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Rowland SN, James LJ, O'Donnell E, Bailey SJ. Influence of acute dietary nitrate supplementation timing on nitrate metabolism, central and peripheral blood pressure and exercise tolerance in young men. Eur J Appl Physiol 2024; 124:1381-1396. [PMID: 38040982 PMCID: PMC11055761 DOI: 10.1007/s00421-023-05369-z] [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: 09/09/2023] [Accepted: 11/08/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE Dietary nitrate (NO3-) supplementation can lower systolic blood pressure (SBP) and improve exercise performance. Salivary flow rate (SFR) and pH are key determinants of oral NO3- reduction and purported to peak in the afternoon. We tested the hypotheses that NO3--rich beetroot juice (BR) would increase plasma [nitrite] ([NO2-]), lower SBP and improve exercise performance to a greater extent in the afternoon (AFT) compared to the morning (MORN) and evening (EVE). METHOD Twelve males completed six experimental visits in a repeated-measures, crossover design. NO3--depleted beetroot juice (PL) or BR (~ 13 mmol NO3-) were ingested in the MORN, AFT and EVE. SFR and pH, salivary and plasma [NO3-] and [NO2-], brachial SBP and central SBP were measured pre and post supplementation. A severe-intensity exercise tolerance test was completed to determine cycling time to exhaustion (TTE). RESULTS There were no between-condition differences in mean SFR or salivary pH. The elevation in plasma [NO2-] after BR ingestion was not different between BR-MORN, BR-AFT and BR-EVE. Brachial SBP was unchanged following BR supplementation in all conditions. Central SBP was reduced in BR-MORN (- 3 ± 4 mmHg), BR-AFT (- 4 ± 3 mmHg), and BR-EVE (- 2 ± 3 mmHg), with no differences between timepoints. TTE was not different between BR and PL at any timepoint. CONCLUSION Acute BR supplementation was ineffective at improving TTE and brachial SBP and similarly effective at increasing plasma [NO2-] and lowering central SBP across the day, which may have implications for informing NO3- supplementation strategies.
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Affiliation(s)
- Samantha N Rowland
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
| | - Lewis J James
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
| | - Emma O'Donnell
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK
| | - Stephen J Bailey
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, LE11 3TU, UK.
- Department of Cardiovascular Science, University of Leicester, Leicester, UK.
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2
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Webb AJ. "Every beet you take": lowering systolic blood pressure and improving vascular function/exercise capacity via the dietary nitrate-nitrite-NO pathway in patients with COPD. Eur Respir J 2024; 63:2302238. [PMID: 38302179 DOI: 10.1183/13993003.02238-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Andrew J Webb
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine and Sciences, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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3
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Cottrell EC. Should the non-canonical pathway of nitric oxide generation be targeted in hypertensive pregnancies? Br J Pharmacol 2023. [PMID: 37921362 DOI: 10.1111/bph.16276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023] Open
Abstract
Hypertension in pregnancy is prevalent, affecting around 10% of pregnancies worldwide, and significantly increases the risk of adverse outcomes for both mothers and their babies. Current treatment strategies for pregnant women with hypertension are limited, and new approaches for the management of hypertension in pregnancy are urgently needed. Substantial evidence from non-pregnant subjects has demonstrated the potential for dietary nitrate supplementation to increase nitric oxide (NO) bioavailability and lower blood pressure, following bioactivation via the non-canonical NO pathway. Emerging data suggest this approach may also be of benefit in pregnant women, although studies are limited. This review aims to summarise the current evidence from preclinical and clinical studies of nitrate supplementation in pregnancy, drawing on data from non-pregnant populations where appropriate and highlighting key gaps in knowledge that remain to be addressed in future trials.
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Affiliation(s)
- Elizabeth C Cottrell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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4
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Giani A, Micciolo R, Zoico E, Mazzali G, Zamboni M, Fantin F. Cardio-Ankle Vascular Index and Aging: Differences between CAVI and CAVI0. J Clin Med 2023; 12:6726. [PMID: 37959192 PMCID: PMC10647579 DOI: 10.3390/jcm12216726] [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: 09/07/2023] [Revised: 10/03/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Cardio-ankle vascular index (CAVI) and CAVI0 (a mathematical expression derived from CAVI, supposed to be less dependent on blood pressure), can describe arterial stiffness, considering a wide proportion of the arterial tree. The aim of this study was to examine the relationship between CAVI, CAVI0 and aging, looking at the differences between the two arterial stiffness indexes. METHODS A total of 191 patients (68 male, mean age 68.3 ± 14.4 years) referred to the Geriatric Ward and Outpatient Clinic at Verona University Hospital were included and underwent a comprehensive clinical evaluation. CAVI and CAVI0 were obtained for each. RESULTS CAVI0 steeply rises in the elderly age strata, widening the gap between CAVI and CAVI0. An inverse relationship is evident between CAVI0 and DBP in older patients, and CAVI0 is shown to be dependent on age, DBP and age-DBP interaction (R2 = 0.508). Age modifies the effect of DBP on CAVI0, but not on CAVI. CONCLUSIONS The real new findings of our study are that the association between CAVI0 and diastolic blood pressure (DBP) is modified by age, whereas the association between CAVI and DBP is not modified by age. From a clinical point of view, these are very important findings, as DBP decreases with aging, affecting in elderly populations the reliability of CAVI0, which strictly depends on DBP in the formula to calculate it. To monitor the effect of CV therapies, progression of CV diseases and to evaluate clinical outcomes in elderly populations, we suggest using CAVI and not CAVI0.
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Affiliation(s)
- Anna Giani
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37100 Verona, Italy; (A.G.); (M.Z.)
| | - Rocco Micciolo
- Centre for Medical Sciences and Department of Psychology and Cognitive Sciences, University of Trento, 38123 Trento, Italy;
| | - Elena Zoico
- Section of Geriatric Medicine, Department of Medicine, University of Verona, 37100 Verona, Italy; (E.Z.); (G.M.)
| | - Gloria Mazzali
- Section of Geriatric Medicine, Department of Medicine, University of Verona, 37100 Verona, Italy; (E.Z.); (G.M.)
| | - Mauro Zamboni
- Section of Geriatric Medicine, Department of Surgery, Dentistry, Pediatric and Gynecology, University of Verona, 37100 Verona, Italy; (A.G.); (M.Z.)
| | - Francesco Fantin
- Section of Geriatric Medicine, Department of Medicine, University of Verona, 37100 Verona, Italy; (E.Z.); (G.M.)
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Liu H, Huang Y, Huang M, Wang M, Ming Y, Chen W, Chen Y, Tang Z, Jia B. From nitrate to NO: potential effects of nitrate-reducing bacteria on systemic health and disease. Eur J Med Res 2023; 28:425. [PMID: 37821966 PMCID: PMC10566198 DOI: 10.1186/s40001-023-01413-y] [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: 01/19/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023] Open
Abstract
Current research has described improving multisystem disease and organ function through dietary nitrate (DN) supplementation. They have provided some evidence that these floras with nitrate (NO3-) reductase are mediators of the underlying mechanism. Symbiotic bacteria with nitrate reductase activity (NRA) are found in the human digestive tract, including the mouth, esophagus and gastrointestinal tract (GT). Nitrate in food can be converted to nitrite under the tongue or in the stomach by these symbiotic bacteria. Then, nitrite is transformed to nitric oxide (NO) by non-enzymatic synthesis. NO is currently recognized as a potent bioactive agent with biological activities, such as vasodilation, regulation of cardiomyocyte function, neurotransmission, suppression of platelet agglutination, and prevention of vascular smooth muscle cell proliferation. NO also can be produced through the conventional L-arginine-NO synthase (L-NOS) pathway, whereas endogenous NO production by L-arginine is inhibited under hypoxia-ischemia or disease conditions. In contrast, exogenous NO3-/NO2-/NO activity is enhanced and becomes a practical supplemental pathway for NO in the body, playing an essential role in various physiological activities. Moreover, many diseases (such as metabolic or geriatric diseases) are primarily associated with disorders of endogenous NO synthesis, and NO generation from the exogenous NO3-/NO2-/NO route can partially alleviate the disease progression. The imbalance of NO in the body may be one of the potential mechanisms of disease development. Therefore, the impact of these floras with nitrate reductase on host systemic health through exogenous NO3-/NO2-/NO pathway production of NO or direct regulation of floras ecological balance is essential (e.g., regulation of body homeostasis, amelioration of diseases, etc.). This review summarizes the bacteria with nitrate reductase in humans, emphasizing the relationship between the metabolic processes of this microflora and host systemic health and disease. The potential effects of nitrate reduction bacteria on human health and disease were also highlighted in disease models from different human systems, including digestive, cardiovascular, endocrine, nervous, respiratory, and urinary systems, providing innovative ideas for future disease diagnosis and treatment based on nitrate reduction bacteria.
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Affiliation(s)
- Hongyu Liu
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yisheng Huang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Mingshu Huang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Min Wang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yue Ming
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Weixing Chen
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Yuanxin Chen
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Zhengming Tang
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China
| | - Bo Jia
- Department of Oral Surgery, School of Stomatology, Southern Medical University, Guangzhou, China.
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6
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Tanaka A, Shibata H, Imai T, Yoshida H, Miyazono M, Takahashi N, Fukuda D, Okada Y, Teragawa H, Suwa S, Kida K, Moroi M, Taguchi I, Toyoda S, Shimabukuro M, Tanabe K, Tanaka K, Nangaku M, Node K. Rationale and design of an investigator-initiated, multicenter, prospective, placebo-controlled, double-blind, randomized trial to evaluate the effects of finerenone on vascular stiffness and cardiorenal biomarkers in type 2 diabetes and chronic kidney disease (FIVE-STAR). Cardiovasc Diabetol 2023; 22:194. [PMID: 37525257 PMCID: PMC10391880 DOI: 10.1186/s12933-023-01928-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND The overactivation of mineralocorticoid receptor (MR) plays a key pathological role in the progression of cardiovascular and renal diseases by promoting pro-inflammatory and pro-fibrotic signaling. Recently, it has been found that finerenone, a novel nonsteroidal selective MR antagonist, can robustly improve cardiorenal outcomes in patients with type 2 diabetes (T2D) and a wide spectrum of chronic kidney disease (CKD). However, the mechanisms underlying the cardiorenal benefits of finerenone are poorly understood. Further, whether the clinical benefits are mediated by an improvement in vascular stiffness is not confirmed. Therefore, the current study aims to evaluate the effects of finerenone on vascular stiffness as assessed using cardio ankle vascular index (CAVI) and relevant cardiorenal biomarkers in patients with T2D and CKD. METHODS The Effects of Finerenone on Vascular Stiffness and Cardiorenal Biomarkers in Type 2 Diabetes and Chronic Kidney Disease (FIVE-STAR) is an ongoing, investigator-initiated, multicenter, prospective, placebo-controlled, double-blind, randomized clinical trial in Japan. Its target sample size is 100 subjects. Recruitment will be performed from September 2023 to July 2024. After obtaining informed consent, eligible participants with T2D and CKD (25 mL/min/1.73 m2 ≤ estimated glomerular filtration ratio [eGFR] < 90 mL/min/1.73 m2 and 30 mg/g Cr ≤ urinary albumin-to-creatinine ratio [UACR] < 3500 mg/g Cr) will be equally randomized to receive 24-week treatment with either finerenone (starting dose at 10 mg once daily in participants with a baseline eGFR < 60 mL/min/1.73 m2 or at 20 mg once daily in those with a baseline eGFR ≥ 60 mL/min/1.73 m2) or dose-matched placebo. The primary endpoint is the change from baseline in CAVI at 24 weeks. The secondary endpoints are changes from baseline in UACR at 12 and 24 weeks and relevant serum and urinary biomarkers at 24 weeks. As an exploratory endpoint, proteomic analysis using the Olink® Target 96 panels will be also performed. DISCUSSION FIVE-STAR is the first trial evaluating the therapeutic impact of finerenone on vascular stiffness and relevant cardiorenal biomarkers in patients with T2D and CKD. This study will provide mechanistic insights on the clinical benefits of finerenone based on recent cardiovascular and renal outcome trials. Trial registration Unique Trial Number, NCT05887817 ( https://clinicaltrials.gov/ct2/show/NCT05887817 ) and jRCTs021230011 ( https://jrct.niph.go.jp/latest-detail/jRCTs021230011 ).
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Yufu, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | | | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Oita University, Yufu, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni-Shi, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masao Moroi
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University, Fukushima, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kenichi Tanaka
- Wakamatsu Hospital of the University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
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7
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Antioxidant Capacity, Nitrite and Nitrate Content in Beetroot-Based Dietary Supplements. Foods 2023; 12:foods12051017. [PMID: 36900534 PMCID: PMC10000616 DOI: 10.3390/foods12051017] [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: 02/01/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
Due to the high content of bioactive substances, beetroot and its preserves might be a valuable constituent of a diet. Research into the antioxidant capacity and content of nitrate (III) and (V) in beetroot-based dietary supplements (DSs) worldwide is limited. The Folin-Ciocalteu method, CUPRAC, DPPH, and Griess methods were used to determine total antioxidant capacity, total phenolic content, nitrites, and nitrates content in fifty DSs and twenty beetroot samples. Moreover, the safety of products was evaluated because of the concentration of nitrites, nitrates, and the correctness of labelling. The research showed that a serving of fresh beetroot provides significantly more antioxidants, nitrites, and nitrates than most daily portions of DSs. Product P9 provided the highest dose of nitrates (169 mg/daily dose). However, in most cases, the consumption of DSs would be associated with a low health value. The acceptable daily intake was not exceeded in the cases of nitrites (0.0015-0.55%) and nitrates (0.056-48%), assuming that the supplementation followed the manufacturer's recommendation. According to European and Polish regulations, 64% of the products tested did not meet all the requirements for labelling food packaging. The findings point to the need for tighter regulation of DSs, as their consumption might be dangerous.
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8
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Karamanos A, Lu Y, Mudway IS, Ayis S, Kelly FJ, Beevers SD, Dajnak D, Fecht D, Elia C, Tandon S, Webb AJ, Grande AJ, Molaodi OR, Maynard MJ, Cruickshank JK, Harding S. Associations between air pollutants and blood pressure in an ethnically diverse cohort of adolescents in London, England. PLoS One 2023; 18:e0279719. [PMID: 36753491 PMCID: PMC9907839 DOI: 10.1371/journal.pone.0279719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/13/2022] [Indexed: 02/09/2023] Open
Abstract
Longitudinal evidence on the association between air pollution and blood pressure (BP) in adolescence is scarce. We explored this association in an ethnically diverse cohort of schoolchildren. Sex-stratified, linear random-effects modelling was used to examine how modelled residential exposure to annual average nitrogen dioxide (NO2), particulate matter (PM2.5, PM10) and ozone (O3), measures in μg/m3, associated with blood pressure. Estimates were based on 3,284 adolescents; 80% from ethnic minority groups, recruited from 51 schools, and followed up from 11-13 to 14-16 years old. Ethnic minorities were exposed to higher modelled annual average concentrations of pollution at residential postcode level than their White UK peers. A two-pollutant model (NO2 & PM2.5), adjusted for ethnicity, age, anthropometry, and pubertal status, highlighted associations with systolic, but not diastolic BP. A μg/m3 increase in NO2 was associated with a 0.30 mmHg (95% CI 0.18 to 0.40) decrease in systolic BP for girls and 0.19 mmHg (95% CI 0.07 to 0.31) decrease in systolic BP for boys. In contrast, a 1 μg/m3 increase in PM2.5 was associated with 1.34 mmHg (95% CI 0.85 to 1.82) increase in systolic BP for girls and 0.57 mmHg (95% CI 0.04 to 1.03) increase in systolic BP for boys. Associations did not vary by ethnicity, body size or socio-economic advantage. Associations were robust to adjustments for noise levels and lung function at 11-13 years. In summary, higher ambient levels of NO2 were associated with lower and PM2.5 with higher systolic BP across adolescence, with stronger associations for girls.
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Affiliation(s)
- A. Karamanos
- School of Life Course/Nutritional Sciences, King’s College London, London, United Kingdom
| | - Y. Lu
- School of Life Course/Nutritional Sciences, King’s College London, London, United Kingdom
- Clinical Research Center of The Third Xiangya Hospital, Central South University, Changsha, China
| | - I. S. Mudway
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
| | - S. Ayis
- Faculty of Life Sciences & Medicine, Department of Population Health Sciences, School of Population Health & Environmental Sciences, King’s College London, London, United Kingdom
| | - F. J. Kelly
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
| | - S. D. Beevers
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
| | - D. Dajnak
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
| | - D. Fecht
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
- NIHR Health Protection Research Unit in Environmental Exposures and Health, Imperial College London, London, United Kingdom
| | - C. Elia
- School of Life Course/Nutritional Sciences, King’s College London, London, United Kingdom
| | - S. Tandon
- Faculty of Life Sciences & Medicine, Department of Population Health Sciences, School of Population Health & Environmental Sciences, King’s College London, London, United Kingdom
| | - A. J. Webb
- Faculty of Life Sciences & Medicine, Department of Clinical Pharmacology, King’s College London BHF Centre of Excellence, School of Cardiovascular Medicine and Sciences, King’s College, London, United Kingdom
| | - A. J. Grande
- Curso de Medicina, Universidade Estadual do Mato Grosso do Sul, Campo Grande, MS, Brazil
| | - O. R. Molaodi
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - M. J. Maynard
- School of Clinical & Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
| | - J. K. Cruickshank
- School of Life Course/Nutritional Sciences, King’s College London, London, United Kingdom
| | - S. Harding
- School of Life Course/Nutritional Sciences, King’s College London, London, United Kingdom
- Faculty of Life Sciences & Medicine, Department of Population Health Sciences, School of Population Health & Environmental Sciences, King’s College London, London, United Kingdom
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Bath PM, Skinner CJC, Bath CS, Woodhouse LJ, Korovesi AAK, Long H, Havard D, Coleman CM, England TJ, Leyland V, Lim WS, Montgomery AA, Royal S, Avery A, Webb AJ, Gordon AL. Dietary nitrate supplementation for preventing and reducing the severity of winter infections, including COVID-19, in care homes (BEET-Winter): a randomised placebo-controlled feasibility trial. Eur Geriatr Med 2022; 13:1343-1355. [PMID: 36385690 PMCID: PMC9668238 DOI: 10.1007/s41999-022-00714-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Infections cause considerable care home morbidity and mortality. Nitric oxide (NO) has broad-spectrum anti-viral, bacterial and yeast activity in vitro. We assessed the feasibility of supplementing dietary nitrate (NO substrate) intake in care home residents. METHODS We performed a cluster-randomised placebo-controlled trial in UK residential and nursing care home residents and compared nitrate containing (400 mg) versus free (0 mg daily) beetroot juice given for 60 days. Outcomes comprised feasibility of recruitment, adherence, salivary and urinary nitrate, and ordinal infection/clinical events. RESULTS Of 30 targeted care homes in late 2020, 16 expressed interest and only 6 participated. 49 residents were recruited (median 8 [interquartile range 7-12] per home), mean (standard deviation) age 82 (8) years, with proxy consent 41 (84%), advance directive for hospital non-admission 8 (16%) and ≥ 1 doses of COVID-19 vaccine 37 (82%). Background dietary nitrate was < 30% of acceptable daily intake. 34 (76%) residents received > 50% of juice. Residents randomised to nitrate vs placebo had higher urinary nitrate levels, median 50 [18-175] v 18 [10-50] mg/L, difference 25 [0-90]. Data paucity precluded clinical between-group comparisons; the outcome distribution was as follows: no infection 32 (67%), uncomplicated infection 0, infection requiring healthcare support 11 (23%), all-cause hospitalisation 5 (10%), all-cause mortality 0. Urinary tract infections were most common. CONCLUSIONS Recruiting UK care homes during the COVID-19 pandemic was partially successful. Supplemented dietary nitrate was tolerated and elevated urinary nitrate. Together, infections, hospitalisations and deaths occurred in 33% of residents over 60 days. A larger trial is now required. TRIAL REGISTRATION ISRCTN51124684. Application date 7/12/2020; assignment date 13/1/2021.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, Nottinghamshire, UK.
| | - Cameron J C Skinner
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK
| | - Charlotte S Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK
| | | | - Hongjiang Long
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
| | - Diane Havard
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK
| | - Christopher M Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH, UK
- Department of Stroke, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | | | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Simon Royal
- University of Nottingham Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW, UK
| | - Amanda Avery
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD, UK
| | - Andrew J Webb
- Clinical Pharmacology, School of Cardiovascular Medicine and Sciences, Kings College London and British Heart Foundation Centre of Research Excellence, St Thomas' Hospital, London, SE1 7EH, UK
| | - Adam L Gordon
- Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Derby, DE22 3NE, Derbyshire, UK
- NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
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10
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Bock JM, Hughes WE, Ueda K, Feider AJ, Hanada S, Casey DP. Dietary Inorganic Nitrate/Nitrite Supplementation Reduces Central and Peripheral Blood Pressure in Patients With Type 2 Diabetes Mellitus. Am J Hypertens 2022; 35:803-809. [PMID: 35639721 PMCID: PMC9434218 DOI: 10.1093/ajh/hpac068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/10/2022] [Accepted: 05/24/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with type 2 diabetes mellitus (T2DM) have increased cardiovascular risk due to elevated blood pressure (BP). As low levels of nitric oxide (NO) may contribute to increased BP, we determined if increasing NO bioavailability via eight weeks of supplementation with beetroot juice containing inorganic nitrate/nitrite (4.03 mmol nitrate, 0.29 mmol nitrite) improves peripheral and central BP relative to nitrate/nitrite-depleted beetroot juice. METHODS Peripheral and central BP were assessed at heart-level in supine subjects using a brachial artery catheter and applanation tonometry, respectively. RESULTS Nitrate/nitrite supplementation reduced peripheral systolic BP (148 ± 16 to 142 ± 18 mm Hg, P < 0.05) but not placebo (150 ± 19 to 149 ± 17 mm Hg, P = 0.93); however, diastolic BP was unaffected (supplement-by-time P = 0.08). Central systolic BP (131 ± 16 to 127 ± 17 mm Hg) and augmented pressure (13.3 ± 6.6 to 11.6 ± 6.9 mm Hg, both P < 0.05) were reduced after nitrate/nitrite, but not placebo (134 ± 17 to 135 ± 16 mm Hg, P = 0.62; 14.1 ± 6.6 to 15.2 ± 7.4 mm Hg, P = 0.20); central diastolic BP was unchanged by the interventions (supplement-by-time P = 0.16). Inorganic nitrate/nitrite also reduced AIx (24.3 ± 9.9% to 21.0 ± 9.6%) whereas no changes were observed following placebo (24.6 ± 9.3% to 25.6 ± 9.9%, P = 0.46). CONCLUSIONS Inorganic nitrate/nitrite supplementation improves peripheral and central BP as well as AIx in T2DM. CLINICAL TRIALS REGISTRATION Trial Number NCT02804932.
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Affiliation(s)
- Joshua M Bock
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - William E Hughes
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Kenichi Ueda
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Andrew J Feider
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Satoshi Hanada
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Darren P Casey
- Department of Physical Therapy & Rehabilitation Science, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Abboud Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Fraternal Order of Eagles Diabetes Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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11
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Shenouda N, Patik JC, Edwards DG. Reflecting on the Blood Pressure Lowering Effects of Inorganic Nitrate Supplementation in Patients With Type 2 Diabetes. Am J Hypertens 2022; 35:792-794. [PMID: 35728074 DOI: 10.1093/ajh/hpac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Ninette Shenouda
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Jordan C Patik
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - David G Edwards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
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12
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Thiruvengadam M, Chung IM, Samynathan R, Chandar SRH, Venkidasamy B, Sarkar T, Rebezov M, Gorelik O, Shariati MA, Simal-Gandara J. A comprehensive review of beetroot ( Beta vulgaris L.) bioactive components in the food and pharmaceutical industries. Crit Rev Food Sci Nutr 2022; 64:708-739. [PMID: 35972148 DOI: 10.1080/10408398.2022.2108367] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Beetroot is rich in various bioactive phytochemicals, which are beneficial for human health and exert protective effects against several disease conditions like cancer, atherosclerosis, etc. Beetroot has various therapeutic applications, including antioxidant, antibacterial, antiviral, and analgesic functions. Besides the pharmacological effects, food industries are trying to preserve beetroots or their phytochemicals using various food preservation methods, including drying and freezing, to preserve their antioxidant capacity. Beetroot is a functional food due to valuable active components such as minerals, amino acids, phenolic acid, flavonoid, betaxanthin, and betacyanin. Due to its stability, nontoxic and non-carcinogenic and nonpoisonous capabilities, beetroot has been used as an additive or preservative in food processing. Beetroot and its bioactive compounds are well reported to possess antioxidant, anti-inflammatory, antiapoptotic, antimicrobial, antiviral, etc. In this review, we provided updated details on (i) food processing, preservation and colorant methods using beetroot and its phytochemicals, (ii) synthesis and development of several nanoparticles using beetroot and its bioactive compounds against various diseases, (iii) the role of beetroot and its phytochemicals under disease conditions with molecular mechanisms. We have also discussed the role of other phytochemicals in beetroot and their health benefits. Recent technologies in food processing are also updated. We also addressed on molecular docking-assisted biological activity and screening for bioactive chemicals. Additionally, the role of betalain from different sources and its therapeutic effects have been listed. To the best of our knowledge, little or no work has been carried out on the impact of beetroot and its nanoformulation strategies for phytocompounds on antimicrobial, antiviral effects, etc. Moreover, epigenetic alterations caused by phytocompounds of beetroot under several diseases were not reported much. Thus, extensive research must be carried out to understand the molecular effects of beetroot in the near future.
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Affiliation(s)
- Muthu Thiruvengadam
- Department of Crop Science, College of Sanghuh Life Science, Konkuk University, Seoul, Republic of Korea
| | - Ill-Min Chung
- Department of Crop Science, College of Sanghuh Life Science, Konkuk University, Seoul, Republic of Korea
| | | | | | - Baskar Venkidasamy
- Department of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu, India
| | - Tanmay Sarkar
- Department of Food Processing Technology, Malda Polytechnic, West Bengal State Council of Technical Education, Government of West Bengal, Malda, India
| | - Maksim Rebezov
- Department of Scientific Advisers, V. M. Gorbatov Federal Research Center for Food Systems, Moscow, Russian Federation
- Department of Scientific Research, K.G. Razumovsky Moscow State University of Technologies and management (The First Cossack University), Moscow, Russia Federation
| | - Olga Gorelik
- Faculty of Biotechnology and Food Engineering, Ural State Agrarian University, Yekaterinburg, Russian Federation
- Ural Federal Agrarian Research Center of the Ural Branch, Russian Academy of Sciences, Yekaterinburg, Russian Federation
| | - Mohammad Ali Shariati
- Department of Scientific Research, K.G. Razumovsky Moscow State University of Technologies and management (The First Cossack University), Moscow, Russia Federation
| | - Jesus Simal-Gandara
- Universidade de Vigo, Nutrition and Bromatology Group, Analytical Chemistry and Food Science Department, Faculty of Science, Ourense, Spain
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13
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Bahadoran Z, Mirmiran P, Carlström M, Ghasemi A. Inorganic nitrate: A potential prebiotic for oral microbiota dysbiosis associated with type 2 diabetes. Nitric Oxide 2021; 116:38-46. [PMID: 34506950 DOI: 10.1016/j.niox.2021.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/07/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Oral microbiota dysbiosis, concomitant with decreased abundance of nitrate (NO3-)-reducing bacteria, oral net nitrite (NO2-) production, and reduced nitric oxide (·NO) bioactivity, is associated with the development of cardiometabolic disorders. Therefore, restoring the oral microbiome to a health-associated state is suggested as a therapeutic approach to potentiate the NO3--NO2--·NO pathway and provide a backup resource for insufficient NO production in conditions including cardiovascular disease and type 2 diabetes mellitus (T2DM). The current review discusses how inorganic NO3- can improve the oral microbial community in patients with T2DM and act as a prebiotic. Both animal and human experiments indicated that inorganic NO3- modulates the oral microbiome by increasing the abundance of health-associated NO3--reducing bacteria (e.g., Neisseria and Rothia) and decreasing the plenty of species Prevotella and Veillonella, leading to oral NO2- accumulation and improved systemic ·NO availability. Supplementation with NO3- reduces caries- and periodontitis-associated bacteria and the pathogenic genus related to insulin resistance and glucose intolerance. In addition, inorganic NO3- may provide a more optimal environment for NO3- reductase activity in the oral cavity, as it increases salivary flow rate and prevents decreased pH by inhibiting acid-producing bacteria.
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Affiliation(s)
- Zahra Bahadoran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parvin Mirmiran
- Department of Clinical Nutrition and Human Dietetics, Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mattias Carlström
- Department of Physiology and Pharmacology, Karolinska Institutet, Biomedicum 5B, Stockholm, SE-171 76, Sweden
| | - Asghar Ghasemi
- Endocrine Physiology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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14
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Giudici A, Khir AW, Reesink KD, Delhaas T, Spronck B. Five years of cardio-ankle vascular index (CAVI) and CAVI0: how close are we to a pressure-independent index of arterial stiffness? J Hypertens 2021; 39:2128-2138. [PMID: 34269333 DOI: 10.1097/hjh.0000000000002928] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pulse wave velocity, a common metric of arterial stiffness, is an established predictor for cardiovascular events and mortality. However, its intrinsic pressure-dependency complicates the discrimination of acute and chronic impacts of increased blood pressure on arterial stiffness. Cardio-ankle vascular index (CAVI) represented a significant step towards the development of a pressure-independent arterial stiffness metric. However, some potential limitations of CAVI might render this arterial stiffness metric less pressure-independent than originally thought. For this reason, we later introduced CAVI0. Nevertheless, advantages of one approach over the other are left debated. This review aims to shed light on the pressure (in)dependency of both CAVI and CAVI0. By critically reviewing results from studies reporting both CAVI and CAVI0 and using simple analytical methods, we show that CAVI0 may enhance the pressure-independent assessment of arterial stiffness, especially in the presence of large inter-individual differences in blood pressure.
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Affiliation(s)
- Alessandro Giudici
- Biomedical Engineering Research Group, Brunel University London, UK
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands
| | - Ashraf W Khir
- Biomedical Engineering Research Group, Brunel University London, UK
| | - Koen D Reesink
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands
| | - Bart Spronck
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, The Netherlands
- Department of Biomedical Engineering, School of Engineering and Applied Science, Yale University, New Haven, Connecticut, USA
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15
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Shannon OM, Easton C, Shepherd AI, Siervo M, Bailey SJ, Clifford T. Dietary nitrate and population health: a narrative review of the translational potential of existing laboratory studies. BMC Sports Sci Med Rehabil 2021; 13:65. [PMID: 34099037 PMCID: PMC8186051 DOI: 10.1186/s13102-021-00292-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dietary inorganic nitrate (NO3-) is a polyatomic ion, which is present in large quantities in green leafy vegetables and beetroot, and has attracted considerable attention in recent years as a potential health-promoting dietary compound. Numerous small, well-controlled laboratory studies have reported beneficial health effects of inorganic NO3- consumption on blood pressure, endothelial function, cerebrovascular blood flow, cognitive function, and exercise performance. Translating the findings from small laboratory studies into 'real-world' applications requires careful consideration. MAIN BODY This article provides a brief overview of the existing empirical evidence basis for the purported health-promoting effects of dietary NO3- consumption. Key areas for future research are then proposed to evaluate whether promising findings observed in small animal and human laboratory studies can effectively translate into clinically relevant improvements in population health. These proposals include: 1) conducting large-scale, longer duration trials with hard clinical endpoints (e.g. cardiovascular disease incidence); 2) exploring the feasibility and acceptability of different strategies to facilitate a prolonged increase in dietary NO3- intake; 3) exploitation of existing cohort studies to explore associations between NO3- intake and health outcomes, a research approach allowing larger samples sizes and longer duration follow up than is feasible in randomised controlled trials; 4) identifying factors which might account for individual differences in the response to inorganic NO3- (e.g. sex, genetics, habitual diet) and could assist with targeted/personalised nutritional interventions; 5) exploring the influence of oral health and medication on the therapeutic potential of NO3- supplementation; and 6) examining potential risk of adverse events with long term high- NO3- diets. CONCLUSION The salutary effects of dietary NO3- are well established in small, well-controlled laboratory studies. Much less is known about the feasibility and efficacy of long-term dietary NO3- enrichment for promoting health, and the factors which might explain the variable responsiveness to dietary NO3- supplementation between individuals. Future research focussing on the translation of laboratory data will provide valuable insight into the potential applications of dietary NO3- supplementation to improve population health.
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Affiliation(s)
- Oliver M Shannon
- Human Nutrition Research Centre, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Easton
- Institute for Clinical Exercise and Health Science, University of the West of Scotland, Blantyre, Scotland, UK
| | - Anthony I Shepherd
- School of Sport, Health & Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Mario Siervo
- School of Life Sciences, The University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK
| | - Stephen J Bailey
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Tom Clifford
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
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16
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Morselli F, Faconti L, Mills CE, Morant S, Chowienczyk PJ, Yeung JA, Cavarape A, Cruickshank JK, Webb AJ. Dietary nitrate prevents progression of carotid subclinical atherosclerosis through blood pressure-independent mechanisms in patients with or at risk of type 2 diabetes mellitus. Br J Clin Pharmacol 2021; 87:4726-4736. [PMID: 33982797 DOI: 10.1111/bcp.14897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/30/2021] [Accepted: 05/09/2021] [Indexed: 12/01/2022] Open
Abstract
AIMS To test if 6 months' intervention with dietary nitrate and spironolactone could affect carotid subclinical atherosclerosis and stiffness, respectively, vs. placebo/doxazosin, to control for blood pressure (BP). METHODS A subgroup of participants in our double-blind, randomized-controlled, factorial VaSera trial had carotid imaging. Patients with hypertension and with/at risk of type 2 diabetes were randomized to active nitrate-containing beetroot juice or placebo nitrate-depleted juice, and spironolactone or doxazosin. Vascular ultrasound for carotid diameter (CD, mm) and intima-media thickness (CIMT, mm) was performed at baseline, 3- and 6-months. Carotid local stiffness (CS, m/s) was estimated from aortic pulse pressure (Arteriograph) and carotid lumen area. Data were analysed by modified intention to treat and using mixed-model effect, adjusted for confounders. RESULTS In total, 93 subjects had a baseline evaluation and 86% had follow-up data. No statistical interactions occurred between the juice and drug arms and BP was similar between the juices and between the drugs. Nitrate-containing vs. placebo juice significantly lowered CIMT (-0.06 [95% confidence interval -0.12, -0.01], P = .034), an overall difference of ~8% relative to baseline; but had no effect on CD or CS. Doxazosin appeared to reduce CS from baseline (-0.34 [-0.62, -0.06]) however, no difference was detected vs. spironolactone (-0.15 [-0.46, 0.16]). No differences were detected between spironolactone or doxazosin on CIMT and CD. CONCLUSIONS Our results show that 6 months' intervention with dietary nitrate influences vascular remodelling, but not carotid stiffness or diameter. Neither spironolactone nor doxazosin had a BP-independent effect on carotid structure and function.
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Affiliation(s)
- Franca Morselli
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Dipartimento di Area Medica, Clinica Medica, Universita' degli Studi di Udine, Udine, Italy.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Charlotte E Mills
- King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Department of Food and Nutritional Sciences, School of Chemistry, Food and Pharmacy, University of Reading, Reading, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven Morant
- Medicines Monitoring Unit (MEMO), University of Dundee, UK
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joshua Au Yeung
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alessandro Cavarape
- Dipartimento di Area Medica, Clinica Medica, Universita' degli Studi di Udine, Udine, Italy
| | - J Kennedy Cruickshank
- King's College London, Department of Nutritional Sciences, School of Life Course Sciences, London, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew J Webb
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, UK.,Biomedical Research Centre, Clinical Research Facility, 4th Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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17
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Bahadoran Z, Mirmiran P, Kashfi K, Ghasemi A. Lost-in-Translation of Metabolic Effects of Inorganic Nitrate in Type 2 Diabetes: Is Ascorbic Acid the Answer? Int J Mol Sci 2021; 22:4735. [PMID: 33947005 PMCID: PMC8124635 DOI: 10.3390/ijms22094735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Beneficial metabolic effects of inorganic nitrate (NO3-) and nitrite (NO2-) in type 2 diabetes mellitus (T2DM) have been documented in animal experiments; however, this is not the case for humans. Although it has remained an open question, the redox environment affecting the conversion of NO3- to NO2- and then to NO is suggested as a potential reason for this lost-in-translation. Ascorbic acid (AA) has a critical role in the gastric conversion of NO2- to NO following ingestion of NO3-. In contrast to AA-synthesizing species like rats, the lack of ability to synthesize AA and a lower AA body pool and plasma concentrations may partly explain why humans with T2DM do not benefit from NO3-/NO2- supplementation. Rats also have higher AA concentrations in their stomach tissue and gastric juice that can significantly potentiate gastric NO2--to-NO conversion. Here, we hypothesized that the lack of beneficial metabolic effects of inorganic NO3- in patients with T2DM may be at least in part attributed to species differences in AA metabolism and also abnormal metabolism of AA in patients with T2DM. If this hypothesis is proved to be correct, then patients with T2DM may need supplementation of AA to attain the beneficial metabolic effects of inorganic NO3- therapy.
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Affiliation(s)
- Zahra Bahadoran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, Iran; (Z.B.); (P.M.)
| | - Parvin Mirmiran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, Iran; (Z.B.); (P.M.)
| | - Khosrow Kashfi
- Department of Molecular, Cellular and Biomedical Sciences, Sophie Davis School of Biomedical Education, City University of New York School of Medicine, New York, NY 10031, USA;
| | - Asghar Ghasemi
- Endocrine Physiology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 19395-4763, Iran
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18
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O'Gallagher K, Borg Cardona S, Hill C, Al-Saedi A, Shahed F, Floyd CN, McNeill K, Mills CE, Webb AJ. Grapefruit juice enhances the systolic blood pressure-lowering effects of dietary nitrate-containing beetroot juice. Br J Clin Pharmacol 2021; 87:577-587. [PMID: 32520418 DOI: 10.1111/bcp.14420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 01/07/2023] Open
Abstract
AIMS Dietary nitrate from sources such as beetroot juice lowers blood pressure (BP) via the nitrate-nitrite-nitric oxide (NO) pathway. However, NO and nitrite are inactivated via reoxidation to nitrate, potentially limiting their activity. Cytochrome P450-3A4 inhibition with troleandomycin prevents nitrite re-oxidation to nitrate in rodent liver. Grapefruit juice contains the CYP3A4 inhibitor furanocoumarin. We therefore hypothesized that grapefruit juice would enhance BP-lowering with beetroot juice by maintaining circulating [nitrite]. METHODS We performed a randomized, placebo-controlled, 7-hour crossover study in 11 healthy volunteers, attending on 3 occasions, receiving: a 70-mL shot of active beetroot juice (Beet-It) and either (i) 250 mL grapefruit juice (Active Beet+GFJ), or (ii) 250 mL water (Buxton, Active Beet+H2 O); or (iii) Placebo Beet+GFJ. RESULTS The addition of grapefruit juice to active beetroot juice lowered systolic BP (SBP): Active Beet+GFJ vs Active Beet+H2 O (P = .02), and pulse pressure, PP (P = .0003). Peak mean differences in SBP and PP were seen at T = 5 hours: -3.3 mmHg (95% confidence interval [CI] -6.43 to -0.15) and at T = 2.5 hours: -4.2 mmHg (95% CI -0.3 to -8.2), respectively. Contrary to the hypothesis, plasma [nitrite] was lower with Active Beet+GFJ vs Active Beet+H2 O (P = .006), as was salivary nitrite production (P = .002) and saliva volume (-0.34 mL/min [95% CI -0.05 to -0.68]). The taste score of Beet+GFJ was 1.4/10 points higher than Beet+H2 O (P = .03). CONCLUSION Grapefruit juice enhanced beetroot juice's effect on lowering SBP and PP despite decreasing plasma [nitrite]. Besides suggesting more complex mechanisms, there is potential for maximising the clinical benefit of dietary nitrate and targeting isolated systolic hypertension.
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Affiliation(s)
- Kevin O'Gallagher
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sarah Borg Cardona
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Callum Hill
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Ali Al-Saedi
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Fawzia Shahed
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Christopher N Floyd
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen McNeill
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
| | - Charlotte E Mills
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Nutritional Sciences, School of Life Course Sciences, King's College London, UK
- Current institution: Food and Nutritional Sciences, University of Reading, England, UK
| | - Andrew J Webb
- School of Cardiovascular Medicine and Sciences, Department of Clinical Pharmacology, King's College London British Heart Foundation Centre of Research Excellence, London, UK
- Biomedical Research Centre, Clinical Research Facility, Guy's and St Thomas' NHS Foundation Trust, London, UK
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19
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Bahadoran Z, Norouzirad R, Mirmiran P, Gaeini Z, Jeddi S, Shokri M, Azizi F, Ghasemi A. Effect of inorganic nitrate on metabolic parameters in patients with type 2 diabetes: A 24-week randomized double-blind placebo-controlled clinical trial. Nitric Oxide 2020; 107:58-65. [PMID: 33340674 DOI: 10.1016/j.niox.2020.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/24/2020] [Accepted: 12/14/2020] [Indexed: 12/19/2022]
Abstract
AIM In this randomized placebo-controlled clinical trial, effect of oral inorganic nitrate (NO3-) on metabolic parameters was assessed in patients with type 2 diabetes mellitus (T2DM). METHODS Seventy-four eligible patients with T2DM were randomly assigned to NO3--rich beetroot powder (5 g/d contains ~250 mg NO3-) and placebo groups to complete intervention over a 24-week period. Blood HbA1c, fasting serum glucose, insulin, C-peptide, as well as lipid profile were assessed at baseline and again at weeks 4, 12, and 24; indices of insulin resistance were also calculated. To assess safety of long-term oral NO3-, liver and renal function tests were measured. An intention-to-treat approach was used for data analysis. To compare effect of intervention over time between the groups (time×group), repeated measures generalized estimating equation (GEE) linear regression models were used. RESULTS Mean age of the participants was 54.0 ± 8.5 (47.9% were male) and mean duration of diabetes was 8.5 ± 6.1 years. A total of 64 patients (n = 35 in beetroot group and n = 29 in placebo group) completed at least two visits and were included in the analyses. No significant difference was observed between the groups for glycemic and lipid parameters over time. Liver and renal function tests, as safety outcome measures, showed no undesirable changes during the study follow-up. CONCLUSION Supplementation with inorganic NO3- had no effect on metabolic parameters in patients with T2DM.
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Affiliation(s)
- Zahra Bahadoran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Norouzirad
- Department of Biochemistry, School of Paramedical Sciences, Dezful University of Medical Sciences, Dezful, Iran
| | - Parvin Mirmiran
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Gaeini
- Nutrition and Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sajad Jeddi
- Endocrine Physiology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Shokri
- Endocrine Physiology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Asghar Ghasemi
- Endocrine Physiology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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20
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Tropea T, Renshall LJ, Nihlen C, Weitzberg E, Lundberg JO, David AL, Tsatsaris V, Stuckey DJ, Wareing M, Greenwood SL, Sibley CP, Cottrell EC. Beetroot juice lowers blood pressure and improves endothelial function in pregnant eNOS -/- mice: importance of nitrate-independent effects. J Physiol 2020; 598:4079-4092. [PMID: 32368787 DOI: 10.1113/jp279655] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022] Open
Abstract
KEY POINTS Maternal hypertension is associated with increased rates of pregnancy pathologies, including fetal growth restriction, due at least in part to reductions in nitric oxide (NO) bioavailability and associated vascular dysfunction. Dietary nitrate supplementation, from beetroot juice (BRJ), has been shown to increase NO bioavailability and improve cardiovascular function in both preclinical and clinical studies. This study is the first to investigate effects of dietary nitrate supplementation in a pregnant animal model. Importantly, the effects of nitrate-containing BRJ were compared with both 'placebo' (nitrate-depleted) BRJ as well as water to control for potential nitrate-independent effects. Our data show novel, nitrate-independent effects of BRJ to lower blood pressure and improve vascular function in endothelial nitric oxide synthase knockout (eNOS-/- ) mice. These findings suggest potential beneficial effects of BRJ supplementation in pregnancy, and emphasize the importance of accounting for nitrate-independent effects of BRJ in study design and interpretation. ABSTRACT Maternal hypertension is associated with adverse pregnancy outcomes, including fetal growth restriction (FGR), due in part to reductions in nitric oxide (NO) bioavailability. We hypothesized that maternal dietary nitrate administration would increase NO bioavailability to reduce systolic blood pressure (SBP), improve vascular function and increase fetal growth in pregnant endothelial NO synthase knockout (eNOS-/- ) mice, which exhibit hypertension, endothelial dysfunction and FGR. Pregnant wildtype (WT) and eNOS-/- mice were supplemented with nitrate-containing beetroot juice (BRJ+) from gestational day (GD) 12.5. Control mice received an equivalent dose of nitrate-depleted BRJ (BRJ-) or normal drinking water. At GD17.5, maternal SBP was measured; at GD18.5, maternal nitrate/nitrite concentrations, uterine artery (UtA) blood flow and endothelial function were assessed, and pregnancy outcomes were determined. Plasma nitrate concentrations were increased in both WT and eNOS-/- mice supplemented with BRJ+ (P < 0.001), whereas nitrite concentrations were increased only in eNOS-/- mice (P < 0.001). BRJ- did not alter nitrate/nitrite concentrations. SBP was lowered and UtA endothelial function was enhanced in eNOS-/- mice supplemented with either BRJ+ or BRJ-, indicating nitrate-independent effects of BRJ. Improvements in endothelial function in eNOS-/- mice were abrogated in the presence of 25 mm KCl, implicating enhanced EDH signalling in BRJ- treated animals. At GD18.5, eNOS-/- fetuses were significantly smaller than WT animals (P < 0.001), but BRJ supplementation did not affect fetal weight. BRJ may be a beneficial intervention in pregnancies associated with hypertension, endothelial dysfunction and reduced NO bioavailability. Our data showing biological effects of non-nitrate components of BRJ have implications for both interpretation of previous findings and in the design of future clinical trials.
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Affiliation(s)
- Teresa Tropea
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Lewis J Renshall
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Carina Nihlen
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, SE-171 77, Sweden
| | - Eddie Weitzberg
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, SE-171 77, Sweden
| | - Jon O Lundberg
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, SE-171 77, Sweden
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Vassilis Tsatsaris
- Obstetrics and Gynecology Unit, Maternité Port-Royal, APHP, Paris V, Paris, France
| | - Daniel J Stuckey
- Centre for Advanced Biomedical Imaging, University College London, London, UK
| | - Mark Wareing
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Susan L Greenwood
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Colin P Sibley
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
| | - Elizabeth C Cottrell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, St. Mary's Hospital, Manchester, UK
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21
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Mills CE, Govoni V, Faconti L, Casagrande M, Morant SV, Crickmore H, Iqbal F, Maskell P, Masani A, Nanino E, Webb AJ, Cruickshank JK. A randomised, factorial trial to reduce arterial stiffness independently of blood pressure: Proof of concept? The VaSera trial testing dietary nitrate and spironolactone. Br J Clin Pharmacol 2020; 86:891-902. [PMID: 31833569 PMCID: PMC7163378 DOI: 10.1111/bcp.14194] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 12/23/2022] Open
Abstract
AIMS To test if spironolactone or dietary nitrate from beetroot juice could reduce arterial stiffness as aortic pulse wave velocity (PWVart), a potential treatment target, independently of blood pressure. METHODS Daily spironolactone (≤50 mg) vs doxazosin (control ≤16 mg) and 70 mL beetroot juice (Beet-It ≤11 mmol nitrate) vs nitrate-depleted juice (placebo; 0 mmol nitrate) were tested in people at risk or with type-2 diabetes using a double-blind, 6-month factorial trial. Vascular indices (baseline, 12, 24 weeks) were cardiac-ankle vascular index (CAVI), a nominally pressure-independent stiffness measure (primary outcome), PWVart secondary, central systolic pressure and augmentation. Analysis was intention-to-treat, adjusted for systolic pressure differences between trial arms. RESULTS Spironolactone did not reduce stiffness, with evidence for reduced CAVI on doxazosin rather than spironolactone (mean difference [95% confidence interval]; 0.25 [-0.3, 0.5] units, P = .080), firmer for PWVart (0.37 [0.01, 0.7] m/s, P = .045). There was no difference in systolic pressure reduction between spironolactone and doxazosin (0.7 [-4.8, 3.3] mmHg, P = .7). Circulating nitrate and nitrite increased on active vs placebo juice, with central systolic pressure lowered -2.6 [-4.5, - 0.8] mmHg, P = .007 more on the active juice, but did not reduce CAVI, PWVart or peripheral pressure. Change in nitrate and nitrite concentrations were 1.5-fold [1.1-2.2] and 2.2-fold [1.3, 3.6] higher on spironolactone than on doxazosin respectively; both P < .05. CONCLUSION Contrary to our hypothesis, in at-risk/type 2 diabetes patients, spironolactone did not reduce arterial stiffness, rather PWVart was lower on doxazosin. Dietary nitrate elevated plasma nitrite, selectively lowering central systolic pressure, observed previously for nitrite.
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Affiliation(s)
- Charlotte E. Mills
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- Hugh Sinclair Unit of Human Nutrition, Department of Food and Nutritional SciencesUniversity of ReadingUK
| | - Virginia Govoni
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Luca Faconti
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical PharmacologyUK
| | - Maria‐Linda Casagrande
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | | | - Hannah Crickmore
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
| | - Fahad Iqbal
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
| | - Perry Maskell
- Medicines Monitoring Unit (MEMO)University of DundeeUK
| | - Alisha Masani
- Medicines Monitoring Unit (MEMO)University of DundeeUK
| | - Elisa Nanino
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Andrew J. Webb
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, Department of Clinical PharmacologyUK
| | - J. Kennedy Cruickshank
- Cardiovascular Medicine Group, Department of Nutritional SciencesSchool of Life Course SciencesKing's College LondonUK
- Biomedical Research Centre, Clinical Research Facility, 4 Floor, North Wing, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation TrustLondonUK
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