Randomised Controlled Trial to Evaluate Impact of Energy Expenditure Information on the Outcome of Weight Loss During a Standardised Multicomponent Weight Management Intervention
Phase: NA
Conditions: Obesity, Severe Obesity, Sleep Apnoea
Sponsor: University of Liverpool

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Aintree University Hospital Research & Development 
ECAL Clinical Protocol 
A Randomized Controlled Trial to Evaluate Impact of Energy Expenditure Information 
from Indirect Calorimeter on the Outcome of Weight Loss during a Standardised 
Multicomponent Weight Management Intervention in Non-diabetic & Pre-diabetic 
Obese Subjects (ECAL) 
 
Original Protocol Submitted & Accepted Version 1.2 (Date: 24/07/2018) 
Protocol Amendment accepted Version 1.3 (Date: 28/08/2020) 
 
 
Prepared by: Dr Jonathan Lim 
Supervisor:  
Prof John Wilding 
Dr Uazman Alam 
 
 
MAIN SPONSOR: Institute of Ageing and Chronic Disease, University of Liverpool 
FUNDERS:  
Institute of Ageing and Chronic Disease, University of Liverpool  
Metabolic Health Solutions Pty Ltd, Australia 
 
STUDY COORDINATION CENTRE:  Liverpool Clinical Trials Unit Research & Development; Third Floor 
Clinical Sciences Centre, University Hospital Aintree, Longmoor Lane, L9 7AL 
REC reference: REC 18/NW/0645 – North-West Research Ethics Committee 
 
Confidentiality Statement 
The Information in this document contains trade secrets and commercial information that are 
privileged or confidential and may not be disclosed unless such disclosure is required by 

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applicable law or regulations. In any event, persons to whom the information is disclosed 
must be informed that the information is privileged or confidential and may not be further 
disclosed by them. These restrictions on disclosure will apply equally to all future information 
supplied to you that is indicated as privileged or confidential. 
Study Team 
 
Chief Investigator: 
Prof John Wilding 
Co-Investigators: 
Dr Jonathan Lim 
Dr Uazman Alam 
Dr Daniel Cuthbertson 
 
Statistician: 
Biostatistics Department  
University of Liverpool  
 
Study Manager: 
Dr Jonathan Lim 
 
Study Coordination Centre  
For general queries, supply of Study documentation, and collection of data, please 
contact:  
 
Study Coordinator: Dr Jonathan Lim 
Address: 
Third Floor Research & Development, 
Clinical Sciences Centre, 
University Hospital Aintree, 
Longmoor Lane 
Liverpool 
L9 7AL 
 
Tel:  
0151 529 5935/ 5939/ 6437 
 
Email:   
j.p.h.wilding@liverpool.ac.uk 
Jonathan.Lim5@nhs.net 
 
 

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Clinical Queries 
Clinical queries should be directed to Prof John Wilding who will direct the query to the appropriate 
person. 
Sponsor 
The University of Liverpool is the research Sponsor for this Study. For further information regarding 
the sponsorship conditions, please contact: 
Alex Astor 
Head of Research Support – Health and Life Sciences 
University of Liverpool 
Research Support Office 
2nd Floor Block D Waterhouse Building 
3 Brownlow Street 
Liverpool L69 3GL 
Email: sponsor@liverpool.ac.uk  
Funder 
Institute of Ageing and Chronic Disease, University of Liverpool 
Metabolic Health Solutions Pty Ltd, Australia 
 
 
 
 
 
 

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Table of Contents 
SYNOPSIS ............................................................................................................................................................. 8 
1. 
INTRODUCTION ................................................................................................................................. 9 
1.1 RATIONALE FOR STUDY ................................................................................................................................. 9 
1.2.1 CURRENT RESEARCH ON ENERGY EXPENDITURE .................................................................................10 
1.2.2 CURRENT RESEARCH ON RESPIRATORY QUOTIENT ..............................................................................10 
1.2.3 CURRENT RESEARCH ON RESTING METABOLIC RATE ...........................................................................11 
1.3.1 DEFINITION OF PREDIABETES ..................................................................................................................11 
1.3.3 PERIPHERAL NEUROPATHY AND PREDIABETES ......................................................................................12 
1.4 SUBSTRATE OXIDATION ...............................................................................................................................12 
1.5 PROPOSED RESEARCH................................................................................................................................13 
2 STUDY OBJECTIVES ........................................................................................................................................13 
2.1 PRIMARY OBJECTIVE ..................................................................................................................................13 
2.2 SECONDARY OBJECTIVES ...........................................................................................................................13 
3 STUDY DESIGN ................................................................................................................................. 13 
PRIMARY ENDPOINT ...........................................................................................................................................13 
4. STUDY POPULATION ...................................................................................................................... 13 
4.1 RECRUITMENT .............................................................................................................................................13 
4.2 INCLUSION CRITERIA ...................................................................................................................................14 
4.3 EXCLUSION CRITERIA ..................................................................................................................................14 
4.4 SAMPLE SIZE ...............................................................................................................................................15 
4.5 WITHDRAWAL CRITERIA ..............................................................................................................................15 
4.6 PROHIBITIONS AND RESTRICTIONS ............................................................................................................16 
5. EXPERIMENTAL PROTOCOL ................................................................................................................... 18 
5.1 SCREENING VISIT ........................................................................................................................................18 
5.2 BASELINE VISIT & RANDOMISATION ............................................................................................................18 
5.3 RANDOMISATION .........................................................................................................................................19 
5.4 STANDARD CARE GROUP CLINICAL VISITS ................................................................................................20 
5.5 - ECAL GROUP CLINICAL VISITS................................................................................................................20 
5.6 CONTROL & INTERVENTION GROUP......................................................................................................................21 
5.7 NEUROPATHY SCREENING QUESTIONNAIRES ...........................................................................................................21 
5.8 VIBRATION PERCEPTION THRESHOLD & NEUROTHESIOMETRY ...................................................................................21 
5.9 INDIRECT CALORIMETRY .....................................................................................................................................22 
5.10 PATIENT AND STAFF ACCEPTABILITY SURVEYS ........................................................................................23 
5.11 FOOD INTAKE ASSESSMENT .....................................................................................................................23 
5.12 PHYSICAL ACTIVITY LEVEL .......................................................................................................................24 
5.13 QUALITY OF LIFE ASSESSMENT ................................................................................................................24 
6 DATA STORAGE AND ANALYSIS ................................................................................................... 24 
6.1 SOURCE DATA .............................................................................................................................................24 
6.2 STATISTICAL ANALYSIS ...............................................................................................................................24 
6.3 STORAGE, ARCHIVING AND DESTRUCTION OF DATA...................................................................................25 
7  ADVERSE EVENTS .......................................................................................................................... 25 
7.1 DEFINITIONS ................................................................................................................................................25 
7.2 REPORTING PROCEDURES .........................................................................................................................26 
7.2.1 Non-Serious AEs ....................................................................................................................................26 
7.2.2 Serious AEs............................................................................................................................................26 

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8 ASSESSMENT AND FOLLOW-UP ................................................................................................... 26 
9 REGULATORY ISSUES..................................................................................................................... 27 
9.1 ETHICS APPROVAL ......................................................................................................................................27 
9.2 CONSENT .....................................................................................................................................................27 
9.3 CONFIDENTIALITY ........................................................................................................................................27 
9.4 INDEMNITY ...................................................................................................................................................27 
9.5 SPONSOR ....................................................................................................................................................28 
9.6 AUDITS .........................................................................................................................................................28 
10 STUDY MANAGEMENT................................................................................................................... 28 
11 END OF STUDY ............................................................................................................................... 28 
12 ARCHIVING ...................................................................................................................................... 28 
13 PUBLICATION POLICY ................................................................................................................... 28 
14 REFERENCES ................................................................................................................................. 29 
 
 
 

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Study Summary 
Title: A Randomized Controlled Trial to Evaluate Impact of Energy Expenditure Information 
from Indirect Calorimeter on the Outcome of Weight Loss during a Standardised 
Multicomponent Weight Management Intervention in Non-diabetic & Pre-diabetic Obese 
Subjects (ECAL) 
Background: Weight loss is important to improve overall health and reduce risk of obesity-
related comorbidities such as diabetes. Most effective weight loss methods require a 
reduction in calorie intake. Some individuals with obesity find it more difficult to lose weight 
than others, due to inter-individual variation of resting metabolic rate and physical inactivity. 
Furthermore, individuals with predisposed genetic propensity to obesity who are deemed to 
be metabolically ‘thrifty’, require further structured intensification of lifestyle changes. Resting 
metabolic rate and respiratory quotient have proven to be effective predictors of weight loss.  
Aims: This study aims to investigate whether providing energy expenditure information to 
patients and clinicians during a standardized multicomponent weight management 
intervention would influence the outcome of weight loss. 
Methods: Participants recruited from the University Hospital Aintree weight management 
clinics, will be subsequently randomised to receive either 1) standard care (SC) - standard 
multicomponent weight management intervention (diet, exercise, behaviour modification 
therapy) or 2) intervention group (ECAL) – SC plus use of energy expenditure information to 
both clinicians and participants to influence dietary advice provided over a 6-month period. 
Primary outcome measure is the magnitude of weight loss. 7-day food diary used to 
establish compliance and MET average physical activity scores will be recorded.  
 
This study will adhere to the principles outlined in the UK Policy Framework for Health and 
Social Care Research (v3.2 10th October 2017). It will be conducted in compliance with the 
protocol, the Data Protection Act, and other regulatory requirements as appropriate. 
 
 
 
 

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GLOSSARY OF ABBREVIATIONS 
AE 
Adverse Events 
BMI 
Body Mass Index 
BP 
Blood Pressure 
BPI-SF 
Brief Pain Inventory short form 
CRF 
Case Report Form 
CI 
Chief Investigator 
DN4 
Douleur Neuropathique 4  
ECAL 
Intervention Group  
eGFR 
Estimated glomerular filtration rate 
EQ-5D 
European Quality of Life – 5 Dimensions 
FBC 
Full blood count 
HbA1c 
Glycated haemoglobin 
HDL 
High Density Lipoprotein 
HRA 
Health Research Authority 
IC 
Indirect calorimetry 
IWQoL-Lite 
Impact of Weight on Quality of Life - Lite 
KOSC 
King’s Obesity Staging Criteria 
LFT 
Liver Function Test 
LDL 
Low Density Lipoprotein 
mTCNS 
modified Toronto Clinical Neuropathy score 
MT 
Meal test 
NEFA 
Non-Esterified Fatty Acids 
OSA 
Obstructive sleep apnoea 
PI 
Principal Investigator 
QoL 
Quality of life 
REC 
Research Ethics Committee 
REE 
Resting energy expenditure 
RMR 
Resting metabolic rate 
RQ 
Respiratory quotient 
SAE 
Serious adverse event 
SAR 
Serious adverse reaction 
SC 
Standard care group 
SOP 
Standard operating procedure 
SUSAR 
Serious unexpected suspected adverse reaction 
TFT 
Thyroid function test 
T2DM 
Type 2 Diabetes Mellitus 
U+Es 
Urea, creatinine and electrolytes 
UAR 
Unexpected adverse reaction 
VAS 
Visual analogue scale for pain 
WL 
Weight loss 
 
KEYWORDS 
Weight management; Obesity; Complex Obesity; Diet; Structured dietary intervention; 
Calorie restriction; Indirect Calorimetry; Resting Energy Expenditure; Resting Metabolic 
Rate; Respiratory Quotient; Substrate oxidation; Macronutrient composition; Weight loss 
predictor; Peripheral neuropathy 
 

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SYNOPSIS 
Study Title 
A Randomized, Controlled Trial to Evaluate Impact of Energy 
Expenditure Information from ECAL Indirect Calorimeter on the Outcome 
of Weight Loss during a Standardised Multicomponent Weight 
Management Intervention in Non-diabetic & Pre-diabetic Obese Subjects 
(ECAL study) 
Study Setting 
The study will be co-ordinated by the appointed research & development 
team based at University Hospital Aintree. The Liverpool Clinical Trials 
unit will provide trial management, statistical input, and database 
management for this trial. The study will include patients attending 
Weight Management Clinics at University Hospital Aintree. 
Trial Design 
A 24-week randomised controlled trial for subjects with obesity referred 
to a specialist weight management service. Participants will be 
randomised to receive 1) standard care (SC) control group receiving 
multicomponent weight management intervention (diet, exercise, and 
behaviour modification therapy), or 2) intervention group (ECAL) energy 
expenditure information via indirect calorimetry to guide the 
multicomponent weight management intervention. The aim of this study 
is to establish whether providing energy expenditure information to both 
clinician and patient from indirect calorimetry would influence the 
outcome of weight loss.  
Trial 
Participants 
All eligible patients currently attending specialist weight management 
services at University Hospital Aintree. 
 
 
 
 
 
 
 
 
 
 

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1. Introduction 
 
Recent figures in 2016 demonstrated that over a 1 in 4 adults in England were obese, with a 
body mass index (BMI) of 30 kg/m2 or higher(1). A further 41% of men and 31% of women 
were overweight, with a BMI of at least 25 but less than 30 kg/m2(1). Obesity is a 
multifactorial condition which results from chronic accumulation of fat in adipose tissue, 
which may stem from excessive energy intake, and or changes in body energy expenditure, 
resulting in a positive energy balance. The total amount of daily energy required to maintain 
normal bodily function including growth, repair of tissues and metabolic function is known as 
the basal metabolic rate (BMR). The BMR is the amount of calories (kcal or kJ) required to 
perform the body’s basic metabolic function, most accurately measured in the lab settings. In 
contrast, the resting metabolic rate (RMR) is measured in a resting state, in the morning 
before any food, without any physical activity and after several hours of restful sleep 
overnight. Although the terms BMR and RMR are used interchangeably, the term resting 
metabolic rate is more commonly used.  The RMR is calculated through application of the 
first law of thermodynamics and the Weir’s formula. Using the principles from the first law of 
thermodynamics and Weir’s formula, the simplified Weir formula(2) states that: 
Resting Metabolic Rate (kcal per day) = 1.44 x (3.94 VO2 + 1.106 VCO2) – 2.17 UN 
Where VO2 is oxygen consumption in millilitres per minute and VCO2 is the rate of carbon 
dioxide production in millilitres per minute.  Indirect calorimetry allows capture of the exhaled 
gas using a face mask or mouthpiece connected to oxygen and carbon dioxide analysers. 
The total daily energy expenditure (TDEE) is an estimation of how much calories an 
individual burn per day, taking into account the amount of calories burned through physical 
activity. TDEE is measured by multiplying BMR with the factor of physical activity level 
(PAL). The physical activity level is estimated using a sum of all physical activities (sum of Δ 
PAL) within a 24-hour period, hence: TDEE  = BMR x factor of physical activity level (PAL). 
The role of physical activity is equally important as energy restriction in inducing and 
maintaining weight loss (3).  
Accurate determination of BMR is possible using validated techniques in clinical trials in the 
research setting (4). Furthermore, indirect calorimetry has also been validated through 
comparison with BMR calculated based on predictive equations like Harris-Benedict 
equation (5). 
1.1 Rationale for study 
 

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Das et al. (2004) prospectively measured total energy expenditure (TEE) and resting energy 
expenditure (REE) in extremely obese individuals and established that these individuals 
have high absolute values for TEE and REE, indicating that excess energy intake 
contributes to the maintenance of excess weight (6).  However, Melo et al. (2008) found that 
obese individuals are economical, from the metabolic point of view (7). Therefore, the energy 
expenditure (EE) per kilogram of body weight at the given time is lower in obese individuals. 
Lam and Ravussin (2017) went on further to demonstrate complexity of the energy 
expenditure equation suggesting the variations between individuals and underlined the 
hypothesised concept of the ‘thrifty’ versus ‘spendthrift’ phenotypes(8). In theory, the thrifty 
individuals are more metabolically energy-conserving and thus are prone to weight gain.  
1.2.1 Current Research on Energy Expenditure 
 
TDEE calculated via predictive equations in obese hospitalised patients were only accurate 
in about half of patients, and tend to overestimate EE (9, 10). Nutrition and energy advice on 
critically ill (11), hospitalised patients or those in a hypocaloric state (12) are increasingly 
reliant on the accuracy of indirect calorimetry. Limited experience and technical variabilities 
of indirect calorimetry use in obese and severely obese individuals require further 
development and exploration (13, 14). Measurement of EE serves as an important 
component of comprehensive clinical nutrition assessment in institutions providing weight 
management interventions for obese patients. The hypothesis in this study is to examine 
whether utilising an indirect calorimeter to provide RMR and RQ would help obese patients 
to lose and maintain their weight loss.   
1.2.2 Current Research on Respiratory Quotient 
 
A prospective study of morbidly obese subjects with a BMI  35kg/m2 with a predisposition to 
weight gain subsequent to the cessation of a conventional rapid-weight-loss-diet or a very 
low-calorie diet were assessed during a 12-month follow up (15). A significant predictor for 
maintenance of weight loss in morbidly obese individuals was the observed differences in 
their resting RQ. The individuals who demonstrated an RQ in the lower range (<0.72) were 
more able to maintain the weight-loss achieved on a caloric restriction and avoid a weight 
loss rebound as compared to those with RQ in the higher range (>0.75)(16). This suggested 
that RQ could prove useful in clinical practice as a prognostic marker for long-term 
effectiveness of low- and very-low-calorie diets used to induce rapid weight loss. The 
Baltimore Longitudinal Study on Aging shared a similar finding that fasting RQ or respiratory 
exchange ratio (RER) adjusted for age, BMI, FFM was positively related to weight 
change(17).(18) 

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1.2.3 Current Research on Resting Metabolic Rate 
 
Fat free mass (FFM) which represents numerous metabolically active tissues (skin, bone, 
muscle) and organs (heart, liver, kidney, brain) is thought to be a major determinant of 
energy expenditure and fat utilization in lean healthy individuals. Resting metabolic rate 
(RMR) adjusted for fat free mass (FFM) was a predictor for change in body weight, with 
studies demonstrating RMR is inversely related to rate of weight gain(19). Two further 
studies by Piaggi et al. (2013, 2015) supports that 24-hour EE was inversely related to rate 
of weight gain, and further demonstrated that a higher 24-hour RQ and EE, but not FFM, 
were independent predictors of ad libitum food intake(15, 20). Similarly, a study on ethnic 
Pima Indians with high prevalence of obesity demonstrated a low RMR was a significant risk 
factor for weight gain(21). Further evaluation of this suggestion of a “Thrifty genotype” 
amongst this population, with obesity prevalence that exceeds 75%, led to the conclusion 
that a low RMR is predictive of overall weight gain(21). Another study comparing the RMR of 
10-year old Pima Children with Caucasian cohorts found that RMR adjusted for body 
composition and FFM was not significantly different(22). However, other studies report no 
significant association was found between RMR and weight gain in obese individuals(17, 
23).  
1.3.1 Definition of Prediabetes  
 
Prediabetes is diagnosed when: 
• 
Glycated haemoglobin (HbA1c) 42 - 47 mmol/mol (24) 
• 
Impaired Fasting Glucose - Fasting blood glucose level of (5.5 mmol/L to 6.9 mmol/L) 
and / or 
• 
Impaired Glucose Regulation - Two-hour glucose tolerance test after ingesting the 
standardized 75 g glucose meal to the blood sugar level of 7.8 – 11.0 mmol/L  
and / or 
We defined prediabetes among individuals without previously diagnosed diabetes using 
HbA1c cut-offs as specified by the NICE(24) . This cut-off has been shown in a meta-
analysis to be predictive of progression to diabetes. Patients who had a previous diagnosis 
of diabetes were excluded because the current glycaemic status of those patients may 
represent diabetes control. The levels above these readings would be a diagnosis for 
diabetes. 

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Prevalence of prediabetes is on the sharp increase from 11.6% to 35.3% from comparative 
surveys in 2003 to 2011(25), while about 1 in 10 individuals with prediabetes progress to 
develop diabetes every year (26).  
1.3.3 Peripheral neuropathy and Prediabetes 
 
A prospective Canadian study demonstrated that individuals with prediabetes carries a 
similar risk of peripheral neuropathy as new-onset type 2 diabetes in people around 50 years 
of age(27). Patients with at least one or more risk factors of developing type 2 diabetes were 
monitored over a 3-year period. Results of PROMISE trial showed that over the course of 
the 3-year monitoring period, 50% of participants had peripheral neuropathy(27). Of those 
that developed prediabetes (either impaired fasting glycaemia or impaired glucose 
tolerance), 49% also had peripheral neuropathy. By comparison, of those participants that 
maintained healthy blood glucose levels, 29% had peripheral neuropathy. 
The results outline that people with prediabetes are at a higher risk of peripheral neuropathy 
than the general population and that monitoring for signs of nerve damage should be carried 
out to reduce the risk of foot damage and potential consequences that can result. 
1.4 Substrate oxidation 
 
Obesity is associated with impaired glucose tolerance and impaired utilisation of fat as a fuel 
during post-absorptive conditions(28). The proposed mechanism of impaired glucose 
tolerance, which is due in part to increased availability of plasma free fatty acids (FFA) and 
reduced capacity of skeletal muscle fat utilization (28, 29), leading to accumulation of 
intracellular fatty acid metabolites that interfere with insulin signalling pathways(30, 31). In 
lean metabolically healthy individuals, measurement of the RQ reveals a higher reliance on 
fat oxidation (lower RQ) during fasting conditions. Insulin infusion in these individuals readily 
suppresses this preference of fat oxidation as muscle shifts to higher reliance upon glucose 
oxidation (higher RQ). Thus metabolically healthy skeletal muscle is characterised by the 
ability to switch easily between glucose and fat oxidation in response to homeostatic signals. 
In comparison, the skeletal muscles of obese individuals and type 2 DM demonstrate a great 
reduction in this metabolic flexibility. RQ values measured in a fasted state are elevated in 
obese and type 2 DM individuals (32), yet the stimulation of glucose oxidation in response to 
insulin is blunted. This blunted capacity and inefficient response to both to the stimulus of 
fasting to enhanced fat oxidation and to the stimulus of glucose oxidation in response to 
insulin, is termed “metabolic inflexibility”.  
 

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1.5 Proposed research  
 
Indirect calorimetry has been extensively used in both research and clinical setting in lean 
and healthy individuals, with lack of congruent results on individuals with complex obesity. 
This study aims to explore the use of indirect calorimetry to provide energy expenditure 
information to clinicians and patients during a 6-month standardised multicomponent weight 
management intervention.  
Research Question: 
• 
Does providing energy expenditure information to both clinicians and patients during 
weight intervention influence the outcome of weight loss? 
2 Study objectives 
2.1 Primary Objective 
• 
To determine whether providing energy expenditure information from indirect 
calorimetry to specialist clinicians and patients influences the outcome of weight loss 
in patients with obesity and severe obesity. 
2.2 Secondary Objectives 
1. To establish the acceptability and reproducibility of using indirect calorimetry to 
measure energy expenditure as compared to use of standard predictive energy 
equations. 
2. To determine whether metabolic parameters of REE or RQ are potential surrogate 
biomarkers to predict weight loss. 
3 Study design 
Type of study: Randomized-controlled trial  
Primary endpoint 
Reduction in body weight from baseline to end-of treatment (24 weeks) 
4. Study population 
 
4.1 Recruitment 
 
Study information will be given to all adult patients attending weight management service at 
Aintree University Hospital. Eligible participants will be identified and provided with patient 
invitation leaflet after their clinic appointment. The researcher will verbally explain the study 
to the patient, confirm eligibility and hand out the patient information leaflet. Individuals who 
are interested in taking part will be invited back for a screening visit, in the Clinical Sciences 

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Centre, Aintree University Hospital. The study will be explained again at the screening visit 
where any questions can be answered and informed consent can be obtained. A letter will 
be written to the participant, their GP and their secondary care diabetes clinician at Aintree 
University Hospital detailing brief overview of the trial. 
 
4.2 Inclusion criteria 
 
• 
Man or woman, 18 to 70 years of age, inclusive 
• 
BMI 30 kg/ m2 to  60 kg/m2 at screening visit 
• 
Stable weight (ie, change of < 5% within 12 weeks before screening based on 
medical history) 
• 
Subjects are in the investigators opinion, well-motivated, capable, and willing to learn 
how to undergo indirect calorimetry testing, as required for study 
• 
Willing and able to adhere to the prohibitions and restrictions specified within this 
protocol 
 
4.3 Exclusion criteria 
 
• 
Taking weight loss medication within 12 weeks prior to randomisation 
• 
Previous or planned bariatric surgery 
• 
History of Type 1, Type 2 diabetes mellitus, DKA or diabetes secondary to 
pancreatitis 
• 
Has a HbA1c of  6.5% (or ≥ 48 mmol/mol) 
• 
History of obesity with a known secondary cause (e.g. Cushing’s disease / 
syndrome)  
• 
Oral corticosteroid use (except in the short term use of a 7-10 day course) 
• 
Ongoing, inadequately controlled thyroid disorder defined as thyroid-stimulating 
hormone >6mIU/litre or <0.4 mIU/litre  
• 
History of malignancy within 3 years before screening (or diagnosis of malignancy 
within this period)  
• 
eGFR ≤30ml/min/1.73m2 on serum testing 
• 
Alanine aminotransferase level is >2.0 times the upper limit of normal or total bilirubin 
is >1.5 times the upper limit of normal at screening 
• 
Other major illness likely to preclude participation in the trial 
• 
History of glucagonoma 

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• 
An MI, unstable angina, revascularization procedure (stent or bypass graft surgery) 
or cerebrovascular accident within 12 weeks before screening 
• 
Heart Failure NYHA Class III-IV 
• 
End-stage Chronic Obstructive Pulmonary Disease (COPD) 
4.4 Sample size 
 
Previous studies in this population from Aintree LOSS(33) community-based, 
multidisciplinary weight management programme for patients with severe and complex 
obesity, demographic data of patients who attended had an average weight loss of 1.29 kg 
(+/- SD 4.88) and mean BMI of 45.6 (+/- SD 6.8) kg/m2. The study will have 80% power to 
detect additional weight loss of 3 kg between the SC and ECAL group. This difference is 
taken from cornerstone studies like the Diabetes Prevention Programme, which suggests a 
weight loss of 3-5% of initial body weight would lead to risk reduction in progression of 
diabetes. Using a power calculator with SD above, the sample size is 42 patients per group; 
hence n = 84 patients (primary outcome). Allowing for attrition rate of 20%, the sample size 
required would be 84 / 0.80 = 105 patients.    
4.5 Withdrawal criteria 
 
Participants may withdraw consent from the study before study completion if they decide to 
do so, at any time and for any reason. If a participant decides to withdraw from the study, 
this will be recorded in the study records. They will be sent a letter thanking them for their 
participation, and informing them that the data collected up to the time point they withdrew 
will be included in the study analysis and that they will not be contacted again with regards to 
this study. They will not be asked to attend further visits. Furthermore, we will emphasise 
that their standard care will not be affected by their withdrawal from this study and that they 
will return to standard care. 
Participants will be withdrawn from this study by the research team as agreed by the PI if: 
• 
They are diagnosed with a terminal illness 
• 
The PI, sponsor or study clinician deem it unsafe for continuation in the study for 
medical, safety, regulatory or other reasons consistent with applicable laws, 
regulations, or Good Clinical Practice (GCP) 
• 
They are considered to be lost to follow-up as deemed by the clinician. 
• 
Loss of capacity during participation in research 
• 
Treatment with medications which the PI determines to require permanent withdrawal 
from the study (e.g. systemic corticosteroids) 

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• 
Female participants with a positive pregnancy test 
4.6 Prohibitions and Restrictions 
 
Potential participants must be willing and able to adhere to the following prohibitions and 
restrictions during the study to be eligible for participation: 
• 
Willing to have an overnight fast of at least 8 hours or greater before the IC 
measurement.  
• 
Willing to avoid stimulants and stressors such as caffeine, nicotine, and tobacco for at 
least 8 hours prior to the test. The allowed beverages are water only for the duration of 
pre-testing phase. 
• 
Willing to avoid strenuous physical activity for 12 hours prior to the measurement. 
 
 

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Figure 1: Recruitment, consent, and randomisation of trial participants.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligible patients screened 
Consent 
Assigned to ECAL 
Assigned to SC 
Randomisation 1:1 
Diet & Exercise Counselling 
based on measured EE 
information from Indirect 
calorimeter 
Excluded 
Indirect Calorimetry energy 
information withheld from 
subjects until the FINAL visit 
Indirect Calorimetry energy 
information provided to 
subjects at EACH visit  
Diet & Exercise Counselling 
based on estimated EE using 
standard Harris-Benedict 
equation  
Meal Test 
Meal Test 
Physical Activity Level 
Assessment 
Physical Activity Level 
Assessment 

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5. Experimental protocol 
5.1 Screening Visit  
The Screening Visit is performed at least one day and up to 2 weeks prior to the 
Randomisation Visit. 
Patients will attend an appointment with a healthcare professional at the study site. The 
healthcare professional will confirm and check their eligibility to participate and explain in 
detail what the study involves and allow for any questions regarding the trial. Full written 
informed consent to participate will then be taken. The person obtaining consent will also 
have been named in the delegation log of staff as undertaking this duty and approved as 
study personnel by the relevant governance procedures.  
After consent has been obtained, a member of the team will perform measurement of 
anthropometrics (height, weight, waist circumference, blood pressure and pulse rate) for all 
the patients in line with study Standard Operating Procedures (SOPs) and arrange for 
standard laboratory testing (listed blood tests – HbA1c, FBC, U+E, Lipids, LFTs, TFTs) and 
urine pregnancy test (female participants of childbearing potential only).  
Each participant will have a copy of the consent form and patient information leaflet. A copy 
will be placed in their hospital medical records and the original copy held in the site 
Masterfile.  
5.2 Baseline visit & Randomisation  
 
Eligible participants will be able to proceed to the Baseline Visit (Week 0). Weight, blood 
pressure and pulse rate will be recorded for all patients in line with study SOPs. The patient 
will also complete questionnaires to provide demographic and medical history details and 
additional data will be collected. Participants will be counselled about the study visits and 
provided with a food diary to record their food intake during the week. Participants will each 
receive support from the dieticians and weight management practitioners and/or clinicians 
with regards to maintaining reduced calorie intake according to their respective groups. 
Participants may contact their study team or GP at any time.  
Eligible participants will then be randomly assigned to one of two groups in a 1:1 ratio: 
1) The control group (SC) – standard care including diet, exercise and behaviour 
modification therapy. Energy expenditure information (RMR, RQ) measured from IC 
will be withheld from participants until the final visit. Participants will receive a 
standard nutritional energy goal based on the Harris-Benedict equation, the standard 
predictive equation used at Tier 3 weight management service at Aintree University 

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Hospital. Both participants and the study clinician providing advice and care will be 
“blinded” to the client and practitioner report until the completion of the final visit 
(week 24). To maintain the “blinding” of both participant and clinician in the SC group, 
the IC measurement is performed and an electronic copy of this is stored in the 
database, without showing the report to the participant or clinician. Upon completion 
of the final visit, SC group participants will be able to request a copy of the relevant 
client reports, should they wish to do so. 
2) The intervention group (ECAL) – diet, exercise, and behaviour modification therapy, 
with the addition of a personalised nutrition energy goal based on the RMR 
measured from the IC at every visit. ECAL group participants will receive a client 
report which is a layperson summary of their personalised RMR, fat burning (%) and 
glucose availability (%) in a client report printout. The client report is generated 
directly from the ECAL indirect calorimeter using the ECHealth software contained 
within. Layperson summary is simplified, easy to understand and has graphic 
representations of their personalised measurements. The participants will be given 
one copy of this client printout after each IC measurement. On the other hand, the 
clinician will receive a practitioner report, a different version to the client printout, also 
generated from the ECHealth software, which contains the clinical results. The 
clinician will make recommendations of dietary modification and physical activity 
counselling based on the clinical results of measured RMR and RQ.  
All participants will receive diet and physical activity counselling and provided with a food 
diary to record their food intake (at least 4 days during the week). Support will be offered 
from the dieticians and weight management practitioners and clinicians with regards to 
maintaining a low-calorie intake. Compliance and adherence to dietary plan will be assessed 
by the dietician or weight management practitioner or clinician review during appropriate 
study visits with diet and physical activity counselling. A discussion about patient’s food 
intake will be carried out and documented alongside self-reported food intakes based on 
their food diary completion. 
5.3 Randomisation 
 
During the baseline visit (week 0), randomisation will be conducted through a validated 
online system provided through the Clinical Trials Unit. Eligible participants will be randomly 
assigned in a 1:1 ratio to: 

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1) SC (control group) – standard care including diet, exercise and behaviour 
modification therapy, but energy expenditure information is withheld from both the 
clinicians and participants until the final visit.  
2) ECAL (intervention group) – in addition to diet, exercise and behaviour modification 
therapy, participants will receive verbal feedback on nutrition energy goal based on 
their REE measurement. The REE information will then be used to guide dietary and 
lifestyle recommendations. The measured energy information will be presented to the 
participant as a layperson summary at respective visits. This includes RMR, RQ and 
any other metabolic measurements obtained from IC tests. 
Participants will be informed of their randomization assignment during the Baseline Visit. A 
letter will be sent to the participant’s GP notifying them of their patient’s participation in the 
study. 
5.4 Standard Care Group Clinical Visits  
(weeks 1, 2, 4, 8, 12, 16, 20 and 24)  
Standard Care (SC) group participants will receive IC testing at baseline (week 0), week 1, 
2, 4, 8, 12, 16, 20 and week 24, but energy expenditure information is withheld from the 
patient until the final visit. Participants would receive a standard nutritional energy goal 
based on standard predictive equations. At the final visit (week 24), a summary of their 
energy expenditure (RMR, RQ) information will be provided and presented as a layperson 
print out.  
SC group participants will continue to receive diet, exercise and behavior modification 
therapy as a standard multicomponent weight management intervention as part of their 
weight management service.  
5.5 - ECAL Group Clinical Visits 
(week 1, 2, 4, 8, 12, 16, 20 and 24) 
In addition to the multicomponent weight management intervention (diet, exercise and 
behavior modification therapy), ECAL group participants will receive energy expenditure 
information measured from IC. 
ECAL group participants will receive IC testing at baseline (week 0), week 1, 2, 4, 8, 12, 16, 
20 and week 24. RMR measured from IC test will is proven to be more accurate and less 
variable than standard predictive equations. REE will provide the basis of specific caloric 
restriction necessary for the individual to maintain their target weight loss. RQ will also be 
generated from the ratio of VCO2/ VO2 which provides information about substrate 
oxidation, more specifically measured fat utilization over the past 24 hours. REE and RQ 

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information will be used to guide clinicians in recommending the appropriate caloric 
restriction and lifestyle changes to help promote active weight loss. Participants will receive 
verbal feedback and a layperson summary of the recommendations. The indirect calorimetry 
can also be used to demonstrate and compare the results of REE and RQ from previous 
weeks.  
5.6 Control & Intervention Group 
 
1) Control group – SC Group. Standard care including multicomponent weight 
management intervention (diet, exercise and behaviour modification therapy) but 
energy expenditure information is withheld from both the clinicians and participants 
until the final visit.   
2) Intervention group - ECAL Group. In addition to standard care, participants will 
receive verbal feedback on nutrition energy goal based on their REE measurement. 
The REE information will then be used to guide dietary and lifestyle changes. The 
measured energy information will be presented as a layperson summary at 
respective visits. This includes RMR, RQ and any other metabolic measurements 
obtained from IC tests.  
5.7 Neuropathy screening questionnaires 
 
(weeks 0, 4, 12 and 24) 
All the participants will be offered 3 neuropathy screening questionnaires DN4, mTCNS, BPI-
SF and a visual analogue scale (VAS) of neuropathic pain at week 0 (baseline), 4, 12 and 
week 24. These questionnaires are anticipated to take no longer than 10 minutes to 
complete.  
5.8 Vibration Perception Threshold & Neurothesiometry 
(weeks 0, 4, 12 and 24) 
For measuring quantitative vibration perception threshold (VPT) a Neurothesiometer 
(Horwell, Scientific Laboratory Supplies, Wilford and Nottingham, UK) will be used. 
Procedure for Neurothesiometer 
The patient should be in a semi-recumbent position, with heels resting on the bed. Prior to 
the testing, patient will be familiarized with the sensation of vibration at the wrist. The probe 
is then balanced on the tip of the great toe (right and left). The amplitude of the vibration for 
the probe should be increased from zero, by turning the Neurothesiometer dial slowly, during 
which patient’s eyes are shut. Participants will be instructed to say “yes” when he/she first 

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detects the slightest “buzzing” or vibration sensation, and this is recorded as the vibration 
perception threshold which is repeated three times on each test site. The unit of VPT is in 
volts and has a range between 0-50 volts. A grading scale which can be used is: no 
neuropathy (VPT < 15V), mild neuropathy (VPT < 25V), moderate neuropathy (25-35V), 
severe neuropathy (VPT > 35V).  
5.9 Indirect Calorimetry  
(Week 0, 1, 2, 4, 8, 12, 16, 20 and 24 weeks) 
Preparing for the Test 
Participants will be advised to abstain from food and alcohol for 7 hours or greater before the 
IC measurement. Participants will be advised to avoid stimulants and stressors such as 
caffeine, nicotine, and tobacco for at least 4 hours prior to the test. Beverages allowed 
include water, caffeine-free and calorie-free drinks. A standard operating procedure for 
ECAL indirect calorimetry will be adhered to as attached in Appendix. 
Steady State Testing 
After measuring their height, weight, and other anthropometric data, the participant will lie 
supine with head elevated 30 degrees, extended limbs in a silent room. In line with safety 
measures for current COVID19 pandemic, patients will be asked to sit behind a 
transportable Perspex screen. Using the screen will prevent large droplet dispersal and 
protect the staff member and surrounding area. Whilst lying in a physically comfortable 
position, the participant will be asked to maintain a regular inspiratory pattern, avoid moving 
and speaking during the test. Participant will be advised to remain rested for at least 10 
minutes. The mouthpiece will be held with either hand, and participant will be required to 
breathe through the mouthpiece, with a single-use nose clip applied over the nostrils. The 
mouthpiece has a two-way filter and will be single-use only. Upon completion it will be 
disposed of in the clinical waste bin.  
REE will be measured using the ECal Indirect calorimetry (Metabolic Health Solutions, 
Australia) at participant’s bedside. Gas and volume calibration of the device will be 
performed before each measurement. A mouthpiece will be used to measure inspired 
oxygen and expired carbon dioxide for up to 6-10 minutes, with the first 2 minutes of data 
discarded. REE (kcal/day) is calculated by the ECal device. Patients were considered to 
have reached a steady-state REE if a minimum of 5 consecutive minutes with less than 10% 
coefficient of variation in VO2 and VCO2 was achieved; otherwise repeat testing was 
indicated.  

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Accordingly, one measure would be sufficient to measure the REE. However, if the operator 
cannot guarantee the stability of the readings, the combination of two or three repetitions 
would increase the precision of the measurements. In such instances, the average of the two 
best readings will be utilized. A designated and trained healthcare professional will be 
responsible to operate and check the accuracy of data collection from IC.  
Energy expenditure (EE) information obtained from indirect calorimetry includes resting 
Energy Expenditure (REE) and respiratory quotient (RQ). 
Measures to ensure safety relating to the current COVID-19 pandemic will be introduced as 
per government guidance at the time of the participant visit. At the time of writing, the 
following measures will be instigated: social distancing, use of protective face masks, and 
any appropriate personal protective equipment when social distancing not possible. One-
way flow of participants and an assessment of any possible COVID-19 symptoms the day 
prior to attendance and day of attendance. If there are any symptoms, advice will be 
provided, and the visit rescheduled for a later date and advised to contact local healthcare 
service and undertake COVID-19 testing. Temperature will be assessed on arrival and if  
37.8C then the visit will be rescheduled. Medical advice / testing will be performed if 
applicable.  
5.10 Patient and staff acceptability surveys 
Following REE measurements, patients completed a short survey of 7 questions examining 
acceptability of the procedure (open-ended; yes/no; 5-point Likert scale). Questions focused 
on the timing and duration of the IC, comfort, and willingness to repeat the procedure. 
Nursing and medical staff were also invited to complete a 10-question survey (open-ended; 
yes/no; 5-point Likert scale). Questions focused on the impact of the IC on ward activities, 
staff role in the procedure, and perceived barriers to implementation of IC into usual care. 
Completion of staff surveys was voluntary and anonymous. 
5.11 Food Intake Assessment 
 
Participants are expected and encouraged to adhere to their prescribed dietary intake as 
advised by their clinicians throughout the study period.   
A food diary for every patient will be provided to assist more accurate measure of food 
consumption. Diary will include all the meals consumed during any two (2) consecutive 
weekdays and one (1) weekend day before the visit. The assessment will include energy 
intake, carbohydrate intake, fat intake, protein intake, and fiber intake. The food diary should 

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be reviewed with the participant in detail for accuracy and completeness by the clinician or 
the dietician. 
5.12 Physical Activity Level 
 
The International Physical Activity Level questionnaire will be administered at four intervals 
during the study at baseline, week 8, 16 and 24. The hours spent in sleep and light, 
moderate, and hard activities were multiplied by respective metabolic equivalent tasks 
(METs), summed and finally expressed as total MET-h/d.  
5.13 Quality of Life Assessment 
 
Assessment of Quality of Life will be conducted via the IWQoL-Lite & EQ-5D-5L 
questionnaires. Participants will be asked to complete these questionnaires at the baseline 
visit and at the final visit.  
 
6 Data storage and analysis 
6.1 Source data 
 
The CRF and study questionnaires are the primary data collection instruments. All data 
requested on the CRF will be recorded. All missing data will be explained. If the item is not 
applicable, then N/A will be written. All entries will be printed legibly in black ink. If any entry 
error has been made, to correct the error, a single line will be drawn through the incorrect 
entry and the correct data entered above it. All such changes will be initialled and dated. For 
clarification of illegible or uncertain entries, the clarification will be printed above, and this will 
be initialled and dated.  
A copy of the patient consent form and the information sheet will be placed in the hospital 
notes of all participants and in the Investigator Site File. A sticker will be placed on the cover 
of the notes (or inside cover) detailing the study title, contact details of the PI, participant ID 
and the fact that the notes should not be destroyed. All study visits and adverse events will 
be recorded in the hospital notes.  
The PI and his / her staff must ensure that these documents are pseudonymised. Past 
medical history within the CRF required for inclusion in the study will be verified by 
participant hospital notes and/or GP medical history.  
6.2 Statistical Analysis 
 

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Patient characteristics and clinical data will be analysed using SPSS software and STATS 
Direct. Normally distributed data will be expressed as mean +/- standard deviation (SD). 
Categorical variables will be analysed by using Chi-squared testing. Continuous variables 
between groups will be evaluated with unpaired student’s t-test (if normal distribution) or 
Mann-Whitney U test (if not normally distributed). P values < 0.05 will be considered 
significant. 
6.3 Storage, archiving and destruction of data 
 
Research data will be stored in an anonymous format. Patients will be given a study number 
which will then be used to link information without identifying individual patient details. All 
information and test results will be fed into a secure password protected computer on the 3rd 
floor of the Clinical Sciences Centre, Aintree University Hospital, and all data and results will 
be coded and securely stored. The Clinical Sciences Centre has secure facilities including 
locked doors requiring ID access, ID badges, 24-hour security and alarm system.  
The study will end once the last participant has completed the last visit and data filed and 
collected. After the study end personal data will not be retained and will be destroyed by 
confidential means. Anonymised data will be kept for 10 years in a locked cupboard on the 
3rd floor of the Clinical Sciences Centre, University Hospital Aintree and will then be 
destroyed by confidential means. 
7  Adverse Events 
7.1 Definitions 
 
Adverse Event (AE): any untoward medical occurrence in a patient or clinical study subject. 
Serious Adverse Event (SAE): any untoward and unexpected medical occurrence or effect 
that: 
• 
Results in death 
• 
Is life‐threatening – refers to an event in which the subject was at risk of death at 
the time of the event; it does not refer to an event which hypothetically might have 
caused death if it were more severe 
• 
Requires hospitalisation, or prolongation of existing inpatients’ hospitalisation 
• 
Results in persistent or significant disability or incapacity 
Medical judgement should be exercised in deciding whether an AE is serious in other 
situations. Important AEs that are not immediately life‐threatening or do not result in death 
or hospitalisation but may jeopardise the subject or may require intervention to prevent one 
of the other outcomes listed in the definition above, should also be considered serious. 

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7.2 Reporting Procedures 
 
All adverse events should be reported. Depending on the nature of the event the reporting 
procedures below should be followed. Any questions concerning adverse event reporting 
should be directed to the Chief Investigator in the first instance. 
7.2.1 Non-Serious AEs 
 
All such events, whether expected or not, should be recorded.  
7.2.2 Serious AEs 
 
An SAE form should be completed and faxed to the Chief Investigator within 24 hours. 
However, relapse and death due to <condition>, and hospitalisations for elective treatment 
of a pre‐existing condition do not need reporting as SAEs. 
All SAEs should be reported to the <name of REC> where in the opinion of the Chief 
Investigator, the event was: 
• 
‘related’, i.e. resulted from the administration of any of the research procedures; and 
• 
‘unexpected’, i.e. an event that is not listed in the protocol as an expected occurrence 
Reports of related and unexpected SAEs should be submitted within 15 days of the Chief 
Investigator becoming aware of the event, using the NRES SAE form for non‐IMP studies. The 
Chief Investigator must also notify the Sponsor of all SAEs. 
Local investigators should  report  any  SAEs  as  required  by  their  Local  Research  
Ethics  Committee, Sponsor and/or Research & Development Office. 
Contact details for reporting AEs 
Please send SAE forms to: 
Research and Development, 
Third Floor Clinical Sciences Building, 
University Hospital Aintree, 
Longmoor Lane, 
Liverpool 
L9 7AL 
Tel: 0151 529 5885 / 0151 529 5917 
Fax: 0151 529 5888 
8 Assessment and Follow-up 
 

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All participants should currently be registered with a weight management service. Should 
they require follow up after the study, they will return to their registered weight management 
service provider for any follow-ups. 
9 Regulatory issues 
9.1 Ethics approval 
 
Approval will be obtained from a Research Ethics Committee and submitted for Site Specific 
Assessment. The Chief Investigator will require a copy of the Trust R&D approval letter 
before accepting participants into the study. The study will be conducted in accordance with 
the recommendations for physicians involved in research on human subjects adopted by the 
18th World Medical Assembly, Helsinki 1964 and later revisions. 
9.2 Consent 
 
Consent to enter the study must be sought from each participant only after a full explanation 
has been given, an information leaflet offered, and time allowed for consideration. Signed 
participant consent should be obtained. The right of the participant to refuse to participate 
without giving reasons must be respected. After the participant has entered the study the 
clinician remains free to give alternative treatment to that specified in the protocol at any 
stage if he/she feels it is in the participant’s best interest, but the reasons for doing so 
should be recorded. In these cases, the participants remain within the study for the purposes 
of follow‐up and data analysis. All participants are free to withdraw at any time from the 
protocol treatment without giving reasons and without prejudicing further treatment. 
9.3 Confidentiality 
 
The Chief Investigator will preserve the confidentiality of participants taking part in the 
study and will abide by the Data Protection Act. All identifiable personal information 
collected for the study will remain strictly confidential accessible only to the research team. 
Once enrolled participants will be given a study number which will be used to identify their 
data and anonymise them. 
Electronic and hard copy data will be stored in a room, accessible only by electronic ID 
access on 3rd Floor, Clinical Sciences Building, University Hospital of Aintree, Lower Lane, 
Liverpool, L9 7AL. 
9.4 Indemnity 
 

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The University of Liverpool holds Indemnity and insurance cover  
9.5 Sponsor 
 
The University of Liverpool will act as the main Sponsor for this study. Institute of Ageing and 
Chronic Disease will sponsor database (REDCAP), statistical support up to £10k, salary for 
Clinical Research Fellow and patient travelling expenses.  
Equipment for study will be provided by Medtronic (CGMS) and Metabolic Health Solutions 
(ECAL indirect calorimeter). 
9.6 Audits 
 
The study may be subject to inspection and audit by the University of Liverpool under their 
remit as sponsor and other regulatory bodies to ensure adherence to GCP and the UK Policy 
Framework for Health and Social Care Research. 
10 Study Management 
 
The day-to-day management of the study will be coordinated through Research & 
Development Centre, Third Floor Clinical Sciences Building, University Hospital Aintree NHS 
Trust. 
 
11 End of Study 
 
End of study is defined as the completion of data collection and data analysis. 
12 Archiving 
 
Data and all appropriate documentation should be stored for a minimum of 5 years after the 
completion of the study, including the follow-up period, unless otherwise directed by the 
funder/sponsor/regulatory bodies.  
13 Publication policy 
 
The use of study methods, protocol, anonymised data, and statistical analysis will contribute 
toward the attainment of a PhD and relevant journal articles as deemed fit by the 
funder/sponsor/regulatory bodies. 
 
 

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