Response to Exercise and Nitric Oxide in PAD

Inclusion Criteria:

1. An ABI less than or equal to 0.90 at baseline.

2. Vascular lab evidence of PAD (such as a toe brachial pressure less than or equal to 0.70 or an ankle brachial index less than or equal to 0.90), or angiographicevidence of PAD defined as at least 70% stenosis of an artery supplying the lowerextremities.

3. An ABI of more than 0.90 and less than 1.00 who experience a 20% or greater drop inABI in either leg after the heel-rise test.

Exclusion Criteria:

1. Above- or below-knee amputation

2. Limb-threatening ischemia defined as an ABI less than 0.40 with symptoms of restpain

3. Wheelchair confinement or requiring a walker to ambulate

4. Walking is limited by a condition other than PAD

5. Current foot ulcer on bottom of foot

6. Failure to complete study-run

7. Unwilling to accept randomization into either group (supervised exercise orattention control)

8. Planning to engage in new walking exercise outside of the study or unwilling torefrain from new walking exercise activity during the trial.

9. Already exercising at a level consistent with exercise intervention, usinginvestigator discretion.

10. End-stage kidney disease (ESKD) that is treated with hemodialysis.

11. Planned major surgery, coronary or leg revascularization during the next six months

12. Major surgery, coronary or leg revascularization or major cardiovascular event inthe previous three months

13. Major medical illness including lung disease requiring oxygen, Parkinson's disease,a life-threatening illness with life expectancy less than six months, or cancerrequiring treatment in the previous two years. [NOTE: potential participants maystill qualify if they have had treatment for an early stage cancer in the past twoyears and the prognosis is excellent. Participants who require oxygen only at nightmay still qualify.]

14. Mini-Mental Status Examination (MMSE) score less than 23 or dementia. If the MMSE isless than 23 and the Principal Investigator evaluation determines that the lowerscore is related to language barriers or education level, the Principal Investigatorhas discretion to allow a participant with MMSE less than 23 to participate, asappropriate. Dementia with sufficient impairment to prevent full engagement in allaspects of the trial will be an exclusion per the investigator's discretion.

15. Allergy to beetroot juice

16. Currently consuming beetroot juice, oral nitrate or nitrite, or a beetrootsupplement and/or unwilling to avoid beetroot juice during the study. Participantswill be asked to discontinue these items for 30 days before baseline testing andthroughout the clinical trial. If the potential participant is unwilling to refrainfrom taking these items, they will not be eligible for the clinical trial.

17. Currently consuming one cup or more of beets daily. Participants will be asked todiscontinue beet ingestion of one cup or more of beets for 30 days before baselinetesting and throughout the clinical trial. If the potential participant is unwillingto refrain from daily beet consumption of one cup or more for 30 days before thetrial and during the trial, they will not be eligible for the clinical trial.

18. Unstable angina

19. Abnormal baseline stress test without subsequent clearance for exercise by physician

20. Non-English speaking. The RESIST PAD interventions are delivered by interventionistswho do not speak non-English languages. The integrity of the clinical trial requiresclear and effective communication for data collection and intervention delivery. Thetrial does not have staff members who are fluent in non-English languages nor doesit have the ability to translate all study materials into other languages.

21. Participation in or completion of a clinical trial in the previous three months. [NOTE: after completing a stem cell or gene therapy intervention, participants willbecome eligible after the final study follow-up visit of the stem cell or genetherapy study so long as at least six months have passed since the finalintervention administration. After completing a supplement or drug therapy (otherthan stem cell or gene therapy), participants will be eligible after the final studyfollow-up visit as long as at least three months have passed since the finalintervention of the trial.] Participants in a study that involved up to three singledoses of nitrate-rich beetroot juice administered on separate days may participateif a month has passed since their last dose of nitrate-rich beetroot juice.

22. Visual impairment that limits walking ability.

23. Baseline blood pressure less than 100/45.

24. Participation in a supervised treadmill exercise program in previous three months orplanning to begin a supervised treadmill exercise program in the next six months.

25. In addition to the above criteria, investigator discretion will be used to determineif the trial is unsafe or not a good fit for the potential participant.