Type 2 diabetes mellitus (T2DM) represents 90 – 95 % of all diabetes cases and is characterized by β-cell dysfunction and insulin resistance leading to hyperglycemia. Hyperglycemia increases oxidative stress, inflammation, and orthosympatic activity and limits bioavailability of nitric oxide (NO), resulting in micro- (nephropathy, neuropathy, retinopathy) and macrovascular (cerebrovascular, cardiovascular, and peripheral artery disease) complications. These complications result in higher morbidity and mortality rates, decrease quality of life, and increase health economic burden. Increasing physical activity and a more balanced, healthy food intake are the first-line management. Herein, the promising vascular health benefits of nutraceuticals, like flavonoids and more specifically flavanols, have gained interest.Flavanols are natural substances present in several fruits, teas, red wines, beans, and predominantly in cocoa and are believed to beneficially affect human health. Based on epidemiological, in vitro-, animal-, and human studies, cocoa flavanols (CF) would have antioxidant properties, improve endothelial function, lower blood pressure (BP), and reduce inflammation. The mechanisms of action of CF are not yet completely understood, but it is believed that increasing NO bioavailability and –activity and antioxidative actions like inhibiting lipid peroxidation and nicotinamide adenine dinucleotide phosphate oxidase and scavenging free radicals play a key role.So far, research into the potential beneficial vascular health properties of CF in patients with diabetes mellitus (DM) is limited and demonstrated inconsistent results. However, based on the pathophysiology of diabetic vascular complications and the believed mechanisms of action of CF, one could assume that CF would exert vascular protection in T2DM subjects. Therefore, this doctoral research investigated whether CF exert vascular health benefits in patients with T2DM through the following 3 aims: (1) examine the evidence for CF-induced vascular health properties in patients with DM, (2) setup of a robust, standardized, clearly described trial protocol, and (3) investigate the acute effects of CF on peripheral vascular reactivity in patients with T2DM via execution of the described acute, randomized, double-blinded, placebo-controlled cross-over trial.First, we published a systematic review and meta-analysis on the vascular health effects of CF in patients with DM. We highlighted the need for more, robust, standardized research because of the high heterogeneity in administered intervention (dose, duration and frequency, nature of intervention), the studied population (age, sex, BMI, medical therapy, stage of disease), and measurement methods. Because of paucity of reports, we could only perform the meta-analysis on the mid/long-term effects of CF on blood pressure (BP) in patients with DM and mixed populations with increased cardiovascular risk. This meta-analysis indicated weak evidence for a reduction in diastolic BP (DBP) of, at best, 1 – 2 mmHg. No effect on systolic BP (SBP) was detected. Furthermore, CF effects on BP would be stronger in female, hypertensive, younger adults, providing a CF dose comprising at least 90 mg epicatechine (EC), and when ingested in 1 daily batch.Second, the protocol paper illustrating our setup acute, randomized, double-blinded, placebo-controlled cross-over trial was published. Here we thoroughly described our protocol trial in which we take into account the limitations in previous studies. We believe that acute studies in which subjects ingest a pure cocoa extract are the first step to gain insight in CF actions as possible confounding impact of additional fat, sugars, milk or other substances could mask/ counteract/ strengthen the effects of CF [...]