Kelci McHugh

Dietetic Student, University of Kentucky, Lexington, Kentucky

May 1, 2017

A Review of the Effects of Beetroot Juice Consumption on Blood Pressure in Adults.

Abstract:

Beetroot juice has vasodilating properties as a result of the nitrates present. Nitrates

increase oxygen supply throughout the body and relax blood vessels, possibly causing a decrease

in systolic and diastolic blood pressure. A variety of small scale research articles were reviewed

analyzing a population range of 5-30 participants, the majority being male. Of the five studies,

three analyzed supplementation once a day in healthy adults and two analyzed effects on

unhealthy, stress induced adults. Results found statistically significant reductions in both systolic

and diastolic blood pressure in males six hours after intake [5],[2],[4], decreases in nocturnal

systolic blood pressure in patients younger than 65 [6], and a decrease in systolic blood pressure

at rest and from induced stress heating [7]. Although supplementation of beetroot juice has been

found to reduce diastolic and systolic blood pressure in adults, more research is needed to

determine optimal dosing recommendations.

Introduction:

Beetroot juice is a popular supplement in the sports and supplement world. It is a simple

powder- a one scoop serving, that is mixed with water and shot back in a chug. Consumption of

beetroot juice is believed to have the capability to increase oxygen supply and stamina to
muscles during physical activity by the vasodilating properties [1]. Athletes most often consume

beetroot juice 30 minutes before intense training, including weight lifting.

From the basis of research discussed below, a foundation of knowledge was produced on

beetroot juice supplementation in healthy adults. This information was then rehypothesized and

applied to athletes, alongside adults with health conditions. Health conditions also lead to bodies

being in a state of stress similar to athletes from physical activity.

Beetroot juice is extracted from the root vegetable beet. Beets have been found to contain not

only essential vitamins and minerals, but also high levels of nitrates. Common supplemental

forms include beet juice, beet juice powder, and beet capsules. Beets can even be dehydrated and

made into a gel form [2]. The high levels of nitrates from beetroot juice are broken down through

a metabolic pathway to form nitric oxide. Nitric oxide is then what influences blood flow in the

body. An increase in nitric oxide eventually leads to an increase in vasodilation in the body,

which reduces blood pressure.

It is already known how nitrates are broken down, but there is not a clear understanding on

how long term consumption influences the circulatory system. If long term consumption of

beetroot juice is statistically significant and proven to decrease both systolic and diastolic blood

pressure, then hypertension rates could decrease. Nearly one in three Americans have

prehypertension and another third of Americans, about 70 million adults, have been diagnosed

with hypertension. Of this 70 million with hypertension, only half of them have their disease

under control [3]. Hypertension increases risk for serious health conditions such as heart disease,

heart attack, stroke and kidney disease. Control of hypertension is important for improving

quality of life and reducing risk of serious health complications. If beet juice is found to be
effective in managing hypertension, about 46 billion dollars in health care costs a year for

treatment and days missed from work because of hypertension, could substantially be reduced

[3]. The hypothesis of this literature review is regular consumption of beetroot juice

supplementation will lower blood pressure in healthy and sick adults of all ages.

Purpose and Methods:

All research was collected from peer reviewed articles and professional websites. The

majority of the research found from an online library database focused on the effects of beetroot

juice on exercise. This is because of the possible effects of beetroot juice in lowering blood

pressure and increasing the abilityy of oxygen replenishing during anaerobic exercise. The

articles further discussed below either took place in the U.S. or in Europe. The purpose of this

review is to determine if the effects of beetroot juice supplementation at a minimum of once a

day has a positive correlation on lowering systolic and diastolic blood pressure in healthy and

sick conditions in adults of all ages.

Topic One: The effects on healthy, disease free adults within normal blood pressure range.

A study by Siervo M et al. [4] evaluated the effects of higher blood pressure and death rates

in America. The research findings indicate that two-thirds of stroke and one-half of ischemic

heart disease events are linked to high blood pressure. The methods of the study included a

systematic review of literature to find effects on blood pressure with beetroot juice consumption.

Included in the review were male and female participants greater than the age of 18. Some

participants are completely healthy adults while others have health complications including

hypertension, diabetes, and peripheral arterial diseases. Three different types of interventions

were reanalyzed by the research team.

 The first classification was randomized clinical trial on the difference of beetroot juice

supplementation by the type of nitrate salt present; potassium or sodium nitrate. Volume,

formulation, frequency, and route of administration for the supplement were also included. The

second intervention type is a combined meta-analysis model for beetroot juice on blood pressure.

This analyzed how well the nitrates were absorbed in the stomach and proximal small intestine

and how strong the bioavailability is. The third intervention was a crossover study to view oral

bioavailability of nitrates in spinach, lettuce, and beetroot compared to the juice or liquid forms.

The studies analyzed had nitrate salts given at a daily amount between 2.5 to 24 mmol/dose

in either distilled water or low nitrate water. The daily amount of beetroot juice was 5.1 and 45

mmol/dose in volumes of 140 to 500 mL/d. Placebos used in the trials were all different and

included distilled water, different fruit juices like apple juice or blackcurrent, and nitrate-depleted

beetroot juice. Most of the studies took measurements of plasma and urinary concentrations of

nitrates to better understand if participants were following protocol on taking their supplements

or eating high nitrate rich foods during the study. Resting or ambulatory blood pressure was

measured during the trials.

The overall results found 12 studies reported a statistically significant reduction in systolic

blood pressure and six studies reported statistically significant reductions in diastolic blood

pressure. Also, beetroot juice had a slightly larger effect on systolic blood pressure compared to

supplementation with inorganic salts of nitrates. The study team reported that more research

needs to be conducted to determine long term associations between beetroot juice

supplementation and blood pressure. Most of the studies included in the analysis were short term

with smaller sample sizes, and primarily young, healthy adult men. This may lead to results

being skewed without a larger and wider aged sample population.

 Compared to the research just described, Coles and Clifton [5] had a narrower focus and

conducted an intervention for a clinical trial. They analyzed the changes in blood pressure from

beetroot juice in healthy adults consuming a normal diet with no restrictions using a double-

blind, randomized, crossover, intervention trial. The beetroot juice nitrate supplement was a

mixture of 72% beetroots and 28% apples, providing 15 mmol nitrate/L. The placebo was apple

juice with added sugar to match sweetness and red dye to match coloring.

The study took place in Australia and included 15 male and 15 female participants who had a

systolic blood pressure greater than 120 mmHg. Participants who were lactating, pregnant, on

blood pressure medicine or diagnosed with Diabetes Mellitus were excluded from the study. The

pre intervention assessment included blood pressure and heart rate measurements within five

minutes of being seated. Randomly selected by the computer, half were given the supplement

while half were given the placebo. It was then drank between five and ten minutes. Participants

remained seated for an hour while three more blood pressure measurements were recorded by a

machine. Then they left to continue a normal day. The machine was worn on the arm for an

additional 24 hours and measurements were automatically taken every half hour during active

periods and hourly during the passive periods. Participants were also given a book to write down

situational influences at times of machine readings that may affect blood pressure and to log their

sleep habits.

Two weeks later, participants came back to the clinic and completed the experiment again

with the opposite juice drink. Table 1 shows the mean blood pressure value over a 24 hour time

period of male and female participants. These numbers show active times when awake compared

to sleeping.
Table 1. Juice Supplements and the Effects on Male and Female Participants [5].

Measurements Male Male Female Female

mmHg Placebo Beetroot Placebo Beetroot
Active Period
(awake)

Systolic BP 126.6 +-3.1 128.7 +-2.3 127.0 +-2.3 124.6 +-1.8

Diastolic BP 77.1 +-2.5 77.5 +-2.0 78.4 +-2.3 77.9 +-1.8

Pulse Pressure 52.5 +-2.1 51.2 +-2.0 48.7 +-1.6 46.9 +-1.4
Passive Period
(asleep)
Systolic BP 111.6 +-2.6 117.0 +-2.9 110.5 +-3.5 109.5 +-2.4
Diastolic BP 62.1 +-2.1 65.9 +-1.9 63.5 +-1.6 65.0 +-1.8
Pulse Pressure 49.5 +-1.8 51.2 +-1.9 47.0 +-2.4 44.5 +-1.5

Results indicated a drop in blood pressure of 4.6 mmHg with beetroot juice and 3.4

mmHg with the placebo occurred at a 3 hour window. At a 6 hour window, a drop in blood

pressure of 6.2 mmHg for beetroot juice and 2.2 mmHg for placebo occurred. Finally, a drop in

blood pressure of 4.5 mmHg for beetroot juice and 2.3 mmHg for placebo occurred at a 24 hour

window. However, the difference between beetroot juice consumption and the placebo was only

statistically significant in males, not females, at the 6 hour window.

One limitation of this study was that females had an average age of 49 compared to 36

for men. Also, half of the women took prescription medications which may have decreased the

effects of beetroot juice on blood pressure decline. More research needs to be done in non

medicated adults with dietary recalls to better assess the blood pressure results of healthy men

compared to healthy women.

Similar to the previously described studies, Silvia DV et al. [2] also looked at the

potential benefits of blood pressure reduction from beetroot juice consumption in healthy
individuals. However, instead of a liquid form, a gel was formulated for use. Only five healthy

adults participated in the study. The participants had to have a blood test beforehand to show

glucose, total cholesterol, LDL, HDL, triglycerides, glutamic oxaloacetic transaminase and

glutamic pyruvic transaminase. The blood test was sampled in conjunction with a urine analysis

to show urea, creatinine and uric acid levels. All levels had to be in normal range for the

participant to be used.

Once selected, the participants were provided with a list of high NO2- and NO3-

containing foods to be avoided while partaking in the study. This was to properly analyze the

effects of nitrate consumption and to keep the nitrate consumption amount as close to the

measured intervention volume as possible. Exercise, alcohol and caffeine all needed to be

avoided the day before the study to decrease the possibility of influences on blood pressure

changes. Systolic and diastolic blood pressure, along with heart rate, were measured before the

100 gram gel intake and every 30 minutes following consumption for a total of three hours.

Fasting blood samples of 5 mL were collected every hour during that three hour time window

and once before consumption to assess blood nitrate levels.

The supplemented beetroot juice gel had a higher carbohydrate level than most juice

forms because it was produced from dehydrated beetroot which could include why it may have

an influence during exercise. The gel also had a higher total antioxidant potential than juice

which could lead to a larger impact on health. Figure 1 shows nitrate concentrations in the blood

by a mean value of 0.003mmol100g1 or known as mol/L by time intervals of minutes. The 60

minute time frame was the only statistically significant time interval before concentrations

dropped back down to baseline measurements.

Figure 1. Blood Nitrate Concentrations Every 60 Minutes [2].

mol/L Blood Concentration

2.5
2
1.5 Time
1 (Minutes
0.5 )

0
Baseline 60 120 180

Results found that systolic blood pressure was decreased by 6.2 mmHg after an hour

when compared to the before consumption measurements. Diastolic blood pressure was

decreased by 5.2 mmHg after 120 minutes when compared to the pre consumption measurement.

Heart rate was also found to decrease by 7 beats per minute. Silvia DV et al. cited results from

another author, Miller et al., on how the third day of consumption of beetroot juice plasma NO2-

levels significantly increased.

In conclusion, beetroot gel had a higher fiber, carbohydrate and antioxidant level

compared to the usual juice form, so, more research on mass production may be beneficial to

encourage the use of the supplementation. The gel was found to decrease both systolic and

diastolic blood pressure in healthy adults. However, further studies need to be conducted in

larger population samples to create a better understanding on the tendency of effects.

Topic Two: The effects on the unhealthy human body when in a state of stress from health

complications, including high blood pressure.

Unlike the three articles above, Siervo et al. [6] looks into the effects of individuals that

are not considered healthy and who already had health complications. In this case, older adults

were used to monitor the possible effects of beetroot juice consumption on blood pressure, and

specifically, nocturnal diurnal blood pressure differences, or better known as dipping. The

participants were 55 years or older. There were 17 healthy, normal weight individuals and the

others were over weight, had type 2 diabetes, high blood pressure or a combination of these.

Four trials were conducted. The first trial lasted three weeks and used 70 mL/day of

beetroot juice and a placebo of blackcurrant juice 200 mL/day. Trial two lasted one week and

had a negative control group that was diet compared to the second group that took beetroot juice

supplementation of 140 mL/day. Both of these trials were cross-over, double-blind, placebo

controlled. Trials three and four lasted two weeks each and alternated the use of beetroot juice

supplementation of 250 mL/day or nitrate free beetroot juice of 250 mL/day.

85 subjects were used between the ages of 55 and 76. Body mass index was measured for

each and the range was 20.2 through 39.5 kg/m2. Participants had to be nonsmokers. Participants

were randomly assigned to trials where resting blood pressure, saliva samples, plasma samples,

and the International Physical Activity Questionnaire were all assessed. Blood pressure was then

constantly measured for the remaining 24 hours at intervals of 30 minutes during the day and 60

minutes over night. After the 24 hour measurement period, participants were given their

intervention or supplementation and a dietary plan to keep nitrate levels constant while wearing a
blood pressure monitor. Once their given trial time elapsed, participants had to return to the

research center to have the same tests measured as previously.

Results showed that there was no serious correlation for reductions in systolic or diastolic

blood pressure from beetroot juice in ambulatory situations. However, nocturnal systolic blood

pressure decreased in patients younger than 65 years but night dipping was much more

controlled after beetroot juice consumption for older adults compared to younger. Further

research is needed for older adults to see if larger doses may increase smooth muscle sensitivity

to nitrates or if the body will better metabolize the higher concentrations given decreased

metabolic function in older adults.

Levitt EL et al. [7] also compares beetroot juice effects in stressed state of health for

humans, specifically how heat-stressed skin can be influenced by the use of beetroot juice to

cause vasodilation and a possible increase in blood flow. According to Levitt EL et al, heat-stress

causes an increase in core temperature, ultimately leading to an increase in vasodilation and

sweating in humans. There were seven participants, all male with an average body mass index of

25 and average age of 22. There were no serious health complications, no one was a smoker, and

no one was taking any medications prior to and during the study.

During the three days worth of nitrate supplementation, participants were asked to refrain

from exercise, use of mouthwash, drinking alcohol, and to eat less than 300 grams worth of

green leafy vegetables per day. Participants were asked to consume three days consecutively of

the supplemented nitrate juice, 70 milliliters worth. The third day of supplementation use was

consumed in the laboratory setting and testing began about two hours after consumption. Testing

was conducted by having the participants lay supine with the tested arm at heart level. A needle
was inserted into the numbed forearm. A fibre was then threaded through the needle to leave the

fibre in the membrane once the needle was removed. The following 45-90 minutes after

placement, fibres were filled with lactated Ringer solution to induce the trauma response. The

first part of this solution was l-arginine analoguel-NAME to inhibit any sort of nitrate synthesis

in that trauma area. Secondly, sodium nitroprusside solution was injected while whole body

heating was occurring from temperature changes within a full body suit worn by the participant.

This solution encourages maximum vasodilation and nitrate synthesis.

Blood pressure was measured every five minutes, heart rate was continuously measured

and body temperature was measured every minute starting at baseline and continuing through the

body heating and cooling periods. To monitor the blood flow response in the heated, stressed

areas, a red blood cell flux laser-Doppler was placed over where the fibre was attached to the

membrane. This showed the bodys response as vasodilation occurred and how optimal the

response is happening. The participants were wearing a water perfused suit to control the body

temperature changes. The suit pumped hot water through it until the body temperature increased

by 0.81.0C. Once the blood flow at the site hit a plateaued rate, the suit then injected cold

water to return body temperature to a normal range.

Results showed that heart rate had a statistically significant increase when the blood flow

hit the plateau. There was no difference during the heat stress test with pre or post nitrate

supplementation. Systolic blood pressure had a statistically significant decrease at resting and

during plateaued heating of an average of 128 mmHg to 116 mmHg and 131 mmHg to 106

mmHg respectfully. Diastolic blood pressure was not statistically significant until body

temperature was restored and supplementation was still taking place in the membrane. This

average drop was 74 mmHg to 63 mmHg. There was no proven statistical significance for blood
flow change pre, through or post nitrate supplementation during the heating process. The

cutaneous vascular conductance data shows that there was no difference between the percentages

of nitrate dependent vasodilation during the heating process. However, there was an increase in

response at the control site after three days of beetroot juice compared to before supplementation

of about 80%. In summary, nitrate dietary supplementation did induce cutaneous vasodilation

and caused a decrease in systolic blood pressure during a stressed state in the body. More

research needs to be done to with a larger population base and long term.

Conclusion:

There were a range of articles used in this literature review. The first three articles analyzed

the effects of beetroot juice consumption in healthy adults on lowering blood pressure. The next

two articles analyzed the effects of beetroot juice consumption in sick adults and adults in a state

of stress with effects on blood pressure. Overall, the hypothesis that regular consumption of

beetroot juice lowers blood pressure in healthy and sick adults of all ages, is supported.

Lowering blood pressure was not specified if it is systolic, diastolic or both. However, reduction

of systolic blood pressure from beetroot juice was found to have statistical significance in the

majority of studies.

Siervo M et al. [4] reviewed twelve studies and found statistical significance in the reduction

of systolic blood pressure and six studies with statistical significance in reduction of diastolic

blood pressure. Coles and Clifton [5] found statistical significance in only males at the 6 hour

window after consumption. Silvia DV et al. [2] found statistical significance for a decrease in

systolic and diastolic blood pressure. A second study by Siervo et al. [6] found nocturnal systolic

blood pressure decreased in patients younger than 65 years. Finally, Levitt EL et al. [7] found
systolic blood pressure had a statistically significant decrease at resting and during plateau

during stress heating.

Even though there was a range of blood pressures being statistically significant, this research

does back up the hypothesis showing consumption has effects on the human body. More research

does need to be conducted to figure long term consumption effects. Also, a much larger

population base is needed compared to all of these small scaled sample populations. If dietitians

can encourage regular consumption use, then the rates of hypertension could decrease along with

the serious health complications associated with hypertension. Safety does not seem to be an

issue unless patients may over indulge. Until further long term studies are conducted, no specific

serving size is available. Overall, the take home message is beetroot juice consumption does play

a role in reducing blood pressure in healthy and non healthy adults.

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