Taking Chocolate to Heart: For Pleasure and Health
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Taking Chocolate to Heart: For Pleasure and Health As one of life’s little pleasures, chocolate and cocoa products do more than provide enjoyment and satisfaction to eating; a rapidly growing body of science suggests they may also support overall health and well‐being when included in a balanced diet and healthy lifestyle. Numerous cultures have used cocoa products throughout history for religious, cultural and medical purposes. The first recorded evidence of cocoa being used for health dates back to the 1500s1. Over the past 20 years, a compelling story has emerged on the impact of cocoa flavanols on cardiovascular health, insulin sensitivity and cognitive function. Numerous population‐based studies have found that the inclusion of modest amounts of cocoa‐containing foods, including chocolate, as an element of a mixed diet, is associated with a range of positive effects, including the maintenance of heart health. In addition, randomized, placebo-controlled clinical trials provide direct evidence that the nutrients and the phytonutrients found naturally in cocoa may help to support circulation, brain function, insulin resistance, and improve markers of inflammation and cardiovascular health. The state of science on cocoa and health has even been evaluated by government bodies. The 2010 Dietary Guidelines Advisory Committee concluded that moderate evidence supports that modest consumption of dark chocolate or cocoa, in the context of a balanced diet, is associated with a reduced risk of cardiovascular disease2. Furthermore, in 2012 the European Food Safety Authority approved a health claim for cocoa flavanols and improved blood flow in healthy adults. The claim substantiates a cause and effect relationship between cocoa flavanols and maintenance of “endothelium-dependent vasodilation,” which contributes to healthy blood flow3. While it is important to manage calories and balance the inclusion of these foods in the overall diet, these independent government reviews provide more assurance that consumers can feel good about enjoying small amounts of their favorite cocoa and chocolate treats as part of a healthy and happy life.
Associations between Cocoa, Chocolate and Cardiovascular Health
Growing evidence supports an association between dietary inclusion of cocoa and chocolate
products and a range of health outcomes, and in particular, cardiovascular disease risk. Over the past
20 years, the cocoa and chocolate eating habits of dozens of studies of thousands of adults of mixed
ages, ethnicities, and genders have been studied. Findings from these population‐based studies
support an association between the inclusion of cocoa and chocolate in the diet and a range of
cardiovascular benefits, including a reduction in overall mortality and blood pressure.
Highlights from these recent studies:
The Zutphen (Elderly) study4 examined the association of cocoa intake with blood pressure
and cardiovascular mortality in a sample of 470 elderly men over 15 years. This prospective
study found cocoa intake was inversely associated with blood pressure and 15‐year
cardiovascular and all‐cause mortality.
The Iowa Women’s Health Study5 followed nearly 35,000 women and estimated dietary
flavonoid intake from various foods, including chocolate, to evaluate the association
between flavonoid intake and cardiovascular disease mortality. Chocolate intake was
specifically associated with a reduced risk of death from cardiovascular disease.
Harvard researchers followed over 31,000 Swedish middle‐
aged and elderly women over a nine‐year period.
Researchers found that moderate chocolate intake (up to
one to two servings of chocolate per week) was associated
with a significantly lower risk of heart failure6.
Among 2,200 adults in the National Heart, Lung, and
Blood Institute (NHLBI) Family Heart Study, moderate
chocolate consumption (up to 2 servings per week) was
inversely associated with certain types of plaque
buildup in the coronary arteries7.
The association between chocolate consumption and blood
pressure was investigated, as well as the incidence of cardiovascular disease, in 19,000 healthy
adults over an eight‐year period. In this study, the consumption of as little as 6 grams of
chocolate per day was associated with a nearly 40 percent reduction in risk of heart
attacks and stroke. This reduction in risk was also accompanied by lower blood pressures
among chocolate consumers8.
37,000 Swedish men were followed over 10 years. High chocolate consumption was found
to be linked to a significantly lower risk of stroke9.
Epidemiologic research demonstrates a positive relationship between the dietary inclusion of cocoa-
based products, including chocolate, and cardiovascular health, however, these results can only
provide associations and cannot establish that these foods caused these positive health effects. Thus,
these studies should be viewed with cautious optimism and though they cannot prove the benefits
of cocoa and chocolate consumption, they do support that cocoa and chocolate products can be an
enjoyable part of a healthy and balanced diet.
Beyond these studies which examined the relationship between dietary habits and health, there are
clinical trials that have looked more directly at the potential benefits related to the consumption of
cocoa-containing products. From these studies, there are indications that select nutrients and
phytonutrients in cocoa may have a promising role in supporting cardiovascular health. These
studies are discussed in the following sections.
Cocoa and the Power of Flavonoids
Flavonoids are naturally‐occurring compounds found in a wide range of
plant-based foods. In recent years, these natural compounds have been
widely studied for their ability to confer important health benefits.
Among the flavonoids of scientific interest are flavanols (specifically the
flavan-3-ols), a subclass of flavonoids prevalent in such commonly
consumed foods as cocoa and chocolate.
Many clinical investigations over the past decade have concluded that
the consumption of certain cocoa and chocolate products naturally
abundant in flavanols have significant cardiovascular health-related
effects.
A number of intervention studies ranging in duration from one day to 18 weeks covering thousands
of participants have investigated the effects of cocoa flavanols on chronic disease risk factors.
Specifically, studies of men, women, healthy adults, overweight individuals and smokers have
demonstrated that consumption of flavanol‐containing dark chocolate and cocoa products can
improve the function of the
cardiovascular system10, 11, 12, 13,
14
Research suggests that the
regular consumption of
products rich in cocoa
flavanols can improve risk
factors for cardiovascular
disease and has been shown to
lower blood pressure15, 16, 17
and improve blood cholesterol
levels in healthy adults and
individuals with high blood
Cocoa Flavanols
pressure18, 19, 20. Furthermore, investigations of healthy adults have shown that cocoa flavanols
improve platelet function by reducing the reactivity of platelets thus making them less prone to form
blood clots21, 22, 23, 24, 25. Emerging research has also shown that cocoa flavanols may improve markers
of inflammation in healthy adults26, 27 and immune function in overweight adults28.
Several systematic reviews of long and short term trials are now available and provide largely
consistent findings29, 30. For example, two recent meta-analyses conducted by the Harvard School of
Medicine evaluated more than 60 clinical trials and found consistent improvements in cardiovascular
disease risk factors blood pressure, lipid profiles, and vascular dilation and promising effects of
cocoa flavanols on insulin and insulin resistance, which are markers of diabetes.31, 32
Clinical studies provide direct evidence that the flavanols in cocoa are bioactive compounds that
may improve markers of heart health. More research is needed to confirm and extend these research
findings, specifically, long-term clinical trials that evaluate development of cardiovascular disease as
an endpoint, as opposed to risk factors such as blood pressure, blood lipids and circulation.
However, results from clinical investigations on cocoa‐based flavanols to date support the
conclusion that the regular inclusion of cocoa and chocolate of products, balanced with calorie
intake, can be part of a dietary approach to help maintain and support cardiovascular health.
Cocoa Butter and the Neutral Effects of Stearic Acid
Cocoa butter is the naturally occurring fat found in cocoa beans and primarily contains a mixture of
saturated and monounsaturated fats. Stearic acid is the predominant saturated fat in cocoa butter
while oleic acid is the primary monounsaturated fat. Stearic acid makes up about one‐third of the
total fat in cocoa butter and more than half of the saturated fat. The remaining saturated fat is
palmitic acid.
Stearic acid is considered a unique
saturated fat as, relative to other
saturated fats and trans fats, it does not
raise LDL cholesterol levels. For this
reason, the 2010 DGAC recommended
that stearic acid not be categorized with
known “cholesterol‐raising” fats,
including other saturated fats and trans
fats33. A systematic review of
epidemiologic and clinical studies
evaluated the effect of stearic acid on
blood LDL cholesterol when substituted
for other types of fats, including trans
fats34. Results indicate that compared to
other saturated fats, stearic acid lowered LDL cholesterol levels, was neutral with respect to HDL
cholesterol, and lowered the ratio of total‐to‐HDL cholesterol. Similarly, the review concluded that
replacing trans fats with stearic acid, compared to other saturated fats in foods that require solid fats,
showed a decrease or no difference on LDL cholesterol levels.
Specific to chocolate, a clinical trial observed the effects on blood lipids when a milk chocolate bar
was substituted daily for a high carbohydrate snack (pretzels and soft drink) without an increase in
total calories35. Researchers found that in this controlled setting, the daily inclusion of chocolate did
not raise LDL‐cholesterol and improved HDL-cholesterol levels.
Chocolate and Well-being
Chocolate has a rich tradition of use as a gift and celebratory food associated with special occasions,
so it may not be surprising that there is emerging evidence that chocolate may induce positive mood
states and feelings of well‐being. In one study, researchers studied the effects of chocolate
preference on health and psychological well‐being in a group of
older men and found that chocolate was associated with lower
body mass index and waist circumference, better subjective health,
optimism, and feelings of happiness.36
Studies on the impact of chocolate and cocoa flavanols on
improving brain function and mood have demonstrated
interesting, although somewhat mixed results. Several research
highlights of key studies on the impact of cocoa and chocolate on
mood and cognitive function are mentioned below. This is an
exciting new area of research with great promise for future
investigation.
Improved Mood States and Reduced Anxiety – A 2012 publication found that study
participants who were given chocolate candy reported higher levels of agreeableness,
independent of mood states and were more likely to volunteer their time37. More recently, a
study published in 2013 found that cocoa flavanols enhanced positive mood and reduced
anxiety in healthy middle-aged adults, however did not affect cognitive function38. Milk and
dark chocolate products were shown to convey different degrees of anxiety-reducing and
energy improving effects based on individual characteristics39.
Cocoa Flavanols and Enhanced Cognitive Function – Research has demonstrated
mixed results of cocoa flavanols on brain function and seems to show the most promising
results in certain subpopulations. Cocoa flavanols have been shown to increase blood flow
to the brain, which increases oxygenation and may convey improvements in cognitive
function, particularly in older people with memory loss.40 Furthermore, preliminary research
suggests that regular consumption of dietary cocoa flavanols may improve cognitive function
in elderly subjects with impaired cognitive function41. Similarly, slightly cognitively impaired
urban children fed flavanol-rich dark cocoa showed significant improvements in memory42.
However, studies of healthy middle-aged adults have yielded mixed results. Some research
suggests an association between cocoa flavanols and cognitive performance, including
reductions in mental fatigue and improvements in visual function in adults43, 44, while other
studies have observed no improvements to cognitive function in this subpopulation45. These
novel preliminary findings on cocoa and cognitive function sparked a lively scientific debate
in the peer-reviewed literature following the amusing lighthearted publication in the New
England Journal of Medicine showing a correlation between Noble laureates per country and
that country’s per capita chocolate consumption.46
Chocolate in Moderation: Balancing Food Enjoyment and Your Health
Health and nutrition authorities such as the Academy of Nutrition and Dietetics and the Dietary
Guidelines for Americans stress the importance of eating mostly nutrient-dense foods such as fruits,
vegetables and whole grains while moderating the intake of foods high in solid fats and added
sugars. Chocolate products are primarily consumed as an enjoyable treat and contribute extra
calories in the form of sugar and fat to the diet. However, chocolate and candy are typically
consumed in small quantities. Chocolate and candy contribute 2 percent of total calories, about 5
percent of dietary sugars and 6 percent of added sugars to the typical American diet.
Interestingly, despite the energy-density of
chocolate, the relationship between chocolate
consumption and weight status remains unclear.
Several cross-sectional studies have reported an
inverse association between chocolate consumption
and weight, while studies of longer term cohorts
have shown mixed results.47, 48, 49, 50, 51, 52, 53. Since
chocolate does contribute extra calories to the diet,
it is advisable to consume chocolate in moderation
with an emphasis on energy balance. This concept
is central to the Nutrition Today publication
“Proposing a Definition for Candy in Moderation”,
which recommends an average daily portion of 50-
100 calories for those who choose to eat candy54.
This point is also highlighted in the USDA Choose
My Plate Ten Tips Series, which states “It’s not
necessary to get rid of all sweets and desserts.
Show kids that a small amount of treats can go a
long way.”
In fact, behavioral research suggests that learning how to include favorite foods, such as chocolate,
may play an important role in achieving and sustaining healthy eating behaviors55. This is supported
by a recent study of the effects of a sweet snack daily, including dark chocolate, on weight loss in
women following a reduced‐calorie diet. Researchers found that incorporating a sweet snack daily as
part of discretionary calories does not inhibit positive changes in body weight and body fat
percentage, and may help reduce cravings for additional sweets56. Furthermore, a recent study found
that people who associated chocolate cake with guilt had lower motivation to eat healthy and were
less successful at maintaining their weight than those who associated chocolate cake with
celebration57.
Research over the past two decades has cast new light on the potential benefits of foods that
consumers have long enjoyed, and cocoa and chocolate are no exception. Emerging research from
population‐based studies, and more directly from clinical research, supports the conclusion that the
enjoyment of moderate amounts of cocoa products, including chocolate, can not only be part of a
healthy lifestyle, but may also help to support health. As chocolate in particular is a calorie‐dense
food, it is important to balance some of the good news around cocoa and chocolate within the
context of an overall diet and lifestyle. The science on cocoa, chocolate and flavanols is not a
justification to eat more of these foods; however, in light of the latest science, consumers can
consider the potential positive benefits and overall enjoyment of these foods in the context of their
overall dietary choices and help provide an informed choice when choosing treats. Consumers can
choose and enjoy including chocolate and cocoa products (and not simply exclude them) in their
everyday diets.
The following tips can help consumers maximize the enjoyment and potential health
benefits of chocolate:
General Guidelines on Managing Treats in a Happy and Healthy Lifestyle
Adopt a lifestyle, not a “diet.” Diet indicates deprivation, restriction and very careful
monitoring with elimination of certain foods. A lifestyle approach involves moderate
changes that can be sustained with the goal to improve or maintain overall health.
Allow all foods. Making foods forbidden may increase their desirability and likelihood of
overindulgence.
Listen to the body’s signals for hunger, such as a
growling stomach, without relying on the clock.
Allow the feeling of hunger, but do not get overly
hungry, which may lead to unhealthy or
overeating.
Fill up on nutrient-dense foods including fruits
and vegetables, whole grains and low-fat protein
to meet nutrient needs and make room for the
occasional little treat.
Practice moderation in food choices and portions. Allow highly palatable foods, such as
chocolate candy, in 50-100 calorie portions, or balance out higher-calorie choices over the
course of several days.
Tips to Enjoy Cocoa and Chocolate Mindfully in Moderation
Eat mindfully. Turn attention to the chocolate treat being eaten—and experience taste,
aroma, texture, and satisfaction. Avoid doing other activities such as watching TV, texting,
reading, or talking on the phone while eating.
To appreciate the complex flavors in chocolate, eat it slowly, and take the time to savor
every bite.
Enjoy the variety of flavor experiences from chocolate,
available in a range of light to very dark. Pair chocolate with
other foods, such as fruit or pretzels, to complement flavors
while enjoying smaller amounts.
View chocolate as a treat and allow yourself to indulge in
moderation without feeling guilty. Guilt may lead to feeling bad
and overeating.
Be mindful of the calories contributed by chocolate and balance
these by choosing nutrient-dense foods and being physically
active.
Take advantage of the nutrition facts label to understand the nutritional content of
favorite products. Many chocolate products carry front of package calorie information for
ease of accessing this information.
To help keep portion sizes modest, plan ahead by having smaller, pre-portioned
chocolates on hand. Most varieties of chocolates are available in smaller individually-
wrapped bite sizes, as well as products in re-sealable packages.
To enjoy the taste of chocolate with fewer calories, consider using cocoa powder.
o Mix cocoa powder with a small amount of water, a little sweetener, and flavoring
such as vanilla, orange or hazelnut to make a simple dip for fruit.
o Try cocoa powder with plain yogurt or milk, fruit (fresh or frozen) and/or honey
and ice for a chocolate smoothie.
o During the winter months, warm up with a steaming cup of hot cocoa.
What is Chocolate?
Understanding the link between chocolate and health begins with awareness of the origin of
chocolate and its components.
Chocolate‐making starts with cocoa beans, which are not actual beans, but rather the seeds
of a fruit produced by the cacao tree, which is grown in tropical locations that fall in a
narrow band 20 degrees north and south of the equator including countries in West Africa,
South America and Asia.
On cocoa farms, cocoa beans are fermented and dried before being shipped to chocolate
factories, where the beans are roasted and shelled. The cocoa bean nib (or center) is ground
into a smooth paste, also referred to as chocolate liquor, which is the essential ingredient of
chocolate.
Chocolate liquor can be pressed to release cocoa butter and cocoa powder. Chocolate
liquor is mixed with varying amounts of cocoa butter, sugar, and other ingredients such as
emulsifiers (e.g., lecithin) and flavors to produce popular chocolate products. The addition
of milk creates the most popular type of chocolate—milk chocolate.
Semi‐sweet (bittersweet) chocolate must contain not less than 35 percent by weight of
chocolate liquor. A similar form, known as sweet chocolate, contains more sweeteners and
cocoa butter with the level of chocolate liquor at least 15 percent by weight.
Dark chocolate is not defined by a
standard of identity, but the term is
often used to describe semisweet
and sweet chocolate. In general,
higher proportions of chocolate
liquor create a darker chocolate.
The % cacao (or % cocoa) content
on a product label indicates the
total content of ingredients derived
from the cocoa bean, which
includes chocolate liquor, cocoa
butter, and cocoa powder. For
example, 60 percent cacao content Dark Chocolate, Milk Chocolate and White Chocolate
means that 40 percent of the product is made up sugar, vanilla, and other ingredients. The
percent cacao does not necessarily correlate with cocoa flavanol content.
Milk chocolate must contain at least 10 percent by weight of chocolate liquor and not less
than 12 percent of milk solids.
Unsweetened chocolate, also called baking or bitter chocolate, does not contain added
sugar and must contain between 50 and 60 percent cocoa butter.
Cocoa powder is made by removing much of the cocoa butter from the cocoa bean and
grinding the remaining material, excluding the shell, to a powder. Alkalized (dutched) cocoa
powder is treated with an alkaline ingredient such as potassium carbonate to help neutralize
cocoa’s natural acidity, producing a smooth and mild flavor. Natural cocoa is not treated. Its
intense bitterness gives a deep chocolate flavor to baked goods.
Nutritional Composition of the Cocoa Bean and Chocolate Products
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