Abstract
The nutritional benefits and immunological advantages of consuming nuts and seeds are well-established. However, the link between nuts and seeds consumption and the susceptibility of being overweight or obese among adolescents is not clear. This study aims to explore this relationship in adolescents aged 12–19. Using a weighted multiple logistic regression model, we analysed data of the Food Patterns Equivalents Database and the U.S. National Health and Nutrition Examination Survey (NHANES) from 2003 to 2018. We found a significant association between nuts and seeds consumption and a reduced odds of being overweight or obese in females. Specifically, females who habitually consumed nuts and seeds had lower odds of being overweight or obese (OR = 0.55, 95% CI: 0.32–0.94). Additionally, we found an L-shaped relationship between nuts and seeds consumption and appropriate waist-to-height ratio in males. The findings suggest that nuts and seeds consumption may contribute to healthier physical development in adolescents.
Introduction
Obesity is typically characterised as excessive body fat accumulation, resulting from a chronic caloric imbalance, whereby daily caloric intake surpasses caloric expenditure (Pulgaron and Delamater Citation2014). Currently, there exists a substantial surge in the incidence of obesity among children and adolescents. Data analysis of studies conducted between 1975 and 2016 unveiled a global escalation of 4.9% and 6.9% in the incidence of obesity amid 5–19-year-old juveniles, respectively (NCD Risk Factor Collaboration (NCD-RisC) Citation2017). The World Obesity Federation estimated there would be 254 million children and adolescents living with obesity in 2030 (NCD Risk Factor Collaboration (NCD-RisC) Citation2017). Consequently, adolescent obesity has already burgeoned into a worldwide epidemic that is associated with dyslipidaemia (Chen et al. Citation2023), fatty liver disease (Pan et al. Citation2023), type 2 diabetes (Zhang et al. Citation2023), insulin resistance (Gravesteijn et al. Citation2023) and even a causal relationship with hypertension in two cohort studies (Wang et al. Citation2023). Additionally, obesity was found profoundly impacting the mental health of young individuals (Smith et al. Citation2020) and increases associated medical expenses (Biener et al. Citation2020). Hence, the prevention and treatment of adolescent obesity are of paramount importance.
The aetiology of obesity is multifaceted, with various genetic, behavioural and sociocultural factors potentially influencing its development (Lee and Yoon Citation2018). In 2023, a longitudinal research reported the use of multicomponent lifestyles to combat youth obesity, such as dietary and activity modifications (Dowda et al. Citation2023; Gedamu et al. Citation2023). García-Hermoso et al. have reported that lifestyle interventions have the potential to improve lipid profiles, insulin sensitivity and blood pressure in obese adolescents (García-Hermoso et al. Citation2023). A systematic review indicated that dietary regimes which entail diminished consumption of sugars and fats, while simultaneously augmenting intake of non-obesogenic victuals such as vegetables, whole grains, fish and nuts, exhibit the lowest correlation with the augmented risk of developing obesity (Liberali et al. Citation2020).
Nuts contain several health-promoting constituents, such as essential nutrients, trace nutrients, fat-soluble bioactive substances, fibre and water-soluble vitamins (Alasalvar et al. Citation2020). A meta-analysis indicated the advantageous effects of consuming nuts in preventing cardiovascular and coronary ailments (Becerra-Tomás et al. Citation2019). Nut intake is also deemed beneficial in reducing the risk of hypertension development, as shown in certain evidence (Qin et al. Citation2023). Additionally, epidemiological studies (Nijssen et al. Citation2023) and clinical trials (Valls-Pedret et al. Citation2015) suggest that long-term nut use may improve cognitive function and be useful in the treatment of dementia. Furthermore, individuals had a 22% lower risk of all-cause mortality with per 28 grams/day of nut intake (Aune et al. Citation2016). In spite of the high energy density, nuts have no demonstrated negative effects on adiposity, and replacing other dietary options with nuts does not result in weight gain (Konieczna et al. Citation2023).
Despite the acknowledged benefits of nuts and seeds for improving health outcomes, existing research on the link between their consumption and adolescent obesity has yielded inconsistent results. To address this gap, we hypothesised that incorporating nuts and seeds into the diet would enhance weight management control. This study explores the association between nuts and seeds consumption and adolescent obesity using U.S. National Health and Nutrition Examination Survey (NHANES) data, contributing to our understanding of the dietary impact on this issue.
Methods
Study population
The NHANES Survey is a nationwide research program conducted biennially since 1999 to evaluate the health and nutritional status of the US population using a sophisticated, multistage, probabilistic sampling design, which employs a representative sample of around 5000 individuals each year. The present study used data from eight NHANES cycles conducted between 2003 and 2018. Of the 80,312 participants in these cycles, 35,522 were adolescents aged 12–19. After excluding individuals with incomplete demographic information, body measurement data and dietary questionnaires, 5511 adolescents were assessed in this study. Detailed information for the selection of samples is available in .
Figure 1. Flowchart of the study design and participants.
Ethical considerations
All participants information within the database is anonymous, and all enrolled participants provided informed consent for the data collection procedures. The NHANES program received ethical approval and informed consent from the participants during data acquisition.
Dietary intake measures
To ensure accuracy, dietary particulars were acquired via the inaugural 24-h dietary recall, administered face-to-face within the confines of a Mobile Examination Center (MEC) by a proficient interviewer. An exhaustive account of the employed dietary interview technique can be found within the NHANES Diet Interview Procedure Manual. The Food Patterns Equivalent Database (FPED) serves as the resource for extracting data concerning the explicit consumption of nuts within the adolescent demographic. The precise varieties of nuts and seeds daily intake incorporated within this investigation comprise: (1) peanuts: embodying peanuts, peanut butter and peanut flour, (2) tree nuts: a collection of almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios and walnuts, (3) seeds: a selection of flax seeds, pumpkin seeds, squash seeds, sesame seeds and sunflower seeds and (4) other sources: a range encompassing almond butter, almond paste, cashew butter, chestnuts, sesame butter and sesame paste; the inclusion of coconuts was consciously omitted. In addition to those consumed individually, nuts and seeds that constituted a component of a meal or served as ingredients in food products were also encompassed by querying the Food Commodity Intake Database (FCID), housing recipes for composite food items. The determination of typical nuts and seeds consumption was subsequently approximated employing the Multiple Source Method (MSM) (Harttig et al. Citation2011), a statistical approach adept at estimating habitual dietary intake for sporadically consumed foods in individuals, validated through a substantial epidemiological investigation.
Variables
This study included the following variables for each participant: (1) demographics, encompassing gender, age, ethnicity and household income; (2) body measurements, including body mass index (BMI), waist circumference, height and waist-to-height ratio; (3) laboratory tests, comprising white blood cells (WBCs), haemoglobin (Hb), platelets (PLTs), uric acid (UA), alkaline phosphatase (ALP), serum calcium (Ca), serum phosphorus (P) and serum iron (iron); and (4) dietary intake data, specifically nut intake and total energy intake. In total, we utilised 18 variables.
Evaluation criterion
To establish the thresholds for overweight/obese weight in each age group of adolescents, we referred to international standards, as overweight defined as BMI ≥1SD and obesity as BMI ≥2SD of the median for age and sex (Cole et al. Citation2000). We categorised all subjects as normal size or overweight/obese.
Statistical analysis
Our analysis utilised suitable sampling weights to adjust for the intricate survey design utilised by the NHANES survey. All subsequent analyses were conducted separately for males and females. In the descriptive analysis, normally distributed continuous variables were presented as mean ± standard deviation (x ± s), while non-normally distributed data were expressed as median (M [P25–P75]). Categorical variables were conveyed using percentages. We utilised the rank sum test and Chi-square test for group comparisons and to jointly depict baseline characteristics.
Subsequently, we adopted a two-part modelling approach to assess the relationship between nut and seed intake and adolescent overweight/obesity. Initially, we examined whether the consumption of any quantity of nuts and seeds was associated with outcome differences compared to non-consumption. Then, we explored how outcomes varied with the quantity of nuts and seeds consumed among participants.
In the first part of the approach, to ascertain the association between demographic information, dietary intake data, laboratory tests and the risk of adolescent overweight/obesity, we employed multivariable logistic regression analysis to identify independent factors. Nut and seed intake was treated as a binary variable (0 g/day vs. >0 g/day), with non-consumers as the reference group.
In the second part of the approach, using weighted multilevel logistic regression models, we calculated the odds ratio (OR) and the corresponding 95% confidence interval (CI) to assess the prevalence of adolescent overweight/obesity disorders associated with nut and seed consumption. We categorised nut and seed intake into quartiles (Q2, Q3 and Q4) with the reference group being those who consumed 0 g (Q1). The first model (model 1) remained unadjusted for any covariates, the second model (model 2) incorporated adjustments for demographic variables and the third model (model 3) further incorporated adjustments for total energy intake, and confounding factors identified as statistically significant in the initial analysis.
For the female demographic subgroup analysis, encompassing factors such as age (12–15 years, 16–19 years), race/ethnicity (white, black, other ethnicity), household income ((poverty income ratio) PIR < 1, 1 ≤ PIR ≤ 4, PIR > 4, categorised as low to moderate to high income) and waist circumference (<78.2, ≥78.2), we performed logistic regression analysis.
To address the non-linearity of the association between nut consumption and youth obesity, a restricted cubic spline (RCS) regression model was implemented, and total energy intake was adjusted.
All statistical analyses were conducted using R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria), with a statistical significance benchmark determined by two-tailed p values less than .05.
Results
Baseline characteristics
illustrates the weighted dissemination of fundamental demographic information garnered in this research. Among the 5511 subjects assessed, the prevalence of overweight or obesity hovered around 30%. Of these, 2865 were male and 2646 were female, with the median age standing at 16 years (spanning from 12 to 19) across both sexes. No notable gender disparities were detected concerning age, ethnicity, diverse income strata, obesity, waist circumference and nut consumption. Normal weight individuals exhibited elevated instances of nut consumption, higher age bracket and enhanced serum iron levels. Conversely, overweight or obese individuals had higher measures of waist circumference, WBC, PLT, ALP and UA. These differences were statistically significant. Further, the group consuming nuts demonstrated reduced waist circumferences, BMI and waist–height ratios, fewer instances of overweight or obesity, diminished UA levels, comparatively higher household income, and a predilection towards the White racial group.
Table 1. Characteristics of the study population.
Factor analysis: multivariate logistic regression
Multivariate logistic regression was utilised to evaluate the significance of the relationship between nut consumption and the prevalence of overweight/obesity in young individuals, stratified by sex, as demonstrated in . Results showed that in both sexes, the occurrence of adolescent overweight/obesity bore an inverse correlation to PLT, ALP and UA levels. Conversely, serum iron was a positive indicator. In females, the odds of overweight/obesity among those consuming nuts were 0.69 times lower compared to non-consumers. In contrast, elevated WBC was identified as an independent factor in males.
Table 2. Logistic regression model of influencing factors on adolescents overweight/obesity.
The association of nut consumption and adolescent overweight/obesity
illustrates the association between nuts and seeds intake levels and the prevalence of youth overweight/obesity among female participants. We categorised nut intake into four groups, namely, non-consumers, low, moderate and high consumers. This classification was achieved by transforming the continuous variable of nuts and seeds consumption into a categorical variable, using the median intake as the benchmark. Logistic regression models were utilised, taking the median value in each category of nut consumption as a continuous variable. The models revealed that higher nut consumption exhibited a significant association with a decreased prevalence of female youth obesity/overweight, which was noted in both crude and adjusted models. In the crude model (model 1), individuals who consumed nuts 14 g per day, 40 g per day and 82.25 g per day demonstrated an OR of 0.74, 0.68 and 0.43, respectively, compared to those who never consumed nuts (p for trend = .018). With adjustment for age, race/ethnicity and household income in model 2, the ORs for female youth obesity/overweight were 0.69, 0.65 and 0.47, respectively. Furthermore, after controlling for independent factors obtained by multivariate logistic regression including iron, PLT, ALP and UA, the ORs for female youth obesity/overweight were 0.87, 0.75 and 0.48 for the three nut intake groups, respectively (p for trend = .024). Supplementary Table 1 presents the association between nuts and seeds intake levels and the prevalence of youth overweight/obesity among male participants. Nevertheless, no statistical significance was observed. The specific characteristics of participants according to consumption of nuts and seeds are presented in Supplementary Tables 2 and 3.
Table 3. Weighted ORs and 95% CIs of female adolescents overweight/obesity according to consumption of nuts and seeds.
Subgroup analysis
To provide a more comprehensive explanation of our findings, we performed a subgroup analysis. By stratifying the study population by age, ethnicity, income and waist circumference, we aimed to determine whether the observed association between nut intake levels and the odds of youth overweight/obesity in females was consistent across all subgroups. The results, presented in , indicate a statistically significant relationship between nut consumption and a lower risk of youth overweight/obesity among subgroups including younger individuals (aged 12–15), white individuals, and those with median income and waist circumference below the median.
Figure 2. Stratified forest plot of the association between nuts intake and adolescent overweight/obesity.
L-shaped association between nuts and seeds consumption and waist–height ratio of adolescents
displays the results of a RCS regression model, which indicated an L-shaped association between nuts and seeds consumption levels and waist–height ratio in the adolescent male population. The likelihood of adolescent males exhibiting a waist–height ratio surpassing the median witnessed a decline commensurate with an increase in nuts consumption ranging from 0 to 76.9 g. However, this propensity commenced an upward trajectory beyond 76.9 g. There is no specificity in the RCS model between nuts and seeds consumption and waist–height ratio in females, as detailed in Supplementary Figure 1.
Figure 3. The dose–response relationship between nuts and seeds consumption and the log ORs of male adolescents’ excessive waist–height ratio risk. The red line and its extended range represent the estimated log ORs and their 95% CIs, respectively. ORs: odds ratios.
Discussion
This study conducted an initial investigation into the correlation between nut intake and overweight/obesity among adolescents in NHANES. The results demonstrated that nut consumption displayed an inverse association with overweight/obesity among female adolescents, which persisted significant after adjusting for demographic characteristics and laboratory tests. Subgroup analyses revealed that the negative association was predominant in 12- to 15-year-olds, whites and middle-income groups. Those who consumed the most nuts, as determined by quintile of intake, were found to be less than half as likely to be overweight/obese as those who did not consume nuts. While there was no significant correlation between nut consumption and overweight/obesity in male adolescents, a relationship in the shape of an L was observed between nut consumption and appropriate waist–height ratio, with an inflection point of 81.5 g.
Adolescent obesity has become an increasingly pressing public health issue. The report by Jebeile et al. revealed a global surge in the occurrence of adolescent obesity over the past half-century (Jebeile et al. Citation2022). Epidemiological investigations have shown that nut consumption may contribute to improved endothelial function (Smeets et al. Citation2021), cognitive performance (Theodore et al. Citation2021), cardiovascular disease, cancer, all-cause mortality (Balakrishna et al. Citation2022), and, most importantly, to a better metabolic state, including decreased fasting blood glucose concentration and a lower incidence of obesity (da Silva et al. Citation2022).
Factors such as elevated levels of pro-inflammatory cytokines and aberrant immune cell activation are potential contributors to systemic inflammation in adolescent obesity. Previous studies have reported that relatively obese adolescents have higher circulating levels of proinflammatory cytokines, including CRP, IL-6, WBC, neutrophil/lymphocyte ratio and M1 macrophages (Mărginean et al. Citation2020). Furthermore, an imbalanced development of oxidative stress states may be another potential mechanism for obesity-related diseases (Ying et al. Citation2020). Pubertal overweight/obese children were found to have higher formation of advanced glycation end products (AGEs) than normal-weight children (Lentferink et al. Citation2019). Conversely, overweight adolescents have been found to have an increasing serum total antioxidant status (D’Alessandro et al. Citation2022).
The ingestion of anti-inflammatory and antioxidant nutrients may be crucial in preventing obesity-related problems. Anti-inflammatory nutrients could regulate both the intestinal flora and inflammatory responses (Bagheri et al. Citation2022). Nuts are a nutrient-dense food source, containing various components such as unsaturated fatty acids, proteins, vitamins (Palomer et al. Citation2018) and active metabolites. The unsaturated fatty acids, a primary component of nuts, positively affect energy expenditure and diet-induced thermogenesis, promoting an anti-inflammatory state, increasing fatty acid β-oxidation and promoting the secretion of IL-10 from adipocytes (Sieber et al. Citation2013). These actions prevent mitochondrial overload and inflammation, ultimately enhancing the lipid profile and reducing obesity risk (Noels et al. Citation2021). Additionally, the consumption of diets that are abundant in pistachios and macadamia nuts has been linked to an enhanced oxidative status (Garg et al. Citation2007), while polyphenols found in nuts possess antioxidant and antiproliferative properties.
Moreover, nutrients in nut can modify metabolic risk factors. Clinical trials have demonstrated that nut consumption can enhance insulin activity and lipid profiles, especially through intake of monounsaturated fatty acids (Gayathri et al. Citation2022). Nut can aid in weight management by increasing satiety and suppressing hunger (Rosas et al. Citation2023). Nut eaters also tend to be more physically active and consume less red and processed meat (Witkowska et al. Citation2019). O’Neil et al. (Citation2012) found that nut consumption was significantly linked to lower BMI Z-scores and a lower incidence of overweight/obesity among populations who aged over 12. Another study demonstrated that a nut-rich diet may facilitate weight loss and offer more favourable effects on serum lipids and systolic blood pressure, in comparison with a typical reduced-energy-density diet (Mayumi Usuda Prado Rocha et al. Citation2023). Nuts have also been linked to reduced waist circumference (Widmer et al. Citation2015). Damasceno et al. (Citation2013) demonstrated that a nut-supplemented diet resulted in substantial reductions in waist circumference in participants with high cardiovascular risk. Additionally, a systematic review involving 5045 subjects concluded that consuming a diet enriched with almonds was significantly correlated with reduced waist circumference (Fernández-Rodríguez et al. Citation2021).
However, the comprehension of the correlation between dietary patterns and the susceptibility of adolescent to obesity, especially in relation to gender disparities, remains insufficient. To address this gap, our study conducted an in-depth analysis into the impact of nut consumption on obesity among male and female adolescents, thereby uncovering gender-specific discrepancies in the consequences of nut consumption. This partially aligned with the findings by Yuan et al. (Citation2016) who reported a positive correlation between a diet primarily composed of rice and wheat and abdominal obesity in males but not in females. Arab’s research (Arab et al. Citation2018) revealed gender-based discrepancies in the efficacy of consuming walnuts in mitigating the prevalence of diabetes, with evidence suggesting that women may benefit more than men. Murdolo et al. (Citation2011) also found that changes in inflammatory cytokines caused by obesity differed between genders, indicating metabolic differences between the sexes. Moreover, the impact of different hormones secreted by teenagers may vary and affect the risk of obesity, such as hyperandrogenaemia, which can increase the risk of obesity by affecting the earlier onset of puberty and menarche. Therefore, further research on the same diet pattern on obesity among different genders is warranted given the research potential.
Additionally, by utilising a RCS regression model, we identified that the most effective threshold for nut consumption is 76.9 g per day to prevent excessive waist–height ratio in male adolescents. Primary research has validated dose–response links between nut consumption and additional metabolic ailments. Jung et al.’s study revealed that regular consumption of some certain types of nuts, at an average of 15 g per week, is beneficial to reduce risk of developing metabolic syndrome (Jung et al. Citation2019). Moreover, a separate study (Arnesen et al. Citation2023) revealed that the daily consumption of 50 g of nuts can confer benefits in reducing the lipoprotein cholesterol levels. Nevertheless, the divergence in optimal threshold estimation between our study and other research can be ascribed to the aggregate consumption of nuts of all varieties and their collective impact on the overall waist–height ratio, rather than being solely founded on an estimation for a specific ailment. Consequently, more research is required to investigate the appropriate amount of nuts intake and its effect on adolescents’ overweight/obesity.
Limitations
However, the present study still has many drawbacks. First, this was a cross-sectional design that precluded the identification of temporal trends in nut consumption and adolescent overweight/obesity, and the study sample was based on U.S. population survey data only, so whether the findings are applicable in other countries and regions requires further research and investigation. Second, we did not collect data on various aspects of participants’ lives such as sleep, physical activity, other dietary intake and prescription taking, and there may be unmeasured confounding factors. Our findings suggest that there are statistical differences between genders on indicators in relation to nuts intake, which may be partially attributed to changes in hormone levels during puberty and the menstrual history of female subjects was not considered. Finally, we were unable to identify participants with a history of hypothyroidism, or anorexia nervosa.
Conclusions
To recapitulate, the higher nut consumption (>57 g/day) was associated with a further decrease in prevalence of obesity/overweight in female adolescents compared to those never consumed nuts, and males who consumed within 76.9 g per day of nuts also showed a protective effect against waist circumference growth. However, despite mounting evidence of the health benefits of nuts, adolescents’ nut intake remains insufficient. Further literature is needed to ascertain whether encouraging nut consumption among adolescents would lead to enhanced health outcomes and reduced obesity prevalence.
Author contributions
Yaqin Yang: conceptualisation, investigation, methodology, formal analysis and writing original draft. Duo Zhang: resources, software, data curation, validation, visualisation, writing review and editing. Baiying Chen: validation, visualisation, writing review and editing. Xinyan Huang: project administration, funding acquisition and supervision.
Supplemental Material
Download PDF (178.4 KB)Acknowledgements
Thanks to Zhang Jing from Tongren Hospital for his exceptional contributions to the NHANES database. His remarkable efforts in developing the nhanesR package and webpage have significantly facilitated our exploration of this database.
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No potential conflict of interest was reported by the author(s).
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References
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