title: The comparative efficacy of lifestyle intervention and metformin by educational attainment in the Diabetes Prevention Program.
abstract: OBJECTIVE
  Educational attainment is inversely associated with type 2 diabetes risk, but it is unknown whether education impacts individuals' diabetes prevention efforts. We examined the comparative efficacy of intensive lifestyle intervention and metformin by educational attainment among participants in the Diabetes Prevention Program (DPP), an ongoing U.S. multi-site trial beginning in 1996.
  
  
  METHODS
  We studied 2,910 DPP participants randomized to receive lifestyle intervention, metformin, or placebo. Stratifying by educational attainment, diabetes incidence and relative risk reductions by treatment assignment were estimated using Cox proportional hazards regression.
  
  
  RESULTS
  47% of participants had completed college and 53% had not. Compared to placebo, lifestyle participants who had completed college demonstrated a 68% reduction in diabetes incidence (95% CI=56, 77), whereas those with less education experienced a 47% risk reduction (95% CI=29, 61). For metformin participants, college graduates experienced a 49% relative risk reduction (95% CI=33, 62), compared to 23% (95% CI=1, 41) among those with lower educational attainment. There was a statistically significant education-by-treatment interaction with incident diabetes (p=0.03).
  
  
  CONCLUSIONS
  Intensive lifestyle intervention and metformin have greater efficacy among highly educated individuals. Future efforts to deliver these treatments and study their dissemination may be more effective if tailored to individuals' educational background.
authors.affiliation: Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg, School of Medicine, 750N. Lake Shore Drive, 10th floor, Chicago, IL 60611, USA; Center for Community Health, Institute for Public Health and Medicine, Northwestern, University Feinberg School of Medicine, 750N. Lake Shore Drive, 6th floor, Chicago, IL 60611, USA. Electronic address: matthew.obrien1@northwestern.edu.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: O'Brien
authors.affiliation: Department of Public Health, Temple University, 1938 Liacouras Walk, Philadelphia, PA 19140, USA; Department of Pediatrics, Temple University School of Medicine, 3500N. Broad Street, Philadelphia, PA, 19140, USA; Center for Obesity Research and Education, Temple University, 3223N. Broad Street, Suite, 175, Philadelphia, PA, 19140, USA. Electronic address: bobwhit@temple.edu.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Whitaker
authors.affiliation: Department of Clinical Sciences, Temple University School of Medicine, 3500N. Broad Street, Philadelphia, PA, 19140, USA. Electronic address: dyu@temple.edu.
authors.forename: Daohai
authors.initials: D
authors.lastname: Yu
authors.affiliation: Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg, School of Medicine, 750N. Lake Shore Drive, 10th floor, Chicago, IL 60611, USA; Center for Community Health, Institute for Public Health and Medicine, Northwestern, University Feinberg School of Medicine, 750N. Lake Shore Drive, 6th floor, Chicago, IL 60611, USA. Electronic address: r.ackermann@northwestern.edu.
authors.forename: Ronald T
authors.initials: RT
authors.lastname: Ackermann
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000517:prevention & control*; D004522:Educational Status; D015444:Exercise; D005260:Female; D006293:Health Promotion; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D008019:Life Style; D008297:Male; D008687:Metformin / Q000627:therapeutic use*; D008875:Middle Aged; D011897:Random Allocation; D040242:Risk Reduction Behavior; D012923:Social Class; D014481:United States; D015431:Weight Loss
chemical_list: D007004:Hypoglycemic Agents; D008687:Metformin
keywords: Diabetes prevention; Educational attainment; Lifestyle intervention; Metformin; Socioeconomic status