Rapid Plaque Progression Amongst Lean Mass Hyper-Responders Following a Ketogenic Diet with Elevated ApoB and LDL-Cholesterol

A recent study by Soto Mota et al. has generated widespread attention for its claim that apolipoprotein B (ApoB) does not contribute to coronary plaque progression in individuals adhering to a ketogenic diet. However, critical examination reveals major concerns about selective outcome reporting, interpretation bias, and scientific framing. The pre-specified primary outcome, percent change in non-calcified plaque volume (NCPV), was not clearly reported in the published manuscript, despite being available and later disclosed via social media as a median increase of 18.8 mm³ (~43% from baseline). This degree of progression, seen in participants with uniformly elevated Apolipoprotein B (ApoB) and Low-Density Lipoprotein Cholesterol (LDL-C) levels, far exceeds rates observed in both low- and high-risk cohorts from prior studies. Moreover, the study’s null association between ApoB/LDL-C and plaque progression is uninterpretable without the variation in exposure of a comparator group, and the use of this exploratory analysis to inform the title and conclusions is scientifically inappropriate. Mischaracterisation of the study as a “trial” and emphasis on biologically uninformative explanations further undermine the credibility of the findings. Given the public health implications and potential for misinterpretation, it is vital to clarify that this study in fact provides evidence of accelerated atherosclerosis in a population described as “metabolically healthy.”