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Perez-Diaz C, Uriz-Martínez M, Ortega-Rico C, Leno-Duran E, Barrios-Rodríguez R, Salcedo-Bellido I, Arrebola JP, Requena P. Phthalate exposure and risk of metabolic syndrome components: A systematic review. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 340:122714. [PMID: 37844863 DOI: 10.1016/j.envpol.2023.122714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/13/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023]
Abstract
Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, i.e. obesity, insulin resistance, hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL-c) levels and arterial hypertension. Phthalates are environmental chemicals which might influence the risk of the aforementioned disturbances, although the evidence is still controversial. The objective of this work was to synthesize the evidence on the association between human phthalate exposure and metabolic syndrome or any of its components. In this systematic review, the PRISMA guidelines were followed and the literature was search in PubMed, Web of Science and Scopus. Longitudinal and cross-sectional studies were included, the later only if a subclinical marker of disease was evaluated. The methodological quality was assessed with the Newcastle Ottawa Scale and a checklist for Analytical Cross-Sectional Studies developed in the Joanna Briggs Institute. A total of 58 articles were identified that showed high heterogenicity in the specific phthalates assessed, time-window of exposure and duration of follow-up. The quality of the studies was evaluated as high (n = 46, score >7 points) or medium (n = 12, score 4-6). The most frequently studied phthalates were DEHP-MEHP, MBzP and MEP. The evidence revealed a positive association between prenatal (in utero) exposure to most phthalates and markers of obesity in the offspring, but contradictory results when postnatal exposure and obesity were assessed. Moreover, postnatal phthalate exposure showed positive and very consistent associations with markers of diabetes and, to a lesser extent, with triglyceride levels. However, fewer evidence and contradictory results were found for HDL-c levels and markers of hypertension. The suggested mechanisms for these metabolic effects include transcription factor PPAR activation, antagonism of thyroid hormone function, antiandrogenic effects, oxidative stress and inflammation, and epigenetic changes. Nevertheless, as the inconsistency of some results could be related to differences in the study design, future research should aim to standardise the exposure assessment.
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Affiliation(s)
- Celia Perez-Diaz
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA). Avda. de Madrid, 15. Pabellón de Consultas Externas 2, 2(a) Planta, 18012, Granada, Spain
| | - Maialen Uriz-Martínez
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain
| | - Carmen Ortega-Rico
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain
| | - Ester Leno-Duran
- Universidad de Granada. Department of Obstetrics and Gynaecology, Medicine School. Parque Tecnologico de La Salud, Av. de La Investigación, 11, 18016, Granada, Spain.
| | - Rocío Barrios-Rodríguez
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA). Avda. de Madrid, 15. Pabellón de Consultas Externas 2, 2(a) Planta, 18012, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Inmaculada Salcedo-Bellido
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA). Avda. de Madrid, 15. Pabellón de Consultas Externas 2, 2(a) Planta, 18012, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Juan Pedro Arrebola
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA). Avda. de Madrid, 15. Pabellón de Consultas Externas 2, 2(a) Planta, 18012, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Pilar Requena
- Universidad de Granada. Department of Preventive Medicine and Public Health, Pharmacy School. Campus de Cartuja S/n, 18071, Granada, Spain; Instituto de Investigación Biosanitaria (ibs.GRANADA). Avda. de Madrid, 15. Pabellón de Consultas Externas 2, 2(a) Planta, 18012, Granada, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, C/ Monforte de Lemos 3-5, Pabellón 11. Planta 0, 28029 Madrid, Spain
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Daneshmand M, Jamshidi H, Farjoo MH, Malekpour MR, Ghasemi E, Mortazavi SS, Shati M, Farzadfar F. Assessment of Hemoglobin A1c Management and Prescription Cost Due to Polypharmacy Among Patients With Diabetes in Iran Based on the STEPS Iran 2016 Survey and a Prescription Database: A Multi-level, Cross-sectional National Study. ARCHIVES OF IRANIAN MEDICINE 2024; 27:1-7. [PMID: 38431954 PMCID: PMC10915928 DOI: 10.34172/aim.2024.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/13/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND Diabetes frequently results in the need for multiple medication therapies, known as 'Polypharmacy'. This situation can incur significant costs and increase the likelihood of medication errors. This study evaluated the prescriptions of patients with diabetes regarding polypharmacy to assess its effect on the control of hemoglobin A1c (HbA1c) levels and prescription costs. METHODS A cross-sectional national study was conducted based on data from linking the Iranians Health Insurance Service prescriptions in 2015 and 2016 with the STEPS 2016 survey in Iran. The association of the individual and sociodemographic factors, as well as polypharmacy, as independent variables, with control of HbA1c levels and the cost of the prescriptions were assessed among diabetic patients using logistic and linear regression, respectively. RESULTS Among 205 patients using anti-diabetic medications, 47.8% experienced polypharmacy. The HbA1c of 74 patients (36.1%) was equal to or less than 7, indicating controlled diabetes. HbA1c control showed no significant association with gender. However, prescription costs were notably lower in females (β=0.559 [0.324‒0.964], P=0.036). No significant correlation was found between the area of residence and prescription costs, but HbA1c was significantly more controlled in urban areas (OR=2.667 [1.132‒6.282], P=0.025). Prescription costs were significantly lower in patients without polypharmacy (β=0.211, [0.106‒0.423], P<0.001), though there was no significant association between polypharmacy and HbA1c levels. CONCLUSION Our results demonstrated that diabetics with polypharmacy paid significantly more for their prescriptions without experiencing a positive effect on the control of HbA1c levels.
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Affiliation(s)
- Mojdeh Daneshmand
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Jamshidi
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hadi Farjoo
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Malekpour
- Non-Communicable Diseases Research Centre, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Erfan Ghasemi
- Non-Communicable Diseases Research Centre, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyede Salehe Mortazavi
- Geriatric Mental Health Research Center, School of Behavioural Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Shati
- Mental Health Research Centre, Department of Epidemiology, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Centre, Tehran University of Medical Sciences, Tehran, Iran
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Debortoli da Silva A, Izidoro NO, de Macedo LR, de Matos IM, Silva M. The effects of grape products on metabolic syndrome risk factors: A systematic review and meta-analysis. PHARMANUTRITION 2023. [DOI: 10.1016/j.phanu.2023.100339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Pérez-Castro E, Godínez-Jaimes F, Vázquez-Medina MU, Ocharan-Hernández ME, Vargas-De-León C. Derivation and validation of sex-specific continuous metabolic syndrome scores for the Mexican adult population. Sci Rep 2022; 12:9659. [PMID: 35688913 PMCID: PMC9187334 DOI: 10.1038/s41598-022-10963-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/31/2022] [Indexed: 11/09/2022] Open
Abstract
Traditionally the diagnosis of Metabolic syndrome (MetS) is binary (present/absent). The goal of this work is to propose a sex-specific continuous score to measure the severity of MetS in Mexican adults using waist circumference and body mass index as adiposity measures. MetSx-WC and MetSx-BMI indexes by sex were derived by confirmatory factor analysis (CFA) using data for 6567 adult participants of the National Health and Nutrition Survey 2018. The overall fit of the two proposed CFA models was excellent. We then validated these scores using a community-based health study of 862 university participants and determined that the reliability and strength of agreement between the MetSx-WC and MetSx-BMI scores were excellent. The ROC analysis of the resulting indexes indicates that they have excellent ability to discriminate a MetS classification according to the different criteria. The correlations of MetSx scores and surrogate markers of insulin resistance and obesity ranged from weak to strong. Subsequently, a retrospective study of 310 hospitalized patients with COVID-19 was used to determined that MetSx-BMI score was associated with the mortality of patients with COVID-19. The proposed indices provide a continuous measure in the identification of MetS risk in Mexican adults.
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Affiliation(s)
- Eduardo Pérez-Castro
- Maestría en Matemáticas Aplicadas, Facultad de Matemáticas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Flaviano Godínez-Jaimes
- Maestría en Matemáticas Aplicadas, Facultad de Matemáticas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Martín Uriel Vázquez-Medina
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico.,Departamento de Investigación, Hospital Central Militar, Secretaria de la Defensa Nacional, Mexico City, Mexico
| | - María Esther Ocharan-Hernández
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | - Cruz Vargas-De-León
- Maestría en Matemáticas Aplicadas, Facultad de Matemáticas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico. .,Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico. .,Divisón de Investigación, Hospital Juárez de México, Mexico City, Mexico.
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Neck Circumference as a Predictor of Metabolic Syndrome in Koreans: A Cross-Sectional Study. Nutrients 2021; 13:nu13093029. [PMID: 34578907 PMCID: PMC8468211 DOI: 10.3390/nu13093029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Metabolic syndrome (MetS) is a complex metabolic disorder and a high-risk condition for type 2 diabetes and cardiovascular disease. Rapid screening of at-risk individuals using accurate and time-saving tools is effective in disease management. Using the Korea National Health and Nutrition Examination Survey (KNHANES) data, we collected data from 2234 participants suitable for the study design, of which 974 (43.6%) were men and 1260 (56.4%) were women. We used receiver operating characteristic (ROC) curve analysis to estimate the optimal sex-specific neck circumference (NC) cut-off point to predict the MetS risk. To analyze the risk of MetS according to the estimated NC, logistic regression analysis was performed to identify the confounding factors. The result of the ROC analysis showed that the optimal neck cut-off points for predicting the risk of MetS were 38.25 cm (AUC: 0.759, 95% CI: 0.729–0.790) in men and 33.65 cm (AUC: 0.811, 95% CI: 0.782–0.840) in women. In the upper NC cut-off point compared to the lower NC cut-off point, NC was associated with an increased MetS risk by 2.014-fold (p = 0.010) in men and 3.650-fold (p < 0.001) in women, after adjustments. The current study supports NC as an effective anthropometric indicator for predicting the risk of MetS. It is suggested that more studies should be conducted to analyze the disease prediction effect of the combined application of anthropometric indicators currently in use and NC.
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Naghipour M, Joukar F, Nikbakht HA, Hassanipour S, Asgharnezhad M, Arab-Zozani M, Mansour-Ghanaei F. High Prevalence of Metabolic Syndrome and Its Related Demographic Factors in North of Iran: Results from the PERSIAN Guilan Cohort Study. Int J Endocrinol 2021; 2021:8862456. [PMID: 33859688 PMCID: PMC8024063 DOI: 10.1155/2021/8862456] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 02/14/2021] [Accepted: 03/20/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The prevalence of metabolic syndrome has increased in recent decades around the world and is currently reaching epidemic levels as it is a major public health and clinical concern. The aim of this study was to evaluate the prevalence of metabolic syndrome and its related demographic factors in a population-based study. METHODS In this cross-sectional study, the target population consisted of 10520 individuals aged 35-70 years in Phase 1 of the Persian Guilan cohort study (Guilan site/Some'e Sara) that was conducted in 2014-2017. Demographic, anthropometric, blood pressure, and biochemical data were used in this study. The IDF definitions were used to diagnose the metabolic syndrome. RESULTS The prevalence of the syndrome according to IDF and ATP definition was 42.87% (95% CI: 41.92-41.81) and 40.68% (95% CI: 39.74-41.62), respectively. The prevalence of components for central obesity, high triglyceride, HDL cholesterol, blood glucose, and hypertension components was 75.8%, 43.1%, 40.6%, 39.2% and 37.9%, respectively. All demographic variables were related to the syndrome, and among them age, gender, and residence were identified as independent and strong predictive variables in the regression model. More than 92% of the population had at least one component of the syndrome. CONCLUSION The results of the study show a high prevalence of metabolic syndrome risk factors. It is essential to educate healthy lifestyle behaviors and further health education in the high-risk groups identified in this study, especially the elderly, women, and rural residents.
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Affiliation(s)
- Mohammadreza Naghipour
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Farahnaz Joukar
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- GI Cancer Screening and Prevention Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Hossein-Ali Nikbakht
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Soheil Hassanipour
- GI Cancer Screening and Prevention Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mehrnaz Asgharnezhad
- Caspian Digestive Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Fariborz Mansour-Ghanaei
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Caspian Digestive Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Pinho LD, Ruas Oliveira R, Gonçalves Pereira L, Oliveira Nobre de Andrade M, Natália Oliveira Teixeira A, Fagundes Neto Soares M. Avaliação da síndrome metabólica em agentes comunitários de saúde em município do norte de Minas Gerais. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2020. [DOI: 10.5712/rbmfc15(42)2605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introdução: A síndrome metabólica se relaciona a doenças crônicas, possui prevalência crescente no Brasil e leva riscos cardiovasculares à população. Objetivo: Comparar a prevalência da síndrome metabólica em agentes comunitários de saúde em município do Norte de Minas Gerais segundo diferentes critérios diagnósticos. Métodos: Foi realizada coleta de dados de 675 profissionais que compunham as variáveis dos critérios diagnósticos propostos pela Internacional Diabetes Federation e National Cholesterol Education Program’s Adult Treatment Panel III. Resultados: Segundo critérios da Internacional Diabetes Federation, diagnosticou-se 42,2% de indivíduos com síndrome metabólica e 33,6% segundo National Cholesterol Education Program’s Adult Treatment Panel III. Há aumento diretamente proporcional ao avançar da idade (p=0,000 para ambos os critérios) e relação intrínseca à dislipidemia e pressão arterial elevada. Conclusão: Pôde-se concluir que a síndrome metabólica tem prevalência muito relevante no público estudado. Em relação às variáveis analisadas, encontrou-se similaridade entre critérios. Assim, nota-se que essas informações são importantes para realização de um diagnóstico precoce e manutenção da saúde dos agentes comunitários de saúde.
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Gender Differences in the Pattern of Socio-Demographics Relevant to Metabolic Syndrome Among Kenyan Adults with Central Obesity at a Mission Hospital in Nairobi, Kenya. High Blood Press Cardiovasc Prev 2020; 27:61-82. [PMID: 31981085 DOI: 10.1007/s40292-020-00360-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/07/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Metabolic syndrome (MetS) is a risk factor for cardiovascular-related morbidity and mortality. Although the risk factors for MetS are well documented, differences in gender-based demographics among Kenyan adults with central obesity are lacking. AIM Determine gender differences in the pattern of socio-demographics relevant to metabolic syndrome among Kenyan adults with central obesity at a mission hospital, Nairobi. METHODS A cross-sectional baseline survey involving adults (N = 404) with central obesity aged 18-64 years, as part of a community-based lifestyle intervention study. Respondents were systematically sampled using the International Diabetes Federation definition for MetS. Lifestyle characteristics, anthropometric, clinical and biochemical markers were measured and analyzed using SPSS. RESULTS High (87.2%) MetS prevalence associated with advanced age in males (p < 0.001) and females (p = 0.002) was observed. MetS was likely among divorced/separated/widowed (p = 0.021) and high income males (p = 0.002) and females (p = 0.017) with high income. Unemployed males (p = 0.008) and females with tertiary education (p = 0.019) were less likely to have MetS. Advanced age was likely to lead to high blood pressure, fasting blood glucose and triglycerides (p < 0.05). Males were more likely (p = 0.026) to have raised triglycerides, while females (p < 0.001) had low high density lipoproteins. CONCLUSION A high prevalence of MetS associated with social and gender differences among Kenyan adults with central obesity. These underscore the need to look beyond the behavioral and biological risks and focus on every nuance of gender differences in addressing MetS and CVDs.
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Bijani A, Hosseini SR, Ghadimi R, Mouodi S. Association of Metabolic Syndrome and Its Components with Survival of Older Adults. Int J Endocrinol Metab 2020; 18:e91837. [PMID: 32308697 PMCID: PMC7144244 DOI: 10.5812/ijem.91837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) as an important risk factor arising from insulin resistance accompanying abnormal adipose deposition and function has become a major challenge to public health around the world. OBJECTIVES This research was conducted to evaluate the association of MetS and its components with survival of older adults. METHODS This prospective study is a part of the Amirkola Health and Ageing Cohort Project (2011 - 2017) conducted among 1562 older adults (aged 60 years and over) living in Amirkola, north of Iran. MetS was defined according to four sets of definition: Iranian definition, International Diabetes Federation (IDF) definition, 2001 Adult Treatment Panel (ATP) III and 2005 Adult Treatment Panel (ATP) III. RESULTS Eight hundred sixty-three (55.2%) males and 699 (44.8%) females with a mean age of 69.3 ± 7.4 years were included in the research. The results showed that 71.9%, 74.3%, 68.8% and 66.7% of older adults had MetS based on 2005 ATP III, Iranian, IDF and 2001 ATP III diagnostic criteria, respectively. Only raised fasting plasma glucose (FPG) had a significant association with a five-year survival rate of older adults (FPG ≥ 110mg/dL: adjusted HR: 2.05; 95% CI: 1.51 - 2.78; P < 0.001). Other MetS components did not show any significant associations with survival (P > 0.05). Nevertheless, MetS itself significantly decreased the survival rate of older adults after adjusting age, gender and number of chronic diseases (HR = 1.67; 95% CI: 1.16 - 2.41; P = 0.006). CONCLUSIONS MetS and one of its components, high FPG, have significant associations with survival of older adults.
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Affiliation(s)
- Ali Bijani
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Seyed Reza Hosseini
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Reza Ghadimi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Simin Mouodi
- Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Corresponding Author: Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.
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