Almonds and Walnuts Consumption Modifies PUFAs Profiles and Improves Metabolic Inflammation Beyond the Impact on Anthropometric Measure
Mónica I. Cardona-Alvarado1, Francisco J. Ortega2, Enrique Ramírez-Chávez3, María E. Tejero4, Jorge Molina-Torres3, José M. Fernández-Real2, Elva L. Perez-Luque1, *
Identifiers and Pagination:Year: 2018
First Page: 89
Last Page: 98
Publisher Id: TONUTRJ-12-89
Article History:Received Date: 30/7/2018
Revision Received Date: 28/9/2018
Acceptance Date: 3/10/2018
Electronic publication date: 26/10/2018
Collection year: 2018
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
To evaluate changes in serum fatty acids, metabolic profile and inflammation markers after a dietary intervention of 15g of walnuts and 15g of almonds for 8 weeks in obese subjects,
Patients and Methods:
We studied a total of 48 sedentary obese grade I subjects (13 men and 35 women). Anthropometric measures, body composition, serum glucose, lipid profile, insulin, lipocalina-2, high sensitivity C-reactive protein (hsCRP), adiponectin, and fatty acids profile were analyzed at the baseline and after dietary intervention.
The adiponectin (30.4%, p = 0.007), and lipocalin-2 concentrations (17.9%, p = 0.014), and total Polyunsaturated Fatty Acids (PUFAs) percentage (1.6% p = 0.040) significantly increased after the intervention; particularly the eicosapentaenoic acid and docosahexaenoic acid percentages were increased marginally. A significant decrease in saturated fatty acids levels (3%, p = 0.001), in particular the C:14, C:16, in total cholesterol (6.7%, p = 0.01), LDL (11.4%, p = 0.002) levels, and in all adiposity measures (weight, waist circumference, hip circumference, BMI and fat mass, p < 0.0001) was found. The effect size was large for all adiposity measures, except for BMI as well as for adiponectin which was moderate.
The intake of almonds and walnuts to short-time may improve significantly the metabolic profile and decrease adiposity.
Obesity has emerged as a serious public health threat of the 21st century . According to the 2016 National Health and Nutrition Survey in the Mexican population, the prevalence of overweight and obesity is 72.5% in adults aged 20 and older . Recent evidence suggests that the amount and type of fat included in the diet contributes to the development of obesity and insulin resistance, influencing the secretion of adipokines from obese adipose tissue .
Several studies have demonstrated that the consumption of almonds [4, 5], walnuts [6, 7] or mixed nuts  has a favorable effect on the lipid profile and insulin resistance. Walnuts have a high content of Polyunsaturated Fatty Acids (PUFAs) 47.2%, especially α-linolenic acid (C:18:3 n-3) 9.1%, and linoleic acid (C:18:2 n-6) 38.1%.  Also, nuts are rich in other bioactive compounds, such as phytosterols . The richness in bioactive compounds may be responsible for a significant increase in High-Density Lipoprotein cholesterol (HDL) and a reduction in Low-Density Lipoprotein cholesterol (LDL), achieved after consumption of 30 g of walnuts for 6 months in fifty-eight subjects aged 59.3 ± 8.1 years . A meta-analysis investigating the impact of walnut consumption on blood lipids showed that walnut-enriched diets significantly decreased total cholesterol and LDL when compared with the control diet . Since almonds contain a high content of Monounsaturated Fatty Acids (MUFAs) (31.5%), and PUFAs (12.1%),  a reduction in LDL range appears to be between 11.6 and 13.4% following the consumption of almonds [12, 13]. However, other reports have failed to show significant changes in weight or Body Mass Index (BMI) after the intake of almonds and walnuts were observed [14, 15]. The intake of 30 g/day of raw nuts (15 g walnuts, 7.5 g/almonds and 7.5 g hazelnuts  is not associated with a reduction in LDL, as neither the consumption from 63 to 108 g/d of walnuts decreased the total cholesterol, LDL, and triglycerides levels .
Adiponectin is an anti-inflammatory adipocytokine that has been suggested to play a causative role in the development of insulin resistance, diabetes, and atherosclerosis . An increase in circulating concentrations of adiponectin is observed after a short-term dietary intake of walnuts in obese subjects . Lipocalin-2 (LCN2) is an extracellular protein expressed by adipose tissue that induces the expression of peroxisome proliferator activated receptor gamma (PPARγ), and its target genes, adiponectin and lipoprotein lipase . An association between LCN2 and BMI, waist circumference, fat percentage, hypertriglyceridemia, and insulin resistance  has been reported, but another study failed to find increased circulating LCN2 concentrations in obese patients . It had also been reported that the circulating LCN2 levels were decreased in patients with long-term type 2 diabetes . Therefore, the role of LCN2 as a potential metabolic and cardiovascular risk factor remains to be fully elucidated. These data show that the beneficial effects on the amount of the intake and type of nuts on metabolism and inflammation are still controversial. In addition, there are few reports that examined the effect of nut consumption on circulating adiponectin levels, and even, it is not known whether consumption of nuts increases LCN2 concentrations. The aim of this work was to evaluate changes in serum Fatty Acids (FA), metabolic profile and inflammation markers after a diet supplemented with a daily intake of 15g of walnuts and 15g of almonds for 8 weeks in obese subjects.
2. MATERIAL AND METHODS
2.1. Participants and Study Design
The present study comprised a clinical trial with 8 weeks of follow-up. A total of 61 obese grade I subjects were included, 13 did not finish the intervention; 10 of them were excluded due to lack of adherence to diet and 3 of them presented a migraine crisis. A preliminary report comprising 30 subjects was done previously. In this study, a total of 48 subjects completed the intervention. The subjects were selected by means of advertisements in local media and shoe factories for a period of 14 months. Obese subjects of 30 to 50 years old with BMI between 30 and 34.9 kg/m2 (grade I obesity) without evidence of chronic degenerative, infectious or neoplastic diseases, neither medication nor actually a dietary treatment, and a physical exercise level < 2 hours/week were recruited. All participants gave their written informed consent to participate in the study. The study was approved by the Institutional Ethics Committee of the Universidad de Guanajuato and was conducted according to the ethical standards laid down in the Declaration of Helsinki 1983 and in agreement with the Good Clinical Practice guidelines.
2.2. Dietary Assessment Method
On baseline and at the end intervention, the usual dietary intake was evaluated by direct application of 24-hour reminders (two weekdays and one weekend), using the United States Departament of Agriculture (USDA) Five-Step Multiple Penetration Automated Method . The energy and nutrient intake were evaluated with the databases of the USDA  and SNUT software (National Institute of Public Health, Mexico) .
2.3. Intervention Protocol
The habitual diet was enriched with 15g of almonds and 15g of walnuts per day for eight weeks, indicating its consumption as a snack, supplied directly to the patient by the researcher. These amounts of walnuts and almonds contain PUFAs approximately 2.02g of omega 3 (ω-3) (alpha-linolenic acid C:18:3 ω-3) and 11.1g of omega 6 (ω-6), linoleic acid C:18:2 ω-6 mostly. In order to evaluate adherence, volunteers were visited every two weeks. Positive Adherence was considered when the consumption of walnuts and almonds was not modified more than ± 20% of the amount indicated by the researcher. For analysis, only those who adhered at least 80% of the consumption of walnuts and almonds were considered.
2.4. Anthropometric and Clinical Measures
Weight was measured with a roman type Tanita BC533 scale, height was measured using a Stadiometer SECA 406. Waist and hip circumferences were measured using a tape SECA 206 according to the technique of Lohman TG . The fat mass percentage was determined by bioimpedance using a Tanita BC533 instrument. The obtained weight and height were used to calculate the BMI. Systolic and diastolic blood pressures were measured in a sitting position after a ten-minute rest. All measures were conducted in duplicate by standardized personnel. All anthropometric and metabolic measures were evaluated at baseline and after eight weeks of treatment.
2.5. Biochemical Measurement
Blood samples were withdrawn after 12 h of fasting to quantify circulating levels of serum glucose, lipids, insulin, LNC2, high-sensitivity CRP (hsCRP) and adiponectin. Serum samples were separated and frozen to -80ºC until analysis. Serum glucose (coefficient of variation 5.6%) and lipids profile were measured using enzymatic methods with a chemistry analyzer (Auto KEM II, Kontrollab, Italy). The coefficient of variation was 4.3% for total cholesterol, 6% for Triglycerides, and 3% for HDL. Serum insulin was measured by radioimmunoassay with a commercial kit (BI-Insulin-IRMA, Cisbio Bioassay, Codolet, France), with an intra-assay Variation Coefficient (VC) of 3.9%. Serum LNC2 was measured using Quantikine ELISA (R & D Minneapolis MN, USA) with 4.4% CV. The hsCRP was quantified by means of hsCRP ELISA Kit (ALPCO Immunodiagnostic AG, Stubenwald-Allee, Bensheim) with 5.5 CV%. For quantification of adiponectin, a radioimmunoassay kit (Millipore, St. Charles, Missouri, USA) with CV of 3.6% was used; while the Homoeostatic Model Assessment was used to estimate insulin resistance (HOMA-IR) .
2.6. Serum fatty Acids Measurement
Serum samples were withdrawn at the baseline and 8 weeks after dietary intervention. The serum was dried under a gentle stream of nitrogen at room temperature and its residues were dissolved in 1 ml of NaOH and 0.5M of methanol. An internal standard consisting of 10 μl of nonadecanoic acid (C19:0, 5 mg/ml) was added. The temperature of the solution was held at 90°C for 1h; each sample was then cooled to room temperature and 1ml of boron trifluoride etherate in methanol (Sigma-Aldrich) was gently added. The samples were reincubated at 90°C for 30 minutes. The solutions were cooled and transferred to a test tube, where 2ml of deionized water and 4ml of hexane were added, after which the organic phase was separated. Each solution was dried again under a stream of nitrogen at room temperature and dissolved in 400μl of isooctane (Fisher Chemical). After that, an aliquot was injected into the chromatograph. Fatty acids were chromatographed on a 30m fused-silica column Zebron ZB-WAX (0.25 mm i.d.). The analysis was performed with an Agilent Technologies 7890A gas chromatograph equipped with a flame ionization detector Agilent Technologies 5975C. The column temperature was held at 50°C for 3 min, and subsequently increased in a stepwise fashion (10ºC/ min) to a plateau of 250°C, and then held for 3 min. The injection temperature was 220°C. Helium was used as carrier gas at 2ml/min. The results of measurements of FA are expressed in percentage (i.e. % serum FA).
2.7. Statistical Analysis
The anthropometric and metabolic data are expressed as the mean ± standard deviation. Data normality was tested using the Kolmogorov-Smirnov’s test. Differences between groups were examined using the paired t-test. Non-parametric variables were transformed to logarithms. In order to examine the size effect of each anthropometric and metabolic indicator, we used the Cohen d. Statistical significance that was set at p < 0.05. Data analysis were performed with the Statistica 6410 for Windows (Statsoft, Tucson AZ) statistical software.
Forty-eight participants finished the intervention (73% women/ 27% men). The Mean age was 37 ± 4 years old, and BMI of 32 ± 2 kg/m2. Significant increase of circulating adiponectin (30.4%, p = 0.003) and LCN2 (17.8%, p = 0.017) concentration were found at the end of the intervention. On average, the participants lost 3.7% (p < 0.0001) of their initial BMI and weight, 4% of waist circumference (p = 0.000002), 2.6% of hip circumference (p = 0.00002), 6.4% of fat mass (p = 0.000005), total cholesterol (6.3%, p = 0.011) and LDL (11.4%, p = 0.002) reduced, and triglycerides concentrations (8.8%, p = 0.06) nominally decreased (Table 1).
n = 48
n = 48
|Mean ± SD||Mean ± SD||t Student||p|
|Weight (kg)||82 ± 11||79 ± 10||7.68||<0.0001|
|Waist circumference (cm)||102 ± 7.5||98 ± 7||5.42||<0.0001|
|Hip circumference (cm)||112 ± 7||109 ± 7||4.72||0.0001|
|BMI (kg/m2)||32.4 ± 2||31 ± 2||7.77||<0.0001|
|Fat mass (%)||39 ± 7.5||36.5 ± 7||5.07||0.0001|
|Muscle mass (kg)||47.3 ± 8.5||48.1 ± 8||0.72||0.46|
|Systolic blood pressure (mmHg)||110 ± 13||108 ± 10||0.82||0.30|
|Diastolic blood pressure (mmHg)||76 ± 7||75 ± 8||0.45||0.12|
|Glucose (mmol/L)||4.8± 0.83||4.7 ± 0.83||0.25||0.56|
|Total cholesterol (mmol/L)||4.43 ± 0.56||4.15 ± 0.87||2.61||0.01|
|HDL-c(mmol/L)||1.49 ± 0.15||1.47 ± 0.18||1.26||0.28|
|LDL-c (mmol/L)||2.21 ± 0.54||1.96 ± 0.59||3.16||0.002|
|Triglycerides (mmol/L)*||2.26± 0.78||2.06 ± 0.53||1.92||0.060|
|LNC-2 (ng/mL)||76 ± 29||89.6 ± 34||-2.53||0.014|
|hsCRP (mg/L)*||4.0 ± 3.2||3.9 ± 3.2||0.16||0.31|
|Adiponectin (μg/mL)||9.2 ± 7.9||12 ± 10.2||-2.79||0.007|
|Insulin (pmol/L)*||61.2 ± 35.4||53.4 ± 31.8||1.34||0.45|
|HOMA-IR||2.1 ± 1.3||1.9 ± 1.2||0.72||0.27|
There were changes in the circulating lipid profile, the percentage of Saturated Fatty Acids (SFA) in serum was decreased after the treatment (3%, p = 0.001), in particular, myristic acid (C:14) (8.6%, p = 0.007) and palmitic acid (C:16) (2.8%, p = 0.002). The percentage of palmitoleic acid also decreased (C:16:1) (8.8%, p = 0.0003). In contrast, the total PUFAs percentage (1.6%, p = 0.04) increased, particularly the Docosahexaenoic Acid (DHA) was increased marginally (C:22:6 ω3) (4.5%, p = 0.07) (Table 2). In women, the percentage of oleic acid was significantly lower, but the percentage of DHA was higher than in men at baseline (Fig. 1). these differences were not significant at the end of the intervention. We observed an unexpected decrease in energy intake of 288 Kcal/day (17%, p < 0.001), but there were no significant changes in the percentages of the macronutrient as compared with habitual consumption.
n = 48
n = 48
|Mean ± SD||Mean ± SD||t Student||p|
|% Fatty acid in blood|
|C:12:0*||0.08 ± 0.04||0.07 ± 0.04||1.88||0.059|
|C:14:0||1.0 ± 0.2||0.86 ± 0.2||2.84||0.007|
|C:16:0||21.2 ± 1.4||20.6 ± 1.4||3.30||0.002|
|C:16:1 (ω-9)||3.4 ± 0.7||3.1 ± 0.5||3.87||0.0003|
|C:18:0||7.5 ± 0.8||7.4 ± 0.8||1.28||0.20|
|C:18:1 (ω-9)||23.2 ± 1.8||23.6 ± 2.2||-1.25||0.21|
|C:18:2 (ω-6)||26.8 ± 2.8||27.4 ± 2.8||-1.60||0.12|
|C:18:3 (ω-3)||1.1 ± 0.2||1.1 ± 0.2||0.90||0.37|
|C:20:0||0.06 ± 0.02||0.07 ± 0.02||-1.81||0.08|
|C:20:1 (ω-9)||0.47 ± 0.1||0.49 ± 0.1||1.26||0.21|
|C:20:3 (ω-6)||2.1 ± 0.4||1.9 ± 0.4||1.44||0.15|
|C:20:4 (ω-6)||6.8 ± 1.2||6.9 ± 1.3||-1.31||0.15|
|C:20:5 (ω-3)||3.7 ± 2.9||3.9 ± 3||-1.89||0.066|
|C:22:6 (ω-3)||2.2 ± 0.6||2.3 ± 0.6||-1.81||0.076|
|SFA||29.9 ± 1.7||29 ± 1.8||3.55||0.001|
|MUFAs||27.2 ± 2.1||27.1 ± 1.9||0.18||0.86|
|PUFAs||43 ± 3||43.7 ± 3||-2.11||0.040|
|• ω-6||35.8 ± 3||36.3 ± 3||0.58||0.56|
|• ω-3||7.1 ± 2.8||7.3 ± 3.1||-0.944||0.35|
|Fig. (1). Percentage of oleic acid and DHA between men and women.|
To know the effect of the intervention on each variable, we calculated the effect size, which was greater in waist circumference, weight, hip circumference, and fat mass. For BMI, adiponectin, LCN2, SFA, C:16:0, C:16:1, the effect size was moderate (Table 3). In the baseline, positive correlations of lauric and stearic acids with hsCRP, and oleic acid with triglycerides were found. Also, negative correlations of the arachidonic acid with BMI and triglycerides, and DHA with BMI were found. At the end of the intervention, a positive correlation of oleic acid with triglycerides and a negative correlation of arachidonic acid with BMI were maintained. In addition, dihomo gamma linoleic acid (20:3 ω-6) positively correlated with LCN2 concentrations. All correlation analyses were adjusted for sex (Table 4).
|Variable||Cohen’s d test||Variable||Cohen’s d test|
|Waist circumference (cm)||1.19||C:16:0||0.50|
|Hip circumference (cm)||0.77||C:16:1 (ω-9)||0.54|
|Fat mass (%)||0.74||C:18:1 (ω-9)||0.19|
|Systolic blood pressure (mmHg)||0.11||C:18:2 (ω-6)||0.30|
|Diastolic blood pressure (mmHg)||0.19||C:18:3 (ω-3)||0.04|
|Glucose (mmol/L)||0.08||C:20:1 (ω-9)||0.30|
|Total cholesterol (mmol/L)||0.32||C:20:3 (ω-6)||0.11|
|HDL-c (mmol/L)||0.13||C:20:4 (ω-6)||0.26|
|LDL-c (mmol/L)||0.46||C:20:5 (ω-3)||0.17|
|Triglycerides (mmol/L)||0.11||C:22:6 (ω-3)||0.37|
In this study, circulating adiponectin levels increased by 30% in obese subjects supplemented with a daily intake of approximately 2g of ω-3 and 11g of ω-6 fatty acids for eight weeks from two sources: 15 g of walnuts and 15 g of almonds. In conformity with our results, previous reports showed an increase of 6.4% in circulating adiponectin after short-term walnut 48 g/d consumption (four days) , and an increase of 23% in circulating concentrations of adiponectin can be observed in women who most closely followed a Mediterranean diet . The circulating LCN2 concentrations also were increased by 17.9% after the intervention. The LCN2 has been reported as a novel regulator of brown adipose tissue activation by modulating the adrenergic independent p38MAPK-PGC-1α-UCP1 pathway . It has also been reported that saturated fats might contribute to the circulating LCN2 concentrations in obese patients with insulin resistance . The evidence and our results suggest that the improvement observed in the metabolic state may be due to, or at least, in part to PPARγ activation and adiponectin expression promoted by the increase in circulating LCN2 concentrations.
In our work, we found a decrease in %SFA, particularly C:14, C:16, and C:16:1. Similar data have previously been reported after walnuts consumption for four weeks.6 It is possible that PUFAs contained in walnuts and almonds might suppress the activity of sterol regulatory element-binding transcription factor 1 (SREBP1c), decreasing the synthesis of fatty acids as described .
In addition, we found a significant decrease in body weight, fat mass, hip and waist circumference, total cholesterol, and LDL concentrations in obese subjects after the intervention. In concordance with our results, various several studies have shown a significant decrease in weight and BMI with the consumption of 50 or 56g of almonds for 3 or 6 months in overweight and obese individuals [4, 5]. Another report showed a decrease in body weight of 18 kg after a low-calorie diet enriched with 84g/d of almonds for a period of 24 weeks in overweight and obese individuals . We indicated a combination of 15 g/d of walnuts and 15g/d almonds, noting that weight loss is significant with a lower consumption for a shorter period. However, previous studies with a diet including almonds have shown no significant effect on body weight, BMI, as compared with control [34, 35].
We also found a decrease of 6.3% in the total cholesterol and 11.3% in the LDL concentrations. A similar decrease of (6%) using 36g of walnuts for 6 weeks was found in another study . Tapsell et al. used 30g of walnuts for 6 months to achieve a 10% reduction in LDL in type 2 diabetic patients . Another study that used 60 g/d almonds for 12 weeks resulted in a significant reduction of the body fat, total cholesterol and LDL concentrations in type 2 diabetic patients . It has also been reported that endothelial function, total and LDL cholesterol improved significantly, but BMI, body fat percent, visceral fat, and fasting glucose did not change after consumption of 56 g/d of walnuts .
Through the calculation of size effect, we could identify which indicator was more modified for the effect of the intervention. The waist circumference, weight, hip circumference, and fat mass were indicators that experimented the majors effects. Only one report showed a greater weight-loss after a hypocaloric almonds-enriched diet . However, it did not evaluate the effect size on other indicators as BMI, adiponectin and LCN2 levels.
The walnut contains a variety of bioactive compounds, such as vitamin E and polyphenols that possess antioxidant and anti-inflammatory activity. Almonds are rich in MUFAs, fiber, α-tocopherol, magnesium and copper that may contribute to hypocholesterolemic benefits. Therefore, it is possible that in addition to the PUFAs, other components to be able also act to bring about the anthropometric and metabolic changes reported in this work. The lack of a control group may be a weakness; however, in a previous report done in 30 subjects we found several miRNAs modified after the intake of walnuts and almonds, including decrease of miR-328, miR-330-3p, miR-221, and miR-125a-5p, and increase mir-192, miR-486-5p, miR-19b, miR-106a, miR769-5p, miR-130b, and miR-18a. In addition miR-106a variations in plasma positively correlated with the changes in PUFAs . In addition, previous studies have reported that total cholesterol and LDL concentration in adults that complied with the walnut diet were lower than in those who followed diet control [11, 39]. The consumption of almonds (50-100g/d) and walnuts (40-84g/d) also decreased the total cholesterol and LDL concentrations, compared with subjects consuming controlled diet . Weight, BMI, waist circumference and total cholesterol decreased significantly in the almonds group compared to the nut-free group .
In conclusion, significant increases of 30% in adiponectin and LCN2 (17.9%) concentrations were found. Additionally, a significant decrease in all adiposity measures (weight, waist circumference, hip circumference, BMI and fat mass), total cholesterol and LDL concentrations after the intervention was observed. The SFA percentage significantly decreased, in particular, the C:14, C:16, and the MUFAs C:16:1. The total PUFAs percentage significantly increased, and particularly the percentages of the eicosapentaenoic acid (EPA, C:20:5 ω-3) and DHA C:22:6 ω-3 marginally increased. The effect size was large for all adiposity measures, except for BMI as well as for adiponectin which was moderate. Our data show that the consumption of almonds and walnuts for a short-time may improve the metabolic inflammation and measure adiposity.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The study was approved by the Institutional Ethics Committee of the Universidad de Guanajuato.
HUMAN AND ANIMAL RIGHTS
No Animals were used in this study. All human research procedures followed were in accordance with the ethical standards laid down in the Declaration of Helsinki 1983 and in agreement with the Good Clinical Practice guidelines.
CONSENT FOR PUBLICATION
All participants submitted their written informed consent to participate in the study.
This work was financially supported by The Research Program of the Direction of Support for Investigation and Postgraduate, University of Guanajuato, Mexico 2013.
CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest.
|||Barness LA, Opitz JM, Gilbert-Barness E. Obesity: Genetic, molecular, and environmental aspects. Am J Med Genet A 2007; 143A(24): 3016-34.
|||Bray GA, Lovejoy JC, Smith SR, et al. The influence of different fats and fatty acids on obesity, insulin resistance and inflammation. J Nutr 2002; 132(9): 2488-91.
|||Abazarfard Z, Salehi M, Keshavarzi S. The effect of almonds on anthropometric measurements and lipid profile in overweight and obese females in a weight reduction program: A randomized controlled clinical trial. J Res Med Sci 2014; 19(5): 457-64.
|||Foster GD, Shantz KL, Vander Veur SS, et al. A randomized trial of the effects of an almond-enriched, hypocaloric diet in the treatment of obesity. Am J Clin Nutr 2012; 96(2): 249-54.
|||Iwamoto M, Imaizumi K, Sato M, et al. Serum lipid profiles in Japanese women and men during consumption of walnuts. Eur J Clin Nutr 2002; 56(7): 629-37.
|||Katz DL, Davidhi A, Ma Y, Kavak Y, Bifulco L, Njike VY. Effects of walnuts on endothelial function in overweight adults with visceral obesity: A randomized, controlled, crossover trial. J Am Coll Nutr 2012; 31(6): 415-23.
|||Casas-Agustench P, López-Uriarte P, Bulló M, Ros E, Cabré-Vila JJ, Salas-Salvadó J. Effects of one serving of mixed nuts on serum lipids, insulin resistance and inflammatory markers in patients with the metabolic syndrome. Nutr Metab Cardiovasc Dis 2011; 21(2): 126-35.
|||Kendall CWC, Esfahani A, Truan J, Srichaikul K, Jenkins DJ. Health benefits of nuts in prevention and management of diabetes. Asia Pac J Clin Nutr 2010; 19(1): 110-6.
|||Tapsell LC, Gillen LJ, Patch CS, et al. Including walnuts in a low-fat/modified-fat diet improves HDL cholesterol-to-total cholesterol ratios in patients with type 2 diabetes. Diabetes Care 2004; 27(12): 2777-83.
|||Banel DK, Hu FB. Effects of walnut consumption on blood lipids and other cardiovascular risk factors: A meta-analysis and systematic review. Am J Clin Nutr 2009; 90(1): 56-63.
|||Li SC, Liu YH, Liu JF, Chang WH, Chen CM, Chen CY. Almond consumption improved glycemic control and lipid profiles in patients with type 2 diabetes mellitus. Metabolism 2011; 60(4): 474-9.
|||Damasceno NRT, Pérez-Heras A, Serra M, et al. Crossover study of diets enriched with virgin olive oil, walnuts or almonds. Effects on lipids and other cardiovascular risk markers. Nutr Metab Cardiovasc Dis 2011; 21(1)(Suppl. 1): S14-20.
|||Fraser GE, Bennett HW, Jaceldo KB, Sabaté J. Effect on body weight of a free 76 Kilojoule (320 calorie) daily supplement of almonds for six months. J Am Coll Nutr 2002; 21(3): 275-83.
|||Martínez-González MA, Bes-Rastrollo M. Nut consumption, weight gain and obesity: Epidemiological evidence. Nutr Metab Cardiovasc Dis 2011; 21(Suppl. 1): S40-5.
|||Casas-Agustench P, Bulló M, Ros E, Basora J, Salas-Salvadó J. Cross-sectional association of nut intake with adiposity in a Mediterranean population. Nutr Metab Cardiovasc Dis 2011; 21(7): 518-25.
|||Mukuddem-Petersen J, Stonehouse Oosthuizen W, Jerling JC, Hanekom SM, White Z. Effects of a high walnut and high cashew nut diet on selected markers of the metabolic syndrome: A controlled feeding trial. Br J Nutr 2007; 97(6): 1144-53.
|||Kawano J, Arora R. The role of adiponectin in obesity, diabetes, and cardiovascular disease. J Cardiometab Syndr 2009; 4(1): 44-9.
|||Aronis KN, Vamvini MT, Chamberland JP, et al. Short-term walnut consumption increases circulating total adiponectin and apolipoprotein a concentrations, but does not affect markers of inflammation or vascular injury in obese humans with the metabolic syndrome: data from a double-blinded, randomized, placebo-controlled study. Metabolism 2012; 61(4): 577-82.
|||Zhang J, Wu Y, Zhang Y, Leroith D, Bernlohr DA, Chen X. The role of lipocalin 2 in the regulation of inflammation in adipocytes and macrophages. Mol Endocrinol 2008; 22(6): 1416-26.
|||Wang Y, Lam KSL, Kraegen EW, et al. Lipocalin-2 is an inflammatory marker closely associated with obesity, insulin resistance, and hyperglycemia in humans. Clin Chem 2007; 53(1): 34-41.
|||Catalán V, Gómez-Ambrosi J, Rodríguez A, et al. Increased adipose tissue expression of lipocalin-2 in obesity is related to inflammation and matrix metalloproteinase-2 and metalloproteinase-9 activities in humans. J Mol Med (Berl) 2009; 87(8): 803-13.
|||De la Chesnaye E, Manuel-Apolinar L, Zarate A, et al. Lipocalin-2 plasmatic levels are reduced in patients with long-term type 2 diabetes mellitus. Int J Clin Exp Med 2015; 8(2): 2853-9.
|||No Title [Internet] 5-Step Multiple-Pass Approach 2014.https://www.ars.usda.gov/northeast-area/ beltsville-md/beltsville-human-nutrition-research-center/ food-surveys-research-group/docs/ampm-usda-automated-multiple-pass-method/ Accessed October 01, 2017.|
|||Agricultural Research Service 2013. USDA National Nutrient Database for Standard Reference, Release 26 Nutrient Data Laboratory Home Page, 2013.http://www.ars.usda.gov/ba/bhnrc/ndl|
|||Instituto Nacional de Salud Pública, México. SNUT 2.1: Sistema de cálculo de vectores nutricionales. México, 1996.|
|||Lohman TG, Roche AF, Martorell R. Anthropometric Standardization Reference Manual. Human Kinetics Book, Champaign II, 1988.|
|||Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 1985; 28(7): 412-9.
|||Mantzoros CS, Williams CJ, Manson JE, Meigs JB, Hu FB. Adherence to the Mediterranean dietary pattern is positively associated with plasma adiponectin concentrations in diabetic women. Am J Clin Nutr 2006; 84(2): 328-35.
|||Zhang Y, Guo H, Deis JA, et al. Lipocalin 2 regulates brown fat activation via a nonadrenergic activation mechanism. J Biol Chem 2014; 289(32): 22063-77.
|||Moreno-Navarrete JM, Manco M, Ibáñez J, et al. Metabolic endotoxemia and saturated fat contribute to circulating NGAL concentrations in subjects with insulin resistance. Int J Obes 2010; 34(2): 240-9.
|||Clarke SD. Polyunsaturated fatty acid regulation of gene transcription: A mechanism to improve energy balance and insulin resistance. Br J Nutr 2000; 83(1)(Suppl. 1): S59-66.
|||Wien MA, Sabaté JM, Iklé DN, Cole SE, Kandeel FR. Almonds vs complex carbohydrates in a weight reduction program. Int J Obes Relat Metab Disord 2003; 27(11): 1365-72.
|||Berryman CE, West SG, Fleming JA, Bordi PL, Kris-Etherton PM. Effects of daily almond consumption on cardiometabolic risk and abdominal adiposity in healthy adults with elevated LDL-cholesterol: A randomized controlled trial. J Am Heart Assoc 2015; 4(1): e000993.
|||Tan SY, Mattes RD. Appetitive, dietary and health effects of almonds consumed with meals or as snacks: A randomized, controlled trial. Eur J Clin Nutr 2013; 67(11): 1205-14.
|||Kalgaonkar S, Almario RU, Gurusinghe D, et al. Differential effects of walnuts vs almonds on improving metabolic and endocrine parameters in PCOS. Eur J Clin Nutr 2011; 65(3): 386-93.
|||Njike VY, Ayettey R, Petraro P, Treu JA, Katz DL. Walnut ingestion in adults at risk for diabetes: Effects on body composition, diet quality, and cardiac risk measures. BMJ Open Diabetes Res Care 2015; 3(1): e000115.
|||Ortega FJ, Cardona-Alvarado M, Mercader JM, et al. Circulating profiling reveals the effect of a polyunsatured fatty acid-enriched diet on common microRNAs. doi:10.1016/j.jnutbio. ISSN: 0955-2863. J of Nutr Bioch 2015; 10(1): 1095-101. Oct;26|
|||Rajaram S, Haddad EH, Mejia A, Sabaté J. Walnuts and fatty fish influence different serum lipid fractions in normal to mildly hyperlipidemic individuals: A randomized controlled study. Am J Clin Nutr 2009; 89(5): 1657S-63S.
|||Mukuddem-Petersen J, Oosthuizen W, Jerling JC. A systematic review of the effects of nuts on blood lipid profiles in humans. J Nutr 2005; 135(9): 2082-9.