Study analysis · JACC: Advances · 2024
Some people on keto have LDL cholesterol over 500 mg/dL—yet their arteries show no more plaque than people with normal cholesterol.
Healthy people on keto with super high cholesterol don’t have more heart plaque than those with low cholesterol.
Overview
What the study found
The study in plain English — the bottom line, every takeaway we extracted, and what to do with them.
In simple terms
This study looks at two groups of people — some on a keto diet with very high cholesterol and others with normal cholesterol — and checks their heart arteries for plaque. It found no difference in plaque between them, but because it didn’t randomly assign people to diets, we can’t say the keto diet caused no harm or benefit — only that there’s no link seen here.
What’s the bottom line?
This study looked at healthy, lean people who eat a keto diet and have very high cholesterol. It checked if they had more plaque in their heart arteries than similar people with normal cholesterol.
How strong is this study?
The study compared similar people using detailed heart scans, which is good. But we don’t know all the details about how it was done because the full paper isn’t available, and it didn’t randomly assign diets, so we have to be careful not to jump to conclusions.
0 / 100
- COI disclosureconflicts of interest not disclosed
- Data availabilitydata not shared
- Code availabilitycode not shared
45 / 100
- Randomizationrandomization unclear
- Blindingblinding unclear
- Control group+15/15
- Sample size (n=160)+11.0/20
- Follow-up+10/10
100 / 100
46 / 100
- P-values+15/15
- Effect sizeno effect size reported
- Confidence intervals+15/15
- Pre-registrationnot pre-registered
Each component is scored out of 100 and then capped by the study design — a case series cannot reach the ceiling a randomised trial can, however well it is reported.
Where it sits
RCT reviewsReviews of RCTs (Meta-analyses)
Max 100Randomized TrialsRandomized Trials
Max 90Reviews of Cohort StudiesReviews of Cohort Studies
Max 85Cohort StudiesCohort Studies
Max 72Reviews of Case-Control StudiesReviews of Case-Control Studies
Max 63Case-Control StudiesCase-Control Studies
Max 58Cross-Sectional & Case SeriesCross-Sectional & Case Series
Max 50Expert OpinionExpert Opinion
Max 547 / 100
Probability of being correct
Groups of people are followed over time to see who develops an outcome. Strong for identifying risk factors and associations, but cannot prove causation as firmly as RCTs.
This design cannot establish causation — the findings describe an association, not a cause. Study is observational (cohort) with no explicit mention of randomization in the abstract; therefore, it cannot support causal claims. Confounding factors may influence results.
Key takeaways
- 01
80 keto eaters had LDL up to 591 mg/dL.
- 02
Their heart plaque levels were not higher than 80 others with LDL around 123 mg/dL.
- 03
Half had zero plaque in both groups.
- 04
Even very high LDL from a keto diet may not lead to more heart plaque in healthy, lean people over nearly 5 years.
Surprising findings
- No significant difference in coronary plaque despite a 149 mg/dL difference in average LDL-C between groups.Standard cardiovascular guidelines assume higher LDL-C directly increases atherosclerosis risk. This study found no such effect in lean, healthy keto eaters—even with LDL levels considered extremely high.
- No correlation between LDL-C level and plaque burden in the keto group.This contradicts the widely accepted 'lower is better' model of LDL-C and heart disease, at least in this population.
Practical takeaways
If you're lean, metabolically healthy, and on a ketogenic diet with high LDL, this study suggests your artery health may still be normal.
This does not prove long-term safety, and findings are limited to imaging over ~5 years. Full methodology and long-term outcomes are unknown.
low confidenceConsider coronary artery calcium or CCTA scanning if you have diet-induced high LDL and want to assess actual plaque, not just risk estimates.
Imaging has costs and radiation exposure; not recommended for everyone. This study only looked at a specific subgroup.
low confidenceWhy this study matters
The Keto Paradox
The study looked at 80 lean, metabolically healthy people on long-term ketogenic diets with LDL-C as high as 591 mg/dL (average 272 mg/dL). Despite these extremely high levels—far above typical heart disease risk thresholds—they had no more coronary plaque than 80 matched controls with LDL-C around 123 mg/dL.
This challenges the common belief that very high LDL always means higher heart disease risk, suggesting context like diet and metabolic health may matter more than the number alone.
No Link Between LDL and Plaque in Keto Users
In the ketogenic diet group, there was no correlation between LDL-C levels and coronary plaque burden measured by CCTA. Even individuals with LDL-C over 500 mg/dL had plaque levels similar to those with much lower cholesterol.
It suggests that for some people, especially those who are lean and metabolically healthy, LDL may not be a reliable predictor of heart disease risk.
Half Had Zero Plaque—Even with Sky-High LDL
Half of the keto group had zero coronary artery calcium and zero total plaque on CCTA—despite an average LDL of 272 mg/dL and some exceeding 500 mg/dL. The control group had similar results.
This shows that having very high LDL doesn’t automatically mean artery damage, at least in this specific group of healthy individuals.
Want the whole report?
Detailed mode opens the full scientific breakdown — every score component, the methodology, conflicts of interest, the evidence analysis behind each claim, and the raw study data.
Overview
What the study found
The study in plain English — the bottom line, every takeaway we extracted, and what to do with them.
Not medical advice. For informational purposes only. Always consult a healthcare professional. Terms
This study looked at healthy, lean people who eat a keto diet and have very high cholesterol. It checked if they had more plaque in their heart arteries than similar people with normal cholesterol.
Research results
80 keto eaters had LDL up to 591 mg/dL. Their heart plaque levels were not higher than 80 others with LDL around 123 mg/dL. Half had zero plaque in both groups.
What this means - more context
Even very high LDL from a keto diet may not lead to more heart plaque in healthy, lean people over nearly 5 years.
The study aimed to assess coronary plaque burden in lean, metabolically healthy individuals with diet-induced high LDL-C (≥190 mg/dL) on carbohydrate-restricted ketogenic diets (KETO), compared to matched controls with lower LDL-C from the MiHeart cohort.
The study compared coronary plaque in 80 individuals on long-term ketogenic diets with very high LDL-C (mean 272 mg/dL, max 591 mg/dL) to 80 matched controls with LDL-C around 123 mg/dL. No significant differences were found in coronary artery calcium scores or total plaque scores via CCTA, and no correlation was observed between LDL-C levels and plaque burden in the ketogenic group.
Methods Used
80 KETO individuals with LDL-C ≥190 mg/dL, HDL-C ≥60 mg/dL, and triglycerides ≤80 mg/dL were 1:1 matched with MiHeart controls for age, gender, race, hyperlipidemia, hypertension, and smoking status. Plaque burden was assessed using coronary artery calcium scoring and coronary computed tomography angiography (CCTA).
Main Finding
There was no significant difference in coronary plaque burden between the KETO group and matched controls: coronary artery calcium score (median 0 vs 1, P = 0.520), CCTA total plaque score (median 0 vs 0, IQRs 0-2 vs 0-4, P = 0.357). No correlation was found between LDL-C level and CCTA plaque score.
Confidence Level
Limited - based on abstract only, full methodology not available
Study Flags
Red Flags
- •Full text not available - methodology details cannot be verified
- •Matching strategy details not fully specified in abstract
- •No effect sizes reported for primary outcomes
No biological mechanisms were identified in this study. This may be an epidemiological, observational, or survey-based study that reports associations rather than proposing causal biological pathways.
Surprising Findings
No significant difference in coronary plaque despite a 149 mg/dL difference in average LDL-C between groups.
Standard cardiovascular guidelines assume higher LDL-C directly increases atherosclerosis risk. This study found no such effect in lean, healthy keto eaters—even with LDL levels considered extremely high.
Practical Takeaways
If you're lean, metabolically healthy, and on a ketogenic diet with high LDL, this study suggests your artery health may still be normal.
RCT reviewsReviews of RCTs (Meta-analyses)
Max 100Randomized TrialsRandomized Trials
Max 90Reviews of Cohort StudiesReviews of Cohort Studies
Max 85Cohort StudiesCohort Studies
Max 72Reviews of Case-Control StudiesReviews of Case-Control Studies
Max 63Case-Control StudiesCase-Control Studies
Max 58Cross-Sectional & Case SeriesCross-Sectional & Case Series
Max 50Expert OpinionExpert Opinion
Max 547 / 100
Probability of being correct
Groups of people are followed over time to see who develops an outcome. Strong for identifying risk factors and associations, but cannot prove causation as firmly as RCTs.
Human Cohort Study
Subject
Moderate probability
on the GRADE evidence scale
This study looks at two groups of people — some on a keto diet with very high cholesterol and others with normal cholesterol — and checks their heart arteries for plaque. It found no difference in plaque between them, but because it didn’t randomly assign people to diets, we can’t say the keto diet caused no harm or benefit — only that there’s no link seen here.
Strengths
- Matched design (1:1) for key confounders (age, gender, race, hypertension, smoking, etc.)
- Use of objective imaging outcomes (coronary artery calcium score and CCTA plaque score)
- Clear definition of the exposure group (LDL-C ≥190 mg/dL on ketogenic diet with specific lipid criteria)
Weaknesses
- Full methodology not available - based on abstract only
- Randomization status: Unknown → cannot be classified as RCT
- Blinding status: Unknown → risk of bias cannot be assessed
Methodology
Evidence Keywords
Statistical Reporting
Not medical advice. For informational purposes only. Always consult a healthcare professional. Terms
This study looked at healthy, lean people who eat a keto diet and have very high cholesterol. It checked if they had more plaque in their heart arteries than similar people with normal cholesterol.
Research results
80 keto eaters had LDL up to 591 mg/dL. Their heart plaque levels were not higher than 80 others with LDL around 123 mg/dL. Half had zero plaque in both groups.
What this means - more context
Even very high LDL from a keto diet may not lead to more heart plaque in healthy, lean people over nearly 5 years.
The study aimed to assess coronary plaque burden in lean, metabolically healthy individuals with diet-induced high LDL-C (≥190 mg/dL) on carbohydrate-restricted ketogenic diets (KETO), compared to matched controls with lower LDL-C from the MiHeart cohort.
The study compared coronary plaque in 80 individuals on long-term ketogenic diets with very high LDL-C (mean 272 mg/dL, max 591 mg/dL) to 80 matched controls with LDL-C around 123 mg/dL. No significant differences were found in coronary artery calcium scores or total plaque scores via CCTA, and no correlation was observed between LDL-C levels and plaque burden in the ketogenic group.
Methods Used
80 KETO individuals with LDL-C ≥190 mg/dL, HDL-C ≥60 mg/dL, and triglycerides ≤80 mg/dL were 1:1 matched with MiHeart controls for age, gender, race, hyperlipidemia, hypertension, and smoking status. Plaque burden was assessed using coronary artery calcium scoring and coronary computed tomography angiography (CCTA).
Main Finding
There was no significant difference in coronary plaque burden between the KETO group and matched controls: coronary artery calcium score (median 0 vs 1, P = 0.520), CCTA total plaque score (median 0 vs 0, IQRs 0-2 vs 0-4, P = 0.357). No correlation was found between LDL-C level and CCTA plaque score.
Confidence Level
Limited - based on abstract only, full methodology not available
Study Flags
Red Flags
- •Full text not available - methodology details cannot be verified
- •Matching strategy details not fully specified in abstract
- •No effect sizes reported for primary outcomes
No biological mechanisms were identified in this study. This may be an epidemiological, observational, or survey-based study that reports associations rather than proposing causal biological pathways.
Surprising Findings
No significant difference in coronary plaque despite a 149 mg/dL difference in average LDL-C between groups.
Standard cardiovascular guidelines assume higher LDL-C directly increases atherosclerosis risk. This study found no such effect in lean, healthy keto eaters—even with LDL levels considered extremely high.
Practical Takeaways
If you're lean, metabolically healthy, and on a ketogenic diet with high LDL, this study suggests your artery health may still be normal.
RCT reviewsReviews of RCTs (Meta-analyses)
Max 100Randomized TrialsRandomized Trials
Max 90Reviews of Cohort StudiesReviews of Cohort Studies
Max 85Cohort StudiesCohort Studies
Max 72Reviews of Case-Control StudiesReviews of Case-Control Studies
Max 63Case-Control StudiesCase-Control Studies
Max 58Cross-Sectional & Case SeriesCross-Sectional & Case Series
Max 50Expert OpinionExpert Opinion
Max 547 / 100
Probability of being correct
Groups of people are followed over time to see who develops an outcome. Strong for identifying risk factors and associations, but cannot prove causation as firmly as RCTs.
Human Cohort Study
Subject
Moderate probability
on the GRADE evidence scale
This study looks at two groups of people — some on a keto diet with very high cholesterol and others with normal cholesterol — and checks their heart arteries for plaque. It found no difference in plaque between them, but because it didn’t randomly assign people to diets, we can’t say the keto diet caused no harm or benefit — only that there’s no link seen here.
Strengths
- Matched design (1:1) for key confounders (age, gender, race, hypertension, smoking, etc.)
- Use of objective imaging outcomes (coronary artery calcium score and CCTA plaque score)
- Clear definition of the exposure group (LDL-C ≥190 mg/dL on ketogenic diet with specific lipid criteria)
Weaknesses
- Full methodology not available - based on abstract only
- Randomization status: Unknown → cannot be classified as RCT
- Blinding status: Unknown → risk of bias cannot be assessed
Methodology
Evidence Keywords
Statistical Reporting
Scoring
How strong is this study?
The study compared similar people using detailed heart scans, which is good. But we don’t know all the details about how it was done because the full paper isn’t available, and it didn’t randomly assign diets, so we have to be careful not to jump to conclusions.
0 / 100
- COI disclosureconflicts of interest not disclosed
- Data availabilitydata not shared
- Code availabilitycode not shared
45 / 100
- Randomizationrandomization unclear
- Blindingblinding unclear
- Control group+15/15
- Sample size (n=160)+11.0/20
- Follow-up+10/10
100 / 100
46 / 100
- P-values+15/15
- Effect sizeno effect size reported
- Confidence intervals+15/15
- Pre-registrationnot pre-registered
Each component is scored out of 100 and then capped by the study design — a case series cannot reach the ceiling a randomised trial can, however well it is reported.
Where it sits
RCT reviewsReviews of RCTs (Meta-analyses)
Max 100Randomized TrialsRandomized Trials
Max 90Reviews of Cohort StudiesReviews of Cohort Studies
Max 85Cohort StudiesCohort Studies
Max 72Reviews of Case-Control StudiesReviews of Case-Control Studies
Max 63Case-Control StudiesCase-Control Studies
Max 58Cross-Sectional & Case SeriesCross-Sectional & Case Series
Max 50Expert OpinionExpert Opinion
Max 547 / 100
Probability of being correct
Groups of people are followed over time to see who develops an outcome. Strong for identifying risk factors and associations, but cannot prove causation as firmly as RCTs.
This design cannot establish causation — the findings describe an association, not a cause. Study is observational (cohort) with no explicit mention of randomization in the abstract; therefore, it cannot support causal claims. Confounding factors may influence results.
Standing
Who’s using this study?
The videos and claims on this site that lean on this study, and the researchers who wrote it.
1 video from Dr Brad Stanfield cite this study, drawing 1 claim from it.
- Conflicting evidence
Evidence points in both directions — no clear conclusion yet.
Evidence
Authored by
10 researchersIf this is your work, this is how we attribute it on Fit Body Science. Matthew Jay Budoff is listed as the lead author.