Abstract
PurposeEvidence for the association between chocolate intake and risk of chronic diseases is inconclusive. Therefore, we aimed to synthesize and evaluate the credibility of evidence on the dose-response association between chocolate consumption with risk of all-cause mortality, coronary heart disease (CHD), stroke, heart failure (HF), type 2 diabetes (T2D), colorectal cancer (CRC), and hypertension.MethodsProspective studies were searched until July 2018 in PubMed, Embase, and Web of Science. Random-effects meta-analyses comparing highest versus lowest intake categories, linear, and non-linear dose-response analyses were conducted. The credibility of evidence was evaluated with the NutriGrade scoring-system.ResultsOverall, 27 investigations were identified (n = 2 for all-cause mortality, n = 9 for CHD, n = 8 for stroke, n = 6 for HF, n = 6 for T2D, n = 2 for hypertension and CRC, respectively). No associations with HF (RR 0.99, 95% CI 0.94, 1.04) and T2D (RR 0.94, 95% CI 0.88, 1.01) per each 10 g/day increase in chocolate intake were observed in the linear dose-response meta-analyses. However, a small inverse association for each 10 g/daily increase could be shown for the risk of CHD (RR 0.96, 95% CI 0.93, 0.99), and stroke (RR 0.90, 95% CI 0.82, 0.98). The credibility of evidence was rated either very low (all-cause mortality, HF, T2D, CRC or hypertension) or low (CHD, stroke).ConclusionChocolate consumption is not related to risk for several chronic diseases, but could have a small inverse association with CHD and stroke. Our findings are limited by very low or low credibility of evidence, highlighting important uncertainty for chocolate–disease associations.
Highlights
Cocoa, mostly consumed as chocolate in Western countries, is rich in various bioactive compounds such as flavanols including catechins, epicatechin, and proanthocyanidins as well theobromine [1]
Out of the 287 records identified by the literature search, 47 full-text articles were assessed in detail (ESM Material 2, ESM Ref), and 27 were included in the meta-analysis as they reported on chocolate consumption and at least one of 7 diseases (ESM Fig. 1)
Two prospective observational studies were included for all-cause mortality [28, 29], 9 reports (10 studies) for coronary heart disease (CHD) [28, 30,31,32,33,34,35,36,37], 8 studies for stroke [28, 30, 31, 33, 36, 38,39,40], 6 studies for heart failure [28, 35, 41,42,43,44], 6 studies for type 2 diabetes (T2D) [23, 45,46,47,48,49], and 2 studies for colorectal cancer (CRC) [50, 51], and hypertension [52, 53], respectively (ESM Table 1)
Summary
Mostly consumed as chocolate in Western countries, is rich in various bioactive compounds such as flavanols including catechins, epicatechin, and proanthocyanidins as well theobromine [1]. The flavanols of cocoa have been found to exert beneficial effects on endothelial function, platelet aggregation, insulin sensitivity, oxidative damage, and inflammation, all of which play a key role in the pathogenesis of major non-communicable diseases (NCD) including cardiovascular diseases (CVD), type 2 diabetes (T2D), and cancer [2]. Diet is recognized as a modifiable risk factor for NCD and a change in dietary behaviour is a cornerstone for disease prevention [3]. The inclusion of chocolate as a part of dietary recommendations for NCD prevention remains controversial. Many food grouping systems classify chocolate together with confectionary and sweets, and dietary recommendations favour lower intakes of this food group due to its high content of fat and added sugar [5, 6]
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