Obesity and metabolic syndrome: Potential benefit
from specific nutritional components
I. Abetea, E. Goyenecheab, M.A. Zuleta, J.A. Martı ´neza,*
aDpto. de Ciencias de la Alimentacio ´n, Fisiologı ´ a y Toxicologı ´ a, Universidad de Navarra, Pamplona (Navarra), Spain
bColegio Oficial de Farmaceu ´ticos, San Sebastia ´n-Donostia, Spain
Received 22 November 2010; received in revised form 13 May 2011; accepted 19 May 2011
Minerals and vitamins
worldwide, and is becoming an important health problem. Actually, MetS includes a combina-
tion of clinical complications such as obesity (central adiposity), insulin resistance, glucose
intolerance, dyslipidemia, non-alcoholic fatty liver disease and hypertension. All these alter-
ations predispose individuals to type 2 diabetes and cardiovascular disease inducing earlier
mortality rates among people.
In general terms, it is difficult for patients to follow a standard long-term diet/exercise
regime that would improve or alleviate MetS symptoms. Thus, the investigation of food compo-
nents that may deal with the MetS features is an important field for ameliorate and facilitate
MetS dietary-based therapies. Currently antioxidants are of great interest due to the described
association between obesity, cardiovascular alterations and oxidative stress. On the other
hand, high MUFA and PUFA diets are being also considered due to their potential benefits on
hypertension, insulin resistance and triglyceride levels. Mineral composition of the diet is also
relevant since high potassium intake may improve hypertension and high calcium consumption
may promote lipid oxidation. Thus, although nutritional supplements are at the peak of die-
tetic therapies, the consumption of some specific foods (legumes, fatty fish, vegetables and
fruits, etc) with bioactive components within an energy-restricted diet is a promising approach
to manage MetS manifestations. Therefore, the present review focuses on some of the most
important food components currently investigated to improve and make easier the nutritional
ª 2011 Elsevier B.V. All rights reserved.
The prevalence of metabolic syndrome (MetS) manifestations is rapidly increasing
* Corresponding author. Departamento de Ciencias de la Alimentacio ´n, Fisiologı ´a y Toxicologı ´a, Universidad de Navarra, C/Irunlarrea 1,
31080-Pamplona (Navarra), Spain. Tel.: þ34 948 425600; fax: þ34 948 425649.
E-mail address: firstname.lastname@example.org (J.A. Martı ´nez).
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/nmcd
Nutrition, Metabolism & Cardiovascular Diseases (2011) 21, B1eB15
0939-4753/$ - see front matter ª 2011 Elsevier B.V. All rights reserved.
Metabolic syndrome (MetS) involves a combination of clini-
cally specific risk features including obesity (central
adiposity), insulin resistance, glucose intolerance, dyslipi-
demia, non-alcoholic fatty liver disease and hypertension
, which is rising worldwide as a consequence of the
continued obesity epidemic [2,3]. In 2005, the International
Diabetes Federation (IDF) established the criteria of central
obesity as (a) waist circumference ?94 cm for men, ?80 cm
for women and two of the following alterations: raised
this lipid abnormality, (b) reduced HDL-c: <40 mg/dl in
or diastolic BP ? 85 mmHg, or treatment of previously
diagnosed hypertension, (d) raised fasting plasma glucose
?100 mg/dl or previously diagnosed type 2 diabetes.
In addition to genetic predisposition, the physical inac-
tivity as well as high-density food availability is among the
Dietary and physical activity advices are the first choice
for treating these metabolic diseases . In spite of the
is poor. Lifestyle changes result very difficult in an obeso-
more weight than they had initially. Overall, there is full
reduction are the first line approach to patients with MetS
features. Energy restriction is a fundamental point to
produce a negative energy balance, but also the macronu-
trient distribution could play an important role improving
weight loss and specific metabolic alterations . More
recently, foods and some specific nutritional components
have received special attention for the treatment of meta-
bolic syndrome patients . Mediterranean diet provides an
nuts, red wine and olive oil which contain several nutritional
components characterized by their anti-inflammatory and
antioxidant properties . Although, it is still necessary for
the development of more and longer nutritional studies,
antioxidants, low glycaemic index carbohydrates, fibre,
monounsaturated and polyunsaturated fatty acids seem to
be very important components of a diet for the treatment of
cardiovascular diseases. Thus, this review article has been
focused on a summary of the most relevant published papers
regarding the effect of the regular consumption of Mediter-
ranean foods and its bioactive components in the treatment
of metabolic syndrome features.
Antioxidants and metabolic syndrome
Antioxidants are of great interest by their positive effects
against oxidative stress, which is a process closely related
to obesity, cardiovascular alterations, some degenerative
diseases and certain types of cancer . Many nutritional
intervention studies have been performed with antioxidant
supplements, but finding controversial results [11e14].
However, current literature emphasizes on the potential
therapeutic effects of micronutrients found in natural
products, indicating positive applications for controlling
the pathogenesis of chronic diseases .
Nutritional studies have obtained positive results on
metabolic syndrome features using botanical or pharma-
healthy and advised compounds are those coming from the
most popular antioxidant-rich foods such as fruits, vegeta-
bles, legumes, olive oil, red wine, green tea and nuts
[13,18e20]. In this sense, the PREDIMED study, which
assessed the adherence to the Mediterranean diet, found
that consumption of legumes, olive oil and red wine (all
antioxidant-rich foods) was associated with lower preva-
an antioxidantsupplementationon 5220subjectsshowingno
benefits on the incidence of MetS. However, baseline serum
negatively associated with the risk of MetS . Further-
more, it is known that antioxidant supplementation beyond
critical concentrations might induce the contrary to awaited
effects . Positive results have been also described,
concretely an individual flavonoid supplementation (quer-
cetin) in 93 obese and overweight subjects with metabolic
syndrome traits decreased systolic blood pressure, HDL-c
concentrations and plasma oxidised LDL concentrations,
while cholesterol, triglycerides and some inflammatory
markers remained unaltered . Although antioxidant
supplementation should be considered with precaution, the
consumption of foods with antioxidants properties should be
in the treatment of cardiovascular diseases.
Fruits and vegetables
Consumption of fruits and vegetables has been associated
with protection against various diseases, including cancer
and cardiovascular and cerebral-vascular diseases. Fruits
and fruit juices, vegetables and vegetable products, teas
and dietary supplements are the major sources of dietary
antioxidants . An interventional study showed that
consumption of strawberries, spinach or other fruits and
vegetables richin antioxidant
increased the serum antioxidant capacity in humans .
Plasma carotenoid concentrations are negatively correlated
with the risk for cardiovascular disease and cancer, and
carotenoids may therefore in part mediate the protective
effect of vegetables and fruits. Interestingly, in the Alpha-
Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study
neither alpha-tocopherol nor beta-carotene serum levels
were associated with lower risk of type 2 diabetes . On
the other hand, observational studies have reported inverse
association between vitamin E and cardiometabolic risks,
but also, results from trials studying supplementation with
antioxidant vitamins failed to confirm any protective effect
of them on cardiovascular diseases [14,18,27,28]. Overall,
Mediterranean diet has been proposed as a therapeutic
approach in inflammatory and oxidative stress diseases
including cardiovascular disease, obesity, type 2 diabetes
and metabolic syndrome . A nutritional intervention
study was carried out in a group of obese men and women
B2I. Abete et al.
Described beneficial effects on metabolic syndrome features through the inclusion of some Mediterranean foods in a dietary programme.
Mediterranean foods included
as part of a dietary pattern
Healthy benefits of its consumption
Insulin resistanceLegumesComplex carbohydrates and
soluble fibre, magnesium,
Phenolic components, MUFAs
Decrease postprandial glycaemia,
improve glycaemic control
Olive oil May exert beneficial effects on
Decrease carbohydrate absorption and
insulin levels and may
reduce the lipid accumulation in the liver
Modestly improvement on HDL
Stimulation of lipid oxidation,
favouring the decrease
of triglyceride level
May improve insulin and leptin levels,
nervous activity and arterial constriction
Increase sodium elimination, decreasing
Angiotensin-converting enzyme inhibition,
control of arterial dilation
Reduce gastric emptying, increase satiety and
dietary adherence, which may improve weight reduction
May improve weight loss
Modulate lipogenic enzymes and favour lipid oxidation,
decreasing fat accumulation
Red wine Antioxidants: Resveratrol
Low HDL cholesterol Fatty fish, olive oil
u3fatty acids, fish proteins,
Omega-3 fatty acids HypertriglyceridemiaFatty fish,
fish oils, nuts
HypertensionFatty fish Omega-3 fatty acids, fish proteins
Legumes, vegetables, fruits
Calcium, bioactive peptides
Abdominal obesity Low glycaemic index carbohydrates,
soluble and insoluble fibre
Omega-3 fatty acids
Low-fat milk, dairy products
Fish or fish oils
Nutritional components and obesity
Selected nutritional intervention studies based on the inclusion of specific foods during the treatment and compared to the control group.
DietLength SubjectsFood and frequency Nutritional interest Main benefits
17% P; 53% CHO;
30% L 
8 weeksObese n Z 16
Obese n Z 16
Legumes: 4 days/week
Conventional balanced diet
High fibre consumption,
low glycaemic index
Improved weight loss
Decreased total and LDL-c
Lower resting metabolic rate change
Weight loss, SBP/DBP reduction
Total and LDL-c reduction, HOMA-IR
Weight loss improvement and higher
waist circumference reduction,
Total and LDL-c reduction, HOMA-IR
decrease, TG reduction
Weight loss improvement, SBP/DBP
reduction, total and LDL-c decrease,
HOMA-IR decrease, TG reduction
Leptin decrease and ghrelin increase
Weight loss improvement, SBP/DBP
Total and LDL-c reduction,
HOMA-IR decrease, TG reduction,
MDA reduction and antioxidant
Weight loss was not improved
compared to control diet
Improved insulin resistance
Decreased leptin levels
Weight loss and fat mass loss were not
improved compared to control diet
Improved the MDA/TAC ratio
20% P; 50% CHO; 30% L
8 weeks Overweight n Z 80 Control: sunflower oil 6
Overweight n Z 80Fish oil: 6 capsules/day High u3-FA consumption
Overweight n Z 84 Fatty fish 3 servings ?
Low SFA consumption and
higher fish protein intake
Overweight n Z 80 Lean fish 3 servings ?
Higher u3-FA consumption,
lower SFA intake and higher
fish protein consumption
17% P; 50% CHO;
30% L 
8 weeksObese n Z 16
Obese n Z 16
Fatty fish restriction
Fatty fish 3 days/week
Conventional balanced diet
Higher u3-FA consumption,
lower SFA intake and fish
15% P; 55% CHO;
30% L [29,133]
8 weeks Obese women n Z 8
Obese women n Z 7
2e3 fruit servings/day
5 or more fruit servings/day
(15% of energy as fructose)
Conventional balanced diet
High fibre consumption,
(vitamins: A, C, E), more
American heart association
High MUFA consumption
15% P; 50% CHO;
35% L 
3 yearsOverweight n Z 59Conventional low-fat diet Weight maintenance
Overweight n Z 65Virgin olive oil (z60 g/day) Weight maintenance; higher
plasma antioxidant capacity
Weight maintenanceOverweight n Z 63Nuts (15 g/day) High PUFA consumption
I. Abete et al.
17% P; 53% CHO;
30% L 
8 weeks Obese n Z 15
Obese n Z 15
Legumes 4 days/week
Conventional balanced diet
High fibre consumption,
Improved weight loss
Decreased total cholesterol
Decreased ox-LDL, MDA and
Regular dietary habits
7.5 yearsSubjects free of
MetS n Z 5220
n Z 2525 antioxidant
n Z 2695 placebo
Subjects were followed for 7.5
years, receiving a supplement
of vitamins C and E, b-carotene,
zinc and selenium at nutritional
doses or placebo
Subjects with MetS at the end of
follow-up had more unhealthy
behaviour than did subjects
Subjects who developed MetS
were more often men or
were older, current smokers,
less educated, less physical
active and had higher BMI
did not affect the risk of MetS,
however, baseline serum vit C
and b-carotene were negatively
associated with the risk of MetS.
Weight maintenance; no metabolic
Weight loss (?13 and -?10 kg);
SBP (?6 and ?6 mmHg); TG
(?13 and -12 mg/dl) men and
Weight loss (?17 and ?18 kg);
SBP (?11 and ?11 mmHg); DBP
(?5 and ?6); TG (?17 and
?18 mg/dl); FBG (?4 and ?6);
HDL-c (þ5 and þ10 mg/dl) men
and women respectively.
The DASH diet was the most
effective reducing the MetS factors
15-20% P; 50-60%
CHO; <30% L 
6 monthsObese with MetS
n Z 40
Obese with MetS
n Z 38
Control diet without
Weight-reducing diet with an
energy restriction of 500 kcal
Patients had to eat as usual
healthy food choices
Obese with MetS
n Z 38
DASH diet with an energy
restriction of 500 kcal
Increased fruits, vegetables,
legumes, whole grains and
low-fat dairy products
consumption. The Ca, K, Mg,
fibre intake was increased.
Na content was limited
to 2.400 mg/d
12 weeksObese with MetS
n Z 25
Obese with MetS
n Z 25
Control groupWithout raw nut supplementation Moderate weight loss, decreased
adiposity and lower blood pressure
Moderate weight loss, decreased
adiposity, lower blood pressure,
decreased fasting insulin and
HOMA index and IL-6 levels
SBP decreased (?2.7 mmHg)
DBP decreased (?1.3 mmHg)
Basal heart rate decreased (4.0 points)
(continued on next page)
Nut groupWith raw nut supplementation
30 g/d (15 g walnuts; 7.5g
almonds; 7.5 g hazelnuts)
Regular dietary habits
12 months 111 hypertriglyceridemic
with untreated normal/
high blood pressure
2 g PUFA supplementationPatients maintained their
regular dietary habits þ 2 g
Nutritional components and obesity
who were assigned in two different dietary groups. Both
groups followed an energy-restricted diet but one of them
was enriched in fruits. After the 8-week nutritional inter-
vention program both groups lost weight but the fruit
enriched group showed more beneficial effects such as
lower levels of oxidized LDL-cholesterol and higher total
antioxidant capacity . On the other hand, metabolic
syndrome patients were instructed on the DASH diet (Die-
tary Approaches to Stop Hypertension) and randomized into
three groups: 0, 8 or 16 fluid ounces of low sodium vege-
table juice. At the end of the study the outcomes showed
that those consuming juice lost more weight, and consumed
more vitamin C, potassium, and dietary vegetables than
individuals who were in the group that only received diet
counselling  (Tables 1 and 2).
Epidemiological studies have found inverse associations
between legume consumption and cardiovascular diseases
. Legumes, besides a high nutritive value, contain
significant quantity of polyphenolic compounds such as
flavonoids, isoflavones, phenolic acids and lignans. In
a nutritional intervention study, soya consumption reduced
plasma malondialdehyde (MDA) levels and increased total
plasma antioxidant capacity (TAC) in postmenopausal
women with metabolic syndrome . Likewise, several
meta-analysis of randomized controlled trials concluded
that soy isoflavones significantly reduce total and LDL-
cholesterol [32e34]. However, not only soy consumption
has interesting benefits on metabolic alterations, but also,
more common legumes, such as beans, lentils, chickpeas.
etc, have improved cardiovascular risk factors and oxida-
tive stress markers . Likewise, an 8-week intervention
study that included legume consumption (4 servings per
week) in a weight reduction program showed that those
patients following the legume diet lost more weight ,
improved their plasma antioxidant capacity and decreased
the oxidized LDL concentration as well as cholesterol levels
(total and LDL-cholesterol) .
On the other hand, besides the higher satiety effect,
some authors have found that the inclusion of such foods in
a weight loss program may reduce the negative effect of
caloric restriction on lean mass loss and basal metabolic
rate [7,36], which is an important factor to be taken into
account due to the ease to put on weight after following
a hypocaloric diet. Anderson et al. previously emphasized
on the health benefits of consuming legumes such as lentils,
chickpeas, peas and beans . Thus, currently, these
kinds of foods are considered relevant components of
a healthy diet because of their important benefits on CVD
Resveratrol is another polyphenolic compound found in
anti-ageing actions and beneficial properties against meta-
bolic diseases [38,39]. Studies in mice have shown that
resveratrol is able to protect against the metabolic changes
Table 2 (continued)
Food and frequency
Ad libitum intervention
in the GI 
n Z 38
Ad libitum diets in which
starches were replaced by
either LGI (n Z 19) or HGI
(n Z 19) starchy foods
LGI diet had a GI < 50
Mean body weight decrease ?1.1 kg
Hunger sensations scales showed a
trend towards a decrease in huger
sensation before lunch and dinner
Decreased total cholesterol; LDL-c;
HGI diet had a GI > 70 in both
groups a list was given to the
subjects indicating the starches
they were allowed to eat and those prohibited.
Mean body weight decrease ?0.3 kg
No significant changes were
observed in the other variables
P: protein; CHO: carbohydrates; L: lipids; SFA: saturated fatty acids; u3-FA: omega-3 fatty acids; LDL-c: low density lipoprotein cholesterol; ox-LDL: oxidized low density lipoprotein
cholesterol; MDA: malondialdehyde; MDA/TAC ratio: malondialdehyde/total antioxidant capacity ratio; TG: triglycerides; SBP/DBP systolic blood pressure and diastolic blood pressure;
VOO: virgin olive oil.
Ca: calcium; K: potassium; Mg: magnesium; Na: sodium; FBG: fating blood glucose; HDL-c: high-density lipoprotein cholesterol; MetS: metabolic syndrome; GI glycaemic index; LGI low
glycaemic index; HGI high glycaemic index.
B6 I. Abete et al.
associated with hypercaloric diets [38,40]. Resveratrol acts
the prothrombotic state induced by metabolic syndrome
[41,42]. In this sense, a study confirmed that resveratrol
improved the left ventricular function of type 2 diabetics,
who suffered recent acute myocardial infarction when
a moderate red wine amount (containing resveratrol) was
taken daily by patients receiving conventional anti-ischae-
mic therapy in comparison with another group treated alone
with anti-ischaemic compounds . It has been also sug-
gested that resveratrol exerts its multiple protective effects
against the MetS through stimulating AMP-activated protein
kinase and promoting mitochondrial biogenesis . A short
intervention study was carried out to determine the in vivo
effects of the red wine consumption (400 mL/day for 2
weeks) where increases in total plasma antioxidant capacity
and decreases in oxidative stress markers (plasma MDA and
glutathione) were found . Another research evaluated
the effect of grape polyphenols supplementation in a group
of pre- and postmenopausal women. At the endpoint, the
supplemented group showed beneficial effects on lipid and
lipoprotein metabolism, oxidative stress and inflammatory
markers in both pre- and postmenopausal women .
Another randomised crossover trial compared the effect of
gin with red wine intake, showing greater antioxidant effect
for the red wine consumption . However, in spite of
most findings about resveratrol are positive, a recent animal
study showed that this micronutrient supplementation
significantly increased homocysteine levels and negatively
affected HDL metabolism .
Green tea is naturally rich in a group of antioxidants known
as catechins . A number of studies including green tea
and other foods with high antioxidant content indicate that
their bioactive components confer a protective effect
against coronary heart disease . Tea catechins reduce
the serum cholesterol concentrations and suppress post-
prandial hypertriacylglycerolemia in animal and human
experimental studies [49,50]. Thus, it has been suggested
that green tea may contribute in the prevention of the
metabolic syndrome [49,50] however, more interventional
trials should be carried out to confirm it.
Overall, antioxidant supplementation is still a contro-
versial issue, however, there is a full agreement that a high
antioxidant (no supplemented) diet based on a combination
of high antioxidant foods is able to improve the benefits of
weight loss alone, and specially in those patients with
cardiovascular alterations and people with metabolic
Other nutritional components and metabolic
Glycaemic index and fibre
The glycaemic index (GI) of carbohydrates as well as fibre
consumption are important dietary factors that can influ-
ence on weight control and metabolic syndrome alterations
. Dietary fibre has been shown to have important health
implications in the prevention of risks of chronic diseases
. It is known that fasting and postprandial triglyceride
responses may depend upon the fibre content of the diet
. High carbohydrate/low fibre consumption increases
fasting serum triglycerides , whereas high carbohy-
cholesterol-lowering effects of soluble fibres often involve
5e10% reduction, but the mechanisms of these are not fully
understood . The comparison of a high-fibre Mediter-
ranean diet with a low-carbohydrate diet for weight
management led to similar weight losses, however, the
high-fibre diet showed more favourable effects on lipids
On the other hand, inconsistent findings from observa-
tional studies have prolonged the controversy over the
effects of dietary GI on the risk of certain chronic diseases
. Studies in animal models have shown that diets based
on consuming high-GI starches promote weight gain,
visceral adiposity and the activity of lipogenic enzymes
than do not produce diets based on low-GI foods [56e58].
On the contrary, diets based on low-GI foods may enhance
weight control, promoting satiety and minimizing post-
prandial insulin secretion [59e61]. In this sense, a low-GI
diet emphasising low-GI breads, cereals, parboiled rice,
pasta, beans, peas and nuts was compared with a high
cereal low-fibre diet with a similar energy intake. In addi-
tion to a more marked improvement in HbA1clevels, the
low-GI diet increased HDL-c, compared with a reduction in
the high-GI low-fibre group . Fibre and whole cereal
intakes may protect against hyperinsulinemia and the risk
of type 2 diabetes. A randomized crossover trial showed
benefits of consuming high-fibre rye bread on insulin
secretion, suggesting an improvement of beta cell function
. Interestingly, the form of the food and botanical
structure may play a role in determining the postprandial
insulin responses rather than the amount of fibre or the
type of carbohydrate. In this sense, Juntunen et al. 
determined the effect of rye fibre in containing these
cerealbreads on postprandial
responses. The findings showed that fibre content did not
explain the lower postprandial insulin response to rye bread
as compared to wheat bread, but structural differences
were responsible of such differences. Thus, the charac-
teristics of a starchy food are able to modify the post-
prandial glucose and insulin responses in humans.
On the other hand, the importance of the macronutrient
composition of the diet for the prevention and management
of obesity has been showed in the Diet, Obesity, and Genes
(Diogenes) study . This European study was designed to
assess the efficacy of moderate-fat diets that vary in protein
content and glycaemic index for preventing weight regain
found that a modest increase in the protein content and
a reduction in the glycaemic index led to an improvement in
study completion and maintenance of weight loss.
Low magnesium (Mg) intake and low Mg status have been
associated with a higher prevalence of MetS [66e68] so
Nutritional components and obesity B7
inadequate Mg consumption is related with glucose and
insulin metabolism impairment . The major dietary
sources of Mg intake include whole grains, legumes, nuts,
and green leafy vegetables . Experimental and clinical
studies suggest that Mg intake may be inversely related to
the risk of hypertension and type 2 diabetes mellitus, and
may decrease blood triglyceride and increase high-density
lipoprotein cholesterol levels . In patients with type 2
diabetes who had low Mg levels, randomization to an oral
supplementation improved insulin sensitivity and glucose
control after 16 weeks [72,73]. In this context, a meta-
analysis of nine randomized double-blind controlled trials
with a total of 370 patients with type 2 diabetes assessed
the effect of oral magnesium supplementation (360 mg/
day) during 4e16 weeks on glycaemic control, blood pres-
sure and lipids. After the treatments, results showed that
magnesium supplementation was effective in reducing
fasting glucose levels and increasing HDL-c concentration.
But, the magnesium addition had no effect on total
cholesterol, LDL-c, triglyceride and blood pressure .
However, there is limited empirical data to evaluate
whether magnesium supplements should or should not be
recommended to patients with diabetes. Although it may
be safe in selected patients at appropriate dosages,
magnesium may cause adverse effects or death at high
dosages . Additional long-term controlled trials in dia-
betic as well as patients with MetS are warranted to assess
the efficacy of magnesium supplementation.
Calcium and dairy products
Dietary calcium appears to play a pivotal role in the regu-
lation of energy metabolism and obesity risk . Initial
studies by Zemel et al. (2000)  reported that those
patients in the highest quartile of adiposity were negatively
associated with calcium and dairy product intake. Another
nutritional intervention trial also demonstrated that higher
low-fat dairy intake among overweight type 2 diabetic
patients on isocaloric-restricted regimens enhances the
weight loss process . Furthermore observational studies
have presented inverse associations between dairy intake
and the prevalence of insulin resistance syndrome and
type 2 diabetes mellitus [78,79]. The Atherosclerosis Risk
in Communities (ARIC) study also revealed that dairy
In a highly educated Mediterranean cohort (SUN), low-
fat dairy consumption, but not whole-fat dairy con-
sumption, was associated with a lower risk of incident
hypertension, even after control for several potential
confounders such as age, sex, physical activity, body mass
index . Indeed, a recent crossover study showed that
dietary supplementation with whole-fat dairy products,
compared to low-fat dairy, was associated with weight gain
while no differential effects were observed for levels of
blood pressure .
Dairy products are the main source of dietary calcium
and different mechanisms have been proposed for explain
the role of calcium in the risk for suffering MetS .
However, there are evidences that calcium provided as
a food supplement or by fortification appears to decrease
LDL-c and triglyceride concentrations, as well as to
increase HDL-c concentrations . The potential hypo-
lipidemic mechanisms of calcium may occur via: (i) the
inhibition of fat absorption accompanying an increased
faecal fat excretion; (ii) inhibition of the absorption of bile
acids; (iii) a calcium-induced increase in the conversion of
cholesterol to bile acids .
In addition to the effects on lipid profile, an inverse
relationship between the MS and dairy intake might have
been mediated by calcium intake to some extent, mediated
by its putative effect in reducing body weight and fat mass
[85e87]. Dietary calcium could affect the body fat mass by
increasing faecal fat excretion as well as by stimulating
lipolysis and inhibiting lipogenesis, which is stimulated in
high dietary calcium . In addition, calcium could partly
account for the observed inverse association between dairy
consumption and the risk of hypertension . The rela-
tionship between calcium intake and coronary artery
disease or stroke, which are two major consequences of
hypertension, could be presented only for calcium from
dairy products but not from other sources . Also, it has
been suggested that some peptides (containing up to 10
amino acids) produced as a result of dairy fermentation or
during the digestive process could have angiotensin-
release-inhibitory activity . However, the antihyper-
tensive potential of the peptides requires that they reach
target sites without being degraded and inactivated by
intestinal or plasma peptidases.
Earlier intervention studies showed that skim milk or
yogurt consumption might decrease plasma cholesterol
levels, while whole milk had neither a hypo- nor hyper-
cholesterolemic effect . A possibility is that the intes-
tinal bacteria can bind bile acids to cholesterol, resulting in
an excretion of bile acidecholesterol complexes in the
On the contrary, a multicenter study recruited middle-
aged overweight subjects (n Z 121) with traits of MetS,
which were randomly assigned into milk or control group.
After the 6-mo intervention study no differences were
observed in body composition, blood pressure, markers of
inflammation, endothelial function, adiponectin or oxida-
tive stress between groups . Many metabolic and die-
tary factors appear to influence the degree to which dairy
affects metabolic syndrome parameters such as calcium
and vitamin D, BMI and age. Very often calcium and vitamin
D availability is also a controversial issue, since dairy
products are a minimal source of vitamin D unless they
were fortified, which have been related to adiposity
Milk and dairy products have been also inversely asso-
ciated to homocysteine levels and positively with folate
levels . Moreover, the inclusion of milk in the diet could
enhance the bioavailability of food folate, due to the whey
protein fraction of milk, which contains a high-affinity
folate-binding protein and protects folate from degrada-
Overall, in spite that many authors have found positive
effects on weight loss and metabolic syndrome compli-
cations of increased intake of dairy products, more and
B8I. Abete et al.
Selenium and zinc
In an observational study, dietary selenium intake was
inversely related to sialic acid, an inflammatory marker,
and to triacylglycerollevels,
a potential anti-inflammatory nutrient . Moreover,
a possible role of selenium intake in the modulation of
serum complement 3, which may be an early marker of
metabolic syndrome manifestations .
Many experimental and clinical studies have docu-
mented that zinc deficiency may predispose to glucose
intolerance, diabetes mellitus, insulin resistance, athero-
sclerosis and coronary artery disease [96e98]. The effect of
zinc on LDL-c and HDL-c has also been reported [97e99].
Moreover, supplementation with zinc provides a significant
prevention of oxidative damage to the heart. Diabetes
causes a significant systemic oxidative stress and also often
is accompanied by zinc deficiency that increases the
susceptibility of the heart to oxidative damage .
Therefore, there is a strong rationale to consider the
strategy of zinc supplementation to prevent or delay dia-
betic complications .
On the other hand, high zinc levels have been also
positively associated with MetS incidence . A hypothesis
about this epidemiological association of serum zinc and
MetS is that could reflect less healthy eating habits such as
high red meat consumption .
Fatty acids and metabolic syndrome
Regarding fatty acids, this part of the article has been
focused on the most consumed foods in the Mediterranean
region. Thus, fatty acids considered in this section have
been fatty acids from fish, fish oil, nuts and olive oil
consumption, excluding other types of vegetal fats.
Fish and fish oils
During the last century increasing evidences have suggested
that the type of fat is more important than the amount of
fat. A number of studies have clearly evidenced the nutri-
tional benefits of fish consumption on several CVD . It
has been described that consumption of long-chain u3-FA
from marine sources may improve certain MetS features,
and thus may reduce risk for CVD . Although
bioavailability of the fatty acids is appreciably higher when
ingested through fish, numerous studies have found
advantages of using fish oil capsules or standardised prep-
arations for long-lasting treatments . As a consequence
over the years, products enriched in u3long chain poly-
unsaturated fatty acid (PUFA) or fish oil capsules have
been used for the prevention and treatment of coronary
In this sense, a retrospective study evaluated the effect
of the long-term PUFA supplementation in 111 hyper-
triglyceridemic subjects with untreated normal-high blood
pressure. Patients were prescribed to consume 2 g PUFA
supplementation for 12 months in order to improve their
plasma lipid pattern. After the treatment, results showed
that PUFA long-term supplementation was associated with
a significant reduction in systolic and diastolic blood
pressure . Several authors have suggested that the
protective effect that these fatty acids produce against
coronary heart disease is partly mediated by its effect
decreasing blood pressure [102,103]. Also, the benefits
could be likely mediated through the activity of transcrip-
tion factors relating to expression of genes involved in lipid
oxidation and synthesis.
Weight loss programs promoting fatty fish intake have
shown increased benefits on lipid profile, blood pressure
and insulin levels [48,100,102]. These health benefits were
previously showed by Mori et al. , who found that
a daily fish meal as part of a weight-reducing regimen was
more effective than either measure alone at reducing lep-
tin, insulin levels, as well as blood pressure. A subsequent
study showed that three servings per week of fatty fish as
part of an energy-restricted diet were enough to specifi-
cally improve insulin sensitivity and leptin levels in obese
subjects . In the same way, a balanced hypocaloric
diet enriched in salmon resulted in a beneficial effect on
the plasma lipid profile . Likewise, the low prevalence
of insulin resistance, metabolic syndrome and diabetes in
Alaskan Eskimos compared to American Indians stimulated
the need to study if the relatively low blood pressures, low
serum triglycerides and high HDL cholesterol levels in
Eskimos resulted from u3-FA consumption [107,108]. Thus,
447 Norton Sound Eskimos were evaluated and results
showed that plasma u3-FA concentrations were highly
correlated with dietary u3-FA and HDL levels and inversely
associated with plasma levels of insulin, HOMA-IR, triglyc-
eride levels and diastolic blood pressure. In the GOCADAN
study , long-chain u3-FA, from fish and sea mammals,
were associated with lower 2-h glucose, insulin and
homeostasis model assessment, lower blood pressure,
serum triglycerides and higher high-density lipoprotein
cholesterol. On the other hand, saturated fat as well as
trans-FA consumption was associated with higher triglyc-
eride levels and blood pressure. In spite of increased
intakes of fatty fish or supplements of u3marine FA could
play a role on insulin sensitivity, it is a highly controversial
issue [100,110]. Indeed, there are also several investiga-
tions wherefish oil supplementation
consumption did not change insulin levels. Thus, in a long-
term study, diets enriched in SFA or MUFA were compared
. Additionally, each diet was supplemented with fish
oil or olive oil (placebo). Findings showed significant
differences in insulin sensitivity when consuming SFA and
MUFA diets. However, fish oil supplementation did not
modify insulin sensitivity. Moreover, favourable effects of
MUFA were only seen at a total fat intake below median
(37E%), suggesting a maximum limit at which the quality of
fat may involve benefits .
Committee of the American Heart Association specifies that
patients without documented coronary heart disease
should eat oily fish twice weekly. Patients with documented
EPA þ DHA daily, preferably from oily fish, although
supplements may be used, and individuals with hyper-
triacylglycerolaemia may be advised to receive 2e4 g
EPA þ DHA daily from capsules .
On the other hand, although more attention has been
paid to u3-FAs, there are also evidences that not only the
Nutritional components and obesityB9
fatty acid content of the fish is important, but also other
nutrients in fish may influence on CVD. In this sense, Erkkila ¨
et al. found that the intake of lean fish at least four times
per week could reduce blood pressure levels in coronary
heart disease patients . Likewise, there are also some
evidences that suggest benefits on body weight [114,115].
In young, overweight men, the inclusion of either lean or
fatty fish, or fish oil as part of an energy-restricted diet
resulted in approximately 1 kg more weight loss after 4
weeks, than did a similar diet without seafood or supple-
ment of marine origin .
In this sense, although more and longer-term studies are
needed, fish and fatty acids should be considered as part of
an effective strategy in the treatment of cardiovascular
diseases and metabolic syndrome.
Olive oil is considered a functional food, which besides
having a high level of MUFA, the oleic acid, contains
multiple minor components with potential biological prop-
erties . In this context, scientific evidence has been
accumulated in the last 2 decades about the beneficial role
of diets with a relatively high MUFA content on cardiovas-
cular risk factors, obesity, and DM . These beneficial
MUFAs are provided by the traditional Mediterranean food
pattern and, specifically, by olive oil and most nuts .
When SFA is replaced by MUFA in the diet, two important
effects are the decrease in LDL-c and maintaining the HDL-
c at a higher level rather than SFA when is substituted by
PUFA or carbohydrates . In LDL-c particles rich in
oleate have been shown to be less susceptible to oxidation
than rich in linoleate. Moreover, olive oil-rich diets increase
the LDL-c particle size more than carbohydrate-rich diets,
being this effect influenced by the apo E genotypes .
Thus, a high-MUFA diet, such as a classical Mediterranean
food pattern, may be a better substitute than the low-fat,
high-carbohydrate diet for a Westernized diet that is rich in
SFA, considering the improving in the HDL-c levels and
inhibition in the LDL-c oxidation.
In addition, a moderate-fat diet rich in MUFA represents
for some people a considerably more palatable alternative
than low-fat approaches for promoting healthy eating and
weight loss in the diabetics and obese individuals, thus
making easier the adherence and the long-term compliance
of participants . The mechanisms of the improved
glycaemic control associated with a high-MUFA diet remain
undefined. There is some evidence that a proportion of
total dietary fat in excess of 40% worsens insulin sensitivity,
particularly when the diet includes high saturated fat .
Olive oil also contains hundreds of non-fat components with
great biological potential, including: (i) polyphenolic
compounds such as phenolic acids (e.g., 4-hydroxybenzoic
acid, protocatechuic acid, gallic acid, etc.), tyrosol,
hydroxytyrosol and derivatives; lignans and flavonoids
(e.g., apigenin, luteolin, quercetin); (ii) chlorophyll and
derivatives; (iii) hydrocarbon (squalene); (iv) carotenoids
(e.g., b-carotene, lutein, neoxanthin) and; (v) tocopherols
(a-, b-, g- and d-) .
The content of the minor components of an olive oil
varies, depending on the cultivar, climate, ripeness of the
olives at harvesting, and the processing system employed to
produce the types of olive oil . In this context, the
EUROLIVE study demonstrated that the consumption of
medium- and high-phenolic content olive oil (25 mL/day)
decreased lipid oxidative damage biomarkers such as
plasma oxidized LDL-c, uninduced conjugated dienes, and
hydroxy fatty acids, besides to increase HDL-c. This
improvement in the lipid oxidative damage was linear with
the phenolic content of the olive oil consumed, providing
a relevant evidence that olive oil is more than a MUFA fat
. MUFA intake could be associated with an increased
sensitivity to insulin, producing a reduction in blood pres-
sure. However, the most accepted explanation is that other
components of olive oil, such as the mentioned phenolics
compounds could be associated with lower blood pressure
and a reduced risk of hypertension.
At the same time, nuts have been considered of interest
since provide many bioactive compounds that may benefit
metabolic syndrome components [121,122]. Several studies
have investigated the possible effect of nut consumption on
healthy humans, and patients with hypercholesterolaemia
or high cardiovascular risk, which are often contradictory.
In a randomized, parallel-group, 12-week feeding trial, 50
patients with MetS were given recommendations for
a healthy diet with (Nut diet) or without (Control diet)
supplementation with 30 g/day of raw nuts (15 g walnuts,
7.5 g almonds and 7.5 g hazelnuts). At the end of inter-
vention, only people without supplementation reported
a significant reduction in LDL-cholesterol. On the other
hand, patients with daily nut consumption showed an
insulin and HOMA-insulin resistance decrease . A meta-
analysis concerning several randomized trials suggested
that almond consumption ranging from 25 to 168 g/day may
decrease total cholesterol without changes on LDL or HDL
cholesterol, triglycerides, or the LDL:HDL ratio .
consumption is associated with a significant lower cardio-
vascular disease risk . Likewise, different trials have
consistently shown an association between nut consump-
tion and reduced risk of CVD as well as an improvement in
serum lipid and lipoprotein profiles , thus, the Amer-
ican Heart Association has recommended nut consumption
since 2000 . Particularly, nuts are high in unsaturated
FA, especially oleic acid (MUFA) and linoleic acid (PUFA),
which can vary their content according to types of nuts.
Actually, several intervention studies have found a choles-
terol-lowering effect in diets supplemented with walnuts,
macadamia nuts, pecans, pistachio nuts, peanuts and
almonds . However, the decreased risk of CVD asso-
ciated with nut consumption is not solely related to the FA
profile, but may be due in part to the presence of other
bioactive components (arginine, fibre, copper and magne-
sium). In addition, they also supply significant amounts of
tocopherols, squalene and phytosterols that are relevant
compounds with antioxidant properties.
Although the beneficial effects of nuts consumption on
metabolic syndrome features are recognized, there is
a continued concern that an increase in consumption of this
that frequent nut
B10 I. Abete et al.
energy-dense, high-fat foods will lead to excessive weight
gain. In this context, an evaluation of SUN cohort found
that participants who ate nuts two or more times per week
had a significantly lower risk of weight gain than those who
never or almost never ate nuts, after adjusting for age, sex,
smoking, leisure time physical activity, and other known
risk factors for obesity .
The dietary treatment of the metabolic syndrome has
achieved beneficial effects on specific metabolic features
such as plasma lipids, blood pressure and plasma glucose.
Indeed, a number of cross-sectional, epidemiological
studies, prospective cohort studies, randomized interven-
tion trials on human or research in animals have evidenced
that substituting dietary saturated fat for MUFA improves
insulin sensitivity (KANWU study) , that tocopherol
supplementation influences the incidence of type 2 dia-
betes (ATBC study) , that weight loss and cardiovascular
risk reduction based on nutrition induced healthy benefits
in patients with metabolic syndrome (DPP) , that the
adherence to the Mediterranean diet improves metabolic
syndrome features (PREDIMED)  as well as the DASH
eating pattern  or ARIC study . The Finish Diabetes
Prevention study also evidenced reduction in diabetes risk
due to nutrition and lifestyle changes .
Interestingly, these healthy effects are often improved
when specific foods are included in the nutritional treat-
ment of the metabolic syndrome. Thus, it is evident that
the inclusion of fruits, vegetables and legumes increases
the consumption of fibre, antioxidants, low glycaemic index
carbohydrates and minerals that produce a crucial effect
on some metabolic syndrome manifestations by inducing
blood pressure regulation, plasma lipid decrease and an
insulin resistance improvement. In this sense, legumes
consumption may contribute to the adherence to dietary
recommendations due to their satiety capacity, which
assures a success weight loss program. Fatty fish and nuts
consumption also are important components of a nutri-
tional treatment, increasing the u3 fatty acids intake,
which is related with the blood pressure regulation, blood
lipids improvements and an insulin resistance decrease.
Low-fat dairy products should be also considered in a die-
tary treatment, given that its consumption increase
calcium content, which could produce important effects
favouring weight loss and maintaining bone health. In
addition, olive oil is one of the most important mono-
unsaturated fatty acid sources, strongly related with
improvements in insulin resistance and low plasma choles-
terol concentrations, so, this type of fat could accompany
most important meals.
In summary, a reduction in the daily energy intake is part
of the dietary treatment in those subjects with metabolic
syndrome, but increasing the consumption of all these
natural foods in this treatment, the benefits could be
increased, favouring the improvement of the metabolic
syndrome features. There is sufficient evidence to recom-
mend a diet rich in a variety of fruits, vegetables, whole
grains, legumes, fish, oils, dairy product and nuts, for an
improvement in the adverse MetS features.
 Reaven GM. Banting lecture 1988. Role of insulin resistance
in human disease. Diabetes 1988;37:1595e607.
 Bruce KD, Hanson MA. The developmental origins, mecha-
nisms, and implications of metabolic syndrome. J Nutr 2010;
 Martinez MA, Puig JG, Mora M, Aragon R, O’Dogherty P,
Anton JL, et al. Metabolic syndrome: prevalence, associated
factors, and C-reactive protein: the MADRIC (MADrid RIesgo
Cardiovascular) study. Metabolism 2008;57:1232e40.
 Phillips CM, Goumidi L, Bertrais S, Field MR, Cupples LA,
Ordovas JM, et al. Gene-nutrient interactions with dietary
fat modulate the association between genetic variation of
the ACSL1 gene and metabolic syndrome. J Lipid Res 2010;
 Druet C, Ong K, Levy Marchal C. Metabolic syndrome in
children: comparison of the International Diabetes Federa-
tion 2007 consensus with an adapted National Cholesterol
Education Program definition in 300 overweight and obese
French children. Horm Res Paediatr 2010;73:181e6.
 Pereira MA, Kottke TE, Jordan C, O’Connor PJ, Pronk NP,
Carreon R. Preventing and managing cardiometabolic risk:
the logic for intervention. Int J Environ Res Public Health
 Muzio F, Mondazzi L, Harris WS, Sommariva D, Branchi A.
Effects of moderate variations in the macronutrient content
of the diet on cardiovascular disease risk factors in obese
patients with the metabolic syndrome. Am J Clin Nutr 2007;
 Steemburgo T, Dall’Alba V, Gross JL, Azevedo MJ. [Dietary
factors and metabolic syndrome]. Arq Bras Endocrinol
 Vernaglione L. The Mediterranean diet: a matter of history,
tradition, culture and health. J Nephrol 2009;22(Suppl. 14):
 Puchau B, Zulet MA, de Echa ´varri AG, Hermsdorff HH,
Martı ´nez JA. Dietary total antioxidant capacity is negatively
associated with some metabolic syndrome features in
healthy young adults. Nutrition 2010;26:534e41.
 Samman S, Koh HS, Flood VM, Blakesmith SJ, Petocz P, Lyons-
Wall PM. Red clover (Trifolium pratense) isoflavones and
serum homocysteine in premenopausal women: a pilot study.
J Womens Health (Larchmt) 2009;18:1813e6.
 Campbell MJ, Woodside JV, Honour JW, Morton MS,
Leathem AJ. Effect of red clover-derived isoflavone supple-
mentation on insulin-like growth factor, lipid and antioxidant
status in healthy female volunteers: a pilot study. Eur J Clin
 Brown AL, Lane J, Coverly J, Stocks J, Jackson S, Stephen A,
et al. Effects of dietary supplementation with the green tea
polyphenol epigallocatechin-3-gallate on insulin resistance
and associated metabolic risk factors: randomized controlled
trial. Br J Nutr 2009;101:886e94.
 Devaraj S, Tang R, Adams-Huet B, Harris A, Seenivasan T, de
Lemos JA, et al. Effect of high-dose alpha-tocopherol
supplementation on biomarkers of oxidative stress and
inflammation and carotid atherosclerosis in patients with
coronary artery disease. Am J Clin Nutr 2007;86:1392e8.
 Soory M. Relevance of nutritional antioxidants in metabolic
syndrome, ageing and cancer: potential for therapeutic
targeting. Infect Disord Drug Targets 2009;9:400e14.
 Malvy DJ, Favier A, Faure H, Preziosi P, Galan P, Arnaud J,
et al. Effect of two years’ supplementation with natural
biomarkers: preliminary data of the SU.VI.MAX study. Cancer
Detect Prev 2001;25:479e85.
Nutritional components and obesityB11
 Christen WG, Gaziano JM, Hennekens CH. Design of Physi-
cians’ Health Study II e a randomized trial of beta-carotene,
vitamins E and C, and multivitamins, in prevention of cancer,
cardiovascular disease, and eye disease, and review of
results of completed trials. Ann Epidemiol 2000;10:125e34.
 Catania AS, de Barros CR, Ferreira SR. [Vitamins and minerals
controversies and perspectives]. Arq Bras Endocrinol Metabol
 Azadbakht L, Kimiagar M, Mehrabi Y, Esmaillzadeh A, Hu FB,
Willett WC. Dietary soya intake alters plasma antioxidant
status and lipid peroxidation in postmenopausal women with
the metabolic syndrome. Br J Nutr 2007;98:807e13.
 Bressan J, Hermsdorff HH, Zulet MA, Martinez JA. [Hormonal
and inflammatory impact of different dietetic composition:
emphasis on dietary patterns and specific dietary factors].
Arq Bras Endocrinol Metabol 2009;53:572e81.
 Babio N, Bullo M, Basora J, Martinez-Gonzalez MA, Fernan-
dez-Ballart J, Marquez-Sandoval F, et al. Adherence to the
Mediterranean diet and risk of metabolic syndrome and its
components. Nutr Metab Cardiovasc Dis 2009;19:563e70.
 Czernichow S, Vergnaud AC, Galan P, Arnaud J, Favier A,
Faure H, et al. Effects of long-term antioxidant supplemen-
tation and association of serum antioxidant concentrations
with risk of metabolic syndrome in adults. Am J Clin Nutr
 Spanou C, Stagos D, Aligiannis N, Kouretas D. Influence of
potent antioxidant leguminosae family plant extracts on
growth and antioxidant defense system of Hep2 cancer cell
line. J Med Food 2010;13:149e55.
 Egert S, Bosy-Westphal A, Seiberl J, Kurbitz C, Settler U,
Plachta-Danielzik S, et al. Quercetin reduces systolic blood
pressureand plasma oxidised
cardiovascular disease risk phenotype: a double-blinded,
placebo-controlled cross-over study. Br J Nutr 2009;102:
 Cao G, Russell RM, Lischner N, Prior RL. Serum antioxidant
capacity is increased by consumption of strawberries,
spinach, red wine or vitamin C in elderly women. J Nutr 1998;
 Kataja-Tuomola M, Sundell JR, Mannisto S, Virtanen MJ,
Kontto J, Albanes D, et al. Effect of alpha-tocopherol and
beta-carotene supplementation on the incidence of type 2
diabetes. Diabetologia 2008;51:47e53.
 Clarke R, Armitage J. Antioxidant vitamins and risk of
cardiovascular disease. Review of large-scale randomised
trials. Cardiovasc Drugs Ther 2002;16:411e5.
 Wu JH, Ward NC, Indrawan AP, Almeida CA, Hodgson JM,
Proudfoot JM, et al. Effects of alpha-tocopherol and mixed
tocopherol supplementation on markers of oxidative stress
and inflammation in type 2 diabetes. Clin Chem 2007;53:
 CrujeirasAB, ParraMD,
Morentin BE, Martinez JA. A role for fruit content in energy-
restricted diets in improving antioxidant status in obese
women during weight loss. Nutrition 2006;22:593e9.
 Shenoy SF, Poston WS, Reeves RS, Kazaks AG, Holt RR,
Keen CL, et al. Weight loss in individuals with metabolic
syndrome given DASH diet counseling when provided a low
sodium vegetable juice: a randomized controlled trial. Nutr J
 Bazzano LA, Thompson AM, Tees MT, Nguyen CH, Winham DM.
Non-soy legume consumption lowers cholesterol levels:
a meta-analysis of randomized controlled trials. Nutr Metab
Cardiovasc Dis 2011;21:94e103.
 Taku K, Umegaki K, Sato Y, Taki Y, Endoh K, Watanabe S. Soy
isoflavones lower serum total and LDL cholesterol in humans:
a meta-analysis of 11 randomized controlled trials. Am J Clin
 Zhan S, Ho SC. Meta-analysis of the effects of soy protein
containing isoflavones on the lipid profile. Am J Clin Nutr
 Zhuo XG, Melby MK, Watanabe S. Soy isoflavone intake lowers
serum LDL cholesterol: a meta-analysis of 8 randomized
controlled trials in humans. J Nutr 2004;134:2395e400.
 Crujeiras AB, Parra D, Abete I, Martinez JA. A hypocaloric
diet enriched in legumes specifically mitigates lipid perox-
idation in obese subjects. Free Radic Res 2007;41:498e506.
 Abete I, Parra D, Martinez JA. Energy-restricted diets based
on a distinct food selection affecting the glycemic index
induce different weight loss and oxidative response. Clin
 Rizkalla SW, Bellisle F, Slama G. Health benefits of low gly-
caemic index foods, such as pulses, in diabetic patients and
healthy individuals. Br J Nutr 2002;88(Suppl. 3):S255e62.
 Sadruddin S, Arora R. Resveratrol: biologic and therapeutic
implications. J Cardiometab Syndr 2009;4:102e6.
 Zern TL, Wood RJ, Greene C, West KL, Liu Y, Aggarwal D,
et al. Grape polyphenols exert a cardioprotective effect in
pre- and postmenopausal women by lowering plasma lipids
and reducing oxidative stress. J Nutr 2005;135:1911e7.
 Rivera L, Moron R, Zarzuelo A, Galisteo M. Long-term
resveratrol administration reduces metabolic disturbances
and lowers blood pressure in obese Zucker rats. Biochem
 Cacciapuoti F. Opposite effects of metabolic syndrome and
calorie restriction on thrombotic disease: heads and tails of
the same coin e resveratrol’s role. Metab Syndr Relat Disord
 Bertelli AA, Das DK. Grapes, wines, resveratrol, and heart
health. J Cardiovasc Pharmacol 2009;54:468e76.
 Liu L, Wang Y, Lam KS, Xu A. Moderate wine consumption in
the prevention of metabolic syndrome and its related
medical complications. Endocr Metab Immune Disord Drug
 Micallef M, Lexis L, Lewandowski P. Red wine consumption
increases antioxidant status and decreases oxidative stress in
 Estruch R, Sacanella E, Mota F, Chiva-Blanch G, Antu ´nez E,
Casals E, et al. Moderate consumption of red wine, but not
gin, decreases erythrocyte superoxide dismutase activity:
a randomised cross-over trial. Nutr Metab Cardiovasc Dis
 Noll C, Hamelet J, Ducros V, Belin N, Paul JL, Delabar JM,
et al. Resveratrol supplementation worsen the dysregulation
of genes involved in hepatic lipid homeostasis observed in
hyperhomocysteinemic mice. Food Chem Toxicol 2009;47:
 Moore RJ, Jackson KG, Minihane AM. Green tea (Camellia
sinensis) catechins and vascular function. Br J Nutr 2009;102:
 Sirtori CR, Galli C, Anderson JW, Sirtori E, Arnoldi A. Func-
tional foods for dyslipidaemia and cardiovascular risk
prevention. Nutr Res Rev 2009;22:244e61.
 Ikeda I. Multifunctional effects of green tea catechins on
prevention of the metabolic syndrome. Asia Pac J Clin Nutr
 Boon N. Health potential for functional green teas? Int J
Vitam Nutr Res 2008;78:275e81.
 Trinidad TP, Mallillin AC, Loyola AS, Sagum RS, Encabo RR.
The potential health benefits of legumes as a good source of
dietary fibre. Br J Nutr 2009;103:569e74.
 Parks EJ, Hellerstein MK. Carbohydrate-induced hyper-
triacylglycerolemia: historical perspective and review of
biological mechanisms. Am J Clin Nutr 2000;71:412e33.
B12I. Abete et al.
 Anderson JW. Dietary fiber prevents carbohydrate-induced
hypertriglyceridemia. Curr Atheroscler Rep 2000;2:536e41.
 Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S,
Greenberg I, et al. Weight loss with a low-carbohydrate,
Mediterranean, or low-fat diet. N Engl J Med 2008;359:
 Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T,
Mitchell P, et al. Glycemic index, glycemic load, and chronic
disease risk e a meta-analysis of observational studies. Am J
Clin Nutr 2008;87:627e37.
 Scribner KB, Pawlak DB, Aubin CM, Majzoub JA, Ludwig DS.
Long-term effects of dietary glycemic index on adiposity,
energy metabolism, and physical activity in mice. Am J
Physiol Endocrinol Metab 2008;295:E1126e31.
 Kabir M, Rizkalla SW, Quignard-Boulange A, Guerre-Millo M,
Boillot J, Ardouin B, et al. A high glycemic index starch diet
affects lipid storage-related enzymes in normal and to
a lesser extent in diabetic rats. J Nutr 1998;128:1878e83.
 Scribner KB, Pawlak DB, Ludwig DS. Hepatic steatosis and
increased adiposity in mice consuming rapidly vs. slowly
absorbed carbohydrate. Obesity (Silver Spring) 2007;15:
 Brand-Miller J, McMillan-Price J, Steinbeck K, Caterson I.
Carbohydrates e the good, the bad and the whole grain. Asia
Pac J Clin Nutr 2008;17(Suppl. 1):16e9.
 de Rougemont A, Normand S, Nazare JA, Skilton MR,
Sothier M, Vinoy S, et al. Beneficial effects of a 5-week low-
glycaemic index regimen on weight control and cardiovas-
cular risk factors in overweight non-diabetic subjects. Br J
 Flint A, Moller BK, Raben A, Sloth B, Pedersen D, Tetens I,
et al. Glycemic and insulinemic responses as determinants of
appetite in humans. Am J Clin Nutr 2006;84:1365e73.
 Jenkins DJ, Kendall CW, McKeown-Eyssen G, Josse RG,
Silverberg J, Booth GL, et al. Effect of a low-glycemic index
or a high-cereal fiber diet on type 2 diabetes: a randomized
trial. JAMA 2008;300:2742e53.
 LeinonenK, LiukkonenK,
Mykkanen H. Rye bread decreases postprandial insulin
response but does not alter glucose response in healthy
Finnish subjects. Eur J Clin Nutr 1999;53:262e7.
 Juntunen KS, Laaksonen DE, Autio K, Niskanen LK, Holst JJ,
Savolainen KE, et al. Structural differences between rye and
wheat breads but not total fiber content may explain the
lower postprandial insulin response to rye bread. Am J Clin
 Larsen TM, Dalskov SM, van Baak M, Jebb SA, Papadaki A,
Pfeiffer AF, et al. Diets with high or low protein content and
glycemic index for weight-loss maintenance. N Engl J Med
 CoricaF, CorsonelloA,
Benedetto A, Perticone F, et al. Serum ionized magnesium
levels in relation to metabolic syndrome in type 2 diabetic
patients. J Am Coll Nutr 2006;25:210e5.
 Guerrero-Romero F, Rodriguez-Moran M. Low serum magne-
sium levels and metabolic syndrome. Acta Diabetol 2002;39:
 He K, Liu K, DaviglusML, MorrisSJ, LoriaCM, VanHorn L, et al.
Magnesium intake and incidence of metabolic syndrome
among young adults. Circulation 2006;113:1675e82.
 McKeown NM, Jacques PF, Zhang XL, Juan W, Sahyoun NR.
Dietary magnesium intake is related to metabolic syndrome
in older Americans. Eur J Nutr 2008;47:210e6.
 Guerrera MP, Volpe SL, Mao JJ. Therapeutic uses of magne-
sium. Am Fam Physician 2009;80:157e62.
 He K, Song Y, Belin RJ, Chen Y. Magnesium intake and the
metabolic syndrome: epidemiologic evidence to date. J
Cardiometab Syndr 2006;1:351e5.
Ientile R, CucinottaD, Di
 Paolisso G, Passariello N, Pizza G, Marrazzo G, Giunta R,
Sgambato S, et al. Dietary magnesium supplements improve
B-cell response to glucose and arginine in elderly non-insulin
dependent diabetic subjects. Acta Endocrinol (Copenh)
 Rodriguez-Moran M, Guerrero-Romero F. Oral magnesium
supplementation improves insulin sensitivity and metabolic
control in type 2 diabetic subjects: a randomized double-
blind controlled trial. Diabetes Care 2003;26:1147e52.
 Song Y, He K, Levitan EB, Manson JE, Liu S. Effects of oral
magnesium supplementation on glycaemic control in Type 2
diabetes: a meta-analysis
controlled trials. Diabet Med 2006;23:1050e6.
 Astrup A, Kristensen M, Gregersen NT, Belza A, Lorenzen JK,
Due A, et al. Can bioactive foods affect obesity? Ann N YAcad
 Zemel MB, Shi H, Greer B, Dirienzo D, Zemel PC. Regulation
of adiposity by dietary calcium. FASEB J 2000;14:1132e8.
 Shahar DR, Abel R, Elhayany A, Vardi H, Fraser D. Does dairy
calcium intake enhance weight loss among overweight dia-
betic patients? Diabetes Care 2007;30:485e9.
 Tremblay A, Gilbert JA. Milk products, insulin resistance
syndrome and type 2 diabetes. J Am Coll Nutr 2009;28(Suppl.
 Lamarche B. Review of the effect of dairy products on non-
lipid risk factors for cardiovascular disease. J Am Coll Nutr
 Lutsey PL, Steffen LM, Stevens J. Dietary intake and the
development of the metabolic syndrome: the Atheroscle-
rosis Risk in Communities study. Circulation 2008;117:
 Alonso A, Beunza JJ, Delgado-Rodriguez M, Martinez JA,
Martinez-Gonzalez MA. Low-fat dairy consumption and
reduced risk of hypertension: the Seguimiento Universidad
de Navarra (SUN) cohort. Am J Clin Nutr 2005;82:972e9.
 Alonso A, Zozaya C, Vazquez Z, Alfredo Martinez J, Martinez-
Gonzalez MA. The effect of low-fat versus whole-fat dairy
product intake on blood pressure and weight in young
normotensive adults. J Hum Nutr Diet 2009;22:336e42.
 van Meijl LE, Vrolix R, Mensink RP. Dairy product consump-
tion and the metabolic syndrome. Nutr Res Rev 2008;21:
 Tholstrup T. Dairy products and cardiovascular disease. Curr
Opin Lipidol 2006;17:1e10.
 Teegarden D, White KM, Lyle RM, Zemel MB, Van Loan MD,
Matkovic V, et al. Calcium and dairy product modulation of
lipid utilization and energy expenditure. Obesity (Silver
 Zemel M. Calcium modulation of adiposity. Obes Res 2003;11:
 Zemel MB. Proposed role of calcium and dairy food compo-
nents in weight management and metabolic health. Phys
 Zemel MB, Miller SL. Dietary calcium and dairy modulation of
adiposity and obesity risk. Nutr Rev 2004;62:125e31.
 Zemel MB. Calcium modulation of hypertension and obesity:
mechanisms and implications. J Am Coll Nutr 2001;20:
428Se35S [Discussion 440Se442S].
 Pfeuffer M, Schrezenmeir J. Milk and the metabolic
syndrome. Obes Rev 2007;8:109e18.
 Wennersberg MH, Smedman A, Turpeinen AM, Retterstol K,
Tengblad S, Lipre E, et al. Dairy products and metabolic
effects in overweight men and women: results from a 6-mo
intervention study. Am J Clin Nutr 2009;90:960e8.
 Ganji V, Kafai MR. Serum total homocysteine concentration
determinants in non-Hispanic White, non-Hispanic Black, and
Mexican-American populations of the United States. Ethn Dis
of randomized double-blind
Nutritional components and obesityB13
 Oshaug A, Bugge KH, Refsum H. Diet, an independent
determinant for plasma total homocysteine. A cross sectional
study of Norwegian workers on platforms in the North Sea.
Eur J Clin Nutr 1998;52:7e11.
 Zulet MA, Puchau B, Hermsdorff HH, Navarro C, Martinez JA.
Dietary selenium intake is negatively associated with serum
sialic acid and metabolic syndrome features in healthy young
adults. Nutr Res 2009;29:41e8.
 Puchau B, Zulet MA, Gonzalez de Echavarri A, Navarro-
Blasco I, Martinez JA. Selenium intake reduces serum C3, an
early marker of metabolic syndrome manifestations, in
healthy young adults. Eur J Clin Nutr 2009;63:858e64.
 Singh RB, Niaz MA, Rastogi SS, Bajaj S, Gaoli Z, Shoumin Z.
Current zinc intake and risk of diabetes and coronary artery
disease and factors associated with insulin resistance in rural
and urban populations of North India. J Am Coll Nutr 1998;17:
 Partida-Hernandez G, Arreola F, Fenton B, Cabeza M, Roman-
Ramos R, Revilla-Monsalve MC. Effect of zinc replacement on
lipids and lipoproteins in type 2-diabetic patients. Biomed
 Song Y, Wang J, Li XK, Cai L. Zinc and the diabetic heart.
 Lee K, Lee J, Bae WK, Choi JK, Kim HJ, Cho B. Efficacy of
low-calorie, partial meal replacement diet plans on weight
and abdominal fat in obese subjects with metabolic
syndrome: a double-blind, randomised controlled trial of two
diet plans - one high in protein and one nutritionally
balanced. Int J Clin Pract 2009;63:195e201.
 Domingo JL. Omega-3 fatty acids and the benefits of fish
consumption: is all that glitters gold? Environ Int 2007;33:
 Woodside JV, Kromhout D. Fatty acids and CHD. Proc Nutr
 Cicero AF, Derosa G, Di Gregori V, Bove M, Gaddi AV,
Borghi C. Omega 3 polyunsaturated fatty acids supplemen-
tation and blood pressure levels in hypertriglyceridemic
patients with untreated normal-high blood pressure and with
or without metabolic syndrome: a retrospective study. Clin
Exp Hypertens 2010;32:137e44.
 Cicero AF, Ertek S, Borghi C. Omega-3 polyunsaturated fatty
acids: their potential role in blood pressure prevention and
management. Curr Vasc Pharmacol 2009;7:330e7.
 Mori TA, Burke V, Puddey IB, Shaw JE, Beilin LJ. Effect of fish
diets and weight loss on serum leptin concentration in
overweight, treated-hypertensive subjects. J Hypertens
 Abete I, Parra D, Crujeiras AB, Goyenechea E, Martinez JA.
Specific insulin sensitivity and leptin responses to a nutri-
tional treatment of obesity via a combination of energy
restriction and fatty fish intake. J Hum Nutr Diet 2008;21:
 Marques M, Parra D, Kiely M, Bandarra N, Thorsdottir I,
Martinez JA. [Omega-3 fatty acids inclusion as part of an
energy restricted diet to improve the effect on blood lipids].
Med Clin (Barc) 2008;130:10e2.
 Ebbesson SO, Risica PM, Ebbesson LO, Kennish JM. Eskimos
have CHD despite high consumption of omega-3 fatty acids:
the Alaska Siberia project. Int J Circumpolar Health 2005;64:
 Ebbesson SO, Risica PM, Ebbesson LO, Kennish JM, Tejero ME.
Omega-3 fatty acids improve glucose tolerance and compo-
Siberia project. Int J Circumpolar Health 2005;64:396e408.
 Ebbesson SO, Tejero ME, Nobmann ED, Lopez-Alvarenga JC,
Ebbesson L, Romenesko T, et al. Fatty acid consumption and
metabolic syndrome components: the GOCADAN study.
J Cardiometab Syndr 2007;2:244e9.
 Mostad IL, Bjerve KS, Basu S, Sutton P, Frayn KN, Grill V.
Addition of n-3 fatty acids to a 4-hour lipid infusion does not
affect insulin sensitivity, insulin secretion, or markers of
oxidative stress in subjects with type 2 diabetes mellitus.
 Vessby B, Uusitupa M, Hermansen K, Riccardi G, Rivellese AA,
Tapsell LC, et al. Substituting dietary saturated for mono-
unsaturated fat impairs insulin sensitivity in healthy men and
women: the KANWU study. Diabetologia 2001;44:312e9.
 Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S,
Franch HA, et al. Diet and lifestyle recommendations revision
2006: a scientific statement from the American Heart Associ-
ation Nutrition Committee. Circulation 2006;114:82e96.
 Erkkila AT, Schwab US, de Mello VD, Lappalainen T,
Mussalo H, Lehto S, et al. Effects of fatty and lean fish intake
on blood pressure in subjects with coronary heart disease
using multiple medications. Eur J Nutr 2008;47:319e28.
 Thorsdottir I, Tomasson H, Gunnarsdottir I, Gisladottir E,
Kiely M, Parra MD, et al. Randomized trial of weight-loss-
diets for young adults varying in fish and fish oil content.
Int J Obes (Lond) 2007;31:1560e6.
 Buckley JD, Howe PR. Anti-obesity effects of long-chain
omega-3 polyunsaturated fatty acids. Obes Rev 2009;10:
 Fito M, de la Torre R, Covas MI. Olive oil and oxidative stress.
Mol Nutr Food Res 2007;51:1215e24.
 Paniagua JA, de la Sacristana AG, Sanchez E, Romero I, Vidal-
Puig A, Berral FJ, et al. A MUFA-rich diet improves
posprandial glucose, lipid and GLP-1 responses in insulin-
resistant subjects. J Am Coll Nutr 2007;26:434e44.
 Martinez-Gonzalez MA, Bes-Rastrollo M. The cardioprotective
benefits of monounsaturated fatty acid. Altern Ther Health
Med 2006;12:24e30. quiz 31.
 Perez-Jimenez F, Ruano J, Perez-Martinez P, Lopez-Segura F,
Lopez-Miranda J. The influence of olive oil on human health:
not a question of fat alone. Mol Nutr Food Res 2007;51:
 Covas MI, Nyyssonen K, Poulsen HE, Kaikkonen J, Zunft HJ,
Kiesewetter H, et al. The effect of polyphenols in olive oil on
heart disease risk factors: a randomized trial. Ann Intern Med
 Ros E. Nuts and novel biomarkers of cardiovascular disease.
Am J Clin Nutr 2009;89:1649Se56S.
 Casas-Agustench P, Lo ´pez-Uriarte P, Bullo ´ M, Ros E, Cabre ´-
Vila JJ, Salas-Salvado ´ J. Effects of one serving of mixed nuts
on serum lipids, insulin resistance and inflammatory markers
in patients with the metabolic syndrome. Nutr Metab Car-
diovasc Dis 2011;21:126e35.
 Phung OJ, Makanji SS, White CM, Coleman CI. Almonds have
a neutral effect on serum lipid profiles: a meta-analysis of
randomized trials. J Am Diet Assoc 2009;109:865e73.
 Li TY, Brennan AM, Wedick NM, Mantzoros C, Rifai N, Hu FB.
Regular consumption of nuts is associated with a lower risk of
cardiovascular disease in women with type 2 diabetes. J Nutr
 Bes-Rastrollo M, Sabate J, Gomez-Gracia E, Alonso A,
Martinez JA, Martinez-Gonzalez MA. Nut consumption and
weight gain in a Mediterranean cohort: the SUN study.
Obesity (Silver Spring) 2007;15:107e16.
 Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR,
Deckelbaum RJ, et al. AHA Dietary Guidelines: revision 2000:
a statement for healthcare professionals from the Nutrition
Committee of the American Heart Association. Circulation
 Ryan E, Galvin K, O’Connor TP, Maguire AR, O’Brien NM.
Fatty acid profile, tocopherol, squalene and phytosterol
content of brazil, pecan, pine, pistachio and cashew nuts. Int
J Food Sci Nutr 2006;57:219e28.
B14 I. Abete et al.
 McBride Download full-text
Underbakke G, Vitcenda M, et al. Putting the Diabetes
Prevention Program into practice: a program for weight loss
and cardiovascular risk reduction for patients with meta-
bolic syndrome or type 2 diabetes mellitus. J Nutr Health
 Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F.
Beneficial effects of a dietary approaches to stop hyperten-
sion eating plan on features of the metabolic syndrome.
Diabetes Care 2005;28:2823e31.
 Lindstrom J, Absetz P, Hemio K, Peltomaki P, Peltonen M.
Reducing the risk of type 2 diabetes with nutrition and
physical activity e efficacy and implementation of lifestyle
interventions in Finland. Public Health Nutr 2010;13:993e9.
 Parra D, Bandarra NM, Kiely M, Thorsdottir I, Martinez JA.
Impact of fish intake on oxidative stress when included into
a moderate energy-restricted program to treat obesity. Eur J
 Ramel A, Parra D, Martinez JA, Kiely M, Thorsdottir I. Effects
of seafood consumption and weight loss on fasting leptin and
ghrelin concentrations in overweight and obese European
young adults. Eur J Nutr 2009;48:107e14.
 Rodriguez MC, Parra MD, Marques-Lopes I, De Morentin BE,
Gonzalez A, Martinez JA. Effects of two energy-restricted
diets containing different fruit amounts on body weight
loss and macronutrient oxidation. Plant Foods Hum Nutr
 Razquin C, Martinez JA, Martinez-Gonzalez MA, Mitjavila MT,
Estruch R, Marti A. A 3 years follow-up of a Mediterranean
diet rich in virgin olive oil is associated with high plasma
antioxidant capacity and reduced body weight gain. Eur J
Clin Nutr 2009;63:1387e93.
Nutritional components and obesityB15