Prevalence of dyslipidemia and its association with other coronary artery disease risk factors among urban population in Southeast of Iran: results of the Kerman coronary artery disease risk factors study (KERCADRS)
© The Author(s). 2016
Received: 18 August 2016
Accepted: 4 October 2016
Published: 21 October 2016
Despite the importance of identifying and screening dyslipidemia to prevent coronary artery diseases CAD(Coronary Artery Disease), little information is available on dyslipidemia in our large area. So the present study aimed to assess the management status of lipid abnormalities and its association with other CAD risk factors in an urban population of southeast of Iran.
This cross-sectional study was a part of the Kerman coronary artery disease risk factor study KERCADRS (Kerman coronary artery disease risk study) as a population-based, epidemiological research among 5900 individuals aged 15 to 75 years who were residents of Kerman city, the largest city in Southeast of Iran. Lipid profile was assessed using enzymatic laboratory methods.
In total, 5558 persons from 5899 participants were assessed in whom 45.1 % were male and 54.9 % female. Overall 20.9 % had borderline level of cholesterol (200–239 mg/dl) and 8.7 % suffered from hypercholesterolemia (≥240 mg/dl). The prevalence of undiagnosed dyslipidemia (UDL) was 16.8 % and of diagnosed dyslipidemia (DDL) was 13.2 % that both UDL and DDL were more prevalent in women. Also, UDL was more revealed in third and fourth age decades. Advanced age, anxiety, obesity (BMI ≥30 Kg/m2), and family history of dyslipidemia predicted dyslipidemia in study population.
The overall prevalence of UDL was higher than of DDL, and was significantly influenced by advanced age, anxiety, obesity, and family history of dyslipidemia. The data showed that our health care management system should improve its strategies to reduce the burden of this important CAD risk factor.
KeywordsDyslipidemia Prevalence Coronary artery disease Prediction KERCADRS
Over the recent decades, many researches have consistently indicated the increased burden of lipid profile abnormalities and its high mortality, morbidity, and medical costs . Dyslipidemia has been clearly identified as an important major risk factor for cardiovascular diseases that are the first cause of death in the developed and developing countries . The World Health Organization recently reported that dyslipidemia is significantly associated with more than half of global cases of ischemic heart disease . In fact, dyslipidemia is not a single primary phenomenon, but is a broad term that refers to inappropriate diet and lifestyle, as well as some genetic susceptibilities . The literature on the epidemiology and economics of dyslipidemia is extensive. Quite literally, it has been demonstrated that a notable number of individuals have total cholesterol levels in excess of 200 mg/dL, and majority of affected ones have levels greater than 240 mg/dL, which is considered a high level necessitating treatment [4–6]. Despite the importance of identifying and screening dyslipidemia in every nation to prevent occurrence and progression of cardiovascular diseases, there are no proper and correct statistics on the incidence of dyslipidemia and its determinants in majority of nations [7, 8]. In this regard, awareness of the incidence and control state of dyslipidemia among high risk groups is now being increased, leading proper control of this serious risk factor in some areas . Moreover, the recent report of the NCEP (National cholestrol education program) suggested that the primary approach to cholesterol lowering is making lifestyle changes in combination with medication to control their dyslipidemia . The lack of enough knowledge to the status of dyslipidemia leads to inappropriately programming and treatment approaches.
Unfortunately, there is little information with respect to present status of lipid abnormalities and its association with other CAD risk factors especially mental health status among some Iranian population. This will lead to difficulties in scheduling suitable national managerial approaches for lipid lowering. Thus, the present study aimed to assess prevalence of lipid abnormalities and its associated CAD risk factors, and the effectiveness of health care system in management of this CAD risk factor in a relatively large population that is representative of the urban population in the Southeast of Iran.
Lipid profiles categories based on the current measurements, history of diagnosis and taking drugs
Lipid profile categories
Average of at the time of recruitment (TC)
Average of at the time of recruitment (HDL-C)
Average of at the time of recruitment (LDL-C)
Average of at the time of recruitment (TG)
Self-reported of previously diagnosed
Self-reported of taking any anti- drug
Optimal/near-optimal serum concentration
≥60 (negative risk factor)
<100 optimal (100–129 near-optimal)
Borderline serum concentration
High-risk/very high-risk serum concentration
≥190 very high
≥500 very high
Controlled - Diagnosed
Positive or Negative
Uncontrolled - Diagnosed
Positive or Negative
Results were presented as mean ± standard deviation (SD) for quantitative variables and were summarized by absolute frequencies and percentages for categorical variables. Continuous variables were compared using t test or ANOVA test or non-parametric Mann–Whitney U or Kruskal-Wallis tests whenever the data did not have normal distribution or when the assumption of equal variances was violated across the groups. Categorical variables were, on the other hand, compared using chi-square test or Fisher’s exact test when more than 20 % of cells with expected count of less than 5 were observed. Main predictors of dyslipidemia were determined by ANCOVA test adjusting baseline variables. For age-sex direct standardizations, we used Kerman population reported in census 2006. All prevalence rates were weighted according to the sampling weight (reciprocal of the probability of selection) and individual response rate. The statistical software SPSS version 20.0 for windows (SPSS Inc., Chicago, IL) was used for statistical analysis. P values of 0.05 or less were considered statistically significant.
The standardized prevalence of abnormal lipid profiles; Cholesterol, Triglyceride, LDL and HDL, Community-Based Cohort Study (KERCADR – 1st Round - N = 5558)
77.4 [75.7, 79.0]
The standardized prevalence of dyslipidemia (undiagnosed and diagnosed lipid profiles), Community-Based Cohort Study (KERCADR – 1st Round - N = 5558)
Primary to high school
Above high school
Current cigarette smoker
Family History of dyslipidemia
Crude and adjusted odds ratio for different predictors of dyslipidemia, Community-Based Cohort Study (KERCADRS – 1st Round - N = (5558)
Primary to high school
Above high school
Current cigarette smoker
Family History of dyslipidemia
The present study aimed to determine prevalence of dyslipidemia based on demographic characteristics as well as medical status of general population and then assesses main correlates of dyslipidemia and its association with other CAD risk factors. In this regard, the overall prevalence of undiagnosed dyslipidemia was 16.8 % and of diagnosed dyslipidemia was 13.2 % that was significantly influenced by advanced age, anxiety, obesity, and family history of dyslipidemia, but not by smoking, education level, opium addiction and depression state. Also, we found a borderline level of cholesterol in 20.9 % and excess level of cholesterol in 8.7 %. These borderline individuals are in risk of being hypercholesterolemic in next few years as this phenomenon was found to increase by advance age. On the other hand the prevalence of undiagnosed dyslipidemia was more than diagnosed dyslipidemia. These statistics show challenge in health education, screening and controlling lipid profile in the population under the study. In agreement with present data a survey in Pakistan revealed that a large proportion of the population had lipid abnormalities and females had significantly greater values of total cholesterol . Study on Jordanian adults showed that almost half of the participants (48.8 %) had elevated serum total cholesterol, 40.7 % had elevated LDL-C, 40.1 % had low HDL-C, and 43.6 % had elevated triglyceride concentrations . In study by Sharifi and colleagues which performed in Zanjan province of Iran, increased total cholesterol (>200 mg/dL) was observed in 35.4 % of the subjects. Except for the hypertriglyceridemia/low HDL-C pattern, which was more common in males, the other abnormal lipid profiles were more common in females . Tabatabaei and her colleagues reviewed and extracted published papers on prevalence of dyslipidemia in Iranian and international journals until September 2011. They found that hypercholesterolemia; high LDL-C and low HDL-C were more prevalent in women, whereas hypertriglyceridemia was more prevalent in men . Also Esteghamati found that the prevalence of hypertriglyceridemia and hypercholesterolemia was 36.4 and 42.9 % respectively in the studied Iranian population and hypercholesterolemia was higher among females and hypertriglyceridemia among males . None of the above studies included considered mental health status as CAD risk factor. The similarity of findings of last three studies with findings of the present study implies that inappropriate effectiveness of our health care system is at the national level.
Another fact was that the peak of prevalence of hyperlipidemia in women was ten years earlier relative to men and this is associated with 10 year earlier peak in low physical activity prevalence (Fig. 2) rendering those susceptible to cardiovascular events. There was more lipid disorder in physically inactive individuals. Also many more obese individuals had undiagnosed dyslipidemia (42 %) and were unaware of it. It is noteworthy that women who were physically inactive and older were more dyslipidemic. The founding that anxiety is a determinant of dyslipidemia along with high prevalence of severe anxiety in our study population (29.1 % in females and 16.7 % in males ) is another caution for our health system menageries. These make the conditions more cautious when considering high prevalence of low physical activity of 39.2 % in men and 45.1 % in women . These facts along with more prevalence of undiagnosed dyslipidemia in our study population means that we must reconsider screening program to detect this potentially reversible and major coronary disease risk factor. In this regard as pointed by Ghayour-Mobarhan  and others  performing appropriate programs for screening and early diagnosing dyslipidemia followed by proper medications resulted in appropriate control of this abnormality. Ghayour-Mobarhan showed that triglyceride, total cholesterol and low density lipoprotein cholesterol were reduced by 27, 20.5 and 22.7 %, respectively and high density lipoprotein cholesterol rose by 8.96 % among 238 hyperlipidemic individuals during one year of attending lipid clinic .
Our data point to high prevalence of the other coronary disease risk factors associated with dyslipidemia such as low physical activity (LPA), obesity, anxiety and smoking in dyslipidemic individuals either presented in the current study or reported elsewhere [21, 22]. The positive association between dyslipidemia and LPA observed in the present study (Table 4) has also been shown between LPA with hypertension and opium use [23, 24]. Opium causes reduction of plasma HDL cholesterol and increases the risk of hypertension .Therefore our local health program must consider these CAD risk factors in order to decrease CAD burden.
We acknowledge the limitation of our study as a cross-sectional survey. Beside, this study benefited from a relative large sample size, random sampling, and high response rate and included new risk factors such as mental health and opium consumption. For further studies, we recommend monitoring the lipid profile by a longitudinal prospective cohort study. Also it is required to assess the efficacy of local and national intervention programs in managing and control of dyslipidemia.
In conclusion the results showed overall prevalence of undiagnosed dyslipidemia 16.8 % and of diagnosed dyslipidemia 13.2 % that was significantly influenced by advanced age, anxiety, obesity, and family history of dyslipidemia. Women are more at risk, although the prevalence of dyslipidemia especially borderline dyslipidemia was high in both sexes and needs urgent actions due to mostly young population of the country approaching middle ages in near future.
Coronary artery disease
Fasting plasma glucose
Kerman coronary artery disease risk study
National cholestrol education program
We thank the men and women who have participated in the KERCADR (Kerman Coronary Artery Diseases Risk Factors) study, the specialists and the nurses and doctors who conducted the clinic interviews at the first round. We should send our best gratitude to Dr Maliheh Shadkam Farrokhi (God bless her soul) who has done a lot for the project and unfortunately passed away in the middle of the first round. The authors declare that there is no conflict of interest.
This research was financially supported by Kerman University of Medical Sciences.
Availability of data and materials
The dataset supporting the conclusions of this article will not be shared publicly, to ensure participants privacy. The data as SPSS program is available upon request.
HN participated in the design and coordination of the study, drafting of the manuscript and interpreting the findings; MS performed the statistical analysis and drafted the manuscript; GU participated in the design of the study and in drafting and finalizing the manuscript; BSA drafted the manuscript; GMK carried out the laboratory tests; MMB participated in drafting the manuscript and interperting the findings; AM participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Not applicable (Design is original article not case report or series. Consent for publication had been a part for consent for participate).
Ethics approval and consent to participate
The study protocol was approved by the Research Ethics Committee at Kerman University of Medical Sciences, Kerman, Iran (Permission No. 88/110KA).
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