In summary, we found that neighborhood socioeconomic deprivation did not moderate the effect of an intensive lifestyle intervention on several clinical outcomes in participants with overweight/obesity and type 2 diabetes. Regardless of the level of deprivation, individuals in the ILI group lost substantial weight at year 1 and regained some weight over the course of 4 years. Additionally, other clinical and biological markers such as HbA1c, blood pressure, and lipids all improved in the intervention arm, with no discernible impact of neighborhood deprivation on the ILI’s effectiveness. Our findings were the same when alternative neighborhood measures, such as neighborhood racial composition and poverty level, were considered. These results align with those of the primary Look AHEAD study.

Our study contributes to the scientific literature regarding the role of the patient’s environment in health. While the correlation between poor living conditions and poor diabetes control is well-established,7 our findings suggest that, for individuals with obesity and diabetes, neighborhood socioeconomic deprivation does not influence the effectiveness of an intensive lifestyle intervention. It is important to reiterate that our focus was on the concept of neighborhood socioeconomic deprivation, as defined by indicators of wealth, education, and occupation.29

To our knowledge, this is the first study to specifically investigate the influence of neighborhood deprivation on the effectiveness of an intensive lifestyle intervention in patients with both overweight and diabetes. Prior studies yielded mixed results. For instance, Zenk et al. reported similar patterns of weight loss and regain in their quasi-experimental study using a generalized difference-in-differences design with an inverse propensity score matched comparison group to evaluate a weight management program for US military veterans.32 They found that the built environment did not influence the effectiveness.32 In contrast, Jiang et al. found that participants from neighborhoods with lower socioeconomic scores had less favorable outcomes in a diabetes prevention intervention for American Indians and Alaska Natives. However, their study was limited by a lack of racial/ethnic diversity.33 Mendez et al. highlighted the moderating effect of neighborhood racial composition in a weight loss intervention but found no evidence of the influence of neighborhood socioeconomic status.18 They did find that that study participants living in racially diverse neighborhoods (in which 25–75% of the residents identified as Black) were more likely to lose weight.18 This study had a relatively small size (127 participants) and a large proportion of White participants (81% of the study population).18 Saint Onge et al. also examined the role of socioeconomic neighborhood disadvantage and other factors of obesogenic environment in a weight loss trial. They found no influence; however, their study provided new insights about the importance of the modality of intervention delivery.34 In that study, participants were randomly assigned to a group receiving the intervention either in-clinic one-on-one sessions, in clinic with group sessions, or by telephone call. Participants assigned to the group sessions lost less weight when they lived in a neighborhood with dollar stores.34 Overall, these studies vary in their measures of neighborhood environment, analysis methods, and populations studied, making direct comparisons difficult.

A possible explanation for our results includes the efficacy of the Look AHEAD trial in addressing neighborhood socioeconomic challenges. Even though residents of poor neighborhoods are more likely to experience limited access to nutritious food,35 higher exposure to unhealthy dietary options,36 and suboptimal built environments, the Look AHEAD ILI may have effectively mitigated these obstacles, by virtue of several key components. First, participants received crucial information and tools about diabetes management, nutrition, and exercise, which may have empowered them to make informed decisions regarding their lifestyles, thus helping them navigate the complexities of their environments. In addition, the presence of group support may have allowed participants to share experiences and strategies, fostering a sense of community and motivation that transcended the barriers presented by their neighborhoods.

An additional factor that could account for our findings relates to the characteristics of the participants in the Look AHEAD trial. The cohort was characterized by very high levels of motivation and commitment. Participants voluntarily consented to engage in a rigorous long-term study with an intensive intervention an over a decade of longitudinal follow-up, and study adherence rates were high.23 Additionally, as part of the trial’s entry requirement, participants completed a thorough behavioral screening,37 which included a 2-week run-in period, during which they recorded daily their dietary habits and physical activity.38 These protocols may have naturally selected for individuals who were more willing and able to invest substantial time and effort in managing their health than the general population. Self-efficacy is predictive of higher adherence not only to the study protocol (increase of physical activity and diet improvement) but also to medication adherence and blood glucose level monitoring.39 As a result, the study participants may have been more able than many to overcome their respective neighborhood barriers.

Another crucial aspect to consider in our study pertains to the use of the neighborhood deprivation score as a metric to capture disparities in neighborhood socioeconomic status. This score has been widely employed in numerous studies to effectively gauge socioeconomic disparities29,33 and serves as a valuable tool for classifying and comparing neighborhoods. However, its utility hinges on the assumption that deprivation is present uniformly within these neighborhoods. When this assumption is met, the neighborhood deprivation score offers valuable insights, yet it can be misleading when applied in contexts where deprivation may not be uniform. In our sample, we observed that the lower deprivation tertile had a higher percentage of female and Black participants, as well as lower educational attainment and lower household income, aligning with what one would typically expect when assessing disparities using the neighborhood deprivation score in the US context. Nonetheless, the study cohort as a whole displayed a notably high level of education and income: 84% had a college degree or greater, and 75% reported an annual income over $40,000. Even in the most deprived neighborhoods within the intervention arm, a substantial proportion of participants held college degrees or higher (at least 74%), and a noteworthy 15.4% reported an income of at least $80,000. Conversely, those with a high school degree or less comprised only 26%, and only 17.7% reported a family income below $20,000. These observations raise the question of whether the term “deprivation” in this context holds the same significance as it does in other, less affluent populations. While our study did indeed capture disparities relative to the specific group examined, it likely does not truly reflect the deprivation levels that exist across the US.

The study has limitations that must be considered. First, it relies on the 2000 US Census data to characterize the neighborhoods, potentially not capturing changes in the neighborhood’s demographic and economic status after that time. Moreover, the deprivation scores were derived from participants’ baseline addresses, without accounting for potential residential changes during the 4-year analysis period. Finally, the study inclusion criteria led to the selection of a predominantly highly educated and high-income population.

Strengths of this study include that it draws upon the well-established and rigorously designed Look AHEAD trial, a randomized controlled trial, lending strong credibility to its findings. Additionally, the study benefits from a large and diverse sample of participants, totaling 1213 individuals, with varying demographic characteristics. This diversity enhances the generalizability of the results to broader populations. Moreover, the study’s comprehensive assessment of clinical outcomes, including weight, HbA1c, blood pressure, and lipid profiles, ensures a thorough evaluation of the intervention’s effects on participants’ health.

In conclusion, this study highlights the complexity of the relationship between neighborhood deprivation and the effect of lifestyle intervention on health outcomes. The results suggest that the Look AHEAD trial’s intensive lifestyle intervention was successful in mitigating the challenges posed by neighborhood socioeconomic factors. The provision of essential information, education, and group support and also a high level of commitment and motivation likely played pivotal roles in helping participants overcome barriers associated with their neighborhood environments. However, it is essential to recognize that these findings may not necessarily apply to individuals with the lowest income and educational attainment, who remain underrepresented in clinical trials.