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Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials
Open accessAbstract
Background There is substantial interest in chocolate and flavan-3-ols for the prevention of cardiovascular disease (CVD).Objective The objective was to systematically review the effects of chocolate, cocoa, and flavan-3-ols on major CVD risk factors.Design We searched Medline, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) of chocolate, cocoa, or flavan-3-ols. We contacted authors for additional data and conducted duplicate assessment of study inclusion, data extraction, validity, and random-effects meta-analyses.Results We included 42 acute or short-term chronic (≤18 wk) RCTs that comprised 1297 participants. Insulin resistance (HOMA-IR: -0.67; 95% CI: -0.98, -0.36) was improved by chocolate or cocoa due to significant reductions in serum insulin. Flow-mediated dilatation (FMD) improved after chronic (1.34%; 95% CI: 1.00%, 1.68%) and acute (3.19%; 95% CI: 2.04%, 4.33%) intakes. Effects on HOMA-IR and FMD remained stable to sensitivity analyses. We observed reductions in diastolic blood pressure (BP; -1.60 mm Hg; 95% CI: -2.77, -0.43 mm Hg) and mean arterial pressure (-1.64 mm Hg; 95% CI: -3.27, -0.01 mm Hg) and marginally significant effects on LDL (-0.07 mmol/L; 95% CI: -0.13, 0.00 mmol/L) and HDL (0.03 mmol/L; 95% CI: 0.00, 0.06 mmol/L) cholesterol. Chocolate or cocoa improved FMD regardless of the dose consumed, whereas doses >50 mg epicatechin/d resulted in greater effects on systolic and diastolic BP. GRADE (Grading of Recommendations, Assessment, Development and Evaluation, a tool to assess quality of evidence and strength of recommendations) suggested low- to moderate-quality evidence of beneficial effects, with no suggestion of negative effects. The strength of evidence was lowered due to unclear reporting for allocation concealment, dropouts, missing data on outcomes, and heterogeneity in biomarker results in some studies.Conclusions We found consistent acute and chronic benefits of chocolate or cocoa on FMD and previously unreported promising effects on insulin and HOMA-IR. Larger, longer-duration, and independently funded trials are required to confirm the potential cardiovascular benefits of cocoa flavan-3-ols.
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“In this regard, the level of flavanols used in this current study is comparable to the level of cocoa flavanols fed in previous studies where improvements in brain blood flow, 19 vascular function, and blood pressure were observed.25”
From Benefits in Cognitive Function, Blood Pressure, and Insulin Resistance Through Cocoa Flavanol Consumption in Elderly Subjects With Mild Cognitive Impairment: The Cocoa, Cognition, and Aging (CoCoA) Study (2012) · cites this paper as [25]
Experimental — accuracy not yet measuredIn the citing paper
“In this regard, although we did not specifically evaluate the effect of cocoa flavanols on endothelial function, a number of studies, some also from our group, clearly demonstrated the ability of flavonoids to improve NO bioavailability in vasculature, 17,18,25 which, in turn, plays a pivotal role in modulating cerebrovascular tone.28”
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“A meta-analysis of 42 acute and short-term randomized controlled trials assessed the impact of flavanols on BP and concluded that daily intake of >50 mg of EC is associated with reductions in SBP and DBP among individuals with elevated BP (76).”
BackgroundEsser, D., Geleijnse, J. M., Matualatupauw, J. C., Dower, J. I., Kromhout, D., Hollman, P. C. H., & Afman, L. A. (2018) · PLoS ONE · doi:10.1371/journal.pone.0194229 · Cited by 33
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Self-citationPolyphenols more than an Antioxidant: Role and Scope
Mustafa, S. K., Oyouni, A. A. A., Aljohani, M. M., & Ahmad, M. A. (2020) · Journal of Pure and Applied Microbiology · doi:10.22207/jpam.14.1.08 · Cited by 31
Effects of Cocoa Polyphenols and Dark Chocolate on Obese Adults: A Scoping Review
Halib, H., Ismail, A., Yusof, B. N. M., Osakabe, N., & Daud, Z. A. M. (2020) · Nutrients · doi:10.3390/nu12123695 · Cited by 31
“In contrast, a meta-analysis of cocoa and chocolate in terms of resistance or sensitivity to glucose and insulin is likely to show beneficial effects on insulin resistance (IR) but not on glucose levels [37].”
Darand, M., Oghaz, M. H., Hadi, A., Atefi, M., & Amani, R. (2021) · Phytotherapy Research · doi:10.1002/ptr.7183 · Cited by 35
“Furthermore, a meta-analysis indicated that chocolate/cocoa has improved fasting insulin and insulin resistance (Hooper et al., 2012).”
BackgroundEvidence for circulatory benefits of resveratrol in humans
Wong, R. H. X., Coates, A. M., Buckley, J. D., & Howe, P. R. C. (2013) · Annals of the New York Academy of Sciences · doi:10.1111/nyas.12155 · Cited by 31
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“Several clinical studies have reported that cocoa-derived products including chocolate, exert a beneficial effect on the cardiovascular system by targeting the endothelial function.(79,80) Consumption of dark chocolate, a product rich in polyphenols (in average 1.”
BackgroundThe acute effects of cocoa flavanols on temporal and spatial attention
Karabay, A., Saija, J. D., Field, D. T., & Akyürek, E. G. (2018) · Psychopharmacology · doi:10.1007/s00213-018-4861-4 · Cited by 31
“Long-term studies revealed that sustained intake of cocoa flavanols (CF) decreases insulin resistance and provides benefits to cardiovascular health (Hooper et al. 2012).”
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“Supporting these studies, two thorough, recent reviews of the literature (Grassi et al., 2015; Hooper et al., 2012) suggest that cocoa and chocolate may offer cardiometabolic protection.”
InfluentialChocolate intake and incidence of heart failure: Findings from the Cohort of Swedish Men
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“Chocolate has been shown to have multiple benefits to cardiovascular health, possibly mediated in part through their high concentration of plant-derived antioxidants called flavonoids.(7,30) Chocolate provides a significant dietary sourceof flavonoids,which are also present in tea andwine.”
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Cocoa Flavanols Improve Endothelial Functional Integrity in Healthy Young and Elderly Subjects
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“Recent dietary studies showed that catechins might have a protective effect against cardiovascular diseases, such as hypertension [50,51].”
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“Finally, recent meta-analyses of human interventional studies performed with flavanol/procyanidin-rich food (cocoa, chocolate and tea) showed improvement in flow-mediated dilatation of blood vessels (Ras et al., 2011; Hooper et al., 2012) which is a measure of endothelial function and a predictor for future cardiovasc…”
BackgroundJardon, K. M. C., Goossens, G. H., Most, J., Galazzo, G., Venema, K., Penders, J., & Blaak, E. E. (2024) · Gut Microbes · doi:10.1080/19490976.2024.2392875 · Cited by 32
Nutrition and Nutraceutical Supplements for the Treatment of Hypertension: Part I
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Do flavanols-rich natural products relieve obesity-related insulin resistance?
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“In this study, total flavonoid intake ranged from 16.6 mg/day to 1080mg/day and control group consumed lowflavonoid cocoa (Hooper et al., 2012).”
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The Effect of Diet on Cardiovascular Disease and Lipid and Lipoprotein Levels
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“A decrease in insulin resistance [8], triglycerides [8], low density lipoprotein-cholesterol (LDL-cholesterol) [9], and blood pressure (BP) [8], as well as an increase in insulin sensitivity and high density lipoprotein-cholesterol (HDL-cholesterol) [8] could be observed in meta-analyses of randomized controlled trial…”
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Dark chocolate and reduced snack consumption in mildly hypertensive adults: an intervention study
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Cocoa-induced (Theobroma cacao) effects on cardiovascular system: HDL modulation pathways.
Santos, H. O., & Macedo, R. C. (2018) · Clinical Nutrition ESPEN · doi:10.1016/j.clnesp.2018.06.001 · Cited by 24
Mayorga-Gross, A. L., & Esquivel, P. (2019) · Nutrients · doi:10.3390/nu11051163 · Cited by 28
“A variety of health benefits have been associated to the intake of cocoa and its derived products, many of them attributed to the intake of polyphenols, particularly flavonoids [32–34]: improvement in insulin resistance by lowering serum insulin and in flow-mediated dilatation [35], as well as improvement in blood pre…”
BackgroundSun, M., Gu, Y., Glisan, S. L., & Lambert, J. D. (2021) · The Journal of Nutritional Biochemistry · doi:10.1016/j.jnutbio.2021.108618 · Cited by 27
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Metadata
- Authors
- Hooper, L., Kay, C., Abdelhamid, A., Kroon, P. A., Cohn, J. S., Rimm, E. B., & Cassidy, A.
- Affiliations
- University of East Anglia (GB)
- Corresponding author
- Hooper, Lee
- Venue
- The American Journal of Clinical Nutrition
- Publisher
- Elsevier BV
- Published
- 2012-03
- Volume
- 95
- Issue
- 3
- Pages
- 740-751
- ISSN
- 0002-9165 (ISSN-L)
- OpenAlex
- W2129761592
- Cited by
- 610
- References
- 90
- Citations by year
- 2026: 15 · 2025: 19 · 2024: 32 · 2023: 24 · 2022: 29 · 2021: 35 · 2020: 37 · 2019: 43 · 2018: 63 · 2017: 56 · 2016: 64 · 2015: 54 · 2014: 50 · 2013: 66 · 2012: 22
- FWCI
- 6.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- American Journal of Clinical Nutrition (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- Research Portal (Queen's University Belfast) (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Funders
- GlaxoSmithKline
- Directorate for Biological Sciences
- Biotechnology and Biological Sciences Research Council (BBS/E/F/00044434)
- Topics
- Health Sciences › Medicine › Biochemistry (medical) › Phytochemicals and Antioxidant Activities
- Life Sciences › Agricultural and Biological Sciences › Food Science › Food Chemistry and Fat Analysis
- Health Sciences › Medicine › Pharmacology (medical) › Coffee research and impacts
- Keywords
- chocolate, Theobroma cacao, flavan-3-ols, epicatechin, cardiovascular disease prevention, insulin resistance, flow-mediated dilation, endothelial function, blood pressure, LDL cholesterol, HDL cholesterol, cardiovascular risk factors, dose-response relationship, quality of evidence, GRADE, adverse effects
- MeSH terms
- Blood Glucose, Blood Pressure, Cacao, Candy, Cardiovascular Diseases, Cardiovascular System, Flavonoids, Humans, Insulin, Risk Factors, Reproducibility of Results, Biomarkers, Randomized Controlled Trials as Topic
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