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International Journal of Diabetes Research 2016, 5(6): 129-134
DOI: 10.5923/j.diabetes.20160506.02
The Potential of Apple Cider Vinegar in the
Management of Type 2 Diabetes
Joanna Morgan1,2, Sapha Mosawy1,2,*
1School of Medical Science, Griffith University, Gold Cost Campus, Queensland, Australia
2Menzies Health Institute Queensland, Griffith University, Gold Cost Campus, Queensland, Australia
Abstract Type 2 Diabetes represents a large burden on public health systems worldwide. The chronic metabolic condition
is characterised by hyperglycaemia and insulin resistance and is frequently associated with obesity, hypertension and
dyslipidaemia. There is a growing need for effective management techniques of these conditions that patients can utilise
complementary to conventional therapy. Apple cider vinegar (ACV) has been the subject of growing interest in this field. The
main component of ACV, acetic acid, has demonstrated effectiveness in reducing hyperglycaemia, correcting dyslipidaemia
and assisting weight loss. The dominant polyphenol compound in ACV, chlorogenic acid may also be useful in managing the
condition.
Keywords Apple cider, Diabetes, Vinegar, Hyperglycaemia, Dyslipidaemia
1. Introduction
In Australia 280 people develop type 2 diabetes each day
which currently affects 1.7 million Australians. The burden
on the public health system is estimated at $14.6 billion [1].
Type 2 diabetes, accounting for 85% of all diabetes, is a
complicated chronic metabolic condition characterised by
insulin resistance and eventually insufficient insulin
production resulting in abnormal glucose metabolism. The
condition is generally associated with obesity, a sedentary
lifestyle, hypertension and dyslipidaemia. Type 2 diabetes
significantly increases the risk of cardiovascular disease.
Management of the condition involves managing the risks
of cardiovascular disease as well as managing blood
glucose levels [2, 3].
Apple cider vinegar (ACV) may be able to play a role in
the day-to-day management of type 2 diabetes as growing
research has demonstrated that certain aspects of the
beverage assist in controlling hyperglycaemia, as well as
reducing cardiovascular disease risks through weight loss,
lowering blood pressure and lowering blood lipids [4, 5].
Not all ACV, however, is made alike. There are several
techniques utilised in commercial vinegar production, from
slower more traditional methods to techniques that can
produce ACV within a day. There are many other factors in
production, from apple cultivar, yeast and bacterial cultures
used, to whether the product was filtered and pasteurised
* Corresponding author:
s.mosawy@griffith.edu.au (Sapha Mosawy)
Published online at http://journal.sapub.org/diabetes
Copyright © 2016 Scientific & Academic Publishing. All Rights Reserved
[4, 6, 7]. Few studies have examined the effect different
production methods have on the final product and the
presence and quantity of organic components. Commercial
varieties also give limited information on package labelling
regarding production methods. The present review focuses
on ACV and its beneficial effects on type 2 diabetes.
2. Production of Apple Cider Vinegar
2.1. Two -Step Fermentation Process
ACV can be produced by a two-step fermentation process,
and this process is characterised by the presence of acetic
acid at a concentration equal to or above 4% [8]. Cider
vinegars are typically 5-6% acetic acid [9]. The pH of
vinegar will depend on acetic acid concentration and is
typically between 2 – 3.5 [10].
Yeasts initially ferment the sugars or starch in raw
materials to form ethanol, which is further fermented by
acetic acid bacteria (AAB) to produce acetic acid. This can
be accomplished with juices/mashes from apples, grapes,
coconuts, rice, potato and others. If a starch is the initial raw
material, it will first need to be hydrolysed into a sugar.
Depending on the method used for the second fermentation,
vinegar can be produced as quickly as within 24 hours or
may be left for months to years to ferment [4]. Figure 1
shows the chemical equations for the 2-step fermentation
process. The final product may be filtered and pasteurised
prior to consumption. This process removes and destroys
AAB, preventing formation of 'mother of vinegar'. Mother of
vinegar develops when unpasteurised vinegar is allowed to
remain in the product, forming an extracellular cellulose
130 Joanna Morgan et al.: The Potential of Apple Cider Vinegar in the Management of Type 2 Diabetes
layer which can be seen as a layer on the surface of the liquid,
or as a cloudy cobweb-like substance, making the fluid
appear murky. It is not unique to ACV.
Production of ACV can occur spontaneously via the
naturally occurring yeasts and bacteria on the surface of the
fruit, allowing the beverage to be easily made in the home
[11]. The product produced in the home will likely differ in
microbiota, acetic acid content and other molecules given
that the spontaneous process is not standardised. Filtering
and pasteurisation may not be done and the 'mother' may be
consumed or used to inoculate subsequent batches of
vinegar.
1) C6H12O6 → 2 CO2 + 2 C2H5OH
Alcoholic Fermentation by Yeasts
2a) 2C2H5OH → 2CH3CHO + 2H2
Oxidation (Anaerobic) by AAB
2b) 2CH3CHO + O2 → 2CH3COOH + 2H2O
Oxidation (Aerobic) by AAB
Figure 1. Chemical equations for 2-step fermentation process
2.2. Other Vinegar Production Techniques
2.2.1. Orleans Process (Traditional)
Orleans process is an early traditional process, in which
wine covered in a film (mother) of AAB, oxidises slowly in a
barrel. The barrel has holes, allowing for air flow and wine is
added beneath the mother. The mother causes the apparatus
to become slimy and slows the rate of vinegar production and
vinegar is removed through the bottom of the barrel [10].
2.2.2. Generator Process (Surface Culture/Quick Process)
The generator process is believed to date back to the 17th
century. AAB are grown in a thick layer on a
non-compacting material, such as beech wood shavings. A
pump circulates the liquid, allowing a slow trickle over the
bacterial culture while air is permitted to circulate through
the apparatus. While generator fermentation is used
commercially, it is considered to be slow and expensive
[10, 12].
2.2.3. Submerged-Culture
In the submerged-culture generator, a mechanical system
keeps the AAB submerged within the liquid in close contact
with aeration. The Frings acetator is a popular
submerged-culture generator. Submerged culture method
was designed for efficient commercial use [10].
2.2.4. Maceration
Maceration is a process already utilised in wine-making in
which the remaining pulp from extracted juice is left to soak
in the juice for a period of time. The phenolic and flavour
compounds within the skin and pulp are extracted via this
process. It has been shown that maceration in combination
with the surface production method yielded the ACV with
the highest phenolic content [6].
3. Production Methods, Apple Cultivar
and End Product
The production method utilised may affect the final
properties and composition of ACV. Different production
techniques have been demonstrated to affect pH, acidity and
phenolic content [6, 13]. Budak et al. [4] concluded that
production method affected the ability of ACV to alter
triglyceride levels in rats with some methods more effective
than others. The total content of phenolic compounds in
ACV and hence, production method, may also be relevant to
the ability of the beverage to promote good health.
The variety of apple (cultivar) used may affect the
phenolic content of the juice product [14] which, not
surprisingly, will also carry over to the cider vinegar [7]. The
level of ripeness that the apples achieved may also affect the
final product. A study that examined the ripening stage of
apples on phenolic compounds in apple cider (non-alcoholic)
found that unripe apples yielded a product with a lower
phenolic content compared to ripened apples. The apples
used in production can also affect the microbial content of
the end product, with organic apples found to produce a more
heterogeneous product compared with conventional apples
[15]. The variations in microbiota may in turn influence the
organic components of ACV which may affect the health
promoting properties.
4. Organic Components of ACV
Acetic acid is the most abundant compound. Organic acids
from an analysis of a commercially produced ACV using
high resolution H NMR spectroscopy are found in Table 1.
ACV is well established that various types of phenolic
compounds are found in cider apples, particularly the
hydroycinnamic acid derivatives, oligomeric flavan-3-ols,
dihydrochalcones, and flavonols [16]. The phenolic content
of ACV will vary with cultivar and processing [17]. Phenolic
content of ACV was determined to consist of gallic acid,
catechin, epicatechin, chlorogenic acid, caffeic acid and
p-coumaric acid. Chlorogenic acid is the dominant phenolic
substance in ACV [6]. The total phenol content and
chlorogenic acid content appear to vary significantly
between different studies, possibly attributed to the different
ACVs being used.
Dietary polyphenols are natural phytochemical
compounds and include the phenolic acid chlorogenic acid, a
hydroxycinnamic acid derivative. Studies demonstrate rapid
absorption of the polyphenolic compounds from the intestine.
Many healthful benefits are attributed to polyphenols, such
as antioxidant, antiallergic, anti-inflammatory, anti-viral
and anti-microbial, anti-proliferative, anti-mutagenic,
anti-carcinogenic, free radical scavenging, and induction of
International Journal of Diabetes Research 2016, 5(6): 129-134 131
antioxidant enzymes [19, 20]. There is also some evidence of
modulation of signalling pathways such as nuclear factor
kappa-B (NF-κB) and mitogen-activated protein kinases
(MAPK) [16].
Table 1. Organic acids in ACV
Compound Concentration (g/L)
Acetic Acid 50.9
Citric Acid 0.02
Formic Acid 0.28
Lactic Acid 0.38
Malic Acid 3.56
Succinic Acid 0.27
Fructose 6.83
Acetoin 0.21
2,3-Butanediol 0.37
Ethanol 1.03
Ethyl acetate 0.14
Values adopted from Caligiani et al (2007) [18]
5. Management of Hyperglycaemia
Using ACV
Hemoglobin A1c (HbA1c) level measures the glycation of
hemoglobin, accurately identifies the average plasma
glucose concentration over the previous three months. A
study which investigated the effect acetic acid had on HbA1c
in type 2 diabetics, found that Hb1Ac values fell by 0.16%
units over the course of the 12-week trial, compared with
controls who did not ingest any vinegar, where HbA1c levels
rose by 0.06% [21]. HbA1c in diabetic rats was also
significantly lowered with ACV consumption [22].
Several mechanisms may explain the ways in which acetic
acid lowers plasma glucose have been suggested. These
include inhibition of disaccharidase activity [23-25] and/or
decrease in the hydrolytic enzyme α-amylase [26], delayed
gastric emptying [27, 28] and an enhanced glucose uptake
and conversion to glycogen in the periphery [23, 29, 30].
Delayed gastric emptying was noted in healthy subjects
who consumed white bread along with a white vinegar
dressing which contained olive oil (18mmol acetic acid in
20g vinegar). White vinegar is an aqueous solution
containing approximaetly 6% acetic acid. Gastric emptying
rate was indirectly measured through consumption of
paracetamol baked into white bread; the blood paracetamol
level was lower in the vinegar group compared with the
control group. During the postprandial phase subjects who
had consumed vinegar had significantly lower blood glucose
levels and the insulin response in these subjects was also
noted to be significantly lower compared with the reference
meal [28]. Paracetamol however, may be absorbed and
metabolised at different rates. Other research has also found
a link to acetic acid consumption with delayed gastric
emptying [27].
Recent investigation found that ACV had a stronger
ability to lower plasma glucose levels than acetic acid alone
[26]. This study found that it was not until day 7 that ACV
significantly reduced plasma glucose levels in diabetic mice.
ACV had comparable antiglycemic effects to the positive
control group treated with the anti-diabetic agent
sulfonylurea Glibenclamide. It was found that ACV treated
groups had a significant decrease in α-amylase. The ability
of ACV to have a stronger effect than acetic acid alone
suggests a role for other components of ACV in controling
hyperglycemia. Another study found that consuming two
tablespoons of ACV prior to sleeping was found to reduce
fasting glucose the following morning [25].
Furthermore, acetic acid was demonstrated to significantly
decrease the activites of the diasscharides sucrase, maltase,
trehalase and lactase in Caco-2 cells, but did not affect the
enzymes at transcriptional or translational levels. It was
suggested that suppression of the disacharrides may occur in
the post-translational processes, such as trafficking of the
enzymes to the cell membrane [24]. Consumption of 100mL
ACV (5% acetic acid) in diabetic rats demonstated a
significant decrease in the activity of maltase, sucrase and
lactase [23]. In addition, vinegar ingestion (10g) was found
to have no effect on postprandial glycemia (PPG) when only
monosaccharides were ingested while a meal of complex
carbohydrates consumed with vinegar did result in decreased
PPG, further indicating that a acetic acid may inhibit
disaccharidase activity [31].
Glycogen uptake by the liver and skeletal muscle was
found to be enhanced in mice fed a diet containing 2g acetic
acid/kg, a contentration that corrosponds to foods prepared
with vinegar. Acetic acid ingestion may inhibit glycolysis
through accumulation of glucose-6-phosphate and a
corrosponding increase in glycogen synthesis, which was
seen in liver and skeletal muscle of rats supplemented with
acetic acid [29, 32, 33], causing an anti-hyperglycemic effect.
Modulation of GK, G6PD and PFK in the liver of rats
consuming ACV has been associated with decreased plasma
glucose levels [23].
The quantity of acetic acid needed to exert effects has been
investigated and a significant dose-response relationship was
found in a study that examined the effects of ingestion of 18,
23 or 28g of white vinegar (6% acetic acid; equivalent to 18,
23, 28 mmol acetic acid, respectively) [34]. Compared with
the control, the highest concentration of acetic acid caused a
significant decrease in plasma glucose and insulin response
postprandially while the lower acetic acid concentrations did
lower blood glucose and insulin response, it was not
signifiant [34].
Chlorogenic acid has been demonstrated to have some
antiglycemic effects that may be useful in the management
of type 2 diabetes. 1mM of chlorogenic acid was found to
significantly inhibit glucose-6-phosphatase (G-6-Pase)
activity in rat hepatocytes. G-6-Pase promotes glucose
production through catalyzing steps in both gluconeogenesis
and glycogenolysis and inhition of this step can decrease
plasma glucose concentration [35]. Synthetic derivatives of
132 Joanna Morgan et al.: The Potential of Apple Cider Vinegar in the Management of Type 2 Diabetes
chlorogenic acid also have been shown to inhibit G-6-Pase
[36]. Liver perfusion experiments, however, did not find a
decrease in glucose production at various chlorogenic acid
concentrations, perhaps due to insufficent uptake of
chlorogenic acid by hepatocytes. However, 1mM
chlorogenic acid was able to significantly reduce the plasma
glucose peak during the oral glucose tolerance test in rats and
this is thought to be due to reduced activity of Na+-dependant
D-glucose transporters in brush-border membrane vesicles,
as administration of chlorogenic acid intravenously was
unable to achieve the same result [35, 37].
Insulin sensitivity was improved in human subjects with
both insulin resistance or type 2 diabetes when 20g of ACV
was consumed with a high-carbohydrate meal [38]. Animal
studies also demonstrated results suggesting improved
insulin sensitivity with chlorogenic acid infusion [39].
Improved insulin sensitivity results in increased glucose
uptake and hence lowered plasma glucose levels. A diet
supplemented with chlorogenic acid has also been shown to
significantly lower insulin levels in mice [40].
6. Management of Hypertension and
Obesity
Diabetes may affect the autonomic nervous system and
endothelium which results in microvascular complication,
which in turn impairs the autoregulation of blood flow.
Diabetic subjects have been shown to have lower levels of
the vasodilator nitric oxide and increased levels of the
vasoconstrictor endothelin-1 which results in a state of
vasoconstriction [41]. A consequence of elevated blood
pressure is vascular damage which leads to cardiovascular
disease.
Acetic acid combined with vinegar were found to
significantly decrease blood pressure (21-30mmHg lower
than the control) and renin activity compared with controls
and subjects consuming only vinegar. A decrease in renin
and the subsequent release in angiotension II may be the
reason for lowered blood pressure. A decrease in aldosterone
was also seen. Both rice vinegar and acetic acid were given at
a concentration of 46.2g/L [42]. Rice vinegar is generally 4%
acetic acid [43], therefore the acetic acid given alone would
be more potent then the vinegar solution. It was suggested
that acetic acid may cause an increase in calcium absorption,
which in turn may cause an calcium influx into renin
secretory cells, inhibiting renin secretion [42]. A
combination of red wine vinegar and grape juice was also
found to decrease activity of angiotensin converting enzyme
(ACE) [44].
Type 2 diabetes is commonly associated with obesity and
weight loss is considered to be an important component in
the management of diabetes [2]. Acetic acid has been
proposed to have a role in reducing food intake. This may
occur as a result of the taste of acetic acid in vinegar and the
nausea it may induce from ingestion [45]. A study found that
supplementation of a meal with white vinegar increased the
subjective rating of satiety compared with a control group.
Improved satiety may result in lowered food consumption
and hence, weight loss [34]. A 12 week study found that
ingestion of both 75g and 150g of acetic acid significantly
reduced the bodyweight, body mass index (BMI), visceral fat
and waist circumference in comparison with a control group
[46].
Chlorogenic acid has been demonstrated to halt the cell
cycle of mouse embryo 3T3-L1 preadipocytes and arrest the
G1 phase, hence preventing proliferation. Preadipocytes
were inhibited in this study in both time- and dose-dependant
manner at a concentration of 100μM. Decreased
preadipocyte differentiation is just one proposed method to
reverse obesity [47]. Another recent study supplementing the
diet of mice on a high fat diet with 0.02% (w/w) chlorogenic
acid resulted in a significant 16% weight loss compared with
the control group and increased adiponectin levels [40].
7. Management of Dyslipidaemia
Type 2 diabetes is frequently associated with
dyslipidaemia. Part of management of the condition involves
attempting to achieve normal blood levels of total cholesterol,
low density lipoprotein (LDL), high density lipoprotein
(HDL) and triglycerides. Dyslipidaemia is highly correlated
with atherosclerosis.
7.1. Dyslipidaemia and ACV
Ingestion of ACV improved lipid profiles in both normal
and diabetic rats, decreasing triglycerides, total cholesterol
and LDL while increasing HDL. These effects became
pronounced after 4 weeks of treatment [23]. Further animal
studies found similar effects on plasma total cholesterol,
triglycerides, HDL and LDL levels [22, 48]. Other research
focused on healthy humans has found the same improvement
in lipid profile with ingestion of 30ml of ACV (4% acetic
acid) [49].
7.2. Dyslipidemia and Acetic Acid
Research studies examining the effect acetic acid has on
blood lipids found that rats fed a diet supplemented with
1% (w/w) cholesterol combined with acetic acid had
significantly lowered total cholestrol and triglycaride levels
compared with controls. Acetic acid was found to lower
liver ATP citrate lyase (ATP-CL) activity, liver
3-hydroxy-3-methylglutaryl-CoA content, all of which are
involved in lipid synthesis. Liver mRNA levels of sterol
regulatory element binding protein-1, ATP-CL and fatty acid
synthase were also found to be decreased. Faceal bile content
was found to be higher in the group fed acetic acid. Blood
lipids in rats fed acetic acid were decreased by both the
inhibition of lipogenesis in the liver and the increased
increment of cholesterol in faecal bile acid [50].
7.3. Dyslipidemia and Chlorogenic Acid
Supplementation of mice on a high fat diet with
International Journal of Diabetes Research 2016, 5(6): 129-134 133
chlorogenic acid significantly lowered plasma triglyceride
and total cholesterol concetrations compared with the control
group on a high fat diet. Adipose tissue triglycerides were
also found to be significantly lowered. Hepatic activity of
HMG-CoA reductase was lowered and fatty acid β-oxidation
levels increased with chlorogenic acid intake [40]. Studies
using obese, hyperlipidemic and insulin resistant (fa/fa)
Zucker rats which were infused with chlorogenic acid
(5mg/Kg body weight/day) found significant decreases in
fasting plasma cholesterol and triglycerides [39].
8. Conclusions
The ACV is a readily available product that is easily able
to be incorporated into meals. Large body of research has
demonstrated its beneficial properties as an entire product, as
well as the abilities of the individual components acetic acid
and chlorogenic acid. ACV may assist in controlling blood
glucose and lipids, weight loss and hypertension and
therefore may be helpful in the management of type 2
diabetes. ACV as a whole may be more effective than acetic
acid alone, although there is little research directly
comparing acetic acid and ACV. Consumption of the
‘mother of vinegar’ may also increase beneficial effects
compared with ACV lacking this component. Production
method of ACV has been shown to alter the components of
ACV, which may in turn affect the beneficial qualities.
Further investigation may be beneficial here to determine the
extent of the effect of production method. Consumption of
ACV may indeed be beneficial in the management of type 2
diabetes.
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