COcoa Supplement and Multivitamin Outcomes Study (COSMOS)

The purpose of this study is to determine whether taking daily, dietary supplements of cocoa extract (containing cocoa flavanols and theobromine from the cocoa bean) and/or a standard multivitamin reduces the risk of developing cardiovascular disease (including heart attack, stroke, coronary revascularization, unstable angina or acute coronary syndrome (ACS) requiring hospitalization, carotid artery surgery, and peripheral artery surgery or angioplasty, and cardiovascular mortality) and cancer.

Study Overview

• Status: Active, not recruiting
• Conditions: Cardiovascular Disease; Cancer
• Intervention / Treatment: Dietary supplement: Multivitamin; Dietary supplement: Multivitamin placebo; Dietary supplement: Cocoa extract; Dietary supplement: Cocoa extract placebo

Detailed Description

The COcoa Supplement and Multivitamin Outcomes Study (COSMOS) is a randomized clinical trial of cocoa extract supplement (containing a total of 600 mg/d cocoa flavanols, including 80 mg. (-)-epicatechins), and a standard multivitamin supplement to reduce the risk of cardiovascular disease and cancer among women aged 65 years and older and men aged 60 years and older.

After the COSMOS trial began, an advanced method to analyze cocoa flavanols was accredited by AOAC International as a First Action Official Method of Analysis (https://doi.org/10.1093/jaoacint/qsaa132). This updated method relies on a reference material (RM8403) recently standardized and made commercially available by the U.S. National Institute of Standards and Technology. While the actual cocoa flavanol content of the COSMOS intervention remained unchanged throughout the trial, the application of this new analytical method led to expected changes in how the total cocoa flavanol content is now reported. Applying AOAC 2020.05/RM8403 to the COSMOS intervention, the total cocoa flavanol content of the COSMOS intervention is now 500 mg/day. Reporting of (-)-epicatechin content remained unaffected. Going forward, we will therefore apply AOAC 2020.05/RM8403 and report that the COSMOS intervention tested 500 mg/day of cocoa flavanols, including 80 mg of (-)-epicatechin.

Participants in COSMOS were recruited from among Women's Health Initiative (WHI) Extension Study cohort members; non-randomized respondents to mailings for the VITamin D and OmegA-3 TriaL (VITAL); respondents to nationwide invitational mailings to age-eligible adults; and volunteers who learned about the trial through the media or through ResearchMatch.org, an electronic recruitment website.

Several small randomized trials have demonstrated benefits for cocoa flavanols on intermediate outcomes, including blood pressure, lipids, insulin sensitivity, and flow-mediated vasodilation. For multivitamins, a prior large-scale randomized trial in middle-aged and older men showed a significant reduction in cancer, but comparable trial data in women are lacking. For both interventions, a large-scale clinical trial such as COSMOS could have major clinical and public health implications.

Eligible participants have been assigned by chance (like a coin toss) to one of four groups: (1) daily cocoa extract and multivitamin; (2) daily cocoa extract and multivitamin placebo; (3) daily cocoa extract placebo and multivitamin; or (4) daily cocoa extract placebo and multivitamin placebo. Participants have an equal chance of being assigned to any of these four groups and a 3 out of 4 chance of receiving at least one active agent.

Participants in all groups take three pills each day: two capsules that contain either cocoa extract or cocoa extract placebo, and one tablet that contains either multivitamin or multivitamin placebo. Participants receive their study pills in convenient calendar packs via U.S. mail.

Participants are asked to complete mailed questionnaires each year. The questionnaires ask about health; lifestyle habits, such as diet, physical activity, and smoking; use of medications and dietary supplements; family history of illness and new medical diagnoses. Occasionally, participants may receive a phone call from study staff to collect information or clarify responses on the questionnaires.

The expected rates for our original primary composite cardiovascular disease (CVD) endpoint were based on the projected age and sex distribution of the trial cohort and CVD event rates from our previously conducted trials. However, we determined that the observed rates of CVD endpoints among COSMOS participants were lower than expected due to a younger population of women, increasing use of statins and other pharmacotherapies as seen in other recently published clinical trials, and the impact of COVID-19 on fewer reports of CVD diagnoses, hospitalizations, and procedures. As a result, the COSMOS Data and Safety Monitoring Board (DSMB) approved a proposal to add three new outcomes to our primary composite CVD endpoint: (1) unstable angina or acute coronary syndrome requiring hospitalization, (2) carotid artery surgery, and (3) peripheral artery surgery or angioplasty. These additional CVD outcomes are consistent with the atherosclerotic mechanisms underlying the postulated effects for the randomized interventions. COSMOS participants have already provided self-reports of these diagnoses since the start of the COSMOS trial that will be adjudicated via medical records. The original primary composite CVD endpoint will still be evaluated as a secondary outcome.

At baseline, approximately 7,000 COSMOS participants provided optional blood and urine samples, which will be used to determine whether the study agents significantly change biomarkers and other risk factors related to cardiovascular disease and cancer. Selected participants either have specimens collected through mailed specimen collection kits that are returned by the participant, or have blood, urine, blood pressure, and anthropometric measurements collected by technicians from Examination Management Services, Inc. (EMSI), a national clinical services provider. A subgroup of those who provide baseline specimens and measurements are asked to provide follow-up samples and measurements.

At baseline and year 2 of the trial, approximately 600 participants living within driving distance of Boston, Massachusetts provide additional measurements from in-clinic study visits at the Clinical and Translational Science Center (CTSC) of Brigham and Women's Hospital. These visits include cognitive function assessments, anthropometrics, physical function assessments, blood pressure and other measurements. The trial will assess whether the study agents significantly affect changes in these variables over time.

Primary Hypotheses:

1. A cocoa extract supplement will reduce the risk of major cardiovascular events, defined as a composite endpoint of myocardial infarction, stroke, cardiovascular mortality, coronary revascularization, unstable angina or ACS requiring hospitalization, carotid artery surgery, and peripheral artery surgery or angioplasty;
2. A daily multivitamin will reduce the risk of invasive cancer (excluding non-melanoma skin cancer).

Secondary Hypotheses:

1. Cocoa extract will reduce the risk of a composite endpoint of MI, stroke, cardiovascular mortality, and coronary revascularization;
2. Cocoa extract will reduce the risk of invasive cancer (excluding non-melanoma skin cancer);
3. A daily multivitamin will reduce the risk of major cardiovascular events;
4. Cocoa extract and/or a daily multivitamin will reduce the combined endpoint of major cardiovascular events plus all-cause mortality;
5. Cocoa extract and/or a daily multivitamin will reduce the risk of individual cardiovascular events, including myocardial infarction, stroke, cardiovascular mortality, coronary revascularization, unstable angina or ACS requiring hospitalization, carotid artery surgery, and peripheral artery surgery or angioplasty, and total mortality; plus site-specific cancers, including breast, colorectal, and lung cancer;
6. A daily multivitamin will reduce the risk of cancer among women and men with a history of cancer at baseline;
7. In a subset of equal numbers of female and male COSMOS respondents who provide baseline bloods, cocoa extract and/or a daily multivitamin will significantly change levels of blood flavonoids from baseline to 2 years of follow-up.

Tertiary Aim:

To assess whether the cocoa extract and/or a daily multivitamin exhibit synergistic effects on risk of major cardiovascular events or cancer, and if the effects vary by nutritional status or medication use.

Aims of Clinical and Translational Science Center (CTSC) Component:

To test whether the cocoa extract and/or a daily multivitamin has beneficial effects on:

1. Systolic and diastolic blood pressure;
2. Pulse wave velocity (PWV) and central blood pressure indices as measured by pulse wave analysis;
3. Cognitive function and memory;
4. Physical performance as assessed by balance tests, grip strength, timed chair stands, and walking speed,
5. Bone loss in the spine, hip and total body as assessed by bone-mineral density (BMD) and changes in body composition as assessed by dual x-ray absorpiometry (DXA);

• Study Type: Interventional
• Enrollment (Actual): 21442
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02215
      • Brigham and Women's Hospital
  • Washington
    • Seattle, Washington, United States, 98109
      • Fred Hutchinson Cancer Research Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 58 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Women ≥ 65 years of age participating in the Women's Health Initiative (WHI) Extension Study.
2. Men ≥ 60 years of age and women age ≥ 65 years of age who were contacted for but not randomized into the VITAL trial.
3. Other women ≥ 65 years of age and men aged ≥ 60 years of age who responded to targeted mass mailings and volunteers who learned about the trial through the media or through ResearchMatch.org, an electronic recruitment website.
4. Willing to participate, as evidenced by providing informed consent and completing all required baseline forms.

Exclusion Criteria:

1. History of myocardial infarction or stroke.
2. Diagnosed with invasive cancer other than non-melanoma skin cancer in the last 2 years prior to enrollment.
3. Any serious illness that would preclude participation and/or completion of the trial, including the diagnosis of kidney failure and current dialysis treatment.
4. Taking cocoa extract or multivitamin supplements and not willing to forego use during the trial.
5. Taking total supplemental vitamin D > 1,000 IU/day and not willing to forego use during the trial.
6. Taking total supplemental calcium > 1,200 mg/day and not willing to forego use during the trial.
7. Extreme sensitivity to caffeine.
8. Consume < 75% of the expected number of both types of supplements during the run-in phase.
9. Unable to communicate in English due to language barrier or mental incapacity.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: Double

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Cocoa extract + multivitamin	Dietary supplement: Multivitamin; Multivitamin; Dietary supplement: Cocoa extract; 2 capsules each day containing a total of 500 mg cocoa flavanols, including 80 mg (-)-epicatechin, and 50 mg theobromine
Active Comparator: Cocoa extract + multivitamin placebo	Dietary supplement: Multivitamin placebo; Multivitamin placebo; Dietary supplement: Cocoa extract; 2 capsules each day containing a total of 500 mg cocoa flavanols, including 80 mg (-)-epicatechin, and 50 mg theobromine
Active Comparator: Cocoa extract placebo + multivitamin	Dietary supplement: Multivitamin; Multivitamin; Dietary supplement: Cocoa extract placebo; Cocoa extract placebo
Placebo Comparator: Cocoa extract placebo + multivitamin placebo	Dietary supplement: Multivitamin placebo; Multivitamin placebo; Dietary supplement: Cocoa extract placebo; Cocoa extract placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cardiovascular disease (CVD) events	CVD events include myocardial infarction, stroke, cardiovascular deaths, coronary revascularization procedures, unstable angina or ACS requiring hospitalization, carotid artery surgery, and peripheral artery surgery or angioplasty. CVD events are confirmed by review of discharge summaries, ECG's, laboratory reports, test reports, radiology reports, surgical reports, medical records for reports of increased pain, use of medication to alleviate pain, and evidence of troponin leak, and death certificates.	5 years
Invasive cancer	Diagnoses of invasive cancer are confirmed by review of discharge summaries, pathology reports, operative reports, surgical reports, and diagnostic or treatment procedure reports, including both inpatient and outpatient procedures.	5 years

Secondary Outcome Measures

Outcome Measure	Time Frame
Stroke	5 years
Myocardial infarction	5 years
Composite endpoint of MI, stroke, cardiovascular mortality, and coronary revascularization	5 years
Combined primary endpoint of major cardiovascular events plus all-cause mortality	5 years
Cardiovascular mortality	5 years
Coronary revascularization	5 years
Unstable angina or ACS requiring hospitalization	5 years
Carotid artery surgery	5 years
Peripheral artery surgery or angioplasty	5 years
Total mortality	5 years
Breast cancer	5 years
Colorectal cancer	5 years
Lung cancer	5 years
Blood flavonoid levels	2 years

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Systolic and diastolic blood pressure		2 years
Pulse wave velocity and central blood pressure indices	Assessed by pulse wave analysis	2 years
Physical performance	Balance tests, grip strength, timed chair stands, walking speed	2 years
Bone mass density in hip, spine, and total body, and body composition	Assessed by dual x-ray absorptiometry	2 years
Body composition		2 years

Collaborators and Investigators

• Sponsor: Brigham and Women's Hospital
• Collaborators: Pfizer; Fred Hutchinson Cancer Center; Mars, Inc.
• Investigators: Principal Investigator: JoAnn E. Manson, MD, Brigham and Women's Hospital

Publications and helpful links

General Publications

• Sesso HD, Rist PM, Aragaki AK, Rautiainen S, Johnson LG, Friedenberg G, Copeland T, Clar A, Mora S, Moorthy MV, Sarkissian A, Wactawski-Wende J, Tinker LF, Carrick WR, Anderson GL, Manson JE; COSMOS Research Group. Multivitamins in the prevention of cancer and cardiovascular disease: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial. Am J Clin Nutr. 2022 Jun 7;115(6):1501-1510. doi: 10.1093/ajcn/nqac056.
• Sesso HD, Manson JE, Aragaki AK, Rist PM, Johnson LG, Friedenberg G, Copeland T, Clar A, Mora S, Moorthy MV, Sarkissian A, Carrick WR, Anderson GL; COSMOS Research Group. Effect of cocoa flavanol supplementation for the prevention of cardiovascular disease events: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial. Am J Clin Nutr. 2022 Jun 7;115(6):1490-1500. doi: 10.1093/ajcn/nqac055.
• Rist PM, Sesso HD, Johnson LG, Aragaki AK, Wang L, Rautiainen S, Hazra A, Tobias DK, LeBoff MS, Schroeter H, Friedenberg G, Copeland T, Clar A, Tinker LF, Hunt RP, Bassuk SS, Sarkissian A, Smith DC, Pereira E, Carrick WR, Wion ES, Schoenberg J, Anderson GL, Manson JE; COSMOS Research Group. Design and baseline characteristics of participants in the COcoa Supplement and Multivitamin Outcomes Study (COSMOS). Contemp Clin Trials. 2022 May;116:106728. doi: 10.1016/j.cct.2022.106728. Epub 2022 Mar 12.
• Baker LD, Rapp SR, Shumaker SA, Manson JE, Sesso HD, Gaussoin SA, Harris D, Caudle B, Pleasants D, Espeland MA; COSMOS-Mind Research Group. Design and baseline characteristics of the cocoa supplement and multivitamin outcomes study for the Mind: COSMOS-Mind. Contemp Clin Trials. 2019 Aug;83:57-63. doi: 10.1016/j.cct.2019.06.019. Epub 2019 Jul 2.

Helpful Links

• COSMOS Trial website

Study record dates

Study Major Dates

• Study Start (Actual): June 1, 2015
• Primary Completion (Actual): July 1, 2022
• Study Completion (Anticipated): September 30, 2023

Study Registration Dates

• First Submitted: April 17, 2015
• First Submitted That Met QC Criteria: April 17, 2015
• First Posted (Estimate): April 21, 2015

Study Record Updates

• Last Update Posted (Actual): July 13, 2022
• Last Update Submitted That Met QC Criteria: July 11, 2022
• Last Verified: July 1, 2022

More Information

Terms related to this study

• Keywords: Cocoa extract multivitamins cardiovascular disease cancer
• Additional Relevant MeSH Terms: Cardiovascular Diseases
• Other Study ID Numbers: 2014P002768