Socioeconomic position and type 2 diabetes: Examining the mediating role of social cohesion—The Maastricht Study

The relationship between socioeconomic position and type 2 diabetes is well-established; individuals of lower socioeconomic position experience substantially higher rates of the disease. This study investigated the mediating role of perceived and ecometric area-level social cohesion in the association between socioeconomic position and incident type 2 diabetes. In a prospective population-based cohort, The Maastricht Study, we analyzed data from 6,604 participants (age¯ = 58.6 years, 55% female) with a median follow-up of 8.1 (IQR 5.1-10.1) years. We examined whether perceived or area-level social cohesion (in 500 m squares, five-character postal code areas, and neighborhood areas) mediated the association between socioeconomic position (represented by educational attainment, occupational status, or income) and incident type 2 diabetes. We employed a causal mediation approach based on linear regression and Cox proportional hazards models. Individuals with lower socioeconomic position were more likely to perceive lower social cohesion and to live in areas with diminished social cohesion. Lower area-level social cohesion was associated with an increased risk of developing type 2 diabetes. The mediating effect of social cohesion was more pronounced in urban areas. In urban areas, the total effect of education (contrasting the 83rd and 17th percentiles) on type 2 diabetes incidence was a hazard ratio (HR) of 2.03 (95% CI: 1.62-2.58), with area-level social cohesion mediating 24.4% (11.1%-40.3%) of this effect. In less urban areas, social cohesion mediated 12.6% (5.2%-23.0%) of a HR of 1.89 (1.50-2.40). Similar findings were observed with occupational status and income, and across other aggregation levels. Socioeconomic position is linked to lower social cohesion, which is associated with an increased risk of type 2 diabetes. Enhancing social cohesion in disadvantaged areas may help reduce diabetes-related health disparities, particularly in urban settings. Further research is needed to better understand the mechanisms underlying these relationships.