Acute Modulatory Effects of Apple Cider Vinegar, Garlic, Ginger, Lemon and Honey Mixture, with and Without Exercise on Postprandial Glycemia in Non-Diabetic Females

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Jurnal Sains Kesihatan Malaysia Isu Khas 2018: 105-111
DOI : http://dx.doi.org./10.17576/JSKM-2018-15
Acute Modulatory Effects of Apple Cider Vinegar, Garlic, Ginger, Lemon and
Honey Mixture, with and Without Exercise on Postprandial Glycemia in
Non-Diabetic Females
(Kesan Modulasi Akut Campuran Cuka Epal, Bawang Putih, Halia, Lemon dan Madu ke atas Glisemia
Posprandial dengan atau tanpa Senaman dalam Wanita Tanpa Diabetes)
ISMARULYUSDA ISHAK, PENNY GEORGE, FARAH WAHIDA IBRAHIM, HANIS MASTURA YAHYA & NOR FARAH
ABSTRACT
Postprandial hyperglycemia is independently related to cardiovascular disease. Garlic, ginger, lemon, honey and apple
cider vinegar are known to have anti-glycemic properties. However, the effectiveness of combination of these natural
products on reducing postprandial glycemia is uncertain. The aim of the present study was to investigate the glucose-
lowering effect of a novel mixture consisting of apple cider vinegar, garlic, ginger, lemon, and honey; alone and in
combination with exercise in response to a high-carbohydrate meal in non-diabetic individuals. Ten, female subjects (mean
age: 25 ± 2.67 years, mean BMI: 22.6 ± 3.5 kg/m2) participated in this randomised, cross-over intervention consisting of
four trials: control (CON), mixture only (MIX), exercise only (EX), and exercise + mixture (EX-MIX). All trials involved
consumption of a high-carbohydrate breakfast, then followed by rest in CON, consumption of natural product mixture
in MIX, brisk-walking exercise in EX, and combination of mixture and exercise in EX-MIX. Blood glucose was measured
at fasting, and at 30, 60, 90, 120 minutes post meal. Postprandial glucose response was calculated as area under the
glucose curve. Two-way repeated measures ANOVA showed a signicant group and time interaction (p < 0.001). Compared
to CON, postprandial glucose responses were 8%, 13% and 15% lower in MIX (p = 0.049), EX (p = 0.001) and EX-MIX
(p = 0.005) respectively. Postprandial glucose was 8% lower in EX-MIX compared to MIX (p = 0.002). In conclusion,
consuming natural product mixture containing garlic, ginger, lemon, honey and apple cider vinegar reduced postprandial
glycemia to a certain extent, however, combining mixture with exercise produced a greater attenuation effect compared
to consuming mixture alone. This nding is indicative of a potential benet of the novel mixture as a complementary
management of hyperglycemia in high-risk individuals.
Keywords: Natural products; glucose; hyperglycemia; exercise
ABSTRAK
Hiperglisemia posprandial adalah berkait dengan penyakit kardiovaskular. Bawang putih, halia, lemon, madu dan cuka
epal terbukti mempunyai sifat anti-glisemik. Namun, keberkesanan campuran produk asli tersebut dalam mengurangkan
glisemia posprandial belum diketahui. Tujuan kajian ini adalah untuk menentukan kesan campuran bawang putih, halia,
lemon, madu dan cuka epal terhadap penurunan respons glukosa posprandial, dan dengan gabungan senaman selepas
diberi makanan tinggi karbohidrat dalam individu tanpa diabetes. Sepuluh subjek wanita (purata umur: 25 ± 2.67 tahun,
purata IJT: 22.6 ± 3.5 kg/m2) telah mengambil bahagian dalam intervensi berbentuk rawak silang yang terdiri daripada
empat jenis intervensi: kawalan (CON), campuran produk asli (MIX), senaman sahaja (EX) dan senaman + campuran
produk asli (EX-MIX). Kesemua intervensi melibatkan sarapan tinggi karbohidrat, diikuti dengan rehat bagi intervensi
CON, minuman campuran produk asli selepas sarapan bagi intervensi MIX, senaman selepas sarapan bagi intervensi
EX, dan gabungan minuman produk asli dan senaman bagi intervensi EX-MIX. Aras glukosa darah ditentukan sebelum
sarapan (0 minit) dan pada 30, 60, 90 dan 120 minit selepas sarapan. Respons glukosa posprandial diukur menggunakan
keluasan di bawah lengkuk glukosa. Analisis ANOVA dua-hala menunjukkan interaksi kumpulan dan masa yang signikan
(p < 0.001). Respons glukosa posprandial adalah lebih rendah sebanyak 8%, 13% dan 15% dalam MIX (p = 0.049), EX
(p = 0.001) and EX-MIX (p = 0.005) masing-masing berbanding kawalan. Respons glukosa posprandial juga adalah
8% lebih rendah dalam EX-MIX berbanding MIX (p = 0.002). Secara kesimpulan, gabungan campuran produk asli
mengandungi bawang putih, halia, lemon, madu dan cuka epal dapat menurunkan respons glukosa posprandial, namun
gabungan campuran produk asli dengan senaman menghasilkan penurunan glukosa posprandial yang lebih berkesan.
Dapatan kajian ini menunjukkan potensi campuran produk asli ini sebagai salah satu kaedah komplementari dalam
pengurusan hiperglisemia dalam individu yang berisiko.
Kata kunci: Produk asli; glukosa; hiperglisemia; senaman
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support the ability of these combined agents to effectively
lower blood glucose levels. Nevertheless, the usage of
these herbal food supplements should not be discounted
by healthcare professionals now that they are becoming
increasingly popular, especially for those whose blood
glucose levels are on the borderline and pharmacological
therapies have not been initiated (Deng 2012).
Therefore, the aim of this study was to evaluate
the effect of a natural products mixture consumption
containing apple cider vinegar, garlic, ginger, lemon and
honey on postprandial blood glucose in response to a high-
carbohydrate meal. To further evaluate the effectiveness of
the mixture, we compared the effect of the mixture against
acute exercise, as exercise has been shown to effectively
attenuate postprandial hyperglycemia (Farah & Gill 2013).
Therefore, this study examined the effects of consumption
of natural products mixture, with or without exercise, on
postprandial hyperglycemia, in untrained, non-diabetic
young women. We postulated that the consumption of
the natural product mixture yielded glucose-lowering
effect comparable to that of exercise, and combination
of the mixture with exercise produced an additive effect
in lowering postprandial hyperglycemia compared to
consumption of natural product mixture alone.
MATERIALS AND METHODS
PARTICIPANTS
Ten, untrained, apparently healthy females (mean age: 25
± 2.6 years; mean BMI: 22.6 ± 3.5 kg/m2) were recruited as
subjects for this study. The research protocol was conducted
in accordance with the ethical standards involving human
research and approved by the UKM Medical Center Ethical
Review Board (NN-2017-109). All participants gave
written informed consent to serve as study subjects. The
exclusion criteria include: 1) use of any tobacco product
or nutritional supplements that may affect blood glucose,
2) have a clinical diagnosis of cardiovascular or metabolic
diseases, and 3) regular exercise at least two d/week for
the past six months, and 4) allergy or intolerance to natural
products used in the study. Subjects were instructed not
to engage in any physical training, alter their habitual
dietary patterns or take any other supplements during the
study period.
EXPERIMENTAL DESIGN
The study employed a randomised, cross-over intervention,
consisted of four postprandial intervention trials: 1) control
(CON); 2) natural product mixture only (MIX); 3) exercise
only (EX); and 4) combination of exercise and natural
product mixture (EX-MIX). Subjects were required to
complete all trials. The wash-out period between each
trial was seven days. The order of trials was randomized
for each subject to minimise bias.
INTRODUCTION
Postprandial hyperglycemia is characterized by abnormally
increased circulating levels of glucose in the blood
following a meal. Accumulating evidence supports the
critical role of acute postprandial hyperglycemia to
incrementally contribute to cardiovascular risk; it better
predicts CVD-related deaths compared with fasting glucose
concentrations, regardless of the presence of diabetes
(Gerich 2003). Hyperglycemia can cause serious damage
to the nerves and blood vessels, leading to macro- and
microvascular complications often seen in diabetes.
Mechanistic evidence suggests that the adverse effects
of hyperglycemia on vascular and nervous functions are
mediated through oxidative stress (Ceriello & Genovese
2016), increased formation of advanced glycation end
products (AGEs) (Nishikawa & Araki 2016) and more
importantly, promotion of inflammatory state (Hansen et
al. 2017). Due to the fact that postprandial hyperglycemia
is implicated in the altered metabolic flux contributing
to accelerated CVD progression, therefore reducing
postprandial hyperglycemia is now becoming a main target
in the prevention and treatment of metabolic diseases.
The management of hyperglycemia includes
pharmacological interventions, physical exercise, and
change of lifestyle and diet. The use of natural products as
an alternative therapy for management of hyperglycemia
has grown exponentially over the past decade. Studies
on the potential role of natural products preparation,
either as pure compounds or as extracts, as having
hypoglycemic effects is rapidly gaining focus. With a
good safety profile and convenience, natural product-based
supplements have increasingly become attractive additions
to the regular pharmacological therapies in the context of
prevention or treatment of cardiovascular and metabolic
diseases (Waltenberger et al. 2016). Indeed, many natural
products are currently being sold in the mass market as
food supplements for promoting general health or as
herbal remedies. Vinegar, garlic (Allium sativum), ginger
(Zingiber ofcinale) lemon (Citrus limon) and honey have
been widely used as dietary spices and natural remedies of
various ailments in folk medicine for centuries (Beidokhti
et al. 2017; Budak et al. 2014; Samarghandian et al. 2017).
Individually, they have been shown to exert hypoglycemic
effects by a number of mechanisms: facilitation of insulin-
dependent glucose uptake by increasing translocation of
glucose transporter GLUT4 to the cell membrane surface
(Li et al. 2012), delaying gastric emptying (Hlebowicz
et al. 2007), and enhanced hepatic glucose uptake and
glycogen synthesis (Erejuwa et al. 2012). Here in Malaysia,
the combination of these natural products is among the
widely-marketed food supplements for treating diabetes-
related symptoms as well as maintenance of general health.
While these natural products may have been shown to have
anti-hyperglycemic properties individually (Bayan et al.
2014; Erejuwa et al. 2012; Farideh et al. 2017; Sharma et
al. 2015; Shidfar et al. 2015), there is little to no evidence to
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EXPERIMENTAL TRIALS
Figure 1 showed the general overview of the experimental
protocol. All test days started in the morning with a
standardised test meal, followed by a 2-hour observation
in the postprandial period. The four trials were described
below:
Control (CON). Subjects consumed a standardised test meal
after reporting to the lab, followed by rest thereafter.
Natural product mixture (MIX). Subjects consumed a
standardised test meal along with 20 ml of the natural
product mixture, followed by rest thereafter.
Exercise (EX). Following a standardised test meal, subjects
performed a brisk walking exercise on a treadmill for 20
minutes, followed by rest thereafter.
Exercise and mixture (EX-MIX). Following a standardised
test meal along with 20 ml of the natural products mixture,
subjects performed a brisk walking exercise on a treadmill
for 20 minutes, and followed by rest thereafter.
CON
MIX
exercise
exercise
0 30 60 90 120 min
EX
EX-MIX
FIGURE 1. Overview of experimental trials for CON: control; MIX: mixture only; EX: exercise only; EX-MIX: exercise + mixture.
Consumption of 400-kcal test meal ( ) and natural product mixture (M) are indicated. Blood samples () were collected at
times indicated.
PREPARATION OF NATURAL PRODUCT MIXTURE
A mixture consisting of apple cider vinegar, garlic, ginger,
lemon juice and pure ‘kelulut’ honey was prepared based on
a ratio of 1: 1: 1: 1: 1. A feasibility test was conducted to test
the palatability of the mixture for subjects’ consumption.
The formulation mixture contained equal quantities of 40
ml of ginger juice (225 g/milled and refined), garlic juice
(100 g/milled and refined), pure lemon juice, apple cider
vinegar and honey (modified from Naseem et al. 2016). All
liquid except honey were reduced to one-fourth of original
volume on medium heat for 30 minutes. The concentrated
mixture was then cooled at room temperature before adding
honey. The final product mixture was kept chilled in a
refrigerator and used within 48 hours.
STANDARDISED TEST MEAL
In all trials, subjects consumed a standardised, high-
carbohydrate meal (400 kcal, 83 g carbohydrate) in the
morning after an 8-hr overnight fast. The meal consisted
of two slices of white bread with 20 g of mixed fruit jam,
two pieces of chocolate cookies and 250 ml of sweetened
beverage. Timing of meal was kept consistent for all
subjects in all trials.
EXERCISE PROTOCOL
Subjects performed a brisk-walking exercise on a
motorized treadmill at the intensity of 50-60% of heart
rate reserve (HRR), equivalent to a moderate intensity. This
was calculated for each individual using the following
Karvonen equation: [(220 – age) × % intensity)] + resting
heart rate (Swain et al. 1994). Subjects were required to
exercise within the individual target heart rates throughout
the exercise duration. The speed and inclination were
tailored to each subject’s preference. Heart rates were
recorded every five minutes during the exercise using heart
rate monitors (POLAR®, Finland).
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BLOOD SAMPLING
Blood samples were collected at fasting (0 min) and at 30,
60, 90 and 120 minutes post test meal in all trials for the
determination of plasma glucose using a glucose analyzer
(ACCU-CHEK Active, Roche). The total area under
glucose versus time curve (AUC 0-120 min), calculated
using the trapezium rule, was used as a summary measure
of the postprandial glucose response in each trial.
STATISTICAL ANALYSIS
Sample size calculation was primarily based on the number
of participants needed to detect a difference in area under
the curve (AUC) of postprandial glucose of approximately
20% (Mettler et al. 2009). A priori power calculation
indicated that 10 participants would enable detection
of a change in postprandial glucose response with 80%
power. Data were analyzed using the SPSS (version 22,
SPSS Inc.) One-way repeated measures ANOVA was used
to compare fasting glucose and area under curve values
for postprandial glucose responses across the four trials.
Two-way repeated-measures ANOVA (trial × time) were
used to compare postprandial glucose changes over time
and across the trials, followed by Bonferonni correction for
pair-wise comparisons to determine the mean differences
between and within trials. Percentages are used to quantify
the differences in total AUC (0-120 min) between trials.
Data are presented as mean values and their standard
errors, unless otherwise stated. Statistical significance was
accepted at p < 0.05.
RESULTS
RESPONSES DURING EXERCISE
The treadmill speed and gradient for both exercise sessions
(EX and EX-MIX) were identical within each subject.
Subjects walked for 20 min at an average speed of 5.5 ±
0.1 km/h on a gradient of 2.2 ± 0.8%. All exercise sessions
were completed without difficulty and subjects rated the
exercise as ‘fairly light’ on the Borg scale of 6-20 in both
the EX and EX-MIX trials. Mean exercise heart rates for
the EX and EX-MIX trials were 133 ± 4 bpm and 134 ± 5
bpm respectively. These values did not differ significantly
between both trials.
POSTPRANDIAL GLUCOSE RESPONSES
Table 1 and Figure 2 showed the fasting and postprandial
glucose responses in all trials. No significant differences
were observed in fasting glucose values across the four
trials. Two-way repeated measures ANOVA revealed a
significant group x time interaction: F(12, 108) = 6.63, p
< 0.001. Plasma glucose peaked at 30 min following the
standardized test meal and was lower in the MIX (-10%,
p > 0.05), EX (-26%, p = 0.002) and EX-MIX (-31%, p =
0.001) trials compared to CON. Plasma glucose remained
significantly lower in the following 60 min in MIX (p =
0.004), EX (p = 0.012) and EX-MIX (p = 0.006) trials
compared to CON. There were no differences in plasma
glucose across all trials following 120 min.
Analysis showed a significant effect of trials on
postprandial glucose AUC0-120 across all conditions [F(4,
12) = 9.89, p < 0.001]. Among all trials, the postprandial
glucose AUC was highest in the CON trial. Compared to
CON, the postprandial glucose AUC values were 13% and
15% lower in the EX (p = 0.005) and EX-MIX (p = 0.001)
respectively. The postprandial glucose AUC in MIX trial
showed an 8% attenuation compared to CON, however this
was borderline significant (p = 0.049). The postprandial
glucose AUC was significantly lower in EX-MIX (-8%, p
= 0.002) compared to MIX trial. No significant differences
were observed in postprandial glucose AUC between EX
and MIX and between EX and EX-MIX trials.
DISCUSSION
The aims of this study were to determine the effect of
natural product mixture consumption on postprandial
glycemia in response to a high-carbohydrate meal, as
well as to determine whether the consumption of natural
product mixture in combination with exercise produced
an additive effect compared to consumption of mixture or
exercise alone. To the best of our knowledge, this is the first
study employing a novel mixture of apple cider vinegar,
garlic, ginger, lemon and honey, and in combination with
TABLE 1. Postprandial glucose responses (mmol/l) and total area under curve (AUC0-120 min) across all trials
Trials 0 min 30 min 60 min 90 min 120 min AUC0-120
CON 4.42 ± 0.35 8.10 ± 2.36 7.21 ± 1.00 6.21 ± 0.93 5.38 ± 0.76 792 ± 115
MIX 4.48 ± 0.32 7.30 ± 0.75b 6.13 ± 1.37a 6.42 ± 0.80 5.25 ± 0.47 730 ± 86b
EX 4.58 ± 0.38 5.94 ± 1.34a 5.75 ± 0.84a 6.14 ± 0.78 5.50 ± 0.61 684 ± 88a
EX-MIX 4.54 ± 0.20 5.56 ± 0.97a 6.01 ± 0.95a 5.86 ± 0.50a 5.27 ± 0.77 670 ± 75a
Values are expressed as mean ± SEM, n = 10
CON: control; MIX: mixture only; EX: exercise only; EX-MIX: exercise + mixture
a significantly different compared to CON
b significantly different compared to EX-MIX
Chap 15.indd 108 31/05/2018 15:30:26

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a single bout of exercise in examining its acute effects on
postprandial glycemia in humans.
The present data demonstrated that the consumption
of the natural product mixture resulted in a trend of
reduction in postprandial glycemia by an average of
13% compared to control. Apple cider vinegar, garlic,
ginger, lemon and honey are among the functional foods
commonly used all around the world, particularly in the
Asian countries. So far, the anti-glycemic effects of these
products have been investigated in isolation particularly in
animal studies. However, the effect of these products when
combined is relatively unknown, especially in humans.
Previously, Naseem et al. (2016) had demonstrated that
administration of a similar mixture (i.e. combination of
apple cider vinegar, garlic, ginger, honey and lemon) in
rabbits fed with atherogenic diet for 15 days attenuated
fasting blood glucose levels by 34% compared to the
control group. In our study, consumption of the mixture
caused a pronounced reduction in postprandial glucose
concentration at 60 min post meal, compared to control, in
addition to an overall reduction on postprandial glycemia
though the difference was not apparent. Nevertheless, the
finding can be considered novel and seems to be indicative
of the anti-glycemic potential of the products combined
together. It is possible that the attenuation would appear
significant in hyperglycemic individuals in contrast to
normoglycemic or non-diabetic individuals, due to higher
glucose peaks and exaggerated postprandial responses in
the former population.
While there is no clear mechanism on how the
combination of these natural products can lower glycemic
response, it is plausible that the anti-glycemic effect was
mediated by the synergistic effect of individual products
in the mixture, which is consistent with the known benefits
of individual products. The hypoglycemic potency of
garlic has been attributed to allicin-derived organosulphur
compounds, which protect insulin from –SH inactivation
by reacting with endogenous thiol-containing molecules
such as cysteine, glutathione and serum albumin (Eidi et
al. 2006). Compelling data show that ginger extract has
hypoglycemic, insulinotropic, and sensitiser effects on
diabetic humans (Shidfar et al. 2015) and on experimental
animals (Ojewole et al. 2006). Meanwhile, the anti-
glycemic effect of acetic acid, the active ingredient in
vinegar, has been attributed to delay gastric emptying
(Liljeberg & Bjorck 1998) as well as to modulate glycolysis/
gluconeogenic cycle in skeletal muscles (Fushimi et al.
2001). Fructose, one the major form of monosaccharide
sugar found in honey, was suggested to contribute to the
anti-glycemic effects of the honey by delaying gastric
emptying and increases hepatic uptake of glucose resulting
in decreasing blood glucose concentrations (Erejuwa et
al. 2012). The anti-glycemic effect of the mixture in the
present study was consistent with the aforementioned
reports, which may explain the combined beneficial effects
of apple cider vinegar, garlic, ginger, lemon and honey on
postprandial glucose response.
The hypoglycemic effects of exercise have been
widely documented. Most studies have shown that
moderate intensity exercise between 30 to 60 min was
effective at lowering postprandial glucose responses
post-meal in healthy subjects (Hashimoto et al. 2013;
FIGURE 2. Postprandial glucose responses across time 0 to 120 min following standardised test meal ( ) for all trials. Values are
means, with SEM represented by vertical bars. CON: control; MIX: mixture only; EX: exercise only; EX-MIX: exercise + mixture.
Exercise in EX and EX-MIX trials is indicated on the timeline. * significantly different compared to CON, # significantly different
compared to EX-MIX.
9.0
CON
MIX
EX
EX-MIX
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0 0
exercise
30 60
Time (min)
Mean plasma glucose
(mmol/L)
90 120
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Roberts et al. 2013; Farah & Gill 2013) as well as in
diabetic individuals (Kearney et al. 2016). Consistent
with published literature, our findings showed that brisk-
walking exercise lowered postprandial glycemia by 15%
following a high-carbohydrate meal compared to no-
exercise control. Exercise is effective in lowering plasma
glucose concentration by increasing uptake of glucose
into cells by up to 50-fold through the simultaneous
stimulation of three key steps: delivery, transport across the
muscle membrane and intracellular flux through metabolic
processes of glycolysis and glucose oxidation (Sylow
et al. 2017). It is noteworthy that the lowering effect of
exercise on postprandial glycemia was evident despite
the shorter exercise duration (20 min) employed in this
study, compared to prolonged duration in previous studies.
This finding is somewhat encouraging in the sense that
brisk-walking is feasible for most people, which could be
generalised into everyday life of hyperglycemic individuals
with little motivation for exercise.
When comparing the reduction in postprandial
glycemia following consumption of mixture alone, the
reduction in glycemic response induced by brisk-walking
exercise alone was slightly greater, i.e. 15% vs. 8% in
the former, though this finding was not significant. Quite
interestingly, this may be indicative of the potential of
the natural product mixture to exert an anti-glycemic
effect that is comparable to the effect induced by exercise
alone. One might speculate that with larger doses than 20
ml used in the study, or with repeated consumption, the
lowering effects would be more pronounced. We used a 20
ml dose of mixture, which was approximately equivalent
to two tablespoons, a volume that many would typically
consume under real-life circumstances with regards to
commercially-available natural product supplements.
Further investigation may bring more insight regarding
the effective dose mixture in lowering postprandial
hyperglycemia that is comparable to exercise. Lastly, the
study also showed that consumption of the mixture in
combination with a short bout of brisk-walking exercise
produced greater attenuation in postprandial glycemia
compared to mixture alone. This finding was somewhat
expected. On the other hand, combining consumption of
mixture with exercise did not produce an additive effect
in lowering postprandial glycemia compared to exercise
alone. The absence of an additive effect could presumably
be due to the acute consumption of the natural product
mixture. Karimi et al. (2015) in their study in obese women,
demonstrated that the combination of water-based exercise
and ginger supplement for six weeks had better effect on
insulin resistance in comparison to water-based exercise or
ginger supplement alone. It is therefore possible, that with
prolonged consumption, the additive effect of the natural
product mixture and exercise would be more evident.
The findings of the present study might be interpreted
in the light of the fact that this was the first study of its
kind in human subjects, which could limit our ability to
determine the appropriate dose and ratio of the natural
product mixture. We believe the dose and ratio of the
natural products are vital in determining the anti-glycemic
properties of the mixture. Certainly, the conclusion about
the modulatory effect of the natural product mixture is
only limited to glycemic responses in healthy individuals.
Therefore, similar studies examining the effects of different
doses and treatment protocol of the mixture on a wider
range of variables (e.g. insulin, insulin resistance, blood
lipids) would shed more light on the potential benefits of
this mixture. No unfavorable effects were observed with the
consumption of the natural product mixture in the study.
CONCLUSION
The combination of apple cider vinegar, garlic, ginger,
lemon and honey appears to have an anti-hyperglycemic
effect on postprandial glycemia in non-diabetic females.
In addition, combination of brisk-walking exercise and
the mixture produced a greater lowering effect, rather than
consuming the mixture alone. The findings of this study
may represent a practical, non-pharmacological option
in the prevention and management of hyperglycemia in
individuals at risk. Future studies with clinically-defined
participants, standardised preparation and dose, and across
a wide range of metabolic parameters are warranted.
ACKNOWLEDGEMENT
This study was supported by the Fundamental Research
Grant Scheme, Ministry of Higher Education Malaysia
[FRGS/2/2014/SS02/UKM/02/2]. The authors would like to
thank all the participants who took part in the study.
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Ismarulyusda Ishak
Penny George
Farah Wahida Ibrahim
School of Diagnostics and Applied Health Sciences
Faculty of Health Sciences
Universiti Kebangsaan Malaysia
53000 Kuala Lumpur
Hanis Mastura Yahya
School of Healthcare Sciences
Faculty of Health Sciences
Universiti Kebangsaan Malaysia
53000 Kuala Lumpur
Nor Farah Mohamad Fauzi
School of Rehabilitation Sciences
Faculty of Health Sciences
Universiti Kebangsaan Malaysia
53000 Kuala Lumpur
Corresponding author: Nor Farah Mohamad Fauzi
Email: norfarah@ukm.edu.my
Tel: 03-26878049
Fax: 03-26810200
Received: August 2017
Accepted for publication: January 2018
Chap 15.indd 111 31/05/2018 15:30:28