Nuts and Whole Grains for Cardiometabolic Health

Penny Kris-Etherton, PhD, RD

Distinguished Professor of Nutrition

The Pennsylvania State University

Outline

Tree Nuts and Peanuts

� Almonds

� Brazil Nuts

� Cashews

� Hazelnuts

� Macadamia Nuts

� Pecans

� Pine Nuts

� Pistachios

� Walnuts

� Peanuts

Whole Grain Foods

� Whole wheat and whole wheat flour

� Whole oats and whole oat flour

� Whole cornmeal and whole corn flour

� Brown rice and brown rice flour

� Whole rye and whole rye flour

� Whole barley

� Bulgur

� Buckwheat

� Popcorn

� Amaranth

� Psyllium

Hu et al. JAMA 2002;288:2569-2578

Prospective Cohort Studies of Relative Risk of CVD and Consumption of Nuts, Fruits and Vegetables, or Whole Grains

Comparison between highest and lowest consumption groups

Relationships between Changes in Food and Beverage Consumption and Weight Changes Every 4 Years, According to Study Cohort

Mozaffarian. N Engl J Med 2011; 364:2392-2404

Frequency of Nut Consumption and CHD Risk Reduction in a Dose-Response Manner

Taken from DGAC 2010 Report.

0.75

0.45

0.52

0.49

0.6

0.82

0.61

0.65

0.61

0.68

0.6

0.43

0

1

2

3

4

5

6

7

8

9

10

11

12

0.2 0.4 0.6 0.8 1 1.2

CARE

Adventist Health

Nurses’ Health

Iowa Women’s Health

Nut Consumption and CHD Risk - Epidemiologic Studies

Relative Risk (RR)

Fatal CHD

Total CHD

Non-fatal MI

Fatal CHD

Total CHD

Total CHDAll-cause mortality

All-cause mortality

Non-fatal MI

Fatal CHD

CHD

Total CHD

TG*LDL/HDLLDL-CTC

-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

Pe

rce

nt

Ch

an

ge

10%

12.2%**

20%

Calories in thediet from nuts

Effect of Nut-Enriched Diets on Serum Lipids and Lipoproteins by Level of Nut Intake: A Pooled

Analysis of 25 Feeding Trials (1284 Data Points)

*TG>150 mg/dL** 43 g

Sabaté J, Oda K, Ros E. Arch Intern Med. 2010;170:821-827.

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

Ch

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in

LD

L-C

fro

m C

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iet

(mm

ol/

L)

Sabate #10

Ros #12

Zambon #13

Iwamoto #14

Chisholm #15

Zhao #16

Abbey #17

Abbey #17

Wien #18

Jenkins #19

Sabate #20

Lovejoy #21

Colquhoun #22

Curb #23

Morgan #24

Rajaram #25

Alphan #26

Observed Changes in LDL-C is Greater than Predicted in Select

Tree Nut Studies

Predicted Observed

Griel & Kris-Etherton. BrJ Nutr. 2006;96(Suppl. 2):S68-S78.

Penny M. Kris-Etherton1,2, J.A. Grieger1, J. Zhang1,2, C.E. Berryman1, J.P. Vanden Heuvel1,2,3, S.G. West1,4

Department of Nutritional Sciences1, Center of Excellence in Nutrigenomics2, Departments of Veterinary and Biomedical Sciences3, Biobehavioral Health4

The Pennsylvania State University, University Park, PA, USA

Acute Effects of Walnut Consumption on Reverse Cholesterol Transport

Serum from Subjects Consuming Whole

Walnuts Increases Cholesterol Efflux

0h 4h 0h 4h

*Serum from subjects after whole walnut

consumption; serum was added as an efflux

inducer to culture media after ABCA1

upregulation by cAMP.Assays conducted

by Dr. George

Rothblat.

Nurses Health Study

BMI of Women According to Frequency of

Nut Consumption (1 oz. serving) at Baseline

Almost Never

(n=29,899)

1-3/mos- 1/wk

(n=43,948)

2-4 times/wk

(n=7746)

> 5 times/wk

(n=4423)

24.8 24.3 23.8 23.4

BMI

Hu et al., BMJ 317: 1341, 1998.

BMI and Energy Intake (kcal)

of Nut Eaters and Non-nut Eaters

Nut eaters

(n=1993)

Non-nut eaters

(n=10,095)

BMI (kg/m2) 23.8 25.0

Energy (kcal/d) 2191 1997

Sabaté. AJCN. 2003;78(Suppl):647S-650S.

26.3

26.6

25.7*

26.1

25

25.5

26

26.5

27

Men Women

Mean BMI of Peanut Users and Nonusers

Users

Nonusers

*P<0.05

Griel et al., J Am Col Nutr. 23:660-668, 2004.

Diet Quality:

Higher calories, MUFA, PUFA, fiber, copper, magnesium and lower CHO, cholesterol and sodium

Health Markers:

Higher HDL-C, RBC & serum folate and lower insulin, glycohemoglobin and CRP

Health Status:

19% decreased risk hypertension, 21% decreased risk low HDL-C

Out-of-Hand Nut Consumption is Associated with Improved Nutrient Intake & Health Risk Markers (Adults)

O’Neil et al. Nutr Research. 2012;32:185-194.

Whole Grains

Multivariable-adjusted Relative Risk (RR) of Type 2 Diabetes and CVD comparing the highest and lowest categories of whole-grain intake in prospective cohort studies

Type 2 Diabetes CVD

Ye E Q et al. J. Nutr. 2012;142:1304-1313

Weighted mean difference in post-treatment

metabolic biomarker concentrations comparing

whole-grain intervention groups to controls

Metabolic biomarkers Studies, nWeighted mean

difference (95% CI)

Fasting insulin, pmol/L 10 −0.29 (−0.59, 0.01)

Fasting glucose, mmol/L 11 −0.93 (−1.65, −0.21)

Total cholesterol, mmol/L 16 −0.83 (−1.24, −0.42)

LDL-cholesterol, mmol/L 15 −0.72 (−1.34, −0.11)

Systolic blood pressure, mm Hg 6 −0.06 (−0.21, 0.10)

Diastolic blood pressure, mm Hg 6 −0.05 (−0.21, 0.11)

Weight gain, kg 9 −0.18 (−0.54, 0.18)

Ye E Q et al. J. Nutr. 2012;142:1304-1313.

Study Data Source Reported Association/Outcome Reference

Health Professionals Follow-Up(42,850 adult men), 14 years of follow-up

18% reduction in coronary heart disease (Jensen et al 2004)

Nurse’s Health Study (75,521 adultwomen), up to 12 years follow-up

36% reduction in ischemic stroke (Liu et al 2000)

Iowa Women’s Health Study (38,470postmenopausal women), 9 years offollow-up

18% reduction in all cardiovascular disease deaths18% reduction in coronary heart disease

(Jacobs et al 1999)

Iowa Women’s Health Study (34,491postmenopausal women), 9 years offollow-up

30% reduction in ischemic heart diseasedeath

(Jacobs et al 1998)

U.S., Boston adult 535 men andwomen

52% reduction in CVD mortality (Sahyoun et al 2006)

Atherosclerosis Risk in Communities(ARIC) Study (15,972 adult men andwomen), 11 year follow-up

23% reduction in all-cause mortality 28% reduction in incident coronary artery

(Steffen et al 2003)

Summary of Large-Scale Observational Studies Showing a Benefit of Increased Whole Grain Consumption on CVD Risk*

Summary of Large-Scale Observational Studies Showing a Benefit of Increased Whole Grain Consumption on CVD Risk*

*Only significant differences are reported unless otherwise stated (P < 0.05).

Seal & Brownlee. Cereal Chem. 2010;87:167-174.

Inverse Association Between Whole

Grain Intake and Type 2 Diabetes

de Munter et al. PLOS Medicine. 2007;4;e261:1385-1395.

Summary: 2 sv/day WG decreased risk 21%

0

2

4

6

8

10

12

Nu

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of

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wit

h P

red

iab

ete

s(n

)

BL ISO HYPO

13% decrease

90% decrease

Prevalence of Prediabetes

Refined Grain Whole GrainData presented by KA Harris at

Experimental Biology, 2012

88

90

92

94

96

98

100

102

104

106

108

Glu

cose

(m

g/d

L)

RG, Normal WG, Normal

RG, PreDiabetic WG, Prediabetic

BL ISO HYPO

Individuals with Prediabetes had Greater Reductions in

Fasting Glucose on the Whole Grain Compared to the

Refined Grain Diet

Prediabetes

cut point

P-value for time x treatment x prediabetic status interaction from repeated measures

ANCOVA (mixed model) including age, sex and BMI at baseline as covariates.

n=10

n=8

n=17n=15

Data presented by KA Harris at

Experimental Biology, 2012

Whole Grain Intake and Incident of Hypertension In Men: Health Professionals Follow-Up Study, 1986-2004

Whole Grain Intake and Incident of Hypertension In Men: Health Professionals Follow-Up Study, 1986-2004

Quintile of whole grain intake

1 2 3 4 5 P for trend

Median intake (g/d)2 3.3 9.8 17.1 26.9 46.0 —

No. of cases 1826 1917 1922 1914 1648 —

Person-years 61,137 68,966 72,196 73,184 69,877 —

Age- and energy-adjusted RR

1.00 0.90 0.83 0.81 0.72 <0.0001

Multivariate-adjusted RR

1.00 0.94 0.89 0.89 0.81 <0.0001

Flint. et al. Am J Clin Nutr. 2009;90:493-498

Relative risks (RRs) and 95% CIs of Incident Hypertension in 31,684 Men by Quintile of Whole-grain Intake: Health Professionals Follow-Up Study, 1986–2004

Quintile of whole-grain intake

1 2 3 4 5 P for trend

Median intake (g/d)2

3.3 (0–6.5)

9.8 (6.6–13.2)

17.1 (13.3–21.4)

26.9 (21.5–34.2)

46.0 (34.3–326.4)

—

No. of cases 1826 1917 1922 1914 1648 —

Person-years 61,137 68,966 72,196 73,184 69,877 —

Age- and energy-adjusted RR3

1.000.90

(0.84, 0.96)

0.83 (0.78, 0.89)

0.81 (0.76, 0.87)

0.72 (0.67, 0.77)

<0.0001

Multivariate-adjusted RR3,4 1.00

0.94 (0.88, 1.01)

0.89 (0.83, 0.95)

0.89 (0.84, 0.96)

0.81 (0.75, 0.87)

<0.0001

Flint et al. Am J Clin Nutr. 2009;90:493-498.

1 RRs derived from proportional hazards models. 2 Ranges in parentheses. 3 95% CIs in parentheses. 4 Adjusted for age, energy, family history of coronary heart disease, family history of hypertension, smoking, alcohol, marital status, profession, height, fruit and vegetable intakes, sodium intake, physical activity, multivitamin use, and cholesterol screening.

Whole Grains & Stroke:Epidemiologic EvidenceWhole Grains & Stroke:Epidemiologic Evidence

• Harvard Nurses’ Health Study (75,000 women)

3 servings of whole grain food/day

36% � risk of ischemic stroke

(24% after controlling for fiber)

Liu et al. JAMA. 2000;284:1534-1540

Whole Grains & Obesity:

Epidemiologic Evidence

WG = 0 O < WG <1 WG >1

BMI 29.0 ± 0.3 28.2 ± 0.4 27.1 ± 0.5a

Waist Circumference

93.9 ± 0.9 91.8 ± 1.1 90.3 ± 1.3a

NHANES 1999-2000

Whole Grain (WG) Intake Inversely Associated with BMI and Waist Circumference in Adult Women

Good et al. JACN 2008;27:80-87.

a Means with superscripts are significantly different from 0 WG servings, p<0.05

Whole Grains and Waist Circumference: Epidemiologic StudiesHigher Whole Grain (WG) Intake (3 servings/day) is associated with Lower Central Adiposity

Whole Grains and Waist Circumference: Epidemiologic StudiesHigher Whole Grain (WG) Intake (3 servings/day) is associated with Lower Central Adiposity

Mean difference (and 95% confidence interval, CI) in waist:hip ratio (WHR)

or waist circumference (WC) when low or no whole-grain intake is

compared with high intake

Harland & Garton. Public Health Nutrition. 2008;11:554-563.

Means and percentages of body mass index and insulin, by category of whole grain intake, MESA 2000–2002

Means and percentages of body mass index and insulin, by category of whole grain intake, MESA 2000–2002

Whole Grain Intake Category

1 2 3 4 5 P trend

Median whole grain intake

0.02 0.15 0.39 0.72 1.39

N 1069 1137 1072 1121 1097

BMI 28.2 28.2 27.9 27.8 27.6 <0.0001

Insulin 5.37 5.42 5.42 5.19 5.16 <0.002

Lutsey et al. Br J Nutr. 2007;98:397–405 .

Whole-grain intake is inversely associated with the metabolic syndrome in older adultsWhole-grain intake is inversely associated with the metabolic syndrome in older adults

Variables

Grain intake

P for trend1Q1 Q2 Q3 Q4

Whole grain

n 135 132 135 133

Median whole grain intake (servings/d)2

0.31 0.86 1.49 2.90 0.001

BMI (kg/m2) 26.4 25.5 25.3 25.2 0.03

Glucose (mg/dL) 114.9 113.1 111.5 108.5 0.01

Metabolic syndrome(Odds ratios)

1.00 0.58 0.41 0.46 0.005

The study population was composed of 179 (33%) men and 356 (67%) women with an average age of 72.1 y for men and 73.4 y for women

Sahyoun et al. Am J Clin Nutr. 2006;83:124-131.

Markers of Cardiovascular Risk in the WHOLEheart Study (RCT) N = 316Markers of Cardiovascular Risk in the WHOLEheart Study (RCT) N = 316

“…there were no significant differences in any markers of CVD risk between groups.” Control vs WG (60g/day)

“…there were no significant differences in any markers of CVD risk between groups.” Control vs WG (60g/day)

Difference (%) from control group mean Significance

Lipid Profile

Total Cholesterol -0.60 NS

HDL -1.63 NS

LDL (calculated) -1.01 NS

TAG 2.24 NS

Insulin Sensitivity

Glucose -0.82 NS

Insulin 1.84 NS

Inflammatory Status

CRP -1.20 NS

IL-6 ND NS

Anthropometric Measures

Systolic BP -0.73 NS

Diastolic BP -0.18 NS

Weight -0.01 NS

Waist 0.1 NS

Body Fat Percentage

0 NS

Brownlee et al. Br J Nutr. 2010;104:125-134.

Cholesterol lowering effects of oat ß-glucanCholesterol lowering effects of oat ß-glucan

Othman RA et al. Cholesterol-lowering effects of oat ß-glucan. Nutr Rev. 2011 Jun; 69(6): 299-309

Whole Grain & Total Mortality:Epidemiologic StudiesWhole Grain & Total Mortality:Epidemiologic Studies

Harvard Male Health Professionals (86,000)

Iowa Women’s Health Study (34,333)

Harvard Male Health Professionals (86,000)

Iowa Women’s Health Study (34,333)

Liu et al. AJCN. 2003;77:594-599; Jacobs et al. Am J Pub Health. 1999;89:322-329

1 or more serving/day of whole grain cereal (compared to none)

MortalityRR 0.80

3 or more servings/day of whole grain foods

HazardRR 0.86

Phytonutrients

� Small but powerful disease fighters found naturally in plant and plant-based foods.

� Whole grains contain significant amounts of the phytonutrients lignan, phytic acid, and phytosterols.

� Aim to get a variety of whole grains in your diet—that way you’re more likely to get all of the phytonutrients your body needs!

Summary

Consume Fiber-Rich Whole Grains!

Enjoy Nuts for Health!