The dietary cholesterol intake & it's impact : Analysing the American Heart Association guidelines
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Previously, dietary guidelines put a limit to dietary cholesterol, less than 300 mg/day . Patients frequently tell me that they eat eggs, but only ‘white part’, and that will keep them ‘safe’ from heart disease. Dietary cholesterol, thus, was demonised for several years by scientists and by general population in India and other countries. Most cholesterol from diets come from the following items; eggs, sausages, beacon, shellfish, butter, organ meats, and in India, whole fat milk and cheese, saturated fat-laden oils, Ghee and coconut oil. Indians diets, while mostly vegetarian, contain many of the items listed above.
This Editorial, in a simpler and explanatory form, is based on recent Science Advisory from American Heart Association, “Dietary Cholesterol and Cardiovascular Risk” , and highlights its implications for Asian Indians, south Asians and populations from other developing countries.
Guidelines for dietary cholesterol (less than 300 mg/day) were changed in 2013 . At this time, American Heart Association/ American College of Cardiology (AHA/ACC) Advisory put no limits for dietary cholesterol. Further, 2015 Dietary Guidelines Advisory Committee (USA)  stated that there was no appreciable relationship between dietary cholesterol intake and serum cholesterol levels. Interestingly, in these guidelines, a more definitive statement was; “Cholesterol was not a nutrient of concern for overconsumption” [2,4].
However, two recent USA-based guidelines suggested caution and advised restrictions in dietary cholesterol intake especially in patients with hypercholesterolemia [5,6]. Dietary cholesterol was again believed to contribute to increase in blood cholesterol, but it was also acknowledged that individual responses to dietary cholesterol may vary (less or more response) . While such updates and research data from India and other developing countries are not available, a dietary recommendation in 2011 for Asian Indians (India) stated that dietary cholesterol should be taken in limited amount (200e300 mg/day) for healthy living and prevention of metabolic disorders .
Intervention studies for dietary cholesterol and cardiovascular disease (CVD) risk are plagued by doubts about correct measurements of cholesterol, saturated fats, monounsaturated fatty acids (MUFA), and polyunsaturated fatty acids (PUFA); thus, introducing major confounding. A recent meta-regression analysis which used Bayesian approach, included 55 studies (2652 subjects) and analysed data using three models. Interestingly, all three statistical models show increase in LDL cholesterol with increase in dietary cholesterol. Specifically, mean predicted changes in LDL cholesterol for an increase of 100 mg dietary cholesterol/d for the linear, nonlinear, and Hill models were 1.90, 4.46, and 4.58 mg/dL, respectively. Feeding studies also showed similar conclusions. Despite these major analyses, firm conclusions cannot be drawn because of presence of multiple confounding factors and low power of studies for statistical analysis.
Eggs remain major point of discussion while considering cholesterol in diets. Eggs contribute to about 25% of dietary cholesterol intake in USA. Further, in USA, meat, eggs, grain products, and milk are four major sources of dietary cholesterol. Such data, including secular trends for dietary cholesterol, are not available in India and most other developing countries. Demands for eggs in India fluctuates, being more in winters than summers. The annual per capita egg consumption also varies according to habitat, more in major cities, (Mumbai, Calcutta, Delhi and Chennai), about 100 or even as high as 150 or 200, while it is as low as 15 eggs in rural areas as reported 12 years back, but some recent data show that consumption has increased.
From these data it appears that in India, and elsewhere, egg consumption is associated with socioeconomic stratum and urban-rural habitat, which may confound its association with cardiovascular risk. Global data of association of egg consumption and CVD risk are conflicting. A recent study shows that among US adults higher consumption of dietary cholesterol/eggs was significantly associated with higher risk of incident CVD and all-cause mortality. A longitudinal study from Korea also showed higher risk of egg consumption in patients with T2DM. Relationship of egg consumption and heart failure is more definitive than for CVD risk.
Before discussing regarding diet and cholesterol consumption in Asian Indian populations, it is important to know that average level of serum cholesterol is rising in Indian population. About 1/4th of the population has high total cholesterol (>200 mg/dL) and ½ have high LDL cholesterol (>100 mg/dL) levels. Interestingly, highest average cholesterol levels were found in southern states (except one), and mostly linked to development (cholesterol levels in mg/dl: Kerala,197; Goa,196; Himachal,185; Odisha,176 and Karnataka, 175). It is important to note that strong association between acute myocardial infarction and total cholesterol levels was seen in south Asians in INTERHEART Study.
Furthermore, awareness, treatment and control of serum cholesterol levels are poor in India. This is especially important in context of rising prevalence of coronary heart disease. This sets an appropriate context for watching dietary cholesterol carefully to prevent rise in cholesterol levels in Asian Indians.
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In developing countries, diets are progressively getting imbalanced, with higher intake of calorie- and saturated fat-dense ‘fast foods’ [18e21]. As emphasized in the advisory, cholesterol is high in most foods with high saturated fats. As emphasises in AHA Advisory, it is important to understand that when ‘healthier’ diets are incorporated in daily routine, amount of saturated fat and dietary cholesterol decrease . If we increase nuts, fibre, green leafy vegetables, fruits, low fat dairy, and fish along with complex carbs, amount of MUFAs and PUFAs will increase in diet, and amount of cholesterol and saturated fats will decrease. Additional important measure would be to decrease saturated fats as used in India (butter, dairy ghee, coconut oil, palm oil), although effects of these on blood levels of HDL cholesterol and LDL may vary.
The AHA Advisory mentions that one egg per day is not an unhealthy option, but with some cautions . First, patients with diabetes, dyslipidemia and heart failure should restrict dietary cholesterol, hence eggs. There are following two implications of egg consumption for India. First, those who are vegetarian (low intake of high quality proteins) or need more protein for sarcopenia (also prevalent in Asian Indians/south Asians) higher number of eggs could be allowed. Specifically, eggs are easily digestible source of high-quality protein, particularly leucine, which is important for skeletal muscle synthesis, and also contain other nutrients like vitamin D and omega-3 polyunsaturated fatty acids. These could be especially beneficial to elderly people with sarcopenia and low nutrient intake. Second, early life introduction of eggs has potential to improve growth and stunting in young children, which is widely prevalent in India.
Overall, data generally suggest that increased dietary cholesterol influences blood cholesterol and should be particularly curbed in those with diabetes, heart failure and hypercholesterolemia. Otherwise, an average intake of one egg per day is a reasonable diet choice, and provides high quality protein. Healthy diet choices with plenty of MUFAs and PUFAs, and low saturated fats will help in further decreasing intake of dietary cholesterol. These advice, in one way or the other, should be applied to all countries, particularly in those in nutrition transition.
Finally, strong nutrition governance, guidelines and more research are needed in developing countries.
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Dr. Anoop Misra
The author is a Padma Shree and Dr BC Roy Awardee , Chairman of Fortis - CDOC Hospital for Diabetes and Allied Science , New Delhi.
National Diabetes ,Obesity and Cholesterol Foundation (N-DOC), New
Diabetes Foundation (India), New Delhi, India
Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases
and Endocrinology, New Delhi, India.
Published unedited by author's permission.
E-mail address: firstname.lastname@example.org.
1871-4021/© 2020 Diabetes India. First Published by Elsevier Ltd. All rights reserved.
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