Nutrition attributes and health effects of pistachio nuts

Abstract

Epidemiological and/or clinical trials have suggested that nut consumption has a beneficial impact on health outcomes such as hypertension, diabetes, CVD, cancer, other inflammatory conditions and total mortality. Nuts are nutrient-dense foods with a healthy fatty acid profile, as well as provide other bioactive compounds with recognised health benefits. Among nuts, pistachios have a lower fat and energy content and the highest levels of K, γ-tocopherol, vitamin K, phytosterols, xanthophyll carotenoids, certain minerals (Cu, Fe and Mg), vitamin B
6
and thiamin. Pistachios have a high antioxidant and anti-inflammatory potential. The aforementioned characteristics and nutrient mix probably contribute to the growing body of evidence that consumption of pistachios improves health. The present review examines the potential health effects of nutrients and phytochemicals in pistachios, as well as epidemiological and clinical evidence supporting these health benefits.

Full text

Nutrition attributes and health effects of pistachio nuts
q
M. Bullo
´
1,2
*, M. Juanola-Falgarona
1,2
, P. Herna
´ndez-Alonso
1
and J. Salas-Salvado
´
1,2
*
1
Human Nutrition Unit, Hospital Universitari de Sant Joan de Reus, Faculty of Medicine and Health Sciences,
IISPV (Institut d’Investigacio
´Sanita
`ria Pere Virgili), Universitat Rovira i Virgili, C/Sant Llorenc¸ 21, 43201 Reus, Spain
2
CIBERobn (Centro de Investigacio
´n Biome
´dica en Red Fisiopatologı
´a de la Obesidad y Nutricio
´n),
Institute of Health Carlos III, Madrid, Spain
(Submitted 19 June 2014 – Final revision received 3 September 2014 – Accepted 4 September 2014)
Abstract
Epidemiological and/or clinical trials have suggested that nut consumption has a beneficial impact on health outcomes such as
hypertension, diabetes, CVD, cancer, other inflammatory conditions and total mortality. Nuts are nutrient-dense foods with a healthy
fatty acid profile, as well as provide other bioactive compounds with recognised health benefits. Among nuts, pistachios have a lower
fat and energy content and the highest levels of K, g-tocopherol, vitamin K, phytosterols, xanthophyll carotenoids, certain minerals
(Cu, Fe and Mg), vitamin B
6
and thiamin. Pistachios have a high antioxidant and anti-inflammatory potential. The aforementioned
characteristics and nutrient mix probably contribute to the growing body of evidence that consumption of pistachios improves health.
The present review examines the potential health effects of nutrients and phytochemicals in pistachios, as well as epidemiological and
clinical evidence supporting these health benefits.
Key words: Pistachios: CVD: Blood glucose: Insulin resistance: Polyphenols: Antioxidants: Body weight
The health benefits of nuts, mainly in relation to CVD as well as
to other chronic conditions, have been widely demonstrated in
both epidemiological
(1)
and clinical
(2,3)
trials. For this reason,
the American Heart Association
(4,5)
, the Canadian Cardio-
vascular Society
(6)
and the US Food and Drug Administration
(7)
recommend the regular consumption of nuts to the general
population, in the context of a healthy diet, to prevent the
risk of CVD. Recently, nut consumption has also been inversely
associated with total mortality
(8,9)
. Nuts are the rich sources
of unsaturated fatty acids, fibre and protein, along with
many vitamins (vitamins E and B
6
, niacin or folic acid),
minerals (Mg, K and Cu) and other phytochemical constituents
(stigmasterol, campesterol, resveratrol and catechins)
(10)
.
Compared with other nuts, pistachios have a lower fat (mostly
from PUFA and MUFA) and energy content, and higher
levels of fibre (both soluble and insoluble), K, phytosterols,
g-tocopherol, vitamin K, and xanthophyll carotenoids
(10)
(Table 1). Pistachios are among the top fifty foods with
a high antioxidant potential
(11)
. In addition, pistachios are
the only nut that contains significant amounts of lutein and
zeaxanthin
(10)
. Polyphenols, xanthophylls and tocopherols
from pistachios have been demonstrated to be rapidly accessible
in the stomach, thus maximising the possibility of absorption
in the upper small intestine, thereby contributing to the
beneficial relationship between pistachio consumption and
health-related outcomes
(12)
.
The present review examines the potential health effects
of compounds in pistachios as well as epidemiological and
q
Publication of these papers was supported by unrestricted educational grants from Federacio
´n Espan
˜ola de Sociedades de Nutricio
´n, Alimentacio
´ny
Diete
´tica (FESNAD), International Nut and Dried Fruit Council (INC), International Union of Nutritional Sciences (IUNS), Fundacio
´n Iberoamericana de
Nutricio
´n (FINUT), Centro de Investigacio
´n Biome
´dica en Red de la Fisiopatologı
´a de la Obesidad y Nutricio
´n (CIBERobn) and Centro Interuniversitario
di Ricerca sulle Culture Alimentari Mediterranee (Ciiscam). The papers included in this supplement were invited by the Guest Editors and have
undergone the standard journal formal review process. They may be cited. The Guest Editors declare that Salas-Salvado
´is a nonpaid member of the
World Forum for Nutrition Research and Dissemination of the International Nut and Dried Fruit Council. Angel Gil is President of the Fundacio
´n
Iberomericana de Nutricio
´n, which is a non-paid honorary position. Lluis Serra-Majem is the President of the Scientific Committee of the Mediterranean
Diet Foundation and Scientific Director of the CIISCAM (Centro Interuniversitario di Ricerca sulle Culture Alimentari Mediterranee), Universita La
Sapienza di Roma which are both non-paid, honorary positions. Goretti Guasch is the Executive Director and Member of the Executive Committee of the
International Nut and Dried Fruit Council, which is a paid position. Mo
`nica Bullo
´declares no conflict of interest.
*Corresponding authors: Dr M. Bullo
´, fax þ34 977759322, email monica.bullo@urv.cat; Dr J. Salas-Salvado
´, fax þ34 977759322, email jordi.salas@urv.cat
Abbreviations: BP, blood pressure; HDL-C, HDL-cholesterol; LDL-C, LDL-cholesterol; T2DM, type 2 diabetes.
British Journal of Nutrition (2015), 113, S79–S93 doi:10.1017/S0007114514003250
qThe Authors 2015
British Journal of Nutrition

clinical evidence supporting the health benefits of pistachio
consumption.
Bioactive components of pistachios
Nuts and diet quality
Recent epidemiological studies conducted in children and
adults have demonstrated a significant association between
nut consumption and a higher diet quality score or improved
nutrient intakes
(13,14)
. O’Neil et al.
(13)
, in a study of 13 292
adults participating in the 1999– 2004 National Health and
Nutrition Examination Survey, observed that tree nut
consumers, defined as those consuming more than 7·09 g/d
of nuts or tree nut butters, had a significantly higher intake
of several nutrients as fibre, vitamins and minerals, and also
a higher Total Healthy Eating Index-2005 score. Similarly, in
an analysis including concatenated data from adults aged
2þyears participating in the National Health and Nutri-
tion Examination Survey 1999– 2000, 2001 – 02 and 2003 – 04,
consumption of more than 7·08 g/d was associated with a
healthier nutrient profile and higher Total Healthy Eating
Index-2005 score in consumers of all age groups. Moreover,
adult consumers showed a better metabolic risk profile
(14)
.
Furthermore, the results of a clinical trial conducted on 124
obese subjects demonstrated that nutritional dietary quality
among nut consumers (those eating 42 g hazelnuts/d for
12 weeks) was appreciably improved compared with other
groups consuming chocolate, potato crisps or no additional
foods
(15)
. Finally, the inclusion of nuts in energy-restricted
diets reduced attrition and increased weight loss, supporting
that nuts enhance palatability and compliance with diets
without compromising beneficial health effects
(16)
.
Fat content
Pistachios, compared with other nuts, are relatively low in
fat, containing 45·4 g total fat per 100 g pistachio kernel
and consisting of 5·6 g SFA, 13·7 g PUFA and 23·8 g MUFA
(Table 1)
(10)
. Within fatty acids, oleic and linoleic fatty
acids, both recognised for their cardiovascular-preventive
properties
(17)
, represent more than 60 % of the total fat content
in pistachios.
The USA (California, Arizona and New Mexico), Iran and
Turkey are the largest producers of pistachios, growing
varieties that differ slightly in nutritional composition.
Whereas US pistachios have less energy and contain higher
amounts of lutein and zeaxanthin, Iranian pistachios are
richer in linoleic acid
(18)
and Turkish pistachios in Ca
(19)
(Table 2). Fatty acid composition and nutritional profile
characteristics also depend on the climate in which the
pistachios are grown. For example, cultivars of pistachio
nuts grown in hot temperatures (over 258C) tend to produce
a lower amount of a saturated fat such as palmitic acid
(20)
.
Protein
Pistachios are a good source of vegetable protein, which
comprises about 20 % of total weight, with approximately 2 %
L-arginine
(21)
. This amino acid, also present in other nuts, is a
precursor to the endogenous vasodilator NO, an important
molecule involved in the cardiovascular system as a key regula-
tor of vascular tone and in numerous pathological conditions
such as hypertension, CVD and neurodegenerative disorders
due to its pro-oxidant capacity
(22,23)
. NO synthase inhibitors
based on arginine have been of special interest for experimental
as well as clinical applications
(24)
. Therefore, pistachios could
Table 1. Macronutrient contents of the selected nuts per 100 g (raw and dry roasted)*
Almonds Hazelnuts Macadamia nuts Peanuts Pecans Pistachio nuts Walnuts
Energy (kJ)
Raw nuts 579 628 718 567 691 562 654
Dry roasted nuts 598 646 718 585 710 567 NA
Total lipids (g)
Raw nuts 49·93 60·75 75·77 49·24 71·97 45·39 65·21
Roasted nuts 52·54 62·40 76·08 49·66 74·27 44·82 NA
SFA (g)
Raw nuts 3·80 4·46 12·06 6·83 6·18 5·56 6·13
Roasted nuts 4·09 4·51 11·94 6·89 6·28 5·45 NA
PUFA (g)
Raw nuts 12·39 7·92 1·5 15·56 21·61 13·74 47·17
Roasted nuts 12·96 8·46 1·5 15·69 20·57 13·44 NA
MUFA (g)
Raw nuts 31·55 45·65 58·88 24·43 40·8 23·82 8·93
Roasted nuts 33·08 46·60 59·27 24·64 43·95 23·67 NA
Proteins (g)
Raw nuts 21·15 14·95 7·91 25·8 9·17 20·27 15·23
Roasted nuts 20·96 15·03 7·79 23·6 9·50 20·95 NA
Carbohydrates (g)
Raw nuts 21·55 16·70 13·82 16·13 13·86 27·51 13·71
Roasted nuts 21·01 17·60 13·38 21·51 13·55 29·38 NA
Fibre (g)
Raw nuts 12·5 9·7 8·6 8·5 9·6 10·3 6·7
Roasted nuts 10·9 9·4 8·0 8·0 9·4 9·9 NA
NA, not available.
* US Department of Agriculture, Nutrient Database for Standard Reference, Release 26, 2013
(10)
.
M. Bullo
´et al.S80
British Journal of Nutrition

play an important protective role in NO synthase-related
diseases. On a per serving basis (28·35 g), pistachios provide
10·6 % US RDA of adult men and 12·9 % of adult women
(25)
.
Compared with the FAO- and WHO-recommended essential
amino acid pattern for an adult, pistachios contain adequate
amounts of all of the essential amino acids
(26)
. Pistachios have
an essential amino acid ratio (essential amino acid:total amino
acid) of 39·1, higher than most of all the commonly consumed
nuts (almonds, walnuts, pecans and hazelnuts). Pistachios also
provide a high percentage of branched-chain amino acids
(1·599 g leucine, 0·932 g isoleucine and 1·262 g valine per
100 g), higher than other tree nuts.
Carbohydrates and fibre
The amount of carbohydrate in pistachios, as in other nuts, is
low to moderate (about 27·5 % by weight), but pistachios are
rich in fibre, containing 10 % by weight of insoluble forms and
0·3 % of soluble forms. Pistachios provide 3 g or 12 % of RDA
per serving basis (Table 1)
(10)
. According to the US Depart-
ment of Agriculture food composition tables, of all nuts,
only almonds have similar amounts of fibre, with 13 % of
weight. Fibre content is important because epidemiological
and clinical studies have consistently demonstrated that fibre
intake is inversely associated with weight gain
(27)
, diabetes
(28)
,
CVD
(29)
and some types of cancer
(28)
. Moreover, pistachios
have a low glycaemic index, which contributes to maintaining
satiety longer and lowering postprandial blood glucose
concentrations
(30,31)
.
Vitamins and minerals
Pistachios are rich in Cu, Mg, Mn, vitamin A, vitamin C and B
vitamins, withthe exception of vitamin B
12
(cyanocobalamin)
(32)
,
compared with other nuts (Table 3). In particular, pistachios
contain relatively high amounts of thiamin (vitamin B
1
),
which is involved in intermediary carbohydrate metabolism,
with 0·87 mg/100 g of pistachios (providing up to 50 % of
the RDA). The amount of pyridoxine (vitamin B
6
) that is
involved in the metabolism of amino acids and in the
production of niacin is about 1·7 mg/100 g of pistachios,
exceeding the RDA. Finally, the amount of folic acid in pista-
chios provides approximately 25 % of the RDA. Folic acid is
necessary for the formation of structural proteins and Hb,
and deficiency leads to an increase in the risk of CVD
(33)
.
Among nuts, pistachios also stand out for high vitamin K
content, with approximately 13·2 mg/100 g (16 % of the RDA;
Table 3). Beyond its role in bone metabolism
(34 – 36)
, a higher
dietary intake of vitamin K has been associated with a lower
risk of several chronic diseases such as type 2 diabetes
(T2DM)
(34)
, cancer
(37,38)
and CVD
(38)
, thus expanding the
potential health benefits of pistachio consumption. The
beneficial role of pistachios in inflammatory-related diseases
may also be explained by the relatively high amount of
g-tocopherol they contain
(39)
.
Pistachios are rich in several minerals such as K, Mg, Ca, Cu
and Mn. Because of their mineral profile, pistachios could
play a beneficial role in blood pressure (BP) regulation or
in bone-related diseases. Pistachios also contain significant
Table 2. Comparison of nutrient contents of pistachio seeds by country of origin
US pistachios*
(roasted/salted, 28 g)
Iranian pistachios† (roasted/
salted, 28 g)
Turkish pistachios‡
(roasted/salted, 28 g)
Nutrients Absolute value % DV Absolute value % DV Absolute value % DV
Total energy (kJ) 669·44 761·48 790·77
Total fat (g) 12·7 20 % 15·1 23 % 16·4 25 %
Energy from fat (kJ) 120 136 147
Saturated fat (g) 1·5 8 % 1·5 8 % 1·8 9 %
Monounsaturated fat (g) 6·7 9·1 11·1
Polyunsaturated fat (g) 3·8 3·9 2·8
Linoleic acid (18 : 2) (g) 3·7 4·0 2·9
Linolenic acid (18 : 3) (g) 0·07 0·06 0·05
Trans-fat (g) 0 ,0·02 ,0·01
Cholesterol (mg) 0 0 % ,0·28 0 % ,0·28 0 %
Na (mg) 121 5 % 163 7 % 162 7 %
Total carbohydrate (g) 8·1 3 % 5·3 2 % 4·4 1 %
Sugars (g) 2·2 1·4 0·8
Fibre (g) 2·8 11 % 3·1 12 % 2·8 11 %
Protein (g) 5·9 12 % 6·1 12 % 5·9 12 %
Vitamin A (mg) 43·8 1% ,5·95 0 % 34·38 1 %
b-Carotene (mg) 44 ,5·7 34·3
a-Carotene (mg) 0 ,5·7 ,5·7
b-Cryptoxanthin (mg) 0 ,5·7 ,5·7
Lycopene (mg) 0 ,5·7 ,5·7
Lutein þzeaxanthin (mg) 329 ,127·7 204
Vitamin C (mg) 0·9 2 % ,0·28 0 % ,0·28 0 %
Ca (mg) 30 3 % 35·7 4 % 45·9 5 %
Fe (mg) 1·1 6 % 0·64 4 % 0·78 4 %
% DV, % daily value.
* US Department of Agriculture National Nutrient Database for Standard Reference, Release 26, 2013
(10)
.
† Covance Certificate of Analysis
(18)
.
‡ Covance Certificate of Analysis
(19)
.
Pistachio nuts and health S81
British Journal of Nutrition

Table 3. Micronutrient contents of the selected nuts per 100 g (raw and dry roasted)*
Almonds Hazelnuts Macadamia nuts Peanuts Pecans Pistachio nuts Walnuts
Vitamin A (mg)
Raw nuts 0·6 12 0 0 33·6 249 12
Roasted nuts 0·6 36·6 0 0 84 155·4 NA
Vitamin C (mg)
Raw nuts 0 6·3 1·2 0 1·1 5·6 1·3
Roasted nuts 0 3·8 0·7 0 0·7 3·0 NA
Vitamin K (mg)
Raw nuts 0 14·2 NA 0 3·5 13·2 2·7
Roasted nuts 0 NA 0 0 NA 13·2 NA
Vitamin B
6
(mg)
Raw nuts 0·14 0·56 0·27 0·34 0·21 1·70 0·53
Roasted nuts 0·13 0·62 0·35 0·25 0·19 1·12 NA
Vitamin B
12
(mg)
Raw nuts 0·14 0 0 0 0 0 0
Roasted nuts 0·00 0 0 0 0 0 NA
Folate (mg)
Raw nuts 44 113 11 240 22 51 98
Roasted nuts 55 88 10 145 16 51 NA
Thiamin (mg)
Raw nuts 0·20 0·73 1·19 0·64 0·66 0·87 0·34
Roasted nuts 0·07 0·33 0·71 0·43 0·45 0·69 NA
Riboflavin (mg)
Raw nuts 1·13 0·11 0·16 0·13 0·13 0·16 0·15
Roasted nuts 1·20 0·12 0·08 0·09 0·10 0·23 NA
Niacin (mg)
Raw nuts 3·61 1·80 2·47 12·06 1·16 1·30 1·12
Roasted nuts 3·64 2·05 2·27 13·52 1·16 1·37 NA
Ca (mg)
Raw nuts 264 114 85 92 70 105 98
Roasted nuts 268 123 70 54 72 107 NA
Fe (mg)
Raw nuts 3·72 4·7 3·7 4·6 2·5 3·9 291
Roasted nuts 3·73 4·3 2·7 2·3 2·8 4·0 NA
Mg (mg)
Raw nuts 270 163 130 168 121 121 201
Roasted nuts 279 173 118 178 132 109 NA
K (mg)
Raw nuts 705 680 368 376 410 1025 441
Roasted nuts 713 755 363 658 424 1007 NA
Na (mg)
Raw nuts 1 0 5 18 0 1 2
Roasted nuts 3 0 4 6 1 6 NA
Total phenol (mg)
Raw nuts 287 687 126 406 1284 867 1576
Roasted nuts NA NA NA NA NA NA NA
Flavonoids (mg)
Raw nuts 15 12 NA 0·7 34 14 3
Roasted nuts NA NA NA NA NA NA NA
Procyanidins (mg)
Raw nuts 184 500 NA 16 494 237 67
Roasted nuts NA NA NA NA NA NA NA
Tocopherols (mg)
Raw nuts 25 33 4 8 4 7 6
Roasted nuts NA NA NA NA NA NA NA
Carotenoids (mg)
Raw nuts 2 106 NA NA 55 332 NA
Roasted nuts NA NA NA NA NA NA NA
Lutein þzeaxanthin (mg)
Raw nuts 1 92 0 0 17 1405 9
Roasted nuts NA NA NA NA NA NA NA
Total phytosterols (mg)
Raw nuts 120 0 116 220 102 214 108
Roasted nuts NA NA NA NA NA NA NA
NA, not available.
* US Department of Agriculture, Nutrient Database for Standard Reference, Release 26, 2013
(10)
. Polyphenol data were obtained from the Phenol-Explorer
database (http://www.phenol-explorer.eu)
(32)
.
M. Bullo
´et al.S82
British Journal of Nutrition

amounts of Zn and Se, both minerals with recognised anti-
oxidant effects that are involved in the prevention of CVD
and some types of cancer
(40,41)
.
Phenol content
Pistachios, pecans and walnuts are rich sources of phenolic
compounds, including anthocyanins, flavonoids, proantho-
cyanidins, flavonols, isoflavones, flavanones, stilbenes,
phenolic acids and hydrolysable tannins, which are important
as antioxidants and also for their chemopreventive, cardio-
protective and vasoprotective properties
(42,43)
. Phenolic
compounds may have protective effects against diseases
related to free radical overproduction, such as CVD and
cancer. A randomised, double-blinded, cross-over study with
placebo v. a supplement of 640 mg anthocyanins daily during
4 weeks in pre-hypertensive men showed a significant increase
in HDL-cholesterol (HDL-C) levels and also blood glucose levels
after anthocyanin v. placebo treatment
(44)
. Furthermore, the
hydrophilic extract from pistachios, which has high antioxidant
activity, increases the resistance of human LDL-cholesterol
(LDL-C) from healthy subjects to Cu-induced oxidation after
2 h of incubation
(45)
.
According to Tomaino et al.
(46)
, all phenolic groups found
in pistachios, and in other nuts, are present in higher
amounts in the skins than in the seeds. Pistacia vera L.
(variety Bronte) skins contain cyanidin-3-O-galactoside
(5865 mg/g), gallic acid (1453 mg/g), catechin (377 mg/g) and
eriodictyol-7-O-rutinoside (366 mg/g). Pistachio kernels contain
quercetin-3-O-rutinoside (98·1 mg/g), genistein (69·1 mg/g),
genistein-7-O-glucoside (47·0 mg/g) and daidzein (42·4 mg/g).
Therefore, the final content of total flavonoids in the skins is
70·27 (SD 5·42)mg of catechin equivalents/g of fresh weight,
whereas in the seeds, it is only 0·46 (SD 0·03) mg of catechin
equivalents/g of fresh weight
(46)
. Pistachios are the only nut
containing anthocyanins, phenolic compounds, in the skin.
These phenolic compounds are known to bind metals through
binding with o-diphenol groups, which is important in the
inhibition of metal-induced lipid oxidation
(47)
. Nonetheless, in
a simulated human digestion model, more than 90% of the
pistachio polyphenols were released to the gastric compartment
without differences between raw or roasted pistachios
(12,48)
.
Carotenoids
Lutein and zeaxanthin are two xanthophyll carotenoids
responsible for giving colour to pistachio nuts. Raw pistachios
contain 1405 mg lutein þzeaxanthin/100 g, about thirteen
times more than the next highest nut type, hazelnuts,
which contain only 92 mg (Table 3). The bioavailability of
carotenoids depends on the source and interaction with
other dietary components. Van Het Hof et al.
(49)
demonstrated
that the interaction of b-carotene and lycopene with the lipid
matrix increases the bioavailability of carotenoids. Notably,
almost 100 % of the bioaccessibility of lutein was found after
in vitro duodenal digestion
(12)
. Carotenoids have antioxidant
properties and have been associated with a reduced risk of
CVD and some types of cancer
(49)
. Moreover, lutein and
zeaxanthin are concentrated in the retina where they thought
to function as antioxidants and/or as a blue light filter, to
protect the underlying tissues from phototoxic damage
(50)
.
This has been proposed as an important factor in the
pathophysiology of age-related macular degeneration
(51)
.
Total phytosterols
Among nuts, pistachios have the highest phytosterol content,
with 214 mg/100 g, including stigmasterol, campesterol and
b-sitosterol. Phytosterols, structurally similar to cholesterol,
have the same basic cyclopentanoperhydrophenanthrene
ring structure but differ in the side chain at C24 and/or the
position and configuration of unsaturated double bonds and
the optical rotation at chiral carbons. Several studies have
demonstrated a dose–response reduction of cholesterol
mediated by phytosterols, even at lower levels similar to
those found in plant-based diets with pistachios
(52)
. Although
500 mg of phytosterols per serving are needed to support the
Food and Drug Administration (FDA) health claim, the levels
of phytosterols in pistachio nuts may be sufficient to play a
synergistic role with unsaturated fatty acids and the low SFA
levels in helping to maintain normal cholesterol levels.
Effects of processing and storage on the final level of
bioactive compounds
Roasting and steam roasting
Roasting and steam roasting are a common method of
processing pistachios to increase the overall safety and palat-
ability and enhance the flavour, colour, texture and appearance
of the nuts
(48)
. However, this process may alter the bioactive
compounds in pistachios
(46)
. In this sense, it was demonstrated
that the antioxidant capacity and total phenol content were
reduced by 60 % in the same lot of Bronte’s pistachio nuts,
before and after exposure at 1608C for 40 min. Proanthocyanidin
content was reduced by about 90 % and loss of vitamin C was
observed, whereas isoflavones were not modified
(45)
. Other
antioxidants could be modified during the roasting processes
as has been demonstrated in vegetables, in which, during a
thermal process, the trans double bonds predominately present
in carotenoids become susceptible to isomerisation, creating
acis configuration
(53)
and lowering the total antioxidant
content
(54)
. Lutein, however, seems to be more stable with res-
pect to degradation compared with other types of carotenoids.
Pistachios, as well as other types of nuts, contain several
protein allergens that may trigger type I hypersensitivity reac-
tions
(55)
. Noorbakhsh et al.
(56)
showed that the IgE-binding
activity of pistachio nuts could be reduced by a steam-roasting
process without any significant changes in the sensory quality
of pistachios, due to the heat-induced denaturation of some
proteins and/or reaction of these proteins to the food matrix.
Storage
Oxidation is one of the most serious problems in the storage
of nuts. Oxidation causes the formation of hydroperoxides,
Pistachio nuts and health S83
British Journal of Nutrition

which are colourless, tasteless and odourless. In addition,
hydroperoxides increase water and soluble antioxidants
by a degradation reaction of polymerised polyphenols to
monomers. Fatty acid oxidation can be controlled by the
application of antioxidants, using processing techniques
that minimise the losses of tocopherols and other natural
antioxidants; inactivate pro-oxidant metals and enzymes;
reduce the exposure of nuts to oxygen, heat and light; pro-
mote hydrogenation of PUFA; and use an inert gas or
vacuum packaging to expel atmospheric oxygen before
long-term storage
(57,58)
.
Storage of nuts requires particular temperature, humidity/
moisture and ventilation conditions. Bellomo et al.
(59)
tested
the stability of lutein and oil in pistachio (P. vera L., variety
Bronte) kernels stored up to 14 months at three temperatures:
10, 25 and 378C. The samples were hermetically packaged using
two films (nylon and ethylene vinyl alcohol) with and without
oxygen scavengers. For each temperature, reference samples
were packaged in open bags. After 14 months, the oil showed
only a slight increase in acidity and peroxide value irrespective
of storage temperature. As for lutein stability, the lowest concen-
trations were observed at 378C with a degradation of about
57·5 %. At 10 and 258C, the samples showed slight differences
in lutein concentrations with a 37 % of degradation. Therefore,
controlled storage is important for preserving pistachio quality.
Oil stability is influenced only by the length of storage; lutein
stability is also influenced by storage temperature and kinetic
degradation. During storage, lutein showed good stability both
at 10 and 258C. In particular, a low storage temperature, such
as 108C, was the most important parameter because it guarantees
good pistachio quality both for pigment and oil (acidity) stability
and the absence of mould and bugs.
In vitro
and animal studies
Recent in vitro studies and studies conducted on animals have
suggested that the healthy properties of pistachios can be attrib-
uted partially to the content of the nut’s dietary antioxidants.
Gentile et al.
(60)
evaluated the effects of a hydrophilic extract
of P. vera L. on the production of reactive oxygen species in
RAW 264.7 macrophage cells. A dose-dependent decrease in
the production of Lipopolysaccharide (LPS)-induced reactive
oxygen species was observed when the cells were incubated
with different concentrations of hydrophilic extract, indicating
proanthocyanidins as the bioactive components responsible
for this effect. Similarly, the incubation of RAW 264.7 murine
macrophages with a pistachio oil extract for 24 h decreased
some LPS-induced inflammatory markers such as Ifit-2, TNF-a
and IL-6
(61)
. This pistachio oil extract also reduced the
expression of Ifirt-2, TNF-a, IL-6 and IL-1bby 78, 55, 58 and
35 %, respectively, in response to LPS stimulation of the same
cells. In two studies on rats, increased antioxidant enzymatic
activity was found in animals fed pistachios for 8 weeks
(62,63)
.
In the first study, rats were divided into three groups of
twelve animals and assigned to a control group fed a standard
diet and two pistachio groups fed with a standard diet containing
20 or 40 % of the energy in the form of pistachios. A significant
increase in the activities of Paraoxonase 1 (PON1) and
arylesterase, both markers of antioxidant capacity, was shown
in both groups supplemented with pistachios compared with
the control group after 10 weeks of intervention
(62)
. In the
second study, rats were assigned to a control diet (standard com-
mercial chow); a control diet supplemented with 1·26 % of the
total energy intake in the form of pistachios; a control diet
with 1·63 % of cholesterol, 0·41 % of cholic acid and 16·3 % of
sunflower oil (hyperlipidaemic diet); or a hyperlipidaemic diet
supplemented with 1·26 % of the total energy intake in the
form of pistachios. After 8 weeks, rats fed with the hyperlipidae-
mic diet supplemented with pistachios had higher total
antioxidant activity, determined by thiobarbituric acid-reactive
substances, than rats fed with the hyperlipidaemic diet
alone
(63)
. In another study, feeding 19-month-old rats with
a 6 or 9 % walnut diet, which was approximately equivalent to
a human eating 28 or 42 g, significantly inhibited the activation
or phosphorylation of P38-Mitogen-activated protein kinase
(MAPK) and the transcription factor NF-kB in brain tissues.
Because both molecules are involved in the inflammatory
response, these results suggest the potential attenuation of
several inflammatory genes mediated by walnuts
(64)
.
Clinical trials in human subjects
Satiety and body-weight control
Despite the fact that nuts, including pistachios, contain a
significant amount of fat and are energy-dense foods, several
epidemiological studies have provided strong evidence that
nut consumption is associated with neither weight gain nor an
increased risk of obesity
(65 – 67)
. In addition, different clinical
trials evaluating the effect of nuts on body weight have been
conducted, but only a few have been designed to evaluate
body weight as the main outcome. One of them, a 6-month
cross-over study, assessed the impact of supplementing the
habitual diet with 28–56 g of walnuts per d. In this study,
walnut supplementation resulted in a much lower than
expected weight gain
(68)
. Similar results were shown in a para-
llel, randomised, controlled trial conducted on 123 overweight
and obese subjects assigned to an almond-enriched/low-
energy diet (containing 56 g almonds to consume daily) or a
free-nut/low-energy diet. After 6 months of follow-up, subjects
in the almond-enriched diet lost slightly but significantly less
weight than those in the free-nut diet, but no significant differ-
ences in body composition were observed after 18 months
of follow-up
(69)
. Most of the clinical trials that have assessed
the influence of nuts on classical or emergent cardiovascular
risk factors have also gathered and evaluated body-weight
changes
(70,71)
. However, review of the available data suggests
that adding nuts to habitual diets of free-living individuals
does not lead to any appreciable weight gain
(72 – 78)
.
In three randomised, controlled clinical trials, the effect of
pistachio consumption on body weight was evaluated
(31,73,76)
.
In a 12-week weight-loss programme with hypoenergetic diets
providing 2092 kJ less than energy recommendations, seventy
overweight or obese individuals were randomly allocated
to a pistachio-diet group (eating 53 g/d of pistachios) or to a
pretzel-enriched diet group (eating 56 g/d of salted pretzels).
M. Bullo
´et al.S84
British Journal of Nutrition

The pistachios or pretzels were consumed as an afternoon
snack. During the intervention, a significant reduction in
BMI in the pistachio-supplemented group was observed
(24·3 % of the BMI). This reduction was higher than that
observed in the pretzel-supplemented group (22 % of the
BMI)
(73)
. Similarly, Wang et al.
(76)
evaluated the impact of a
12-week normoenergetic diet intervention supplemented or
not with two different doses of pistachio nuts (70 or 42 g/d)
on total body-weight maintenance in ninety subjects with the
metabolic syndrome. The results indicated that the consumption
of any dosage of pistachios resulted in no changes in BMI or
waist:hip ratio compared with the group of individuals follow-
ing the American Heart Association Step I recommendations.
More recently, a 24-week, randomised controlled trial, including
sixty metabolic syndrome subjects randomised to either the
pistachio (20 % of total energy in the form of pistachio nuts
daily) or control group for 6 months, failed to find significant
differences in body weight. However, Gulati et al.
(31)
observed
a significant decrease in waist circumference and a trend
towards a reduction in subcutaneous adipose tissue in the
pistachio group compared with the control group.
Furthermore, five randomised feeding trials evaluated the
effect of pistachio consumption on body weight and/or BMI
as a secondary outcome. In all five studies, participants
consumed at least 15 % of the total energy intake in the
form of pistachio nuts. No significant effect on body weight
and/or BMI was observed compared with participants
assigned to the control diet group
(79 – 83)
(Table 4).
Several biological mechanisms may explain the unexpected
null effect of nut consumption on adiposity. Nuts are rich in
unsaturated fatty acids, and evidence suggests that MUFA
and PUFA are more readily oxidised
(84)
and have a greater
thermogenic effect
(85)
than SFA, which can lead to less fat
accumulation. Several lines of evidence also demonstrate
that nuts have high satiety properties. Nuts are energy dense
and a good source of fibre, protein and unsaturated fats,
dietary factors that increase satiety ratings. Nuts exert a
strong suppression of hunger and therefore subsequent food
intake is curtailed
(86 – 88)
. In fact, two recent published studies
have evaluated the satiating properties of pistachio nuts. The
impact of consuming in-shell pistachios or pistachio kernels
on fullness and energy intake was evaluated in a randomised,
cross-over, controlled feeding trial including 140 university
students aged 18– 24 years. Consumption of in-shell pistachios
resulted in a lower energy intake than consumption of
kernels
(89)
. The same authors, in a second cross-over feeding
trial with 118 healthy individuals (mean age 47 (SD 10) years),
demonstrated that the visual cue of the empty pistachio shells
may have helped the participants to consume fewer
pistachios and about 18 % less energy
(90)
(Table 5).
The physical structure of nuts may also contribute to their
satiety effect; they are crunchy and must be mechanically
reduced to particles small enough for swallowing. Mastication
activates mechanical, nutrient and sensory signalling systems
that may modify appetitive sensations
(91)
.
Furthermore, a small degree of fat malabsorption has been
reported after nut intake, which is attributed to the fat being
contained within walled cellular structures that are incompletely
digested in the gut, an effect that can be compounded by
incomplete mastication
(92)
. In fact, a cross-over trial conducted
on sixteen healthy volunteers consuming pistachios (42 and
84 g/d) or a free-nut diet for 3 weeks, as part of a controlled
diet, demonstrated that the metabolisable energy of pistachios,
calculated from differences in faecal energy excretion during
the different dietary treatments, is 5 % less than the energy
calculated by the Atwater general factors, suggesting that the
energy from pistachios is not totally utilisable
(93)
.
Classical markers of CVD
In a pooled analysis of twenty-five intervention trials,
participants who consumed an average of 67 g/d of nuts saw
a 5 % decrease in total cholesterol, a nearly 7·5 % decrease in
LDL-C levels and an 8 % decrease in the LDL-C:HDL-C ratio.
The effects of nut consumption were dose-related, and
different types of nuts had similar effects on blood lipid
levels
(94)
. The effect of pistachio consumption on cardiovascular
risk markers has been evaluated in five randomised clinical trials
as a primary outcome
(79 – 83)
and in other studies as a secondary
outcome
(73,76,95)
, giving from 10 to 20 % of energy or from 42 to
100 g/d as pistachios v. diets avoiding the consumption of nuts
(Table 4). From them, in a total of five studies, the authors
found significant reductions in plasma total cholesterol con-
centrations in the pistachio-supplemented group
(79,80,82,83,95)
,
and in six of them, they found a significant reduction in the
total cholesterol:HDL-C ratio and LDL-C:HDL-C ratio
(79 – 83,95)
.
Moreover, LDL-C concentrations were decreased in the
pistachio-supplemented group in three studies
(82,83,95)
, whereas
two studies reported no significant reductions in this recog-
nised major cardiovascular risk factor
(79,80)
, although the
levels decreased but not significantly in Kocyigit et al.
(80)
.
Only Wang et al.
(76)
, in a study of Chinese subjects with the
metabolic syndrome, found an increase in plasma LDL-C
levels after a 12-week period of dietary intervention with a
normoenergetic diet including different amounts of pistachios
compared with the normoenergetic diet alone. According to
Wang et al.
(76)
, the nutrient content of the diet was under-
powered to show changes in the secondary analyses of risk
factors such as blood lipids. Notably, dietary intake was not
controlled or reported, so it is difficult to ascertain the reason
why LDL-C levels increased in the high-pistachio group. With
respect to plasma HDL-C, only Sheridan et al.
(81)
found
a significant increase in this parameter in those subjects
supplemented with pistachios.
A beneficial effect of pistachios on BP has also been
demonstrated recently in a randomised, cross-over, clinical
trial conducted on twenty-eight dyslipidaemic individuals.
Participants were randomised to three 4-week interventions:
a low-fat control diet; a diet containing 10 % of the total
energy content in the form of pistachios; a diet containing
20 % of the total energy as pistachios. A dose-dependent
reduction in systolic BP was observed in those subjects
supplemented with pistachios, and a decrease in peripheral
vascular dilation was observed in those supplemented with
higher doses of pistachios
(96)
. The BP-lowering effects of
pistachios have also been evaluated in three additional
Pistachio nuts and health S85
British Journal of Nutrition

Table 4. Summary of cross-over, parallel and sequential intervention studies and their characteristics
References
Subjects
(n) (M/F)
Type of
subjects (age)
Study design
(length of
the intervention) Control group Intervention group(s) Primary outcome Secondary outcomes
Edwards
et al.
(79)
10 (4/6) Moderate
hypercholesterolaemic
(28– 64 years)
Cross-over
(3 weeks
each period)
RD 20 % of energy
in the form of
pistachios (PD)
Significant decreases in TC,
TC:HDL-C ratio and LDL-C:HDL-C
ratio in the PD group compared
with the RD group. Non-significant
changes in LDL-C, TAG and
HDL-C in the PD group compared
with the RD group
Non-significant changes
in body weight and blood
pressure between the
interventions
Sheridan
et al.
(81)
15 Moderate
hypercholesterolaemic
subjects (36– 75 years)
Cross-over
(4 weeks
each period)
RD 15 % of energy in the
form of pistachios (PD)
Significant decreases in TC:HDL-C
ratio and LDL-C:HDL-C ratio, and
increases in HDL-C in the PD
group compared with the RD
group. Non-significant changes
in TC, TAG, LDL-C and VLDL-C
Non-significant changes
in BMI and blood
pressure between
the interventions
Gebauer
et al.
(82)
28 (10/18) Subjects with elevated
LDL-C ($2·8 mmol/l)
(35– 61 years)
Cross-over
(4 weeks
each period)
CD PD1: 10 % of energy
in the form of pistachios
Both PD interventions significantly
decreased TC, LDL-C and
non-HDL-C compared with the
CD intervention
Non-significant changes
in body weight between
the interventionsPD2: 20 % of energy
in the form of pistachios
Kay
et al.
(97)
28 (10/18) Subjects with
elevated LDL-C
($2·8 mmol/l)
(35– 61 years)
Cross-over
(4 weeks
each period)
CD PD1: 10 % of energy
in the form of pistachios
Both PD interventions significantly
decreased oxidised LDL and
increased serum antioxidants
(g-tocopherol, lutein and
b-carotene)
PD2: 20 % of energy
in the form of pistachios
Baer
et al.
(93)
16 (8/8) Healthy subjects
(29– 64 years)
Cross-over
(3 weeks
each period)
CD Traditional
American diet
PD1: CD þ42 g/d of pistachios Pistachios contain significantly
5 % less energy than the
value calculated from the
Atwater factors
PD2: CD þ84 g/d of pistachios
West
et al.
(96)
28 (10/18) Subjects with
elevated LDL-C
($2·8 mmol/l)
(35– 61 years)
Cross-over
(4 weeks
each period)
CD PD1: CD þ10 % of energy
in the form of pistachios
Significant reduction in SBP
in the PD1 v. PD2 intervention.
Significant decrease in peripheral
vascular dilatation and heart
rate in the PD2 v. CD intervention
PD2: CD þ20 % of energy
in the form of pistachios
Kocyigit
et al.
(80)
44 (24/20) Healthy subjects
(24– 40 years)
Parallel
(3 weeks
of follow-up)
RD 20 % of energy in the
form of pistachios (PD)
Significant decreases in TC,
TC:HDL-C ratio and LDL-C:HDL-C
ratio in the PD intervention
compared with the RD
intervention. Non-significant
changes in LDL-C, TAG and HDL-C
in the PD intervention compared
with the RD intervention
Non-significant changes
in body weight between
the interventions.
Significant improvement
in oxidative status
(increases in AOP
and AOP:MDA ratio,
and decreases in MDA)
in the PD intervention
compared with the
RD intervention
Li et al.
(73)
52 (M/F) Healthy obese
subjects
(20– 65 years)
Parallel (12 weeks) 2092kJ energy-
restricted diet
with 56 g of
pretzels included
(CD)
2092 kJ energy-restricted
diet with 53g/d of
pistachios included (PD)
Significant reduction in body
weight and BMI in the PD
intervention compared
with the CD intervention
Decrease in TAG in the
pistachio group.
Non-significant
changes in glucose
or insulin levels
Wang
et al.
(76)
90 (41/49) Subjects with the
metabolic syndrome
(25– 65 years)
Parallel (12 weeks) CD PD1: CD þ42 g/d of pistachios Non-significant changes
in body weight, BMI
or waist:hip ratio
Non-significant
changes in blood
pressure, fasting
glucose and blood
lipid levels in the PD1
or PD2 intervention
compared the with
CD intervention
PD2: CD þ70 g/d
of pistachios
M. Bullo
´et al.S86
British Journal of Nutrition

Table 4. Continued
References
Subjects
(n) (M/F)
Type of
subjects (age)
Study design
(length of
the intervention) Control group Intervention group(s) Primary outcome Secondary outcomes
Gulati
et al.
(31)
60 (30/30) Subjects with the
metabolic syndrome
(42·5 (SD 8·2) years)
Parallel (24 weeks) CD PD: 20 % of energy
in the form of pistachios
Non-significant differences
in body weight (P¼0·7).
Significant decrease
in waist circumference (P¼0·02)
and trend towards reduction in
subcutaneous adipose tissue
(P¼0·07) in the PD v.
CD intervention
Significant decrease in
glucose levels and
non-significant insulin
(P¼0·54) reduction
in the PD v.CD
intervention. Significant
reduction in TC and
LDL-C levels, non-
significant reduction
in TAG levels, and
non-significant
increase in HDL-C
levels in the PD v.
CD intervention
Sari
et al.
(83)
32 (M) Healthy subjects
(21– 24 years)
Sequential
feeding trial
(4 weeks on the
Mediterranean
diet followed
by 4 weeks
on the PD)
No CD Mediterranean-type
diet with 20% of energy
in the form of pistachios (PD)
Significant decrease in TC, TAG,
LDL-C, TC:HDL-C ratio,
LDL-C:HDL-C ratio and
non-significant increase in
HDL-C in the PD intervention
compared with the MD intervention
Non-significant changes
in body weight and
blood pressure
between the groups.
Decrease in IL-6
concentrations and
improvement of
antioxidant capacity
in the PD v.MD
intervention.
Significant decrease
in fasting glucose
levels in the PD v.
MD intervention
Aldemir
et al.
(95)
17 (M) Individuals
with erectile
dysfunction
(38– 59 years)
Sequential
feeding trial
(3 weeks of
intervention diet)
No CD Pistachio diet: 100 g Improvements of erectile
function measured by
the IIEF-15 score after
the pistachio intervention
Significant decrease
in TC, LDL-C,
TC:HDL-C ratio and
LDL-C:HDL-C ratio
throughout the
intervention, and
significant increase
in HDL-C
M, male; F, female; RD, regular diet; PD, pistachio diet; TC, total cholesterol; HDL-C, HDL-cholesterol; LDL-C, LDL-cholesterol; VLDL-C, VLDL-cholesterol; CD, control diet; SBP, systolic blood pressure; AOP, antioxidant potential;
MDA, malondialdehyde; IIEF, International Index of Erectile Function.
Pistachio nuts and health S87
British Journal of Nutrition

Table 5. Summary of acute intervention studies and their characteristics
References
Subjects
(n) (M/F)
Type of
subjects (age)
Study design
(length of the
intervention) Control group Intervention group(s) Primary outcome
Secondary
outcomes
Kendall
et al.
(105)
10 (3/7) Overweight
healthy
subjects
(48·3 (SD 6·4) years)
Acute
postprandial
trial
Study 1: WB1 Study 1: pistachio (28, 56
and 84 g) (PD1a)
WB1 þpistachio
(28, 56 and 84 g) (PD1b)
Pistachios had a significant
dose-dependent glycaemic
response: 56 and 86 g of
pistachios þWB
significantly resulted
in the reduction
of glycaemic responses
compared with the WB1
intervention
Study 2: WB2
and SM2
Study 2: meal þ56 g
pistachios (PD2)
PD2 resulted in significantly
reduced glycaemic responses
compared with the WB2 and
SM2 interventions
Honselman
et al.
(89)
140 (25/93 and
23 subjects with
no specified sex)
Healthy subjects
(18–24 years)
Acute feeding trial No control diet (1) In-shell pistachios Select in-shell pistachios
significantly reduced
energy consumption
No differences
in fullness or
satisfaction
(2) Unshelled pistachios
Kennedy-Hagan
et al.
(90)
118 (16/102) Healthy subjects
(47 ^10·8 years)
Acute feeding trial No control diet (1) Pistachio shells piled up
in bowls next to
the participants
Energy consumption
significantly decreased
when the shells
remained as the visual cue(2) Pistachio shells removed
Kendall et al.
(30)
20 (8/12) Subjects with the
metabolic
syndrome
(40–65 years)
Acute postprandial
trial (cross-over)
Study 1: 50 g of
available
CHO – WB1,
butter
and cheese
Study 1: WB þ85·046 g
pistachios (PD1)
Both PD1 and PD2
interventions significantly
reduced postprandial
glycaemia compared
with the WB1 and WB2
interventions, respectively
Study 2: 12 g of
available
CHO – WB2
Study 2: pistachios (PD2) PD1 and PD2 interventions
increased GLP-1
compared with the WB1
and WB2 interventions,
respectively
WB, white bread; SM, specific meal; PD, pistachio diet; CHO, carbohydrate; GLP-1, glucagon-like peptide 1.
M. Bullo
´et al.S88
British Journal of Nutrition

controlled feeding trials as a secondary outcome showing
non-significant differences in the changes in systolic or
diastolic BP between those subjects supplemented with pista-
chios and those who did not receive supplementation
(76,81,83)
.
In conclusion, some evidence suggests that pistachios may
improve the blood lipid profile and reduce BP, which could
contribute to decreased cardiovascular risk.
Emerging risk factors of CVD
Pistachios are a rich matrix of fat-soluble antioxidants that
could have important effects on the control of oxidative
stress and a reduced risk of chronic diseases. In a study
conducted on forty-four healthy men and women, half of
the subjects were randomised to a regular diet group and
the other half to a pistachio group (accounting for 20 %
of their daily energy intake in the form of pistachios) for
3 weeks. The study showed an increased blood antioxidant
potential determined by the production of thiobarbituric
acid-reactive substances and decreased malondialdehyde
levels, which is an important indicator of lipid peroxidation,
in those volunteers consuming pistachios compared with
those following a free-nut diet
(80)
. A cross-over, randomised,
controlled feeding trial conducted by Kay et al.
(97)
on
twenty-eight hypercholesterolaemic adults showed that the
consumption of diets containing 10 and 20 % of energy from
pistachios (32 – 63 and 63 – 126 g/d, respectively) increased
antioxidant concentrations in serum, such as g-tocopherol,
lutein and b-carotene, whereas it decreased oxidised LDL
concentrations relative to the consumption of a control diet
without pistachios. Finally, in a prospective study, Sari et al.
(83)
assessed the effect of a traditional Mediterranean diet sup-
plemented with pistachios by replacing the monounsaturated
fat content constituting approximately 20 % of daily energy
intake on thirty-two healthy young men for 4 weeks. They
found a significant improvement in endothelium-dependent
vasodilation, whereas endothelium-independent vasodilation
remained unchanged compared with the Mediterranean diet.
An increase in total antioxidant status and superoxide dismutase
and a decrease in inflammation and other oxidative markers
were also observed. Taken together, these results provide
evidence of the beneficial effects of pistachios on the risk
of CVD beyond the lipid-lowering effect.
Insulin resistance and type 2 diabetes
Diabetes mellitus is one of the most common diseases
worldwide, largely the result of an increase in the prevalence
of obesity and physical inactivity. Moreover, T2DM is a
recognised risk factor for CVD and other chronic conditions
and diseases, and is thus becoming a serious public health
burden
(98,99)
. Data from epidemiological and interventional
studies suggest that the frequency of nut consumption is inver-
sely related to an increased risk of T2DM, mainly attributed
to the fibre, healthy fats, antioxidants and anti-inflammatory
compounds
(72,100 – 104)
in nuts. In addition, among all nuts,
pistachios have a low glycaemic index, suggesting a possible
effect on reducing postprandial glycaemia and insulinaemia,
thereby potentially decreasing the risk of diabetes. The
effect of pistachios, consumed alone or combined with
meals, on postprandial glycaemia has been evaluated
(30,105)
(Table 5). Thus, whereas pistachios consumed alone had a
minimal effect on postprandial glycaemia, the addition of
pistachios (56 g) to foods with a high glycaemic index
(pasta, parboiled rice and instant mashed potatoes) reduced,
in a dose-dependent manner, the total postprandial glycaemic
response by 20 –30 %
(105)
. In a recent randomised, cross-over
study conducted on twenty subjects with the metabolic syn-
drome, 85·04 g of pistachios consumed with bread reduced
postprandial glycaemia levels and increased glucagon-like
peptide levels compared with bread alone
(30)
.
In three clinical studies, the effect of pistachio supple-
mentation on glucose concentrations as a secondary outcome
was evaluated, with contradictory results. In a controlled,
cross-over, clinical trial, participants were randomised to a
Mediterranean diet or a Mediterranean diet supplemented
with 20 % of energy intake as pistachios for 4 weeks in each
arm. Subjects in the intervention period showed a significant
decrease in fasting plasma glucose concentrations in compari-
son to the control period
(83)
. The second study evaluated the
effect of the American Heart Association Step I diet sup-
plemented with 42 or 70 g/d of pistachios compared with the
effect of a control diet (American Heart Association Step I), in
Chinese subjects with the metabolic syndrome using a random-
ised, parallel-group, controlled study design. After 12 weeks of
intervention, no differences in fasting plasma glucose or insulin
levels were observed between the groups, although compared
with baseline values, blood glucose levels increased signi-
ficantly in the control group at week 12 but not in the two
pistachio groups
(76)
. Finally, in a third parallel study conducted
on sixty subjects with the metabolic syndrome randomised to
either an unsalted pistachios diet (20 % energy) or a control
diet for 24 weeks, a significant decrease in glucose levels but
not in blood insulin levels was observed
(31)
.
In addition to the fibre, healthy fats and low available
carbohydrate content, the effect of pistachios on glucose
metabolism may be a result of the rich content of carotenoids.
A 9-year longitudinal study conducted on 1389 healthy elderly
volunteers demonstrated a 58 % lower risk for the development
of impaired fasting glucose levels or T2DM mellitus in subjects
in the highest quartile of total plasma carotenoids than in
those in the lowest quartile, even after adjusting for possible
confounding variables
(106)
. In a randomised controlled study,
the intake of 75 g/d of mixed nuts (including pistachios) in
117 T2DM subjects during 3 months as a replacement for
carbohydrate-containing foods in comparison to the intake
of healthy whole-wheat muffins, or half portions of both,
demonstrated for the first time a significant decrease in HbA
1c
levels, even though the subjects were on oral antidiabetic
medication. Additionally, and despite the subjects consuming
statins, an improvement in total cholesterol was observed
(3)
.
Despite the positive results observed for glucose metabolism
in fasting conditions or postprandial status, more studies are
necessary to evaluate the long-term effects of pistachio con-
sumption on insulin resistance, secretion or diabetes control.
Pistachio nuts and health S89
British Journal of Nutrition

Summary and conclusions
Pistachios are nutrient-dense nuts with a healthy nutritional
profile including fibre, healthy fats, phytosterols and anti-
oxidant compounds, contributing to a reduced risk of heart
disease. Growing evidence suggests that consumption of
nuts, including pistachios, improves diet quality and provides
several bioactive compounds with recognised properties for
weight management, glycaemic control and vascular health.
Acknowledgements
The authors thank Carles Munne
´(Rovira i Virgili University,
Reus, Spain) for his help as editor assistance.
Institut d’Investigacio
´Sanita
`ria Pere Virgili (IISPV) received
research funding from American Pistachios Growers (USA)
and Paramount Farms International.
All the authors contributed equally to this work.
M. B., M. J.-F. and P. H.-A. have no conflict of interest. J. S.-S.
is a non-paid member of the Scientific Advisory Council of the
International Nut Council.
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