Taking Chocolate to Heart: For Pleasure and Health As one of life’s little pleasures, chocolate and cocoa products do more than provide enjoyment and satisfaction to eating; a rapidly growing body of science suggests they may also support overall health and well‐being when included in a balanced diet and healthy lifestyle. Numerous cultures have used cocoa products throughout history for religious, cultural and medical purposes. The first recorded evidence of cocoa being used for health dates back to the 1500s1. Over the past 20 years, a compelling story has emerged on the impact of cocoa flavanols on cardiovascular health, insulin sensitivity and cognitive function. Numerous population‐based studies have found that the inclusion of modest amounts of cocoa‐containing foods, including chocolate, as an element of a mixed diet, is associated with a range of positive effects, including the maintenance of heart health. In addition, randomized, placebo-controlled clinical trials provide direct evidence that the nutrients and the phytonutrients found naturally in cocoa may help to support circulation, brain function, insulin resistance, and improve markers of inflammation and cardiovascular health. The state of science on cocoa and health has even been evaluated by government bodies. The 2010 Dietary Guidelines Advisory Committee concluded that moderate evidence supports that modest consumption of dark chocolate or cocoa, in the context of a balanced diet, is associated with a reduced risk of cardiovascular disease2. Furthermore, in 2012 the European Food Safety Authority approved a health claim for cocoa flavanols and improved blood flow in healthy adults. The claim substantiates a cause and effect relationship between cocoa flavanols and maintenance of “endothelium-dependent vasodilation,” which contributes to healthy blood flow3. While it is important to manage calories and balance the inclusion of these foods in the overall diet, these independent government reviews provide more assurance that consumers can feel good about enjoying small amounts of their favorite cocoa and chocolate treats as part of a healthy and happy life.

Associations between Cocoa, Chocolate and Cardiovascular Health Growing evidence supports an association between dietary inclusion of cocoa and chocolate products and a range of health outcomes, and in particular, cardiovascular disease risk. Over the past 20 years, the cocoa and chocolate eating habits of dozens of studies of thousands of adults of mixed ages, ethnicities, and genders have been studied. Findings from these population‐based studies support an association between the inclusion of cocoa and chocolate in the diet and a range of cardiovascular benefits, including a reduction in overall mortality and blood pressure. Highlights from these recent studies: 

The Zutphen (Elderly) study4 examined the association of cocoa intake with blood pressure and cardiovascular mortality in a sample of 470 elderly men over 15 years. This prospective study found cocoa intake was inversely associated with blood pressure and 15‐year

cardiovascular and all‐cause mortality. 





The Iowa Women’s Health Study5 followed nearly 35,000 women and estimated dietary flavonoid intake from various foods, including chocolate, to evaluate the association between flavonoid intake and cardiovascular disease mortality. Chocolate intake was specifically associated with a reduced risk of death from cardiovascular disease. Harvard researchers followed over 31,000 Swedish middle‐ aged and elderly women over a nine‐year period. Researchers found that moderate chocolate intake (up to one to two servings of chocolate per week) was associated with a significantly lower risk of heart failure6. Among 2,200 adults in the National Heart, Lung, and Blood Institute (NHLBI) Family Heart Study, moderate chocolate consumption (up to 2 servings per week) was

inversely associated with certain types of plaque buildup in the coronary arteries7. 



The association between chocolate consumption and blood pressure was investigated, as well as the incidence of cardiovascular disease, in 19,000 healthy adults over an eight‐year period. In this study, the consumption of as little as 6 grams of chocolate per day was associated with a nearly 40 percent reduction in risk of heart attacks and stroke. This reduction in risk was also accompanied by lower blood pressures among chocolate consumers8. 37,000 Swedish men were followed over 10 years. High chocolate consumption was found to be linked to a significantly lower risk of stroke9.

Epidemiologic research demonstrates a positive relationship between the dietary inclusion of cocoabased products, including chocolate, and cardiovascular health, however, these results can only

provide associations and cannot establish that these foods caused these positive health effects. Thus, these studies should be viewed with cautious optimism and though they cannot prove the benefits of cocoa and chocolate consumption, they do support that cocoa and chocolate products can be an enjoyable part of a healthy and balanced diet. Beyond these studies which examined the relationship between dietary habits and health, there are clinical trials that have looked more directly at the potential benefits related to the consumption of cocoa-containing products. From these studies, there are indications that select nutrients and phytonutrients in cocoa may have a promising role in supporting cardiovascular health. These studies are discussed in the following sections. Cocoa and the Power of Flavonoids Flavonoids are naturally‐occurring compounds found in a wide range of plant-based foods. In recent years, these natural compounds have been widely studied for their ability to confer important health benefits. Among the flavonoids of scientific interest are flavanols (specifically the flavan-3-ols), a subclass of flavonoids prevalent in such commonly consumed foods as cocoa and chocolate. Many clinical investigations over the past decade have concluded that the consumption of certain cocoa and chocolate products naturally abundant in flavanols have significant cardiovascular health-related effects. A number of intervention studies ranging in duration from one day to 18 weeks covering thousands of participants have investigated the effects of cocoa flavanols on chronic disease risk factors. Specifically, studies of men, women, healthy adults, overweight individuals and smokers have demonstrated that consumption of flavanol‐containing dark chocolate and cocoa products can improve the function of the cardiovascular system10, 11, 12, 13, 14 Research suggests that the regular consumption of products rich in cocoa flavanols can improve risk factors for cardiovascular disease and has been shown to lower blood pressure15, 16, 17 and improve blood cholesterol levels in healthy adults and individuals with high blood Cocoa Flavanols

pressure18, 19, 20. Furthermore, investigations of healthy adults have shown that cocoa flavanols improve platelet function by reducing the reactivity of platelets thus making them less prone to form blood clots21, 22, 23, 24, 25. Emerging research has also shown that cocoa flavanols may improve markers of inflammation in healthy adults26, 27 and immune function in overweight adults28. Several systematic reviews of long and short term trials are now available and provide largely consistent findings29, 30. For example, two recent meta-analyses conducted by the Harvard School of Medicine evaluated more than 60 clinical trials and found consistent improvements in cardiovascular disease risk factors blood pressure, lipid profiles, and vascular dilation and promising effects of cocoa flavanols on insulin and insulin resistance, which are markers of diabetes.31, 32 Clinical studies provide direct evidence that the flavanols in cocoa are bioactive compounds that may improve markers of heart health. More research is needed to confirm and extend these research findings, specifically, long-term clinical trials that evaluate development of cardiovascular disease as an endpoint, as opposed to risk factors such as blood pressure, blood lipids and circulation. However, results from clinical investigations on cocoa‐based flavanols to date support the conclusion that the regular inclusion of cocoa and chocolate of products, balanced with calorie intake, can be part of a dietary approach to help maintain and support cardiovascular health. Cocoa Butter and the Neutral Effects of Stearic Acid Cocoa butter is the naturally occurring fat found in cocoa beans and primarily contains a mixture of saturated and monounsaturated fats. Stearic acid is the predominant saturated fat in cocoa butter while oleic acid is the primary monounsaturated fat. Stearic acid makes up about one‐third of the total fat in cocoa butter and more than half of the saturated fat. The remaining saturated fat is palmitic acid. Stearic acid is considered a unique saturated fat as, relative to other saturated fats and trans fats, it does not raise LDL cholesterol levels. For this reason, the 2010 DGAC recommended that stearic acid not be categorized with known “cholesterol‐raising” fats, including other saturated fats and trans fats33. A systematic review of epidemiologic and clinical studies evaluated the effect of stearic acid on blood LDL cholesterol when substituted for other types of fats, including trans fats34. Results indicate that compared to

other saturated fats, stearic acid lowered LDL cholesterol levels, was neutral with respect to HDL cholesterol, and lowered the ratio of total‐to‐HDL cholesterol. Similarly, the review concluded that replacing trans fats with stearic acid, compared to other saturated fats in foods that require solid fats, showed a decrease or no difference on LDL cholesterol levels. Specific to chocolate, a clinical trial observed the effects on blood lipids when a milk chocolate bar was substituted daily for a high carbohydrate snack (pretzels and soft drink) without an increase in total calories35. Researchers found that in this controlled setting, the daily inclusion of chocolate did not raise LDL‐cholesterol and improved HDL-cholesterol levels. Chocolate and Well-being Chocolate has a rich tradition of use as a gift and celebratory food associated with special occasions, so it may not be surprising that there is emerging evidence that chocolate may induce positive mood states and feelings of well‐being. In one study, researchers studied the effects of chocolate preference on health and psychological well‐being in a group of older men and found that chocolate was associated with lower body mass index and waist circumference, better subjective health, optimism, and feelings of happiness.36 Studies on the impact of chocolate and cocoa flavanols on improving brain function and mood have demonstrated interesting, although somewhat mixed results. Several research highlights of key studies on the impact of cocoa and chocolate on mood and cognitive function are mentioned below. This is an exciting new area of research with great promise for future investigation. 

Improved Mood States and Reduced Anxiety – A 2012 publication found that study participants who were given chocolate candy reported higher levels of agreeableness, independent of mood states and were more likely to volunteer their time37. More recently, a study published in 2013 found that cocoa flavanols enhanced positive mood and reduced anxiety in healthy middle-aged adults, however did not affect cognitive function38. Milk and dark chocolate products were shown to convey different degrees of anxiety-reducing and energy improving effects based on individual characteristics39.



Cocoa Flavanols and Enhanced Cognitive Function – Research has demonstrated mixed results of cocoa flavanols on brain function and seems to show the most promising results in certain subpopulations. Cocoa flavanols have been shown to increase blood flow to the brain, which increases oxygenation and may convey improvements in cognitive function, particularly in older people with memory loss.40 Furthermore, preliminary research

suggests that regular consumption of dietary cocoa flavanols may improve cognitive function in elderly subjects with impaired cognitive function41. Similarly, slightly cognitively impaired urban children fed flavanol-rich dark cocoa showed significant improvements in memory42. However, studies of healthy middle-aged adults have yielded mixed results. Some research suggests an association between cocoa flavanols and cognitive performance, including reductions in mental fatigue and improvements in visual function in adults43, 44, while other studies have observed no improvements to cognitive function in this subpopulation45. These novel preliminary findings on cocoa and cognitive function sparked a lively scientific debate in the peer-reviewed literature following the amusing lighthearted publication in the New England Journal of Medicine showing a correlation between Noble laureates per country and that country’s per capita chocolate consumption.46 Chocolate in Moderation: Balancing Food Enjoyment and Your Health Health and nutrition authorities such as the Academy of Nutrition and Dietetics and the Dietary Guidelines for Americans stress the importance of eating mostly nutrient-dense foods such as fruits, vegetables and whole grains while moderating the intake of foods high in solid fats and added sugars. Chocolate products are primarily consumed as an enjoyable treat and contribute extra calories in the form of sugar and fat to the diet. However, chocolate and candy are typically consumed in small quantities. Chocolate and candy contribute 2 percent of total calories, about 5 percent of dietary sugars and 6 percent of added sugars to the typical American diet. Interestingly, despite the energy-density of chocolate, the relationship between chocolate consumption and weight status remains unclear. Several cross-sectional studies have reported an inverse association between chocolate consumption and weight, while studies of longer term cohorts have shown mixed results.47, 48, 49, 50, 51, 52, 53. Since chocolate does contribute extra calories to the diet, it is advisable to consume chocolate in moderation with an emphasis on energy balance. This concept is central to the Nutrition Today publication “Proposing a Definition for Candy in Moderation”, which recommends an average daily portion of 50100 calories for those who choose to eat candy54. This point is also highlighted in the USDA Choose My Plate Ten Tips Series, which states “It’s not necessary to get rid of all sweets and desserts. Show kids that a small amount of treats can go a long way.”

In fact, behavioral research suggests that learning how to include favorite foods, such as chocolate, may play an important role in achieving and sustaining healthy eating behaviors55. This is supported by a recent study of the effects of a sweet snack daily, including dark chocolate, on weight loss in women following a reduced‐calorie diet. Researchers found that incorporating a sweet snack daily as part of discretionary calories does not inhibit positive changes in body weight and body fat percentage, and may help reduce cravings for additional sweets56. Furthermore, a recent study found that people who associated chocolate cake with guilt had lower motivation to eat healthy and were less successful at maintaining their weight than those who associated chocolate cake with celebration57. Research over the past two decades has cast new light on the potential benefits of foods that consumers have long enjoyed, and cocoa and chocolate are no exception. Emerging research from population‐based studies, and more directly from clinical research, supports the conclusion that the enjoyment of moderate amounts of cocoa products, including chocolate, can not only be part of a healthy lifestyle, but may also help to support health. As chocolate in particular is a calorie‐dense food, it is important to balance some of the good news around cocoa and chocolate within the context of an overall diet and lifestyle. The science on cocoa, chocolate and flavanols is not a justification to eat more of these foods; however, in light of the latest science, consumers can consider the potential positive benefits and overall enjoyment of these foods in the context of their overall dietary choices and help provide an informed choice when choosing treats. Consumers can choose and enjoy including chocolate and cocoa products (and not simply exclude them) in their everyday diets. The following tips can help consumers maximize the enjoyment and potential health benefits of chocolate: General Guidelines on Managing Treats in a Happy and Healthy Lifestyle  Adopt a lifestyle, not a “diet.” Diet indicates deprivation, restriction and very careful monitoring with elimination of certain foods. A lifestyle approach involves moderate changes that can be sustained with the goal to improve or maintain overall health.  Allow all foods. Making foods forbidden may increase their desirability and likelihood of overindulgence.  Listen to the body’s signals for hunger, such as a growling stomach, without relying on the clock. Allow the feeling of hunger, but do not get overly hungry, which may lead to unhealthy or overeating.  Fill up on nutrient-dense foods including fruits and vegetables, whole grains and low-fat protein to meet nutrient needs and make room for the occasional little treat.



Practice moderation in food choices and portions. Allow highly palatable foods, such as chocolate candy, in 50-100 calorie portions, or balance out higher-calorie choices over the course of several days.

Tips to Enjoy Cocoa and Chocolate Mindfully in Moderation  Eat mindfully. Turn attention to the chocolate treat being eaten—and experience taste, aroma, texture, and satisfaction. Avoid doing other activities such as watching TV, texting, reading, or talking on the phone while eating.  To appreciate the complex flavors in chocolate, eat it slowly, and take the time to savor every bite.  Enjoy the variety of flavor experiences from chocolate, available in a range of light to very dark. Pair chocolate with other foods, such as fruit or pretzels, to complement flavors while enjoying smaller amounts.  View chocolate as a treat and allow yourself to indulge in moderation without feeling guilty. Guilt may lead to feeling bad and overeating.  Be mindful of the calories contributed by chocolate and balance these by choosing nutrient-dense foods and being physically active.  Take advantage of the nutrition facts label to understand the nutritional content of favorite products. Many chocolate products carry front of package calorie information for ease of accessing this information.  To help keep portion sizes modest, plan ahead by having smaller, pre-portioned chocolates on hand. Most varieties of chocolates are available in smaller individuallywrapped bite sizes, as well as products in re-sealable packages.  To enjoy the taste of chocolate with fewer calories, consider using cocoa powder. o Mix cocoa powder with a small amount of water, a little sweetener, and flavoring such as vanilla, orange or hazelnut to make a simple dip for fruit. o Try cocoa powder with plain yogurt or milk, fruit (fresh or frozen) and/or honey and ice for a chocolate smoothie. o During the winter months, warm up with a steaming cup of hot cocoa. What is Chocolate? Understanding the link between chocolate and health begins with awareness of the origin of chocolate and its components.  Chocolate‐making starts with cocoa beans, which are not actual beans, but rather the seeds of a fruit produced by the cacao tree, which is grown in tropical locations that fall in a









  

narrow band 20 degrees north and south of the equator including countries in West Africa, South America and Asia. On cocoa farms, cocoa beans are fermented and dried before being shipped to chocolate factories, where the beans are roasted and shelled. The cocoa bean nib (or center) is ground into a smooth paste, also referred to as chocolate liquor, which is the essential ingredient of chocolate. Chocolate liquor can be pressed to release cocoa butter and cocoa powder. Chocolate liquor is mixed with varying amounts of cocoa butter, sugar, and other ingredients such as emulsifiers (e.g., lecithin) and flavors to produce popular chocolate products. The addition of milk creates the most popular type of chocolate—milk chocolate. Semi‐sweet (bittersweet) chocolate must contain not less than 35 percent by weight of chocolate liquor. A similar form, known as sweet chocolate, contains more sweeteners and cocoa butter with the level of chocolate liquor at least 15 percent by weight. Dark chocolate is not defined by a standard of identity, but the term is often used to describe semisweet and sweet chocolate. In general, higher proportions of chocolate liquor create a darker chocolate. The % cacao (or % cocoa) content on a product label indicates the total content of ingredients derived from the cocoa bean, which includes chocolate liquor, cocoa butter, and cocoa powder. For Dark Chocolate, Milk Chocolate and White Chocolate example, 60 percent cacao content means that 40 percent of the product is made up sugar, vanilla, and other ingredients. The percent cacao does not necessarily correlate with cocoa flavanol content. Milk chocolate must contain at least 10 percent by weight of chocolate liquor and not less than 12 percent of milk solids. Unsweetened chocolate, also called baking or bitter chocolate, does not contain added sugar and must contain between 50 and 60 percent cocoa butter. Cocoa powder is made by removing much of the cocoa butter from the cocoa bean and grinding the remaining material, excluding the shell, to a powder. Alkalized (dutched) cocoa powder is treated with an alkaline ingredient such as potassium carbonate to help neutralize cocoa’s natural acidity, producing a smooth and mild flavor. Natural cocoa is not treated. Its intense bitterness gives a deep chocolate flavor to baked goods.

Nutritional Composition of the Cocoa Bean and Chocolate Products

References 1

Dillinger T.L., Barriga P., Escarcega S., Jimenez M., Salazar Lowe D., Grivetti L.E. Food of the gods: Cure for humanity? A cultural history of the medicinal and ritual use of chocolate. J Nutr. 2000;130:2057S–2072S. 2

U.S Department of Agriculture, Center for Nutrition Policy and Promotion. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. Part D: The Science Base; Section 3: Fatty Acids and Cholesterol. http://www.cnpp.usda.gov/sites/default/files/dietary_guidelines_for_americans/2010DGACRepo rt-camera-ready-Jan11-11.pdf. Accessed August 2, 2010. 3

EFSA Panel on Dietetic Products, Nutrition and Allergies. Scientific Opinion on the substantiation of a health claim related to cocoa flavanols and maintenance of normal endothelium-dependent vasodilation pursuant to Article 13(5) of Regulation (EC) No 1924/2006. EFSA Journal. 2012;10(7):2809. 4

Buijsse B, Feskens EJ, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006;27;166(4):411-7. 5

Mink PJ, Scrafford CG, Barraj LM, Harnack L, Hong CP, Nettleton JA, Jacobs DR Jr. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr. 2007;85(3):895-909. 6

Mostofsky E, Levitan EB, Wolk A, Mittleman MA. Chocolate intake and incidence of heart failure: A population-based, prospective study of middle-aged and elderly women. Circ Heart Fail. 2010;3:612-616. 7

Djoussé L, Hopkins PN, Arnett DK, Pankow JS, Borecki I, North KE, Curtis Ellison R. Chocolate consumption is inversely associated with calcified atherosclerotic plaque in the coronary arteries: The NHLBI Family Heart Study. Clin Nutr. 2011;30(1):38-43. 8

Buijsse B, Weikert C, Drogan D, Bergmann M, Boeing H. Chocolate consumption in relation to blood pressure and risk of cardiovascular disease in German adults. Eur Heart J. 2010;31(13):161623. 9

Larrson SC, Virtamo J, Wolk A. Chocolate consumption and risk of stroke: A prospective cohort of men and meta-analysis. Neurology. 2013; 80:1173-1174. 10

Heiss C, Kleinbongard P, Dejam A, Perré S, Schroeter H, Sies H, Kelm M. J Am Coll. Acute consumption of flavanol-rich cocoa and the reversal of endothelial dysfunction in smokers. Cardiol. 2005;46(7):1276-83. 11

Heiss C, Finis D, Kleinbongard P, Hoffmann A, Rassaf T, Kelm M, Sies H. Sustained increase in flow-mediated dilation after daily intake of high-flavanol cocoa drink over 1 week. J Cardiovasc Pharmacol. 2007;49(2):74-80.

12

Schroeter H, Heiss C, Balzer J, Kleinbongard P, Keen CL, Hollenberg NK, Sies H, Kwik-Uribe C, Schmitz HH, Kelm M. (-)-Epicatechin mediates beneficial effects of flavanol-rich cocoa on vascular function in humans. Proc Natl Acad Sci. 2006;103(4):1024-9. 13

West SG, McIntyre MD, Piotrowski MJ, Poupin N, Miller DL, Preston AG, Wagner P, Groves LF, Skulas-Ray AC. Effects of dark chocolate and cocoa consumption on endothelial function and arterial stiffness in overweight adults. Br J Nutr. 2014;111(4):653-61. doi: 10.1017/S0007114513002912. 14

Hammer A, Koppensteiner R, Steiner S, Niessner A, Goliasch G, Gschwandtner M, Hoke M. Dark chocolate and vascular function in patients with peripheral artery disease: A randomized controlled cross-over trial. Clin Hemorheol Microcirc. 2014. [Epub ahead of print] 15

Taubert D, Roesen R, Lehmann C, Jung N, Schomig E. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: a randomized controlled trial. JAMA. 2007;298(1):49–60. 16

Grassi D, et al. Cocoa reduces blood pressure and insulin resistance and improves endotheliumdependent vasodilation in hypertensives. Hypertension. 2005;46:1-8. 17

Faridi Z, Njike VY, Dutta S, Ali A, Katz DL. Acute dark chocolate and cocoa ingestion and endothelial function: a randomized controlled crossover trial. Am J Clin Nutr. 2008; 88:58-63. 18

Di Renzo L, Rizzo M, Sarlo F, Colica C, Iacopino L, Domino E, Sergi D, De Lorenzo A. Effects of dark chocolate in a population of normal weight obese women: a pilot study. Eur Rev Med Pharmacol Sci. 2013;17(16):2257-66. 19

Sarriá B, Martínez-López S, Sierra-Cinos JL, García-Diz L, Mateos R, Bravo L. Regular consumption of a cocoa product improves the cardiometabolic profile in healthy and moderately hypercholesterolaemic adults. Br J Nutr. 2014;111(1):122-34. doi: 10.1017/S000711451300202X. 20

Martínez-López S, Sarriá B, Sierra-Cinos JL, Goya L, Mateos R, Bravo L. Realistic intake of a flavanol-rich soluble cocoa product increases HDL-cholesterol without inducing anthropometric changes in healthy and moderately hypercholesterolemic subjects. Food Funct. 2014;5(2):364-74. doi: 10.1039/c3fo60352k. 21

Rein D, Paglieroni TG, Wun T, Pearson DA, Schmitz HH, Gosselin R, Keen CL. Cocoa inhibits platelet activation and function. Am J Clin Nutr. 2000;72(1):30-5. 22

Murphy KJ, Chronopoulos AK, Singh I, Francis MA, Moriarty H, Pike MJ, Turner AH, Mann NJ, Sinclair AJ. Dietary flavanols and procyanidin oligomers from cocoa (Theobroma cacao) inhibit platelet function. Am J Clin Nutr. 2003;77(6):1466-73. 23

Heptinstall S, May J, Fox S, Kwik-Uribe C, Zhao L. Cocoa flavanols and platelet and leukocyte function: recent in vitro and ex vivo studies in healthy adults. J Cardiovasc Pharmacol. 2006;47Suppl2:S197-205.

24

Ostertag LM, O'Kennedy N, Kroon PA, Duthie GG, de Roos B. Impact of dietary polyphenols on human platelet function--a critical review of controlled dietary intervention studies. Mol Nutr Food Res. 2010;54(1):60-81. 25

Ostertag LM, Kroon PA, Wood S, Horgan GW, Cienfuegos-Jovellanos E, Saha S, Duthie GG, de Roos B. Flavan-3-ol-enriched dark chocolate and white chocolate improve acute measures of platelet function in a gender-specific way--a randomized-controlled human intervention trial. Mol Nutr Food Res. 2013 Feb;57(2):191-202. doi: 10.1002/mnfr.201200283. Epub 2012 Nov 8. 26

Hamed M, Gambert S, Bliden K, Bailon O, Anand S, Antonino M, Hamed F, Tantry U, and Gurbel P. Dark Chocolate Effect on Platelet Activity, C-Reactive Protein and Lipid Profile: A Pilot Study. Southern Medical Journal. December 2008; 1203-1208(12): 1203-1208. 27

Baba, S., Osakabe, N., Kato, Y., Natsume, M., Yasuda A, Kido, T., Fukuda, K., Muto, Y. and Kondo, K. Continuous intake of polyphenolic compounds containing cocoa powder reduces LDL oxidative susceptibility and has beneficial effects on plasma HDL-cholesterol concentrations in humans. Am J Clin Nutr. 2007; 85: 709-17 28

Esser D, Mars M, Oosterink E, Stalmach A, Müller M, Afman LA. Dark chocolate consumption improves leukocyte adhesion factors and vascular function in overweight men. FASEB J. 2014;28(3):1464-73. doi: 10.1096/fj.13-239384. 29

Desch S, Schmidt J, Kobler D, Sonnabend M, Eitel I, Sareban M, Rahimi K, Schuler G, Thiele H. Effect of cocoa products on blood pressure: systematic review and meta-analysis. Am J Hypertens. 2010;23(1):97-103. 30

Ding EL, Hutfless SM, Ding X, Girotra S. Chocolate and prevention of cardiovascular disease: a systematic review. Nutr Metab (Lond). 2006;3:2. 31

Shrime MG, Bauer SR, McDonald AC, Chowdhury NH, Coltart CE, Ding EL. Flavonoid-rich cocoa consumption affects multiple cardiovascular risk factors in a meta-analysis of short-term studies. J Nutr. Nov 2011;141(11):1982-1988. 32

Hooper L, Kay C, Abdelhamid A, Kroon PA, Cohn JS, Rimm EB, Cassidy A. Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials. Am J Clin Nutr. 2012; 95(3):740-51 33

U.S Department of Agriculture, Center for Nutrition Policy and Promotion. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. Part D: The Science Base; Section 3: Fatty Acids and Cholesterol. http://www.cnpp.usda.gov/sites/default/files/dietary_guidelines_for_americans/2010DGACRepo rt-camera-ready-Jan11-11.pdf. Accessed August 2, 2010. 34

Hunter JE, Zhang J, Kris-Etherton PM. Cardiovascular disease risk of dietary stearic acid compared with trans, other saturated, and unsaturated fatty acids: a systematic review. Am J Clin Nutr. 2010;91(1):46-63.

35

Kris-Etherton PM, Derr JA, Mustad VA, Seligson FH, Pearson TA. A milk chocolate bar/day substituted for a high carbohydrate snack increases high density lipoprotein cholesterol in young men on a NCEP/ADA Step One diet. Am J Clin Nutr. 1994;60:1037S-42S. 36

Strandberg TE, Strandberg AY, Pitkälä K, Salomaa VV, Tilvis RS, Miettinen TA. Chocolate, wellbeing and health among elderly men. Eur J Clin Nutr. 2008;62(2):247-53. 37

Meier BP, Moeller SK, Riemer-Peltz M, Robinson MD. Sweet taste preferences and experiences predict prosocial inferences, personalities, and behaviors. J Pers Soc Psychol. 2012;102(1):163-174. 38

Pase MP, Scholey AB, Pipingas A, Kras M, Nolidin K, Gibbs A, Wesnes K, Stough C. Cocoa polyphenols enhance positive mood states but not cognitive performance: a randomized, placebocontrolled trial. J Psychopharmacol. 2013;27(5):451-458. 39

Martin FP, Antille N, Rezzi S, Kochher S. Everyday eating experiences of chocolate and nonchocolate snacks impact postprandial anxiety, energy and emotional states. Nutrients. 2012; 4(6): 554567. 40

Sorond FA, Lipsitz LA, Hollenberg NK, Fisher ND. Cerebral blood flow response to flavanolrich cocoa in healthy elderly humans. Neuropsychiatr Dis Treat. 2008;4(2):433-40. 41

Desideri G, Kwik-Uribe C, Grassi D, Necozione S, Ghiadoni L, Mastroiacovo D, Raffaele A, Ferri L, Bocale R, Lechiara MC, Marini C, Ferri C. Benefits in cognitive function, blood pressure, and insulin resistance through cocoa flavanol consumption in elderly subjects with mild cognitive impairment: the Cocoa, Cognition, and Aging (CoCoA) study. Hypertension. 2012;60(3):794-801. 42

Calderon-Garciduenas L, Mora-Tiscareno A, Franco-Lira M et al. Flavonal-rich dark cocoa significantly decreases plasma endothelin-1 and improves cognition in urban children. Front Pharmacol. 2013; 4:104, doi: 10.3389/fphar.2013.00104 43

Scholey AB, French SJ, Morris PJ, Kennedy DO, Milne AL, Haskell CF. Consumption of cocoa flavanols results in acute improvements in mood and cognitive performance during sustained mental effort. J Psychopharmacol. 2010;24(10):1505-1514. 44

Field DT, Williams CM, Butler LT. Consumption of cocoa flavanols results in an acute improvement in visual and cognitive functions. Physiol Behav. 2011;103(3-4):255-260. 45

Pase MP, Scholey AB, Pipingas A, Kras M, Nolidin K, Gibbs A, Wesnes K, Stough C. Cocoa polyphenols enhance positive mood states but not cognitive performance: a randomized, placebocontrolled trial. J Psychopharmacol. May 2013;27(5):451-458. 46

Messerli FH. Chocolate consumption, cognitive function, and Nobel laureates. N Engl J Med. 2012;367(16):1562-4. 47

Golomb BA, Koperski S, White HL. Association between more frequent chocolate consumption and lower body mass index. Arch Intern Med. 2012;172(6):519-521.

48

Murphy MM, Barraj LM, Bi X, Stettler N. Body weight status and cardiovascular risk factors in adults by frequency of candy consumption. Nutr J. 2013;12(1):53. 49

O'Neil CE, Fulgoni VL, 3rd, Nicklas TA. Candy consumption was not associated with body weight measures, risk factors for cardiovascular disease, or metabolic syndrome in US adults: NHANES 1999-2004. Nutr Res. 2011;31(2):122-130. 50

O'Neil CE, Fulgoni VL, 3rd, Nicklas TA. Association of candy consumption with body weight measures, other health risk factors for cardiovascular disease, and diet quality in US children and adolescents: NHANES 1999-2004. Food Nutr Res. 2011;55. 51

O'Neil CE, Nicklas TA, Liu Y, Berenson GS. Candy consumption in childhood is not predictive of weight, adiposity measures or cardiovascular risk factors in young adults: the Bogalusa Heart Study. J Hum Nutr Diet. [Epub ahead of print] Dec 30 2013. doi: 10.1111/jhn.12200 52

Cuenca-Garcia M, Ruiz JR, Ortega FB, Castillo MJ. Association between chocolate consumption and fatness in European adolescents. Nutrition. 2014; 30 236–239. 53

Greenberg JA, Buijsse B. Habitual chocolate consumption may increase body weight in a doseresponse manner. PLoS One. 2013;8(8):e70271. 54

Hornick, B, Duyff, R, Murphy, M and Shumow, L. Proposing a Definition of Candy in Moderation for Health and Well-Being. Nutrition Today. 2014;49:87-94 55

Polivy J. Psychological consequences of food restriction. J Am Diet Assoc. 1996;96:589-92.

56

Piehowski KE, Preston AG, Miller DL, Nickols-Richardson SM. Consuming a sweet snack daily while following a reduced-calorie diet lowers body weight, body fat percentage and food cravings: A pilot study. Abstract. J Am Diet Assoc. 2010;110(Suppl 2):A-11. 57

Kuijer RG, Boyce JA. Chocolate cake. Guilt or celebration? Associations with healthy eating attitudes, perceived behavioural control, intentions and weight-loss. Appetite. 2014;74:48-54. doi: 10.1016/j.appet.2013.11.013.