An Apple a Day

We (the authors and editors) at SBM get accused of many nefarious things. Because we deliberately engage with the public over controversial medical questions, we expect nothing less. It goes with the territory. In fact, if there were a lack of critical pushback we would worry that we were not doing our job.

Still, it is disconcerting to see the frequently-repeated ideological accusations in response to simply evaluating and reporting the evidence. That is what we do here – follow the science and evidence. When that trail leads to a conclusion that some people do not like (usually for ideological reasons) a common response is to accuse us of ideology, malfeasance, being part of a conspiracy, or having conflicts of interest or ulterior motives. That is easier, I suppose, than engaging with us on the science.

One common accusation is that we are shills for the pharmaceutical industry, and downplay or ignore the benefits of diet and “natural” treatments. A search through the SBM archives demonstrates that this accusation is false – we criticize bad science and poor-quality control, regardless of who is committing it. Sometimes pseudoscience is used to promote a drug, sometimes a nutritional supplement, and sometimes pure magic.

We have been consistently critical of the marketing of routine vitamin and mineral supplementation because there is simply a lack of evidence to support it. Scott Gavura will be writing tomorrow on three new studies published recently in the Annals of Internal Medicine, all of which provide further evidence for the lack of a health benefit from routine multivitamin use.

I have found this to be a topic full of irony, because whenever I have taken the position that the evidence does not support routine supplementation, I am commonly accused of being a pharma shill. This is ironic because supplements are largely sold by large corporations, including pharmaceutical companies. Further, what I do recommend is a well-rounded diet instead – eat your five portions of fruits and vegetables a day and have a generally well-rounded diet with appropriate calorie control. I still fail to see how recommending a healthful diet over a product of the pharmaceutical industry makes me a pharma shill – but the ideologues only have so many arrows in their quiver, and they are going to use them.

Specifically the evidence shows that taking a multivitamin is not a substitute for a healthy diet.

A recent paper in the BMJ further makes the point that promoting a healthy diet can have a significant impact on reducing vascular risk. This is not a study, but rather a statistical model that uses existing evidence and asks two questions:

– What would happen if everyone over 50 were offered a statin, and 70% complied?

– What would happen if everyone over 50 were told to eat an apple a day (or one extra portion of some fruit) and 70% complied (and assuming no overall increase in calorie consumption)?

This is what the numbers showed:

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).

That statin would save 9,400 lives, while eating an apple would save 8,500 lives per year. Not only is an apple a day just about as effective as taking a statin, it has fewer side effects. The increased statin use would also cause over a thousand cases of muscle disease and 10,000 new diagnoses of diabetes.

The authors did not recommend replacing statin use with eating more fruit. Using statins still has a net benefit to overall mortality. But it does show that a simple nutritional intervention has the potential for a similar benefit, at lower cost and without side effects.


Star Trek’s Dr. McCoy famously said, “I can do more for you if you just eat right and exercise regularly.” This just shows that over 40 years ago (or 250 years from now, depending on how you look at it) the bottom-line best medical advice has not changed.

This is a very strong and consistent signal in the clinical literature. Eat a well-rounded diet with plenty of fruits and vegetables (five portions a day), and exercise regularly, and this will have a significant positive impact on your health and longevity. This simple statement is what all the research boils down to, but this won’t sell many books or supplements.

The evidence also shows that taking vitamins does not substitute for a good diet. In fact one of our criticisms of pushing vitamins is that it may lead to a false sense of security and give people psychological “permission” to persist with a suboptimal diet.

I think it’s important, in fact, to keep our message as simple as possible. I am concerned that getting overwhelmed with all the minute details of specific nutrients and nuanced diets has an overall negative effect on public health, because the more basic messages are getting lost in the noise. There is an entire industry, in fact, based upon that noise (including statistical noise in the research).

If you want to live longer, here is what the evidence clearly shows in terms of lifestyle:

– Eat a well-rounded healthy diet
– Exercise regularly
– Get enough sleep
– Don’t smoke
– Use alcohol in moderation

I would add – get appropriate medical care and screening where appropriate (get your mammograms and colonoscopies). Beyond those basic lifestyle recommendations, there are diminishing returns, with greater and greater complexity and difficulty for smaller and smaller benefit (if any).

The latest publication shows that simple messaging can potentially have a huge impact.

Eat an apple a day (or your fruit of choice, I personally like bananas).

Posted in: Nutrition, Public Health

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