2-5 Intermittent Caloric Restriction for Weight Loss and Insulin Resistance in HIV-Infected Adults With Features of the Metabolic Syndrome
Phase: NA
Conditions: Human Immunodeficiency Virus, Metabolic Syndrome
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

2-5 Intermittent Caloric Restriction for Weight Loss and Insulin 
Resistance in HIV-infected Adults with Features of the Metabolic 
Syndrome
Protocol Number: 18-I-0075
Sponsored by:
National Institute of Allergy and Infectious Diseases (NIAID)
Principal Investigator (PI): Colleen Hadigan, MD, MPH
Laboratory of Immunoregulation (LIR)
NIAID
National Institutes of Health (NIH)
Building 10, Room 11C103
(301) 594-5754
hadiganc@niaid.nih.gov 
Version 3.0 
20 October 2020

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Table of Contents
Table of Contents .............................................................................................................2
List of Figures ...................................................................................................................3
List of Tables ....................................................................................................................3
List of Abbreviations .........................................................................................................4
Protocol Summary ............................................................................................................5
Précis................................................................................................................................6
1
Background Information and Scientific Rationale......................................................7
1.1
Background Information .....................................................................................7
1.1.1
Weight Gain and Obesity in HIV .................................................................7
1.1.2
Caloric Restriction and Intermittent Fasting ................................................8
1.2
Rationale ..........................................................................................................10
2
Study Objectives......................................................................................................11
2.1
Primary Objectives ...........................................................................................11
2.2
Secondary Objectives ......................................................................................11
3
Study Design ...........................................................................................................11
3.1
Description of the Study Design.......................................................................11
3.1.1
Study Endpoints........................................................................................12
3.1.1.1
Primary Endpoint...................................................................................12
3.1.1.2
Secondary Endpoints ............................................................................12
4
Study Population .....................................................................................................12
4.1
Recruitment Plan..............................................................................................12
4.2
Subject Inclusion Criteria..................................................................................12
4.3
Subject Exclusion Criteria ................................................................................13
4.4
Justification for Exclusion of Special Populations ............................................14
5
Study Interventions..................................................................................................14
5.1
Assessment of Subject Compliance with Study Intervention(s) .......................14
5.2
Concomitant Medications and Procedures ......................................................14
5.3
Prohibited Medications and Procedures ..........................................................15
6
Study Schedule and Procedures.............................................................................15
6.1
Screening .........................................................................................................15
6.2
Baseline Assessments .....................................................................................15
6.3
Randomization (Day 0).....................................................................................16
6.4
Study Phase (Weeks 1-12) ..............................................................................16
6.5
Final Follow-up Visit (Week 24)........................................................................17
6.6
Early Termination Visit .....................................................................................17
6.7
Pregnancy and Follow-up Visit.........................................................................18
7
Study Procedures/Evaluations ................................................................................18
7.1
Return of Research Results .............................................................................20
8
Potential Risks and Benefits....................................................................................20
8.1
Potential Risks..................................................................................................20
8.2
Potential Benefits .............................................................................................21
9
Research Use of Stored Human Samples, Specimens or Data..............................21
10
Remuneration Plan for Subjects ..........................................................................22
11
Assessment of Safety ..........................................................................................22

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11.1
Toxicity Scale ...................................................................................................22
11.2
Recording/Documentation................................................................................23
11.3
Definitions.........................................................................................................24
11.4
Reporting Procedures ......................................................................................24
11.5
Reporting of Pregnancy....................................................................................24
11.6
Type and Duration of the Follow-up of Subjects after AEs ..............................24
11.7
Withdrawal of an Individual Subject .................................................................24
11.8
Replacement of a Subject Who Discontinues Study Treatment ......................25
11.9
Safety Monitoring Plan .....................................................................................25
12
Statistical Considerations.....................................................................................25
12.1
Overview and Design .......................................................................................25
12.2
Study Hypotheses ............................................................................................25
12.3
Sample Size Justification .................................................................................25
12.4
Description of the Analyses..............................................................................26
13
Ethics/Protection of Human Subjects...................................................................26
13.1
Informed Consent Process...............................................................................26
13.1.1
Considerations for Consent of NIH Staff...................................................27
13.2
Subject Confidentiality......................................................................................27
14
Data Handling and Record Keeping ....................................................................27
14.1
Data Capture and Management.......................................................................27
14.2
Record Retention .............................................................................................27
15
Data Sharing........................................................................................................28
16
References...........................................................................................................28
APPENDICES.................................................................................................................33
Appendix A: Remuneration Schedule.........................................................................33
List of Figures
Figure 1.............................................................................................................................9
Figure 2.............................................................................................................................9
List of Tables 
Table 1. ATPIII Clinical Identification of the Metabolic Syndrome [41] ...........................13
Table 2. Venipuncture Volumes for Subjects .................................................................18

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List of Abbreviations
2-5 ICR
2 days intermittent caloric restriction/week with 5 days of ad lib eating
AE
Adverse Event
AHA
American Heart Association
AIDS
acquired immunodeficiency syndrome
ART
antiretroviral therapy
BDNF
brain-derived neurotrophic factor
BMI
body mass index 
CAP
controlled attenuation parameter
CCR
continuous caloric restriction
CD4
cluster of differentiation 4 
CRIMSON
Clinical Research Information Management System of the NIAID
CRP
C-reactive protein
DXA
dual-energy X-ray absorptiometry  
GCP
Good Clinical Practice
HIV
human immunodeficiency virus 
HOMA-IR
homeostatic model assessment of insulin resistance 
ICR
intermittent caloric restriction
IRB
Institutional Review Board
NIAID
National Institute of Allergy and Infectious Diseases
NIH
National Institutes of Health
OCRPRO
Office of Clinical Research Policy and Regulatory Operations
OGTT
oral glucose tolerance test
PANAS
Positive and Negative Affect Schedule
PI
Principal Investigator
PYY
peptide YY
REE
resting energy expenditure 
SAE
Serious Adverse Event
TFEQ
Three-factor Eating Questionnaire
VAS
Sisual analog scale

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Protocol Summary
Full Title:
2-5 Intermittent Caloric Restriction for Weight Loss and 
Insulin Resistance in HIV-infected Adults with Features of 
the Metabolic Syndrome
Short Title:
2-5 to WIN
Conducted by:
National Institute of Allergy and Infectious Diseases and 
National Institutes of Health Clinical Center
Principal Investigator:
Colleen Hadigan, MD, MPH
Sample Size:
N = 50; 25 subjects in intermittent caloric restriction arm, 
25 subjects in lifestyle modification standard of care arm 
Accrual Ceiling:
100 
Study Population:
Human immunodeficiency virus (HIV)-infected adults aged 
18 to 65 with a body mass index ≥30 kg/m2 (obese) and at 
least one feature of the metabolic syndrome (increased waist 
circumference, systolic hypertension, dyslipidemia)
Accrual Period:
3 years
Study Design:
Randomized study with 2 parallel arms 
Study Duration:
5 years (estimated start date of February 2018; end date 
January 2023
Intervention Description: Prospective randomized 12-week diet intervention study; 
2 days of intermittent caloric restriction (fasting) per week vs 
standard of care. 
Primary Objective:
To evaluate the effects of 12 weeks of intermittent caloric 
restriction 2 days per week on weight and insulin sensitivity 
in obese HIV-infected individuals with features of the 
metabolic syndrome
Primary Endpoint:
Changes in weight and insulin sensitivity as measured by 
homeostatic model assessment of insulin resistance 
(HOMA-IR) between baseline and week 12

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Précis
The high prevalence of obesity coupled with chronic inflammation and immune 
activation places human immunodeficiency virus (HIV)-infected individuals at increased 
risk for metabolic complications, emphasizing the need for more aggressive 
management of obesity and related comorbidities in the aging HIV-infected population. 
The most effective treatment for obesity and metabolic syndrome is lifestyle 
modification, usually with a combination of caloric restriction and increased exercise. 
Intermittent caloric restriction (ICR) or intermittent fasting simplifies caloric restriction by 
severely limiting calories only a few days per week and allowing ad lib diet on the other 
days. Weight loss benefits are similar to those seen with conventional diets; however, 
data suggest possible added health benefits from intermittent fasting.
We propose to study the benefits of a 2-5 ICR strategy on weight, insulin resistance, 
and cardiovascular disease markers in obese HIV-infected adults with features of the 
metabolic syndrome. In a prospective pilot study, 50 HIV-infected adults will be 
randomized 1:1 to ICR or standard-of-care instruction of healthy diet and lifestyle for a 
12-week intervention period. We hypothesize that ICR (2 days per week) will be an 
effective and acceptable diet strategy that will result in significant weight reduction, 
improvements in insulin sensitivity, and related metabolic parameters.  

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1 Background Information and Scientific Rationale
1.1
Background Information
Since the introduction of antiretroviral therapy (ART), human immunodeficiency virus 
(HIV)-infected individuals have lower morbidity from opportunistic infections and 
increased life expectancy. However, as HIV-infected individuals live longer, the 
prevalence of comorbid conditions, including obesity and metabolic syndrome, is 
increasing. 
In HIV-negative populations, obesity, alone or as part of the metabolic syndrome, is 
associated with increased risk of diabetes, hypertension, cardiovascular disease, and 
dementia. HIV infection and ART are independent risk factors for comorbidities, 
including central obesity, insulin resistance, diabetes, atherosclerosis, and dementia. 
Coupled with HIV-related inflammation and immune activation, the high prevalence of 
obesity places HIV-infected individuals at increased risk for metabolic complications and 
highlights the need for more aggressive management of obesity and related 
comorbidities in the aging HIV-infected population.
Both treated HIV infection and excess adipose tissue promote similar changes in 
immune activation that are implicated in the development of a range of chronic 
diseases; however, at present, there are little data on whether the effects of treated HIV 
and excess adiposity are synergistic or additive.
1.1.1 Weight Gain and Obesity in HIV 
Many HIV-infected individuals starting ART experience a significant gain in weight, 
regardless of weight at the time of antiretroviral initiation [1-4]. With the move towards 
earlier start of ART, an increasing number of HIV-infected individuals will initiate ART 
with normal or excess body weight. 
In a cohort of 175 HIV-infected ART-naïve adults with advanced HIV/acquired 
immunodeficiency syndrome (AIDS) (cluster of differentiation 4 [CD4] < 100 cell/mm3) 
followed in the NIAID/Clinical Center intramural HIV/AIDS outpatient clinic from 2010 to 
2012, 32% were overweight or obese at the time of ART initiation; rates nearly doubled 
after one year of therapy, with 63% of individuals overweight or obese. We have 
recently shown that this weight gain is accompanied by metabolic complications that 
include a high prevalence of non-alcoholic steatohepatitis and cardiac dysfunction [5, 6]. 
Our observations are mirrored in other cohorts. In one large US outpatient cohort, 
nearly half of HIV-infected individuals were overweight or obese at the time of ART 
initiation and weight increased to a higher body mass index (BMI) category within 
2 years of initiation in 20% [4]. In a Veterans' Affairs cohort, HIV-positive veterans 
gained significantly more weight one year after initiation of ART compared to age and 
sex-matched HIV-negative controls [7].
Not surprisingly, these weight changes translate to increased risk of metabolic 
complications. In the Veterans’ Affairs cohort, weight gain was more strongly associated 
with increased risk of incident diabetes mellitus in HIV-positive individuals (10% more 
risk per 5-lb gain) compared with HIV-negative individuals (6% more risk per 5-lb gain). 

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In the multi-cohort Data Collection on Adverse Events (AEs) of Anti-HIV Drugs (D:A:D) 
study, weight gain in the first year after initiation of ART is associated with an increased 
risk of cardiovascular disease and diabetes [8]. Taken together, these data suggest that 
weight gain in HIV-infected adults has significant implications for long-term health 
outcomes.
Treatment
For both HIV-infected and non-HIV-infected individuals, the most effective treatment for 
obesity and metabolic syndrome is lifestyle modification, usually a combination of 
caloric restriction and increased exercise [9-11]. A few small studies looking at lifestyle 
modification in HIV have shown improvement in dyslipidemia, waist circumference, 
systolic blood pressure, and hemoglobin (Hgb) A1C levels with dietary or exercise 
interventions [12-14].
Beyond lifestyle modification, subsequent approaches include drug therapy and, in 
obese individuals with serious medical comorbidities, bariatric surgery. In HIV-infected 
adults with lipodystrophy, a number of potential therapies have been studied 
unsuccessfully, including changes in ART, use of insulin-sensitizing agents, hormonal 
therapies such as growth hormone, growth hormone–releasing hormone, testosterone, 
and HMG-CoA reductase inhibitors (statins) [15].
1.1.2 Caloric Restriction and Intermittent Fasting
Caloric restriction without malnutrition slows aging and increases lifespan in a variety of 
organisms, including worms, spiders, fish, and rodents. In rhesus monkeys, caloric 
restriction reduces the incidence of type 2 diabetes mellitus, cardiovascular disease, 
and cancer, and may increase longevity [16, 17]. Caloric restriction also protects 
monkeys against age-related muscle loss and grey matter volume shrinkage in several 
key subcortical regions [18].
Studies in humans have confirmed the benefits of sustained calorie restriction; however, 
controversy exists related to subject selection, diet composition, and the duration of 
restriction required for beneficial effects to emerge. In one trial, adults following a 
calorie-restricted diet for 6 years (n=18) had improved body composition, lipid profile, 
blood pressure, insulin sensitivity, C-reactive protein (CRP), and carotid artery intima-
media thickness compared to adults on an unrestricted diet (n=18) [19]. In a 6-month, 
randomized study of calorie restriction with or without exercise in overweight, non-obese 
adults (n=48), caloric restriction reduced metabolic rate independently of weight change 
and improved insulin sensitivity [20].
One hypothesis to explain the beneficial, anti-aging effects of calorie restriction is 
reduced energy expenditure with a consequent reduction in the production of reactive 
oxygen species (ROS) [21]. However, other metabolic effects associated with calorie 
restriction, including alterations in insulin sensitivity and signaling, neuroendocrine 
function, stress response, or a combination of these, may also contribute to the benefits 
[22]. 
ICR or intermittent fasting simplifies caloric restriction by severely limiting calories only a 
few days per week and allowing ad lib diet on the other days. Benefits are similar to 
those seen with caloric restriction (where daily caloric intake is reduced but meal 

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frequency is maintained). However, data from animal models and a few human studies 
suggest possible added benefits from intermittent fasting [23-25]. For example, in 
mouse studies performed by Dr. Mattson and his colleagues, intermittent fasting is 
superior to continuous calorie restriction for improving insulin sensitivity, cardiovascular 
function, and for protecting neurons in animal models of Alzheimer’s and Parkinson’s 
diseases [25-28].
In a cohort of overweight adults with asthma, Dr. Mattson’s group has shown that 
8 weeks of alternate day caloric restriction decreased weight (~ -8% of baseline body 
weight), reduced peripheral insulin resistance, reduced plasma inflammatory markers, 
including decreased tumor necrosis factor-α (TNF-α, Figure 1), and decreased levels of 
ROS-induced 8-isoprostane, protein carbonyl, and nitrotyrosine (Figure 2) [29]. 
Figure 1. 
The effect of alternate day calorie restriction (CR) on serum TNF-α. By the 8-week time point, 
concentrations were greatly reduced regardless of assessment on ad libitum (AL) or restricted 
(CR) days.
Figure 2. 
The effect of alternate day calorie restriction (CR) on serum levels of nitrotyrosine. By the 8-week 
time point, levels decreased regardless of assessment on ad libitum (AL) or restricted (CR) days.

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In a 6-month study comparing intermittent with continuous caloric restriction (CCR) in 
overweight women, both regimens produced comparable weight loss (average loss of 
6 kg) and reductions in total and low-density lipoprotein cholesterol, triglycerides, blood 
pressure, and CRP [30]. ICR resulted in significantly greater reduction in visceral fat and 
improvement in insulin sensitivity relative to continuous restriction and was easier for 
subjects to maintain. Several short-term studies have shown similar benefits and 
confirmed the safety of the approach, with no evidence of overconsumption on 
unrestricted diet days [31-35].
The mechanisms underlying the benefits of intermittent fasting are beginning to be 
established. Fasting mice have higher levels of brain-derived neurotrophic factor 
(BDNF), a protein that regulates synaptic plasticity, neurogenesis, and neuronal survival 
in the brain. Recent work by Dr. Mattson and others has identified a widespread role for 
BDNF in regulation of energy homeostasis. BDNF influences multiple cell types in the 
body that are involved in glucose metabolism, including pancreatic β cells (increased 
insulin production), hepatocytes (decreased glucose production), and skeletal muscle 
(increased insulin sensitivity) [36-38]. Fasting also appears to increase autophagy, a 
mechanism by which cells can eliminate damaged molecules, including ones that have 
been previously associated with Alzheimer's, Parkinson's, and other neurological 
diseases. Moreover, in contrast to caloric restriction without fasting, intermittent fasting 
results in depletion of liver glycogen stores, release of fatty acids from adipose cells, 
and metabolism of the fatty acids to generate ketone bodies. Ketone bodies may 
mediate some of the beneficial effects of intermittent fasting on the brain and 
cardiovascular systems [39], and recent findings suggest that ketones can protect 
neurons in experimental models relevant to HIV-associated neurocognitive disorders 
[40].
1.2
Rationale
With the rising prevalence of overweight and obesity in HIV-infected individuals, 
strategies to prevent and reverse weight-related comorbidities are needed. Caloric 
restriction can reduce weight and improve insulin resistance; however, daily caloric 
restriction is difficult to maintain long-term. Limited data suggest ICR may be easier to 
achieve and is superior to CCR for improving insulin sensitivity, cardiovascular function, 
and neuroprotection. 
This study seeks to evaluate the tolerability and effects of ICR on body weight, insulin 
sensitivity, cardiovascular disease risk, and cognitive function. Additionally, we aim to 
characterize the effects on body composition, hepatic steatosis, resting energy 
expenditure (REE), plasma biomarkers of inflammation, immune activation, and 
metabolism. The results of this study may provide valuable information on the 
interactions between obesity and HIV-related inflammation and associated risk of 
non-AIDS disorders, and educate the design of future studies of obesity and associated 
comorbidities in HIV-infected populations.

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2 Study Objectives
2.1
Primary Objectives

To evaluate the effects of 12 weeks of ICR 2 days per week on weight and insulin 
sensitivity in obese HIV-infected individuals with features of the metabolic syndrome. 
2.2
Secondary Objectives

To evaluate the effects of ICR on body composition, including visceral adiposity and 
hepatic steatosis, lipids levels, metabolic biomarkers, biomarkers of inflammation 
and immune activation, and mood. 

To assess the tolerability of ICR.
3 Study Design
3.1
Description of the Study Design
After completing screening procedures and establishing eligibility, all subjects will 
receive standard-of-care recommendations for healthy diet and lifestyle and will be 
randomized 1:1 to either 2 days of ICR per week with 5 days of ad lib eating (2-5 ICR) 
or no additional intervention (see below). 
Standard of Care
(n=25)
2-5 ICR
(n=25)

AHA dietary counselling

Lifestyle and physical activity 
counselling

Pedometer and instructions for use

AHA dietary counselling

Lifestyle and physical activity 
counselling

Pedometer and instructions for use
-----

ICR guidelines and instructions

Supplemental beverages for ICR days
All subjects will receive dietary counseling consistent with the American Heart 
Association (AHA) diet recommendations. Like the standard-of-care arm, the 2-5 ICR 
subjects will implement the AHA diet 5 days per week; however, on 2 days per week will 
consume approximately 25% of their estimated daily caloric needs in the form of 
supplemental beverages or small meals. Assessments will occur prior to randomization 
and at 1, 4, 8, and 12 weeks. All subjects will then complete a follow-up visit to assess 
changes in weight and metabolic parameters 12 weeks after the intervention period is 
complete.

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3.1.1 Study Endpoints
3.1.1.1
Primary Endpoint
Change in weight and insulin sensitivity as measured by homeostatic model 
assessment of insulin resistance (HOMA-IR) between baseline and week 12. 
3.1.1.2
Secondary Endpoints 
1. Tolerance and adherence to diet assignment
2. Change in the following after 12 weeks of caloric restriction:
Visceral adiposity as measured by dual x-ray absorptiometry (DXA) and 
waist circumference
Fat and lean mass as measured by DXA 
Hepatic steatosis and liver stiffness as measured by transient 
elastography
Lipid profile
REE as measured by indirect calorimetry
Serum biomarkers of inflammation (eg, CRP, TNF-alpha) and immune 
activation
4 Study Population
4.1
Recruitment Plan
Subjects will be recruited from existing National Institutes of Health (NIH) cohorts as 
well as HIV care clinics in the greater Washington, DC area. In addition, we will use the 
OP8 Clinic recruitment strategies that are in place and include a full-time subject 
recruiter and community-based outreach within local area clinics specializing in HIV 
care. 
4.2
Subject Inclusion Criteria
1. Aged 18 to 65 years
2. HIV RNA level ≤200 copies/mL for ≥1 year (1 measure ≥200 allowed if also <500 
and preceded and followed by one or more undetectable values)
3. CD4 >200 cells/mL and no active opportunistic infection or malignancy
4. BMI ≥30 kg/m2
5. One or more components of the metabolic syndrome as defined in the table 
below.

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Table 1. ATPIII Clinical Identification of the Metabolic Syndrome [41]
Risk Factor
Defining Level
Waist circumference
       Men
>102 cm
       Women
>88 cm
Triglycerides
≥150 mg/dL
High density lipoprotein (HDL) 
cholesterol 
      Men
<40 mg/dL
      Women
<50 mg/dL
Blood pressure
≥130/≥85 
mmHg
Fasting glucose
≥110 mg/dL
6. Fasting blood glucose >60 mg/dL at screening
7. Willingness to allow sample storage for future research
8. Able to provide informed consent
4.3
Subject Exclusion Criteria
1. Established diagnosis of diabetes mellitus, use of anti-diabetes medications, or a 
Hgb A1C of >7.0%
2. History of eating disorder, uncontrolled mood or thought disorder, significant 
gastrointestinal disorder or malabsorption, or significant hepatic or renal 
impairment
3. Current use of medical therapy for overweight/obesity including phentermine, 
orlistat, lorcaserin, naltrexone/bupropion, and liraglutide or history of weight loss 
surgery. Concomitant use of medications with side effects known to potentially 
influence appetite are allowed if on a stable dose for at least 12 months
4. History of symptomatic hypoglycemia. 
5. Use of systemic glucocorticoids (stable dose daily inhaled corticosteroid allowed)
6. Chronic viral hepatitis C; subjects with a history of hepatitis C successfully 
treated can enroll >12 months after sustained virologic response
7. Alcohol or substance use disorder in the past year as defined by DSM-V or 
positive urine drug screen
8. Current pregnancy, actively seeking to become pregnant or breastfeeding

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9. Any serious health or other condition which, in the opinion of the PI or their 
designee, could potentially interfere with the ability of a subject to comply with the 
procedures and assessments of the protocol or to safely participate and 
complete the study.
Co-enrollment Guidelines: Co-enrollment in other trials is restricted, other than 
enrollment on observational studies. Study staff should be notified of co-enrollment as it 
may require the approval of the PI.
4.4
Justification for Exclusion of Special Populations
Exclusion of Pregnant and/or Breastfeeding Women:  

Pregnancy: Pregnant women are excluded from this study because the effects 
of ICR on the developing human fetus are unknown. Additionally, the metabolic 
changes associated with pregnancy could would confound assessment of the 
effects of diet intervention.

Breastfeeding: Nursing mothers are excluded from study participation because 
the nutritional needs of nursing mothers require stable caloric intake and the 
potential risk of maternal intermittent fasting nursing is unknown.
Exclusion of Subjects <18 years of age: Persons age <18 years are excluded from 
this study because there are insufficient data regarding the risk of ICR in adults to judge 
the potential risk in growing children and young adults.
Exclusion of Subjects >65 years of age: Persons age >65 are excluded from this 
study because there are insufficient data regarding the risk of ICR in adults <65 years of 
age to judge the potential risk in aging adults. Additionally, changes in body composition 
and resting metabolic rate independent of weight change, occur with advanced age and 
could potentially confound study measures [42].
Exclusion of Subjects Who Cannot Provide Informed Consent: To ensure 
compliance with study-mandated diet and lifestyle, subjects must be able to provide 
initial and ongoing informed consent to participate in this study.
5 Study Interventions 
5.1
Assessment of Subject Compliance with Study Intervention(s) 
Subjects will be asked to keep a daily diary, which will record how well they complied 
with their assigned diet as well as their daily step count. Subjects in the ICR arm will be 
asked to indicate which days they restrict calories. These diaries will be reviewed with 
the study team at all study visits. 
5.2
Concomitant Medications and Procedures 
All concomitant medications, including prescription, over-the-counter, and 
non-prescription medications will be recorded.

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5.3
Prohibited Medications and Procedures 
During study participation, subjects may not initiate medical therapy or undergo surgical 
intervention intended to promote weight loss. Any change in medications, including 
supplement and vitamin use, or proposed surgical intervention should be discussed with 
the study team.
6 Study Schedule and Procedures
6.1
Screening 
The following procedures will be performed at the NIH Clinical Center to determine if a 
subject is eligible for study participation and are expected to be completed over 2 visits:
1. History and physical exam and vital signs including measurement of blood 
pressure, height, and weight
2. Blood collection for laboratory assessments including acute care, hepatic, and 
mineral panels, Hgb A1c, fasting glucose and insulin, fasting lipid profile, 
complete blood counts, CRP, HIV viral load, CD4+ T-cell count, and hepatitis 
serologies
3. Urine studies including urinalysis, urine protein/creatinine ratio and 
albumin/creatinine ratio, and urine drug screen
4. Blood or urine pregnancy testing for women of childbearing potential
5. Nutrition consultation for body composition measurements including weight, and 
waist and hip circumference. Subjects will also receive instructions on completion 
of 3-day food diary.
6. Receive a pedometer and instruction on its use to assess daily activity level
7. 1-day trial of the very low-calorie diet (approximately 25% of estimated needs) to 
assess ability and motivation to lose weight through ICR
6.2
Baseline Assessments
Prior to randomization, subjects will undergo baseline assessments to include:
1. Additional laboratory studies including fasting glucose and insulin (for HOMA-IR), 
lipid panel, CRP, leptin, ghrelin, peptide YY (PYY), BDNF, urine ketones, and 
inflammatory biomarkers
2. Oral glucose tolerance test (OGTT)
3. Indirect calorimetry (REE)
4. Nutrition consultation for review of 3-day food diary and counseling on the AHA 
diet and caloric restriction. Subjects will also receive information on 
recommended physical activity and ways to increase daily steps.
5. Questionnaires:
a. Three-factor eating questionnaire (TFEQ) [43]  

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b. Symptoms Review Questionnaire
c. Beck Depression Inventory II
d. RAND Medical Outcomes Study 36-Item (SF-36; quality of life)
e. Positive and Negative Affect Schedule (PANAS)
f.
Modified visual analog scales (eg, mood, hunger)
6. DXA
7. Blood or urine pregnancy testing for women of childbearing potential 
8. Transient elastography with controlled attenuation parameter (CAP) (Fibroscan®, 
Echosens, Paris, France)
Baseline assessments may be completed over multiple visits within 4 weeks of 
randomization.
6.3
Randomization (Day 0)
Study subjects will be randomized sequentially to the ICR arm or the observation arm.
All subjects will receive dietary counseling consistent with the AHA diet 
recommendations, physical activity recommendations for healthy lifestyle, and a 
pedometer. Subjects randomized to the 2-5 ICR group will implement the AHA diet 
5 days per week, and on 2 non-consecutive days per week, will consume approximately 
25% of estimated caloric need in the form of supplemental beverages or small meals. 
Subjects randomized to the standard-of-care group will receive the AHA dietary 
guidelines, which will include healthy food selection, portion size control, education on 
caloric goals for healthy weight management, physical activity recommendations, and 
pedometers, but not instruction on intermittent fasting. 
6.4
Study Phase (Weeks 1-12)
Interim safety visits will be scheduled for weeks 1, 4, 8, and 12. Subjects will visit the 
NIH Clinical Center as outpatients. The following assessments and procedures will 
occur:
1. Vital signs including weight and blood pressure
2. Physical exam and interval medical history at weeks 4, 8, and 12
3. Fasting blood collection for acute care, hepatic, and mineral panels, insulin, 
glucose and lipids, and CRP, as well as serum, plasma, and PBMCs for storage 
at weeks 4, 8 and 12. Hgb A1C at week 12. Leptin, ghrelin, PYY, BDNF, 
inflammatory markers, urine ketones and HIV viral load will be repeated at 
weeks 4, 8, and 12.
4. Nutrition consultation at weeks 4 and 12: Completion of 3-day food diary and 
waist and hip measurements at weeks 4 and 12
5. Review of subject diary documenting compliance and daily steps at weeks 1, 4, 
8, and 12

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6. Symptoms Review Questionnaire at weeks 1, 4, 8 and 12
7. TFEQ at weeks 4, 8, and 12
8. Modified visual analog scales at week 12
9. At week 12, baseline assessments will be repeated. Assessments include:

Beck Depression Inventory, RAND SF-36, and PANAS questionnaires

REE

OGTT

DXA

Blood or urine pregnancy testing for women of childbearing potential

Transient elastography with CAP (Fibroscan®, Echosens, Paris, France)
Study visit windows are as follows: Week 1: +/-3 days, Weeks 4, 8, and 12: +/- 7 days.
6.5
Final Follow-up Visit (Week 24)
After completing the 12-week randomized portion of the study, subjects will be followed 
for an additional 12 weeks during which time they will not be instructed to follow any 
specific dietary pattern. Both groups’ visits will occur at week 24. (+/- 4 weeks)
The following procedures will be performed:
1. Vital signs including weight and blood pressure 
2. Physical exam and interval medical history
3. Fasting blood collection for acute care, hepatic, and mineral panels, Hgb A1C, 
insulin, glucose and lipids, as well as serum, plasma, PBMCs for storage 
4. Symptoms Review Questionnaire
5. Modified visual analogue scale 
6. Transient elastography with CAP
7. 3-day food diary and anthropometric measurements
8. REE  
9. DXA scan
10.Blood or urine pregnancy testing for women of childbearing potential
6.6
Early Termination Visit
If a subject’s participation is terminated before completing the study, then they will be 
asked to return to the NIH Clinical Center for a Termination Visit. Laboratory tests and 
study evaluations to be conducted at that visit will be determined on the basis of the 
subject’s health, their willingness, and the appropriateness of the test at that time point.

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6.7
Pregnancy and Follow-up Visit 
If a subject becomes pregnant during the course of participation, then her participation 
in the study will be stopped and she will be counseled to discuss diet and nutrition with 
her obstetrician. The study team will request that the subject notify the team of the 
pregnancy outcome.
7 Study Procedures/Evaluations
History and Physical Examination 
The initial history, performed at the screening visit, will consist of a comprehensive 
review of the subject’s medical history, including any previous surgical procedures and 
any previous significant medical conditions. A comprehensive review of systems will 
also be performed. A detailed medication history will be taken. Allergies and all current 
medications will be recorded. Interval history, performed at all subsequent visits, will 
consist of questioning subjects about any new medical issues or any noted changes in 
health. The most recent medication list will be reviewed with subjects to assess for any 
changes in dosing, new medications, or medication discontinuation. Physical 
examination will consist of a review of vital signs as well as examination of general 
appearance (visualization), heart (auscultation), lungs (auscultation), abdomen 
(palpation and auscultation), and extremities (visualization and palpation). Additional 
elements of the physical examination may be performed at the investigator’s discretion.  
Blood Draw
To assess clinical safety parameters, as well as research measures, blood will be drawn 
at time points listed above. 
Table 2. Venipuncture Volumes for Subjects 
Screen
Baseli
ne
Week 1
Week 4
Week 8
Week 12
Week 24
Day +/- Window
−1 to 1
1 ± 1
3 ± 1
5 ±1
8 ± 1
11 ± 1
29 + 6
Safety hematology, 
chemistry and 
OGTT tests
X
26mL
X
22mL
--
X
19mL
X
19mL
X
32mL2
X3
22mL2
Blood for Serum
X
8mL
X
16mL
--
X
16mL
X
16mL
X
16mL
X
16mL
Blood for Plasma 
X
12mL
--
--
X
12mL
X
12mL
X
12mL
X
12mL
Blood for PBL 
Storage
--
20mL
--
20mL
20mL
20mL
20mL
Total volume
46mL
58mL
--
67mL
67mL
80mL
70mL
Total for all study 
visits
388mL

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Pedometer
To assess activity at baseline and the impact of the diet intervention on activity, subjects 
will use a pedometer to record daily steps. This will be recorded on a patient diary and 
reviewed by the study staff at clinic visits.
Transient Elastography and CAP
Liver stiffness will be determined using transient elastography [44] and hepatic fat 
content estimated by CAP. At least ten measurements will be made using the M-probe 
according to the manufacturer’s recommendations and the median will be expressed in 
kilopascal (kPa) units. If measurements from the M-probe are unsuccessful at the 
baseline assessment, the XL probe may be used at the operator’s discretion. Use of the 
XL probe at baseline will be noted, and the XL probe will also be used for subsequent 
assessment of that subject.
Whole Body DXA will be performed to determine total body and regional percent fat, 
lean body mass, and bone density. The technique has a precision error (1 SD) of 3% for 
fat and 1.5% for lean body mass [45]. Trunk, extremity, and trunk-to-extremity ratio will 
also be assessed [46, 47].
REE
REE is measured by indirect calorimetry. Following at least a 4-hour fast, a large plastic 
cover or “bubble” is placed over the subject’s head while a plastic sheet covers the 
subject’s upper body to prevent external air from entering the bubble. Oxygen flows into 
the bubble through a valve at the top. The calorimeter measures the amount of oxygen 
(O2) consumed and the amount of carbon dioxide (CO2) produced while at rest by 
comparing the concentrations of O2 and CO2 in the air inspired by the subject with the 
concentration in the air expired by the subject. The modified Weir equation is used to 
convert the volume of O2 consumed and the volume of CO2 produced per minute into a 
value for REE expressed in calories [48]. 
Genetic Analysis  
PBMCs will be stored and analyzed for single nucleotide polymorphisms that may affect 
metabolism and immunology. 
OGTT
75-g OGTT will be performed with sampling for insulin and glucose at 0, 30, 60,  and 
120 min. 
Nutritional Analysis 
A 3-day food record, completed at baseline and weeks 4 and 12, will be analyzed for 
protein, carbohydrate, fat, micronutrient, and alcohol intake (Nutrition Data Systems). 
Anthropometric Measurements 
Measurements of waist-to-hip ratio will be performed using a standardized technique 
[49].

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TFEQ and Modified Visual Analog Scale
The TFEQ will be administered to measure three aspects of eating attitudes: cognitive 
restraint of eating, disinhibition, and hunger [50]. Modified visual analog scales (VAS) 
will be used to assess subjective hunger and satiety three times a day the days prior to 
week 0 and week 12 assessments [51, 52]. VAS assesses 'desire to eat,' 'hunger', 
'fullness,' and 'prospective consumption.’.
PANAS
Subjects will report on Likert scales how they feel emotionally. The PANAS is a 
common index of emotional state [53].
Symptoms Review Questionnaire
Subjects will report on Likert scales their mood, level of energy, difficulty concentrating, 
headaches, feeling cold, constipation, negative emotions (depression, anxiety, 
irritability), hunger, and preoccupation with food for the week prior to the visit. 
RAND SF-36 scale
This questionnaire gauges physical and psychosocial effects of the dietary 
interventions. It has been used as a quality of life assessment in previous studies of ICR 
[30].
7.1
Return of Research Results
Any clinically relevant test results will be shared with the subject throughout the study. 
Results of research procedures or evaluations (including incidental findings) will be 
shared with participants if they are medically actionable. Such results will be discussed 
with the participant along with guidance for appropriate follow-up with their healthcare 
provider. Any findings discovered beyond the completion of the primary research will not 
be returned.
8 Potential Risks and Benefits
8.1
Potential Risks
Blood Draw. Collection of blood may be associated with discomfort, bruising, local 
hematoma formation and, on rare occasions, infections, lightheadedness, and fainting. 
The amount of blood drawn for research purposes will be within the limits allowed for 
adult subjects by the NIH CC (Medical Administrative Policy 95-9: Guidelines for Limits 
of Blood Drawn for Research Purposes in the Clinical Center: http://cc-
internal.cc.nih.gov/policies/PDF/M95-9.pdf.
Pedometer. No risks are associated with pedometer use and it is associated with 
minimal inconvenience.
OGTT. No serious risks are associated with the OGTT. Some subjects experience 
temporary abdominal discomfort after drinking the sugar solution. If the results of an 
OGTT demonstrate glucose intolerance or insulin resistance, recommendations will be 
made for appropriate follow-up monitoring and management.
REE. Subjects may experience claustrophobia during the measurements.

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Transient elastography. There are no foreseeable risks associated with this non-
invasive procedure.
DXA. Subjects will be exposed to radiation from three DXA scans, for total estimated 
effective dose in 1 year of 0.00007 rem. This is considered a low exposure. The risk of 
this exposure is too low to be reliably measured.
Caloric restriction. [29, 30, 57, 58] In previous studies of ICR, no serious adverse 
events (SAEs) occurred. In the study by Harvie et al., a 6-month trial, 8% of subjects on 
the 2-5 ICR regimen reported physical symptoms including lack of energy, headaches, 
feeling cold, and constipation. Minor psychological symptoms were reported in 15% of 
the 2-5 ICR group, including lack of concentration, bad temper, and a preoccupation 
with food. These adverse effects abated after caloric restriction was stopped [29, 30]. 
Conversely, 6% of 2-5 ICR subjects reported better health and increased energy [30]. 
Furthermore, 32% of 2-5 ICR had increased self-confidence and positive mood. Overall, 
a minority of subjects (9-15%) would be expected to develop minor physical and 
psychological AEs related to 2-5 ICR. Such AEs include lethargy, feeling cold, difficulty 
concentrating, and irritability. Study subjects will be counseled on potential side effects 
and will record symptoms in the diet and symptom diary. 
8.2
Potential Benefits
Subjects may not receive any benefit from this study. However, there is the potential 
that the nutrition counseling and diet support received may result in reductions in weight 
and/or improvements in insulin sensitivity, visceral adipose tissue, hepatitis steatosis, 
and adipose-tissue associated inflammation, potentially reducing cardiovascular 
disease risk. 
9
Research Use of Stored Human Samples, Specimens or 
Data

Intended Use: Samples and data collected under this protocol may be used to 
study HIV, immune disorders, metabolic disorders, and inflammation. Limited 
genetic testing will be performed. 

Storage:  Access to stored samples will be limited using a locked room or locked 
freezer. Samples and data will be stored using codes assigned by the 
investigators. Data will be kept in password-protected computers. Only 
investigators will have access to the samples and data. 

Tracking: Samples and data acquired as part of this protocol will be tracked 
using the Clinical Research Information Management System of the NIAID 
(CRIMSON) database.

Disposition at the Completion of the Protocol: In the future, other 
investigators (both at NIH and outside) may wish to use these samples and/or 
data for research purposes. If the planned research falls within the category of 
“human subjects research” on the part of the NIH researchers, IRB review and 
approval will be obtained. This includes the NIH researchers sending out coded 

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and linked samples or data and getting results that they can link back to their 
subjects.

Reporting the Loss or Destruction of Samples/Specimens/Data to the IRB:
Any loss or unanticipated destruction of samples (for example, due to freezer 
malfunction) or data (for example, misplacing a printout of data with identifiers) 
that meets the definition of a reportable event will be reported to the NIH IRB 
according to Human Research Protections Program (HRPP) Policy 801. 
Additionally, subjects may decide to withdraw from research participation at any 
point and not have their samples stored. In this case, the PI will destroy all known 
remaining samples and report what was done to both the subject and to the IRB. 
This decision will not affect the subject’s participation in other protocols at NIH.
10
Remuneration Plan for Subjects 
Eligible subjects will receive partial remuneration from the NIH for immediate costs 
associated with study-related expenses (eg, transportation and lodging) according to 
established NIH/NIAID guidelines. Subjects will also be compensated for the time and 
inconvenience of study participation according to the attached schedule (see Appendix 
A). Thus, remuneration up to $880 for completion of the entire study, commensurate 
with the time and inconvenience of study participation including blood draws, imaging, 
inpatient assessments, and optional adipose tissue biopsies.
11
Assessment of Safety
11.1 Toxicity Scale
The investigator will assess all AEs with respect to Seriousness (criteria referenced in 
Section 11.3 Definitions), Severity (intensity or grade) and Causality (relationship to 
study interventions according to the following guidelines
Severity: The Investigator will grade the severity of each AE according to the “Division 
of AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric Adverse Events” 
Version 2.1, July 2017, which can be found at:
https://rsc.tech-res.com/docs/default-source/safety/division-of-aids-(daids)-table-for-grading-the-
severity-of-adult-and-pediatric-adverse-events-corrected-v-2-1.pdf
Some grade 1 lab parameters on the DAIDS Toxicity Table (fibrinogen, potassium [low], 
uric acid [males only, elevated]) fall within the NIH lab reference range for normal 
values. These normal values will not be recorded as grade 1 AEs. The grade 1 values 
for these tests will be recorded as follows:
Fibrinogen: 100-176 mg/dL
Potassium (low): 3.0-3.3 mmol/L
Uric acid (males): 8.7-10.0 mg/dL
Magnesium (low): 0.60-0.65 mmol/L
Causality: Causality (likelihood that the event is caused by the study intervention will be 
assessed considering the factors listed under the following categories:

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Definitely Related:

there is no alternative etiology
Probably Related:

reasonable temporal relationship

follows a suspected response pattern (based on similar agents)

no evidence of a more likely alternative etiology
Possibly Related

reasonable temporal relationship

little evidence for a more likely alternative etiology
Unlikely Related

does not have a reasonable temporal relationship
or

good evidence for a more likely alternative etiology
Not related 

does not have a temporal relationship
or

definitely due to an alternative etiology
Other factors will also be considered for each causality category when appropriate. 
Causality assessment is based on available information at the time of the assessment 
of the AE. The investigator may revise the causality assessment as additional 
information becomes available.
11.2 Recording/Documentation
At each contact with the subject, information regarding AEs will be elicited by 
appropriate questioning and examinations. All events, both expected/unexpected and 
related/unrelated will be recorded on a source document. Source documents will include 
progress notes, laboratory reports, consult notes, phone call summaries, survey tools 
and data collection tools. Source documents will be reviewed in a timely manner by the 
research team. All reportable AEs that are identified will be recorded in CRIMSON. The 
start date, the stop date, the severity of each reportable event, and investigator 
judgment of the relationship and expectedness to the study intervention(s) will also be 
recorded in CRIMSON.

reasonable temporal relationship

follows a known response pattern

clear evidence to suggest a causal relationship

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11.3 Definitions
Reportable events and adverse events are defined in NIH HRPP Policy 801.
11.4 Reporting Procedures
Unanticipated problems (UPs), non-compliance, and other reportable events will be 
reported to the NIH IRB according to Policy 801. 
The principal investigator will report UPs, major protocol deviations, and deaths to the 
NIAID clinical director according to institutional timelines.
11.5 Reporting of Pregnancy
In the event of pregnancy:

The subject will discontinue the study intervention (caloric restriction) and 
procedures but continue to follow-up in person and/or over the phone for 
safety and outcome 

Pregnancy will be reported to the IRB

Research subject will be advised to notify the obstetrician of her study 
participation 
11.6 Type and Duration of the Follow-up of Subjects after AEs
AEs that occur from the time of enrollment of the subject are followed until the final 
outcome is known or until the end of the study follow-up period. SAEs that have not 
resolved by the end of the follow-up period are followed until final outcome is known. If it 
is not possible to obtain a final outcome for an SAE (eg, the subject is lost to follow-up), 
then the reason a final outcome could not be obtained will be recorded by the 
investigator.
11.7 Withdrawal of an Individual Subject
An individual subject will be withdrawn for any of the following:

An individual subject’s decision (the investigator will attempt to determine the 
reason for the subject’s decision.)

Non-compliance with study procedures to the extent that it is potentially harmful 
to the subject or to the integrity of the study data.

Any clinical AE, laboratory abnormality, intercurrent illness, other medical 
condition or situation occurs such that continued participation in the study would 
not be in the best interest of the subject.

The subject loses the capacity to provide ongoing informed consent.

Development of an exclusion criteria may be cause for discontinuation.

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11.8 Replacement of a Subject Who Discontinues Study Treatment
If a subject withdraws after fewer than 12 weeks on study diet assignment, then they will 
be replaced. If a subject is replaced, their data will still be included for the safety 
assessments.
11.9 Safety Monitoring Plan
The data gathered during this study will be monitored by the PI for safety and 
compliance with protocol-specified requirements. Subjects will be closely monitored for 
weight loss. If a subject loses ≥5% of their body weight within a 2-week period, 
additional safety visits will be scheduled to monitor body weight more closely. If weight 
loss in that range or greater continues to occur, subjects will be asked to discontinue 
caloric restriction and monitored. 
12 Statistical Considerations 
12.1 Overview and Design
This is a randomized controlled, study of 12 weeks of ICR versus standard of care. 
Changes from baseline to 12 weeks in measures of the primary endpoints (weight and 
insulin sensitivity) and secondary endpoints (eg, hepatic fat content, inflammatory 
biomarkers) will be compared between the 2 study arms. The 12-week follow-up period 
after the randomized portion of the study is designed to monitor changes in weight and 
metabolic parameters after completion of the 2-5 ICR diet arm and the standard-of-care 
arm.
12.2 Study Hypotheses
Subjects in the 2-5 ICR group will experience greater weight loss and greater 
improvements in insulin sensitivity and related metabolic parameters, including 
decreased visceral adipose tissue and hepatic fat content, compared to subjects in the 
standard of care arm.
12.3 Sample Size Justification
Using an alternate day fasting strategy for weight loss in obese adults (n=13), Catenacci 
et al [57] observed that subjects lost 8.2±0.9 kg (mean ± standard error of the mean) 
after 8 weeks. For sample size justification, we will use a conservative estimate of 8-kg 
weight loss after 12 weeks with ICR, and assume 4-kg weight loss among the 
observation group due to monitoring and counselling through study visits. Therefore, 
using the standard deviation estimate from Catenacci et al. of 3.24, we will have 96.7% 
power to detect a 4-kg difference in weight loss between treatment arms with 
25 subjects in each arm. With 17 subjects per arm (ie, approximately a 30% dropout 
rate), the power will be 93.7% to detect a 4-kg difference in weight loss.
In previous studies of ICR, HOMA-IR improvements ranged from 9% to 30%, depending 
on a number of factors, including the duration of the study, extent and timing of caloric 
restriction, and whether or not meals were provided [59]. Assuming a baseline 
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25 subjects per arm, we will have >80% power to detect the difference between a 25% 
improvement in insulin sensitivity with ICR versus a 10% improvement in the 
observation arm as measured by HOMA-IR. The power to detect this difference will be 
72.1% with 17 subjects per arm.
12.4 Description of the Analyses
For the primary endpoint, the between group effect on weight will be tested using a 
two-sided t-test (p-value <0.05) of the calculated change in weight from baseline to 
12 weeks. This will be conducted using on-treatment data, ie, data from all randomized 
subjects who completed baseline and 12 weeks evaluations regardless of reported 
compliance. Similarly, between group differences in insulin resistance measured by 
HOMA-IR will be determined. A secondary analysis will use analysis of covariance to 
adjust for the baseline value of the given endpoint. 
In the analyses of the secondary endpoints (eg, visceral adiposity, serum lipids, markers 
of inflammation, hepatic fat content results), two-sided t-test comparing change from 
baseline to 12 weeks will be calculated between groups. In addition, within group paired 
t-tests may be performed to determine if, during the 12 week follow up if any of the 
changes during the randomized intervention portion of the study are sustained after 
12 weeks of no intervention.
13 Ethics/Protection of Human Subjects
13.1 Informed Consent Process
Informed consent is a process where information is presented to enable persons to 
voluntarily decide whether or not to participate as a research subject. It is an on-going 
conversation between the human research subject and the researchers which begins 
before consent is given and continues until the end of the subject's involvement in the 
research. Coercion and undue influence will be minimized by informing participants that 
their decision to join the study will not affect any medical care they are currently 
receiving or their eligibility to participate in other research studies at the NIH. 
Participants will be given as much time as they need to read the consent form and ask 
questions of the investigators. Participants will also be given time to discuss their 
participation with family members, friends, and other healthcare providers.
Informed consent will be obtained in person in a private setting by a study team member 
authorized to obtain consent. The subjects will sign the informed consent document 
prior to undergoing any research procedures. The subjects may withdraw consent at 
any time throughout the course of the trial. A copy of the informed consent document 
will be given to the subjects for their records. The researcher will document the signing 
of the informed consent form in the subject’s medical record. The rights and welfare of 
the subjects will be protected by emphasizing to them that the quality of their medical 
care will not be adversely affected if they decline to participate in this study. 

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13.1.1 Considerations for Consent of NIH Staff
Even though NIH staff members are not targeted, if they are incidentally enrolled, then 
informed consent will be obtained as detailed above with following additional 
protections:
Consent from staff members will be obtained by an individual independent of the staff 
member’s team whenever possible. Otherwise, the consent procedure will be 
independently monitored by the Clinical Center Department of Bioethics Consultation 
Service in order to minimize the risk of undue pressure on the staff member.
13.2 Subject Confidentiality
All records will be kept confidential to the extent provided by federal, state and local law. 
The study monitors and other authorized representatives of the Sponsor may inspect all 
documents and records required to be maintained by the Investigator, including but not 
limited to, medical records. Records will be kept locked and all computer entry and 
networking programs will be done with coded numbers only. Clinical information will not 
be released without written permission of the subject, except as necessary for 
monitoring by IRB or Office for Human Research Protections. 
To further protect the privacy of study participants, a Certificate of Confidentiality has 
been issued by the NIH. This certificate protects identifiable research information from 
forced disclosure. It allows the investigator and others who have access to research 
records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or 
local level. By protecting researchers and institutions from being compelled to disclose 
information that would identify research participants, Certificates of Confidentiality help 
achieve the research objectives and promote participation in studies by helping assure 
confidentiality and privacy to participants.
14 Data Handling and Record Keeping
14.1 Data Capture and Management 
Study data will be maintained in CRIMSON and collected directly from subjects during 
study visits and telephone calls, or will be abstracted from subjects’ medical records. 
Source documents include all recordings of observations or notations of clinical 
activities and all reports and records necessary to confirm the data abstracted for this 
study. Data entry into CRIMSON will be performed by authorized individuals. The 
Investigator is responsible for assuring that the data collected are complete, accurate, 
and recorded in a timely manner.
14.2 Record Retention
The investigator is responsible for retaining all essential documents listed in the 
International Conference on Harmonisation Good Clinical Practice Guideline. Study 
records will be maintained by the PI for a minimum of 7 years and in compliance with 
institutional, IRB, state, and federal medical records retention requirements, whichever 

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is longest. All stored records will be kept confidential to the extent required by federal, 
state, and local law.
Should the investigator wish to assign the study records to another party and/or move 
them to another location, the investigator will provide written notification of such intent to 
Office of Clinical Research Policy and Regulatory Operations (OCRPRO)/NIAID with the 
name of the person who will accept responsibility for the transferred records and/or their 
new location. NIAID will be notified in writing and written OCRPRO/NIAID permission 
shall be obtained by the site prior to destruction or relocation of research records. 
15 Data Sharing
What data will be shared?
The study team will share human data generated in this study for future research as 
follows 

De-identified data in an NIH-funded repository.

De-identified or identified data with approved outside collaborators under 
appropriate agreements.
How and where will the data be shared? 
Data will be shared through:

An NIH-funded repository. After the study is completed data and samples will be 
transferred and maintained under the following protocol: Protocol for the 
Management and Use of Stored Human Specimens NIAID Protocol Number: 09-
I-N066. 

Approved outside collaborators under appropriate individual agreements.

Publication and/or public presentations.
When will the data be shared? 
At the time of publication or shortly thereafter.
16 References
1.
Hasse, B., et al., Obesity Trends and Body Mass Index Changes After Starting 
Antiretroviral Treatment: The Swiss HIV Cohort Study. Open Forum Infect Dis, 
2014. 1(2): p. ofu040.
2.
Krishnan, S., et al., Changes in metabolic syndrome status after initiation of 
antiretroviral therapy. J Acquir Immune Defic Syndr, 2015. 68(1): p. 73-80.
3.
Lakey, W., et al., Short communication: from wasting to obesity: initial 
antiretroviral therapy and weight gain in HIV-infected persons. AIDS Res Hum 
Retroviruses, 2013. 29(3): p. 435-40.
4.
Tate, T., et al., HIV infection and obesity: where did all the wasting go? Antivir 
Ther, 2012. 17(7): p. 1281-9.

2-5 to WIN
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Page 29 of 33
5.
Morse, C.G., et al., Nonalcoholic Steatohepatitis and Hepatic Fibrosis in HIV-1-
Monoinfected Adults With Elevated Aminotransferase Levels on Antiretroviral 
Therapy. Clin Infect Dis, 2015. 60(10): p. 1569-78.
6.
Thiara, D.K., et al., Abnormal Myocardial Function Is Related to Myocardial 
Steatosis and Diffuse Myocardial Fibrosis in HIV-Infected Adults. J Infect Dis, 
2015. 212(10): p. 1544-51.
7.
Herrin, M., et al., Weight Gain and Incident Diabetes Among HIV-Infected 
Veterans Initiating Antiretroviral Therapy Compared With Uninfected Individuals. 
J Acquir Immune Defic Syndr, 2016. 73(2): p. 228-36.
8.
Achhra, A.C., et al., Short-term weight gain after antiretroviral therapy initiation 
and subsequent risk of cardiovascular disease and diabetes: the D:A:D study. 
HIV Med, 2016. 17(4): p. 255-68.
9.
Dube, M.P., et al., Guidelines for the evaluation and management of dyslipidemia 
in human immunodeficiency virus (HIV)-infected adults receiving antiretroviral 
therapy: recommendations of the HIV Medical Association of the Infectious 
Disease Society of America and the Adult AIDS Clinical Trials Group. Clin Infect 
Dis, 2003. 37(5): p. 613-27.
10.
Jensen, M.D., et al., 2013 AHA/ACC/TOS guideline for the management of 
overweight and obesity in adults: a report of the American College of 
Cardiology/American Heart Association Task Force on Practice Guidelines and 
The Obesity Society. Circulation, 2014. 129(25 Suppl 2): p. S102-38.
11.
Stein, J.H., et al., Prevention strategies for cardiovascular disease in HIV-
infected patients. Circulation, 2008. 118(2): p. e54-60.
12.
Barrios, A., et al., Effect of dietary intervention on highly active antiretroviral 
therapy-related dyslipemia. AIDS, 2002. 16(15): p. 2079-81.
13.
Jones, S.P., et al., Short-term exercise training improves body composition and 
hyperlipidaemia in HIV-positive individuals with lipodystrophy. AIDS, 2001. 
15(15): p. 2049-51.
14.
Fitch, K., et al., Effects of lifestyle modification and metformin on atherosclerotic 
indices among HIV-infected patients with the metabolic syndrome. AIDS, 2012. 
26(5): p. 587-97.
15.
Morse, C.G. and J.A. Kovacs, Metabolic and skeletal complications of HIV 
infection: the price of success. JAMA, 2006. 296(7): p. 844-54.
16.
Colman, R.J., et al., Caloric restriction delays disease onset and mortality in 
rhesus monkeys. Science, 2009. 325(5937): p. 201-4.
17.
Mattison, J.A., et al., Impact of caloric restriction on health and survival in rhesus 
monkeys from the NIA study. Nature, 2012. 489(7415): p. 318-21.
18.
Colman, R.J., et al., Attenuation of sarcopenia by dietary restriction in rhesus 
monkeys. J Gerontol A Biol Sci Med Sci, 2008. 63(6): p. 556-9.

2-5 to WIN
V3.0
10/20/2020
Page 30 of 33
19.
Fontana, L., et al., Long-term calorie restriction is highly effective in reducing the 
risk for atherosclerosis in humans. Proc Natl Acad Sci U S A, 2004. 101(17): p. 
6659-63.
20.
Heilbronn, L.K., et al., Effect of 6-month calorie restriction on biomarkers of 
longevity, metabolic adaptation, and oxidative stress in overweight individuals: a 
randomized controlled trial. JAMA, 2006. 295(13): p. 1539-48.
21.
Roth, G.S., et al., Aging in rhesus monkeys: relevance to human health 
interventions. Science, 2004. 305(5689): p. 1423-6.
22.
Redman, L.M. and E. Ravussin, Endocrine alterations in response to calorie 
restriction in humans. Mol Cell Endocrinol, 2009. 299(1): p. 129-36.
23.
Mattson, M.P. and R. Wan, Beneficial effects of intermittent fasting and caloric 
restriction on the cardiovascular and cerebrovascular systems. J Nutr Biochem, 
2005. 16(3): p. 129-37.
24.
Anson, R.M., et al., Intermittent fasting dissociates beneficial effects of dietary 
restriction on glucose metabolism and neuronal resistance to injury from calorie 
intake. Proc Natl Acad Sci U S A, 2003. 100(10): p. 6216-20.
25.
Wan, R., S. Camandola, and M.P. Mattson, Intermittent fasting and dietary 
supplementation with 2-deoxy-D-glucose improve functional and metabolic 
cardiovascular risk factors in rats. FASEB J, 2003. 17(9): p. 1133-4.
26.
Mager, D.E., et al., Caloric restriction and intermittent fasting alter spectral 
measures of heart rate and blood pressure variability in rats. FASEB J, 2006. 
20(6): p. 631-7.
27.
Griffioen, K.J., et al., Dietary energy intake modifies brainstem autonomic 
dysfunction caused by mutant alpha-synuclein. Neurobiol Aging, 2013. 34(3): p. 
928-35.
28.
Halagappa, V.K., et al., Intermittent fasting and caloric restriction ameliorate age-
related behavioral deficits in the triple-transgenic mouse model of Alzheimer's 
disease. Neurobiol Dis, 2007. 26(1): p. 212-20.
29.
Johnson, J.B., et al., Alternate day calorie restriction improves clinical findings 
and reduces markers of oxidative stress and inflammation in overweight adults 
with moderate asthma. Free Radic Biol Med, 2007. 42(5): p. 665-74.
30.
Harvie, M.N., et al., The effects of intermittent or continuous energy restriction on 
weight loss and metabolic disease risk markers: a randomized trial in young 
overweight women. Int J Obes (Lond), 2011. 35(5): p. 714-27.
31.
Wegman, M.P., et al., Practicality of intermittent fasting in humans and its effect 
on oxidative stress and genes related to aging and metabolism. Rejuvenation 
Res, 2015. 18(2): p. 162-72.
32.
Klempel, M.C., et al., Intermittent fasting combined with calorie restriction is 
effective for weight loss and cardio-protection in obese women. Nutr J, 2012. 11: 
p. 98.

2-5 to WIN
V3.0
10/20/2020
Page 31 of 33
33.
Kroeger, C.M., et al., Improvement in coronary heart disease risk factors during 
an intermittent fasting/calorie restriction regimen: Relationship to adipokine 
modulations. Nutr Metab (Lond), 2012. 9(1): p. 98.
34.
Bhutani, S., et al., Improvements in coronary heart disease risk indicators by 
alternate-day fasting involve adipose tissue modulations. Obesity (Silver Spring), 
2010. 18(11): p. 2152-9.
35.
Varady, K.A., et al., Improvements in body fat distribution and circulating 
adiponectin by alternate-day fasting versus calorie restriction. J Nutr Biochem, 
2010. 21(3): p. 188-95.
36.
Yamanaka, M., et al., Brain-derived neurotrophic factor enhances glucose 
utilization in peripheral tissues of diabetic mice. Diabetes Obes Metab, 2007. 
9(1): p. 59-64.
37.
Tsuchida, A., et al., The effects of brain-derived neurotrophic factor on insulin 
signal transduction in the liver of diabetic mice. Diabetologia, 2001. 44(5): p. 555-
66.
38.
Nonomura, T., et al., Brain-derived neurotrophic factor regulates energy 
expenditure through the central nervous system in obese diabetic mice. Int J Exp 
Diabetes Res, 2001. 2(3): p. 201-9.
39.
Mattson, M.P., et al., Meal frequency and timing in health and disease. Proc Natl 
Acad Sci U S A, 2014. 111(47): p. 16647-53.
40.
Hui, L., et al., Ketone bodies protection against HIV-1 Tat-induced neurotoxicity. 
J Neurochem, 2012. 122(2): p. 382-91.
41.
Grundy, S.M., et al., Diagnosis and management of the metabolic syndrome: an 
American Heart Association/National Heart, Lung, and Blood Institute Scientific 
Statement. Circulation, 2005. 112(17): p. 2735-52.
42.
St-Onge, M.P. and D. Gallagher, Body composition changes with aging: the 
cause or the result of alterations in metabolic rate and macronutrient oxidation? 
Nutrition, 2010. 26(2): p. 152-5.
43.
de Lauzon, B., et al., The Three-Factor Eating Questionnaire-R18 is able to 
distinguish among different eating patterns in a general population. J Nutr, 2004. 
134(9): p. 2372-80.
44.
Sandrin, L., et al., Transient elastography: a new noninvasive method for 
assessment of hepatic fibrosis. Ultrasound Med Biol, 2003. 29(12): p. 1705-13.
45.
Mazess, R.B., et al., Dual-energy x-ray absorptiometry for total-body and regional 
bone-mineral and soft-tissue composition. Am J Clin Nutr, 1990. 51(6): p. 1106-
12.
46.
Hadigan, C., et al., Fasting hyperinsulinemia and changes in regional body 
composition in human immunodeficiency virus-infected women. J Clin Endocrinol 
Metab, 1999. 84(6): p. 1932-7.

2-5 to WIN
V3.0
10/20/2020
Page 32 of 33
47.
Falutz, J., et al., A placebo-controlled, dose-ranging study of a growth hormone 
releasing factor in HIV-infected patients with abdominal fat accumulation. AIDS, 
2005. 19(12): p. 1279-87.
48.
Weir, J.B., New methods for calculating metabolic rate with special reference to 
protein metabolism. 1949. Nutrition, 1990. 6(3): p. 213-21.
49.
Lohman, T.G., A.F. Roche, and R. Martorell, Anthropometric standardization 
reference manual. 1988, Champaign, IL: Human Kinetics Books. vi, 177 p.
50.
Stunkard, A.J. and S. Messick, The three-factor eating questionnaire to measure 
dietary restraint, disinhibition and hunger. J Psychosom Res, 1985. 29(1): p. 71-
83.
51.
Burley, V.J., et al., Across-the-day monitoring of mood and energy intake before, 
during, and after a very-low-calorie diet. Am J Clin Nutr, 1992. 56(1 Suppl): p. 
277S-278S.
52.
Bond, A.J., D.C. James, and M.H. Lader, Physiological and psychological 
measures in anxious patients. Psychol Med, 1974. 4(4): p. 364-73.
53.
Crawford, J.R. and J.D. Henry, The positive and negative affect schedule 
(PANAS): construct validity, measurement properties and normative data in a 
large non-clinical sample. Br J Clin Psychol, 2004. 43(Pt 3): p. 245-65.
54.
McDonnell, J., et al., Minimal cognitive impairment in UK HIV-positive men who 
have sex with men: effect of case definitions and comparison with the general 
population and HIV-negative men. J Acquir Immune Defic Syndr, 2014. 67(2): p. 
120-7.
55.
Cysique, L.A., et al., The assessment of cognitive function in advanced HIV-1 
infection and AIDS dementia complex using a new computerised cognitive test 
battery. Arch Clin Neuropsychol, 2006. 21(2): p. 185-94.
56.
Falleti, M.G., et al., Practice effects associated with the repeated assessment of 
cognitive function using the CogState battery at 10-minute, one week and one 
month test-retest intervals. J Clin Exp Neuropsychol, 2006. 28(7): p. 1095-112.
57.
Catenacci, V.A., et al., A randomized pilot study comparing zero-calorie 
alternate-day fasting to daily caloric restriction in adults with obesity. Obesity 
(Silver Spring), 2016. 24(9): p. 1874-83.
58.
Williams, K.V., et al., The effect of short periods of caloric restriction on weight 
loss and glycemic control in type 2 diabetes. Diabetes Care, 1998. 21(1): p. 2-8.
59.
Barnosky, A.R., et al., Intermittent fasting vs daily calorie restriction for type 2 
diabetes prevention: a review of human findings. Transl Res, 2014. 164(4): p. 
302-11.

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V3.0
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APPENDICES
Appendix A: Remuneration Schedule