Algorithm 2. Incretin-first, tapered carbohydrate reduction to AKMP

Indication: patients unable to “on-ramp” into AKMP due to reward-driven eating, severe cravings, chaotic schedules, or prior failed ketogenic attempts. Steps: (i) Start a professionally supervised Mediterranean diet; (ii) initiate a GLP-1RA or dual GLP-1/GIP agonist; (iii) taper carbohydrates by 25–50 g every 2 weeks while monitoring satiety and biomarkers (target β-hydroxybutyrate ≥ 0.6 mmol/L for ≥2 consecutive weeks); (iv) when hunger/food preoccupation is blunted and BHB threshold is met, transition to AKMP Phase 2 (adaptive metabolic optimization). Mechanistic aim: use incretin therapy to reduce appetite and food-reward responsivity [145,196], then consolidate the behavioral and metabolic gains under AKMP’s biomarker-guided framework.