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Apples Reduce All-cause & Cause-specific Mortality

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It looks like an apple a day helps keep the grim reaper away, at least in elderly women according to this new study [1] shared by Al Pater (thanks Al!).  


Researchers followed 1500 Australian women for 15 years, assessing their intake of various fruits every few years. Over the years their reported intake of apples and other fruits remained quite stable. The authors focused on the four fruits that made up the bulk (75%) of total fruit consumption - apples (20%), pears (11%), citrus fruit (23%), & bananas (21%).


They found that women who ate more than 100g of apple per day (for reference, an average medium apple weighs 182g) had a 35% lower risk of all-cause mortality during the follow-up period, even after adjusting for a bunch of potential confounders, including age, BMI, smoking status, socio-economic status, diabetes, CVD, cancer, use of antihypertensive medication, use of cholesterol-lowering medication, use of low-dose aspirin, physical activity, energy intake and alcohol intake.


Here are a couple interesting figures from the full text (available from Al). First, a needle plot of morality for the different fruits and causes of death:




 As you can see, pears and especially citrus weren't all that great for mortality. But apples, bananas and total fruit were all beneficial. Interestingly, bananas were the best of all these fruit for cardiovascular mortality, perhaps because of the important role potassium plays in CVD risk [2].


The one reservation/caveat I can see is that higher apple intake is associated with lots of other markers for an overall healthy diet, as you can see from this figure:




Women who ate a lot of apples also ate (not surprisingly) a lot more fiber, flavonoids, total fruit etc. Although the authors didn't report on it, I suspect they also probably ate more vegetables, less trans and saturated fat, etc. So while apples are certainly healthy, they may also be an indicator of an overall healthy diet and lifestyle, and therefore not the (entire) cause of reduced mortality in these women.





[1] Apple intake is inversely associated with all-cause and disease-specific mortality in elderly women.


Hodgson JM, Prince RL, Woodman RJ, Bondonno CP, Ivey KL, Bondonno N, Rimm EB, Ward NC, Croft KD, Lewis JR.
Br J Nutr. 2016 Mar;115(5):860-7. doi: 10.1017/S0007114515005231. Epub 2016 Jan 20.
Higher fruit intake is associated with lower risk of all-cause and disease-specific mortality. However, data on individual fruits are limited, and the generalisability of these findings to the elderly remains uncertain. The objective of this study was to examine the association of apple intake with all-cause and disease-specific mortality over 15 years in a cohort of women aged over 70 years. Secondary analyses explored relationships of other fruits with mortality outcomes. Usual fruit intake was assessed in 1456 women using a FFQ. Incidence of all-cause and disease-specific mortality over 15 years was determined through the Western Australian Hospital Morbidity Data system. Cox regression was used to determine the hazard ratios (HR) for mortality. During 15 years of follow-up, 607 (41·7 %) women died from any cause. In the multivariable-adjusted analysis, the HR for all-cause mortality was 0·89 (95 % CI 0·81, 0·97) per sd (53 g/d) increase in apple intake, HR 0·80 (95 % CI 0·65, 0·98) for consumption of 5-100 g/d and HR 0·65 (95 % CI 0·48, 0·89) for consumption of >100 g/d (an apple a day), compared with apple intake of <5 g/d (P for trend=0·03). Our analysis also found that higher apple intake was associated with lower risk for cancer mortality, and that higher total fruit and banana intakes were associated lower risk of CVD mortality (P<0·05). Our results support the view that regular apple consumption may contribute to lower risk of mortality.
Key words
Apples; Fruits; All-cause mortality; Disease-specific mortality; CVD; Cancer
PMID: 26787402


[2] J Clin Hypertens (Greenwich). 2002 May-Jun;4(3):198-206.

Importance of potassium in cardiovascular disease.
Sica DA(1), Struthers AD, Cushman WC, Wood M, Banas JS Jr, Epstein M.
Author information: 
(1)Section of Clinical Pharmacology and Hypertension, Division of Nephrology,
Medical College of Virginia/Virginia Commonwealth University, Richmond, VA 23298,
USA. dsica@hsc.vcu.edu
The pivotal role of potassium (K+) in cardiovascular disease and the importance
of preserving potassium balance have become clinical hot points, particularly as 
relates to new and emerging cardioprotective and renoprotective therapies that
promote potassium retention. Although clinicians may be aware of the critical
nature of this relationship, quite frequently there is some uncertainty as to the
best way to monitor potassium levels in the face of a host of pathologic states
and/or accompanying drug therapies that affect serum levels and/or total body
potassium balance. Moreover, guidelines for monitoring of serum potassium levels 
are at best tentative and oftentimes are translated according to the level of
concern of the respective physician. To address these uncertainties, an expert
group was convened that included representatives from multiple disciplines. They 
attempted to reach consensus on the importance of K+ in hypertension, stroke, and
arrhythmias as well as practical issues on maintaining K+ balance and avoiding K+
depletion. Because of the complexity of this topic, issues of hyperkalemia will
be addressed in a forthcoming manuscript.
Copyright 2002 Le Jacq Communications, Inc.
PMID: 12045369
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Thanks Dean and Al!


While apples are certainly healthy, they may also be an indicator of an overall healthy diet and lifestyle, and therefore not the (entire) cause of reduced mortality in these women.


I think that's very likely.


I saw nothing in Al's list post about sources of funding. Is it noted in the full text you got?


- Brian

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I saw nothing in Al's list post about sources of funding. Is it noted in the full text you got?


Good call. From the full text: 


[The lead author and two others] have received funding support from the Department of Agriculture and Food, Western Australia and Fruit West to support research into the development and evaluation of new apple varieties.


That doesn't mean that the research was tainted or invalid. But perhaps we should be suspicious that they may have tipped the balance towards making apples the hero of the story...



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I kind of doubt that Dean.  The comparison is with apples versus oranges type of experiment and the two funding agencies would not in my book have reason to be balanced.  The two major fruits in the area were bananas and citrus:



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You wrote:

I kind of doubt that Dean. 


Presumably in reference to my statement the authors of PMID 26787402 might have a bias in favor of apples. It may be just me, but again I've found this statement and your post hard to wrap my mind around.


First of all, you do know you can go back and edit a post, rather than making another post in an attempt to correct the first one, right? Just click on the word "Edit" at the bottom of the post you'd like to change/update.


Second, your banana link is broken due to the extra space (' ') you included at the end of the link you posted. Here is the correct link. I presume what you are pointing to is the following statement:


Bananas are Australia’s number one selling supermarket product and the second biggest national horticulture industry after citrus.


Notice it says bananas and citrus are Australia's top fruits, but no necessarily western Australia's biggest fruit crops - they may be, I'm not sure. It is the western Australia agriculture department who are among the sponsors for this study.


Plus, more importantly, regardless of the overall focus/bias of the sponsoring agency(ies), the authors themselves acknowledge that their funding is specifically apple-centric (my emphasis):


[The lead author and two others] have received funding support from the Department of Agriculture and Food, Western Australia and Fruit West to support research into the development and evaluation of new apple varieties.


Given this statement that they have been paid to specifically research apples, it seems hard to fathom how you could doubt the possibility that the author's might have a vested interest in seeing apples come out on top.



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I read somewhere that apple skins have a unique compound not found in other foods that can reverse the damage caused by advanced glycation end products.  Now I'm not sure where I read that, would like to track down the source.  Other studies have found apple skins in particular to be very beneficial, the flesh is probably not so good for you in general (bit of fiber, lots of fructose).  The problem with eating a lot of skins is that apples are one of the top foods for pesticide exposure (and I don't really trust supermarket organic apples but I might be wrong, they are also very expensive).  


My solution is to grow my own apples, and eat all the skins I possibly can when they are in season.  So far this has been fun and I love the self sufficiency aspect of it.  Plenty of reputable places to buy healthy 2-3 year old trees online (I've used Adams County Nursury and Burnt Ridge before).  I've got about 12 trees now, if one dies I plant a new one.  Only 3 of them are real big producers right now, but I end up with hundreds of apples.  In a few more years I'll probably have more than I can even deal with, might have to recruit people to help with the organic techniques I use.   I also raise solitary bees which helps keep the yields high on the trees that are big enough to be productive.



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Here is a study [1] you may be thinking of, showing the highest antioxidant activity in apples comes from the peel. Here is a study [2] of the various polyphenols in apple peels.


Thanks for sharing those pointers to your website. I loved reading about all your experiments, including the apple bagging and beekeeping you pointed to, as well as your mushroom growing, bat houses, and the footmouse. You've done some really inspiring projects!


P.S. I'm still going strong eating the wild (somewhat gnarly) apples I harvested late last summer from the untended apple trees growing in my neighborhood (a former apple orchard). They remain crisp and tasty. I figure I still have about 3 months supply left.





[1] J Agric Food Chem. 2003 Jan 29;51(3):609-14.

Antioxidant activity of apple peels.
Wolfe K(1), Wu X, Liu RH.
Author information: 
(1)Institute of Comparative and Environmental Toxicology and Department of Food
Science, Stocking Hall, Cornell University, Ithaca, New York 14853-7201, USA.
Consumption of fruits and vegetables has been shown to be effective in the
prevention of chronic diseases. These benefits are often attributed to the high
antioxidant content of some plant foods. Apples are commonly eaten and are large 
contributors of phenolic compounds in European and North American diets. The
peels of apples, in particular, are high in phenolics. During applesauce and
canned apple manufacture, the antioxidant-rich peels of apples are discarded. To 
determine if a useful source of antioxidants is being wasted, the phytochemical
content, antioxidant activity, and antiproliferative activity of the peels of
four varieties of apples (Rome Beauty, Idared, Cortland, and Golden Delicious)
commonly used in applesauce production in New York state were investigated. The
values of the peels were compared to those of the flesh and flesh + peel
components of the apples. Within each variety, the total phenolic and flavonoid
contents were highest in the peels, followed by the flesh + peel and the flesh.
Idared and Rome Beauty apple peels had the highest total phenolic contents (588.9
+/- 83.2 and 500.2 +/- 13.7 mg of gallic acid equivalents/100 g of peels,
respectively). Rome Beauty and Idared peels were also highest in flavonoids
(306.1 +/- 6.7 and 303.2 +/- 41.5 mg of catechin equivalents/100 g of peels,
respectively). Of the four varieties, Idared apple peels had the most
anthocyanins, with 26.8 +/- 6.5 mg of cyanidin 3-glucoside equivalents/100 g of
peels. The peels all had significantly higher total antioxidant activities than
the flesh + peel and flesh of the apple varieties examined. Idared peels had the 
greatest antioxidant activity (312.2 +/- 9.8 micromol of vitamin C equivalents/g 
of peels). Apple peels were also shown to more effectively inhibit the growth of 
HepG(2) human liver cancer cells than the other apple components. Rome Beauty
apple peels showed the most bioactivity, inhibiting cell proliferation by 50% at 
the low concentration of 12.4 +/- 0.4 mg of peels/mL. The high content of
phenolic compounds, antioxidant activity, and antiproliferative activity of apple
peels indicate that they may impart health benefits when consumed and should be
regarded as a valuable source of antioxidants.
PMID: 12537430
[2] Chem Cent J. 2014 Jul 10;8:45. doi: 10.1186/1752-153X-8-45. eCollection 2014.

Polyphenols profile and antioxidant activity of skin and pulp of a rare apple
from Marche region (Italy).

Giomaro G(1), Karioti A(2), Bilia AR(2), Bucchini A(1), Giamperi L(1), Ricci
D(3), Fraternale D(3).

Author information:
(1)Dipartimento di Scienze della Terra, della Vita e dell'Ambiente, Università
degli Studi di Urbino "Carlo Bo", Via Bramante 28, 61029 Urbino, PU, Italy.
(2)Dipartimento di Chimica Edificio di Scienze Farmaceutiche, Università di
Firenze, Via U. Schiff 6, 50019 Sesto Fiorentino, FI, Italy. (3)Dipartimento di
Scienze Biomolecolari, Università degli Studi di Urbino "Carlo Bo", Via Bramante
28, 61029 Urbino, PU, Italy.

BACKGROUND: Apples are an important source of polyphenols in the human diet and
the consumption of this fruit has been linked to the prevention of degenerative
identified both in the peel and pulp. Procyanidins, catechins and flavonols
represent the main constituents of peel. Concerning the antioxidant activity, in
the reduction of the stable DPPH radical and in the inhibition of lipid
peroxidation, the ethanolic extracts of red peel and red pulp showed a good
similar activity comparable to ascorbic acid in the DPPH test and about ten times
more active than BHT in the lipoxygenase test, and were much more active than
aqueous extracts. The ORAC value of red pulp aqueous extract resulted comparable
to that of red berries: vaccinium, rubus and ribes, foods appreciated for their
health value.
CONCLUSION: This apple contains an appreciable amount of polyphenols also in the
flesh; this variety with red flesh can also be useful for researchers engaged in
apples varietal innovation in addition to being used as food apple.

PMCID: PMC4099019
PMID: 25067944

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First, fruit is healthy, no doubt.  The thing about that figure comparing the effects of apples, bananas, oranges and other citrus, pears and total fruit, all fruit categories were analyzed by the same multivariate analysis, so you would expect that citrus for example would have the same healthy attributes associated with it as apples.  Regarding the healthiness of apple peals, I imagine the citrus-o-vores were not eating the peels of the fruit.  Aside from its special goodies, even the USDA site's "optimum health" ratings are better for whole oranges than peeled oranges, for example.  The ratings for apples are better when the peel is eaten, but the difference is not as great as it is for oranges +/- peels.  And the USDA ratings are better for oranges than apples generally.


I missed the part in the Acknowledgements about the authors' other projects related to apple varieties in the extensive section and noted that the study itself was done using grant monies independent of their previous projects related to apple varieties.


I am sorry that I failed to use the Forum's bells and whistles.


You just quoted the first sentence of the Australian Department of Agriculture and Food's web site, and note the letterhead on the site says Western Australia.  Western Australia seems to me to be clearly what they were talking about:



Bananas are Australia’s number one selling supermarket product and the second biggest national horticulture industry after citrus.

The Department of Agriculture and Food is working closely with both growers and marketers of this important crop.

Carnarvon is Western Australia’s largest banana growing area and Kununurra is also making a comeback. Carnarvon bananas are typically smaller and sweeter than bananas from eastern Australia.

As WA is free of many of the pests and diseases that plague other growing areas, this means a reduced level of pesticides and fungicides."


Wiki says: "Carnarvon is a coastal town situated approximately 900 kilometres north of PerthWestern Australia."

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