nutrients
Review
Dietary Cholesterol and the Lack of Evidence in
Cardiovascular Disease
Ghada A. Soliman ID
Department of Environmental, Occupational, and Geospatial Health Sciences, CUNY Graduate School of Public
Health and Health Policy, The City University of New York, 55 W. 125th Street, New York, NY 10027, USA;
ghada.soliman@sph.cuny.edu; Tel.: +1-646-364-9515
Received: 18 May 2018; Accepted: 13 June 2018; Published: 16 June 2018
Abstract:
Cardiovascular disease (CVD) is the leading cause of death in the United States. For years,
dietary cholesterol was implicated in increasing blood cholesterol levels leading to the elevated risk
of CVD. To date, extensive research did not show evidence to support a role of dietary cholesterol
in the development of CVD. As a result, the 2015–2020 Dietary Guidelines for Americans removed
the recommendations of restricting dietary cholesterol to 300 mg/day. This review summarizes the
current literature regarding dietary cholesterol intake and CVD. It is worth noting that most foods
that are rich in cholesterol are also high in saturated fatty acids and thus may increase the risk of
CVD due to the saturated fatty acid content. The exceptions are eggs and shrimp. Considering that
eggs are affordable and nutrient-dense food items, containing high-quality protein with minimal
saturated fatty acids (1.56 gm/egg) and are rich in several micronutrients including vitamins and
minerals, it would be worthwhile to include eggs in moderation as a part of a healthy eating pattern.
This recommendation is particularly relevant when individual’s intakes of nutrients are suboptimal,
or with limited income and food access, and to help ensure dietary intake of sufficient nutrients in
growing children and older adults.
Keywords:
dietary cholesterol; LDL-cholesterol; cardiovascular disease (CVD); randomized control
trials (RCT); observational studies; HMG CoA reductase; LDL and HDL
1. Introduction
Cardiovascular disease (CVD) is a leading cause of death in the US with approximately one in
every four deaths occurring from heart diseases [
1
]. According to the CDC, 610,000 individuals die
from CVD in the US [
2
]. The landmark of CVD is atherosclerosis, which is a chronic inflammatory
condition instigated by deposition of cholesterol and fibrous tissues in the arterial walls which build up
and eventually lead to narrowing and thickening or blocking of the arterial lumen. The inflammation
regulates the plaque formation as well as the thrombotic complications of atherosclerosis [
3
].
The hypothesis that dietary cholesterol contributes to the risk of heart disease was initially suggested
in 1968 and based on the research literature at the time [
4
,
5
]. Subsequently, the American Heart
Association adopted a recommendation of limiting dietary cholesterol intake to 300 mg/day for
healthy individuals in the United States, and with recommendations of restricting egg consumption
to a maximum of three whole eggs per week [
6
]. However, the totality of scientific evidence and
experimental data did not validate the hypothesis that dietary cholesterol increases blood cholesterol,
and by extension increases the risk of CVD. Investigators have reported that increased intake of dietary
cholesterol (exogenous) is associated with decreased synthesis of endogenous de novo cholesterol,
possibly as a compensatory mechanism that keeps cholesterol homeostasis constant [
7
,
8
]. In fact,
the 2015–2020 Dietary Guidelines for Americans removed the recommendations of setting a limit to the
maximum intake of 300 mg/day cholesterol. The Guidelines still advised eating as little as possible of
Nutrients 2018,10, 780; doi:10.3390/nu10060780 www.mdpi.com/journal/nutrients
