Shaminie J. Athinarayanan

Background/Objectives: Incretin-based obesity medications (IOMs) produce substantial weight loss, but the added benefit of structured nutritional therapy remains unclear. We compared 12-month weight loss between individualized carbohydrate-reduced nutritional therapy combined with IOMs (VINT+IOM) and IOM-based care without structured nutritional therapy (IOM only). Methods: In this retrospective cohort study, we analyzed 4,269 adults enrolled in a telemedicine obesity care program (VINT+IOM, n = 1,658; IOM only, n = 2,611). Both pathways included clinician-guided medication management and behavioral coaching. The primary analysis included GLP-1-naive participants taking a single agent (semaglutide or tirzepatide). Adjusted weight change was estimated using longitudinal linear mixed-effects models. Results: Retention at 12 months was 77% in the VINT+IOM group and 72% in the IOM-only group. Among GLP-1-naive semaglutide users, adjusted 12-month weight loss was greater with VINT+IOM than with IOM only (13.9 vs. 10.9 kg; difference 3.0 kg, 95% CI 0.6 to 5.4; P = 0.012), and observed percentage weight loss was 13.3% vs. 11.1%. Among tirzepatide users, adjusted weight loss was 20.8 vs. 15.6 kg (difference 5.2 kg, 95% CI 1.8 to 8.7; P = 0.003), and observed percentage weight loss was 19.7% vs. 15.6%. Responder rates also favored VINT+IOM. In the overall cohort, adjusted weight loss was 13.3 vs. 9.8 kg (P < 0.001), and the advantage persisted among participants with prior GLP-1 exposure. Weight loss continued between 6 and 12 months in both groups. Approximately 80% of participants in each pathway had an IOM proportion of days covered of 80% or higher. Self-reported side effects were similar (63.6% vs. 64.6%). Conclusions: In this real-world cohort, adding individualized carbohydrate-reduced nutritional therapy to IOM-based care was associated with greater 12-month weight loss than IOM-based care without structured nutritional therapy. These findings support further evaluation of individualized nutrition as an adjunct to incretin-based pharmacotherapy, ideally in randomized trials.

Introduction: Sleep disturbance, depressive symptoms, and musculoskeletal pain are common in type 2 diabetes (T2D). The long-term patient-reported effects of nutrition-based interventions targeting metabolic dysfunction remain unclear. We examined 5-year changes in sleep, depressive symptoms, and knee pain in adults with T2D participating in a digitally delivered continuous care intervention providing individualized nutrition therapy supporting nutritional ketosis. Methods: Adults with T2D enrolled in the intervention arm of a non-randomized clinical trial were followed for 5 years ( N = 194). Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), depressive symptoms with the Center for Epidemiologic Studies Depression Scale (CES-D), and knee outcomes with the Knee Injury and Osteoarthritis Outcome Score (KOOS). Linear mixed-effects models evaluated change over time in the full cohort and symptom-defined subgroups. Clinical thresholds and minimal clinically important differences (MCID) were also examined. Results: PSQI scores improved at all follow-ups, with 19–25% reductions from baseline to 5 years; the proportion classified as poor sleepers decreased from 63 to 48%. Depressive symptoms decreased by 10 weeks and were sustained through 2 years; at 5 years the full cohort returned to baseline, but participants with baseline elevations maintained scores below the screening cut-off. KOOS subscales improved significantly; among those with baseline weekly knee pain, 57–74% exceeded the 10-point MCID. Discussion: A low-carbohydrate nutrition-focused, digital program targeting T2D was associated with durable sleep and pain benefits and sustained mood gains in symptomatic participants over 5 years.

Background: Lifestyle interventions targeting metabolic health may influence chronic kidney disease (CKD) risk, particularly among adults with type 2 diabetes and obesity. We evaluated real‐world associations between a telehealth‐delivered, individualized nutrition therapy program (VINT) and CKD incidence and progression compared with usual care. Methods: We conducted a retrospective, propensity score–matched cohort study using the Komodo Healthcare Map, a longitudinal U.S. administrative claims database. Adults enrolled in a telehealth‐delivered nutrition therapy emphasising carbohydrate reduction, VINT ( n = 11 077) were matched 1:1 to usual‐care controls on demographic, clinical, and medication covariates, over 5 years of follow‐up. Primary outcomes were new‐onset CKD, CKD stage ≥ 3, and CKD stage ≥ 4. Secondary outcomes included renal safety events. Cox proportional hazards and Poisson regression models were used to estimate hazard ratios (HRs) and incidence rate ratios (IRRs). Results: VINT participation was associated with a lower incidence of new‐onset CKD (10.1 vs. 15.6 per 1000 person‐years; HR 0.64, 95% CI 0.53–0.77; p < 0.001), CKD stage ≥ 3 (HR 0.57, 95% CI 0.45–0.73; p < 0.001), and CKD stage ≥ 4 (HR 0.38, 95% CI 0.18–0.79; p = 0.009). No increased risk of kidney stones, metabolic acidosis, diabetic ketoacidosis, or gout was observed in VINT compared with the UC group. Conclusions: In this large, real‐world matched cohort, participation in a telehealth‐delivered nutrition therapy emphasising carbohydrate reduction was associated with lower CKD incidence and progression without increased renal adverse events. These findings suggest that individualized nutrition therapy may be a safe and scalable approach to CKD prevention and management in adults with metabolic disease, warranting further prospective investigation.

South Asians appear to be particularly susceptible to diabetes. India hosts 18 percent of the world’s population but more than 25 percent of the world’s diabetics, and individuals of South Asian descent carry this presumed increased risk for diabetes when they emigrate to other parts of the world. One conundrum is that the epidemic of diabetes began around Calcutta (modern day Kolkata) in east India well before it appeared in the United States and Europe, and this emergence occurred despite the frequent occurrence of famines and starvation in India. Here we review the history of diabetes in India and the possible significance of high carbohydrate in low-protein diet contexts. We suggest that the circumstantial relationship between diet and a spectrum that includes diabetes associated with obesity at one end, and impaired glucose tolerance and protein malnutrition (kwashiorkor) at the other, could be significant. If the cause of type 2 diabetes in South Asians is primarily nutritional, and, as suggested by others, aggravated by starvation and famine that increased the risk for low birth weight as an additional risk factor for diabetes, these insights may together help explain an enhanced susceptibility of South Asians to diabetes.

Chronic low-grade inflammation contributes to the development and complications of type 2 diabetes (T2D). Nutritional ketosis improves glycemic control and weight, but its broader immunomodulatory effects are less well defined. In this post-hoc analysis, adults with T2D (n = 195) or prediabetes (n = 89) in a two-year continuous care intervention (CCI) with individualized carbohydrate reduction emphasizing nutritional ketosis were compared with T2D participants receiving usual care (UC, n = 63). Serum was collected at baseline, 1, and 2 years for high-sensitivity CRP, 15 cytokines/adhesion molecules, and comprehensive blood count (CBC)-derived indices. Linear mixed-effects models evaluated longitudinal changes, while regression (including least absolute shrinkage and selection operator, LASSO) examined associations with mean β-hydroxybutyrate (BHB), weight change, HbA1c, and HOMA-IR. Nineteen of 21 markers declined at 1 year in CCI, largely sustained at 2 years; UC showed no changes. Higher BHB predicted reductions in WBC, ICAM-1, VEGF-A, and systemic immune-inflammation index (SII), while weight loss correlated with IL-6, IL-18, IL-1β, and TNF-α. CCI induced broad, durable anti-inflammatory effects, supporting its role in lowering systemic inflammation and cardiometabolic risk.

Background and Aims: Metabolic dysfunction–associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction–associated steatohepatitis (MASH), can lead to significant morbidity and mortality in adults with type 2 diabetes (T2D) and obesity. This study evaluated whether participation in an individualized, nutrition-focused telemedicine care model emphasizing carbohydrate reduction (Virta Individualized Nutrition Therapy, VINT) was associated with reduced onset of MASLD, MASH, and advanced liver disease. Approach and Results: Adults with T2D, prediabetes, overweight,or obesity who enrolled in VINT (2015–2024) were identified in the Komodo Healthcare Map and matched 1:1 to usual care (UC) controls (n=5031 per group). Using 3 complementary analytic approaches, incidence and time-to-event analyses were performed for new-onset liver disease. Across all strategies, VINT participants consistently showed a lower incidence of any liver-related diagnosis (27.3 vs. 42.8 per 1000 person-years; HR=0.61, p p p p p =0.02) compared with VINT participants who lost less weight. Conclusions: Participation in individualized nutrition-focused telemedicine care was associated with significantly lower incidence and risk of new-onset MASLD, MASH, and advanced liver disease. These findings support lifestyle-first interventions that are potentially scalable to reduce liver disease burden in adults with T2D and obesity.

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.

Importance: Carbohydrate-reduced nutrition improves multiple metabolic risk factors, but its influence on long-term cardiovascular (CV) outcomes remains uncertain. Objective: To evaluate the impact of an individualized telemedicine nutrition therapy on the incidence of CV events. Design: Claims-based cohort study of adults with type 2 diabetes or obesity receiving telemedicine nutrition therapy versus a propensity score matched control group between January 1, 2016 and June 1, 2025, with a median follow-up of approximately two years. Setting: The intervention cohort, a US-based nationwide digital health clinic, received individualized telemedicine nutrition and clinical care. The matched control cohort was derived from a commercial claims database. Participants: Adults with type 2 diabetes or obesity and no CV events one year prior to index date. Exposure: Individualized nutrition therapy (INT) program combining telemedicine clinical care and carbohydrate-reduced nutrition counseling. Main Outcomes and Measures: Four prespecified primary outcomes included 1) 3-point major adverse CV events (MACE), defined as nonfatal myocardial infarction, nonfatal stroke, or death from any cause; 2) 6-point MACE, adding percutaneous coronary intervention, hospitalization for heart failure or unstable angina; 3) all new-onset CV events; and 4) new-onset hypertension. Secondary outcomes included all-cause mortality, and safety outcomes related to arrhythmias. Results: In 4,877 participants in each cohort (mean age, 51 [SD 9.5] years; 2,939 [60.3%] female), INT was associated with reduced risk of all primary outcomes. Incidence per 1,000 person-years was 4.1 vs 9.3 for MACE-3, 5.7 vs 10.8 for MACE-6, 27.7 vs 36.9 for all new onset CV disease, and 41.8 vs 49.3 for new-onset hypertension. Hazard ratios were 0.44 (95% CI, 0.29-0.65; P <0.001) for MACE-3, 0.52 (95% CI, 0.37-0.73; P <0.001) for MACE-6, 0.70 (95% CI, 0.59-0.82; P <0.001) for all CV disease, and 0.81 (95% CI, 0.70-0.93; P <0.001) for new-onset hypertension. Conclusions and Relevance: Individualized telemedicine nutrition therapy was associated with lower CV event incidence compared to controls, suggesting the intervention may confer cardioprotection. KEY POINTS: Question: What is the impact of an individualized telemedicine nutrition program on cardiovascular events? Findings: In this claims-based cohort study, individuals receiving carbohydrate-reduced nutrition therapy had significantly reduced risk of all primary outcomes compared with matched controls: 56% lower 3-point MACE, 48% lower 6-point MACE, 30% lower risk of all new-onset cardiovascular events, and 19% lower new-onset hypertension. The risk of all-cause mortality was also directionally reduced. Meaning: Telemedicine nutrition therapy was associated with favorable cardiovascular outcomes compared to usual care.

Background and Aims: Metabolic dysfunction–associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction–associated steatohepatitis (MASH), lead to significant morbidity and mortality in adults with type 2 diabetes (T2D) and obesity. This study evaluated whether participation in an individualized, nutrition-focused telemedicine care model emphasizing carbohydrate reduction (Virta Individualized Nutrition Therapy, VINT) was associated with reduced onset of MASLD, MASH, and advanced liver disease. Approach and Results: Adults with T2D, prediabetes, overweight, or obesity who enrolled in VINT (2015–2024) were identified in the Komodo Healthcare Map and matched 1:1 to usual care (UC) controls (n = 5,031 per group). Using three complementary analytic approaches, incidence and time-to-event analyses were performed for new-onset liver disease. Across all strategies, VINT participants consistently showed lower incidence of any liver-related diagnosis (27.8 vs 42.8 per 1,000 person-years; HR = 0.61, p < 0.001), MASH and beyond (4.2 vs 10.7; HR = 0.38, p < 0.001), advanced liver disease (2.8 vs 8.7; HR = 0.33, p < 0.001) and any liver complications (2.0 vs 7.7; HR = 0.25, p < 0.001). VINT participants who lost ≥15% body weight was at lower risk of new-onset liver disease (21.2 vs 31.8 per 1,000 person-years; HR = 0.66, p = 0.02) compared to VINT participants who lost less weight. Conclusions: Participation in individualized nutrition-focused telemedicine care was associated with significantly lower incidence and risk of new-onset MASLD, MASH, and advanced liver disease. These findings support lifestyle-first interventions that is potentially scalable to reduce liver disease burden in adults with T2D and obesity. Infographic: Plain Language Summary: People with type 2 diabetes and obesity are more likely to develop liver conditions such as metabolic dysfunction–associated steatotic liver disease (MASLD) and metabolic dysfunction–associated steatohepatitis (MASH), which can progress to cirrhosis, decompensation or liver cancer. This study examined whether a nutrition-focused remote care program could help prevent these liver diseases. The Virta Individualized Nutrition Therapy (VINT) program uses telemedicine and personalized, carbohydrate-reduced nutrition to support long-term weight loss and metabolic health. Using health claims data, researchers compared more than 5,000 participants in the VINT program with matched individuals receiving standard of care. Those in the VINT group had significantly fewer new cases of MASLD, MASH, and advanced liver disease. Participants who lost 15% or more of their body weight were especially protected. These findings suggest that individualized, nutrition-based remote care can help prevent liver disease in people with type 2 diabetes and obesity.