WO2021239823A1

WO2021239823A1 - Preventing or treating nitric oxide deficiency related conditions

Info

Publication number: WO2021239823A1
Application number: PCT/EP2021/064074
Authority: WO
Inventors: Brechtje Johanna DAAMS
Original assignee: Daams Brechtje Johanna
Priority date: 2020-05-26
Filing date: 2021-05-26
Publication date: 2021-12-02
Also published as: NL2025679B1

Abstract

The present invention relates to nitrate and/or a nitric oxide donor in combination with N- acetylcysteine and/or N-acetylcysteine amide; and ascorbic acid and/or ascorbate, for use in prevention or treatment of a condition related to nitric oxide deficiency in a patient. In a preferred embodiment the nitrate is inorganic nitrate, and the nitrate and/or a nitric oxide donor is comprised in edible plants or parts, extracts, concentrates thereof, wherein the edible plant is selected from the group comprising: Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, Rorippa, or any combination thereof. The nitrate and/or a nitric oxide donor may be comprised in Beta vulgaris, preferably Beta vulgaris subsp. vulgaris.

Description

Preventing or treating nitric oxide deficiency related conditions

Technical field

The present invention relates to the prevention or treatment of nitric oxide deficiency related conditions and other conditions in which supplementation with nitric oxide will have beneficial effects on health.

Background of the invention

Nitric oxide (NO), an ubiquitous cell signaling molecule, is a potent vasodilator, an important endothelium-dependent relaxing factor, a natriuretic agent and an inhibitor of platelet aggregation. NO plays an important role in the innate immune system and in regulation of cardiovascular function. NO stimulates production of Erythropoietin (EPO) in the kidney, it inhibits platelet aggregation and provides protection against cardiac arrhythmia. NO is widely implicated in vasodilation, inflammation, ischemic preconditioning and cell death. NO may also act as a hormone, neurotransmitter, paracrine messenger, mediator, cytoprotective molecule, and cytotoxic molecule. Due to the small size of the NO molecule it is capable of diffusing through cellular membranes and as such, acts as a gaseous signalling molecule.

NO also plays an important role in the immune system and it is a key molecule in the pathogenesis of infectious diseases.

Consumption of too little NO precursors and/or NO donors, and/or problems with the NO metabolism may lead to NO deficiency. NO deficiency may subsequently lead to many symptoms and diseases, especially symptoms related to the metabolic syndrome: high blood pressure, cardiovascular disease, obesity, asthma and diabetes.

Conditions which are related to NO deficiency may be treated and/or prevented by enhancing the NO supply in the body. The human body has two systems for providing NO. The first system is the ‘L-arginine pathway’, wherein NO is biosynthesized from a NO precursor by a NO synthase. A second system for providing NO to the human body, the ‘NO₃-NO₂-NO- pathway’, is by consuming food or medication containing nitrates. A nitrate is a polyatomic ion with the molecular formula NO₃-. Organic compounds that contain the nitrate ester as a functional group (RONO₂) are also called nitrates. Nitrates form a source of NO and are used widely as pharmacological agents.

NO is short-lived and highly reactive. The only way to administer NO to a subject is as inhaled NO gas, however this treatment can only be performed in hospital, it may have serious side effects, and the amount of NO that can be inhaled is limited. Hence, it is generally more common to enhance the NO supply in the body by administering for example NO precursors, NO donors, nitrites, and/or nitrates, which are then converted into NO in the body.

It is the object of the present disclosure, among other objects, to provide a new and improved strategy for the prevention and/or treatment of NO deficiency related conditions.

Summary of the invention

The current disclosure relates to a new and improved strategy for the prevention and/or treatment of NO deficiency.

The present inventor surprisingly found that a combination comprising

- a nitrate and/or a nitric oxide donor in combination with

- N-acetylcysteine (NAC) and/or N-acetylcysteine amide; and/or

- ascorbic acid and/or ascorbate (i.e. vitamin C), wherein the ascorbic acid and/or ascorbate is preferably provided in an amount of between 250-2500 mg, provides a synergistic therapeutic effect in the prevention and/or treatment of NO deficiency related conditions.

According to the current disclosure, the nitrate and/or a nitric oxide donor, N-acetylcysteine (NAC) and/or N-acetylcysteine amide; and/or ascorbic acid and/or ascorbate, may be administered separately, sequentially or simultaneously.

Also according to the current disclosure, the nitrate and/or a nitric oxide donor, N- acetylcysteine (NAC) and/or N-acetylcysteine amide; and/or ascorbic acid and/or ascorbate may be administered in separate formulations or may be administered together in a single composition.

The present inventor furthermore found that the use of electrical stimulation may further drastically enhance the therapeutic effect of the combination as taught herein in the prevention and/or treatment of NO deficiency related conditions.

The present inventor found that administration of the combination leads to a surprisingly improved circulation, wound healing and reduction of disorders and diseases related to reduced circulation and nitric oxide deficiency. The effect of improved circulation, wound healing and reduction of disorders and diseases related to reduced circulation and nitric oxide deficiency is enhanced as compared to only applying the elements of the combination individually. In another aspect of the disclosure, the condition related to nitric oxide deficiency is preferably chosen from atherosclerosis, wounds such as skin wounds, reduced blood flow, decubitus, hypertension, asthma, or type 2 diabetes.

Detailed Description of the Invention

COMBINATION FOR USE IN THE PREVENTION AND/OR TREATMENT OF NO DEFICIENCY RELATED CONDITIONS

The present disclosure provides for

- a nitrate and/or a nitric oxide donor;

- N-acetylcysteine and/or N-acetylcysteine amide; and/or

- ascorbic acid and/or ascorbate, wherein the ascorbic acid and/or ascorbate is preferably provided in an amount of between 250-2500 mg, for use in prevention or treatment of a condition related to nitric oxide deficiency in a subject and/or for increasing NO level in said subject.

The term ‘NO deficiency’ relates to a decreased NO level in a subject. For example, the NO levels may be determined in the gas exhaled by a subject. A chemiluminescence analyser is frequently used for immediate and highly sensitive and specific measurement of NO gas even at extremely low concentrations (in parts per billion range). The normal NO concentrations in the nasal passage are 10-100 times higher than in the lower airways. The NO concentrations may furthermore be dependent on the age of the subject and/or the ambient NO values (Shapiro et al. Ann Am Thorac Soc. 2020 Feb;17(2):e1-e12). Therefore, it is generally difficult to generate a single NO cut-off value to distinguish between subjects having deficient or low NO levels. The skilled person and/or authorized practitioner is familiar with the optimal method to measure NO levels in a subject and relate the values of NO in said subject to values typically obtained in patients known to suffer NO deficiency. For example, a nasal NO level below 200 ppb is found in subjects suffering primary ciliary dyskinesia (PCD) which are known to have NO deficiency, whereas a nasal NO level above 400 ppm typically corresponds to healthy individuals (Wodehouse et al. Eur Respir J. 2003 Jan;21(1):43-7, Antosova et al. Physiol Res. 2017 Sep 22;66(Suppl 2):S247-S255). The nitrite/nitrate levels in the saliva or serum may also be determined as a systemic marker of NO levels (Modi et al. Nitric Oxide. 2017 Apr 1; 64: 16-21). Normal serum nitrite/nitrate levels are typically in the range of 24-25 micromol/l (Ghasemi et al. Life Sci. 2008 Aug 29;83(9-10):326-31). Subjects may also test their bodies NO levels using commercial saliva test strips. For example, the Berkeley Life Nitric Oxide Test Strips may establish NO deficiency when the NO level is indicated as either ‘depleted level’ or ‘low level’ by the test strip. The skilled person and/or authorized practitioner may also diagnose NO deficiency based on the specific sy pto (s) of a subject, either or not in combination with a diagnostic method.

The term ‘NO deficiency related conditions’ relates to both NO deficiency and conditions that benefit from the presence of more NO. Example of conditions that benefit from the presence of more NO are conditions related to reduced blood flow, motility disorders, abnormal blood vessel formation, kidney malfunctioning and pathological erythropoietin (EPO) production, brain malfunctioning and neurodegenerative disorders, urinary tract and bladder malfunctioning, liver disease, malfunctioning in the female reproductive system, inflammatory lung diseases, diseases of the eye, abnormal low stamina and muscle force, malfunctioning of the immune system, infections, decreased mobility, chronic bedrest, reduced wound healing, malfunctioning in fat metabolism, insulin resistance, wounds such as skin wounds, ischemia; and/or cardiac arrhythmia.

In one aspect of the invention, the condition related to NO deficiency or the condition that benefits from the presence of more NO is selected from: a condition related to blood circulation, or reduced blood flow, selected from Alzheimer’s disease, angina, atherosclerosis, bowel ischemia, brain ischemia, cancer, cardiac arrhythmia, cardiac ischemia, cerebrovascular accident, cold feet, congestive heart failure, coronary artery disease, cutaneous ischemia, decubitus, dementia, dementia with Lewy bodies, embolism, erectile problems, frontotemporal dementia, vascular dementia, gangrene, heart disease, heart failure, hypertension, hypertensive heart disease, hypoxemia, immersion foot syndrome, intermittent claudication, ischemia, limb ischemia, multiple sclerosis, myalgic encephalomyelitis, myocardial infarction, periodontal disease, gingivitis, periodontitis, peripheral artery disease, peripheral neuropathy, Prinzmetal’s angina, Raynaud syndrome, restless leg syndrome, sleep disorders, thrombosis, thromboembolic disease, type 1 diabetes, type 2 diabetes, wounds such as skin wounds, venous thrombosis; a condition related to digestion, selected from motility disorders, achalasia, diarrhea, constipation, irritable bowel syndrome, anal fissure, poor digestion; a condition related to formation of blood vessels, selected from pre-eclampsia, cancer, cancer metastases, wounds such as skin wounds, muscle atrophy; a condition related to kidney malfunctioning and EPO production, selected from anaemia, wounds such as skin wounds, inflammatory bowel disease, nephropathy, proteinuria; a condition related to brain functioning and neurodegenerative disorders, selected from neural degeneration, problems with neurotransmission, memory problems, Parkinson’s disease, Alzheimer's disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis, myalgic encephalomyelitis, sleep disorders, schizophrenia, bipolar disorder, major depressive disorder; a condition related to urinary tract and bladder malfunctioning, selected from nocturia, bladder storage disorder, urinary retention, benign prostatic hyperplasia; a condition related to the liver, selected from hepatitis, fatty liver disease, other liver diseases; a condition related to the female reproductive system, selected from female infertility, pre-eclampsia, premature birth; a condition related to breathing and lungs, selected from asthma, COPD, ARDS, bronchitis, pneumonia, dyspnea, increased respiratory rate; a condition related to the eye, selected from high eye pressure, glaucoma; a condition related to stamina and muscle force, selected from low energy level, fatigue, cachexia, low maximal muscle force, low stamina, mitochondrial diseases; a condition related to infection and/or the immune system, selected from bronchitis, cachexia, cancer, pneumonia, sepsis, septic shock, nephritis, colitis, wet gangrene, periodontitis, autoimmune diseases, multiple sclerosis, myalgic encephalomyelitis, inflammatory bowel disease, a weak immune system, immune tolerance during organ transplantation, any infection, also infections with bacteria or viruses that are not recognised by the adaptive immune system (e.g. SARS- CoV and SARS-CoV2); a condition related to mobility and motility, selected from bedridden, cachexia, rheumatic disorders, rheumatoid arthritis, gout, osteoarthritis, afflictions of the musculoskeletal system, afflictions of the joints, afflictions of the heart, afflictions of the lungs, large wounds, decubitus, obesity, multiple sclerosis, myalgic encephalomyelitis, dementia, Parkinson’s disease; a condition related to the skin, selected from wounds, decubitus, Raynaud syndrome; a condition related to fat metabolism, selected from obesity, hypercholesterolemia, fatty liver; a condition otherwise, selected from cardiac arrhythmia, prevention of ischemia/reperfusion injury.

In another aspect of the invention, the condition related to NO deficiency or the condition that benefits from the presence of more NO is selected from: altitude sickness or mountain sickness, sickle cell disease, complications of blood transfusion, Meniere’s disease, presbyacusis, Norrie disease, mitochondrial encephalomyopathy, lactic acidosis, and stroke like episodes (MELAS) syndrome, panic disorders, paroxysmal nocturnal hemoglobinuria, Huntington’s disease, skin aging, ischemia-reperfusion injury, bone healing, necrotizing Enterocolitis (NEC), prevention of excessive scar formation, oligospermia, asospermia, Virchow’s triad, hypercoagulability, thrombophilia, vasospasm, ergotism, dental caries, hypoglycemia, heart failure, central sympathetic overactivation in disease, Duchenne Muscular Dystrophy, Becker muscular dystrophy, benign Prostatic Hyperplasia, prostate cancer, acetaminophen intoxication of the liver, and/or intoxication of the liver.

In an embodiment of the present disclosure, the condition related to NO deficiency or the condition that benefits from the presence of more NO is not insomnia, a sleep disorder, a condition related to sleep such as jetlag, a memory disorder, depression, a condition related to breathing and lungs, a condition related to infection and/or the immune system, a condition related to kidney malfunctioning and EPO production, and/or a condition related to the liver.

Chronic cardiovascular disorders can lead to NO deficiency or NO deficiency related conditions as taught herein, for example chronic cardiovascular disorders may be caused by a dysfunctional endothelium and/or a lack of NO production or maintenance of NO homeostasis and signalling. Consumption of too little NO precursors and/or problems with the NO metabolism may lead to NO deficiency. Nitric oxide deficiency may lead to many of the symptoms and diseases mentioned above, especially symptoms related to the metabolic syndrome: high blood pressure, cardiovascular disease, obesity, asthma and diabetes.

In another aspect of the disclosure, the condition related to nitric oxide deficiency is atherosclerosis, decubitus, hypertension, asthma or type 2 diabetes.

NO plays an important role in the immune system and it is a key molecule in the pathogenesis of infectious diseases. In a variety of microbial infections, NO biosynthesis occurs through the expression of an inducible nitric oxide synthase (iNOS). NO has been reported to have antiviral effects against a variety of DNA and RNA viruses, including a murine coronavirus, SARS-CoV and SARS-CoV2. Inhalation of medicinal NO gas by patients with SARS showed not only an immediate improvement of oxygenation but also a lasting effect on the disease itself after termination of inhalation of NO (Keyaerts et al. , 2004). Akerstrom et al. (2009) found that apart from its general effects in the immune system, NO has a dual effect on the replication of SARS-CoV:

1. NO or its derivatives can reduce the viral spike protein of SARS-CoV, which hinders the fusion of the virus and its receptor, angiotensin converting enzyme 2 (ACE2).

2. NO or its derivatives cause a reduction in viral RNA production in the early steps of viral replication of SARS-CoV.

The virus SARS-CoV2 is similar to the SARS-CoV virus, e.g. it uses the same receptor (ACE2) to enter the cell. Hence NO may have the same two effects on the replication of SARS-CoV2.

In one of the embodiments, the present disclosure provides for the use of combinations based on nitrate and/or a nitric oxide donor for increasing the NO level in a subject.

The term ‘N-acetylcysteine’ relates to a drug with the chemical formula C5H9NO3S. N- acetylcysteine is also known as acetylcysteine. N-acetylcysteine is abbreviated herein as NAC. NAC is a medication that is for example used to treat paracetamol (acetaminophen) overdose, and to loosen thick mucus in individuals with chronic bronchopulmonary disorders like pneumonia and bronchitis. It is suggested that NAC has antioxidant activity. One of the mechanism-of-actions of NAC is that it acts as a prodrug to L-cysteine, a precursor to the biologic antioxidant glutathione. Hence administration of acetylcysteine replenishes glutathione store.

The term ‘N-acetylcysteine amide’ relates to an amide derivative of NAC. N-acetylcysteine amide is abbreviated herein as NACA. The chemical formula of NACA is C5H10N2O2S. It is suggested that NACA may have antioxidant activity, but it may have a better blood-brain barrier permeability and bioavailability as compared to NAC.

The N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) as taught in the present disclosure may be comprised in the combination in the range of 100 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, most preferably from 600 mg to 1800 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure comprising said.

The human body has two systems for providing NO. The first system, the ‘L-arginine pathway’, is the biosynthesis of NO by a nitric oxide synthase. Nitric oxide (NO) can be synthesized by the human body from NADPH, L-arginine and oxygen by nitric oxide synthase (NOS) enzymes. There are three different types of NOS: endothelial NOS (eNOS), which relaxes smooth muscle tissue, immune NOS (iNOS) which plays a role in the functioning of the immune system and neuronal NOS (nNOS), for signal transduction between nerve cells.

A second system for providing nitric oxide to the human body, the ‘N0₃-N0₂-N0-pathway’, is by consuming food or medication containing nitrates (NOt)· A nitrate is a polyatomic ion with the molecular formula NO-3. Organic compounds that contain the nitrate ester as a functional group (RONO2) are also called nitrates. Nitrates form a source of nitric oxide and are used widely as pharmacological agents. Upon eating nitrate rich food, nitrate is converted to nitrite (NO2) by microorganisms in the mouth and throat area. These micro organisms use nitrate for respiration and by doing so, consume an oxygen atom of the nitrate molecule, and thereby convert nitrate to nitrite. After nitrite enters the gastrointestinal tract, the acidic environment of the stomach releases an oxygen atom from the nitrite molecule, leaving nitric oxide. The NO diffuses from the gastrointestinal tract into the blood circulatory system, where it performs its beneficial effects.

NO is very reactive and will combine with other molecules after a few seconds. In the vasculature, NO can only be released again by exercising the muscles or by applying electrostimulation. Dietary nitrate may fuel the nitrate-nitrite-NO pathway and partly compensate for disturbances in endogenous NO generation from NOS. Dietary amounts of nitrate clearly have robust NO-like effects in humans, including blood pressure reduction, inhibition of platelet aggregation, and vasoprotective activity. In animal models, nitrates protects against ischaemia-reperfusion injuries and several other types of cardiovascular disorders. In addition, nitrate most surprisingly decreases whole body oxygen cost during exercise with preserved or even enhanced maximal performance (Lundberg et al. , 2011).

For the conversion of NO3 to NO, the prerequisites are:

Sufficient intake of nitrates (NO₃-).

Sufficient production of saliva.

Sufficient nitrifying bacteria in the oral cavity.

Sufficient gastric acid.

Sufficient physical exercise or electrostimulation.

Blood pressure in the human body is regulated by the renin-angiotensin system (RAS). This hormone system is one of the systems regulating blood pressure via multiple feedback loops. NO influences the RAS. NO antagonizes the effects of Ang II on vascular tone, cell growth, and renal sodium excretion, and also down-regulates the synthesis of angiotensin-converting enzyme (ACE) and Ang II type 1 receptors. NO is a natriuretic agent and it relaxes the vascular smooth muscle.

The ascorbic acid and/or ascorbate as taught in the present disclosure may be comprised in the combination in the range of 15 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, preferably from 250 to 2500 mg, or from 500 mg to 2500 mg, more preferably from 500 mg to 2000 mg, even more preferably form 500 mg to 1500 mg, most preferably from 500 mg to 1000 mg, e.g. per dose or per ml or per g of formulation or composition comprising said.

In an embodiment, the present disclosure also provides for a combination as according to the present disclosure, in further combination with electrostimulation (device) as disclosed herein, wherein preferably the combination is not for use in prevention or treatment of a condition related to nitric oxide deficiency in a subject and/or for increasing NO level in said subject.

The present disclosure furthermore provides for

- a nitrate and/or a nitric oxide donor; - N-acetylcysteine and/or N-acetylcysteine amide; and/or

- ascorbic acid and/or ascorbate, wherein the ascorbic acid and/or ascorbate is preferably provided in an amount of between 250-2500 mg, for use in prevention or treatment of a condition related to nitric oxide deficiency in a subject and/or for increasing NO level in said subject, wherein the nitrate is an inorganic nitrate.

The term ‘NO donor’ relates to a substance which can release NO. The release of NO may occur through an enzymatic reaction (typically called indirect release) and/or the release of NO from a NO donor may occur without molecular metabolism (typically called direct release). NO donors may act as prodrugs for NO. Nitrate is an example of an NO donor. The NO donor as taught herein may also comprise NO precursors. The term ‘NO precursor’ relates to a product that is a substrate for the family of enzymes nitric oxide synthetases (NOS). For example, L-Arginine is converted to citrulline and nitric oxide. Citrulline itself has been called a precursor because it can be recycled back to arginine through the enzymes of the urea cycle. Nitrite medication and nitrite-based medications are also considered as NO donors as taught herein. The nitrite NO can be reduced to NO for example by the acid environment.

In an embodiment of the current disclosure, the NO donor comprises inorganic nitrate, organic nitrate, nitroglycerin, nicorandil, molsidomine, pentaerythritol tetranitrate, nitroprusside, sodium nitroprusside, isosorbide mononitrate, isosorbide dinitrate, S- nitrosothiols, and/or S-nitrosoglutathion, or combinations thereof.

Preferably, the NO donor and/or nitrate as taught herein is inorganic nitrate. Inorganic nitrates have simple ionic structures and are present in the human diet. Organic nitrates on the other hand are more complex, medicinally synthesized products. Organic nitrates may have a profound and acute effect on vessel dilatation, which may be useful in emergencies but is not preferred in daily life. The pharmacodynamic effects of inorganic nitrates on the other hand, are more subtle than those of organic nitrate. The effect of inorganic nitrates is more gradual and there is no habituation effect. For optimal effects, a nitrate-free period of at least 8 hours between successive administrations according to the invention, wherein no nitrate is consumed, should be adhered to. A longer nitrate-free period up to 24 hours may be even more effective.

The present inventors surprisingly found that

- nitrate and/or a nitric oxide donor;

- N-acetylcysteine and/or N-acetylcysteine amide; and/or

- ascorbic acid and/or ascorbate at a dose of 250 mg to 2500 mg, wherein the nitrate is inorganic nitrate at a dose of 120 mg to 1250 g in the form of beetroot juice has a has a synergistic effect in enhancing NO production.

The present disclosure furthermore relates to the use of N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NAC) for preventing and/or treating NO deficiency related conditions, wherein the NAC and/or NACA can be combined with:

- ascorbic acid and/or ascorbate present at 250-2500 mg; and/or

- nitrate, nitrite, nitric oxide, nitric oxide donor, and/or an inorganic nitrate, wherein the nitrate, nitrite, nitric oxide, nitric oxide donor, and/or an inorganic nitrate is comprised in edible plants or parts, extracts, concentrates thereof, wherein the edible plant is selected from the group comprising: Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, Rorippa, or any combination thereof.

The present disclosure moreover relates to the use of N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) for preventing and/or treating NO deficiency related conditions, wherein the NAC and/or NACA can be combined with:

- ascorbic acid and/or ascorbate at 250-2500 mg; and/or

- nitrate, nitrite, nitric oxide, nitric oxide donor, and/or an inorganic nitrate, wherein the nitrate, nitrite, nitric oxide, nitric oxide donor, and/or an inorganic nitrate is comprised in Beta vulgaris, preferably Beta vulgaris subsp. vulgaris.

Preferably, the nitrate and/or NO donor according to the present disclosure is comprised in edible plants or parts, extracts, concentrates thereof, wherein the edible plant is selected from the group comprising: Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, Rorippa, or any combination thereof. These types of plants, many of them belonging to the ‘leafy green vegetables’, contain particularly high levels of inorganic nitrates. In particular, nitrate and/or a nitric oxide donor according to the present disclosure is comprised in Beta vulgaris, preferably Beta vulgaris subsp. vulgaris, such as chard or beetroot. Beetroots ( Beta vulgaris subsp. vulgaris) have a particularly beneficial effect on blood circulation. In addition, the inventor considered that beetroots, or juice thereof do not influence the clotting time of blood as opposed to nitrate rich leafy vegetables. This is particularly advantageous for patients taking blood thinning medication, for whom an increase in clotting time is undesirable.

Preferably, the nitrate, nitrite and/or NO donor according to the present disclosure may be comprised in Beta vulgaris, preferably Beta vulgaris subsp. Vulgaris, and wherein the Beta vulgaris is in the form of a powder, bonbon, juice, fermented juice, or a combination thereof. Other substances in beetroots may add to the health effect. Red beet contains betalains like betanine, isobetanin, probetanin, neobetanin, indicaxanthin and vulgaxanthin. Betalains are anti-inflammatory and they are identified by in vitro methods as antioxidants, which may protect against oxidation of low-density lipoproteins. Red beet also contains trimethylglycine (TMG), a type of betaine. Biologically, TMG is an important cofactor in methylation which contributes to many physiological processes in the human body, amongst which detoxification of homocysteine.

Beetroot can be consumed fresh, boiled, baked, fried, dried as chips or as powder, pressed as juice, fermented (juice or whole root). Beetroot can also form an ingredient in other food (e.g. in bread, cookies, chocolate, fruit drinks, smoothies etc.).

Preferably, the nitric oxide is derived from nitrate and/or a nitric oxide donor, and a route of administration of nitrate and/or a nitric oxide donor is oral. To understand the combined effect of nitrate and/or a nitric oxide donor, it is good to know how nitrates (NOt), which may be comprised in ingested beetroot juice) are converted into nitric oxide (NO) via the intermediate nitrite (NO ) in the human body.

Conversion of ingested NOt to NO can be seen as a two-step process:

1. From NOt to NO . First NOt is taken up from the digestive tract into the blood.

NO₃ is excreted in saliva. Bacteria at the back of the oral cavity/in the throat convert NO₃ into NO2-.

2. From NO2 to NO. Saliva, bacteria and NO2 are swallowed together and in the stomach the NO2 will be reduced to NO by the acid environment.

It is therefore preferred that nitrate enters the body orally, as this enables the conversion of nitrate to nitric oxide. Following this pathway of conversion to NO, nitrite and nitric oxide are released gradually and regulated at such a rate that they are biologically most effective.

Preferably, the use is further characterized in that the nitrate and/or nitric oxide is administered in the form of a bolus, wherein Beta vulgaris subsp. vulgaris is administered within 1 to 30 minutes and wherein an amount of the Beta vulgaris subsp. vulgaris juice is between 0.15 and 0.5 L and a nitrate concentration of the Beta vulgaris subsp. vulgaris juice is between 800 and 2500 mg/L.

Wruss et al. (2015) found that the amount of nitrates in commercial beetroot juice available in Austria on average was 909 mg/I.

In one of the embodiments of the current disclosure, the beetroot juice may be consumed in a single administration per day, and may not be distributed over several points during the day. A ‘washout period’, or nitrate free period of at least 8 hours but preferably 24 hours, may be present to obtain the most beneficial effect.

For people who are tube fed, beetroot juice may be given as a supplement, as a bolus once a day. The beetroot juice may not be mixed with the enteral tube feed when the tube feed is distributed slowly throughout the day, because this will decrease the effectiveness of the treatment significantly. For people who cannot swallow, their flow of saliva may not be attenuated by medication (e.g. with Scopolamine) but their saliva may be collected, e.g. sucked away, and fed through a tube into their stomach, in order to obtain the described effects. The intake of 0.25 to 0.5 L beetroot juice per day may lower systolic blood pressure by 8 points and diastolic blood pressure by 5 points. Beetroot juice can be consumed together with blood vessel dilating medication. The effects of beetroot juice is cumulative to the medication.

In one of the embodiments of the current disclosure, the nitrate and/or nitric oxide is administered as saliva from another human. Saliva of someone else will have the same effect as one’s own saliva. An optimal effect may be generated by saliva from someone who consumed beetroot (in any form) or inorganic nitrates 1 to 5 hours before administering it to a patient. For people who produce too little saliva and have symptoms of NO deficiency, stimulation of saliva (together with intake of beetroot and/or inorganic nitrates and application of electrostimulation) can aid to increase the amount of NO.

The nitrate as taught in the present disclosure may be comprised in the combination in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, such as per dose or per formulation.

The inorganic nitrate as taught in the present disclosure may be comprised in the combination in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, such as per dose or per formulation.

The edible plant selected from the group comprising Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, and/or Roripp as taught in the present disclosure, may be comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

The edible plant selected from the group comprising Beta vulgaris as taught in the present disclosure, may be comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

The edible plant selected from the group comprising Beta vulgaris subsp. vulgaris as taught in the present disclosure, may be comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

The Beta vulgaris juice as taught in the present disclosure may be comprised in the combination in an amount of 0.035 L to 5 L, more preferably 0.15 L to 1 L, most preferably 0.25 L to 0.5 L.

The Beta vulgaris juice as taught in the present disclosure may be comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

The Beta vulgaris subsp. vulgaris juice as taught in the present disclosure may be comprised in the combination in an amount of 0.035 L to 5 L, more preferably 0.15 L to 1 L, most preferably 0.25 L to 0.5 L.

The Beta vulgaris juice and/or Beta vulgaris subsp. vulgaris juice as taught in the present disclosure may be comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

FORMULATIONS AND COMPOSITIONS FOR USE IN THE PREVENTION AND/OR

TREATMENT OF NO DEFICIENCY RELATED CONDITIONS

The N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) as taught herein may be administered separately, sequentially and/or simultaneously to the ascorbic acid and/or ascorbate.

In an embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) and the ascorbic acid and/or ascorbate are administered in separate formulations, whereby there may be a separation in time between the administration of the N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) and the ascorbic acid and/or ascorbate. In another embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) and the ascorbic acid and/or ascorbate are administered at the same time in a separate formulation. In yet another embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) and the ascorbic acid and/or ascorbate are administered at the same time in the same formulation, or as a composition. The N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) as taught herein may be administered separately, sequentially and/or simultaneously to the nitrate and/or nitric oxide donor.

In an embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) and the NO, NO donor, and/or an (inorganic) nitrate are administered in separate formulations, whereby there may be a separation in time between the administration of the N-acetylcysteine (NAC) and/or N-acetylcysteine amide (NACA) and the nitrate and/or nitric oxide donor.

In another embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) and the nitrate and/or nitric oxide donor are administered at the same time in a separate formulation.

In yet another embodiment of the current disclosure, the N-acetylcysteine (NAC) and/or N- acetylcysteine amide (NACA) and the nitrate and/or nitric oxide donor are administered at the same time in the same formulation, or as a composition.

The ascorbic acid and/or ascorbate as taught herein may be administered separately, sequentially and/or simultaneously to the nitrate and/or nitric oxide donor.ln an embodiment of the current disclosure, the ascorbic acid and/or ascorbate and the nitrate and/or nitric oxide donor are administered in separate formulations, whereby there may be a separation in time between the administration of the ascorbic acid and/or ascorbate and the nitrate and/or nitric oxide donor.

In another embodiment of the current disclosure, the ascorbic acid and/or ascorbate and the nitrate and/or nitric oxide donor are administered at the same time in a separate formulation.

In yet another embodiment of the current disclosure, the ascorbic acid and/or ascorbate and the nitrate and/or nitric oxide donor are administered at the same time in the same formulation, or as a composition.

In an embodiment of the current disclosure, the nitrate and/or a nitric oxide donor, N- acetylcysteine and/or N-acetylcysteine amide, and/or ascorbic acid and/or ascorbate as taught herein are comprised in a dosage form suitable for oral intake by a subject, preferably a capsule, a tablet, a powder, a liquid, and/or a liquid beverage. COMBINATION FOR USE IN SUBJECTS APPLYING ELECTRICAL STIMULATION

In another aspect of the invention, the patient may be comatose and/or bedridden, and/or be unable to exercise for other reasons. Comatose and bedridden patients have a greatly reduced ability to exercise. Therefore, electrical stimulation is particularly useful for these types of patients.

The present inventor found that the use of electrical stimulation may drastically further enhance the therapeutic effect of the combination as taught herein in the prevention and/or treatment of NO deficiency related conditions.

Hence, the present disclosure also provides for a kit of parts, or combination, comprising

- an electrical muscle stimulation device, preferably a neuromuscular electrical stimulation (NMES) device;

- a nitrate and/or a nitric oxide donor as according to the present disclosure, preferably as contained in edible plant or parts, extracts, concentrates thereof, wherein the edible plant is preferably selected from the group comprising: Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, Rorippa, or any combination thereof;

- N-acetylcysteine and/ or N-acetylcysteine amide as according to the present disclosure; and/or

- ascorbic acid and/or ascorbate as according to the present disclosure.

The present disclosure furthermore provides for a kit of parts, or combination, comprising:

- acetylcysteine and/ or N-acetylcysteine amide according to the present disclosure comprised in the kit of parts, or combination, at 100 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, most preferably from 600 mg to 1800 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure.

- nitrate and/or a nitric oxide donor according to the present disclosure comprised in the kit of parts, or combination, at 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure;

- ascorbic acid and/or ascorbate according to the present disclosure comprised in the kit of parts, or combination, at 15 mg to 10 g, preferably from 200 mg to 4 g, or preferably from 400 mg to 3 g, or preferably from 250 to 2500 mg, more preferably from 500 mg to 2500 mg, or more preferably from 500 mg to 2000 mg, even more preferably form 500 mg to 1500 mg, most preferably from 500 mg to 1000 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure; and/or

- Beta vulgaris according to the present disclosure comprised in the kit of parts, or combination, in an amount chosen such that the amount of the nitrate according to the present disclosure is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure.

In one of the embodiments of the kit of parts or combination, the individual compounds are physically separated and used simultaneously by a subject. In another embodiment, the individual compounds are physically separated and used separately by a subject. In yet another embodiment, the individual compounds are physically separated and used sequentially by a subject.

- an electrical stimulation device;

- N-acetylcysteine and/ or N-acetylcysteine amide according to the present disclosure comprised in the kit of parts, or combination, for example at 100 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, most preferably from 600 mg to 1800 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure.

- nitrate and/or a nitric oxide donor according to the present disclosure comprised in the kit of parts, or combination, for example at 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure;

- ascorbic acid and/or ascorbate according to the present disclosure comprised in the kit of parts, or combination, for example at 15 mg to 10 g, preferably from 200 mg to 4 g, or preferably from 400 mg to 3 g, or preferably from 250 to 2500 mg, more preferably from 500 mg to 2500 mg, or more preferably from 500 mg to 2000 mg, even more preferably form 500 mg to 1500 mg, most preferably from 500 mg to 1000 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure; and/or - Beta vulgaris according to the present disclosure comprised in the kit of parts, or combination, for example in an amount chosen such that the amount of the nitrate according to the present disclosure is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition according to the present disclosure, or per kit of parts according to the present disclosure.

In one of the embodiments of the kit of parts or combination, the individual compounds and/or electrical stimulation device are physically separated and used simultaneously by a subject.

In another embodiment, the individual compounds and/or electrical stimulation device are physically separated and used separately by a subject. In yet another embodiment, the individual compounds and/or electrical stimulation device are physically separated and used sequentially by a subject.

In one of the embodiments of the kit of parts comprising an electrical stimulation device, the compounds that are not the electrical stimulation device are comprised in the same formulation or in a composition.

The electrical stimulation device may be a transcutaneous nerve stimulation (TENS) device, a functional electrical stimulation (FES) device, a Russian stimulation (RS) device, a interferential current stimulation (IFS) device, a high voltage stimulation (HVS) device, and/or a neuromuscular electrical stimulation (NMES) device, most preferably NMES device.

The present disclosure relates to a combination for use in subjects applying (or have applied/will apply) electrical stimulation, wherein the combination comprises

- nitrate and/or a nitric oxide donor, wherein preferably the nitrate and/or a nitric oxide donor is provided in an amount of between 120-1250 mg;

- N-acetylcysteine and/or N-acetylcysteine amide, wherein preferably the N-acetylcysteine and/or N-acetylcysteine amide is provided in an amount of between 600-1800 mg; and

- ascorbic acid and/or ascorbate, wherein preferably the ascorbic acid and/or ascorbate is provided in an amount of between 250-2500 mg, and wherein the subjects applying electrical stimulation apply the electrical stimulation for the prevention and/or treatment NO deficiency related conditions.

The term ‘electrical stimulation’, or ‘electrostimulation’, relates to a technique used to elicit a muscle contraction typically using electrical impulses. Typically, electrodes, controlled by a unit, provide the electrical impulses. The electrodes may be placed on the skin over one or several predetermined areas. Electrical stimulation may be utilized for example as a strength training tool, as a rehabilitation and preventive tool for partially or totally immobilized patients, or as a post-exercise recovery tool for athletes. Moreover, electrical stimulation is typically also used to decrease pain and inflammation, improve circulation, improve wound healing, and assist in proper muscle contraction.

In electrical stimulation, or electrostimulation, electrical pulses are applied to the body, via at least two electrodes that are in direct contact with the skin. These electrical pulses can vary in pulse time, frequency, shape of the pulse, and intensity (amplitude). The pulses can be symmetric or asymmetric, mono-phasic or bi-phasic, intermittent or continuous. With two sets of electrodes, the pulses can be given simultaneous or alternating. Electrical characteristics of the pulses can be varied during an electrostimulation session (e.g. the frequency can be modulated or the pulse time can be modulated). The pulses will travel through the body from one electrode to the other electrode and will exert various effects on amongst others nerves, muscles, vessels and skin.

The electrodes can be applied at the location of different muscles or at different locations of the same muscle. An electrical muscle stimulation device can generate impulses that mimic the action potential of the central nervous system. The muscles are activated via the nerves that innervate those muscles. At high intensities, electric pulses can activate muscles directly but this is used only for patients whose muscles have lost innervation. These pulses can generate many different health effects on different parts of the body, such as significantly raising blood flow in a patient. Electrostimulation used on muscles will amongst others promote muscle building, strength and the growth of new blood vessels. This is an important benefit for atrophied muscles. Stimulated muscles will amongst others stimulate the release of neurotrophins and Brain Derived Neurotrophic Factors in the brain. These factors are needed for nerve health and nerve growth. This is an important benefit for neurodegenerated brains. Electrostimulation of the muscles will also stimulate the release of various myokines, that have a myriad of healthy effects. Myokines are involved in exercise-associated metabolic changes, in tissue regeneration and repair, maintenance of healthy bodily functioning, immunomodulation and cell signaling, expression and differentiation.

Transcutaneous electrical nerve stimulation (TENS) can be used to increase blood flow and is widely practised. TENS applies electrical current transcutaneously to excite nerves. Often, pulses produced by a TENS device are used to achieve analgesia. In general a TENS device is connected to the skin via two or more electrodes, and pulses are applied at frequencies varying between 1 and 100 Hz.

Preferably, the electrical stimulation is neuromuscular electrical stimulation (NMES). NMES is an electrical stimulation method applied to the skin over the muscle of a subject. Muscles are contracted by the use of a sufficiently high current with an appropriate frequency and pulse width. The acute application of NMES increases muscle blood flow. When used regularly, NMES is able to rehabilitate partially- or totally immobilized patients by preserving muscle mass and function of bed ridden or comatose patients. Release of NO and relaxation of the vessels will already occur at stimulation with a low intensity at which the muscles do not yet contract. Thus for relaxation of the vessels, muscle contraction is not a necessary condition during electrostimulation. However, contraction of the muscles during electrostimulation has added benefits, like keeping the muscles in good shape when the patient is bedridden or can not exercise, and the release of Brain Derived Neurotrophic Factors in the brain. Preferably, a stimulation frequency for NMES is 35 to 65 Hz and the pulse duration for NMES is 150-250 ps for small muscles and 250 to 400 ps for large muscles.

In order to increase circulation, electrical stimulation can be applied to the hand, to activate a specific nerve that is connected to the brain, allowing the brain to relax blood vessels via other connected nerves. The electrodes used for electrical stimulation may preferably be set to either 100 Hz or 2 Hz. This stimulation method is referred to as Kaada-stimulation.

Another option to increase circulation is to stimulate blood vessels directly by placing electrodes of an electrical stimulation device on any muscle and stimulate these muscles .

A specific electrical stimulation device is foreseen and particularly useful in combination with the present disclosure, wherein said device can be programmed for (at least) 24 hours in cycles, with alternately electrostimulation (intermittent or continuously), preferably with diverse intensity and breaks of 1-10 minutes or 10-60 minutes between sessions.

In a preferred embodiment, the electrical stimulation is simultaneously applied to multiple muscle groups, preferably 2 to 16 muscle groups, more preferably 8 to 16 muscle groups, most preferably 12 to 16 muscle groups. Nitrate and/or nitric oxide donor administration, via beetroot consumption or otherwise, combined with electrostimulation on two muscle groups gives a synergetic effect, which is enhanced as compared to nitrate and/or nitric oxide donor administration or electrical stimulation separately. In addition, the combination is much more efficacious in easing, supporting, healing or curing various medical conditions. Nitrate and/or nitric oxide administration, via beetroot consumption or otherwise, combined with Whole Body Electrostimulation (most large muscle groups stimulated at once) is even more efficacious.

Preferably, the nitrate and/or nitric oxide donor is combined with N-acetylcysteine (NAC).

NAC is a sulfhydryl donor. The presence of sulfhydryl groups seems to be fundamental to nitrate-induced vasodilation. NAC can increase the duration of the vessel dilating effect of beetroot juice. Adding N-acetylcysteine may support or even improve the combinatorial effect of electrical stimulation and nitrate and/or nitric oxide donors, and may extend the time during which the electrostimulation will trigger the release of NO. With availability of cysteine, the bioavailability of the nitric oxide is increased. Furthermore, NAC may counteract a tolerance for nitrates. It has been suggested that a depletion of the critical sulfhydryl cofactors essential for smooth muscle relaxation by nitrates is a major cause of tolerance. NAC is a sulfhydryl donor and may therefore contribute to the beneficial effect of NO on vasodilation (Vincent et al. , 1992). In addition, NAC has a beneficial effect on the immune system and enhances blood vessel growth.

Instead of NAC, N-acetylcysteine amide may be used, or derivatives of these with similar functions. N-acetylcysteine amide (abbrev. NACA, also known as acetylcysteinamide) is an amide derivative of N-acetylcysteine that appears to have better blood-brain barrier permeability and bioavailability and a similar antioxidant capability (Sunitha et al., 2013).

In one aspect of the invention, the electrical stimulation is preferably consecutively applied for more than 30 minutes in combination with physical exercise. Electrostimulation of muscles also stimulates the brain, especially when the electrostimulation is performed for longer than 30 minutes and with physical exercise at the same time. Together with increased blood flow caused by release of NO, this gives the brain a boost, especially when the brain is insufficiently stimulated (e.g. when normal functioning is not possible and/or when muscles cannot be used). This electrostimulation with exercise triggers (amongst others) the release of brain derived neurotrophic factors (BDNF’s) in the brain. These BDNF’s are indispensable to the neurons.

The electrical stimulation may be chosen from:

- transcutaneous nerve stimulation (TENS);

- functional electrical stimulation (FES);

- Russian stimulation (RS);

- interferential current stimulation (IFS);

- High Voltage Stimulation (HVS); and/or

- and/or neuromuscular electrical stimulation (NMES).

The subjects applying electrical stimulation using the combination as taught herein may use the combination before applying electrical stimulation, during applying electrical stimulation, or after applying electrical stimulation.

In an embodiment of the current disclosure, the combination is used 1-12 hours prior to applying electrical stimulation, preferably 1-8 hours prior to applying electrical stimulation, most preferably 1-5 hours prior to applying electrical stimulation. The subjects applying electrical stimulation using the combination as taught herein preferably use the combination when applying electrical stimulation at least once a week, with or without breaks within the cycles.

The subjects applying electrical stimulation using the combination as taught herein preferably have applied the electrical stimulation not more than a month, not more than a week, or not more than a day, prior to use of said composition.

The subjects applying electrical stimulation using the combination as taught herein preferably apply the electrical stimulation with a stimulation frequency between 2 and 100 Hz.

The subjects applying electrical stimulation using the combination as taught herein preferably apply the electrical stimulation simultaneously to multiple muscle groups, preferably 2 to 16 muscle groups, more preferably 8 to 16 muscle groups, most preferably 12 to 16 muscle groups.

The subjects applying electrical stimulation using the combination as taught herein preferably apply the electrical stimulation not later than a month, not later than a week, or not later than a day after the use of said composition.

The electrostimulation that may be applied according to the present disclosure has characteristics for muscle strengthening and the therapy sessions lasted for 30 to 45 minutes. The equipment used was a TensMed S82 from the Dutch company Enraf-Nonius, with two pair of adhesive electrodes, or a StimaWELL Whole Body Electrostimulation apparatus, manufactured by the German company Schwa-Medico. The TensMed S82 can stimulate two muscle groups simultaneously or alternating. The electrodes were placed symmetrically on the left and right side of the body, either on the upper leg (over the vastus medians, which is a part of the quadriceps muscle) or on the lower arm (over the extensor muscles). The StimaWell Whole Body Electrostimulation apparatus can exert electrostimulation on most of the muscles of trunk, arms and legs. For optimal effect, the electrostimulation should be performed about 1 to 5 hours after ingestion of the beetroot juice. Outside this time window, electrostimulation will also trigger the release of NO but it may be less effective. On the other hand, with electrostimulation certainly more NO will be generated than without. Using electrostimulation will always be advantageous, even outside the 1 to 5 hour window.

The present disclosure also provides for a kit of parts, or combination, according to the present disclosure, comprising a manual or instruction manual, comprising methods to the use of: a NMES device according to the current disclosure, such as relating to a use of a stimulation frequency for NMES of between 35 to 65 Hz or such as relating to a use of a pulse duration for NMES of 150-250 ps for small muscles and 250 to 400 ps for large muscles according to the current disclosure . a TENS device according to the current disclosure, such as relating to the connection of the TENS device to the skin via two or more electrodes or such as relating to applying pulses with the TENS at frequencies varying between 1 and 100 Hz according to the current disclosure; an electrical stimulation device according to the current disclosure, such as the connection of an electrical stimulation device through electrodes to multiple muscle groups, preferably 2 to 16 muscle groups, more preferably 8 to 16 muscle groups, most preferably 12 to 16 muscle groups according to the current disclosure; an electrical stimulation device according to the current disclosure, such as relating to the setting of the electrical stimulation device to either 100 Hz or 2 Hz, for example according to the methods of Kaada-stimulation according to the current disclosure an electrical stimulation device according to the current disclosure, such as relating to the programming of the device, for example the programming for at least 24 hours in cycles, with alternately electrostimulation, and the application of breaks of 1-10 minutes or 10-60 minutes between sessions according to the current disclosure; N-acetylcysteine and/or N-acetylcysteine amide according to the current disclosure, such as the use of acetylcysteine and/or N-acetylcysteine for example at 100 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, most preferably from 600 mg to 1800 mg, e.g. per dose or per ml or per g of formulation or composition comprising said according to the current disclosure; nitrate and/or a nitric oxide donor according to the current disclosure, such as the use of nitrate and/or a nitric oxide donor for example at 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition comprising said according to the current disclosure; ascorbic acid and/or ascorbate according to the current disclosure, such as the use of ascorbic acid and/or ascorbate for example at 500 mg to 2000 mg, preferably from 500 mg to 1500 mg, most preferably from 500 to 1000 mg, e.g. per dose or per ml or per g of formulation or composition comprising said according to the current disclosure;

Beta vulgaris according to the current disclosure, such as the use of Beta vulgaris for example in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 g to 1250 m, e.g. per dose or per ml or per g of formulation or composition comprising said according to the current disclosure; and/or Beta vulgaris comprised in a juice according to the current disclosure, for example such as the use in an amount of 0.035 L to 5 L, more preferably 0.15 L to 1 L, most preferably 0.25 L to 0.5 L, , e.g. per dose or per ml or per g of formulation or composition comprising said according to the current disclosure.

Brief Description of the Drawings

Fig. 1 shows the recognized NO levels after treatment with NAC, beetroot juice and different dosages ascorbic acid, either with or without electrical stimulation.

Fig. 2 Shows the width of a wound over time. Fig. 2A (upper panel): Measurements of the width of a wound over time wherein the patient is on a regular diet with much leafy vegetables and receives electrostimulation. Fig 2B (lower panel): Measurements of the width of a wound over time wherein the same patient is on a regular diet, receives a glass of beetroot juice per day and performs daily exercise. In both figures, the ‘+’ symbols indicate measurements of the width of the wound, and the line is a trendline through these measurement points, indicating the average rate of healing of the wound. The circles indicate days whereon electrostimulation is applied on the patient. The lower horizontal striped lines with arrows indicate periods wherein the patient received insulin medication. The lower horizontal dotted line indicates a period wherein the patient received beetroot juice and performed daily exercise.

Fig. 3 Shows toenails during (upper left and right panel) and after (lower panel) daily intake of beetroot powder and beetroot bonbons. At the time the top pictures were taken, the beetroot powder and bonbons were already consumed for some time with effect. This shows best in the upper left panel, where the dark, thickened part of the nail can be distinguished clearly from the new healthy light-coloured and non-deformed part of the nail.

In this document and in its claims, the verb "to comprise" and its conjugations is used in its non-limiting sense to mean that items following the word are included, but items not specifically mentioned are not excluded. In addition, reference to an element by the indefinite article "a" or "an" does not exclude the possibility that more than one of the element is present, unless the context clearly requires that there be one and only one of the elements. The indefinite article "a" or "an" thus usually means "at least one". References

Akerstrom, S., Gunalan, V., Tat Keng, C., Tan, Y.-J. and Mirazimi, A., 2009. Dual effect of nitric oxide on SARS-CoV replication/ Viral RNA production and palmitoylation of the S protein are affected. Virology, 395. Pp. 1-9. https://doi.Org/10.1016/j.virol.2009.09.007

Bryan, N.S. and Loscalzo, J., 2017. Chapter 1 Introduction. In; Nitrite and Nitrate in Human Health and Disease. Humana Press imprint. Cham: Springer Nature.

Jones, A. M., Thompson, C., Wylie, L.J. and Vanhatalo, A., 2018. Dietary Nitrate and Physical Performance. Annual Review of Nutrition 38, pp. 303-328.

Kamali, F., Mirkhani, H., Nematollahi, A., Heidari, S., Moosavi, E. and Mohamadi, M., 2017. The Effect of Transcutaneous Electrical Nerve Stimulation of Sympathetic Ganglions and Acupuncture Points on Distal Blood Flow. Journal of Acupuncture and Meridian Studies, 10:2.

Keyaerts, E., Vijgen, L, Chen, Luni, Maes, P., Hedenstierna, G. and Van Ranst, M., 2004. Inhibition of SARS-coronavirus infection in vitro by S-nitroso-N-acetylpenicillamine, a nitric oxide donor compound. International Journal of Infectious Diseases, 8, pp. 223-226. https://doi.Org/10.1016/j.ijid.2004.04.012

Lundberg, J.O., Carlstrom, M., Larsen, F.J. and Weitzberg, E., 2011. Roles of dietary inorganic nitrate in cardiovascular health and disease. Cardiovascular Research, 89, pp. 525- 532. https://doi.Org/10.1093/cvr/cvq325

Sunitha, K., Hemshekhar, M., Thushara, R.M., Sebastin Santhosh, M., Yariswamy, M., Kemparaju, K. and Girish , K.S., 2013. N-Acetylcysteine amide- a derivative to fulfill the promises of N-Acetylcysteine. Free Radical Research, 47(5), pp. 357-367. https://doi.org/10.3109/10715762.2013.781595

Vincent, J., Kongpatanakul, S., Blaschke, T.F. and Hoffman, B.B., 1992. Desensitization of nitrate-induced venodilation: Reversal with oral N-Acetylcysteine in humans. Journal of Cardiovascular Pharmacology, 20, pp. 907-912.

Wruss, J., Waldenberger, G., Huemer, S., Uygun, P., Lanzerstorfer, P., Muller, U., Hoglinger, O. and Weghuber, J., 2015. Compositional characteristics of commercial beetroot products and beetroot juice prepared from seven beetroot varieties grown in Upper Austria. Journal of Food Composition and Analysis, 42, pp. 46-55. Yamabata, S., Shiraishi, H., Munechika, M,. et al., 2016. Effects of electrical stimulation therapy on the blood flow in chronic critical limb ischemia patients following regenerative therapy. SAGE Open Med.] 4.

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Examples

Example 1

This example shows how selective ingredients may affect NO-enhancing effect of NAC. In addition to NAC, inorganic nitrate in the form of beetroot juice is provided as NO donor. Furthermore, alpha-lipoic acid, ascorbic acid , or vitamin D are provided as supplements that may regulate NO production. Lipoic acid may potentiate endothelial NO synthesis and bioactivity (Visioli et al. Redox Rep. 2002;7(4):223-7). Ascorbic acid may support NO metabolism (Mortensen et al. Vitamin Nitric Oxide. 2014 Jan 30;36:51-7). Vitamin D may increase NO production by regulating NO synthase (Andrukhova et al. Mol Endocrinol. 2014 Jan;28(1):53-64.).

Measurement of NO

NO saliva test strips (Berkeley) are used to measure saliva nitrite levels, which is an indicator of NO levels. NO saliva test strips are an easy and non-invasive way to evaluate how supplements or drugs may improve NO-bioavailability. The NO saliva test strips show good validity for salivary nitrite, compared to standard lab measures (Modi et al. Nitric Oxide. 2017 Apr 1; 64: 16-21). The result of the test strip is matched to the colour scale provided, indicating NO-bioavailability as ‘depleted levels’, ‘low levels’, ‘threshold levels’, ‘target levels’, ‘high levels’.

Inclusion/exclusion of participants

Participants in the age of 21 - 65 years are included that are free of drug use and free of diagnosed conditions related to NO deficiency, such as diabetes, and cardiovascular disease. Participants are excluded when exhibiting any symptoms of illness, including signs of infection or fever. Comparable baseline levels among participants are ensured by having the participants applying the test strips on two consecutive days in the morning and in the evening. Participants are excluded if the test strip indicates ‘depleted levels’, ‘low levels’, or ‘high levels’ for any of the baseline measurements.

Treatment NAC treatment is taken in capsule form at 600 mg once daily. NO donor and/or nitrate is taken in the form of one dosis of sports-beetroot juice, which comprises 35 ml of beetroot juice containing 400 mg of nitrates. Alpha-lipoic acid is taken in capsule form, at 1000 milligram once daily. Ascorbic acid is taken in capsule form at 500 mg, 1500 mg or 2500 mg, all once daily. Vitamin D is taken in capsule form at 600 IU, once daily (International Units). The treatments are taken for five consecutive days. The test strip is applied by the participants every day, two hours after the last meal.

The participants are randomly assigned to one of the following treatment groups: Group 1) Placebo Group 2) NAC Group 3) Beetroot juice Group 3) NAC + beetroot juice Group 4) NAC + beetroot juice + alpha-lipoic acid Group 5) NAC + beetroot juice + vitamin D

Group 6) NAC + beetroot juice + ascorbic acid (500 mg)

Group 7) NAC + beetroot juice + ascorbic acid (1500 mg)

Group 8) NAC + beetroot juice + ascorbic acid (2500 mg) Outcome

As illustrated by Table 1, the intake of NAC (Group 2) or beetroot juice (Group 3) may be moderately beneficial for NO production when compared to no treatment (Group 1). The intake of NAC, beet juice, and ascorbic acid at 500 mg or 1500 mg may be highly beneficial for NO production.

Table 1: shows the recognized NO levels as measured on the fifth day.

This example shows how selective ingredients may drastically increase the NO-enhancing effect of NO. Furthermore, this example shows that the combination of NAC, beet juice, and ascorbic acid in a specific dose range, surprisingly is a highly effective combination to stimulate the NO production. Although the scientific literature discloses alpha-lipoic acid and vitamin D as NO-enhancing supplements, surprisingly they do no further promote the NO- enhancing effects of NAC.

Table 1 shows that the optimal daily ascorbic acid dose is somewhere between 500 and 2500 mg. Based on preliminary tests (not shown), it was already concluded that lower intake of beetroot juice, i.e. 200 cc in total per day (± 150 mg nitrate), does not enhance the effect of NO. Therefore, a minimal amount of beet juice/nitrate seems required.

It is expected that similar effects as reported in Table 1 can be obtained for more quantitative systemic indicators of NO, such as the nasal NO, or the serum nitrite and nitrate concentrations as measured after methanol extraction by HPLC-coupled Griess reaction (Modi et al. Nitric Oxide. 2017 Apr 1; 64: 16-21).

Example 2

This example shows how the combination of NAC, beet juice, and ascorbic acid in subjects can restore NO production in subjects with low NO levels.

Experimental design

Largely the same experimental design is used in the current example as Example 1. In total, eight patients with ‘depleted levels’ of NO are included, based on the NO saliva strips.

NAC treatment is taken in capsule form at 600 mg once daily. Sports beetroot juice is provided as to guarantee a daily intake of 1000 mg or 2500 mg nitrate. Ascorbic acid is taken in capsule form at 1000 mg or 3000 mg, all once daily. The NO is measured on the fourteenth day.

Outcome As illustrated by Table 2, the intake of NAC together with beetroot juice may restore NO levels (Subjects 1-4). Based on Table 2, an intake of beetroot juice corresponding to a nitrate amount of 1000 mg (Subjects 1-2) is expected to be more beneficial than intake of beetroot juice corresponding to an amount of 3000 mg (Subjects 3-4). The addition of ascorbic acid at dose of 1000 mg leads to further enhanced NO production to target levels. The addition of ascorbic acid at 3000 mg is expected to be less effective.

Table 2: shows the recognized NO levels.

In this example, it is illustrated that ascorbic acid at a dose of 1000 mg has a putative synergistic effect in enhancing NO production together with NAC and inorganic nitrate in the form of beetroot juice. This example shows that inorganic nitrate and ascorbic acid within a specific dose range is expected to be needed for this synergistic effect in enhancing NO levels.

It is expected that results similar as reported in Table 2 can be obtained for more quantitative systemic indicators of NO, such as the nasal NO, or the serum nitrite and nitrate concentrations as measured after methanol extraction by HPLC-coupled Griess reaction (Modi et al. Nitric Oxide. 2017 Apr 1; 64: 16-21). Example 3

This example shows how the combination of NAC, beet juice, and ascorbic acid in different dosages in subjects can restore NO production, either in absence or in presence of electrical stimulation.

Experimental design

Largely the same experimental design is used in the current example as Example 1. NAC treatment is taken in capsule form at 600 mg once daily. Sports beetroot juice is provided as to guarantee a daily intake of 1000 mg nitrate. Ascorbic acid is taken in capsule form at 250 mg or 1000 mg, or 3000 mg all once daily. For electrical stimulation, the StimaWell Whole Body Electrostimulation apparatus (Schwa-Medico) is used three times a week (35 minutes with one minute warming up and one minute cooling down). The intensity (amplitude) is set to what the subject maximally can bear as comfortable. The NO is measured after five days.

Groups

Group 1: NAC + beetroot juice + no ascorbic acid Group 2: NAC + beetroot juice + 250 mg ascorbic acid Group 3: NAC + beetroot juice + 1000 mg ascorbic acid Group 4: NAC + beetroot juice + 3000 mg ascorbic acid

Outcome

The average putative effects that are measured for at least two subjects are illustrated in Figure 1. The intake of vitamin enhances NO production both in presence or absence of electrical stimulation. NO levels only reach high levels when 250/1000 mg ascorbic acid is taken in combination with electrical stimulation.

In this example, electrical stimulation leads to an unexpected further improvement in NO levels when providing NO-stimulating ingredients. Surprisingly, ascorbic acid at a relatively low dose of 250 mg may already restore NO production when it is combined with electrical stimulation. This example shows that ascorbic acid may have an optimal therapeutic dose somewhere between 250 mg and 3000 mg when used in combination with electrical stimulation.

It is expected that results similar as reported in Figure 1 can be obtained for more quantitative systemic indicators of NO, such as the nasal NO, or the serum nitrite and nitrate concentrations as measured after methanol extraction by HPLC-coupled Griess reaction (Modi et al. Nitric Oxide. 2017 Apr 1; 64: 16-21). Example 4 (Male, age: 83)

This example concerns a man aged 83 year with a healthy lifestyle (daily exercise and eating much vegetables and plenty of fruit) but nevertheless suffering from atherosclerosis, severe asthma, heart problems and high blood pressure. His daily medication consisted of various heart medication, N-acetylcysteine and high doses of asthma medication (Theophylline, Flixotide and Ventolin).

The male had survived three strokes, that left him bedridden with aphasia. After hospitalization with pneumonia and treatment with prednison, he developed temporary diabetes type 2 and decubitus wounds that would not heal. When returned home from the hospital, the atherosclerosis in his lower legs and feet was advanced to such a degree that the vessels were too constricted to administer contrast fluid for a scan. Therefore a scan of the vessels could not be made. His feet hurt and had an unhealthy appearance because of the ischemia and hypoxia as a consequence of the atherosclerotic vessels. The vessels were constricted to such a degree that a finger prick to measure I NR in the blood yielded no blood at all, not a drop. According to the doctor, the only perspective was to amputate both feet. Given his many health problems, this would mean his death. The family doctor started palliative care with morphine and a high dose of paracetamol.

We started the man on a wound healing diet, and started to exert electrostimulation over the vastus medians muscle (part of the quadriceps muscle). Both left and right side of the body received treatment. The characteristics of the electrostimulation were those for muscle strengthening of large muscles. During stimulation, the stimulated muscles were exercised at the same time. Electrostimulation was intended daily, but exerted on average only about three times a week because of practical reasons.

The male was daily fed plenty of fruit and leafy vegetables like cale, salad, spinach, turnip greens and endives. We also doubled his dose of daily N-acetylcysteine, in consultation with the doctor. One day after supplementation with a lot of leafy vegetables, a finger prick to measure INR in the blood generated a spray of blood instead of no drop of blood at all.

Over the next days, the pain subsided, the appearance of the foot returned to normal, developing decubitus disappeared and very slowly the wound started healing. The palliative care was discontinued. It was calculated that at this rate, the wound would be healed completely within ten months (Fig. 2A). At each electrostimulation session, ten minutes after the beginning the man started breathing more slowly and relax, nearly falling asleep. We had to keep him awake to remind him of the leg exercise during electrostimulation.

Ten weeks after starting the treatment we started serving the man one glass of fermented beetroot juice a day. This juice is commercially available in all supermarkets in the Netherlands. We did not use electrostimulation anymore, because the man was now able to exercise more by himself and adding electrostimulation to these exercises would be too exhausting for him. With one glass of beetroot juice a day, the wound healed within two months (Figs. 2B and 2C) Without beetroot juice and with electrostimulation, the wound was expected to heal in seven months from the same point. The application of beetroot juice accelerated the healing process with 350%. The man, who had been bedridden for five months, started to walk again when the wound was healed. A week after starting the first daily glass of beetroot juice, we noticed that the man’s asthma had disappeared.

Remarkable, because his asthma had been invalidating since his youth.

The present inventor concludes that the combination of a glass of beetroot juice a day, a daily double dose of N-acetylcysteine, a wound healing diet (including fruit) and electrostimulation of the muscles and/or physical exercise improved atherosclerosis, decubitus, wound healing and asthma. It accelerated the healing process of the decubitus wound with 350%.

Example 5 (Male, age: 83)

The man from example 4 had another stroke and was hospitalized and in coma. He was breathing heavily and his heartbeat was high. Doctors did not allow the man to receive any nutrition, not even beetroot juice. His perspective was that he was bound to catch pneumonia and die.

About 39 hours after his stroke, we started to apply electrostimulation to his muscles, alternating between legs ( vastus medians muscles, setting of apparatus: muscle strengthening of large muscles) and lower arms (the extensor muscles of the lower arm, setting of apparatus: muscle strengthening of small muscles). The electrostimulation was applied for 30 to 45 minutes.

Each time after around 10 minutes of electrostimulation, the man started breathing 4x/min more slowly, had a slower heartbeat and he seemed more relaxed. E.g. on the second day after the stroke, he breathed 36 x per minute before electrostimulation and after 10 minutes of electrostimulation he breathed 32 x per minute. On the third day after the stroke, he breathed 32 x per minute before electrostimulation and after 10 minutes of electrostimulation he breathed 28 x per minute. The effect lasted until about 15 to 30 minutes after the end of the electrostimulation. Therefore we applied numerous sessions per day. But continuous electrostimulation did not generate the desired effect. We found that for the electrostimulation to be effective, a break of about half an hour was needed between sessions.

We found that after four days, the effect disappeared: electrostimulation did not trigger slower breathing etc. anymore. On the fourth day the male breathed 36 x per minute and this did not change with electrostimulation. From then on, electrostimulation did not have any effect any more. On the fifth day he breathed 42 x per minute and on the sixth day his breathing pace raised from 44 x per minute to more than 50 x per minute. From the 13^th day after the stroke, we used our own saliva (nitrate-rich because of the intake of beetroot juice) to donate nitrate to the man, which would increase the level of NO in his blood. I collected my own saliva and fed a small amount (about 0.1 ml) to the man, after which I applied electrostimulation. Ten minutes later, the man breathed 4x/min more slowly, had a slower heartbeat and seemed more relaxed. The nitrate-rich saliva by itself was not sufficient to trigger the effect, it only worked when electrostimulation was applied as well.

The combination of nitrate-rich saliva (obtained by drinking beetroot juice) and electrostimulation of the muscles can improve tachycardia, lower increased respiratory rate and increase general relaxation. The source of the saliva may be someone else. The electrostimulation can be mild, it is not required to generate muscle contractions in order to obtain the desired effect.

Example 6 (Female, age: 51)

A 51 year old woman had several health problems: asthma, nocturia, an overactive bladder, urinary retention, gingivitis, digestive problems, poor strength and poor stamina when exercising. She was often ill with a cold or the flu, until she found out a few years ago that a daily dose of N-acetylcysteine improved her health to such extent that she would seldom catch a cold or the flu anymore. Since then, she took 600 mg of N-acetylcysteine daily.

She used a maintenance dose of asthma medication daily (a Symbicort 400pg inhaler, which is a corticosteroid combined with a bronchodilator), to prevent a flare-up of asthma when having a cold. Her bladder problems were annoying but not serious enough to seek treatment. She followed the advice from her dentist to cure the gingivitis by brushing her teeth well twice a day and using a toothpick daily, but this did not lead to improvement. Eating sugar- and gluten free improved the gingivitis but did not cure the last periodontal pockets. With digestion, food would pass the intestinal tract in a few hours and was not sufficiently digested. Changes in diet had led to improvement of the digestion time but digestion was still not complete. Her strength and stamina were poor, but she thought that this was normal as she was a petite female. Apart from these health problems, she had a healthy lifestyle, did not smoke, ate healthy with a lot of vegetables and fruit, drank no more than two glasses of alcohol a week and exercised nearly daily for at least half an hour in the open air. She had a Body Mass Index of 24. Without change in her situation, the health of this woman was not expected to change.

The woman started drinking 1/3 glass of commercially available fermented beetroot juice three times a day at mealtime. She expected that dividing the beetroot juice over the day would improve the effect. One day a week, she did not drink beetroot juice. She exercised nearly daily for at least half an hour in the open air, as she did before. The woman experienced that her asthma subsided, but did not disappear completely.

Thereafter, the woman took one glass of beetroot juice a day in one go, always around the same time of day. She did so six days a week, leaving one day without beetroot juice. From the day she drank her first glass of beetroot juice, the woman experienced no asthma symptoms anymore and she stopped using her asthma medication without any problem.

Even more so: she felt much healthier than before. When she had a cold, she drank a larger amount of beetroot juice, up to about 250 ml (but only once a day). After a few days of having a cold, she could feel her bronchi but the asthmatic feeling never became so bad that she needed her astma medication (no Symbicort nor Bricanyl or Ventolin). To her surprise, over several days to weeks her other health problems subsided or even disappeared. Bladder problems (nocturia, overactive bladder and urinary retention) subsided. The gingivitis and the last periodontal pockets disappeared completely after a few weeks. This was confirmed by a surprised dental hygienist. Over the course of several weeks, strength and stamina increased and consequently physical exercise became easier and more pleasant to perform. Any small wounds would heal much faster than before and give less discomfort.

The woman started to use a StimaWell Whole Body Electrostimulation apparatus (manufactured by the German company Schwa-Medico). This is a machine which can exert electrostimulation on nearly all large muscle groups of the body at the same time. She started on Whole Body Electrostimulation on average twice a week. She used a program to improve condition, for 35 minutes with one minute warming up and one minute cooling down. She set the intensity (amplitude) to what she could bear comfortably. While performing electrostimulation, she performed light exercises involving arms, legs and torso. Whole Body Electrostimulation is thus more intensive than electrostimulation on only two muscles. During the period when she performed Whole Body Electrostimulation, the woman continued to drink one glass of beetroot juice a day, eat fruit and take N-acetylcysteine daily. The Whole Body Electrostimulation in combination with the single daily glass of beetroot juice and NAC improved the woman’s digestion, made her stronger and made her feel fitter. She managed to keep a better sleep rhythm and fell asleep faster.

The intake of beetroot juice, combined with daily exercise, intake of N-acetylcysteine and eating fruit (vitamin C), made asthma, nocturia, an overactive bladder, urinary retention and gingivitis with periodontal pockets disappear completely. Physical strength and stamina improved. Small wounds healed faster. The additional application of Whole Body Electrostimulation made the woman stronger and feel fitter, improved her digestion and her sleep.

Example 7 (Female, age: 49)

Situation. A 49 year old woman suffered from Myalgic Encephalomyelitis (ME), invalidating brain fog, problems concentrating, thermostatic instability (problems with fluctuations of temperature), low blood pressure (down to 70/50 mmHg), Raynaud’s syndrome, hypersensitivity of skin to sunlight, excessive sweating, dry eyes and mouth, an overactive bladder, digestive problems (diarrhea), cold feet, a sleep disorder, tense muscles, a pale complexion, slow healing of e.g. overload and sprain, a painful lymph node in the groin, a poor immune system, low strength and a very low energy level and stamina. Over the years she had tried to improve her health with life style changes, diet and food supplements, in which she only partly succeeded. For about 25 years she had been unable to earn a living due to her health problems, mainly because of her brain fog and low energy level.

She ate healthy (plenty of vegetables and fruit) and took several food supplements daily, amongst which N-acetylcysteine. The health of this woman was not expected to change. The women first started on commercially available beetroot juice (fermented, one glass a day, six days a week). Later she added electrostimulation on two muscle groups (alternating both arms or both legs, similar to the electrostimulation in example 4), once daily.

After the woman started drinking beetroot juice, her immune system improved and her skin became less hypersensitive to sunlight. Her strength, low energy level and stamina and Myalgic Encephalopathy in general improved slightly. After she added electrostimulation to the beetroot juice, her blood circulation improved remarkably, which became apparent by the disappearance of cold feet and Raynaud’s syndrome. At the same time, the woman’s blood pressure, that used to be too low, did not become any lower with ingestion of the beetroot juice. The woman started to use a StimaWell Whole Body Electrostimulation apparatus (the same equipment as used in example 5). She started on Whole Body Electrostimulation about once a week, later increasing the frequency to twice a week and later three times a week. She used the program ‘Static, muscle/condition, untrained person’, setting the amplitude so low that the current did not activate the muscles. While performing electrostimulation, she laid down to rest and did no exercise at all. Although this was a very mild version of electrostimulation, it was applied on many muscles and in that way was more intensive than electrostimulation on only two muscles. During the period when she performed Whole Body Electrostimulation, the woman continued to drink one glass of beetroot juice a day and she continued to eat healthy vegetables and fruit and take her food supplements, amongst which N-acetylcysteine.

Whole Body Electrostimulation and beetroot juice had many more effects. After one of the first sessions, the painful lymph node in her groin, which had bothered her for years, disappeared completely. After each session, the woman felt more relaxed (with more relaxed muscles) and she had a feeling she slept deeper. Physical overload and sprain healed perceptibly faster as a direct result of Whole Body Electrostimulation. After a number of sessions, brain fog and concentration problems improved remarkably. Both her overactive bladder and her digestion improved significantly. Her complexion became less pale and her eyes and mouth were less dry. Cold feet, excessive sweating and overall sensitivity for temperature changes disappeared over time. Her strength, low energy level and stamina and Myalgic Encephalopathy in general improved significantly, especially after performing Whole Body Electrostimulation twice or three times a week.

Beetroot juice thus improved a few health problems. It did not aggravate low blood pressure. The combination of beetroot juice and electrostimulation on the other hand, improved more health problems. Performing Whole Body Electrostimulation in combination with beetroot juice intake improved even more health problems remarkably - most of all the difficult to tackle cognitive problems (brain fog and concentration). This is the more remarkable, because no cure for those symptoms could be found up to now.

Electrostimulation improves the effect of beetroot juice significantly, especially Whole Body Electrostimulation. Fruit (ascorbic acid) and N-acetylcysteine may help to prolong this effect.

Example 8 (Female, age: 53) MS patients often have cold feet, which can be extremely unpleasant to them but doctors do not take this symptom seriously and dismiss it as a minor health problem for which they have no cure. Cold feet are a sign of poor blood flow. Electrostimulation can improve blood flow.

To test if it would be feasible to wear electrostimulation during daily activities, an outfit was designed which contained four sets of electrostimulation electrodes for arms and legs, similar to the electrostimulation in the previous examples but this time all four muscles were stimulated at the same time. Settings of the electrostimulation were as in the examples before.

A woman wore the outfit and used the electrostimulation all day. The electrical stimuli did not interfere with daily business, although a visit to the toilet was hampered slightly by the electrical cords that connected the electrodes to the electrostimulation equipment. In addition, the woman consumed NAC and a glass of beetroot juice daily and ate plenty of fruit.

Electrostimulation improved concentration slightly. It was also perfectly possible to wear the electrodes all day and operate the electrostimulation all day, with intervals of at least half an hour. An unexpected finding was that the woman, sitting in a t-shirt at a computer for a long time in a cold room, was not bothered by the cold at all (as she normally would in such a situation). She did feel the temperature, which was cool, but the cold did not bother her. Neither did she feel ‘cold to the bone’ after an hour in the cold room. This indicated that her blood flow had improved. The effect appeared every time about ten minutes after starting electrostimulation and wore off some time after the electrostimulation ended. A minimal pause of 15 to 30 minutes between sessions, enhanced the desired effect.

Light electrostimulation (without muscle contraction) in combination with ingestion of beetroot juice, NAC and fruit (vitamin C) improves blood flow perceptibly. It does not hinder daily business and it may improve concentration when at work. It is feasible to repeat electrostimulation as often as needed, with an interval of at least 15 to 30 minutes between sessions.

Example 9 (Female, age: 52)

A 52 year old woman with Myalgic Encephalomyelitis (ME) had serious gum problems, cold feet and symptoms of restless leg syndrome. Those last two conditions are symptoms of poor blood flow. The woman had been suffering from gingivitis and paradontitis for over 20 years. The situation was so bad that when she was 30 years old, the dentist predicted that she would lose all of her teeth within 10 years. She managed to stabilize the situation with meticulous care so she did not lose her teeth, but the gingivitis and paradontitis remained a problem. Her gums hurt, her teeth were relatively loose and three times a year she would receive treatment with antibiotics.

At night, painful cramp in her legs would woke her up and she would have to move her legs and walk around and stamp on the ground to stop the cramp and the pain. The resulting broken nights were tiring her out. Because of the Myalgic Encephalomyelitis, the woman had not much physical exercise and was prone to muscle pain. There were no signs that her situation would change.

The woman started to drink one glass of commercially available beetroot juice a day. From the first day the woman started on beetroot juice, the symptoms of restless leg syndrome were gone. The woman was overjoyed, not only because she was not in pain any more, but also because she slept much better and was therefore less tired by day. Her feet were slightly less cold after starting on beetroot juice. So she continued to drink one glass of beetroot juice a day.

After some time, she had the impression that her gums improved. Three months after starting on beetroot juice, her dental hygienist was surprised to see that the inflammation of the gums was nearly gone. At the next visit three months later, the dental hygienist burst out in tears of joy because this nasty gingivitis/paradontitis was finally gone after 20 years. The damage that was present could not be undone, but the woman was very happy with the perspective of a stable situation without inflammation.

The woman continued to drink one glass of commercially available beetroot juice a day. She could not exercise daily because of ME, therefore she received electrostimulation equipment. She started using this once a day, with a TENS programme for pain relief. She used it every day on a different part of her body, depending on where she had muscle pain. When the woman used the TENS program on a muscle, the muscle pain would subside. In addition, when she used it on her calf muscles, her cold feet would really warm up, more than with beetroot juice alone.

Gingivitis, paradontitis and symptoms of restless leg syndrome can improve by the intake of a daily glass of beetroot juice. Electrostimulation can ease muscle pain. Beetroot juice combined with electrostimulation of the calf muscles with a TENS programme can promote blood flow even more than beetroot juice alone, warming up cold feet.

Example 10 (Reference example, Female, age: 86) An 86 year old woman suffered from lung cancer, dementia, high eye pressure and primary open-angle glaucoma. Her liver had not been working optimally all her life. Over the last years, the nails of her big toes had changed and become brown and deformed, which may be a sign of poor blood flow to the toes. The only medication she received was Erlotinib (brand name Tarceva) for the lung cancer and N-acetylcysteine to support her liver.

At a certain point, she got metastases of the tumour in the brain, for which the doctor prescribed another medication: instead of Erlotinib, the woman received Osimertinib (brand name Tagrisso). Around that time, a scientific publication indicated that poor blood flow and hypoxia in the brain may constitute important factors in dementia (in a hypoxic environment, proteins are prone to improper folding).

Both her tumour and dementia were expected to worsen over time. The eye pressure, liver function, blood flow to the toes and appearance of the toenails were not expected to change.

Beetroot juice was offered to the woman, to improve the blood flow in her brain. This may help to support the brain against dementia. We expected that the higher NO level in her blood might help to lower her high eye pressure and reduce the progress of the glaucoma. But the woman loathed beetroot and refused to drink the juice.

For her benefit, a bonbon with a filling containing ample beetroot powder was presented to her. Two bonbons contain the nutrients and nitrates of about half a glass of beetroot juice, but this is a very rough estimate. The bonbons have more added health benefits. They contain chocolate without sugar, which keeps the blood sugar level more constant than normal chocolate with sugar would do. As tumours thrive on high blood sugar, this seemed a sensible thing to do. Furthermore, the filling of the bonbons was spiced with several spices which have anti-inflammatory and anti-coagulation properties.

The woman loved the bonbons and eagerly ate on average two bonbons a day. Even more so, everybody who tasted the bonbons loved them. Friends and family were enthusiastic. They loved the taste and they also loved the idea that the bonbons were so healthy that there was no reason to feel guilty to indulge in them!

Later we discovered that the woman would drink tea containing beetroot powder, 600 mg of N-acetylcysteine and 1000 mg of vitamin C. From then on, we gave her NAC and vitamin C in her tea and beetroot powder in both tea and bonbons.

Incidentally, we applied electrostimulation to her upper legs ( vastus medians ), but this happened only once a week on average. After starting on beetroot bonbons (and later on beetroot powder in the tea), the toenails of the woman began to appear normal again. Figs. 3A and 3B show her toenails three months after the change of medication from Erlotinib to Osimertinib, before ingestion of any beetroot powder in the form of bonbons. Fig. 3C was taken a year later, and about half a year after a change of medication from Osimertinib to Afatinib. This may be due to improved blood flow to the extremities. According to the pulmonologist, the change of medication from Erlotinib to Osimertinib at the same time could have contributed as well (Erlotinib apparently may hamper blood flow to the extremities and Osimertinib does not). But when the medication later was changed from Osimertinib to Afatinib (a medication very similar to Erlotinib with similar side effects), the toenails stayed perfectly healthy. This indicates that the bonbons with beetroot powder probably did contribute to improved blood flow.

The eye pressure of the woman was measured only once every few months. The ophthalmologist was not willing to measure it more frequently to investigate the effect of beetroot on eye pressure. We had the impression that the eye pressure was lower on days when the woman had taken her daily dose of beetroot powder, and higher on days when she had not ingested beetroot powder. However, the measurements were too few to draw a clear conclusion.

The main blood values of the woman were exceptionally good, above expectation for someone of her age, with her afflictions and her tumour medication. Her HB was 7.7, her kidney value was 58 (very good for her age, because 60 is considered to be optimal but for elderly the values are generally lower) and for the liver values, ALAT, ASAT and Gamma CT were normal. This is remarkable, because her liver did not function optimally all her life.

Bonbons and tea with beetroot powder are effective in supplying nitrates to a patient. Nitrates from beetroot (powder) can improve blood flow, also in the extremities (toes), and can return toenails that are deformed and brown because of limited blood circulation to normal, even without electrostimulation.

Example 11 (Female, age: 56)

A 56 year old woman had myalgia, a headache, and was very tired. Her lungs hurt slightly and her breath became constricted. She drank one and a half glass of beetroot juice every morning and took 2.000 mg ascorbate and 600 mg NAC daily, this had a small positive effect on her breath but not enough to make her feel good. She felt like she needed asthma medication, even after drinking sufficient beetroot juice. She tried to relax her bronchi with electrostimulation on the extensors of her arms. Every time when she turned on the electrostimulation, after 10 minutes the breath constriction and the pain in her lungs subsided to a level that it was hardly noticable and she could breathe normally again. Her lungs felt good (although she still had the headache, myalgia and tiredness...).

The addition of electrical stimulation to the ingested food supplements and beetroot juice worked surprisingly well, even better than expected. The effect wore off some time after the electrostimulation finished. Therefore she applied the electrostimulation many times a day, with at least 30 min. interval between sessions. It worked every time, although the effect was slightly reduced at the end of the day. She did not need any asthma medication.

Her symptoms lasted for about a week. She used electrostimulation for the first four days, after that her lungs were not constricted anymore. The combination of ingesting beetroot juice and applying electrostimulation over a pair of small muscles like the extensors of the lower arm, can have a very effective relaxing effect on constricted breath. Beetroot juice, NAC and ascorbate together has a slight positive effect, too, but combining it with electrostimulation has a significantly larger effect. The electrostimulation unleashed the full potential of this treatment.

Example 12 (Female, age: 86)

The health of the female from example 10, with lung cancer, brain tumours and dementia, deteriorated. She showed clear signs of cachexia. Cachexia is a syndrome causing ongoing muscle loss, lost appetite and fatigue. Cachexia is associated with an underlying illness and can improve with treatment of the underlying illness, but no other effective treatment exists. Cachexia is associated with increased mortality and poor quality of life. Cachexia is most often associated with end-stage cancer.

The woman showed significantly decreased muscle strength, fatigue and anorexia. She needed help to sit up. Her BMI (body mass index) was slightly under 18 kg/m². She had a foul odor about her, according to the pulmonologist this could be caused by the cachexia. Her urine had a very foul odor.

As stated in example 10, the female daily consumed 600 mg NAC and 1000 mg ascorbic acid in her tea and beetroot powder in both tea and bonbons and once a week on average we applied electrostimulation to her upper legs. She was often confused, due to either the brain tumours, dementia or both. The cachexia left the woman bedridden. She mainly slept through the day, she hardly ate and she did not speak much (did not initiate conversations and gave only short answers to questions). The pulmonologist said the woman had only a few weeks left to live. She increased the medication (Osimertinib, trade name Tagrisso) from 80 to 120 mg per day.

After a week the woman was less confused (though her memory did not yet improve).

The side effects of the medication slowly increased, therefore after two and a half weeks of 120 mg Tagrisso the dosis was lowered to the original 80 mg a day. The result was that the side effects decreased slightly, but nothing else changed. The confusion did not return.

A week later we started to intensify the frequency of the electrostimulation. We used electrostimulation on the muscles of her arms for 35 minutes, two to four times daily, with 20 to 30 minute intervals in between. The intensity was ‘comfortable’ and just not high enough to contract muscles. The woman did not mind the treatment. Her cognition slowly improved.

Three weeks after that, we increased the frequency of electrostimulation on the arms to 8 to 12 times a day, with 20 to 30 minute intervals in between. One week later, we applied electrostimulation on both arms and legs (again 8 to 12 times a day, with 20 to 30 minute intervals in between). When we did this, the foul body odor disappeared and the urine went from very foul smelling to odorless. The woman became more talkative, answering in sentences instead of with one or two words. She still slept nearly all day, but was not confused any more when awake. Her short term memory appeared to improve slightly (after offering her something to drink for the fourth time within 20 minutes, she would remark that we had already asked three times- that was remarkable and this happened on several days). Her muscle force and appetite were both little, but in general stable and did not deteriorate. Sometimes she would sit up by herself, without our help. Although she did not eat much more than before, she again took initiative to eat, taking something to eat by herself when we would not be around.

When incidentally the frequency of electrostimulation decreased to three times a day, the foul body odor and very foul smelling urine would return temporarily.

Ten weeks after the visit to the pulmonologist, the woman caught gastroenteritis. Her health deteriorated but she continued using the electrostimulation and although she seemed to lose weight, the cachexia smell did not return (although she did smell of acetone, an indication that fat was being burnt) and her skin remained in very good condition. No decubitus developed. Three months ago, the pulmonologist predicted that the woman had no more than a few weeks to live. With NAC, ascorbic acid, beetroot powder and bonbons and electrostimulation, she improved slightly and is in a stable condition now. NAC, ascorbic acid, Beetroot powder and bonbons combined with very frequent but not very intensive electrostimulation of the muscles influences the health of a cancer patient with cachexia and dementia. Some aspects improved (cognition, odor, speech, initiative, sitting up), some aspects were stable (muscle force, appetite, sleep). Deterioration only set in after the woman caught gastroenteritis. Still, after three months the woman’s health was better than expected.

Example 13

In a 40 day treatment period with 49 patients, they are subjected to neuromuscular electrical stimulation (NMES) twice a day. In addition, they receive an oral dose of beetroot juice (Beta vulgaris) of 0.5 liter once a day. Three control groups receive either NMES, beetroot juice or no stimulation or beetroot juice.

Example 14 (Female, age: 57)

A female subject took one cup of beetroot juice and 600 mg NAC daily for nearly 6 years to prevent asthma. Over the last year, she also took 1000 mg of ascorbic acid daily. This worked very well, she did not need any asthma medication during those years. Not even when she contracted COVID-19. The woman wanted to find out if she could do without NAC.

The woman continued to take one glass of beetroot juice and 1000 mg of ascorbic acid a day. She did not take NAC any more. After two days she experienced a slightly asthmatic feeling that grew stronger over the following days. She also had a frequent, sometimes continuous urge to urinate. On the seventh day after discontinuing the NAC, the asthmatic feeling was so disagreeable that she started taking NAC again, 600 mg twice daily (double the normal dose) for the first days. The asthmatic feeling and the frequent urge to urinate receded slowly and disappeared completely seven days after starting with NAC again. After feeling healthy for five days, the woman stopped taking NAC once more (but continued with beetroot juice and ascorbate). Seven days after discontinuation of the NAC, the asthmatic feeling started again and the continuous urge to urinate started again. The asthmatic feeling was slightly less than last time, but the continuous urge to urinate was so annoying that the woman started on NAC again after four days. The first days she took double the dose of NAC. A few days later the asthmatic feeling and the frequent urge to urinate had disappeared again.

The present inventor concludes that daily beetroot juice and ascorbate but without NAC, two symptoms of NO deficit (asthma and a frequent and sometimes even continuous urge to urinate) occurred after a few days. When adding daily NAC again, the symptoms receded again. This happened twice in a row. NAC may be an indispensable element of the NO- therapy.

Example 15 (female, age: 89)

In the following examples, a ‘normal’ blood pressure is acknowledged to be 120/80, a ‘pre- high’ blood pressure’ is acknowledged to be between 120/80 and 140/90, a ‘high’ blood pressure is acknowledged to be more than 140/90.

A woman had high blood pressure all her adult life. She was prescribed medication that brought her blood pressure down, but with 168 mmHg (systolic pressure) over 100 mmHg (diastolic pressure) she still suffered from significant hypertension. She had an active lifestyle. The woman started taking one portion of sports-beetroot juice with 400 mg nitrates and 600 mg NAC once a day. After a week, her blood pressure was 146/94 mmHg. She took beetroot juice and NAC for some more weeks, with similar results. After two months, she included a daily dose of 1,000 mg ascorbic acid in her diet, while continuing the daily intake of beetroot juice and NAC. After a week, the woman’s blood pressure was measured and it had even further decreased to 138/89 mmHg. This was a surprising decline. The woman was very happy and continued with the daily beetroot juice, NAC and ascorbic acid. Considering her age, her doctor was satisfied with her blood pressure which continued to be around 140/90 mmHg.

The present inventor concludes that a woman with refractory hypertension which cannot be controlled with medication, lowered her blood pressure to an acceptable level by taking daily beetroot juice, NAC and ascorbic acid, combined with an active life style. There appears to be a synergistic effect of nitrate and/or a NO donor, NAC, and ascorbic acid in treating hypertension.

Example 16 (male, age: 35)

A man was diagnosed with hypertension, with a blood pressure of 155/94 mmHg. He did not want to take blood pressure lowering medication.

The man started taking one glass of commercially available beetroot juice, 600 mg NAC and 600 mg ascorbic acid a day. He cycled to work daily and exercised regularly, as he always did. After a week, his blood pressure was 122/84 mmHg. Since then, he continued with this regimen and his blood pressure remained within healthy limits. No side effects were noted. The present inventor concludes that the combination of nitrate and/or a NO donor, NAC, and ascorbic acid is highly effective in treating hypertension without side effects and does not even require use of blood pressure lowering medication (presumably associated with more risk of having complications due to medication).

Claims

1. Nitrate and/or a nitric oxide donor in combination with

- N-acetylcysteine and/or N-acetylcysteine amide; and

- ascorbic acid and/or ascorbate, wherein the ascorbic acid and/or ascorbate is provided in an amount of between 250-2500 mg, for use in prevention or treatment of a condition related to nitric oxide deficiency in a subject and wherein the use is for increasing nitric oxide level in a subject.

2. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to claim 1, wherein the nitrate and/or a nitric oxide donor is nitrate, preferably inorganic nitrate.

3. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to claim 1 or claim 2, wherein the nitrate and/or a nitric oxide donor is comprised in edible plants or parts, extracts, concentrates thereof, wherein the edible plant is selected from the group comprising: Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens, Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare, Portulaca oleracea, Rorippa, or any combination thereof.

4. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any of the preceding claims, wherein the nitrate and/or a nitric oxide donor is comprised in Beta vulgaris, preferably Beta vulgaris subsp. vulgaris.

5. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any one of claim 4-5, wherein the Beta vulgaris is in the form of a powder, bonbon, extract, juice, fermented juice, or a combination thereof.

6. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any of the preceding claims, wherein the subject is comatose and/or bedridden.

7. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any of the preceding claims, wherein the condition related to nitric oxide deficiency is selected from: a condition related to blood circulation, or reduced blood flow selected from Alzheimer’s disease, angina, atherosclerosis, bowel ischemia, brain ischemia, cancer, cardiac arrhythmia, cardiac ischemia, cerebrovascular accident, cold feet, congestive heart failure, coronary artery disease, cutaneous ischemia, decubitus, dementia, dementia with Lewy bodies, embolism, erectile problems, frontotemporal dementia, vascular dementia, gangrene, heart disease, heart failure, hypertension, hypertensive heart disease, hypoxemia, immersion foot syndrome, intermittent claudication, ischemia, limb ischemia, multiple sclerosis, myalgic encephalomyelitis, myocardial infarction, periodontal disease, gingivitis, periodontitis, peripheral artery disease, peripheral neuropathy, Prinzmetal’s angina, Raynaud syndrome, restless leg syndrome, sleep disorders, thrombosis, thromboembolic disease, type 1 diabetes, type 2 diabetes, wounds such as skin wounds, venous thrombosis; a condition related to digestion, selected from motility disorders, achalasia, diarrhea, constipation, irritable bowel syndrome, anal fissure, poor digestion; a condition related to formation of blood vessels, selected from pre-eclampsia, cancer, cancer metastases, wounds such as skin wounds, muscle atrophy; a condition related to kidney malfunctioning and EPO production, selected from anaemia, wounds such as skin wounds, inflammatory bowel disease, nephropathy, proteinuria; a condition related to brain functioning and neurodegenerative disorders, selected from neural degeneration, problems with neurotransmission, memory problems, Parkinson’s disease, Alzheimer's disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis, myalgic encephalomyelitis, sleep disorders, schizophrenia, bipolar disorder, major depressive disorder; a condition related to urinary tract and bladder malfunctioning, selected from nocturia, bladder storage disorder, urinary retention, benign prostatic hyperplasia; a condition related to the liver, selected from hepatitis, fatty liver disease, other liver diseases; a condition related to the female reproductive system, selected from female infertility, pre-eclampsia, premature birth; a condition related to breathing and lungs, selected from asthma, COPD, ARDS, bronchitis, pneumonia, dyspnea, increased respiratory rate; a condition related to the eye, selected from high eye pressure, glaucoma; a condition related to stamina and muscle force, selected from low energy level, fatigue, cachexia, low maximal muscle force, low stamina, mitochondrial diseases; a condition related to infection and/or the immune system, selected from bronchitis, cachexia, cancer, pneumonia, sepsis, septic shock, nephritis, colitis, wet gangrene, periodontitis, autoimmune diseases, multiple sclerosis, myalgic encephalomyelitis, inflammatory bowel disease, a weak immune system, immune tolerance during organ transplantation, any infection, also infections with bacteria or viruses that are not recognised by the adaptive immune system (e.g. SARS-CoV and SARS-CoV2); a condition related to mobility and motility, selected from bedridden, cachexia, rheumatic disorders, rheumatoid arthritis, gout, osteoarthritis, afflictions of the musculoskeletal system, afflictions of the joints, afflictions of the heart, afflictions of the lungs, large wounds, decubitus, obesity, multiple sclerosis, myalgic encephalomyelitis, dementia, Parkinson’s disease; a condition related to the skin, selected from wounds, decubitus, Raynaud syndrome; a condition related to fat metabolism, selected from obesitas, hypercholesterolemia, fatty liver; a condition otherwise, selected from cardiac arrhythmia, prevention of ischemia/reperfusion injury.

8. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any of the preceding claims, wherein the condition related to nitric oxide deficiency is selected from atherosclerosis, decubitus, wounds, reduced blood flow, hypertension, asthma or type 2 diabetes.

9. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to claim 8, wherein the condition related to nitric oxide deficiency is a skin wound and/or hypertension.

10. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any of the preceding claims, wherein:

- Nitrate and/or a nitric oxide donor is comprised in the combination from 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg, e.g. per dose or per ml or per g of formulation or composition comprising said;

- N-acetylcysteine and/or N-acetylcysteine amide is comprised in the combination from 100 mg to 10 g, preferably from 200 mg to 4 g, more preferably from 400 mg to 3 g, most preferably from 600 mg to 1800 mg, e.g. per dose or per ml or per g of formulation or composition comprising said; and/or;

- Ascorbic acid and/or ascorbate is preferably comprised in the combination from 500 mg to 2000 mg, more preferably from 500 mg to 1500 mg, most preferably from 500 to 1000 mg, e.g. per dose or per ml or per g of formulation or composition comprising said.

11. Nitrate and/or a nitric oxide donor in combination with N-acetylcysteine and/or N- acetylcysteine amide; and ascorbic acid and/or ascorbate, for use according to any one of the preceding claims, wherein the Beta vulgaris and/or Beta vulgaris subsp. Vulgaris is comprised in the combination in an amount chosen such that the nitrate dose is in the range of 10 mg to 10 g, preferably from 50 mg to 5 g, more preferably from 100 mg to 2 g, most preferably from 120 mg to 1250 mg.

12. Kit of parts, comprising

- a nitrate and/or a nitric oxide donor containing edible plant or parts, extracts, concentrates thereof, wherein the edible plant is selected from the group comprising:

Beta vulgaris, Spinacia oleracea, Eruca sativa, Brassica oleracea, Apium graveolens,

Cichorium endivia, Brassica rapa, Brassica sinensis, Lactuca, Foeniculum vulgare,

Portulaca oleracea, Rorippa, or any combination thereof; and

- N-acetylcysteine and/or N-acetylcysteine amide.

13. Kit of parts according to claim 12, wherein the kit of parts further comprises ascorbic acid and/or ascorbate.

14. Kit of parts according to any of one of claim 12-13, wherein the nitrate and/or a nitric oxide donor containing edible plant or parts, extracts, concentrates thereof is Beta vulgaris subsp. vulgaris, preferably Beta vulgaris subsp. vulgaris juice.