Correspondence
An Apple a Day?
N Engl J Med 1994; 331:815-816September 22, 1994
- Article
To the Editor:
I do want to make an apology to the American people for my role in what turned out to be the bad-apple hypothesis (March 17 issue)1. It was all a terrible mistake. I remember very clearly the advice I gave to my economist colleague. It was the same advice I gave to the Senate Finance Committee: a program in outcomes research must include clinical trials. In the case of Mrs. Clinton's audacious theory that an apple a day keeps the doctor away, the first step may well be a correlation study of apple eating and visits to doctors in small areas. If the results are positive, if they suggest that the health care crisis could be solved by an old adage, then prudence dictates a second step: test the hypothesis with a clinical trial.
My advice to Congress remains the same. We need a way to assure the American people that the needed evaluations of clinical theory are done in a timely way, before plausible but wrong ideas get institutionalized into the everyday practice of medicine. Congress must see to it that clinical trials become an integral part of outcomes research conducted by the Agency for Health Care Policy and Research. An apple a day keeps the doctor away? Let's find out!
1 ReferencesJohn E. Wennberg, M.D.
Dartmouth Medical School, Hanover, NH 03755-38631
Phelps CE . An apple a day -- a futuristic parable. N Engl J Med 1994;330:797-799
Full Text | Web of Science | Medline
To the Editor:
In “An Apple a Day,” Phelps provided an excellent historical overview of the apple-a-day program, but he neglected several important points. First, he fails to note recent work substantiating the scientific bases of other tales of housepersons of indeterminate age (see A.O. Berg, “The Constant Ratio of Cure to Prevention: 15.8 ±0.6,” 2004, and Idem, “Glass House Injuries -- Los Angeles,” 2012).
Second, although he refers to the sensitivity of the cost effectiveness of the program to the price of apples and to Kodak's lobbying for import restrictions on foreign apples, he completely neglects the evidence that indicates that a major detailing effort by the apple industry resulted in the prescription primarily of expensive, proprietary apples, rather than inexpensive, generic apples, greatly increasing the cost of the apple-a-day program (see R.G. Evans, “Thar's Jonagold in Them Thar Bills,” 2010, and B.G. Saver, “Comparing Apples to Apples: With Malus Aforethought,” 2011).
Third, Phelps focused on the cost of visits to physicians engendered by the need to obtain a prescription every three years, but he ignored the potential benefits of these visits. We have analyzed the effects of the Early Apple Treatment (EAT) Program, which offered an additional daily apple to all pregnant women. After the EAT legislation was enacted in 2010, pregnant women with incomes under the federal poverty level had their first prenatal visit a mean of 1.2 weeks earlier (95 percent confidence interval, 1.0 to 1.5). This resulted in a 14 percent drop in births of children weighing less than 1 kg and a savings of $1.73 for every dollar spent (unpublished data). The benefit would have been almost doubled had only generic apples been used.
Barry G. Saver, M.D., M.P.H.
University of Washington, Seattle, WA 98195To the Editor:
Dr. Phelps's vision of a 20-year deluge of bureaucratic ritual resulting from government's attempts to establish an apple-a-day health care program seems efficient as compared with the very real research history surrounding aspirin.
The first prescription for aspirin coincides with the beginnings of medicine itself: Hippocrates recommended salicylic acid for the treatment of pain and fever. In 1950, Lawrence L. Craven reported his clinical trials of aspirin in the prevention of coronary thrombosis1. In 1991, James E. Dalen summarized the 41 years of aspirin studies that followed, concluding that “if Craven's rule of `an aspirin a day' had been adopted by Americans in 1950, hundreds of thousands of myocardial infarctions and strokes might have been prevented”2. The story continues with the January 8, 1994, announcement in the British Medical Journal that it was “devoting 50 pages to overviews. . . . Altogether, some 300 randomised controlled trials assessing the potential benefits of antiplatelet treatment” were considered,3 marking 44 years of continuing study of aspirin.
The apple- or aspirin-a-day program belongs on the menu at Kafka's castle, where much activity and blame are generated but nothing conclusive ever materializes. As a young researcher in medical science, I am surprised that so much attention is paid to apple polishing; as an advocate of preventive medicine, I am perplexed by the comparatively little effort made to get the apple on the table.
3 ReferencesKen McCardle, B.Sc., B.A.
St. Joseph's Hospital and Medical Center, Phoenix, AZ 850131
Craven LL . Acetylsalicylic acid, possible prevention of coronary thrombosis. Ann West Med Surg 1950;4:95-99
Medline2
Dalen JE . An apple a day or an aspirin a day? Arch Intern Med 1991;151:1066-1069
CrossRef | Web of Science | Medline3
Underwood MJ ,More RS . The aspirin papers. BMJ 1994;308:71-72
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Phelps replies:
To the Editor: I did not intend to implicate Dr. Wennberg as the progenitor of the apple-a-day program; his question merely started the events in motion, and I concur with him on the importance of using the best possible scientific evidence to understand when and when not (and for whom and for whom not) to use various medical interventions.
As for Dr. McCardle's summary of the history of aspirin therapy to prevent myocardial infarction and strokes, I can only reflect on the further problems that might have emerged in learning about that use of aspirin had it not escaped the clutches of the Food and Drug Administration thanks to its long-standing status as a nonprescription drug.
Charles E. Phelps, Ph.D.
University of Rochester, Rochester, NY 14627
