Five-year Evaluation of Chronic Diseases in Hamadan, Iran: 2005–2009

Introduction

Today the increasing growth of noncommunicable diseases (NCDs) is a serious threat to health and hence is the major health challenges worldwide (1). In all but the poorest countries, the mortality and morbidity from noncommunicable diseases now exceeds that from communicable diseases comprising 49%, in comparison with about 40% respectively (2). The major NCDs, mainly cardiovascular diseases, cancers, diabetes and chronic respiratory diseases caused an estimated 35 million deaths in 2005. This figure represents 60% of all world deaths and 80% of deaths due to NCDs occurring in low and middle income countries (1). The rapidly increasing burden of these diseases affects all countries but with an increasing trend in developing countries particularly in poorer regions of the world. This trend contributes to widening health gaps between and within countries (1,3). Although NCDs are among the most prevalent and costly health problems, they are also among the most preventable and modifiable common risk factors such as tobacco use, unhealthy diet, physical inactivity and alcohol abuse. These risk factors explain the vast majority of death due to NCDs at all ages worldwide including 4.9 million deaths as a result of tobacco use; 2.6 million deaths as a result of being overweight or obese; 4.4 million deaths as a result of hypercholesterolemia; and 7.1 million deaths as a result of hypertension (1, 4). On the other hand, up to 80% of heart diseases and strokes; 80% of type 2 diabetes; and 40% of cancers could be eliminated through preventing these major risk factors (1,5).

World Health Organization (WHO) suggested a tool for assessing the NCDs risk factors in low and middle income countries - the STEPwise approach to Surveillance (STEPS) (4). This tool was used in Iran as in many other countries worldwide to establish a survey on major NCDs risk factors. The present study which is part of this national survey was carried out in Hamadan Province, the west of Iran, in 2005 and continued to 2009 in order to determine the major risk factors of non-communicable diseases and to measure their impact on the chronic diseases.

Materials and Methods

Results

A total of 6500 subjects, including 3250 males and 3250 females, were enrolled voluntarily in this five-year survey. The participants aged between 15 to 64 years with mean age of 45.4 years. The overall response rate for step 1 (questionnaire-based information) and step 2 (physical measurements) was 81% but the response rate for step 3 (biochemical measurements) was 73%.

The results of descriptive analysis were summarized in Table 1, 2, and 3. The analytic results were shown in Table 4 and 5. Table 1 summarizes the results of the questionnaire-based information related to behavioral risks of the participants. Table 2 summarizes results of the standardized physical measurements of the participants. Table 3 summarizes the results of the biochemical measurements of the participants. Table 4 indicates the effect of age and gender on BMI, SBP, DBP, FBS, TC, TG, and HDL levels. Table 5 reveals the effect of BMI on SBP, DBP, FBS, TC, TG, and HDL levels.

Discussion

The present study represents the first comprehensive provincial-based estimates of NCDs risk factors in Iran including both descriptive and analytic findings resulted from a five-year sequential survey in Hamadan province, the west of Iran, from 2005 to 2009. Although the results of Iranian first national survey for major risk factors of NCDs in 2005 was published previously (7).

Cigarette smoking is among the most preventable and modifiable common risk factors that explains the vast majority of death due to NCDs particularly chronic obstructive pulmonary diseases (COPD) and lung cancer (1). The total prevalence of tobacco use in target population was estimated 18% (35.1% in men) with 15 cigarettes per day on average. On the other hand, 40.6% and 41.4% of the smokers experienced smoking in the second and third decades of life respectively. These evidences revealed the fact that male adolescents and youths represent the priority target group for health education and prevention programs. This finding is similar to the results of national survey in 2005 (7) as well as the results of Iraqi STEPS survey in 2006 (8) with the same method and target population which reported the prevalence of tobacco use 17.9% and 21.6% respectively.

Fruit and vegetables are essential components of a healthy diet that can help prevent major chronic diseases such as cardiovascular diseases (9) and certain cancers principally of the gastrointestinal system (10). At least 400 g per day of total fresh fruit and vegetables is recommended to reduce the risk of cardiovascular diseases, stroke and hypertension (11). On the other hand, low intake of fruit and vegetables as part of daily diet is responsible for almost three million deaths a year from these diseases (12). Based on presenting findings, nearly 26.3% of the citizens aged 15 to 64 years eat five or more servings of fruits and vegetables per day. This reveals the fact that average intake of fruits and vegetables is very low in vast majority (73.7%) of the population. Nonetheless, this finding is different from what reported by the national survey in 2005 which reported the rate of this behavior about 5% (7) for Iranian citizens. A survey which was conducted in 2002 in USA reported similar results and indicated that 75.5% of the adults eat fewer than five servings of fruits and vegetables per day (13). Another survey which was conducted in Iraq indicated that 91.4% of the Iraqi people eat low fruit and vegetables (8).

Reduced physical activity is likely to be one of the major well-known leading causes of overweight and obesity (11). Although the exact estimation of the daily physical activity is not straight forward, our findings indicated that transportation related physical activity comprises the major physical activity of the both men and women compared to work or leisure time related physical activity. This finding is similar to the result of national survey in 2005 (7). Nonetheless, men spent much more than women on work and leisure time physical activity. Accordingly, women are at higher risk of overweight and obesity. This finding is unlike the results of national survey (7) that reported women spent more time on leisure time related physical activity. On the other hand, the results of the present study indicated that leisure time related physical activity decreased with age in both sexes whereas regular physical activity particularly in adults and older people can reduce the risk of NCDs for mortality and morbidity.

Our findings indicated that almost 47.2% of the target population was either overweight or obese. The national survey in 2005 (7) reported a similar result and estimated that 54.7% of the Iranian population were overweight or obese. In addition, based on the present study, women are 1.8 more likely than men to be overweight or obese [95% CI 1.66 to 2.04]. We know that overweight and obesity are the results of unhealthy diet coupled with lack of physical activity. Furthermore, overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglyceride, and insulin resistance (12). Accordingly, it is expected the prevalence of hypertension, diabetes, and hyperlipidemia to be more common among women than among men. The analytic results of this study indicated this fact clearly. There was a significant association between female gender and obesity on one hand, and between female gender and hypertension, diabetes, and hyperlipidemia on the other hand. Thus women represent the target group for weight control programs and should be the focus of the policymakers’ special attention.

This study had several limitations. First, this was an observational study, hence could be prone to selection or information biases. However, we attempted as much as we could to take a balance sample of age-sex groups of the target population. Second, because data were collected through a sequential cross-sectional survey, incidence-prevalence bias might result from using prevalence odds ratio to estimate the association between variables under study. Third, the potential bias might have occurred in the results by those who refused to participate in the study as well as those who might have responded incorrectly or imprecisely to the questionnaire. Fourth, because data were collected cross-sectionally, we cannot determine the temporality of cause and effect among some variables such as obesity and hyperlipidemia and/or hypertriglyceridemia. Fifth, biochemical measurements were not undertaken for all years due to financial and logistic limitations.

Despite its limitations, the current study may have a number of implications for health care policy. First, the prevalence of several NCDs risk factors was evaluated in the target population for five sequential years. Second, the effect of age and gender on chronic diseases risk factors was indicated clearly. Furthermore, the association of BMI with blood pressure, blood sugar, cholesterol, and triglyceride was measured quantitatively as well. Therefore, we hope the results of present study help policymakers who plan preventive program to reduce incidence of NCDs predisposing factors.

The same survey with the same method and target population was conducted simultaneously in all provinces of Iran in 2005. Most of the results of present survey were confirmed by the results of the national survey. Accordingly, it is expected this survey can represent the profile of the NCDs risk factors in Iran in the last five years and its results may be generalized to the vast majority of Iranian population.

In conclusion, the results of this five-year survey indicated that the prevalence of cigarette smoking was very high particularly in men, fruits and vegetables consumption was very low, and work and leisure time related physical inactivity was high among the target population particularly in women. Almost most of the target population exposed to at least two or more risk factors. These evidences along with high prevalence of overweight and obesity, hyperglycemia, and hyperlipidemia particularly in the women promise a silent progressive epidemic of chronic diseases among Iranian citizens that may lead to an increasing growth of NCDs in the next decade.

Ethical Considerations

Ethical issues (Including plagiarism, Informed Consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc) have been completely observed by the authors.