Flavonoid-rich apples and nitrate-rich spinach augment nitric oxide status and improve endothelial function in healthy men and women: a randomized controlled trial

Free Radic Biol Med. 2012 Jan 1;52(1):95-102. doi: 10.1016/j.freeradbiomed.2011.09.028. Epub 2011 Oct 1.


Flavonoids and nitrates in fruits and vegetables may protect against cardiovascular disease. Dietary flavonoids and nitrates can augment nitric oxide status via distinct pathways, which may improve endothelial function and lower blood pressure. Recent studies suggest that the combination of flavonoids and nitrates can enhance nitric oxide production in the stomach. Their combined effect in the circulation is unclear. Here, our objective was to investigate the independent and additive effects of flavonoid-rich apples and nitrate-rich spinach on nitric oxide status, endothelial function, and blood pressure. A randomized, controlled, crossover trial with healthy men and women (n=30) was conducted. The acute effects of four energy-matched treatments (control, apple, spinach, and apple+spinach), administered in random order, were compared. Measurements included plasma nitric oxide status, assessed by measuring S-nitrosothiols+other nitrosylated species (RXNO) and nitrite, blood pressure, and endothelial function, measured as flow-mediated dilatation of the brachial artery. Results are means and 95% CI. Relative to control, all treatments resulted in higher RXNO (control, 33 nmol/L, 26, 42; apple, 51 nmol/L, 40, 65; spinach, 86 nmol/L, 68, 110; apple+spinach, 69 nmol/L, 54, 88; P<0.01) and higher nitrite (control, 35 nmol/L, 27, 46; apple, 69 nmol/L, 53, 90; spinach, 99 nmol/L, 76, 129; apple+spinach, 80 nmol/L, 61, 104; P<0.01). Compared to control, all treatments resulted in higher flow-mediated dilatation (P<0.05) and lower pulse pressure (P<0.05), and apple and spinach resulted in lower systolic blood pressure (P<0.05). No significant effect was observed on diastolic blood pressure. The combination of apple and spinach did not result in additive effects on nitric oxide status, endothelial function, or blood pressure. In conclusion, flavonoid-rich apples and nitrate-rich spinach can independently augment nitric oxide status, enhance endothelial function, and lower blood pressure acutely, outcomes that may benefit cardiovascular health.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Blood Pressure
  • Brachial Artery / physiopathology
  • Cardiovascular Diseases / blood
  • Cardiovascular Diseases / diet therapy
  • Cardiovascular Diseases / prevention & control*
  • Cross-Over Studies
  • Endothelium, Vascular / metabolism*
  • Female
  • Flavonoids / metabolism*
  • Humans
  • Male
  • Malus / chemistry
  • Malus / metabolism*
  • Middle Aged
  • Nitrates / metabolism*
  • Nitric Oxide / biosynthesis*
  • Nitric Oxide / blood
  • Nitrites / blood
  • S-Nitrosothiols / analysis
  • Spinacia oleracea / chemistry
  • Spinacia oleracea / metabolism*
  • Systole
  • Vasodilation / physiology


  • Flavonoids
  • Nitrates
  • Nitrites
  • S-Nitrosothiols
  • Nitric Oxide