Cocoa, Dark Chocolate

Assessment and Plan: Cocoa, Dark Chocolate

• Cocoa and chocolate contains caffeine and theobromine. Caffeine intake up to 300 mg per day is generally safe for healthy adults. Older patients or those with hypertension, cardiovascular disease, or cerebrovascular disease should avoid more than 1-2 cups of caffeinated beverages per day (no more than 100-200 mg of cafeine intake per day). One cup of coffee contains on average, about 100 mg of caffeine. Each standard sized milk chocolate bar such as Hershey’s contains about 10 mg of caffeine, and each standard size dark chocolate bar contains about 31 mg of caffeine. Standard caffeine intake is generally recognized as safe by the FDA and AMA but can be dangerous with adverse effects such as high bp, stroke, and arrythmias reported. If more than 1-2 cups of caffeinated beverages are consumed per day, it is prudent to seek physician and/or pharmacist approval of caffeine consumption with any medications or supplements. Please see caffeine section for more detail. Cocoa and chocolate also contains theobromine which is known to act as a stimulant, vasodilator, and diuretic which may be responsible for some of the therapeutic action of cocoa (12). Theobromine and cocoa may intensify the blood pressure lowering effects of any blood pressure medications. Therefore a physician should oversee the care of a patient taking cocoa or chocolate for high blood pressure.

• Hypertension:

• Higher intakes of dark chocolate were associated with lower systolic and diastolic blood pressure, regardless of age or family history of hypertension (1).

• Sudarma V et al found that 30 g/day of dark chocolate daily (containing 70% cocoa) plus dietary counseling for 15 days resulted in increased nitric oxide blood levels over placebo (7.70 vs 1.92, respectively) and decreased systolic blood pressure (120.64 vs. 131.19) (2).

• A 100-g dark polyphenol-rich chocolate bar once per day containing 500 mg of polyphenols showed an average decrease in systolic and diastolic blood pressure (BP) of 5.1 mmHg and 1.8 mmHg compared to white chocolate, respectively, but after the intervention was stopped, BP returned to pre-study values within 2 days (3).

• Pregnancy:

• Triche EW et al determined the following: 1) Women who consumed the most chocolate an highest concentrations of theobromine in cord blood were 69% less likely to develop preeclampsia; 2) 5 or more servings of chocolate per week in the 3rd trimester were 40% less likely to develop pre-eclampsia than once per week; and 3) Women in the 1st trimester eating 5 or more servings per week of chocolate had a 19% lower risk of preeclampsia (4)

• Saftlas, AF et al noted that a higher chocolate intake in the 1st or 3rd trimester was associated with a lower risk of pre-eclampsia, and that a higher intake in the 1st trimester was related to a lower risk of high blood pressure (5).

• Cholesterol:

• Elderly adults who took 500 mL of skim milk daily with 40g of cocoa powder for 4 weeks found that milk plus cocoa increased HDL (good) cholesterol levels by 2.67 mg/dL, and reduced oxidized LDL cholesterol levels of -12.3 U/L compared to milk only (6).

• Cocoa powder was tested as a beverage with hot water at a dose of 13g, 19.5g or 26g per day resulted in the following improvements: total cholesterol, LDL, and triglycerides decreased by 1.15%, 3.77%, and 5.11% respectively, and HDL increased by 9.52% (7).

• Coronary artery disease:

• Total chocolate intake by 4,970 men and women, 25-93 years old was studied and it was found that chocolate intake 1-4 times per week lowered risk of coronary artery disease by 26%, and chocolate intake over 5 times a week lowered risk 57% compared with controls. Also, non-chocolate candy was associated with a 49% higher risk of CHD when comparing 5 or more times per week vs. none per week. (8)

• Djoussé, L et al measured calcified atherosclerotic plaque in coronary arteries by cardiac computer tomography, and after comparing non-eaters of chocolate as a baseline with those who consumed 1-3 servings per month had a 6% reduced size of coronary artery plaque. Also, once per week chocolate eaters had a 22% reduction, and twice per week chocolate eaters had a 32% reduction. (9)

• Chocolate and stroke: Consumption of chocolate has been found to significantly reduce the risk of both ischemic stroke and hemorrhagic stroke in a large cohort study on women who ate a median of 66.5 grams per week of chocolate (13). In a large cohort study on men, a median intake of 62.9 grams of chocolate per week was associated with a decrease in risk of stroke by about 17% (14).

• Endothelial function: After cocoa intake, blood vessel response to nitric oxide and endothelial function improved, but the vessels of older adults responded to a greater extent (10).

• Chronic Fatigue Syndrome: Results of a small double-blind, randomized crossover study indicated that consumption of a 15 gram bar of 85% cocoa, 3 times daily significantly improved symptoms of chronic fatigue (10).

• Chocolate and asthma: Cocoa and chocolate have a significant effect on lung function due to the theobromine and theophylline content. Simons FE et al found that an average dose of 468 mg of theobromine and an average dose of 249 mg of theophylline each separately promoted significant improvements in all pulmonary function tests (15). 468 mg of theobromine is equivalent to about 50 grams of a dark chocolate bar containing 70-90% cocoa (standard chocolate bars contain 100 grams of dark chocolate). Dark chocolate is less palatable than milk chocolate, but contains much more theobromine per given amount of fat content. Cocoa powder may also be mixed into a drink or used in a recipe of choice. Chocolate and cocoa is also known to act as a cough suppressant (16).