Plain English Summary
Background and study aims
The Metabolic Syndrome (MetS) is a cluster of cardiovascular risk factors (obesity, hypertension, insulin resistance, and dyslipidaemia) associated with inflammation, pro-thrombotic state and non-alcoholic fatty liver disease (NAFLD)/steatohepatitis (NASH). Neither pharmacological (medications) approaches nor diet/exercise (due to low long-term compliance) have proven to be efficient in preventing/treating obesity and its comorbidities therefore new approaches are thus needed. Here we propose to nutritionally modulate nitric oxide (NO) signaling to revert the effects of the MetS. In rodents, nutritional supplementation with inorganic nitrate reduces weight and visceral fat, improves glucose metabolism, and promotes fat burning in organs such as skeletal muscle and adipose tissue. Nitrate-rich vegetables and extracts thus have potential as therapeutic interventions for MetS and NAFLD/NASH. In fact, NAFLD results from excessive storage of lipids, where the capability of the hepatocytes to store, burn and process the lipids is exceeded. Increasing fat burning in the liver has been proposed as a promising strategy for NAFLD management. Preliminary pre-clinical results show that inorganic nitrate promotes metabolic health and interferes with the mechanisms leading to NASH (i.e. fat accumulation, inflammation) through a mechanism of enhanced fat burning. This study aims to investigate whether a short term beetroot juice supplementation can improve the metabolic health of patients with fatty liver by lowering fat accumulation in the liver and interfering with the mechanisms that allow fatty liver progression and worsening.
Who can participate?
Men aged 30-55 years old who have a diagnosis of NAFLD/NASH.
What does the study involve?
Participants are randomly allocated to one of two groups. All participants are asked to revise their diet for the entire duration of the study. The first group consume a small bottle of beetroot juice twice a day. For the first 28 days this is a nitrate free drink and the next 28 days the juice will be nitrate-enriched. Those in the second group drink a small bottle of beetroot juice twice a day. The first 28 days the drink contains the nitrate and the next 28 days the drink is nitrate free. Participants are followed up four times to assess their body composition, lifestyle and liver function (through blood and urine tests).
What are the possible benefits and risks of participating?
There is no direct benefits to research participants. If the human nutritional trial confirms our pre-clinical observations, we might observe an improvement in the metabolic profile of the markers of liver damage while the participants are on the nitrate-rich beetroot juice; on the other hand, we do not expect a net clinical therapeutic advantage (i.e. a complete regression of NAFLD) due to the short duration of the challenge. The main side effect of beetroot juice is beeturia (red urine) and red stool. This change in urine/faeces colour is not associated with any pathological state, neither is it a hallmark of disease.
Where is the study run from?
Addenbrooke's Hospital (Cambridge, UK)
When is the study starting and how long is it expected to run for?
April 2016 to April 2019
Who is funding the study?
Medical Research Council (UK)
Who is the main contact?
Dr Michele Vacca
Mr Gabriele Mocciaro
Dr Michele Vacca
Lipid Dynamics and Regulation at the University of Cambridge (Department of Biochemistry)
Institute of Metabolic Science
University of Cambridge
+44 747 4301 485
Beneficial Effects of Inorganic Nitrates in Liver Steatosis
This study aims to investigate whether a short term beetroot juice supplementation can improve the metabolic health of patients with fatty liver by lowering fat accumulation in the liver and interfering with the mechanisms that allow fatty liver progression and worsening.
East of England - Cambridge Central Research Ethics Committee, 08/05/2017, ref: 17/EE/0002
Randomised; Interventional; Design type: Dietary
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Specialty: Hepatology, Primary sub-specialty: Hepatology; UKCRC code/ Disease: Oral and Gastrointestinal/ Diseases of liver, Metabolic and Endocrine/ Metabolic disorders
The main intervention consists of drinking a small bottle of beetroot juice twice a day. The beetroot juice contains a high or low concentration of nitrates: neither the participant nor the research team will know in which order the participant is taking the two versions of the juice. Before starting the juice intervention and between the two treatments participants have a one-week washout period with no beetroot juice. During the study, the participants are also asked to revise their diet. Specifically, the nutritional intervention during this study (70 days) includes foods with low or absent nitrate levels.
Patients are randomised in two different arms: 15 patients are enrolled in the “Placebo-First” Arm (28 days of nitrate-free treatment followed by 28 days of nitrates-enriched treatment), the other 15 patients are enrolled in the “Nitrates-First” Arm (28 days of nitrate-enriched treatment followed by 28 days of nitrates-free treatment). The randomisation applied in this study is constrained and it is done through the website http://randomization.com/.
During the first visit consent form, clinical and lifestyle information as well as blood and urine samples are collected.
In addition to the first visit, 4 short visits are conducted to collect:
2. Lifestyle questionnaires
3. Body composition
4. Liver stiffness
5. Blood, and urine samples
Primary outcome measures
1. The primary outcome will be assessed through the changes measured at baseline, 7, 35, 42 and 70 days and include:
1.1. Plasma 3-aminoisobutyric acid which will be measured using liquid chromatography-mass spectrometry (LC-MS),
1.2. Changes in gene expression and activity of the key metabolic transcription factors peroxisome-proliferator activated receptor 1 alpha and delta in peripheral blood mononuclear cells using reverse-transcription and quantitative polymerase chain reaction
Secondary outcome measures
1. The effect of nitrate supplementation on body composition measured using a bioelectrical impedance device at baseline, 7, 35, 42 and 70 days
2. The effect of nitrate supplementation on plasma lipidome using LC-MS at baseline, 7, 35, 42 and 70 days
3. The effect of nitrate supplementation on plasma and urine nitrate and polyphenols levels using mass spectrometry methods at baseline, 7, 35, 42 and 70 days
Overall trial start date
Overall trial end date
Participant inclusion criteria
1. Men with clinical diagnosis of non-alcoholic steatohepatitis and a mild (F0-F2) fibrosis stage as predicted by a FIB-4 score < 2.67
2. Age between 30-55 years
3. BMI between 25-35
4. Glycaemia > 5.5 mmol/L
5. Triglycerides ≥ 1.7 mmol/L
Target number of participants
Planned Sample Size: 30; UK Sample Size:30
Participant exclusion criteria
1. Current participation in other interventional clinical trials (to avoid confounding with other study outcomes), observational studies are allowed
2. Other hepatic diseases: i.e alcoholic (> 21U/wk), viral and autoimmune hepatitis (AIH, PSC, PBC), genetic conditions (e.g. hemochromatosis), drug-induced hepatitis, etc.
3. History of chronic conditions that could influence the study outcomes such as
3.1. Anaemia (Hb< 11g/dL) or abnormal values in WBC, platelet count, or INR
3.2. Glomerular filtration rate lower than 60 mL/min/1.73m2 or diuretics
3.3. Active cancer and any diagnosis of malignant cancer in the last 5 years
3.4. Chronic Inflammatory disease (e.g. IBD, rheumatoid arthritis) in chronic treatment with NSAIDs/Corticosteroids
3.5. Type 1 diabetes
4. Treatments that could influence the study outcomes such as:
4.1. Anti-Diabetic medications (Metformin, TZDs, insulin)
4.2. Lipid-lowering agents (Fibrates/Omega3)
4.3. Nitrate-derived agents
4.6. Weight loss medications (sibutramine, orlistat, rimonabant) and history of bariatric surgery (weight loss related changes in systemic metabolism)
4.7. Hormonal therapies (oestrogens, thyroxine, and progesterone)
4.8. Anti-psychiatric drugs (antidepressants, sedatives, antipsychotics)
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
Cambridge University Hospitals NHS Foundation Trust
Co-sponsored with The University of Cambridge
+44 1223 245151
Medical Research Council
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Planned publication in a high-impact peer reviewed journal.
IPD sharing statement:
Part of the datasets generated during and/or analysed during the current study will be stored in a publically available repository. Specifically, pseudonymised "Omics" data (including genomics and transcriptomics) will be available on dedicated platforms (e.g. National Center for Biotechnology Information, Gene Expression Omnibus, European Bioinformatics Institute, etc.). These data will be available only if the patient will agree signing a consent form. Any residual biological material from this study will be kept in Prof Griffin’s Lab at the Department of Biochemistry for a period of time of 15 years. These samples will be available to the scientific community (if requested) for further analyses (e.g. genes, metabolites) to generate more knowledge in the field of NASH and nitrates. The patients will provide signed permission for the use of the samples outside the remits of the actual project, upon agreeing to make these available, and the researchers will need to seek adequate ethical authorisation for further use without the need to ask consent of the patients for additional uses of their samples. Lastly, pseudonymised biological samples (urine and blood) will be analysed by Addenbrooke's Hospital (Cambridge, UK), University of Leeds (UK), University of Newcastle (UK), and University of Parma (Italy). For all the above mentioned points favourable ethical approval has been received.
Intention to publish date
Participant level data
Stored in repository
Results - basic reporting