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Cater with Care : impact of protein-enriched foods and drinks for elderly people
Beelen, J. - \ 2016
Wageningen University. Promotor(en): Lisette de Groot; Frans Kok, co-promotor(en): Nicole de Roos. - Wageningen : Wageningen University - ISBN 9789462578814 - 142 p.
undernutrition - hospital catering - hospitals - protein - elderly - protein intake - food - beverages - diet studies - dietetics - dietitians - randomized controlled trials - ondervoeding - ziekenhuiscatering - ziekenhuizen - eiwit - ouderen - eiwitinname - voedsel - dranken - dieetstudies - diëtetiek - diëtisten - gestuurd experiment met verloting
Protein undernutrition is a major health concern for older adults, especially for those who are ill. There is growing consensus for a protein intake target of 1.2 - 1.5 gram per kg bodyweight per day (g/kg/d) for these older adults. However, this target is not reached by the majority of older adults. Therefore, more effective and novel strategies to increase protein intake are warranted, including the use of protein-enriched foods and drinks. This thesis evaluated the impact of the developed protein-enriched foods and drinks on protein intake and physical performance among older adults. The studies in this thesis were done as part of the Cater with Care® project; a collaboration between the university, care organizations, and partners from the food industry. The industrial partners developed the products, focusing each on different product categories: Carezzo Nutrition developed bread, pastry, and fresh juices and soups; The Kraft Heinz Company focused on long shelf-life and convenience foods; and the Veal Promotion Foundation produced veal meat.
To fit the products to the needs of the target group, interviews with undernourished older adults (at home or hospitalized) and with dietitians were conducted (chapter 2). These interviews showed that undernutrition awareness is low among older adults. To treat undernutrition by changing their eating habits, older adults need to be aware of their health problem, they need to be willing to change, and they need to be able to understand and implement the dietitian’s advices. This process takes time while undernutrition should be treated immediately. For immediate treatment, enriched products could be used, without first creating awareness. According to the interviewees, enriched products should fit within older adults’ eating habits, and have small portion sizes.
To gain insights in food choices of hospitalized older adults (65 years and older) an observational study was conducted. In this study, energy and protein intakes of 80 hospitalized older patients at low and high risk of undernutrition were assessed (chapter 3). Patients who received an energy- and protein-rich menu, because of their risk of undernutrition, were better able to reach the protein and energy targets than patients with a low risk of undernutrition receiving a standard menu. Based on these results we proposed that all hospitalized older adults – both at low and high risk of undernutrition – should receive an energy- and protein-rich menu.
Subsequently, a pilot study was done in a care home and a rehabilitation center with the aim to explore the potential of the developed protein-enriched products to increase protein intake (chapter 4). Participants did not compensate their consumption of regular protein-rich foods (e.g. dairy, cheese) upon the introduction of protein-enriched foods and drinks. The 22 institutionalized elderly (mean age 83 years) consumed 12 gram protein per day more than they did before the intervention. Consequently, more people met the protein target of 1.2 g/kg/d than before the intervention. We concluded that protein-enriched products enabled institutionalized elderly to reach protein intake targets. Furthermore, we gained valuable feedback to improve the assortment of protein-enriched products for the effectiveness study.
In the final study, effects of the protein-enriched products on protein intake and physical performance were studied in a randomized controlled trial during hospitalization and subsequent recovery at home. During the hospital period in which 147 older patients participated, patients that received protein-enriched products increased their protein intake compared to the control group that already received a protein-rich hospital menu (chapter 5). As a result, 79% of the intervention group reached a protein intake of 1.2 g/kg/d, compared to 48% of the control group. Finally, effects of the protein-enriched products were tested at home, for a longer period (chapter 6). Half of the hospital phase participants (n = 75) continued the intervention at home for 12 weeks. The protein-enriched products were successfully implemented in the daily menu of the older adults: the intervention group had a higher average protein intake (1.5 ± 0.6 g/kg/d) than the control group (1.0 ± 0.4 g/kg/d) during the 12-week intervention period. Seventy-two percent of the intervention group reached a protein intake of 1.2 g/kg/d during the 12-week intervention, compared to 31% of the control group. Protein intake of the intervention group was mainly increased by the following protein-enriched products: bread, dairy drinks, dairy desserts, soups, and fruit juices. However, despite the successful improvement of protein intake, we found no added value on physical performance in the first 6 months after hospitalization.
It was concluded that with the protein-enriched familiar foods and drinks, we have a feasible, acceptable, and appetizing long-term strategy to increase protein intake of older adults in various settings. We envisage a beneficial role of these protein-enriched products in combination with physical activity in older adults with lower protein intakes.
Health in exchange for privacy : the adoption of personalised nutrition advices
Berezowska, A. - \ 2016
Wageningen University. Promotor(en): Hans van Trijp, co-promotor(en): Arnout Fischer. - Wageningen : Wageningen University - ISBN 9789462578227 - 165 p.
diet studies - privacy - cognitive psychology - nutrition and health - individual feeding - dieetstudies - cognitieve psychologie - voeding en gezondheid - individuele voeding
To prevent disease and optimise health, nutrition advice is personalised based on an individuals’ lifestyle, health status and/or genetics. Although due to its high degree of personal relevance personalised nutrition advice is highly beneficial, the adoption of such advice may be hindered by the fact that it requires disclosure of personal and sensitive health information which induces the potential risk of privacy loss. This thesis investigates individuals’ intention to adopt personalised nutrition advice from the perspective of a trade-off between perceived privacy risk and perceived personalisation benefit. To understand this trade-off knowledge regarding factors that affect individuals’ perceptions of privacy risk and personalisation benefit is key. This thesis studies such factors by addressing three research lines: 1) How does service design affect the risk-benefit trade-off?; 2) What is the cognitive process behind the risk-benefit trade-off?; 3) How is the cognitive process that drives the risk-benefit trade-off affected by self-regulation?
An overview of personalised nutrition services currently available in the market place shows that the design of personalised nutrition services mainly differs in terms of service providers, the used communication channels, advice scope, and advice frequency (Chapter 2). The required personal information hardly differs between services, with information related to lifestyle and health status being most common. When compared to lifestyle and health status, perceptions of privacy risk increase when a personalised nutrition service requires genotypic information (Chapters 3 and 4). Disclosure of genotypic information does, however, not increase perceptions of personalisation benefit. Furthermore, perceptions of personalisation benefit increase and perceptions of privacy risk decrease when a personalised nutrition service allows for face-to-face communication. In addition, perceptions of personalisation benefit increase when services provide regular follow-up and combined dietary advice with physical activity.
The cognitive process is driven by the trustworthiness and competence of service providers (Chapters 3 and 4). The more trustworthy a service provider seems to be the more control individuals perceive to have over the disclosed personal information, which reduces perceptions of privacy risk. In terms of competence, service providers that induce high perception of competence increase the extent to which a personalised nutrition service is perceived as effective, which in turn amplifies individuals’ perceptions of personalisation benefit. Within the trade-off between perceived privacy risk and perceived personalisation benefit, benefits weigh heavier than risks independent of individuals’ nationality.
Whether individuals eat healthily by volition (i.e. autonomous motivation) or because they feel forced to do so (i.e. controlled motivation) affects the extent to which perceived privacy risk, perceived personalisation benefit, and their determinants predict adoption intention (Chapter 5). Within this cognitive process, high levels of autonomous motivation strengthen relations related to perceived personalisation benefit and weaken relations related to perceived privacy risk. In contrast to autonomous motivation, high levels of controlled motivation strengthen relations related to perceived privacy risk and weaken relations related to perceived personalisation benefit. Autonomous individuals therefore seem to pay more attention to personalisation benefit, while controlled individuals seem to pay more attention to privacy risk. The trustworthiness of a service provider is relevant to all, regardless the level of autonomous or controlled motivation.
Individual’s motivation to either prevent negative outcomes (i.e. prevention focus) or promote positive outcomes (i.e. promotion focus), called regulatory focus also affects perceptions of privacy risk and personalisation benefit (Chapter 6). The effect of the different regulatory foci on perceptions of privacy risk and personalisation benefit occurs through the interaction between an individual’s regulatory focus and the timing of health outcomes. Individuals focused on prevention have lower perceptions of privacy risk and higher perceptions of personalisation benefit when health outcomes are immediate rather than delayed. In the case of individuals with a promotion focus offering immediate or delayed health outcomes does not affect perceptions of privacy risk or perceptions of personalisation benefit.
Overall, this thesis shows that individuals’ intention to adopt personalised nutrition advice mainly depends on perceptions of personalisation benefit, which are largely determined by one’s confidence in the effectiveness of the personalised nutrition service. Individual differences related to motivations do, however, affect the extent to which perceived personalisation benefit determines adoption intention.
Effectiveness of zinc fortified drinking water on zinc intake, status and morbidity of rural Kenyan pre-school children
Kujinga-Chopera, P. - \ 2016
Wageningen University. Promotor(en): Michael Zimmermann, co-promotor(en): Inge Brouwer; D. Moretti. - Wageningen : Wageningen University - ISBN 9789462577572 - 127 p.
preschool children - drinking water - zinc - fortification - kenya - diarrhoea - nutrient deficiencies - morbidity - childhood diseases - diet - diet studies - peuters en kleuters - drinkwater - zink - fortificatie - diarree - voedingsstoffentekorten - morbiditeit - kinderziekten - dieet - dieetstudies
Measurement errors in dietary assessment using duplicate portions as reference method
Trijsburg, L.E. - \ 2016
Wageningen University. Promotor(en): Pieter van 't Veer; Anouk Geelen; Jeanne de Vries. - Wageningen : Wageningen University - ISBN 9789462576421 - 128 p.
diet studies - nutritional assessment - questionnaires - reference standards - correction factors - validity - body mass index - regression analysis - food intake - food - protein - potassium - sodium - energy intake - methodology - dieetstudies - voedingstoestandbepaling - vragenlijsten - referentienormen - correctiefactoren - geldigheid - quetelet index - regressieanalyse - voedselopname - voedsel - eiwit - kalium - natrium - energieopname - methodologie
Measurement errors in dietary assessment using duplicate portions as reference method
Background: As Food Frequency Questionnaires (FFQs) are subject to measurement error, associations between self-reported intake by FFQ and outcome measures should be corrected for measurement error with data from a reference method. Whether the correction is adequate depends on the characteristics of the reference method used in the validation study. The duplicate portion method (DP), compared to the often used 24h recall (24hR), seems a promising reference method as correlated errors between FFQ and DP, such as memory bias, errors in portion size estimations and food composition databases, are not expected.
Aim: This thesis aimed to determine the validity of the DP compared to the 24hR as a reference method for FFQ validation. The second aim was to explore the validity of nutrient densities for DP, 24hR and FFQ. The third aim was to determine the factors associated with misreporting of energy, protein and potassium as estimated by DP, 24hR and FFQ.
Methods: Within the DuPLO-study, a Dutch validation study which is part of the NQplus study, two DPs, two FFQs, two blood and urinary biomarkers and one to fifteen 24hRs (web-based and/or telephone-based) were collected in 198 subjects, within 1.5 years. Also, one or two doubly labelled water measurements were available for 69 participants. Multivariate measurement error models were used to assess proportional scaling bias, error correlations with the FFQ, validity coefficients and attenuation factors. Furthermore linear regression analysis was used to determine the association between misreporting and various factors.
Results: The DP was less influenced by proportional scaling bias, had lower correlated errors with the FFQ and showed higher attenuation factors than the 24hR for potassium, sodium and protein. Also, the DP seemed a better reference method than the 24hR for the assessment of validity coefficients for the FFQ for various fatty acids. The attenuation factors for the FFQ, using either the DP or 24hR as reference method, agreed reasonably well. Furthermore, the DP showed, when using plasma fatty acids as reference, slightly better ranking of participants according to their intake of n-3 fatty acids (0.33) and the n‑3/LA ratio (0.34) than the 24hR (0.22 and 0.24, respectively). Less group level bias was observed for protein and sodium densities compared to their absolute intakes for FFQ, 24hR and DP, but not for potassium. Overall the validity coefficients and attenuation factors for DP, 24hR and FFQ did not improve for nutrient densities compared to absolute intakes, except for the attenuation factor for sodium density. Lastly, BMI proved to be the most consistent determinant associated with misreporting (group level bias) of energy, protein and potassium for DP, 24hR and FFQ. Men tended to underreport protein by the DP, FFQ and 24hR and persons of older age underreported potassium but only by the 24hR and FFQ. Other explorative determinants did not show a consistent association with misreporting of energy or nutrients by the different dietary assessment methods.
Conclusion: With respect to error correlations and attenuation factors the DP performed slightly better than the 24hR as a reference method for validating FFQs in epidemiological research. Furthermore, the use of nutrient densities does not necessarily improve the validity of the dietary intake estimates from DP, 24hR and FFQ. Moreover, it was shown that BMI is an important determinant of misreporting of energy, protein and potassium for these three assessment methods.
Effects of rye inclusion in grower diets on immunity-related parameters and performance of broilers
Krimpen, M.M. van; Borgijink, S. ; Vastenhouw, S.A. ; Bree, F.M. de; Bossers, A. ; Fabri, T. ; Jansman, A.J.M. ; Rebel, J.M.J. ; Smits, M.A. ; Emous, R.A. van - \ 2015
Wageningen : Wageningen UR Livestock Research (Livestock Research report 889) - 33
pluimveehouderij - vleeskuikens - pluimveevoeding - dieetstudies - rogge - arabinoxylanen - diergezondheid - poultry farming - broilers - poultry feeding - diet studies - rye - arabinoxylans - animal health
An experiment was conducted to investigate the effects of dietary inclusion of three levels (0, 5, and 10%) of rye between 14 and 28 days of age on gut health and performance in broilers. A total of 960 one-day-old male Ross 308 chicks were allocated to 24 pens (40 birds per pen). The inclusion of 5 or 10% rye in the diet between day 14 and 28 in a broiler diet resulted in decreased performance and litter quality, but in increased villus height and crypt depth in the small intestine (jejunum) of the birds. Relative bursa and spleen weights were not affected by dietary treatments. In the jejunum, no effects on number and size of goblet cells, and only small effects on microbiota composition in the digesta were observed. Dietary rye inclusion affected expression of genes involved in cell cycle processes of the epithelial gut cells, thereby influencing cell growth, cell differentiation and cell survival. This observation is consistent with the observed differences in the morphology of the gut wall. Whether this also affected the barrier function of the epithelial layer, cannot be concluded. The complement and coagulation pathways, which are also affected by providing rye-rich diets, are parts of the innate immune system. These pathways are involved in eradicating invasive pathogens. Overall, it is concluded that inclusion of 5% or 10% rye to the grower diet of broilers in the current study had limited effects on performance. Ileal gut morphology, microbiota composition of jejunal digesta, and gene expression profiles of jejunal tissue, however, were affected by dietary rye inclusion levels.
Resource ecology : spatial and temporal dynamics of foraging
Prins, H.H.T. ; Langevelde, F. van - \ 2008
Dordrecht : Springer (Wageningen UR Frontis series vol. 23) - ISBN 9781402068485 - 304
natuurlijke hulpbronnen - hulpbronnenbeheer - ecologie - herbivoren - begrazing - foerageren - voeropname - dieetstudies - bevolkingsspreiding - kuddes (herds) - vee - migratie - voedingsgedrag - ruimtelijke verdeling - grote grazers - plant-herbivoor relaties - natural resources - resource management - ecology - herbivores - grazing - foraging - feed intake - diet studies - population distribution - herds - livestock - migration - feeding behaviour - spatial distribution - large herbivores - plant-herbivore interactions
This multi-author book deals with 'resource ecology', which is the ecology of trophic interactions between consumers and their resources. Resource ecology is perhaps the most central part of ecology. In its linkage between foraging theory and spatial ecology, it shows how old and fundamental questions can be tackled afresh. It addresses crucial aspects of the interactions between consumers and resources. Foraging is the central process in resource ecology because it leads to growth, survival and reproduction of the animal. Resource ecology forms the basis for comprehending the functioning of multi-species assemblages, and is thus key to grasp the organisation of biodiversity. For the purposes of stimulating future research, each chapter ends with two or three testable hypotheses. Each chapter is followed by a comment. This makes the book ideal for teaching and course work, because it highlights the fact that ecology is a living and active research field.
Validation of Monte Carlo models for estimating presticide intake of Dutch infants
Voet, H. van der; Boon, P.E. ; Klaveren, J.D. van - \ 2003
Wageningen : DLO, Rikilt, Analyse & Ontwikkeling (Report / RIKILT 2003.002)
monte carlo-methode - pesticiden - dieetstudies - zuigelingen - nederland - monitoring - gegevens verzamelen - waarschijnlijkheidsmodellen - blootstelling - opname (intake) - monte carlo method - pesticides - diet studies - infants - netherlands - data collection - probabilistic models - exposure - intake
24-hour dietary recalls as reference calibration measurements in EPIC: from statistical theory to epidemiological application
Slimani, N. - \ 2002
Wageningen University. Promotor(en): W.A. van Staveren; E. Riboli. - S.l. : S.n. - ISBN 9789058087102 - 262
voedingsanamnese - voedingsonderzoektechnieken - dieetstudies - dieetonderzoeken - voeding - ziektestatistieken - statistiek - kwaliteitscontroles - internationale vergelijkingen - intercultureel onderzoek - europa - dietary history - diet study techniques - diet studies - dietary surveys - nutrition - disease statistics - statistics - quality controls - international comparisons - cross cultural studies - europe
<p>Large multi-centre cohort studies have been set up with the aim of increasing the statistical power to detect an association between diet and disease by including study populations varying both in dietary exposures and outcome diseases. However, such studies raise also new statistical and methodological challenges to improve the comparability of dietary measurements collected from populations from different geographical and socio-cultural origins. In the European Prospective Investigation into Cancer and Nutrition (EPIC), involving half a million subjects from 23 centres in 10 European countries, a calibration approach was adopted to correct for systematic errors in individual dietary measurements obtained by means of different dietary assessment methods across centres, by re-expressing them according to the same reference scale (between-cohort calibration). 24-hour diet recall was selected as the reference calibration method in EPIC. In order to meet the theoretical requirements, such a reference calibration method must be highly standardized across study centres, provide accurate dietary estimates at the population level and should not be an obstacle to the collection of data from a representative sub-sample of the entire cohort. This thesis deals with translating the theoretical statistical concept of the calibration into an epidemiological application in the context of a large multi-centre study on diet and cancer.</p><p>The thesis presents first some theoretical concepts of the main sources of measurement errors associated with the 24-hour diet recall method and the standardisation procedures used to prevent or minimize them in the context of a large multi-centre study. An ad hoc face-to-face computerized 24-hour diet recall interview programme (EPIC-SOFT) is then described as the end product used as reference calibration method across the EPIC centres. The rationale and a new theoretical concept of standardizing food composition tables in large multi-centre studies such as EPIC is discussed separately. In a second part, the design and the populations of the calibration sub-studies set up in each EPIC centre are described, as well as the representativeness of the calibration sub-sample compared to the whole cohort.</p><p>In order to estimate the degree of standardisation of the 24-hour diet recalls across interviewers an analysis of variance was performed using mean total energy per interviewer as dependent variable. Furthermore, a validation study using urinary nitrogen as independent reference measurements was conducted to estimate the reliability of mean 24-hour diet recall measurements of protein (and total energy) for between-cohort calibration. Finally, the 36,900 24-hour recalls collected in EPIC were used to study the large heterogeneity in dietary patterns existing between the EPIC centres, using the same detailed dietary methodology.</p><p>This was the first time that calibration sub-studies using the same dietary methodology has been set up in a large multi-centre European study. Despite inherent methodological and practical problems, the calibration worked well in a large multi-centre setting, and the calibration sub-sample can reasonably be considered to be representative of the entire EPIC cohort in most centres. The standardisation across interviewers and the validation of 24-hour diet recalls for between-cohort calibration shown encouraging results. However, measurement errors, particularly conscious or unconscious behaviour of respondents and/or interviewers, cannot be prevented entirely, and the problem of measurement errors and its determinants need to be considered in the application of the calibration, as well as day of the week and seasonal coverage. This first experience should also lead to additional improvements in the reference method and setting up nested calibration sub-studies in the future. Furthermore, it demonstrates that standardized dietary methodologies can be developed in an international context and opens perspectives for using the EPIC-SOFT programme or other approaches in large European nutritional studies.
Genetic disposition and response of blood lipids to diet : studies on gene-diet interaction in humans
Weggemans, R.M. - \ 2001
Wageningen University. Promotor(en): M.B. Katan; P.L. Zock. - S.l. : S.n. - ISBN 9789058083388 - 144
voedingsonderzoek bij de mens - genetische variatie - genetische polymorfie - bloedvetten - dieetstudies - cholesterolarme diëten - human nutrition research - genetic variation - genetic polymorphism - blood lipids - diet studies - low cholesterol diets
<p>Even though a cholesterol-lowering diet is effective for most people, it is not for all. Identification of genetic determinants of the serum lipid response to diet may be of help in the identification of subjects who will not benefit from a cholesterol-lowering diet. It may also clarify the role of certain proteins in cholesterol metabolism. The objective of our research was to determine whether genetic polymorphisms affect the response of serum lipids to diet in humans.</p><p>We first assessed sex differences in the response of serum lipids to changes in the diet. Men had larger responses of total and low-density lipoprotein cholesterol to saturated fat and cafestol than women. There were no sex differences in the responses to trans fat and dietary cholesterol. We also used these data to study the effect of 11 genetic polymorphisms on responses of serum lipids to the various dietary treatments. Apoprotein E, A4 347 and 360, and cholesteryl-ester transfer protein TaqIb polymorphisms affected the lipid response to diet slightly.</p><p>We further studied the effect of the apoprotein A4 360-1/2 polymorphism on response of serum lipids to dietary cholesterol in a controlled trial specially designed for this purpose. The apoprotein A4 360-1/2 polymorphism did not affect the response of serum lipids to a change in the intake of cholesterol in a group of healthy Dutch subjects who consumed a background diet high in saturated fat.</p><p>Although it is not directly related to genetic polymorphisms and lipid response, we finally reviewed the effect of dietary cholesterol on the ratio of total to high-density lipoprotein cholesterol, which is a more specific predictor of coronary heart disease than either lipid value alone. Dietary cholesterol raised the ratio of total to high-density lipoprotein cholesterol.</p><p>In conclusion, the effect of genetic polymorphisms on serum lipid response to diet is small. It is therefore not possible to identify individuals who will not benefit from a cholesterol-lowering diet on the basis of a specific genetic polymorphism.</p>
Dietary catechins and their potentially protective role in cardiovascular diseases and cancer
Arts, I.C.W. - \ 2001
Wageningen University. Promotor(en): Daan Kromhout; Peter Hollman; E.J.M. Feskes. - S.l. : S.n. - ISBN 9789058083777 - 159
flavanolen - catechine - hart- en vaatziekten - neoplasma's - hartziekten - beroerte - dieetstudies - flavanols - catechin - cardiovascular diseases - neoplasms - heart diseases - stroke - diet studies
<p>Catechins are polyphenolic compounds in plant foods that belong to the family of flavonoids. Due to their strong antioxidant activity and their capacity to influence mammalian enzyme systems, catechins were hypothesized to affect risk of cardiovascular diseases and cancer in humans. After optimizing the extraction and quantification of six major catechins from foods, a database containing catechin contents of more than 130 commonly consumed plant foods and beverages was created. Catechin levels varied between 5 and 610 mg/kg and were particularly high in tea, chocolate, fruits and red wine. Among 6,200 participants of the Dutch National Food Consumption Survey 1998, the average catechin intake was 50 mg/day. Catechin intake increased with age, and the intake was higher in women (60 mg/day) than in men (40 mg/day). Tea was the main catechin source in all age groups. The role of catechins in chronic disease prevention was studied in two prospective cohort studies: the Zutphen Elderly Study (~800 Dutch men, 65-84 years old, followed since 1985) and the Iowa Women's Health Study (~34,000 postmenopausal American women, 55-69 years old, followed since 1986). In Zutphen, a high intake of catechins was associated with a 51% lower risk of coronary heart disease (CHD) mortality, but not with myocardial infarction incidence or stroke. In Iowa, a 24% lower risk of CHD mortality was found in the highest quintile of intake of (+)-catechin and (-)-epicatechin, catechins typical of foods other than tea. Catechins derived from tea were not associated with CHD mortality. Lung cancer incidence was studied in both the Zutphen Elderly Study and the Iowa Women's Health Study. Whereas in Zutphen a borderline significant inverse association with lung cancer was found for catechins from foods other than tea, particularly apple, catechins were not associated with lung cancer in Iowa. The incidence of other cancers studied in Zutphen - total epithelial cancer and epithelial cancers other that those of the lung - was not associated with catechin intake. In Iowa, among several cancers studied, total catechin intake and the intake of catechins from tea were inversely associated with rectal cancer risk only. Thus, catechins are quantitatively important minor constituents of the diet. Major catechin sources in both the Netherlands and the USA are tea, apples, and chocolate. Overall, our data do not support a strong protective effect of the studied catechins against myocardial infarction, stroke and cancer incidence. However, certain catechins may lower the risk of CHD mortality and possibly certain cancers.</p>