Introduction
Arterial hypertension (AH) is one of clinical manifestations of advanced stages of endothelial dysfunction attributed to dysregulation of the vascular tone and resulting in a sustained elevation of blood pressure [1]. According to World Health Organization, AH affects approximately 20% of the global population [2]. In Russian Federation, the prevalence of AH was 53.9% in 2023 [3]. Appropriate management of AH is needed to prevent high mortality due to chronic and acute cardiovascular and cerebrovascular disorders. Standard cardiovascular risk factors include hyperlipidemia, diabetes mellitus, AH, and smoking, which are associated with altered nitric oxide (NO) production, endothelial dysfunction, and eventual development of atherosclerotic lesions.
NO is one of the key paracrine and endocrine mediators responsible for normal regulations of the vascular tone, and NO deficiency may be due to reduced synthesis of NO from L-arginine or NO inactivation by reactive oxygen species produced in endothelial dysfunction or inflammation [4]. Endothelial dysfunction is one of the early stages of various cardiovascular diseases and is manifested as AH, metabolic syndrome, inflammation, or obesity [4].
The results of a number of clinical studies indicate that decreased levels of NO can be replenished by various dietary supplements providing exogenous sources of nitrate and nitrite ions (NOx) that can be directly reduced to NO through various metabolic pathways or indirectly enhance endogenous NO production or stability [5-8]. Regular consumption of exogenous NOx normalizes circulating and tissue levels of NO [6-8]. Raw beetroot is known to have a very high NOx content naturally [9]. Thus, beetroot was used to develop dry powder "BETA-NO●-BOOST" (Figure 1) that was used as a natural source of NOx in the present pilot clinical trial. Clinical trials of beetroot-derived nutritional supplements in Russia have not been reported previously. Thus, the present study aimed to evaluate the effect of beetroot powder on serum lipids and inflammatory and metabolic markers.
Figure 1. The Label of beetroot powder named “BETA-NO-BOOST” (in Russian).
Material and Methods
Patients
The present pilot study enrolled 22 male patients based on the following inclusion criteria: male; 18-60 years of age; diagnosed with early-stage AH or compensated AH, with blood pressure levels determined by 24-h blood pressure monitoring while on a stable regimen of antihypertensive therapy; and signed informed consent for participation in the trial. Participants consumed a daily oral dose of 20 g of beetroot powder equivalent to 650-700 mg NOx for 7 days. All participants were instructed to abstain from consumption of certain vegetables (beetroot, green leafy vegetables and salads, and cabbage), preserved foods, and processed meat products for at least 12 h prior to blood sampling. The study was approved by Local Independent Ethic Committee of National Medical Research Center for Therapy and Preventive Medicine compliant with the ethical principles of the 1964 Helsinki Declaration; Approval No: 01-07124; date of registration: 28.10.2024.
The following exclusion criteria were applied: intolerance to beetroot powder; diabetes mellitus; acute or exacerbated chronic diseases; and voluntary withdrawal from the study.
Study Protocol
Patients ingested a daily oral dose of 20 g of dry beetroot powder, which was equivalent to 650-700 mg of NOx as determined previously [9], over 7 days. The participants continued their regular previously prescribed antihypertensive therapy. Blood samples were collected from the cubital vain at baseline and endpoint for analysis.
Beetroot Powder
Finely dispersed beetroot powder (BETA-NO●-BOOST) was produced by infrared dehydration and subsequent milling and provided by the Scientific and Production Center for Healthy Nutrition Technologies of Razumovsky Saratov State Medical University commissioned by National Medical Research Center for Therapy and Preventive Medicine. NOx concentrations in were quantified as described previously [9] to assess NOx equivalent of the daily dose [6].
Biochemical Assays
Blood samples were collected after fasting from the cubital vein into Vacutainer tubes (Becton Dickinson, Crawley, UK). Serum was obtained by centrifugation at 1,000 g for 20 min. at room temperature, aliquoted, and stored at -24°C until analysis.
Erythrocyte and platelet counts were determined in whole blood using an automated MEK-8222K hematology analyzer (Nihon Kohden, Japan) and Isotonac-3, Hemolynac-3N, and Hemolynac-5 reagents supplied by Nihon Kohden.
Levels of total cholesterol, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were determined enzymatically using an Architect C650-7000 analyzer (Abbott, USA) and the corresponding reagent kits. Triglycerides were measured by the glycerophosphate oxidase method. High-density lipoprotein (HDL) cholesterol was quantified using the detergent-accelerated homogeneous enzymatic method. Creatinine was assayed by the Jaffe method. C-reactive protein (CRP) was measured by immunoturbidimetry. Glucose was determined by the hexokinase method. All assay kits were provided by Abbott (USA). Low-density lipoprotein (LDL) cholesterol was estimated using the Friedewald equation.
Serum NOx levels were assayed as described previously [9].
Statistical Analysis
The data were analyzed using SPSS IBM Statistics version 23 (USA) and Statistica version 7 (USA). Paired values at baseline and endpoint for continuous variables were not normally distributed, and the differences were thus evaluated by non-parametric Wilcoxon signed rank test. Data are presented as the median and 25-75percentile range. A p-value of <0.05 was considered statistically significant.
Results
The present study enrolled 22 male patients 46.5 (40.0-52.0) years of age, with a low (2.23%) cardiovascular risk according to SCORE (Systematic COronary Risk Evaluation). Patients (N=8) were prescribed antihypertensive therapy, including angiotensin II receptor blockers (36.3%; N=8), and diuretics (9%; N=2), and lipid-lowering medications, including statins (13.6%; N=3) and ezetimibe (4.5%; N=1). None of the participants were treated with anticoagulants.
Almost all biochemical parameters in the serum were within normal reference ranges at baseline, with the exception of slightly elevated total and LDL cholesterol levels (Table 1). Consumption of beetroot powder for 7 days resulted in a 2.4-fold increase in serum NOx (Table 1). The levels of total cholesterol were decreased by 0.58 mmol/L (by 10%; P<0.05), and the levels of ALT were decreased by 6.7 U/L (by 18.5%; P<0.05) in all participants. The changes in the total cholesterol and NOx levels were positively correlated with each other (Spearman rank correlation coefficient r=0.5; P=0.04). However, no other correlations between various parameters were observed at baseline or endpoint. The levels of HDL cholesterol and triglycerides were somewhat decreased at endpoint but this trend did not reach significance (P>0.05).
Table 1. Hematological and biochemical parameters of the participants (N=22) at baseline and endpoint after 7-day consumption of beetroot powder at a dose of 20 g/day equivalent to 650-700 mg NOx/day
|
Parameters |
Reference |
Baseline, Median (IQR 25%; 75%) |
Endpoint, Median (IQR 25%; 75%) |
P* |
|
Age (years) |
|
46.5 (40.0; 52.0) |
|
|
|
NOx (µM) |
|
28.92 (22.2; 47.4) |
69.76 (46.23; 105.82) |
0.008 |
|
Total cholesterol (mmol/L) |
<5.0 |
5.91 (4.95; 7.13) |
5.33 (4.62; 6.21) |
0.07 |
|
HDL-cholesterol (mmol/L) |
>1.0 |
1.51 (1.30; 1.68) |
1.36 (1.21; 1.53) |
0.18 |
|
LDL-cholesterol (mmol/L) |
See note1 |
3.92 (3.24; 4.53) |
3.57 (2.97; 4.51) |
0.06 |
|
Triglycerides (mmol/L) |
<1.7 |
1.14 (1.04; 1.38) |
1.09 (0.79; 1.37) |
0.37 |
|
C-reactive protein (mg/L) |
See note2 |
1.28 (0.86; 1.78) |
0.95 (0.51; 1.79) |
0.97 |
|
Creatinine (µmol/L) |
65-110 |
90.00 (82.70; 101.30) |
89.90 (83.35; 95.00) |
0.06 |
More than 50% of the participants demonstrated a significant decrease in inflammatory markers (Table 2), including CRP and leukocyte counts, which were reduced by 1.7- and 1.2-fold in 57% and 62% of the participants, respectively (Table 2). A significant decrease in hemoglobin levels by 5 g/L was observed in 71% of the participants, although the endpoint values remained well within the normal reference range. A decreased in the levels of glucose was observed in 62% of patients.
Table 2. Statistically significant changes in various parameters after 7-day supplementation with beetroot powder
|
Parameter (unit) |
Patients, % |
Baseline, Median (IQR 25%; 75%) |
Endpoint, Median (IQR 25%; 75%) |
P* |
|
HDL-cholesterol (mmol/L) |
62 |
1.56 (1.32; 1.67) |
1.29 (1.16; 1.40) |
0.0008 |
|
LDL-cholesterol (mmol/L) |
57 |
4.23 (3.40; 5.07) |
3.09 (2.93; 3.97) |
0.002 |
|
Triglycerides (mmol/L) |
62 |
1.18 (1.08; 1.53) |
0.89 (0.79; 1.12) |
0.001 |
|
C-reactive protein (mg/L) |
57 |
1.26 (0.97; 2.09) |
0.75 (0.44; 1.17) |
0.002 |
|
Creatinine (µmol/L) |
62 |
100.8 (86.2; 104.1) |
85.8 (81.4; 93.6) |
0.003 |
|
Glucose (mmol/L) |
62 |
6.0 (5.4; 6.5) |
5.7 (5.1; 5.8) |
0.002 |
|
AST (U/L) |
66,6 |
26.50 (23.00; 46.00) |
23.50 (21.00; 40.00) |
0.002 |
|
Leukocytes (× 109/L) |
62 |
7.20 (6.7; 8.00) |
6.00 (5.40; 6.30) |
0.002 |
|
Platelets (cells/µL) |
52 |
250 (191; 288) |
210 (174; 239) |
0.003 |
|
Erythrocytes (× 106/µL) |
52 |
5.10 (4.81; 5.38) |
4.73 (4.7; 5.11) |
0.003 |
|
Hemoglobin (g/L) |
71 |
154.0 (149.0; 162.0) |
149.0 (139.0; 155.0) |
0.001 |
Discussion
This pilot study revealed a 10% decrease in the baseline levels of total cholesterol after 7 days of beetroot powder supplementation in patients with early-stage arterial hypertension. A positive correlation between changes in NOx and cholesterol levels was observed. However, NOx levels are known to be negatively correlated with total and LDL cholesterol levels (r=-0.40; p<0.01; and r=-0.47; p<0.003; respectively) in patients with hypercholesterolemia [10]. Another study demonstrated that prolonged supplementation with dietary nitrate did not influence plasma cholesterol levels [11]. Thus, these associations should be further assessed in an expanded crossover study.
Only certain plant-based nutritional supplements induce a decreased in cholesterol levels. For example, a study that used Lycium barbarum as natural plant-based source of dietary nitrate did not demonstrate an association between consumption of the supplement and cholesterol [12]. Moreover, organic juice from beet leaf and stalk was shown to have a positive effect on lipid profile parameters [13].
Supplementation of obese mice with inorganic nitrate is known to moderately influence carbohydrate and lipid metabolism [14]. In the present study, beetroot powder consumption was associated with a reduction in glucose levels by 0.3 mmol/L in 62% of patients. This finding is consistent with a study of Henstridge et al., which demonstrated that nitrate supplementation is beneficial for glucose metabolism independent of plasma insulin concentration [15].
A decrease in hemoglobin levels in 71% of patients observed in the present study is consistent with a 15% decrease shown in a study in rats treated with a nitrate supplement [16]. Other investigations reported that a similar dose of nitrate modulates tissue oxygen transport in rodents and humans [17, 18]. The mechanism of these changes may involve NO-mediated vasodilation that leads to reduced systemic oxygen demand to eventually attenuate the production of erythropoietin, which controls hemoglobin levels, resulting in downregulation of hemoglobin concentrations in the blood.
Beneficial influence of BETA-NO●-BOOST in the present study included a decrease in inflammatory markers (CRP and leukocyte counts) in more than 50% of the participants. The results of other authors support these findings indicating that nitrate supplementation significantly decreases inflammation and adverse consequences of oxidative stress [19]. This effect is partially mediated by commensal microflora that covert nitrate to NO to reduce the levels of leukocyte and platelet adhesion molecules, including ICAM-1 [19]. Additionally, NOx supplementation modulates intestinal microbiome and enhances antimicrobial activity against certain pathogens, including Helicobacter pylori, Yersinia enterocolitica, and Salmonella enteritidis [19].
Conclusion
Moderate consumption of plant-derived exogenous NOx induced a range of beneficial effects that may contribute to a reduction in cardiovascular risk factors. The findings of the present study demonstrated feasibility of an expanded controlled randomized crossover study. Thus, intake of nitrate-containing plant-based nutritional supplements may be beneficial for prevention and treatment of chronic cardiovascular and inflammatory diseases.
Limitations
The conclusions of the present pilot study are based on relatively small number of participants, and the results require confirmation in an expanded randomized crossover-controlled trial of beetroot powder (BETA-NO●-BOOST).
Ethical approval
The study was approved by Local Independent Ethic Committee of National Medical Research Center for Therapy and Preventive Medicine compliant with the ethical principles of the 1964 Helsinki Declaration; Approval No: 01-07124; date of registration: 28.10.2024.
Funding
This work was supported by the Russian Ministry of Health as part of the scientific work “Development of an algorithm for the clinical application of exogenous sources of nitric oxide (NO-boost) and a regimen for monitoring the level of nitric oxide metabolites in blood serum for the prevention, diagnosis, and treatment of patients with cardiovascular diseases”, No. 124013100892-7, performed at the National Medical Research Center for Therapy and Preventive Medicine in 2024–2026.
Author Contributions
Material collection and processing: N.L. Bogdanova; statistical analysis, manuscript writing, study concept and design: N.G. Gumanova; pilot testing execution, data collection, manuscript editing: K.S. Samatova; pilot testing execution, data collection: A.I. Korolev and V.S. Ososkov; administration: A.Y. Gorshkov and A.R. Kiselev; project supervision: O.M. Drapkina.
Conflict of Interest
The authors declare no conflicts of interest.
- Mordi I, Mordi N, Delles C, Tzemos N. Endothelial dysfunction in human essential hypertension. J Hypertens 2016; 34(8): 1464-1472. https://doi.org/10.1097/HJH.0000000000000965.
- World Health Organization. Global report on hypertension: the race against a silent killer. Global report. September 19, 2023. https://www.who.int/ru/news/item/19-09-2023-first-who-report-details-devastating-impact-of-hypertension-and-ways-to-stop-it.
- Balanova YuA, Drapkina OM, Kutsenko VA, Imaeva AE, Kontsevaya AV, Maksimov SA, et al. Hypertension in the Russian population during the COVID-19 pandemic: sex differences in prevalence, treatment and its effectiveness. Data from the ESSE-RF3 study. Cardiovascular Therapy and Prevention. 2023; 22(8S): 3785. Russian. https://doi.org/10.15829/1728-8650-700-2023-3785.
- Vanhoutte PM, Shimokawa H, Feletou M, Tang EH. Endothelial dysfunction and vascular disease – a 30th anniversary update. Acta Physiol (Oxf) 2017; 219(1): 22-96. https://doi.org/10.1111/apha.12646.
- Clifton P. From sodium intake restriction to nitrate supplementation: Different measures with converging mechanistic pathways? Nutr Metab Cardiovasc Dis 2015; 25(12): 1079-1086. https://doi.org/10.1016/j.numecd.2015.09.008.
- Gumanova NG. The significance of exogenous nitrate and nitrite of plant origin for vascular health. Russian Journal of Preventive Medicine 2024; 27(11): 141-146. Russian. https://doi.org/10.17116/profmed202427111141.
- Gumanova NG. Nitric oxide and its circulating NOx metabolites, their role in human body functioning and cardiovascular death risk prediction (part I). Russian Journal of Preventive Medicine 2021; 24(9): 102-109. Russian. https://doi.org/10.17116/profmed202124091102.
- Gumanova NG. Nitrogen oxide and its circulating NOx metabolites, their role in human body functioning and cardiovascular death risk prediction (Part II). Russian Journal of Preventive Medicine 2021; 24(10): 119-125. Russian. https://doi.org/10.17116/profmed202124101119.
- Bogdanova NL, Gumanova NG, Kiselev AR, Drapkina OM. Pharmacokinetic study and phytochemical analysis of beetroot powder as an initial stage of the development of an NO-boosting formulation as a food supplement with cardioprotective properties and potential donor of nitric oxide. Russ Open Med J 2024; 13: e0410 https://doi.org/10.15275/rusomj.2024.0410.
- Tanaka S, Yashiro A, Nakashima Y, Nanri H, Ikeda M, Kuroiwa A. Plasma nitrite/nitrate level is inversely correlated with plasma low-density lipoprotein cholesterol level. Clin Cardiol 1997; 20(4): 361-365. https://doi.org/10.1002/clc.4960200412.
- Marsch E, Theelen TL, Janssen BJ, Briede JJ, Haenen GR, Senden JM, et al. The effect of prolonged dietary nitrate supplementation on atherosclerosis development. Atherosclerosis 2016; 245: 212-221. https://doi.org/10.1016/j.atherosclerosis.2015.11.031.
- Toh DWK, Xia X, Sutanto CN, Low JHM, Poh KK, Wang JW, et al. Enhancing the cardiovascular protective effects of a healthy dietary pattern with wolfberry (Lycium barbarum): A randomized controlled trial. Am J Clin Nutr 2021; 114(1): 80-89. https://doi.org/10.1093/ajcn/nqab062.
- Gomes APO, Ferreira MA, Camargo JM, Araújo MO, Mortoza AS, Mota JF, et al. Organic beet leaves and stalk juice attenuates HDL-C reduction induced by high-fat meal in dyslipidemic patients: A pilot randomized controlled trial. Nutrition 2019; 65: 68-73. https://doi.org/10.1016/j.nut.2019.03.004.
- Fischer A, Lüersen K, Schultheiß G, de Pascual-Teresa S, Mereu A, Ipharraguerre IR, et al. Supplementation with nitrate only modestly affects lipid and glucose metabolism in genetic and dietary-induced murine models of obesity. J Clin Biochem Nutr 2020; 66(1): 24-35. https://doi.org/10.3164/jcbn.19-43.
- Henstridge DC, Duffy SJ, Formosa MF, Ahimastos AA, Thompson BR, Kingwell BA. Oral nitrate therapy does not affect glucose metabolism in healthy men. Clin Exp Pharmacol Physiol 2009; 36(11): 1086-1092. https://doi.org/10.1111/j.1440-1681.2009.05195.x.
- Ashmore T, Fernandez BO, Evans CE, Huang Y, Branco-Price C, Griffin JL, et al. Suppression of erythropoiesis by dietary nitrate. FASEB J 2015; 29(3): 1102-1112. https://doi.org/10.1096/fj.14-263004.
- Larsen FJ, Schiffer TA, Borniquel S, Sahlin K, Ekblom B, Lundberg JO, et al. Dietary inorganic nitrate improves mitochondrial efficiency in humans. Cell Metab 2011; 13(2): 149-159. https://doi.org/10.1016/j.cmet.2011.01.004.
- Lundberg JO, Weitzberg E, Gladwin MT. The nitrate-nitrite-nitric oxide pathway in physiology and therapeutics. Nat Rev Drug Discov 2008; 7(2): 156-167. https://doi.org/10.1038/nrd2466.
- Rocha BS, Nunes C, Laranjinha J. Tuning constitutive and pathological inflammation in the gut via the interaction of dietary nitrate and polyphenols with host Microbiome. Int J Biochem Cell Biol 2016; 81(Pt B): 393-402. https://doi.org/10.1016/j.biocel.2016.10.021.
Received 21 November 2025, Revised 5 December 2025, Accepted 10 December 2025
© 2025, Russian Open Medical Journal
Correspondence to Anton R Kiselev. Email: antonkis@list.ru.