TLDR - If you are a ketogenic lean mass hyper responder with high LDL, insist on imaging to determine your atherosclerotic risk, as this study indicates the LDL and ApoB by itself doesn't indicate a growth in plaque.
Background - Changes in low-density lipoprotein cholesterol (LDL-C) among people following a ketogenic diet (KD) are heterogeneous. Prior work has identified an inverse association between body mass index and change in LDL-C. However, the cardiovascular disease risk implications of these lipid changes remain unknown.
Objectives - The aim of the study was to examine the association between plaque progression and its predicting factors.
Methods - One hundred individuals exhibiting KD-induced LDL-C ≥190 mg/dL, high-density lipoprotein cholesterol ≥60 mg/dL, and triglycerides ≤80 mg/dL were followed for 1 year using coronary artery calcium and coronary computed tomography angiography. Plaque progression predictors were assessed with linear regression and Bayes factors. Diet adherence and baseline cardiovascular disease risk sensitivity analyses were performed.
Results - High apolipoprotein B (ApoB) (median 178 mg/dL, Q1-Q3: 149-214 mg/dL) and LDL-C (median 237 mg/dL, Q1-Q3: 202-308 mg/dL) with low total plaque score (TPS) (median 0, Q1-Q3: 0-2.25) were observed at baseline. Neither change in ApoB (median 3 mg/dL, Q1-Q3: −17 to 35), baseline ApoB, nor total LDL-C exposure (median 1,302 days, Q1-Q3: 984-1,754 days) were associated with the change in noncalcified plaque volume (NCPV) or TPS. Bayesian inference calculations were between 6 and 10 times more supportive of the null hypothesis (no association between ApoB and plaque progression) than of the alternative hypothesis. All baseline plaque metrics (coronary artery calcium, NCPV, total plaque score, and percent atheroma volume) were strongly associated with the change in NCPV.
Conclusions - In lean metabolically healthy people on KD, neither total exposure nor changes in baseline levels of ApoB and LDL-C were associated with changes in plaque. Conversely, baseline plaque was associated with plaque progression, supporting the notion that, in this population, plaque begets plaque but ApoB does not. (Diet-induced Elevations in LDL-C and Progression of Atherosclerosis [Keto-CTA]
Full Paper: https://doi.org/10.1016/j.jacadv.2025.101686
Dave Feldman does a interview going over the controversy of the Keto-CTA study https://youtu.be/xP0jK39yHds
Dave Feldman summerizer
Discussing Keto-CTA with Darius Sharpe
In this interview with Darius Sharpe, Dave Feldman addresses criticism regarding the recent Keto-CTA study, especially focusing on the oversight of not including crucial numerical data in the results. He acknowledges mistakes made during the publication and emphasizes the importance of transparency and communication with their audience. The discussion revolves around the findings related to LDL levels, plaque progression, and the need for better reporting in future studies, as well as the view that further research is required to understand the implications of these results.
Key Points
Error in Data Presentation
Dave Feldman admits to a significant oversight in the Keto-CTA study, where the primary endpoint numerical data was not included in the publication, which led to considerable frustration among supporters and critics alike. He takes personal responsibility for this mistake and highlights the need for better communication and transparency.
Community Frustration
Darius Sharpe expresses concerns from the community regarding the lack of accessible data after the study's publication, emphasizing that supporters expected concrete results that were not delivered. This sentiment is echoed by many who have invested time and money into the study, demanding accountability and clarity.
Clarification of Study Findings
Dave explains that the Keto-CTA study demonstrated a lack of association between high LDL levels and plaque progression, but acknowledged that the significant increase in plaque volume over the year raised questions that need further investigation. He outlines the heterogeneous nature of the data and the need for careful analysis moving forward.
Planned Future Research
Both speakers discuss the importance of future studies to explore the data collected during the Keto-CTA study, suggesting that more papers will be written to shed light on various aspects of the data. The aim is to use this research to better understand the relationship between diet, LDL levels, and cardiovascular health.
Emphasis on Individualized Care
The conversation concludes with a focus on the importance of individual health metrics, encouraging listeners to seek appropriate imaging to assess their cardiovascular health and adjust their diets accordingly. The idea is to ensure each person's unique health journey is considered in managing their dietary and health choices.
Stephen Thomas also does a paper review https://youtu.be/auXq5jQs0aY
stephen thomas summerizer
Keto CTA Study and More
In this video, Coach Stephen discusses a recent keto study focusing on the impact of LDL levels on coronary plaque in lean mass hyper-responders. He critiques the study methodology, highlights historical biases in cholesterol research, and emphasizes the need for better data interpretation and control groups. Stephen also addresses the confusion surrounding HbA1c levels and their implications for individuals on a carnivore or keto diet.
Key Points
Historical issues with cholesterol research
Stephen explains the origins of cholesterol studies, beginning with a dubious experiment in the 1910s where rabbits were fed cholesterol to observe plaque formation. He critiques how these early studies laid a flawed foundation for the belief that LDL cholesterol directly causes heart disease.
Flaws in the National Cholesterol Education Program
He describes how the National Cholesterol Education Program, starting in the late 1980s, correlated with increased statin prescriptions and emphasized LDL levels as a guiding metric for health, showing conflicts of interest in the members involved.
Limitations of the recent keto study
The recent study on lean mass hyper-responders is critiqued for its lack of control groups and the implications of self-reported dietary adherence. Stephen argues that without randomization, the data may not reliably reflect broader population impacts.
Critique of ApoB and LDL theories
Stephen notes that the correlation between increasing ApoB levels and plaque progression is not substantiated by the study's data, suggesting that high LDL levels do not inherently lead to heart disease.
Discussion on HbA1c levels in ketogenic diets
He discusses the rise in HbA1c levels in individuals on a ketogenic diet, explaining that these levels can be misleading due to factors such as the lifespan of red blood cells, emphasizing a need for further investigation into blood glucose metrics for those on high-fat diets.