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ONCOLOGY NUTRITION linked to weight and muscle loss from side effects like decreased dietary intake (4,5). Studied have reported that loss of muscle Does Beetroot or Beetroot and lean body mass can increase the risk and severity of dose limiting toxicities (5,6). Lean Juice Improve Oncological tissue loss can be most severe if the patient is experiencing cancer cachexia, which is Outcomes? characterized by metabolic aberrations, decreased fat mass, loss of skeletal muscle By Corey Hawes MS, RDN, CNSC, Dr. Luigi Brunetti PharmD, BCPS, CGP, mass, and changes in pro-inflammatory Dr. Jane Ziegler DCN, RD, LDN cytokines (8). Cancer cachexia affects 50% to 85% of cancer patients at some point during Abstract cancer care, and is estimated to cause up to Dietary supplement usage continues to increase among cancer patients, 20% of cancer deaths (8). with the goal of aiding in cancer remission and cure. Beetroot is of Etiology and pathophysiology of cancer interest, because it contains betanin, a phytochemical believed to cachexia is driven by pro-inflammatory have synergistic anti-tumor activity with concurrent chemotherapy. cytokines initiating acute phase protein Betalains are the red and yellow nitrogen containing pigments found response, resulting in loss of skeletal muscle in beets. Betalains are also of interest as they have been implicated in even with adequate protein-energy intakes (8). Nitrates are created during skeletal muscle synergistically enhancing cytotoxic abilities of chemotherapy. The high metabolism, and are converted to nitric oxide nitrogen content of beetroot also may benefit patients experiencing in the body (9). Nitric oxide (NO)-associated increased protein metabolism and muscle wasting. Concurrent treatment processes in the body include blood flow and with beetroot demonstrated an increase in cytotoxic properties in energy metabolism (9). Nitrates lower oxygen usage during exercise and increase efficiency prostate and breast cancer human cells and has been shown to improve of cellular ATP-consuming processes and protein metabolism and nitrogen balance in cancer patients. Future mitochondrial ATP synthesis, which improves clinical trials are necessary to further assess the efficacy of concurrent muscle strength while increasing muscle treatment with beetroot supplements and chemotherapy agents. growth potential (8). The use of beetroot juice, because of its high nitrate content and anti- inflammatory properties, has been the focus flavonoids, and is one of the few vegetables Introduction of research into adjunct treatments to that contain a highly bioactive group of With the cancer epidemic growing, and, minimize exacerbated muscle loss, lessen pigments known as betalains. Betalains are a a 2017 incidence of 1,735,350 new cases immunodeficiency, and provide nitrates to red nitrogen pigment found in foods that are expected to be diagnosed in 2018(1), many help build muscle tissue (8). Consequently, we absent of anthocyanin (3). They are a highly individuals affected by cancer search for any were interested in how beetroot may improve bioavailable antioxidant known to prevent and every treatment option that may provide oncological outcomes. a survival benefit, including new medications, oxidative processes and anti-inflammatory properties (3). Betalains have also been found clinical trials, chemotherapy, radiation therapy, Results or combination therapies. According to a 2008 to inhibit lipid peroxidation in very low Many plant extracts and phytochemicals are study by Velicer et al, in the Journal of Clinical concentrations (3). Cytotoxic properties of reported to work synergistically with a variety of Oncology, between 14% and 23% of people betalains are of interest, as these compounds chemotherapy agents. One such combination is with cancer begin using dietary supplements are thought to work synergistically to enhance that of beetroot and doxorubicin. Kapadia et after diagnosis(2). the cytotoxic activity of chemotherapy drugs al reviewed the synergistic antiproliferative (3). Cancer treatments have severe cytotoxic activity of red beetroot and doxorubicin in Red beetroot, also known as Beta vulgaris effects that cause apoptosis of cancer cells prostate and breast human tumor cells (10). rubra, has gained attention as a potentially and may affect normal cells as well. Numerous Cytotoxic effects on two cancer cell lines beneficial supplemental therapy for cancer side effects dependent on medication type, (prostate PC-3, and breast MCF-7), were tested patients (3). Although the interest in beetroot dosage, number of medications, and using a variety of beetroot and doxorubicin is primarily due to the dietary nitrates it provides, treatment types have been reported (3). concentrations ranging between 0.29-290 ug/ other compounds in beetroot also contribute Cytotoxic medicines can affect the bone ml and in combinations of 1:0, 1:1, 5:1, 1:5, and to its beneficial effects (3). Beetroot is rich in marrow, which subsequently alters and 0:1 of beetroot to doxorubicin(10). Synergy ascorbic acid, carotenoids, phenolic acids, and depresses the immune system, and have been was assessed using the Chou-Talalay method, 18 ❙ Oncology Nutrition Connection ❙ Volume 25, Number 3, 2018

which assesses effects of drug combinations doxorubicin, Das et al looked at MDA-MB-231 250 and 500mg/kg of BVE, respectively, (11). Chou-Talalay is based on the median- cell apoptosis after 48 hours of treatment with compared to the GM treated group (p <0.01) effect equation, derived from the mass-action doxorubicin and beetroot juice (12). The same (10). Non-protein sulfhydryl (NP-SH) are thiols law principle (11). The resulting combination concentrations from previous cycles were used which can be found throughout the body. index (CI) theorem of Chou-Talalay offers a and showed a significant increase (P<0.001) in NP-SHs are important as they have been linked quantitative definition for additive effect cell apoptosis for all concentrations when to antioxidant properties and gastroduodenal (CI = 1), synergism (CI < 1), and antagonism combined with doxorubicin, at a rate of nearly integrity (12). More specifically, they have been (CI > 1) in drug combinations (11). double when compared to the doxorubicin noted to protect against cell, tissue, and organ only treated group (12). Animal data suggest damage that was chemically-induced (12). The study noted an overall positive reduction beetroot extract may have protective effects NP-SH was significantly reduced by GM in cell growth in both cell lines. The best during cancer treatment as well. Gamal, et al. (37.94%), however, there was a noted increase synergism was noted at a ratio of 1:5 of assessed the efficacy of beetroot extract to in NP-SH when treated with BVE (12). This beetroot to doxorubicin, in both cell lines (10). ameliorate gentamicin-induced nephrotoxicity suggests BVE can aid in replenishing NP-SH to in rats (13). Serum urea, uric acid, serum total normal levels, indicating that BVE can decrease Another study tested the concurrent protein, creatinine, and histopathology of protein catabolism and rebalance nitrogen (12). treatment of doxorubicin with beetroot juice kidney failure were monitored to assess For both catalase and total protein levels, GM and its effects on the breast cancer cell line, nephrotoxicity during gentamicin (GM) therapy treated rats experienced significant decrease in MDA-MB-231(12). Since doxorubicin is known (13). The rats were divided into 4 groups, 6 serum concentrations. When treated with BVE, to be cardiotoxic, this study also investigated animals per group; group 1 served as a control however, there was a significant increase beetroot juice’s ability to reduce the while groups 2, 3, and 4 received GM (13). in both catalase and total protein levels, percentage of cardiomyocyte cell death (12). Group 2 was given 85mg/kg/day of GM for 8 demonstrating initiation of normal kidney Das et al. created cell treatment groups of days without beetroot to determine effect of cell proliferation and ability to restore levels adult rat cardiomyocytes and the cancer cell GM alone compared with control. Groups 3 indicative of kidney function (12). Anti- line MDA-MB-231. The cardiomyocytes and and 4 were treated with 85mg/kg/day of GM inflammatory properties of BVE were MDA-MB-213 cells were exposed to different and beetroot extract at 250 and 500mg/kg, demonstrated through decreases in IL-6 concentrations (0.5, 5, 50, 250, 500 µg/ml) of respectively, for 20 days prior to GM treatment and myeloperoxidsase activity (12). beetroot juice, with or without doxorubicin and during the standard 8-day treatment (13). (2µM, with a control of growth medium) (12). Blood was collected 24 hours after the last GM Histopathological assessments on kidney Doxorubicin administered alone at a dose to assess creatinine, uric acid, and urea tissues demonstrated interstitial nephritis with concentration of 2µM significantly increased serum concentrations (13). Kidney tissues were shedding of renal tubule cells with GM only (P<0.001) cardiotoxicity compared with used to assess malondialdehyde, non-protein treatment. Subjects concurrently treated with the control group (12). When comparing sulfhydryl, catalase, myeloperoxidase levels, GM and BVE at 500mg/kg/d demonstrated doxorubicin alone to beetroot juice alone and and serum total protein content of the kidneys normal glomeruli and tubules, and decreased to beetroot juice + doxorubicin, there was a (13). It was noted that beetroot (Beta Vulgaris nephritis (13). Nowacki, et al further looked at significant decrease of cardiomyocyte death L.) extract (BVE), combined with GM did reduce betanin’s role in cell death of MCF-7 cells, a (P<0.001) in all groups except for the 500µg/ blood urea (P <0.001), uric acid (P <0.001) and human breast adenocarcinoma cell line, ml beetroot juice + doxorubicin combination creatine serum levels (P <0.001), as well as typically treated with anti-estrogens (14). (12). Twenty-four hours post-treatment increase protein concentration (P <0.01) Measuring apoptosis-related protein, however, cardiotoxicity increased as the compared with GM alone (13). Blood expression (Bad, TRAILR4, FAS, and p53) of concentration of beetroot juice increased, concentrations of uric acid, urea, and creatinine MCF-7 cells treated with betanin-enriched compared to the control, but overall remained all increased while protein decreased with GM extract (BEE) showed a significant increase in lower than the doxorubicin only treated group alone when compared to the placebo (13). apoptosis and decrease cancer cell proliferation (12). These results were duplicated with (14). Treatment with BEE decreased MCF-7 cell significant (P<0.001) values after 48 hours BVE also demonstrated an effect on viability. Cell cytotoxicity revealed that wild as well (12). MDA-MB-231 cancer cell viability malondialdehyde, a highly reactive compound type p53 cancer cell lines were highly sensitive was not significantly reduced at concentrations resulting from lipid peroxidation that is to BEE treatment, but mutated p53 cells were of beetroot juice under 250µL (P>0.05), potentially mutagenic (12). Malondialdehyde less sensitive to treatment (14). This suggests however, cell viability was significantly exponentially increased after treatment with BEE can inhibit aggregated cancer cell reduced in MDA-MB-231 cancer cells with GM which indicates oxidative stress. Concurrent proliferation of p53 mutated cells, which are beetroot juice concentrations of 250 and treatment with BVE showed an expected dose- known to be more resistant to apoptosis 500 µg/ml (P<0.001)(12). dependent reduction in malondialdehyde, induction (14). A decrease in G1 cell numbers because BVE is an antioxidant substance (12). and an increase in cells in the S phase were also To further assess beetroot juice’s ability as Results from the study noted 37.54% and noted (14). Furthermore, the viability of MCF-7 an effective concurrent treatment with 58.28% malondialdehyde reduction for cells was strongly decreased when treated with Oncology Nutrition Connection ❙ Volume 25, Number 3, 2018 ❙ 19

BEE. The lack of significant changes noted when BEE was applied to normal cells indicate BEE treatment yields limited adverse side effects (14).

Discussion Betanin and Betalain, similar red pigments found in red beetroot, have shown significant ability alone, and in combination with chemotherapy drugs, to induce cytotoxicity in an array of cancer cell lines. The antioxidant properties of these phytochemicals, and their ability to work synergistically with cytotoxic drugs, provides a promising avenue for further research. Further, not only do beetroot, beetroot juice, and beetroot supplements provide increased nitrates, which may be beneficial for cancer patients to maintain adequate nitrate intake for appropriate lean body mass maintenance through increased ATP production, it also appears to provide further protection for those undergoing cytotoxic treatments (8,9,12-14). Due to inadequate intake of protein/nitrates, cancer patients are more susceptible to cancer cachexia or loss of lean body mass (9). Beetroot juice may provide assistance in maintaining lean body mass during chemotherapy, which can aid in improving outcomes (9). The cell and animal studies presented demonstrate betanins or beetroot/beetroot juice improve cytotoxicity when compared to controls, and may also enhance cancer cell cytotoxic properties of chemotherapy agents. Beetroot also may reduce renal specific adverse effects of chemotherapy agents (14). Beetroot decreased the risk of acute renal failure associated with chemotherapy treatments in rats, while increasing the kidney’s ability to preserve protein, resulting in a decreased risk of lean body mass loss (14).

Although these studies provide positive data to support the concurrent use of dietary beetroot or beetroot supplements/juices, during chemotherapy, there are limitations in the quantity and types of studies (10-14). The studies on human cell lines and rat models need to be validated in human trials. Other limitations include the small selection of chemotherapy agents tested compared to the array of chemotherapy agents currently in use in oncology treatment. Further studies are required to determine if beetroot also works 20 ❙ Oncology Nutrition Connection ❙ Volume 25, Number 3, 2018

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