Your cholesterol went up at your last physical. You didn't change a thing. Same breakfast, same walks, same everything. So what gives?

It's not your oatmeal, and it's not in your head. The SWAN study, which followed more than 3,000 women through the menopause transition, found that LDL cholesterol jumps in the year around your final period, faster than aging alone can explain. One big reason: estrogen helps your liver pull LDL out of your blood. When estrogen packs up, more LDL sticks around.

So this October, let's talk about the most basic fall food in the orchard. The apple. 🍎

Spoiler: one apple a day didn't do much. Two did.

First, a little apple drama

"An apple a day keeps the doctor away" has been on refrigerator magnets since roughly the invention of refrigerators. In 2015, a team at Dartmouth finally fact-checked. They looked at 8,399 American adults and compared the daily apple eaters with everyone else.

The verdict? After adjusting for things like education and smoking, apple eaters were no better at keeping the doctor away. The doctor shows up either way. They were, however, a little more likely to skip prescription medications.

(The paper's subtitle is "Appealing the Conventional Wisdom." Yes, scientists pun too. My people!)

But a survey can't tell you cause and effect. For that, you need a trial.

Plot twist: someone ran the trial

In 2020, researchers in the UK and Italy ran a randomized, controlled crossover trial in 40 adults with mildly high cholesterol. Twenty-three were women, and the average age was 51. Hello, HOPsters.

Everyone did two 8-week rounds, with a month off in between:

• Round #1: Two whole apples a day, peel on.
• Round #2: A sweetened apple drink (half apple juice, plus added sugar), matched to the whole apples for sugar content.

Same sugar. The big difference was the whole fruit.

Here's how the whole-apple weeks stacked up against the juice-drink weeks:

• LDL cholesterol about 4% lower
• Total cholesterol about 4% lower
• Triglycerides about 10% lower
• Small blood vessels that relaxed and opened better, a sign of a healthier vessel lining

Is 4% going to replace a statin? Nope. But from a snack that costs about a dollar and rides around in your purse? I'll take it!

Why the whole apple wins

An apple is basically a fiber delivery system wearing a polyphenol jacket.

The fiber

Apples are rich in pectin, a soluble fiber that can help lower cholesterol. Two apples aren't a big dose on their own, so the researchers think the fiber and the apple's polyphenols work as a team. Your gut bacteria also ferment pectin into short-chain fatty acids, including butyrate, the fuel your gut lining runs on. Translation? Your gut bugs turn apple fiber into lunch for your colon.

The jacket (aka the peel)

A lot of the good stuff lives in the apple’s skin, including quercetin, a powerful antioxidant. Plus, the apples used in this study were specifically selected for their high levels of proanthocyanidins, another group of beneficial plant compounds. In the “whole apple” round of the study, all participants ate the apples with the skin on.

Apple juice leaves the fiber and peel behind, so you get all of the sugar and none of the key benefits.

How to HOP to it

The basics that still matter

1. Eat the peel. Wash it, but don't peel it.
2. Whole beats juice. Apple cider season, I'm looking at you.
3. Know your numbers. Ask for a lipid panel during perimenopause, and ask about ApoB while you're at it. SWAN says that's when things move.

The hidden levers

1. Two is the number. The trial used two apples a day, not one. The refrigerator magnet was off by an apple.
2. Pair it with protein. An apple with peanut butter or a slice of cheese is a steadier snack than an apple alone.
3. Stack your soluble fiber. Oats, beans, lentils, and pears play on the same team as pectin.

The HOP Box play

1. Dihydroberberine. A form of berberine built for better absorption. The cholesterol research is on berberine itself: a 2023 review of 18 placebo-controlled trials found that it lowered LDL. Berberine has also been studied for blood sugar.
2. Tributyrin. Delivers butyrate directly, the same short-chain fatty acid your gut bacteria make from apple fiber.
3. Quercetin. The flavonoid apples keep in their skin, working in our Damage Control pill alongside fisetin and apigenin.

The bottom line

An apple a day won't keep the doctor away. Two might keep your LDL in line. Eat the peel, skip the juice, and get your numbers checked this fall.

HOP to it!

Dr. Amy Killen & the HOP Team

P.S. The trial used a green Italian apple called Renetta Canada. I have never once seen it at my grocery store. Until someone runs the Honeycrisp trial, pick a crisp apple you'll actually eat, peel and all.

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References

1. Koutsos A, Riccadonna S, Ulaszewska MM, et al. Two apples a day lower serum cholesterol and improve cardiometabolic biomarkers in mildly hypercholesterolemic adults: a randomized, controlled, crossover trial. Am J Clin Nutr. 2020;111(2):307-318. doi:10.1093/ajcn/nqz282
   
   
2. Davis MA, Bynum JP, Sirovich BE. Association between apple consumption and physician visits: appealing the conventional wisdom that an apple a day keeps the doctor away. JAMA Intern Med. 2015;175(5):777-783. doi:10.1001/jamainternmed.2014.5466
   
   
3. Matthews KA, Crawford SL, Chae CU, et al. Are changes in cardiovascular disease risk factors in midlife women due to chronological aging or to the menopausal transition? J Am Coll Cardiol. 2009;54(25):2366-2373. doi:10.1016/j.jacc.2009.10.009
   
   
4. Blais JE, Huang X, Zhao JV. Overall and sex-specific effect of berberine for the treatment of dyslipidemia in adults: a systematic review and meta-analysis of randomized placebo-controlled trials. Drugs. 2023;83(5):403-427. doi:10.1007/s40265-023-01841-4
   
   
5. Boyer J, Liu RH. Apple phytochemicals and their health benefits. Nutr J. 2004;3:5. doi:10.1186/1475-2891-3-5