go nuts?

A place to get your questions answered from McDougall staff dietitian, Jeff Novick, MS, RDN.

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go nuts?

Postby landog » Sat Nov 23, 2013 6:56 am

Given the "latest health news" :), is it time to reconsider nuts?

People who ate nuts seven or more times per week had a 20 percent lower death rate

..and by reconsider, I mean go from this:

JeffN wrote:if someone was to follow an optimal health supporting diet, and they wanted to include some nuts/seeds, then there is probably no problem with the inclusion of 1 or 2 oz of nuts/seeds (without oil and/or salt).


..to: "there are clear benefits with the inclusion of 1 or 2 oz of nuts on regular basis to your healthy diet?"
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Science vs Sensationalism: A Simple Lesson in Critical Think

Postby JeffN » Sat Nov 23, 2013 8:22 am

landog wrote:Given the "latest health news" :), is it time to reconsider nuts?

People who ate nuts seven or more times per week had a 20 percent lower death rate

..and by reconsider, I mean go from this:

JeffN wrote:if someone was to follow an optimal health supporting diet, and they wanted to include some nuts/seeds, then there is probably no problem with the inclusion of 1 or 2 oz of nuts/seeds (without oil and/or salt).


..to: "there are clear benefits with the inclusion of 1 or 2 oz of nuts on regular basis to your healthy diet?"



As with everything, the results have to be put in proper context and perspective.


POINT 1- Breaking Health News

See my article,"Today's Breaking Health News"

http://www.jeffnovick.com/RD/Articles/E ... ews!!.html

the thread on "High Quality Foods"

http://www.drmcdougall.com/forums/viewt ... 22&t=28413

especially the part on "effect size."

http://www.drmcdougall.com/forums/viewt ... 15#p377392

and my talk, "Nuts & Health."

http://www.jeffnovick.com/RD/Nuts_%26_Health.html

https://secure2.vegsource.com/catalog/p ... cts_id=501


POINT 2 - The Bigger Picture

EPIC is a large study of diet and health having recruited over half a million (520,000) people in ten European countries: Denmark, France, Germany, Greece, Italy, The Netherlands, Norway, Spain, Sweden and the United Kingdom.EPIC was designed to investigate the relationships between diet, nutritional status, lifestyle and environmental factors and the incidence of cancer and other chronic diseases.

Many studies have come out of this database but 2 important ones are..

1) They followed 25,663 Adults, Aged 45-79 Years Since 1993-2006

They found

- Eating 5 servings of fruit & veggies/day gives you the life expectancy of someone 3 yrs younger.
- Not smoking turned the clock back by 4-5 years.
- Increasing exercise by a moderate amount takes up to three years off.

Following these three simple changes was the equivalent of adding 10 more healthy years to your life expectancy

Khaw KT, Bingham S, Welch A, Luben R, Wareham N, et al. (2001) Relation between plasma ascorbic acid and mortality in men and women in EPIC-Norfolk prospective study: a prospective population study. European Prospective Investigation into Cancer and Nutrition. Lancet 357: 657–663. Find this article online

Khaw KT, Jakes R, Bingham S, Welch A, Luben R, et al. (2006) Work and leisure time physical activity assessed using a simple, pragmatic, validated questionnaire and incident cardiovascular disease and all-cause mortality in men and women: The European Prospective Investigation into Cancer in Norfolk prospective population study. Int J Epidemiol 35: 1034–1043

2) In a separate study that came out about a year later, they added in alcohol intake and found if someone followed the three behaviors above and limited alcohol intake, it was the equivalent of adding up to 14 more healthy years to your life expectancy.


Khaw KT, Wareham N, Bingham S, Welch A, Luben R, et al. (2008) Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study . PLoS Med 5(1): e12 doi:10.1371/journal.pmed.0050012

In the WHO report, "Preventing Chronic Diseases: A Vital Investment' 06/06/2005," they found that of the 35 million deaths from chronic disease each year, three most important modifiable risk factors are:

- unhealthy diet and excessive energy intake; (which are really 2 issues 1) poor diet, 2) excess weight)
- physical inactivity;
- tobacco use.

And, that these 3 modifiable risk factors cause/lead to the intermediate risk factors of raised blood pressure, raised glucose levels, abnormal blood lipids (particularly low density lipoprotein-LDL cholesterol), and overweight (body mass index 25- 29.9 kg/m2) and obesity (body mass index > 30 kg/m2).

They Estimated that of the 3 most important modifiable risk factors,

-4.9 Mil Die As a Result of Tobacco Use,
-2.7 Mil Die As a Result of Low Fruit/Vegetable Intake,
-1.9 Mil Die As a Result of Physical Inactivity

Added together, these three simple lifestyle behaviors themselves account for over 40% of the lifestyle related premature deaths.

In addition, they estimated that
-2.6 million people die as a result of Excess Weight
-7.1 million people die as a result of raised blood pressure;
-4.4 million people die as a result of raised total cholesterol levels

These add up to almost 24 million deaths per year, which is 65% of the 35 million people who die prematurely from chronic diseases that can easily be prevented by a few simple lifestyle behaviors.

And, since the WHO says that the first 3 cause the second 3, we can then also say that the first 3 simple lifestyle behaviors themselves could prevent over 65% of the premature death from chronic disease.

They also said, "the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented."

As a result of the above and other similar studies, these 5 behaviors, not smoking, maintaining a healthy weight, eating a healthy diet (with at least 5 servings of fruits and veggies/day), exercising a min 150 min/week and not drinking or not drinking above the recommended minimums, are known as the 5 Healthy Lifestyle Characteristics and when practiced together, can eliminate about 70% (or more) of the total burden of preventable chronic disease.

In this recent study, those who met the criteria of 4 out of 5, had a lower death rate by 80%.

Low-Risk Lifestyle, Coronary Calcium, Cardiovascular Events, and Mortality: Results From MESA. American Journal of Epidemiology, 2013; DOI: 10.1093/aje/kws453

The MESA study followed 6,200 men and women, age 44-84, from white, African-American, Hispanic and Chinese backgrounds for an average of 7.6 years. They looked at 4 Lifestyle Behaviors

- Healthy Diet,
- BMI
- Physical Activity
- Smoking Status.

Following all 4 behaviors lowered death rate by 80%

The above recent study also showed us the impact of smoking as not smoking was the most important factor as smokers with 2 or more other HLC had lower survival rates than nonsmokers who were sedentary and obese.

WOW! :)

And this recent study showed the impact of just eating a few more fruits and/or veggies...

In the study, Fruit & vegetable consumption & all-cause mortality: a dose-response analysis. (Am J Clin Nutr August 2013 ajcn.056119), 71,000 participants were followed for 13 years.

- Those who ate 5 servings of fruits & veggies/day lived 3 years more and had 35% lower mortality rate
- Those who ate just 1 servings fruit/day lived 19 months longer
- Those who consumed 3 servings veggies/day lived 32 months longer

Regardless of which fruit or vegetable!

Double WOW! :)


POINT 3- Proper Application

The current study in discussion comes from data from the Nurses Health Study and the Health Professionals Follow-up Study.

"We examined the association between nut consumption and subsequent total and cause-specific mortality among 76,464 women in the Nurses' Health Study (1980–2010) and 42,498 men in the Health Professionals Follow-up Study (1986–2010)."

We have discussed this group many times and they are not a very healthy group.

When they look at 84,129 women participating in the Nurses' Health Study from 1980-1994 for the following 5 healthy characteristics.

- Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- Healthy BMI
- Moderate alcohol (< 5g/d)

- Only 12.7% practiced any three of the above
- Only 7.2% practiced any four of the above
- Only 3.1% practiced all 5 Healthy Lifestyle Characteristics

Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000; 343: 16–22

When they looked at 42,847 men in the Health Professionals Follow-up Study, 40 to 75 years of age and free of disease in 1986 for the following 5 healthy characteristics.

- Not currently smoking
- Diet score top 40%
- Exercise ≥30 min/d
- BMI
- Moderate alcohol (5–30 g/d) or less

Only 32% practiced any two of the above
Only 28% practiced any three of the above
Only 14% practiced any four of the above

and

Only 4% practiced all 5 Healthy Lifestyle Characteristics

Circulation. 2006 Jul 11;114(2):160-7. Epub 2006 Jul 3.Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications.

So, amongst this group, most do not follow a health lifestyle and so are nothing like you or me or anyone following a WF, PB diet low in SOS who are also active, at a healthy weight, and don't drink or don't smoke.

So, I am not sure how showing a behavior that lowers death rate 20% in a population where only 4% meet the criteria for the 5 Healthy Lifestyle Characteristics has anything to do with a population that easily meets the 5 criteria and most all of us also far surpass the 5 Healthy Lifestyle Characteristics, which, in and of themselves, can lower death rate by 80%.


POINT 4 - Effect Size

In regard to effect size...

If you take a group of people who do not meet the 5 Healthy Lifestyle Characteristics and are eating an unhealthy diet most likely low in many nutrients, and you give them a few servings a week of a healthy food fairly rich in nutrients, they will do better. No Doubt! And, we will see this impact regardless of whether it is a few more servings of kale, broccoli, blueberries, acai berries, walnuts, brown rice, etc etc. That is because this food will have a positive impact on their poor diet. And, that is why we see this in the news all the time about broccoli, kale, cauliflower, carrots, walnuts, etc etc etc.

But, that means absolutely nothing at all to anyone already consuming a diet that consists predominately of a variety of unrefined, minimally processed plant foods rich in fruits and vegetables. Where is there any evidence at all that adding another few servings a week of kale, blueberries, or walnuts to such a diet, has any effect?

There is none because it doesn't exist. The only evidence is when it is added to a poor(er) diet.

Truth is, using the above approach of adding several servings a week of a fruit or vegetables to a poor(er) diet, all and any fruits and veggies could be shown to be super foods. If they tracked broccoli intake, they would find it increases lifespan by X%, carrots extend life by X%, and so on and so on.

Oh, they already do that, as you can see here...

http://www.drmcdougall.com/forums/viewt ... 15#p429750

:)

As I mentioned earlier...

In the study, Fruit & vegetable consumption & all-cause mortality: a dose-response analysis. (Am J Clin Nutr August 2013 ajcn.056119), 71,000 participants were followed for 13 years.

- Those who ate 5 servings of fruits & veggies/day lived 3 years more and had 35% lower mortality rate
- Those who ate just 1 servings fruit/day lived 19 months longer
- Those who consumed 3 servings veggies/day lived 32 months longer

Regardless of which fruit or veggie!

The fact that these studies are being done is not the surprise, as showing the impact of dietary patterns is a good thing. The surprise is when they use the data to turn certain foods into super foods and when people fall prey to this, especially those of you who are here who should know better as you already "get it" in regard to these tricks when the egg board or dairy industry etc etc do it.


POINT 5 - Statistical Significance vs Clinical Relevance

In this pooled analysis of nuts and blood lipids....

Nut consumption and blood lipid levels: a pooled analysis of 25 intervention trials. Sabaté J, Oda K, Ros E. Arch Intern Med. 2010 May 10;170(9):821-7.PMID: 20458092

http://archinte.jamanetwork.com/article.aspx?articleid=415912

they concluded,

"Nut consumption improves blood lipid levels in a dose-related manner, particularly among subjects with higher LDL-C or with lower BMI."

If you look at Table 2.

http://archinte.jamanetwork.com/article.aspx?articleid=415912#ioi90167t2

The drop in Total Cholesterol was 5.1% and the drop in LDL was 7.1%, both of which were highly significant with a P value of .001.

The question is, does this “statistically significant" drop in cholesterol matter to you?

Let's see....

Scenario 1)

You are typical American eating the SAD and you are at high risk and have a Total Cholesterol of 260 and an LDL of 175. Based on the study above, by consuming about 2.4 oz of nuts a day, your Total Cholesterol would drop to 247 and your LDL would drop to 162. These are both still considered high risk and you have not changed your clinical risk. The change is statistically significant but it is not clinically relevant to you.


Scenario 2)

You are typical American eating the SAD and you are at borderline high risk and have a Total Cholesterol of 239 and an LDL of 145. Based on the study above, by consuming about 2.4 oz of nuts a day, your Total Cholesterol would drop to 227 and your LDL would drop to 135. These are both still considered borderline high risk and you have not changed your clinical risk. The change is statistically significant but it is not clinically relevant to you.


Scenario 3)

You are eating a healthy lower fat, lower calorie dense, minimally processed, low/no SOS diet and you are at very low to no risk and have a Total Cholesterol of 165 and an LDL of 70. Based on the study above, by consuming about 2.4 oz of nuts a day, your Total Cholesterol would drop to 156 and your LDL would drop to 65. These are both still considered very low to no risk and you have not changed your clinical risk. The change may be statistically significant but it is not clinically relevant to you.

The authors also stated that "Greater cholesterol-lowering effect is found when nuts replace saturated fat than when olive oil or carbohydrates are replaced" and that "Nut consumption had greater relative effects in reducing TC and LDL-C (−7.4% and −9.6%, respectively) when assessed against a Western control diet vs against Mediterranean (−4.3% and −6.7%, respectively) or low-fat (−4.1% and −6.0%, respectively) control diets (Figure 2).

[NOTE: this is normal and something we alway see, the better results are in those who have the most to gain. I explained this in my thread, When Low Risk Means High Risk & Hi Benefit Means No Benefit]

https://www.drmcdougall.com/forums/viewtopic.php?f=22&t=43681

So, if you are on a very unhealthy diet like the SAD, and you snack on beef jerky and you switch from the beef jerky to 2.4 oz of nuts a day, and you get the better the average benefit, you can expect to see a statistically significant drop in your total & LDL cholesterol that has little to no clinical relevance to you.

(NOTE: If you apply the higher reduction found on the Western Diet (-7.4% for total cholesterol and -9.6% for LDL), you may go from High Risk to Borderline High Risk).

If you are on a pseudo healthy diet, and you substitute 2 oz of nuts for some food high in saturated fat, and you get the average benefit you can expect to see a statistically significant drop in your total & LDL cholesterol that has no clinical relevance to you.

If you are on a healthy lower fat, lower calorie dense, minimally processed, low/no SOS diet and you are at very low to no risk, and you substitute 2 oz of nuts for some healthy carbohydrate rich foods (as there will be no foods high in saturated fat to substitute the nuts for), and you get the less then average benefit (If any benefit at all since the nuts are not replacing any saturated fat), you will mostly likely not see any change at all, let alone one that will have any meaningful benefit to you.

Now, if you look at the data from Pritikin, the average drop in Total Cholesterol and LDL in 3 weeks, without consuming any nuts or seeds, is 23%, which is not only statistically significant but also very clinically relevant.

This point on statistical significance vs clinical relevance was recently discussed in the news here

Statisticians issue warning over misuse of P values
Policy statement aims to halt missteps in the quest for certainty.
Monya Baker
07 March 2016

"And a P value cannot indicate the importance of a finding; for instance, a drug can have a statistically significant effect on patients’ blood glucose levels without having a therapeutic effect."

http://www.nature.com/news/statistician ... es-1.19503



POINT 6 - Funding

If funding matters to you, you should note that the study was partially funded by the by the International Tree Nut Council Nutrition Research and Education Foundation, a trade group formed by nut manufacturers.


POINT 7 - My Recommendations

If you have seen my presentation, From Oil to Nuts and/or Nuts and Health, or have spent time in these forums, then you know my recommendations which I have taught for over 20 years, which are also taught at the McDougall program (and I taught at the Pritikin Program from 1998-2007 and at the E2 Immersions), are that for most people, the inclusion of "up to" 1-2 oz of nuts per day is fine. In the Nuts and Health talk, I even go "up to" 4 oz/day for certain populations in certain situations. A serving is 1 oz. So, that means, for most everyone, I am allowing 7-14 servings a week and for some populations, up to 28 servings a week.

So, how does the comment, "people who ate nuts seven or more times per week had a 20 percent lower death rate," elicit the comment, "is it time to reconsider nuts?"

Do you mean to reduce my recommendations? :)


POINT 8 - Interpretation, Association & Application

In addition, this is an observational study and as the authors themselves said, because of that, and like any observational study..

"Given the observational nature of our study, it is not possible to conclude that the observed inverse association between nut consumption and mortality reflects cause and effect."

Of course not. No observational study can do that.

But it can show up potential associations. So lets look closer at the data

http://www.nejm.org/doi/full/10.1056/NEJMoa1307352

If you look at Table 1, you will see that those who ate the most nuts and lived the longest, also smoke a great deal less (9.8% vs 17.3%), they ate way more fruits and veggies (6.3 serv/day vs 4.5 serv/day), were way more active (34.2 vs 19.2 met eq/wk) and they weighed less at the start and throughout the study (24.9 vs 26).

Without knowing anything else about the specifics of their diet, there should be no surprise to anyone that amongst this unhealthy population, those who smoked much less, ate much more fruits and veggies, was way more active and weighed less, had a lower death rate.

So, why would you want to misrepresent the researchers conclusion, "it is not possible to conclude that the observed inverse association between nut consumption and mortality reflects cause and effect," to one saying, "there are clear benefits?"

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Re: go nuts?

Postby JeffN » Sat Nov 23, 2013 11:28 am

I received the following comments in regard to the above post..

I don't understand why you are so nut-phobic and so anti-nuts. There is enough evidence supporting their use that no one should be so against nuts as you are!


Thanks!

Perhaps you missed this.. :)

JeffN wrote: If you have seen my presentation, From Oil to Nuts and/or Nuts and Health, or have spent time in these forums, then you know my recommendations which I have taught for over 20 years, which are also taught at the McDougall program (and I taught at the Pritikin Program from 1998-2007 and at the E2 Immersions), are that for most everyone, the inclusion of 1-2 oz of nuts per day is fine. In the Nuts and Health talk, I even go up to 4 oz/day for certain populations in certain situations. A serving is 1 oz. So, that means, for most everyone, I am recommending 7-14 servings a week and for some populations, up to 28 servings a week.


I also received this one on FB..

Rather than all this silly arguing about nuts and seeds by health focused groups , I'd much rather see dead aim taken at plenty of other things, like mega food corps, the fast food industry, the growing love affair with more and more television channels featuring food shows making up he worst kinds of food imaginable, and of course the union of the mega food industry with our government. What they want said is said . As far as I'm concerned if you don't want to eat nut or seeds in an otherwise healthy diet fine, and if you want to eat some nuts and seeds in an otherwise healthy diet, that's fine with me too.


I agree.

However, the issue is that the very food industry and mega food corporations you are talking about (along with the media and even many health professionals) are the ones making these foods into super foods and propping them up way more than they should be, and are the same industries who are sponsoring many of those cooking shows you mentioned, mostly for their own financial gain, which sends a very misleading and confusing message to the public and to those who are trying to eat better. So, taking a few minutes to put it all into perspective is not arguing or silly, but a simple lesson that is of great value to all.

What is silly, is when experts and health care professionals who should know better buy into, promote & even argue for this same reductionist, industry funded super-food concept.

At some point in our lives, we believed in magic and that magicians could really pull a live rabbit out of their hat. Eventually, we learned the secret behind this and while watching the trick is still fun, we fully understand what is going on and no longer believe in magic.

Yet, in spite of being shown and explained the issue with nuts, over and over, again and again, some people still choose to believe in super foods and that the magician is still really pulling a rabbit out of his hat. It is appropriately called, "magical thinking."

Do you still believe in magic?

That is why understanding this issue and perspective, is much more important than any of the minor details of any of these studies.

Otherwise, as David Katz, MD said, "anyone telling you anything different is either 'misguided, selling something or both'."

Thanks!

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Re: go nuts?

Postby JeffN » Fri Apr 03, 2015 5:53 pm

Finally, someone puts it in proper context and perspective as I did above.

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Jeff

Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systematic review and meta-analysis of epidemiologic studies.
Am J Clin Nutr. 2015 Apr;101(4):783-793.
http://www.ncbi.nlm.nih.gov/pubmed/25833976

BACKGROUND:Recent pooled analyses supported a beneficial impact of nut consumption on health, but to our knowledge, whether nuts are associated with overall decreased mortality has not been previously reviewed. OBJECTIVES:We aimed to systematically review prospective studies that explored the effects of nut consumption on all-cause, cardiovascular disease (CVD), and cancer mortality and quantify the size effect through a meta-analysis. We also reviewed confounding factors associated with nut consumption to assess potential clustering with other covariates. DESIGN: We searched PubMed and EMBASE for studies published up to June 2014. Study characteristics, HRs, and 95% CIs were generated on the basis of quantitative analyses. A dose-response analysis was performed when data were available. RESULTS:Seven studies for all-cause mortality, 6 studies for CVD mortality, and 2 studies for cancer mortality were included in the meta-analysis with a total of 354,933 participants, 44,636 cumulative incident deaths, and 3,746,534 cumulative person-years. Nut consumption was associated with some baseline characteristics such as lower body mass index and smoking status as well as increased intakes of fruit, vegetables, and alcohol. One-serving of nuts per week and per day resulted in 4% (RR: 0.96; 95% CI: 0.93, 0.98) and 27% (RR: 0.73; 95% CI: 0.60, 0.88) decreased risk of all-cause mortality, respectively, and decreased risk of CVD mortality [RR: 0.93 (95% CI: 0.88, 0.99) and 0.61 (95% CI: 0.42, 0.91), respectively]. Effects were primarily driven by decreased coronary artery disease deaths rather than stroke deaths. Nut consumption was also associated with decreased risk of cancer deaths when highest compared with lowest categories of intake were compared (RR: 0.86; 95% CI: 0.75, 0.98), but no dose-effect was shown. CONCLUSION:Nut consumption is associated with lower risk of all-cause, CVD, and cancer mortality, but the presence of confounding factors should be taken into account when considering such findings.
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Another Nutty Lesson About Nuts

Postby JeffN » Fri Jul 10, 2015 9:21 am

Last month, another nut study made the headlines claiming that nuts can save your life.

Examples included...

A handful of nuts can save your life, says new study.
The Daily Telegraph, June 11 2015
http://www.telegraph.co.uk/news/health/ ... study.html

Half a handful of NUTS a day can prevent early death: Peanuts 'slash risk of cancer, dementia, heart attacks and diabetes'.
Daily Mail, June 11 2015
http://www.dailymail.co.uk/health/artic ... betes.html

Nuts 'protect against early death'.
BBC News, June 11 2015
http://www.bbc.co.uk/news/health-33076815

Really?

Here is the study..

Relationship of tree nut, peanut and peanut butter intake with total and cause-specific mortality: a cohort study and meta-analysis. The International Journal of Epidemiology. Published online June 11 2015
http://ije.oxfordjournals.org/content/e ... 6260e0cbae

Abstract

Background:
Nut intake has been associated with lower mortality, but few studies have investigated causes of death other than cardiovascular disease, and dose-response relationships remain unclear.

Methods:
We investigated the relationship of nut (tree nut, peanut) and peanut butter intake with overall and cause-specific mortality. In the Netherlands Cohort Study, 120 852 men and women aged 55–69 years provided information on dietary and lifestyle habits in 1986. Mortality follow-up until 1996 consisted of linkage to Statistics Netherlands. Multivariate case-cohort analyses were based on 8823 deaths and 3202 subcohort members with complete data on nuts and potential confounders. We also conducted meta-analyses of our results with those published from other cohort studies.

Results:
Total nut intake was related to lower overall and cause-specific mortality (cancer, diabetes, cardiovascular, respiratory, neurodegenerative diseases, other causes) in men and women. When comparing those consuming 0.1−<5, 5−<10 and 10+ g nuts/day with non-consumers, multivariable hazard ratios for total mortality were 0.88, 0.74 and 0.77 [95% confidence interval (CI), 0.66–0.89], respectively (Ptrend = 0.003). Cause-specific hazard ratios comparing 10+ vs 0 g/day varied from 0.56 for neurodegenerative to 0.83 for cardiovascular disease mortality. Restricted cubic splines showed nonlinear dose-response relationships with mortality. Peanuts and tree nuts were inversely related to mortality, whereas peanut butter was not. In meta-analyses, summary hazard ratios for highest vs lowest nut consumption were 0.85 for cancer, and 0.71 for respiratory mortality.

Conclusions:
Nut intake was related to lower overall and cause-specific mortality, with evidence for nonlinear dose-response relationships. Peanut butter was not related to mortality.

Let's take a closer look.

1) Average total nut intake in the study was 8.1g a day for men and 4.4g a day for women. Average intake of peanut butter was 1.4g for men and 1.2g for women. 28 grams is an ounce so 8.1 grams is a little over a 1/4 oz, 4.4 grams is little over 1/7th of an ounce and 1.2 to 1.4 grams is a very small amount.

These are all fairly small amounts (which would make nuts not a super food but a miracle food). :)

2) The trend for nut consumption were..

- 12% reduced risk for 0.1-5g/day
- 26% decreased risk for 5-10g/day
- 23% reduced risk for > 10g a day/day

3) There was no clear and consistent trend showing increased nut consumption and lower risk as the risk was lowest in the middle consumption category of 5-10g a day which is around 1/6 - 1/3 oz.

4) The resulting number of deaths in each group was also fairly small which makes the results even less reliable.

Once again, this is an observational study so it cannot prove direct cause and effect as associations are usually influenced by other factors. In this study, higher nut intake was associated with higher fruit intake, higher vegetable intake and higher educational level for both men and women, and in addition for women, not smoking and a lower BMI.

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Re: go nuts?

Postby JeffN » Tue Sep 29, 2015 1:12 pm

Let see what the renowned Cochrane Collaboration has to say about nuts...

Nut consumption for the primary prevention of cardiovascular disease.
Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD011583.
DOI: 10.1002/14651858.CD011583.pub2.

http://www.cochrane.org/CD011583/VASC_e ... ar-disease

Review question
This Cochrane review aims to answer the question whether or not eating nuts can prevent cardiovascular disease.

Background
Cardiovascular diseases are a group of conditions that affect the heart and blood vessels. They are a major cause of death worldwide. The food we eat may influence the risk of getting cardiovascular disease. Nuts, if consumed regularly and at relatively high doses (50 g to 100 g), are believed to reduce total cholesterol and low-density lipoprotein (LDL) cholesterol (bad cholesterol).

Study characteristics
This review includes randomised controlled trials, which lasted at least 12 weeks. Participants were between 37 to 54 years old on average. The evidence is current up to 30 July 2015.

Key results
We included five trials (435 participants), one of which had two treatment arms. All five trials investigated the effects of eating nuts. No studies were found which investigated the effect of giving advice to eat more nuts. None of the studies reported on deaths or cardiovascular events. None of the results show a clear effect on total cholesterol levels and blood pressure. One study reported one case of an allergic reaction to nuts. Three studies reported no significant weight gain with increased nut consumption. No other adverse events were reported.

Quality of the evidence
All included trials are small, with 60 to 100 participants, and have a high level of variation (heterogeneity). Therefore the results should be interpreted with caution. Overall we regarded the included trials as being at unclear risk of bias.

Authors' conclusions:
Currently there is a lack of evidence for the effects of nut consumption on CVD clinical events in primary prevention and very limited evidence for the effects on CVD risk factors. No conclusions can be drawn and further high quality longer term and adequately powered trials are needed to answer the review question.

Background:
Nuts contain a number of nutritional attributes which may be cardioprotective. A number of epidemiological studies have shown that nut consumption may have a beneficial effect on people who have cardiovascular disease (CVD) risk factors. However, results from randomised controlled trials (RCTs) are less consistent.

Objectives:
To determine the effectiveness of nut consumption for the primary prevention of CVD.

Search strategy:
We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science Core Collection, CINAHL, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA) and Health Economics Evaluations Database (HEED) up to 30 July 2015. We searched trial registers and reference lists of reviews for further studies. We did not apply any language restrictions.

Selection criteria:
We included RCTs of dietary advice to increase nut consumption or provision of nuts to increase consumption lasting at least three months and including healthy adults or adults at moderate and high risk of CVD. The comparison group was no intervention or minimal intervention. The outcomes of interest were CVD clinical events and CVD risk factors.

Data collection and analysis:
Two review authors independently selected trials for inclusion, abstracted the data and assessed the risk of bias in included trials.

Main results:
We included five trials (435 participants randomised) and one ongoing trial. One study is awaiting classification. All trials examined the provision of nuts to increase consumption rather than dietary advice. None of the included trials reported on the primary outcomes, CVD clinical events, but trials were small and short term. All five trials reported on CVD risk factors. Four of these trials provided data in a useable format for meta-analyses, but heterogeneity precluded meta-analysis for most of the analyses. Overall trials were judged to be at unclear risk of bias.

There were variable and inconsistent effects of nut consumption on CVD risk factors (lipid levels and blood pressure). Three trials monitored adverse events. One trial reported an allergic reaction to nuts and three trials reported no significant weight gain with increased nut consumption. None of the included trials reported on other secondary outcomes, occurrence of type 2 diabetes as a major risk factor for CVD, health-related quality of life and costs.

Sounds familiar :)

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Re: go nuts?

Postby JeffN » Thu Oct 22, 2015 6:27 am

Glorified by association

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Nut consumption is associated with better nutrient intakes: results from the 2008/09 New Zealand Adult Nutrition Survey.
Br J Nutr. 2015 Oct 20:1-8.

A limited number of studies have examined associations between nut consumption and nutrient intakes or diet quality. None has investigated these associations in the Southern Hemisphere. The purpose of this study was to examine associations between nut consumption and nutrient intakes among adult New Zealanders. Data from the 24-h recalls of 4721 participants from the cross-sectional 2008/09 New Zealand Adult Nutrition Survey (2008/09 NZANS) were used to determine whole nut intake and total nut intake from all sources as well as nutrient intakes. Regression models, both unadjusted and adjusted for potential confounders, were used to estimate differences in nutrient intakes between those consuming and those not consuming nuts. From adjusted models, compared with non-whole nut consumers, whole nut consumers had higher intakes of energy and percentage of energy from total fat, MUFA and PUFA, whereas percentage of energy from SFA and carbohydrate was lower (all P≤0·025). After the additional adjustment for energy intake, whole nut consumers had higher intakes of dietary fibre, vitamin E, folate, Cu, Mg, K, P and Zn (all P≤0·044), whereas cholesterol and vitamin B12 intakes were significantly lower (both P≤0·013).Total nut consumption was associated with similar nutrient profiles as observed in whole nut consumers, albeit less pronounced. Nut consumption was associated with better nutrient profiles, especially a lower intake of SFA and higher intakes of unsaturated fats and a number of vitamins and minerals that could collectively reduce the risk for chronic disease, in particular for CVD.


http://www.ncbi.nlm.nih.gov/pubmed/26481949
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Re: go nuts?

Postby JeffN » Fri Mar 11, 2016 7:13 am

It is good to see this in the news,

I make this same point here in these forums again & again and at every 10 day program in my lecture on From Oil to Nuts, explaining how Science really works. Something can be statistically significant yet have absolutely no clinical relevance or application. In the lecture (as in the discussion above), I use some of the nut studies to highlight this point.

Statisticians issue warning over misuse of P values
Policy statement aims to halt missteps in the quest for certainty.
Monya Baker
07 March 2016

"And a P value cannot indicate the importance of a finding; for instance, a drug can have a statistically significant effect on patients’ blood glucose levels without having a therapeutic effect."

http://www.nature.com/news/statistician ... es-1.19503


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Re: go nuts?

Postby JeffN » Sat Mar 12, 2016 9:59 am

I updated the discussion in my initial response above adding an additional point on "Statistical Significance vs Clinical Relevance"

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Going Nuts, Again!

Postby JeffN » Sun Sep 03, 2017 4:50 pm

At the last 10-Day program, during my presentation, The Facts on Fats: From Oil to Nuts, someone (well experienced in research) challenged my critique of the studies saying, they can't really be doing what I am saying they are doing, including calling these results significant and having it spread around the media as breaking news.

I said, welcome to the new science.

On that note, this study just came out and is getting quite a bit of attention. Harvard wrote it up. Some well respected researchers have even shared in on social media.

So, lets take a closer look (with a touch of sarcasm).

OK, a little more then a touch :)


The study is...

Cashew consumption reduces total and LDL cholesterol: a randomized, crossover, controlled-feeding trial
Am J Clin Nutr, Epub 2017 Mar 2
doi: 10.3945/ajcn.116.150037.

https://www.ncbi.nlm.nih.gov/pubmed/28356271

As we can see, it was recently published in the AJCN, which is considered one of the better, if not the best, nutrition journal.

The results state....

Consumption of the cashew diet resulted in a significantly greater median change from baseline in total cholesterol …. LDL cholesterol …. non-HDL cholesterol ... and the total-cholesterol:HDL-cholesterol ratio

WOW, significantly greater median change!!!

The Conclusion states:

In comparison with a control diet, the incorporation of cashews into typical American diets decreases total cholesterol and LDL cholesterol. Results from this study provide support that the daily consumption of cashews, when substituted for a high-carbohydrate snack, may be a simple dietary strategy to help manage total cholesterol and LDL cholesterol.

WOW!

If you eat nuts instead of carbs(!!!), you get better total cholesterol and LDL cholesterol.

Now, for the closer look....

First, it was very well controlled, providing most of the meals and instructions on what to eat for the other meals.

"The study was conducted as a randomized, crossover, isocaloric, controlled-feeding study, with two 28-d intervention periods and a 2-wk washout period between interventions"

Second, lets look at the results and conclusions...

From Table 4
- LDL cholesterol went from 155.5 to 142.8

It dropped 4.8% and went from high risk to still in high risk (which is anything over 100, or if you have disease, we say anything over 70)

- Total cholesterol went from 224.5 to 220.

It dropped 3.9% and went from high risk to still in high risk (which is anything over 190, though we want it under 165)

- HDL went from 52.5 to 50.5,

Even thought it went down, both could be considered good, which is anything over 40, though they say over 60 is considered ideal.

- Non-HDL went from 172 to 161

It dropped 5.3% and went from high risk to still in high risk (which is anything over "30 mg higher then the goal LDL", which would be 130, or even 100)

- The Total Cholesterol/HDL Ratio went from 4.4 to 4.3

It dropped 0% (statistically) and they recommend it should be below 3.5

- Triglycerides went from 91 to 95

They went up but who cares, as anything below 100 is ideal.

Now, here is the best part. To get these "worthless" results, the cashews were compared to eating a high-carbohydrate snack.

Hmmm…

which high carbohydrate food was provided as the snack?

It was...

...

...

...

...

...

... POTATO CHIPS!!!

Yes, potato chips!

Yes, this is the CRAP they publish calling the results significant and that gets spread around in the media as breaking news.

As a reminder, I am not "against" nuts, which is the message many seem to get from this. If you happen to think that, you may want read this full post starting at the top :) I am against CRAP research.

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Re: go nuts?

Postby JeffN » Thu Apr 19, 2018 5:06 pm

Now, where have we heard this before, for the least 25 years?

:)

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Study

Cardiac risk factors and prevention
Original research article
Nut consumption and incidence of seven cardiovascular diseases
Heart Published Online First: 16 April 2018.
doi: 10.1136/heartjnl-2017-312819

Abstract

Background
Nut consumption has been found to be inversely associated with cardiovascular disease mortality, but the association between nut consumption and incidence of specific cardiovascular diseases is unclear. We examined the association between nut consumption and incidence of seven cardiovascular diseases.

Methods
This prospective study included 61 364 Swedish adults who had completed a Food Frequency Questionnaire and were followed up for 17 years through linkage with the Swedish National Patient and Death Registers.

Results
Nut consumption was inversely associated with risk of myocardial infarction, heart failure, atrial fibrillation and abdominal aortic aneurysm in the age-adjusted and sex-adjusted analysis. However, adjustment for multiple risk factors attenuated these associations and only a linear, dose–response, association with atrial fibrillation (ptrend=0.004) and a non-linear association (pnon-linearity=0.003) with heart failure remained. Compared with no consumption of nuts, the multivariable HRs (95% CI) of atrial fibrillation across categories of nut consumption were 0.97 (0.93 to 1.02) for 1–3 times/month, 0.88 (0.79 to 0.99) for 1–2 times/week and 0.82 (0.68 to 0.99) for ≥3 times/week. For heart failure, the corresponding HRs (95% CI) were 0.87 (0.80 to 0.94), 0.80 (0.67 to 0.97) and 0.98 (0.76 to 1.27). Nut consumption was not associated with risk of aortic valve stenosis, ischaemic stroke or intracerebral haemorrhage.

Conclusions
These findings suggest that nut consumption or factors associated with this nutritional behaviour may play a role in reducing the risk of atrial fibrillation and possibly heart failure.




Article

NY Times
Nuts May Be Good for the Heart, but Are Hardly a Miracle Food
By NICHOLAS BAKALAR
APRIL 17, 2018

https://www.nytimes.com/2018/04/17/well ... -food.html

There is considerable research showing that nuts, with their high levels of unsaturated fatty acids, fiber and minerals, may help reduce the risk for cardiovascular disease. But a large Swedish analysis published in Heart has found that the benefits are limited and depend largely on other healthy behaviors.

Researchers followed 61,364 adults for up to 17 years. They had all completed questionnaires on diet, lifestyle and other risk factors for chronic disease.

Nut consumption was associated with lowered risk for heart attack, heart failure, stroke and the irregular rapid heartbeat called atrial fibrillation, or A-fib. But people who routinely consumed nuts were on average younger and more highly educated, had lower body mass index, were more likely to be physically active, less likely to smoke, and more likely to eat fruits and vegetables.

When the researchers controlled for these factors, nut consumption was associated only with a lower risk for A-fib, and had no significant effect on the other cardiovascular diseases.


“It’s possible that previous studies didn’t control for as many factors as we did,” said the lead author, Susanna C. Larsson, an associate professor of epidemiology at the Karolinska Institute. “Nuts are a good food, but they may not provide as much benefit as we once thought.”
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Re: go nuts?

Postby JeffN » Mon Nov 12, 2018 8:14 pm

Dr. Greger on nuts...

In March 2012, Dr Greger was interviewed by Dr Fuhrman and in the interview, he said this...

https://web.archive.org/web/20120311151 ... er-md.html

Dr. Fuhrman: Do you think some of the present vegan authors seem to hide from any science that may weaken their prior (sub-optimal) pronouncements on nutrition?

Dr. Greger: Yes, I have learned it's always best to seek out the primary sources to review them rather than rely on expert opinion. Too often we hear outdated information that is ego-based and supporting old theories that have been proposed. These include extremely low fat vegan diets, without nuts and seeds, or centering one's diet around white potatoes or white rice. This is just not the best science-based advice.


In this current issue (Fall 2018) of Health Science, the membership journal of the National Health Association, current President and health advocate Mark Huberman interviewed Dr Greger.

https://www.healthscience.org/sites/def ... Greger.pdf

Mark: Dr. Caldwell Esselstyn, Jr. argues strongly that nuts should be largely avoided, particularly for those suffering heart issues, while others, like Dr. Joel Fuhrman, take the opposite view and claim they not only shouldn’t be avoided, but should be consumed as heart-healthy foods. What is your opinion on this issue?

Dr Greger: Dr Greger has no opinion on anything. Dr Greger just cares about the science

Mark: What does Dr. Greger say the science says about this?

Dr Greger: Thank you, that’s the question. What we now know is that heart disease is reversible without medications, because that’s the clinical data that we have. We put people on plant-based diets because it lowers cholesterol. Nuts also lower cholesterol; they are anti-inflammatory. So, one would expect a low-fat diet with nuts to be even better at reversing heart disease, but no one has ever done that study. My suspicion is it would work better. But, if you’re dying from heart disease, you go with the data from randomized controlled trials that show a low-fat, plant-based diet works until we learn otherwise. In theory, this other diet might even work better, but we don’t have the data yet. Until it’s put to the test, you use what’s been proven.

I agree!

Glad he has seen the light.

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Re: Going Nuts, Again!

Postby JeffN » Tue May 07, 2019 9:01 am

JeffN wrote:At the last 10-Day program, during my presentation, The Facts on Fats: From Oil to Nuts, someone (well experienced in research) challenged my critique of the studies saying, they can't really be doing what I am saying they are doing, including calling these results significant and having it spread around the media as breaking news.

I said, welcome to the new science.



Here is how they do it

Level and Prevalence of Spin in Published Cardiovascular Randomized Clinical Trial Reports With Statistically Nonsignificant Primary Outcomes - A Systematic Review
Original Investigation Medical Journals and Publishing
May 3, 2019
JAMA Netw Open. 2019;2(5):e192622. doi:10.1001/jamanetworkopen.2019.2622

Key Points

Question Do authors of cardiovascular randomized clinical trials present statistically nonsignificant primary outcomes accurately and objectively?

Findings In this systematic review that included 93 reports of randomized clinical trials from 6 high-impact journals, positive spin of statistically nonsignificant primary outcomes was found in 57% of abstracts and 67% of main text of the published articles.

Meaning Despite peer review, manipulation of language in the cardiovascular literature is common and may have implications for scientific integrity, patient care, peer review, and medical progress.

Abstract
Importance Clinical researchers are obligated to present results objectively and accurately to ensure readers are not misled. In studies in which primary end points are not statistically significant, placing a spin, defined as the manipulation of language to potentially mislead readers from the likely truth of the results, can distract the reader and lead to misinterpretation and misapplication of the findings.

Objective To determine the level and prevalence of spin in published reports of cardiovascular randomized clinical trial (RCT) reports.

Data Source MEDLINE was searched from January 1, 2015, to December 31, 2017, using the Cochrane highly sensitive search strategy.

Study Selection Inclusion criteria were parallel-group RCTs published from January 1, 2015, to December 31, 2017 in 1 of 6 high-impact journals (New England Journal of Medicine, The Lancet, JAMA, European Heart Journal, Circulation, and Journal of the American College of Cardiology) with primary outcomes that were not statistically significant were included in the analysis.

Data Extraction and Synthesis Analysis began in August 2018. Data were extracted and verified by 2 independent investigators using a standard collection form. In cases of disagreement between the 2 investigators, a third investigators served as arbitrator.

Main Outcomes and Measures The classifications of spin type, severity, and extent were determined according to predefined criteria. Primary clinical outcomes were divided into safety of treatment, efficacy of treatment, and both.

Results Of 587 studies identified, 93 RCT reports (15.8%) met inclusion criteria. Spin was identified in 53 abstracts (57%; 95% CI, 47%-67%) and 62 main texts of published articles (67%; 95% CI, 57%-75%). Ten reports (11%; 95% CI, 6%-19%) had spin in the title, 35 reports (38%; 95% CI, 28%-48%) had spin in the results section, and 50 reports (54%; 95% CI, 44%-64%) had spin in the conclusions. Among the abstracts, spin was observed in 38 results sections (41%; 95% CI, 31%-51%) and 45 conclusions sections (48%; 95% CI, 38%-58%).

Conclusions and Relevance This study suggests that in reports of cardiovascular RCTs with statistically nonsignificant primary outcomes, investigators often manipulate the language of the report to detract from the neutral primary outcomes. To best apply evidence to patient care, consumers of cardiovascular research should be aware that peer review does not always preclude the use of misleading language in scientific articles.
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