Original Paper

Effect of Pistachio Nuts on Serum Lipid Levels in

Patients with Moderate Hypercholesterolemia

Karen Edwards, MS, Isidore Kwaw, MD, Jose Matud, Ira Kurtz, MD
Nephrology Division (K.E., I.K., I.K.), Bio-Statistics Department (J.M.), UCLA School of Medicine, Los Angeles, California
Key words: pistachio nuts, hypercholesterolemia, lipids, cardiac risk

Background: Elevated serum cholesterol levels play an important role in the development of coronary artery
disease. Previous studies have suggested that nut consumption benefits lipid profile. Pistachio nuts are widely
available, inexpensive and frequently consumed by the general population.
Objective: To determine whether substituting 20% of the daily caloric intake in the form of pistachio nuts
will improve the lipid profiles of humans with primary, moderate hypercholesterolemia.
Design: Controlled, randomized crossover design.
Setting: Outpatient dietary modification, counseling and blood analysis.
Patients: Ten patients with moderate hypercholesterolemia.
Intervention: Three weeks of dietary modification with 20% caloric intake from pistachio nuts.
Measurements: Body weight, blood pressure, total cholesterol, LDL, HDL, and triglycerides were moni-
tored. Lipid profiles were analyzed prior to, during and after dietary modification.
Results: After three weeks, there was a decrease in total cholesterol (p,0.04), an increase in HDL (p,0.09),
a decrease in the total cholesterol/HDL ratio (p,0.01) and a decrease in the LDL/HDL ratio (p,0.02).
Triglycerides and LDL levels decreased, but not significantly. Body weight and blood pressure remained
constant throughout the study.
Conclusions: Results suggest that eating pistachio nuts instead of other dietary fat calories can improve lipid
profiles, thereby decreasing coronary risk. Further studies will be required to confirm these results and to
determine the mechanism of this effect.

INTRODUCTION
Epidemiologic studies have shown that diets with a high
monounsaturated fat to saturated fat ratio and polyunsaturated
fat to saturated fat ratio seem to bring about lower serum
cholesterol levels and reduce the incidence of coronary artery
disease [1,2]. Current research suggests that diets high in poly-
unsaturated fat are potentially carcinogenic, especially for car-
cinoma of the breast in women [3].
Recently, a number of studies have reported the beneficial
effects of nuts, especially almonds and walnuts, on serum lipid
levels and subsequent coronary artery disease (CAD) [4 –7].
The specific mechanism or mechanisms determining these im-
proved lipid profiles and reduced risk of CAD are unknown,
but may be related to the unsaturated fat content [2,8,9]. Al-
though all nuts have high levels of either mono (M) or poly-
unsaturated (P) fats and low levels of saturated (S) fats, the
fatty acid composition of each type of nut varies [10] (Fig. 1).
Additionally, nuts are generally high in vitamin E and fiber,
characteristics which would make them healthier alternatives to
snack foods such as microwave popcorn, buttered popcorn,
most candy bars, potato chips and the like. The benefit of nuts
has been attributed to their high level of polyunsaturated fats, a
high P/S ratio, and their high monounsaturated fat content
[2,7–9] (Table 1).
The “guilt” associated with the ingestion of nuts as a snack
could be attenuated if a benefit could be demonstrated for the
substitution of nuts for candy bars, dairy products and other
high saturated fat foods. For this reason, we chose to study the
substitution of pistachio nuts for the high fat snacks just men-
tioned to determine whether or not there was a significant effect
on lipid profiles in patients with moderate hypercholesterol-
emia.

Address reprint requests to: Karen Edwards, M.S., 11444 West Olympic Boulevard, Los Angeles, CA 90064.

Journal of the American College of Nutrition, Vol. 18, No. 3, 229 –232 (1999)
Published by the American College of Nutrition

229
Effect of Pistachio Nuts on Lipid Profile

Fig. 1. Fatty acid content of selected nuts (grams per one ounce serving).

Table 1. P/S Ratio and Percent Monounsaturated Fatty Acid treated for hyperlipidemia. Patients with secondary hyperlipid-
Content of Selected Nuts emia due to diabetes mellitus, hypothyroidism, nephrotic syn-
drome, dysglobulinemias, Cushing’s syndrome or acute inter-
P/S Ratio % MUFA
mittent prophyria were excluded; in addition, patients on
Almonds 2.21 65% glucocorticoids or estrogen therapy were excluded. Patients
Cashews 0.85 59%
with hypertension and angina were also excluded. No patients
Peanuts 2.32 50%
Pecans 3.00 62% were on medications, including beta blockers and thiazide
Pistachio Nuts 1.21 67% diuretics. Smokers were not excluded; however, no subject
English Walnuts 6.94 23% smoked. Although not excluded, no subject was a vegetarian.
The subjects were asked to maintain similar physical activity
and other lifestyle habits, and they kept diaries to record any
signs of illness and to record any new medications taken. One
METHODS patient was dropped from the study because he was inadver-
tently placed on thiazide diuretics.
Patient Selection
Subjects were obtained by physician referral. They included Experimental Design
a group of four men (ages forty-one to fifty-three) and six
A controlled, randomized crossover design was utilized, and
women (ages twenty-eight to sixty-four); the median age was subjects served as their own controls. One half of the subjects
forty-six years. All subjects had moderate hypercholesterol- were randomized to a pistachio group for three weeks, and the
emia (serum cholesterol greater than 210 mg/dL). The range other half maintained their regular diets for three weeks. All
was 214 mg/dL to 336 mg/dL with a median of 243 mg/dL. subjects had their lipid profiles measured during an initial visit
Subjects’ median weight was 66.9 kg with a range of 49.8 to (baseline) and on days five and seven of the third week of each
101.8 kg. Median blood pressure was 120/78 mm Hg with dietary period. The subjects were then crossed over and lipid
systolic values ranging from 98 to 140 mm Hg and diastolic profiles were remeasured in the same way. There was no
values ranging from 50 to 100 mm Hg. lag time between the diet crossover. The experimental design
Excluded from the study were those patients with renal was approved by the UCLA Human Subjects Protection Com-
failure (creatinine greater than 1.5) and those patients being mittee.

230 VOL. 18, NO. 3

 Effect of Pistachio Nuts on Lipid Profile

Dietary Intervention Table 2. Summary of Values Registering the Median Change

in the Sample
Prior to the study period and prior to any scheduled meet-
ings with the dietitian, the subjects were required to submit a Variable (units) Initial Final Difference p-value
consecutive three-day food record (the reference diet). Diets Total Cholesterol (mg/dL) 243 239 29 ,0.04
were analyzed for calorie and macronutrient (percentage of HDL (mg %) 50 56 14 ,0.09
carbohydrates, fat, protein and fiber) content. Half of these LDL (mg %) 180 158 211 N.S.
patients were placed on a pistachio diet. This involved substi- Triglycerides (mg/dL) 113 108 26 N.S.
Total Cholesterol/HDL 4.8 4.5 20.7 ,0.01
tuting roasted, unsalted pistachio nuts for 20% of their daily
LDL/HDL 3.2 3.1 20.3 ,0.02
caloric intake. The subjects otherwise consumed the compo-
nents of their regular diets. Subjects who normally consumed
high fat snacks were instructed to substitute the pistachios nuts. because the limited sample size did not allow for any assump-
If a subject did not normally consume high fat snacks, pistachio tions regarding the normality of the sampling distribution.
nuts were substituted as fat calories. Subjects kept one-day food Two-sided p values are given.
records for each of the six weeks; these were analyzed to ensure
that the subjects were consuming the appropriate quantities of
pistachio nuts. Subjects met with the dietitian weekly to discuss RESULTS
the pistachio substitutions and were educated as to any neces-
sary changes. After three weeks the subjects on the pistachio The data are reported as the median change of each variable
diets were crossed over to their regular diets, and the subjects for the ten subjects. The lipid changes are summarized in Table
on the regular diets were crossed over to the pistachio diet. 2. Total cholesterol fell from 243 mg/dL to 239 mg/dL
(p,0.04). HDL cholesterol rose from 50 mg/dL to 56 mg/dL
(p,0.09). LDL cholesterol fell from 180 mg/dL to 158 mg/dL,
Measurements although the probability of this decrease was not statistically
significant. Triglycerides fell from 113 mg/dL to 108 mg/dL,
The subjects were age, sex and weight matched. A dietitian
but, as it happened with the LDL, there was too much variation
calculated the daily caloric intake, including the quantity of
to obtain a significant p-value. The ratio of total cholesterol to
saturated, monounsaturated and polyunsaturated fatty acids,
HDL fell from 4.8 to 4.5 (p,0.01). The ratio of LDL/HDL
protein, carbohydrate and fiber consumed by subjects on a
cholesterol also fell, from 3.2 to 3.1 (p,0.04). There were no
weekly basis to ensure that the diets did not change signifi-
significant changes in body weight and blood pressure during
cantly. Any signs of illness or any new medications taken were
the study.
recorded in diaries.
The pistachio diet yielded a significant decrease in subjects’
Body weights as measured without shoes or heavy clothing
saturated fat consumption and increases in monounsaturated
were recorded the first three days during week one of the
and polyunsaturated fat and fiber consumption when these were
reference diet and the experimental diet and the first three days
compared to the reference diet. The results are summarized in
of week three at the end of each dietary period.
Table 3. Saturated fat consumption decreased from 23 to 16
Following an overnight fast, 10 cc of venous blood samples
grams (p,0.01). Monounsaturated and polyunsaturated fat
were taken from an anticubital vein into evacuated tubes with
consumption increased from 23 to 32 grams and from 9.6 to 14
1.2 mg ethylene diaminetetra acetic acid (EDTA)/mL blood.
grams, respectively (p,0.04). These changes increased the
The tubes were then immediately put into ice water. Within two
monounsaturated fat to saturated fat ratio (1.0 vs. 2.0) and the
hours, plasma was separated by centrifugation, 25003g at 4°C
polyunsaturated fat to saturated fat ratio (0.42 vs. 0.88). Fiber
and stored at 270°C prior to analysis. High density lipoprotein
consumption increased from 12 to 20 grams (p,0.01).
(HDL) was separated by sodium phosphotungstate precipita-
tion of the low density lipoprotein (LDL) in the bottom fraction
Table 3. Summary of Values Registering the Median Change
at d51.006 g/ml. Cholesterol and triglycerides in plasma were
between the Reference Diet and Pistachio Diet
determined by enzymatic methods. LDL was calculated by the
method of Friedewald [11]. Blood was drawn on days one and Reference Pistachio
Dietary Variable Difference p-value
three of the first week and days five and seven of the third week Diet Diet
of each dietary period (reference diet and pistachio diet). Total calories (kCal) 1900 1905 5 N.S.
% Protein 17 16 1 N.S.
% CHO 47 44 3 N.S.
Statistical Analysis % Fat 37 39 2 N.S.
SAT (g) 23 16 7 ,0.01
The data were analyzed with the assistance of the Bio- MUFA (g) 23 32 9 ,0.01
Statistics Department of UCLA School of Medicine. Signifi- PUFA (g) 9.6 14 4.4 ,0.01
Fiber 12 20 8 ,0.01
cance was determined by the exact Wilcoxon Signed Rank Test

JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 231

Effect of Pistachio Nuts on Lipid Profile
DISCUSSION
The purpose of this randomized crossover trial was to
determine the effect of pistachio nuts on serum lipids in sub-
jects with moderate hypercholesterolemia. The results of the
present study demonstrate that a substitution of 20% of daily fat
calories with pistachio nuts as snacks significantly improves
the lipid profile in subjects with hypercholesterolemia. The data
suggest that the substitution of pistachio nuts for other high fat
snacks may be beneficial in moderating coronary risk factors. It
was not clear, however, whether this was due to a change in the
P/S ratio or the monounsaturated fat content of the pistachio
diet.
A previous study by Fraser and colleagues [4] has demon-
strated that the frequent consumption of nuts may protect
against coronary artery disease, although no distinction was
made between the type of nut ingested. Subsequent studies
investigating the effect of walnuts by Sabaté and associates [5]
and Abbey and colleagues [6] and the effect of almonds by
Spiller and associates [7] demonstrated an improved lipid pro-
file in healthy volunteers. Sabaté and colleagues [5] demon-
strated a reduction in total cholesterol, LDL cholesterol, HDL
cholesterol and LDL/HDL ratio. The study by Spiller and
associates [7] detected significant changes in total cholesterol
and LDL cholesterol only. The results of the present study
compare favorably with these previous results. After only three
weeks, subjects ingesting pistachio nuts had a significant de-
crease in total cholesterol, total cholesterol/HDL cholesterol,
LDL/HDL cholesterol and an increase in HDL cholesterol.
When comparing almonds and walnuts, Abbey and colleagues
found a significant decrease in total cholesterol and LDL cho-
lesterol; however, no changes in HDL cholesterol could be
demonstrated. None of the studies (including the present study)
detected any significant change in serum triglycerides.
The serum lipid parameters which are most predictive of
subsequent coronary artery disease remain controversial. A
recent study by Kinosian and colleagues [12] showed that
changes in total cholesterol/HDL and LDL/HDL ratios were
better predictors of coronary heart disease than changes in LDL
alone. Pistachio nuts altered these important parameters (total
cholesterol/HDL and LDL/HDL cholesterol) in the cardiopro-
tective direction.
CONCLUSION
The substitution of pistachio nuts for other fat calories in the
form of snacks for a consecutive three-week period can signif-
icantly improve the lipid profile in patients with moderate
232
hypercholesterolemia. Further studies will be required to deter-
mine the mechanism achieving this effect and to document that
the improved serum lipid profile decreases the risk of coronary
artery disease.
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Received May 1998; revision accepted December 1998.
VOL. 18, NO. 3