Muhammad Mainuddin Patwary , Mohammad Javad Zare Sakhvidi, Sadia Ashraf, Payam Dadvand, Matthew Browning , Md Ashraful Alam, Michelle L. Bell, Peter James, Thomas Astell-Burt

Metabolic Syndrome presents a significant public health challenge associated with an increased risk of noncommunicable diseases such as cardiovascular conditions. Evidence shows that green spaces and the built environment may influence metabolic syndrome. We conducted a systematic review and meta-analysis of observational studies published through August 30, 2023, examining the association of green space and built environment with metabolic syndrome. A quality assessment of the included studies was conducted using the Office of Health Assessment and Translation (OHAT) tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessment was used to evaluate the overall quality of evidence. Our search retrieved 18 studies that met the inclusion criteria and were included in our review. Most were from China (n=5) and the U.S. (n=5), and most used a cross-sectional study design (n=8). Nine studies (50%) reported only green space exposures, seven (39%) reported only built environment exposures, and two (11%) reported both built environment and green space exposures. Studies reported diverse definitions of green space and the built environment, such as availability, accessibility, and quality, particularly around participants’ homes. The outcomes focused on metabolic syndrome; however, studies applied different definitions of metabolic syndrome. Meta-analysis results showed that an increase in normalized difference vegetation index (NDVI) within a 500-m buffer was associated with a lower risk of metabolic syndrome (odds ratio [OR]=0.90, 95%CI=0.87−0.93, I2=22.3%, n=4). A substantial number of studies detected bias for exposure classification and residual confounding. Overall, the extant literature shows a ‘limited’ strength of evidence for green space protecting against metabolic syndrome and an 'inadequate' strength of evidence for the built environment associated with metabolic syndrome. Studies with more robust study designs, better controlled confounding factors, and stronger exposure measures are needed to understand better what types of green spaces and built environment features influence metabolic syndrome.