by Marion Nestle

Currently browsing posts about: Cholesterol

Nov 4 2015

Does eating eggs raise blood cholesterol levels?

The Physicans Committee for Responsible Medicine (PCRM), a group advocating against use of animals in research but for vegetarian and vegan diets, has started a campaign to restore egg-and-cholesterol recommendations to the Dietary Guidelines for Americans.

Eggs are the largest source of cholesterol in American diets.

The campaign involves billboards like this one, in six locations in Texas:


It also involves a new organization ( with an interactive website on a dozen issues related to egg production and consumption.

The one that particularly caught my eye was #5.

A 2013 review suggested that high-cholesterol foods have only a modest effect on blood cholesterol. Of the 12 studies it relied on, 11 were industry-funded.

In a letter to Congressman K. Michael Conaway (Rep-TX), Dr. Neal Barnard, PCRM’s president, wrote:

This week, billboards near your Texas offices will alert you to the dangers Americans face if cholesterol warnings are removed…Eggs are the leading source of cholesterol in the American diet.  A report (which I’ve included for your review) in the autumn 2015 Good Medicine magazine finds that this recommendation may have been influenced by egg-industry-funded cholesterol research. America’s heart disease and diabetes epidemics will continue unabated if the egg industry succeeds in its efforts to get cholesterol warnings out of the guidelines.

The 2015 Dietary Guidelines Advisory Committee (DGAC) said this about dietary cholesterol.

Cholesterol. Previously, the Dietary Guidelines for Americans recommended that cholesterol intake be limited to no more than 300 mg/day. The 2015 DGAC will not bring forward this recommendation because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol, consistent with the conclusions of the AHA/ACC report.2,35 Cholesterol is not a nutrient of concern for overconsumption.

The DGAC based its unconcern about dietary cholesterol on two references:

2.  Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-99. PMID: 24222015. Its conclusion:

There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL–C.

35.  Shin JY, Xun P, Nakamura Y, He K. Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(1):146-59. PMID: 23676423. This study, which was also independently funded, concluded:

compared with those who never consume eggs, those who eat 1 egg per day or more are 42% more likely to develop type 2 diabetes. Among diabetic patients, frequent egg consumers (ie, > 1 egg/d) are 69% more likely to have CVD comorbidity…This meta-analysis suggests that egg consumption is not associated with the risk of CVD and cardiac mortality in the general population. However, egg consumption may be associated with an increased incidence of type 2 diabetes among the general population and CVD comorbidity among diabetic patients.

Were these references based largely on studies funded by the egg industry?  If so, PCRM is correct in arguing that the question of egg consumption and blood cholesterol levels merits much closer scrutiny and analysis than it is currently receiving.

What does a study funded by the egg industry look like?  Here are two one from my recent collection:

The effect of a high-egg diet on cardiovascular risk factors in people with type 2 diabetes: the Diabetes and Egg (DIABEGG) study—a 3-mo randomized controlled trial, by Nicholas R Fuller, Ian D Caterson, Amanda Sainsbury, Gareth Denyer, Mackenzie Fong, James Gerofi, Katherine Baqleh, Kathryn H Williams, Namson S Lau, and Tania P Markovic.  Am J Clin Nutr 2015; 101:705-713.

  • Conclusion: High egg consumption did not have an adverse effect on the lipid profile of people with T2D [type 2 diabetes] in the context of increased MUFA [monounsaturated fatty acid] and PUFA [polyunsaturated fatty acid] consumption. This study suggests that a high-egg diet can be included safely as part of the dietary management of T2D, and it may provide greater satiety.
  • Sponsor: Australian Egg Corporation

Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis. Berger, S., Raman, G., Vishwanathan, R., Jacques, P.F., Johnson, E.J., 2015. Am J Clin Nutr ajcn100305. doi:10.3945/ajcn.114.100305.  Am J Clin Nutr August 2015
vol. 102 no. 2 276-294

  • Conclusion: Reviewed studies were heterogeneous and lacked the methodologic rigor to draw any conclusions regarding the effects of dietary cholesterol on CVD risk.  [Implication: suggestions that eggs might raise cardiovascular risk are unwarranted]
  • Sponsor: Supported by USDA agreement 1950-51000-073 and the American Egg Board, Egg Nutrition Center.  The funders did not have a role in the study selection, quality assessment, data synthesis, or manuscript preparation.
Feb 12 2015

What’s up with the cholesterol guideline?

The Washington Post says that the 2015 Dietary Guidelines Advisory Committee is about to drop the long-standing guideline about restricting dietary cholesterol.

The 2010 Dietary Guidelines said “Consume less than 300 mg per day of dietary cholesterol.”

This is about the amount in one egg.

I have no idea what’s going on.  The Advisory Committee report has not yet been released so I don’t know what it says (I’ve heard rumors that it is to be released this week, which could mean late Friday afternoon on a holiday weekend).

Recall: no matter what the Advisory Committee says in its report, it does not write the Dietary Guidelines.  The agencies—USDA and HHS—do whatever they choose with the committee’s research report.

If the Committee really is dropping the guideline, I’d like to see its research rationale.

I’m wondering if research sponsored by the egg industry could have anything to do with this.

See, for example, this recent study concluding that people with coronary heart disease don’t have to worry about eating eggs.

We found no evidence of adverse effects of daily egg ingestion on any cardiac risk factors in adults with CAD over a span of 6 weeks.

You have to read the study carefully to find the funding source (these are usually at the end of articles, but this one is in the middle):

Disclosures. This study was conducted with funding from the Egg Nutrition Center/American Egg Board and the Centers for Disease Control and Prevention (Grant
No. 5U48DP001945-05).

And you have to read the tables carefully to find out that 90.6% of the subjects in this study were taking statins, nearly 90% were taking drugs to lower blood pressure, and nearly 80% were taking aspirin.  The discussion, however, does not mention this point making this study a classic example of the problems with conflicts of interest in research.

If the Advisory Committee is dropping the cholesterol recommendation, could it be because so many people are taking statins that dietary cholesterol doesn’t appear to matter so much anymore?

This story is getting a lot of press.  Here’s one from USA Today that quotes me and changes my name as it goes along (they have now fixed that).

Can’t wait to see what the report really says.






Nov 18 2013

What’s up with the new cholesterol/statin guidelines?

Last week, a Feedback comment from a reader, Judith Rice-Jones, inspired me to try to understand what’s going on with the new heart disease prevention guidelines (I can’t say I’m succeeding very well).

Looking forward to your response to the recent recommendations for more people to take statins. Don’t see anything in the new recommendations about changing lifestyle or diet to reduce risks of stroke or heart attack.

Yes, there are lifestyle recommendations.   But lifestyle changes do not make money for drug companies, and they don’t get press attention.

The American College of Cardiology (ACC) and American Heart Association (AHA) issued four sets of guidelines:

  1. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
  2. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults
  3. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk
  4. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

These organizations say:

AHA and ACC are pleased to announce a series of new cardiovascular prevention guidelines for the assessment of cardiovascular risk, lifestyle modifications that reduce risk, management of elevated blood cholesterol, and management of increased body weight in adults. These guidelines are based on rigorous, comprehensive, systematic evidence reviews originally sponsored by the NHLBI. The ACC and AHA collaborated with professional organizations to finalize these AHA/ACC cardiovascular prevention guidelines, and stakeholder organizations were invited to review and endorse the final documents.

So these guidelines are a major big deal.  The New York Times said you need to know three things about them:

  • You don’t need to know your cholesterol number (unless it is very high).
  • You do need to know your risk (for this you need to use the risk calculator and, therefore, to know your LDL and HDL levels and blood pressure).
  • If you are at risk, take a statin (most, at least, are generics).

But wait!

As the New York Times also suggested, the new guidelines have taken many by surprise.

This is an understatement.

Problem #1: Authoritative clinicians say more patients should not be taking statins

This announcement is not a result of a sudden epidemic of heart disease, nor is it based on new data showing the benefits of lower cholesterol. Instead, it is a consequence of simply expanding the definition of who should take the drugs — a decision that will benefit the pharmaceutical industry more than anyone else.

This opinion piece points out that members of the group writing the recommendations have financial ties to drug makers, as do both the AHA and ACC.

The guidelines might make sense, they say, if statins

actually offered meaningful protection from our No. 1 killer, heart disease; if they helped people live longer or better; and if they had minimal adverse side effects. However, none of these are the case…as shown in a recent BMJ article co-written by one of us.

Perhaps more dangerous, statins provide false reassurances that may discourage patients from taking the steps that actually reduce cardiovascular disease…80 percent of cardiovascular disease is caused by smoking, lack of exercise, an unhealthy diet, and other lifestyle factors. Statins give the illusion of protection to many people, who would be much better served, for example, by simply walking an extra 10 minutes per day.

Problem #2: The risk calculator greatly overestimates risk

The lead article in today’s Times summarizes studies to be published in The Lancet tomorrow concluding that the risk calculator makes the risks seem greater than they really are.


New Picture (1)

It will lead many doctors to prescribe statin drugs to people who do not need to take them (from the standpoint of drug companies, that’s the point).

The calculator overpredicted risk by 75 to 150 percent, depending on the population. A man whose risk was 4 percent, for example, might show up as having an 8 percent risk. With a 4 percent risk, he would not warrant treatment — the guidelines that say treatment is advised for those with at least a 7.5 percent risk and that treatment can be considered for those whose risk is 5 percent.

What to do?

  • Best to discuss this one with your doctor.
  • For sure, eat your veggies and be active.
  • If you still smoke cigarettes, stop.
  • Stay tuned for further developments.

Just for fun

Let’s let Brian McFadden (Sunday’s New York Times Week in Review) have the last word for today.

Jul 6 2008

Statin drugs for 8-year-olds?

The nutrition committee of the American Academy of Pediatrics has just issued a new set of recommendations for cholesterol screening.  The advice of this august body?  Screen 2-year-olds for high cholesterol and start prescribing statin drugs at age 8.  OK, they are just recommending this for kids with risk factors, such as high LDL cholesterol (the bad one), family history of heart disease, obesity, diabetes, metabolic syndrome, etc.   This sounds great for doctors, testing labs, and drug companies.  Is it a good idea for kids?  Which kids?  Who is going to pick up the tab for this?