The effectiveness and cost effectiveness of dark chocolate consumption as prevention therapy in people at high risk of cardiovascular disease: best case scenario analysis using a Markov model

A Novel Promising Frontier for Human Health: The Beneficial Effects of Nutraceuticals in Cardiovascular Diseases

Cardiovascular diseases (CVDs) such as hypertension, atherosclerosis, myocardial infarction, and diabetes are a significant public health problem worldwide. Although several novel pharmacological treatments to reduce the progression of CVDs have been discovered during the last 20 years, the better way to contain the onset of CVDs remains prevention. In this regard, nutraceuticals seem to own a great potential in maintaining human health, exerting important protective cardiovascular effects. In the last years, there has been increased focus on identifying natural compounds with cardiovascular health-promoting effects and also to characterize the molecular mechanisms involved. Although many review articles have focused on the individual natural compound impact on cardiovascular diseases, the aim of this manuscript was to examine the role of the most studied nutraceuticals, such as resveratrol, cocoa, quercetin, curcumin, brassica, berberine and Spirulina platensis, on different CVDs.

Using digital health technology to evaluate the impact of chocolate on blood pressure: Results from the COCOA-BP study

Background

High blood pressure (BP) is a major risk factor for cardiovascular disease (CVD). Consumption of dark chocolate, which is high in flavonoids that may reduce CVD risk, is an attractive intervention to reduce to BP. Additionally, the use of mobile health (mHealth) technologies (eg, telehealth, smartphones, and wearable devices) can improve outcomes in patients with CVD.

Objective

The purpose of this study was to investigate the impact of dark chocolate intake on BP, subject use of mHealth, and integration of mHealth into a clinical trial.

Methods

The COCOA-BP (ChOcolate COnsumption And Blood Pressure) study was a prospective, single-center, pre-/postintervention study that enrolled 62 healthy volunteers. The study consisted of 3 phases: smartwatch/smart BP monitor familiarization and washout from chocolate (week 1); control (week 2); and intervention (weeks 3 and 4). During the intervention phase, subjects consumed 50 g of dark chocolate per day. The primary endpoint was change in resting systolic BP between the intervention and control phases. Additional endpoints included device accuracy and correlation with physical activity.

Results

Mean resting systolic BP was 116.4 mm Hg before chocolate intake among 62 participants (mean age 37 years; 61% female). After chocolate intake, mean resting systolic BP was 116.0 mm Hg (difference –0.4; P = .69). These findings suggest that 2 weeks of dark chocolate intake did not reduce resting systolic BP. There was poor agreement between mHealth device and standard (nurse-performed) measurements.

Conclusion

In this study, short-term dark chocolate intake did not seem to reduce BP. mHealth technology shows great potential for use in clinical studies, but challenges related to device accuracy and compliance need to be addressed.

The sweet side of dark chocolate for chronic kidney disease patients

Chocolate is a widely appreciated foodstuff with historical appreciation as a food from the gods. In addition to its highly palatable taste, it is a rich source of (poly)phenolics, which have several proposed salutogenic effects, including neuroprotective anti-inflammatory, anti-oxidant and cardioprotective capabilities. Despite the known benefits of this ancient foodstuff, there is a paucity of information on the effects of chocolate in the context of chronic kidney disease (CKD). This review focusses on the potential salutogenic contribution of chocolate intake, to mitigate inflammatory and oxidative burden in CKD, its potential, for cardiovascular protection and on the maintenance of diversity in gut microbiota, as well as clinical perspectives, on regular chocolate intake by CKD patients.

Cardioprotective Mechanisms of Cocoa

Cardiovascular diseases are the main cause of deaths in highly developed countries. Dietetic interventions that involve recommendations for consumption of products with a confirmed health-improving action are an important aspect of prevention of cardiovascular diseases. Cocoa is an alimentary product with significant cardioprotective potential due to its high content of bioactive compounds. The aim of the present study was to review the most recent literature concerning the effectiveness and mechanisms of action of compounds contained in cocoa with regard to selected cardiovascular risk factors and cardiometabolic markers. Study results indicate that cocoa consumption, especially in the form of dark chocolate with high flavonoid content, may be a good strategy to diminish cardiovascular risk due to its beneficial effect on platelet aggregation, decreasing blood pressure, diminishing dyslipidemia, and decreasing blood plasma glucose concentration. Many studies have shown that cocoa-derived flavonoids have antioxidant and anti-inflammatory activity and also play a significant role in preventing insulin resistance. However, in order to completely confirm the potential cardiovascular benefits, it is necessary to conduct larger and longer studies, also with regard to potential dangers associated with long-term consumption of large amounts of flavonoids and determination of a safe and effective dose. Key teaching points Cocoa consumption may be a good strategy in diminishing cardiovascular risk. Beneficial effects on platelet aggregation, blood pressure, dyslipidemia, glycemia, as well as antioxidant and anti-inflammatory activity are observed. There is a need to conduct larger and longer studies to determine a safe and effective dose of cocoa flavonoids.

Dark chocolate modulates platelet function with a mechanism mediated by flavan-3-ol metabolites

Cocoa is a rich source bioactive compounds, i.e., flavan-3-ols, and its consumption has been associated with several beneficial effects, such as the positive modulation of the hemostasis targeted by the platelet function. However, these phenolic compounds have a very low bioavailability and extensively undergo phase I and II metabolism, with the appearing into the bloodstream of (epi)catechin conjugates and phenyl-γ-valerolactones and their conjugates, at different times.The aims of this study were to explore the effect of dark chocolate on platelet function and to investigate the relationship between this interplay and flavan-3-ol derived metabolites.Eighteen healthy male volunteers ingested 50 g of 90% cocoa chocolate within 5 minutes. Blood samples were collected immediately before chocolate ingestion (T0) and 4 hours afterwards (T1). Platelet function analyzer (PFA)-100 closure time was assessed using collagen/adenosine-5'-diphosphate (COL/ADP) and collagen/epinephrine (COL/EPI) cartridges. Plasma flavan-3-ol metabolites were identified and quantified by means of liquid chromatography coupled to a triple quadrupole mass spectrometer (UHPLC-ESI-MS/MS).Results evidenced a significant increase of COL/ADP-induced PFA-100 closure time, but not COL/EPI, 4 hours after ingestion of dark chocolate. Total plasma structurally-related (epi)catechin metabolite (SREM) concentration significantly increased at T1, together with 4 out of the 6 detected metabolites. Total phenyl-γ-valerolactone concentrations remained unchanged. Spearman correlations evidenced a strong correlation between COL/ADP closure time and SREMs, mainly led by (epi)catechin-sulfate isomers.These data confirm that the potential beneficial effect of dark chocolate on primary hemostasis may be mediated by flavan-3-ol circulating metabolites.

Is there a role for lifestyle changes in cardiovascular prevention? What, when and how?

BACKGROUND AND AIMS

Lifestyle has been found to play an important role in the prevention of cardiovascular disease (CVD). There is evidence to suggest that if lifestyle factors are modified successfully, the relative risk of CVD can be reduced. Risk factors for CVD such as high blood pressure, diabetes mellitus and dyslipidaemias can be modified by lifestyle changes. The main aim of this article is to provide best practice approaches and support for healthcare professionals on the role of lifestyle changes in the prevention of CVD.

METHODS

A working group of experts discussed existing guidelines, clinical practice and evidence, and provided their recommendations on ten topics concerning the role of lifestyle in CVD prevention. These topics covered important lifestyle factors as well as tools/approaches to assess or encourage lifestyle changes.

RESULTS

The group of clinical experts collaborated to provide their opinion on the following topics: one diet versus customised diets; the role of alcohol consumption in a healthy diet; a diet based on nutrient composition or on whole foods; a Mediterranean versus low-fat diet; the role of dietary supplements; physical activity; smoking cessation; the role of a nutritionist/dietitian in a CVD risk multidisciplinary team; tools to be implemented to assess diet, physical activity and smoking status; and the most effective approaches to encourage lifestyle changes.

CONCLUSIONS

The expert working group agreed that lifestyle changes were important in preventing CVD and provided recommendations which complemented current guidance and increased clarity on several topics.

Dark Chocolate: Opportunity for an Alliance between Medical Science and the Food Industry?

Dark chocolate (DC) was originally introduced in human nutrition as a medicinal product consumable in a liquid form. Century-long efforts of food industry transformed this hardly appealing product into a valuable modern culinary delight with clear predominance of confectionery brands of DC on the market. However, current epidemiological data as well as multiple experimental and clinical observations reveal that DC consumption may have a profound effect on cardiovascular, central nervous systems, hemostasis, and lipid metabolism. However, despite of growing body of modern scientific evidence revealing medicinal properties of cocoa-based products, DC remains more gourmet culinary item than medicinal food product. Even today there are no clear dietary recommendations on consumption of cocoa flavonoids (flavanols) for health purpose. Clinical trials with DC rarely include monitoring of plasma flavanol concentration in volunteers. Moreover, there is no standardized assay or any quantitative requirements for flavanol content in the commercial brands of DC. High flavanol content is often sacrificed during manufacturing for a better taste of DC due to bitterness of cocoa flavonoids. All these problems including subsequently arising ethical issues need to be addressed by joint efforts of food industry and medical science. Moreover, application of microencapsulation technology in DC manufacturing, as well as molecular selection of best flavanol producers may drastically change bioavailability of DC bioactive ingredients and DC production technology. Nevertheless, only strict causative approach, linking possible health effect of DC to its bioactive ingredients considered as nutraceuticals, may change the current landscape in nutritional research related to cocoa-based products and create a trustworthy path for their medicinal use.

The impact of dark chocolate intake on arterial elasticity in individuals with HIV/AIDS undergoing ART: a randomized, double-blind, crossover trial

An increase in the frequency of cardiovascular diseases has been observed in the HIV/AIDS population. Studies involving healthy subjects or subjects with other diseases have shown benefits of chocolate supplementation on endothelial function and vasodilation. We evaluate the impact of chocolate consumption on arterial elasticity in people living with human immunodeficiency virus - PLHIV. A double-blind, crossover trial including 110 PLHIV (19 to 59 years) on antiretroviral therapy - ART for at least 6 months and with a viral load of <500 copies per mL was conducted. All subjects were randomly assigned to 15-d dietary supplements containing dark chocolate or placebo with a 15-d washout period. Each participant received one of the two sequences: A (dark chocolate, placebo chocolate); B (placebo chocolate, dark chocolate). Arterial elasticity was measured using the HDI/PulseWave™ CR-2000 CardioVascular Profiling System®. Body composition, lipid profile, C-reactive protein, and thiobarbituric acid reactive substances were also assessed. Analysis of variance (ANOVA) for repeated measures using the Stata 11.0® program was used for cross-over analysis. Most subjects were men (59.0%) and Caucasian (46.1%) and the mean age was 44.6 ± 7.1 years. The mean time since diagnosis of HIV infection was 13.7 ± 5.3 years and the mean duration of ART was 12.9 ± 4.2 years. Chocolate consumption resulted in significant alterations in the large artery elasticity index - LAEI (p = 0.049) and the mean concentration of HDL-c was higher after supplementation with dark chocolate (p = 0.045). This is the first study to evaluate the effect of chocolate on arterial elasticity in PLHIV. The results showed that dark chocolate consumption for 15 days improved the elastic properties of the LAEI in PLHIV. These findings, added to the noninvasive method used, may expand the knowledge of CVDs in this population.

A single dose of dark chocolate increases parasympathetic modulation and heart rate variability in healthy subjects

ABSTRACT Objective: The aim of this study was to investigate the acute effect of a single dose of dark chocolate (70% cocoa) on blood pressure and heart rate variability. Methods: Thirty-one healthy subjects (aged 18-25 years; both sexes) were divided into two groups: 10 subjects in the white chocolate (7.4 g) group and 21 in the dark chocolate (10 g) group; measurements were performed at the university's physiology lab. An electrocardiogram measured the sympathovagal balance by spectral and symbolic analysis. Results: A single dose of dark chocolate significantly reduced systolic blood pressure and heart rate. After consuming 10 g of dark chocolate, significant increases were observed for heart rate variability, standard deviation of RR intervals standard deviation of all NN intervals, square root of the mean squared differences between adjacent normal RR intervals root mean square of successive differences, and an increase in the high frequency component in absolute values, representing the parasympathetic modulation. Conclusion: In conclusion the importance of our results lies in the magnitude of the response provoked by a single dose of cocoa. Just 10 g of cocoa triggered a significant increase in parasympathetic modulation and heart rate variability. These combined effects can potentially increase life expectancy because a reduction in heart rate variability is associated with several cardiovascular diseases and higher mortality.

Habitual cocoa intake reduces arterial stiffness in postmenopausal women regardless of intake frequency: a randomized parallel-group study

Arterial stiffness is substantially higher in postmenopausal than in premenopausal women. Daily cocoa intake has been shown to reduce central arterial stiffness in health adults, regardless of age; however, the effect of cocoa-intake frequency on arterial stiffness in postmenopausal women remains unclear. Therefore, the purpose of this study was to investigate the effects of cocoa-intake frequency on arterial stiffness in postmenopausal women. A total of 26 postmenopausal women (mean age ± standard deviation 64±12 years) were randomly assigned to two groups with different cocoa-intake frequencies: one group ingested 17 g of cocoa once daily except on Sundays (every-day group, n=13), and the other ingested 17 g of cocoa twice daily every other day (every-other-day group, n=13). These intake regimens were maintained in both groups for 12 weeks. Carotid–femoral pulse-wave velocity and femoral–ankle pulse-wave velocity were measured in both groups at baseline and again at the end of the 12-week study period. Compared to baseline, both pulse-wave velocities had significantly decreased after the 12-week study period in both groups (P<0.05). However, no significant difference in degree of change was observed between the two groups. Although this study did not include a sedentary control group, these results suggest that regardless of frequency, habitual cocoa intake reduces central and peripheral arterial stiffness in postmenopausal women.

Can oral vitamin D prevent the cardiovascular diseases among migrants in Australia? Provider perspective using Markov modelling

The study was designed to model the effectiveness and cost effectiveness of oral Vitamin D supplementation as a primary prevention strategy for cardiovascular disease among a migrant population in Australia. It was carried out in the Community Health Service, Kensington, Melbourne. Best-case scenario analysis using a Markov model was employed to look at the health care providers' perspective. Adult migrants who were vitamin D deficient and free from cardiovascular disease visiting the medical centre at least once during the period from 1 January 2010 to 31 December 2012 were included in the study. The blood pressure-lowering effect of vitamin D was taken from a published meta-analysis and applied in the Framingham 10 year cardiovascular risk algorithm (with and without oral vitamin D supplements) to generate the probabilities of cardiovascular events. A Markov decision model was used to estimate the provider costs associated with the events and treatments. Uncertainties were derived by Monte Carlo simulation. Vitamin D oral supplementation (1000 IU/day) for 10 years could potentially prevent 31 (interquartile range (IQR) 26 to 37) non-fatal and 11 (IQR 10 to 15) fatal cardiovascular events in a migrant population of 10,000 assuming 100% compliance. The provider perspective incremental cost effectiveness per year of life saved was AU$3,992 (IQR 583 to 8558). This study suggests subsidised supplementation of oral vitamin D may be a cost effective intervention to reduce non-fatal and fatal cardiovascular outcomes in high-risk migrant populations.

(-)-Epicatechin Attenuates Degradation of Mouse Oxidative Muscle Following Hindlimb Suspension

The purpose of this study was to conduct a 14-day hindlimb suspension (HS) with and without (-)-epicatechin supplementation to determine whether (-)-epicatechin treatment can attenuate the loss in muscle degradation, angiogenesis, and mitochondrial signaling in oxidative skeletal muscle. Adult mice were randomized into 3 groups: (a) control (C); (b) HS with vehicle (HS-V); and (c) HS with (-)-epicatechin (HS-(-)-Epi). Animals in the HS-(-)-Epi group received (-)-epicatechin (1.0 mg · kg(-1) of body mass) twice daily through oral gavage. For markers related to muscle degradation, the HS-V group had significantly higher protein expression compared with the control and HS-(-)-Epi groups. Moreover, protein expression for myosin heavy chain type I was significantly reduced by approximately 45% in the HS-V group compared with the control and HS-(-)-Epi groups. In addition, capillarity contact and capillary-to-fiber ratio were significantly higher in the HS-(-)-Epi group compared with the HS-V group. Furthermore, protein expression for thrombospondin-1 was significantly higher in HS-V group compared with the control and HS-(-)-Epi groups. Hindlimb suspension also significantly reduced protein expression for mitochondrial signaling compared with the control and HS-(-)-Epi groups. These findings suggest that (-)-epicatechin supplementation attenuates degradation in oxidative muscles after HS.

Lifestyle patterns in early pregnancy linked to gestational diabetes mellitus diagnoses when using IADPSG criteria. The St Carlos gestational study

Early-pregnancy lifestyle (EPL) could influence the development of gestational diabetes mellitus(GDM), depending on the diagnostic criteria used.

OBJECTIVE

We studied EPL in 1750 pregnant women using Carpenter-Coustan criteria(CCc), and in 1526 with the International Association of Diabetes and Pregnancy Study Groups criteria(IADPSGc).

METHODS

GDM risk factors were assessed in women between 24 and 28 weeks of gestational age during two consecutive years. A semiquantitative frequent-food-consumption questionnaire was used to evaluate lifestyle during pregnancy. Multiple logistic regression analysis was conducted to assess GDM risk with different lifestyle patterns.

RESULTS

Using IADPSGc, the GDM ORs (95%CI) for intake/week were: nuts >3 times: 0.59 (0.39-0.91; p < 0.015), refined cereals ≤1 serving: 0.72(0.58-0.89; p < 0.003), juices <4 servings: 0.77 (0.62-0.95; p < 0.017), cookies and pastries <4 servings: 0.71(0.57-0.89; p < 0.003) as compared to opposite habits. No significant nutritional patterns were found to be significant using CCc. The OR (95%CI) for GDM with none of the four risk patterns as compared to having three-four risk factors was 0.21(0.07-0.62; p < 0.005), remaining significant after stratification by BMI, age, obstetric events, parity and family history. The multiple logistic regression model including nutritional categories and pregestational BMI, age, obstetric history, parity, personal/family history, had an area under the curve(AUC) of the receiver operating curve(ROC) for the probability to predict GDM of 0.66 (CI 95%: 0.63-0.69; p < 0.001).

CONCLUSION

Our study is the first to identify four early-pregnancy nutritional patterns associated with the GDM when using IADPSGc. Adherence to a low-risk nutritional pattern from early pregnancy on could be an effective strategy for GDM prevention.

Nutraceuticals for blood pressure control

Significant effects on blood pressure (BP) have been reported from large nutritional interventions, particularly the Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean diet. In more recent years, numerous studies have investigated the possible BP-lowering effect of different nutraceuticals; these range from specific foods to minerals, lipids, whole proteins, peptides, amino acids, probiotics, and vitamins. While a very large body of evidence supports the use of potassium, L-arginine, vitamins C and D, cocoa flavonoids, beetroot juice, some probiotics, coenzyme Q10, controlled-release melatonin, aged garlic extract, and coffee, the use of other nutraceuticals, such as green tea, flaxseed, and resveratrol, has not as yet been supported by adequate evidence. In some cases, e.g. proteins/peptides, the responsible component needs also to be fully uncovered. Finally, while for most of the products only short-term studies are available, with no specific end-points, an ongoing very large prospective study on chocolate flavanols will answer the question whether this may reduce cardiovascular risk. Thus, in addition to data on long-term safety, further clinical research is advisable in order to identify, among active nutraceuticals, those with the best cost-effectiveness and risk-benefit ratio for a wide use in the general population with a raised cardiovascular risk consequent to uncomplicated hypertension.

Evidence for cost-effectiveness of lifestyle primary preventions for cardiovascular disease in the Asia-Pacific Region: a systematic review

Background

Countries of the Asia Pacific region account for a major share of the global burden of disease due to cardiovascular disease (CVD) and this burden is rising over time. Modifiable behavioural risk factors for CVD are considered a key target for reduction in incidence but their effectiveness and cost-effectiveness tend to depend on country context. However, no systematic assessment of cost-effectiveness of interventions addressing behavioural risk factors in the region exists.

Methods

A systematic review of the published literature on cost-effectiveness of interventions targeting modifiable behavioural risk factors for CVD was undertaken. Inclusion criteria were (a) countries in Asia and the Pacific, (b) studies that had conducted economic evaluations of interventions (c) published papers in major economic and public health databases and (d) a comprehensive list of search words to identify appropriate articles. All authors independently examined the final list of articles relating to methodology and findings.

Results

Under our inclusion criteria a total of 28 studies, with baseline years ranging from 1990 to 2012, were included in the review, 19 conducted in high-income countries of the region. Reviewed studies assessed cost-effectiveness of interventions for tobacco control, alcohol reduction, salt intake control, physical activity and dietary interventions. The majority of cost-effectiveness analyses were simulation analyses mostly relying on developed country data, and only 6 studies used effectiveness data from RCTs in the region. Other than for Australia, no direct conclusions could be drawn about cost-effectiveness of interventions targeting behavioural risk factors due to the small number of studies, interventions that varied widely in design, and varied methods for measurement of costs associated with interventions.

Conclusions

Good quality cost-effectiveness information on interventions targeting behavioural interventions for the Asia-Pacific region remains a major gap in the literature.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-014-0079-3) contains supplementary material, which is available to authorized users.

Energy compensation in the real world: good compensation for small portions of chocolate and biscuits over short time periods in complicit consumers using commercially available foods

While investigations using covert food manipulations tend to suggest that individuals are poor at adjusting for previous energy intake, in the real world adults rarely consume foods of which they are ill-informed. This study investigated the impact in fully complicit consumers of consuming commercially available dark chocolate, milk chocolate, sweet biscuits and fruit bars on subsequent appetite. Using a repeated measures design, participants received four small portions (4 × 10-11 g) of either dark chocolate, milk chocolate, sweet biscuits, fruit bars or no food throughout five separate study days (counterbalanced in order), and test meal intake, hunger, liking and acceptability were measured. Participants consumed significantly less at lunch following dark chocolate, milk chocolate and sweet biscuits compared to no food (smallest t(19) = 2.47, p = 0.02), demonstrating very good energy compensation (269-334%). No effects were found for fruit bars (t(19) = 1.76, p = 0.09), in evening meal intakes (F(4,72) = 0.62, p = 0.65) or in total intake (lunch + evening meal + food portions) (F(4,72) = 0.40, p = 0.69). No differences between conditions were found in measures of hunger (largest F(4,76) = 1.26, p = 0.29), but fruit bars were significantly less familiar than all other foods (smallest t(19) = 3.14, p = 0.01). These findings demonstrate good compensation over the short term for small portions of familiar foods in complicit consumers. Findings are most plausibly explained as a result of participant awareness and cognitions, although the nature of these cognitions cannot be discerned from this study. These findings however, also suggest that covert manipulations may have limited transfer to real world scenarios.

Reduction in blood pressure and serum lipids by lycosome formulation of dark chocolate and lycopene in prehypertension

Twenty-nine healthy volunteers aged 47–69 years old were randomly assigned to a 28-day oral intake of different dark chocolate (DC) formulations. The main group received daily 30 g of proprietary lycopene-containing (L-tug) lycosome formulation of DC with enhanced bioavailability of cocoa flavanols. Two control groups daily consumed either 30 g of regular DC alone or along with 7 mg of lycopene, which corresponds to the amount of lycopene ingested with L-tug formulation. It was found that L-tug was more efficient in reducing diastolic blood pressure (mean value of −6.22 mmHg, 95% CI: 5.00, 8.00) when compared with the regular DC group (−3.00 mmHg, P < 0.05) or the group which ingested the DC and lycopene as two separate formulations (mean reduction of −4 mmHg, 95% CI: 2.47, 6.00, P = 0.0262). Only marginal superiority for L-tug formulation in the reduction in systolic blood pressure was seen. However, the L-tug formulation was the only formulation of DC which affected serum lipids. There was a reduction in total cholesterol (from median 228.00 mg/dL [95% CI: 206.2, 242.5] to 187.00 mg/dL [95% CI: 166.2, 202.2, P < 0.05]) with corresponding decline of low-density lipoprotein (LDL) cholesterol (from a median of 166.00 mg/dL [95% CI: 130.8, 177.0] to 151.00 mg/dL [95% CI: 122.8, 167.4; P < 0.05]) at the end of the intervention period. Similar decline was seen in serum triglycerides (P < 0.05). Serum high-density lipoprotein (HDL) cholesterol, glucose levels, and C-reactive protein (CRP) values remained statistically unchanged in all study groups throughout the intervention period. A superior biological activity of the L-tug lycosome formulation of DC extending beyond its antihypertensive effect to lipid-lowering ability opens up new possibilities for the use of DC for health purposes helping to reduce daily caloric intake without compromising on the health benefits of DC consumption.

Theobromine enhances absorption of cacao polyphenol in rats

Several concentrations of theobromine (TB) and (-)-epicatechin (EC) were coadministered to rats, and plasma EC and its metabolites were determined using ultra-high-performance liquid chromatography-tandem mass spectrometry. It has been demonstrated that TB increases the absorption of EC in a dose-dependent manner. Cocoa powder had a similar effect, and the mechanism involved is not thought to depend on tight junctions.

Chocolate--guilty pleasure or healthy supplement?

Dark chocolate and other cocoa products are popular in the population as a whole, but their overall health benefit remains controversial. Observations from the Kuna Indian population have shown an impressive cardiovascular health benefit from cocoa. For various reasons, this benefit has not been as robust as in other populations. Additionally, several mechanisms have been proposed that might confer cocoa's possible health benefit, but no consensus has been reached on cocoa's physiologic role in promoting cardiovascular health. Flavanols, as well as theobromine, may contribute to enhancements in endothelial function and subsequent improvements in various contributors to cardiovascular disease (CVD) including hypertension, platelet aggregation and adhesion, insulin resistance, and hypercholesterolemia. While the benefits of cocoa may be altered at the various stages of growth, development, and production, it appears that for many people "healthy" dark chocolate may, indeed, provide a pleasurable role in CVD risk reduction. The objectives of this review are to discuss the associations of cocoa with decreased blood pressure and improved CVD risk, to describe the possible mechanisms for these potential benefits, and to highlight considerations for the use of cocoa as a dietary supplement.

Tea and flavonoids: where we are, where to go next

There is a need to evaluate the evidence about the health effects of tea flavonoids and to provide valid, specific, and actionable tea consumption information to consumers. Emerging evidence suggests that the flavonoids in tea may be associated with beneficial health outcomes, whereas the benefits and risks of tea extracts and supplements are less well known. The next steps in developing tea science should include a focus on the most promising leads, such as reducing the risk of cardiovascular disease and stroke, rather than pursuing smaller, more diffuse studies of many different health outcomes. Future tea research should also include the use of common reference standards, better characterization of intervention products, and application of batteries of biomarkers of intakes and outcomes across studies, which will allow a common body of evidence to be developed. Mechanistic studies should determine which tea bioactive constituents have effects, whether they act alone or in combination, and how they influence health. Clinical studies should use well-characterized test products, better descriptions of baseline diets, and validated biomarkers of intake and disease risk reduction. There should be more attention to careful safety monitoring and adverse event reporting. Epidemiologic investigations should be of sufficient size and duration to detect small effects, involve populations most likely to benefit, use more complete tea exposure assessment, and include both intermediary markers of risk as well as morbidity and mortality outcomes. The construction of a strong foundation of scientific evidence on tea and health outcomes is essential for developing more specific and actionable messages on tea for consumers.

Health benefits of cocoa

PURPOSE OF REVIEW

In modern society, cocoa is being eaten as a confectionery, contrary to its medicinal use in the past. However, since the last decade, there has been a revival of talks about cocoa's health beneficial effects. Development has been made at the molecular level recently. This review discusses the recent progresses on potential health benefits of cocoa and/or its derivatives, with a focus on the areas that have been paid little attention so far, such as the role of cocoa in immune regulation, inflammation, neuroprotection, oxidative stress, obesity, and diabetes control.

RECENT FINDINGS

Thanks to the advancement in analytical technologies, the cocoa's metabolic pathways have now been properly mapped providing essential information on its roles. Cocoa helps in weight loss by improving mitochondrial biogenesis. It increases muscle glucose uptake by inserting glucose transporter 4 in skeletal muscles membrane. Because of its antioxidant properties, cocoa offers neuron protection and enhances cognition and positive mood. It lowers immunoglobulin E release in allergic responses. It can affect the immune response and bacterial growth at intestinal levels. It reduces inflammation by inhibiting nuclear factor-κB.

SUMMARY

Keeping in view the pleiotropic health benefits of cocoa, it may have the potential to be used for the prevention/treatment of allergies, cancers, oxidative injuries, inflammatory conditions, anxiety, hyperglycemia, and insulin resistance.

Mechanisms for food polyphenols to ameliorate insulin resistance and endothelial dysfunction: therapeutic implications for diabetes and its cardiovascular complications

The rising epidemic of diabetes is a pressing issue in clinical medicine worldwide from both healthcare and economic perspectives. This is fueled by overwhelming increases in the incidence and prevalence of obesity. Obesity and diabetes are characterized by both insulin resistance and endothelial dysfunction that lead to substantial increases in cardiovascular morbidity and mortality. Reciprocal relationships between insulin resistance and endothelial dysfunction tightly link metabolic diseases including obesity and diabetes with their cardiovascular complications. Therefore, therapeutic approaches that target either insulin resistance or endothelial dysfunction alone are likely to simultaneously improve both metabolic and cardiovascular pathophysiology and disease outcomes. Moreover, combination therapies with agents targeting distinct mechanisms are likely to have additive or synergistic benefits. Conventional therapies for diabetes and its cardiovascular complications that are both safe and effective are insufficient to meet rising demand. Large, robust, epidemiologic studies demonstrate beneficial metabolic and cardiovascular health effects for many functional foods containing various polyphenols. However, precise molecular mechanisms of action for food polyphenols are largely unknown. Moreover, translation of these insights into effective clinical therapies has not been fully realized. Nevertheless, some functional foods are likely sources for safe and effective therapies and preventative strategies for metabolic diseases and their cardiovascular complications. In this review, we emphasize recent progress in elucidating molecular, cellular, and physiological actions of polyphenols from green tea (EGCG), cocoa (ECG), and citrus fruits (hesperedin) that are related to improving metabolic and cardiovascular pathophysiology. We also discuss a rigorous comprehensive approach to studying functional foods that is essential for developing novel, effective, and safe medications derived from functional foods that will complement existing conventional drugs.

(-)-Epicatechin is associated with increased angiogenic and mitochondrial signalling in the hindlimb of rats selectively bred for innate low running capacity

Alternative approaches to reduce congenital muscle dysfunction are needed in cases where the ability to exercise is limited. (-)-Epicatechin is found in cocoa and may stimulate capillarity and mitochondrial proliferation in skeletal muscle. A total of 21 male rats bred for LCR (low running capacity) from generation 28 were randomized into three groups: vehicle for 30 days (control); (-)-epicatechin for 30 days; and (-)-epicatechin for 30 days followed by 15 days without (-)-epicatechin. Groups 2 and 3 received 1.0 mg of (-)-epicatechin/kg of body mass twice daily, whereas water was given to the control group. The plantaris muscle was harvested for protein and morphometric analyses. In addition, in vitro experiments were conducted to examine the role of (-)-epicatechin on mitochondrial respiratory kinetics at different incubation periods. Treatment for 30 days with (-)-epicatechin increased capillarity (P<0.001) and was associated with increases in protein expression of VEGF (vascular endothelial growth factor)-A with a concomitant decrease in TSP-1 (thrombospondin-1) and its receptor, which remained after 15 days of (-)-epicatechin cessation. Analyses of the p38 MAPK (mitogen-activated protein kinase) signalling pathway indicated an associated increase in phosphorylation of MKK3/6 (MAPK kinase 3/6) and p38 and increased protein expression of MEF2A (myocyte enhancer factor 2A). In addition, we observed significant increases in protein expression of PGC-1α (peroxisome-proliferator-activated receptor γ co-activator 1α), PGC-1β, Tfam and cristae abundance. Interestingly, these increases associated with (-)-epicatechin treatment remained after 15 days of cessation. Lastly, in vitro experiments indicated that acute exposure of LCR muscle to (-)-epicatechin incubation was not sufficient to increase mitochondrial respiration. The results suggest that increases in skeletal muscle capillarity and mitochondrial biogenesis are associated with 30 days of (-)-epicatechin treatment and sustained for 15 days following cessation of treatment. Clinically, the use of this natural compound may have potential application in populations that experience muscle fatigue and are unable to perform endurance exercise.

Natural cocoa ingestion reduced liver damage in mice infected with Plasmodium berghei (NK65)

PURPOSE

This study tested whether natural cocoa powder ingestion could mitigate hepatic injury coincident with murine malaria. Plasmodium berghei infection causes liver damage including hepatic sinusoidal distension, and elevated serum alanine transaminase (ALT) and aspartate transaminase (AST) levels. According to literature, these pathologies largely result from activity of reactive oxygen species (ROS) and may be extenuated by antioxidants.

ANIMALS AND METHODS

Thirty Balb/c mice were randomly assigned to three equal groups. One of two groups of mice inoculated with 0.2 mL of P. berghei-parasitized red blood cells (RBCs) was given unrestricted 24-hour access to a natural cocoa powder beverage (2% by weight) in place of water. The third group of mice were neither infected nor given cocoa. All mice were fed the same standard chow. After 6 days, mice were sacrificed and their livers processed for histomorphometric assessment of mean hepatic sinusoidal diameter as a quantitative measure of altered morphology. Serum ALT and AST were measured as a gauge of functional impairment.

RESULTS

Compared with uninfected mice, hepatic sinusoidal diameter in P. berghei-infected mice not given cocoa increased by 150%, whereas a smaller increase of 83% occurred in infected mice that ingested cocoa. Mean serum ALT increased by 127% in infected mice not given cocoa and 80% in infected mice that consumed cocoa, compared with the value for uninfected mice. Similarly, mean serum AST was raised by 141% in infected mice not given cocoa and 93% in infected mice that drank cocoa.

CONCLUSION

Distension of hepatic sinusoidal diameter in P. berghei-infected mice was reduced by 67%, whereas respective elevations of serum ALT and AST concentrations were reduced by 47% and 48% via ingestion of cocoa. Anti-inflammatory and antioxidant components of cocoa probably mediated the demonstrated hepatoprotective benefit by blunting pernicious ROS activity in P. berghei-infected mice.