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Effects of Cashew Nut
Effects of Cashew Nut
Clinical Study
Effects of Cashew Nut (Anacardium occidentale L.) Seed Flour in
Moderately Malnourished Children: Randomized Clinical Trial
Ana Cristina Pereira de Jesus Costa,1 Mércia Kelly dos Santos Silva,1
Samae Batista de Oliveira,1 Luana Leite Silva,1 Alessandra Cruz Silva,1
Raidanes Barros Barroso,1 José de Ribamar Macedo Costa,2 Virlane Kelly Lima Hunaldo,2
Marcelino Santos Neto,1 Lı́via Maia Pascoal,1
Márcia Caroline Nascimento Sá Ewerton Martins,1 Floriacy Stabnow Santos,1
Leonardo Hunaldo dos Santos,3 Gledson Weslley Pereira Santos,4
Maria Aparecida Alves de Oliveira Serra ,1 Ariadne Siqueira de Araújo Gordon,1
Thiago Moura de Araújo,5 and Márcio Flávio Moura de Araújo 5
1
Nursing Department, Maranhão Federal University, University Avenue, S/N, Imperatriz, MA, Brazil
2
Food Engineering Department, Maranhão Federal University, University Avenue, S/N, Imperatriz, MA, Brazil
3
Natural Sciences Department, Maranhão Federal University, University Avenue, S/N, Imperatriz, MA, Brazil
4
Physical Education Department, Maranhão Federal University, University Avenue, S/N, Imperatriz, MA, Brazil
5
Health Sciences Institute, University for International Integration of the Afro-Brazilian Lusophony,
José Franco de Oliveira Street, S/N, Redenção, CE, Brazil
Received 13 September 2019; Revised 22 February 2020; Accepted 24 March 2020; Published 5 May 2020
Copyright © 2020 Ana Cristina Pereira de Jesus Costa et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
The monitoring and combined use of dietary supplements to restore adequate growth are paramount and highly recommended in
child malnutrition, an important public health problem. The objective of this study was to analyze the effects of cashew nut seed
flour in children with moderate malnutrition, treated at primary healthcare services. This is a randomized clinical trial conducted
from April to October 2017 in the city of Imperatriz, Brazil. The sample comprised 30 children born at term, aged between 2 and
5 years, and newly diagnosed with malnutrition (60 days or less), randomized into experimental and control groups. The in-
tervention consisted of daily intake of cashew nut seed flour. There was intragroup statistically significant difference in the glucose
levels of children who were assigned to the control group (p � 0.02) and in the glycated hemoglobin in the experimental group
(p < 0.01). Intergroup analysis of glycated hemoglobin levels showed statistically significant differences in favor of the exper-
imental group (p � 0.01). HDL and LDL had, respectively, increased and decreased in the experimental group. The use of cashew
nut seed flour in a 24-week period had positive effects on glycated hemoglobin, HDL, and LDL parameters in moderately
malnourished children.
affect the entire body depending on the length [4]. Some clinical and metabolic complications of malnu-
According to the intensity and permanence, these changes trition can be detected based on these biochemical pa-
will cause a greater or lesser degree of clinical signs and rameters, which often are related to infections, anemia,
symptoms [5]. hypovitaminosis, and functional deficiencies. Such com-
Regardless of the initial cause, nutritional imbalances plications generate decreased physical capacity, stunted
can lead to changes in the body’s reserves, resulting in growth, and deficits in cognitive and behavioral develop-
biochemical/metabolic disorders [6]. Functional disorders ment in children [21, 22]. The aim of this study was to
are clinical manifestations detectable in the physical ex- determine whether the intake of cashew nut seed flour
amination of severely malnourished individuals with widely modifies the biochemical parameters of moderately mal-
recognized anatomical changes that may be reversible or nourished children in Brazilian primary care services.
evolve into loss of function or even death [2]. Some guidelines specify the treatment or management of
Child malnutrition is a risk factor for morbidity and moderate malnutrition, considering the impact of this problem
mortality, and it is often associated with changes in the child on death from common diseases or increased risk for acute and/
health indicators [7]. The most used parameter in the or severe malnutrition and its associated complications [23].
analysis of the nutritional status is the assessment of growth To the best of our knowledge, this is the first randomized
through regular monitoring of standards such as weight-for- clinical trial that used biochemical parameters to evaluate
age, height-for-age, and weight-for-height. However, it is moderately malnourished children. We hypothesized that
strongly recommended that other indicators be monitored, children with normal height and moderate malnutrition (when
which makes it possible to expand knowledge of organic the weight deficit considered normal for the age is below 25 and
imbalances caused by malnutrition [8, 9]. 40%), aged from 2 to 5 years, showed improvement in bio-
Currently, there is no consensus on which dietary chemical parameters after the use of cashew nut flour.
supplements are the best to treat malnutrition. Throughout
the human history, supplements have been used in the 2. Methods
treatment of diseases as part of popular culture, which is
often discredited [10, 11]. However, given the scale of 2.1. Design. This is a randomized, open, prospective trial
malnutrition and socioeconomic and health costs associated that was conducted from April 2017 to October 2017 in the
with it, there is growing scientific interest in this issue, given city of Imperatriz, Brazil.
the fact that many families use and continue to use dietary
natural products to combat malnutrition [3, 12].
Studies show that dietary supplementation may be ef- 2.2. Participants. The study population was composed of
fective in the recovery of malnourished children, when it is malnourished or low weight children, according to the
composed of essential nutrients for growth/development criteria of the World Health Organization (WHO), z score
and when it is associated with periodic anthropometric, (−2<z < −3), and the indicator weight x height x body mass
biochemical, and nutritional assessments [2, 13, 14]. index (BMI) for age [3]. The sample comprised children
The nutritional status of a population is directly related registered with and assiduous in primary healthcare services
to socioeconomic factors, dietary patterns, and frequency of of the study location.
food intake. Thus, the biochemical evaluation of the use of The eligibility criteria were as follows: being a child born
food supplements is essential to prevent, diagnose, and treat at term, age between 2 and 5 years, of both sexes, with a
malnutrition [15]. There is evidence of significant decrease in recent diagnosis of moderate malnutrition or low weight
iron concentration, glucose, and serum albumin of mal- (60 days or less) recorded in the clinical record; absence of
nourished children compared to healthy children [16]. liver or kidney problems (based on medical records); and
Cashew nut (Anacardium occidentale L.) is a major absence of allergy to products derived from cashew nuts. We
Brazilian cash crop. It is a high value edible nut and a source excluded children with severe malnutrition (z < -3 for any
of carbohydrates, proteins, phosphorous, iron, zinc, mag- anthropometric indices) and children receiving interven-
nesium, fibers, and fatty acids [17]. However, the bio- tions for malnutrition.
chemical effects of the use of dietary supplements in The sample size was determined using a model for paired
malnourished children, such as the cashew nut seed flour, comparison data [24]. We have adopted the following pa-
are not well established. rameters: nP: number of pairs; Zα/2: α error value of 1.96
Blood biochemical parameters are rarely used in the (5%); Zβ: ß error value of 0.84 (20%); SD: standard deviation
evaluation of malnourished children in primary care services of the difference between pairs, 0.20; and D : mean difference
[18]. The inclusion of these data in the prevention and between pairs: 0.15.
control of malnutrition contributes to the assessment of risk To obtain the sample size using the parameters men-
factors, inflammatory responses, fluid balance, and nutri- tioned above, we used results from a study reporting an
tional monitoring [19]. assessment of nutritional status of Brazilian children [25],
Biochemical measurements are used as a supplement for totaling approximately 14 pairs. Thus, the final sample was
the nutritional, anthropometrical, and clinical assessments composed of 15 pairs (30 participants) distributed between
[18]. The evaluation of glycemia, total cholesterol and its the experimental and control groups, due to the difficulty of
fractions, minerals, and vitamins is also underutilized in the adherence of the participants who initiated the research, as
professional clinical routine [20]. the study flowchart shows in Figure 1:
Journal of Nutrition and Metabolism 3
Excluded (n = 6)
Enrollment Declined to participate (n = 6)
Randomized (n = 30)
Allocation
Follow-up
Analysis
Analysed (n = 30)
Excluded from analysis (n = 0)
2.3. Randomization. The randomization obeyed a rule for of colonies forming units (CFU) of yeast and molds esti-
peer pairing using the following parameters: glycated he- mation [27]. No coliforms were found at a temperature of
moglobin, triglycerides, total cholesterol, and its fractions, 35°C, indicating that all samples were in agreement with the
with the objective to pair children with as similar values as Resolution No. 12 [28] and the current legislation. For yeasts
possible for these parameters. After the collection of bio- and molds, all samples evaluated in the study were in the
chemical data, each child from each pair was randomized to range 102–103, which is also in accordance with the current
case or control group by tossing a coin. legislation, thus indicating that the process to obtain the
flour was performed in a correct and efficient manner,
ensuring the appropriate sanitary hygienic conditions of the
2.4. Cashew Nut Seed Flour Production. The cashew nut flour final product. This analysis was guided by quality inspection
used in this study was obtained using roasted cashew kernels guidelines of the Brazilian Association of Technical Stan-
(Anacardium occidentale L.) collected at the same season, dards (ABNT) No. 5426.
from an industry located in Fortaleza, Brazil. To obtain the
flour, broken kernels were vacuum-packed and transported
to the city of Imperatriz, where they were processed in a 2.5. Intervention. Fifteen participants received the cashew nut
domestic blender for one minute. The flour was produced in flour in the ratio of two daily tablespoons (12 g), fractionated in
a public laboratory of food and herbs. To ensure quality, the the usual infant feeding (breakfast, lunch, and dinner), daily for
flour was submitted to tests in the laboratory according to a 24-week period. This amount is in accordance with scientific
the guidelines from the Adolfo Lutz Institute [26]. The articles about food supplementation and undernutrition
results were as follows: water content was 4.8%, lipids were [29–31] and it is supported by food professionals consulted for
43.2%, protein was 14.6%, fiber was 1.2%, ash was 2.6%, and this study (a food engineer and a nutritionist). All selected
carbohydrates were 33.6%. The percentage of carbohydrates participants and children with adhesion superior to 75%
was determined by difference. Approximately 388 kcal (ki- completed the trial, with a total sample of 30 participants: 15 in
localories) was found in 100 grams of the cashew flour. the experimental group and 15 in the control group. Subse-
Micro and macroscopic analysis were made to ensure quently, we made home visits to deliver the remaining pouches
that the product had appropriate color, odor, flavor, and (for the following four weeks). On these occasions, the used
texture and to guarantee the absence of parasites fragments, sachets were taken back for the records. Those participants with
insects, rodents, and dirt. The microbiological evaluation adhesion lower than 75% were excluded (discontinuity crite-
was carried out as required by the Resolution No. 12 of ria). Participants from the control group received care as usual
January 2, 2003, and Normative Instruction No. 01 of at the study locations.
January 7, 2000 [27], in triplicate, using the most probable Children’s parents were asked to give up other offers of
number per gram (MPN g-1) test of coliforms, the total additional dietary supplements during the study period.
coliforms at 45°C (thermotolerant) method, and the number Biochemical parameters were measured at baseline and at
4 Journal of Nutrition and Metabolism
the end of the study. The laboratory analysis was made using were also similar in mean age: experimental group (2.93
12-hour fasting blood samples, obtained at the beginning years) and control group (2.46 years).
and at the end of the study. Analyses included fasting plasma After the intervention, there was intragroup statistically
glucose (FPG), glycated hemoglobin (HbA1c), triglycerides significant difference (p � 0.02) regarding FPG in the
(TG), total cholesterol (TC), HDL-C, and LDL-C. control group and regarding HbA1c in the experimental
The blood samples were collected by a nurse technician group (p < 0.01). With regard to the postintervention serum
who is a research collaborator. This person is qualified in the lipids dosage, we found no intragroup significant difference
practice of handling blood samples and transportation of the regarding TG. However, there was a significant increase in
samples for the laboratory. The samples were collected using the average values of TG in the control group and values
®
the BD Vacutainer vacuum collection system, and the
venipuncture was performed in the antecubital fossa.
went beyond the reference value for children (less than or
equal to 100 mg/dl), as presented at Table 1.
In addition, the children’s parents answered questions The control group also presented increased values of TC
about sociodemographic and economic characteristics of the throughout the study, reaching the limit that is considered as
family in the beginning of the study. normal for a healthy child (170 to 199 mg/dl). On the other
The FPG, TG, TC, HDL-C, and LDL-C analyses were hand, in the experimental group, the TC values continued
made using the enzymatic assay method (Biosystems within the optimum standard (<170 mg/dL) with a slight
Spectrophotometer A15). The HbA1c analysis was measured increase. Children at the control group had a significant
using liquid chromatography (HPLC) (National Glyco- decrease of HDL-C values over time (p � 0.04), reaching an
hemoglobin Standardization Program, United States). average value inferior to the average shown by the experi-
Initially, we conducted descriptive analyses of socio- mental group, which presented an increase of HDL-C values
demographic, economic, and perinatal variables. Then, over time. The LDL-C levels reached the optimum values in
statistical tests were performed to verify possible changes in both groups over time (<110 mg/dl), as presented at Table 1.
biochemical parameters within and between the groups, The results showed that there was a significant decrease
after 24 weeks of the intervention. (p � 0.01) in the HbA1c values in the experimental group
Throughout the process of data collection and inter- (−0.16 ± 0.15). The HDL posttreatment values decreased in
vention monitoring, nursing consultations were carried out the control group and increased in the experimental group,
with children from both groups and their parents. The re- while the LDL values increased in the control group and
sults from the blood tests made before and after the in- decreased in the experimental group, as presented in Table 2.
tervention were disclosed for the parents. Participants in both groups showed statistically signifi-
cant increases in weight and height throughout the study
(Table 3). In the comparison by groups we did not identify
2.6. Statistical Analysis. First, we tested normality of data statistically significant differences, at the end of the study,
using the Shapiro–Wilk test and the homogeneity of vari- between the experimental and control groups (Table 4).
ance using the Bartlett’s homogeneity test. If any of these
tests were significant, then we used nonparametric tests.
Except for weight and BMI, all variables presented non- 4. Discussion
parametric distribution. We used the paired Wilcoxon’s t-
To the best of our knowledge and based on the current
test for intragroup analysis and the Wilcox-
literature available, this is the first randomized clinical trial
on–Mann–Whitney test for intergroup comparison [32].
that examined the effects of cashew nut seed flour in children
The data were entered in a spreadsheet (Microsoft Excel
with moderate malnutrition.
®
2016 ) and analyzed using Statistical Analysis System
From previous studies it is known that cashew nut flour
®
(SAS) at 5% level of significance [33]. can exert positive effects on FPG, HbA1c, TG, TC, HDL-C,
and LDL-C, directly and indirectly, based on its composition
2.7. Ethical Aspects. The study was registered in the Brazilian for the lipid metabolism (48.35%), protein (21.76%), starch
Ministry of Health’s Brazilian Registry of Clinical Trials (17.30%), and total sugar (8.23%) [17].
(Registro Brasileiro de Ensaios Clı́nicos, ReBec) under the In this study, we have determined, through both
number U1111.1213.9219. The study was approved by the intragroup (experimental) and intergroup analysis (versus
Ethics Committee of the Maranhão Federal University experimental group), that children with moderate malnu-
(protocol no. 1,627,934) and all parents gave their oral and trition using cashew nut flour showed an improvement
written informed consent to participate. (decrease) in glycated hemoglobin value.
Children control group have received healthcare pro- Investigations confirm that HbA1c tests are being
vided by nurses and pediatricians from the local health requested more and more, and so their acceptance as an
service. That is, they had access to child growth and de- evidence-based practice has increased. The use of HbA1c
velopment consultations and guidance on healthy nutrition. parameters was validated in clinical trials with regard to its
importance in the evaluation of glycemic control in patients
3. Results with chronic diseases or complications, as well as its use as a
screening test or diagnostic test for diabetes mellitus in
A predominance of females was observed in both groups: children, replacing the fasting plasma glucose and the oral
control (53.33%) and experimental (73.33%). The groups glucose tolerance test (OGTT) [34, 35]. The HbA1c relates to
Journal of Nutrition and Metabolism 5
Table 1: Mean values and standard deviations of biochemical parameters in moderately malnourished children before and after 24 weeks of
intervention (n � 30), Imperatriz, Brazil, 2017.
Group control Experimental group
Before After p value Before After p value
Glycemia 72.33 ± 10.08 78.53 ± 12.82 0.02 ∗ 78.00 ± 9.52 78.33 ± 17.15 0.95 ∗∗
HbA1c∗∗∗ 5.31 ± 0.26 5.28 ± 0.49 0.82 ∗∗ 5.40 ± 0.19 5.24 ± 0.22 <0.01 ∗
Triglycerides 89.53 ± 33.51 101.20 ± 59.59 0.47 ∗∗ 71.27 ± 32.49 86.53 ± 37.34 0.21 ∗
Total cholesterol 167.53 ± 20.49 170.93 ± 34.17 0.58 ∗ 160.20 ± 27.51 161.93 ± 23.49 0.77 ∗∗
HDL 50.60 ± 8.26 43.20 ± 11.34 0.04 ∗ 46.93 ± 12.99 47.07 ± 12.65 0.96 ∗∗
LDL 99.13 ± 19.02 99.80 ± 33.11 0.94 ∗ 92.80 ± 29.33 97.53 ± 20.58 0.59 ∗∗
∗ ∗∗ ∗∗∗
Student’s t-test for dependent samples (paired groups). Wilcoxon t-test. Glycated hemoglobin. Source: survey data, 2017.
Table 2: Mean values and standard deviations for the differences (before minus after) in the biochemical parameters in moderately
malnourished children, after 24 weeks of intervention (n � 30), Imperatriz, Brazil, 2017.
Group control (N � 15) Experimental group (N � 15) p value∗
Glycemia 6.20 ± 9.20 20.04 ± 0.33 0.31∗
HbA1c ∗∗∗ −0.02 ± 0.45 −0.16 ± 0.15 0.01∗∗
Triglycerides 11.67 ± 61.89 15.27 ± 45.53 0.31∗∗
Total cholesterol 23.44 ± 3.40 22.31 ± 1.73 0.84∗
HDL −7.40 ± 12.59 10.33 ± 0.13 0.08∗∗
LDL 14.28 ± 7.86 −1.26 ± 22.30 0.33∗∗
∗ ∗∗ ∗∗∗
Student’s t-test for independent samples. Wilcoxon–Mann–Whitney test. Glycated hemoglobin. Source: survey data, 2017.
Table 3: Mean values ± standard deviations of anthropometric measurements of underweight or moderately malnourished children, before
and after treatment, according to the group (experimental and control), Imperatriz, Brazil, n � 30, 2017.
Control group Experiment group
Before After p∗ value Before After p∗ value
Height (cm) 92.33 ± 13.53 95.80 ± 13.64 <0.001 100.93 ± 12.19 104.13 ± 10.95 <0.001
Weight (kg) 13.55 ± 3.46 14.11 ± 3.17 <0.001 15.03 ± 3.78 15.82 ± 3.98 <0.001
BMI∗∗ 15.80 ± 1.55 15.41 ± 1.97 0.13 14.63 ± 1.60 14.44 ± 1.39 0.38
∗ ∗∗
Student’s t-test for dependent samples (paired groups). Body mass index.
Table 4: Mean values ± standard deviations for differences (after/before) in anthropometric measurements of underweight or malnourished
children according to the group (experimental and control), Imperatriz, Brazil, n � 30, 2017.
Control group Experimental group p∗ value
Height (cm) 3.46 ± 2.09 3.20 ± 2.11 0.73
Weight (kg) 0.55 ± 0.68 0.79 ± 0.59 0.33
BMI∗∗ −0.38 ± 0.92 −0.18 ± 0.80 0.53
∗ ∗∗
Student’s t-test for dependent samples (paired groups). Body mass index.
a group of substances consisting of reactions between the he- hemoglobin provides a medium glycemic control evaluation
moglobin A (HbA) and certain sugars. The HbA is the most within 90 to 120 days before the exam, which makes this
important and natural form of hemoglobin, while the hemo- parameter an important indicator of the amount of sugar in
globin alpha 1 (HBA1) is a series of glycated variants resulting the body [14]. Studies have shown that the HbA1c represents
from attachment of various carbohydrates to N terminal valine the overall weighted average of daily blood glucose levels
of hemoglobin. HbA1c represents the attachment of glucose to (including fasting and postprandial levels) over the last two
N terminal amino acid valine of the beta chain of hemoglobin, to three months [37, 38].
leading to an increased negative charge [36]. Clinical trials show that the glycemic variability deter-
On the other hand, participants in the control group mines the range of variation of glycemic levels at different
have shown elevated blood glucose and HDL-C. What may times throughout the day. In malnutrition, these levels
result from this group’s weight gain, however, cannot be constitute an isolated risk factor independent of mean blood
credited to their diet since eating habits variables were not glucose levels, regarding the potential risk for disorders such
evaluated during the follow-up in this research. as cardiovascular diseases [15, 39, 40]. A research has shown
Red cells have an average lifespan of 120 days. The that weight gain and height in children do not appear to be
measurement of the amount of glucose attached to significantly altered by glycemic control [41]. The linear
6 Journal of Nutrition and Metabolism
growth is mediated by the growth hormone (GH) and by the rigidity [46]. HDL-C belongs to a class of lipoproteins
IGF1 growth factor, which become abnormal during periods produced by the intestine and liver, consisting of phos-
of malnutrition. pholipids and apolipoproteins. It has an important function
The ideal concentration of HbA1c in children has not that relates to the transport of cholesterol from peripheral
been determined yet, unlike the values for adults. With the tissues to the liver, therefore reducing the amount of cho-
increasing prevalence of diseases related to nutrition, es- lesterol in the blood or in cells and reducing the likelihood of
pecially malnutrition, obesity, and diabetes mellitus in diseases associated with hypercholesterolemia [47].
children, the evaluation of HbA1c concentration has become Nutritional deficiencies cause a mechanism in which
an important parameter in controlling these diseases [37]. HDL-C receives part of both LDL-C and apoprotein, con-
Thus, scientists have dedicated themselves to getting more tributing to the return of LDL-C to the liver. This allows
reliable concentrations of HbA1c parameters for children. LDL-C and HDL-C to combine and maintain the balance of
A Brazilian study held at the end of the 90 s evaluated cholesterol from cells, where LDL-C carries cholesterol to
two groups of malnourished children, divided into appro- arteries and HDL-C removes it [45–47].
priate and inappropriate HbA1c controls. The authors Therefore, the increase in HDL-C protects the organism
identified significant differences between the groups: height against atherosclerosis, since it removes cholesterol from the
was normal in the group with adequate control, while in the blood vessels, transporting it to the liver where it is removed
group with inadequate control, a chronological age of more from the body. This may explain our findings, since the total
than five years and a longer duration of nutritional damage cholesterol did not increase in the postexperiment group,
were detected [42]. suggesting a possible cardiovascular protection in the ex-
These results differ from the present investigation, since perimental group.
the changes in HbA1c occurred due to the experiment, A study showed that malnutrition and obesity are not the
which strengthens the inference of a possible protective only consequences of nutritional problems, but there are also
effect of the regular use of cashew nut flour. cardiovascular diseases [48]. A research points out that
The glycemic assessment is key to malnourished children hypertension is associated with malnutrition, mainly in girls
care. Among the clinical and metabolic complications of [49, 50].
malnutrition, the most relevant disorders include hypo- The product used in our intervention has functional
glycemia and hyperglycemia, hypothermia, dehydration, nutritional characteristics that are biologically relevant for
and diarrhea [16]. health. The cashew nut seed has an excellent nutritional
There is other evidence that changes of blood glucose profile, whose composition contains fatty acids (mainly oleic
levels during malnutrition occur due to an increased glucose and linoleic acids), phytosterols with 100 to 200 mg of ß-
production from other pathways, reducing insulin synthesis, sitosterol, high vitamin E content, selenium, and insoluble
stimulating the production of glucagon, and increasing dietary fiber. A study shows that the consumption of these
circulating epinephrine levels [43]. phytochemicals nutrients is directly associated with a re-
Since glycogen is rapidly consumed, the body starts the duced risk of cardiovascular diseases and some types of
production of glucose through glycerol and free amino acid cancer such as colon, rectum, esophagus, prostate, and
coming from fatty acids, thus increasing gluconeogenesis stomach [47].
[37]. During malnutrition, with increased glucose produc- Effects of phytosterols on serum lipid profile were
tion by these alternative routes and the increasing reduction demonstrated in 41 studies submitted to a meta-analysis that
in the macronutrient stocks, it becomes difficult to ade- evaluated the effectiveness of their use in reducing LDL-C.
quately maintain glucose levels, providing a hypoglycemic The authors concluded that the ingestion of phytosterols
condition when there is no efficient nutritional supple- (about 2 g/day) reduced LDL-C by 10%, and when the
mentation [38]. consumption is associated with a diet low in saturated fat
In our investigation, we suggest that the reduction of and cholesterol, this reduction can reach up to 20% [51].
HbA1c in moderately malnourished children of the ex- Furthermore, another study also highlights the presence
perimental group was related to the use of cashew nut flour, of glutamine in cashew nuts [52]. Glutamine is an essential
since these children did not have conditions such as he- amino acid for the catabolic individuals, such as malnour-
molytic anemia, hemoglobinopathies, and hypothyroidism, ished, burned, or postoperative patients. The importance of
that promote decreases in the level of HbA1c due to the this amino acid in the presence of such health conditions is
decrease in the number of erythrocytes, hemoglobin, and attributed to its contribution to the synthesis of nucleotides,
hematocrit. There are publications that point to the anti- being a substrate for hepatic gluconeogenesis and an im-
inflammatory and prebiotic effect of cashews [44, 45]. portant energy source for the cells of the gastrointestinal
Children who received supplementation with cashew nut epithelium, lymphocytes, fibroblasts, and reticulocytes [53].
flour presented an increase in the serum concentrations of Therefore, researchers have verified in laboratory that
HDL-C and a decrease in the concentrations of LDL-C. supplementation with glutamine in immunocompromised
These results are consistent with studies which found that an mice undergoing bowel resection or malnourished mice
improvement in serum lipids is favorable for enhancing the improved the immune response and stimulated the intes-
survival of malnourished children [46]. tinal mucosa function [53].
From a physiological and clinical point of view, serum A study in humans confirmed the efficacy of glutamine
lipids are constituents of cell membranes increasing its in the feed for increasing the survival of malnourished and
Journal of Nutrition and Metabolism 7
critically ill patients in intensive care units over six months, Maranhão for the concession of equipment and materials for
receiving parenteral nutrition supplemented with 2.5% the experiment; and all study participants for their time. This
glutamine [54]. Therefore, the consumption of cashew nut research was funded by the Foundation for Research and
flour contributes to the achievement of essential amino acid Scientific and Technological Development of Maranhão,
requirements, assisting patients in the recovery of health. Grant no. 01405/16.
There are no studies that show associations or correla-
tions between the use of cashew nut flour and possible References
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