Linking To And Excerpting From “TOWARD, a metabolic health intervention, demonstrates robust 1-year weight loss and cost-savings through deprescription”

Posted on November 30, 2025 by Tom Wade MD

Today, I review, link to, and excerpt from TOWARD, a metabolic health
intervention, demonstrates robust 1-year weight loss and cost-savings through deprescription [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Front Nutr. 2025 Feb 14:12:1548609. doi: 10.3389/fnut.2025.1548609. eCollection 2025.

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Abstract

Background

Cost, scalability, and durability represent major challenges to the implementation of intensive lifestyle treatments for obesity and diabetes. We previously reported pilot data from a 6-month intervention in which a self-insured manufacturing company partnered with a metabolic health clinic that utilizes therapeutic carbohydrate reduction (TCR), asynchronous monitoring, and a community-based approach to treat employees with metabolic disease. This manuscript presents weight loss and cost-savings from deprescription at the 12-month time point.

Methods

50 employees, mean BMI 43.2 ± 8.7 kg/m2, 64% with prediabetes or type 2 diabetes, were enrolled in the multimodal TOWARD telemedicine intervention, which includes: Text-based communications, Online interactions, Wellness coaching, Asynchronous education, Real-time biofeedback and remote monitoring, and Dietary modifications that emphasizes TCR.

Results

41 completed the one-year intervention. Mean weight loss for the 50 subjects in the intention-to-treat analysis was 19.5 ± 11.4 kg, corresponding to 15.5% total body weight loss with concomitant deprescription of 96 medications, while starting only 8 medications. In patients who discontinued GLP-1 receptor agonists, weight loss continued or was maintained. Annualized cost savings from the TOWARD approach were approximately -$1700 per patient, as compared to an annualized cost burden of roughly +$13000 per patient for a GLP-1 receptor agonist.

Conclusion

The TOWARD approach represents a scalable metabolic health intervention that demonstrates robust improvements in weight while simultaneously allowing for deprescription leading to substantial cost savings. TOWARD could serve as a scalable tool to facilitate intensive lifestyle intervention with efficacy on par with GLP-1 receptor agonists.

Keywords: GLP1, diabetes, ketogenic, obesity, telemedicine, therapeutic carbohydrate reduction, carnivore diet, intermittent fasting

Graphical Abstract

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Introduction

Behavioral and lifestyle changes are considered a viable first-line treatment for diet-related noncommunicable diseases, including Type 2 Diabetes (T2D), prediabetes, hypertension, metabolic syndrome and obesity (). The prevalence of these diseases is increasing, with 38% of adults in the United States having prediabetes or diabetes and 42% having obesity (, ). The economic burden of metabolic disease is also high, with $412 billion spent on T2D and $173 billion on obesity annually in the form of direct care cost ().

Novel medications, including GLP-1 receptor agonists (GLP-1 RA), are becoming a cornerstone of obesity management of metabolic disease given demonstrated improvements in glycemia, adiposity, and cardiovascular outcomes (). However, these medications are not without limitations. Trials have consistently found weight regain upon discontinuation (), necessitating a lifetime commitment to the drug to retain weight loss and other health benefits. Some patients are nonresponders and do not meet the clinically significant weight loss goal of 5%. Fully 25% of subjects in the semaglutide 2.4 mg “STEP 5” trial experienced a < 5% reduction in body weight over 104 weeks (). This trial also reported that cravings and hunger started to return toward baseline at 20 weeks to nearly or entirely equal to the placebo group at week 104 (). An analysis of the SUSTAIN 8 clinical trial found that 30 to 40% of weight loss came from lean body mass (muscle) with the use of semaglutide over 52 weeks (). Lean mass loss with GLP-1RA is of potential long-term concern because of the implications of sarcopenia on metabolism and its association with increased all-cause mortality ().

Serious and widespread side effects of GLP-1 RAs are additional cause for concern. Some 82.2% of subjects in the STEP 5 trial were reported to experience gastrointestinal side effects on semaglutide 2.4 mg at 2 years (). A small but notable increase in risk for all thyroid cancer and medullary thyroid cancer was also observed after 1–3 years treatment on GLP-1RAs in an analysis from the French national health care insurance system database ().

  • 9.Bezin J, Gouverneur A, Penichon M, et al. GLP-1 receptor agonists and the risk of thyroid Cancer. Diabetes Care. (2023) 46:384–90. doi: 10.2337/DC22-1148, PMID: [DOI] [PubMed] [Google Scholar]

For people with diabetes, outcomes may be less robust than reported. For instance, a follow-up study to the SCOPE trial (semaglutide 2.4 mg) reported significantly reduced HbA1c, yet this observation was derived from data on only 30 out of 343 subjects (). Further, in a real-world retrospective study of 82,624 adults (mostly men), GLP-1RAs were found to be the least well tolerated medication, with a deprescription rate of more than 50%, among 5 medications prescribed for people with T2D. This deprescription rate was 10% higher than the next-most deprescribed drug (). Another real-world study published in July 2023 investigated claims of 16 million commercially insured members and found that almost 70% of patients stopped GLP-1RA treatment within less than a year after starting (). A prominent concern with these weight loss therapeutics is the price tag, with more than 142 million Americans qualifying for the medication and a price ranging from $800 to $1700/month, annual costs on the healthcare system could reach over a trillion dollars (). The need for cost-effective alternatives as either a replacement or adjunct to GLP-1 RAs is therefore paramount.

Two studies have documented sustained weight loss maintenance with GLP-1RA discontinuations. A supervised exercise intervention was found to maintain body weight and body composition for 1 year following the discontinuation of GLP-1RA (). Likewise, a retrospective analysis on 154 individuals demonstrated that a ketogenic diet prevented weight regain and protected against any increase in HbA1c at both six and 12 months following deprescription from GLP-1 RAs (). The mean HbA1c of the deprescribed cohort rose 0.2% at 12 months yet remained in the non-diabetic range (). These data suggest that programs that incorporate intensive health coaching, exercise prescriptions and TCR may represent important interventions to mitigate cost as well as limit weight regain and potential other harms from GLP-1 RA use.

Historically, few employee wellness programs have documented strong efficacy in managing diabetes or obesity. Our previously published 6-month data using the TOWARD approach demonstrated significant results on weight, Atherosclerotic Cardiovascular Disease (ASCVD) risk and cost-savings (). In this paper, we present a focused review of the one-year weight loss results and cost savings from medication deprescription from 50 patients who self-selected to participate.

Materials and methods

Intervention

The TOWARD intervention employed by the metabolic health clinic is a combination of five well-defined, evidence-based best practices, including Text-based communications and messaging, Online interactions, Wellness coaching, Asynchronous education & community support, Real-time biofeedback and remote monitoring of body composition, blood pressure, blood glucose and ketones, as well as Dietary modifications that emphasize TCR and intermittent fasting (IF) approaches (Figure 1).

Figure 1.

Figure 1

Components of the intervention.

For more detailed information on each of the above steps, please see the article.

Baseline and quarterly assessments

Blood tests for all patients at baseline, 12 weeks, 24 weeks, and 52 weeks were collected after a 10–16 h overnight fast and included a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, vitamin B12, folate, C-reactive protein, HbA1c, lipid panel, and insulin (Figure 2).

Figure 2.

Figure 2

Measurements across time.

Establishment of an employee metabolic health wellness program

A self-insured manufacturing company approached the metabolic clinic to establish an employee metabolic wellness program in October 2021. The company advertised the program through internal posters, fliers, emails, and live webinars. The clinic held monthly virtual information sessions for the company. Further outreach was conducted through email campaigns which targeted employees with markers of metabolic syndrome, obesity or diabetes with data obtained from annual corporate lab screenings. Thereafter, employees voluntarily applied to the program, were selected (described below), and established care with the clinic.

Patient enrollment, consent, and completion

All employees of the company were offered virtual webinars and meetings to learn about metabolic health. After these meetings a QR code was shared with employees to apply if they were interested in participating in the program. An informational campaign to enroll employees using email, posters, and table tents also took place. The clinic received hundreds of applications (Figure 3), and due to limitations in on-boarding capacity, patients were prioritized based on the presence of metabolic syndrome, diabetes status, and BMI. 50 patients were selected based on clinical judgment of overall medical need following assessment of the severity of obesity (BMI) and diabetes (HbA1c). Polypharmacy was a key factor in patient selection, with preference given to individuals on multiple medications particularly for conditions related to metabolic disease. Additionally, patients at risk of adverse events due to specific medications or combinations of medications were prioritized to ensure timely and effective intervention. Other factors also examined include the clinical profile of applicants including comorbidities, safety, and readiness to participate in the program. These criteria ensured that patients with the highest medical need and those at risk of complications were included promptly. Every employee was given access to the TOWARD smartphone app for education and engagement purposes and when clinical availability allowed further employees were enrolled. All patients were initially onboarded purely with clinical intent (details below).

Figure 3.

Figure 3

Participant flowchart.

Statistics

Data was analyzed in both a per-protocol (PP) and an intent-to-treat (ITT) fashion (with the last observation timepoint being carried over).

Data management and statistical analyses were performed using R version 4.0.3 (with R Studio version: 1.3.1093), and all the R packages were updated to their latest version (30 April 2024). Descriptive data were summarized using mean and standard deviation and confidence intervals were calculated with mean bootstrap. Drug costs were estimated using those listed on GoodRx [GoodRx.com (accessed in January 2024)].

 

 

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