Effect of Apple Cider Vinegar in Type 2 Diabetic Patients with Poor Glycemic Control: A Randomized Placebo Controlled Design

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International Journal of Medical Research &
Health Sciences, 2019, 8(2): 149-159
149
ISSN No: 2319-5886
ABSTRACT
Aim: The aim of the trial was to measure the effect of apple cider vinegar on glycemic control and biochemical
parameters in type 2 diabetes mellitus (DM) patients with poor glycemic control. Methods: A single-blind, randomized,
placebo-controlled trial was conducted on 110 eligible types 2 DM patients who were selected and allocated into 2
groups. The interventional group was given 15 ml apple cider vinegar in 200 ml water during dinner for 3 months
while the other group was placebo. Before and after HbA1C (glycosylated hemoglobin), fasting lipid prole, fasting
blood sugar, anthropometrics, and dietary changes were assessed and analyzed using IBM SPSS version 20, through
statistical tests. Formal ethical approval was obtained from the local institutional review board. Results: Signicant
mean change was found in interventional group in HbA1c (p<0.001), blood sugar fasting (p<0.001), total cholesterol
(p=0.002), triglyceride (p=0.002) and hip-waist ratio (p=0.002). No signicant change was observed in the mean
of these statistics in the placebo group. No signicant change was observed in height, weight, mid-upper arm
ratio, and low density lipoprotein, high density lipoprotein and food frequency in intervention and placebo groups
before and after. Conclusion: Apple cider vinegar if used regularly is effective in controlling diabetes, lowering
hypercholesterolemia and hypertriglyceridemia in DM type 2 patients.
Keywords: Vinegar, Diabetes, Hyperglycemia, Hypercholesterolemia, Nutraceutical
Abbreviations: DM: Diabetes Mellitus; T2DM: Type 2 Diabetes Mellitus; ACV: Apple Cider Vinegar; HbA1c: A
form of Hemoglobin (a blood Pigment that carries oxygen); LDL: Low Density Lipoproteins; HDL: High Density
Lipoproteins; TC: Total Cholesterol; TG: Total Triglyceride; BMI: Body Mass Index; BSF: Blood Sugar Fasting;
RCT: Randomized Control Trail; WHO: World Health Organization; SD: Standard Deviation; SPSS: Social Packages
Statistical Software
Effect of Apple Cider Vinegar in Type 2 Diabetic Patients with Poor
Glycemic Control: A Randomized Placebo Controlled Design®
Soa Kausar1*, Muhammad Arshad Abbas2, Hajra Ahmad3, Nazia Yousef4, Zaheer
Ahmed3, Naheed Humayun5, Hira Ashfaq6 and Ayesha Humayun7
1 Department of Liver Transplant Unit, Shaikh Zayed Hospital Medical Complex, Lahore,
Pakistan
2 Department of General Surgery, Ameer Udin Medical College/PGMI, Lahore General Hospital
Lahore, Pakistan
3 Department of Environmental Design, Health and Nutritional Sciences, Allama Iqbal Open
University, Islamabad, Pakistan
4 Shalamar Institute of Health Sciences, Lahore, Pakistan
5 FMH College of Medicine and Dentistry, Lahore, Pakistan
6 Akhtar Saeed Medical and Dental College, Lahore, Pakistan
7 Department of Public Health and Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan
Medical College and Shaikh Zayed Postgraduate Medical Institute, Shaikh Zayed Medical
Complex, Lahore, Pakistan
*Corresponding e-mail: Soa.kausar@yahoo.com
INTRODUCTION
Diabetes mellitus (DM) has been considered globally as a major public health problem linked with changing life style,
reduced physical activity and obesity [1]. Development of diabetes mellitus is due to endocrine disorders which cause

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Kadhim, et al.
impaired insulin secretion, hepatic glucose over production and insulin resistance. Complications can occur along
with co-morbidities such as dyslipidemia, atherosclerosis, and hypertension [2].
World Health Organization (WHO) predicted DM to be the 7th cause of mortality by the year 2030 [3]. The 2013
estimates of the International Diabetes Federation (IDF) showed that about 382 million people globally have diabetes,
and it will increase to 592 million by the year 2035. About 80% of populations with diabetes are from poor socio-
economic countries and 60% of them are from Asia whereas, one-third is from China. In developing countries, the
rapid rise of type 2 DM is observed [4]. Prevalence of diabetes mellitus is found to be high in south Asian developing
countries and India is topping the list. Pakistan is also facing a progressive increase in the diabetes burden. National
level surveys showed DM prevalence of 13.14% in Punjab and 13.9% in Sindh [5].
Food additives which are grown by natural origin have been more popular in recent year for treating the diseases even
without showing evidence of medical benets. The ethnic, cultural and religious belief of various communities and
easy access to internet information enhanced their preference for natural treatment remedies for various diseases [6].
Natural products have fewer side effects as compared to medical therapies, as perceived by the general population.
Diabetics are 1.6 times more likely to use alternative medical products and complementary food than non-diabetics
individuals [7]. Obese individuals are more likely to use alternative products or dietary supplements for reduction of
their body weight and to gain other benecial metabolic effects [6].
The word vinegar is derived from French word “vin aigre” meaning sour and it can be made almost from any
fermentable sugar (carbohydrate) source such as apple, dates, grapes, and sorghum, etc. Acetic acid is an active
component in apple cider vinegar responsible for its pungent, biting odour and tart avour containing to 3%-9%
acidity [2]. Apple cider vinegar is produced by fermenting apples in the form of an acidic solution. Its contain minerals,
vitamins, and other trace elements and vinegar also contains a potent supply of potassium, as potassium is essential for
the replacement of worn-out tissues within the body and repair of soft tissue [8].
Apple cider vinegar has benecial effects in the treatment of endocrinal, gastrointestinal, renal, neurological, nasal,
joints, cardiovascular and muscular disorders and many skin infections. Some studies reports showed that vinegar
affects the glucose and insulin responses to a sucrose or starch load [8]. Acetic acid is the active component in
apple cider vinegar which affects blood glucose metabolism and many other mechanisms which contribute to explain
antiglycemic effects of vinegar. The mechanism by which vinegar reduces glucose levels are still unclear, acetic acid
may slow gastric emptying [9]. Alternatively, acetic acid may inhibit disaccharides activity in the small intestine
blocking the complete digestion of starch molecules and also promotes skeletal muscles glucose uptake in the body
[10,11].
Vinegar usage improves hyperinsulinaemia, hypertriglyceridaemia, insulin sensitivity and can also reduce the level
of random blood glucose in diabetic patients as well as in healthy individuals [12]. Evidence of many studies showed
that a single dose of vinegar (20 g) with 5% acidity can decrease PPG (post prandial glucose) in diabetic as well as
in healthy individuals by 50% [6,13]. This study showed that apple cider has anti-diabetic, anti-hyperlipidemic and
anti-obesity effects in diabetes mellitus [6]. Insulin response and postprandial glucose can be inuenced by type and
dose of vinegar [13-15].
A randomized control trial (RCT) showed two different concentration of vinegar, 0.16%, and 1.6% found to be
effective on 7th days of intervention onwards but not after 3rd day [8]. Many clinical trials found that apple cider
vinegar can reduce obesity, hyperglycemia, hyperlipidemia, and hyperinsulinaemia. Emphasizing that apple vinegar
is helpful for diabetes management as a complementary agent in diet [16,17].
A study conducted in pre-diabetic healthy individuals showed signicant (p=0.05) reduction in HbA1C, in apple
cider vinegar group [18]. Many RCTs of human and animals showed the hypolipidemic effects of ACV [19-21]. Anti-
obesity effect of apple cider vinegar is also found in many studies [22-24]. There is still a lot of research trials on the
effectiveness of apple cider vinegar in different sets of the population of diabetes. The aim of the trial was to measure
the effect of apple cider vinegar on glycemic control and biochemical parameters in type 2 DM patients with poor
glycemic control attending a tertiary care hospital in Lahore, Pakistan.
METHODOLOGY
Study Design and Setting
This study was a single-blind, placebo controlled trial. Parallel design using 1:1 allocation ratio was used. This clinical

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trial was registered www.clinicaltrials.gov and also follows the CONSORT guidelines and prepared the CONSORT
checklist.
Participants
Adult patients having type 2 diabetes mellitus, of both genders within the age group from 30-60 years were included in
the study. All having body mass index between 20-30 kg/m2, non-smoker and non-alcoholics and all were on standard
medical therapy for diabetes, tablet TagipMet (Metformin+Sitagliptin group). To maintain the uniformity (Metformin
plus sitagliptin) drug receiving patients were selected and secondly, this drug was commonly prescribed by physician
among the Pakistani population. To avoid discrepancy of results single and same drug user patients were selected.
Patients suffering from known chronic renal disease and history of cardiovascular diseases, stroke, ischemic heart
disease, and known allergy or intolerance to vinegar, reported by the patient or relative and any kind of acute infection
were excluded from the study (Figure 1).
Figure 1 Flow diagram of study participants
The trial period was 3 months from August 15, 2017, to November 15, 2017. This study was conducted at a 1050 bed,
tertiary care, and teaching hospital of Lahore, Pakistan. This hospital has high diabetes mellitus out-patient turnover
as a reputable center in the management of diabetes.
Intervention
Experimental: intervention group: Intervention group patients taking their diet according to their original meal
pattern only dietary instruction in the view of (American diabetic association dietary guideline) were given regarding
high glycemic and low glycemic diet (which diet should be helpful for controlling diabetes) [25]. Medical treatments
continued (including tablet TagipMet 50 mg or 1000 mg twice a day) (Metformin+Sitagliptin group). About 15 ml
apple cider vinegar (American garden organic vinegar) (containing 5% acetic acid as veried/approved by food drug
authority) was mixed in 200 ml water during a meal at night time was prescribed [2].
Placebo comparator: comparison group: Control group also taking their diet according to their original meal
pattern only dietary instruction in the view of (American diabetic association dietary guideline) were given regarding
high glycemic and low glycemic diet (which diet should be helpful for controlling diabetes) [25]. Medical treatment
continued (including Tablet TagipMet 50 mg or 1000 mg twice a day) (Metformin+Sitagliptin group). About 15 ml

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Kadhim, et al.
articial avor of apple cider vinegar was mixed in 200 ml plain water during a meal at night time was used as a
placebo [2].
Outcome Measure (Dependent Variables)
Primary outcome measure:
• HbA1c (glycosylated hemoglobin): Before the start of intervention and after intervention 5 ml venous
blood sample was taken for biochemical analysis of HbA1C (glycosylated hemoglobin) in sterilized tubes,
commercial kits of Siemens for Dimension RXL used and the HbA1C measurement is based on a turbidimetric
inhibition immunoassay (TINIA) principle
Secondary outcome measures:
• Blood sugar fasting (BSF): Before the start of intervention and after intervention 5 ml venous blood sample was
taken with 12 hours fasting for biochemical analysis of blood sugar fasting in sterilized dray tubes, commercial
kits of Siemens for Dimension XL and photometric methods for analysis was used
• Fasting lipid prole: Before the start of intervention and after intervention 5 ml venous blood sample was taken
with 12 hours fasting for biochemical analysis of fasting lipid prole commercial kits of Rodex for Dimension
RXL and photometric methods for analysis were used
• Anthropometric measurements: Height was measured in centimeter to nearest 0.1 cm by using standard
stadiometer before intervention and weight was measured in kilogram to nearest 100 g with wearing light cloth
by using a calibrated weighing scale machine before and after the intervention. Hip/waist ratio and mid upper
arm were measured with measuring tape in centimeter to nearest 0.1 cm. The BMI of study participants were
classied as underweight, normal, over weight and obese according to WHO criteria weight was measured as
weight/height (kg/m2) [26]
Confounding Variables
Dietary intake: Diet of study participants can inuence and confound the intervention during the study period so
it was assessed through a food frequency questionnaire. Food frequency was lled 2 times before and after the
intervention to measure change during the study period which can actually confound the effect of apple cider vinegar.
The food frequency questionnaire (FFQ) was structured according to Pakistan’s cultural food preferences and choices.
FFQs contained methods of food preparation, frequency per day and per week and portion size/amount of food
consumed in categories from never, monthly to 1-7 days in a week. Food exchange lists were used to assess the
portion size of food. FFQ was composed of cereal group, fruits, vegetable, meat, milk, fat/oil, snacks, and beverages.
Independent Variable/Intervention
This selected nutraceutical (apple cider vinegar) was given for 3 months. Apple cider vinegar was provided to patients
and instructions were given to all participants about the uses of apple cider vinegar.
Sample Size
The sample size of 110 (55 in each group) was estimated by using 95% condence level, 80% power with an expected
mean change in HbA1c 0.53% and 0.11% for cases treated with apple vinegar and placebo respectively with a SD
of 0.77% (by using power+precision 3.0 software) [2]. Assuming a 12.6% non-response rate, RCT started with 126
patients, 63 patients in each group. Total 16 patients were lost to follow up during the study period, so nally statistical
analysis was done on 110 patients 55 in each group.
Randomization
Principal researcher/investigator approached participants in the outpatient department and after determining their
eligibility they were allocated using the lottery method to a group, intervention or placebo.
Implementation
The trial period was 3 months. Randomization of all participants was done and intervention was started from August
15, 2017, and ended on November 15, 2017.

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Blinding
All study participants were blinded regarding the intervention of apple cider vinegar and placebo but the investigator
was not blind.
Statistical Analysis
Descriptive statistical analysis was done for the demographic prole, categorical and numerical variables by
measuring frequency, percentage, the mean and standard deviation of all samples. Paired sample T-test was used
for anthropometrics measurement and biochemical assessment for 2 time assessment before and after intervention
for both the groups (between groups). One-way ANOVA was used for comparison within the groups. McNemar
statistical test was used to assess the food frequency questionnaire before and after the intervention.
Ethical Considerations
Proper ethical clearance was obtained from local Institutional Review Board. (Approval of Technical Research
Committee and Institutional Review Board of Federal post graduate medical institute Shaikh Zayed Hospital Lahore
Pakistan, National Health Research Complex, National Institute of Kidney Diseases, National Institute of Nursing
Allied Sciences, approval letter number was 1418).
RESULTS
Statistical Analysis
Demographics and social factors: The mean age of patients in the intervention group was 51.1636 ± 7.91568 ranging
from 30-60 years. The mean age of patients in the placebo group was 50.4909 ± 7.78382 ranging from 30-60 years. In
the intervention group, 34 (61.8%) were females while in placebo group 29 (52.7%) were female. In the current study,
29.1% of patients were illiterate in the intervention group while 14.5% were illiterate in placebo group followed by
other categories of literacy. Occupational status of study participants in the intervention and placebo group is shown
in Table 1. Frequency and percentage of age, gender, educational status and occupational status of intervention and
placebo group has been described in Table 1.
Table 1 Demographic characteristic of study participants
Intervention Group Placebo Group
Characteristics Percent Characteristics Percent
Age (Years)
30-40 14.5% 30-40 14.5%
41-50 30.9% 41-50 30.9%
51-60 54.5% 51-60 54.5%
Gender
Male 38.2% Male 47.3%
Female 61.8% Female 52.7%
Educational Status
Illiterate 29.1% Illiterate 14.5%
Middle 10.9% Middle 21.8%
Metric 23.6% Metric 21.8%
Intermediate 18.2% Intermediate 29.1%
Graduate 12.7% Graduate 10.9%
Above graduate 5.5% Above graduate 1.9%
Occupational Status
Medical 5.5% Medical 12.7%
Teaching 18.2% Teaching 10.9%
Other 76.4% Other 76.4%
Medication, diet and test material adherence/compliance: About 38.2% of participants were strictly following
their prescribed medication, 45.5% moderately and 16.3% irregularly compliant in the intervention group. In the
placebo group, 27.3% participants were strictly following their prescribed medication, 56.4% were moderately
following and 16.3% were irregularly compliant. About 8 (14.5%) patients were strictly following their prescribed

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diet plan, 37 (67.3%) were moderately following and 10 (18.2%) patients were irregular in their diet plan follow up
in the intervention group. 12 (21.8%) participants were strictly following their prescribed diet plan, 34 (61.8%) were
moderately and 9 (16.4%) patients were irregularly compliant in the placebo group. Apple cider vinegar strictly used
by patients was 21 (38.2%), moderately used were 20 (36.4%) and irregular were 14 (25.5%) in intervene group. Total
16 (29.1%) strictly follow placebo, moderately follower was 26 (47.3%) and irregular follower was 13 (23.6%) in the
placebo group (Table 2).
Co-morbidities and complications: Among complications of diabetes, the visual problem was 74.5% in intervention
group and 60.0% in the placebo group. About 49.1% of participants in the intervention group were hypertensive as
compared to 38.2% in the placebo group. Neuropathy with diabetes was found in 50.9% in intervention group and
43.6% in the placebo group. Frequency and percentage of diabetes and co-morbidity, life style, diet, medication, test
material and placebo material of intervention and placebo group has been described in Table 2.
Table 2 Diabetes, co-morbidities and life style activities
Intervention Group Placebo Group
Characteristics Percent Characteristics Percent
Vision problem Yes 74.5% Vision problem Yes 60.0%
No 25.5% No 40.0%
Blood pressure Yes 49.1% Blood pressure Yes 38.2%
No 50.9% No 61.8%
Neuropathy Yes 50.9% Neuropathy Yes 43.6%
No 49.1% No 56.4%
Physical activities
Heavy 5.5%
Physical activities
Heavy 12.7%
Moderate 67.3% Moderate 56.4%
Light 27.3% Light 30.9%
Exercise
Daily 1.8%
Exercise
Daily 5.5%
Once in Week 18.2% Once in Week 9.1%
Monthly 5.5% Monthly 10.9%
Never 74.5% Never 74.5%
Walk
Half Hour 54.5%
Walk
Half Hour 54.5%
1 Hour 20.0% 1 Hour 9.1%
None 25.5% None 36.4%
Sleeping
Below 5 hours 9.0%
Sleeping
Below 5 hours 3.6%
5-7hours 20.1% 5-7hours 41.8%
above 7 hours 70.9% above 7 hours 54.5%
Medication Follow
up
Strictly Follow 38.2% Medication Follow
up
Strictly Follow 27.3%
Moderately Follow 45.5% Moderately Follow 56.4%
Irregular 16.3% Irregular 16.3%
Diet plan Follow up
Strictly Follow 14.5%
Diet plan Follow up
Strictly Follow 21.8%
Moderately Follow 67.3% Moderately Follow 61.8%
Irregular 18.2% Irregular 16.4%
Apple cider vinegar
follow up
Strictly Follow 38.2%
Placebo follow up
Strictly Follow 29.1%
Moderately Follow 36.4% Moderately Follow 47.3%
Irregular 25.5% Irregular 23.6%
Anthropometric measurements: On paired sample T-test no signicant change was found in intervention and
placebo groups for height, weight and mid arm circumference, before and after intervention were seen. A signicant
change in mean for hip waist ratio was found in the intervention group before intervention (BI) mean of 37.9 ± 2.74
SD and after intervention (AI) mean ± SD 37.5 ± 3.09 and p=0.002. No signicant change was found in the placebo
group (Table 3). One-way ANOVAs for anthropometric measurements within groups showed insignicant ndings.
Table 3 Anthropometric and biochemical measurements
Intervention Group Placebo Group
Characteristics Mean ± SD p-values Characteristics Mean ± SD p-values

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Height before 162.83 ± 8.66 0.322 Height before 161.18 ± 10.91 0.322
Height after 162.83 ± 8.66 Height after 161.54 ± 10.90
Weight before 72.38 ± 10.59 0.164 Weight before 71.76 ± 11.53 0.255
Weight after 72.07 ± 10.81 Weight after 71.85 ± 11.56
MUA circumference before 11.30 ± 1.95 0.033 MUA circumference before 11.38 ± 2.08 0.322
MUA circumference after 11.09 ± 1.97 MUA circumference after 11.40 ± 2.07
H/W circumference before 37.90 ± 2.74 0.002 H/W circumference before 37.76 ± 3.46 0.060
H/W circumference after 37.50 ± 3.09 H/W circumference after 37.92 ± 3.47
HBA1C before 9.32 ± 1.74 0.000 HBA1C before 9.07 ± 1.76 0.206
HbA1C after 8.65 ± 1.81 HbA1C after 10.71 ± 9.41
BSF before 170.14 ± 62.42 0.000 Blood sugar fasting before 170.36 ± 66.18 0.034
BSF after 157.32 ± 58.16 Blood sugar fasting after 170.81 ± 65.99
Total cholesterol before 195.81 ± 47.97 0.002 Total cholesterol before 190.18 ± 68.06 0.057
Total cholesterol after 180.09 ± 48.59 Total cholesterol after 192.92 ± 68.46
HDL before 43.49 ± 11.29 0.112 HDL before 49.69 ± 24.66 0.014
HDL after 45.70 ± 8.23 HDL after 49.10 ± 24.61
LDL before 121.66 ± 38.10 0.030 LDL before 108.05 ± 37.44 0.129
LDL After 114.18 ± 39.60 LDL after 111.16 ± 40.67
Triglyceride before 192.21 ± 77.98 0.002 Triglyceride before 185.32 ± 87.40 0.036
Triglyceride after 180.27 ± 79.67 Triglyceride after 197.14 ± 83.68
Level of signicance (p<0.05); Intervention group hip/waist ratio p<0.002; Intervention group HbA1C p<0.001; Intervention
group Blood sugar fasting p<0.001; Intervention group total cholesterol p<0.002; Triglyceride intervention group p<0.002
Biochemical assessments: Paired sample T-test results showed that HbA1C and blood sugar fasting signicantly
changed in intervene group after apple cider vinegar intervention of 3 months. HbA1C before intervention (BI) mean
was 9.32 ± 1.74 SD and AI mean was 8.65 ± 1.81 SD with p<0.001. BSF BI mean was 170.14 ± 62.42 SD, while BSF
after intervention (AI) mean was 157.32 ± 58.16 SD with p<0.001. No signicant change in HbA1C and BSF was
found in before and after in placebo group (Figure 2).
Figure 2 Mean plot chart of HbA1c before the intervention of intervention and placebo groups

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Total cholesterol was signicantly changed in the intervention group, with a mean difference of total cholesterol BI
means was 195.81 ± 47.9 SD and AI mean was 180.09 ± 48.5 SD with p=0.002. But there was no signicant change
in the placebo group. Triglyceride signicantly changed in the intervention group with mean difference BI was 192.2
± 77.9 AI was 180.2 ± 79.6 with p=0.002. There was no signicant change in the placebo group. High density
lipoprotein (HDL) was not signicantly changed in both groups. No signicant change was found in both groups for
low density lipoprotein (LDL) (Table 3). One-way ANOVAs for biochemical assessments within groups showed
insignicant ndings.
Confounder variables including (age, gender, occupation, education, physical activity, exercise, walk, and sleeping)
were also measured by using regression model so, no signicant effect of confounder variables on dependant variable
(HbA1C) was found after an interventional period of both groups (Table 4 and Figure 3).
Table 4 Confounders’ effect on HbA1C
Groups Models Unstandardized Coefcients Standardized
coefcients Tail p-values
B St error Beta
Intervene
Constant 9.172 2.966 - 3.092 0.003
Age 0.454 0.357 0.173 1.271 0.210
Gender 0.825 0.531 0.223 1.552 0.127
Occupation -0.334 0.462 -0.104 -0.723 0.473
Education 0.235 0.174 0.205 1.349 0.184
Physical activity 0.407 0.427 0.120 0.954 0.345
Exercise 0.229 0.196 0.158 1.169 0.248
Walk -0.431 0.184 -0.299 -2.340 0.024
Sleeping -1.365 0.555 -0.304 -2.459 0.018
Placebo
Constant 34.385 14.216 - 2.419 0.020
Age -2.988 1.900 -0.233 -1.573 0.123
Gender -1.178 2.909 -0.063 -0.405 0.687
Occupation -0.874 2.059 -0.065 -0.424 0.673
Education -2.129 1.199 -0.297 -1.775 0.083
Physical activity -2.141 2.132 -0.146 -1.004 0.321
Exercise -0.073 1.142 -0.009 -0.064 0.950
Walk -1.211 0.963 -0.182 -1.258 0.215
Sleeping 0.692 2.541 0.042 0.273 0.786
Figure 3 Mean plot chart of HbA1c after the intervention of intervention and placebo groups

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DISCUSSION
In intervention and placebo groups, the mean age was not much different (51.1 ± 7.9 and 50.4 ± 7.7 respectively) with
female predominance in both (61.8% in intervention group and 52.7% in placebo). A study conducted in Iran showed
a similar demographical picture of study participants but with different sample size [2,23]. The current study showed
complications of diabetes including visual problem, neuropathy, and hypertension. While few studies documented no
complication in early diagnosed type 2 diabetic patients [18].
In the current study no signicant change found in height, weight and mid upper arms circumference in both groups
before and after. Hip/waist ratio signicantly reduced after intervention (p=0.002) but no signicant difference found
in the placebo group (p=0.06). A study conducted in Japanese showed apple cider vinegar signicantly reduced
bodyweight, waist circumference, and BMI in vinegar treated group as compared to placebo [23]. Another animal
study results highlighted signicant reduction in daily gained and in routine body weight in normal healthy rats with
normal diet and in obese rats with high calories diet in vinegar treated group but no signicant change occurred in
the placebo group [24]. The reason for the reduction in body weight and BMI may be due to the difference in the
physiology of human and animals and dose of vinegar, duration of intervention and sample size.
In current study HbA1C and blood sugar fasting were signicantly reduced in the intervention group, HbA1C
(p<0.001), blood sugar fasting (p<0.001) no signicant difference in mean of HbA1C, BSF in the placebo group.
Previous study results showed HbA1C (p=0.002) and BSF (p=0.006) signicantly reduced in the intervention group
but not signicantly changed in these parameters of the placebo group [2]. Another study showed a signicant
reduction in fasting blood sugar (p=0.05), in vinegar (750 mg) ingestion group when compared with vinegar pills (40
mg acetic acid) as control group after 12 weeks trail but no signicant change in Hb1C and post prandial glucose was
found [18].
The results of the current study showed vinegar had a hypercholesterolemic and hypotriglyceridemic effect. Total
cholesterol and triglyceride were signicantly reduced in the intervention group (total cholesterol, p=0.002, and
triglyceride, p=0.002), no signicant change in the placebo group. An animal study showed that dietary acetic acid
had efcacy to reduced hypercholesterolemia and hypertriglyceridaemia in vinegar ingestion group of rats but not in
the placebo group [27].
HDL and LDL remained the same before and after intervention in intervention and placebo group. A study showed
no signicant difference in total cholesterol, total triglyceride LDL and HDL after one month intervention of white
vinegar as compared to the placebo group [2]. The reason for the insignicant effect of vinegar on hyperlipidaemia
could be a short duration of the intervention. Another animal study showed a signicant change in blood glucose,
total cholesterol, LDL and HDL by indigestion of apple, coconut, grape, sugarcane and palm vinegar with apple cider
vinegar most effective in triglyceride, LDL and glucose with 15% concentration for 6 weeks (p=0.005) [28]. Total
cholesterol, triglyceride, LDL signicantly reduced and HDL also increased but not signicantly in hyperlipidemic
patients in another study [19].
In the current study before and after intervention in groups, diet remained the same no signicant difference was
found in any food component before and after. Human subjects study results showed that diet should remain the same
before and after the intervention of acetic acid in type 2 diabetic patients to ensure comparability [16].
Confounder variables including (age, gender, occupation, education, physical activity, exercise, walk, and sleeping)
were found to have no effect on dependant variable (HbA1C) in both groups. A study conducted on human subjects
showed physical activities and life style remained the same before and after the invention and no signicant effect of
these confounders was found [2]. The current limitation was a small sample size and nancial constrains because this
study was conducted without funding by any national and international organization. One-way ANOVAs (analysis of
variance) for anthropometric measurements and biochemical assessments within groups showed insignicant ndings.
CONCLUSION
The current study concludes that apple cider vinegar had a positive effect on controlling diabetes in diabetic patients
and lowering hypercholesterolemia and hypertriglyceridemia. HbA1C, fasting blood glucose, total cholesterol, and
triglyceride, and hip/waist circumference values were signicantly reduced in the intervened group after 3 months

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Kadhim, et al.
of apple cider vinegar intervention. No signicant change occurred in the values of LDL, HDL and body weight.
Physical activities, adequate sleep, diet plan follow up, adherence to prescribed medication and use of apple cider
vinegar as a nutraceutical can be benecial in reducing HbA1C, hypercholesterolemia, and hypertriglyceridemia in
type 2 diabetic patients.
DECLARATIONS
Trial Registration
This clinical trial has been registered at www.clinicaltrials.gov, retrospectively, trial registration #NCT03593135, on
18th July 2018.
Acknowledgement
The researcher wants to thanks the administration and staff of Sheikh Zayed hospital Lahore especially diabetic clinic
staff for their assistance and cooperation in data collection and all my study participants who took part in the research.
The research motivation behind publication was my worthy teachers and faculty members of the Department of
Environmental Design, Health and Nutrition Sciences of AIOU Islamabad. Special thanks to Mr. Asim Jaja and Mr.
Abdul Rehman for their assistance and guidelines in statistical analysis.
Conict of Interest
The authors declared no potential conicts of interest with respect to the research, authorship, and/or publication of
this article.
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