Low Carb High Fat - Ketogenic

Clinical mission — test medical dogma against patient outcomes

• Tro Kalayjian reached 350 lb and experienced fatigue and pain; calorie counting was ineffective. He lost 150 lb with ketogenic eating, reconsidered conventional nutritional guidance and shifted his career toward chronic metabolic disease remission.
• Kalayjian is an internal- and obesity-medicine physician, SMHP board member and Toward Health chief medical officer. The remote practice combines physicians, coaches, messaging, CGMs, connected scales, blood-pressure monitoring and individualized feedback, alongside general medicine, hormones, microbiome problems and cancer prevention.
• Disease remission and medication deprescribing are explicit clinical goals. Continuous care operates between visits through repeated support and monitoring, while published clinical observations enable wider clinical use.
• Institutional guidance is challenged through published observations that patients and clinicians can use when evaluating withheld care options. The studies were self-funded, conflicts and affiliations were disclosed, and one collaborator was employed by a pharmaceutical company.
• Two recent studies examine AHA PREVENT-estimated cardiovascular risk and strong LDL reductions after ezetimibe among ketogenic patients. [1][2]
• Other ketogenic clinical trials cover metabolic psychiatry, heart failure, weight loss and deprescribing, with further randomized results pending and a growing body of evidence.

Diabetes and triglycerides — metabolic improvement without major weight loss

• The ADA focused on weight loss for diabetes improvement. In early clinical cases, HbA1c decreased from about 12% to 6% after four months of ketogenic eating and intermittent fasting, all diabetes drugs were stopped, and weight loss was only a few pounds; glycemia improved before substantial weight loss. The early data received little interest from the ADA and were subsequently published. [3]
• The National Lipid Association warned against ketogenic diets in severe hypertriglyceridemia because high fat intake might elevate triglycerides and induce pancreatitis. The annual pancreatitis-risk estimates cited were 10% at 1,000 mg/dL and 50% at 5,000 mg/dL. [4]
• Carbohydrate restriction lowers insulin and fasting triglycerides. A two-patient series found severe triglyceride values around 800–1,000 mg/dL or higher decreasing below 200 mg/dL within weeks of ketogenic eating and intermittent fasting, contrary to that contraindication. [5]

Food addiction and binge eating — dietary change with psychological support

• Some psychiatrists and mental-health professionals associated restriction with worsening binge eating and equated keto or fasting with eating disorders. A 2020 case series found marked improvement in binge-eating and food-addiction symptoms when food addiction was still controversial. [6]
• In a larger 2025 TOWARD cohort of about 50 people, approximately 40% experienced significant food-addiction symptom improvement and 34% experienced binge-eating symptom improvement during carbohydrate-restricted continuous care. [7]
• The ketogenic care model combines coaching, group visits, biofeedback and psychological support. Its binge-eating improvement was similar in magnitude to published stimulant-drug effects; GLP-1 drugs may produce larger improvements, while underlying psychological concerns and nutritional adequacy remain important.
• Jen Unwin's low-carbohydrate and psychoeducational work found sustained food-addiction improvement at one year, with possible two-year follow-up. Nutritional and psychosocial care were combined. [8]

Durable weight loss — continuous care and medication reduction

• A six-month employer-wellness pilot published in 2022 was followed by a 2025 one-year study of 50 manufacturing employees. Average weight loss was 15.5%, similar in magnitude to semaglutide; unpublished 24-month clinic data showed nearly comparable weight loss. [9][10]
• At one year, 80% continued losing weight, 82% remained engaged and 92% had lost at least 5% of initial body weight. These results support an employer-based scalable continuous-care approach combining diet with ongoing clinical support. [10]
• About two medications per participant were stopped and eight were initiated across the cohort when needed. Medication management was individualized, with deprescribing an important outcome. [10]

PREVENT — the AHA's risk scorecard versus its dietary guidance

• The AHA placed ketogenic diets in the lowest dietary-alignment tier in 2023. The ranking assessed compatibility with nutritional guidance on grains, fruit and fats, not outcomes from a clinical trial of this care model. [11]
• The AHA introduced cardiovascular-kidney-metabolic (CKM) syndrome, which Kalayjian viewed as a renamed version of insulin resistance and metabolic syndrome, and called for disruptive CKM care models. The clinic evaluated its outcomes with the AHA risk calculator. [12]
• PREVENT estimates 10- and 30-year probabilities of total cardiovascular disease, ASCVD and heart failure in people without known cardiovascular disease. Inputs include age, sex, blood pressure, total and HDL cholesterol, kidney function, diabetes, smoking and BMI, with optional HbA1c, urine albumin and social deprivation. These are calculated probabilities, not observed cardiovascular events. [13]
• The intervention combined physician-led continuous care, remote monitoring, coaching, messaging, group support, specialized curricula, an app and AI-assisted clinical tools. Its ketogenic diet targeted fewer than 30 g of carbohydrate daily, limited grains, legumes, starches and fruit, favored animal proteins and fats, avoided seed oils and allowed olive oil, avocado oil, tallow, butter and coconut oil.
• The cohort included 120 employees enrolled in 2022–2023; 91 reached about one year, around 90 had paired 10-year estimates and 73 qualified for 30-year calculations. Mean age was 52, and the 30-year findings were still unpublished. [1]
• After one year, estimated 10-year total cardiovascular risk decreased 28%, ASCVD risk 29% and heart-failure risk 42%. These were relative changes in PREVENT risk calculations, not measured cardiovascular events. [1]
• The risk changes persisted in sensitivity analyses holding medication use, diabetes status, cholesterol or kidney function constant, consistent with changes across multiple metabolic measures. [1]
• Median weight decreased 12.2%, systolic blood pressure decreased 10.7%, HbA1c decreased 0.48 percentage points amid medication deprescribing, triglycerides also decreased and 13 participants achieved medication-free diabetes remission. [1]
• Across separate publications, the 29% estimated ASCVD-risk reduction was similar to one-year bariatric-surgery findings, compared with roughly 15% for statins or semaglutide and about 13% for DASH. These were indirect, non-head-to-head comparisons, while surgery entailed much greater expense and invasiveness. [14]
• The design was an observational before-and-after analysis, not a randomized dietary trial or a cardiovascular-events trial. The AHA PREVENT equations were applied to a ketogenic care model whose diet differs substantially from AHA guidance. [1]

LDL — two ways to manage ketogenic hypercholesterolemia

• LDL is a major unresolved issue in ketogenic diets. A Soto-Mota and Ludwig meta-analysis associated larger LDL increases with lower BMI, with stable or decreased LDL more common at higher BMI. [15]
• Earlier lean-mass hyper-responder research found that adding approximately 25–50 g of carbohydrate could substantially lower elevated LDL in some lean ketogenic patients, providing a dietary management option. [16]
• A non-statin LDL-lowering option was investigated for people continuing ketogenic eating, including those with high cardiovascular risk or difficulties with statins. The statin concerns included muscle and liver effects, mitochondrial function, insulin resistance and potentially reversible cognitive symptoms.
• Fourteen ketogenic patients with high cholesterol who used ezetimibe were examined, including 12 receiving monotherapy. Clinical assessments also included coronary calcium, genetic markers and cholesterol absorption or synthesis indicators such as campesterol, beta-sitosterol and lanosterol. [2]
• Median LDL decreased from about 254 to 127 mg/dL, approximately two to three times the usual manufacturer-listed response. HDL remained broadly stable, and triglycerides decreased slightly with uncertain causation. [2]
• Conventional genetic variants and sterol markers did not predict response. Low insulin increasing intestinal cholesterol absorption is a proposed mechanism for unusually large effects from ezetimibe's absorption blockade, not an established explanation. [2]
• Marked ketogenic LDL elevation was uncommon in the clinic and concentrated among very lean people or those with major weight loss. Modest carbohydrate reintroduction and ezetimibe were two potential LDL-management options. [2][16]

Closing thesis — make observations reproducible

• The studies form a strategy of publishing clinical findings to challenge established medical assumptions, improve disease remission and medication reduction, and expand options available for clinical evaluation.
• Other clinics can calculate PREVENT scores, examine ezetimibe responses, compare findings and publish results. The SMHP's Journal of Metabolic Health has published a therapeutic carbohydrate-reduction consensus guideline, and collaboration can expand the evidence base. [17]

References

1. [03:32] One-year change in PREVENT-estimated cardiovascular risk during telehealth metabolic care centered on a therapeutic ketogenic diet — https://doi.org/10.1016/j.ajpc.2026.102087
2. [03:35] Increased LDL-C reduction with ezetimibe in ketogenic diet-induced hypercholesterolemia — https://doi.org/10.1186/s12944-026-03034-w
3. [09:00] Treating Diabetes Utilizing a Low Carbohydrate Ketogenic Diet and Intermittent Fasting Without Significant Weight Loss: A Case Report — https://doi.org/10.3389/fnut.2021.687081
4. [09:51] Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: A scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force — https://doi.org/10.1016/j.jacl.2019.08.003
5. [10:42] Reversal of severe hypertriglyceridemia with intermittent fasting and a very-low-carbohydrate ketogenic diet: a case series — https://doi.org/10.1097/MED.0000000000000566
6. [11:52] Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series — https://doi.org/10.1186/s40337-020-0278-7
7. [12:47] TOWARD: a metabolic health intervention that improves food addiction and binge eating symptoms — https://doi.org/10.3389/fpsyt.2025.1612551
8. [14:39] Low carbohydrate and psychoeducational programs show promise for the treatment of ultra-processed food addiction: 12-month follow-up — https://doi.org/10.3389/fpsyt.2025.1556988
9. [15:13] A Company Is Only as Healthy as Its Workers: A 6-Month Metabolic Health Management Pilot Program Improves Employee Health and Contributes to Cost Savings — https://doi.org/10.3390/metabo12090848
10. [15:16] TOWARD, a metabolic health intervention, demonstrates robust 1-year weight loss and cost-savings through deprescription — https://doi.org/10.3389/fnut.2025.1548609
11. [17:22] Popular Dietary Patterns: Alignment With American Heart Association 2021 Dietary Guidance: A Scientific Statement From the American Heart Association — https://doi.org/10.1161/CIR.0000000000001146
12. [18:14] Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association — https://doi.org/10.1161/CIR.0000000000001184
13. [19:24] Development and Validation of the American Heart Association's PREVENT Equations — https://doi.org/10.1161/CIRCULATIONAHA.123.067626
14. [25:12] Reduced Risk of Cardiovascular Diseases After Bariatric Surgery Based on the New Predicting Risk of Cardiovascular Disease EVENTs Equations — https://doi.org/10.1161/JAHA.124.038191
15. [26:58] Increased low-density lipoprotein cholesterol on a low-carbohydrate diet in adults with normal but not high body weight: A meta-analysis — https://doi.org/10.1016/j.ajcnut.2024.01.009
16. [27:29] Elevated LDL Cholesterol with a Carbohydrate-Restricted Diet: Evidence for a "Lean Mass Hyper-Responder" Phenotype — https://doi.org/10.1093/cdn/nzab144
17. [33:51] A Delphi consensus-based guideline for the implementation of therapeutic carbohydrate reduction in metabolic disorders — https://doi.org/10.4102/jmh.v9i1.152