Review

Novel Lines of Research on the Environmental and Human

Health Impacts of Nut Consumption
Linda Tapsell 1, Joan Sabaté 2, Raquel Martínez 2, Marc Llavanera 3,4, Elizabeth Neale 1 and Albert Salas-Huetos 5,6,7,*

1 School of Medical Indigenous and Health Sciences, University of Wollongong,

Wollongong, NSW 2522, Australia
2 Center for Nutrition, Lifestyle and Disease Prevention, School of Public Health, Loma Linda University,

Loma Linda, CA 92350, USA

3 Unit of Cell Biology, Department of Biology, Faculty of Sciences, University of Girona, 17003 Girona, Spain

4 Biotechnology of Animal and Human Reproduction (TechnoSperm), Institute of Food and Agricultural

Technology, University of Girona, 17003 Girona, Spain

5 Unit of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Universitat Rovira

i Virgili, 43201 Reus, Spain

6 Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University,

Boston, MA 02115, USA

7 Consorcio CIBER, M.P., Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III

(ISCIII), 28029 Madrid, Spain

* Correspondence: [email protected]; Tel.: +34-977-75-93-79

Abstract: Nuts have formed part of human diets throughout the ages. In recent decades, research
has shown they are key foods in dietary patterns associated with lower chronic disease risk. The
current state of climate change, however, has introduced an imperative to review the impact of di-
etary patterns on the environment with a shift to plant-based diets. Nuts emerge as a significant
source of protein in plant-based diets and are a minimally processed and sustainable food. Research
in this area is evolving to drive better production methods in varying climate conditions. Neverthe-
less, nut consumption remains an important contributor to human health. The mechanisms of action
can be explained in terms of the nutrients they deliver. Studies of nut consumption have linked
Citation: Tapsell, L.; Sabaté, J.; components such as monounsaturated fatty acids, plant omega-3 fatty acids, antioxidants, and plant
Martínez, R.; Llavanera, M.; sterols to improved lipoprotein profiles, lower blood pressure, and reduced cardiovascular disease
Neale, E.; Salas-Huetos, A. Novel
risk. Preliminary research also indicates possible beneficial effects of nut consumption on reproduc-
Lines of Research on the
tive health. In any case, the ultimate effects of foods on health are the results of multiple interactive
Environmental and Human Health
factors, so where nuts fit within dietary patterns is a significant consideration for research transla-
Impacts of Nut Consumption.
tion. This has implications for research methodologies, including categorization within food groups
Nutrients 2023, 15, 955.
https://doi.org/10.3390/nu15040955
and inclusion in Healthy Dietary Indices. The aim of this narrative review is to outline new focal
points for investigation that examine the environmental and some novel human health impacts of
Academic Editor: Licia Iacoviello
nut consumption and discuss future directions for research.
Received: 17 January 2023
Revised: 10 February 2023 Keywords: nuts; environment; sustainability; reproduction; sexual function; diet; dietary patterns
Accepted: 13 February 2023
Published: 14 February 2023

1. Introduction
Copyright: © 2023 by the authors. Li- As naturally occurring edible and nutritious foods, nuts have been part of the human
censee MDPI, Basel, Switzerland. diet throughout the ages [1]. Modern nutrition science provides evidence of their health
This article is an open access article benefits, but foods have not always been the object of nutrition research, with a focus in
distributed under the terms and con-
past decades on nutrients contained in foods. At the same time, the industrialization of
ditions of the Creative Commons At-
the food supply saw the emergence of chronic lifestyle-related diseases, such as obesity,
tribution (CC BY) license (https://cre-
cardiovascular disease (CVD), and type 2 diabetes. Research identified so-called ‘nega-
ativecommons.org/licenses/by/4.0/).
tive’ components of the diet including dietary fat and excess energy consumption [2],

Nutrients 2023, 15, 955. https://doi.org/10.3390/nu15040955 www.mdpi.com/journal/nutrients

Nutrients 2023, 15, 955 2 of 17

which translated to dietary advice and created an ambiguous position for nuts as a high-
energy, high-fat food.
Population-based dietary guidelines appeared in the 1980s aimed at providing ade-
quate nutrition and preventing chronic disease. Early guidelines referred to staple food
groups, with advice to avoid foods high in fat, sugar, and salt [2]. The position of nuts in
food groups was variable, but the value of naturally occurring foods, captured in the con-
cept of food synergy [3], and an appreciation of the relationship between nutrients, foods,
and dietary patterns [4] led to today’s guidelines having a greater focus on dietary pat-
terns. Research on nuts followed this direction, expanding beyond their nutritional con-
tributions to nuts as a significant food in healthy dietary patterns. Direct clinical evidence
of health effects came from trials involving at-risk populations. Basic science research pro-
vided insights into the molecular pathways underlying health effects, and epidemiologi-
cal studies confirmed that associations between nut consumption and health outcomes
occurred in the broader population. Each of these types of research were important in
building the body of evidence, despite challenges in providing timely and consistent stud-
ies to support nutrition policy and practice [5–7]. At the same time, clinical evidence re-
view methodology has developed further to consider the quality as well as quantity of
research. This development recognized that research practices and study designs require
sufficient scrutiny to assure confidence in results and valid translation to practice [8].
Today, evidence supporting nut consumption is extensive. It goes beyond chronic
disease prevention to other forms of human health—including reproductive health—and
then to the planet’s health. The environmental impact of healthy dietary patterns is part
of the evidence analysis, as nuts are significant foods in plant-based diets. The global im-
perative to address climate change calls for additional research methodologies that ad-
dress the environmental impact of foods [8]. Today, there are strong calls to combine im-
peratives for human health with that of the environment [9].
The aim of this narrative review is to outline new focal points for research that exam-
ine the environmental and novel human health impacts of the consumption of nuts and
discuss future directions.

2. Nuts and Environmental Sustainability

Environmental sustainability is one of the most pressing new areas of research on
food today. Food production and consumption face unprecedented scrutiny as their im-
pact on the natural environment and human health becomes more evident. How foods
are grown (including water use), processed, sold, prepared, cooked, consumed, and dis-
posed of is crucial. In studying nuts and environmental sustainability, all these stages of
production and consumption (the ‘food system’) must be considered.
The global food system produces enough calories for a growing world population.
However, about half of the population is malnourished with almost 1 billion people not
consuming enough food and experiencing hunger, and almost 2 billion overconsuming
foods low in nutritional quality associated with micronutrient and phytonutrient deficien-
cies, obesity, and increased incidence of chronic disease. Globally, the non-optimal intake
of foods in the diet is estimated to account for approximately 22% of all deaths among
adults and 15% of disability-adjusted life-years [10]. At the same time, agriculture uses
~70% of the global freshwater [11]. The food supply chain is responsible for ~26% of global
greenhouse gas emissions (GHGe), occupies ~43% of habitable land, causes ~78% of the
ocean and freshwater eutrophication, and ~32% of terrestrial acidification worldwide [12].
Several strategies have been proposed to decrease the environmental pressures ex-
erted by the food systems. These include (1) improving agricultural technologies to en-
hance productivity and reduce harmful emissions; (2) reducing food loss and waste to
decrease food production requirements and waste emissions in landfills; and (3) shifting
to the production and consumption of foods that support human and planetary health
[13–16]. Thus, the type and amount of food produced and consumed are major determin-
ing factors in promoting human health within planetary boundaries [17,18]. Research can
Nutrients 2023, 15, 955 3 of 17

identify where nuts fit within these parameters. Addressing the environmental impacts of
the lifecycle of nuts (LCA, Lifecycle Analysis), from production to consumption, is one
way to approach this.
According to the Food and Agriculture Organization (FAO), environmentally sus-
tainable diets are “those diets with low environmental impacts which contribute to food
and nutrition security and to healthy life for present and future generations (…) while
optimizing natural and human resources [19].” We have previously identified four deter-
minants for, or dimensions of, a sustainable diet from the consumer’s perspective. These
dimensions are based on the ratios of dietary characteristics. They are (1) the proportion
of foods in the diet of animal versus plant origin, (2) the proportion of processed versus
whole foods, (3) the proportion of seasonal/locally sourced foods versus out-of-sea-
son/context, and (4) the proportion of foods consumed versus wasted [18] (Figure 1).

Figure 1. Characteristics of foods in a diet that determines its sustainability. The graphic illustrates
that a sustainable diet has a higher proportion of foods that are plant-based, whole, in-season, and
consumed with no or minimal waste [18].

Most diets (and most meals) have a mix of foods, each having different characteris-
tics. The inclusion of nuts in the diet is variable. The larger the amount and proportion of
foods in a meal or diet whose constituent foods are animal-sourced, processed, out of sea-
son or context (requiring transportation or refrigeration for storage), and wasted, the less
sustainable the diet is. Reciprocally, the higher the proportion of foods of plant origin
consumed, minimally processed, in season, and locally sourced, the more sustainable the
diet is. Thus, nuts would appear to have a place in sustainable diets.

2.1. Nuts as Sustainable Foods

At the consumption level, nuts are plant foods consumed whole or very minimally
processed; they have a “long season” (since they do not require refrigeration for storage,
can be transported and stored with minimal energy use), and have little waste. Thus, nuts
appear to be sustainable foods.
At the production level, however, concerns have been raised regarding the high wa-
ter usage and chemical inputs in the production of nuts under intensive agricultural prac-
tices. Importantly, this is not the case when nuts are grown in extensive or traditional
agricultural practices.
Nutrients 2023, 15, 955 4 of 17

2.1.1. Life Cycle Analysis

There is a relative paucity of published data from Lifecycle Analysis (LCA) on nuts.
Environmental impacts of foods can be measured using various units, including, per
weight (of edible amount), per serving, or, depending on the nutritional contribution of
each food, per grams of protein or energy (kcal) [20–22]. This can be problematic for some
foods such as nuts. For example, many food comparisons regarding environmental im-
pacts have been based on edible amounts (by weight), giving nuts mixed results. A com-
monly recommended nut serving size is small (approximately 30 g) compared to other
foods (often 50–120 g or even 240 g for most beverages). However, nuts are also energy-
dense foods (less than 5% water) whose main nutrients are fat and protein. As a result,
the environmental impacts of certain nuts measured per grams of protein are very low
compared to other animal-sourced protein-rich foods.
We conducted a LCA of five common food sources of protein: legumes, nuts, eggs,
poultry, and red meat—specifically, kidney beans (Phaseolus sp.), almonds (Prunus dulcis),
eggs, chicken, and beef as produced in Californian agricultural practices [23]. When using
beans as the reference (legumes are nature’s most efficient production of protein), almond
protein is the second best ranked after beans for most environmental parameters except
for pesticides (Figure 2).

Figure 2. Relative Environmental Impacts of Protein Food Sources in relation to protein from beans
[23].

Clark and colleagues [24] analyzed LCA data from meta-analyses to determine the
impact of fifteen foods on environmental depreciation, encompassing five components:
plausible acidification, eutrophication, GHGe, land use, and scarcity-weighted water use.
Of the fifteen analyzed foods, red meat (100 g), chicken (100 g), eggs (50 g), legumes (50 g
dried weight; DW), and nuts (28 g) represent protein sources [25]. Each food was depicted
in a radar plot, illustrating the rank-ordered impingement on designated environmental
parameters per daily food serving. When comparing nuts, eggs, and red meat, nuts per-
formed relatively well on all environmental parameters except water use. The environ-
mental impact per serving of eggs per day serves as an intermediate. Red meat received
the highest or most detrimental rank in all five environmental parameters, thus corre-
sponding with previous research [23].
Nutrients 2023, 15, 955 5 of 17

The foods were rank-ordered from least to most environmentally impactful per serv-
ing produced [24]. Nuts ranked lowest (least harmful) for GHGe among all fifteen foods.
Among the five protein food sources, nuts ranked lowest in eutrophication potential and
second lowest in acidification and land use. However, in conjunction with previous schol-
arly [26] and media [27,28] critiques on nut production and water use, nuts ranked second
highest in scarcity-weighted water use, only exceeded by red meat. These findings imply
that the environmental impact of a 28 g serving of nuts is less aggravating than that of a
100 g serving of red meat, although water use is of concern.

2.1.2. Water Footprint

The situation for nuts requires further examination of the term ‘water use’. This com-
plex issue may be better addressed by considering distinct ‘water footprints’ referring to
‘blue water’ (surface plus groundwater, often used in irrigation [29]) and ‘green water’
(rainwater consumed with agricultural production [26]). Mekonnen and Hoekstra calcu-
lated the water footprints of nuts [26] and farm animals [30] from 1996 to 2005. Vanham
and colleagues [31] applied the water footprint computations to demonstrate the blue and
green water footprint of nuts and animal proteins (beef, eggs, chicken, pig meat, and sheep
meat) in liters per kilogram and liters per gram of protein. In the context of liters per kil-
ogram, shelled cashew (Anacardium occidentale) nuts have the most prominent combined
blue and green water footprint among all nuts and triple that of beef. The water footprints
of almonds and pistachios are also considerable, exceeding 10,000 L per kilogram. Among
the selected animal proteins, eggs have the lowest water footprint. When comparing the
water footprint by food weight, the sustainability of nuts appears unfavorable; however,
as previously mentioned, protein is a sizable component of nuts’ nutrients, suggesting
that water footprint expressed per gram of protein may be a more accurate representation
for this environmental impact.
Further clarification on the position of different types of nuts is seen through the wa-
ter footprint articulated in liters per gram of protein. Accordingly, the water footprint of
cashews remains higher than that of beef, whereas that of peanuts is lower than all five
animal proteins [31]. Moreover, the average green and blue water footprint of almonds,
hazelnuts (Corylus sp.), pistachios (Pistacia vera), and walnuts (Juglans sp.), combined, re-
main lower than beef’s water footprint when based on liters per gram of protein. Com-
paring the environmental impact of foods based on protein content rather than weight
may be valuable from a nutritional perspective, as eating patterns focus on nutrient levels
rather than weight.
Researchers must also address the location of nut production, as agricultural produc-
tion in water-scarce areas may have a greater impact on water footprint than locations
with greater water availability. Indeed, water stress, defined as the ratio of water used to
available water [32], varies according to region. For example, in California, the power-
house of almond production [33], high water stress [31] and water demand [34] are evi-
dent even though the carbon footprint is relatively low [35]. Agricultural practices, includ-
ing intensive versus extensive agriculture [36], require further consideration because these
determine the magnitude of resource utilization.

2.2. Future Research on Nuts and Sustainability

First and foremost, future research should prioritize collecting data on nut produc-
tion and sustainability using environmental parameters beyond water and GHGe. Alt-
hough data regarding acidification and eutrophication potency are available [24], they are
limited, and this confines the current comprehension of the environmental impact of pro-
ducing nuts. Furthermore, collecting and comparing data on the environmental impact of
nut production according to agricultural methods (intensive versus extensive), climate
setting, and location may clarify whether previous critiques of nut production and sus-
tainability are consistently reasonable across varied agricultural conditions.
Nutrients 2023, 15, 955 6 of 17

Certainly, an increase in the production and consumption of nuts, as recommended

by the EAT–Lancet Commission [9], a global initiative on food and planetary health, beck-
ons the question of whether eating more nuts is more sustainable than “healthier” diets.
If “healthier” diets were to incorporate conventional meat analogs, it would be necessary
to compare their sustainability with that of nuts. This would require quantifying the LCA
of nuts versus conventional meat analogs in isocaloric and isoprotein conditions. Addi-
tional modeling or use of diet records can be useful in describing the environmental im-
pact of nuts in previously defined dietary patterns.
The future of nuts in the diet may even involve replacing well-known meat analogs,
including texturized vegetable protein (TVP) [37], with nut-based meat analogs. Notably,
this implies assessing and comparing the sustainability of nut-based meat analogs with
current TVPs using the parameters discussed above.
In addition, nuts are an excellent source of fat, almost entirely unsaturated. They con-
tain mainly monounsaturated fatty acids (MUFAs) and some polyunsaturated fatty acids
(PUFAs), mostly n-6 PUFAs, while walnuts are a good source of vegetable n-3 PUFAs [38].
Given the importance of these essential and healthy fats, relevant research could include
the computation of LCA environmental inputs relative to the different food sources of
unsaturated fats, including n-3 PUFAs.
Unsustainable and unhealthy foods harm both planetary health and human well-be-
ing. Further research is required demonstrating and quantifying the environmental sus-
tainability of nuts. Specifically, more needs to be known about the efficient use of natural
resources and environmental protection in the production, preparation, and disposal of
nuts. Consumption needs to be addressed in terms of nuts as a single food, as an alterna-
tive to other foods, and in the context of healthy dietary patterns.

3. Nuts and Male Reproductive Health

From environmental concerns to effects on human biology, research on the health
effects of nuts has extended beyond the scope of chronic non-communicable diseases to
the support of human growth and development. One particularly novel area is that of
infertility, defined as the incapacity to conceive after one year or longer of unprotected
intercourse. Infertility affects approximately 15% of the world’s population [39]. Male fac-
tors are responsible for 40–50% of infertility cases, and an evident decline in semen quality
parameters has been reported over the last fifty years [40–43]. A recent meta-regression
analysis, including 185 studies and more than 42,000 men without known fertility prob-
lems, estimated a 50–60% decrease in sperm counts between 1973 and 2011 [44]. Accord-
ingly, despite the multicausal nature of male infertility, the examination of the factors neg-
atively affecting semen quality is warranted to develop novel strategies to prevent, diag-
nose, and treat male infertility disorders [45]. Several etiologies of male infertility have
been uncovered over the years, such as specific lifestyle factors, congenital/genetic disor-
ders, hormonal imbalances, or sexually transmitted diseases [45,46]. Among all male
(in)fertility-associated factors, lifestyle habits are modifiable factors highly associated
with sperm quality, which plays a key role in reproductive health [47].
Dietary patterns, specific foods, and their nutrient components have been reported
as essential factors for proper sperm function and male fertility [48]. The adherence to a
healthy diet [49–57], including the consumption of fruits and vegetables, nuts, fish, sea-
food, and whole-grain cereals, while avoiding excessive intake of processed high-fat prod-
ucts, alcoholic beverages, caffeine, and sugary drinks [49,58–61] have been positively as-
sociated with sperm quality (Figure 3).
Nutrients 2023, 15, 955 7 of 17

Figure 3. Supplement/nutrient intake, food consumption, and dietary pattern adherence positively
associated with sperm quality parameters [61].

In this regard, adhering to unhealthy dietary habits could exert a negative impact on
semen quality, thus impairing the function of male gametes and reducing or preventing
fecundability [45]. This warrants the study of novel dietary habits contributing to improv-
ing sperm quality and thereby reducing male-factor infertility.
Recognized as a component of healthy dietary patterns, nuts are nutrient-dense foods
rich in unsaturated fatty acids, fiber, minerals, vitamins (among them, tocopherols), phy-
tosterols, polyphenols, and other antioxidants. Nuts deserve special attention for their po-
tential role in male reproductive health, given the general beneficial impact on several
health outcomes [38,62–64]. The next section of the review examines the potential impact
of nut consumption on sperm quality and functionality, as well as on sexual function.

3.1. Nuts and Sperm Quality and Functionality

Animal models have demonstrated possible benefits of nut consumption for sperm
quality and functionality. Two recent articles focused on the effects of hazelnut [65] and
cashew [66] supplementation. In one study, Kara et al. randomized a group of rats into a
control (ad libitum laboratory standard diet) and hazelnut-supplemented feed group,
with a daily dose of 3 g hazelnut kg−1 bodyweight. The authors reported that the supple-
mentation corresponded to 5.5% of hazelnut in the diet and equated to 30 g day−1 in hu-
mans. Following a thirty-day intervention, the inclusion of hazelnuts significantly im-
proved sperm vitality. Moreover, the hazelnut intervention also significantly improved
the Johnsen’s testicular histologic score, a system conventionally used to evaluate the com-
pleteness of testicular spermatogenesis, and reduced apoptotic indices [65]. In another
study, Akomolafe et al. investigated the effect of cashew nut supplementation on fertility
in rats. The rats were randomly divided into six diet groups with varying cashew nut (10
to 20%) and clomiphene citrate composition in the diets. The combination of cashew nut
supplementation and clomiphene citrate significantly increased epididymal sperm count,
vitality, and motility, and decreased total sperm abnormalities in comparison to the con-
trol [66]. These findings suggest that the inclusion of nuts (e.g., hazelnuts or cashews) may
be useful to treat male partners suffering from sperm quality problems and infertility is-
sues.
The effects of nut consumption on sperm quality have been tested in humans in two
randomized clinical trials (RCT) [67,68]. Robbins and collaborators were the first to report
Nutrients 2023, 15, 955 8 of 17

substantial improvements in sperm vitality, motility, and morphology after the inclusion
of 75 g day−1 of walnuts for 12 weeks by 117 healthy men following Western-style diets
[67]. The authors attributed these improvements to the increase in blood n-6 PUFAs and
alpha-linolenic acid (ALA), the vegetable n-3 PUFA, hypothesizing on potential mecha-
nisms of action (ALA is a well-established biomarker of walnut consumption [69,70]). In
a second study, the FERTINUTS trial, Salas-Huetos et al. evaluated the effect of chronic
consumption of mixed nuts (almonds, hazelnuts, and walnuts) on changes in conven-
tional semen parameters, implicating several potential mechanisms. A total of 119 healthy
reproductive-age men consuming a Western-style diet were randomized and allocated to
two diet groups, one enriched with 60 g mixed nuts day−1 and the other devoid of nuts.
The inclusion of nuts significantly improved total sperm count and sperm cell vitality,
motility, and morphology, and these findings were explained in terms of a reduction in
sperm DNA fragmentation [68]. Nut consumption was also associated with a reduction
in the micro-RNA hsa-miR-34b-3p expression level [68] and with differential methylation
in 36 genomic regions between the baseline and the end of the trial [71]. These studies
suggest that sperm epigenome mechanisms can respond to diet.

3.2. Nuts and Sexual Function

Erectile function and sexual desire are directly influenced by lifestyle factors such as
diet through the vascular and nervous systems. For example, Esposito et al. described a
direct association between Mediterranean diet adherence and erectile function [72,73], but
few authors have studied the most relevant food groups. One early prospective study on
nuts involved 17 male patients with erectile dysfunction in an intervention provided with
100 g of pistachios per day for 3 weeks. The authors demonstrated for the first time that a
pistachio-supplemented diet improved several of the scores in the International Index of
Erectile Function (IIEF), including those related to sexual desire, orgasmic function, and
erectile function, among others [74]. However, this was a non-randomized clinical study
with outcomes measured before and after the intervention only, which detracts from its
quality and casts doubt on the findings. On the other hand, using data from the
FERTINUTS trial, Salas-Huetos et al. demonstrated that 60 g day−1 of mixed nuts (walnuts,
hazelnuts, and almonds) during 14 weeks positively modulated erectile function and sex-
ual desire scores [75]. However, these studies failed to show that these improvements re-
sulted from changes in peripheral levels of nitric oxide or E-selectin, two of the main en-
dothelial function markers. Highlighting the limitations of this research, the authors called
for equivalence trials with defined primary outcomes to demonstrate these effects.

3.3. Future Research on Nuts and Reproductive Health

Although investigations have begun in this fascinating area, questions remain largely
open. In general, more observational studies of good quality and RCTs with larger sample
sizes and well-defined inclusion/exclusion criteria are needed to make any recommenda-
tions for the general population. We need a better understanding of the mechanisms of
action that modulate fertility status and sexual function. Consuming nuts may help to
improve the main parameters of semen quality, but there are no current RCTs addressing
the effect of paternal and maternal nut consumption and fecundability outcomes. Well-
designed intervention and prospective studies in preconception cohorts will help under-
stand the role of nuts in fecundability rates.

4. Nuts as Components of Healthy Dietary Patterns

Research involving nuts that addresses the pressing needs of environmental sustain-
ability and novel areas of health, such as reproductive health, both come back to the ques-
tion of how nuts fit within healthy dietary patterns. This level of research is also evolving,
with particular implications for methodological development and translation to policy
and practice. While there is a strong history of cultural use of nuts in the human diet,
Nutrients 2023, 15, 955 9 of 17

particularly in the Mediterranean regions [1], their broad inclusion in dietary guidance
reflects advances in nutrition science. In the last century, there was a focus on nutrients as
the basis for providing this guidance [2], but this has evolved to dietary patterns as the
burden of disease has shifted to chronic lifestyle-related disease. These non-communica-
ble diseases have multiple and interacting dietary determinants, which best reflect a pat-
tern of food consumption and the synergy that exists between nutrients in foods and foods
in a diet [4]. Dietary patterns are now listed among research priorities in a number of
authoritative nutrition-related areas, including the US National Institutes of Health
“https://dpcpsi.nih.gov/onr/strategic-plan (accessed on 12 February 2023)”, The Austral-
ian Academy of Science “https://www.science.org.au/files/userfiles/support/reports-and-
plans/2019/2019-nutrition-decadal-plan.pdf (accessed on 12 February 2023)”, and the Eu-
ropean collaboration reflected in the EAT–Lancet papers [9].
As naturally occurring plant foods, nuts have a unique nutritional composition char-
acterized by significant proportions of unsaturated fatty acids, fiber and phytosterols, key
micronutrients (such as vitamin E and selenium), and polyphenols. Importantly, this re-
flects the biochemistry of the nut as a living organism, with an interdependence of the
nutrients contained therein [76]. Not surprisingly, research has shown that nuts form part
of healthy dietary patterns. This last section of the review outlines the research on nuts in
healthy dietary patterns, issues relating to their positioning, and directions for future re-
search.

4.1. Nuts in Healthy Dietary Patterns

Nut consumption is a key component of numerous dietary patterns known to be as-
sociated with a range of health benefits [77]. For instance, nuts feature prominently in diet
quality indices such as the Healthy Eating Index (HEI), Alternate Healthy Eating Index
(AHEI), and Dietary Approaches to Stop Hypertension (DASH) score, all of which have
been associated with a significant reduction in risk of all-cause mortality and incidence of
chronic diseases such as (CVD), type 2 diabetes, and cancer [78]. The Mediterranean diet,
which has been consistently associated with reduced risk of chronic diseases [79], has reg-
ular consumption of nuts as a key feature. Furthermore, examination of a posteriori die-
tary patterns identified in prospective cohort studies observed that ‘prudent diets’ were
associated with reduced risk of coronary heart disease and included a range of beneficial
foods, including nuts [80].
Clinical trials have confirmed the beneficial effects of including nuts as components
of healthy dietary patterns. For example, the PREDIMED trial, which examined the effect
of a Mediterranean diet supplemented with either mixed nuts or olive oil, found a range
of health benefits, including reduced incidence of cardiovascular events, when compared
to advice on a low-fat diet [62]. A network meta-analysis comparing the effects of con-
sumption of foods and markers of disease in RCTs found that, of the food groups exam-
ined, increased consumption of nuts, legumes, and whole grains resulted in the greatest
improvements in intermediate risk markers for CVD, nuts being particularly beneficial
for reducing LDL cholesterol [81]. Similarly, the inclusion of 30 g of walnuts a day in ad-
dition to an interdisciplinary intervention (inclusive of dietary support) for 12 months was
found to result in greater weight loss in overweight participants compared to a control
diet [82]. These findings are particularly relevant given that nuts are an energy-dense
food, with consumers reporting concern regarding the effects of nuts on body weight
[83,84]. However, recent meta-analyses have demonstrated that nut consumption does
not result in weight gain or increased abdominal adiposity [85], regardless of whether
nuts are advised or not to be substituted for other foods [86]. Taken together, these results
suggest that nut consumption plays an important role in healthy dietary patterns, with no
adverse effects on body weight.
Given the recognized importance of nuts in healthy dietary patterns, regular con-
sumption of nuts is recommended in dietary guidelines globally [87]. While some dietary
guidelines [88,89] classify nuts as a food group, many others categorize them with other
Nutrients 2023, 15, 955 10 of 17

foods, typically either protein foods [90–95] or fats and oils [96–98], and some guidelines
include nuts in both food groups [99–101]. Quantitative recommendations for nut con-
sumption vary between guidelines and appear based on recommendations for the food
group, which includes nuts, although the serving size provided in guidelines typically
ranges from 15 to 30 g. While approaches to food categorization tend to reflect the protein
and fat composition of nuts, variations in food group allocations present challenges when
comparing population intakes to recommendations.
Despite the current inclusion in dietary guidelines, population intakes do not appear
to meet recommended levels for nut consumption. The 2017 Global Burden of Disease
Study noted that global consumption of nuts was approximately 12% of the optimal intake
of nuts and seeds (considered to be 21 g per day) [10]. Results from national surveys sim-
ilarly highlight a common issue of low nut consumption. For instance, a secondary anal-
ysis of a subset of the 2005–2018 National Health and Nutrition Examination Survey
(NHANES) from the United States of America found 12.9% of adult males and 9.1% of
adult females met recommendations to consume 30 g or more of nuts per day [102]. Anal-
ysis of the 2011–2013 National Nutrition and Physical Activity Survey in Australia found
5.6% of individuals consuming nuts met the recommendation to eat 30 g of nuts per day
[103]. Of note, under 40% of Australians reported consuming nuts during the survey, de-
spite nut consumption including nuts in mixed dishes such as breakfast cereals or muesli
bars. Similarly, the European Prospective Investigation into Cancer and Nutrition (EPIC)
study found that on the day of the 24 h recall, less than 30% of respondents consumed
nuts from any source, although it should be noted that nut intake did vary substantially
among countries [104]. These results suggest that population intakes globally do not
match current recommendations for nut consumption and highlight the need for in-
creased nut consumption as part of a healthy dietary pattern.

4.2. Positioning Nuts in the Diet

Translating the evidence supporting nuts in healthy dietary patterns requires an un-
derstanding of nut consumption with other foods and within meals. The lack of congru-
ence between recommendations and actual intakes suggests more work is required in that
area. Nuts can serve as snack foods, and while research has exposed their impact on diet
quality when substituted for poor-quality snacks [105], positioning them as snacks can
align them with incidental, non-staple foods. In addition, theoretical positions of nuts in
trials of healthy dietary patterns does not always translate to their inclusion as a staple
food. For example, nuts were critical foods in the PREDIMED study, which demonstrated
the CVD-preventive effects of the Mediterranean diets supplemented with extra-virgin
olive oil or mixed nuts [62], but were less obvious in a study of staple foods in the context
of food insecurity in the USA [106]. On the other hand, nuts are emerging as key foods in
sustainable diets [107].
Behind this issue lies the question of collecting and managing research data on nuts.
One suggestion is to create a separate food group of nuts, possibly with seeds as contem-
poraries [108]. This would clarify measurement in dietary surveys, albeit with a need to
address the name of the group, serving size, and frequency of consumption. There are also
implications for how nuts might be included in dietary indices that evaluate diet quality
and how they might fit within a cuisine pattern. Even if this were the case, there have been
major shifts away from naming food groups in terms of actual foods, with a greater focus
on degree of processing.
The NOVA system of food categorization [109] places nuts favorably in the desired
‘unprocessed or minimally processed’ food category. This position is consistent with ac-
companying research that indicates a risk to cardiovascular health with ultra-processed
foods, explainable through the loss of natural food synergy, displacement of healthy
foods, and high content of saturated fat, sugar, and salt [110]. There is substantial debate
on this methodological development, arguing the issue of misclassification with the
NOVA system, the lack of associated conventional research, and the adequacy of current
Nutrients 2023, 15, 955 11 of 17

nutrient scoring systems [111]. Nevertheless, the minimally processed food category is
consistent with staple foods recommended in dietary guidelines [112], which may assist
in better compliance. The debate has brought into question not just food groupings, but
food classification systems in general used in the review of dietary guidelines [113].
Whether these are nutrient-based rating or scoring systems, or food categories based on
processing (such as NOVA), or dominant nutrient contribution (as in dietary guidelines),
there is wide variation in agreement in the way they present the health potential of indi-
vidual foods.
Healthy dietary patterns tend to be investigated using forms of diet quality indices
or scores (for example, Mediterranean diet scores) [114]. They address the whole of diet
relationships with health outcomes, such as CVD risk, and take various approaches to the
consumption of foods and nutrients and/or dietary patterns/cuisines. It is important to
note, however, that they also serve various purposes: from health promotion activity to
food labeling requirements and from measuring relationships in observational studies to
effects seen in intervention trials. The positioning of nuts in instruments that address die-
tary patterns would need to take into consideration the purpose of the research activity.

4.3. Future Research on Nuts in Healthy Dietary Patterns

The ability to discern the impact of nuts in a dietary pattern, as with any food, will
depend on how they are categorized and treated in the analysis [77]. Of the two main
analytical approaches: a posteriori (looking for groups, identifying and naming patterns),
or a priori (using pre-determined dietary patterns), those using an Index (a priori ap-
proach) are the commonest, followed by Factor or Principal Component Analysis (a pos-
teriori approaches) [115]. This is also a developing area, with varying applications and
reporting systems, as well as attention to foods and/or nutrients. Building an argument
that deals with the interrelationship between foods and nutrients, however, strengthens
the evidence of food effects. For example, using Principal Component Analysis in a study
of baseline relationships between nutrients, foods, and dietary patterns with blood pres-
sure, the dietary pattern categorized by nuts, seeds, fruit, and fish was significantly asso-
ciated with lower blood pressure and with lower sodium:potassium ratio (a nutrient ratio
related to blood pressure) [116]. In this case, the analyses based on healthy foods and in-
tervening nutrients produced congruent outcomes.
Building the evidence base for nuts in healthy dietary patterns continues to rely on
epidemiology to provide evidence of associations, clinical trials to demonstrate effects,
and experimental laboratory studies to expose explanatory mechanisms [4]. Systematic
reviews, meta-analyses, and quality assessments add rigor to the process, but this is a
dynamic system requiring regular updates, oversight, and dedicated funding [7]. The pur-
pose of building the evidence base will also inform the nature of the research, and this
includes a consideration of transitional issues such as consumer communications. For ex-
ample, research has shown the presence of health claims influences consumer purchasing,
but there is more to do around how consumers understand and act on health claims in
relation to meal contexts and overall dietary patterns [117].

5. Conclusions
Nuts are healthy foods: they are a source of important micronutrients, unsaturated
fatty acids, protein, fiber, and plant sterols, and they form part of recognized healthy die-
tary patterns. Today, however, there is an imperative to review the impact of dietary pat-
terns on the environment. This has led to a shift to plant-based diets, where nuts emerge
as a significant source of protein. Health perspectives see nuts as a minimally processed
and sustainable food, but research at the production level is evolving. Given their high
nutritional value, environmental research is likely to drive better nut production methods
in varying climate conditions. Nuts remain an important contributor to human health,
with the mechanisms of action explained in terms of the nutrients they deliver. Studies
have linked nut consumption to better blood lipoprotein profiles and lower CVD risk, but
Nutrients 2023, 15, 955 12 of 17

early research is now indicating possible beneficial effects of nut consumption at the other
end of the life spectrum, namely reproductive health. This is a novel and interesting area
of new research with many questions open for further investigation. Whether we consider
the production of nuts or their consumption, the position of nuts in the dietary pattern
remains an issue. The ultimate effects of food on health are the results of multiple interac-
tive factors, so where nuts fit within dietary patterns is a significant consideration for re-
search translation. There are implications for research methodologies, including categori-
zation within food groups and inclusion in Healthy Dietary Indices.
One of the most significant issues for research translation is that the consumption of
nuts in many jurisdictions across the globe does not meet evidence-based recommenda-
tions. New areas of research, such as reproductive health discussed here, may help to in-
crease the recognition of nuts as important foods in the diet. Likewise, their role in plant-
based diets aimed at addressing environmental as well as health concerns may be casual.
While continuing to build the evidence base on the health benefits of nuts, a focus should
remain on methodology affecting the positioning of nuts in dietary assessment instru-
ments, which may, in turn, influence forms of communication to consumers.
In dietary surveys, a separate category of nuts (and possibly seeds) may address the
problem, as could the inclusion of nuts in healthy diet indices. Translational targets also
require clarity of purpose in research. The nutrition science community recognizes the
diversity of research methods to ‘advance discovery, interpretation and application of
knowledge’ [118]. This includes an appreciation of how different layers of knowledge cre-
ate the evidence base that enables appropriate (dietary) recommendations. In research on
the health benefits of nuts, expanding the scope of interest to health throughout the lifecy-
cle, especially in the area of reproductive health, and integrating research on environmen-
tal issues and sustainable diets represent very positive ways forward.

Author Contributions: Conceptualization, J.S., L.T. and A.S.-H.; Writing—Original Draft Prepara-
tion, J.S., L.T., M.L., E.N., R.M. and A.S.-H.; Writing—Review and Editing, J.S., L.T. and A.S.-H.;
Supervision, J.S., L.T. and A.S.-H. All authors have read and agreed to the published version of the
manuscript.
Funding: The NUTS 2022 conference was planned by the Rovira i Virgili University, with all the
expenses of the organization covered by Barcelo Congresos, including the fees related to publishing
the Proceedings in Nutrients. Barcelo Congresos SA has received funds from the International Nut
& Dried Fruit Council (INC). Neither the researchers attending the NUTS 2022 Conference, nor the
Rovira i Virgili University have received funds from the INC for this manuscript. Researchers’ travel
expenses and accommodation have been covered by Barcelo Congresos. Researchers did not receive
any additional financial support related to their participation in the NUTS 2022 conference. Spon-
sors did not have any role in organizing the conference, selecting, or inviting the speakers, nor in
the writing or reviewing the proceedings of the conference.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: We are grateful to the organizers and expert researchers participating in the
NUTS 2022: Where are we and where are we going? conference held in Reus, Spain.
Conflicts of Interest: L.T., J.S., E.N., and A.S.-H.; have received research funding through their in-
stitutions from several nut commodity boards. L.T. and J.S.; were non-paid members of California
Walnut Commission Scientific (CWC) Advisory Council. J.S.; has received honoraria from the CWC
for presentations. All other authors declare no competing interest.
Nutrients 2023, 15, 955 13 of 17

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