Q&A: Eggs and health: Sunny side up or down?

Takeaway messages 🔑 

Introduction 🥚

Eggs have been consumed by humans for millennia and remain one of the most widely consumed animal-source foods worldwide. Although eggs from a range of bird species, including ducks, quail, geese, turkeys, guinea fowl, ostriches and emus, are eaten in various cultures, chicken eggs account for the overwhelming majority of global consumption. Their popularity is attributable to their affordability, widespread availability, culinary versatility, consumer acceptance and the efficiency of modern poultry production systems.

In many countries, including South Africa, eggs are recognised as a staple food (1) and are afforded preferential tax treatment because of their importance in supporting food and nutrition security. Even though egg prices may fluctuate due to factors such as feed costs, energy prices and disease outbreaks such as avian influenza, eggs generally remain one of the most affordable sources of high-quality animal protein available to consumers. Compared with many meat products, eggs often provide protein at a substantially lower cost per gram (2), making them particularly valuable in resource-constrained settings and among at risk populations (3).

Eggs are among the most nutrient-dense foods, providing high-quality protein and a wide range of essential vitamins, minerals and bioactive compounds. Despite their favourable nutritional profile, eggs remain one of the most debated foods in nutrition science. Much of this controversy stems from their cholesterol content and concerns regarding potential effects on cardiovascular health. Research has examined associations between egg consumption and a wide range of health outcomes, including cardiovascular disease, blood lipid profiles, type 2 diabetes, cognitive function, weight management, gastrointestinal health and allergic disease. An important challenge in interpreting the evidence is that eggs are rarely consumed in isolation. Their health effects may be influenced by cooking methods, overall dietary patterns and the foods typically consumed alongside them. For example, boiled or poached eggs may have different health implications than eggs prepared with large amounts of added fat, while accompanying foods such as processed meats (bacon, sausages etc.) may independently affect disease risk. Consequently, observed associations between egg consumption and health outcomes may partly reflect the broader dietary context in which eggs are consumed rather than the effects of eggs themselves. Given the evolving evidence surrounding their health effects, an objective evaluation of the available literature is warranted. Here I examine the current evidence regarding egg consumption and health outcomes to provide an evidence-based perspective.

Nutrients in eggs

Eggs are nutrient-dense foods composed of two distinct components: the albumen (egg white; is 92% water, with a mixture of around 148 different proteins, with almost no fat or carbohydrates) and the yolk containing fats/lipids (including approximately 185–200 mg of cholesterol). The protein in eggs is regarded as one of the highest-quality dietary proteins because it contains all nine essential amino acids in proportions that closely match human requirements and is highly digestible. Eggs have a relatively high biological value for protein of 94% indicating the proportion of absorbed protein that becomes incorporated into the proteins of the body. Egg protein has traditionally served as a reference standard against which other dietary proteins are compared. Dietitians typically classify eggs within the meat and meat substitute exchange group, with one large chicken egg considered equivalent to one medium-fat meat exchange, providing approximately 6–7 g protein and 5 g fat with negligible carbohydrate.

Beyond protein, eggs are rich sources of several essential nutrients. Eggs are an important source of minerals, including phosphorus (25% daily value (DV) per 100 g), zinc (11% DV), selenium (58% DV) and iodine (33% DV), as well as vitamins such as vitamin A (19% DV), riboflavin (42% DV), pantothenic acid (28% DV), vitamin B₁₂ (46% DV) and vitamin D (15% DV). Eggs also provide lutein and zeaxanthin, carotenoids that support eye health, and are a significant source of choline (60% DV). The nutrient composition of eggs is not fixed but can be substantially modified through changes in the laying hen's diet. Consequently, eggs have been successfully enriched with several bioactive nutrients, including omega-3 fatty acids, folate, vitamins D and E, selenium, iodine, lutein and zeaxanthin, enhancing their nutritional value and supporting their use as a functional food (4-8).

Cage-free eggs are laid by hens that are not confined to cages but are typically housed indoors, whereas free-range eggs come from hens that have outdoor access during daylight hours. Pasture-raised eggs are produced by hens with greater access to outdoor pasture, allowing natural foraging behaviours such as consuming grasses and insects. While eggs from all production systems provide high-quality protein and similar amounts of most nutrients, some studies have reported modestly higher concentrations of omega-3 fatty acids, vitamin D, and carotenoids (such as lutein and zeaxanthin) in free-range and pasture-raised eggs, largely due to differences in feed and sunlight exposure (9). However, these nutritional differences are generally small and consumers often choose free-range or pasture-raised eggs primarily for animal welfare and environmental reasons rather than substantial nutritional advantages.

Eggs provide high-quality protein and a range of essential micronutrients that are often lacking in South African diets, making them a valuable and affordable contributor to nutrient adequacy and health throughout the lifespan, from pregnancy and infancy to older adulthood (1). Furthermore, genetic polymorphisms in pathways involved in choline and folate metabolism, including variants in the PEMT, CHDH, MTHFD1 and MTHFR genes, can influence choline requirements and susceptibility to deficiency (10). Because eggs are among the richest dietary sources of choline, regular egg consumption may be particularly beneficial for individuals carrying these variants. These findings support a role for eggs in personalised nutrition and highlight the importance of genetic variation in nutrient requirements.

Eggs and aging: cognition, Alzheimer’s and eye health 👵🧠

Emerging evidence suggests that egg consumption may support cognitive health. In a prospective cohort study of 2,497 Finnish men followed for nearly 22 years, neither dietary cholesterol nor egg consumption was associated with dementia or Alzheimer’s disease risk, including among carriers of the APOE ε4 genotype; furthermore, moderate egg intake was associated with better performance on tests of executive and frontal lobe function (11). Similarly, a systematic review and dose–response meta-analysis of 21 observational studies involving 99,453 participants reported that egg consumption was associated with a lower risk of cognitive decline, with the greatest benefit observed at an intake of approximately 50–60 g/day (about one egg per day), suggesting a U-shaped relationship between egg intake and cognitive health (12). Supporting these findings, a prospective cohort study of 39,498 adults from the Adventist Health Study-2 found that higher egg consumption was associated with a progressively lower risk of Alzheimer’s disease, with individuals consuming eggs five or more times per week experiencing a 27% lower risk than those who rarely or never consumed eggs (13).

Lutein and zeaxanthin are carotenoid antioxidants that accumulate in the macula, the central region of the retina responsible for sharp, detailed vision. Often referred to as macular pigments, they help protect the eyes by filtering harmful blue light and reducing oxidative damage. In a randomised crossover study of 33 adults over 60 years of age, consuming one egg per day for five weeks increased serum concentrations of the eye-protective carotenoids lutein (26%) and zeaxanthin (38%) without affecting total cholesterol, LDL cholesterol, HDL cholesterol or triglyceride levels, suggesting a potential benefit for eye health without adverse effects on blood lipids (14).

Eggs and cardiovascular disease ❤️

Collectively, prospective cohort studies demonstrate that moderate egg consumption is not associated with an increased risk of cardiovascular disease, myocardial infarction or stroke in the general population. In a meta-analysis of seven prospective cohort studies, consumption of up to one egg per day was associated with a 12% lower risk of stroke and was not associated with an increased risk of coronary heart disease (15). However, some studies have reported less favourable associations among individuals with diabetes, indicating that further research is needed to clarify the relationship between egg consumption and cardiovascular risk in this subgroup.

Table 1. Prospective cohort studies evaluating egg consumption and cardiovascular disease risk

APOE ε4, apolipoprotein E epsilon 4 genotype; CAD, coronary artery disease; CHD, coronary heart disease; CVD, cardiovascular disease; IMT, intima-media thickness; MI, myocardial infarction.

Circulating blood lipids 🩸

Although a large egg contains approximately 185–200 mg of cholesterol, current evidence indicates that dietary cholesterol has a relatively small effect on blood cholesterol concentrations in most individuals compared with saturated fat intake. Intervention studies consistently demonstrate that egg consumption has neutral or beneficial effects on blood lipids and cardiovascular risk markers, particularly when consumed as part of healthy dietary patterns.

Table 2. Intervention studies evaluating the effects of egg consumption on blood lipids and cardiovascular risk markers

ApoA1, apolipoprotein A1; ApoB, apolipoprotein B; BP, blood pressure; CRP, C-reactive protein; DASH, Dietary Approaches to Stop Hypertension; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; T2D, type 2 diabetes; TG, triglycerides; VLDL, very-low-density lipoprotein. Omega-3-enriched eggs were obtained from hens fed omega-3-rich diets. Endothelial function is a marker of vascular health and cardiovascular risk.

A small proportion of individuals are hyper-responders to dietary cholesterol, meaning that their blood cholesterol concentrations increase more markedly in response to cholesterol-rich foods such as eggs. These individuals may have genetic variants affecting cholesterol absorption and transport, including variants in the ATP-binding cassette subfamily G member 5 (ABCG5) and ATP-binding cassette subfamily G member 8 (ABCG8), and may therefore require a more individualised approach to egg consumption (27).

Inflammation 🔥

In a randomised crossover trial of 29 adults with type 2 diabetes, consuming one egg per day for five weeks reduced the inflammatory marker tumour necrosis factor-alpha (TNF-α) and the liver enzyme aspartate aminotransferase (AST), suggesting that eggs may improve markers of inflammation (28). However, no effect of whole egg consumption on C-reactive protein (CRP) was observed in a systematic review and meta-analysis of 22 studies, suggesting that eggs do not adversely affect systemic inflammation (29).

Trimethylamine-N-oxide (TMAO)

Another potential mechanism linking eggs to cardiovascular disease risk involves trimethylamine-N-oxide (TMAO), a metabolite produced in the body when gut bacteria metabolise nutrients such as choline, carnitine and phosphatidylcholine. A systematic review and meta-analysis of 22 studies found that whole egg consumption had no effect on plasma trimethylamine N-oxide (TMAO) concentrations, despite increasing plasma choline levels in the short term (29). Although egg consumption can transiently increase TMAO production in some individuals, controlled intervention studies have generally not shown sustained increases in fasting TMAO concentrations or adverse effects on cardiovascular risk markers (as reviewed by (27)). Current evidence suggests that both cholesterol and TMAO responses to egg consumption vary considerably between individuals and are influenced by genetics, gut microbiome composition and overall dietary patterns (as reviewed by (27)).

Carotid plaque burden

Carotid plaque burden reflects the extent of atherosclerotic plaque accumulation in the carotid arteries and is used as an indicator of cardiovascular risk. In a cross-sectional study by Spence et al. (30) of 1,262 patients, greater lifetime egg-yolk consumption ("egg-yolk years") was associated with increased carotid plaque burden, even after adjustment for traditional cardiovascular risk factors. However, because plaque burden was measured at a single time point, the study could identify associations but could not establish causality.

Homocysteine

Elevated circulating homocysteine concentrations (hyperhomocysteinaemia) are associated with endothelial dysfunction, oxidative stress, inflammation and an increased risk of cardiovascular disease, stroke, cognitive decline and adverse pregnancy outcomes. Consequently, homocysteine is often considered a marker of impaired one-carbon metabolism and suboptimal status of folate and related B vitamins. Because eggs contain choline and choline has been shown to lower homocysteine concentrations (31), egg consumption may contribute to homocysteine regulation through enhanced remethylation of homocysteine to methionine. In a folate-restricted rat model of hyperhomocysteinaemia, diets containing egg protein prevented the rise in circulating homocysteine concentrations observed with a casein-based diet, an effect associated with increased hepatic betaine-homocysteine S-methyltransferase (BHMT) activity (32). Similarly, acute and short-term human intervention studies have shown that egg consumption increases circulating choline and betaine concentrations, key methyl donors involved in homocysteine metabolism, although homocysteine itself was generally not measured as an outcome (33).

A study demonstrated that supplementing laying hen diets with folic acid substantially increased the folate content of eggs, with folate concentrations in egg yolks more than doubling and remaining stable during storage (4). Given the established role of folate in homocysteine remethylation, consumption of folate-enriched eggs could further enhance the homocysteine-lowering potential of eggs beyond that attributable to egg protein and choline alone, potentially providing additional protection against hyperhomocysteinaemia. However, direct human intervention studies evaluating the effects of regular egg consumption or folate-enriched eggs on plasma homocysteine concentrations are lacking, and further research is needed to confirm.

Eggs and diabetes 🩺🍳

Observational studies have reported positive associations between higher egg consumption and type 2 diabetes risk, although these findings should be interpreted cautiously because of the potential for residual confounding. In a Lithuanian case–control study, individuals consuming 3–4.9 eggs per week and ≥5 eggs per week had approximately two- to threefold higher odds of type 2 diabetes than those consuming fewer than one egg per week (34). Similarly, a cross-sectional study of Chinese adults found that higher egg consumption was associated with a greater prevalence of type 2 diabetes, particularly among women, although the association was attenuated after adjustment for body mass index (35). As both studies were observational in nature, causality cannot be inferred, and the findings may reflect differences in overall dietary patterns, adiposity, lifestyle behaviours or underlying metabolic health rather than a direct effect of egg consumption itself.

In contrast, intervention studies, particularly randomised controlled trials, provide a stronger basis for evaluating cause-and-effect relationships because participants are prospectively assigned to specific dietary exposures, thereby reducing the influence of confounding factors. Collectively, these trials consistently demonstrate neutral or beneficial effects of egg consumption on glycaemic control, insulin sensitivity and satiety (Table 3). Across diverse populations, including healthy adults, individuals with metabolic syndrome, prediabetes and type 2 diabetes, egg consumption did not adversely affect fasting glucose, glycated haemoglobin (HbA1c), insulin concentrations or other markers of glucose regulation. Several studies reported improvements in insulin sensitivity, reductions in insulin resistance and enhanced satiety. Given that intervention trials are better suited than observational studies to assess causal effects, the current intervention evidence does not support a detrimental effect of egg consumption on diabetes risk or glycaemic control and suggests that eggs can be included as part of a healthy dietary pattern.

Table 3. Intervention studies evaluating the effects of egg consumption on glucose regulation and insulin sensitivity

HbA1c, glycated haemoglobin; HOMA-IR, Homeostatic Model Assessment of Insulin Resistance; T2D, type 2 diabetes. Glycaemic control refers to the regulation of blood glucose concentrations over time and includes measures such as fasting glucose, HbA1c and insulin. Insulin sensitivity reflects the body's ability to respond effectively to insulin, whereas insulin resistance refers to a reduced biological response to insulin. Omega-3-enriched eggs were produced by modifying hen feed to increase the omega-3 fatty acid content of the eggs. Satiety refers to feelings of fullness that reduce subsequent food intake.

Eggs, growth and weight management ⚖️

Poor-quality diets that provide sufficient or excess energy but inadequate protein and micronutrients can impair linear growth (leading to stunting) while promoting fat accumulation, contributing to the double burden of stunting and overweight observed in many low- and middle-income countries (39). A 2024 meta-analysis of 7 studies reporting on 9 unique interventions in 3,575 participants concluded that egg supplementation produces a modest but significant improvement in child growth, with increases in both height/length and weight compared with control groups (40). The authors concluded that eggs are an affordable and nutritious option for supporting child growth, although larger and longer studies are needed (40).

Furthermore, eggs are highly satiating foods. Owing to their high-quality protein content, they help reduce hunger and increase feelings of fullness compared with lower-protein or refined carbohydrate meals (41, 42). Several studies have shown that egg-based breakfasts can suppress appetite, enhance satiety and reduce subsequent energy intake, making eggs a useful food for weight loss and weight maintenance strategies (43-47). In overweight and obese adults, egg breakfasts have been shown to increase fullness, reduce hunger and lower subsequent energy intake compared with energy-matched bagel or cereal breakfasts (44, 45, 47). Among individuals following a weight-loss diet, an egg breakfast was associated with greater reductions in body mass index (BMI), waist circumference and body weight than a bagel breakfast (46). However, in healthy university students, regular egg-based breakfasts did not influence body weight or blood lipid concentrations compared with non-egg breakfasts (38). Consistent with these findings, a systematic review and meta-analysis of 32 controlled clinical trials concluded that whole egg consumption has no overall effect on body weight, body mass index, waist circumference or fat-free mass, although eggs may support weight loss when incorporated into energy-restricted diets (48). Overall, eggs appear unlikely to adversely affect weight status and may help improve satiety and support weight-management efforts in certain populations.

Eggs and gastrointestinal health 🦠

A systematic review and meta-analysis of 22 studies found that the effects of eggs on the gut microbiome, microbial diversity and other gastrointestinal health outcomes were inconsistent, highlighting the need for further research to clarify the relationship between habitual egg consumption and gastrointestinal health (29).

Eggs and allergies 👶🚫

Egg allergy remains one of the most common food allergies in infancy and early childhood, although emerging evidence suggests that early introduction of eggs may help reduce the risk of allergic sensitisation in some children (49). A systematic review identified five clinical studies suggesting that quail egg-based supplements (QES), particularly when combined with zinc, may improve symptoms of allergic rhinitis, including nasal congestion, rhinorrhoea, sneezing and itchy eyes, while also enhancing nasal airflow and reducing the need for symptomatic medications (50).

Eggs and food safety 🛡️🍽️

Eggs are generally considered safe and nutritious foods when handled, stored and cooked appropriately. The principal food safety concern is contamination with Salmonella enterica, particularly Salmonella Enteritidis, which can occur through contamination of the shell or, less commonly, the interior of the egg (51). Refrigeration, avoidance of cracked eggs, good kitchen hygiene and thorough cooking especially for vulnerable populations (pregnant women, older adults, immunocompromised individuals) substantially reduce the risk of foodborne illness (CDC, 2024; USDA, 2024). Pasteurised eggs are eggs that have undergone a carefully controlled heat treatment to inactivate pathogenic microorganisms, particularly Salmonella, while preserving the appearance and functional properties of raw eggs (52). They provide an additional level of food safety and are especially useful in foods containing raw or lightly cooked eggs, such as homemade mayonnaise, hollandaise sauce, mousse and certain salad dressings. While pasteurised shell eggs are more widely available in countries such as the United States, most shell eggs sold at retail in South Africa are not pasteurised. Consequently, foods prepared with raw or lightly cooked eggs may carry a small risk of Salmonella infection and vulnerable individuals are advised to consume thoroughly cooked eggs.

Conclusion ✅

For most individuals, eggs are an affordable, versatile, nutrient-dense food that can contribute positively to diet quality, satiety, pregnancy nutrition and healthy aging. Current evidence does not support restricting egg intake in healthy people solely because of their cholesterol content; instead, eggs should be considered within the context of the overall dietary pattern and individual cardiometabolic risk profile. The South African Food-Based Dietary Guideline, “Fish, chicken, lean meat and eggs can be eaten daily,” recognises eggs as nutrient-dense foods that provide high-quality protein and essential micronutrients, including vitamin A, B vitamins, iron and zinc, which are commonly lacking in South African diets (1). The guideline concludes that moderate consumption of eggs (approximately four eggs per week), alongside other animal-source foods, can contribute meaningfully to nutrient adequacy and overall diet quality, with no scientific justification for excluding eggs from a healthy diet when consumed as part of a balanced eating pattern (1).

Reflections💭

·        If you struggle to consume enough protein each day, have you considered including eggs more regularly as an affordable and convenient source of high-quality protein?

·        If you dislike taking vitamin or mineral supplements, would adding an egg to your daily diet help increase your intake of important nutrients such as choline, vitamin B₁₂, selenium and iodine?

·        When you eat eggs, what foods do you typically eat with them? Could choosing healthier accompaniments (e.g. vegetables, whole grains and fruit rather than processed meats such as bacon and cheese grillers) improve the overall nutritional quality of the meal?

·        Could an egg-based breakfast help you feel fuller for longer and reduce unnecessary snacking later in the day?

·        Considering their affordability, versatility and nutrient density, are eggs a food that could help you improve your diet quality without substantially increasing your food budget?

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References 📚

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In developing this work, the author utilised ChatGPT-4 to assist with language editing.