Effects of Dietary Nitrate Supplementation on Performance during Single and Repeated Bouts of Short-Duration High-Intensity Exercise: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Exploring the therapeutic potential of beetroot juice in patients with peripheral artery disease: A Narrative review

Peripheral artery disease (PAD) is a circulatory disorder caused by atherosclerosis, leading to the narrowing or blockage of peripheral arteries, often affecting the arteries in the lower limbs. This condition can result in intermittent claudication and severe limb ischemia, significantly reducing patients' quality of life. In recent years, increasing evidence suggests that dietary interventions play a crucial role in the prevention and management of PAD, offering a safe and non-invasive treatment option. Beetroot, a natural root vegetable, demonstrates significant health benefits through its various bioactive compounds. It is rich in nitrate and betaine, which are metabolized in the body via the nitrate-nitrite- nitric oxide (NO) pathway, increasing the bioavailability of NO. NO is an important vasodilator that can improve blood flow and lower blood pressure. Additionally, the active compounds in beetroot may further enhance its health effects by altering the activity of the oral microbiome. This review explores the potential therapeutic effects of beetroot juice (BRJ) in the management of PAD. The findings indicate that BRJ can improve exercise performance, lower blood pressure, improve endothelial function, enhance skeletal muscle microvascular function and central autonomic nervous system function. Based on these findings, beetroot and its rich bioactive compounds hold promise as a novel supportive therapy for improving PAD.

Dietary Nitrate Supplementation and Exercise Performance: An Umbrella Review of 20 Published Systematic Reviews with Meta-analyses

BACKGROUND

Dietary nitrate (NO3-) supplementation is purported to benefit exercise performance. However, previous studies have evaluated this nutritional strategy with various performance outcomes, exercise tasks, and dosing regimens, often yielding inconsistent results that limit the generalizability of the findings.

OBJECTIVE

We aimed to synthesize the available evidence regarding the effect of NO3- supplementation on 11 domains of exercise performance.

METHODS

An umbrella review was reported in accordance with the Preferred Reporting Items for Overviews of Reviews guideline. Seven databases (MEDLINE, EMBASE, Cochrane Database, CINAHL, Scopus, SPORTDiscus, and Web of Science) were searched from inception until July 2024. Systematic reviews with meta-analyses comparing NO3- supplementation and placebo-controlled conditions were included. Literature search, data extraction, and methodological quality assessment (A Measurement Tool to Assess Systematic Reviews Assessing the Methodological quality of SysTemAtic Review [AMSTAR-2]) were conducted independently by two reviewers.

RESULTS

Twenty systematic reviews with meta-analyses, representing 180 primary studies and 2672 unique participants, met the inclusion criteria. Our meta-analyses revealed mixed effects of NO3- supplementation. It improved time-to-exhaustion tasks [standardized mean difference (SMD): 0.33; 95% confidence interval (CI) 0.19-0.47] with subgroup analyses indicating more pronounced improvements when a minimum dose of 6 mmoL/day (372 mg/day) and chronic (> 3 days) supplementation protocol was implemented. Additionally, ergogenic effects of NO3- supplementation were observed for total distance covered (SMD: 0.42; 95% CI 0.09-0.76), muscular endurance (SMD: 0.48; 95% CI 0.23-0.74), peak power output (PPO; SMD: 0.25; 95% CI 0.10 to 0.39), and time to PPO (SMD: - 0.76; 95% CI - 1.18, - 0.33). However, no significant improvements were found for other performance outcomes (all p > 0.05). The AMSTAR-2 ratings of most included reviews ranged from low to critically low.

CONCLUSIONS

This novel umbrella review with a large-scale meta-analysis provides an updated synthesis of evidence on the effects of NO3- supplementation across various aspects of exercise performance. Our review also highlights significant methodological quality issues that future systematic reviews in this field should address to enhance the reliability of evidence.

CLINICAL TRIAL REGISTRATION

This study was registered in the International Prospective Register of Systematic Review (PROSPERO) database (registration number: CRD42024577461).

The effect of dietary nitrate supplementation on resistance exercise performance: A dose-response investigation

Dietary nitrate (NO3-) can enhance skeletal muscle contractile function and explosive-type exercise by modulating type II muscle fibers; however, limited attention has been directed at exploring the optimal dosing guidelines and potential performance-enhancing effects of NO3- supplementation during resistance-type exercise. The purpose of our investigation was to examine potential dose-response effects of concentrated NO3--rich beetroot juice on neuromuscular performance during resistance exercise. Eighteen resistance-trained men were assigned in a double-blind, randomized, crossover design, to four conditions to consume beetroot juice containing: negligible NO3- (PL); ~ 6 mmol NO3- (BR-LOW); ~ 12 mmol NO3- (BR-MOD); and ~ 24 mmol NO3- (BR-HIGH). Participants completed 1 set of vertical countermovement jumps (CMJ), 2 sets × 3 repetitions of barbell back squats, and 2 sets × 3 repetitions of barbell bench press 2.5 h post-supplementation. Plasma [NO3-] increased in a dose-dependent manner (P < 0.01). Plasma [nitrite] ([NO2-]) increased in all BR conditions compared to PL (P < 0.05), such that BR-MOD vs. BR-LOW (P < 0.01) and BR-LOW vs. PL (P < 0.01), but BR-HIGH was not different compared to BR-MOD (P > 0.05). Performance was not different between conditions in CMJ, 50% one-repetition maximum (1RM) and 75%1RM back squats, or 50%1RM and 75%1RM bench press (P > 0.05). The change in plasma [NO2-] was significantly correlated with peak power (r = - 0.65, P = 0.003), mean power (r = - 0.52, P = 0.03), and mean velocity (r = - 0.48, P = 0.04) during 50%1RM back squats following BR-LOW vs. PL but not in other conditions (P > 0.05). This study indicates that dietary NO3- does not impact resistance exercise performance at any of the doses assessed in the current study.

Multiday Beetroot Juice Ingestion Improves Some Aspects of Neuromuscular Performance in Semi-Professional, Male Handball Players: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study

The aim of this study was to examine the effects of multiday beetroot juice ingestion on neuromuscular performance in semi-professional, male handball players. Twelve handball players competing in the second Spanish national division received 70 ml of beetroot juice (6.4 mmol of nitrate [NO3-]) or 70 ml of a placebo beetroot juice (0.04 mmol NO3-) for three consecutive days in a randomized, double-blind, crossover manner with a 1-week washout between conditions. Following supplementation in each condition, players completed a neuromuscular test battery involving handball throwing, isometric handgrip strength, countermovement jump, change-of-direction speed, and repeated-sprint assessments, with side effects also measured. Countermovement jump (4.7%; p = .038; Hedge's gav = 0.29) and isometric handgrip strength (7.8%; p = .021; gav = 0.59) were significantly superior with beetroot juice ingestion compared to the placebo. In contrast, nonsignificant differences were evident between conditions for all other neuromuscular performance variables (p > .05; gav = 0.00-0.27). Red urine production was the only side effect, demonstrating a significantly higher prevalence (p = .046) with beetroot juice ingestion. Three days of beetroot juice supplementation may be a useful nutritional strategy in semi-professional, male handball players given its ergogenic benefit to some aspects of neuromuscular performance.

Acute inorganic nitrate ingestion does not impact oral microbial composition, cognitive function, or high-intensity exercise performance in female team-sport athletes

The purpose of this study was to investigate the effects of acute nitrate (NO3-)-rich beetroot juice ingestion on explosive and high-intensity exercise performance, oral microbiota composition, and cognitive flexibility (i.e., function), before and after maximal intermittent running exercise. Fifteen women team-sport athletes were assigned in a randomized, double-blind, crossover design to consume concentrated NO3--depleted beetroot juice (PL; 0.1 mmol NO3-) and NO3--rich beetroot juice (BR; 12.0 mmol NO3-) 2.5 h prior to performing a battery of exercise performance tasks and cognitive testing before and after the Yo-Yo intermittent recovery level 1 (YYIR1) running test. Resting plasma [NO3-] and plasma nitrite ([NO2-]) were elevated following BR (P < 0.001). BR did not impact global composition or relative abundance of taxa in the oral microbiome (P > 0.05) or cognitive flexibility before or after exercise (P > 0.05). There was no significant difference in performance during 20-m (PRE, PL: 4.38 ± 0.27 vs. BR: 4.38 ± 0.32 s; POST, PL: 4.45 ± 0.29 vs. BR: 4.43 ± 0.35 s) and 10-m sprints (PRE, PL 2.78 ± 0.15 vs. BR 2.79 ± 0.18 s; POST, PL: 2.82 ± 0.16 vs. BR: 2.81 ± 0.19 s), isokinetic handgrip dynamometry, medicine ball throw, horizontal countermovement jump, or YYIR1 (PL: 355 ± 163 m vs. BR: 368 ± 184 m) between BR and PL (P > 0.05). These findings indicate that acute dietary NO3- may not influence the oral microbiome, explosive and high-intensity exercise performance, or cognitive function in women team-sport athletes.

Effects of low and high dietary nitrate intake on human saliva, plasma and skeletal muscle nitrate and nitrite concentrations and their functional consequences

Dietary nitrate (NO3-) supplementation has been shown to reduce blood pressure (BP), improve exercise performance, and alter the oral microbiome. Following a "control" diet (CON), we manipulated dietary NO3- intake to examine the effect of a short-term (7-day) low NO3- diet (LOW) followed by a 3-day high NO3- diet (HIGH), compared to a 7-day standard (STD) NO3- diet followed by HIGH, on saliva, plasma, and muscle [NO3-] and nitrite ([NO2-]), BP, and cycling exercise performance in healthy young adults. We also examined the effect of LOW on the oral microbiome. Saliva [NO3-] and [NO2-], and plasma [NO3-] were significantly lower than CON following LOW (all P < 0.05) but there was no change in plasma [NO2-] or muscle [NO3-] and [NO2-] (all P > 0.05). Following HIGH, saliva and plasma [NO3-] and [NO2-], and muscle [NO3-], were significantly elevated above CON, LOW and STD (all P < 0.05), but there was no difference between CON-LOW-HIGH and CON-STD-HIGH (P < 0.05). BP and exercise performance were not altered following LOW (P > 0.05). HIGH significantly reduced systolic and diastolic BP compared to CON when preceded by STD (both P < 0.05) but not when preceded by LOW (P > 0.05). Peak (+4 %) and mean (+3 %) power output during sprint cycling was significantly improved following HIGH (both P < 0.05), with no differences between CON-LOW-HIGH and CON-STD-HIGH (both P > 0.05). LOW altered the oral microbiome composition, including decreases in relative abundances of phylum Proteobacteria and genus Neisseria. The findings indicate that a short-term low NO3- diet lowers plasma but not skeletal muscle [NO3-]. The maintenance of plasma [NO2-] and muscle [NO3-] and [NO2-] following LOW may be indicative of their importance to biological functions, including BP regulation and exercise performance.

The Top 5 Can't-Miss Sport Supplements

Background/Objectives: Sports supplements have become popular among fitness enthusiasts for enhancing the adaptive response to exercise. This review analyzes five of the most effective ergogenic aids: creatine, beta-alanine, nitrates, caffeine, and protein. Methods: We conducted a narrative review of the literature with a focus on the sport supplements with the most robust evidence for efficacy and safety. Results: Creatine, one of the most studied ergogenic aids, increases phosphocreatine stores in skeletal muscles, improving ATP production during high-intensity exercises like sprinting and weightlifting. Studies show creatine supplementation enhances skeletal muscle mass, strength/power, and muscular endurance. The typical dosage is 3-5 g per day and is safe for long-term use. Beta-alanine, when combined with the amino acid histidine, elevates intramuscular carnosine, which acts as a buffer in skeletal muscles and delays fatigue during high-intensity exercise by neutralizing hydrogen ions. Individuals usually take 2-6 g daily in divided doses to minimize paresthesia. Research shows significant performance improvements in activities lasting 1-4 min. Nitrates, found in beetroot juice, enhance aerobic performance by increasing oxygen delivery to muscles, enhancing endurance, and reducing oxygen cost during exercise. The recommended dosage is approximately 500 milligrams taken 2-3 h before exercise. Caffeine, a central nervous system stimulant, reduces perceived pain while enhancing focus and alertness. Effective doses range from 3 to 6 milligrams per kilogram of body weight, typically consumed an hour before exercise. Protein supplementation supports muscle repair, growth, and recovery, especially after resistance training. The recommended intake for exercise-trained men and women varies depending on their specific goals. Concluions: In summary, creatine, beta-alanine, nitrates, caffeine, and protein are the best ergogenic aids, with strong evidence supporting their efficacy and safety.

Effects of Dietary Nitrate Supplementation on High-Intensity Cycling Sprint Performance in Recreationally Active Adults: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis investigated the influence of dietary nitrate supplementation on performance metrics during cycling sprint exercise according to the PRISMA guidelines. Searches were conducted on MEDLINE, PubMed, ScienceDirect, Scopus, and SPORTDiscus databases up to September 2023. Inclusion criteria were healthy recreationally active men and women who consumed nitrate-rich and nitrate-deficient beetroot juice to assess performance outcomes of mean power, peak power, time-to-peak power, and minimum power during 30-s cycling sprints. Risk of bias was assessed using the Cochrane Risk of Bias 2 and TESTEX tools and funnel plots. A random effects model was performed on six studies and showed that dietary nitrate had significant effects on time-to-peak power (SMD: -0.66, 95% CI: -1.127 to -0.192, p = 0.006) but not on mean power, peak power, or minimum power. Subgroup analysis revealed that an acute low nitrate dose improved time-to-peak power (SMD: -0.977, 95% CI: -1.524 to -0.430, p < 0.001) but not after a multiday moderate nitrate dose (SMD: -0.177, 95% CI: -0.619 to -0.264, p = 0.431). These data suggest that acute nitrate supplementation can benefit time-to-peak power during 30-s cycling sprints, but due to the limited availability of data and heterogeneity in methodology, these results should be interpreted with caution. There was insufficient data on women to analyze sex-based differences. Future studies are required to provide insight on how supplementation regimen and population impact the effects of dietary nitrate for enhancing cycling sprint performance.

Consuming Beetroot Juice Improves Slalom Performance and Reduces Muscle Soreness in Alpine Skiers under Hypoxic Conditions

Background

Beetroot juice (BRJ) supplementation has been shown to increase sports performance under hypoxic conditions and to improve athletes' recovery.

Objectives

In the present study, we aimed to investigate the effect of acute BRJ supplementation on slalom (SL) run performance and muscle soreness (MS) in Alpine skiers at moderate to high altitudes.

Methods

Ten male Alpine skiers received 220 mL of BRJ (8.9 mmol/L nitrate) or placebo (PLA) in 2 sessions with a 7-d wash out interval in a randomized, crossover, PLA-controlled, double-blind study. The 90-s box jump (BJ90), agility hexagonal obstacle jump (Hex Jump), and wall-sit tests were measured before on-hill SL runs in both sessions. After the functional tests, SL run performance was measured by time to complete 2 runs on the SL course; immediately after each SL run, the rating of perceived exertion (RPE) was recorded. In addition, perceived MS was recorded using the visual analog scale at 12, 24, and 48 h after the SL runs.

Results

The data were meticulously analyzed using 2-way repeated measures analysis of variance and paired t tests with significance set at P < 0.05. The findings were significant, indicating that compared with PLA, BRJ notably improved wall-sit and BJ90 performances (P < 0.05), while a substantial reduction was observed in RPE, Hex Jump, and MS (P < 0.05). A 1.74% shorter time to complete SL runs was observed in the BRJ group compared with the PLA group; however, there were no significant differences between the PLA and BRJ groups (P > 0.05).

Conclusions

These results underscore the potential of BRJ supplementation to enhance sports performance and reduce MS in Alpine skiers under hypoxic conditions.

Exploring the Impact of Alternative Sources of Dietary Nitrate Supplementation on Exercise Performance

An increase in the level of nitric oxide (NO) plays a key role in regulating the human cardiovascular system (lowering blood pressure, improving blood flow), glycemic control in type 2 diabetes, and may help enhance exercise capacity in healthy individuals (including athletes). This molecule is formed by endogenous enzymatic synthesis and the intake of inorganic nitrate (NO3-) from dietary sources. Although one of the most well-known natural sources of NO3- in the daily diet is beetroot (Beta vulgaris), this review also explores other plant sources of NO3- with comparable concentrations that could serve as ergogenic aids, supporting exercise performance or recovery in healthy individuals. The results of the analysis demonstrate that red spinach (Amaranthus spp.) and green spinach (Spinacia oleracea) are alternative natural sources rich in dietary NO3-. The outcomes of the collected studies showed that consumption of selected alternative sources of inorganic NO3- could support physical condition. Red spinach and green spinach have been shown to improve exercise performance or accelerate recovery after physical exertion in healthy subjects (including athletes).

Acute beetroot juice supplementation did not enhance intermittent running performance in trained rugby players

ABSTRACTPurpose: Since the effect of dietary nitrate (NO3-) supplementation on rugby performance is unclear, the aim of the present study was to determine the effect of acute NO3- supplementation, on the modified Yo-Yo intermittent recovery level 1 (IR1) performance test in trained male rugby players.Methods: In a randomised, counterbalanced, double-blind, placebo-controlled crossover design, 12 trained rugby union players performed two experimental trials three hours after supplementation of either 140 mL NO3--rich (BRJ; ∼12.8 mmol NO3-) or NO3--depleted (PLA) BRJ. After blood sampling, players performed the modified Yo-Yo IR1 test. Countermovement jumps (CMJ) were also measured before (pre-CMJ) and after (post-CMJ) the prone Yo-Yo IR1 test.Results: Plasma NO3- (BRJ: 570 ± 146 µM vs. PLA: 72 ± 23 µM) and nitrite (NO2-) concentrations (BRJ: 320 ± 123 nM vs. PLA: 103 ± 57 nM) were increased after BRJ compared to PLA supplementation (both P < 0.001). Performance in the modified Yo-Yo IR1 test did not differ between BRJ (542 ± 209 m) and PLA (498 ± 185 m, P = 0.3). The jump height in pre-CMJ and in post-CMJ were similar between trials (both P > 0.05).Conclusions: Acute BRJ supplementation increased plasma NO3- and NO2- concentrations but had no benefit on an intermittent running test that reflects the demands of rugby performance, and CMJ performances. The findings do not support acute high-dose NO3- supplementation as an ergogenic aid to enhance physical performance in trained male rugby players.