Nuts shown to offer health benefits

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1 134 Nuts shown to offer health benefits J.F. Diehl This article is by Johannes Friedrich Diehl, who was director of the Federal Research Center for Nutrition in Karlsruhe, Germany, until his retirement in His postretirement activities have included an honorary professorship at the University of Karlsruhe and being co-editor of Acta Alimentaria. Until a few years ago, nutritional advice was characterized by various prohibitions. Consumers were warned to reduce consumption of or not to eat this or that food: butter, eggs, sugar, salt, vegetables rich in nitrate, fruit containing pesticide residues, and so on. This kind of nutritional guidance was not very useful. Many consumers thought that if everything was harmful anyway, they might as well go on eating as before. More recently, the issue has shifted from harmful to beneficial properties of certain kinds of food. A high consumption of fruit and vegetables is now at the top of nutritional advice. The German Nutrition Society, for instance, recommends that adults consume 200 g of cooked vegetables, 100 g of fresh vegetables, 75 g of salad, and 250 to 300 g of fruit each day. The question of which kinds of fruit and vegetables provide the highest health benefits and which constituents of plants are responsible for the beneficial effects is currently under investigation in laboratories all over the world. Although tree nuts are also fruit, their role in the diet went unnoticed in the past. Mentioned infrequently if at all, nuts have been perceived for a long time as a high-fat, high-calorie food to be avoided or to be consumed with strict moderation. The results of recent research have changed this situation completely. To eat a handful of mixed nuts a day is now considered good nutritional advice in the context of a healthful and balanced diet. The first reports indicating a beneficial role of nut consumption came as part of the Adventist Health Study carried out by Fraser and collaborators at Loma Linda University in California.

2 135 Dietary habits of Seventh-Day Adventists, a Christian group strongly represented in California, differ markedly from the American average. They eat mostly cereal products, fruit, and vegetables, but little or no meat. Some 30 years ago, more than 30,000 Adventists agreed to participate in a study that obliged them to fill out questionnaires on their dietary habits and their health status over a period of many years. As time progressed, investigators evaluating the questionnaires recognized to their surprise that nut consumption correlated with a lowered risk of coronary heart disease (CHD). Compared to participants eating nuts less than once a month, those eating nuts once or twice a month had a 22% lower risk of fatal CHD. With increasing nut consumption the effect became more pronounced. Those eating nuts daily or more than once a day had a 59% lower risk of fatal CHD. Men, women, vegetarians, nonvegetarians, hypertensives, nonhypertensives, relatively obese or relatively thin subjects, and older or younger persons who ate nuts frequently all had a substantially lower CHD risk than their counterparts rarely eating nuts. Other epidemiologic studies confirmed these results. The Iowa Women s Health Study followed some 35,000 postmenopausal women without cardiovascular disease since Seven years of data showed that women who ate nuts more than four times a month were found to have a 40% reduction in risk of CHD compared to those who never ate nuts. This was despite the fact that, in this population, the proportion of participants with a high nut consumption was much smaller than in the Adventist Study. The Nurses Health Study followed more than 86,000 nurses for 14 years and found that those consuming five or more ounces (140 g) of nuts per week had a 35% reduced risk for total CHD, a 39% reduced risk for fatal CHD, and a 32% decreased risk for nonfatal heart infarction compared with those who consumed less than one ounce of nuts (28 g) per week. Similarly, in the Physicians Health Study of 22,000 male physicians the risk of cardiac death decreased as nut consumption increased. In the Cholesterol and Recurrent Events Study, the effect of nut consumption on recurrence of heart infarction was investigated. Compared with those who rarely ate nuts, those eating nuts at least twice a week had a 25% lower risk of recurrence. The results of those five epidemiologic studies in different populations are remarkably consistent; they all confirm an inverse association between the frequency of nut consumption and the risk of fatal or nonfatal CHD. This effect persists when adjustments are made for other known risk factors, such as smoking, alcohol use, or lack of exercise. The epidemiologic evidence showing a cardioprotective effect of nut consumption has sparked much interest in the scientific community. Do all kinds of nuts show this effect or are some kinds more heart protective than others? Which constituents of nuts are responsible for the beneficial effects? Clinical studies, so-called intervention studies, are an important tool for providing answers to these questions. For a period of several weeks, groups of volunteers consume either a diet free of nuts (the control group ) or a diet containing a certain amount of mixed nuts or of one kind of nuts (the experimental group ). In one of the latest investigations of this kind by Almario and colleagues at the University of California Davis, four Those eating nuts had a 22% lower risk of fatal CHD.

3 136 groups of participants consumed (a) a habitual diet, (b) a habitual diet plus walnuts (about 50 g/day), (c) a low-fat diet, or (d) a low-fat diet plus walnuts. Some studies have followed a crossover design in which only one group of volunteers was used, alternately receiving a nut-free or a nut-containing diet for a specified period of time. In such studies, each participant thus serves as his or her own control. Blood samples are collected, usually at the beginning and at the end of a dietary period, and total blood cholesterol, LDL (low-density lipoprotein or bad cholesterol ), HDL (high-density lipoprotein or good cholesterol ), and sometimes other blood constituents considered to be risk factors for cardiovascular disease are determined. To date, about a dozen studies have evaluated the effects of nut diets. Almonds, walnuts, hazelnuts, pecans, pistachio nuts, and macadamia nuts have been tested. Several of these investigations were carried out in the United States, some in Australia, New Zealand, Japan, Turkey, and Spain. The participants sometimes were healthy adults, sometimes hypercholesterolemic patients. In some studies, the basic diet was freely chosen by the participants; in other studies, a strictly controlled low-fat diet was prescribed. The amount of nuts consumed per day also varied. The diet containing nuts and the basic (nut-free) diet sometimes were isocaloric and sometimes not. Despite these differences in design, all reports indicated a lowering of blood cholesterol levels by about 5 to 15% as a result of nut consumption during a few weeks, with a similar effect on LDL levels. HDL was unaffected in most studies. These results compare very favorably with those achieved by application of cholesterol-lowering drugs. Nuts are a good source of unsaturated fatty acids, and the cholesterollowering effects of diets rich in unsaturated fatty acids are well known. The question of whether the cardioprotective effect of nuts can be explained solely by the favorable fatty acid profile of nuts or whether other constituents contribute to this effect cannot yet be answered with certainty. The issue is complicated by the fact that the fatty acid composition differs considerably in different kinds of nuts. Monounsaturated fats vary from 9 g/100 g in walnuts to 59 g/100 g in macadamia nuts. Polyunsaturated fats range from 1 g/100 g in macadamias to 47 g/100 g in walnuts. The proportion of saturated fats is relatively low in all species of nuts (see Table 1). In the Nurses Health Study, for each 5% increase in energy intake from saturated fatty acids (compared with the equivalent intake from carbohydrate), CHD risk increased by 17%, whereas for each 5% increase in energy intake from mono- and polyunsaturated fatty acids, CHD risk decreased by 24 and 60%, respectively. On this basis, Kris-Etherton and coworkers at Pennsylvania State University at University Park, Pennsylvania, estimated the percent change in CHD risk attributable to the changes in fatty acid profile after consuming nuts. They concluded that the fatty acid profile of nuts can explain only part of the total reduction in CHD risk and that other bioactive components in nuts probably contribute to this effect. This conclusion is supported by the results of animal feeding studies carried out in France by Roussel and colleagues. When rabbits or rats were fed either walnut oil or fat-free walnut meal, a similar cholesterol-lowering effect was observed. Substances in the fat-free portion of the nuts must be exerting an effect comparable to that of the fatty acids. What these may be is open to speculation. The fat-free walnut meal is rich in proteins having a high arginine content. In the animal and human organism, arginine serves as a precursor of the endotheliumderived relaxing factor, which has been identified as nitric oxide (NO). NO is a potent dilator of blood vessels and can affect blood clotting by inhibiting platelet adhesion and aggregation. Thus, it has been proposed that the cardioprotective effect of nuts may be partly related to the arginine NO pathway. Other explanations postulated for a health benefit of nuts have mentioned their high content of phytosterols and other phytochemical compounds including ellagic acid, luteolin, and other flavonoids and polyphenols. Relatively high levels of magnesium, copper, selenium, potassium, fiber, folic acid, tocotrienols and tocopherols may also contribute. Obviously, many interesting questions remain to be studied. We can expect further publications on epidemiologic, clinical, and animal studies, as well as analytical investigations on bioactive compounds in various nut species in the near future. Efforts to integrate the conclusions from all these reports into a convincing scientific concept and, last but not least, into specific dietary recommendations to consumers are bound to follow. B IBLIOGRAPHY Almario, R.U., V. Vonghavaravat, R. Wong, and S.E. Kasim-Karakas, Effects of Walnut Consumption on Plasma Fatty Acids and

4 137 Table 1 Nutrients in 100 grams of unsalted tree nuts Nutrient Unit Almond Cashew Hazelnut Macadamia Pecan Pistachio Walnut Calories kcal Protein gram Total fat gram Carbonydrate gram Fiber gram Sugars gram 5 NA Calcium mg Iron mg Magnesium mg Phosphorus mg Potassium mg , Sodium mg Zinc mg Copper mg Manganese mg Selenium mcg Vitamin C mg Thiamin mg Riboflavin mg Niacin mg Pantothenic acid mg Vitamin B6 mg Folate mcg Vitamin B12 mcg Vitamin A IU Vitamin A mcg RE Vitamin E mg ATE Cholesterol mg Saturated fat gram MUFA gram PUFA gram Linoleic acid gram Linolenic acid gram Phytosterols mg Amino acids Tryptophan gram Threonine gram Isoleucine gram Leucine gram Lysine gram Methionine gram Cystine gram Phenylalanine gram Tyrosine gram Valine gram Arginine gram Histidine gram Alanine gram Aspartic acid gram Glutamic acid gram Glycine gram Proline gram Serine gram mg, milligram; mcg, microgram; IU, international unit; RE, retinol equivalent; ATE, α-tocopherol equivalent; NA, not available Source: U.S. Department of Agriculture Nutrient Database for Standard Reference

5 138 Lipoproteins in Combined Hyperlipidemia, Am. J. Clin. Nutr. 74:72 79 (2001). Fraser, G.E., Nut Consumption, Lipids, and Risk of a Coronary Event, Clin. Cardiol. 22 (Suppl. III):11 15 (1999). Hu, F.B., and M.J. Stampfer, Nut Consumption and Risk of Coronary Heart Disease: A Review of Epidemiologic Evidence, Curr. Atheroscl. Rep. 1: (1999). Kris-Etherton, P.M., G. Zhao, A.E. Binkoski, S.M. Coval, and T.D. Etherton, The Effects of Nuts on Coronary Heart Disease Risk, Nutr. Rev. 59: (2001). Roussel, A.M., A. Ravel, J. Alary, and J. Laturaze, Le Tourteau de Noix. Propriétés Hypolipidémiantes et Antiagrégantes chez le Rat. Relation avec sa Composition, Sci. Alim. 7: (1987). Sabaté, J., Nut Consumption, Vegetarian Diets, Ischemic Heart Disease Risk, and All-Cause Mortality: Evidence from Epidemiologic Studies, Am. J. Clin. Nutr. 70 (Suppl.):500S 503S (1999). Spiller, G.A., D.A.J. Jenkins, O. Bosello, J.E. Gates, L.N. Cragen, and B. Bruce, Nuts and Plasma Lipids: An Almond-Based Diet Lowers LDL-C While Preserving HDL-C, J. Am. Coll. Nutr. 17: (1998). Zambon, D., J. Sabaté, S. Munoz, B. Campero, E. Casals, M. Merlos, J.C. Laguna, and E. Ros, Substituting Walnuts for Monounsaturated Fat Improves the Serum Lipid Profile of Hypercholesterolemic Men and Women. A Randomized Crossover Trial, Ann. Int. Med. 132: (2000). Readers may contact the author at: Wildbader Str. 6, D Karlsruhe, Germany (phone: ; fax: ; J.F.Diehl@t-online.de).

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