A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy
2.2. Study Selection and Data Extraction
2.3. Assessment of Quality and Data Analysis
3. Results
3.1. Description of the Included Studies
3.2. Quality and Characteristics of the Selected Studies
3.3. Overall Impact of the Supplementation with Flavanol-Containing Tea, Cocoa or Apple Products on Blood Lipids, BMI and WC
3.4. Analysis of the Potential Factors Influencing Inter-Individual Responses to Flavanols Consumption
3.4.1. Stratification by the Individuals’ Baseline BMI, Sex, Smoking, and Country
3.4.2. Stratification by the Individuals’ Medication and Health/Disease Status
3.4.3. Stratification by the Source/Administration Form of the Flavanols and the Diet during the Intervention
3.4.4. Multiple Meta-Regression Analysis of BMI Modulators of the Response to Flavanol-Containing Products Consumption
4. Discussion
4.1. Baseline BMI
4.2. Sex
4.3. Country Where the Study Was Carried Out
4.4. Health and Medication Status
4.5. Source and Form of Administration of the Flavanols
4.6. Magnitude of the Changes
4.7. Additional Recent Evidences
5. Conclusions
Supplementary Materials
Acknowledgments
Author Contributions
Conflicts of Interest
References
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Factors | |||||||
---|---|---|---|---|---|---|---|
Baseline BMI | <25.0 a (normal and/or underweight) | ≥25.0 (overweight and/or obese) | |||||
Sex | Women | Men | |||||
Smoking | Non-smokers | Smokers | |||||
Country where the study was undertaken | East Asian countries (Japan, Korea, China, Thailand, Taiwan) | All other countries | North America (USA, Canada) | European countries | |||
Non-Mediterranean countries (Denmark, Finland, The Netherlands, Germany, Poland, UK, Switzerland) | Mediterranean countries (Italy, Spain, Portugal, Greece) | ||||||
Medication | Yes | No | |||||
Healthy vs. non-healthy | Healthy individuals b | Individuals at a risk of disease c | Individuals with a reported disease d | Different disorders: overweight and/or obese, dyslipidemia, glucose disorders, blood pressure disorders, mixed e | |||
Source of flavanols | Cocoa products | Apple products | Tea products | Tea drinks | Tea extracts (capsules, powder) | Tea purified EGCG | |
Diet during intervention | Controlled diet | Usual diet (includes usual with some restrictions and NR) |
n | NT | NS | NC | SDM | 95% CI | Z | p-Value | Tau2 | Q | df (p-Value) | I2 (%) | Egger’s Regression | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Intercept | p-Value (2-Tailed) | |||||||||||||
BMI | 74 | 4156 | 2127 | 2029 | −0.153 | −0.227, −0.078 | −4.009 | <0.001 | 0.027 | 99.6 | 73 (0.021) | 26.7 | 1.04 | 0.024 |
WC | 46 | 2875 | 1478 | 1397 | −0.293 | −0.438, −0.147 | −3.932 | <0.001 | 0.168 | 156.7 | 45 (<0.001) | 71.3 | −1.47 | 0.101 |
TC | 112 | 5812 | 2982 | 2830 | −0.214 | −0.328, −0.099 | −3.651 | <0.001 | 0.273 | 479.1 | 111 (<0.001) | 76.8 | −0.76 | 0.226 |
LDL-C | 105 | 5726 | 2928 | 2798 | −0.235 | −0.345, −0.125 | −4.171 | <0.001 | 0.229 | 408.0 | 104 (<0.001) | 74.5 | −0.46 | 0.459 |
HDL-C | 112 | 5928 | 3023 | 2905 | 0.152 | 0.047, 0.256 | 2.836 | 0.005 | 0.214 | 408.0 | 111 (<0.001) | 72.8 | 0.72 | 0.208 |
TAGs | 120 | 5931 | 3023 | 2908 | −0.114 | −0.215, −0.013 | −2.213 | 0.027 | 0.209 | 407.7 | 119 (<0.001) | 70.8 | −0.33 | 0.570 |
Factor | Baseline BMI | Sex | Smoking | Country Where the Study Was Undertaken | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Subgroup | <25.0 | ≥25.0 | Women | Men | Non-Smokers | Smokers | East Asian Countries | All Other Countries | North America | All European Countries | European Countries | |
Med Countries | Non-Med Countries | |||||||||||
BMI | 0.003 a | −0.165 | −0.102 | −0.321 | −0.148 | NR | −0.204 | −0.126 | −0.042 | −0.235 | −0.306 | −0.176 |
p-value | (NS) | (0.001) | (NS) | (0.003) | (0.018) | (0.001) | (0.007) | (NS) | (0.001) | (0.024) | (0.091) | |
(n, N) | (11, 477) | (42, 2410) | (15, 831) | (8, 339) | (24, 1046) | (23, 1511) | (51, 2645) | (15, 719) | (20, 1051) | (7, 392) | (13, 659) | |
WC | −0.102 | −0.362 | −0.643 | −0.932 | −0.252 | NR | −0.217 | −0.355 | −0.123 | −0.573 | −1.279 | −0.181 |
p-value | (NS) | (0.000) | (0.037) | (0.024) | (0.008) | (0.055) | (0.000) | (NS) | (0.006) | (0.001) | (NS) | |
(n, N) | (3, 253) | (36, 2002) | (9, 464) | (5, 266) | (16, 750) | (19, 1458) | (27, 1471) | (6, 206) | (13, 757) | (5, 269) | (8, 488) | |
TC | −0.047 | −0.165 | −0.493 | −0.100 | −0.221 | 0.147 | −0.195 | −0.223 | −0.303 | −0.254 | −0.255 | −0.252 |
p-value | (NS) | (0.011) | (0.012) | (NS) | (0.001) | (NS) | (0.054) | (0.002) | (0.027) | (0.032) | (0.003) | (0.003) |
(n, N) | (19, 504) | (50, 2863) | (15, 873) | (14, 557) | (41, 1572) | (2, 88) | (37, 2297) | (75, 3515) | (23, 1097) | (30, 1296) | (15, 609) | (15, 639) |
LDL-C | −0.062 | −0.195 | −0.545 | −0.131 | −0.156 | −0.341 | −0.236 | −0.234 | −0.379 | −0.185 | −0.246 | −0.140 |
p-value | (NS) | (0.002) | (0.004) | (NS) | (0.039) | (NS) | (0.017) | (0.001) | (0.006) | (NS) | (0.042) | (NS) |
(n, N) | (13, 396) | (48, 2698) | (15, 868) | (10, 416) | (42, 1764) | (2, 88) | (31, 2334) | (74, 3392) | (25, 1117) | (27, 1176) | (12, 537) | (15, 639) |
HDL-C | 0.229 | 0.176 | 0.226 | 0.272 | 0.090 | 0.152 | 0.105 | 0.176 | 0.286 | 0.165 | 0.320 | 0.029 |
p-value | (NS) | (0.063) | (NS) | (NS) | (NS) | (NS) | (NS) | (0.008) | (0.095) | (NS) | (0.078) | (NS) |
(n, N) | (17, 455) | (52, 2872) | (15, 902) | (16, 634) | (45, 1945) | (2, 88) | (37, 2410) | (75, 3518) | (22, 978) | (34, 1495) | (15, 679) | (18, 816) |
TAGs | −0.058 | −0.098 | −0.067 | 0.109 | −0.051 | 0.089 | −0.196 | −0.052 | −0.098 | −0.185 | −0.161 | −0.203 |
p-value | (NS) | (NS) | (NS) | (NS) | (NS) | (NS) | (0.034) | (NS) | (NS) | (0.099) | (NS) | (NS) |
(n, N) | (23, 596) | (53, 2599) | (16, 887) | (18, 781) | (55, 2243) | (2, 88) | (35, 1975) | (83, 3796) | (23, 921) | (41, 1969) | (18, 939) | (24, 1100) |
Factor | Medication | Health Status | Type of Disorder | ||||||
---|---|---|---|---|---|---|---|---|---|
Subgroup | Yes | No | Healthy Individuals | Individuals at Risk | Individuals with a Disease | Overweight/Obese | Lipid Disorders | Glucose Disorders | Blood Pressure Disorders |
BMI | −0.053 a | −0.222 | −0.119 | −0.195 | −0.128 | −0.191 | −0.063 | −0.028 | −0.054 |
p-value | (NS) | (0.001) | (NS) | (0.009) | (0.069) | (0.011) | (NS) | (NS) | (NS) |
(n, N) | (15, 744) | (28, 1312) | (18, 868) | (26, 1753) | (25, 1008) | (22, 1488) | (4, 179) | (5, 265) | (5, 225) |
WC | −0.363 | −0.445 | −0.092 | −0.392 | −0.169 | −0.426 | NI | −0.057 | NI |
p-value | (NS) | (0.003) | (NS) | (0.000) | (NS) | (0.000) | (NS) | ||
(n, N) | (5, 309) | (21, 1237) | (4, 250) | (26, 1485) | (9, 466) | (25, 1447) | (4, 188) | ||
TC | −0.205 | −0.296 | −0.266 | −0.161 | −0.241 | −0.148 | −0.227 | −0.372 | −0.515 |
p-value | (0.089) | (0.001) | (0.015) | (NS) | (0.014) | (NS) | (NS) | (NS) | (NS) |
(n, N) | (24, 1174) | (47, 2169) | (38, 1520) | (32, 2243) | (38, 1859) | (24, 1813) | (9, 491) | (8, 463) | (5, 275) |
LDL-C | −0.200 | −0.289 | −0.210 | −0.192 | −0.311 | −0.187 | −0.336 | −0.579 | −0.754 |
p-value | (NS) | (0.004) | (0.028) | (0.061) | (0.003) | (0.082) | (NS) | (0.042) | (0.041) |
(n, N) | (21, 1020) | (43, 2311) | (37, 1782) | (29, 2049) | (36, 1756) | (23, 1742) | (9, 491) | (6, 408) | (4, 146) |
HDL-C | 0.162 | 0.128 | 0.163 | 0.229 | 0.091 | −0.062 | 0.476 | 0.032 | 0.115 |
p-value | (NS) | (NS) | (NS) | −0.055 | (NS) | (NS) | −0.005 | (NS) | (NS) |
(n, N) | (25, 1212) | (48, 2042) | (37, 1670) | (32, 2187)) | (39, 1881) | (20, 1541) | (12, 654) | (8, 488) | (6, 301) |
TAGs | −0.165 | −0.135 | −0.144 | −0.08 | −0.103 | −0.008 | −0.258 | 0.065 | −0.251 |
p-value | (NS) | −0.063 | (NS) | (NS) | (NS) | (NS) | (NS) | (NS) | (NS) |
(n, N) | (23, 1132) | (63, 3019) | (45, 2669) | (31, 1205) | (39, 1931) | (24, 912) | (12, 585) | (7, 536) | (6, 250) |
Factor | Source of Flavanols | Diet during Supplementation | ||||||
---|---|---|---|---|---|---|---|---|
Subgroup | Cocoa Products | Apple Products | Tea Products | Tea Drinks | Tea Extracts | Tea Purified EGCG | Controlled | Usual |
BMI | 0.001 a | −0.11 | −0.224 | −0.223 | −0.212 | −0.290 | −0.162 | −0.149 |
p-value | (NS) | (NS) | (0.000) | −0.007 | (0.002) | (0.022) | (0.030) | (0.001) |
(n, N) | (21, 1014) | (5, 319) | (46, 2704) | (20, 1167) | (26, 1537) | (7, 384) | (23, 1032) | (49, 2990) |
WC | −0.106 | −0.206 | −0.354 | −0.22 | −0.506 | −0.465 | −0.500 | −0.164 |
p-value | (NS) | (NS) | (0.000) | (NS) | (0.000) | (NS) | (0.000) | (0.084) |
(n, N) | (8, 430) | (2, 155) | (34, 2228) | (16, 1074) | (17, 1110) | (2, 171) | (18, 903) | (27, 1868) |
TC | −0.177 | −1.352 | −0.143 | −0.083 | −0.208 | −0.051 | −0.215 | −0.213 |
p-value | −0.018 | −0.041 | (0.036) | (NS) | (0.008) | (NS) | (0.032) | (0.003) |
(n, N) | (38, 1625) | (7, 402) | (65, 3666) | (36, 2051) | (26, 1615) | (7, 437) | (39, 1682) | (73, 4130) |
LDL-C | −0.252 | −0.587 | −0.191 | −0.119 | −0.270 | −0.216 | −0.184 | −0.260 |
p-value | −0.013 | −0.007 | (0.008) | −0.045 | (0.000) | (NS) | (0.062) | (0.000) |
(n, N) | (35, 1577) | (8, 386) | (61, 3723) | (35, 2235) | (26, 1488) | (7, 206) | (38, 1540) | (67, 4186) |
HDL-C | 0.16 | 0.197 | 0.150 | 0.17 | 0.13 | −0.291 | 0.245 | 0.104 |
p-value | (NS) | (NS) | (0.031) | −0.071 | (NS) | (NS) | (0.008) | (NS) |
(n, N) | (37, 1603) | (7, 386) | (66, 3820) | (38, 2292) | (27, 1484) | (7, 437) | (40, 1759) | (72, 4169) |
TAGs | −0.183 | −0.173 | −0.050 | −0.047 | −0.053 | 0.314 | −0.139 | −0.105 |
p-value | −0.047 | (NS) | (NS) | (NS) | (NS) | −0.077 | (NS) | (NS) |
(n, N) | (39, 1691) | (10, 455) | (69, 3700) | (38, 2121) | (30, 1544) | (7, 437) | (46, 1939) | (73, 3922) |
Covariate | Coefficient | SE | 95% Lower | 95% Upper | Z | p-Value |
---|---|---|---|---|---|---|
Intercept | −0.0679 | 0.0899 | −0.2440 | 0.1082 | −0.76 | 0.4500 |
Medication (No vs. Yes) | 0.2481 | 0.0995 | 0.0530 | 0.4431 | 2.49 | 0.0127 |
Source of flavanols (Cocoa vs. Tea) | −0.3278 | 0.1022 | −0.5282 | −0.1274 | −3.21 | 0.0013 |
Test of the Model | ||||||
QR | 15.64 | |||||
df | 2 | |||||
p-value | 0.0004 | |||||
R2 | 0.94 | |||||
Number of studies included | 40 (54% of the total studies used in the meta-analysis) |
© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
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González-Sarrías, A.; Combet, E.; Pinto, P.; Mena, P.; Dall’Asta, M.; Garcia-Aloy, M.; Rodríguez-Mateos, A.; Gibney, E.R.; Dumont, J.; Massaro, M.; et al. A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy. Nutrients 2017, 9, 746. https://doi.org/10.3390/nu9070746
González-Sarrías A, Combet E, Pinto P, Mena P, Dall’Asta M, Garcia-Aloy M, Rodríguez-Mateos A, Gibney ER, Dumont J, Massaro M, et al. A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy. Nutrients. 2017; 9(7):746. https://doi.org/10.3390/nu9070746
Chicago/Turabian StyleGonzález-Sarrías, Antonio, Emilie Combet, Paula Pinto, Pedro Mena, Margherita Dall’Asta, Mar Garcia-Aloy, Ana Rodríguez-Mateos, Eileen R. Gibney, Julie Dumont, Marika Massaro, and et al. 2017. "A Systematic Review and Meta-Analysis of the Effects of Flavanol-Containing Tea, Cocoa and Apple Products on Body Composition and Blood Lipids: Exploring the Factors Responsible for Variability in Their Efficacy" Nutrients 9, no. 7: 746. https://doi.org/10.3390/nu9070746