March 2025 Issue
CPE Monthly: Health Benefits of Apple Cider Vinegar
By Emily Cooper, RDN
Today’s Dietitian
Vol. 27 No. 3 P. 38
Take this course and earn 2 CEUs on our Continuing Education Learning Library
Apple cider vinegar has been used for a wide variety of applications and ailments, from sunburns and scratches to digestion and diabetes. The word vinegar is derived from the French phrase vin aigre (“sour wine”), hearkening back to when the sour liquid was first produced from wine. According to legend, the discovery of vinegar was the unexpected result of forgotten wine left sitting for several months. This turned it sour and fermented into the pungent liquid known today.1 Now, vinegar is made from a variety of other sources as well, such as rice, malted barley, and apple cider.2
The two most common varieties of apple cider vinegar are unfiltered and distilled. The main difference is the presence of what’s often referred to as “the Mother,” found in the raw or unfiltered variety of apple cider vinegar. It’s the combination of yeast and bacteria left from the vinegar-making process that is a natural source of probiotics.3 The Mother most often is removed during the pasteurization and filtering process of distilled apple cider vinegars, which is why the two types have different appearances.1
This continuing education course identifies and examines the health claims and considerations associated with apple cider vinegar and provides strategies dietitians can use to help clients decide whether incorporating the vinegar into their diets is appropriate, safe, and effective.
History and Production
The earliest accounts of vinegar date back more than 10,000 years, traced to the Babylonians and Egyptians. Early uses of vinegar went far beyond simple culinary preparations. Its acidity made it popular as a preservative, a hand-washing agent to prevent infection, means of managing wounds, and treatment for ailments such as poison ivy, stomachache, and edema.4
To produce vinegar, a sugar-containing source such as cider or wine must undergo a two-step fermentation process. During the first step, yeast feeds on the naturally occurring sugars in the starter liquid to produce alcohol. The alcohol is then exposed to oxygen and acetic acid bacteria, Acetobacter, to further ferment into vinegar. The fermentation process can vary in length depending on the type of vinegar produced. Traditionally produced vinegars can take weeks, months, or even years to ferment, while modern, commercially produced vinegars can be made in a matter of days.4
Acetic acid, or ethanoic acid, is the chemical compound that gives vinegar its pungent odor and taste. The FDA requires all vinegars to contain a concentration of at least 4% acetic acid.5 Most household vinegars found on supermarket shelves are diluted with water to create a mixture with a 4% to 8% concentration of acetic acid by volume.1 Vinegars used for pickling tend to have higher concentrations of acetic acid, with some reaching as high as 18%. Typically, vinegar has a relatively low pH of 2 to 3.5, depending on the concentration of acetic acid used.2
Unfiltered vs Distilled
Both unfiltered and distilled apple cider vinegars start off in a similar fashion, with a base of water with crushed apples or cider. What differentiates these two types is the filtering and pasteurization processes.
Most distilled apple cider vinegars are both filtered and pasteurized as a means of reducing the presence of potential harmful bacteria and pathogens, and improving the clarity and appearance of the vinegar. On the other hand, raw and unfiltered apple cider vinegar doesn’t undergo either of these processes, which results in a darker, cloudy appearance, but it’s still generally as safe to consume and use as distilled vinegar.3
Unfiltered apple cider vinegar includes the Mother, which is believed to carry additional health benefits and has received increased attention in the past few years.3 While this weblike substance contains trace amounts of vitamins, minerals, and enzymes, there’s no significant scientific evidence to support the health claims associated with raw and unfiltered varieties of apple cider vinegar. Most of the research conducted attributes the efficacy and health benefits of apple cider vinegar to its main component, acetic acid, which is found in both the unfiltered and distilled varieties.
Potential Health Benefits
As an affordable and readily available ingredient, apple cider vinegar has gained popularity as both a health aid and home remedy for several ailments and issues. Some of its reported benefits include diabetes management, cardiovascular health, weight loss, and improved digestion. While scientific evidence supports some of these claims, other benefits are purely anecdotal.
Diabetes Management
Apple cider vinegar may improve blood glucose and overall diabetes management. A 2021 meta-analysis published in BMC Complementary Medicine and Therapies found that consumption of apple cider vinegar significantly decreased fasting glucose levels. The analysis showed promising results in the reduction of HbA1C levels, but further research is needed to draw significant benefits. While the exact mechanisms of action still need to be further defined, delayed gastric emptying, increasing cellular uptake of glucose, and improvements in insulin secretion are attributed to apple cider vinegar consumption.6
Promising results were noted in a 2020 study in the Journal of Diabetes Research. Daily intake of apple cider vinegar was associated with lower fasting blood sugars, a moderate decrease in triglycerides and LDL cholesterol, and moderate increase in HDL cholesterol when paired with a high calorie diet. These findings were the result of an animal study, which calls for further research in human studies to show significance.7
Similar results have been noted with the ingestion of apple cider vinegar after a high-carbohydrate meal. An older 2004 study also published in Diabetes Care revealed a 34% increase in insulin sensitivity in participants with insulin resistance and a 19% increase in those with type 2 diabetes after consuming a high-carbohydrate meal with a beverage consisting of apple cider vinegar, water, and saccharine.8
These studies were relatively small in size, with 55 or fewer participants in each, and their results haven’t yet been replicated in additional studies. This research, however, shows preliminary benefits and suggests the need for additional and larger studies to explore the efficacy and use of apple cider vinegar for blood sugar management.
The key component of apple cider vinegar thought to be responsible for these results is acetic acid. Since this ingredient is found in most other types of vinegars, those varieties also may be beneficial for blood glucose management. A study review in Clinical Nutrition ESPEN noted a 20% decrease in glucose response in participants who consumed 10 g of apple cider vinegar after a carbohydrate-rich meal.9
While the mechanism of action isn’t completely understood, the impact of acetic acid on delayed gastric emptying and reduction of starch digestion may be contributing factors to these results.6 These findings may suggest the inclusion of vinegar as a complementary treatment within a blood glucose management program. However, these results haven’t been replicated and don’t suggest the use of any type of vinegar as a means of replacing current medical treatment or medications.
Cardiovascular Health
Consuming vinegar daily has been explored for its potential to improve heart disease risk factors such as high cholesterol, blood pressure, and triglycerides. According to a 2016 systematic review, consumption of 15 mL vinegar (containing 750 mg of acetic acid) per day was associated with improvements in conditions such as hypertension, hyperlipidemia, and obesity.10
In addition, a 2018 study published in the Journal of Medicinal Food found that obese rats fed a high-fat diet along with a daily dose of apple cider vinegar had a significant reduction in the oxidative stress induced by obesity and a lower risk of CVD.11
Similar results were found in a 2021 meta-analysis of nine studies where apple cider vinegar consumption was associated with lower total cholesterol levels in participants with type 2 diabetes. These participants consumed less than 15 mL of apple cider vinegar per day for at least eight weeks or longer. This analysis did not find significant changes in LDL or HDL levels.6
As with other health outcomes associated with vinegar, it’s believed that acetic acid plays a significant role in these reductions of cardiovascular risk factors. The decrease in total cholesterol and triglycerides may be due to acetic acid’s facility in the inhibition of lipogenesis in the liver and its impact on increasing bile acid excretion in the feces.12
Weight Management
A health claim for consumption of apple cider vinegar that’s received a lot of attention is its ability to aid in weight loss. A 2009 study in Bioscience, Biotechnology, and Biochemistry explored the effects of daily vinegar intake on body weight and body fat among individuals with obesity. Participants who consumed 1 T of vinegar per day for the duration of the 12-week study lost an average of 2.6 lbs, decreased their overall body fat percentage by 0.9%, and decreased their serum triglycerides by 26%.13
Furthermore, participants who consumed 2 T of the vinegar a day lost an average of 3.7 lbs and decreased their overall body fat percentage by 0.9%, but experienced no greater reduction in serum triglyceride levels than those consuming 1 T of vinegar. The researchers suggest that the vinegar played a role in lipogenesis inhibition and stimulation of fatty acid oxidation in order to produce these beneficial results.13
Similar results were found in a 2018 study in the Journal of Functional Foods where those who combined 2 T of vinegar with a calorie-restricted diet over the course of 12 weeks experienced nearly twice as much weight loss, BMI improvements, and decreased hip circumference as compared with those adhering to a calorie-restricted diet alone.14 One suggested explanation of these results is vinegar’s effect on satiety, which can lower overall daily caloric intake. A study published in the European Journal of Clinical Nutrition concluded that intake of vinegar alongside a high-carbohydrate meal reduced the blood glucose response and increased satiety levels. However, this study was short term and included only 12 participants.15
The results of these studies suggest that apple cider vinegar can play a role in weight maintenance, but additional research is needed. A further exploration of this relationship can help dietitians make better recommendations for clients regarding safe, effective use and dosage for those looking to include vinegar in their diets.
Digestion
Drinking apple cider vinegar is a common home remedy for many digestive issues, such as indigestion and heartburn. The theory is that apple cider vinegar increases the acidity of the stomach, which may improve digestion of protein- or fat-heavy meals. This theory lacks scientific validity or adequate research, and other studies suggest vinegar consumption may worsen symptoms in certain cases.
A 2014 study in the International Journal of Obesity found that participants who consumed a beverage containing 25 g of vinegar alongside a meal reported increased feelings of nausea, more so when the vinegar was ingested in a nonpalatable form made with a minimal amount of sweetener.16
Consuming apple cider vinegar also may be contraindicated for those with type 1 diabetes suffering from gastroparesis. This condition is marked by a delay in gastric emptying, which can lead to secondary symptoms of heartburn, nausea, and bloating. A 2007 study in BMC Gastroenterology noted further delays in gastric emptying in participants with insulin-dependent diabetes after they ingested 2 T of apple cider vinegar.17
Both of these studies were small, indicating a need for further research on the connection between apple cider vinegar and digestion. However, these findings suggest that consuming vinegar with meals may increase unwanted symptoms rather than provide relief for those suffering from gastroparesis, heartburn, and/or indigestion.
Safety and Risks
For the general population, apple cider vinegar can be used safely and consumed by most individuals, but certain circumstances and factors should be considered first.
Acidity
The acidity of apple cider vinegar can sometimes cause issues and adverse side effects if the vinegar is consumed or applied topically without diluting. Drinking or rinsing the mouth with pure apple cider vinegar is acidic enough to weaken tooth enamel, leaving teeth more prone to decay, cavities, and sensitivity. A 2021 study in the Journal of Medicinal Foodreported an 18% increase in tooth erosion in participants who consumed 2 T of vinegar diluted in one cup of water daily for eight weeks.18
Skin burns and erosions can also occur with the use of undiluted apple cider vinegar. A 2022 report in the International Journal of Dermatology reported the presence of a chemical burn on the skin of an 8-year-old boy after his mother applied apple cider vinegar to an infection on the leg.19 Diluting apple cider vinegar with water before ingesting or applying to the skin is recommended to prevent adverse effects of its acidity. Significant research hasn’t been conducted on a large enough scale to provide specific dosages.
Potassium Levels
Prolonged consumption of large amounts of apple cider vinegar can have a significant effect on blood potassium levels. A 2019 review in the journal Clinical Nutrition ESPEN reported that a 28-year-old female who consumed 8 oz of apple cider vinegar diluted in water daily for six years was admitted to the hospital with low potassium levels, abnormal blood chemistry, and osteoporosis. The high amount of acetic acid ingestion was thought to have contributed to a disturbance in the acid/base status in the body.9 While this amount of vinegar isn’t widely consumed by most individuals, potassium levels should be a consideration for those incorporating high amounts of apple cider vinegar into their diets on a regular basis.
Medications
Certain medications may interact with apple cider vinegar and should be considered before regular consumption. Apple cider vinegar’s potential effect on lowering blood sugar and blood potassium levels can alter the efficacy of certain medications, such as those for managing diabetes and blood pressure, as well as laxatives. Some of these medications include digoxin, furosemide, and hydrochlorothiazide.20
Pregnancy
Due to the risk of foodborne illness, pregnant women are advised to avoid raw or unpasteurized foods or beverages. While there’s no conclusive research regarding the use of unpasteurized apple cider vinegar by those who are pregnant, it’s a safer practice to avoid raw varieties of apple cider vinegar during pregnancy. Distilled vinegars that have undergone the pasteurization process can be safely consumed during pregnancy as long as they’re not consumed in high, undiluted doses.21
Additional Uses
Aside from its medicinal properties, apple cider vinegar has been a medium for several home remedies and household uses throughout the years. Some of these uses include sunburn relief, hair care, household cleansing, and a variety of culinary applications.
Minor Sunburns
It may seem counterintuitive to apply something acidic to a burn, but a longstanding home remedy for relieving the pain of mild sunburns is the application of apple cider vinegar. While there are no scientific studies or research to support these claims, the theory is that apple cider vinegar’s antiseptic properties help to kill germs and relieve pain, while also balancing the skin’s pH.22
Hair Care
Apple cider vinegar is a touted home remedy for a variety of scalp-related issues such as dull, frizzy, or brittle hair, or an itchy scalp. It’s thought that the acidic and antibacterial properties of the vinegar help remove pathogens or bacteria present on the scalp and lower the pH to reduce itchiness, dryness, and damage. There’s no scientific research that supports these claims, though anecdotal reports claim success.23
Produce Wash
Soaking and washing fresh fruits and vegetables in a vinegar solution is a safe and effective method for removing up to 98% of bacteria that may be present on the produce. Soaking produce in a ratio of one part vinegar to three parts water for five to 10 minutes is most effective at removing potentially harmful bacteria, such as Listeria.
However, washing or soaking produce with clean water, which may be a more cost-effective and less time-consuming method, is just as effective as the vinegar solution for removing dirt and bacteria. There’s no significant evidence supporting claims that soaking or washing produce in a vinegar solution extends the shelf life of these foods. Using either method for washing produce can be an effective way to reduce potentially harmful pathogens and the risk of foodborne illness.24,25
Household Cleaner
Using apple cider vinegar as a household cleaning agent can be an effective way to disinfect surfaces from a variety of bacteria and pathogens. According to the CDC, undiluted vinegar is effective against both E coli and Salmonella typhi, and studies have shown that apple cider vinegar can also be effective against Staphylococcus aureus.26,27
While apple cider vinegar can be a safe antibacterial cleanser, it isn’t registered with the Environmental Protection Agency and doesn’t protect against all types of bacteria and pathogens that may be present in the home.27
Culinary Uses
Apple cider vinegar’s acidic properties make it useful in a variety of ways as a culinary ingredient. One of the most commonly used applications is as a preservation agent, such as in the pickling process. The low pH of vinegar creates an environment that can prevent the growth and development of pathogenic bacteria, which makes it an effective medium for food preservation.
Vinegar can also tenderize meat by weakening collagen and muscle fibers that can make certain cuts of meat tough. Vinegar-based marinades should be used in smaller amounts or for shorter durations, as prolonged use can result in too much breakdown in muscle fibers and a resulting mushy texture.28
The use of apple cider vinegar in foods can alter not only the texture and flavor of a dish but also the color. When added to green vegetables such as broccoli and spinach during the cooking process, vinegar interacts with chlorophyll, turning the vegetables from a bright green to a dull olive color.29
The opposite effect can be seen with red- and white-fleshed produce. Adding vinegar to red-pigmented fruits or vegetables such as cherries and red cabbage enhances and brightens their color during cooking or baking. This can counteract the color-altering effects of basic ingredients such as baking soda, which tends to change the color of these red-pigmented foods to a shade of blue.
Apple cider vinegar also can deter browning on cut white-fleshed produce, such as potatoes or apples. The vinegar, which slows down the enzymatic activity that causes browning, can help maintain an appealing, bright color.29
Vinegar-Based Beverages
A growing trend in the last few years is the market of vinegar-based beverages. These include items such as switchels, fire ciders, and drinking vinegars, each with their own flavor profiles, ingredients, and health claims. Despite their popularity and use, the benefits and/or considerations of vinegar-based beverages haven’t been widely explored. Switchel, a sports drink, is a rendition of a colonial-era sports drink often made with water, ginger, a sweetener such as honey or maple syrup, and apple cider vinegar. It’s making a comeback as a more palatable way to add vinegar into the diet. It can be made at home and is also commercially available from several brands.30
Fire cider is another popular drink among apple cider vinegar enthusiasts. An herbal remedy thought to improve digestion and boost immunity during the winter months, fire cider is usually made with ingredients such as freshly grated horseradish, ginger, garlic, cayenne pepper, and apple cider vinegar. The mixture sits and infuses for weeks or months at a time before it’s consumed straight or mixed with water or honey.31 No studies have explored the immune and digestion claims of fire cider, but it’s a long-standing home remedy that many still use in the hope of preventing colds and the flu.
Drinking vinegars, also referred to as shrubs, were thought to be one of the first cocktail mixers and typically are made with fruits, sugar, herbs, spices, and vinegar. Although shrubs made their way from Turkey to America in the 1700s as a mixer for alcohol, drinking vinegars are now widely available in a variety of flavor combinations and are simply enjoyed on their own by a growing number of people looking to including vinegar in their diets.32
Vinegar Pills
The increased interest, use, and consumption of apple cider vinegar for its potential health effects led to the introduction of apple cider vinegar pills. Made with a dehydrated, powdered form of apple cider vinegar, these pills are designed for those who want to incorporate apple cider vinegar into their diets but dislike the taste, smell, or acidity of the liquid form.33
A 2020 study in the Journal of Nutrition and Metabolism found that commercial vinegar pills did not have the same effect as liquid vinegar at reducing postmeal glucose levels. Additionally, supplements aren’t regulated by the FDA, and many can have a variable number of ingredients and concentration of apple cider vinegar depending on the brand and pill size.34
A 2005 study in the Journal of the American Dietetic Association examined eight varieties of apple cider vinegar tablets. Of those tested, significant variability in pH, tablet size, acid content, and label claims were reported, calling into question the accuracy and quality of the supplements.35 These factors make it difficult to accurately measure the amounts of acetic acid present in apple cider vinegar pills in order to compare them with quantities found in liquid forms.
Putting It Into Practice
For almost as long as it has been around, apple cider vinegar has been praised for its myriad health benefits and uses. According to preliminary studies, apple cider vinegar shows potential for improving certain health outcomes such as blood sugar management and cardiovascular health but hasn’t been researched on a large scale or measured for its long-term efficacy to fully support its use with these health concerns.
As a readily accessible ingredient with a variety of potential health benefits, apple cider vinegar can easily be incorporated into clients’ diets in a number of applications. RDs can advise clients to make a simple apple cider vinaigrette dressing for salads and vegetables or add the vinegar to marinades for tenderizing and flavoring meat or poultry. Apple cider vinegar can also be a flavorful medium for those interested in pickling or preserving their own foods.
If clients wish to consume it directly, apple cider vinegar should be diluted in water first to prevent the adverse effects of its acidity. Adding it to unsweetened and flavored carbonated or sparkling water, or consuming it in prepared beverages such as flavored drinking vinegars, can be a more palatable way for clients to incorporate the vinegar into their diets, in the event they don’t enjoy its pungent sour flavor.
— Emily Cooper, RDN, is a New Jersey-based award-winning recipe developer, food and nutrition writer, and author of the blog Sinful Nutrition.
Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Describe three potential health benefits of apple cider vinegar.
2. Provide clients with options for incorporating apple cider vinegar into their diets.
3. Assess contraindications and other safety concerns with the use of apple cider vinegar.
Examination
1. What’s the main component in apple cider vinegar responsible for its pungent taste and odor?
a. Malic acid
b. Tartaric acid
c. Acetic acid
d. Citric acid
2. What percentage of acid does the FDA require for all vinegars?
a. 1%
b. 4%
c. 6%
d. 10%
3. Which processes differentiate unfiltered apple cider vinegar from distilled varieties?
a. Mashing and straining
b. Blending and pulverizing
c. Boiling and freezing
d. Pasteurizing and straining
4. Apple cider vinegar can potentially cause what if applied directly to the skin?
a. Boils
b. Lesions
c. Burns
d. Scars
5. What components are needed to produce vinegar?
a. Carbon dioxide, salt, yeast, and sugar
b. Yeast, acetic acid, Acetobacter, and oxygen
c. Oxygen, salt, malic acid, and water
d. Sodium bicarbonate, tartaric acid, carbon dioxide, and sugar
6. According to a 2009 study in Bioscience, Biotechnology, and Biochemistry, what was the average amount of weight loss in participants who consumed 2 T of apple cider vinegar a day?
a. 1.6 lbs
b. 3.7 lbs
c. 5.8 lbs
d. 6.2 lbs
7. What is one way apple cider vinegar appears to benefit patients with diabetes?
a. Eliminates the need for medication
b. Lowers hemoglobin A1c levels
c. Alters metabolism
d. Delays gastric emptying
8. According to a 2009 study, which of the following decreased with higher doses of vinegar intake?
a. Body weight and body fat percentage
b. LDL cholesterol and triglycerides
c. Glucose and albumin
d. Vitamin D and calcium
9. Apple cider vinegar can preserve the color of which foods during cooking or baking?
a. Green and yellow foods
b. Orange and blue foods
c. Red and white foods
d. Purple and brown foods
10. Consuming undiluted apple cider vinegar can result in which of the following?
a. Acid reflux
b. Weakened tooth enamel
c. Urine retention
d. Rapid heart rate
References
1. Johnston CS, Gaas CA. Vinegar: medicinal uses and antiglycemic effect. MedGenMed. 2006;8(2):61.
2. Vinegar. New World Encyclopedia website. https://www.newworldencyclopedia.org/entry/Vinegar. Accessed January 16, 2024.
3. McDonald E. Debunking the health benefits of apple cider vinegar. UChicago Medicine website. https://www.uchicagomedicine.org/forefront/health-and-wellness-articles/2018/august/debunking-the-health-benefits-of-apple-cider-vinegar. Published August 23, 2018. Accessed January 16, 2024.
4. Budak NH, Aykin E, Seydim AC, Greene AK, Guzel-Seydim ZB. Functional properties of vinegar. J Food Sci. 2014;79(5):R757-R764.
5. Food and Drug Administration. CPG sec. 525.825 vinegar, definitions — adulteration with vinegar eels. https://www.fda.gov/media/71937/download . Updated March 1995. Accessed January 16, 2024
6. Hadi A, Pourmasoumi M, Najafgholizadeh A, Clark CCT, Esmaillzadeh A. The effect of apple cider vinegar on lipid profiles and glycemic parameters: a systematic review and meta-analysis of randomized clinical trials. BMC Complement Med Ther. 2021;21(1):179.
7. Ousaaid D, Laaroussi H, Bakour M, et al. Beneficial effects of apple vinegar on hyperglycemia and hyperlipidemia in hypercaloric-fed rats. J Diabetes Res. 2020;2020:9284987.
8. Johnston CS, Kim CM, Buller AJ. Vinegar improves insulin sensitivity to a high-carbohydrate meal in subjects with insulin resistance or type 2 diabetes. Diabetes Care. 2004;27(1):281-282.
9. Santos HO, de Moraes WMAM, da Silva GAR, Prestes J, Schoenfeld BJ. Vinegar (acetic acid) intake on glucose metabolism: a narrative review. Clin Nutr ESPEN. 2019;32:1-7.
10. Samad A, Azlan A, Ismail A. Therapeutic effects of vinegar: a review. Curr Opin Food Sci. 2016;8:56-61.
11. Halima BH, Sonia G, Sarra K, Houda BJ, Fethi BS, Abdallah A. Apple cider vinegar attenuates oxidative stress and reduces the risk of obesity in high-fat-fed male Wistar rats. J Med Food. 2018;21(1):70-80.
12. Fushimi T, Suruga K, Oshima Y, Fukiharu M, Tsukamoto Y, Goda T. Dietary acetic acid reduces serum cholesterol and triacylglycerols in rats fed a cholesterol-rich diet. Br J Nutr. 2006;95(5):916-924.
13. Kondo T, Kishi M, Fushimi T, Ugajin S, Kaga T. Vinegar intake reduces body weight, body fat mass, and serum triglyceride levels in obese Japanese subjects. Biosci Biotechnol Biochem. 2009;73(8):1837-1843.
14. Khezri SS, Saidpour A, Hosseinzadeh N, Amiri Z. 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. J Funct Foods. 2018;43:95-102.
15. Östman E, Granfeldt Y, Persson L, Björck I. Vinegar supplementation lowers glucose and insulin responses and increases satiety after a bread meal in healthy subjects. Eur J Clin Nutr. 2005;59(9):983-988.
16. Darzi J, Frost GS, Montaser R, Yap J, Robertson MD. Influence of the tolerability of vinegar as an oral source of short-chain fatty acids on appetite control and food intake. Int J Obes (Lond). 2014;38(5):675-681.
17. Hlebowicz J, Darwiche G, Björgell O, Almér LO. Effect of apple cider vinegar on delayed gastric emptying in patients with type 1 diabetes mellitus: a pilot study. BMC Gastroenterol. 2007;7:46.
18. Anderson S, Gonzalez LA, Jasbi P, Johnston CS. Evidence that daily vinegar ingestion may contribute to erosive tooth wear in adults. J Med Food. 2021;24(8):894-896.
19. Elhage KG, St. Claire K, Daveluy S. Acetic acid and the skin: a review of vinegar in dermatology. Int J Dermatol. 2022;61(7):804-811.
20. Apple cider vinegar. Alberta Rheumatology website. https://albertarheumatology.com/natural-health-products/apple-cider-vinegar/. Accessed January 18,2024.
21. People at risk: pregnant women. FoodSafety.gov website. https://www.foodsafety.gov/people-at-risk/pregnant-women. Updated September 25, 2020.
22. Does apple cider vinegar really help sunburn? Wound Care Society website. http://woundcaresociety.org/does-apple-cider-vinegar-really-help-sunburn. Published September 30, 2015. Accessed January 18, 2024.
23. White A. Can apple cider vinegar benefit your hair?: things to watch out for. Healthline website. https://www.healthline.com/health/apple-cider-vinegar-hair#cautions. Updated March 13, 2023.
24. Should I wash fresh fruit in vinegar? Best Food Facts website. https://www.bestfoodfacts.org/fruit-vinegar/. Published September 26, 2018. Accessed January 18,2024.
25. Kilonzo-Nthenge A, Chen FC, Godwin SL. Efficacy of home washing methods in controlling surface microbial contamination on fresh produce. J Food Prot. 2006;69(2):330-334.
26. Yagnik D, Ward M, Shah AJ. Antibacterial apple cider vinegar eradicates methicillin resistant Staphylococcus aureus and resistant Escherichia coli. Sci Rep. 2021;11(1):1854.
27. Disinfection of healthcare equipment. Centers for Disease Control and Prevention website. https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/healthcare-equipment.html. Updated November 28, 2023.
28. Harvard School of Public Health. Vinegar. The Nutrition Source website. https://www.hsph.harvard.edu/nutritionsource/food-features/vinegar/. Published October 2019. Accessed January 18, 2024.
29. Universe of Illinois Extension. The Whys and Hows of Cooking Vegetables. https://extension.illinois.edu/sites/default/files/the_whys_and_hows_of_cooking_vegetables.pdf. Published September 5, 2014. Accessed January 18, 2024.
30. Jiang H, McBride B. Five things everyone should know about … Switchel. GROW magazine website. https://grow.cals.wisc.edu/deprecated/five-things/five-things-everyone-should-know-about-switchel. Published March 7, 2018. Accessed January 25, 2024.
31. Bauman H. Free fire cider: traditional remedy remains generic after landmark case. HerbalGram. 2020;1(125):58-65. https://www.herbalgram.org/resources/herbalgram/issues/125/table-of-contents/hg125-feat-firecider/. Accessed January 18, 2024.
32. University of California Cooperative Extension Master Food Preserver. Shrubs & switchels. https://ucanr.edu/sites/mfp_of_cs/files/315888.pdf. Published November 16, 2019. Accessed January 18, 2024.
33. Organic apple cider vinegar pills. Ora Organic website. https://shop.ora.organic/products/organic-apple-cider-vinegar-pills. Accessed January 18, 2024 .
34. Feise NK, Johnston CS. Commercial vinegar tablets do not display the same physiological benefits for managing postprandial glucose concentrations as liquid vinegar. J Nutr Metab. 2020;2020:9098739.
35. Hill LL, Woodruff LH, Foote JC, Barreto-Alcoba M. Esophageal injury by apple cider vinegar tablets and subsequent evaluation of products. J Am Diet Assoc. 2005;105(7):1141-1144.