Inequalities in education and national income are associated with poorer diet: Pooled analysis of individual participant data across 12 European countries

PLoS One. 2020 May 7;15(5):e0232447. doi: 10.1371/journal.pone.0232447. eCollection 2020.


Background: Malnutrition linked to noncommunicable diseases presents major health problems across Europe. The World Health Organisation encourages countries to conduct national dietary surveys to obtain data to inform public health policies designed to prevent noncommunicable diseases.

Methods: Data on 27334 participants aged 19-64y were harmonised and pooled across national dietary survey datasets from 12 countries across the WHO European Region. Weighted mean nutrient intakes were age-standardised using the Eurostat 2013 European Standard Population. Associations between country-level Gross Domestic Product (GDP) and key nutrients and nutrient densities were investigated using linear regression. The potential mitigating influence of participant-level educational status was explored.

Findings: Higher GDP was positively associated with total sugar intake (5·0% energy for each 10% increase in GDP, 95% CI 0·6, 9·3). Scandinavian countries had the highest vitamin D intakes. Participants with higher educational status had better nutritional intakes, particularly within lower GDP countries. A 10% higher GDP was associated with lower total fat intakes (-0·2% energy, 95% CI -0·3, -0·1) and higher daily total folate intakes (14μg, 95% CI 12, 16) in higher educated individuals.

Interpretation: Lower income countries and lower education groups had poorer diet, particularly for micronutrients. We demonstrate for the first time that higher educational status appeared to have a mitigating effect on poorer diet in lower income countries. It illustrates the feasibility and value of harmonising national dietary survey data to inform European policy regarding access to healthy diets, particularly in disadvantaged groups. It specifically highlights the need for strong policies supporting nutritional intakes, prioritising lower education groups and lower income countries.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Diet Surveys
  • Diet*
  • Diet, Healthy
  • Educational Status
  • Energy Intake
  • Europe / epidemiology
  • Female
  • Humans
  • Income
  • Linear Models
  • Male
  • Malnutrition / epidemiology*
  • Malnutrition / prevention & control
  • Micronutrients / administration & dosage
  • Middle Aged
  • Multivariate Analysis
  • Nutritional Status
  • Poverty
  • Socioeconomic Factors*
  • Young Adult


  • Micronutrients

Grant support

This project was funded by the WHO Regional Office for Europe. The co-authors Joao Breda and Jo Jewell were staff members of the World Health Organization Regional Office for Europe at the time of research. The views expressed in this publication are the authors’ own and do not necessarily represent the decisions or stated policy of WHO. JB and JJ provided insight on WHO policy matters and access to key contacts. They, like all authors, reviewed and approved the final manuscript.