Content uploaded by Atoosa Saidpour
Author content
All content in this area was uploaded by Atoosa Saidpour on Jul 08, 2018
Content may be subject to copyright.
Beneficial effects of Apple Cider Vinegar on weight management, Visceral Adiposity Index
and lipid profile in overweight or obese subjects receiving restricted calorie diet: A
randomized clinical trial
Solaleh Sadat Khezri 1, Atoosa Saidpour 2*, Nima Hosseinzade 3 and Zohreh Amiri 4
1 M.Sc. in Nutrition, Faculty of Nutrition and Food Technology, Shahid Beheshti University of
Medical Sciences, Tehran, Islamic Republic of Iran, +989127810654,
solalesadat_khezri@yahoo.com
2* Assistant Professor (PhD), Department of Clinical Nutrition & Dietetics, Faculty of Nutrition
and Food Technology, National Nutrition and Food Technology Research Institute, Shahid
Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran.
a.saidpour@sbmu.ac.ir
3 M.Sc. in Biostatistics, Faculty of Biostatistics, Shahid Beheshti University of Medical Sciences,
Tehran, Islamic Republic of Iran, +989126350910, nima_ingwie@yahoo.com
4 Associate Professor (PhD), Department of Clinical Nutrition & Dietetics, Faculty of Nutrition
and Food Technology, National Nutrition and Food Technology Research Institute, Shahid
Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran, +09128136212,
amiri_z@sbmu.ac.ir
* Correspondence and offprint requests to: Atoosa Saidpour, PhD, Department of Clinical
Nutrition & Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition
and Food Technology Research Institute, P.O. Box: 19395-4741, Tehran, Islamic Republic of
Iran.
Email: atoosa.saidpour@gmail.com; a.saidpour@sbmu.ac.ir
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Tel: (+9821) 22357483-5
Fax: (+9821) 22360660
Running Title: Apple Cider Vinegar on Visceral Adiposity Index and lipid profile
Funding support:
This project was supported by the National Nutrition and Food Technology Research Institute of
Iran.
2
23
24
25
26
27
28
29
Abstract
A randomized, clinical trial was performed to examine whether Apple cider vinegar (ACV) can
result in dietary modifications that provides beneficial effects on the management of body weight
and serum metabolic profiles in overweight or obese individuals. The participants (n=39) were
randomly allocated into the ACV (subjected to a restricted calorie diet (RCD) with 250 kcal/day
energy deficit and 30mL/d of ACV)) or the control group (RCD only) for 12 weeks. The ACV
significantly reduced body weight, BMI, Hip circumference, visceral adiposity index (VAI) and
appetite score (P≤0.00). Furthermore, Plasma triglyceride (TG) and total cholesterol (TC) levels
significantly decreased and high density lipoprotein cholesterol (HDL-C) concentration
significantly increased in the ACV group in comparison to the control group (P≤0.05). Thus,
ACV along with RCD can be considered as an effective strategy for reducing anthropometric
parameters, TG and TC level, VAI, appetite and increasing HDL-C concentration in overweight
or obese individuals.
Key words: Apple cider vinegar; Obesity; Appetite; Neuropeptide Y; Lipid profile, restricted
calorie diet; visceral adiposity index
3
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
1. Introduction
Obesity has become a critical challenge worldwide in the recent decades and is associated with
many public health problems such as dyslipidemia, cardiovascular disease, and type 2 diabetes
(Al-Kuraishy & Al-Gareeb, 2016; Health, 2000). The most effective strategies for the
management of obesity are energy intake restriction, increased physical activity, behavioral
modifications, pharmacotherapy, and bariatric surgery(Health, 2000). Unfortunately, these
treatments have had a maximum success rate of only 21% (Wing & Hill, 2001).
Traditional and complementary medicine is becoming more popular worldwide generally due
to fewer side effects (Ajaykumar, Anandarajagopal, Jainaf, Venkateshan, & Ananth, 2012).
Apple cider vinegar (ACV) is widely used as a flavoring (or dressing) and preservative in foods.
In addition, ACV is a traditional natural treatment that has two main active constituents including
acetic acid (Kondo, Kishi, Fushimi, Ugajin, & Kaga, 2009) and polyphenolic compounds (Denis
et al., 2013). Recently ACV has attracted a lot of interest for its beneficial effects on controlling
body weight and visceral fat accumulation (Kondo et al., 2009). So far, a few animal studies and
clinical trials have been performed investigating the effects of ACV on anthropometric
measurements, body composition and plasma lipids. Some of these studies show that vinegar
administration has favorable effects on anthropometric parameters especially body weight
regulation (Kondo et al., 2009; Lim et al., 2009; Ok et al., 2013; Seo et al., 2014), whereas
others did not find these effects (Lee et al., 2013; Park et al., 2014). In addition, the effects of
vinegar on lipid parameters were contradictory in the previous studies (Kondo et al., 2009; Ok et
al., 2013; Park et al., 2014; Seo et al., 2014). Furthermore, based on the current evidence, there is
a general lack of research investigating the effects of ACV on plasma concentrations of
neuropeptide-Y (NPY) which is the most potent orexigenic peptide, regulating food intake
4
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
(Tatemoto, 2004). Moreover, it seems that evaluating the visceral adiposity index (VAI) is a
beneficial marker determining adipose tissue dysfunction, in regards to subcutaneous and
visceral adipose tissue in the abdominal region (Al-Kuraishy & Al-Gareeb, 2016). Therefore, the
present study aimed to evaluate the impact of ACV along with restricted calorie diet (RCD) on
the anthropometric measurements, body composition, VAI, plasma lipids, NPY, and appetite in
overweight or obese individuals.
2. Methodology
2.1. Subjects and ethical aspects
A randomized, controlled trial conducted from October to December 2014, this study was not
blinded as the subjects in the ACV group were aware of the nature of the samples due to the
strong odor and taste. No odor masking techniques were used as the control group were only
subjected to the RCD. In this two-arm parallel study with 9 kg difference detection and a pooled
standard deviation of 9.8 kg (Kondo et al., 2009), the minimum sample size was estimated 19 at
a power (1 –β) of 80% (α= 0.05). Forty-four metabolically healthy overweight or obese adults
(men and women) with the body mass index (BMI) of more than 27 kg/m2 (range 27-40) were
selected using convenience sampling from the Specialized Clinic of Nutrition & Diet Therapy
located in the Faculty of Nutrition Sciences and Food Technology of Shahid Beheshti University
of Medical Sciences in Tehran, Iran.
Subjects enrolled in this study did not have infectious diseases, thyroid disorders, diabetes, or
gastrointestinal diseases. In addition, patients who had regularly used ACV within one month
prior to the beginning of the study were excluded.
5
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
The guidelines of the Helsinki Declaration was applied in this study and the Ethics Committee of
the National Nutrition and Food Technology Research Institute of Iran has approved all
proceedings. This clinical trial was registered at Iranian Registry of Clinical Trials (IRCT) under
IRCT2013122815968N1.
2.2. Protocol
The Research Committee of the National Nutrition and Food Technology Research Institute of
Iran has approved this study protocol. Informed consent was signed by all subjects before
initiation of the study. The participants were randomly assigned to either ACV or the control
group. This allocation was completed by block randomization, block size of 4 was chosen and
possible balanced combinations with 2 C (control) and 2 A (ACV) subjects, calculated as 6
blocks (AACC, ACAC, ACCA, CAAC, CACA, CCAA). Then, blocks were randomly chosen,
based on a simple random sampling method to determine the assignment of all subjects into the
groups. The block randomization was performed by a trained dietician. Furthermore, all
procedures including implementation of the allocation sequence, participants registration, and
allocating subjects to interventions were performed by a research director.
Subjects in the ACV group received 30 mL/day of apple cider vinegar and were subject to
restricted calorie diet (RCD) for 12 weeks, while those in the control group followed the RCD.
The subjects in the ACV group consumed 15 mL of apple cider vinegar with salad at lunch and
15 mL at dinner. Consuming salads with lunch and dinner was also suggested to the control
group.
The subjects in both groups followed an RCD throughout the study. The RCD had 250 kcal/ day
lower than estimated energy requirement for each patient based on the Mifflin-St Jeor equation
6
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
(Mifflin et al., 1990). Diets were designed to provide approximately 55% carbohydrate, 30% fat
and, 15% protein. The study protocol did not change after the trial was commenced.
2.3. Dietary intake assessment
A 3-day dietary recall was used to assess the dietary intakes of subjects (2 week days and 1
weekend) at baseline and six and twelfth weeks of the study. Diets of participants were analyzed
by Nutritionist IV software (N Squared Computing, San Bruno, CA, USA).
2.4. ACV preparation and acetic acid content
ACV was purchased from traditional medicine stores in Tehran (Iran). These stores provide
natural homemade ciders without industrial interference. The apples are prepared by washing and
then cut into smaller pieces, then 1 kilogram of white vinegar was added for each 3 kilograms of
apples and were put in containers and stored in warm place. Stirring of the containers occurred
once a week and after 30 days the ACV was prepared.
High-performance liquid chromatography (HPLC) measurements were conducted, all tests were
performed at the same laboratory (Shahid Beheshti University of nutrition and food science)
(Morales, Gonzalez, & Troncoso, 1998). Blanks and acid standards were respectively used as
positive and negative controls, in HPLC analysis. Duplicate samples were used in all the tests
and none of the samples were blinded to the researchers. In preparation for HPLC analysis,
samples from each brand were vortexed and centrifuged, and filtered HPLC was performed with
a Waters chromatography system (Millipore) at a flow rate of 0.5 mL per minute and an injection
valve set at 10 L with a variable ultraviolet wave length detector set at 210 nm. The separation
was performed with a carbohydrate analysis column (3.9 300 mm) (Waters chromatography,
7
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
Millipore). The mobile phase of all the samples was 0.1% H3PO4 adjusted to PH 1. Eventually,
the sample with higher purity degree of 486 mg/100ml acid acetic concentration was used.
2.5. Anthropometric assessment and body composition
Weight, hip and waist circumferences (WC) were assessed at baseline and the end of six and the
end of 12 weeks of the study. Weight was measured to the nearest 0.1 kg, using a beam balance
scale. A beam balance scale was used to measure the weight to the nearest 0.1 kg. Height was
recorded by stadiometer to the nearest 0.1 cm. All readings were taken by light indoor clothing
and without shoes. Then, BMI was calculated as weight in kilograms divided by height in meters
squared. A plastic measuring tape was used for measuring the waist and hip circumferences by
using the smallest girth below the rib cage and above the umbilicus (K. Hammond, 2008) and the
largest girth between the waist and knees (K. A. Hammond, 2000). All readings were taken to the
nearest 0.1 cm. Waist to hip ratio (WHR) was calculated as WC divided by hip girth. Total fat
mass and lean body mass were assessed using bioelectric impedance analysis device (QuadScan
4000; Bodystat, Douglas, United Kingdom) at baseline and the end of 6 and 12 weeks of the
study. Primary outcome of the study was anthropometric parameters and body composition. VAI
is measured through the under formula which on WC (in cm), triglyceride (TG), and high-
density lipoprotein (HDL-C) in mmol/L(Amato & Giordano, 2014).
Females :VAI=( WC
36.58+
(
1.89× BMI
)
)×(TG
0.81 )×(1.52
HDL )
Males :VAI=( WC
39.68+
(
1.88 × BMI
)
)×(TG
1.03 )×(1.31
HDL )
2.6. Physical activity assessment
8
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
At baseline and the end of week 6 and 12, a valid Modifiable Activity Questionnaire (MAQ)
(Kriska et al., 2006) was performed to assess the physical activity by calculating the metabolic
equivalent (MET). The physical activity intensities were classified into low (MET <600
min/wk), moderate (MET 600–1499 min/wk), and high (MET ≥1500 min/wk) (Sesso,
Paffenbarger, & Lee, 2000).
2.7. Appetite assessment
Appetite was assessed by the Simplified Nutritional Appetite Questionnaire (SNAQ). SNAQ is a
4-item questionnaire and more recommended to be used for clinical purposes (Wilson et al.,
2005). A 5-point scale (A=1 to E=5) was used for scoring each. The SNAQ items were as follow:
: #1, Appetite; #2, Feeling full; #3, Food tastes; #4, Feeling hunger and the sum of the 4 items
scores constitutes the total SNAQ score and ranges from 4 to 20. The total score of 4 to 14 and
15 to 20 indicate low and normal appetite, respectively (Wilson et al., 2005).
2.8. Blood samples and biochemical assessment
At baseline and the end of week 12, 7 ml of blood was drown from the participant using EDTA-
coated tubes after fasting for a 12- to 14-hour. The plasma of samples was collected after
centrifugation at 2000 rpm for 10 minutes and the specimens were divided into small aliquots
and then were stored at -70°C until further processing.
In the current study, secondary outcomes were plasma triglyceride, total cholesterol, HDL-C and
low- density lipoprotein (LDL-C). Various colorimetric methods using commercial kits (Pars
Azemoon, Tehran, Iran) and Selectra 2 Autoanalyzer (Vital Scientific, Spankeren, The
Netherlands) were applied to assess the triglyceride, total cholesterol and HDL-C plasma
9
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
concentrations. Intra-assay coefficients of variation (CV) for plasma triglyceride, total
cholesterol and HDL-C were less than 3%. Since the plasma triglyceride level of all participants
was below 400 mg/dL, Friedwald equation was used to estimate the plasma LDL-C (Friedewald,
Levy, & Fredrickson, 1972). Plasma concentration of NPY was determined by enzyme-linked
immunosorbent assay kit (Cusabio Biotech, Wuhan, China) and the intra-assay coefficient of
variation (CV) was 7.7%. Samples were thawed at one time and all analyses were performed in
duplicate.
2.9. Statistical analysis
Data is expressed as mean± standard deviation (SD) or percentage (%). The Statistical Package
for the Social Sciences for Windows version 21.0 was applied for statistical analysis (SPSS, Inc.,
Chicago, IL, USA). Intention-to-treat principle (ITT) and per-protocol analysis were applied for
analyzing the data; the ITT results was only displayed because of the same outputs. Furthermore,
ITT was completed with expectation maximization clustering algorithm. For comparing
qualitative variables between the two groups, a χ2 test was used. Since the distribution for all
quantitative parameters was normal, based on Kolmogorov-Smirnov test, repeated measures
ANOVA and paired t-test were used to compare parameters within groups. For comparing
parameters between groups, Student's t-test was used and in order to adjust confounding factors
(changes in body fat and energy intake), an analysis of covariance was also performed. The
assumption of homogeneity of variance was tested using Levene’s test. As dietary and
anthropometric measurements were recorded 3 times throughout the study, analysis of variance
for repeated measurements was applied to compare the effect of ACV at these time points. A p-
value of ≤0.05 was considered as statistically significant.
10
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
3. Results
Of the 44 obese and overweight subjects eligible for this trial, 2 subjects in the ACV group
(inability to cooperate or medical treatments) and 3 subjects in the control group (using medical
treatments) were excluded (Figure 1).
3.1. Baseline characteristics
No significant differences were found in the baseline characteristics of the subjects between the
two groups (Table 1).
3.2. Dietary intakes and physical activity
The mean dietary energy intake reduced in both group following the trial. The ACV group
showed significant reductions in energy intake during the study in comparison to baseline
(p=0.01); however, significant difference was not detected between the two groups at the week 6
or 12 (Table 2). The dietary fat intake was significantly reduced in both groups compared to
baseline throughout the study (p=0.03 in the ACV group and p=0.02 in the control group).
Furthermore, the intakes of saturated fatty acid (SFA) and mono-unsaturated fatty acid (MUFA)
decreased significantly in the ACV group in comparison to baseline during the study (p=0.001).
SFA intake reduction was marginally significant in comparison with the control group by week
12 (p=0.05). In addition, poly-unsaturated fatty acid (PUFA) intake was significantly reduced in
the control group compared to baseline by week 12 (p=0.03). Significant differences were not
observed between the two groups with respect to energy intake as well as protein, carbohydrate,
cholesterol, calcium and dietary fiber intake (Table 2). Changes in dietary intakes were adjusted
11
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
for body fat changes. Also, no statistical significance was found in regards to the physical
activity of subject in both groups.
3.3. Effects on anthropometric measurements
BMI, body fat (BF), waist and Hip circumference reduced significantly in ACV and the control
group in comparison to baseline (p=0.001). Moreover, body weight and WHR were also
decreased significantly in the control group compared to baseline (p=0.0, p=0.002; respectively).
Lean body mass (LBM) was also significantly reduced in the ACV group in comparison to
baseline (p=0.03). Furthermore, WHR significantly decreased in the control group in comparison
to baseline (P=0.002). Body weight, BMI and hip girth were significantly reduced in the ACV
group in comparison to the control group during the 12 weeks (p<0.05).VAI was significantly
decreased in the ACV group compared to the control group in both sexes (in male: p=0.02; in
female: p=0.001); however VAI was also significantly decreased in the female of ACV group
compared to baseline by week 12 (p=0.004) (Table 3). Anthropometric measurements were
adjusted for energy intake.
3.4. Effects on plasma lipids and NPY
Plasma TG concentrations reduced in the ACV group by week 12 was observed in comparison to
baseline and this reduction was also significant in comparison to control group (p=0.001), also
there was significant increases in TG levels in the control group compared to baseline (p=0.035).
HDL-C level was also significantly increased in the ACV compared to the control group
(p=.0049). Furthermore, total cholesterol (TC) was also significantly decreased in the ACV
group compared to the baseline. Moreover, the changes observed in plasma concentrations of
12
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
LDL-C, LDL-C/HDL-C and NPY were not statistically significant during the study period (Table
4). Lipid profiles were adjusted for baseline TG and body fat changes.
3.5. Effects on appetite
At the end of the study, the SNAQ score reduced significantly in the ACV group in comparison
to the control group (p=0.04). Appetite reduction was also demonstrated in ACV group by week
12 (p=0.001) (Figure 2).
4. Discussion
In the present study, oral administration of ACV along with RCD significantly decreased body
weight, BMI, hip circumference and Visceral Adiposity Index (VAI) in comparison to the
control. No clinical trials have investigated the effects of ACV and RCD together on
anthropometric parameters in overweight or obese subjects. However, few animal studies (Lee et
al., 2013; Lim et al., 2009; Ok et al., 2013; Seo et al., 2014) and clinical trials (Kondo et al.,
2009; Park et al., 2014) have been performed investigating the effects of vinegar consumption on
overweight or obesity. In accordance with our study, Kondo et al. showed that apple vinegar
consumption (15 or 30 mL/day) for 12 weeks reduced body weight, BMI, hip circumference, and
WHR (Kondo et al., 2009). In addition, some animal studies indicated that vinegar intake has a
favorable effect on controlling body weight (Lim et al., 2009; Ok et al., 2013; Seo et al., 2014).
In contrast, Park reported that daily consumption of pomegranate vinegar for 8 weeks did not
significantly reduce body weight and BMI in overweight or obese subjects (Park et al., 2014).
Also, Lee et al. showed that tomato vinegar had no significant effects on body weight in
comparison to the control group in obese rats (Lee et al., 2013). Although, inconsistencies
somehow can be related to the different type of vinegar and the study design. In the present
13
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
study, regarding the beneficial effect of ACV on anthropometric parameters and VAI as a gender
dependent mathematical model, reflecting visceral adiposity (Al-Kuraishy & Al-Gareeb, 2016);
it seems that ACV may play a synergetic role along with RCD on weight reduction in obesity.
Several mechanisms have been suggested for the beneficial effect of vinegar consumption on
body weight. The first mechanism is a hunger reduction and consequently a decrease in food
intake (Petsiou, Mitrou, Raptis, & Dimitriadis, 2014). Accordingly, at the end of our study,
SNAQ scores, as an appetite indicator, reduced significantly in the ACV group in comparison to
the control group, while no statistical significant was found in the control group. Ostman et al.
indicated that the effect of vinegar consumption on the satiety score was directly related to acetic
acid content of the vinegar (Östman, Granfeldt, Persson, & Björck, 2005). In our study, ACV
consumption had no effect on plasma NPY concentration, as an appetite-stimulating
neuropeptide. Therefore, it seems that appetite control by ACV is not related to plasma NPY. The
second mechanism of the effect of vinegar consumption on body weight is an increase in energy
expenditure (Petsiou et al., 2014). However, the thermic effect or dietary induced thermogenesis
of ACV consumption was not investigated in our study but in accordance with the level of
restricted calorie intake (-289 calorie for 12 weeks), approximately half a kilogram weight loss
more than the expected amount for this duration may be related to the thermic effect of ACV.
In the present study, BF and waist circumference significantly decreased in both groups, but
no significant reductions in these variables between the two groups were found. In addition,
WHR was significantly decreased in the control group but this was not significantly different
between the two groups. Based on the currently available literature, no previous study
investigated the effect of ACV and RCD together on BF and waist circumference in overweight
or obese subjects. However, Kondo et al. demonstrated that apple vinegar consumption (15 or 30
14
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
mL/ day) for the period of 12 weeks significantly reduced waist circumference in comparison to
the control (Kondo et al., 2009). Also, Park et al reported that daily consumption of pomegranate
vinegar for 8 weeks significantly reduced total fat mass in overweight or obese subjects
compared to the control group, but pomegranate vinegar consumption had no effect on lean
tissue (Park et al., 2014).
In current study, plasma TG level reduced significantly in the ACV group by week 12 in
comparison to the placebo group. In accordance with this result, Kondo et al. revealed that apple
vinegar ingestion significantly reduced serum triglyceride (Kondo et al., 2009). In addition, some
animal studies indicated that vinegar consumption had a hypotriglyceridemic effect (Ok et al.,
2013; Seo et al., 2014). The mechanism of the effect of vinegar consumption on serum
triglyceride may be attributed to reduction in the formation of triglycerides in the liver (Fushimi
et al., 2006) due to a reduction in body weight. However, Park et al. reported that serum
triglyceride of overweight women remained unchanged after consumption of pomegranate
vinegar (Park et al., 2014). Moreover, HDL-C level significantly increased in ACV compared to
the control group. Previous studies implied that the HDL-C enhancing effect of ACV may be
related to its ability to decreased the glycemic index of high glycemic index foods (Petsiou et al.,
2014). In this study, no significant changes in plasma TC and LDL-C levels were observed after
apple cider vinegar consumption. However, findings of other studies on lipid parameters have
been contradictory (Kondo et al., 2009; Ok et al., 2013; Park et al., 2014). This may be due to
differences in study design, baseline lipid parameters, duration, amount and type of consumed
vinegar. So according to the contradictory results and scarce human clinical trials (Beheshti et
al., 2012; Panetta, Jonk, & Shapiro, 2013), further research are needed in this field to confirm
our results.
15
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
Some recognized limitations of this study should be addressed, including the design not being a
double-blinded placebo-controlled study due to odor of the ACV, so an odor masking method
could have been used. However, the treatment was assigned randomly to the groups. Moreover,
capsule administration might have caused taste-blinding and limited the full physiological effect
of vinegar. Since clinical trials have been rarely conducted in the field, the design used in the
present study is one of its strengths. On the other hand, gold standard technique was not used for
measuring body composition; however bioelectrical impedance analysis has a good validity and
reliability. Another point that should be addressed is insufficient sample size (which made it
impossible to perform the longitudinal data analysis) and also the higher female participants
make extrapolation difficult; so a larger scale study is required to be conducted for more
representable data. Another limitation is attributed to the lack of polyphenol analysis. Other
strengths which should be addressed are the use of 3-day food records and the long follow-up
period.
5. Conclusion
This study indicates that apple cider vinegar consumption along with restricted calorie diet can
decrease appetite, body weight, BMI, hip circumference, VAI, plasma triglyceride, total
cholesterol concentration and also increase HDL-C level in overweight or obese subjects. An
implication of this is the possibility that ACV could be used as an adjunctive therapy in
concomitant with RCD or other standard way of weight management therapy through appetite
controlling or increasing thermic effect of food component. Taken together, these results suggest
that larger randomized clinical trial along with evaluation of thermic effect of ACV and another
anorexigenic neurotransmitters or gut peptides is needed for getting more elucidative results.
Acknowledgments
16
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
The authors thank the staff of Specialized Clinic of Nutrition & Diet Therapy located at the
Faculty of Nutrition Sciences and Food Technology of Shahid Beheshti University of Medical
Sciences in Tehran, Iran, for their invaluable assistance, and the staff of the research laboratory
of Research Institute for Endocrine Sciences and the Nutrition research laboratory of the Faculty
of Nutrition and Food Technology for their technical assistance.
Conflict of interest
The authors declare that they have no conflict of interest.
Author Contribution SKH and AS had full access to all of the data in the study and took
responsibility for the integrity of the data and the accuracy of data analysis. NH, ZA and AS
conceived and designed the study and provided administrative support. SKH, NH, ZA, and AS
conducted the study. SKH and AS wrote the manuscript
17
328
329
330
331
332
333
334
335
336
337
338
References
Ajaykumar, T., Anandarajagopal, K., Jainaf, R., Venkateshan, N., & Ananth, R. ( 2012).
ANTIHYPERLIPIDEMICS: EFFECT OF APPLE CIDER VINEGAR ON LIPID
PROFILES. International Journal of Biological & Pharmaceutical Research, 3(8), 942-
945.
Al-Kuraishy, H. M., & Al-Gareeb, A. I. (2016). Effect of orlistat alone or in combination with
Garcinia cambogia on visceral adiposity index in obese patients. Journal of intercultural
ethnopharmacology, 5(4), 408.
Amato, M. C., & Giordano, C. (2014). Visceral adiposity index: an indicator of adipose tissue
dysfunction. International journal of endocrinology, 2014.
Beheshti, Z., Chan, Y. H., Nia, H. S., Hajihosseini, F., Nazari, R., & Shaabani, M. (2012).
Influence of apple cider vinegar on blood lipids. Life Sci J, 9(4), 2431-2440.
Denis, M. C., Furtos, A., Dudonne, S., Montoudis, A., Garofalo, C., Desjardins, Y., . . . Levy, E.
(2013). Apple peel polyphenols and their beneficial actions on oxidative stress and
inflammation. PLoS ONE, 8(1), e53725. doi: 10.1371/journal.pone.0053725 [doi]
PONE-D-12-30019 [pii]
Friedewald, W. T., Levy, R. I., & Fredrickson, D. S. (1972). Estimation of the concentration of
low-density lipoprotein cholesterol in plasma, without use of the preparative
ultracentrifuge. Clin Chem, 18(6), 499-502.
Fushimi, T., Suruga, K., Oshima, Y., Fukiharu, M., Tsukamoto, Y., & Goda, T. (2006). Dietary
acetic acid reduces serum cholesterol and triacylglycerols in rats fed a cholesterol-rich
diet. Br J Nutr, 95(5), 916-924. doi: S000711450600119X [pii]
Hammond, K. (2008). Assessment: Dietary and clinical data. Krause, s Food and nutrition
therapy, 372.
Hammond, K. A. (2000). Dietary and clinical assessment. Krause’s food and nutrition therapy,
372.
Health, N. I. o. (2000). National Heart LaBI, North American Association for the Study of
Obesity. The Practical Guide: Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults. Bethesda, Md: US Department of Health and Human Services,
Public Heatlh Service, National Institutes of Health, National Heart, Lung, and Blood
Institute.
Kondo, T., Kishi, M., Fushimi, T., Ugajin, S., & Kaga, T. (2009). Vinegar intake reduces body
weight, body fat mass, and serum triglyceride levels in obese Japanese subjects. Biosci
Biotechnol Biochem, 73(8), 1837-1843. doi: JST.JSTAGE/bbb/90231 [pii]
Kriska, A. M., Edelstein, S. L., Hamman, R. F., Otto, A., Bray, G. A., Mayer-Davis, E. J., . . .
Regensteiner, J. G. (2006). Physical activity in individuals at risk for diabetes: Diabetes
Prevention Program. Med Sci Sports Exerc, 38(5), 826-832. doi:
10.1249/01.mss.0000218138.91812.f9 [doi]
00005768-200605000-00004 [pii]
Lee, J.-H., Cho, H.-D., Jeong, J.-H., Lee, M.-K., Jeong, Y.-K., Shim, K.-H., & Seo, K.-I. (2013).
New vinegar produced by tomato suppresses adipocyte differentiation and fat
accumulation in 3T3-L1 cells and obese rat model. Food chemistry, 141(3), 3241-3249.
18
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
Lim, S., Yoon, J. W., Choi, S. H., Cho, B. J., Kim, J. T., Chang, H. S., . . . Kim, Y.-B. (2009).
Effect of ginsam, a vinegar extract from Panax ginseng, on body weight and glucose
homeostasis in an obese insulin-resistant rat model. Metabolism, 58(1), 8-15.
Mifflin, M. D., St Jeor, S. T., Hill, L. A., Scott, B. J., Daugherty, S. A., & Koh, Y. (1990). A new
predictive equation for resting energy expenditure in healthy individuals. The American
journal of clinical nutrition, 51(2), 241-247.
Morales, M. L., Gonzalez, A. G., & Troncoso, A. M. (1998). Ion-exclusion chromatographic
determination of organic acids in vinegars. Journal of Chromatography A, 822(1), 45-51.
Ok, E., Do, G.-M., Lim, Y., Park, J.-E., Park, Y.-J., & Kwon, O. (2013). Pomegranate vinegar
attenuates adiposity in obese rats through coordinated control of AMPK signaling in the
liver and adipose tissue. Lipids in health and disease, 12(1), 1.
Östman, E., Granfeldt, Y., Persson, L., & Björck, I. (2005). Vinegar supplementation lowers
glucose and insulin responses and increases satiety after a bread meal in healthy subjects.
European journal of clinical nutrition, 59(9), 983-988.
Panetta, C. J., Jonk, Y. C., & Shapiro, A. C. (2013). Prospective randomized clinical trial
evaluating the impact of vinegar on lipids in non-diabetics. World Journal of
Cardiovascular Diseases, 3(02), 191.
Park, J. E., Kim, J. Y., Kim, J., Kim, Y. J., Kim, M. J., Kwon, S. W., & Kwon, O. (2014).
Pomegranate vinegar beverage reduces visceral fat accumulation in association with
AMPK activation in overweight women: A double-blind, randomized, and placebo-
controlled trial. Journal of Functional Foods, 8, 274-281. doi:
http://dx.doi.org/10.1016/j.jff.2014.03.028
Petsiou, E. I., Mitrou, P. I., Raptis, S. A., & Dimitriadis, G. D. (2014). Effect and mechanisms of
action of vinegar on glucose metabolism, lipid profile, and body weight. Nutrition
reviews, 72(10), 651-661.
Seo, K.-I., Lee, J., Choi, R.-Y., Lee, H.-I., Lee, J.-H., Jeong, Y.-K., . . . Lee, M.-K. (2014). Anti-
obesity and anti-insulin resistance effects of tomato vinegar beverage in diet-induced
obese mice. Food & function, 5(7), 1579-1586.
Sesso, H. D., Paffenbarger, R. S., Jr., & Lee, I. M. (2000). Physical activity and coronary heart
disease in men: The Harvard Alumni Health Study. Circulation, 102(9), 975-980.
Tatemoto, K. (2004). Neuropeptide Y: History and Overview. In M. C. Michel (Ed.),
Neuropeptide Y and Related Peptides (pp. 1-21). Berlin, Heidelberg: Springer Berlin
Heidelberg.
Wilson, M. M., Thomas, D. R., Rubenstein, L. Z., Chibnall, J. T., Anderson, S., Baxi, A., . . .
Morley, J. E. (2005). Appetite assessment: simple appetite questionnaire predicts weight
loss in community-dwelling adults and nursing home residents. Am J Clin Nutr, 82(5),
1074-1081. doi: 82/5/1074 [pii]
Wing, R. R., & Hill, J. O. (2001). Successful weight loss maintenance. Annu Rev Nutr, 21, 323-
341. doi: 10.1146/annurev.nutr.21.1.323 [doi]
21/1/323 [pii]
19
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
Figure 1- Summary of the patient flow diagram
Figure 2. The appetite scores in the ACV (with apple cider vinegar) and the control group (without
vinegar); data are presented as mean ± SE during the study period.
- SNAQ: Simplified Nutritional Appetite Questionnaire; ACV: apple cider vinegar
20
422
423
424
425
426
427
428
429
430
431
432
Table 1. Baseline characteristics of subjects in ACV and control groups
Table 2. Dietary intakes and physical activity in ACV and control groups 1a
Table 3. Anthropometric parameters and body composition in ACV and Control groups1a
Table 4. Plasma concentrations of lipids and NPY in ACV and control groups1a
21
433
434
435
436
