A Cardiologist’s Dilemma: High LDL & ApoB Doesn’t Predict Plaque in This Group of People

Ketogenic therapy is transforming lives. Around the world, tens of thousands of people use this powerful metabolic intervention to improve their physical health, treat chronic diseases, and find relief from serious mental illness.

But for some, a new issue emerges:

A dramatic rise in LDL cholesterol.

Despite clear clinical improvements like better mood, clearer thinking, stabilized blood sugar, better insulin sensitivity, reduced inflammation, weight loss, and medication reductions, these individuals often face medical pushback. Elevated LDL levels prompt concern from clinicians, and patients are left wondering: Is this therapy helping me or hurting me?

We’re proud to share the publication of a groundbreaking study supported by Baszucki Group that addresses this question head-on.

This landmark research was co-led by senior author Dr. Matthew Budoff, MD, Investigator, Program Director and Director of Cardiac CT, and the endowed chair of preventative cardiology at The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center. The study leaders included independent researchers Nick Norwitz, PhD, Dr. Adrian Soto-Mota, MD, and Dave Feldman, who initiated the project.

This new research demonstrated that elevated LDL cholesterol did not predict  increased cardiovascular risk for a specific group of metabolically healthy individuals following a ketogenic diet.

Now Published: Plaque Begets Plaque but LDL-C and ApoB do not

Published in the Journal of the American College of Cardiology: Advances, this study focused on a fascinating and often misunderstood population: Lean Mass Hyper-Responders (LMHRs). LMHRs are individuals who respond to ketogenic diets with major increases in LDL-C and ApoB levels despite otherwise healthy metabolic marker levels including low triglycerides, high HDL, low blood pressure, low insulin resistance, and low body mass index. The one-year study tracked 100 such individuals who had been following a low-carb ketogenic diet for an average of nearly six years.

This study measured plaque, which is the buildup of fats, cholesterol and other substances in and on the heart’s artery walls. Plaque can cause arteries to narrow, blocking blood flow. The plaque can also burst, leading to a blood clot. The diagnosis given to a person experiencing significant plaque buildup is atherosclerosis. In this study, plaque was measured at the start of the study and after one year using sophisticated cardiac imaging protocols. The findings are striking: LDL cholesterol and apolipoprotein B (ApoB) levels were not associated with coronary plaque progression in this population. Instead, the strongest predictor of future plaque accumulation was baseline plaque.

What does this mean?

It means that despite having LDL cholesterol levels that would cause most cardiologists to consider these patients a “ticking time bomb,” there was little or no plaque progression, and LDL and ApoB levels were not predictive of cardiovascular disease.

These findings build on previous work from the research team demonstrating that LMHR individuals have similar levels of coronary plaque to a carefully-matched comparison group with normal LDL levels, highlighting that ketogenic diet-induced LDL increases may not indicate a higher risk of coronary plaque.

These results challenge the prevailing "lipid hypothesis" that posits that high LDL-C and ApoB levels not only correlate with but directly cause heart disease. This study suggests that LDL cholesterol and ApoB are not reliable markers of cardiovascular risk for all individuals. For metabolically healthy individuals whose cholesterol rises in response to therapeutic carbohydrate reduction, a more appropriate approach for assessing risk is to look directly at the arteries using advanced cardiac imaging tests such as CAC or CT angiogram. .

Why This Matters to the Mental Health Community

Many people are turning to ketogenic therapy to manage mental health conditions like bipolar disorder, major depressive disorder, schizophrenia, and anorexia. As research increasingly shows, these conditions share underlying metabolic disruptions like impaired glucose metabolism, oxidative stress, and inflammation. Ketogenic diets show promise in addressing these pathologies, offering a novel path toward healing, especially when conventional treatments fall short.

For some lean, metabolically healthy individuals, the emergence of high cholesterol while on a ketogenic diet has been a source of concern, and even a barrier to continued treatment. This new study helps clarify that elevated LDL-C in this context does not necessarily equate to increased cardiovascular risk. These research findings can empower individuals to ask for imaging tests like CAC and CT angiograms that look directly for disease.

Bringing the Science to Life: The Cholesterol Code Documentary

The story doesn’t end with the research. The Cholesterol Code documentary, which will be released later this year, follows the researchers, the citizen scientists, and real stories of LMHRs who are thriving on ketogenic therapy despite having very high LDL cholesterol.

The film explores how science, skepticism, and self-experimentation converged to spark one of the most provocative conversations in modern cardiology.

Stay in the Loop

If you're interested in the intersection of metabolic health, mental health, and cardiovascular science, we invite you to stay connected. Visit https://cholesterolcodemovie.com/ to sign up for updates on the documentary, access to upcoming patient and clinician resources, and future research on ketogenic therapy and cardiovascular health. You’ll be among the first to know when the film is released, and you’ll receive insights and resources as this story continues to unfold.

A New Era for Metabolic Health

This study and The Cholesterol Code represent more than a breakthrough in cardiology. They’re a beacon of hope to individuals using ketogenic therapy to manage serious mental illness or other chronic diseases. It affirms what they’ve already experienced firsthand: healing is possible, even if biomarkers don’t look like what conventional medicine expects.

At Metabolic Mind and the Baszucki Group, we believe in challenging assumptions when the science demands it—and in supporting the research, stories, and people changing the way we think about health.