Taking Chocolate to Heart: For Pleasure and Health

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Taking Chocolate to Heart: For Pleasure and Health
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.
Taking Chocolate to Heart: For Pleasure and Health
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
Taking Chocolate to Heart: For Pleasure and Health
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
Taking Chocolate to Heart: For Pleasure and Health
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
Taking Chocolate to Heart: For Pleasure and Health
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
Taking Chocolate to Heart: For Pleasure and Health
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.”
Taking Chocolate to Heart: For Pleasure and Health
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.
Taking Chocolate to Heart: For Pleasure and Health
   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
Taking Chocolate to Heart: For Pleasure and Health
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.
Taking Chocolate to Heart: For Pleasure and Health
Nutritional Composition of the Cocoa Bean and Chocolate Products
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