Coffee and chocolate have spent years in and out of medicine’s good books.
One month, coffee is blamed for palpitations, high blood pressure and sleepless nights. The next, it is being praised for lowering the risk of diabetes, liver disease and early death.
Chocolate is treated no better. A study mentions cocoa and heart health, and before long, a family-sized bar is being regarded less as a treat than as a prescription.
Both are bitter by nature. Both have been sweetened, marketed and misunderstood. Coffee is how many people begin the day, survive the night shift, settle an argument or postpone one. Chocolate appears at Valentine’s, birthdays, funerals, courtships, apologies and the bottom drawer of office desks.
This week, the American Heart Association delivered news that millions of coffee drinkers had been waiting to hear. Coffee, it seems, is not the enemy of the heart.
It was reported that moderate coffee consumption is associated with lower risks of coronary artery disease and stroke. Low to moderate intake has also been linked with a reduced risk of heart failure. There was even some reassurance for people with an abnormal rhythm called atrial fibrillation: in one randomised trial, caffeinated coffee did not provoke the recurrence many patients had feared.
There are caveats. Caffeine can briefly raise blood pressure, heart rate and alertness. People respond to it very differently. Coffee may increase premature ventricular beats in some drinkers and high doses of purified caffeine have been associated with dangerous arrhythmias. The reassuring evidence about ordinary coffee also cannot simply be transferred to highly caffeinated energy drinks.
In other words, coffee has been cleared of many charges but, like some politicians, not given diplomatic immunity.
Long before coffee came in paper cups with misspelled names from bored baristas, it was valued for what it did to the mind and body. People knew it could sharpen alertness and push back sleep.
Before chocolate became a sweet bar, cacao was consumed as a bitter drink and used in ritual and medicine in the Americas. Its medicinal use later crossed into Europe, where chocolate was prescribed for various complaints and sometimes used to carry other medicines. Coffee and cacao became part of ordinary life partly because people noticed their effects long before science could explain them.
A recent family visit to the Cocoa Panyol Museum in Flanagin Town with my close friend Ronnie Boodoosingh brought the story of chocolate much closer to home. Cocoa was history, labour, memory and identity. The old tools, photographs and stories recalled the villagers whose hard work helped shape the industry. Walking through the museum with Baby Daniel, it was impossible not to feel that every cup of cocoa tea or freshly ground coffee carries a much older story.
Large observational studies have found that coffee drinkers tend to have lower rates of several illnesses and, in some studies, lower mortality. A European investigation involving more than half a million people found that higher coffee consumption was associated with lower all-cause mortality. Other large studies have linked coffee consumption with a lower risk of type 2 diabetes and chronic liver disease.
Interestingly, some of these associations have also appeared with decaffeinated coffee. Coffee contains many other compounds that may affect metabolism and inflammation.
Nevertheless, coffee drinkers may differ from non-drinkers in ways researchers cannot fully measure. They may exercise more, eat differently or have other habits that influence health. Nobody should begin drinking six cups a day because a graph bends in an encouraging direction. The liver evidence is particularly interesting, but coffee does not cancel the effects of excess alcohol, obesity, viral hepatitis or poorly controlled diabetes.
Older randomised trials found that boiled or unfiltered coffee could raise total and LDL cholesterol. Passing the drink through a paper filter removed much of the oily material responsible. French press, boiled and similar unfiltered preparations may therefore affect cholesterol differently from paper-filtered coffee, particularly when consumed in large quantities.
For most healthy adults, the US Food and Drug Administration cites 400 milligrams of caffeine a day as an amount not generally associated with harmful effects. But people vary enormously in how they respond.
The American College of Obstetricians and Gynecologists recommends keeping caffeine intake below 200 milligrams a day in pregnancy.
Cocoa contains flavanols, plant compounds that may influence blood-vessel function. It also contains theobromine, a mild stimulant related to caffeine, as well as a smaller amount of caffeine itself.
Dark chocolate (my favourite with nuts) generally contains more cocoa than milk chocolate. It also remains a concentrated food containing calories and, very often in supermarkets, sugar, fat, caramel, biscuit, nougat and optimism.
The largest serious test so far was the COSMOS trial. More than 21,000 older adults were randomly assigned to receive cocoa extract or a placebo.
The cocoa extract did not significantly reduce the study’s main outcome of total cardiovascular events. There was a lower rate of cardiovascular death, a secondary finding that deserves further investigation, but this was not proof that chocolate bars prevent heart attacks. The researchers tested a measured cocoa extract. They did not test a box of assorted chocolates eaten during a stressful weekend.
Smaller trials suggest that flavanol-rich cocoa may modestly improve blood-vessel function or reduce blood pressure in some people.
A small study conducted in T&T also found short-term blood-pressure reductions after participants consumed a cocoa drink. Dr Naveen Seecharan and his team at the University of the West Indies also found a favourable effect of cocoa on platelets in a delightfully named “Éclair” pilot study. Larger and more rigorous randomised trials are needed before drawing firm conclusions.
No sensible doctor is going to replace a patient’s blood-pressure tablets with a chocolate bar. Cocoa cannot substitute for exercise, weight management, reduced salt intake or properly prescribed medication. A square of dark chocolate may fit comfortably into a healthy diet.
Limited research found improved mood after daily consumption of 85 per cent dark chocolate, alongside changes in gut bacteria. A cup of coffee shared with a friend may matter because of the friend. A piece of chocolate may be valuable because it is enjoyed slowly, not because someone extracted a flavanol from it in a laboratory.
So what do I tell patients?
You do not need to begin drinking coffee for your health. If you already enjoy it, tolerate it and sleep well, moderate consumption is reasonable for most adults. But stop pretending it has no effect if your hands shake, your heart races or you are awake at two in the morning.
Drink your coffee earlier. Drink less if it makes your heart race or keeps you awake. Try decaffeinated coffee if you enjoy the ritual.
Choose a small amount of chocolate that you actually enjoy. Dark chocolate may contain more cocoa, but there is no medal for grimly chewing 90 per cent while wishing it tasted like milk chocolate. Mind the portion and watch the sugar.
Coffee and chocolate do not need to be miracles to have a place in a healthy life. They can simply be what they have always been: comfort, ritual, pleasure and, in moderation, two of life’s better bitters.
