Lower educational level is a predictor of incident type 2 diabetes in European countries: The EPIC-interact study

Carlotta Sacerdote, Fulvio Ricceri, Olov Rolandsson, Ileana Baldi, Maria Dolores Chirlaque, Edith Feskens, Benedetta Bendinelli, Eva Ardanaz, Larraitz Arriola, Beverley Balkau, Manuela Bergmann, Joline WJ Beulens, Heiner Boeing, Françoise Clavel-Chapelon, Francesca Crowe, Blandine de Lauzon-Guillain, Nita Forouhi, Paul W. Franks, Valentina Gallo, Carlos GonzalezJytte Halkjær, Anne Kathrin Illner, Rudolf Kaaks, Timothy Key, Kay Tee Khaw, Carmen Navarro, Peter M. Nilsson, Susanne Oksbjerg Dalton, Kim Overvad, Valeria Pala, Domenico Palli, Salvatore Panico, Silvia Polidoro, J. Ramón Quirós, Isabelle Romieu, María José Sánchez, Nadia Slimani, Ivonne Sluijs, Annemieke Spijkerman, Birgit Teucher, Anne Tjønneland, Rosario Tumino, A. Daphne van der, Anne Claire Vergnaud, Patrik Wennberg, Stephen Sharp, Claudia Langenberg, Elio Riboli, Paolo Vineis, Nicholas Wareham

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124 Citations (Scopus)


Background: Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases worldwide. In high-income countries, low socioeconomic status seems to be related to a high incidence of T2DM, but very little is known about the intermediate factors of this relationship. Method: We performed a case-cohort study in eight Western European countries nested in the EPIC study (n = 340 234, 3.99 million person-years of follow-up). A random sub-cohort of 16 835 individuals and a total of 12 403 incident cases of T2DM were identified. Crude and multivariate-adjusted hazard ratios (HR) were estimated for each country and pooled across countries using meta-analytical methods. Age-, gender- and country-specific relative indices of inequality (RII) were used as the measure of educational level and RII tertiles were analysed. Results: Compared with participants with a high educational level (RII tertile 1), participants with a low educational level (RII tertile 3) had a higher risk of T2DM [HR: 1.77, 95% confidence interval (CI): 1.69-1.85; P-trend < 0.01]. The HRs adjusted for physical activity, smoking status and propensity score according to macronutrient intake were very similar to the crude HR (adjusted HR: 1.67, 95% CI: 1.52-1.83 in men; HR: 1.88, 95% CI: 1.73-2.05 in women). The HRs were attenuated only when they were further adjusted for BMI (BMI-adjusted HR: 1.36, 95% CI: 1.23-1.51 in men; HR: 1.32, 95% CI: 1.20-1.45 in women). Conclusion: This study demonstrates the inequalities in the risk of T2DM in Western European countries, with an inverse relationship between educational level and risk of T2DM that is only partially explained by variations in BMI. Published by Oxford University Press on behalf of the International Epidemiological Association

Original languageEnglish
Article numberdys091
Pages (from-to)1162-1173
Number of pages12
JournalInternational journal of epidemiology
Issue number4
Publication statusPublished - 1 Aug 2012


  • Cohort studies
  • Education
  • Epidemiologic research design
  • Relative index of inequality
  • Socio-economic status
  • T2DM

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