Egg and cholesterol consumption and mortality from cardiovascular and different causes in the United States: A population-based cohort study

Abstract

Background: Whether consumption of egg and cholesterol is detrimental to cardiovascular health and longevity is highly debated. Data from large-scale cohort studies are scarce. This study aimed to examine the associations of egg and cholesterol intakes with mortality from all causes, cardiovascular disease (CVD), and other causes in a US population.

Methods and findings: Overall, 521,120 participants (aged 50-71 years, mean age = 62.2 years, 41.2% women, and 91.8% non-Hispanic white) were recruited from 6 states and 2 additional cities in the US between 1995 and 1996 and prospectively followed up until the end of 2011. Intakes of whole eggs, egg whites/substitutes, and cholesterol were assessed by a validated food frequency questionnaire. Cause-specific hazard models considering competing risks were used, with the lowest quintile of energy-adjusted intake (per 2,000 kcal per day) as the reference. There were 129,328 deaths including 38,747 deaths from CVD during a median follow-up of 16 years. Whole egg and cholesterol intakes were both positively associated with all-cause, CVD, and cancer mortality. In multivariable-adjusted models, the hazard ratios (95% confidence intervals) associated with each intake of an additional half of a whole egg per day were 1.07 (1.06-1.08) for all-cause mortality, 1.07 (1.06-1.09) for CVD mortality, and 1.07 (1.06-1.09) for cancer mortality. Each intake of an additional 300 mg of dietary cholesterol per day was associated with 19%, 16%, and 24% higher all-cause, CVD, and cancer mortality, respectively. Mediation models estimated that cholesterol intake contributed to 63.2% (95% CI 49.6%-75.0%), 62.3% (95% CI 39.5%-80.7%), and 49.6% (95% CI 31.9%-67.4%) of all-cause, CVD, and cancer mortality associated with whole egg consumption, respectively. Egg white/substitute consumers had lower all-cause mortality and mortality from stroke, cancer, respiratory disease, and Alzheimer disease compared with non-consumers. Hypothetically, replacing half a whole egg with equivalent amounts of egg whites/substitutes, poultry, fish, dairy products, or nuts/legumes was related to lower all-cause, CVD, cancer, and respiratory disease mortality. Study limitations include its observational nature, reliance on participant self-report, and residual confounding despite extensive adjustment for acknowledged dietary and lifestyle risk factors.

Conclusions: In this study, intakes of eggs and cholesterol were associated with higher all-cause, CVD, and cancer mortality. The increased mortality associated with egg consumption was largely influenced by cholesterol intake. Our findings suggest limiting cholesterol intake and replacing whole eggs with egg whites/substitutes or other alternative protein sources for facilitating cardiovascular health and long-term survival.

Trial registration: ClinicalTrials.gov NCT00340015.

Fig 1. Multivariable-adjusted HRs of all-cause and cause-specific mortality for whole egg, egg white/substitute, and cholesterol consumption.

Forest plots show the multivariable HRs of total and cause-specific mortality associated with each additional half a whole egg/day, egg white/substitute consumption (consumers versus non-consumers), or each additional 300 mg of cholesterol/day. HRs were adjusted for model 6 covariates for whole eggs, egg whites/substitutes, and cholesterol. Horizontal lines represent 95% CIs. CI, confidence interval; HR, hazard ratio.

Fig 2. Multivariable-adjusted hazard ratios of all-cause and cause-specific mortality by replacing 1 whole egg with equivalent amounts of other protein sources.

Forest plots show the multivariable HRs of (A) total, (B) CVD, (C) cancer, (D) respiratory disease, (E) Alzheimer disease, and (F) diabetes mortality associated with replacing half a whole egg/day with an equivalent amount of egg whites/substitutes, poultry, fish, dairy products, nuts, or legumes. HRs were adjusted for age; sex; BMI; race; education; marital status; household income; smoking; alcohol; vigorous physical activity; usual activity at work; history of hypertension, hypercholesteremia, heart disease, stroke, diabetes, and cancer at baseline; total energy intake; and intakes of fruit, vegetables, potatoes, whole grains, refined grains, coffee, and sugar-sweetened beverages. Horizontal lines represent 95% CIs. CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio.