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The Journal of Nutrition
Obesity and Eating Disorders
Avocado Consumption, Abdominal Adiposity,
and Oral Glucose Tolerance Among Persons
with Overweight and Obesity
Naiman A Khan,1,2Caitlyn G Edwards,2Sharon V Thompson,2Bridget A Hannon,2Sarah K Burke,3
Anne DM Walk,4Richard WA Mackenzie,5Ginger E Reeser,1Barbara H Fiese,6,7Nicholas A Burd,1,2
and Hannah D Holscher1,2,8
1Department of Kinesiology and Community Health, University of Illinois, Urbana, IL, USA; 2Division of Nutritional Sciences, University
of Illinois, Urbana, IL, USA; 3Department of Physical Therapy, University of Florida, Gaineville, FL, USA; 4Department of Psychology,
Eastern Illinois University, Charleston, IL, USA; 5Department of Life Science, Whitelands College, University of Roehampton, London, UK;
6Department of Human Development and Family Studies, University of Illinois, Urbana, IL, USA; 7Family Resiliency Center, University of
Illinois, Urbana, IL, USA; and 8Department of Food Science and Human Nutrition, University of Illinois, Urbana, IL, USA
ABSTRACT
Background: Although intake of Hass avocado has been cross-sectionally linked to lower abdominal obesity,
knowledge of the effects of avocado consumption on abdominal adiposity and glycemic outcomes remains limited.
Objective: The effects of avocado consumption on abdominal adiposity, insulin resistance, oral-glucose-tolerance test
(OGTT), and estimated β-cell function were evaluated.
Methods: A total of 105 adults aged 25–45 y (61% female) with BMI ≥25 kg/m2were randomly assigned to an
intervention (N =53) that received a daily meal with 1 fresh Hass avocado or a control (N =52) that received an isocaloric
meal with similar ingredients without avocado for 12 wk. DXA was used to assess the primary outcomes of abdominal
adiposity [visceral adipose tissue (VAT), subcutaneous abdominal adipose tissue (SAAT), and the ratio of VAT to SAAT
(VS Ratio)]. Fasted glucose and insulin were used to assess the primary outcomes of insulin resistance (HOMA-IR),
and insulin sensitivity (Matsuda index) and β-cell function (Insulinogenic index) were estimated using an OGTT. Changes
between groups were compared using an ANCOVA. Secondary analyses were conducted based on sex.
Results: The control group exhibited a greater reduction in SAAT [–54.5 ±155.8 g (control) compared with 17.4 ±155.1
g (treatment), P=0.017] and increase in VS Ratio [0.007 ±0.047 (control) compared with –0.011 ±0.044 (treatment),
P=0.024]. Among females, the treatment group exhibited a greater reduction in VAT [1.6 ±89.8 g (control) compared
with –32.9 ±81.6 g (treatment), P=0.021] and VS Ratio [0.01 ±0.05 (control) compared with –0.01 ±0.03 (treatment),
P=0.001]. Among males, there was no signicant difference between groups in changes in abdominal adiposity or
glycemic outcomes.
Conclusions: Daily consumption of 1 fresh Hass avocado changed abdominal adiposity distribution among females
but did not facilitate improvements in peripheral insulin sensitivity or β-cell function among adults with overweight and
obesity. This study was registered at clinicaltrials.gov as NCT02740439. J Nutr 2021;151:2513–2521.
Keywords: ber, monounsaturated fatty acids, abdominal adiposity, insulin, obesity
Introduction
The epidemic of elevated overweight and obesity presents a
major public health challenge in the USA, currently affecting
∼70% of the adult population (1). Further, increased abdominal
obesity, a hallmark of fat or adiposity-related metabolic
dysfunction, impacts over 1 in 3 adults (2). Visceral adipose
tissue (VAT) is more closely associated with obesity-related
metabolic diseases than subcutaneous abdominal adipose tissue
(SAAT) (3–5). Increased VAT has been cross-sectionally and
prospectively implicated in impaired glucose tolerance and
insulin resistance, and onset of type 2 diabetes, relative to
other adipose depots (6,7). Dietary intervention offers a poten-
tially efcacious solution for abdominal obesity management;
however, the inuence of diet in reducing VAT is unclear.
Weight loss interventions can be effective in reducing VAT and
risk of type 2 diabetes (8,9), but unfortunately inducing and
maintaining weight loss is unsuccessful for most individuals
(10). Therefore, dietary approaches that promote reduction in
VAT and reduction in type 2 diabetes risk, without relying
on hypocaloric diets and weight loss, may hold translational
potential for individuals with overweight and obesity.
C
The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition. This is an Open Access article distributed under the terms
of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution,
and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
Manuscript received February 7, 2021. Initial review completed March 12, 2021. Revision accepted May 17, 2021.
First published online June 30, 2021; doi: https://doi.org/10.1093/jn/nxab187. 2513
Regular consumption of nutrient-dense whole foods can
serve as a nonpharmacological approach to modifying adipose
tissue distribution and alleviating the metabolic effects of
adiposity. The avocado (Persea americana) is a fruit that is
rich in dietary ber and MUFAs, 2 nutrients that are benecial
for metabolic health (11). One fresh Hass avocado (∼136 g)
contains ∼13 g MUFAs, 10 g ber, and carotenoids and
other bioactive components (12). Diets rich in MUFAs and
ber have received considerable attention for their potential to
reduce obesity and lower the risk of type 2 diabetes (13–15).
Avocado consumers have lower abdominal obesity compared
with nonconsumers (11,16). Further, in a longitudinal study
among over 55,000 individuals, habitual consumption of
avocados was associated with lower weight gain and reduced
risk of having overweight or obesity when assessed 11 y later
(17). In a recent 12-wk randomized controlled weight loss
study, it was demonstrated that avocados can be consumed
as part of a hypocaloric diet weight loss program as well
(18). Therefore, avocado consumption is not only a marker of
a higher quality diet but can also improve metabolic health
and weight status. However, the effects of daily avocado
consumption on adipose tissue distribution and related insulin
resistance, insulin sensitivity, and pancreatic β-cell function
are unclear. The present work involved an investigator-blinded
randomized controlled trial to examine the effects of consuming
a daily meal with an avocado, relative to an isocaloric meal
without the avocado, on abdominal adiposity, insulin resistance,
and oral glucose tolerance among young-to-middle-aged adults
with overweight or obesity. We hypothesized that participants
consuming a daily meal with an avocado would exhibit greater
declines in VAT, VS Ratio, insulin resistance, and improvement
in glycemic outcomes.
Methods
Participants and study design
A randomized controlled trial design [Persea americana for Total Health
(PATH) Study] was undertaken to assess the effects of daily avocado
consumption on abdominal adiposity and glycemic measures among
adults with overweight or obesity. Data collection procedures were
administered at baseline, prior to treatment allocation, and at follow-
up 12 wk later. All subjects provided written informed consent prior
to study participation. Procedures were administered in accordance
with the Declaration of Helsinki and were approved by the Ethics
Committee of the University of Illinois. The study was registered
as a clinical trial on clinicaltrials.gov (NCT02740439). Adults aged
between 25 and 45 y with a BMI ≥25 (in kg/m2) were recruited using
university e-mail listservs and yers posted in community buildings
and on buses frequented by the public. Data were collected in central
The research was funded by the Hass Avocado Board. SVT was supported by a
fellowship provided bythe College of Agricultural, Consumer, and Environmental
Sciences. BAH was supported by the Agriculture and Food Research Initiative
Competitive Grant no. 2015-68001-23248 from the USDA National Institute of
Food and Agriculture to Cooperative Extension.
Author disclosures: The authors report no conicts of interest.
HDH is a member of The Journal of Nutrition Editorial Board and played no role
in the evaluation of the manuscript.
Supplemental Tables 1 and 2 are available from the “Supplementary data” link
in the online posting of the article and from the same link in the online table of
contents at https://academic.oup.com/jn/.
Address correspondence to NAK (e-mail: nakhan2@illinois.edu).
Abbreviations used: FDR, false discovery rate; GLTEQ, Godin Leisure Time
Exercise Questionnaire; IGI, insulinogenic index; OGTT, oral-glucose-tolerance
test; PATH, Persea americana for Total Health; SAAT, subcut aneous abdominal
adipose tissue; VAT, visceral adipose tissue.
Illinois between 2016 and 2018. Participant exclusion criteria included
BMI <25, pregnancy or lactation, tobacco use, food allergies and
lactose intolerance, latex allergy, prior diagnosis of cognitive, metabolic,
and gastrointestinal disease, use of medications that alter normal
bowel function and metabolism, and prior malabsorptive or restrictive
bariatric surgery within previous 2 y. Given that previously published
research on avocado consumption effects on adipose tissue distribution
and glucose tolerance were lacking, an aprioripower calculation using
a moderate effect size (Cohen’s d =0.50), 2-sided αof 0.05, and 80%
power, estimated that a sample size of 64 participants/group would be
sufcient to address the primary study aims.
Study treatment and control meals
Randomization was completed by a member of the research team
(ADMW) who was not involved in data collection or administration
of the intervention. Participants randomly assigned to the treatment
group consumed 1 meal a day with 175 g (male) and 140 g
(female) fresh Hass avocado, whereas the control group consumed an
isocaloric meal matched for macronutrient composition without an
avocado. A complete description of the meals and ingredient list can
be found in Supplemental Table 1. Per serving (50 g), an avocado
provides 80 kcal. The majority of the calories in avocados (∼90%)
are derived from fats with the greatest proportion accounted for
by MUFAs (5 g/serving) and 1 g/serving for polyunsaturated and 1
g/serving for saturated fats. The carbohydrates are predominantly in
the form of dietary ber (4 out of 5 g/serving) whereas proteins are
only 1 g/serving. Avocados also provide ≤20 minerals and vitamins.
As outlined in Tab l e 1, owing to the macronutrient composition of
avocados, the treatment meals were higher in total ber and lower
in saturated fats and higher in MUFAs. Over 90% of the ingredients
were identical between the meals but were scaled to meet the desired
caloric and macronutrient proles. The energy content and proportion
of macronutrients of meals for females was 20% lower compared
with males due to estimated energy needs. The study meals were
provided on a 7-d menu cycle designed to be similar to a typical
American diet and meet the Acceptable Macronutrient Distribution
Ranges (AMDR) set by the Institute of Medicine (∼45% carbohydrates,
35% fat, and 15% protein). Examples of meals included modied
versions of Penne Pasta, Cranberry Salad, Spanish Rice, Asian Penne,
Turkey Wrap, Spring Bowl, and an Egg Scramble. Participants traveled
to the test site twice weekly to pick up meals. Insulated meal coolers, ice
packs, and information about food safety procedures were provided.
Compliance was assessed using daily logs that participants completed
to indicate meal consumption and, for participants in the intervention,
avocado consumption. Concealment of allocation was maintained using
sequentially numbered containers for meal dispensation. Additionally,
staff who prepared and provided participants with the meals were not
involved in the data collection procedures.
Dietary assessment
Background diet was monitored prior to and during the nal week
of the intervention. Participants were asked to record all beverages
and foods consumed for ≥7 d and were provided a food diary with
detailed instructions given by a trained member of the research staff
at the completion of their rst laboratory visit. In addition, the record
contained written instructions for recording food intake (including how
to describe food preparation methods, added fats, brand names, and
ingredients of mixed dishes and recipes) and visual aids to estimate
serving sizes. Trained staff entered food records into the Nutrition
Data Systems-Research Version 2015 [Nutrition Coordinating Center
(NCC), University of Minnesota, Minneapolis, MN, USA] software
under supervision of a registered dietitian (NAK).
Physical activity
Participants were asked to recall their average weekly physical activity
during their leisure time over the past month using the Godin
Leisure Time Exercise Questionnaire (GLTEQ) (19,20). The GLTEQ
contains 3 open-ended physical activity questions pertaining to the
average frequency of mild, moderate, and strenuous physical activities
2514 Khan et al.
TABLE 1 Nutrient comparison between meals with avocado (treatment) and without (control)
avocado provided to participants with overweight or obesity1
Control Treatment
Nutrient Males Females Males Females
Energy, kcal 662 530 660 528
Total ber, g 4.0 3.2 16.0 12.8
Soluble ber, g 1.0 0.8 6.0 4.8
Pectins, g 0.0 0.0 4.0 3.2
Insoluble ber, g 3.0 2.4 10.0 8.0
Protein, % 16 12.8 14 11.2
Total fat, % 39 40
SFAs, % 17 7
MUFAs, % 10 24
PUFAs, % 9 5
Carbohydrate, % 45 45
1Comparison of nutritional proles between daily meals consumed by participants with (intervention) and without a fresh Hass
avocado (treatment).
(with examples of each) during free time during a typical week. All
participants were asked to refrain from changes in their physical activity
levels throughout the intervention.
Anthropometrics and abdominal adiposity
assessment
Standing height and weight measurements were completed to calculate
BMI with participants wearing lightweight clothing and no shoes.
Height and weight were assessed using a stadiometer (model 240;
SECA) and a digital scale (WB-300 Plus; Tanita), respectively. Measures
were recorded in triplicate and the average value was used in the
analyses. Whole body, VAT, and SAAT components were estimated
using a Hologic Horizon W densitometer using the standard software
(APEX Software version 5.6.0.5; Hologic). These procedures have been
previously described in detail (21,22).
Oral-glucose-tolerance test.
At baseline and 12 wk, a standard oral-glucose-tolerance test (OGTT)
was administered following a 12-h overnight fast. Participants rested for
≥30 min prior to the insertion of a Teon catheter into an antecubital
vein for repeated blood sampling and remained patent by a 0.9% saline
drip. After baseline blood collection, participants ingested 75 g glucose
bolus (NOW foods) dissolved in 250 mL of water within 2 min (t=
0min)(21). Venous blood was collected at the following time points:
0, 15, 30, 45, 60, 90, and 120 min after glucose ingestion into EDTA
containing tubes (BD Biosciences). Blood glucose concentration was
determined using a biochemical analyzer (YSI 2900 Life Sciences) in
duplicate and subsequently centrifuged at 1000 ×gfor 10 min at
4◦C. Aliquots of plasma were frozen and stored at –20◦C until analyses.
Plasma insulin concentrations were determined using a commercially
available ELISA (ALPCO).
Plasma glucose and insulin concentrations were used to determine
the Matsuda index and HOMA-IR according to established formulas
(23,24). The Matsuda index was calculated by:
10,000
(( fastingglucose×f asting insulin)×(average glucoseval ues)×(averageinsul in values))
(1)
HOMA-IR was calculated by:
Fasting Gl ucose ×F asting Insul in
405 (2)
Further, the insulinogenic index (IGI) was utilized as a measure of β-
cell function and calculated as ratio of insulin concentration at 30 min
minus fasting insulin to the difference of glucose at the same time (25).
Statistical analyses
Data from participants who completed the 12-wk intervention
(control =53, treatment =52) were used to conduct per protocol
analyses (see Figure 1). We applied a cutoff of 80% compliance
for study meal consumption throughout the trial, for per protocol
analyses. Additionally, intent-to-treat analyses were conducted among
all participants who were randomly assigned and provided complete
data at baseline. Missing values at follow-up were carried forward from
baseline values for the intent-to-treat analyses.
Baseline differences in between groups were assessed by independent
samples t-test. Primary analyses, i.e., intervention effects on abdominal
adiposity (i.e., VAT, SAAT, VS Ratio), insulin resistance (i.e., HOMA-
IR), and OGTT (i.e., Matsuda index and IGI) measures were subjected
to a univariate ANCOVA whereby change (posttest–baseline) measures
were compared between groups, following adjustment of changes in
reported energy intake. Critical values were adjusted for false discovery
rate (FDR) to act as a check on ination of Type 1 error (26). In the
present analyses, the FDR was set to 0.05, the acceptable level of family-
wise error. Secondary analyses separated by sex were conducted since
there were signicant differences in adiposity variables between females
and males. Statistical signicance level was set at P<0.05 (2-tailed) and
data were analyzed using SPSS version 25 (IBM).
Results
Per protocol analyses
Participants and baseline variables.
Participant recruitment and inclusion/exclusion is illustrated
in Figure 1. One hundred and fty-six participants who were
randomly assigned provided complete data at baseline and
136 were retained in the study at follow-up. The overall
retention rate of the study was 87%. There were no discernable
differences in characteristics between participants who dropped
out of the study compared with those who remained in the study.
Specically, there were no signicant differences in age and
baseline adiposity and glycemic variables between participants
who dropped out compared with those who remained in the
study (all Ps>0.209).
Following exclusion of participants who either did not pro-
vide follow-up data for adiposity variables or those who did not
meet the compliance threshold of 80%, 105 participants were
included in the nal per protocol analyses for adiposity variables
of interest. Only 64 participants [34 (control), 30 (treatment)]
successfully completed both baseline and follow-up OGTT
measures for calculating HOMA-IR, Matsuda index, and IGI.
Participant demographic and anthropometric information is
summarized in Tabl e 2 . Persons with overweight comprised
41% of the sample whereas 59% had obesity. The majority
Avocado effects on adiposity and glucose tolerance 2515
FIGURE 1 Participant recruitment and inclusion/exclusion information.
of the participants were of Caucasian descent (80%) and
female (61%). Signicant differences in adiposity variables
were observed based on sex whereby females had higher
SAAT (2383.9 ±598.5 g compared with 1675.5 ±749.8
g, P<0.001) whereas males had a higher VS Ratio (0.43 ±
0.14 compared with 0.30 ±0.09, P<0.001). However, there
were no differences in VAT between males and females [711.7 ±
303.7 g (females) compared with 678.0 ±348.3 g (males),
P=0.601]. There were no signicant differences between
treatment and control group participants of the same sex.
Background diet and physical activity.
There were no statistically signicant differences in changes
in leisure time physical activity score between the treatment
and control groups [–3.6 ±29.9 (control) compared with
11.4 ±41.6 (treatment), P=0.59]. However, there was a
signicant difference between changes in energy consumption
between the control and treatment groups [–109.7 ±549.7
kcal (control) compared with 174.3 ±568.4 kcal (treatment),
P=0.011]. As the intervention aimed to maintain overall
caloric intake throughout the study and between groups,
subsequent statistical analyses adjusted for change in energy
consumption to account for background changes in energy
consumption between groups.
Intervention effects on central adiposity.
The baseline values for the adiposity measures are summarized
in Tabl e 3 for descriptive purposes. Baseline and follow-up
insulin resistance and sensitivity is described in Tabl e 4 .The
summary of statistical tests contrasting change in adiposity
2516 Khan et al.
TABLE 2 Baseline demographic information and anthropometric characteristics of adults with
overweight or obesity participating in the PATH randomized controlled trial1
All (N =105) Control (N =53) Treatment (N =52)
Age, y 34.5 ±5.9 34.2 ±6.0 34.9 ±5.8
Race, n(%)
White or Caucasian 83 (80) 42 (79) 41 (79)
Asian 11 (11) 5 (9) 6 (12)
Black or African American 5 (5) 3 (6) 2 (4)
American Indian or Alaska Native 1 (1) 1 (2) 0 (0)
Other and multiracial 4 (4) 2 (4) 2 (4)
Household income, n(%)
≤$41,000 28 (27) 14 (26) 14 (26)
$41,000–$70,000 39 (37) 21 (40) 18 (35)
≥$70,000 38 (36) 18 (34) 20 (39)
Height, cm 171.2 ±8.9 171.1 ±9.6 171.2 ±8.2
Weight, kg 95.7 ±19.4 96.9 ±20.5 94.5 ±18.4
BMI, kg/m232.6 ±6.1 33.0 ±6.2 32.1 ±6.0
Overweight (25–29.9) 43 (41) 21 (40) 22 (42)
Obesity Class 1 (30–34.9) 32 (31) 14 (26) 18 (35)
Obesity Class 2 (35–39.9) 17 (16) 8 (15) 9 (17)
Obesity Class 3 (≥40) 13 (12) 10 (19) 3 (6)
1Continuous data presented as mean ±SD where indicated. PATH, Persea americana for Total Health.
and glycemic outcomes is summarized in Tabl e 5 . There was
no signicant difference between groups in VAT. The control
group had a signicantly larger reduction in SAAT. There
was a signicant difference between groups in change in VS
Ratio. Examining the results based on sex revealed that, among
females, there was a signicant difference between groups in
changes in VAT, SAAT, and VS Ratio. On the other hand, among
males, there was no signicant difference between groups in
changes in VAT, SAAT, and VS Ratio. Following controlling for
FDR, the differences in changes in VS Ratio between groups
remained signicant. Similarly, the differences in changes in VS
Ratio and SAAT among females persisted following controlling
for FDR.
Intervention effects on insulin resistance and sensitivity.
The baseline values for the glucose- and insulin-based outcomes
are summarized in Tabl e 4 and comparison of changes
based on sex and group are summarized in Tabl e 5.There
was no difference between groups in changes in HOMA-
IR (P=0.100), Matsuda index (P=0.285), and the IGI
(P=0.67). Similarly, there were no changes among females or
males.
Intent-to-treat analyses
Intervention effects on central adiposity.
Intent-to-treat analyses for the adiposity variables were con-
ducted among all participants who were randomly assigned
and completed baseline testing in the control [N =79 (52
females; 27 males)] and treatment [N =77 (49 females; 28
males)] groups. There was no signicant difference between
groups in VAT (P=0.44).The control group had a signicantly
larger reduction in SAAT (P=0.012). However, there was a
difference between groups in VS Ratio (P=0.045). Examining
the results based on sex revealed that, among females, there
was no signicant difference between groups in changes in
VAT ( P=0.227). However, there were signicant differences
in SAAT (P=0.002), and VS Ratio (P=0.010). On the other
hand, among males, there was no signicant difference between
groups in changes in VAT (P=0.940), SAAT (P=0.545),
and VS Ratio (P=0.611). Following controlling for FDR, the
signicant differences in changes in VS Ratio and SAAT among
females persisted.
Intervention effects on insulin resistance and sensitivity.
There was a signicant difference between groups in changes
in HOMA-IR (P=0.036). However, there was no signicant
TABLE 3 Baseline and follow-up adiposity of adults with overweight or obesity participating in the PATH randomized controlled trial
based on sex and group1
Females Males
Control (N =34) Treatment (N =30) Control (N =19) Treatment (N =22)
Baseline Follow-up Baseline Follow-up Baseline Follow-up Baseline Follow-up
Weight, kg 94.6 ±18.6 94.4 ±18.3 92.4 ±16.6 92.0 ±16.5 101.0 ±23.5 99.9 ±23.7 97.3 ±20.7 97.9 ±20.9
Fat, % 44.3 ±6.2 44.0 ±6.2 42.9 ±4.3 42.5 ±4.6 32.3 ±8.6 31.6 ±8.2 31.6 ±7.6 31.9 ±7.7
VAT, g 743.9 ±334.0 745.5 ±324.2 675.2 ±266.1 642.3 ±258.0 672.4 ±409.3 618.4 ±351.4 682.8 ±295.8 664.7 ±272.5
SAAT, g 2476.6 ±595.0 2415.3 ±633.8 2279.0 ±594.7 2292.6 ±599.4 1701.2 ±792.4 1684.0 ±867.2 1653.4 ±729.2 1675.8 ±744.2
VS Ratio 0.30 ±0.10 0.31 ±0.11 0.29 ±0.08 0.28 ±0.08 0.42 ±0.16 0.40 ±0.17 0.44 ±0.12 0.41 ±0.11
1Data presented as mean ±SD. PATH, Persea americana for Total Health; SAAT, subcutaneous abdominal adipose tissue; VAT, visceral adipose tissue; VS Ratio, visceral to
subcutaneous abdominal adipose tissue.
Avocado effects on adiposity and glucose tolerance 2517
TABLE 4 Baseline and follow-up insulin resistance and sensitivity of adults with overweight or obesity participating in the PATH
randomized controlled trial based on sex and group1
Females Males
Control (N =21) Treatment (N =16) Control (N =13) Treatment (N =14)
Baseline Follow-up Baseline Follow-up Baseline Follow-up Baseline Follow-up
Glucose, mg/dL 83.5 ±12.5 82.7 ±11.5 77.5 ±13.8 82.3 ±11.0 80.4 ±10.2 84.3 ±14.0 80.7 ±11.3 87.7 ±8.7
Insulin, μIU/L 10.9 ±6.8 11.0 ±4.8 8.3 ±3.7 9.5 ±5.3 9.3 ±4.7 9.7 ±4.6 9.6 ±5.9 11.3 ±7.3
HOMA-IR 2.3 ±1.7 2.3 ±1.2 1.6 ±0.9 2.0 ±1.2 2.0 ±1.3 2.0 ±1.1 1.9 ±1.2 2.5 ±1.9
Matsuda index 5.4 ±3.2 5.0 ±2.7 6.7 ±4.4 5.6 ±3.8 5.2 ±2.5 4.6 ±2.4 5.5 ±3.2 4.5 ±2.5
Insulinogenic index 2.3 ±2.8 2.0 ±2.6 2.0 ±2.2 1.8 ±1.7 2.1 ±4.1 1.2 ±0.6 1.3 ±1.2 1.5 ±1.5
1Description of baseline insulin resistance and sensitivity values among participants with overweight and obesity allocated to a group consuming a daily fresh Hass avocado
(treatment) compared with a group consuming an isocaloric meal without avocado (control) for 12 wk. Data presented as mean ±SD. PATH, Persea americana for Total Health.
difference between groups in changes in Matsuda index
(P=0.286) and the IGI (P=0.779). There were no changes
among females (all Ps≥0.161) or males (all Ps≥0.16).
Following controlling for FDR, there were no signicant
differences in changes across glycemic outcomes.
Discussion
The present work determined the effects of daily avocado
consumption on abdominal adiposity, insulin resistance, and
oral glucose tolerance among adults with overweight and
obesity. There were signicant differences in VS Ratio between
groups, likely due to the greater change in SAAT among
control group participants. The greater reduction in SAAT
among control group participants was an unexpected result.
However, change in SAAT in the control group was not
associated with changes in overall energy consumption or
change in self-reported leisure time physical activity (data
not shown). Therefore, although we do not know the cause
of the SAAT change observed in the control group, this
change is not related to self-reported changes in overall energy
consumption and leisure time physical activity. Analyses based
on sex revealed that females in the treatment group exhibited a
greater reduction in VS Ratio whereas control group females
had a greater reduction in SAAT. However, there were no
improvements in HOMA-IR, insulin sensitivity, and β-cell
function (i.e., IGI).
Although avocado consumption is a marker of higher diet
quality and potentially protects against metabolic risk (11,16,
27,28), there has been limited experimental work on adiposity
and oral glucose tolerance outcomes. A recent hypocaloric
weight loss trial with the inclusion of avocado reported
reductions in adiposity and improvements in presumably
fasting glucose; however, there were no differences between the
treatment and control groups (18). Previous research observed
that avocado consumers had higher BMI, waist circumference,
and metabolic syndrome risk (16). In a longitudinal study
among over 55,000 older adults, it was observed that, among
avocado consumers who had healthy weight status at baseline,
there was a reduction in the odds of developing overweight or
obesity compared with those who did not eat avocado (17).
The present work revealed that consuming a daily meal with
an avocado improved fat distribution as indicated by a lower
VS Ratio among female participants. Relative to other adipose
tissue depots, VAT accumulation, surrounding internal organs
such as the liver, is associated with type 2 diabetes (6,29,30),
dyslipidemia (31), inammation, increased risk of thrombosis
(32,33), and nonalcoholic fatty liver disease (34). Therefore,
the decrease in VS Ratio among treatment group participants
suggests that avocado intake imparts a benecial abdominal
adiposity prole. However, given that these benets were not
observed among males, the robustness of the treatment effect
is limited and additional experimental research is needed to
further characterize the effects of daily avocado consumption
on fat distribution.
TABLE 5 Change in adiposity and glycemic outcomes among adults with overweight or obesity participating in the PATH
randomized controlled trial based on sex and group1
Females Males
Adiposity outcomes
Control
(N =34)
Treatment
(N =30) P
Control
(N =19)
Treatment
(N =22) P
VAT, g 1.6 ±89.8 –32.9 ±81.6∗0.021 –39.7 ±99.2 –18.1 ±107.1 0.500
SAAT, g –61.2 ±152.7 13.7 ±133.1∗0.0212–42.4 ±164.7 22.4 ±184.2 0.268
VS Ratio 0.117 ±0.047 –0.015 ±0.030∗0.0012–0.002 ±0.046 –0.007 ±0.057 0.812
Glycemic outcomes
Control
(N =21)
Treatment
(N =16) P
Control
(N =13)
Treatment
(N =14) P
HOMA-IR –0.02 ±0.99 0.34 ±0.89 0.377 0.10 ±1.0 0.43 ±0.80 0.332
Matsuda index –0.47 ±2.57 –1.12 ±2.26 0.412 –0.58 ±2.01 –0.95 ±1.82 0.615
Insulinogenic index –0.09 ±1.49 –0.26 ±1.28 0.611 –0.48 ±1.28 0.21 ±0.93 0.121
1Comparison of changes (), using univariate ANOVA following adjustment for changes in energy consumption, in adiposity and glycemic outcomes between participants with
overweight and obesity allocated to a group consuming a daily fresh Hass avocado (treatment) compared with a group consuming an isocaloric meal without avocado (control)
for 12 wk. Data presented as mean ±SD. ∗Indicates signicant difference in changes (follow-up–post) between groups.
2Signicance retained following false discovery rate correction.
PATH , Persea americana for Total Health; SAAT, subcutaneous abdominal adipose tissue; VAT, visceral adipose tissue; VS Ratio, visceral to subcutaneous abdominal adipose
tissue.
2518 Khan et al.
The mechanisms by which avocados may contribute to
VAT changes are possibly derived from the higher ber and
MUFA content (16). A whole avocado contains ∼10 g of
total ber, contributing to ≤40% of the recommendations
among females or 30% for males. Greater dietary ber intake
is cross-sectionally associated with lower VAT (35,36)and
related to lower gains in VAT (37). Further, independent of
caloric restriction, supplemental ber intake reduces BMI and
waist circumference (38). Dietary ber, specically insoluble
ber (contributing to 70% of ber in an avocado), could
affect VAT by increasing fecal bulk and shortening transit
time (39), and lowering absorption of nutrients and energy
(40). Acutely, meals with higher dietary ber elicit a moderate
postprandial blood glucose response, stimulating a greater
sensation of satiety in healthy adults (41). It has also been
hypothesized that the elevated postprandial glucose and insulin
response can affect macronutrient partitioning in a manner
that favors adipose tissue accumulation, and that VAT may
be more susceptible to the inuence of high insulin responses
relative to SAAT (42,43). There is also evidence that the
lipid compositional properties of adipose tissue differentially
impact whole body and abdominal obesity (44). The degree
of obesity and abdominal distribution of body fat have
been negatively correlated with the MUFAs and n−3PUFA
contents of adipose tissue. Given that SFAs were higher
and MUFAs were lower in perivisceral than in subcutaneous
fat, it is possible that consuming diets that substitute SFAs
with MUFAs has the potential to shift abdominal adipose
distribution. Indeed, dietary fatty acid intake is known to be an
important determinant of changes in adipose tissue composition
(45).
Regarding potential clinical or biological relevance of our
ndings, previous work indicates that inducing a 26% reduction
in VAT over the course of 12 mo, using a healthy eating and
physical activity/exercise program, corresponds to signicant
improvement in cardiorespiratory tness, plasma inammatory
markers, lipid proles, and OGTT (46). The change in VAT
tissue among females in the treatment group in the current
study was ∼5%; therefore, the change observed in our study
was modest. However, considering that the present study
was relatively short (3 mo) and did not include an exercise
component, the modest change in VAT is not surprising. It
is possible that maintaining the treatment regimen over the
course of a longer period could have provided the necessary
cumulative reduction in VAT to be clinically meaningful. A
previous large prospective study observed that annual increases
of 3%, 4%, and 3% of VAT, SAAT, and VS Ratio, respectively,
were related to an increased risk of diagnosis of diabetes among
adults with higher BMI (47). Interestingly, the proportional
changes in these measures in the present study were similar
in magnitude, albeit the SAAT effects were only observed in
the control group. Overall, the changes in abdominal adiposity
compartments observed in the present study were modest
but could have possible clinical signicance if the trajectories
for reduction in VAT and VS Ratio were accumulated over
a longer period of time. Future longer duration studies are
needed to characterize the clinical meaningfulness of these
ndings.
Interestingly, we observed selective benets of participating
in the intervention for females but not males. This is not entirely
surprising since sexual dimorphism in lifestyle interventions
targeting obesity have been observed previously (48,49).
Although the explanations for the sexual dimorphism observed
in obesity prevalence and differential responses to lifestyle
interventions are unclear, recent trends indicate that obesity
and extreme obesity prevalence have signicantly increased
among females, further increasing the need for interventions
targeting females. However, additional research that includes
equal samples of male participants is necessary to gain a com-
prehensive understanding of dietary intervention effects. The
majority of lifestyle interventions are predominantly comprised
of female participants (27% male compared with 73% female)
(49), resulting in limited knowledge on dietary implications
for adiposity among males. Although the proportions of males
(41%) in the present work was greater than most studies,
it is possible that we failed to observe signicant effects for
males due to inadequate sample size of males and/or lower
adiposity status of males compared with females at baseline.
Given the known differences in adiposity partitioning based
on sex, differential effects for adiposity may also have been
driven by the fact that the treatment could have contributed
to the participants’ nutrient recommendations differently. For
example, the avocado provided ∼51% of Adequate Intake for
ber for females and ∼42% for males. Future studies are needed
to determine the extent to which dosage impacts changes in
adiposity distribution between males and females following
avocado consumption.
The present work also examined the implications of daily
avocado consumption on insulin resistance, OGTT-derived
peripheral insulin sensitivity, and β-cell function. Adding
approximately half an avocado to a meal has been shown to
increase satiety 4–5 h later and reduce postprandial insulin
concentrations (50,51), suggesting that manipulation of meals
with avocado could promote both satiety and metabolic
benets. To our knowledge, the present study represents the rst
randomized controlled study to examine effects of consuming
a whole avocado on glucose and insulin over several months
among persons with overweight and obesity. We did not observe
signicant effects of avocado consumption for glucose and
insulin outcomes. Given that VAT and insulin sensitivity and
resistance are closely linked, this was a surprising nding.
However, it is possible that we did not observe benets for
glycemic outcomes due to the modest reductions in VAT among
females only. It is also possible that a longer intervention
duration is necessary to observe metabolic benets for insulin
sensitivity following avocado consumption. A limitation of the
study was that only a subsample of the participants were
able to successfully complete the OGTT procedure. This was
primarily due to the invasive nature of the procedure and
challenges in successful catheter placement among persons
with overweight and obesity (52,53). Therefore, the ndings
for OGTT should be interpreted with caution. Nevertheless,
these ndings are consistent with previous work that examined
glycemic responses following several weeks of consuming
nutrients found in avocados. Lerman-Garber and colleagues
observed that a high MUFA diet was associated with a greater
decrease in triglycerides; however, there were no benets for
glycemic measures following a test mixed-meal (28). Although
our ndings did not support our a priori hypothesis regarding
glycemic outcomes, this work suggests that daily consumption
of a meal including an avocado, a fruit that is rich in fatty acids,
does not detrimentally affect insulin resistance or oral glucose
tolerance among adults with overweight and obesity. Additional
experiments examining the effects of avocado consumption on
glucose and insulin responses is needed to further characterize
the effects of avocados on insulin resistance and sensitivity.
In conclusion, consumption of a daily meal with an
avocado altered abdominal fat distribution over a 12-wk period.
Avocado effects on adiposity and glucose tolerance 2519
However, there were no improvements in insulin sensitivity or
β-cell function. Future research is necessary to examine the
underlying causes of the differential adiposity-related ndings
based on sex. Given the increasing prevalence of excess
adiposity, there is a vital need to develop and test food-
based approaches to reducing adiposity as well as improving
metabolic health.
Acknowledgments
We would like to thank Christine Madden for her management
of the metabolic kitchen and production of the study meals. We
also acknowledge the contributions Corinne Cannavale, Mor-
gan Chojnacki, Melisa Bailey, Joe Beals, Jennifer Kaczmarek,
and Andrew Taylor for their assistance in conducting the testing
procedures.
The authors’ contributions were as follows—NAK, HDH,
NAB, and BHF: conceptualized and obtained funding for the
research; CGE, SVT, BAH, and SKB: conducted the research;
ADMW: conducted randomization procedures; NAK: analyzed
data; all authors: contributed to the interpretation of the results
and writing of the manuscript; NAK: had primary responsibility
for nal content; and all authors: read and approved the nal
manuscript.
Data Availability
Data described in the manuscript, code book, and analytic code
will be made available upon request pending application and
approval.
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