All-cause mortality, cholesterol and eggs.

To the Editor: The review by Spence et al concludes that those at risk of vascular disease (which Canadian is not?) should avoid cholesterol, particularly eggs. Before abandoning eggs, let us first consider total cholesterol and all-cause mortality. In most population studies, those with low(est) cholesterol die first. Typical is the Austrian Vorarlberg study with top mortality in the bottom quartile for cholesterol, an association not reaching full statistical significance only in men younger than 50 years. Interestingly, the Quebec Cardiovascular Study found no link between cholesterol and coronary disease in men. The article offers no placebo-controlled studies with cholesterol or egg feeding and clinical endpoints; 15 references are opinion pieces, and 41 are observational studies (epidemiologic, human, animal, in vitro) with surrogate endpoints such as flow-mediated dilation, lipid changes, and sudanophylic (lipid) stains in arteries. The authors suggest that statins lower cholesterol approximately 5 times more than “low-fat” diets do, but there are no studies showing that even statins lower mortality in women, also a finding for anybody in all atorvastatin (Lipitor) studies ever done (references in). How could egg avoidance do better? The authors discuss oxidized cholesterol as confounder. Soft-boiled or poached eggs have none, as opposed to dried yolk (found in many processed foods), jerky, or crispy bacon. No cited rabbit, knockout mouse, primate, or pig study used fresh yolk. The authors argue that dietary (cholesterol-raising) saturated fat and cholesterol may be as toxic as cigarettes: “[S]topping egg consumption after a myocardial infarction or stroke would be like quitting smoking after lung cancer.” First, cholesterol is not a risk factor for stroke. Second, low and lowering cholesterol, especially after ages 50 or 60, is a risk factor for early death, cognitive decline, heart failure, and survival after infarcts, all among the dozens of “cholesterol paradoxes.” Eggs are tasty and cheap sources of unprocessed, high-quality nutrients, including carotenoids such as lycopene, and vitamin D3. Eggs may marginally raise high-density lipoprotein and total cholesterol, which, especially in older people, may be of overall benefit. If cardiac risk would be from oxysterols, the authors should have suggested the avoidance of products containing dried or overfried fats and cholesterol but mentioned that fresh boiled, poached, or “over easy” eggs are fine. Such a suggestion would have brought the authors in line with their references 1 through 5, which conclude that eggs are of no harm.