Is chocolate consumption associated with health outcomes? An umbrella review of systematic reviews and meta-analyses

Background & aims: The literature regarding the potential health benefits of chocolate consumption are unclear and the epidemiological credibility has not been systematically scrutinized, while the strength of the evidence is undetermined. We therefore aimed to map and grade the diverse health outcomes associated with chocolate consumption using an umbrella review of systematic reviews. Methods: Umbrella review of systematic reviews of observational and interventional studies (randomized placebo-controlled trials, RCTs). For each association, random-effects summary effect size, 95% confidence interval, and 95% prediction interval were estimated. We also assessed heterogeneity, evidence for small-study effect and evidence for excess significance bias. For significant outcomes of the RCTs, the GRADE assessment was furtherly used. Results: From 240 articles returned, 10 systematic reviews were included (8 of which included a meta-analysis), including a total of 84 studies (36 prospective observational studies and 48 interventional). Nineteen different outcomes were included. Among observational studies, including a total of 1,061,637 participants, the best available evidence suggests that chocolate consumption is associated with reduced risk of cardiovascular disease (CVD) death (n=4 studies), acute myocardial infarction (n=6), stroke (n=5) and diabetes (n=6), although this was based on a weak evidence of credibility. Across meta-analyses of intervention studies, chocolate consumption was positively associated with flow-mediated dilatation at 90-150 minutes (n=3) and at 2-18 weeks (n=3), and insulin resistance markers (n=2). However, using the GRADE assessment, the evidence for these outcomes was low or very low. Data from two systematic reviews, reported that chocolate consumption was not associated with depressive mood or cognitive function. Conclusions: There is weak evidence to suggest that chocolate consumption may be associated with favorable health outcomes.