Cocoa Flavanol Intake and Biomarkers for Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Lin, Xiaochen; Zhang, Isabel; Li, Alina; Manson, JoAnn E.; Sesso, Howard D.; Wang, Lu; Liu, Simin

doi:10.3945/jn.116.237644

Cited by 126 publications

(87 citation statements)

References 69 publications

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“…This neutral effect of cocoa and dark chocolate on LDL-C is consistently shown in the recent metaanalysis of 19 randomized controlled trials in which chocolate or cocoa consumption did not change the LDL-C concentration. 31 Both the ALD and CHOC+ALD decreased LDL-C by a comparable degree; however, there were different treatment effects on LDL subclasses. The ALD decreased large buoyant LDL particles, whereas the CHOC+ALD decreased small dense LDL particles.…”

Section: Discussionmentioning

confidence: 91%

Effects of Dark Chocolate and Almonds on Cardiovascular Risk Factors in Overweight and Obese Individuals: A Randomized Controlled‐Feeding Trial

Lee

Berryman

West

et al. 2017

JAHA

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BackgroundConsumption of almonds or dark chocolate and cocoa has favorable effects on markers of coronary heart disease; however, the combined effects have not been evaluated in a well‐controlled feeding study. The aim of this study was to examine the individual and combined effects of consumption of dark chocolate and cocoa and almonds on markers of coronary heart disease risk.Methods and ResultsA randomized controlled, 4‐period, crossover, feeding trial was conducted in overweight and obese individuals aged 30 to 70 years. Forty‐eight participants were randomized, and 31 participants completed the entire study. Each diet period was 4 weeks long, followed by a 2‐week compliance break. Participants consumed each of 4 isocaloric, weight maintenance diets: (1) no treatment foods (average American diet), (2) 42.5 g/d of almonds (almond diet [ALD]), (3) 18 g/d of cocoa powder and 43 g/d of dark chocolate (chocolate diet [CHOC]), or (4) all 3 foods (CHOC+ALD). Compared with the average American diet, total cholesterol, non–high‐density lipoprotein cholesterol, and low‐density lipoprotein cholesterol after the ALD were lower by 4%, 5%, and 7%, respectively (P<0.05). The CHOC+ALD decreased apolipoprotein B by 5% compared with the average American diet. For low‐density lipoprotein subclasses, compared with the average American diet, the ALD showed a greater reduction in large buoyant low‐density lipoprotein particles (−5.7±2.3 versus −0.3±2.3 mg/dL; P=0.04), whereas the CHOC+ALD had a greater decrease in small dense low‐density lipoprotein particles (−12.0±2.8 versus −5.3±2.8 mg/dL; P=0.04). There were no significant differences between diets for measures of vascular health and oxidative stress.ConclusionsOur results demonstrate that consumption of almonds alone or combined with dark chocolate under controlled‐feeding conditions improves lipid profiles. Incorporating almonds, dark chocolate, and cocoa into a typical American diet without exceeding energy needs may reduce the risk of coronary heart disease.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01882881.

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Section: Discussionmentioning

confidence: 91%

Effects of Dark Chocolate and Almonds on Cardiovascular Risk Factors in Overweight and Obese Individuals: A Randomized Controlled‐Feeding Trial

Lee

Berryman

West

et al. 2017

JAHA

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“…Recent meta-analyses (Table S3) [138,139,140,141,142,143,144,145,146,147,148,149,150,151] suggest that the consumption of flavanol-containing tea and tea products could reduce total- and LDL-cholesterol as well as body mass index (BMI) and waist circumference (WC), while chocolate and cocoa flavanols also appear to regulate blood lipid levels. Nonetheless, the results of these analyses are inconsistent, partly due to the large heterogeneity of the clinical trials included.…”

Section: Discussionmentioning

confidence: 99%

A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy

et al. 2017

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Several randomized controlled trials (RCTs) and meta-analyses support the benefits of flavanols on cardiometabolic health, but the factors affecting variability in the responses to these compounds have not been properly assessed. The objectives of this meta-analysis were to systematically collect the RCTs-based-evidence of the effects of flavanol-containing tea, cocoa and apple products on selected biomarkers of cardiometabolic risk and to explore the influence of various factors on the variability in the responses to the consumption of these products. A total of 120 RCTs were selected. Despite a high heterogeneity, the intake of the flavanol-containing products was associated using a random model with changes (reported as standardized difference in means (SDM)) in body mass index (−0.15, p < 0.001), waist circumference (−0.29, p < 0.001), total-cholesterol (−0.21, p < 0.001), LDL-cholesterol (−0.23, p < 0.001), and triacylglycerides (−0.11, p = 0.027), and with an increase of HDL-cholesterol (0.15, p = 0.005). Through subgroup analyses, we showed the influence of baseline-BMI, sex, source/form of administration, medication and country of investigation on some of the outcome measures and suggest that flavanols may be more effective in specific subgroups such as those with a BMI ≥ 25.0 kg/m2, non-medicated individuals or by specifically using tea products. This meta-analysis provides the first robust evidence of the effects induced by the consumption of flavanol-containing tea, cocoa and apple products on weight and lipid biomarkers and shows the influence of various factors that can affect their bioefficacy in humans. Of note, some of these effects are quantitatively comparable to those produced by drugs, life-style changes or other natural products. Further, RCTs in well-characterized populations are required to fully comprehend the factors affecting inter-individual responses to flavanol and thereby improve flavanols efficacy in the prevention of cardiometabolic disorders.

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“…Results of that study suggest that chocolate intake result in beneficial changes in liver enzymes and protect against insulin resistance (55). The results of a randomized controlled trial also support a role for cocoa flavanol intake in improving insulin resistance (48). The current data is insufficient to recommend chocolate and cocoa for glycemic control.…”

Section: Polyphenolsmentioning

confidence: 94%

“…Previous studies have failed to observe benefits of cocoa polyphenols on blood lipids in subjects with hypertension stage 1 (45), overweight (46) and in patients with heart failure (47). A recent meta-analysis of 19 randomized controlled trials of varying designs with a total of 1,131 participants indicated that cocoa flavanols were associated with reductions in total triglycerides (−0.10 mmol/L) and increases in HDL-C (0.06 mmol/L) intake (48). Recently published results from the Flaviola Health Study revealed that twicedaily ingestion of 450 mg of cocoa flavanols for 1 month decreased TC by 0.20 mmol/L and LDL-C by 0.17 mmol/L whereas HDL-C increased by 0.10 mmol/L in a low risk, primary prevention population.…”

Section: Polyphenolsmentioning

confidence: 99%

The role of nutraceuticals in the prevention of cardiovascular disease

Sosnowska

Penson

Banach

2017

Cardiovasc. Diagn. Ther.

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IntroductionCardiovascular disease (CVD) is common, indeed the majority of adults above sixty years of age will experience some manifestation of CVD. Based on data from 2012 and 2013, it has been estimated that CVD is responsible for 17.3 million deaths annually worldwide (1). Morbidity is also high, and in Europe, 200 billion Euros of healthcare expenditure is attributable to CVD (2). Risk factors for CVD can be categorized as modifiable and non-modifiable. Modifiable risk factors include obesity, hypertension, hyperlipidemia, diabetes mellitus, metabolic syndrome and lifestyle risk factors such as unhealthy diet, smoking and physical inactivity. Dietary factors are also important contributors to cardiovascular risk, either directly, or through their effects on other risk factors including hypertension, dyslipidemia and diabetes mellitus (3). Reduction of risk factors in the population, especially blood pressure reduction and lipid-lowering can have important impacts upon mortality from CVD (4).Protective effects against CVD have been demonstrated for several foods and dietary supplements (5) thus presenting new possibilities for population-level reduction of CVD risk. Evidence suggests that this approach is very promising. For example, in the PREDIMED observational study, participants in the highest quintile of polyphenol consumption had a relative risk of CVD of 54% compared to those in the lowest quintile (6). The aim of this review is to present an update on the most recent evidence relating to the use of nutraceuticals in the context of the prevention and treatment of CVD. Unfortunately, few studies have measured the associations between nutraceutical consumptions and "hard" outcomes such as mortality. Large randomized controlled trials are particularly rare, and thus there is a paucity of evidence in this area. Thus, our discussion will be largely focused on the effects of NutraceuticalsThe term "nutraceuticals" was introduced by Stephen DeFelice, founder and chairman of the Foundation for Innovation in Medicine, in 1989. A nutraceutical is defined as a "food, or parts of a food, that provide medical or health benefits, including the prevention and treatment of disease" (7). The definition encompasses medicinal products made from natural ingredients. Several classes of nutraceuticals have been proposed to have potential benefits in the treatment of CVD and the ones with the strongest evidence are briefly summarized below. Sterols/stanolsPlant sterols/stanols are phytosterols, and have been identified in a range of plant products including various fruits and vegetables, cereals, seeds and nuts. Their biological activity results from their molecular structural similarity to cholesterol (8). PolyphenolsPolyphenols are phytochemicals with widespread distribution in foods of plant origin. They are found in fruits, vegetables, cereal and legumes. Additionally, they are found in beverages produced from plant products such as tea, coffee, wine and cocoa. Polyphenols are structurally diverse, and over 8,000 have...

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Cocoa Flavanol Intake and Biomarkers for Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract: Background: Cocoa flavanols may improve cardiometabolic health. Evidence from small short-term randomized clinical

Cited by 126 publications

References 69 publications

Effects of Dark Chocolate and Almonds on Cardiovascular Risk Factors in Overweight and Obese Individuals: A Randomized Controlled‐Feeding Trial

Effects of Dark Chocolate and Almonds on Cardiovascular Risk Factors in Overweight and Obese Individuals: A Randomized Controlled‐Feeding Trial

A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy

The role of nutraceuticals in the prevention of cardiovascular disease

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