Keto vs GLP-1: New Study Reveals Advantages of Lifestyle

New Paper: "All 50 patients – 100% – lost weight, with an average weight loss of 15.5% body weight or 43 pounds over the year."

Is the Keto diet Unsustainable? Are GLP-1s ushering in a new era for Obesity Medicine? And – in the best-case scenario – which is a more powerful weight loss intervention?

In this letter, I promise to answer these questions, but not in the way you expect. There will be twists, turns and nuance. And I also promise, I’ll culminate with a message that is moderate and inclusive, not blaming or dividing.

(If you prefer to watch, rather than read, a video version of this letter can be found at the end)

New Paper!

Our story centers on a new paper that colleagues and I recently published covering a 1-year study in which a self-insured manufacturing company approached a metabolic health clinic in seek of support for their employees. The metabolic health clinic enrolled 50 employees. Because of clinic capacity, they selected the employees with the greatest medical need, factoring in the presence of metabolic syndrome diabetes, obesity and the number of medications they were taking.

The average starting BMI of the 50 enrolled subject was 43.2 kg/m2 (or 271 pounds) and 64% had type 2 diabetes or prediabetes.

These patients had near universally tried and failed lifestyle treatments and diets before, a common plight for middle-aged Americans that often leads to learned helplessness and a disheartening resolution that, ‘this is just how it is.’

Pause: Consider if you or someone you know has ever found themselves in this valley of diet despair.

But the metabolic health clinic took on the challenge and enrolled 50 participants in an intense multi-modal lifestyle change program, abbreviated TOWARD – I’ll unpack that in a moment – that centered on patients consuming a ketogenic diet of <30 grams of carbs per day. But patients were explicitly NOT told to attempt caloric restriction and instead eat according to their subjective hunger.

Now, what was “TOWARD?” It stands for:

• Text-based communications and messaging

• Online interactions

• Wellness coaching

• Asynchronous education and community support

• Real-time biofeedback

• Diet (Keto and Time Restricted Feeding)

Basically, in addition to diet, patients were given access to a messaging platform where they could contact members of the healthcare team in real time to get their questions answered. I’ll tell you – in my own coaching – this form of support is invaluable.

When a patient or client is shopping, for example, they might have a question about the ingredients list or nutrition label of different products. Being able to inquire about these with a trusted support can facilitate rapid, progressive learning of practical dietary knowledge.

And once clients and patients have developed a hunger for learning, it’s best to provide them with a buffet of information. In this study, this buffet was provided via a smartphone application with a multi-media curriculum focusing on the science of hunger and appetite, food addiction, as well as the role of stress, sleep and other variables on metabolic health.

But if you really want to empower people, you put their own data in their own hands.

With the emergence and availability of continuous glucose monitors (CGMs), ketone blood meters, and more tools on the horizon, we can provide members of the general public with real-time biofeedback tools.

If you have a soda and see your blood sugar spike to 300 mg/dl, that’s a teaching moment more potent than any scientific study. The metabolic health clinic used these tools – CGM and ketone monitors – as well.

In summary, this wasn’t just an isolated dietary intervention insofar as people weren’t just given instructions and let off into the world. It was a dietary intervention buffered by education and community support. I’ll get to the pros and cons of this when I discuss limitations, but let’s first reveal the stunning results.

Results: Better than Ozempic?

All 50 patients – 100% – lost weight, with an average weight loss of 15.5% body weight or 43 pounds over the year. That’s impressive...

But what’s perhaps even more impressive is … did you catch I said all 50? In a 1-year diet and lifestyle study like this, it’s inevitable there will be some dropouts.

So, these impressive results are even more impressive when you consider:

1. The incredible retention rate of 82%, i.e. 41 of 50 were still enrolled at 12 months

2. This “intention-to-treat analysis” including all 50 patients included those dropouts.

In the per protocol analysis, looking at those still enrolled at 12 months, health improvements and weight loss were even greater, at 16.6% body weight loss on average.

But it gets more interesting...

Some patients were on GLP-1 receptor agonist weight loss medications. Weight loss in these patients was comparable to those not taking GLP-1s. And, of the dozens of medications deprescribed, 4 patients were taken off GLP-1s and did not gain back weight – which is counter to the common knowledge that the fat returns when you terminate these medications. “I’ll Be Back!”

Cost Savings

And what’s another big advantage of deprescribing medications? Cost savings!

From net deprescription and medication changes alone, cost savings were over $83,000, or about $1700 per patient per year. By contrast, the annual cost per patient of a common GLP-1 medication is ~$13000 per year.

So, returning to the title: “Keto vs GLP-1: New Study Reveals Advantages of Lifestyle.”

Well, not only did the multi-modal lifestyle intervention stick for 82% of patients and lead to slightly more average weight loss over the year than GLP-1 medications, but medical costs went in the opposite direction: Down not Up.

It’s like have your cake and eat it too, but in this case: Have your weight loss and money too.

Limitations and Strengths

Now let’s talk about the limitations and strengths of this study, which are, actually, largely the same. This was a multi-modal study, meaning it wasn’t “just diet.”

From a scientific point of view, this is a limitation insofar as one can’t claim from this study the keto diet was the magic bullet. It’s also notable there wasn’t a control group, and it would be interested to know what the results would have been if an identical clinic provided similar care but focusing on a different dietary intervention, like a vegan diet or standard Mediterranean diet. That’s true.

However, actually feel the multimodal intervention was this study’s and program’s greatest strength because it helps make the point we can’t just give people dietary guidelines and rules and expect them to succeed in this food environment.

The developed world is saturated with bad nutrition information and dietary booby traps.

People need supportive communities and education to make diet sustainable. And, when these are provided, we can achieve consistent, progressive, and sustainable results.

I myself am 100% convinced of this fact. Firsthand, through my metabolic health coaching, and secondhand, through my engagement in the metabolic health space, I’ve seen people demonstrate incredible life transformations so shocking most people can’t believe it. In the current world, these people are outliers.

But what we must ask is what makes these outliers outliers and how can we generalize the results to the general population.

This study is paving the way, and offers a glimpse of a solution that’s sustainable, both in terms of weight loss and economics.

I’m pumped. I’m optimistic about the future and I want to challenge you to be the outlier! Start by educating yourself about metabolic health (translation: subscribe to my socials, below, start binging content) and get your data in your hands (see below).

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Video Coverage