Effect of VLCD on the Reduction of Liver Steatosis and Fibrosis in Subjects With Obesity and NAFLD
Effect of VLCD on the Reduction of Liver Steatosis and Fibrosis in Subjects With Obesity and NAFLD
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.
 It is hypothesized that VLCD reduce liver steatosis and fibrosis measured non-invasively with
 transient elastography. The main aim is #1 to assess the effect of VLCD on liver fatty
 infiltration and fibrosis. There are also two 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 and #3 assess the effect of VLCD on
 changes of salivary and fecal microbiome in the setting of NAFLD. This pilot project will
 produce preliminary data for the development of a larger grant application to study the
 efficacy of VLCD and a physical activity intervention in the management of NAFLD.
 Furthermore, it will potentially identify factors that mediate improvement of NAFLD after
 VLCD. Twenty to 25 subjects with obesity and NAFLD will be treated for 8 weeks with a
 physical activity intervention and VLCD and obtain transient elastography before and after
 the interventions along with other measurements of interest. Of note, there will not be a
 control parallel group because of funding limitation. This 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 design: The investigators plan to perform a non-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. The investigators do not plan to include a parallel control
 group because the main objective of this budget-limited pilot clinical trial is to collect
 preliminary data for a larger grant proposal. Data prior to VLCD intervention will serve as
 control for each subject. Hereby, it is hypothesized that VLCD reduces liver steatosis and
 fibrosis.

 Study Subjects: Potential adult participants with obesity [age ≥ 21 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 sex-specific abnormal ALT
 (female ≥ 32 U/L; male ≥ 41 U/L), but less than 100 U/L, with negative tests for viral
 hepatitis C and autoimmune hepatitis, and elastography results positive for fibrosis grade F2
 through F4 (that is, LSM between 6 and 124 kPa) and/or steatosis grade S1 through S3 (that
 is, CAP ≥ 248 dB/m) within the last 6 months. The above tests, along with complete blood
 count (CBC), basic metabolic profile (BMP), TSH with reflex free T4 and 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 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:

 Visit #1 (enrolment visit): Subjects who meet the above criteria will be invited for visit #1
 at UIHC Clinical Research Unit. Subjects will fast for 12 hours for visit #1. 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) and miR will also be drawn during
 visit #1. 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 physical activity interventions
 during visit #1. The research manager will dispense 2-week worth of Optifast® replacement
 meals, a Fitbit device and a wireless scale.

 Visit #2: At the end of week #3, the participant will return to the UIHC Clinical Research
 Unit, when vital signs will be assessed and blood samples for laboratory tests will be drawn
 (table 1). On visit #2, sodium, potassium and creatinine will be assessed. Participants will
 complete of an adverse event questionnaire. Very low-calorie diets will be dispensed at visit
 #2.

 Visit #3: At the end of week #5, the participant will return to the UIHC Clinical Research
 Unit, when vital signs will be assessed and blood samples for laboratory tests will be drawn
 (table 1). On visit #3, 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 visit #3.

 Visit #4 (closing visit): At the end of week #9, the participant will return to the UIHC
 Clinical Research Unit for visit #4. Subjects will fast 12 hours for visit #4 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 instructed 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 and 2
 months after termination of the study.

 Telephone and/or video-call contacts: Between visits #1 and #4, the research manager will
 contact the participant by telephone or video-call on a weekly basis for diet and physical
 activity compliance, and assessment of adherence, response and adverse events of VLCD for 8
 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 2 months. 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 Clinical
 Research Unit on weeks #1, #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).

 Exercise intervention: Participants will be provided a Fitbit activity monitor (Inspire 2) to
 wear on the wrist each day throughout the 8-week VLCD intervention. Participants will also
 receive access to the Fitbit mobile app. Participants will be encouraged to wear their Fitbit
 24 hours/day for a 7-day period (baseline). Participants will then connect with a health
 coach via Zoom. During this conversation, participants will: 1) establish a daily walking
 goal with the intent of meeting the physical activity guidelines (150 minutes/week of
 moderate intensity physical activity); 2) identify and problem solve barriers that are
 preventing them from being active; 3) establish an action plan for meeting their walking
 goal. Participants will be encouraged to self-monitor their progress towards their daily
 goals by accessing the dashboard on the Fitbit app each day. Participants will also be
 invited to a private social network through the Fitbit app. In the social group, participants
 will receive educational/motivational on the benefits of physical activity and tips for
 becoming more active. Finally, participants will be invited to participate in regular walking
 games and challenges through the Fitbit app to help them meet their walking goal.

 The investigators will objectively measure physical activity (steps, time spent engaged in
 sedentary, light-intensity, moderate-intensity, and vigorous-intensity activity) on a daily
 frequency. The Fitbit Inspire 2 is a small tri-axial accelerometer-based activity monitor.
 Fitbits have been demonstrated as an accurate measure of daily steps (overall mean error =
 -9%), time spent sedentary (overall mean error = <10%), energy expenditure (overall mean
 error = +4%) in free living conditions when compared to accelerometers which are considered
 gold standard field measures of physical activity. The investigators will track user's daily
 physical activity throughout the 8 weeks through the Fitbit website. Participants will be
 encouraged to wear the Fitbit monitor 24 hours/day throughout the 8-week intervention
 including sleep time. Participants should remove the monitor only to charge it and during
 swimming/bathing when the monitor will be submerged in water. Participants will need to
 create a Fitbit profile and share their username and password with our team so that we can
 download their physical activity data through the Fitbit website. Compliance with the
 intervention (days met walking goal) will also be measured with the Fitbit activity monitor.
Inclusion Criteria:

 1. Male and female subjects with age ≥ 21 years old and < 70 years old.

 2. BMI ≥ 30 kg/m2 and ≤ 50 kg/m2

 3. Abnormal sex-specific ALT (female ≥ 32 U/L; male ≥ 41 U/L), but less than 100 U/L
 within the last 3 months

 4. Negative tests for viral hepatitis C (hepatitis C antibody) and autoimmune hepatitis
 (anti-smooth muscle antibody)

 5. Elastography result positive for fibrosis grade F2 through F4 (that is, LSM between 8
 and 124 kPa) and/or steatosis grade S1 through S3 (that is, CAP ≥ 248 dB/m) within the
 last 3 months

 Exclusion Criteria:

 1. Type 1 diabetes mellitus

 2. Subjects with type 2 diabetes mellitus who use insulin

 3. Heart failure NYHA stage 3 or 4

 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

 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 medicines for weight loss within last 3 months

 19. Use of warfarin, lithium, chronic use of prednisone (20mg or more daily)