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Nut Consumption and Decreased Risk of Sudden Cardiac Death in the Physicians' Health Study
Christine M. Albert, MD, MPH;
J. Michael Gaziano, MD, MPH;
Walter C. Willett, MD, DrPH;
JoAnn E. Manson, MD, DrPH
Arch Intern Med. 2002;162:1382-1387.
ABSTRACT
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Background Dietary nut intake has been associated with a reduced risk of coronary
heart disease mortality; however, the mechanism is unclear. Since components
of nuts may have antiarrhythmic properties, part of the benefit may be due
to a reduction in sudden cardiac death.
Methods We prospectively assessed whether increasing frequency of nut consumption,
as ascertained by an abbreviated food frequency questionnaire at 12 months
of follow-up, was associated with a lower risk of sudden cardiac death and
other coronary heart disease end points among 21 454 male participants
enrolled in the US Physicians' Health Study. Participants were followed up
for an average of 17 years.
Results Dietary nut intake was associated with a significantly reduced risk
of sudden cardiac death after controlling for known cardiac risk factors and
other dietary habits (P for trend, .01). Compared
with men who rarely or never consumed nuts, those who consumed nuts 2 or more
times per week had reduced risks of sudden cardiac death (relative risk, 0.53;
95% confidence interval, 0.30-0.92) and total coronary heart disease death
(relative risk, 0.70; 95% confidence interval, 0.50-0.98). In contrast, nut
intake was not associated with significantly reduced risks of nonsudden coronary
heart disease death or nonfatal myocardial infarction.
Conclusion These prospective data in US male physicians suggest that the inverse
association between nut consumption and total coronary heart disease death
is primarily due to a reduction in the risk of sudden cardiac death.
INTRODUCTION
RECENT RANDOMIZED dietary trials have reported markedly reduced risks
of recurrent events and cardiac death in patients assigned to the Mediterranean
diet after a myocardial infarction.1-2
In one trial, this benefit appeared to be at least partly due to an increase
in the plasma level of  -linolenic acid (an n-3 fatty acid) in the Mediterranean
diet arm.3 Small to moderate amounts of n-3
fatty acids have been demonstrated to have antiarrhythmic effects4 and to prevent sudden cardiac death in patients who
have had a myocardial infarction.5 Therefore,
the protective effects on cardiac mortality of the Mediterranean diet may
be partly related to antiarrhythmic effects of n-3 fatty acids and resultant
reduction in sudden cardiac death.
Nuts are both an important component of the Mediterranean diet and a
source of small to moderate amounts of -linolenic acid.6-8
In addition, nuts are a source of other unsaturated fats, magnesium, and vitamin
E, and result in an improved lipoprotein profile when added to the diet6-9 if caloric
intake remains constant. On the basis of experimental and observational data,
all of these potential effects would be expected to reduce sudden cardiac
death.10-12 In
3 large prospective observational studies,13-15
reductions in coronary heart disease mortality were observed among those who
consumed nuts more frequently, but none of these studies have specifically
examined the end point of sudden cardiac death. To further understand the
mechanism underlying the apparent protective effect of nut consumption, we
examined the associations between nut consumption and risk of sudden cardiac
death and other coronary heart disease end points in a cohort of 21 454
US male physicians followed up for an average of 17 years.
SUBJECTS AND METHODS
The Physicians' Health Study has been described in detail elsewhere.16-17 Briefly, 22 071 male physicians
who were 40 to 84 years old in 1982 and had no history of myocardial infarction,
stroke, transient ischemic attacks, or cancer (except nonmelanoma skin cancer)
were assigned at random by means of a 2 x 2 factorial design to receive
aspirin, beta carotene, both active drugs, or both placebos. At baseline,
the physicians completed questions on health status and risk factors for cardiovascular
disease, including alcohol and vitamin use, dietary intake of selected foods,
and exercise. Information on cardiovascular events was updated every 6 months
for the first year and annually thereafter through brief follow-up questionnaires.
Dietary intakes of selected foods were ascertained by 2 abbreviated semiquantitative
food frequency questionnaires consisting of 20 items each18
administered at baseline and 12 months.
ASSESSMENT OF NUT CONSUMPTION
At 12 months, the physicians were asked to indicate how often, on average,
they had consumed nuts (small packet or 1 oz) during the past year. There
were 7 possible response categories ( 2 times per day, daily, 5-6 times
per week, 2-4 times per week, once per week, 1-3 times per month, and rarely
or never), and on the basis of the frequency distribution of the responses,
4 categories of nut consumption were created (rarely or never, 1-3 times per
month, once per week, and 2 times per week). The validity of this question
was assessed in a cohort of female nurses, and the correlation coefficient
was found to be 0.6619 compared with repeated
1-week dietary records. Of the total cohort, 21 454 men returned the
12-month questionnaire and provided information on nut consumption. We chose
not to exclude participants who developed evidence of cardiovascular disease
during follow-up, but controlled for evidence of cardiovascular disease before
the return of the 12-month questionnaire in the multivariate model, since
previous disease could have influenced nut consumption.
END POINT ASCERTAINMENT AND DEFINITIONS
Information on cardiovascular events was updated every 6 months for
the first year and annually thereafter. The ascertainment of cardiovascular
disease events was by self-report on follow-up questionnaires, and deaths
were generally reported by postal authorities or next of kin. All such events
were reviewed by an end points committee of physicians for confirmation by
medical records obtained from hospitals and attending physicians. The next
of kin was interviewed regarding the circumstances surrounding the death if
not adequately documented in the medical record. Deaths in which there was
evidence of coronary heart disease at or before death and in which a noncoronary
cause of death was not found were classified as coronary heart disease deaths
(International Classification of Diseases, Ninth Revision, codes 410-414). Cases of nonfatal myocardial infarction were confirmed
with the use of the World Health Organization criteria.20
To ascertain the specific end point of sudden cardiac death, medical
records and reports from next of kin for all cardiovascular deaths (excluding
strokes) were rereviewed by 2 cardiologists (including C.M.A.) unaware of
exposure status, and agreement was reached. Sudden cardiac death was defined
as death within 1 hour of symptom onset and/or a witnessed cardiac arrest
or abrupt collapse not preceded by more than 1 hour of symptoms that precipitated
the terminal event. Information from the death certificate was not used in
the determination of the timing of death. To increase our specificity for
"arrhythmic death," we excluded anyone who had evidence of collapse of the
circulation (hypotension, exacerbation of congestive heart failure, and/or
altered mental status) before the disappearance of the pulse.21
Unwitnessed deaths with no information on timing but with an autopsy
consistent with arrhythmic cardiac death (ie, acute coronary thrombosis or
severe coronary artery disease without myocardial necrosis or other pathologic
findings to explain death) were considered possible sudden cardiac deaths,
and the analysis was performed both including and excluding these deaths.
STATISTICAL ANALYSIS
Participants contributed follow-up time from the date of return of the
12-month questionnaire. Age-adjusted means or proportions of baseline risk
factors and treatment group assignment were computed for the 4 categories
of nut consumption (rarely or never, 1-3 times per month, once per week, and 2
times per week). The significance of associations was tested with the Mantel-Haenszel  2 test for trend for categorical variables and linear regression for
continuous variables. Relative risks were computed with Cox proportional hazards
models,22 controlling for age and randomized
aspirin and beta carotene assignment. Multivariate Cox proportional hazards
models were used to control for potential confounders, including previous
cardiovascular disease, body mass index, smoking, history of diabetes, history
of hypertension, history of hypercholesterolemia, alcohol consumption, vigorous
exercise, vitamin E use, vitamin C use, multivitamin use, and other dietary
factors associated with nut intake (fish, red meat, vegetables, fruits, and
dairy products). Participants with missing data on covariates included in
the multivariate model were excluded from analysis. For each relative risk,
2-sided P values and 95% confidence intervals were
calculated. Tests for trend were performed by assigning an ordinal variable
for each level of consumption and then modeling this as a continuous variable
in separate Cox proportional hazards models. SAS software (SAS Institute Inc,
Cary, NC) was used for all analyses.
RESULTS
NUT INTAKE
The distribution of nut consumption among the 21 454 participants
is displayed in Figure 1. Twenty
percent of the cohort rarely or never consumed nuts, and the majority of the
men who consumed nuts did so between 1 to 3 times per month and 2 to 4 times
per week. Few men reported consuming nuts 5 or more times per week (6.3%). Table 1 shows the baseline cardiac risk
factor profile across 4 categories of nut intake. The men who ate nuts more
frequently were younger and less likely to smoke 20 or more cigarettes per
day or have a history of hypertension. In addition, these men exercised more
frequently and were more likely to take antioxidant supplements and drink
light to moderate amounts of alcohol. Nut intake was also directly associated
with various dietary factors. We therefore analyzed the relationship of nut
consumption with sudden cardiac death with and without adjustment for all
of these variables.
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Distribution of self-reported nut consumption (small packet or 1
oz) at 12 months of follow-up.
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Table 1. Relationship of Nut Intake at 12 Months to Coronary Heart
Disease Risk Factors at Baseline*
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SUDDEN CARDIAC DEATHS
Among the 21 454 eligible participants, 201 sudden deaths (176
definite and 25 probable) were documented during 17 years of follow-up. The
association between nut consumption at 12 months and subsequent risk of sudden
cardiac death is presented in Table 2.
After adjustment for age and aspirin and beta carotene assignment, men who
ate nuts more frequently tended to have a lower risk of sudden cardiac death
(P for trend, .04). This relationship persisted and
was strengthened after adjustment for coronary risk factors, previous cardiovascular
disease, and other dietary factors (P for trend,
.01). Compared with men who consumed nuts less than monthly, the multivariate
adjusted relative risk of sudden cardiac death for those who consumed nuts
2 or more times per week was 0.53 (95% confidence interval, 0.30-0.92). The
relationship between nut consumption and sudden cardiac death appeared linear,
and there was no clear evidence for a threshold effect over the distribution
of nut consumption. When possible events were excluded from the analysis,
the multivariate adjusted relative risk of sudden cardiac death for those
who consumed nuts 2 or more times per week was similar at 0.51 (95% confidence
interval, 0.28-0.94), and the P for trend across
the 4 categories remained significant (P = .007).
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Table 2. Relative Risk of Sudden Death According to Nut Intake*
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OTHER CORONARY HEART DISEASE END POINTS
In contrast to the inverse relationship with sudden cardiac death, nut
consumption was not significantly associated with risk of nonsudden coronary
heart disease death or nonfatal myocardial infarction (Table 3). The risk of nonsudden coronary heart disease death was
somewhat lower among the men who ate nuts 2 or more times per week; however,
this reduction was not statistically significant. With respect to nonfatal
myocardial infarction, there was no suggestion of any benefit associated with
nut consumption. Rather, there was a slight elevation in risk among men who
consumed nuts up to once per week compared with those who never consumed nuts;
however, the P for trend was not significant (P = .87). When all fatal coronary heart disease events
were examined, nut intake was associated with a trend toward a reduced risk
of total coronary heart disease death (P for trend,
.06), primarily because of a reduction in sudden cardiac death. However, the
risk reduction was apparent only in the highest intake category. The men who
consumed nuts 2 or more times per week had a 30% reduced risk of coronary
heart disease death compared with those who rarely or never consumed nuts
(P = .04).
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Table 3. Relative Risk of Other Coronary Heart Disease End Points According
to Nut Intake*
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COMMENT
In this large prospective cohort study of US male physicians, dietary
nut intake was associated with a significantly reduced risk of sudden cardiac
death, even after controlling for known cardiac risk factors and other dietary
habits. The effect appeared linear with a significant trend across the range
of nut intake in this study. Compared with men who rarely or never consumed
nuts, those who consumed nuts 2 or more times per week had a 47% lower risk
of sudden cardiac death and a 30% lower risk of total coronary heart disease
death. In contrast, nut intake was not associated with significantly reduced
risks of other types of coronary heart disease death and nonfatal myocardial
infarction. This pattern of benefit on coronary heart disease end points suggests
that at least part of the effect of nut consumption on sudden cardiac death
may be due to a reduction in fatal ventricular arrhythmias. If the effect
were due entirely to an effect on atherosclerosis or thrombosis, one would
expect to observe a beneficial association with nonfatal myocardial infarction.
Rather, there was a slight elevation in the risk among those consuming nuts
up to once per week. If a component of nuts is antiarrhythmic, then fatal
events could be converted to nonfatal events in the men who consumed nuts.
There are several components of nuts that, on the basis of observational
and experimental data, may have antiarrhythmic properties. Nuts are a source
of small to moderate amounts of -linolenic acid,6-8
the main nonmarine n-3 fatty acid in the diet. This fatty acid can be elongated
and desaturated after ingestion to form eicosapentaenoic acid (C20:5n-3) and
docosahexaenoic acid (C22:6n-3), the primary n-3 fatty acid found in fish.4 This class of fatty acids has been demonstrated to
have antiarrhythmic properties in experimental models4
and to reduce the risk of sudden cardiac death among patients who have had
myocardial infarctions in a randomized trial.5
Walnuts, in particular, contain high amounts of -linolenic acid (6.3
g per 100 g), whereas other nuts such as almonds, pistachios, and pecans contain
much smaller amounts (0.4 to 0.7 g per 100 g).8
Previous studies in this23 and other24-25 cohorts suggest that antiarrhythmic
effects may occur even with very small amounts of n-3 fatty acid intake. In
addition to -linolenic acid, nuts are rich in other polyunsaturated
and monounsaturated fatty acids and result in an improved lipoprotein profile
when substituted for other sources of fat in the diet.6-9
Although not clearly antiarrhythmic, an improved lipoprotein profile could
reduce the risk of plaque rupture, which is often an inciting event in sudden
cardiac death.12 Nuts are also rich in magnesium,
potassium, and vitamin E, all nutrients with potential antiarrhythmic effects.6-8,10-12
Finally, nuts also contain flavonoids,8 which
have been associated with reductions in coronary heart disease mortality in
prospective studies26-27; however,
the specific association between this constituent and sudden cardiac death
has not been explored.
Our results regarding fatal coronary heart disease are consistent with
other prospective studies; however, our results regarding nonfatal myocardial
infarction are disparate from at least 1 prospective study. Three large-scale
prospective studies have reported consistent inverse associations between
nut consumption and fatal coronary heart disease. In the Adventist Health
Study,13 subjects who consumed nuts 5 or more
times per week had significantly reduced risks of both fatal coronary heart
disease (relative risk, 0.52) and nonfatal myocardial infarction (relative
risk, 0.49). The Iowa Women's Health Study14
reported similar reduced risks of fatal coronary heart disease among women
who consumed nuts 2 to 4 times per week. Data on nonfatal events were not
available in this study. Finally, the Nurses' Health Study15
reported a 35% reduced risk of total coronary heart disease among women who
consumed nuts 5 or more times per week. When fatal and nonfatal myocardial
infarction were examined separately, the relationship with nut consumption
remained significant only for fatal coronary heart disease after adjustment
for other dietary variables.
Plausible explanations for the disparate results with respect to nonfatal
myocardial infarction within this cohort and the Adventist Health Study include
differences in the amount of nuts consumed and other dietary habits of the
participants. Twenty-four percent of the subjects in the Adventists study
consumed nuts 5 or more times per week compared with only 6.3% of the physicians.
If large quantities of nuts are required to obtain the benefit on nonfatal
myocardial infarction, then it is possible that such a benefit could be missed
in our cohort. Second, the Adventists study had a high proportion of vegetarians
(approximately 50% of the cohort) who substituted nuts for meat as part of
meals, whereas the physicians may have been consuming nuts as snacks. In the
Adventist Health Study, the association between nut consumption and total
coronary heart disease was significant in the nonvegetarians; however, the P for trend was weaker and the risk reduction was apparent
only among those who ate nuts at least 5 times per week.28
There are several limitations of the present study. As with any observational
study, the association between nut consumption and sudden cardiac death could
be due, at least in part, to residual confounding. The men who consumed nuts
had fewer coronary risk factors and practiced healthier lifestyle habits (Table 1) and, therefore, nut consumption
may be a marker for a healthier lifestyle and/or diet. Arguing against this
possibility, the association between nut consumption and sudden cardiac death
became stronger after adjustment for lifestyle, cardiac risk factors, and
diet. In addition, if nut consumption were simply a marker for a healthier
lifestyle, a similar association should have been found for nonsudden coronary
heart disease death and nonfatal myocardial infarction. Since we did not collect
complete information on diet, this study cannot exclude the possibility that
some other dietary factor associated with nut consumption could be responsible
for the observed association. However, the relationship with nut consumption
remained significant after controlling for intake of meat, fruits and vegetables,
dairy products, and, more important, fish intake, the only other dietary factor
known to be associated with sudden cardiac death.23
Another important limitation of the study is the single measure of self-reported
nut intake raising the possibility of misclassification, which, if random,
would tend to underestimate the magnitude of benefit or risk. Health professionals
have been found to reliably report nut intake19;
however, the inability to account for changes in intake occurring over time
would tend to obscure associations if the effect of nut intake is of short
duration.
In summary, this large prospective cohort study suggests that increasing
nut consumption among men is associated with a significantly reduced risk
of sudden cardiac death and fatal coronary heart disease, but not nonfatal
myocardial infarction. Since sudden cardiac death is often the first manifestation
of coronary heart disease,29 primary prevention
is of the utmost importance in reducing the incidence of sudden cardiac death.
However, despite the large numbers of sudden cardiac deaths in the population,
the overall incidence is only 0.1% per year, and our ability to predict sudden
cardiac death in the general population is poor.30
Therefore, to reduce the incidence of sudden cardiac death, we must either
accurately identify those at risk or develop safe, low-cost interventions
that can be applied to the population at large. If the observed associations
between dietary habits such as nut and fish consumption are causal, then these
dietary interventions could be applied with little risk. In addition, further
research directed at understanding the underlying mechanism by which nuts
may protect against sudden cardiac death specifically and coronary heart disease
in general could also lead to the development of novel preventive therapeutics.
AUTHOR INFORMATION
Accepted for publication October 23, 2001.
This study was supported by grants CA-34944 and CA-40360 from the National
Cancer Institute and HL-26490 and HL-34595 from the National Heart, Lung,
and Blood Institute, Bethesda, Md. Dr Albert is supported by Mentored Clinical
Scientist Development Award 1-K08-HL-03783 from the National Heart, Lung,
and Blood Institute.
An earlier analysis of these data (12 years of follow-up) was presented
in abstract form at the American Heart Association Meeting, Dallas, Tex, November
9, 1998.
We acknowledge the crucial contributions of the entire staff of the
Physicians' Health Study, under the leadership of Charlene Belanger, MA, as
well as Mary Breen, Vadim Bubes, PhD, Jean MacFadyen, Geneva McNair, David
Potter, Leslie Power, Harriet Samuelson, MA, Miriam Schvartz, MD, Mickie Sheehey,
Joanne Smith, and Phyllis Johnson Wojciechowski. We are also indebted to the
22 071 men who have participated and continue to participate in the Physicians'
Health Study.
Corresponding author and reprints: Christine M. Albert, MD, MPH,
Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth
Ave E, Boston, MA 02215-1204 (e-mail: calbert{at}partners.org).
From the Division of Preventive Medicine (Drs Albert, Gaziano, Manson),
Channing Laboratory (Drs Willett and Manson), and Cardiovascular Medicine
(Dr Gaziano), Department of Medicine, Brigham and Women's Hospital; Cardiovascular
Division, Department of Medicine, Massachusetts General Hospital (Dr Albert);
and Departments of Epidemiology (Drs Willett and Manson) and Nutrition (Dr
Willett), Harvard School of Public Health, Boston, Mass.
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A Walnut Diet Improves Endothelial Function in Hypercholesterolemic Subjects: A Randomized Crossover Trial
Ros et al.
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Cardiovascular Disease Resulting From a Diet and Lifestyle at Odds With Our Paleolithic Genome: How to Become a 21st-Century Hunter-Gatherer
O'Keefe and Cordain
Mayo Clin Proc. 2004;79:101-108.
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Progression of Age-Related Macular Degeneration: Association With Dietary Fat, Transunsaturated Fat, Nuts, and Fish Intake
Seddon et al.
Arch Ophthalmol 2003;121:1728-1737.
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Plant-based foods and prevention of cardiovascular disease: an overview
Hu
Am. J. Clin. Nutr. 2003;78:544S-551.
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Nut consumption and body weight
Sabate
Am. J. Clin. Nutr. 2003;78:647S-650.
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Effects of a Dietary Portfolio of Cholesterol-Lowering Foods vs Lovastatin on Serum Lipids and C-Reactive Protein
Jenkins et al.
JAMA 2003;290:502-510.
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Optimal Diets for Prevention of Coronary Heart Disease
Hu and Willett
JAMA 2002;288:2569-2578.
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