Obesity, vitamin D deficiency and old age a serious combination with respect to coronavirus disease-2019 severity and outcome.

PURPOSE OF REVIEW: Old age, obesity and vitamin D deficiency are considered as independent risk factors for severe courses of COVID-19. The aim of the review is to discuss common features of these risk factors and the impact of vitamin D. RECENT FINDINGS: The recently discovered relationship between vitamin D and the infection pathway of the virus via the renin--angiotensin system (RAS) and the adipokines leptin and adiponectin play an important role. The frequency of studies showing a relationship between a low vitamin D status in comorbidities and severe COVID-19 courses makes an impact of vitamin D effects likely. SUMMARY: There is a direct relationship between vitamin D, body fat and age in COVID-19 courses. With age, the ability of the skin to synthesize vitamin D decreases, and leads to vitamin D-deficits. If the skin is insufficiently exposed to sunlight, severe deficits can develop. As vitamin D plays an important role not only in the immune system but also in the RAS, and thus at the point where the virus attacks, a good vitamin D supply is an important basis for reducing the risk of severe COVID-19 processes. Treatment with vitamin D supplements should be based on severity of the vitamin D deficiency.

Climate Change Enhanced Carotenoid Pro-Vitamin A Levels of Selected Plantain Cultivars.

Diet diversification and the exploitation of traditional, micronutrient-rich germplasm of staple crops are generally regarded as sustainable and low-cost approaches to increase the micronutrient intake of resource-poor people. Sun's UV index was collected daily throughout the year. The study assessed the seasonality of provitamin A carotenoids in three plantain cultivars in response to climatic condition. Fruits were harvested at three maturities and freeze-dried before analysis. The results showed that there were high levels of the sun's UV-B radiations throughout the year with the highest occurring from November to May when the area experienced clear skies with minimal cloud cover. These high levels of the sun's UV-B index occurred between 9.00 h GMT and 17.00 h GMT. The study also showed that α-carotene content increased with maturity in "Apantu" during the rainy seasons ranging from 95 to 172 µg/100 g of dry pulp. Similar trends were observed during the dry season with a range of 28 to 489 µg/100 g. The α-carotene contents were very high in the periods of high sun's UV-B radiations compared to the periods of low sun's UV-B radiations. The α-carotene levels in the giant French plantains showed similar trends. Intermediate French "Oniaba" and False Horn "Apantu" plantain cultivar showed the highest content of ß-carotene during the dry season. The high provitamin A carotenoid levels in the cultivars coincided with the high levels of the sun's UV index.

Validation of the CIMI-Ethiopia Program and Seasonal Variation in Maternal Nutrient Intake in Enset (False Banana) Growing Areas of Southern Ethiopia.

BACKGROUND: Tools for the rapid and accurate analysis of nutrient intakes from diets of individuals in Southern Ethiopia are lacking. The Calculator of Inadequate Micronutrient Intake program for Ethiopia (CIMI-Ethiopia) has been developed to overcome this problem. CIMI-Ethiopia also computes protein and energy intakes from the diet. The objectives of the current study were to validate CIMI-Ethiopia for the dietary pattern of Southern Ethiopia, and assess the nutrient intakes in postharvest dry and lean wet seasons. METHODS: 24-h dietary recall (24HR) data was collected from 578 women of a reproductive age in postharvest dry and lean wet seasons in 2017. For analysis, 24HR data was entered into NutriSurvey (NS), which was the reference nutrition software, and then into CIMI-Ethiopia. For validation, the mean and standard deviation (SD) of the difference between CIMI-Ethiopia and NS were computed. The percentage of participants with an inadequate intake was calculated. The correlation between CIMI-Ethiopia and NS results was determined. The nutrient intakes in postharvest dry and lean seasons were compared. RESULTS: Among the nutrients, pantothenic acid, vitamin B1, and protein showed a very high accuracy in CIMI-Ethiopia calculation (|difference (D)| < 5.0% of the NS result). Nutrients with a good accuracy (|D| = 5%-15%) were iron, zinc, magnesium, vitamin B12, vitamin B6, and energy. The accuracy for calcium, niacin, and vitamin A was moderate (|D| = 15%-30%). The intakes calculated by CIMI-Ethiopia and NS of iron, zinc, magnesium, calcium, B-complex vitamins, vitamin A, protein, and energy were highly correlated (r = 0.85-0.97, p < 0.001). NS analysis identified a significant reduction in the mean intake of iron; zinc; magnesium; pantothenic acid; vitamin B1, B12, and D; protein; and energy in the lean wet season; however, calcium and vitamin A intake increased. CONCLUSIONS: It has been found that CIMI-Ethiopia is a valid tool for estimating nutrient intakes at an individual level in Southern Ethiopia. The study demonstrated a decline in intakes of iron; zinc; magnesium; pantothenic acid; vitamin B1, B12, and D; protein; and energy in the lean wet season. This result provides some hint for fortification and supplementation programs that aim to combat maternal malnutrition in rural Southern Ethiopia.

Dietary Diversity and Anthropometric Status of Mother-Child Pairs from Enset (False Banana) Staple Areas: A Panel Evidence from Southern Ethiopia.

BACKGROUND: A sizable cross-sectional studies demonstrated a low dietary diversity in Southern Ethiopia. However, its seasonal trend has not been well studied in areas where nutrient-poor enset (false banana (Ensete ventricosum)) foods are major staple. Moreover, there is scarcity of information on seasonal nature of anthropometric status of mother-child pairs (MCP) from the same areas in Southern Ethiopia. Therefore, the present study aimed to investigate the dietary diversity and anthropometric status of MCP in postharvest dry and lean wet seasons and identify factors associated with anthropometric status. METHODS: The dietary intake and anthropometric data were collected from 578 households (578 mothers and 578 children) January-June 2017. The study compared data of the two seasons using McNemar's test for dichotomous, Wilcoxon signed-rank test for non-normally distributed, and paired samples t-test for normally distributed continuous data. Logistic regression was conducted to identify risk factors for malnutrition. In addition, Spearman's Rho test was used to determine correlations between maternal and child variables. RESULTS: Over 94% of the mothers did not fulfil the minimum diet diversity score in both seasons. The meal frequency and pulses/legumes intake significantly declined in lean wet season; however, dark green leaves consumption increased. Meat, poultry, and fish consumption dropped to almost zero in the lean wet season. The dietary diversity and anthropometric status of the MCP were correlated. Weight-for-age (WAZ) and weight-for-height (WHZ) of children significantly declined in the lean wet season. In the same way, maternal mid upper arm circumference (MUAC), body weight, and body mass index (BMI) dropped (p < 0.001) in this season. Being pregnant and a lactating mother, poverty, and the ability to make decisions independently predicted maternal undernutrition (low MUAC). On the other hand, maternal undernutrition and education were associated with child underweight. CONCLUSIONS: The results demonstrated that the dietary diversity of MCP is low in both postharvest dry and lean wet seasons. This suggests the need for continuous nutrition intervention to improve the dietary diversity. In addition, the anthropometric status of MCP declines in lean wet season. This may provide some clue for policy targeting on improving nutritional status of mothers and children in rural Southern Ethiopia.

Animal-based food taboos during pregnancy and the postpartum period of Southeast Asian women - A review of literature.

This paper gives an overview of the various taboos on animal products and the reasons behind such practices among women in the member countries of the Association of Southeast Asian Nations (ASEAN), while they are pregnant, during their postpartum period, and while breastfeeding. Three data search engines, Google® Scholar, PubMed and Scopus, were used one after the other, to generate the papers for this review. The online searches using the term food taboo, its synonyms, and truncations, in combination with the terms pregnancy, postpartum, and breastfeeding, and with the country name, were conducted from January to February 2017. In total, 28 papers were pooled and included in this review. The taboos and the justification for avoidance were collated and grouped per their occurrence, and according to the country where they are practiced. Nine papers provided information on the food taboos during pregnancy, 16 on postpartum food taboos, and six on breastfeeding. The food taboos included various river or seafood, meat from terrestrial animals, and derived products like fish paste, blood and internal organs. Healthcare providers should be aware of the food taboos being adhered to in the region to provide the right information and guidance to the women practicing them. There is a need to educate the public in general, and women, in particular, about the risk of malnutrition when food taboos are followed, and to support their nutritional requirements during pregnancy and the postpartum period by promoting dietary diversification. More research could be conducted to fill in the gap in information with regards to the food taboos and their impact in some of the ASEAN members. Culture-sensitive health interventions based on timely research work can contribute to the attainment of the sustainable development goal of reducing the maternal and under-five mortality ratios in Southeast Asia.

Vitamin A Supplementation by Endotracheal Application of a Nano-encapsulated Preparation Is Feasible in Ventilated Preterm Lambs.

BACKGROUND: Vitamin A (VA) is crucial for lung growth and development. In premature infants, inadequate VA levels are associated with an increased risk of bronchopulmonary dysplasia (BPD). Intramuscular VA supplementation has been shown to decrease the incidence of BPD, but is not widely used in the clinical setting due to concerns about feasibility and pain. We studied VA kinetics, distribution, and the induction of early genetic expression of retinoid homeostatic genes in the lung after endotracheal and intravenous application in a preterm lamb model. METHODS: Lambs were delivered prematurely after 85% of gestation, intubated, and ventilated for 3 hours. The animals were randomized to receive no VA ("control"), a bolus of VA intravenously ("i.v."), or VA endotracheally directly after administration of surfactant ("e.t."). RESULTS: Animals treated with VA endotracheally directly after administration of surfactant showed significant increases of VA in serum and lung compared to controls. Animals treated with a bolus of VA intravenously showed significant increases of VA in serum, lung, and liver; however, peak serum concentrations and mRNA levels of homeostatic genes raised concerns about toxicity in this group. CONCLUSIONS: Endotracheal VA supplementation in preterm lambs is feasible and might offer advantages in comparison to i.v. Further studies are warranted to explore biological effects in the context of BPD.

Multivitamin/mineral supplements: Rationale and safety.

Multivitamin/mineral supplements (MVMs) are widely used in many populations. MVMs, together with iron and folic acid, are recommended for pregnant women to improve birth outcome and to reduce low-birthweight and rates of miscarriage. However, MVM use is common in the general population as well. The aim of the present review was to evaluate the safety of long-term use of these supplements. To examine the safety of MVM use, we performed a literature search for randomized controlled studies involving supplementation with a combination of at least nine vitamins and three minerals at a maximum concentration of 100% of the Recommended Dietary Allowance. We found nine studies evaluating the use and efficacy of MVMs in pregnant women and healthy adults and six studies in the elderly where adverse effects were explicitly addressed. Only minor adverse events (e.g., unspecific gastrointestinal symptoms) were reported in all studies. In particular, there were no significant differences between treatment and placebo groups. MVM use within the range of the Dietary Reference Intake will not result in excess intake, even when including the effect of food and fortified food, and does not increase mortality. Taken together, these findings indicate that MVMs can be safe for long-term use (>10 y).

Multivitamin/mineral supplements: Rationale and safety - A systematic review.

Multivitamin/mineral supplements (MVM) are widely used in many populations. In particular, in pregnant women, MVM together with iron and folic acid are recommended to improve birth outcome and reduce low birth weight and rates of miscarriage. However, MVM use is common in the general population. This raises questions regarding the safety of long-term use of these supplements. To estimate the safety of MVM use, we performed a literature search for randomized, controlled studies for supplements with a combination of at least nine vitamins and three minerals at a maximum concentration of 100% of the recommended dietary allowance. We found nine studies evaluating the use and efficacy of MVM in pregnant women and healthy adults and six studies in the elderly where adverse effects were explicitly addressed. Only minor adverse effects (e.g., unspecific gastrointestinal symptoms) were reported in all studies. In particular, there were no significant differences between treatment and placebo groups. MVM use within the range of the dietary reference intake will not result in excess intake, even when including the impact of food and fortified food, and does not increase mortality. Taken together, these findings indicate that MVM can be safe for long-term use (more than 10 y).

Nutrition meets the microbiome: micronutrients and the microbiota.

There is increasing evidence that food is an important factor that influences and shapes the composition and configuration of the gut microbiota. Most studies have focused on macronutrients (fat, carbohydrate, protein) in particular and their effects on the gut microbiota. Although the microbiota can synthesize different water-soluble vitamins, the effects of vitamins synthesized within the microbiota on systemic vitamin status are unclear. Few studies exist on the shuttling of vitamins between the microbiota and intestine and the impact of luminal vitamins on the microbiota. Studying the interactions between vitamins and the microbiota may help to understand the effects of vitamins on the barrier function and immune system of the intestinal tract. Furthermore, understanding the impact of malnutrition, particularly low micronutrient supply, on microbiota development, composition, and metabolism may help in implementing new strategies to overcome the deleterious effects of malnutrition on child development. This article reviews data on the synthesis of different micronutrients and their effects on the human microbiota, and further discusses the consequences of malnutrition on microbiota composition.

Impact of Food Rations and Supplements on Micronutrient Status by Trimester of Pregnancy: Cross-Sectional Studies in the Maela Refugee Camp in Thailand.

Micronutrient fortified flour (MFF), supplementary food rations and micronutrient (MN) supplements may prevent deficiencies among pregnant women. Objectives of cross-sectional surveys in 2004 (n = 533) and 2006 (n = 515) were to assess the impact of new food rations (flour, oil) and supplements on MN status by trimester of pregnancy in the Maela refugee camp. Hemoglobin, iron status, zinc, retinol, ß-carotene and tryptophan decreased, while α-/γ-tocopherol and 5-methyltetrahydrofolate (5-MTHF) increased from first to third trimester. In 2006, mean zinc and α-tocopherol for each trimester was significantly higher than in 2004. The weeks of supplemented thiamine and folic acid were positively correlated with thiamine diphosphate (TDP) and 5-MTHF, but not for ferrous sulfate as iron deficiency was observed in 38.5% of third-trimester women. Frequent consumption of fish paste and owning a garden or animal were associated with significantly higher iron status, retinol, ß-carotene, and 5-MTHF. In conclusion, MFF and supplementary oil were most likely to explain improved zinc and α-tocopherol status, while thiamine and folate supplements ensured high TDP and 5-MTHF in late pregnancy. MN supplements, MN-rich staple food, small gardens, and programs to improve iron compliance are promising strategies to prevent MN deficiencies during pregnancy in vulnerable populations.

Increased Intake of Foods with High Nutrient Density Can Help to Break the Intergenerational Cycle of Malnutrition and Obesity.

A workshop held at the University Medical Center in Groningen, The Netherlands, aimed at discussing the nutritional situation of the population in general and the role diet plays during critical windows in the life course, during which the body is programmed for the development of non-communicable diseases (NCDs). NCDs are increasingly prevalent as our society ages, and nutrition is well known to play an important role in determining the risk and the time of onset of many common NCDs. Even in affluent countries, people have difficulties to achieve adequate intakes for a range of nutrients: Economic constraints as well as modern lifestyles lead people to consume diets with a positive energy balance, but low in micronutrients, resulting in increasing prevalence of obesity and suboptimal nutritional status. Information about nutrient density, which refers to the content of micronutrients relative to energy in food or diets, can help identify foods that have a low calorie to nutrient ratio. It thus allows the consumption of diets that cover nutritional needs without increasing the risk of becoming obese. Given the impact a nutrient dense, low energy diet can have on health, researchers, food industry and governments jointly should develop options for affordable, appealing nutrient-rich food products, which, in combination with physical activity, allow for optimal health throughout the life-course.

There's life in the old dog yet: vitamin C as a therapeutic option in endothelial dysfunction.

The use of vitamin C against different diseases has been controversially and emotionally discussed since Linus Pauling published his cancer studies. In vitro and animal studies showed promising results and explained the impact of vitamin C, particularly in cases with endothelial dysfunction. Indeed, studies (reviewed in this issue of Critical Care by Oudemans-van Straaten and colleagues) using high-dose vitamin C and the parenteral route of application seem to be more successful than oral vitamin C delivery.

Massive and long-lasting decrease in vitamin C plasma levels as a consequence of extracorporeal circulation.

OBJECTIVE: The use of cardiopulmonary bypass (CPB) is suggested to induce oxidative stress, reflected by an imbalance between prooxidant and antioxidant substances. The majority of studies published have either focused on only one aspect (prooxidant or antioxidant side) or covered only a short observation period. Therefore, the aim of this study was to investigate the long-term effects of CPB on the balance of prooxidative markers and antioxidant substances in one single group of patients, being able to estimate the degree of oxidative stress. METHODS: Blood samples were taken from 29 patients undergoing cardiovascular surgery beginning the day before surgery through postoperative day 6 (discharge). Plasma concentrations of vitamins C (total ascorbic acid) and E and malondialdehyde were measured by high-performance liquid chromatography. Plasma levels of ascorbyl free radical were determined using electron paramagnetic resonance spectroscopy. RESULTS: The study showed a significant decrease in vitamin C plasma levels during CPB without any recovery of vitamin C up to the time of discharge. Furthermore, CPB induced a significant increase in malondialdehyde plasma concentrations immediately after unclamping, accompanied by a significant increase in the ascorbyl free radical to total ascorbic acid ratio. The latter stayed elevated until the end of observation. CONCLUSIONS: Our findings indicate that the oxidative stress event after CPB can be divided into two phases: Immediately after reperfusion, a massive oxidative stress occurs, reflected by the increase in malondialdehyde. During convalescence, there must be an ongoing situation of oxidative stress, especially in the water-soluble compartment, leading to the consumption of vitamin C. Because the main antioxidant substance, vitamin C, did not increase again over the entire observation period, supplementation should be given consideration.

Micronutrients supplementation and nutritional status in cognitively impaired elderly persons: a two-month open label pilot study.

BACKGROUND: Malnutrition is a widespread problem in elderly people and is associated with cognitive decline. However, interventional studies have produced ambiguous results. For this reason, we wanted to determine the effect of micronutrient supplementation on blood and tissue levels and on general nutritional status in persons with mild or moderate cognitive impairment. METHODS: We performed a 2-month, open-label trial, administering a daily micronutrient supplement to 42 memory clinic patients with mild cognitive deficits. Blood levels of antioxidants, zinc, and B vitamins were determined before and after supplementation. In addition, we assessed metabolic markers for B vitamins and intracellular (buccal mucosa cell [BMC]) antioxidant levels. Nutritional status was assessed by using the Mini Nutritional Assessment (MNA). RESULTS: Blood levels of B vitamins, folic acid, lutein, ß-carotene, α-carotene, and α-tocopherol increased significantly. Decreases in homocysteine levels and the thiamine pyrophosphate effect and an increase in holotranscobalamin were observed. We found no increase in intracellular antioxidant levels of BMC. The MNA score in subjects at risk for malnutrition increased significantly, mainly owing to better perception of nutritional and overall health status. CONCLUSIONS: Micronutrient supplementation improved serum micronutrient status, with improved metabolic markers for B vitamins but not for intracellular antioxidant status, and was associated with improved self-perception of general health status. Our data underline the necessity of determining micronutrient status and support the use of additional assessments for general health and quality of life in nutritional supplementation trials.

Health benefits of nut consumption with special reference to body weight control.

Nuts are an integral part of the Mediterranean food patterns, and their incorporation into the regular diets of human beings is believed to provide many health benefits. The recent recognition of nuts as "heart-healthy" foods by the U.S. Food and Drug Administration has given a major boost to the positive image of nuts. Nut consumption has been associated with several health benefits, such as antioxidant, hypocholesterolemic, cardioprotective, anticancer, anti-inflammatory, and antidiabetic benefits, among other functional properties. However, although nuts possess these many health benefits, their consumption has been hampered by a lack of adequate information regarding those benefits. In addition, because nuts are energy-dense foods with high-fat content, there is a misconception among consumers that increased consumption may lead to unwanted gain in body weight with the risk of developing overweight/obesity. Nonetheless, available epidemiologic studies and short-term controlled feeding trials have supported the theory that the inclusion of nuts in the typical diet does not induce weight gain, despite an expected increase in total caloric intake. To address the misperception about nuts and body weight gain, the present review focuses mainly on the relation between nut consumption and body weight gain, in the context of the many health benefits of nuts.

Supplementary feeding with locally-produced Ready-to-Use Food (RUF) for mildly wasted children on Nias Island, Indonesia: comparison of daily and weekly program outcomes.

Ready-to-Use Foods (RUFs) in the form of fortified cereal/nut/legume-based biscuits (±500 kcal and 8-10% protein per 100 g) were tested among mildly wasted children from October 2007 to June 2008, and were labelled as RUF-Nias biscuits. This study reports on a comparison of supplementary feeding program outcomes of mildly wasted children with weight-for-height z-score (WHZ) >=-2 to <-1.5 SD aged >=6 to <60 months old given locally produced RUF-Nias biscuits within daily (in semi-urban areas) and weekly (in rural remote regions) distribution and supervision program settings. In the Church World Service project area, all eligible children were recruited continuously from monthly community-based screening programs and admitted into existing nutrition centers managed by the community on Nias Island, Indonesia. Individual discharge criterion of the programs was WHZ >=-1.5 SD. Of the index children admitted in daily programs (n=51), 80.4% reached target WHZ, which was higher than in weekly programs (72.9%; n=48) by a similar length of stay of about 6 weeks. Weight gain of the children in daily programs was higher (3.1±3.6 g/kg body weight/day) than in weekly programs (2.0±2.1 g/kg body weight/day), and they achieved significantly higher WHZ at discharge. However, the majority of caretakers preferred weekly programs due to lower time constraints. Locally produced RUF in the form of biscuits for treatment of mild wasting among children demonstrated promising results both in daily and weekly community-based intervention programs.

Combined intensive nutrition education and micronutrient powder supplementation improved nutritional status of mildly wasted children on Nias Island, Indonesia.

To assess the impact of intensive nutrition education (INE) with or without the provision of micronutrient powder (MNP) on the nutritional status of mildly wasted children in Nias, Indonesia, two groups of mildly wasted (>=-1.5 to <-1.0 WHZ) children aged >=6 to <60 months in the Church World Service (CWS) project areas were assigned by village randomization to receive INE (n=64) or INE+MNP (n=51) in a weekly program. Another two groups of mildly wasted children who were living at a clear distance from INE and INE+MNP villages were selected to receive a monthly non-intensive nutrition education program (NNE) with or without MNP (n=50 both respectively). WHZ, weight, height, haemoglobin (Hb) level, and morbidity data were assessed at admission, during the study, and at individual discharge. Children's weight gain (g/kg body weight/day) was highest in INE+MNP group (2.2±2.1), followed by INE (1.1±0.9), NNE+MNP (0.3±0.5) and NNE (0.3±0.4) group. In both MNP intervention groups (INE+MNP, NNE+MNP), supplements significantly increased Hb value (g/L) of respective children (10.0±10.0; p<0.001 and 3.0±8.0; p<0.05 respectively). Proportion of children who reached discharge criterion was highest among the INE+MNP (70.6%; n=36), followed by INE (64.1%; n=41), NNE+MNP (26.0%; n=13), and NNE (20.0%; n=10) groups (p<0.001). Shortest length of stay until recovery was observed among children in the INE+MNP group (29.9 days), followed by INE (40.0 days), NNE+MNP (80.6 days), and NNE (86.2 days) respectively (p<0.001). Weekly intensive nutrition education supported by MNP supplementation produced the best results regarding weight gain and haemoglobin status of mildly wasted children.

Dietary antioxidants and dementia in a population-based case-control study among older people in South Germany.

Oxidative stress is believed to play a central role in the pathogenesis of Alzheimer's disease (AD), a neurodegenerative disease. Antioxidants may prevent the onset AD as high dietary intake of vitamin C and E were reported to be associated with lower risk of the disease. The objective of this study was to evaluate the serum levels of antioxidants in persons with mild dementia to test whether it is associated with lower levels of antioxidants in a cross-sectional study in the population of the "Activity and Function in the Ederly in Ulm" (ActiFE) study. Main exposure measures were vitamin C, vitamin E, ß-carotene, lycopene, and coenzyme Q10 as analyzed by HPLC. Main outcome measures were mild cognitive impairment among 74 mildly demented compared to 158 age- and gender-matched controls. We found that blood vitamin C and ß-carotene concentrations were significantly lower in demented than in control persons even after adjusting for school education, intake of dietary supplements, smoking habits, body mass index, and alcohol consumption (3rd versus 1st tertile: OR: 0.29, 95% CI, 0.09-0.96 and 0.13, 95% CI, 0.03-0.55, respectively). No associations were found for vitamin E, lycopene, and coenzyme Q10. Our findings suggest an association of vitamin C and ß-carotene with dementia. However this is limited to the cross-sectional character of our study and longitudinal data will give further insight into this association.

Protection by flavanol-rich foods against vascular dysfunction and oxidative damage: 27th Hohenheim Consensus Conference.

Criteria for assessing the purported protection by flavanol-rich foods against vascular dysfunction and oxidative damage to biomolecules was the subject of the 27th Hohenheim Consensus Conference held on July 11, 2011. State-of-the-art evidence was put into perspective, focusing on several questions that were followed by a consensus answer. Among the topics addressed were the major sources of flavanols in the human diet, the bioavailability of flavanols, biomarkers for "health benefit," and the biological function of flavanols. Consensus was reached on these topics. No conclusion was reached on the design of randomized, controlled trials for substantiation of health claims for flavanol-rich foods as to the necessity of a study arm with an isolated pharmacologically active compound, e.g., (-)-epicatechin.