Efficacy of Beetroot Juice in Patients With Peripheral Artery Disease: A Systematic Review

Abstract

Peripheral artery disease (PAD) is a prevalent manifestation of atherosclerosis, characterized by reduced blood flow to the lower extremities and associated with claudication, pain, and limited exercise capacity. Nitric oxide (NO) plays an essential role in vascular homeostasis, and beetroot juice (BRJ) is a natural source of dietary nitrate that has emerged as a potential therapeutic option for improving vascular function and exercise tolerance in PAD. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, including a flow diagram, a checklist, and reporting items, and was registered in PROSPERO (number CRD420251059989). We searched PubMed and ScienceDirect from inception to February 2025 for randomized controlled trials (RCTs), cohort, and case-control studies evaluating the effects of BRJ in adults (>18 years) with stable PAD. Inclusion required a confirmed diagnosis of PAD (ankle-brachial index <0.9) and history of intermittent claudication. Outcomes included claudication onset time (COT), peak walking time (PWT), and blood pressure changes. Risk of bias was assessed using the Cochrane Risk of Bias tool. From an initial yield of 315 articles, five RCTs met the inclusion criteria, encompassing a total of only 64 patients (age range: 52-80 years; 57.8% male). Four of five trials utilized crossover designs and one was a parallel RCT, all comparing BRJ to placebo over short follow-up periods ranging from one to 84 days, which contributed to significant heterogeneity in outcomes. Two studies demonstrated significant differences in COT and PWT, while others reported either no significant changes or improvements in both groups. Reductions in systolic and diastolic blood pressure were observed in three studies, and two reported increased serum nitrate/nitrite levels following BRJ intake. No adverse events were reported. In conclusion, while beetroot juice intake may offer potential benefits such as enhanced exercise capacity and reduced blood pressure in PAD patients, these findings are based on preliminary evidence from a small number of studies with limited sample sizes and varying methodologies. The proposed mechanism of action via nitric oxide bioavailability remains a hypothesis, not directly confirmed by the included trials. Given the moderate-to-high risk of bias, small study populations, and heterogeneity in dosing, duration, and outcome definitions, these results should be interpreted cautiously. Larger, long-term randomized trials with standardized protocols are warranted to clarify its clinical utility and support its incorporation into therapeutic strategies for PAD.