{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T04:30:45Z","timestamp":1786681845016,"version":"build-2736575974"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T00:00:00Z","timestamp":1786665600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Adults with T2D enrolled in the intervention arm of a non-randomized clinical trial were followed for 5\u202fyears (\n                      <jats:italic>N<\/jats:italic>\n                      \u202f=\u202f194). 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.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>PSQI scores improved at all follow-ups, with 19\u201325% reductions from baseline to 5\u202fyears; the proportion classified as poor sleepers decreased from 63 to 48%. Depressive symptoms decreased by 10\u202fweeks and were sustained through 2\u202fyears; at 5\u202fyears 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\u201374% exceeded the 10-point MCID.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>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\u202fyears.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fnut.2026.1855196","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T04:22:36Z","timestamp":1786681356000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Five-year patient-reported outcomes of individualized nutrition therapy supporting nutritional ketosis in adults with type 2 diabetes"],"prefix":"10.3389","volume":"13","author":[{"given":"Rebecca N.","family":"Adams","sequence":"first","affiliation":[{"name":"Virta Health Corp.","place":["Denver, CO, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shaminie J.","family":"Athinarayanan","sequence":"additional","affiliation":[{"name":"Virta Health Corp.","place":["Denver, CO, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen D.","family":"Phinney","sequence":"additional","affiliation":[{"name":"School of Medicine, University of California, Davis","place":["Davis, CA, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeff S.","family":"Volek","sequence":"additional","affiliation":[{"name":"Department of Human Sciences, The Ohio State University","place":["Columbus, OH, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy L.","family":"McKenzie","sequence":"additional","affiliation":[{"name":"Lingo Biowearables","place":["Alameda, CA, United 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