Does dietary cholesterol matter? A cardiologist’s perspective on diet and heart health

Most people know that too much cholesterol is bad for the heart. But that’s where understanding stops, and confusion about food sets in—the relationship between dietary cholesterol intake and heart health isn’t as simple as it may seem.

Logic may tell us we should eliminate dietary cholesterol so that it doesn’t increase our low-density lipoprotein (LDL), aka the “bad” cholesterol. But experts are backing away from recommending specific daily dietary cholesterol targets, and instead recommending a more heart-healthy lifestyle.

Several leading institutions that set dietary guidelines for Americans are taking this more nuanced approach. The Dietary Guidelines for Americans, published by the US Department of Health and Human Services, and the American Heart Association and American College of Cardiology recommendations now focus on a heart-healthy or Mediterranean-style diet. Rather than specific dietary cholesterol numbers, these recommendations emphasize nutritional balance and education to create and maintain a healthy heart.

So, does dietary cholesterol even matter? Why the sudden shift? Here’s what you need to know about cholesterol and your diet.

The science on specific dietary cholesterol targets

As a physician, I turn to science to answer questions like this and to help me make nutritional recommendations for my patients. In this case, that means evaluating various clinical trials and studies on blood cholesterol levels, cardiovascular risk and diet.

I’ve found inconsistent results when evaluating the independent relationship of dietary cholesterol and cardiovascular risk. With definitive results lacking, it is not possible for me to categorically tell all my patients to consume a certain limit of cholesterol per day based on their heart health. The data just isn’t there.

Refocusing on a heart-healthy diet and lifestyle

What I can confidently tell my patients—and you—is this: the cardiovascular benefits of diets that are rich in fruits and vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds and some liquid vegetable oils.

I frequently refer patients to the Mediterranean diet, which incorporates all these elements and is easy to follow. If you’re concerned about your heart health, I suggest the same to you.

If you’re still worried about dietary cholesterol, here’s something to keep in mind. Did you know, in the US, most cholesterol is consumed in the form of eggs (25%) with the rest coming from red meat and other sources? One egg contains between 186-219 mg of cholesterol, basically your cholesterol source for the entire day if you were to follow the previous dietary cholesterol targets. To add, for many Americans, their breakfast plate often includes 2-3 eggs along with bacon or sausage that is full of saturated fat.

It’s no surprise that making the switch from that plate above to a plate full of fruits, vegetables, whole grains, lean protein, nuts, seeds, and low-fat or fat-free dairy is a good move for your heart health and cholesterol.

Making sense of the cholesterol confusion

If a patient comes to me eating an “average” American diet and asks me to help sort out the cholesterol content of different foods to identify cut-off points, I offer several general observations:

• If you don’t have any known cardiovascular disease, then 300 mg of cholesterol per day may be appropriate.
• If you have either pre-diabetes, diabetes or cardiovascular disease, then less than 200 mg of cholesterol per day is most likely right.

The most important thing I ask patients to monitor is the saturated fats that comprise their diet. But again, focusing on a balanced, heart-healthy diet and lifestyle is a better strategy than trying to adhere to specific cholesterol targets.

Pay attention to your lipids

Knowing your LDL and HDL levels is important. Thankfully, every annual physical exam with your primary care physician includes cholesterol screening. The screening generally also includes a lipid panel, a blood test that is used to monitor and screen for cardiovascular disease.

The lipid panel includes three measures of your cholesterol level and a measure of your triglycerides. High triglycerides plus high cholesterol generally indicates a higher risk for heart attack, stroke and pancreatitis.

LDL cholesterol concentration is a stronger predictor of cardiovascular risk, more so than total cholesterol. There is no significant association between dietary cholesterol and either LDL (“bad”) cholesterol or HDL (“good”) cholesterol concentrations, so again, dietary cholesterol doesn’t seem to be a significant factor here.

In addition to knowing your cholesterol, make sure you pay attention to your lipid levels. Lipids and Lipoprotein a are the new numbers that physicians are paying close attention to as the focus shifts from specific daily cholesterol intake targets.

Bottom line: while there is no one-size-fits-all recommendation for dietary cholesterol, your diet still plays a big role in your heart health. If you’re worried about your heart, talk to your doctor about whether any dietary changes can help.

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