The Cocoa Supplement and Multivitamin Outcomes Study (COSMOS) was a five-year undertaking by scientists at the Brigham and Women’s Hospital in the US, with support from Mars Inc’s nutrition division, Mars Edge. It is noteworthy for both its scale and scope.
Building on a growing body of evidence pointing to the benefits of flavanols on cardiovascular markers like blood pressure, endothelial function and cholesterol levels, COSMOS was the first research to look at the hardest endpoint: deaths and hospitalisations. It is also the first time that a study of this size has been conducted on a bioactive, with a total of 21,442 participants. And the initial results are in.
Overall, participants in the group assigned to cocoa supplements saw 10% fewer total cardiovascular events, a level that is not considered statistically significant. However, CVD death was reduced by 27%.
“Pause for a second,” Mars Edge VP of R&D, Scientific and Regulatory Affairs Catherine Kwik-Uribe told FoodNavigator. “That's not only a statistically significant number, that's quite meaningful. If it could be translated across a population, that would be a lot fewer deaths attributable to cardiovascular disease.”
Indeed, CVDs are the leading cause of mortality globally. According to the World Health Organization, an estimated 17.9m people died of CVDs globally in 2019, accounting for 32% of global deaths.
Even this result could be downplaying the true potential of flavanols in the heart health space, Kwik-Uribe believes. If you strip out participants who said they didn’t comply with the supplementation regime, looking only at the results of people who reported taking their 500mg of cocoa flavanols a day, the figures are more compelling still. There was a 15% reduction in cardiovascular events and a 39% drop in cardiovascular deaths. Where the numbers might not be considered statistically significant, Kwik-Uribe stressed they all ‘point in the same direction’ – towards a positive correlation between flavanol consumption and reduced cardiovascular risk.
She describes this as ‘breath-taking’ both because of the potential impact on public health and the fact that the study was carried out on older adults. “The idea that you can have a positive impact on cardiovascular health after so many decades of life is pretty exciting for the field of nutrition and is pretty exciting for the field of flavanols as well.”
Moving towards dietary recommendations
Kwik-Uribe believes that the strength of this research, published last month in The American Journal of Clinical Nutrition, could help tip the balance on our understanding of the relationship between flavanols and cardiovascular health, paving the way for the introduction of national dietary recommendations.
“We are particularly excited because we think this fundamentally opens the door for the ability to make dietary recommendations around flavanols,” we were told. This could see recommended daily intakes suggested, comparable with the RDA of nutrients currently suggested for nutrients like Vitamin C or B12.
“There is increasing recognition that foods are more than a sum of the macronutrient and micronutrient parts. We are beginning to move towards recommendations around bioactives like flavanols. But you really do need studies of this size to be able to say they are having meaningful impact on health.”
Whether we are at a point where dietary recommendations can be made was a hot topic at the International Conference on Polyphenols and Health, a gathering of leading international experts in the field staged in London last month.
"That is what they were pondering: Is the totality of evidence now at a point where we can say ‘yes we should be recommending flavanols in a meaningful way’? Do we have an obligation now that the data is so robust that we should be talking about people consuming flavanols in their daily diet?”
The Chinese authorities already recommend consumption of the flavanol found in soy to support health. Similar backing from US and European health regulators is some way off. Kwik-Uribe estimates it will be ‘probably five plus years’ before we start to see further flavanol RDAs introduced to national dietary guidelines. However, she predicts that support from professional bodies like the American Heart Association or European Heart Network could be much closer – possibly 12-24 months away.
“Professional organisations make preventative recommendations already. If there is enough evidence to support recommendations [on flavanols], you might see them first emerge in these societies then eventually it translates to federal polices and guidelines,” she forecast.
Why do RDAs matter?
Flavonoids are naturally occurring polyphenolic compounds found in plant-based foods, including tea leaves, cocoa, grapes, wine, and chocolate. However, they are very sensitive to agricultural practices, storage practices, and cooking. The presence of flavanols is not something that is currently measured and labelled in the same way as vitamins or minerals. This means that, currently, if you wanted to take a food-first approach to upping your flavanol intake today, it basically boils down to guesswork.
The introduction of recommendations would see a ‘natural evolution’ towards measuring and labelling systems that are a vital bridge between the health benefits on offer and the end consumer, the Mars Edge nutrition expert suggested.
“If flavanols follow the course of other nutrients a recommendation triggers mechanisms so consumers can begin to make the connection between the recommendation and what they eat. There is a lot more work to be done but it begins with, first, recognition that flavanols are something we should be including in our diet. Then, how much? What does that mean? Which foods? Then labelling.
“You will see this evolution, but it will be anchored in first and foremost what is that recommended amount.”
Should we be eating more chocolate?
Did the iconic 1960s slogan for Mars’ namesake confectionery product ‘a Mars a day…’ foreshadow the outcome of this research? Could eating more chocolate – and therefore more cocoa flavanols – reduce cardiovascular risk?
The short answer is no.
“Chocolate is a lovely treat and cocoa does contain flavanols. But as much as we want to believe that story, we are not talking about the levels of flavanols that are going to have an impact on health. At the end of the day, enjoy your chocolate as a treat but if this research takes us to the point of recommendations we are going to be talking about it as it relates to a variety of foods, whether it is specific fruits, vegetables and grains or enriched and fortified products,” Kwik-Uribe said.
Mars Edge supplied the study with the cocoa extract that was used in the trial – and which is commercially available in the US under the CocoaVia brand. For the time being, supplementation remains the most effective way to increase and control your flavanol consumption, Kwik-Uribe advised.
“We've been commercialising CocoaVia for over a decade as a supplement. Why did we do a supplement? It was the idea of being able to get it into a regiment. Flavanols are something you need in your diet every day to obtain the benefits. Given the variabilities in the food supply and the lack of labelling, a supplement made more sense for us initially as an opportunity to provide a consistent amount.”
However, she continued, COSMOS opens the door to look at whether cocoa flavanol extracts can be used in different ways within the Mars portfolio.
“This is not our excuse to put out more chocolate. It is our opportunity to think about new vehicles for getting nutritious forms of flavanols in a variety of formats to consumers. We are having internal discussions about what those opportunity spaces could be. I would imagine an interesting pipeline of products in the next 12 or 24 months from a Mars perspective,” Kwik-Uribe revealed.
Tip of the iceberg for flavanols and health
The findings of the first COSMOS study are set to spur innovation across Mars’ range of products as the group’s innovation teams look at fresh formats for delivery. “In our food portfolio there is a nice opportunity to say where could these flavanols be added to diversify? There are definitely opportunities across the portfolio from pets to ordinary everyday foods where we could begin to see more flavanols appear,” Kwik-Uribe said.
She also hinted that this first publication from the COSMOS study is the tip of the iceberg when it comes to the health outcomes of flavanol consumption, which other research suggests can range from cognitive gains to microbiome benefits.
"COSMOS is a milestone moment, a landmark moment. But there is still much more to come. On cognition, we know that in the next couple of months there will be one of the first papers from a cognitive perspective to come out of COSMOS.
"Beyond that, we are going to have data on microbiome, we're going to have data on eye health, we are going to have data on kidney function. We don't know if flavanols will work in all of those areas but if they do it opens up new avenues for discussion around benefits and more research in this area.
"When you look at COSMOS it is the opening of a new chapter of research and opportunities for flavanols and health."
'Effect of cocoa flavanol supplementation for the prevention of cardiovascular disease events: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial'
The American Journal of Clinical Nutrition
Authors: Howard D Sesso, JoAnn E Manson, Aaron K Aragaki, Pamela M Rist, Lisa G Johnson, Georgina Friedenberg, Trisha Copeland, Allison Clar, Samia Mora, M Vinayaga Moorthy