Cholesterol and eggs: what’s a heart patient to believe? Registered Dietitian Cheryl Strachan tells all!

 Carolyn Thomas   ♥  @HeartSisters

Cheryl Strachan is a Registered Dietitian, nutritionist, cardiac specialist, and author of the 30-Minute Heart Healthy Cookbook (HINT: a terrific holiday gift idea for yourself or any heart patient!)  Cheryl says she loves “to banish food stress and help people with heart concerns get comfortable in the kitchen again.”  Much of Cheryl’s professional career was spent working with local cardiac support groups and rehabilitation programs in Calgary. I’ve been following her patient-friendly Sweet Spot Nutrition blog for several years, and when I read her recent article about eggs and cholesterol, I immediately asked her permission to share this controversial and often misunderstood topic here for my own readers living with heart disease. Keep on reading, below. . .

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“What’s the deal with eggs if you have heart concerns?”

Guest post by Cheryl Strachan, originally published on Sweet Spot Nutrition 10/24/24

“If you’ve had heart concerns for longer than five minutes, you’ve probably heard conflicting news about eggs.

• March 2019, CNN, “Three or more eggs a week increase your risk of heart disease and early death”
• Feb 2020, Washington Post,  “One egg a day will not increase cardiovascular disease risks…”
• July 2021, Washington Post, “Eating too many eggs can still be risky…”
• January 2024, USA Today:  “Experts claim eggs can be heart-healthy.”

“It’s so frustrating!  Truly, most studies (and headlines), don’t find that eggs raise risk of cardiovascular disease. However, a few do, particularly in people with diabetes, cholesterol problems, or a risk for heart failure.

“Read on to see what those findings suggest, in terms of your relationship with the mighty egg.

“Why the fuss about eggs?

“It’s the cholesterol. Historically, eggs have been viewed with suspicion because of their uniquely high cholesterol content (in the yolks, not the whites). For example, a 100 gram (3.5 ounce) serving of chicken breast has 85 mg of cholesterol. The same amount of ribeye steak: 76 mg. Two large eggs: 373 mg!

“Logically, you’d think that eating more cholesterol would increase the level of cholesterol in your blood, but for most people, the increase is small. Most of the cholesterol in the body is made by the liver, because it’s actually something we need, for important jobs like making cell walls, hormones, and bile acid.  But cholesterol becomes a problem if there’s too much of it in your blood. Specifically, too much of certain “lipoproteins” – particles that ferry cholesterol around the body. Chief among the troublemakers is the “low density lipoprotein,” or LDL. Too much of that and it will push its way into the walls of your blood vessels, creating plaque and possibly leading to a heart attack, stroke, or other related problem.

“How do you end up with too much LDL cholesterol?

“Cholesterol levels are largely driven by the genes you inherit, but your eating habits can affect them as well. For example, more saturated and trans fats cause the liver, in effect, to produce more LDL cholesterol.  But does eating more cholesterol cause LDL cholesterol to go up? As I said above, for most people, it doesn’t go up much. But about 25% of the population actually does see a bump in LDL cholesterol when they eat more cholesterol-rich foods. They call these people hyper-responders.

‘How do you know if you’re a hyper-responder? Unfortunately, there’s no test for it. But if your LDL cholesterol is stubbornly high, despite a committed effort to implement dietary changes, you could certainly try cutting back on cholesterol-rich foods between blood tests, and see if it makes a difference. (Hi! A dietitian could help you with this.)

‘In addition to people with cholesterol troubles, another group who might want to take it easy on the eggs…

‘People with type 2 diabetes

‘Having diabetes, a major heart disease risk factor, is another reason to potentially consider limiting eggs. Two out of three studies in people with type 2 diabetes (one in 1999 and one in 2007) found a link with egg intake and coronary heart disease (when blocked arteries cause trouble in the heart). The third study (in 2008) didn’t find that association, but reported a dose-dependent increased risk of death among people with diabetes who ate the most eggs.

‘How many eggs are we talking?

‘In the 1999 study, eating more than one egg per day, on average, for people with diabetes, was associated with about 1.5x (for women) to 2x (for men) the risk of coronary heart disease, compared to less than one egg per week. That’s a pretty big difference.  In the 2007 study, again only in the people with diabetes, having more than six eggs a week was associated with twice the risk of coronary artery disease, compared with people who had less than one a week.

‘Similarly, the 2008 study found that in the participants with diabetes, eating seven or more eggs per week was associated with a twofold increased risk of dying for any reason compared with less than one egg a week.

‘Isn’t this weak evidence?

‘Keep in mind that these studies are a relatively weak form of evidence, because they’re based on observational data, where researchers ask people about their eating habits and then check in years later to see how they’re doing. This type of study can’t prove that the eggs caused the heart problems, because something else about the big egg eaters might be at work. Maybe they eat a lot of bacon and sausage with those eggs. (Although researchers do try to adjust the data for things like that as much as possible.)  People may also report their dietary habits inaccurately, or change them during the course of the study.

‘A better way to answer this question would be a randomized controlled trial (RCT), where half the people are randomly assigned to eat more eggs, and half aren’t. But it’s tough to do studies like that last long enough for a significant portion of the participants to have heart attacks or die.

‘However, a 2017 systematic review of six short-term RCTs found that having 6 to 12 eggs a week didn’t affect LDL cholesterol or other heart disease risk factors, compared to eating few or no eggs. So that’s good. But as always, they concluded by saying that firm conclusions couldn’t be drawn. More research needed.

‘Meanwhile, one more group to think about:

‘Men: Could you be at risk for heart failure?

‘Strangely, this next finding only applies to men. Three studies found that having more than one egg a day, on average, was linked with a 20-30% higher risk of heart failure, but in men only. Same caveats as above though – this kind of study can’t prove cause and effect.

‘What increases your risk for heart failure? Having a heart attack or other evidence of coronary artery disease, high blood pressure, diabetes, being over 65, smoking, and several other factors.

‘The case for eggs

‘On the other hand, eggs are a nutrient-rich, relatively affordable protein source. They give you vitamins A, D and B12 and a nutrient called choline that’s involved in regulating mood and memory.  They also deliver two antioxidants, lutein and zeaxanthin, which may actually help prevent atherosclerosis as well as age-related macular degeneration.

‘(If you don’t eat many eggs, you can also get lutein and zeaxanthin from dark green leafy vegetables like spinach, kale, and more.)

‘Eggs as part of a healthy diet

‘Interestingly, some evidence suggests that eating more eggs as well as more high saturated fat foods (hello bacon!) and/or little fibre (eg. white toast) might be what triggers blood cholesterol to rise in response to a higher cholesterol intake.  So if you do eat more eggs, it likely helps to eat them in the context of an overall lower saturated fat, higher fibre (i.e. heart-healthy) diet.

‘What do the guidelines say?

‘Back in 2013 and 2015, the “Dietary Guidelines for Americans” and the American Heart Association’s “Guideline on Lifestyle Management to Reduce Cardiovascular Risk,” removed previous statements about limiting dietary cholesterol, citing insufficient evidence of an impact on blood cholesterol.

‘That’s what lead to the idea that eggs had been exonerated. But keep in mind these guidelines are for the general public.

‘On the other hand, the 2015 National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia,” which gives guidance for treating people with high cholesterol, still recommended limiting dietary cholesterol to less than 200 mg per day “to lower LDL cholesterol and non–high-density lipoprotein (HDL) cholesterol concentrations”.  (To keep cholesterol that low, you’d have to limit eggs, meat, poultry, and/or fish.)

‘And more recently, one of the key nutrition recommendations of the 2019 American College of Cardiology / American Heart Association “Guideline on the Primary Prevention of Cardiovascular Disease” is that “A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk.” (ASCVD = atherosclerotic cardiovascular disease.)  So you can see that if you have heart concerns, it’s not necessarily a free-for-all with eggs.

‘It’s always your decision

‘If you have type 2 diabetes, high cholesterol, or are at risk for heart failure, do you have to cut way back on eggs? Of course not.  That decision is yours, and depends in part on how conservative you want to be. Some people I’ve worked with are highly motivated to avoid another heart event and so will take whatever precautions they can, even if the evidence isn’t solid. And some want to focus on just whatever makes the biggest impact. Or what’s most doable for them.

‘It’s all good with me. I’m just here to support whatever goals you have.

‘Also, how much do you like eggs? That matters too!  😋

‘And if not eggs, what will you eat instead, assuming it’s breakfast? A bowl of corn flakes would be worse (no question that refined grains are problematic).

‘It’s a good idea to replace the protein in the eggs with something like plain Greek yogurt, peanut butter, or cottage cheese. And to get those dark green leafy vegetables often, for the lutein and zeaxanthin, among other things.”

‘So bottom line, how many eggs?

‘I like to reference the American Heart Association’s guidance:

“Healthy individuals can include up to a whole egg or equivalent daily.  Vegetarians (lacto-ovo) who do not consume meat-based cholesterol-containing foods may include more dairy and eggs in their diets within the context of moderation discussed herein.  Patients with dyslipidemia (a metabolic disorder in which abnormally high or low amounts of lipids or lipoproteins in the blood.particularly those with diabetes mellitus or at risk for heart failure)  should be cautious in consuming foods rich in cholesterol.”

“For older patients with normal cholesterol levels,  given the nutritional benefits and convenience of eggs, consumption of up to 2 eggs per day is acceptable within the context of a heart-healthy dietary pattern.”

Similarly, here’s what the the European Society of Cardiology’s “Dietary recommendations for prevention of atherosclerosis” says:

“…a moderate consumption of eggs (up to three servings of two eggs per week, or one egg per day) can be permitted.

“This may not apply to people with hyperlipidaemia or diabetes for whom more caution is appropriate.  A similar caution would be suitable in populations with a western dietary pattern rich in foods with a high content of saturated fatty acids; in this case, it may be wise not to exceed a weekly consumption of three eggs.”

“So you can see, people with diabetes or high cholesterol can definitely have eggs. But maybe not a 3-egg omelette every day. And ideally in the context of overall heart-healthy eating habits.

“Most importantly…

“If you need to lower LDL cholesterol, the most important change you can make is to cut back on saturated fat, particularly from foods like processed and red meat and butter, and switch to more unsaturated fat instead (think salmon, nuts, avocado, olive oil).  And don’t let the egg question distract you from the food habit that has the best evidence for overall heart health: A Mediterranean-style pattern of eating (which, by the way, includes eggs in moderation).

“Otherwise it’s mostly plant-based, with plenty of vegetables and fruit, legumes, nuts and seeds, whole grains, olive oil, and fish. Not too much red meat, and at least some meals are vegetarian. You know the drill.”

Join the conversation!

Learn more in Cheryl’s FREE e-book called The Sweet Spot Guide to Eating Well With Heart Concerns .

And remember that Cheryl’s beautiful cookbook, 30-Minute Heart Healthy Cookbook (Delicious Recipes for Easy, Low-Sodium Meals) also makes a useful (and perhaps even life-changing!) holiday gift.

Do you want to learn more about evidence-based heart-healthy eating? Join the many savvy cooks and other learners in Cheryl’s “Sweet Spot Heart-Healthy Cooking Club” on Facebook.

Thank you once again Cheryl for letting my Heart Sisters readers discover great food information from your Sweet Spot Nutrition blog!

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©2024 Cheryl Strachan ~ Sweet Spot Nutrition