The prevalence of type 2 diabetes and prediabetes among armed

forces personnel: a systematic review and meta-analysis

Research article

Keywords: Prevalence, Diabetes mellitus, Prediabetes, Military personnel, police officers

Posted Date: January 7th, 2021

DOI: https://doi.org/10.21203/rs.3.rs-28477/v3

License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License

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Abstract
Background: Previous studies of diabetes among armed forces personnel did not assess a comprehensive disease prevalence. We
conducted a systematic review and meta-analysis to estimate the prevalence of type 2 diabetes and prediabetes among military personnel
and police officers.

Methods: We carried out a systematic search on electronic databases from January 2000 to July 2020. All studies with a report of the
prevalence of diabetes and/or prediabetes among armed forces personnel were selected. The Cochran test and I2 statistics were used to
determine the heterogeneity of the studies. Random- or fixed-effects model, along with subgroup analysis on diabetes or prediabetes as
well as the component of armed forces, was carried out to determine the overall prevalence. All analyses were conducted using STATA
software.

Results: Among 858 citations, 30 studies were entered into the meta-analysis, involving 1879170 individuals. The meta-analysis estimated
the prevalence of type 2 diabetes among the military personnel (9.15%; 95% confidence intervals [CI]: 5.35-12.96) and police officers
(9.58%; CI: 5.98-13.18). The overall prevalence of prediabetes among the military personnel and the police officers were 7.32% (CI: 4.22-
10.42) and 6.35% (CI: 5.26-7.44), respectively.

Conclusion: The prevalence of diabetes and prediabetes among armed forces was consistent with global reports among the general
population. These results will inform policy-makers and healthcare providers to find solutions and help to take action to reduce diabetes
risk factors on a wider scale, particularly among armed forces personnel.

Background
Diabetes mellitus is a major global healthcare challenge. Based on the International Diabetes Federation (IDF) diabetes atlas, 463 million
people influenced by diabetes in 2019 worldwide and estimated to be 700 million by 2045 [1]. The expenditure of annual global health on
diabetes is approximately USD 760 billion [2]. Diabetes causes a number of micro- and macrovascular complications, as the main reason
for morbidity and mortality among patients with diabetes [3]. Furthermore, it significantly affects the life expectancy and quality of
patients as well as the development of other diseases [4].

Among the risk factors of diabetes, the occupation has a crucial role. Nowadays, the relationship between occupational factors and the
prevalence of diabetes takes the interest of researchers [5]. Armed forces are at high risk of developing cardiometabolic syndrome
because they have unique lifestyles and expose to stressful situations [6]. A body of evidence demonstrated that this occupational group,
compared to the general population, had a higher prevalence of metabolic diseases, including diabetes [7, 8]. Additionally, other
occupational characteristics, like dietary regimens, atypical physical activity, long work hours, social isolation, and ergonomic problems,
have a negative impact on the health conditions of armed forces personnel [9, 10]. The countries’ human development index (HDI) as
another remarkable factor impress the quality of life and incidence of many diseases among different occupations [11]. The HDI is a
statistic composite indicator of life expectancy, education, and income, ranked countries into four categories including low (0.350-0.549),
medium (0.550-0.699), high (0.700-0.799), and very high (0.800-1.000) [12].

The combination of these elements contributes to making negative changes in lifestyle among this occupational group. The results of a
cohort study showed that armed forces are more prone to non-communicable diseases, especially at earlier ages, and they die much
earlier compared to other groups [13].

This evidence warrants for more comprehensive strategies of monitoring and screening to reduce the prevalence of diabetes and its
burden. Therefore, we carried out a systematic review and meta-analysis of relevant studies to improve the understanding and knowledge
of the prevalence of type 2 diabetes and prediabetes among different components of armed forces personnel (military personnel and
police officers) around various geographical parts of the world.

Methods
The current study is a systematic review and meta-analysis conducted to estimate the prevalence of prediabetes and diabetes among
armed forces personnel in 2020. The study was carried out based on Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) [14].

Literature Search

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A comprehensive literature search of published studies was conducted using Medline/PubMed, Scopus, ProQuest, and Web of Science, as
well as Google Scholar in July 2020. The medical subject headings (MeSH) keywords included “army”, ”military”, ”soldiers”, ”police”,
”policemen”, ”cop”, ”conscript” “diabetes”, “prediabetes”, “metabolic syndrome”, and “prevalence”. The keywords dashboard is represented
in Supplementary file 1. All articles list were imported to EndNote X7 (Thomson Reuters, Carlsbad, CA, USA) library, and the duplicates were
automatically removed. Moreover, the references list of included studies were manually searched to ensure satisfying coverage.

Selection criteria

The primary screening was performed according to the title and abstract by two independent researchers (MF and SH). After that, data
extraction and quality assessment were done by reading the full-text of the remaining articles. In the case of conflict in any of the
secondary stages, the corresponding author (MS) made the final decision.

The primary inclusion criteria were original studies with a report of the prevalence of diabetes and/or prediabetes among in-service armed
forces personnel. The selected studies consist of cross-sectional studies as well as cohort studies reported the prevalence in the baseline.
Studies with an inappropriate population (retired personnel, veterans, and outlier ages), estimation of incidence, and non-English language,
as well as conference abstracts, poster papers, and editorial, were excluded.

Definitions

Type 2 diabetes was defined as a fasting blood glucose (FBG) level of ≥126 mg/dL (7.0 mmol/L), hemoglobin A1c (Hb1Ac) level of ≥6.5
%, current use of anti-diabetic drugs (either insulin, oral anti-diabetic drugs, or both), or a previous diagnosis made by a physician.

Prediabetes was defined as FBG level of 110 to 125 mg/dL (6.1 mmol/L to 6.9 mmol/L), impaired oral glucose tolerance test, or Hb1Ac
level of 5.7-6.4 %.

Data extraction

A spreadsheet was prepared using all targeted statistics. This checklist included the name of the first author, year of publishing, time
period, location of study, number of participants, method of diagnosis, and frequency (with lower and upper 95% confidence intervals) for
diabetes and prediabetes.

Quality assessment

The Joanna Briggs Institute (JBI) checklist was applied in order to evaluate the quality of the included studies [15]. This appraisal is aimed
to estimate the methodological quality and to assess the possibility of bias in the design, conduct, and analysis of studies. The included
studies were scored out of nine using this assessment tool and categorized as satisfactory (score = 7-9), good (score = 4-6), and low
(score = 1-3) quality.

Meta-regression analysis

The meta-regression was utilized due to the high level of heterogeneity of the included studies. One of these subgroup analyses was the
country’s HDI as a relative index of life expectancy and quality as well as literacy and education. The other subgroups consisted of the
mean age of participants, sample size, and publication year of study.

Meta-analysis

The Cochran test (with a significance level of <0.1) in combination with I2 statistics (with a significance level of >50%) was used to
determine the heterogeneity of the studies. Thereafter, the random-effects model with the inverse-variance method was applied in the
presence of heterogeneity. The subgroup analysis was performed in the case of heterogeneity based on the type of disease (diabetes or
prediabetes), the component of armed forces personnel (military personnel or police officers), geographical regions (America, Asia, or
Africa), and sample size (<1000 or >1000 subjects). All analyses were conducted using STATA software (version 13).

Sensitivity analysis

In order to evaluate the quality and consistency of the findings and to assess the robustness of the obtained results, sensitivity analysis
was conducted through deleting each study separately.

Assessing risk of bias

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The publication bias was evaluated using the Egger test [16].

Results
Results of the search

The primary stage of searches yielded 858 citations. Additionally, 44 studies also identified through gray literature. After removing
duplicates, 657 studies selected to investigate the titles and abstracts, and 108 articles remained for the full-text review. Of these, 46
studies fulfilled the inclusion criteria. Finally, 30 articles, involving 1879170 individuals, were extracted for the meta-analysis. The reasons
for exclusion of 645 papers were irrelevant title (n = 567), studies with inappropriate population (n = 12), not reporting prevalence of either
diabetes or prediabetes (n = 11), reporting incidence of either diabetes or prediabetes (n = 2), review or meta-analysis study (n = 6), non-
English papers (n = 10), and editorial, conference abstracts, or poster papers (n = 7). The flowchart of the included studies is shown in Fig.
1.

Description of studies

Among 30 included studies (26 cross-sectional and four cohort studies), 11 studies conducted in India [7, 8, 17-25], four in the USA [26-29],
two in Iran [30, 31], two in Saudi Arabia [32, 33], one in Brazil [34], one in Sweden [35], one in Canada [36], one in Poland [37], one in
Zambia [38], one in Jordan [39], one in Guinea-Bissau [40], one in Thailand [41], one in Brunei [42], one in Sri Lanka [43], and one in
Ethiopia [6], with report of diabetes (n = 30) and prediabetes (n = 9) prevalence. Studies participants consisted of military personnel,
soldiers, and conscripts, as well as police personnel and officer. The participants’ age ranged from 17 to 60 years old. FBG was used as
the main diagnosis method of diabetes and prediabetes in most studies. The basic characteristics of the included studies are shown in
Table 1.

Quality assessment

Based on the JBI checklist, included studies categorized as satisfactory (n = 21), good (n = 9), and low (n = 0) quality. The results of the
quality assessment are summarized in Table 1 and Supplementary file 1.

Heterogeneity

Considerable inter-study heterogeneity was observed based on the Cochran test and the I2 index. The results of heterogeneity and the
models of analysis are expressed in Table 2.

Results of the meta-regression

The Results of meta-regression demonstrated an association between publication year of study and the prevalence of diabetes among
military personnel (Reg Coef = 0.062, p = 0.069). However, this was not significantly associated with HDI score (Reg Coef = -8.11, p =
0.441), sample size (Reg Coef = 0.001, p = 0.935), and mean age of the participants (Reg Coef = 0.024, p = 0.879).

On the other hand, the obtained results showed an association between the mean age of the participants and the prevalence of diabetes
among police officers (Reg Coef = 0.064, p = 0.089). Such a meaningful finding was not observed for HDI score (Reg Coef = 2.21, p =
0.182), sample size (Reg Coef = -0.001, p = 0.593), and publication year of study (Reg Coef = -0.001, p = 0.919).

Results of the meta-analysis

Prevalence of diabetes

The analysis of pooled data indicated the overall prevalence of diabetes among the military personnel was 9.15% (95% confidence
intervals [CI]: 5.35-12.96; I2 = 99.8%, p <0.001). The results of subgroup analyses showed the Asian countries had the highest prevalence
of diabetes among the military personnel (12.38%; CI: 5.89-18.86) (Supplementary file 3). The prevalence of diabetes among the police
officers was 9.58% (CI: 5.98-13.18; I2 = 98.6%, p <0.001). The obtained results of subgroup analysis also demonstrated the highest
prevalence of diabetes among police officers was related to Asian countries (13.09%; CI: 5.47-20.70) (Supplementary file 4). The results of
the meta-analysis of diabetes prevalence stratified by a different variable are demonstrated in Table 2.

Prevalence of prediabetes

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The overall prevalence of prediabetes among the arm forces personnel was 6.51% (CI: 5.49-7.53, I2 = 62.7%, p = 0.006). The results of
subgroup analyses indicated the prevalence of prediabetes among the military personnel and police officers were 7.32% (CI: 4.22-10.42, I2
= 44.3%, p = 0.166) and 6.35% (CI: 5.26-7.44, I2 = 70.0%, p = 0.005), respectively (Supplementary file 7). The results of the meta-analysis of
prediabetes prevalence among armed forces personnel are demonstrated in Table 2.

Sensitivity analysis

The findings were reanalyzed by deleting each study separately. The results demonstrated the studies with small sample size, and the
outlier studies had no significant effect on the final finding.

Publication bias

Results of Egger’s tests demonstrated a lack of publication bias (p >0.10).

Discussion
To the best of authors’ knowledge, this is the first meta-analysis conducted on the prevalence of diabetes and prediabetes among armed
forces personnel. Several investigations have reported the prevalence of diabetes and prediabetes among different components of armed
forces. However, the result of these studies has demonstrated a range of variability in the prevalence. The reported prevalence of diabetes
in armed forces was varied from 0.0% to 34.7% or even higher, depending on different diagnostic criteria, age, HDI of countries, special
diet, various comorbidities, and other environmental factors. The present meta-analysis also indicated that different types of armed forces
might play a significant role in the prevalence of dysglycemia.

The obtained results demonstrated that the prevalence of diabetes among the military personnel (9.15%) is relatively lower compared to
that of the police officers (9.58%). The highest reported prevalence of diabetes (>30%) was also related to studies carried out among
police officers [7, 17, 20, 23]. The overall prevalence of diabetes among military personnel, not police officers, is under the global
prevalence of diabetes (9.30%) [44]. The highest prevalence of diabetes among arm forces personnel (>30%) were related to the medium
HDI countries. This prevalence is uneven since policemen are expected to be in good shape with regular physical activities. Several
previous studies conducted among police officers demonstrated the high prevalence of overweight and obesity made them susceptible to
metabolic and heart disease [45, 46]. These risk factors of dysglycemia also were associated with a mean age of study population, and
elderly participants were more prone to develop diabetes [46].

The most frequent and highly rated stressors might be the other main reasons for the high prevalence of many mental and non-
communicable diseases in this occupation group [47, 48]. Moreover, ergonomic problems, long work hours, and a particular nutrition
regimen should not be underestimated [49, 50]. Recent comprehensive studies also showed the prevalence of metabolic syndrome, and its
component is high among policemen relative to the general population [9, 20].

However, the overall prevalence of diabetes among military personnel was lower than that of other components of armed forces. Several
studies reported that diabetes only affected less than two percent of this occupational group [31, 35, 39]. In addition to a more appropriate
lifestyle, there are some other factors contributing to the relatively low prevalence of diabetes in the military unit. Men are initially recruited
at younger ages and undergo regular medical checkups, physical training, and calorie-controlled diets. Then, those individuals with
underlying medical conditions, including central obesity, are exempted from these services or replaced in public services [9, 51]. Hence,
some included military personnel in the present investigation might have a better health-related quality of life compared to the police
officers or the general population [51].

The results also showed that the prevalence of diabetes among this population was not associated with the year of study. There are
several other studies that indicated the prevalence of diabetes is increasing, passing the time [52, 53]. These are not only related to the
increasing trend of physical inactivity and consumption of unhealthy diet but also progression in diagnostic techniques as well as
effective strategies for detection and follow-up people with dysglycemia [54]. However, this kind of association was not observed in the
present study.

Our findings demonstrated that the prevalence of prediabetes among the military personnel and the police officers were 7.32% and 6.35%,
respectively. A body of evidence has demonstrated a range of prevalence of dysglycemia in armed forces according to different
biochemical criteria. Some studies reported a prevalence of impaired fasting glucose about 30-40%, particularly among police officers [17,
20, 34, 55-57]. In several studies conducted on the arm forces personnel, age as well as obesity were found to be the strongest predictors

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for prediabetes, especially in men. However, due to the low number of studies reported the prevalence of prediabetes, we could not conduct
more analyses on the risk factors of prediabetes. The overall prevalence of prediabetes in included studies is under the estimated
prevalence of the adult population (7.30%) around the world [58]. However, the fasting blood glucose should be screened regularly among
armed forces personnel as an affordable and invaluable biochemical factor, and impaired fasting glucose would be better to consider as a
critical index for early detection and prevention of at-risk population.

Strengths and limitations

The main strength of the current study is that this is the first analysis that showed the prevalence of diabetes and prediabetes among
armed forces personnel. This study can supply reliable baseline information and may guide other scholars to design and conduct novel
researches.

However, several limitations reflected by some factors of data are confirmed. Sufficient information was not available to conduct separate
or subgroup analyses in terms of assessment of all age groups. The lack of data regarding lifestyle, physical activity, nutritional habits,
and comorbid factors of the participants, which could explain the estimated prevalence of diabetes, is another main limitation. Because of
the high level of heterogeneity of the included studies, it was only attempted to analyze the results according to countries’ HDI.

Conclusion
In summary, this meta-analysis clearly demonstrated that the prevalence of diabetes and prediabetes among all types of armed forces
personnel was consistent with global reports of these diseases among the general population. These results will inform policy-makers and
healthcare providers to find solutions and help to take action to reduce diabetes risk factors on a wider scale, particularly among armed
forces personnel. Future large-scale investigations studying the prevalence of diabetes and its associated factors among armed forces
personnel would also help to estimate the more exact prevalence of dysglycemia, and help to take effective strategies in prevention, early
detection, and management of diabetes among this occupational group.

Abbreviations
CI: 95% confidence interval; IDF: International Diabetes Federation; HDI: human development index; PRISMA: Preferred Reporting Items for
Systematic Reviews and Meta-Analyses; MeSH: medical subject headings; JBI: Joanna Briggs Institute.

Declarations
Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

All data is presented within the manuscript file.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors' contributions

All authors were responsible for conceiving and designing the protocol. MF, SH, and MS designed the study. MF and MT did the literature
search and, together with SH, selected the studies, extracted the relevant data. SH and MS synthesized the data. MF wrote the first draft of

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the Manuscript. MS and SA provided critical guidance on the analysis and overall direction of the study. All authors critically revised
successive drafts of the paper and approved the final version.

Acknowledgements

Thanks Dr. Maryam Saleh for the invaluable comments on the study and for editing the final draft.

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Tables
Characteristics of the studies included in the review.

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 Author, year Time Country Population Sex Age Sample methods Prevalence Quality
period size of assessment
diagnosis DM PDM

1 Gielerak, 2020 [37] 2013- Poland Military Both ≥40 9440 D, SR 11.0 - 8
2015 soldiers
2 Masih, 2019 [17] 2017- India Police Male 40- 155 FBG 31.6 - 5
2018 officers 60
3 Shrestha, 2019 [28] 2012 USA Military Both 17- 263430 D, SR 9.8 - 8
personnel 64
4 Gendron, 2019 [36] 2015- Canada Police Both - 2685 SR 1.3 - 7
2016 officers
5 Bandopadhyay, 2018 India Traffic Both 20- 196 FBG 7.1 - 8
2018 [22] police 60
6 Jayaweera, - Sri Police Male - 417 FBG 0.1 - 7
2018 [43] Lanka officers
7 Phiri, 2017 [38] - Zambia Police Both - 148 FBG, M, 9.1 - 8
officers SR
8 Ravikumar,2017 [23] 2013- India Police Both 30- 1618 FBG, SR 34.7 - 6
2015 personnel 59
9 Bhatia, 2017 [24] 2015 India Police Both ≥18 982 FBG, SR 2.6 - 7
officers
10 Lindman, 2017 [40] 2009- Guinea- Police Both 19- 1104 HbA1c 4.1 4.2 7
2010 Bissau officers 83
11 Rush, 2016 [29] 2007- USA Military Both - 42200 SR 2.3 - 8
2008 personnel
12 Tesfaye, 2016 [6] 2015 Ethiopia Federal Both 18- 936 FBG 5.0 8.0 9
police 55
commission
13 Moline, 2016 [26] 2008- USA Law Both ≥40 2497 FBG, SR 14.0 - 7
2010 enforcement
officers
14 Crump, 2016 [35] 1969- Sweden Military Male 18 1547478 FBG 0.8 - 8
1979 conscripts
15 Win, 2015 [42] 2012 Brunei Police Both - 365 FBG 9.0 - 8
personnel
16 Afifi, 2015 [32] 2010- Saudi Armed force Male 40- 117 RBG 21.4 - 5
2011 Arabia recruits 54
17 Filho, 2014 [34] 2012 Brazil Military Male 42- 451 FBG 10.6 - 7
police corps 57
18 Yoo, 2013 [27] 2008- USA Law Male 22- 106 FBG, D 17.9 - 5
2009 enforcement 60
officers
19 Ramakrishnan, 2013 India Police Both 20- 256 FBG, D 33.6 7.0 8
2013 [7] officers 59
20 Kumar, 2013 [18] 2011 India Police Both 20- 1817 FBG, 15.0 6.8 9
personnel 59 OGTT
21 Thayyil, 2012 [19] - India Police Male 26- 823 FBG, D 7.0 6.7 6
officers 58
22 Khoshdel, 2012 [30] 2010- Iran Military Male 20- 96 FBG 5.2 4.2 8
2011 parachutists 50
23 Madhusudhana, - India Military Both 25- 600 FBG 6.7 - 7
2011 [8] personnel 55
24 Kamble, 2011 [25] 2007 India Police Male - 55 FBG, D 36.4 - 6
officers
25 Saengdidtha, 2006 Thailand Military Both - 445 FBG 4.3 - 6
2009 [41] personnel
26 Heydari, 2010 [31] - Iran Military Male 20- 341 FBG 1.8 8.5 9
personnel 54
27 Tharkar, 2008 [20] - India Police Male ≥ 318 FBG 32.1 - 9
officers 30
28 Kumar, 2008 [21] - India Police Male 20- 2160 FBG 11.5 6.2 9
officers 60
29 Khazale, 2007 [39] 2006 Jordan Military Male - 111 FBG, SR 0.0 9.6 6
pilots
30 Al-Qahtani, 2004 Saudi Military Male 20- 1079 FBG, SR 9.9 - 6
2005 [33] Arabia soldiers 60

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abetes mellitus, PDM; prediabetes, FBG; fasting blood glucose, RBG; random blood glucose, HbA1c; hemoglobin A1c,
ral glucose tolerance test, SR; self-reporting, D; use of anti-diabetic drugs.
Table 2 Result of meta-analysis.
Subgroups Variable Number of study Prevalence (95% CI) I2 P value
Diabetes Military personnel Region Asia 6 12.38 (5.89-18.86) 95.6 <0.001
America 2 8.86 (6.33-11.40) - -
Europe 1 0.8 (0.79-0.81) - -
Sample size <1000 6 12.96 (5.66-20.27) 94.7 <0.001
>1000 3 9.15 (5.35-12.96) 99.8 <0.001
Police officers Region Africa 3 4.98 (3.39-6.56) 56.8 0.099
Asia 5 13.09 (5.47-20.70) 98.4 <0.001
America 2 7.63 (4.81-20.08) - -
Sample size <1000 6 10.27 (5.73-14.80) 95.9 <0.001
>1000 4 8.57 (1.73-15.42) 99.4 <0.001
Prediabetes Military personnel 3 7.32 (4.22-10.42) 44.3 0.166

Police officers 6 6.35 (5.28-7.44) 70.0 0.005

Figures

Figure 1

Flowchart of the included studies.

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download.

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PRISMA2009checklist.doc
Supplementaryfile1.docx
Supplementaryfile2.docx
Supplementaryfile3.pdf
Supplementaryfile4.pdf
Supplementaryfile5.pdf
Supplementaryfile6.pdf
Supplementaryfile7.pdf

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