Chocolate intake and heart disease and stroke in the Women's Health Initiative: a prospective analysis

Am J Clin Nutr. 2018 Jul 1;108(1):41-48. doi: 10.1093/ajcn/nqy073.


Background: Three recent meta-analyses found significant prospective inverse associations between chocolate intake and cardiovascular disease risk. Evidence from these meta-analyses suggests that such inverse associations may only apply to elderly individuals or those with pre-existing major chronic disease.

Objective: We assessed the association between habitual chocolate intake and subsequent incident coronary heart disease (CHD) and stroke, and the potential effect of modification by age.

Design: We conducted multivariable Cox regression analyses using data from 83,310 postmenopausal women free of baseline pre-existing major chronic disease in the prospective Women's Health Initiative cohort. Chocolate intake was assessed using a food-frequency questionnaire. Physician-adjudicated events or deaths were ascertained up to 30 September 2013.

Results: After exclusions, there were 3246 CHD and 2624 stroke events or deaths, representing incidence rates of 3.9% and 3.2% during 1,098,091 and 1,101,022 person-years (13.4 y), respectively. We found no association between consumption of chocolate and risk of CHD (P for linear trend = 0.94) or stroke (P = 0.24). The results for CHD and stroke combined were similar (P = 0.30), but were significantly modified by age (P for interaction = 0.02). For women age <65 y at baseline, those who ate 1 oz (28.35 g) of chocolate <1/mo, 1 to <1.5/mo, 1.5 to <3.5/mo, 3.5/mo to <3/wk, and ≥3/wk had HRs (95% CIs) of 1.00 (referent), 1.17 (1.00, 1.36), 1.05 (0.90, 1.22), 1.09 (0.94, 1.25), and 1.27 (1.09, 1.49), respectively (P for linear trend = 0.005). No association was apparent for older women.

Conclusion: We observed no association between chocolate intake and risk of CHD, stroke, or both combined in participants free of pre-existing major chronic disease. The relation for both combined was modified by age, with a significant positive linear trend and an increased risk in the highest quintile of chocolate consumption among women age <65 y. This trial was registered at as NCT03453073.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Chocolate*
  • Energy Intake
  • Exercise
  • Feeding Behavior*
  • Female
  • Heart Diseases / etiology*
  • Heart Diseases / mortality
  • Humans
  • Middle Aged
  • Models, Biological
  • Proportional Hazards Models
  • Prospective Studies
  • Risk Factors
  • Stroke / etiology*
  • Stroke / mortality

Associated data