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case_images: A recent cohort study of 548 persons on carbohydrate-restricted diets (CRDs) revealed inverse associations between triglyceride/HDL-C ratio (TG/HDL-C) and LDL-C change, and between BMI and LDL-C change, on CRD. This means leaner persons with lower TG/HDL-C ratios generally exhibit larger increases in LDL-C on CRD. Individuals with a particularly pronounced high LDL-C, high HDL-C, low TG ratio are termed "Lean Mass Hyper-Responders." This report provides a clinical vignette of a patient who exhibits the Lean Mass Hyper-Responder phenotype, with LDL-C as high as 545 mg/dl, despite normal pre-CRD LDL-C of 95 mg/dl and consuming a CRD with a high unsaturated/saturated fat ratio. Coronary CT angiography conducted after 2.5 years of extremely elevated LDL-C reveals no detectable plaque development.
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case_images: Results of lipid panels conducted between August 2020 and October 2021, in conjunction with data extracted from LM's dietary records, are presented in  Table 1  and  Figure 1 . Finally, testing in October 2021 following further weight gain of 4 lbs (BMI 20.2 kg/m2), and in the context of a diet far richer in saturated fat, LDL-C measured at 411 mg/dl (HDL-C 116 mg/dl, TG 39 mg/dl) ( Table 1  and  Figure 1 ).
case_images: Patient timeline. Above: LM experienced his first colitis flare in March 2017. Episodic flares persisted, despite treatment with oral and suppository mesalamine and hydrocortisone enemas. LM commenced a ketogenic diet in June 2019, followed by a period of continued remission associated with ketosis. Medications for colitis were discontinued. Below: Between August 2020 and October 2021, LM began a practice of fastidiously recording dietary intake (see Supplemental Information) prior to scheduled lipid panels. Pie graphs represent fat pro!le of LM's diet in the 7 days prior to testing. Further details provided in text, 
  Supplemental Information
  , and 
  Table 1
  .
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case_images: No plaque or stenosis was observed in any vessels CAD-RADS = 0 ( Figure 2 ).