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• ILI reduced T2D risk by 22% in people with PD, when compared with general advice; • The observed protection tended to be smaller the longer the duration of follow-up; • Higher protection was observed in studies with predominance of women; • The relative risk was influenced by the diagnostic criteria used for T2D. To evaluate the effectiveness of intensive lifestyle intervention (ILI) on the risk of type 2 diabetes (T2D) in prediabetes (PD). We searched the Cochrane Central, Embase, MEDLINE, and Web of Science (until February 2024) to include RCTs of adults with PD, comparing ILI vs. general advice on the incidence of T2D. Two authors extracted the data, applied the Cochrane Risk of Bias (RoB) 2.0 tool and the GRADE framework. Meta-analysis was performed using random effects models, estimating relative risk (RR) and the 95%CI. Fifteen studies (n = 8,563, 46.7 % female, 53.3 ± 8.7 years, BMI 26.7 ± 5.4 Kg/m2) were included. ILI reduced T2D risk by 22 % when compared with general advice (RR 0.78; 95 %CI 0.72–0.85; I2 = 40 %; low certainty of evidence). Most studies had high risk of bias or raised some concerns. Sensitivity analysis showed that studies with mostly female populations and those using the WHO 1985 criteria for T2D had lower risk of the disease and that the longer the follow-up, the lower the protection. ILI can prevent T2D in subjects with PD. Healthcare teams should aim for structured ILI to maintain long-term lifestyle improvements. [ABSTRACT FROM AUTHOR]