Apple Cider Vinegar - A Pharmacist's Perspective
This week we rant about something very serious: apple cider vinegar. Before you read another line, I ask a favor to prove a point. If you use/like/swear by apple cider vinegar, email me and tell me your story. No judgement; I really want to hear it. I'd never put you down!
“Really Neal? A salad dressing is going to make you rant??” Hey now... I'm not that melodramatic! Apple cider vinegar is not just for salads. Apple cider vinegar represents all that’s wrong with the world (of natural products). OK, maybe I am.
I mean, apple cider vinegar does everything. From killing warts to stopping reflux to curing cancer, it's championed as a potent, magical compound with healing potential out of Dr. Internet Face’s wildest dreams.
Along with the endless claims, we have those apple cider vinegar experts who bang on fermentation pots and pans while singing their happy vinegar songs. These “experts” will be referred to from here on out as “Vinaigrettes.”
If outrageous claims and fake experts aren't enough, there are a multitude of product quality issues around apple cider vinegar.
The thing that makes apple cider vinegar truly rant-worthy is us. How can something with so little going for it be used by so many?
Is Neal The Guy That Thinks Nothing Works?
Before we get started, I want to clarify a point. Many of my rants point out how some holistic thing doesn’t really work. Very true.
But I’m not a nay-sayer. As you’ll see here, I’m a ranter because not only do things “not work” but there are “remedies” that CAN’T work. Like, it’s physically impossible!
What is most important to me is that consumers see the manipulation that is taking place. The industry is creating a mindset. They’re telling us that if something isn’t wrong with you right now, there will be something wrong in the future. A boogeyman or 4 will come get you! And the way to fix this or to stop it is with this “thing dejour” for $24.99.
I’m telling you a few things:
- Don’t read stuff on the internet. Except me. Those other guys have no scruples and will make you think there’s something wrong.
- Do stuff, don’t take stuff to solve and prevent your problems.
- If you need to take stuff, don’t look to “thing dejour,” because like with apple cider vinegar, there’s no possible way some of these natural options COULD do something.
My theme, if you don’t look deep enough, is “that doesn’t work.”
The REAL theme, is really, “try it if you want, but look out for these things, and I would/would not recommend it because of this or that.”
There are many who use apple cider vinegar or other things I don’t recommend. They feel there is a benefit. And frankly, that’s all that matters. We put our medicine on the spoon and take it and we feel better. Why? Sometimes it’s the medicine. Sometimes it’s just the spoon.
I’m ok with any of it, as long as the spoon isn’t going to kill you too. The people who recommend things with no data? They get the full force of the Neal venom.
WARNING: As you can tell, I’m a little extra vinegary in this one (a little spice with some sour), so remember I do this not to judge you, the consumer, but to make fun of the system while also giving you tools to make the best decisions.
What Is Apple Cider Vinegar?
Before we discuss the insanely complex science behind the healing powers of apple cider vinegar (that’s a joke), we should first talk about vinegar.
Vinegar is made by taking something rich in alcohol or sugars, adding special bacteria (called acetic acid bacteria or Acetobacterium), and allowing the product to ferment. Vinegar is what you get if you stink at making wine. You blow past the booze phase and go directly into the “meh I guess I can add this to lettuce” phase.
Vinegar is chemically a solution of acetic acid. Acetic acid. Vinegar has a pH of 5. If you are unfamiliar or need a refresher on pH, here’s a scale:
Vinegar is between rain and wine. It’s not melt-your-face-off acidic, but it is acidic nonetheless.
I stress this for reasons that will be clear a bit later.
Apple cider vinegar, then, is merely vinegar made from apples. It will have a darker color. Otherwise, no difference.
We’ve all seen vinegar before. It’s a clear liquid, brown or not. Sometimes vinegar can get a little funk in it. This funk has a name that signifies some higher, life giving purpose: mother of vinegar.
It was a toss up between the meme and a Game of Thrones Reference (Daenerys Fruit Born, Mother of Vinegar), but I didn’t want anyone to accuse me of spoilers!
Back at it... The mother of vinegar, or MOTHER, can be used to create more vinegar. It is basically just the acetic acid bacteria and left over plant compounds like cellulose. It is typically filtered off, though, as it doesn't have the greatest taste. “Yo momma’s so gross they use her to make vinegar!” Did I just invent a new “yo momma” joke?
What Apple Cider Vinegar Can Help You With
Hit the Google machine up for a quick jaunt around "apple cider vinegar" town. What do you see? I see stuff like this:
Man, it really sounds like apple cider vinegar has enormous potential for making me healthier! I mean, multiple PROVEN benefits! Almost as if the titles of articles are made to entice you to click through to an article, where revenue is generated by the person writing the article...
Here are some of the proposed health benefits of apple cider vinegar and my reading of the real literature:
Apple Cider Vinegar for Diabetes
The quote goes like this: "Several studies show apple cider vinegar can reduce after-meal blood sugars, reducing incidence of diabetes." What they neglect to say is that all of those studies are small, and some are stupid small (less than a dozen people).
Apple Cider Vinegar for Weight Loss
Again, small studies have shown people who use apple cider vinegar lose more weight than dieting alone. The problem? One of those studies is in obese rats. I'm not one of those, so I'm not sure of the relevance. One article even noted that the weight loss probably comes from the lack of appetite caused by nausea after ingesting the vinegar. Nice.
Apple Cider Vinegar for High Blood Pressure
Apple cider vinegar has natural compounds control blood pressure without meds, they say. We'll discuss this in a bit. But, no.
Apple Cider Vinegar for Cancer
Apple cider vinegar will literally cure cancer. Because cancer is just one thing. And Big Pharma doesn't want you to know about this because they make more money treating it than being the organization that can cure cancer.
Apple Cider Vinegar for Vaginal Health
Vaginal cleansing - Ok, no. Vinegar shouldn't go near your vagina. This goes double for men.
Apple Cider Vinegar for Warts
Can you believe the next sentence after discussing vinegar for the vagina is how it can remove warts? Anecdotally, yep, vinegar can remove warts - it helps. But so would any acidic liquid, no? Is it the apple cider vinegar or is it the acidity that removes warts? A better study wouldn't be vinegar vs placebo, it would be vs placebo vs another non-vinegar liquid of the same pH.
Even the most strict practitioners will tip their hat to one or two apple cider vinegar studies, but normally they will preface it with, “We need further evidence to verify this.”
How Apple Cider Vinegar Cures Everything
Regardless of the data or straight up silliness of the claims about apple cider vinegar, Vinaigrettes will still promote the smack out of it.
We need some sort of explanation for just how apple cider vinegar has all of these amazing health benefits. Don’t you worry - the Vinaigrettes have figured it all out for you!
I’ve taken classes in public relations before so I know people can take quotes and edit them or take them out of context. For the record, this next part is sarcastic...
Apple cider vinegar will prevent you from dying of old age and prevent all associated chronic diseases because of all the nutrients - the vitamins, minerals, good carbs and fibrous materials, proteins and amino acids, and even naturally occurring enzymes.
Heart disease risk is reduced by apple cider vinegar because it is rich in pectin, which is a type of soluble fiber, meaning it sucks up cholesterol and takes it out of play, lowering your total cholesterol. Your blood pressure will go down because of the high amounts of potassium.
You’ll even lose weight with apple cider vinegar, due to the high fiber content which can fill you up and suppress your appetite.
I mean that all sounds super awesome and I’m definitely in. All we have to do is just verify that apple cider vinegar has all of those great nutrients and we can get started!
The Nutritional Value of Apple Cider Vinegar
We would expect that the nutritional analysis of apple cider vinegar would line up with what the Vinaigrettes are saying. They wouldn’t lie to us, would they?
Thankfully, apple cider vinegar’s nutritional profile is clearly known. It is easily verified by any of the numerous nutritional databases accessible on the internet. You can check out the USDA one on it here.
Here's what you'll find: apple cider vinegar doesn't have a nutritional profile.
Almost all vinegars for human consumption are no more than 5% acetic acid. The remaining amount (95% for those without their calculators handy) is simply water. Vinegar amounts exceeding 5% can be harmful for human consumption. Vinegar as low as 10% can cause corrosion of our teeth, gums, skin, and GI tract.
There are no macronutrients - proteins or fats - in any amount in vinegar products. Carbs will be found in trace amounts in almost all vinegars, save balsamic which has a bunch of carbs and is extra tasty. There are no fibers or other complex carbs, it is mostly just fruit sugars. Pectin levels hover right around the “nada” region.
Because it lacks all macronutrients, apple cider vinegar (and most other vinegars) are calorie free.
“But apple cider vinegar has lots of healthy minerals!” says the blogger who is not qualified to discuss this. One of the lead Vinaigrette quacks, D.C. Jarvis, who I’ll properly introduce in a bit, has said:
“[Apple cider vinegar] is also rich in enzymes and mineral content, particularly potassium.”
We can check this easily. We see that a tablespoonful of apple cider vinegar will have:
- 0.03 mg of iron (your iron supplement will have 30mg - 1000x this)
- 11 mg of potassium (a banana has 100mg - 10x this)
- 1 mg of sodium
- less than 0.01mg of other minerals like Zinc, Copper, or Manganese
- no other vitamins
So, I’ll say it again: There is no nutritional value to apple cider vinegar. Therefore, the proposed mechanisms in which apple cider vinegar is claimed to work are completely inaccurate. Something can't work via pectin if there isn't any darn pectin in it.
I mean, apples themselves have all of that stuff. They have potassium, calcium, fiber, pectin, some amino acids and more. Eating apples is a healthy choice. Vinegar made from apples will not contain any of those healthy things and therefore cannot have any of those health benefits.
Even if you get the unpasteurized and unfiltered stuff with the MOTHER still present, you’re not adding much nutritional value at all. You’ll get a lil’ bit extra bacteria and some sugars with a teensy bit of fiber via cellulose. Those doses will be nowhere near significant, still.
There’s got to be some OTHER mechanism, then, for apple cider vinegar to have all its curative properties, right?
“Yes,” says the over-confident Vinaigrette Supreme. “It’s because apple cider vinegar restores the body’s proper pH and stabilizes the alkaline-acid balance in the body.”
The Acid/Alkaline Discussion (Again)
There are many in the natural products world that will say many of our diseases comes from an imbalance of the body’s pH, or acidity and alkalinity. We eat too many acidic foods, and that acidity causes disease, they say. We need a more alkaline diet, and you should test yourself via pH strips to ensure you are moving in the right direction.
Like all theories, we’ve discussed this one at length (HAVE WE?). Here’s the simple version: You can’t change your pH.
Here's the slightly longer version:
1. There isn’t one “pH of the body.”
Check out our awesome graphic:
2. You can't change your pH.
If we eat something - acidic or alkaline - it enters the pit of acid that is our stomach. There’s no getting over that, it’s instantly turned into an acidic pH. We can reduce the amount of acid in the stomach via antacids, but we never really get it to a point where the stomach is neutral. That would be bad - bacteria would grow everywhere. As the food moves through the GI tract, the pH will change multiple times.
Even though it is not physically possible to alter the pH of the gut significantly, acid/alkaline folks will say that the absorbed nutrients will continue their rippling effect of amazing health benefits and change the pH of the blood.
This is the most wrong thing anyone can ever say. More melodrama, but it's for realz.
Listen close: anyone who says that the pH of the blood can be modified from its extremely narrow range (7.3-7.5) lacks a basic understanding of human biology. Our body’s almost sole purpose - what all of the cells are doing - are attempting to maintain a normal pH in the blood. If we were able to modify it, even to go to 7.6, it would be a real issue and we could end up in the hospital quickly.
The pH of the urine and spit are the only things that really can be altered. Urine pH is normally 6, but swings from 4.5 to 8 based on what we eat. Even then, It’s only when the pH is outside of 5 or 8 that we consider the urine acidic or basic.
The thing is, the pH of spit and urine will change based on what you ate *in the last 12 hours. Eat a tomato, you go acidic in the urine or spit. Have some aspirin, same deal. In fact, if we have aspirin toxicity, we’ll give someone a bunch of bicarb (basic) and that will make the aspirin leave the body sooner.
You can’t change your pH, except slightly in the upper GI tract and widely (but not clinically significantly) in the urine and spit.
3. Measurement of your 'pH,' then, is silly.
You also are not a jacuzzi tub, so keep the pH strips for that and that alone. You can’t measure your overall pH. You’d have to measure at different access points, usually the urine or your spit.
And those are unreliable and based solely on what we most recently ate.
If someone asks to purchase those pH test strips from us, instead of selling them something (I could have made thousands off this alone if I lacked integrity), I will direct them to a local pool store. This, I hope, gently awakens them to the idea that it’s a bit silly.
This isn't me spitballing or some medical conspiracy. Literally everything is broken if this weren't true. Altering pH is as close as "flat earth" in biology as you can get.
Even so, let's ask the real question...
Does Apple Cider Vinegar Affect Body pH?
No. Apple cider vinegar will not change the pH of the GI tract or “the body.” There is no such thing as “body pH” and thankfully for our lifespans we really can’t impact the pH of important things like the blood.
I've beaten this dead, alkaline, scientifically inaccurate horse enough.
There is an additional layer to the silliness of apple cider vinegar altering pH that we should discuss. It's bass ackwards.
Vinegar is acidic as I stressed ominously before. pH advocates say we need less acid and more alkaline. So they recommend you use vinegar, A GOSH DARN ACID, to accomplish this. What?!?
They've got an answer for that slight discrepancy: this acid "releases" alkaline much like the Baha Men let the dogs out in the early 2000s.
They'll tell you ingesting this acid will help with ACID reflux. HUH?!?!?
Vinaigrettes were missing a few days in 10th grade chemistry.
The pH, in fact, is the cause for all the side effects of apple cider vinegar. I hope you're not surprised it can cause harm... It's not like apple cider vinegar is all rainbows and butterflies. It carries risks like almost everything. I mean, it's vinegar.
Adverse Effects of Apple Cider Vinegar
Oh, how the Vinaigrettes love to forget to mention those side effects as they wax poetic. There are risks with apple cider vinegar, established to a much higher degree than any of the "studies" on it "working."
Here are those side effects of apple cider vinegar:
- Regular use will damage tooth enamel
- Daily use or using an undiluted product will damage the esophagus
- A decrease in bone density
- A decrease in potassium levels
Imagine for a moment the doctor wants you to use a medicine that will reduce your risk of a heart attack significantly. The side effects, though, are the 4 I mentioned above. How many blog articles would be written about how dangerous that product is? What's the real likelihood the drug would be even recommended by a professional if the benefit wasn't REALLY big?
We can't get people to use many meds because of the "risks." We are quick to downplay the downsides of natural products while amplifying the downsides of traditional medications.
All I want from Vinaigrettes and consumers alike is consistency. I'm all for anyone wanting to try natural options. We have to apply the same distrust of Big Pharma to Big Supplements, because they are the same. We have to apply the same guarded approach and hesitancy to new supplements as we do with medications, because quite often supplements are worse or even dangerous. And we shouldn't take something so risky unless there is a significant benefit, not just because we read about it informally or "heard someone say" it's good.
Who Recommends Apple Cider Vinegar?
Let's start with who DOESN'T recommend apple cider vinegar to prevent or treat disease: almost everyone in the medical community.
Apple cider vinegar is regarded as a goofy thing. Anyone who took a year of college chemistry and a semester of anatomy would go, "Huh?" when you tell them vinegar will do all of these healthy things. Most professionals would instantly think of all the possible side effects of regular, high dose consumption of vinegar that we covered above.
The FDA has issued numerous warning letters to sites and product manufacturers for claims that apple cider vinegar does anything.
Even the National Center for Complementary and Alternative Medicine (NCCAM), a division of the National Institutes of Health specifically tasked to investigate natural or unconventional modalities, has found no studies to support vinegar. And these guys are advocates of supplements.
Most of this comes from a gent named D.C. Jarvis, a Vermont doctor who wrote a book on folk medicine. He believed apple cider vinegar would do all those things we covered before and was the originator of spreading this misinformation. His “Honegar” product - a mixture of honey and vinegar - was seized by the FDA along with copies of his book because of the claims.
I mean, folk music is fine, but we’ve evolved to understand medicine much better. Heck we don’t use medicine that was invented in the 80s at times because we’ve learned so much. Why promote something that’s a couple thousand years old, especially because we know so much about it?
"I really believe it works," the modern D.C. Jarvis’s state preemptively on their blog. This isn't the Tooth Fairy. Either it works or it doesn't. They don't take their stand for noble causes. If you have integrity, you ask the tough questions. When you do so with apple cider vinegar, it all falls apart.
It’s one thing for a consumer to want to try a natural product they’ve heard works from other people. It’s a whole other, really messed up situation that the origin of a lot of this are fake experts who actively ignore not just the data, but basic scientific realities.
They have no leg to stand on when they make these recommendations. The big problem for me is how they dress themselves up to fake credibility. They shun traditional medicine, but call themselves Dr. this or that, despite many of them not being real doctors. I have a doctorate, so should I call myself Dr. Neal or could that cause confusion to people who don’t know I’m just a pharmacist? They cite “evidence” and they are using the same vocabulary as the traditional establishment. It’s literally the oldest trick in the book: the appeal to authority.
All they have is folklore and anecdotes. I believe it is unethical to recommend something that has such a risk of harm, no realistic mechanism of action, no clinical evidence to support it, and an overwhelming consensus from health professionals that at best, apple cider vinegar won’t do anything, but at its worst could hurt you.
They do it for clicks. For attention. To sell a mindset. To position themselves as unique, possessing some hidden knowledge. In the end, the actions are for money.
Who Uses Apple Cider Vinegar
Despite all of the stuff above - the lack of a mechanism of action, poor study data, obvious bias, and a real risk of horrible adverse events - so many people use and swear by apple cider vinegar.
Just a cynical approach here based on modern America: if apple cider vinegar does all that wonderful stuff, wouldn't it get turned into a "Big Pharma" product, charge $2000 a month, and keep it off insurances?
Many of my patients ask me about it. When I tell them how I feel, they're confused. Even my own aunt - an extremely smart medical professional - uses it daily for reflux. She says it helps her better than anything else.
Here's a few anecdotes I received from my request above:
- I've been using apple cider vinegar for about 10 years now. It was recommended to me by someone, long forgotten, when I had an episode of reflux and my gastroenterologist recommended a series of medicines, all designed to lower the acidity in my stomach, blah, blah, blah.
I started trying, 1 tablespoon every morning, immediately followed by rinsing my teeth with water, to reduce the danger of acid etching my teeth. I also use it occasionally later in the day when I feel the onset of acid reflux. As far as I know, my esophagus is fine. I like not being on a medicine and I love the taste of the brand I use.
- Sorry to contradict as I am a fan and a client.. I have great success with ACV in reducing bloat and cutting stomach acid.. I am too much of a realist to call it placebo... I’ve done personal tests using it and not using it. It seems to balance my metabolism in some way and definitely my digestive system... maybe it doesn’t work for a million people ... but it works for me...
- I suffered HORRIBLY from chronic diarrhea after a lengthy course of IV antibiotics to treat my (equally horrible) Lyme disease. Actually, I was almost happy to settle for diarrhea in order to finally be rid of my Lyme symptoms.
Then I started taking a spoonful of ACV, mixed into 8 oz of warm water. I did this a few times a week. Within two or three months I had normal, regular bowel movements. Coincidence? Maybe. But I keep ACV on hand just in case “the trots” return.
- I stopped using shampoo years ago and my hair stop falling out. My hairdresser suggested that I dilute apple cider with water and use that every six months or so.
For several winters I suffered from a skin rash on my neck. And again on my abdomen.It would last most of the winter season. Very itcht and angry looking and I could not scratch it without it spreading. Again I went to a dermatologist and after several failed attempts of prescriptions I would both drink ACV and also apply it to the rash. Within a week it was gone for good for the season. I no longer get this winter itch.I also use it to disinfect my floors from bugs and fleas along with Murphy soap and essential oil mix. Keeps them down to a minimum if at all.I use it when I need to burn off some weight. If I take it at night and first thing in the morning and cut back on breads and sweets I drop a few pounds, more with it than without it.
It’s ok. I’m ok with a consumer saying “I like using it” or “I want to try it.”
I’m going to nudge back, as I do. All I want to know is, “Why?”
Like I said in the flu shot article, you’re all adults and can do as you please. I just want to make sure we are being responsible because it seems as if everyone’s going against your best interests.
If you hear about apple cider vinegar from a talking head, you’ll want to do your research. Just scrolling through the search results will make you think this is something you’ll want to do. Other talking heads are telling you to do it and promoting all the health benefits. If you’re NOT using apple cider vinegar, I don’t believe you should start. I’ve made that case.
If you’re using apple cider vinegar, let’s reevaluate. Again, why? Do you feel a noticeable difference? Is this really something that would be the best option for you? Have you considered the potential real downsides? Could you experiment with some time off - 2 weeks - and see what happens?
At the end of it, just make sure you are using a quality product, understanding there are many with flaws.
Which brings us to the next important point...
Apple Cider Vinegar Product Concerns
We've talked extensively about apple cider vinegar *the ingredient.* It's important that in our minds when we discuss any natural products, we MUST separate the products we can buy from the active ingredients we talk about.
What do I mean? Here's a few examples outside the vinegar world:
- Omega-3 fatty acids being so beneficial, yet most Fish Oil products are rancid, low dose, and overpriced
- Probiotics are beneficial to gut health but many probiotic products are mislabelled, contaminated, and have no ability to even colonize the gut.
- Turmeric has potent anti-inflammatory effects yet it is one of the most adulterated products on the market.
The old adage from me stands: Just because a product says "Apple Cider Vinegar" on the label, does not mean you are getting the best version of the product - the one that (if possible) would do anything for your health and wellness. As we discussed previously, you could be getting the mediocre middle apple cider vinegar, or worse, the dangerous bottom feeder.
Over the years there has been numerous analysis of apple cider vinegar products, and surprise surprise, they're a mess. Considerable variability was found between the brands in pH, component acid content, and label claims.
ConsumerLab recently did a review on a few brands. The liquids were good, but the capsules and tabs were a hot mess. The amount of actual acetic acid varied from 2mg to 20mg per capsule, while liquids would have about 8-900mg of acetic acid per tablespoonful. That’s a big difference, so we have to pay attention to the dose, not just the label. Avoid tablets or capsules if you can, unless you want to get a really small dose of acetic acid.
As for what brands are good, you should look for something that tastes good from a reputable vinegar company. Besides acetic acid content (should be about 5%), taste is a big concern. I don’t really have a dog in this fight, as I would tell you that as apple cider vinegar is best as a food product, not a supplement. So go with what tastes best to you!
The Birds, Bees, and Supplements
I liken supplement use to the birds and the bees talk I’m going to have to give my kids in the near future. As an aside, if you haven’t seen them, feel free to friend me on Facebook!
No matter what I tell my kids about the birds and bees - the facts, figures, advice, experience, guidance - they’re going to do what they want.
There are some extravagant claims out there about apple cider vinegar: curing diabetes and cancer, lowering cholesterol and preventing heart disease, reducing weight, treating warts, and even making your hair, skin, and nails shine.
The thing is, it doesn't. It's just vinegar made from apple juice. It's physically impossible to even have those effects in people. The "evidence" is super small, and any positive signs only indicate a larger trial is needed.
On top of that, there's a real risk of getting a bad product. Apple cider vinegar carries real risks.
For the Vinaigrettes, I shake my finger at you. For what that’s worth. I would hope that people would be more responsible in the advice they give people. I don’t want my kids to hear incorrect information, and there are too many “cool kids” telling people what they want to hear.
But, after all of this, some people are going to use apple cider vinegar. To believe what they hear. Some people have been using apple cider vinegar for awhile.
It’s ok to experiment. Just make sure you do so with a brand you really care about. One you have a relationship with. And please, be careful. Use protection? I don’t know, this joke is going too far.
You get the point. See you next time.
Just trying to keep it real,
Neal Smoller, PharmD
Owner, Pharmacist, Big Mouth