Algorithm 1. AKMP-first, step-up to incretin therapy if adherence threatens to fail

Indication: motivated patients willing to adopt structured menus and monitoring. Steps: (i) Initiate ketogenic–Mediterranean induction per AKMP Phase 1; (ii) maintain dynamic, biomarker-guided adjustments (protein up to 1.6 g/kg IBW if hunger; or −100–200 kcal/day if satiety adequate); (iii) Add a GLP-1/GIP agonist if any of the following triggers occur: –confirmed plateau ≥ 14 days with ketosis plus rising hunger (VAS ≥ 60/100) despite protein optimization; –adherence hazards: social pressure/events, family meal constraints, travel, cost/time burden of meal prep, taste monotony, GI symptoms (constipation), seasonal festivities, caregiver stress; –repeated ketone < 0.3 mmol/L despite counseling; –high risk neurobehavioral patterns (food-addiction phenotype) jeopardizing continuation Mechanistic aim: preserve lean mass (adequate protein + anti-catabolic ketosis) and offset incretin metabolic neutrality by leveraging the ketogenic metabolic advantage [79,83,153], while dual agonism (tirzepatide) may permit dose escalation via GIP-mediated nausea attenuation and enhance efficacy [79,147,197].