The prevalence of metabolic syndrome in drivers: A meta-analysis and systematic review

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IOS Press

Review Article

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The prevalence of metabolic syndrome

in drivers: A meta-analysis and systematic review

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Mohammadreza Soltaninejad^a,b, Hamed Yarmohammadi^c, Elham Madrese^d, Saeed Khaleghi^e, Mohsen Poursadeqiyan^f,g, Mohsen Aminizadeh^h,iand Amin Saberinia^j,^∗

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aDepartment of Clinical Psychology and Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran

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bRajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

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cResearch Center for Environmental Determinants of Health(RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

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dDepartment of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

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eDepartment of Nursing, Alborz University of Medical Sciences, Karaj, Iran

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fDepartment of occupational health Engineering, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran

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gHealth Sciences Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran

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hHealth in Emergency and Disaster Research center, Kerman University of Medical Sciences, Kerman, Iran

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iHealth in Emergency and Disaster Research center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

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jDepartment of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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Received 16 May 2019

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Accepted 27 February 2020

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Abstract.

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BACKGROUND:Metabolic syndrome is an increasing disorder, especially in night workers. Drivers are considered to work during 24 hours a day. Because of job characteristics such as stress, low mobility and long working hours, they are at risk of a metabolic syndrome disorder.

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OBJECTIVES:The purpose of this study is a meta-analysis and systematic review of the prevalence of metabolic syndrome in drivers.

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METHODS:In this systematic review, articles were extracted from national and international databases: Scientific Infor- mation Database (SID), Iran Medex, Mag Iran, Google Scholar, Science Direct, PubMed, ProQuest, and Scopus. Data analysis was performed using meta-analysis and systematic review (random effect model). The calculation of heterogeneity was carried out using the I2 index and Cochran’s Q test. All statistical analyses were performed using STATA software version 11.

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∗Address for correspondence: Amin Saberinia, Department of Emergency Medicine, School of Medicine, Shahid Beheshti

University of Medical Sciences, Tehran, Iran. E-mail:

[email protected].

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2 M. Soltaninejad et al. / The prevalence of metabolic syndrome in drivers

RESULTS:A total of nine articles related to the prevalence of metabolic syndrome in drivers in different regions of the world from 2008 to 2016 were obtained. The total sample size studied was 26156 with an average of 2906 samples per study.

The prevalence of metabolic syndrome in drivers was 34% (95% CI: 30–37).

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CONCLUSION:According to the results of this study, the prevalence of metabolic syndrome in drivers is high. Occupational stress, unhealthy diet and physical inactivity cannot be cited as causes of metabolic syndrome prevalence in drivers. Therefore, to maintain and to improve the health of this group, the implementation of preventive, therapeutic and rehabilitation measures for these people as well as training should be considered.

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Keywords: Metabolic syndrome, driver, meta-analysis, systematic review

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1. Introduction

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Metabolic syndrome (syndrome X) means the

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simultaneous incidence of cardiovascular risk fac-

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tors such as abdominal obesity, hypertension, glucose

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intolerance, or impaired metabolism of insulin and

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lipid disorders. This disease is also known as insulin

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resistance syndrome and dysmetabolic syndrome [1].

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The metabolic syndrome includes a set of risk fac-

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tors that increase the risk of cardiovascular disease,

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type 2 diabetes, and eventually increase cardiovas-

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cular mortality in individuals [2]. Several factors are

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involved in the etiology of metabolic syndrome, inc-

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luding insulin resistance, obesity (especially abdom-

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inal obesity), lipid abnormalities, impaired glucose

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tolerance, hypertension, pro-inflammatory status,

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genetic factors, intrauterine growth retardation, rapid

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urbanization process, nutritional factors, inactivity,

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social, economic and cultural factors, educational

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level and psychosocial stress, environment [1]. The

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syndrome is associated with other disorders including

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stroke, osteoarthritis, some cancers, non-alcoholic

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fatty liver, hyperuricemia, polycystic ovary syndrome

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and obstructive sleep apnea; it also imposes heavy

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costs on the health system, and, in general, it reduces

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the quality of life. Regardless of the underlying cause,

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the total mortality rate in people with this syndrome

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is more than other people [3–5]. The syndrome has

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attracted the attention of many researchers due to its

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association with diabetes and cardiovascular disease,

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as well as high prevalence among populations, and is

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one of the issues recently addressed by epidemiolo-

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gists [6].

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The prevalence of metabolic syndrome varies in

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societies and studies, due to its causes, differences in

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race, and numerous definitions for this syndrome [7].

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The prevalence of this syndrome is high in the West-

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ern and Asian countries. A high prevalence of this

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syndrome has also been reported in other countries

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of the world [8–11]. The prevalence of this syndrome

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in the United States has steadily risen, so that it affects

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25% of the American adult population and 2.9% of

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American teenagers [12]. Today, 24-hour operation is ⁷⁷ an unavoidable component to continue the operating ⁷⁸ in various industries. Night work is an essential con- ⁷⁹ dition for a large part of the workforce. The police ⁸⁰ forces, firefighters, Hospital staff and drivers are ⁸¹ considered as the occupations that have the activity ⁸² during 24 hours a day [13]. One of the characteris- ⁸³ tics of a driving job is a long working time that can ⁸⁴ be tedious. This job is relatively sedentary. Drivers ⁸⁵ typically have only a short period of activity during ⁸⁶ the loading and unloading. On the other hand, driv- 87

ing the heavy vehicles is a stressful and high-risk job, ⁸⁸ and the combination of above factors with unhealthy ⁸⁹ eating habits often leads to overweight and obesity in ⁹⁰ this group of workers [14, 15]. Drivers, due to their ⁹¹ working conditions, are more susceptible to diseases, ⁹² especially the components of the metabolic syndrome ⁹³ and its complications.. Although these diseases can ⁹⁴ damage the driver, but due to the role and responsi- ⁹⁵ bility of these people, the health of other individuals ⁹⁶ can also be compromised. In the previous studies, the ⁹⁷ occupational stress, lack of mobility, work shift, and ⁹⁸ changes in food habits have been announced as the ⁹⁹ major health risks among drivers [16]. Also, these dis- ¹⁰⁰ orders affect the health status of individuals and are ¹⁰¹ led to increasing the risk of road accidents, increasing 102

the absenteeism and even temporary and permanent ¹⁰³ disabilities in drivers [17]. Due to the high prevalence ¹⁰⁴ of metabolic syndrome in the community, and the ¹⁰⁵ severe health and economic consequences associated ¹⁰⁶ with this problem, its higher risk for drivers compared ¹⁰⁷ to other people and lack of precise awareness towards ¹⁰⁸ its prevalence rate among the drivers, the purpose of ¹⁰⁹ this study is a meta-analysis and systematic review of ¹¹⁰ the prevalence of metabolic syndrome in drivers. ¹¹¹

2. Method ¹¹²

In this meta-analysis and systematic review, the ¹¹³ prevalence of metabolic syndrome in drivers was ¹¹⁴ examined based on published articles in internal and ¹¹⁵ external journals without time limitations. All articles ¹¹⁶

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Fig. 1. Flowchart The stages of the introduction of systematic and analytical studies.

in internal and external journals in the national

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and international information databases (SID), Iran

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Medex, Mag Iran, Google Scholar, Science Direct,

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PubMed, Proquest and Scopus, which examined the

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prevalence of metabolic syndrome in drivers, were

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collected. The collected articles were searched with

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appropriate keywords and their combination. Also,

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the sources of the studied articles were reviewed

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for access to other articles. At first, all articles in

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which the prevalence of metabolic syndrome was

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mentioned in the drivers were collected by the

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researchers. All articles published in Persian and

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English, which examined the prevalence of metabolic

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syndrome in drivers, were included in the study. Data

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extraction: Based on inclusion and exclusion crite-

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ria, the abstracts of the articles were studied by the

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researchers, and then unrelated articles and related

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articles were identified to obtain their complete text

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and to extract the data. A form was used for data

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extraction which was including the variables, i.e., ¹³⁶ number of samples, type of studies, age, geographi- ¹³⁷ cal area, country, prevalence of metabolic syndrome, 138

sample size, authors’ name and year of publication ¹³⁹ (Fig. 1). In this study, inclusion criteria were the ¹⁴⁰ research which had the prevalence of metabolic syn- ¹⁴¹ drome in drivers, and the exclusion criteria included ¹⁴² the lack of access to full text of articles, inadequate ¹⁴³ data, and non-relevance of studies with the subject. ¹⁴⁴ The current study was conducted on the basis of ¹⁴⁵ the meta-analysis and systematic review (PRISMA) ¹⁴⁶ reporting system [18]. In addition, based on this, in ¹⁴⁷ order to prevent the subversion, the search, selection ¹⁴⁸ of studies, qualitative evaluation and data extraction, ¹⁴⁹ was independently conducted by three researchers. ¹⁵⁰ If there is a disagreement about the eligibility of an ¹⁵¹ article, that article is judged by another author who ¹⁵² is expert in the field of meta-analysis and system- 153

atic review. Then, the desired data obtained from ¹⁵⁴

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the selected articles was recorded in a checklist with

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information such as the title of the article, the first

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author’s name, the year of publication, the location

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of the study, the sample size, the target community,

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and the access database.

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2.1. Statistical analysis

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Meta-analysis and systematic review was per-

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formed to estimate the prevalence of metabolic

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syndrome in drivers with averaged ages between

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34.5 and 45.9 years. Heterogeneity was calculated

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using the τ² and Cochran’s Q tests, and inconsis-

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tency was expressed as Higgins I². For the Cochran’s

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Q test, P< 0.10 was considered statistically signifi-

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cant. I²values of 25%, 50% and 75% correspond to

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low, moderate and high heterogeneity, respectively.

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Considering the remarkable heterogeneity among

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studies, pooled estimates of the prevalence and the

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corresponding 95% confidence intervals (CI) were

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calculated using random effects models. The pooled

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estimate Calculated after Freeman-Tukey Double

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Arcsine Transformation to stabilize the variances.

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We conducted sensitivity analyses by excluding each

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study at a time from the Meta-analysis and system-

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atic review, in order to examine its influence on the

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pooled estimate. Potential cofactor associated with

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heterogeneity (i.e. publication year) was also ana-

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lyzed by a meta-regression. All statistical analyses

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were performed using STATA version 11.0 (Stata

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Corp, College Station, TX, USA) and the results were

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represented as forest, bubble and funnel plots.

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3. Results

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3.1. Study characteristics

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The characteristics of the included studies are pre-

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sented in Table 1. These studies were published

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between 2008 (Cavagioni LC and et al.) and 2016

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(Ebrahimi and et al. & Prakaschandra R and et al.).

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The sample size of the included articles varied from

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117 (C´ardenas OA and et al.) to 12138 (Mohebbi and

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et al.), with a total of 26156 cases.

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3.2. Evaluation of heterogeneity and

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meta-analysis

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The results of Cochran’s Q test and I² statis-

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tics indicated substantial heterogeneity among the

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included studies (Q= 165.75, d.f.=8, P< 0.001 and

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Table 1

Description of the studies included in the Meta-analysis and systematic review

First Author publication Location Sample Prevalence

Year size of metabolic

syndrome

Cavagioni LC 2008 Brazil 258 0.24

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Saberi H (16) 2009 Iran 429 0.36

Mohebbi I (20) 2009 Iran 626 0.32

YazdiZ (13) 2012 Iran 192 0.23

Mohebbi I (21) 2012 Iran 12138 0.31

Azak S (17) 2015 Iran 10000 0.34

C´ardenas OA (22) 2015 Colombia 117 0.49

Ebrahimi MH (23) 2016 Iran 1018 0.32

Prakaschandra R 2016 South Africa 1378 0.46 (24)

I²= 95.17). Thus, random effects model was used for ¹⁹⁹ all analysis. The pooled prevalence of metabolic syn- 200

drome was 34% (95% CI: 30–37). As seen in Fig. 2, ²⁰¹ the highest and lowest prevalence was reported by ²⁰² C´ardenas OA and et al. in Colombia (49%, 95% CI: ²⁰³ 40–58) and Yazdi Z and et al. in Iran (23%, 95% CI: ²⁰⁴

18–29) respectively. ²⁰⁵

3.3. Meta regression ²⁰⁶

Meta regression was used to explore the sources of 207

between-study heterogeneity, including the year of ²⁰⁸ study. According to the results and Fig. 3, although ²⁰⁹ the prevalence of metabolic syndrome increased in ²¹⁰ years, this amount wasn’t statistically significant. So, ²¹¹ the year of study didn’t relate to prevalence (P> 0.05). ²¹²

3.4. Publication bias ²¹³

As seen in Fig. 4, the funnel plots showed sym- ²¹⁴ metry, demonstrating the absence of publication bias ²¹⁵ among the included studies. The Egger’s and Begg’s ²¹⁶ tests also confirmed the absence of publication bias ²¹⁷ among the included studies (P= 0.548 andP= 0.835, ²¹⁸

respectively). ²¹⁹

3.5. Sensitivity analysis ²²⁰

To evaluate the influence of each individual study, ²²¹ we performed sensitivity analyses by excluding each ²²² study from the Meta-analyses and comparing the po- ²²³ int estimates before and after excluding each specific ²²⁴ individual study. Based on the sensitivity analysis, ²²⁵ exclusion of individual studies did not change the ²²⁶ results substantially, with pooled prevalence.

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Fig. 2. Forest plot showing prevalence of metabolic syndrome in drivers.

Fig. 3. Meta-regression (bubble) plot of metabolic syndrome

prevalence based on year of study. Fig. 4. Funnel plot for assessing publication bias in Meta-analysis and systematic review for prevalence of metabolic syndrome in drivers.

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4. Discussion and conclusion

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This meta-analysis and systematic review was con-

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ducted to determine the prevalence of metabolic

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syndrome in drivers. In the present study, the total

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number of subjects was 26,156 in nine papers from

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different parts of the world and published in the years

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from 2008 to 2016 were entered into the final meta-

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analysis and systematic review; the average sample

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size in these studies was 2906. The prevalence of

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metabolic syndrome in drivers was calculated to be

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34% (95% CI: 30–37). The highest prevalence of

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metabolic syndrome was related to the study con-

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ducted by C´ardenas in Colombia in (49%, 95% CI:

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40–58) and the lowest prevalence was observed in

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Iran in the study of Yazdi (23%, 95% CI: 18–29).

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Alizadeh et al. examined the prevalence of metabolic

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syndrome in the general population in Iran. The

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results of this review showed that the prevalence of

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metabolic syndrome in adults is relatively high [1].

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In the studies, the prevalence rate was obtained to be

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between 20% and 35.8%. These rates are significantly

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higher than estimated global prevalence (20–25%)

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[1]. In Italy, the prevalence rate was 22% in men and

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18% in women [25]. The prevalence rate in the United

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States was 22.9% [26]. According to the results of

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this study, the prevalence rate of metabolic syndrome

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among the drivers is higher than its rate in the general

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population and some other occupations. The reason

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for this may be factors such as unavoidable inactivity,

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high caloric intake, lack of awareness, lack of health

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check by these individuals, occupational stress and

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night work [16]. Drivers have irregular work hours

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because of their work needs. Long working hours,

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including night work are the main feature of this job.

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Night work may lead to chronic sleep deprivation

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and obesity which are commonly seen among these

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people [27]. Among the drivers, the high prevalence

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of wrong inactive lifestyles or sedentary lifestyles,

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inappropriate food habits, and obesity is observed.

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They usually smoke and have high blood pressure

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[27, 28]. These features pose this population at risk

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for diseases such as cardiovascular, digestive and

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metabolic diseases [29]. Stoohs et al. stated that the

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prevalence of hypertension among truck drivers is

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16and high percentage of these people was unaware

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of their illness [30]. High blood pressure in drivers is

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likely to be due to low mobility and lifestyle, which

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requires more attention [31]. Irregular working hours

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are one of the important factors in the development

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of obesity in drivers, and it also led to lessening the

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chance for regular physical activity [32]. Moreover,

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other factors of high weight in drivers can be the use ²⁷⁸ of fatty foods in restaurants and sedentary lifestyle ²⁷⁹ and lack of information on overweight effects [16]. ²⁸⁰ Whitfield-Jacobson et al. suggested that the imple- ²⁸¹ mentation of health programs for drivers can prevent ²⁸² several diseases such as obesity [33]. These programs ²⁸³ can include training and supporting activities and ²⁸⁴ providing nutritional advice to restaurants. The devel- ²⁸⁵ opment of such Preventive programs is justified not ²⁸⁶ only for economic reasons but also is important for ²⁸⁷ driver safety [29]. Metabolic syndrome is an impor- ²⁸⁸ tant medical, social, and economic concern and its ²⁸⁹ prevalence, in developing countries, is one of the ²⁹⁰ increasing medical problems due to increasing the ²⁹¹ sedentary lifestyle and obesity. Therefore, the impor- 292

tance of examining the prevalence of this disease ²⁹³ through a similar screening and diagnostic guideline, ²⁹⁴ as well as considering the risk factors and different ²⁹⁵ ethnic groups seems to be necessary [1]. ²⁹⁶

5. Conclusion ²⁹⁷

According to the results of this study, the preva- ²⁹⁸ lence of metabolic syndrome in drivers is high. ²⁹⁹ Occupational stress, unhealthy diet and physical ³⁰⁰ inactivity cannot be attributed to the prevalence of ³⁰¹ metabolic syndrome in drivers. Therefore, it is sug- ³⁰² gested that training of these people should be carried ³⁰³ out with preventive measures, treatment and disabil- 304

ity, in order to maintain and improve the health of this ³⁰⁵

group. ³⁰⁶

Conflict of interest ³⁰⁷

None to report. 308

References ³⁰⁹

[1] Alizade Z, Azadbakht L. Review of epidemiology of ³¹⁰ metabolic syndrome in Iran. Iranian Journal of Diabetes and 311

Metabolism. 2017;15(3):143-57. 312

[2] Mehrdad SM, Hosseinpanah F, Azizi F. [Metabolic syn- 313

drome prevalence in 3-9 years old children: Tehran 314

Glucose and Lipid Study (Persian)]. Research in Medicine. 315

2006;30(4):337-46. 316

[3] Jaber LA, Brown MB, Hammad A, et al. The prevalence of 317

the metabolic syndrome among Arab Americans. Diabetes 318

Care. 2004;27:234-8. 319

[4] McNeill AM, Rosamond WD, Girman CJ, et al. The 320

metabolic syndrome and 11-year risk of incident cardio- 321

vascular disease in the atherosclerosis risk in communities’ 322

study. Diabetes Care. 2005;28:385-90. 323

(7)

[5] Shiwaku K, Nogi A, Kitajima K, Anuurad E, Enkhmaa

324

B, Yamasaki M, Kim JM, Kim IS, Lee SK, Oyunsuren T,

325

Yamane Y. Prevalence of the metabolic syndrome using the

326

modified ATP III definitions for workers in Japan, Korea and

327

Mongolia. Journal of Occupational Health. 2005;47(2):126-

328

35.

329

[6] Marek H. Dominiczak. Metabolic syndrome editorial com-

330

ment. Curr Opin Lipidol. 2003;14 329-32.

331

[7] Alberti KGMM, Zimmet P, Shaw J. the IDF Epidemiology

332

Task Force Consensus Guoup. The metabolic syndrome – a

333

new world-wide definition. Lancet. 2005;366:1059-63.

334

[8] Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR,

335

Heymsfield SB. The metabolic syndrome: prevalence and

336

associated risk factor findings in the US population from the

337

Third National Health and Nutrition Examination Survey,

338

1988-1994. Arch Intern Med. 2003;163:427-36.

339

[9] Oh JY, Hong YS, Sung YA, Barrett-Connor E. Prevalence

340

and factor analysis of metabolic syndrome in an urban

341

Korean population. Diabets Care. 2004;27:2027-32.

342

[10] Makuyana D, Gomo Z, Munyombwe T, Matenga JA, Hakim

343

JG. Metabolic syndrome disorders in urban black Zim-

344

babweans with type 2 Diabetes mellitus. Cent Afr J Med.

345

2004;50:24-9.

346

[11] Isezuo SA, Ezunu E. Demographic and clinical correlates

347

of metabolic syndrome in Native African type-2 diabetic

348

patients. J Natl Med Assoc. 2005;97:557-63.

349

[12] Tan CE, Ma S, Wai D, et al. Can we apply the National

350

Cholesterol Education Program Adult Treatment Panel def-

351

inition of the Metabolic syndrome to Asians? Diabetes Care.

352

2004;27:1182-6.

353

[13] Yazdi Z, Sareshtehdary M, Tayefi M. Prevalence of

354

Metabolic Syndrome among Truck Drivers and Its Relation

355

to Shift Work. Qom Univ Med Sci J. 2012;5(4):68-72.

356

[14] Horne J, Reyner L. Vehicle Accidents Related to Sleep: A

357

Review. Occup Environ Med. 1999;56(5):289-94.

358

[15] George CF. Sleep Apnea, Alertness, and Motor Vehicle

359

Crashes. Am J Perspir Crit Care Med. 2007;176(10):954-56.

360

[16] Saberi H, Moraveji A, Parastouie K. Metabolic syndrome

361

among professional bus and truck drivers in Kashan, 2008.

362

Iran South Med J. 2009;12(2):126-32.

363

[17] Azak S, Mohebbi I, Salarilak S, Gharaaghaji Asl R. Preva-

364

lence of Metabolic Syndrome and Related Risk Factors in

365

Professional Drivers in West Azerbaijan Province, 2010-

366

2012. J Urmia Univ Med Sci. 2015;26(9):775-84.

367

[18] Shamseer L, Moher D, Clarke M, et al. eds. Prisma-p

368

Group. Preferred reporting items for systematic review and

369

meta-analysis protocols (PRISMA-P) 2015: elaboration and

370

explanation. BMJ. 2015;349:g7647.

371

[19] Cavagioni LC, Bensen˜or IM, Halpern A, Pierin AM.

372

S´ındrome metab´olica em motoristas profissionais de trans-

373

porte de cargas da rodovia BR-116 no trecho Paulista-R´egis

374

Bittencourt. Arquivos Brasileiros de Endocrinologia &

375

Metabologia. 2008;52(6):1015-23.

376

[20] Mohebbi I, Matinkhah M, Nabizadeh F, Blouri A, Saba 377

A, Shirazi A. The Metabolic Syndrome and its Associa- 378

tion with Over Time Driving in Iranian Professional Bus 379

Drivers. International Journal of Occupational Hygiene. 380

2010;2(1):37-41. 381

[21] Mohebbi I, Saadat S, Aghassi M, Shekari M, Matinkhah 382

M, Sehat S. Prevalence of metabolic syndrome in Iranian 383

professional drivers: results from a population-based study 384

of 12,138 men. Plos One. 2012;7(2):e31790. 385

[22] C´ardenas OA. Metaloproteinasas y leptina en conduc- 386

tores de veh´ıculo de servicio p´ublico con s´ındrome 387

metab´olico en Armenia, Quind´ıo. Endocrinolog´ıa y 388

Nutrici´on. 2015;62(9):430-6. 389

[23] Ebrahimi MH, Delvarianzadeh M, Saadat S. Prevalence of 390

metabolic syndrome among Iranian occupational drivers. 391

Diabetes & Metabolic Syndrome: Clinical Research & 392

Reviews. 2016;10(1): S46-51. 393

[24] Prakaschandra R, Naidoo DP. Increased waist circumfer- 394

ence is the main driver for the development of the metabolic 395

syndrome in South African Asian Indians. Diabetes & 396

Metabolic Syndrome: Clinical Research & Reviews. 2016 397

Dec 15. 398

[25] Giampaoli S, Stamler J, Donfrancesco C, Panico S, Vanuzzo 399

D, Cesana G, et al. The metabolic syndrome: a critical 400

appraisal based on the Cuore epidemiologic study. Prev 401

Med. 2009;48(6):525-31. 402

[26] Beltran-Sanchez H, Harhay MO, Harhay MM, McEllig- 403

ott S. Prevalence and trends of metabolic syndrome in 404

the adult U.S. population, 1999-2010. J Am Coll Cardiol. 405

2013;62(8):697-703. 406

[27] Moreno CR, Louzada FM, Teixeira LR, Borges F, Lorenzi- 407

Filho G. Short sleep is associated with obesity among truck 408

drivers. Chronobiol Int. 2006;23(6):1295-303. 409

[28] Hakkanen H, Summala H. Sleepiness at work among com- 410

mercial truck drivers. Sleep. 2000;23(1):49-57. 411

[29] Siedlecka J. [Selected work-related health problems in 412

drivers of public transport vehicles]. Med Pr. 2006;57(1):47- 413

52. 414

[30] Stoohs RA, Bingham LA, Itoi A, Guilleminault C, Dement 415

WC. Sleep and sleep-disordered breathing in commercial 416

long-haul truck drivers. Chest. 1995;107(5):1275-82. 417

[31] Wang PD, Lin RS. Coronary heart disease risk factors in 418

urban bus drivers. Public Health. 2001;115:261-4. 419

[32] Pasqua IC, Moreno CR. The nutritional status and eat- 420

ing habits of shift workers: a chronobiological approach. 421

Chronobiol Int. 2004;21(6):949-60. 422

[33] Whitfield Jacobson PJ, Prawitz AD, Lukaszuk JM. Long- 423

haul truck drivers want healthful meal options at truckstop 424

restaurants. J Am Diet Assoc. 2007;107(12):2125-9. 425