Nutrient loading (notably nitrogen and phosphorus) to coastal oceans from food production, fossil fuel burning, aquaculture operations, and wastewater from humans, livestock, and industry has accelerated during the past decades, causing over-enrichment of nutrients, or eutrophication. Eutrophication degrades coastal water quality with two most common symptoms, hypoxia and harmful algal blooms, creating profound ecological and societal consequences such as biodiversity decline, seagrass loss, coral bleaching, fish kills and marine mammal mortalities, and human health threats. Such marine pollution symptoms have persisted although billions of dollars have been invested in both research and management as well as efforts of restorations in many developed countries. Consequently, we are still witnessing trends in the expansion of coastal eutrophication and hypoxia from developed regions into developing regions. Though the limited efficacy of mitigation witnessed so far suggests the complexity of the issue, we contend that closing the knowledge gaps in the causality between eutrophication and hypoxia is essential and crucial towards making science-and evidence-based policies. We recognize that the non-linear cause-effect relationship in coastal marine ecosystem degradation caused by multi-stressors is complex.The strength and synergistic effect of multiple driving forces of coastal eutrophication is dependent on regional geographic feature, economic development, and societal management, while the long-term trends of eutrophication and hypoxia are subject to the control of the trends in nutrient loadings and physical dynamics under a changing climate. This review also examines lessons from past eutrophication management practices, and advocates for a better, more efficient indexing system of coastal eutrophication and an advanced regional earth system modeling framework to facilitate the development and evaluation of effective policy and restoration actions.