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BackgroundMeasuring the distribution of health is a part of assessing health system performance. This study aims to estimate health inequality between different socioeconomic groups and its determinants in Tehran, the capital of Iran.MethodsSelf-rated health (SRH) and demographic characteristics, including gender, age, marital status, educational years, and assets, were measured by structured interviews of 2464 residents of Tehran in 2008. A concentration index was calculated to measure health inequality by economic status. The association of potential determinants and SRH was assessed through multivariate logistic regression. The contribution to concentration index of level of education, marital status and other determining factors was assessed by decomposition.ResultsThe mean age of respondents was 41.4 years (SD 17.7) and 49% of them were men. The mean score of SRH status was 3.72 (range: 1–5; SD 0.93). 282 respondents (11.5%) rated their health status as poor or very poor. The concentration index was −0.29 (SE 0.03; p<0.001). Age, marital status, level of education and household economic status were significantly associated with SRH in both the crude and adjusted analyses. The main contributors to inequality in SRH were economic status (47.8%), level of education (29.2%) and age (23.0%).ConclusionsSub-optimal SRH was more in lower than in higher economic status. After controlling for age, the levels of education and household wealth have the greatest contributions to SRH inequality.

OBJECTIVE: The purpose of this study was to provide the first national estimate on the prevalence of the metabolic syndrome and its components and the first ethnic-specific cutoff point for waist circumference in the Eastern Mediterranean Region. RESEARCH DESIGN AND METHODS: This national survey was conducted in 2007 on 3,024 Iranians aged 25-64 years living in urban and rural areas of all 30 provinces in Iran. The metabolic syndrome was defined by different criteria, namely the definition of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), the International Diabetes Federation (IDF) criteria, and the modified definition of the NCEP/ATP III (ATP III/American Heart Association [AHA]/National Heart, Lung, and Blood Institute [NHLBI]). RESULTS: The age-standardized prevalence of the metabolic syndrome was about 34.7% (95% CI 33.1-36.2) based on the ATP III criteria, 37.4% (35.9-39.0%) based on the IDF definition, and 41.6% (40.1-43.2%) based on the ATP III/AHA/NHLBI criteria. By all definitions, the prevalence of the metabolic syndrome was higher in women, in urban areas, and in the 55- to 64-year age-group compared with the prevalence in men, in rural areas, and in other age-groups, respectively. The metabolic syndrome was estimated to affect >11 million Iranians. The optimal cutoff point of waist circumference for predicting at least two other components of the metabolic syndrome as defined by the IDF was 89 cm for men and 91 cm for women. CONCLUSIONS: The high prevalence of the metabolic syndrome with its considerable burden on the middle-aged population mandates the implementation of national policies for its prevention, notably by tackling obesity. The waist circumference cutoff points obtained can be used in the region.

Background: A previous analysis of the Osteoarthritis Initiative study reported a dose-response relationship between physical activity and improved physical function in adults with knee osteoarthritis, using conventional statistical methods. These methods are subject to bias when confounders are affected by prior exposure. Methods: We used baseline and 1-, 2-, and 3-year follow-up data from the Osteoarthritis Initiative study of 2545 US adults with knee osteoarthritis recruited between 2004 and 2006 from 4 clinical sites. Physical activity was measured using the Physical Activity Scale for the Elderly, and outcomes were functional performance measured by the timed 20-meter walk test and self-reported knee pain measured by the Western Ontario and McMaster Universities Osteoarthritis Index. We estimated the effect of physical activity on each outcome using inverse probability-weighted (IPW) estimators of marginal structural models. For each outcome, we fitted 2 separate IPW models adjusting for concurrent or lagged confounders. Results: The mean differences in walking speed for the second, third, and fourth quartiles of physical activity relative to the first were 0.48 (95% confidence interval = -0.12 to 1.08), 0.45 (-0.23 to 1.13), and 0.46 (-0.29 to 1.22) meters/min based on the IPW model adjusting for concurrent confounders. When adjusting for lagged confounders, the results were 1.35 (0.64 to 2.07), 1.33 (0.54 to 2.14), and 1.26 (0.40 to 2.12). Both IPW models indicated that physical activity did not affect knee pain. Conclusions: Physical activity has no effect on knee pain and may have either a very small effect or no effect on functional performance in adults with knee osteoarthritis.

The cut-off points of waist circumference and body mass index (BMI) are varied according to different races. There is a dearth of information on these indices especially in Iranian adults. We sought to estimate the cut-off points of waist circumference and BMI for detecting diabetes, hypercholesterolemia, and hypertension. The data were gathered by the First Iranian Non-Communicable Disease Survey in 2005. In total, 70,981 participants between 25 and 64 years of old were selected via random multistage cluster sampling. Receiver operating characteristic curves were used to show the cut-off points of waist circumference and BMI for detecting diabetes, hypercholesterolemia, and hypertension. The maximum value the sum of sensitivity and specificity indicated the cut-off point. The cut-off points of waist circumference according to maximum sum of sensitivity and specificity for detecting hypertension, diabetes, and hypercholesterolemia in men were 89.7 cm, 89.4 cm and 88.2 cm and in women were 93.9 cm, 96.2 cm and 90 cm respectively. The cut-off points of BMI according to maximum sum of sensitivity and specificity for detecting hypertension, diabetes, and hypercholesterolemia in men were 25.7 kg/m(2), 24.8 kg/m(2) and 24 kg/m(2) and in women were 26.9 kg/m(2), 26.3 kg/m(2) and 26.1 kg/m(2) respectively. This was a population-based study on a huge sample on the basis of a national survey. The Iranian BMI was different from the values suggested by the WHO. The waist circumference in Iranian women was higher than that in men.

Noninvasive markers for predicting significant fibrosis and inflammation have not yet been validated in an unselected group of chronic hepatitis B virus (HBV) carriers. The aim of this study was to create noninvasive models to predict significant fibrosis and inflammation in chronic HBV carriers. A total of 276 (229 HBeAg negative, 47 HBeAg positive) unselected consecutive treatment naïve patients chronically infected with HBV who attended our center over a 36-month period underwent liver biopsy. HBeAg negative patients were randomly divided into two cohorts: training group (N = 130) and validation group (N = 99). HBeAg positive patients were analyzed as a whole without separation. Thirteen parameters were analyzed separately in HBeAg negative and HBeAg positive patients to predict significant fibrosis (Ishak stage >or=3) and inflammation (Ishak grade >or=7). In HBeAg negative patients significant liver fibrosis was best predicted using the variables HBV DNA levels, alkaline phosphatase, albumin, and platelet counts with an area under ROC curve (AUC) of 0.91 for the training group and 0.85 for the validation group. Using the low cutoff probability of 4.72, significant fibrosis could be excluded with negative predictive value of 99% in the entire cohort, and liver biopsy would have been avoided in 52% of patients. The best model for predicting significant inflammation included the variables age, HBV DNA levels, AST, and albumin with an AUC of 0.93 in the training and 0.82 in the validation group. In HBeAg positive patients no factor could predict accurately stages of liver fibrosis, but the best factor for predicting significant inflammation was AST with an AUC of 0.87. Significant hepatic fibrosis and necroinflammation can reliably be predicted using routinely checked tests and HBV DNA levels.

Young people's health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people's health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10–24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. The leading causes of death in 2013 for young people aged 10–14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15–19 years (14·2%) and 20–24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20–24 years (17·1%) and the fourth highest for girls aged 15–19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15–19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20–24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20–24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20–24 years. Alcohol and drug use in those aged 10–24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people's health risk factors and their determinants in health information systems. Bill & Melinda Gates Foundation.

The objective of this study was to compare the prevalence of musculoskeletal complaints and rheumatic disorders in Caucasians and Turks in an identical environment. Subjects were selected randomly for an interview from Tehran’s 22 districts. The Community Oriented Program for Control of Rheumatic Diseases questionnaire was filled in, positive cases were examined, and if needed, laboratory or X-ray tests were performed. A total of 4,096 houses were visited, and 10,291 persons were interviewed. They were 71.4% Caucasians and 23.1% Turks with similar distribution of age and gender. Musculoskeletal complaints of the past 7 days were detected in 40.8% of Caucasians and 45.5% of Turks ( p  < 0.001). In Caucasians, the total of musculoskeletal complaints in men was 33.8% (95% CI, 31.4–36.2%) versus 48.3% in women (95% CI, 45.7–50.8%). In Turks, the total of musculoskeletal complaints in men was 36.6% (95% CI, 32.2–41.1%) versus 55.8% in women (95% CI, 55.8–60.6%). The data of Caucasians versus Turks were as follows: knee pain 20.2% (95% CI, 18.2–22.1) versus 24.1% (95% CI, 20.5–27.6), with p  < 0.001; dorso-lumbar spine pain 15.1% (95% CI, 13.6–16.6) versus 18.4% (95% CI, 15.1–21.8), with p  < 0.001; shoulder pain 10.7% (95% CI, 9.4–11.9) versus 12.3% (95% CI, 9.7–14.8), with p  = 0.025; osteoarthritis 14.1% (95% CI, 12.8–15.2) versus 16.4% (95% CI, 14.3–18.6), p  = 0.04; and knee osteoarthritis 12.3% (95% CI, 11.8–14.1) versus 15.3% (95% CI, 13.3–17.4), with p  < 0.001). There were no significant differences regarding the prevalence of soft tissue rheumatism, rheumatoid arthritis, ankylosing spondylitis, Behcet’s disease, fibromyalgia, and gout. Although musculoskeletal complaints were more frequent in Turks than in Caucasians, the prevalence of rheumatic disorders was rather similar except for knee osteoarthritis.

First Nationwide Study of the Prevalence of the Metabolic Syndrome and Optimal Cutoff Points of Waist Circumference in the Middle East The National Survey of Risk Factors for Noncommunicable Diseases of Iran Alireza Delavari , MD 1 , Mohammad Hossein Forouzanfar , MD, MPH, PHD 1 , 2 , Siamak Alikhani , MD, MPH 3 , Afsaneh Sharifian , MD 4 and Roya Kelishadi , MD 5 1 Endocrine and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran; 2 Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran; 3 Ministry of Health and Medical Education, Tehran, Iran; 4 Kordestan Digestive Research Center, Kordestan University of Medical Sciences, Sanandaj, Iran; 5 Isfahan Cardiovascular Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. Corresponding author: Roya Kelishadi, kelishadi{at}med.mui.ac.ir . Abstract OBJECTIVE The purpose of this study was to provide the first national estimate on the prevalence of the metabolic syndrome and its components and the first ethnic-specific cutoff point for waist circumference in the Eastern Mediterranean Region. RESEARCH DESIGN AND METHODS This national survey was conducted in 2007 on 3,024 Iranians aged 25–64 years living in urban and rural areas of all 30 provinces in Iran. The metabolic syndrome was defined by different criteria, namely the definition of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), the International Diabetes Federation (IDF) criteria, and the modified definition of the NCEP/ATP III (ATP III/American Heart Association [AHA]/National Heart, Lung, and Blood Institute [NHLBI]). RESULTS The age-standardized prevalence of the metabolic syndrome was about 34.7% (95% CI 33.1–36.2) based on the ATP III criteria, 37.4% (35.9–39.0%) based on the IDF definition, and 41.6% (40.1–43.2%) based on the ATP III/AHA/NHLBI criteria. By all definitions, the prevalence of the metabolic syndrome was higher in women, in urban areas, and in the 55- to 64-year age-group compared with the prevalence in men, in rural areas, and in other age-groups, respectively. The metabolic syndrome was estimated to affect >11 million Iranians. The optimal cutoff point of waist circumference for predicting at least two other components of the metabolic syndrome as defined by the IDF was 89 cm for men and 91 cm for women. CONCLUSIONS The high prevalence of the metabolic syndrome with its considerable burden on the middle-aged population mandates the implementation of national policies for its prevention, notably by tackling obesity. The waist circumference cutoff points obtained can be used in the region. Footnotes The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Received October 1, 2008. Accepted March 4, 2009. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details. © 2009 by the American Diabetes Association.

The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010). We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010. Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases—especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis—increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place. Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world—although these disorders do still persist in LICs—whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed. Bill & Melinda Gates Foundation.

we aimed to recap and highlight the major results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 by mortality and morbidity to clarify the current health priorities and challenges in Iran. We estimated Iran's mortality and burden of 289 diseases with 67 risk factors and 1160 sequelae, which were used to clinically present each disease and its disability or cause of death. We produced several measures to report health loss and status: all-cause mortality, cause-specific mortality, years of life lost due to death (YLL), healthy years of life lost due to disability (YLD), disability-adjusted life years (DALYs), life expectancy, and healthy life expectancy, for three time periods: 1990, 2005, and 2010. We found out that life expectancy at birth was 71.6 years in men and 77.8 years in women. Almost 350 thousand deaths occurred in both sexes and all age groups in 2010. In both males and females and all age groups, ischemic heart disease was the main cause of death, claiming about 90 thousand lives. The main contributors to DALYs were: ischemic heart disease (9.1%), low back pain (9.0%), road injuries (7.3%), and unipolar depressive disorders (6.3%). The main causes of death under 5 years of age included: congenital anomalies (22.4%), preterm birth complications (18.3%), and other neonatal disorders (13.5%). The main causes of death among 15 - 49 year olds in both sexes included: injuries (23.6%) and ischemic heart disease (12.7%) The highest rates of YLDs were observed among 70+ year olds for both sexes (27,365 per 100,000), mainly due to low back pain, osteoarthritis, diabetes, falls, and major depressive disorder. The main risk factors to which deaths were attributable among children under 5 years included: suboptimal breast feeding, ambient PM pollution, tobacco smoking, and underweight. The most important risk factors among 15 to 49 year olds were: dietary risks, high blood pressure, high body mass index, physical inactivity, smoking, and ambient PM pollution. The pattern was similar among 50+ year olds. Although non-communicable diseases had the greatest burden in 2010, the challenge of communicable and maternal diseases for health system is not over yet. Diet and physiological risk factors appear to be the most important targets for public health policy in Iran. Moreover, Iranians would greatly benefit from effective strategies to prevent injury and musculoskeletal disorders and expand mental care. Persistent improvement is possible by strengthening the health information system to monitor the population health and evaluate current programs.