Effects of eggs on plasma lipoproteins in healthy populations†
Maria Luz Fernandez*
Received 19th July 2010, Accepted 6th September 2010
Extensive research has not clearly established a link between egg consumption and risk for coronary
heart disease. This lack of connection can be explained by two major reasons: First, eggs are a good
source of numerous nutrients including lutein and zeaxanthin, potent antioxidants, which may exert
a protective effect against lipoprotein oxidation. Second, it has been well established that dietary
cholesterol increases the concentrations of both circulating LDL and HDL cholesterol in those
individuals who experience a higher increase in plasma cholesterol following egg consumption
(hyper-responders). It is also important to note that 75% of the population experiences a mild increase
or no alterations in plasma cholesterol concentrations when challenged with high amounts of dietary
cholesterol (normal responders and hypo-responders). Egg intake has been shown to promote the
formation of large LDL and HDL subclasses in addition to shifting individuals from the LDL pattern
B to pattern A, which is less atherogenic. For these reasons, dietary recommendations aimed at
restricting egg consumption should be taken with caution and not include all individuals. We need to
acknowledge that diverse healthy populations experience no risk in developing coronary heart disease
by increasing their intake of cholesterol but in contrast, they may have multiple beneficial effects by the
inclusion of eggs in their regular diet.
Dietary guidelines aimed at reducing the risk for coronary heart
disease (CHD) recommend no more than 300 mg of dietary
cholesterol per day, a recommendation that bears on egg
consumption.1Although the American Heart Association has
modified its previous policy of eating only two eggs per week to
allowing the consumption of one yolk per day while restricting
the rest of the dietary cholesterol,2eggs continue to be regarded
with caution by the majority of the population. It is important to
note that guidelines from other countries such as Canada,3New
Zealand4and the European countries5do not support the idea of
recommending an upper limit for dietary cholesterol and their
policies are restricted to control the intake of saturated fat and
Extensive research does not support a relationship between
egg intake and CHD incidence.6,7A review of multiple case-
controlled studies measuring intake of cholesterol and disease
incidence, reported that a relationship could not be clearly
established between this dietary component and increase in CHD
risk. Furthermore, data gathered from the Lipid Research
Clinics Prevalence Follow-up Study,8which examined both men
and women (n ¼ 4546) found no significant relationships
between deaths attributable to CHD and dietary cholesterol
intake. Analyses of several studies,9–11including the elderly
population,12have also failed to find an association between the
incidence of CHD and egg consumption. More recent studies
also indicate the lack of correlation between egg intake and risk
for coronary heart disease, or stroke.13,14It is noteworthy to
mention that recent studies have also shown that diabetic indi-
viduals may not benefit from egg consumption14and that this
may increase their risk for all cause mortality.15However, the
intent of this review is to focus on healthy populations.
The lack of association between egg intake and CHD reported
in these epidemiological studies4–10,12–14could partly be explained
by the fluctuations in response to dietary cholesterol among all
individuals, which varies from no changes, slight increase or
higher increases in plasma cholesterol. However, it is important
to note that for those individuals (25% of the population) who
have a higher response to dietary cholesterol, there is a consistent
increase in both plasma LDL cholesterol (LDL-C) and HDL
cholesterol (HDL-C) concentrations with no alterations in the
LDL-C/HDL-C ratio, a major determinant of CHD risk. This
inter-individual variation in response to dietary cholesterol can
be attributed in part to differences in absorption rates,16the
body’s ability to down regulate cholesterol synthesis17or to
increase biliary excretion.18,19These variations could have
a significant genetic component, mediated in part by candidate
genes involved in lipoprotein metabolism. The presence of
a variant allele may influence the metabolism of cholesterol in
a way that deviates from classical understanding.
Gene polymorphisms and response to dietary
There are very limited studies addressing the effects of different
genotypes on the response to dietary cholesterol. One study
reported that individuals identified as homozygous for the
variant adenosine binding cassette transporter (ABC)G5 allele
(G/G) have greater plasma total cholesterol response to dietary
cholesterol intake.20In contrast to this report, we have found
Department of Nutritional Sciences, The University of Connecticut, 3624
Horsebarn Road Extension, Storrs, CT, 06269. E-mail: maria-luz.
firstname.lastname@example.org; Fax: +1 (860) 486-3674; Tel: +1 (860) 486-5547
† There was no financial support for this review; Maria Luz Fernandez
has no conflicts of interest in any of the information presented in this
156 | Food Funct., 2010, 1, 156–160 This journal is ª The Royal Society of Chemistry 2010
REVIEWwww.rsc.org/foodfunction | Food & Function
that individuals possessing the C/C genotype experienced
a greater increase in both LDL cholesterol (P < 0.05) and a trend
for lutein (P ¼ 0.08) after consuming 3 eggs for one month
compared to those individuals with the C/G (heterozygote) or
obtained from a small number of subjects, suggest that the
ABCG5 polymorphism may play a role in the plasma response to
dietary cholesterol and carotenoids.21
The effect of the A278-C promoter polymorphism on the
rate limiting enzyme of conversion of cholesterol to bile acids,
cholesterol 7a-hydroxylase (CYP7A1) was studied in 496 nor-
a mean intake of 742 mg per day of dietary cholesterol for
3–4 weeks. All subjects had a significant increase in HDL-C
following the dietary cholesterol challenge. The CYP7A1
polymorphism was found to have a significant effect on the
increases in HDL cholesterol.22However, the APOC3 and
APOC4 polymorphisms although associated to plasma lipid
parameters, have not been found to be related to the responses
to dietary cholesterol.23
Eggs and plasma cholesterol responses in different
The current dietary recommendations of no more than 300 mg of
dietary cholesterol per day pose a controversial issue for those
individuals who might derive health benefits by including eggs in
their diets while simultaneously, they are not increasing their risk
for CHD. An analysis of various cholesterol-feeding studies,
conducted over a 50 year period, has produced evidence that
a modest increase in total cholesterol of 0.056–0.061 mmol L?1
(95% CI 0.051–0.069 mmol L?1) can be predicted in response to
a 100 mg per day increase in dietary cholesterol.7If this moderate
increase is used as a reference, those who experience elevations in
TC higher than 0.061 mmol L?1(95% CI 0.064–0.14 mmol L?1)
would be classified as hyper-responders to dietary cholesterol.
The hypo-responders would be those who experience an increase
of <0.036 mmol L?1(95% CI 0.025–0.049 mmol L?1).7
Clinical trials conducted in children,24younger adults25,26and
the elderly27,28have clearly demonstrated that while hyper-
responders, which correspond to 25% of the population exhibit
increases in both LDL-C and HDL-C with the result of no
changes in the LDL-C/HDL-C ratio. These responses to dietary
cholesterol are independent of fat intake.24–28Recent studies in
my laboratory have also shown that during a weight loss inter-
vention, participants consuming 3 eggs per day had no increases
in LDL-C while a significant increase in HDL-C was observed.29
In contrast, subjects consuming egg substitutes hadno changes in
HDL-C following the intervention.29Further, when lipoprotein
particle size and subclasses were analyzed by nuclear magnetic
resonance (NMR), significant increases in both LDL and HDL
particles were observed as well as an increase in lecithin choles-
terol acyl transferase (LCAT) and cholesterol ester transfer
protein (CETP) activities.30These data suggest that dietary
cholesterol provided by eggs enhances reverse cholesterol trans-
port. Fig. 1 presents comparisons between subjects consuming
3 whole eggs or the equivalent amount of egg substitutes on
different parameters of HDL metabolism.30
Responses to dietary cholesterol in children
Eggs are a central food item in Mexico, which spans all socio-
economic classes. Because the northern part of Mexico is char-
acterized by dyslipidemias conducive to the metabolic syndrome
and CHD,31,32we evaluated the effects of consuming two whole
eggs per day compared to egg whites only, on plasma lipids and
the atherogenicity of the LDL particle in Mexican children aged
10–12 y.24We reported that the increases in plasma cholesterol
due to dietary cholesterol was present in 1/3 of the children and
was associated with increases in both LDL and HDL with no
alterations in the LDL-C/HDL-C ratio. However, when we
adjusted the body weight to 70 kg, the response to dietary
cholesterol was not present in any of the children. In addition,
egg consumption resulted in the formation of buoyant LDL
particles associated with pattern A. The significance of this
finding derives from the high prevalence of pattern B LDL
present in this population.33A predominance of LDL particles in
this pattern B sub-class has been shown to be associated with
a three-fold increase in CHD risk,34which may be due to the easy
entry of this particle into the arterial wall and its high suscepti-
bility to oxidation. Thus, egg consumption did not alter the
LDL-C/HDL-C ratio in these Mexican children and there was
a shift of LDL size to a less atherogenic particle.
The potential beneficial effects of eggs in children suffering
from Smith-Lemli-Opitz syndrome, which is a condition of
impaired cholesterol synthesis and birth defects related to mental
retardation, was evaluated.35Dietary cholesterol provided by
eggs increased both LDL-C and HDL-C in these subjects sug-
gesting that egg intake may be a potential therapeutic effect for
Responses to dietary cholesterol in young adults
Early reports from the Framingham study show a lack of asso-
ciation between dietary cholesterol and heart disease.36Other
studies conducted in the 1980s demonstrated that there were no
differences in plasma cholesterol and triglyceride concentrations
in young males consuming either 150 mg per 1000 kcal or 500 mg
per 1000 kcal of dietary cholesterol.37Similar results were
reported in young adult males when they ate 400 versus 1400 mg
of dietary cholesterol for 4 weeks.38
More recent studies conducted in 40 men aged 20–50 years
old25and in 51 pre-menopausal women, 50% of which were of
Hispanic origin26reported that men and women classified as
hypo-responders to dietary cholesterol (70% of the population),
had no changes in LDL or HDL-C after consuming 3 eggs per
day for 30 days. In contrast, those individuals who were classified
as hyper-responders did experience an increase in both LDL-C
and HDL-C. In addition, intake of eggs resulted in the produc-
tion of larger LDL particles with no increased susceptibility to
oxidation.39These results indicate that pre-menopausal women
and men with initial plasma cholesterol concentrations that place
them at a low risk for CHD do not experience the development of
an atherogenic lipoprotein profile following the consumption of
additional dietary cholesterol, regardless of their response clas-
A study carried out in 18 healthy lacto-vegetarian Indians
demonstrated an increase in blood cholesterol in subjects after
This journal is ª The Royal Society of Chemistry 2010 Food Funct., 2010, 1, 156–160 | 157
4 weeks of consuming one boiled egg per day.40However, the
mean LDL-C and HDL-C were not different after 8 weeks of egg
consumption although some hyper-responders still presented
elevations in total cholesterol after this period of time.40
Responses to dietary cholesterol in adults
By the year 2020, the number of people worldwide over the age of
60 is expected to reach one billion, which suggests that the inci-
dence of age-related disease will continue to increase. The
physiologic and economical changes, as well as the increased risk
of chronic disease, associated with advancing age places the
elderly at an interesting crossroads. Widely accepted risk factors
that have been identified for CHD may not be applicable to
elderly populations. Although elevated plasma cholesterol
concentrations have been shown to predict CHD risk in middle-
aged individuals, this parameter does not seem to be relevant for
the elderly demographic.41However, low-fat diets are commonly
prescribed to many elderly individuals in an attempt to lower
elevated cholesterol concentrations. Unfortunately, this can
result in an increase in dietary carbohydrates. This change in diet
composition can be detrimental, causing increases in triglycer-
ides, which are generally accompanied by low HDL-C levels.
Low HDL-C has been identified as the best indicator of CHD
risk in elderly individuals.27
Furthermore, the consumption of a diet high in simple sugars
can cause changes in lipoprotein metabolism that result in the
production of smaller, denser LDL particles.42In a study con-
ducted in post-menopausal women and men 60 y or older, similar
results were observed compared with the younger pop-
ulations,27,28no changes in the LDL-C/HDL-C in those indi-
viduals classified as hyper-responders and a shift to the larger,
more buoyant LDL particle. Furthermore, the increases in HDL
were associated with larger HDL particles and the number of
LDL particles and apo B concentrations did not change
following egg consumption confirming that egg intake resulted in
the formation of larger LDL.43In this study,27participants were
challenged by eating 3 eggs per day. We decided to investigate the
effects of consuming only one egg per day for 12 weeks in
a population of subjects aged 40 to 65 y.44Surprisingly, we
observed no increases in LDL cholesterol, while an increase in
HDL cholesterol was reported for all subjects43implying once
more the role of dietary cholesterol in promoting reverse
Similar results were reported in a study conducted in
110 elderly Japanese subjects who were fed additional 750 mg of
dietary cholesterol for 4 weeks.28Subjects experienced a signifi-
cant increase in HDL-C with no changes in LDL-C at the end of
the dietary treatment. However, there were significant increases
in the larger LDL particle as well as the less dense HDL
Different plasma lipid responses (total cholesterol, LDL-C,
HDL-C and LDL-C/HDL-C ratio) to egg consumption between
hyper and hypo-responders in various studies are summarized in
Responses to dietary cholesterol during insulin
To evaluate whether insulin resistance with or without obesity
influences the response to dietary cholesterol,45197 healthy
subjects participated in a randomized crossover design and
were fed 0, 2 and 4 eggs per 4 weeks with one month washout
between periods. The subjects were classified as insulin sensitive
(IS n ¼ 65), insulin resistant (IR n ¼ 75) and obese insulin-
resistant (OIR n ¼ 58). IR and IS subjects had a significant
increase in LDL-C of 7.8 and 3.3% only after consuming 4 eggs
while OIR subjects had no changes in LDL-C when consuming
0, 2 or 4 eggs. In contrast HDL-C was significantly increased
for all groups even after the consumption of 2 eggs. These
studies suggest that dietary management of OIR individuals
should focus more on restricting calories rather than dietary
baseline (black bar) and at week 12 (white bar). NS ¼ non significant; * P < 0.05; ** P < 0.001.
Comparisons in differentparametersof HDL metabolismin subjectswhoconsumed3eggs(EGG)or the equivalentof3 eggsubstitutes(SUB)at
158 | Food Funct., 2010, 1, 156–160 This journal is ª The Royal Society of Chemistry 2010
Eggs and carotenoids
Eggs also are major sources of lutein and zeaxanthin, two potent
antioxidants, which in addition to their protective effects against
macular degeneration and cataract formation,44,46they may also
play a role in decreasing the susceptibility of the LDL particle to
oxidation.47Epidemiological studies indicate an inverse rela-
tionship between intake of these carotenoids and both cataract
and age-related macular degeneration.47These carotenoids
circulate in plasma mostly carried in the HDL particle.
Plasma lutein and zeaxanthin have been shown to increase
significantly after egg supplementation in moderately hyper-
cholesterolemic men and women.48We have demonstrated that
in pre-menopausal women and younger men classified as hyper-
responders, there was a significant increase in lutein and
zeaxanthin compared to those individuals classified as hypo-
responders.49We also found that female hyper-responders had
significantly higher plasma lutein concentrations than male
hyper-responders following egg consumption despite the finding
that the dietary intake of lutein + zeaxanthin was similar between
the groups. One explanation for why female hyper-responders
had higher plasma lutein levels than men could be found in
lipoprotein analysis. Female hyper-responders had significantly
higher plasma HDL-C levels (76.0 ? 14.0 mg dL?1) than males
(48.7 ? 7.8 mg dL?1) therefore they experienced the same
carotenoid response possibly due to the fact that HDL is the
major lipoprotein transporting lutein in plasma. When LDL and
HDL subclasses were evaluated in an elderly population,
a significant correlation was found between large HDL and
lutein and zeaxanthin content following intake of 3 eggs for
This review of epidemiological data and results from recent
clinical trials related to egg consumption present reliable
evidence that in multiple populations including children, young
adults and the elderly, there are consistent results on both plasma
cholesterol distribution in lipoprotein subclasses and on the
formation of larger LDL and HDL. The maintenance of the
LDL-C/HDL-C ratio, the presence of more buoyant LDL
without increases in the susceptibility of LDL to oxidation, the
increased concentration of large HDL and the higher plasma
lutein and zeaxanthin seen in these individuals clearly suggest
that healthy populations benefit from egg consumption.
The sole author has the responsibility for all the parts of the
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LDL-CHDL-C LDL-C/HDL-C Ratio
2 eggs/d for 4 weeks
3 eggs/d for 4 weeks
3 eggs/d 12 weeks, weight- loss
1 egg/d for 12 weeks
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