Bushehr Elderly Health (BEH) Program, Phase III: The Study Profile

Bushehr Elderly Health (BEH) Program, Phase III: The Study Profile | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Bushehr Elderly Health (BEH) Program, Phase III: The Study Profile Kazem Khalagi, Zahra Hoseini Tavassol, Hanieh-Sadat Ejtahed, Gita Shafiee, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7362426/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The Bushehr Elderly Health (BEH) Program is a population-based prospective cohort study, designed to address the increasing health challenges associated with an aging population. The third phase of BEH program was carried out with aim to repeat the measurements about the state of non-communicable diseases (NCDs), particularly cardiovascular and musculoskeletal diseases, and cognitive function, and their determinants and consequences in the older adults. This article presents the profile of the third phase measurements of BEH program. Methods Phase III of the BEH Program was conducted six years after the second phase (stage), involving repeated measurements among participants aged 60 and above residing in Bushehr city. Previous phase participants were invited to take part in this phase. This phase was a repeat of the measurements conducted in the previous phases implicated comprehensive questionnaires, physical and anthropometric examinations, whole body and bone density scan, diagnostic laboratory tests, and biobanking of biological samples included serum, EDP, stool, and saliva. Results The successful assessment has been completed for a representative sample of older adults, with an extensive data for future analysis. In this phase of BEH program, a total of 1,345 participants were enrolled in the study, a response rate of 64.7%. The mean (standard deviation) age was 74.3 (4.6) years and 50.4% of the participants were males. Conclusion The BEH program’s repeated measures provide valuable insights into how health-related variables among participants change over time, as well as the needs of older Iranian adults. Also, adding stool and saliva samples to the BEH program biobank allows for expanded microbiota evaluation in this study. This study results inform public health policy to address the growing burden of NCDs among older adults and will guide clinicians, policymakers, and health managers in developing effective strategies to promote health outcomes and quality of life of older adults. Aged Cardiovascular Diseases Musculoskeletal Diseases Cognitive Function Cohort Studies Iran Figures Figure 1 Figure 2 Introduction Alongside the rising life expectancy, the world’s population is aging rapidly. It is anticipated that the global population of individuals aged 65 years and older will rise from 9.3% in 2020 to approximately 16% in 2050 [ 1 ]. The number of elderly population will increase from 0.7 billion in 2019 to 1.5 billion in 2050 [ 2 ] and 2.2 billion by the 2070s [ 3 ]. This increase of the older adult population is expected to continue, especially in lower and middle-income countries [ 4 ]. In Iran, the population of older adults aged 65 and older stands at 9.2% in 2025 and is predicted to rise to approximately 22% (19 million) by 2050. Also, the population aged 80 and older is projected to reach 3.8% by 2050 [ 5 – 7 ]. This increase in the proportion and the number of older adults highlights the growing need to understand the impacts and outcomes of aging on health, social structures, and economies. The health and economic burden of aging are significant both globally and in Iran. Aging is an irreversible process [ 8 ]. According to a report between 2004 and 2030, there will be a 55% increase in global disability-adjusted life years (DALYs) among those aged 60 and older due to population aging. Also, Health conditions among older adults aged 60 and above account for 23% of the total global burden of disease. [ 9 ]. Considering the demographic shifts, the necessity for comprehensive research aimed at developing effective prevention and management strategies for non-communicable diseases (NCDs), which are associated with older adults, becomes more important [ 10 ]. Among NCDs, cardiovascular, musculoskeletal, and cognitive diseases are highly important with the leading contributors to disease burden of 30.3%, 7·5%, and 6·6%, respectively [ 9 ]. In Iran, between 1990 and 2015, CVDs were the first leading cause of DALYs, and there was an increase in age-standardized DALY due to musculoskeletal, mental, and neurological disorders [ 11 ]. These conditions directly impact the quality of life, independence, and daily functioning of older adults, and require special attention in health and treatment programs. Furthermore, as the proportion of elderly people increases, so does the potential burden on healthcare systems, social services, and economic resources. Therefore, elderly health has become one of the main priorities of public health systems [ 4 ]. In response to these serious concerns, Bushehr Elderly Health (BEH) program, as a population-based prospective cohort study in southern Iran, was designed and executed with the aim of determining the factors affecting the health of older adults, and providing the information needed for decision-making by clinicians, policy makers, and health program managers. The baseline data gathering of the first recruitment of the BEH program was carried out in two phases [ 12 , 13 ]. This article presents the profile of the third phase of the study's first recruitment (see Fig. 1 ). This phase was designed and implemented to repeat the measurements of the previous phases and investigated the prevalence, risk factors, and consequences of cardiovascular diseases, musculoskeletal diseases, and cognitive function in the participants of the BEH program's first recruitment. Methods Study design Specific objectives The BEH program is a population-based prospective cohort study with the purpose of investigation the prevalence of NCDs and their risk factors, as well as the incidence of outcomes associated with NCDs in the older adult population [ 12 , 13 ]. This study is a collaborative effort between Tehran University of Medical Sciences and Bushehr University of Medical Sciences. The third phase (repeated measurements) was conducted six years after the successful completion of the first and second phases (stage 2) of the first recruitment (the baseline measurements) of this study (Fig. 1 ). This phase of the study was carried out with the following specific objectives: Determining the state of cardiovascular diseases and their determinants and consequences in the older adults Determining the state of musculoskeletal diseases and their determinants and consequences in the older adults Determining the state of cognitive function and its determinants and consequences among the older adults 1.2. Study population and inclusion and exclusion criteria The first recruitment of BEH program population included people aged 60 years and older living in Bushehr city. In the first phase, conducted from March 2013 to October 2014, 3000 eligible people living in Bushehr were selected and enrolled in the study. In the second phase (stage 2) of this recruitment of the study at 2015–2016, 2,426 individuals participated. In the present phase, participants from the previous phase of the first recruitment were invited to take part in the study (Fig. 1 ). The inclusion criteria were as follows: men and women aged 60 years and older who participated in the previous phase of the first recruitment of the study; participants must reside in Bushehr and not plan to leave the city for at least the next five years; and individuals must have sufficient physical and mental capability to participate in the study. Participants are required to sign a written informed consent form (ICF). Older adults living in nursing homes were excluded from the study. 1.3. Sampling method To ensure a representative sample of the people aged 60 and over in Bushehr city, 3000 eligible individuals were selected through a multi-stage cluster random sampling method in 2013, which has been described in detail in previous article [ 12 ]. 1.4. Invitation Participants from the second phase (stage II) of the first recruitment were invited to the third phase of the study via phone call. Up to 10 phone calls were made to both landline and mobile numbers, or to the contact numbers of their companions. The inviter, after introducing themselves and explaining the reason for the call, invited individuals to return for the new phase. After each phone call, the status and outcome of the call, as well as the reason for any disagreement, were recorded. If the participant accepted the invitation, the study nurse reminded participants to bring all their medications and insurance cards, wore light clothing, fasted for 12 hours before the test, arrived on time at the study site, and be assured of the confidentiality of their information. 2. Ethics and dissemination The third phase of BEH program Study was approved by the ethical committee of the Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1396.00223). Study participants were provided with an information sheet containing all necessary details about the study’s purpose, procedures, benefits, and participants’ rights, and ICFs were signed by them in duplicate, covering all components of the study, including data and biological sample collection, utilization, secondary data analysis, and potential publication of findings. One copy was archived at the Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences, while the other was retained by the participant. Participants' right to withdraw from the study at any time is respected without any impact on their healthcare management plan. Additionally, after withdrawing, they were free to allow researchers to use the data collected from them in the study or to request their deletion. If people were diagnosed with diseases requiring treatment during the study, the necessary treatments were initiated, or they were referred to relevant specialists. This study was conducted in accordance with the Declaration of Helsinki and adhered to Iranian national guidelines for ethics in research. 3. Measurements Data were collected via questionnaires, physical examinations, body composition and Bone Mineral Density (BMD) assessments through Dual-energy X-ray absorptiometry (DXA (, and the diagnostic tests. All collected data were entered into an electronic case report form (eCRF). 3.1. Questionnaires The list of standardized questionnaires for this study is presented in Table 1 . The questionnaires were completed through face-to-face interviews with study participants. Table 1 The list of questionnaires of phase III of the BEH Program The questionnaire name Domain/component/description 1 Participants’ demographic characteristics Personal information Age/sex Marital status Contact information 2 Socio-Economic Status Employment status Basic Insurance Supplementary Insurance Income Assets Residence status 3 Cardiovascular Diseases Risk Factors Smoking (Life-time, Current, History, Frequency, Quantity, Quit attempts, Ex-smoking) Alcohol Consumption (Current, History, amount) Drug abuse (Life-time, Type, Age of onset, Duration) 4 International Physical Activity Questionnaire (IPAQ) [ 14 ] Work-Related Activities Transport Activities Domestic Activities Leisure Activities Sitting 5 Geriatric Locomotive Function Scale-5 (GLFS-5) Difficulty in climbing up and down stairs Difficulty in fast walking Difficulty in carrying a 2 kg weight Difficulty in carrying tasks Overall assessment of locomotion 6 Fertility History Questions (for women only) Menstrual cycle start Sex hormone replacement therapy Contraceptive History Hysterectomy /Oophorectomy 7 Cardiovascular Diseases and its Family History Questionnaire Familial Diabetes, Hypertension, and Stroke Stroke 8 Rose Questionnaire [ 15 , 16 ] Awareness of Cardiovascular Symptoms 9 Heart Failure-Specific Health Literacy Scale [ 17 ] Physical Functioning and Cardiovascular Related Events 10 Bone and Muscle Health Questionnaire [ 13 ] Sunlight exposure Diagnosis, treatment, and adherence to treatment of Osteoporosis History of long corticosteroid use Self and parental history of fragility fractures Fall history Muscle health Height loss Screening for secondary osteoporosis Medication history affecting osteoporosis 11 Health-Related Quality of Life Questionnaire (EQ-5D) [ 18 ] Mobility Self-Care Usual activities Pain/Discomfort Anxiety/Depression 12 Quality of Life Questionnaire 12-item Short Form Health Survey (SF-12) [ 19 ] Physical functioning Limited Physical Role Function Physical pain Vitality (energy) Perceived mental health Limited emotional role function Social functioning General health 13 Social Frailty [ 20 ] Living Situation Social Relations Social Support Social Activities Emotional Well-being 14 Medical History - History of: Hypertension, Dyslipidemia, Myocardial Infarction, Stroke, Heart Failure, Diabetes, Hyperthyroidism, Hypothyroidism, Parkinson's Disease, Alzheimer's Disease, Rheumatism, Osteoarthritis, Kidney Stones, Chronic Kidney Failure, Epilepsy, Depression, Lung Disease, Liver Disease, Cancer, HIV infection, Viral Hepatitis, Gastrointestinal Surgery (excluding Appendectomy and Cholecystectomy), and Inflammatory Bowel Disease -History of Hospitalization: Cause, Duration, and Location -Unintentional Weight Loss of More than 5 kg in the Last Year -COVID-19 and history of diagnosis and Vaccination 15 Medication Registration Form Drug Name Type of Drug Dose of drug Duration of Use 16 Assessment of Activities of Daily Living (ADL)[ 21 ] Basic Activities of Daily Living (BADL): Ambulating Feeding Dressing Personal Hygiene Toileting Continence Instrumental Activities of Daily Living (IADL): Use of telephone Shopping Meal preparation Housekeeping, and laundry Mode of transportation Medication management Money management 17 Cognitive Impairment Test (6CIT) [ 22 ] What year is it? What month is it? Remember an address phrase with 5 components About what time is it? Count backwards from 20 to 1 Say the months of the year in reverse order Repeat the 5-component address phrase to assess delayed memory 18 Patient Health Questionnaire-9 (PHQ-9) [ 23 ] Loss of Interest or Pleasure Depressed Mood or Hopelessness Sleep Disturbances Fatigue or Low Energy Appetite Changes Negative Self-Perception Difficulty Concentrating Psychomotor Changes (Restlessness or Slowness) Suicidal Thoughts or Self-Harm 19 24-hour Dietary Recall Assessment Details of all foods and beverages consumed in seven meals over the past day 20 Mini Nutritional Assessment (MNA) in the elderly [ 24 ] Changes in food intake over the past three months Recent weight loss Mobility status Psychological stress or acute disease history Neuropsychological problems Body Mass Index (BMI) 21 Pittsburgh Sleep Quality Questionnaire (PSQI) [ 25 ] Subjective Sleep Quality Sleep Latency Sleep Duration Habitual Sleep Efficiency Sleep Disturbances Use of Sleeping Medication Daytime Dysfunction 22 Epworth Sleepiness Scale (ESS) [ 26 ] When: Reading Watching TV Inactivity in Public (e.g., theater) Car Passenger for an Hour Afternoon Resting Talking to Someone Sitting Quietly After Lunch Stopped in Traffic 3.2. Physical examinations Physical examinations of the study participants included various anthropometric measurements such as height, weight, waist circumference (WC), hip circumference (HC), neck circumference, upper arm circumference, forearm circumference, wrist circumference, thigh circumference, calf circumference, upper arm length, and lower leg length. Additional tests consisted of the hand grip strength measurement, single leg stance test, short physical performance battery (SPPB), which includes five times sit to stand test, balance test, and gait speed test. Blood pressure measurement, an electrocardiogram (ECG), a visual acuity test, and a whispering test were also performed. 3.2.1. Anthropometric measurements Anthropometric measurements were conducted with participants wearing light clothing and no shoes. Height and weight were measured using a fixed stadiometer and calibrated digital scale. Other anthropometric indices were measured using a flexible tape. WC was measured at the horizontal plane midway between the lowest ribs and the iliac crest. HC was measured at the maximum extension of the buttocks. Neck circumference was measured in the midway of the neck, between mid-cervical spine and mid anterior neck. Upper arm circumference was measured at the midpoint between the olecranon process and the acromion while the right arm is hanging relaxed. Right forearm circumference was measured around the widest part, just below the elbow. Wrist circumference was measured around the right wrist, just above the wrist bone. Thigh circumference was measured at the midway between the trochanterion (top of the thigh bone, femur) and tibiae lateral (top of the tibia bone) of right thigh. Calf circumference was measured at the widest point of the calf. The upper arm length was measured while the individual was standing upright with their right arm flexed at a 90º angle, from the acromial landmark (shoulder tip) to the posterior surface of the olecranon (the bony prominence of the elbow). The lower leg length was measured while the individual is sitting with their back straight and knees at a 90-degree angle, from the top of the patella (kneecap) to the underside of the foot. All measurements were read to the nearest 0.1 cm while the participant was standing upright. 3.2.2. Performance-based tests and muscle strength Handgrip strength was measured bilaterally using a digital calibrated dynamometer. For each hand, three measurements were taken twice. The dominant hand was evaluated first, followed by a 15-second rest period, after which the non-dominant hand was assessed. The Single Leg Stance Test for both the right and left legs was performed twice with the participant's eyes open and arms placed on their hips. The participant was asked to stand unassisted on one leg, and the time was recorded in seconds from the moment one foot is lifted off the floor until it either touches the ground, contacts the standing leg, or an arm moves away from the hips. The five times sit to stand test was done to assess the lower limb strength, balance, postural control and functional mobility. This test involves the individual standing up from a chair and sit back down five times with the arms crossed over the chest. The time taken to complete all five stands was measured, test was stopped if the individual could not complete the stands or showed signs of discomfort or was not suitable for participation. The balance tests, including Side-by-Side Stance, Semi-Tandem Stance and Full Tandem Stance were conducted with the support of the interviewer. In the Side-by-Side Stance, participants stood with their feet together, side by side. For the Semi-Tandem Stance, the heel of one foot was placed next to the big toe of the other foot. In the Full Tandem Stance, one foot was positioned directly in front of the other, with the heel touching the toe. The timer for these tests was stopped when 10 seconds have elapsed or when participants move their feet. To assess '4.57-m and 2.44-m gait speed,' the usual walking speed were measured over a distance of 4.57 and 2.44 meters. While assessing gait speed, the participant's usual walking style and use of assistive devices like canes or walkers were also considered. 3.2.3. Blood pressure measurements and electrocardiogram Blood was measured using a mercury sphygmomanometer to determine systolic and diastolic pressures by assessing blood flow in the arm. Participants were seated comfortably for five minutes with their arm supported at heart level. The first and fifth Korotkoff sounds indicated the systolic and diastolic pressures, respectively, and each measurement was recorded separately after two readings. Electrocardiography was performed by a trained nurse using a 12-lead system to capture information on ischemia, arrhythmias, and other cardiac conditions. The procedure requires the participant to lie comfortably on the bed, with electrodes attached to the upper limbs (above the wrists) and the lower limbs (above the ankles) and thoracic leads fixed in six specific precardiac positions (V1-V6) to accurately record the heart's electrical activity, which was then displayed as an electrocardiogram (ECG). 3.2.4 Visual acuity test The Tumbling E chart was used to assess visual acuity. Participants were asked to identify the direction of the "E" letters from a distance of 3 meters. The level of visual acuity is the last row in which the patient can identify at least half of the letters. If the participants wore glasses, they would be asked to wear them during the test. 3.2.5 Whisper test The whisper test was performed to assess participants' hearing ability. The interviewer stood 60 cm behind the seated person, whispering a sequence of three words consisting of numbers and letters, and asks the patient to repeat them. A total of six words were used for each ear. If the participants had a hearing aid, the test was conducted while they were wearing it. 3.3. Expanded Bone Mineral Density Assessment Bone Mineral Density (BMD) was measured for all participants in the study, using Dual-energy X-ray Absorptiometry (DXA) (Horizon® DXA System, Hologic, USA). Scans were performed at the lumbar vertebrae (L1 to L4), the total hip, and the femoral neck, according to standardized protocols. To perform BMD measurements, participants were positioned as follow: For lumbar vertebrae scans, participants were placed supine with their hips positioned over a foam block (if necessary) to eliminate lumbar lordosis, ensuring the spine was centered and aligned with the scanner's longitudinal axis. For femur measurements, legs were internally rotated using a triangular positioning device to optimize femoral neck alignment. This is also the dual-hip scanning protocols, allow simultaneous bilateral acquisition; individual positioning adjustments may still be necessary to ensure consistent abduction angles and minimize inter-scan variability. According to the world health organization (WHO) recommendations on the NHANES III study [ 27 ], Caucasian women aged 20–29 are used as the reference population to calculate T-scores. A T-score of -2.5 or less indicates osteoporosis. This standardized protocol minimized postural variability across measurements. In addition to BMD body composition analysis (BCA) by whole body DXA, vertebral fracture assessment (VFA), and trabecular bone score (TBS) analyze were also integrated. Whole-body scans required participants to lie supine with their arms parallel to their torso (palms flat), their legs secured at the ankles with Velcro straps while toes pointing vertically, and radiolucent pillows supporting the head when necessary to maintain neutral positioning. Whole-body scans provided body composition metrics, including fat mass (%), lean mass (g), bone mineral content (BMC), and appendicular skeletal muscle mass (ASM) calculated as the sum of muscle mass in all four limbs. VFA was performed using lateral spine images acquired in dual-energy mode, with vertebral deformities identified using the scanner’s integrated morphometric software. For trabecular bone microstructure evaluation, TBS iNsight® software (v4.1, Med-Imaps) analyzed lumbar spine DXA images, with T-scores referenced to NHANES-based European normative data on Caucasian women aged 20–29 (validated for BMI 15–37 kg/m²). These measurements were conducted at the study site by a trained technician, and the DXA device was calibrated before the data collection process began. Individuals weighing over 150 kg and those who had undergone bilateral hip replacement were excluded from this measurement. Participants were instructed to remove radiopaque objects and to avoid calcium supplements for 24 hours prior to the measurement. 3.4. Biological samples collection and biobanking Biological samples (blood, feces, and saliva) were collected from participants for testing and biobank storage. Approximately 8 cc of venous blood was collected in two sampling tubes containing clot activator, and 2 cc was collected in two separate tubes containing K2EDTA. These samples were processed immediately to separate serum and plasma, which then were used for biochemical measurements and store in the biobank. Additionally, with the aim of development a microbiota biobank, fecal and saliva samples were collected from a sub sample of the participants. This work was conducted according to the specific sample collection, storage, and transportation protocols established for the operator and participants to ensure the integrity and viability of microbiota. 3.5. Diagnostic Laboratory Tests Complete Blood Count (CBC), Fasting Blood Sugar (FBS), Hemoglobin A1C (HbA1c), Cholesterol, Triglyceride (TG), High-density lipoprotein cholesterol (HDL-C), Low-density lipoprotein cholesterol (LDL-C), Alkaline Phosphatase (ALP), Alanine Transaminase (ALT), Aspartate Aminotransferase (AST), Parathyroid Hormone (PTH), Thyroid-stimulating hormone (TSH), Free Thyroxine (T4), Vitamin D (25OH), Iron, Total iron-binding capacity (TIBC), Phosphate, Calcium, Urea, Uric Acid, Creatinine, and Albumin are biochemical markers that were measured in this phase of the study. CBC was measured using the automated hematology analyzer KX-21 (Sysmex Corporation, Kobe, Japan). The biochemical measurements were conducted using BS-200 chemical analyzer (Shenzhen Mindray Bio-Medical Electronics Co, Ltd, Shenzhen, China), except for the PTH test, which was performed using the Cobas e411 autoanalyzer (Roche Diagnostics, Basel, Switzerland) and TSH, T4, and Vitamin D (25OH), that were measured using Dynex automated ELISA DS2® processing system (Dynex technologies, Chantilly, VA, USA). The biochemical kits used are presented in the Table 2 . Table 2 The Biochemical Kits used in the phase III of BEH Program Biochemical Factors Company Biochemical Factors Company Fasting Blood Sugar (FBS) MAN Free Thyroxine (T4) Pishtaz Teb Hemoglobin A1C (HbA1c), Paadco Vitamin D (25OH) Pishtaz Teb Total Cholesterol (TC) MAN Iron Biomed Triglyceride (TG) MAN Total iron-binding capacity (TIBC ( MAN + Paadco High-density lipoprotein cholesterol (HDL-C) MAN + Audit Phosphate MAN Low-density lipoprotein cholesterol (LDL-C) MAN + Audit Calcium MAN + Audit Alkaline Phosphatase (ALP) MAN Urea MAN Alanine Transaminase (ALT) Audit Uric Acid MAN Aspartate Aminotransferase (AST) Audit Creatinine Audit Parathyroid Hormone (PTH) Roche Albumin Biomed Thyroid-stimulating hormone (TSH) Pishtaz Teb 4. Training and quality assurance To ensure the validity of the measured variables, the responsible staff were trained at the beginning of the study based on the study protocol and standard procedures. The agreement between the questioners and the trainer were evaluated. 5. Monitoring and supervision Monitoring of the true implementation of the study (in accordance with the current protocol) was conducted by inspectors visiting the data collection process and using monitoring checklists. During study monitoring by inspectors, all processes were evaluated, and any deviations from the protocol and related issues were addressed. 6. Data Management Collected data was recorded in an eCRF. The eCRF was an electronic questionnaire and data collection form designed to help researchers collect data from each participant and record the results of the questionnaires and other tests and measurements (physical examinations and diagnostic laboratory tests). To ensure minimal data loss, each participant's eCRF was completed during every visit and within one week of the availability of diagnostic tests results. The data file was updated every three months and was shared with the project manager in EMRI-TUMS, Tehran. The interviewer responsible for conducting visits and completing the eCRFs had access to these forms. A physician is also permitted to complete eCRFs if individuals were referred for further clinical evaluations. All collected data, including questionnaires, physical examination results, BMD and body composition assessments, and diagnostic laboratory tests, were treated as confidential information. The members of the research team who had permission to access such data were identified. A data protection expert was appointed to monitor the data management process and was responsible for providing periodic reports on this matter. Each participant was assigned the unique code of the previous phase of BEH program, so that their identity remains unknown during any future use of their data. All printed copies of questionnaires and data collection forms were stored in Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences. A digital file of the collected data was created and updated every month. Additionally, a copy of the data file was saved to an external drive every week. 7. Statistical analyses Continuous variables will be reported as mean (standard deviation) or median (interquartile range), while categorical variables as frequency and percentage. In cases of non-normal distributions for continuous variables, transformation of the data will be considered, or non-parametric tests will be used. When exploring the associations, if the outcome variable is continuous, depending on the hypothesis being tested, a T-test, analysis of variance (ANOVA), analysis of covariance (ANCOVA), or linear regression models will be employed. If the outcome variable is categorical, a chi-square test or appropriate regression analysis will be performed. Risk Ratio, Rate Ratio, Odds Ratio, and Hazard Ratio will be used to illustrate the relationship between the relevant risk factors and the study outcomes. Pearson or Spearman correlation coefficients will be used to assess the correlation between continuous or ordinal variables. Partial correlation will be conducted to control the effects of confounding variables. Multiple linear regression analysis will be performed to investigate the relationship between continuous dependent variables and their potential risk factors. In the case of dichotomous dependent variables, logistic regression will be used. For survival analysis, the life table and Kaplan-Meier methods will be used. To compare groups, the log-rank test will be employed. Cox proportional hazards models and other appropriate multiple survival analysis methods will be used to adjust for potential confounders. Results Participation status The third phase of the BEH program's first recruitment was conducted from January 2022 to March 2023. During this phase, about 2079 subjects who participated in the second phase (stage 2) of the study and were still alive and residing in Bushehr were invited. Finally, 1,345 participants who met the study's criteria were enrolled in the third phase (a response rate of 64.7%). The details of participation status the reasons for non-participation are presented in Fig. 2 . Demographic characteristics of the participants Among the participants, 667 (49.6%) were female. The age range of the study participants was 66 to 100 years, with a mean (standard deviation) age of 74.3 (4.6) years. Female participants had an age range of 66 to 93 years, while male participants ranged from 68 to 100 years. The mean (standard deviation) age for females was 74.2 (4.3) years and for males was 74.5 (4.9) years. The demographic characteristics of the study participants are detailed in Table 3 . Table 3 Demographic characteristics of participants in the third phase of the BEH Program Variables description Gender (Male) n (%) 678 (50.4) Age [year, Mean (SD)] 74.3 (4.6) Age (year) n (%) 65–69 160 (11.9) 70–74 751 (55.8) 75–79 277 (20.6) >=80 157 (11.7) Education n (%) Illiterate 343 (25.5) Primary school 499 (37.1) Secondary school 351 (26.1) Academic 135 (10) Marital status n (%) Married 941 (70) Widowed 381 (28.3) Divorced/Separate with partner 17 (1.3) Single 6 (0.4) Biobanking of biological samples The biobank stored a total of 4,035 serum samples (three 1 cc vials per participant) and 1,345 EDTA plasma (EDP) samples (one 1 cc vial per participant) from 1,345 participants at the Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences. An additional serum and EDP vial for each participant were stored at the Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences. To create a new microbiota biobank, stool and saliva samples were collected from a subsample of participants. Due to the difficulties of stool sampling at home and its proper transport to the study site, this was fully achieved for a sub sample of 499 participants. These samples included two cryotubes containing 1 gram of stool and one 250 mg cryotube of stool, along with a 1 cc saliva sample in a 15 cc Falcon tube for each participant. In total, 1,497 stool samples and 564 saliva samples were stored at the EMRI biobank. Samples were immediately frozen and stored at − 80°C to preserve microbial composition and integrity, which is the gold standard for long-term microbiome biobanking. Discuss the significance BEH program has comprehensive data collection, which includes demographic information, general health status, and medical history, helping to achieve a better understanding of elderly health. Additionally, the precise design using multi-stage cluster sampling ensures that the samples are representative of the larger population, providing more generalizable data. This plan for repeated measurements allows researchers to examine changes in key variables and health status over time. This comprehensive assessment provides a clearer path forward for healthcare providers and policymakers in developing public health strategies aimed at promoting healthy aging and increasing community awareness. The BEH biobank of biological samples is of great importance and provides critical opportunities for various future wet lab analyses. With the new collection of stool and saliva samples, further evaluation of the microbiota profile, related microbial assessments, and their associations with health conditions is possible. However, BEH program has some limitations. A decrease in participation rate compared to the second phase (stage 2) due to reasons such as death, migration, declining to participate, and physical disability impacts the interpretation of results and affects the quality of comparisons with the previous phases. This factor may limit the generalizability of the results. However, such limitation can be partially addressed by applying methodological approaches, such as weighting based on the probability of dropout, to account for potential biases. Also, there were some challenges in data collection from participants and engaging in assessments, due to physical or mental health issues. Conclusion In conclusion, the third phase of first recruitment of the BEH program serves as a repetition of the measurements from the previous phases. The data collected will be used to assess changes in the health-related variables of interest among participants over this time interval. This study will help to identify health trends among older adults and develop effective strategies for the prevention and management of NCDs in the elderly, as well as improve their health and quality of life. Abbreviations BEH Bushehr Elderly Health NCDs Non-communicable diseases DALYs Global disability-adjusted life years ICF Informed consent form eCRF electronic case report form IPAQ International Physical Activity Questionnaire GLFS-5 Geriatric Locomotive Function Scale-5 EQ-5D Health-Related Quality of Life Questionnaire SF-12 12-item Short Form Health Survey ADL Activities of Daily Living BADL Basic Activities of Daily Living IADL Instrumental Activities of Daily Living 6CIT Cognitive Impairment Test PHQ-9 Patient Health Questionnaire-9 MNA Mini Nutritional Assessment PSQI Pittsburgh Sleep Quality Questionnaire ESS Epworth Sleepiness Scale BMI Body Mass Index WC Waist circumference HC Hip circumference SPPB Short physical performance battery ECG Electrocardiogram WHO World health organization BMD Bone Mineral Density DXA Dual-energy X-ray absorptiometry BCA Body composition analysis VFA Vertebral fracture assessment TBS Trabecular bone score BMC Bone mineral content ASM Appendicular skeletal muscle mass CBC Complete Blood Count FBS Fasting Blood Sugar HbA1c Hemoglobin A1C TG Triglyceride HDL-C High-density lipoprotein cholesterol LDL-C Low-density lipoprotein cholesterol ALP Alkaline Phosphatase ALT Alanine Transaminase AST Aspartate Aminotransferase PTH Parathyroid Hormone TSH Thyroid-stimulating hormone T4 Free Thyroxine (Tetraiodothyronine) TIBC Total iron-binding capacity ANOVA Analysis of variance ANCOVA Analysis of covariance EMRI Endocrinology and Metabolism Research Institute Declarations Ethics approval and Consent to participate The third phase of the BEH program study was approved by the Ethics Committee of the Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1396.00223). Participants were fully informed about the study procedures and their rights. Written informed consent was obtained from all participants for all components of the study, including data and biological sample collection, utilization, secondary data analysis, and potential publication of findings. This study was conducted in accordance with the Declaration of Helsinki and adhered to Iranian national guidelines for ethics in research. Competing Interests The authors declare that they have no conflict of interest. Authors information KKH: [email protected] , https://orcid.org/0000-0002-0890-6232 ZHT: [email protected] , https://orcid.org/0000-0002-2432-2114 HSE: [email protected] , https://orcid.org/0000-0002-6395-4915 GSH: [email protected] , https://orcid.org/0000-0003-3441-3578 FR: [email protected] , https://orcid.org/0000-0003-2350-9574 VH: [email protected] , https://orcid.org/0000-0001-8337-0602 MJM: [email protected] , https://orcid.org/0000-0002-0666-7928 DJ: [email protected] ZS: [email protected] EH: [email protected] , https://orcid.org/0000-0002-2802-1677 SH: [email protected] , https://orcid.org/0000-0003-0393-1196 MS: [email protected] , https://orcid.org/0000-0003-2992-6184 AF: [email protected] , https://orcid.org/0000-0002-0655-8342 RH: [email protected] , https://orcid.org/0000-0002-9498-6397 KV: [email protected] , https://orcid.org/0000-0001-9782-2067 NF: [email protected] , https://orcid.org/0000-0001-6205-9794 BL: [email protected] , https://orcid.org/0000-0001-5386-7597 AO: [email protected] , https://orcid.org/0000-0001-8670-5797 IN: [email protected] , https://orcid.org/0000-0002-1785-0883 Funding This phase of BEH Program is jointly financed by the Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran and Bushehr University of Medical Sciences, Bushehr, Iran. (Number: 1396-03-103-2221) Author Contribution KKH, ZHT, HSE, GSH, FR, VH, MJM, DJ, RH, KV, NF, BL, AO and IN: Conceptualization and study design. KKH, ZHT, DJ, ZS, EH, SH, MS, AF, KV and IN: Data collection. KKH, ZHT, NF and AO: Drafting of the manuscript. HSE, GSH, FR, VH, MJM, DJ, ZS, EH, SH, MS, AF, RH, KV, BL and IN: Critical review and intellectual revision. All authors provided their final approval of the version to be published. Furthermore, all authors take responsibility for the integrity of the work presented and endorse the accuracy of the study profile as reported. Acknowledgement We would like to express our gratitude to all the employees of the Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, and Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences for their expertise, dedication, and contributions to this project. We also extend our appreciation to the participants and their families, whose willingness to engage in this program was essential for its success. Finally, we acknowledge all individuals and organizations whose support and assistance made this project possible; without their collaboration, this work would not have been achievable. Data Availability The datasets used in this study are available from the corresponding author upon reasonable request. Due to licensing restrictions, the data are not publicly available. References Economic UNDo, Affairs S. World Population Ageing 2020. Highlights: United Nations; 2021. Cheng X, Yang Y, Schwebel DC, Liu Z, Li L, Cheng P, et al. Population ageing and mortality during 1990–2017: A global decomposition analysis. PLoS Med. 2020;17(6):e1003138. 10.1371/journal.pmed.1003138 . United Nations Department of Economic and Social Affairs, Population Division. (2024). World Population Prospects 2024: Summary of Results (UN DESA/POP/2024/TR/NO. 9). 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Bushehr Elderly Health (BEH) programme: study protocol and design of musculoskeletal system and cognitive function (stage II). BMJ Open. 2017;7(8):e013606. 10.1136/bmjopen-2016-013606 . Moghaddam MB, Aghdam FB, Jafarabadi MA, Allahverdipour H, Nikookheslat SD, Safarpour S. The Iranian Version of International Physical Activity Questionnaire (IPAQ) in Iran: content and construct validity, factor structure, internal consistency and stability. World Appl Sci J. 2012;18(8):1073–80. Rose GA. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. Bull World Health Organ. 1962;27(6):645–58. Khalili D, Hadaegh F, Fahimfar N, Shafiee G, Sheikholeslami F, Ghanbarian A, et al. Does an electrocardiogram add predictive value to the rose angina questionnaire for future coronary heart disease? 10-year follow-up in a Middle East population. J Epidemiol Community Health. 2012;66(12):1104–9. Barati M, Taheri-Kharameh Z, Farghadani Z, Rasky E. Validity and Reliability Evaluation of the Persian Version of the Heart Failure-Specific Health Literacy Scale. Int J Community Based Nurs Midwifery. 2019;7(3):222–30. 10.30476/IJCBNM.2019.44997 . Adib-Hajbaghery M, Abasinia M. Assessing Quality of life of elders with femoral neck fractures, using SF36 and EQ5D. Iran J Nurs Res. 2010;4(15):71–9. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC Public Health. 2009;9(1):341. 10.1186/1471-2458-9-341 . Makizako H, Shimada H, Tsutsumimoto K, Lee S, Doi T, Nakakubo S, et al. Social Frailty in Community-Dwelling Older Adults as a Risk Factor for Disability. J Am Med Dir Assoc. 2015;16(11):1003. 10.1016/j.jamda.2015.08.023 . Mehraban AH, Soltanmohamadi Y, Akbarfahimi M, Taghizadeh G. Validity and reliability of the persian version of lawton instrumental activities of daily living scale in patients with dementia. Med J Islamic Repub Iran. 2014;28:25. Jefferies K, Gale TM. 6-CIT: Six-Item Cognitive Impairment Test. In: Larner AJ, editor. Cognitive Screening Instruments: A Practical Approach. London: Springer London; 2013. pp. 209–18. Dadfar M, Kalibatseva Z, Lester D. Reliability and validity of the Farsi version of the Patient Health Questionnaire-9 (PHQ-9) with Iranian psychiatric outpatients. Trends Psychiatry Psychother. 2018;40(2):144–51. 10.1590/2237-6089-2017-0116 . Amirkalali B, Sharifi F, Fakhrzadeh H, Mirarefin M, Ghaderpanahi M, Larijani B. Evaluation of the Mini Nutritional Assessment in the elderly, Tehran, Iran. Public Health Nutr. 2010;13(9):1373–9. 10.1017/S1368980010000303 . Farrahi Moghaddam J, Nakhaee N, Sheibani V, Garrusi B, Amirkafi A. Reliability and validity of the Persian version of the Pittsburgh Sleep Quality Index (PSQI-P). Sleep Breath. 2012;16(1):79–82. 10.1007/s11325-010-0478-5 . Sadeghniiat Haghighi K, Montazeri A, Khajeh Mehrizi A, Aminian O, Rahimi Golkhandan A, Saraei M, et al. The Epworth Sleepiness Scale: translation and validation study of the Iranian version. Sleep Breath. 2013;17(1):419–26. 10.1007/s11325-012-0646-x . Burt VL, Harris T. The third National Health and Nutrition Examination Survey: contributing data on aging and health. Gerontologist. 1994;34(4):486–90. 10.1093/geront/34.4.486 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":376823,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy Timeline and Key Phases of the Bushehr Elderly Health (BEH) Program\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7362426/v1/2b572167e0f22a74b7e6e92c.jpeg"},{"id":92572937,"identity":"e33d8fd9-838a-4a40-8493-593417302616","added_by":"auto","created_at":"2025-10-01 08:05:40","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":312290,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of Participation in Phase III of the first recruitment of the BEH program\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7362426/v1/bd09bd23a189dc3ef43cd024.jpeg"},{"id":101771086,"identity":"6dc6caf6-22c2-461f-b783-5f33d278ae87","added_by":"auto","created_at":"2026-02-03 13:12:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1951651,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7362426/v1/5b8c2c95-3b8f-4b87-b93c-aad0f11ec325.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bushehr Elderly Health (BEH) Program, Phase III: The Study Profile","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlongside the rising life expectancy, the world\u0026rsquo;s population is aging rapidly. It is anticipated that the global population of individuals aged 65 years and older will rise from 9.3% in 2020 to approximately 16% in 2050 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The number of elderly population will increase from 0.7\u0026nbsp;billion in 2019 to 1.5\u0026nbsp;billion in 2050 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and 2.2\u0026nbsp;billion by the 2070s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This increase of the older adult population is expected to continue, especially in lower and middle-income countries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Iran, the population of older adults aged 65 and older stands at 9.2% in 2025 and is predicted to rise to approximately 22% (19\u0026nbsp;million) by 2050. Also, the population aged 80 and older is projected to reach 3.8% by 2050 [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This increase in the proportion and the number of older adults highlights the growing need to understand the impacts and outcomes of aging on health, social structures, and economies.\u003c/p\u003e\u003cp\u003eThe health and economic burden of aging are significant both globally and in Iran. Aging is an irreversible process [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. According to a report between 2004 and 2030, there will be a 55% increase in global disability-adjusted life years (DALYs) among those aged 60 and older due to population aging. Also, Health conditions among older adults aged 60 and above account for 23% of the total global burden of disease. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsidering the demographic shifts, the necessity for comprehensive research aimed at developing effective prevention and management strategies for non-communicable diseases (NCDs), which are associated with older adults, becomes more important [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among NCDs, cardiovascular, musculoskeletal, and cognitive diseases are highly important with the leading contributors to disease burden of 30.3%, 7\u0026middot;5%, and 6\u0026middot;6%, respectively [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In Iran, between 1990 and 2015, CVDs were the first leading cause of DALYs, and there was an increase in age-standardized DALY due to musculoskeletal, mental, and neurological disorders [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These conditions directly impact the quality of life, independence, and daily functioning of older adults, and require special attention in health and treatment programs. Furthermore, as the proportion of elderly people increases, so does the potential burden on healthcare systems, social services, and economic resources. Therefore, elderly health has become one of the main priorities of public health systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn response to these serious concerns, Bushehr Elderly Health (BEH) program, as a population-based prospective cohort study in southern Iran, was designed and executed with the aim of determining the factors affecting the health of older adults, and providing the information needed for decision-making by clinicians, policy makers, and health program managers.\u003c/p\u003e\u003cp\u003eThe baseline data gathering of the first recruitment of the BEH program was carried out in two phases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This article presents the profile of the third phase of the study's first recruitment (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This phase was designed and implemented to repeat the measurements of the previous phases and investigated the prevalence, risk factors, and consequences of cardiovascular diseases, musculoskeletal diseases, and cognitive function in the participants of the BEH program's first recruitment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSpecific objectives\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThe BEH program is a population-based prospective cohort study with the purpose of investigation the prevalence of NCDs and their risk factors, as well as the incidence of outcomes associated with NCDs in the older adult population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This study is a collaborative effort between Tehran University of Medical Sciences and Bushehr University of Medical Sciences. The third phase (repeated measurements) was conducted six years after the successful completion of the first and second phases (stage 2) of the first recruitment (the baseline measurements) of this study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis phase of the study was carried out with the following specific objectives:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eDetermining the state of cardiovascular diseases and their determinants and consequences in the older adults\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDetermining the state of musculoskeletal diseases and their determinants and consequences in the older adults\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDetermining the state of cognitive function and its determinants and consequences among the older adults\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.2. Study population and inclusion and exclusion criteria\u003c/h2\u003e\u003cp\u003eThe first recruitment of BEH program population included people aged 60 years and older living in Bushehr city. In the first phase, conducted from March 2013 to October 2014, 3000 eligible people living in Bushehr were selected and enrolled in the study. In the second phase (stage 2) of this recruitment of the study at 2015\u0026ndash;2016, 2,426 individuals participated. In the present phase, participants from the previous phase of the first recruitment were invited to take part in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The inclusion criteria were as follows: men and women aged 60 years and older who participated in the previous phase of the first recruitment of the study; participants must reside in Bushehr and not plan to leave the city for at least the next five years; and individuals must have sufficient physical and mental capability to participate in the study. Participants are required to sign a written informed consent form (ICF). Older adults living in nursing homes were excluded from the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e1.3. Sampling method\u003c/h2\u003e\u003cp\u003eTo ensure a representative sample of the people aged 60 and over in Bushehr city, 3000 eligible individuals were selected through a multi-stage cluster random sampling method in 2013, which has been described in detail in previous article [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e1.4. Invitation\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eParticipants from the second phase (stage II) of the first recruitment were invited to the third phase of the study via phone call. Up to 10 phone calls were made to both landline and mobile numbers, or to the contact numbers of their companions. The inviter, after introducing themselves and explaining the reason for the call, invited individuals to return for the new phase. After each phone call, the status and outcome of the call, as well as the reason for any disagreement, were recorded. If the participant accepted the invitation, the study nurse reminded participants to bring all their medications and insurance cards, wore light clothing, fasted for 12 hours before the test, arrived on time at the study site, and be assured of the confidentiality of their information.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e2. Ethics and dissemination\u003c/h3\u003e\n\u003cp\u003e The third phase of BEH program Study was approved by the ethical committee of the Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1396.00223). Study participants were provided with an information sheet containing all necessary details about the study\u0026rsquo;s purpose, procedures, benefits, and participants\u0026rsquo; rights, and ICFs were signed by them in duplicate, covering all components of the study, including data and biological sample collection, utilization, secondary data analysis, and potential publication of findings. One copy was archived at the Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences, while the other was retained by the participant. Participants' right to withdraw from the study at any time is respected without any impact on their healthcare management plan. Additionally, after withdrawing, they were free to allow researchers to use the data collected from them in the study or to request their deletion. If people were diagnosed with diseases requiring treatment during the study, the necessary treatments were initiated, or they were referred to relevant specialists. This study was conducted in accordance with the Declaration of Helsinki and adhered to Iranian national guidelines for ethics in research.\u003c/p\u003e\n\u003ch3\u003e3. Measurements\u003c/h3\u003e\n\u003cp\u003eData were collected via questionnaires, physical examinations, body composition and Bone Mineral Density (BMD) assessments through Dual-energy X-ray absorptiometry (DXA (, and the diagnostic tests. All collected data were entered into an electronic case report form (eCRF).\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Questionnaires\u003c/h2\u003e\u003cp\u003eThe list of standardized questionnaires for this study is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The questionnaires were completed through face-to-face interviews with study participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe list of questionnaires of phase III of the BEH Program\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe questionnaire name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDomain/component/description\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipants\u0026rsquo; demographic characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePersonal information\u003c/p\u003e\u003cp\u003eAge/sex\u003c/p\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003cp\u003eContact information\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocio-Economic Status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmployment status\u003c/p\u003e\u003cp\u003eBasic Insurance\u003c/p\u003e\u003cp\u003eSupplementary Insurance\u003c/p\u003e\u003cp\u003eIncome\u003c/p\u003e\u003cp\u003eAssets\u003c/p\u003e\u003cp\u003eResidence status\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCardiovascular Diseases Risk Factors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSmoking (Life-time, Current, History, Frequency, Quantity, Quit attempts, Ex-smoking)\u003c/p\u003e\u003cp\u003eAlcohol Consumption (Current, History, amount)\u003c/p\u003e\u003cp\u003eDrug abuse (Life-time, Type, Age of onset, Duration)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInternational Physical Activity Questionnaire (IPAQ) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWork-Related Activities\u003c/p\u003e\u003cp\u003eTransport Activities\u003c/p\u003e\u003cp\u003eDomestic Activities\u003c/p\u003e\u003cp\u003eLeisure Activities\u003c/p\u003e\u003cp\u003eSitting\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeriatric Locomotive Function Scale-5 (GLFS-5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDifficulty in climbing up and down stairs\u003c/p\u003e\u003cp\u003eDifficulty in fast walking\u003c/p\u003e\u003cp\u003eDifficulty in carrying a 2 kg weight\u003c/p\u003e\u003cp\u003eDifficulty in carrying tasks\u003c/p\u003e\u003cp\u003eOverall assessment of locomotion\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFertility History Questions (for women only)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMenstrual cycle start\u003c/p\u003e\u003cp\u003eSex hormone replacement therapy\u003c/p\u003e\u003cp\u003eContraceptive History\u003c/p\u003e\u003cp\u003eHysterectomy /Oophorectomy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCardiovascular Diseases and its Family History Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFamilial Diabetes, Hypertension, and Stroke\u003c/p\u003e\u003cp\u003eStroke\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRose Questionnaire [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAwareness of Cardiovascular Symptoms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeart Failure-Specific Health Literacy Scale [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysical Functioning and Cardiovascular Related Events\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBone and Muscle Health Questionnaire [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSunlight exposure\u003c/p\u003e\u003cp\u003eDiagnosis, treatment, and adherence to treatment of Osteoporosis\u003c/p\u003e\u003cp\u003eHistory of long corticosteroid use\u003c/p\u003e\u003cp\u003eSelf and parental history of fragility fractures\u003c/p\u003e\u003cp\u003eFall history\u003c/p\u003e\u003cp\u003eMuscle health\u003c/p\u003e\u003cp\u003eHeight loss\u003c/p\u003e\u003cp\u003eScreening for secondary osteoporosis\u003c/p\u003e\u003cp\u003eMedication history affecting osteoporosis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth-Related Quality of Life Questionnaire (EQ-5D)\u003c/p\u003e\u003cp\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMobility\u003c/p\u003e\u003cp\u003eSelf-Care\u003c/p\u003e\u003cp\u003eUsual activities\u003c/p\u003e\u003cp\u003ePain/Discomfort\u003c/p\u003e\u003cp\u003eAnxiety/Depression\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuality of Life Questionnaire 12-item Short Form Health Survey (SF-12) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysical functioning\u003c/p\u003e\u003cp\u003eLimited Physical Role Function\u003c/p\u003e\u003cp\u003ePhysical pain\u003c/p\u003e\u003cp\u003eVitality (energy)\u003c/p\u003e\u003cp\u003ePerceived mental health\u003c/p\u003e\u003cp\u003eLimited emotional role function\u003c/p\u003e\u003cp\u003eSocial functioning\u003c/p\u003e\u003cp\u003eGeneral health\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial Frailty [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLiving Situation\u003c/p\u003e\u003cp\u003eSocial Relations\u003c/p\u003e\u003cp\u003eSocial Support\u003c/p\u003e\u003cp\u003eSocial Activities\u003c/p\u003e\u003cp\u003eEmotional Well-being\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical History\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- History of: Hypertension, Dyslipidemia, Myocardial Infarction, Stroke, Heart Failure, Diabetes, Hyperthyroidism, Hypothyroidism, Parkinson's Disease, Alzheimer's Disease, Rheumatism, Osteoarthritis, Kidney Stones, Chronic Kidney Failure, Epilepsy, Depression, Lung Disease, Liver Disease, Cancer, HIV infection, Viral Hepatitis, Gastrointestinal Surgery (excluding Appendectomy and Cholecystectomy), and Inflammatory Bowel Disease\u003c/p\u003e\u003cp\u003e-History of Hospitalization: Cause, Duration, and Location\u003c/p\u003e\u003cp\u003e-Unintentional Weight Loss of More than 5 kg in the Last Year\u003c/p\u003e\u003cp\u003e-COVID-19 and history of diagnosis and Vaccination\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedication Registration Form\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDrug Name\u003c/p\u003e\u003cp\u003eType of Drug\u003c/p\u003e\u003cp\u003eDose of drug\u003c/p\u003e\u003cp\u003eDuration of Use\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssessment of Activities of Daily Living (ADL)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBasic Activities of Daily Living (BADL):\u003c/p\u003e\u003cp\u003eAmbulating\u003c/p\u003e\u003cp\u003eFeeding\u003c/p\u003e\u003cp\u003eDressing\u003c/p\u003e\u003cp\u003ePersonal Hygiene\u003c/p\u003e\u003cp\u003eToileting\u003c/p\u003e\u003cp\u003eContinence\u003c/p\u003e\u003cp\u003eInstrumental Activities of Daily Living (IADL):\u003c/p\u003e\u003cp\u003eUse of telephone\u003c/p\u003e\u003cp\u003eShopping\u003c/p\u003e\u003cp\u003eMeal preparation\u003c/p\u003e\u003cp\u003eHousekeeping, and laundry\u003c/p\u003e\u003cp\u003eMode of transportation\u003c/p\u003e\u003cp\u003eMedication management\u003c/p\u003e\u003cp\u003eMoney management\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCognitive Impairment Test (6CIT) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhat year is it?\u003c/p\u003e\u003cp\u003eWhat month is it?\u003c/p\u003e\u003cp\u003eRemember an address phrase with 5 components\u003c/p\u003e\u003cp\u003eAbout what time is it?\u003c/p\u003e\u003cp\u003eCount backwards from 20 to 1\u003c/p\u003e\u003cp\u003eSay the months of the year in reverse order\u003c/p\u003e\u003cp\u003eRepeat the 5-component address phrase to assess delayed memory\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient Health Questionnaire-9 (PHQ-9) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLoss of Interest or Pleasure\u003c/p\u003e\u003cp\u003eDepressed Mood or Hopelessness\u003c/p\u003e\u003cp\u003eSleep Disturbances\u003c/p\u003e\u003cp\u003eFatigue or Low Energy\u003c/p\u003e\u003cp\u003eAppetite Changes\u003c/p\u003e\u003cp\u003eNegative Self-Perception\u003c/p\u003e\u003cp\u003eDifficulty Concentrating\u003c/p\u003e\u003cp\u003ePsychomotor Changes (Restlessness or Slowness)\u003c/p\u003e\u003cp\u003eSuicidal Thoughts or Self-Harm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24-hour Dietary Recall Assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDetails of all foods and beverages consumed in seven meals over the past day\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMini Nutritional Assessment (MNA) in the elderly [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChanges in food intake over the past three months\u003c/p\u003e\u003cp\u003eRecent weight loss\u003c/p\u003e\u003cp\u003eMobility status\u003c/p\u003e\u003cp\u003ePsychological stress or acute disease history\u003c/p\u003e\u003cp\u003eNeuropsychological problems\u003c/p\u003e\u003cp\u003eBody Mass Index (BMI)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePittsburgh Sleep Quality Questionnaire (PSQI) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSubjective Sleep Quality\u003c/p\u003e\u003cp\u003eSleep Latency\u003c/p\u003e\u003cp\u003eSleep Duration\u003c/p\u003e\u003cp\u003eHabitual Sleep Efficiency\u003c/p\u003e\u003cp\u003eSleep Disturbances\u003c/p\u003e\u003cp\u003eUse of Sleeping Medication\u003c/p\u003e\u003cp\u003eDaytime Dysfunction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpworth Sleepiness Scale (ESS) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWhen:\u003c/p\u003e\u003cp\u003eReading\u003c/p\u003e\u003cp\u003eWatching TV\u003c/p\u003e\u003cp\u003eInactivity in Public (e.g., theater)\u003c/p\u003e\u003cp\u003eCar Passenger for an Hour\u003c/p\u003e\u003cp\u003eAfternoon Resting\u003c/p\u003e\u003cp\u003eTalking to Someone\u003c/p\u003e\u003cp\u003eSitting Quietly After Lunch\u003c/p\u003e\u003cp\u003eStopped in Traffic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Physical examinations\u003c/h2\u003e\u003cp\u003ePhysical examinations of the study participants included various anthropometric measurements such as height, weight, waist circumference (WC), hip circumference (HC), neck circumference, upper arm circumference, forearm circumference, wrist circumference, thigh circumference, calf circumference, upper arm length, and lower leg length. Additional tests consisted of the hand grip strength measurement, single leg stance test, short physical performance battery (SPPB), which includes five times sit to stand test, balance test, and gait speed test. Blood pressure measurement, an electrocardiogram (ECG), a visual acuity test, and a whispering test were also performed.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1. Anthropometric measurements\u003c/h2\u003e\u003cp\u003eAnthropometric measurements were conducted with participants wearing light clothing and no shoes. Height and weight were measured using a fixed stadiometer and calibrated digital scale. Other anthropometric indices were measured using a flexible tape. WC was measured at the horizontal plane midway between the lowest ribs and the iliac crest. HC was measured at the maximum extension of the buttocks. Neck circumference was measured in the midway of the neck, between mid-cervical spine and mid anterior neck. Upper arm circumference was measured at the midpoint between the olecranon process and the acromion while the right arm is hanging relaxed. Right forearm circumference was measured around the widest part, just below the elbow. Wrist circumference was measured around the right wrist, just above the wrist bone. Thigh circumference was measured at the midway between the trochanterion (top of the thigh bone, femur) and tibiae lateral (top of the tibia bone) of right thigh. Calf circumference was measured at the widest point of the calf. The upper arm length was measured while the individual was standing upright with their right arm flexed at a 90\u0026ordm; angle, from the acromial landmark (shoulder tip) to the posterior surface of the olecranon (the bony prominence of the elbow). The lower leg length was measured while the individual is sitting with their back straight and knees at a 90-degree angle, from the top of the patella (kneecap) to the underside of the foot. All measurements were read to the nearest 0.1 cm while the participant was standing upright.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2. Performance-based tests and muscle strength\u003c/h2\u003e\u003cp\u003eHandgrip strength was measured bilaterally using a digital calibrated dynamometer. For each hand, three measurements were taken twice. The dominant hand was evaluated first, followed by a 15-second rest period, after which the non-dominant hand was assessed.\u003c/p\u003e\u003cp\u003e The Single Leg Stance Test for both the right and left legs was performed twice with the participant's eyes open and arms placed on their hips. The participant was asked to stand unassisted on one leg, and the time was recorded in seconds from the moment one foot is lifted off the floor until it either touches the ground, contacts the standing leg, or an arm moves away from the hips.\u003c/p\u003e\u003cp\u003eThe five times sit to stand test was done to assess the lower limb strength, balance, postural control and functional mobility. This test involves the individual standing up from a chair and sit back down five times with the arms crossed over the chest. The time taken to complete all five stands was measured, test was stopped if the individual could not complete the stands or showed signs of discomfort or was not suitable for participation.\u003c/p\u003e\u003cp\u003eThe balance tests, including Side-by-Side Stance, Semi-Tandem Stance and Full Tandem Stance were conducted with the support of the interviewer. In the Side-by-Side Stance, participants stood with their feet together, side by side. For the Semi-Tandem Stance, the heel of one foot was placed next to the big toe of the other foot. In the Full Tandem Stance, one foot was positioned directly in front of the other, with the heel touching the toe. The timer for these tests was stopped when 10 seconds have elapsed or when participants move their feet. To assess '4.57-m and 2.44-m gait speed,' the usual walking speed were measured over a distance of 4.57 and 2.44 meters. While assessing gait speed, the participant's usual walking style and use of assistive devices like canes or walkers were also considered.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3. Blood pressure measurements and electrocardiogram\u003c/h2\u003e\u003cp\u003eBlood was measured using a mercury sphygmomanometer to determine systolic and diastolic pressures by assessing blood flow in the arm. Participants were seated comfortably for five minutes with their arm supported at heart level. The first and fifth Korotkoff sounds indicated the systolic and diastolic pressures, respectively, and each measurement was recorded separately after two readings.\u003c/p\u003e\u003cp\u003eElectrocardiography was performed by a trained nurse using a 12-lead system to capture information on ischemia, arrhythmias, and other cardiac conditions. The procedure requires the participant to lie comfortably on the bed, with electrodes attached to the upper limbs (above the wrists) and the lower limbs (above the ankles) and thoracic leads fixed in six specific precardiac positions (V1-V6) to accurately record the heart's electrical activity, which was then displayed as an electrocardiogram (ECG).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 Visual acuity test\u003c/h2\u003e\u003cp\u003eThe Tumbling E chart was used to assess visual acuity. Participants were asked to identify the direction of the \"E\" letters from a distance of 3 meters. The level of visual acuity is the last row in which the patient can identify at least half of the letters. If the participants wore glasses, they would be asked to wear them during the test.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.5 Whisper test\u003c/h2\u003e\u003cp\u003eThe \u003cb\u003ewhisper test\u003c/b\u003e was performed to assess participants' hearing ability. The interviewer stood 60 cm behind the seated person, whispering a sequence of three words consisting of numbers and letters, and asks the patient to repeat them. A total of six words were used for each ear. If the participants had a hearing aid, the test was conducted while they were wearing it.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Expanded Bone Mineral Density Assessment\u003c/h2\u003e\u003cp\u003eBone Mineral Density (BMD) was measured for all participants in the study, using Dual-energy X-ray Absorptiometry (DXA) (Horizon\u0026reg; DXA System, Hologic, USA). Scans were performed at the lumbar vertebrae (L1 to L4), the total hip, and the femoral neck, according to standardized protocols.\u003c/p\u003e\u003cp\u003eTo perform BMD measurements, participants were positioned as follow: For lumbar vertebrae scans, participants were placed supine with their hips positioned over a foam block (if necessary) to eliminate lumbar lordosis, ensuring the spine was centered and aligned with the scanner's longitudinal axis.\u003c/p\u003e\u003cp\u003eFor femur measurements, legs were internally rotated using a triangular positioning device to optimize femoral neck alignment. This is also the dual-hip scanning protocols, allow simultaneous bilateral acquisition; individual positioning adjustments may still be necessary to ensure consistent abduction angles and minimize inter-scan variability.\u003c/p\u003e\u003cp\u003eAccording to the world health organization (WHO) recommendations on the NHANES III study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Caucasian women aged 20\u0026ndash;29 are used as the reference population to calculate T-scores. A T-score of -2.5 or less indicates osteoporosis. This standardized protocol minimized postural variability across measurements.\u003c/p\u003e\u003cp\u003eIn addition to BMD body composition analysis (BCA) by whole body DXA, vertebral fracture assessment (VFA), and trabecular bone score (TBS) analyze were also integrated. Whole-body scans required participants to lie supine with their arms parallel to their torso (palms flat), their legs secured at the ankles with Velcro straps while toes pointing vertically, and radiolucent pillows supporting the head when necessary to maintain neutral positioning. Whole-body scans provided body composition metrics, including fat mass (%), lean mass (g), bone mineral content (BMC), and appendicular skeletal muscle mass (ASM) calculated as the sum of muscle mass in all four limbs.\u003c/p\u003e\u003cp\u003eVFA was performed using lateral spine images acquired in dual-energy mode, with vertebral deformities identified using the scanner\u0026rsquo;s integrated morphometric software. For trabecular bone microstructure evaluation, TBS iNsight\u0026reg; software (v4.1, Med-Imaps) analyzed lumbar spine DXA images, with T-scores referenced to NHANES-based European normative data on Caucasian women aged 20\u0026ndash;29 (validated for BMI 15\u0026ndash;37 kg/m\u0026sup2;).\u003c/p\u003e\u003cp\u003eThese measurements were conducted at the study site by a trained technician, and the DXA device was calibrated before the data collection process began.\u003c/p\u003e\u003cp\u003eIndividuals weighing over 150 kg and those who had undergone bilateral hip replacement were excluded from this measurement. Participants were instructed to remove radiopaque objects and to avoid calcium supplements for 24 hours prior to the measurement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Biological samples collection and biobanking\u003c/h2\u003e\u003cp\u003eBiological samples (blood, feces, and saliva) were collected from participants for testing and biobank storage.\u003c/p\u003e\u003cp\u003eApproximately 8 cc of venous blood was collected in two sampling tubes containing clot activator, and 2 cc was collected in two separate tubes containing K2EDTA. These samples were processed immediately to separate serum and plasma, which then were used for biochemical measurements and store in the biobank. Additionally, with the aim of development a microbiota biobank, fecal and saliva samples were collected from a sub sample of the participants. This work was conducted according to the specific sample collection, storage, and transportation protocols established for the operator and participants to ensure the integrity and viability of microbiota.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Diagnostic Laboratory Tests\u003c/h2\u003e\u003cp\u003eComplete Blood Count (CBC), Fasting Blood Sugar (FBS), Hemoglobin A1C (HbA1c), Cholesterol, Triglyceride (TG), High-density lipoprotein cholesterol (HDL-C), Low-density lipoprotein cholesterol (LDL-C), Alkaline Phosphatase (ALP), Alanine Transaminase (ALT), Aspartate Aminotransferase (AST), Parathyroid Hormone (PTH), Thyroid-stimulating hormone (TSH), Free Thyroxine (T4), Vitamin D (25OH), Iron, Total iron-binding capacity (TIBC), Phosphate, Calcium, Urea, Uric Acid, Creatinine, and Albumin are biochemical markers that were measured in this phase of the study. CBC was measured using the automated hematology analyzer KX-21 (Sysmex Corporation, Kobe, Japan). The biochemical measurements were conducted using BS-200 chemical analyzer (Shenzhen Mindray Bio-Medical Electronics Co, Ltd, Shenzhen, China), except for the PTH test, which was performed using the Cobas e411 autoanalyzer (Roche Diagnostics, Basel, Switzerland) and TSH, T4, and Vitamin D (25OH), that were measured using Dynex automated ELISA DS2\u0026reg; processing system (Dynex technologies, Chantilly, VA, USA). The biochemical kits used are presented in the Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe Biochemical Kits used in the phase III of BEH Program\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiochemical Factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCompany\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBiochemical Factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCompany\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFasting Blood Sugar (FBS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFree Thyroxine (T4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePishtaz Teb\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin A1C (HbA1c),\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePaadco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVitamin D (25OH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePishtaz Teb\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Cholesterol (TC)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIron\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBiomed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTriglyceride (TG)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal iron-binding capacity (TIBC (\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMAN\u0026thinsp;+\u0026thinsp;Paadco\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh-density lipoprotein cholesterol (HDL-C)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u0026thinsp;+\u0026thinsp;Audit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhosphate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow-density lipoprotein cholesterol (LDL-C)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u0026thinsp;+\u0026thinsp;Audit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCalcium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMAN\u0026thinsp;+\u0026thinsp;Audit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlkaline Phosphatase (ALP)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUrea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlanine Transaminase (ALT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAudit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUric Acid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMAN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAspartate Aminotransferase (AST)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAudit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCreatinine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAudit\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParathyroid Hormone (PTH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoche\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAlbumin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBiomed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThyroid-stimulating hormone (TSH)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePishtaz Teb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e4. Training and quality assurance\u003c/h3\u003e\n\u003cp\u003eTo ensure the validity of the measured variables, the responsible staff were trained at the beginning of the study based on the study protocol and standard procedures. The agreement between the questioners and the trainer were evaluated.\u003c/p\u003e\n\u003ch3\u003e5. Monitoring and supervision\u003c/h3\u003e\n\u003cp\u003eMonitoring of the true implementation of the study (in accordance with the current protocol) was conducted by inspectors visiting the data collection process and using monitoring checklists. During study monitoring by inspectors, all processes were evaluated, and any deviations from the protocol and related issues were addressed.\u003c/p\u003e\n\u003ch3\u003e6. Data Management\u003c/h3\u003e\n\u003cp\u003eCollected data was recorded in an eCRF. The eCRF was an electronic questionnaire and data collection form designed to help researchers collect data from each participant and record the results of the questionnaires and other tests and measurements (physical examinations and diagnostic laboratory tests). To ensure minimal data loss, each participant's eCRF was completed during every visit and within one week of the availability of diagnostic tests results. The data file was updated every three months and was shared with the project manager in EMRI-TUMS, Tehran. The interviewer responsible for conducting visits and completing the eCRFs had access to these forms. A physician is also permitted to complete eCRFs if individuals were referred for further clinical evaluations. All collected data, including questionnaires, physical examination results, BMD and body composition assessments, and diagnostic laboratory tests, were treated as confidential information. The members of the research team who had permission to access such data were identified. A data protection expert was appointed to monitor the data management process and was responsible for providing periodic reports on this matter. Each participant was assigned the unique code of the previous phase of BEH program, so that their identity remains unknown during any future use of their data. All printed copies of questionnaires and data collection forms were stored in Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences. A digital file of the collected data was created and updated every month. Additionally, a copy of the data file was saved to an external drive every week.\u003c/p\u003e\n\u003ch3\u003e7. Statistical analyses\u003c/h3\u003e\n\u003cp\u003eContinuous variables will be reported as mean (standard deviation) or median (interquartile range), while categorical variables as frequency and percentage. In cases of non-normal distributions for continuous variables, transformation of the data will be considered, or non-parametric tests will be used. When exploring the associations, if the outcome variable is continuous, depending on the hypothesis being tested, a T-test, analysis of variance (ANOVA), analysis of covariance (ANCOVA), or linear regression models will be employed. If the outcome variable is categorical, a chi-square test or appropriate regression analysis will be performed. Risk Ratio, Rate Ratio, Odds Ratio, and Hazard Ratio will be used to illustrate the relationship between the relevant risk factors and the study outcomes. Pearson or Spearman correlation coefficients will be used to assess the correlation between continuous or ordinal variables. Partial correlation will be conducted to control the effects of confounding variables. Multiple linear regression analysis will be performed to investigate the relationship between continuous dependent variables and their potential risk factors. In the case of dichotomous dependent variables, logistic regression will be used. For survival analysis, the life table and Kaplan-Meier methods will be used. To compare groups, the log-rank test will be employed. Cox proportional hazards models and other appropriate multiple survival analysis methods will be used to adjust for potential confounders.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eParticipation status\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe third phase of the BEH program's first recruitment was conducted from January 2022 to March 2023. During this phase, about 2079 subjects who participated in the second phase (stage 2) of the study and were still alive and residing in Bushehr were invited. Finally, 1,345 participants who met the study's criteria were enrolled in the third phase (a response rate of 64.7%). The details of participation status the reasons for non-participation are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eDemographic characteristics of the participants\u003c/h3\u003e\n\u003cp\u003eAmong the participants, 667 (49.6%) were female. The age range of the study participants was 66 to 100 years, with a mean (standard deviation) age of 74.3 (4.6) years. Female participants had an age range of 66 to 93 years, while male participants ranged from 68 to 100 years. The mean (standard deviation) age for females was 74.2 (4.3) years and for males was 74.5 (4.9) years. The demographic characteristics of the study participants are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of participants in the third phase of the BEH Program\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003edescription\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender (Male)\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e678 (50.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e [year, Mean (SD)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.3 (4.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e65\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160 (11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026ndash;74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e751 (55.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e75\u0026ndash;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e277 (20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;=80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e157 (11.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e343 (25.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e499 (37.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e351 (26.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcademic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135 (10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e941 (70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e381 (28.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced/Separate with partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (1.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (0.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eBiobanking of biological samples\u003c/h3\u003e\n\u003cp\u003eThe biobank stored a total of 4,035 serum samples (three 1 cc vials per participant) and 1,345 EDTA plasma (EDP) samples (one 1 cc vial per participant) from 1,345 participants at the Endocrinology and Metabolism Research Institute (EMRI) of Tehran University of Medical Sciences. An additional serum and EDP vial for each participant were stored at the Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences.\u003c/p\u003e\u003cp\u003eTo create a new microbiota biobank, stool and saliva samples were collected from a subsample of participants. Due to the difficulties of stool sampling at home and its proper transport to the study site, this was fully achieved for a sub sample of 499 participants. These samples included two cryotubes containing 1 gram of stool and one 250 mg cryotube of stool, along with a 1 cc saliva sample in a 15 cc Falcon tube for each participant. In total, 1,497 stool samples and 564 saliva samples were stored at the EMRI biobank. Samples were immediately frozen and stored at \u0026minus;\u0026thinsp;80\u0026deg;C to preserve microbial composition and integrity, which is the gold standard for long-term microbiome biobanking.\u003c/p\u003e\n\u003ch3\u003eDiscuss the significance\u003c/h3\u003e\n\u003cp\u003eBEH program has comprehensive data collection, which includes demographic information, general health status, and medical history, helping to achieve a better understanding of elderly health. Additionally, the precise design using multi-stage cluster sampling ensures that the samples are representative of the larger population, providing more generalizable data. This plan for repeated measurements allows researchers to examine changes in key variables and health status over time. This comprehensive assessment provides a clearer path forward for healthcare providers and policymakers in developing public health strategies aimed at promoting healthy aging and increasing community awareness.\u003c/p\u003e\u003cp\u003eThe BEH biobank of biological samples is of great importance and provides critical opportunities for various future wet lab analyses. With the new collection of stool and saliva samples, further evaluation of the microbiota profile, related microbial assessments, and their associations with health conditions is possible.\u003c/p\u003e\u003cp\u003eHowever, BEH program has some limitations. A decrease in participation rate compared to the second phase (stage 2) due to reasons such as death, migration, declining to participate, and physical disability impacts the interpretation of results and affects the quality of comparisons with the previous phases. This factor may limit the generalizability of the results. However, such limitation can be partially addressed by applying methodological approaches, such as weighting based on the probability of dropout, to account for potential biases. Also, there were some challenges in data collection from participants and engaging in assessments, due to physical or mental health issues.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the third phase of first recruitment of the BEH program serves as a repetition of the measurements from the previous phases. The data collected will be used to assess changes in the health-related variables of interest among participants over this time interval. This study will help to identify health trends among older adults and develop effective strategies for the prevention and management of NCDs in the elderly, as well as improve their health and quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBEH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBushehr Elderly Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-communicable diseases\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDALYs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGlobal disability-adjusted life years\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInformed consent form\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eeCRF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eelectronic case report form\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIPAQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Physical Activity Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGLFS-5\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeriatric Locomotive Function Scale-5\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEQ-5D\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth-Related Quality of Life Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSF-12\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e12-item Short Form Health Survey\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eADL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eActivities of Daily Living\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBADL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBasic Activities of Daily Living\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIADL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInstrumental Activities of Daily Living\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e6CIT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCognitive Impairment Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHQ-9\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePatient Health Questionnaire-9\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMNA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMini Nutritional Assessment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePittsburgh Sleep Quality Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eESS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEpworth Sleepiness Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody Mass Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWaist circumference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHip circumference\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPPB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eShort physical performance battery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectrocardiogram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld health organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBone Mineral Density\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDXA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDual-energy X-ray absorptiometry\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody composition analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVertebral fracture assessment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTBS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTrabecular bone score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBone mineral content\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAppendicular skeletal muscle mass\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComplete Blood Count\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFBS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFasting Blood Sugar\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHbA1c\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHemoglobin A1C\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTriglyceride\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHDL-C\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHigh-density lipoprotein cholesterol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLDL-C\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow-density lipoprotein cholesterol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlkaline Phosphatase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlanine Transaminase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAspartate Aminotransferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eParathyroid Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTSH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThyroid-stimulating hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eT4\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFree Thyroxine (Tetraiodothyronine)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTIBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal iron-binding capacity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of variance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANCOVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of covariance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEndocrinology and Metabolism Research Institute\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and Consent to participate\u003c/h2\u003e\u003cp\u003e The third phase of the BEH program study was approved by the Ethics Committee of the Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences (IR.TUMS.EMRI.REC.1396.00223). Participants were fully informed about the study procedures and their rights. Written informed consent was obtained from all participants for all components of the study, including data and biological sample collection, utilization, secondary data analysis, and potential publication of findings. This study was conducted in accordance with the Declaration of Helsinki and adhered to Iranian national guidelines for ethics in research.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAuthors information\u003c/h2\u003e\u003cp\u003eKKH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-0890-6232\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-0890-6232\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eZHT: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-2432-2114\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-2432-2114\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eHSE: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-6395-4915\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-6395-4915\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eGSH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0003-3441-3578\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0003-3441-3578\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eFR: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0003-2350-9574\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0003-2350-9574\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eVH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-8337-0602\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0001-8337-0602\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eMJM: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-0666-7928\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-0666-7928\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eDJ: [email protected]\u003c/p\u003e\u003cp\u003eZS: [email protected]\u003c/p\u003e\u003cp\u003eEH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-2802-1677\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-2802-1677\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eSH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0003-0393-1196\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0003-0393-1196\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eMS: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0003-2992-6184\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0003-2992-6184\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAF: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-0655-8342\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-0655-8342\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eRH: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-9498-6397\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-9498-6397\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eKV: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-9782-2067\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0001-9782-2067\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eNF: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-6205-9794\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0001-6205-9794\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eBL: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-5386-7597\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0001-5386-7597\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eAO: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0001-8670-5797\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0001-8670-5797\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eIN: [email protected], \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://orcid.org/0000-0002-1785-0883\u003c/span\u003e\u003cspan address=\"https://orcid.org/0000-0002-1785-0883\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis phase of BEH Program is jointly financed by the Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran and Bushehr University of Medical Sciences, Bushehr, Iran. (Number: 1396-03-103-2221)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKKH, ZHT, HSE, GSH, FR, VH, MJM, DJ, RH, KV, NF, BL, AO and IN: Conceptualization and study design. KKH, ZHT, DJ, ZS, EH, SH, MS, AF, KV and IN: Data collection. KKH, ZHT, NF and AO: Drafting of the manuscript. HSE, GSH, FR, VH, MJM, DJ, ZS, EH, SH, MS, AF, RH, KV, BL and IN: Critical review and intellectual revision. All authors provided their final approval of the version to be published. Furthermore, all authors take responsibility for the integrity of the work presented and endorse the accuracy of the study profile as reported.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our gratitude to all the employees of the Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, and Persian Gulf Biomedical Sciences Research Institute of Bushehr University of Medical Sciences for their expertise, dedication, and contributions to this project. We also extend our appreciation to the participants and their families, whose willingness to engage in this program was essential for its success. Finally, we acknowledge all individuals and organizations whose support and assistance made this project possible; without their collaboration, this work would not have been achievable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used in this study are available from the corresponding author upon reasonable request. Due to licensing restrictions, the data are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEconomic UNDo, Affairs S. World Population Ageing 2020. Highlights: United Nations; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng X, Yang Y, Schwebel DC, Liu Z, Li L, Cheng P, et al. Population ageing and mortality during 1990\u0026ndash;2017: A global decomposition analysis. 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Gerontologist. 1994;34(4):486\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/geront/34.4.486\u003c/span\u003e\u003cspan address=\"10.1093/geront/34.4.486\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Aged, Cardiovascular Diseases, Musculoskeletal Diseases, Cognitive Function, Cohort Studies, Iran","lastPublishedDoi":"10.21203/rs.3.rs-7362426/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7362426/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThe Bushehr Elderly Health (BEH) Program is a population-based prospective cohort study, designed to address the increasing health challenges associated with an aging population. The third phase of BEH program was carried out with aim to repeat the measurements about the state of non-communicable diseases (NCDs), particularly cardiovascular and musculoskeletal diseases, and cognitive function, and their determinants and consequences in the older adults. This article presents the profile of the third phase measurements of BEH program.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePhase III of the BEH Program was conducted six years after the second phase (stage), involving repeated measurements among participants aged 60 and above residing in Bushehr city. Previous phase participants were invited to take part in this phase. This phase was a repeat of the measurements conducted in the previous phases implicated comprehensive questionnaires, physical and anthropometric examinations, whole body and bone density scan, diagnostic laboratory tests, and biobanking of biological samples included serum, EDP, stool, and saliva.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe successful assessment has been completed for a representative sample of older adults, with an extensive data for future analysis. In this phase of BEH program, a total of 1,345 participants were enrolled in the study, a response rate of 64.7%. The mean (standard deviation) age was 74.3 (4.6) years and 50.4% of the participants were males.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe BEH program\u0026rsquo;s repeated measures provide valuable insights into how health-related variables among participants change over time, as well as the needs of older Iranian adults. Also, adding stool and saliva samples to the BEH program biobank allows for expanded microbiota evaluation in this study. This study results inform public health policy to address the growing burden of NCDs among older adults and will guide clinicians, policymakers, and health managers in developing effective strategies to promote health outcomes and quality of life of older adults.\u003c/p\u003e","manuscriptTitle":"Bushehr Elderly Health (BEH) Program, Phase III: The Study Profile","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 08:05:34","doi":"10.21203/rs.3.rs-7362426/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2463ba24-c961-4e1b-ba23-7d3c59da4aac","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T13:10:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-01 08:05:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7362426","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7362426","identity":"rs-7362426","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}