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An apple a day or a statin a day: Which better keeps the doctor away?

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Which would you rather consume, an apple a day or a statin a day? Can both keep the doctor away? Or is one safer in the long term with fewer side effects than the other? An apple a day or a statin a day is equally likely to keep the doctor away, says new study, "A statin a day keeps the doctor away: comparative proverb assessment modeling study," published December 17, 2013 in the British Medical Journal (BMJ).

The study notes that researchers find that a 150 year old proverb is able to match modern medicine and is likely to have fewer side effects, according to the December 26, 2013 Swanson Research update, "An Apple a Day Could Help Keep Heart Disease at Bay." But adding one apple a day to an unhealthy diet and a sedentary lifestyle isn't going to make much difference other than adding a few more calories. Or would it motivate a person to add a lot more of raw vegetables and fruits to the diet starting with a baby step: an apple a day?

The controversy is about food as medicine. Food costs less than medicine when used for prevention

On the other hand, researchers explained in a new study that they "find that a 150 year old proverb is able to match modern medicine and is likely to have fewer side effects." In a study published in the special Christmas edition of BMJ, researchers compared the estimated population-wide effects of statin drug treatment on vascular disease with those of an apple per day in people over age 50. Statin effect estimates were derived from the Cholesterol Treatment Trialists’ meta-analysis. The effects of an apple per day on the entire UK population were estimated using a widely published comparative risk assessment model.

Assuming a 70% compliance rate, prescribing statins to 22.8 million people in the UK over age 50 would result in an estimated 9,400 fewer vascular deaths annually, compared with 8,500 fewer annual vascular deaths for an apple per day. The estimated side-effects arising from such widespread statin use include 1,200 excess cases of myopathy, 200 cases of rhabdomyolysis and 12,300 cases of diabetes. The study authors concluded that, comparing statin treatment to an apple a day, “a 150 year old health promotion message is able to match modern medicine and is likely to have fewer side effects.”

Check out the original study published December 17, 2013 by authors Briggs ADM, Mizdrak A, and Scarborough P. "A statin a day keeps the doctor away: comparative proverb assessment modeling study." BMJ 2013.

The study's objects focused on modeling the effect on UK vascular mortality of all adults over 50 years old being prescribed either a statin or an apple a day. The study was done in the UK on a population of adults over the age of 50. Participants took either a statin a day for people not already taking a statin or an apple a day for everyone, assuming 70% compliance and no change in calorie consumption. The modeling used routinely available UK population datasets; parameters describing the relations between statins, apples, and health were derived from meta-analyses. The researchers' main goal was to measure mortality due to vascular disease.

Results noted the estimated annual reduction in deaths from vascular disease of a statin a day, assuming 70% compliance and a reduction in vascular mortality of 12% (95% confidence interval 9% to 16%) per 1.0 mmol/L reduction in low density lipoprotein cholesterol, is 9400 (7000 to 12 500). The equivalent reduction from an apple a day, modelled using the PRIME model (assuming an apple weighs 100 g and that overall calorie consumption remains constant) is 8500 (95% credible interval 6200 to 10 800). At the end of the study, researches concluded that both nutritional and pharmaceutical approaches to the prevention of vascular disease may have the potential to reduce UK mortality significantly. With similar reductions in mortality, a 150 year old health promotion message is able to match modern medicine and is likely to have fewer side effects.

Researchers wrote in the study that, “An apple a day keeps the doctor away,” a public health message delivered by parents and teachers since the 19th century, is an example of how concise, clear, and accurate Victorian health promotion can truly stand the test of time, whereas other Victorian practices—such as the use of leeches in primary care—have fallen away. The goal is lifestyle changes. If people ate more vegetables and fruits and less white flour, sugar, red meat, and fattening foods, that is changed their diets, this first step for primary prevention of vascular disease might work as well as the rising recommendations of greater use of drugs as the first intervention for prevention.

People have different reactions to statins due to genetic variations

Further limitations of this research are that fruit costs were taken in the autumn (a relatively cheap season) but are likely to vary around the year, and people may save money by spending less on their weekly shopping trip. The uncertainty estimates surrounding changes in mortality do not represent uncertainty associated with compliance or with the structural uncertainty of the PRIME model, explain the researchers in the study.

If just 31% of the population are having five portions of fruit and vegetables a day in the first place, such substitutions may not be an option for many people. People may also choose to consume fewer total calories by replacing foods with a higher energy density with the low energy dense apple, potentially leading to even greater benefits on vascular mortality through reduced body mass index, say the researchers.

What the study shows that small dietary changes as well as increased use of statins at a population level may significantly reduce vascular mortality in the UK, but statins have side effects and apples don't, if you take the food as medicine attitude

The five a day campaign to increase UK fruit and vegetable consumption is laudable in its aims and has the potential to deliver true population health benefits, the researchers explain in the study. If you look at trial data, you can see that statins reduce the risk of vascular events irrespective of baseline cardiovascular disease risk.

Statins have side effects, and some people have a genetic variation where they react badly to statins. On the other hand, the study adds that an apple a day or a statin a day is equally likely to keep the doctor away, the researchers note in their study.

High intake of white fruits and vegetables may protect against stroke, say recent studies

An apple or pear a day may keep strokes away, says a study published in Stroke: Journal of the American Heart Association in which researchers found that eating a lot of fruits and vegetables with white flesh may protect against stroke, the news release, "An apple or pear a day may keep strokes away" reported.

In Sacramento and other Northern California locations, stroke rates among young blacks in the Kaiser Permanente study more than doubled between 2000 and 2008, according to Dr. Sidney. The researchers conducted studies to identify underlying reasons for this trend, according to the news release, "NIH awards $40 million in grants to reduce stroke disparities in the US."

Strokes in young people on the increase

Now, a new analysis published in The Lancet finds a startling 25% increase in the number of stroke cases among people aged 20 to 64 years during the last 20 years. Findings come from the first comprehensive and comparable analysis of the regional and country-specific burden of stroke between 1990 and 2010.

A second study published in The Lancet Global Health shows that in 2010, three-fifths (61.5%) of the disability and more than half (51.7%) of the lives lost to stroke were the result of haemorrhagic strokes despite being half as common as ischaemic strokes. Can a diet that includes more white fruits and vegetables and citrus fruits help reduce this burgeoning phenomena?

According to a Huffington Post, Healthy Living (section) news article, stroke is increasing in young people

In a new report in The Lancet, the results of a new study shows an increasing number of young and middle-aged adults are being affected by it. Researchers from around the world examined new cases of stroke, its overall prevalence, and deaths from stroke from 1990 to 2012 (looking specifically at time points of 1990, 2005 and 2010).

They found that strokes have increased 25 percent globally in the past 20 years in people ages 20 to 64. Currently, 20-to-64-year-olds make up 31 percent of all strokes. Before 1990, they made up just 25 percent.

Apples and pears studied for health benefits and possibly reducing risk of stroke

You can read the original study's abstract on apples and pears, "Clinical Sciences: Colors of Fruit and Vegetables and 10-Year Incidence of Stroke." A 2011 study of white fruits and vegetables, such as apples and pears, or cucumbers and cauliflower, showed that these white-fleshed fruits and vegetables may help reduce the risk of stroke.

While studies have linked high consumption of fruits and vegetables with lower stroke risk, the researchers' prospective work in 2011 had been the first to examine associations of fruits and vegetable color groups with stroke. The color of the edible portion of fruits and vegetables reflects the presence of beneficial phytochemicals such as carotenoids and flavonoids.

Researchers examined the link between fruits and vegetable color group consumption with 10-year stroke incidence in a population-based study of 20,069 adults, with an average age of 41

The participants were free of cardiovascular diseases at the start of the study and completed a 178-item food frequency questionnaire for the previous year. Almost every month, the news is filled with the results of studies about the health benefits of apples.

In the Netherlands, one study says that a high intake of fruits that are white inside—including apples and pears—reduced the risk of stroke by 50%. What the investigators found is that for each 25 gram per day increase in white fruit and vegetable consumption was associated with a 9 percent decrease in stroke risk, according to Dr. Stephen Sinatra's article on a new study, "Stroke Risk Factors—Why Younger People Are Having Strokes."

And regarding the 2011 study, because this initial research is still so new, the researchers caution against jumping to big conclusions. Nonetheless, these early findings published in the September 2011 online release of the journal Stroke are encouraging. Also check out the October 24, 2013 news article, "More Young Adults Being Affected By Stroke, Report Finds."

From a nutrition aspect, apples and pears and other white fruits and vegetables confer a number of health benefits, and fall is an excellent time to add them to your diet

White potatoes are a starch, for example, but cauliflower and cucumbers are considered white vegetables, among several other vegetables that have white flesh but are not considered a starch vegetable, and white fruit such as pears and apples were included in the study.

Try organic so you don't get the herbicides, insecticides, and pesticides. The most contaminated by pesticides of fruits and berries are strawberries. So stick to organic varieties. Also the most heavily sprayed fruits with pesticides are peaches, and apples. So you want to look for organic peaches and apples or pears. Also see the sites, "Stroke risk factors" or "Intracranial atherosclerotic stenosis."

Fruits and vegetables were classified in four color groups:

  • Green, including dark leafy vegetables, cabbages and lettuces
  • Orange/Yellow, which were mostly citrus fruits
  • Red/Purple, which were mostly red vegetables
  • White, of which 55 percent were apples and pears

During 10 years of follow-up, 233 strokes were documented. Green, orange/yellow and red/purple fruits and vegetables weren't related to stroke. However, the risk of stroke incidence was 52 percent lower for people with a high intake of white fruits and vegetables compared to people with a low intake.

Each 25 gram per day increase in white fruits and vegetable consumption was associated with a 9 percent lower risk of stroke. An average apple is 120 grams

"To prevent stroke, it may be useful to consume considerable amounts of white fruits and vegetables," said Linda M. Oude Griep, M.Sc., according to the September 15, 2011 news release, "An apple or pear a day may keep strokes away." Gripe is the lead author of the study and a postdoctoral fellow in human nutrition at Wageningen Uninversity in the Netherlands. "For example, eating one apple a day is an easy way to increase white fruits and vegetable intake. "However, other fruits and vegetable color groups may protect against other chronic diseases. Therefore, it remains of importance to consume a lot of fruits and vegetables."

Apples and pears are high in dietary fiber and a flavonoid called quercetin. In the study, other foods in the white category were bananas, cauliflower, chicory and cucumber

Potatoes were classified as a starch. Previous research on the preventive health benefits of fruits and vegetables focused on the food's unique nutritional value and characteristics, such as the edible part of the plant, color, botanical family and its ability to provide antioxidants.

U.S. federal dietary guidelines include using color to assign nutritional value. The U.S. Preventive Health Services Taskforce recommends selecting each day vegetables from five subgroups: dark green, red/orange, legume, starchy and other vegetables. Before the results are adopted into everyday practice, the findings should be confirmed through additional research,

Oude Griep said in the news release, An apple or pear a day may keep strokes away.

"It may be too early for physicians to advise patients to change their dietary habits based on these initial findings," she stated in the news release. An accompanying editorial notes that the finding should be interpreted with caution because food frequency questionnaires may not be reliable.

In addition, "the observed reduction in stroke risk might further be due to a generally healthier lifestyle of individuals consuming a diet rich in fruits and vegetables," writes Heike Wersching, M.D., M.Sc., of Institute of Epidemiology and Social Medicine at the University of Münster, in Germany.

Study co-authors are: W.M. Monique Verschuren, Ph.D.; Daan Kromhout, M.P.H., Ph.D.; Marga C. Ocké, Ph.D.; and Johanna M. Geleijnse, Ph.D. Author disclosures are on the manuscript. Revenues from pharmaceutical and device corporations are available at the American Heart Association's corporate funding website. Also in another study, citrus fruits also helped prevent stroke, according to the news release, "Eating citrus fruit may lower women's stroke risk."

Additional resources:

  • The American Heart Association recommends eating a diet rich in a variety of colors and types of vegetables and fruits, at least 4.5 cups a day. To learn more visit: Eat More Fruits and Vegetables and Tips to boost fruits and vegetables to your diet
  • Cooking with white fruits and vegetables can be easy – and healthy. Check out these recipes at the American Heart Association's Nutrition Center:
    • Cool Cucumber Dip
    • Modern Tuna Pasta Casserole (add extra cauliflower)
    • Pear and Cherry Crumble
  • Downloadable stock footage, animation, and an image gallery are located at the Heart News site under Multimedia.
  • For more information on stroke, visit the American Stroke Association website.


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