Beetroot Supplementation for Blood Pressure Reduction
Beetroot juice supplementation shows modest blood pressure-lowering effects (approximately 4-5 mmHg systolic reduction in hypertensive individuals), but it is not included in any Class I guideline recommendations and should be considered only as an adjunct to proven interventions, not as primary therapy. 1
Guideline Position on Beetroot
The 2017 ACC/AHA Hypertension Guidelines do not include beetroot or dietary nitrate supplementation among their Class I (strongest) recommendations for blood pressure management. 1 The guidelines explicitly state that various nonpharmacological interventions have been reported to lower blood pressure, but "the extent and/or quality of the supporting clinical trial experience is less persuasive" for interventions beyond the core six recommendations. 1
The six Class I, Level A interventions that should be prioritized over beetroot are:
- Weight loss (approximately 1 mmHg reduction per kg lost) 1
- DASH diet (11 mmHg systolic reduction in hypertensives, 3 mmHg in normotensives) 1
- Sodium reduction (5-6 mmHg systolic reduction in hypertensives, 2-3 mmHg in normotensives) 1
- Potassium supplementation (4-5 mmHg reduction in hypertensives, preferably through dietary modification) 1
- Structured exercise programs (5-8 mmHg systolic reduction) 1
- Alcohol moderation (≤2 drinks/day for men, ≤1 for women; 4 mmHg systolic reduction) 1
Evidence for Beetroot Effectiveness
Magnitude of Effect
Recent meta-analyses demonstrate that beetroot juice can reduce systolic blood pressure by approximately 4-5 mmHg in hypertensive individuals, though the certainty of evidence is low. 2 A 2024 meta-analysis of 11 trials (349 patients) found a mean reduction of -5.31 mmHg in clinical systolic blood pressure (95% CI -7.46 to -3.16), but noted moderate to high heterogeneity and graded the evidence as low certainty. 2
The American Heart Association notes that hypertensive individuals and those who are overweight or obese may experience greater benefits from beetroot juice supplements compared to normotensive individuals. 3
Dose-Response Relationship
The blood pressure-lowering effect appears dose-dependent, with larger reductions observed at higher doses (500 mL/day vs. 70-140 mL/day) and longer durations (≥14 days vs. <14 days). 4 Daily ingestion of 200-800 mg of nitrate from beetroot juice may be required for clinical effect. 2
Mechanism of Action
Beetroot's effects are primarily attributed to its high inorganic nitrate content, which is converted through the enterosalivary nitrate-nitrite-nitric oxide pathway. 5, 4 However, some evidence suggests potential nitrate-independent effects from secondary metabolites in Beta vulgaris. 4
Critical Limitations and Contradictory Evidence
A significant limitation is that beetroot juice may not be effective in patients already on antihypertensive medications. A 2015 randomized controlled trial found no difference in home blood pressure or 24-hour ambulatory blood pressure after 1 week of nitrate-rich beetroot juice in treated hypertensive subjects, despite a 3-fold increase in plasma nitrite and nitrate. 6 This suggests that beetroot supplementation may not provide additional benefit beyond standard pharmacotherapy.
The evidence quality is compromised by moderate to high heterogeneity across studies, short study durations (most trials lasting only 1-2 weeks), and small sample sizes. 2, 4
Clinical Implementation Considerations
When to Consider Beetroot
Beetroot juice can be considered as part of a comprehensive dietary approach for:
- Untreated hypertensive patients who are implementing lifestyle modifications before or alongside medication initiation 3
- Pre-hypertensive individuals as part of primary prevention strategies 5
- Patients seeking additional dietary interventions after implementing the six Class I recommendations 3
Safety Precautions
Patients on blood pressure medications should consult healthcare providers before adding beetroot supplements due to potential additive effects. 3 Patients with kidney disease should exercise caution with high-nitrate supplements due to potential potassium content and impaired nitrate metabolism. 3
Practical Dosing
Based on available evidence, 250-500 mL/day of raw beetroot juice (providing 200-800 mg nitrate) for at least 2 weeks appears necessary for potential blood pressure effects. 2, 7 Raw beetroot juice appears more effective than cooked beet, with greater improvements in endothelial function and systemic inflammation. 7
Clinical Bottom Line
Beetroot supplementation should never replace proven Class I interventions for hypertension management. 1 While it may provide modest additional blood pressure reduction (4-5 mmHg systolic) in untreated hypertensive patients, the evidence is of low certainty and the effect size is smaller than established interventions like the DASH diet (11 mmHg), sodium reduction (5-6 mmHg), or structured exercise (5-8 mmHg). 1, 3, 2
For patients already on antihypertensive medications, beetroot supplementation is unlikely to provide additional benefit and should not be routinely recommended. 6 The American Heart Association recognizes beetroot juice as part of the "healthy drinks" category in lifestyle modifications, but it remains a supplementary rather than primary intervention. 3