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Egg Nutrition Roundtable Report for Healthcare Professionals

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					Egg Nutrition Roundtable Report
for Healthcare Professionals
May 2010
        In July 2009, a group of Australian healthcare professionals gathered to review available
        research on the nutritional contribution of eggs and provide advice to healthcare
        professionals on recommending the consumption of up to six eggs a week to their
        patients or clients.
        This report was prepared as a consensus document, and its content and recommendations have
        received the support and approval of those healthcare professionals who attended the roundtable,
        as well as a wider review group.
        The participants in the roundtable were:
        • Dr Tania Markovic, Endocrinologist, Royal Prince Alfred Hospital and Clinical Senior Lecturer,
          University of Sydney
        • Dr Don McNamara, former managing director of the Egg Nutrition Centre in Washington DC, US
        • Dr Manny Noakes, Senior Research Dietitian, CSIRO
        • Ms Sharon Natoli, Accredited Practising Dietitian and Founding Director, Food & Nutrition
          Australia
        • Dr Peter Clifton, Obesity and Preventative Health Flagship, CSIRO and Affiliate Professor of
          Medicine and Biomedical Science, University of Adelaide
        • Dr Peter Williams, Associate Professor Nutrition and Dietetics, Smart Foods Centre, University of
          Wollongong
        • Dr John Barlow, General Practitioner, Bankstown Medical Centre, Sydney
        • Dr Ross Walker, Consultant Cardiologist, Dr Ross Walker Clinic, Sydney
        Reviewers of report:
        • Ms Barbara Eden, Senior Food Supply Manager, National Heart Foundation of Australia
        • Dr Karam Kostner, lipidologist and cardiologist, Associate Professor of Medicine at the University
          of Queensland, Princess Alexandra Hospital, Brisbane, Australia




2   Egg Nutrition Roundtable Report for Healthcare Professionals
Introduction
The myths surrounding the negative impact of egg consumption on health have been firmly embedded in the public
psyche for decades. Ever since March 1984, when the front cover of Time magazine featured two eggs and a
rasher of bacon to illustrate high cholesterol and the risk of cardiovascular disease (CVD), the nutritional benefits of
eggs have been overridden by the perception of this single food item as a contributor to CVD.
The link between egg consumption and an increase in serum cholesterol is not as strong as previously believed and
this is supported by numerous epidemiological and scientific studies.1
Research has also demonstrated that many consumers have been missing out on the numerous benefits offered by
eggs, a nutritionally rich, protein dense and economical food, by unnecessarily restricting them in their diet.
It is not only that members of the general public have been self-limiting the number of eggs that they consume.
Market research of GP attitudes2 found some healthcare professionals may still be relying on outdated nutrition
advice around egg consumption.
Market research has showed that almost 80% of GPs believe that four or less eggs a week is a healthy level of
consumption for the majority of people.
Almost half of the GPs surveyed believe that the potential increase in serum cholesterol outweighs any dietary
benefits of eggs. Almost 75% surveyed also believe that dietary cholesterol has a moderate or significant effect
on increasing serum cholesterol levels, despite scientific evidence that the effect of dietary cholesterol on plasma
cholesterol is minor, particularly in comparison to saturated fat.
The research also found more than half of the GPs surveyed would at some time recommend restricting egg
consumption to patient groups who are trying to lose weight, lessen CVD risk, reduce hypercholesterolaemia,
improve diet and nutrition, or who have diabetes.
These types of recommendations do not reflect contemporary nutrition research and independent analysis of the
benefits of egg consumption.
The weight of this scientific evidence has led some of the world’s leading heart health organisations to review their
advice around the appropriate level of egg consumption. After a major review of available data, the National Heart
Foundation of Australia has found that up to six eggs a week can be included as part of a healthy balanced diet that
is low in saturated fat without increasing the risk of heart disease.3
The recommendation from the Heart Foundation for six eggs a week, as part of a healthy balanced diet low in
saturated fat, is appropriate for most Australians including those with diabetes or metabolic syndrome. Those people
diagnosed as sensitive to dietary cholesterol may need specific dietary advice.
Though an egg contains approximately 5g of fat, most of this fat is in the form of unsaturated fat which is needed for
a healthy diet. Of the 5g of fat, 1.5g is saturated fat. There is no trans fat (which is related to increases in both blood
LDL cholesterol and the risk of heart disease).




                                                   Egg Nutrition Roundtable Report for Healthcare Professionals               3
    Busting the myths around eggs
      Eggs and Serum Cholesterol
      The myth: Eggs are bad for your serum cholesterol and therefore bad for your heart.
      The reality: The effects of foods that contain dietary cholesterol – including eggs – on serum
      cholesterol are small in the context of a low saturated fat diet.

    Changes in dietary saturated fatty acids (SFAs) influence the level of circulating low density lipoprotein (LDL)
    cholesterol to a much greater extent than the dietary cholesterol in foods.3
    The myth surrounding dietary cholesterol and its negative impact on cardiovascular health has its basis on the
    types of study models that were used in early research. In these studies animals such as rabbits and rats were fed
    cholesterol or cholesterol-rich foods and developed increased atherosclerosis.
    It was concluded that as cholesterol was the key component of the atherosclerotic lesions, it was the dietary
    cholesterol that was the main cause of the disorder in both animals and humans.4
    However, one cannot directly extrapolate the results from the animal models to humans because of the
    unphysiological quantities of fat fed to animals that normally feed on low-fat, high-carbohydrate diets. There are also
    considerable variations in lipoprotein physiology, response to diet and susceptibility to coronary disease between
    different animal species.4,5
    In light of the findings of this early research into dietary and serum cholesterol, strong and clear messages about
    restricting egg consumption in healthy diets were issued – particularly in the United States – during the 1970s.
    These messages, along with strong media images such as Time magazine’s ubiquitous front cover embedded the
    restriction of egg consumption in the mind of the public for generations.
    Patients may need to be informed that based on current evidence, while dietary cholesterol has a small effect on
    serum cholesterol levels, it has substantially less impact than saturated and trans fat.3 Reducing saturated fat is the
    primary strategy recommended for reducing cholesterol levels.


      Eggs and Coronary Heart Disease
      The myth: The cholesterol in eggs can increase the risk of people developing coronary heart disease.
      The reality: There is no consistent evidence that reducing egg consumption reduces the risk of CHD
      and stroke in most people.

    Despite the observations that dietary cholesterol modestly increases serum cholesterol in some people, researchers
    have noted there is no consistent evidence from the 30 or more years of prospective studies that dietary
    cholesterol, or specifically egg consumption, has an independent association with risk of heart disease.1, 5, 6, 7
    Combined prospective survey data from the Health Professionals’ Follow-up Study and the Nurses’ Health study (a
    total of more than one million subjects) indicated that there was no difference in cardiovascular risk (CHD or stroke)
    between people who consumed fewer than one egg a week or more than one egg a day.8
    Eggs are nutrient dense, rich in high quality protein and omega-3, not high in SFAs or in energy and are also a
    valuable source of many essential micro-nutrients.

      Eggs and Fat
      The myth: Eggs are high in fat.
      The reality: Eggs are only a moderate source of dietary fat. They contain no trans fat, and the majority
      of fat in an egg is unsaturated.

    The fat total in a serve of eggs (2x 60g eggs – 104g edible portion) is about 10.3 grams of fat, of which saturated fat
    is only 3.4g – the remainder is polyunsaturated and monounsaturated fat.
    The National Nutrition Survey9 showed that egg products and dishes contributed just 2% of the average total fat
    intake and only 1.6% of the average total saturated fat intake in the Australian diet.


4   Egg Nutrition Roundtable Report for Healthcare Professionals
How many eggs and why six a week?
The Heart Foundation recently joined an increasing number of health advisory bodies around the world in revising
its recommendation around the consumption of eggs. The Heart Foundation recommends that all Australians can
consume up to six eggs a week, in a healthy, balanced diet low in saturated fat, without increasing their risk of
Cardiovascular Disease (CVD).
The decision followed the Heart Foundation’s 2009 review of dietary fats and dietary cholesterol and their effects on
cardiovascular health. Its advice has always been that eggs are a nutritious food – containing high quality protein and
long chain omega-3 fatty acids, as well as at least 11 vitamins and minerals – that are affordable and readily available.

               Fresh chicken eggs automatically qualify for the Tick because they are a
               nutritious food. People with health concerns should seek dietary advice from
               their doctor or dietitian.


People can enjoy one egg on most days or have three serves (two eggs per serve) in three different meals, to make
up their six eggs a week.
The Heart Foundation joins organisations including the World Health Organization, British Heart Foundation, The
Heart and Stroke Foundation of Canada and the Irish Heart Foundation, in either not putting a limit on the number of
eggs consumed or increasing the recommended consumption to either six or seven eggs a week.10
Table 1: Nutrient content of raw Australian hen eggs
Source: AECL nutritional analysis, October 2007

                                                                              %Daily Intake*/Recommended Daily
 Nutrient                                     Two large eggs (104g)
                                                                              Intake**
 Energy (kJ)                                  581                             7%*
 Protein (g)                                  12.7                            25%*
 Fat (g)                                      10.3                            15%*
 Saturated fat (g)                            3.4                             14%*
 Monounsaturated fat (g)                      5.3                             -
 Polyunsaturated fat (g)                      1.7                             -
 Cholesterol (mg)                             398                             -
 Sodium (mg)                                  141                             6%*
 Phosphorous (mg)                             208                             21%**
 Iron (mg)                                    1.7                             14%**
 Selenium (µg)                                41                              59%**
 Zinc (mg)                                    0.5                             4%**
 Iodine (µg)                                  43                              29%**
 Thiamin (mg)                                 0.12                            11%**
 Vitamin B12 (µg)                             0.8                             40%**
 Vitamin B5 (mg) (Pantothenic acid)           2.1                             42%**
 Folate (µg)                                  97                              49%**
 Vitamin A (µg) (Retinol)                     239                             32%**
 Vitamin D (µg)                               0.8                             8%
 Vitamin E (mg)                               2.4                             24%**
 Short chain Omedga-3 (g)                     0.06                            5-8% Adequate Intake
 Long chain Omega-3 (g)                       114                             71-127% Adequate Intake
 Omega-3 (total) (g)                          0.18                            12-20% Adequate Intake
 Omega -6 (g)                                 1.42                            11-18% Adequate Intake
 Lutein + zeaxanthin (µg)                     530                             -
 Choline (mg)                                 31.59                           57%-74%**


                                                      Egg Nutrition Roundtable Report for Healthcare Professionals          5
    Egg benefits throughout life’s journey
    Expectant Mothers
    Eggs are a good source of folate and choline, two nutrients that can play important roles in preventing neural tube
    defects and in the brain development of infants.
    Choline is required for the normal development of brain tissue in infants. Choline intake is of particular interest during
    pregnancy and lactation. Requirements for choline, which is transported through the placenta and mammary gland
    to the developing and nursing infant, increase at this time.11

       Eggs are an excellent source of choline, as are beef and chicken livers

    Choline has been shown to play an important role in the reduction of homocysteine in the blood.12 Elevated maternal
    homocysteine has been associated with an increased incidence of birth defects. Women with diets deficient in
    choline have a two times greater risk of their babies having neural tube defects such as spina bifida.11, 13, 14, 15
    A serve of eggs contains 31.5mg of choline which is 57% of the RDI for men and 74% for women.

    Children and Adolescents
    Eggs are ideal for children and can play an important role in their diet. They can be fun to eat, are self-contained and
    versatile - an important factor when parents are dealing with fussy eaters.
    Eggs are nutritious and provide useful amounts of folate, Vitamin A, iron, zinc, iodine and long chain omega-3s. They
    are also a good source of protein, which assists growth during childhood, and are naturally low in sodium.
    Eggs are a core food within the ‘meat and alternatives’ group of the Australian Guide to Healthy Eating and
    are recommended in the National Health and Medical Research Council’s Dietary Guidelines for Children and
    Adolescents as a highly nutritious food that can add variety to the diet. Though some key nutrients have been found
    to be low in some children’s diets compared with Estimated Average Requirements (EARs), the 2007 Children’s
    Nutrition Survey shows children generally consume sufficient energy and key nutrients to maintain good health.16
    The key nutrients found to be low in some children’s diets included calcium, phosphorous, folate and vitamins D
    and E. With the exception of calcium, eggs can provide good amounts of each of these nutrients and help meet
    nutritional requirements during childhood.

    Table 2: Eggs and their contribution to Recommended Dietary Intakes (RDI) for Children17
                                        % RDI for Children
                      Amount in
     Nutrient                                         Boys            Girls           Functions
                      2x60g eggs*       4-8 years
                                                      9-13 years      9-13 years
     Protein          12.7g             64%           32%             36%             Synthesis of body cells, tissues,
                                                                                      enzymes, hormones and antibodies
     Vitamin A        239µg             60%           40%             40%             Essential for growth; cell differentiation
                                                                                      and eyesight development
     Folate           97µg              49%           32%             32%             Growth and maintenance of healthy
                                                                                      cells
     Zinc             0.5mg             13%           8%              8%              Building and developing muscle tissue
                                                                                      and internal organs; immune function
     Iron             1.7mg             16%           20%             20%             Healthy blood cells and promoting
                                                                                      growth
     Iodine           43µg              48%           36%             36%             Proper mental development;
                                                                                      metabolism
     Long chain       114mg             207%          163%            163%            Infant growth and development; behaviour,
     omega-3s                                                                         attention and learning in children
    *One serve = 2x60g eggs (104g edible portion)




6   Egg Nutrition Roundtable Report for Healthcare Professionals
Adults
Eggs provide an easy and simple way for Australian adults to receive key nutrients, vitamins and protein without
risking excess kilojoules. Eggs are low in salt, unsaturated fats and completely trans fat free.
Eggs have the highest nutritional quality protein of all food sources, providing all the essential amino acids in
amounts that closely match human requirements. Greater than 95% of egg protein is digestible and eggs are
classified as a highly digestible protein source18 that may provide enhanced satiety.19
The National Health and Medical Research Council recommends that for good health no more than 20-35% of total
intake should be from fat with saturated fat providing less than 10% of total energy.20 For an ‘average’ person consuming
8,700 kilojoules (2,070 calories) per day, this equates to 70 grams of fat – 24 grams from saturated sources.21


  One serve of eggs would therefore contribute 15% of the total fat and 14% of the
  saturated fat recommended daily in an average diet. In comparison, two slices (40g) of
  cheese contributes more than 35% of daily fat.

Due to their contribution of a wide range of nutrients in the diet, eggs are a valuable inclusion in a healthy diet,
contributing only moderate amounts of total fat, the majority of which is unsaturated, as well as useful amounts of
omega-3 fatty acids.

Eggs and Older Australians
Ensuring adequate nutrient intake becomes increasingly important for people over 65 years of age, as about 70 per
cent of deaths in Australians aged 65-85 is due to cardiovascular disease or cancer, both of which have diet-related
risk factors.
The 1995 National Nutrition Survey showed that people 65 and over eat less than the recommended number of
serves from each of the food groups and have low intakes of vitamins and minerals.9
Many older adults have increased nutrient requirements and decreased food intakes, so that they may not be
receiving enough nutrients such as fibre, calcium, vitamins A, E, B6 and B12, folate, vitamin C, iron, magnesium
and zinc.22, 23


  Given the quality of protein in eggs and its high bioavailability, eggs are an ideal protein
  source for the elderly as they are economical, easy to prepare and also easy to chew and
  consume.

Age-related physiological changes such as decreased immune function, increased oxidative stress, decreased
mineral absorption, decreased gastric acid production – along with drug-nutrient interactions – and other changes in
the gastrointestinal tract can increase the requirements for vitamins B6, B12, E, C, D, folic acid, zinc, calcium, iron
and carotenoids.22
As muscle mass reduces with ageing, elderly Australians may benefit from additional protein that might reduce age-
related muscle wasting.24 Increased protein intake may also assist in wound healing in the elderly.
Another issue for older Australians is eye health. There is emerging evidence that high-dose supplementation with
beta-carotene, antioxidants and zinc may reduce the amount of visual degeneration in the elderly.25
A recent study conducted in older adults showed eating 2-4 eggs a day for 5 weeks can increase macular pigment
optical density, a risk factor for age-related macular degeneration.26




                                                  Egg Nutrition Roundtable Report for Healthcare Professionals              7
    Eggs and their contribution to good health
    Eggs and Obesity
    Recent research shows that the satiety provided by eating eggs, which are rich in high quality protein, may assist
    in weight management. In a survey which examined beliefs and practises around egg intake27 28% of respondents
    restricted their egg intake because they were either trying to lose weight, improve their diet or thought that eggs
    were fattening.
    However, one serve of eggs provides only 15% of a person’s daily fat requirements, while being a good source
    of high quality protein and providing at least 11 vitamins and minerals. This standard serve of eggs is also low in
    kilojoules, providing 7% of a person’s daily kilojoule requirements – approximately a similar kilojoule count as two
    medium apples or two small slices of whole grain bread.
    A review of dietary protein in the regulation of food intake has shown that protein makes a stronger contribution to
    satiety than carbohydrates and fat, and also causes greater suppression of food consumption.28
    Consequently, individuals experience reduced hunger on a higher-protein low-kilojoule diet resulting in better compliance.

      A British Nutrition Foundation 2006 review paper included a summary of key studies
      promoting the satiating effect of eggs in assisting weight control. The researchers
      concluded that “moderate consumption of eggs (one to two eggs per day) should be
      actively encouraged as part of an energy restricted, weight-losing dietary regimen”.5

    Though few studies have specifically examined the effect of eggs on weight loss, new evidence supports the
    inclusion of eggs in energy restricted diets, with one study suggesting eggs may even enhance weight loss. 29,30,31

    Eggs and Eye Health
    Antioxidants play a role in protecting against the development of eye diseases including macular degeneration – the
    leading cause of age related blindness – and cataracts.32,33
    The two primary carotenoids found in the macular region of the retina are lutein and zeaxanthin34 and it is thought
    that these antioxidants play a protective role in the prevention of eye disease.
    Eggs contain both of these antioxidants, with one serve of eggs providing 530µg. Though the amount is lower than in
    some plant sources, it is more bioavailable due to the fat in eggs, which increases antioxidant absorption.35

    Eggs and Heart Health
    The Heart Foundation’s recommended consumption of up to six eggs a week as part of a healthy balanced diet
    came following the organisation’s review of robust national and international studies, which showed there was
    insufficient evidence to restrict egg consumption more than this.
    Some nutrients found in eggs also may be associated with protection from coronary heart disease or its risk factors.
    The long chain omega-3 fatty acids found in eggs have also been associated with a lower risk of CHD.36

    Eggs and Vegetarians
    Sometimes a vegetarian diet can lead to low intake of key nutrients such as protein, vitamin B12, selenium, iodine,
    iron and omega-3s.37 Eggs can play a significant role in helping address these potential shortfalls.
    Eggs are a rich source of high quality protein and as such can be useful in the diet of ovo-vegetarians.
    Eggs are also an excellent source of bioavailable vitamin B12 with one serve (2x60g eggs) providing 40% of the RDI
    for vitamin B12 and 14% of the RDI for iron.
    Vegetarians generally consume adequate amounts of most minerals except iodine, calcium (vegans only) and
    possibly selenium.38
    One serve of eggs contains good amounts of selenium (59% RDI) and iodine (29% RDI) and is therefore useful in a
    vegan diet.


8   Egg Nutrition Roundtable Report for Healthcare Professionals
Eggs and Diabetes
Diabetes, and type 2 diabetes in particular, is a rapidly growing health issue with reports indicating that more than
one million Australians have the condition.39
Some, but not all, epidemiologic studies suggest an increased risk of cardiovascular disease and mortality with
increased egg consumption in people with type 2 diabetes.40 There have also been a small number of clinical
studies that have not shown adverse effects of increasing egg consumption but research into eggs, dietary
cholesterol and diabetes management is very limited in quality and quantity.
More research into this area is needed to fully assess the impact of egg consumption on people with diabetes.
Prudent advice is that eggs can be included in a diet low in saturated fat, containing known cardio-protective foods
and meeting the guidelines for diabetes management. Research supports the inclusion of around six eggs a week
as part of a healthy diet.



Six eggs a week and six good reasons
The National Heart Foundation, after its recent position statement of Dietary fats and dietary sterols for
cardiovascular health, recommends that Australians can enjoy six eggs a week as part of a healthy, balanced diet
low in saturated fat.

1. Low in fat and kilojoules
One serve of eggs provides just 15% of a person’s fat and 14% of saturated fat intake, while being a good source
of high quality protein and providing at least 11 vitamins and minerals. This standard serve of eggs is also low in
kilojoules, providing 7% of a person’s daily kilojoule requirements – a similar kilojoule count as two medium applies or
two small slices of wholegrain bread.

2. Nutrient Rich
Eggs are a highly nutritious food containing at least 11 vitamins and minerals and are also a good source of high
quality protein.
One serve of eggs (2x60g eggs) is a source (>10% RDI) of iron and thiamine and is a good source (>25% RDI) of
selenium, folate, vitamin B5, vitamin B12, vitamin A, iodine, riboflavin, vitamin E and phosphorous.

3. A good source of long chain omega-3
Eggs are a good source of omega-3 fatty acids. One serve provides 180mg of omega-3, which is 12% of the
daily Adequate Intake (AI) recommendation for men and 20% for women. Of this, 114mg is made up of long-chain
omega-3 fatty acids, providing 71% and 127% of the long-chain daily AI for men and women, respectively.
An increased intake of omega-3 fatty acids is known to reduce the risk of heart disease3 some inflammatory and
autoimmune disorders including rheumatoid arthritis41 and emerging evidence in the treatment of depression42 and
inflammatory bowel disease.43
Though many Australians are meeting the recommended daily AI for long-chain omega-3 fatty acids, they are failing to
meet the optimal intake for disease prevention.17




                                                  Egg Nutrition Roundtable Report for Healthcare Professionals             9
     4. Antioxidants
     Eggs contain the antioxidants lutein and zeaxanthin, which are thought to play a protective role in the prevention
     of eye disease. One serve of eggs provides a combined total of 530µg of these antioxidants. Though the amount
     is lower than in some plant sources, it is more bioavailable due to the fat in eggs, which increases antioxidant
     absorption.

     5. Protein
     The biological protein value and digestibility of egg protein contributes to the high nutritional quality of eggs.
     This highly digestible source of protein has benefits for people throughout life’s journey, from aiding growth and
     development in children and adolescents to helping to preserve lean muscle mass in athletes, and stimulating
     muscle protein formation and wound healing in the elderly.
     The high quality protein in eggs may also be of benefit to vegetarians, given the protein digestibility and lower
     biological protein value of many plant proteins. This can result in deficient dietary intakes of essential amino acids in
     some vegetarian diets.18
     Eggs are classified as a highly digestible protein source, with 95% of egg protein being digestible.

     6. Affordable and easy to prepare and consume
     Eggs are a nutritious food source that is self-contained, affordable and easy to cook. They can be prepared in a
     variety of ways and added to the diet at any meal or snack times – breakfast, lunch and dinner. They are also easy
     to eat and digest.




        Recommendations to Health Professionals
        The authors of this report recommend that healthcare professionals:

        1. Communicate the Heart Foundation message of up to six eggs a week may be consumed by all
           Australians as part of a healthy balanced diet, low in saturated fat.

        2. Explain that the effect of dietary cholesterol on raising serum cholesterol is generally not as strong
           as is commonly believed, especially in the context of a balanced diet, low in saturated fat.

        3. Communicate the nutritional benefits of eggs to specific patient groups – expectant mothers,
           parents of children, vegetarians, athletes and the elderly.

        4. Reassure those concerned about egg consumption and the risk of CVD that recent clinical and
           epidemiological research has shown up to six eggs a week provides a range of nutritional benefits
           without increasing the risk of heart disease.

        5. Explain that people with diabetes may consume up to six eggs a week, as part of a low saturated
           fat diet.

        6. Inform patients that eggs are a nutrient and protein rich food source than can contribute positively
           to their health.




10   Egg Nutrition Roundtable Report for Healthcare Professionals
References
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                                                               Egg Nutrition Roundtable Report for Healthcare Professionals                                    11
This report has been prepared on behalf of the Australian Egg Corporation Pty Ltd.

				
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