Skip to main content Accessibility help

Dietary cholesterol: from physiology to cardiovascular risk

  • Jean-Michel Lecerf (a1) and Michel de Lorgeril (a2)

Dietary cholesterol comes exclusively from animal sources, thus it is naturally present in our diet and tissues. It is an important component of cell membranes and a precursor of bile acids, steroid hormones and vitamin D. Contrary to phytosterols (originated from plants), cholesterol is synthesised in the human body in order to maintain a stable pool when dietary intake is low. Given the necessity for cholesterol, very effective intestinal uptake mechanisms and enterohepatic bile acid and cholesterol reabsorption cycles exist; conversely, phytosterols are poorly absorbed and, indeed, rapidly excreted. Dietary cholesterol content does not significantly influence plasma cholesterol values, which are regulated by different genetic and nutritional factors that influence cholesterol absorption or synthesis. Some subjects are hyper-absorbers and others are hyper-responders, which implies new therapeutic issues. Epidemiological data do not support a link between dietary cholesterol and CVD. Recent biological data concerning the effect of dietary cholesterol on LDL receptor-related protein may explain the complexity of the effect of cholesterol on CVD risk.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Dietary cholesterol: from physiology to cardiovascular risk
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Dietary cholesterol: from physiology to cardiovascular risk
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Dietary cholesterol: from physiology to cardiovascular risk
      Available formats
Corresponding author
*Corresponding author: Dr J.-M. Lecerf, fax +33 3 20 87 72 96, email
Hide All
1 Turley, SD (1999) Dietary cholesterol and the mechanism of cholesterol absorption. Eur Heart J 1, Supp., S29S35.
2 Carr, TP & Jesch, FD (2006) Food components that reduce cholesterol absorption. Adv Food Nutr Res 51, 165204.
3 Kruit, JK, Ploscht, J, Havinga, R, et al. (2005) Increased fecal neutral sterol loss upon liver X receptor activation is independant of biliary sterol secretion in mice. Gastroenterology 128, 147156.
4 Wilson, MD & Rudel, LL (1994) Review of cholesterol absorption with emphasis on dietary and biliary cholesterol. J Lip Res 35, 943955.
5 Samuel, P & Mc Namara, DJ (1983) Differential absorption of exogenous and endogenous cholesterol in man. J Lipid Res 24, 265276.
6 Dawson, PA & Rudel, LL (1999) Intestinal cholesterol absorption. Curr Opin Lipidol 10, 315320.
7 Hauser, H, Dyer, JH, Nandy, A, et al. (1998) Identification of a receptor mediating absorption of dietary cholesterol in the intestine. Biochemistry 37, 1784317850.
8 Wang, DQ & Carey, MC (2002) Susceptibility to murine cholesterol gallstone formation is not affected by partial disruption of the HDL receptor SR-B1. Biochim Biophys Acta 1583, 141150.
9 Altmann, SW, Davis, HR, Zhu, LJ, et al. (2004) Niemman-Pick C1 like protein is critical for intestinal cholesterol absorption. Science 303, 12011204.
10 Smart, EJ, Derose, RA & Farber, SA (2004) Annexin 2 caveolin 1 complex is a target of ezetimibe and regulates intestinal cholesterol transport. Proc Natl Acad Sci USA 101, 34503455.
11 Ostlund, RE (2007) Phytosterols, cholesterol absorption and healthy diets. Lipids 42, 4145.
12 Plat, J & Mensink, RP (2005) Plant stanol and sterol esters in the control of blood cholesterol levels: mechanism and safety aspects. Am J Cardiol 96, Suppl., 15D22D.
13 Plōsch, T, Kok, T, Bloks, VW, et al. (2002) Increased hepato-biliary and fecal cholesterol excretion upon activation of the liver X receptor is independent of ABCA1. J Biol Chem 277, 3387033877.
14 Gylling, H & Miettinen, TA (1992) Cholesterol absorption, and synthesis related to low density lipoprotein metabolism during LDL kinetics during varying cholesterol intake in men with different apo E phenotypes. J Lipid Res 33, 13611371.
15 Kesaniemi, YA, Ehnholm, C & Miettinen, TA (1987) Intestinal cholesterol efficiency in man is related to apoprotein E polymorphism. J Lip Res 80, 578581.
16 Pedro-Botet, J, Schaefer, EJ, Bakker-Arrema, RG, et al. (2001) Apolipoprotein E genotype affects plasma lipid response to atorvastatin in a gender specific manner. Atherosclerosis 158, 183193.
17 Lammert, F & Wang, DQ (2005) New insights into the genetic regulation on intestinal cholesterol absorption. Gastroenterology 129, 718734.
18 Mac Murray, MP, Connor, WE, Lin, DS, et al. (1985) The absorption of cholesterol and the sterol balance in the Tarahumara Indians of Mexico fed cholesterol-free and high cholesterol diets. Am J Clin Nutr 41, 128138.
19 Sudhop, T, Lütjohann, D, Kodal, A, et al. (2002) Inhibition of intestinal absorption by ezetimibe in humans. Circulation 106, 19431948.
20 Clarenbach, JJ, Reber, M, Lütjohann, D, et al. (2006) The lipid lowering effect of ezetimibe in pure vegetarians. J Lipid Res 47, 28202824.
21 Wang, DQH (2002) Aging per se is an independant risk factor for gallstone formation in gallstone susceptible mice. J Lipid Res 43, 19501959.
22 Bosner, MS, Ostlund, RE, Osofisan, O, et al. (1993) Assessment of percent cholesterol absorption in humans with stable isotopes. J Lipid Res 34, 10471053.
23 Ostlund, RE, Bosner, MS & Stenson, NF (1999) Cholesterol absorption efficiency declines at moderate dietary doses in normal human subjects. J Lipid Res 40, 14531458.
24 Sachs, FM, Salazar, J, Miller, L, et al. (1984) Ingestion of egg raises plasma low density lipoproteins in free-living subjects. Lancet 1, 647649.
25 Vuoristo, M & Miettinen, TA (1994) Absorption modulation and serum concentrations of cholesterol in vegetarians: effects of cholesterol feeding. Am J Clin Nutr 59, 13251331.
26 Mac Namara, DJ, Kolb, R, Parker, TS, et al. (1987) Heterogeneity of cholesterol homeostasis in man. J Clin Invest 79, 17291739.
27 Hegsted, DM (1986) Serum cholesterol response to dietary cholesterol: a re-evaluation. Am J Clin Nutr 44, 299305.
28 Apfelbaum, M (1992) Which is the nutritional advantage of the consumption of a free-cholesterol butter? Rev Prat 42, 19251926.
29 Weggemans, RM, Zock, PL & Katan, MB (2001) Dietary cholesterol from eggs increases the ratio of total cholesterol to high density lipoprotein cholesterol in humans: a meta-analysis. Am J Clin Nutr 73, 885891.
30 Vorster, HH, Benade, AJ, Barnard, HC, et al. (1992) Egg does not change plasma lipoprotein and coagulation profiles. Am J Clin Nutr 55, 400410.
31 Tillotson, JL, Bartsch, GE, Gorder, D, et al. (1997) Food group and nutrient intakes at baseline in the Multiple Risk Factor Intervention Trial. Am J Clin Nutr 65, Suppl. 1, 228S257S.
32 Kern, F (1991) Normal plasma cholesterol of an 88 year old man who eats 25 eggs a day. Mechanisms of adaptation. N Engl J Med 324, 896897.
33 Simons, LA, Von Konigsmark, M, Simons, J, et al. (1993) Effect of an egg per day on plasma cholesterol levels in moderate hypercholesterolemia. Nutr Metab Cardiovasc Dis 3, 7882.
34 Edington, J, Geekie, R, Carter, R, et al. (1987) Effect of dietary cholesterol on plasma cholesterol concentration in subjects following reduced fat, high fibre diet. Br Med J 294, 333336.
35 Fielding, CJ, Havel, RJ, Todd, KM, et al. (1995) Effects of dietary cholesterol and fat saturation on plasma lipoproteins in an ethnically diverse population of healthy young men. J Clin Invest 95, 6168.
36 Harman, NL, Leeds, AR & Griffin, BA (2008) Increased dietary cholesterol does not increase plasma low density lipoprotein when accompanied by an energy-restricted diet and weight loss. Eur J Clin 47, 287293.
37 Kestin, M, Clifton, PM, Rouse, IK, et al. (1989) Effect of dietary cholesterol in normolipidemic subjects is not modified by nature and amount of dietary fat. Am J Clin Nutr 50, 528532.
38 Ginsberg, HN, Karmally, W, Siddiqui, M, et al. (1995) Increases in dietary cholesterol are associated with modest increases in both LDL and HDL cholesterol in healthy young women. Arterioscler Thromb Vasc Biol 15, 169178.
39 Mutungi, G, Ratliff, J & Puglisi, M (2008) Dietary cholesterol from eggs increases plasma cholesterol in overweight men consuming a carbohydrate restricted diet. J Nutr 138, 272276.
40 Green, CM, Zern, TL & Wood, RJ (2005) Maintenance of the LDL cholesterol/HDL cholesterol ratio in an elderly population given a dietary cholesterol challenge. J Nutr 135, 27932798.
41 Sutherland, WHF, Ball, MJ & Walker, H (1997) The effect of increased egg consumption on plasma cholesteryl ester transfer activity in healthy subjects. Eur J Clin Nutr 51, 172176.
42 Rader, DJ (2007) Illuminating HDL – is it still a viable therapeutic target? N Engl J Med 357, 21802183.
43 Ordovas, JM & Schaeffer, EJ (1999) Genes, variation of cholesterol and fat intake and serum lipids. Curr Opin Lipidol 10, 1522.
44 Sarkkinen, E, Kurhonen, M, Erkkila, A, et al. (1998) Effect of apolipoprotein E polymorphism on serum lipid response to the separate modification of dietary fat and dietary cholesterol. Am J Clin Nutr 68, 12151222.
45 Gylling, H, Strandberg, T & Tilvis, R (1994) Regulation of serum cholesterol level in middle-aged and elderly men. Relation of cholesterol absorption and synthesis to lipoprotein metabolism. Arterioscler Thromb 14, 694700.
46 Jones, PJ (1997) Regulation of cholesterol biosynthesis by diet in humans. Am J Clin Nutr 66, 438446.
47 Mustad, VA, Ellsworth, JF & Cooper, AD (1996) Dietary linoleic acid increases and palmitic acid decreases hepatic LDL receptor protein and mRNA abundance in young pigs. J Lipid Res 37, 23102323.
48 Jones, PJH, Pappu, AS, Hatcher, L, et al. (1996) Dietary cholesterol feeding suppresses human cholesterol synthesis measured by deuterium incorporation and urinary mevalonic acid levels. Arterioscler Thromb Vasc Dis 16, 12221228.
49 Miettinen, TA & Kesaniemi, YA (1989) Cholesterol absorption: regulation of cholesterol synthesis and elimination and within population variations of serum cholesterol levels. Am J Clin Nutr 49, 629635.
50 Gylling, H & Miettinen, TA (2002) Inheritance of cholesterol metabolism of probands with high or low cholesterol absorption. J Lipid Res 43, 14721476.
51 Asztalos, B, Lefebvre, M, Wong, L, et al. (2000) Differential response to low-fat diet between low and normal HDL cholesterol subjects. J Lipid Res 41, 321328.
52 Rantala, M, Rantala, TT & Savolainen, MJ (2000) Apoliprotein B gene polymorphisms and serum lipids: meta analysis of the role of genetic variation to diet. Am J Clin Nutr 71, 713724.
53 Masson, LF, Mc Neill, G & Avenell, A (2003) Genetic variation and the lipid response to dietary intervention: a systematic review. Am J Clin Nutr 77, 10981111.
54 Aitken, WAE, Chisolma, WAH, Duncan, AW, et al. (2006) Variation in the cholesteryl ester transfer protein (CETP) gene does not influence individual plasma cholesterol response to changes in the nature of dietary fat. Nutr Metab Cardiovasc Dis 16, 353363.
55 Tchernof, A (2007) Visceral adipocytes and the metabolic syndrome. Nutr Rev 95, Suppl., S24S29.
56 Ritchie, SA & Connell, JMC (2007) The link between abdominal obesity, metabolic syndrome and cardiovascular disease. Nutr Metab Cardiovasc Dis 17, 319326.
57 Gylling, H & Miettinen, TA (2005) Cholesterol absorption: influence of body weight and the role of plant sterols. Curr Atherosclerosis Rep 7, 466467.
58 Lamon-Fava, S, Diffenderfer, MR, Barrett, PH, et al. (2007) Effects of different doses of atovastatin on human apolipoprotein B-100, B48, and A1 metabolism. J Lipid Res 48, 17481753.
59 Van Himbergen, T, Matthan, NR, Restegnini, NA, et al. (2009) Comparison of the effects of maximal dose atorvastatin and rosuvastatin therapy on cholesterol synthesis and absorption markers. J Lipid Res 30, 730739.
60 Hedman, M, Miettinen, TA, Gylling, H, et al. (2006) Serum noncholesterol sterols in children with heterozygous familial hypercholesterolemia undergoing pravastatin therapy. J Pediatr 148, 241246.
61 Miettinen, TA & Gylling, H (2002) Ineffective decrease cholesterol by simvastatin in a subgroup of hypercholesterolemic coronary patients. Atherosclerosis 164, 147152.
62 Miettinen, TA, Strandberg, TE & Gylling, H (2000) Noncholesterol sterols and cholesterol lowering by long-term simvastatin treatment in coronary patients: relation to basal serum cholestanol. Arterioscler Thromb Vasc Biol 20, 13401346.
63 Miettinen, TA, Gylling, H, Strandberg, T, et al. (1998) Baseline serum cholestanol as predictor of recurrent coronary events in subgroup of Scandinavian simvastatin survival study. BMJ 316, 11271130.
64 Kajinami, K, Brousseau, ME, Nartsupha, C, et al. (2004) ATP binding cassette transporter G5 and G8 genotypes and plasma lipoprotein levels before and after treatment with atorvastatin. J Lipid Res 45, 653656.
65 Lecerf, JM (2007) Phytosterols and cardiovascular risk. Nutr Clin Metab 21, 1727.
66 Lakoski, SG, Xu, F, Vega, GL, et al. (2010) Indices of cholesterol metabolism and relative responsiveness to ezetimibe and simvastatin. J Clin Endocrinol Metab 95, 800809.
67 Boucher, P, de Lorgeril, M, Salen, P, et al. (1998) Effect of dietary cholesterol on LDL-receptor, HMGCoA reductase and LRP mRNA expression in healthy humans. Lipids 33, 11771186.
68 Shekelle, RB, Mac Millan Shryock, A, Paul, O, et al. (1981) Diet, serum cholesterol and death from CHD – The Western Electric Study. N Engl J Med 304, 6570.
69 Mc Gee, DL, Reed, DM, Yano, K, et al. (1984) Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Am J Epidemiol 119, 667676.
70 Stamler, JS & Shekelle, RB (1988) Dietary cholesterol and human coronary heart disease. Arch Pathol Lab Med 112, 10321040.
71 Dawber, TR, Nickerson, RJ, Brand, FN, et al. (1982) Eggs, serum cholesterol and coronary heart disease. Am J Clin Nutr 36, 617625.
72 Hu, FB, Stampfer, MJ, Rimm, EB, et al. (1999) A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA 281, 13871394.
73 Djousse, L & Gaziano, JM (2008) Egg consumption in relation to cardiovascular disease and mortality: the Physicians' Health Study. Am J Clin Nutr 87, 964969.
74 Qureshi, AI, Suri, FK, Ahmed, S, et al. (2007) Regular egg consumption does not increase the risk of stroke and cardiovascular diseases. Med Sci Monit 13, CR1CR8.
75 Gyllin, GH, Laaksonen, DE, Atalay, M, et al. (2007) Markers of absorption and synthesis of cholesterol in men with type 1 diabetes. Diabetes Metab Res Rev 23, 372377.
76 Miettinen, TA, Gylling, H, Tuominen, J, et al. (2004) Low synthesis and high absorption of cholesterol characterize type 1 diabetes. Diabetes Care 27, 5358.
77 Nakamura, Y, Okamura, T, Tamaki, S, et al. (2004) Egg consumption, serum cholesterol and cause-specific and all-cause mortality: the National Integrated Project for Prospective Observation of Non-communicable Disease and Its Trends in the Aged. Am J Clin Nutr 80, 5863.
78 Nakamura, Y, Iso, H, Kita, Y, et al. (2006) Egg consumption serum total cholesterol concentrations and coronary heart disease incidence: Japan Public Health Center-based Prospective Study. Br J Nutr 96, 921928.
79 Ravnskov, U, Rosch, PJ, Sutter, MC, et al. (2006) Should we lower cholesterol as much as possible? BMJ 332, 13301332.
80 Okuyama, H, Ichikawa, Y, Sun, Y, et al. (2007) Association of high total cholesterol with coronary heart disease mortality differs among subject populations. Familial hypercholesterolemia as a key concept. World Rev Nutr Diet 96, 1937.
81 Boucher, P, Gotthardt, M, Li, WP, et al. (2003) LRP: role in vascular wall integrity and protection from atherosclerosis. Science 300, 329332.
82 Espirito Santo, SM, Pires, NM, Boesten, LS, et al. (2004) Hepatic LRP deficiency in mice increases atherosclerosis independent of plasma cholesterol. Blood 103, 37773782.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

British Journal of Nutrition
  • ISSN: 0007-1145
  • EISSN: 1475-2662
  • URL: /core/journals/british-journal-of-nutrition
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed