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Meena Kumari, PhD; Jenny Head, MSc; Michael Marmot, FRCP

Arch Intern Med. 2004;164:1873-1880.

Background  Social inequalities in the incidence of type 2 diabetes and the relation of health behaviors and psychosocial factors to the incidence of type 2 diabetes are not well established.

Methods  Prospective occupational cohort study of 10 308 civil servants aged 35 to 55 years at baseline in phase 1 (1985-1988). Diagnosis of diabetes was ascertained by questionnaire at baseline and follow-up at phases 2 (1989), 3 (1992-1993), 4 (1995), and 5 (1997-1999) and glucose tolerance tests in phases 3 and 5.

Results  Participants working in the lower employment grades had a higher incidence of diabetes than those in higher employment grades (men: odds ratio [OR], 2.9; 95% confidence interval [CI], 1.9-4.4; women: OR, 1.7 [95% CI, 0.8-3.7]). Body mass index and other risk factors considered traditional for type 2 diabetes were found to be so in this cohort. In men, of the psychosocial risk factors examined, only effort-reward imbalance was related to incidence of diabetes (OR, 1.7 [95% CI, 1.0-2.8]). The General Health Questionnaire depression subscale was related to incidence of diabetes and impaired glucose tolerance (OR, 1.25 [95% CI, 1.0-1.6]). These associations remained after adjustment for other confounding factors. In men only, social difference in incidence of diabetes was reduced but still significant after adjustment for conventional risk factors.

Conclusions  An inverse relationship exists between social position and incidence of diabetes that is partly explained by health behaviors and other risk factors. Effort-reward imbalance, which is reportedly associated with coronary heart disease, is also associated with type 2 diabetes.

From the International Centre for Health and Society, Department of Epidemiology and Public Health, University College London, London, England. The authors have no relevant financial interest in this article.

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