Neal D. Barnard and Angela Eakin: Yes, cholesterol matters

In February 2015, the US Dietary Guidelines Advisory Committee reported that dietary cholesterol was no longer a “nutrient of concern.” According to the Committee’s report, “available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol….” In the ensuing media tempest, some food writers saw a green light for indulgence in eggs, sausage, and other high cholesterol foods. Others went further, exonerating high blood cholesterol levels, and patients began asking their physicians whether cholesterol matters. 

It does, and here is why:

Despite cholesterol’s essential functions—it is a part of cell membranes and a raw material for bile acids and certain hormones, such as testosterone and estrogens—plasma cholesterol concentrations are strongly associated with cardiovascular disease risk.

Yes, plasma cholesterol levels are driven upward by saturated fat intake—on average, a one percent increase in energy from saturated fat increases LDL cholesterol concentration about two percent. But they are also influenced by dietary cholesterol. Beginning in the 1950s, Ancel Keys, Mark Hegsted, and other researchers found that dietary cholesterol boosts blood cholesterol in a roughly linear relationship within normal intake levels, with a diminishing effect at the higher intakes used in some research studies.

Since then, the relationship between dietary cholesterol and circulating cholesterol has been repeatedly reaffirmed. A 1988 National Institutes of Health conference arrived at the same conclusion as Hegsted, and a meta-analysis published in 1992 and two more published in 1997 agreed: cholesterol you eat raises cholesterol levels in your blood.

In 2002, the Institute of Medicine reviewed the evidence, concluding that cholesterol consumed in foods clearly raises blood cholesterol levels. The Food and Drug Administration agreed as it weighed the question of whether cholesterol content should be reported on food labels in the Federal Register of 3 March 2014.

So how did the Dietary Guidelines Advisory Committee arrive at its not-guilty verdict? The committee wrote that its finding of no relationship between dietary cholesterol and serum cholesterol was “consistent with the conclusions of the AHA/ACC report,” citing a 2014 report by the American Heart Association and American College of Cardiology.

However, the AHA/ACC report did not actually reach this conclusion. It summarized evidence published after 1998—that is, after the most recent meta-analyses were published—and called for more research, but did not suggest that there was no relationship between dietary cholesterol and serum cholesterol. Of course, the issue may be largely theoretical, because most cholesterol-containing foods also contain saturated fat—and both raise LDL cholesterol concentrations.

In dismissing the risks of dietary cholesterol, the committee may have inadvertently further confused an already bewildered public, many of whom do not differentiate dietary cholesterol from blood cholesterol, or cholesterol from saturated fat.

What is to be done? The 2010 Dietary Guidelines for Americans recommended that cholesterol intake be limited to 300 mg/d, or 200 mg/d for persons with or at high risk for cardiovascular disease or type 2 diabetes. Given the evidence, it would be prudent not to disregard those limits, but rather to strengthen them. The optimal cholesterol intake may well be zero.

When it comes to cholesterol, caution is advisable.

Competing interests: The authors have no conflicts of interest to declare.

neal_barnardNeal D Barnard is adjunct associate professor of Medicine at George Washington University School of Medicine and Health Sciences. 

 

 

angela_eakinAngela Eakin, Valley Family Medicine, Valley Medical Center, Renton.

  • DanielFaster

    Great summary, really appreciate this.

  • Johan Wallström

    The industry replaced the fat with sugar, which was not a good idea. The USDA knew that but they fell for the pressure from the lobbyists. A lot of other things happened at the same time too. More food overall, more fast food, more processed food, more meat, more cheese, more candy, more sodas, less everyday motion. You can’t easily single out one of the factors

  • Johan Wallström

    You wanna have some fat in your diet… It’s an important nutrient for us. But skip the saturated

  • Ashwani Garg MD

    There are some who are genetically predisposed to higher cholesterol, but for most people a “vegan” diet is not necessarily the way to lower cholesterol. However, a truly low fat, whole food, plant based, no oil diet is the best way. In this eating plan, you eat maximum amounts of fruits, vegetables, whole grains, and legumes, with only a minimum amount of nuts and seeds, and minimum amounts of higher fat foods such as avocado, olives, and coconuts, with absolutely no oil. Also maximize greens into the eating plan; generally 1/2 of veggies are uncooked. A vegan diet can mean so many different things, but a whole food, plant based diet is the way to go for those with high cholesterol. This diet will decrease the fat content of foods to less than 10%, with almost no saturated fat, and the fiber content increases to about 40-70 grams of fiber / day. Whole foods has videos on its website called “healthy cooking 101” that includes a method of “steam frying” without oil! Instead use water, veggie broth, etc.

  • Ashwani Garg MD

    Dr. Barnard has an agenda and that is maximizing the public’s health and minimizing the suffering of animals. I don’t see a conflict here. As a psychiatrist, Dr. Barnard has unique insights, and formed his nonprofit PCRM a long time ago. He has a great team including registered dieticians and other physicians, and offers training in “food for life” to spread the message of health and wellness. Dr. Barnard’s research has shown that a low fat, plant based diet can improve diabetes as well or better than many diabetic drugs, and also that a workplace wellness program can improve health and promote weight loss by focusing on a plant-based eating plan. The research was peer reviewed and published in medical journals. I am not aware of any prospective peer-reviewed medical research that shows that a diet high in meat and cheese is superior to a diet that is exclusively whole food, plant based. As a physician, Dr. Neal Barnard understands medical research and has a team to support him. He makes available free continuing medical education to all who have an interest, and a book on nutrition free to all medical students, this book is heavily referenced.

  • Ashwani Garg MD

    The Academy of Nutrition and Dietetics actually has an official statement on vegetarian diets as being therapeutic to health: “Well-balanced vegetarian diets reduce risks of many chronic diseases, and may treat, improve or reverse obesity, heart disease, high blood pressure, type 2 diabetes, and some digestive problems. They also offer promise in treatment for cancer and kidney disease.” They have formed an official division that is focused on vegetarian diets: vegetariannutrition.net and from what I can see it’s focused on vegan eating (vegetarian without milk, egg, cheese)

  • fredhahn

    Here is what the author of this article, Dr. Barnard and other docs here who have commented such as Dr. Greger, Dr. McDougall don’t understand: correlation does not imply causation.

    From the article:

    “Despite cholesterol’s essential functions—it is a part of cell membranes and a raw material for bile acids and certain hormones, such as testosterone and estrogens—plasma cholesterol concentrations are strongly associated with cardiovascular disease risk.”

    Associated with not caused by. So now what?

    Associations, if strong, call for randomized controlled trials to see if the associations are causal. Lo and behold, when you look at the randomized controlled trials that have been done, high fat, low carbohydrate/sugar diets always show improvements in the subjects blood panels.

    Low fat diets often show more detriment to the subjects blood panel than a high fat diet. But if you don’t read the studies, you don’t know that. I challenge Drs. Barnard, Greger, McDougall, Ornish, Esselstyn, to produce a single RCT indicating that a high fat, low carbohydrate diet is detrimental to health when compared to a low fat, high carb diet.

    They won’t be able too.

    Remember folks, doctors have and push their personal agendas just like anyone else. The doctors mentioned above, as well as many others, ignore the RCTs in order to push their pro vegan/vegetarian agendas. This perpetuates and spreads false and misleading information to the gen pop.

    References:

    http://www.nmsociety.org/low-carb-research.html

  • Debbie Casey

    Dr Ashwani, thank you for your response….

  • fredhahn

    No fat or cholesterol in the diet is a very bad idea. No sugar in the diet and minimal starch and carbohydrates is the way to improved health.

  • fredhahn

    There is nothing wrong with a cholesterol level of 225. Blaming cholesterol for CAD/CHD is like blaming firemen for the fires they put out. Ditch the statins and reduce your sugar/carb intake. Your triglycerides will plummet, your HDL will rise, you’ll get leaner and feel much healthier.

  • Josh Garrett

    And it was specifically animal fat that evolved our brains? How do you know it wasn’t fat in general? How do you know it wasn’t due to an overall increase in calories? Why is it limited to animal fat as if animal flesh is some kind of miracle tissue? 1 gram of fat contains 9 kCal regardless of the source. There are plently of sources of fat in grocery stores besides animal fat. Paleolithic humans didn’t have the luxury of walking to Whole Foods Market to obtain calories.

  • Jeff Jensen

    Fred Hahn

    “Here is what the author of this article, Dr. Barnard and
    other docs here who have commented such as Dr. Greger, Dr. McDougall don’t
    understand: correlation does not imply causation.”

    Be serious. They understand correlation does not imply
    causation better than you and the tobacco industry.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677007/

    Dr. Barnard has undertaken randomized controlled trials. Have you?

    “From the article:

    ‘Despite cholesterol’s essential functions—it is a
    part of cell membranes and a raw material for bile acids and certain hormones,
    such as testosterone and estrogens—plasma cholesterol concentrations are
    strongly associated with cardiovascular disease risk.’

    Associated with not caused by. So now what?

    Associations, if strong, call for randomized controlled
    trials to see if the associations are causal.”

    You are correct. Correlation does not imply causation,
    but the opposite is true. Causation entails correlation. So if the correlations
    are strong enough, you can hypothesize what may be the cause. Randomized
    controlled trials on humans is the best way to go. Again, you are correct.

    http://www.jeffnovick.com/RD/Articles/Entries/2015/2/11_Dietary_Guidelines%2C_Cholesterol%2C_Something_Old_%26_Something_New.html

    Odd, how I don’t see these being low carbohydrate/sugar
    diets being used here, as you suggest below are the best way to improve blood panels.

    “Lo and behold, when you look at the randomized
    controlled trials that have been done, high fat, low carbohydrate/sugar diets
    always show improvements in the subjects blood panels.”

    Perhaps the first study
    that Novick cites is not low in carbohydrate/sugar, as cholesterol was the only
    variable. But the previously mentioned study by Barnard was low in sugar and
    produced a significantly greater drop in total cholesterol and LDL cholesterol
    than the standard ADA diet, itself not unsuccessful in showing improved blood
    panels. Neither diet was low carbohydrate. And while low carbohydrate entails
    low sugar, low sugar does not imply low carbohydrate. Yet you make it sound
    like complex and simple carbohydrates should be grouped together. McDougall, Ornish, Barnard,
    Pritikin Campbell and Campbell all promote diets high in fiber and complex
    carbohydrate, low in sugar. The results have been demonstrated repeatedly.

    You claim that “high fat, low carbohydrate/sugar diets
    always show improvements in the subjects blood panels” and suggest that these
    were demonstrated in “randomized controlled trials.” For example?

  • Jeff Jensen

    Lesley, argumentum ad hominem.
    He’s not a nutritionist, but neither are cardiologists, such as Ornish or
    Atkins, nor are internists, family practitioners, etc. But, like all
    psychiatrists, he is a medical doctor first and foremost in training, as
    are cardiologists, internists, and family practitioners. However, most doctors
    have no training in nutrition. Whether specialists or general practitioners, if
    they wasn’t to understand nutrition, they must do research to expand into new
    areas. Barnard has done research with Dr. David JA Jenkins in the article in my
    reply to Fred Hahn. Jenkins has both an MD and a PhD in nutrition. You want to
    read nutrition on this topic–Jenkins, Dr. T. Colin Campbell, Dr. James J.
    Kenney, and Jeff Novick. Oh, by the way. Are you a nutritionist?

  • Josh Garrett

    And it was specifically animal fat that evolved our brains? How do you know it wasn’t fat in general? How do you know it wasn’t due to an overall increase in calories? Why is it limited to animal fat as if animal flesh is some kind of miracle tissue? 1 gram of fat contains 9 kCal regardless of the source. There are plently of sources of fat in grocery stores besides animal fat. Paleolithic humans didn’t have the luxury of walking to Whole Foods Market to obtain calories.

  • Jeff Jensen

    You make claims without supporting evidence. Never heard of a no fat diet, by the way. None of the above whom you dispute advocate such a diet, so this is a straw man argument.

  • Ashkar Lessirey

    I really wish someone teach these lessons to those masai tribe & french.. They are not having enough heart attacks gorging on those deadly saturated fat & cholesterol !!

    May be they dont know science..

  • Iva Lottasay
  • Iva Lottasay
  • Thank you for an honest and encouraging response, Dr. Garg. Dr. Barnard and colleagues have truly done and excellent job at promoting healthful plant-based eating to the public, for which I am very thankful.

  • Kat Kamp

    I went from Paleo to vegetarian, my A1C went down as well as blood pressure and cholesterol (HDL went from 25 to 65, LDL went from 130 to 96). Higher cholesterol has been associated with heart attacks. My mother just had a bypass and hers was 325 so I’d rather not go there.

  • High cholesterol is predictive of longevity both on women and on elderly people. Take a look at Figure 2 of the HUNT 2 study (via Petro).

    Take into account that both low fat proposers like Dr. Barnard and low carb ones as Ivor Cummins minimize omega-6 fat exposure. Perhaps it explains the old Soviet Union paradox.

    We having a gallbladder points toward us being carivorous/omnivorous. Too low fat intake perhaps may give rise to gallstones and a high fat diet cures it.

  • So let me get this straight:

    We shouldn’t worry about eating foods with cholesterol but we should consider taking statins to get rid of the cholesterol in our blood?

    What a country!

  • Jim Felder

    True, but there is no need to add refined fats to our diet. All whole plant food contain fat to the degree that we need them in our diet. Shoot, even broccoli gets 10% of its calories from fat. It is literally impossible to eat a completely fat free diet without eating completely refined foods with all the fat artificially removed. A diet made up of whole food contains all the fat needed.

  • Jim Felder

    You can eat absolute crap and still eat a vegan diet. A strict “vegan” lunch can consist of a veggie burger fried in oil with vegan cheese on a white bread bun, french fries, and Oreo cookies, all washed down with a Coke. So the more important question is whether you ate a whole-food plant-based diet with no added oil. If you didn’t, then you might want to consider trying it again, but this time really try. The results might shock you.

  • Johan Wallström

    The argument being that dietary cholesterol doesn’t raise serum cholesterol. Which happens to be false

  • Johan Wallström

    But they have low serum cholesterol, which is further evidence of the diet-heart hypothesis.

    Did you look into the parasites/cholesterol connection? Basically the argument is that all people living in unhygenic environments, like our ancestors and today’s hunter/gatherers, will have a pathogen load. Parasites and infections. These consume cholesterol in our blood, which make them work like natural statins. Also, the body lower the production of cholesterol to deprive the parasites. In the western world, we’re gonna have to keep our cholesterol down by eating a diet low in saturated fat instead.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1142336/

  • Megan Rush Jones

    The source of vitamin B12 in the animals that humans consume is a bacteria present in the soil that is inadvertently also consumed when the animals eat plant foods. Because of our modern-day cleanliness standards we do not get any of the bacteria along with our plant foods. This does not mean that we need to eat animals to get B12. I’ll take my daily supplement and enjoy my non-existent chance of both CV and type 2 diabetes, and reduced chance of many cancers thanks to my varied, whole-food, plant-based diet. Also, unlike 2/3 of the American population, I’m not fat. Also, many animals farmed for food are feed B12 fortified foods, so if you’re eating meat, you’re probably also inadvertently supplementing this vitamin through the animals you eat.

  • tommy bone

    I’m late to the party, but those reports of Masai and Inuit supposedly being ‘healthy’ due to their supposedly low carb diet, often cited by the keto/paleo/low carb crowd, wasn’t based on solid scientific study. In fact, when autopsies were later performed on those Masai, they were found to have significant signs of arteriosclerosis.