Short-term effects of a high nitrate diet on nitrate metabolism in healthy individuals

Beetroot in deep waters: Navigating the risks of supplement-induced blackouts in aquatic training

Beetroot powder, a popular athletic supplement high in nitrates, purportedly enhances exercise performance. However, recent incidents during breath-hold swims in Air Force Special Warfare training, associated with beetroot powder use, raise safety concerns. Two cases of hypoxic events prompt discussion on interactions between beetroot supplementation and cardiovascular responses to breath-hold diving, suggesting a risk for blackout. Beetroot-induced vasodilation may counteract normal cardiovascular responses during swimming, emphasizing the need for further research to quantify risks. With inconsistent dosing and lack of standardized recommendations, heightened awareness of these risks is crucial for informed decision-making regarding beetroot supplements, especially in tactical athletes.

Seven-day dietary nitrate supplementation clinically significantly improves basal macrovascular function in postmenopausal women: a randomized, placebo-controlled, double-blind, crossover clinical trial

Introduction

Cardiovascular disease (CVD) is the leading cause of death in women, with increased risk following menopause. Dietary intake of beetroot juice and other plant-based nitrate-rich foods is a promising non-pharmacological strategy for increasing systemic nitric oxide and improving endothelial function in elderly populations. The purpose of this randomized, placebo-controlled, double-blind, crossover clinical trial was to determine the effects of short-term dietary nitrate (NO3 -) supplementation, in the form of beetroot juice, on resting macrovascular endothelial function and endothelial resistance to whole-arm ischemia-reperfusion (IR) injury in postmenopausal women at two distinct stages of menopause.

Methods

Early-postmenopausal [1-6 years following their final menstrual period (FMP), n = 12] and late-postmenopausal (6+ years FMP, n = 12) women consumed nitrate-rich (400 mg NO3 -/70 mL) and nitrate-depleted beetroot juice (approximately 40 mg NO3 -/70 mL, placebo) daily for 7 days. Brachial artery flow-mediated dilation (FMD) was measured pre-supplementation (Day 0), and approximately 24 h after the last beetroot juice (BR) dose (Day 8, post-7-day BR). Consequently, FMD was measured immediately post-IR injury and 15 min later (recovery).

Results

Results of the linear mixed-effects model revealed a significantly greater increase in resting FMD with 7 days of BRnitrate compared to BRplacebo (mean difference of 2.21, 95% CI [0.082, 4.34], p = 0.042); however, neither treatment blunted the decline in post-IR injury FMD in either postmenopausal group. Our results suggest that 7-day BRnitrate-mediated endothelial protection is lost within the 24-h period following the final dose of BRnitrate.

Conclusion

Our findings demonstrate that nitrate-mediated postmenopausal endothelial protection is dependent on the timing of supplementation in relation to IR injury and chronobiological variations in dietary nitrate metabolism.

Clinical trial registration

https://classic.clinicaltrials.gov/ct2/show/NCT03644472.

Effects of S-Allylcysteine-Rich Garlic Extract and Dietary Inorganic Nitrate Formula on Blood Pressure and Salivary Nitric Oxide: An Open-Label Clinical Trial Among Hypertensive Subjects

INTRODUCTION

 The conversion of dietary inorganic nitrate (NO3-) to nitric oxide (NO) is a non-canonical pathway that plays an important role in NO biology, especially under pathological conditions. Inorganic NO3- supplementation is a proven method for controlling mild hypertension. Recent reports have suggested that another gaseous transmitter, hydrogen sulfide (H2S), influences NO biosynthesis and metabolism. Here, data are presented from an open-label clinical trial examining the effect of an encapsulated formulation (Vascanox® HP) that combines dietary sources of inorganic NO3- and S-allylcysteine (SAC), a source of H2S from garlic, on NO bioavailability and blood pressure in subjects experiencing elevated blood pressure or mild hypertension.

METHODS

 An open-label clinical trial was conducted among patients with hypertension. Participants took Vascanox® for four weeks. Blood pressure was measured at baseline, two weeks, and four weeks. Salivary nitrite (NO2-), a surrogate of NO bioavailability, and NO3- were assessed prior to and two, six, and 24 hours after dosing on the first day of the study and prior to and two hours after dosing at subsequent study visits using saliva NO test strips. Changes in study outcomes over time were evaluated via analysis of variance (ANOVA) and paired t-tests.

RESULTS

 Twelve participants completed the clinical trial. Vascanox® HP decreased systolic blood pressure by ~11 mmHg (p < 0.001) at two weeks and persisted beyond four weeks with daily supplementation. It also decreased the diastolic blood pressure of hypertensive subjects but not normotensive ones. The magnitude of the decrease was 11 mmHg (p < 0.01) at four weeks of study. Measurements of salivary concentrations of NO2- revealed high peak levels (743 uM) at two hours post-administration and a slow decay to elevated levels (348 uM) at 24 hours. NO2- salivary concentrations, a surrogate biomarker of NO bioavailability, remained above baseline for the duration of the study.

CONCLUSIONS

 Vascanox® HP was shown to be a safe, effective, quick-acting, and long-lasting dietary supplement for controlling mild hypertension.

Is there an association between a plant-based eating pattern and clinical findings of a migraine headache?

Aims

The present study was conducted among Iranian individuals diagnosed with migraine headaches to investigate the association between plant-based eating patterns and the clinical features of a migraine headache.

Methods

In total, 262 patients aged 20-50 years who were diagnosed with migraine headaches were included in the current cross-sectional study. Participants' dietary intake was assessed using a validated 168-item, semi-quantitative food frequency questionnaire (FFQ). Three versions of the plant-based diet index (PDI) comprising overall PDI, healthy PDI (hPDI), and unhealthy PDI (uPDI) were generated. Headache frequency, duration, and severity were assessed via a 30-day headache diary. Migraine-related disability was assessed with a validated version of the headache impact test (HIT-6) questionnaire. Serum nitric oxide (NO) was measured using the Griess method utilizing serum samples.

Results

After controlling for potential confounders, an increase in mean PDI score from 48.22 to 61.67 decreased the frequency of headaches by -2.95 (95% CI: 0.06, 0.53; p_trend = 0.005). PDI was inversely associated with serum levels of NO in those with the highest scores of PDI compared to those with the lowest scores after adjustment for confounders (β = -7.69; 95% CI: -14.68, -0.69; p_trend = 0.028). After adjustment for potential confounders, an increase in the mean hPDI score from 47.96 to 65.25 decreased serum levels of NO by -11.92 (95% CI: -19.74, -4.10; p_trend = 0.003).

Conclusion

Our findings suggest that higher adherence to a plant-based eating style, as evidenced by higher PDI and hPDI values, was significantly associated with lower headache frequency and serum levels of NO.

A Critical Review on Vasoactive Nutrients for the Management of Endothelial Dysfunction and Arterial Stiffness in Individuals under Cardiovascular Risk

Pathophysiological conditions such as endothelial dysfunction and arterial stiffness, characterized by low nitric oxide bioavailability, deficient endothelium-dependent vasodilation and heart effort, predispose individuals to atherosclerotic lesions and cardiac events. Nitrate (NO₃^-), L-arginine, L-citrulline and potassium (K⁺) can mitigate arterial dysfunction and stiffness by intensifying NO bioavailability. Dietary compounds such as L-arginine, L-citrulline, NO₃^- and K⁺ exert vasoactive effects as demonstrated in clinical interventions by noninvasive flow-mediated vasodilation (FMD) and pulse-wave velocity (PWV) prognostic techniques. Daily L-arginine intakes ranging from 4.5 to 21 g lead to increased FMD and reduced PWV responses. Isolated L-citrulline intake of at least 5.6 g has a better effect compared to watermelon extract, which is only effective on endothelial function when supplemented for longer than 6 weeks and contains at least 6 g of L-citrulline. NO₃^- supplementation employing beetroot at doses greater than 370 mg promotes hemodynamic effects through the NO₃^--NO2-/NO pathway, a well-documented effect. A potassium intake of 1.5 g/day can restore endothelial function and arterial mobility, where decreased vascular tone takes place via ATPase pump/hyperpolarization and natriuresis, leading to muscle relaxation and NO release. These dietary interventions, alone or synergically, can ameliorate endothelial dysfunction and should be considered as adjuvant therapies in cardiovascular diseases.

Double-blind controlled dietary cross-over intervention with differentially fertilised intact lettuce leaves shows acute reduction in blood pressure in young adults, associated with faster uptake of nitrate than of phenolics

PURPOSE

To compare acute effects on blood pressure (BP) of ingestion of visually similar lettuce with controlled high and low content of either nitrate or phenolic compounds.

METHODS

In a randomised cross-over design, 19 healthy participants (22-31 years) received 50 g of lettuce containing either 530 mg (8.4 mmol) nitrate + 11 mg (0.03 mmol) phenolic compounds (HNLP); or 3 mg nitrate (0.05 mmol) + 77 mg (0.2 mmol) phenolic compounds (LNHP), obtained by differential fertilisation. Ambulatory BP was recorded along with plasma, salivary and urinary nitrate and nitrite and plasma concentrations of cyclic guanosine monophosphate (cGMP), phenolic metabolites, Trolox equivalent antioxidant capacity (TEAC) and ferric reducing antioxidant power (FRAP).

RESULTS

Compared with LNHP, 3 h post ingestion of HNLP, plasma nitrate increased 0.31 ± (95%CI) 0.12 mM (+ 240%), and salivary nitrate 5.5 ± 1.4 mM (+ 910%); accumulated urinary nitrate excretion increased 188 ± 72 mg (+ 296%) (all P < 0.001). Systolic BP was reduced 4.9 ± 4.2 mmHg (P = 0.031) between 3 and 6 h after ingestion of HNLP compared with LNHP; systolic BP differences were negatively correlated (P = 0.004) with differences in saliva nitrate concentrations. LNHP increased plasma phenolics at 6 h, predominantly 3'-methoxycinnamic acid-4'-glucuronide (ferulic acid-4'-glucuronide), 116%, 204 ± 138 nM more than HNLP (P = 0.001); increased cGMP 14% (P = 0.019); and reduced FRAP 3.1% (P = 0.009).

CONCLUSION

The acute BP difference within 6 h of consumption matched the plasma/saliva nitrate peak, not the slower changes of plasma phenolics. This is the first double-blind controlled dietary intervention demonstrating differential effects on human physiology by consumption of an intact plant food, where compositional differences were obtained by controlling growing conditions, indicating potential opportunities for health claims relating to precision/vertical farming.

CLINICAL TRIAL REGISTRATION

The trial was retrospectively registered on ClinicalTrials.gov, with identifier NCT02701959, on March 8, 2016.

Efficacy and Variability in Plasma Nitrite Levels during Long-Term Supplementation with Nitrate Containing Beetroot Juice

Long-term consumption of beetroot juice on efficacy of converting dietary nitrate to plasma nitrate and nitrite was investigated. Adults were randomized to consume either beetroot juice with 380 mg of nitrate (BR) or a beetroot juice placebo (PL) for 12-weeks. Plasma nitrate and nitrite were measured before and 90-minutes after consuming their intervention beverage. Percent change in nitrite across the 90 min was greater in BR (273.2 ± 39.9%) vs. PL (4.9 ± 36.9%). Long-term consumption of nitrate containing beetroot juice increased fasting nitrate and nitrite plasma levels compared to baseline.

The potential of salivary biomarkers of nutritional status and dietary intake: A Systematic Review

OBJECTIVES

To explore whether nutritional salivary biomarkers could be used to aid nutritional status assessment and/or support traditional dietary assessment methods for patients.

DATA AND SOURCES

Searches were performed using four electronic databases; MEDLINE, EMBASE, Scopus and Web of Science. Trial registers (i.e. Cochrane), grey literature and reference lists were searched.

STUDY SELECTION

Studies which measured nutritional salivary biomarkers related to nutritional status and/or dietary intake outcome were included. No restrictions on participants' age, study design, publication date, setting or health status. Animal studies, non-English language studies, commentaries, and conference abstracts were excluded.

RESULTS

Study titles and abstracts were screened (n = 7982), full-texts assessed (n = 176) and 85 studies were included in a narrative synthesis. The most promising salivary biomarkers for nutritional status included: glucose, where saliva and serum levels were positively correlated in those with type 2 diabetes (T2D), higher salivary calcium levels in post-menopausal women in general and specifically those with lower bone mineral density (BMD), and salivary vitamin D to assess vitamin D status in healthy volunteers. Higher salivary total antioxidant capacity (TAC), nitrate/nitrite and fluoride were observed with increased antioxidant, nitrate/nitrite and fluoride dietary intake, respectively. A meta-analysis found significantly higher mean salivary glucose (n = 12) in T2D compared with healthy controls, but there was substantial heterogeneity (I²=94%) and evidence of publication bias.

CONCLUSIONS

The most promising salivary biomarkers identified in this systematic review were, glucose, vitamin D, calcium, TAC, nitrate/nitrite and fluoride. However, this was based on a small number of studies of varying quality, with many lacking a salivary assay performance assessment.

CLINICAL SIGNIFICANCE

At present, nutritional salivary biomarkers cannot be used alone to assess nutritional status or dietary intake. Further research into the most promising nutritional salivary biomarkers is required.

FOXE1 polymorphisms and chronic exposure to nitrates in drinking water cause metabolic dysfunction, thyroid abnormalities, and genotoxic damage in women

Nitrates in drinking water has been associated to adverse health effects, including changes in glucose and lipid levels, thyroid hormone imbalance and adverse reproductive effects. We analyzed metabolic and thyroid hormone alterations and genotoxic damage in women with chronic exposure to nitrates in drinking water. The concentration of nitrates in drinking water was quantified and according to this parameter, participants were divided into three exposure scenarios. Blood and urine samples were collected from 420 women living in Durango, Mexico and biomarkers were determined. We found nitrates concentrations in drinking water above the permissible limit (>50 mg/L), and an increase in the percentage of methemoglobin (p=0.0001), nitrite in blood plasma and urine (p=0.0001), glucose (p=0.0001), total cholesterol (p=0.001), LDL (p=0.001) and triglycerides (p=0.0001). We also found alterations in TSH (p=0.01), fT3 (p=0.0003), T4T (p=0.01) and fT4 (p=0.0004) hormones. Frequency of subclinical hypothyroidism was 8.33%; differences in FOXE1 (rs965513, rs1867277) genotypes distribution were found and both polymorphisms were associated with a decrease in TSH. A high percentage of micronucleus in binucleate lymphocyte cells was found (35%, p=0.0001). In conclusion, the chronic exposure to nitrates in water for human consumption caused metabolic and hormonal alterations and genotoxic damage in women.

Association of exposures to perchlorate, nitrate, and thiocyanate with allergic symptoms: A population-based nationwide cohort study

Allergic diseases have been one of the leading causes of chronic disorders in the United States. Animal studies have suggested that exposures to perchlorate, nitrate, and thiocyanate could induce allergic inflammation. However, the associations have not been examined among general populations. Here, we investigated data of 7030 participants aged ≥6 years from the National Health and Nutritional Examination Survey (NHANES) 2005-2006. Urinary levels of perchlorate, nitrate, and thiocyanate were measured by ion chromatography combined with electrospray tandem mass spectrometry. Information on allergic symptoms (hay fever, allergy, rash, sneeze, wheeze, eczema, and current asthma) was collected by questionnaire. Allergic sensitization was defined by a concentration ≥150 kU/L for total immunoglobulin E (IgE) levels. The associations were estimated using multivariate-adjusted logistic regression models. A positive association was observed for urinary nitrate and eczema (p < 0.001 for the trend). Compared with quartile 1 (lowest quartile), the odds ratios of eczema with 95% confidence intervals [ORs (95% CIs)] from quartiles 2 to 4 were 1.72 (95% CI, 1.41, 2.09), 1.94 (1.53, 2.47) and 2.10 (1.49, 2.97) for urinary nitrate. In addition, urinary thiocyanate was positively related to sneeze (OR_{Q4 vs. Q1}: 1.25, 95% CI: 1.01, 1.55; p = 0.015 for the trend). However, urinary perchlorate was not correlated with any allergic-related outcome. Additionally, the associations were different among subgroups in a four-level polytomous model. Thus, our results suggested that exposures to nitrate and thiocyanate may be associated with allergic symptoms. Further investigations are warranted to concentrate on the practical strategies to monitor exposure levels and the latent mechanisms of the relationship between exposure and allergy.

A single-dose nitrate-producing dietary supplement affects cardiorespiratory endurance and muscular fitness in healthy men: A randomized controlled pilot trial

Introduction:

The main aim of this pilot study was to examine the effects of a single-dose intervention with a novel nitrate-producing formulation (MagNOVOx™) on biomarkers of cardiorespiratory endurance and muscular fitness in 12 healthy men.

Methods:

The study participants (age = 22.7 ± 2.8 years, height = 184.1 ± 5.7 cm, and weight = 82.5 ± 8.4 kg) were randomly allocated to receive either a single dose of MagNOVOx™ or a placebo (inulin) in a cross-over design. The primary outcome for this study was the change in running time to exhaustion evaluated at baseline (before supplementation) and post-intervention.

Results:

Time to exhaustion was improved after the intervention in 8 out of 11 participants (72.7%) who received MagNOVOx™, and in 1 out of 11 participants (9.1%) who received placebo (p = 0.004), and MagNOVOx™ outcompeted placebo in terms of improving leg press performance (p < 0.01). No significant differences between MagNOVOx™ and placebo were found for blood pressure responses (p > 0.05).

Conclusion:

These promising findings should be further corroborated in medium- and long-term trials, and different populations, while the exact mechanism of MagNOVOx™ requires additional physiological studies.

Acceptability and Feasibility of a 13-Week Pilot Randomised Controlled Trial Testing the Effects of Incremental Doses of Beetroot Juice in Overweight and Obese Older Adults

Nitrate-rich food can increase nitric oxide production and improve vascular and brain functions. This study examines the feasibility of a randomised controlled trial (RCT) testing the effects of prolonged consumption of different doses of dietary nitrate (NO3-) in the form of beetroot juice (BJ) in overweight and obese older participants. A single-blind, four-arm parallel pilot RCT was conducted in 62 overweight and obese (30.4 ± 4 kg/m2) older participants (mean ± standard deviation (SD), 66 ± 4 years). Participants were randomized to: (1) high-NO3- (HN: 2 × 70 mL BJ/day) (2) medium-NO3- (MN: 70 mL BJ/day), (3) low-NO3- (LN: 70 mL BJ on alternate days) or (4) Placebo (PL: 70 mL of NO3--depleted BJ on alternate days), for 13 weeks. Compliance was checked by a daily log of consumed BJ, NO3- intake, and by measuring NO3- and NO2- concentrations in plasma, saliva, and urine samples. Fifty participants completed the study. Self-reported compliance to the interventions was >90%. There were significant positive linear relationships between NO3- dose and the increase in plasma and urinary NO3- concentration (R2 = 0.71, P < 0.001 and R2 = 0.46 P < 0.001, respectively), but relationships between NO3- dose and changes in salivary NO3- and NO2- were non-linear (R2 = 0.35, P = 0.002 and R2 = 0.23, P = 0.007, respectively). The results confirm the feasibility of prolonged BJ supplementation in older overweight and obese adults.

Plasma soluble P-selectin correlates with triglycerides and nitrite in overweight/obese patients with schizophrenia

Background:

Soluble P-selectin (sP-selectin) is associated with risk factors for cardiovascular disease (CVD) but this association has not been evaluated in patients with schizophrenia. This study primarily evaluated the association of sP-selectin with plasma lipids and nitrite (NO₂−) respectively in overweight/obese adults with schizophrenia.

Methods:

One-hundred and six patients with schizophrenia (mean age 32.9 years; 71.60% male) were recruited from a psychiatric hospital. Participants completed a structured interview and provided a fasting blood sample. Body mass index (BMI) was used to divide the sample into normal weight and overweight/obese groups. Pearson’s and partial correlation coefficients (controlling for age, sex, race, education, and inflammation) were calculated to examine the association of sP-selectin with plasma lipids, and NO₂− in the overweight/obese patients (primary analysis), as well as in the normal weight patients and the total sample (exploratory analyses).

Results:

After controlling for potential confounders, sP-selectin positively correlated with triglycerides (r = 0.38, p = 0.01) and NO₂− (r = 0.40, p < 0.01) in the overweight/obese group only.

Conclusions:

Future longitudinal studies should evaluate the utility of sP-selectin as a biomarker of CVD in overweight/obese adults with schizophrenia (for example, by relating sP-selectin to incidence of cardiovascular events).

Inorganic nitrite bioactivation and role in physiological signaling and therapeutics

The bioactivation of inorganic nitrite refers to the conversion of otherwise 'inert' nitrite to the diatomic signaling molecule nitric oxide (NO), which plays important roles in human physiology and disease, notably in the regulation of vascular tone and blood flow. While the most well-known sources of NO are the nitric oxide synthase (NOS) enzymes, another source of NO is the nitrate-nitrite-NO pathway, whereby nitrite (obtained from reduction of dietary nitrate) is further reduced to form NO. The past few decades have seen extensive study of the mechanisms of NO generation through nitrate and nitrite bioactivation, as well as growing appreciation of the contribution of this pathway to NO signaling in vivo. This review, prepared for the volume 400 celebration issue of Biological Chemistry, summarizes some of the key reactions of the nitrate-nitrite-NO pathway such as reduction, disproportionation, dehydration, and oxidative denitrosylation, as well as current evidence for the contribution of the pathway to human cardiovascular physiology. Finally, ongoing efforts to develop novel medical therapies for multifarious conditions, especially those related to pathologic vasoconstriction and ischemia/reperfusion injury, are also explored.

Effects of diets high in animal or plant protein on oxidative stress in individuals with type 2 diabetes: A randomized clinical trial

High-protein diet is a promising strategy for diabetes treatment supporting body weight control, improving glycaemic status, cardiovascular risk factors and reducing liver fat. Here, we investigated effects of diets high in animal (AP) or plant (PP) protein on oxidative stress and antioxidant status in individuals with type 2 diabetes (T2DM). 37 obese individuals (age 64.3 ± 1.0 years) with T2DM were randomized to an isocaloric diet (30 energy(E)% protein, 30 E% fat and 40 E% carbohydrates) rich in AP or PP for 6 weeks. Markers of oxidative and nitrosative stress and antioxidant status in plasma and nitrate/nitrite levels in urine were assessed. Gene expression in subcutaneous adipose tissue (SAT) was analysed by RNA-Seq and real-time PCR. Both AP and PP diets similarly reduced plasma levels of malondialdehyde (PAP = 0.003, PPP = 1.6 × 10-4) and protein carbonyls (PAP = 1.2 × 10-4, PPP = 3.0 × 10-5) over 6 weeks. Nitrotyrosine (NT) increased upon both AP and PP diets (PAP = 0.005, PPP = 0.004). SAT expression of genes involved in nitric oxide (NO) and oxidative stress metabolism and urine NO metabolite (nitrate/nitrite) levels were not changed upon both diets. Plasma levels of carotenoids increased upon PP diet, whereas retinol, alpha- and gamma-tocopherol slightly decreased upon both diets. AP and PP diets similarly improve oxidative stress but increase nitrosative stress markers in individuals with T2DM. Mechanisms of the NT regulation upon high-protein diets need further investigation.

Environmental exposure to perchlorate, nitrate, and thiocyanate in relation to obesity: A population-based study

BACKGROUND

Perchlorate, nitrate, and thiocyanate are well-known thyroid disrupters and may contribute to changes in body weight. However, the associations between environmental exposure to these chemicals and obesity-related outcomes remain unclear.

OBJECTIVES

We aim to examine the urinary levels of perchlorate, nitrate, and thiocyanate and their associations with obesity and abdominal obesity in the U.S.

METHODS

Here, we investigated the data of 16,265 adults aged 20-85 years from the National Health and Nutritional Examination Survey (NHANES) in 2001-2014. Urinary levels of perchlorate, nitrate, and thiocyanate were measured by ion chromatography combined with electrospray tandem mass spectrometry. Obesity and abdominal obesity were defined by the body mass index and waist circumference, respectively. Logistic regression models were used to estimate the associations.

RESULTS

Overall, 5794 (35.6%) cases of obesity and 9090 cases (55.9%) of abdominal obesity were observed among the participants. In multivariable-adjusted logistic regression models, urinary nitrate was inversely associated with obesity (p = 0.0022 for trend), while urinary thiocyanate was positively related to obesity (p < 0.001 for trend). Compared with the lowest quartile, the odds ratios with 95% confidence intervals (CIs) across increasing quartiles were 0.95 (95% CI, 0.83-1.08), 0.88 (0.75-1.03), and 0.74 (0.60-0.90) for urinary nitrate and 1.31 (1.16-1.48), 1.53 (1.36-1.73), and 1.73 (1.47-2.03) for urinary thiocyanate. Urinary perchlorate was not correlated with obesity. Similar associations were also found between exposure to these chemicals and abdominal obesity.

CONCLUSIONS

A higher exposure to urinary nitrate was associated with a lower risk of obesity, while a positive association was observed for urinary thiocyanate. These findings emphasize the need to longitudinally evaluate environmental exposure to perchlorate, nitrate, and thiocyanate with respect to their effect on obesity in humans.

A Clinician's Guide to Healthy Eating for Cardiovascular Disease Prevention

Despite continued advances in health care, the cardiovascular disease (CVD) mortality rate has plateaued in recent years and appears to be trending upward. Poor diet is a leading cause of obesity and type 2 diabetes mellitus, which are leading contributors to CVD morbidity and mortality. Although dietary modification is a cornerstone of CVD prevention, implementation in clinical practice is limited by inadequate formal training in nutrition science. In this report, we review the individual components of a heart-healthy diet, evidence-based dietary recommendations, and the impact of diet on CVD risk factor prevention and management. Furthermore, we examine the unique difficulties of dietary counseling in low-socioeconomic-status environments and provide an evidence-based approach to better serve these populations. We utilized PubMed searches in adults with no date restriction with the following search terms: "carbohydrate," "fat," protein," "DASH," "Mediterranean," "plant-based," "vegetarian," "cardiovascular disease," "obesity," "weight loss," "diabetes," "socioeconomic status," and "race." In this review, we demonstrate that patients should focus on implementing a general diet plan that is high in fruits, whole grains, legumes, and nonstarchy vegetables while low in trans-fats, saturated fats, sodium, red meat, refined carbohydrates, and sugar-sweetened beverages. The Dietary Approaches to Stop Hypertension, Mediterranean, and vegetarian diets have the most evidence for CVD prevention. Clinicians should understand the barriers that patients may face in terms of access to healthy dietary choices. Further research is needed to determine the dietary changes that are most economically, socioculturally, and logistically feasible to reduce these barriers. Improvement in diet is a public health priority that can lead to a significant population-level reduction in CVD morbidity and mortality. It is imperative that clinicians understand current dietary practice guidelines and implement evidence-based dietary counseling in those at high risk for CVD.

Montmorency cherry supplement does not affect aerobic exercise performance in healthy men

Aim: To determine the effects of short-term Montmorency cherry (MC) supplementation upon exercise performance, total blood nitrate levels, muscle oxygenation, and slow-component [Formula: see text]O₂ kinetics. Methods: Twelve healthy male participants ingested a MC or placebo (PL) supplement in a randomized cross-over fashion over a six day period then cycled at a power output achieved at 70% of [Formula: see text]O₂ peak for a maximum of 30 minutes or until exhaustion. Near-Infrared Spectroscopy sensors were used to determine muscle oxygenation. Blood was collected one hour post-supplement consumption on day one, day six, and one hour post-exercise. Results: All results are presented as mean ± SEM. Blood nitrate (μM/L) levels were not different one hour post-ingestion (MC = 8.30 ± 2.15, PL = 8.18 ± 1.86), following six days of supplementation (MC = 9.14 ± 1.89, PL = 7.24 ± 1.75) or one hour post-exercise (MC = 9.63 ± 1.61, PL = 7.97 ± 1.92) for treatment F = 0.26, p = 0.62; for time F = 0.45, p = 0.64; or treatment by time interaction F = 2.28, p = 0.13. Muscle oxygenation was not different between treatments for the right or left vastus lateralis, F = 0.68, p = 0.81 nor was time to respiratory compensation point (minutes) (MC = 18.40 ± 1.48, PL = 17.16 ± 1.78) F = 0.52, p = 0.60. MC supplement ingestion does not alter blood nitrate levels. Conclusion: Short-term MC ingestion does not increase muscle oxygenation during cycling exercise nor does it change slow-component [Formula: see text]O₂ kinetics.

Estimation and Validation of Dietary Nitrate and Nitrite Intake in Iranian Population

BACKGROUND

The aim of this study was calibration of a nitrate (NO₃)/nitrite (NO₂) database for estimated its dietary intakes.

METHODS

Overall, 250 healthy Tehranian adults were assessed in 2015 for dietary intakes of NO₃ and NO₂ and its serum and urine concentration. Food composition values for NO₃ and NO₂ were derived from a recent survey conducted on frequently consumed food items among Iranians. The correlation of dietary intakes of NO₃/NO₂ and its urinary and serum values was evaluated.

RESULTS

Mean (±SD) intakes of dietary NO₃ and NO₂ were 505±160 and 7.7±2.2 mg/d, respectively. The correlation coefficient of intake and urinary NO₃ was 0.83 (95% CI=0.56-0.91) and 0.57 (95% CI=0.49-0.67) in men and women, respectively. A moderate agreement was also observed between NO₂ intake and its urinary levels (r=0.27, 95% CI=0.13-0.37, and 0.29, 95% CI=0.17-0.41, in men and women, respectively).

CONCLUSION

Using a national database of NO₃ and NO₂ content of food items along with a valid food frequency questionnaire could provide a valid estimation of dietary intakes of NO₃ in the target population.

Assessment, mapping, and management of health risk from nitrate accumulation in onion for Iranian population

Excess accumulation of nitrate in vegetable crops is normally related to the excessive use of nitrogen fertilizers applied in agricultural fields. This study was performed to evaluate the level of nitrate concentration in onion production in Isfahan province of Iran and the potential health risks associated with high level of nitrate in this crop, as an example of a case-study. The risk was estimated by using the United States Environmental Protection Agency (USEPA) method and presented as risk maps. Additionally, the impact of an improved fertilizer management practice in selected vulnerable fields for reducing nitrate concentration in onion production was evaluated. For this assessment, four different onion fields in which onion bulb nitrate concentration was higher than the safety level (70 mg kg^-1 FW), provided by Welch (2003) in a survey study, were chosen. The risk maps showed that despite higher risk possibility in adults, in comparison with children, all values were lower than the acceptable level. Further, the split application of nitrogen fertilizers in all fields significantly reduced plant nitrate concentration with no reduction in yield and even observed increase in the overall economic yield production. Therefore, considering crop yields and nitrate accumulation impacts, improved nitrogen management could provide an opportunity to promote onion crop production while reducing negative health effects in high-risk regions in Isfahan province of Iran.

Association of plasma nitrite levels with obesity and metabolic syndrome in the Old Order Amish

OBJECTIVES

Plasma nitrite is a metabolite of nitric oxide and reflects endogenous nitric oxide synthase (NOS) activity. Although plasma nitrites were previously linked with obesity and metabolic syndrome (MetS), the direction of association remains inconsistent, possibly due to sample heterogeneity. In a relatively homogeneous population, we hypothesized that nitrite levels will be positively associated with overweight/obesity and MetS.

METHODS

Fasting nitrite levels were measured in 116 Old Order Amish (78% women). We performed age-and-sex-adjusted ancovas to compare nitrite levels between three groups (a) overweight/obese(-)MetS(-), (b) overweight/obese(+)MetS(-) and (c) overweight/obese(+)MetS)(+). Multivariate linear regressions were conducted on nitrite associations with continuous metabolic variables, with successive adjustments for demographics, body mass index, C-reactive protein and neopterin.

RESULTS

Nitrite levels were higher in the obese/overweight(+)MetS(+) group than in the other two groups (p < 0.001). Nitrites were positively associated with levels of triglycerides (p < 0.0001), total cholesterol (p = 0.048), high-density lipoprotein/cholesterol ratio (p < 0.0001) and fasting glucose (p < 0.0001), and negatively correlated with high-density lipoprotein-cholesterol (p < 0.0001). These associations were robust to adjustments for body mass index and inflammatory markers.

CONCLUSION

Further investigation of the connection between obesity/MetS and plasma nitrite levels may lead to novel dietary and pharmacological approaches that ultimately may contribute to reducing the increasing burden of obesity, MetS and cardiovascular morbidity and mortality.

Potential health impacts from different vegetable nitrate intake scenarios and providing strategies to manage the risks for Iranian population

Health risk from nitrate was predicted for different scenarios of vegetable consumption and nitrate contents in Iran. Finally, certain management scenarios were presented for nitrate risk mitigation under worst-case scenario considering each vegetable contribution in nitrate intake. Two fruit (bell pepper and tomato) and two leafy vegetables (lettuce and mint) were sampled in a combined randomized method from fields, greenhouses, and markets of Isfahan province, Iran during October to December 2015. To assess the potential health impacts of nitrate from the vegetable ingestion, the present status and three different scenarios of increasing vegetable consumption and/or increasing plant nitrate concentrations were considered. Two management scenarios for reducing the total nitrate intake below the allowable values were predicted. By increasing vegetable consumption under scenario 1 and nitrate concentration under scenario 3, the total hazard quotient (THQs) was increased, although the highest increase (12-fold) in the THQs was provided by lettuce. Health risk from nitrate for sensitive groups was effectively reduced by a 70% decrease in lettuce nitrate concentration. In the second management scenario, decreasing upper nitrate concentrations in the other sources (except lettuce) by 30% declined nitrate intake in children (< 6 years old) and boys (7-14 years old) below acceptable daily intake (ADI). By taking into account the increases in the amounts of consumption and nitrate in vegetables at different scenarios, it was revealed that the critical factor for a high dietary exposure to nitrate is not the absolute amount of vegetables consumed but the type of vegetable (lettuce) and the concentration of nitrate related to the conditions of production. Therefore, to manage any risks to human health from dietary nitrate exposure resulting from vegetable consumption, focus on lettuce instead of taking other vegetables equally into account is needed.

Total antioxidant capacity of the diet modulates the association between habitual nitrate intake and cardiovascular events: A longitudinal follow-up in Tehran Lipid and Glucose Study

Background

Considering the lack of data on the association between habitual dietary intakes of nitrate (NO₃⁻) and nitrite (NO₂⁻) and cardiovascular events, we assessed possible effects of dietary NO₃⁻ and NO₂⁻, in the context of total antioxidant capacity (TAC) of the diet, with the risk of cardiovascular (CVD) outcomes.

Methods

Adult men and women without CVD (n = 2369) were recruited from the Tehran Lipid and Glucose Study and were followed for a mean of 6.7 years. Dietary NO₃⁻ and NO₂⁻ intakes, as well as dietary TAC and nitric oxide (NO) index were assessed at baseline (2006–2008). Multivariable-adjusted Cox proportional hazards regression models were used to estimate risk of CVD above and below median of dietary intakes of NO₃⁻/NO₂⁻ and dietary TAC and NO index. Due to a significant interaction between NO₃⁻/NO₂⁻ intake and TAC, stratified analyses were done for < and ≥ median dietary TAC.

Results

Daily mean (SD) dietary NO₃⁻ and NO₂⁻ intakes were 460 (195) and 9.5 (3.9) mg; mean (SD) dietary TAC and NO index was 1406 (740) and 338 (197) μmol trolox equivalent (TE)/100 g. In subjects with lower dietary TAC, higher intake of NO₃⁻ (≥ 430 mg/d) was accompanied with an increased risk of CVD (HR = 3.28, 95% CI = 1.54–6.99). There were no significant associations between dietary intakes of NO₂⁻, TAC of the diet and NO index with the occurrence of CVD events during the study follow-up.

Conclusion

High habitual intake of NO₃⁻, in the context of low TAC of the food, may be associated with the risk of CVD outcomes.

Nitrite-induced acute kidney injury with secondary hyperparathyroidism: Case report and literature review

RATIONALE

Acute kidney injury (AKI) with hyperparathyroidism caused by nitrite was rare, and renal function and parathyroid hormone (PTH) decreased to normal range after therapy.

PATIENT CONCERNS

Acute kidney injury was diagnosed in a 40-year-old male with hyperparathyroidism and cyanosis of his hands and both forearms.

DIAGNOSES

The patient ate some recently pickled vegetables, and he experienced nausea, vomiting and diarrhoea without oliguria or anuria; Additionally, his hands and both forearms had a typical blue ash appearance. After admission, the laboratory findings indicated theincreasing serum creatinine (Scr) and parathyroid hormone (PTH). He was diagnosed as acute kidney injury with hyperparathyroidism caused by nitrite.

INTERVENTIONS

The patient stopped eating the pickled vegetables and was given rehydration, added calories and other supportive therapy without any glucocorticoids.

OUTCOMES

According to his clinical manifestations, laboratory findings and imaging results, the patient was diagnosed with acute kidney injury with secondary hyperparathyroidism. He was given symptomatic supportive care therapy. After one week, the serum creatinine, parathyroid hormone (PTH), hypercalcemia, hyperphosphatemia, proteinuria, and urine red blood cell values decreased to normal range.

LESSONS

Nitrite-induced acute kidney injury with secondary hyperparathyroidism was relatively rare. After therapy, the function of the kidney and parathyroid returned to normal. This case suggests that detailed collection of medical history, physical examination and correct symptomatic treatment is very important.

Trending Cardiovascular Nutrition Controversies

The potential cardiovascular benefits of several trending foods and dietary patterns are still incompletely understood, and nutritional science continues to evolve. However, in the meantime, a number of controversial dietary patterns, foods, and nutrients have received significant media exposure and are mired by hype. This review addresses some of the more popular foods and dietary patterns that are promoted for cardiovascular health to provide clinicians with accurate information for patient discussions in the clinical setting.

Re-evaluation of sodium nitrate (E 251) and potassium nitrate (E 252) as food additives

The Panel on Food Additives and Nutrient Sources added to Food (ANS) provided a scientific opinion re-evaluating the safety of sodium nitrate (E 251) and potassium nitrate (E 252) when used as food additives. The current acceptable daily intakes (ADIs) for nitrate of 3.7 mg/kg body weight (bw) per day were established by the SCF (1997) and JECFA (2002). The available data did not indicate genotoxic potential for sodium and potassium nitrate. The carcinogenicity studies in mice and rats were negative. The Panel considered the derivation of an ADI for nitrate based on the formation of methaemoglobin, following the conversion of nitrate, excreted in the saliva, to nitrite. However, there were large variations in the data on the nitrate-to-nitrite conversion in the saliva in humans. Therefore, the Panel considered that it was not possible to derive a single value of the ADI from the available data. The Panel noticed that even using the highest nitrate-to-nitrite conversion factor the methaemoglobin levels produced due to nitrite obtained from this conversion would not be clinically significant and would result to a theoretically estimated endogenous N-nitroso compounds (ENOC) production at levels which would be of low concern. Hence, and despite the uncertainty associated with the ADI established by the SCF, the Panel concluded that currently there was insufficient evidence to withdraw this ADI. The exposure to nitrate solely from its use as a food additive was estimated to be less than 5% of the overall exposure to nitrate in food based on a refined estimated exposure scenario. This exposure did not exceed the current ADI (SCF, 1997). However, if all sources of exposure to dietary nitrate are considered (food additive, natural presence and contamination), the ADI would be exceeded for all age groups at the mean and the highest exposure.

Re-evaluation of potassium nitrite (E 249) and sodium nitrite (E 250) as food additives

The Panel on Food Additives and Nutrient Sources added to Food (ANS) provided a scientific opinion re-evaluating the safety of potassium nitrite (E 249) and sodium nitrite (E 250) when used as food additives. The ADIs established by the SCF (1997) and by JECFA (2002) for nitrite were 0-0.06 and 0-0.07 mg/kg bw per day, respectively. The available information did not indicate in vivo genotoxic potential for sodium and potassium nitrite. Overall, an ADI for nitrite per se could be derived from the available repeated dose toxicity studies in animals, also considering the negative carcinogenicity results. The Panel concluded that an increased methaemoglobin level, observed in human and animals, was a relevant effect for the derivation of the ADI. The Panel, using a BMD approach, derived an ADI of 0.07 mg nitrite ion/kg bw per day. The exposure to nitrite resulting from its use as food additive did not exceed this ADI for the general population, except for a slight exceedance in children at the highest percentile. The Panel assessed the endogenous formation of nitrosamines from nitrites based on the theoretical calculation of the NDMA produced upon ingestion of nitrites at the ADI and estimated a MoE > 10,000. The Panel estimated the MoE to exogenous nitrosamines in meat products to be < 10,000 in all age groups at high level exposure. Based on the results of a systematic review, it was not possible to clearly discern nitrosamines produced from the nitrite added at the authorised levels, from those found in the food matrix without addition of external nitrite. In epidemiological studies there was some evidence to link (i) dietary nitrite and gastric cancers and (ii) the combination of nitrite plus nitrate from processed meat and colorectal cancers. There was evidence to link preformed NDMA and colorectal cancers.

Impaired flow-mediated dilation in hospitalized patients with community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is complicated by cardiovascular events as myocardial infarction and stroke but the underlying mechanism is still unclear. We hypothesized that endothelial dysfunction may be implicated and that endotoxemia may have a role.

METHODS

Fifty patients with CAP and 50 controls were enrolled. At admission and at discharge, flow-mediated dilation (FMD), serum levels of endotoxins and oxidative stress, as assessed by serum levels of nitrite/nitrate (NOx) and isoprostanes, were studied.

RESULTS

At admission, a significant difference between patients with CAP and controls was observed for FMD (2.1±0.3 vs 4.0±0.3%, p<0.001), serum endotoxins (157.8±7.6 vs 33.1±4.8pg/ml), serum isoprostanes (341±14 vs 286±10 pM, p=0.009) and NOx (24.3±1.1 vs 29.7±2.2μM). Simple linear correlation analysis showed that serum endotoxins significantly correlated with Pneumonia Severity Index score (Rs=0.386, p=0.006). Compared to baseline, at discharge CAP patients showed a significant increase of FMD and NOx (from 2.1±0.3 to 4.6±0.4%, p<0.001 and from 24.3±1.1 to 31.1±1.5μM, p<0.001, respectively) and a significant decrease of serum endotoxins and isoprostanes (from 157.8±7.6 to 55.5±2.3pg/ml, p<0.001, and from 341±14 to 312±14 pM, p<0.001, respectively). Conversely, no changes for FMD, NOx, serum endotoxins and isoprostanes were observed in controls between baseline and discharge. Changes of FMD significantly correlated with changes of serum endotoxins (Rs=-0.315; p=0.001).

CONCLUSIONS

The study provides the first evidence that CAP is characterized by impaired FMD with a mechanism potentially involving endotoxin production and oxidative stress.

Low dose dietary nitrate improves endothelial dysfunction and plaque stability in the ApoE-/- mouse fed a high fat diet

BACKGROUND

Nitric oxide (NO) is an important vascular signalling molecule. NO is synthesised endogenously by endothelial nitric oxide synthase (eNOS). An alternate pathway is exogenous dietary nitrate, which can be converted to nitrite and then stored or further converted to NO and used immediately. Atherosclerosis is associated with endothelial dysfunction and subsequent lesion formation. This is thought to arise due to a reduction in the bioavailability and/or bioactivity of endogenous NO.

AIM

To determine if dietary nitrate can protect against endothelial dysfunction and lesion formation in the ApoE^-/- mouse fed a high fat diet (HFD).

METHODS AND RESULTS

ApoE^-/- fed a HFD were randomized to receive (i) high nitrate (10mmol/kg/day, n=12), (ii) moderate nitrate (1mmol/kg/day, n=8), (iii) low nitrate (0.1mmol/kg/day, n=8), or (iv) sodium chloride supplemented drinking water (control, n=10) for 10 weeks. A group of C57BL6 mice (n=6) received regular water and served as a healthy reference group. At 10 weeks, ACh-induced vessel relaxation was significantly impaired in ApoE^-/- mice versus C57BL6. Mice supplemented with low or moderate nitrate showed significant improvements in ACh-induced vessel relaxation compared to ApoE^-/- mice given the high nitrate or sodium chloride. Plaque collagen expression was increased and lipid deposition reduced following supplementation with low or moderate nitrate compared to sodium chloride, reflecting increased plaque stability with nitrate supplementation. Plasma nitrate and nitrite levels were significantly increased in all three groups fed the nitrate-supplemented water.

CONCLUSION

Low and moderate dose nitrate significantly improved endothelial function and atherosclerotic plaque composition in ApoE^-/- mice fed a HFD.

The Association of Dietary l-Arginine Intake and Serum Nitric Oxide Metabolites in Adults: A Population-Based Study

This study was conducted to investigate whether regular dietary intake of l-arginine is associated with serum nitrate + nitrite (NOx). In this cross-sectional study, 2771 men and women, who had participated in the third examination of the Tehran Lipid and Glucose Study (2006–2008), were recruited. Demographics, anthropometrics and biochemical variables were evaluated. Dietary data were collected using a validated 168-food item semi-quantitative food frequency questionnaire and dietary intake of l-arginine was calculated. To determine any association between dietary l-arginine and serum NOx, linear regression models with adjustment for potential confounders were used. Mean age of participants (39.2% men) was 45.9 ± 15.9 years. After adjustment for all potential confounding variables, a significant positive association was observed between l-arginine intake and serum NOx concentrations in the fourth quartile of l-arginine (β = 6.63, 95% CI = 4.14, 9.12, p for trend = 0.001), an association stronger in women. Further analysis, stratified by age, body mass index and hypertension status categories, showed a greater association in middle-aged and older adults (β = 9.12, 95% CI = 3.99, 13.6 and β = 12.1, 95% CI = 6.48, 17.7, respectively). l-arginine intakes were also strongly associated with serum NOx levels in overweight and obese subjects in the upper quartile (β = 10.7, 95% CI = 5.43, 16.0 and β = 11.0, 95% CI = 4.29, 17.5); a greater association was also observed between l-arginine intakes and serum NOx in non-hypertensive (HTN) compared to HTN subjects (β = 2.65, 95% CI = 2.1–3.2 vs. β = 1.25, 95% CI = −1.64–4.15). Dietary l-arginine intakes were associated to serum NOx and this association may be affected by sex, age, body mass index, and hypertension status.

The effect of prolonged dietary nitrate supplementation on atherosclerosis development

BACKGROUND

Short term dietary nitrate or nitrite supplementation has nitric oxide (NO)-mediated beneficial effects on blood pressure and inflammation and reduces mitochondrial oxygen consumption, possibly preventing hypoxia. As these processes are implicated in atherogenesis, dietary nitrate was hypothesized to prevent plaque initiation, hypoxia and inflammation.

AIMS

Study prolonged nitrate supplementation on atherogenesis, hypoxia and inflammation in low density lipoprotein receptor knockout mice (LDLr(-/-)).

METHODS

LDLr(-/-) mice were administered sodium-nitrate or equimolar sodium-chloride in drinking water alongside a western-type diet for 14 weeks to induce atherosclerosis. Plasma nitrate, nitrite and hemoglobin-bound nitric oxide were measured by chemiluminescence and electron parametric resonance, respectively.

RESULTS

Plasma nitrate levels were elevated after 14 weeks of nitrate supplementation (NaCl: 40.29 ± 2.985, NaNO3: 78.19 ± 6.837, p < 0.0001). However, prolonged dietary nitrate did not affect systemic inflammation, hematopoiesis, erythropoiesis and plasma cholesterol levels, suggesting no severe side effects. Surprisingly, neither blood pressure, nor atherogenesis were altered. Mechanistically, plasma nitrate and nitrite were elevated after two weeks (NaCl: 1.0 ± 0.2114, NaNO3: 3.977 ± 0.7371, p < 0.0001), but decreased over time (6, 10 and 14 weeks). Plasma nitrite levels even reached baseline levels at 14 weeks (NaCl: 0.7188 ± 0.1072, NaNO3: 0.9723 ± 0.1279 p = 0.12). Also hemoglobin-bound NO levels were unaltered after 14 weeks. This compensation was not due to altered eNOS activity or conversion into peroxynitrite and other RNI, suggesting reduced nitrite formation or enhanced nitrate/nitrite clearance.

CONCLUSION

Prolonged dietary nitrate supplementation resulted in compensation of nitrite and NO levels and did not affect atherogenesis or exert systemic side effects.