Eggs and Heart Health: A “hot topic” update for health professionals

Eggs and Heart Health: A “hot topic” update for health professionals

JEN HOUCHINS, PHD, RD

Cardiometabolic Health

Nutritious Dietary Patterns

In 2013, after decades of research, the American Heart Association and the American College of Cardiology published a new guideline on lifestyle management to reduce cardiovascular risk which concluded, “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-cholesterol1.”  This was followed by the removal of the 300 mg per day cholesterol restriction within the 2015 Dietary Guidelines for Americans and a greater focus on overall healthy dietary patterns2.  Today, eggs are recommended as part of heathy eating patterns by both the Dietary Guidelines for Americans and the American Heart Association3,4.  Yet, many people, including health professionals, remain concerned about dietary cholesterol5.

In a new article published in Hot Topics in Primary Care, a special supplement to the Journal of Family Practice, Dr. Maria Luz Fernandez highlights recent research around eggs and cardiovascular health and highlights the evolution of science around the impact of dietary cholesterol on blood cholesterol6.  While the science is clear that elevated LDL-cholesterol increases the risk for cardiovascular disease, the impact of dietary cholesterol and egg intake is not straightforward.  For most people, egg consumption does not impact blood cholesterol levels.  For those whose blood cholesterol responds to dietary cholesterol, generally there is an increase in both LDL-cholesterol and HDL-cholesterol, leaving the ratio between the two unchanged. The ratio of LDL to HDL is recognized as an important indicator of cardiovascular disease risk7.

Further, if there is a change in blood cholesterol secondary to egg consumption, the lipoproteins generated tend to be large, less atherogenic LDL particles that are “preferentially removed by [the] liver rather than by endothelial cells.”  The HDL particles generated secondary to egg consumption have improved functionality and a larger surface area which can transport a higher concentration of carotenoids6.  Overall, these exciting data illustrate that science has moved far beyond looking at the impact of isolated dietary cholesterol on total blood cholesterol, and instead, we are now evaluating the impact of foods (i.e.eggs) on health outcomes.

Most recent publications demonstrate egg consumption is not associated with cardiovascular disease risk8-10, and that is the basis for current guidelines that recommend eggs across the lifespan.  It is important to recognize the benefits of eggs within the diet and their role in optimizing health.  Dr. Fernandez lists several protective effects of eggs6:

  • Generation of HDL-cholesterol with improved function11,12
  • Highly bioavailable lutein and zeaxanthin, carotenoids known to accumulate in the eye and reduce risk of age-related macular degeneration13
  • An excellent source of choline, which is essential for brain health
  • High quality protein for maintenance of health

While the American Heart Association identifies a research gap for people who have abnormal blood lipids4, a growing body of evidence demonstrates eggs can be beneficial even for people at risk of cardiovascular disease11,14,15.  Of course, an overall healthy diet pattern is essential for maintenance of health3,4. For meal inspiration, check out our collection of heart-healthy recipes.

 

Photo by Sara Haas, RDN.

  1. Eckel, R.H., 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): p. S76-99.

  2. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 2015; 8:[Available from: http://health.gov/dietaryguidelines/2015/guidelines/].

  3. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

  4. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.

  5. Ipsos, American Egg Board Nutrition Messaging Project. 2021.

  6. Fernandez, M.L., The Role of Eggs in Healthy Diets. Supplement to the Journal of Family Practice, 2022. 71(6): p. S71-S75.

  7. Blesso, C.N. and M.L. Fernandez, Dietary Cholesterol, Serum Lipids, and Heart Disease: Are Eggs Working for or Against You? Nutrients, 2018. 10(4).

  8. Drouin-Chartier, J.P., et al., Egg consumption and risk of cardiovascular disease: three large prospective US cohort studies, systematic review, and updated meta-analysis. Bmj, 2020. 368: p. m513.

  9. Dehghan, M., et al., Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr, 2020.

  10. Shin, J.Y., et al., Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr, 2013. 98(1): p. 146-59.

  11. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.

  12. Andersen, C.J., et al., Egg consumption modulates HDL lipid composition and increases the cholesterol-accepting capacity of serum in metabolic syndrome. Lipids, 2013. 48(6): p. 557-67.

  13. Johnson, E.J., Role of lutein and zeaxanthin in visual and cognitive function throughout the lifespan. Nutr Rev, 2014. 72(9): p. 605-12.

  14. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. The Journal of Nutrition, 2021. 151(12): p. 3651-3660.

  15. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study.
    Nutrients, 2022.14(10).

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Eggs and Heart Health – A Review of the Latest Research and Reports

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Eggs and Heart Health:

A Review of the Latest Research and Reports

Mickey Rubin, PhD

Cardiometabolic Health

Nutrient-rich eggs are part of heart-healthy diet patterns, according to findings from leading researchers and health authorities

In 2015, the Dietary Guidelines Advisory Committee (DGAC) removed dietary cholesterol from the list of nutrients of public health concern1. Up until that point, there had historically been a limit of 300 milligrams per day for dietary cholesterol, even though eggs were listed as a nutrient-rich food and part of healthy dietary patterns in previous guidelines2.

In making this decision, the 2015 DGA Committee referenced, among other sources, a 2013 systematic review that examined the relationship between egg consumption and cardiovascular disease in almost 350,000 participants across 16 studies3. The review and meta-analysis found no relationship between egg intake and cardiovascular disease, ischemic heart disease, or stroke.

Since 2015, the science evaluating the relationship between dietary cholesterol, eggs, and cardiovascular health has continued to grow4,5, with several new research studies and authoritative reports building on our existing knowledge.

 

LATEST RESEARCH FINDINGS FROM OBSERVATIONAL COHORTS

There are often competing headlines in nutrition science, with one study showing one thing, and another study showing the opposite. This is often true with a nutrient like cholesterol – or a food like eggs – in which our knowledge has evolved considerably over the years. Rather than getting caught with nutrition science whiplash, it is important to not focus too much on any one study, but rather view the research in totality.

For example, one observational study of U.S. cohorts published early in 2019 found a small but statistically significant increase in cardiovascular risk with egg consumption6. However, another observational study published just a few weeks later and analyzing data from over 400,000 men and women in Europe for over an average of 12 years, found a small but statistically significant decrease in risk for ischemic heart disease with egg intake7. While these two examples appear similar in design and provide conflicting results, additional studies published later in the year had design aspects that provided unique insights.

 

PURE Cohort Results Reinforce Earlier Findings and Identify New Insights
A study published in the American Journal of Clinical Nutrition assessed the association of egg consumption with blood lipids, cardiovascular disease, and mortality in three large international cohorts8.  In one cohort, the Prospective Urban Rural Epidemiology (PURE) study, egg consumption was assessed in 146,011 individuals from 21 countries. The researchers also studied 31,544 patients with vascular disease in 2 multinational studies: ONTARGET and TRANSCEND, both of which were originally designed to test treatments for hypertension.

The findings from the PURE cohort found no link between egg consumption and cardiovascular disease outcomes. In fact, in the PURE cohort, researchers found that higher egg intake was associated with a lower riskof myocardial infarction, a finding that is consistent with other recent studies of cohorts outside the U.S.7. In the ONTARGET and TRANSCEND cohorts of individuals with vascular disease, the researchers also reported no link between egg consumption and cardiovascular events.

Thus, these findings from the PURE investigators reinforce previous research regarding egg consumption in otherwise healthy individuals, but took a big step forward in our understanding of this relationship in individuals with vascular disease.


Harvard School of Public Health Findings Reveal Decades of Strong Evidence
Yet another study was published in 2020 that was a follow-up to a landmark investigation first published in 1999. The original study, led by Hu and colleagues from the Harvard School of Public Health, reported no relationship between egg intake and coronary heart disease or stroke in women from the Nurses’ Health Study (NHS) cohort and men from the Health Professionals Follow-Up Study (HPFS) cohort9.  At that time the researchers concluded that an egg a day did not impact heart disease or stroke risk.

The current study, an updated analysis of the study published in 1999, includes up to 32 years of follow-up and extends the analysis to the younger cohort of Nurses’ Health Study II10. Thus, this latest analysis included 83,349 women from NHS; 90,214 women from NHS II; and 42,055 men from HPFS. Additionally, to compare these new findings to the extensive literature base on the topic of egg intake and cardiovascular risk, the researchers performed a systematic review and meta-analysis of 27 other published studies from the U.S., Europe, and Asia.

Results from the updated analysis from NHS, NHS II, HPFS, as well as the updated meta-analysis of global cohorts are consistent:

  • Egg consumption of one egg per day on average is not associated with cardiovascular disease risk overall
    • Results were similar for coronary heart disease and stroke
  • Egg consumption seems to be associated with a slightly lower cardiovascular disease risk among Asian cohorts

An important strength of this study is the use of repeated dietary assessments over the course of several decades in contrast to some observational cohorts which utilize only a single dietary measure at enrollment. According to the authors, it is desirable to have repeated dietary assessments over time to account for variation of dietary intake and other factors that contribute to atherosclerosis.

The studies from the PURE cohort and Harvard School of Public Health make significant contributions to the scientific literature on egg intake and cardiovascular health. These results are also consistent with the 2015 Dietary Guidelines recommendation that cholesterol is not a nutrient of public health concern.

 

NEW RECOMMENDATIONS FROM LEADING HEALTH AUTHORITIES

In the past year, we have also had multiple recommendations from leading health authorities that have assessed the totality of evidence for dietary cholesterol and cardiovascular disease, as well as the role of eggs in heart-healthy diet patterns across the lifespan. A common theme from these authoritative recommendations is that eggs can be a part of heart-healthy diet patterns, and in some cases nutrient dense eggs should be emphasized in diet patterns due to their unique nutrient package.

American Heart Association: Eggs Fit in Heart-Healthy Diet Patterns
In late 2019, the American Heart Association (AHA) Nutrition Committee published a science advisory on Dietary Cholesterol and Cardiovascular Risk11. According to the authors, “the elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease.” This review examined evidence from observational cohorts and randomized controlled trials and concluded that “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.” The science advisory recommends heart-healthy eating patterns such as the Mediterranean-style and DASH (Dietary Approaches to Stop Hypertension)–style diets. Specifically, regarding eggs, the advisory concluded:·

  • Healthy individuals can include up to a whole egg daily in heart-healthy dietary patterns.
  • For older healthy individuals, 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.
  • Vegetarians who do not consume meat-based cholesterol-containing foods may include more eggs in their diets within the context of moderation.

Australian Heart Foundation: No Evidence to Limit Egg Consumption
It wasn’t only the American Heart Association that clarified the role of eggs in a heart-healthy diet, but the Australian Heart Foundation (AHF) made similar recommendations with a new position statement on eggs and cardiovascular health12The AHF summary of evidence concluded there is no evidence to suggest any limit on egg consumption for normal, healthy individuals. The review does suggest a limit to fewer than 7 eggs per week for those with type 2 diabetes or cardiovascular disease that require LDL cholesterol- lowering interventions.

Both the AHA and AHF guidelines were clearly a step forward, building on the knowledge that dietary cholesterol is not a nutrient of concern in healthy individuals.

A growing body of evidence indicates that nutrient-rich eggs can also be enjoyed as part of healthy dietary patterns for those at risk for cardiovascular disease.

There appears to be agreement that eggs can be included as part of healthy dietary patterns for healthy people, however, the AHA continues to place caution on eating food higher in cholesterol for those with abnormal blood cholesterol, “…particularly those with diabetes mellitus or at risk for heart failure…11.” While this is an area of ongoing research, a growing body of evidence supports eggs as an important addition to the diet even for those at risk for cardiovascular disease.

Recent studies have explored how eating eggs can impact blood cholesterol and health outcomes in people who are at risk for heart disease:

  • Eating two eggs daily improved the function of HDL (good) cholesterol and did not impact total cholesterol, HDL cholesterol, or LDL cholesterol in postmenopausal women who were overweight13.
  • Adding three eggs per day to the diet of people who have metabolic syndrome did not increase LDL (bad) cholesterol.  “…whole eggs could be considered a healthful food choice for people with metabolic syndrome14.”
  • There was no link between egg consumption and cardiovascular events in 31,544 patients with vascular disease in two multinational studies (ONTARGET and TRANSCEND)8.
  • Consumption of cholesterol from eggs is linked to lower mortality among people with high blood pressure, while consumption of cholesterol from other foods is linked to higher mortality.  However, total cholesterol is not related to mortality among a sample of people with high blood pressure who live in China15.
  • Eating two eggs daily, as part of a plant-based diet, did not adversely affect markers of heart health in adults at risk for type 2 diabetes.  In fact, eating eggs improved self-reported intake of selenium and choline16.
  • Adding two eggs + spinach to breakfast, as part of a plant-based healthy diet, improved body weight and HDL-cholesterol in people with metabolic syndrome.  There were no differences observed in plasma LDL-cholesterol, triglycerides, glucose, insulin, or blood pressure between the intervention and control group17.

Overall, these findings support that including eggs, as part of healthy dietary patterns, may be beneficial even for people at risk of CVD11.  Healthy dietary patterns include a variety of vegetables, fruits (especially whole fruit), whole grains, dairy foods, protein foods (including lean meats, poultry, eggs, seafood, beans, peas, lentils, nuts, seeds, and soy products), and oils (including oils in foods)18.

 

SUMMARY

The science on dietary cholesterol and eggs continues to grow and demonstrates that eggs are an important part of healthy dietary patterns across the lifespan. Overall, these data support the value of eggs as a nutrient dense food within healthy dietary patterns. Eggs are a good or excellent source of eight essential nutrients including choline and high-quality protein, plus 252 mcg of the carotenoids lutein and zeaxanthin. The 70-calorie egg is an exceptionally nutrient-rich choice that can help improve dietary intake and optimize health.

See our recipes that fit into a heart-healthy diet or heart health toolkit for more information.

 
  1. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture,. 2015; Available from: https://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf.

  2. U.S. Department of health and Human Services and U.S. Department of Agriculture. 2010 Dietary Guidelines for Americans. 2010; Available from: https://www.dietaryguidelines.gov/about-dietary-guidelines/previous-editions/2010-dietary-guidelines.

  3. Shin, J.Y., et al., Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr, 2013. 98(1): p. 146-59.

  4. Fernandez, M.L. and A.G. Murillo, Is There a Correlation between Dietary and Blood Cholesterol? Evidence from Epidemiological Data and Clinical Interventions. Nutrients, 2022. 14(10).

  5. Fernandez, M.L., The Role of Eggs in Healthy Diets. Supplement to the Journal of Family Practice, 2022. 71(6): p. S71-S75.

  6. Zhong, V.W., et al., Associations of Dietary Cholesterol or Egg Consumption With Incident Cardiovascular Disease and Mortality. Jama, 2019. 321(11): p. 1081-1095.

  7. Key, T.J., et al., Consumption of Meat, Fish, Dairy Products, Eggs and Risk of Ischemic Heart Disease: A Prospective Study of 7198 Incident Cases Among 409,885 Participants in the Pan-European EPIC Cohort. Circulation, 2019.
  8. Dehghan, M., et al., Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr, 2020.

  9. Hu, F.B., et al., A prospective study of egg consumption and risk of cardiovascular disease in men and women. Jama, 1999. 281(15): p. 1387-94.

  10. Drouin-Chartier, J.P., et al., Egg consumption and risk of cardiovascular disease: three large prospective US cohort studies, systematic review, and updated meta-analysis. Bmj, 2020. 368: p. m513.

  11. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.

  12. National Heart Foundation of Australia. Summary of Evidence: Eggs & Cardiovascular Health. 2019; Available from: https://www.heartfoundation.org.au/getmedia/c1f95635-f0cb-4d9f-8221-f08463e61975/Nutrition_Evidence_papers_-_Summary_EGGS_FINAL.pdf.

  13. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.

  14. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome.Nutrients, 2020. 12(10).

  15. Wu, F., et al., Egg and Dietary Cholesterol Consumption and Mortality Among Hypertensive Patients: Results From a Population-Based Nationwide Study. Frontiers in Nutrition, 2021. 8(830).

  16. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. J Nutr, 2021.

  17. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study. Nutrients, 2022. 14(10).

  18. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

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Growing evidence supports eggs as a beneficial addition to healthy diets, even for people who are at higher risk for cardiovascular disease

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Growing evidence supports eggs as a beneficial addition to healthy diets, even for people who are at higher risk for cardiovascular disease

Jen Houchins, PhD, RD

Cardiometabolic Health

Nutritious Dietary Patterns

The American Heart Association (AHA) Science Advisory: Dietary Cholesterol and Cardiovascular Risk indicates that “healthy individuals can include up to a whole egg or equivalent daily” as part of a heart-healthy dietary pattern.  “For older normocholesterolemic patients, 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 pattern1.”  The AHA expresses caution, however, around the consumption of dietary cholesterol for patients with dyslipidemia, suggesting a gap in research for a subgroup of the population at risk for cardiovascular disease.  Of importance, a growing body of evidence indicates that eating eggs as part of a healthy diet does not negatively impact blood cholesterol levels and may benefit health, even in people at risk for cardiovascular disease2-5.

A recent randomized controlled crossover intervention recruited 30 men and women aged 35-70 with metabolic syndrome (MetS) to follow a plant-based healthy diet (excluding meat, poultry, fish, and seafood) for 13 weeks.  Participants were randomized to eat spinach with two eggs for breakfast or spinach with egg substitute and then crossed over to the opposite intervention.  The data showed lower body weight and higher HDL cholesterol after the egg intervention compared to the substitute.  No differences were observed in plasma LDL cholesterol, triglycerides, glucose, insulin, or blood pressure.  Blood levels of choline were higher after the egg intervention compared to the substitute; lutein increased during both interventions, and zeaxanthin increased only after the egg intervention.  The authors conclude, “This study demonstrates that consuming whole eggs in combination with a plant-based diet offers a healthier dietary pattern when compared to egg substitutes by favorably affecting plasma lipids and antioxidant carotenoids, as well as choline, thereby reducing disease risk3.”

Importantly, this is also consistent with other studies that have similarly found a beneficial impact of including eggs in the diet:

  • Thirty-five adults at risk for type 2 diabetes mellitus included two eggs daily in the context of a plant-based (vegan) diet for six weeks. Eating eggs improved diet quality without adversely impacting cardiometabolic risk factors when compared to egg exclusion4,6.
  • Twenty overweight, postmenopausal women added two whole eggs to the diet for four weeks. This study found improvement in HDL function (cholesterol efflux capacity) with no other changes in lipid biomarkers when compared to eating egg whites only5.

While more research is always needed, these recent intervention studies support the value of eggs as part of healthy dietary patterns for everyone, regardless of cardiovascular disease risk status.  For heart-healthy recipe ideas, please see our collection of recipes here.

  1. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.
  2. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome. Nutrients, 2020. 12(10).
  3. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study. Nutrients, 2022. 14(10).
  4. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Diet Quality in Adults at Risk for Type 2 Diabetes: A Randomized Single Blind Cross-over Controlled Trial. Journal of the American Nutrition Association, 2022: p. 1-10.
  5. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.
  6. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. The Journal of Nutrition, 2021. 151(12): p. 3651-3660.

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New Study Shows Value of Eggs as Part of Plant-Based Diets for People at Risk for Diabetes

M Plant Based Diabetes Study 1125x1125

New study shows value of eggs as part of plant-based diets for people at risk for diabetes

Mickey Rubin, Phd & Jen houchins, PHD

Nutritious Dietary Patterns

A new study demonstrates adding eggs to plant-based diets in people who are at risk of type 2 diabetes mellitus (T2DM) can improve nutrient intake without impacting cardiovascular risk.1  In this study, plant-based diets were based on the USDA healthy vegetarian meal plan, with modifications to exclude eggs and dairy products.    

This randomized, controlled trial included two dietary interventions: 1) six weeks of an exclusively plant-based diet with no animal-sourced foods or, 2) six weeks of an exclusively plant-based diet + 2 eggs per day. Participants were individuals at risk for T2DM.

Results showed that including two eggs per day in the otherwise exclusively plant-based diet had no impact on measures of cardiometabolic health, including endothelial function, lipid profile, blood pressure, insulin sensitivity, or body weight, despite an expected increase in dietary cholesterol intake. This is consistent with dietary recommendations that indicate eggs can be part of overall healthy diet patterns.2 Importantly, including eggs in a plant-based diet did significantly improve selenium and choline intakes, while there was a decrease in calcium and vitamin K intake.

Choline is important for the brain, nervous system and membranes that surround the body’s cells.3,4  Importantly, the plant-based diet + eggs significantly improved dietary choline intake, but at 410 mg/day, this still does not reach the Adequate Intake (AI) for women. These data show that careful planning is required to meet choline intake, and it might be especially difficult to meet the AI without eating eggs or taking a dietary supplement.5 Additionally, selenium has wide ranging functions and can support overall cardiovascular and immune health.6

This study is particularly strong in demonstrating the value of eggs as part of plant-based diets because other animal-sourced foods have been removed from the intervention. In this way, these new data were able to isolate the impact of eggs and showed no impact on indicators of cardiometabolic health.  However, animal-sourced foods can be important for meeting nutrient needs, as illustrated by inadequate calcium during this study potentially due to exclusion of dairy foods. 

Overall, this new study demonstrates that consuming two eggs daily as part of plant-based diets does not impact cardiometabolic risk factors in adults at risk for T2DM. The authors state, “Eggs could be used as an adjuvant to enhance plant-based diets that are typically recommended for those at risk of T2DM.1”  While larger trials are needed, these new data build on existing literature demonstrating the value of eggs as part of healthy diet patterns for people who have diabetes or are at risk for diabetes.7-11

  1. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. J Nutr, 2021.
  2. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.
  3. National Institutes of Health. Choline: Fact Sheet for Health Professionals. 2021; Available from: https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/.
  4. National Institutes of Health. Selenium: Fact Sheet for Health Professionals. 2021; Available from: https://ods.od.nih.gov/factsheets/Selenium-HealthProfessional/.
  5. Wallace, T.C. and V.L. Fulgoni, Usual Choline Intakes Are Associated with Egg and Protein Food Consumption in the United States. Nutrients, 2017. 9(8).
  6. Weeks, B.S., M.S. Hanna, and D. Cooperstein, Dietary selenium and selenoprotein function. Medical science monitor : international medical journal of experimental and clinical research, 2012. 18(8): p. RA127-RA132.
  7. Baghdasarian, S., et al., Dietary Cholesterol Intake Is Not Associated with Risk of Type 2 Diabetes in the Framingham Offspring Study. Nutrients, 2018. 10(6).
  8. Lin, H.P., et al., Dietary Cholesterol, Lipid Levels, and Cardiovascular Risk among Adults with Diabetes or Impaired Fasting Glucose in the Framingham Offspring Study. Nutrients, 2018. 10(6).
  9. Pourafshar, S., et al., Egg consumption may improve factors associated with glycemic control and insulin sensitivity in adults with pre- and type II diabetes. Food Funct, 2018. 9(8): p. 4469-4479.
  10. Fuller, N.R., et al., 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. Am J Clin Nutr, 2015. 101(4): p. 705-13.
  11. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome. Nutrients, 2020. 12(10).

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Eggs, Diabetes, and the Current Scientific Evidence

M Eggs Diabetes Current Evidence 1125x1125

Eggs, Diabetes, and the Current Scientific Evidence

Jen Houchins, PhD

Cardiometabolic Health

Nutritious Dietary Patterns

The Dietary Guidelines for Americans no longer provide a limit for dietary cholesterol for healthy people,  however,1 some questions remain about the cardiovascular impact in people with diabetes or impaired fasting glucose.  New evidence supports that eggs can be included in a healthy dietary pattern without adverse effects linked to diabetes, and in some cases, can be linked to beneficial outcomes.

Data from the Framingham Offspring Study were used to evaluate the effects of dietary cholesterol alone and in combination with markers of a healthy diet.  No statistically significant differences in glucose levels across different categories of dietary cholesterol intake were found over 20 years follow-up, and there was not an increased risk of type 2 diabetes mellitus or impaired fasting glucose associated with higher cholesterol intake.2  In a separate analysis, these prospective data showed “…no adverse association between dietary cholesterol and serum lipid levels or CVD risk amongst those with impaired fasting glucose or Type 2 diabetes.”3  Although eggs contribute cholesterol to the diet, confounding factors have been thought to impact the relationship between egg consumption and risk of diabetes.  A recent study found egg consumption is not independently associated with type 2 diabetes risk.4

A 12-week randomized controlled trial in individuals with pre- and type 2 diabetes found that adding one large egg to the daily diet for 12 weeks did not have a negative impact on total cholesterol levels.  In this trial, fasting blood glucose was significantly reduced by 4.4% at the final measurement for the egg group.5  Finally, participants with prediabetes or type 2 diabetes had no adverse changes in cardiometabolic markers when 12 eggs/week were incorporated into a 3-month weight loss diet.6

The American Diabetes Association7 and the American Heart Association8 encourage people with diabetes to consume a healthy dietary pattern that includes nutrient-rich foods.  A large egg provides eight essential vitamins and minerals, 6 grams of protein (12% DV), as well as 252 mcg of  lutein and zeaxanthin, two carotenoids important for eye health.  These new data continue to support that eggs are a beneficial part of healthy dietary patterns.

  1. U.S. Department of Health and Human Services and U.S. Department of Agriculture.  2015-2020 Dietary Guidelines for Americans.  8th Edition.  December 2015.  Available at http://health.gov/dietaryguidelines/2015/guidelines/.
  2. Baghdasarian S, Lin H-P, Pickering RT, et al. Dietary Cholesterol Intake Is Not Associated with Risk of Type 2 Diabetes in the Framingham Offspring Study.  Nutrients 2018.  doi: 10.3390/nu10060665.
  3. Lin H-P, Baghdasarian S, Singer MR, et al.  Dietary Cholesterol, Lipid Levels, and Cardiovascular Risk among Adults with Diabetes or Impaired Fasting Glucose in the Framingham Offspring Study.  Nutrients 2018.  doi: 10.3390/nu10060770.  Diabetologia.2009;52:1479–1495.
  4. Sabaté J, Burkholder-Cooley NM, Segovia-Siapco G et al.  Unscrambling the relations of egg and meat consumption with type 2 diabetes risk.  Am J Clin Nutr 2018;108:1-8.
  5. Pourafshar S, Akhavan NS, George KS, et al.  Egg consumption may improve factors associated with glycemic control and insulin sensitivity in adults with pre- and type II diabetes.  Royal Society of Chemistry 2018.
  6. Fuller NR, Sainsbury A, Caterson ID, et al. Effect of a high-egg diet on cardiometabolic risk factors in people with type 2 diabetes: the Diabetes and Egg (DIABEGG) Study – randomized weight-loss and follow-up phase.  Am J Clin Nutr 2018;107:1-11.
  7. American Diabetes Association.  Standards of Medical Care in Diabetes – 2017.  Diabetes Care. 2017;40 (supplement 1): S33-43.
  8. Fox CS, Golden SH, Anderson C, et al. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association.  Diabetes Care 2015;38:1777-1803.

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New Harvard Study: Eggs Not Associated with Cardiovascular Risk

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New Harvard Study: Eggs Not Associated with Cardiovascular Risk

Mickey Rubin, PhD

Cardiometabolic Health

Mounting evidence continues to support the role of eggs in a heart-healthy diet.

A new Harvard study updates findings first published over 20 years ago, and reinforces that eating eggs is not associated with cardiovascular disease.

The latest study is a follow-up to a landmark investigation first published in 1999. The original study, led by Hu and colleagues from the Harvard School of Public Health, reported no relationship between egg intake and coronary heart disease or stroke in women from the Nurses’ Health Study (NHS) cohort and men from the Health Professionals Follow-Up Study (HPFS) cohort. At that time the researchers concluded that an egg a day did not impact heart disease or stroke risk.

The current study is an updated analysis of the study published in 1999 and includes up to 24 additional years of follow-up and extends the analysis to the younger cohort of Nurses’ Health Study II. Thus, this latest analysis included 83,349 women from NHS; 90,214 women from NHS II; and 42,055 men from HPFS. Additionally, to compare these new findings to the extensive literature base on the topic of egg intake and cardiovascular risk, the researchers performed a systematic review and meta-analysis of 27 other published studies from the U.S., Europe, and Asia.

Results from the updated analysis from NHS, NHS II, HPFS, as well as the updated meta-analysis of global cohorts are consistent:

  • Egg consumption of one egg per day on average is not associated with cardiovascular disease risk overall
    • Results were similar for coronary heart disease and stroke
  • Egg consumption seems to be associated with a slightly lower cardiovascular disease risk among Asian cohorts

An important strength of this study is the use of repeated dietary assessments over the course of several decades in contrast to some observational cohorts which utilize only a single dietary measure at enrollment. According to the authors, it is desirable to have repeated dietary assessments over time to account for variation of dietary intake and other factors that contribute to atherosclerosis.

This latest study makes a significant contribution to the scientific literature on egg intake and cardiovascular health. These results are also consistent with the 2015 Dietary Guidelines recommendation that cholesterol is no longer a nutrient of concern for Americans and guidelines published in a science advisory from the American Heart Association in 2019.

Eggs are a good or excellent source of eight essential nutrients including choline and lutein, nutrients important for brain and memory development along with long-term health. Eggs can be an important part of all healthy eating plans.

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Are Eggs Only for Healthy People?

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Are Eggs Only for Healthy People?

Mickey Rubin, PhD

Cardiometabolic Health

In late 2019, the American Heart Association (AHA) Nutrition Committee published a science advisory in which the authors state that “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.”1 The science advisory recommends heart-healthy eating patterns such as the Mediterranean-style and DASH (Dietary Approaches to Stop Hypertension)–style diets. Specifically, regarding eggs, the advisory concluded:

  • Healthy individuals can include up to a whole egg daily in heart health dietary patterns.
  • For older healthy individuals, 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.
  • Vegetarians who do not consume meat-based cholesterol-containing foods may include more eggs in their diets within the context of moderation.

The AHA science advisory was clear that these recommendations were specific to otherwise healthy individuals, and that individuals “with dyslipidemia, particularly those with diabetes mellitus or at risk for heart failure, should be cautious in consuming foods rich in cholesterol.” Perhaps one reason for the cautious approach with this population is the lack of research on the association between egg intake and cardiovascular events in individuals with a history of cardiovascular disease, but a new study begins to shed some light on this very question.

The latest study, published in the American Journal of Clinical Nutrition assessed the association of egg consumption with blood lipids, cardiovascular disease, and mortality in 3 large international cohorts.2 In one cohort, the Prospective Urban Rural Epidemiology (PURE) study, egg consumption was assessed in 146,011 individuals from 21 countries. The researchers also studied 31,544 patients with vascular disease in 2 multinational studies: ONTARGET and TRANSCEND, both of which were originally designed to test treatments for hypertension.

The findings from the PURE cohort reinforced the 2019 AHA recommendations, finding no link between egg consumption and cardiovascular disease outcomes. In fact, in the PURE cohort, researchers found that higher egg intake was associated with a lower risk of myocardial infarction, a finding that is consistent with other recent studies of cohorts outside the U.S. 3,4 In the ONTARGET and TRANSCEND cohorts of individuals with vascular disease, the researchers also reported no link between egg consumption and cardiovascular events.

Thus, this latest paper both reinforces previous research regarding egg consumption in otherwise healthy individuals, but takes a big step forward in our understanding of this relationship in individuals with vascular disease.

  1. Carson JAS, Lichtenstein AH, Anderson CAM, Appel LJ, Kris-Etherton PM, Meyer KA, Petersen K, Polonsky T, Van Horn L; on behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Peripheral Vascular Disease; and Stroke Council. Dietary cholesterol and cardiovascular risk: a science advisory from the American Heart Association. Circulation. 2019;140: e-pub ahead of print.

  2. Dehghan et al., Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr, 2020. E-pub ahead of print.

  3. Key, T.J., et al., Consumption of Meat, Fish, Dairy Products, Eggs and Risk of Ischemic Heart Disease: A Prospective Study of 7198 Incident Cases Among 409,885 Participants in the Pan-European EPIC Cohort. Circulation, 2019. 18;139(25):2835-2845.

  4. Qin, et al. Associations of egg consumption with cardiovascular disease in a cohort study of 0.5 million Chinese adults. Heart 2018;104(21):1756–63

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When Consumed as Part of a Heart-Healthy Diet, Egg Consumption is Not of Concern, According to 2019 Guidelines

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When Consumed as Part of a Heart-Healthy Diet, Egg Consumption is Not of Concern, According to 2019 Guidelines

Mickey Rubin, PhD

Cardiometabolic Health

The 2015 Dietary Guidelines Advisory Committee (DGAC) made both history and headlines when dietary cholesterol was removed from the list of nutrients of public health concern.1 Up until this point, there had historically been a limit of 300 milligrams per day for dietary cholesterol, even though eggs were listed as a nutrient-rich food and part of healthy dietary patterns in previous guidelines.2

In making the decision to not bring a cholesterol limit forward for recommendations, the 2015 DGA committee referenced, among other sources, a 2013 systematic review that examined the relationship between egg consumption and cardiovascular disease in almost 350,000 participants across 16 studies.3 The review and meta-analysis found no relationship between egg intake and cardiovascular disease, ischemic heart disease, or stroke.

Since 2015, the science evaluating the relationship between dietary cholesterol, eggs, and cardiovascular health has continued to grow. One observational study of U.S. cohorts published early in 2019 found a small but statistically significant increase in cardiovascular risk with egg consumption. 4 However, another observational study analyzing data from over 400,000 men and women in Europe for over an average of 12 years, found a small but statistically significant decrease in risk for ischemic heart disease with egg intake.5

It is important to note that observational studies examining eggs are likely confounded by other dietary components, thus it is important to also examine results from randomized controlled trials.6 These trials consistently show only modest effects, if any, of egg intake on cardiovascular risk factors.6 In some cases, eggs show a significant benefit, as was the case with another 2019 study that reported improved function of high-density lipoproteins (HDL) after an intervention that included approximately 2 whole eggs per day.7

In 2019 two global health organizations re-assessed the science since the 2015 DGA and provided new recommendations around dietary cholesterol, eggs, and heart-healthy diet patterns that both build on previous findings and provide some helpful details.

First, the Australian Heart Foundation (AHF) made international headlines in 2019 with a new position statement on eggs and cardiovascular health.8 The AHF summary concluded there is no evidence to suggest any limit on egg consumption for normal, healthy individuals. The review does suggest a limit to fewer than 7 eggs per week for those with type 2 diabetes or cardiovascular disease that require LDL cholesterol-lowering interventions. However, these AHF guidelines were clearly a step forward in acknowledging the scientific evidence that shows eggs can be part of a heart-healthy eating pattern when consumed with fruits, vegetables, whole grains, nuts, legumes, and other lean proteins.

Additionally, in late 2019, the American Heart Association (AHA) Nutrition Committee published a science advisory on Dietary Cholesterol and Cardiovascular Risk.6 According to the authors, “the elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease.” This review examined evidence from observational cohorts and randomized controlled trials and concluded that “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.” The science advisory recommends that within the context of heart-healthy eating patterns, such as the Mediterranean-style and DASH (Dietary Approaches to Stop Hypertension)–style diets, replacing saturated fats is expected to produce greater reductions in LDL cholesterol concentrations than reducing dietary cholesterol alone. Specifically, the advisory concluded:

  • To achieve healthy dietary patterns, consumers are advised to eat a dietary pattern characterized by fruits, vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds, and vegetable oils, consistent with those recommended in the 2015 to 2020 DGA.
  • Healthy individuals can include up to a whole egg daily in heart-healthy dietary patterns.
  • For older healthy individuals, 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.
  • Vegetarians who do not consume meat-based cholesterol-containing foods may include more eggs in their diets within the context of moderation.

The release of these new guidelines in 2019 from leading health organizations demonstrates how the science on dietary cholesterol and eggs continues to reinforce the 2015 DGAC report’s recommendation to not limit dietary cholesterol to an arbitrary number. Eggs can be a part of a heart-healthy eating pattern. In fact, vegetarians (lacto-ovo) and older individuals have reason to incorporate even more eggs into their diets, according to the AHA. Indeed, eggs are more than just a source of dietary cholesterol. Eggs provide a good or excellent source of eight essential nutrients including choline, six grams of high-quality protein, 252 mcg of the carotenoids, lutein and zeaxanthin, making them the perfect complement to heart-healthy diets.

  1. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture,. 2015

  2. Dietary Guidelines Advisory Committee. Scientific Report of the 2010 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture,. 2010

  3. Shin, J.Y., et al., Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr, 2013. 98(1): p. 146-59.

  4. Zhong, V.W., et al., Associations of Dietary Cholesterol or Egg Consumption with Incident Cardiovascular Disease and Mortality. JAMA, 2019. 321(11): p. 1081-1095.

  5. Key, T.J., et al., Consumption of Meat, Fish, Dairy Products, Eggs and Risk of Ischemic Heart Disease: A Prospective Study of 7198 Incident Cases Among 409,885 Participants in the Pan-European EPIC Cohort. Circulation, 2019. 18;139(25):2835-2845.

  6. Carson JAS, Lichtenstein AH, Anderson CAM, Appel LJ, Kris-Etherton PM, Meyer KA, Petersen K, Polonsky T, Van Horn L; on behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Peripheral Vascular Disease; and Stroke Council. Dietary cholesterol and cardiovascular risk: a science advisory from the American Heart Association. Circulation. 2019;140: e-pub ahead of print.

  7. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019. 110(3):617-627.

  8. Australian Heart Foundation; Eggs and Cardiovascular Health: Summary of Evidence. 2019.

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