1. There was no statistically significant relationship between apple ingestion and health care utilization.
2. However, patients who reported routine apple consumption were found to use, on average, fewer prescription medications than those who did not.
Evidence Rating Level: 3 (Average)
Study Rundown: Historically, the consumption of the fruit of Malus domestica, or the apple, has been thought to improve health and wellness. However, objective evidence regarding this practice has been lacking. The authors of this study hypothesized that ample apple consumption might provide a cost-effective and delicious benefit to health, based on previous work demonstrating an association between fruit consumption and improved cardiovascular health, weight loss, and prevention of neurologic degradation. While the studies did find a positive relationship between apple eating and keeping the doctor away, it did not meet statistical significance when adjusted for confounders. The study did find a statistically significant relationship between apple eating and decreased number of prescription medications.
The cross-sectional design of this study precludes any analysis of cause and effect. However, the authors do note that the likelihood of reverse causality (that those with fewer prescriptions feel compelled to eat more apples) is quite low. Further, though this nationally sourced data did allow the authors to adjust for covariables that may confound the relationship between apples and health, it may be that those that eat more apples are more health conscious than those who do not. Though the structure of this study was not without limitations, it provides a cogent argument that apple-eating may not in fact keep the doctor away.
In-Depth [cross-sectional study]: Data was obtained through the National Health and Nutrition Examination Survey (NHANES), a continuous, cross-sectional, survey of non-hospitalized patients across the United States for the years 2007-2009, and 2009-2010. Adults over the age of 18 years were studied, with exclusion criteria being twofold: incomplete logging of 24 hour dietary data, and diets that were patient-reported to be non-representative of their typical usual food choices. A total of 8728 patients comprised the sample study. The authors were able to identify the grams of raw apple ingested by each study participant. Those who ate more than 149 grams of apple per day (one small sized apple) were called “apple eaters”. Further, patients were subclassified into groups that ate 149 grams, 182 grams, and 223 grams in order to explore a potential dose-response relationship. A sensitivity analysis was planned to compare the effects of eating raw apples with the effects of eating apples processed into other forms.
The authors studied self-reported use of health care providers and analyzed this versus apple-eating status. Those that saw a physician no more than once per year were called “kept the doctor away” versus the other group, “did not”. Compared with non–apple eaters, apple eaters were more likely to be from racial or ethnic minorities (14.8% vs 9.7%; p < 0.001), with mean higher educational attainment and less likely to smoke. After adjusting for covariables, the relationship between apple-eating and keeping the doctor away was not statistically significant (OR 1.19; 95%CI .93-1.53; p = 0.15). However, the relationship between apple eating and avoidance of prescription medications was statistically significant (OR 1.27; 95%CI 1.00-1.63).
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