Continuous glucose monitoring has become a common adjunct in the management of Diabetes Mellitus. However, there has been a recent trend among individuals without diabetes using these devices as a means of monitoring their health. The increased visibility of glucose data has allowed users to study the effect lifestyle has upon post-prandial glucose levels. Although post-prandial hyperglycemia is well understood in the setting of diabetes, its impact in individuals without diabetes is less well defined. This article reviews the factors which contribute to post-prandial hyperglycemia in individuals without diabetes and how the data obtained from continuous glucose monitoring can be used to improve an individual's metabolic health.

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.

Abstract Background In a previous study, we assessed a novel, remotely monitored carbohydrate restricted diet regimen including nutritional ketosis in patients with type 2 diabetes and reported significant improvements in weight, glycemic control, abdominal fat and inflammation from baseline to 2 years. Knee outcome measures were collected as a secondary outcome in the trial. This study aims to assess the effect of this intervention on knee functional scores and to identify if changes in weight, central abdominal fat (CAF), glycemic status and high sensitivity C-reactive protein (hsCRP) were associated with its improvement. Methods This prospective analysis included continuous care intervention (CCI, n = 173) and usual care (UC, n = 69) trial participants with type 2 diabetes that reported knee pain at baseline. Knee outcome measures included the Knee injury and Osteoarthritis Outcome Score (KOOS) pain, symptoms, activities of daily living (ADL), sports and recreation function, and knee-related quality of life subscales, and total KOOS score were assessed from baseline to 2 years. Missing data at each time point were replaced with multiple imputation under the assumption of missing at random. To assess if the primary analysis of the knee scores changed under plausible missing not at random assumptions, sensitivity analysis was also performed using pattern mixture models. In CCI, we also assessed factors associated with the improvement of knee scores. Results In the primary analysis, CCI participants demonstrated a statistically significant improvement in total KOOS and all KOOS individual subscale scores at 1 year and maintained through 2 years as opposed to UC patients who showed no significant changes from baseline to 2 years. The significant improvement in total KOOS and its individual subscale scores from baseline to 2 years remained relatively stable in CCI in the sensitivity analysis under different missing not at random scenarios confirming the robustness of the findings from the primary analysis. Approximately 46% of the CCI participants met the 10 points minimal clinically important change at 2 years. A reduction in CAF was associated with improvement in total KOOS and KOOS ADL, while a decrease in hsCRP was associated with improvement in KOOS symptoms scores. Conclusion A very low carbohydrate intervention including nutritional ketosis resulted in significant improvements in knee pain and function among patients with T2D. The improvements in knee function were likely secondary to a reduction in central adiposity and inflammation. Future research on the applicability of this intervention in radiographically confirmed OA patients is important. Trial registration Clinical trial registration: NCT02519309 (10/08/2015).

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.

Regression from prediabetes (preD) to normoglycemia (NG) is associated with reduced progression to type 2 diabetes (T2D). Carbohydrate restriction including nutritional ketosis (CR) has emerged as a safe, effective, and sustainable treatment for regression of hyperglycemia in T2D, yet its multi-year effects on preD are unknown. Also, some patients have difficulty initiating and/or sustaining provider-recommended lifestyle changes. Thus, we hypothesized that a remotely delivered continuous care intervention (CCI) emphasizing CR would improve glycemia and weight in patients with preD. In a single-arm, prospective, longitudinal study, we assessed incidence of regression from preD to NG, progression from preD to T2D, and prevalence of metabolic syndrome (MetS) and class II or greater obesity in participants following two years of treatment. Patients with a preD diagnosis enrolled in the study (n=116). Outcomes were assessed among 96 participants (age: 52±10 y; BMI: 39.2±7.1 kg/m2) with preD defined as HbA1c<6.5% with metformin use or HbA1c 5.7-6.4% (inclusive) without glycemic control medication. Retention at two years was 75% (72/96). The crude incidence for first occurrence of regression from preD to NG (HbA1c <5.7% without medication) was 47.6 cases per 100 person-years. Estimated cumulative incidence of NG at two years was 52.3%. One new case of T2D each year was observed, and crude incidence of T2D diagnosis was 1.5 cases per 100 person-years. Estimated cumulative incidence of T2D at two years was 3%. Prevalence of MetS was reduced from 94% to 30% at one and 47% at two years (both P<4.4x10-16). Prevalence of class II or greater obesity was reduced from 67% to 38% at one and 39% at two years (both P<.0013). Among two-year completers, 62.5% achieved ≥7% weight loss. Given these observations, this study demonstrates the potential utility of a CCI emphasizing CR for treatment of preD. Disclosure A. McKenzie: Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. S.J. Athinarayanan: Employee; Self; Virta Health Corp. J. McCue: Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. R.N. Adams: Employee; Self; Virta Health Corp. J.P. McCarter: Employee; Self; Abbott Laboratories. Stock/Shareholder; Self; Virta Health. J. Volek: Advisory Panel; Self; Atkins Nutritionals, Cook Keto, Virta Health Corp. Stock/Shareholder; Self; PangeaKeto, Virta Health Corp. Other Relationship; Self; Beyond Obesity. Funding Virta Health Corp

Background: We have previously reported that in patients with type 2 diabetes (T2D) consumption of a very low carbohydrate diet capable of inducing nutritional ketosis over two years (continuous care intervention, CCI) resulted in improved body weight, glycemic control, and multiple risk factors for cardiovascular disease (CVD) with the exception of an increase in low density lipoprotein cholesterol (LDL-C). In the present study, we report the impact of this intervention on markers of risk for atherosclerotic cardiovascular disease (CVD), with a focus on lipoprotein subfraction particle concentrations as well as carotid-artery intima-media thickness (CIMT). Methods: Analyses were performed in patients with T2D who completed 2 yrs of this study (CCI; n=194; usual care (UC): n=68). Lipoprotein subfraction particle concentrations were measured by ion mobility at baseline, 1, and 2 yrs and CIMT was measured at baseline and 2 yrs. Principal component analysis (PCA) was used to assess changes in independent clusters of lipoprotein particles. Results: At two years, CCI resulted in a 23% decrease of small LDL IIIb and a 29% increase of large LDL I with no change in total LDL particle concentration or ApoB. The change in proportion of smaller and larger LDL was reflected by reversal of the small LDL subclass phenotype B in a high proportion of CCI participants (48.1%) and a shift in the PC representing the atherogenic lipoprotein phenotype characteristic of T2D from a major to a secondary component of the total variance. The increase in LDL-C in the CCI group was mainly attributed to larger cholesterol-enriched LDL particles. CIMT showed no change in either the CCI or UC group. Conclusion: Consumption of a very low carbohydrate diet with nutritional ketosis for 2 yrs in patients with type 2 diabetes lowered levels of small LDL particles that are commonly increased in diabetic dyslipidemia and are a marker for heightened CVD risk. A corresponding increase in concentrations of larger LDL particles was responsible for higher levels of plasma LDL-C. The lack of increase in total LDL particles, ApoB, and in progression of CIMT, provide supporting evidence that this dietary intervention did not adversely affect risk of CVD.

The phylum Nematoda occupies a huge range of ecological niches, from free-living microbivores to human parasites. We analyzed the genomic biology of the phylum using 265,494 expressed-sequence tag sequences, corresponding to 93,645 putative genes, from 30 species, including 28 parasites. From 35% to 70% of each species' genes had significant similarity to proteins from the model nematode Caenorhabditis elegans. More than half of the putative genes were unique to the phylum, and 23% were unique to the species from which they were derived. We have not yet come close to exhausting the genomic diversity of the phylum. We identified more than 2,600 different known protein domains, some of which had differential abundances between major taxonomic groups of nematodes. We also defined 4,228 nematode-specific protein families from nematode-restricted genes: this class of genes probably underpins species- and higher-level taxonomic disparity. Nematode-specific families are particularly interesting as drug and vaccine targets.

Background The ketone bodies beta-hydroxybutyrate (BHB) and acetone are endogenous products of fatty acid metabolism. Although ketone levels can be monitored by measuring either blood BHB or breath acetone, determining the precise correlation between these two measurement methods has been challenging. The purpose of this study is to characterize the performance of a novel portable breath acetone meter (PBAM) developed by Readout, Inc., to compare single versus multiple daily ketone measurements, and to compare breath acetone (BrAce) and blood BHB measurements. Methods We conducted a 14-day prospective observational cohort study of 21 subjects attempting to follow either a low-carbohydrate/ketogenic or a standard diet. Subjects were asked to concurrently measure both blood BHB and BrAce five times per day and report the results using an online data entry system. We evaluated the utility of multiple daily measurements by calculating the coefficient of variation (CV) for each daily group of measurements. We calculated the correlation between coincident BrAce and blood BHB measurements using linear ordinary least squares regression analysis. We assessed the ability of the BrAce measurement to accurately predict blood BHB states using receiver operating characteristic (ROC) analysis. Finally, we calculated a daily ketone exposure (DKE) using the area under the curve (AUC) of a ketone concentration versus time graph and compared the DKE of BrAce and blood BHB using linear ordinary least squares regression. Results BrAce and blood BHB varied throughout the day by an average of 44% and 46%, respectively. The BrAce measurement accurately predicted whether blood BHB was greater than or less than the following thresholds: 0.3 mM (AUC = 0.898), 0.5 mM (AUC = 0.854), 1.0 mM (AUC = 0.887), and 1.5 mM (AUC = 0.935). Coincident BrAce and blood BHB measurements were moderately correlated with R2 = 0.57 (P < 0.0001), similar to literature reported values. However, daily ketone exposures, or areas under the curve, for BrAce and blood BHB were highly correlated with R2 = 0.80 (P < 0.0001). Conclusions The results validated the performance of the PBAM. The BrAce/BHB correlation was similar to literature values where BrAce was measured using highly accurate lab instruments. Additionally, BrAce measurements using the PBAM can be used to predict blood BHB states. The relatively high daily variability of ketone levels indicate that single blood or breath ketone measurements are often not sufficient to assess daily ketone exposure for most users. Finally, although single coincident blood and breath ketone measurements show only a moderate correlation, possibly due to the temporal lag between BrAce and blood BHB, daily ketone exposures for blood and breath are highly correlated.

ObjectiveOne year of comprehensive continuous care intervention (CCI) through nutritional ketosis improves glycosylated haemoglobin(HbA1c), body weight and liver enzymes among patients with type 2 diabetes (T2D). Here, we report the effect of the CCI on surrogate scores of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis.MethodsThis was a non-randomised longitudinal study, including adults with T2D who were self-enrolled to the CCI (n=262) or to receive usual care (UC, n=87) during 1 year. An NAFLD liver fat score (N-LFS) >−0.640 defined the presence of fatty liver. An NAFLD fibrosis score (NFS) of >0.675 identified subjects with advanced fibrosis. Changes in N-LFS and NFS at 1 year were the main endpoints.ResultsAt baseline, NAFLD was present in 95% of patients in the CCI and 90% of patients in the UC. At 1 year, weight loss of ≥5% was achieved in 79% of patients in the CCI versus 19% of patients in UC (p<0.001). N-LFS mean score was reduced in the CCI group (−1.95±0.22, p<0.001), whereas it was not changed in the UC (0.47±0.41, p=0.26) (CCI vs UC, p<0.001). NFS was reduced in the CCI group (−0.65±0.06, p<0.001) compared with UC (0.26±0.11, p=0.02) (p<0.001 between two groups). In the CCI group, the percentage of individuals with a low probability of advanced fibrosis increased from 18% at baseline to 33% at 1 year (p<0.001).ConclusionsOne year of a digitally supported CCI significantly improved surrogates of NAFLD and advanced fibrosis in patients with T2D.Trial registration numberNCT02519309; Results.

We previously showed that a digitally-monitored continuous care intervention (CCI) including nutritional ketosis (NK) substantially improved weight and HbA1c in adults with T2D. In this intervention, health coaches provided personalized nutrition guidance informed by biomarker data participants entered into a mobile app. Here, we examined whether indicators of early treatment engagement (i.e., messaging coaches, logging biomarkers, achieving NK) predicted the decreases in weight and HbA1c at 1 and 2 years. 262 adults with T2D (mean age=54 years, 67% female, mean HbA1c %=7.6, 92% obese) in the CCI were counseled to eat a whole foods very low carbohydrate diet. The percentage of days participants messaged their coach and logged ≥1 biomarker or symptom, and percentage of blood beta-hydroxybutyrate (BHB) readings ≥0.5 mM (indicating NK) during the first 10 weeks were obtained from the app. Weight and HbA1c were measured in clinic. We conducted correlation and GLM intent-to-treat analyses to assess relations between measures of treatment engagement and percent change in weight and HbA1c from baseline to 1 and 2 years. Coach messaging and logging were not correlated with percent change in weight or HbA1c; however, a greater percentage of BHB readings ≥0.5 was correlated with a greater percent decrease in weight (r=-0.25, p=0.001) and HbA1c (r=-0.19, p=0.004) from baseline to 1 year (but not 2 years). In GLM analyses, a greater percentage of BHB readings ≥0.5 predicted greater percent decrease in weight (b=-0.06, p=0.01) and HbA1c (b=-0.06, p=0.03) at 1 year after accounting for coach messaging, logging, and baseline demographic and medical characteristics. Results indicate that greater adherence to NK during the first 10 weeks explained a significant proportion of the variance in weight loss and A1c reduction, whereas simple app-based engagement did not. Future analyses should explore the role of maintaining NK over the remainder of the year on 1 year outcomes. Disclosure R.N. Adams: Employee; Self; Virta Health Corp. A. McKenzie: Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. S.J. Athinarayanan: Employee; Self; Virta Health Corp. S. Hallberg: Advisory Panel; Self; Atkins Nutritionals, Inc. Employee; Self; Virta Health Corp. Stock/Shareholder; Self; Virta Health Corp. J.P. McCarter: Employee; 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.

Objective Sleep disruption is frequently associated with type 2 diabetes (T2D) and hyperglycemia. We recently reported the effectiveness of a continuous care intervention (CCI) emphasizing nutritional ketosis for improving HbA1c, body weight and cardiovascular risk factors in T2D patients. The present study assessed the effect of this CCI approach on sleep quality using a subjective patient-reported sleep questionnaire. Methods A non-randomized, controlled longitudinal study; 262 T2D and 116 prediabetes patientsenrolled in the CCI and 87 separately recruited T2D patients continued usual care (UC) treatment. Patients completed the Pittsburgh Sleep Quality Index (PSQI) questionnaire. A PSQI score of >5 (scale 0 to 21) was used to identify poor sleepers. Results Global sleep quality improved in the CCI T2D (p<0.001) and prediabetes (p<0.001) patients after one year of intervention. Subjective sleep quality (component 1), sleep disturbance (component 5) and daytime dysfunction (component 7), also showed improvements in the CCI T2D (p<0.01 for sleep quality and sleep disturbance; and p<0.001 for daytime dysfunction) and prediabetes patients (p<0.001 for all three components); compared to the UC T2D group after one year. The proportion of patients with poor sleep quality was significantly reduced after one year of CCI (T2D; from 68.3% at baseline to 56.5% at one year, p=0.001 and prediabetes; from 77.9% at baseline to 48.7% at one year, p<0.001). Conclusion This study demonstrates improved sleep quality as assessed by PSQI in patients with T2D and prediabetes undergoing CCI including nutritional ketosis but not in T2D patients receiving UC. The dietary intervention benefited both sleep quality and the severity of T2D symptoms suggesting that nutritional ketosis improves overall health via multiple mechanisms.

Introduction: Type 2 diabetes (T2D) is a major driver of health care costs, thus treatments enabling T2D reversal may reduce expenditures. We examined the impact of a T2D continuous care intervention (CCI) on health care utilization. Previous research documented that CCI, including individualized nutrition supported by remote care, simultaneously reduced hemoglobin A1c and medication use and improved cardiovascular status after two years; however, the impact on utilization is unknown. Methods: This study used four years of data (two years pre-intervention, two years post-intervention) from the Indiana Network for Patient Care (INPC) health record. Two methods estimated the impact of CCI on utilization. First, an interrupted time series (ITS) including only CCI participants (n=193) compared post-intervention utilization to expected utilization had the pre-intervention trend persisted. Deviation from the trend was estimated non-parametrically for each 6-month interval after the implementation of CCI . Second, a 1:3 matched comparator group (n=579) was constructed and used for a difference-in-differences (DiD) analysis. The primary outcome was annualized outpatient encounters. Secondary outcomes included emergency encounters and hospitalizations. Results: In two years prior to intervention, CCI participants had a mean of 5.77 annualized encounters (5.62 outpatient, 0.04 hospitalizations, 0.11 emergency). The CCI group showed a reduction in outpatient utilization after intervention. In ITS analysis, 1.6 to 1.9 fewer annualized outpatient encounters occurred in each 6-month interval post-intervention relative to expected utilization based on pre-intervention trends (p<0.01 each 6-month period; 28-33% reduction). The DiD analysis suggested a larger reduction; 5 fewer annualized outpatient encounters in the quarter after intervention, diminishing to 2.5 fewer after 2 years (p<0.01 each quarter). The study was underpowered to draw conclusions about hospitalization and emergency encounters due to the limited number of CCI patients and the rarity of encounters. Conclusions: Outpatient encounters were significantly reduced for a T2D patient population up to 2 years after receiving an individualized intervention supporting nutrition and behavior change through remote care.

Background: We recently reported 55% of the patients reversed type 2 diabetes in the continuous care intervention (CCI) while 18% of the patients achieved remission at 2 years. In this post hoc analysis, factors identified in previous studies as predictors of diabetes reversal and remission were examined. Methods: Baseline factors including diabetes duration, HbA1c, fasting glucose and a composite index (HbA1c, fasting insulin and ALT1) were examined as potential predictors of T2D reversal and remission in the CCI group along with percentage weight loss over the study period. Spearman correlation was used to assess relationships between predictors and 2 years reversal and remission. Factors with significant correlation were analyzed using logistic regression. Results: Diabetes duration, baseline HbA1c, fasting glucose and the composite index were significantly correlated with diabetes reversal and remission (Table 1). Logistic regression analyses showed that diabetes duration (OR=1.2, p=7.0x10-6) and baseline HbA1c (OR=1.5, p=0.003) were associated with diabetes reversal at 2 years whereas weight loss percentage during the study period was not. Conclusion: Shorter diabetes duration and lower baseline HbA1c are two factors strongly related to achieving diabetes reversal and remission in CCI participants at 2 years. Disclosure S.J. Athinarayanan: Employee; Self; Virta Health Corp. A. McKenzie: Employee; Self; Virta Health Corp. Stock/Shareholder; 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. J.P. McCarter: Employee; 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. Funding 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

Purpose: Studies on long-term sustainability of low-carbohydrate approaches to treat diabetes are limited. We previously reported the effectiveness of a novel digitally-monitored continuous care intervention (CCI) including nutritional ketosis in improving weight, glycemic outcomes, lipid, and liver marker changes at 1 year. Here, we assess the effects of the CCI at 2 years.Materials 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. Primary outcomes were retention, glycemic control, and weight changes at 2 years. Secondary outcomes included changes in body composition, liver, cardiovascular, kidney, thyroid and inflammatory markers, diabetes medication use and disease status.Results: Reductions from baseline to 2 years in the CCI group resulting from intent-to-treat analyses included: HbA1c, fasting glucose, fasting insulin, weight, systolic blood pressure, diastolic blood pressure, triglycerides, and liver alanine transaminase, and HDL-C increased. Spine bone mineral density in the CCI group was unchanged. Use of any glycemic control medication (excluding metformin) among CCI participants declined (from 55.7 to 26.8%) including insulin (-62%) and sulfonylureas (-100%). The UC group had no changes in these parameters (except uric acid and anion gap) or diabetes medication use. There was also resolution of diabetes (reversal, 53.5%; remission, 17.6%) in the CCI group but not in UC. All the reported improvements had p < 0.00012.Conclusion: The CCI group 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.Clinical Trial Registration:Clinicaltrials.gov NCT02519309

Employee Virta Health. Ownership interest Virta Health