Development of a Novel Asian Mediterranean Diet and Its Acceptability in Non- Alcoholic Fatty Liver Disease (NAFLD)- a Pre-intervention Study
Conditions: Fatty Liver, Nonalcoholic
Sponsor: Singapore Institute of Technology

Associate Professor Verena Tan Ming Hui 
SINGAPORE INSTITUTE OF TECHNOLOGY  10 Dover Drive, Singapore 138683 
Study Protocol and Statistical Analysis Plan 
 
Development of a Novel Asian Mediterranean Diet and Its Acceptability in NAFLD 
 
02 Feb 2024 
  

Overview 
This will be the first study that aims to develop an Asian version of the clinically 
beneficial Mediterranean diet using ingredients commonly consumed in the Asian diet. 
With the developed AMD, we then aim to evaluate its acceptability among subjects with 
NAFLD. Despite numerous studies conducted using the Mediterranean diet in NAFLD, 
there is a paucity of information of the acceptability of Mediterranean diet among Asian 
patients with NAFLD. This can be attributed to the cultural differences in dietary habits 
between the western Mediterranean diet and the Asian cuisine. This study aims to 
reconstruct the traditional Mediterranean diet using Asian recipes and food preparation 
techniques and evaluate its acceptability in Asian subjects with NAFLD.     
Study Protocol 
There will be 2 phases to this study:   
Phase 1 – Asian Mediterranean Diet Development  
This phase of the study involves desktop research and recipe trials in SIT, and does not 
require IRB review as no human subjects are involved.  We will ascertain the nutritional 
composition of the traditional Mediterranean diet by conducting a comprehensive 
literature review. This review will help us map out the portion sizes of foods commonly 
consumed in Mediterranean countries that adhere closely to this diet. Following this, we 
will identify substitute ingredients that are frequently consumed in the Asian diet. 
Subsequently, we will review the polyphenol studies and match the polyphenol content 
of both Mediterranean to Asian ingredients. The serving sizes of these ingredients will be 
determined based on this mapping.  Using this information, we will develop a 4-week 
cycle menu for an Asian Mediterranean diet.     
Phase 2 – Sensory Evaluation Study  
We will collaborate with a food catering company with SFA license to produce the 
recipes for 1 of the weeks in the 4-week cycle menu. Recipe trials will be conducted by 
the food company. Finalized recipes will be packaged as ready-to-eat meals for use in 
Phase 2 of our study.   

Study Population  
We plan to recruit 30 adults diagnosed with NAFLD from the Department of Hepatology 
in Singapore General Hospital.  
Inclusion criteria include: 
 
Diagnosis of NAFLD, as determined clinically by imaging evidence of hepatic 
steatosis on ultrasound/CT/MRI.  
 
Aged from 21 to 60 years old. 
Exclusion criteria include: 
 
Secondary causes of NAFLD (e.g. medication-induced), unstable  body weight 
(variation >5% within the preceding 3 months),  
 
Current use of weight loss medications,  
 
Other liver diseases (viral hepatitis, auto-immune or cholestatic liver disease, 
Wilson’s disease, hemochromatosis, alpha-1 anti  trypsin deficiency),  
 
Unstable diabetes (HbA1c >8.5%),  
 
Renal failure,  
 
Inability to provide informed consent,  
 
Pregnancy and lactation,  
 
Problems with tasting and smelling,  
 
Food allergy/intolerances/restrictions.   
Study Visits Procedure  
All eligible subjects will be given a participant information sheet and a consent form if 
they wish to participate in the study. The PI will also be available for any clarifications 
either through phone call or via email. With permission from the subjects, the SIT 
research team will message them to remind subjects of the requirements before coming 
for their study visits.  Anthropometric data (weight, height, body mass index, waist 
circumference) and body composition using bioelectrical impedance will be assessed.  
Recruited subjects will be invited to SIT@Dover campus tentatively in the months of Mar  
2024 to Dec 2024 for two sessions of sensory evaluation test on the acceptability of the 
Asian Mediterranean diet (AMD) sample meals. All the ready meals will be heated up to 

the required temperature before consumption. Subjects will taste a total of 14 different 
food items, over 2 study visits. This is to minimize taste fatigue if more than 5-7 samples 
are tasted at each study visit. After tasting the food items, subjects will be required to 
evaluate the food items tasted. A sensory evaluation form will be provided to the 
subjects. Subjects are required to complete the form before leaving the food tasting lab. 
The duration of each session is expected to take 60 minutes. Reimbursement will be 
given upon the completion of both study visits.   
Sensory evaluation food tasting preparatory steps will involve: 
1. All ready meals will be reheated to the appropriate consumption temperature 
when the subject arrives at SIT’s food-tasting lab.   
2. All trays, crockeries and cutleries will be provided. Environment settings will be 
standardised throughout all sessions.   
3. Subject verification and registration will be carried out before subjects enter the 
food-tasting lab.   
4. Before the commencement of the food-tasting session, subjects will be briefed on 
the food-tasting procedure and instructions.   
5. A total of 7 food items will be served to participants and 50g of each food 
product will be portioned out. A pictorial illustration of the actual ready meal will 
be provided to the subject.   
6. Subjects will be required to fill up the online food-tasting evaluation forms.   
7. Throughout the tasting session, subjects will not be allowed to communicate with 
other subjects in the food-tasting lab.   
8. Subjects will leave the food-tasting lab when they have finished evaluating all the 
food items.   
9. Trays, crockeries, and cutleries will be collected back. 
Statistical Analysis Plan 
As we are piloting the novel Asian Mediterranean diet, the primary objective is to obtain 
comments and feedback on the acceptability of the ready meals from NAFLD patients. 
The sensory data from this study were analysed using a Kruskal–Wallis test, and a one-

way analysis of variance (ANOVA) was used with significant differences detected for p 
<0.05.   
Information about liver enzymes (ALT, AST, Albumin, bilirubin, alkaline phosphatase, and 
GGT), platelet count, and lipid profile (total cholesterol, LDL, HDL, TG) will be obtained 
from the subjects’ medical records using the most recent laboratory data.  Subjects will 
be required to complete a semi-quantitative food frequency questionnaire (FFQ) that 
includes foods and beverages commonly consumed in Singapore. The aim is to assess 
subjects' usual dietary intake over the past 6 months and evaluate their baseline dietary 
intake and adherence to the Mediterranean Diet.  
Data collected by collaborators will be anonymized. Recruited participants will be de-
identified through a subject ID to ensure the responses are kept anonymous.  
Participants’ identifiable information like names, contact numbers, emails, gender, race, 
and age will be collected and stored securely in an encrypted password-protected file. 
Identity of participants will be kept in a separate file from the research data. Only the 
study investigators will have access to this file. The files containing all research data will 
be password-protected and stored in project PDDS folder. Access to data will be 
restricted to only authorised people who are involved in this study. The data will be 
retained in SIT for 10 years in line with SIT Research Data Management Policy Version 
1.1.