Dietary Cholesterol and Cardiovascular Disease: The Triangular Relationship Between Evidence-Based Medicine, Public Health Policy, and the Food Industry as Seen Through the Evolution of Dietary Guidelines

Abstract

The relationship between dietary cholesterol and cardiovascular disease is one of the most controversial topics in the history of nutritional science. This paper systematically reviews the historical evolution of dietary cholesterol recommendations in dietary guidelines since the mid-20th century, revealing the complex interplay among evidence-based medicine, public health policy, and the food industry that underlies this evolution. The study finds that the evolution of dietary cholesterol recommendations is not a simple narrative of scientific progress, but rather a tortuous process involving “hypothesis establishment—policy entrenchment—scientific revision—and interest-based bargaining.” From the 1950s to the 1970s, Ancel Keys’ “lipid hypothesis” was established as the dominant paradigm within a specific historical context, and strategic interventions by the sugar industry further reinforced the singular attribution of health risks to “fat and cholesterol.” The first edition of the U.S. Dietary Guidelines in 1980 established a daily upper limit of 300 mg for dietary cholesterol, a standard adopted by many countries over the following four decades. However, the 2015 U.S. Dietary Guidelines’ decision to remove the cholesterol limit marked a fundamental shift in scientific understanding—from a focus on individual nutrients to a holistic dietary pattern. The issue of industry influence exposed in the 2025 edition of the U.S. Dietary Guidelines reveals the tension between scientific consensus and policy-making. The “ultra-processed foods” classification system in the Brazilian Dietary Guidelines represents a new path away from the reductionist paradigm. This article argues that the essence of the dietary cholesterol controversy lies in the conflict between “reductionist” and “holistic” scientific paradigms. Public health decision-making requires the establishment of more robust mechanisms to prevent conflicts of interest, while future nutritional science should transcend debates over individual nutrients and return to the fundamentals of whole foods and dietary patterns.