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Background: Considering the importance of cardiovascular disease (CVD) risk prediction for healthcare systems and the limited information available in the Middle East, we evaluated the SCORE and Globorisk models to predict CVD death in a country of this region. Methods: We included 24 427 participants (11 187 men) aged 40-80 years from four population-based cohorts in Iran. Updating approaches were used to recalibrate the baseline survival and the overall effect of the predictors of the models. We assessed the models’ discrimination using C-index and then compared the observed with the predicted risk of death using calibration plots. The sensitivity and specificity of the models were estimated at the risk thresholds of 3%, 5%, 7%, and 10%. An agreement between models was assessed using the intra-class correlation coefficient (ICC). We applied decision analysis to provide perception into the consequences of using the models in general practice; for this reason, the clinical usefulness of the models was assessed using the net benefit (NB) and decision curve analysis. The NB is a sensitivity penalized by a weighted false positive (FP) rate in population level. Results: After 154 522 person-years of follow-up, 437 cardiovascular deaths (280 men) occurred. The 10-year observed risks were 4.2% (95% CI: 3.7%-4.8%) in men and 2.1% (1.8-2%.5%) in women. The c-index for SCORE function was 0.784 (0.756-0.812) in men and 0.780 (0.744-0.815) in women. Corresponding values for Globorisk were 0.793 (0.766- 0.820) and 0.793 (0.757-0.829). The deviation of the calibration slopes from one reflected a need for recalibration; after which, the predicted-to-observed ratio for both models was 1.02 in men and 0.95 in women. Models showed good agreement (ICC 0.93 in men, and 0.89 in women). Decision curve showed that using both models results in the same clinical usefulness at the risk threshold of 5%, in both men and women; however, at the risk threshold of 10%, Globorisk had better clinical usefulness in women (Difference: 8%, 95% CI: 4%-13%). Conclusion: Original Globorisk and SCORE models overestimate the CVD risk in Iranian populations resulting in a high number of people who need intervention. Recalibration could adopt these models to precisely predict CVD mortality. Globorisk showed better performance clinically, only among high-risk women.

Objectives This study aims to estimate the prevalence of coronavirus disease 2019 (COVID-19) in the general population of Iran. Methods The target population was all Iranian people aged 6 years and older in the country. A stratified random sampling design was used to select 28 314 people from among the individuals registered in the electronic health record systems used in primary health care in Iran. Venous blood was taken from each participant and tested for the IgG antibody against COVID-19. The prevalence of COVID-19 was estimated at provincial and national levels after adjusting for the measurement error of the laboratory test, non-response bias and sampling design. Results Of the 28 314 Iranians selected, 11 256 (39.75%) participated in the study. Of these, 5406 (48.0%) were male and 6851 (60.9%) lived in urban areas. The mean (standard deviation) participant age was 35.89 (18.61) years. The adjusted prevalence of COVID-19 until 20 August 2020 was estimated as 14.2% (95% uncertainty interval 13.3%–15.2%), which was equal to 11 958 346 (95% CI 11 211 011–12 746 776) individuals. The adjusted prevalences of infection were 14.6%, 13.8%, 16.6%, 11.7% and 19.4% among men, women, urban population, rural population and individuals aged 60 years or more, respectively. Ardabil, Golestan and Khuzestan provinces had the highest prevalence and Alborz, Hormozgan and Kerman provinces had the lowest. Conclusions Based on the study results, a large proportion of the Iranian population had not yet been infected by COVID-19. The observance of hygienic principles and social restrictions should therefore continue until the majority of the population has been vaccinated.

Aims/Introduction To examine the incidence rate of severe non‐proliferative and proliferative diabetic retinopathy (severe‐NPDR/PDR) and determine its potential risk factors. Materials and Methods The study consisted of 1,169 participants (675 women) with type 2 diabetes mellitus, aged ≥20 years. A trained interviewer collected information about the history of pan‐retinal photocoagulation as a result of diabetic retinopathy. Multivariable Cox proportional hazards regression models were applied. Results We found 187 cases (126 women) of severe‐NPDR/PDR during a median follow‐up period of 12.7 years; the corresponding incidence rate was 13.6 per 1,000 person‐years. Being overweight (hazard ratio [HR], 95% confidence interval [CI] 0.60, 0.39–0.92) and obese (HR 0.48, 95% CI 0.27–0.83) were associated with lower risk, whereas being smoker (HR 1.75, 95% CI 1.12–2.74), having fasting plasma glucose levels 7.22–10.0 mmol/L (HR 2.81, 95% CI 1.70–4.62), fasting plasma glucose ≥10 mmol/L (HR 5.87, 95% CI 3.67–9.41), taking glucose‐lowering medications (HR 2.58, 95% CI 1.87–3.56), prehypertension status (HR 1.65, 95% CI 1.05–2.58) and newly diagnosed hypertension (HR 1.96, 95% CI 1.06–3.65) increased the risk of severe‐NPDR/PDR. Among newly diagnosed diabetes patients, being male was associated with a 59% lower risk of severe‐NPDR/PDR (HR 0.41, 95% CI 0.21–0.79). Furthermore, patients who had an intermediate level of education (6–12 years) had a higher risk of developing PDR (HR 1.86, 95% CI 1.05–3.30) compared with those who had

Background Cardiovascular diseases (CVDs) are among the most common causes of death worldwide, including in Iran. Considering the adverse effects of CVDs on physical and psychosocial health; this study aims to investigate the association between experience of CVDs and health-related quality of life (HRQoL) in adult participants of the Tehran Lipid and Glucose Study (TLGS). Methods The participants of this cross-sectional study were 7009 adults (≥ 20 years) who participated in the TLGS during 2014–2017. Demographic information and HRQoL data was collected through validated questionnaires by trained interviewers. HRQoL was assessed by the Iranian version of the SF-12 questionnaire. Data was analyzed using the SPSS software. Results The mean age of participants was 46.8 ± 14.6 years and 46.1% of them were men. A total of 9.0% of men and 4.4% of women had CVDs. In men, the mean physical HRQoL summary score was significantly lower in those with CVDs compared to those without CVDs (46.6 ± 0.8 vs. 48.5 ± 0.7, p > 0.001). In women, the mean mental HRQoL summary scores was significantly lower in those with CVDs compared to those without CVDs (42.8 ± 1.0 vs. 45.2 ± 0.5, p = 0.009). In adjusted models, men with CVDs were more likely to report poor physical HRQoL compared to men without CVDs (OR(95%CI): 1.93(1.32–2.84), p = 0.001); whereas for women, the chance of reporting poor mental HRQoL was 68% higher in those with CVDs than those without CVDs (OR(95%CI): 1.68(1.11–2.54), p = 0.015). Conclusion The findings of the current study indicate poorer HRQoL in those who experienced CVDs compared to their healthy counterparts with a sex specific pattern. While for men, CVDs were associated with more significant impairment in the physical dimension of HRQoL, women experienced a similar impairment in the mental dimension of HRQoL.

This study investigates the trajectory of the risk factors of prediabetes progression to overt diabetes.The study retrospectively investigated 1610 prediabetic individuals. The trajectory of metabolic indicators was investigated using the generalized estimated equation method with autoregressive working correlation structure through a linear model with the identity link function.During 15 years of follow-up, the trajectories of metabolic risk factors changed from 3 years before diabetes occurrence for fasting plasma glucose (FPG) and 2-hour plasma glucose (2hPG), 6 years for waist circumference (WC), 9 years for high-density lipoprotein cholesterol (HDL-C), and earlier for body mass index, triglyceride (TG), and TG:HDL ratio. It was shown that the differences in the trajectory of WC and HDL were stable after adjustment for other metabolic risk factors. The trajectories of FPG and 2hPG remained stable after considering multiple insulin resistance markers.Deterioration of metabolic risk factor status can be a predictor of diabetes many years before its occurrence, but the abrupt change in plasma glucose is evident 3 years before diabetes mellitus onset. It seems that the HDL-C and WC trajectories are two independent predictors for diabetes incidence. It was also found that when the rising trend in plasma glucose starts, preventive strategies to lessen insulin resistance might not be efficient.背景: 本研究探讨糖尿病前期的危险因素向显性糖尿病发展的轨迹。 方法: 对1610例糖尿病前期患者进行回顾性调查。采用具有自回归工作相关结构的广义估计方程法, 通过具有同一性链接函数的线性模型, 对代谢指标的运动轨迹进行了研究。 结果: 在15年的随访中, 代谢危险因素从糖尿病发生前3年就开始发生改变, 包括空腹血糖(FPG)和2小时血糖(2hPG), 发病前6年腰围(WC)出现改变, 发病前9年高密度脂蛋白胆固醇(HDL-C)出现变化, 以及更早就会变化的体重指数(BMI), 甘油三酯(TG)和甘油三酯(TG)/高密度脂蛋白胆固醇(TG/HDL)。结果表明, 在调整其他代谢危险因素后, WC和HDL的轨迹差异是稳定的。在考虑多个胰岛素抵抗标志物后, 空腹血糖和2hPG的轨迹保持稳定。 结论: 代谢危险因素状态恶化可作为糖尿病发病前多年的预测指标, 但血糖的突然变好在糖尿病发病前3年明显。似乎HDL-C和WC轨迹是糖尿病发病率的两个独立预测因子。研究还发现, 当血糖开始上升时, 减轻胰岛素抵抗的预防性策略可能并不有效。.

Background To examine the impact of weight change on incident cardiovascular disease and coronary heart disease (CVD/CHD) among an Iranian population with type 2 diabetes mellitus (T2DM). Methods The study population included 763 participants with T2DM aged ≥ 30 years without a history of CVD and cancer at baseline. Two weight measurements done at baseline and about 3 years later. Based on their weight change, they categorized into: > 5% loss, 3–5% loss, stable (± 5% gain. Participants were then followed for incident CVD/CHD annually up to 20 March 2018. Multivariable Cox proportional hazard models, adjusted for age, sex, body mass index, educational level, current smoking, glucose-lowering drug use, family history of CVD, hypertension, hypercholesterolemia, chronic kidney disease, and fasting plasma glucose (FPG) were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of weight change categories for incident CVD/CHD, considering stable weight as reference. Results After the weight change measurement, during a median follow-up of 14.4 years, 258 CVD and 214 CHD occurred. Over 5% weight gain was associated with reduced risks of CVD and CHD development by the HRs of 0.70 [95% CI 0.48–1.01; P-value: 0.058] and 0.61 [0.40–0.93], respectively, in multivariable analysis. After further adjustment for FPG change, the HRs of weight gain > 5% were attenuated to 0.75 [0.51–1.10; P-value: 0.138] and 0.66 [043–1.01; P-value: 0.053] for incident CVD and CHD, respectively. The effect of weight loss > 5% was in opposite direction among those older versus younger than 60 years; with suggestive increased risk (not statistically significant) of incident CHD/CVD for the older group. Moreover, weight gain > 5% significantly reduced the risk of CHD only among those older than 60 years (P-value for interaction 5% had an association with lower risk of CVD and CHD among sulfonylurea users (0.56 [0.32–0.98] for CVD and 0.54 [0.29–0.99] for CHD). Conclusions Our results with a long-term follow-up showed that weight gain > 5% was associated with better CVD/CHD outcomes among Iranian participants with T2DM, especially older ones. Moreover, we did not find an unfavorable impact on incident CVD/CHD for sulfonylurea-induced weight gain.

Background Understanding the distinct patterns (trajectories) of variation in blood lipid levels before diagnosing cardiovascular disease (CVD) might carry important implications for improving disease prevention or treatment. Methods We investigated 14,373 participants (45.5% men) aged 45–84 from two large US prospective cohort studies with a median of 23 years follow-up. First, we jointly estimated developmental trajectories of lipid indices, including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG) concentrations using group-based multi-trajectory modeling. Then, the association of identified multi-trajectories with incident CVD, heart failure, and all-cause mortality were examined using Cox proportional hazard model. Results Seven distinct multi-trajectories were identified. The majority of participants (approximately 80%) exhibited decreasing LDL-C but rising TG levels and relatively stable HDL-C levels. Compared to the individuals with healthy and stable LDL-C, HDL-C, and TG levels, those in other groups were at significant risk of incident CVD after adjusting for other conventional risk factors. Individuals with the highest but decreasing LDL-C and borderline high and rising TG levels over time were at the highest risk than those in other groups with a 2.22-fold risk of CVD. Also, those with the highest and increased triglyceride levels over time, over optimal and decreasing LDL-C levels, and the lowest HDL-C profile had a nearly 1.84 times CVD risk. Even individuals in the multi-trajectory group with the highest HDL-C, optimal LDL-C, and optimal TG levels had a significant risk (HR, 1.45; 95% CI 1.02–2.08). Furthermore, only those with the highest HDL-C profile increased the risk of heart failure by 1.5-fold (95% CI 1.07–2.06). Conclusions The trajectories and risk of CVD identified in this study demonstrated that despite a decline in LDL-C over time, a significant amount of residual risk for CVD remains. These findings suggest the impact of the increasing trend of TG on CVD risk and emphasize the importance of assessing the lipid levels at each visit and undertaking potential interventions that lower triglyceride concentrations to reduce the residual risk of CVD, even among those with the optimal LDL-C level.

It is well documented that physical inactivity is related to weight gain and a whole host of chronic diseases. This study investigated trends of low physical activity among Iranian adolescents in urban and rural areas between 2006–2011. A total of 12,178 adolescents, aged between 15 and 19 years, participated in National Surveys of Risk Factors for Non-Communicable Diseases. Data on physical activity was obtained using the global physical activity questionnaire. A complex sample survey and multinomial logistic regression were used to model physical activity levels. The percentage of adolescents who had low levels of physical activity increased from 2006 to 2011 in both urban and rural areas. Low and moderate levels of physical activity were lower in rural girls as compared with urban girls, with a prevalence ratio of 0.59 (95% CI 0.47–0.74) and 0.59 (95% CI 0.47–0.74), respectively. The corresponding values for boys residing in rural areas compared with boys in urban areas were 0.56 (95% CI 0.43–0.75) and 0.60 (95% CI 0.48–0.74), respectively. The adolescents' lifestyles showed an increasing trend for physical inactivity in both genders; however, in rural areas, only girls had a rising affinity for a sedentary lifestyle throughout the 2006–2011 years.

Background and aims Dietary macronutrient composition plays an important role in the prevention of cardiovascular disease (CVD). This study aimed at assessing the iso-energetic substitution of dietary macronutrients in relation to the incidence of CVD. Materials and results This prospective study was conducted on 5102 individuals of Tehran lipid and glucose study participants, aged 20–70 years who were followed for 5.3 years. A valid and reliable semi-quantitative food frequency questionnaire was used to assess dietary intakes. The hazard ratio of CVD for each 5% of energy from macronutrients at the expense of another macronutrient was calculated using the substitution model. During follow-up, a total of 206 CVD outcomes were identified. Mean age of participants (44.2% men) was 47.0 ± 12 and 45.6 ± 11 for men and women, respectively. Substituting 5% of energy from all types of macronutrients by 5% percentage of energy from combined saturated fatty acids (SFA) and monounsaturated fatty acids (MUFA) was associated with a decrease in the risk of CVD by almost 20%. Higher energy intake from total-, starchy-, and nonstarchy carbohydrates replaced by other macronutrients was not significantly associated with the risk of CVD. Each 5% of energy from animal protein (HR: 1.09 and CI: 1.02–1.16) independently increased the risk of CVD in the adjusted Cox proportional hazard regression analyses. Conclusion Higher percentage of energy from animal protein independently increased the risk of CVD, replacement of SFA and MUFA together with other macronutrients was inversely associated with CVD risk.

Background Following the global upward trend of cardiovascular diseases (CVD/CHD), much attention has been paid to lifestyle behaviors such as physical activity (PA). However, most of previous studies were conducted in developed countries and with just one measurement of physical activity. The aim of the current study is to assess the effect of changes in the PA on the incidence of CVD/CHD in middle-aged and older men and women in an Eastern-Mediterranean population, over a decade follow-up. Methods This study has been conducted within the framework of the Tehran Lipid and Glucose Study (TLGS) including 4073 (57% women) participants without CVD/CHD at baseline. The participants were followed up for an average period of 12 years. The Iranian version of Modified Activity Questionnaire (MAQ) was used to measure PA at baseline and at the closest follow-up to the outcome. Subsequently, participants were categorized as “compliers”, “non-compliers”, “adopters” and “relapsers”, based on their adherence to the PA guideline recommendations. All analysis has been conducted in two separate age groups including middle-aged and elderly in both men and women. The effect of PA patterns on incidence of CVD/CHD was investigated using Cox proportional hazard model. Variables including marital status, job status, education, smoking, and family history of CVD/CHD were adjusted in the models. Results Adherence to guideline recommendation increased from 63.5 to 66.6% between the two measurements. At the second measurement of PA, the percentages of compliers, non-compliers, adopters and relapsers were 48.4, 18.3, 18.2, and 15.1%, respectively. In fully adjusted models, HRs of CVD and CHD for men aged 40–60 years in the complier group were 0.58 (95% CI: 0.38–0.87, P = 0.008) and 0.58 (95% CI: 0.38–0.89, P = 0.01), respectively. HRs of CVD and CHD for men aged 40–60 years in adopter group were 0.61 (95% CI: 0.38–0.96, P = 0.03) and 0.60 (95% CI: 0.37–0.97, P = 0.04) respectively. The corresponding values were not significant in women. Conclusions Adhering to established PA recommendations have a protective effect on the incidence of CVD/CHD among middle-aged men; findings which need to be considered in reducing cardiovascular outcomes in this population.

Background The present study aimed to evaluate the effect of Echium amoenum (EA) on the severity of premenstrual syndrome (PMS) in comparison with placebo. Methods The present study was a randomized double-blind controlled clinical trial. A checklist questionnaire was completed by 120, 18 to 35-year-old, college students. And then, 84 eligible women (20 to 35 years old) were enrolled in the trial; they were randomly assigned to two groups of intervention (EA) and control (placebo), with 42 participants in each group. Participants in the intervention group received 450 mg capsules of EA per day (three times a day) from the 21st day of their menstrual cycle until the 3rd day of their next cycle for two consecutive cycles. The severity of PMS was measured and ranked using the premenstrual symptoms screening tool (PSST). The generalized estimating equation was used to compare the total score of the severity of PMS between the two groups. Results Sixty-nine women with regular menstrual cycles suffering from PMS completed the study. The mean scores of the symptoms in the EA group were 35.3 and 16.1 (P ≤ 0.001) at baseline and after 2 months, respectively, while the mean scores of the symptoms in the placebo group were 31.0 and 28.3 (P = 0.09) at baseline and after 2 months, respectively. The evaluation of the first and the second follow-ups in the intervention group showed that, after being adjusted for age and body mass index (P ≤ 0.001), the mean scores of the premenstrual syndrome, using GEE analysis, have decreased to 6.2 and 11.6, respectively. Conclusion Based on the results, in comparison with the placebo group, EA was found to be more effective in improving the symptoms of PMS, and is highly recommended for treatment of this syndrome. Trial registration IRCT2015110822779N3; Registration date: 2015–11–27.

To determine levels of change in risk factors for cardiovascular disease among people with and without a previous diagnosis of diabetes from 2007 to 2016 in Iran. Data were obtained from five rounds of the World Health Organization STEPwise approach to Surveillance (STEPS) cross-sectional surveys. Participants were 7665 and 93,733 adults with and without known diabetes, respectively, aged 25–65 years. We used logistic and linear regressions to assess the trends of risk factors. Individuals with known diabetes compared to those without the condition, experienced greater reductions in mean levels of systolic blood pressure (3.0 vs. 0.5 mmHg among women and 3.9 vs. 1.6 mmHg among men), diastolic blood pressure (6.4 vs. 5.11 mmHg in women and 3.3 vs. 1.8 mmHg in men), and non-HDL cholesterol (42.4 vs. 27.2 mg/dL among women and 30.3 vs. 21.0 mg/dL among men) throughout these years. Men with diabetes also showed a greater reduction in the prevalence of daily cigarette smoking compared to their non-diabetic counterparts (7.3% vs. 2.3%). Fasting plasma glucose decreased among subjects with diabetes but increased among those without diabetes. Significant increases were observed in proportions who met goals for blood pressure, triglycerides, non-HDL cholesterol and LDL cholesterol in both groups; however, almost half of diabetic subjects did not achieve risk factor goals in 2016. Secondary prevention in diabetic patients was more effective than primary prevention in the general population; however, the rate of diabetic patients who met the designated goals for each risk factor was still suboptimal.

STUDY QUESTIONDo oral contraceptives (OCs) containing progestins with low androgenic or antiandrogenic activities have different effects to those containing levonorgestrel (LNG) on clinical, androgenic and metabolic manifestations of polycystic ovarian syndrome (PCOS)?SUMMARY ANSWERThe three OCs tested had similar effects on clinical findings of hyperandrogenism (HA), whereas products containing LNG were less effective on androgenic profiles and had detrimental effects on lipid profiles.WHAT IS KNOWN ALREADYDespite data available on the effects of OCs, the superiority of products with low androgenic or antiandrogenic progesterone components in comparison with older products used in women with PCOS has not been clarified.STUDY DESIGN, SIZE, DURATIONThis study is a crossover randomized controlled six-arm trial, with all six arms including two 6-month treatment periods, one period with OCs containing LNG, and the other with one of three OCs containing desogestrel (DSG), cyproterone acetate (CPA) or drospirenone (DRSP). The trial was conducted between February 2016 and January 2018 and enrolled 200 patients with PCOS.PARTICIPANTS/MATERIALS, SETTING, METHODSTwo hundred women with PCOS (ages 18–45 years) were recruited at the endocrine outpatient clinic of the Research Institute for Endocrine Sciences (RIES) of the Shahid Beheshti University of Medical Sciences, Tehran, Iran. A blocking or stratification random allocation (block size = 6) using a computer-based random number generator was prepared to assign participants to treatment groups. Both the clinical examiner and data analyst were blinded to participants during the trial. Outcomes of interest, including anthropometric and clinical manifestations and hormonal, and biochemical parameters were assessed at baseline, after 3 and 6 months of each treatment and after the washout period.MAIN RESULTS AND THE ROLE OF CHANCEThis study detected a higher decrease in free-androgen index (FAI) levels after 3 months of treatment with OCs containing DSG (95% CI: −2.3, −1.0), CPA (95% CI: −2.4, −1.1) and DRSP (95% CI: −2.6, −1.4), compared with products containing LNG (P LIMITATIONS, REASONS FOR CAUTIONConsidering this trial was conducted in women diagnosed with Androgen Excess Society criteria, the results may not be generalizable for mild phenotypes diagnosed using Rotterdam criteria. Other limitations of the study include the high dropout rate, the lack of a gold standard androgen assay and the multiple end points.WIDER IMPLICATIONS OF THE FINDINGSOur results support the views of clinicians, who suggest an OC with a low androgenic or antiandrogenic progestin, if available, to treat PCOS.STUDY FUNDING/COMPETING INTEREST(S)This study was supported by the RIES, Shahid Beheshti University of Medical Sciences, Tehran, Iran. There are no conflicts of interest.TRIAL REGISTRATION NUMBERIRCT201702071281N2.TRIAL REGISTRATION DATE21 February 2017.DATE OF FIRST PATIENT’S ENROLMENT21 March 2017.

Summary 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.

Objectives The aim of this study was to identify risk factors of in-hospital mortality among diabetic patients infected with COVID-19. Study design Retrospective cohort study. Methods Using logistic regression analysis, the independent association of potential prognostic factors and COVID-19 in-hospital mortality was investigated in three models. Model 1 included demographic data and patient history; model 2 consisted of model 1, plus vital signs and pulse oximetry measurements at hospital admission; and model 3 included model 2, laboratory test results at hospital admission. The odds ratios (ORs) and 95% confidence intervals (95% CIs) were reported for each predictor in the different models. Moreover, to examine the discriminatory powers of the models, a corrected area under the receiver-operating characteristic curve (AUC) was calculated. Results Among 560 patients with diabetes (men = 291) who were hospitalised for COVID-19, the mean age of the study population was 61.8 (standard deviation [SD] 13.4) years. During a median length of hospitalisation of 6 days, 165 deaths (men = 93) were recorded. In model 1, age and a history of cognitive impairment were associated with higher mortality; however, taking statins, oral anti-diabetes drugs and beta-blockers were associated with a lower risk of mortality (AUC = 0.76). In model 2, adding the data for respiratory rate (OR 1.07 [95% CI 1.00–1.14]) and oxygen saturation (OR 0.95 [95% CI 0.92–0.98]) slightly increased the AUC to 0.80. In model 3, the data for platelet count (OR 0.99 [95% CI 0.99–1.00]), lactate dehydrogenase (OR 1.002 [1.001–1.003]), potassium (OR 2.02 (95% CI 1.33–3.08]) and fasting plasma glucose (OR 1.04 [1.02–1.07]) significantly improved the discriminatory power of the model to AUC 0.86 (95% CI 0.83–0.90). Conclusions Among patients with type 2 diabetes, a combination of past history and pulse oximetry data, with four non-expensive laboratory measures, was significantly associated with in-hospital COVID-19 mortality.

Background Studies on knowledge, attitude, and practice (KAP) can be valuable for public health to help to develop targeted educational programs and assess the effectiveness of intervention programs. The purpose of this study was to develop and examine the validity and reliability of a questionnaire on knowledge, attitude, and practice (KAP) regarding cardiovascular diseases (CVDs), their risk factors, and symptoms among an Iranian general population. Methods This cross-sectional study was conducted on an Iranian population older than 20 years referred to some of Tehran’s healthcare centers. An initial 62-item questionnaire was developed, and the face, content, and construct validities were assessed. Results In all, 300 adults with a mean age (SD) of 39.79 (12.1) years participated in this study. Based on the results of the content validity, a questionnaire with 30 essential items was designed. Exploratory factor analysis suggested a four-factor subscale with 29 finalized items (CVD-KAP29), and acceptable goodness of fit indices was demonstrated by confirmatory factor analysis. The Cronbach’s alpha and McDonald’s ω coefficients were higher than 0.60 for all domains except the nutrition and smoking subscales. Conclusions Results provided evidence of the validity of the CVD-KAP29 for KAP studies for cardiovascular diseases in the general population.

Background Cardiovascular diseases are the first leading cause of mortality in the world. Practical guidelines recommend an accurate estimation of the risk of these events for effective treatment and care. The UK Prospective Diabetes Study (UKPDS) has a risk engine for predicting CHD risk in patients with type 2 diabetes, but in some countries, it has been shown that the risk of CHD is poorly estimated. Hence, we assessed the external validity of the UKPDS risk engine in patients with type 2 diabetes identified in the national diabetes program in Iran. Methods The cohort included 853 patients with type 2diabetes identified between March 21, 2007, and March 20, 2018 in Lorestan province of Iran. Patients were followed for the incidence of CHD. The performance of the models was assessed in terms of discrimination and calibration. Discrimination was examined using the c-statistic and calibration was assessed with the Hosmer–Lemeshow χ2 statistic (HLχ2) test and a calibration plot was depicted to show the predicted risks versus observed ones. Results During 7464.5 person-years of follow-up 170 first Coronary heart disease occurred. The median follow-up was 8.6 years. The UKPDS risk engine showed moderate discrimination for CHD (c-statistic was 0.72 for 10-year risk) and the calibration of the UKPDS risk engine was poor (HLχ2=69.9, p

BackgroundRegarding the inconclusive results of previous investigations, this study aimed to determine the association between pathology, as a possible predictor, with remission outcomes, to know the role of pathology in the personalized decision making in acromegaly patients.MethodsA retrospective cohort study was performed on the consecutive surgeries for growth hormone (GH) producing pituitary adenomas from February 2015 to January 2021. Seventy-one patients were assessed for granulation patterns and prolactin co-expression as dual staining adenomas. The role of pathology and some other predictors on surgical remission was evaluated using logistic regression models.ResultsAmong 71 included patients, 34 (47.9%) patients had densely granulated (DG), 14 (19.7%) had sparsely granulated (SG), 23 (32.4%) had dual staining pituitary adenomas. The remission rate was about 62.5% in the patients with SG and DG adenomas named single staining and 52.2% in dual staining groups. Postoperative remission was 1.53-folds higher in the single staining adenomas than dual staining-one (non-significant). The remission rate was doubled in DG group compared to two other groups (non-significant). By adjusting different predictors, cavernous sinus invasion and one-day postoperative GH levels decreased remission rate by 91% (95% CI: 0.01–0.67;p = 0.015) and 64% (95% CI: 0.19–0.69;p ConclusionVarious pathological subtypes of pituitary adenomas do not appear to have a predictive role in estimating remission outcomes. Cavernous sinus invasion followed by one-day postoperative GH is the strongest parameter to predict biochemical remission.

Background Non-participation in cohort studies, if associated with both the exposure and occurrence of the event, can introduce bias in the estimates of interest. This study aims to identify factors associated with follow-up participation in Tehran Lipid and Glucose Study, a large-scale community-based prospective study in West Asia. Methods A sample of 10,368 adults from TLGS was included in the analysis. All analyses were split according to sex and age groups (20–39, 40–59, and 60 years). The associations between socio-demographic, health, and lifestyle factors with response rate were identified using the Generalized Estimating Equations model. Results Over the median of 15.7 years of follow up the response rate was 64.5%. The highest response rate was observed in those aged 40–59 years for both sexes. Current smokers had lower odds of response in both sexes for all age groups, ranging from 0.51 to 0.74, p p ≤ 0.01, respectively for men and women) and unemployed (OR = 0.73, OR = 0.76, p ≤ 0.01, respectively for men and women) in both sexes, high physical activity in men (OR = 0.77, p p = 0.02) and obesity (OR = 0.85, p = 0.05) in women were associated with lower response rate. For the middle-aged group, diabetes in men (OR = 0.77, p = 0.05) and hypertension (OR = 0.84, p = 0.05), and having a history of cancer (OR = 0.43, p = 0.03) in women were factors associated with lower response rates. Finally, interventions for both sexes (OR = 0.75, OR = 0.77, p ≤ 0.05, respectively for men and women) and being divorced/widow in women (OR = 0.77, p = 0.05) were the factors associated with the lower response rate in the elderly. Conclusions Long-term participation was influenced by socio-demographic, health, and lifestyle factors in different sex- and age-specific patterns in TLGS. Recruitment strategies targeting these factors may improve participant follow-up in longitudinal studies.

Background Despite strong evidence demonstrating the role of estrogen as a protective factor for kidney function in women, limited data are available regarding the influence of endogenous estrogen exposure (EEE) on chronic kidney disease (CKD). The present study aimed to assess the incidence of CKD in women with various levels of EEE. Methods In a prospective population-based study over a 15-year follow-up, a total of 3043 eligible women aged 30–70 years, participating in Tehran-Lipid and Glucose-Study were recruited and divided into two groups (EEE Results The total cumulative incidence rate of CKD was 50.1 per 1000 person years; 95% CI: 47.7–52.6); this was 53.9 (95%CI, 50.2–57.8) and 47.1 (95%CI, 44.0–50.4) per 1000 person years in women with EEE Conclusion This study shows a higher HR of CKD incidence in women with low EEE levels in their later life. Screening of these women for CKD may be recommended.

Sudden cardiac death (SCD) is described as death within one hour, if observed, from the onset of symptoms, and within 24 h of being alive and well if not observe. Study population includes 3705 men and 4446 women, aged ≥ 30 years. Multivariable Cox proportional hazard models were used to determine the risk factors associated with SCD. After a median follow-up of 17.9 years, 244 SCD (165 in males) occurred. The age-standardized incidence rate (95% confidence intervals (CI)) of SCD was 2.3 (2.1–2.7) per 1000 person-year. Current smoking [Hazard ratio (HR): 2.43, 95% CI: 1.73–3.42], high waist circumference [1.49: 1.04–2.12], hypertension [1.39: 1.05–1.84], type 2 diabetes mellitus [2.78: 2.09–3.69], pulse rate ≥ 90 beats per/minute [1.72: 1.22–2.42] and prevalent cardiovascular disease [1.75: 1.26–2.45] were significant risk factors. The corresponding population attributed fractions (PAF) were 14.30, 16.58, 14.03, 19.60, 7.62, and 8.30, respectively. Being overweight [0.58: 0.40–0.83] and obese [0.61: 0.38–0.98] decreased the risk of SCD. After excluding known diabetes cases from our data analysis, the newly diagnosed diabetes still showed an HR of 2.0 (1.32–3.00) with a PAF of 7.15% in the full adjustment model. To deal with sudden death as a catastrophic outcome, multi-component strategies by policy health makers are suggested.

Background The Framingham hypertension risk score is a well-known and simple model for predicting hypertension in adults. In the current study, we aimed to assess the predictive ability of this model in a Middle Eastern population. Methods We studied 5423 participants, aged 20–69 years, without hypertension, who participated in two consecutive examination cycles of the Tehran Lipid and Glucose Study (TLGS). We assessed discrimination based on Harrell’s concordance statistic (c-index) and calibration (graphical comparison of predicted vs. observed). We evaluated the original, recalibrated (for intercept and slope), and revised (for beta coefficients) models. Results Over the 3-year follow-up period, 319 participants developed hypertension. The Framingham hypertension risk score performed well in discriminating between individuals who developed hypertension and those who did not (c-index = 0.81, 95% CI: 0.79–0.83). Initially, there was a systematic underestimation of the original risk score (events predicted), which was readily corrected by a simple model revision. Conclusions The revised Framingham hypertension risk score can be used as a screening tool in public health and clinical practice to facilitate the targeting of preventive interventions in high-risk Middle Eastern people.

BackgroundUnderstanding long-term patterns (trajectories) of cardiovascular diseases (CVD) risk and identifying different sub-groups with the same underlying risk patterns could help facilitate targeted cardiovascular prevention programs.MethodsA total of 3699 participants of the Tehran Lipid and Glucose Study (TLGS) (43% men, mean age = 53.2 years), free of CVD at baseline in 1999–2001 and attending at least one re-examination cycle between the second (2002–2005) and fourth cycles (2009–2011) were included. We examined trajectories of CVD risk, based on the ACC/AHA pooled cohort equation, over ten years and subsequent risks of incident CVD during eight years later. We estimated trajectories of CVD risk using group-based trajectory modeling. The prospective association of identified trajectories with CVD was examined using Cox proportional hazard model.ResultsThree distinct trajectories were identified (low-low, medium-medium, and high-high risk). The high-high and medium-medium CVD risk trajectories had an increasing trend of risk during the time; still, this rising trend was disappeared after removing the effect of increasing age. Upon a median 8.4 years follow-up, 146 CVD events occurred. After adjusting for age, the medium-medium and high-high trajectories had a 2.4-fold (95% CI 1.46–3.97) and 3.46-fold (95% CI 1.56–7.70) risk of CVD compared with the low-low group, respectively. In all trajectory groups, unfavorable increasing in fasting glucose, but favorable raising in HDL and decreasing smoking and total cholesterol happened over time.ConclusionsAlthough the risk trajectories were stable during the time, different risk factors varied differently in each trajectory. These findings emphasize the importance of attention to each risk factor separately and implementing preventive strategies that optimize CVD risk factors besides the CVD risk.

In this, the first study to be conducted in the Middle East and North Africa (MENA) on the subject, we examined the impact of temperature and air pollution on cardiovascular disease (CVD) and all-cause mortality. The Tehran Lipid and Glucose Study followed 9731 participants, aged ≥30 years (men = 4409), during the period 1999–2014, reporting 1350 CVDs (men = 796) and 725 deaths (men = 447). Air pollution level was measured using the air quality index (AQI). Data were analyzed using the distributed lag nonlinear model, with 30 °C temperature and AQI = 50 minimum risk values, as the relative risks' (RR) reference values. Although for the whole sample, no significant effect of air pollution was observed on CVD, for the under 60 year olds, two significant peaks occurred in AQI = 180 at lags 2 and 6 days (RR = 1.94, 95% CI: 1.02–3.67 and 2.06, 95% CI: 1.09–3.88, respectively). Temperature had no significant effect on CVD, yet the closest case to significance happened at 36 °C and lag 5 days (RR = 1.43, 95% CI: 0.97–2.11), for ages ≥60 y. The largest significant effects of air pollution on death, occurred in AQI = 180 and lag 1 day (RR = 2.40, 95% CI: 1.0.-5.59 and 3.29, 95% CI: 1.15–9.36, for the whole sample and the

Introduction The purpose of this study is to evaluate the long-term effectiveness of a community-based lifestyle education on primary prevention of metabolic syndrome in a middle-income country. Study design This study followed 3,180 individuals free of metabolic syndrome who were under the coverage of three health centers in Tehran from 1999 until 2015. They were undergoing triennial examinations resulting in four re-exams. People in one of three areas received interventions consisting of family-, school-, and community-based educational programs, including a face-to-face educational session at baseline. Data were analyzed considering the incidence of metabolic syndrome at each re-exam and also repeated-measure analysis including all re-exams together. Weighting was considered to correct selection bias because of loss to follow-up. Data were analyzed in 2017. Results After 3 years, 149 of 852 participants in the intervention and 471 of 2,328 people in control area developed metabolic syndrome at first re-exam resulting in a RR of 0.78 (95% CI=0.67, 0.92). The difference between groups remained unchanged up to the 6-year follow-up (RR=0.79, 95% CI=0.66, 0.93, at second re-exam), but disappeared during the third and fourth re-exams (RR=1.04, 95% CI=0.91, 1.18 and RR=1.03, 95% CI=0.91, 1.16, respectively). Marginal models for longitudinal data showed a significant interaction between intervention and time of re-exams. Further analyses showed that the effect of the intervention might have been rooted in improvement of lipid profile and glucose level. Conclusions In a middle-income country, face-to-face educational sessions followed by a long-term maintenance community-level educational program could reduce the risk of metabolic syndrome for up to 6 years. A booster face-to-face session is recommended to retain this preventive effect. Trial registration This study is registered at Iran Registry for Clinical Trials ( http://irct.ir ) IRCT138705301058N1.

In this study, using latent class analysis (LCA), we investigated whether there are any homogeneous subclasses of individuals exhibiting different profiles of metabolic syndrome (MetS) components. The current study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS), a population-based cohort including 6448 subjects, aged 20–50 years. We carried out a LCA on MetS components and assessed the association of some demographic and behavioral variables with membership of latent subclasses using multinomial logistic regression. Four latent classes were identified:(1) Low riskclass, with the lowest probabilities for all MetS components (its prevalence rate in men: 29%, women: 64.7%), (2) MetS with diabetes medication (men: 1%, women: 2.3%), (3) Mets without diabetes medication (men: 32%, women: 13.4%), (4) dyslipidemia (men: 38%, women: 19.6%). In men the forth subclass was more significantly associated with being smoker (odds ratio: 4.49; 95% CI: 1.89–9.97). Our study showed that subjects with MetS could be classified in sub-classes with different origins for their metabolic disorders including drug treated diabetes, those with central obesity and dyslipidemia associated with smoking.

Objective To evaluate the incidence of hypertension, metabolic syndrome, dyslipidemia, and obesity in comparing women with polycystic ovary syndrome (PCOS) and a control group of healthy women. Design Prospective cohort study with the median and interquartile range of 12.9 (10.8–13.9) years. Setting Population-based cohort of the Tehran Lipid and Glucose Study. Patient(s) A total of 1,702 reproductive-age women including 178 women with PCOS and 1,524 controls. Intervention(s) None. Main Outcome Measure(s) Cumulative incidence of each outcome estimated using the Kaplan-Meier method and compared using the log-rank statistic; univariate and multiple extended Cox proportional hazards regression with age as the time scale to estimate the adjusted hazard ratio (HR) of developing outcomes in relation to PCOS and ages ≤40 years and >40 years with heavyside functions. Result(s) The incidence rates of hypertension, metabolic syndrome, dyslipidemia, and obesity were 13.9, 21.0, 46.1, 24.6, and 50.6, respectively, per 1,000 person-years for women with PCOS; and 13.8, 22.7, 46.0, and 24.0, respectively, per 1,000 person-years for the healthy control women. Women with PCOS aged ≤40 years had an adjusted higher risk of developing hypertension (HR 2.08; 95% confidence interval, 1.0–3.9) and the metabolic syndrome (HR 1.81; 95% confidence interval, 1.1–2.9), but the risk disappeared after age 40. The risks of central obesity and obesity had borderline statistical significance and were higher in women with PCOS aged ≤40 than in healthy controls. The risk of developing dyslipidemia showed no statistically significant difference between the two groups in the unadjusted or multiple adjusted models at any age. Conclusion(s) In this long-term population-based cohort study, the risk of developing hypertension and the metabolic syndrome in young women with PCOS was higher than in controls, but these risks were diluted in the late reproductive period.

Objectives: This study aimed to provide an overview of prediction models of undiagnosed type 2 diabetes mellitus (U-T2DM) or the incident T2DM (I-T2DM) using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) checklist and the prediction model risk of the bias assessment tool (PROBAST). Data Sources: Both PUBMED and EMBASE databases were searched to guarantee adequate and efficient coverage. Study Selection: Articles published between December 2011 and October 2019 were considered. Data Extraction: For each article, information on model development requirements, discrimination measures, calibration, overall performance, clinical usefulness, overfitting, and risk of bias (ROB) was reported. Results: The median (interquartile range; IQR) number of the 46 study populations for model development was 5711 (1971 - 27426) and 2457 (2060 - 6995) individuals for I-T2DM and U-T2DM, respectively. The most common reported predictors were age and body mass index, and only the Qrisk-2017 study included social factors (e.g., Townsend score). Univariable analysis was reported in 46% of the studies, and the variable selection procedure was not clear in 17.4% of them. Moreover, internal and external validation was reported in 43% the studies, while over 63% of them reported calibration. The median (IQR) of AUC for I-T2DM models was 0.78 (0.74 - 0.82); the corresponding value for studies derived before October 2011 was 0.80 (0.77 - 0.83). The highest discrimination index was reported for Qrisk-2017 with C-statistics of 0.89 for women and 0.87 for men. Low ROB for I-T2DM and U-T2DM was assessed at 18% and 41%, respectively. Conclusions: Among prediction models, an intermediate to poor quality was reassessed in several aspects of model development and validation. Generally, despite its new risk factors or new methodological aspects, the newly developed model did not increase our capability in screening/predicting T2DM, mainly in the analysis part. It was due to the lack of external validation of the prediction models.

BackgroundThis study aims to estimate the prevalence of COVID-19 in the general population of Iran.MethodsThe target population was all Iranian people aged six years and older in the country. A stratified random sampling design was used to select 28,314 subjects from among the individuals registered in the electronic health record systems used in primary health care in Iran. Venous blood was taken from each participant and tested for the IgG antibody against COVID-19. The prevalence of COVID-19 was estimated at provincial and national levels after adjusting for the measurement error of the laboratory test, non-response bias, and sampling design.ResultsOf the 28,314 Iranians selected, 11,256 (39.75%) participated in the study. Of these, 5406 (48.0%) were male, and 6851 (60.9%) lived in urban areas. The mean (standard deviation) participant age was 35.89 (18.61) years. The adjusted prevalence of COVID-19 until August 20, 2020 was estimated as 14.2% (95% uncertainty interval: 13.3%, 15.2%), which was equal to 11,958,346 (95% confidence interval: 11,211,011–12,746,776) individuals. The prevalence of infection was 14.6%, 13.8%, 16.6%, 11.7%, and 19.4% among men, women, urban population, rural population, and individuals ≥60 years of age, respectively. Ardabil, Golestan, and Khuzestan provinces had the highest prevalence, and Alborz, Hormozgan, and Kerman provinces had the lowest.ConclusionsBased on the study results, a large proportion of the Iranian population had not yet been infected by COVID-19. The observance of hygienic principles and social restrictions should therefore continue until the majority of the population has been vaccinated.

Background: Analyzing and monitoring the spatial-temporal patterns of the new co onavirus disease (COVID-19) pandemic can assist local authorities and researchers in detecting disease outbreaks in the early stages. Because of different socioeconomic profiles in Tehran's areas, we will provide a clear picture of the pandemic distribution in Tehran's neighbourhoods during the first months of its spread from February to July 2020, employing a spatial-temporal analysis applying the geographical information system (GIS). Disease rates were estimated by location during the 5 months, and hot spots and cold spo s were highlighted.Methods: This study was performed using the COVID-19 incident cases and deaths recorded in the Medical Care Monitoring Centre from February 20, to July 20, 2020. The local Getis-Ord Gi* method was applied to identify the hotspots where the infectious disease distribution had significantly clustered spatially. A statistical analysis for incidence and mortality rates and hot spots was conducted using ArcGIS 10.7 software.Results: The addresses of 43,000 Tehrani patients (15,514 confirmed COVID-19 cases and 27,486 diagnosed as probable cases) were changed in its Geo-codes in the GIS. The highest incidence rate from February to July 2020 was 48 per 10,000 and the highest 5-month incidence rate belonged to central and eastern neighbourhoods. According to the Cumulative Population density of patients, the higher number is estimated by more than 2500 people in the area;however, the lower nu ber is highlighted by about 500 people in the neighborhood. Also, the results from the local Getis-Ord Gi* method indicate that COVID-19 has formed a hotspot in the eastern, southeast, and central districts in Tehran since February. We also observed a death rate hot spot in eastern areas. Conclusion: Because of the spread of COVID-19 disease throughout Tehran's neighborhoods with different socioeconomic status, it seems essential to pay attention to health behaviors to prevent the next waves of the disease. The findings suggest that disease distribution has formed a hot spot in Tehran's eastern and central regions. © Iran University of Medical Sciences

Background: Autoimmune thyroid diseases (AITD) are among the most common autoimmune diseases in the world. They are usually accompanied by the presence of anti-thyroid antibodies as the early predictive marker. Genetic determinants of the susceptibility to develop thyroid antibodies are still poorly understood. This study aimed to investigate the relation between thyroid peroxidase (TPO) gene variants (53 SNPs) and positive TPOAb and also to evaluate the effect of some environmental factors on changes from negative to positive TPOAb (Seroconversion). Methods: Participants from the Tehran Thyroid Study (TTS) in phases 1 and 2 (N=5317, ≥ 20 years) were evaluated for the positive TPOAb and its relationship with 53 SNPs from TPO gene (a cross-sectional approach). At the second stage of the study (a longitudinal approach), negative TPOAb participants (control group, N= 4815) were followed up for about 5.5 (5.54±1.62) years until they have had positive results for TPOAb (“TPOAb seroconversion”). The association between TPO gene polymorphisms and TPOAb seroconversion was evaluated using logistic regression analysis and SKAT (sequence kernel association test) package. Results: In cross-sectional analyses, 17 SNPs were associated with TPOAb positivity (521 positive TPOAb participants) after the adjustment for age, sex, body mass index (BMI), smoking, the number of parity and oral contraceptive consumption (P Conclusions: TPOAb seroconversion could be affected by some thyroid peroxidase gene variants.

Background and Objectives The prevalence of both obesity and type 2 diabetes has increased in recent years. In this study, we aimed to evaluate the prevalence of obesity and type 2 diabetes and to investigate the contribution of obesity to the increased prevalence of type 2 diabetes in urban and rural Iranian communities. Methods This study was based on four surveys from the Surveillance Survey of Risk Factors of Non-communicable Diseases (SuRFNCD), conducted in 2005, 2007, 2011, and 2016. The contribution of general and abdominal obesity to the prevalence of type 2 diabetes was determined based on the population attributable fraction (PAF). Results The mean (95% CI) age and body mass index (BMI) of the participants were 36.9 years (36.8–36.9) and 25.9 kg/m2 (25.9–26.0), respectively. The increasing rates of general obesity and diabetes were 37% and 80% among urban residents and 63% and 68% among rural residents, respectively. The PAF of general obesity and abdominal obesity to the prevalence of type 2 diabetes was 20.2% and 33.4% in urban residents and 11.8% and 21.0% in rural residents, respectively. Conclusion The prevalence of both obesity and type 2 diabetes has increased over the past 12 years. Besides, general and abdominal obesity played a substantial role in increasing the prevalence of type 2 diabetes in both urban and rural populations.

AimsTo identify sex specific trajectories of waist circumference (WC),triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and fasting plasma glucose (FPG) during adulthood and examine their associations with incident hypertension.MethodsThe cohort consisted of 5030 participants (2051 males) with at least 2 repeated measurement during a median of 12 years follow up. We identified trajectory groups using latent class growth mixture model, their association with hypertension was examined using multivariate Cox-regression analysis.ResultsWe found 997 cases of hypertension (483 male). For both exposures, three distinct trajectory groups were identified in both genders. For WC, in women: low-increasing, 82.4%; high-stable, 13.4%; high-increasing, 4.2% and in men: stable, 94.6%; low-increasing, 3.6% and for high- increasing, 1.7%. For TG, in women: stable, 91.3%; decreasing, 5.9%; inverse U-shape, 2.8%; in men: stable, 89.7%; inverse U- shape, 6.2% and for decreasing, 4.1%.Regarding WC, high stable and high-increasing trajectories were associated with hypertension in the multivariate model [(hazard ratio (HR) = 1.66 (95% CI 1.26–2.20) and 2.78(1.79–3.60), respectively]. Among men, this association was shown only for the low-increasing trajectory [2.76: 1.49–5.10]. For TG, among women decreasing and inverse U-shape trajectories were significantly associated with hypertension in the multivariate model [1.32:1.01–1.76] and [2.23:1.58–3.23, respectively].We did not find any impact of increasing trajectories of FPG and HDL-C on incident hypertension. Considering TC, all individuals followed a stable trajectory.ConclusionWC dynamic changes in both gender and TG trajectory among women were significantly associated with incident hypertension.

This study is the first to evaluate familial aggregation, heritability and inheritance mode of type 2 diabetes (T2D) in Tehran Lipid Glucose Study (TLGS) participants as a representative sample of the Iranian population.From the ongoing family-based TLGS cohort, 13,741 individuals at least 20 years of age (mean ± standard deviation, 39.71±16.56) were assessed. After correcting family structures using genomic information from the Tehran Cardiometabolic Genetic Study, 2,594 constituent pedigrees were constructed. Familial aggregation was assessed based on genealogic index testing, familial intraclass correlation and positive family history. Family-based heritability was checked with 2 linear mixed models, including 2 different random components: the kinship matrix and the genomic relationship matrix. The mode of inheritance of T2D was investigated by complex segregation analysis (CSA).Familial aggregation of T2D was significant (p0.05), and family-based heritability showed a high degree of genetic variation in T2D between individuals at 65% (standard error, 0.034). Within first-degree relatives (parent/offspring and siblings), the likelihood of a parental affect was higher than in siblings (odds ratio, 4.11 vs 1.65). Family history of T2D among first-degree relatives was more noteworthy than for second-degree relatives (odds ratio, 3.84 vs 0.59). CSA revealed that the polygenic model is best to illustrate the mode of inheritance of T2D for TLGS participants.Our findings demonstrate that the heritability of T2D with polygenic mode in the Iranian population is higher than the global average. We also found that T2D is transmitted equally into siblings, with parental affect the leading risk factor. These data suggest that policymakers should change individual-level to family-level prevention.

Background: Serological surveillance of COVID-19 through conducting repetitive population-based surveys can be useful in estimating and monitoring changes in the prevalence of infection across the country. This paper presents the protocol of nationwide population-based surveys of the Iranian COVID-19 Serological Surveillance (ICS) program. Methods: The target population of the surveys is all individuals ≥6 years in Iran. Stratified random sampling will be used to select participants from those registered in the primary health care electronic record systems in Iran. The strata are the 31 provinces of the country, in which sampling will be done through simple random sampling. The sample size is estimated 858 individuals for each province (except for Tehran province, which is 2574) at the first survey. It will be recalculated for the next surveys based on the findings of the first survey. The participants will be invited by the community health workers to the safe blood sampling centers at the district level. After obtaining written informed consent, 10 mL of venous blood will be taken from the participants. The blood samples will be transferred to selected reference laboratories in order to test IgG and IgM antibodies against COVID-19 using an Iranian SARS-CoV-2 ELISA Kit (Pishtaz Teb). A serologically positive test is defined as a positive IgG, IgM, or both. After adjusting for the measurement error of the laboratory test, nonresponse bias, and sampling design, the prevalence of COVID-19 will be estimated at the provincial and national levels. Also, the approximate incidence rate of infection will be calculated based on the data of both consecutive surveys. Conclusion: The implementation of these surveys will provide a comprehensive and clear picture of the magnitude of COVID-19 infection and its trend over time for health policymakers at the national and subnational levels.

Since its emergence in late 2019, the COVID-19 pandemic has attracted the attention of researchers in various fields, including urban planning and design. However, the spreading patterns of the disease in cities are still not clear. Historically, preventing and controlling pandemics in cities has always been challenging due to various factors such as higher population density, higher mobility of people, and higher contact frequency. To shed more light on the spread patterns of the pandemic, in this study we analyze 43,000 confirmed COVID-19 cases at the neighborhood level in Tehran, the capital of Iran. To examine spatio-temporal patterns and place-based factors contributing to the spread of the pandemic, we used exploratory spatial data analysis and spatial regression. We developed a geo-referenced database composed of 12 quantitative place-based variables related to physical attributes, land use and public transportation facilities, and demographic status. We also used the geographically weighted regression model for the local examination of spatial non-stationarity. According to the results, population density (R2 = 0.88) and distribution of neighborhood centers (R2 = 0.59), drugstores (R2 = 0.64), and chain stores (R2 = 0.59) are the main factors contributing to the spread of the disease. Additionally, density of public transportation facilities showed a varying degree of contribution. Overall, our findings suggest that demographic composition and major neighborhood-level physical attributes are important factors explaining high rates of infection and mortality. Results contribute to gaining a better understanding of the role of place-based attributes that may contribute to the spread of the pandemic and can inform actions aimed at achieving Sustainable Development Goals, particularly Goals 3 and 11.

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 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.

To examine the trends of 7 cardiovascular health metrics (CVH metrics) incorporate of smoking, physical activity, diet, body mass index (BMI), fasting plasma glucose (FPG), total cholesterol (TC), and blood pressure (BP) level during three cross-sectional STEPwise approaches to surveillance (STEPS), 2007–2016, among Iranian adults. The study population consisted of 19,841 women and 17,243 men, aged 20–65 years. The CVH metrics were categorized as ‘ideal’, ‘intermediate’, and ‘poor’. The sex-stratified weighted prevalence rate of each CVH metrics was reported. The conditional probability of each poor versus combined intermediate and ideal metric was analyzed using logistic regression. In 2016 compared to 2007, the prevalence of poor BP level (20.4% vs. 23.7%), smoking (13.7% vs. 23.8%), TC ≥ 240 mg/dl (2.4% vs. 11.2%) and FPG 2 (62.8% vs. 57.8%) increased. Despite a high prevalence of obesity among women, it remained constant in women but showed an increasing trend in men; moreover, the trends of low physical activity and current smoking were better for women. Despite some improvement in CVH metrics

Background The use of statins for primary prevention of cardiovascular diseases is associated with different benefit and harm outcomes. The aime of this study is how important these outcomes are for people and what people's preferences are. Methods We conducted a preference-eliciting survey incorporating a best–worst scaling (BWS) instrument in Iran from June to November 2019. The relative importance of 13 statins-related outcomes was assessed on a sample of 1085 participants, including 913 general population (486 women) and 172 healthcare providers from the population covered by urban and rural primary health care centers. The participants made trade-off decisions and selected the most and least worrisome outcomes concurrently from 13 choice sets; each contains four outcomes generated using the balanced incomplete block design. Results According to the mean (SD) BWS scores, which can be (+ 4) in maximum and (− 4) in minimum, in the general population, the most worrisome outcomes were severe stroke (3.37 (0.8)), severe myocardial infarction (2.71(0.7)), and cancer (2.69 (1.33)). While myopathy (− 3. 03 (1.03)), nausea/headache (− 2.69 (0.94)), and treatment discontinuation due to side effects (− 2.24 (1.14)) were the least worrisome outcomes. Preferences were similar between rural and urban areas and among health care providers and the general population with overlapping uncertainty intervals. Conclusion The rank of health outcomes may be similar in various socio-cultural contexts. The preferences for benefits and harms of statin therapy are essential to assess benefit-harm balance when recommending statins for primary prevention of cardiovascular diseases.

To develop a risk prediction model for early discrimination between transient and permanent congenital hypothyroidism (CH). In a retrospective cohort, 1047 confirmed CH neonates, from 15 randomly selected provinces in Iran, were entered to the study. Clinical and biochemical information of transient and permanent cases, distinct at the age of 3 years were retrospectively gathered. Among CH neonates, the overall prevalence of permanent CH was 57.1%. Using forward stepwise multivariable logistic regression analysis, confirmatory venous TSH, total T4

Introduction Despite the evidence available on the adverse impact of gestational diabetes (GDM) and thyroid disorders on developing type 2 diabetes (T2DM), the concurrent influence of these disorders on the incidence of T2DM has not been reported yet. Methods In this prospective study, 1894 non-diabetic women aged 20 to 60 years, with a history of at least one term delivery, without diagnosed hyperthyroidism were selected at the initiation of the Tehran Thyroid Study (TTS). Pooled logistic regression analyses were used to investigate the association of GDM, thyroid disorders i.e., hypothyroidism and/or thyroid peroxidase antibody (TPOAb) positivity and interaction between GDM and thyroid disorders with the risk of incident T2DM. Results Of the 1894 participants of the present study, 346 (18.3%) had a history of GDM, and 832 (43.9%) had thyroid disorders. The total cumulative incidence rate of T2DM at the median follow-up time of ~ 12 years was overall 12/1000 person-years (95% confidence interval (CI): 10/1000–13/1000), with an incidence rate of 16/1000 (95%CI: 13/1000–20/1000) in women with GDM; and 11/100,000 (95%CI: 9/100,000–12/1000) among those without GDM. After adjustment for age, the risk of incident T2DM increased among individuals with the previous GDM compared to women without a history of GDM (odds ratio (OR): 1.54, 95%CI: 1.06, 2.25). No significant associations were found between either thyroid disorders or the interaction between GDM and thyroid disorders with the development of T2DM; (OR: 1.14, 95%CI: 0.82, 1.58) and (OR: 1.27, 95%CI: 0.66, 2.43), respectively. Conclusion GDM and thyroid disorders have no concurrent impacts on the incidence of T2DM.

Background and objective A limited number of studies have evaluated the effects of oral contraceptives (OCs) on the quality of life (QOL) of polycystic ovary syndrome (PCOS) patients. This study aimed to compare the effects of using OCs containing levonorgestrel (LNG) and those containing desogestrel (DSG), cyproterone acetate (CPA) or drospirenone (DRSP) for 6 months on the QOL with PCOS. Methods In this crossover randomized controlled 6-arm trial, 200 eligible patients with PCOS scheduled for OC therapy were randomly assigned to one of the 6 study arms. All 6 arms include two 6-month treatment periods, one period with OCs containing LNG, and the other with each of the 3 OCs containing DSG, CPA, or DRSP. Outcomes of interest were the total score of QOL and its domains, which were assessed using a specific and valid health-related quality of life questionnaire for PCOS, which is consisted of six domains, including psychosocial–emotional, self-image, fertility, sexual function, hirsutism, and obesity– menstrual disorders. Results Finally, a total of 88 patients were analyzed for this study. The results showed that use of OCs containing DSG, CPA, and DRSP for 3 months was not associated with significant differences in the total scores of QOL compared to those OCs containing LNG, whereas, after 6 months of treatment, patients treated with OCs containing CPA had more improvements in their total scores of QOL, in comparison to OCs containing LNG (P Conclusions This crossover study demonstrated non-inferiority of OCs with newer generation progestins on different domains of QOL, in comparison with older compounds, although usage of products containing CPA was significantly associated with more improvement in total QOL of PCOS patients, compared to those containing LNG after 6-month of treatment. Trial registration IRCT201702071281N2.

This study aims to assess the effects of a community-based lifestyle intervention program on the incidence of type 2 diabetes (T2D). For this purpose, three communities in Tehran were chosen; one community received a face-to-face educational session embedded in a long-term community-wide lifestyle intervention aimed at supporting lifestyle changes. We followed up 9,204 participants (control: 5,739, intervention: 3,465) triennially from 1999 to 2015 (Waves 1–5). After a median follow-up of 3.5 years (wave 2), the risk of T2D was 30% lower in the intervention community as compared with two control communities by (Hazard-ratio: 0.70 [95% CI 0.53; 0.91]); however, the difference was not statistically significant in the following waves. After a median follow-up of 11.9 years (wave 5), there was a non-significant 6% reduction in the incidence of T2D in the intervention group as compared to the control group (Hazard-ratio: 0.94 [0.81, 1.08]). Moreover, after 11.9 years of follow-up, the intervention significantly improved the diet quality measured by the Dietary Approaches to Stop Hypertension concordance (DASH) score. Mean difference in DASH score in the intervention group versus control group was 0.2 [95% CI 0.1; 0.3]. In conclusion, the intervention prevented T2D by 30% in the short-term (3.5 years) but not long-term; however, effects on improvement of the diet maintained in the long-term.Registration: This study is registered at IRCT, a WHO primary registry (https://irct.ir). The registration date 39 is 2008-10-29 and the IRCT registration number is IRCT138705301058N1.

BACKGROUND: Evaluating the process of changes in the Metabolic Syndrome (MetS) components over time is one of the ways to study of the MetS natural history. This study aimed to determine the trend of changes in the progression of MetS from its isolated components. METHODS: This longitudinal study was performed on four follow-up periods of the Tehran Lipid and Glucose Study (TLGS) between 1999 and 2015. The research population consisted of 3905 adults over the age of 18 years. MetS was diagnosed based on the Joint Interim Statement (JIS). The considered components were abdominal obesity, hypertension, hyperglycemia, and dyslipidemia. RESULTS: The highest incidence of MetS from its components was related to hypertension in the short term (3.6-year intervals). In the long run, however, the highest increase in the MetS incidence occurred due to abdominal obesity. Overall, the incidence of MetS increased due to obesity and dyslipidemia, but decreased due to the other factors. Nonetheless, the trend of MetS incidence from all components increased in total. The most common components were dyslipidemia with a decreasing trend and obesity with an increasing trend during the study. CONCLUSION: The results indicated that obesity and hypertension components played a more important role in the further development of MetS compared to other components in the Iranian adult population. This necessitates careful and serious attention in preventive and control planning.

Background: Iran is one of the first few countries that was hit hard with the coronavirus disease 2019 (COVID-19) pandemic. We aimed to estimate the total number of COVID-19 related infections, deaths, and hospitalizations in Iran under different physical distancing and isolation scenarios. Methods: We developed a susceptible-exposed-infected/infectious-recovered/removed (SEIR) model, parameterized to the COVID-19 pandemic in Iran. We used the model to quantify the magnitude of the outbreak in Iran and assess the effectiveness of isolation and physical distancing under five different scenarios (A: 0% isolation, through E: 40% isolation of all infected cases). We used Monte-Carlo simulation to calculate the 95% uncertainty intervals (UIs). Results: Under scenario A, we estimated 5 196 000 (UI 1 753 000-10 220 000) infections to happen till mid-June with 966 000 (UI 467 800-1 702 000) hospitalizations and 111 000 (UI 53 400-200 000) deaths. Successful implantation of scenario E would reduce the number of infections by 90% (ie, 550 000) and change the epidemic peak from 66 000 on June 9, to 9400 on March 1, 2020. Scenario E also reduces the hospitalizations by 92% (ie, 74 500), and deaths by 93% (ie, 7800). Conclusion: With no approved vaccination or therapy available, we found physical distancing and isolation that include public awareness and case-finding and isolation of 40% of infected people could reduce the burden of COVID-19 in Iran by 90% by mid-June.

Background: High burden of chronic cardio-metabolic disorders including type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and cardiovascular disease (CVD) have been reported in the Middle East and North Africa region. We aimed to externally validate a non-laboratory risk assessment tool for the prediction of the chronic cardio-metabolic disorders in the Iranian population. Methods: The predictors included age, body mass index, waist circumference, use of antihypertensive, current smoking, and family history of cardiovascular disease and/or diabetes. For external validation of the model in the Tehran lipids and glucose study (TLGS), the Area under the curve (AUC) and the Hosmer-Lemeshow (HL) goodness of fit test were performed for discrimination and calibration, respectively. Results: Among 1310 men and 1960 women aged 28-85 years, 29.5% and 47.4% experienced chronic cardio-metabolic disorders during the 6 and 9-year follow-up, respectively. The model showed acceptable discrimination, with an AUC of 0.72(95% CI: 0.69-0.75) for men and 0.73(95% CI: 0.71-0.76) for women. The calibration of the model was good for both genders (min HL P=0.5). Considering separate outcomes, AUC was highest for CKD (0.76(95% CI: 0.72-0.79)) and lowest for T2DM (0.65(95% CI: 0.61-0.69)), in men. As for women, AUC was highest for CVD (0.82(95% CI: 0.78-0.86)) and lowest for T2DM (0.69(95% CI: 0.66-0.73)). The 9-year follow-up demonstrated almost similar performances compared to the 6-year follow-up. Using Cox regression in place of logistic multivariable analysis, model’s discrimination and calibration were reduced for prediction of chronic cardio-metabolic disorders; the issue which had more effect on the prediction of incident CKD among women. Moreover, adding data of educational levels and marital status did not improve, the discrimination and calibration in the enhanced model.Conclusion: This model showed acceptable discrimination and good calibration for risk prediction of chronic cardio-metabolic disorders in short and long-term follow-up in the Iranian population.

Background: Recent evidence recommended stepwise screening methods for identifying individuals at high risk of type 2 diabetes to be recruited in the lifestyle intervention programs for the prevention of the disease. This study aims to assess the performance of different stepwise screening methods that combine non-invasive measurements with lab-based measurements for identifying those with 5-years incident type 2 diabetes. Methods: 3037 participants aged ≥30 years without diabetes at baseline in the Tehran Lipid and Glucose Study (TLGS) were followed. Thirty-two stepwise screening methods were developed by combining a non-invasive measurement (an anthropometric measurement (waist-to-height ratio, WtHR) or a score based on a non-invasive risk score [Australian Type 2 Diabetes Risk Assessment Tool, AUSDRISK]) with a lab-based measurement (different cut-offs of fasting plasma glucose [FPG] or predicted risk based on three lab-based prediction models [Saint Antonio, SA; Framingham Offspring Study, FOS; and the Atherosclerosis Risk in Communities, ARIC]). The validation, calibration, and usefulness of lab-based prediction models were assessed before developing the stepwise screening methods. Cut-offs were derived either based on previous studies or decision-curve analyses. Results: 203 participants developed diabetes in 5 years. Lab-based risk prediction models had good discrimination power (area under the curves [AUCs]: 0.80-0.83), achieved acceptable calibration and net benefits after recalibration for population’s characteristics and were useful in a wide range of risk thresholds (5%-21%). Different stepwise methods had sensitivity ranged 20%-68%, specificity 70%-98%, and positive predictive value (PPV) 14%-46%; they identified 3%-33% of the screened population eligible for preventive interventions. Conclusion: Stepwise methods have acceptable performance in identifying those at high risk of incident type 2 diabetes.

Background The assessment of the natural history of metabolic syndrome (MetS) has an important role in clarifying the pathways of this disorder. Objective This study purposed to provide a rational statistical view of MetS progression pathway. Methods We performed a systematic review in accordance with the PRISMA Statement until September 2019 in the Medline/PubMed, Scopus, Embase, Web of Science and Google Scholar databases. From the 68 found studies, 12 studies were eligible for review finally. Results The selected studies were divided in 2 groups with Markovian and non-Markovian approach. With the Markov approach, the most important trigger for the MetS chain was dyslipidemia with overweight/obesity in the under-50 and with hypertension in the over-50 age group, where overweight/obesity was more important in women and hypertension in men. In non-Markov approach, the most common trigger was hypertension. Transition probability (TP) from no component to MetS were higher in all Markovian studies in men than in women. In the Markovians the combination of dyslipidemia with overweight/obesity and in non-Markovians, hyperglycemia with overweight/obesity were the most common combinations. Finally, the most important components, which predict the MetS, were 2-component states and hyperglycemia in Markovian approach and overweight/obesity in non-Markovians. Conclusions Among the components of the MetS, dyslipidemia and hypertension seems to be the main developer components in natural history of the MetS. Also, in this chain, the most likely combination over time that determines the future status of people seems to be the combination of dyslipidemia with obesity or hyperglycemia. However, more research is needed.