Dietary cholesterol not safe for heart says latest AHA advisory

The American Heart Association (AHA) has released a science advisory regarding dietary cholesterol and cardiovascular risk. The advisory, published in the Circulation journal, was developed after a review of human studies on the relationship of dietary cholesterol with blood lipids, lipoproteins, and cardiovascular disease risk to address questions about the relevance of dietary cholesterol guidance for heart health.

According to the document, "The elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease."

"Evidence from observational studies conducted in several countries generally does not indicate a significant association with cardiovascular disease risk. Although meta-analyses of intervention studies differ in their findings, most associate intakes of cholesterol that exceed current average levels with elevated total or low-density lipoprotein cholesterol concentrations," says the document.

The Dietary Guidelines for Americans stopped suggesting a cap on cholesterol intake in 2016. This was followed by periodic media blitzes on eggs as the poster child for decades of wrong advice as studies continued to volley back and forth.

The AHA and American College of Cardiology were silent on the limits of cholestrol intake in the 2013 lifestyle guidelines for cardiovascular risk reduction and 2018 cholesterol management guidelines. But the 2019 primary prevention guidelines give a general class IIa recommendation to a reduced-cholesterol diet to decrease atherosclerotic cardiovascular disease.

The new advisory suggested to limit cholestrol intake through AHA-recommended diet patterns (like the Mediterranean and DASH diets) -- that are inherently relatively low in cholesterol with typical levels similar to the current U.S. intake. But it did not specify how much cholesterol is safe to eat.

"Dietary guidance should focus on healthy dietary patterns (eg, Mediterranean-style and DASH [Dietary Approaches to Stop Hypertension]–style diets) that are inherently relatively low in cholesterol with typical levels similar to the current US intake. These patterns emphasize fruits, vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds, and liquid vegetable oils," said the document.

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Recommendations in the science advisory included:

• Choose liquid nontropical vegetable oils and plant-based protein sources to limit cholesterol intake


• Limit egg yolk intake to "current levels" -- up to the equivalent of a whole egg daily for healthy people or up to two for seniors with normal cholesterol levels


• Shrimp and other shellfish are okay when part of an overall healthy diet focused on other lean or plant-based protein sources


• Vegetarians can include more dairy and eggs in their diets within moderation


• People with high cholesterol, particularly those with diabetes mellitus or at risk for heart failure, should still be cautious about cholesterol-rich foods.

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"A recommendation that gives a specific dietary cholesterol target within the context of food-based advice is challenging for clinicians and consumers to implement; hence, guidance focused on dietary patterns is more likely to improve diet quality and to promote cardiovascular health," acknowledged the document.

Saturated fat and cholesterol often go together, and saturated fat (largely from animal fats) is the bigger concern due to links to cardiovascular risk, it added.