Cited by 610Phytochemicals and Antioxidant ActivitiesFood Chemistry and Fat AnalysisCoffee research and impacts

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Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials

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Hooper, Lee, Kay, Colin, Abdelhamid, Asmaa, Kroon, Paul A, Cohn, Jeffrey S, Rimm, Eric B, Cassidy, Aedín·2012·The American Journal of Clinical Nutrition

DOI 10.3945/ajcn.111.023457

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Abstract

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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“These changes were seen with 19-54 grams of cocoa per day, or 46-100 grams of PRC per day [71].”
BackgroundResultInfluential
Associations between dietary flavonoids and retinal microvasculature in older adults
Gopinath, B., Liew, G., Lewis, J. R., Bondonno, N. P., Bondonno, C. P., Burlutsky, G., Hodgson, J. M., & Mitchell, P. (2019) · European Journal of Nutrition · doi:10.1007/s00394-019-02148-5 · Cited by 5
“This is in line with the published literature [41, 42] that showed chronic intake of chocolate was associated with beneficial effects on cardiovascular health—including BP and flow-mediated dilatation.”
Result
The leaf extract of Ribes nigrum L. is a potent stimulator of the endothelial formation of NO in cultured endothelial cells and porcine coronary artery rings
Tabart, J., Schini‐Kerth, V. B., Pincemail, J., Kevers, C., Pirotte, B., Defraigne, J.-O., & Dommès, J. (2016) · Journal of Berry Research · doi:10.3233/jbr-160129 · Cited by 5
“Indeed, in humans, regular intake of food enriched in polyphenols such as black chocolate [8], green tea [9] and red wine in moderate amounts [10] has been shown to improve endothelial function with a concomitant reduction of arterial blood pressure.”
Background
Cocoa-flavanols enhance moderate-intensity pulmonary $$\dot{V}{\text{O}}_{2}$$ kinetics but not exercise tolerance in sedentary middle-aged adults
Sadler, D. G., Draijer, R., Stewart, C. E., Jones, H., Marwood, S., & Thijssen, D. H. J. (2021) · European Journal of Applied Physiology · doi:10.1007/s00421-021-04682-9 · Cited by 6
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C-Ring Structure-Dependent Redox Properties of Flavonoids Regulate the Expression of Bioactivity
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Cocoa and chocolate consumption and prevention of cardiovascular diseases and other chronic diseases
Singh, R., Singh, R. B., Mojto, V., Pella, D., Fedačko, J., Vargová, V., Hristová, K., Wilczyńska, A., Mojtová, M., & Gvozdjáková, A. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-819815-5.00012-4 · Cited by 5
Cocoa, Flavonoids and Cardiovascular Protection
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BackgroundMethod
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A select review reporting the quality of studies measuring endothelial dysfunction in randomised diet intervention trials
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A newly isolated intestinal bacterium involved in the C-ring cleavage of flavan-3-ol monomers and the antioxidant activity of the metabolites
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Theobroma cacao and Theobroma grandiflorum: Bioactive Compounds and Associated Health Benefits
Genovese, M. I., & Barros, H. R. D. M. (2017) · Reference series in phytochemistry · doi:10.1007/978-3-319-54528-8_15-1 · Cited by 3
Effects of chocolate-based products intake on blood glucose, insulin and ghrelin levels and on satiety in young people: a cross-over experimental study
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“comparison with control groups in acute or shortterm chronic ( 18weeks) interventions (Hooper et al. 2012).”
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From sodium intake restriction to nitrate supplementation: Different measures with converging mechanistic pathways?
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“…an analysis of 42 acute or short-term chronic clinical studies, that included 1297 participants, showed that flow-mediated dilatation and insulin resistance parameters was improved by chocolate or cocoa consumption, in association with a significant reductions in serum insulin (Hooper et al. 2012).”
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“The main effects reported at the meta-analytic level therefore should be seen as robust indicators of a BP lowering effect with cocoa consumption (Desch et al., 2010; Hooper et al., 2012).”
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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
ORCID: Hooper, Lee
Kay, Colin
Abdelhamid, Asmaa
Kroon, Paul A
Cohn, Jeffrey S
Rimm, Eric B
Cassidy, Aedín
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)
DOI: 10.3945/ajcn.111.023457
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: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 4010 d)
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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Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials

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