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Prevalence of Metabolic Syndrome and Its Components in the Iranian Adult Population: A Systematic Review and Meta-Analysis

AUTHORS

Bahareh Amirkalali 1 , Hossein Fakhrzadeh 2 , * , Farshad Sharifi 2 , Roya Kelishadi 3 , Farhad Zamani 1 , Hamid Asayesh 4 , Saeid Safiri 5 , Tahereh Samavat 2 , Mostafa Qorbani 6 , 7 , 8 , *

1 Gastrointestinal and Liver disease research Center (GILDRC), Iran University of Medical Sciences, Tehran, IR Iran

2 Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran

3 Child Growths and Development Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran

4 Department of Medical Emergencies, Qom University of Medical Sciences, Qom, IR Iran

5 Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, IR Iran

6 Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, IR Iran

7 Non-communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran

8 Department of Epidemiology, Iran University of Medical Sciences, Tehran, IR Iran

Corresponding Authors:

How to Cite: Amirkalali B, Fakhrzadeh H, Sharifi F, Kelishadi R, Zamani F, et al. Prevalence of Metabolic Syndrome and Its Components in the Iranian Adult Population: A Systematic Review and Meta-Analysis, Iran Red Crescent Med J. 2015 ; 17(12):e24723. doi: 10.5812/ircmj.24723.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 17 (12); e24723
Published Online: December 27, 2015
Article Type: Review Article
Received: October 20, 2014
Revised: April 30, 2015
Accepted: June 15, 2015
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Abstract

Context: Metabolic syndrome (MetS) increases the risk of most non-communicable diseases; gathering information about its prevalence can be very effective in formulating preventive strategies for metabolic diseases. There are many different studies about the prevalence of MetS in Iran, but the results and the study populations of these studies are very different; therefore, it is very important to have an overall estimation of its prevalence in Iran.

Objectives: This study systematically reviewed the findings of all available studies on MetS in the adult Iranian population and estimated the overall prevalence of MetS in this population.

Data Sources: International databases (Scopus, ISI Web of Science, and PubMed) were searched for papers published from January, 2000 to December, 2013 using medical subject headings (MeSH), Emtree, and related keywords (metabolic syndrome, dysmetabolic syndrome, cardiovascular syndrome, and insulin resistance syndrome) combined with the words “prevalence” and “Iran.” The Farsi equivalent of these terms and all probable combinations were used to search Persian national databases (IranMedex, Magiran, SID, and Irandoc).

Study Selection: All population-based studies and national surveys that reported the prevalence of MetS in healthy Iranian adults were included.

Data Extraction: After quality assessment, data were extracted according to a standard protocol. Because of between-study heterogeneity, data were analyzed by the random effect method.

Results: We recruited the data of 27 local studies and one national study. The overall estimation of MetS prevalence was 36.9% (95% CI: 32.7 - 41.2%) based on the Adult Treatment Panel III (ATP III) criteria, 34.6% (95% CI: 31.7 - 37.6%) according to the International Diabetes Federation (IDF), and 41.5% (95% CI: 29.8 - 53.2%) based on the Joint Interim Societies (JIS) criteria. The prevalence of MetS determined by JIS was significantly higher than those determined by ATP III and IDF. The prevalence of MetS was 15.4% lower in men than in women (27.7% versus 43.1%) based on the ATP III criteria, and it was 11.3% lower in men based on the IDF criteria; however according to the JIS criteria, it was 8.4% more prevalent in men.

Conclusions: There is a high prevalence of MetS in the Iranian adult population, with large variations based on different measurement criteria. Therefore, prevention and control of MetS should be considered a priority.

Keywords

Metabolic Syndrome Prevalence Meta-Analysis Iran

Copyright © 2015, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Context

Metabolic syndrome (MetS) (1) is a collection of interrelated disorders, namely obesity, dyslipidemia, hyperglycemia, and hypertension. Each MetS component increases the risk of cardiovascular disease (CVD), diabetes, and all-cause mortality. According to a study conducted by Gami et al., the synergistic effects of these disorders increase the risk of further disease and mortality much more than the sum of the risk increases from each component (2). However, other studies have provided different results (3-5). MetS increases total mortality from cardiovascular disease by 1.5 fold and risk for cardiovascular death by 2.5 fold (6). Moreover, individuals with MetS are five times more likely to develop type 2 diabetes (7). The main causes of MetS remain to be determined. However, it seems that abdominal obesity and insulin resistance are the key components (6-8). The most commonly used definitions for MetS are those provided by the world health organization (WHO), the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III), the international diabetes federation (IDF), and the joint interim societies (JIS), as presented in following sections.

MetS is a common disorder, and given that its predisposing factors including obesity, sedentary lifestyle, and exposure to some environmental factors are escalating in many countries, the incidence of MetS is increasing as well (9). Therefore, MetS is now an emerging health problem at the public and individual levels. Because programs for primary prevention of non-communicable diseases emphasize appropriate evaluation and management of risk factors, (10) gathering reliable information about the prevalence of MetS in various populations can be very effective in the planning and use of preventive strategies for such diseases.

The prevalence of MetS is not only influenced by excess weight but also by ethnic predisposition, gender, age, race, cultural and lifestyle habits, and environmental factors; thus, its prevalence has large variations in different societies (11, 12). Grundy reported that between 20% and 30% of the adult population in most countries have MetS (13). Asians have an ethnic predisposition to MetS (14, 15), and it is of special concern for Middle Eastern populations, which are predicted to experience the greatest global burden of diabetes by 2020 (14). As a country in this region, Iran is reported to have one of the highest prevalence rates of MetS worldwide (16). The nationwide prevalence of MetS is reported to be 35.6% based on ATP III criteria (14). In metropolitan Tehran, 42% of women and 24% of men have MetS, with a total age-standardized prevalence of 33.7% (16). Iran is a vast country with about 70 million people and different ethnicities including Turkish, Kurdish, Arab, Fars, Turkmen, and Baluch living in different regions of the country. The difference in their cultures, socioeconomic status, lifestyle habits, and environmental factors may cause variation in the prevalence of MetS (17-23), so it is very important to have an overall estimation of its prevalence in Iran.

2. Objectives

This study aimed to systematically review the findings of available studies and to combine them to estimate the overall prevalence of MetS in Iran. The other objective of this study was to explore potential sources of heterogeneity in the study findings.

3. Data Sources

The English-language medical literature was searched from January, 2000 to December, 2013 in Scopus, ISI Web of Science, and PubMed. Using medical subject headings (MeSH), Emtree, and related keywords, we searched for “metabolic syndrome,” “dysmetabolic syndrome,” “cardiovascular syndrome,” and “insulin resistance syndrome” combined with “prevalence” and “Iran,” including all subheadings. The Farsi equivalent of these terms and all probable combinations were used to search in Persian databases (i.e., IranMedex, Magiran, SID, and Irandoc). Moreover, the references of selected citations and non-published national surveys were hand-searched. In addition, when articles had incomplete data, at least three e-mails were sent to corresponding authors.

4. Study Selection

All types of studies, including local and national surveys that reported the prevalence of MetS and were conducted in Iran were reviewed. However, the final review was limited to studies with random sampling on healthy adults and/or on the general population who were aged 18 years and over. The studies that were conducted on subjects with known health disorders were excluded. In the case of multiple publications from the same population, only the largest study was included. The STROBE (strengthening the reporting of observational studies in epidemiology) statement was used for quality control of the studies (24). The quality of studies was assessed according to variables related to the study objectives, characteristics of the study population, clearly explained inclusion/exclusion criteria, data collection method, as well as the validity, explicit findings, and appropriate data analysis methods of the studies. Non-qualified studies were excluded. Moreover, duplicated citations were not included.

5. Data Extraction

After determining the qualified papers, data were extracted according to a standard protocol. To improve accuracy and critical appraisal, data extraction was conducted by two independent researchers, and disputes between researchers were resolved by consensus. The following items were extracted from the studies:

General information: first author’s name, study location, study date, publication date, definition used for MetS

Population characteristics: sex groups, mean age, and age range

Methodological information: sampling method, sample size, scope of study (urban, rural, or survey)

Study outcomes: reported prevalence of MetS extracted by sex (men, women, and total), and its 95% confidence interval (CI) concerning the prevalence of MetS components.

5.1. Statistical Analysis

Prevalences are reported with 95% confidence intervals (CI). A Chi-square-based Q test was used to analyze the heterogeneity of reported prevalences and was regarded to be statistically significant at P < 0.1. Tau-square (τ2) was estimated (using the restricted likelihood method) as the indicator of heterogeneity. After using the heterogeneity test, we found significant variations between study findings; thus, in order to obtain better results, the random effect model was used to estimate the overall prevalence of MetS in Iran. The findings are described in forest plots (the point estimations and their 95% CI). In the next step, meta-regression was used to check the effects of age and publication date as possible sources of heterogeneity among the study findings. The analyses were conducted with STATA software, version 11.0.

6. Results

In our primary search, and after removing duplicates, we found 379 relevant articles. After excluding non-eligible studies, we recruited the data of 27 local studies and one national study, which included all provinces of Iran. The details of our study selection method are shown in Figure 1. In each selected study, the prevalence of MetS was reported according to different criteria. Among the 28 studies, we found 21 reports given according to ATP III (including 12 based on ATP III (25) and nine based on modified ATP III (26)), six reports according to IDF (7), and one report according to the Iranian modified IDF (27), one report according to the WHO criteria, (28) and five reports according to the JIS criteria (29).

Flow Diagram of the Study Selection Process
Figure 1. Flow Diagram of the Study Selection Process

The findings of this systematic review are summarized in Table 1. For data analysis, we merged the ATP III and modified ATP III reports. The reports of IDF and Iranian modified IDF (27) were also merged; the meta-analysis was performed on three groups of reports: ATP III, IDF, and JIS. The only study that had used the WHO criteria for MetS was excluded from the analysis. If an article reported the prevalence of MetS according to both ATP III and modified ATP III, both were used as separate reports in the analysis.

Table 1. The Prevalence (95% CI) of Metabolic Syndrome in Iranian Adults in Population-Based Studies
ReferenceLocation and Study TypeStudy PopulationSampling MethodStudy DatePublication DateAge Range, YMean Age (Mean ± SD)GenderUrban/RuralSample SizeCriteriaConsiderationsPrevalence of MetS (95% CI)
Faam et al. (30)Tehran (TLGS, phase 3), local studyHealthy adultsRandom sampling2005 - 2008201320 - 70T: 40.7 ± 13.9BothUT: 4,665; M: 1,976; F: 2,689JISParticipants who had diabetes mellitus (n = 390) or body mass index (BMI) less than 18 kg/m (n = 152) were exclude.Waist circumference cut-off points were not mentionedT: 31.5 (30.1 - 32.8)
Ziaee et al. (31)Mindoodar district of Qazvin, local study Healthy adultsMultistage random cluster sampling2010 - 2011201320 - 78T: 40.08 ± 10.33; M: 42.31 ± 10.56; F: 38.02 ± 9.69BothRT: 1,107; M: 529; F: 578JISWaist circumference cut-off points were ≥ 94 cm in men or ≥ 80 cm in womenT: 39.3 (36.4 - 42.2)
Movahed et al. (32)Bushehr Port, (Iranian Multicentral Osteoporosis Study), local studyPostmenopausal womenRandomcluster sampling2006201250 - 83F: 58.78 ± 7.8FUT: 382ATP IIIT: 68.32 (63.3 - 72.9)
Yousefzadeh et al. (33)Kerman,local study Healthy adultsRandom sampling201215 - 75T: 46.52 ± 14.76BothUT: 200; M: 81; F: 119Modified ATP IIIT: 60 (52.8 - 66.8)
Azimi-Nezhad et al. (34)Greater Khorasan province, (National Survey on Non-communicable Disease), local studyHealthy adultsMultistage random sampling2003201235 - 55BothT: 1,194; M: 58; F: 605Modified ATP IIIT: 42.66 (39.8 - 45.4); M: 30.1 (26.3 - 33.9); F: 55.0 (50.9 - 59.0)
Hadaegh et al. (35)Tehran (TLGS, phase 1), local studySubjects free of CVDRandom sampling1999 - 2001201240 ≤T:54 ± 9.8; M: 55.3 ± 10.5; F: 53.0 ± 9.3BothUT: 4,248; M:1,856 F:2,392JISWaist circumference cut-off point was ≥ 94.5 cm for both Iranian men and womenT: 51.6 (50 - 53.1); M: 45.7 (43.4 - 47.9); F: 56.2 (54.1 - 58.1)
Talaei et al. (36)Isfahan, Arak and Najafabad, local studyHealthy adultsMultistage random sampling20012012≥ 35T: 50.7 ± 11.6; M: 51.1 ± 11.9; F: 50.3 ± 11.3BothBothT: 6,323; M: 3,068; F: 3,255Modified ATP IIIT: 37.1 (35.9 - 38.3); M: 21.5 (20.0 - 23.0); F: 51.7 (49.9 - 53.4)
Zarkesh et al. (37)Tehran, (TLGS, phase III), local studyHealthy adultsRandom sampling2006 - 20082012≥ 19T: 46.1 ± 16.1BothUT: 365; M: 134; F: 231JISWaist circumference cut-off point was > 89 cm in men and > 91 cm in womenT: 43.8 (38.6 -49)
Ghorbani et al. (38)Semnan, local studyHealthy adultsMultistage random sampling1384201230 - 70T: 45.7 ± 10.06; M: 46.6 ± 10.4; F: 45.1 ± 9.8BothBothT: 3,799; M: 1,695; F: 2,104Modified ATP III; IDFT: 28.5 (27.1 - 29.9); M: 17 (15.2 - 18.8); F: 37.8 (35.7 - 39.8). T: 35.8 (34.3-37.3); M: 25.4 (23.3-27.5); F: 44.1 (41.9-46.2)
Rezaianzadeh et al. (39)Yazd (phase I of Yazd Healthy Heart Program)Healthy adultsCluster sampling2004 - 2005201220 - 74T: 48.75 ± 15; M: 48.8 ± 15; F: 48.6 ± 15BothUT: 2,000IDFT: 30.16 (0.02); M: 31.6 (0.02); F: 30.2 (0.02)
Hosseinpanah et al. (40)Ghazvin, Kermanshah, Golestan, and Hormozgan (Iranian PCOS Prevalence Study), multicity studyFemalesStratified, multistage cluster sampling2009 - 2010201118 - 45T: 36 ± 7.5FUT: 423JISWaist circumference cut-off point was ≥ 91 cmT: 18.3 (15.1 - 21.5)
Esteghamati et al. (27)Tehran, (the Third National Surveillance of Risk Factors of Non-communicable Diseases), local studyIndividuals with body mass index < 18.5 kg/m2 were excludedRandom Cluster sampling2007201125 - 64T: 43.18 ± 0.3; M:43.4 ± 0.3; F: 43.0 ± 0.3BothUT: 2,660; M: 1,245; F: 1,415Modified ATP III; Iranian modified IDF (waist circumference cut-off point was ≥ 90 cm for both men and women)Individuals with self-reported diabetes were excludedT: 38.09 (36.23 - 39.9); M: 29.9 (27.3 - 32.5); F: 45.3 (42.6 - 47.9). T: 38.4 (36.5-40.2); M: 39.1 (36.3-41.8); F: 37.8 (35.2-40.3)
Sahebari et al. (41)Great Khorasan province, local studyHealthy adults2011T: 45.6 ± 12; M: 44.7 ± 12; F: 44.1 ± 13BothBothT: 500; M: 69; F: 431ATP III; IDFT: 53.8 (49.3 - 58.2); M: 21.7 (12.7 - 33.3); F: 51 (46.2 - 55.8). T: 34.2 (30 - 38.5); M: 29 (18.6 - 41.1); F: 57.8 (52.9 - 62.4)
Esmaillzadeh et al. (42)Tehran, local studyFemale teachersMultistage random cluster sampling2007201140 - 60T: 49 ± 6FUT: 486ATP IIISubjects taking antihypertensive, lipid lowering, or antidiabetic medications were excludedT: 30 (25.9 - 34.3)
Esteghamati et al. (43)All 30 provinces of Iran (the Third National Surveillance of Risk Factors of Non-Communicable Diseases ) (SuRFNCD), national studyHealthy adultsRandom cluster sampling2007201125 - 64T: 43.59 ± 11.2; M: 43.69±11.6; F: 43.5 ± 10.9BothBothT: 3,045; M: 1,468; F: 1,577IDFWaist circumference cut-off point was ≥ 90 cm in both males and femalesT: 39.9 (38.1 - 41.6); M: 38.2 (35.7 - 40.7); F: 41.5 (39 - 43.9)
Ramezani et al. (44)Ghazvin, Kermanshah, Golestan, and Hormozgan, multicity studyHealthy adultsMultistage random cluster sampling201118 - 45FUT: 914Modified ATP IIIT: 17.5 (15.09 - 20.1)
Ghasemi et al. (45)Tehran, (TLGS, phase 3), local studyHealthy adultsMultistage, stratified random cluster sampling2007 - 2008201060 - 90BothUT: 137; M: 89; F: 48ATP IIIT: 43.8 (35.3 - 52.5); M: 30.3 (21.03 - 40.99); F: 68.8 (53.6 - 61.3)
Delavari et al. (14)All 30 provinces in Iran, national studyHealthy adultsMultistage Random cluster sampling2007200925 - 64T: 41.3 ± 3.81; M: 41.5 ± 2.64; F: 41.2 ± 2.74BothBothT: 2,966 M: 1,431; F: 1,535ATP III; Modified ATP IIIT: 35.6 (34.1 - 37.1); M: 28.8 (27.0-30.5); F: 42.8 (40.4 - 45.1). T: 42.3 (40.7-43.8); M: 36.3 (34.4-38.1); F: 48.5 (46.2-50.9)
Jalali et al. (46)Akbar abad Koar Fars near Shiraz, local studyHealthy adultsSimple random sampling2008 200918 - 90T: 38.7 ± 14.3; M: 40.5 ± 15.9; F: 37.4 ± 13.7BothRT: 1,402; M: 360; F: 1,042ATP III; Modified ATP III; IDFT: 25.6 (23.3 - 27.9); M: 29.16 (24.5 - 34.1); F: 24.28 (21.7 - 27.0). T: 29 (26.5 - 31.4). T: 33 (30.4 - 35.4)
Delavar et al. (47)Babol, local studyFemale adultsSystematic random sampling200930 - 50F: 40.2 ± 0.2FUT: 944ATP IIIT: 31 (28.1-33.9)
Sharifi et al. (48)Zanjan, local study Healthy adultsStratified, multistage random sampling2002 - 20032009> 20BothUT: 2,941; M: 1,396; F: 1,545Modified ATP IIIT: 23.7 (22.1 - 25.2); M: 23.1 (20.8 - 25.2); F: 24.4 (22.2 - 26.5)
Sarrafzadegan et al. (49)Isfehan, Irak, and Najaf-Abad, local studyHealthy adultsTwo-stage random cluster sampling2000 - 20012008≥ 19BothBothT: 12,514; M: 6,123; F: 6,391ATP IIIT: 23.3 (22.5 - 24.0); M: 10.7 (9.9 - 11.4) F: 35.1 (33.9 - 36.2)
Hadaegh et al. (50)Tehran, (TLGS, phase 1), local studyHealthy adultsMultistage random cluster sampling1999 - 20012008≥ 20T: 42.6 ± 13.6BothUT: 4,568; M: 1,882; F: 2,686WHODiabetes patients were excludedT: 9.2 (8.3 - 10.0)
Zabetian et al. (51)Tehran, (TLGS, phase 1), local studyHealthy adultsMultistage random cluster sampling1999 - 20012007≥ 20T: 42.7 ± 15.0 ; M: 44.1 ± 15.6; F: 41.7 ± 14.4BothUT: 10,368 M: 4,397; F: 5,971IDFT: 31 (30.1 - 31.8); M: 21 (19.7 - 22.2); F: 41 ; (39.7 - 42.2)
Nabipour et al. (52)Bushehr, Genaveh, and Deilam, local studyHealthy adultsRandom Cluster sampling2003 - 20042007≥ 25BothBothT: 3,723; M: 1,746; F: 1,977ATP IIIT: 52.1 (47.3 - 50.6); M: 54.6 (50.3 - 53.6); F: 49.9 (44.5 - 48.5)
Sadrbafghi et al. (53)Yazd, local studyHealthy adultsRandom Cluster sampling2004 200620 - 74T:49 ± 18; M: 48.9 ± 15.4; F: 49.2 ± 21.4BothUT: 1,110; M: 550; F: 557ATP IIIT: 32.1 (29.3 - 34.9); M: 37.8 (33.7 - 42.0); F: 62.2 (57.9 - 66.1)
Fakhrzadeh et al. (54)Tehran, local studyHealthy adultsSingle-stage cluster sampling2003200625 - 64T: 41.26 ± 12.06BothUT: 1,480; M: 571; F: 909ATP IIIT: 29.9 (27.6 - 32.2); M: 20.3 (17.08 - 23.85); F: 35.9 (32.74 - 39.07)
Azizi et al. (16)Tehran, (TLGS, phase 1), local studyHealthy adultsMultistage, stratified random cluster sampling1999 - 20012003≥ 20BothUT: 10,368; M: 4,397; F: 5,971ATP IIIT: 33.7 (32.8 - 34.6); M: 24 (22.7 - 25.2); F: 42 (40.7 - 43.2)

The total sample sizes of studies using the criteria of ATP III, IDF, and JIS were 54,043, 23,774, and 1,088, respectively (Table 2). For ATP III criteria, the maximum and minimum sample sizes were 12,514 (in Isfahan) and 137 (in Tehran), respectively. Maximum and minimum sample sizes for IDF were 10,368 and 486 (both in Tehran) and for JIS, they were 4,665 and 365 (both in Tehran), respectively. The overall estimation of MetS prevalence was 36.9% (95% CI: 32.7 - 41.2%) according to ATP III, 34.6% (95% CI: 31.7 - 37.6%) for IDF, and 41.5% (95% CI: 29.8 - 53.2%) based on the JIS criteria (Table 2 and Figure 2). The prevalence of MetS measured by JIS was higher than those measured by the ATP III and IDF definitions (41.5% versus 36.9% and 34.6%); however, this difference was not statistically significant. Maximum and minimum prevalence rates of MetS were 60% and 23% based on the ATP III criteria, 40% and 30% for the IDF criteria, and 52% and 31% for the JIS criteria, respectively (Figure 2).

Table 2. The Overall Prevalence of Metabolic Syndrome in the Iranian Adult Population According to Different Criteria and Sex Using Random Effect Meta-Analysis of Data From Population-based Studies
CriteriaExtracted articles (n)Sample size (n)Prevalence (%)CI 95%
ATP III
Male1524,76027.721.8 - 33.6
Female1932,04643.137.9 - 48.4
Total1754,04336.932.7 - 41.2
Heterogeneity ATP III (I-square)
Male99.9%P < 0.001
Female99.8%P < 0.001
Total99.8%P < 0.001
IDF
Male6 9,87430.723.9 - 37.5
Female6 12,49842.037.4 - 46.6
Total723,77434.631.7 - 37.6
Heterogeneity IDF (I-square)
Male99.6%P < 0.001
Female99%P < 0.001
Total98.9%P < 0.001
JIS
Male11,85645.744.6 - 46.8
Female22,81537.332.4 - 42.2
Total410,38541.529.8 - 53.2
Heterogeneity JIS (I-square)
Male-
Female99.9%P < 0.001
Total99.8%P < 0.001
Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Adult Population
Figure 2. Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Adult Population

According to the ATP III criteria, the prevalence of MetS was significantly (15.4%) lower in men than in women (27.7% versus 43.1%, respectively). The same trend was obtained for the IDF definition, which found MetS to be 11.3% less prevalent in men than in women (30.7% versus 42.0%, respectively). However, the reverse was true for the JIS definition, which showed a significantly higher (8.4%) prevalence in men than in women (45.7% versus 37.3%, respectively) (Table 2, Figures 3 and 4).

Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Male Adult Population
Figure 3. Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Male Adult Population
Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Female Adult Population
Figure 4. Forest Plot of the Prevalence of Metabolic Syndrome in the Iranian Female Adult Population

The results of the meta-regression show that the main source of heterogeneity in findings was the mean age of participants. The results show that by each year increase in the mean age of individuals after the age of 18, the prevalence of MetS increased by 0.004% (coefficient: 0.0048792, P = 0.005).

Nine studies reported the prevalence of MetS components according to different criteria (Table 3). Among these studies, in six the prevalence of components was calculated in subjects with MetS. Most of the subjects with MetS had three components (54.7% - 95%). The prevalences of four and five components in MetS subjects were 0.6 - 34% and 0 - 11.8%, respectively.

Table 3. Prevalence of Metabolic Syndrome Components in the Iranian Adult POPULATION in Population-Based Studiesa
ReferenceLocation and type of studyStudy populationSampling methodStudy datePublication dateAge range (years)Mean age (mean ± SD)SexUrban/ruralSample sizeCriteriaPrevalence of MetS components (%)
Tohidi et al. (44)Ghazvin, Kermanshah, Golestan, and Hormozgan, multicity studyHealthy adultsMultistage random cluster sampling201118 - 45FUT: 914Modified ATP III3 components: 11.4; 4 components: 5.1; 5 components: 1
Fakhrzadeh et al. (54)Isfahan (cohort study), local studyHealthy adultsRandom stratified sampling201143 - 8256.42 ± 9.52BothBothT: 468; M: 236; F: 232ATP III3 components: 55.2; 4 components: 34; 5 components: 10.8
Jalali et al. (46)Akbar abad Koar Fars near Shiraz, local studyHealthy adultsSimple random sampling2008 (1387)200918 - 90T: 38.7 ± 14.3; M: 40.5 ± 15.9; F: 37.4 ± 13.7BothRT: 1,402; M: 360; F: 1,042ATP III; Modified ATP III; IDFTotal, 3 components: 95; 4 components : 0.6; 5 components: 4.5; male, 3 components: 99; 4 components: 0; 5 components:1; female, 3 components: 93.4; 4 components: 0.6; 5 components: 6. Total, 3 components: 66.3; 4 components: 27.1; 5 components: 6.7; male, 3 components: 71.4; 4 components: 26.1; 5 components: 2.5; female, 3 components: 64.1; 4 components: 27.5; 5 components: 8.4. Total, 3 components: 54.7; 4 components: 33.4; 5 components: 11.8; Male, 3 components: 38.4; 4 components: 44.8; 5 components: 16.8; Female, 3 components: 59; 4 components: 30.5; 5 components: 10.5
Delavar et al. (47)Babol, local studyFemale adultsSystematic random sampling200930 - 50F: 40.2 ± 0.2FUT: 944ATP III1 component: 30.8; 2 components: 28.9; 3 components: 22.6; 4 components: 7.4; 5 components: 0.8
Sharifi et al. (48)Zanjan, local studyHealthy adultsStratified, multistage random sampling2002 - 20032009> 20BothUT: 2,941; M: 1,396; F: 1,545Modified ATP III3 components: 75.6; 4 components: 24.4; 5 components: 0
Nabipour et al. (52)Bushehr, Genaveh, and Deilam, local studyHealthy adultsRandom cluster sampling2003 - 20042007≥ 25BothBothT: 3,723; M: 1,746; F: 1,977ATP III0 components: 4.0; 1 component: 15.1; 2 components: 28.7; 3 components: 30.8; 4 components: 17.7; 5 components: 3.6
Sadrbafghi et al. (53)Yazd, local studyHealthy adultsRandom cluster sampling2004 (1383)200620 - 74T: 49 ± 18; M: 48.9 ± 15.4; F: 49.2 ± 21.4BothUT: 1,110; M: 550; F: 557ATP III0 components: 19.2; 1 component: 21.1; 2 components: 27.6; 3 components: 20.8; 4 components: 9; 5 components: 2.3
Fakhrzadeh et al. (54)Tehran, local studyHealthy adultsSingle stage cluster sampling2003200625 - 64T: 41.26 ± 12.06BothUT: 1,480; M: 571; F: 909ATP III0 component: 12; 1 component: 29; 2 components: 29.1; 3 components: 22.7; 4 components: 7.1; 5 components: 0.2
Azizi et al. (16)Tehran, (TLGS, phase 1), local studyHealthy adultsMultistage stratified random cluster sampling1999 - 20012003≥ 20BothUT:10,368; M: 4,397; F: 5,971ATP IIITotal, 3 components: 58; 4 components: 33; 5 components: 9; Male, 1 component: 29; 2 components: 32; 3 components: 16; 4 components: 7; 5 components: 1; Female, 1 component: 28; 2 components: 23; 3 components: 20; 4 components: 14; 5 components: 4

aAbbreviations: F, female; M, male; T, total.

7. Conclusions

Our findings show that the prevalence of MetS is relatively high in Iran according to all three definitions (ATP III: 36.9%, IDF: 34.6%, and JIS: 41.5%). These observed prevalence rates are noticeably higher than the estimated prevalence around the world, which is between 20% and 25% (7). The mean prevalence of MetS in Iran was found to be higher than in many other countries (e.g., Portugal [27.6%], (55) Spain [26.6%], (56) France [25% in males and 15.3% in females], (57) and Italy [22% in males and 18% in females]) (3). It was also higher than in the United States of America (22.9%) (58). The prevalence of MetS in Iran is much closer to that in North Africa (30%), (59) Asia-China (33.9%), (60) Turkey (36.6%), (60) and some Latin American countries such as Colombia (34.8%) (61)and Venezuela (35.3%) (62). Therefore it can be assumed that some reasons other than urbanization and inactivity have resulted in this relatively high prevalence of MetS in Iran. In a study conducted by Delavari et al., greater waist circumference values and lower HDL cholesterol have also been reported in Iranian communities than in Western populations, which support the idea of an ethnic predisposition of the Iranian community to MetS (14).

It is noteworthy to acknowledge that comparisons between Iran and other countries must be made with caution. First, because most of these studies were conducted in a small area or a city, they cannot be representative of the entire country. Thus, generalizing the estimated prevalence to a country is a point of concern. Second, it has been shown that MetS is highly age-dependent (63). This was also found in our study; the prevalence of MetS in the Iranian population increased around 0.004% by each year of age increase after the age of 18. Therefore, even in a study with population-based sampling, comparing countries with different age pyramids might result in different prevalence rates, even with comparable risks of MetS. In recent years, the population of Iran has been growing older, and this might be one of the reasons for such a high prevalence of MetS in this country.

Another finding of this study was the significantly higher prevalence of MetS and its reverse sex distribution according to JIS compared to the other two definitions. According to the ATP III and IDF definitions, MetS prevalence was significantly higher in women (15.4% and 11.3% higher than the prevalence in men, respectively). However, based on the JIS criteria, MetS was 8.4% more prevalent in men, which was also significant. The lack of consensus on MetS definitions and the cutoff points used for its components, especially regarding waist circumference, has resulted in these differences. In the JIS definition, the cut-off point for waist circumference is usually higher than those of ATP III and IDF for women and lower for men, which may have resulted in a higher prevalence of MetS being measured in men according to the JIS definition, and contrary to the ATP III and IDF definitions. These differences influence health policies and clinical practice, in which underestimation or overestimation may result in inappropriate distribution of health services. Barbosa et al. performed a cross-sectional study on 1,439 adults in Brazil and concluded that NCEP-ATP III (64) underestimated the prevalence of MetS, particularly in men. This study showed that MetS is a public health problem in Iran. It has a high prevalence and it is expected to have an increasing trend in coming years as the mean age of the Iranian population grows. Therefore, by implementing an appropriate screening and treatment system, many metabolic diseases (such as diabetes and cardiovascular disease) that are costly to society can be prevented.

The main limitation of this study is that estimated prevalences were not adjusted based on the size of the target populations. Regarding this point, the results of a cluster analysis method are much more reliable, but cluster sampling is not practical because it is very difficult and expensive to perform. It seems that meta-analysis could be an efficient substitute strategy.

The prevalence of MetS is relatively high in the Iranian adult population. The lack of consensus on MetS definitions has resulted in different reports of its prevalence. However, even considering the lowest prevalence of 34.6%, the prevalence of MetS in Iran is considerably higher than the estimated prevalence around the world (20 - 25%). Therefore, applying an appropriate screening and treatment system for MetS could prevent many chronic diseases that are costly to society.

Footnotes

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