(OR12-04-26) Five-A-Day Fruit and Vegetable Intake Recommendation Does Not Result in Flavanol Intake Levels Associated With Cardiovascular Benefits

Sunday, July 26, 2026

2:54 PM - 3:06 PM ET

Location: Maryland Ballroom D

Presenting Author(s)

Yasmine Y. Bouzid, PhD, RD (she/her/hers)

Postdoctoral Researcher
University of California, Davis
Sacramento, California, United States

Disclosure(s): No relevant financial relationship(s) with ineligible companies to disclose.

Co-Author(s)

JO

Javier I. Ottaviani, PhD

Mars, Inc., Virginia, United States
JE

John W. Erdman, Jr., PhD

Emeritus Professor of Food Science and Human Nutrition
University of Illinois Urbana-Champaign
Urbana, Illinois, United States
Francene M. Steinberg, PhD, RD (she/her/hers)

Professor, Department Chair
University of California, Davis
Davis, California, United States
JM

JoAnn E. Manson, MD MPH DrPH

Brigham and Women's Hospital and Harvard Medical School; Harvard T.H. Chan School of Public Health
Boston, Massachusetts, United States
HS

Howard D. Sesso, ScD PhD

Brigham and Women's Hospital and Harvard Medical School; Harvard T.H. Chan School of Public Health
Boston, Massachusetts, United States
HS

Hagen Schroeter, PhD

Mars, Inc., Virginia, United States
GK

Gunter G. Kuhnle, PhD

University of Reading, England, United Kingdom

Disclosure(s):

Yasmine Y. Bouzid, PhD, RD: No relevant financial relationship(s) with ineligible companies to disclose.

John W. Erdman, PhD, Jr.: Abbott Nutrition: Grant/Research Support (Ongoing)

Objectives: Outcomes from the COSMOS (Cocoa Supplement and Multivitamin Outcomes Study) trial have reinforced the notion of flavanols as important plant-derived bioactives contributing to cardiovascular health, with a 27% reduction in cardiovascular disease mortality. However, there is ongoing debate on whether dietary references should be developed for these compounds. Current dietary guidelines emphasizing fruit and vegetable (FV) intake may already yield sufficient flavanol intake levels, wherein a dietary reference would be redundant. Therefore, we aimed to assess if adherence to dietary recommendations for FV intake achieves flavanol intake levels of 500 mg/day, the amount shown to have cardiovascular benefits in the COSMOS trial.

Methods: Flavanol intake was objectively evaluated using two validated and complementary biomarkers, 5-(3’, 4’-dihydroxyphenyl)- γ-valerolactone metabolites (gVLM_B) and structurally related (-)-epicatechin (SREM_B) from urine, in two geographically distinct studies: COSMOS (US; n = 6,509) and EPIC (European Prospective Investigation into Cancer and Nutrition)-Norfolk (UK; n = 24,154). FV intake was assessed using a food frequency questionnaire and a 7-day food record in COSMOS and EPIC-Norfolk, respectively.

Results: COSMOS participants in the highest quartile for FV intake met and often surpassed the 5 servings/day recommendation. Nevertheless, < 25% of participants meeting dietary guidelines for FV intake or with high overall diet quality (assessed with the alternative Healthy Eating Index) achieved an estimated flavanol intake of 500 mg/day. In EPIC-Norfolk, only 16% of participants in the highest quartile for FV intake met the 500 mg/day threshold. Similar findings were observed in complementary analyses simulating flavanol intake levels based on reported flavanol content in F&V commonly consumed in the United States.

Conclusions: In conclusion, adherence to existing dietary guidelines does not yield flavanol intake levels comparable to those shown to provide cardiovascular benefits in COSMOS. Thus, specific dietary reference values for flavanols may be necessary to increase the intake of these dietary compounds.

Funding Sources: Mars, Inc; Haleon; US National Institutes of Health (NIH); Cancer Research UK