LIFE is much more stressful at the bottom than the top, according to a long-running study.

Men who spend their working lives being told what to do by others are almost three times as likely to develop diabetes as are their bosses.

The latest results from a long-running Whitehall study of civil servants suggests, in Archives of Internal Medicine, that those who work hard for the least reward are the most likely to get adult-onset diabetes.

Professor Sir Michael Marmot and colleagues from University College London have been following more than 10,000 civil servants since 1985. At intervals since then they have discovered, through questionnaires, how many have developed Type 2 diabetes, the form of the disease that usually develops in middle age.

Diabetes is a very common disease and is becoming more so. It is often linked to heart disease and can lead to a number of serious complications and early death.

For heart disease, a number of factors have been identified in addition to the classical risk factors of obesity, high cholesterol, high blood pressure and smoking.

Low job control, low social support, depression and effort-reward imbalance are all psychosocial factors linked to heart disease. But until now only a few studies have hinted at a similar link to diabetes, including one that showed that air traffic controllers with a high-stress, high-demand job are especially prone to the disease. Another study, of Japanese men, showed that those who do an excessive amount of overtime have an increased risk of diabetes.

Meena Kumari, Jenny Head and Sir Michael, all from UCL, examined data from the Whitehall II study to see if there was any link between diabetes and any of these factors. Men and women from 20 London-based Whitehall departments recruited between 1985 and 1988 were questioned at intervals over the next 11 years, and the team compared the incidence of diabetes with the rank occupied in the highly heirarchical civil service.

By the time of the final questionnaire, about 4 per cent of the participants had developed diabetes. The disease was much more common in the lower grades.

Civil servants at the bottom end are 2.9 times as likely to develop the disease if they are men and 1.7 times as likely to do so if they are women. Part of the reason is that the lower-grade civil servants lead less healthy lives, in terms of diet and other behaviours, and this can explain the different incidence of the disease in women. But in men it cannot.

“Effort-reward imbalance” is the extra factor that explains the added risk in men. Men who feel that the rewards they get from work are disproportionate to the effort they put in seem to be the ones at higher risk.

So bottom dogs are less healthy and die younger than top dogs. So long as heirarchies exist, equalising health outcomes is going to be much harder than governments might like to think.

• A study by Professor Hussein Ammar, of the National Research Centre in Cairo, presented at the British Pharmaceutical Conference in Manchester, suggests that people with diabetes may soon be able to swap tablets for creams, ointments or patches.

  Research in Egypt on rats has shown that the active ingredients in diabetes medications can pass through the skin and achieve the right response.
  
  1.4m SUFFER

• Diabetes occurs in two forms. Type 1 is caused by a failure to produce insulin, the hormone that moves glucose from the blood into the cells. Type 2 can be caused either by a shortage of insulin or by a fault in the way the body responds to it
• 1.4 million people in Britain have diagnosed diabetes, but charities believe there may be a million more
• Men and women are equally likely to get the disease, but women are more likely to die earlier
• Risk factors for diabetes include obesity, family history and ethnicity
• Diabetes increases the risk of ill-health

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