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Coronary Heart Disease / Stroke / Cardiovascular Diseases · Journal article
Journal of Diabetes and Metabolic Disorders · July 2, 2026
Early or partial results. Treat as a signal, not a conclusion.
This cross-sectional analysis of 16,552 Iranian adults estimates that 19.2% of prevalent cardiovascular disease could be statistically associated with insufficient physical activity under a counterfactual scenario of adequate activity. The authors acknowledge substantial reverse causation bias inherent to the cross-sectional design and position findings as policy-oriented scenario measures rather than causal effects.
Cross-sectional population survey with population attributable fraction estimation. Iranian adults aged ≥40 years from the nationally representative Iran STEPS 2021 survey.. Intervention: Counterfactual scenario of sufficient physical activity (≥600 MET-minutes/week non-occupational activity). Compared with: Current prevalence of insufficient physical activity (<600 MET-minutes/week). n = 16,552. Iran.
Weighted CVD prevalence 11.48% (95% CI: 10.95, 12.04); estimated PAF 19.2% (95% CI: 15.1, 23.2) under sufficient activity scenario Weighted CHD prevalence 10.43% (95% CI: 9.91, 10.96); estimated PAF 15.9% (95% CI: 11.2, 20.5) Weighted stroke prevalence 2.17% (95% CI: 1.94, 2.43); estimated PAF 17.1% (95% CI: 11.5, 22.5)
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These findings identify insufficient physical activity as a potentially modifiable factor associated with a substantial proportion of prevalent CVD burden in Iranian adults, with particular relevance for women and older adults. However, the cross-sectional design prevents causal inference; clinicians should interpret these as policy-scenario estimates highlighting subgroups for physical activity intervention rather than direct clinical effect measures.
Cross-sectional survey estimating population attributable fractions with acknowledged reverse causation bias; provides policy-relevant scenario estimates but cannot establish causality or direct clinical effects.
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These findings identify insufficient physical activity as a potentially modifiable factor associated with a substantial proportion of prevalent CVD burden in Iranian adults, with particular relevance for women and older adults. However, the cross-sectional design prevents causal inference; clinicians should interpret these as policy-scenario estimates highlighting subgroups for physical activity intervention rather than direct clinical effect measures.
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Background. Insufficient physical activity (IPA) is a well-established cardiovascular risk factor. Iran has one of the highest cardiovascular disease (CVD) burdens in the Middle East and North Africa region. This study estimated prevalence-based, scenario-driven population-attributable fractions (PAFs) of prevalent CVD, coronary heart disease (CHD), and stroke statistically associated with insufficient non-occupational physical activity among Iranian adults aged ≥ 40 years under a counterfactual model of sufficient physical activity.Methods. We analyzed data from 16,552 adults aged ≥ 40 years from the nationally representative Iran STEPS 2021 survey. IPA was defined as < 600 MET-minutes/week of non-occupational physical activity. PAFs were estimated using Miettinen's formula combining the prevalence of IPA among cases with sex-specific relative risks from a prospective meta-analysis after transformation to reflect IPA versus sufficient activity. Analyses incorporated sampling weights and complex survey design; 95% confidence intervals (CIs) were estimated via bootstrap.Results. Weighted prevalence was 11.48% (95% CI: 10.95, 12.04) for CVD, 10.43% (95% CI: 9.91, 10.96) for CHD, and 2.17% (95% CI: 1.94, 2.43) for stroke. Under a counterfactual scenario of sufficient activity, the estimated PAF was 19.2% (95% CI: 15.1, 23.2) for CVD, 15.9% (95% CI: 11.2, 20.5) for CHD, and 17.1% (95% CI: 11.5, 22.5) for stroke. Higher fractions were observed among women (25.2% for CVD) and adults aged ≥ 60 years (19.7% for CVD).Conclusions. These scenario-driven estimates suggest that a substantial proportion of prevalent CVD would be statistically associated with IPA under a counterfactual model. Due to the cross-sectional design, reverse causation is likely and may upwardly bias estimates. Findings highlight women and older adults as priority subgroups for physical activity promotion. The PAF estimates should be interpreted as policy-oriented scenario measures rather than direct causal effects.Trial registration. Not applicable.Supplementary information. The online version contains supplementary material available at 10.1007/s40200-026-01992-7.
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