REVIEW

PAPER

ChocolateGuilty Pleasure or Healthy Supplement?

Laura S. Latham, PharmD;1 Zeb K. Hensen, MD;2 Deborah S. Minor, PharmD2
From the Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS;1 and Department of Medicine, University of Mississippi
Medical Center, Jackson, MS2

Dark chocolate and other cocoa products are popular in the

population as a whole, but their overall health benefit
remains controversial. Observations from the Kuna Indian
population have shown an impressive cardiovascular health
benefit from cocoa. For various reasons, this benefit has not
been as robust as in other populations. Additionally, several
mechanisms have been proposed that might confer cocoas
possible health benefit, but no consensus has been reached
on cocoas physiologic role in promoting cardiovascular
health. Flavanols, as well as theobromine, may contribute to
enhancements in endothelial function and subsequent
improvements in various contributors to cardiovascular

Patients are frequently on the lookout for a pleasurable

way to approach their health. With this in mind, dark
chocolate and cocoa products have garnered attention as
a dietary supplement and approach to decrease blood
pressure (BP) and modify other cardiovascular disease
(CVD) risk factors.1 An extract from the Theobroma
cacao tree, cocoa is a rich source of plant polyphenols, a
heterogeneous group of molecules found primarily in
fruits and vegetables. Cocoa is especially rich in flavanols,
a polyphenol subtype proposed as the mediator for
cardiovascular benefits.2 Flavanols are also found in
other plant-based foods (Table I).1,3 While the contributions of the various components of these foods continue
to evolve, the flavanol content appears to augment the
cardiovascular benefits. Regular dietary intake of plantderived foods and beverages is inversely associated with
the risk of CVD among the general population.4
Interest in the effect of cocoa on CVD began with
observations among the Kuna Indian population in the
San Blas Islands of Panama. This group had distinctively
low rates of hypertension and CVD, coupled with an
absence of the age-related increases in BP observed in
other populations.1,5 Environmental, rather than
genetic, factors appeared to confer this protective
role.1,5 Unique to this population was their cocoa
intake. On average, traditional island-dwelling Kuna
Indians consume approximately four 8-ounce cups of
unprocessed cocoa beverages per day.5,6 Even in
patients older than 65 years, the mean BP was 110/

Address for correspondence: Deborah S. Minor, PharmD, Division of

General Medicine/Hypertension, Department of Medicine, University of
Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216
E-mail: DMinor@umc.edu
Manuscript received: August 12, 2013; revised: September 18, 2013;
accepted: September 27, 2013
DOI: 10.1111/jch.12223

disease (CVD) including hypertension, platelet aggregation

and adhesion, insulin resistance, and hypercholesterolemia.
While the benefits of cocoa may be altered at the various
stages of growth, development, and production, it appears
that for many people healthy dark chocolate may, indeed,
provide a pleasurable role in CVD risk reduction. The
objectives of this review are to discuss the associations of
cocoa with decreased blood pressure and improved CVD
risk, to describe the possible mechanisms for these potential
benefits, and to highlight considerations for the use of cocoa
as a dietary supplement. J Clin Hypertens (Greenwich).
2014;16:101106. 2013 Wiley Periodicals, Inc.

TABLE I. Flavanol Concentrations Found in Food3

Source

Flavanol Content, mg/kg or mg/L

Chocolate

460610

Legume-type beans
Apricots

350550
100250

Grapes
Blackberries

30175
130

Apples
Green tea

20120
100800

Black tea
Red wine

60500
80300

70 mm Hg.5,6 Conversely, migrant Kuna Indians consume up to 10 times less cocoa and experience a BP
increase with age and hypertension prevalence comparable to Western populations.1,5,6 Salt consumption
among the island-dwelling population was equivalent or
greater compared with migrant Indians and there were
no significant differences in body mass index (BMI).1,5
Independent of cocoa, sodium, and weight, other factors
may influence the observed changes in BP. Physical
activity, smoking status, stress level, and diet may also
be related to the CVD risk increase experienced with the
migrant Kuna population.5
For many, dietary changes and other lifestyle modifications are effective for the prevention and treatment
of hypertension and are critical for reduction of CVD.4
In this review, we discuss the clinically relevant effects
of cocoa, focusing on possible mechanisms involved in
the cardiovascular response to cocoa and the potential
implications associated with consumption.

FLAVANOL CONTENT
Structurally, flavanols exist as low-molecular-weight
monomeric compounds, such as epicatechin, which have
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Guilty Pleasure or Healthy Supplement? | Latham et al.

effects on the vascular endothelium,7 or as complex

higher-molecular-weight oligomeric and polymeric compounds (eg, procyanidins), which are less vasoactive.2,8
The profile and ratio of the various flavanols in cocoa
products vary considerably and can be altered at many
stages of growth, development, and production.1,7,8
Flavanol content in cocoa products is dependent on the
crop cultivar type, post-harvest handling practices, and
manufacturer processing techniques.2 Fresh and fermented cocoa beans contain approximately 10% flavanols (100 mg/g) prior to processing, while the cocoa
powder consumed by the Kuna Indians contains about
3.6% flavanols. In contrast, cocoa-rich dark chocolate
contains approximately 0.5% flavanols. Milk and white
chocolate have lower flavanol content or even flavanolfree composition, respectively.1 Because flavanols are
bitter and often considered unpalatable, processes are
used for flavor enrichment. The cocoa powder consumed
by the Kuna Indians would be unpleasurable to most
individuals in the Western population. Fermentation,
roasting up to 120C, and dutching (ie, alkalizing), as
well as the addition of sugar, milk, vanilla, and emulsifiers, are techniques used to improve cocoas palatability.7,9 These modifications, however, can practically
eliminate the presence of flavanols in finished products,
and thus may abrogate the potential CVD benefits of
cocoa.9 The percentage of cocoa is not a reliable
indicator of the flavanol content present in a given
product. As a result, a 70% cocoa bar from one company
may contain an entirely different flavanol composition
than a 70% cocoa product from another supplier.1

MECHANISMS AND EFFECTS ON CVD RISK

FACTORS
Observational studies support the association between
high cocoa intake and reduced CVD.10,11 Based on the
Kuna Indian observations, investigational trials were
designed to further define the cardiovascular and antihypertensive effects of cocoa consumption. Although a
variety of mechanisms have been proposed, many of the
findings involve improvements in endothelial function.
Prospective studies have demonstrated an association
between endothelial dysfunction and increased risk of
CVD. Endothelial function may improve following the
consumption of flavanol-rich cocoa, with subsequent
improvement of various contributors to CVD including
hypertension, platelet aggregation and adhesion, insulin
resistance, and hypercholesterolemia.12
For the purpose of this review, we searched for
published studies from 2003 to 2013 addressing the use
of cocoa in the management of CVD risk factors. Using
PubMed, we searched by the following MeSH terms
individually and in combination: cocoa, dark chocolate, flavanols, hypertension, human, platelets, lipids, cardiovascular disease, and insulin.
We also reviewed the Natural Medicine Comprehensive
Database. Table II highlights examples of studies
designed to assess the effects of cocoa on cardiovascular
risk factors.
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While intriguing, significant limitations apply to all of

the cocoa studies reviewed. The paucity of available
data may also indicate a publication bias in favor of
positive findings. White chocolate was often used as a
control, thus preventing participant blinding. Flavanol
content of test foods, when reported, varies considerably among studies, complicating interpretations and
comparisons. Additionally, most studies had a relatively
small sample size, were of short duration, and measured
only surrogate markers of CVD risk. This limits the
generalizability of the results as well as translation to
any long-term clinical implications or benefits. While
the following observations are provoking, confirmation
is needed in well-controlled, well-designed studies.
Blood Pressure
The relationship between BP and CVD risk is continuous and independent of other risk factors, and small
reductions in BP can lead to substantial decreases in
CVD.4 One suggested pathway for the benefits of cocoa
on BP and CVD involves endothelial nitric oxide (NO).
Cocoa intake increases NO generation. This process
may be triggered by upregulation of endothelial NO
synthase (eNOS), which synthesizes NO from L-arginine. Enhancement of NO by cocoa leads to vasodilation and BP reduction, as well as prevention of
leukocyte adhesion and migration, smooth muscle cell
proliferation, and platelet adhesion and aggregation.3,13
In patients with cardiovascular risk factors, a cocoa
drink high in flavanol content (176185 mg) rapidly
increased circulating levels of bioactive NO by more
than a third. In turn, flow-mediated vasodilation, a
commonly used marker to quantify endothelial function, was increased.14 Furthermore, this flavanol-related
increase in vasodilation and improvement in endothelial
function can be reversed by L-NG-monomethyl arginine,
a competitive eNOS inhibitor, resulting in a significant
reduction in blood flow.3,14 It can be argued, therefore,
that the reduced BP and cardiovascular risk in individuals who consume flavanol-rich foods is the result of the
favorable effect on eNOS activity.15
Cocoa flavanols also exert antioxidant effects.
Consumption of 40 g of commercially available dark
chocolate (74% cocoa) significantly improves plasma
antioxidant status 2 hours after ingestion.16 It is likely
that, in addition to eNOS induction and NO concentration elevation, a reduction in oxidative stress occurs
from cocoa ingestion. NO breakdown by reactive
oxidant species is reduced, which contributes to
enhanced endothelial function, especially under conditions with a high oxidative stress burden, such as
smoking.16 In addition, antioxidants may prevent NO
transformation into peroxynitrite, a powerful oxidant,
and thus protect against vascular damage.3
Another mechanism by which flavanols may lower BP
is by inhibition of angiotensin-converting enzyme
(ACE).2 ACE inhibition is a highly utilized and
evidence-based therapeutic approach to the treatment
of hypertension. In vitro and, more recently, in vivo

Guilty Pleasure or Healthy Supplement? | Latham et al.

TABLE II. Study Examples: Cocoa and Cardiovascular Risk Factors

References

Design/Duration

No.

Intervention

Observed Intervention Effect

Taubert

Randomized, single-blind,
parallel groupa/18 wk

44

DC (6.3 g, 30 mg flavanol) vs
WC (5.6 g, flavanol-free)

NO poolband in SBPb and DBPb

Heiss14

Randomized, double-blind,
crossover/ 2 h, 2 d total

11

Cocoa drink 100 mL with

high (176185 mg) vs

FMDb and circulating NO poolb

Hermann16

Randomized, parallel

20

Persson18

group/2 h, 24 h total
Open-label/3 h

low (<11 mg) flavanol content

Noir Intense) vs
DC (40 g, 74% cocoa, Nestle

Galak)
WC (40 g, 4% cocoa, Nestle

16

DC (75 g, 72% cocoa)

13

FMDb and improvement in antioxidant

statusb and platelet functionb
NO pool and inhibition of ACE activityb

Taubert19

Randomized, single-blind,
crossovera,c/2 wk

13

DC (100 g, 500 mg flavanol) vs

WC (90 g, flavanol-free)

SBPb and DBPb

Grassi20

Randomized, single-blind,
crossovera,c/15 d

20

DC (100 g, 88 mg flavanol) vs
WC (90 g, flavanol-free)

FMDb and insulin sensitivityb and

SBP,b DBP,b LDL,b and total cholesterolb

Muniyappa21

Randomized, double-blind,
placebo-controlled,

20

Cocoa drink 150 mL twice daily

with high (~900 mg/d) vs

No reduction in BP or improvement in insulin

resistance

crossovera,c/2 wk

low (~28 mg/d)

flavanol content

Engler22

Randomized, double-blind,
placebo-controlled/2 wk

21

Flammer26

Randomized, double-blind,
placebo-controlled/2 h and 4 wk

20

Randomized, single-blind/4 h

30

Innes27

High-flavonoid DC (46 g, DOVE)

vs low-flavonoid DC (46 g)

Noir
DC (40 g, 70% cocoa, Nestle
Intense) vs placebo chocolate
(28.4 g, flavanol-free)
DC (100 g, 75% cocoa) vs milk chocolate
(100 g, 20% cocoa) vs WC (100 g,

FMDb and no reduction in BP

FMD (acute and chronic effect)b and in
platelet adhesion (acute effect)b
Inhibition of collagen-induced
platelet aggregationb

Ostertag28

Randomized, single-blind/2

42

flavanol-free)
Flavanol-rich DC (60 g) vs standard

Grassi29

and 6 h
Randomized, single-blind,

19

DC (60 g) vs WC (60 g)
DC (100 g, flavanol-rich) vs WC

Women: aggregationb
FMD,b insulin sensitivity,b and b-cell

Desideri30

crossovera,c/15 d
Randomized, double-blind,

90

(100 g, flavanol-free)
Cocoa drink with high (~990 mg)

functionb and SBP and DBPb

Cognitive function and insulin resistance

parallel groupa/8 wk

vs mid (~520 mg) vs

low (~45 mg) flavanol content

Men: platelet activity and aggregationb

Seen with mid and high flavanol groups

Mursa32

Open-labela/3 wk

45

Polyphenol-enriched DC (75 g) vs standard

DC (75 g) vs WC (75 g)

HDL-Cb
b
Seen by both DC groups

Baba33

Randomized, controlled/12 wk

25

Cocoa group (26 g cocoa powder +12 g

sugar) vs control group (12 g sugar)

in LDL-C, in HDL-Cb, and suppression of

oxidized LDL-Cb

Neufingerl34

Randomized, double-blind,
placebo-controlled,

Drink 200 mL with cocoa (150 mg TB and

325 mg flavanols), pure TB

HDL-C,b apolipoprotein AI,b

apolipoprotein B,b and LDL-Cb

parallel groupd/4 wk

152

(850 mg TB), cocoa

with added TB (1000 mg TB

Seen with the pure TB group only

and 325 mg flavanols), or placebo

Abbreviations: increased; decreased; DC, dark chocolate; DBP, diastolic blood pressure; FMD, flow-mediated dilation; HDL-C, high-density
lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NO, nitric oxide; SBP, systolic blood pressure; TB, theobromine; WC, white
chocolate. aSeven-day cocoa/flavanol-free run-in period. bStatistically significant finding. cSeven-day washout period before crossover. dFourteen-day
cocoa/flavanol-free run-in period.

studies support the occurrence of ACE inhibition by

flavanols.17,18 In healthy volunteers, the average inhibition of ACE activity was 18% 3 hours after intake of
75 g of dark chocolate, a level consistent with the
magnitude achieved with the ACE inhibitor class of
medications.18
Several randomized controlled trials have investigated
the effects of dark chocolate on BP in patients with
hypertension. Trials published in 2003 and 2005 used
similar designs with patients randomized to receive
either 100 g of dark chocolate or 90 g of flavanol-free

white chocolate daily for 2 weeks. After a 7-day

washout period, patients were crossed over to the
alternative treatment. Dark chocolate consumption
decreased systolic BP (SBP) and diastolic BP (DBP;
meanstandard deviation) by 5.12.4 mm Hg and
1.82.0 mm Hg, respectively, in the 2003 trial and
11.97.7 mm Hg and 8.55.0 mm Hg in the 2005
trial.19,20 In both studies, the reduction in BP following
dark chocolate consumption reached statistical significance. White chocolate consumption did not reduce
BP.19,20 In 2007, the effects of lower doses of dark
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chocolate (6.3 g of chocolate containing 30 mg of

flavanols) and white chocolate (5.6 g of flavanol-free
chocolate) were assessed over 18 weeks.13 Compared
with baseline, SBP was significantly reduced by
2.91.6 mm Hg and DBP by 1.91.0 mm Hg in the
dark chocolate group. Again, white chocolate had no
significant effect. These findings suggest that habitual
intake of low doses of dark chocolate may have
sustained antihypertensive effects.13 Other studies,
however, have shown no effect of dark chocolate on
BP. One study found that consumption of a flavanolrich cocoa drink for 2 weeks did not significantly reduce
BP in patients with primary hypertension.21 Another
randomized controlled trial found no significant
changes in BP following flavanol-rich cocoa intake in
healthy adults.22
A 2012 meta-analysis of 20 studies revealed a
statistically significant BP-reducing effect of flavanolrich cocoa products compared with controls, with mean
reductions of 2.77 mm Hg and 2.20 mm Hg in SBP and
DBP, respectively.1 This meta-analysis provides additional support that dark chocolate may have a small but
clinically significant BP-lowering effect. Generally, a
3 mm Hg reduction in SBP is estimated to reduce the
relative risk of stroke mortality by 8%, coronary artery
disease mortality by 5%, and all-cause mortality by
4%.2
BP is clearly influenced by diet as documented by the
Dietary Approaches to Stop Hypertension (DASH)
eating plan. Adoption of this type of diet rich in fruits,
vegetables, and low-fat dairy products is associated with
an 8 mm Hg to 14 mm Hg reduction in SBP and 5 mm
Hg decrease in DBP.23 Additionally, certain dietary
supplements (coenzyme Q10, fish oil, garlic, and vitamin C) have evidence of antihypertensive effects. The BP
reduction following cocoa intake is not as robust as that
exhibited by the DASH diet or these dietary supplements.24 Although cocoa may be consumed as a part of
a healthy DASH diettype approach to BP management,
insufficient evidence exists to recommend it as a
supplement for additional antihypertensive effects.
Platelet Function
Platelet dysfunction is another hallmark of CVD, and
the ability of flavanols to reduce platelet activity might
partly explain the beneficial effects of these compounds.25 Cocoa reduces adenosine diphosphate/collagen-activated, platelet-related primary hemostasis
within hours of ingestion. As a result, platelet aggregation and adhesion are diminished. Flavanols exert
additional antiplatelet effects by reducing glycoprotein
IIb/IIIa expression.3,26 A significant reduction in platelet
adhesion was observed in young smokers shortly after
consuming flavanol-rich dark chocolate; however, this
effect was not sustained after 4 weeks of daily consumption.26 Platelet aggregation was also reduced in
participants who consumed 100 g of dark chocolate,
with no effect after ingestion of white or milk chocolate.27 Sex-specific differences in platelet response have
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been reported. Men experienced a significant reduction

in both platelet activity and aggregation while women
had only a reduction in platelet aggregation.28 This
study concluded that high-flavanol dark chocolate has a
positive effect on platelet function in both sexes, but the
benefits may be greater in men.28
Insulin Resistance
Impairment of insulin-stimulated production of NO
from the vascular endothelium contributes to metabolic
insulin resistance.21 The resulting decreases in insulinstimulated blood flow reduces the delivery of insulin
and metabolic substrates to skeletal muscle. Thus, by
ameliorating NO bioavailability, flavanols may
decrease insulin resistance. Insulin resistance has been
reported to be reduced in patients with hypertension
after a 15-day diet that included 100 g of flavanol-rich
cocoa daily.29
Alteration in the insulin-signaling pathway has been
suggested as a contributor to cognitive dysfunction
because of insulins pivotal role in modulating brain
function. Chronic dysglycemia is thought to further
contribute to cognitive dysfunction by promoting the
development of cerebral microvascular disease and
inflammation.30 Elderly individuals who consumed at
least 520 mg of flavanols daily demonstrated significant
improvement in cognitive performance that was associated with a reduction in insulin resistance.30 Compounds such as flavanol-rich cocoa that improve
endothelial function concurrently decrease insulin resistance, enhance insulin sensitivity, and increase b-cell
function.3,20,21 Dietary inclusion of flavanols could be
one approach to maintain and improve cardiovascular
health and cognitive function.
Lipids
Increased concentrations of low-density lipoprotein
cholesterol (LDL-C) are associated with the development of atherosclerosis, while a negative correlation
exists between increased high-density lipoprotein cholesterol (HDL-C) and CVD. Evidence also indicates that
oxidized LDL-C progresses to fatty streak formation
and has a pathogenic role in atherosclerosis.31 Improved
LDL-C and HDL-C concentrations and LDL-C resistance to oxidation may contribute to a reduction of
atherosclerosis. Flavanol substances lower LDL-C by
inhibiting cholesterol absorption in the digestive tract,
inhibiting LDL-C biosynthesis, suppressing hepatic
secretion of apolipoprotein B, and increasing hepatic
expression of LDL-C receptors.31 The pathways
through which flavanols elevate plasma HDL-C concentrations remain unclear, but a potential mechanism
involves inhibition of vascular endothelial activation via
apolipoprotein A1.31 Lastly, flavanols increase the
resistance of LDL-C to oxidation by either scavenging
chain-initiating oxygen radicals or chelating transitional
metal ions.31
Several prospective studies have demonstrated a benefit of flavanol-rich cocoa products on cholesterol. In

Guilty Pleasure or Healthy Supplement? | Latham et al.

hypertensive patients, daily consumption of 100 g of

flavanol-rich chocolate over 2 weeks led to a significant
12% reduction of LDL-C and total cholesterol.20
Another study found that daily consumption of 75 g of
dark chocolate over 3 weeks increased HDL-C concentration up to 14% and inhibited lipid peroxidation in
healthy adults.32 A 2007 study of hypercholesterolemic
patients also demonstrated lipid improvements over
12 weeks with consumption of 26 g of cocoa powder
daily. A 12.6% reduction in LDL-C, 23.4% elevation in
HDL-C, and suppression of oxidized LDL-C (expressed
as 9.4% prolongation in lag time) was observed with all
endpoints except LDL-C reduction reaching significance.33
Conflicting results exist about the effect of cocoa on
HDL-C concentrations. Studies that demonstrated an
HDL-C increase with cocoa used theobromine-free
products as the comparator or control.34 In studies
where the control contained theobromine, no HDL-C
benefit was observed. A recent study showed that daily
consumption of 850 mg of pure theobromine independently and significantly increased HDL-C concentrations by 6.12 mg/dL in healthy patients, an effect not
seen with the cocoa treatment arm (150 mg theobromine).34 This finding suggests that theobromine in
cocoa, rather than flavanols, may contribute to or even
be responsible for the HDL-C benefit.

OTHER CONSIDERATIONS FOR COCOA

INTAKE
Although the positive effects of chocolate and cocoa
products seem apparent, precautions exist. An obvious
concern with the high intake of most commercially
available products is the significant caloric (about
500 kcal/100 g), saturated fat, and sugar content.
Excess caloric intake can lead to adverse metabolic
effects, including weight gain and blood glucose elevations, negating the positive effects of cocoa.35 This is a
particular concern with our current obesity epidemic
and national recommendations for decreased fat and
sugar intake among the general population. Although
less palatable, cocoa-based products with little or no
sugar or added fat are certainly preferred. In most trials
previously cited, body weight and glucose concentrations over the study period were found to be unaffected
with the doses provided. Again, studies were typically
conducted over a short time, and long-term consequences are unknown.
While chocolate has been reported to cause gastrointestinal complaints, migraine headaches, and jitteriness,
these effects have not been demonstrated in clinical
trials.1 Chocolate contains caffeine, possibly increasing
the risk of tachyarrhythmias and sleep disturbances.
Caffeine intake may also lead to medication interactions. Increased central nervous system stimulant
effects, decreased sedative effects, decreased theophylline clearance, and increased risk of clozapine toxicity
are among the potential interactions. Additionally,
cocoa itself may potentiate the effects of anticoagu-

lants.36 Typical serving sizes of chocolate do not contain

enough caffeine to warrant concern; however, overall
caffeine intake from all sources must be considered.37
In clinical trials, the amount of dark chocolate
ingested ranged from 6.3 g to 105 g daily, containing
30 mg to 1080 mg (mean 545.5 mg) of flavanols. In
general, 6 g are equal to one small square of a 100 g (3.5
ounce) dark chocolate bar, although exact concentrations are often difficult to identify.1 In addition to other
study limitations identified, cocoa preparations used as
dietary supplements have the same concerns as other
products for which there is no quality oversight. Content
inconsistencies, lack of standardization, and variable
formulations make product selection challenging and
specific dosing recommendations difficult to determine.
From another perspective, dark chocolate may offer a
relatively safe and inexpensive approach to support
CVD prevention in patients at risk. The estimated
incremental cost-effectiveness ratio was $50,000 per
years of life saved when only $42 per person per year was
spent on a prevention strategy utilizing dark chocolate.38

CONCLUSIONS
For centuries, cocoa has been recognized for its delectable taste and proposed health benefits, perhaps as just
wishful thinking for many. Research suggests that cocoa
does indeed exert beneficial cardiovascular effects,
mediated largely through the flavanol components.3
The effects of cocoa are likely the result of modifications
of NO activity. Increased NO bioavailability may
explain the improvement in endothelial function and
the potentially beneficial effects on BP, platelet function,
insulin resistance, and lipids.3 Unfortunately, like other
dietary supplements, unresolved issues regarding dosing
and the lack of clarity surrounding product components
make it difficult to recommend chocolate for health
benefits. Further investigation is needed before cocoa
products should be recommended as a treatment option
for BP reduction or other CVD parameters.35 Insufficient evidence exists to recommend cocoa as a supplement specifically for CVD risk reduction. A prudent
approach is consideration of the inclusion of healthy
dark chocolate in moderation as a part of overall
lifestyle modifications for the prevention or treatment of
cardiovascular risk factors.35 While chocolate can be a
healthy supplement, potential benefits may be diminished with the excess caloric intake caused by consuming most commercially available chocolates, making this
guilty pleasure a particular concern in our obese
population. However, addition of healthy dark
chocolate to a well-balanced calorically appropriate
diet offers a pleasurable and palatable option with little
burden for many people.
Disclosures: The authors have no conflicts of interest or financial disclosures
to declare.

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