Food and Nutrition
Proposing a Definition of Candy in Moderation: For Health and Well-being
Hornick, Betsy MS, RD; Duyff, Roberta L. MS, RD, FADA, CFCS; Murphy, Mary M. MS, RD; Shumow, Laura MS
Betsy Hornick, MS, RD, is a nutrition writer and consultant, specializing in food, nutrition, and health communications.
Roberta L. Duyff, MS, RD, FADA, CFCS, is a food and nutrition consultant, speaker, and author, focusing on the “power of positive nutrition” and providing practical, science-based healthy eating guidance.
Mary M. Murphy, MS, RD, is a consultant on nutrition issues including examination of food consumption patterns and associations between food and nutrient intakes and measures of health. She is Senior Managing Scientist at Exponent, Inc, Center for Chemical Regulation & Food Safety.
Laura Shumow, MS, is director of Technical and Regulatory Affairs at the National Confectioners Association in Washington, DC.
Source of support: National Confectioners Association.
Ms Hornick has declared that she is a member of FoodMinds’ expert network. FoodMinds is a food and nutrition affairs company that represents a range of food, nutrition, and wellness organization, including the National Confectioners Association.
Ms Duyff received an honorarium for her contributions to this manuscript.
Ms Murphy has declared that Exponent, Inc. was retained by the National Confectioners Association to conduct research on candy consumption patterns and contribute to this manuscript.
Correspondence: Betsy Hornick, MS, RD, 3016 Fairchild Street, Poplar Grove, IL 61065 ( firstname.lastname@example.org).
Advice to practice “moderation” in eating conveys that reasonable amounts of specific foods or beverages can fit into healthful meal patterns. However, interpretation of moderation varies widely between both health professionals and consumers. Evidence suggests that candy can have a place in an overall lifestyle that supports health, wellness, and happiness. Recognizing the importance of managing calories, a proposed definition for consuming candy in moderation offers realistic and practical advice for individuals wishing to include confections within the context of a healthful diet and lifestyle. Quantifying candy in moderation is proposed as a range of up to 50 to 100 calories per day depending on energy needs. This amount falls within dietary guidance from leading health authorities for calories from added sugars and fats. The purpose of this article was to summarize current intakes of candy, examine the potential role of candy in health and well-being, and provide support for a proposed definition of “candy in moderation” for those who choose to consume confections, including chocolates, hard and chewy candy, and chewing gum.
Candy is generally described as a broad category of sweet foods, also referred to as “confections.” The word candy derives from its key ingredient, sugar. In Arabic, qandi means something made with sugar. Hard and soft candies, chocolate, and gum all contain sweeteners such as sugars, syrups, honey, or nonnutritive sweeteners. Some also contain fats such as milk fat or cocoa butter. Other ingredients can include dried fruit, nuts, seeds, flavorings, spices, and colorings. From a regulatory standpoint, the US Food and Drug Administration has standards of identity for various types of chocolate and cocoa,1 but there is no standard of identity or legal definition for candy or confections. For the purposes of this article, candy is defined as chocolate and nonchocolate confections and chewing gum. However, candy categories used in food consumption surveys may not include chewing gum.
Past and present nutrition guidance embraces the dietary goal of moderation—or consuming all foods in reasonable amounts—as part of an overall healthful eating pattern and a lifestyle that achieves energy balance. However, use of the term moderation and its interpretation can vary widely. Although moderation typically is not quantified for specific foods, with the exception of alcoholic beverages,2 a definition of moderation for certain popular foods in the context of energy balance is prudent. According to the Academy of Nutrition and Dietetics’ (formerly American Dietetic Association) annual public opinion survey, “Nutrition and You: Trends 2011,” most (82%) consumers report that they do not want to give up foods they like, a sentiment that increased by 9%, from 73% in 2008.3 In fact, Americans say they need guidance on how to include favorite foods, and fewer (43%) believe that there are foods they should never eat (down from 54% in 2008), which suggests that consumers are receptive to messages about moderation.3
Moderation as applied to foods such as candy may help demonstrate realistic strategies for including occasional treats within average daily calorie goals. Frequency data indicate that nearly all Americans eat candy at least once per year, and recent evidence suggests that current levels of candy intake are not associated with health risks.4–6 The purpose of quantifying candy in moderation is not to encourage Americans to add candy or increase their consumption, but rather to provide a practical and realistic approach for those who choose to include candy as part of a healthful eating pattern. A definition of consuming candy in moderation, in the context of a total diet and compatible with current dietary guidance, is proposed (Box 1). This proposed definition aligns with guidance on added sugars from leading health authorities (Table 1) and amounts of candy in realistic portions for daily or weekly consumption (Table 2), while allowing use of most of the calories from solid fats and added sugars (SoFAS), as defined by the 2010 Dietary Guidelines for Americans (DGA), for other food choices.
Advice for how to include candy in moderation requires communicating the importance of first choosing nutrient-dense forms of foods, such as fruits, vegetables, whole grain foods, low-fat and fat-free dairy foods, and lean protein foods. Minimizing solid fats, added sugars, and refined starches in food choices, as well as increasing physical activity, helps to allow room for calories from treats, such as candy.2 For those who choose to include candy, a range of calories is proposed to accommodate individuals with lower calorie intakes to choose candy amounts at the lower end of the calorie range, while increased calorie needs would allow for more flexibility. It is also noteworthy that many types of candy include ingredients that contribute small amounts of nutrients in addition to calories, such as nuts, raisins, peanut butter, or milk. Examples of candy in moderation, illustrated by amounts that fit within the proposed daily and weekly definitions, are presented in Table 2.
MODERATION IN DIETARY GUIDANCE
The concept of “moderation” in US dietary guidance was first introduced in the 1979 publication Food, when the US Department of Agriculture (USDA) began addressing the role of fats, sugars, and sodium in risk factors for chronic diseases.7 The food guide released in 1979, known as the Hassle-Free Guide to a Better Diet, was modified from the previous Basic Four to highlight a fifth group—fats, sweets, and alcoholic beverages—targeted for moderation. When the first edition of the DGA was released in 1980, the basic tenets of balance, variety, and moderation, rather than dietary restriction, became goals for healthful eating.8 Although the language has evolved, the philosophy of these goals has withstood the test of time.
Current dietary guidance from leading nutrition and health authorities recognizes that an eating pattern built upon current evidence-based recommendations can include small amounts of treats.2,9,10 The Academy of Nutrition and Dietetics supports an approach of sensible discretion in its position that “all foods can fit within a healthful eating style, if consumed in moderation with appropriate portion size and combined with regular physical activity.”11 In the context of a total diet, no single food or type of food can ensure good heath, and none is necessarily detrimental to health either. Rather than target specific nutrients or foods to restrict or avoid, this position recognizes the role of energy balance in healthful eating, with a focus on balancing food and physical activity over time in a healthful lifestyle.11
The 2010 DGA and ChooseMyPlate.gov encourage an overall healthful lifestyle, emphasizing the importance of maintaining calorie balance over time.2,12 The DGA advises reducing intake of calories from SoFAS but also recognizes that when nutrient-dense forms of foods are chosen, there is room in the daily diet for treats. A core consumer message to “enjoy your food, but eat less” emphasizes portion control without the need to avoid any food entirely.2 Specific to sweets, the MyPlate consumer message advises that “it’s not necessary to eliminate sweets and desserts, just serve small portions.”13Table 1 describes the varying approaches from leading health and nutrition authorities for dietary guidance related to added sugars.
The USDA Food Patterns identify a daily limit for calories from SoFAS (Table 3), described as the remaining amount of calories in each food pattern after selecting the specified amounts in each food group in nutrient-dense forms.2 Solid fats are defined as containing primarily saturated and trans-fatty acids. However, stearic acid, a predominant saturated fatty acid in chocolate, is recognized as a neutral fat that does not raise blood cholesterol levels.14 Added sugars are designated as the sugars, syrups, and other caloric sweeteners added to foods during processing, preparation, or consumed separately.2 Calories from SoFAS can be used for foods within food groups that contain solid fats and/or added sugars, or it can be used for treats, such as occasional sweets. Recognition of an optional calorie allowance for extras, such as candy or other treats, illustrates that moderation goals and nutrient adequacy can be met in a variety of ways.
ENCOURAGING MODERATION VERSUS RESTRICTION
As a strategy for regulating food intake, moderation in eating conveys that an individual can enjoy an appropriate portion of food and not feel the urge to overconsume, knowing the food will be available again. Self-regulation of food intake is an essential skill for children and adults to learn and practice, offering clear advantages over forbidding certain foods.15,16 Research indicates that moderate intake through portion control can be more effective than complete restriction of a highly palatable food, whether for weight management or in an attempt to improve overall dietary health.17 In fact, making favorite foods available and moderating amounts may reduce the appeal and likelihood of overindulgence. Research examining this effect, referred to as the counteractive self-control theory, suggests that the practice of moderation can trigger goal-directed behavior, thus empowering an individual with self-regulation and control.18
The practice of restricting certain foods may be counterproductive to developing and maintaining healthy eating behaviors.19 Researchers speculate that strict limitations on food may lead to future increases in intake and possible overconsumption. The association between restrictive eating and the tendency to overeat has been studied primarily in children. Parents may restrict certain foods in an effort to moderate a child’s intake of calories; however, a review of child-feeding behaviors found that highly restrictive eating practices are consistently associated with childhood overweight.16 Although the review does not identify specific restricted foods, it points to a relationship between restricting desirable foods and weight gain as an unintended consequence.16 Restrained eaters, or those individuals who chronically restrict their intake to avoid weight gain, have been shown to be more susceptible to preoccupation with restricted foods and subsequent weight fluctuations.20
CONFECTIONS IN THE TOTAL DIET
The daily amount and frequency of candy consumed by the US population 2 years or older were estimated using 2003–2006 National Health and Nutrition Examination Survey (NHANES) data.4 The estimates were derived from responses to a food frequency questionnaire (FFQ) on chocolate and nonchocolate candy consumption over the previous 12 months and from reported intakes of the amount of candy consumed per eating occasion from two 24-hour recalls. The FFQ did not specifically ask about chewing gum consumption. The estimates derived from the FFQ may be more representative of long-term or usual intakes than data from 1-day dietary recalls.
Frequency of candy consumption among the US population 2 years or older is shown in the Figure. Three percent of the population reported consuming no candy in the previous year. Per capita candy intake among the US population 2 years or older was estimated at 0.38 eating occasions per day, or approximately 2.7 eating occasions per week.4 Data collected from market data sources estimate daily per capita frequencies of total candy intake (excluding gum) at 0.42 eating occasions per day.21 Both these intake frequencies correspond to approximately 2.9 eating occasions per week, which are comparable with the frequency of intakes estimated from the NHANES data.
Results from NHANES research show that the median usual intake of candy is 4.8 g/d.4 Half of the total US population therefore consumes 4.8 g/d or less of candy, an amount equivalent to 1 piece of hard candy or one-half of a fun-size bar. Across the total population 2 years or older, mean usual candy intake was estimated at 11.5 g/d.4 This is similar to per capita total candy intakes of 11.4, 13.0, and 9.0 g/d previously reported for populations of children aged 2 to 13 years, adolescents aged 14 to 18 years, and adults, respectively.5,6
Energy, Added Sugars, and Saturated Fat From Candy
Consumption data among all Americans indicate that candy contributes a relatively small amount of calories, added sugars, and saturated fat to the total diet for most people. Among the total US population 2 years or older, including both candy consumers and nonconsumers, candy accounts for approximately 2.2% of total energy intake, or about 47 calories per day on average.22,23 This amount is equivalent to about 1 licorice string (41 calories) or a fun-size (∼10 g) chocolate bar (43 calories). Unpublished results from the analysis of frequency of candy intake in combination with amount of candy reported per eating occasion indicate that approximately 1 of 6 individuals (16%) 2 years or older consumed 100 calories or more per day from candy on average.4 Only 1 in 10 young children 2 to 8 years of age consumed 100 calories or more daily from candy, whereas approximately 22% of adolescents 9 to 18 years of age and 9% to 18% of adults 19 to more than 51 years of age had candy intakes of 100 calories or more per day.4
Of the average 21 tsp of added sugars consumed by all adults and children daily, candy contributes an average of 1.3 tsp of added sugars per day.24 These estimates include both chocolate and nonchocolate candy but do not specifically identify chewing gum intake. Given its relatively modest contribution of added sugars, candy ranks fifth as a source of added sugars in the US diet (6.1% of added sugars), after sugary drinks (soda/energy/sports/sweetened bottled water drinks; 35.7%), grain-based desserts (12.9%), sugar-sweetened fruit drinks (10.5%), and dairy-based desserts (6.6%).25 In addition, candy is not a leading source of saturated fat in the diets of those 2 years or older, contributing 3.1% to total saturated fat intake.26
ROLE OF CONFECTIONS IN HEALTH AND WELL-BEING
The first confections date back in antiquity to Asia, India, the Middle East, Greece, and Rome. Flowers, fruits, seeds, and stems were coated with honey, not only for the pleasant flavor but also as a preservative. Confections often were used for intended health effects, both therapeutic and preventive.27 For example, so-called chamber spices, or candied cloves, ginger, aniseed, juniper nuts, almonds, and pine kernels, were reputed to relieve intestinal gas. Today, confections most often are associated with moments of pleasure as a treat and in celebrations and holiday traditions, yet emerging science suggests that certain confections also may support overall health and well-being.
Association With Overall Health and Happiness
Two recent studies examined the association of candy consumption with body weight measures, risk factors for cardiovascular disease (CVD), and diet quality in children and adults. A study of more than 15 000 US adults 19 years or older explored the association of intakes of total candy, chocolate candy, and nonchocolate candy with weight status, CVD risk factors, and metabolic syndrome.5 Results showed that while candy contributed modestly to caloric intake on days when it was consumed, there was no association of total candy intake to increased weight/body mass index (BMI). There were decreased levels of risk factors for CVD, including lower diastolic blood pressure and C-reactive protein and metabolic syndrome, among candy consumers compared with non–candy consumers.5
A companion study of 11 182 US children and adolescents aged 2 to 18 years found slightly higher intakes of total energy and added sugars in the candy consumers; however, they were less likely to be overweight or obese than non–candy consumers.6 No associations existed between candy consumption and cardiovascular risk factors in children and adolescents, including no differences in blood pressure or blood lipid levels. Results from both studies indicate that children and adults who eat candy are likely to be consuming candy in moderate amounts, at levels that do not contribute to weight gain, heart disease, or diabetes risk factors.5,6
More recently, associations between frequency of candy consumption and body weight status and cardiovascular risk factors were examined in adults.28 Using responses to an FFQ on chocolate and nonchocolate candy consumption over the previous 12 months in NHANES 2003–2006, adults were divided into 3 categories: frequent candy consumers (>3.5 times per week), moderate consumers (>3 times per month to 3.5 times per week), and infrequent consumers (≤3 times per month). Frequency of candy consumption was not associated with the risk of obesity using measures of BMI, waist circumference, and skinfold thickness or markers of CVD risk including blood pressure, low- and high-density lipoprotein cholesterol, triglycerides, and insulin resistance.28 The lack of an association between frequency of candy consumption and cardiovascular risk factors could be a reflection of reduced candy intake among overweight adults as a result of dieting or recommendations from health professionals.
Related to oral health, slowly dissolving candies are cited as 1 of the dietary factors associated with increased risk for dental caries, along with sugar-sweetened liquids, sticky foods such as raisins, sugary-starchy snacks, and simple sugars such as sucrose, honey, and molasses.29,30 In addition to daily oral care, dental health authorities recommend reducing the amount of time sugars and starches are in the mouth and recognize that dental caries is associated with various foods and beverages rich in carbohydrates, including both added and naturally occurring sugars.30
Researchers studied the association of candy preference on health and psychological well-being in a group of 1300 older men who reported regular candy consumption. The results indicated that preference for chocolate was associated with lower BMI and waist circumference, better subjective health, optimism, and feelings of happiness.31
Emerging Science on Cocoa and Chocolate
A significant body of published research has shown that consumption of cocoa flavanols helps support healthy circulation and cardiovascular health. More recently, evidence is pointing to an association with brain function and cognition. These potential health effects have been attributed to flavanols, a group of naturally occurring plant-based compounds particularly abundant in cocoa.
Over the past decade, evidence from numerous population-based studies has supported an association between the inclusion of modest amounts of cocoa and chocolate and a range of positive effects on cardiovascular health.32–36 Intervention studies indicate that consumption of flavanol-containing dark chocolate and cocoa products may improve the function of the cardiovascular system and reduce blood pressure and cardiovascular risk factors37,38; reduce the reactivity of platelets, making them less prone to form clots39–41; and improve markers of inflammation.42,43 Clinical research also links the regular consumption of products rich in cocoa flavanols to lowered blood pressure.44–46 More recently, 2 meta-analyses of 66 randomized clinical trials found consistent short- and long-term improvements in blood pressure, insulin resistance, lipid profiles, and vascular dilation associated with chocolate and cocoa consumption.47,48
Related to brain function, preliminary research suggests that regular consumption of dietary cocoa flavanols may improve cognitive function in elderly subjects with early memory decline.49 This effect may be related to the effects of flavanols on improving brain blood flow. The science surrounding the potential health benefits of cocoa and chocolate is still emerging. Although more research is needed to confirm and extend these findings, clinical investigations on cocoa-based flavanols support the inclusion of cocoa and chocolate, balanced with calorie intake, as part of a dietary approach to help maintain and support cardiovascular health.
The Role of Chewing Gum
Although chewing gum provides a small contribution to calorie intake and is often not captured in dietary surveys, a number of research studies have shown benefits of chewing gum. For example, the oral health benefits of sugar-free gum are well established. Chewing sugar-free gum after meals stimulates the flow of saliva in the mouth, which helps to clean the mouth of food debris and neutralize and buffer plaque acids and contributes to the remineralization of enamel to strengthen teeth and help prevent dental caries.29 Systematic reviews of clinical and observational studies concluded that the evidence supports the caries-reducing effect of using sugar-free chewing gum as part of normal oral hygiene after meals. It is also noteworthy that sugar-free gum has more health claims approved by the European Food Safety Authority than any other food category.50,51
Preliminary observational research revealed that chewing gum before snacking may help reduce hunger and cravings for sweets and may decrease calorie intake from snacks.52 These results were confirmed in a study of restrained eaters where chewing gum was found to reduce snack intake by about 10%; hunger and the desire to eat also were suppressed significantly.53 In a similar study, gum chewers specifically decreased their calorie intake of high-sugar snack foods.54
Emerging research suggests that chewing gum may also confer benefits related to attention and focus. A preliminary study examining the effects of chewing gum on standardized math scores found that adolescent students allowed to chew gum during class and testing improved standardized test scores and maintained higher grades in math class compared with those who did not.55
It is increasingly important to provide consumers with practical information that helps them make better food choices and realistically include the foods they enjoy as part of a healthful and balanced diet and active lifestyle. The 2010 DGA acknowledges that as long as the foods and beverages consumed meet nutrient needs within calorie goals, individuals can select foods they enjoy as part of a healthful eating pattern maintained over time.2 Given the potential negative effects of restriction on food behavior and intake, offering realistic guidance that quantifies limits while accommodating small portions of treats, such as candy, without guilt may empower consumers with greater control over their food choices and help promote overall energy balance.
With the goal of moving toward more healthful eating patterns, consumers must learn food regulation skills for achieving calorie balance. Teaching consumers to choose nutrient-dense forms of foods and increase physical activity levels can free up calories for extras. Emphasis on education and information rather than restriction offers consumers the practical guidance they need to learn how to moderate food choices and incorporate extras, such as candy, into their eating and activity patterns. However, achieving balance between eating pleasure, meeting nutrient needs, and staying within daily energy requirements can be a significant challenge. It must be recognized that about 35% of total calories are currently coming from solid fats (19%) and added sugars (16%), suggesting that efforts to limit or modify major food sources of these components are needed to stay within the goal of 8% to 19% of total calories from SoFAS in USDA food patterns.2 As noted previously, candy is fairly small contributor of added sugars and solid fats compared with other foods.2,24–26 Acknowledging that candy is a popular treat, the proposed definition of moderation can help to establish realistic and useful limits for candy consumers.
Evidence suggests that candy consumers are no more likely to have negative health outcomes than those who do not eat candy,5,6 and usual intakes of candy contribute a relatively small amount of calories to the total diet for the average American.22,23 In addition, consumption data suggest that current candy intake is considered moderate in the context of energy contribution, with most of the population and subpopulations with usual intakes of candy within the proposed definition for moderation.4 About 22% of adolescents appear to be consuming the most calories from candy (>100 calories per day),4 suggesting that extra efforts to communicate moderation guidelines to this subpopulation may be warranted. However, energy needs for adolescents are typically higher because of activity and growth, which would accommodate a higher calorie range for moderate candy consumption. Recognizing that the allowance for SoFAS can be used for “extras” or for food group choices with solid fats or added sugars, a proposed definition for candy in moderation of up to 50 to 100 calories per day (Box 1) is consistent with guidelines for healthful eating, including guidance on added sugars (Table 1), for those who choose to include confections.
2. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC: US Government Printing Office, December 2010.
4. Shumow L, Barraj LM, Murphy MM, Bi X, Bodor AR. Candy consumption in the United States [abstract]. FASEB J (Abstract). 2012; 26: 1005.3
5. O’Neil CE, Fulgoni VL, Nicklas TA. Candy consumption was not associated with body weight measures, risk factors for cardiovascular disease, or metabolic syndrome in US adults: NHANES 1999–2004. Nutr Res. 2011; 31:(2): 122–130.
6. O’Neil CE, Fulgoni VL, Nicklas TA. Association of candy consumption with body weight measures, other health risk factors for cardiovascular disease, and diet quality in US children and adolescents: NHANES 1999–2004. Food Nutr Res. 2011; 55: 5794.
7. US Department of Agriculture. Hassle-Free Guide to a Better Diet. Washington, DC: US Government Printing Office; 1979; .
8. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 1980. 1st ed. Washington, DC: US Government Printing Office; 1980; .
9. Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet. 2012; 112: 739–758.
10. Van Horn L, Johnson RK, Flickinger BD, Vafiadis DK, Yin-Piazza S. Translation and implementation of added sugars consumption recommendations: a conference report from the American Heart Association Added Sugars Conference 2010. Circulation. 2010; 122: 2470–2490.
11. American Dietetic Association. Position of the American Dietetic Association: total diet approach to communication food and nutrition information. J Am Diet Assoc. 2007; 107: 1224–1232.
14. US Department of Agriculture; Center for Nutrition Policy and Promotion. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. 2010. http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm
. Accessed October 30, 2012.
15. Anzman SL, Birch L. Low inhibitory control and restrictive feeding practices predict weight outcomes. J Pediatr. 2009; 155: 651–656.
16. Clark HR, Goyder E, Bissell P, Blank L, Peters J. How do parents’ child-feeding behaviours influence child weight? Implications for childhood obesity policy. J Pub Health. 2007; 29: 132–141.
17. Piehowski KE, Preston AG, Miller DL, Nickols-Richardson SM. A reduced-calorie dietary pattern including a daily sweet snack promotes body weight reduction and body composition improvements in premenopausal women who are overweight and obese: a pilot study. J Am Diet Assoc. 2011; 111: 1198–1203.
18. Myrseth KO, Fishbach A, Trope Y. Counteractive self-control: when making temptations available makes temptations less tempting. Pyschol Sci. 2009; 20: 159–163.
19. Polivy J, Coleman J, Herman CP. The effect of deprivation on food cravings and eating behavior in restrained and unrestrained eaters. Int J Eat Disord. 2005; 38: 301–309.
20. Markowitz JT, Butryn ML, Lowe MR. Perceived deprivation, restrained eating and susceptibility to weight gain. Appetite. 2008; 51: 720–722.
21. NPD Group. Snack Track®Survey, 2010 and 2011. Frequency of total candy intake. Rosemont, IL: The NPD Group, Inc-Food & Beverage.
26. National Cancer Institute. Sources of saturated fat in the diets of the U.S. population ages 2 years and older, NHANES 2006–2006. Risk factor monitoring and methods. Cancer Control and Population Sciences. Updated 2010. http://riskfactor.cancer.gov/diet/foodsources/sat_fat/sf.html
. Accessed October 17, 2012.
27. Herbst SH, Herbst R . The New Food Lover’s Companion. New York, NY: Barron’s Educational Series, Inc; 2007; .
28. Murphy MM, Barraj LM, Bi X, Stettler N. Body weight status and cardiovascular risk factors in adults by frequency of candy consumption. Nutr J. 2013; 12: 53
29. 29. Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: oral health and nutrition. J Acad Nutr Diet. 2013; 113: 693–701.
30. American Dental Association. Eating habits for a healthy smile and body. J Am Diet Assoc. 2010; 141: 1544
31. Strandberg TE, Strandberg AY, Pitkälä K, Salomaa VV, Tilvis RS, Miettinen TA. Chocolate, well-being and health among elderly men. Eur J Clin Nutr. 2008; 62:(2): 247–253.
32. Buijsse B, Feskens EJ, Kok FJ, Kromhout D. Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study. Arch Intern Med. 2006; 27: 411–417.
33. Buijsse B, Weikert C, Drogan D, Bergmann M, Boeing H. Chocolate consumption in relation to blood pressure and risk of cardiovascular disease in German adults. Eur Heart J. 2010; 31: 1616–1623.
34. Djoussé L, Hopkins PN, Arnett DK, et al. Chocolate consumption is inversely associated with calcified atherosclerotic plaque in the coronary arteries: the NHLBI Family Heart Study. Clin Nutr. 2011; 30:(1): 38–43.
35. Mink PJ, Scrafford CG, Barraj LM, et al. Flavonoid intake and cardiovascular disease mortality: a prospective study in postmenopausal women. Am J Clin Nutr. 2007; 85: 895–909.
36. Mostofsky E, Levitan EB, Wolk A, Mittleman MA. Chocolate intake and incidence of heart failure: a population-based, prospective study of middle-aged and elderly women. Circ Heart Fail. 2010; 3: 612–616.
37. Heiss C, Finis D, Kleinbongard P, et al. Sustained increase in flow-mediated dilation after daily intake of high-flavanol cocoa drink over 1 week. J Cardiovasc Pharmacol. 2007; 49:(2): 74–80.
38. Schroeter H, Heiss C, Balzer J, et al. (-)-Epicatechin mediates beneficial effects of flavanol-rich cocoa on vascular function in humans. Proc Natl Acad Sci U S A. 2006; 103: 1024–1029.
39. Rein D, Paglieroni TG, Wun T, et al. Cocoa inhibits platelet activation and function. Am J Clin Nutr. 2000; 72: 30–35.
40. Murphy KJ, Chronopoulos AK, Singh I, et al. Dietary flavanols and procyanidin oligomers from cocoa (Theobroma cacao) inhibit platelet function. Am J Clin Nutr. 2003; 77: 1466–1473.
41. Heptinstall S, May J, Fox S, Kwik-Uribe C, Zhao L. Cocoa flavanols and platelet and leukocyte function: recent in vitro and ex vivo studies in healthy adults. J Cardiovasc Pharmacol. 2006; 47:(suppl 2): S197–S205.
42. Hamed MS, Gambert S, Bliden KP, et al. Dark chocolate effect on platelet activity, C-reactive protein and lipid profile: a pilot study. South Med J. 2008; 101: 1203–1208.
43. Baba S, Osakabe N, Kato Y, et al. Continuous intake of polyphenolic compounds containing cocoa powder reduces LDL oxidative susceptibility and has beneficial effects on plasma HDL-cholesterol concentrations in humans. Am J Clin Nutr. 2007; 85: 709–717.
44. Taubert D, Roesen R, Lehmann C, Jung N, Schomig E. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: a randomized controlled trial. JAMA. 2007; 298: 49–60.
45. Grassi D, Necozione S, Lippi C, et al. Cocoa reduces blood pressure and insulin resistance and improves endothelium-dependent vasodilation in hypertensives. Hypertension. 2005; 46: 398–405.
46. Faridi Z, Njike VY, Dutta S, Ali A, Katz DL. Acute dark chocolate and cocoa ingestion and endothelial function: a randomized controlled crossover trial. Am J Clin Nutr. 2008; 88: 58–63.
47. Hooper L, Kay C, Abdelhamid A, et al. Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials. Am J Clin Nutr. 2012; 95: 740–751.
48. Shrime MG, Bauer SR, McDonald AC, Chowdhury NH, Coltart CE, Ding EL. Flavonoid-rich cocoa consumption affects multiple cardiovascular risk factors in a meta-analysis of short-term studies. J Nutr. 2011; 141: 1982–1988.
49. Desideri G, Kwik-Uribe C, Grassi D, et al. Benefits in cognitive function, blood pressure, and insulin resistance through cocoa flavanol consumption in elderly subjects with mild cognitive impairment: the Cocoa, Cognition, and Aging (CoCoA) Study. Hypertension. 2012; 60: 794–801.
50. Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: a systematic review of original randomized controlled trials and observational studies. J Am Dent Assoc. 2008; 139: 1602–1614.
51. Mickenautsch S, Leal SC, et al. Sugar-free chewing gum and dental caries: a systematic review. J Appl Oral Sci. 2007; 15: 83–88.
52. Hetherington MM, Boyland E. Short term effects of chewing gum on snack intake and appetite. Appetite. 2007; 48: 397–401.
53. Hetherington MM, Regan MF. Effects of chewing gum on short-term appetite regulation in moderately restrained eaters. Appetite. 2011; 57: 475–482.
54. Geiselman PJ, Martin C, Coulon S, Ryan D, Apperson M. Effects of chewing gum on specific macronutrient and total caloric intake in an afternoon snack. FASEB J. 2009; 23: 101.3
55. Johnston CA, Tyler C, Stansberry SA, Moreno JP, Foreyt JP. Brief report: gum chewing affects standardized math scores in adolescents. J Adolesc. 2012; 35:(2): 455–459.
56. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2006; .
57. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009; 120: 1011–1020.
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