LMHRs & the KETO-CTA Trial

Summary

* Lean Mass Hyper Responder (LMHR) was the term developed by Dave Feldman to describe lean, fit, metabolically healthy people, who exhibit striking increases in cholesterol when adopting a ketogenic diet.

* This week's note looks at the recent (April 2025) paper from the LMHR research team. The paper was called “Plaque begets plaque, ApoB does not: Longitudinal data from the KETO-CTA Trial.”

* I have written previously about LMHRs and the Lipid Energy Model – the hypothesis for why this phenomenon happens.

* While researching the debate around the latest paper, I went back to some previous work by the LMHR team.

1) The “cut points” that define the LMHR have changed over time. Originally, they were LDL-C of 200 mg/dL (5.2 mmol/l) or higher; HDL-C of 80 mg/dL (2.1 mmol/l) or higher; and triglyceride levels of 70 mg/dL (0.79 mmol/l) or lower. In the recent paper, the “cut points” were LDL-C of 190 mg/dL or higher (not 200); HDL-C of 60 mg/dL or higher (not 80); and triglyceride levels of 80 mg/dL or lower (not 70).

2) Participants were recruited for this research via a web survey seeking people meeting the LMHR profile. The paper by Norwitz et al (November 2021) separated respondents to this web survey into 100 LMHRs and 448 non-LMHRs. At the time of that paper, the original cut points applied. Under the revised cut points, on average, the non-LMHRs would be LMHRs. From male/female numbers, we also know that the 100 in the recent paper were not the same as the 100 in the November 2021 paper. How 100 people were chosen at different stages of the LMHR research was not clear.

* The eligibility criteria define a rare and specific person. The LMHR profile may have other defining characteristics that could impact coronary artery disease and which haven’t been addressed (exercise, stress/personality type, alcohol, supplements etc).

* The research has generated much debate on X. Next week's post will review the results and the reaction.