The headline of a prestigious health and nutrition publication reads, “Do we need to limit dietary cholesterol?” For decades, the answer was yes. We were told to limit our intake of cholesterol to 300 milligrams (mg) or less daily to decrease the risk of heart attack. Was it just a catchy headline?

Cholesterol is not the devil incarnate. We would die without it. Cholesterol is a part of all cell membranes, needed to make vitamin D, bile acids and some hormones. Some medical specialists have long cautioned that cholesterol is not the culprit in cardiovascular disease. One of the world’s most famous cardiac surgeons remarked that many of his heart attack patients had normal blood cholesterol levels. We know that if we consume too much cholesterol, the liver makes less of it. If we fail to eat enough, the liver makes more of it, operating just like thermostats that keep our homes the right temperature. We’ve also been told that there’s good cholesterol, high-density lipoproteins (HDL). It’s good because it travels in the body to the liver. Bad cholesterol, low density lipoproteins (LDL), builds up plaque in coronary arteries, triggering heart attack.

Dr. Alice H. Lichtenstein, an international authority on nutrition, says, “Dietary cholesterol is no longer a nutrient of public health concern.” She points to research showing that “dietary cholesterol at the levels currently consumed does not have a big influence on cholesterol levels in the blood.” But the headline is tricky. Lichtenstein and the American Heart Association haven’t given us carte blanche permission to disregard dietary cholesterol. Rather, they’re saying that other dietary factors can affect cholesterol levels and cardiovascular disease.

What’s the real culprit? Lichtenstein labels it dietary fat. She points out that most foods contributing to cholesterol levels are meat and full-fat dairy products which are high in saturated fats or consumed with foods high in saturated fats. For instance, cholesterol-rich eggs are not a problem. In fact, there has been a lot of research conducted on eggs and egg substitutes. Plenty of studies show that although eggs are a significant source of dietary cholesterol, they are not associated with an elevated risk of heart disease. Rather, the concern is that eggs are often eaten with saturated-fat-rich butter, bacon and sausage. This fat increases bad cholesterol buildup in coronary arteries.

Nutrition experts changing their guidance about dietary cholesterol is the result of good research, not whimsy. Recall the words of John Maynard Keynes, the famous economist, who was criticized for reversing his position on an important economic matter. He replied, “When circumstances change, I change my mind. What do you do?” The take home message is that we should establish and stick to healthy eating patterns that promote cardiovascular health. This means eating nutritious foods, such as whole grains, plenty of fruits and vegetables, and healthy proteins like fish, nuts, and seeds, all low in cholesterol. And cut down on foods high in saturated fats, such as meat and high-fat dairy products. Always limit sugar and salt. It’s good advice to stop labelling cholesterol as an arch enemy. But there are still unsolved questions about cholesterol. For instance, why is it that men living in Stockholm, Sweden, and Edinburgh, Scotland, share the same blood level of cholesterol. Yet the Scots have three times the death rate of coronary artery disease. Perhaps they are enjoying too much of their own scotch!

Winston Churchill, prime minister of England, wrote, “To almost every question there is an answer that is clear, concise, coherent and wrong.” What will experts say about cholesterol years from now. We wish we knew.

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– W. Gifford-Jones, MD