR 3.41; 95% CI 1.58, 7.34; P-trend = 0.001 and OR 2.99; 95% CI 1.31, 6.82; P-trend = 0.010) and adjusted models (OR 3.69; 95% CI 1.67, 8.16; P-trend = 0.001 and OR 3.38 95% CI 1.42, 8.07; P-trend = 0.009). But, there were no association between UPFs intake and other indices of lipid profile. Also, we found significant associations between UPFs intake and dietary nutrient profiles. In conclusion, UPFs consumption could worsen the nutritional profile of the diet and lead to negative changes in some indices of the lipid profile.

The approach of Iranian clinical pharmacists in the treatment of dyslipidemia based on international guidelines

Introduction: Optimal treatment of dyslipidemia is a top priority in the prevention of cardiovascular diseases. For this purpose, clinicians in Iran usually refer to four current international guidelines. The aim of this study was to assess the approach of Iranian clinical pharmacists in the treatment of dyslipidemia based on international guidelines. Methods: A structured questionnaire was prepared. Questions (n=24) included the demographics (n=7), dyslipidemia references (n=3), dyslipidemia general knowledge of respondents (n=10), and questions (n=4) designed based on the difference among the latest version of guidelines participants stated they use in their practice. After validity conformation, the questionnaire was distributed to 120 clinical pharmacists, electronically from May to August 2021. Results: Response rate was 77.5% (n=93). The majority of participants (80.6%, n=75) claimed to have used the 2018 ACC/AHA guideline. The Median (interquartile range [IQR]) score of the general knowledge questions was 5.0 (2.0) out of 10. The Median (IQR) score of questions designed based on the difference among guidelines was calculated 3(1) out of 4. There was no significant (P=0.25) difference in score among participants according to their guideline selection. Moreover, the gender and length of experience as a clinical pharmacist had no significant (P>0.05) effect on the score of participants. Conclusion: In this study, Iranian clinical pharmacists answered half of the dyslipidemia general knowledge questions correctly. Also, Participants were up-to-date on 75% of the questions designed based on the latest version of the guideline they had been using in their practice.

Prevalence of comorbidities in patients with multiple sclerosis using administrative data from 2007 to 2016 in Iran

BACKGROUND

Research interest in the impact of comorbidities in MS has been expanding. Based on studies, certain comorbidities are more prevalent in MS population such as depression, anxiety, hypertension and hypercholesterolemia, diabetes, and hypothyroidism.

OBJECTIVE

This study aims to describe the prevalence of comorbidities in MS population based on the health insurance claims data.

METHOD

This retrospective database analysis was conducted using patient-level medicinal and pharmacy claims data from a leading insurance group (Iranian health insurance) in 2007-2016. MS population was identified based on their Disease Modifying Therapies prescribed by a neurologist (qualified to diagnose MS). Comorbidities in MS and non-MS population were assessed by their prescriptions. Crude and age-standardized prevalence rate (ASPR) of coverage of comorbidities in different age and sex groups and their odds ratio versus non-MS population were assessed.

RESULTS

The most common comorbidities were depression (15.50%) and anxiety (10.1%). Hypercholesterolemia, diabetes, hypertension, and hypothyroidism were prevalent in 6%, 3.6%, 3.5%, and 2.7% respectively. Anxiety and depression were more prevalent in middle age group (45-65 years old). But other comorbidities were more prevalent in older age groups. All comorbidities were more prevalent in female except hypertension in patients ≥45 years old. The odds of all comorbidities were higher for male patients with MS rather than their parallel age group in non-MS patients. These also applied for female patients with MS 18-44 years old (except hypertension).

CONCLUSION

Using claims data, the prevalence of taking treatment for selected comorbidities in MS population and their association with sex and age, can guide patients, healthcare providers, and policy makers to help improve MS patients' wellbeing.

Action status and willingness to change health-promoting behaviors during the COVID-19 pandemic among elementary school children: a study based on Prochaska's stages of behavior change theory (TTM)

BACKGROUND & AIM

COVID-19 pandemic has significant effects on lifestyle and health-promoting behaviors and adolescence is a very critical period due to the importance of identity formation and individual behaviors. Therefore, the aim of this study was to determine the status of health- promoting behaviors in the sixth grade male students attending elementary schools in Ardabil city based on Prochaska 's stages of behavior change (TTM).

MATERIALS & METHODS

This analytical cross-sectional study was conducted on the 619 sixth grade male students attending elementary schools during 2021. The data were collected using two instruments (a researcher-made questionnaire and Health Promoting Lifestyle Profile-II (HPLP-II) questionnaire). The data were analyzed using SPSS version 22 and one-way analysis of variance.

RESULTS

The majority of students in physical activity and healthy eating behaviors were in the pre-contemplation stage, 29.6% (183 people) and 33.1% (205 people), respectively. All dimensions of health-promoting behaviors were observed to have a significant relationship with the stages of Prochaska's theory behavior change in students, their decision-making balance and self-efficacy scores (P < 0.001).

CONCLUSION

The health of students is under serious threat due to the poor state of health-promoting behaviors and the weak desire to change behavior. By planning in educating the students, significant changes can be made in changing their behavior and improving their health.

Mean versus variability of lipid measurements over 6 years and incident cardiovascular events: More than a decade follow-up

Background

Lipid variability (LV) has emerged as a contributor to the incidence of cardiovascular diseases (CVD), even after considering the effect of mean lipid levels. However, these associations have not been examined among people in the Middle East and North Africa (MENA) region. We aimed to investigate the association of 6-year mean lipid levels versus lipid variability with the risk of CVD among an Iranian population.

Methods

A total of 3,700 Iranian adults aged ≥ 30 years, with 3 lipid profile measurements, were followed up for incident CVD until March 2018. Lipid variability was measured as standard deviation (SD), coefficient of variation (CV), average real variability (ARV), and variability independent of mean (VIM). The effects of mean lipid levels and LV on CVD risk were assessed using multivariate Cox proportional hazard models.

Results

During a median 14.5-year follow-up, 349 cases of CVD were recorded. Each 1-SD increase in the mean levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), TC/high-density lipoprotein cholesterol (HDL-C), and non-HDL-C increased the risk of CVD by about 26-29%; for HDL-C, the risk was significantly lower by 12% (all p-values < 0.05); these associations resisted after adjustment for their different LV indices. Considering LV, each 1-SD increment in SD and ARV variability indices for TC and TC/HDL-C increased the risk of CVD by about 10%; however, these associations reached null after further adjustment for their mean values. The effect of TC/HDL-C variability (measured as SD) and mean lipid levels, except for LDL-C, on CVD risk was generally more pronounced in the non-elderly population.

Conclusion

Six-year mean lipid levels were associated with an increased future risk of incident CVD, whereas LV were not. Our findings highlight the importance of achieving normal lipid levels over time, but not necessarily consistent, for averting adverse clinical outcomes.

The association between low-density and non-high-density lipoprotein cholesterol with incident cardiovascular disease among low-risk Iranians during 2 decades follow-up

INTRODUCTION

To examine the associations between low-density and non-high-density lipoprotein cholesterol (LDL-C and non-HDL-C, respectively) with incident cardiovascular disease (CVD) in low-risk subjects.

MATERIALS AND METHODS

From a total of 2476 non-diabetic aged 40-70 years, free of CVD with LDL-C range 1.81≤LDL-C<4.91mmol/L with 10-year atherosclerotic cardiovascular disease (ASCVD) risk <7.5%, the associations of LDL-C and non-HDL-C with incident CVD were assessed using multivariable Cox proportional hazard regression analyses adjusted for age, sex, body mass index, waist circumference, HDL-C, triglycerides, chronic kidney disease, current smoking, hypertension, and family history of CVD.

RESULTS

During a median follow-up of 18 years, 559 CVD events occurred. Compared to the LDL-C <2.59 mmol/L as reference, the categories of 2.59≤LDL-C<3.36, 3.36≤LDL-C<4.14, and ≥4.14 mmol/L were associated with hazard ratios (95% confidence intervals) of 1.39(0.89-2.18), 1.72(1.11-2.68), and 2.19(1.36-3.51) for incident CVD (P for trend<0.0001), respectively. Compared to the non-HDL-C<3.36 as reference, the categories of 3.36≤non-HDL-C<4.14, 4.14≤non-HDL-C<4.91, and ≥4.91 mmol/L were associated with 1.48(0.96-2.30), 1.37(0.89-2.16), and 2.15(1.36-3.39) higher risk for incident CVD (P for trend <0.0001), respectively. Among those with ASCVD score <5% (n=2070), even the 2.59≤LDL-C<3.36 mmol/L increased the risk for CVD [1.73(1.01-2.97)]. Results for non-HDL-C categories remained unchanged except for the category of 4.14≤non-HDL-C<4.91 mmol/L that was not associated with CVD.

CONCLUSIONS

Among Iranian individuals with ASCVD risk as little as <5%, LDL-C≥2.59 mmol/L and non-HDL-C≥3.36 mmol/L, independent of traditional risk factors, were associated with a significantly higher risk of incident CVD, individuals that might potentially benefit from pharmacological therapy.

Assessing the effect of socioeconomic factors on prevalence of dyslipidemia among iranian adult population; district level analysis from 2016 STEPS national study using small area estimation

Background

Atherosclerotic Cardiovascular Disease (CVD) is the leading cause of death globally and dyslipidemia plays a critical role in the development of this condition. This study aimed to analyze the potential impact of socioeconomic factors on the prevalence of dyslipidemia at district level in Iran. Understanding these factors is important for development of future risk factor control programs.

Methods

We used the nationwide Iran STEPwise approach to risk factor Surveillance (STEPS) 2016 survey as a representative dataset on the Non-Communicable Diseases (NCDs) risk factors in Iran. To obtain a district level dyslipidemia estimates, we utilized the small area estimation method with a Bayesian spatial hierarchical multilevel regression and multilevel mixed models. The principal component analysis was applied to derive household wealth index. For evaluation of education, successful years of schooling was calculated at district level. Urbanization ratio was defined as the proportion of residents in the urban area to the urban and rural areas for each district.

Results

The highest difference was found for hypercholesterolemia coverage with 9.11 times difference among the lowest and highest prevalence across the country's district for males. Men with lower income, lower urbanization, and lower education levels had lower values of high-density lipoprotein (HDL) cholesterol, and higher level of hypercholesterolemia, and hypertriglyceridemia (P-value < 0.001). Triglyceride levels were directly correlated with all analyzed socioeconomic factors in both females and males (P-value < 0.001).

Conclusion

We demonstrated that there is an inverse relationship between socioeconomic levels and dyslipidemia indices as populations with higher socioeconomic levels consistently had higher mean dyslipidemia levels. Our findings provide an excellent fundamental framework for healthcare administrators and policymakers to set goals and pursue effective preventive strategies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01027-x.

Level and trend of total plasma cholesterol in national and subnational of Iran: a systematic review and age-spatio-temporal analysis from 1990 to 2016

Purpose

We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran.

Methods

Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016.

Results

At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3-61·1) to 22·4%(20·5-24·3) in women and 53·2%(49·1-57·3) to 18·0%(16·4-19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected.

Conclusion

The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01052-w.

Phyto-Enrichment of Yogurt to Control Hypercholesterolemia: A Functional Approach

Cholesterol is essential for normal human health, but elevations in its serum levels have led to the development of various complications, including hypercholesterolemia (HC). Cholesterol accumulation in blood circulation formsplaques on artery walls and worsens the individuals’ health. To overcome this complication, different pharmacological and non-pharmacological approaches are employed to reduce elevated blood cholesterol levels. Atorvastatin and rosuvastatin are the most commonly used drugs, but their prolonged use leads to several acute side effects. In recent decades, the potential benefit of ingesting yogurt on lipid profile has attracted the interest of researchers and medical professionals worldwide. This review aims to give an overview of the current knowledge about HC and the different therapeutic approaches. It also discusses the health benefits of yogurt consumption and highlights the overlooked phyto-enrichment option to enhance the yogurt’s quality. Finally, clinical studies using different phyto-enriched yogurts for HC management are also reviewed. Yogurt has a rich nutritional value, but its processing degrades the content of minerals, vitamins, and other vital constituents with beneficial health effects. The option of enriching yogurt with phytoconstituents has drawn a lot of attention. Different pre-clinical and clinical studies have provided new insights on their benefits on gut microbiota and human health. Thus, the yogurtphyto-enrichment with stanol and β-glucan have opened new paths in functional food industries and found healthy andeffective alternatives for HC all along with conventional treatment approaches.

National and subnational burden of stroke in Iran from 1990 to 2019

BACKGROUND

Data on the burden of stroke and changing trends at national and subnational levels are necessary for policymakers to allocate recourses appropriately. This study presents estimates of the stroke burden from 1990 to 2019 using the results of the Global Burden of Disease (GBD) 2019 study.

METHODS

For the GBD 2019, verbal autopsy and vital registration data were used to estimate stroke mortality. Cause-specific mortality served as the basis for estimating incidence, prevalence, and disability-adjusted life years (DALYs). The burden attributable to stroke risk factors was calculated by a comparative risk assessment. Decomposition analysis was applied to determine the contribution of population aging, population growth, and changes in the age-specific incidence rates.

RESULTS

In 2019, the number of prevalent cases, incident cases, and deaths due to stroke in Iran were 963,512; 102,778; and 40,912, respectively. The age-standardized incidence rate (ASIR) and the age-standardized death rate (ASDR) decreased from 1990 to 2019. Of national stroke ASDRs in 2019, 44.7% (35.7-54.7%) were attributable to hypertension and 28.8% (15.2-57.4) to high fasting plasma glucose. At the subnational level, the trend of the stroke incidence and mortality rate decreased in all provinces. Stroke was responsible for 4.48% of total DALYs in 2019 (3.38% due to ischemic stroke, 0.87% due to intracerebral hemorrhage, and 0.22% due to subarachnoid hemorrhage).

CONCLUSION

ASIR and ASDR of stroke are decreasing nationally and subnationally; however, the number of incident cases and deaths are increasing in all SDI quintiles, possibly due to population growth.

Health system performance in Iran: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Better evaluation of existing health programmes, appropriate policy making against emerging health threats, and reducing inequalities in Iran rely on a comprehensive national and subnational breakdown of the burden of diseases, injuries, and risk factors.

METHODS

In this systematic analysis, we present the national and subnational estimates of the burden of disease in Iran using the Global Burden of Disease Study 2019. We report trends in demographics, all-cause and cause-specific mortality, as well as years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by major diseases and risk factors. A multi-intervention segmented-regression model was used to explore the overall impact of health sector changes and sanctions. For this analysis, we used a variety of sources and reports, including vital registration, census, and survey data to provide estimates of mortality and morbidity at the national and subnational level in Iran.

FINDINGS

Iran, which had 84·3 million inhabitants in 2019, had a life expectancy of 79·6 years (95% uncertainty interval 79·2-79·9) in female individuals and 76·1 (75·6-76·5) in male individuals, an increase compared with 1990. The number of DALYs remained stable and reached 19·8 million (17·3-22·6) in 2019, of which 78·1% were caused by non-communicable diseases (NCDs) compared with 43·0% in 1990. During the study period, age-standardised DALY rates and YLL rates decreased considerably; however, YLDs remained nearly constant. The share of age-standardised YLDs contributing to the DALY rate steadily increased to 44·5% by 2019. With regard to the DALY rates of different provinces, inequalities were decreasing. From 1990 to 2019, although the number of DALYs attributed to all risk factors decreased by 16·8%, deaths attributable to all risk factors substantially grew by 43·8%. The regression results revealed a significant negative association between sanctions and health status.

INTERPRETATION

The Iranian health-care system is encountering NCDs as its new challenge, which necessitates a coordinated multisectoral approach. Although the Iranian health-care system has been successful to some extent in controlling mortality, it has overlooked the burden of morbidity and need for rehabilitation. We did not capture alleviation of the burden of diseases in Iran following the 2004 and 2014 health sector reforms; however, the sanctions were associated with deaths of Iranians caused by NCDs.

FUNDING

Bill & Melinda Gates Foundation.

Association of different lipid measures with incident bone fractures: Tehran Lipid and Glucose Study

OBJECTIVE

to investigate the association between different lipid measures and long-term hospitalization-required incident fracture among Iranian men and women.

METHODS

A total of 3309 individuals aged ≥50 years (men = 1598) were included in the study. Multivariate Cox proportional hazard analyses were performed to assess the risk of incident fracture across quintiles, considering first quintile as reference, as well as for 1-standard deviation (SD) increase in each lipid measures i.e. total cholesterol (TC), triglycerides (TG), low and high density lipoprotein cholesterol (LDL-C and HDL-C, respectively), non-HDL-C, and related indices (TG/HDL-C and TC/HDL-C). Covariates included age, body mass index, current smoking, type 2 diabetes mellitus, hypertension, lipid lowering-drugs, and steroid medications (for women).

RESULTS

During a median follow-up of 18 years, incident fracture was observed in 201 cases (men=87). In both gender no linear association were found between different lipid measures and incident fracture. Among men only the fourth quartile of TG was associated with lower risk of fracture in the age adjusted analysis with hazard ratio (HR) and 95% confidence interval (CI) as [0.45 (0.21-0.95)]. Among women, the age-adjusted HRs and 95% CIs for the second, third, fourth and fifth quintiles of non-HDL-C were [0.46 (0.25-0.87)], [0.73 (0.42-1.25)], [0.90 (0.54-1.51)], [0.52 (0.29-0.95)], respectively; the corresponding values in the multivariate model, were [[0.48 (0.26-0.90)], [0.76 (0.4-1.32)], [0.94 (0.56-1.58)], and [0.52 (0.28-0.95)], respectively. The second quintile of LDL-C was also associated with lower risk for incident fracture in the multivariate analysis [0.53 (0.29-0.98)].

CONCLUSIONS

Among Iranian women a nonlinear association between non-HDL-C and LDL-C and incident fracture were found as the second and fifth quintile of the former and the second quintile of the latter were associated with about 50% lower risk of fracture .Generally our findings did not support harmful impact of these lipid measures on incident fracture.

Association between being metabolically healthy/unhealthy and metabolic syndrome in Iranian adults

Introduction

The prevalence of metabolically healthy obesity (MHO) varies based on different criteria. We assessed the prevalence of MHO and metabolic unhealthiness based on body mass index (BMI) and their association with metabolic syndrome (MetS) in a nation-wide study.

Methods

Data were taken from the STEPs 2016 study, from 18,459 Iranians aged ≥25 years. Demographic, metabolic, and anthropometric data were collected. Subjects were stratified by BMI, metabolic unhealthiness, and having MetS. The latter was defined based on National Cholesterol Education Program Adult Treatment Panel III 2004 (NCEP ATP III), was then assessed.

Results

The prevalence of MHO and metabolic unhealthiness in obese subjects was 7.5% (about 3.6 million) and 18.3% (about 8.9 million), respectively. Most of the metabolic unhealthy individuals were female (53.5%) or urban residents (72.9%). Low physical activity was significantly and positively associated (Odds Ratio: 1.18, 95% CI: 1.04–1.35) with metabolic unhealthiness, while being a rural residence (0.83, 0.74–0.93), and having higher education (0.47, 0.39–0.58) significantly but negatively affected it. Dyslipidemia was the most frequent MetS component with a prevalence rate of 46.6% (42.1–51.1), 62.2% (60.8–63.6), 76.3% (75.1–77.5), and 83.4% (82.1–84.6) among underweight, normal weight, overweight and obese phenotypes, respectively.

Conclusion

BMI aside, an additional set of criteria such as metabolic markers should be taken into account to identify normal weight but metabolically unhealthy individuals. Given the highest prevalence of dyslipidemia among obese subjects, further interventions are required to raise public awareness, promote healthy lifestyles and establish lipid clinics.

Current Inequities in Smoking Prevalence on District Level in Iran: A Systematic Analysis on the STEPS Survey

BACKGROUND

The prevalence of tobacco smoking and its burden on societies is not homogenous at the national and district levels. This nationwide study aimed to investigate current inequalities in the prevalence of smoking at the district level and the association of smoking behaviors with gender, wealth, education, and urbanization in Iran.

STUDY DESIGN

A cross-sectional study.

METHODS

This study was conducted by analyzing the data of the STEPS survey 2016 with 30 541 participants. The small-area estimation method using the Bayesian spatial hierarchical multilevel regression model was employed to generate district-level prevalence of all types of smoking by gender. The inequalities between the groups by wealth, education, and urbanization were investigated via concentration index.

RESULTS

The prevalence rates of current daily cigarette smoking were found to be at the range of 4.6-40.9 and 0-4.5 among men and women, respectively. Current daily cigarette smoking was higher in men than in women: 19.0 (95% CI: 9.5-28.7) vs 0.7 (95% CI: 0-6.9). Women with lower wealth, education, or urbanization were more likely to smoke tobacco or be exposed to secondhand smoking. On the other hand, men with higher wealth or education indices were more likely to smoke tobacco. Men with lower wealth, education, or urbanization were more likely to be exposed to secondhand smoking.

CONCLUSION

The smoking behavior varied significantly at the district level in Iran. Gender, wealth, education, and urbanization were determinants of smoking prevalence.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

BACKGROUND

As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs.

METHODS AND FINDINGS

We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.

CONCLUSIONS

Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

Pattern of infectious diseases in northern Iran: An approach to internal medicine management

BACKGROUND

Despite the development of their prevention and treatment, infectious diseases cause high mortality, many disabilities and inadequate living conditions worldwide. The aim of this study was to evaluate the pattern of infectious diseases in northern Iran with an approach to internal medicine management.

METHODS

This cross-sectional research was conducted in 2019 on all 7095 infectious diseases patient records that referred to Ghaemshahr Razi Hospital, Mazandaran Province, Iran during 2012-2018. A checklist prepared by investigator was used to collect the data. The extracted data were coded and entered into SPSS 22 and analyzed using K2 and independent t-test at p<.05.

RESULTS

The mean age of the study patients was 29.7±26.4. 4372 (61%) of the cases were males and the mean duration of hospitalization was 41.6±33.5. Age was significantly correlated to infectious diseases (P=.001). Gastroenteritis was the most common infectious disease among the men and women with 2442 (60.5%) and 1594 (39.47%), respectively. Based on the Pearson's correlation test, the relationship between leptospirosis, brucellosis, pulmonary tuberculosis, shigellosis, sepsis and infectious mononucleosis with gender, habitation, admission mode, discharged mode and age was significant (p<.05).

CONCLUSION

As the high frequent diseases were gastroenteritis, leptospirosis, brucellosis and sepsis and an increasing trend was in the prevalence of gastroenteritis, leptospirosis and lung tuberculosis, health system managers should consider training courses, preventive strategies, real-time interventions, increased hospital bed rate for patients with infectious diseases and so on.

Non-communicable diseases' risk factors in Iran; a review of the present status and action plans

Non-communicable Diseases (NCDs) are the leading causes of death globally, imposing a heavy burden on the healthcare systems, especially in low- and middle-income countries. Iran is a country in the Middle-East region with an aging population and changing disease risk factors, and now is facing NCDs as the major health problem of the country. Investigating NCDs' risk factors and tackling preventable ones is the main intervention to control their heavy burden. In this review, we discussed the most critical risk factors in Iran and the implemented programs and action plans to control them. A better knowledge on current status of risk factors and plans to tackle them, could help policymakers effectively rule policies and allocate resources to curb heavy burden of NCDs in Iran.

The risk and added values of the atherosclerotic cardiovascular risk enhancers on prediction of cardiovascular events: Tehran lipid and glucose study

BACKGROUND

In 2013 American College of Cardiology and the American Heart Association released a guideline on the management of atherosclerotic cardiovascular disease (ASCVD) including a composite of death from CVD, non-fatal myocardial infarction, or non-fatal stroke (hard CVD). This guideline recommended a risk score that was calculated using pooled cohort equations (ASCVD-PCE). The guideline was updated in 2018/2019 and further risk discussion was suggested for deciding whether to continue or initiate statin therapy among non-diabetic individuals with ASCVD-PCE score ranged 5-20%. They recommended a risk discussion with considering risk enhancing factors (ASCVD-REFs) including family history of premature CVD, chronic kidney disease, triglycerides ≥ 175 mg/dl, low-density lipoprotein cholesterol (LDL-C) ≥ 160 mg/dl, metabolic syndrome (Mets), and for women premature menopause, and hypertensive disorders of pregnancy (HDP). In the current study, we aimed to examine the predictability of recommended ASCVD-REFs on incident hard CVD in non-diabetic individuals with LDL-C 70-189 mg/dl, with ASCVD-PCE risk 5-20% during 10 and 15-year follow-up.

METHODS

Among a total of 3546 non-diabetic individuals aged 40-75 years, after excluding those with ASCVD-PCE score < 5% and ≥ 20% (n = 2342), 1204 individuals (women = 332) were included. The univariable and multivariable (further adjusted for ASCVD-PCE) Cox regression analysis were used to evaluate the association of each potential ASCVD-REFs with hard CVD. Additionnaly, the role of different components of Mets and a history of gestational diabetes (GDM)/macrosomia was also examined. The predictive ability of each significant ASCVD-REFs, then was evaluated by the discrimination accuracy and risk reclassification index.

RESULTS

During the 10-year follow-up, 73 hard CVD events occurred. Although in univariable analysis, high blood pressure (BP) component of Mets, GDM/macrosomia, and HDP remained as significant ASCVD-REFs, in the multivariable analysis, only the history of HDP (5.35 (1.22-23.38)) and GDM/macrosomia (3.18 (1.05-9.65)) showed independent risks. During the 15-year follow-up, Mets (1.47 (1.05-2.06)) and its components of high waist circumference (1.40 (1.0-1.95)) and high BP (1.52 (1.07-2.15)) significantly increased the risk. These ASCVD-REFs did not improve discrimination or predictive ability.

CONCLUSIONS

In a decade follow-up, only conditions specific for women and in longer follow-up, the presence of Mets perse, and its components of high WC and high BP were shown as significant ASCVD-REFs.

Current Tobacco Smoking Prevalence Among Iranian Population: A Closer Look at the STEPS Surveys

Objectives: To determine the current tobacco smoking prevalence among Iranian adults, its geographical distribution in 2011, 2016, and time trend during 2004-2016.

Methods: We conducted a pooled analysis of the published reports of 2004, 2007, 2008, 2009, and the data of 2011 and 2016 of the STEPwise approach to chronic disease risk-factor surveillance (STEPS) surveys.

Results: The prevalence of current tobacco smoking and current daily cigarette smoking in 2016 was 14.1 and 9.7%, respectively. Only 0.2% of participants smoked water-pipe. Current tobacco smoking prevalence remained unchanged during 2004-2016 for both men and women. The prevalence of passive smoking at home or workplace was 27.4%. Current tobacco smoking prevalence and current daily cigarette smoking was significantly lower among women than men. Current tobacco smoking prevalence showed a geographical pattern throughout the country. In both 2011 and 2016, current tobacco smoking prevalence was higher among men who lived in the western provinces, especially the north-west, than those who lived in the eastern and southern provinces.

Conclusions: The current tobacco smoking prevalence among Iranian population has not changed significantly during 2004-2016 and does not conform to the international guidelines. Therefore, it remains crucial yet challenging that effective nationwide policies be implemented to reduce the use of tobacco products. One cannot hope for any reductions in smoking prevalence until a cocktail of interventions are built around strong commitment to government policy.

Population attributable fraction estimates of cardiovascular diseases in different levels of plasma total cholesterol in a large-scale cross-sectional study: a focus on prevention strategies and treatment coverage

PURPOSE

Cardiovascular diseases (CVDs) are the main cause of deaths among non-communicable diseases. Arguments about the best prevention strategy to control CVDs' risk factors continue. We evaluated the population attributable fraction (PAF) of CVDs in different levels of plasma cholesterol.

METHODS

Patients' data were obtained from Iran STEPs 2016 study. In phase 0 we estimated PAF regardless of cholesterol levels and clinical factors. In phase 1 we calculated PAF based on three levels of cholesterol (<200, 200-240, ≥240 mg/dl). In phase 2 we estimated PAF in 3 groups considering lipid-lowering drugs. In phase 3 all treated participants and not treated hypercholesterolemic people were included, to evaluate the impact of treatment. Estimations were done for Ischemic heart disease (IHD) and ischemic stroke (IS), and for two sex.

RESULTS

In phase 0, the highest PAF for IHD and IS were 0.35 (95% confidence interval 0.29-0.41) and 0.22 (0.18-0.27) for females and 0.27 (0.22-0.32) and 0.18 (0.14-0.22) for males. In phase 1, the highest PAF belonged to population with cholesterol ≥240 mg/dl and IHD, as 0.90 (0.85-0.94) for females, and 0.90 (0.85-0.96) for males. In phase 2, the pre-hypercholesterolemic group had higher PAFs than the hypercholesteremic group in most of the population. Phase 3 showed treatment coverage significantly lowered fractions in all age groups, for both causes.

CONCLUSION

An urgent action plan and a change in preventive programs of health guidelines are needed to stop the vast burden of hypercholesterolemia in the pre-hypercholesterolemic population. Population-based prevention strategies need to be more considered to control further CVDs.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-020-00673-3.

The association between dietary pattern and coronary artery disease: A case-control study

Introduction: Dietary patterns are an important factors in the progress of cardiovascular disease. This study aimed to assess the association between dietary patterns and coronary artery disease (CAD).

Methods: A case-control study was carried on 550 participants. Food expenditure was collected using a validated 168-item food-frequency questionnaire. Dietary patterns were extracted by principal component analysis (PCA). Multiple logistic regressions was used to assess the association between dietary patterns and the risk of CAD.

Results: Three major dietary patterns were identified: the "Quasi-Western Pattern" was characterized by higher intakes of sweets and desserts, snacks, legumes, honey or jam, ketchup, mayonnaise, yellow vegetables, potatoes, red meat, refined grains; the "Sugar and Fast foods Pattern" was characterized by higher intakes of sugar, soft drinks, fast foods, high-fat dairy, hydrogenated fats, and the "Quasi-Mediterranean Pattern" was characterized by higher intakes of fruits, cruciferous vegetables, green leafy vegetables, other vegetables, nuts, coffee. In both sexes, the "Quasi-Western Pattern" and the "Sugar and Fast foods Pattern" were positively associated with the risk of CAD. For "Quasi-Western Pattern", adjusted-ORs were (OR: 1.35, 95% CI: 0.99-1.83, P = 0.05) and (OR: 1.38, 95% CI: 1.03-1.83, P = 0.03)for men and women respectively. The ORs were for "Sugar and Fast foods Pattern" (OR: 3.64, 95% CI:2.25-5.89, P < 0.001) and (OR: 3.91, 95% CI: 2.42-6.63, P < 0.001) for men and women respectively.There was a significant inverse relationship among "Quasi-Mediterranean pattern" and CAD in the crude model in women (OR: 0.7, 95% CI: 0.55-0.89, P = 0.0.004).

Conclusion: High adherence to the "Quasi-Western Pattern" and "Sugar-Fast foods Pattern" dietary patterns were associated with a higher risk of CAD. The "Quasi-Mediterranean pattern" reduced the risk of CAD.

Secular trend in dietary patterns of Iranian adults from 2006 to 2017: Tehran lipid and glucose study

BACKGROUND

Based on data regarding nutrition transition in the Middle East and North Africa, this study aim to investigate the general structure and secular trend of dietary patterns reported from the Tehran Lipid and Glucose Study (TLGS) and adherence to these dietary patterns among Iranian population from 2006 till 2017.

METHODS

We investigated on four examination waves of TLGS, including wave 1 (2006-2008), wave 2 (2009-2011), wave 3 (2012-2014), and wave 4 (2015-2017), using a validated and reliable food frequency questionnaire. Generalized Estimating Equations was used to assess secular trends in anthropometric, biochemical, and dietary variables across the study period. To identify general structure and secular trend of dietary patterns during each waves, principle component analysis (PCA) and K-mean cluster analysis were used, respectively.

RESULTS

After adjusting for potential confounders including age, sex, body mass index, and total energy intake, the carbohydrate and protein intake gradually increased and the total fat intake decreased during study period (P-value< 0.001), although total energy intake remained stable. During the study period, participants consumed noticeably less refined grains, solid fat, dairy products, and simple sugars. Snack and dessert consumption increased and meat intakes showed no significant changes during a decade (all P-values< 0.001). Three dietary patterns extracted using PCA, included: Healthy dietary pattern characterized by higher intakes of vegetable, fruit, dairy products, liquid oil, nuts and seeds, and honey and jam; Western dietary pattern featured by refined grain, solid fat, meat, snack and dessert, potato, and soft drink, and the Mixed dietary pattern, highlighted by tea and coffee, and simple sugar. Based on cluster analysis, 27.8% of participants in wave 4 followed a Western dietary pattern, and 34.1% followed the Mixed dietary pattern. The Healthy dietary pattern was stable among the study population during the last decade.

CONCLUSIONS

The structure and the type of foods that participants preferred to eat changed since 2006, a new secular trend in dietary patterns, including a stability of Healthy dietary pattern, a decline of the Western dietary pattern and an increase in the Mixed dietary pattern was obsereved in our investigation.

Association of Serum Uric Acid with cardio-metabolic risk factors and metabolic syndrome in seafarers working on tankers

BACKGROUND

There is still controversy over the clinical interpretation of the association between metabolic syndrome (MetS) and serum uric acid (SUA) levels. Therefore, the aim of this study was to investigate the association of SUA levels with MetS and other cardio-metabolic risk factors (CMRF) in seafarers working on tankers.

METHODS

This cross-sectional study was conducted in 2015 and included 234 male seafarers working on tankers. The participants were divided into three groups based on the tertiles of SUA. The report from of the National Committee of Obesity was used to define the MetS. The relationship between SUA, CMRF and MetS adjusted for age, educational level, job history, shift work, smoking and BMI was assessed by logistic regression analysis.

RESULTS

The subjects were aged 36.0 ± 10.3 years (mean ± SD). A notable upward trend was observed in mean weight, body mass index (BMI), triglyceride (TG), total cholesterol (TC), low density lipoprotein (LDL) and very low-density lipoprotein (VLDL) as tertiles of SUA increased (P < 0.001). In all models of the logistic regression analyses, the odds ratio (OR) of high TG for participants in the 3rd tertile of SUA was four times higher than that for participants in the 1st tertile of SUA (P < 0.001). The odds ratio of high TC and the SUA levels increased, so that the odds ratio of high TC for participants in the 2nd tertile was 2.47 (95% CI: 1.10-5.53) (P < 0.05) as compared with that for participants in the 1st tertile. Significant association was observed between MetS and the levels of SUA; 6.10 (95% CI: 1.77-20.94) (P < 0.05).

CONCLUSIONS

Findings revealed that SUA levels were associated with MetS, high TG and high TC. Therefore, it is recommended that clinical attention should be given to symptoms related to elevated SUA - being one of the most important remediable risk factors for MetS - in the annual medical examinations of seafarers.

Metabolic health in the Middle East and north Africa

The Middle East and north Africa are home to different populations with widely varying cultures, histories, and socioeconomic settings. Hence, their health status, health management, and access to appropriate health care differ accordingly. In this Review, we examine data on the historical and prospective status of metabolic diseases in this region including obesity, diabetes, hypertension, dyslipidaemia, and non-alcoholic fatty liver disease. Women in the Middle East and north Africa have the highest risk of metabolic diseases of all women globally, whereas men rank second of all men in this respect. Metabolic risk factors are responsible for more than 300 deaths per 100 000 individuals in this region, compared with a global mean of fewer than 250. Physical inactivity, especially in women, and an unhealthy diet (ie, low consumption of whole grains, nuts, and seafoods) stand out. More than one in every three women are obese in most countries of the region. Prevention programmes have not fully been achieved in most of these countries and the projected future is not optimistic. Comprehensive surveillance and monitoring of metabolic diseases, robust multisectoral systems that support primordial and primary preventions, continuous education of health-care providers, as well as collaboration between countries for joint projects in this region are urgently needed to overcome the paucity of data and to improve the metabolic health status of inhabitants in the Middle East and north Africa.

Prevalence of hyperlipidaemia in adults and its relation to the Mediterranean diet: the Hellenic National Nutrition and Health Survey (HNNHS)

Objectives

A long-term abnormal blood lipid profile increases the risk of cardiovascular disease (CVD). A probable protective role may be played by the Mediterranean diet. The aim of this study was to assess prevalence of dyslipidaemia, assess blood lipid status and treatment and examine the association between blood lipids, dyslipidaemia and Mediterranean diet.

Methods

Data were from the Hellenic National Nutrition and Health Survey (HNNHS). Data from 3775 adults (40.8% males) were obtained by trained personnel and disease status was categorized according to the International Classification of Diseases codes (10th version). Blood lipid measurements were obtained from a subsample ( N = 1080, mean age 40.1 years; 37.8% male). The Mediterranean diet score (MedDiet score) was calculated from 24-h recalls. The relationships between higher MedDiet score (>23), lipid levels and status were examined using linearized multiple linear and logistic regressions, respectively.

Results

In total, 20.7% of the population was dyslipidaemic, with 59.0% (no sex differences) receiving treatment, and 46.6% of the treated having a normal lipid profile. Lipid status awareness was 35.5% (64.5% unaware). Males aged 19–39 had higher total cholesterol, low-density lipoprotein cholesterol and triglycerides, and lower high-density lipoprotein cholesterol levels than females (in mg/dl; p for all <0.05); these were significantly higher in overweight and obese individuals in all age groups, except high-density lipoprotein cholesterol ( p for all <0.001). Higher MedDiet score was associated with significantly lower low-density lipoprotein cholesterol in the pooled sample (−6.39 mg/dl; 95% confidence interval (CI): −12.60, 0.17), in all males (−10.61 mg/dl; 95% CI: −19.89, −1.34) and in overweight and obese males (−15.6 mg/dl; 95% CI: −29.25, –1.94).

Conclusion

This study underlines the abnormal lipid profile in the young, mostly male, population who are highly unaware and under-treated.