Potential Heart Health Benefits of Cocoa Polyphenols

Prof. Norman K. Hollenberg, MD, PhD

The proper place of any element in the diet can only be understood in the context of our overall thoughts on the subject of nutrition. Concerns about adequacy of nutrition, and concepts of what represents an optimal diet have evolved continuously over the past century. Early in the twentieth century, major emphasis was given to deficits, ranging from vitamin deficiencies to frank starvation. Beginning at about the middle of the twentieth century, a progressive rise in the frequency and severity of obesity has become the subject of a widespread, sustained, and appropriate concern. As a by-product of that concern, there seems to be a knee-jerk response to thoughts about chocolate intake: In a world in which obesity is rampant, who needs yet another source, albeit a pleasurable one, of 'empty calories'? This question raises two additional questions. Does chocolate intake actually make a substantial contribution to obesity? Do chocolate and cocoa provide only empty calories? The answer to both questions is encouraging.

Does chocolate intake lead to obesity? It is instructive to compare countries in which chocolate use is very high with countries that consume a much more limited per capita chocolate intake. The countries with the two highest levels of chocolate intake, Switzerland and Norway, are not commonly associated with obesity. One the other hand, the U.S.A. and Finland have a chocolate intake about a third of that found in Norway and Switzerland, and in both obesity is rampant.

What about the issue of empty calories? There is growing evidence that at least some chocolate and cocoa might offer substantial health benefits. Again, that information must be viewed in the broader context. We live in a world in which the notion of the health benefits of antioxidants, and the potential benefits of specific items in the diet such as red wine and green tea appear in the newspapers almost daily. In November 1999, one of the most conservative general magazines in the world, Consumer Reports, featured an article on the health benefits of green tea. Indeed, the article included a table which ranked the various green teas for their health benefits!

There is a hierarchy in the quality of evidence available on any health subject. The best evidence comes from large, carefully controlled, randomized clinical trials. Evidence from smaller trials, designed in the same way, stands second. Evidence from observational studies, from epidemiology, stands a distant third: At best, only an association can be found. Studies on mechanisms, if they concur with the epidemiological evidence, increase the likelihood that the association is real. Far behind comes evidence from uncontrolled trials, case reports, and anecdotes. It is sobering that the best available evidence in this area, whether the subject be red wine, green tea, or antioxidants, comes from ‘evidence of the third class' association, perhaps supplemented by pathophysiological, mechanistic considerations. Indeed, when we consider vitamin E, the epidemiological evidence remains supportive whereas the well-designed, well-controlled clinical trials have largely been negative.

The positive properties of red wine, green tea, and many fruits is widely considered to involve an antioxidant class of polyphenols, which in addition to their antioxidant properties have a range of pharmacological properties that could have health benefits. These benefits include a salutary action on platelets and blood vessels. Evidence to be presented at this symposium includes the fact that polyphenol-rich cocoa and chocolate lead to measurable plasma levels of the potentially useful agents; at the concentration in vitroand in vivo, there is a useful influence on platelet function that matches the influence of aspirin; that in vitro cocoa polyphenols activate nitric oxide synthesis which is an important element in the endothelial function. Endothelial dysfunction is characterises atherosclerosis, hypertension, and diabetes mellitus.

Although the evidence is still preliminary, it is worthwhile and constructive to consider the fact that the evidence suggesting a health benefit of cocoa and chocolate is at least comparable to the level of evidence supporting positive health effects of green tea and red wine.

Please Note: Sugar-free sweeteners are not for use by diabetics without the advice of a physician. They are not reduced calorie products and excess consumption may have a laxative effect.

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