Effect of VLCD on the Reduction of Liver Steatosis and Fibrosis in Subjects With Obesity and NAFLD

Effect of Very Low-calorie Diet on the Reduction of Liver Steatosis and Fibrosis in Subjects With Obesity and Non-alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) is a common complication of obesity which can progress to deadly complications like end-stage liver disease and hepatocellular carcinoma. In the wake of the obesity epidemic, NAFLD is becoming the main etiology of liver transplantation in the US. Currently, there are no FDA approved pharmacological treatments for NAFLD. Weight loss through lifestyle modifications, pharmacotherapy and bariatric surgery can be effective strategies for the management of NAFLD. Even though substantial weight loss and improvement in NAFLD can be achieved with bariatric surgery, only a small proportion of patients with obesity undergo surgery. Very-low calorie diets (VLCD) are replacement meals manufactured to substitute natural foods and limited total intake of 800-960 kcal in divided meals. Very low-calorie diets can produce substantial weight loss of 10% over 2 to 3 months. We hypothesize that VLCD reduce liver steatosis and, fibrosis measured non-invasively with transient elastography. Our main aim is #1 to assess the effect of VLCD on liver fatty infiltration and fibrosis. We also have three exploratory aims exploring novel pathogenic factors that mediate the improvement of NAFLD by VLCD: #2 assess the effect of VLCD on micro RNAs (miRs) associated with pathophysiology of NAFLD: #3 assess the effect of VLCD on changes of salivary and fecal microbiome in the setting of NAFLD: #4 to determine the effect of VLCD on platelet function. This pilot project will produce preliminary data for the development of a larger grant application to study the efficacy of VLCD in the management of NAFLD. Furthermore, it will potentially identify factors that mediate improvement of NAFLD after VLCD. We will treat 10 subjects with obesity and NAFLD for 8 weeks with VLCD or lower calorie diet (control group) and obtain transient elastography before and after the interventions along with other measurements of interest. Our project may have significant impact by establishing VLCD as a clinically effective option for the improvement of liver steatosis and fibrosis in patients with obesity and NAFLD ineligible or without access to bariatric surgery.

Study Overview

• Status: Recruiting
• Conditions: NAFLD
• Intervention / Treatment: Dietary supplement: Dietary intervention with very low calorie diet (VLCD); Other: Control Arm

Detailed Description

Study design: The investigators plan to perform a controlled, non-randomized, open-label, pilot clinical trial to evaluate the effect of an 8-week VLCD intervention on NAFLD. The main variable of this study is the magnitude of liver steatosis and fibrosis assessed non-invasively by elastography. The investigators will compare these variables before and after the VLCD intervention. Hereby, it is hypothesized that VLCD reduces liver steatosis and fibrosis.

Study Subjects: Potential adult participants with obesity [age ≥ 18 years old; body mass index (BMI) ≥ 30 kg/m2 and ≤ 50 kg/m2] will be recruited at the Weight Management Clinic, at the Diabetes Center and at the Digestive Health Center, all at University of Iowa Health Care (UIHC). The investigators will invite potential participants with negative tests for viral hepatitis C and autoimmune hepatitis, and elastography results positive for fibrosis grade F0 through F4 and/or steatosis grade S1 through S3 within the last 6 months. The above tests, along with complete blood count (CBC), basic metabolic profile (BMP), thyroid stimulating hormone (TSH) with reflex free thyroxine (free T4) and hemoglobin A1c are routinely obtained as part of the standard of care at the recruitment clinics. Oral health status of these patients will be obtained from the available dental charts, if not, a dental examination will be performed. With Institutional Board Review (IRB) authorization, the investigators will interrogate the charts to verify whether subjects meet criteria for participation. Case managers will contact potential participants by telephone, electronic mail or letter.

Detailed sessions:

Week 0 Visit (enrolment visit): Subjects who meet the above criteria will be invited for week 0 visit at UIHC Preventive Intervention Center. Subjects will fast for 12 hours for week 0 visit. After signing informed consent, the inclusion/exclusion criteria will be reviewed again. Clinical history and physical exam will be charted from the last clinical note. Subjects will fill the AUDIT C, a screening questionnaire for alcohol consumption. Vitals signs (that is, seated and standing blood pressure and heart rate, ambient air pulse saturation of O2, weight, height, and neck and waist circumferences). Blood samples for sodium, potassium, creatinine, CBC, AST, ALT, triglycerides, glucose, insulin, A1c (table 1), miR, and platelets will also be drawn during week 0 visit. Female participants at reproductive age will be asked to provide urine sample for pregnancy test. Unstimulated saliva will be collected from the participants by asking them to spit into a collection tube. Supplies for stool collection with instructions for sample return will be provided for assessment of baseline fecal microbiome testing. Stools samples should be returned to the research center before VLCD initiation. The participant will also meet the research manager for education about the VLCD and lower calorie diet during week 0 visit. The research manager will dispense 2-week worth of Optifast® replacement meals.

Week 2 Visit: At the end of week 2, the participant who consumes VLCD, but not a lower calorie diet, will return to the UIHC Preventive Intervention Center, when vital signs will be assessed and blood samples for laboratory tests will be drawn (table 1). On week 2 visit, sodium, potassium and creatinine will be assessed. Participants will complete of an adverse event questionnaire. Very low-calorie diets will be dispensed at week 2 visit.

Week 4 Visit: At the end of week 4, the participant who consumes VLCD, but not a lower calorie diet, will return to the UIHC Preventive Intervention Center, when vital signs will be assessed and blood samples for laboratory tests will be drawn (table 1). On week 4 visit, sodium, potassium, creatinine, ALT, AST, and uric acid will be assessed. Participants will complete of an adverse event questionnaire. Very low-calorie diets will be dispensed at week 4 visit.

Week 8 Visit (closing visit): At the end of week 8, the participant who consumes VLCD or a lower calorie diet will return to the UIHC Preventive Intervention Center for week 8 visit. Subjects will fast 12 hours for week 8 visit when saliva and blood samples for sodium, potassium, creatinine, CBC, ALT, AST, triglycerides, glucose, insulin, A1c (table 1) and miR will be collected. The participant will be instructed to bring a stool sample for microbiome analysis using collection supplies dispensed beforehand. The post-VLCD elastography will be performed during the final visit. Participants will complete of an adverse event questionnaire. The participant will also meet the research manager and receive education about transitioning from VLCD to a low calorie, low fat diet during the closure visit. The participants will be recommended to weight themselves weekly after the VLCD intervention. The research manager will contact the participant by telephone or video-call to assess adherence to low calorie, low fat diet and to review the weight trajectory 1 month after termination of the study.

Telephone and/or video-call contacts: Between week 0 and 8 visits, the research manager will contact the participant by telephone or video-call on a weekly basis for diet compliance, and assessment of adherence, response and adverse events of VLCD or lower calorie diet for 8 weeks, and then for 4 weeks after termination of the diet. Therefore, the total time of participation in the study is 12 weeks.

Very low-calorie diet treatment: The VLCD program will last 8 weeks and then will be followed by a gradual re-introduction of food through the next 1 month. The only sources of nutrition during this phase are the Optifast® products providing up to 800 kcal per day. Two liters (67.63 fl oz) of water should also be consumed each day. Participants will receive Optifast® replacement meals at no cost. The replacement meals will be dispensed at the UIHC Preventive Intervention Center on weeks 0, 2, and 4. Participants will be instructed to use 5 replacement meals per day (800 kcal total) with 40% of calories as protein, 40% as carbohydrate, and 20% as fat (Ard, Lewis et al. 2019).

• Study Type: Interventional
• Enrollment (Estimated): 20
• Phase: Phase 1

Contacts and Locations

• Study Contact: Name: Marcelo L Correia, MD PhD; Phone Number: 1-319-541-4513; Email: marcelo-correia@uiowa.edu
• Study Contact Backup: Name: Constance R Shelsky, RN; Phone Number: 319-384-5058; Email: constance-shelsky@uiowa.edu

Study Locations

• United States
  • Iowa
    • Iowa City, Iowa, United States, 52242
      • Recruiting
      • University of Iowa Health Care
      • Contact: Marcelo L Correia; Phone Number: 319-541-4513; Email: marcelo-correia@uiowa.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 70 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion and Exclusion Criteria

The inclusion criteria for participation are as follows:

1. Male and female subjects with age ≥ 18 years old and < 70 years old.
2. BMI ≥ 30 kg/m2 and ≤ 50 kg/m2
3. Negative tests for viral hepatitis C (hepatitis C antibody) and autoimmune hepatitis (anti-smooth muscle antibody)
4. Evidence of liver steatosis on an image method such as ultrasound, CT scan or MRI, or subjects with elastography score F1 and above and/or S1 and above can be included

The exclusion criteria are as follows:

1. Type 1 diabetes mellitus
2. Subjects with type 2 diabetes mellitus who use insulin
3. Heart failure
4. Myocardial infarction within last 6 months
5. Unstable angina
6. Chronic kidney disease with eGFR ≤ 30 mL/min/1.73 m²
7. Chronic obstructive pulmonary disease requiring O2 supplementation
8. Coexisting liver disease or end-stage liver disease
9. Severe or uncontrolled mental health disease, including eating disorders
10. Gout
11. History of uric acid nephrolithiasis
12. Porphyria
13. Conception attempts, confirmed pregnancy or breast feeding
14. Past or active cholecystitis without cholecystectomy
15. Uncontrolled hyperthyroidism
16. Uncontrolled hypothyroidism with TSH ≥ 10 mcIU/mL
17. Excessive alcohol consumption (that is, an AUDIT-C score ≥ 4 for men and ≥ 3 for women)
18. Use of warfarin, lithium, chronic use of prednisone (20mg or more daily)
19. Subjects with no elastography in the previous 12 months will be excluded from the study
20. Subjects with F0 and S0 on elastography will be excluded

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Very Low Calorie Diet Arm; We plan to perform a controlled, non-randomized, open-label, pilot clinical trial to evaluate the effect of an 8-week VLCD intervention on NAFLD.	Dietary supplement: Dietary intervention with very low calorie diet (VLCD); The VLCD program will last 8 weeks. The only sources of nutrition during this phase are the Optifast® products providing up to 800 kcal per day. Two liters (67.63 fl oz) of water should also be consumed each day. Participants will be instructed to use 5 replacement meals per day (800 kcal total) with 40% of calories as protein, 40% as carbohydrate, and 20% as fat.; Other Names: VLCD Arm
Other: Control Arm; The control group will consume a lower calorie diet and will be instructed to reduce their usual intake of normally consumed foods by up to 500 kcal per day but no less than 1200 kcal per day.	Other: Control Arm; The control group will consume a lower calorie diet and will be instructed to reduce their usual intake of normally consumed foods by up to 500 kcal per day but no less than 1200 kcal per day.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Liver steatosis	The investigators will assess the effect of VLCD on liver steatosis using transient elastography. The elastography parameter of interest is the controlled attenuation parameter (CAP) reported as a continuous variable in decibel per meter (dB/m).	8 weeks
Liver fibrosis	The investigators will assess the effect of VLCD on liver fibrosis using transient elastography. The elastography parameter of interest is the liver stiffness measurement (LFM) reported as a continuous variable in kilopascal (kPa).	8 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Micro RNA (miRNA)	Assess the effect of VLCD therapy on micro RNAs expressed as percent change or fold change associated with the pathophysiology of NAFLD.	8 weeks
Fecal microbiome	Assess the effect of VLCD therapy on qualitative and percent changes of fecal microbiome species in the setting of NAFLD	8 weeks
Salivary microbiome	Determine the effect of VLCD therapy on qualitative and percent changes of salivary microbiome species in the setting of NAFLD	8 weeks
Platelet function	Assess the effect of VLCD therapy on platelet function in patients with obesity and NAFLD. Specifically, we will study platelet aggregation in response to diverse platelet activators (collagen, CRP, TRAP, ADP), and clot retraction in response to thrombin.	8 weeks

Collaborators and Investigators

• Sponsor: University of Iowa
• Investigators: Principal Investigator: Marcelo L Correia, MD PhD, University of Iowa

Publications and helpful links

General Publications

• Ard JD, Lewis KH, Rothberg A, Auriemma A, Coburn SL, Cohen SS, Loper J, Matarese L, Pories WJ, Periman S. Effectiveness of a Total Meal Replacement Program (OPTIFAST Program) on Weight Loss: Results from the OPTIWIN Study. Obesity (Silver Spring). 2019 Jan;27(1):22-29. doi: 10.1002/oby.22303. Epub 2018 Nov 13.
• Bajaj JS, Betrapally NS, Hylemon PB, Heuman DM, Daita K, White MB, Unser A, Thacker LR, Sanyal AJ, Kang DJ, Sikaroodi M, Gillevet PM. Salivary microbiota reflects changes in gut microbiota in cirrhosis with hepatic encephalopathy. Hepatology. 2015 Oct;62(4):1260-71. doi: 10.1002/hep.27819. Epub 2015 May 6.
• Lin WY, Wu CH, Chu NF, Chang CJ. Efficacy and safety of very-low-calorie diet in Taiwanese: a multicenter randomized, controlled trial. Nutrition. 2009 Nov-Dec;25(11-12):1129-36. doi: 10.1016/j.nut.2009.02.008. Epub 2009 Jul 9.
• Mikolasevic I, Orlic L, Franjic N, Hauser G, Stimac D, Milic S. Transient elastography (FibroScan((R))) with controlled attenuation parameter in the assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease - Where do we stand? World J Gastroenterol. 2016 Aug 28;22(32):7236-51. doi: 10.3748/wjg.v22.i32.7236.
• Acharya C, Sahingur SE, Bajaj JS. Microbiota, cirrhosis, and the emerging oral-gut-liver axis. JCI Insight. 2017 Oct 5;2(19):e94416. doi: 10.1172/jci.insight.94416.
• Gjorgjieva M, Sobolewski C, Dolicka D, Correia de Sousa M, Foti M. miRNAs and NAFLD: from pathophysiology to therapy. Gut. 2019 Nov;68(11):2065-2079. doi: 10.1136/gutjnl-2018-318146. Epub 2019 Jul 12.
• Anfossi G, Russo I, Trovati M. Platelet dysfunction in central obesity. Nutr Metab Cardiovasc Dis. 2009 Jul;19(6):440-9. doi: 10.1016/j.numecd.2009.01.006. Epub 2009 Apr 5.

Study record dates

Study Major Dates

• Study Start (Actual): October 1, 2023
• Primary Completion (Estimated): December 1, 2024
• Study Completion (Estimated): December 1, 2025

Study Registration Dates

• First Submitted: April 21, 2021
• First Submitted That Met QC Criteria: April 25, 2021
• First Posted (Actual): April 27, 2021

Study Record Updates

• Last Update Posted (Estimated): December 18, 2023
• Last Update Submitted That Met QC Criteria: December 14, 2023
• Last Verified: December 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Liver Diseases; Fatty Liver
• Other Study ID Numbers: 202008444

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No