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J Am Heart Assoc. 2014 Jul 2;3(4). pii: e001072. doi: 10.1161/JAHA.114.001072.

Dark chocolate acutely improves walking autonomy in patients with peripheral artery disease.

Author information

Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy (L.L., L.P., E.C., P.P., M.B., C.N., S.B., R.C., F.V.).
Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy (E.D.F., G.F.).
Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy (E.D.F., G.F.) Department of AngioCardioNeurology, IRCCS NeuroMed, Pozzilli, Italy (G.F.).

Erratum in

  • J Am Heart Assoc. 2014 Aug;3(4):e000456.



NOX-2, the catalytic subunit of NADPH oxidase, has a key role in the formation of reactive oxidant species and is implicated in impairing flow-mediated dilation (FMD). Dark chocolate exerts artery dilatation via down-regulating NOX2-mediated oxidative stress. The aim of this study was to investigate whether dark chocolate improves walking autonomy in peripheral artery disease (PAD) patients via an oxidative stress-mediated mechanism.


FMD, serum levels of isoprostanes, nitrite/nitrate (NOx) and sNOX2-dp, a marker of blood NOX2 activity, maximal walking distance (MWD) and maximal walking time (MWT) were studied in 20 PAD patients (14 males and 6 females, mean age: 69±9 years) randomly allocated to 40 g of dark chocolate (>85% cocoa) or 40 g of milk chocolate (≤35% cocoa) in a single blind, cross-over design. The above variables were assessed at baseline and 2 hours after chocolate ingestion. Dark chocolate intake significantly increased MWD (+11%; P<0.001), MWT (+15%; P<0.001), serum NOx (+57%; P<0.001) and decreased serum isoprostanes (-23%; P=0.01) and sNOX2-dp (-37%; P<0.001); no changes of the above variables were observed after milk chocolate intake. Serum epicatechin and its methylated metabolite significantly increased only after dark chocolate ingestion. Multiple linear regression analysis showed that Δ of MWD was independently associated with Δ of MWT (P<0.001) and Δ of NOx (P=0.018). In vitro study demonstrated that HUVEC incubated with a mixture of polyphenols significantly increased nitric oxide (P<0.001) and decreased E-selectin (P<0.001) and VCAM1 (P<0.001).


In PAD patients dark but not milk chocolate acutely improves walking autonomy with a mechanism possibly related to an oxidative stress-mediated mechanism involving NOX2 regulation.

CLINICAL TRIAL REGISTRATION URL: Unique identifier: NCT01947712.


antioxidant; atherosclerosis; chocolate; oxidant stress; peripheral vascular disease

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