Applied nutritional investigation
Effect of pistachio diet on lipid parameters, endothelial function,inflammation, and oxidative status: A prospective study
Ibrahim Sari, M.D.
a ,
*, Yasemin Baltaci, M.D.
, Cahit Bagci, M.D.
,Ozcan Erel, M.D.
, Hakim Celik, M.D.
, Nur Aksoy, M.D.
,and Mehmet Aksoy, M.D.
a
Cardiology Department, Gaziantep University, School of Medicine, Gaziantep, Turkey
b
Physiology Department, Gaziantep University, School of Medicine, Gaziantep, Turkey
c
Biochemistry Department, Harran University, School of Medicine, Sanliurfa, Turkey
d
Biochemistry Department, Gaziantep University, School of Medicine, Gaziantep, Turkey
Manuscript received December 15, 2008; accepted May 30, 2009.
Abstract Objective:
Recent studies have suggested that nuts have favorable effects beyond lipid lowering. WeaimedtoinvestigateeffectoftheAnteppistachio(
PistaciaveraL.
)onbloodglucose,lipidparameters,endothelial function, inflammation, and oxidation in healthy young men living in a controlledenvironment.
Methods:
A Mediterranean diet was administered to normolipidemic 32 healthy young men (meanage 22 y, range 21–24) for 4 wk. After 4 wk, participants continued to receive the Mediterraneandiet but pistachio was added for 4 wk by replacing the monounsaturated fat content constituting
z
20% of daily caloric intake. Fasting blood samples and brachial endothelial function measurementswere performed at baseline and after each diet.
Results:
Compared with the Mediterranean diet, the pistachio diet decreased glucose (
P
<
0.001,
À
8.8
6
8.5%), low-density lipoprotein (
P
<
0.001,
À
23.2
6
11.9%), total cholesterol (
P
<
0.001,
À
21.2
6
9.9%), and triacylglycerol (
P
¼
0.008,
À
13.8
6
33.8%) significantly and high-densitylipoprotein (
P
¼
0.069,
À
3.1
6
11.7%) non-significantly. Total cholesterol/high-density lipoproteinand low-density lipoprotein/high-density lipoprotein ratios decreased significantly (
P
<
0.001 for both). The pistachio diet significantly improved endothelium-dependent vasodilation (
P
¼
0.002,30% relative increase), decreased serum interleukin-6, total oxidant status, lipid hydroperoxide, andmalondialdehyde and increased superoxide dismutase (
P
<
0.001 for all), whereas there was nosignificant change in C-reactive protein and tumor necrosis factor-
a
levels.
Conclusion:
In this trial, we demonstrated that a pistachio diet improved blood glucose level,endothelial function, and some indices of inflammation and oxidative status in healthy young men.These findings are in accordance with the idea that nuts, in particular pistachio nuts, have favorableeffects beyond lipid lowering that deserve to be evaluated with prospective follow-up studies.
Ó
2010 Published by Elsevier Inc.
Keywords:
Pistachio; Endothelium; Lipid; Inflammation; Oxidation
Introduction
Epidemiologic studies have shown that frequent nut consumption decreases the risk of coronary heart disease(CHD). Compared with people who consumed nuts lessthan one time per week, people who ate nuts at least fivetimes per week showed a 50% reduction in risk[1–4]. Nutsare rich in monounsaturated fatty acid (MUFA) and polyun-saturated fatty acid (PUFA), which are known to have favor-able effects on the lipid profile[5]. However, the potentialbenefitsofthenutsondecreasingCHDarenotlimitedtotheir effects on lipid parameters. Nuts are also a good source of
Financial support of the present study was provided by the PistachioInvestigation Group of the Gaziantep Chamber of Commerce.*Corresponding author. Tel.: 90-342-360-6060; fax: 90-342-360-3928.
E-mail address:
Ó
2010 Published by Elsevier Inc.doi:10.1016/j.nut.2009.05.023Nutrition 26 (2010) 399–404www.nutritionjrnl.com
dietary fiber, vitamins, micronutrients, antioxidants, aminoacids (e.g., arginine), and plant stenols[5].The majority of the nut studies were performed with wal-nuts, almonds, and peanuts. Thus far, to our knowledge,only three studies have been conducted in humans investigat-ingtheeffectsofpistachionuts,whichwereperformedasout-patientdietaryinterventiontrials[6–8].Investigatorsaremorefocusedonthefavorableeffectsofnutsbeyondtheireffectsonlipidparameters.Endothelialdysfunctionisanearlykeyevent in the atherosclerotic process that predicts future CHD devel-opment [9,10]. Endothelial function measurement can benon-invasively performed. A recent study has demonstratedthat substituting walnuts for MUFA in a Mediterranean diet improved endothelium-dependent vasodilation (EDV) in hy-percholesterolemic subjects as a measurement of endothelialfunction[11]. Like the walnut, the pistachio is a good sourceof
L
-arginine, which is a precursor of endogenous vasodilator nitricoxide.Toourknowledge,thereareasyetnodataregard-ing the effect of a pistachio diet on endothelial function.Inflammation and oxidation play an important role in thepathogenesis and progression of CHD. Some studies haveshown that nuts have favorable effects on inflammation andoxidative status; however, our knowledge about the impact of pistachios on inflammatory and oxidative balance islimited. In this study we therefore investigated the effect of anAnteppistachio(
PistaciaveraL.
)dietonlipidparameters,endothelial function, inflammation, and oxidative status inhealthy young men living in a controlled environment, whichhas not been studied previously.
Materials and methods
Study population
To our knowledge, previous nut studies were organized asoutpatient dietary modification studies. Although all of thepreviously published studies have reported good complianceof the participants to the administered diet, we believe that subjects living in a controlled environment would providea better sample population in a dietary intervention study.After providing therequired legalpermissions, weperformedthestudyinthevocationalpoliceeducationschoolofGazian-tep, Turkey. In the vocational police education school of Gaziantep, all students were living in a controlled environ-ment and eating in the same place. Sleeping and wakinghours and daily activities of the students were similar. Theywere not allowed to go outside the school borders and theywere not provided any additional food other than that servedduring meal times, except unlimited water.Thirty-three healthy students (mean age 22 y, range21–24) were included in the study. All enrolled subjectswere free of acute or chronic medical disorders and were of normal body habitus. All subjects underwent a detailedmedical history and physical examination by the investigator physicians. Exclusion criteria were smoking any amount,history of eating nuts frequently (more than once a week),a history of a food or nut allergy, regular use of any drugsincluding vitamin supplements, and a history of any knowndisease. Subjects with concomitant inflammatory diseasessuch as infections, recent surgical procedures, or dyslipide-mia were also excluded from the study. Participants wererequested to abstain from coffee products and alcoholconsumption during the recruitment period. The study proto-col was approved by the ethical committee of GaziantepUniversity and all participants gave informed consent.Participants were offered free pistachios but no monetarycompensation.
Protocol
Before the study, students were eating the same kind of regular diet (total energy from protein 20%, carbohydrate47%, and fat 33%) prepared in the school kitchen. Althoughthey were eating the same kind of food, the amount was not standardized for each student. They were allowed to eat asmuch as they wanted if the food remained. To overcomethe disparities across the food intakes of the participants(amount, calories, proportions of protein, fat, carbohydrate,etc.), we accepted the recruitment period as a run-in period.A Mediterranean-type diet was administered for 4 wk. After 4 wk, the participants continued to receive the Mediterra-nean-type diet but pistachio was added by replacing theMUFA content constituting
z
20% of daily caloric intake.Because diet-induced lipoprotein changes stabilize in lessthan 4 wk, we planned the diet periods as 4 wk[12]. Theprotocol description was summarized inTable 1.The Mediterranean-type diet was composed of naturalfood stuff. It was rich in vegetable and fish, whereas redmeat, fat products, and egg products were limited. The pista-chio diet was similar to the Mediterranean-type diet, but pistachio partly replaced MUFA-rich foods. Prepackaged,roasted unsalted pistachios (60 to 100 g) were administeredasanappetizerduringthesecond4-wkperiod.Inthepistachiodiet,pistachiocontributed
z
20%oftotalenergyandreplaced32% of the energy obtained from MUFAs in the control diet
Table 1Protocol description in summaryWeight, blood pressure,laboratory and endothelialfunction measurements
/
33 healthy young men living ina controlled environment Mediterranean diet
Y
4 wkWeight, blood pressure,laboratory and endothelialfunction measurements
/
Pistachio was added to theMediterranean diet byreplacing 32% of energyobtainedby monounsaturatedfatty acid
Y
4 wkWeight, blood pressure,laboratory and endothelialfunction measurements
/
32 participants finished theprotocol
I. Sari et al. / Nutrition 26 (2010) 399–404
400
(Table 2). The pistachio diet was equivalent to the Mediterra-nean diet in total calory intake and proportions of carbohy-drate and protein intakes; however, saturated fatty acid andPUFA intakes were lower (
P
¼
0.02 and
P
<
0.001, respec-tively) and MUFA and fiber intakes were higher (
P
<
0.001and
P
<
0.001, respectively). According to the data providedby the Pistachio Investigation Institute, Gaziantep, the com-position of 100 g of pistachio was 18.3 g of protein, 52.7 gof fat (saturated fatty acid 6.7 g, MUFA 36.2 g, and PUFA9.8 g), 20 g of carbohydrate, and 7.4 g of fiber.During the study period a registered dietitian supervisedmealtimes and ensured the complete intake of the respectivemeals. The components of the food during the study periodwere prepared and served by a food company (Tam Sofra Inc., Gaziantep, Turkey) under the supervision of the regis-tered dietitian. The participants ate their breakfast, lunch,and dinner in the same field. Leftover foodstuffs werecollected and weighed by the dietitian to determine compli-ance. Any deviations from the study protocol were recordedand reviewed by the investigators during the study.Fasting blood sample collection, endothelial function,body weight, and blood pressure measurements wereperformed three times (during the run-in period, after 4 wk[4wk after the Mediterranean-type diet], and after 8 wk[4 wk after pistachio diet administration]). Because theschoolprogramandtheactivitiesoftheparticipantswerepre-planned for the entire education year, there was no change indaily activities of the participants during the study period.
Endothelial function measurement
Endothelialfunctionmeasurementswereperformedbythesame examiner who was unaware of the stage of the study.Each subject was studied in the morning hours (08:00 to10:00) after fasting
>
8 h before the examination. Studieswere performed in a quiet, semi-dark, temperature-controlledroom (20–25
C) with the subject lying in a supine position.Images were obtained using a commercially available device(Vivid7,GEVingmedUltrasoundAS,Horten,Norway)witha12-MHzlineararraytransducer.Accordingtothepowercal-culation, to provide 80% power at 5% significance to detect a 2% mean absolute difference in EDV and endothelium-independent vasodilation as significant, 25 subjects wouldneed to complete the study.The measurements were performed as previouslydescribed[13]. The brachial artery was imaged longitudi-nally, 2 to 5 cm above the antecubital crease. An occludingcuff placed proximally on the forearm was inflated to a pres-sure of 200 mmHg for 5 min and rapidly deflated to inducereactive hyperemia. Brachial artery scans were obtained 30s before cuff inflation (first baseline), at 60 to 90 s after cuff deflation to assess EDV, after a 10-min rest (secondbaseline), and 3 min after 0.4 mg of sublingual glyceryl trini-trate to evaluate endothelium-independent vasodilation.Arterial diameter was measured with ultrasonic calipers at end diastole, incident with the R wave on the electrocardio-gram. Three cardiac cycles were analyzed for each scan,andmeasurementswereaveraged.Reliabilityofthemeasure-ments was qualified by having them remeasure a randomsample of 15 subjects.
Laboratory measurements
Venous blood samples of the participants were collectedfrom the antecubital vein while patients rested in a supinepositionafteranovernightfast.Serumandethylenediaminete-tra-acetic acid plasma samples were stored at
À
80
C and an-alyzed at the end of the study period. Total cholesterol (TC),high-density lipoprotein (HDL), and triacylglycerol (TG)levels were determined by enzymatic–colorimetric methods.Low-density lipoprotein (LDL) was calculated by the Friede-waldformula. Oxidized LDLwascalculatedby a monoclonalantibody–based immunoassay.Apolipoproteins(Apo) AlandBweredetermined byturbidimetry.Homocysteinewasdeter-mined by fluorescence polarization immunoassay.High-sensitivity C-reactive protein (hs-CRP) was mea-sured by chemiluminescent immunometric assay. Interleu-kin-6 and tumor necrosis factor-
a
were determined byenzyme-linked immunosorbent assay. Total oxidant status(TOS) was determined as previously described[14]. Serumlipid hydroperoxide level was determined by the ferrousion oxidation–xylenol orange method. Malondialdehyde(MDA) was measured by a standard high-performance liquidchromatographic method. Superoxide dismutase (SOD)levels were performed by a commercially available SODkit. All laboratory analyses were done in duplicate.
Statistical analysis
Continuous variables are expressed as mean
6
standarddeviation and categorical data are expressed as percentages.Two-tailed
t
test for paired samples was used to comparechanges in outcome variables in response to diets. The differ-ences between the compositions of the Mediterranean andpistachio diets were tested with unpaired
t
test or chi-squaretest. Because hs-CRP was highly skewed, a logarithmictransformation was used to obtain a normal distribution
Table 2Comparison of nutritional status of subjects during the Mediterranean andpistachio dietsVariable Mediterranean diet Pistachio diet
P
Total calories (kcal/d) 1966
6
224 1983
6
241
>
0.1CHO (% energy) 48.7
6
3.2 49.2
6
2.8
>
0.1Protein (% energy) 17.1
6
1.5 16.8
6
1.7
>
0.1Fat (% energy) 33.5
6
2.2 33.1
6
1.9
>
0.1SFA 5.9
6
1.1 4.8
6
1.4 0.02MUFA 13.3
6
1.6 20.2
6
2.3
<
0.001PUFA 14.2
6
1.3 7.1
6
1.0
<
0.001Fiber (g) 6.4
6
2.1 11.3
6
2.4
<
0.001CHO, carbohydrate; MUFA, monounsaturated fatty acid; PUFA, polyun-saturated fatty acid; SFA, saturated fatty acid.
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