Effects of cocoa extract and a multivitamin on cognitive function: A randomized clinical trial

Abstract

Introduction: Dietary supplements are touted for cognitive protection, but supporting evidence is mixed. COSMOS-Mind tested whether daily administration of cocoa extract (containing 500 mg/day flavanols) versus placebo and a commercial multivitamin-mineral (MVM) versus placebo improved cognition in older women and men.

Methods: COSMOS-Mind, a large randomized two-by-two factorial 3-year trial, assessed cognition by telephone at baseline and annually. The primary outcome was a global cognition composite formed from mean standardized (z) scores (relative to baseline) from individual tests, including the Telephone Interview of Cognitive Status, Word List and Story Recall, Oral Trail-Making, Verbal Fluency, Number Span, and Digit Ordering. Using intention-to-treat, the primary endpoint was change in this composite with 3 years of cocoa extract use. The pre-specified secondary endpoint was change in the composite with 3 years of MVM supplementation. Treatment effects were also examined for executive function and memory composite scores, and in pre-specified subgroups at higher risk for cognitive decline.

Results: A total of 2262 participants were enrolled (mean age = 73y; 60% women; 89% non-Hispanic White), and 92% completed the baseline and at least one annual assessment. Cocoa extract had no effect on global cognition (mean z-score = 0.03, 95% CI: -0.02 to 0.08; P = .28). Daily MVM supplementation, relative to placebo, resulted in a statistically significant benefit on global cognition (mean z = 0.07, 95% CI 0.02 to 0.12; P = .007), and this effect was most pronounced in participants with a history of cardiovascular disease (no history: 0.06, 95% CI 0.01 to 0.11; history: 0.14, 95% CI -0.02 to 0.31; interaction, nominal P = .01). Multivitamin-mineral benefits were also observed for memory and executive function. The cocoa extract by MVM group interaction was not significant for any of the cognitive composites.

Discussion: Cocoa extract did not benefit cognition. However, COSMOS-Mind provides the first evidence from a large, long-term, pragmatic trial to support the potential efficacy of a MVM to improve cognition in older adults. Additional work is needed to confirm these findings in a more diverse cohort and to identify mechanisms to account for MVM effects.

Highlights: COSMOS-Mind was a large simple pragmatic randomized clinical trial in older adults conducted by mail and telephone. The trial used a two-by-two factorial design to assess treatment effects of two different interventions within a single large study. We found no cognitive benefit of daily cocoa extract administration (containing 500 mg flavanols) for 3 years. Daily multivitamin-mineral (MVM) supplementation for 3 years improved global cognition, episodic memory, and executive function in older adults. The MVM benefit appeared to be greater for adults with cardiovascular disease.

Keywords: aging; clinical trial; cocoa extract; cognition; cognitive function; flavanols; multivitamin; older adults.

FIGURE 1.

Consort diagram showing flow of participants from first approach through randomization to each of the 4 treatment combinations in the two-by-two factorial design. Abbreviations: CE, cocoa extract; MVM, multivitamin-mineral.

FIGURE 2.

Three-year change in global cognition composite by assignment to (A) daily cocoa extract supplementation, and (B) daily multivitamin-mineral supplementation. Forest plot marginal differences by baseline subgroups for (C) cocoa extract and (D) multivitamin-mineral treatment groups.

FIGURE 2.

Three-year change in global cognition composite by assignment to (A) daily cocoa extract supplementation, and (B) daily multivitamin-mineral supplementation. Forest plot marginal differences by baseline subgroups for (C) cocoa extract and (D) multivitamin-mineral treatment groups.

FIGURE 3.

Three-year change in global cognition composite for the active and placebo multivitamin-mineral groups by history of cardiovascular disease, which was based on self-report of transient ischemic attack, congestive heart failure, coronary artery bypass graft, angioplasty, or stent. Plotted values are mean standardized (z) scores (relative to baseline) with 95% confidence intervals.

FIGURE 4.

Three-year change in the episodic memory composite (A) and executive function composite (B) for the active and placebo multivitamin-mineral groups.