Effects of daily multivitamin–multimineral and cocoa extract supplementation on epigenetic aging clocks in the COSMOS randomized clinical trial

Wu, Z., Zhang, W., Qu, J. & Liu, G. H. Emerging epigenetic insights into aging mechanisms and interventions. Trends Pharmacol. Sci. 45, 157–172 (2024).
Google Scholar
Kennedy, B. K. et al. Geroscience: linking aging to chronic disease. Cell 159, 709–713 (2014).
Google Scholar
Campisi, J. et al. From discoveries in ageing research to therapeutics for healthy ageing. Nature 571, 183–192 (2019).
Google Scholar
Sandalova, E. & Maier, A. B. Targeting the epigenetically older individuals for geroprotective trials: the use of DNA methylation clocks. Biogerontology 25, 423–431 (2024).
Google Scholar
Moqri, M. et al. Biomarkers of aging for the identification and evaluation of longevity interventions. Cell 186, 3758–3775 (2023).
Google Scholar
Passarelli, S. et al. Global estimation of dietary micronutrient inadequacies: a modelling analysis. Lancet Glob. Health. 12, e1590–e1599 (2024).
Google Scholar
Rautiainen, S., Manson, J. E., Lichtenstein, A. H. & Sesso, H. D. Dietary supplements and disease prevention – a global overview. Nat. Rev. Endocrinol. 12, 407–420 (2016).
Google Scholar
Yetley, E. A. Multivitamin and multimineral dietary supplements: definitions, characterization, bioavailability, and drug interactions. Am. J. Clin. Nutr. 85, 269s–276s (2007).
Google Scholar
Gaziano, J. M. et al. Multivitamins in the prevention of cancer in men: the Physicians’ Health Study II randomized controlled trial. JAMA 308, 1871–1880 (2012).
Google Scholar
Christen, W. G. et al. Effects of multivitamin supplement on cataract and age-related macular degeneration in a randomized trial of male physicians. Ophthalmology 121, 525–534 (2014).
Google Scholar
Baker, L. D. et al. Effects of cocoa extract and a multivitamin on cognitive function: a randomized clinical trial. Alzheimers Dement. 19, 1308–1319 (2023).
Google Scholar
Sachs, B. C. et al. Impact of multivitamin–mineral and cocoa extract on incidence of mild cognitive impairment and dementia: results from the COcoa Supplement and Multivitamin Outcomes Study for the Mind (COSMOS-Mind). Alzheimers Dement. 19, 4863–4871 (2023).
Google Scholar
Yeung, L. K. et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am. J. Clin. Nutr. 118, 273–282 (2023).
Google Scholar
Vyas, C. M. et al. Effect of multivitamin–mineral supplementation versus placebo on cognitive function: results from the clinic subcohort of the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial and meta-analysis of 3 cognitive studies within COSMOS. Am. J. Clin. Nutr. 119, 692–701 (2024).
Google Scholar
Sesso, H. D. et al. Multivitamins in the prevention of cancer and cardiovascular disease: the COcoa Supplement and Multivitamin Outcomes Study (COSMOS) randomized clinical trial. Am. J. Clin. Nutr. 115, 1501–1510 (2022).
Google Scholar
Sae-Lee, C. et al. Dietary intervention modifies DNA methylation age assessed by the epigenetic clock. Mol. Nutr. Food Res. 62, e1800092 (2018).
Google Scholar
Obeid, R., Hübner, U., Bodis, M., Graeber, S. & Geisel, J. Effect of adding B-vitamins to vitamin D and calcium supplementation on CpG methylation of epigenetic aging markers. Nutr. Metab. Cardiovasc. Dis. 28, 411–417 (2018).
Google Scholar
Michels, K. B. & Binder, A. M. Impact of folic acid supplementation on the epigenetic profile in healthy unfortified individuals – a randomized intervention trial. Epigenetics 19, 2293410 (2024).
Google Scholar
Chen, L. et al. Effects of vitamin D3 supplementation on epigenetic aging in overweight and obese African Americans with suboptimal vitamin D status: a randomized clinical trial. J. Gerontol. A Biol. Sci. Med. Sci. 74, 91–98 (2019).
Google Scholar
McGee, K. C. et al. A combination nutritional supplement reduces DNA methylation age only in older adults with a raised epigenetic age. Geroscience 46, 4333–4347 (2024).
Google Scholar
García-García, I. et al. Examining nutrition strategies to influence DNA methylation and epigenetic clocks: a systematic review of clinical trials. Front. Aging 5, 1417625 (2024).
Google Scholar
Martin, M. Á & Ramos, S. Impact of cocoa flavanols on human health. Food Chem. Toxicol. 151, 112121 (2021).
Google Scholar
Sesso, H. D. et al. 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. 115, 1490–1500 (2022).
Google Scholar
Brickman, A. M. et al. Dietary flavanols restore hippocampal-dependent memory in older adults with lower diet quality and lower habitual flavanol consumption. Proc. Natl Acad. Sci. USA 120, e2216932120 (2023).
Google Scholar
Fang, M. Z. et al. Tea polyphenol (−)-epigallocatechin-3-gallate inhibits DNA methyltransferase and reactivates methylation-silenced genes in cancer cell lines. Cancer Res. 63, 7563–7570 (2003).
Google Scholar
Rist, P. M. et al. Design and baseline characteristics of participants in the COcoa Supplement and Multivitamin Outcomes Study (COSMOS). Contemp. Clin. Trials 116, 106728 (2022).
Google Scholar
Horvath, S. DNA methylation age of human tissues and cell types. Genome Biol. 14, R115 (2013).
Google Scholar
Hannum, G. et al. Genome-wide methylation profiles reveal quantitative views of human aging rates. Mol. Cell 49, 359–367 (2013).
Google Scholar
Levine, M. E. et al. An epigenetic biomarker of aging for lifespan and healthspan. Aging (Albany NY) 10, 573–591 (2018).
Google Scholar
Lu, A. T. et al. DNA methylation GrimAge strongly predicts lifespan and healthspan. Aging (Albany NY) 11, 303–327 (2019).
Google Scholar
Belsky, D. W. et al. DunedinPACE, a DNA methylation biomarker of the pace of aging. Elife 11, e73420 (2022).
Google Scholar
Faul, J. D. et al. Epigenetic-based age acceleration in a representative sample of older Americans: associations with aging-related morbidity and mortality. Proc. Natl Acad. Sci. USA 120, e2215840120 (2023).
Google Scholar
Higgins-Chen, A. T. et al. A computational solution for bolstering reliability of epigenetic clocks: implications for clinical trials and longitudinal tracking. Nat. Aging 2, 644–661 (2022).
Google Scholar
Christopher, C. et al. Effects of randomized multivitamin supplementation on carotenoids and alpha-tocopherol in the COSMOS trial. J. Acad. Nutr. Diet. https://doi.org/10.1016/j.jand.2026.156299 (2026).
Baker, L. D. et al. Design and baseline characteristics of the cocoa supplement and multivitamin outcomes study for the mind: COSMOS-Mind. Contemp. Clin. Trials 83, 57–63 (2019).
Google Scholar
Li, S. et al. Effects of 2-year cocoa extract supplementation on inflammaging biomarkers in older US adults: findings from the COcoa Supplement and Multivitamin Outcomes Study randomised clinical trial. Age Aging 54, afaf269 (2025).
Chervova, O. et al. Breaking new ground on human health and well-being with epigenetic clocks: a systematic review and meta-analysis of epigenetic age acceleration associations. Ageing Res. Rev. 102, 102552 (2024).
Google Scholar
O’Connor, E. A. et al. Vitamin and mineral supplements for the primary prevention of cardiovascular disease and cancer: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 327, 2334–2347 (2022).
Google Scholar
Loftfield, E. et al. Multivitamin use and mortality risk in 3 prospective US cohorts. JAMA Netw. Open 7, e2418729 (2024).
Google Scholar
Lopez-Otin, C., Blasco, M. A., Partridge, L., Serrano, M. & Kroemer, G. Hallmarks of aging: an expanding universe. Cell 186, 243–278 (2023).
Google Scholar
Xu, Q. et al. Multivitamin use and telomere length in women. Am. J. Clin. Nutr. 89, 1857–1863 (2009).
Google Scholar
Scott, A. J., Ellison, M. & Sinclair, D. A. The economic value of targeting aging. Nat. Aging 1, 616–623 (2021).
Google Scholar
Gensous, N. et al. One-year Mediterranean diet promotes epigenetic rejuvenation with country- and sex-specific effects: a pilot study from the NU-AGE project. Geroscience 42, 687–701 (2020).
Google Scholar
Oblak, L., van der Zaag, J., Higgins-Chen, A. T., Levine, M. E. & Boks, M. P. A systematic review of biological, social and environmental factors associated with epigenetic clock acceleration. Ageing Res. Rev. 69, 101348 (2021).
Google Scholar
Horvath, S. & Raj, K. DNA methylation-based biomarkers and the epigenetic clock theory of ageing. Nat. Rev. Genet. 19, 371–384 (2018).
Google Scholar
Yusipov, I., Kalyakulina, A., Trukhanov, A., Franceschi, C. & Ivanchenko, M. Map of epigenetic age acceleration: a worldwide analysis. Ageing Res. Rev. 100, 102418 (2024).
Google Scholar
Sehgal, R. et al. DNAm aging biomarkers are responsive: insights from 51 longevity interventional studies in humans. Preprint at bioRxiv https://doi.org/10.1101/2024.10.22.619522 (2024).
Borrus, D. S. et al. When to trust epigenetic clocks: avoiding false positives in aging interventions. Preprint at bioRxiv https://doi.org/10.1101/2024.10.22.619720 (2024).
Waziry, R. et al. Effect of long-term caloric restriction on DNA methylation measures of biological aging in healthy adults from the CALERIE trial. Nat. Aging 3, 248–257 (2023).
Google Scholar
Marioni, R. E. et al. Tracking the epigenetic clock across the human life course: a meta-analysis of longitudinal cohort data. J. Gerontol. A Biol. Sci. Med. Sci. 74, 57–61 (2019).
Google Scholar
Bischoff-Ferrari, H. A. et al. Individual and additive effects of vitamin D, omega-3 and exercise on DNA methylation clocks of biological aging in older adults from the DO-HEALTH trial. Nat. Aging 5, 376–385 (2025).
Google Scholar
Ellinger, S. & Stehle, P. Impact of cocoa consumption on inflammation processes – a critical review of randomized controlled trials. Nutrients 8, 321 (2016).
Google Scholar
Milenkovic, D. et al. Flavanol consumption in healthy men preserves integrity of immunological–endothelial barrier cell functions: nutri(epi)genomic analysis. Mol. Nutr. Food Res. 66, e2100991 (2022).
Google Scholar
Crescenti, A. et al. Cocoa consumption alters the global DNA methylation of peripheral leukocytes in humans with cardiovascular disease risk factors: a randomized controlled trial. PLoS ONE 8, e65744 (2013).
Google Scholar
Krolevets, M. et al. DNA methylation and cardiovascular disease in humans: a systematic review and database of known CpG methylation sites. Clin. Epigenetics 15, 56 (2023).
Google Scholar
Bell, C. G. et al. DNA methylation aging clocks: challenges and recommendations. Genome Biol. 20, 249 (2019).
Google Scholar
Bernabeu, E. et al. Refining epigenetic prediction of chronological and biological age. Genome Med. 15, 12 (2023).
Google Scholar
Sehgal, R. et al. Systems Age: a single blood methylation test to quantify aging heterogeneity across 11 physiological systems. Nat. Aging 5, 1880–1896 (2025).
Google Scholar
Bassuk, S. S. et al. Baseline characteristics of participants in the VITamin D and OmegA-3 TriaL (VITAL). Contemp. Clin. Trials 47, 235–243 (2016).
Google Scholar
Zhou, W., Triche, T. J. Jr., Laird, P. W. & Shen, H. SeSAMe: reducing artifactual detection of DNA methylation by Infinium BeadChips in genomic deletions. Nucleic Acids Res. 46, e123 (2018).
Google Scholar
Aryee, M. J. et al. Minfi: a flexible and comprehensive Bioconductor package for the analysis of Infinium DNA methylation microarrays. Bioinformatics 30, 1363–1369 (2014).
Google Scholar
Tian, Y. et al. ChAMP: updated methylation analysis pipeline for Illumina BeadChips. Bioinformatics 33, 3982–3984 (2017).
Google Scholar
Johnson, W. E., Li, C. & Rabinovic, A. Adjusting batch effects in microarray expression data using empirical Bayes methods. Biostatistics 8, 118–127 (2007).
Google Scholar
McCullough, M. L. et al. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance123. Am. J. Clin. Nutr. 76, 1261–1271 (2002).
Google Scholar
Steen, J., Loeys, T., Moerkerke, B. & Vansteelandt, S. medflex: an R package for flexible mediation analysis using natural effect models. J. Stat. Softw. 76, 1–46 (2017).
Chen, B. H. et al. DNA methylation-based measures of biological age: meta-analysis predicting time to death. Aging (Albany NY) 8, 1844–1865 (2016).
Google Scholar
Fahy, G. M. et al. Reversal of epigenetic aging and immunosenescent trends in humans. Aging Cell 18, e13028 (2019).
Google Scholar
Levine, M. E. Assessment of epigenetic clocks as biomarkers of aging in basic and population research. J. Gerontol. A Biol. Sci. Med. Sci. 75, 463–465 (2020).
Google Scholar




