Effects of Education and Income on Incident Type 2 Diabetes and Cardiovascular Diseases: A Dutch Prospective Study

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Education and income, as two primary socioeconomic indicators, are often used interchangeably in health research. However, there is a lack of clear distinction between these two indicators concerning their associations with health.
This study aimed to investigate the separate and combined effects of education and income in relation to incident type 2 diabetes and cardiovascular diseases in the general population.
Design and Participants
Participants aged between 30 and 65 years from the prospective Dutch Lifelines cohort study were included. Two sub-cohorts were subsequently created, including 83,759 and 91,083 participants for a type 2 diabetes cohort and a cardiovascular diseases cohort, respectively.
Main Measures
Education and income level were assessed by self-report questionnaires. The outcomes were incident type 2 diabetes and cardiovascular diseases (defined as the earliest non-fatal cardiovascular event).
Key Results
A total of 1228 new cases of type 2 diabetes (incidence 1.5%) and 3286 (incidence 3.6%) new cases of cardiovascular diseases were identified, after a median follow-up of 43 and 44 months, respectively. Low education and low income (<1000 euro/month) were both positively associated with a higher risk of incident type 2 diabetes (OR 1.24 [95%CI 1.04–1.48] and OR 1.71 [95%CI 1.30–2.26], respectively); and with a higher risk of incident cardiovascular diseases (OR 1.15 [95%CI 1.04–1.28] and OR 1.24 [95%CI 1.02–1.52], respectively); independent of age, sex, lifestyle factors, BMI, clinical biomarkers, comorbid conditions at baseline, and each other. Results from the combined associations of education and income showed that within each education group, a higher income was associated with better health; and similarly, a higher education was associated with better health within each income group, except for the low-income group.
Education and income were both independently associated with incident type 2 diabetes and cardiovascular diseases. The combined associations of these two socioeconomic indicators revealed that within each education or income level, substantial health disparities existed across strata of the other socioeconomic indicator. Education and income are two equally important socioeconomic indicators in health, and should be considered simultaneously in health research and policymaking.
Original languageEnglish
Number of pages10
JournalJournal of General Internal Medicine
Publication statusE-pub ahead of print - 13-Apr-2022


  • socioeconomic status
  • education
  • income
  • type 2 diabetes
  • cardiovascular diseases
  • health disparities
  • status inconsistency

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