ArticleFrontiers in public health2026
Widening educational inequalities in type 2 diabetes risk and mediators across successive generations: a prospective cohort study.
Article in Frontiers in public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Lower educational attainment has been associated with incident T2DM and adverse outcomes among people with established diabetes, but these stages have largely been studied separately. Whether education-related inequalities span the trajectory from T2DM onset to subsequent cardiovascular disease (CVD) and death, and whether these inequalities differ across birth cohorts, remains uncertain. Methods: This study included participants from the UK Biobank who were free of diabetes at baseline. Participants were stratified into three birth cohorts (pre-1949, 1950-1959, and post-1960) to investigate intergenerational differences in educational inequalities. We employed Fine-Gray proportional subdistribution hazards models and multi-state competing risks models to evaluate the impact of education on the risk of incident T2DM and its subsequent progression to cardiovascular disease (CVD) and mortality. The Relative Index of Inequality (RII) was calculated to quantify the magnitude of disparities. Pathway analysis was conducted to estimate the extent to which socioeconomic, behavioral, and metabolic factors explained the association between educational attainment and T2DM risk. Results: During a median follow-up of 16.5 years, 19,931 incident cases of T2DM were documented among the 460,797 included participants. Primary education or less was associated with increased risks of incident T2DM (HR 1.92, 1.85-1.99), progression to CVD (HR 1.33, 1.30-1.37), and mortality (HR 1.53, 1.49-1.57) compared with college education, and these disparities widened across successive birth cohorts. Overall, the adjusted RII was 2.37 (2.25-2.50), increasing from 2.31 (2.16-2.47) in the pre-1949 cohort to 2.53 (2.29-2.79) in the 1950-1959 cohort and 2.53 (2.18-2.93) in the post-1960 cohort. Socioeconomic, metabolic, and behavioral factors mediated a substantial proportion of the educational inequality, accounting for 42.2% (39.2%-45.2%), 42.6% (38.2%-47.3%), and 20.5% (18.9%-22.2%), respectively. Conclusion: Education-related inequalities extend from T2DM incidence to subsequent progression and have widened across successive birth cohorts. Socioeconomic, behavioral, and metabolic factors mediated a substantial proportion of these disparities.
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