<![CDATA[Background: Adherence to ketogenic diets remains challenging among adults at risk for coronary heart disease (CHD), potentially limiting the sustainability of dietary interventions. Evidence regarding the combined use of digital education and structured family support in relation to dietary adherence, psychosocial outcomes, and cardiovascular biomarkers remains limited, particularly in Indonesian primary healthcare settings. Purpose: This study aimed to assess ketogenic diet adherence, psychosocial outcomes, and cardiovascular biomarkers following digital education combined with structured family support among adults at risk for CHD and to explore factors influencing dietary adherence. Methods: This quantitative-dominant sequential explanatory mixed-methods study included a quasi-experimental pretest–posttest control-group phase involving 60 adults at risk for CHD. The intervention group received six months of digital ketogenic diet education combined with structured family support, whereas the control group received routine nutritional education. Outcomes included ketogenic diet adherence, self-efficacy, perceived family support, LDL cholesterol, HDL cholesterol, triglycerides, and small dense LDL (sd-LDL). Quantitative outcomes were analyzed using analysis of covariance (ANCOVA), with adjustment for relevant baseline covariates. The subsequent qualitative phase used interviews and focus group discussions, followed by thematic analysis to explore factors influencing dietary adherence. Results: The intervention group showed significantly greater improvements in ketogenic diet adherence, self-efficacy, and perceived family support vs. control group (p<0.001). Significant between-group differences were also observed in sd-LDL, LDL cholesterol, triglycerides, and HDL cholesterol (p<0.05). Qualitative findings indicated that practical family involvement, emotional support, and flexible access to digital education facilitated dietary adherence, whereas habitual consumption of carbohydrate-rich foods remained an important barrier. Conclusion: Digital ketogenic diet education combined with structured family support was associated with greater improvements in dietary adherence, psychosocial outcomes, and cardiovascular biomarkers among adults at risk for CHD. Qualitative findings further identified family involvement and accessible digital education as facilitators of adherence, while habitual carbohydrate consumption remained a barrier. Further studies are warranted to confirm these findings using larger samples and more rigorous experimental designs.]]>
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