Yacaman Mendez Diego, Trolle Lagerros Ylva, Ponce de Leon Antonio, Tynelius Per, Fors Stefan, Lager Anton
Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
Centre for Epidemiology and Community Medicine (CES), Stockholm Health Care Services, Stockholm, Sweden.
Eur J Public Health. 2025 Aug 1;35(4):605-610. doi: 10.1093/eurpub/ckaf056.
There is a well-established social gradient in the occurrence of type 2 diabetes, but the extent to which behavioural or metabolic risk factors explain these inequalities remains unclear. Leveraging data from 7123 adults and over 20 years of follow-up, we used counterfactual mediation analysis to estimate the direct effect of low socioeconomic status (measured as educational attainment and occupational class) on the risk of type 2 diabetes, and the indirect effect through behavioural and metabolic risk factors. Mediators included were smoking, high alcohol consumption, low physical activity, diet low in vegetables or fruits, high body mass index (BMI), high fasting glucose, and hypertension. We compared the results to mediation analysis using the difference and the product of coefficients methods. We found an association between low educational attainment 1.31 (95% CI 1.16, 1.45) and low occupational class 1.24 (95% CI 1.09, 1.38) with future risk of type 2 diabetes. In the counterfactual mediation analysis, behavioural and metabolic risk factors explained 60% (95% CI 41%, 75%) of the effect of low educational attainment and 42% (95% CI 19%, 65%) of the effect of occupational class on the risk of type 2 diabetes. The difference and product of coefficients methods yielded similar results. Well-established behavioural and metabolic mediators explained roughly half of the health inequalities in the incidence of type 2 diabetes. Public health interventions should consider alternative mechanisms to reduce disparities in the incidence of type 2 diabetes.
2型糖尿病的发生存在着既定的社会梯度，但行为或代谢风险因素在多大程度上解释了这些不平等现象仍不清楚。利用来自7123名成年人的数据及20多年的随访，我们采用反事实中介分析来估计低社会经济地位（以教育程度和职业阶层衡量）对2型糖尿病风险的直接影响，以及通过行为和代谢风险因素产生的间接影响。纳入的中介因素包括吸烟、大量饮酒、缺乏体育锻炼、蔬菜或水果摄入量低的饮食、高体重指数（BMI）、高空腹血糖和高血压。我们将结果与使用系数差值法和系数乘积法的中介分析结果进行了比较。我们发现低教育程度1.31（95%置信区间1.16，1.45）和低职业阶层1.24（95%置信区间1.09，1.38）与未来2型糖尿病风险之间存在关联。在反事实中介分析中，行为和代谢风险因素解释了低教育程度影响的60%（95%置信区间41%，75%）以及职业阶层对2型糖尿病风险影响的42%（95%置信区间19%，65%）。系数差值法和系数乘积法得出了相似的结果。既定的行为和代谢中介因素解释了2型糖尿病发病率中约一半的健康不平等现象。公共卫生干预措施应考虑采用其他机制来减少2型糖尿病发病率的差异。
