Cocoa Consumption, Cocoa Flavonoids, and Effects on Cardiovascular Risk Factors: An Evidence-Based Review

Abstract

There has been considerable interest in the health effects of cocoa products. Cocoa flavonoids have especially been associated with cardiovascular disease (CVD) risk factors. We summarize the effects of total flavonoid and cocoa flavonoid consumption on CVD endpoints in observational studies and intermediate risk factors in experimental designs. From an evidence-based review, there is strong evidence that high cocoa intake lowers blood pressure, improves vascular endothelial function, and potentially increases insulin sensitivity. However, evidence does not support effects on blood lipids and body weight. Total flavonoid intake, and potentially cocoa flavonoid intake, is associated with coronary heart disease mortality in observational studies; however, there is conflicting evidence regarding the dose at which cocoa flavonoids are beneficial. Moreover, because chocolate is often nutritionally energy dense and with added sugar, considerations must be given to caloric balance and body weight. Overall, combining the multiple lines of evidence from experimental and observational studies on the effects of cocoa flavonoids and cocoa intake on cardiovascular risk factors, there is rather strong evidence supporting and demonstrating that cocoa consumption improves several important cardiovascular risk factors and likely reduces the risk of CVD, although more research is needed to further examine etiological mechanisms, demonstrate efficacy on hard clinical CVD endpoints in large-scale randomized trials, as well as carefully estimate attributable disease burden. More importantly, as intake of cocoa is inextricably linked with increased calories in chocolate consumption, further careful risk-benefit analysis is needed to assess whether consuming cocoa in the form of energy-dense chocolate products may yield a net benefit on cardiovascular risks.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Ding EL, Hutfless SM, Ding X, Girotra S. Chocolate and prevention of cardiovascular disease: a systematic review. Nutr Metab Lond. 2006;3:2.

    PubMed  Article  Google Scholar 

  2. 2.

    Wollgas J. The contents and effects of polyphenols in chocolate. Qualitative and quantitative analyses of polyphenols in chocolate and chocolate raw products as well as evaluation of potential implications of chocolate consumption in human health. Gießen, Germany: University of Gießen, Faculty of Agricultural and Nutritional Sciences, Home Economics, and Environmental Management. Institute of Nutritional Sciences; 2004.

  3. 3.

    Grivetti LE, Shapiro H-Y. Chocolate: history, culture, and heritage. Wiley; 2009.

  4. 4.

    Miller KB, Hurst WJ, Flannigan N, et al. Survey of commercially available chocolate- and cocoa-containing products in the United States. 2. Comparison of flavan-3-ol content with nonfat cocoa solids, total polyphenols, and percent cacao. J Agric Food Chem. 2009;57(19):9169–80.

    PubMed  CAS  Article  Google Scholar 

  5. 5.

    Anonymous. USDA database for the flavonoid content of selected foods. Release 2.1 2007. Accessed Oct 31, 2010.

  6. 6.

    Payne MJ, Hurst WJ, Miller KB, Rank C, Stuart DA. Impact of fermentation, drying, roasting, and Dutch processing on epicatechin and catechin content of cacao beans and cocoa ingredients. J Agric Food Chem. 2010;58(19):10518–27.

    PubMed  CAS  Article  Google Scholar 

  7. 7.

    Arts IC, van de Putte B, Hollman PC. Catechin contents of foods commonly consumed in The Netherlands. 1. Fruits, vegetables, staple foods, and processed foods. J Agric Food Chem. 2000;48(5):1746–51.

    PubMed  CAS  Article  Google Scholar 

  8. 8.

    Kris-Etherton PM, Keen CL. Evidence that the antioxidant flavonoids in tea and cocoa are beneficial for cardiovascular health. Curr Opin Lipidol. 2002;13(1):41–9.

    PubMed  CAS  Article  Google Scholar 

  9. 9.

    • Corti R, Flammer AJ, Hollenberg NK, Luscher TF. Cocoa and cardiovascular health. Circulation. 2009;119(10):1433–41. This is a systematic review of cocoa and cardiovascular disease, with a focus on mechanisms.

    PubMed  Article  Google Scholar 

  10. 10.

    Taubert D, Roesen R, Schomig E. Effect of cocoa and tea intake on blood pressure: a meta-analysis. Arch Intern Med. 2007;167(7):626–34.

    PubMed  CAS  Article  Google Scholar 

  11. 11.

    Desch S, Schmidt J, Kobler D, et al. Effect of cocoa products on blood pressure: systematic review and meta-analysis. Am J Hypertens. 2009;23(1):97–103.

    PubMed  Article  Google Scholar 

  12. 12.

    Hooper L, Kroon PA, Rimm EB, et al. Flavonoids, flavonoid-rich foods, and cardiovascular risk: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2008;88(1):38–50.

    PubMed  CAS  Google Scholar 

  13. 13.

    • Ried K, Sullivan T, Fakler P, Frank OR, Stocks NP. Does chocolate reduce blood pressure? A meta-analysis. BMC Med. 2010;8:39. This is an updated meta-analysis evaluating randomized controlled trials of cocoa supplementation and blood pressure.

    PubMed  Article  Google Scholar 

  14. 14.

    Actis-Goretta L, Ottaviani JI, Fraga CG. Inhibition of angiotensin converting enzyme activity by flavanol-rich foods. J Agric Food Chem. 2006;54:229–34.

    PubMed  CAS  Article  Google Scholar 

  15. 15.

    Fisher ND, Hughes M, Gerhard-Herman M, Hollenberg NK. Flavanol-rich cocoa induces nitric-oxide-dependent vasodilation in healthy humans. J Hypertens. 2003;21(12):2281–6.

    PubMed  CAS  Article  Google Scholar 

  16. 16.

    Taubert D, Roesen R, Lehmann C, Jung N, Schomig E. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: a randomized controlled trial. JAMA. 2007;298(1):49–60.

    PubMed  CAS  Article  Google Scholar 

  17. 17.

    Danaei G, Ding EL, Mozaffarian D, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6(4):e1000058.

    PubMed  Article  Google Scholar 

  18. 18.

    http://www.ajcn.org/content/93/2/338.abstract. Accessed 24 Jan 2011.

  19. 19.

    Engler MB, Engler MM, Chen CY, et al. Flavonoid-rich dark chocolate improves endothelial function and increases plasma epicatechin concentrations in healthy adults. J Am Coll Nutr. 2004;23(3):197–204.

    PubMed  CAS  Google Scholar 

  20. 20.

    Grassi D, Necozione S, Lippi C, et al. Cocoa reduces blood pressure and insulin resistance and improves endothelium-dependent vasodilation in hypertensives. Hypertension. 2005;46(2):398–405.

    PubMed  CAS  Article  Google Scholar 

  21. 21.

    Wang-Polagruto JF, Villablanca AC, Polagruto JA, et al. Chronic consumption of flavanol-rich cocoa improves endothelial function and decreases vascular cell adhesion molecule in hypercholesterolemic postmenopausal women. J Cardiovasc Pharmacol. 2006;47 Suppl 2:S177–86. discussion S206–S179.

    PubMed  CAS  Article  Google Scholar 

  22. 22.

    Balzer J, Rassaf T, Heiss C, et al. Sustained benefits in vascular function through flavanol-containing cocoa in medicated diabetic patients a double-masked, randomized, controlled trial. J Am Coll Cardiol. 2008;51(22):2141–9.

    PubMed  CAS  Article  Google Scholar 

  23. 23.

    Davison K, Coates AM, Buckley JD, Howe PR. Effect of cocoa flavanols and exercise on cardiometabolic risk factors in overweight and obese subjects. Int J Obes Lond. 2008;32(8):1289–96.

    PubMed  CAS  Article  Google Scholar 

  24. 24.

    Grassi D, Desideri G, Necozione S, et al. Blood pressure is reduced and insulin sensitivity increased in glucose-intolerant, hypertensive subjects after 15 days of consuming high-polyphenol dark chocolate. J Nutr. 2008;138(9):1671–6.

    PubMed  CAS  Google Scholar 

  25. 25.

    • Njike VY, Faridi Z, Shuval K, et al. Effects of sugar-sweetened and sugar-free cocoa on endothelial function in overweight adults. Int J Cardiol. Dec 23 2009. This is the largest randomized controlled trial evaluating the effect of cocoa supplementation on endothelial function. It also compares cocoa products with and without sugar supplementation.

  26. 26.

    Heiss C, Jahn S, Taylor M, et al. Improvement of endothelial function with dietary flavanols is associated with mobilization of circulating angiogenic cells in patients with coronary artery disease. J Am Coll Cardiol. 2010;56(3):218–24.

    PubMed  CAS  Article  Google Scholar 

  27. 27.

    Farouque HM, Leung M, Hope SA, et al. Acute and chronic effects of flavanol-rich cocoa on vascular function in subjects with coronary artery disease: a randomized double-blind placebo-controlled study. Clin Sci Lond. 2006;111(1):71–80.

    PubMed  CAS  Article  Google Scholar 

  28. 28.

    Faridi Z, Njike VY, Dutta S, Ali A, Katz DL. Acute dark chocolate and cocoa ingestion and endothelial function: a randomized controlled crossover trial. Am J Clin Nutr. 2008;88(1):58–63.

    PubMed  CAS  Google Scholar 

  29. 29.

    Schroeter H, Heiss C, Balzer J, et al. (−)-Epicatechin mediates beneficial effects of flavanol-rich cocoa on vascular function in humans. Proc Natl Acad Sci USA. 2006;103(4):1024–9.

    PubMed  CAS  Article  Google Scholar 

  30. 30.

    Heiss C, Dejam A, Kleinbongard P, Schewe T, Sies H, Kelm M. Vascular effects of cocoa rich in flavan-3-ols. JAMA. 2003;290:1030–1.

    PubMed  Article  Google Scholar 

  31. 31.

    Hermann F, Spieker LE, Ruschitzka F, et al. Dark chocolate improves endothelial and platelet function. Heart. 2006;92(1):119–20.

    PubMed  CAS  Article  Google Scholar 

  32. 32.

    Heiss C, Kleinbongard P, Dejam A, et al. Acute consumption of flavanol-rich cocoa and the reversal of endothelial dysfunction in smokers. J Am Coll Cardiol. 2005;46(7):1276–83.

    PubMed  CAS  Article  Google Scholar 

  33. 33.

    Jia L, Liu X, Bai YY, et al. Short-term effect of cocoa product consumption on lipid profile: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2010;92(1):218–25.

    PubMed  CAS  Article  Google Scholar 

  34. 34.

    Grassi D, Lippi C, Necozione S, Desideri G, Ferri C. Short-term administration of dark chocolate is followed by a significant increase in insulin sensitivity and a decrease in blood pressure in healthy persons. Am J Clin Nutr. 2005;81(3):611–4.

    PubMed  CAS  Google Scholar 

  35. 35.

    Murphy KJ, Chronopoulos AK, Singh I, et al. Dietary flavanols and procyanidin oligomers from cocoa (Theobroma cacao) inhibit platelet function. Am J Clin Nutr. 2003;77(6):1466–73.

    PubMed  CAS  Google Scholar 

  36. 36.

    Sanbongi C, Suzuki N, Sakane T. Polyphenols in chocolate, which have antioxidant activity, modulate immune functions in humans in vitro. Cell Immunol. 1997;177(2):129–36.

    PubMed  CAS  Article  Google Scholar 

  37. 37.

    Mao T, Van De Water J, Keen CL, Schmitz HH, Gershwin ME. Cocoa procyanidins and human cytokine transcription and secretion. J Nutr. 2000;130(8S Suppl):2093S–9S.

    PubMed  CAS  Google Scholar 

  38. 38.

    Mao TK, Powell J, Van de Water J, et al. The effect of cocoa procyanidins on the transcription and secretion of interleukin 1 beta in peripheral blood mononuclear cells. Life Sci. 2000;66(15):1377–86.

    PubMed  CAS  Article  Google Scholar 

  39. 39.

    Mao TK, Van de Water J, Keen CL, Schmitz HH, Gershwin ME. Effect of cocoa flavanols and their related oligomers on the secretion of interleukin-5 in peripheral blood mononuclear cells. J Med Food. 2002;5(1):17–22.

    PubMed  CAS  Article  Google Scholar 

  40. 40.

    Mao TK, van de Water J, Keen CL, Schmitz HH, Gershwin ME. Modulation of TNF-alpha secretion in peripheral blood mononuclear cells by cocoa flavanols and procyanidins. Dev Immunol. 2002;9(3):135–41.

    PubMed  CAS  Article  Google Scholar 

  41. 41.

    Mao TK, Van De Water J, Keen CL, Schmitz HH, Gershwin ME. Cocoa flavonols and procyanidins promote transforming growth factor-beta1 homeostasis in peripheral blood mononuclear cells. Exp Biol Medicine Maywood. 2003;228(1):93–9.

    CAS  Google Scholar 

  42. 42.

    Otaki N, Kimira M, Katsumata S, Uehara M, Watanabe S, Suzuki K. Distribution and major sources of flavonoid intakes in the middle-aged Japanese women. J Clin Biochem Nutr. 2009;44(3):231–8.

    PubMed  Article  Google Scholar 

  43. 43.

    Johannot L, Somerset SM. Age-related variations in flavonoid intake and sources in the Australian population. Public Health Nutr. 2006;9(8):1045–54.

    PubMed  Article  Google Scholar 

  44. 44.

    Beking K, Vieira A. An assessment of dietary flavonoid intake in the UK and Ireland. Int J Food Sci Nutr. Sep 22. http://www.ncbi.nlm.nih.gov/pubmed/20858155.

  45. 45.

    Ovaskainen ML, Torronen R, Koponen JM, et al. Dietary intake and major food sources of polyphenols in Finnish adults. J Nutr. 2008;138(3):562–6.

    PubMed  CAS  Google Scholar 

  46. 46.

    Chun OK, Chung SJ, Song WO. Estimated dietary flavonoid intake and major food sources of U.S. adults. J Nutr. 2007;137(5):1244–52.

    PubMed  CAS  Google Scholar 

  47. 47.

    Huxley RR, Neil HA. The relation between dietary flavonol intake and coronary heart disease mortality: a meta-analysis of prospective cohort studies. Eur J Clin Nutr. 2003;57(8):904–8.

    PubMed  CAS  Article  Google Scholar 

  48. 48.

    Arts IC, Hollman PC, Feskens EJ, Bueno de Mesquita HB, Kromhout D. Catechin intake might explain the inverse relation between tea consumption and ischemic heart disease: the Zutphen elderly study. Am J Clin Nutr. 2001;74(2):227–32.

    PubMed  CAS  Google Scholar 

  49. 49.

    Hertog MG, Kromhout D, Aravanis C, et al. Flavonoid intake and long-term risk of coronary heart disease and cancer in the seven countries study. Arch Intern Med. 1995;155(4):381–6.

    PubMed  CAS  Article  Google Scholar 

  50. 50.

    Rimm EB, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Relation between intake of flavonoids and risk for coronary heart disease in male health professionals. Ann Intern Med. 1996;125(5):384–9.

    PubMed  CAS  Google Scholar 

  51. 51.

    Hertog MG, Feskens EJ, Hollman PC, Katan MB, Kromhout D. Dietary antioxidant flavonoids and risk of coronary heart disease: the Zutphen elderly study. Lancet. 1993;342(8878):1007–11.

    PubMed  CAS  Article  Google Scholar 

  52. 52.

    Hirvonen T, Virtamo J, Korhonen P, Albanes D, Pietinen P. Intake of flavonoids, carotenoids, vitamins C and E, and risk of stroke in male smokers. Stroke. 2000;31(10):2301–6.

    PubMed  CAS  Google Scholar 

  53. 53.

    Arts IC, Jacobs DRJ, Harnack LJ, Gross M, Folsom AR. Dietary catechins in relation to coronary heart disease death among postmenopausal women. Epidemiology. 2001;12(6):668–75.

    PubMed  CAS  Article  Google Scholar 

  54. 54.

    Yochum L, Kushi LH, Meyer K, Folsom AR. Dietary flavonoid intake and risk of cardiovascular disease in postmenopausal women. Am J Epidemiol. 1999;149(10):943–9.

    PubMed  CAS  Google Scholar 

  55. 55.

    Knekt P, Kumpulainen J, Jarvinen R, et al. Flavonoid intake and risk of chronic diseases. Am J Clin Nutr. 2002;76(3):560–8.

    PubMed  CAS  Google Scholar 

  56. 56.

    Knekt P, Jarvinen R, Reunanen A, Maatela J. Flavonoid intake and coronary mortality in Finland: a cohort study. BMJ (Clin Res Ed). 1996;312:478–81.

    CAS  Google Scholar 

  57. 57.

    Mink PJ, Scrafford CG, Barraj LM, et al. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr. 2007;85(3):895–909.

    PubMed  CAS  Google Scholar 

  58. 58.

    Arts IC, Hollman PC, Feskens EJ, Bueno de Mesquita HB, Kromhout D. Catechin intake and associated dietary and lifestyle factors in a representative sample of Dutch men and women. Eur J Clin Nutr. 2001;55(2):76–81.

    PubMed  CAS  Article  Google Scholar 

  59. 59.

    Hertog MG, Sweetnam PM, Fehily AM, Elwood PC, Kromhout D. Antioxidant flavonols and ischemic heart disease in a Welsh population of men: the Caerphilly study. Am J Clin Nutr. 1997;65(5):1489–94.

    PubMed  CAS  Google Scholar 

  60. 60.

    Serafini M, Bugianesi R, Maiani G, Valtuena S, De Santis S, Crozier A. Plasma antioxidants from chocolate. Nature. 2003;424(6952):1013.

    PubMed  CAS  Article  Google Scholar 

  61. 61.

    Roura E, Andrés-Lacueva C, Estruch R, et al. Milk does not affect the bioavailability of cocoa powder flavonoid in healthy human. Ann Nutr Metab. 2007;51(6):493–8.

    PubMed  CAS  Article  Google Scholar 

  62. 62.

    Halliwell B. Plasma antioxidants (communication arising): health benefits of eating chocolate? Nature. 2003;426(6968):787.

    PubMed  CAS  Article  Google Scholar 

  63. 63.

    Richelle M, Tavazzi I, Enslen M, Offord EA. Plasma kinetics in man of epicatechin from black chocolate. Eur J Clin Nutr. 1999;53(1):22–6.

    PubMed  CAS  Article  Google Scholar 

  64. 64.

    Buijsse B, Feskens EJ, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen elderly study. Arch Intern Med. 2006;166(4):411–7.

    PubMed  Article  Google Scholar 

  65. 65.

    Sesso HD, Gaziano JM, Liu S, Buring JE. Flavonoid intake and the risk of cardiovascular disease in women. Am J Clin Nutr. 2003;77(6):1400–8.

    PubMed  CAS  Google Scholar 

  66. 66.

    Keli SO, Hertog MG, Feskens EJ, Kromhout D. Dietary flavonoids, antioxidant vitamins, and incidence of stroke: the Zutphen study. Arch Intern Med. 1996;156(6):637–42.

    PubMed  CAS  Article  Google Scholar 

  67. 67.

    • Mostofsky E, Levitan EB, Wolk A, Mittleman MA. Chocolate intake and incidence of heart failure/clinical perspective. Circ Heart Fail. 2010;3(5):612–6. This is the largest, most recent prospective cohort study evaluating the effect of chocolate intake on risk of heart failure.

    PubMed  CAS  Article  Google Scholar 

  68. 68.

    Lee IM, Paffenbarger RSJ. Life is sweet: candy consumption and longevity. BMJ Clin Res Ed. 1998;317(7174):1683–4.

    CAS  Google Scholar 

  69. 69.

    Djoussé L, Hopkins PN, North KE, Pankow JS, Arnett DK, Ellison RC. Chocolate consumption is inversely associated with prevalent coronary heart disease: The National Heart, Lung, and Blood Institute Family Heart Study. Clinical Nutrition. 2011, Corrected Proof. http://www.clinicalnutritionjournal.com/article/S0261-5614(10)00157-3/abstract.

  70. 70.

    Buijsse B, Weikert C, Drogan D, Bergmann M, Boeing H. Chocolate consumption in relation to blood pressure and risk of cardiovascular disease in German adults. Eur Heart J. 2010;31(13):1616–23.

    PubMed  CAS  Article  Google Scholar 

  71. 71.

    Janszky I, Mukamal KJ, Ljung R, Ahnve S, Ahlbom A, Hallqvist J. Chocolate consumption and mortality following a first acute myocardial infarction: the Stockholm Heart Epidemiology Program. J Intern Med. 2009;266(3):248–57.

    PubMed  CAS  Article  Google Scholar 

  72. 72.

    Hu FB, Stampfer MJ, Willett WC. Reply to PM Kris-Etherton et al. Am J Clin Nutr. 2000;72(4):1059–60.

    CAS  Google Scholar 

  73. 73.

    Rusconi M, Conti A. Theobroma cacao L., the Food of the Gods: a scientific approach beyond myths and claims. Pharmacol Res. 2010;6(():5–13.

    Article  Google Scholar 

  74. 74.

    Rogers PJ, Smit HJ. Food craving and food "addiction": a critical review of the evidence from a biopsychosocial perspective. Pharmacol Biochem Behav. 2000;66(1):3–14.

    PubMed  CAS  Article  Google Scholar 

  75. 75.

    Kurlandsky S, Stote K. Cardioprotective effects of chocolate and almond consumption in healthy women. Nutr Res (NY NY). 2006;26(10):509–16.

    CAS  Article  Google Scholar 

  76. 76.

    • Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009;120(11):1011–20. This is a scientific statement from the American Heart Association regarding dietary sugar intake and cardiovascular disease.

    PubMed  CAS  Article  Google Scholar 

  77. 77.

    Franco OH, Bonneux L, de Laet C, Peeters A, Steyerberg EW, Mackenbach JP. The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%. BMJ. 2004;329(7480):1447–50.

    PubMed  Article  Google Scholar 

  78. 78.

    Ried K, Frank O, Stocks N. Dark chocolate or tomato extract for prehypertension: a randomised controlled trial. BMC Complement Altern Med. 2009;9(1):22.

    PubMed  Article  Google Scholar 

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Disclosure

Scott R. Bauer reports no potential conflict of interest relevant to this article. Eric L. Ding reports no potential conflict of interest relevant to this article. Liesbeth A. Smit reports no potential conflict of interest relevant to this article.

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Scott R. Bauer and Eric L. Ding contributed equally to the manuscript.

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Bauer, S.R., Ding, E.L. & Smit, L.A. Cocoa Consumption, Cocoa Flavonoids, and Effects on Cardiovascular Risk Factors: An Evidence-Based Review. Curr Cardiovasc Risk Rep 5, 120–127 (2011). https://doi.org/10.1007/s12170-011-0157-5

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Keywords

  • Cocoa
  • Chocolate
  • Flavonoids
  • Coronary heart disease
  • Blood pressure
  • Lipids
  • Body mass index
  • Weight
  • Cardiovascular disease
  • Stroke
  • Review
  • Procyanidins
  • Catechins
  • Epicatechins