Population Attributable Fraction of Cardiovascular Disease, Coronary Heart Disease, and Stroke Associated With Insufficient Non-Occupational Physical Activity in Iranian Adults: Findings From the Steps 2021 Survey Publisher



Sabbagh Alvani M ; Karimi K ; Khosravi S ; Naderian M ; Azizpour Y ; Golestani A ; Payab M ; Selk Ghaffari M ; Ejtahed H S ; Takian A ; Ostovar A ; Daroudi R ; Ahmadnezhad E ; Akbarpour S Show All Authors
Source: Journal of Diabetes and Metabolic Disorders Published:2026

Abstract

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. © The Author(s), under exclusive licence to Tehran University of Medical Sciences 2026.