Beetroot nitrates are a natural product, but concentrated supplements are not suitable for everyone. The editorial team explains for whom taking nitrate shots and powders is undesirable, in which cases a doctor's consultation is needed, and how 'beetroot on the plate' differs from a sports concentrate.
Contraindications: absolute and relative
Beetroot nitrates are not a medicine, so they have no official instructions with a list of contraindications. However, concentrated nitrate products have a distinct physiological effect - they lower blood pressure, change vascular tone, and affect nitrite metabolism. So for some groups of people their intake is undesirable or requires mandatory agreement with a doctor.
The editorial team conditionally divides the restrictions into two groups. The first - situations where concentrates should not be used at all (for example, infants) or only under a doctor's direct supervision. The second - conditions in which intake is possible but requires caution, a smaller dose, or a different source of nitrate.
It is important to distinguish 'beetroot on the plate' from 'beetroot concentrate.' An ordinary portion of borscht or a salad with beetroot is not equivalent to a sports shot with several hundred milligrams of nitrate. Most of the restrictions described below concern precisely concentrated products and the regular intake of high doses.
If you recognize yourself in one of the groups below, this is not a verdict but a signal to discuss the matter with a doctor who knows your medical history and list of medications.
Cardiovascular conditions and medications
The most important group of restrictions is related to blood pressure. Nitrates, through nitric oxide, dilate blood vessels, and in studies they noticeably lowered blood pressure (Webb et al., 2008; Kapil et al., 2015). For a person with normal or elevated pressure this can even be beneficial, but with hypotension an additional drop in pressure can cause dizziness and fainting.
People taking antihypertensive drugs should remember the possible enhancement of the effect. A doctor may decide that nitrates are acceptable, but then it is useful to monitor pressure at home in the first days of intake. You must not change medication doses on your own because of beetroot juice.
Special attention goes to phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) and medicinal organic nitrates (nitroglycerin, isosorbide mononitrate and dinitrate). Combining PDE-5 inhibitors with organic nitrates is contraindicated because of the risk of a sharp drop in pressure. Dietary nitrate is a different compound with a milder action, but the mechanism is shared, so combining it with these drugs should be discussed with a doctor.
For people with serious heart diseases - heart failure, severe aortic valve stenosis, a recent heart attack - any supplements that affect vascular tone must be agreed with a cardiologist. Studies of nitrates in some cardiac conditions are ongoing, but this is a clinical context, not self-use.
Kidneys and kidney stone disease
Nitrate is eliminated from the body mainly by the kidneys. In chronic kidney disease its elimination slows down, and the concentration in the blood may remain elevated longer. In addition, beetroot contains a lot of potassium, and with reduced kidney function potassium is often limited because of the risk of heart rhythm disturbances.
Beetroot also belongs to the products high in oxalates. For people who have already had calcium oxalate kidney stones, urologists usually recommend limiting such products. Concentrated beetroot juices and powders can contain a noticeable amount of oxalates, although it is usually not indicated on the labels.
If nitrates are important to you but beetroot is undesirable because of oxalates, a doctor can help select other sources - for example, some leafy vegetables with a lower oxalate content. But here too it is worth taking potassium and the overall dietary context into account.
Finally, people who are on dialysis or have a transplanted kidney should discuss any new supplements - not just nitrates - with a nephrologist. In such patients even ordinary food products sometimes require restriction, and concentrates are no exception here.
| Group | Reason for caution | Editorial recommendation |
|---|---|---|
| Hypotension | Additional drop in blood pressure | Consult a doctor, monitor blood pressure |
| Blood pressure medications | Enhancement of the effect | Agree with a doctor, home monitoring |
| PDE-5 inhibitors, organic nitrates | Shared mechanism through NO | Do not combine without a doctor's permission |
| Kidney disease | Slowed elimination, potassium | Concentrates - only with a nephrologist's permission |
| Oxalate stones | High oxalate content in beetroot | Limit beetroot, alternative sources |
| Infants | Risk of methemoglobinemia | Do not give concentrates |
| Pregnancy and breastfeeding | Lack of data on concentrates | Dietary vegetables - yes, supplements - with a doctor |
Children, pregnancy, and breastfeeding
Infants are the highest-risk group. They still have immature enzyme systems that restore methemoglobin, and a less acidic stomach, which promotes the conversion of nitrate into nitrite by bacteria. The American Academy of Pediatrics (Greer et al., 2005) describes cases of methemoglobinemia in infants linked to nitrates in water and some vegetable products. So concentrated nitrate products must not be given to infants, and it is advised not to introduce beetroot and spinach into complementary feeding too early.
For older children and adolescents, sports nitrate supplements have not been properly studied. The editorial team believes it is more appropriate for young athletes to get nitrates from ordinary vegetables as part of a balanced diet.
As for pregnancy and breastfeeding, there is insufficient research on the safety of concentrated nitrate products. Vegetables remain an important part of the diet during these periods, but taking sports shots or powders with high doses of nitrate without agreement with a doctor is not advisable.
Separately, we mention rare congenital conditions that increase the tendency to methemoglobinemia. People with such diagnoses should discuss any sources of nitrates and nitrites in high doses with a doctor.
Other situations requiring attention
People with iron deficiency should know that beeturia - a pink coloring of the urine after beetroot - occurs more often in them (Mitchell, 2001). The effect itself is safe, but it can mask or imitate real blood in the urine, so it is important to understand where the color comes from.
Besides the main risk groups, there are a number of situations that are not contraindications in the strict sense but influence the decision to take nitrates or the expected effect.
- Sensitive intestines:large volumes of juice can worsen bloating and diarrhea.
- Carbohydrate metabolism disorders:ordinary beetroot juice contains a noticeable amount of sugar.
- Regular use of antiseptic mouthwashes:not a contraindication, but the effect of nitrates will be weaker (Govoni et al., 2008).
- Athletes undergoing doping control:nitrates are permitted, but choose certified products because of the risk of contamination.
People who regularly take several medications at once, especially the elderly, should remember: even a 'dietary' supplement becomes one more factor affecting blood pressure. Consult a doctor or pharmacist about whether the beetroot concentrate will enhance the action of already prescribed medications.
Finally, it is categorically not recommended to use nitrite salts or 'pure' chemical nitrates as an alternative to beetroot. Sodium nitrite has caused fatal poisonings, and no category of people should experiment with it.
Editorial conclusions
For most healthy adults, beetroot nitrates in the doses from studies are safe. But concentrated products are unsuitable for infants, and people with hypotension, kidney diseases, a tendency to oxalate stones, as well as those taking blood pressure medications, PDE-5 inhibitors, or organic nitrates, need a prior doctor's consultation.
During pregnancy and breastfeeding, as well as in childhood, it is better to get nitrates from vegetables as part of an ordinary diet.
It is also useful to read our materials 'Side effects of beetroot nitrate,' 'What to combine beetroot nitrate with,' and 'Beetroot nitrate: what it is and how it works.'
References
- Webb AJ, Patel N, Loukogeorgakis S, et al. Acute blood pressure lowering, vasoprotective, and antiplatelet properties of dietary nitrate via bioconversion to nitrite. Hypertension. 2008;51(3):784–790.
- Kapil V, Khambata RS, Robertson A, et al. Dietary nitrate provides sustained blood pressure lowering in hypertensive patients: a randomized, phase 2, double-blind, placebo-controlled study. Hypertension. 2015;65(2):320–327.
- Greer FR, Shannon M; American Academy of Pediatrics Committee on Nutrition. Infant methemoglobinemia: the role of dietary nitrate in food and water. Pediatrics. 2005;116(3):784–786.
- Mitchell SC. Food idiosyncrasies: beetroot and asparagus. Drug Metab Dispos. 2001;29(4 Pt 2):539–543.
- EFSA Panel on Contaminants in the Food Chain. Nitrate in vegetables: scientific opinion. EFSA Journal. 2008;689:1–79.
- Govoni M, Jansson EA, Weitzberg E, Lundberg JO. The increase in plasma nitrite after a dietary nitrate load is markedly attenuated by an antibacterial mouthwash. Nitric Oxide. 2008;19(4):333–337.
- Hord NG, Tang Y, Bryan NS. Food sources of nitrates and nitrites: the physiologic context for potential health benefits. Am J Clin Nutr. 2009;90(1):1–10.
- Clements WT, Lee SR, Bloomer RJ. Nitrate ingestion: a review of the health and physical performance effects. Nutrients. 2014;6(11):5224–5264.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
