NUTS! The Story of My Life. Prof. Joan Sabaté Department of Nutrition Loma Linda University

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1 NUTS! The Story of My Life Prof. Joan Sabaté Department of Nutrition Loma Linda University

2 Dr. Joan Sabate Chair, Nutrition, School of Public Health, Loma Linda University CA From Spain, Dr. Sabaté is a board certified physician in internal medicine who moved to the U.S. to further train in Public Health Nutrition. He obtained the degree of Doctor of Public Health in Nutrition from Loma Linda University. He was an American Heart Association post doctoral fellow in the Preventive Medicine Department then became an Assistant Professor in the Department of Epidemiology & Biostatistics and in the Department of Nutrition. Shortly after, he rose to Associate Professor. In 1998 he was named Chair of the Department of Nutrition while continuing his teaching commitments in epidemiology. Dr. Sabaté served as principal investigator in a nutrition research study that directly linked the consumption of walnuts to significant reductions in serum cholesterol. His findings were published in the New England Journal of Medicine in 1993 and received the attention of more than 400 media sources, both national and international. Bringing the research full circle Archives of Internal Medicine has recently published the findings of his pooled analysis of 25 intervention trials establishing the benefits of nut consumption on blood lipid levels and lowering the risk of heart disease. Dr. Sabaté continues to research the relationship of almonds, pecans, and walnuts to heart disease risk factors.

3 Postdoctoral Fellow 1988 to 1990

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5 Out of 65 foods in the questionnaire Three foods related to heart disease Meat increased risk Whole grains provided protection Nuts provided protection

6 Adventist Health Study, 1992 Risk of coronary heart disease to frequency of nut consumption P for trend <0.005 P for trend <0.001 Nut Frequency < 1/week 1-4/week 5/week Myocardial Infarction Fatal CHD

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12 Nurses Health Study Nuts and Heart Diseases Relative Risk Non-Fatal Myocardial Infarction Fatal CHD Almost Never 1-3/month to once/week 2-4 times/week >5 times/week Hu, et al. BMJ 1998 Frequency of nut consumption

13 Results of 4 Population Studies 1.2 CHD Risk Adventist Iowa Women Nurses Physicians 0

14 The Nuts CHD Risk Connection A dose-response gradient in each study Across the studies an 8.3% reduction in CHD risk is observed for each weekly serving of nuts

15 The LLU Walnut Study (1993)

16 The LLU Walnut Study (1993) Study Diets 20% Walnut 100% Energy from NCEP Step 1 Diet 80% Energy from NCEP Step 1 Diet Control Diet Walnut Diet % En. from total fat: % En. from S/M/P fat: 10/10/10 6/8/16

17 The LLU Walnut Study (1993) Experimental Design 4 Weeks 4 Weeks NCEP Step 1 diet Walnut diet Run-in Period 1 Week R Walnut diet NCEP Step 1 diet A controlled, single-blinded, randomized crossover design 18 normocholesterolemic young men

18 The Loma Linda Walnut Study (1993) Serum Lipid values throughout the Study Walnut diet followed by Step I diet Step I diet followed by walnut diet

19 The Loma Linda Walnut Study (1993) % Changes from Baseline, Compared to American Diet % Step 1 Walnut -20 Blood Cholesterol Triglycerides

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22 BARCELONA WALNUT TRIAL 1996

23 Dose-response Almond Study at LLU

24 Dose-response Almond Study at LLU Percentage Changes from Baseline Control Diet Low Almond Diet High Almond Diet TC LDL HDL ApoA1 ApoB

25 Blood lipids Loma Linda University Study Compared to the control diet, the nut-rich diets lower: Total cholesterol LDL cholesterol LDL/HDL ratio Changes are observed for males as well as females

26 Walnuts or Fish Study at LLU

27 The LLU Walnut or Fish Study Percent Changes from Control Diet % TC LDL HDL LDL:HDL TG* Apo B:A1 Walnut Fish

28 Nut Studies by others Over 40 Human nutrition studies conducted in 4 continents have evaluated the effect of nut containing diets on blood lipids Studies varied in length, size, study design, dietary control. However, almost everyone shows favorable results

29 Pooled Analysis

30 LLU Pooled Analysis Nuts and Serum Lipids Combines individual subject data from 25 dietary trials on nut Provides a more precise quantitative estimate of the effects of nuts on serum lipids To determine if results are consistent among population subgroups To test for a dose response to the proportion of nuts in a diet Dataset includes 1284 observations from 583 unique participants and include unpublished studies Sabaté, et al., Arch Int Med 2010

31 LLU Pooled Analysis Changes (%) in Serum Lipids & Lipoproteins 1 0 TC LDL-C HDL-C TG LDL:HDL TC:HDL -1-2 % ** ** p< ** ** **

32 LLU Pooled Analysis Results For an average intake of 67 g of nuts, mean reduction of total & LDL cholesterol were 10.9 mg/dl (5.1%) and 10.2 mg/dl (7.4%), respectively The LDL/HDL and total cholesterol/hdl ratios by 0.22 (8.3%) and 0.24 (5.6%) respectively Triglyceride levels were lowered only in patients with hypertriglyceridemia

33 LLU Pooled Analysis % Change by Nut Calories % Change % 12.2% 20% TC LDL-C LDL-C/HDL-C TG

34 Feb 25, 2013 (Epub ahead of print)

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36 N Engl J Med 2013

37 Cardio Vascular Disease N Engl J Med Hazard Ratios (95% CI) Hazard Ratios (95% CI) Unadjusted Adjusted (1) Addtionallyadj (2) 0.2 Unadjusted Adjusted (1) Additionally adj. (2) (1). Stratified according to recruiting center and adjusted for sex, age, family history of premature coronary heart disease, and smoking status. (2) Additionallly adjusted for body-mass index, waist-to-height ratio, hypertension at baseline, dyslipidemia at baseline, and diabetes at baseline.

38 Primary end-point (MI, stroke or death from CV causes)

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41 PreDiMed DMSB members (Data Management and Safety Board) Joan Sabaté, Frank Hu, Xavier Pi-Sunyer, Carlos Gonzalez Loma Linda University, Harvard University, Columbia University, University of Barcelona

42 Important Thought Daily intake of a small quantity of nuts is one of the most acceptable lifestyle interventions for the prevention of coronary heart disease

43 Practical Applications People regularly shop for foods rather than nutrients Nuts can fit any diet pattern or lifestyle Nuts do not require cooking, preparation or conservation and can be easily transported and apportioned

44 The Story of my Life

45 Evolution of Our Understanding of Nut Consumption and Heart Disease Risk 1992 Does nut consumption protect against IHD? European Journal of Clinical Nutrition 1993 A probable role for nuts in the prevention of CHD Primary Cardiology 1994 Nuts: A new protective food against CHD Current Opinion in Lipidology 1996 Nut consumption and CHD risk Chapter in Lipids in Human Nutrition 2000 The role of nuts in cardiovascular disease prevention: A review Chapter in Nutraceuticals & Functional Foods

46 Evolution of Our Understanding of Nut Consumption and Heart Disease Risk 2003 Nut consumption and body weight Archives of Internal Medicine 2006 Nuts: nutrition and health outcomes British Journal of Nutrition 2007 Nut consumption and change in weight: the weight of the evidence British Journal of Nutrition 2008 The role of tree nuts and peanuts in the prevention of coronary heart disease: Multiple potential mechanisms Journal of Nutrition 2009 Nuts and health outcomes: new epidemiologic evidence American Journal of Clinical Nutrition 2010 Nut consumption and blood lipids: A pooled analysis of 25 intervention trials Archives of Internal Medicine

47 The Story of my Life

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54 Golden Nut Award Recipient

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58 The Story of my Life

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60 Medical School at Sant Pau University Hospital Barcelona 1971 to 1977

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62 Kilimanjaro Expedition

63 A Trail of Nuts Through Life Eating nuts at home Walnuts Pine nuts Almonds Hazelnuts Spain While hiking the Pyrenees Post Doctoral Fellow at LLU Conducted Walnut Study Loma Linda Walnut Study New England Journal of Medicine USA Spain Eating nuts as Medical Student Discovery 1992 Nuts protect against heart attack The Adventist Health Study Barcelona Walnut Trial

64 A Trail of Nuts Through Life Conducted many other nut trials Almonds Peanuts Pecans Walnuts EPIC Study WHO Center in Lyon While hiking Kilimanjaro USA USA 2003 Europe 2004/5 USA 2010 Africa 2011 Spain/USA Testify before the US Food and Drug Administration for health claim on nuts Nut Studies Pooled Analysis Archives of Internal Medicine Walnuts and Healthy Aging Dual Center Barcelona Loma Linda

65 Nuts: An essential component of any plant-based diet Vegetarian NUTS Mediterranean Adventist

66 Golden or not, nuts are of immense value to me!

67 Joan Sabaté

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