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Benjamim CJR, Lopes da Silva LS, Valenti VE, Gonçalves LS, Porto AA, Tasinafo Júnior MF, Walhin JP, Garner DM, Gualano B, Bueno Júnior CR. Effects of dietary inorganic nitrate on blood pressure during and post-exercise recovery: A systematic review and meta-analysis of randomized placebo-controlled trials. Free Radic Biol Med 2024; 215:25-36. [PMID: 38403254 DOI: 10.1016/j.freeradbiomed.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 02/10/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES A systematic review with meta-analysis was completed to study the effects of dietary inorganic nitrate (NO3-) oral ingestion from vegetables and salts on blood pressure responses during and following exercise. BACKGROUND NO3- is a hypotensive agent with the potential to reduce blood pressure peaks during exercise and amplify exercise-induced hypotensive effects. Several randomized and controlled trials have investigated the effects of NO3- on hemodynamic responses to physical exercise, however this still has yet to be studied systematically. METHODS The searches were conducted on EMBASE, Medline, and SPORTSDiscus databases. The study included masked randomized controlled trials (RCTs) with participants ≥18 years old. The NO3-intervention group received at least 50 mg NO3-/day with similar sources amid NO3- and placebo conditions. Included studies reported systolic blood pressure (SBP) or diastolic blood pressure (DBP) values during or following exercise performance. RESULTS 1903 studies were identified, and twenty-six achieved the inclusion criteria. NO3- daily dosages ranged from 90 to 800 mg/day. Throughout exercise, SBP had smaller increases in the NO3- group (-2.81 mmHg (95%CI: -5.20 to -0.41), p=0.02. DBP demonstrated lower values in the NO3- group (-2.41 mmHg (95%CI: -4.02 to -0.79), p=0.003. In the post-exercise group, the NO3- group presented lower SBP values (-3.53 mmHg (95%CI: -5.65 to 1.41), p=0.001, while no changes were identified in DBP values between NO3- and placebo groups (p=0.31). Subgroup meta-analysis revealed that SBP baseline values, exercise type, duration of NO3- ingestion, and its dosages mediated blood pressure responses during and following exercise. CONCLUSIONS NO3- ingestion prior to exercise attenuated the increases in SBP and DBP during exercise, and increased the decline in SBP after exercise. These results are dependent on factors that moderate the blood pressure responses (e.g., health status, type of exercise, resting blood pressure values).
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Affiliation(s)
- Cicero Jonas R Benjamim
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| | | | | | - Leonardo S Gonçalves
- School of Physical Education of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | | | - Jean-Philippe Walhin
- Centre for Nutrition, Exercise and Metabolism, University of Bath, Bath, United Kingdom
| | - David M Garner
- Cardiorespiratory Research Group, Department of Biological and Medical Sciences, Oxford Brookes University, Gipsy Lane, Oxford, OX3 0BP, United Kingdom
| | - Bruno Gualano
- Center of Lifestyle Medicine, Applied Physiology & Nutrition Research Group, University of São Paulo, Medical School (FMUSP), São Paulo, SP, Brazil
| | - Carlos R Bueno Júnior
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; School of Physical Education of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Zoughaib WS, Fry MJ, Singhal A, Coggan AR. Beetroot juice supplementation and exercise performance: is there more to the story than just nitrate? Front Nutr 2024; 11:1347242. [PMID: 38445207 PMCID: PMC10912565 DOI: 10.3389/fnut.2024.1347242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/31/2024] [Indexed: 03/07/2024] Open
Abstract
This mini-review summarizes the comparative effects of different sources of dietary nitrate (NO3-), beetroot juice (BRJ) and nitrate salts (NIT), on physiological function and exercise capacity. Our objectives were to determine whether BRJ is superior to NIT in enhancing exercise-related outcomes, and to explore the potential contribution of other putatively beneficial compounds in BRJ beyond NO3-. We conducted a comparative analysis of recent studies focused on the impact of BRJ versus NIT on submaximal oxygen consumption (VO2), endurance performance, adaptations to training, and recovery from muscle-damaging exercise. While both NO3- sources provide benefits, there is some evidence that BRJ may offer additional advantages, specifically in reducing VO2 during high-intensity exercise, magnifying performance improvements with training, and improving recovery post-exercise. These reported differences could be due to the hypothesized antioxidant and/or anti-inflammatory properties of BRJ resulting from the rich spectrum of phytonutrients it contains. However, significant limitations to published studies directly comparing BRJ and NIT make it quite challenging to draw any firm conclusions. We provide recommendations to help guide further research into the important question of whether there is more to the story of BRJ than just NO3-.
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Affiliation(s)
- William S. Zoughaib
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Indianapolis, Indianapolis, IN, United States
| | - Madison J. Fry
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Indianapolis, Indianapolis, IN, United States
| | - Ahaan Singhal
- School of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Andrew R. Coggan
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Indianapolis, Indianapolis, IN, United States
- Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indianapolis, IN, United States
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Zoughaib WS, Hoffman RL, Yates BA, Moorthi RN, Lim K, Coggan AR. Short-term beetroot juice supplementation improves muscle speed and power but does not reduce blood pressure or oxidative stress in 65-79 y old men and women. Nitric Oxide 2023; 138-139:34-41. [PMID: 37244392 PMCID: PMC10527284 DOI: 10.1016/j.niox.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
We have previously demonstrated that acute ingestion of inorganic nitrate (NO3-)-rich beetroot juice (BRJ), a source of nitric oxide (NO) via the NO3- → nitrite (NO2-) → NO pathway, can improve muscle speed and power in older individuals. It is not known, however, whether this effect is maintained or perhaps even enhanced with repeated ingestion, or if tolerance develops as with organic nitrates, e.g., nitroglycerin. Using a double-blind, placebo-controlled, crossover design, we therefore studied 16 community-dwelling older (age 71 ± 5 y) individuals after both acute and short-term (i.e., daily for 2 wk) BRJ supplementation. Blood samples were drawn and blood pressure was measured periodically during each ∼3 h experiment, with muscle function determined using isokinetic dynamometry. Acute ingestion of BRJ containing 18.2 ± 6.2 mmol of NO3- increased plasma NO3- and NO2- concentrations 23 ± 11 and 2.7 ± 2.1-fold over placebo, respectively. This was accompanied by 5 ± 11% and 7 ± 13% increases in maximal knee extensor speed (Vmax) and power (Pmax), respectively. After daily supplementation for 2 wk, BRJ ingestion elevated NO3- and NO2- levels 24 ± 12 and 3.3 ± 4.0-fold, respectively, whereas Vmax and Pmax were 7 ± 9% and 9 ± 11% higher than baseline. No changes were observed in blood pressure or in plasma markers of oxidative stress with either acute or short-term NO3- supplementation. We conclude that both acute and short-term dietary NO3- supplementation result in similar improvements in muscle function in older individuals. The magnitudes of these improvements are sufficient to offset the decline resulting from a decade or more of aging and are therefore likely to be clinically significant.
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Affiliation(s)
- William S Zoughaib
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Purdue University, Indianapolis, USA
| | - Richard L Hoffman
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Purdue University, Indianapolis, USA
| | - Brandon A Yates
- Indiana Center for Musculoskeletal Health, School of Medicine, Indiana University School of Medicine, USA
| | - Ranjani N Moorthi
- Division of Nephrology & Hypertension, School of Medicine, Indiana University School of Medicine, USA
| | - Kenneth Lim
- Division of Nephrology & Hypertension, School of Medicine, Indiana University School of Medicine, USA
| | - Andrew R Coggan
- Department of Kinesiology, School of Health & Human Sciences, Indiana University Purdue University, Indianapolis, USA; Indiana Center for Musculoskeletal Health, School of Medicine, Indiana University School of Medicine, USA.
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Franceković P, Gliemann L. Endothelial Glycocalyx Preservation-Impact of Nutrition and Lifestyle. Nutrients 2023; 15:nu15112573. [PMID: 37299535 DOI: 10.3390/nu15112573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
The endothelial glycocalyx (eGC) is a dynamic hair-like layer expressed on the apical surface of endothelial cells throughout the vascular system. This layer serves as an endothelial cell gatekeeper by controlling the permeability and adhesion properties of endothelial cells, as well as by controlling vascular resistance through the mediation of vasodilation. Pathogenic destruction of the eGC could be linked to impaired vascular function, as well as several acute and chronic cardiovascular conditions. Defining the precise functions and mechanisms of the eGC is perhaps the limiting factor of the missing link in finding novel treatments for lifestyle-related diseases such as atherosclerosis, type 2 diabetes, hypertension, and metabolic syndrome. However, the relationship between diet, lifestyle, and the preservation of the eGC is an unexplored territory. This article provides an overview of the eGC's importance for health and disease and describes perspectives of nutritional therapy for the prevention of the eGC's pathogenic destruction. It is concluded that vitamin D and omega-3 fatty acid supplementation, as well as healthy dietary patterns such as the Mediterranean diet and the time management of eating, might show promise for preserving eGC health and, thus, the health of the cardiovascular system.
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Affiliation(s)
- Paula Franceković
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Universitetsparken 13, DK-2100 Copenhagen, Denmark
| | - Lasse Gliemann
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Universitetsparken 13, DK-2100 Copenhagen, Denmark
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Bacanoiu MV, Danoiu M, Rusu L, Marin MI. New Directions to Approach Oxidative Stress Related to Physical Activity and Nutraceuticals in Normal Aging and Neurodegenerative Aging. Antioxidants (Basel) 2023; 12:antiox12051008. [PMID: 37237873 DOI: 10.3390/antiox12051008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
Oxidative stress (OS) plays, perhaps, the most important role in the advanced aging process, cognitive impairment and pathogenesis of neurodegenerative disorders. The process generates tissue damage via specific mechanisms on proteins, lipids and nucleic acids of the cells. An imbalance between the excessive production of oxygen- and nitrogen-reactive species and antioxidants leads to a progressive decline in physiological, biological and cognitive functions. Accordingly, we need to design and develop favourable strategies for stopping the early aging process as well as the development of neurodegenerative diseases. Exercise training and natural or artificial nutraceutical intake are considered therapeutic interventions that reduce the inflammatory process, increase antioxidant capacities and promote healthy aging by decreasing the amount of reactive oxygen species (ROS). The aim of our review is to present research results in the field of oxidative stress related to physical activity and nutraceutical administration for the improvement of the aging process, but also related to reducing the neurodegeneration process based on analysing the beneficial effects of several antioxidants, such as physical activity, artificial and natural nutraceuticals, as well as the tools by which they are evaluated. In this paper, we assess the recent findings in the field of oxidative stress by analysing intervention antioxidants, anti-inflammatory markers and physical activity in healthy older adults and the elderly population with dementia and Parkinson's disease. By searching for studies from the last few years, we observed new trends for approaching the reduction in redox potential using different tools that evaluate regular physical activity, as well as antioxidant and anti-inflammatory markers preventing premature aging and the progress of disabilities in neurodegenerative diseases. The results of our review show that regular physical activity, supplemented with vitamins and oligomolecules, results in a decrease in IL-6 and an increase in IL-10, and has an influence on the oxidative metabolism capacity. In conclusion, physical activity provides an antioxidant-protective effect by decreasing free radicals and proinflammatory markers.
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Affiliation(s)
- Manuela Violeta Bacanoiu
- Sport Medicine and Physical Therapy Department, Faculty of Physical Education and Sport, University of Craiova, 200585 Craiova, Romania
| | - Mircea Danoiu
- Sport Medicine and Physical Therapy Department, Faculty of Physical Education and Sport, University of Craiova, 200585 Craiova, Romania
| | - Ligia Rusu
- Sport Medicine and Physical Therapy Department, Faculty of Physical Education and Sport, University of Craiova, 200585 Craiova, Romania
| | - Mihnea Ion Marin
- Faculty of Mechanics, University of Craiova, 200585 Craiova, Romania
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Worley ML, Reed EL, Chapman CL, Kueck P, Seymour L, Fitts T, Zazulak H, Schlader ZJ, Johnson BD. Acute beetroot juice consumption does not alter cerebral autoregulation or cardiovagal baroreflex sensitivity during lower-body negative pressure in healthy adults. Front Hum Neurosci 2023; 17:1115355. [PMID: 36742355 PMCID: PMC9892911 DOI: 10.3389/fnhum.2023.1115355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/06/2023] [Indexed: 01/20/2023] Open
Abstract
Introduction Beetroot juice (BRJ) improves peripheral endothelial function and vascular compliance, likely due to increased nitric oxide bioavailability. It is unknown if BRJ alters cerebrovascular function and cardiovagal baroreflex control in healthy individuals. Purpose We tested the hypotheses that BRJ consumption improves cerebral autoregulation (CA) and cardiovagal baroreflex sensitivity (cBRS) during lower-body negative pressure (LBNP). Methods Thirteen healthy adults (age: 26 ± 4 years; 5 women) performed oscillatory (O-LBNP) and static LBNP (S-LBNP) before (PRE) and 3 h after consuming 500 mL of BRJ (POST). Participants inhaled 3% CO2 (21% O2, 76% N2) during a 5 min baseline and throughout LBNP to attenuate reductions in end-tidal CO2 tension (PETCO2). O-LBNP was conducted at ∼0.02 Hz for six cycles (-70 mmHg), followed by a 3-min recovery before S-LBNP (-40 mmHg) for 7 min. Beat-to-beat middle cerebral artery blood velocity (MCAv) (transcranial Doppler) and blood pressure were continuously recorded. CA was assessed using transfer function analysis to calculate coherence, gain, and phase in the very-low-frequency (VLF; 0.020-0.070 Hz) and low-frequency bands (LF; 0.07-0.20 Hz). cBRS was calculated using the sequence method. Comparisons between POST vs. PRE are reported as mean ± SD. Results During O-LBNP, coherence VLF was greater at POST (0.55 ± 0.06 vs. 0.46 ± 0.08; P < 0.01), but phase VLF (P = 0.17) and gain VLF (P = 0.69) were not different. Coherence LF and phase LF were not different, but gain LF was lower at POST (1.03 ± 0.20 vs. 1.12 ± 0.30 cm/s/mmHg; P = 0.05). During S-LBNP, CA was not different in the VLF or LF bands (all P > 0.10). Up-cBRS and Down-cBRS were not different during both LBNP protocols. Conclusion These preliminary data indicate that CA and cBRS during LBNP in healthy, young adults is largely unaffected by an acute bolus of BRJ.
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Affiliation(s)
- Morgan L. Worley
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Emma L. Reed
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
- Department of Human Physiology, Bowerman Sports Science Center, University of Oregon, Eugene, OR, United States
| | - Christopher L. Chapman
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
- Department of Human Physiology, Bowerman Sports Science Center, University of Oregon, Eugene, OR, United States
| | - Paul Kueck
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Lauren Seymour
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Triniti Fitts
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Hannah Zazulak
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Zachary J. Schlader
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
- Department of Kinesiology, School of Public Health, Indiana University Bloomington, Bloomington, IN, United States
| | - Blair D. Johnson
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
- Department of Kinesiology, School of Public Health, Indiana University Bloomington, Bloomington, IN, United States
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Moreno B, Morencos E, Vicente-Campos D, Muñoz A, González-García J, Veiga S. Effects of beetroot juice intake on repeated performance of competitive swimmers. Front Physiol 2023; 13:1076295. [PMID: 36703935 PMCID: PMC9871287 DOI: 10.3389/fphys.2022.1076295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Abstract
Background: Beetroot juice is a sport supplement with a high level of evidence on the physical performance enhancement. However, in swimming, there is no clear data about the effects of beetroot juice on performance. Objective: To investigate whether an acute intake of beetroot juice (BJ) improves the performance of competitive swimmers in a repeated maximum swimming effort. Method: Thirteen national-level swimmers (six females and seven males), participated in this randomized, double-blind crossover study. In two different trials, swimmers ingested a 70-mL placebo shot (.04 mmol NO3 -; PLA) or a 70-mL Beet-It shot (6.4 mmol of NO3 -beet juice [BJ]) 3 h before undergoing a 6 × 100-m front-crawl maximal effort test with 7 min rest between each 100 m. Results: Overall, 100-m times showed no difference between the BJ and PLA groups (p = .364), although a possibly shorter time was observed for BJ in the last repetition (p = .104; mean difference [MD] = -.99 s, mean-based inference [MBI] = 49/51/0). Participants in the BJ condition showed a possibly lower rate of perceived exertion in the first (p = .242, MD = -.85, MBI = 70/28/2) and second repetitions (p = .165, MD = 1.15, MBI = 83/16/1), whereas Total Quality Recovery scale scores were likely higher in the first (p = .110, MD = 1.15, MBI = 83/16/1) and third (p = .082, MD = -.77, MBI = 70/29/1) repetitions compared with those in the PLA group. Blood lactate concentration [La+] levels showed no differences between groups in any of the repetitions (p > .05, unclear), and we observed an increase in 100-m times for both BJ and PLA (BJ: p = .014, MD = -1.51 s; PLA: p = .029, MD = -1.57 s) after the fifth repetition. Conclusion: No clear differences in performance were observed in a 6 × 100-m repeated sprint test by competitive swimmers when supplementing (or not) with BJ. However, there was a trend toward a better recovery between efforts and a better tolerance of fatigue when swimmers ingested BJ.
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Affiliation(s)
- Berta Moreno
- Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain,Departamento de Deportes, Universidad Politécnica de Madrid, Madrid, Spain
| | - Esther Morencos
- Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | - Davinia Vicente-Campos
- Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | - Alejandro Muñoz
- Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | - Jaime González-García
- Facultad de Ciencias de la Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | - Santiago Veiga
- Departamento de Deportes, Universidad Politécnica de Madrid, Madrid, Spain,*Correspondence: Santiago Veiga,
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Qadir OK, Seal CJ, Ashor AW, Tassotti M, Mena P, Del Rio D, Siervo M, Brandt K. Double-blind controlled dietary cross-over intervention with differentially fertilised intact lettuce leaves shows acute reduction in blood pressure in young adults, associated with faster uptake of nitrate than of phenolics. Eur J Nutr 2022; 61:4191-4203. [PMID: 35871120 PMCID: PMC9596532 DOI: 10.1007/s00394-022-02961-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/08/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare acute effects on blood pressure (BP) of ingestion of visually similar lettuce with controlled high and low content of either nitrate or phenolic compounds. METHODS In a randomised cross-over design, 19 healthy participants (22-31 years) received 50 g of lettuce containing either 530 mg (8.4 mmol) nitrate + 11 mg (0.03 mmol) phenolic compounds (HNLP); or 3 mg nitrate (0.05 mmol) + 77 mg (0.2 mmol) phenolic compounds (LNHP), obtained by differential fertilisation. Ambulatory BP was recorded along with plasma, salivary and urinary nitrate and nitrite and plasma concentrations of cyclic guanosine monophosphate (cGMP), phenolic metabolites, Trolox equivalent antioxidant capacity (TEAC) and ferric reducing antioxidant power (FRAP). RESULTS Compared with LNHP, 3 h post ingestion of HNLP, plasma nitrate increased 0.31 ± (95%CI) 0.12 mM (+ 240%), and salivary nitrate 5.5 ± 1.4 mM (+ 910%); accumulated urinary nitrate excretion increased 188 ± 72 mg (+ 296%) (all P < 0.001). Systolic BP was reduced 4.9 ± 4.2 mmHg (P = 0.031) between 3 and 6 h after ingestion of HNLP compared with LNHP; systolic BP differences were negatively correlated (P = 0.004) with differences in saliva nitrate concentrations. LNHP increased plasma phenolics at 6 h, predominantly 3'-methoxycinnamic acid-4'-glucuronide (ferulic acid-4'-glucuronide), 116%, 204 ± 138 nM more than HNLP (P = 0.001); increased cGMP 14% (P = 0.019); and reduced FRAP 3.1% (P = 0.009). CONCLUSION The acute BP difference within 6 h of consumption matched the plasma/saliva nitrate peak, not the slower changes of plasma phenolics. This is the first double-blind controlled dietary intervention demonstrating differential effects on human physiology by consumption of an intact plant food, where compositional differences were obtained by controlling growing conditions, indicating potential opportunities for health claims relating to precision/vertical farming. CLINICAL TRIAL REGISTRATION The trial was retrospectively registered on ClinicalTrials.gov, with identifier NCT02701959, on March 8, 2016.
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Affiliation(s)
- Othman K Qadir
- Human Nutrition Research Centre, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Food Science and Quality Control Department, College of Agricultural Engineering Sciences, University of Sulaimani, 46001, Sulaymaniah, Kurdistan Region, Iraq
| | - Chris J Seal
- Human Nutrition Research Centre, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Ammar W Ashor
- Human Nutrition Research Centre, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Internal Medicine, College of Medicine, Mustansiriyah University, Baghdad, Iraq
| | - Michele Tassotti
- Human Nutrition Unit, Department of Food and Drugs, University of Parma, Medical School Building C, Via Volturno, 39, 43125, Parma, Italy
| | - Pedro Mena
- Human Nutrition Unit, Department of Food and Drugs, University of Parma, Medical School Building C, Via Volturno, 39, 43125, Parma, Italy
| | - Daniele Del Rio
- Human Nutrition Unit, Department of Food and Drugs, University of Parma, Medical School Building C, Via Volturno, 39, 43125, Parma, Italy
- School of Advanced Studies on Food and Nutrition, University of Parma, Parma, Italy
| | - Mario Siervo
- Human Nutrition Research Centre, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- School of Life Sciences, Queen's Medical Centre, Nottingham University, Nottingham, NG7 2UH, UK
| | - Kirsten Brandt
- Human Nutrition Research Centre, Population Health Sciences Institute, William Leech Building, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.
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Plant-Based Foods and Vascular Function: A Systematic Review of Dietary Intervention Trials in Older Subjects and Hypothesized Mechanisms of Action. Nutrients 2022; 14:nu14132615. [PMID: 35807796 PMCID: PMC9268664 DOI: 10.3390/nu14132615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
Cardiovascular diseases, still the leading cause of mortality in the world, are closely related to vascular function. Older subjects are more susceptible to endothelial dysfunction and therefore it is important to define possible preventive or support strategies, such as consumption of foods with health-promoting effects. This systematic review aims to summarize the currently available evidence on acute or chronic trials testing the effect of selected plant-based foods on vascular function parameters in older subjects, and consider plausible mechanisms that may support the main findings. A total of 15 trials were included and analyzed, testing the effects of beetroot, plum, blueberry, and vegetable oils. We found some interesting results regarding markers of vascular reactivity, in particular for beetroot, while no effects were found for markers of arterial stiffness. The amelioration of vascular function seems to be more related to the restoration of a condition of nitric oxide impairment, exacerbated by diseases or hypoxic condition, rather than the enhancement of a physiological situation, as indicated by the limited effects on healthy older subjects or in control groups with young subjects. However, the overall set of selected studies is, in any case, rather limited and heterogeneous in terms of characteristics of the studies, indicating the need for additional high-quality intervention trials to better clarify the role of vegetable foods in restoring and/or improving vascular function in order to better elucidate the mechanisms through which these foods may exert their vascular health benefits in older subjects.
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Moreira LDSG, Fanton S, Cardozo L, Borges NA, Combet E, Shiels PG, Stenvinkel P, Mafra D. Pink pressure: beetroot (Beta vulgaris rubra) as a possible novel medical therapy for chronic kidney disease. Nutr Rev 2021; 80:1041-1061. [PMID: 34613396 DOI: 10.1093/nutrit/nuab074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic kidney disease (CKD) manifests with systemic inflammation, oxidative stress, and gut dysbiosis, resulting in metabolic disorders and elevated rates of cardiovascular disease-associated death. These all correlate with a high economic cost to healthcare systems. Growing evidence indicates that diet is an indispensable ally in the prevention and management of CKD and its complications. In this context, the root vegetable beetroot (Beta vulgaris rubra) deserves special attention because it is a source of several bioactive compounds, such as nitrate, betaine, and betalain, and has shown beneficial effects in CKD, including reduction of blood pressure, anti-inflammatory effects, and antioxidant actions by scavenging radical oxidative species, as observed in preclinical studies. Beetroot consumption as a possible therapeutic strategy to improve the clinical treatment of patients with CKD and future directions for clinical studies are addressed in this narrative review.
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Affiliation(s)
- Laís de Souza Gouveia Moreira
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Susane Fanton
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ludmila Cardozo
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Natalia A Borges
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Emilie Combet
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Paul G Shiels
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Denise Mafra
- L.d.S.G. Moreira and D. Mafra are with the Graduate Program in Medical Sciences, Fluminense Federal University, Niterói, Rio de Janiero, Brazil. S. Fanton, L. Cardozo, and D. Mafra are with the Graduate Program in Cardiovascular Sciences, Federal Fluminense University, Niterói-Rio de Janeiro, RJ, Brazil. N.A. Borges is with the Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil. E. Combet is with the School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. P.G. Shiels is with the Wolfson Wohl Translational Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom. P. Stenvinkel is with the Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
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Repeated administration of inorganic nitrate on blood pressure and arterial stiffness: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2021; 38:2122-2140. [PMID: 32723980 DOI: 10.1097/hjh.0000000000002524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE We aim to synthesize effects of repeated administration (≥3 days) of inorganic nitrate on blood pressure and arterial stiffness measures. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials with at least 3 days treatment of inorganic nitrate on blood pressure and arterial stiffness in individuals with or without elevated cardiovascular disease risk. MEDLINE, EMBASE and the Cochrane Library were searched through 2 July 2019. Two independent reviewers extracted relevant study data. Data were pooled using the generic inverse variance method with random-effects model, and expressed as mean differences with 95% confidence intervals. Certainty in the evidence was assessed using GRADE. RESULTS Forty-seven trials were included (n = 1101). Administration of inorganic nitrate significantly lowered SBP [mean difference: -2.91 mmHg, 95% confidence interval (95% CI): -3.92 to -1.89, I = 76%], DBP (mean difference: -1.45 mmHg, 95% CI: -2.22 to -0.68, I = 78%], central SBP (mean difference: -1.56 mmHg, 95% CI: -2.62 to -0.50, I = 30%) and central DBP (mean difference: -1.99 mmHg, 95% CI: -2.37 to -1.60, I = 0%). There was no effect on 24-h blood pressure, augmentation index or pulse wave velocity. Certainty in the evidence was graded moderate for central blood pressure, pulse wave velocity and low for peripheral blood pressure, 24-h blood pressure and augmentation index. CONCLUSION Repeated administration (≥3 days) of inorganic nitrate lower peripheral and central blood pressure. Results appear to be driven by beneficial effects in healthy and hypertensive individuals. More studies are required to increase certainty in the evidence.
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12
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He Y, Liu J, Cai H, Zhang J, Yi J, Niu Y, Xi H, Peng X, Guo L. Effect of inorganic nitrate supplementation on blood pressure in older adults: A systematic review and meta-analysis. Nitric Oxide 2021; 113-114:13-22. [PMID: 33905826 DOI: 10.1016/j.niox.2021.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Previous clinical studies have shown controversial results regarding the effect of inorganic nitrate supplementation on blood pressure (BP) in older individuals. We performed this systematic review and meta-analysis to assess the effect of inorganic nitrate on BP in older adults. METHODS Eligible studies were searched in Cochrane Library, PubMed, Scopus, Web of Science, and Embase. Randomized controlled trials which evaluated the effect of inorganic nitrate consumption on BP in older adults were recruited. The random-effect model was used to calculate the pooled effect sizes. RESULTS 22 studies were included in this meta-analysis. Overall, inorganic nitrate consumption significantly reduced systolic blood pressure (SBP) by -3.90 mmHg (95% confidence interval: -5.23 to -2.57; P < 0.001) and diastolic blood pressure (DBP) by -2.62 mmHg (95% confidence interval: -3.86 to -1.37; P < 0.005) comparing with the control group. Subgroup analysis showed that the BP was significantly reduced when participants' age≥65, BMI>30, or baseline BP in prehypertension stage. And both SBP and DBP decreased significantly after acute nitrate supplementation of a single dose (<1 day) or more than 1-week. However, participants with hypertension at baseline were not associated with significant changes in both SBP and DBP. Subgroup analysis of measurement methods showed that only the resting BP group showed a significant reduction in SBP and DBP, compared with the 24-h ambulatory BP monitoring (ABPM) group and daily home BP measurement group. CONCLUSION These results demonstrate that consuming inorganic nitrate can significantly reduce SBP and DBP in older adults, especially in whose age ≥ 65, BMI>30, or baseline BP in prehypertension stage.
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Affiliation(s)
- Yayu He
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Jinshu Liu
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Hongwei Cai
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Jun Zhang
- The Second Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Jiang Yi
- The Second Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Yirou Niu
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Huihui Xi
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Xinyue Peng
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
| | - Lirong Guo
- School of Nursing, Jilin University, Changchun, Jilin, 130021, China.
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13
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Henning T, Weber D. Redox biomarkers in dietary interventions and nutritional observation studies - From new insights to old problems. Redox Biol 2021; 41:101922. [PMID: 33756398 PMCID: PMC8020480 DOI: 10.1016/j.redox.2021.101922] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose The purpose of this review is to give an overview on recently published articles investigating the associations of diet and dietary interventions with biomarkers of oxidative stress with special emphasis on different categories of redox biomarkers. Findings Intervention and observational studies both in healthy participants and patients that investigated associations of dietary habits, foodstuffs or isolated nutrients with biomarkers of oxidative stress were included in this review. Recently published observation studies confirm the inverse association between fruit and vegetable intake and oxidative stress markers. Studies investigating the effect of vitamin D and vitamin E, magnesium, zinc, chromium, selenium, probiotic supplementation and several phytochemicals reported consistent changes in redox biomarkers. Of 88 articles included in this review, only seven studies measured biomarkers from the three categories: oxidative damage, endogenous antioxidants, and exogenous antioxidants. Many studies rely on controversial assays for total antioxidant capacity, thus there is potential in many studies to improve biomarker repertoire to cover all three categories of biomarkers and to turn away from such assays. Oxidative stress can be assessed by specific biomarker categories. Three biomarker categories: oxidative damage, endogenous, exogenous antioxidants. Only seven studies performed measurements of all three biomarker categories. TAC, TRAP, FRAP, ORAC should not be used as stand-alone redox marker. Several interventions reported improvements in markers of oxidative stress.
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Affiliation(s)
- Thorsten Henning
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), 14558, Nuthetal, Germany; Food4Future (F4F), c/o Leibniz Institute of Vegetable and Ornamental Crops (IGZ), Theodor-Echtermeyer-Weg 1, 14979, Grossbeeren, Germany
| | - Daniela Weber
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), 14558, Nuthetal, Germany; Food4Future (F4F), c/o Leibniz Institute of Vegetable and Ornamental Crops (IGZ), Theodor-Echtermeyer-Weg 1, 14979, Grossbeeren, Germany; NutriAct-Competence Cluster Nutrition Research Berlin-Potsdam, 14558, Nuthetal, Germany.
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14
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Jakubcik EM, Rutherfurd-Markwick K, Chabert M, Wong M, Ali A. Pharmacokinetics of Nitrate and Nitrite Following Beetroot Juice Drink Consumption. Nutrients 2021; 13:nu13020281. [PMID: 33498220 PMCID: PMC7908977 DOI: 10.3390/nu13020281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Nitrate (NO3
-)-rich beetroot (BR) juice supplementation has been shown to improve cardiovascular function via reduction to nitrite (NO2
-) and then to the bioactive molecule nitric oxide (NO). However, limited research exists for the role of inorganic NO2
- that is contained naturally within BR. OBJECTIVE As BR juice can naturally contain both NO3
- and NO2
- the objective of this study was to evaluate the individual effects of NO3
- and NO2
- consumed from BR on plasma [NO3
-]/[NO2
-] and their subsequent effects on various cardiovascular measures. DESIGN In four separate treatments, 11 healthy adults consumed 250 mL of BR containing one of the following: (i) high NO3
-, low NO2
- (HL; 572 mg NO3
-, 32 mg NO2
-); (ii) medium NO3
-, medium NO2
- (MM; 280 mg NO3
-, 237 mg NO2
-); (iii) low NO3
-, medium NO2
- (LM; 43 mg NO3
-, 262 mg NO2
-); (iv) placebo (PL; low NO3
-, low NO2
-: 8 mg NO3
-, 5.8 mg NO2
-). Plasma [NO3
-]/[NO2
-], blood pressure, heart rate, mean arterial pressure (MAP), cardiac output and stroke volume were measured at baseline and every hour or second hour for 6 h post-BR consumption. OUTCOMES Ingestion of the HL and MM BR increased plasma [NO2
-] and [NO3
-] after 2 h, with both remaining elevated after 6 h (p < 0.05). LM increased plasma [NO3
-] (p < 0.05) but did not increase plasma [NO2
-] compared to PL (p = 0.177). MAP was lower following the consumption of HL at 4 h and LM at 6 h (p < 0.05). CONCLUSION Inorganic NO3
- consumption is the critical factor in elevating plasma [NO3
-] and [NO2
-]; however, both NO2
- and NO3
- show potential to reduce MAP. The known reduction of systolic blood pressure (SBP)/diastolic blood pressure (DBP) following NO3
- supplementation was not observed, making it unclear if NO2
- contributes to a reduction in SBP/DBP alongside NO3
-.
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Affiliation(s)
| | - Kay Rutherfurd-Markwick
- School of Health Sciences, Massey University, Auckland 0745, New Zealand;
- Centre for Metabolic Health Research, Massey University, Auckland 0745, New Zealand
| | | | - Marie Wong
- School of Food and Advanced Technology, Massey University, Auckland 0745, New Zealand;
| | - Ajmol Ali
- School of Sport, Exercise and Nutrition, Massey University, Auckland 0745, New Zealand;
- Centre for Metabolic Health Research, Massey University, Auckland 0745, New Zealand
- Correspondence:
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15
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Cramer MN, Hieda M, Huang M, Moralez G, Crandall CG. Dietary nitrate supplementation does not influence thermoregulatory or cardiovascular strain in older individuals during severe ambient heat stress. Exp Physiol 2020; 105:1730-1741. [PMID: 32816341 DOI: 10.1113/ep088834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022]
Abstract
NEW FINDINGS What is the central question of this study? Does dietary nitrate supplementation with beetroot juice attenuate thermoregulatory and cardiovascular strain in older adults during severe heat stress? What is the main finding and its importance? A 7-day nitrate supplementation regimen lowered resting mean arterial pressure in thermoneutral conditions. During heat stress, core and mean skin temperatures, vasodilatory responses, sweat loss, heart rate and left ventricular function were unchanged, and mean arterial pressure was only transiently reduced, post-supplementation. These data suggest nitrate supplementation with beetroot juice does not mitigate thermoregulatory or cardiovascular strain in heat-stressed older individuals. ABSTRACT This study tested the hypothesis that dietary nitrate supplementation with concentrated beetroot juice attenuates thermoregulatory and cardiovascular strain in older individuals during environmental heat stress. Nine healthy older individuals (six females, three males; aged 67 ± 5 years) were exposed to 42.5 ± 0.1°C and 34.0 ± 0.5% relative humidity conditions for 120 min before (CON) and after 7 days of dietary nitrate supplementation with concentrated beetroot juice (BRJ; 280 ml, ∼16.8 mmol of nitrate daily). Core and skin temperatures, body mass changes (indicative of whole-body sweat loss), skin blood flow and cutaneous vascular conductance, forearm blood flow and vascular conductance, heart rate, arterial blood pressures and indices of cardiac function were measured. The 7-day beetroot juice regimen increased plasma nitrate/nitrite levels from 27.4 ± 15.2 to 477.0 ± 102.5 μmol l-1 (P < 0.01) and lowered resting mean arterial pressure from 90 ± 7 to 83 ± 10 mmHg at baseline under thermoneutral conditions (P = 0.02). However, during subsequent heat stress, no differences in core and skin temperatures, skin blood flow and vascular conductance, forearm blood flow and vascular conductance, whole-body sweat loss, heart rate, and echocardiographic indices of systolic function and diastolic filling were evident following nitrate supplementation (all P > 0.05). Mean arterial pressure was lower in BRJ vs. CON during heat stress (treatment-by-time interaction: P = 0.02). Overall, these findings suggest that dietary nitrate supplementation with concentrated beetroot juice does not attenuate thermoregulatory or cardiovascular strain in older individuals exposed to severe ambient heat stress.
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Affiliation(s)
- Matthew N Cramer
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michinari Hieda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX, USA.,School of Medicine, Kyushu University, Fukuoka, Japan
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX, USA.,Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gilbert Moralez
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX, USA.,Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, TX, USA
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16
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Berry MJ, Miller GD, Kim-Shapiro DB, Fletcher MS, Jones CG, Gauthier ZD, Collins SL, Basu S, Heinrich TM. A randomized controlled trial of nitrate supplementation in well-trained middle and older-aged adults. PLoS One 2020; 15:e0235047. [PMID: 32574223 PMCID: PMC7310701 DOI: 10.1371/journal.pone.0235047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 06/05/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Nitrate (NO3-), through its conversion to nitrite (NO2-) and nitric oxide, has been shown to increase exercise tolerance in healthy younger adults and older diseased patients. Nitrate’s effect in well-trained middle to older-aged adults has not been studied. Therefore, the purpose of this investigation was to examine the effects of a NO3- rich beverage on submaximal constant work rate exercise time in well-trained middle to older-aged adults. Methods This was a randomized controlled cross-over trial with 15 well-trained middle to older-aged adults, 41–64 year-old, who received one of two treatments (NO3- rich beverage then placebo or placebo then NO3- rich beverage), after which an exercise test at 75 percent of the subject’s maximal work rate was completed. Results The NO3- rich beverage increased plasma NO3- and NO2- levels by 260 μM and 0.47 μM, respectively (p<0.001). Exercise time was not significantly different (p = 0.31) between the NO3- rich versus placebo conditions (1130±151 vs 1060±132 sec, respectively). Changes in exercise time between the two conditions ranged from a 55% improvement to a 40% decrease with the NO3- rich beverage. Oxygen consumption and rating of perceived exertion were not significantly different between the two conditions. Conclusion In middle to older-aged well-trained adults, NO3- supplementation has non-significant, albeit highly variable, effects on exercise tolerance. ClinicalTrials.gov Identifier: NCT03371966
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Affiliation(s)
- Michael J. Berry
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Gary D. Miller
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Daniel B. Kim-Shapiro
- Physics Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Macie S. Fletcher
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Caleb G. Jones
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Zachary D. Gauthier
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Summer L. Collins
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Swati Basu
- Physics Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
| | - Timothy M. Heinrich
- Health and Exercise Department, Wake Forest University, Winston-Salem, North Carolina, United States of America
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17
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Zamani H, de Joode MEJR, Hossein IJ, Henckens NFT, Guggeis MA, Berends JE, de Kok TMCM, van Breda SGJ. The benefits and risks of beetroot juice consumption: a systematic review. Crit Rev Food Sci Nutr 2020; 61:788-804. [PMID: 32292042 DOI: 10.1080/10408398.2020.1746629] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Beetroot juice (BRJ) has become increasingly popular amongst athletes aiming to improve sport performances. BRJ contains high concentrations of nitrate, which can be converted into nitric oxide (NO) after consumption. NO has various functions in the human body, including a vasodilatory effect, which reduces blood pressure and increases oxygen- and nutrient delivery to various organs. These effects indicate that BRJ may have relevant applications in prevention and treatment of cardiovascular disease. Furthermore, the consumption of BRJ also has an impact on oxygen delivery to skeletal muscles, muscle efficiency, tolerance and endurance and may thus have a positive impact on sports performances. Aside from the beneficial aspects of BRJ consumption, there may also be potential health risks. Drinking BRJ may easily increase nitrate intake above the acceptable daily intake, which is known to stimulate the endogenous formation of N-nitroso compounds (NOC's), a class of compounds that is known to be carcinogenic and that may also induce several other adverse effects. Compared to studies on the beneficial effects, the amount of data and literature on the negative effects of BRJ is rather limited, and should be increased in order to perform a balanced risk assessment.
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Affiliation(s)
- H Zamani
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M E J R de Joode
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - I J Hossein
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - N F T Henckens
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M A Guggeis
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J E Berends
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - T M C M de Kok
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - S G J van Breda
- Department of Toxicogenomics, GROW-school for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
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18
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Choi J, Kwon D, Kim K, Park J, Orbe DD, Gu J, Ahn J, Cho I, Jeong Y, Oh Y, Park I. Synergetic Effect of Porous Elastomer and Percolation of Carbon Nanotube Filler toward High Performance Capacitive Pressure Sensors. ACS APPLIED MATERIALS & INTERFACES 2020; 12:1698-1706. [PMID: 31825585 DOI: 10.1021/acsami.9b20097] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Wearable pressure sensors have been attracting great attention for a variety of practical applications, including electronic skin, smart textiles, and healthcare devices. However, it is still challenging to realize wearable pressure sensors with sufficient sensitivity and low hysteresis under small mechanical stimuli. Herein, we introduce simple, cost-effective, and sensitive capacitive pressure sensor based on porous Ecoflex-multiwalled carbon nanotube composite (PEMC) structures, which leads to enhancing the sensitivity (6.42 and 1.72 kPa-1 in a range of 0-2 and 2-10 kPa, respectively) due to a synergetic effect of the porous elastomer and percolation of carbon nanotube fillers. The PEMC structure shows excellent mechanical deformability and compliance for an effective integration with practical wearable devices. Also, the PEMC-based pressure sensor shows not only the long-term stability, low-hysteresis, and fast response under dynamic loading but also the high robustness against temperature and humidity changes. Finally, we demonstrate a prosthetic robot finger integrated with a PEMC-based pressure sensor and an actuator as well as a healthcare wristband capable of continuously monitoring blood pressure and heart rate.
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Affiliation(s)
- Jungrak Choi
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Donguk Kwon
- Package Process Development Team , Samsung Electronics , Seoul , South Korea
| | - Kyuyoung Kim
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Jaeho Park
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Dionisio Del Orbe
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Jimin Gu
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Junseong Ahn
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Incheol Cho
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Yongrok Jeong
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
| | - Yongsuk Oh
- Center for Bio-Integrated Electronics (CBIE) , Northwestern University , Evanston , Illinois 60208 , United States
| | - Inkyu Park
- Department of Mechanical Engineering , Korea Advanced Institute of Science and Technology (KAIST) , 291 Daehak-ro, Yuseong-gu , Daejeon 305-701 , South Korea
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19
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Carlström M, Lundberg JO, Weitzberg E. Mechanisms underlying blood pressure reduction by dietary inorganic nitrate. Acta Physiol (Oxf) 2018; 224:e13080. [PMID: 29694703 DOI: 10.1111/apha.13080] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/28/2018] [Accepted: 04/18/2018] [Indexed: 12/20/2022]
Abstract
Nitric oxide (NO) importantly contributes to cardiovascular homeostasis by regulating blood flow and maintaining endothelial integrity. Conversely, reduced NO bioavailability is a central feature during natural ageing and in many cardiovascular disorders, including hypertension. The inorganic anions nitrate and nitrite are endogenously formed after oxidation of NO synthase (NOS)-derived NO and are also present in our daily diet. Knowledge accumulated over the past two decades has demonstrated that these anions can be recycled back to NO and other bioactive nitrogen oxides via serial reductions that involve oral commensal bacteria and various enzymatic systems. Intake of inorganic nitrate, which is predominantly found in green leafy vegetables and beets, has a variety of favourable cardiovascular effects. As hypertension is a major risk factor of morbidity and mortality worldwide, much attention has been paid to the blood pressure reducing effect of inorganic nitrate. Here, we describe how dietary nitrate, via stimulation of the nitrate-nitrite-NO pathway, affects various organ systems and discuss underlying mechanisms that may contribute to the observed blood pressure-lowering effect.
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Affiliation(s)
- M. Carlström
- Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
| | - J. O. Lundberg
- Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
| | - E. Weitzberg
- Department of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
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20
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Does dietary nitrate say NO to cardiovascular ageing? Current evidence and implications for research. Proc Nutr Soc 2018; 77:112-123. [DOI: 10.1017/s0029665118000058] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CVD are characterised by a multi-factorial pathogenesis. Key pathogenetic steps in the development of CVD are the occurrence of endothelial dysfunction and formation of atherosclerotic lesions. Reduced nitric oxide (NO) bioavailability is a primary event in the initiation of the atherosclerotic cascade. NO is a free radical with multiple physiological functions including the regulation of vascular resistance, coagulation, immunity and oxidative metabolism. The synthesis of NO proceeds via two distinct pathways identified as enzymatic and non-enzymatic. The former involves the conversion of arginine into NO by the NO synthases, whilst the latter comprises a two-step reducing process converting inorganic nitrate $({\rm NO}_3^ - )$ into nitrite and subsequently NO.Inorganic ${\rm NO}_3^ - $ is present in water and food, particularly beetroot and green leafy vegetables. Several investigations have therefore used the non-enzymatic NO pathway as a target for nutritional supplementation (${\rm NO}_3^ - $ salts) or dietary interventions (high-${\rm NO}_3^ - $ foods) to increase NO bioavailability and impact on cardiovascular outcomes. Some studies have reported positive effects of dietary ${\rm NO}_3^ - $ on systolic blood pressure and endothelial function in patients with hypertension and chronic heart failure. Nevertheless, results have been inconsistent and the size of the effect appears to be declining in older individuals. Additionally, there is a paucity of studies for disorders such as diabetes, CHD and chronic kidney failure. Thus, whilst dietary ${\rm NO}_3^ - $ supplementation could represent an effective and viable strategy for the primary and secondary prevention of age-related cardiovascular and metabolic diseases, more large-scale, robust studies are awaited to confirm or refute this notion.
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Waldron M, Waldron L, Lawlor C, Gray A, Highton J. Beetroot supplementation improves the physiological responses to incline walking. Eur J Appl Physiol 2018; 118:1131-1141. [PMID: 29546639 DOI: 10.1007/s00421-018-3843-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/08/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE We investigated the effects of an acute 24-h nitrate-rich beetroot juice supplement (BR) on the energy cost, exercise efficiency and blood pressure responses to intermittent walking at different gradients. METHODS In a double-blind, cross-over design, eight participants were provided with a total of 350 ml of nitrate-rich (~ 20.5 mmol nitrate) BR or placebo (PLA) across 24 h before completing intermittent walking at 3 km/h on treadmill at gradients of 1, 5, 10, 15 and 20%. RESULTS Resting mean arterial pressure (MAP) was ~ 4.1% lower after BR (93 vs. 89 mmHg; P = 0.001), as well as during exercise (102 vs. 99 mmHg; P = 0.011) and recovery (97 vs. 94 mmHg; P = 0.001). Exercising (1227 vs. 1129 ml/min P < 0.001) and end-stage (1404 vs. 1249 ml/min; P = 0.002) oxygen uptake ([Formula: see text]O2) was lower in BR compared to PLA, which was accompanied by an average reduction in phase II [Formula: see text]O2 amplitude (1067 vs. 940 ml/min; P = 0.025). Similarly, recovery [Formula: see text]O2 (509 vs. 458 ml/min; P = 0.001) was lower in BR. Whole blood potassium concentration increased from pre-post exercise in PLA (4.1 ± 0.3 vs. 4.5 ± 0.3 mmol/L; P = 0.013) but not BR (4.1 ± 0.31 vs. 4.3 ± 0.2 mmol/L; P = 0.188). CONCLUSIONS Energy cost of exercise, recovery of [Formula: see text]O2, MAP and blood markers were ameliorated after BR. Previously-reported mechanisms explain these findings, which are more noticeable during less-efficient walking at steep gradients (15-20%). These findings have practical implications for hill-walkers.
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Affiliation(s)
- Mark Waldron
- School of Sport, Health and Applied Science, St Mary's University, Waldegrave Road, Twickenham, London, TW1 4SX, UK. .,School of Science and Technology, University of New England, Armidale, NSW, 2350, Australia.
| | - Luke Waldron
- Medical Education Centre, Royal Cornwall Hospitals NHS Trust, Truro, TR1 3LJ, UK
| | - Craig Lawlor
- School of Science and Technology, University of New England, Armidale, NSW, 2350, Australia
| | - Adrian Gray
- School of Science and Technology, University of New England, Armidale, NSW, 2350, Australia
| | - Jamie Highton
- Department of Sports and Exercise Sciences, University of Chester, Parkgate Road, Chester, CH14BJ, UK
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22
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Tsikas D, Schwedhelm KS, Surdacki A, Giustarini D, Rossi R, Kukoc-Modun L, Kedia G, Ückert S. S-Nitroso- N-acetyl-L-cysteine ethyl ester (SNACET) and N-acetyl-L-cysteine ethyl ester (NACET)-Cysteine-based drug candidates with unique pharmacological profiles for oral use as NO, H 2S and GSH suppliers and as antioxidants: Results and overview. J Pharm Anal 2017; 8:1-9. [PMID: 29568662 PMCID: PMC5859134 DOI: 10.1016/j.jpha.2017.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 12/21/2022] Open
Abstract
S-Nitrosothiols or thionitrites with the general formula RSNO are formally composed of the nitrosyl cation (NO+) and a thiolate (RS−), the base of the corresponding acids RSH. The smallest S-nitrosothiol is HSNO and derives from hydrogen sulfide (HSH, H2S). The most common physiological S-nitrosothiols are derived from the amino acid L-cysteine (CysSH). Thus, the simplest S-nitrosothiol is S-nitroso-L-cysteine (CysSNO). CysSNO is a spontaneous potent donor of nitric oxide (NO) which activates soluble guanylyl cyclase to form cyclic guanosine monophosphate (cGMP). This activation is associated with multiple biological actions that include relaxation of smooth muscle cells and inhibition of platelet aggregation. Like NO, CysSNO is a short-lived species and occurs physiologically at concentrations around 1 nM in human blood. CysSNO can be formed from CysSH and higher oxides of NO including nitrous acid (HONO) and its anhydride (N2O3). The most characteristic feature of RSNO is the S-transnitrosation reaction by which the NO+ group is reversibly transferred to another thiolate. By this way numerous RSNO can be formed such as the low-molecular-mass S-nitroso-N-acetyl-L-cysteine (SNAC) and S-nitroso-glutathione (GSNO), and the high-molecular-mass S-nitrosol-L-cysteine hemoglobin (HbCysSNO) present in erythrocytes and S-nitrosol-L-cysteine albumin (AlbCysSNO) present in plasma at concentrations of the order of 200 nM. All above mentioned RSNO exert NO-related biological activity, but they must be administered intravenously. This important drawback can be overcome by lipophilic charge-free RSNO. Thus, we prepared the ethyl ester of SNAC, the S-nitroso-N-acetyl-L-cysteine ethyl ester (SNACET), from synthetic N-acetyl-L-cysteine ethyl ester (NACET). Both NACET and SNACET have improved pharmacological features over N-acetyl-L-cysteine (NAC) and S-nitroso-N-acetyl-L-cysteine (SNAC), respectively, including higher oral bioavailability. SNACET exerts NO-related activities which can be utilized in the urogenital tract and in the cardiovascular system. NACET, with high oral bioavailability, is a strong antioxidant and abundant precursor of GSH, unlike its free acid N-acetyl-L-cysteine (NAC). Here, we review the chemical and pharmacological properties of SNACET and NACET as well as their analytical chemistry. We also report new results from the ingestion of S-[15N]nitroso-N-acetyl-L-cysteine ethyl ester (S15NACET) demonstrating the favorable pharmacological profile of SNACET.
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Affiliation(s)
- Dimitrios Tsikas
- Institute of Toxicology, Core Unit Proteomics, Hannover Medical School, 30623 Hannover, Germany
| | - Kathrin S Schwedhelm
- Institute of Toxicology, Core Unit Proteomics, Hannover Medical School, 30623 Hannover, Germany
| | - Andrzej Surdacki
- Second Department of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Daniela Giustarini
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Ranieri Rossi
- Department of Life Sciences, Laboratory of Pharmacology and Toxicology, University of Siena, 53100 Siena, Italy
| | - Lea Kukoc-Modun
- Department of Analytical Chemistry, Faculty of Chemistry and Technology, University of Split, 21000 Split, Croatia
| | - George Kedia
- Department of Urology and Urological Oncology, Hannover Medical School, 30623 Hannover, Germany
| | - Stefan Ückert
- Department of Urology and Urological Oncology, Hannover Medical School, 30623 Hannover, Germany
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