Dietary Cholesterol Restriction:
Much Hype About Nothing
Alice H. Lichtenstein, D.Sc.
Gershoff Professor of Nutrition Science and Policy
Tufts University, Boston, MA
© Tufts University, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging
Introduction
 Early work suggested that dietary cholesterol increases plasma total cholesterol and later LDL cholesterol concentrations in experimental animal models and humans.  Elevated total and LDL cholesterol concentrations are associated with increased CVD risk, hence, since the 1960’s dietary guidelines have consistently recommended limiting food sources of cholesterol.
 Comfortable logic – dietary cholesterol translates directly to plasma/LDL cholesterol concentrations.
Introduction
 More recent data suggests the effect of dietary cholesterol on lipoprotein profiles is mixed.
 Concern raised that some of the original findings may have been confounded by covarying with saturated fat and body weight, and very high levels of dietary cholesterol (600 mg to 900 mg/day).
 Current intakes are approaching recommended levels. Dietary Cholesterol (females)
2015 DGAC report
Dietary Cholesterol (males)
2015 DGAC report
Dietary Cholesterol
 2013 AHA/ACC Lifestyle Guideline Committee;
“There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL‐C.”
Eckel R, et al. JACC 2014l;63:2960
Dietary Cholesterol
 2015 Dietary Guidelines Advisory Committee “Cholesterol is not a nutrient of concern for overconsumption.”
2015 DGAC report
Dietary Cholesterol
Citations identified through
database searches (20032013)
(n = 113)
Citations after duplicates removed
(n = 94)
Records screened by
title and abstract
(n = 94)
Griffin JD, Lichtenstein AH. Curr Nutr Rep 2013;2:274
Full-text articles
assessed for eligibility
(n = 17)
Studies included in
qualitative synthesis
(n = 12 )
Duplicate citations removed
(n = 19)
Citations excluded based on title
and abstract screening
(n = 77)
Reasons For Exclusion:
- Not relevant (n = 27)
- Prespecified outcomes not
reported (n= 43)
- Not RCT(n= 7)
Full-text articles excluded (n = 5)
- Lacked adequate controls (n = 2)
- Duplicate publication (n = 2)
- Pre-specified outcome not
reported (n = 1)
Dietary Cholesterol
 Intervention studies (2003‐2013);
o Wide range study designs
o Wide range inclusion criteria (age, weight status, insulin sensitivity)
o Isocaloric, hypocaloric
o Intervention periods broad, 4‐12 weeks
o Cholesterol intakes broad, 1‐3 eggs/day
o Significant effects only identified when data were stratification on basis of cholesterol responsiveness or ABCG5 genotype
Griffin JD and Lichtenstein AH. Curr Nutr Rep 2013; 2:274
Dietary Cholesterol
Conclusions;
 Within the context of contemporary dietary cholesterol intakes, effects on plasma lipid concentrations, with emphasis on LDL‐
cholesterol, was modest and limited to population subgroups.  For subgroups who are responsive, restrictions of dietary cholesterol are warranted.
 Biological determinants of inter‐individual variability remain relatively understudied.
Dietary Cholesterol
August 2015; 102: 276‐294
Dietary Cholesterol – LDL‐C (>5 eggs/day)
(3.5‐5 eggs/day)
(<3.5 eggs/day)
Berger S, et al. AJCN. 2015;102: 276-294
Dietary Cholesterol – HDL‐C (>5 eggs/day)
(3.5‐5 eggs/day)
(<3.5 eggs/day)
Berger S, et al. AJCN. 2015;102: 276-294
Dietary Cholesterol – TC/HDL‐C
Berger S, et al. AJCN. 2015;102: 276-294
Dietary Cholesterol – LDL‐C
2 large eggs = ~372 mg cholesterol
Weggemans RM, Zock PL, Katan MB J Clin Nutr 2001;73:885
Saturated or Trans
Fat
Saturated Fat
Green Vegetable
Dietary Cholesterol
Refined Carbohydrate
November 1, 1993
Dietary Cholesterol – Summary  Within the context of current dietary cholesterol intakes, the effect on LDL and HDL cholesterol concentrations modest, and appears to be limited to population subgroups.  In these cases, restrictions in dietary cholesterol, in addition to achieving and maintaining a healthy body weight and adhering to a heart health diet, is warranted.