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 NewsSee my article,"Today's Breaking Health News"
http://www.jeffnovick.com/RD/Articles/E ... ews!!.htmlthe thread on "High Quality Foods"
http://www.drmcdougall.com/forums/viewt ... 22&t=28413especially the part on "effect size."
http://www.drmcdougall.com/forums/viewt ... 15#p377392and my talk, "Nuts & Health."
http://www.jeffnovick.com/RD/Nuts_%26_Health.htmlhttps://secure2.vegsource.com/catalog/p ... cts_id=501POINT 2 - The Bigger PictureEPIC 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 expectancyKhaw 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 ApplicationThe 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 SizeIn 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#p429750As 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 RelevanceIn 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=415912they 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#ioi90167t2The 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=43681So, 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-1.19503POINT 6 - FundingIf 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 RecommendationsIf 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 & ApplicationIn 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/NEJMoa1307352If 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?"In Health
Jeff