Issue #79 (May 2021)

Issue #79 May 2021
Table of Contents
Mini: Sports nutrition tips for active women
We provide some of the big-picture takeaways from a recent narrative review covering
nutritional strategies for active women.
Nulls: January-February 2021

Get a quick rundown of recent studies that found no evidence for an effect in the latest
installment of Nulls!
A modified keto diet may slow some declines associated with Alzheimer’s disease
This recent trial found that a keto diet helped people with mild Alzheimer's disease perform
activities of daily living while improving their quality of life.
Deeper Dive: Cinnamon may improve biomarkers of metabolic diseases

This meta-analysis found cinnamon supplementation can improve lipid levels, blood
pressure, glycemic control, and waist circumference in adults with metabolic diseases.
While these results are promising, there are still quite a few open questions.
Deeper Dive: A spoonful of vinegar might make blood sugar go down

Acetic acid may help with glycemic control while lowering triglycerides, but the studies
included in this meta-analysis had a high risk of bias.
Deeper Dive: Flavonoids may slightly speed up recovery from muscle-damaging exercise
According to this recent meta-analysis, flavonoid-containing polyphenolic supplements can
slightly improve muscle soreness and strength after a single bout of heavy exercise.
Investigating the efficacy of protein supplementation for older people with and without
resistance training
This randomized controlled trial found that protein supplementation needs to be paired with
heavier resistance training to help keep older people's muscles healthy.
Betaine supplementation: a double-edged sword for CVD markers

This meta-analysis suggested that betaine doses under 4 grams daily can lower
homocysteine without necessarily raising LDL-C, but there's still a lot of uncertainty.
2
From the Editor
We all have our biases, and one article in this issue helped me correct one of mine.
Before I read the meta-analysis on supplementation for exercise-induced muscle damage that we
cover in this issue, I wasn’t a fan of Montmorency tart cherry supplementation. Not because it didn’t
work for me. And not because I’m not sure if I pronounce “Montmorency” correctly, since I read it
more often than I say it (#editorlife). Instead, I wasn’t a fan because the trials I read on the topic
had similar flaws that rubbed me the wrong way.
The trials I’ve read on Montmorency tart cherry supplementation had almost universally small
sample sizes and measured many variables. Some of those variables reached statistical
significance, and some didn’t. But the articles tended to focus on the variables that passed the
magic 0.05 threshold for statistical significance. In short: the analyses mostly reeked of p-hacking.
On top of this, a few of these studies were funded by supplement companies, which may have
influenced the positive spin being put on the limited evidence.
So, none of these articles on their own convinced me that there was much to tart cherry
supplementation. But a whole lot of “not much” can add up to something. That’s the point of meta-
analysis: a bunch of weak signals can be averaged together to get a better picture. And that’s what
the meta-analysis we cover in this volume provided for me. Synthesizing the evidence of the effects
of flavonoid-containing polyphenolic supplements on muscle recovery convinced me that there
might be something to supplementing tart cherry.
Of course, not all the supplements investigated in the meta-analysis were derived from tart
cherries, but most of them were. Plus, the authors emphasized that future research needs to dig
deeper into the specifics of which polyphenols may have the biggest impact. This is particularly
important given the small effect sizes they found, which could plausibly be an average of some
components that have larger effect sizes being combined with those that have close to none. I also
have some other concerns, like the authors using the more forgiving PEDro scale to assess the risk
of bias and the lack of exploration about the role of their funding source. Plus, the meta-analysis’s
scope is limited only to supplementing around a single muscle-damaging exercise event, not
consistent supplementation over time.
But even with these concerns, this article helped change my mind.
3
Gregory Lopez, MA, PharmD
Editor-in-chief, Study Deep Dives
4
Mini: Sports nutrition tips for active
women
 Tags: Womens Health
 Read this article online at Examine.com
Women are increasingly engaged in sports and recreational exercise, which has raised awareness
about the effects of sex hormones on performance[1] and nutrition[2]. This has led to more research
into nutritional strategies for active and athletic women, which has been recently summarized in an
open-access narrative review.
The main points are covered below. This Mini skims over some of the finer details of the discussion
and doesn’t examine the physiological mechanisms that differ between men and women, but since
the review is open-access, you can read it in its entirety if you’re interested and start a discussion
in the private Facebook forum.
Please note that narrative reviews have no predetermined research question or systematic search
strategy. Rather, they generally explore the current evidence on a topic of interest.
Key point 1: The menstrual cycle correlates with changes in macronutrient metabolism
Hormones fluctuate throughout the menstrual cycle, which corresponds with changing calorie and
macronutrient needs. For example, during the luteal phase, protein and fat oxidation may be
higher, which can be accompanied by an increase in appetite. The basics of these changes are
laid out in Figure 1.
Figure 1: How the menstrual cycle corresponds to

macronutrient metabolism
5
Key point 2: Active women have specific macronutrient needs, which can depend on the
menstrual cycle
Macronutrient needs may differ depending on the phase of the menstrual cycle. The following are
some recommendations and sport-specific nutritional strategies that take female hormonal
fluctuations into account.
Figure 2: Main macronutrient suggestions for active

women
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Key point 3: Tips to optimize energy availability for active women
Under-consuming calories can lead to a deficit in energy availability (EA), which is calculated as:
(total energy consumed - energy expended during exercise) ÷ kilograms of fat-free mass = EA.
Optimal EA is necessary to maximize performance and to maintain a normal menstrual cycle.
Maintaining a normal menstrual cycle is critical to protect bone density. To ensure optimal EA,
active women should aim to consume enough food to have an EA of 40–45 kcal per kilogram of
fat-free mass per day. A specific example taking these principles into account is laid out in Figure
3.
Figure 3: Energy availability example
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Key point 4: Select supplements have evidence supporting their efficacy in women
Supplements can be helpful for maximizing health and performance, but most supplements have
been mostly studied in male participant populations. The following dietary supplements have been
studied in women and support improvements in various health, body composition, and performance
outcomes.
8
Figure 4: An overview of key supplements that have
been studied in women
Supplement Purpose Dose
Beta-alanine • Enhances exercise • 4–6 grams/day in 1–2 gram

performance divided doses for 4 weeks
• Reduces muscle acidity • Muscle carnosine levels may be

during high intensity increased more when using a
exercise slow-releasing supplement
• Reduces fatigue
• Optimizes post-exercise
recovery
Caffeine • Increases athletic Doses of 3–9 mg/kg of body weight result

performance in ergogenic effects when consumed 60
minutes before exercise
• Spares glycogen by
increasing fat metabolism
• Decreases pain
perception
Calcium • Vital for muscle 1,000 mg/day

contraction and relaxation
• Helpful for bone density
Creatine • Enhances exercise 0.3g/kg of body weight 4 times a day for

Monohydrate performance 5–7 days for a “loading phase,” followed
by a “maintenance” phase of 5 grams per
• Decreases injury risk
day
• Enhances rehabilitation
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• Decreases disease risk in

young, middle aged, and
older people
• Increases fat free mass
• Effective during menses,

pregnancy, and
postpartum (regulates
mood and decreases
depression)
• Beneficial for mental

health
• Beneficial for bone health
• Neuroprotective
Folate Decreases the chance of anemia 400 ug/day
Iron Decreases the chance of anemia 18 mg/day
Omega-3 • Anti-inflammatory Supplement 1–3 grams per day to

experience the benefits of omega-3s
• Decreases the overall risk
of disease
• Plays a vital role in growth

and development
• Improves immune function
• Decreases depression
Probiotics • Regulates immune and • Consuming a multistrain probiotic

digestive functions may be the most efficient way to
experience a benefit
• Regulates the urogenital
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tract • Probiotics taken daily should

include 10–20 billion colony
• Promotes skin health
forming units (CFU)
• Reduces inflammation
Riboflavin • Supports skin health • 1.1 mg/day

(vitamin B2)
• Regulates endocrine • 1.6 mg per 1,000 calories (if
function exercising or lactating)
Vitamin B12 Decreases the chance of anemia 2.4 ug/day
Vitamin D3 Promotes bone health 2,000–4,000 IU is safe and beneficial
Whey • Improves body 20–30 gram boluses throughout the day

Protein composition can help attain the recommended 1.6g/
kg/day for active women
• Increases bone mineral
density
• Important for muscle

protein synthesis
• Increases time to
exhaustion during
exercise
• Improves recovery
^ Go back to table of contents
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 References
1. ^ Tanja Oosthuyse, Andrew N Bosch. The effect of the menstrual cycle on exercise
metabolism: implications for exercise performance in eumenorrhoeic women. Sports
Med. (2010)
2. ^ Melissa J Benton, Andrea M Hutchins, J Jay Dawes. Effect of menstrual cycle on
resting metabolism: A systematic review and meta-analysis. PLoS One. (2020)
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Nulls: January-February 2021
 Tags: Nulls
Here’s a very quick summary of some randomized controlled trials (RCTs) and meta-analyses of
RCTs that were published in January or February 2021 and didn’t find evidence of an effect. This
is known as a null effect.
Keep the following in mind when interpreting a null effect:
• While one study can provide evidence that something doesn’t work, it doesn’t prove it.
Similar, repeatable results from multiple studies make for stronger evidence, whether the
finding is positive or negative.
• Not all null effects are the same. A meta-analysis of low-quality studies or a small clinical
trial usually won’t provide strong evidence, whether the finding is positive or negative.
• The population matters. For instance, the lack of an effect in healthy young people doesn’t
necessarily mean that an intervention wouldn’t work in people who are older and have a
specific health condition.
Cardiovascular disease
Fish oil found to do little to prevent further cardiovascular problems after a heart attack[1]
• What was studied? Whether adding fish oil (930 mg of EPA and 660 mg of DHA daily over
two years) to standard care two to eight weeks after a heart attack could prevent further
negative cardiovascular outcomes in people over 70 years old.
• Why study it? There’s reasons to suspect omega-3 supplementation could prevent
cardiovascular disease, but its follow-up use after a heart attack hasn’t been well studied.
• What was(n’t) found? Supplementation did not significantly affect the composite primary
outcome of death, another heart attack, stroke, unscheduled revascularization, or
hospitalization due to heart failure. None of these individual outcomes look to have been
affected, either.
• How null was it? Somewhat. On the one hand, this was a well-designed, long term trial
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with over a thousand participants. On the other hand, the trial wound up being
underpowered due to negative outcomes being less frequent than expected. Thus, this trial
is evidence against huge effects, but doesn’t necessarily rule out more moderately-sized
benefits.
• Anything else? This study adds to other recent evidence that fish oil may increase the risk
of new-onset atrial fibrillation, in that people in the fish oil group tended to have higher rates
of atrial fibrillation compared to the control group. On the plus side, this study didn’t find any
evidence of increased bleeding risk in the fish oil group.
Diabetes & blood sugar

Chlorella had little effect on metabolic measures in people with type 2 diabetes[2]
• What was studied? Researchers investigated how 1,500 mg of daily chlorella for eight
weeks affected glycemic control measures, blood pressure, food intake, and more in people
with type 2 diabetes.
• Why study it? Chlorella is a single-celled green algae. It’s packed full of potentially
beneficial micronutrients, and evidence in mice and human studies in people with
nonalcoholic fatty liver disease suggests that it can help with glycemic control. However, it
hasn’t been tested in people with type 2 diabetes before.
• What was(n’t) found? No effects were found for the primary outcome, HbA1c, or any other
metric, including blood lipids, body weight, blood pressure, and more.
• How null was it? The study was designed to detect a 0.5% change in HbA1c, so the
evidence is against there being clinically relevant effects for this metric. However, the
population had relatively well-controlled diabetes and the study length was short. This
leaves open the possibility that effects could be seen in longer trials with people with less
well-controlled diabetes, perhaps at higher doses.
Fat loss
VITAL trial offshoot finds little evidence that vitamin D supplementation influences body
composition[3]
• What was studied? Researchers evaluated how 2,000 IU of daily vitamin D affected body
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composition over the course of two years.
• Why study it? Observational studies suggest that vitamin D is associated with body
composition, but whether this link is causal or not is open to question.
• What was(n’t) found? There was no clear effect of vitamin D supplementation on any
metric of body composition measured, including weight, waist circumference, and fat mass.
• How null was it? This was a secondary analysis of a smaller sub-study of the main VITAL
trial, so these results shouldn’t be taken as definitive. Also, this substudy had an average
participant age over 60, so the results may not extend to younger populations.
• Anything else? Subgroup analyses hinted that vitamin D supplementation could improve
body fat percentage in people with a BMI of less than 25. However, the signal for this effect
wasn’t very strong, and requires further follow-up.
Vitamin E supplementation does not seem to affect weight of waist circumference[4]
• What was studied? Researchers meta-analyzed randomized controlled trials using vitamin
E supplementation that measured body weight, BMI, or waist circumference.
• Why study it? There are a few mechanistic reasons to suspect vitamin E could have some
effect on weight. For instance, one form of vitamin E, alpha-tocopherol, may boost
adiponectin expression, which could ultimately lead to more fat being burned. More
generally, vitamin E could reduce certain inflammatory markers linked to obesiy like IL-6
and TNF-alpha. However, evidence from clinical trials is mixed, suggesting that a meta-
analysis could help clarify the situation.
• What was(n’t) found? No statistically significant effect on weight, BMI, or waist

circumference was found.
• How null was it? Pretty null. The confidence intervals suggest that the evidence isn’t
compatible with clinically significant changes in any of the parameters. Also, the
heterogeneity was very low, although there was some risk of bias detected in key areas in
some of the included studies.
Herbal supplements
A specific Ayurvedic herbal combination had no clear effect on metabolic markers in people with
impaired glycemic control[5]
• What was studied? Researchers evaluated whether Mohana Choorna, a 20-herb
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combination used in Ayurvedic medicine for type 2 diabetes, affected metabolic markers in
people with impaired glucose tolerance.
• Why study it? This herbal combination is used to treat or prevent type 2 diabetes in
Ayurvedic medicine, and there’s some animal and test tube evidence suggesting that
certain herbs in the combination could exert the desired effect. However, there is little
clinical evidence supporting this mixture.
• What was(n’t) found? Researchers concluded that 500 mg of Mohana Choorna taken
three times per day for four weeks had no statistically significant effect on any metric of
glycemic control, blood lipids, or blood pressure.
• How null was it? A power calculation wasn’t performed, making it difficult to interpret the
null results found here. However, the study did use a crossover design involving 22
participants, which is a decent sample size.
• Anything else? There was some evidence suggesting that Mohana Choorna may raise
fasting insulin and inflammatory gene expression in fat tissue, raising possible concerns
about the safety of the herbal mixture. However, this data was only suggestive, and
requires further follow-up.
Infants, children & teenagers

Maternal iodine supplementation during pregnancy may not affect child’s growth or
neurodevelopment[6]
• What was studied? This meta-analysis was designed to evaluate whether clinical trials
involving women supplementing iodine during pregnancy found any effect on the growth or
neurodevelopment of their children.
• Why study it? Iodine is necessary for proper growth and brain development, and maternal
supplementation of iodine increases during pregnancy. This has led the American Academy
of Pediatrics and the Endocrine Society to recommend that women who are or plan to be
pregnant supplement with 150 micrograms of iodine daily. However, randomized trial
results exploring iodine’s efficacy have been mixed.
• What was(n’t) found? Meta-analyzing five trials found that maternal iodine
supplementation had no clear effect on childrens’ growth or neurodevelopment up to age 2.
• How null was it? There’s a lot of room for more data for three reasons. First, the mothers
in the studies tended to be mildly iodine deficient at best, suggesting that benefit could be
seen in more iodine-deficient populations. Second, the iodine supplementation tended to
16
start rather late in pregnancy, leaving room open for the possibility of early supplementation
having a stronger effect. Finally, there weren’t very many studies exploring the issue,
leaving a lot of room for uncertainty.
Muscle gain & exercise

Creatine may not help much with short-term recovery from exercised-induced muscle damage[7]
• What was studied? Researchers meta-analyzed randomized controlled trials to determine

whether creatine supplementation can help muscles recover from exercise-induced muscle
damage.
• Why study it? There are theoretical reasons for thinking that creatine may help with
muscle recovery in the short term. The clinical trial results, however, have been mixed, and
this evidence has not been meta-analyzed previously.
• What was(n’t) found? Creatine supplementation had no clear effect on muscle strength,
soreness, or muscle damage markers up to 96 hours post-exercise. There was one
exception: creatine kinase was lower 48 hours post-exercise in people taking creatine, but
this could have just been a statistical blip.
• How null was it? While the quality of the studies covered tended to be good, there weren’t
very many studies and they were all small: only 13 studies were found, including a total of
just 278 participants. Also, these studies had different dosing regimens, different
populations ranging from untrained to athlete, and different methods for inducing muscle
damage. Thus, averaging all these studies together may not mean much. Larger studies
looking at specific populations would be useful before ruling out creatine’s short-term
effects on exercise-induced muscle damage entirely.
Outside the box

Grape powder failed to blunt after-meal spikes in blood glucose and lipids in people with obesity[8]
• What was studied? Researchers evaluated whether 46 grams of grape powder (equivalent
to 252 grams of fresh grapes) served at breakfast affected post-meal blood glucose and
triglyceride levels after high-fat, high-sugar breakfasts and lunch in people with obesity (BMI
between 30 and 40).
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• Why study it? Big spikes in blood sugar and triglycerides after a meal both predict
cardiovascular disease risk. Polyphenols found in grapes have been found to mitigate these
spikes. However, most of the research has focused on single-meal responses after
breakfast. The authors aimed to extend this timeframe by monitoring blood triglycerides and
glucose after both breakfast and lunch.
• What was(n’t) found? There were no clear differences between the placebo and grape
powder groups in glucose, nor in any other parameter measured.
• How null was it? Pretty null, for this dose. The study was powered to detect a pretty
modest difference of about 3.2 mg/dL in blood glucose between the two groups after lunch,
so this is decent evidence that there may not be much of an effect. However, there was
also no difference in plasma antioxidant between the groups. This is surprising, since the
grape polyphenols should have boosted this parameter. This finding strongly suggests that
the dose used in this study was too low, and underscores the need for further studies that
use higher doses of polyphenols.
Pain, joints & bones

A combination of four promising supplements had little effect on hand osteoarthritis pain[9]
• What was studied? This study was designed to determine whether a combination of 250
mg of Boswellia serrata extract, 100 mg of pine bark extract, 1,500 mg of
methylsulfonylmethane (MSM), and 168 mg of curcumin daily for 12 weeks could improve
hand pain in people with hand osteoarthritis.
• Why study it? These four supplements were found to be promising from a systematic
review conducted by the authors of this trial. However, their systematic review also raised
some concerns about past study quality and most of the evidence focused on knee
osteoarthritis, so they decided to run their own trial to determine if a combination of these
promising supplements would work for hand arthritis.
• What was(n’t) found? No clear reduction of hand pain (the primary outcome) in the
treatment group compared to placebo was found.
• How null was it? This study was done completely over the internet, so important metrics
like compliance were self-reported, which could have skewed the results. Also, the lowest
doses with some evidence of efficacy were chosen for some of the supplements to reduce
pill burden and complexity, raising the possibility of higher doses yielding better results.
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Vitamins & minerals
Mendelian randomization study finds that vitamin D doesn’t play much of a role in a host of
diseases[10]
• What was studied? The authors intended to determine the effects vitamin D levels have
on a large range of diseases and biomarkers through a Mendelian randomization study.
• Why study it? Vitamin D receptors are spread throughout most tissues in the body,
suggesting that vitamin D could affect a wide range of disease states. Furthermore,
observational studies have found strong associations between vitamin D, disease risk, and
a variety of biomarkers. However, whether these associations are causal is still unclear.
• What was(n’t) found? There was no evidence that vitamin had a causal effect on most
biomarkers and disease states studied, ranging from obesity to cognitive function,
cardiovascular disease, and cancer.
• How null was it? Wide confidence intervals for some metrics leave room for more
evidence, and it’s possible that the effects of interventional trials could differ from those
seen in Mendelian randomization studies.
• Anything else? One notable exception to the lack of effect was evidence suggesting a
causal role of vitamin D in multiple sclerosis.
Vitamin C and zinc failed to clearly speed up recovery for people with COVID-19[11]
• What was studied? Researchers evaluated whether 8 grams of vitamin C, 50 mg of zinc

gluconate, or both, helped reduce the number of days it took for COVID-19 symptoms to
halve in outpatients.
• Why study it? Both zinc and vitamin C may have some utility in mitigating respiratory tract
infection symptoms and improving recovery. However, their efficacy in the context of
COVID-19 specifically is unclear.
• What was(n’t) found? The trial was stopped early due to a low probability of finding an
effect.
• How null was it? The trial participants knew what they were receiving and there was no
placebo control. This, combined with the fact that symptoms were self-reported, could have
influenced outcomes. Also, the dosing of zinc may have been suboptimal.
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 References
1. ^ Are Annesønn Kalstad, et al. Effects of n-3 Fatty Acid Supplements in Elderly
Patients After Myocardial Infarction: A Randomized, Controlled Trial. Circulation.
(2021)
2. ^ Amir Mehdi Hosseini, et al. The effects of Chlorella supplementation on glycemic
control, lipid profile and anthropometric measures on patients with type 2 diabetes
mellitus. Eur J Nutr. (2021)
3. ^ Sharon H Chou, et al. Effects of Vitamin D3 Supplementation on Body Composition
in the VITamin D and OmegA-3 TriaL (VITAL). J Clin Endocrinol Metab. (2021)
4. ^ Mohammad Reza Emami, et al. Can vitamin E supplementation affect obesity
indices? A systematic review and meta-analysis of twenty-four randomized controlled
trials. Clin Nutr. (2021)
5. ^ Diederik Esser, et al. Ayurvedic Herbal Preparation Supplementation Does Not
Improve Metabolic Health in Impaired Glucose Tolerance Subjects; Observations from
a Randomised Placebo Controlled Trial. Nutrients. (2021)
6. ^ Pantea Nazeri, Mamak Shariat, Fereidoun Azizi. Effects of iodine supplementation
during pregnancy on pregnant women and their offspring: a systematic review and
meta-analysis of trials over the past 3 decades. Eur J Endocrinol. (2021)
7. ^ Bethany Northeast, Tom Clifford. The Effect of Creatine Supplementation on
Markers of Exercise-Induced Muscle Damage: A Systematic Review and Meta-
Analysis of Human Intervention Trials. Int J Sport Nutr Exerc Metab. (2021)
8. ^ Esther García-Díez, et al. Acute supplementation with grapes in obese subjects did
not affect postprandial metabolism: a randomized, double-blind, crossover clinical
trial. Eur J Nutr. (2021)
9. ^ X Liu, et al. Efficacy and safety of a supplement combination on hand pain among
people with symptomatic hand osteoarthritis an internet-based, randomised clinical
trial the RADIANT study. Osteoarthritis Cartilage. (2021)
10. ^ Xia Jiang, Tian Ge, Chia-Yen Chen. The causal role of circulating vitamin D
concentrations in human complex traits and diseases: a large-scale Mendelian
randomization study. Sci Rep. (2021)
11. ^ Suma Thomas, et al. Effect of High-Dose Zinc and Ascorbic Acid Supplementation
vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With
SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial. JAMA Netw
Open. (2021)
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A modified keto diet may slow some
declines associated with Alzheimer’s
disease
 Tags: Alzheimer's Disease, Keto Diet, Older Adults
 Study under review: Randomized crossover trial of a modified ketogenic diet in

Alzheimer's disease
Quick Takes
• What was the question? Can a modified ketogenic diet
affect cognition, daily function, and quality of life in people
with Alzheimer’s disease?
• How was it answered? Researchers conducted a
randomized crossover trial.
• Who was studied? People with mild Alzheimer’s disease
who had a partner at home willing to also participate in the
modified ketogenic diet made up the participant population.
• What was the intervention? Participants followed a
modified ketogenic diet plan consisting of 79% of calories
from fat, 17% from protein, and 4% from carbohydrates, or
their regular diet adapted to low-fat eating guidelines. Each
diet lasted 12 weeks, with a 10-week washout period before
the switch.
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• What's the main takeaway? Participants on the ketogenic
diet experienced an improvement in their ability to perform
activities of daily living and reported improved quality of life.
There was no clear impact on cognition, though.
• Any caveats? COVID-19 restriction measures that occurred
in the last five weeks of the trial may have affected cognition
results due to increased stress. Also, food intake was not
tracked, although ketosis was biochemically confirmed during
the keto diet, making it difficult to know whether the
participants followed the suggested low-fat eating guidelines.
What was the question?

Does a modified (less strict) ketogenic diet affect cognition, daily function, and quality of life of
people with Alzheimer’s disease?
Why was the question worth asking?

Alzheimer’s disease is a progressive, irreversible neurodegenerative disease that results in
impaired cognition, decreased ability to care for oneself, and ultimately death due to
complications[1]. Alzheimer’s disease has no cure, no elucidated cause, and treatment options only
delay the worsening of symptoms. It affects 17% of people age 75–84, and 32% of people age 85
and older[2]. Driven by an increase in life expectancy in industrialized countries, the absolute
prevalence of Alzheimer’s disease is increasing. When adjusted for age, however, prevalence
appears to be declining, most likely attributable to improved management of risk factors like
hypertension and smoking[2].
Characteristics of Alzheimer’s disease include dysregulated neuronal mitochondria, pathogenic

extracellular amyloid-β fragments[3], intracellular neurofibrillary tangles containing tau[4] protein[5],
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and altered brain metabolism, including inflammation, insulin resistance, and impaired glucose
utilization[6]. Type 2 diabetes[7] and epilepsy[8] are strong risk factors for Alzheimer’s disease[9], and
they share some metabolic traits, primarily related to glucose and glycogen metabolism. Epilepsy is
one of the diseases that can be treated with a ketogenic diet, which led to an initial wave of
attention to the diet a century ago[10], thus setting the theoretical groundwork for the metabolic
treatment of neurological disease. Type 2 diabetes is more recently emerging as a disease whose
symptoms may be treated with a ketogenic diet[11].
Previous research in animals[12] and humans[13] has indicated that ketosis could affect the signs[14]
(e.g. metabolic, mitochondrial, inflammatory) and symptoms (e.g. cognitive, physical) of
Alzheimer’s[15] disease[16]. Ketosis is a metabolic state in which the body predominantly relies on
ketone bodies derived from fat, rather than glucose, for fuel. Ketosis can be induced nutritionally by
eating a diet high in fat and very low in carbohydrates. A classical “strict” ketogenic diet is
composed of 90% of calories from fat, 6% from protein, and 4% from net carbohydrates[17].
Modified versions that allow for more carbohydrate (up to about 15% of calories) or protein (up to
about 30% of calories) and cause less extreme ketosis are called “modified ketogenic diets” and
are often used to alleviate the burden of such a strict diet. Other modifications include using oral
ketone body supplements (i.e. ketone salts), liberal use of medium-chain triglycerides (“MCT oil”),
and the addition of time restricted feeding. Each of these strategies to induce ketosis have been
studied in the context of Alzheimer’s disease[12][13], but nutritional ketosis with a ketogenic diet has
only been studied in three randomized controlled trials[18][19]. A 2020 meta-analysis including these
and other studies concluded that the efficacy of ketogenic therapies for symptoms of Alzheimer’s
disease appears promising[13] for cognitive symptoms, but not necessarily so for symptoms of
functional decline. However, differences in the means used to achieve ketosis, the diet
macronutrient composition, source population (i.e. confirmed vs. suspected Alzheimer’s disease),
duration, and study design make the results of these studies too heterogeneous to draw firm
conclusions.
The study under review is the longest and largest randomized controlled crossover study of a
ketogenic diet for Alzheimer’s disease to date, and likely the first to only include participants with an
Alzheimer’s disease diagnosis confirmed by NINCDS-ADRDA[20] criteria.
Alzheimer’s disease shares characteristics with other conditions

that involve metabolic and mitochondrial dysfunction and can be
positively influenced by a ketogenic diet. Previous research in
animals and small clinical trials in humans have confirmed that the
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ketogenic diet may have positive effects on mitochondrial function
and glucose metabolism of brain cells, but these studies suffer
from methodological shortcomings and heterogeneity. The present
study is a first for its size, duration, and rigorous inclusion of only
participants with confirmed Alzheimer’s disease.
How was the question answered?

This was a randomized controlled assessor-blinded crossover trial, meaning each of the 26
participants went through both interventions. The basics of the study design are laid out in Figure
1. The two treatments were a modified ketogenic diet and the participant’s usual diet with additional
low-fat diet resources. Participants adhered to their assigned diet for 12 weeks, followed by a
10-week washout period during which participants resumed their usual diet, and then finished the
trial with another 12-week treatment period on the other diet.
Figure 1: Study design
Participants were 57–79 years old (mean of 70), had an Alzheimer’s disease diagnosis confirmed
24
by NINCDS-ADRDA[20] criteria, and had a cohabiting partner that could help modify their diet.
Participants were excluded for depression, malnutrition, recent changes in blood pressure
medication, and cerebrovascular disease. The NINCDS-ADRDA[20] criteria are the most rigorous
and most validated assessment method for confirming an Alzheimer’s disease diagnosis outside of
biopsy or post-mortem examination of brain tissue. Participants were genotyped for apolipoprotein
E (APO-E) polymorphism, as this gene affects fatty acid transport through low-density lipoprotein
cholesterol and it is a strong predictor of cardiovascular disease and Alzheimer’s disease[21]. This
is relevant due to the increased fat intake and increased fat transport associated with the ketogenic
diet, as opposed to balanced or low-fat diets.
In the baseline diet, 37% of calories came from fat, 19% from protein, and 44% from carbohydrate.
The target macronutrient ratio for the modified ketogenic diet was 79% of calories from fat, 17%
from protein, and 4% from carbohydrates, representing a slightly higher protein content than a
traditional ketogenic diet. The calorie breakdown for the “optional” low-fat diet was 23% fat calories,
18% protein, and 59% carbohydrate. The keto group received healthy ketogenic recipes adapted
from ruled.me, a website for ketogenic diet resources, whereas the usual diet group received
optional low-fat recipes based on New Zealand’s low-fat healthy eating guidelines. Neither
participants nor their caregivers were provided with food for this study, and dietary adoption
support was limited to two emails and one pre-recorded video per week. Except for blood ketone
level measurements, dietary adherence was not evaluated.
Primary outcomes were the average changes in participant test scores on cognition as measured
by the Addenbrooke’s Cognitive Examination - III (ACE-III)[22], daily function and participation in
activities of daily living as measured by the Alzheimer’s Disease Cooperative Study—Activities of
Daily Living (ADCS-ADL) inventory[23], and quality of life as measured by the Quality of Life in
Alzheimer’s Disease (QOL-AD)[24] from baseline to week 12. Secondary outcomes were mean
within-individual changes in the following cardiometabolic risk factors: weight, body mass index
(BMI), percent glycated hemoglobin A1c (HbA1c), triglycerides, high-density lipoprotein cholesterol
(HDL-C), low-density lipoprotein cholesterol (LDL-C), and total cholesterol. Measures were taken at
baseline, at the midpoint of the study (6 weeks), and at the end of the intervention. Notably, New
Zealand closed its borders, called a State of National Emergency, and mandated self-isolation to
control COVID-19 during weeks 7 to 11 (the latter part of the second half) of the trial.
This randomized controlled crossover study involved a 12 week

diet intervention, followed by a 10 week wash-out period, and then
12 weeks on the other diet. Participants were assigned to either
their usual diet accompanied by low-fat diet resources or a
25
modified ketogenic diet. Researchers measured cognition, daily
function, quality of life, ketone levels and cardiometabolic markers.
This study adds to the mounting evidence base suggesting that,
although it is not a cure, a ketogenic diet could be a therapeutic
option for symptoms of Alzheimer’s disease.
What was the answer?

Compared to their habitual diet, participants on the ketogenic diet experienced an improvement in
their daily function (+3.13, out of 78 possible points) and quality of life (+3.37 points, out of 52
possible points). These results were statistically significant even though they had a large
uncertainty range. Although small, the size of these improvements are regarded as clinically
meaningful in drug intervention studies[25], and must also be understood in the context that
functional and cognitive decline, not maintenance, is expected in people with Alzheimer’s disease.
The small improvement in cognitive function test scores (+2.12 points, out of 100 possible points)
was not statistically significant.
In terms of cardiometabolic markers, the modified ketogenic diet resulted in lower blood glucose,
2.6 kg of mean weight loss (even though participants were instructed to eat to satiation), decreased
HbA1c, increased LDL, HDL, and total cholesterol and no significant change observed for
triglycerides. More details are laid out in Figure 2. Even though the participants in this study
regarded the average 5–6 pounds of weight loss as favorable, unintentional weight loss in
participants with Alzheimer’s disease may be a risk factor for mortality[26].
Figure 2: Timeline of statistically significant

improvements in keto group compared to optional low-
fat control
26
Of the 21 total participants, 18 sustained ketosis, defined as more than .6 mmol/L, with an average
level of 0.95 mmol/L. As the authors had expected, relative to other non-keto diet interventions, the
dropout rate during the ketogenic diet was high, at 19%. However, it’s important to note that only
one participant dropped out due to a side effect of the diet. In this case: diarrhea caused by eating
too much coconut oil at one time. The other five participants who dropped out declined to adhere to
the intervention. This dropout rate is on par with or better than that seen in comparable ketogenic
diet interventions[13].
A modified ketogenic diet resulted in clinically relevant and

statistically significant improvements in daily function and quality of
life relative to the same participant’s experience with their typical
diet with or without additional low-fat diet recommendations. The
data also suggests a positive trend for cognition, but this result
was not statistically significant. Various markers of cardiometabolic
health changed, most notable of which was 5–6 pounds of weight
loss.
27
How much should you trust the answer?
Although this might be considered a small study by most standards, it is the largest crossover trial
on the topic to date. After dropouts, the study retained 21 people, which is above the 18-participant
minimum needed to see a statistically significant result with a clinically meaningful change in the
primary outcomes, as calculated beforehand by the authors. Compared to other ketogenic diet
studies[13] with dropout rates in excess of 30%, the relatively low 20% dropout rate seen here is
likely due to the resources and continued support the caregivers and participants received.
The crossover design allows each participant to serve as their own control, which helps rule out the
influence of unmeasured variables that aren’t equally distributed in each treatment arm. However, a
cross-over design cannot compensate for any possible effects of New Zealand’s COVID-19-related
restrictions during the last five weeks of the trial. The increased stress due to the pandemic and the
lockdown, for example, could explain why the cognitive function test scores, which included
questions that assessed stress levels, decreased over this period in both groups, despite having
been previously trending up in the keto group. Adding validity to this argument is the suggestion in
previous research that cognitive decline precedes and predicts functional decline in Alzheimer’s
disease, and that the effect of treatments on cognition are more likely to be measured than effects
on functional measures[25]. The data suggests a positive effect on functional capacity, so the null
effect on cognition is unexpected. Previous studies have generally, though not unanimously, shown
that a ketogenic diet may have a positive effect on cognition in people[13] with Alzheimer’s. This
study cannot add or detract to that body of literature due the effect of the pandemic.
Food intake was not measured. Only circulating ketone body levels were used to assess
adherence, so it’s not known whether participants changed their usual diet to the recommended
low-fat eating pattern or stuck to their unmodified habitual diets. With 23% of calories coming from
fat, the latter was slightly higher in fat than common low-fat diets. The authors provided similar
amounts of passive support to both groups, but the control diet being “optional” and the
intervention diet being required resulted in two effects. First, the effects of the interventions were
asymmetric in intensity. Akin to the Hawthorne effect, defined as “behavioral change due to an
awareness of being observed[27],” participants receiving the added attention of their caregiver when
on a ketogenic diet may be responding positively to the added attention, in addition to the diet
itself. If caregivers didn’t make the optional low-fat changes in the participants’ usual diet, but did
make the changes for the ketogenic diet, then the data would not be able to tease out the
difference between changes due to the diet and changes due to the added attention.
Second, there are key pieces of data missing that would fully explain the findings. It’s not clear
whether people on a standard Western diet or people on a low-fat diet experience a decrease over
time in cognition and functionality. Similarly, it’s not clear whether it is the ketogenic diet or the
28
weight loss induced by a ketogenic diet that is responsible for the positive effects on cognition and
quality of life.
Finally, the authors’ knowledge of other research in this space was markedly limited. Although the
authors stated that only two trials (one open label, the other still in progress) had ever evaluated
the effect of a ketogenic diet on Alzheimer’s disease, multiple contemporaneous systematic
reviews have pointed to no less than three randomized controlled trials[19][18] on a ketogenic diet,
numerous additional RCTs[12][13] on ketone salt[16] and MCT[15] oil supplements to achieve ketosis,
and unnumbered open label trials. This is a concern in that the authors may not have been aware
of best practices for delivering a ketogenic diet to their participant population and may have had an
incomplete understanding on the mechanisms by which a ketogenic diet might exert its effects.
This study is the largest and longest randomized crossover trial on

this topic to date, and may be the first to include only participants
with a confirmed Alzheimer’s disease diagnosis. Thanks to the
study’s relatively low dropout rate for a keto study, the significance
of the results was not diminished, as is the case in other restrictive
diet studies. On the other hand, the major limitation was that the
control intervention was not well-controlled. The authors
themselves use the term “optional” to describe the low-fat diet
intervention. Though not a methodological limitation, the trial was
too small to look at secondary analyses and it’s not clear if the
benefits the participants experienced with the ketogenic diet was
due to their weight loss. In addition, measures intended to control
the spread of COVID-19 were implemented in the last five weeks
of the study, casting doubt on the observed lack of effect of the
ketogenic diet on cognitive tests.
29
What’s the take-home?
A modified whole-foods ketogenic diet consisting of about 80% of calories from fat may slightly
improve daily function and quality of life in people with an Alzheimer’s disease diagnosis confirmed
by NINCDS-ADRDA[20] criteria. The individual responses varied widely and the effect sizes were
rather small, suggesting that further work should elucidate which populations may experience the
greatest benefit from this kind of dietary intervention. Ultimately, this study adds some certainty that
a ketogenic diet may have a positive effect on functional symptoms and quality of life in people with
Alzheimer’s disease, but that certainty is undermined by the fact that the level of caregiver
involvement in each intervention was not balanced.
Does this article add to your knowledge of Alzheimer’s disease

and aging? See what other readers are saying at the private
Examine Members Facebook forum.
30
 References
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11. ^ Joshua Z Goldenberg, et al. Efficacy and safety of low and very low carbohydrate
diets for type 2 diabetes remission: systematic review and meta-analysis of published
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Systematic Review of Randomized Controlled Trials Assessing the Effects of
Ketogenic Therapy on Alzheimer Disease. Adv Nutr. (2020)
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15. ^ a b Konstantinos I Avgerinos, et al. Medium Chain Triglycerides induce mild ketosis
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16. ^ a b Lauren S Dewsbury, Chai K Lim, Genevieve Z Steiner. The Efficacy of
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18. ^ a b Jason Brandt, et al. Preliminary Report on the Feasibility and Efficacy of the
Modified Atkins Diet for Treatment of Mild Cognitive Impairment and Early Alzheimer's
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19. ^ a b Krikorian R, et al. Dietary ketosis enhances memory in mild cognitive
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20. ^ a b c d G McKhann, et al. Clinical diagnosis of Alzheimer's disease: report of the
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21. ^ Chia-Chen Liu, et al. Apolipoprotein E and Alzheimer disease: risk, mechanisms
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(2013)
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32
Deeper Dive: Cinnamon may improve
biomarkers of metabolic diseases
 Tags: Cinnamon, Meta-analysis, Metabolic Syndrome, Supplementation
 Study under review: The beneficial effects of cinnamon among patients with metabolic
diseases: A systematic review and dose-response meta-analysis of randomized-controlled
trials
Metabolic diseases[1] affect over a billion people worldwide, and the prevalence of metabolic
diseases has increased dramatically during the last decades. The costs and burden[2] to
governments and communities are tremendous, with diabetes accounting for a global cost of over
$1.3 trillion USD of global gross domestic product[3]. Lifestyle modifications such as a healthy diet,
physical activity, stress management, and pharmacotherapy are currently the most prevalent
interventions for treating metabolic diseases[4]. Since pharmacological interventions are often
accompanied by unwanted side effects, scientists have been exploring alternative treatment
options[5]. Plant-based therapeutics[6] such as cinnamon[7] have recently become more popular and
could be used as an alternative or complementary therapy to treat metabolic diseases.
Cinnamon is one of the most common flavorings worldwide and may also have potential health
benefits due to its high amounts of bioactive compounds[8]. In traditional medicine, cinnamon has
been used for centuries[8] as an antitussive, antiarthritic, antimicrobial, antifungal, anti-oxidant, and
anti-inflammatory agent[7]. The main bioactive components of cinnamon include cinnamaldehyde,
cinnamic acid, eugenol, and coumarin[9]. These compounds influence various biological pathways
and exert antimicrobial[10], anti-inflammatory[11], antioxidant[12], and anti-diabetic effects[13].
However, as shown in Figure 1, cinnamon species contain different amounts of these bioactive
compounds, most notably coumarin, which can be toxic in higher doses[14].
Figure 1: Some major bioactive compounds and their

amounts found in different cinnamon species
33
References: Wang et al. J Agric Food Chem. 2013 May.[15]
Zhu et al. Pharmacol Res. 2017 Aug.[16]
Doyle et al. Fitoterapia. 2019 Nov. [17]
Shreaz et al. Fitoterapia. 2016 Jul.[18]
Adisakwattana. Nutrients. 2017 Feb.[19]
De et al. Curr Med Chem. 2011.[20]
Anlar et al. Turk J Med Sci. 2018 Feb.[21]
Fujisawa et al. Adv Exp Med Biol. 2016.[22]
Barboza et al. Oxid Med Cell Longev. 2018 Oct.[23]
Shen et al. J Tradit Complement. Med. 2012. Jan.[24]
The two most widely used cinnamon species are Cinnamomum zeylanicum (typical baker’s or
Ceylon cinnamon, sometimes also called C. verum) and Cinnamomum cassia (Chinese cinnamon).
The two species differ significantly in their coumarin content. Since C. cassia contains high
amounts of coumarin[25] (7–18 mg of coumarin per teaspoon), consuming too much could exceed
the daily tolerable limit[26] of 0.1 mg of coumarin per kilogram of bodyweight. On the other hand,
Ceylon cinnamon has a lower coumarin content, which makes it appear safer at first glance.
However, C. cassiaalso contains higher amounts of other bioactive compounds, which could
explain why studies found higher anti-diabetic effects of C. cassia than Ceylon. This is why there is
still controversy as to which cinnamon species to use for optimal outcomes and sufficient safety in
clinical practice. However, the current evidence suggests Ceylon is the safer option and that the
bioactive compounds of cinnamon have beneficial properties to treat various metabolic diseases[8].
In particular, the potential beneficial effects of cinnamon on lipid profiles[27], glycemic status[28],
blood pressure[29], and body composition[30] attract the most research attention and have been
studied in detail. Experimental evidence suggests that cinnamon may positively affect lipid
metabolism[24]. Studies have shown that the bioactive compounds of cinnamon can decrease fatty
acid synthesis by influencing critical enzymes involved in hepatic lipid degradation[31]. For example,
cinnamaldehyde[16], one of the main bioactive compounds that give cinnamon its odor and flavor,
may stimulate lipolysis (the breakdown of fatty acids) by inhibiting the synthesis of fatty acids[24].
34
Also, evidence suggests that cinnamon could help treat dyslipidemia, as bioactive compounds of
cinnamon were shown to inhibit lipoprotein lipase[32], an enzyme involved in lipolysis and secretion
of lipids into systemic circulation. Two recent meta-analyses from 2017[33] and 2020[27] provide
clinical evidence that cinnamon may improve lipid profiles in both healthy adults and participants
with type 2 diabetes.
Experimental studies[34] showed that cinnamon improves glucose metabolism and insulin
sensitivity via various biological mechanisms such as enhancing insulin receptor[35] activity,
increasing secretion of glucagon-like peptide-1 (GLP-1)[36], improving glucose uptake[37], and
modulation of glycolysis (e.g., by stimulating peroxisome proliferation[38] and inhibiting the gene
expression of pyruvate kinase[39]). In addition, cinnamon extract has been shown to inhibit
glucosidase[37] (an enzyme breaking down starch to glucose) in rats with diabetes, leading to
decreased carbohydrate digestion and thus avoiding postprandial hyperglycemia, a major risk
factor for diabetic complications. Cinnamon’s ability to slow digestion was observed in another
study reporting that cinnamon reduced postprandial glucose response and delayed gastric
emptying without affecting satiety[40]. However, these metabolic processes are complex, and the
exact mechanism of cinnamon is not fully understood yet. Nevertheless, the experimental evidence
incentivized scientists to conduct RCTs to investigate whether cinnamon could help manage type 2
diabetes and related aspects of metabolic syndrome in clinical practice. Two recent[41][28] studies
meta-analyzed the clinical evidence and found that cinnamon improved the glycemic status of
participants with type 2 diabetes, showing reduced fasting serum glucose levels. However, both
meta-analyses report high heterogeneity, so these findings should be viewed with caution.
Cinnamon may also improve blood pressure. Two recent[42][29] meta-analyses from 2020
investigated the anti-hypertensive effects of cinnamon supplementation in healthy adults and found
significant reductions in blood pressure. A possible biological mechanism is that cinnamon has a
high antioxidant capacity[43] and may neutralize reactive oxygen species and increase nitric oxide
levels[44], thus improving vasodilation and decreasing blood pressure. However, the two meta-
analyses also report significant heterogeneity between the RCTs, most notably for disease state
and type of cinnamon used. So, cinnamon may be a potent anti-hypertensive compound with
clinical relevance, but further studies are required to confirm these properties.
Overall, there is still controversy regarding whether cinnamon has beneficial effects in terms of
treating metabolic diseases. For example, the most recent Cochrane Review on cinnamon[45] did
not find a disease-protective or curative effect of cinnamon in the context of type 2 diabetes due to
a lack of pertinent evidence. Ever since the review was published, though, the clinical evidence has
substantially grown, and more recent[41][28] meta-analyses found beneficial effects of cinnamon in
this regard. Other meta-analyses[28][33] report controversial and mixed effects on different
outcomes. So, there exists a ‘cinnamon controversy’, in that the efficacy of cinnamon as a
preventive or medicinal compound for metabolic syndrome is still widely debated.
35
The present study[46] was designed to shed more light on the cinnamon controversy. The
researchers meta-analyzed 35 placebo-controlled RCTs that investigated the effects of cinnamon
on various cardiometabolic risk markers in adults with metabolic diseases. Unlike previous meta-
analyses, the present study focused on metabolic disorders in general and analyzed multiple
outcomes. In contrast, previous studies either focused on specific conditions like type 2 diabetes[28]
or particular outcomes such as lipid profiles[27] and blood pressure[29]. Thus, the present study is
one of the most comprehensive meta-analyses on the effects of cinnamon in metabolic diseases to
date.
Metabolic diseases affect over a billion people worldwide and pose

a severe economic and healthcare burden. Cinnamon could
ameliorate critical features of metabolic disorders, thus improving
outcomes and increasing quality of life while cutting healthcare
costs. Even though the putative biological mechanisms of
cinnamon are promising, there is still controversy about
cinnamon’s practical efficacy, with some studies showing
beneficial effects and others showing mixed results. The present
study was designed to clarify this cinnamon controversy by meta-
analyzing 35 RCTs, more than any meta-analysis had tackled
before, on the various effects of cinnamon in adults with metabolic
diseases.
What was studied?

The present study is a systematic review and meta-analysis of 35 RCTs published between 2003
and 2020 that investigated the effects of cinnamon among adults with metabolic diseases. Notably,
the researchers did not specify which type of cinnamon was used in the included RCTs. The
researchers assessed the changes in lipid profiles (total cholesterol, total triglycerides, HDL-C, and
LDL-C), markers of glycemic status (fasting serum glucose, fasting serum insulin, HbA1c, and
HOMA-IR), blood pressure (systolic and diastolic blood pressure), and waist circumference.
Studies that lacked sufficient data for the outcomes of interest or were not placebo-controlled were
36
excluded. The pooled sample size was 2,282 participants with metabolic diseases, ranging from 17
to 200 participants per study, with follow-ups of 6–26 weeks and doses of 0.12–12 grams per day.
The most common metabolic disease was pre-diabetes and type 2 diabetes (26 of 35 RCTs), with
the remaining studies including polycystic ovary syndrome, obesity, rheumatoid arthritis, and
others.
The researchers used a random-effects model for the meta-analysis and reported their findings
based on the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA)[47]
statement guidelines. The researchers also conducted subgroup analyses to delineate the effects
of cinnamon at different doses, study durations, and types of metabolic diseases. Notably, the
researchers did not preregister their meta-analysis. To evaluate the quality of the included RCTs,
the researchers used the Cochrane scoring system[48] to assess risk of bias as high risk, low risk,
or unclear risk. The risk of publication bias was judged by visual inspection of funnel plots and
Egger’s test[49]. The researchers also performed a sensitivity analysis to investigate the effect of
individual RCTs on the overall effect estimates.
The present study is a meta-analysis of 35 RCTs investigating the

effects of cinnamon in 2,282 adults with metabolic diseases.
Specifically, the researchers assessed the effects of cinnamon on
lipid profiles, markers of glycemic status, blood pressure, and waist
circumference. Subgroup analysis was used to examine the effects
of melatonin on different doses, study durations, and types of
diseases.
What were the findings?

As shown in Figure 2, cinnamon significantly improved the lipid profiles, glycemic status, blood
pressure, and waist circumference of adults with metabolic diseases. Also, serum insulin dropped
by 7.6 pmol/L and HOMA-IR changed by -0.6. Overall, the effects of cinnamon on these risk factors
may be large enough to have clinical relevance for participants with metabolic diseases.
Figure 2: Effect of cinnamon on metabolic markers
37
(with 95% confidence intervals)
However, the researchers found considerable heterogeneity in all outcomes except for waist
circumference, meaning the effects of cinnamon varied widely between the RCTs used in the meta-
analysis. The researchers state two reasons to explain this heterogeneity: First, the risk of bias was
unclear for most RCTs (31 of 35), with only three studies showing a low risk of bias, suggesting
that the quality of the included RCTs is questionable. Second, the researchers identified the dose
and study duration as two possible factors that could explain some of the heterogeneity. RCTs
using doses of no more than 1.5 grams per day and study durations of more than 8 weeks showed
more pronounced effects of cinnamon in terms of reducing total cholesterol (-18.4 and -15.7 mg/
dL), triglycerides (-20.0 and -18.1 mg/dL), and LDL-C (-8.5 and -8.6 mg/dL). Daily doses of no
38
more than 1.5 grams taken for more than 8 weeks also reduced fasting serum glucose (-12.4 and
-15.0 mg/dL) more effectively than the overall effect estimate. However, blood pressure and waist
circumference were not influenced by cinnamon dose and study duration. Notably, dose and
duration could not explain all the heterogeneity observed for these outcomes, indicating that other
confounding factors may be present.
The researchers assessed the dose-response relationship in more detail to better understand the
effects of dose and duration on the effects of cinnamon. Interestingly, a non-linear dose-response
relationship was found between changes in triglycerides and LDL-C with dose and changes in LDL-
C and fasting serum glucose with duration. These findings could explain why cinnamon was more
effective in the context of doses of no more than 1.5 grams per day for durations of more than 8
weeks. The relevance of these findings is discussed further in the next section.
Cinnamon significantly improved lipid profiles, markers of glycemic

status, blood pressure, and waist circumference in adults with
metabolic diseases. However, the researchers found substantial
heterogeneity for all outcomes except waist circumference and an
unclear risk of bias for most of the included RCTs. Different doses
and study durations could, in part, explain the heterogeneity. Daily
doses of no more than 1.5 grams supplemented for more than 8
weeks significantly improved the beneficial effects of cinnamon in
terms of reducing total cholesterol, triglycerides, LDL-C, and
fasting serum glucose compared to the overall effect estimate.
However, dose and duration did not influence blood pressure and
waist circumference and could not explain all of the heterogeneity,
indicating that other confounding factors may play a role.
The bigger picture

The positive findings of the present study seem promising. Cinnamon showed various beneficial
effects on lipid profiles, glycemic status, blood pressure, and waist circumference. However, the
39
attentive reader may raise some justified questions: If cinnamon has such beneficial effects on
these risk markers, why was there so much controversy regarding its efficacy? How does the
present study stand concerning previous meta-analyses? And how relevant are the measured
effects in clinical practice? Answering these questions requires diving deeper into the study under
review in order to assess it in relation to the current body of literature.
The present study is in good agreement with two previous meta-analyses from 2017[33] (in adults)
and 2020[27] (in participants with type 2 diabetes). All three meta-analyses found that cinnamon
significantly reduced total cholesterol (-12 to -14 mg/dL), triglycerides (-16 to -26 mg/dL), and LDL
(-6 mg/dL). However, the two previous meta-analyses did not find any statistically significant
improvements in HDL-C, while the present study reports a significant increase in HDL-C (+1.35
mg/dL). That said, the 95% confidence intervals from each study shown in Figure 3 indicate that
the studies are still roughly compatible with each other, even if the previous two didn’t find
statistically significant results.
Figure 3: HDL-C changes in this study compared to

two previous meta-analyses (with 95% confidence
intervals)
40
So how relevant are these effects? Given the American Heart Association’s recommendations (see
Table 1), the effects of cinnamon on cholesterol and triglycerides may be clinically relevant.
Notably, cinnamon reduced triglycerides most significantly by 16 to 26 mg/dL, which could make a
clear difference in participants with dyslipidemia, characterized by triglyceride levels of more than
200 mg/dL, aiming for levels of less than 150 mg/dL. Cinnamon’s effect on total cholesterol (-16.3
mg/dL) and LDL-C (-6.4mg/dL) is also considerable and could make a difference. Based on a
recent cohort study of 12.8 million adults[50], a change in total cholesterol of -16 mg/dL in adults
with blood levels of more than 200 mg/dL would be associated with approximately 5% lower all-
cause mortality risk. Similarly, the reduced LDL-C levels found for cinnamon could lead to
approximately 8% lower risk for coronary artery diseases (CAD), based on a recent Mendelian
randomization analysis. The small yet significant increase in HDL-C caused by cinnamon may not
be as clinically relevant as its lipid-lowering effects. Overall, the beneficial effects of cinnamon on
lipid profiles are promising, but must be interpreted with caution. As decreasing risk markers do not
necessarily lead to improved clinical outcomes, future RCTs investigating the effect of cinnamon on
hard clinical outcomes such as decreased mortality rates are needed.
Besides blood lipids, cinnamon could be beneficial to improve the glycemic status of people with
type 2 diabetes. Animal studies showed that cinnamon could inhibit numerous digestive enzymes,
such as alpha-glucosidase[51] and sucrase[52], and decrease the influx of glucose into the systemic
41
circulation, thus avoiding high insulin spikes. Like previous meta-analyses, the present study found
a significant reduction in fasting serum glucose (-11.4 mg/dL) caused by cinnamon. If
supplemented for more than 8 weeks, this glucose-lowering effect of cinnamon was even more
pronounced (-15.0 mg/dL). As diabetes is diagnosed when fasting serum glucose levels are above
126 mg/dL (see Table 2), cinnamon could be clinically relevant for diabetes management. A recent
Mendelian randomization study and meta-analysis[53] found that a 18 mg/dL higher fasting glucose
was causally linked to an 48% higher risk of ischaemic stroke. That means it’s possible that the
fasting glucose-lowering effect in the present study could meaningfully lower stroke risk by up to
40%, if cinnamon is supplemented for a prolonged period of time, although this is not confirmed.
In contrast to the previous meta-analyses, which probably lacked statistical power, the present
study also found significant improvements for HbA1c (-0.23%), serum insulin (-7.6 pmol/L), and
HOMA-IR (-0.59). These effect estimates could be clinically relevant, e.g., by improving the
parameters of a participant with diabetes from moderate to slight insulin resistance. However, it
remains an open question as to whether cinnamon could improve clinical outcomes such as
disease progression or mortality rates. The positive findings of the present study could incentivize
scientists to conduct further research on this topic.
Cinnamon may also have an effect on blood pressure. In 2020, two meta-analyses[29][30] were
published that assessed the anti-hypertensive effects of cinnamon in adults. The findings were
somewhat incompatible and created some controversy: While the first study found significant
improvements for both systolic (-6.2 mmHg) and diastolic blood pressure (-3.9 mmHg), the other
reported only a slight effect on diastolic blood pressure (-0.9 mmHg) and no significant effect on
systolic blood pressure. The present study now provides a third perspective: cinnamon improved
both systolic (-4.0 mmHg) and diastolic blood pressure (-3.4 mmHg) significantly. The effect was
even more pronounced in studies of more than 8 weeks in duration (-6.7 and -8.9 mmHg,
respectively). These findings are in good agreement with the other meta-analysis that showed
positive effects of cinnamon on blood pressure. Also, both studies found that longer
supplementation periods yielded more pronounced blood pressure improvements, indicating that
cinnamon may exert biological effects, which emerge only after long-term administration.
Based on current evidence, the blood pressure-lowering benefits of cinnamon may have clinical
relevance (see Table 3 for reference values). A meta-analysis of 123 studies including more than
613,000 participants[54] found a 13% risk reduction in all-cause mortality for a 10 mmHg decrease
in systolic blood pressure. The anti-hypertensive effects of cinnamon could thus lead to an
approximately 5–9% reduced risk for all-cause mortality, assuming a linear dose-response
relationship between blood pressure and all-cause mortality risk. However, due to the high
heterogeneity (i.e., the included studies varied a lot in design and findings) and unclear risk of bias,
the effect estimates of cinnamon on blood pressure cannot be taken for granted and need to be
viewed with caution.
42
Overall, the present meta-analysis has several strengths. Most notably, the present study is one of
the most extensive meta-analyses of 35 RCTs that investigated the effects of cinnamon in 2,282
participants with different metabolic diseases. The sample size of the present meta-analysis
allowed the researchers to identify significant changes where previous meta-analyses may have
lacked the statistical power to do so.
However, there are three important limitations to consider when interpreting the reported effect
estimates. First, the heterogeneity of the overall effect estimates was high, thus limiting the
explanatory power of the results. A possible explanation that could account for part of the high
heterogeneity may be the broad range of metabolic diseases analyzed. Apparently, the effects of
cinnamon may vary for different metabolic diseases. Second, the researchers did not specify the
type of cinnamon (C. verum or C. cassia), probably because most RCTs did not report on the type
of cinnamon used. However, the type of cinnamon is a crucial factor that could account for some of
the heterogeneity observed. In addition, different types of cinnamon differ by their bioactive
compound content, most notably the potentially toxic coumarin. In fact, the non-linear dose
response and upper limit of no more than 1.5 grams of cinnamon daily could be explained by most
RCTs using C. cassia (high in coumarin) instead of Ceylon cinnamon. Future RCTs should thus
carefully outline which type of cinnamon was used to make subgroup analyses and thus more
specific supplement recommendations popular. Third, the complex multitude of biological
mechanisms cinnamon is involved in makes it difficult to study the effects of cinnamon, especially
in the context of such complex diseases as metabolic syndrome. Future studies may shed more
light on the complex mechanisms and effects of cinnamon that could provide important information
about general efficacy, the kind of people who benefit most, optimal dosage, and maybe even ideal
timing.
The present study is one of the most comprehensive meta-

analyses on cinnamon and metabolic diseases to date. Overall,
the present study’s findings are in broad agreement with previous
research but provide higher statistical power. This may be why the
present study found significant effects that were previously only
assumed, but not established. Cinnamon’s positive effects on lipid
profiles, glycemic status, and blood pressure may have clinical
relevance, especially if taken in the optimal dose (no more than 1.5
grams) over more extended periods (more than 8 weeks).
43
However, the present study’s findings are limited by the high
heterogeneity of the effects, unclear risk of bias for most the
included RCTs, and unknown type of cinnamon used in the
studies. Future studies should address these limitations to shed
more light on the possible positive effects of cinnamon to treat
metabolic diseases.
Frequently asked questions

Q. What is the optimal dose of cinnamon?
The precise dose to benefit from the optimal effects of cinnamon is still being debated. The present
study suggests that doses of up to 1.5 grams per day may be sufficient for optimal health effects.
However, the type of cinnamon (C. zeylanicum vs. C. cassia) is crucial to consider. As C. cassia
contains higher amounts of the bioactive compound coumarin[25] (7–18 mg of coumarin per
teaspoon), which can be toxic to the liver[26]. However, there is also a debate ongoing regarding
whether coumarin may also be the bioactive agent responsible for most of the health benefits
conveyed by cinnamon. This hypothesis is supported by recent evidence showing higher anti-
diabetic effects of C. cassia than Ceylon.
However, considering the possible side effects of cinnamon, such as headache and diarrhea
caused by high doses of its bioactive compounds, and the present study’s findings, lower amounts
(no more than 1.5 grams per day) may be sufficient to reap the health benefits of cinnamon while
staying on the safe side. This upper limit reported in the present study could indeed be explained
by most RCTs using C. cassia instead of Ceylon cinnamon. Yet until more evidence is available, a
precise number cannot be given at this time.
What should I know?

Over one billion people worldwide live with metabolic diseases, and incidence rates are steadily
increasing. Cinnamon has been recommended to treat metabolic disorders due to its high content
of bioactive compounds showing antimicrobial, anti-inflammatory, antioxidant, and anti-diabetic
44
effects.
The present study meta-analyzed 35 RCTs of 2,282 participants with metabolic diseases to assess
the effects of cinnamon on lipid profiles, glycemic status, blood pressure, and waist circumference.
Cinnamon significantly improved all of the investigated risk markers, showing the most pronounced
effects with doses of no more than 1.5 grams of cinnamon per day taken over more than 8 weeks.
However, the researchers found considerable heterogeneity in the effects, indicating that the
included RCTs differed widely in design and outcome and potentially the presence of confounding
factors.
If future studies confirm the positive results of cinnamon, its effects may have clinical relevance as
an adjunct therapy due to its anti-hypertensive effects, ability to reduce cholesterol and blood
glucose, and its beneficial effect on insulin sensitivity. However, more RCTs validating the positive
effects of cinnamon, and preferably showing clinical outcomes, must confirm cinnamon as an
adjunct therapeutic in clinical practice.
Do you use cinnamon or just like it in your oatmeal? Share your

experience in the private Examine Members Facebook forum.
45
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glycemic status in patients with type 2 diabetes: A systematic review and meta-
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in adults: A systematic review and dose-response Meta-analysis of randomized
controlled trials. Crit Rev Food Sci Nutr. (2019)
30. ^ a b Seyed Mohammad Mousavi, et al. Cinnamon supplementation positively affects
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signaling in 3T3-L1 adipocytes. Int J Mol Sci. (2014)
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regulation of pyruvate kinase, phosphoenolpyruvate carboxykinase, and GLUT4
translocation in experimental diabetic rats. Chem Biol Interact. (2010)
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emptying, and satiety in healthy subjects. Am J Clin Nutr. (2007)
41. ^ a b Serawit Deyno, et al. Efficacy and safety of cinnamon in type 2 diabetes
mellitus and pre-diabetes patients: A meta-analysis and meta-regression. Diabetes
Res Clin Pract. (2019)
42. ^ Abed Ghavami, et al. What is the impact of cinnamon supplementation on blood
pressure? A systematic review and meta-analysis. Endocr Metab Immune Disord
Drug Targets. (2020)
43. ^ Ernesto L Schiffrin. Antioxidants in hypertension and cardiovascular disease. Mol
Interv. (2010)
44. ^ Kamal A Amin, Thanaa M Abd El-Twab. Oxidative markers, nitric oxide and
homocysteine alteration in hypercholesterolimic rats: role of atorvastatine and
cinnamon. Int J Clin Exp Med. (2009)
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48
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metabolic diseases: A systematic review and dose-response meta-analysis of
randomized-controlled trials. Crit Rev Food Sci Nutr. (2021)
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randomised trials. BMJ. (2011)
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mortality by sex and age: a prospective cohort study among 12.8 million adults. Sci
Rep. (2019)
51. ^ H Mohamed Sham Shihabudeen, D Hansi Priscilla, Kavitha Thirumurugan.
Cinnamon extract inhibits α-glucosidase activity and dampens postprandial glucose
excursion in diabetic rats. Nutr Metab (Lond). (2011)
52. ^ Adisakwattana S, et al. Inhibitory activity of cinnamon bark species and their
combination effect with acarbose against intestinal α-glucosidase and pancreatic α-
amylase. Plant Foods Hum Nutr. (2011)
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ischaemic stroke: a Mendelian randomisation study and meta-analysis. Diabetologia.
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and death: a systematic review and meta-analysis. Lancet. (2016)
49
Deeper Dive: A spoonful of vinegar might
make blood sugar go down
 Tags: Blood Glucose, Vinegar, Supplementation, Body Fat, Metabolic Syndrome
 Study under review: Effect of Dietary Acetic Acid Supplementation on Plasma Glucose,
Lipid Profiles, and Body Mass Index in Human Adults: A Systematic Review and Meta-
analysis
Quick Takes
• What was the question? Does supplementing with dietary
acetic acid (vinegar) improve metabolic and body fat
measures?
• How was it studied? Researchers conducted a systematic
review and meta-analysis of randomized trials examining the
effect of acetic acid (or acetate) provided through a dietary
source.
• Who was studied? Adults who were at least 18 years old,
regardless of health status, made up the participant
population.
• What was the intervention? Supplementation with acetic
acid (or acetate) that lasted at least one week or more.
• What’s the main takeaway? Supplementing between 750
and 3,600 mg of acetic acid per day over an average of 8
50
weeks lowered triglyceride levels in people who were
overweight and had obesity. It also lowered fasting blood
glucose among people with type 2 diabetes. However, there
was no significant effect on BMI or other metabolic
parameters.
• Any caveats? Most of the studies included in the analysis
had a relatively high risk of bias, some of the subgroup
analyses included too few studies for robust conclusions, and
there is not much evidence regarding the optimal dose or
duration of supplementation.
Introduction
Lifestyle interventions, such as diet and exercise[1], are commonly used interventions with good
effectiveness, assuming high adherence, for addressing obesity and type 2 diabetes[2]. In addition
to these lifestyle interventions, there are myriad specific dietary interventions that have been
examined as tools to help address many of the symptoms that result from obesity, metabolic
syndrome, and type 2 diabetes, such as elevated fasting blood glucose, dyslipidemia, and high
blood pressure. Of these dietary interventions, consumption of acetic acid from dietary sources has
been proposed as a strategy for improving the metabolic issues that arise from having obesity or
type 2 diabetes.
Some studies have shown that acetic acid, the main acid in vinegar, has beneficial effects on
glucose and lipid metabolism. For example, in one study, consuming acetic acid prior to a meal
increased glucose uptake in skeletal muscle and decreased plasma triglycerides in people with
impaired glucose tolerance. In another study,[3] consuming acetic acid prior to a high-carbohydrate
meal raised post-meal insulin sensitivity among participants with impaired insulin sensitivity and
participants with diagnosed type 2 diabetes. However, the outcomes of the studies have varied,
with some studies showing minimal to no effect[4]. To date, there have been numerous randomized
trials conducted examining the effect of varying sources and doses of acetic acid on various
aspects of metabolism. The present study was a systematic review and meta-analysis that
51
summarized the available evidence from randomized trials and was designed to examine the effect
of acetic acid on metabolism, as well as body fat measures in adults with and without chronic
metabolic conditions.
Several dietary interventions have been proposed to be included in

nutritional interventions in people with metabolic disease. Acetic
acid, usually in the form of vinegar, has been shown to improve
insulin sensitivity and lipid metabolism in randomized trials. The
present study was a systematic review and meta-analysis
examining the effect of dietary acetic acid supplementation on
metabolic and body fat measures.
What was studied?

The study under review was a systematic review and meta-analysis of randomized controlled trials
examining the effect of acetic acid on metabolic and anthropometric outcomes (e.g. body fat) in
adults with and without chronic diseases. The study was registered through PROSPERO and was
conducted in accordance with PRISMA[5] guidelines.
This study included randomized controlled trials in adults (18 years and older) with or without
chronic metabolic diseases. Studies were included if they provided a dietary source of acetic acid,
included a placebo or low-dose group, had a duration of at least one week, and included baseline
and follow-up measurements for key metabolic parameters and body fat. Studies that provided
acetic acid through non-food sources or through intravenous or pill form were excluded from the
study. In studies that compared different doses, the group with the highest dose was selected to be
included in the analysis.
No singular primary outcome was noted. However, several outcomes were considered major
outcomes of the study: fasting blood glucose, triglyceride, high-density lipoprotein, low-density
lipoprotein, glycated hemoglobin (HbA1c), and BMI.
Subgroup analyses were performed based on the populations included in the studies: 1) healthy, 2)
overweight or obese but otherwise healthy, 3) metabolic conditions that included metabolic
syndrome, prediabetes, or hypercholesterolemia, and 4) type 2 diabetes. Bias was assessed using
52
the Cochrane Risk of Bias tool[6]. Studies were classified as having “low risk,” “high risk,” or
“unclear risk.” Heterogeneity was assessed using the I2 statistic and was deemed significant if the
value exceeded 50%. Sensitivity analyses were performed to examine sources of heterogeneity
and sources of bias. Publication bias was assessed using Egger’s and Begg’s test as well as by
visual inspection of funnel plots.
The meta-analysis included 16 studies involving 910 participants ages 23–72 and BMIs ranging
from approximately 21 to approximately 30. The populations in the studies consisted of healthy
(two studies), overweight or obese but otherwise healthy (four studies), metabolic conditions such
as prediabetes, metabolic syndrome, or hypercholesterolemia (three studies), and type 2 diabetes
(six studies).
The study under review was a systematic review and meta-

analysis of 16 trials including 910 total participants. The
researchers examined the effect of acetic acid on fasting blood
glucose, triglyceride, high-density lipoprotein, low-density
lipoprotein, glycated hemoglobin (HbA1c), and BMI. Publication
and study bias and heterogeneity were also assessed.

Acetic acid supplementation showed a significant effect on blood glucose, reducing it by about 36
mg/dL, on average. These improvements were observed in only four of the five studies involving
participants with type 2 diabetes. Furthermore, there was high heterogeneity (I2 = 98%) in the
group with type 2 diabetes, but much lower heterogeneity among the groups in which there was no
significant effect (I2 = 0%). There was also no statistically significant effect of acetic acid
supplementation on HbA1c in any group. However, the 95% confidence interval suggests the data
are mostly compatible with benefit in people with type 2 diabetes (95% CI: -2.95–0.16), suggesting
a possible benefit. Acetic acid supplementation also failed to produce a significant effect on either
BMI or body fat percentage in any of the groups studied.
Acetic acid supplementation also lowered triglyceride in participants with overweight and obesity by
about 21 mg/dL and in participants with type 2 diabetes by about 7.5 mg/dL. Heterogeneity was
relatively low in the groups with overweight and obesity (I2 = 4%) and the group with type 2
53
diabetes (I2 = 0%). There was no significant effect of acetic acid supplementation on either HDL-C
or LDL-C, except in one study that examined the effect on people with hypercholesterolemia, which
found an increase of approximately 4 mg/dL in HDL-C and a decrease of 45 mg/dL in LDL-C.
Figure 1: Subgroups that may benefit from acetic acid

supplementation
Overall, there was a high risk of bias present in the studies included in the analysis: 10 of the 16
studies were labeled as having “high risk,” 4 studies were labeled as having “unclear risk,” and only
2 studies were labeled as having “low risk.”
Acetic acid improved fasting blood glucose and triglyceride levels

in people with type 2 diabetes and participants with overweight or
obesity but who were otherwise metabolically healthy. There were
no improvements observed in participants with no disease states,
nor were there improvements in HbA1c among any group. There
was no effect on BMI or body fat in any group.
54
The bigger picture
The present data suggest that dietary acetic acid may help lower fasting blood glucose in people
with diabetes, and lower triglycerides in people with overweight and obesity, as well as with type 2
diabetes. However, in the two studies in healthy, non-overweight or obese participants included in
this systematic review, no benefits were detected. The intervention also had no effect on BMI or
body fat, regardless of which group it was studied in. Overall, people with type 2 diabetes or with
overweight or obesity are the most likely to see benefit on cardiometabolic risk factors from acetic
acid supplementation.
These data are supported by previous meta-analyses that examined the effects of acetic acid
supplementation on both postprandial glucose levels as well as fasting glucose levels. One of
these meta-analyses[7], which focused on the acute effects of vinegar ingestion, found that the
consumption of acetic acid in the form of vinegar with a meal lowered both postprandial glucose
and insulin levels. Another meta-analysis[8] that focused on trials performed in participants with
type 2 diabetes found that consuming acetic acid in the form of vinegar led to lower fasting blood
glucose. However, unlike the current study, this study found that acetic acid also lowered HbA1c.
Also unlike the meta-analysis at hand, the authors observed reductions in body weight and fat
mass. Preclinical studies[9] performed in mice also support these findings, as acetic acid and
vinegar improved serum lipids in diet-induced obese mice.
Even if statistically significant benefits are established to exist, the question of clinical relevance
regarding the achieved glucose and lipid improvements remains. One way to determine clinical
relevance is to compare the effects seen in this study to pharmaceutical effects. The present study
found that in people with diabetes, acetic acid supplementation lowered fasting blood glucose by
about 35 mg/dL, while metformin lowers blood glucose [10]by about 20 mg/dL at lower doses and
about 80 mg/dL at higher doses. Furthermore, the present study did not find any statistically
significant reduction in HbA1c, which is a measure of longer-term glycemic control, whereas
metformin has shown reductions in HbA1c of about 1–2%[10], depending on the dosage used.
While the present study did not find it to be statistically significant, there may indeed be a benefit
on HbA1c, given the confidence intervals (CI: -2.95–0.16). Acetic acid lowered fasting triglycerides
by about 21 mg/dL, while the fibrate class of drugs used for lowering blood lipids in people with
diabetes showed reductions between 50mg/dL and 180 mg/dL[11], with reductions of up to 50%[12]
seen in some trials.
Figure 2: How the effects of acetic acid compare to

select drugs
55
References: Garber et al. Am J Med. 1997 Dec.[10]
Damci et al. Eur J Intern Med. 2003 Oct.[11]
There are several proposed mechanisms by which acetic acid might improve cardiometabolic risk
factors in people with diabetes, metabolic syndrome, or obesity. In rodent studies[13] and in vitro
studies[14], acetic acid has been shown to activate a protein called AMP-activated protein kinase
(AMPK) which stimulates glucose uptake and lipid oxidation (AMPK is one of the targets of the
drug metformin). Additionally, studies in diet-induced obese mice[15] found that acetic acid
increases the expression of genes regulating fatty acid oxidation in the liver and attenuates body
fat accumulation in mice. In a previous study[16] in humans with type 2 diabetes, acute acetic acid
consumption improved glucose kinetics without substantially altering lipid metabolism, suggesting
an acute increase in insulin sensitivity, possibly through AMPK. There are also some hints[9] from
animal research suggesting that the gut microbiome may play a role in vinegar’s mechanism of
56
action.
The study under review has some limitations that should be considered when interpreting the
results. First, there was a relatively high risk of bias, with about 63% (10/16) of the studies showing
a “high risk” of bias, and only about 13% (2/16) showing a “low risk” of bias. Second, there was no
standardization of the form of acetic acid consumed across trials, nor was there any real control for
dosing, either experimentally or statistically, which may be important, given the previous dose-
response experiments[17]. Third, there were relatively few trials among different populations, which
limits the power of the analysis and the ability to draw conclusions. Finally, the present study did
not examine the effect of the length of the intervention, as the duration of included studies ranged
from 4 to about 13 weeks.
Previous meta-analyses are consistent with the current findings of

reduced fasting blood glucose levels as a result of acetic acid
supplementation, and previous randomized trials and preclinical
data provide evidence to support the reduction in triglycerides
seen in people with type 2 diabetes. However, the overall quantity
and quality of the evidence is low. In this context, the overall high
risk of bias, various potentially outcome-relevant methodological
differences between the input studies, and subgroup analyses
based on few, or in one case only two, studies, should be kept in
mind.

Q. Which foods provide the most acetic acid?
Acetic acid is most commonly found in vinegar[18]. Many of the most commonly consumed forms of
vinegar are apple cider vinegar, rice vinegar, balsamic vinegar, and white wine vinegar. This is why
many pickled foods, including kimchi, pickled cucumbers, and kombucha are also good dietary
sources of acetic acid.
Q. What are the side effects of consuming too much acetic acid?
57
Generally speaking, in most randomized trials with moderate dosages (up to approximately 4
grams of acetic acid per day), acetic acid has minimal to no documented side effects. However,
there are some case reports that suggest practicing some caution when dosing and choosing to
consume acetic acid. For example, chronic intake of higher doses of acetic acid (about 12.5 grams
per day) can alter electrolyte handling, leading to hypokalemia[19]. There has also been a report of
ulcerative esophageal injury[20] and negative effects on liver function[21] due to acetic acid
consumption.
What should I know?

This systematic review and meta-analysis indicates that supplementing with acetic acid may
provide some benefit for fasting glucose and blood lipids (triglycerides) in people with diabetes,
overweight, or obesity, and who are otherwise healthy. However, there were a limited number of
studies for each population studied, and the current body of literature has a high risk of bias
overall, limiting the confidence in the present findings. Based on the overall findings of this present
study, acetic acid supplementation does not appear to provide much benefit, except for potentially
improving blood glucose in people with type 2 diabetes. Much more evidence is needed to confirm
which populations benefit, what sources are most effective, and what doses and durations are
needed to see an effect.
Is this evidence strong enough for you to consider acetic acid

supplementation worthwhile, or does the high heterogeneity and
risk of bias in this study raise red flags? Share your take on the
evidence and read what your peers think at the private Examine
Members Facebook Forum.
58
 References
1. ^ Clare L Gillies, et al. Pharmacological and lifestyle interventions to prevent or delay
type 2 diabetes in people with impaired glucose tolerance: systematic review and
meta-analysis. BMJ. (2007)
2. ^ Knowler WC, et al. Reduction in the incidence of type 2 diabetes with lifestyle
intervention or metformin. N Engl J Med. (2002)
3. ^ 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)
4. ^ Kondo T, et al. Vinegar intake reduces body weight, body fat mass, and serum
triglyceride levels in obese Japanese subjects. Biosci Biotechnol Biochem. (2009)
5. ^ David Moher, et al. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med. (2009)
7. ^ Shishehbor F, Mansoori A, Shirani F. Vinegar consumption can attenuate
postprandial glucose and insulin responses; a systematic review and meta-analysis of
clinical trials. Diabetes Res Clin Pract. (2017)
8. ^ Ling Jie Cheng, et al. A systematic review and meta-analysis: Vinegar consumption
on glycaemic control in adults with type 2 diabetes mellitus. J Adv Nurs. (2020)
9. ^ a b Boon Kee Beh, et al. Anti-obesity and anti-inflammatory effects of synthetic
acetic acid vinegar and Nipa vinegar on high-fat-diet-induced obese mice. Sci Rep.
(2017)
10. ^ a b c A J Garber, et al. Efficacy of metformin in type II diabetes: results of a double-
blind, placebo-controlled, dose-response trial. Am J Med. (1997)
11. ^ a b Taner Damci, et al. Fenofibrate treatment is associated with better glycemic
control and lower serum leptin and insulin levels in type 2 diabetic patients with
hypertriglyceridemia. Eur J Intern Med. (2003)
12. ^ Yeongmin Woo, et al. Effect of fenofibrate in 1113 patients at low-density
lipoprotein cholesterol goal but high triglyceride levels: Real-world results and factors
associated with triglyceride reduction. PLoS One. (2018)
13. ^ Sakakibara S, et al. Acetic acid activates hepatic AMPK and reduces
hyperglycemia in diabetic KK-A(y) mice. Biochem Biophys Res Commun. (2006)
14. ^ Hitomi Maruta, et al. Activation of AMP-Activated Protein Kinase and Stimulation of
59
Energy Metabolism by Acetic Acid in L6 Myotube Cells. PLoS One. (2016)
15. ^ Kondo T, et al. Acetic acid upregulates the expression of genes for fatty acid
oxidation enzymes in liver to suppress body fat accumulation. J Agric Food Chem.
(2009)
16. ^ Panayota Mitrou, et al. Vinegar Consumption Increases Insulin-Stimulated Glucose
Uptake by the Forearm Muscle in Humans with Type 2 Diabetes. J Diabetes Res.
(2015)
17. ^ Ostman E, et al. Vinegar supplementation lowers glucose and insulin responses
and increases satiety after a bread meal in healthy subjects. Eur J Clin Nutr. (2005)
18. ^ Ho CW, et al. Varieties, production, composition and health benefits of vinegars: A
review. Food Chem. (2017)
19. ^ K Lhotta, et al. Hypokalemia, hyperreninemia and osteoporosis in a patient
ingesting large amounts of cider vinegar. Nephron. (1998)
20. ^ C H Chung. Corrosive oesophageal injury following vinegar ingestion. Hong Kong
Med J. (2002)
21. ^ Carol S Johnston, Andrea M White, Shannon M Kent. A preliminary evaluation of
the safety and tolerance of medicinally ingested vinegar in individuals with type 2
diabetes. J Med Food. (2008)
60
Deeper Dive: Flavonoids may slightly speed
up recovery from muscle-damaging
exercise
 Tags: Meta-analysis, Flavonoids, Polyphenols, Exercise Recovery, Supplementation
 Study under review: Flavonoid Containing Polyphenol Consumption and Recovery from
Exercise-Induced Muscle Damage: A Systematic Review and Meta-Analysis
Quick Takes
• What was the question? Can flavonoid-containing
polyphenol supplementation improve recovery from exercise-
induced muscle damage?
• How was it answered? Researchers conducted a meta-
analysis of randomized, placebo-controlled trials.
• Who was studied? Most of the participants were men,
whose training status ranged from untrained to semi-
professional athletes.
• What was the intervention? Included studies usually
involved between 500 and 1,500 mg of polyphenols from
various sources. Supplements were administered during, a
few days before, and sometimes after a standardized
muscle-damaging exercise protocol, depending on the study.
Tart cherry and various tea extracts were the most frequently
61
used sources of polyphenols.
• What’s the main takeaway? Supplementation led to small
improvements in muscle soreness and strength up to three to
four days after the exercise bout. Trained participants tended
to see better improvements than untrained participants.
• Any caveats? Strength improvements were mostly assessed
using lab equipment, which may not directly translate to
athletic performance gains in the real world. Also, several
subgroup analyses had small sample sizes, so their results
should be considered preliminary.
Introduction
Exercise, especially when it involves high-force eccentric or unaccustomed loading[1], can produce
substantial muscle fiber damage. It is thought[2] that the initial structural damage from mechanical
loading causes uncontrolled movement of calcium ions into the cytoplasm, leading to further
degradation of structural proteins. While the inflammatory response that follows is aimed at clearing
damaged tissue, it may result in an excessive production of reactive oxygen species, which further
damage the muscle fibers. Eventually, this exercise-induced muscle damage (EIMD) manifests[3]
as muscle pain and swelling, strength and power loss, reduced range of motion (ROM), and
delayed onset muscle soreness (DOMS), with these symptoms usually subsiding[4] five to seven
days after exercise.
Some research suggests that flavonoids[5], a class of polyphenols found in high concentrations in
fruits, vegetables, and other plants, may promote exercise recovery and protect against EIMD
thanks to their antioxidative and anti-inflammatory properties. For example, a 2019 meta-analysis[6]
found that the consumption of whole fruits high in anthocyanins (a type of flavonoid) improved
exercise-induced inflammation and oxidative stress in healthy adults. Moreover, a 2019 narrative
review[7] of randomized controlled trials suggested that supplementation with more than 1,000 mg
of polyphenols for three days before and after exercise may enhance recovery from EIMD.
62
However, a meta-analysis quantitatively analyzing the results of the available randomized
controlled trials specifically looking at the effects of flavonoid polyphenols on markers of EIMD is
lacking.
Sidebar: Dietary polyphenols

Polyphenols are a large family of naturally occurring organic compounds that are found
abundantly in plants. Although polyphenols are chemically characterized as compounds
with phenolic structures, they are highly diverse, and contain several sub-groups. Grouping
them is complicated by the fact that a lot of polyphenols have modified sugars attached to
them in their natural form. However, it becomes easier to classify them if you ignore the
sugars — these structures are called “aglycones.”
As shown in Figure 1, categorizing polyphenols according to the chemical structures of their

aglycones results in the following four polyphenol classes: phenolic acids, which can be
further divided into benzoic acids and cinnamic acids; flavonoids, which can also be further
divided into different sub-groups like anthocyanins and flavonols; polyphenolic amides; and
other polyphenols.
Figure 1: A polyphenol family tree
63
References: Tsao. Nutrients. 2012 Dec.[8]
Panche et al. J Nutr Sci. 2016 Dec.[5]
Flavonoid polyphenols, potentially because of their antioxidative

and anti-inflammatory properties, may promote recovery from
exercise-induced muscle damage. Although randomized controlled
trials have examined this possibility, there was a need for a meta-
analysis that quantitatively analyzed their results.
64
What was studied?
This was a systematic review and meta-analysis that was designed to evaluate the efficacy of
flavonoid supplementation for improving markers of EIMD. As shown in Figure 2, eligible studies
had to be randomized placebo-controlled trials involving adults ages 18–60 supplementing with
flavonoid polyphenols for at least six days. Also, the participants had to have performed a single
bout of either high-intensity exercise or eccentric muscle contractions causing EIMD.
Figure 2: Key study characteristics
The primary outcomes, assessed at baseline and at less than 2 hours, as well as 24, 48, 72, and
96 hours after exercise, were: muscle strength as measured by isometric or isokinetic maximal
voluntary contraction (MVC), DOMS as measured by visual analogue scale and adjusted to a
100-point scale, and creatine kinase concentrations (a blood biomarker of muscle damage).
65
Ultimately, 26 studies comprising 27 trials were included in the meta-analysis. Of these, 18 trials
involving 350 participants reported data on muscle strength, 22 trials involving 406 participants
reported data on DOMS, and 20 trials involving 469 participants reported data on creatine kinase.
Of the 26 studies, 18 employed only men, 1 employed only women, and 7 employed both men and
women. Participants ranged in training status from untrained to semi-professional athletes. Most
studies provided between 500 and 1,500 mg of polyphenols per day, with the sources including tart
cherry (n=9), various tea extracts (n=7), pomegranate (n=3), quercetin (n=2), lemon verbena (n=1),
blackcurrant (n=2), cacao (n=1), and mixed fruit anthocyanin juice (n=1).
To explore potential sources of heterogeneity, the researchers performed subgroup analyses

based on the time point of outcome assessment (less than 2, 24, 48, 72, or 96 hours), trial design
(parallel or crossover), plant source of flavonoid polyphenol, the manner of ingestion (capsule or
beverage), treatment duration (no more than 10 days or more than 10 days), and training status of
the participants (trained or untrained). The trials were pooled in a random effects model.
To assess the methodological quality of individual studies, the researchers used the Physiotherapy
Evidence Database (PEDro[9]) scale, which contains 11 criteria aimed at assessing the internal
validity, and the sufficiency of detail to allow results of RCTs to be accurately interpreted.
Heterogeneity was evaluated using the I2 statistic. Publication bias was not assessed, and the
study was not preregistered.
This was a systematic review and meta-analysis of 27 randomized

placebo-controlled trials evaluating the efficacy of flavonoid
supplementation for improving three markers of exercise-induced
muscle damage (muscle strength, muscle soreness, and creatine
kinase concentrations) in mostly male, young and middle-aged
adults who performed a single bout of muscle damaging exercise.

In the overall analyses, flavonoid polyphenol supplementation improved the recovery of muscle
strength by 7.1% (95% CI: 5.5–8.8; with moderate levels of heterogeneity detected), and reduced
muscle soreness by 4.1% (95% CI: 2.4–5.8; with low levels of heterogeneity detected), but had no
effect on creatine kinase concentrations (with considerable levels of heterogeneity detected).
66
In the subgroup analyses based on the time point at which the outcome was assessed, flavonoid
polyphenol supplementation improved the recovery of muscle strength at 24, 48, 72, and 96 hours
after the exercise bout, and reduced muscle soreness at 24, 48, and 72 hours after the exercise
bout. Both the main and subgroup analyses are shown in Figure 3.
Figure 3: Improvements in muscle strength and

soreness (with 95% confidence intervals)
In the remaining subgroup analyses for the outcome of muscle strength, there was greater
67
recovery of muscle strength with tart cherry flavonoids, compared with pomegranate interventions,
at 24 and 72 hours after the exercise bout, with beverage as the form of ingestion, compared with
capsules, at 24 hours after the exercise bout, and in trained participants compared with untrained
participants at 24 hours after the exercise bout.
In the remaining subgroup analyses for the outcome of muscle soreness, there was greater
improvement in muscle soreness in trained participants, compared to untrained participants, at 48
hours after the exercise bout.
With regard to the methodological quality of the trials, the average PEDro score was 9.6 out of a
maximum of 11, which indicates high quality.
Flavonoid polyphenol supplementation improved the recovery of

muscle strength by 7%, with the effects being statistically
significant at 24, 48, 72, and 96 hours after the exercise bout, and
reduced muscle soreness by 4%, with the effects being statistically
significant at 24, 48, and 72 hours after the exercise bout.
Flavonoid polyphenol supplementation had no effect on creatine
kinase concentrations. The trials included in the analysis were
assessed as being of high methodological quality.
The bigger picture

The meta-analysis under review found a small (7%) but statistically significant effect of flavonoid
polyphenol supplementation for improving muscle strength in the four-day period following a
muscle damaging exercise bout, with the greatest improvement (9.5%) observed 48 hours after the
exercise bout. These findings suggest that athletes with multiple competition events within four
days of one another may benefit from flavonoid supplementation. However, it should be kept in
mind that muscle strength was assessed through isometric or isokinetic maximal voluntary
contraction tests, and may not directly transfer to athletic performance. For example, one trial[10]
found no improvements in 30 meter sprint times or reactive strength in the 72 hours after muscle
damaging exercise with flavonoid supplementation, but did report improvements in jump height.
These results suggest that flavonoid polyphenol supplementation may improve some isolated
68
measures of performance, rather than actual sports performance after muscle damaging exercise.
The meta-analysis also found a very small (4%) but statistically significant effect of flavonoid
polyphenol supplementation for improving muscle soreness in the three-day period following a
muscle damaging exercise bout, with the greatest improvement (6.2%) observed 72 hours after the
exercise bout. One obvious issue here is that the size of the effect is likely too small to be of much
practical relevance.
In the subgroup analyses, there were greater improvements in muscle strength recovery with
flavonoids from tart cherry (compared to pomegranate), with beverage as the form of ingestion
(compared to capsules), and in trained participants (compared to untrained participants). There
were also greater improvements in muscle soreness in trained participants. However, it should be
noted that the pomegranate and capsules subgroups only included three and two trials,
respectively, and that the improvements based on the form of ingestion and training status were
only apparent at a single time point. Moreover, the results of the subgroup analyses were poorly
reported in the published paper, with the effect sizes and heterogeneity not reported at all. As such,
the findings of the subgroup analyses should be considered exploratory.
The meta-analysis under review found no effects of flavonoid supplementation with regard to
creatine kinase concentrations. However, despite its popularity, creatine kinase has been criticized
because of its large inter-individual variability[11] in response to muscle damaging exercise (which
is also reflected in the high levels of heterogeneity detected), and its unreliable[12] correlation with
muscle function after exercise. As such, the results of the meta-analysis relating to creatine kinase
may simply be a reflection of the potential inability of creatine kinase to accurately assess the
impact of the intervention on recovery from muscle damaging exercise.
One strength of this meta-analysis is the use of a random effects model for data analysis, as this
shows that the researchers didn’t assume that the trials employed similar methodologies. The
random effects model also tends to result in wider confidence intervals than a fixed effects model,
and is more conservative in terms of detecting significant results, which means more confidence
can be placed in the detected effects being real.
Another strength is the high quality of the trials included in the meta-analysis, with an average
PEDro score of 9.6, and all studies reaching a score of at least 7. That said, the PEDro scale does
not require the mandatory reporting of critical protocol components, such as trial randomization,
and the blinding of study treatments. With this in mind, it’s no surprise that some research has
reported substantial disagreements between the PEDro scale and the Cochrane Collaboration’s[13]
risk of bias assessment tool in assessing trial quality, with many of the trials considered to be of
adequate quality based on the PEDro scale not meeting the accepted quality standards as defined
by the Cochrane tool.
69
Despite the potential limitations of the PEDro scale, the overall quality of evidence in the meta-
analysis under review is good, and we can be fairly confident that the effects detected in the overall
analyses are real.
Flavonoid polyphenol supplementation for at least six days

improves maximal voluntary contraction to a small degree in the
four-day period following a muscle damaging exercise bout.
Whether these benefits translate to improved athletic performance
remains questionable, though. The same goes for the potentially
practically irrelevant degree of reduced muscle soreness in the
three-day period following a muscle damaging exercise bout.
Despite these and other limitations, it’s fairly reasonable to be
confident that the detected effects are real.

Q. How exactly are flavonoid polyphenols thought to improve EIMD?
While it’s not entirely clear exactly how flavonoid polyphenols may improve EIMD, their limited
bioavailability[14] means that their potential antioxidant effects may be mostly indirect, rather than
direct (i.e., where they would scavenge excess free radicals produced in the body).
Indirectly, even small amounts of polyphenols may alter[15] cell signaling stress response
pathways, promoting the production of endogenous antioxidant enzymes. Moreover, polyphenols
may inhibit[16] prostaglandin synthesis, subsequently downregulating the expression of nuclear
factor-κB, resulting in reduced production of reactive oxygen species and pro-inflammatory
cytokines.
These indirect effects of polyphenols on endogenous antioxidant enzymes, reactive oxygen

species, and pro-inflammatory cytokines may reduce the excessive inflammatory response and
oxidative stress that contribute to EIMD.
Q. What are some examples of specific supplementation protocols?
70
The following are examples of specific supplementation protocols from trials included in the meta-
analysis under review:
In a 2019 study[17], the participants consumed an anthocyanin-rich antioxidant juice that consisted
of a mixture of clariﬁed apple juice, with prune, blueberry, maqui berry, raspberry, and cranberry
concentrates. The participants consumed 240 milliliters of the juice twice per day for nine days.
Each 240 milliliter dose contained 58 milligrams of anthocyanins.
In a 2006 study[18], the participants consumed 355 milliliters of freshly prepared tart cherry juice
twice per day for eight days. Each 355 milliliter bottle of the juice provided at least 600 milligrams of
phenolic compounds, and at least 40 milligrams of anthocyanins.
In a 2010 study[19], the participants consumed 480 milliliters of a pomegranate extract drink twice
per day for nine days, with each 480 milliliter dose containing 650 milligrams of pomegranate
polyphenols, consisting of 95.5% ellagitannins, 3.5% ellagic acid, and 1% anthocyanins.
What should I know?

Flavonoid polyphenols, potentially due to their antioxidative and anti-inflammatory properties, may
promote recovery from exercise-induced muscle damage. This was the first meta-analysis of
randomized controlled trials to quantitatively investigate these potential effects.
According to the results, in which a fair degree of confidence can be placed, flavonoid polyphenol
supplementation for at least six days improves maximal voluntary contraction to a small degree in
the four-day period following a muscle damaging exercise bout, and reduces muscle soreness to a
potentially practically irrelevant degree in the three-day period following a muscle damaging
exercise bout. Whether these benefits translate to improved athletic performance remains
questionable, though.
Have you tried flavonoid polyphenols? What have been your

experiences? Share them in the private Examine Members
Facebook forum!
71
 References
1. ^ Stéphanie Hody, et al. Eccentric Muscle Contractions: Risks and Benefits. Front
Physiol. (2019)
2. ^ Daniel J Owens, et al. Exercise-induced Muscle Damage: What Is It, What Causes
It and What Are the Nutritional Solutions?. Eur J Sport Sci. (2019)
3. ^ Robert D Hyldahl, Monica J Hubal. Lengthening our perspective: morphological,
cellular, and molecular responses to eccentric exercise. Muscle Nerve. (2014)
4. ^ Peake JM, et al. Muscle damage and inflammation during recovery from exercise. J
Appl Physiol (1985). (2017)
5. ^ a b A N Panche, A D Diwan, S R Chandra. Flavonoids: an overview. J Nutr Sci.
(2016)
6. ^ Taylor K Bloedon, et al. Impact of anthocyanin-rich whole fruit consumption on
exercise-induced oxidative stress and inflammation: a systematic review and meta-
analysis. Nutr Rev. (2019)
7. ^ Joanna Bowtell, Vincent Kelly. Fruit-Derived Polyphenol Supplementation for
Athlete Recovery and Performance. Sports Med. (2019)
8. ^ Rong Tsao. Chemistry and biochemistry of dietary polyphenols. Nutrients. (2010)
9. ^ R Herbert, A Moseley, C Sherrington. PEDro: a database of randomised controlled
trials in physiotherapy. Health Inf Manag. (1998)
10. ^ Meghan A Brown, Emma J Stevenson, Glyn Howatson. Montmorency tart cherry
(Prunus cerasus L.) supplementation accelerates recovery from exercise-induced
muscle damage in females. Eur J Sport Sci. (2019)
11. ^ Koch AJ, Pereira R, Machado M. The creatine kinase response to resistance
exercise. J Musculoskelet Neuronal Interact. (2014)
12. ^ Warren GL, Lowe DA, Armstrong RB. Measurement tools used in the study of
eccentric contraction-induced injury. Sports Med. (1999)
14. ^ Patricia Cosme, et al. Plant Phenolics: Bioavailability as a Key Determinant of Their
Potential Health-Promoting Applications. Antioxidants (Basel). (2020)
15. ^ Henry J Forman, Kelvin J A Davies, Fulvio Ursini. How do nutritional antioxidants
really work: nucleophilic tone and para-hormesis versus free radical scavenging in
vivo. Free Radic Biol Med. (2014)
72
16. ^ Anna Tresserra-Rimbau, Rosa M Lamuela-Raventos, Juan J Moreno. Polyphenols,
food and pharma. Current knowledge and directions for future research. Biochem
Pharmacol. (2018)
17. ^ Leonardo C R Lima, et al. Consumption of An Anthocyanin-Rich Antioxidant Juice
Accelerates Recovery of Running Economy and Indirect Markers of Exercise-Induced
Muscle Damage Following Downhill Running. Nutrients. (2019)
18. ^ D A J Connolly, et al. Efficacy of a tart cherry juice blend in preventing the
symptoms of muscle damage. Br J Sports Med. (2006)
19. ^ Justin R Trombold, et al. Ellagitannin consumption improves strength recovery 2-3
d after eccentric exercise. Med Sci Sports Exerc. (2010)
73
Investigating the efficacy of protein
supplementation for older people with and
without resistance training
 Tags: Resistance Training, Older Adults, Exercise, Supplementation, Protein
 Study under review: The effect of daily protein supplementation, with or without
resistance training for 1 year, on muscle size, strength, and function in healthy older adults:
A randomized controlled trial
Quick Takes
• What was the question? Can protein supplementation, with
or without resistance training, prevent age-related declines in
muscle mass and strength?
• How was it answered? Researchers conducted a
randomized controlled trial (RCT).
• Who was studied? Healthy people at least 65 years old
made up the participant population.
• What was the intervention? Participants were assigned to
one of five groups over the course of a year. The control
group received 30 grams of carbohydrates twice a day. The
second group received 20 grams of collagen plus 10 grams
of carbs twice a day. The final three groups all received 20
grams of whey protein plus 10 grams of carbs twice a day,
74
combined with either light resistance training with resistance
bands, heavier full body resistance training, or no training.
• What’s the main takeaway? The combination of whey with
heavy training resulted in increases in muscle strength, size,
and function compared to supplementing whey alone. The
light training plus whey group experienced increases in
function only. No other group saw clear benefits.
• Any caveats? A large proportion of participants didn’t report
how well they complied with supplementation. This leaves
open the possibility that the participants took more or less
whey, protein, or collagen than the target doses. Also, there
was no group looking at the effects of resistance training
alone, making it difficult to say whether protein
supplementation was a necessary add-on.
What was the question?

Can protein supplementation, with or without resistance training for one year, increase muscle
mass, strength, and function in healthy adults older than 65?
Why was the question worth asking?

Age-related loss of muscle size (sarcopenia) and function (dynapenia)[1] is a significant problem in
people older than 65. Longitudinal studies[2] suggest that muscle size and function are lost
incipiently from middle age at a rate of 0.1–1% and 3–4% per year, respectively, leading to
physical frailty and impaired whole-body metabolic health with age. In severe instances, age-
related sarcopenia can lead to about 50% lost muscle mass by the 8–9th decade of life[2]. Not
75
surprisingly, these losses of muscle size and function are associated with an increased risk for all-
cause mortality[3] and chronic diseases such as diabetes[4], arthritis[5], and cancer[6].
As physical activity and food intake are the two major controllable factors influencing muscle mass
and function[1], resistance exercise[7] and higher protein intake[8] are recommended for older adults
to counteract the negative consequences of age-related sarcopenia. While physical strength
training is evidently the most potent method[9] of maintaining and increasing muscle size[10] and
strength[11], adherence rates for heavy resistance training in older adults[12] can be insufficient to
achieve optimal effects. Instead, light-weight training (e.g., using rubber bands at home) has been
recommended as a way of effectively enhancing muscle mass, albeit with less pronounced effects
than heavy resistance training[13]. In fact, a recent meta-analysis[14] found that heavy training loads
led to more considerable strength gains, but also reported that light to moderate resistance training
could be sufficient to gain muscle mass.
In addition to resistance training, research suggests that higher protein intakes could be
recommended for older adults[15] to prevent the age-related loss of muscle mass and function. As
higher protein intake is positively associated with the formation and preservation of muscle mass in
adults older than 65[16], the daily recommended protein intake for older adults[8] has been
increased[17] to 1.1–1.3 grams of protein per kilogram of body weight (g/kg) by nutrition societies
worldwide. In contrast to these recommendations, older adults generally consume less than the
recommended amount[18]. In the U.S., for example, 40% of elderly people consume less than 0.8 g/
kg, and 60% consume less than 1.0 g/kg. Thus protein supplements such as whey (one of the best
proven protein supplements to date[19]) could be helpful for older adults seeking to increase their
total protein intake. However, intervention[20] studies[21] showed mixed results when investigating
whether protein supplementation alone could prevent age-related sarcopenia. Also, protein
supplements made of collagen hydrolysate are becoming more popular, e.g., for treating
osteoarthritis[22] and to counteract age-related muscle loss[23].
Overall, the topic remains highly debated in the literature, and more evidence from longer-term
intervention trials are needed[15] that examine the efficacy of increased protein intakes in older
people to support skeletal muscle health. Two possible caveats of these previous studies are their
limited durations (less than six months) and not controlling for protein quality. The researchers
conducting the present study[24] aimed to fill this gap by conducting a one-year RCT to investigate
the effect of protein supplementation, with or without resistance training, on muscle size and
function in healthy adults older than 65.
Age-related loss of muscle mass and function (sarcopenia) is

associated with physical frailty, increased risk for chronic diseases,
76
and all-cause mortality in older adults. Higher protein intakes and
resistance training are recommended to prevent age-related
sarcopenia. However, previous intervention studies showed mixed
results and were limited in duration to less than six months. The
present study was a one-year RCT designed to shed more light on
this issue.
How was the question answered?

The researchers conducted a preregistered, one-year RCT called ‘Counteracting Age-related Loss
of Skeletal Muscle Mass’ or CALM, for short. The CALM study was designed[25] to examine the
effect of protein supplementation twice a day alone and combined with light or heavy resistance
training on muscle size, strength, and function in 208 healthy older adults (53% men, 47% women)
with a mean age of 70 ± 4 years. Overall, there were three intervention groups supplementing
carbohydrates (20 grams of maltodextrin plus 10 grams of sucrose), collagen (20 grams of bovine
collagen hydrolysate plus 10 grams of sucrose), and whey (20 grams of whey protein hydrolysate
plus 10 grams of sucrose). The researchers also tested the effect of whey protein supplementation
combined with light intensity (home training with rubber bands, three to five times per week) and
heavy resistance training (center-based, supervised full-body workout, three times per week). The
heavy resistance training program was about an hour long and consisted of three exercises for the
lower extremities (leg extensions, leg press, and leg curls) and two upper-body exercises (pull-
down, chest press). The researchers also periodized the training into three-month cycles,
increasing the load progressively from hypertrophy (3 sets of 12 repetitions) to heavier training (5
sets of 6 repetitions) each cycle. The light training group was instructed to mimic the muscle groups
and movements used in the heavy training program using bands instead.
The average starting protein intakes and how much those intakes changed over the course of the
study are laid out in Figure 1.
Figure 1: Average change in total protein intake over

the course of the 12-month study for each group
77
The primary outcome was the change in quadricep muscle size after one year of intervention
compared to baseline, assessed by the MRI-measured change in quadricep cross-sectional area
(qCSA). Secondary outcomes included lower extremity strength and function. To quantify muscle
strength of the quadriceps, the researchers tested the maximal voluntary isometric contractions
(MVIC) using isokinetic dynamometry[26] – a standardized and reliable method to quantify muscle
strength (see sidebar). The researchers also determined the dynamic peak torque (DPT) and the
rate of force development (RFD) to quantify muscle function. In addition, the researchers measured
the body composition of the participants to determine changes in the lean tissue mass and body fat
percentage. Also, the general activity level (i.e., daily steps), functional capability (as assessed by
the 400-meter walk test), dietary intake, and self-perceived quality of life were measured. To
control for other age-related complications that could interfere with the study outcome, the
researchers monitored participant insulin resistance (glycated hemoglobin), kidney function
(creatinine levels), and lipid profiles (cholesterol and triglycerides).
Measuring muscle strength and function
78
using isokinetic dynamometry
Isokinetic dynamometry[26] is a standardized, reliable method used to quantify muscle
strength during isokinetic muscle contraction. First introduced in 1967[27], isokinetic
dynamometry has become the gold standard for assessing muscular strength and
functionality among athletic populations and populations engaging in rehabilitation
programs. During an isokinetic muscle contraction[26], a muscle shortens as it contracts but,
unlike an isotonic contraction, it does so at a consistent rate of speed. In a sense, isokinetic
dynamometers are passive devices that resist the forces applied by the muscle and control
the speed of exercise at a predetermined rate, thus providing a record of applied force
throughout a joint range of motion. Muscle strength is usually given as the peak torque,
while muscle function is measured by the dynamic peak torque (DPT) and rate of force
development (RFD). Previous studies[28][29] have verified the reproducibility[30] and
reliability[31] of the MVIC measurement. However, there are limitations to the MVIC test[32],
including, for example, gravitational errors, which depend on the angular position and torque
potential and require correction.
The study under review was a one-year RCT examining the effects
of protein supplementation alone or in combination with light or
heavy resistance training on muscle mass, strength, and function
in 208 healthy older adults.
What was the answer?

Overall, only heavy resistance training plus whey supplementation significantly improved muscle
mass, strength, and function of healthy older adults after one year. The researchers found no
significant differences between protein supplementation alone (collagen and whey) compared to
carbohydrates for any measured parameters, even though protein supplementation increased the
total daily protein intake by about 20–35 grams. No negative effects on the measured health
parameters were found in any groups.
79
The whey plus heavy resistance training group showed significantly improved muscle size (qCSA
+1.68 m2, +3%), strength (MVIC +23.9 Nm, +14%), function (DPT +18.4 Nm, +12% and RFD +73.5
Nm/s, +12%), improved functional capability (400-meter gait times), and lean tissue mass (+0.4 kg,
+1%) compared to whey alone. In contrast, the whey plus light-intensity training group showed no
significant changes in muscle size and strength, functional capability, and lean body mass
compared to whey alone. However, light-intense training supplemented with whey protein
significantly increased muscle function (DPT +13.7 Nm, +9%) with a non-significant but notable
increase in RFD (+52.1 Nm/s, +8%). Also, the adherence rates were higher for light training (89%),
compared to heavy resistance training (72%).
Protein supplementation alone didn’t improve any measured

parameter. Adding heavy resistance training improved muscle
mass, strength, and function. Light training plus supplementation
only improved muscle function, although adherence rates were
higher than for the heavier intensity group.
How much should you trust the answer?

The present study contributes valuable data to the highly debated question if increasing dietary
protein intake alone improves muscle mass and strength in older adults. The results suggest that,
in people with habitual protein intakes of more than 1.0 g/kg per day, protein supplementation
alone is ineffective. Light resistance exercise plus whey had a small effect on muscle function. Only
heavy training plus whey increased muscle size, strength, and function significantly. To assess how
much confidence can be placed in these results, the present study’s findings and its intrinsic
limitations need to be viewed from a physiological standpoint, in direct comparison to other trials.
Also, the practical relevance of the observed effects needs to be discussed.
Overall, these results make sense from a physiological standpoint. Inadequate protein intakes and
physical inactivity promote age-related muscle atrophy[1]. Muscle mass is regulated by the dynamic
balance of muscle protein synthesis (MPS) and breakdown (MPB), which are influenced, among
other factors, by food intake and physical activity. Protein intake stimulates MPS by providing
essential amino acids as building blocks and the branched-chain amino acid leucine as a trigger,
while suppressing MPB, as triggered by increasing intracellular amino acid concentrations.
80
However, this process is often impaired in older adults through a phenomenon also called ‘anabolic
resistance’ during which the anabolic stimuli of protein intake are dampened due to age-related
metabolic changes. As summarized in Figure 2, anabolic resistance can set off a vicious cycle in
older adults, which can increase disease risk. Two recent meta-analyses[33][34] have explored the
effects of anabolic resistance in more detail. Anabolic resistance may explain why the present
study only found significant effects for heavy resistance training combined with whey protein
supplementation. Overall, these results suggest that both higher protein intake and resistance
training with sufficient load are required for optimal effects. Future studies should investigate if
heavy resistance training alone would be sufficient, or whey protein supplementation is specifically
required.
Figure 2: The vicious cycle of anabolic resistance
Adapted from: Beaudry et al. Front Nutr. 2019 Aug.[35]
Another physiologically relevant distinction is muscle size, as opposed to muscle strength. A

quantitative review from 2012[2] found that older adults lose muscle strength two to five times faster
81
than muscle size. Thus, the researchers concluded that loss of strength is a more consistent risk
for disability and death than loss of muscle mass. In the present study, the positive effects of heavy
resistance training plus whey were more pronounced for muscle strength (+19%) than for muscle
size (+3%). Assuming muscle strength is a better predictor of reduced risk for future disability, the
improvements in muscle strength found in the present study may be more important than the gains
in muscle size. Nevertheless, this raises a vital question: why were the improvements in muscle
strength so much higher than gains in muscle size? To answer this question, consider the results of
previous trials and potential mechanisms.
While the improvements in strength (MVIC +14%) and function (DTP +9%) induced by heavy
resistance exercise plus whey supplementation were comparable to previous studies[36][37], the
gains in muscle mass (qCSA +3%) were lower than the 5–10% improvements reported by several
other trials[38][39][40]. However, other intervention studies[41][42][43] also report lower than expected
gains in muscle size. Overall, the evidence shows a wide spectrum of muscle size gains, while
improvements in muscle strength are more consistent. One possible explanation is the different
adherence rates observed in these studies, necessarily leading to diverse outcomes. Another
potential reason is the underlying mechanism of muscle deterioration, which is primarily driven by
two interrelated processes: muscle fiber atrophy and muscle fiber loss. While reversing muscle
fiber atrophy (i.e., hypertrophy), muscle fiber loss is often accompanied by loss of muscle stem
cells[44] and neuromuscular degeneration[45], meaning the loss of neurons on skeletal muscles. As
a consequence, loss of neuromuscular junctions [46](i.e., the crossroad where neurons and
muscles connect) leads to denervated fibers, reducing voluntary control of the muscle. This
process contributes significantly to age-related anabolic resistance, which could explain the
general divergence of muscle size and strength gains, with the latter being promoted by increased
reinnervation, improving voluntary muscle activation. However, these putative mechanisms of
neuromuscular remodeling are still subject to basic physiological research, and thus need to be
viewed with caution. In the light of this still ongoing research, interpretation of the present study is
limited.
Besides these limitations in physiological understanding, the present study has three notable
limitations worth discussing. First, the authors recruited only healthy, well-functioning participants
with a rather active lifestyle and already high protein intakes of about 1.2 g/kg/d (which is higher
than 80% of the elderly population[18]). This makes it difficult to extrapolate the present study’s
findings to older people in general, as the average adult older than 65 is often less active and
eating less energy and protein than participants in the study under review.
Second, adherence rates were suboptimal. About 20% of participants did not report their
adherence to the dietary supplement and the actual protein intake was only calculated, not
measured. This issue is related to the general lack of dietary control (e.g., via repeated
questionnaires), which is a significant source of error in this study. Thus, estimated protein intakes
82
calculated for the supplement alone groups need to be viewed with caution. Insufficient protein
intakes in these intervention groups would explain why whey protein alone did not improve muscle
mass without resistance training. Also, most participants reported being on vacation for 3–4 weeks
during the intervention, meaning they did not engage in resistance training for a prolonged
duration. These training pauses could have negatively affected the gains in muscle size, strength,
and function. In fact, a previous study[47] found that only one month of detraining could completely
reverse the muscle mass and strength gains from a six-month training program.
Lastly — and this is one of the most important caveats — the study lacked a control group for
training without supplementation. Such a control group would have been important to test whether
whey protein supplementation positively affected the improvements in muscle mass, strength, and
function observed for the high resistance training group. For example, a recent meta-analysis[48]
suggests that whey protein supplementation can improve adaptation to resistance training in older
adults. However, another systematic review[49] found no beneficial effects of protein
supplementation in resistance-exercising older adults. Future studies are needed to verify if whey
protein could be helpful to augment resistance training in older adults.
Assuming future research verifies the present study results, the positive effects of heavy resistance
training plus whey may have practical and clinical relevance for older adults. Higher muscle mass,
strength, and function are associated with lower risk for physical frailty[50], cardiovascular disease
incidence[51], and all-cause mortality[52]. Also, the significant improvements in the 400-meter walk
test observed in the heavy resistance plus whey group suggest generally improved general fitness.
Previous research indicates that 400-meter gait times can predict the functional capability[53] of
older adults and is associated with an increased risk for mortality, cardiovascular disease, mobility
limitation, and mobility disability[54]. However, it remains to be researched if the improvements in
400-meter gait times found in the present study (about 8 seconds) have any practical relevance on
the measured outcomes. Again, extrapolating a one-year study to several decades of older age is
uncertain, and thus requires RCTs with longer durations. The present study, being one of the few
studies that lasted longer than six months, is an important first step in the right direction.
The present study confirms that heavy resistance training (plus

whey protein supplementation) is a potent method for preserving
and even increasing muscle size, strength, and function in older
adults. However, the researchers found no beneficial effects for
protein supplementation only. One possible explanation is that the
participants were already healthy and well-functioning, which is not
83
the case for older people in general. More studies are needed to
examine the role of protein supplementation in improving muscle
mass, strength, and function in elderly people.
What’s the take-home?

Increasing daily protein intake by consuming 20 grams of either whey or collagen protein twice a
day had no beneficial effects on the ability of adults older than 65 to preserve or increase muscle
mass, strength, or function. In addition to heavy resistance training, however, whey effectively
improved muscle size, strength, and function, as well as functional capability and lean body mass.
Light resistance exercise plus whey protein supplementation was inferior to heavy training, showing
no effects on muscle size and strength, but improving some aspects of muscle function.
The present study’s findings indicate that heavy resistance training is the most effective way to
preserve and increase muscle mass, strength, and function to counteract age-related sarcopenia.
However, it remains to be investigated if heavy resistance training alone would be as effective as
heavy resistance training plus whey protein supplementation.
Do you or will you be lifting heavy as you get older? Share your
experience in the private Examine Members Facebook forum.
84
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effect of protein supplementation on resistance training-induced gains in muscle mass
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49. ^ Danielle K Thomas, et al. Protein Supplementation Does Not Significantly Augment
the Effects of Resistance Exercise Training in Older Adults: A Systematic Review. J
Am Med Dir Assoc. (2016)
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Nutr Health Aging. (2011)
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88
Betaine supplementation: a double-edged
sword for CVD markers
 Tags: Supplementation, CVD, Meta-analysis
 Study under review: Effects of betaine supplementation on cardiovascular markers: A

systematic review and Meta-analysis
Quick Takes
• What was the question? How does betaine
supplementation affect the biomarkers of cardiovascular
disease?
• How was it answered? Researchers conducted a meta-
analysis of randomized controlled trials.
• Who was studied? About half the studies involved healthy
participants, and half included participants with a wide variety
of conditions, ranging from chronic renal failure to fatty liver.
• What was the intervention? Participants took 1.5 to 20
grams of betaine daily (median: 4 grams) for 2–52 weeks.
• What’s the main takeaway? Betaine lowered homocysteine
levels, but also raised total and LDL cholesterol levels by
clinically significant amounts: about 14 mg/dL and 10 mg/dL,
respectively. Subgroup analysis suggested that doses under
4 grams still lowered homocysteine levels without necessarily
89
raising cholesterol, but the uncertainty in the subgroup
analyses was large.
• Any caveats? The evidence mostly consists of small trials in
a wide variety of populations. More evidence is needed to
confirm whether supplementation of doses under 4 grams
raises LDL and total cholesterol levels and whether this
offsets any risk lowering that may be associated with lower
homocysteine levels.
Introduction
Complex systems tend to have weak points by nature of being made up of many interwoven parts.
Identifying a weak point is a great way to approach what may seem like an insurmountable
problem. Many diseases are both complex and can appear overwhelming when it comes to curing
them or treating the associated symptoms. But if a disease state has a weak point, those
weaknesses can be targeted.
One possible weakness when it comes to targeting cardiovascular disease (CVD) is high
homocysteine levels. Homocysteine might be considered the weak point of the complex, metabolic
sensing [1]homocysteine-methionine cycle (see sidebar). Elevated homocysteine is a disease
biomarker[2] that is generally recognized as an independent risk factor for CVD, suggesting that
interventions that lower homocysteine can also lower the risk of CVD. However, this idea is quite
controversial because it’s not clear[3] whether high homocysteine is a consequence or a cause of
CVD. This uncertainty hasn’t stopped research looking at interventions that reduce homocysteine
levels, which is understandable given that CVD is the leading cause[4] of global mortality, and
homocysteine levels could be a modifiable risk factor[5]. Beyond ensuring adequate status of
vitamins B6[6], B9[6] (folate), and B12[6], which can support the homocysteine-methionine cycle,
supplementation of betaine has emerged as a potential homocysteine-lowering intervention, as it is
involved in another transmethylation pathway independent of[7] B vitamin intake.
90
The homocysteine-methionine cycle in a
nutshell
The homocysteine-methionine cycle[5] is a key metabolic cycle that senses[1] many other
biochemical processes and serves multiple functions. One of its key roles is to produce
S-adenosyl-methionine, which is a direct methyl donor for various pathways involving
synthesis of proteins, creatine, phospholipids, hormones, polyamines, carnitine, adrenaline,
and DNA methylation. Methylation[1] is essential for modification of DNA, RNA, protein, and
other small molecules. It allows for regulation of gene expression, activation, and
stabilization. Following methyl transfer, S-adenosyl-methionine converts to S-adenosyl-
homocysteine that is then transformed to homocysteine to allow for its remethylation to
methionine and the continuation of the cycle. As you can see in Figure 1, homocysteine can
be remethylated back to methionine via two transmethylation (methyl group transport)
pathways involving either vitamin B12 or betaine, or can be metabolized into cysteine via a
vitamin B6-dependent pathway. Thus, abnormally high homocysteine levels can indicate
that something is wrong within the homocysteine-methionine cycle.
Reference: Craig. Am J Clin Nutr. 2004 Sep.[8]
Betaine (trimethylglycine) is a methyl derivative of the amino acid glycine that has been
demonstrated to have an inverse relationship with homocysteine levels. Betaine is mainly present
in the liver and kidney and its main physiological functions[8] are to maintain fluid balance
(supporting cell integrity and waste disposal) and donate methyl groups (supporting homocysteine
metabolism; see sidebar). Grains are the main source[9] of betaine in the Western diet, while beets,
spinach, and shrimp are also good sources, though are not as commonly consumed. Dietary intake
of betaine generally ranges from 1 to 2.5 grams per day.
Figure 2: The lowdown on some high-betaine foods
91
Reference: Zeisel et al. J Nutr. 2003 May.[10]
While a meta-analysis[11] of five randomized controlled trials (RCTs) suggests that supplementing
4–6 grams of betaine per day for at least six weeks can lower plasma homocysteine concentrations
by up to 12% in healthy people, this potential benefit may come at a cost: some of the included
studies reported increases in total cholesterol and low density lipoprotein cholesterol (LDL-C),
which are well-established biomarkers[12] of CVD risk. However, another study[13] demonstrated no
change in homocysteine or lipid profile following betaine supplementation, when a recent
systematic review and meta-analysis[14] found that supplementation with at least 4 grams of
betaine per day can moderately increase total cholesterol, but not LDL-C. Thus, both the benefits
and drawbacks of betaine supplementation are still quite unclear.
The authors of the systematic review and meta-analysis under review aimed to provide further
insights on this topic by exploring the latest evidence of how betaine affects CVD markers, taking
dose into account.
Betaine is a substance involved in the homocysteine-methionine
92
cycle. It has been demonstrated to exert controversial effects on
cardiovascular disease (CVD) markers in trials, in that
supplementation has the potential to reduce homocysteine levels,
but may also increase total and LDL cholesterol. The authors of
the systematic review and meta-analysis under review aimed to
determine an optimal dosage that might reduce homocysteine
without increasing blood lipids.
What was studied?

This systematic review and random effects meta-analysis evaluated 12 human RCTs that
evaluated the effect of betaine supplementation on CVD markers.
Seven studies included healthy participants, while the other five studies involved participants with
chronic renal failure, nonalcoholic steatohepatitis, mildly elevated homocysteine, prediabetes, and
mild fatty liver disease. The mean age of participants ranged from 21 to 63 years, their BMI varied
from 23 to 34, and a majority (60%) of participants were men. Betaine dosage ranged from 1.5 to
20 grams per day (median: 4 grams per day), while duration of intervention varied from 2 to 52
weeks and sample sizes ranged from 24 to 78 participants. Studies were excluded if the treatment
duration was less than 2 weeks or if there was no control group.
Outcomes of interest included homocysteine, dimethylglycine (a betaine metabolite), methionine,

lipid profile, C-reactive protein, blood pressure, and liver enzymes. Only the mean change and
standard deviation from baseline to endpoint were considered for each outcome measure.
Subgroup analysis based on body mass index (BMI; healthy, overweight, obese), study duration (at
least 8 weeks or less than 8 weeks), and supplement dose (at least 4 grams or less than 4 grams
per day) were conducted.
The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials and the Grading of
Recommendations Assessment, Development, and Evaluation (GRADE) framework were used to
assess study quality and strength of outcome evidence, respectively. Sensitivity analysis was
conducted by removing each study and recalculating the pooled effect of the remaining studies.
Publication bias was monitored by using Begg’s rank correlation[15] test, Egger’s regression
asymmetry[16] test, and a funnel plot visual test. The study was not preregistered and followed
93
PRISMA guidelines.
This random effects systematic review and meta-analysis identified

12 human RCTs that evaluated the effect of betaine
supplementation on CVD markers, including homocysteine, lipid
profile, and more. Seven of the 12 studies included healthy adults,
while the five others included participants with different ailments.
Follow-up periods lasted from 2 to 52 weeks and used doses of
1.5–20 grams of betaine per day (median: 4 grams per day).

Betaine supplementation decreased homocysteine concentrations by -1.3 micromoles per liter.
Subgroup analysis suggests this occurs at all intervention doses and durations. However,
supplementation also increased total cholesterol by 15.5 mg/dL and LDL-C by 10.3 mg/dL. Here,
subgroup analysis only found statistically significant results at doses greater than 4 grams per day.
These results are plotted in Figure 3.
Figure 3: Change in LDL and total cholesterol with

betaine supplementation (with 95% confidence
intervals)
94
Betaine supplementation did not have a statistically significant effect on serum triglyceride, HDL
cholesterol, liver enzyme, blood pressure, C-reactive protein, or fasting blood glucose levels.
However, it did boost serum betaine levels, as well as two main byproducts of homocysteine
metabolism, dimethylglycine, and methionine, which indicates the participants in the included trials
tended to comply with the treatment protocol and that supplementation had some biochemical
effects on the homocysteine-methionine cycle.
Ten studies were classified as high-quality studies, while two were of low quality. The quality of
evidence was low for most outcomes, except for total, LDL, and HDL cholesterol, homocysteine,
and some liver enzymes. Heterogeneity was high for serum betaine, methionine, and
95
dimethylglycine, and moderate for homocysteine, LDL cholesterol, triglycerides, C-reactive protein,
blood pressure, and some liver enzymes. Publication bias was detected only for betaine when
using Egger’s test. Sensitivity analysis showed a substantial change in effect size for methionine
following the removal of one specific study[17].
Betaine supplementation decreased homocysteine concentrations

at all intervention doses and durations. Supplementation raised
total and LDL cholesterol when betaine doses exceeded 4 grams
per day. The quality of evidence was low for most of the other
outcomes and a moderate to high level of heterogeneity across
biomarkers was reported.
The bigger picture

The decreases in homocysteine and increases in methionine and dimethylglycine from the study
under review confirms that betaine supplementation does help to normalize the homocysteine
methionine cycle. A previous meta-analysis[11] involving most of the same studies reached a similar
conclusion. However, while homocysteine is a biomarker of CVD, it is still intensely debated[3]
whether high homocysteine levels are a consequence or a causative factor of CVD. A systematic
review and random effects meta-analysis[18] of six prospective studies did not find an association
between dietary choline (a precursor to betaine) or betaine and CVD incidence and mortality,
despite their ability to reduce homocysteine[19] levels.
Moreover, although B6, B9, and B12 multivitamin interventions have been shown to reduce
homocysteine levels, only a small effect was found for stroke in a systematic review by the
Cochrane Collaboration[6], and no effect was found for myocardial infarction or overall mortality.
Differences may also depend on variations in genes[20] related to homocysteine and vitamins B6,
B9, and B12. In another study, B vitamins also did not alter the occurrence of CVD outcomes
(stroke, angioplasty, CVD death) in kidney transplant recipients[21].
So, while the study under review found that betaine lowered homocysteine levels, it’s far from clear
that this effect could translate into disease prevention when all the evidence discussed above is
taken into account. What’s more concerning is that this study found that betaine raises two more
well-founded cardiovascular risk markers: total and LDL cholesterol. However, the study also found
96
some evidence that betaine doses under 4 grams per day may hit the sweet spot of lowering
homocysteine while not having a statistically significant effect on cholesterol levels. While this
agrees somewhat with another recent meta-analysis[14] that reported increases in total cholesterol
following betaine supplementation of at least 4 grams per day, statistical significance can be
deceiving. The 95% confidence intervals in Figure 3 show that there’s a lot of uncertainty in the
subgroup analyses. More evidence is needed before it can be said that doses under 4 grams won’t
bump cholesterol levels. A possible explanation[22] for the increase in blood lipids is that the
supplemental betaine is sparing its precursor, choline, which can then go on to become
phosphatidylcholine that is necessary for very-low-density lipoprotein (VLDL, a precursor of LDL)
metabolism, but this is a very speculative mechanism.
Overall, the results from the study under review should also be interpreted with caution, as there
was high heterogeneity and a lack of adequate studies for several biomarkers, small sample sizes
with varying populations and health statuses, and a small number of studies for subgroup
analyses. Given these weaknesses, a bit of skepticism is warranted concerning the possible benefit
of betaine supplementation, even at doses under 4 grams per day. One thing can be said with
certainty: betaine’s role in CVD prevention is complicated!
This study supports the idea that betaine supplementation lowers

homocysteine levels at any dose, but also suggests that doses
above 4 grams per day are associated with increases in total
cholesterol that could offset the putative CVD benefits of reduced
homocysteine levels. However, the uncertainty of those estimates,
the small number of studies in the subgroup analyses, and the
unknowns involving homocysteine’s possible role in CVD, leads to
a lot of unanswered questions regarding the possible benefits of
betaine.

Q. Does betaine from supplements have different effects than betaine from food?
Obtaining betaine from the diet may help counteract any adverse effects on blood lipids. A
97
crossover study[23] in eight men comparing a betaine-rich diet (800 mg per day) with a betaine
supplement (500 mg twice per day) for 14 days demonstrated a decrease in LDL cholesterol on
day 13 for participants following the betaine-rich diet, while the supplement group did not
experience a change. Both groups attenuated a post-methionine load rise in homocysteine levels.
Q. What else might betaine be good for?
Studies have demonstrated potential for improving body composition[24] and physical performance,
as well as for schizophrenia[25], longevity[26], and reducing cancer risk[27]. Due to its role in fluid
balance[28], betaine is mostly present in the liver and kidneys and is involved in their functioning as
well. Studies evaluating betaine supplementation for liver disease have demonstrated mixed
results[29]. However, most of the literature for these uses is rather sparse and the mechanisms are
unclear.
Q. Since choline is a precursor to betaine, why not supplement choline instead?
Choline is essential for proper liver, muscle, and brain function, lipid metabolism, and cell
membrane maintenance, along with its role as a precursor for betaine. As a substrate, choline is a
bottleneck and low, if not insufficient, choline[30] intakes have been previously reported by people
following a Western diet. Supplementation with betaine targets homocysteine remethylation
directly, thus sparing choline[31] for its other essential roles. If choline were supplemented, there is
a chance that choline might be used for its various other functions instead of being converted to
betaine for homocysteine reduction. For this reason, choline supplementation would be a much
less precise intervention.
What should I know?

This random effects systematic review and meta-analysis of 12 RCTs suggests that betaine
supplementation can lower homocysteine levels. The analysis also suggested that doses of 4
grams or higher could raise LDL and total cholesterol. The data suggested that lower doses may
not bump blood lipids, but due to the low number of studies and high uncertainty in the
measurements, more research is needed to confirm that lower-dose betaine doesn’t adversely
affect blood lipids.
Bet betaine helps with CVD? Let us know your thoughts in our
private Examine Members Facebook Forum!
98
99
 References
1. ^ a b c Wen Shen, et al. Homocysteine-methionine cycle is a metabolic sensor
system controlling methylation-regulated pathological signaling. Redox Biol. (2020)
2. ^ A D Smith, H Refsum. Homocysteine - from disease biomarker to disease
prevention. J Intern Med. (2021)
3. ^ a b Steven G Chrysant, George S Chrysant. The current status of homocysteine as
a risk factor for cardiovascular disease: a mini review. Expert Rev Cardiovasc Ther.
(2018)
4. ^ Simon Barquera, et al. Global Overview of the Epidemiology of Atherosclerotic
Cardiovascular Disease. Arch Med Res. (2015)
5. ^ a b Avinash Kumar, et al. The metabolism and significance of homocysteine in
nutrition and health. Nutr Metab (Lond). (2017)
6. ^ a b c d Arturo J Martí-Carvajal, et al. Homocysteine-lowering interventions for
preventing cardiovascular events. Cochrane Database Syst Rev. (2017)
7. ^ Steenge GR, Verhoef P, Katan MB. Betaine supplementation lowers plasma
homocysteine in healthy men and women. J Nutr. (2003)
8. ^ a b Craig SA. Betaine in human nutrition. Am J Clin Nutr. (2004)
9. ^ Alastair B Ross, Alicia Zangger, Seu Ping Guiraud. Cereal foods are the major
source of betaine in the Western diet--analysis of betaine and free choline in cereal
foods and updated assessments of betaine intake. Food Chem. (2014)
10. ^ Zeisel SH, et al. Concentrations of choline-containing compounds and betaine in
common foods. J Nutr. (2003)
11. ^ a b Marc P McRae. Betaine supplementation decreases plasma homocysteine in
healthy adult participants: a meta-analysis. J Chiropr Med. (2013)
12. ^ Ravi Dhingra, Ramachandran S Vasan. Biomarkers in cardiovascular disease:
Statistical assessment and section on key novel heart failure biomarkers. Trends
Cardiovasc Med. (2017)
13. ^ Schwab U, et al. Long-term effect of betaine on risk factors associated with the
metabolic syndrome in healthy subjects. Eur J Clin Nutr. (2011)
14. ^ a b Emilia E Zawieja, Bogna Zawieja, Agata Chmurzynska. Betaine
Supplementation Moderately Increases Total Cholesterol Levels: A Systematic
Review and Meta-Analysis. J Diet Suppl. (2021)
15. ^ C B Begg, M Mazumdar. Operating characteristics of a rank correlation test for
100
publication bias. Biometrics. (1994)
16. ^ Egger M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ.
(1997)
17. ^ Margreet R Olthof, et al. Low dose betaine supplementation leads to immediate
and long term lowering of plasma homocysteine in healthy men and women. J Nutr.
(2003)
18. ^ Katie A Meyer, Jonathan W Shea. Dietary Choline and Betaine and Risk of CVD: A
Systematic Review and Meta-Analysis of Prospective Studies. Nutrients. (2017)
19. ^ Wendy Atkinson, et al. Dietary and supplementary betaine: acute effects on plasma
betaine and homocysteine concentrations under standard and postmethionine load
conditions in healthy male subjects. Am J Clin Nutr. (2008)
20. ^ Shuai Yuan, et al. Homocysteine, B vitamins, and cardiovascular disease: a
Mendelian randomization study. BMC Med. (2021)
21. ^ Andrew G Bostom, et al. Homocysteine-lowering and cardiovascular disease
outcomes in kidney transplant recipients: primary results from the Folic Acid for
Vascular Outcome Reduction in Transplantation trial. Circulation. (2011)
22. ^ Steven H Zeisel. Betaine supplementation and blood lipids: fact or artifact?. Nutr
Rev. (2006)
23. ^ Atkinson W, et al. Dietary and supplementary betaine: effects on betaine and
homocysteine concentrations in males. Nutr Metab Cardiovasc Dis. (2009)
24. ^ Xiang Gao, et al. Effect of Betaine on Reducing Body Fat-A Systematic Review and
Meta-Analysis of Randomized Controlled Trials. Nutrients. (2019)
25. ^ Tetsuo Ohnishi, et al. Investigation of betaine as a novel psychotherapeutic for
schizophrenia. EBioMedicine. (2019)
26. ^ Andrey A Parkhitko, et al. Methionine metabolism and methyltransferases in the
regulation of aging and lifespan extension across species. Aging Cell. (2019)
27. ^ Shanwen Sun, et al. Choline and betaine consumption lowers cancer risk: a meta-
analysis of epidemiologic studies. Sci Rep. (2016)
28. ^ Stephen A Kempson, Komi Vovor-Dassu, Christopher Day. Betaine transport in
kidney and liver: use of betaine in liver injury. Cell Physiol Biochem. (2013)
29. ^ Sandeep Mukherjee. Role of betaine in liver disease-worth revisiting or has the die
been cast?. World J Gastroenterol. (2020)
30. ^ Sanjiv Agarwal, et al. Comparison of prevalence of inadequate nutrient intake
based on body weight status of adults in the United States: an analysis of NHANES
2001-2008. J Am Coll Nutr. (2015)
31. ^ Taylor C Wallace, et al. Choline: The Underconsumed and Underappreciated
Essential Nutrient. Nutr Today. (Nov-Dec)
101
Credits
Researchers
Antonis Damianou, MSc; Brad Dieter, PhD; Nick Milazzo, MS(c); Thomas Reichhart, MSc; Brandon
Roberts PhD, MS, CSCS; Lucas Roldos, BSc, MSc(c); Jill Ryer-Powder, PhD; Detrick Snyder,
MPH, RDN; Lucas Tafur, PhD; Nattha Wannissorn, PhD, RNH, FDN-P
Editors
Gregory Lopez, MA, PharmD
Reviewers
Stephan Guyenet, PhD & Adel Moussa, PhD
Copy Editor
Dmitri Barvinok
Infographics
Antonius Khengdro & Calla Lee
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Issue #79 May 2021

Nulls: January-February 2021

Deeper Dive: Cinnamon may improve biomarkers of metabolic diseases

Deeper Dive: A spoonful of vinegar might make blood sugar go down

Betaine supplementation: a double-edged sword for CVD markers

 Read this article online at Examine.com

Figure 1: How the menstrual cycle corresponds to

Figure 2: Main macronutrient suggestions for active

Figure 3: Energy availability example

Beta-alanine • Enhances exercise • 4–6 grams/day in 1–2 gram

• Reduces muscle acidity • Muscle carnosine levels may be

Caffeine • Increases athletic Doses of 3–9 mg/kg of body weight result

Calcium • Vital for muscle 1,000 mg/day

• Helpful for bone density

Creatine • Enhances exercise 0.3g/kg of body weight 4 times a day for

• Decreases disease risk in

• Increases fat free mass

• Effective during menses,

• Beneficial for mental

• Beneficial for bone health

Folate Decreases the chance of anemia 400 ug/day

Iron Decreases the chance of anemia 18 mg/day

Omega-3 • Anti-inflammatory Supplement 1–3 grams per day to

• Plays a vital role in growth

• Improves immune function

Probiotics • Regulates immune and • Consuming a multistrain probiotic

tract • Probiotics taken daily should

Riboflavin • Supports skin health • 1.1 mg/day

Vitamin B12 Decreases the chance of anemia 2.4 ug/day

Vitamin D3 Promotes bone health 2,000–4,000 IU is safe and beneficial

Whey • Improves body 20–30 gram boluses throughout the day

• Important for muscle

^ Go back to table of contents

 Read this article online at Examine.com

Keep the following in mind when interpreting a null effect:

Diabetes & blood sugar

Vitamin E supplementation does not seem to affect weight of waist circumference[4]

• What was(n’t) found? No statistically significant effect on weight, BMI, or waist

• What was studied? Researchers evaluated whether Mohana Choorna, a 20-herb

Infants, children & teenagers

Muscle gain & exercise

• What was studied? Researchers meta-analyzed randomized controlled trials to determine

Outside the box

Pain, joints & bones

• What was studied? Researchers evaluated whether 8 grams of vitamin C, 50 mg of zinc

^ Go back to table of contents

 Study under review: Randomized crossover trial of a modified ketogenic diet in

 Read this article online at Examine.com

What was the question?

Why was the question worth asking?

Characteristics of Alzheimer’s disease include dysregulated neuronal mitochondria, pathogenic

Alzheimer’s disease shares characteristics with other conditions

How was the question answered?

Figure 1: Study design

This randomized controlled crossover study involved a 12 week

What was the answer?

Figure 2: Timeline of statistically significant

A modified ketogenic diet resulted in clinically relevant and

This study is the largest and longest randomized crossover trial on

Does this article add to your knowledge of Alzheimer’s disease

^ Go back to table of contents

 Read this article online at Examine.com

Figure 1: Some major bioactive compounds and their

Metabolic diseases affect over a billion people worldwide and pose