1. 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 11 2012 Presented by Goodarz Danaei

2. 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

3. 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

4. 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

5. Outline Background Data sources and methods Findings Conclusion and future directions

6. Outline Background Data sources and methods Findings Conclusion and future directions

7. Global epidemiological transition Lopez et al. Lancet 2006

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

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

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

11. 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

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

13. Outline Background Data sources and methods Findings Conclusion and future directions

14. 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

15. Non-communicable diseases surveillance survey 2005 Multistage systematic cluster sampling 89,400 adults aged 15-64 years –Questionnaire and physical measurements 50,200 adults aged 25-64 years –lab data including fasting blood sample

16. Analytical framework Relative risks Risk factor exposure Optimal exposure level

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

18. 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

19. 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

22. 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

23. 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) )

24. 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

25. 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

26. Selected regions for subnational analysis

27. Outline Background Data sources and methods Findings Conclusion and future directions

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

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

30. 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)

31. 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)

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

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

34. 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.

35. 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