Apple cider vinegar (ACV) is the fermented juice of crushed apples. It contains pectin, vitamins, minerals and acetic acid or citric acid (NMD, 2024). It also contains amino acids, polyphenols, specifically flavonoids which are believed to contribute a health benefit (Abou-Khalil, 2023). This blog will explore the role of apple cider vinegar and lymphedema but does not replace advice from your regulated health professional.
Like other vinegars, apple cider vinegar it is made through double fermentation. The first converts the natural sugars in the apples to alcohol by yeast then the second converts the ethanol to acetic acid through fermentation with acetic acid bacteria.
Apple cider vinegar is found in most grocery stores and the label can be consulting for specific details. Most will list that there is 5% acetic acid in the product. Other considerations on the food label would be terms such as “organic”, “with mother”, “filtered” or “unfiltered”, “pasteurized” and “raw”. Here is what these terms mean:
- Filtered vinegar – the vinegar is passed through a filter which captured the solid particles. Apple cider vinegar that has been filtered will be less cloudy and will have less sediment in the bottle.
- Pasteurized – the vinegar is heated to destroy bacteria, this is recommended for those who are immuno-compromised to avoid exposure to potentially harmful bacteria
- Raw- this means unpasteurized and this means that the products bacteria have not been destroyed by heat treatment
- Organic- the apples are produced according to organic agricultural practices which would specify the types of inputs that could be used on the apple trees
- Mother- this is the biofilm made up of bacteria and yeast that participated in the fermentation process as well as cellulose. Presence of the mother makes the vinegar more cloudy and with sediment. The mother is harmless if consumed.
There is another product that is often confused with apple cider vinegar and that is apple cider-flavored vinegar. This would be white vinegar with apple flavoring and caramel color added. This is not what I’m talking about when I refer to apple cider vinegar instead, the research that I am citing used authentic apple cider vinegar fermented from crushed apples.
Apple cider vinegar can be eaten on food, it’s often used as a salad dressing, it can be taken in larger amounts for therapeutic benefit and it can be applied to the skin. I was not able to find any published studies on ACV and oral or topical use for lymphedema. But, I did find some on ACV and weight loss, blood sugar and blood lipid management and as an application for skin ailments. Some of this may all be relevant to assisting with lymphedema indirectly. I will share those studies with you below.
Apple Cider Vinegar and Weight Loss
One double-blinded, placebo controlled study was published including 120 overweight and obese adolescents and young adults aged 12 to 25 years old living in Lebanon (Abou-Khalil, 2023).
The 120 subjects were divided into one of four groups, who received the following drinks every morning for 12 weeks:
- 5 ml of ACV + 8 oz of water
- 10 ml of ACV + 8 oz of water
- 15 ml of ACV + 8 oz of water
- Placebo (water that tasted and looked like ACV but in fact contained lactic acid)
Each participant was unaware of what they were drinking but were instructed to drink it every morning on an empty stomach. Researchers were also not aware which participant had received which solution and therefore the study was “double-blinded”. Importantly, the subjects were to continue with their usual diet and activities.
Results of Weight Loss Study
The addition of ACV to the diet resulted in significant decreases in body weight at weeks 4, 8 and 12 as compared to their starting weight. The most weight reduction came from the group drinking 15 ml apple cider vinegar in 8 oz of water. In addition to weight loss, there was a reduction in waist and hip circumference and body fat ratio.
By comparison, those that drank the look-alike placebo did not experience any significant changes in their weight, circumference measurements or body fat ratio. When the researchers analyzed the food and exercise records, they did not differ amongst the four groups, suggesting that the ACV was the one variable that was different.
The authors concluded their study by saying that “these results suggest that apple cider vinegar might have potential benefits in improving metabolic parameters related to obesity and metabolic disorders in obese individuals.”
Apple Cider Vinegar for Blood Sugar and Lipid Levels
For this topic, I will cite a meta-analysis that included 9 randomized controlled trials for a total of 686 participants that all used apple cider vinegar in adults while assessing blood sugar and blood lipid levels (Hadi, 2021).
The studies were focused as follows:
- 5 studies focused on individuals with diabetes
- 2 studies included individuals who were overweight or obese
- 1 of these studies included a calorie restricted diet along with the apple cider vinegar
- 1 study included type 2 diabetes and high blood lipids
- 1 study did not specify their target
The studies lasted between 30 and 90 days. The dose of apple cider vinegar ranged from 1 tbsp (15 ml) to 770 ml (26 oz) per day.
Results for Blood Sugar and Lipid Levels
The meta-analysis revealed that:
- Apple cider vinegar consumption decreased total cholesterol levels by 6 mg/dl (a normal total cholesterol level is < 200 mg/dl).
- There was also a trend towards reduction of triglycerides
- HDL cholesterol went up by 0.92 mg/dl (not statistically significant)
- LDL cholesterol went down by 2.12 mg/dl (not statistically significant)
When results were examined more closely by looking at only those participants with diabetes, the reduction in triglycerides and total cholesterol were even more pronounced, with triglycerides reducing by 22mg/dl and total cholesterol going down by 12 mg/dl. The length of the intervention seems to matter, as none of the studies that lasted less than 8 weeks saw a significant reduction in blood lipids in non-diabetics. The amount of apple cider vinegar that appears to provide the maximum effective dose was 15 ml/day (1 Tbsp).
Six of the studies that looked at fasting blood sugars saw an average reduction of 8 mg/dl and HbA1C reduced by 0.5 mg/dl, but no significant reduction in serum insulin levels. The blood sugar lowering results were seen in studies lasting 8 weeks or more. But these results seemed to rely on the strength of one study in the meta-analysis, when this study was removed from the analysis there was no significant effect on HbA1C after consuming apple cider vinegar.
In addition to the meta-analysis described above, the study of the Lebanese young adults also examined blood sugars, triglycerides and cholesterol. It was not included in the meta-analysis since it came out two years after the meta-analysis was published. Does this newer study add anything to the results of the meta-analysis? These were the findings related to blood sugars and blood lipids after 1-3 tsp of ACV in water every morning for 12 weeks:
- Serum glucose levels decreased significantly compared to baseline
- Triglycerides decreased significantly compared to baseline
- Total cholesterol decreased significantly compared to baseline
The most effective dose was 15 ml (1 tbsp) of apple cider vinegar in 8 oz of water.
How Does Apple Cider Vinegar Improve Blood Sugars?
There are several possible mechanisms that are theorized:
- Delaying gastric emptying
- Enhancing cellular glucose utilization and lipolysis (fat breakdown)
- Suppressing liver glucose production and lipogenesis (creation of new fat)
- Facilitating insulin secretion
How Does Apple Cider Vinegar Improve Weight Loss?
The mechanisms above would all support weight loss plus:
- Regulating appetite and satiety by increasing gut-derived satiety hormones GLP-1 and PYY
How Does Apple Cider Vinegar Improve Blood Lipids?
There are some theories around this mechanism:
- Apple cider vinegar may stimulate bile acid excretion (taking cholesterol with it)
- Increase in lipolysis (fatty acid breakdown)
- Decrease in lipogenesis (creation of new fat storage)
- Decrease in gluconeogenesis (creation of glucose from other substrates including amino acids)
Side Effects of Oral Intake of Apple Cider Vinegar
In the studies in which apple cider vinegar was taken by mouth, there were some side effects reported, namely stomach burning and a vague mention of “apple cider vinegar intolerance”, which did not provide further detail. Though not mentioned in this article, but reported to me by a client who was taking apple cider vinegar “shots”. Her dentist had advised her to stop as it was compromising her teeth enamel. A couple of potential solutions for this would include, diluting the ACV with water and not taking it as a full strength “shot”, not brushing your teeth immediately afterwards, but instead either drinking more water or rinsing your mouth with baking soda and water to neutralize the acid and help protect the teeth.
Another possibly side effect is heart burn, also known as gastro-esophageal reflux disease or GERD, which was reported in some subjects who were excluded from a study (Abou-Khalil, 2023). But after excluded those subjects from the start of the research, there were no side effects reported in the 120 subjects who continued with the study for 12 weeks (Abou-Khalil, 2023).
After analysis of the nine studies in the meta-analysis, the authors of the meta-analysis concluded that “apple cider vinegar appears to be a safe natural supplement with a functional role in controlling glycemic and lipid profiles.” But overall, more research is needed including studies with blinding to evaluate results in a non-biased way.
There was one case report of hypokalemia (low blood potassium levels), hyperrninemia (an elevated renin response linked to kidney decline) and osteoporosis when 250 ml (8 oz) was taken daily for 6 years (NMD, 2024), obviously, this is an extreme amount and is 16 times the amount used in most studies.
Apple Cider Vinegar for Skin Issues
There are several skin issues that are common in lymphedema, here are some of them (Fife, 2017):
- Bacterial infection called cellulitis
- Lymphorrhea – leakage of lymph fluid through cracks in the skin
- Ulceration, also called wounds, bed sores, pressure injuries, skin fissures
- Hyperkeratosis – thickening of the skin, specifically an excess of keratin which is the fibrous protein that forms our skin
- Papillomas and fibromas
- Mossy lesions
- Frogs spawn
- Fungal infections
In reviewing the treatments for these skin conditions, in a well written paper by Fife (that includes plenty of photos, if you’re interested in seeing what these conditions look like), there is no mention of vinegar of any type as a treatment.
Instead it recommends:
- Daily hygiene and careful washing with non-drying cleansers
- Avoiding skin damage e.g. well fitting shoes that don’t rub, electric razors, protection from sun burns etc.
- Using emollients to moisturize such as bath oils and ceramide-containing emollients
- Dermatological treatments such as anti-fungals, antimicrobials and topical steroids
Outside of the published research is a different story though. I’ve often seen on social media recommendations to treat hyperkeratosis, a common skin issue in lymphedema with dilute apple cider vinegar applied topically, with excellent results reported.I did find one publication reporting on the use of various “folk remedies” for skin issues (Gaurav, 2023). There were several reported uses of vinegar (not just apple cider vinegar) and these were:
- As an antibacterial in chronic non-healing wounds using daily soaks with 1-5% vinegar for a number of days. Studies used diluted vinegar as a wound bath or a compress.
- As an anti-fungal – used in combination with ketoconazole shampoo or soaking or even vinegar soaked cotton socks.
Obviously, the descriptions contained in this text are not a prescription and there is insufficient detail to use any of the treatments without additional information and input from your health care team.
Side Effects of Topical Use of Apple Cider Vinegar
Irritation of the skin and chemical burns are the main issues from topical application (NMD, 2024). It’s important to remember that even though apple cider vinegar is a “home remedy” or a “folk remedy” it can still result in side-effects, so use caution and seek the guidance of your health care professional.
If you do have cellulites, which is a bacterial infection of the skin, common in lymphedema, don’t fool around with home remedies, go to your doctor or emergency room immediately and get medical treatment, as cellulitis can become a serious medical issue if not treated properly at the first signs.
Botton Line on ACV for Lymphedema
There is no published research that I could find on apple cider vinegar taken orally to help with lymphedema specifically. But, there is one double-blinded trial of 120 subjects showing benefits for weight loss, cholesterol lowering and blood sugar lowering. There is also a meta-analysis of 9 studies totaling over 680 people that showed benefit for cholesterol lowering and blood sugar lowering. These may indirectly benefit lymphedema. Most obviously, weight loss has been shown to reduce lymphedema. Blood sugar lowering, may also help indirectly, if you are overweight and have elevated blood sugars along with lymphedema, then lowering these may assist with weight loss (although the research didn’t show a reduction in insulin levels).
Regarding cholesterol lowering, there are a couple of studies that show a connection between cholesterol and lymphedema. In one study, researchers examined blood lipid levels in those with and without lymphedema. There was no difference in total cholesterol, HDL cholesterol or triglycerides between the two groups, but there was a modest elevation, within normal blood values, in LDL cholesterol for the women with lymphedema compared to those without. In addition, the atherogenic index (the ratio of TG:HDL) was significantly higher in the lymphedema group. The researchers concluded that an increase in atherogenic index along with serum LDL cholesterol may be positively associated with lymphedema risk (Ryu, 2016).
The second study looks at the role of cholesterol in the prevention of lymphedema fibrosis, that’s because, the accumulation of fat appears to be key in the development of fibrosis. The fats that deposit themselves in the lymphatic fluid include chylomicrons, free fatty acids and cholesterol (Azhar, 2020). Changes in the cholesterol balance in fat cells (adipocytes) can alter metabolic and pro-inflammatory adipose tissue function (Azhar, 2020).
Reverse cholesterol transport – the transport of cholesterol joined to high density lipoprotein (HDL) from peripheral tissues back to the systemic circulation may be altered in lymphedema (Azhar, 2020). This could result in an accumulation of cholesterol in the lymphedema limb, which in turn could encourage more adipose remodeling (Azhar, 2020). It is unclear what role dietary cholesterol, and the type and quantity of fats in the diet might have on the development of fibrosis. Likewise, it is also unclear what impact blood levels of cholesterol or cholesterol lowering medications or apple cider vinegar might have on the progression of lymphedema fibrosis.
Given all the unknowns, it would be hard to argue that someone with lymphedema would benefit from apple cider vinegar, but certainly when looking at other co-morbidities, improving body weight, blood sugars, and heart heath markers would be beneficial. All in all, to say that taking apple cider vinegar orally will help with your lymphedema is a stretch and would involve lots of conjecture (be cautious if you seem someone making this claim, and be sure to check back on my blog for more updates).
Regarding the topical use of apple cider vinegar for lymphedema, I could find only evidence of vinegars of various sources having a folk medicine history and anecdotal reports of using dilute apple cider vinegar to treat hyperkeratosis in lymphedema. I look forward to research in this area, but like many folk remedies, research is generally slow to come and of poor quality. In the meantime, if you have skin issues related to your lymphedema, see a dermatologist, certified lymphedema therapist or other health professional.
To find out more about diet and complementary therapies for lymphedema, read:
References
Abou-Khalil R, Andary J, El-Hayek E. Apple cider vinegar for weight management in Lebanese adolescents and young adults with overweight and obesity: a randomised, double-blind, placebo-controlled study. BMJ Nutr Prev Health. 2024 Mar 12;7(1):61-67. doi: 10.1136/bmjnph-2023-000823. PMID: 38966098; PMCID: PMC11221284.
Azhar SH, Lim HY, Tan BK, Angeli V. The Unresolved Pathophysiology of Lymphedema. Front Physiol. 2020 Mar 17;11:137. doi: 10.3389/fphys.2020.00137. PMID: 32256375; PMCID: PMC7090140.
Fife CE, Farrow W, Hebert AA, Armer NC, Stewart BR, Cormier JN, Armer JM. Skin and Wound Care in Lymphedema Patients: A Taxonomy, Primer, and Literature Review. Adv Skin Wound Care. 2017 Jul;30(7):305-318. doi: 10.1097/01.ASW.0000520501.23702.82. PMID: 28617750.
Gaurav V, Bhoi AK, Mehta N. Home Remedies in Dermatology. Indian Dermatol Online J. 2023 Oct 13;14(6):864-870. doi: 10.4103/idoj.idoj_166_23. PMID: 38099029; PMCID: PMC10718121.
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 Jun 29;21(1):179. doi: 10.1186/s12906-021-03351-w. PMID: 34187442; PMCID: PMC8243436.
Natural Medicines Database. Apple Cider Vinegar Professional Monograph. Last updated Feb 6, 2024. Accessed July 29, 2024.
Ryu E, Yim SY, Do HJ, Lim JY, Yang EJ, Shin MJ, Lee SM. Risk of secondary lymphedema in breast cancer survivors is related to serum phospholipid fatty acid desaturation. Support Care Cancer. 2016 Sep;24(9):3767-74. doi: 10.1007/s00520-016-3197-z. Epub 2016 Apr 4. PMID: 27041742.
Tehrani SD, Keshani M, Rouhani MH, Moallem SA, Bagherniya M, Sahebkar A. The effects of apple cider vinegar on cardiometabolic risk factors: A systematic review and meta-analysis of clinical trials. Curr Med Chem. 2023 Aug 22. doi: 10.2174/0929867331666230822102021. Epub ahead of print. PMID: 37608660. https://pubmed.ncbi.nlm.nih.gov/37608660/
