Keto-CTA Study Confusion: Addressing the Misunderstandings with Dr. Budoff

There’s been a lot of buzz—and confusion—about the new Keto-CTA study, examining plaque progression in Lean Mass Hyper-Responders (LMHRs).

Much of the social media debate has centered on whether high LDL on keto is safe or dangerous, driven largely by how to interpret the supplemental table comparing this study to others on LDL and plaque progression.

In this episode of the Metabolic Mind Podcast, we sit down with Dr. Matthew Budoff, a world-renowned cardiologist, cardiac CT researcher, and the study's lead investigator, to discuss the the supplemental table, what the plaque markers mean, and how this fits into the discussion of high- vs -low-risk plaque progression.

In this episode, we cover:

✅ What PAV (Percent Atheroma Volume) is, what it actually measures, and why it matters

✅ Why a 50% increase in plaque may sound scary, but can be deceiving

✅ The difference between “treatment-naive” and “treated” participants

✅ What the Miami Heart Study comparison reveals about keto, LDL, and plaque

✅ Why LDL alone may not tell the whole story about heart disease risk

✅ How some high-risk individuals may still benefit from statins and other therapies

This study doesn’t answer whether keto causes heart disease or not. Instead, it shows that high LDL on a ketogenic diet is not a reliable predictor of plaque progression across all individuals. What is predictive? The presence of existing plaque.

💡 *Key takeaway:* Relying on surrogate markers of heart disease, like LDL and ApoB, is not the best way to assess heart disease risk in all populations.

If you're concerned about how elevated LDL may be affecting your heart health, the best next step is to speak with your doctor about cardiac imaging to directly assess plaque and gain a clearer picture of your individual risk.

*Expert Featured:*
Dr. Matthew Budoff

*Resources Mentioned:*
Plaque Begets Plaque, ApoB Does Not

Interview with Dave Feldman

Dr. Scher Summarizes Keto-CTA Study

*CMEs Mentioned:*
_Managing Major Mental Illness with Dietary Change: The New Science of Hope_

_Brain Energy: The Metabolic Theory of Mental Illness_

Follow our channel for more information and education from Bret Scher, MD, FACC, including interviews with leading experts in Metabolic Psychiatry.

*About us:*
Metabolic Mind is a non-profit initiative of Baszucki Group working to transform the study and treatment of mental disorders by exploring the connection between metabolism and brain health. We leverage the science of metabolic psychiatry and personal stories to offer education, community, and hope to people struggling with mental health challenges and those who care for them.

Our channel is for informational purposes only. We are not providing individual or group medical or healthcare advice nor establishing a provider-patient relationship. Many of the interventions we discuss can have dramatic or potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or medications.

*Timestamps:*
0:00 - Introduction to the misconceptions on the new Keto CTA study and Dr. Matt Budoff.
2:22 - What is the definition of PAV (Plaque Atheroma Volume)? Are PAV studies translatable to prior studies done with invasive methods?
5:06 - How should the change in PAV from supplemental table 1 from the study be interpreted? Is this finding being misinterpreted? How does the study population factors affect this finding?
8:08 - How does Dr. Budoff view the absolute plaque progression in the study population? Is it normal to expect some plaque progression from otherwise healthy individuals? What about those with higher plaque to begin with?
13:33 - Did the keto diet cause plaque progression, based on what is seen in this study?
15:28 - How was the Miami Heart study used for comparison to the study cohort? What were the differences in metrics measured?
18:38 - Will there be future papers on the cohort from the Keto CTA study looking at other risk factors such as Lp(a), inflammatory markers, etc? Have some of the responses to this paper been misguided?
24:19 - How does NCPV (non-calcified plaque volume) differ from PAV?
28:54 - Conclusions & real world implications.

[pknag]

The progression of plaque will basically will put the average LMHR who is super lean and metabolically fit with no risk factors other than high LDL into severe plaque levels in short order. Scary!

[TheProofWithSimonHill]

“We proved the keto diet specifically did not cause plaque progression" - Dr Budoff. Brett...how can Dr Budoff make this claim - we are talking about a non controlled observational study where participants on the aggregate had significant plaque progression?

[Bbarfo]

I'm still questioning the effectiveness of the statins. Some physicians claim that they are useless and others it's a life saver. I'm 64 years old and I began low carb with 16/8 intermittent fasting over four years ago. I lost 60 pounds and was able to quit taking 10mg of Lisinopril for my blood pressure, (last measure was 115/60). I began taking 20mg of Atorvastatin in around 2005 and quit them in 2022. I had a CAC in November 2024, and it was 79 so I began taking a baby aspirin twice per week. My TG is low and HDL hovers around 95; glucose is in the mid 80's and LDL hovers between 225 to 325. Unfortunately, my LP(a) was 170 at last testing. I will continue my present eating routine coupled with plenty of exercise and enjoy life the best I can. Thanks for the update on the subject.

[midnight]

What study are you reading? Their own study proved that LHR with high LDL had rapidly increased plaque progression.

[craige]

IF LDL was the cause of rapid plaque build up, then the people in the study with 600 LDL would progress much faster than the ones with 250 LDL. AND THAT DID NOT HAPPEN. LDL WAS IRRELEVANT AND NOT ASSOCIATED WITH PLAQUE PROGRESSION, OTHER FACTORS UNKNOWN WERE. I eat what I want (kinda low carb), so I have no horse in this race. But I am 60 years old with a 250 LDL lifelong and 0 CAC, symptoms, or events. I can't tell you how many of my vegan martathon runner 70 LDL friends have dropped dead from CVD. It's NOT THE LDL, and even when it matters a little, it is like 1% of the issue, there are 25 other higher risk factors than LDL, IF LDL is even a risk factor.

[huntersparmesancheese]

Just Saw Gil’s interview, and now I’m confused what is going on with this study?

[csmcrckrs]

Statistician here. Even the first sentence is blatantly wrong from a theoretical perspective (did not bother to watch anything past that point). Failure to find a proof for an effect is NOT a proof that the effect does not exist ... that's just not how hypothesis testing works.

[davidzip]

Dr. Budof is saying that if you are on a ketogenic diet and you have plaque, then you need to be on a statin or another lipid lowering drug. Everyone loves to ignore this basic fact. He is also saying that, of course the people in this study had much more rapid progression of plaque than the other studies because they are untreated. He’s not saying they didn’t have progression. He is saying they had more rapid progression than people who are metabolically unhealthy with typical risk factors because they aren’t on a statin.

[kmrenard]

@14:50 the Dr says he does prescribe a statin. Not to lower the Keto-induced LDL??? It high LDL doesn’t cause atherosclerosis, and lowering LDL isn’t necessary, then why prescribe the statin? What other benefits do statins have for atherosclerosis?

[md]

13:54 he says they’ve proven that keto diet is not causing atherosclerosis, however it is very hard to explain then why this cohort’s plaque buildup is 3x faster than other non-treated normal population plaque buildup.

If it is not apob, not ldl then why keto lmhr group progressed faster?

[ebarr]

"Neither LDL nor ApoB predicted plaque change. That is the main novel finding of the paper." All 100 participants, by design, had an ApoB assay above the 99th percentile. As with glucose and hrt disease, adding more at the upper limits of the measured assay doesn't confer more risk. Ergo, risk is not infinitely linear. Smoking 3 pack v. 6 packs per day has no linier risk for the outlier. A SHAM hypothesis obviously to those who look at these data, but still the authors try to present a silk purse from what is a sow's ear. Their interpretation of their short study, lacking a control cohort, should be ignored. HOWEVER, it's a self indicting reveal of what actually is a deadly and ill health producing dieting behavior when exceedingly high blood lipid values are ignored. Despite the bluster, I thank the authors for their data, which is irrefutable, but the spin is unconscionable!

[babybalrog]

Dr. Budoff needs to do another interview with Dr Gil. His first really opens some questions that i hope this final paper answers.

[UN-gmur]

Whats the name of the trial mentioned at 23:10 that had the same PAV change?

[davidbarnes]

Many thanks for putting the findings in perspective. Dr Budoff has made the best possible presentation in a scientifically balanced way.

[rtay]

So we know it’s not saturated fat, it’s not ldl or apob. I’m not seeing a downside to keto or carnivore. It definitely improves metabolic health, and that’s a step in the right direction

[konradk]

Dr Budoff is such badass. Thanks for this sir.

[marcinw]

Study involving Dr. Budoff using Cleerly among people with similar age, no additional CVD risk factors, no lipid lowering meds. Annual change in PAV% greater than 0.275% is defined as rapid progression.
"The median and interquartile range [IQR] for annualized change in PAV% for slow progression was 0.03 (0.0, 0.05), intermediate progression was 0.17 (0.12, 0.20) and 0.46 (0.35, 0.67) for rapid progressors."

Source:
"Abstract 4139421: Rates Of Atherosclerosis Progression In The Absence Of Cardiovascular Events And Cardiovascular Medications On Cardiac Computed Tomography."

[Brandon-dglu]

Dr. Budoff states at 25:55 that "there is a lot of outcome data for PAV and PAV% changes", but had previously at 5:45 states that "you can't do it on a percent, because the denominator was very low, " so how is he interpreting this data then? How does this compare to other data? When I look at the chart frequently posted, first at 5:07 all the Keto based groups, at least where the baseline PAV is measured, have a significantly high percentage PAV change even when the baseline PAV is higher.

[ketontrack]

Can someone comment on the specific number reported? 18.8mm3 .
This is an absolute number, not a relative one

[elkin_a.v]

WHAT A SHAME!

He told that we don't need to look at relative numbers.... but absolute annual progression of NCPV was 18 mm3!

Its much higher than what was found in this report - "Atherosclerotic Plaque Progresses Over Time in Healthy Individuals Without MACE, Risk Factors, or Interventions". These on average LESS HEALTHY people WITHOUT STATIN treatment have annual progression of 4.9 mm3!!! In this study annual PAV in RAPID PROGRESSORS was 0.46%!