Fluke or Trend? Lifestyle vs Heart Disease in Diabetes

So . . . did you hear the news?  There's no need to diet & exercise anymore!  At least not if you're a diabetic!  Why?  Lifestyle did not protect diabetics from heart disease.  In the Look AHEAD trial published early online yesterday in the New England Journal of Medicine, the authors concluded that intensive lifestyle modifications aimed at weight loss in diabetics did not reduce heart disease events.

Really?  Are we sure?  Couldn't this just be a fluke outcome?  After all, the trend in studies is that of benefit from lifestyle modifications.  How could this one come out against diet & exercise?  Well, the authors followed for almost 10 years 5,145 (wo)men avg age 59 w/avg body mass index 36 (obese by definition) who'd had diabetes for an average of 5yrs already.  These participants had been randomized to either intensive lifestyle intervention focusing on weight loss via diet & exercise vs the control group who were given standard diabetic education.

At the end of the 1st year, those randomized to intervention lost 8.6% body weight compared to 0.7% in the control group.  By the end of the study, the difference had narrowed dramatically to just 6% in the intervention group vs 3.5% in the control group.  This minor difference in weight loss might account for the lack of difference in heart disease.

However, those in the intervention group who lost weight & kept it off did demonstrate greater decrease in A1c as well as better fitness & cardiovascular risk factors (aside from LDL).  And while it's not clear whether the egg came before the hen or vice versa, those in the intensive intervention group had a lower rate of cardioprotective medication use.  Could that lower rate of use led to the lack of difference in heart disease outcomes?  Or perhaps, the lower need for medications was a result of benefit gained from intensive interventional change in lifestyle.  If you're a cynic and look for trends, check out the editorial for plausible reasons to explain this fluke.  

As for me, I look at all the benefits gained from lifestyle modifications and the lack of harm, too.  I believe this study is a fluke in that it didn't show benefit in heart disease.  But just you wait & see.  Given a large enough study for a long enough period of time w/great enough inter-group differences . . . 

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