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Replacing Carbs With Nuts May Be Beneficial in Diabetes

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 7/13/2011
  • Valid for credit through: 7/13/2012, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, cardiologists, endocrinologists, and other specialists who care for patients with type 2 diabetes.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the association between nut intake and hemoglobin A1c level in patients with type 2 diabetes.
  2. Describe the effect of substituting nuts for a muffin on lipid levels in patients with type 2 diabetes.


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  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor; Director of Research and Faculty Development, Department of Family Medicine, University of California, Irvine at Orange


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Replacing Carbs With Nuts May Be Beneficial in Diabetes

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 7/13/2011

Valid for credit through: 7/13/2012, 11:59 PM EST


Clinical Context

There are concerns about the effect of refined carbohydrates on glycemia in patients with type 2 diabetes, and studies on patients without diabetes have shown a positive effect of nut intake on cholesterol levels with no weight gain. However, the effect of substituting nuts for carbohydrates in patients with diabetes is not well known.

This randomized controlled trial by Jenkins and colleagues compares the effect of a full serving of nuts vs half a serving of nuts vs half a serving of a muffin and a muffin-only serving on hemoglobin A1c (HbA1c) and lipid levels in patients with type 2 diabetes. Mixed nuts were substituted as a source of fat and proteins to replace carbohydrate foods (muffin) without changing the total energy intake for 3 months.

Study Synopsis and Perspective

Mixed nuts may be a good replacement for some carbohydrates in the diabetic diet, according to the results of a randomized controlled trial reported online June 29 in Diabetes Care.

"Fat intake, especially monounsaturated fatty acid (MUFA), has been liberalized in diabetic diets to preserve HDL [high-density lipoprotein] cholesterol and improve glycemic control, yet the exact sources have not been clearly defined," write David J. A. Jenkins, MD, from the Clinical Nutrition and Risk Factor Modification Center at St. Michael's Hospital Toronto in Ontario, Canada, and colleagues. "Therefore, we assessed the effect of mixed nut consumption as a source of vegetable fat on serum lipids and HbA1c in type 2 diabetes."

For 3 months, 117 participants with type 2 diabetes were randomly assigned to receive 1 of 3 treatments, with supplements given at 475 kcal per a 2000-kcal diet as mixed nuts (75 g/day of unsalted and mostly raw almonds, pistachios, walnuts, pecans, hazelnuts, peanuts, cashews, and macadamias), muffins with similar protein content to the nuts but no MUFAs, or half portions of both. Change in HbA1c level was the main study endpoint.

Compared with muffins, the full-nut dose was associated with a relative increase in MUFAs of 8.7% energy. The full-nut dose (mean intake, 73 g/day) was associated with a decrease in HbA1c levels of −0.21% absolute HbA1c units (95% confidence interval [CI] −0.30 to −0.11; P < .001), but there was no change with the half-nut dose or muffin, according to the intent-to-treat analysis (n = 117). The half-nut dose was not significantly different from muffin, but the full-nut dose was significantly different from both the half-nut dose (P = .004) and muffin (P = .001).

Compared with muffins, the full-nut dose was associated with a significant reduction in levels of low-density lipoprotein (LDL) cholesterol. With the half-nut dose, there was an intermediate reduction in LDL cholesterol levels, but this finding did not differ significantly from the other treatments. Similar patterns were observed with improvements in the apolipoprotein (apo) B and the apoB:apoA1 ratio. There was an inverse association of nut intake with changes in levels of HbA1c (r = −0.20; P = .033) and LDL cholesterol (r = −0.24; P = .011).

"Two ounces of nuts daily as a replacement for carbohydrate foods improved both glycemic control and serum lipids in type 2 diabetes," the study authors write.

Limitations of this study include use of a self-reported 7-day diet history, lack of blinding for participants and dietitians, high nut consumption, and the attempt to show a dose response to nuts when the primary objective of establishing whether nuts improved glycemic control had not first been demonstrated.

"[N]ut consumption not only improved glycemic control but also lipid risk factors for [coronary heart disease]," the study authors conclude. "We have no explanation for the lack of antioxidant effects of nuts seen with previous studies but may relate to antioxidants in wheat bran and apple concentrate used in the muffins. We conclude that mixed, unsalted, raw, or dry-roasted nuts have benefits for both blood glucose control and blood lipids and may be used to increase vegetable oil and protein intake in the diets of type 2 diabetic patients as part of a strategy to improve diabetes control without weight gain."

The Canada Research Chair Endowment of the Federal Government of Canada, the International Tree Nut Council Nutrition Research & Education Foundation, and the Peanut Institute supported this study. Two of the study authors have disclosed various financial relationships with Unilever, the Sanitarium Company, the California Strawberry Commission, the Almond Board of California, the International Tree Nut Council Nutrition Research & Education Foundation, Barilla, Unilever Canada, and/or Loblaws.

Diabetes Care. Published online June 29, 2011.

Study Highlights

  • Participants were recruited by newspaper advertisement and from previous studies.
  • 117 participants were randomly assigned, and the study was conducted from 2007 to 2008.
  • Participants were men or postmenopausal women with diabetes who were taking antidiabetic agents except acarbose, with stable medications for 3 months; HbA1c values between 6.5% and 8.0%; and no renal, liver, or cardiovascular disease.
  • The study was conducted as a 3-month, parallel-group randomized trial with 2 supplements and 3 treatment groups.
  • Participants were randomly assigned to either 1 full serving of nuts, half a serving of nuts and half of a muffin, or a full serving of a muffin daily for 3 months.
  • 40 were assigned to a full dose of nuts only, 38 to half dose of nuts, and 39 to muffins only.
  • Participants were told to maintain their usual medications.
  • If HbA1c levels increased to more than 8.5% during the study, participants were withdrawn from the study (n = 2).
  • The nuts provided consisted of a mixture of unsalted and mostly raw almonds, walnuts, pecans, hazelnuts, peanuts, cashews, and macadamias.
  • Energy requirements were calculated for each participant. Patients with requirements of 2400 kcal or more daily were prescribed 100 g of nuts or 4 muffins. For the half-dose group, half of each was prescribed.
  • Those who required 1600 to 2400 kcal daily were given 75 g of nuts (for the nut group) or 3 muffins (for the muffin group).
  • Participants requiring less than 1600 kcal daily were given 50 g of nuts for the nut group and 2 muffins for the muffin-only group.
  • They were seen at baseline and at weeks 2, 4, 8, 10, and 12. Weighing data and fasting blood samples were taken.
  • Mean age of the patients was 62 years, 65% were men, more than half were white, and mean body mass index was 29 kg/m2.
  • 43% were obese and wished to lose weight and were given advice on portion size and fat intake.
  • Most participants were close to the target of less than 7.0% for HbA1c levels at baseline. The majority (72%) were treated with 1 or more statins.
  • 97.5% of those in the full-dose nut group completed the study vs 84% of the half-dose nut group and 82% of the muffin-only group.
  • HbA1c levels decreased significantly (−0.21%; 95% CI −0.30 to −0.11; P < .001) in the full-dose nut group but not in the other 2 groups.
  • There was a significant difference between the full-dose nut and half-dose nut groups and the muffin-only group, but no difference was found between the half-dose nut and muffin groups.
  • There were also greater reductions in total cholesterol levels in the full-dose nut group vs the other 2 groups.
  • The reductions were −0.24 mmol/L for total cholesterol levels and −0.23 (P = .006) for the total:HDL cholesterol ratio for the full-dose nut group.
  • All 3 diets increased HDL cholesterol levels.
  • There were no significant weight changes among the groups at 3 months.
  • The authors concluded that a full-dose nut substitution for carbohydrates in patients with type 2 diabetes was associated with improved HbA1c levels and lipid profile but that a half-dose substitution was not associated with these benefits.
  • They noted that the overall dropout rate of 12% was lower than with other dietary changes in patients with diabetes and that weight was maintained with the nut substitution.

Clinical Implications

  • Substitution of carbohydrates with nuts (but not half a substitution) in patients with type 2 diabetes is associated with improved glycemic control at 3 months.
  • Full nut substitution is also associated with improved total cholesterol levels and improved ratio of total cholesterol to HDL cholesterol.

CME Test

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