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▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
heartjnl-2015-309203).
1 Swedish adults and we performed a meta-analysis of
Unit of Nutritional
Epidemiology, Institute of
Environmental Medicine,
Karolinska Institutet,
Stockholm, Sweden
2
Unit of Cardiovascular
Epidemiology, Institute of
Environmental Medicine,
Karolinska Institutet,
Stockholm, Sweden
3
Division of Cardiovascular
Medicine, Department of
Clinical Sciences, Danderyd
University Hospital, Stockholm,
Sweden
Correspondence to
Dr Susanna C Larsson, Unit of
Nutritional Epidemiology,
Institute of Environmental
Medicine, Karolinska Institutet,
Stockholm SE-17177, Sweden;
susanna.larsson@ki.se
Received 18 December 2015
Revised 8 February 2016
Accepted 11 February 2016
Published Online First
2 March 2016
▸ http://dx.doi.org/10.1136/
heartjnl-2016-309468
To cite: Larsson SC,
Åkesson A, Gigante B, et al.
Heart 2016;102:
1017–1022.
ORIGINAL ARTICLE
Chocolate consumption and risk of myocardial
infarction: a prospective study and meta-analysis
Susanna C Larsson,1 Agneta Åkesson,1 Bruna Gigante,2,3 Alicja Wolk1
ABSTRACT
Objective To examine whether chocolate consumption
is associated with a reduced risk of ischaemic heart
disease, we used data from a prospective study of
available prospective data.
Methods and results The Swedish prospective study
included 67 640 women and men from the Cohort of
Swedish Men and the Swedish Mammography Cohort
who had completed a food-frequency questionnaire and
were free of cardiovascular disease at baseline.
Myocardial infarction (MI) cases were ascertained
through linkage with the Swedish National Patient and
Cause of Death Registers. PubMed and EMBASE
databases were searched from inception until 4 February
2016 to identify prospective studies on chocolate
consumption and risk of ischaemic heart disease.
Results The results from eligible studies were combined
using a random-effects model. During follow-up (1998–
2010), 4417 MI cases were ascertained in the Swedish
study. Chocolate consumption was inversely associated
with MI risk. Compared with non-consumers, the
multivariable relative risk for those who consumed ≥3–4
servings/week of chocolate was 0.87 (95% CI 0.77 to
0.98; p for trend =0.04). Five prospective studies on
chocolate consumption and ischaemic heart disease were
identified. Together with the Swedish study, the meta-
analysis included six studies with a total of 6851
ischaemic heart disease cases. The overall relative risk for
the highest versus lowest category of chocolate
consumption was 0.90 (95% CI 0.82 to 0.97), with
little heterogeneity among studies (I2=24.3%).
Conclusions Chocolate consumption is associated with
lower risk of MI and ischaemic heart disease.
INTRODUCTION
Mounting evidence from randomised controlled
trials indicates beneficial effects of chocolate and
cocoa flavanols on blood pressure, endothelial
function, insulin sensitivity and lipoprotein concen-
trations.1–3 Furthermore, prospective studies have
shown that chocolate consumption is inversely
associated with stroke incidence and cardiovascular
disease (CVD) mortality.4–6 Findings from pro-
spective studies of chocolate consumption in rela-
tion to risk of ischaemic heart disease (IHD) have
been less consistent.7–11 Most previous studies on
chocolate consumption and IHD were based on a
small number of IHD cases,8–10 assessed a narrow
range of chocolate consumption7 10 and/or exam-
ined the association of chocolate consumption with
recurrent myocardial infarction (MI) in patients
with MI.8 Only one previous study has assessed the
Larsson SC, et al. Heart 2016;102:1017–1022. doi:10.1136/heartjnl-2015-309203
Coronary artery disease
association between chocolate consumption and
first event of MI specifically.9
To further clarify the association between choc-
olate consumption and incidence of IHD, we used
data from two large prospective cohorts of Swedish
men and women to investigate the association
between chocolate consumption and MI incidence.
We also evaluated whether the association was
modified by overweight and history of diabetes,
hypertension and hypercholesterolaemia. Moreover,
we performed a meta-analysis by incorporating
results from the current study with published pro-
spective data on chocolate consumption and risk of
MI or IHD.
METHODS
Study population
We used data from two prospective population-
based cohorts of men and women from three
Swedish counties (Västmanland, Örebro and
Uppsala): the Cohort of Swedish Men (COSM) and
the Swedish Mammography Cohort (SMC). In the
late autumn of 1997, 48 850 men and 39 227
women responded to a 350-item questionnaire that
sought information on diet and other risk factors
for chronic diseases. We omitted men and women
with a missing or an erroneous personal registra-
tion number (n=297 men and n=243 women),
those who died before start of follow-up (n=55
men and n=26 women), those with a history of
cancer (n=2592 men and n=1811 women) or
CVD (IHD, heart failure and stroke; n=5761 men
and n=4319 women) and those with implausible
total energy intake (ie, 3 standard deviations from
the loge-transformed mean energy intake; n=441
men and n=405 women) or with missing data on
chocolate consumption (n=3169 men and n=3155
women). After these exclusions, 67 640 partici-
pants (36 535 men and 31 105 women) aged 45
−83 years remained for the analysis. The Regional
Ethical Review Board at Karolinska Institutet in
Stockholm, Sweden approved the study.
Completion of the self-administered questionnaire
was considered to imply informed consent.
Assessment of chocolate consumption
Information on consumption of chocolate and
other foods was obtained from a self-administered
96-item food-frequency questionnaire (FFQ) com-
pleted by participants at baseline in 1997.
Participants were asked to report how often on
average over the past year they had consumed
chocolate. The FFQ had only one question on
chocolate consumption (type of chocolate was not
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Coronary artery disease
specified). The FFQ had eight predefined frequency consump-
tion categories (never, 1–3/month, 1–2/week, 3–4/week, 5–6/
week, 1/day, 2/day and ≥3/day). Participants were categorised
into four groups according to their chocolate consumption:
never, 1–3/month, 1–2/week and ≥3–4/week. The five highest
frequency categories were collapsed because only 8.7% of parti-
cipants consumed chocolate ≥3–4 times/week. The validity and
reproducibility of the FFQ have been previously published.12
Assessment of covariates
Information on education, family history of MI before 60 years
of age, smoking, aspirin use, physical activity (including walking/
bicycling and leisure-time exercise), body weight, height, history
of diabetes, hypertension and hypercholesterolaemia, and
alcohol intake was obtained by a self-administered questionnaire.
Information on history of diabetes and hypertension was also
obtained from the Swedish National Diabetes Register (diabetes
only) and the Swedish National Patient Register. Body mass
index (BMI) was calculated as weight (in kg) divided by the
square of height (in metres). Pack-years of smoking history were
computed by multiplying the number of packs of cigarettes
smoked per day by the number of years of smoking.
Case ascertainment
Incident MI cases (including fatal cases) were ascertained by
linkage of participants (using the unique personal registration
number assigned to each Swedish resident) to the Swedish
National Patient Register and the Swedish Cause of Death
Register at the National Board of Health and Welfare. MI was
classified using the International Classification of Diseases 10th
Revision code I21 for acute MI. Deaths were ascertained by
linkage with the Swedish Cause of Death Register.
Statistical analysis
For each participant, person-years of follow-up accrued from 1
January 1998 until the date of diagnosis of MI, date of death
(from any cause) or 31 December 2010, whichever came first.
Cox proportional hazards regression models were used to esti-
mate hazard ratios (hereafter referred to as relative risks (RR))
with 95% CI of MI according to categories of chocolate con-
sumption. The first multivariable model was stratified by base-
line age (in years) and sex and included education (less than
high school, high school, university), family history of MI
before 60 years of age (no, yes), smoking (never; past <20 or
≥20 pack-years; current <20 or ≥20 pack-years), aspirin use
(never, 1–6 tablets/week, ≥7 tablets/week or users with
unknown number of tablets), walking/bicycling (almost never,
<20 min/day, 20–40 min/day, 40–60 min/day, >1 h/day), exer-
cise (<1 h/week, 1 h/week, 2–3 h/week, 4–5 h/week, >5 h/
week) and intakes of total energy (kcal/day; continuous),
alcohol (g/day; quintiles), processed meat (servings/week; quin-
tiles) and fruits and vegetables (servings/day; quintiles). In a
second multivariable model, we included the above covariates
plus potential intermediates: BMI (kg/m2; continuous) and
history and diagnosis of diabetes (no, yes), hypertension (no,
yes) and hypercholesterolaemia (no, yes) at baseline. A separate
category for missing was used to handle missing covariate data
(missing was ≤3%, with the exception for exercise (5.5%)).
Further adjustment for intake of unprocessed red meat, fish,
dairy products, sweetened beverages, coffee and tea did not
alter the results; therefore, these variables were not included in
the multivariable model. The proportional hazards assumption
was tested using Schoenfeld residuals and was found to be
satisfactory.
1018
Tests for linear trend across categories of chocolate consump-
tion were performed by creating a variable containing the
median value of chocolate consumption for each category and
treating this variable as a continuous variable in the Cox model.
In a sensitivity analysis, we excluded cases diagnosed during the
first 3 years of follow-up. We examined whether the association
between chocolate consumption and MI risk was modified by
sex, high educational level (high school or university), over-
weight (BMI ≥25 kg/m2) and history of diabetes, hypertension
and hypercholesterolaemia at baseline. The statistical signifi-
cance of the potential effect modifications was tested using the
likelihood ratio test, comparing models with and without inter-
action terms. Analyses were performed with SAS V.9.3 (SAS
Institute, Cary, North Carolina, USA). All p values were 2-tailed
and the significance level was set at an α of 0.05.
Meta-analysis
We performed a meta-analysis that incorporated results from the
current Swedish study into findings from previous prospective
studies of the association of chocolate consumption with risk of
MI or IHD. Inclusion criteria were prospective study and results
for chocolate intake in relation to MI/IHD incidence or mortal-
ity. We excluded letters, abstracts, systematic reviews and
meta-analyses; case–control, cross-sectional, ecological and
experimental studies. We searched PubMed (http://www.ncbi.
nlm.nih.gov/pubmed) and EMBASE (http://www.embase.com)
from inception until 4 February 2016, using the search terms
chocolate or cocoa combined with cardiovascular disease or
myocardial infarction or heart disease. No restrictions were
applied. Reference lists of pertinent articles were reviewed to
identify further relevant studies. From each study, we extracted
the following data: the first author’s last name, publication year,
the name of the study, study location, sex and age of partici-
pants, years of follow-up, sample size (number of events and
total number of participants), chocolate intake categories, cov-
ariates adjusted for in the multivariable model and the most
fully adjusted RRs.
We combined the RRs for the highest versus lowest category
of chocolate consumption. We also performed a dose–response
meta-analysis using the method by Greenland and Longnecker13
and Orsini et al14 to compute the trend from the correlated log
RRs across categories of chocolate consumption. Studies were
included in the dose–response meta-analysis if they reported
RRs for at least three categories of chocolate consumption. If
results were reported in servings of chocolate, we assumed that
one serving equals 30 g chocolate, which is the approximate
serving size of chocolate in Swedish men.12 Study-specific RRs
were combined using a random-effects model,15 which consid-
ers both within-study and between-study variation (weighting
was based on the inverse of the variance). The I2 statistic16 was
used to quantify heterogeneity between studies. Publication bias
was assessed with Egger’s test.17 We used Stata V.14.1
(StataCorp, College Station, Texas, USA) to analyse the data.
RESULTS
Swedish study
Over 13 years (mean 12.0±2.6 years, median 13 years) of
follow-up, we identified 4417 incident cases of MI (3067 in
men and 1350 in women), including 897 fatal cases, among the
67 640 Swedish adults. Compared with non-consumers of choc-
olate, men and women who consumed ≥3–4 servings/week of
chocolate were more likely to have a university education but
less likely to be current smokers, overweight and to have a
history of diabetes, hypertension and hypercholesterolaemia
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Table 1 Baseline age-standardised characteristics by categories of chocolate consumption in 67 640 Swedish men and women
Category of chocolate consumption, servings

Characteristic* 0 (n=10 037) 1–3/month (n=34 231) 1–2/week (n=17 487) ≥3–4/week (n=5885) p for trend†

Age, years 61.0 (9.2) 59.3 (8.9) 58.8 (9.0) 60.7 (9.6) <0.001
Sex, men, % 53 52 57 57 <0.001
Postsecondary education, % 17 18 22 24 <0.001
Family history of myocardial infarction, % 16 15 15 14 <0.001
Current smoker, % 26 24 23 26 0.83
Aspirin use ≥7 tablets/week, % 6.5 6.5 6.0 7.2 0.48
Walk/bicycle ≥40 min/day, % 36 34 32 34 <0.001
Exercise ≥2 h/week, % 58 58 57 55 <0.001
Body mass index ≥25 kg/m2, % 53 50 48 44 <0.001
Diabetes, % 14 3.8 3.1 3.2 <0.001
Hypertension, % 24 20 19 18 <0.001
Hypercholesterolaemia, % 12 10 10 10 0.002
Total energy intake, kcal/day 2100 (830) 2200 (800) 2400 (850) 2700 (940) <0.001
Alcohol intake, g/day 11 (22) 10 (16) 11 (15) 12 (17) <0.001
Processed meat, servings/week 4.8 (4.6) 4.8 (3.9) 5.4 (4.1) 5.9 (4.9) <0.001
Fruits and vegetables, servings/day 4.6 (3.0) 4.4 (2.5) 4.4 (2.4) 4.6 (2.7) 0.37
*Data represent mean (standard deviation) or percentage.
†Assessed by using linear regression for continuous variables and χ² test for categorical variables.

(table 1). They also had higher intakes of total energy and pro-
cessed meat.
Chocolate consumption was inversely associated with MI risk
(table 2). In the minimally adjusted multivariable Cox model,
men and women who consumed ≥3–4 servings/week of choc-
olate had a 20% (95% CI 10% to 30%) lower risk of MI com-
pared with non-consumers (table 2). The association was
attenuated, but remained statistically significant after further
adjustment for BMI and history of diabetes, hypertension and
hypercholesterolaemia at baseline; the corresponding reduction
in MI risk was 13% (95% CI 2% to 23%). The association
between chocolate consumption and MI risk was not modified
by sex ( p for interaction between chocolate consumption and
sex in relation to MI =0.38). Excluding cases of MI diagnosed
during the first 3 years of follow-up did not change the results,
but widened the CI owing to fewer cases in the analysis
(n=3551) (RR 0.87, 95% CI 0.76 to 1.00, for the highest vs
lowest category).
In stratified analysis, the association between chocolate con-
sumption and MI risk appeared to be stronger in individuals
with diabetes (multivariable model 2: RR 0.69, 95% CI 0.46 to
1.05, for highest vs lowest category) than in non-diabetics (cor-
responding RR 0.93, 95% CI 0.82 to 1.06) ( p for interaction
between chocolate consumption and diabetes in relation to MI
=0.002), but results for diabetics were based on a small number
of individuals (n=3434) and were not statistically significant.
The relation between chocolate consumption and MI was not
modified by high education, overweight or history of hyperten-
sion or hypercholesterolaemia ( p for interaction between choc-
olate intake and the potential effect modifier in relation to
MI risk >0.25 for all).
Meta-analysis
Our literature search identified five prospective studies investigat-
ing the association between chocolate consumption and risk of
IHD (see online supplementary eFigure 1). Together with the
Swedish study, six studies from five different countries (two from
Sweden and one each from Germany, the UK, the USA and
Australia) with a total of 6851 IHD cases ascertained among
144 823 adults were included in the meta-analysis (table 3). Only

Table 2 RR (95% CI) of MI by chocolate consumption in 67 640 Swedish men and women, 1998−2010
Categories of chocolate consumption, servings

0 1–3/month 1–2/week ≥3–4/week p for trend

MI cases*/participants (%) 833/10 037 (8.3%) 2142/34 231 (6.3%) 1049/17 487 (6.0%) 393/5885 (6.7%)
Total person-years 116 942 413 046 211 491 69 317
Age-adjusted and sex-adjusted 1.00 0.82 (0.76 to 0.89) 0.77 (0.70 to 0.84) 0.76 (0.67 to 0.85) <0.001
Multivariable model 1† 1.00 0.85 (0.79 to 0.92) 0.82 (0.75 to 0.90) 0.80 (0.70 to 0.90) 0.002
Multivariable model 2‡ 1.00 0.91 (0.84 to 0.99) 0.89 (0.81 to 0.97) 0.87 (0.77 to 0.98) 0.04
*Non-fatal and fatal cases.
†The Cox proportional hazards regression model is stratified by baseline age (in years) and sex and includes education (less than high school, high school, university), family history of
MI before 60 years of age (no, yes), smoking (never; past <20 or ≥20 pack-years; current <20 or ≥20 pack-years), aspirin use (never, 1–6 tablets/week, ≥7 tablets/week), walking/
bicycling (almost never, <20 min/day, 20–40 min/day, 40–60 min/day, >1 h/day), exercise (<1 h/week, 1 h/week, 2–3 h/week, 4–5 h/week, >5 h/week) and intakes of total energy (kcal/
day; continuous), alcohol (g/day; quintiles), processed meat (servings/week; quintiles) and fruits and vegetables (servings/day; quintiles).
‡Adjusted for the same covariates as above and further for body mass index (kg/m2; continuous) and history and diagnosis of diabetes (no, yes), hypertension (no, yes) and
hypercholesterolaemia (no, yes).
MI, myocardial infarction; RR, relative risk.

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Table 3 Characteristics of prospective studies of chocolate consumption and risk of IHD
Follow-up Number of Category of
Reference Study name, country Study population (years) cases chocolate intake RR (95% CI) Adjustments

Mink et al7
Iowa Women’s Health 34 489 CVD-free 16 1329 fatal IHD 0 1.00 (reference) Age, marital status, education, blood pressure, diabetes, BMI,
Study, USA postmenopausal women, cases >0 serving/week 0.98 (0.88 to 1.10) waist-to-hip ratio, physical activity, smoking, oestrogen use and energy
55–69 years intake
Janszky et al8 Stockholm Heart 1169 non-diabetic men and 8 250 recurrent Never 1.00 (reference) Age, sex, education, smoking, obesity, physical inactivity, alcohol
Epidemiology Program, women with MI, 45–70 years non-fatal MI <1 serving/month 0.95 (0.61 to 1.49) consumption, filtered coffee consumption and sweet score
Sweden cases 1 serving/week 1.02 (0.68 to 1.55)
≥2 servings/week 0.86 (0.54 to 1.37)
Buijsse et al9 EPIC-Potsdam, Germany 19 357 CVD-free men and 8.3 166 non-fatal 11.9 g/week 1.00 (reference) Age, sex, employment status, education, smoking, BMI, waist
women not using and fatal MI 13.3 g/week 0.65 (0.40 to 1.05) circumference, prevalence of diabetes, occupational physical activity,
antihypertensive medication, cases 23.1 g/week 1.02 (0.65 to 1.60) sports, cycling and intakes of total energy, alcohol, coffee, tea, red
35–65 years 52.5 g/week 0.73 (0.47 to 1.15) meat, processed meat, dairy, fruits, vegetables and cereal fibre
Lewis et al10 NA, Australia 1216 women, NA 9.5 153 non-fatal <1 serving/week 1.00 (reference) Age, socioeconomic status, BMI and energy intake
and fatal IHD ≥1 serving/week 0.65 (0.46 to 0.94)
cases
Larsson SC, et al. Heart 2016;102:1017–1022. doi:10.1136/heartjnl-2015-309203

Kwok et al11 EPIC-Norfolk, UK 20 952 CVD-free men and 11.9 2434 non-fatal 0 1.00 (reference) Age, sex, smoking, physical activity, BMI, diabetes, systolic blood
women, mean age 59 years and fatal IHD 4.2–24.5 g/week 1.03 (0.91 to 1.15) pressure, low-density lipoprotein cholesterol, high-density lipoprotein
cases 28.7–49.9 g/week 1.03 (0.91 to 1.17) cholesterol and intake of energy and alcohol
50.4–108.5 g/week 0.92 (0.81 to 1.05)
≥109.2 g/week 0.91 (0.80 to 1.04)
Larsson et al, Cohort of Swedish Men 67 640 CVD-free men and 13 4417 non-fatal 0 1.00 (reference) Age, sex, education, family history of MI, smoking status and
2016 (current and Swedish women, 45–83 years and fatal MI 1–3/month 0.91 (0.84 to 0.99) pack-years of smoking, aspirin use, walking/bicycling, exercise, BMI,
study) Mammography Cohort, cases 1–2/week 0.89 (0.81 to 0.97) history of diabetes, hypertension and hypercholesterolaemia, intakes of
Sweden ≥3–4/week 0.87 (0.77 to 0.98) total energy, alcohol, processed meat and fruits and vegetables
BMI, body mass index; CVD, cardiovascular disease; EPIC, European Prospective Investigation into Cancer; IHD, ischaemic heart disease; MI, myocardial infarction; NA, not available; RR relative risk.
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Coronary artery disease

Figure 1 Forest plot for the meta-analysis of chocolate consumption (highest vs lowest category) and risk of myocardial infarction or ischaemic
heart disease. Squares indicate study-specific RR (size of the square reflects the study-specific statistical weight); the horizontal lines indicate 95%
CIs; diamond indicates the overall RR with its 95% CI. *These studies have multiple categories for chocolate consumption; the other studies have
only two categories (see table 3). COSM, Cohort of Swedish Men; EPIC, European Prospective Investigation into Cancer; IWHS, Iowa Women’s
Health Study; NA, not available; RR, relative risk; SHEEP, Stockholm Heart Epidemiology Program; SMC, Swedish Mammography Cohort.

two studies defined type of chocolate consumption.9 11 In the
Postdam arm of the European Prospective Investigation into
Cancer (EPIC) study, chocolate consumption included chocolate
bars.9 In the EPIC-Norfolk cohort, chocolate consumption
included plain chocolate, chocolate snack bars and cocoa powder
(for cocoa drinks).11 When results from all six studies were com-
bined, the overall RR for the highest versus lowest category of
chocolate consumption was 0.90 (95% CI 0.82 to 0.97), with
little between-study heterogeneity (I2=24.3%) (figure 1).
Excluding the Swedish study did not alter the results appreciably,
although the CI was somewhat widened (RR, 0.89; 95% CI 0.79
to 1.01). We found no statistically significant publication bias
( p=0.12).
The current Swedish study and three other studies8 9 11
reported results for three or more categories of chocolate con-
sumption and were included in the dose–response meta-analysis.
The overall RR per 50 g/week increment of chocolate consump-
tion was 0.95 (95% CI 0.92 to 0.98), without heterogeneity
among studies (I2=0%) (see online supplementary eFigures 2
and 3).
DISCUSSION
In this large prospective study of Swedish adults, high chocolate
consumption was associated with a significant 13% reduced risk
of MI. In a complementary meta-analysis, including the Swedish
study and five published prospective studies, we observed that a
high consumption of chocolate was associated with a significant
10% lower risk of IHD.
Although several studies have examined the association
between chocolate consumption and risk of total IHD incidence
or mortality,7 10 11 only one previous study has assessed the
relation between chocolate consumption and risk of MI in a
population without previous MI.9 That study included 166 MI
cases and found a statistically non-significant 27% lower risk of
MI when comparing the highest with the lowest quartile of
chocolate consumption.9 The present study of Swedish adults is
the largest study to date on chocolate consumption and risk of
Larsson SC, et al. Heart 2016;102:1017–1022. doi:10.1136/heartjnl-2015-309203
MI or IHD. Because of the large number of MI cases, we had
high statistical power to detect an association.
A beneficial effect of chocolate consumption on risk of MI/
IHD is biologically plausible. Findings from a meta-analysis of
several short-term randomised controlled trials showed that
interventions with chocolate or cocoa significantly improved
insulin sensitivity and endothelial function as well as reduced
fasting insulin concentration, diastolic blood pressure and mean
arterial pressure.1 Chocolate or cocoa flavanol intake was also
found to increase high-density lipoprotein cholesterol and to
decrease low-density lipoprotein cholesterol and triglycerides.1
A randomised trial conducted in 90 individuals showed that
those who were allocated to daily consume a drink high in
cocoa flavanols for 8 weeks had statistically significant improve-
ments in insulin sensitivity, blood pressure and lipid profile as
well as reduced lipid peroxidation and plasma glucose and
insulin concentrations compared with the control group who
consumed a drink low in flavanols.2 Another recent randomised
controlled trial showed that a high cocoa flavanol intake, com-
pared with control, increased flow-mediated vasodilation by
1.2%, decreased systolic and diastolic blood pressure by respect-
ively 4.4 and 3.9 mmHg, decreased pulse wave velocity by
0.4 m/s and improved blood lipid concentrations.3 Not all trials,
however, have found significant effects of cocoa flavanols on
blood pressure.18
Major strengths of the current study of Swedish adults are the
large sample size, the large number of incident MI cases, the pos-
sibility to adjust for major potential confounders and the object-
ive data on MI diagnoses obtained through linkage with Swedish
registries. A limitation is that chocolate consumption was assessed
with only one question in the FFQ and the lack of information
on type of chocolate (eg, plain chocolate or chocolate bars).
Moreover, we could not distinguish between dark chocolate and
milk chocolate. An inverse association between chocolate con-
sumption and MI is assumed to be stronger for dark chocolate,
which has higher cocoa content than milk chocolate. Swedish
milk chocolate normally contains at least 30% cocoa solids.8
Although we had no information on the proportion of dark
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Coronary artery disease
versus milk chocolate intake in the whole study population, in a
subsample of participants who had completed an extensive FFQ
in 2010, 54% of participants reported that they consumed more
dark chocolate than milk chocolate (unpublished data). Another
limitation is that chocolate intake was self-reported and measured
at baseline only, which may have resulted in some misclassifica-
tion of long-term chocolate intake. In a reproducibility study
conducted in subsample of women from the study cohort, the
reliability of chocolate consumption assessed by two FFQs admi-
nistered 1 year apart was found to be relatively high (correlation
coefficient for the unadjusted data was 0.65; unpublished data).
Because the study population comprised middle-aged and older
Caucasian men and women, our findings may not be generalis-
able to younger individuals and other ethnic groups. Finally, as in
any observational study, we cannot rule out the possibility of
residual confounding.
CONCLUSIONS
In summary, results from this Swedish prospective study and a
complementary meta-analysis indicate that chocolate consump-
tion is inversely associated with risk of MI and IHD. Although
chocolate consumption may lower the IHD risk, chocolate
should be consumed in moderation because it is high in sugar,
calories and saturated fat.
Key messages
What is already known on this subject?
Available evidence indicates beneficial effects of chocolate and
cocoa flavanols on cardiovascular health. Furthermore,
prospective studies have reported an inverse association
between chocolate consumption and stroke incidence and
cardiovascular disease mortality.
What might this study add?
In this prospective study of 67 640 Swedish adults, chocolate
consumption was significantly inversely associated with risk of
myocardial infarction. In a complementary meta-analysis, high
consumption of chocolate was associated with a 10% lower risk
of ischaemic heart disease.
How might this impact on clinical practice?
Chocolate consumption in moderation might lower the risk of
ischaemic heart disease.
Contributors SCL analysed the data, conducted the literature review and wrote the
manuscript. AW participated in the data collection. SCL, AÅ, BG and AW interpreted
the data and critically reviewed the paper. All authors read and approved the final
manuscript.
1022
Funding This work was supported by the Swedish Research Council and by a
Young Scholars Award grant from the Strategic Research Area in Epidemiology at
Karolinska Institutet.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Regional Ethical Review Board at Karolinska Institutet, Stockholm,
Sweden.
Provenance and peer review Not commissioned; externally peer reviewed.
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Larsson SC, et al. Heart 2016;102:1017–1022. doi:10.1136/heartjnl-2015-309203
 Downloaded from http://heart.bmj.com/ on December 20, 2016 - Published by group.bmj.com

Chocolate consumption and risk of

myocardial infarction: a prospective study
and meta-analysis
Susanna C Larsson, Agneta Åkesson, Bruna Gigante and Alicja Wolk

Heart 2016 102: 1017-1022 originally published online March 2, 2016

doi: 10.1136/heartjnl-2015-309203

Updated information and services can be found at:

http://heart.bmj.com/content/102/13/1017

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References This article cites 18 articles, 10 of which you can access for free at:
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Acute coronary syndromes (2742)
Clinical diagnostic tests (4779)

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