Nutrition, Metabolism & Cardiovascular Diseases (2014) xx, 1e10
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
META-ANALYSIS
Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies Z.Q. Shi 1, J.J. Tang 1, H. Wu, C.Y. Xie, Z.Z. He* Department of Anesthesiology & Surgic Intensive Care Unit, South Branch, Ren Ji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai 201112, China Received 16 March 2014; received in revised form 13 June 2014; accepted 16 June 2014 Available online - - -
KEYWORDS Nut; Legume; Stroke; Meta-analysis
Abstract Background and aim: The relationships between dietary nuts and legume intake and risk of stroke are inconsistent. We summarized the evidence by a meta-analysis of prospective cohort studies. Methods and results: We systematically searched the MEDLINE and EMBASE databases up to 31 January 2014. Random-effects models were used to calculate summary relative risks (SRRs) and 95% confidence intervals (CIs). Between-study heterogeneity was assessed using the Cochran’s Q and I2 statistics. Eight prospective studies with a total of 468,887 subjects and 10,493 stroke events were included in the meta-analysis. Overall, a diet containing greater amounts of legumes may be n o t a s s o c i a t e d w i t h a l o w e r r i s k o f s t r o k e ( S R R Z 0 . 9 5 , 9 5 % C I : 0 . 8 4 e1. 0 8 ; Pheterogeneity Z 0.091, I2 Z 43.2%); however, a diet containing greater amounts of nuts may be associated with a lower risk of stroke (SRR Z 0.90, 95% CI: 0.81e0.99; Pheterogeneity Z 0.527, I 2 Z 0). Gender significantly modified the effects of nut consumption on stroke risk, and high nut intake was associated with reduced risk of stroke in women (SRR Z 0.85, 95% CI: 0.75e0.97) other than in men (SRR Z 0.95, 95% CI: 0.82e1.11). Conclusion: The current meta-analysis provides some evidences for the hypothesis that high intake of dietary nut was inversely associated with stroke risk, whereas dietary legumes intake was not associated with stroke risk. ª 2014 Elsevier B.V. All rights reserved.
Introduction Stroke is the second leading cause of death in both developed and developing countries, and its prevalence and disability burden are expected to increase in the future
* Corresponding author: Department of Anesthesiology & Surgic Intensive Care Unit, South Branch, Ren Ji Hospital, School of Medicine, Shanghai JiaoTong University, 2000 Jiangyue Road, Minhang District, Shanghai 201112, China. Tel./fax: þ86 021 58752345. E-mail address: [email protected] (Z.Z. He). 1 Both authors contributed equally to this work.
due to population aging [1]. In the United States, every 40 s, one person suffers from a stroke, and every 4 min, one person dies of stroke [2]. Therefore, knowledge of risk factors and protective factors associated with stroke is essential for the development of prevention strategies. Both hypertension and type 2 diabetes (type 2 DM) are major risk factors for stroke and can be influenced by modifiable lifestyle factors including diet. Among dietary factors, both nuts and legumes are good sources of vegetable protein, fiber, phytosterols, vitamins, and minerals [3], and are low in saturated fatty acids and high in monoand polyunsaturated fat acids (MUFAs and PUFAs,
http://dx.doi.org/10.1016/j.numecd.2014.06.009 0939-4753/ª 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
2
respectively). Evidences from in vitro and in vivo studies indicated that legumes might reduce the risk of stroke via effects on improving insulin sensitivity [4] and antiinflammation [5]. Findings from observational studies and clinical trials suggested that dietary legume intake was inversely associated with risk factors for stroke such as hypertension [6,7] and type 2 DM [8]. For dietary nut intake, preventative effects of high nut consumption on the pathogenesis of hypertension and type 2 DM had been observed in several cohort studies [9e11], although not in the others [12e15]. It is thus possible that these physiologic effects of nuts and legumes may confer a lower risk of stroke among people who consume them on a regular basis. In this meta-analysis of the associations between dietary nut and legume intake and risk of stroke, we focused on only prospective cohort studies due to the following: (1) no systematic reviews and meta-analyses have looked at the effects of dietary nut and legume intake on the overall risk of stroke. (2) Both caseecontrol and crosssectional designs are subjected to the selection and recall bias, and the prospective evidences on these associations have been reported with inconsistent results [16e22]. (3) Only two clinical trials were reported for stroke risk and intakes of soy [23] and nut [24], respectively. Therefore, we preformed the quantitative review to examine these associations following the meta-analysis of observational studies in epidemiology (MOOSE) [25]. Methods Literature search Two investigators (S.Z.Q. and T.J.J.) made a systemic search of MEDLINE and EMBASE up to 31 January 2014 to identify all published articles including the following medical subject headings or keywords: (1) soy OR soybeans OR beans OR peas OR legumes OR tofu OR lentils OR vegetable OR nut OR peanut OR walnut OR almond OR pine OR hazel OR ginkgo; (2) cerebrovascular accident OR brain ischemia OR intracranial hemorrhages OR cerebral hemorrhage OR subarachnoid hemorrhage OR stroke. There was no language limitation. A manual search of the references cited in all of the obtained literature was also conducted. Any disagreements were solved by a third reviewer (H.Z.Z.). Study selection To be included, studies had to meet the criteria as follows: (1) prospective cohort studies published as original articles; (2) providing legume/nut consumption categories and stroke risk; and (3) reporting relative risks (RRs) and corresponding 95% confidence intervals (CIs) quantifying the association between consumption of legumes/nuts and stroke risk. Animal studies, in vitro researches, case reports, ecological studies, and reviews were not considered eligible. If multiple papers reported results from the same cohort, we included the one with the largest number of cases. Two investigators (S.Z.Q. and T.J.J.) independently
Z.Q. Shi et al.
reviewed all potentially relevant articles to determine whether an article met the general inclusion criteria, and disagreement was resolved by a third reviewer (H.Z.Z.). Data extraction From each study, the following characteristics were extracted by two investigators (S.Z.Q. and T.J.J.): first author’s surname, publication year, study location, duration of follow-up, the number and age of the subjects, the methods used for collection of data on exposure, stroke outcomes, confounding factors, and the RR estimates with the corresponding 95% CI for all categories of intake. Most of the studies assessed stroke risk with respect to total legume/nut consumption. When more than one type of legume/nut was evaluated, we selected the most representative one. This measurement was prioritized in a descending order of total legumes/nuts, a certain type of legumes/nuts or its product. If separate risk estimates for men and women and for subtypes of stroke were available in one study, we treated it as separate studies. From each study, we extracted the risk estimates with the greatest number of adjustments. Assessment of study quality Two investigators (S.Z.Q. and T.J.J.) assessed the quality of each selected study using the NewcastleeOttawa quality assessment Scale (NOS) [26]. Any discrepancies were addressed by a third reviewer (H.Z.Z.). For cohort studies, the NOS consists of three parameters of quality: selection (four points), comparability (two points), and outcome (three points), and a maximum of nine points reflect the highest quality. A total score of seven or greater was used to indicate high-quality studies and a total score of six or smaller indicated low-quality studies. Statistical methods We used the statistical program STATA, version 11.0 (STATA, College Station, TX, USA) for the analysis. A twotailed P < 0.05 was considered statistically significant. We used the method of a random-effects model, which accounts for heterogeneity among studies [27], to calculate summary RRs (SRRs) and 95% CIs for the highest versus lowest analysis. Statistical heterogeneity among studies was assessed using both the Q statistic and the I2. Results were defined as heterogeneous for P-values 50% was considered a measure of moderate-high heterogeneity, a value 6; Supplementary Table 1). Legume consumption and total stroke risk Six studies, including 173,229 participants and 4030 stroke events, presented results on the highest versus lowest level of dietary legume intake and total stroke risk [18e22]. As shown in Fig. 2A, the SRR was 0.95 (95% CI: 0.84e1.08) for subjects in the highest category of legume consumption compared with those in the lowest category. There was moderate heterogeneity among studies (Pheterogeneity Z 0.091, I2 Z 43.2%). When we included only
Figure 1 Flow diagram of systematic literature search on nut and legume intake and risk of stroke.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
4
Author/Year/Country
Study characteristics
Follow-up, yrs Dietary assessment Outcome ascertainment
Exposure details
Risk estimation (95% CI) Adjustments
Legumes van der Schouw/2005/ EPIC Netherland N Z 16,165, F, age: 49e70; n Z 147 Kokubo/2007/Japan
Nagura/2009/Japan
Mizrahi/2009/Finnish
6.3
JPHC 12.5 N Z 40,462; age: 40e59 n Z 587; M þ F
JACC N Z 59,485, M þ F n Z 1053; age: 40e79
12.7
FFQ-79, validated
fatal or non-fatal Isoflavones Q1 cerebrovascular Isoflavones Q2 events Isoflavones Q3 Isoflavones Q4 FFQ-147, validated non-fatal IS Soy: 0e2 d/week, M Soy: 3e4 d/week, M Soy: 5 d/week, M Soy: 0e2 d/week, F Soy: 3e4 d/week, F Soy: 5 d/week, F self-administered FFQ-33
Finnish Mobile Clinic Health Examination Survey: N Z 3,932, M þ F, age:40-74, n Z 625
24
Bernstein/2012/USA
NHS, N Z 121,700; F; Age:30e55 n Z 2633
22
self-administered FFQ validated
non-fatal Total IS ICH
Bernstein/2012/USA
HPFS: N Z 51,529; M; Age:40e75 n Z 1397
26
self-administered FFQ validated
non-fatal Total IS ICH
9
Validated FFQ-127
Fetal stroke
Nuts Yochum,2000/USA
IWHS,N Z 34,492, F, aged 55e69 y; n Z 215
self-administered FFQ validated
Fatal Total ICH IS
fatal or non-fatal IS ICH
1.00 0.96 1.09 1.05 1.00 0.85 0.95 1.0 0.81 0.64
(0.60e1.52) (0.68e1.73) (0.64e1.70) (0.65e1.11) (0.72e1.26) (0.55e1.19) (0.43e0.95)
Bean: 0$8 servings/week Bean: 1$8 servings/week Bean: 3.0 Servings/week Bean: 4.5 servings/week Legumes: 0e2 g/d, IS Legumes: 3e5 g/d, IS Legumes: 6e9 g/d, IS Legumes: 10e101 g/d, IS Legumes: 0e2 g/d, ICH Legumes: 3e5 g/d, ICH Legumes: 6e9 g/d, ICH Legumes: 10e101 g/d, ICH Legumes: 0.07 Servings/d Legumes: 0.14 Servings/d Legumes: 0.17 Servings/d Legumes: 0.24 Servings/d Legumes: 0.43 Servings/d Legumes: 0.07 Servings/d Legumes: 0.14 Servings/d Legumes: 0.17 Servings/d Legumes: 0.24 Servings/d Legumes: 0.43 Servings/d
0$79 (0$59e1$06) 0$74 (0$55e1$00) 0$72 (0$54e0$96) 1.00 1$34 (0$64e2$79) 1$31(0$62e2$74) 1$44 (0$70e2$96) 1.00 0.99 (0.87e1.13) 1.19 (1.04e1.36) 1.05 (0.92e1.19) 1.06 (0.93e1.22) 1.00 1.03 (0.86e1.23) 1.06 (0.89e1.26) 1.04 (0.87e1.24) 1.07 (0.89e1.29)
Nuts Nuts Nuts Nuts
1.00 0.85 (0.61, 1.18) 0.79 (0.50, 1.24) 0.73 (0.41, 1.29)
and and and and
seeds:0 times/mo seeds:1e2 times/mo seeds:3e4 times/mo seeds: >4 times/mo
1$00 1$02 (0$85, 1$22)
Age, BMI, smoking, physical activity, DM, HBP, hypercholesterolemia, HRT use, etc Age; sex; smoking; alcohol use; BMI; HBP, DM; medication use for hypercholesterolemia; education level; sports; dietary intake, menopausal status, etc. Age, sex, BMI, smoking, alcohol intake, walking, hours of sleep, education, HBP, DM, etc.
1$14(0$95, 1$38) 0$95 (0$79, 1$16) 1.00
Age, sex, BMI, smoking, physical activity, serum cholesterol level, HBP and energy intake
Age, BMI, cigarette smoking, physical exercise, parental history, menopausal status, etc. Age, BMI, cigarette smoking, physical exercise, parental history of early myocardial infarction, menopausal status, etc. Age, total energy intake, BMI, HBP, DM, ERT, alcohol intake, education, marital status,
Z.Q. Shi et al.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
Table 1 Characteristics of the studies of the association between legume and nut consumption and stroke risk.
Bernstein/2012/USA
Bernstein/2012/USA
PHS, N Z 21,078, M, Age: 54.6, n Z 1424
21
NHS, N Z 121,00; F; Age:30e55 n Z 2633
22
HPFS: N Z 51,529; M; Age:40e75 n Z 1397
26
Validated FFQ-19
fatal or non-fatal Nuts: 0/week Total Nuts:
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
META-ANALYSIS
Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies Z.Q. Shi 1, J.J. Tang 1, H. Wu, C.Y. Xie, Z.Z. He* Department of Anesthesiology & Surgic Intensive Care Unit, South Branch, Ren Ji Hospital, School of Medicine, Shanghai JiaoTong University, Shanghai 201112, China Received 16 March 2014; received in revised form 13 June 2014; accepted 16 June 2014 Available online - - -
KEYWORDS Nut; Legume; Stroke; Meta-analysis
Abstract Background and aim: The relationships between dietary nuts and legume intake and risk of stroke are inconsistent. We summarized the evidence by a meta-analysis of prospective cohort studies. Methods and results: We systematically searched the MEDLINE and EMBASE databases up to 31 January 2014. Random-effects models were used to calculate summary relative risks (SRRs) and 95% confidence intervals (CIs). Between-study heterogeneity was assessed using the Cochran’s Q and I2 statistics. Eight prospective studies with a total of 468,887 subjects and 10,493 stroke events were included in the meta-analysis. Overall, a diet containing greater amounts of legumes may be n o t a s s o c i a t e d w i t h a l o w e r r i s k o f s t r o k e ( S R R Z 0 . 9 5 , 9 5 % C I : 0 . 8 4 e1. 0 8 ; Pheterogeneity Z 0.091, I2 Z 43.2%); however, a diet containing greater amounts of nuts may be associated with a lower risk of stroke (SRR Z 0.90, 95% CI: 0.81e0.99; Pheterogeneity Z 0.527, I 2 Z 0). Gender significantly modified the effects of nut consumption on stroke risk, and high nut intake was associated with reduced risk of stroke in women (SRR Z 0.85, 95% CI: 0.75e0.97) other than in men (SRR Z 0.95, 95% CI: 0.82e1.11). Conclusion: The current meta-analysis provides some evidences for the hypothesis that high intake of dietary nut was inversely associated with stroke risk, whereas dietary legumes intake was not associated with stroke risk. ª 2014 Elsevier B.V. All rights reserved.
Introduction Stroke is the second leading cause of death in both developed and developing countries, and its prevalence and disability burden are expected to increase in the future
* Corresponding author: Department of Anesthesiology & Surgic Intensive Care Unit, South Branch, Ren Ji Hospital, School of Medicine, Shanghai JiaoTong University, 2000 Jiangyue Road, Minhang District, Shanghai 201112, China. Tel./fax: þ86 021 58752345. E-mail address: [email protected] (Z.Z. He). 1 Both authors contributed equally to this work.
due to population aging [1]. In the United States, every 40 s, one person suffers from a stroke, and every 4 min, one person dies of stroke [2]. Therefore, knowledge of risk factors and protective factors associated with stroke is essential for the development of prevention strategies. Both hypertension and type 2 diabetes (type 2 DM) are major risk factors for stroke and can be influenced by modifiable lifestyle factors including diet. Among dietary factors, both nuts and legumes are good sources of vegetable protein, fiber, phytosterols, vitamins, and minerals [3], and are low in saturated fatty acids and high in monoand polyunsaturated fat acids (MUFAs and PUFAs,
http://dx.doi.org/10.1016/j.numecd.2014.06.009 0939-4753/ª 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
2
respectively). Evidences from in vitro and in vivo studies indicated that legumes might reduce the risk of stroke via effects on improving insulin sensitivity [4] and antiinflammation [5]. Findings from observational studies and clinical trials suggested that dietary legume intake was inversely associated with risk factors for stroke such as hypertension [6,7] and type 2 DM [8]. For dietary nut intake, preventative effects of high nut consumption on the pathogenesis of hypertension and type 2 DM had been observed in several cohort studies [9e11], although not in the others [12e15]. It is thus possible that these physiologic effects of nuts and legumes may confer a lower risk of stroke among people who consume them on a regular basis. In this meta-analysis of the associations between dietary nut and legume intake and risk of stroke, we focused on only prospective cohort studies due to the following: (1) no systematic reviews and meta-analyses have looked at the effects of dietary nut and legume intake on the overall risk of stroke. (2) Both caseecontrol and crosssectional designs are subjected to the selection and recall bias, and the prospective evidences on these associations have been reported with inconsistent results [16e22]. (3) Only two clinical trials were reported for stroke risk and intakes of soy [23] and nut [24], respectively. Therefore, we preformed the quantitative review to examine these associations following the meta-analysis of observational studies in epidemiology (MOOSE) [25]. Methods Literature search Two investigators (S.Z.Q. and T.J.J.) made a systemic search of MEDLINE and EMBASE up to 31 January 2014 to identify all published articles including the following medical subject headings or keywords: (1) soy OR soybeans OR beans OR peas OR legumes OR tofu OR lentils OR vegetable OR nut OR peanut OR walnut OR almond OR pine OR hazel OR ginkgo; (2) cerebrovascular accident OR brain ischemia OR intracranial hemorrhages OR cerebral hemorrhage OR subarachnoid hemorrhage OR stroke. There was no language limitation. A manual search of the references cited in all of the obtained literature was also conducted. Any disagreements were solved by a third reviewer (H.Z.Z.). Study selection To be included, studies had to meet the criteria as follows: (1) prospective cohort studies published as original articles; (2) providing legume/nut consumption categories and stroke risk; and (3) reporting relative risks (RRs) and corresponding 95% confidence intervals (CIs) quantifying the association between consumption of legumes/nuts and stroke risk. Animal studies, in vitro researches, case reports, ecological studies, and reviews were not considered eligible. If multiple papers reported results from the same cohort, we included the one with the largest number of cases. Two investigators (S.Z.Q. and T.J.J.) independently
Z.Q. Shi et al.
reviewed all potentially relevant articles to determine whether an article met the general inclusion criteria, and disagreement was resolved by a third reviewer (H.Z.Z.). Data extraction From each study, the following characteristics were extracted by two investigators (S.Z.Q. and T.J.J.): first author’s surname, publication year, study location, duration of follow-up, the number and age of the subjects, the methods used for collection of data on exposure, stroke outcomes, confounding factors, and the RR estimates with the corresponding 95% CI for all categories of intake. Most of the studies assessed stroke risk with respect to total legume/nut consumption. When more than one type of legume/nut was evaluated, we selected the most representative one. This measurement was prioritized in a descending order of total legumes/nuts, a certain type of legumes/nuts or its product. If separate risk estimates for men and women and for subtypes of stroke were available in one study, we treated it as separate studies. From each study, we extracted the risk estimates with the greatest number of adjustments. Assessment of study quality Two investigators (S.Z.Q. and T.J.J.) assessed the quality of each selected study using the NewcastleeOttawa quality assessment Scale (NOS) [26]. Any discrepancies were addressed by a third reviewer (H.Z.Z.). For cohort studies, the NOS consists of three parameters of quality: selection (four points), comparability (two points), and outcome (three points), and a maximum of nine points reflect the highest quality. A total score of seven or greater was used to indicate high-quality studies and a total score of six or smaller indicated low-quality studies. Statistical methods We used the statistical program STATA, version 11.0 (STATA, College Station, TX, USA) for the analysis. A twotailed P < 0.05 was considered statistically significant. We used the method of a random-effects model, which accounts for heterogeneity among studies [27], to calculate summary RRs (SRRs) and 95% CIs for the highest versus lowest analysis. Statistical heterogeneity among studies was assessed using both the Q statistic and the I2. Results were defined as heterogeneous for P-values 50% was considered a measure of moderate-high heterogeneity, a value 6; Supplementary Table 1). Legume consumption and total stroke risk Six studies, including 173,229 participants and 4030 stroke events, presented results on the highest versus lowest level of dietary legume intake and total stroke risk [18e22]. As shown in Fig. 2A, the SRR was 0.95 (95% CI: 0.84e1.08) for subjects in the highest category of legume consumption compared with those in the lowest category. There was moderate heterogeneity among studies (Pheterogeneity Z 0.091, I2 Z 43.2%). When we included only
Figure 1 Flow diagram of systematic literature search on nut and legume intake and risk of stroke.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
4
Author/Year/Country
Study characteristics
Follow-up, yrs Dietary assessment Outcome ascertainment
Exposure details
Risk estimation (95% CI) Adjustments
Legumes van der Schouw/2005/ EPIC Netherland N Z 16,165, F, age: 49e70; n Z 147 Kokubo/2007/Japan
Nagura/2009/Japan
Mizrahi/2009/Finnish
6.3
JPHC 12.5 N Z 40,462; age: 40e59 n Z 587; M þ F
JACC N Z 59,485, M þ F n Z 1053; age: 40e79
12.7
FFQ-79, validated
fatal or non-fatal Isoflavones Q1 cerebrovascular Isoflavones Q2 events Isoflavones Q3 Isoflavones Q4 FFQ-147, validated non-fatal IS Soy: 0e2 d/week, M Soy: 3e4 d/week, M Soy: 5 d/week, M Soy: 0e2 d/week, F Soy: 3e4 d/week, F Soy: 5 d/week, F self-administered FFQ-33
Finnish Mobile Clinic Health Examination Survey: N Z 3,932, M þ F, age:40-74, n Z 625
24
Bernstein/2012/USA
NHS, N Z 121,700; F; Age:30e55 n Z 2633
22
self-administered FFQ validated
non-fatal Total IS ICH
Bernstein/2012/USA
HPFS: N Z 51,529; M; Age:40e75 n Z 1397
26
self-administered FFQ validated
non-fatal Total IS ICH
9
Validated FFQ-127
Fetal stroke
Nuts Yochum,2000/USA
IWHS,N Z 34,492, F, aged 55e69 y; n Z 215
self-administered FFQ validated
Fatal Total ICH IS
fatal or non-fatal IS ICH
1.00 0.96 1.09 1.05 1.00 0.85 0.95 1.0 0.81 0.64
(0.60e1.52) (0.68e1.73) (0.64e1.70) (0.65e1.11) (0.72e1.26) (0.55e1.19) (0.43e0.95)
Bean: 0$8 servings/week Bean: 1$8 servings/week Bean: 3.0 Servings/week Bean: 4.5 servings/week Legumes: 0e2 g/d, IS Legumes: 3e5 g/d, IS Legumes: 6e9 g/d, IS Legumes: 10e101 g/d, IS Legumes: 0e2 g/d, ICH Legumes: 3e5 g/d, ICH Legumes: 6e9 g/d, ICH Legumes: 10e101 g/d, ICH Legumes: 0.07 Servings/d Legumes: 0.14 Servings/d Legumes: 0.17 Servings/d Legumes: 0.24 Servings/d Legumes: 0.43 Servings/d Legumes: 0.07 Servings/d Legumes: 0.14 Servings/d Legumes: 0.17 Servings/d Legumes: 0.24 Servings/d Legumes: 0.43 Servings/d
0$79 (0$59e1$06) 0$74 (0$55e1$00) 0$72 (0$54e0$96) 1.00 1$34 (0$64e2$79) 1$31(0$62e2$74) 1$44 (0$70e2$96) 1.00 0.99 (0.87e1.13) 1.19 (1.04e1.36) 1.05 (0.92e1.19) 1.06 (0.93e1.22) 1.00 1.03 (0.86e1.23) 1.06 (0.89e1.26) 1.04 (0.87e1.24) 1.07 (0.89e1.29)
Nuts Nuts Nuts Nuts
1.00 0.85 (0.61, 1.18) 0.79 (0.50, 1.24) 0.73 (0.41, 1.29)
and and and and
seeds:0 times/mo seeds:1e2 times/mo seeds:3e4 times/mo seeds: >4 times/mo
1$00 1$02 (0$85, 1$22)
Age, BMI, smoking, physical activity, DM, HBP, hypercholesterolemia, HRT use, etc Age; sex; smoking; alcohol use; BMI; HBP, DM; medication use for hypercholesterolemia; education level; sports; dietary intake, menopausal status, etc. Age, sex, BMI, smoking, alcohol intake, walking, hours of sleep, education, HBP, DM, etc.
1$14(0$95, 1$38) 0$95 (0$79, 1$16) 1.00
Age, sex, BMI, smoking, physical activity, serum cholesterol level, HBP and energy intake
Age, BMI, cigarette smoking, physical exercise, parental history, menopausal status, etc. Age, BMI, cigarette smoking, physical exercise, parental history of early myocardial infarction, menopausal status, etc. Age, total energy intake, BMI, HBP, DM, ERT, alcohol intake, education, marital status,
Z.Q. Shi et al.
Please cite this article in press as: Shi ZQ, et al., Consumption of nuts and legumes and risk of stroke: A meta-analysis of prospective cohort studies, Nutrition, Metabolism & Cardiovascular Diseases (2014), http://dx.doi.org/10.1016/j.numecd.2014.06.009
Table 1 Characteristics of the studies of the association between legume and nut consumption and stroke risk.
Bernstein/2012/USA
Bernstein/2012/USA
PHS, N Z 21,078, M, Age: 54.6, n Z 1424
21
NHS, N Z 121,00; F; Age:30e55 n Z 2633
22
HPFS: N Z 51,529; M; Age:40e75 n Z 1397
26
Validated FFQ-19
fatal or non-fatal Nuts: 0/week Total Nuts:
