National and subnational mortality effects of major metabolic risk factors and smoking in Iran: a comparative risk assessment Scientific Webinars Farzadfar et al PHM 2011 May Presented by Goodarz Danaei

What is the most common cause of death and disabilities in Iran in men? a.Ischemic heart disease b.Stroke c.Lung cancer d.Road traffic injuries

What is the most common cause of death and disabilities in Iran in women? a.Ischemic heart disease b.Stroke c.Lung cancer d.Road traffic injuries

What is the most important NCD risk factor for mortality in Iran? a.Overweight/obesity b.High blood pressure c.Smoking d.High serum cholesterol e.Diabetes and high blood glucose

Outline Background Data sources and methods Findings Conclusion and future directions

Outline Background Data sources and methods Findings Conclusion and future directions

Global epidemiological transition Lopez et al. Lancet 2006

Cardiovascular mortality in high-income countries Vital registration data from WHO MaleFemale

Regional trends in blood pressure North America Male Female Danaei et al. Lancet 2011

Regional trends in blood pressure North America Male Female North Africa and Middle East Danaei et al. Lancet 2011 North Africa and Middle East

Male Female Trends in CVD risk factors in Iran TCBMISBP Farzadfar et al. Lancet 2011, Finucane et al. Lancet 2011, Danaei et al. Lancet 2011

Selected risk factors Systolic blood pressure (SBP) Body mass index (BMI) Fasting plasma glucose (FPG) Total cholesterol (TC) Smoking

Outline Background Data sources and methods Findings Conclusion and future directions

Data sources Risk factor exposure: Non-communicable diseases surveillance survey (2005) Relative risks: Danaei et al 2009 Law 2003 Prospective Studies Collaboration 2007 Mortality: Death registration system (2005) Tehran cemetery

Non-communicable diseases surveillance survey 2005 Multistage systematic cluster sampling 89,400 adults aged years –Questionnaire and physical measurements 50,200 adults aged years –lab data including fasting blood sample

Analytical framework Relative risks Risk factor exposure Optimal exposure level

Population attributable fraction Analytical framework Relative risks Risk factor exposure Optimal exposure level

Population attributable fraction Analytical framework Relative risks Risk factor exposure Optimal exposure level Disease-specific attributable deaths Disease-specific deaths Correction for incompleteness Redistribution of deaths with unspecified cause

Analytical challenges Risk factor exposure: No exposure data in older age groups Disease-specific deaths: Incompleteness of death registration system Redistribution of deaths with unspecified cause Uncertainty in estimates: Sampling uncertainty Etiological effects uncertainty Uncertainty in the model for missing older age groups Completeness estimation uncertainty Uncertainty in proportional redistribution of deaths with unspecified cause

Analytical challenges Risk factor exposure: No exposure data in older age groups Insufficient data on smoking history Disease-specific deaths: Incompleteness of death registration system Redistribution of deaths with unspecified cause Uncertainty in estimates: Sampling uncertainty Etiological effects uncertainty Uncertainty in the model for missing older age groups Completeness estimation uncertainty Uncertainty in proportional redistribution of deaths with unspecified cause

Smoking Impact Ratio The accumulated hazards of smoking depend: the age at which smoking began number of cigarettes smoked per day and cigarette type These data are extremely rare. Estimation of Disease Burden CLC= Age-sex specific lung cancer mortality rate in a population NLC= Age-sex specific lung cancer mortality rate of never-smokers in the same population S*LC and N*LC = Age-sex specific lung cancer mortality rates for smokers and never-smokers in a reference population (Cancer Prevention Study II (CPS- II) )

Analytical challenges Risk factor exposure: No exposure data in older age groups Insufficient data for smoking history Disease-specific deaths: Incompleteness of death registration system Redistribution of deaths with unspecified cause Uncertainty in estimates: Sampling uncertainty Etiological effects uncertainty Uncertainty in the model for missing older age groups Completeness estimation uncertainty Uncertainty in proportional redistribution of deaths with unspecified cause

Analytical challenges Risk factor exposure: No exposure data in older age groups Insufficient data for smoking history Disease-specific deaths: Incompleteness of death registration system Redistribution of deaths with unspecified cause Uncertainty in estimates: Sampling uncertainty Etiological effects uncertainty Uncertainty in the model for missing older age groups Completeness estimation uncertainty Uncertainty in proportional redistribution of deaths with unspecified cause

Selected regions for subnational analysis

Outline Background Data sources and methods Findings Conclusion and future directions

Exposure to selected risk factors in 2005, by region and sex SBP (mmHg) SoutheastNorth-NortheastWestCentralNational

Exposure to selected risk factors in 2005, by region and sex SBP (mmHg) SoutheastNorth-NortheastWestCentralNational SoutheastNorth-NortheastWestCentralNational FPG (mmol/L)

Exposure to selected risk factors in 2005, by region and sex SBP (mmHg) SoutheastNorth-NortheastWestCentralNational BMI (Kg/m^2) SoutheastNorth-NortheastWestCentralNational SoutheastNorth-NortheastWestCentralNational FPG (mmol/L)

Number of deaths attributable to each risk factor in 2005, by sex (in thousands) Risk factorMaleFemale Smoking9 (8.6, 9.4)2 (1.9, 2.1) BMI13 (11, 15)17 (14, 20) TC18 (16, 20)16 (14, 18) FPG17 (14, 20) SBP41 (38, 44)39 (36, 42)

Risk-deleted life expectancy in 2005, by risk factor and region

Risk-deleted life expectancy in 2005, by risk factor and region

Conclusions Few metabolic risk factors account for a substantial loss of life from non-communicable diseases in Iran Non-optimal blood pressure was the most important risk factor and accounted for almost 1 in 6 deaths in adults The selected risk factors did not account for much of the variation in longevity across gender or region.

Future directions Conducting a comprehensive burden of disease study including estimation of role of a wider set of risk factors Evaluating the determinants of exposure to risk factors Designing interventions to reduce exposure to risk factors Conducting experimental studies to evaluate the effectiveness of interventions Implementing interventions and monitoring and evaluation