It's worth taking a moment to recognize Dave Feldman and colleagues for helping bring clarity to a long-running social media debate in lipidology and cardiovascular health.
The LMHR ("Lean Mass Hyper-Responder") phenomenon emerged from a mix of personal anecdotes, enthusiastic self-experimentation, and selective interpretation of observational data. Over time, the theory evolved into a broader narrative: that extreme elevations in LDL cholesterol, if accompanied by other markers like low triglycerides and high HDL, might somehow be benign.
After nearly a decade of vigorous promotion, this hypothesis finally underwent a formal test: the KETO-CTA study. In 100 individuals following a ketogenic diet with associated LDL elevations, non-calcified plaque volume (NCPV) increased significantly over just one year.
These findings are critical. They show that despite favorable surface markers — lean body mass, low triglycerides, high HDL — profound hypercholesterolemia still drives atherosclerosis.
In a way, this is an important service to the field. The debate around whether hyper-elevated LDL could be harmless in the setting of "metabolic health" has now been answered with empirical evidence. It is not.
Statistical survivorship doesn't negate the overall risk. Just because some individuals might remain stable doesn't make it wise to induce sky-high ApoB and LDL through dietary manipulation. Public health recommendations aren't built around the lucky few — they're designed to protect the majority.