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Global educational disparities in the associations between body mass index and diabetes mellitus in 49 low-income and middle-income countries
  1. Aolin Wang1,
  2. Karien Stronks2,
  3. Onyebuchi A Arah1,2,3
  1. 1Department of Epidemiology, The Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
  2. 2Department of Public Health, Academic Medical Center, Amsterdam, The Netherlands
  3. 3UCLA Center for Health Policy Research, Los Angeles, California, USA
  1. Correspondence to Professor Onyebuchi A Arah, Department of Epidemiology, UCLA Fielding School of Public Health, 650 Charles E. Young Drive South, Los Angeles, CA 90095-1772, USA; arah{at}


Background Despite the well-established link between body mass index (BMI) and diabetes mellitus (DM), it remains unclear whether this association is more pronounced at certain levels of education. This study assessed the modifying effect of educational attainment on the associations between BMI and DM—as well as the joint associations of BMI and education with DM—in low-income countries (LICs) and middle-income countries (MICs).

Methods The authors used cross-sectional data from 160 381 participants among 49 LICs and MICs in the World Health Survey. Overweight and obesity levels were defined using WHO's classification. Educational attainment was classified in four categories: ‘no formal education’, ‘some/completed primary school’, ‘secondary/high school completed’ and ‘college and beyond’. We used random-intercept multilevel logistic regressions to investigate the modifying influence of educational attainment on the associations of different BMI levels—as well as their joint associations—with DM.

Results We found positive associations between excessive BMI and DM at each education level in both LICs and MICs. We found that the joint associations of BMI and education with DM were larger than the product of their separate single associations among females in LICs. With joint increases in BMI and education, males and females in LICs had similar increased odds of DM, but males had higher such odds than females in MICs.

Conclusions BMI and education are associated with the DM, but the associations seem to differ in complex ways between LICs and MICs and by gender.

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