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Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study



High prevalence of coexisting morbidity in people with type 2 diabetes highlights the need to include interactions with education and comorbidity in the assessments of societal consequences of type 2 diabetes. The purpose of this study was to estimate the joint effects of education, type 2 diabetes and six frequent comorbidities.


Nationwide administrative register data on type 2 diabetes diagnosis, hospital admissions, education and disability pension were grouped at the individual level by means of a unique personal identification number. Included were all people (N = 2,281,599) in the age span of 40–59 years living in Denmark in the period 2005 to 2017, covering a total of 17,754,788 person-years. We used both Cox proportional hazards and Aalen additive hazards models to estimate relative and absolute joint effects of type 2 diabetes, educational attainment and six common comorbidities (CVD, cancer and cerebrovascular, respiratory, musculoskeletal and psychiatric diseases). We decomposed the joint effects of educational level, type 2 diabetes and comorbidities into main effects and the interaction effect, measured as extra cases of disability pension.


Lower level of educational attainment, type 2 diabetes and comorbidities independently contributed to additional granted disability pensions. The joint number of cases of disability pension exceeded the sum of the three exposures, which is explained by a synergistic effect of lower educational level, type 2 diabetes and comorbidity.


In this population study, the joint effects of type 2 diabetes, lower education and comorbidity were associated with larger than additive rates of disability pension. An integrated approach that takes into account socioeconomic barriers to type 2 diabetes rehabilitation may slow down disease progression and increase the working ability of socially disadvantaged people.

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Fig. 1



Civil Registration System


Disease management programme


Danish National Diabetes Register


Danish National Prescription Registry


International Standard Classification of Education


Rate difference


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The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.

Author information




AMB conducted the analysis and was responsible for writing the manuscript. All authors were involved in the conception and design of the study. All authors discussed data analyses, critically revised the manuscript and approved the final version of the manuscript. AMB is responsible for the integrity of the work as a whole.

Corresponding author

Correspondence to Anne Mette Bender.

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Bender, A.M., Vrangbæk, K., Lange, T. et al. Joint effects of educational attainment, type 2 diabetes and coexisting morbidity on disability pension: results from a longitudinal, nationwide, register-based study. Diabetologia (2021).

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  • Comorbidity
  • Disability pension
  • Inequality
  • Integrated care
  • Interaction
  • Socioeconomic position
  • Type 2 diabetes mellitus