The COSMOS Study: A Review of Multivitamin, Cocoa Extract, and Biological Aging

Introduction

In the quest to understand how best to promote good health during ageing, large-scale clinical research plays a crucial role.

The COCOa Supplement and Multivitamin Outcomes Study (COSMOS) study represents a significant effort to scientifically evaluate the effects of daily supplements.

With a rigorous methodology and a large number of participants, the study has contributed new knowledge about how multivitamins and cocoa flavanols interact with different physiological systems in older individuals.

Study design: a methodological foundation

The study involved 21,442 participants, divided into men (≥60 years) and women (≥65 years), who at the start of the study were free of major medical conditions such as heart attack, stroke or newly diagnosed cancer.

The 2x2 factorial design was central to the reliability of the study. By randomly assigning participants into groups that either obtained cocoa extract (500 mg flavanols per day), multivitamin (Centrum Silver), a combination of both, or placebo, the researchers were able to isolate the effects of each intervention.

This setup is the gold standard in clinical research and minimizes the risk of external factors skewing the results.

Cocoa Extract and Inflammatory Markers

The main objective of the cocoa extract intervention was to evaluate its potential to reduce cardiovascular events.

However, the results showed no statistically assured reduction in primary outcome. Despite this, secondary analyzes have provided interesting indications.

Data have shown a lowering of hs-CRP - a protein that acts as a marker of systemic inflammation - as well as an increased concentration of IFN-γ.

These findings are particularly interesting as they suggest that cocoa flavanols may have a role in modulating inflammatory processes, so-called “inflammaging,” which is an area of great interest in gerontological research.

The effect of multivitamins on cognition

The role of the multivitamin in the COSMOS study has been linked primarily to cognitive health. Through follow-ups in the clinic subcohort and the COSMOS-MIND study, small but statistically significant improvements were observed in global cognition, memory functions, and executive ability.

Meta-analyses of these data have been described in the context of research as a cognitive effect corresponding to a reduced rate of cognitive aging.

However, it is important to emphasize that while the results are consistent across the substudies, the question remains as to how these effects translate into long-term clinical benefit for the individual individual.

Epigenetic Clocks: Biological Aging

One of the most high-profile reports from the COSMOS study, published in 2026, analyzed whether dietary supplements can affect biological aging as measured via DNA methylation.

The researchers used five established “epigenetic clocks,” including PCPhenoage and PCGrimage, to measure biological age.

The results indicated that daily intake of multivitamin slowed down the rate of biological aging in comparison with placebo.

Particularly noteworthy is that the effect was more pronounced in those participants who, at the start of the study, exhibited accelerated biological aging. In contrast, the cocoa extract showed no significant influence on these epigenetic markers.

Interpretation and clinical relevance

It is paramount to interpret these findings with scientific caution. The observed effects - whether relating to cognition or biological age markers - are moderate.

In clinical research, this means that the results provide an indication of physiological impact, but they do not constitute proof that these supplements prevent age-related disease conditions.

The researchers behind COSMOS emphasize that further, long-term studies are necessary to determine the clinical relevance of the small changes observed in the epigenetic and cognitive measures.

Summary

The COSMOS study represents a comprehensive contribution to our knowledge of dietary supplements and aging.

By using large-scale clinical trials and modern molecular biology analysis methods, the study has given us a more detailed picture of how multivitamins and cocoa flavanols interact with the body's systems.

While cocoa extract primarily shows potential in inflammatory modulation, multivitamins contribute knowledge around cognitive support and biological markers of age.

This research underscores the importance of maintaining a good nutritional status and to continue exploring how diet and supplementation can work as part of a long-term health strategy.

About Relivo

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Sources

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• Habiger et al. (2021). Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results from a Cluster-Randomized Controlled Trial (COSMOS). JAMDA.

• Hawkins et al. (2017). Cognitive and Self-Regulatory Mechanisms of Obesity Study (COSMOS). Contemporary Clinical Trials.

• Husebø et al. (2019). The Effect of a Multicomponent Intervention on Quality of Life in Residents of Nursing Homes: A Randomized Controlled Trial (COSMOS). JAMDA.

• Li et al. (2025). Effects of 2-year cocoa extract supplementation on inflammatory biomarkers in older US adults. Aged and Ageing.

• Li et al. (2023). Cocoa Extract Supplementation and Risk of Type 2 Diabetes: The Cocoa Supplement and Multivitamin Outcomes Study (COSMOS). Diabetes Care.

• Rist et al. (2022). Design and baseline characteristics of participants in the CoCOa Supplement and Multivitamin Outcomes Study (COSMOS). Contemporary Clinical Trials.

• Sesso et al. (2022). Multivitamins in the prevention of cancer and cardiovascular disease: the CoCoA Supplement and Multivitamin Outcomes Study (COSMOS). The American Journal of Clinical Nutrition.

• Vyas et al. (2023). Effect of cocoa extract supplementation on cognitive function: results from the clinical subcohort of the COSMOS trial. The American Journal of Clinical Nutrition.

• Sesso et al. (2026). Effects of daily multivitamin-multimineral and cocoa extract supplementation on epigenetic aging clocks in the COSMOS randomized clinical trial. Nature Medicine.