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Aims: To evaluate the association between ideal cardiovascular health metrics (ICVHM) and incident low estimated glomerular filtration rate (eGFR) among the Iranian population., Methods: The study population included 6927 Iranian adults aged 20-65 years (2942 male) without prevalent low eGFR [i.e., eGFR < 60 ml/min/1.73 m2] and free of cardiovascular disease. The ICVHM was defined according to the 2010 American Heart Association. The multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratios (HRs) of ICVHM both as continuous and categorical variables., Results: Over the median of 12.1 years of follow-up, we found 1259 incident cases of low eGFR among the study population. In this population, ideal and intermediate categories of body mass index (BMI) and blood pressure (BP) and only the ideal category of fasting plasma glucose (FPG) significantly decreased the risk of developing low eGFR; the corresponding HRs and (95% confidence intervals) were (0.87, 0.77-0.99), (0.84, 0.76-0.99), (0.79, 0.68-0.93), (0.70, 0.60-0.83) and (0.76, 0.64-0.91). Also, one additional ICVHM was associated with a reduced risk of low eGFR for the global (0.92, 0.88-0.97) and biological cardiovascular health (0.88, 0.82-0.93) in these participants. A sensitivity analysis using the interval-censoring approach demonstrated that our method is robust, and results remained essentially unchanged. In a subgroup population with dietary data (n = 2285), we did not find the beneficial impact of having intermediate/ideal categories of nutrition status compared to its poor one on incident low eGFR., Conclusion: We found a strong inverse association between having higher global ICVHM with incident low eGFR among the non-elderly Iranian population; the issue is mainly attributable to normal BP, BMI, and FPG levels., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Alizadeh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To explore the association between sex-specific adiposity trajectories among Adolescents to early adulthood with incident high blood pressure (HBP) and high plasma glucose (HPG)., Methods: We studied body mass index (BMI) trajectories among1159 (male = 517) and 664 (male = 263) Iranian adolescents, aged 12-20 years, for incident HPG and HBP, respectively. Latent Class Growth Mixture Modeling (LCGMM) on longitudinal data was used to determine sex-specific and distinct BMI trajectories. Logistic regressions were applied to estimate the relationship between latent class membership with HBP and HPG, considering normal trajectory as the reference., Results: For both HBP and HPG, LCGMM determined two and three distinct BMI trajectories in males and females, respectively. During a follow-up of 12Years 104 (male = 62) and 111(male = 59) cases of HPG and HBP were found, respectively. Among females, faster BMI increases (i.e. overweight to early obese trajectory) but not overweight (i.e. those with BMI = 27.3 kg/m2 at baseline) trajectories increased the risk of HPG by adjusted odds ratios (ORs), 2.74 (1.10-5.80) and 0.79 (0.22-2.82), respectively; regarding HBP, the corresponding value for overweight to late obese trajectory was 3.72 (1.37-11.02). Among males, for HBP, the overweight trajectory increased the risk [2.09 (1.04-4.03)]; however, for incident HPG, none of the trajectories showed significant risk., Conclusions: Among females, trend of increasing BMI parallel with age can be a better predictor for risk of developing HPG and HBP than those with higher BMI at baseline., Competing Interests: The authors have declared that no competing interests exist.

Background: To investigate the associations of marital status with major clinical outcomes including type 2 diabetes (T2D), hypertension, cardiovascular disease (CVD) and all-cause mortality., Methods: The study cohort (1999-2014) included 9,737 (45% male) Iranian adults with a mean age of 47.6 years. Marital status was defined as married versus never married, divorced and widowed. The relationship between marital status and the four above mentioned outcomes were investigated using Cox regression models adjusted for the main confounders, specific to each outcome., Results: After more than 12 years of follow-up, 1,889 (883 men) individuals developed hypertension, 1,038 (468 men) T2D, 1015 (597 men) CVD and 668 (409 men) all-cause mortality. Compared with married, being never married in men was associated with higher risk of hypertension [hazard ratio (HR): 1.55; 95% confidence interval (CI), 1.11-2.16] and all-cause mortality (2.17; 0.95-5.00; p-value = 0.066) after adjusting for confounders. Among women, compared with married status, widowed status was associated with a lower risk of T2D (0.74; 0.56-0.97) in the confounders adjusted model. Moreover, never married women had a lower risk of hypertension (0.58; 0.37-0.90) compared to married ones in the age adjusted model, a finding that did not achieve significance, after further adjustment for confounders., Conclusion: We found that the relationship between marital status and health outcomes varied by gender. Being never married was an important risk factor for hypertension and tended to be a significant risk factor for mortality in men. However, among women, being widowed was associated with a lower risk of T2D., Competing Interests: The authors have declared that no competing interests exist.

Background: To examine the trend of cardiovascular diseases (CVD) risk factors among a Middle Eastern population with prevalent CVD during a median follow up of 12 years., Methods: Patients with prevalent CVD (n = 282, men = 167), with a mean age of 60.76 years were evaluated in four study phases of the TLGS (Tehran lipid glucose study), 2002-2005, 2005-2008, 2008-2011, and 2011-2014. Trends of CVD risk factors were estimated using generalized estimation equation (GEE) models, by adjusting for gender, age and propensity scores., Result: The adjusted prevalence of general and central adiposity, diabetes and physical inactivity at baseline was 25.18, 60.14, 25.03 and 43.74%, respectively and had increasing trends during the study period, reaching 41.32, 66.74, 43.20 and 50.32%, respectively, at the last visit. Although systolic, but not diastolic blood pressure, decreased from 134.88 to 129.86 mmHg, the prevalence of hypertension did not decrease (64.21% vs 68%, p value = 0.326). The prevalence of low high density lipoprotein cholesterol (HDL-C), hypertriglyceridemia and high non-HDL-C at baseline was 74.54, 59.89 and 96.53%, respectively, and showed improved trends reaching 44.87, 47.12 and 96.06% respectively; however, the favorable trend was not observed for high low density cholesterol. Significant increasing trends were observed in the consumption of anti-hypertensive, lipid and glucose lowering medications, but not for aspirin. The prevalence of current smoking (11.05 vs 16.83%, p value = 0.042) and chronic kidney disease (44.16 vs 51.65%, p value = 0.054) increased during follow up., Conclusion: Except for lipid profile status, dangerous trends for other CVD risk factors were demonstrated among CVD patients, which can be a harbinger for high rates of CVD mortality; these findings highlight the need for urgent implementation of multicomponent interventions to control CVD risk factors among these patients.

Background: To examine the association between potentially modifiable risk factors with cardiovascular disease (CVD) and all-cause mortality and to quantify their population attributable fractions (PAFs) among a sample of Tehran residents., Methods: Overall, 8108 participants (3686 men) aged≥30 years, were investigated. To examine the association between risk factors and outcomes, multivariate sex-adjusted Cox proportional hazard regression analysis were conducted, using age as time-scale in two models including general/central adiposity: 1)adjusted for different independent variables including smoking, education, family history of CVD and sex for both outcomes and additionally adjusted for prevalent CVD for all-cause mortality 2)further adjusted for obesity mediators (hypertension, diabetes, lipid profile and chronic kidney disease). Separate models were used including either general or central adiposity., Results: During median follow-up of >10 years, 827 first CVD events and 551 deaths occurred. Both being overweight (hazard ratio (HR), 95%CI: 1.41, 1.18-1.66, PAF 13.66) and obese (1.51, 1.24-1.84, PAF 9.79) played significant roles for incident CVD in the absence of obesity mediators. Predicting CVD, in the presence of general adiposity and its mediators, significant positive associations were found for hypercholesterolemia (1.59, 1.36-1.85, PAF 16.69), low HDL-C (1.21, 1.03-1.41, PAF 12.32), diabetes (1.86, 1.57-2.27, PAF 13.87), hypertension (1.79, 1.46-2.19, PAF 21.62) and current smoking (1.61, 1.34-1.94, PAF 7.57). Central adiposity remained a significant positive predictor, even after controlling for mediators (1.17, 1.01-1.35, PAF 7.55). For all-cause mortality, general/central obesity did not have any risk even in the absence of obesity mediators. Predictors including diabetes (2.56, 2.08-3.16, PAF 24.37), hypertension (1.43, 1.11-1.84, PAF 17.13), current smoking (1.75, 1.38-2.22, PAF 7.71), and low education level (1.59, 1.01-2.51, PAF 27.08) were associated with higher risk, however, hypertriglyceridemia (0.83, 0.68-1.01) and being overweight (0.71, 0.58-0.87) were associated with lower risk., Conclusions: Modifiable risk factors account for more than 70% risk for both CVD and mortality events., Competing Interests: The authors have declared that no competing interests exist.

Introduction: To examine the associations between smoking and cardiovascular disease (CVD) / coronary heart disease (CHD) and all-cause mortality events in men with and without type 2 diabetes (T2D) in a Middle Eastern cohort during a median follow-up of 12 years., Methods: The study population included 2230 subjects aged ≥ 40 years, free from CVD, comprised of 367 participants with diabetes (21.2% current smokers) and 1863 without (27.3% current smokers). Multivariate Hazard ratios (HR) and 95% confidence intervals (CI) were calculated for smoking (considering different definitions) for those with and without diabetes. Potential confounding factors including age, body mass index, estimated Glomerular Filtration Rate, hypertension, hypercholesterolemia and educational level were entered in the multivariate analysis., Results: In men with diabetes, the HR (95% CI) of comparing current and non-smokers was 1.25 (0.74-2.12) for incident CHD, 1.52 (0.96-2.40) for CVD and 2.10 (1.27-3.47) for mortality events; the corresponding values for men without diabetes were 1.65 (1.24-2.20), 1.70 (1.30-2.22) and 1.72 (1.14-2.58), respectively (all P values for interactions > 0.46). After pooling past smokers with current smokers, among diabetic individuals there was no significant risk for CVD [1.29 (0.89-1.86)] or mortality events [1.25 (0.81-1.92)]; however, among non-diabetic individuals the HRs of current/past smokers reached significant levels for CVD [1.53 (1.23-1.91)] but not for mortality outcomes (all P values for interactions > 0.51)., Conclusions: The strength of the associations between smoking habits and incident CVD/CHD and mortality events from all causes did not differ significantly among diabetic and non-diabetic participants. Therefore, a comprehensive community-based smoking prevention program is important, given the increasing trend of smoking among the Iranian population regardless of diabetes status.

Objective: Prehypertension is associated with cardiovascular disease (CVD). There is no study to examine the incidence and risk factors of prehypertension in a sex stratified setting. The aim of this study was to examine the effect modification of sex for different risk factors which predicts the progression from normotension to prehypertension in a Middle East population-based cohort, during a median follow-up of 9.2 years., Methods: A multivariate Cox analysis was performed among 1466 and 2131 Iranian men and women, respectively, who were free of prehypertension, hypertension, CVD and diabetes at baseline and free of incident hypertension without preceding prehypertension at follow-up. Incident prehypertension at follow-up was defined as systolic blood pressure (SBP) of 120-139 mmHg and/or diastolic blood pressure (DBP) of 80-89 mmHg., Results: Overall, 1440 new cases of prehypertension were identified resulting in an incidence rate of 593/10000 person-years; the corresponding values for women and men were 489/10000 and 764/10000person-years, respectively. There were significant interactions between gender with age, DBP, waist-to-hip-ratio (WHpR) and estimated glomerular filtration rate (eGFR) (all P-values <0.05) in multivariate analysis. Strong associations were found between age, body mass index (BMI) and SBP with incident prehypertension in both genders. However, the effect of DBP and WHpR was significant among women and 2-hour post challenge plasma glucose (2h-PCPG)was an independent risk factor for men. In the sex-adjusted analysis, glomerular hyperfiltration [Hazard ratio (HR) and 95%CI: 1.01 (1.00-1.01), P-value = 0.02], age, BMI, WHpR, SBP and DBP had higher risks while being female [HR (95%CI): 0.81(0.69-0.94), P-value = 0.01] had a lower risk for incident prehypertension., Conclusion: According to this study results, among Iranian population with high incidence of prehypertension, general adiposity and glomerular hyperfiltration in total, 2h-PCPG in men and central adiposity in women should be emphasized as risk factors for prehypertension.

Aims/hypothesis: To investigate secular trends in cardiovascular disease (CVD) risk factors during a decade of follow-up in a Middle Eastern cohort, and to compare observed trends between diabetic and non-diabetic populations., Methods: In a population of 6181 participants (2622 males and 3559 females), diabetes status and CVD risk factors were evaluated in 4 study phases from 1999-2011. 1045 subjects had type 2 diabetes mellitus at baseline and 5136 participants were diabetes-free. To examine the trends of CVD risk factors, generalized estimation equation models were constructed. The interaction between the diabetes status and each phase of the study was checked in a separate model., Results: During the follow-up period diabetic females significantly gained better control of their blood pressure, serum low density lipoprotein cholesterol and general and central obesity measures compared to non-diabetic counterparts, although 60% of them had high BP and 64% had high serum LDL-C levels till the end of the study. Diabetic males however, experienced significantly better control on their serum LDL-C and general and central obesity measures compared to their non-diabetic controls; but 24% of them were still smoker, 63% had high BP and 60% had high serum LDL-C levels at the end of the follow-up (all Ps interaction <0.05). Use of lipid-lowering and antihypertensive medications increased consistently in both diabetic and non-diabetic populations., Conclusions/interpretation: Although CVD risk factors have been controlled to some extent among diabetic population in Iran, still high numbers of people with diabetes have uncontrolled CVD risk factors that prompt more attention.

Background: Data on incidence of coronary heart disease (CHD) is scarce in the Middle East and little is known about the contribution of known risk factors in this area., Methods: The incidence of CHD and the effect of modifiable risk factors were explored in 2889 men and 3803 women aged 30-74 years in the population based cohort of the Tehran Lipid and Glucose Study, during 1999-2010. Average population attributable fraction (aPAF) was calculated for any risk factor using direct method based on regression model., Results: The crude incidence rate in men was about twice that in women (11.9 vs. 6.5 per 1000 person-years). The aPAF of hypertension, diabetes, high total cholesterol and low-HDL cholesterol was 9.4%, 6.7%, 7.3% and 6.1% in men and 17%, 16.6%, 12% and 4.6% in women respectively. This index was 7.0% for smoking in men. High risk age contributed to 42% and 22% of risk in men and women respectively., Conclusions: The incidence in this population of Iran was comparable to those in the US in the seventies. Well known modifiable risk factors explained about 40% and 50% of CHD burden in men and women respectively. Aging, as a reflection of unmeasured or unknown risk factors, bears the most burden of CHD, especially in men; indicating more age-related health care is required.

Objective: To investigate the population-based incidence of type 2 diabetes and its potential risk factors in a sex-split cohort of Iranian population., Materials and Methods: A total of 8400 non-diabetic participants, aged ≥20 years (3620 men and 4780 women) entered the study. Crude and age standardized incidence rates per 1000 person-years were calculated for whole population and each sex separately. Cox proportional hazard models were used to evaluate hazard ratios (HR) and 95% confidence intervals for all potential risk factors in both uni-variable and multivariable models., Results: During a median follow-up of 9.5 years, 736 new cases of diabetes were identified, including 433 women and 303 men. The annual crude and age-standardized incidence rates (95% CI) of diabetes in the total population were 10.6 (9.92-11.4) and 9.94 (7.39-13.6) per 1000 person-years of follow-up and the corresponding sex specific rates were 10.2 (9.13-11.4) and 9.36 (5.84-14.92) in men and 11.0 (9.99-12.0) and 10.1 (7.24-13.9) in women, respectively. In the multivariable model, the risk for incident diabetes was significantly associated with fasting and 2 hour post challenge plasma glucose as well as family history of diabetes in both men and women. However, among women, only the contribution of wrist circumference to incident diabetes achieved statistical significance [HR: 1.16 (1.03-1.31)] with waist/height ratio being marginally significant [HR: 1.02 (0.99-1.04)]; while among men, only body mass index was a significant predictor [HR: 1.12 (1.02-1.22)]. Additionally, low education level conferred a higher risk for incident diabetes only among men [HR: 1.80 (1.23-2.36); P for interaction with sex = 0.003]., Conclusion: Overall, sex did not significantly modify the impact of risk factors associated with diabetes among Iranian adults; however, among modifiable risk factors, the independent role of lower education and general adiposity in men and central adiposity in women might require different preventive strategies.

To determine, the predictors of incident metabolic syndrome (MetS) in a community-based cohort of West Asians, during a mean follow-up of 9.3 years, a sample of 2858 non-MetS Iranian adults aged ≥ 20 years were examined at baseline and followed at three year intervals during three consecutive phases. The MetS was defined using the joint interim statement. Cox proportional hazard regression was used to determine the independent variables associated with incident MetS. Overall, 1117 new cases MetS were identified resulting in an incidence rate of 550.9/10000 person years (95% CI: 519.5-584.2). The corresponding incidence rates among women and men were 433.5/10000 person years (95% CI: 398.8-471.2) and 749.2/10000 person years (95% CI: 689.9-813.5), respectively. Baseline-adjusted predictors of developing MetS included all of the MetS components, being overweight or obese in both gender, and family history of diabetes and age only in women. There were significant effect modifications of gender on age (P<0.001), high blood pressure (0.026), high waist circumference (P<0001) and obesity categories (all P ≤ 0.01) in multivariate analysis. After considering HOMA-IR in the model, among women, all of the MetS predictors as well as those with HOMA-IR ≥ 2.23 showed a significant risk for incident MetS [HR: 1.63 (1.16-2.28)]; however, among men all the MetS components (WC was marginally significant) as well as the fourth quartile of HOMA-IR [HR: 1.50 (1.03-2.17)] and being overweight showed a significant risk. Finally, in the pooled analysis, we showed that female gender had lower risk for incident MetS than male [HR: 0.58 (0.47-0.70)]. In the Iranian population, high incidence of MetS, especially among men, was shown. Our findings confirmed that sex- specific risk predictors should be considered in primary prevention for incident MetS.

Objective: The aim of this study was to evaluate the validity of cause of death stated in death certificates in Tehran using outcome measures of the Tehran Lipid and Glucose Study (TLGS), an ongoing prospective cohort study., Methods: The cohort was established in 1999 in a population of 15005 people, 3 years old and over, living in Tehran; 3551 individuals were added to this population three years later. As part of cohort's outcome measures, deaths occurring in the cohort are investigated by a panel of medical specialists (Cohort Outcome Panel--COP) and underlying cause of death is determined for each death. The cause of death assigned in a deceased's original death certificate was evaluated against the cause of death determined by COP and sensitivity and positive predictive values (PPV) were determined. In addition, determinants of assigning accurate underlying cause of death were determined using logistic regression model., Result: A total of 231 death certificates were evaluated. The original death certificates over reported deaths due to neoplasms and underreported death due to circulatory system and transport accidents. Neoplasms with sensitivity of 0.91 and PPV of 0.71 were the most valid category. The disease of circulatory system showed moderate degree of validity with sensitivity of 0.67 and PPV of 0.78. The result of logistic regression indicated if the death certificate is issued by a general practitioner, there is 2.3 (95% CI 1.1, 5.1) times chance of being misclassified compared with when it is issued by a specialist. If the deceased is more than 60 years, the chance of misclassification would be 2.5 times (95% CI of 1.1, 5.9) compared with when the deceased is less than 60 years.

To examine, the predictors of incident chronic kidney disease (CKD) in a community-based cohort of Middle East population, during a mean follow-up of 9.9 years. In a sample of 3313 non-CKD Iranian adults ≥20 years the estimated glomerular filtration rate (eGFR) was calculated at baseline and at three year intervals during three consecutive phases. The eGFR <60 mL/min/1.73 m2 was defined as CKD. Multivariate Logistic regression analysis was used to determine the independent variables associated with incident CKD. The incidence density rates of CKD were 285.3 and 132.6 per 10,000 person-year, among women and men, respectively. Female gender per se was associated with higher risk of CKD, compared with males. Among women, age, eGFR, known diabetes, being single or divorced/widowed, hypertension (marginally significant) and current smoking were independent risk factors for CKD; however the intermediate degree of education and family history of diabetes decreased the risk by 40% (P<0.05). Among male subjects, independent predictors of developing CKD included aging and hypertension (with significantly higher risk than in women, P for interaction<0.05), eGFR, new diagnosed diabetes, high normal blood pressure; abdominal obesity decreased the risk of CKD about 30% which was marginally significant. In the Iranian population,>2% of individuals develops CKD each year. Our findings confirmed that sex- specific risk predictors should be considered in primary prevention for incident CKD.