An Apple (or Statin) a Day Will Keep the Doctor Away: Population Health Analysis

December 18, 2013

OXFORD, UK — So, that old chestnut your mother told you turns out to be rooted in valid, scientific evidence: eating an apple a day really would keep the doctor away[1]. In fact, according to the new analysis by British researchers, if individuals ate just one extra apple a day, approximately 8500 deaths from vascular disease could be prevented in the UK.

The reduction in vascular deaths by adding an apple to the diet is on par with the reduction that would be observed if all UK individuals over 50 years of age were prescribed statin therapy. In that scenario, 9400 deaths from vascular disease could be prevented if these adults were started on simvastatin 40 mg.

"Statins and apples are both iconic," lead researcher Dr Adam Briggs (University of Oxford, UK) told heartwire . "An apple a day is known throughout the English-speaking world as a saying for health, and statins are now some of the most widely prescribed drugs in the world. So, when you now have a debate in the medical world about increasing the amount of statins prescribed for primary prevention, we wanted to look at what that would mean for population health and if there were other ways of doing it."

In the US, as reported by heartwire , the new American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for the management of cholesterol suggest treating primary-prevention patients if they have an LDL-cholesterol level between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%. In the UK, the guidelines are less aggressive and recommend statin therapy for primary prevention of cardiovascular disease if the 10-year risk score is >20%.

However, Briggs said there is debate in UK about expanding the use of statins to all patients 50 years of age or older.

"What we're trying to say from this analysis is that dietary changes initiated at the population level can have a really meaningful effect on population health," he said. "And second, so can increasing drug prescriptions. Now, we're not trying to say that people should be swapping their statins for apples; that's not where we're going. However, if they want to add an apple to that as part of disease prevention, then by all means do so, because you'll be further along in reducing your risk of fatal heart attacks and strokes."

The new report is published December 17, 2013 in the Christmas issue of BMJ. In addition to this "Comparative Proverb Assessment Modelling Study" by Briggs and colleagues, the lighthearted Christmas issue includes research that takes a  longitudinal look at virgin births in the US to raise awareness about the need for sex education, while another "meta-narrative analysis" looks at why individuals follow bad celebrity medical advice.

Apples Are Both Nutritious and Delicious

To assess the potential benefits of putting more patients on statins, the researchers used data from the Cholesterol Treatment Trialists' meta-analysis that showed vascular mortality is reduced 12% for every 1.0-mmol/L reduction in LDL cholesterol. This was applied to the annual reduction in vascular mortality rates in UK individuals 50 years of age or older who were not currently taking a statin for primary disease prevention.

For the apple-a-day assessment, they used a widely published risk-assessment model (PRIME). This model includes a multitude of dietary variables, in which investigators can substitute different food choices to assess the effects on population health. The apple was assumed to weigh 100 g, and calorie intake was assumed to remain constant. This allowed investigators to assess the effect of substituting in one apple daily on vascular mortality in the UK population.

For statin therapy, offering the treatment to an extra 17 million individuals and assuming 70% compliance would prevent 9400 vascular deaths each year. Assuming 70% compliance with the apple, even though "apples are of course both delicious and nutritious," say the researchers, the estimated reduction in vascular deaths would be 8500. They add that prescribing statins to all those eligible would lead to 1200 cases of myopathy, 200 cases of rhabdomyolysis, and 12 300 new diagnoses of diabetes mellitus.

Interestingly, the cost of statin therapy from the drug alone would be £180 million compared with £260 million for the apples. However, the authors point out that the National Health Services (NHS) might be able to negotiate apple price freezes ("although defrosted apples may not be so palatable," they add).

To heartwire , Briggs said he was surprised at how well the apples compared with statin therapy. However, he stressed the point is not to encourage patients to stop taking their medication. He points out that the UK has a "five-a-day" campaign to increase fruit and vegetable consumption, but 69% of the population do not meet the recommendations.

Having now studied the science underlying an apple a day for keeping the doctor away, the group jokingly states they will next "model the effect of inquisitiveness on feline mortality rates."

Briggs, along with coauthors Drs Anja Mizdrak and Peter Scarborough (University of Oxford) report no conflicts of interest. Briggs consumes at least five fruits and vegetables per day, Mizdrak tries to, and Scarborough is a vegetarian. All their diets include apples. None of the researchers take statins, and all "purport to be under 50 years old."

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