Health Benefits of Chocolate

Replies to This Discussion

Permalink Reply by ChocoFiles on September 2, 2008 at 8:46am

Samantha,

Thanks so much for another informative, lengthy, and well thought out response! Everything you wrote makes a lot of sense. I really appreciate your contributions here.

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Permalink Reply by Clay Gordon on September 2, 2008 at 7:12pm

Sam:

I have to second Olorin's response - your posts have always been very thoughtful and well researched. Thanks.

Anecdotally, I have to agree with your assessment about the difference in nutrient takeup between nibs and powder. The difference in particle size is probably very important and your story about your dogs speaks to this.

I agree that there is probably comparatively little difference between the antioxidant effectiveness of liquor and powder as long as the amount being consumed is adjusted for the difference in fat content (i.e., a low-fat cocoa powder is 10-12% fat while liquor is 45-55% fat; when consuming 10g of powder about 1% is fat while with 10g of liquor about 50% is fat).

When people ask me about the health benefits of chocolate, I always suggest that they look for ways to incorporate low-fat, "natural" (i.e., non-alkalized) cocoa powder into their diet.

My kids like pancakes in the morning so I add cocoa powder to the batter. I add it to oatmeal and other hot cereals, often with a dash of cinnamon.

Make your own chocolate syrup with the sweetener of your choice. Instead of buying chocolate yogurt buy plain yogurt and add either cocoa powder or the chocolate syrup you make (although as Sam has pointed out there is some evidence that suggests that milk proteins get in the way of the body absorbing the nutrients in the cacao).

Add cocoa powder to smoothies (use a non-dairy milk). Add it to chile, stews, and sauces.

There are lots of ways to do it - and you don't need to take in a lot to make a difference.

PS. For what it's worth - and Sam and I were on the same University of Chocolate trip in 2005 - chicha is definitely an acquired taste. One that I did not acquire in my short contact with it.

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Permalink Reply by Steve Parker, M.D. on January 3, 2009 at 2:20am

I'm close to posting the following on my healthy lifestyle blog (Advanced Mediterranean Diet Blog), and wondered if you guys had any comments.
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Theobroma cacao, the cocoa tree, has been cultivated in Central and South America for over 3000 years. Cocoa is derived from the tree's seed, also known as the cocoa bean.

Chocolate is a product of the processed cocoa bean. Dark chocolate has at least 65% cocoa content, and has much more of the potentially healthy chemicals from the cocoa bean, as compared with milk chocolate. White chocolate isn't really chocolate.

It's been a little over 10 years since we first read in a medical journal about cocoa and chocolate as potential sources of antioxidants for health. What have we learned since then?

Phytochemicals are chemicals produced by plants, and there are hundreds of thousands of them. Polyphenols are a subset of phytochemicals. Flavonoids, with strong antioxidant properties, are a subset of polyphenols. And a subset of flavonoids, called flavonols, have particularly potent biological effects in humans. Prominent flavonols in dark chocolate are flavan-3-ol, catechin, and epicatechin. Also metabolically active are proanthocyanidins, which are polymeric condensation products of flavan-3-ol.

Are you bored yet? Have I convinced you of my authority on the subject? Say yes, or I'll keep going! [Please say yes: I'm boring myself!]

Note that some chocolate manufacturers process the cocoa beans to remove some of the polyphenols, to reduce bitterness or pungency.

Other rich sources of flavonols are wine, tea, and various fruits and berries.

How could dark chocolate, especially its flavonoids, be healthful?

* Flavonoids are antioxidants that protect from injury caused by free radicals
* Enhanced nitric oxide production, leading to relaxation of arteries (vasodilation), leading to reduced blood pressure: up to 6 mmHg systolic and 3 mmHg diastolic
* Elevation of HDL cholesterol, with no effect on total and LDL cholesterol
* Inhibition of platelet aggregation and activation, leading to fewer blood clots that cause heart attacks and strokes
* Decreased inflammation
* Reduction of C-reactive protein, a marker of inflammation
* Decreased neutrophil (white blood cell) activation. White blood cells play a role in inflammation
* Decreased LDL cholesterol oxidation, leading to fewer atherosclerotic complications
* Improved function of the cells that line blood vessels (endothelium)
* Possible enhanced insulin sensitivity
* May act as anti-carcinogens and neuro-protective agents
* May act as an antidepressant

Bottom line? Dark chocolate, especially because of flavonoids, may well be protective against cardiovascular disease such as heart attacks and strokes.

[Did you notice I'm waffling . . . may be protective.]

What's in dark chocolate other than flavonoids?

A 40 gram serving of fine dark chocolate has:

* Calories: 200
* Calories from fat: 150
* Fiber: 4.5 grams (a good source of fiber on a "per calorie" basis)
* Sugar: 11 grams
* Saturated fats: 10 grams

"But aren't saturated fats bad for me?"

The fats in dark chocolate are 1/3 oleic (healthy monounsaturated, as in olive oil), 1/3 stearic (saturated, but no effect on cholesterol levels, unlike some other saturated fats), and 1/3 palmitic (saturated, and could increase cholesterol levels and heart risk). So it's sort of a wash.

[I'm not getting into the diet-heart hypothesis now. Don't bait me.]

What's the healthy "dose" of dark chocolate?

No one is sure. It's certainly no more than 100 grams (3.5 ounces) a day, and the optimal dose may be as low as 20 grams every three days. If you eat too much, it will make you fat. 100 grams is 500 calories; that's probably way too much. Even if you start eating 20 grams - 100 calories - every three days, you will gain weight unless you give up some other food or exercise a little more.

"Parker, why are you waffling?"

Because no one has ever done a study to see if adding dark chocolate actually reduces death rates or sickness from specific diseases in humans. I think it probably does, but who knows for sure? Nobody. What we need is a randomized, controlled trial of dark chocolate as a supplement in 10,000 middle-aged adults followed over the course of 10 years. I'd sign up for that in a heartbeat. Just don't give me the placebo.

Steve Parker, M.D.
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References:

Erdman, J.W., et al. Effects of cocoa flavanols on risk factors for cardiovascular disease. Asian Pacific Journal of Clinical Nutrition, 17 supplement 1 (2008): 284-287.

Farouque, H.M, 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. Clinical Science, 111 (2006): 71-80.

Heptinstall, S., et al. Cocoa flavanols and platelet and leukocyte function: recent in vitro and ex vivo studies in healthy adults. Journal of Cardiovascular Pharmacology, 47 supplement 2 (2006): S197-205.

Keen, C.L., et al. Cocoa antioxidants and cardiovascular health. American Journal of Clinical Nutrition, 81 supplement 1 (2005): 298S-303S.

Mehrinfar, R. and Frishman, W.H. Flavanol-rich cocoa: a cardioprotective nutraceutical. Cardiology Reviews, 16 (2008): 109-115.

Engler, M.B, and Engler, M.M. The emerging role of flavonoid-rich cocoa and chocolate in cardiovascular health and disease. Nutrition Reviews, 64 (2006): 109-118.

Lippi, G. et al. Dark chocolate: consumption for pleasure or therapy? Journal of Thrombosis and Thrombolysis, September 23, 2008 (Epub ahead of print).

Hooper, L, et al. Flavonoids, flavonoid-rich foods, and cardiovascular risk: a meta-analysis of randomized controlled trials. American Journal of Clinical Nutrition, 88 (2008): 38-50.

Cooper, K.A., et al. Cocoa and health: a decade of research. British Journal of Nutrition, 99 (2007): 1-11. Epub August 1, 2007.

Aron, P.M., and Kennedy, J.A. Flavon-3-ols: nature, occurrence and biological activity. Molecular Nutrition and Food Research, 52 (2008): 79-104.

Buijsse, B, et al. Cocoa intake, blood pressure, and cardiovascular mortality [in men]: the Zutphen Elderly Study. Archives of Internal Medicine, 166 (2006): 411-417.

Ding, E.L., et al. Chocolate and prevention of cardiovascular disease: a systematic review. Nutrition and Metabolism, 3 (2006): 2.

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Permalink Reply by Clay Gordon on January 4, 2009 at 11:39am

Steve:

Overall I think this is going in the right direction, however:

-) There is no evidence that cacao was being cultivated in South America 3000 years ago. There is evidence of the use of cocoa beans to make beverages in Mesoamerica at least as far back as 1900BC and because cacao is not native to Mesoamerica it is assumed that it was cultivated. (In South America, the pulp was used to make alcoholic beverages and there is evidence that the seeds were consumed.)

-) There is no legal definition for "dark" chocolate. There is a minimum cacao content for "sweet" chocolate (which covers both semi-sweet and bittersweet). Conventionally, dark chocolate is any chocolate that does not contain any dairy products. However, this definition is not entirely useful as the FDA standards of identity for even chocolate liquor allow manufacturers to include dairy fats in their recipes. A workable definition of dark chocolate is a chocolate that does not contain any dairy ingredients and you have to read the ingredients label to figure it out because there is nothing in the standards of identity or labeling laws that covers the use of the word "dark" when it is applied to chocolate. Ironically, there is a standard of identity for white chocolate, so legally (anyway, in the US) white chocolate is really chocolate.

-) If your readership understands what is meant by "... which are polymeric condensation products ..." then it is an unusual group of readers. If not, you might want to consider either defining what this means or changing the phrase.

-) I don't know of any manufacturers who say, "Let's remove the polyphenols in the chocolate to make it less bitter." Instead, they use various practices to remove bitterness, the result of which processes is the reduction of the level of polyphenols (and other chemicals).

-) There is no absolute measurement for the caloric content of 40 grams of chocolate or the percentage of those calories that come from fat, and the inclusion of the word "fine" is a little confusing. Calorie content is not dependent on processing, it's dependent on the makeup of the chocolate. 40 grams of a "fine" 100% cocoa content bar is going to have a different fat/calorie ratio than a 72% bar. In fact, there will be variations in 72% bars depending on the total fat content.

-) You are right, there is no RDA for chocolate and there probably never will be. If there is a bit of advice I would offer it is that chocolate (and cocoa products) made using "natural" (non-alkalized or non Dutch processed) cocoa tend to be much higher in antioxidants than chocolate products made with alkalized cocoa. Although cocoa butter tends to be neutral in people with "normal" cholesterol metabolism, choosing cocoa products that are also low-fat (such as cocoa powder) is an alternative to consider. Thus, if one is interested in maximizing the potential wellness benefits from cacao, finding ways to incorporate low-fat, non-alkalized cocoa powder into the diet is one way to go. I am satisfied based on my reading that cocoa butter is in part responsible for the regulation of the ratios of LDL/HDL/triglycerides so some cocoa butter in the diet is a good thing. How much? Who knows? The health aspects of eating chocolate are a bonus, not a reason, to eat chocolate.

-) One of the reasons that the double-blind study you're suggesting might not ever happen is that whoever organizes it will need to completely characterize the chemical makeup of the chocolate(s) being used for the study - which hasn't been done until now. Then, someone would need to find correlations between the chemical makeup and the results. So, it probably shouldn't be a placebo that gets used, but several chocolates with precisely known, but different chemical makeups in an attempt to understand (if possible) which aspects of chocolate's chemistry contribute to which benefits.

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Permalink Reply by Steve Parker, M.D. on January 5, 2009 at 12:44am

Thanks very much for your critique, Clay.

My reference to cacao cultivation in South America is from "Regular consumption of dark chocolate is associated with low serum concentrations of C-reactive protein in a healthy Italian population," by Romina di Guiseppe, et al, in the journal, Nutritional Epidemiology, vol. 138, page 1939, published in 2008. They mention specifically Northern South America. But the authors don't cite a primary source.

Yes, my use of "fine chocolate" is vague. I'm trying to differentiate generic Easter bunny chocolate and "mockalate" from serious brand-name chocolate (e.g., by Lindt?)

I'll try to link back to here from my healthy lifestyle blog post.

-Steve

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Permalink Reply by Steve Parker, M.D. on January 19, 2009 at 7:42am

If Dark Chocolate Is Healthy, What’s The Right Dose?

Antioxidant flavonoids and other phytonutrients in dark chocolate are thought possibly to improve health, primarily through reduction in cardiovascular diseases such as heart attacks and strokes.

In terms of a medicinal agent, we have not been sure of the therapeutic “dose.” A recent study (2008) out of Italy provides a clue.

Researchers at Catholic University, Campobasso, Italy, surveyed residents in southern Italy regarding chocolate intake and measured their C-reactive protein (CRP) levels. CRP is a marker of inflammation and a predictor of coronary artery disease such as heart attacks. Generally, higher levels of CRP are associated with higher risk of heart attacks. If you have a choice, go for lower levels of CRP.

Participants in the study were selected by simple random sampling from city hall registries and were at least 35 years old. Researchers were looking for healthy people, so the following were excluded from the study: those who reported known cardiovascular disease, eating a special diet, or on drug therapy for high blood pressure, diabetes, or adverse blood lipids. Twenty percent of initial recruits refused to participate. Of the 10,994 initial recruits, 4,849 men and women made it into the final study.

Of the 4,849 subjects, two subgroups were identified: 1) a control group of 1,317 (27%) who never ate any type of chocolate, and 2) a test group of 824 (17%) subjects who regularly ate dark chocolate only.

Interviewers administered questionnaires to the subjects to document clinical and personal information such as dietary habits, socioeconomic status, physical activity, medical history, risk factors for cardiovascular disaese and tumors, family history of cardiovascular disease, drug use, etc.

Regarding chocolate consumption, participants were asked about frequency - daily, weekly, or monthly - of a “standard dose” (20 grams) and about type of chocolate: milk, dark, nut chocolate, or any type. Someone eating more than one type of chocolate was classified as “any type.”

Other measurements: blood pressure, weight, height, waist circumference, blood glucose, serum lipids (various cholesterols and triglycerides), and high-sensitivity C-reactive protein.

Findings

Age-adjusted CRP levels were lower in dark chocolate users (1.13 mg/L) than in the nonconsumers of chocolate (1.30 mg/L).

Dark chocolate eaters were divided into thirds: the lowest third of average consumption, the middle third, and the highest third. The lowest third ate under 19 grams per week. The middle third ate between 19 and 47 grams per week. The highest third ate over47 grams per week. The chocolate-related reduction in CRP was lost in people who were in the highest third (or tertile), i.e., eating more than 47 grams a week or 20 grams every three days. People in the lowest tertile of dark chocolate consumption had a CRP reduction the same as the middle third.

Systolic blood pressure in dark chocolate consumers was 3 mmHg lower than the pressure in nonconsumers. No difference in diastolic pressures.

Discussion

The researchers cite two clinical trials that investigated the effect of cocoa on markers of inflammation but did not find any association. They wonder if those studies enrolled too few participants, or whether the relatively high doses of chocolate masked the effect. In the present study, the lowering of CRP was seen in consumption of up to 20 grams every three days, but seemed to disappear at higher doses.

The authors write that:

". . . regular intake of small amounts of dark chocolate . . . consumption should have no harmful effect on anthropometric variables such as BMI [body mass index] and waist:hip ratio and can be viewed as a promising behavioural approach to lower, in a quite pleaseant way, cardiovascular risk factors at a general population level." And . . .

"According to data reported in apparently healthy American men and women, ranges of serum CRP measured in our nonchocolate consumer population would belong to a “moderate” risk estimate quintile, whereas the ranges found in dark chocolate consumers would beclassified as a “mild” risk estimate. For the decrease in serum CRP values from moderate to mild quintile, the relative risk of suffering a future cardiovascular event would apparently decrease by 26% in men and 33% in women."

The authors are careful to point out that this study does not prove that low-dose dark chocolate lowers CRP levels. It’s an association. “Additional studies are necessary to explain the mechanisms linking dark chocolate consumption and regulation of serum CRP concentrations.”

My Comments

The healthy dose of dark chocolate may be quite small: no more than 20 grams every three days, and perhaps quite a bit less. This is not much by U.S. standards. The serving size listed on many bars in the U.S. is 40 grams. Forty grams has about 100 calories. Twenty grams twice a week translates to 6 calories a day.

The authors of this study don’t address whether 40 grams a week would be just as healthy as 80 grams every two weeks.

Eating more, on average, than 20 grams every three days may entirely wipe out the healthy effects. This effect is like wine’s: a little is probably good for you, too much is either neutral or harmful.

I’m sorry to be so wishy-washy on this issue, but that’s the state of the science today. The study at hand may help us optimize dark chocolate’s effect on C-reactive protein. But dark chocolate’s other healthy effects may require other doses, higher or lower.

The next step is to take 20,000 middle-aged people, give half of them various doses of scheduled dark chocolate, give the other half placebos, then record rates of diseases and death over the next 10 years. Who would pay for this multi-million dollar study? Either government or chocolate manufacturers.

-Steve Parker, M.D.
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Reference: Di Giuseppe, Romina, et al. Regular Consumption of Dark Chocolate Is Associated with Low Serum Concentrations of C-Reactive Protein in a Healthy Italian Population. Journal of Nutrition, , 138 (2008): 1,939-1,945.

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