An Apple a Day Keeps the Doctor Away, but It May Not Be Worth the Squeeze

We've all heard the saying, “an apple a day keeps the doctor away.” The health benefits of eating at least 1 to 2 pieces of whole fruit daily are well‐documented; ¹ , ² however, the impact of fruit juice is less known. To help patients achieve the 5‐a‐day target for fruits and vegetables, fruit juice is considered a healthful, convenient beverage and is readily available around the globe, including in food deserts. In this issue of the Journal of the American Heart Association (JAHA), Xu et al ³ describe the results of a population‐based study in Australia designed to determine whether fruit consumed as juice may negate the beneficial effects of consuming whole fruit in people with cardiovascular disease (CVD).

Although a similar pattern was seen among men, women with CVD who had high fruit juice consumption had associated with a higher risk of mortality over time in both crude and adjusted models (hazard ratio [HR],  1.74 [95% CI, 1.58–1.91]; versus HR,  1.26 [95% CI, 1.12–1.41], P<0.03). Even when women ate whole fruit in conjunction with a high intake of fruit juice, an increased relative risk of 18% remained. Therefore, the authors suggest caution for women with CVD in consuming higher amounts of fruit juice. One explanation proposed by the authors may be the lower dietary fiber content and the higher energy density when comparing fruit juice with fresh fruit as seen with a recent meta‐analysis by D ‘Elia et al. ⁴ Although 100% fruit juice does not have added sugar, the biological response compared with sugar‐sweetened beverages is equivalent. ⁴

When it comes to fruit juice, the options are quite diverse. This presents a key challenge, with some beverages adding extra sugar and/or containing <10% juice, while others are 100% organic juice and include the pulp. A limitation in the study by Xu et al, as for any epidemiological research, is the inability to specify the type, and quality of juice. Also unknown is whether or not these beverages contain high fructose corn syrup or other added sugars. ⁵ Intake of high excess free fructose beverages, including high fructose corn syrup, including sweetened soft drinks, fruit drinks, and apple juice, may be associated with childhood asthma, adult idiopathic chronic bronchitis/chronic obstructive pulmonary disease, and autoimmune arthritis, may possibly be attributable to underlying fructose malabsorption. ⁶ Underlying fructose malabsorption may contribute to the intestinal in situ formation of proinflammatory advanced glycation end‐products that are eventually absorbed and induce inflammation of the coronary arteries. ⁶ Therefore contributing to pulmonary and autoimmune diseases which are comorbidities for CVD. ⁷

Also important to mention as we look at applicability to the clinical setting; this study was fairly homogeneous in its patient population, with many patients being White, older (>80 years) and having an increased income. The study did have many strengths with (1) a focus on sex differences, (2) a large cohort of men and women with CVD followed over time, and (3) new evidence about the joint effects of fruit and fruit juice intake on mortality. So, what do we know, and what new knowledge has been generated from this study? Likely, whole fruit and fruit juice cannot be interchanged. It is important to educate our patients that sweetened fruit beverages have high rates of sugar and less fiber compared with 100% juice. These results are in correlation with the new 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. ⁸ The Figure recommends replacing sugar‐sweetened beverages such as fruit drinks with whole fruit and other plant‐based nutrition. The guideline also suggests reduction of simple carbohydrates, such as high fructose corn syrup, which has adverse effects on lipoproteins, including low‐density lipoprotein cholesterol, apo B, and plasma triglycerides. ⁹ , ¹⁰

Figure . Key takeaway messages for patients.

CVD indicates cardiovascular disease.

Mediterranean‐style nutrition continues to be the mainstay for both primary and secondary prevention. ² A new meta‐analysis by Laffond et al ² suggests that higher adherence to the Mediterranean diet may be associated with a lower risk of cardiovascular mortality. By enabling our patients through education, we can teach them the importance of adhering to the Mediterranean nutrition regimen. Future research should focus on improving quantification in quality of fruit juice, presence or absence of high excess free fructose beverages, and further standardizing nutritional habits of adults with CVD.

Key takeaway messages for patients

1. Portion control: use fruit juice sparingly to prevent CVD in women.

2. Fresh is always best. Avoid added sugar.

3. Eating the whole fruit provides additional fiber, nutrients, and a sense of feeling fuller.

4. Fruit juice serving size can range from one‐third to one‐half cup for 15 grams of carbohydrates; consider switching to whole fruit.

Disclosures

None.