Running head: CHOCOLATE EXHIBITS HEALTH BENEFITS

Chocolate Exhibits Health Benefits Related to Blood Pressure, Cardiovascular Disease and Cholesterol Carolina Arango Drexel University

CHOCOLATE EXHIBITS HEALTH BENEFITS Abstract Cocoa, the bean from the Theobroma cacao plant, is most commonly known in its chocolate form. Cocoa beans have been used in history for their valuable medicinal properties. It was not until recently that we began acknowledging and studying their important attributes, which are believed to be caused by the high percentage of polyphenols they contain. It is important to be familiar with the processing the beans undertake in their journey to become chocolate, as extensive processing can truly decrease the amount of polyphenols and therefore its health benefits. These polyphenols function as antioxidant and anti-inflammatory agents, and have demonstrated to increase the bioavailability of nitric oxide, which in turn improves endothelial

function. This paper examines the results of several studies performed to test chocolates effects on blood pressure, cardiovascular disease (CVD), and cholesterol lipids. It also reviews its neuroprotective properties and mood enhancement qualities. Chocolate is a wonderful food to include as part of a healthy diet, keeping in mind that it does have some possible adverse effects and should be used in moderation to avoid weight gain due to its high fat content.

CHOCOLATE EXHIBITS HEALTH BENEFITS Chocolate Exhibits Health Benefits Related to Blood Pressure, Cardiovascular Disease and Cholesterol Throughout history, cacao has exhibited important health benefits. Although its medicinal uses have diminished over time, recent attention has been brought back to cacao because it contains polyphenols, which have been associated with overall well being and a

decrease in risk for important chronic diseases. Cacao is used to produce chocolate, a favorite of many consumers due to its appealing flavor and unique texture. Chocolate comes in many varieties, mainly dark, milk or white. Dark chocolate, in particular, has been studied for its clinical benefits --among the most prominent, its effects in lowering cholesterol levels and blood pressure, lessening the risk for cardiovascular disease, as well as having neuroprotective functions and improving mood. History and a plethora of studies have demonstrated it is beneficial in these areas. There are, however, a few contradicting results which, without a doubt, more detailed research can clarify. History of Chocolate Cacao is the unprocessed cocoa bean from the tropical fruit Theobroma cacao, which originated around the equator in the Americas (McShea et al., 2008). The bean is finely ground, fermented, roasted, and milled to produce chocolate (Hoskin, 1994; McShea et al., 2008). As a medicine, chocolate was first introduced to the Old World in 1502-1504 by Christopher Columbus in its beverage form, then in its solid form around 1828, and it began to be mass produced in 1847 (Hoskin, 1994). T. cacao belongs to the Stenculiaceae family and it exists in three major varietals: Forastero (bulk grade), Criollo (fine grade), and Trinitario (most common) (Hoskin, 1994; McShea et al., 2008), each which requires unique processing. In the northern climates the consumption of chocolate products is estimated at 5 10 kg per person per year, and

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world demands are high, at about 3.5 million tons in 2008 (McShea et al., 2008). Because of the large amounts of chocolate products consumed throughout the world, it is important to understand the health benefits and adverse effects its consumption can have on the body. Components in Chocolate that Exert Wellbeing Polyphenols found in the T. cacao plant are a defense mechanism against predators (Heim, Tagliaferro, & Bolbiva, 2002). Polyphenols belong to a larger class of organic components called phytonutrients, which are found in plants and are believed to promote human health. They can be classified as non-flavonoids or flavonoids. The polyphenols found in cocoa are flavonoids. Figures 1 and 2 show the further classifications of flavonoids and flavanols. Over 4,000 flavonoids have been identified (Heim, Tagliaferro, & Bolbiva, 2002). The key flavonoids found in cocoa, proantocyanidins, make up 12% to 48% of the dry cocoa bean by weight (Ross, 2007). Flavonols, also known as flavan-3-ols or catechins, derive from proantocyanidins as procyanidin polymers or (-)-epicatechin and (+)-catechin monomers (Fernandez-Murgaa, Tarinb, Garcia-Perez, & Canoa, 2011; Heim, Tagliaferro, & Bolbiva, 2002). A 40 gram serving of dark chocolate contains up to 2.8 grams of (-)-epicatechin, the most bioavailable antioxidant in cacao (McShea et al., 2008). Flavonols can be found in the fermented T. cacao seeds, as well as in a triglyceride matrix in dark chocolate (McShea et al., 2008).

Figure 1: Flavanol Classifications. This figure shows catechin, epicatechin, and procyanidin as flavonol derivatives (Fernandez-Murgaa, Tarinb, Garcia-Perez, & Canoa, 2011).

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Figure 2: Flavonoid Classifications. This figure shows proanthocyanin as sub-classification of flavonoids (McShea et al., 2008). Aside from flavonols, cocoa contains arginine, the amino acid necessary for the production of nitric oxide (Ross, 2007), and Magnesium (Mg), which has shown to influence blood pressure (Almoosawil, Fyfel, Ho, & Al-Dujaili, 2010). Chocolate can in fact provide us with more polyphenols per serving than popular sources like vegetables, fruits, wine and tea (Almoosawil, Fyfel, Ho, & Al-Dujaili, 2010), which makes it a valuable herb to use for clinical purposes. The Effect of Flavonoids on Health Flavonoids are believed to be responsible for chocolates health benefits through their antioxidant and anti-inflammatory functions in the body. Flavonoids activate antioxidant enzymes (Heim, Tagliaferro, & Bolbiva, 2002), and their antioxidant activity against free radicals is believed to be stronger than that of vitamin C, vitamin E, -carotene, selenium and zinc (Ross, 2007). This is significant because antioxidants have been associated with reducing risk of disease. They also decrease the breakage of small blood vessels, enhance vascular function, and inhibit platelet activation and aggregation, which improves blood pressure and

CHOCOLATE EXHIBITS HEALTH BENEFITS reduces the risk for CVD (Hoskin, 1994). The flavonoids found in cocoa release nitric oxide making it more bioavailable (Heim, Tagliaferro, & Bolbiva, 2002) an important feature because a decrease in nitric oxide bioavailability has shown to contribute to endothelial dysfunctions (Heim, Tagliaferro, & Bolbiva, 2002). These important functions depict chocolate as having significant medicinal uses.

The Effects of Processing on Chocolate Flavonoids

Since cocoa is rarely consumed raw, to look at its health benefits, one must also look at the other ingredients and the processes it can be subjected to. Most cocoa is consumed as chocolate and not all chocolate is created uniformly. Therefore, it is important to be familiar with the processing of the cacao beans, as this will affect the final products flavonoid and antioxidant content (McShea et al., 2008; Ross, 2007), and therefore diminish the acclaimed clinical benefits. Although chocolate undergoes many processes, one that significantly reduces the amount of flavonols is dutching, a process to improve the flavor of the beans and reduce the amount of free acids and volatile by-products (McShea et al., 2008). The problem with underprocessing the cacao beans, is that it decreases palatability. For example, under-fermented and under-roasted cacao will exert greater health benefits due to higher antioxidant content, yet the more cutting flavor will be almost revolting to our taste buds (McShea et al., 2008). For this reason, it is important to find the minimum dosage of polyphenols that will exert health benefits.

Other ingredients found in chocolate can also interfere with its health benefits. Varying amounts of cocoa, sugar, and milk can be found in different kinds of chocolate. Dark chocolate will contain a higher amount of antioxidant cocoa flavonols than milk chocolate, yet recent

CHOCOLATE EXHIBITS HEALTH BENEFITS studies indicate that milk chocolate retains the antioxidant activity in proportion to its cacao flavonol content (McShea et al., 2008); hence, even milk chocolate can have positive health effects at a smaller scale. There is still a debate on whether or not the addition of milk to chocolate hinders the ingestion of polyphenols. Further research should focus on establishing if there are any other factors that can inhibit polyphenol absorption by the body, and therefore prevent them from exerting utmost benefits, as this will determine which kinds of chocolate are recommended for clinical purposes. Chocolate Has Exhibited Important Health Benefits Chocolate Can Help Reduce Blood Pressure

Much of the debate on cocoas benefits on lowering blood pressure began after observing the Kuna populations of Panama, whose protection against hypertension and cardiovascular disease is believed to be due to their high intake of cocoa (Almoosawil, Fyfel, Ho, & Al-Dujaili, 2010; Fernandez-Murgaa et al., 2011; Hollenberg, Fisher, & McCullough, 2009). According to Hollenberg, Fisher, and McCullough (2009), the Kuna Amerinds are the community with the largest polyphenol consumption known, consuming about 1880 mg of flavonoids daily. Despite the fact that they intake more sodium and chloride than most Western populations, their blood pressure does not tend to rise with age, and many over the age of 60 have an incredible average blood pressure lower than 110 mm Hg/70 mm Hg (Hollenberg, Fisher, & McCullough, 2009). After making these observations, it seemed possible that this novelty was due to good genes, yet Hollenberg, Fisher, and McCullough (2009) found that Kuna who moved to an urban environment developed hypertension, and that the main difference in their lifestyles and diet was the diminished consumption of cocoa.

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A parallel randomized clinical trial by Sudarma, Sukmaniah, and Siregar (2011) tested 20 male and 10 female subjects who had been diagnosed with prehypetension and were between the ages of 25 and 44 on how the consumption of 30 grams of dark chocolate a day, for 15 days affected their nitric oxide serum levels and their blood pressure. The subjects were divided into two groups whose characteristics and energy and sodium intake at the start were not significantly different (Sudarma, Sukmaniah, & Siregar, 2011). One consumed polyphenol rich dark chocolate while the other did not. Results showed a significant decrease in systolic blood pressure between groups (p=0,001) and an increase in nitric oxide serum levels (Sudarma, Sukmaniah, & Siregar, 2011), consistent with Hollenberg, Fisher, and McCullough (2009) who found levels of flavonols were six times higher and urinary nitrate and nitrite levels were two times higher in Kuna living on the island than those from Kuna living on the mainland. These results are possibly due to the island habitants higher cocoa consumption. This is significant because higher levels of nitrate and nitrite in urine reflect greater nitric oxide synthesis, and nitric oxide is believed to help control blood pressure by dilating blood vessels (Ross, 2007), therefore its increase would mean better blood pressure control.

Studies that have reported lower blood pressure after the consumption of dark chocolate include that by Grassi et al. (2008) where 11 males and 8 females with a family history of hypertension and diabetes consumed either a 100 g bar of flavonol-rich dark chocolate or a 100 g bar of flavonol-free white chocolate for 15 days (Grassi et al., 2008). Results of the study showed that flavonol-rich dark chocolate decreased systolic and diastolic blood pressure, while the flavonoid-free white chocolate did not modify systolic nor diastolic blood pressures in the subjects (Grassi et al., 2008). Taubert, Roesen, Lehmann, Jung, and Schomig (2007) also found a decrease in systolic blood pressure ( 2.9 /1.6 mm Hg) and diastolic blood pressure ( 1.9/1.0

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mm Hg) when 44 male and female volunteers between the ages of 55 to 75 with prehypertension or stage 1 hypertension consumed either a 6.3 gram dose of polyphenol-rich dark chocolate or a 5.6 gram dose of polyphenol-free white chocolate daily for 18 weeks. Results showed no change in those consuming the white chocolate (Taubert et al., 2007). These are impressive findings that make it worthy to take into consideration consuming small amounts of chocolate daily to improve blood pressure.

Studies Have Demonstrated Improved Lipid Profiles

Aside from decreasing blood pressure, chocolate has been addressed in numerous studies for its encouraging effects on lipid profiles. Maintaining healthy lipid profiles promotes wellness, and findings have revealed chocolate can reduce low density lipoproteins (LDL or bad cholesterol) and increase high density lipoproteins (HDL or good cholesterol). LDL has a cholesterol-depositing role, while HDL removes cholesterol from cells and returns it to the liver where it can be excreted in the bile. Therefore, maintaining a low HDL: LDL ratio is beneficial in maintaining healthy cholesterol levels which in turn can maintain well being and help prevent the development of chronic diseases. Grassi et al. (2008) not only demonstrated chocolates effects on lowering blood pressure, but also found that the consumption of 100 g bar of polyphenol-rich dark chocolate decreased serum total cholesterol and LDL cholesterol in the participants, while polyphenol-free white chocolate consumption had no effect on their lipid profile. A significant LDL cholesterol lowering effect was also found by Nanetti et al. (2012) in female participants, but not in the males, an interesting factor that should be further researched.

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Mursu et al. (2004) found HDL cholesterol increased in 12 healthy men and 33 healthy women between the ages of 19 and 49. Subjects in this study were given the option of consuming 75 g of white chocolate with less than 1 mg of polyphenols, dark chocolate with 274 mg of polyphenols, or dark chocolate enriched with cocoa polyphenols with a total of 418 mg of polyphenols daily for 3 weeks (Mursu et al., 2004). HDL cholesterol concentration increased by 11.4% in the dark chocolate group and 13.7% in the dark chocolate enriched with cocoa polyphenols group, while it only increased by 2.9% in the group consuming the white chocolate (Mursu et al., 2004). Results by Hamed et al. (2008) showed an 8% increase in HDL and a 6% decrease in LDL in 28 healthy volunteers, and Nanetti et al. (2012) reported an increase in HDL cholesterol concentrations and a decrease in triglycerides in 25 male and 25 female subjects between 28 and 45 years old after 3 weeks of consuming 50 grams of dark chocolate daily. Some contradicting results are those by Grassi et al. (2008) which showed no increases in HDL cholesterol from dark chocolate consumption, and Hamed et al. (2008) which found no significant changes in triglycerides or total cholesterol. Mursu et al. (2004) found no significant changes in serum total, LDL cholesterol or triglyceride concentrations. Shiina et al. (2007) also found no differences in total cholesterol, LDL cholesterol, or even HDL cholesterol and triglyceride levels in male subjects. Valuable studies have demonstrated chocolate does have potential to improve lipid profiles, the few contradicting results should be further explored to determine what factors can prevent the improvement. Chocolate Demonstrates It Reduces Risk for Cardiovascular Disease Aside from chocolates beneficial effects on lipid profiles, it has also been associated with reducing the risk for CVD, noteworthy because CVD is a major cause of death in the United States and abroad. Several components are responsible for the positive relationship between

CHOCOLATE EXHIBITS HEALTH BENEFITS chocolate and decreased CVD risk, amongst them Theobromine and flavonols, which create vasodilative effects and exert antioxidant, anti-platelet and anti-inflammatory functions that

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improve endothelial function and therefore decrease CVD risk (Shiina et al., 2007). Hamed et al. (2008) had 28 healthy volunteers, ages 24 to 60, consume 100 grams of Lindt dark chocolate with 70% cacao and 700 mg of flavonoids daily for a week. Results showed decreased inflammation in women only (19 of the 28 participants were female) and decreased platelet reactivity in the entire group, both of which are related to enhanced heart health. Nitric oxide plays an important role in keeping the heart healthy. It dilates blood vessels while regulating blood flow and inflammation (Ross, 2007). The flavonols found in chocolate increase the bioavailability of nitric oxide through increased nitric oxide synthase activity and increase brachial artery endothelial function (Shiina et al., 2007). This is important because it shows that chocolate helps prevent endothelial dysfunctions which are believed to be the key events in developing atherosclerosis, which then leads to CVD. Studies test flow-mediated dilation to assess endothelium function. The capacity of blood vessels to dilate shows healthy function. Shiina et al. (2007) demonstrated flow-mediated dilation and coronary flow velocity reserve significantly increased (3.38+/-0.82 to 4.28+/-0.85) when subjects consumed flavonoid-rich dark chocolate. In the study, 39 healthy male subjects between 23 and 40 years old consumed either flavonoid-rich dark chocolate with 550 mg of polyphenols or non-flavonoid white chocolate, and dilation was found in only the group consuming dark chocolate (Shiina et al., 2007). Grassi et al. (2008) also demonstrated increased flow-mediated dilation of the brachial artery with the consumption of dark chocolate, while there was no effect on vascular reactivity with the consumption of white chocolate. These results

CHOCOLATE EXHIBITS HEALTH BENEFITS demonstrate chocolates powerful effects in keeping the heart healthy by proper endothelial function. Chocolate has Demonstrated Neuroprotective Functions and Mood Improvement Chocolate continues to amaze us with its numerous health benefits. Its intake improves cerebral blood flow which may have a positive impact on cerebrovascular diseases (McShea et

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al., 2008) and an improvement in neural function and visual contrast sensitivity (Field, Williams, & Butler, 2011). These findings should be further explored as it would be great to include improved vision as one of the benefits provided by chocolate consumption. Aside from improving our physical well being, chocolate has been noted for keeping us happy through its mood enhancing effects. Macht and Dettmer (2006) examined the effects eating a chocolate bar versus an apple had on a variety of emotions in 37 healthy women of BMI of 21.6 between the ages of 19 and 30. Results, measured on a bipolar and a unipolar scale, showed that eating chocolate increased activation, reduced hunger and tiredness, brought out joy, and elevated mood more than eating an apple (Macht & Dettmer, 2006). It did however, also create feelings of guilt. These results are valuable to note because improving our emotional standing could be an added value to the use of chocolate. Adverse Effects and Contraindications of Chocolate Although safe for many, adverse effects have been reported in some studies. In the study by Taubert et al. (2007) a few subjects reported nausea, possibly due to chocolates stimulatory effect which can cause anxiety and nervousness (Ross, 2007). Laxative effects, as well as a bloated feeling were also reported by Taubert et al., 2007. Chocolate contains caffeine and vasoactive amines which are associated with the start of migraines (Ross, 2007), therefore

CHOCOLATE EXHIBITS HEALTH BENEFITS individuals who suffer from migraines should avoid its consumption. Mursu et al. (2004) reported weight increased slightly in participants consuming dark chocolate throughout the study, an important factor because eating large amounts of chocolate is usually associated with weight gain.

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Contraindications on the use of cocoa and selective serotonin reuptake inhibitors (SSRIs) medications were reported by Cederberg, Knight, Svenson, and Hakan (2004), from a patient who developed an itch through his arms, abdomen and legs after eating a piece of chocolate cake while being under SSRI medication. This report suggests that careful use must be employed when using chocolate or cocoa products under SSRI medications, especially for those individuals sensitive to serotonin increases since it is a component found in chocolate (Cederberg et al., 2004). It is also recommended that those with active herpes infections stay away from chocolate because it contains the amino acid arginine, which is necessary for the replication of the virus (Ross, 2007). None of the effects mentioned above were serious and they all ended after discontinuing the consumption of the cacao product. If used correctly, chocolate can have more positive than negative effects on health, yet, like with any herb or medication, being aware of the possible side effects and counterinteractions can help avoid an unpleasant experience. Discussion Chocolate use has been found beneficial in lowering blood pressure, improving lipid profiles and decreasing the risk for cardiovascular disease, as well as improving mood and neuronal function. Studies have addressed these health benefits with different amounts of chocolate and varying time periods and most have reported positive outcomes. A few studies do show contradicting results. Yet, its impressive uses throughout history and the unusual health

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patterns displayed by the elderly Kuna population, who consume large amounts of cocoa on the island they reside, show that these contradicting results just need some clarification. It is also important to note that cocoa consumption does not come without possible side effects, some of which have been reported in the previously stated studies. Chocolate should be consumed in moderation to avoid weight gain due to its high fat content. Sorting out the minor incongruities will help determine an adequate routine at which chocolates maximal health benefits can be achieved.

CHOCOLATE EXHIBITS HEALTH BENEFITS References Almoosawil, S., Fyfel, L., Ho, C., & Al-Dujaili, E. (2010). The effect of polyphenol-rich dark

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chocolate on fasting capillary whole blood glucose, total cholesterol, blood pressure and glucocorticoids in healthy overweight and obese subjects. British Journal of Nutrition, 103, 842-850. doi:10.1017/S0007114509992431 Cederberg, J., Knight, S., Svenson, S., & Hakan, M. (2004). Itch and skin rash from chocolate during fluoxetine and sertraline treatment: Case report. BMC Psychiatry, 4(36). doi:10.1186/1471-244X-4-36 Fernandez-Murgaa, L., Tarinb, J. J., Garcia-Perez, M. A., & Canoa A. (2011). The impact of chocolate on cardiovascular health. Maturitas, 69, 312-321. doi:10.1016/j.maturitas.2011.05.011 Field, D. T., Williams, C. M., & Butler, L. T. (2011). Consumption of cocoa flavanols results in an acute improvement in visual and cognitive functions. Physiology & Behavior, 103, 255-260. doi:10.1016/j.physbeh.2011.02.013 Grassi, D., Desideri, G., Necozione, S., Lippi, C., Casale, R., Properzi, G., Blumberg, J. B., & Ferri, C. (2008). Blood pressure is reduced and insulin sensitivity increased in glucose intolerant, hypertensive subjects after 15 days of consuming high-polyphenol dark chocolate. Journal of Nutrition, 138, 1671-1676. Retrieved from http://jn.nutrition.org Hamed, M. S., Gambert, S., Bliden, K., Bailon, O., Anand, S., Antonino, M. J., Hamed, F., Tantry, U. S., & Gurbel, P. A. (2008). Dark chocolate effect on platelet activity, Creactive protein and lipid profile: A pilot study. Southern Medical Journal, 101(12), 1203-1208.

CHOCOLATE EXHIBITS HEALTH BENEFITS Heim, K. E., Tagliaferro, A. R., & Bobilva, D. J. (2002). Flavonoid antioxidants: Chemistry, metabolism and structure-activity relationships. Journal of Nutritional Biochemistry, 13, 572-584 Hollenberg, N. K., Fisher, N. D. L., & McCullough, M. L. (2009). Flavanols, the Kuna, cocoa consumption, and nitric oxide. Journal of the American Society of Hypertension, 3(2), 105-112. doi:10.1016/j.jash.2008.11.001 Hoskin J. C. (1994). Sensory properties of chocolate and their development. The American Journal of Clinical Nutrition, 60(suppl), 1068S-170S. Retrieved from http://www.ajcn.org Macht, M., & Dettmer, D (2006). Everyday mood and emotions after eating a chocolate bar or an apple. Appetite, 46, 332-336.

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McShea, A., Ramiro-Puig, E., Munro, S. B., Casadesus, G., Castell, M., & Smith, M. A. (2008). Clinical benefit and preservation of flavonols in dark chocolate manufacturing. Nutrition Reviews, 66(11), 630641. doi:10.1111/j.1753-4887.2008.00114.x Mursu, J., Voutilainen, S., Nurmi, T., Rissanen, T. H., Virtanen, J. K., Kaikkonen, J., Nyysso, K., & Salonen, J. T. (2004). Dark chocolate consumption increases HDL cholesterol concentration and chocolate fatty acids may inhibit lipid peroxidation in healthy humans. Free Radical Biology & Medicine, 37(9), 1351-1359. doi:10.1016/j.freeradbiomed.2004.06.002 Nanetti, L., Raffaelli, F., Tranquilli, A. L., Fiorini, R., Mazzanti, L., & Vegnini, A. (2012). Effect of consumption of dark chocolate on oxidative stress in lipoproteins and platelets in women and in men. Appetite, 58, 400-405. doi:10.1016/j.appet.2011.11.010

CHOCOLATE EXHIBITS HEALTH BENEFITS Ross, S. M. (2007). Chocolate: Be bad, to feel good. Holistic Nursing Practice, 21(1), 5051.

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Shiina, Y., Funabashi, N., Lee, K., Murayama, T., Nakamura, K., Wakatsuki, Y., Daimon, M., & Komuro, I. (2007). Acute effect of oral flavonoid-rich dark chocolate intake on coronary circulation, as compared with non-flavonoid white chocolate, by transthoracic Doppler echocardiography in healthy adults. Department of Cardiovascular Science and Medicine, 424-429. doi:10.1016/j.ijcard.2007.07.131 Sudarma, V., Sukmaniah, S., & Siregar, P. (2011). Effect of dark chocolate on nitric oxide serum levels and blood pressure in prehypertension subjects. University of Indoneia Journal of Internal Medicine, 43(4), 224-228. Taubert, D., Roesen, R., Lehmann, C., Jung, N., & Schomig, E. (2007). Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. JAMA, 298(1), 4960. Retrieved from http://jama.ama-assn.org

Intellectual Honesty Certification

I certify that: This paper is entirely my own work, with any words and/or ideas from other sources (print, Web, other media, other individuals or groups) being properly indicated (words with quotation marks) cited in text, and referenced. I have not submitted this paper to satisfy the requirements of any other course.

Students Signature: Carolina Arango

Date: June 3rd, 2012