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Context and disease when disease risk is low: the case of type 1 diabetes in Sweden
  1. K F Lynch1,2,
  2. S V Subramanian3,
  3. H Ohlsson1,
  4. B Chaix1,4,
  5. Å Lernmark2,5,
  6. J Merlo1
  1. 1Unit of Social Epidemiology, Department of Clinical Sciences, Malmö University Hospital, Lund University, Malmö, Sweden
  2. 2Unit of Diabetes and Celiac Disease, Department of Clinical Sciences, Malmö University Hospital, Lund University, Malmö, Sweden
  3. 3Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA
  4. 4Inserm U707, UMR-S Inserm—Université Pierre et Mariae Curie-Paris6, Paris, France
  5. 5Department of Medicine, University of Washington, Seattle, Washington, USA
  1. Correspondence to Kristian F Lynch, Department of Clinical Sciences, CRC, Entrance 72, House 28, Floor 12, Malmö University Hospital, 205 02 Malmö, Sweden; kristian.lynch{at}


Background Several European studies have found significant small area variation in the risk of childhood onset (type 1) diabetes (T1D) which has been interpreted as evidence for contextual determinants of T1D. However, this conclusion may be fallacious since the limited number of newborn infants and the low risk for T1D is a source of spurious variability not properly handled by usual statistical methods. This study investigates the existence of contextual effects in the genesis of T1D, compares conclusions in previous reports with results obtained in a multilevel regression framework and highlights analysis of variance as a useful approach in public health.

Methods All singletons born in Sweden between 1987 and 1991 were identified in the Medical Birth Registry (n=560 766) and followed for diabetes until age 14 using the Hospital Discharge Registry. Area variation in the cumulative incidence of T1D was estimated by different statistical methods including multilevel logistic regression.

Results The risk of T1D ranged from 4.3 to 6.5 per 1000 newborns across the counties (n=24) and from 0.0 to 19.2 per 1000 newborns across the municipalities (n=284). These differences were significant in standard statistical tests (counties, p=0.02; municipalities, p=0.007). However, according to multilevel analyses, the risk of T1D ranged from 4.7 to 5.7 and from 4.4 to 6.0 per 1000 newborns in counties and municipalities, respectively, and the area variation was small and without practical relevance (counties, σ2=0.006; municipalities, σ2=0.017).

Conclusions Previous reports based on standard statistical tests are misleading. According to multilevel analysis, administrative areas have minor relevance for individual risk of T1D in Sweden.

  • Multilevel modelling
  • diabetes
  • variations
  • small area epidemiology
  • diabetes DI

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  • Funding This investigation was supported by a Doctoral Grant from the Faculty of Medicine at the Lund University to KFL, by the Swedish Research Council to JM (DNR 2007-1772), the Center for Economic Demography, the Swedish Diabetes Association to ÅL and by a government Grand ALF Research program to JM (DNR M: B 39 977).

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the regional ethical review board in Southern Sweden (DNR 71/2006).

  • Provenance and peer review Not commissioned; externally peer reviewed.