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The Journal of Nutrition

Nutrition and Disease

Inorganic Nitrate and Beetroot Juice


Supplementation Reduces Blood Pressure
in Adults: A Systematic Review and
Meta-Analysis1–3
Mario Siervo,* Jose Lara, Ikponmwonsa Ogbonmwan, and John C. Mathers

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Human Nutrition Research Centre, Institute for Ageing and Health, Newcastle University, Campus for Ageing and Vitality,
Newcastle on Tyne, UK

Abstract
Diets including food products rich in inorganic nitrate are associated with lower blood pressure (BP). The evidence for the
BP-lowering effects of inorganic nitrate and beetroot in randomized clinical trials has not been systematically assessed.
The objective was to conduct a systematic review and meta-analysis of randomized clinical trials that examined the effects
of inorganic nitrate and beetroot supplementation on BP. Medline, EMBASE, and Scopus databases were searched from
inception to February 2013. The specific inclusion criteria were: 1) randomized clinical trials; 2) trials reporting effects on
systolic or diastolic BP or both; and 3) trials comparing inorganic nitrate or beetroot juice supplementation with placebo
control groups. Random-effects models were used to assess the pooled BP effect sizes. Sixteen trials met the eligibility
criteria for the systematic review. All studies had a crossover study design. The trials were conducted between 2006 and
2012 and included a total of 254 participants with 7–30 participants/study. The duration of each intervention ranged from
2 h to 15 d. Inorganic nitrate and beetroot juice consumption were associated with greater changes in systolic BP [24.4 mm Hg
(95% CI: 25.9, 22.8); P < 0.001] than diastolic BP [21.1 mm Hg (95% CI: 22.2, 0.1); P = 0.06]. The meta-regression
showed an association between daily dose of inorganic nitrate and changes in systolic BP (P < 0.05). Inorganic nitrate
and beetroot juice supplementation was associated with a significant reduction in systolic BP. These findings need to
be tested in long-term trials and in individuals at greater cardiovascular risk. J. Nutr. 143: 818–826, 2013.

Introduction
Hypertension (DASH) is one of the most effective nutritional
Hypertension exceeds smoking as a causal factor in total attrib- interventions for the prevention and nonpharmacological man-
utable mortality (1). Globally, two-thirds of stroke and one-half agement of hypertension (5,6). The diet highlights the impor-
of ischemic heart disease events are linked to non-optimal blood tance of an increased fruit and vegetable intake (7,8) and recent
pressure (BP)4 control, which contributes to ~13% of all deaths research has suggested that the beneficial effects of the DASH
and 4.5% of all disability-adjusted life years (1). diet on BP are related to the high inorganic nitrate content of
Antihypertensive drugs have attenuated the adverse effects of some of the food products included in the DASH dietary plan
BP on cardiovascular health, but an adequate and sustained control (e.g., green leafy and root vegetables) (9).
of BP is achieved in only ;50% of hypertensive cases (2,3). Larsen et al. (10) tested for the first time in a double-blind
Therefore, nutritional and lifestyle-based interventions are unani- crossover study the effects of sodium nitrate on BP in healthy
mously recognized as important strategies for the primary preven- volunteers and reported a significant reduction in diastolic BP
tion of hypertension and as adjuvants in pharmacological therapies (23.7 mm Hg). Beetroot is particularly rich in inorganic nitrate
to reduce cardiovascular risk (4). The Dietary Approach to Stop content (typically ranging from 110 to 3670 mg nitratekg21) (11)
and it has therefore been utilized in several studies as a nutritional
1
strategy to test the effects of inorganic nitrate intake on BP. For
Author disclosures: M. Siervo, J. Lara, I. Ogbonmwan, and J. C. Mathers, no
conflicts of interest.
example, Webb et al. (12) showed in healthy participants that 24 h
2
Supplemental Figure 1–4 and Supplemental Tables 1–5 are available from the after a single dose of 500 mL beetroot juice, systolic and diastolic
‘‘Online Supporting Material’’ link in the online posting of the article and from the BP were reduced by 10.4 and 8.0 mm Hg, respectively.
same link in the online table of contents at http://jn.nutrition.org. The BP-lowering effects of inorganic nitrate may derive from
3
PROSPERO Database registration: CRD42012002144, http://www.crd.york.
increased generation of nitric oxide (NO) (13,14), a pleiotro-
ac.uk/prospero/.
4
Abbreviations used: BP, blood pressure; cGMP, cyclic GMP; DASH, Dietary
pic molecule involved in the vasodilation of large arteries and
Approach to Stop Hypertension. resistance vessels (13,14). The endothelial isoform of the NO
* To whom correspondence should be addressed. E-mail: mario.siervo@ncl.ac.uk. synthase uses arginine and molecular oxygen as precursors to
ã 2013 American Society for Nutrition.
818 Manuscript received September 28, 2012. Initial review completed November 3, 2012. Revision accepted February 28, 2013.
First published online April 17, 2013; doi:10.3945/jn.112.170233.
tonically release NO in the endothelium, which is important for the search was conducted based on predefined search terms (dietary, inorganic,
control of vascular tone, smooth muscle growth, platelet aggrega- nitrate, beetroot, beet root, BP, hypertension, vascular, NO, endothelial)
tion, and inflammation (15,16). Reduced NO bioavailability has and using specific building blocks (Boolean terms, truncation) to create the
been associated with impairment of endothelial function and algorithms entered in each database. The full details of the algorithms are
reported in the Supplemental Methods (Box 1).
increased risk of hypertension and cardiovascular diseases (17–20).
A nonenzymatic pathway for the generation of NO in humans Selection of studies. Two investigators (M.S., I.O.) assessed articles
has been proposed (nitrate-nitrite-NO pathway), which may con- independently for eligibility. The first screening phase was based on the
tribute to increased NO bioavailability (21). Dietary and endog- analysis of titles and abstracts. When full agreement had been reached,
enous inorganic nitrate molecules may be reduced by facultative the article was either discarded or moved to the next phase. In case of
anaerobic bacteria on the dorsal surface of the tongue to nitrite, disagreement, the article was moved to the next phase to increase the
which can be chemically (low pH) and enzymatically (xanthine inclusiveness level. Reference lists of included papers and relevant reviews
oxidoreductase, myoglobin, cytochrome P450, complexes of the were searched for articles potentially missed during the electronic search. In
mitochondrial electron transport chain) further reduced to NO the second phase, the full text of the selected articles was independently
(21). This pathway may represent a plausible mechanism to assessed by 2 investigators. When full agreement had been reached, the
article was either discarded or moved to the next phase for full data
explain the beneficial effects of dietary inorganic nitrate intake
extraction. In case of disagreement, the article was evaluated by a third
on BP (21). The main mechanistic pathways involved in the

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investigator (J.L.) and a final decision was reached by consensus.
enzymatic and nonenzymatic generation of NO are described
in Supplemental Figure 1. Data extraction and bias. Two investigators extracted the data using a
Here, we conducted a systematic review of the evidence from standardized data collection form. A list of the extracted variables is
randomized studies investigating the efficacy of inorganic nitrate provided in the Supplemental Methods (Box 2). When BP measurements
and beetroot supplementation on BP in humans. The results will were incomplete, the corresponding authors were contacted to request
inform whether inorganic nitrate supplementation and nitrate- the missing data. The quality of each study was assessed using the Cochrane
enriched diets could be considered as effective nutritional strategies Risk of Bias Tool (25) to assess the following domains: selection bias
for the prevention of hypertension and cardiovascular diseases. (random sequence generation and allocation concealment), performance
bias (blinding of participants and personnel to which intervention a
participant received), detection bias (blinding of outcome assessment),
attrition bias (completeness of outcome data, including attrition and
Methods exclusions from the analysis), and reporting bias (selective outcome
The present systematic review was conducted according to estab- reporting).
lished guidelines and is reported according to PRISMA guidelines (22).
Measurement of treatment effect. The qualitative and quantitative
Types of studies. Randomized clinical trials in human participants interpretation of the data was based on the absolute mean differences in
were included and the specific characteristics and designs of the trials BP (in mm Hg) relative to baseline readings and SD of the mean differences
(type of placebo, parallel or crossover design, blinding of the interventions, (SDdiff). For matched study design (crossover studies), the effect of dietary
and duration) were assessed. supplementation (inorganic nitrate or beetroot juice) on BP was calculated
as the difference between the supplementation and placebo groups at the
Subjects. Adult male and female participants (age >18 y) with or without end of each intervention. The SDdiff was calculated using the SDs for each
health comorbidities (hypertension, diabetes, and peripheral arterial intervention (SDE = intervention; SDC = control) and an imputed
diseases) were included. Studies reporting data from participants with correlation coefficient (r) for the pre-post measurements (26). The
different BMIs, ethnic backgrounds, and physical activity levels were formula used for the calculation of the SDdiff is:
not excluded. pffiffiffiffiffiffiffiffiffi
SDdiff ¼ SD2E þ SD2C 2ð23r3SDE 3SDC Þ:
Types of interventions. Randomized clinical trials investigating the
effects of inorganic nitrate or beetroot juice supplementation and providing An imputed correlation value of 0.50 was used to provide a conservative
information on the type of nitrate salt (potassium or sodium nitrate), volume, estimate based on the assumption that this value would minimize the error
formulation, frequency, and route of administration were included. Studies of the effect size estimates. A sensitivity analysis was conducted to test the
that delivered the nitrate or beetroot supplementation alongside another validity of the approach by entering a sequential range of low correlation
intervention (e.g., exercise, pharmacological agent, or dietary supple- coefficients (r = 0.10, r = 0.25) to evaluate changes in the effect size of the
ment) were excluded if the interventions were different between groups. A models.
combined meta-analysis model was derived for inorganic nitrate solutions
and beetroot juice on BP. This approach was based on the evidence that Meta-analysis. A meta-analysis was conducted using Comprehensive
inorganic nitrate is rapidly absorbed from the stomach and proximal small Meta-Analysis software (Biostat). Data are presented as mean differences
intestine with high bioavailability (23). A crossover study was specifically of systolic BP and diastolic BP (in mm Hg) and 95% CI. A random effect
conducted to determine the oral bioavailability of nitrate from spinach, model was used to provide a more conservative estimate of the pooled
lettuce, and beetroot (24). A high bioavailability of the nitrate present in effect size for diastolic and systolic BP. The BP differences were combined
the 3 food products (98 6 12% for spinach, 110 6 14% for lettuce, and across studies using a weighted DerSimonian-Laird random effects model
110 6 15% for beetroot) compared with nitrate in aqueous solution was (27). Forest plots were generated for graphical presentations of the BP
observed, which supports our analytical strategy to determine the pooled outcomes. Statistical heterogeneity across studies was assessed using the I2
effect of the 2 interventions (24). and the Q tests according to specific categories (low = 25%, moderate =
50%, high = 75%) and significance level (P < 0.10), respectively (28).
Outcome measures. The primary outcomes of the analyses were changes Funnel plots and EggerÔs regression test were used to evaluate potential
in diastolic and systolic BP after nitrate and/or beetroot supplementation. If publication bias and selective reporting bias. Additional analyses were
reported, changes in nitrate and nitrite concentrations in biological fluids conducted to evaluate the impact of publication bias on the effect size
(plasma, urine, saliva) were also assessed. by removing studies with the largest effects. Sensitivity analyses were
conducted to evaluate whether changes in diastolic and systolic BP were
Search strategy. A literature search of the PubMed, Embase, and influenced by study duration (<3 vs. $3 d), type of intervention (beetroot
Scopus databases was undertaken from inception to February 2013. The juice vs. inorganic nitrate solution), and the removal of studies including
systematic review was restricted to articles published in English. The highly trained participants. One study was published in abstract form only

Inorganic nitrate, beetroot juice, and blood pressure 819


and reported a nonsignificant effect of inorganic nitrate on BP (29). This Participant characteristics. The majority of the studies recruited
study was not included in the meta-analysis, because full data were not young, nonsmoking, healthy participants and 2 studies were
available after request. The potential influence of the nonsignificant results conducted in older healthy participants (38) and overweight
from the study on the pooled systolic BP and diastolic BP estimates was and obese older individuals with type 2 diabetes (40). In addition,
evaluated by entering into the model a null effect (mean difference = 0), the
most of the participants were men (;60%) and the male:female
mean of the pooled SD, and the sample size of each study. A random
effects meta-regression model was conducted to evaluate whether changes
ratio was not reported in 2 studies (33,42). The mean BMI of the
in plasma nitrite concentrations (in nmol/L), study duration (in hours), participants ranged between 22.3 and 30.8 kgm22 and was not
and daily dose of inorganic nitrate (in mmol) were associated with mean reported in 2 studies (10,36). Seven studies investigated the effects
differences in diastolic and systolic BP. of inorganic nitrate and beetroot juice on exercise performance
and recruited primarily young, physically active men (30–
32,34,35,37,38).
Results
Nitrate supplementation. Beetroot juice and nitrate salt
Main search. A total of 10,184 articles was identified by the (sodium nitrate/potassium nitrate) supplementation was tested
primary search and, after the removal of duplicates (n = 6607), in 12 (12,30–35,37–41) and 5 (10,29,33,36,42) studies, respectively.
3577 articles were screened for titles and abstracts. Then 41 articles The daily amount of inorganic nitrate (sodium or potassium nitrate)

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were selected for a full-text review and 16 studies (10,12,29–42) consumed in these studies ranged from ;2.5 to 24 mmol/dose
were included in the systematic review (qualitative analysis) after (157–1488 mg). Nitrate was dissolved either in distilled water
the exclusion of 25 articles. One study was published as abstracts or low-nitrate water. The daily amount of nitrate in the beetroot
only (29). However, this study matched the inclusion and exclusion juice consumed varied between 5.1 and 45 mmol/dose (321–2790
criteria and it was included in the systematic review (qualitative mg). The volume of the beetroot juice drinks ranged from 140 to
analysis) but excluded from the meta-analysis (quantitative anal- 500 mL/d and the beetroot juice was given as a concentrated
ysis), because the full results on changes in BP were not available. A solution in 2 studies (32,38). The choice of the placebo varied
flow chart of the literature search is shown in Figure 1. All eligible between studies and included equivalent volumes of water (3 studies)
studies used a crossover, double-blind, placebo-controlled, ran- (12,33,41), isomolar potassium and sodium chloride solutions
domized study design. The trials were conducted between 2006 (5 studies) (10,29,33,36,42), blackcurrant juice (3 studies) (30,31,37),
and 2012 and included a total of 254 participants, with 7–30 apple juice (1 study) (39), and nitrate-depleted beetroot juice
participants per individual study. The duration of the interventions (5 studies) (32,34,35,38,40). All solutions were given orally. Partic-
ranged from 2 h to 15 d and the washout period from 6 to 28 d. ipants were asked to refrain from consuming nitrate-enriched foods
One article reported the results of 3 individual trials from which 2 in 9 studies (10,12,30,31,33,35,36,41–42), whereas participants
trials were eligible and were entered in the final analysis (33). The were invited to maintain their prestudy dietary habits and physical
main characteristics of the studies included in the analysis are activity level in 6 studies (32,34,37–40). The compliance with
presented in Supplemental Table 1. the dietary prescriptions (low-nitrate diet, habitual dietary habits)

FIGURE 1 Flow chart of the


literature search. BP, blood pres-
sure.

820 Siervo et al.


TABLE 1 Meta-analysis of randomized clinical trials reporting the effects of beetroot juice and inorganic
nitrate supplementation on systolic and diastolic BP1

Effect size [mean


Studies difference (95% CI)] P value I2 Q value (P value)

n mm Hg
Systolic BP
,3 d 8 24.9 (27.6, 22.2) ,0.001 77.6 31.3 (,0.001)
$3 d 8 23.8 (25.6, 22.1) ,0.001 46.2 13.0 (0.07)
Diastolic BP
,3 d 7 20.2 (21.3, +0.9) 0.71 0 2.5 (0.86)
$3 d 7 21.7 (23.6, +0.1) 0.07 69.1 19.4 (0.003)
Type of intervention
Systolic BP
Beetroot juice 12 24.5 (26.4, 22.5) ,0.001 73.7 41.4 (,0.001)

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Inorganic nitrate 4 24.2 (26.1, 22.2) ,0.001 0.5 2.5 (0.47)
Diastolic BP
Beetroot juice 10 20.9 (22.3, +0.5) 0.21 58.8 21.6 (0.01)
Inorganic nitrate 4 21.3 (23.0, +0.4) 0.13 25.1 4.1 (0.26)
1
The meta-analysis was stratified by study duration (,3 d, $3 d) and type of intervention (beetroot juice, inorganic nitrate). A random model
was applied to each subgroup to obtain the pooled estimate of the mean difference. Variability of the estimates was reported as 95% CI.
Heterogeneity of the studies in each subgroup of studies was evaluated using the Q test and the I2 test. BP, blood pressure.

was only evaluated in a few studies using diet diaries (37) of 24-h systolic and diastolic BP. The beneficial effects of beetroot juice
dietary recall (34,35). The assessment of the compliance to the supplementation on BP were not confirmed when ambulatory
nitrate supplementation was not reported, but the majority of the 24-h BP monitoring was used to measure changes in BP (39–
studies measured plasma or urinary concentrations of nitrate and/ 41), including a group of older (>60 y) overweight and obese
or nitrite, which could have provided information on the adher- participants with type 2 diabetes (40) (Supplemental Table 2).
ence to the nitrate supplementation. One study did not report the
measurement of nitrate/nitrite concentrations (39). BP quantitative results (meta-analysis). Inorganic nitrate
and beetroot juice consumption was associated with greater
Study quality. Resting BP was the primary outcome in 15 trials changes in systolic BP [24.4 mm Hg (95% CI: 25.9, 22.8);
(10,12,29–38,42) and ambulatory 24-h BP was used in 3 studies P < 0.001] (Fig. 2) than diastolic BP [21.1 mm Hg (95% CI:
(39–41). Three studies reported that the main aim of the study 22.2, 0.1); P = 0.06] (Fig. 3). The stratification of the analyses
was concealed (30,31,37) to the study participants (30,31,40). by duration (<3 and $3 d) and type of interventions (beetroot
All studies were double blind and reported information on the juice and inorganic nitrate salts) did not modify the effects on
duration of washout periods and dropout rates. The order of the systolic BP, because the meta-analysis models were significant
interventions in each trial was randomized. Three studies did not in studies of a shorter [<3 d, 24.9 mm Hg (95%CI: 27.6, 22.2);
report data on diastolic BP (29,34,35). Therefore, a meta-analysis P < 0.001] (12,33,34,36,39,41,42) and longer [$3 d, 23.8 mm
of the effects of inorganic nitrate and beetroot supplementation on Hg (95% CI: 25.6, 22.1); P < 0.001] duration. Similarly, the
systolic and diastolic BP was performed for 16 (10,12,30–42) and stratification by study duration did not modify the effect on diastolic
13 (10,12,30–33,36–42) studies, respectively. Funding sources BP, because the model was not significant for both longer studies
were disclosed in the majority of the studies, whereas 6 studies [$3 d, 21.7 mm Hg (95% CI: 23.6, 0.1); P = 0.07] (10,30–
declared potential conflicts of interest (33,35,38–41). The majority 32,35,37) and shorter [<3 d, 20.2 mm Hg (95% CI: 21.3, 0.9);
of studies was rated high quality or low risk of bias. A small P = 0.71] interventions (12,33,34,36,39,41,42). The effects of
proportion of studies were rated as having high performance beetroot juice supplementation [24.5 mm Hg (95% CI: 26.4,
and detection bias (Supplemental Fig. 2). 22.5); P < 0.001] (12,30–35,37–41) and inorganic nitrate
[24.2 mm Hg (95% CI: 26.1, 22.2); P < 0.001] (10,33,36,42)
Adverse events. Information on adverse events that occurred on systolic BP were both significant, whereas neither beetroot
during the study was reported in 8 studies (12,30,31,33,37,40– juice nor inorganic nitrate supplementation was associated with
42). Only one study reported a major adverse event (heartburn) significant changes in diastolic BP (Table 1). The meta-regression
requiring the exclusion of the participant from the trial (33). showed that mean differences in systolic BP were directly associ-
However, the unblinding of the study codes revealed that the ated with the daily dose of inorganic nitrate (P < 0.05) (Fig. 4A) but
participant was assigned to the placebo intervention, which not with the study duration (P = 0.67) (Fig. 4B) or plasma nitrite
excluded the link of nitrate with the onset of the event. The most concentrations (P = 0.40) (Fig. 4C). Changes in diastolic BP were
common side effect reported in the beetroot juice trials was not associated with the the daily dose of inorganic nitrate, study
beeturia (red urine) and red stools (12,30,31,37,40–42). duration or plasma nitrite concentrations (Fig. 5).

BP qualitative results (systematic review). Twelve studies Publication bias and heterogeneity. Funnel plots for systolic
showed a significant reduction in systolic BP (12,29–31,33– BP revealed an overall symmetric distribution of the studies
35,37,38,41,42), whereas a significant change in diastolic BP around the mean effect size, indicating the absence of publication
was observed in 6 studies (10,30,33,36–38). Beetroot juice supple- bias (Supplemental Figs. 3 and 4). EggerÕs regression test confirmed
mentation had a greater effect than inorganic nitrate on both the nonsignificant association between the mean differences and
Inorganic nitrate, beetroot juice, and blood pressure 821
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FIGURE 2 Forest plot of randomized clinical trials investigating the effects of beetroot juice and inorganic nitrate supplementation on SBP. A
random model was applied to obtain the pooled mean differences in SBP. Data for SBP are presented as mean differences and 95% CI. Two
trials were reported in the same manuscript (33). BP, blood pressure; SBP, systolic blood pressure.

the SEs of each study (P = 0.47). However, we advocate for a effect on BP] reduced the mean difference in systolic BP by 0.6
careful interpretation of the results in consideration of the small mm Hg (from 4.4 to 3.8 mm Hg), but the pooled effect size
number of participants, the short duration of the interventions, remained significant (P < 0.001) (Supplemental Table 3). The
and the over-representativeness of healthy participants. We inclusion of the study did not modify the results for diastolic
observed a high heterogeneity for systolic (I2 = 66%, Q = 44.3, BP (P < 0.05) (Supplemental Table 4). The removal of the
P < 0.001) and moderate heterogeneity for diastolic (I2 = 45%, studies investigating primarily the impact of inorganic nitrate
Q = 25.7, P < 0.01) BP meta-analysis models. The stratification of and beetroot juice on exercise performance (30–32,34–38) did
the meta-analysis by study duration and type of intervention not change the results for systolic BP (23.9 mm Hg; P = 0.003)
helped to identify potential sources of heterogeneity for systolic BP, (Supplemental Table 3) and diastolic BP (0.2 mm Hg; P = 0.70)
because shorter duration (<3 d) and beetroot juice supplementation (Supplemental Table 4).
were associated with greater heterogeneity (Table 1). In addition,
the exclusion of the study with the largest effect (12) and of studies
including physical activity outcomes (30,31,34,35,37,38) did not
Discussion
modify the heterogeneity for both systolic (Supplemental Table 3) Summary of main results. Inorganic nitrate and beetroot juice
and diastolic (Supplemental Table 4) BP. supplementation were associated with a significant decrease in BP. The
pooled effect for the 2 interventions showed a reduction in systolic
Sensitivity analysis. Imputation of different correlation coeffi- BP of 4.4 mm Hg with a more modest decrease (21.1 mm Hg)
cients (r = 0.1, r = 0.25 instead of r = 0.5) entered for the calculation in diastolic BP. Beetroot juice was not associated with greater
of the effect size did not change the results for both systolic and changes in systolic BP than inorganic nitrate solutions (24.5 vs.
diastolic BP (Supplemental Table 5). Similarly, the inclusion of 24.2 mm Hg, respectively). The meta-regression indicated that a
a null mean difference in systolic and diastolic BP [to evaluate higher daily amount of the dose of inorganic nitrate may be
the potential effect of the study (29) reporting a nonsignificant associated with greater reductions in systolic BP. Overall, studies

FIGURE 3 Forest plot of randomized clinical trials investigating the effects of beetroot juice and inorganic nitrate supplementation on DBP. A
random model was applied to obtain the pooled mean differences in DBP. Data for DBP are presented as mean differences and 95% CI. Two
trials were reported in the same manuscript (33). BP, blood pressure; DBP, diastolic blood pressure.

822 Siervo et al.


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FIGURE 4 Meta-regression of moderators of SBP
after inorganic and beetroot juice supplementation.
(A) Meta-regression on the effects of the daily dose
of inorganic nitrate (in mmol) on mean differences in
SBP. Slope = 20.12, Q = 3.8, d.f. = 1, P , 0.05. (B)
Meta-regression on the effects of the study dura-
tion (in hours) on mean differences in SBP. Slope =
0.005, Q = 0.69, d.f. = 1, P = 0.40. (C) Meta-
regression on the effects of plasma nitrite concen-
trations (in nmol) on mean differences in SBP.
Slope = 0.004, Q = 0.02, d.f. = 1, P = 0.87. SBP,
systolic blood pressure.

were characterized by a small sample size, short duration, and assess the interaction with gender, which needs to be tested in
over-representation of young, healthy men. future studies. One study investigated the effects of beetroot juice
supplementation in older (>60 y) overweight and obese individuals
Study quality, bias, and applicability of evidence. The with type 2 diabetes and reported no significant effect of beetroot
overall quality of the studies was high. All studies were random- juice on 24-h ambulatory BP. A beneficial effect of a 3-d beetroot
ized and double-blind and the crossover study design of the trials juice supplementation on resting systolic and diastolic BP was
was justified by the type of interventions and outcomes. All studies observed in older, healthy participants. In addition, the duration of
reported the duration of washout periods, which was adequate to the interventions was short and it is not known whether the
minimize the influence of carryover effects. The studies reported a observed BP-lowering effects will be maintained in the long
high compliance with the interventions, which may be explained term. These are critical factors to evaluate to understand if nitrate/
by the short duration of the trials. Participants recruited in the beetroot interventions may represent effective strategies for the
studies were mostly healthy, normal-weight men and therefore the primary and/or secondary prevention of hypertension-related
results may not be applicable to a female population or to cardiovascular diseases.
individuals with cardiovascular or metabolic diseases. Kapil et al.
(33) have suggested a possible interaction with gender, as the Potential biases in the review process. This study has several
BP-lowering effect of inorganic nitrate was more marked in potential limitations. The meta-analyses are based on retrospective
men. However, we were unable to perform a sensitivity analysis to analytical inference, which may be affected by several factors, such
Inorganic nitrate, beetroot juice, and blood pressure 823
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FIGURE 5 Meta-regression of moderators of
DBP after inorganic and beetroot juice supplemen-
tation. (A) Meta-regression on the effects of the
daily dose of inorganic nitrate (in mmol) on mean
differences in DBP. Slope = 0.03, Q = 0.33, d.f. = 1,
P = 0.56. (B) Meta-regression on the effects of the
study duration (in hours) on mean differences in
DBP. Slope = 20.002, Q = 0.30, d.f. = 1, P = 0.58.
(C) Meta-regression on the effects of plasma nitrite
concentrations (in nmol) on mean differences in
DBP. Slope = 20.002, Q = 0.85, d.f. = 1, P = 0.35.
DBP, diastolic blood pressure.

as the quality of the studies included, inclusiveness of the search results debatable. In addition, some of the studies included
strategy to identify eligible studies to include in the meta-analysis, individuals with high physical activity levels (30–32,34,35,37), as
assumptions on consistency of methodologies applied across the the primary aim of the studies was to test the effect of inorganic
different studies, inconsistency in reporting study results, limited nitrate on exercise performance. However, the exclusion of these
accessibility to individual study data, and inability to ascertain the studies did not modify the magnitude of the lowering effect on
exact source of heterogeneity. In addition, we limited our search to systolic BP. The analysis was also based on the imputation of pre-
articles published in English and in peer-reviewed journals, which postintervention correlation of BP changes and the sensitivity
may have increased the risk of publication bias. The clear analysis confirmed that the models for systolic BP and diastolic
delineation of a priori inclusion and exclusion criteria and the BP were not affected by the inclusion of different correlation values.
comprehensive search of 3 major electronic databases and refer-
ence lists are likely to have minimized bias and increased the Agreements and disagreements with previous results. Our
representativeness of the results. A robust selection procedure analyses showed that beetroot juice supplementation (24.5 mm
was particularly important in the identification of studies explor- Hg) may not be associated with a greater reduction in systolic BP
ing relationships among inorganic nitrate, beetroot juice, and BP compared with inorganic nitrate supplementation (24.2 mm Hg).
control. However, all studies were characterized by a small sample However, a careful interpretation of the results is needed until the
size and short duration and most of the studies recruited young, effects of the 2 interventions can be tested in a trial specifically
healthy, nonsmoking men, making the representativeness of the designed to test this hypothesis. The results seem to indicate
824 Siervo et al.
that the similar effects on BP may be accounted for by comparable 2. Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends
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11. European FSAE. Opinion of the Scientific Panel on Contaminants in the
NO bioactivity (13). Only 2 studies have tested the relation- Food chain on a request from the European Commission to perform a
ship between cGMP and changes in BP after oral inorganic nitrate scientific risk assessment on nitrate in vegetables. EFSA J. 2008;689:1–79.
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decrease the risk of mortality due to stroke by 14% and mortality
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nutritional approaches can be recommended, the long-term
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efficacy of inorganic nitrate needs to be tested in people at higher causes and consequences in patients with diabetes mellitus. Diabetes Res
cardiovascular risk together with an assessment of the tolerance, Clin Pract. 2008;82 Suppl 2:S94–101.
safety, compliance, and cost-effectiveness of the interventions. 19. Siervo M, Corander M, Stranges S, Bluck L. Post-challenge hyper-
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Acknowledgments putative role of asymmetric dimethylarginine (ADMA). Nutr Metab
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The authors are very grateful to Dr. Larsen, Professor Weitzberg,
20. Charakida M, Deanfield JE, Halcox JPJ. The role of nitric oxide in early
Dr. Kapil, Professor Ahluwalia, Professor Lovegrove, Dr. Cermak, atherosclerosis. Eur J Clin Pharmacol. 2006;62:69–78.
and Professor Jones for providing the original data from their 21. Lundberg JO, Gladwin MT, Ahluwalia A, Benjamin N, Bryan NS,
studies. The systematic review was conceived by J.C.M., J.L., Butler A, Cabrales P, Fago A, Feelisch M, et al. Nitrate and nitrite in
and M.S; I.O. and M.S. searched, collected, and analyzed the biology, nutrition and therapeutics. Nat Chem Biol. 2009;5:865–9.
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to the final revision of the manuscript; and M.S. is the guarantor
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