Tag Archives: cardiovascular disease

Huge U.S. Study Confirms Health and Longevity Benefits of the Mediterranean Diet

This is a reprint of my very first blog post, from December 24, 2007, at the old Advanced Mediterranean Diet Blog

We now have results of the first U.S. study on mortality and the Mediterranean dietary pattern.  380,000 people, aged 50-71, were surveyed on their dietary habits and scored on their conformity to the Mediterranean diet.  They were visited again 10 years later.  As you would expect, some of them died.  12,105 to be exact: 5985 from cancer, 3451 from cardiovascular disease, 2669 from other causes.  However, the people with the highest adherence to the Mediterranean diet had better survival overall, and specifically better odds of avoiding death from cardiovascular disease and cancer.  Compared to the people with low conformity to the Mediterranean diet, the high conformers were 15-20% less likely to die over the 10 years of the study.  The study authors, funded by the National Institutes of Health, noted eight similar studies in Europe and one in Australia with similar results.

Once again, my promotion of the Mediterranean diet is vindicated by the scientific literature.  I’m not aware of any other diet that can prove anywhere near this degree of health benefit.  If you are, please share

Reference: Mitrou, Panagiota N., et al.  Mediterranean Dietary Pattern and Prediction of All-Cause Mortality in a US Population,  Archives of Internal Medicine, 167 (2007): 2461-2468.

Health Benefits of Dark Chocolate

Theobroma cacao, the cocoa tree, has been cultivated in Central and South America for over 3000 years. Cocoa is derived from the tree’s seed, also known as the cocoa bean.

Chocolate is a product of the processed cocoa bean. Sweet chocolate is chocolate combined with sugar. Milk chocolate is sweet chocolate combined with milk powder or condensed milk. Dark chocolate typically has no added dairy products, has at least 65% cocoa content, and has much more of the potentially healthy chemicals from the cocoa bean as compared with milk chocolate. White chocolate is cocoa butter (aka cacao fat), milk solids, and sugar without the cocoa solids or mass; in many countries it is not considered chocolate.

It’s been a little over 10 years since we first read in a medical journal about cocoa and chocolate as potential sources of antioxidants for health. What have we learned since then?

Phytochemicals are chemicals produced by plants, and there are hundreds of thousands of them. Polyphenols are a subset of phytochemicals. Flavonoids, with strong antioxidant properties, are a subset of polyphenols. And a subset of flavonoids, called flavonols, have particularly potent biological effects in humans. Prominent flavonols in dark chocolate are flavan-3-ol, catechin, and epicatechin. Also metabolically active are proanthocyanidins, which are polymeric condensation products of flavan-3-ol.

Are you bored yet? Have I convinced you of my authority on the subject? Say yes, or I’ll keep going! [Please say yes: I’m boring myself!]

Note that some chocolate manufacturers process the cocoa beans to remove some of the polyphenols, which reduces bitterness or pungency.

Other rich sources of flavonols are wine, tea, and various fruits and berries.

How could dark chocolate, especially its flavonoids, be healthful?

  • Flavonoids are antioxidants that protect from injury caused by free radicals
  • Enhanced nitric oxide production, leading to relaxation of arteries (vasodilation), leading to reduced blood pressure: up to 6 mmHg systolic and 3 mmHg diastolic
  • Elevation of HDL cholesterol, with no effect on total and LDL cholesterol
  • Inhibition of platelet aggregation and activation, leading to fewer blood clots that cause heart attacks and strokes
  • Decreased inflammation
  • Reduction of C-reactive protein, a marker of inflammation
  • Decreased neutrophil (white blood cell) activation. White blood cells play a role in inflammation
  • Decreased LDL cholesterol oxidation, leading to fewer atherosclerotic complications
  • Improved function of the cells that line blood vessels (endothelium)
  • Possible enhanced insulin sensitivity
  • May act as anti-carcinogens and neuro-protective agents
  • May act as an antidepressant

Note also that low-fat natural non-alkalized cocoa powder is also a rich source of antioxidant flavonoids.

Bottom line? Dark chocolate, especially because of flavonoids, may well be protective against cardiovascular disease such as heart attacks and strokes.

[Did you notice I’m waffling . . . may be protective.]

What’s in dark chocolate other than flavonoids?

A 40 gram serving of a fine dark chocolate bar has:

  • Calories: 200
  • Calories from fat: 150
  • Fiber: 4.5 grams (dark chocolate is a good source of fiber on a “per calorie” basis)
  • Sugar: 11 grams
  • Saturated fats: 10 grams

But aren’t saturated fats bad for me?

The fats in dark chocolate are 1/3 oleic (healthy monounsaturated, as in olive oil), 1/3 stearic (saturated, but no effect on cholesterol levels, unlike some other saturated fats), and 1/3 palmitic (saturated, and could increase cholesterol levels and heart risk). So it’s sort of a wash.

[I’m not getting into the diet-heart hypothesis now. Don’t bait me.]

What’s the healthy “dose” of dark chocolate?

No one is sure. It’s certainly no more than 100 grams (3.5 ounces) a day, and the optimal dose may be as low as 20 grams every three days. If you eat too much, it will make you fat. 100 grams is 500 calories; that’s probably way too much. Even if you start eating 20 grams – 100 calories – every three days, you will gain weight unless you give up some other food or exercise a little more.

Parker, why are you waffling?

Because no one has ever done a study to see if adding dark chocolate actually reduces death rates or sickness from specific diseases in humans. I think it probably does, but who knows for sure? Nobody. What we need is a randomized, controlled trial of dark chocolate as a supplement in 10,000 middle-aged adults followed over the course of 10 years. I’d sign up for that in a heartbeat. Just don’t give me the placebo.

Steve Parker, M.D.

Additional Resources:

Clay Gordon, author of the book Discover Chocolate, kindly critiqued an early version of this blog post here. If the link doesn’t work, go to The Chocolate Life and search “Health Benefits of Chocolate” in the Forums.


Erdman, J.W., et al. Effects of cocoa flavanols on risk factors for cardiovascular disease. Asian Pacific Journal of Clinical Nutrition, 17 supplement 1 (2008): 284-287.

Farouque, H.M, et al. Acute and chronic effects of flavanol-rich cocoa on vascular function in subjects with coronary artery disease: a randomized double-blind placebo-controlled study. Clinical Science, 111 (2006): 71-80.

Heptinstall, S., et al. Cocoa flavanols and platelet and leukocyte function: recent in vitro and ex vivo studies in healthy adults. Journal of Cardiovascular Pharmacology, 47 supplement 2 (2006): S197-205.

Keen, C.L., et al. Cocoa antioxidants and cardiovascular health. American Journal of Clinical Nutrition, 81 supplement 1 (2005): 298S-303S.

Mehrinfar, R. and Frishman, W.H. Flavanol-rich cocoa: a cardioprotective nutraceutical. Cardiology Reviews, 16 (2008): 109-115.

Engler, M.B, and Engler, M.M. The emerging role of flavonoid-rich cocoa and chocolate in cardiovascular health and disease. Nutrition Reviews, 64 (2006): 109-118.

Lippi, G. et al. Dark chocolate: consumption for pleasure or therapy? Journal of Thrombosis and Thrombolysis, September 23, 2008 (Epub ahead of print).

Hooper, L, et al. Flavonoids, flavonoid-rich foods, and cardiovascular risk: a meta-analysis of randomized controlled trials. American Journal of Clinical Nutrition, 88 (2008): 38-50.

Cooper, K.A., et al. Cocoa and health: a decade of research. British Journal of Nutrition, 99 (2007): 1-11. Epub August 1, 2007.

Aron, P.M., and Kennedy, J.A. Flavon-3-ols: nature, occurrence and biological activity. Molecular Nutrition and Food Research, 52 (2008): 79-104.

Buijsse, B, et al. Cocoa intake, blood pressure, and cardiovascular mortality [in men]: the Zutphen Elderly Study. Archives of Internal Medicine, 166 (2006): 411-417.

Ding, E.L., et al. Chocolate and prevention of cardiovascular disease: a systematic review. Nutrition and Metabolism, 3 (2006): 2.

If Dark Chocolate Is Healthy, What’s The Right Dose?

Antioxidant flavonoids and other phytonutrients in dark chocolate are thought possibly to improve health, primarily through reduction in cardiovascular diseases such as heart attacks and strokes. I previously blogged about these and other potential health benefits of dark chocolate.

In terms of a medicinal agent, we have not been sure of the therapeutic “dose.” A recent study out of Italy provides a clue.

Researchers at Catholic University, Campobasso, Italy, surveyed residents in southern Italy regarding chocolate intake and measured their C-reactive protein (CRP) levels. CRP is a marker of inflammation and a predictor of coronary artery disease such as heart attacks. Generally, higher levels of CRP are associated with higher risk of heart attacks. If you have a choice, go for lower levels of CRP.


Participants in the study were selected by simple random sampling from city hall registries and were at least 35 years old. Researchers were looking for healthy people, so the following were excluded from the study: those who reported known cardiovascular disease, eating a special diet, or on drug therapy for high blood pressure, diabetes, or adverse blood lipids. Twenty percent of initial recruits refused to participate. Of the 10,994 initial recruits, 4,849 men and women made it into the final study.

Of the 4,849 subjects, two subgroups were identified: 1) a control group of 1,317 (27%) who never ate any type of chocolate, and 2) a test group of 824 (17%) subjects who regularly ate dark chocolate only.

Interviewers administered questionnaires to the subjects to document clinical and personal information such as dietary habits, socioeconomic status, physical activity, medical history, risk factors for cardiovascular disaese and tumors, family history of cardiovascular disease, drug use, etc.

Regarding chocolate consumption, participants were asked about frequency – daily, weekly, or monthly – of a “standard dose” (20 grams) and about type of chocolate: milk, dark, nut chocolate, or any type. Someone eating more than one type of chocolate was classified as “any type.”

Other measurements: blood pressure, weight, height, waist circumference, blood glucose, serum lipids (various cholesterols and triglycerides), and high-sensitivity C-reactive protein.


Age-adjusted CRP levels were lower in dark chocolate users (1.13 mg/L) than in the nonconsumers of chocolate (1.30 mg/L).

Dark chocolate eaters were divided into thirds: the lowest third of average consumption, the middle third, and the highest third. The lowest third ate under 19 grams per week. The middle third ate between 19 and 47 grams per week. The highest third ate over47 grams per week. The chocolate-related reduction in CRP was lost in people who were in the highest third (or tertile), i.e., eating more than 47 grams a week or 20 grams every three days. People in the lowest tertile of dark chocolate consumption had a CRP reduction the same as the middle third.

Systolic blood pressure in dark chocolate consumers was 3 mmHg lower than the pressure in nonconsumers. No difference in diastolic pressures.


The researchers cite two clinical trials that investigated the effect of cocoa on markers of inflammation but did not find any association. They wonder if those studies enrolled too few participants, or whether the relatively high doses of chocolate masked the effect. In the present study, the lowering of CRP was seen in consumption of up to 20 grams every three days, but seemed to disappear at higher doses.

The authors write that:

. . . regular intake of small amounts of dark chocolate . . . consumption should have no harmful effect on anthropometric variables such as BMI [body mass index] and waist:hip ratio and can be viewed as a promising behavioural approach to lower, in a quite pleasant way, cardiovascular risk factors at a general population level.

According to data reported in apparently healthy American men and women, ranges of serum CRP measured in our nonchocolate consumer population would belong to a “moderate” risk estimate quintile, whereas the ranges found in dark chocolate consumers would be classified as a “mild” risk estimate. For the decrease in serum CRP values from moderate to mild quintile, the relative risk of suffering a future cardiovascular event would apparently decrease by 26% in men and 33% in women.

The authors are careful to point out that this study does not prove that low-dose dark chocolate lowers CRP levels. It’s an association. “Additional studies are necessary to explain the mechanisms linking dark chocolate consumption and regulation of serum CRP concentrations.”

My Comments

The healthy dose of dark chocolate may be quite small: no more than 20 grams every three days, and perhaps quite a bit less. This is not much by U.S. standards. The serving size listed on many bars here is 40 grams. Forty grams has about 200 calories. Twenty grams twice a week translates to 29 calories a day.

The authors of this study don’t address whether 40 grams a week would be just as healthy as 80 grams every two weeks.

Eating more, on average, than 20 grams every three days may entirely wipe out the healthy effects. This effect is like wine’s: a little is probably good for you, too much is either neutral or harmful.

I’m sorry to be so wishy-washy on this issue, but that’s the state of the science today. The study at hand may help us optimize dark chocolate’s effect on C-reactive protein. But dark chocolate’s other healthy effects may require other doses, higher or lower.

The next step is to take 20,000 middle-aged people, give half of them various doses of scheduled dark chocolate, give the other half placebos, then record rates of diseases and death over the next 10 years. Who would pay for this multi-million dollar study? Either government or chocolate manufacturers.

Steve Parker, M.D.

Reference: Di Giuseppe, Romina, et al. Regular Consumption of Dark Chocolate Is Associated with Low Serum Concentrations of C-Reactive Protein in a Healthy Italian Population. Journal of Nutrition, 138 (2008): 1,939-1,945.

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Yo-Yo Dieting In Women Has No Effect On Death Rates

Yo-yo dieting isn’t so bad after all.

Fifteen years ago there was lots of hand-wringing in the medical community about the potential dire physical consequences of “weight cycling” – also known as yo-yo dieting. You know, lose a bunch of weight, gain it back, lose it again, gain it back, etc.

After a while, yo-yo dieting as a medical issue dropped off the radar screen. 

A 2009 study in the Archives of Internal Medicine reported on the cardiovascular and mortality effects of yo-yo dieting in women in the massive Nurses’ Health Study. One in four of these women could be classified as weight cyclers. The worst ones were defined as those who lost at least 9.1 kg ( 20 pounds) at least three times.

It turns out the weight cyclers had the same rates of death from cardiovascular disease or any cause as the women who didn’t cycle. They did eventually gain more overall weight as they aged, compared to the non-cyclers.

Note that this study investigated death rates only. So there may have been effects on rates of high blood pressure, diabetes, gout, stroke, etc, that we wouldn’t know about.

Steve Parker, M.D.

Field, Alison, et al. Weight cycling and mortality among middle-aged or older women. Archives of Internal Medicine, 169 (2009): 881-886.

Which Components of the Mediterranean Diet Prolong Life?

Researchers at Harvard and the University of Athens (Greece) report that the following specific components of the Mediterranean diet are associated with lower rates of death:

  • moderate ethanol (alcohol) consumption
  • low meat and meat product intake
  • high vegetable consumption
  • high fruit and nut consumption
  • high ratio of monounsaturated fat to saturated fat
  • high legume intake

Minimal, if any, contribution to mortality was noted with high cereal, low dairy, or high fish and seafood consumption.

The researchers examined diet and mortality data from over 23,000 adult participants in the Greek portion of the European Prospective Investigation into Cancer and nutrition. You’ll be hearing more about the EPIC study for many years. Over an average follow-up of 8.5 years, 1,075 of participants died. 652 of these deaths were of participants in the lower half of Mediterranean diet adherence; 423 were in the upper half.

Alcohol intake in Greece is usually in the form of wine at mealtimes.

The beneficial “high ratio of monounsaturated fat to saturated fat” stems from high consumption of olive oil and low intake of meat.

It’s not clear if these findings apply to other nationalities or ethnic groups. Other research papers have documented the health benefits of the Mediterranean diet in at least eight other countries over three continents.

The researchers don’t reveal in this report the specific causes of death. I expect those data, along with numbers on diabetes, stroke, and dementia, to be published in future articles, if not published already. Prior Mediterranean diet studies indicate lower death rates from cardiovascular disease and cancer.

Steve Parker, M.D.

Reference: Trichopoulou, Antonia, et al. Anatomy of health effects of the Mediterranean diet: Greek EPIC prospective cohort study. British Medical Journal, 338 (2009): b2337. DOI: 10.1136/bmj.b2337.

Additional Information: Childs, Dan. Take it or leave it? The truth about 8 mediterranean diet staples. ABC News online, June 24, 2009. Accessed June 25, 2009.


Here’s a direct quote from the study at hand:

Among the presumed beneficial components of the Mediterranean diet score, high consumption of all but fish and seafood was inversely associated with mortality, although none of these associations was statistically significant.

“. . . none of these associations was statistically significant.” So I can understand some skepticism about this journal article. The researchers had to use some very sophisticated statistical manipulation to come up with the “healthy components” list. I’m not saying that’s wrong. I will admit that the statistical analysis is beyond my comprehension, so I’m trusting the authors and peer-review process to be honest and effective. My college statistics course was too many years ago.

The take-home point for me is that the health benefits of the Mediterranean diet probably stem from an overall combination of multiple foods rather than any single component.

And remember to exercise regularly, maintain a healthy weight (BMI 18.5-25), keep your blood pressure under 140/90, and don’t smoke.


Is the Paleo Diet Just a Fad?

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The paleo diet—aka Stone Age, caveman, or hunter-gatherer diet—has been growing in popularity since 2009.  Do we have firm evidence that it’s a healthy way of eating?

Swedish investigators at Karolinska Institutet found diminished weight, body mass index, blood pressure, and waist circumference in 14 healthy medical students eating a paleo diet for three weeks.

Published in 2008, this seems to be one of the seminal scientific studies of the paleo diet in modern Europeans.

Their version of the paleo diet:

  • Allowed ad lib: All fresh or frozen fruits, berries and vegetables except legumes, canned tomatoes w/o additives, fresh or frozen unsalted fish and seafood, fresh or frozen unsalted lean meats and minced meat, unsalted nuts (except peanuts – a legume), fresh squeezed lemon or lime juice (as dressing), flaxseed or rapeseed oil (as dressing), coffee and tea (w/o sugar, milk, honey, or cream), all salt-free spices.
  • Allowed but with major restrictions: dried fruit, salted seafood, fat meat, potatoes (two medium-sized per day), honey, cured meats
  • Prohibited: all milk and dairy products, all grain products (including corn and rice), all legumes, canned food except tomatoes, candy, ice cream, soft drinks, juices, syrups, alcohol, sugar, and salt

What Did They Find After Three Weeks?

  • Average weight dropped from 65.2 kg (144 lb) to 62.9 (139 lb)
  • Average body mass index fell from 22.2 to 21.4
  • Average waist circumference decreased from 74.3 cm (29.25″) to 72.6 cm (28.58″)
  • Average systolic blood pressure fell from 110 to 104 mmHg
  • plasminogen activator inhibitor-1 decreased from 5.0 kIE/l to 2.8 kIE/l
  • All of these changes were statistically significant

The researchers looked at a number of other blood tests and didn’t find any significant differences.

Five men and three women completed the study. Of the 20 who originally signed up, one could not fulfill the diet, three became ill (no details), two failed to show up.

So What?

That’s a remarkable weight loss over just three weeks for slender people eating ad lib.

The study authors concluded that these paleo diet-induced changes could reduce risk for cardiovascular disease. They called for a larger study with a control group. (If it’s been done, I haven’t found it yet.)

Sounds reasonable.

It’s too soon to say whether the paleo diet is just a fad.  It will depend somewhat on short- and long-term health effects of paleo-style eating, which may take years to clarify.  On the other hand, it’s hard to imagine large swaths of the population giving up grains, legumes, and dairy products, even if it’s a healthier way of eating.

Steve Parker, M.D.

PS: You’d think they would have said more about the three participants who got sick, rather than leave us wondering if the diet made them ill.

PPS:  I’m considering whether the paleo diet is healthy for people with diabetes.  Follow my progress at PaleoDiabetic.com.

Reference: Österdahl, M; Kocturk, T; Koochek, A; Wändell, PE. Effects of a short-term intervention with a paleolithic diet in healthy volunteers. European Journal of Clinical Nutrition, 62 (2008): 682-685.