The Influence of Glycemic Control and Obesity on Energy Balance and Metabolic Flexibility in Type 1 Diabetes
Conditions: Type 1 Diabetes
Sponsor: AdventHealth Translational Research Institute

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 1 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Study Protocol Title: 
The Influence of Glycemic Control and Obesity on Energy Balance and Metabolic Flexibility in 
Type 1 Diabetes. 
 
 
Study Sponsor:   
Florida Hospital 
 
Principal Investigator: 
 
Translational Research Institute for Metabolism and Diabetes 
Richard Pratley, MD  
Senior Investigator and Diabetes Program Lead, Translational Research Institute for Metabolism 
and Diabetes 
Adjunct Professor, Sanford Burnham Prebys Medical Discovery Institute 
301 Princeton Ave 
Orlando, Florida 32804 
Phone: 407 303-2519 
Fax: 407 303-2507 
Richard.Pratley@flhosp.org 
 
 
Sub-Investigators: 
Translational Research Institute for Metabolism and Diabetes 
Karen D, Corbin, PhD, RD 
Investigator 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 2 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Table of Contents: 
 
List of Abbreviations: ..................................................................................................................... 5 
Introduction ..................................................................................................................................... 7 
Background Information and Scientific Rationale ......................................................................... 7 
Study Objectives ............................................................................................................................. 8 
Primary Objective/Aim/Goal/Hypothesis ................................................................................... 8 
Secondary Objective/Aim/Goal/Hypothesis ............................................................................... 8 
Study Design ................................................................................................................................... 8 
Research Design.......................................................................................................................... 8 
Study Agent, Device, and/or Intervention Description ............................................................... 9 
Study Site(s)/Location(s) and Number of Subjects .................................................................... 9 
Multi-Site Research Logistics/Communication Plan ................................................................ 10 
Research Conducted in a Foreign Country ............................................................................... 10 
Community-Based Participatory Research ............................................................................... 10 
Subject Selection ........................................................................................................................... 11 
Vulnerable Populations ............................................................................................................. 11 
Inclusion Criteria ...................................................................................................................... 11 
Exclusion Criteria ..................................................................................................................... 11 
Resources Available...................................................................................................................... 12 
Study Procedures .......................................................................................................................... 12 
Subject Recruitment and Screening .......................................................................................... 12 
Consent Process ........................................................................................................................ 13 
Non-English Speaking Subjects ................................................................................................ 13 
Subjects who are not yet adults (infants, children, teenagers) .................................................. 13 
Not applicable ........................................................................................................................... 13 
Cognitively Impaired Adults ..................................................................................................... 13 
Not applicable ........................................................................................................................... 13 
Not applicable ........................................................................................................................... 13 
Documentation of Informed Consent Process .......................................................................... 13 
Waiver of Written Documentation of Consent or Waiver of Consent ...................................... 13 
Not applicable ........................................................................................................................... 13 
Randomization .......................................................................................................................... 13 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 3 of 39 
Research Study protocol template version date 11/3/2016 
 
Study Visits ............................................................................................................................... 14 
Analytical / Clinical procedures................................................................................................ 19 
Medical History and Physical Exam ..................................................................................... 19 
Anthropometric Screening .................................................................................................... 19 
Vital Sign Measurements ...................................................................................................... 19 
Study Duration .......................................................................................................................... 26 
Materials of Human Origin:  Collection, Preparation, Handling and Shipping........................ 26 
Study Outcome Measures (Endpoints) ......................................................................................... 27 
Data Management and Quality Plan ............................................................................................. 28 
Data De-identification ............................................................................................................... 28 
Data Confidentiality, Storage, and Retention ........................................................................... 28 
Data Quality .............................................................................................................................. 29 
Data Sharing (outside of Florida Hospital) ............................................................................... 29 
Sample Size Determination........................................................................................................... 30 
Statistical Analysis Plan ................................................................................................................ 30 
Details of analytical procedures will be documented in a Statistical Analysis Plan. ................... 30 
Primary Objective Analysis ...................................................................................................... 30 
Secondary Objective Analysis .................................................................................................. 30 
Potential Risks and Benefits ......................................................................................................... 31 
Potential Benefits ...................................................................................................................... 31 
Potential Risks .......................................................................................................................... 31 
Mitigation of Risks ................................................................................................................... 33 
Provisions to Protect the Privacy Interest of Subjects .............................................................. 33 
Early Withdrawal of Subjects ....................................................................................................... 33 
Investigator Withdrawal of Subjects ......................................................................................... 33 
Subject Request for Withdrawal from Study ............................................................................ 34 
Data Collection and Follow-up for Withdrawn Subjects .......................................................... 34 
Adverse Event Reporting .............................................................................................................. 34 
Recording and Notification of Adverse Events ........................................................................ 34 
Safety Monitoring Plan ................................................................................................................. 34 
Safety Monitoring ..................................................................................................................... 35 
Data and Safety Monitoring Board (DSMB) or Equivalent ..................................................... 35 
Ethical Considerations .................................................................................................................. 35 
Sharing of Results with Subjects .............................................................................................. 35 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 4 of 39 
Research Study protocol template version date 11/3/2016 
 
Funding Source ............................................................................................................................. 35 
Subject Stipends or Payments ....................................................................................................... 35 
Publication Plan ............................................................................................................................ 36 
References ..................................................................................................................................... 36 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 5 of 39 
Research Study protocol template version date 11/3/2016 
 
List of Abbreviations: 
ACT1ON- Advancing Care for Type 1 Diabetes Obesity Network 
AE- Adverse event 
ALT - Alanine aminotransferase 
AST - Aspartate aminotransferase 
BIS-15 - Barratt Impulsiveness Scale  
BMI - Body mass index 
BP - Blood Pressure 
CAP™ - Controlled Attenuation Parameter 
CBC - Complete Blood count 
CES-D - Center for Epidemiological Studies-Depression  
CGM – Continuous glucose monitoring 
CITI - Collaborative Institutional Training Initiative  
CMP - Comprehensive Metabolic Panel 
Conmed- Concomitant medication 
Co-PI - Co- Principal Investigator 
CRF - Case Report Forms 
CRU – Clinical Research Unit 
DCCT – Diabetes Control and Complications Trial 
DEPS-R - Diabetes Eating Problem Survey 
DEXA – Dual-Energy X-ray Absorptiometry  
DI - Diabetes Institute 
DKA – diabetic ketoacidosis 
DSMB - Data and Safety Monitoring Board  
EE – Energy Expenditure  
EKG - Electrocardiogram 
FDA- Food and Drug Administration  
FH - Florida Hospital 
FISMA - Federal Information Security Management Act 
GCP- Good Clinical Practices 
GFR - Glomerular filtration rate 
GI- Gastrointestinal 
HIPPA - Health Insurance Portability and Accountability Act 
ICH- International Conference on Harmonization 
IHL - Intrahepatic Lipid 
IRB - Institutional Review Board 
jMRUI - Java-Based Magnetic Resonance User Interface 
kcal - kilogram calorie 
kPa  - kilopascals  
LDL - Low density lipoprotein 
LSM - Liver stiffness measurement 
MFC - Mass flow controllers 
mmol/L – millimoles per liter 
MPI - Multi Principal Investigator  
MRE - Magnetic Resonance Elastography 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 6 of 39 
Research Study protocol template version date 11/3/2016 
 
MRI - Magnetic Resonance Imaging 
MRS - Magnetic Resonance Spectroscopy  
NCT – ClinicalTrials.gov registry number 
NDSR - Nutrient Data System for Research 
NIDDK  - National Institute of Diabetes and Digestive and Kidney Diseases 
NIH - National Institute of Health 
PDFF- Proton Density Fat Fraction 
PDPAR - Physical Activity Recall  
PHI - Protected Health Information  
PI - Principal Investigator 
PID -Participant Identifier 
PRESS - point resolved spectroscopy  
QBC - quadrature body coil 
RD - Registered Dietician 
rDNA- Recombinant Deoxyribonucleic Acid 
RNA-seq - RNA sequencing 
RPAQ - Recent Physical Activity Questionnaire 
RQ  Respiratory Quotient 
SBPMDI - Sanford Burnham Prebys Medical Discovery Institute  
SDV - Source Data Verification  
SIRS - Sheps Integrated Research System  
SOP - Standard operating procedures 
SSL - Secure Sockets Layer  
SSP - Study Specific Procedures  
T1D – Type 1 Diabetes 
THC - Tetrahydrocannabinol  
TRI-MD – Translational Research Institute for Metabolism and Diabetes 
TSH- Thyroid stimulating hormone 
UNC - University of North Carolina 
UNC- NORC - University of North Carolina Nutrition Obesity Research Center  
USDA  - United States Department of Agriculture 
VCH4 – Methane production 
VCO2 – Carbon dioxide production 
VCTE™ - vibration-controlled transient elastography 
VO2 – Oxygen consumption 
  
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 7 of 39 
Research Study protocol template version date 11/3/2016 
 
Introduction 
This document describes a clinical research protocol to investigate the influence of glycemic 
control and obesity on energy balance and metabolic flexibility in T1D. The study will be 
conducted in compliance with the protocol, Good Clinical Practices (GCP) International 
Conference on Harmonization (ICH) Guidelines (E6) for GCPs standards as adopted by the Food 
and Drug Administration (FDA) and associated Federal regulations, and all applicable institutional 
research requirements.  
 
Note: Minor modifications have been made to this protocol compared to the original grant with 
respect to the flow of events and number of visits (particularly, the addition of an extra inpatient 
visit for metabolic acclimatization). We also removed some procedures due to budget cuts: 4-
Hour Mixed MEAL Test and Ad-Libitum Buffet Test Meal. In addition to the portion funded by 
the NIH (Phase 1), this IRB protocol includes a second set of studies (Phase 2) that will be 
funded by internal funds. We also added procedures to Phase 1 that are not included in the 
original grant and will be covered by internal funds: 1) FibroScan/MRE/Whole Body MR for 
acquiring more in-depth data on metabolism and fat deposition and 2) Stool collection for future 
analysis of the gut microbiome. This IRB protocol covers only the aim of the grant that will be 
completed at TRI (Aim 1, Study 1).  
 
Background Information and Scientific Rationale 
There has been an alarming increase in the prevalence of obesity in type 1 diabetes (T1D) in recent 
years. Among young adults with T1D, recent data indicate that 31% are overweight and 15% are 
obese [1]. Consistent with longitudinal studies that have shown that obesity increases in people 
with T1D as they age, other studies have shown that the prevalence of overweight and obesity 
exceeds 50% in adults with T1D [1-4]. Thus, the prevalence of overweight and obesity in patients 
with T1D now approaches that of the general population.  
While some of the increase in obesity in patients with T1D is likely due to temporal trends in diet 
and physical activity affecting the population at large, it is probable that the widespread adoption 
of intensive insulin therapy for the treatment of T1D has also contributed to the increases in obesity 
in this population. The US Diabetes Control and Complications Trial (DCCT) demonstrated that 
intensive insulin therapy significantly decreased risk for microvascular complications, but also 
showed that this intervention was associated with significant weight gain [5]. Emerging evidence 
suggests that obesity contributes to insulin resistance, dyslipidemia and cardiometabolic 
complications in T1D [6,7]. For example, participants in the DCCT intensive treatment arm who 
experienced excessive weight gain manifested a worse cardiometabolic profile [6]. 
Young adults with T1D, in particular, appear to struggle to manage the competing priorities of 
glycemic control and optimal weight. Recent T1D Exchange data demonstrate age-dependent 
increases in HbA1c, with a peak mean of over 9% in 17-year-olds, which remains elevated above 
8% until age 30 y [8]. Some patients with T1D omit insulin or purposefully deliver less insulin 
than is needed to avoid weight gain [9]. Uncontrolled diabetes causes glucosuria and an increase 
in metabolic rate [10]. These adaptations promote weight loss at the expense of higher HbA1c 
levels and an increased risk of complications.  
The American Diabetes Association recommends that for “overweight or obese adults with type 2 
diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to 
promote weight loss” but does not address obesity management for T1D [11]. Standard equations 
for estimating energy expenditure and dietary requirements in healthy individuals are not adequate 
for those with T1D. First, in patients with uncontrolled T1D, glycosuria can account for 300-400 
kcal/day in obligate energy losses [5]. Second, most studies demonstrate a modest increase in 
resting energy expenditure (REE; range=100-300 kcal/day) in people with T1D relative to healthy 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 8 of 39 
Research Study protocol template version date 11/3/2016 
 
controls or predicted values [5-9]. Finally, there are virtually no prospective studies of obesity 
treatment in patients with T1D on which to base recommendations.  
There is, thus, an urgent need for specific, evidence-based recommendations for the prevention 
and management of obesity in T1D aimed at optimizing not just one, but two key outcomes; 
glycemic control and weight status. To facilitate the development of these recommendations, we 
propose to develop a quantitative model of energy balance in young adults with T1D, accounting 
for differences in sex, glycemic control and body composition. The model will address energy 
requirements in T1D and provide preliminary data on variability in macronutrient metabolism. 
This information is important for designing interventions that are better matched to metabolic 
needs and, thus, are more likely to lead to successful control of blood glucose and weight. Further, 
we will pilot a dietary intervention to promote weight loss and improved glycemic control.    
 
Study Objectives 
 
Primary Objective/Aim/Goal/Hypothesis 
             The Primary Objective of this study is to develop a comprehensive model of energy   
             balance and metabolic flexibility for T1D that accounts for the degree of hyperglycemia  
             and differences in body composition.  
 
             To address this aim, we will enroll 33 young adults 19-30 years of age (8 lean T1D, 8  
             overweight T1D, and 8 obese T1D, with 3 sex- and weight-matched non-diabetic  
             controls for each group), measure body composition (DEXA and whole-body MRI) and  
             measure 24-hour energy expenditure and substrate oxidation rates in the respiratory  
             chambers at the Translational Research Institute for Metabolism and Diabetes (TRI-MD).  
 
Secondary Objective/Aim/Goal/Hypothesis 
The Secondary Objective of this research protocol is to: Perform a pilot study of the 
safety, tolerability and metabolic effects of a 4-week low-carbohydrate calorie-restricted 
diet intervention on glycemic control, body weight, liver fat and volume, body 
composition and energy expenditure on overweight and obese subjects. 
 
Study Design 
Research Design 
This is a non-randomized, cross sectional study comparing the metabolic phenotype of a range of 
body weights in individuals with and without T1D. We will assess the same parameters only in 
overweight and obese individuals to T1D after 1 month of a low carbohydrate, reduced calorie 
diet. This research protocol consists of 2 phases.  
 
Phase 1: This phase of this research protocol consists of a cross-sectional study in 24 weight-stable 
young adults (~12 males, 12 females; 19-30 years of age) with T1D of at least 1-year duration and 
a range of glycemic control (A1c 6.5-13%) and age (also 19-30 years of age), sex, and BMI (+/- 3 
kg/m2) matched non-diabetic controls (total n=33). Participants will be divided equally among 3 
groups: lean (BMI 18-24.9 kg/m2), overweight (BMI  25-29.9 kg/m2), and obese (BMI 30-39.9 
kg/m2). Participants with T1D can be on any insulin delivery method for their medical care and 
will remain on their own program throughout the study. Participants will be admitted to the TRI 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 9 of 39 
Research Study protocol template version date 11/3/2016 
 
Clinical Research Unit (CRU) for 4 days (3 nights) for a comprehensive metabolic assessment, 
including measurement of body composition by Dual Energy X-ray Absorptiometry (DEXA) and 
whole-body MRI, continuous glucose monitoring (CGM), and 24-hour energy expenditure and 
substrate oxidation rates in whole room calorimeters with simultaneous measurement of 24-hour 
urinary glucose excretion. From these data we will develop a comprehensive model of energy 
balance for young adults with T1D that accounts for clinically relevant factors including sex, 
glycemia, insulin use and body composition. 
 
Phase 2: This phase consists of a 4-week low-carbohydrate calorie-restricted dietary intervention 
on glycemic control, body weight, body composition and energy expenditure. Overweight and 
obese participants with T1D from Phase 1 (n = 10) will be asked to alter their diet under the 
guidance of a nutritionist or registered dietitian (RD) and the medical team over a 4-week period 
(3 weeks outpatient self-selected, 5 days outpatient with provided meals and 2 days inpatient). 
After approximately 4 weeks on this diet, participants will return to the TRI-MD for re-evaluation 
using a protocol identical to that employed at baseline (Phase 1). 
  
Study Agent, Device, and/or Intervention Description  
The Phase 2 diet prescription will have a 500 kcal/day calorie deficit and will contain 
approximately 14% of calories from carbohydrate. Participants/Study Staff will perform 
continuous glucose monitoring via CGM or Point of Care (POC) blood glucose for the entire 
period so that insulin can be adjusted as necessary to prevent hypoglycemia. They will meet weekly 
with a nutritionist or a registered dietitian either in person or by phone and have their insulin 
adjusted on a daily basis or as needed in consultation with the PI and the medical staff of the TRI.  
 
Twenty-four hour heart rate monitoring will be performed simultaneously with energy 
expenditure measurements in the chamber to allow calibration and refinement of the model for 
free-living energy expenditure we will derive in patients with type 1 diabetes. As such, this data 
is not a primary or secondary endpoint, but is considered exploratory. Heart rate data from 
wearable devices could then be used, along with age, sex, HbA1c and estimates of body 
composition to provide more accurate estimates of energy requirements for dietary interventions, 
for example.  There are no safety issues that require heart rate monitoring in this particular 
population or study. We do not anticipate any output from this monitoring that would require 
real-time monitoring, consequently, we will only use the device to capture data for subsequent 
downloading.  
 
Study Site(s)/Location(s) and Number of Subjects 
This study will be conducted by Investigators at the Florida Hospital Translational Research 
Institute for Metabolism and Diabetes (TRI-MD). All study visits will take place at the TRI-MD 
facility. This study represents one aim of a multicenter NIH grant awarded to UNC Chapel Hill 
on which Dr. Pratley is a PI and Dr. Corbin is a Co- PI. 
 
Estimated number of subjects enrolled at TRI-MD:  
33 weight-stable young adult participants. 
 
Name of external site(s) outside of Florida Hospital:  

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 10 of 39 
Research Study protocol template version date 11/3/2016 
 
N/A 
 
Estimated number of subjects at external sites:  
0 
 
Total number of all sites:  
1  
 
Estimated number of subjects at all sites combined:  
33 
 
Multi-Site Research Logistics/Communication Plan 
Florida Hospital TRI-MD is the single clinical site enrolling participants.  
 
Florida Hospital is sharing samples and data with other investigators. 
• All other sites conducting work on samples collected during the clinical study will 
have the most current version of the protocol, consent document, and HIPAA 
authorization. 
• All required approvals will have been obtained at each site (including approval by the 
site’s IRB of record). 
• All modifications will have been communicated to sites, and approved (including 
approval by the site’s IRB of record) before the modification is implemented. 
• All engaged participating sites will safeguard data as required by local information 
security policies. 
• All local site investigators will conduct the study appropriately. 
• Any non-compliance with the study protocol or applicable requirements will be 
reported in accordance with local policy. 
Describe the method for communicating to participating sites:  
• Problems - will be handled as per the attached MPI plan as submitted to NIH 
• The closure of a study - will be handled as per the attached MPI plan as submitted to 
NIH 
Research Conducted in a Foreign Country 
               Not Applicable  
 
Community-Based Participatory Research 
               Not Applicable  
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 11 of 39 
Research Study protocol template version date 11/3/2016 
 
Subject Selection 
Vulnerable Populations  
Florida Hospital (FH) Employees: Recruitment efforts will follow FH recruitment Standard 
Operating Procedures (SOPs) for research. FH Employees will not be individually targeted nor 
excluded from study participation based on employment. FH employees who engage the TRI-MD 
asking to participate in the study will be processed per standard consent procedures for 
participants.  In addition, during the consent process, the study staff will review standard consent 
language stating that an employee’s participation or lack of participation in the study will not affect 
their employment status or relationship with Florida Hospital. 
Cognitively impaired individuals, children or people incarcerated in a correction facility will not 
be recruited. 
 
Inclusion Criteria 
Subjects must meet all of the following criteria to be eligible for participation: 
 
1. Males and females, 19 to 30 years of age, inclusive. 
2. Type 1 Diabetes Cohort: 
a. Diagnosis of type 1 diabetes for greater than 1 year at screening. 
b. Hemoglobin A1c 6.5-13%  
            or 
Non-Diabetes Control Cohort: 
a. Healthy individuals (non-diabetic) matched to T1D cohort by BMI, and gender  
3. Able to provide informed consent. 
4. BMI 18-39.9 
 
Exclusion Criteria 
1. Type 2 diabetes 
2. History or presence of cardiovascular disease (unstable angina, myocardial infarction or 
coronary revascularization within 6 months, clinically significant abnormalities on EKG, 
presence of cardiac pacemaker, implanted cardiac defibrillator) 
3. Liver disease (AST or ALT >2.5 times the upper limit of normal), history of hepatitis 
4. Kidney disease (creatinine >1.6 mg/dl or estimated GFR<60 ml/min) 
5. Triglycerides >800 mg/dl, LDL >200 mg/dl 
6. Anemia (hemoglobin <12 g/dl in men, <11 g/dl in women) 
7. Thyroid dysfunction. Participants with a TSH > 10 µ IU or less than 0.4 µ IU are 
excluded. Participants on thyroid replacement medication may be enrolled providing they 
have been on a stable dose of medication for at least 6 weeks prior to screening and their 
TSH is within the range specified above.  
8. Uncontrolled hypertension (BP >160 mmHg systolic or > 100mmHg diastolic) 
9. History of cancer within the last 5 years (skin cancers, with the exception of melanoma, 
may be acceptable).  
10. Initiation or change in hormone replacement therapy within the past 3 months (including, 
but not limited to thyroid hormone, birth control or estrogen replacement therapy) 
11. History of organ transplant 
12. History of HIV, active Hepatitis B or C, or Tuberculosis 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 12 of 39 
Research Study protocol template version date 11/3/2016 
 
13. Pregnancy, lactation or 6 months postpartum from screening visit  
14. History of major depression 
15. Psychiatric disease prohibiting adherence to study protocol 
16. History of eating disorders  
17. Cushing’s disease or syndrome 
18. History of bariatric surgery 
19. Tobacco use within the past 3 months 
20. History of drug or alcohol abuse (≥3 drinks per day) within the last 5 years, except 
positive Tetrahydrocannabinol (THC) is acceptable.  
21. Use of oral or injectable anti-hyperglycemic agents (except insulin) 
22. Current use of beta-adrenergic blocking agents 
23. Drugs that affect immune, weight or metabolic function, including but not limited to: oral 
corticosteroids, oral or injectable anti-obesity medications, oral or injectable 
antihyperglycemic medications other than insulin within 3 months of screening. Drugs 
for dyslipidemia (statins, ezetimibe, etc) and a daily full strength or baby aspirin for 
atherosclerosis prevention will be allowed, provided patients have been on stable doses 
for at least 6 weeks prior to screening.    
24. Use of antibiotics within the past 3 months 
25. Weight >450 lbs. (This is DEXA table weight limit) 
26. Metal implants (pace-maker, aneurysm clips) based on Investigator’s judgment at 
screening 
27. Unable to participate in MRI or MRS assessment based on Investigator’s judgment at 
screening 
28. Participants with strict dietary concerns (e.g. vegetarian or kosher diet, multiple food 
allergies, or allergies to food we will provide them during the study) 
29. Gastrointestinal disorders including: inflammatory bowel disease or malabsorption, 
swallowing disorders, suspected or known strictures, fistulas or physiological/mechanical 
GI obstruction, history of gastrointestinal surgery, Crohn’s disease or diverticulitis. 
30. Presence of any condition that, in the opinion of the investigator, compromises 
participant safety or data integrity or the participant’s ability to complete study visits 
 
 
Resources Available 
We attest that all TRI faculty and staff will be trained and this training will be documented. We 
will adhere to FH ORA SOP 06 (Research Personnel Selection, Qualification, Responsibilities, 
and Training) and POLICY-TRI-QM-002 (Training Policy). 
 
Study Procedures 
Subject Recruitment and Screening 
Subjects will be identified by physician referrals from the patient database of the Florida 
Hospital Diabetes Institute, as well as the database of the Translational Research Institute.  
Recruitment methods utilized may include, but will not be limited to the following: 
advertising in multiple media such as print ads, flyers, brochures, posters and social 
media advertisements and/or postcards will also be used to reach out to potential subjects. 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 13 of 39 
Research Study protocol template version date 11/3/2016 
 
All advertising materials will be submitted to the IRB for review prior to using or 
publishing them. A database search via Florida Hospital’s Medical Record may also be 
utilized to identify potential candidates. 
 
Recruitment efforts will follow FH recruitment SOPs for research. Florida Hospital (FH) 
Employees will not be individually targeted nor excluded from study participation based 
on employment. FH employees who engage the TRI-MD asking to participate in the 
study will be processed per standard consent procedures for participants. In addition, 
during the consent process, the study staff will review standard consent language stating 
that an employee’s participation or lack of participation in the study will not affect their 
employment status or relationship with Florida Hospital. 
 
Consent Process  
We attest that all study staff delegated the authority to obtain informed consent will follow FH 
ORA SOP 08 (Informed Consent) and the INVESTIGATOR GUIDANCE: Informed Consent 
(HRP-802), as well as INVESTIGATOR GUIDANCE: Documentation of Informed Consent 
(HRP-803)”. 
 
Non-English Speaking Subjects 
We will not recruit non-English speaking subjects.  
 
Subjects who are not yet adults (infants, children, teenagers) 
    Not applicable 
 
Cognitively Impaired Adults 
    Not applicable 
 
Adults Unable to Consent 
    Not applicable 
 
Documentation of Informed Consent Process 
Documentation of the informed consent process is required to establish that the participant was 
accurately and adequately informed and that no study-related procedures were initiated prior to 
obtaining informed consent.  A research team member will note in the source documentation the 
consent process, date consent was obtained and that consent was obtained prior to initiating any 
research procedures. 
 
Waiver of Written Documentation of Consent or Waiver of Consent  
    Not applicable 
 
Randomization 
    Not applicable 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 14 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Study Visits  
 
Please refer to Appendix A for corresponding Schedule of Activities.  
 
Visit 1- Screening Visit/ Day -28 to -1 (outpatient, 2-3 hours): Subjects will take part in a 
screening visit in the TRI-MD clinic or the TRI-MD Diabetes Institute (DI) clinic. 
 
After the participant has read and signed the study informed consent and agreed to study 
participation, the following procedures will be completed: 
 
• Assessment of medical history; completion of Demographics and Health History 
Form (Appendix B) 
• Physical exam 
• Height and weight measurement 
• BMI calculation 
• Measurement of Waist and Hip Circumference 
• Vital signs (Heart rate x 2, blood pressure x 2, respirations, temperature) 
• AE/Conmed Assessment 
• EKG 
• Screening blood: CBC, CMP, HbA1c, thyroid function tests, lipid panel 
• Urinalysis 
• Urine drug screen 
• Urine pregnancy test for female subjects of childbearing potential (all women are 
considered to be of childbearing potential unless they have undergone a 
hysterectomy, or have had an absence of menses for > 2 years) 
Recruited candidates meeting all enrollment criteria will be scheduled for visits 2-3 
(Phase 1). A subset of participants will be scheduled for visits 4-8 (Phase 2).  
Female participants will be scheduled to fall within their Follicular phase Day 0 -14 (after 
menses are completed) of their menstruation cycle during the inpatient stay(s).  
 
Phase 1 (24 individuals with T1D with a range of body weights; 9 matched controls)  
 
Visit 2/ Day 1 (outpatient, 1-2 hours): Participants will complete:  
• AE/ Conmed Assessment 
• Vital Signs 
• Urine Pregnancy test 
• DEXA 
• CGM placement (Type 1 diabetes group only) 
• Activity Monitor Distribution 
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 15 of 39 
Research Study protocol template version date 11/3/2016 
 
Visit 2/Day 1-7 (phone call). These two questionnaires will be completed through phone 
interviews done by the UNC Nutrition Obesity Research Center (UNC NORC). There will be a 
total of two phone calls between days 1 and 7.  
• 24-hour Dietary Recall  
• Previous Day Physical Activity Recall 
 
Visit 3/ Day 8-11 (inpatient): Participants will be admitted to the TRI Clinical Research Unit 
(CRU) for 4 days (3 nights) for a comprehensive metabolic assessment including: 
 
Day 8: Subjects will be admitted to the CRU in the evening and receive a calculated weight 
maintaining meal. 
• Check into CRU 
• AE/Conmed Assessment 
• Vital Signs 
• Activity monitor collection 
• Inpatient Standard Diet- dinner meal only and a possible snack 
• Overnight stay 
 
Day 9: Subjects will complete following: 
• AE/Conmed Assessment  
• Vital Signs 
• Inpatient standard diet- controlled meal three times a day and a possible snack 
• Fasting blood samples will be collected for archiving and lipid panel 
• FibroScan®  
• Whole-body Magnetic Resonance Imaging (MRI)  
• Magnetic Resonance Imaging and Spectroscopy (MRI/S)  
• Magnetic Resonance Elastography (MRE)  
• CGM placement (initial insertion for non-diabetes group) 
• Stool collection and banking 
• Paper Questionnaires (Appendices C-M)  
• Overnight stay 
 
Day 10: Subjects will complete following: 
• AE/Conmed Assessment 
• Vital Sigs 
• Inpatient Standard Diet- controlled meal three times a day plus a possible snack. 
• Check into calorimeter 
• Whole Room Calorimetry for 23 hours 
• Polar chest strap and Polar watch for heart rate monitoring 
• Activity Monitor Distribution 
• 24-hour urine collection  
• Overnight stay 
 
Day 11: Subjects will complete following: 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 16 of 39 
Research Study protocol template version date 11/3/2016 
 
• AE/ Conmed Assessment 
• Vital Signs 
• Inpatient Standard Diet- breakfast only 
• Check out of calorimeter 
• CGM collection (for Phase 1 only participants) 
• Remove Polar chest strap and watch 
• Activity Monitor collection 
• Check out of CRU 
 
Phase 2 (10 overweight/obese participants with T1D) 
 
Visit 3/Day 11: Initial instruction in low carbohydrate, calorie restricted diet 
After exiting the calorimeter, subjects participating in Phase 2 will meet with the research 
registered dietitian (RD). Counseling sessions will occur weekly on day 11, 18 +/- 2 and 25 +/- 2 
to review their dietary adherence and adjust recommendations as necessary to meet the diet 
prescription of a low carbohydrate, calorie restricted diet. Additional counseling can occur by 
phone during the scheduled twice-weekly phone calls. In-person sessions with the nutritionist 
and/or registered dietitian will include audio recording of the session. Recordings of the RD 
sessions will be utilized to modify and refine the low carbohydrate education materials in 
preparation for the study's later dietary interventions, which will happen at UNC and Stanford. 
Training in ketone and glucose testing for safety. 
 
Phone Calls (Phase 2 only)  
Participants will be contacted by phone from a TRI- staff member approximately twice a week to 
monitor glycemic control, adjust insulin as necessary, and answer any questions they may have.  
 
Visit 4/ Day 18 ±2 (outpatient):  
• AE/ Conmed Assessment 
• Vital Signs 
• Home blood glucose and ketone test 
• Urine Pregnancy test 
• Diet counseling- low carbohydrate diet 
 
Visit 4/Day 18 +/-2 through Day 24 (phone calls).  
• At least 1 call to monitor diet adherence and tolerability 
• At least 2 phone calls to monitor glycemic control, adjust insulin as necessary, and 
answer any questions they may have.  
• Home glucose and ketone testing to continue.  
• Continue outpatient low carbohydrate diet (self-selected foods based on counseling) 
 
Visit 4-7/Day 18+/-2 through Day 35 (phone calls). These two questionnaires will be 
completed through phone interviews done by the UNC Nutrition Obesity Research Center (UNC 
NORC). There will be a total of two phone calls between days 18 and 35.  
• 24-hour Dietary Recall  

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 17 of 39 
Research Study protocol template version date 11/3/2016 
 
• Previous Day Physical Activity Recall 
 
Visit 5/ Day 25±2 (outpatient): 
• AE/ Conmed Assessment 
• Vital Signs 
• Home blood glucose and ketone test 
• Urine Pregnancy test 
• Diet counseling- low carbohydrate diet 
 
Visit 5/Day 25 +/-2 through Day 31 (phone calls).  
• At least 1 call to monitor diet adherence and tolerability 
• At least 2 phone calls to monitor glycemic control, adjust insulin as necessary, and 
answer any questions they may have.  
• Daily home glucose and ketone testing to continue.  
• Continue outpatient low carbohydrate diet (self-selected foods based on counseling) 
 
Visit 6/ Day 32 (outpatient): 
• AE/Conmed Assessment 
• Vital Signs 
• Home blood glucose and ketone test 
• Activity Monitor Distribution 
• Pick up 3-day supply of controlled diet food (low carbohydrate, 500 calorie deficit) 
• Consume outpatient low carbohydrate diet for 3 days (provided foods) 
 
Visit 7/Day 35 (outpatient) 
• AE/ Conmed Assessment 
• Vital Signs 
• Urine pregnancy test 
• Home blood glucose and ketone test 
• Pick up 3-day supply of controlled diet food (low carbohydrate, 500 calorie deficit) 
• Consume outpatient low carbohydrate diet (provided foods) 
 
Visit 8/ Day 37-40 (inpatient): Participants will be admitted to the TRI Clinical Research Unit 
(CRU) for 4 days (3 nights) for a comprehensive metabolic assessment including: 
 
Day 37: Subjects will be admitted to the CRU in the evening and receive a calculated. 
low carbohydrate, 500 calorie deficit meal. 
• Check into CRU 
• AE/Conmed Assessment 
• Vital signs 
• Activity monitor collection 
• Inpatient low carbohydrate, 500 calorie deficit diet- dinner meal only and possible 
snack 
• Overnight stay 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 18 of 39 
Research Study protocol template version date 11/3/2016 
 
• Urine pregnancy 
• Home glucose and ketone testing to continue  
 
 
Day 38: Subjects will complete following: 
• AE/Conmed Assessment  
• Vital signs 
• Inpatient low carbohydrate, 500 calorie deficit diet- controlled meal three times a 
day plus a possible  snack . 
• Fasting blood samples will be collected for archiving and Lipid panel 
• MRI/S 
• MRE 
• Stool collection and banking 
• Paper Questionnaires (Appendices C-N)  
• Overnight stay 
• Home glucose and ketone testing to continue  
 
 
Day 39: Subjects will complete following: 
• AE/Conmed Assessment 
• Vital signs 
• Inpatient low carbohydrate, 500 calorie deficit diet- controlled meal three times a 
day and possible snack.  
• Check into calorimeter 
• Whole Room Calorimetry for 23 hours 
• Polar Chest strap and Polar watch for heart rate monitoring 
• Activity Monitor Distribution 
• 24-hour urine collection 
• Overnight stay 
• Home glucose and ketone testing to continue  
 
Day 40: Subjects will complete following: 
• AE/ Conmed Assessment 
• Vital signs 
• Inpatient low carbohydrate, 500 calorie deficit diet - breakfast only 
• Check out of calorimeter 
• Remove Polar chest strap and watch 
• Activity Monitor collection 
• Home glucose and ketone testing to continue  
• CGM collection 
• Check out of CRU 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 19 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Analytical / Clinical procedures 
 
Medical History and Physical Exam 
A comprehensive health history will be obtained utilizing a standard Demographics and Health 
History Form that will be implemented for all aims of the grant (See Appendix B).  A standard 
physical examination will be performed by a study physician, physician assistant, or nurse 
practitioner. 
 
Anthropometric Screening 
Body weight (calibrated scale), height, waist and hip circumference will be obtained while in a 
gown, without shoes. BMI will be calculated.  
 
Screening Labs 
The laboratory assessments below (at minimum) will be used to confirm study eligibility 
(Inclusion/Exclusion Criteria), as well as overall health status: 
• complete blood count (CBC) 
• comprehensive metabolic panel (CMP) 
• HbA1C 
• lipid panel 
• thyroid function tests: thyroid stimulating hormone (TSH)  
• urinalysis 
• urine drug test  
• urine pregnancy test, for female subjects of childbearing potential 
 
 
Vital Sign Measurements 
Measurement of vital signs will include heart rate (HR), blood pressure (BP), respirations and 
temperature will be measured sitting for at least 5 min.   
 
Continuous Glucose Monitoring (CGM) 
Starting at Visit 2, participants with type 1 diabetes will wear an unblinded continuous glucose 
monitor (CGM) for the duration of the study as a safety measure for glucose levels. Non-diabetes 
participants will have the CGM inserted during Visit 3 for the inpatient stay, for a data 
comparison. The CGM can be worn for up to 7 days at a time and will be replaced as needed. 
The CGM will not be worn in the MRI as the interference from CGM devices on MRI data has 
not been tested. It will be removed up to several days prior to the MRI and replaced after the 
MRI is completed. During time periods where blood glucose data is not available for CGM, 
point of care testing will continue. 
 
The continuous glucose monitor will be placed by a member of the study team and participants 
will be instructed on the use and removal of the device, as well as reinsertion of the device as 
needed. During CGM wear, participants will be instructed to perform blood glucose 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 20 of 39 
Research Study protocol template version date 11/3/2016 
 
measurements approximately every 12 hours to calibrate the device, which can be completed by 
the participant or a trained clinical staff member. The FDA-approved system includes a sensor, 
transmitter, and receiver. It measures interstitial fluid glucose levels in the range of 40 mg/dl to 
400 mg/dl every 5 minutes for up to 7 days. 
 
Blood Glucose and Ketone testing  
A small portable dual-purpose blood glucose and ketone meter, including lancets, test strips, and 
control solutions will be provided to the participant. A trained staff member will demonstrate and 
instruct the participant on proper techniques to check Blood Glucose and Ketone levels. The 
testing will be done via a small blood sample from a finger stick.  
 
Measurement of 24-hour Energy Expenditure and Substrate Oxidation Rates: 
Whole Room Calorimeter  
Whole room indirect calorimetry allows for the simultaneous measure of total energy 
expenditure (kcals/min) and substrate oxidation (RQ) in a free-living environment with multiple 
activities. Room calorimeters provide greater precision in the measure of oxygen consumption 
and carbon dioxide production as they provide a controlled testing environment and use more 
robust gas analyzers. Fat oxidation will be highest during periods of low activity [and fasting] as 
the metabolic system switches to relying on fat stores as the main energy source.  Fat oxidation 
decreases as metabolic rate (kcal/min) increases through muscle activity.  
 
The calorimeter will be maintained at thermoneutrality 75°F/22.5°C and a relative humidity of 
40-%. The chamber is ventilated with medical air at a rate controlled by the chamber software to 
maintain CO2 levels ~0.4% with a range of 20-90L/min. The room has two windows, and is 
furnished with a bed, desk and chair, television, sink and toilet with privacy curtain, a treadmill, 
a chilled air-locking pass-through for the storage of urine and fecal samples, and an air-locking 
food pass-through for meal delivery. Video cameras and microwave motion detectors 
continuously monitor the participant’s movement.   
 
Energy expenditure and substrate oxidations (including RQ) are calculated from O2 
consumption, CO2 production and 24-hour urinary nitrogen excretion by using the equations 
established by Weir.  
 
Brief overview of calorimetry routine: The participant will void prior to entry into the chamber. 
At this point, a timed urine collection will begin for the duration of the stay in the chamber. 
Participants will follow a set routine in the calorimeter that matches the activity routine in the 
CRU acclimatization period. Rest, meals, treadmill walking, desk time, and other activities are 
scripted to the minute and observed by the staff of the CRU and the Energy Expenditure Core via 
camera. Conditions during the stay will be standardized based on TRI’s standard procedures 
(NCT 01967563). Inflow and chamber concentrations of O2 and CO2 are measured continuously, 
as are activity and environmental conditions and the rate of air flowing in to and out of the 
calorimeter via high accuracy mass flow controllers (MFCs). Urinary Nitrogen are measured 
over 24 hours for all days in the calorimeter. These values are fed into a computer system 
(PiLR™) that stores the data, calculates VO2, VCO2, and VCH4, and converts these into EE 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 21 of 39 
Research Study protocol template version date 11/3/2016 
 
(kcal/minute) and RQ output every minute. Combined, fat, carbohydrate, and protein oxidations 
will be calculated as per Elia and Livesey and our recent publication in the American Journal of 
Clinical Nutrition.  
 
During Phase 1, participants will consume a diet to achieve energy balance. During Phase 2, 
participants will consume a diet that reflects a 500-calorie deficit. Details of the calorimeter 
routine and energy balance procedures will be documented in a study specific procedure.  
 
Continuous Heart Rate Monitoring  
A chest strap (which is a Heart rate sensor) and Polar Watch will be worn by the participant during 
their 23-hour calorimetry chamber stay to continuously monitor the participant’s heart rate while 
in the calorimetry room. The polar watch will record heart rate, time worn, steps, and energy 
expenditure (based on the entered age (in years only), weight, height, and gender). The collected 
data is considered exploratory and therefore does not pose a risk to the participant.  The collected 
data will be uploaded to the software that accompanies the heart rate monitoring devices 
(Polarflow). 
 
Dual Energy X-Ray Absorptiometry (DEXA) 
DEXA Scans will be performed to measure body fat and estimate muscle mass using a GE Lunar 
iDXA whole-body scanner.  The participant will remove all metal accessories, and may be asked 
to change into a hospital gown.  The participant will lie on the DEXA table while the scanner arm 
emits low energy X-rays as it passes along the body.  The scan takes up to 15 minutes and the 
radiation dose is less than 1 mrem, less than half the average daily radiation dose in America. A 
urine pregnancy test will be completed on all women of childbearing potential (all women except 
those with prior hysterectomy, tubal ligation, or absence of menses for >2 years) prior to the DEXA 
scan for safety.   
 
FibroScan® 
Approximation of liver fat and stiffness by FibroScan® will occur at scheduled visits outlined in 
Appendix A: Schedule of Events.  FibroScan® uses ultrasound based VCTE™ (vibration-
controlled transient elastography) to obtain Liver Stiffness Measurement (LSM) and Controlled 
Attenuation Parameter (CAP™); LSM is correlated to liver fibrosis stage, and CAP is correlated 
to hepatic steatosis.  By using an ultrasound transducer probe, a painless, mechanical impulse is 
delivered to the skin above the liver using a low frequency elastic wave (50 MHz).  The wave 
produces a mechanical deformation that moves towards and then through the liver.  The velocity 
of the shear wave in the liver is measured and is directly proportional to its stiffness (stiffer 
tissue, faster velocity).  Using a proprietary algorithm, the device determines whether the shear 
wave propagated into the liver and is valid.  The LSM, expressed in kilopascals (kPa), is only 
calculated on valid measures.  Liver stiffness measurement values range from 1.5 to 75 kPa; 
lower values indicate a more elastic liver.  CAP™ measures the ultrasonic attenuation coefficient 
in the forward and return path through the liver at 3.5 MHz and is expressed in decibels/meter.  
CAP™ is evaluated simultaneously with LSM using the same radio-frequency data and is only 
appraised if the LSM is “valid.”  The specific FibroScan® model being utilized is the 502 Touch 
(Echosens, Paris, France).   

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 22 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Participants will lie on their back (supine) with their right arm raised in abduction to increase the 
intercostal space.  A water-based gel will be applied to the skin and the transducer probe will 
then be placed on the participant’s skin, in the intercostal space directly above the liver with 
slight pressure.  At least ten valid measurements will be taken and the results will be immediate.  
To minimize the potential for confounding factors to affect the measurements, FibroScan® will 
be conducted following a fast (except water) of at least 4 hours and as much as practically 
possible.  Only study staff members who are trained in the use of FibroScan® are permitted to 
acquire measures of liver stiffness and CAP™.   
 
The test takes a total of about 10 minutes, with total scan time (including setup) of approximately 
30 minutes.   
 
Magnetic Resonance Imaging, Elastography and Spectroscopy 
The goal of this test is to assess liver lipid content, liver stiffness, volumetric fat and organ 
volume quantitation using an Achieva 3T (Philips, Amsterdam, the Netherlands).  
 
MRI/S: Intrahepatic Lipid (IHL) content will be measured using both imaging and spectroscopy. 
Scans will be performed under standardized conditions with participants in a supine position. 
Standard clinical MR Imaging, including 3-plane localization and T1 weighted images, will be 
completed to obtain anatomical images for voxel / slice localization and liver volume (to 
ascertain changes in hepatomegaly as compared to liver volume from whole body MRI). A 1H 
quadrature body coil (QBC) and torso XL coil will be used to measure intrahepatic fat stores. A 
single voxel point resolved spectroscopy (PRESS) sequence will be acquired from a 2 x 2 x 2 
cm3 volume in the upper right lobe of the liver in an area that is free from heavy vascularization 
as determined from the scout images.  Proton Density fat fraction (PDFF) imaging sequences 
will be performed covering at least the entirety of the liver. (Day 9 (Phase 1) and Day 38 (Phase 
2)). 
   
Whole-Body MRI: Volumetric measurement of fat, muscle, organs and bone will be completed 
across the whole body. These measurements are important for understanding metabolism since 
increases in size of metabolically active organs and adipose tissue distribution may contribute to 
alterations in energy expenditure.  Scans will be performed under standardized conditions with 
participants in a supine position using the quadrature body coil and torso XL. Low resolution scans 
will be completed to determine appropriate positioning for high resolution images. (Day 9 only)  
 
MRE: Liver stiffness will be measured using Magnetic Resonance Elastography (MRE).  The 
MRE driver will be placed on the participant’s abdomen for the duration of the MR acquisition.  
After acquisition of low resolution scans to determine positioning for MRE scans, the driver 
creates known pressure waves, which are applied during acquisition of tagged MR sequences, from 
which the liver stiffness is calculated.  These sequences will be acquired over several sections of 
the liver. (Day 9 and Day 38).   
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 23 of 39 
Research Study protocol template version date 11/3/2016 
 
Images which are degraded due to motion may be repeated as time permits. Individual scans and 
acquisition parameters are listed in the study specific imaging documents. 
 
Total MR scan time will be approximately 90 minutes. 
 
Resultant images will be analyzed using Analyze 11.0 (Biomedical Imaging Resource, Mayo 
Clinic, Rochester MN) to segment depots of fat (e.g. subcutaneous vs. visceral) as well as bone 
and muscle volume. Spectroscopy will be analyzed using jMRUI (the MRUI Consortium).      
 
If required any Imaging (MRI, Fibroscan, and DEXA) can be scheduled +/- 2-day window.  
However, the preference would be to get the Imaging completed on the listed day (Day 1, 9 and/or 
Day 38 respectively). 
 
Physical activity monitoring 
Physical activity will be quantified with activity monitors using a small, portable accelerometer 
that can be worn on wrist and/or waist.  Overall physical activity levels, daily changes, amount 
of time spent in sedentary, moderate, vigorous intensity categories and activity-associated energy 
expenditures will be extracted.   
 
The participant will wear the monitor on the waist from Day 1 to Day 7 (it will be removed upon 
check-in in day 8) and day 32-36 (it will be removed upon check in on day 37). The goal is to 
collect at least 4 days of data to assess habitual activity. During Day 10-11 and Day 39-40, the 
participant will wear the monitor on the wrist and waist while in the calorimetry chamber. The 
goal of this dual assessment is to generate higher quality data for estimating activity energy 
expenditure that can then be translated to a free-living condition with high reproducibility. In 
addition, the wrist location will permit us to quantify sleeping quality. Poor sleep quality is a 
variable classically associated with negative health outcomes in patients with diabetes.    
 
24-hour urine collection 
During visit 3 and 8, all urine will be collected for measurement of total nitrogen, creatinine and 
glucose. Urine aliquots will also be archived for future use. 
 
Stool Collection 
A stool sample will be collected from participants during each of their inpatient stays. 
Participants will be provided with a container that fits over the commode and will be instructed 
on the proper way to provide the sample. Details of the stool collection kit and methods will be 
in an SSP and the Laboratory Manual.    
 
 
In-patient diet procedures. 
Participants will be fed meals in the TRI-MD dining room, clinical research unit or calorimeter.  
Participants will be provided a calculated weight-maintaining diet of 50% of calories as 
carbohydrate, 35% as fat, and 15% as protein (Phase 1) or a 500-kcal deficit diet with 14% of 
calories as carbohydrate, 58% as fat and 28% as protein (Phase 2). Given that quantifying energy 
balance is a primary goal of the study all meals will be observed by TRI staff.  Participants will 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 24 of 39 
Research Study protocol template version date 11/3/2016 
 
be asked to consume 100% of meals. In the event this does not happen, food not consumed will 
be returned to the kitchen, weighed and recorded. In the calorimeter, macronutrient comparable 
units will be provided or removed to achieve energy balance or 500-calorie deficit.  
 
Out-patient diet procedures.  
Participants in Phase 2 will pick up meals containing 14% of calories from carbohydrate and a 
500 kcal deficit on two occasions prior to the second inpatient evaluation. See Appendix A for 
details.   
 
Dietary Counseling 
The purpose of the low carbohydrate diet counseling will be to assist young adult, overweight 
study participants with Type 1 diabetes in adhering to a lower calorie diet (500 calorie deficit) that 
contains around 14% carbohydrate, 28% protein and 58% fat (majority polyunsaturated and 
monounsaturated fats).  Study participants will attend an initial counseling session (60- 90 
minutes) from a Registered Dietitian (RD) that covers general steps for problem solving, contents 
of eating a general healthy diet. An introduction to using MyFitnessPal to track their intake is done 
at Visit 2 (Day 1) and will be utilized thru Phase 1 (optional) and Phase 2 to help participant and 
study team to summarize food intake.  The RD will also use the participant’s 24-hour recall to 
discuss areas where lower carbohydrate and lower calorie foods could be substituted for foods the 
participant eats on a regular basis.  Calorie balance will also be discussed as well as 
recommendations for insulin bolusing as carbohydrate intake is reduced and protein and fat intake 
is increased. Participants will also be provided with several sample low carbohydrate, low calorie 
meal plans, snack ideas, and food lists.  At the end of the session, participants will work with the 
interventionist to set reasonable goals to adhere to the new low carbohydrate, low calorie diet for 
the next three weeks.   Sessions 2 and 3 (30 minutes) will consist of the interventionist check-in 
and a more in-depth discussion of low carbohydrate and low-calorie consumption, as well as a 
concentration on saturated verses unsaturated fats. 
 
24-hour Dietary Recall and Previous Day Physical Activity Recall (PDPAR)  
These questionnaires will both be conducted by phone and are expected to take approximately 1 
hour to complete. 
 
As part of the Metabolic Chamber study, all participants will be asked to complete two 24-hour 
recall interviews.  The 24-hour recall is a diet assessment instrument used to enable researchers 
to collect diet data on foods consumed by the participant during the previous 24 hours. A subset 
of participants of 10 participants will be asked to complete an additional two 24-hour recalls 
after being instructed on and living on a low carb diet.   
 
To optimize the accuracy of the assessment of dietary intake data, 24-hour dietary recalls will be 
completed using the USDA multi-pass method and will be administered by trained diet recall 
technicians. Participants will self-report on intake of the previous 24 hours of food and beverage 
intake. Diet recalls will be conducted in English and will last 20-30 minutes.  Dietary data will be 
entered and analyzed using NDS-R software (Nutrient Data System for Research, St. Paul, MN).   
Study participants will also be asked to complete the Previous Day Activity Recall after the 24-hr 
Dietary Recall. This portion of the interview will collect information about physical activity from 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 25 of 39 
Research Study protocol template version date 11/3/2016 
 
the previous 24-hour period and will take an additional 5-10 minutes to complete after the 24-hour 
recall.   To increase precision of short-term usual dietary intake and physical activity, interviews 
will be completed on two non-consecutive days (one weekday and one weekend day).   
 
Telephone recalls will be completed by the UNC Diet and Physical Activity Core (DPAC) in the 
NIH/NIDDK funded UNC Nutrition Obesity Research Center.  All DPAC research staff are 
trained to collect 24-hour recalls using the USDA multiple pass method and are required to 
complete the Collaborative Institutional Training Initiative (CITI) Program for Social and 
Behavioral Research.   
 
Study site staff will provide UNC with participant contact information including name, contact 
phone number, as well as best times to contact in order to conduct the diet/physical activity recalls 
via telephone.  Participants will also be asked if they prefer to text or receive a phone call to arrange 
a time to conduct the 24-hour recall.  Participants may opt out of texting and UNC DPAC will not 
contact via text.   
 
All participant information provided to UNC, such as name, phone number, and best times to 
contact, will be stored in the Sheps Integrated Research System (SIRS), a secure online database 
developed and maintained by the UNC Cecil Sheps Center for Health Services Research.  The 
participant information is imported into the Sheps secure database by the study site.  Access to the 
participant information is only accessible via Sheps and login is only available to approved study 
site staff and trained UNC interviewers.  All system login procedures and data submissions will 
be encrypted via the Secure Sockets Layer (SSL).  Sheps Center programmers and research staff 
who work with sensitive data are required to complete appropriate HIPAA training with periodic 
updates, complete Sheps Center internal training, comply with the UNC IT Security Policies, and 
agree to the provisions of the Sheps Center’s Rules of Behavior and Sanction Policy. The Sheps 
Center strives to implement reasonable security controls guided by FISMA, HIPAA, and OMB 
Circular A-130. 
 
All data entered in the NDSR data analysis system as well as data coded for the PDPAR is 
deidentified. Participant IDs as provided to the UNC DPAC by the study site are used in lieu of 
any identifying information to enter data.  There is no link from participant ID to sensitive 
participant information.  Once all data collection is complete, all participant and related study 
information is permanently deleted from the UNC Sheps database.   
 
 
Questionnaires During Inpatient Stay: 
These questionnaires will be administered while participants are domiciled at TRI during both 
phases. They are paper questionnaires (See Appendices C-N for the content of each questionnaire) 
and are expected to take approximately 1-2 hours to complete. 
 
Questionnaire 
Description 
Food Frequency 
Habitual dietary patterns will be assessed using the 26-item Dietary 
Screener Questionnaire developed for the National Health and Nutrition 
Examination Survey. 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 26 of 39 
Research Study protocol template version date 11/3/2016 
 
Diabetes Eating Problem 
Survey 
Diabetes related eating problems will be assessed using the Diabetes 
Eating Problem Survey (DEPS-R). 
Dutch Eating Behavior 
Questionnaire 
The Dutch Eating Behavior Questionnaire assesses emotional eating, 
externality, and restrained eating behavior. 
BIS-15 
The Barratt Impulsiveness Scale (BIS-15) assesses trait impulsivity, 
including non-planning, motor impulsivity, and attention impulsivity. 
Food Craving Inventory 
The Food Craving Inventory assess the degree of craving for a variety of 
foods. 
Nutrition Knowledge 
Questionnaire 
The Nutrition Knowledge Survey assesses healthful eating knowledge, 
carbohydrate counting, blood glucose response to foods and nutrition label 
reading. It has been validated in people with T1D. 
Diabetes-Related Quality of 
Life 
Diabetes-specific quality of life will be measured using the DCCT-
validated measurement form. 
Hypoglycemia Fear Survey 
(HFS) 
The HFS will be utilized to assess anxieties and behaviors related to 
hypoglycemia. 
Recent Physical Activity 
Questionnaire (RPAQ) 
Self-reported physical activity patterns over the preceding month will be 
conducted using the Recent Physical Activity Questionnaire (RPAQ). 
Sleep Disorders 
Questionnaire 
The Sleep Disorders Questionnaire will be used to obtain sleep duration 
and quality over the preceding month. 
CES-D 
The Center for Epidemiological Studies-Depression (CES-D) is a 20-item 
measures that asks participants to rate how often over the past week they 
experienced symptoms associated with depression, such as restless sleep, 
poor appetite and feeling lonely. 
Acceptability of Defined 
Diets  
(Only During Phase 2) 
The diet acceptability form will be utilized following the low carbohydrate 
pilot to assess acceptability of the diet. An appropriate instrument with 
known psychometric properties to systematically assess acceptability of 
specific diets could not be identified in the literature. Therefore, we 
developed and are now piloting this simple assessment for this purpose (5 
simple questions plus open-ended query).  
   
Study Duration 
The study will initiate participant recruitment in January 2018. The estimated duration to enroll all 
study participants is 6 months. The study consists of 3 visits (Phase 1) or 8 visits (Phase 2 
participants only) including screening. Participation in Phase 1 will last 28-42 days (inclusive of 
the screening window) while it will be approximately 68 days for participants in Phase 2.  We 
estimate that the study, including analysis will be completed in 12 months. 
 
Materials of Human Origin:  Collection, Preparation, Handling and Shipping 
All biological materials will be obtained per the procedures described in study visits. For all study 
procedures, Study Specific Procedures (SSPs) have been prepared. Biospecimens will be collected 
and analyzed according to the SSPs and techniques established at the TRI-MD laboratory or at 
SBP laboratories. 
Biospecimens collected for study-related endpoints (blood, urine and fecal samples), will be 
collected by a study team member, processed according to their respective protocols and stored at 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 27 of 39 
Research Study protocol template version date 11/3/2016 
 
TRI-MD until analysis takes place. Biospecimen samples will be stored in ultralow temperature 
freezers and liquid nitrogen dewars or other storage units located at the TRI-MD Laboratory Room 
2404. The TRI-MD facility is secured via key card and equipped with a back-up generator system. 
Laboratory personnel in the facility have 24/7 key controlled access to the laboratory.  Chain of 
custody of biospecimen samples is maintained through requisition forms and in the StarLIMS 
database. Specimen tubes are coded, and specimen requests and distribution are documented. 
 
The biospecimens collected for this study will be separated into biospecimens that will be used for 
the study and biospecimens that were collected to be archived for future use. After study aims have 
been achieved and study related endpoints have been measured and analyzed, any remaining 
biospecimens will be stored at the TRI-MD Laboratory Room 2404 and will also be considered as 
“archived biospecimens.”  
 
Archived biospecimens will be used for any additional hypothesis-related experimentation or 
testing for the purposes of this study, consistent with the original aims, which cannot be predicted 
at the time the protocol is being developed due to the evolving nature of scientific exploration. 
 
Archived biospecimens may be stored indefinitely for future research. Archived biospecimens 
could be used for separate research by both Florida Hospital scientists and scientists outside of 
Florida Hospital. This would be allowed if the research is consistent with the original aims of this 
study and if they have scientific merit as determined by the Principal Investigator, or with an 
additional review by the respective Program Director. For research outside of Florida Hospital, a 
Material Transfer Agreement will be obtained, which will govern the transfer and chain of custody 
of the biospecimens outside of FH. 
    
Study Outcome Measures (Endpoints) 
The following data variables and materials will be collected for analysis in this study: 
• Patient information: age, gender, medical history. 
• Physical exam: height, weight, calculation of BMI, heart rate, blood pressure, 
respirations, temperature. 
• Blood samples: Fasting blood sample for hormonal analysis. A separate blood sample 
will be used for DNA sequencing and single-nucleotide polymorphism identification of 
genes affecting taste and metabolism. 
• Stool samples: stool sample collection will be used for the measurement of phylogenetic 
(16S rDNA) and transcriptional (RNA-seq) analyses of fecal microbiota, metabolomics 
analyses including short-chain fatty acids. 
• Body composition measures (DEXA) 
• Body composition measures (MRI) 
• 24-hour energy expenditure and substrate oxidation rates (calorimetry) 
• Dietary questionnaires 
• Diabetes questionnaires 
• Diet adherence, glycemic control and insulin dosing (Phase 2) 
• Liver fat percent via MRI/S 
• Controlled Attenuation Parameters (marker of liver fat) via FibroScan® 
• Liver stiffness via FibroScan® and MRE 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 28 of 39 
Research Study protocol template version date 11/3/2016 
 
• Organ size and body composition via MRI [including, but not limited to, brain, heart, 
kidneys, adipose tissue (visceral, subcutaneous, intramuscular), skeletal muscle] 
 
Data Management and Quality Plan 
Data De-identification 
Participants will be enrolled using Cerner’s Patient Protocol Manager; the application assigns each 
participant a unique participant identifier, or “PID”.  This PID is a code consisting of a combination 
of numerals and letters, which serves as the identifier for this participant for this research study 
and links them back to their hospital medical record and their protected health information (PHI).  
Access to the “link” between the PIDs, the PHI, and to the clinical data are only granted to the 
clinical research team as assigned on the Delegation of Authority Log.   All the clinical research 
data is recorded in a de-identified fashion onto our paper source documents, which is then 
transcribed into our electronic case report forms, (CRF). The CRF is used for storage (a database) 
and facilitates analysis.  Clinical data generated by research devices also uses the PID, and once 
the data has been transformed into interpretable results it is stored into the clinical research 
database, iDiscover. Both storage locations are secured and only assessable to the assigned clinical 
research team.  The “link” will not be used to re-identify participants except in the event of a 
serious adverse event (SAE) requiring “unblinding” to treat the participant.  The “link” will be 
stored in the Patient Protocol Manager and in i-Discover, where only the TRI-MD research team 
has access. These secure databases are stored/accessed on the Florida Hospital password-protected 
computer network. No one outside of Florida Hospital investigators or researchers will have access 
to the databases.  
 
Data Confidentiality, Storage, and Retention 
The identity and personal health information will be kept confidential to the extent permitted by 
the applicable laws and/or regulations and will not be made publicly available. If results of this 
study are published or presented, the identities will not be revealed. Confidentiality will be 
maintained during and after the study.  This information is also included in the informed consent, 
which is discussed with participant prior to enrollment. 
 
All paper sourced study documentation will be stored in the medical records room at TRI-MD, 
which is behind badge access doors, continuously locked, monitored and provides for limited 
access.  The data records may also be stored as electronic records.  This data is safeguarded so that 
only those on the research team have access to it via limited badge access to the medical records 
room (paper) or role relationship (electronic)).  The electronic data is maintained under Adventist 
Information Technology security controls.  
 
The duration of study data retention will be determined by governing FDA regulations and/or 
sponsor contract mandate (if applicable). TRI-MD retention policy is maintained in the Records 
Management Policy.  Electronic de-identified data will be kept indefinitely in our data warehouse. 
 
The Polar watch will record heart rate (from sensor in chest strap), time worn, steps and energy 
expenditure (based on the entered age, weight, height, and gender).  There are no personal 
identifiers (ea. names or DOB) or PID’s utilized during the recording. The collected data 
(mentioned above) will be immediately uploaded to the cloud based program provided by 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 29 of 39 
Research Study protocol template version date 11/3/2016 
 
Polarflow) which generated the report  to be saved with the participant PID on the TRI -MD 
secure server. 
 
Nutrition consult audio recording will be recorded on a portable recording device. After the 
session the data will be downloaded to the TRI H:drive as an audio file including the participants 
PID, initials and date of recording. Once confirmed that the data is correctly downloaded and 
saved the recording will be deleted from the recording device. The saved file will then be 
uploaded from the H:drive to the UNC Data system (RedCap) which is username and password 
protected.  
  
Data Quality  
Data quality and integrity will be governed by the system of ISO 9001 driven data management 
SOPs. These SOPs delineate how quality is built into the identification, collection, handling, and 
processing of the data. 
 
The types of data collected may include data that are: (a) manually abstracted or electronically 
extracted from medical records, (b) observed in clinical exams, (c) obtained from laboratory and 
diagnostic tests, or from various biological monitoring devices, and (d) patient-reported items. 
Each data type can be understood by its source and the associated collection mechanism. Only the 
SOPs and associated workflows applicable to the study will be used.  
Within the study quality control steps may include: 
 
• Source Data Verification (SDV) 
• Query Management 
• Parallel Processing by a second party 
• Completely re-processing a percentage of the data and comparing to the original  
• Change Control; If changes are made they need to be documentation that covers what 
was changed, why it was changed, who changed it and when they changed.  
 
Data Sharing (outside of Florida Hospital)  
Deidentified data, potentially including archived biospecimens, will be shared with the University 
of North Carolina and Stanford University under a Data Use Agreement. This study is part of a 
Multi-PI NIH grant with three site PI’s: Elizabeth Mayer-Davis, PhD (UNC Chapel Hill Site PI; 
UNC is the prime awardee and coordinating center), David Maahs, MD (Stanford Site PI) and 
Richard Pratley, MD, (TRI-MD Site PI). The Data Use Agreement(s) will identify the purpose for 
data sharing, the specific data elements to be shared, and will govern the sharing of data related to 
this study.  Data will be de-identified, but a link/code is managed within an electronic research 
management system and maintained by a study coordinator. 
Data sharing with other organizations would be allowed, as defined in respective Data Use 
Agreements, if the research is consistent with the original aims of this study and if they have 
scientific merit as determined by the three site Principal Investigators. 
Some data sharing for the UNC to contact participants for the phone contact questionnaires (24-
hour Dietary Recall and Previous Day Physical Activity Recall) requires the study site staff to 
provide UNC with participant contact information including name, contact phone number, as well 
as best times to contact in order to conduct the diet/physical activity recalls via telephone.  

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 30 of 39 
Research Study protocol template version date 11/3/2016 
 
Participants will also be asked if they prefer to text or receive a phone call to arrange a time to 
conduct the 24-hour recall.  Participants may opt out of texting and UNC DPAC will not contact 
via text (for more information see section 24-hour Dietary Recall and Previous Day Physical 
Activity Recall (PDPAR)). 
  
Sample Size Determination 
This is a pilot study from which we intend to collect information to perform larger studies. 
However, a total sample size of 33 will allow a power of 80% to detect a correlation of energy 
expenditure with glycemic control of 0.4 using a type 1 error of 0.1. Since this is a pilot study, this 
should be sufficient power for the stated modeling and estimation goals. 
 
Statistical Analysis Plan 
Overview of Statistical Plan: Similar to work we have done previously, calorimetry data will be 
utilized to determine the 24-hour energy cost of maintaining a specific level of glycemia and 
body weight, body composition and activity, using exponential modeling similar to that reported 
by Hall et al (2011). This will involve fitting a multivariate regression model, correcting for food 
intake, urinary glucose excretion, and energy expenditure while in the calorimeter, while also 
accounting for body composition, glycemia based on CGM while in the chamber, as well as 
HbA1c, age, sex, insulin dosing, and diabetes duration, and solving for the missing energy 
variable. Energy modeling using only variables available in the Phase 2 SMART pilot will also 
be derived and will be used to establish calorie prescriptions for the SMART pilot. For research 
questions related to RQ, substrate utilization, and metabolic flexibility, regression modeling will 
be done to determine differences between T1D and non- diabetic controls accounting for the 
matched design as well as age, gender, and other important co- variates.  
 
Details of analytical procedures will be documented in a Statistical Analysis Plan.  
 
Primary Objective Analysis 
To develop a comprehensive model of energy balance and metabolic flexibility for T1D 
that accounts for the degree of hyperglycemia and differences in body composition we 
will combine data from calorimetry, body composition, glycemic control and 
demographics to generate a regression equation based on the variables that impact energy 
requirements. General linear models with multiple covariates (age, sex, lean body mass, 
fat mass, HbA1c, mean glucose levels on CGM will be employed initially. Additional 
mathematical modeling tools may also be implemented. This is the first study of its kind 
and is intended to generate pilot data for understanding energy balance across the 
spectrum of body weight in individuals with T1D. Therefore, several methods may need 
to be employed to generate the final model that will be used in latter phases of the overall 
grant.  
 
Secondary Objective Analysis 
This objective is piloting a low carbohydrate diet to generate the first comprehensive 
metabolic data set in individuals with T1D across a range of body weights. Here the goal 
is primarily to assess the tolerability and safety of a restricted carbohydrate, hypocaloric 
diet in patients with T1D and to evaluate the instruction methods and tools necessary to 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 31 of 39 
Research Study protocol template version date 11/3/2016 
 
implement such as diet. In addition, we will assess the effects of the diet n energy 
expenditure to further enhance the modeling performed in the primary objective.   
 
 
Potential Risks and Benefits 
Potential Benefits 
Participation in this study will not result in any direct benefits to the subjects in this study, however 
participation in the screening may identify previously unrecognized medical conditions, which 
may provide a general health risk assessment. Subjects will also receive some general medical 
information, including laboratory testing and medical examination. No promise can be made 
concerning the study outcome, because results from a clinical research study cannot be predicted.  
 
Potential Risks 
 
Venipuncture: The placement of intravenous needles may cause transient pain, vasovagal 
syncope, and may also result in infection, bruising, bleeding, and/or clotting at the site of needle 
insertion. The application of direct pressure at the catheterization site will be used to help prevent 
these symptoms. There is a possibility that a catheter placement would be unsuccessful or need to 
be removed.  If this should occur, another catheter would be placed. It is possible that this may 
occur more than once during the subject’s participation in the protocol. Staff trained and certified 
in the SOP will be used. 
Protection Against Risk: 
• All venipuncture will be conducted by qualified staff using aseptic techniques to 
reduce these risks.   
• We are recruiting young, healthy individuals and do not anticipate the blood volume 
for this study to be problematic. However, the following precautions will be taken. 
Total amount of blood that will be drawn throughout the study will be approximately 65 
ml.   
DEXA scan: There is a very small risk of cancer with excessive exposure to any radiation. Each 
scan takes about 15 minutes and the radiation dose for one scan is approximately 0.6 mrem, which 
is equal to about half a day of background radiation. This radiation exposure is below the guideline 
of 5000 mrem per year allowed for research participants by the NIH Radiation Safety Committee. 
The use of the DEXA scan apparatus may cause some minimal discomfort in claustrophobic 
participants and may cause some minimal back pain in a small minority of the individuals.     
Protection against Risk: 
• The radiation dose from the scans is less than a chest x-ray, or about the same 
amount a person would receive from one day of background radiation from the sun.   
• A urine pregnancy test will be done prior to scans of all women of childbearing 
potential (all women except those with prior hysterectomy, tubal ligation, or absence 
of menses for >2 years). 
 
Magnetic Resonance Spectroscopy: There are no known biological risks associated with 
magnetic resonance spectroscopy. Some short-term discomfort may be experienced.  The short-
term risks associated with MRI are minimal, but include heating, loud noises and claustrophobia.  
There are some people who should not undergo MRI; the contraindication is largely based on the 
presence of certain metal objects within a person (i.e. pacemaker, aneurysm clip, metal fragments, 
etc.).   

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 32 of 39 
Research Study protocol template version date 11/3/2016 
 
Protection against Risk: 
• There will be a strict safety screening protocol, to ensure any people with 
contraindications are excluded from volunteering in MR portion of study 
• Incidental Findings: There will be no diagnostic analysis associated with any of the 
MR sequences used in this protocol; the images will not be sent for radiology 
review.  However, some of the MR images we obtain as part of this protocol may 
show incidental medical findings.  In the case where a medical abnormality is 
apparent on an image, the image will first be reviewed by an investigator on this 
protocol.  If the abnormality is confirmed, then the participant will be instructed to 
seek medical attention from their health care provider 
 
Activity Monitoring: There are no risks associated with the wearing of activity monitors.  
 
Heart Rate Monitoring: There are no risks associated with the wearing of the chest strap and 
Polar Watch.  
 
Metabolic chamber: Besides inconveniences that can reasonably be expected as a result of 
spending an extensive time (24h) in the live-in room calorimeter, there is no risk to participants’ 
physical health. Claustrophobia is an exclusionary criterion.  All participants will be given an 
opportunity to experience the metabolic chamber prior to enrollment in the study. 
 
Protection against Risk: 
• 
Participants will be closely monitored to ensure they are comfortable while in the 
calorimeter.  
 
Low Carbohydrate Diet: Low carbohydrate diets could lead to hypoglycemia and diabetic 
ketoacidosis (DKA).  
Protection against Risk: 
Participants will have at least bi-weekly calls to assess maintenance of glycemic 
control. Furthermore, participants will be asked to check their blood sugar 
approximately every 12 hours plus blood ketones at least once per day. Participants 
will keep a log of their daily values and contact the study team immediately (see 
below) if values are out of range. If the ketone values are elevated (> 0.6 mmol/L) 
or if they display any symptoms of elevated ketone levels, they will contact the 
investigator immediately. Early symptoms of elevated Ketone levels include; 
polydipsia and polyuria several days before the onset of DKA. Other common 
symptoms include generalized weakness, weight loss, nausea, vomiting, and 
abdominal pain. Prolonged elevated levels of ketones can lead to swelling in brain, 
loss of consciousness, diabetic coma and death.  
Contact: 
 
Translational Research Institute for Metabolism and Diabetes 301 East 
Princeton Street, Orlando FL 32804 
Phone Number: 407-303-7100. 
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 33 of 39 
Research Study protocol template version date 11/3/2016 
 
Participants are also wearing a continuous glucose monitor for the duration of the of the study 
that will alert them to glucose trends and allow them to take corrective/preventive action as 
necessary. 
 
Participants will be provided with Hypoglycemia, Hyperglycemia (visit 2) and diabetic 
ketoacidosis (visit 4) information/instructions sheets 
 
Continuous Glucose Monitor Risks: The risks of wearing the CGM are minimal. Bruising, 
redness, discomfort, and some bleeding can occur.  Mild skin irritation is common. Rarely an 
infection can occur at the site of CGM sensor needle placement. Any infection, or sign of 
infection, will be treated immediately. An allergic reaction to the tape used to hold the sensor in 
place is possible.  If there is pain, redness, irritation, or rash at insertion site, the sensor will be 
removed and re-inserted in a different site. 
 
Protection against Risk: 
• CGM placement will be conducted by qualified staff using aseptic techniques to 
reduce these risks. Participants will be trained on proper insertion techniques so that 
they can replace sensors at home as necessary.  
 
Other Risks: In addition to the risks listed above, participants may experience a previously 
unknown risk or side effect.  They will be asked in advance about any previous injury, which could 
prevent them from participating in this test. 
 
Mitigation of Risks  
Invasive procedures (blood sampling and vessel cannulation) will be conducted at the TRI by 
qualified staff following institutional policies and procedures including sterile dressing to the site.  
 
Provisions to Protect the Privacy Interest of Subjects 
Subjects will be assigned unique identifiers for study-related records. All precautions will be taken 
to make sure that only authorized individuals will access subject research records.  The collection 
of sensitive information about subjects will be limited to minimum necessary to achieve the aims 
of the research, so that no unneeded sensitive information will be collected. 
 
Early Withdrawal of Subjects 
 
Investigator Withdrawal of Subjects 
The participation in this study may be stopped at any time by the study PI without the participant’s 
consent because: 
• The study Medical investigator thinks it necessary for subject’s health or safety; 
• Participant has not followed study instructions; 
• Participant has not followed study supplement consumption compliance 
• Participant has not followed dietary compliance 
• The TRI-MD has stopped the study; 
• Administrative reasons require the participant’s withdrawal; 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 34 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Subject Request for Withdrawal from Study 
Participation in this study is voluntary. Participants may decide not to participate in this study or 
may withdraw from this study at any time without penalty or loss of benefits. If a participant 
leaves the study before the final regularly scheduled visit, she/he may be asked by the study 
doctor to make a final visit for some ‘end-of–study’ procedures. This is to make sure that there 
are no safety concerns 
 
Data Collection and Follow-up for Withdrawn Subjects 
Participants who request withdrawal or who are withdrawn by the PI from the study will have their 
data maintained in the research database up to the point of withdrawal.  This data will be included 
in subsequent analysis because a participant may have withdrawn due to possible drug side effects 
and keeping these participants in the analysis is essential for study validity. 
 
Adverse Event Reporting 
An adverse event (AE) is an untoward medical occurrence in a subject administered a product 
and which does not necessarily have a causal relationship with this treatment. An AE can 
therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of a product, whether or not considered 
related to the product. Each participant is evaluated for adverse events at every study visit.  Any 
event that is reported to the study staff and which meets the criteria of an adverse event will be 
documented as such and graded as to its attribution (unrelated to protocol, or possibly, probably, 
or definitely related to protocol) and severity (mild, moderate, or severe). Any severe and/or 
unanticipated adverse event will be immediately reported to the IRB. 
 
Recording and Notification of Adverse Events 
At each contact with the subject, the study team will seek information on adverse events by specific 
questioning and, as appropriate by the Provider through examination.  Information on all adverse 
events will be recorded immediately in the source document, and also in the appropriate adverse 
event module of the case report form (CRF).  All clearly related signs, symptoms, and abnormal 
diagnostic procedures results will be recorded in the source document. 
All adverse and unexpected events will be reported according to Florida Hospital IRB guidelines. 
 
Safety Monitoring Plan   
We will provide the following safety and monitoring procedures, in compliance with the policy of 
the NIH that all investigative sites provide a plan regarding monitoring and oversight of the 
conduct of the clinical trial to ensure the safety of volunteers and the validity and integrity of the 
data. Data and safety monitoring will be performed in accordance with all local IRB, NIH, and 
other applicable federal regulatory guidelines. Research and treatment procedures will also be 
conducted in accordance with the Principles of Good Clinical Practice (GCP) guidelines. Standard 
FH and SBPMDI IRB procedures and infrastructure for data and safety monitoring will be utilized.  

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 35 of 39 
Research Study protocol template version date 11/3/2016 
 
 
Safety Monitoring 
All adverse events will be documented by the study team.  The study coordinator will review 
adverse events with a medical provider (PA, ARNP, and/or MD) on a routine basis. In addition, 
the Translational Research Institute has a standing committee that meets monthly to review all 
adverse events in our clinical trials and will additionally be charged with review of the study.  
Adverse events will be reported to the Florida Hospital IRB as required per HRP 801-
INVESTIGATOR GUIDANCE: Prompt Reporting Requirements.   
 
Data and Safety Monitoring Board (DSMB) or Equivalent 
Although a DSMB is not required for this study, we will report to the ACT1ON DSMB who will 
evaluate safety and data quality for the grant in its entirety.  Drs. Mayer-Davis, Maahs and 
Pratley will represent the ACT1ON consortium in interactions with the DSMB. Their focus will 
be the statistical analyses related to Aim 3 of the grant which will be conducted at Stanford and 
UNC Chapel Hill. The DSMB will review the final study protocol and any significant changes to 
the protocol over the course of the study especially as related to participant burden or safety. The 
DSMB will monitor and advise on study participant accrual and retention, progress and 
completeness for all standardized measurement visits and attendance at intervention sessions. 
Adverse events will be monitored, as well as staff training and certifications. A summary of the 
DSMB report will be sent to both the local site IRBs and NIDDK as part of the annual progress 
report. The DSMB has already been established and consists of external experts in in 
endocrinology, nutrition, health psychology and behavior change, and study design and statistical 
analysis. The DSMB convened for its inaugural meeting on 9/28/2017. Please refer to grant 
documents for details on committee membership/  
 
Ethical Considerations 
Participation in this study is voluntary. Subjects may decide not to participate in this study or may 
withdraw from this study at any time without penalty or loss of benefits. No vulnerable populations 
will be studied in this protocol.  
Sharing of Results with Subjects 
Participants will be offered the opportunity to meet with the Principal Investigator or designated 
medical staff to review the results of their lab assessments or other standard clinical data. Copies 
of their testing results will be made available to the participants upon request. In addition, the 
Principal Investigator or designated study staff will provide an overview of the study's outcome to 
the participant if he or she requests the information.  
 
Funding Source 
Phase 1 is funded through a National Institutes of Health Grant awarded to the University of 
North Carolina with Florida Hospital as a Subcontract. Procedures not originally in the grant 
along with Phase 2 will be funded through internal funds.  
 
Subject Stipends or Payments 
After the participant’s completion of study visits, a Mastercard® payment will be processed for 
each study phase. Mastercard® payments may take up 3 business days to be processed, once 
requested. Enrolled participants that successfully complete the study requirements for Phase 1 will 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 36 of 39 
Research Study protocol template version date 11/3/2016 
 
receive a one-time payment of $660. If participant has successfully completed Phase 2 the total 
stipend is$ 1495 (Phase 1 and Phase 2 combined). Screened participants that that do not meet study 
criteria will receive a one-time payment of $50. Participants that voluntarily or administratively 
withdrawn due to lack of compliance will not receive any payment. Participants that are withdrawn 
due to: a 1) health or safety concerns (as assessed by the medical investigator), b) discontinuation 
of the study, or c) other administrative reasons (not related to compliance) will receive prorated 
payments dependent on time of participation (i.e. $25 for screening, $25 for each completed visit).  
Participants who agree to take part in this study will be paid for completed study visits according 
to the following schedule: 
 
Phase 1 
Visit 1 (Screening) 
$ 50 
Visit 2 (Day 1) 
$ 75 
Visit 3 (Day 8) 
$ 125 
Visit 3 (Day 9) 
$ 125 
Visit 3 (Day 10) 
$ 200 
Visit 3 (Day 11) 
$ 85 
Total Phase 1 
$ 660 
 
 
 
Publication Plan 
TRI-MD will publicly disclose data. Whenever possible, data dissemination will occur through 
presentation at major scientific conferences and/or publication in peer-reviewed journals, and will 
be complete, accurate, balanced, and timely. We attest that the TRI faculty and staff will adhere to 
POLICY-TRI-ADM-005 (Access to Clinical Trial Data for Publication Purposes). Since this study 
is one component of a multi-center study, publications, abstracts and presentations will be 
reviewed and approved by a Publications and Presentation Committee as delineated in the 
submitted grant documents.     
 
References 
 
1. 
Miller, K.M., et al., Current state of type 1 diabetes treatment in the U.S.: updated data 
from the T1D Exchange clinic registry. Diabetes Care, 2015. 38(6): p. 971-8. 
2. 
Chillaron, J.J., et al., Obesity and type 1 diabetes mellitus management. Minerva 
Endocrinol, 2015. 40(1): p. 53-60. 
3. 
Maahs, D.M., et al., Association of glycaemia with lipids in adults with type 1 diabetes: 
modification by dyslipidaemia medication. Diabetologia, 2010. 53(12): p. 2518-25. 
4. 
Diabetes, C., et al., Modern-day clinical course of type 1 diabetes mellitus after 30 years' 
duration: the diabetes control and complications trial/epidemiology of diabetes interventions 
and complications and Pittsburgh epidemiology of diabetes complications experience (1983-
2005). Arch Intern Med, 2009. 169(14): p. 1307-16. 
5. 
Jacob, A.N., et al., Potential causes of weight gain in type 1 diabetes mellitus. Diabetes 
Obes Metab, 2006. 8(4): p. 404-11. 
Phase 2 
Visit 4 
$ 75 
Visit 5 
$ 75 
Visit 6 
$ 75 
Visit 7 
$ 75 
Visit 8 (Day 37) 
$ 125 
Visit 8 (Day 38) 
$ 125 
Visit 8 (Day 39) 
$ 200 
Visit 8 (Day 40) 
$ 85 
Total Phase 2 
$ 835 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 37 of 39 
Research Study protocol template version date 11/3/2016 
 
6. 
Rigalleau, V., et al., Resting energy expenditure in uremic, diabetic, and uremic diabetic 
subjects. J Diabetes Complications, 2004. 18(4): p. 237-41. 
7. 
Carlson, M.G. and P.J. Campbell, Intensive insulin therapy and weight gain in IDDM. 
Diabetes, 1993. 42(12): p. 1700-7. 
8. 
Greco, A.V., et al., Daily energy metabolism in patients with type 1 diabetes mellitus. J 
Am Coll Nutr, 1995. 14(3): p. 286-91. 
9. 
Nair, K.S., D. Halliday, and J.S. Garrow, Increased energy expenditure in poorly 
controlled Type 1 (insulin-dependent) diabetic patients. Diabetologia, 1984. 27(1): p. 13-6. 
 
 
 
 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 38 of 39 
Research Study protocol template version date 11/3/2016 
 
Appendix A: Schedule of Activities 
Phase 1 
Phase 2 
 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
 
SV  
Day -28 to 
Day -1 
Day 1 
Day 8 
Day 9 
Day 
10 
Day 
11 + 
28 
Day 18 
+/- 2 
Day 25 
+/-2 
Day 32 
Day 35 
Day 
37 
Day 
38 
Day 
39 
Day 
40 
Informed Consent 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
History and Physical 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Height 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Weight 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Calculated BMI 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Waist/Hip 
Circumference 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Vital Signs 
X 
X  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
AE/Conmed 
Assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
CBC 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
CMP 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
HbA1c 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
TSH 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Lipid Panel 
X 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
Urinalysis 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Glucose and Ketone 
test1 (point of care) 
  
  
  
  
  
X 
X 
X 
X 
X 
 X 
 X 
X  
X 
Toxicology screen 
X 
  
  
  
  
  
  
  
  
  
  
  
  
  
Urine pregnancy test 
X 
X 
  
  
  
  
X 
X 
 X 
X 
 X 
  
 
  
DEXA 
  
X 
  
  
  
  
  
  
  
 
  
  
  
  
24-hour Dietary 
Recall2 
  
X 
  
  
  
 
X 
  
  
  
  
 
Previous Day Physical 
Activity Recall 
(PDPAR) 
  
X 
  
  
  
 
X 
  
  
  
 
Bi-weekly calls 
  
  
  
  
  
X 
X 
X 
X 
X 
  
  
  
 
CGM 
Placement/Collection 
(T1D group)3 
  
X 
  
  
  
 X 
  
  
  
  
  
  
  
X  
CGM 
Placement/Collection 
(Healthy group) 
 
 
 
X 
 
X 
 
 
 
 
 
 
 
 
Activity Monitor 
Distribution 
  
X 
  
  
  
  
  
  
X 
  
  
  
  
  
Activity Monitor 
Collection 
  
  
X 
  
  
  
  
  
  
  
X 
  
  
  
Check into CRU 
  
  
X 
  
  
  
  
  
  
  
X 
  
  
  
Overnight Stay 
  
  
X 
X 
X 
  
  
  
  
  
X 
X 
X 
  
Check out of CRU 
  
  
  
  
  
X 
  
  
  
  
  
  
  
X 
Inpatient Standard 
Diet 
  
  
X 
X 
X 
X 
  
  
  
  
 
 
 
 
Diet Counseling- Low 
carb, hypocaloric4 
  
  
  
  
  
X 
X 
X 
  
  
  
  
  
 
Pick up outpatient 
controlled diet- Low 
carb, hypocaloric4 
  
  
  
  
  
  
  
  
X 
X 
  
  
  
  
Outpatient Low Carb 
Diet 
  
  
  
  
  
 
  
 
X 
X 
  
  
  
  
Inpatient low carb diet 
  
  
  
  
  
  
  
  
  
  
X 
X 
X 
X 

 
 
 
Current Version Date: 
23Oct2019 
IRBNet #: 
1144866 
Previous Version 
14Jun/2018 
Page 39 of 39 
Research Study protocol template version date 11/3/2016 
 
Phase 1 
Phase 2 
 
Visit 1 
Visit 2 
Visit 3 
Visit 4 
Visit 5 
Visit 6 
Visit 7 
Visit 8 
 
SV  
Day -28 to 
Day -1 
Day 1 
Day 8 
Day 9 
Day 
10 
Day 
11 + 
28 
Day 18 
+/- 2 
Day 25 
+/-2 
Day 32 
Day 35 
Day 
37 
Day 
38 
Day 
39 
Day 
40 
Blood Collection for 
Archiving 
  
  
  
X 
  
  
  
  
  
  
  
X 
  
  
FibroScan 
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
MRE 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
MRI/S 
  
  
  
X 
  
  
  
  
  
  
  
X  
  
  
Whole Body MR 
  
  
  
X 
  
  
  
  
  
  
  
  
  
  
Stool Collection and 
Banking 
  
  
  
X 
  
  
  
  
  
  
X 
  
Diabetes, Ingestive 
Behavior, Nutrition 
Knowledge 
Questionnaires 5 
  
  
  
X 
  
  
  
  
  
  
  
X 
  
  
Acceptability of 
Defined Diets 
Questionnaire   
  
  
  
 
  
  
  
  
  
  
  
X 
  
  
Check into 
calorimeter 
  
  
  
  
X 
  
  
  
  
  
  
  
X 
  
Whole Room 
Calorimetry- 23 hours 
  
  
  
  
X 
  
  
  
  
  
  
  
X 
  
Polar Heart Rate 
Monitor placement 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
Polar Heart Rate 
Monitor collection 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
24-hour urine 
collection 
  
  
  
  
X 
  
  
  
  
  
  
  
X 
  
Check out of 
calorimeter 
  
  
  
  
  
X 
  
  
  
  
  
  
  
X 
1. 
Glucose testing to be performed at least twice per day and ketone testing at least once per day 
2. 
Two phone calls will be conducted by UNC between Day 1 through Day 7 and Day 18 through Day 35.  
3. 
Participant will continuously wear CGM until collection at either the end of Phase 1 or Phase 2 as appropriate. The site must be 
changed at least every 7 days.  
4. 
Phase II participants only 
5. 
Food Frequency Questionnaire, Diabetes Eating Problem Survey, Dutch Eating Behavior Questionnaire, Barratt Impulsiveness Scale 
(BIS-15), Food Craving Inventory, Nutrition Knowledge Survey, Diabetes Quality of Life, Hypoglycemia Fear Survey (HFS), Recent 
Physical Activity Questionnaire (RPAQ), Sleep Disorder Questionnaire, The Center for Epidemiological Studies-Depression (CES-D)