Nutr Metab Cardiovasc Dis. 2026 Aug 5:104955. doi: 10.1016/j.numecd.2026.104955. Online ahead of print.
ABSTRACT
BACKGROUND AND AIM: Cardiovascular-kidney-metabolic (CKM) syndrome confers elevated mortality risk, but whether dietary ketogenic ratio (KDR) is associated with mortality in this population remains unclear. We examined the association of KDR with mortality in adults with CKM syndrome and whether it persisted after accounting for broader diet-quality metrics.
METHODS AND RESULTS: We analysed adults with CKM stages 1-4 from NHANES 2003-2018 with mortality follow-up through 2019. Participants required a reliable Day 1 24-h dietary recall, non-missing KDR, and classifiable CKM stage. The primary cohort included 31,761 adults; 28,221 also contributed to a 2-day sensitivity analysis. Survey-weighted Cox models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), with KDR analysed per 1-SD increase and by quartiles. During follow-up, 4481 all-cause deaths and 1199 heart disease deaths occurred. In the fully adjusted model, each 1-SD higher KDR was associated with lower all-cause mortality (HR 0.94, 95% CI 0.90-0.98), and the highest quartile had lower risk than the lowest quartile (HR 0.86, 95% CI 0.78-0.96). The association attenuated after adjustment for source-oriented low-carbohydrate diet (LCD) scores, changed little after Healthy Eating Index-2015 (HEI-2015) adjustment alone, and showed a similar pattern in the 2-day dietary cohort. Associations with heart disease mortality were not statistically robust.
CONCLUSION: Higher KDR was associated with lower all-cause mortality in CKM syndrome, but this association was partly attenuated by broader diet-quality metrics. KDR may be better interpreted as a complementary dietary metric rather than an independent dietary target.
PMID:42624724 | DOI:10.1016/j.numecd.2026.104955
