Can beetroot juice help manage hypertension?

Beetroot Juice for Blood Pressure Management

Beetroot juice can modestly lower systolic blood pressure by approximately 4-5 mmHg in hypertensive individuals, but it is not recognized as a primary intervention by major hypertension guidelines and should only be considered as an adjunct to proven lifestyle modifications and pharmacotherapy when indicated. 1, 2, 3

Guideline Position on Beetroot Juice

Major hypertension guidelines do not specifically recommend beetroot juice as a standard intervention for blood pressure management. 1, 2

• The American College of Cardiology and American Heart Association categorize beetroot juice among interventions that are "insufficiently proved" for blood pressure management. 2
• The 2024 ESC Guidelines, 2013 ESH/ESC Guidelines, and other major guidelines prioritize proven interventions including the DASH diet (8-14 mmHg systolic reduction), sodium restriction to <5-6 g/day (4-5 mmHg reduction), weight loss (5-20 mmHg per 10 kg), physical activity (4-9 mmHg), and alcohol moderation (2-4 mmHg). 1

Evidence for Blood Pressure Reduction

The most recent high-quality meta-analysis from 2024 provides the strongest evidence for beetroot juice's effects:

• Systolic blood pressure reduction: Beetroot juice containing 200-800 mg of dietary nitrate daily produces a mean reduction of 5.31 mmHg in clinical systolic blood pressure compared to placebo (95% CI -7.46 to -3.16 mmHg) in hypertensive individuals. 3
• Diastolic blood pressure: No significant effect on diastolic blood pressure was observed. 3
• Certainty of evidence: The evidence quality is rated as LOW by GRADE criteria, with moderate to high heterogeneity between studies, meaning results should be interpreted with caution. 3

Mechanism of Action

Beetroot juice works through the nitrate-nitrite-nitric oxide (NO₃⁻/NO₂⁻/NO) pathway, which increases nitric oxide bioavailability and promotes vasodilation. 4, 5

Who May Benefit Most

Specific populations appear to derive greater benefit from beetroot juice:

• Uncontrolled hypertensives: Those with uncontrolled hypertension show significant blood pressure reductions, while those with controlled hypertension on medications show minimal to no additional benefit. 6, 7
• Overweight/obese individuals: May experience greater blood pressure-lowering effects. 8
• Prehypertension or stage 1 hypertension: Beetroot juice may be most appropriate for motivated patients willing to try dietary interventions alongside proven strategies like the DASH diet and sodium reduction. 2

Important Negative Finding

A 2015 randomized controlled trial found no effect of one week of nitrate-rich beetroot juice on blood pressure in treated hypertensive individuals, despite achieving 3-fold increases in plasma nitrite/nitrate levels. 6 This suggests that beetroot juice may not provide additional benefit when blood pressure is already controlled with medication.

Clinical Application Algorithm

For patients with hypertension, follow this approach:

1. First-line interventions (always prioritize these): 1

   • Sodium restriction to <5-6 g/day (4-5 mmHg reduction)
   • DASH diet implementation (8-14 mmHg reduction)
   • Weight loss if BMI >25 kg/m² (5-20 mmHg per 10 kg)
   • Regular aerobic exercise ≥150 min/week (4-9 mmHg reduction)
   • Alcohol moderation (2-4 mmHg reduction)

2. Pharmacotherapy when indicated: 1

   • Stage 2 hypertension (≥140/90 mmHg) requires medication
   • Target blood pressure: 120-129/<80 mmHg in most adults
   • ACE inhibitors, ARBs, CCBs, and thiazide diuretics are first-line agents

3. Consider beetroot juice as adjunct only if: 2, 8, 3

   • Patient has uncontrolled hypertension or prehypertension
   • Patient is motivated for dietary interventions
   • Patient understands this is supplementary to proven interventions
   • Typical dose: 200-800 mg nitrate daily (approximately 250 mL beetroot juice)

Critical Safety Considerations

Patients on antihypertensive medications must consult their healthcare provider before adding beetroot juice due to potential additive blood pressure-lowering effects that could cause symptomatic hypotension. 2, 8

• Patients with chronic kidney disease should exercise caution with high-nitrate supplements due to potential potassium content and impaired nitrate metabolism. 8
• Beetroot juice should never delay or replace indicated antihypertensive medication in patients with stage 2 hypertension or those with cardiovascular risk factors requiring pharmacotherapy. 2

Additional Benefits Beyond Blood Pressure

Raw beetroot juice may provide benefits beyond blood pressure reduction:

• Improved endothelial function (increased flow-mediated dilation). 5
• Reduced systemic inflammation (decreased hs-CRP, TNF-α, IL-6, ICAM-1, VCAM-1). 5
• Decreased LDL cholesterol and non-HDL cholesterol (particularly in uncontrolled hypertensives). 5, 7
• Increased total antioxidant capacity. 5

Raw beetroot juice appears more effective than cooked beetroot for these cardiovascular benefits. 5

Common Pitfalls to Avoid

• Do not recommend beetroot juice as monotherapy for patients requiring pharmacological blood pressure control. 1, 2
• Do not assume benefit in patients already well-controlled on medications – evidence suggests minimal additional effect in this population. 6, 7
• Do not neglect proven lifestyle interventions that have stronger evidence and greater magnitude of effect (DASH diet, sodium restriction, weight loss). 1
• Do not ignore the low certainty of evidence – the 2024 meta-analysis rates evidence quality as LOW with moderate-to-high heterogeneity. 3