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Nutritional epidemiology in the context of nitric oxide biology: A risk–benefit
evaluation for dietary nitrite and nitrate
Andrew Milkowskia, Harsha K. Gargb, James R. Coughlinc, Nathan S. Bryanb,d,*
aMuscle Biology Laboratory, Department of Animal Sciences, University of Wisconsin, Madison, WI, USA
bBrown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center, Houston, TX, USA
cCoughlin & Associates, Laguna Niguel, CA, USA
dThe University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
a r t i c l e i n f o
Received 6 August 2009
Revised 25 August 2009
Available online 11 September 2009
a b s t r a c t
The discovery of the nitric oxide (NO) pathway in the 1980s represented a critical advance in understand-
ing cardiovascular disease, and today a number of human diseases are characterized by NO insufficiency.
In the interim, recent biomedical research has demonstrated that NO can be modulated by the diet inde-
pendent of its enzymatic synthesis from L-arginine, e.g., the consumption of nitrite- and nitrate-rich foods
such as fruits, leafy vegetables, and cured meats along with antioxidants. Regular intake of nitrate-con-
taining food such as green leafy vegetables may ensure that blood and tissue levels of nitrite and NO
pools are maintained at a level sufficient to compensate for any disturbances in endogenous NO synthe-
sis. However, some in the public perceive that dietary sources of nitrite and nitrate are harmful, and some
epidemiological studies reveal a weak association between foods that contain nitrite and nitrate, namely
cured and processed meats, and cancer. This paradigm needs revisiting in the face of undisputed health
benefits of nitrite- and nitrate-enriched diets. This review will address and interpret the epidemiological
data and discuss the risk–benefit evaluation of dietary nitrite and nitrate in the context of nitric oxide
biology. The weak and inconclusive data on the cancer risk of nitrite, nitrate and processed meats are
far outweighed by the health benefits of restoring NO homeostasis via dietary nitrite and nitrate. This
risk/benefit balance should be a strong consideration before there are any suggestions for new regulatory
or public health guidelines for dietary nitrite and nitrate exposures.
? 2009 Elsevier Inc. All rights reserved.
Today, we are bombarded with media reports of studies relating
diet to a number of chronic diseases, including coronary heart dis-
ease, cancer, type 2 diabetes and osteoporosis. For the past several
decades, observational studies of diet and cancer have yielded
many inconsistent results [1,2]. Given the limited variation in die-
tary intakes within many study populations and the seemingly
weak diet–cancer associations that have been observed, results of
such studies depend critically on an accurate assessment of dietary
exposure [3,4]. Measurement error in exposure can lead to serious
errors in the reported relative risks of cancer for dietary intakes
and can substantially reduce the statistical power to detect true
existing relationships [3,4]. Extreme caution is required when
interpreting associations, or the lack thereof, between dietary fac-
tors and disease.
Overall, the media does a fairly good job of reporting the limita-
tions of the studies and the fact that the published results are
merely expressions of risk probability. However, a recent, promi-
nent Perspective article in the New England Journal of Medicine
 noted that all too frequently, what is conveyed about health
and disease by many journalists is wrong or misleading, especially
when they ignore complexities or fail to provide context. When
this happens, the public health messages conveyed are inevitably
distorted or inadequate. Therefore, the news media need to
become more knowledgeable and to more fully embrace their role
in delivering accurate, complete and balanced messages about
This is especially needed when the results being communicated
to the public are diet-health associations, due mainly to the com-
plexity of the diet compared to a drug/placebo clinical trial. There
has been a dramatically increased interest in nutrition and health
over the past decade. What we eat or don’t eat is constantly being
linked to various diseases, and there is a constant flow of anxiety-
provoking media headlines on television, radio, print and more
recently the Internet. ‘‘Carcinogen-of-the-month” reporting has be-
come very alarming to consumers, and dietary epidemiological
1089-8603/$ - see front matter ? 2009 Elsevier Inc. All rights reserved.
* Corresponding author. Address: Brown Foundation Institute of Molecular
Medicine, The University of Texas Houston Health Science Center, 1825 Pressler
St., SRB 530B, Houston, TX 77030, USA. Fax: +1 713 500 2447.
E-mail address: Nathan.email@example.com (N.S. Bryan).
Nitric Oxide 22 (2010) 110–119
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/locate/yniox
Author's personal copy
studies always seem to be contradicting each other, leading to
much nutrition nonsense and food faddism. Because of these fears,
consumers become sporadic or chronic avoiders of specific foods
and ingredients, such as salt, fat, soft drinks, artificial sweeteners,
carbohydrates in general, coffee/caffeine and meat products.
In a recent issue of Archives of Internal Medicine, Sinha et al. 
reported in a large prospective study that red and processed meat
intakes were associated with modest increases in total mortality,
cancer mortality, and cardiovascular disease mortality. Like many
other studies, it failed to completely consider several additional
factors that can contribute to chronic disease, including partici-
pants’ behavior as to alcohol and tobacco use, exercise, weight
and access to health care. It also failed to recognize the role of beef,
pork and other red meat in providing essential and under-con-
sumed nutrients. In response to such reporting deficiencies, many
individuals become either confused or alarmed about their own
personal situation. There are also calls by numerous public health
and consumer organizations to change our lifestyles as a matter of
public policy. Therefore, it is important for participants in the so-
cial debate to also understand the strengths and limits of epidemi-
ological research. We will review the science of epidemiology,
introduce the criteria for interpretation of the data and then dis-
cuss some published reports on diet and risk of disease. Since foods
are heterogenous and complex in terms of their composition and
contribution to the overall diet, ascribing an individual component
of food as ‘‘good” or ‘‘bad” is fraught with difficulty. We will pres-
ent a cursory review of current epidemiological data, but we will
also focus primarily on the context of nitrite and nitrate in foods
and what is reported about them, in order to present a balanced
view of dietary sources of essential nutrients and a potential
Epidemiology as a scientific discipline
Modern epidemiology is the branch of medicine that deals with
the study of the causes, distribution and control of disease fre-
quency in human populations. Historically, epidemiology began
as the study of epidemics of infectious disease. Epidemiology
essentially looks for patterns of disease (time, place, exposures,
personal characteristics). Nothing affects our health more than
what we choose to eat. Many studies relate the association be-
tween processed meats and cancer to their nitrite and nitrate con-
tents. The primary concern for exposure to dietary nitrite (and
nitrate as a precursor to nitrite) is its propensity to form potentially
carcinogenic N-nitrosamines and their consequent potential to
cause human cancer [7,8]. In terms of human cancer risk and diet,
most of the publications, discussion and media attention have fo-
cused on data from epidemiological studies. Therefore, it is impor-
tant to understand the different types of dietary epidemiological
studies, while at the same time noting that epidemiological associ-
ations reported between dietary components, specific foods (or
food groups) and chronic disease are rarely sufficient to establish
cause and effect relationships. The results of epidemiological
investigations must also be evaluated through other types of sup-
portive studies (animal studies, mechanistic studies, metabolic
studies, human clinical intervention trials, etc.) before persuasive
causal relationships can be firmly established [9,10].
There are several types of epidemiological studies, each with
their own strengths and weaknesses . Ecologic/descriptive
studies are the simplest and least persuasive type. They character-
ize differences between large and diverse populations by simple
generalizations and can help formulate hypotheses; however, they
cannot control for potential confounding factors, i.e., factors that
are known risk factors for the disease. Case-control studies focus
on individuals and provide stronger evidence for an association
than ecologic studies. ‘‘Recalled” past diets of individuals diag-
nosed with a disease (cases) are compared to those of individuals
without the disease (controls) in a retrospective case-control
study. Many researchers rely on this type of study because of lower
cost, smaller sample size and ability to study many potential fac-
tors. However, such retrospective studies are subject to recall bias
and unavailable or incomplete data particularly accurate dietary
exposure data. There may also be questions regarding adequacy
of the ‘‘control” group. Follow-up (prospective cohort) studies, on
the other hand, are considered to provide the most definitive infor-
mation and are the most persuasive study design. In these studies a
cohort (group) of individuals, who do not yet have a specific dis-
ease, are selected and followed over a period of time while collect-
ing specific information regarding diet and other factors related to
the development of the disease. However, prospective studies are
more costly and require more time and larger numbers of subjects.
Following on the results of these types of epidemiological study, it
is critical to conduct human, randomized clinical intervention
studies in order to ultimately establish cause–effect relationships.
Interpretation of epidemiological studies demands causation
To evaluate research findings in any area of scientific investiga-
tion, certain scientific standards, established by experts in each
field, need to be applied. This is especially true when trying to
determine the health effects of the inclusion or exclusion or varying
levels of components in the diets of humans. The eminent British
biostatistician and epidemiologist A. Bradford Hill published a sem-
inal paper in 1965  offering a number of interpretation criteria
that would be useful when interpreting the statistical results ob-
served in epidemiological studies. The goal of these criteria was
to guide epidemiologists in inferring causation (or establishing
‘‘causal inference”) from the associations observed in such studies.
In effect, Bradford Hill tried to provide a framework to judge
whether associations observed in a body of epidemiological work
could be determined to be causal. Since the time of his publication,
these criteria (which Bradford Hill urged others to call ‘‘viewpoints”
and not true criteria) have become a de facto standard to evaluate
the statistical associations found in epidemiological research.
Bradford Hill pointed out, however, that none of these nine
viewpoints provide indisputable evidence for or against a cause
and effect hypothesis. What he claimed they could do, with greater
or less strength, was to help answer the fundamental question of
whether there is any other way of explaining the set of observed
facts, i.e., is there any other answer equally, or more likely than
cause and effect? His criteria are still very relevant to the scientific
and public discussion of diet and disease relationships. Bradford
Hill’s causation criteria are described below, with examples given
to help illustrate each of the criteria.
The interpretation criteria for epidemiological associations pre-
sented by A. Bradford Hill in 1965.
1. Strength of
Magnitude of the effect
Exposure must precede the disease
Similar findings in many studies without
supports the findings
No alternate hypotheses
No confounding factors are found
Higher risk with higher exposure
Animal and in vitro experiments show the effect
9. AnalogySimilar findings in other situations can apply
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
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1. Strength of association: The stronger the relationship between the
independent variable (the risk factor) and the dependent variable
(the disease), the less likely it is that the relationship is due to an
extraneous variable (a confounder). For example, the relative risk
of smokers developing lung cancer is around 10 or above (i.e., a
10-fold higher risk than for non-smokers). The relative risk associ-
ated with consumption of grains containing mycotoxins and liver
cancer is around 6. These are quite strong associations, and by con-
trast, modest relative risks on the order of 2 or less should be
viewed with skepticism due to the likelihood of many potential
confounders. This was recognized in 1994 when the U.S. National
Cancer Institute publicly indicated that relative risks values less
than 2 were not strong enough to use for public policy pronounce-
ments  (this document is available through the National Cancer
Institute’s CancerFax and CancerNet services, and in the News Sec-
tion of the NCI’s PDQ database. To get the document from Cancer-
Fax, dial +1 301 402 5874 from the handset on your fax machine
and follow the recorded instructions to receive the contents list:
U.S. National Cancer Institute Press Release, Oct 16, 1994).
2. Temporality: The exposure must precede the disease by a rea-
sonable amount of time, i.e., a cause must precede an effect in time.
For example, cigarette smoking over a period of years is well-
established to increase lung cancer risk. While this relationship
seems obvious, there have been published findings that have occa-
sionally violated this criterion.
3. Consistency: Multiple observations of an association, with dif-
ferent people under different circumstances and with different
measurement instruments, increase the credibility of a causal find-
ing. Different methods (e.g., ecological, cohort and case-control
studies) should produce the same conclusion. The relationship
should also hold for different groups of people (in males and fe-
males, in different populations on different continents). This crite-
rion is greatly debated, however, because consistency is often in
the eye of the beholder. Some reviewers can conclude that six of
ten studies with a statistically significant association represent a
consistent finding, while others can see the same set of data as
4. Theoretical plausibility: It is easier to accept an association as
causal when there is a rational and theoretical basis for such a con-
clusion supported by known biological and other facts. While our
knowledge of physiology today is vast, there is still much that is
unknown about the complex interactions of ingested foods and
food components and their metabolism, interactions and potential
5. Coherence: A cause-and-effect interpretation for an observed
association is clearest when it does not conflict with what is known
about the variables under study and when there are no plausible
competing theories or rival hypotheses. In other words, the associ-
ation must be coherent with other existing knowledge. The conclu-
sion that smoking causes lung cancer, based on decades of
epidemiologic, laboratory animal, pharmacokinetic, clinical and
other biological data, showed that all available facts stuck together
as a coherent whole.
6. Specificity in the causes: In the ideal situation, the effect has
only one cause. In other words, showing that a disease outcome
is best predicted by one primary factor adds credibility to a
causal claim. But this is often not the norm. High consumption
of one food, food ingredient or nutrient can be covariate with
low consumption of another food or ingredient, and it is often
difficult to determine which of the two is more important. Other
non-dietary confounders must also be considered. For example,
chronic Helicobacter pylori infection is a strongly suspected risk
factor forgastriccancer .
studies that fail to account for the incidence of this infection in
the population studied should therefore be viewed with caution.
7. Dose–response relationship: There should be a direct biological
gradient (or dose–response) between the risk factor (the indepen-
dent variable) and people’s status on the disease variable (the
dependent variable). Many dietary epidemiological studies report
a significant statistical trend for dose–response, but on closer
examination, the data can be highly inconsistent. The data may
only span a very narrow range of dietary intakes or in some cases
such a wide range of intakes that upper intakes are representative
of a grossly unbalanced diet. Calculated relative risks may some-
times decline to non-significant levels with higher intakes, or in
some cases one quartile of intake may have a high enough calcu-
lated risk to skew the overall results. Such data patterns, when
deviating from the linear dose–response, need to be considered
as unlikely dose–response relationships and also be considered
as part of the consistency criterion.
8. Experimental evidence: Any related research (animal, in vitro,
etc.) that is based on experiments and supports the conclusions
of epidemiological studies will make a causal inference more plau-
sible. This must be tempered with the understanding that animals
are not people, and results from lifetime, chronic feeding bioassays,
where rodents are dosed at levels up to and sometimes exceeding
maximum tolerated doses (MTDs), in such testing programs as the
U.S. National Toxicology Program, may often be very useful but are
not definitive by themselves.
9. Analogy: Sometimes a commonly accepted phenomenon in
one area can be applied to another area. For instance, a newly dis-
covered N-nitrosamine may be considered to be a carcinogen if it
has structural similarities to other well-known carcinogenic N-
nitrosamines. However, analogy is an obtuse criterion, and thus
is considered to be a weaker form of evidence. This makes the
application of the analogy consideration even more uncertain than
the application of considerations on plausibility and coherence.
Bradford Hill developed his list of ‘‘criteria” that continues to be
used today. When using them, it’s important not to forget Hill’s
own advice: ‘‘None of these nine viewpoints can bring indisputable
evidence for or against a cause and effect hypothesis... What they
can do, with greater or less strength, is to help answer the funda-
mental question – is there any other way of explaining the set of
facts before us, is there any other answer equally, or more, likely
than cause and effect?” Phillips and Goodman  have recently
provided observations on the use of Hill’s ‘‘causal criteria.” They ar-
gued that the uncritical repetition of Hill’s criteria is probably
counterproductive in promoting sophisticated understanding of
causal inference, but they set out a simplified list of the key Hill
considerations that they thought is worthy of repeating:
? ‘‘Statistical significance should not be mistaken for evidence of a
? Association does not prove causation (other evidence must be
? Precision should not be mistaken for validity (non-random
? Evidence (or belief) that there is a causal relationship is not suf-
ficient to suggest action should be taken.
? Uncertainty about whether there is a causal relationship (or
even an association) is not sufficient to suggest action should
not be taken.”
The authors pointed out that while these points may seem obvi-
ous when stated so briefly and bluntly, causal inference and health
policy decision-making would benefit tremendously if they were
considered more carefully and more often.
The International Food Information Council (IFIC) Foundation
has addressed the issue of ‘‘How to Understand and Interpret Food
and Health-Related Scientific Studies” . They discuss the types
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
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of epidemiological research studies and what journalists, educators
and health professionals should look for when critically reviewing
scientific studies. When evaluating an epidemiological report, IFIC
suggested that the following questions can be asked:
? Could the study be interpreted to say something else?
? Are there any methodological flaws in the study that should be
considered when making conclusions?
? Are the study’s results generalizable to other groups?
? How does the work fit with the body of research on the subject?
? What are the inherent limitations of this type of study and does
the research design fit the stated purpose of the study?
? Has the author omitted important points in the background sec-
tion which could have a meaningful effect on the study design or
interpretation of the results?
? Are there any major design flaws in the study and are the data
collection measures appropriate to answer the study questions?
? Were methodological limitations acknowledged and discussed
and what influence might these have had on the results?
? What is the real and statistical significance of the results?
? To whom do the results apply and how do the results compare
to those of other studies on the subject?
? Are the conclusions supported by the data?
? Are the conclusions of the study related to the stated purpose of
the study? If not, does the study design and results support the
A recent Commentary addressed the important issue of false-
positive results that are inherent in the testing of hypotheses con-
cerning cancer and other human illnesses . The authors point
out that epidemiology has been increasingly criticized for produc-
ing results that are often sensationalized in the media and some-
times fail to be upheld in subsequent studies. They suggested
general guidelines or principles, including editorial policies requir-
ing the prominent listing of study caveats, which may help reduce
the reporting of misleading results. The authors also urged in-
creased humility by study authors regarding findings and conclu-
sions in epidemiology, noting that this would go a long way
toward diminishing the detrimental effects of false-positive results
in several areas: (1) the allocation of limited research resources;
(2) the advancement of knowledge of the causes and prevention
of cancer and (3) the scientific reputation of epidemiology. They
concluded that such efforts would help to prevent oversimplified
interpretations of results by the media and the public.
Diet and cardiovascular disease
Now with these epidemiological criteria in mind, we will pres-
ent the available data on certain foods and risk of specific diseases,
namely cardiovascular disease (CVD) and cancer. Nothing is more
important to our health than our diet, and there are well-estab-
lished and recognized dietary patterns that confer health benefits.
Numerous dietary epidemiological data have generally indicated
an inverse relationship between dietary intake of fruits and vege-
tables and incidence of both CVD and cancer. The specific constit-
uents of fruits and vegetables that afford protection from CVD have
and continue to be widely researched and debated. Although there
are many dietary components which may have protective effects,
antioxidants appear to be one of the groups of phytochemicals that
play a significant role.
One group of antioxidants present in fruits and vegetables is
known as ‘‘polyphenols” or ‘‘polyphenolics” and is believed to neu-
tralize free radicals formed in the body, thus minimizing or pre-
venting damage to cell membranes and other cell structures.
Although antioxidants are generally credited with improving states
of oxidative stress, epidemiological studies which have evaluated
the efficacy of supplementation with a high dose of an antioxidant
alone, such as vitamin E, have shown no apparent improvement
and in some cases a decrease in cardiovascular protection .
Yet, when these antioxidants are consumed through the diet in
the form of fruits and vegetables, there is a significant degree of
protection, best represented by the decrease in mortality rates
from CVD of those consuming the popular Mediterranean diet
. Although Mediterranean diets vary by country, seasonal
availability of ingredients and traditional cooking habits, they all
tend to be rich in fruits, vegetables and monounsaturated fatty
acids while low in saturated fat and meat. Epidemiological studies,
such as the Seven Countries Study [19–25], have led to theories
describing why and how the Mediterranean diet may promote a
lower incidence of CVD, and antioxidants are emerging as a key
component. However, since antioxidant supplementation alone
does not confer the cardiovascular benefits, there must be more
to explain the cardioprotection afforded by fruits and vegetables.
The data and emerging story presented in this context provide a
convincing argument for nitrite and nitrate as probable protective
components[26,27].The SevenCountriesStudyconstitutesthe first
nutritional epidemiological investigation that provided solid data
for cardiovascular disease rates in different populations. The Seven
Countries Study is the prototypical comparison study of popula-
tions,madeacross a widerange of diet,risk,and diseaseexperience.
It was the first to explore associations among diet, risk, and disease
in contrasting populations (ecologic correlations). Central chemical
analysis of foods consumed among randomly selected families in
tive test of the dietary hypothesis. The study was unique for its
time, in standardization of measurements of diet, risk factors, and
disease; training its survey teams; and central, blindfold coding
and analysis of data. In this study the results for all-cause death
rates in Greece, Japan and Italy were quite favorable compared with
the USA, Finland, the Netherlands and the former Yugoslavia; the
results also showed a lower incidence of CVD after a 5-year fol-
low-up for the same countries that exhibited low mortality. The
diet consumed by the Mediterranean cohorts studied was associ-
ated with a very low incidence of CVD and was called the Mediter-
ranean diet by Keys . Following the Seven Countries Study, the
Mediterranean diet has oftentimes been singled out as a healthy
diet. Additional studies later confirmed the association of the Med-
iterranean diet with decreased incidence and prevalence of chronic
diseases, mainly CVD, in countries where it was consumed.
There are food peculiarities for the different populations in the
Mediterranean basin. However, beyond the apparent differences,
there are nutritional characteristics common to all or most of the
diets in the Mediterranean region. The Mediterranean diet is char-
acteristically low in saturated and high in monounsaturated fats
(olive oil), low in animal protein, rich in carbohydrates, and rich
in vegetables and leguminous fiber. People consuming a Mediter-
ranean diet eat a relatively large amount of fish and white meat,
abundant fruits and vegetables and a low amount of red meat,
but they also drink moderate amounts of red wine . The health
benefits of Mediterranean diets have been attributed, at least in
part, to the high consumption of antioxidants provided by fruit,
vegetables and wine and to the type of fat, rich in monounsatu-
rated and x–3 fatty acids from vegetables and fish, and especially
to a balancedx–6/x–3 fatty acid ratio, as is found in the traditional
diet of Greece prior to 1960 . Emerging data reveal that part of
the health benefits may be mediated through their nitrite/nitrate
content since diets rich in fruits and vegetables, i.e., Mediterranean
diet are enriched in nitrite and particularly nitrate [26,27]. In fact,
based on a convenience sample from each, a typical Mediterranean
diet may contain as much as 20 times higher nitrite and nitrate
than a typical western diet .
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
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Diet and cancer
In contrast to the evidence on diet and CVD, epidemiological
data on the consumption of meats and the risk of cancer some-
times reveal a slightly increased risk. Since dietary factors, which
can be numerous and complex, may yield both positive and neg-
ative risk associations, they are of great interest to the research
community, public health agencies and to the public. A total of
1,479,350 new cancer cases and 562,340 deaths from cancer
are projected to occur in the U.S. in 2009 . The U.S. National
Institutes of Health estimate overall costs of cancer in 2007 at
$219.2 billion. Smoking, poor nutrition, and physical inactivity
are important risk factors for cancer. There is evidence that die-
tary patterns, foods, nutrients, and other dietary constituents are
closely associated with the risk for several types of cancer. And
while it is not yet possible to provide quantitative estimates of
the overall risks, it has been estimated that up to 35 percent of
cancer deaths may be related to dietary factors . Many epide-
miologic studies have shown that populations that eat diets high
in vegetables and fruits and low in animal fat, meat, and/or cal-
ories have reduced risk of some of the most common cancers.
Coincidently, fruits and vegetables are enriched with nitrite and
nitrate from the soil. Colorectal cancer is the third leading cause
of cancer-related deaths for both males and females in the U.S.
Consumption of specific food components has been associated
with risk of colorectal cancer. Dietary factors associated with in-
creased colorectal cancer risk, include red meats and processed
meats, while dietary fiber consumption is associated with de-
creased risk in low risk populations.
The consumption of red meat and, in particular, processed or
preserved or cured meats (i.e., meats treated with nitrite as a food
additive, including ham, bacon, hot dogs, etc.), has been related to
the incidence of colorectal cancer since 1975 in several epidemio-
logical studies. A worldwide recommendation for moderation in
the consumption of preserved meats, such as sausages, salami, ba-
con and ham, was launched by the World Health Organization in
2003 . However, a 2007 report by the World Cancer Research
Fund and the American Institute of Cancer Research (WCRF/AICR)
has presented a recommendation to ‘‘avoid processed meats”
, based on a meta-analysis of a limited number of selected co-
hort studies showing increased risk of colorectal cancer with in-
creased intake of processed meats. The summary estimate of
relative risk was determined to be 1.21 (95% confidence inter-
val = 1.04–1.42) per 50 g intake/day and was supported by case-
control studies. A separate Swedish meta-analysis of 14 cohort
studies reported a slightly lower summary hazard ratio estimate
of 1.09 (95% confidence interval = 1.05–1.13) per 30 g intake/day
. However, these findings must be viewed with skepticism, con-
sidering that a relative risk ratio of 1.0 indicates no increase in risk
and anything less than 2.0 should not be used for public policy rec-
ommendations, according to the U.S. National Cancer Institute .
According to the WCRF/AICR summary estimate of relative
risk, a decrease of 50 g/day in processed meat consumption
may then lower the total number of colorectal cancer cases by
approximately 20%. A relative risk estimate of <1.3 would nor-
mally receive little attention in the epidemiological community.
However, exposure to processed meats is so widespread, even a
modest association, if proven causal, may have considerable pub-
lic health consequences . Curiously, the same literature re-
view by the WCRF/AICR found a statistically significant 26%
protective effect against rectal cancer for the highest meat con-
sumption level, an important finding not referenced in the
WCRF/AICR report or the press release that accompanied the re-
port. However, there are also large epidemiologic studies show-
ing no association between colorectal cancer and exposure to
red or processed meats [37,38], and a recent meta-analysis pub-
lished since the release of the WCRF/AICR report does not appear
to support an independent association between animal fat intake
or animal protein intake and colorectal cancer . In addition,
the findings of another recent meta-analysis showed no support
for an independent relation between red or processed meat in-
take and kidney cancer . Although some of the summary re-
sults were positive, all were weak in magnitude, most were not
statistically significant, and associations were attenuated among
studies that adjusted for key potential confounding factors, as
has often been seen in many cancer epidemiology studies of
The International Agency for Research on Cancer (IARC), a Uni-
ted Nations/World Health Organization body headquartered in
Lyon, France, has the mission to coordinate and conduct research
on the causes of human cancer and the mechanisms of carcinogen-
esis and to develop scientific strategies for cancer control. The
agency is involved in both epidemiological and laboratory research
and disseminates scientific information through publications,
meetings, courses, and fellowships. IARC Director Peter Boyle and
his colleagues responded to the media confusion caused by the re-
lease of the WCRF/AICR in an editorial in the Annals of Oncology .
They strongly objected to the report’s downplaying the causative
role of tobacco smoking and second-hand smoke in cancer causa-
tion and also criticized the report’s conclusions on overweight,
obesity and diet as major cancer causation factors. Boyle and col-
leagues specifically cast doubt on the rationale used to classify as
‘‘convincing” the evidence linking high meat intake to colorectal
cancer risk. In fact, they argued that this conclusion on meat and
cancer raised questions about the WCRF/AICR evaluation process
and about the robustness of the classification system. Pointing
out the fragile grounds on which the conclusions of the WCRF re-
port were based, the editorial’s authors felt that the information
to the media should have been more cautious and less confusing,
and that after decades of dietary research activity, we still do not
know how we need to change what we eat to reduce our cancer
Firm evidence of cancer causation in humans is lacking for die-
tary nitrite and nitrate. A comprehensive review  could find no
epidemiological evidence linking stomach, brain, esophageal and
nasopharyngeal cancers to dietary intake of nitrate, nitrite or N-ni-
troso compounds. This conclusion was further supported by a
study showing that cured meat consumption was not linked to
adult or childhood brain cancer in the U.S. . The epidemiolog-
ical data on meats, particularly cured and processed meats, be-
comes important in terms of exposure because such products are
known to contain nitrite and nitrate. There are many other con-
founding factors in meats (saturated fats for example), but the di-
rect implications for nitrite and nitrate content are far from
conclusive. Early reports implicated nitrite and nitrate in processed
meats as the culprit. Since the 1950s, when the potential to form
carcinogenic N-nitrosamines from the reaction of nitrous acid with
secondary amines was recognized, the use of nitrite salts as food
preservatives has been under intense scrutiny. Numerous case-
control studies have been conducted worldwide to determine if
there is a link between gastric cancer and nitrate intake [41,43,44].
It is well known that elevated dietary nitrate intake leads to ele-
vated salivary nitrate levels and, after reduction by oral bacteria,
higher levels of ingested nitrite [45–47]. Studies in Canada, Italy,
Sweden and Germany involving thousands of study subjects have
failed to show an association or demonstrated an inverse associa-
tion between estimated nitrate intake and gastric cancer, perhaps
because much of the nitrate was from vegetables . Occupa-
tional exposure to very high levels of nitrate occurs in fertilizer
workers, who have elevated body burdens of nitrate and elevated
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
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salivary nitrate and nitrite levels show no increased incidence of
gastric cancers.. Case-control studies attempting to link nitrate
and nitrite consumption to brain, esophageal, and nasopharyngeal
cancers have also been inconclusive . In other studies pub-
lished over two decades, the relationship between the consump-
tion of cured meats during pregnancy and the risk of brain and
other tumors in offspring was examined . In a review of 14 epi-
demiological studies, 13 of which were case-control studies, Blot
et al.  could not conclude a relationship between cured meat
consumption during pregnancy and brain or any other cancers. It
may be that in the limited number of epidemiological studies link-
ing nitrate, nitrite or cured meats to a specific cancer site, other as-
yet uncharacterized dietary or environmental factors may be
Thus, the concern for the use of added nitrite in processed
meats (added nitrate is only used in a very limited number of
products outside the U.S.) has waxed and waned as numerous
studies were published and independent review and food regula-
tory panels have been convened to make determinations about
nitrite for use as a food additive and public policy. In 2000, the
results of a comprehensive battery of rodent carcinogenicity
and mutagenicity studies by the U.S. National Toxicology Pro-
gram (NTP), including a standard, 2-year chronic cancer bioassay
of sodium nitrite in rats and mice, were presented to the NTP
Technical Reports Review Subcommittee for evaluation. The final
NTP Technical Report  indicated that the only adverse finding
in both rats and mice was an ‘‘equivocal evidence” finding that
sodium nitrite weakly increased the number of forestomach tu-
mors in female mice but not in male mice or male or female rats.
All other organ sites in both rats and mice showed no evidence
of carcinogenicity. In short, any suspicion of sodium nitrite’s car-
cinogenicity in rodents was not supported by this state-of-the-art
cancer bioassay study. Shortly thereafter, in 2000, nitrite was
also reviewed and evaluated for potential listing as a develop-
mental and reproductive toxicant under the Proposition 65 Stat-
ute in California. A review of 99 studies on sodium nitrite led the
state’s Developmental and Reproductive Toxicant Identification
Committee of eight independent scientists to conclude that so-
dium nitrite should not be listed as a developmental toxicant
or as a male or female reproductive toxicant under California’s
Proposition 65 law. The literature and activities associated with
the above events were reviewed and published by Archer .
The latest review of ingested nitrate and nitrite carcinogenicity
was conducted in June 2006 by an expert working group convened
by IARC . The IARC working group made a decision to classify
nitrate and nitrite for their potential as human carcinogens as
‘‘Ingested nitrate or nitrite under conditions that result in
endogenous nitrosation is probably carcinogenic to humans
The expert group found that nitrate/nitrite was weakly associ-
ated with human stomach cancer only. They also appeared to
disregard or misinterpret the findings of the NTP cancer rodent
bioassay, which showed sodium nitrite was not carcinogenic in
rats and mice. The above conclusion, which in a very narrow
sense may be accurate, has in a broader biological sense ques-
tionable and minimal practical application. In simple terms, this
overall evaluation means that the ingestion of food and water
that contain nitrate or nitrite (e.g., spinach and other green leafy
combination with amines and amides commonly found in food,
can react in the stomach to form N-nitrosamines and N-nitrosa-
mides, which are known animal carcinogens already classified by
beer, cured meats),in
Antimicrobial benefits of nitrite in the food supply
Despite the very weak associations sometimes reported be-
tween dietary nitrite/nitrate and cancer, we must not forget the
essential nature of these ‘‘curative” salts in the safety of the food
we eat. The antibotulinal properties of nitrite have long been rec-
ognized. The use of nitrite to preserve meat has been employed
either indirectly or directly for thousands of years. Nitrite inhibits
outgrowth of Clostridium botulinum spores in temperature-abused
(i.e., non-refrigerated) meat products. The mechanism for this
activity was extensively investigated and results from inhibition
of iron–sulfur clusters essential to energy metabolism in this obli-
gate anaerobe [51–53]. Importantly, the broad antimicrobial ef-
fects of nitrite and implications for human health are still being
researched. Commensal bacteria that reside within and on the hu-
man body can reduce nitrate, thereby supplying a large and alter-
native source of nitrite. Thus, ingested nitrite is also derived from
reduction of salivary nitrate . About 25% of orally ingested
available nitrate is actively secreted into the saliva. This nitrate is
partially converted to nitrite by oral bacteria and then dispropor-
tionates with formation of NO after entering the acidic environ-
ment of the stomach, helping to reduce gastrointestinal tract
infection, increase mucous barrier thickness and increase gastric
blood flow .
Humans, unlike prokaryotes, are thought to lack the enzymatic
machinery to reduce nitrate back to nitrite. However, recent dis-
coveries reveal a functional mammalian nitrate reductase .
Lundberg and Govoni demonstrated that plasma nitrite increases
after consuming nitrate . Therefore, dietary and enzymatic
sources of nitrate are potentially large sources of nitrite in the hu-
man body. The nitrite in saliva has significant antimicrobial bene-
fits when it is swallowed and converted to nitrous acid and other
nitrogen oxides in the intestinal tract. The bactericidal effects of
gastric fluids are significantly enhanced by the presence of in-
gested nitrite. This has been demonstrated for known foodborne
pathogens such as Escherichia coli 0157:H7 and Salmonella
[56,57]. Nitrite and nitric oxide are also effective bacteriocidal
agents against other microorganisms associated with diseases such
as H. pylori, which has been linked to gastric cancer  and skin
pathogens [59–61]. As a food additive, nitrite is also important in
controlling potential growth of Listeria monocytogenes in processed
meats. Models that estimate the effects of ingredients on microbial
growth show dramatic reductions when nitrite is included [62–
68]. The use of such models has enabled formulations of nitrite-
cured processed meat products that will not support growth of L.
monocytogenes. To date, this has not been achieved for uncured
counterparts where the only ingredient difference is nitrite. There-
fore, addition of nitrite appears essential and requisite for ensuring
The United States Department of Agriculture (USDA) has done
extensive research to develop models to predict growth of patho-
gens under a variety of conditions . In their models, incorpora-
tion of nitrite at current levels significantly inhibits growth of
Listeria, E. coli, Staphylococcus aureus, and Bacillus cereus. By way
of illustration, the following predictions were calculated from the
USDA Pathogen Modeling program 7.0 model  and imply sig-
nificant pathogen risk reduction when nitrite is included in prod-
ucts (see Table 1).
A second illustration from the same USDA model shown below
is in agreement with the reports of enhanced bactericidal effects of
nitrite in gastric fluid (see Table 2).
The tradition of curing meats and more recent knowledge sur-
rounding the use of sodium nitrite to address risk of pathogens
has been embodied in modern food manufacturing systems. The
use of these approaches in cured meats has been estimated to sig-
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
Author's personal copy
nificantly reduce the risk of listeriosis ascribed to such products
. If the products were not cured (i.e., no nitrite was used), the
risk reduction would be greatly diminished and major efforts
would be needed to develop systems to produce equivalently safe
Nitrite is now known to be an intrinsic signaling molecule
[71,72] capable of producing NO under appropriate conditions as
well as forming nitrosothiols [71,73]. Nitrite has been shown to in-
crease regional blood flow , increasing oxygen delivery to hyp-
oxic tissues. Enhancing nitrite availability through therapeutic
intervention by administering bolus nitrite prior to cardiovascular
insult has shown remarkable effects in reducing the injury from
myocardial infarction, ischemic liver and kidney injury, stroke
and cerebral vasospasm [75–80] in animal models. These first re-
ports on the efficacy of nitrite in cytoprotection have led to nine
current clinical trials for the use of nitrite and/or nitrate in both
healthy volunteers and patients with specific cardiovascular com-
plications (www.clinicaltrials.gov). Most recently, nitrite has been
shown to precondition the myocardium when given 24 h prior to
ischemic insult due to the modulation of mitochondrial electron
transfer  as well as augment ischemia-induced angiogenesis
and arteriogenesis . Nitrite also presents remarkable efficacy
in promoting regional blood flow in sickle cell patients . Plasma
nitrite levels increase in response to exercise in healthy individu-
als, whereby in aged patients with endothelial dysfunction there
is no increase in nitrite from exercise . Nitrite has also been
shown to predict exercise capacity  and enhance exercise effi-
ciency in humans . Physical activity can even prevent age-re-
lated impairment in NO availability in elderly athletes . We
now know that nitrite is just as efficacious when given orally at
restoring NO biochemistry , reversing hypertension from NOS
inhibition , protecting from myocardial ischemia–reperfusion
injury , inhibiting microvascular inflammation, reversing
endothelial dysfunction and reducing levels of C-reactive protein
. This provides proof of concept that dietary sources of nitrite
have important physiological functions.
According to the World Health Organization, cardiovascular dis-
ease (CVD) is the number one killer of both men and women in the
U.S. These deaths represent a staggering 40% of all deaths. Close to
1 million people die each year and more than 6 million are hospi-
talized. The cost of CVD, in terms of health care and lost productiv-
ity, is over $270 billion and increasing as the baby boom
population ages. Ischemic heart disease, as the underlying cause
of most cases of acute myocardial infarction, congestive heart fail-
ure, arrhythmias, and sudden cardiac death, is the leading cause of
morbidity and mortality in all industrialized nations. In the United
States, ischemic heart disease causes nearly 20% of all deaths
(?600,000 deaths each year), with many of these deaths occurring
before the patient arrives at the hospital. Heart disease is very
likely the result of a dysfunctional endothelium.
One of the most important substances released by our body is
NO. The discovery that the human body makes NO from L-arginine
revolutionized science and medicine. Continuous generation of NO
is essential for the integrity of the cardiovascular system and a de-
creased production and/or bioavailability of NO is central to the
development of cardiovascular disorders. It is also important for
communication in our nervous system and a critical molecule
which our immune system uses to kill invading pathogens, includ-
ing bacteria and cancer cell. Reduced NO availability is a hallmark
of a number of disorders, including CVD. Understanding strategies
to enhance and restore NO homeostasis is critical to developing
treatments to cardiovascular disease and more importantly strate-
gies to prevent disease from developing.
The notion that there may be certain foods that can enrich NO
within our body is revolutionary. Therapeutics is the branch of
medicine concerned with the remedial treatment of disease. It is
prudent at this juncture to take a step back and look at nitrite
and nitrate as a means of prevention of a number of diseases asso-
ciated with NO insufficiency. Early intervention to restore NO/ni-
troso homeostasis through natural dietary means may prove to
be a cost-effective and natural means to prevent disease. It is
becoming increasingly clear that a deficiency in NO is a hallmark
of a number of disease conditions. It is highly unlikely that nature
devised a singular pathway which requires a complex five-electron
oxidation of a semi-essential amino acid requiring multiple co-fac-
tors and prosthetic groups. There is, by design, enormous redun-
dancy in physiology where there are multiple pathways and
regulatory processes for critical biological functions. This redun-
dancy ensures that if one pathway is absent or dysfunctional, there
is an alternative to produce and regulate critical signaling mole-
cules and pathways. Maintenance of NO homeostasis by nitrite
may be the redundant backup system in NO biology. A simple
one-electron reduction of nitrite to form NO or bimolecular reac-
tion with thiols to form nitrosothiols is a viable and effective sys-
tem for recapitulating NO biochemistry. Since at least half of our
body’s pool of nitrite is derived from what we eat, we can at will,
affect NO biochemistry through dietary means. Discovery and rec-
ognition of this pathway is likely to affect public health and strat-
egies to prevent and/or treat disease. We are currently faced with
an enormous public health crisis as our aging baby boomers suc-
cumb to disease, particularly CVD. Treatment and care of our great-
est generation is a tremendous economic burden, and developing
strategies to prevent disease or reduce injury from a cardiovascular
accident will improve patient outcome and enhance quality of life.
Recognizing a natural and inexpensive regimen of foods rich in ni-
Predicted growth time (hours) for pathogenic organisms from log 3.0 CFU/mL to log 6.0 cfu/mL under anaerobic conditions in broth culture at pH 6.0 in the presence of 2.0%
sodium chloride and different levels of sodium nitrite.
Organism Temperature (?C) No nitriteSodium nitrite (60 ppm) Sodium nitrite (120 ppm)
E. coli 0157:H7
Predicted 6.0 log reduction time (hours) for pathogenic organisms in broth culture at
pH 4.0, 25 ?C in the presence of 2.0% sodium chloride and different levels of sodium
E. coli 0157:H7
AOutside valid parameter range.
A. Milkowski et al./Nitric Oxide 22 (2010) 110–119
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trite and nitrate to restore NO homeostasis can have profound ef-
fects on public health. It is time for health care professionals, clin-
ical nutritionists, dieticians, food scientists and epidemiologists to
begin discussion and appreciate contemporary views of nitrite and
nitrate in the context of indispensable nutrients.
As with any remedy or treatment, a risk–benefit reward eval-
uation should be considered. A 2009 Expert Report published by
the Institute of Food Technologists (IFT) provided a comprehen-
sive review of the safety and regulatory processes for making
decisions about the risks of chemicals in foods . This report
described the need for scientists, health professionals and public
health authorities to evaluate the health benefits of a specific
food or food group when also assessing the health risks that
may be posed by the food or food group. Numerous case exam-
ples were cited in the report, specifically the weighing of the
risks of methyl mercury contamination of certain fish compared
to the nutritional benefits of fish consumption, the cancer-reduc-
ing effects of coffee consumption even with the presence of trace
levels of animal carcinogens in roasted coffee, and the potential
cancer risks of heat-induced carcinogens (known to occur at
trace levels) in otherwise healthy and nutritional foods and bev-
erages. One of the key conclusions of this expert report was that
the risks and benefits of the whole food should be evaluated in-
stead of simply focusing on the risks of individual chemical com-
ponents of the food.
Using the concepts discussed in the IFT Expert Report, we pre-
dict that the benefits of dietary nitrite and nitrate will strongly out-
weigh any potential risks, particularly for patients with conditions
of NO insufficiency. The now recognized and undisputed benefits
of dietary nitrite and nitrate should be put in context to the very
weak associations to its potential risks. In an editorial comment,
Katan  eloquently put this point in perspective: ‘‘...evidence
for adverse effects of dietary nitrate and nitrite is weak, and intakes
above the legal limit might well be harmless. This is not unusual in
regulatory toxicology. Many chemicals and contaminants might
well be safe at intakes above their legal limit. Authorities willingly
accept that possibility; erring on the safe side with many chemicals
is justified if it keeps just one true carcinogen out of the food sup-
ply. But the trade-off changes when excessive caution deprives us
of beneficial substances, as claimed by Hord et al. for nitrate .
In that case, the evidence for harm needs to be weighed against the
A long history of safe use as a food additive, minimal endoge-
nous production of N-nitrosamines and natural metabolism of in-
gested nitrite all argue that nitrite as currently used in foods is a
safe food additive and even beneficial to human health. Dietary in-
take of nitrate is a well-known marker of a health-promoting fruit
and vegetable diet. In addition, nitrite and nitrate per se, as individ-
ual chemical compounds, have never been shown to be carcino-
gens in animal or human studies. Nitrate itself is not capable of
reacting with amines to form N-nitrosamines. One could ask the
question then, how simultaneous ingestion of nitrite/nitrate and
nitrosatable amines/amides could be prevented or reduced by pub-
lic policy considerations stemming from IARC’s ‘‘probably carcino-
genic to humans” conclusion, when the majority of ingested
(swallowed) nitrite is endogenously produced in saliva and the
major source of nitrate is the consumption of health-promoting
fruits and vegetables. Thus, to eat is to ingest nitrite, nitrate,
amines and amides, regardless of the specific diet. Specifically,
the consumption of processed, cured meats would be no more or
less risky given the low amount of residual nitrite in such products
ready to consume (approximately 10 ppm in individual servings,
and sometimes even undetectable).
There will very likely be considerable debate about the emerg-
ing health benefits of dietary nitrite and nitrate in light of the fact
that we have been told to limit their intake. However, when con-
sidered in the context of evolving research about the biological
function of all nitrogen oxides (including nitrite and nitrate) and
their metabolism, any changes to current food regulations on ni-
trite are simply unwarranted, as are any regulatory implications
for the unavoidable presence of nitrate in fruits and vegetables.
The use of nitrite as a direct food additive represents only a small
addition to the body burden of endogenously produced nitrogen
oxides. It is hard to believe that the ingestion of nitrite from cured
meats or nitrate from fruits and vegetables could have any poten-
tial adverse toxic outcomes. As more is understood about the hu-
man metabolic nitrogen oxide cycle, it will become apparent that
nitrite is a safe and appropriate food additive providing many more
benefits to society than risks, and nitrate naturally occurring in
fruits and vegetables and some drinking waters poses insignificant
risks. In fact, the inherent nitrate content of Traditional Chinese
Medicines and their ability to convert nitrite to NO in essence pro-
vide over 5000 years of phase 1 safety data in humans with known
curative properties for certain ailments and conditions .
Consumers should avoid getting caught up in fads to the point
where they might ignore sound science and common sense. Die-
tary fads seem to have varying lifetimes, sometimes 3 months to
even 3 years and, often in retrospect, some common sense critical
thinking at the early stages of dietary research reporting could
avoid a lot of poor dietary advice. We have seen a variety of diet
vs. disease fads, some spanning decades, such as the low-fat craze
which, according to some observers, has led to significant increases
in the incidence of both obesity and type 2 diabetes. Such fads may
have negative consequences where they not only fail to improve
public health, but actually result in unintended adverse health ef-
fects. The importance of dietary variety, balance and moderation
should be stressed along with the importance of protective factors
(including adequate consumption of fruits and vegetables) in the
total diet, combined with a physically active lifestyle. We believe
that the weak and inconclusive data on nitrite and nitrate cancer
risks described here are far outweighed by the health benefits of
restoring NO homeostasis as described by the volumes of pub-
lished work over the past 10 years [72,95–101]. The risk/benefit
balance should be a strong consideration before there are any sug-
gestions for new regulatory or public health guidelines for dietary
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