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Phytoestrogen Content of Cereals and Cereal-Based Foods Consumed in the


UK
Gunter G. C. Kuhnle a; Caterina Dell'Aquila a; Sue M. Aspinall a; Shirley A. Runswick a; Angela A. Mulligan b;
Sheila A. Bingham a
a
MRC Dunn Human Nutrition Unit, Cambridge, England b EPIC, Department of Public Health and Primary
Care, Institute of Public Health, University of Cambridge, Cambridge, England

Online Publication Date: 01 May 2009

To cite this Article Kuhnle, Gunter G. C., Dell'Aquila, Caterina, Aspinall, Sue M., Runswick, Shirley A., Mulligan, Angela A. and
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Cancer,61:3,302 — 309
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Nutrition and Cancer, 61(3), 302–309
Copyright © 2009, Taylor & Francis Group, LLC
ISSN: 0163-5581 print / 1532-7914 online
DOI: 10.1080/01635580802567141

Phytoestrogen Content of Cereals and Cereal-Based Foods


Consumed in the UK
Gunter G. C. Kuhnle, Caterina Dell’Aquila, Sue M. Aspinall,
and Shirley A. Runswick
MRC Dunn Human Nutrition Unit, Cambridge, England

Angela A. Mulligan
EPIC, Department of Public Health and Primary Care, Institute of Public Health,
University of Cambridge, Cambridge, England

Sheila A. Bingham
MRC Dunn Human Nutrition Unit, Cambridge, England
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

diovascular disease (4), and cancer (5). Although mechanisms


Dietary phytoestrogens may be involved in the occurrence of for the beneficial effects of these foods remain to be eluci-
chronic diseases. Reliable information on the phytoestrogen con- dated, they have been attributed to individual components such
tent in foods is required to assess dietary exposure and disease risk as antioxidants, fiber, and other phytochemicals such as lig-
in epidemiological studies. However, there is little information on
isoflavone, lignan, and coumestrol content of cereals and cereal-
nans (5,6). Lignans are structural plant components (7) that can
based foods, leading to an underestimation of intake. This is the be converted into enterodiol and enterolactone by mammalian
first study of phytoestrogens (isoflavones: biochanin A, daidzein, gut microflora (8). These compounds—as well as isoflavones,
formononetin, genistein, glycitein; lignans: matairesinol, secois- which are also found in cereals (9)—are bioactive as phyto-
plariciresinol; coumestrol) in a comprehensive selection of 101 estrogens because of their structural and functional similarity to
cereals and cereal-based foods—including breads, breakfast ce-
reals, biscuits, pasta and rice—consumed in the UK using a sensi-
17β-estradiol (10). Dietary intake of phytoestrogens has been
tive LCMS technique with 13 C-labelled internal standards. Phyto- shown in recent studies to have beneficial health effects with
estrogens were detected in all foods analyzed; bread contained the regard to cancer (11–14), cardiovascular disease (13,15), osteo-
highest amount of phytoestrogens—many as isoflavones—with an porosis (13,16) menopausal symptoms (13,17), male infertility
average content of 375 ± 67 µg/100 g wet weight (excluding soya- (18), and obesity and Type 2 diabetes (19).
linseed bread with 12,000 µg/100 g). Most other foods contained
However, increased levels of endogenous sex hormones are
less than 100 µg/100 g, many as lignans. Our study shows that all
foods analyzed contained phytoestrogens, with the highest amount generally associated with an increased risk of breast cancer in
found in breads, making them one of the main sources of dietary women (20), and recent studies have shown an increased risk for
phytoestrogens in the UK. These results will allow a more accurate breast cancer associated with high exposure compared with low
estimation of exposure to dietary phytoestrogens. exposure (21,22). Previously, strong gene-nutrient interactions
between phytoestrogens and polymorphisms of the estrogen re-
ceptor (ESR1 and NR1I2) (23,24), the sex-hormone binding
INTRODUCTION globulin (SHBG) (25), CYP17 (26), and probably aromatase
(CYP19) (27) have also been shown. As a result of their bioac-
Cereals and cereal-based foods are part of the staple diet in
tivity, there are concerns that phytoestrogens increase the risk
most societies and are consumed by more than 90% of the
of recurrence and stimulate tumor growth—and as these com-
adult population in the UK (1). The consumption of cereal
pounds can act either as estrogens or antiestrogens, there are
products—in particular, whole grain—has been associated with
concerns surrounding the use of phytoestrogen supplements in
a reduced risk of Type 2 diabetes (2), hypertension (3), car-
breast cancer patients (28,29). The UK Committee on Toxic-
ity recommended more research into the health effects of these
compounds because of the ambiguity of previous results (30).
Submitted 23 May 2008; accepted in final form 4 September 2008. To investigate dietary exposure to phytoestrogens, urinary
Address correspondence to Gunter G. C. Kuhnle, MRC Dunn
Human Nutrition Unit, Wellcome Trust/MRC Building, Hills Road, and plasma biomarkers can be used and have been used suc-
Cambridge CB2 0XY, UK. Fax: +44 (0) 1223 252765. E-mail: cessfully in previous studies (21,23,31–33). However, this is
ggck2@cam.ac.uk not always possible, in particular in large cohorts or for the

302
PHYTOESTROGEN CONTENT OF CEREALS CONSUMED IN THE UNITED KINGDOM 303

determination of exposure of the population, and intake has to Analysis


be estimated using dietary data. For this reason, accurate in- Samples were analyzed as described previously (40). Briefly,
formation on dietary phytoestrogens is crucial to determine ex- approximately 100 mg freeze-dried food was extracted 3 times
posure and investigate health effects further. However, despite with 2.0 ml 10% methanol in sodium acetate (0.1%, pH 5)
several studies analyzing phytoestrogens in food, there is still and deconjugated with a hydrolysis reagent consisting of pu-
insufficient information, and exposure is likely to be underesti- rified helix pomatia juice (β-glucuronidase), cellulase, and β-
mated (34), in particular since many studies have focused only glucosidase. Deconjugated samples were then extracted using
on a few compounds. In particular, for cereals and cereal-based Strata C-18E SPE cartridges (50 mg/ml; Phenomenex, Mac-
foods, very little information is available. clesfield, Cheshire, UK), dried, reconstituted in 40% aqueous
Previously, we have developed a robust and sensitive methanol, and analyzed using LC/MS/MS. Analysis was per-
LC/MS/MS method incorporating stable 13 C3 standards to de- formed on a LC/MS/MS system consisting of a Jasco HPLC
termine urinary and plasma phytoestrogen concentrations as system (Jasco, Great Dunmow, UK) using a diphenyl column
biomarkers of intake to assess cancer risks and interaction with (Varian Pursuit, 3 µm, 150 × 2 mm; Varian, Oxford, Oxford-
gene variants (35). Adapting this method for the analysis of shire, UK) and a Waters Quattro Ultima triple quadrupole MS
food samples, we have investigated the isoflavone (biochanin instrument (Waters, Manchester, UK) fitted with an electro-
A, daidzein, formononetin, genistein, and glycitein), lignan spray ion source in negative ion mode and a LC/MS/MS sys-
(matairesinol and secoisolariciresinol), and coumestrol content tem consisting of a Agilent 1100 CapHPLC System (Agilent,
in more than 100 cereal-based foods such as breads, break- Wokingham, Berkshire, UK) and an ABI 4000 QTRAP mass
fast cereals, biscuits, pasta, and rice available in the UK. spectrometer (Applied Biosystems, Warrington, Cheshire, UK)
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

These data will allow a more accurate determination of di- fitted with an electrospray ion source in negative ion mode.
etary phytoestrogen exposure and investigation of their effects in Compounds were quantified using corresponding 13 C3 -labeled
vivo. internal standards; for coumestrol, 13 C3 -enterolactone was
used.
The method was validated on both LC/MS/MS systems. The
EXPERIMENTAL intrabatch cv of this method is between 3 and 14% and the
interbatch between 1 and 6%. As quality control, a sample con-
Chemicals
sisting of equal amounts of red cabbage, orange, and celery was
Biochanin A, daidzein, genistein, glycitein, formononetin,
analyzed with each batch. The limit of detection of this method
secoisolariciresinol, matairesinol, and coumestrol were pur-
is 1.5 µg/100 g dry weight.
chased from Plantech (Reading, Berkshire, UK). 13 C3 -biochanin
A, 13 C3 -daidzein, 13 C3 -genistein, 13 C3 -glycitein, 13 C3 -formon-
onetin, 13 C3 -matairesinol, 13 C3 -secosiolariciresinol, and 13 C3 - Data Analysis
enterolactone were obtained from Dr. Nigel Botting (University Each sample was prepared in triplicate and analyzed twice.
of St Andrews, Fife, UK) (36–39). β-glucuronidase (from Helix Data given is the average of two analyses and is in µg/100 g wet
Pomatia), β-glucosidase (from almonds), and cellulase (from weight.
Trichoderma reesi) were purchased from Sigma (Poole, Dorset,
UK). Water, methanol, acetic acid, and ammonia were purchased RESULTS
from Sigma and Fisher Scientific (Loughborough, Leicester- All foods analyzed contained detectable amounts of phy-
shire, UK). To inhibit losses of target compounds by adsorption toestrogens (Table 1). The highest amounts of phytoestrogens
to glassware, only silanized glassware was used. (mainly in the form of isoflavones) among the foods tested were
found in breads, with an average 375 ± 67 µg/100 g (excluding
the soya-linseed bread with 12,000 µg/100 g); whereas most
Sampling other foods contained less than 100 µg/100 g phytoestrogens,
Samples of each food were purchased from at least 5 dif- mainly as lignans, with the notable exception of “luxury/extra
ferent food outlets (where possible) in Cambridgeshire, UK. If fruit muesli,” which contained 4,775 µg/100 g isoflavones and
possible, the foods bought at each outlet were from different 381 µg/100 g lignans.
manufacturers, varieties, countries of origin, and/or batch num- Daidzein, genistein, and glycitein were the most common
bers. Each sample was weighed, prepared, and a representative isoflavones detected, whereas only small amounts of biochanin
portion (approximately 35 g dry weight) was taken from each of A and formononetin were found. In most foods, secoisolari-
the 5 samples. The samples were frozen (−20◦ C), freeze-dried ciresinol was the main lignan, with the notable exception of
if necessary (BOC Edwards, Crawley, Sussex, UK), and stored “soya lecithin fortified quick cook porridge oats,” which con-
at −20◦ C until analysis. For analysis, samples of each food were tained 120 µg/100 g matairesinol but only 7 µg/100 g sec-
pooled (equal amounts), mixed, weighed, and processed as de- oisolariciresinol. Except for breads, only a few foods contained
scribed below. large amounts of isoflavones, in particular porridge oats and raw
304 G. G. C. KUHNLE ET AL.

TABLE 1
Phytoestrogen content in cereals and cereal-based foodsa
Isoflavones Lignans
Food Daidzein Genistein Glycitein Biochanin A Formononetin Secoisolariciresinol Matairesinol Coumestrol
Bread
Bread, brown, sliced 155 246 14 — <1 10 <1 <1
Bread, Danish type 235 465 36 5 <1 2 3 <1
Bread, granary, sliced 89 154 18 — <1 8 <1 <1
Bread, mixed grain, sliced 106 171 16 4 — 214 2 <1
Bread, rye 8 13 <1 3 <1 21 9 —
Bread, soya—linseed 3,065 6,807 709 20 8 1,374 5 —
Bread, white, added fiber 229 403 37 6 <1 5 1 —
Bread, white, sliced 185 298 28 8 <1 6 <1 <1
Bread, whole meal, sliced 209 333 39 <1 <1 19 <1 <1
French stick/baguette, 122 206 19 10 — 8 3 <1
white
Malt loaf <1 2 <1 14 <1 26 4 —
Pappadum, grilled 6 24 29 15 3 22 19 2
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

Pumpernickel bread 7 3 2 — 3 39 27 —
Wheat germ bread, sliced 149 249 24 <1 <1 11 <1 <1
Breakfast cereals
Bran flakes — — <1 — 2 53 3 <10
Chocolate puffed rice — 1 4 — 1 2 8 —
Corn flakes 19 — 2 6 2 6 1 <10
Crunchy oat cereal — 1 — — <1 12 3 <1
Crunchy wheat & malted — 3 <1 11 — 19 2 —
barley cereal
Crunchy/Honey nut corn 2 5 9 — <1 10 4 —
flakes
Frosted flakes <1 9 <1 — 1 <1 — <1
Bran flakes with fruit — <1 — <1 <1 12 2 <1
High Fiber Bran cereal 2 3 4 <1 2 53 6 <1
Malted Wheat type cereal 2 2 2 <1 2 30 — —
Muesli, luxury/extra fruit 1,693 3,065 13 — 4 355 26 —
Muesli, Swiss style — 3 <1 — 1 7 3 <1
Muesli, unsweetened — 2 <1 — 1 7 2 <1
Multigrain hoops <1 1 3 — <1 7 3 <1
Oat bran flakes — <1 — — 3 14 1 <1
Porridge oats, quick cook 8 19 5 11 24 7 120 —
+ soya lecithin
Porridge oats, quick cook 13 5 22 1 15 47 53 —
+ vitamin + minerals
Puffed rice (leading brand) <1 3 1 3 2 3 3 <1
Puffed Rice n.s. 3 2 <1 4 1 4 <1 <1
Puffed wheat n.s. — 6 — — 2 8 3 <1
Rice a—wheat flakes <1 2 <1 <1 <1 6 10 <1
Rolled oats <1 — <1 6 <1 5 <1 <1
Shredded whole wheat <1 <1 7 — 1 11 5 —
cereal
Shredded whole wheat — 6 <1 1 <1 11 10 <1
filled with raisins
Sugar/golden puffs type <1 — — 5 3 21 1 <10
cereal
Sultana bran, n.s. — — 5 — 1 3 11 —
Wheat cereal biscuit 4 11 2 — <1 18 <1 <1
(Continued on next page)
PHYTOESTROGEN CONTENT OF CEREALS CONSUMED IN THE UNITED KINGDOM 305

TABLE 1
Phytoestrogen content in cereals and cereal-based foodsa (Continued)
Isoflavones Lignans
Food Daidzein Genistein Glycitein Biochanin A Formononetin Secoisolariciresinol Matairesinol Coumestrol
Wholegrain wheat flakes — — 5 — 1 12 10 —
with nuts
Wholewheat flakes 2 2 1 1 3 129 — <1
Biscuits and other snacks
Chocolate biscuit, full 7 25 3 8 <1 14 14 <1
coated
Chocolate coated 4 9 <1 5 <1 4 4 <1
marshmallow biscuit
Chocolate Wafer biscuit 7 20 1 11 <1 2 3 —
Cookie type biscuit with 3 7 1 7 <1 3 6 <1
chocolate chip
Cracker bread type 1 5 1 — <1 8 7 1
Cracker, wheat and rye <1 1 <1 4 <1 9 16 <1
Cracker/thin, cheese <1 2 <1 16 <1 6 5 <1
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

Cream cracker, plain — <1 4 5 — 3 2 —


Digestive biscuit, 3 10 <1 5 <1 7 3 <1
chocolate (milk)
Digestive biscuit, plain <1 1 <1 13 — 6 8 —
Ginger nut/ginger snap — <1 4 10 2 48 3 —
biscuit
Sponge biscuit with orange 3 7 <1 2 <1 7 <1 1
filling and chocolate top)
Oat based biscuit, plain <1 <1 <1 18 <1 10 5 <1
Oat cake — <1 <1 9 — 8 12 —
Plain/semisweet <1 4 <1 14 <1 7 11 <1
biscuit—rich tea type
Pop corn, cooked — — 9 14 — 19 <1 <1
Pop corn, raw — — 15 7 <1 19 6 2
Rice cake, cracker — — 5 2 <1 3 3 —
Rye crispbread type 2 2 2 — 3 59 30 <1
Sandwich biscuit, 3 9 <1 12 <1 3 2 <1
chocolate filling and
chocolate coating
Sandwich biscuit, <1 3 <1 14 <1 4 7 <1
chocolate with chocolate
filling, bourbon type
Sandwich biscuit, cream 5 17 <1 11 <1 4 1 <1
filling and chocolate
coating
Sandwich biscuit, cream <1 8 <1 17 <1 3 <1 <1
filling, custard cream
type
Short sweet <1 8 <1 24 <1 7 11 <1
biscuit—malted
milk/shorties
Water biscuits <1 2 — 10 <1 4 3 <1
Cereal grains, brans, germs, and flour type foods
Arrowroot <1 2 <1 <1 — 1 1 <1
Corn flour — 6 <1 <1 <1 1 1 —
Maize meal — <1 <1 8 <1 2 <1 1
Oat bran/germ <1 — <1 7 — 14 4 —
Oatmeal <1 <1 <1 6 <1 4 <1 <1
306 G. G. C. KUHNLE ET AL.

TABLE 1
Phytoestrogen content in cereals and cereal-based foodsa (Continued)
Isoflavones Lignans
Food Daidzein Genistein Glycitein Biochanin A Formononetin Secoisolariciresinol Matairesinol Coumestrol
Pearl barley <1 <1 <1 14 <1 7 <1 <1
Semolina <1 <1 <1 7 <1 2 — <1
Tapioca <1 1 <1 5 <1 8 <1 —
Wheat bran <1 <1 2 6 1 5 <1 3
Wheat flour, brown, <1 1 <1 7 <1 6 — <1
self—raising & strong
Wheat flour, white, plain 1 6 2 — <1 34 <1 2
Wheat flour, whole meal <1 — <1 9 <1 6 <1 <1
Wheat germ — 2 <1 — 4 26 9 —
Pasta and noodles
Lasagna, green, cooked <1 — <1 <1 <1 <1 <1 <1
Lasagna, green, raw 1 <1 <1 — <1 4 3 —
Lasagna, white, cooked <1 — <1 — — 2 <1 —
Lasagna, white, raw <1 — <1 — — 4 1 —
Lasagna, whole wheat, <1 <1 <1 2 — 1 2 —
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

cooked
Lasagna, whole wheat, raw <1 4 <1 10 — 2 <1 —
Macaroni, white, cooked <1 — <1 — <1 <1 <1 —
Macaroni, white, raw 1 <1 <1 — — 4 <1 —
Noodles, cooked <1 <1 <1 <1 — <1 1 —
Noodles, instant, raw 4 6 2 1 3 <1 17 —
Pasta (whole wheat), — 3 — 5 <1 9 1 —
macaroni & fusilli,
cooked
Pasta (whole wheat), <1 3 <1 8 <1 9 3 —
macaroni & fusilli, raw
Spaghetti, white, cooked <1 — <1 — — 2 <1 —
Spaghetti, white, raw 1 — <1 — — 5 1 —
Spaghetti, whole wheat, <1 — <1 — <1 6 <1 —
cooked
Spaghetti, whole wheat, <1 — <1 — <1 3 2 —
raw
Rice
Rice, brown, cooked — <1 <1 <1 <1 2 <1 —
Rice, brown, raw 55 76 7 5 <1 9 <1 <1
Rice, savory, cooked <1 2 1 2 <1 7 1 <1
Rice, white, long grain, — <1 <1 <1 <1 <1 <1 <1
cooked
Rice, white, long grain, raw — <1 <1 7 2 5 <1 <1
a
Data are given as µg per 100 g wet weight; the data are the average of 3 different samples analyzed in duplicate. — indicates content was
below the limit of detection.

brown rice. These foods also contained the highest amount of this study, we showed that most breads analyzed contain mainly
total phytoestrogens in their respective group. soya-type isoflavones (daidzein, genistein, and glycitein) but
only small amounts of other isoflavones. Except for rye bread,
pumpernickel bread, and malt loaf, all breads contained more
DISCUSSION isoflavones than lignans, although most other cereal-based foods
Bread has been identified as one of the major dietary sources contained similar amounts or a higher proportion of lignans.
of phytoestrogens in the UK (34), and the main reason for this Thompson et al. (41) analyzed Canadian breads and found
is that soya is used in the preparation of many breads. This is similar, although slightly lower, amounts of lignans but only
also shown by the fact that the phytoestrogen content (in par- small amounts of isoflavones (1.5 µg/100 g), suggesting that
ticular, isoflavones) in flour is much lower than in bread. In the breads analyzed were prepared differently from the breads
PHYTOESTROGEN CONTENT OF CEREALS CONSUMED IN THE UNITED KINGDOM 307

TABLE 2
Comparison of phytoestrogen content found in this study and content published previously by Adlercreutz & Mazur (43),
Horn-Ross et al. (42), Valsta et al. (44), and Thompson et al. (41)
Daidzein Genistein Secoisolariciresinol Matairesinol
Bread, white
This study 185 298 6 <1
Horn-Ross et al. 606 831 0 0
Valsta et al. <1 <1 20 14
Thompson et al. 0 1 1 0
Bread, rye
This study 8 13 21 9
Valsta et al. 0 0 32 44
Thompson et al. 0 3 122 0
Bread, whole meal
This study 209 333 19 <1
Horn-Ross et al. 156 142 <1 <1
Thompson et al. 0 0 3 0
Downloaded By: [Kuhnle, Gunter G. C.] At: 00:12 17 April 2009

Rice
This study 0 <1 5 <1
Thompson et al. 1 1 0 0
Wheat meal, white
This study <1 0 6 <1
Adlercreutz & Mazur <1 <1 8 0
Wheat bran
This study <1 <1 5 <1
Adlercreutz & Mazur 7 4 110 0
Oatmeal
This study <1 <1 4 <1
Adlercreutz & Mazur 0 0 13 0
Oat bran
This study <1 <1 14 4
Adlercreutz & Mazur 0 0 24 155

available in the UK. In contrast, Horn-Ross et al. (42) analyzed strogen content much compared with white or whole wheat
breads from California and found isoflavone levels that were lasagna. In all types of pasta and noodles, cooking decreased
higher (for white bread) or slightly smaller (whole meal bread) the amount of isoflavones present; because of the small number
than those found here (see Table 2 for details). These results of samples, it is not possible to determine whether this differ-
emphasize the importance of food analyses of locally available ence is statistically significant. However, a similar pattern was
foods for the determination of dietary phytoestrogens. observed in rice. Surprisingly, the isoflavone content of brown
Most breakfast cereals contained less than 71 µg/100 g rice decreased more than 70-fold following cooking, and it is
phytoestrogens—mainly as lignans—with a few notable ex- likely that water soluble isoflavones have leached into the water
ceptions with a significantly higher phytoestrogen content during preparation, which was discarded afterward.
(luxury/extra fruit muesli: 5,156 µg/100 g; porridge oats: So far, few data on the phytoestrogen content in cereals
175 µg/100 g; and whole wheat flakes: 138 µg/100 g). Break- and cereal-based foods have been published. The only study
fast cereals are consumed by approximately 50% of the adult of a comprehensive selection of cereal-based foods by Liggins
(19–64 yr) population in the UK (1), and even though the av- et al. (9) analyzed exclusively daidzein and genistein but not any
erage phytoestrogen content (excluding luxury muesli) is only other isoflavones, lignans, or coumestrol and used the addition
41 µg/100 g, they are therefore an important food group con- method rather than stable 13 C-labeled standards for quantifica-
tributing to total phytoestrogen exposure. In pasta and noodles, tion. In other studies that have covered more compounds, only a
only small amounts of phytoestrogens were detected. Interest- very limited selection of these foods has been analyzed. For this
ingly, the spinach in green lasagna did not affect the phytoe- reason, it is difficult to compare results found here with results
308 G. G. C. KUHNLE ET AL.

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available. The results of this study will contribute to databases
21. Grace PB, Taylor JI, Low YL, Luben RN, Mulligan AA, et al.: Phytoe-
for the assessment of dietary intake of phytoestrogens and al-
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strogen concentrations in serum and spot urine as biomarkers for dietary


low a more accurate determination of exposure in free-living phytoestrogen intake and their relation to breast cancer risk in European
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22. Ward H, Chapelais G, Kuhnle G, Luben R, Wareham NJ, et al.: Risk
ACKNOWLEDGMENTS of breast cancer in relation to biomarkers of phytoestrogen intake in a
This work was funded by the United Kingdom Food Stan- population cohort study. Breast Cancer Res 10, R32, 2008.
dards Agency (FSA), contract number T05028, and the Medical 23. Low Y-L, Taylor JI, Grace PB, Dowsett M, Scollen S, et al.: Phytoestrogen
exposure correlation with plasma estradiol in postmenopausal women in
Research Council (MRC). European Prospective Investigation of Cancer and Nutrition-Norfolk may
involve diet-gene interactions. Cancer Epidemiol Biomarkers Prev 14, 213–
220, 2005.
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