It appears that intensive intervention, was not intensive throughout the study period and although population at start of study was obese/overweight in both groups, however, majority of CV risk factors were fairly controlled. The baseline average BP was 129 in both groups and A1C was 0.07, that is pretty good control for both major parameters and LDL was 2.9 mmol/L [112 g/dl]. Unfortunately LDL didn't significantly changed with intensive intervention.

The major effect in intensive intervention was seen at 1 year and after that everything plateaued [see Figure 1, the weight increased, abdominal girth increased, physical fitness decreased and A1c incraesed] and at the end of the study the average weight loss in intervention group was only 3.5.

The, so called Control group was not completely physically inactive and did get education to control risk factors and benefits of exercise, so likely these individuals remained active and not as physically active as the intervention group.

Interestingly the weight continued to decline in the control group throughout the study, where as the weight dropped significantly in the first year but after that this group regained over 50% of the weight they lost in the first year [Figure 1].

So, in short this trial again reiterates the story everyone has heard in their childhood of "The Turtle and the Hare" - "Slow and steady wins the race!"

I think a good point in all these trials is how many of the participants did actually lose weight. There was a proportion of individuals that actually gained weight as usual.

The point of interest here, the way I see it, is who do we target for these trials and are all people suitable to be put under an intensive nutritional intervention?

One size does not fit all in weight loss interventions and I think that is always going to affect study results. In practice people are offered alternatives that suit them and they have flexibility in order to maintain their motivation.

The Counterweight is a very good example of how combining different approaches you can successfully achieve weight loss and save the health system money.

To me the LOOKAHEAD results only say that the intensive intervention they used is not suitable to be applied in the general population.

I would still wait for the secondary analysis to see what happens when they split the groups.

In contrast to LookAhead showing no CV benefit of sustained modest weight loss among those with T2D, the PREDIMED study showed that among those at high risk of CVD (50% of participants had either T2D, or atleast 3 other RF: smoking, HT, dyslipidemia, overweight-90%, fam history of prem IHD), they achieved 30% risk reduction in major CVE from the addition of either olive oil or nuts to their diet with recommendations to follow a Med diet, rather than the control group who received advice to reduce dietary fat.

However, there were some important differences in the characteristics of the patients studied in LookAhead vs PREDIMED:

PREDIMED had 97% European vs LOOK AHEAD 63%

PREDIMED had BMI 30 vs LOOK AHEAD 36

PREDIMED age 67 vs LA age 58

PREDIMED smokers 16% vs LA 4%

LOOK AHEAD had longer duration of diabetes based on % on insulin ( 16% vs 4%)

LOOK AHEAD enrolled 14% with cardiovascular disease vs 0% in PREDIMED

Medication use differed

LA statin use 65% cf PM 40%

LA antihypertensive 80% vs 30%

La insulin use 30% by end of study vs 5%

So in summary LOOKAHEAD although younger were more co-morbid, more obese, and with a longer history of diabetes, and less likely to be white, and more heavily medicated

Suggests (1) diet quality might matter more than body mass achieved (2) there might be a window of opportunity for lifestyle intervention that is not so much age related but stage of disease related?