"Beet" the cold: beetroot juice supplementation improves peripheral blood flow, endothelial function, and anti-inflammatory status in individuals with Raynaud's phenomenon

Supplementation with l-arginine and nitrates vs age and individual physiological reactivity

Ageing is a natural ontogenetic phenomenon that entails a decrease in the adaptive capacity of the organism, as a result of which the body becomes less adaptable to stressful conditions. Nitrate and nitrite enter the body from exogenous sources and from nitrification of ammonia nitrogen by intestinal microorganisms. This review considers the mechanisms of action of l-arginine, a known inducer of nitric oxide (NO) biosynthesis, and nitrates as supplements in the processes of ageing and aggravated stress states, in which mechanisms of individual physiological reactivity play an important role. This approach can be used as an element of individual therapy or prevention of premature ageing processes depending on the different levels of initial reactivity of the functional systems. A search was performed of the PubMed, Scopus, and Google Scholar databases (n = 181 articles) and the author's own research (n = 4) up to May 5, 2023. The review presents analyses of data on targeted treatment of NO generation by supplementation with l-arginine or nitrates, which is a promising means for prevention of hypoxic conditions frequently accompanying pathological processes in an ageing organism. The review clarifies the role of the individual state of physiological reactivity, using the example of individuals with a high predominance of cholinergic regulatory mechanisms who already have a significant reserve of adaptive capacity. In studies of the predominance of adrenergic influences, a poorly trained organism as well as an elderly organism correspond to low resistance, which is an additional factor of damage at increased energy expenditure.

CONCLUSION

It is suggested that the role of NO synthesis from supplementation of dietary nitrates and nitrites increases with age rather than from oxygen-dependent biosynthetic reactions from l-arginine supplementation.

Influence of acute dietary nitrate supplementation on oxygen delivery/consumption and critical impulse during maximal effort forearm exercise in males: a randomized crossover trial

Beetroot juice supplementation (BRJ) should increase nitric oxide bioavailability under conditions of muscle deoxygenation and acidosis that are a normal consequence of the maximal effort exercise test used to identify forearm critical impulse. We hypothesized BRJ would improve oxygen delivery:demand matching and forearm critical impulse performance. Healthy males (20.8 ± 2.4 years) participated in a randomized crossover trial between October 2017 and May 2018 (Queen's University, Kingston, ON). Participants completed 10 min of rhythmic maximal effort forearm handgrip exercise 2.5 h post placebo (PL) vs. BRJ (9 completed PL/BRJ vs. 4 completed BRJ/PL) within a 2 week period. Data are presented as mean ± SD. There was a main effect of drink (PL > BRJ) for oxygen extraction (P = 0.033, ηp2 = 0.351) and oxygen consumption/force (P = 0.017, ηp2 = 0.417). There was a drink × time interaction (PL > BRJ) for oxygen consumption/force (P = 0.035, ηp2 = 0.216) between 75 and 360 s (1.25-6 min) from exercise onset. BRJ did not influence oxygen delivery (P = 0.953, ηp2 = 0.000), oxygen consumption (P = 0.064, ηp2 = 0.278), metabolites ((lactate) (P = 0.196, ηp2 = 0.135), pH (P = 0.759, ηp2 = 0.008)) or power-duration performance parameters (critical impulse (P = 0.379, d = 0.253), W' (P = 0.733, d = 0.097)). BRJ during all-out handgrip exercise does not influence oxygen delivery or exercise performance. Oxygen cost of contraction with BRJ is reduced as contraction impulse is declining during maximal effort exercise resulting in less oxygen extraction.

Nitrate ingestion blunts the increase in blood pressure during cool air exposure: a double-blind, placebo-controlled, randomized, crossover trial

Cold exposure increases blood pressure (BP) and salivary flow rate (SFR). Increased cold-induced SFR would be hypothesized to enhance oral nitrate delivery for reduction to nitrite by oral anaerobes and to subsequently elevate plasma [nitrite] and nitric oxide bioavailability. We tested the hypothesis that dietary nitrate supplementation would increase plasma [nitrite] and lower BP to a greater extent in cool compared with normothermic conditions. Twelve males attended the laboratory on four occasions. Baseline measurements were completed at 28°C. Subsequently, participants ingested 140 mL of concentrated nitrate-rich (BR; ∼13 mmol nitrate) or nitrate-depleted (PL) beetroot juice. Measurements were repeated over 3 h at either 28°C (Norm) or 20°C (Cool). Mean skin temperature was lowered compared with baseline in PL-Cool and BR-Cool. SFR was greater in BR-Norm, PL-Cool, and BR-Cool than PL-Norm. Plasma [nitrite] at 3 h was higher in BR-Cool (592 ± 239 nM) versus BR-Norm (410 ± 195 nM). Systolic BP (SBP) at 3 h was not different between PL-Norm (117 ± 6 mmHg) and BR-Norm (113 ± 9 mmHg). SBP increased above baseline at 1, 2, and 3 h in PL-Cool but not BR-Cool. These results suggest that BR consumption is more effective at increasing plasma [nitrite] in cool compared with normothermic conditions and blunts the rise in BP following acute cool air exposure, which might have implications for attenuating the increased cardiovascular strain in the cold.NEW & NOTEWORTHY Compared with normothermic conditions, acute nitrate ingestion increased plasma [nitrite], a substrate for oxygen-independent nitric oxide generation, to a greater extent during cool air exposure. Systolic blood pressure was increased during cool air exposure in the placebo condition with this cool-induced blood pressure increase attenuated after acute nitrate ingestion. These findings improve our understanding of environmental factors that influence nitrate metabolism and the efficacy of nitrate supplementation to lower blood pressure.

Influence of acute dietary nitrate supplementation on oxygen delivery/consumption and limit of tolerance during progressive forearm exercise in men: a randomized crossover trial

Beetroot juice (BRJ) supplementation increases nitric oxide bioavailability with hypoxia and acidosis, characteristics of high-intensity exercise. We investigated whether BRJ improved forearm oxygen delivery:demand matching in an intensity-dependent manner. Healthy men (21 ± 2.5 years) participated in a randomized crossover trial between October 2017 and May 2018 (Queen's University, Kingston, ON, Canada). Participants completed a forearm incremental exercise test to limit of tolerance (IET-LOT) 2.5 h post placebo (PL) versus BRJ (2 completed PL/BRJ vs. 9 completed BRJ/PL) within a 2-week period. Data are presented as mean ± standard deviation. There was a significant main effect of drink (PL < BRJ; P = 0.042, ηp2 = 0.385) and drink × intensity interaction for arteriovenous oxygen difference (PL < BRJ; P = 0.03; ηp2= 0.197; 20%-50% and 90% LOT). BRJ did not influence oxygen delivery (P = 0.893, ηp2 = 0.002), forearm blood flow (P = 0.589, ηp2 = 0.03) (forearm vascular conductance (P = 0.262, ηp2 = 0.124), mean arterial pressure (P = 0.254,ηp2 = 0.128)), oxygen consumption (P = 0.194, ηp2 = 0.179) or LOT (P = 0.432, d = 0.247). In healthy men, BRJ did not improve forearm oxygen delivery (vasodilatory or pressor response) during IET-LOT. Increased arteriovenous oxygen difference at submaximal intensities did not significantly influence oxygen consumption or performance across the entire range of forearm exercise intensities. This study adds to the growing body of evidence that BRJ does not influence small muscle mass blood flow in humans regardless of exercise intensity.

Short-term cocoa bioflavanol supplementation does not improve cold-induced vasodilation in young healthy adults

PURPOSE

Cold-induced vasodilation (CIVD) is an oscillatory rise in blood flow to glabrous skin that occurs in cold-exposed extremities. Dietary flavanols increase bioavailable nitric oxide, a proposed mediator of CIVD through active vasodilation and/or withdrawal of sympathetic vascular smooth muscle tone. However, no studies have examined the effects of flavanol intake on extremity skin perfusion during cold exposure. We tested the hypothesis that acute and 8-day flavanol supplementation would augment CIVD during single-digit cold water immersion (CWI).

METHODS

Eleven healthy adults (24 ± 6 years; 10 M/1F) ingested cocoa flavanols (900 mg/day) or caffeine- and theobromine-matched placebo for 8 days in a double-blind, randomized, crossover design. On Days 1 and 8, CIVD was assessed 2 h post-treatment. Subjects immersed their 3rd finger in warm water (42 °C) for 15 min before CWI (4 °C) for 30 min, during which nail bed and finger pad skin temperature were measured.

RESULTS

Flavanol ingestion had no effect on CIVD frequency (Day 1, Flavanol: 3 ± 2 vs. Placebo: 3 ± 2; Day 8, Flavanol: 3 ± 2 vs. Placebo: 3 ± 1) or amplitude (Day 1, Flavanol: 4.3 ± 1.7 vs. Placebo: 4.9 ± 2.6 °C; Day 8, Flavanol: 3.9 ± 1.9 vs. Placebo: 3.9 ± 2.0 °C) in the finger pad following acute or 8-day supplementation (P > 0.05). Furthermore, average, nadir, and apex finger pad temperatures during CWI were not different between treatments on Days 1 or 8 of supplementation (P > 0.05). Similarly, no differences in CIVD parameters were observed in the nail bed following supplementation (P > 0.05).

CONCLUSION

These data suggest that cocoa flavanol ingestion does not alter finger CIVD. Clinical Trial Registration Clinicaltrials.gov Identifier: NCT04359082. April 24, 2020.

Increased nitrate intake from beetroot juice over 4 weeks affects nitrate metabolism, but not vascular function or blood pressure in older adults with hypertension

The decline in vascular function and increase in blood pressure with aging contribute to an increased cardiovascular disease risk. In this randomized placebo-controlled crossover study, we evaluated whether previously reported cardiovascular benefits of plant-derived inorganic nitrate via nitric oxide (NO) translate into improved vascular function and blood pressure-lowering in 15 men and women (age range: 56-71 years) with treated hypertension. We investigated the effects of a single ∼400 mg-dose at 3 hours post-ingestion (3H POST) and the daily consumption of 2 × ∼400 mg of nitrate through nitrate-rich compared with nitrate-depleted (placebo) beetroot juice over 4 weeks (4WK POST). Measurements included nitrate and nitrite in plasma and saliva; endothelial-dependent and -independent forearm blood flow (FBF) responses to acetylcholine (FBFACh) and glyceryltrinitrate (FBFGTN); and clinic-, home- and 24-hour ambulatory blood pressure. Compared to placebo, plasma and salivary nitrate and nitrite increased at 3H and 4WK POST following nitrate treatment (P < 0.01), suggesting a functioning nitrate-nitrite-NO pathway in the participants of this study. There were no differences between treatments in FBFACh and FBFGTN-area under the curve (AUC) ratios [AUC ratios after (3H POST, 4WK POST) compared with before (PRE) the intervention], or 24-hour ambulatory blood pressure or home blood pressure measures (P > 0.05). These findings do not support the hypothesis that an increased intake of dietary nitrate exerts sustained beneficial effects on FBF or blood pressure in hypertensive older adults, providing important information on the efficacy of nitrate-based interventions for healthy vascular aging. This study was registered under ClinicialTrials.gov (NCT04584372).

The Integral Role of Diets Including Natural Products to Manage Rheumatoid Arthritis: A Narrative Review

Genetic and environmental factors including lifestyle are thought to play a key role in the pathophysiology of rheumatoid arthritis (RA). There is evidence that diet can enhance the inflammatory response in genetically predisposed individuals. On the other hand, certain types of diets can alleviate RA symptoms due to their anti-inflammatory and antioxidant activities. Also, natural compounds with potential effectiveness in RA management belong to different chemical classes such as flavonoids, polyphenols, carotenoids, and alkaloids with their antioxidant characteristics as well as probiotics. The nutritional approaches to prevent or extenuate the disease progress were examined in this narrative review which was conducted using the PubMed, ScienceDirect and Google Scholar databases and conforms to the Scale for the Assessment of Narrative Review Articles (SANRA) guidelines. Mediterranean and vegan diets equally have been shown to exhibit positive effects on RA as the consumption of dietary fiber, antioxidants and anti-inflammatory compounds from fruits, vegetables, grains, nuts, and seeds are high. Whereas Mediterranean diet additionally includes beneficial nutrients of animal origin such as omega-3 polyunsaturated fatty acids from fish and seafood, patients on vegan diet need to be monitored closely for intake of all critical nutrients. Certain calorie restrictions and intermittent fasting diets have been shown to benefit RA patients although there is an obvious need for further studies to establish solid evidence-based recommendations and guidelines. The research data available strongly suggest that dietary approaches with anti-inflammatory properties may help delay the onset of RA and/or improve symptoms and thus nutrition should be routinely addressed to facilitate management of the disease.

Understanding human aging and the fundamental cell signaling link in age-related diseases: the middle-aging hypovascularity hypoxia hypothesis

Aging-related hypoxia, oxidative stress, and inflammation pathophysiology are closely associated with human age-related carcinogenesis and chronic diseases. However, the connection between hypoxia and hormonal cell signaling pathways is unclear, but such human age-related comorbid diseases do coincide with the middle-aging period of declining sex hormonal signaling. This scoping review evaluates the relevant interdisciplinary evidence to assess the systems biology of function, regulation, and homeostasis in order to discern and decipher the etiology of the connection between hypoxia and hormonal signaling in human age-related comorbid diseases. The hypothesis charts the accumulating evidence to support the development of a hypoxic milieu and oxidative stress-inflammation pathophysiology in middle-aged individuals, as well as the induction of amyloidosis, autophagy, and epithelial-to-mesenchymal transition in aging-related degeneration. Taken together, this new approach and strategy can provide the clarity of concepts and patterns to determine the causes of declining vascularity hemodynamics (blood flow) and physiological oxygenation perfusion (oxygen bioavailability) in relation to oxygen homeostasis and vascularity that cause hypoxia (hypovascularity hypoxia). The middle-aging hypovascularity hypoxia hypothesis could provide the mechanistic interface connecting the endocrine, nitric oxide, and oxygen homeostasis signaling that is closely linked to the progressive conditions of degenerative hypertrophy, atrophy, fibrosis, and neoplasm. An in-depth understanding of these intrinsic biological processes of the developing middle-aged hypoxia could provide potential new strategies for time-dependent therapies in maintaining healthspan for healthy lifestyle aging, medical cost savings, and health system sustainability.

Transport of nitrite from large arteries modulates regional blood flow during stress and exercise

Background

Acute cardiovascular stress increases systemic wall shear stress (WSS)-a frictional force exerted by the flow of blood on vessel walls-which raises plasma nitrite concentration due to enhanced endothelial nitric oxide synthase (eNOS) activity. Upstream eNOS inhibition modulates distal perfusion, and autonomic stress increases both the consumption and vasodilatory effects of endogenous nitrite. Plasma nitrite maintains vascular homeostasis during exercise and disruption of nitrite bioavailability can lead to intermittent claudication.

Hypothesis

During acute cardiovascular stress or strenuous exercise, we hypothesize enhanced production of nitric oxide (NO) by vascular endothelial cells raises nitrite concentrations in near-wall layers of flowing blood, resulting in cumulative NO concentrations in downstream arterioles sufficient for vasodilation.

Confirmation and implications

Utilizing a multiscale model of nitrite transport in bifurcating arteries, we tested the hypothesis for femoral artery flow under resting and exercised states of cardiovascular stress. Results indicate intravascular transport of nitrite from upstream endothelium could result in vasodilator-active levels of nitrite in downstream resistance vessels. The hypothesis could be confirmed utilizing artery-on-a-chip technology to measure NO production rates directly and help validate numerical model predictions. Further characterization of this mechanism may improve our understanding of symptomatic peripheral artery occlusive disease and exercise physiology.

Moderate doses of dietary nitrate elicit greater effects on blood pressure and endothelial function than a high dose: A 13-week pilot study

BACKGROUND & AIMS

Few studies have explored the prolonged effects of dietary nitrate on vascular health. This pilot study tested the effects of prolonged consumption (13 weeks) of a range of doses of dietary nitrate (NO₃^-), provided as beetroot juice (BJ), on blood pressure (BP) and endothelial function in overweight and obese older participants.

METHODS AND RESULTS

Sixty-two overweight or obese older participants (60-75 years) were randomized to the following interventions: (1) high NO₃^- (2) medium NO₃^-, (3) low NO₃^-, or (4) placebo. Resting clinic and home BP were measured pre- and post-intervention. Laser Doppler iontophoresis was used to quantify changes in endothelial-dependent and independent microvascular blood flow.

RESULTS

This pilot study showed that medium and low doses of NO₃^- were more effective in lowering resting-clinic SBP (P = 0.04 and, P = 0.03, respectively) than was PL. The lower doses of NO₃^- also resulted in significant increases in microvascular perfusion (medium, P = 0.02; low, P = 0.002) relative to baseline values.

CONCLUSION

These findings indicate that supplementation with medium and low, but not high, doses of NO₃^- for 13 weeks had positive effects on BP and endothelial function in older overweight and obese adults. These findings require confirmation in larger studies.

Influence of acute beetroot juice supplementation on cold-induced vasodilation and fingertip rewarming

PURPOSE

Vasoactive ingredients in beetroot (BR) such as nitrate are known to induce vasodilation in temperate conditions. This study investigated the effect of BR ingestion on cold induced vasodilation (CIVD) and rewarming of finger skin temperature (T_fing) during and after hand immersion in cold water.

METHODS

Twenty healthy males (mean ± SD; age 22.2 ± 0.7 years, height 172.6 ± 6.0 cm, body mass 61.3 ± 11.7 kg) repeated a hand cold water immersion test twice with prior BR or water beverage ingestion (randomised order). They rested for 2 h in thermoneutral conditions (27 °C, 40% relative humidity) after consuming the beverage, then immersed their non-dominant hand in 8 °C water for 30 min. They then rewarmed their hand in the ambient air for 20 min. Skin temperature at seven body sites, T_fing, finger skin blood flow (SkBF_fing), and blood pressure were measured.

RESULTS

During hand immersion parameters of CIVD (T_fing and SkBF_fing) were not different between BR and water conditions although skin temperature gradient from proximal to distal body sites was significantly smaller with BR (P < 0.05). During rewarming, SkBF_fing and cutaneous vascular conductance were significantly higher with BR than with water (P < 0.05). The rewarming speed in T_fing and SkBF_fing was significantly faster with BR at 15- (BR 1.24 ± 0.22 vs water 1.11 ± 0.26 °C/min) and 20-min rewarming (P < 0.05). Additionally, individuals with slower rewarming speed with water demonstrated accelerated rewarming with BR supplementation.

CONCLUSION

BR accelerated rewarming in T_fing and SkBF_fing after local cold stimulus, whereas, CIVD response during hand cold immersion was not affected by BR ingestion.

Plasma biomarkers of endothelial function, inflammation and oxidative stress in individuals with non-freezing cold injury

NEW FINDINGS

What is the central question of this study? Are biomarkers of endothelial function, oxidative stress and inflammation altered by non-freezing cold injury (NFCI)? What is the main finding and its importance? Baseline plasma [interleukin-10] and [syndecan-1] were elevated in individuals with NFCI and cold-exposed control participants. Increased [endothelin-1] following thermal challenges might explain, in part, the increased pain/discomfort experienced with NFCI. Mild to moderate chronic NFCI does not appear to be associated with either oxidative stress or a pro-inflammatory state. Baseline [interleukin-10] and [syndecan-1] and post-heating [endothelin-1] are the most promising candidates for diagnosis of NFCI.

ABSTRACT

Plasma biomarkers of inflammation, oxidative stress, endothelial function and damage were examined in 16 individuals with chronic NFCI (NFCI) and matched control participants with (COLD, n = 17) or without (CON, n = 14) previous cold exposure. Venous blood samples were collected at baseline to assess plasma biomarkers of endothelial function (nitrate, nitrite and endothelin-1), inflammation [interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor alpha and E-selectin], oxidative stress [protein carbonyl, 4-hydroxy-2-nonenal (4-HNE), superoxide dismutase and nitrotyrosine) and endothelial damage [von Willebrand factor, syndecan-1 and tissue type plasminogen activator (TTPA)]. Immediately after whole-body heating and separately, foot cooling, blood samples were taken for measurement of plasma [nitrate], [nitrite], [endothelin-1], [IL-6], [4-HNE] and [TTPA]. At baseline, [IL-10] and [syndecan-1] were increased in NFCI (P < 0.001 and P = 0.015, respectively) and COLD (P = 0.033 and P = 0.030, respectively) compared with CON participants. The [4-HNE] was elevated in CON compared with both NFCI (P = 0.002) and COLD (P < 0.001). [Endothelin-1] was elevated in NFCI compared with COLD (P < 0.001) post-heating. The [4-HNE] was lower in NFCI compared with CON post-heating (P = 0.032) and lower than both COLD (P = 0.02) and CON (P = 0.015) post-cooling. No between-group differences were seen for the other biomarkers. Mild to moderate chronic NFCI does not appear to be associated with a pro-inflammatory state or oxidative stress. Baseline [IL-10] and [syndecan-1] and post-heating [endothelin-1] are the most promising candidates for diagnosing NFCI, but it is likely that a combination of tests will be required.

The effect of beetroot juice on airway inflammation in a murine model of asthma

The effects of beetroot juice on airways inflammation, cytokine levels, and oxidative stress biomarkers were evaluated using an allergen-induced murine model of asthma. Ovalbumin (OVA)-sensitized and challenged BALB/c mice were used as an asthma model. BALB/c mice were randomly assigned into four groups: control (Ova sensitization and normal saline challenge), control and beetroot (Ova sensitization and normal saline challenge plus beetroot juice), Ova S/C [Ova sensitization and challenge (Ova S/C)], Ova S/C and beetroot juice (Ova S/C plus beetroot juice). The bronchoalveolar lavage fluid (BALF) was analyzed for total and differential inflammatory cells count. The levels of cytokines [interleukin (IL)-10, IL-13, and IL-18], and oxidative stress biomarkers [glutathione peroxidase (GPx), catalase, and thiobarbituric acid reactive substances (TBARS)] were analyzed in the lung tissue. Simultaneous administration of beetroot juice and Ova S/C significantly increased the total inflammatory cells compared to the control (p = .0001) and Ova S/C (p = .013) groups and significantly increased the number of eosinophils (p ˂ .0001) and macrophages (p ˂ .0001) compared to the control. Moreover, the simultaneous administration of beetroot juice and Ova S/C did not affect the level of IL-10, IL-13, IL-18, GPx, or TBARS compared to the control (p > .05), but it significantly increased the level of catalase (p = .002). Results suggest that beetroot juice aggravates asthma by enhancing airway inflammation. However, it does not affect airway inflammation in healthy mice. PRACTICAL APPLICATIONS: Asthma is a chronic airway inflammatory disease that is characterized by variable degrees of airways inflammation and obstruction. Paradox data are reported in the literature regarding beetroot and asthma. The present study revealed that beetroot juice exacerbates asthma by enhancing airway inflammation. However, it is safe and has no effects on airway inflammation in healthy mice. Patients having asthma or a history of asthma are advised to avoid the consumption of beetroot.

Effect of high nitrate vegetable juice supplementation on plasma nitrate and blood pressure in adults: a pilot randomized crossover intervention in healthy volunteers

Beetroot juice (BRJ) has been demonstrated to decrease blood pressure (BP) due to the high inorganic nitrate content. This pilot randomized crossover trial aimed to investigate the effect of two different high nitrate vegetable juices on plasma nitrate concentrations and BP in healthy adults. Eighteen healthy volunteers were randomized to receive 115 ml of BRJ or 250 ml of green leafy vegetable juice for 7 d which contained similar amounts of nitrate (340 mg) daily. Blood samples were collected, and clinic BP measured at baseline and at the end of each juice consumption. Daily home BP assessment was conducted 2 h after juice consumption. Nitrate and nitrite concentrations were analysed using a commercially available kit on a Triturus automated ELISA analyser. Hills and Armitage analysis was used for the two-period crossover design and paired sample t-tests were performed to compare within-group changes. Plasma nitrate and nitrite concentrations significantly increased and there was a significant reduction in clinic and home systolic blood pressure (SBP) mean during the BRJ period (P-values 0⋅004 and 0⋅002, respectively). Home diastolic blood pressure (DBP) reduced significantly during green leafy vegetable juice consumption week (P-value 0⋅03). The difference between groups did not reach statistical significance during the formal crossover analysis adjusted for period effects. BRJ and green leafy vegetable juice may reduce SBP or DBP, but there was no statistically significant difference between the two juices, although this was only a pilot study.

Raynaud's phenomenon and digital ulcers: advances in evaluation and management

PURPOSE OF REVIEW

The aim of this review is to give an update on advances in evaluation and management of systemic sclerosis (SSc)-related Raynaud's phenomenon and digital ulceration, focusing on reports from the last 18 months. The increasing recognition of the huge impact of Raynaud's phenomenon and of digital ulceration on the everyday lives of patients with SSc has sparked enthusiasm internationally to develop better outcome measures and better treatments, and so a review is timely.

RECENT FINDINGS

There have been recent advances in the development of patient reported outcome instruments [e.g. the Hand Disability in Systemic Sclerosis-Digital Ulcers (HDISS-DU) instrument] and also in noninvasive imaging techniques, including thermography and laser Doppler methods. Improved outcome measures will facilitate future clinical trials, both early phase proof-of-concept and later phase trials. New insights have been gained into mechanisms of action and methods of administration of 'conventional' therapies, for example phosphodiesterase inhibitors and intravenous prostanoids. New treatment approaches are being investigated, including topical and procedural therapies.

SUMMARY

Clinicians can look forward to seeing these advances translating into clinical benefit over the next 5 years. To help ensure this, they should strive whenever possible to recruit patients with SSc-related digital vasculopathy into observational studies and clinical trials.

Capillaroscopic Evidence of Microvascular Damage in Volleyball Players

Volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Literature reports that repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow. These anomalies could be related to the presence of dysfunctional endothelium. The aim of this study is to correlate the capillaroscopic findings by nailfold video capillaroscopy (NVC) to volleyball practice in order to early detect possible anomalies and perform an adequate follow-up to avoid damages that could negatively affect sport practice and the players' health status. In this study, 38 subjects were enrolled, 19 volleyball players and 19 healthy non-players as a comparison group. In almost all the players, we found capillaroscopic alterations of the "aspecific pattern" type without substantial gender differences. We may assume that the repeated traumas involving players' fingers can negatively modify their microcirculation. Based on these observations, it could be a desirable clinical practice to screen professional volleyball players with NVC in order to implement preventive strategies aimed at protecting the health of athletes.

Korean traditional foods as antiviral and respiratory disease prevention and treatments: A detailed review

BACKGROUND

Korean traditional food (KTF), originated from ancestral agriculture and the nomadic traditions of the Korean peninsula and southern Manchuria, is based on healthy food that balances disease prevention and treatment. Fermented foods that include grains, herbs, fruits, and mushrooms are also an important practice in KTF, providing high levels of Lactobacilli, which confer relevant health benefits, including antiviral properties. Some of these probiotics may also protect against the Influenza virus through the modulation of innate immunity.

SCOPE AND APPROACH

The emerging of the COVID-19 pandemic, in addition to other diseases of viral origin, and the problems associated with other respiratory disorders, highlight how essential is a healthy eating pattern to strengthen our immune system.Key Findings and Conclusions: The present review covers the information available on edible plants, herbs, mushrooms, and preparations used in KTF to outline their multiple medicinal effects (e.g., antidiabetic, chemopreventive, antioxidative, anti-inflammatory, antibacterial), emphasizing their role and effects on the immune system with an emphasis on modulating properties of the gut microbiota that further support strong respiratory immunity. Potential functional foods commonly used in Korean cuisine such as Kimchi (a mixture of fermented vegetables), Meju, Doenjang, Jeotgal, and Mekgeolli and fermented sauces, among others, are highlighted for their great potential to improve gut-lung immunity. The traditional Korean diet and dietary mechanisms that may target viruses ACE-2 receptors or affect any step of a virus infection pathway that can determine a patient's prognosis are also highlighted. The regular oral intake of bioactive ingredients used in Korean foods can offer protection for some viral diseases, through protective and immunomodulatory effects, as evidenced in pre-clinical and clinical studies.

Dietary nitrate and population health: a narrative review of the translational potential of existing laboratory studies

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.

Beverages in Rheumatoid Arthritis: What to Prefer or to Avoid

Background: The role of nutrition in the pathogenesis of rheumatic diseases, including rheumatoid arthritis (RA), has gained increasing attention in recent years. A growing number of studies have focussed on the diverse nutritional contents of beverages, and their possible role in the development and progression of RA. Main body: We aimed to summarise the current knowledge on the role of a range of beverages in the context of RA. Beverages have a key role within the mosaic of autoimmunity in RA and potential to alter the microbiome, leading to downstream effects on inflammatory pathways. The molecular contents of beverages, including coffee, tea, and wine, have similarly been found to interfere with immune signalling pathways, some beneficial for disease progression and others less so. Finally, we consider beverages in the context of wider dietary patterns, and how this growing body of evidence may be harnessed by the multidisciplinary team in patient management. Conclusions: While there is increasing work focussing on the role of beverages in RA, integration of discussions around diet and lifestyle in our management of patients remains sparse. Nutrition in RA remains a controversial topic, but future studies, especially on the role of beverages, are likely to shed further light on this in coming years.

Effects of Oral Sodium Nitrite on Blood Pressure, Insulin Sensitivity, and Intima-Media Arterial Thickening in Adults With Hypertension and Metabolic Syndrome

The nitrate-nitrite-NO pathway regulates NO synthase-independent vasodilation and NO signaling. Ingestion of inorganic nitrite has vasodilatory and blood pressure-lowering effects. Preclinical studies in rodent models suggest there may be a benefit of nitrite in lowering serum triglyceride levels and improving the metabolic syndrome. In a phase 2 study, we evaluated the safety and efficacy of chronic oral nitrite therapy in patients with hypertension and the metabolic syndrome. Twenty adult subjects with stage 1 or 2 hypertension and the metabolic syndrome were enrolled in an open-label safety and efficacy study. The primary efficacy end point was blood pressure reduction; secondary end points included insulin-dependent glucose disposal and endothelial function measured by flow-mediated dilation of the brachial artery and intima-media diameter of the carotid artery. Chronic oral nitrite therapy (40 mg/3× daily) was well tolerated. Oral nitrite significantly lowered systolic, diastolic, and mean arterial pressures, but tolerance was observed after 10 to 12 weeks of therapy. There was significant improvement in the intima-media thickness of the carotid artery and trends toward improvements in flow-mediated dilation of the brachial artery and insulin sensitivity. Chronic oral nitrite therapy is safe in patients with hypertension and the metabolic syndrome. Despite an apparent lack of enzymatic tolerance to nitrite, we observed tolerance after 10 weeks of chronic therapy, which requires additional mechanistic studies and possible therapeutic dose titration in clinical trials. Nitrite may be a safe therapy to concominantly improve multiple features of the metabolic syndrome including hypertension, insulin resistance, and endothelial dysfunction. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01681810.

No thermoregulatory or ergogenic effect of dietary nitrate among physically inactive males, exercising above gas exchange threshold in hot and dry conditions

The aim of this study was to determine the effect of five days dietary nitrate (NO₃^-) consumption on exercise tolerance and thermoregulation during cycling in hot, dry conditions. In a double-blind, randomised crossover design, 11 healthy males participated in an exercise tolerance test (T_lim) in the heat (35°C, 28% relative humidity), cycling above the thermoneutral gas exchange threshold, after five days of dietary supplementation, with either NO₃^-rich beetroot juice (BR; ∼ 9.2 mmol NO₃^-) or placebo (PLA). Changes in plasma [NO₃^-] and nitrite [NO₂^-], core and mean skin temperatures, mean local and whole-body sweat rates, heart rate, perceptual ratings and pulmonary gas exchange were measured during exercise, alongside calorimetric estimations of thermal balance. Mean arterial pressures (MAP) were recorded pre-T_lim. There were no differences in T_lim between conditions (BR = 22.8 ± 8.1 min; Placebo = 20.7 ± 7.9 min) (P = 0.184), despite increases in plasma [NO₃^-] and [NO₂^-] (P < 0.001) and a 3.8% reduction in resting MAP (P = 0.004) in the BR condition. There were no other differences in thermoregulatory, cardio-metabolic, perceptual or calorimetric responses to the T_lim between conditions (P > 0.05). Dietary NO₃^- supplementation had no effect on exercise tolerance or thermoregulation in hot, dry conditions, despite reductions in resting MAP and increases in plasma [NO₃^-] and [NO₂^-]. Healthy, yet physically inactive individuals with no known impairments in vasodilatory and sudomotor function do not appear to require BR for ergogenic or thermolytic effects during exercise in the heat.

Effects of Beetroot Juice Ingestion on Physical Performance in Highly Competitive Tennis Players

Beetroot juice (BJ) contains high levels of inorganic nitrate (NO₃⁻) and its intake has good evidence in increasing blood nitrate/nitrite concentrations. The ingestion of BJ has been associated with improvements in physical performance of endurance sports, however the literature in intermittent sports is scarce. The aim of this study was to investigate whether BJ could improve physical performance in tennis players. Thirteen well-trained tennis players (25.4 ± 5.1 years) participated in the study during their preparatory period for the tennis season. Subjects were randomly divided into two groups and performed a neuromuscular test battery after either BJ or placebo (PLA) consumption. Both trials were executed on two separate days, in randomized order, with one week of wash out period. The test battery consisted of serve velocity test (SVT), countermovement jump (CMJ), isometric handgrip strength (IHS), 5-0-5 agility test (5-0-5), and 10 m sprint (10-m). No significant differences were found in SVT (1.19%; p = 0.536), CMJ (0.96%; p = 0.327), IHS (4.06%; p = 0.069), 5-0-5 dominant and nondominant side (1.11–2.02%; p = 0.071–0.191) and 10-m (1.05%; p = 0.277) when comparing BJ and PLA ingestion. Thus, our data suggest that low doses of BJ (70 mL) consumption do not enhance tennis physical performance.