DIABETICMedicine

DOI: 10.1111/j.1464-5491.2010.03108.x

Short Report
High-cocoa polyphenol-rich chocolate improves
HDL cholesterol in Type 2 diabetes patients

D. D. Mellor, T. Sathyapalan*, E. S. Kilpatrick†, S. Beckett‡ and S. L. Atkin*

HONEI, University of Hull, *Hull York Medical School, †Chemical Pathology, Hull and Yorkshire Hospitals NHS Trust, Hull and ‡Sporomex, Driffield,
East Riding of Yorkshire, UK

Accepted 3 August 2010

Abstract
Aim To examine the effects of chocolate on lipid profiles, weight and glycaemic control in individuals with Type 2 diabetes.
Methods Twelve individuals with Type 2 diabetes on stable medication were enrolled in a randomized, placebo-controlled
double-blind crossover study. Subjects were randomized to 45 g chocolate with or without a high polyphenol content for
8 weeks and then crossed over after a 4-week washout period. Changes in weight, glycaemic control, lipid profile and high-
sensitivity C-reactive protein were measured at the beginning and at the end of each intervention.
Results HDL cholesterol increased significantly with high polyphenol chocolate (1.16  0.08 vs. 1.26  0.08 mmol ⁄ l,
P = 0.05) with a decrease in the total cholesterol: HDL ratio (4.4  0.4 vs. 4.1  0.4 mmol ⁄ l, P = 0.04). No changes were seen
with the low polyphenol chocolate in any parameters. Over the course of 16 weeks of daily chocolate consumption neither
weight nor glycaemic control altered from baseline.
Conclusion High polyphenol chocolate is effective in improving the atherosclerotic cholesterol profile in patients with diabetes
by increasing HDL cholesterol and improving the cholesterol:HDL ratio without affecting weight, inflammatory markers,
insulin resistance or glycaemic control.
Diabet. Med. 27, 1318–1321 (2010)
Keywords cardiovascular risk, chocolate, HDL cholesterol, polyphenols, type 2 diabetes

disease, cancer and stroke [6]. Short-term administration of dark

Introduction
Dyslipidaemia is a risk factor for cardiovascular disease,
especially in individuals with Type 2 diabetes [1].
Cardiovascular risk in Type 2 diabetes has been associated
with dietary factors [2] and high intakes of refined carbohydrates
such as sucrose are associated with worse glycaemic control,
increased obesity and hypertriglyceridaemia [3]. Concern over
the effect of sugar on glycaemia has been altered by work on the
glycaemic index [4]. The concept of the glycaemic index has led
to the realization that foods such as chocolate, although high in
carbohydrate, and in particular sugar, may have a lesser effect on
blood glucose than foods that are low in sugar, including
potatoes and bread [5].
It has been hypothesized that flavonoid compounds found in
foods, including epicatechins found in high-cocoa-solid
chocolates, decrease the risk of death from coronary heart
Correspondence to: Stephen L. Atkin, Hull York Medical School, Hull HU3
2RW, UK. E-mail: stephen.atkin@hyms.ac.uk
chocolate was followed by a significant increase in insulin
sensitivity and a decrease in blood pressure in healthy subjects [7].
Dark chocolate consumption has been reported to increase HDL
cholesterol concentration and chocolate fatty acids may inhibit
lipid peroxidation in healthy subjects [8].
Therefore, our hypothesis was that that the daily consumption
of chocolate (45 g daily) containing polyphenol-rich, high-cocoa
solids would improve cardiovascular risk factors when taken
chronically, whilst being safe for patients with Type 2 diabetes.
Patients and methods
This randomized, placebo-controlled, double-blind crossover
study was undertaken in the Clinical Trials Unit of the Michael
White Diabetes Centre, Hull Royal Infirmary, Hull, UK. All
participators were screened between January 2008 and October
2008. The chocolate for the study was provided as an
unrestricted gift from Nestle PTC, York and was funded
through the Diabetes Research and Development fund. The

ª 2010 The Authors.

1318 Diabetic Medicine ª 2010 Diabetes UK
 Short report
study was approved by the local National Health Service
Research Ethics Committee and written consent was obtained
from all subjects prior to enrolment.
Twelve subjects (seven males, five females) with Type 2
diabetes [age—median (range) 68 (42–71) years)] were enrolled
and completed the study. The mean duration of diagnosis of
diabetes was (mean  sd) (18  5) months. Inclusion criteria
were a diagnosis of Type 2 diabetes based on the World Health
Organization guidelines [9]. Exclusion criteria included HbA1c
greater than 9.0% (Diabetes Control and Complications Trial
aligned), treatment with insulin, use of steroids, any change in use
of medication in the previous 8 weeks and not having attended a
structured diabetes education programme. Five of the subjects
had their diabetes managed with metformin, eight were treated
with statin therapy and three were treated with anti-hypertensive
agents. None of the patients were on any other oral
hypoglycaemic agents or other lipid-lowering medications. All
of the subjects’ chronic medications were maintained at stable
doses for at least 3 months prior to the start of the study.
The active product was high-polyphenol chocolate containing
85% cocoa solids (derived from a high-cocoa liquor content)
compared with chocolate containing cocoa butter alone that
contained no non-fat cocoa solids (cocoa liquor) (iso-calorific
and macronutrient profile matched chocolate), which was low in
polyphenols and that was dyed to the same colour as high-
polyphenol chocolate. Individual 15-g foil wrapped bars were
provided and subjects were asked to consume one bar three times
daily. This would provide a total of 326 kcal for the three bars,
with high-polyphenol chocolate providing 16.6 mg of
epicatechins and the low-polyphenol chocolate < 2 mg.
Randomization was undertaken by Nestec Ltd., with enough
chocolate being given to subjects for the 8-week period. To
monitor compliance, subjects were asked to return all empty
wrappers, noting the time and date when it was consumed on the
wrapper. Subjects were advised not to consume any other
chocolate for the duration of the study; apart from this, subjects
were instructed to make no further changes to their diet and
lifestyle. To monitor the potential acute effects on glycaemia, and
as a safety measure, all subjects were supplied with a glucometer
(Glucomen; Menarini Diagnostics, Wokingham, UK) and asked
to measure 7-point profiles on at least 2 days of the week on two
separate weeks for each of the two intervention arms.
Reassuringly, there were no significant excursions in blood
glucose.
Following an overnight fast, measurement of weight and blood
pressure were made and blood samples were collected at the
beginning and the end of the each of the two 8-week phases.
Weight was measured using calibrated weighing scales in light
clothing and bare feet, fasting and with an empty bladder.
Dietary recall of eating patterns to estimate energy and
macronutrient intake was performed at each visit by a
registered dietitian.
Fasting venous blood samples were separated by
centrifugation at 3000 g for 15 min at 4 C and the aliquots
stored at –80 C within 1 h of collection. Sitting blood pressure
ª 2010 The Authors.
Diabetic Medicine ª 2010 Diabetes UK
DIABETICMedicine
was measured after 10 min of rest using an automated device
(NPB-3900; Nellcor Puritan Bennett, Pleasanton, CA, USA).
Total cholesterol, triglyceride and HDL cholesterol levels were
measured enzymatically using a Synchron LX20 analyser
(Beckman-Coulter, High Wycombe, UK). LDL cholesterol was
calculated using the Friedewald equation. Plasma glucose was
measured using a Synchron LX20 analyser (Beckman-Coulter)
and serum insulin was assayed using a competitive
chemiluminescent immunoassay performed using the DPC
Immulite 2000 analyser (Euro ⁄ DPC, Llanberis, UK). The
coefficient of variation of this method was 8%, calculated
using duplicate study samples. The insulin resistance was
calculated using the homeostasis model assessment method
(HOMA-IR) [10]. HbA1c was measured on an HA-8140
analyser (Menarini Diagnostics). The sample size calculation
was based on an estimate of the standard error of mean of the
treatment difference (the difference between treatment and
control measurements of plasma HDL cholesterol taken on an
individual) of 0.3 mmol ⁄ l [11]. At the P < 0.05 level of
significance, a sample size of 12 subjects in a crossover fashion
will provide > 90% power to detect a 0.4-mmo ⁄ l change in
plasma HDL cholesterol concentration.
Results
Dietary recall suggested that the chocolate tended to replace
other snack foods and there was some reduction in portion size at
the subsequent meal, resulting in no significant change in energy
or macronutrient intake. Compliance based on returned
wrappers was 93.8%. Weight was unchanged at the end of the
study 89.4  6.3 kg (P = 1.00); there were also no effects on
glycaemia in terms of HbA1c (P = 0.84).
The differences that were found between high-polyphenol
chocolate and low-polyphenol chocolate are shown in Table 1.
HDL cholesterol improved significantly (P = 0.05) and the
cholesterol:HDL ratio significantly decreased (P = 0.04). This
change was reflected when these data were examined as a
percentage change from the initial baseline. The percentage
change of the lipid profile before and after each intervention is
shown in Fig. 1.
Subjects were reviewed 3 and 6 months after the end of
the study, when the HDL and HDL:cholesterol ratio and
glycaemic control did not differ between screening and post-
study measurements (data not shown).
Discussion
High-polyphenol chocolate has the potential to be included in the
diet of individuals with Type 2 diabetes as part of a sensible,
balanced approach to diet and lifestyle, with a potential
reduction in cardiovascular risk and without detrimental
effects on weight or glycaemic control. These benefits are in
addition to the potential psychosocial benefits through
liberalization of eating behaviours and reduction of food-
related guilt [12].
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DIABETICMedicine High-cocoa polyphenol-rich chocolate improves HDL cholesterol • D. D. Mellor et al.

Table 1 Mean values ( sem) for biochemical of cardiovascular risk

Pre-HPC Post-HPC P-value Pre-LPC Post-LPC P-value

Systolic blood pressure (mmHg) 132  5 134  6 0.67 132  5 134  5 0.55
Diastolic blood pressure (mmHg) 80  3 82  3 0.10 82  3 84  2 0.51
HbA1c (%) 6.4  0.2 6.5  0.2 0.07 6.4  0.2 6.4  0.2 0.63
Fasting plasma glucose (mmol ⁄ l) 7.0  0.4 6.9  0.4 0.71 6.8  0.4 7.2  0.4 0.17
Fasting insulin (uIU ⁄ l) 13.9  2.6 14.1  3.1 0.92 10.8  2.4 14.8  2.8 0.07
HOMA 4.5  1.0 4.5  1.1 0.95 3.4  1.0 4.6  1.0 0.08
High-sensitivity C-reactive protein (mmol ⁄ l) 3.0  0.6 2.0  0.4 0.22 2.6  0.7 2.4  0.6 0.72
Serum cholesterol (mmol ⁄ l) 5.0  0.4 5.0  0.4 0.94 5.0  0.4 4.9  0.4 0.55
Serum triglycerides (mmol ⁄ l) 1.25  0.19 1.20  0.18 0.32 1.25  0.26 1.26  0.18 0.52
Serum LDL cholesterol (mmol ⁄ l) 3.29  0.41 3.14  0.36 0.83 3.08  0.35 3.10  0.33 0.18
Serum HDL cholesterol (mmol ⁄ l) 1.16  0.08 1.26  0.08 0.05 1.25  0.08 1.18  0.08 0.78
Cholesterol:HDL ratio 4.4  0.4 4.1  0.4 0.04 4.0  0.5 4.5  0.4 0.83

P-values were obtained by t-test and Wilcoxon’s signed-rank test for clinical measurements.
All biochemical tests were tested for normality using the Kolmogorov–Smirnov test, which none of the data violated.
HOMA, homeostatis model assessment; HPC, high-polyphenol content chocolate; LPC, low-polyphenol content chocolate.

Mean % change HPC Mean % change LPC

9.1
2.0
0.6 0.6
–1.6 –1.5 –1.6
–6.3
Total cholesterol Triglycerides HDL cholesterol LDL cholesterol
(P = 0.55) (P = 0.92) (P = 0.04) (P = 0.41)
FIGURE 1 Change in lipid profile comparing the effect of consuming
either high-polyphenol chocolate (HPC) for 8 weeks or low-polyphenol
chocolate (LPC). The data were tested for normality using the Kolmogorov–
Smirnov test and the P-value was obtained from a paired t-test.
This is the first study to report on the effects of giving chocolate
to individuals with Type 2 diabetes, chronically over a period of
16 weeks. It demonstrates that feeding of high-polyphenol
chocolate for 2 months can improve lipid profile, particularly
through increased HDL cholesterol, whilst improving the
cholesterol:HDL ratio. This shows a potential for reduction in
cardiovascular risk and combined with a lack of any deleterious
effects on weight, markers of inflammation, insulin resistance or
glycaemic control. This appears to occur even in subjects treated
with lipid-lowering therapies, indicating a beneficial additive
effect through an alternate pathway. However, when the high-
polyphenol chocolate intervention stopped, then those beneficial
effects were reversed back to baseline.
This study differs from previous studies that have used much
shorter intervention periods and have tended only to use cocoa
[13]. The effect on HDL cholesterol is in accord with a study in
subjects without diabetes [8] and these data indicate that
this effect may be sustained. However, the mechanism of how
high-polyphenol chocolate may influence this improvement in
lipid profile remains unclear. It has been suggested that the
12.1 polyphenols may have either an insulin sensitizing effect
[7],which was not seen in this study, or that there is reduced
inflammation independent of insulin action [8] through reduced
lipid perioxidation, although this too was not inferred as the
high-sensitivity C-reactive protein levels here did not differ
between groups. It has been hypothesized that additional
beneficial effects of polyphenols on the endothelium may be
mediated through increasing nitric oxide levels [7].
–8.3 Because of the small sample size, there is a potential for type 2
HDL: cholesterol
(P = 0.04) errors, although the crossover design probably served to
overcome this to some extent. Being a crossover study, there
was concern that subjects may have been able to tell the
difference between the two preparations. Therefore, a blinded
taste study was undertaken prior to the trial that showed that the
subjects could not tell any difference in appearance or taste
between the high-polyphenol chocolate and low-polyphenol
chocolate preparations, thus avoiding the bias if one could have
been perceived better than the other. The measurement of plasma
polyphenols in this study was not undertaken, although this
may be potentially useful in the future if dose–response studies
are to be undertaken.
Conclusion
Consuming high-polyphenol chocolate, sweetened with sucrose,
over an 8-week period improved cardiovascular risk indices by
increasing HDL cholesterol without a detrimental effect on
glycaemic control, insulin resistance, inflammation or weight.
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