Dietary Cholesterol and Cardiovascular Risk: AHA Advisory

Carson JS, Lichtenstein AH, Anderson CA, et al.
Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation 2019;Dec 16:[Epub ahead of print].

The following are key points to remember from the American Heart Association (AHA) Advisory on dietary cholesterol and cardiovascular risk:

  1. The elimination of specific dietary cholesterol target recommendations in recent guidelines raised questions about its role with respect to cardiovascular disease (CVD). This advisory was developed after a review of human studies on the relationship of dietary cholesterol with blood lipids, lipoproteins, and CVD risk to address questions about the relevance of dietary cholesterol guidance for heart health.
  2. The mean cholesterol intake in the United States is about 137 mg/1000 kcal, which is modestly higher in men and some racial/ethnic groups. Meat including poultry, mixed dishes, red meat, processed meat, and seafood contribute 42% of the total cholesterol intake, eggs 25%, and other food groups about a third.
  3. Findings in observational studies from 1980-2012, collectively with more than 250,000 subjects, have not supported an association between dietary cholesterol and CVD risk (fatal or nonfatal myocardial infarction or stroke), particularly when adjusting for total energy intake. Similarly, egg intake is not associated with CVD risk. But the observations for eggs may be confounded by other dietary, socioeconomic, and lifestyle factors that covary with eggs.
  4. Most observational studies of cholesterol intake on CVD risk are limited in value because they do not adjust for types of dietary fat (saturated, polyunsaturated fatty acid [PUFA] and monounsaturated fatty acid). A meta-regression analysis of randomized controlled diet interventions found a dose-response between dietary cholesterol and low-density lipoprotein cholesterol (LDL-C) after adjustment for dietary fat composition using predicted lipoprotein changes. Every 100 mg/day increase in dietary cholesterol predicted an LDL-C increase of from 1.90-4.58 mg/dl depending on the model. Increasing intake of dietary cholesterol was marginally associated with a significant change in high-density lipoprotein cholesterol.
  5. The controlled studies are limited in generalizability. In the American diet, dietary cholesterol and saturated fat rise together as eggs are often accompanied by bacon or sausage. From a practical perspective, there is greater potential to optimize plasma lipoprotein profiles by improving the ratio of dietary saturated fatty acid to PUFA than by reducing dietary cholesterol. Importantly, heart-healthy dietary patterns (Mediterranean-style and DASH-style diets) characterized by fruits, vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds, and vegetable oils have a relatively high ratio of PUFA to saturated fatty acid and are low in cholesterol with typical menus containing <300 mg/d cholesterol, similar to the current US intake. For older normocholesterolemic patients, given the nutritional benefits and convenience of eggs, consumption of up to two eggs per day is acceptable within the context of a heart-healthy dietary pattern.

Keywords: Cardiovascular Diseases, Cholesterol, Cholesterol, Dietary, Cholesterol, HDL, Cholesterol, LDL, Dairy Products, Diet, Eggs, Energy Intake, Ethnic Groups, Fatty Acids, Monounsaturated, Fatty Acids, Unsaturated, Life Style, Lipids, Meat, Myocardial Infarction, Nuts, Primary Prevention, Risk Factors, Stroke, Vegetables

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