LETTER TO THE EDITOR: Pomegranate Juice is Useful for the Management of Hypertension and the Improvement of Cardiovascular Health
Authors: Tziomalos Konstantinos , Doumas Michael , Athyros Vasilios G. 
Published: November 2013

DEAR EDITOR

We thank Prof. Liberopoulos and Dr Barkas you for their
letter [1], which helps to enhance the understanding of the
message of the associated Editorial.

Price and availability of pomegranate juice (PJ) are indeed
two major issues. The daily cost of PJ consumption is
ranging from 0.5 to 1 $ per day, according to the dose used.
PJ is available in almost all Western and several Asian countries.
PJ is preserved in deep refrigeration and is readily
available during the entire year. PJ circulates mainly in two
forms: pure juice in 200 to 500 mL bottles (adulteration is
practically impossible, because the color and the taste are
unique) and in 1 L bottles, blended with purple grape juice
without added sugar. The later contains resveratrol, a type of
natural phenol and a phytoalexin, found in the skin of red
grapes with definite antidiabetic effects and proposed but not
proved yet anti-aging and anticancer effects. Resveratrol
treatment has shown beneficial effects on glucose and lipid
metabolism in some, but not all studies [2,3]. Study population,
resveratrol source, and dose vary widely, potentially
explaining inconsistency of findings among studies. Enhancement
in endothelial function, systolic blood pressure,
and markers of oxidative stress and inflammation in several
studies have been reported [2,3].

The quantity and calorie intake is not a problem. Most
studies (performed by Prof Aviram team) used a 50 mL PJ
intake [4], mainly from the “wonderful” variety [5]. The
juice has a 10% content of sugar (5 g/d). Thus, calorie intake
is not significant. In regard to diabetes mellitus the use of PJ,
especially if this is mixed with purple crape juice, substantially
reduces blood glucose and the risk of diabetes, and not
the other way around [2-5]. As a matter of fact PJ has more antiatherogenic effects on patients with diabetes
than in non-diabetic individuals [4-6].

The studies showing a beneficial effect of PJ on cardiovascular
risk factors indeed included a small number of participants,
were mostly not double blinded and evaluated only
surrogate end-points. This is why we suggest that PJ might
be only used as an adjunctive therapy for arterial hypertension
(HTN) on top of other non-pharmacological interventions
or drug therapy [7], and mainly in patients with HTN
and high oxidative burden such as this caused by diabetes,
obesity, metabolic syndrome or smoking [7]. This is not a
first line therapy and is not suggested for monotherapy [7]. It
is unfortunate that up to day there have been no sponsors or
grants available to clear this issue once and for all, regardless
of the findings, with a large scale, prospective, randomized,
controlled survival study in humans.

The effect of PJ on blood pressure is reported by some
studies to be as high as a 21% reduction in systolic blood
pressure, which is rather sizable reduction [8].
The long term (3-years) effects of PJ on a surrogate endpoint
(carotid atherosclerosis) were shown in a clinical study
[8]. There were no adverse effects as reported with other
antioxidants, such as alpha-tocopherol and beta-carotene [8].
Finally, PJ was shown to have the highest antioxidant potential
than any other functional food or supplementary treatment
[9].

Common sense suggests that all appropriate pharmacological
or non-pharmacological interventions should be implemented
for the optimal control of HTN, however, the use
of PJ (the other parts of the fruit have no antioxidant actions)
could be considered as an adjunctive therapy to improve the
control of HTN and the related, mainly cardiovascular, adverse
events.