Socorro Gutierrez

Kimberly Moore
04/04/13
NFSC 340

Li T, Brennan A, Wedick N, Mantzoros C, Rifai N, Hu F. Regular Consumption of Nuts is
Associated with a Lower Risk of Cardiovascular Disease in Women with Type 2 Diabetes. The
Journal of Nutrition. 2009:139;1333-1338.

Introduction
In this study the association of nut consumption and rate of cardiovascular disease in
women with type 2 diabetes was examined. More specifically the hypothesis that regular
consumption of nuts will decrease risks of cardiovascular disease in women who have type 2
diabetes. This study consisted of 6,309 women with type 2 diabetes who participated in multiple
surveys, and gave blood samples over a 22 year period. These 6,309 women were previously
registered nurses who joined the Nurses Health Study when they developed diabetes; this study
lasted from 1980 to 2002.
Methods
This study utilizes a cohort study design. A cohort design is a rather strong study design
and ranks at the top end of the study design spectrum it uses observation to compile findings.
The study participants observed in this study are all women who were at one time registered
nurses who have developed type 2 diabetes.
In this study the researchers applied the National Diabetes Data Group criteria to
determine whether or not a woman did in fact have type 2 diabetes. These criteria were used
because at the time the American Diabetes Association criteria was not yet developed. To meet
the National Diabetes Data Group criteria for type 2 diabetes the woman had to meet at least one
of three determining criteria. Also any women who had cancer or any Cardiovascular disease at
the time of enrollment were not included into the study. This study recruited their participants in
a convenient manner with all the participants having been Registered Nurses at one point.
The 6,309 women were determined to have type 2 diabetes according to the National
Diabetes data at study entry. This cohort group participated in dietary assessments, blood sample
collections, and assessments of other variables. Over the 22-year study these women reported in
six different dietary assessments on their relative consumption of nuts and peanut butter. Their
responses were condensed into 4 possible answers, almost never, 1-3 servings per month to 1
serving per week, 2-4 servings per week, and at least 5 servings per week. Total nut consumption
was calculated as nuts and peanut butter consumed. Some women also participated in giving
blood samples. They were sent phlebotomy kits and instructions, 97% of all blood samples were
returned within 26 hours of being taken. Samples were frozen to track any changes due to
prolonged storage. The blood samples were used to measure and evaluate cholesterol levels,
Apolipoprotein-B-100, tumor necrosis factor receptor 11, intercellular adhesion molecule-1, E-
selectin, C-reactive protein and fibrinogen. Plasma lipid and other biochemical analyses were
completed in 2003, this is a concern due to long-term storage, however there because of the
extreme cold the samples were stored at the possibility of degradation is relatively low.
Participants also completed a questionnaire every two years regarding lifestyle choices
including smoking, alcohol consumption, and physical activity level. These women took part in
the various assessments and blood sampling until they suffered from a cardiovascular endpoint.
The study defines a cardiovascular endpoint as cardiovascular heart disease, stroke, a nonfatal
myocardial infarction, and coronary angioplasty/ coronary bypass surgery. All cardiovascular
deaths, including sudden deaths were confirmed by autopsy reports and or review of medical
records. The doctors that did these reviews were not aware of the studies hypothesis. Out of all
deaths during this study a total of 98 percent were considered complete.
The statistical analysis used in this study where regression and relative risk. Relative risk
is a way to measure the outcome, in this case a cardiovascular endpoint, and a variable,
consumption of nuts and or peanut butter. Regression analysis is used to compare one dependent
variable, being type 2 diabetes, to one or more independent variables, rate of consumption of
nuts and or peanut butter.
Results
Throughout the 54,656 person-years of follow-up there were 634 cases of CVD; 452
nonfatal and fatal myocardial infarctions and 182 strokes. Evidence also saw at study entry
women that had a high peanut butter and nut intake appeared to be leaner, tended not to smoke,
and were more physically active. An important finding was that these women had slightly longer
duration of diabetes and less hypertension. The key dependent variables are the occurrence of
cardiovascular disease (CVD) or as the authors referred to it as cardiovascular endpoint in the
cohort of women diagnosed with type 2 diabetes at study entry, meeting the criteria the
American Diabetes Associations diagnostic definition. The independent variables in this study,
regular consumption of nuts and/ or peanut butter in the experimental groups dietary intake.
From 1986 to 2002, variables were measured by collecting total nut consumption data from the
follow-up dietary questionnaires containing 9 possible answers into 4 exposure categories to
choose from for how often nuts were consumed per week. Therefore, allowing researchers to
calculate the sum of dietary intake of peanuts and other nuts based on frequency distribution.
It is possible that there may be confounding (control) variables. In terms of data
collection and analysis of multivariates there may be unmeasured nutrients such as arginine and/
or phytosterols, or unknown related factors such as genetic precursors in DNA that may require
additional genetic testing, also heart disease in family history in the cohort group briefly
mentioned by the authors.
Table 1 summarized relevant results including baseline characteristics of 6,309 women
with type 2 diabetes consuming > 5 servings/wk of nuts and peanut butter had significantly
higher intakes of total energy, polyunsaturated fat, red meat, fruits, and vegetables and
significantly lower glycemic load than the other exposure categories of nut consumption. One
serving of nuts equaled 16g and 1 serving of peanut butter equaled 28g per serving, with values
indicating means + SD. Table 2 measured frequent peanut butter and nut consumption had
inverse association with total CVD risk in age-adjusted RR analysis and multivariate RR,
meaning researchers can control for relative risk of age and other variables associated with the
risk of CVD and the consumption of nut and peanut butter consumption. Researchers did not find
proof for a significant linear trend across increasing categories of nut consumption for either MI
or CVD endpoints, once adjustment for CVD risk factors was applied. Therefore, diabetic
women consuming a significant amount of nuts and/ or peanut butter, which according to the
data is at least 5 serving/wk, have shown to lower their risks of CVD by 44% and MI by 44%.
Table 3 showed analysis performed on plasma lipid concentrations taken from the sub
group of participants for whom blood samples were made available. We see the association of
nut and peanut butter consumption with plasma lipids among this subgroup (n = 1171). Again,
indicating a significantly lower LDL cholesterol and total cholesterol concentrations than those
who consumed >5 servings of nuts and/ or peanut butter per week. Inverse association in
multivariate-adjusted analysis for one serving per day increment with the plasma lipids
mentioned: -0.17 mmol/L, -0.08 mmol/L, and -0.04 g/L, with P-values: 0.008, 0.014, 0.007, and
0.016, respectively. Researchers were sure to identify and measure the confounders such as red
meat, vegetables, fruits, whole grain, and dairy in order to analyze multivariates to indicate basis
of a strong study.
Summary
The authors are accurate in their conclusions because in this cohort study research
indicates a significant association between frequent nut and peanut butter consumption of at least
5 servings per week, with lower risk of cardiovascular disease and Myocardial infarction onset.
Furthermore, in comparison to other studies the current study extends the criteria of other studies
to show benefits for diabetic women who are at risk for developing CVD. The current study also
contained a number of strengths, taking into account the large sample size, the long duration of
potential analysis with follow up performed biennially ensuring a strong study over a long period
of time; all factoring into a strong study.
Apparent flaws such as limitations were listed in this particular research design. There
were a number of limitations listed; first, misclassification of exposure in this study, it is reported
that by doing so is a bias towards the null in results credible in comparison. Second, nutritional
benefits differ in nuts this cohort study was not able to differentiate the specific types of nuts.
Lastly, due to the lack of complete blood samples insufficient assessment was prepared to
correlate nut consumption to the biomarkers. The data collection and analysis of multivariates
may have been unmeasured for example, nutrients such as arginine and/ or phytosterols, or
genetic precursors in DNA and/ or heart disease in family history in the cohort group.
This prospective cohort study is a type of medical study that follows overtime a
conveniently recruited group of people with common statistical characteristics. This type of
study is without bias and is often used to look for potential risk factors by measuring exposure
variables before the occurrence of an outcome. This quality of study design falls in the cohort
studies of the evidence pyramid, considered substantially superior quality.
I would have preferred the researchers practiced a consistent measurement of nut
consumption at study entry and throughout, rather than manipulating raw data for the sake of
reaching a strong study. By manipulating the statistical regression, there may be a bias to support
the desired outcome in the results as the authors divulged in the article. In a study this large there
is room for critical variables being excluded, so areas might have been covered but removed at a
later time to focus on important markers in normal distribution of evidence. I would like to have
seen more information concerning the lifestyle of the women who were able to have a less
duration of hypertension and the association of diabetes onset.