Factors Affecting the Absorption, Metabolism, and Excretion of Cocoa

Review pubs.acs.org/JAFC

Factors Affecting the Absorption, Metabolism, and Excretion of Cocoa Flavanols in Humans Tania Cifuentes-Gomez,† Ana Rodriguez-Mateos,§ Isidro Gonzalez-Salvador,† María Elena Alañon,† and Jeremy P. E. Spencer*,† †

Molecular Nutrition Group, School of Chemistry, Food and Pharmacy, University of Reading, Reading RG2 6AP, United Kingdom Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf 40225, Germany

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ABSTRACT: Cocoa is rich in a subclass of flavonoids known as flavanols, the cardiovascular health benefits of which have been extensively reported. The appearance of flavanol metabolites in the systemic circulation after flavanol-rich food consumption is likely to mediate the physiological effects on the vascular system, and these levels are influenced by numerous factors, including food matrix, processing, intake, age, gender, or genetic polymorphisms, among others. This review will focus on our current understanding of factors affecting the absorption, metabolism, and excretion of cocoa flavanols in humans. Second, it will identify gaps in these contributing factors that need to be addressed to conclusively translate our collective knowledge into the context of public health, dietary guidelines, and evidence-based dietary recommendations. KEYWORDS: absorption, cocoa flavanols, (−)-epicatechin, excretion, metabolism, pharmacokinetics

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INTRODUCTION The extent to which flavanols (present in many types of finished food products, including red wine, grape and apple juices, tea, and cocoa),1,2 including their monomeric forms (i.e., epicatechin (EC) and catechin) and polymeric derivatives (known as procyanidins), induce cardiovascular benefits has been the subject of extensive research. Much of the evidence for their benefits has been derived from human intervention trials that have indicated their efficacy toward endothelial function, blood pressure, platelet aggregation, and mediation of inflammatory conditions.3−5 Importantly, the bioactivity of flavanols appears to be linked to the appearance of and, to a lesser extent, the concentration of flavanol metabolites in the systemic circulation after flavanol intake. As such, to gain a fuller understanding of how dietary flavanols affect human cardiovascular health it is necessary to (1) understand the relative absorption, metabolism, and excretion of cocoa flavanols in individuals of different populations, that is, age, sex, genetic polymorphisms, and background diet; and (2) determine the extent to which factors such as food matrix and nutrient−nutrient interaction may influence flavanol absorption, distribution, metabolism, and excretion (ADME). Recently, (−)-epicatechin-3′-β-D-glucuronide, (−)-epicatechin-3′-sulfate, and 3′-O-methyl-(−)-epicatechin-5/7-sulfate have been identified as the major in vivo metabolites present in the bloodstream at 1−3 h after ingestion of cocoa, chocolate products, or pure compounds.6,7 Additionally, it has been demonstrated that dietary procyanidins do not contribute to the systemic pool of flavanols in humans, suggesting that their causal role as mediators of the cardiovascular health benefits is unlikely.8 However, procyanidins undergo biotransformation through the action of the gut microbiome, resulting in a host of smaller phenolic metabolites that may possess potential bioactivity, such as 5-(hydroxyphenyl)-γ-valerolactones and hydroxyphenylvaleric acids.8,9 Data relating to the metabolic and pharmacokinetic profile of flavanols, to date, derived from © XXXX American Chemical Society

intervention studies with differing human populations and differing flavanol interventions, indicate variability in the ADME most likely driven by factors such as food matrix, processing, nutrient−drug interactions, level of intake, genetic polymorphisms, specifically those influencing the activity of phase I and II metabolic enzymes, and background diet. Such factors will, in turn, influence the extent of cardiovascular benefits induced following flavanol intake via their direct impact on the metabolic profile of flavanols in the circulation (Figure 1). In this context, the present review will focus on our current understanding of factors relating to the absorption, metabolism, and excretion of cocoa flavanols in humans and will identify gaps in these contributing factors that need to be addressed. Such an understanding is necessary to conclusively translate the benefits of cocoa flavanol intake to the wider population in the context of public health, dietary guidelines, and evidence-based dietary recommendations.

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CLASSIFICATION AND DAILY INTAKE OF COCOA FLAVANOLS Flavonoids represent a chemically defined family of polyphenols that can be found in a variety of foods such as fruits, vegetables, and other plant-based foods. The basic chemical structure of a flavonoid consists of two aromatic rings (A and B) linked via an oxygenated heterocycle (ring C). Flavanols represent one specific class of flavonoids and are found in grapes, apples, and red wine, with tea and cocoa being among the richest sources.2 Special Issue: 27th ICP and 8th Tannin Conference (Nagoya 2014) Received: January 23, 2015 Revised: February 24, 2015 Accepted: February 25, 2015

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DOI: 10.1021/acs.jafc.5b00443 J. Agric. Food Chem. XXXX, XXX, XXX−XXX

Review

Journal of Agricultural and Food Chemistry

Figure 1. Schematic describing the main factors affecting the absorption, metabolism, and excretion of cocoa flavanols, together with the health benefits mediated by the circulating (−)-epicatechin metabolites.

Figure 2. Chemical structures of (A) (−)-epicatechin, (B) (+)-catechin, (C) procyanidin dimer B2, (D) procyanidin trimer C1, and (E) procyanidin tetramer A2.

polymeric derivatives of flavanols characterized by their degree of polymerization (DP), also named proanthocyanidins), and, to a lesser extent, anthocyanins.10 The term “cocoa flavanols”

The polyphenol content of cocoa consists predominately of flavanols (monomeric forms: (−)-epicatechin, (+)-epicatechin, (−)-catechin, and (+)-catechin), procyanidins (oligomeric and B


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Journal of Agricultural and Food Chemistry Table 1. Bioavailability and Pharmacokinetics of Epicatechin after Consumption of Cocoa Flavanols in Humansa Cmax reference Richelle et al., 199940 Baba et al., 200034 Rein et al., 200039 Wang et al., 200044

Holt et al., 200229 Schramm et al., 200336 Natsume et al., 200333 Schroeter et al., 200358 Roura et al., 200548 Schroeter et al., 200649 Neukam et al., 200746 Roura et al., 200747 Taubert et al., 200743 Balzer et al., 200845

Loke et al., 200877 Neilson et al., 200938 Mullen et al., 200935 Spadafranca et al., 201042 Ottaviani et al., 201132 Rodriguez-Mateos et al., 201241 Ottaviani et al., 20127 Ottaviani et al., 20128 Actis-Goretta et al., 20126

tmax

AUC

urinary excretionb

source

n

intake

(nM)

(h)

(nM·h)

(% of EC intake)

chocolate chocolate cocoa chocolate chocolate chocolate chocolate chocolate cocoa cocoa pure (−)-EC cocoa cocoa cocoa cocoa cocoa chocolate cocoa cocoa cocoa pure (−)-EC chocolate cocoa cocoa chocolate pure (−)-EC chocolate cocoa cocoa chocolate

8 8 5 5 10 13 13 10 5 6 4 12 5 10 10 21 22 10 10 10 12 6 6 9 20 7 15 10 12 5

82 mg EC 164 mg EC 220 mg (−)-EC 220 mg (−)-EC 137 mg EC 35 mg (−)-EC 69 mg (−)-EC 104 mg (−)-EC 323 mg EC+C 1.53 mg EC+C/kg BW (115 mg/75 kg) 1000 mg (−)-EC 5.44 mg EC+C/kg BW (408 mg/75 kg) 54 mg (−)-EC 174 mg EC 61 mg EC 28.2 mg (−)-EC 5.1 mg EC 16.8 mg EC 78.9 mg EC 203 mg EC 200 mg (−)-EC 27 mg EC 27 mg EC 6.7 mg (−)-EC 58 mg EC 1.5 mg (−)-EC/kg BW (112 mg/75 kg) 58 mg EC 1.8 mg (−)-EC/kg BW (135 mg/75 kg) 1.8 mg (−)-EC/kg BW (135 mg/75 kg) 79 mg (−)-EC

383 700 4920 4770 257 133 258 355 5920 1021 21599d − 626 2750c 63 330 13 194e 529e 964e 2870 32 43 143d 362 889 608 1234d 880 873d

2.0 2.6 2.0 2.0 2.0 2.0 2.0 2.0 2.0 1.6c − − − 2.0 1.0 2.0 1.3 − − − − 2.3 0.9 1.0−1.4 − 2.0 2.0 2.0 2.0 3.2−3.8

1535 3688 − − − 500 1000 1500 − 4230 − 8888 − − − − 43 − − − − 121 132 296d − − 1672 − − 4154d

−f − 29.8 25.3 − − − − − − − − − − − − − − − − − − − 18.3 − 3 − − 5.1c 21

a

Cmax, maximum plasma concentration; tmax, time to reach maximum concentration; AUC, area under the curve of the concentration over time; EC, epicatechin; C, catechin; BW, body weight. bUrine collected over a 24 h period. cData interpreted visually from a graph. dValues represent total epicatechin metabolites summed by the author. eValues derived by subtracting baseline values. f−, unavailable data in the manuscript.

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ADME After oral intake, (−)-EC is exposed to enterocytes20,21 in the small intestine, where they enter via passive diffusion22 and are rapidly metabolized. The aglycone undergoes phase II enzymatic metabolism forming sulfate, glucuronide, and methylated sulfate/glucuronide metabolites through the respective actions of sulfotransferases (SULTs), uridine-5′diphosphate glucuronosyltransferases (UGTs), and catechol-Omethyltransferases (COMTs).23,24 Once absorbed, any unmetabolized (−)-EC undergoes rapid glucuronidation, sulfation, and O-methylation in the liver. Although a degree of enterohepatic recirculation was initially proposed,25 recent intestinal perfusion studies have reported only a relatively modest elimination of (−)-EC via the bile.26 Procyanidins were suggested to undergo depolymerization in the gastrointestinal (GI) tract, resulting in monomers,27 although subsequent studies have indicated that this is unlikely and that they are very poorly absorbed, if at all, in humans.8,28 Indeed, to date, only flavanol dimers have been detected in human plasma and in very low amounts compared with monomers.29 However, once in the large intestine, procyanidins together with flavanol monomers undergo rapid C-ring fission induced by the gut microbiome, yielding a host of smaller phenolic acids and 5(hydroxyphenyl)-γ-valerolactones.8,9,30 These are absorbed and further metabolized in the liver prior to their renal excretion.

includes both the monomeric forms (mainly (−)-epicatechin and to a lesser extent (+)-catechin) and the oligomeric procyanidins ranging from dimers to decamers (DP 2−10) (Figure 2). The average intake of cocoa flavanols has been recently estimated in Europe at 105 mg/day,11 below the 200 mg/day considered by EFSA to be sufficient to help maintain normal endothelium-dependent vasodilation.12 The primary flavanol in cocoa beans is (−)-epicatechin, ranging from 0.1 to 13.5 mg/g, with lower levels of (+)-catechin,13−15 whereas oligomeric and polymeric procyanidin content ranges from 18 to 27 mg/g and from 9 to 16 mg/g, respectively.16 In milk and dark chocolates, the epicatechin content (both enantiomers, (−) and (+) forms) has been reported between 0.18 and 1.25 mg/g, with catechin between 0.05 and 0.40 mg/g and oligomeric and polymeric procyanidin content around 1.1− 11.2 and 0.8−7.0 mg/g, respectively.16−18 The flavanol monomer content of chocolate is predominantly in the (−) form, accounting for approximately 95 and 89% of EC and catechin present, respectively.18 Considering that cocoa beans do not contain (−)-catechin, it has been reported that the presence of this stereoisomer in chocolate might be due to the epimerization of (−)-epicatechin to (−)-catechin during processing.14,19 C


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revealed a significant level of glucuronide and sulfate conjugates of 5-(3′,4′-dihydroxyphenyl)-γ-valerolactone and 5-(3′-methoxy-4′-hydroxyphenyl)-γ-valerolactone.9 Such metabolites may be generated from both monomeric and oligomeric flavanols, and data indicate that intake of monomeric flavanols or procyanidins (degree of polymerization ranging from 2 to 10) results in urinary levels of γ-valerolactone metabolites representing 43 and 54% of intake, respectively.8 The excretion of phenolic acids, mainly vanillic, ferulic, 3,4-dihydroxyphenylacetic, and 3-hydroxyphenylacetic acids, is also known to be increased 6−48 h after flavanol intake,9,37 with vanillic acid showing a different peak excretion between 0 and 3 h.30 In plasma, glucuronide conjugates of dihydroxyphenylvalerolactones were increased after regular cocoa intake,9 whereas a recent study also reported an enhancement of circulating total phenolic acids between 0 and 6 h after consumption of a cocoa−nut cream containing 176 μmol (51.1 mg) of EC and catechin.37 In summary, although there are a number of studies relating to the absorption, metabolism, and excretion of cocoa flavanols, only very recently has the precise and detailed profile of flavanol ADME been elucidated due to developments in analytical techniques and the availability of authentic flavanol metabolites. Much is known about structure microbiota-derived catabolites, but data relating to the extent to which specific bacterial profiles may alter the generation of smaller phenolic metabolites are presently lacking.

The pharmacokinetics of (−)-EC in blood and urine following cocoa flavanol consumption has been extensively studied in numerous human intervention trials (Table 1), although it should be noted that the accurate identification and quantification of flavanols have been limited for several reasons. First, the analytical methodology used often fails to capture the full metabolic profile, for example, by failing to profile flavanol metabolite stereoisomers. Added to this, a lack of reference standards has made it difficult to accurately standardize flavanol metabolite characterization in different studies. Instead, it has been necessary to report total flavanol absorption based on the hydrolysis of sulfates of (methyl)epicatechins using enzymes to convert the conjugated forms to aglycones. It is now known that such an approach is flawed due to the ineffective cleavage of flavanol conjugates under experimental conditions and has led to an underestimation of total EC bioavailability.31 The stereochemical configuration of flavanols has also been reported to play a crucial role with regard to the absorption and metabolism of cocoa flavanols. The oral bioavailability of the stereoisomers has been studied and indicated that flavanol monomeric enantiomers significantly differed from each other with regard to their levels of nonmethylated metabolites present in plasma and urine ((−)-epicatechin > (+)-epicatechin = (+)-catechin > (−)-catechin).32 Generally, in the majority of human trials the amounts of monomers epicatechin and catechin consumed by the volunteers ranged between 20 and 300 mg, a level that leads to maximum plasma concentrations of epicatechin and catechin of around 30 and 5000 nM, between 0.9 and 3.2 h after consumption (Table 1). Only one study has reported maximum concentrations of around 21 μM after consumption of 1 g of EC, an amount unlikely to be relevant to dietary intake even following the consumption of a high-flavanol diet.33 With respect to the precise metabolic profile, access to chemically synthesized EC metabolites has allowed the identity of the major flavanol metabolites to be elucidated.6,7 After consumption of a cocoa flavanol drink containing 1.8 mg of (−)-epicatechin/kg of body weight, the conjugates (−)-epicatechin-3′-β-D-glucuronide, (−)-epicatechin-3′-sulfate, and 3′O-methyl-(−)-epicatechin-5/7-sulfate were the major in vivo metabolites found in the circulation 2 h after intake, accounting for 46, 28, and 17% of all plasma flavanol metabolites, respectively, whereas (−)-epicatechin-5-sulfate and (−)-epicatechin-7-sulfate (representing 3.1 and 1.1%, respectively) were present at lower levels.7 These data are in agreement with another human trial in which volunteers consumed dark chocolate containing 79 mg of (−)-epicatechin. In this case, 3′O-methyl-(−)-epicatechin-4-sulfate and (−)-epicatechin-4′-βD-glucuronide were also identified, accounting for 7 and 4% of all metabolites detected in the bloodstream.6 The urinary excretion of structurally related EC metabolites has been reported between 21 and 30% of the ingested dose over a period of 24 h, of which >80% was excreted in the first 8−10 h,6,34,35 with the exception of two studies that reported (+)-catechin > (−)-catechin,66 such epimerization together with other processing techniques is likely to greatly affect the bioavailability and bioactivity of cocoa flavanols. Drug−Flavanol Interactions. As described previously, flavanols are substrates of phase II conjugation enzymes and thus share a metabolic pathway similar to that of many drugs.23,24,67 However, the extent to which flavanols may alter drug metabolism in vivo is currently unknown, although a few studies have shown that flavanols may modulate the activity of phase II enzymes in vitro.68−70 Notably, EC has been shown to inhibit the enzyme UGT2B17, albeit at concentrations above those that are physiologically possible.69 EC and catechin have also been observed to inhibit human SULT1A1 and SULT1A3 with IC50 values in the micromolar range.70 Catechin and EC, however, appear unable to influence P-glycoprotein drug transporter activity in intestinal cells.68 Although these in vitro studies suggest that EC might be able to alter drug metabolism, results without in vivo confirmation should be interpreted with caution. A recent in vitro study investigating the cellular uptake and metabolism of EC and its major in vivo metabolites showed that the conjugates formed in the cells only account for one of the four major metabolites in human plasma, suggesting that the in vitro models do not accurately reflect the

in vivo situation.21 In vitro studies with both parental flavanols and their metabolites at physiologically relevant concentrations and human in vivo studies investigating potential drug−flavanol interactions are warranted. Intake. The influence of the intake level of overall absorption and metabolism has also been investigated. Consumption of 27, 53, and 80 g of chocolate resulted in measured plasma EC levels (Cmax and AUC) that increased in an intake-dependent fashion.44 The same trend was observed in another study providing 40 and 80 g of chocolate, although in this case tmax was slightly delayed from 2 to 2.6 h, respectively.40 Together the data suggest that there is a good correlation between intake and Cmax (R2 = 0.954), considering the diversity of the study conditions (Figure 3). When 1 g of pure (−)-EC

Figure 3. Linear correlation between plasma concentrations of epicatechin metabolites (expressed as Cmax) and intake of epicatechin for 22 studies shown in Table 1.

was consumed, plasma concentrations of total EC metabolites were 6269 ng/mL (≈21.56 μM) at 1 h after consumption,33 whereas consumption of only 6.7 mg of (−)-EC from a cocoa drink resulted in Cmax values of 143 nM.35 The average Cmax, normalized to the ingestion of 1 mg of EC, indicates that 9.4 ± 1.3 nM of total EC metabolites is present in the circulation per milligram of EC consumed (Table 1). As such, it appears that the saturation of (−)-EC absorption does not occur in this dosage range. However, it remains unclear as to how increasing amounts of (−)-EC intake might influence the overall pattern of flavanol metabolism. For example, in rats it has been reported that increased (−)-EC methylation occurs at higher intake levels.71 To what extent this may occur in humans remains to be established. Genetic Polymorphisms. Interindividual variability in the absorption and metabolism of cocoa flavanols is thought to be at least partially caused by genetic polymorphisms, in particular, in phase II enzymes involved in flavanol metabolism. A single nucleotide polymorphism (SNP) in the gene encoding for COMTs, which is responsible for flavanol O-methylation, involves a single G to A transition that result in a change from valine to methionine.72 In this polymorphism (COMT Val 158Met) the variant allele COMT-Met (also called COMT-A) has shown a 40% reduction of enzymatic activity compared with the wild type allele COMT-Val (also named F


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Journal of Agricultural and Food Chemistry COMT-G) in in vitro studies.73 Thus, polymorphisms such as the COMT Val158Met might result in modified flavanol Omethylation relative to other forms of the enzyme. Although there are no studies addressing this issue specifically for cocoa flavanols, studies have investigated the effect of COMT Val158Met polymorphism on flavanol absorption and metabolism following green tea consumption. In a cross-sectional analysis with 660 subjects, men possessing the low-activity genotype (COMT-AA) had lower urinary levels of five tea polyphenol metabolites, including epigallocatechin, O-methylepigallocatechin, EC, and valerolactones, relative to the other genotypes (COMT-GG and COMT-AG).74 In contrast, in an intervention study investigating the same polymorphism with 10 volunteers harboring allele COMT-A and 10 volunteers with the wild type allele COMT-G, no significant differences in the plasma catechin concentrations were observed between COMT groups following intake of a decaffeinated green tea extract,75 although significantly lower urinary levels of 4′-O-methylepigallocatechin during the first 5.5 h were reported in the COMT-AA group (lowest activity genotype).76 Further large-scale pharmacokinetics studies are warranted to expand these investigations along with studies designed to assess the impact of other polymorphic variants of phase II drug-metabolizing enzymes such as UGTs and SULTs.

Funding

M.E.A. thanks Fundación Alfonso Martı ́n Escudero for a postdoctoral fellowship. Notes

The authors declare no competing financial interest.

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ABBREVIATIONS USED ADME, absorption, metabolism, distribution, and excretion; AUC, area under the curve; Cmax, maximum concentration; EC, epicatechin; tmax, time to reach the maximum concentration

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SUMMARY AND FUTURE RESEARCH Current literature strongly supports the notion that the consumption of cocoa flavanols is causally related to benefits in the cardiovascular function. Importantly, the large majority of circulating flavanols are present in the form of their phase II metabolites, which are likely to mediate these effects. Despite their being a number of dietary intervention studies reporting the absorption, metabolism, and excretion of flavanols, only very few report the precise structures, profile, and quantification of flavanol metabolites in the systemic circulation in humans. Further research is required to conclude on the pharmacokinetic profiles of microbiota-derived catabolites, such as valerolactones and phenolic acids, and ultimately whether these may underpin biological activity in humans. The extent to which (−)-EC is absorbed/metabolized from cocoa depends on numerous factors. The food matrix influences flavanol bioavailability in different ways, with EC absorption from liquid food matrices occurring more rapidly than that observed for solid chocolate. The codelivery of flavanols in a carbohydrate matrix may also increase flavanol absorption. In contrast, lipids, proteins, and milk appear not to influence overall flavanol absorption, although milk may affect the metabolic profile of flavanol metabolites generated. Further investigation is also required to establish how intake level, common food-processing techniques, drugs, and genetic polymorphisms influence the absorption, metabolism, and excretion of cocoa flavanols in humans. Finally, the influence of age, sex, reproductive status, and/or dietary background on flavanol intake/health markers should be a focus of immediate future research. Such data will help to define a minimum amount of flavanols necessary to achieve population-based health benefits and thus contribute to the creation of flavanolspecific dietary guidelines and recommendations.

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*(J.P.E.S.) Phone: 004411837868724. Fax: 00441183788709. E-mail: [email protected]. G


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Factors Affecting the Absorption, Metabolism, and Excretion of Cocoa

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