New injectable diabetes medications, including semaglutide (Ozempic) and tirzepatide (Mounjaro), are clearly the most effective weight loss drugs ever developed. These drugs, known as GLP-1 receptor agonists, might also be the most potent diabetes treatments since the discovery of insulin, offering massive improvements in blood sugar control and A1C.

But there’s a catch, and a big one: You probably have to take them forever. Experts agree that patients who want to sustain their weight loss and glucose improvements need to keep using their GLP-1s indefinitely. When you stop using Ozempic, you can expect your appetite to return, your weight to come back, and your blood sugar to go back up.

A recent study found that patients without diabetes who used tirzepatide (Zepbound) regained about half of the weight they’d originally lost a year after discontinuing the drug. That overall weight loss was still impressive, but experts seem resigned that most patients would eventually regain it all. Study coauthor Louis Aronne, MD, told Everyday Health, “If you stop the medication, you regain the weight — there’s no question that will happen.”

Millions of people have already encountered this problem: More than two-thirds of GLP-1 users stop using their new medication within a year. There are many reasons why people might cease using these powerful therapies, including the high cost (especially when insurance changes or coupons expire), side effects, supply shortages, or simple discomfort with the idea of taking a weight loss drug for years.

And there isn’t much good advice for people coming off of these potent drugs. Many articles have been written on how to keep the weight off (and glucose under control) after discontinuing a drug like Ozempic, but there is evidently no easy fix. Most advice — healthy diet, portion control, exercise — is, while undoubtedly accurate, exactly what so many people living with type 2 diabetes or obesity have already heard a million times before.

A Low-Carb Diet Helped Patients Keep the Pounds Off

There’s a new study in Diabetes Therapy suggesting that a very low-carb or keto diet can help people maintain weight loss after discontinuing a GLP-1 medication.

The study was performed by Virta Health, a leading online type 2 diabetes management platform. The business identified 154 customers who had been deprescribed a GLP-1 medication such as Ozempic or dulaglutide (Trulicity), and matched them with an equal number of patients who continued to use a GLP-1 drug, and compared the outcomes. (Many of the former GLP-1 users switched to metformin.)

Before the study began, the GLP-1 medications had helped both arms of the study achieve an average A1C under 6.5 percent and impressive weight loss (about 28 pounds).

All study participants were encouraged to eat fewer than 30 grams of carbohydrates per day (vegans were allowed 50 g) and to eat plenty of protein (1.5 g per kilogram of body weight), about twice as much as recommended by the American health authorities. Virta users are also instructed on the fundamentals of a “well-formulated ketogenic diet,” full of wholesome low-carb options like veggies, nuts, seeds, and berries.

One year after discontinuing their weight loss drug, Virta users on their low-carb diet:

Maintained their weight loss just as well as the participants who continued to use their GLP-1. There was no statistically significant difference in body weight between those who went off the drug and those who continued to use it.
Experienced a slight increase in blood sugar levels. Though A1Cs rose after deprescription, they largely remained in a healthy range. Twelve months after discontinuing a GLP-1, the average participant saw their blood sugar rise 0.6 percentage points, up to 6.2 percent, still below the official range for diabetes.

The authors speculated that the low-carb diet may have been reducing hunger and appetite just as effectively as the GLP-1 medication. There is a wealth of information suggesting that low-carb and keto diets can help people with diabetes lose weight. Some keto dieters even find that they lose weight almost effortlessly because they fill up on rich low-carb foods before eating too many calories.

We should certainly take this result with a grain of salt. This was a retrospective analysis rather than a randomized controlled trial, and it examined people who signed up for (and stuck with) a low-carb diabetes program — not the average Ozempic user. Perhaps more importantly, the analysis was performed by employees of Virta Health itself, introducing an obvious hazard of bias in study design and analysis.

Nevertheless, the results may be encouraging for anyone with diabetes who is planning to discontinue Ozempic, Trulicity, or Mounjaro and is concerned about losing the health benefits. A low-carb approach could be an effective off-ramp.

Virta Health routinely releases real-world data on its users. A  five-year study of the outcomes of 200 Virta patients found that the program conferred weight loss (an average of 19 pounds), improved A1C, reduced reliance on diabetes medication, and other related metabolic benefits such as improved cholesterol.

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