日本語

Summary

  • Nuts are good sources of several micronutrients, as well as unsaturated fatty acids, protein, fiber, and phytochemicals. (More information)
  • Results from large prospective cohort studies show an association between regular nut consumption (≥5 ounces/week) and lower risk of coronary heart disease. There is strong evidence from randomized controlled trials that nut consumption lowers blood cholesterol concentrations. (More information)
  • There is little evidence to support an association between regular nut consumption and a lower risk of developing type 2 diabetes mellitus. However, there is some evidence suggesting that nut consumption can improve glycemic control in individuals with type 2 diabetes mellitus. (More information)
  • Current epidemiological data indicate that higher nut consumption does not result in greater weight gain; rather, incorporating nuts into the diet may benefit weight control and contribute to reductions in body weight and waist circumference in energy-restriction diets (i.e., weight-loss diets). (More information)
  • Meta-analyses of prospective cohort studies show that nut consumption is associated with a reduced risk of all-cause mortality and mortality due to chronic conditions. (More information)
  • Peanuts and tree nuts can cause life-threatening allergy reactions. Current guidelines for the primary prevention of allergy set by the National Institute of Allergy and Infectious Diseases discourage nut avoidance by non-allergic women during pregnancy and encourage the early introduction to peanuts in age-appropriate foods in infants with no peanut allergy. (More information)
  • Substituting nuts for unhealthy snacks is a good strategy to avoid weight gain and improve the nutritional quality of one’s diet. (More information)

Introduction

In the not too distant past, nuts were considered unhealthy because of their relatively high fat content. Recent research, however, suggests that regular nut consumption is an important part of a healthful diet. Although the fat content of nuts is relatively high (13-20 grams (g)/ounce), most of the fats in nuts are monounsaturated and polyunsaturated fats rather than saturated fats (see Table 1). The term "nuts" refers to tree nuts like almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pistachios, and walnuts. Despite their name, peanuts are legumes like peas and beans. However, because they are nutritionally similar to tree nuts, they may share some of the same beneficial properties. Studies mentioned in this article have examined the effects of tree nuts and peanuts either together or separately.

Disease Prevention

Cardiovascular disease

In large prospective cohort studies, regular nut consumption has been consistently associated with significant reductions in the risk of coronary heart disease (CHD). An early study that followed more than 30,000 Seventh Day Adventists over 12 years found that participants who consumed nuts at least five times weekly had a 48% lower risk of death from CHD and a 51% lower risk of nonfatal myocardial infarction (MI) compared to those who consumed nuts less than once weekly (1). In addition, the risk of death from CHD was 39% lower in Seventh Day Adventists older than 83 years who ate nuts at least five times weekly compared to those who consumed nuts less than once weekly (2). More recently, an analysis of data from the Nurses' Health Study I that followed 84,136 women (ages at enrollment, 30-55 years) for 26 years reported a 32% lower risk of CHD in those who ate an average of 2.8 servings/week compared to those who never ate nuts (3). A 2014 meta-analysis of 13 prospective cohort studies, including the Seventh Day Adventists and Nurses' Health Studies, found a 34% lower risk of CHD with the highest versus lowest level of nut consumption (4). A dose-response analysis indicated that every 1 serving/week increment in nut consumption was associated with a 5% reduction in CHD risk (4). In another meta-analysis that included data from over 200,000 participants enrolled in three large cohort studies, weekly intake of at least five servings of nuts was associated with a 20% lower risk of CHD when compared to no consumption (5). However, there was no evidence of an association between nut consumption and risk of stroke. In contrast, another recent meta-analysis of prospective cohort studies found a 12% lower risk of stroke (14 studies) and a 19% lower risk of stroke-related death (seven studies) with the highest versus lowest intake of nuts (6).

The PREDIMED (Prevención con Dieta Mediterránea) study that took place between 2003-2011 was a multicenter, randomized controlled trial that examined the effect of a Mediterranean diet, with either extra-virgin olive oil or nuts, compared to a control diet, in the primary prevention of cardiovascular events in 7,447 adults (≥55 years) at high risk of cardiovascular disease (7). Adherence to a Mediterranean diet, supplemented with olive oil or mixed nuts for nearly five years resulted in a 30% lower risk of cardiovascular events and no weight gain (7).

Finally, a modeling study estimated that an increase in daily nut intake from 5 g to 30 g could have prevented 7,680 incidental cardiovascular events and saved about 65,000 years of life that were lost to stroke or heart attack in a scenario based on data from the Swedish population in 2013 (8).

Risk factors

Blood lipids: In a cross-sectional analysis of a representative sample of the US population — the National Health and Nutrition Examination Survey [NHANES] 2005-2010 — tree nut consumers (≥¼ ounce/day) were found to have higher blood HDL-cholesterol concentrations and lower body mass index (BMI), waist circumference, and systolic blood pressure than subjects consuming <¼ ounce/day (9). However, these observations may be due to reverse causation, in particular because health-conscious people are more likely to consume healthy diets that include nuts. A 2015 meta-analysis assessed the evidence of the effect of tree nut consumption on blood lipid profile using findings from 42 randomized controlled studies in a total of 2,101 participants, among which 45% were at risk of cardiovascular disease and untreated. Results indicated lower concentrations of total and LDL-cholesterol concentrations but no effect on concentrations of HDL-cholesterol or triglycerides (10). Similar observations were made in meta-analyses of interventions examining the specific effect of walnut (11, 12), almond (13), hazelnut (14), or pistachio (15) consumption on blood lipid profile of people with normal or elevated blood cholesterol. Interestingly, in a small recent trial in 46 statin-treated participants, the daily consumption of 100 g (~3.5 ounces) of almonds for four weeks led to a 4.9% reduction in non-HDL-cholesterol (i.e., total cholesterol minus HDL-cholesterol) concentration (16).

Blood pressure: Adherence to a Mediterranean diet for nearly four years in the PREDIMED trial led to significant improvements in diastolic (but not systolic) blood pressure compared to a control diet. However, there were no differences in blood pressure changes whether the Mediterranean diet was supplemented with nuts or olive oil (17). A meta-analysis of 21 randomized controlled trials in 1,652 participants found little evidence for an effect of nut supplementation on either systolic or diastolic blood pressure. A blood pressure-lowering effect of nuts was reported when only subjects without type 2 diabetes mellitus were considered. Of note, this meta-analysis included four trials that used either peanuts or soy nuts, which are not tree nuts (18).

Endothelial function: Measures of brachial flow-mediated dilation (FMD), a surrogate marker of endothelial function, are inversely associated with risk of cardiovascular events. A 2017 meta-analysis of eight randomized controlled trials suggested that supplementation with walnuts (four studies), pistachios (three studies), or almonds (one study) for up to 12 weeks may help increase FMD in subjects at risk of cardiovascular disease (19). Similar observations were reported in another recent meta-analysis of randomized controlled trials (20).

Chronic low inflammation: A 2016 meta-analysis of 20 small randomized controlled trials conducted primarily in subjects at high risk for cardiovascular disease found no evidence of an effect of nut supplementation for up to 12 weeks (only two studies lasted longer) on markers of inflammation in blood (21). Of note, four of the trials included in this meta-analysis exclusively supplemented participants with either peanuts or soy nuts. Nonetheless, a similar conclusion was reached in another meta-analysis of 25 interventions (19).

Of note, a recent systematic review of meta-analysis corroborated the account of the cardiovascular health benefits of nut consumption presented above (22).

Cardioprotective compounds in nuts

Nuts are energy-dense in particular because of their high fat content; yet, most of their fat is in the form of monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs). MUFAs and PUFAs are fatty acids that respectively contain one or more carbon-carbon double bonds (C=C) in their chemical structure, as opposed to saturated fatty acids that have none. Tree nuts contain more MUFAs than PUFAs with the exception of walnuts and pine nuts, which have more PUFAs than MUFAs, and Brazil nuts, which contain equivalent amounts of MUFAs and PUFAs (Table 1). Walnuts are especially rich in α-linolenic acid (~0.8 g/ounce), an omega-3 fatty acid with cardioprotective properties (see the article on Essential Fatty Acids). Other bioactive compounds, including micronutrients, phytosterols, and fiber, may also contribute to improving the cardiometabolic profile (Table 1 and Figure 1). Some nuts (pecans, pistachios, almonds, and hazelnuts) are a source of flavonoids that may contribute to cardiovascular health (see the article on Flavonoids) (23). For more information on the nutrient content of nuts, search the USDA Food Composition Database.

Table 1. Energy, Protein, Fat, Phytosterols, and Fiber in a 1-ounce Serving of Selected Tree Nuts and Peanuts
Nut (1 ouncea) Energy (kcal) Protein (g) Total fat (g) MUFAb (g) PUFAc (g) Phytosterols (mg) Fiber (g)
Almonds
164
6.0
14.2
8.9
3.5
39
3.5
Brazil nuts
187
4.1
19.0
6.8
6.9
21
2.1
Cashews
163
5.2
13.1
7.7
2.2
45
0.9
Hazelnuts
178
4.2
17.2
12.9
2.2
31
2.7
Macadamia nuts
204
2.2
21.5
16.7
0.4
33
2.4
Peanutsd
161
7.3
14.0
6.9
4.4
2.4
Peanut butter, smoothd (2 tbsp)
191
7.1
16.4
8.3
4.0
1.6
Pecans
196
2.6
20.4
11.6
6.1
36
2.7
Pine nuts (pignoli)
191
3.9
19.4
5.3
9.7
43
1.0
Pistachios
159
5.7
12.8
6.6
4.1
61
3.0
Walnuts, Black
175
6.8
16.8
4.4
10.3
34
1.9

The greatest contributions to energy, protein, fatty acids, phytosterols, and fiber are highlighted in bold.
aOne serving of nuts ~1 ounce-equivalent (oz-eq) ~28 grams
bMonounsaturated fatty acids
cPolyunsaturated fatty acids
dPeanuts are legumes, related to beans, lentils, soybeans, and dried peas, yet they are nutritionally similar to tree nuts.

The US Food and Drug Administration (FDA) has acknowledged the current evidence for a relationship between nut consumption and cardiovascular disease by approving the following qualified health claim for nuts (24): "Scientific evidence suggests but does not prove that eating 1.5 ounces per day of most nuts (such as macadamia nuts (25)) as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease" (24).

 Figure 1. Best Sources of Calcium, Iron, Magnesium, Manganese, Phosphorus, Potassium, Zinc, and Vitamin E Among Tree Nuts and Peanuts. The figure shows the micronutrient content in milligrams (mg)/ounce or micrograms/ounce of nuts; noted in parentheses here. Best sources of calcium (mg/ounce) include almonds (76), Brazil nuts (45), hazelnuts (32), and pistachios (30). Best sources of copper (micrograms/ounce) include cashews (622), Brazil nuts (494), hazelnuts (489), and walnuts (386). Best sources of iron (mg/ounce) include cashews (1.9), pine nuts (1.6), hazelnuts (1.3), and macadamia nuts (1.1). Best sources of magnesium (mg/ounce) include Brazil nuts (107), cashews (83), almonds (77), and pine nuts (71). Best sources of manganese (mg/ounce) include Brazil nuts (2.5), cashews (1.8), almonds (1.3), and pine nuts (1.2). Best sources of phosphorus (mg/ounce) include Brazil nuts (206), cashews (168), pine nuts (163), and walnuts (145). Best source of potassium (mg/ounce) include pistachios (291), almonds (208), peanuts (200), and hazelnuts (193). Best sources of zinc (mg/ounce) include pine nuts (1.8), cashews (1.6), pecans (1.3), and Brazil nuts (1.2). Best sources of vitamin E (mg/ounce) include almonds (7.3), hazelnuts (4.3), pine nuts (2.7), and peanuts (2.4). For reference, the adult Recommended Dietary Allowances (RDA) are as follows: Calcium: 1,000 mg/day; Copper: 900 micrograms/day; Iron: 8 mg/day for men and 18 mg/day for women (19-50 years); Magnesium 400 mg/day for men and 310 mg/day for women (19-30 years); Manganese: 2.3 mg/day for men and 1.8 mg/day for women; Phosphorus: 700 mg/day; Potassium (Adequate Intake instead of an RDA): 4,700 mg/day; Zinc: 11 mg/day for men and 8 mg/day for women; and Vitamin E (alpha-tocopherol): 15 mg/day.

[Figure 1 - Click to Enlarge]

Type 2 diabetes mellitus

Early results from the Nurses' Health Study I suggested that nut and peanut butter consumption might be inversely associated with the risk of type 2 diabetes mellitus in women (26). However, two independent meta-analyses of more recent prospective cohort reported no evidence of an association between nut consumption and risk of type 2 diabetes (27, 28).

Nonetheless, a meta-analysis of 12 randomized controlled trials in 450 participants with type 2 diabetes showed that supplementation with tree nuts for a median of eight weeks could reduce fasting glucose concentration and glycated hemoglobin (HbA1c) concentration, a measure of glycemic control (29). Although there were no significant effects on fasting insulin concentration or a measure of insulin resistance (HOMA-IR) (29), these findings suggest that nuts might be part of a healthful diet for the management of hyperglycemia in individuals with type 2 diabetes.

Weight control

A frequent concern is that increased consumption of nuts, which are high in fatty acids and energy dense, may cause weight gain and obesity. A data analysis of NHANES 2005-2010 found that tree-nut consumers (≥¼ ounce/day) had significantly lower BMI and waist circumference than non-consumers (<¼ ounce/day) and were 23% less likely of becoming overweight or obese (9). In addition, in the European Prospective Investigation into Cancer and Nutrition study (EPIC-PANACEA) that followed 373,293 adults (ages, 25-70 years), weight gain over a five-year period was significantly lower (-0.07 kg) in those in the highest quartile of nut intake (median, 12.4 g/day) compared to non-consumers (30). Moreover, the risk of becoming overweight or obese was also 5% lower in those in the highest quartile of nut intake compared to non-consumers (30). A 2013 meta-analysis of small randomized controlled trials found that changes in measures of body weight (28 trials, 1,806 participants), BMI (14 trials, 1,057 participants), or waist circumference (5 trials, 681 participants) were similar when nut-rich diets were compared to standard diets (31). There was some weak evidence suggesting modest reductions in body weight, BMI, and waist circumference measures with nut-rich diets (compared to standard diets) in energy-restriction rather than weight-maintenance interventions (31).

Current epidemiological data indicate that higher nut consumption does not result in greater weight gain; rather, incorporating nuts into diets may be beneficial for weight control.

Finally, it has been suggested that higher amounts of protein and fiber in nuts could enhance satiety and suppress hunger (32). In a recent randomized controlled trial in 100 overweight or obese participants, weight loss and improvements in blood lipid profile and blood pressure over a six-month period were found to be similar regardless of whether walnuts were supplemented to a reduced-energy density diet (33). In addition, there was no difference in reports of satiety between groups (33).

Cancer

Only a few observational studies have examined nut intake in relation to cancer risk. In the Netherlands Cohort Study that followed 120,852 adults (ages, 55-69 years) for about 20 years, there was no association between tree nut, peanut, peanut butter, and total nut consumption and the risk of pancreatic cancer (34). Another analysis of data from 62,573 women in this cohort showed that the highest versus lowest quartile of total nut intake (≥10 g/day versus 0 g/day) was associated with a 45% reduced risk of certain breast cancer subtypes, namely ER- and ER-/PR- (estrogen receptor-negative/progesterone receptor-negative) breast cancers (35). Nut intakes were not associated with other breast cancer subtypes or total breast cancer (35). In a recent analysis of the NIH-AARP Diet and Health Study that followed 566,407 men and women (ages, 50-71 years) for a median 15.5 years, the highest versus lowest quartile (median, 2.20 g/1,000 kcal versus 0 g/1,000 kcal) of total nut intakes (walnuts, peanuts, seeds, and other nuts) was associated with a 27% lower risk of gastric noncardia adenocarcinoma (36). There were no associations between total nut intake and risk of gastric cardia adenocarcinoma, esophageal adenocarcinoma, or esophageal squamous cell carcinoma (36). Although nuts contain many anti-carcinogenic compounds, including some vitamins, minerals, unsaturated fatty acids, phytosterols, and fiber, there is very little evidence that nut consumption might protect against cancer.

Cognitive function

An analysis of NHANES data from the 1988-1994 and 1999-2002 surveys suggested higher scores on cognitive tests in participants (ages ≥20 years) with regular intakes of walnuts (>10 g/day) compared to non-consumers (37). In the Nurses' Health Study I, which included 19,415 women ≥70 years of age, the highest quintile of long-term nut intake (≥5 servings/week) was associated with higher scores on global cognition and verbal memory tests compared to the lowest quintile of intake (<1 serving/month) (38). However, total nut intake in this study was not linked to rate of cognitive decline among individuals over a six year-period (38). Results from the PREDIMED study in 522 participants (mean age, 74.6 years) at high vascular risk showed higher global cognition test scores in those assigned to a Mediterranean diet supplemented with either extra-virgin olive oil or mixed nuts compared to those fed a control diet for 6.5 years (39). Although participants in each intervention group were unlikely to be cognitively different as a result of randomization at the start of the study, baseline cognitive status was not assessed and thus the conclusions of this study are limited (39). A follow-up PREDIMED study in 334 older adults (mean age, 66.8 years) whose cognitive functions have been assessed both at enrollment and at study completion showed little-to-no evidence of differences in changes in individual test scores over four years between intervention groups and the control group (40). However, when composite test scores were considered to better describe cognitive functions, the result showed that the consumption of a diet supplemented with either extra-virgin olive oil or mixed nuts prevented the decline of global cognitive function, as well as verbal and episodic memory and frontal cognitive functions (attention, cognitive flexibility, and working memory), which was reported in the subjects randomized to the control diet.

Mortality

A meta-analysis of 15 prospective cohort studies, including 819,448 participants, found a 19% lower mortality risk with the highest versus lowest levels of total nut intake (41). Intakes of tree nuts (four studies), peanuts (five studies), and peanut butter (two studies), separately, were also inversely associated with mortality. In addition, there was a non-linear dose-response relationship between total nut intake and mortality, suggesting a greater benefit of increasing intakes when intakes are initially low and no additional protection with intakes beyond 15 to 20 g/day. Higher intakes of total nuts were also found to be inversely associated with mortality related to respiratory disease (three studies) and diabetes mellitus (four studies) (41). These results corroborated findings from other recent meta-analyses (27, 42, 43).

It has been hypothesized that nut consumption could reduce the risk of disease and prolong life through influencing the length of telomeres that protect the ends of chromosomes. Bioactive compounds in nuts might regulate oxidative stress and inflammation, which are important drivers of telomere shortening, a marker of biological aging. A few cross-sectional studies have examined the associations between nut consumption and leukocyte telomere length, yet the findings have been rather inconsistent (44-47).

Safety

Nut allergies

Peanuts and tree nuts are among the most common foods to trigger allergic reactions, potentially severe (anaphylaxis) and fatal (48). Such reactions can be triggered by a primary antibody response against some nut proteins or by antibodies raised against protein in pollen but cross-reacting with structurally similar proteins in nuts. Mixed method-based estimates of peanut allergy in US children suggest that the condition is increasingly prevalent and ranges between 2 and 5% (49). Estimates based solely on self reports suggest a prevalence of tree nut allergy <1% in US adults and <2% in US children (50). Individuals with peanut or tree nut allergies need to take special precautions to avoid inadvertently consuming peanuts or tree nuts by checking labels and avoiding unlabeled snacks, candies, and desserts (50). See the Food Allergy Research and Education website for additional tips to avoiding unintentional peanut or tree nut exposure.

Nut consumption during pregnancy and lactation

In the 2010 'Guidelines for the Diagnosis and Management of Food Allergy in the United States,' the National Institute of Allergy and Infectious Diseases discourages nut avoidance during pregnancy or breastfeeding as a way of preventing food intolerance in the offspring (51). Results from two birth cohort studies suggested an inverse association between maternal peanut or tree nut consumption during, shortly before, or just after their pregnancy and the risk of food allergy (including nut allergy) in the offspring (52, 53), supporting the current recommendations. Yet, prior studies found higher peanut consumption in mothers of children with peanut allergy (54). Additional studies are needed to clarify the effect of maternal nut intake on food tolerance in the offspring.

Introduction to peanuts during infancy

A 2017 addendum to the 2010 'Guidelines for the Diagnosis and Management of Food Allergy in the United States' included recommendations for the prevention of peanut allergy through the early introduction of peanuts in infants' diet (55) (Table 2).

Table 2. 2017 Recommendations for the Introduction of Age-appropriate Peanut-containing Foods for Peanut Allergy Prevention (55)
Infant Criteria Earliest Age for Peanut Introduction Recommendations
Severe eczema and/or egg allergy  4-6 months
  • Peanut introduction only after measurement of peanut-specific antibodies and/or skin prick testing are found negative.
  • Peanut introduction should start after the introduction of solid foods without peanuts.
  • Infant may still benefit from early peanut introduction even if the 4-6 month window is missed.
Mild-to-moderate eczema ~6 months
  • Introduce peanut-containing foods.
No eczema or food allergies Age-appropriate and in accordance with family preferences
  • Introduce peanut-containing foods.

Adverse effects

Brazil nuts grown in areas of Brazil with selenium-rich soil may provide more than 100 µg of selenium in one nut, while those grown in selenium-poor soil may provide 10 times less (56). For information regarding toxicity of selenium, see the article on Selenium.

Intake Recommendations

Regular nut consumption, equivalent to 1 ounce of nuts five times weekly, has been consistently associated with significant reductions in risk of coronary heart disease in epidemiological studies. Consuming nuts daily as part of a diet that is low in saturated fat has been found to lower serum total and LDL-cholesterol in a number of controlled clinical trials. Since an ounce of most nuts provides at least 160 calories (kcal), simply adding an ounce of nuts daily to one's habitual diet without eliminating other foods may result in weight gain. Substituting unsalted nuts for less healthy snacks or for meat in main dishes are two ways to make nuts part of a healthful diet. A modeling study that used 2009-2012 NHANES data from 17,444 individuals (≥1 year old) estimated that substituting tree nuts for between-meal snacks on a calorie-per-calorie basis would improve the nutritional quality of dietary intakes through a shift in fatty acid intake (less saturated and more unsaturated fatty acids), a reduction in added sugar and sodium (salt), and an increase in potassium, magnesium, and fiber (57).

The 2015-2020 Dietary Guidelines for Americans encourage the consumption of nuts, seeds, and soy products as part of a healthy diet. The recommendations are presented in Table 3.

Table 3. 2015-2020 Dietary Guidelines for Americans: Recommendationsa for Nuts, Seeds, and Soy Products
Life Stage Age Mediterranean-style or US-style Eating Patternsc Vegetarian Eating Patternd
Children 2-3 years 2-3 2-3
Children 4-8 years 2-4 2-7
Children 9-13 years 4-5 5-9
Adolescents 14-18 years 4-6 6-13
Adults 19 years and older 5-6 7-10

aDietary guidelines apply when no quantitative Dietary Reference Intake (DRI) value is available.
bThe recommendations in ounce-equivalent (oz-eq) per week are based on estimated energy needs that vary with age and gender (see Appendix 2: Estimated Calorie Needs per Day, by Age, Sex, and Physical Activity Level). Recommended weekly intakes of nuts, seeds, and soy products, at all calorie requirement levels can be found in the '2015-2020 Dietary Guidelines for Americans' report.
cRecommended amounts for nuts, seeds, and soy products.
dRecommended amounts for nuts and seeds. Separate recommendations are made for soy products.


Authors and Reviewers

Originally written in 2003 by:
Jane Higdon, Ph.D.
Linus Pauling Institute
Oregon State University

Updated in December 2005 by:
Jane Higdon, Ph.D.
Linus Pauling Institute
Oregon State University

Updated in March 2018 by:
Barbara Delage, Ph.D.
Linus Pauling Institute
Oregon State University

Reviewed in September 2018 by:
Emilio Ros, M.D., Ph.D.
Former Director
Lipid Clinic, Endocrinology & Nutrition Service, Hospital Clínic
University of Barcelona
Barcelona, Spain

Copyright 2003-2018  Linus Pauling Institute 


References

1.  Fraser GE, Sabate J, Beeson WL, Strahan TM. A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist Health Study. Arch Intern Med. 1992;152(7):1416-1424.  (PubMed)

2.  Fraser GE, Shavlik DJ. Risk factors for all-cause and coronary heart disease mortality in the oldest-old. The Adventist Health Study. Arch Intern Med. 1997;157(19):2249-2258.  (PubMed)

3.  Bernstein AM, Sun Q, Hu FB, Stampfer MJ, Manson JE, Willett WC. Major dietary protein sources and risk of coronary heart disease in women. Circulation. 2010;122(9):876-883.  (PubMed)

4.  Ma L, Wang F, Guo W, Yang H, Liu Y, Zhang W. Nut consumption and the risk of coronary artery disease: a dose-response meta-analysis of 13 prospective studies. Thromb Res. 2014;134(4):790-794.  (PubMed)

5.  Guasch-Ferre M, Liu X, Malik VS, et al. Nut consumption and risk of cardiovascular disease. J Am Coll Cardiol. 2017;70(20):2519-2532.  (PubMed)

6.  Shao C, Tang H, Zhao W, He J. Nut intake and stroke risk: A dose-response meta-analysis of prospective cohort studies. Sci Rep. 2016;6:30394.  (PubMed)

7.  Ros E, Martinez-Gonzalez MA, Estruch R, et al. Mediterranean diet and cardiovascular health: Teachings of the PREDIMED study. Adv Nutr. 2014;5(3):330s-336s.  (PubMed)

8.  Eneroth H, Wallin S, Leander K, Nilsson Sommar J, Akesson A. Risks and benefits of increased nut consumption: cardiovascular health benefits outweigh the burden of carcinogenic effects attributed to aflatoxin B(1) exposure. Nutrients. 2017;9(12).  (PubMed)

9.  O'Neil CE, Fulgoni VL, 3rd, Nicklas TA. Tree nut consumption is associated with better adiposity measures and cardiovascular and metabolic syndrome health risk factors in U.S. Adults: NHANES 2005-2010. Nutr J. 2015;14:64.  (PubMed)

10.  Del Gobbo LC, Falk MC, Feldman R, Lewis K, Mozaffarian D. Effects of tree nuts on blood lipids, apolipoproteins, and blood pressure: systematic review, meta-analysis, and dose-response of 61 controlled intervention trials. Am J Clin Nutr. 2015;102(6):1347-1356.  (PubMed)

11.  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.  (PubMed)

12.  Guasch-Ferre M, Li J, Hu FB, Salas-Salvado J, Tobias DK. Effects of walnut consumption on blood lipids and other cardiovascular risk factors: an updated meta-analysis and systematic review of controlled trials. Am J Clin Nutr. 2018;108(1):174-187.  (PubMed)

13.  Musa-Veloso K, Paulionis L, Poon T, Lee HY. The effects of almond consumption on fasting blood lipid levels: a systematic review and meta-analysis of randomised controlled trials. J Nutr Sci. 2016;5:e34.  (PubMed)

14.  Perna S, Giacosa A, Bonitta G, et al. Effects of hazelnut consumption on bood lipids and body weight: a systematic review and Bayesian meta-analysis. Nutrients. 2016;8(12).  (PubMed)

15.  Lippi G, Cervellin G, Mattiuzzi C. More pistachio nuts for improving the blood lipid profile. Systematic review of epidemiological evidence. Acta Biomed. 2016;87(1):5-12.  (PubMed)

16.  Ruisinger JF, Gibson CA, Backes JM, et al. Statins and almonds to lower lipoproteins (the STALL Study). J Clin Lipidol. 2015;9(1):58-64.  (PubMed)

17.  Toledo E, Hu FB, Estruch R, et al. Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med. 2013;11:207.  (PubMed)

18.  Mohammadifard N, Salehi-Abargouei A, Salas-Salvado J, Guasch-Ferre M, Humphries K, Sarrafzadegan N. The effect of tree nut, peanut, and soy nut consumption on blood pressure: a systematic review and meta-analysis of randomized controlled clinical trials. Am J Clin Nutr. 2015;101(5):966-982.  (PubMed)

19.  Neale EP, Tapsell LC, Guan V, Batterham MJ. The effect of nut consumption on markers of inflammation and endothelial function: a systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2017;7(11):e016863.  (PubMed)

20.  Xiao Y, Huang W, Peng C, et al. Effect of nut consumption on vascular endothelial function: A systematic review and meta-analysis of randomized controlled trials. Clin Nutr. 2018;37(3):831-839.  (PubMed)

21.  Mazidi M, Rezaie P, Ferns GA, Gao HK. Impact of different types of tree nut, peanut, and soy nut consumption on serum C-reactive protein (CRP): A systematic review and meta-analysis of randomized controlled clinical trials. Medicine (Baltimore). 2016;95(44):e5165.  (PubMed)

22.  Schwingshackl L, Hoffmann G, Missbach B, Stelmach-Mardas M, Boeing H. An umbrella review of nuts intake and risk of cardiovascular disease. Curr Pharm Des. 2017;23(7):1016-1027.  (PubMed)

23.  Bolling BW, Chen CY, McKay DL, Blumberg JB. Tree nut phytochemicals: composition, antioxidant capacity, bioactivity, impact factors. A systematic review of almonds, Brazils, cashews, hazelnuts, macadamias, pecans, pine nuts, pistachios and walnuts. Nutr Res Rev. 2011;24(2):244-275.  (PubMed)

24.  US Food and Drug Administration. Qualified Health Claims: Letter of Enforcement Discretion - Nuts and Coronary Heart Disease (Docket No 02P-0505). 07/09/2015. Available at: http://wayback.archive-it.org/7993/20171114183724/https://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm072926.htm. Accessed 2/17/18. 

25.  US Food and Drug Administration. FDA Completes Review of Qualified Health Claim Petition for Macadamia Nuts and the Risk of Coronary Heart Disease. 12/07/2017. Available at: https://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm568052.htm. Accessed 2/17/18.

26.  Jiang R, Manson JE, Stampfer MJ, Liu S, Willett WC, Hu FB. Nut and peanut butter consumption and risk of type 2 diabetes in women. JAMA. 2002;288(20):2554-2560.  (PubMed)

27.  Luo C, Zhang Y, Ding Y, et al. Nut consumption and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):256-269.  (PubMed)

28.  Zhou D, Yu H, He F, et al. Nut consumption in relation to cardiovascular disease risk and type 2 diabetes: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr. 2014;100(1):270-277.  (PubMed)

29.  Viguiliouk E, Kendall CW, Blanco Mejia S, et al. Effect of tree nuts on glycemic control in diabetes: a systematic review and meta-analysis of randomized controlled dietary trials. PLoS One. 2014;9(7):e103376.  (PubMed)

30.  Freisling H, Noh H, Slimani N, et al. Nut intake and 5-year changes in body weight and obesity risk in adults: results from the EPIC-PANACEA study. Eur J Nutr. 2018;57(7):2399-2408.  (PubMed)

31.  Flores-Mateo G, Rojas-Rueda D, Basora J, Ros E, Salas-Salvado J. Nut intake and adiposity: meta-analysis of clinical trials. Am J Clin Nutr. 2013;97(6):1346-1355.  (PubMed)

32.  Mattes RD, Dreher ML. Nuts and healthy body weight maintenance mechanisms. Asia Pac J Clin Nutr. 2010;19(1):137-141.  (PubMed)

33.  Rock CL, Flatt SW, Barkai HS, Pakiz B, Heath DD. Walnut consumption in a weight reduction intervention: effects on body weight, biological measures, blood pressure and satiety. Nutr J. 2017;16(1):76.  (PubMed)

34.  Nieuwenhuis L, van den Brandt PA. Total nut, tree nut, peanut, and peanut butter consumption and the risk of pancreatic cancer in the Netherlands Cohort Study. Cancer Epidemiol Biomarkers Prev. 2018;27(3):274-284.  (PubMed)

35.  van den Brandt PA, Nieuwenhuis L. Tree nut, peanut, and peanut butter intake and risk of postmenopausal breast cancer: The Netherlands Cohort Study. Cancer Causes Control. 2018;29(1):63-75.  (PubMed)

36.  Hashemian M, Murphy G, Etemadi A, Dawsey SM, Liao LM, Abnet CC. Nut and peanut butter consumption and the risk of esophageal and gastric cancer subtypes. Am J Clin Nutr. 2017;106(3):858-864.  (PubMed)

37.  Arab L, Ang A. A cross sectional study of the association between walnut consumption and cognitive function among adult US populations represented in NHANES. J Nutr Health Aging. 2015;19(3):284-290.  (PubMed)

38.  O'Brien J, Okereke O, Devore E, Rosner B, Breteler M, Grodstein F. Long-term intake of nuts in relation to cognitive function in older women. J Nutr Health Aging. 2014;18(5):496-502.  (PubMed)

39.  Martinez-Lapiscina EH, Clavero P, Toledo E, et al. Mediterranean diet improves cognition: the PREDIMED-NAVARRA randomised trial. J Neurol Neurosurg Psychiatry. 2013;84(12):1318-1325.  (PubMed)

40.  Valls-Pedret C, Sala-Vila A, Serra-Mir M, et al. Mediterranean diet and age-related cognitive decline: a randomized clinical trial. JAMA Intern Med. 2015;175(7):1094-1103.  (PubMed)

41.  Aune D, Keum N, Giovannucci E, et al. Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis of prospective studies. BMC Med. 2016;14(1):207.  (PubMed)

42.  Grosso G, Yang J, Marventano S, Micek A, Galvano F, Kales SN. Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systematic review and meta-analysis of epidemiologic studies. Am J Clin Nutr. 2015;101(4):783-793.  (PubMed)

43.  Mayhew AJ, de Souza RJ, Meyre D, Anand SS, Mente A. A systematic review and meta-analysis of nut consumption and incident risk of CVD and all-cause mortality. Br J Nutr. 2016;115(2):212-225.  (PubMed)

44.  Karimi B, Nabizadeh R, Yunesian M, Mehdipour P, Rastkari N, Aghaie A. Foods, dietary patterns and occupational class and leukocyte telomere length in the male population. Am J Mens Health. 2018;12(2):479-492.  (PubMed)

45.  Nettleton JA, Diez-Roux A, Jenny NS, Fitzpatrick AL, Jacobs DR, Jr. Dietary patterns, food groups, and telomere length in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr. 2008;88(5):1405-1412.  (PubMed)

46.  Tucker LA. Consumption of nuts and seeds and telomere length in 5,582 men and women of the National Health and Nutrition Examination Survey (NHANES). J Nutr Health Aging. 2017;21(3):233-240.  (PubMed)

47.  Zhou M, Zhu L, Cui X, et al. Influence of diet on leukocyte telomere length, markers of inflammation and oxidative stress in individuals with varied glucose tolerance: a Chinese population study. Nutr J. 2016;15:39.  (PubMed)

48.  Al-Muhsen S, Clarke AE, Kagan RS. Peanut allergy: an overview. CMAJ. 2003;168(10):1279-1285.  (PubMed)

49.  Bunyavanich S, Rifas-Shiman SL, Platts-Mills TA, et al. Peanut allergy prevalence among school-age children in a US cohort not selected for any disease. J Allergy Clin Immunol. 2014;134(3):753-755.  (PubMed)

50.  McWilliam V, Koplin J, Lodge C, Tang M, Dharmage S, Allen K. The prevalence of tree nut allergy: a systematic review. Curr Allergy Asthma Rep. 2015;15(9):54.  (PubMed)

51.  Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 Suppl):S1-58.  (PubMed)

52.  Frazier AL, Camargo CA, Jr., Malspeis S, Willett WC, Young MC. Prospective study of peripregnancy consumption of peanuts or tree nuts by mothers and the risk of peanut or tree nut allergy in their offspring. JAMA Pediatr. 2014;168(2):156-162.  (PubMed)

53.  Maslova E, Granstrom C, Hansen S, et al. Peanut and tree nut consumption during pregnancy and allergic disease in children-should mothers decrease their intake? Longitudinal evidence from the Danish National Birth Cohort. J Allergy Clin Immunol. 2012;130(3):724-732.  (PubMed)

54.  Thompson RL, Miles LM, Lunn J, et al. Peanut sensitisation and allergy: influence of early life exposure to peanuts. Br J Nutr. 2010;103(9):1278-1286.  (PubMed)

55.  Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2017;139(1):29-44.  (PubMed)

56.  Chang JC. Selenium content of Brazil nuts from two geographic locations in Brazil. Chemosphere. 1995(30):801-802.  (PubMed)

57.  Rehm CD, Drewnowski A. Replacing American snacks with tree nuts increases consumption of key nutrients among US children and adults: results of an NHANES modeling study. Nutr J. 2017;16(1):17.  (PubMed)