Chocolate: Not a “Health Food,” But “Health-Positive”

“As a nutritionist with over four decades of experience, however, I know it’ll take more than my fondness for chocolate to make it so.”

It takes evidence.

Evidence about various bioactive compounds in the cocoa bean has been accumulating for years, and this recent review [MDPI, open access, click to read] gives more reasons to investigate chocolate and cocoa as a help, not a hindrance, to better health.

Chocolate and cocoa have demonstrated an ability to improve “flow-mediated dilation” (FMD). Plainly put: when blood flow increases, you want the arteries to expand to accommodate that higher blood flow. If they don’t, they are too “tense,” as in “hypertension.” Chocolate helps the arteries expand when necessary, so higher blood volume flows more easily.  All good.

This review also outlines what’s been learned about the impact of the cocoa bean’s bioactive components that have potential benefits for health and well-being. To prevent the “chemistry lesson from hell,” I’ve boiled it down as much as possible without destroying the meaning. 

Bioactive compounds in dark chocolate and cocoa provide benefits in two categories:

1. Anti-inflammatory activity, and
2. Antioxidant activity

Benefits of Anti-Inflammatory Cocoa Bioactives

These help regulate your immune system and inhibit the production of inflammatory enzymes and pathways.  You want your immune system to react when necessary, but you don’t want it irritated or overly reactive, such as when you have allergic responses, or worse, autoimmune diseases.

Benefits of Cocoa Antioxidants  

Antioxidants are compounds that prevent free radicals from forming and causing damage to the body. The best way to explain antioxidants is to give an example:

• When cocoa butter gets rancid, the fat in it has become “oxidized” by free radicals that damage the fat.  Vitamin E (tocopherols), is another example that occurs naturally in vegetable oils and helps prevent rancidity.
• In your body, free radicals cause "oxidative stress" a little differently. They can nick the sides of your blood vessels, giving plaques a place to attach. When enough plaque builds up, arteries get clogged. Cocoa flavanols help prevent this damage.

In addition to the cardiovascular benefits, this review also showed there are other benefits, particularly for lowering risk factors for “metabolic dysfunction-associated steatotic liver disease” (MASLD). 

Hear me out: this is just a more refined term for what used to be included under the less-specific term “fatty liver.” MASLD interferes with liver function, metabolism and can impact how other organs function, since the liver has its functional hand everywhere.

As you can imagine, fat building up in your liver is unhealthy.  A “fatty liver” was once thought to be a consequence of alcoholism but there’s more to it than that.  MASLD can also be a consequence of other medical conditions. Per the CDC, roughly 70% of people with type 2 diabetes also have MASLD.

Even aside from type 2 diabetes, diet plays a role; chronically eating to excess, especially too much sugar and refined carbs, and not exercising enough, can contribute to MASLD too, even without alcohol.

Enter Chocolate & Cocoa

The reviewed research found the best benefits from dark (no milk added), high percentage cocoa content chocolate with high flavanol content (no Dutch-processed chocolate – few flavanols there), to take advantage of the higher level of bioactive compounds. Some of the reviewed studies’ findings:

• 30 grams of 88% dark chocolate for 4 weeks reduced LDL-cholesterol and triglycerides [PubMed].  White chocolate had no effect.
• 40 grams of 85% dark chocolate, but not 35% milk chocolate, improved inflammatory markers [PubMed] in patients with a severe form of MASLD

The studies’ authors acknowledge some limitations in the studies reviewed. Limitations are often due to finances or logistical issues beyond the control of the researcher, such as:

• Human studies are expensive, so they often only include small groups of subjects, and/or are of short duration, limiting their generalizability to the broader population.
• Control groups are absent in some studies.
• Percentage cocoa varies by study, as does the portion of chocolate used, so it’s hard to recommend specific amounts.
• Flavanol content can vary among chocolate samples used, even among chocolates of similar percentages. Not all 80% bars have the same cocoa flavanol content!

Keep in mind the importance of eating flavanol-rich foods. Dark chocolate is one of them, but there are many others.  Think colorful fruits and vegetables, like berries, citrus fruits, most veggies, especially green leafy ones, and tea.

Chocolate Still Won’t Earn the “Health Food” Label

The collective findings on dark chocolate strongly suggest anti-inflammatory properties and risk reduction for CVD and MASLD, but stronger evidence is needed before it could realistically be used as a “therapeutic or prevention” strategy.  

Summary

While chocolate may never be labelled a healthy food,  there seems to be enough emerging research to justify considering that dark chocolate has more to offer than just taste and enjoyment. That said, any physician will tell you that “prescribing” a food we know is good for you (think broccoli) still won’t get people to eat it every day.  But it may be the taste and enjoyment of chocolate that results in daily and consistent use, making those benefits more likely to be realized.

Dr Keith Ayoob is Associate Clinical Professor Emeritus at the Albert Einstein College of Medicine in New York City where he directed a nutrition clinic for 33 years for persons with special needs. He received his doctorate from Columbia University’s Teachers College, his Master’s from the Columbia University College of Physicians and Surgeons.

In the private sector, Dr. Ayoob has actively advocated for positive strategic change. He co-authored a landmark global nutrition policy for the Walt Disney Corporation in 2006 and updated them in 2012. These guidelines received wide acclaim, including endorsement by the White House and First Lady Michelle Obama.