Rebecca N. Adams

Importance: Dyslipidemia, hypertension, and diabetes are highly prevalent conditions for which medical nutrition therapy (MNT) is guideline-recommended, yet access remains limited, and real-world evidence on technology-enabled MNT models at scale is sparse. Objective: To characterize lipid, blood pressure, and glycemic outcomes among adults receiving virtual MNT (vMNT) across three cardiometabolic conditions. Design: Retrospective cohort study of adults with a first Nourish appointment before November 2025, followed for 6 months. Setting: National vMNT platform. Participants: Adults meeting enrollment criteria for dyslipidemia, hypertension, or diabetes and remaining engaged in care with ≥1 follow-up measurement at 3 or 6 months. Final cohorts: dyslipidemia (n=6,501), hypertension (n=13,704), diabetes (n=2,444); 18,965 unique patients overall. Exposure: vMNT delivered by a registered dietitian via telehealth visits, with technology-enabled support between visits. Main Outcomes and Measures: Outcomes were LDL cholesterol, total cholesterol, HDL cholesterol, and triglycerides (dyslipidemia); systolic and diastolic blood pressure (SBP, DBP) (hypertension); and HbA1c (diabetes), assessed at enrollment, 3, and 6 months. Weight was a secondary outcome. The proportion achieving guideline-recommended targets (HbA1c <7.0%, SBP <130 mmHg) was also assessed. Results: Among 18,965 patients (mean [SD] age, 42.9 [11.6] years; 15,770 [83.2%] female), significant changes from baseline to 6 months included: LDL cholesterol (−14.0 mg/dL [SE, 0.56]); total cholesterol (−19.4 mg/dL [SE, 0.61]); HDL cholesterol (−0.5 mg/dL [SE, 0.15]); triglycerides (−28.6 mg/dL [SE, 1.06]); SBP (−5.5 mmHg [SE, 0.16]); DBP (−4.5 mmHg [SE, 0.11]); and HbA1c (−1.37 percentage points [SE, 0.04]) (all P<.001). Among those with elevated SBP, 57.3% achieved <130 mmHg by 6 months; among those with elevated HbA1c, 54.7% achieved <7.0%. Outcomes among patients with stable medication regimens were similar to the full cohort. Conclusions and Relevance: In this study of 18,965 patients, vMNT delivered through a technology-enabled care model was associated with clinically meaningful improvement across three prevalent cardiometabolic conditions. These findings support technology-enabled virtual care as a scalable approach to delivering effective MNT.

Structured Importance: Type 2 diabetes and obesity drive substantial morbidity and spending. Rigorous evidence on the impacts of digitally delivered lifestyle interventions on healthcare cost and utilization are critical to assessing their value. Objective: Determine the impact of a telehealth-delivered individualized nutrition therapy (INT) program on per-member-per-month (PMPM) total cost of care and utilization over one and two years. Design: Retrospective propensity score matched difference-in-differences analysis of cost and utilization outcomes over the study period of January 2016–March 2025. Setting: US adults participating in a telehealth T2D and obesity management program. Participants: Enrolled in INT for >1 day or had PCP visit for T2D or obesity during study period; had ≥12 months pre-index and ≥90 days post-index claims coverage (allowing ≤30-day gaps). Final matched sample: 6,580 participants and 6,580 controls (per arm: 3,819 with type 2 diabetes and 2,761 with obesity). Exposures: Telehealth-delivered, continuous care integrating individualized carbohydrate-reduced nutrition support, clinician-guided medication management, health coaching, and remote biometric monitoring. Main Outcomes and Measures: Outcomes included PMPM allowed inpatient, outpatient, and prescription medication costs, inpatient, emergency department, primary care, cardiology, and endocrinology visits. For the T2D cohort, PMPM spending and proportion of days covered for each T2D medication. Results: Among 3,819 adults with T2D and 2,761 adults with obesity, program participation was associated with $240 and $256 PMPM reductions in the total cost of care at 12 months (−$230 and $189 over 24 months, all P<.001). In the T2D cohort, savings were driven by deprescription of SGLT2 inhibitors (66.8% reduction in PMPM cost), sulfonylureas (51.7%), insulin (43.9%), and GLP-1s (32.2%). In the obesity cohort, reductions accrued across inpatient, outpatient and prescription medication settings. Conclusions and Relevance: In this large, real-world analysis, a nutrition-first digital care model was associated with sustained reductions in cost and utilization over 12–24 months, with immediate prescription medication cost reductions in the cohort with T2D and broader savings in the cohort with obesity. Together with prior clinical evidence, these findings suggest alignment of clinical effectiveness and cost reductions of a telehealth-delivered lifestyle intervention. Key points: Question: Is participation in a telehealth-delivered individualized nutrition therapy program associated with changes in healthcare costs and utilization among adults with type 2 diabetes (T2D) or obesity? Findings: In this retrospective cohort study of 13,000 matched adults, participation was associated with lower total cost of care at one year (−$240 and −$256 for adults with T2D and obesity respectively) and over two years (T2D: -$230; obesity: $-189). Among adults with T2D, reductions were driven by inpatient costs and all T2D medications, including GLP-1s. Among adults with obesity, reductions occurred across inpatient, outpatient, and prescription medication costs. Meaning: Telehealth-delivered nutrition therapy may reduce healthcare spending for adults with T2D or obesity.

Aim: To evaluate the long‐term effectiveness and safety of a remote, medically supervised ketogenic nutrition therapy intervention for Veterans with type 2 diabetes (T2D). Materials and Methods: This retrospective observational analysis examined de‐identified medical records of Veterans with T2D who engaged in a remote continuous care intervention. Outcomes were HbA1c, weight, diabetes medication use and cardiometabolic markers (lipids, liver enzymes, kidney function) among those who remained enrolled for 2 or 3 years. Separately, we assessed weight, glucose and medication changes at programme departure among Veterans who discontinued before 2 years. Outcomes were analysed across subgroups. Linear mixed‐effects models and paired t‐tests evaluated changes over time. Results: Among 640 enrolled Veterans (mean age: 59 years, BMI: 35 kg/m ² , HbA1c: 8.4%), 310 (49%) remained engaged at 2 years and 197 (33%) at 3 years. At both time points, HbA1c was reduced by approximately 0.8%, alongside decreases in diabetes medication use. Weight decreased by approximately 9% at both 2 and 3 years. Overall, reductions in HbA1c and weight were seen across subgroups. Veterans who discontinued before 2 years experienced metabolic improvements, with greater benefits among those enrolled at least 6 months. Conclusions: For US Veterans, long‐term participation in a remote ketogenic nutrition therapy intervention was associated with sustained improvements in glycaemic control, weight, medication use and select cardiometabolic markers. A 0.8% HbA1c reduction is associated with meaningful reductions in diabetes‐related complications, highlighting the potential clinical relevance of these findings.

Depressive symptoms are prevalent among people with type 2 diabetes (T2D) and, even at low severity levels, are associated with worse diabetes outcomes. Carbohydrate restriction is an effective treatment for T2D but its long-term impacts on depressive symptoms are unclear. In the current study we explored changes in depressive symptoms over 2 years among 262 primarily non-depressed T2D patients participating in a continuous remote care intervention emphasizing carbohydrate restriction. Subclinical depressive symptoms decreased over the first 10 weeks and reductions were maintained out to 2 years. Increased frequency of blood ketone levels indicative of adherence to low carbohydrate eating predicted decreases in depressive symptoms. Concerns have been raised with recommending restrictive diets due to potential negative impacts on quality-of-life factors such as mood; however, results of the current study support positive rather than negative long-term impacts of closely monitored carbohydrate restriction on depressive symptoms.

Background: Prediabetes phenotypes differ based on whether an individual exhibits impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. The traditional diabetes prevention approach focused on weight loss via fat/caloric restriction and exercise appears less effective in those with IFG. Given that even transient regression to normal glucose regulation is associated with reduced risk of progression to type 2 diabetes, interventions that elicit normal fasting glucose (NFG) may be beneficial. Here, we explored predictors of normalization of fasting glucose (FG) over one-year treatment with carbohydrate restricted nutrition therapy (Carb-R) delivered via a continuous remote care model. Methods: Data were obtained from medical records of adults with prediabetes who were treated at least one year at time of analysis. Of 738 patients with an antecedent prediabetes diagnosis, 460 had IFG (100mg/dL to 125mg/dL) at enrollment in the clinic and were included in this analysis. Patients were counseled on Carb-R targeting nutritional ketosis (NK) and reported fasting blood glucose, blood beta-hydroxybutyrate (BHB), and weight via an app facilitating remote monitoring and medical/coaching support. BHB ≥0.5 mM indicated NK. Cox proportional hazard regression was used to model time of first incidence of NFG at 3, 6, 9, and 12 months and to assess if normalization of fasting glucose was associated with baseline factors, weight change, metformin use, and degree or frequency of NK achieved, analyzed separately. Mean±SE is reported. Results: Patients with IFG were 53.9±0.4 years of age, 64.0% female, HbA1c 5.92±0.02%, and fasting glucose 114.5±0.8 mg/dL at enrollment. During treatment, 199 (43.3%) patients normalized FG at ≥1 time point with mean weight loss of 10.0±0.4 kg (-8.9%) at time of normalization, 192 (41.7%) did not, and 69 (15.0%) were missing glucose data. In an adjusted multivariate model, lower baseline HbA1c (HR 0.60, p=0.03), female sex (HR 1.39, p=0.04), and greater mean BHB value (HR 1.83, pConclusions: Greater adherence to Carb-R indicated by greater BHB values and a greater proportion of days in NK were strongly associated with normalization of FG in prediabetes patients with IFG. Weight loss, a common goal for diabetes prevention, was not associated with reversion to NFG. Future studies should assess the effects of Carb-R including NK in other prediabetes phenotypes and on progression to type 2 diabetes.

The purpose of this study is to assess the effects of an alternative approach to type 2 diabetes prevention. Ninety-six patients with prediabetes (age 52 (10) years; 80% female; BMI 39.2 (7.1) kg/m²) received a continuous remote care intervention focused on reducing hyperglycemia through carbohydrate restricted nutrition therapy for two years in a single arm, prospective, longitudinal pilot study. Two-year retention was 75% (72 of 96 participants). Fifty-one percent of participants (49 of 96) met carbohydrate restriction goals as assessed by blood beta-hydroxybutyrate concentrations for more than one-third of reported measurements. Estimated cumulative incidence of normoglycemia (HbA1c < 5.7% without medication) and type 2 diabetes (HbA1c ≥ 6.5% or <6.5% with medication other than metformin) at two years were 52.3% and 3%, respectively. Prevalence of metabolic syndrome, class II or greater obesity, and suspected hepatic steatosis significantly decreased at two years. These results demonstrate the potential utility of an alternate approach to type 2 diabetes prevention, carbohydrate restricted nutrition therapy delivered through a continuous remote care model, for normalization of glycemia and improvement in related comorbidities.

Background: Only about half of patients with type 2 diabetes (T2D) achieve the HbA1c <7% target, and maintenance often requires medication intensification over time. A continuous remote care intervention (CCI) including ketosis via carbohydrate restriction nutrition therapy was previously demonstrated to improve glycemic outcomes in adults with T2D for at least two years; here, we assess the proportion of patients meeting glycemic targets and accompanying medication use. Methods: Adults with T2D selected to receive the CCI (n=262) or usual care (UC; n=87). We utilized GEE to assess change in the proportion of patients at HbA1c <7% target and accompanying medication use at 1 and 2 years compared to baseline. Analyses were conducted among completers and on an intent-to-treat basis with missing data considered as missing the HbA1c target. Results: The proportion of CCI patients meeting the HbA1c <7% target significantly increased at 1 and 2 years (Table 1). A similar improvement trend was seen among those treated with a single drug (monotherapy), and the proportion of patients at target without the use of medication approximately tripled. No changes occurred among patients who selected UC. Conclusion: This suggests the CCI is an effective means to help more patients achieve the HbA1c <7% target, including with monotherapy or no medication, among those who choose it. Disclosure: S.J. Athinarayanan: Employee; Self; Virta Health Corp. R.N. Adams: Employee; Self; Virta Health Corp. S. Hallberg: Advisory Panel; Self; Atkins Nutritionals, Inc. Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. S. Phinney: Advisory Panel; Self; Atkins Nutritionals, Inc. Stock/Shareholder; Self; Beyond Obesity LLC (publishing), Virta Health Corp. A. McKenzie: Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is associated with type 2 diabetes (T2D) progression. Our 2-year study of T2D patients demonstrated a continuous care intervention (CCI) including nutritional ketosis improved non-invasive scores of steatosis and fibrosis, in addition to weight and glycemic control. This post hoc analysis assesses factors affecting steatosis and fibrosis resolution. Methods: 262 T2D CCI patients were analyzed. Intent-to-treat correlation and ANCOVA assessed relationships between changes in selected variables (Table 1) and changes in NAFLD liver fat (NLF) and NAFLD fibrosis (NFS) scores, steatosis and fibrosis status. Results: Changes in HOMA-IR, central abdominal fat (CAF) and beta-hydroxybutyrate (BHB) were correlated with changes in NLF, while changes in HbA1c, CAF and HDL-cholesterol were correlated with changes in NFS, even after adjustment for age, gender, race, diabetes duration and baseline BMI. ANCOVA confirmed that patients who resolved steatosis had greater BHB increase (p=0.01), HOMA-IR reduction (p=1.3x10-5) and CAF reduction (p=0.01) than those who did not. Conclusions: Following the CCI, increased BHB and decreased insulin resistance are associated with steatosis resolution, while decreased visceral obesity is associated with steatosis and fibrosis reduction. Disclosure: S.J. Athinarayanan: Employee; Self; Virta Health Corp. R.N. Adams: Employee; Self; Virta Health Corp. A. McKenzie: Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. S. Hallberg: Advisory Panel; Self; Atkins Nutritionals, Inc. Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. S. Phinney: Advisory Panel; Self; Atkins Nutritionals, Inc. Board Member; Self; Virta Health Corp. Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. Other Relationship; Self; Beyond Obesity. J.P. McCarter: Employee; Self; Virta Health Corp. Funding: Virta Health Corp

OBJECTIVE: Studies on long-term sustainability of low-carbohydrate approaches to treat diabetes are limited. We aim to assess the effects of a continuous care intervention (CCI) on retention, glycemic control, weight, body composition, cardiovascular, liver, kidney, thyroid, inflammatory markers, diabetes medication usage and disease outcomes at 2 years in adults with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: An open label, non-randomized, controlled study with 262 and 87 participants with T2D were enrolled in the CCI and usual care (UC) groups, respectively. RESULTS: Significant changes from baseline to 2 years in the CCI group included: HbA1c (−12% from 7.7±0.1%); fasting glucose (−18% from 163.67±3.90 mg/dL); fasting insulin (−42% from 27.73±1.26 pmol L ^-1 ); weight (−10% from 114.56±0.60 kg); systolic blood pressure (−4% from 131.7±0.9 mmHg); diastolic blood pressure (−4% from 81.8±0.5 mmHg); triglycerides (−22% from 197.2±9.1 mg/dL); HDL-C (+19% from 41.8±0.9 mg/dL), and liver alanine transaminase (−21% from 29.16±0.97 U/L). Spine bone mineral density in the CCI group was unchanged. Glycemic control medication use (excluding metformin) among CCI participants declined (from 56.9% to 26.8%, P=1.3×10 ^-11 ) including prescribed insulin (−62%) and sulfonylureas (−100%). The UC group had no significant changes in these parameters (except uric acid and anion gap) or diabetes medication use. There was also significant resolution of diabetes (reversal, 53.5%; remission, 17.6%) in the CCI group but not in UC. All the reported improvements had p-values <0.00012. CONCLUSIONS: The CCI sustained long-term beneficial effects on multiple clinical markers of diabetes and cardiometabolic health at 2 years while utilizing less medication. The intervention was also effective in the resolution of diabetes and visceral obesity, with no adverse effect on bone health. TRIAL REGISTRATION: Clinicaltrials.gov NCT02519309