Natural Standard® Patient Monograph, Copyright © 2014 (www.naturalstandard.com). All Rights Reserved. Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.

Background

Cocoa and chocolate come from the cacao bean. Cacao is native to South America and has been grown in the tropics for at least 3,000 years. The African country Ivory Coast is the one of the largest suppliers of raw cocoa.

Cocoa products have been considered delicacies by many cultures. Cocoa contains flavonoids, which are compounds with antioxidant effects, blood thinning properties, and possibly other health benefits. For this reason, and because it is so popular, chocolate is widely researched.

Chocolate has been studied for heart disease, skin conditions, constipation, and various other conditions. The strongest evidence exists for cocoa's ability to decrease blood pressure.

Dosing

The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.

Adults (18 years and older)

CocoaVia®, a cocoa drink and snack bar brand, has been commonly used in studies.

For use as an antioxidant, one serving of CocoaVia® drink has been taken by mouth.

For anxiety, 20-25 grams of dark or milk chocolate has been taken by mouth twice daily for two five-day intervals over two weeks.

For heart disease, 13.5-80 grams of chocolate have been taken as a single dose or 1-3 times daily for two days to more than 26 weeks. Forms of chocolate have included chocolate bars, cocoa beverages (e.g. CocoaVia®), dark chocolate, or cocoa powder.

For chronic fatigue syndrome, a 15 gram chocolate bar has been taken by mouth three times daily for eight weeks.

For cirrhosis, 200 milliliters of test meal (Ensure® Plus) mixed with 0.55 grams per kilogram of dark chocolate has been taken by mouth as a single dose.

For mental performance, 10-37 grams of chocolate has been taken by mouth as a single dose or once daily for up to 30 days. Forms of chocolate included chocolate bars, cocoa drinks, and cocoa powder (e.g. Cocoapro®).

For diabetes, 15 grams of chocolate has been taken by mouth three times daily for eight weeks.

For exercise recovery, 330 milliliters of cocoa drink has been taken by mouth immediately after exercise, two hours after exercise, and before bed.

For high blood sugar/glucose intolerance up to 100 grams of chocolate has been taken by mouth once or twice daily for five days to 18 weeks as a chocolate bar or a cocoa beverage.

For high cholesterol, 13-105 grams of chocolate has been taken by mouth once or twice daily for two weeks to more than 26 weeks. Forms of chocolate have included cocoa beverages (sometimes with cocoa fiber), cocoa powder, snack bars, dark or milk chocolate bars, and CocoaVia® Crunch bars.

For high blood pressure, 6-100 grams chocolate has been taken by mouth once or twice daily for seven days to more than 26 weeks. Forms of chocolate have included cocoa, dark chocolate, unspecified chocolate, or cocoa drink.

For mood, 0.5 ounce of dark chocolate has been taken by mouth twice daily over three days.

For Parkinson's disease, a single dose of 200 grams dark or white chocolate has been taken by mouth in 15 minutes.

For pregnancy support, 30 grams of chocolate has been taken by mouth daily from approximately the 13th week of gestation until delivery.

For skin conditions, cocoa powder dissolved in hot water has been taken by mouth daily for 12 weeks. 20 grams of chocolate droplets have been taken by mouth daily for 12 weeks for ultraviolet light protection.

For weight loss, one dark chocolate square and one 8 ounce cocoa drink have been taken by mouth twice daily for 18 weeks.

For use as an insect repellent, a preparation of cocoa oil has been used on the skin.

For wound healing, a cocoa butter preparation has been massaged into the burn scar for 30 minutes twice a week for five weeks.

Children (under 18 years old)

For constipation, 4-8 grams of cocoa husk have been taken twice daily for four weeks.

For dental plaque, 10 milliliters of mouthwash containing 0.1% cocoa bean husk extract was used to rinse the mouth for 30 seconds twice daily for two months.

Evidence

These uses have been tested in humans or animals.  Safety and effectiveness have not always been proven.  Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Key to grades

A
Strong scientific evidence for this use
B
Good scientific evidence for this use
C
Unclear scientific evidence for this use
D
Fair scientific evidence against this use (it may not work)
F
Strong scientific evidence against this use (it likely does not work)

Grading rationale

Evidence gradeCondition to which grade level applies
A

High blood pressure

Since chocolate contains caffeine, eating large amounts may increase blood pressure. However, research has shown that dark chocolate or chocolate with high flavonols decreases blood pressure by a small amount in people with elevated blood pressure.
B

Cirrhosis (chronic liver disease)

Early research has shown that dark chocolate decreased high blood pressure and improved blood flow in the liver. High blood pressure in the veins of the liver is commonly associated with cirrhosis. Further research is needed in this area.
C

Aging

Chocolate may be beneficial for elderly people living in nursing homes. Research in area is limited and further study is needed to draw conclusions.
C

Anxiety

Early research produced mixed results for the effects of chocolate on anxiety and stress levels. Further research is needed in this area.
C

Chronic fatigue syndrome

Limited research suggests that chocolate decreased tiredness in people with chronic fatigue syndrome, a condition of severe tiredness unaffected by rest. High-quality research is needed in this area.
C

Constipation

The fiber found in cacao husk may be a noteworthy source of dietary fiber. Early evidence suggests that cacao husk fiber may be helpful in treating constipation in children. More studies are needed in this area.
C

Dental conditions

Early evidence shows that using mouthwash with a cocoa product decreased bacteria in the mouth of children. Further research is needed in this area.
C

Diabetes

The effects of chocolate on diabetes and diabetes risk are unclear. Further research is needed.
C

Exercise recovery

Research has shown benefits of drinking chocolate milk for exercise recovery. The effects of chocolate alone are unclear. Further research is necessary.
C

Heart disease

Research suggests that a diet high in cocoa flavonoids may help protect against heart disease. However, more studies are needed before a conclusion can be drawn.
C

High blood sugar/glucose intolerance

Cocoa flavonols had mixed effects on high blood sugar levels. Further research is needed in this area.
C

High cholesterol

Consuming cocoa butter or chocolate had mixed effects on cholesterol levels. More study is needed in this area.
C

Insect repellant

Early research suggests that cocoa oil may be an effective insect repellant. However, additional studies are needed in this area.
C

Mental performance

In early research, a drink with cocoa flavonols improved mental performance in people with mildly impaired mental abilities. Further research is needed to draw conclusions.
C

Mood

Limited study suggests that chocolate may improve mood for a short period of time. Further research is needed to draw conclusions.
C

Parkinson's disease

Early research has shown that chocolate lacks an effect on Parkinson's disease. Additional study is needed in this area.
C

Pregnancy support

Early study shows that chocolate may benefit pregnant women. However, due to the caffeine content, large amounts of chocolate should be avoided as they may have adverse effects on the pregnancy. Further research is needed to draw conclusions.
C

Skin conditions

Research has suggested that flavonols, which are found in chocolate, may protect the skin from sun damage. Additional study is needed in this area.
C

Weight loss

The effects of chocolate on weight loss are unclear. Further study is necessary to draw conclusions.
C

Wound healing

Early research shows that cocoa butter may help with burn scars. However, more research is needed before firm conclusions may be made.

Uses based on tradition or theory

The below uses are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Acne, Alzheimer's disease, antibacterial, antidepressant, anti-inflammatory, antioxidant, antiviral, aphrodisiac (improves sex drive), asthma, blood thinner, bone loss, bronchitis (airway inflammation), cancer, childbirth (inducing labor), cough, dementia, diarrhea, diuretic (increase urine flow), eating disorders, energy enhancement, eye problems, fever, food uses, fragrance, hair loss, immune system regulation, kidney and bladder disorders, lactose intolerance, liver conditions, malaria, menstrual flow stimulant, migraine, myopathy (muscle disease), nephrosis (kidney disease), neurodegenerative diseases (nervous tissue disease), pain, rheumatism (joint problems), sensory stimulation, snakebite, stimulant, stroke, tonic.

Interactions

Interactions with Drugs

Chocolate may affect blood sugar levels. Caution is advised when using medications that may also affect blood sugar. People taking insulin or drugs for diabetes by mouth should be monitored closely by a qualified healthcare professional, including a pharmacist. Medication adjustments may be necessary.

Chocolate may increase the risk of bleeding when taken with drugs that increase the risk of bleeding. Some examples include aspirin, anticoagulants ("blood thinners") such as warfarin (Coumadin®) or heparin, anti-platelet drugs such as clopidogrel (Plavix®), and non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Aleve®).

Chocolate may affect blood pressure. Caution is advised in people taking drugs that affect blood pressure.

Chocolate may also interact with activated charcoal, agents for bone loss, agents for teeth, agents that affect blood vessel width, agents that affect mental function, agents that affect the heart (including heart rhythm), agents that affect the immune system, agents that affect the nervous system, agents that affect the stomach and intestines, agents that damage the liver, angiotensin-converting enzyme (ACE), antianxiety agents, anticancer agents, aspirin, antidepressants (selective serotonin reuptake inhibitors, SSRIs), anti-inflammatory agents, calcium salts, cannabinoids (present in marijuana), cholesterol-lowering agents, fertility agents, gamma-aminobutyric acid (GABA), iron salts, painkillers, salbutamol, and sunscreens.

Interactions with Herbs and Dietary Supplements

Chocolate may affect blood sugar levels. Caution is advised when using herbs or supplements that may also affect blood sugar. Blood glucose levels may require monitoring, and doses may need adjustment.

Chocolate may increase the risk of bleeding when taken with herbs and supplements that are believed to increase the risk of bleeding. Multiple cases of bleeding have been reported with the use of Ginkgo biloba, and fewer cases with garlic and saw palmetto. Numerous other agents may theoretically increase the risk of bleeding, although this has not been proven in most cases.

Chocolate may affect high blood pressure. Caution is advised in people taking herbs or supplements that affect blood pressure.

Chocolate may also interact with activated charcoal, anticancer herbs and supplements, antidepressants (selective serotonin reuptake inhibitors, SSRIs), anti-inflammatory herbs and supplements, antioxidants, caffeine, calcium, cannabinoids, cholesterol-lowering herbs and supplements, copper, fertility herbs and supplements, gamma-aminobutyric acid (GABA), ginseng, grapefruit, herbs and supplements for bone loss, herbs and supplements for teeth, herbs and supplements that affect blood vessel width, herbs and supplements that effect mental function, herbs and supplements that affect the heart (including heart rhythm), herbs and supplements that affect the immune system, herbs and supplements that affect the nervous system, herbs and supplements for the stomach and intestines, herbs and supplements that damage the liver, iron, painkillers, plant sterols, probiotics, stimulants, sunscreens, and vitamins.

Methodology

This information is based on a systematic review of scientific literature and was peer-reviewed and edited by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Monograph methodology

Related terms

Anandamide, bitter water, black chocolate (BC), Butyrum cacao, cacahuatl (Nahuatl), cacao (Brazilian Portuguese, English, Spanish), cacao bean husk extract, cacao tree, cacaoboom (Dutch), cacaoeiro (Brazilian Portuguese), cacaoyer (French), cacaueiro (Brazilian Portuguese), caffeine, carboxylic acids, catechin, CBC, CBH, chicolatl (Nahuatl), chocol (Mayan), chocolate flavonoids, chocolate milk, chocolate tree, choxi, cinnamtannin, clovamide, cocoa bean, cocoa bean husk extract, cocoa bran, cocoa butter, cocoa husk, cocoa liquor, cocoa oil, cocoa powder, cocoa solids, cocoa tree, dark chocolate, dried cocoa bean, Dutch chocolate, epicatechin, FCMC, fermented cocoa bean, fiber, flavan-3-ols, flavanols, flavonoids, granos de cacao (Spanish), harilik kakaopuu (Estonian), hot chocolate, inulin, isomalt, kakao (Danish), Kakao (German), kakaó(fa) (Hungarian), Kakaobaum (German), Kakaopflanze (German), kakaotræ (Danish), kakaowiec (Polish), kakav (Slovenian), kawkaw (Mayan), ke ke (Chinese), lipids, methylxanthine alkaloids, methylxanthines, milk chocolate, N-linoleoylethanolamine, N-oleolethanolamine, N-phenylpropenoyl-L-amino acid amide, oleic acid, oligofructose, palmitic acid, phenylethylamine, phytochemicals, phytosterols, polyphenols, procyanidin oligomers, procyanidins, purine alkaloids, saturated fatty acids, sorbitol, stearic acid, Sterculiaceae (family), stimulant drug, sucrose, Theobroma cacao L., Theobroma cacao phenolic extracts, theobromine, white chocolate, xocoatl (Mayan, Nahuatl), xocolatl (Mayan, Nahuatl).

Note: This monograph covers cacao, cocoa products, and chocolate. Chocolate contains caffeine. For a more complete overview, information on caffeine is available in the Natural Standard caffeine monograph.

Safety

The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.

Allergies

Avoid with known allergy or sensitivity to chocolate, cocoa, any of its parts (including caffeine), or members of its plant family. Migraine headaches, allergic skin reactions, and slowed digestion have been reported.

Side Effects and Warnings

Note: Chocolate contains caffeine. The chronic use of caffeine, especially in large amounts, may produce tolerance or dependence. Abrupt discontinuation of caffeine may result in physical withdrawal symptoms, including headache, irritation, nervousness, anxiety, and dizziness. Safety information associated with caffeine is not specifically discussed in this monograph. For more information, the Natural Standard monograph on caffeine is available.

Chocolate is likely safe when used in amounts found in foods and when up to 25 grams is used daily. Cocoa butter is likely safe when used on the skin, and when used to help carry medicine.

Use with caution in people with addictive tendencies, anemia, gut disorders, bone loss, and high cholesterol levels. Use with caution in people prone to migraine headaches or kidney stones. Use with caution in people who are overweight or obese and in those trying to become pregnant.

Use with caution in people using angiotensin-converting enzyme inhibitors (ACE) or salbutamol.

Use cautiously in children, due to the risk of developing habits that could lead to obesity and poor health.

Chocolate may affect blood sugar levels. Caution is advised in people with diabetes or hypoglycemia, and in those taking drugs, herbs, or supplements that affect blood sugar. Blood glucose levels may need to be monitored by a qualified healthcare professional, including a pharmacist, and medication adjustments may be necessary.

Chocolate may increase the risk of bleeding. Caution is advised in people with bleeding disorders or those taking drugs that may increase the risk of bleeding. Dosing adjustments may be necessary.

Chocolate may affect blood pressure. Caution is advised in people with high blood pressure and in those taking drugs, herbs, or supplements that affect blood pressure.

Avoid with known allergy or sensitivity to chocolate, cocoa, any of its parts (including caffeine), or members of its plant family.

Avoid large amounts of chocolate during pregnancy or breastfeeding.

Chocolate may cause acne, allergic skin reactions, bloating, colic in infants, constipation, decreased bone density, dental caries, eczema, gas, headaches, improved insulin sensitivity, increased cholesterol levels, increased insulin levels, irregular heart rhythms, increased oxalate levels in urine, irritable bowel syndrome, irritability, jitteriness, kidney damage and disorders, migraines, nausea, neck pain, nervousness, shakiness, sleep disturbances, stomach rumbling, stomach upset, swelling under the skin, unpleasant taste, upset stomach, vomiting, weight gain.

Pregnancy and Breastfeeding

Avoid large amounts of chocolate during pregnancy and breastfeeding due to reports of early delivery, low birth weight, and abortion. Chocolate also contains two compounds that may cause birth defects.

Use with caution in people trying to become pregnant.

Selected references

  1. Bhate K and Williams HC. Epidemiology of acne vulgaris. Br.J Dermatol. 2013;168(3):474-485.
  2. d'El-Rei J, Cunha AR, Burla A, et al. Characterisation of hypertensive patients with improved endothelial function after dark chocolate consumption. Int J Hypertens. 2013;2013:985087.
  3. Davison G, Callister R, Williamson G, et al. The effect of acute pre-exercise dark chocolate consumption on plasma antioxidant status, oxidative stress and immunoendocrine responses to prolonged exercise. Eur.J Nutr 2012;51(1):69-79.
  4. Fogleman CD. Effect of cocoa on blood pressure. Am Fam.Physician 4-1-2013;87(7):484.
  5. Grassi D, Desideri G, Necozione S, et al. Protective effects of flavanol-rich dark chocolate on endothelial function and wave reflection during acute hyperglycemia. Hypertension 2012;60(3):827-832.
  6. Mellor DD, Madden LA, Smith KA, et al. High-polyphenol chocolate reduces endothelial dysfunction and oxidative stress during acute transient hyperglycaemia in Type 2 diabetes: a pilot randomized controlled trial. Diabet.Med. 2013;30(4):478-483.
  7. Nehlig A. The neuroprotective effects of cocoa flavanol and its influence on cognitive performance. Br.J Clin Pharmacol. 2013;75(3):716-727.
  8. Netea SA, Janssen SA, Jaeger M, et al. Chocolate consumption modulates cytokine production in healthy individuals. Cytokine 2013;62(1):40-43.
  9. Neufingerl N, Zebregs YE, Schuring EA, et al. Effect of cocoa and theobromine consumption on serum HDL-cholesterol concentrations: a randomized controlled trial. Am J Clin Nutr 2013;97(6):1201-1209.
  10. Ostertag LM, Kroon PA, Wood S, et al. 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;57(2):191-202.
  11. Rein MJ, Renouf M, Cruz-Hernandez C, et al. Bioavailability of bioactive food compounds: a challenging journey to bioefficacy. Br.J Clin Pharmacol. 2013;75(3):588-602.
  12. Ros E and Hu FB. Consumption of plant seeds and cardiovascular health: epidemiological and clinical trial evidence. Circulation 7-30-2013;128(5):553-565.
  13. Sorond FA, Hurwitz S, Salat DH, et al. Neurovascular coupling, cerebral white matter integrity, and response to cocoa in older people. Neurology 9-3-2013;81(10):904-909.
  14. Stote KS, Clevidence BA, Novotny JA, et al. Effect of cocoa and green tea on biomarkers of glucose regulation, oxidative stress, inflammation and hemostasis in obese adults at risk for insulin resistance. Eur.J Clin Nutr 2012;66(10):1153-1159.
  15. van Dam RM, Naidoo N, and Landberg R. Dietary flavonoids and the development of type 2 diabetes and cardiovascular diseases: review of recent findings. Curr Opin.Lipidol. 2013;24(1):25-33.

This evidence-based monograph was prepared by The Natural Standard Research Collaboration

www.naturalstandard.com