Effects of Dark Chocolate on the Heart: Annotated Bibliography

Veronese, N., Demurtas, J., Celotto, S., Caruso, M. G., Maggi, S., Bolzetta, F., & Yang, L. (2018). Is Chocolate Consumption Associated With Health Outcomes? An Umbrella Review of Systematic Reviews and Meta-Analyses. Clinical Nutrition.

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The paper tries to have an insight into the relationship between the consumption of chocolate and health outcomes due to its ingestion. According to the authors, literature that explains the potential health benefits when one consumes chocolate is unclear. Also, the research has lacked systematic scrutinization, hence undermining the evidence such literature provides. The article, therefore, primarily aims at mapping and grading the various health aftermaths due to chocolate consumption subjecting systematic reviews to an umbrella review (a review that helps policymakers and decision makers to understand a topic of concern easily).

In the study, the researchers followed standardized procedures for an umbrella review. They used a systematic review to search the MEDLINE/PubMed, Scopus, Embase, and Cochrane Library/DARE databases from their inception. Then, they proceeded to search reference lists of articles, starting with the eligible one, to those whose authors they could not identify. In the search, they included, without language restrictions, a formal systematic review with an option of considering meta-analyses of both interventional and observational studies focusing on the effects of chocolate on human health. While two authors did a primary screening, a third author resolved any disagreements by screening the abstract or the title that the first two disagreed. The authors also did a peer-reviewed systematic review, a meta-analysis of observational studies, and meta-analyses of randomized controlled trials (RCTs).

The results of the investigation showed that outcomes of cardiovascular disease (CVD) death, stroke, acute myocardial infarction, and diabetes did not provide strong evidence, whereas heart failure, coronary artery disease, and atrial fibrillation had an insignificant association with the chocolate intake. Systematic reviews also showed that chocolate consumption did not protect one against depression. The significance of these results is the indication of the misperception people have on chocolate consumption relating to health matters.

Kerimi, A., & Williamson, G. (2015). The Cardiovascular Benefits of Dark Chocolate. Vascular Pharmacology, 71, 11-15.

According to the article, dark chocolate has biologically active components like lipids, sucrose, catechins procyanidins, and theobromine, all of which affect the cardiovascular system. Studies suggest that cocoa benefits its consumers by improving the functioning of endothelial. Cocoa also improves blood pressure and platelet aggregation. On the other hand, the effect of chocolate is complex since the lipids and sucrose may adversely impact on the endothelial function by nitric oxide bioavailability and insulin signalling. Chocolate components such as epicatechin and sugar may sometimes oppose one another in their action, or from time to time act together, like in the case of components like epicatechin and theobromine. And despite cocoa providing benefits to the cardiovascular system as studies confirm, it is still yet not clear its exact components that influence the benefits.

Usually, after consuming dark chocolate, its components are distinctively digested and absorbed in different ways. Depending on their combination, theobromine, catechins, procyanidins, sucrose, and lipid have either opposing or complementary effects on cardiovascular biomarkers as well as endothelial function. Other than being derived from caffeine metabolism, theobromine is also a xanthine alkaloid. The component is resistant to cocoa processing which exists at high levels in dark chocolate. Due to the feature, the component is used to indicate cocoa content in chocolates. Studies have shown that theobromine gets absorbed effectively into the blood, with a half-life of 7.2 hours.

Even though sucrose lacks in cocoa, the component is added at the manufacturing stage of dark chocolate production. The sucrose then gets hydrolyzed into fructose and glucose in the small intestine by the enzyme sucrose-isomaltase, which gets absorbed into the blood by sugar transporters. Therefore, after a person consumes dark chocolate, their blood contains higher levels of theobromine, epicatechin, glucose, fructose, and triglycerides. On the basis of bioavailability studies, epicatechin and theobromine have short-lived direct effects. However, genetic changes from them could last longer. Both fat and sugar help in generating energy for the body, but their excess supply is stored, exposing the body to effects, both in the short and long run.

Generally, it is difficult to establish the main determinant of any perceived benefits, or relationships of the components that make up the dark chocolate. Challenges like disparities in the cohort backgrounds, study duration, as well as lack of appropriate controls also pose threats to researches relating to dark chocolate. As some studies suggest, benefits on blood pressure measurements, diabetes, and lipids are only evident on individuals, hence cannot be the general situation on the ground. In addition, information is still limited, and the little available is inadequate to be applied in sound decision making.

Patel, K., & Watson, R. R. (2018). Chocolate and Its Component's Effect on Cardiovascular Disease. In Lifestyle in Heart Health and Disease (pp. 255-266).

In this publication, authors examine and discuss the benefits of chocolate and the impacts of its constituent elements on cardiovascular diseases. According to experimental and observational studies, consumption of cocoa reduces the risks of cardiovascular diseases. Cocoa also has an association with reduced blood pressure. Chocolate components like minerals, fiber, theobromine, flavonoids, and lipids have useful cardioprotective properties. Flavonoids, a component of chocolate, usually originates from foods like wine, tea, berries, grapes, and cocoa. Flavanol, a sub-class of flavonoids, is the particular type present in chocolate. The degree of cocoa in a chocolate determines the concentration of flavanols present. For instance, whereas milk chocolate has just a few flavanols, dark chocolate has more of the components. The flavanols have anti-oxidant, anti-hypertensive, and anti-inflammatory qualities, which make them possess numerous cardiovascular health benefits. Despite many studies showing that consumption of cocoa has significant nitric oxide, and bioavailability effects, there is still a missing explanation to the mechanism in which the component reduces cardiovascular diseases.

The paper reviewed English language publications for clinical, observational, and experimental studies. In the review, the authors focused on such terms as flavonoids (flavonols, flavanols, catechins, epicatechins, and procyanidins), stearic acid, and chocolate. They also concentrated on outcomes like coronary heart disease, ischemic heart disease, stroke, cholesterol, blood pressure, platelet, oxidation, and thrombosis. During the evaluation, the researchers looked at the quality of the studies reviewed, the consistency of information available across the studies, and the biological applicability of their findings and recommendations.

The paper concluded that over time, cocoa production and subsequent consumption has risen. Hence, there is a need to create an association for chocolate with CVD risks. Based on the review, evidence from laboratory experiments, and randomized trials show that whereas stearic acid may be neutral, flavonoids have higher chances of protecting a person against CVD. The paper's authors also call for a further investigation into an estimation that consuming 50g of dark chocolate a day can reduce CVD risks by around 10%. Therefore, more priority should go to the relationship between chocolate and CVD. Meanwhile, the elements of chocolate still prove to positively impact related diseases.

Kwok, C. S., Loke, Y. K., Welch, A. A., Luben, R. N., Lentjes, M. A., Boekholdt, S. M., & Myint, P. K. (2016). Habitual Chocolate Consumption and the Risk of Incident Heart Failure among Healthy Men and Women. Nutrition, Metabolism and Cardiovascular Diseases, 26(8), 722-734.

The authors of this paper aimed to examine the relationship between chocolate consumption and the possible resultant heart failure among the people living in the United Kingdom. In their study, the researchers conducted a systematic review alongside a meta-analysis to quantify the chocolate intake - heart failure association among males and females. They used data from the European Prospective Investigation into Cancer (EPIC)-Norfolk cohort. The quantity of chocolate consumed was assumed to be related to the frequency of food intake. The researches also supported primary data with both meta-analysis studies and systematic review. The two approaches helped them to evaluate the risk of heart failure due to a chocolate intake. With 53% (11089) female participants, of mean age of 58, almost 0.1% developed heart failure during the study. Later, the researchers adjusted dietary and lifestyle factors, and found approximately 19% fall in heart failure cases among the population they sampled. However, when the researchers adjusted potential mediators, no significant change was observed.

In assessing heart failure incidences, the authors assigned a unique National Health Service number to the patients and linked it to the East Norfolk Commission Record (ENCORE) database. Moreover, in the case of death, the UK Office of National Statistics issued certificates as a way to track fatal cases. During data collection, they excluded individuals with cancer, prevalent baseline heart failure, and patients with any kind of missing data. Results for the study indicated that generally, younger age and participants with low systolic blood pressure exhibited a higher chocolate intake. People with hypertension, diabetes, and myocardial infarction, but with high intake of energy also showed higher chocolate consumption. Additionally, males and females showed equal prevalence to heart failure as a result of chocolate intake. Ideally, consuming chocolate reduced chances of the participants' heart failure. Also, the results showed that chocolate has anti-inflammatory effects on those who consume it, due to its constituent elements. This study is key and can be used by decision makers in the health sector to create awareness of chocolate consumption, as well as curbing heart failures.

Discussion

Studies have shown the relationship between chocolate consumption and heart-related health concerns. Evidently, there is no direct relationship between gender and the effects of chocolate intake in relation to heart failure - both males and females express similar response to heart failure and chocolate consumption. Studies also show that since younger people consuming more chocolates, they reduce their risks to heart failure. Also, there exists a direct relationship between the quantity of chocolate a person consumes and the possible prevention of cardiovascular diseases.

Different components of a chocolate result to different outcomes, depending on their nature, and what other components they combine with. For instance, since the flavanols have anti-inflammatory, anti-hypertensive, and anti-oxidant properties, it is best suited for many cardiovascular health conditions. Chocolate components like sucrose also get dissolved and assimilated into the bloodstream after digestion, making its presence high in people who consume a lot of chocolate than those taking only smaller portions of the food. Others like epicatechin and sugar counteract o...