1. The effect of dietary nitrate on blood pressure in type 2 diabetes Dr Mark Gilchrist Peninsula Medical School 12 th September 2011

2. Background

3. Health and vegetable rich diet Effects attributed to multiple factors: Carter et al BMJ 2010 Chlorophyll β-carotene Polyphenols Ascorbic acid Mg 2+

4. Inorganic nitrate and vegetables Green leafy vegetables (and beetroot) particularly rich in inorganic nitrate In mammals previously thought to be inert waste product

5. Organic vs inorganic nitrate Isosorbide mononitrateNitrate ion

6. Nitric oxide key regulator of vascular tone Palmer et al Nature 1987 Diminished production of NO in hypertension, hyperlipidemia, chronic kidney disease, type 2 diabetes Forte et al Lancet 1997 Scherrer et al Eur J Endocrinol 2000 Nitrate, nitrite, and nitric oxide

7. Nitrate involved in complex cycle with nitrite and nitric oxide NO 3 -NO 2 - NO Nitrate NitriteNitric oxide Nitrate, nitrite, and nitric oxide

8. Generate 1mmol nitrate/day from oxidation nitric oxide from L-arginine NOS pathway 1-2mmol nitrate per day typical Western diet Nitrate and nitrite may act as a storage pool of NO, delivering nitric oxide where it is required Lundberg et al Nat Rev Micro 2004

9. Simplified representation of the entero-salivary circulation of dietary nitrate Gilchrist et al Cardiovasc Res 2011 Duncan et al Nature Med 1995

10. Nitrate, nitrite, and blood pressure Reichart Am J Med Sci 1880 Stieglitz JAMA 1930

11. Larsen et al NEJM 2006 Nitrate, nitrite, and blood pressure

12. Effect of oral nitrate on plasma nitrite and BP Webb et al Hypertension 2008 Systolic Blood PressurePlasma Nitrite Time (hours)

13. Beneficial effects of dietary nitrate and nitrite Protection against IR injury (Webb et al Hypertension 2008) Improvement in exercise efficiency (Bailey et al JAP 2009) Reverse features of metabolic syndrome in eNOS KO mice (Carlstrom et al PNAS 2010)

14. 2 weeks Placebo Active Study design Randomised, double blind, placebo controlled crossover design Active Placebo 4 weeks 24 hr ABPM

15. Placebo Beetroot juice treated with anion exchange resin Purolite A520e Selectively removes nitrate Active juice (250mls) nitrate dose 7.5mmol Placebo juice nitrate (250mls) dose 0.002mmol

16. Results 23 subjects, 15male, 8 female MeanSD Age (yrs) 67.25.0 Duration of diabetes (yrs) 13.88.6 Systolic BP (mmHg) 143.412.3 Diastolic BP (mmHg) 82.39.0 BMI 30.83.3 HbA1c (%) 7.61.2 Number antihypertensives 2.21.1

17. Plasma nitrate

18. Plasma nitrite

19. Dietary nitrate and BP 133.5 134.7 77.6 75.6 95.6 94.7 (p=0.43) (95% CI: -1.87 to 4.23).

20. Conclusion and discussion Dietary nitrate supplementation did not have a detectable effect on blood pressure in individuals with type 2 diabetes

21. Future work Is nitrate, nitrite and NO handling disordered in type 2 diabetes? Is this partly responsible for excess cardiovascular risk in type 2 diabetes?

22. Acknowledgements Supervisors –Prof Nigel Benjamin –Prof Angela Shore –Prof Paul Winyard CRF Nurses Christine Anning Claire Ball Linda Haynes Andrew Pitt Supported by: Peninsula NIHR Clinical Research Facility

24. WHO JEFCA 2003 Overall, the epidemiological studies showed no consistently increased risk for cancer with increasing consumption of nitrate. These data, combined with the results of the epidemiological studies considered by the Committee at its forty-fourth meeting, do not provide evidence that nitrate is carcinogenic to humans.

25. Ionic composition of juices SourcePlaceboTypical Daily Intake Sodium4.43mmol4.1mmol150mmol Potassium19.15mmol18.25mmol71mmol Calcium0.12mmol0.095mmol20mmol Magnesium1.85mmol1.93mmol7mmol Chloride6.83mmol15.13mmol150mmol