Research Original Research: Brief| Volume 121, ISSUE 2, P314-326.e4, February 2021

Chocolate Candy and Incident Invasive Cancer Risk in the Women’s Health Initiative: An Observational Prospective Analysis

Published:August 04, 2020DOI:



      Laboratory and animal studies suggest an inverse association between chocolate consumption and the risk of cancer. Epidemiological studies have yielded inconsistent evidence.


      To assess the association of chocolate candy consumption with incident, invasive total, breast, colorectal, and lung cancers in a large cohort of postmenopausal American women.


      Prospective cohort study with a mean 14.8-year follow-up. Chocolate candy intake was assessed by food frequency questionnaire. Invasive cancer events were assessed by physician adjudication.


      The Women’s Health Initiative Study enrolled 161,808 postmenopausal women at 40 clinical centers nationwide between 1993 and 1998. Of these women, 114,281 with plausible food frequency or biometric data and no missing data on chocolate candy exposure were selected for analysis.

      Main outcome measures

      Cancer risk in quartiles of chocolate candy consumption with the first quartile as referent.

      Statistical analyses

      Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals.


      There were 16,164 documented incident invasive cancers, representing an incidence rate of 17.0 per 100 participants and 12.3 per 1000 person years during follow-up among participants without any preexisting cancers or missing outcome data. There were no statistically significant associations for total invasive cancer (P-linear = .47, P-curvature = .14), or invasive breast cancer (P-linear = .77, P-curvature = .26). For colorectal cancer P-linear was .02, P-curvature was .03, and compared with women eating a 1 oz (28.4 g) chocolate candy serving <1 time per month, the hazard ratio for ≥1.5 times/wk was 1.18 (95% confidence interval: 1.04-1.35). This result may be attributable to the excess adiposity associated with frequent chocolate candy consumption.


      In the Women’s Health Initiative, there was no significant association between chocolate candy consumption and invasive total or breast cancer. There was a modest 18% higher risk of invasive colorectal cancer for women who ate chocolate candy at least 1.5 times/wk. These results require confirmation.


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      J. A. Greenberg is an emeritus professor, Department of Health and Nutrition Sciences, Brooklyn College of the City University of New York, Brooklyn.


      M. L. Neuhouser is the program head and, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.


      L. F. Tinker is a nutrition scientist, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.


      D. S. Lane is a distinguished service professor and vice chair, Department of Family, Population and Preventive Medicine, School of Medicine, Stony Brook University, Stony Brook, NY.


      E. D. Paskett is a Marion N. Rowley professor of cancer research, Department of Internal Medicine, Division of Cancer Prevention and Control, College of Medicine, Comprehensive Cancer Center, Ohio State University, Columbus, OH.


      S. Sealy-Jefferson is an assistant professor, Division of Epidemiology, College of Public Health, both at Ohio State University, Columbus, OH.


      L. V. Van Horn is the chief of nutrition, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.


      S. Wassertheil-Smoller is a distinguished university professor emerita, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.


      J. M. Shikany is an endowed professor of cardiovascular disease and associate director for research, Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham. , Boston, MA


      L. Qi is a professor, Department of Public Health Sciences, School of Medicine, University of California Davis. , Boston, MA


      J. E. Manson is a professor, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA