Brown Adipose Tissue as a Therapeutic for the Metabolic and Cardiac Dysfunction With Senescence (BATSR)
Phase: NA
Conditions: Metabolic Diseases
Sponsor: AdventHealth Translational Research Institute

 
 
 
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Study Protocol Title: 
BAT as a therapeutic for the metabolic and cardiac dysfunction with senescence (BATSR)  
 
Study Sponsor:   
AdventHealth  
 
Principal Investigator: 
Paul M. Coen, Ph.D. 
 
Medical Investigator: 
Richard Pratley, M.D. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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Table of Contents: 
List of Abbreviations: ..................................................................................................................... 4 
Introduction ..................................................................................................................................... 5 
Background Information and Scientific Rationale ......................................................................... 6 
Study Objectives ............................................................................................................................. 7 
Primary Objective ....................................................................................................................... 7 
Study Design ................................................................................................................................... 7 
Research Design .......................................................................................................................... 7 
Study Site(s)/Location(s) and Number of Participants ............................................................... 8 
Multi-Site Research Logistics/Communication Plan .................................................................. 8 
Research Conducted in a Foreign Country ................................................................................. 8 
Community-Based Participatory Research ................................................................................. 8 
Participants Selection ...................................................................................................................... 9 
Vulnerable Populations (if applicable) ....................................................................................... 9 
Inclusion Criteria ........................................................................................................................ 9 
Exclusion Criteria ....................................................................................................................... 9 
Resources Available ...................................................................................................................... 11 
Study Procedures .......................................................................................................................... 11 
Participants Recruitment and Screening ................................................................................... 11 
Consent Process ........................................................................................................................ 12 
Non-English Speaking Participants .......................................................................................... 12 
Participants who are not yet adults (infants, children, teenagers) ............................................. 12 
Cognitively Impaired Adults ..................................................................................................... 12 
Adults Unable to Consent ......................................................................................................... 12 
Documentation of Informed Consent Process .......................................................................... 12 
Waiver of Written Documentation of Consent or Waiver of Consent ...................................... 12 
Randomization .......................................................................................................................... 12 
Study Visits ............................................................................................................................... 12 
Study Duration .......................................................................................................................... 19 
Materials of Human Origin:  Collection, Preparation, Handling and Shipping ........................ 20 
Study Outcome Measures (Endpoints) ......................................................................................... 20 
Data Management and Quality Plan ............................................................................................. 20 
Data De-identification ............................................................................................................... 20 
Data Confidentiality, Storage, and Retention ........................................................................... 21 
Data Quality .............................................................................................................................. 21 
Data Sharing (outside of AdventHealth Orlando) .................................................................... 22 
Sample Size Determination ........................................................................................................... 22 

 
 
 
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Statistical Analysis Plan ................................................................................................................ 22 
Potential Risks and Benefits ......................................................................................................... 22 
Potential Benefits ...................................................................................................................... 22 
Potential Risks .......................................................................................................................... 22 
Provisions to Protect the Privacy Interest of Participants ......................................................... 24 
Early Withdrawal of Participants .................................................................................................. 24 
Investigator Withdrawal of Participants ................................................................................... 24 
Participant Request for Withdrawal from Study ....................................................................... 24 
Data Collection and Follow-up for Withdrawn Participants .................................................... 24 
Adverse Event Reporting .............................................................................................................. 25 
Adverse Events ......................................................................................................................... 25 
Recording of Adverse Events ................................................................................................... 25 
Notification of Adverse Events ................................................................................................. 25 
Safety Monitoring Plan ................................................................................................................. 25 
Safety Monitoring ..................................................................................................................... 25 
Data and Safety Monitoring Board (DSMB) or Equivalent ..................................................... 25 
Ethical Considerations .................................................................................................................. 26 
Sharing of Results with Participants ......................................................................................... 26 
Funding Source ............................................................................................................................. 26 
Participant Stipends or Payments .................................................................................................. 26 
Publication Plan ............................................................................................................................ 27 
References ..................................................................................................................................... 29 
 
 
 
 

 
 
 
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List of Abbreviations: 
ACSM:  American College of Sports Medicine’s 
BAT: Brown Adipose Tissue 
BMI: Body Mass Index (kg/m2) 
BP: Blood Pressure 
CBC:  Complete Blood Count 
CMP:  Complete Metabolic Panel 
DEXA:  Dual-energy X-ray absorptiometry 
DO:  Doctor of Osteopathic Medicine 
DVT:  Deep Vein Thrombosis 
ECG:  Electrocardiogram 
EMR:  Electronic Medical Record 
eGFR: estimated Glomerular Filtration Rate 
FDA:  Food and Drug Administration 
HbA1c:  Hemoglobin A1c 
HDL:  High-Density Lipoprotein 
HIPAA:  Health Insurance Portability and Accountability Act 
HIV:  Huma Immunodeficiency Virus 
IRB: Institutional Review Board 
LDL:  Low-Density Lipoprotein 
MD:  Medical Doctor 
MI:  Medical Investigator 
MMSE:  Mini Mental State Examination 
MRI: Magnetic Resonance Imaging 
NP:  Nurse Practitioner 
OS: Old Sedentary 
PA: Physician Assistant 
PASE:  Physical Activity Scale for the Elderly  
PC:  Personal Computer 
PI:  Principal Investigator 
RER:  Respiratory Exchange Ratio 
RM: Repetition Maximum 
SOP: Standard Operating Procedure 
SPPB:  Short Physical Performance Battery 
TRI:  Translational Research Institute  
TSH:  Thyroid Stimulation Hormone 
UF:  University of Florida 
VLDL:  Very Low-Density Lipoprotein 
VO2: Volume of Oxygen Consumed 
WI:  Working Instruction 
YA: Young Active 
 

 
 
 
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Introduction 
 
This document is a protocol for a human research study. This study is to be conducted in 
accordance with applicable Federal regulations and institutional research policies and procedures. 
 
The US population is rapidly aging. It is projected by 2030, more than 20% of the population will 
be over 65 years of age (An Aging Nation:  The Older Population in the United States. Current 
Population Reports (US Census Bureau), 1-28 (2014)). Aging per se is the strongest risk factor for 
a multitude of diseases including both metabolic and cardiovascular disease. Increased age is also 
associated with a reduction on physical activity levels and exercise intolerance, resulting in 
decreased cardiorespiratory fitness (VO2max). Many studies have shown that VO2max strongly 
correlates to all-cause mortality (21). The effects of aging on the body include a loss of functional 
independence, a decrease in the quality of life, and an increased risk of mortality. The increase in 
the aged population has elevated the significance of elucidating potential therapeutic treatments. 
 
Increasing age is directly correlated to greater prevalence of both metabolic and cardiovascular 
disease (6). Aging results in impaired glucose metabolism and increased insulin resistance; a third 
of the population over 60 years of age has diabetes (elderly-onset diabetes), and an additional third 
of this population presents with prediabetes (18). There is also a higher prevalence of 
cardiovascular mortality in older adults with impaired glucose metabolism compared to those with 
normal glucose tolerance. An important tissue that combats metabolic disease and is 
cardioprotective is brown adipose tissue (BAT) (3, 8, 31, 36, 39). BAT is a thermogenic tissue that 
contains large amounts of mitochondria to dissipate chemical energy as heat. When activated, 
either by cold-stimulation or increasing the amount of BAT by transplantation, BAT increases 
energy expenditure, decreases plasma glucose and lipids, and improves systemic metabolism.  
Previous work have demonstrated that increasing the amount of BAT by transplantation improves 
metabolic health and has an endocrine effect on the heart (14, 36, 38). Additionally, studies have 
identified that cold-activation or exercise releases from BAT a “batokine”, the lipid 12,13-
diHOME, which has a robust effect on metabolism (25, 35) 
 
BAT has great potential as a therapeutic target to combat both metabolic and cardiovascular 
disease, but BAT mass decreases with age (8, 12, 30-32, 39). The objective of this study is to 
define the effect of aging on BAT mass in a cohort of older sedentary adults and older athlete 
adults. A secondary objective is to define how changes in BAT mass with aging relate to changes 
in BAT derived lipokines (12,13 diHOME). Finally, we would like to further validate the method 
for determining BAT mass using MRI. 
 
This work embodies a multidisciplinary and multi-Investigator approach and is the product of an 
ongoing successful collaboration between experts in magnetic resonance imaging, BAT, and aging 
at AdventHealth Translational Research Institute (TRI), Orlando, FL. 
 
The proposed study is a prospective, two group, controlled exercise training study consisting of 
three distinct but connected phases:  
I) Screening Phase and Pre-Intervention testing,  
II) Exercise Training Intervention Phase, and  
III) Post-Intervention testing.  
 
Eligible participants will be assigned to one of two groups:  
1. Older adults who are regularly engaged in endurance exercise (OA-Older Athlete) 
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2. Older adults who are sedentary (OS-Older Sedentary). 
 
The expected duration for a participant in this study is approximately 120 days. 
 
A series of physiologic and clinical/health outcomes will be assessed before and after the 
exercise intervention period: 
1. Morning resting fasted variables: blood pressure; blood glucose and lipids 
2. Physical Examination, Resting ECG, Urine collection 
3. Cardiorespiratory fitness (VO2peak) determined via a graded cycle ergometry test. 
4. Physical function: The Short physical performance battery (SPPB) will be used to 
measure lower extremity performance as a secondary outcome. 
5. Body composition by DEXA scan - bone mineral density, total and partitioned lean 
mass, estimated visceral fat. 
6. Muscle strength and power: Quadriceps muscle performance testing (maximal strength 
and power) will be performed using a Biodex dynamometer. 
7. Hyperinsulinemic euglycemic glucose clamp to assess whole body insulin sensitivity. 
8. Echocardiograph measurements to assess cardiac function. 
9. MR Imaging for BAT mass. 
 
Participants in the OS group will enter a progressive 8-week supervised aerobic and resistance 
training program at the exercise training facility at the AdventHealth TRI.  Blood will be 
collected before and after the intervention to assess circulating Batokines. 
 
Background Information and Scientific Rationale 
 
Metabolic and cardiovascular dysfunction with age. It is well established that metabolic and 
cardiovascular diseases are closely related with the aging process. Obesity, visceral adiposity, and 
insulin resistance are observed much more frequently in the elderly, resulting in a greater incidence 
of type 2 diabetes. These metabolic disorders contribute to the cardiovascular disease in the elderly. 
There is also a progressive decline in diastolic and systolic function, a blunted contractile reserve 
and hypertrophy, which manifests as Heart Failure with Preserved Ejection Fraction (HFpEF). The 
collective effect is that ~75% of people over 60 have a cardiovascular disease, with mortality 
upwards of ~40%(46). 
 
Physical inactivity and aging. Together, the collective effect of aging on metabolism, the 
cardiovascular system, and other organ systems concomitant with a reduction on physical activity 
levels leads to exercise intolerance. This inactivity decreases VO2max, a leading risk factor in 
cardiovascular disease and all-cause mortality (21). This decrease in physical activity can result in 
a loss of functional independence and a decrease in quality of life. 
 
Brown adipose tissue (BAT) and aging. BAT is a thermogenic tissue that produces energy as 
heat. It is characterized by a multilocular appearance, increased mitochondria, and increased 
expression of uncoupling protein-1 (UCP1)(30). Modulation of BAT metabolism influences whole 
body energy balance, and increased BAT activity counteracts obesity and diabetes (2, 7, 11, 13, 
14, 24, 30, 36, 39). BAT is influenced by cold exposure through increased sympathetic activity 
(20, 28), various secreted factors (20, 25, 28), or exercise (4, 15-17, 22, 23, 27, 29, 34, 37, 41-45, 
47). BAT mass and activity are decreased in humans and mice with aging (7, 12, 31-33). The 
decrease in BAT with age is due to blunted sympathetic activity (32, 33), altered endocrine control 
(32), and the loss of brown adipocyte regenerative capacity due to dysfunctional stem cells (32, 

 
 
 
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33). This decreased BAT activity is manifested in a diminished response to cold temperatures (i.e., 
reduced heat generation via non-shivering thermogenesis) (26, 31). There is also an inverse 
relationship of BAT to body mass index and visceral fat mass (7, 31). These data suggest that the 
loss of BAT contributes to the metabolic dysfunction with aging. 
 
BAT and metabolism. Previous studies have demonstrated that increasing the amount of BAT in 
rodents using a transplantation model improved whole-body and metabolic health and increase 
insulin-stimulated glucose uptake (14, 36). BAT transplantation reduced body weight and 
adiposity and improved whole-body glucose metabolism. BAT transplantation increases glucose 
metabolism specifically in the heart, white adipose tissue (WAT), and the endogenous BAT (36). 
 
BAT and cardiovascular function. Recent studies have investigated the endocrine role of BAT 
to influence cardiovascular function. UCP1-/- knockout mice had greater cell death, greater 
adverse remodeling, and worse survival in catecholamine-induced cardiomyopathy (38). These 
detrimental effects in UCP1-/- knockout mice were prevented with transplantation of BAT from 
wild-type mice, suggesting that thermogenically active BAT has a cardioprotective effect. 
Additionally, BAT transplantation increases glucose uptake to the heart (36). Taken together, these 
studies indicated that BAT can influence heart function. 
 
BAT as an endocrine organ. BAT functions as a secretory organ, releasing various secreted 
factors that act on other tissues and organs (2, 14, 36, 40). Several BAT-derived molecules, called 
“batokines” have been identified to function in an autocrine, paracrine, and endocrine manner (40). 
Previous studies have demonstrated that increasing the amount of BAT through a transplantation 
model improved whole-body metabolic health and increased insulin-stimulated glucose uptake in 
the heart and WAT (14, 36). Recent work has identified a batokine, the lipid 12,13-diHOME, to 
be increased in circulation in response to various stimuli in both rodents and humans and increases 
fatty acid uptake in BAT and skeletal muscle (25, 39). In line with a reduction in BAT, 12,13-
diHOME is decreased in older adults in comparison to young counterparts (35). These studies 
suggest the inability of BAT to secrete batokines with aging may impair whole-body metabolism 
and cardiovascular function in older adults. 
 
Study Objectives 
 
Primary Objective 
To define the role of BAT and 12,13-diHOME in the age-induced impairments in 
metabolism and cardiac function, and determine if increasing BAT mass or its endocrine 
function is a viable therapeutic strategy to improve metabolic and cardiovascular function 
in the elderly. 
 
Study Design 
 
Research Design 
 
The proposed clinical study is a single site prospective, two group, controlled exercise 
training study of older athletes (OA) (n=15 completers) and older sedentary (OA) (n=15 
completers) consisting of three distinct but connected phases:  
 
Phase I:  Pre-Intervention, Screening and Baseline testing  
 
Phase II:  Intervention, Exercise Training  

 
 
 
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Phase III:  Post-Intervention, Follow-Up testing  
A series of physiologic and clinical/health outcomes will be assessed before and after the 
exercise intervention period: 
 
1. Morning resting fasted variables: blood pressure; blood glucose and lipids 
2. Physical Examination, Resting ECG, Urine collection 
3. Cardiorespiratory fitness (VO2peak) determined via a graded cycle ergometry test. 
4. Physical function: The Short physical performance battery (SPPB) will be used to 
measure lower extremity performance as a secondary outcome. 
5. Body composition by DEXA scan - bone mineral density, total and partitioned lean 
mass, estimated visceral fat. 
6. Muscle strength and power: Quadriceps muscle performance testing (maximal strength 
and power) will be performed using a Biodex dynamometer. 
7. Hyperinsulinemic euglycemic glucose clamp to assess whole body insulin sensitivity. 
8. Echocardiograph measurements to assess cardiac function. 
9. MR Imaging for BAT Mass 
 
Participants in the OS group will enter a progressive 8-week supervised aerobic and 
resistance training program at the exercise training facility at the TRI.  Blood will be 
collected before and after the intervention to assess circulating Batokines. A complete 
Schedule of Activities (SOA) can be found in the Appendix. 
 
The expected duration for a participant in this study is approximately 120 days. 
 
Males and females in the age ranges 65-90 years will be recruited from AdventHealth’s 
electronic medical record (EMR), senior centers, television, radio and social media 
advertisements, mass mailing lists from the Orlando, FL catchment area, and by contacting 
potential participants on the AdventHealth TRI’s participant database. 
 
Study Site(s)/Location(s) and Number of Participants 
 
 
AdventHealth Orlando site locations: Translational Research Institute, 301 E. Princeton 
Street. Orlando, Florida 32804. 
 
Estimated number of participants at AdventHealth Orlando site (including screenings): 36 
Estimated number of participants at external sites: 0 
Total number of all sites: 1 
 
Estimated number of participants at all sites combined (including screenings): 36 
 
Multi-Site Research Logistics/Communication Plan 
 
N/A 
Research Conducted in a Foreign Country 
 
N/A 
Community-Based Participatory Research 
N/A 
 
 

 
 
 
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Participants Selection 
 
Vulnerable Populations (if applicable) 
 
 
AdventHealth Orlando Employees:  Recruitment efforts will follow AdventHealth Orlando 
recruitment SOPs for research.   AdventHealth Orlando Employees will not be individually 
targeted nor excluded from study participation based on employment. AdventHealth 
Orlando employees who engage the AdventHealth TRI 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 AdventHealth Orlando.   
 
Inclusion Criteria 
 
1. Males and Females between the ages of 65 to 90 years of age.  
 
2. BMI £ 35kg/m2, inclusive at time of screening. 
 
3. Stable weight (No gain/loss of ≥ 10 lbs within 6 months prior to screening). 
 
4. Non-smokers as defined by not smoking any tobacco or using nicotine-containing products 
and not using vape pens or vaporizers within 3 months prior to screening.  
 
5. Participant must have renal function with an estimated glomerular filtration rate (eGFR) > 
45 ml/min/1.73m2 determined at screening. 
 
6. Triglyceride level is < 350 mg/dl and LDL cholesterol is ≤ 150 mg/dl at screening. 
 
7. States willingness to follow protocol as described, including the prescribed exercise level 
and completing any forms needed throughout the study. 
 
8. Voluntarily signed and dated an informed consent form, approved by an Institutional 
Review Board/Independent Ethics Committee, and provided Health Insurance Portability 
and Accountability Act authorization (HIPAA) or other privacy authorization prior to any 
participation in study. 
 
Group Specific Inclusion Criteria: 
 
9. Older Athletes (OA) Only: Endurance trained athletes, defined as exercising (running, 
cycling, swimming) >3days/wk for >6 months without layoff. This will be verified by self-
report and triaxial accelerometry. 
 
10. Older Sedentary (OS) Only: Defined as <1day/wk of structured exercise and determined 
by self-report and triaxial accelerometry. 
 
Exclusion Criteria 
 
1. History of type 1 or type 2 diabetes per self-report at screening visit 1. 
 
2. Actively pursuing weight loss and/or lifestyle changes at time of screening. 

 
 
 
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3. Untreated or poorly controlled hypertension (SBP > 150, DBP > 95). 
 
4. Mini Mental State Exam (MMSE) <21. 
 
5. Participant has had a significant cardiovascular event (e.g. myocardial infarction, stroke) ≤ 
6 months prior to screening visit; or stated history of congestive heart failure; or participant 
has evidence of cardiovascular disease assessed during the ECG at screening. In the event 
of a positive stress test, participants are referred to their primary care physician. If the 
electrocardiogram (ECG) is determined to be a false positive, participant may be allowed 
to participate in study after confirmatory records obtained. 
 
 
6. Current infection (requiring prescription antimicrobial or antiviral medication, or 
hospitalization), or corticosteroid treatment (with the exception of inhaled or topical 
steroids) in the last 3 months prior to screening visit. 
 
7. Participant is currently taking anti-inflammatory medication or has had anti-inflammatory 
medication within 1 week prior to screening (including over the counter formulations; e.g. 
Aleve, Motrin, ibuprofen, naproxen, low dose aspirin).   
 
8. Surgery requiring >2 days of hospitalization in the last 3 weeks prior to screening visit. 
 
9. Participant has an active malignancy (with the exception of basal cell) or autoimmune 
disease. 
 
10. Participant has a chronic, contagious, infectious disease, such as active tuberculosis, 
Hepatitis B or C, or HIV, per self-report. 
 
11. Participant is an amputee and/or has presence of partial or full artificial limb. 
 
12. Participant currently has uncontrolled severe diarrhea, nausea or vomiting. 
 
13. Participant has uncontrolled severe (including stage III or above) gastrointestinal 
absorption-related disorders, within 3 months of screening, such as:  obstruction of the 
gastrointestinal 
tract, 
inflammatory 
bowel 
disease, 
short 
bowel 
syndrome, 
gastroesophageal reflux disease, gastroparesis, peptic ulcer disease, celiac disease, 
intestinal dysmotility, diverticulitis, ischemic colitis and bariatric surgery. 
 
14. Cannot abstain from alcohol for the duration of the testing periods. 
 
15. Subjects who fulfill any of the contraindications for MRI; examples include metal implants, 
devices, paramagnetic objects contained within the body and excessive or metal-containing 
tattoos. 
 
16. Unable to participate in MR or DEXA assessments due to physical limitations of equipment 
tolerances (e.g., MRI bore size and DEXA 450-pound weight limit), claustrophobia, or 
based on Investigator’s judgment at screening. 
 
17. Participant cannot refrain from taking medications/dietary supplements/herbals or 
substances that could modulate glucose metabolism, or are considered anabolic, or reduce 
weight (fat mass) in the opinion of the PI or Physician, starting two weeks prior to 
enrollment and over the entire course of the study. These include progestational agents, 

 
 
 
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steroids, 
growth 
hormone, 
dronabinol, 
marijuana, 
calcium-betahydroxy-
betamethylbutyrate (CaHMB), free amino acid supplements and dietary supplements to aid 
weight loss. 
 
18. Participant has hypothyroidism (TSH ≥10 mIU/L) or hyperthyroidism (TSH < 0.4 mIU/L). 
 
19. Presence of any condition that, in the opinion of the Investigator, compromises participant 
safety or data integrity or the participant’s ability to complete the study. 
 
20. Because all women participating in this project will be post-menopausal, there will be no 
need for a pregnancy test prior to DEXA procedures. Females currently on hormone 
replacement therapy (HRT) can participate in the study if they have been on a stable dose 
of HRT for at least 6 months and will continue to be on HRT during the study. 
 
21. Potential participants taking stable doses of medications for the last 30 days prior to 
screening for Blood pressure, cholesterol, GERD may be permitted to participate. 
 
22. Participant becomes Covid-19 positive at any point during the study. 
 
Resources Available 
We attest that all AdventHealth Translational Research Institute faculty and staff will be trained, 
and this training will be documented as described in AdventHealth Translational Research Institute 
Work Instruction 031.100.015 Documentation of Protocol Training.   
 
We will implement regular, ongoing discussions between the PI and coordinator as per the 
AdventHealth Translational Research Institute SOP 030.000.002 Oversight of Research Studies at 
the Translational Research Institute. The coordinator will review source and communicate with all 
applicable study team members involved in the study on a regular basis regarding reportable new 
information, implementing amendments, study progress, and quality assurance/control.   
 
The AdventHealth Translational Research Institute facilities are state of the art and we have within 
our building all required resources and staff to execute the study. We have a medical oversight 
team, Medical Oversight Committee, as well as a Quality Committee to appropriately monitor and 
address adverse events. 
 
Study Procedures 
 
Participants Recruitment and Screening 
 
Males and females in the age ranges 65-90 years will be recruited from AdventHealth 
EMR, senior centers, television, radio, social media advertisements, text messaging, 
emailing, newsletters, and mass mailing lists from the Orlando, FL catchment area, and by 
contacting potential participants on the AdventHealth TRI’s participant database.  
 
Potential participants will be medically screened to determine good health and without any 
contraindication to exercise. Approximately equal numbers of men and women will be 
recruited. Neither race nor ethnicity will be exclusions.  
 
We will recruit volunteers through public advertisement by placing advertisements in 
community newspapers and radio, as well as on social media. Individuals who respond to 

 
 
 
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the ads will be contacted by telephone for preliminary screening and will be given an 
opportunity to ask initial questions and be provided additional description of the study. 
Potential volunteers who seem to meet criteria will be scheduled for an outpatient 
examination at AdventHealth TRI. Informed, written consent will be obtained at the 
screening visit.  
 
We anticipate ~400 phone screens to successfully enroll and complete 18 participants per 
group (anticipating 15 completers per group).  
 
Consent Process  
 
We attest that all study staff delegated the authority to obtain informed consent will 
follow “Investigator Guidance: Informed Consent (HRP-802)”, as well as 
“Investigator Guidance: Documentation of Informed Consent (HRP-803)”.   
 
Non-English Speaking Participants 
 
We will not be enrolling Non-English speaking participants due to the complexity 
of the visits, number of visits and length of the study.  The participant population 
will be English speaking.   
 
Participants who are not yet adults (infants, children, teenagers) 
 
 
We are not enrolling participants who are not yet adults. 
 
Cognitively Impaired Adults 
 
 
We will not enroll cognitively impaired adults. 
 
Adults Unable to Consent 
 
 
We will not enroll adults who are unable to provide consent. 
 
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  
 
N/A 
 
Randomization 
 
 
N/A 
 
Study Visits  
All study visits will be conducted at the AdventHealth Translational Research Institute.  
 
 
 

 
 
 
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PHASE I – SCREENING AND PRE-INTERVENTION TESTING 
 
Both older athlete and older sedentary groups will undergo the screening and pre-
intervention testing phase.  See “Appendix: Schedule of Activities” for a table description 
of the  procedures that will be performed during PHASE I. 
 
Screening:  SV1  
Approximate visit time:  ~ 3 1/2 hours 
Volunteers will arrive, after an 8 hour overnight fast, to the AdventHealth TRI. Following 
voluntary written informed consent, all research participants will undergo a screening 
process for eligibility. This process may be repeated if necessary, under the discretion of 
the Medical PI.  The following listed below procedures will be performed:  
 
Demographics, Medication & Medical History, Physical Examination, Vital Signs, 
and Anthropometrics will be obtained.  A full physical examination will be performed by 
a study physician, physician assistant, or nurse practitioner and will include general 
assessment of the following: head, ears, nose, eyes, throat, heart, lungs, abdomen, 
extremities, skin, neurological functioning, and any other impressions or problems noted 
by the provider at the time of exam. This will also include height, weight (metabolic), BMI, 
blood pressures, heart rate, respirations, temperature, medication, supplement history and 
a basic assessment of cognitive functioning via the Mini Mental State Examination 
(MMSE). 
 
Electrocardiogram (ECG).  A standard 12-lead ECG will be performed.  Electrodes will 
be placed on the chest to provide a tracing of the electrical activity of the heart. 
 
Physical activity questionnaires will be administered at screening. The Exercise History 
and Physical Activity Scale for the Elderly (PASE) are instruments that measures the level 
of habitual physical activity for individuals. The CHAMPS Physical activity health 
questionnaires will also be administered at screening. The MMSE will be administered at 
this time too. 
 
Fasting blood draw to measure: a lipid panel; Complete Metabolic Panel (CMP); 
Complete blood count with differential (CBC w/ diff); TSH and HbA1c. Total blood 
volume for screen labs 14mls. Safety labs may be repeated per Investigator discretion, if 
needed. Blood draws may also take place at visit 2 or visit 3.   
 
Urine collection for urinalysis. 
 
Waist Circumference Measurements which are a surrogate measure of abdominal fat 
will be conducted during screening. The Gulick II tape measure will be used for accuracy 
in obtaining duplicate waist measurements. All circumferences will be measured in 
centimeters directly on the skin. 
 
Hand-Grip Strength Test. All participants will perform a hand grip test that will be 
conducted three times with 1 minute of rest between each repetition using the dominant 
hand of each participant. The greatest grip strength and the average of the three tests will 
be recorded.   
  

 
 
 
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Lower extremity performance battery. The Short Physical Performance Battery (SPPB) 
is a brief performance-based test that will be used to measure lower extremity performance. 
The SPPB consists of three tasks: five repeated timed chair stands, timed standing balance 
(with feet in parallel, semi-tandem, and tandem positions), and a 4-meter walk to determine 
usual gait speed.  
 
Step Test:  Each participant will be asked to complete a timed step test. 
 
Covid Testing:  Participant must have a negative covid test 1 week prior to the next visit.  
Covid testing may take place on a separate visit when SV1 is not within 1 week of V1. 
 
Screening tests may be repeated if the Investigator deems necessary. 
 
Visit 1 
Approximate visit time:  ~ 3 hours 
 
Review of Adverse Events, Concomitant Medications 
Vital Signs 
Body Weight 
 
3-Day Food Diary: Participants will be given a food diary and asked to record what foods 
and drinks they eat over a 3-day period. Participants will return the completed diary on 
visit 2. 
 
Fasting blood draw to collect EDTA plasma.  Circulating lipids related to BAT activity 
and mass will be measured in plasma samples.  Total blood volume will be 10 mls. Safety 
labs may be repeated per Investigator discretion, if needed.  
 
MR Imaging for BAT Mass. Brown adipose tissue will be differentiated from white 
adipose tissue using fat fraction and T2* relaxation time maps generated from a 
commercially available modified 6-point Dixon (mDixon) water-fat separation method. 
MRI scans will be performed on a Philips 3T using axial, coronal, and sagittal slice 
orientations to provide anatomical reference scans in the neck and body area.  Quantitative 
mDixon scans will be used for calculating proton density fat fraction (PDFF) maps. The 
participant may be removed from the magnet and repositioned during the exam in order to 
determine the same day variability of this method. 
 
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. 
 
Indirect Calorimetry: Indirect calorimetry will be used during the maximal oxygen 
consumption test (VO2max) to measure the metabolic rate, respiratory quotient (RQ) and 
substrate utilization using a MAX II Metabolic cart (AEI Technologies, Pittsburgh, PA).  
The analyzer will be calibrated before each subject with standardized gases containing 5% 

 
 
 
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CO2, 21% O2 and balance N2. Calculations of O2 consumption (VO2) and CO2 
production (VCO2) will be made by comparing a single measure of the O2 and CO2 
concentrations of the testing room to continuous measurements of O2 and CO2 
concentrations in expired air diluted in a constant air flow (20-50 L/min) generated by a 
pump.  From the above, energy expenditure standardized for temperature, pressure, and 
moisture will be calculated at one-minute intervals.    
 
Maximal Oxygen Consumption (VO2max). Aerobic fitness will be determined by 
measuring maximal O2 consumption (VO2max) during a stationary bicycle exercise test.  
Provider monitoring will follow The American College of Sports Medicine’s (ACSM) 
Guidelines for Exercise Testing and Prescription and AdventHealth TRI BATS-Pilot SSP.  
Heart rate, blood pressure and ECG will be recorded throughout this test. During the test, 
participants will breathe through a low resistance mouthpiece and wear a nose clip. Expired 
gases will be measured by indirect calorimetry.  Following a standardized warm up, 
participants will begin exercising at a moderate intensity with the workload (resistance on 
a cycle ergometer) increased every minute until the participant can no longer continue. VO2 
max tests will take as little time as possible in order to ensure that test termination is due 
to the participant reaching VO2 max rather than terminating the test due to muscle 
exhaustion. A leveling-off (plateau) or decline in oxygen uptake should be demonstrated 
in order to be reasonably sure that a participant has achieved the maximum capacity for 
aerobic metabolism. However, there are several additional criteria that will be used to 
determine if maximal aerobic capacity is achieved. These criteria are: the respiratory 
exchange ratio (RER) increased to 1.10 or higher and the participant’s heart rate increased 
to within 10 beats of the age-predicted maximum (208 – [0.7 x age]).  This test will be 
supervised by a qualified Medical Provider as stated in AdventHealth TRI SOP 
030.100.015 Procedural Staffing. 
 
In the event of a positive stress test, participants are referred to their primary care physician. 
If the electrocardiogram (ECG) is determined to be a false negative, participant may be 
allowed to continue participating in the study. 
 
Triaxial Activity Monitor: Two tri-axial accelerometer-based activity monitors will be 
placed during Visit 2.  One will be placed on the wrist and the other on the triceps of the 
same arm. The monitors integrate motion sensor data from the tri-axial accelerometer to 
estimate the energy cost of free-living activity. The participant will wear the monitors for 
5-7 days, except while showering or bathing. The participant will have the monitors 
removed and the data uploaded at Visit 2 or Visit 3. 
 
Visit 2 
Approximate visit time:  ~ 3 hour  
 
Review of Adverse Events, Concomitant Medications 
Vital Signs 
Body Weight (metabolic) 
Collection of Activity Monitors 
 
Cardiac Function- Echocardiogram: Echocardiography measurements (systolic and 
diastolic function) will be performed using a Philips Epic or comparable level cardiac 
imaging system. Subjects will be properly hydrated 30 minutes prior to testing. 2D 
imaging, spectral and Tissue Doppler, and Strain with Heart Model Imaging will be 

 
 
 
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performed before any exercise testing. Left ventricular mass, left ventricular ejection 
fraction, left atrial volume and ejection fraction will be measured using Heart Model and 
estimation of right atrial pressure will be done using the most recent standards of The 
American Society of Echocardiography. The Doppler measurements and calculations will 
include aortic valve and left ventricular outflow tract velocity time integrals, E/A ratio, 
E/e’ ratio, D/E slope, left ventricular myocardial performance index, isovolumic relaxation 
time, and tricuspid regurgitation peak velocity.  In the event of scheduling challenges, the 
Echo can be on the business day before or after this scheduled visit.  
 
Muscle Power Testing. Muscle power testing will be performed using a Biodex 
pneumatic-driven dynamometer which is equipped with load cells and potentiometers (for 
helping measure changes in joint angle). The dynamometer is connected to a PC with 
software to measure muscle power and velocity. After the participant is seated at rest for 
~5 minutes, a blood pressure measurement is taken. If the value is below 160/100 mm Hg, 
the participant continues with the procedures below. If the value is above 160 and/or100 
mm Hg, the participant’s blood pressure is re-checked after five minutes and one final time 
after 10 min rest or until it is within an acceptable range. If after three attempts the 
participant’s blood pressure is greater than 160 and/or100 mm Hg, the participant’s test is 
re-scheduled for another day. If the BP is in acceptable range, the participant will warm up 
with one minute of free pedaling on a cycle ergometer (seat height is adjusted by setting 
the seat height at standing hip height and adjusting while participant is on the bike for 10o 
of flexion at the knee when leg is fully extended). Tester then explains the power test and 
also describes the responses to the pain/discomfort (P/D) scale (range = 0 to 6) and that the 
participant may decide to discontinue testing at any time. After the ~1-minute bike warm-
up the participant will be seated on the Biodex machine with the lateral condyle of the knee 
lined up with the axis of rotation of the machine arm and the seat belts should then be 
fastened snugly. Both legs will be tested. The participant will be instructed to keep arms 
crossed across the chest and to remember to maintain normal breathing patterns.  
participant will perform three power tests on each leg at each resistance of 60, 120 and 180 
degrees per second with a ~2-minute rest between each adjustment in resistance and a ~5-
minute rest between the right and left leg trials. The order of the resistance will be selected 
randomly. The participant will give a P/D rating after each trial. After both legs have been 
tested BP should be taken again immediately at conclusion of test and after ~5 minutes of 
rest.  If BP reading is normal the visit will continue. If it is above 160/100 mm Hg the 
participant will rest for ~2 minutes and BP will be taken again. If BP has not normalized 
to below 160/100 mm Hg, the visit will be discontinued, and the participant will remain in 
the facility for at least ten more minutes while monitoring blood pressure. When BP finally 
normalizes, the participant will be sent home with the recommendation to contact their 
physician. The PI and the Medical PI will also be notified.  
 
Termination criteria for maximal power testing: 
- A participant asks to discontinue testing. 
- Equipment failure 
Relative termination criteria: 
- Participant reports >3 on the P/D scale (with explanation that the pain persists after the 
cessation of movement or if the participant reports >3 in any area besides the knee, upper 
or lower leg. 
 
Muscle strength (1-RM) assessments.  The initial weights for knee extension should be 
set based on the participant’s predicted 1 repetition maximum (1 RM). Based on previous 

 
 
 
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research, males and females < 65 years of age have a predicted 1 RM of 90% and 60% of 
their body weight, respectively, for the knee extension. For each additional 10 years of age 
the 1 RM should decrease 10% (ex. 91 year old male would have a predicted 1 RM of 60% 
of his body weight). This number should be calculated and recorded on the data collection 
sheet. One can then calculate the participant’s first 5 lifts at 0, 20, 35, 50, and 70 percent 
of predicted 1 RM. This weight scale is followed, and weight is continually increased until 
termination of the test. Both legs will be tested, and the first leg will be selected randomly.  
The participant will be instructed to keep arms crossed across the chest and to remember 
to maintain normal breathing patterns.  Appropriate rest intervals will be provided during 
testing and the participant will give an RPE rating and P/D if needed after each trial.  Prior 
to 1-RM testing, if participant’s blood pressure is less than 160/100 mm Hg, then the 
participant will warm-up on a bike for ~1-minute with no resistance. If BP was elevated 
the participant should rest for 5 more minutes. If BP is still elevated greater than 160/100 
mm Hg, the participant will be sent home with the recommendation to contact their 
physician, and this participant will be followed up for potential re-testing.  After both legs 
have been tested a BP will be taken after ~5 minutes.  
 
Termination criteria for maximal strength testing: 
- A participant asks to discontinue testing. 
- An individual moves a weight through a full range of motion with relative comfort but 
cannot move through the full ROM with a two-unit increase. 
- Participant cannot move through full ROM with proper form (participant lifts lower or 
upper back away from padded seat, participant kicks pad using acceleration force to lift 
weight, hands not crossed across chest, uneven or jerky ROM). 
 
Relative termination criteria: 
- Participant reports >3 on P/D scale with explanation that the pain persists after the 
cessation of movement or if the participant reports >3 in any area besides the knee, upper 
or lower leg. 
- Participant reports >18 on RPE scale. 
 
Covid Testing:  Participant must have a negative covid test prior to the next visit.  Covid 
testing may take place on a separate visit when V2 is not within 1 week of V3. 
 
 
Visit 3 Day -7  
Approximate visit time:  10 minutes + Evening admission (~6:00pm) overnight. 
 
Review of Adverse Events, Concomitant Medications 
Body Weight 
 
Fasting Finger Stick to collect glucose for clamp preparation.  Participants will be asked 
to fast overnight prior to blood draw.   
 
Standardized Meal: Participants will visit the metabolic kitchen at AdventHealth TRI 
on the evening before the glucose clamp and consume a standardized meal (10 kcal/kg) 
consisting of 50% carbohydrate, 15% protein, and 35% fat.  
 
Visit 3 Day -6 
Afternoon discharge (~2:00pm)    
 

 
 
 
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Vital Signs 
Body Weight 
 
Resting Metabolic Rate/Respiratory Quotient (RMR/RQ): Indirect calorimetry will 
used at two times during the hyperinsulinemic-euglycemic clamp to measure the resting 
metabolic rate/respiratory quotient (RMR/RQ) and substrate utilization using a MAX II 
Metabolic cart (AEI Technologies, Pittsburgh, PA).  The analyzer will be calibrated before 
each subject with standardized gases containing 5% CO2, 21% O2 and balance N2. 
Subjects will be instructed to lie in a Semi-Fowler’s position and remain motionless and 
awake during these periods.  A transparent plastic hood connected to the device will be 
placed over the head of the subject. Calculations of O2 consumption (VO2) and CO2 
production (VCO2) will be made by comparing a single measure of the O2 and CO2 
concentrations of the testing room to continuous measurements of O2 and CO2 
concentrations in expired air diluted in a constant air flow (20-50 L/min) generated by a 
pump.  From the above, energy expenditure standardized for temperature, pressure, and 
moisture will be calculated at one-minute intervals.    
 
Hyperinsulinemic-Euglycemic Clamp: The glucose clamp is the gold standard for 
measurement of insulin sensitivity and will be performed as previously described by our 
group (1, 5, 9, 10). After an overnight 8-hour fast, an intravenous catheter will be placed 
in the vein for infusion of insulin and glucose.  A second catheter will be placed in the vein 
of the contra-lateral arm for blood withdrawal. After baseline blood is collected, a primed 
(210 mg/m2), continuous (2 mg/min/m2) infusion of [6,6-2H2] glucose will be initiated for 
assessment of endogenous glucose production. A 2-step euglycemic clamp will be started 
with a 2-hour infusion of insulin (Humulin-R) at 15 mU/m2/min, followed by 2 hours at 40 
mU /m2/min.  Plasma glucose will be measured at 5-10 min intervals via NOVA StatStrip 
Glucose Meter. Plasma glucose will be allowed to either decrease to ~90 mg/dl or will be 
increased to ~90 mg/dl in each participant depending on the fasting blood glucose levels. 
Euglycemia (~90 mg/dL) will be maintained with a variable 20% dextrose infusion 
enriched with [6,6-2H2] glucose. Rates of glucose disposal (M) and endogenous glucose 
production (EGP) will be calculated by non–steady-state equations based on plasma [6,6-
2H2] glucose enrichment determined by gas chromatography mass spectrometry. A 
baseline blood sample will be collected prior to -30 mins. Then three blood samples will 
be collected for determination of plasma insulin, free fatty acid (FFAs), C-Peptide, and 
glucose concentrations prior to the insulin infusion, and at the beginning of each steady 
state and every 10 minutes during the two steady state portions of the clamp which will last 
approximately 4 hours from the time at which the insulin infusion is initiated (-30min, -
20min, -10min, 0min, +30min, +60min, +100min, +110min, +120min, +220min, 
+230min, and +240min). Participants will complete a 24-hour urine collection on days 
where hyperinsulinemic-euglycemic clamps are run. Total blood volume during this 
procedure will be approximately 192 mls. 
Calculations: Hepatic glucose production is expected to be completely suppressed at this 
level of insulin, even in diabetic subjects.  In this case, peripheral glucose uptake (Rd) 
should equal the glucose infusion rate (GINF) during steady state (the last 30 minutes of 
each step of the clamp) after correction for urinary glucose loss.    
That is: - Rd = Steady State GINF - urinary glucose loss 
Insulin sensitivity (SI) will be calculated using the formula: SI = Rd / (steady state insulin 
level - basal insulin level) where steady state insulin equals the average insulin 

 
 
 
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concentration during the last 40 minutes of the clamp and basal insulin equals the average 
insulin level in the 30 minutes before starting the insulin infusion.   
Fasting and insulin-suppressed FFA [IS-FFA] will be measured with an ultrasensitive FFA 
assay from Wako. Glucose disposal rate [GDR] will be expressed as mg/kg FFM 
[DEXA]/minute. 
Metabolic flexibility of substrate oxidation 
Before and during the steady state of the clamp, we will measure substrate oxidation 
using a MAX I  Metabolic Cart (AEI Technologies, Pittsburgh, PA) to measure 
‘metabolic flexibility’ as described by Kelley and Mandarino (19). 
 
PHASE II – EXERCISE TRAINING INTERVENTION 
Older sedentary participants will undergo 8 weeks of exercise training.  Exercise training 
visits may extend up to 3 weeks through Phase III in rare circumstances to help 
accommodate staffing scheduling availability.  The exercise program will be supervised by 
a certified exercise physiologist and will take place at the AdventHealth TRI exercise 
training facility. After the first week of exercise training at TRI, exercise training may take 
place remotely in rare circumstances, for example, if the participant has a short trip planned 
or the participant becomes ill and must skip a session during their intervention phase.  
Remote exercise will be brisk walking outside for a duration and intensity that is intended 
to be similar to the exercise performed at TRI.  For remote exercise, the participant will be 
given and taught how to appropriately use a portable heart rate monitor to record their 
exercise sessions and a tracking log to document their session.  A certified exercise 
physiologist will call a remotely exercising participant each day a remote exercise session 
is scheduled to provide instruction and to assess exercise compliance. Upon return to TRI, 
the data will be downloaded and added to the participant’s exercise session files for 
analysis.   
 
Exercise compliance will be monitored for exercise training 4 days per week (minimum of 
32 total sessions). Aerobic training will be 30 minutes of brisk walking, jogging, cycle 
ergometry. Walking will be the primary mode of aerobic exercise given its widespread 
popularity and ease of administration across a broad segment of the older adult population. 
Walking will be at a moderate intensity and determined based on Heart Rate (50-70% of 
Maximal HR from most recent VO2max) and rating of perceived exertion using Borg’s 
scale (ranges from 6 to 20). Other forms of endurance activity (e.g., stationary cycling) will 
be utilized on a limited basis when regular walking is contraindicated either medically or 
behaviorally. This is the exercise regimen that has demonstrated substantial increases in 
muscle size and strength in elderly people.  See “Appendix: Schedule of Activities” for a 
table description of the  procedures that will be performed during PHASE II. 
 
PHASE III – POST-INTERVENTION TESTING 
Following the exercise training intervention, participants in the OS group will participate 
in post-intervention testing.  The testing procedures are a subset of those performed during 
the pre-intervention testing period (PHASE I). A detailed description of the procedures can 
be found above. The testing procedures will be taken over a 2-week period following the 
exercise intervention.  See “Appendix: Schedule of Activities” for a table description of 
the  procedures that will be performed during PHASE III. 
 
Study Duration 
 

 
 
 
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Estimated start date for enrollment is Sept 30, 2019. Active recruitment and testing will 
continue until the end of the funding period or until 15 participants per group have been 
recruited. The study is funded by the National Institute of Aging until 01/31/2024. 
 
Materials of Human Origin:  Collection, Preparation, Handling and Shipping 
 
Materials of human origin will be collected in the manner described in the specific study 
visits section of this protocol.   
 
Biospecimen samples will be stored in ultralow temperature freezers and liquid nitrogen 
dewars or other storage units located at the AdventHealth TRI Laboratory Room 2404. The 
AdventHealth TRI 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 plasma/serum samples will be stored indefinitely, or until a sample is fully used. All 
biological specimens will be stored without identifiers or linkage codes.  
 
After study aims have been achieved and study related endpoints have been measured and 
analyzed, any remaining biospecimens will be stored at the AdventHealth TRI Laboratory 
Room 2404 and will then 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 developed due to the evolving nature of scientific 
exploration.   
 
Additionally, archived biospecimen samples may be stored indefinitely for future research.   
Archived biospecimens could be used for separate research by both AdventHealth 
Orlando scientists and scientists outside of AdventHealth TRI.  This would be allowed for 
research of any type (without limitation to disease, process, or research methods) if it has 
scientific merit as determined by the Principal Investigator, with an additional review by 
the respective Program Director.  For research outside of AdventHealth Orlando, a Material 
Transfer Agreement will be obtained, which will govern the transfer and chain of custody 
of the biospecimens outside of AdventHealth Orlando. 
 
Study Outcome Measures (Endpoints) 
 
The major outcomes of the study are collection of imaging of BAT by magnetic resonance 
imaging and circulating lipokines (12,13-diHOME) from 15 participants in each of the 
older athlete and sedentary groups. In addition, collection of all phenotype data are 
considered secondary outcome measures, including: Aerobic fitness (VO2max test, DEXA, 
Muscle power and strength, Physical function (SPPB), and accelerometry data). 
 
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 

 
 
 
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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. 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).  The “link” will be stored in the Patient Protocol Manager and the 
clinical research database, where only the AdventHealth TRI research team has access. 
These secure databases are stored/accessed on the AdventHealth Orlando password-
protected computer network. No one outside of AdventHealth Orlando 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 the participant prior to 
enrollment. 
 
Study documentation and paperwork will be stored in our locked medical records 
room.  The data records will also be stored in as electronic records.  This data will be 
safeguarded so that only those on the research team have access to any of the clinical data 
(both source documentation and data warehouse storage).  The electronic data is 
maintained by Adventist Information Technology (AIT) security controls.   
 
The duration of study data retention will be determined by the AdventHealth TRI Records 
Management Policy.  Electronic de-identified data will be kept indefinitely in our data 
warehouse. 
 
Data Quality  
Data quality control will occur according to our SOPs on Data Entry, Quality Control 
Procedures and Query Management.  All data will be entered into an electronic data capture 
(EDC) system and checked against the paper source for accuracy by a second party (Data 
Entry SOP) and errors resolved through the Query Management SOP.  Ten percent of the 
data points will be routinely checked at the beginning, middle, and close of a study for 
quality control (Quality Control SOP).  Finally, all critical endpoints (as determined by the 
PI or Sub-I) will be assessed using quality control analyses.  The data will be loaded into 
the clinical research database.  Data in the warehouse will also be routinely monitored over 
time. 
 
The device data will directly be imported into spreadsheets or entered and confirmed into 
the EDC.  Data from the VO2max, activity monitors, and DEXA data are exported directly 
into spreadsheets for further calculations. Data for each of the endpoint analyses will be 
imported into an SAS database linked with a participant ID.  

 
 
 
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Data Sharing (outside of AdventHealth Orlando)  
This is a collaboration partnership between AdventHealth TRI, and its affiliates. Certain 
data elements will need to be shared along with the biospecimen samples (primarily plasma 
samples). Should archived biospecimens be needed for research outside of AdventHealth 
Orlando and certain data elements that are connected to the archived biospecimen samples 
be needed to conduct the research, then Data Use Agreement(s) will be obtained.  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.  
  
Sample Size Determination 
 
The primary purpose of this protocol is to understand the role of physical activity on BAT mass 
and circulating batokines, and how these variables relate to cardiac and physical function in older 
adults. A formal sample size calculation was not performed. Rather, we referred to published 
studies with similar experimental designs (determination of BAT mass by PET scan) as a guide 
for sample size determination. From the published literature we determine that an n=15 per group 
(active and sedentary) will provide sufficient statistical power to detect differences in BAT mass. 
 
Statistical Analysis Plan 
 
The analysis will involve multiple steps and draw on statistical methods ranging from simple 
descriptive statistics to the modeling of repeated measures outcome data accounting for potential 
missing observations. The major outcomes of the study, the BAT mass, circulating batokines, 
muscle mass, strength, power and quality, and VO2max will be compared using an unpaired 
student t-test to explore baseline differences between older athletes and older sedentary groups. 
Additionally, repeated measures ANOVA will be performed on the dependent variables as a 
function of the exercise intervention in the older sedentary group. Multiple linear regression will 
be used to determine how BAT mass and circulating batokines explain variation in physical 
characteristics of muscle (strength, quality) and cardiovascular health (VO2max). Sex will be 
explored as a biological variable. 
 
Potential Risks and Benefits 
Potential Benefits 
 
Participants will likely receive no direct benefit from taking part in this research study. 
 
Potential Risks 
 
RMR/RQ.  There is no physical risk associated with RMR/RQ. Other risks include a 
feeling of claustrophobia experienced by some participants while under the transparent 
“hood”. 
 
Protection Against Risk: 
• A member of the study staff will remain with the subject at all times to ensure 
his/her comfort. 
 

 
 
 
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Blood draws and Intravenous lines (lab samples and infusions, e.g.). There is a risk of 
pain, vasovagal syncope, hematomas, and/or infection at the blood draw site (low risk of 
serious AEs).  The total volume of blood drawn is over the course of the study is 
approximately 372 mls. 
 
DEXA scan. There is a very small risk of cancer with excessive exposure to any radiation.  
There are also risks for unborn children associated with radiation exposure. The radiation 
dose from the scan is less than a chest x-ray, or less than half the average amount a person 
would receive in a day in America. 
 
Maximal Oxygen Consumption (VO2max). There is a risk of changes to blood pressure, 
irregular, fast or slow heart rhythm, fainting, and in rare instances (<0.01%) heart attack, 
stroke, or death with exercise testing, at similar rates to exercising during daily life.   
 
Activity/Heart Rate Monitoring. There are no risks associated with the wearing of 
activity monitors.  However, the Bodymedia armband has sensor pads that touch the skin 
that may be irritating for some participants.  Participants with nickel allergies will not be 
required to wear the Bodymedia activity monitor. 
 
Biodex/Strength testing/Exercise/Maximal Oxygen Consumption (VO2max). There is a 
risk of changes to blood pressure, irregular, fast or slow heart rhythm, fainting, and in rare 
instances (<0.01%) heart attack, stroke, or death with exercise testing, at similar rates to 
exercising during daily life.   
 
Magnetic Resonance Imaging and Spectroscopy. There are no known biological risks 
associated with magnetic resonance imaging and 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 metal objects 
within a person (i.e. pacemaker, aneurysm clip, metal fragments, etc.).   
 
Cardiac Function - Echocardiogram A transthoracic echocardiogram carries no risk. 
There’s a chance for slight discomfort when the electrodes are removed from the skin. This 
may feel similar to pulling off a Band-Aid. 
 
Hyperinsulinemic-euglycemic clamp. There is a risk of hypoglycemia (low blood sugar) 
during the clamp.   
 
Mitigation of Risks  
 
 
Blood draws and Intravenous lines (lab samples and infusions, e.g.). All venipuncture will 
be conducted by qualified staff using aseptic techniques.   
DEXA scan. 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). 
 
Activity Monitoring. Participants with nickel allergies will not be required to wear the 
Bodymedia activity monitor.  
 

 
 
 
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Biodex/Strength testing/Exercise/Maximal Oxygen Consumption (VO2max). Prior to 
conducting any exercise testing, a history and physical including ECG will be conducted 
and will be used to determine whether a participant is clear to participate in exercise testing. 
An MD/DO/NP/PA will be available during exercise testing for participants who are at risk 
according to the American College of Sports Medicine (ACSM) Guidelines. ECG, blood 
pressure and heart rate may be monitored during the test. 
 
Magnetic Resonance Imaging and Spectroscopy. There will be a strict safety screening 
protocol, to ensure any people with contraindications are excluded from volunteering. 
There will be no diagnostic analysis associated with any of the MR sequences used in this 
protocol.  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.   
 
Hyperinsulinemic-Euglycemic Clamp. In-house supervision by a qualified physician or 
mid-level provider at all times during the procedure. Constant monitoring of blood glucose 
during the procedure (every 5-10 minutes). Immediate availability of corrective measures 
(IV 50% dextrose and/or glucagon). 
 
Provisions to Protect the Privacy Interest of Participants 
 
Participants will be assigned unique identifiers for study-related records.   All precautions 
will be taken to make sure that only authorized individuals will access participant research 
records.  The collection of sensitive information about participants 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 Participants 
 
Investigator Withdrawal of Participants 
 
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 participant’s health or safety; 
-Participant has not followed study instructions; 
-The AdventHealth TRI has stopped the study; or 
-Administrative reasons require the participant’s withdrawal. 
 
Participant 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.  
 
Data Collection and Follow-up for Withdrawn Participants 
 
Participants who request withdrawal or who are withdrawn by the PI from the study will 
have their data maintained in the research database.  This data and biospecimens from the 

 
 
 
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withdrawn participant may be included in subsequent analysis. Participant withdrawal of 
biospecimens is not an option. 
 
Adverse Event Reporting 
 
Adverse Events 
 
An adverse event (AE) is defined as both an expected side effect that is of a serious nature, 
or an unexpected side effect/event regardless of severity. 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).  
 
Recording of Adverse Events 
 
At each contact with the participant, the investigator will seek information on adverse 
events by specific questioning and, as appropriate, by 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. 
 
Notification of Adverse Events 
 
Adverse events will be reported according to AdventHealth Orlando IRB guidelines. 
 
Safety Monitoring Plan   
 
Safety Monitoring 
 
Research and safety data will be reviewed by the PI. This review will take place at regular 
meetings with the clinical coordinator and medical investigator where the safety labs for 
each new participant will be reviewed. Other items discussed will include: progress or 
adverse events occurring in the following: participant confidentiality, participant 
recruitment, and consent process. All will monitor response to tolerance of and 
effectiveness of the exercise program.  
 
Progress reports, including patient recruitment, retention/attrition, and AEs from the 
reviews will be compiled into an annual report and will include a list and summarization 
of adverse events.  In addition, the annual report will address (1) whether adverse event 
rates are consistent with pre-study assumptions; (2) reason for dropouts from the study; (3) 
whether all participants met entry criteria; (4) whether continuation of the study is justified 
on the basis that additional data are needed to accomplish the stated aims of the study; and 
(5) conditions whereby the study might be terminated prematurely.   
 
Data and Safety Monitoring Board (DSMB) or Equivalent 
 
N/A 

 
 
 
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Ethical Considerations 
 
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. No vulnerable 
populations will be studied in this protocol.  
 
Sharing of Results with Participants 
 
Participants will be offered the opportunity to meet with the PI to review the results 
of their outcomes. Copies of their testing results will be made available to the 
participants. In addition, the PI will provide an overview of the study's outcome to 
the participant if he or she requests the information. 
 
Funding Source 
 
This study will be supported by a sub award from a prime award from the National Institutes of 
Health, National Institute of Aging (R01 AG060542), P.I., Kristin Stanford, Ph.D. Sub Award PI 
and Co-Investigator, Paul Coen, Ph.D. The IRBNet # for this grant is 1456947. 
 
Participant Stipends or Payments 
 
Participants will receive a total of $1425.00 (or up to $1641 with exercise extension visits) if in 
the OS group, and $500.00 if in the OA group, upon the completion of all study visits.  Ride 
shared services, for example Uber Health or Lyft, may be made available to the participants by 
the study team with PI approval.  Travel services will be arranged only by the study team with 
approval.  If participant is unable to complete all study visits, the stipends will be prorated to the 
following:  
 
 Athlete Group 
Total Payment:  
$500 
Phase 1 
SV1 
$0 
V1 
$75 
V2 
$75 
V3 
$350 
 
 
 
 
 
Sedentary Group 
Total Payment: 
$1425 
 
(up to $1641 with 
Extension Visits) 
Phase 1 
SV1 
$0 
V1 
$75 
V2 
$75 
V3 
$150 
Phase II 
V4, 5, 6, 7 
$75 
V8, 9, 10, 11 
$75 
V12, 13, 14, 15 
$75 
V16, 17, 18, 19 
$75 
V20, 21, 22, 23 
$75 
V24, 25, 26, 27 
$75 
V28, 29, 30, 31 
$75 
V32, 33, 34, 35 
$75 
Exercise Extension 
$18/visit 
V36 
$75 

 
 
 
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Phase 
III 
V37 
$150 
V38 
$150 
V39 
$150 
 
 
 
 
A Mastercard® will be the method of payment and will be requested upon completion of the 
study or on their last day of participation, should they find they cannot complete the study.   
 
Publication Plan 
 
We attest that the AdventHealth TRI faculty and staff will adhere to POLICY-TRI-ADM-005 
(Access to Clinical Trial Data for Publication Purposes). The goal will be to publish novel and 
interesting findings from this research. Assignment of authorship and the contributions of each 
author will be determined by the International Committee of Medical Journal Editors (ICMJE) 
policy to guide authorship. 
 
 
 
 
 
 
 
 
 

 
 
 
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Appendix:  Schedule of Activities 
 
**Scheduling Windows are noted here as a general guide. Visits can be scheduled slightly outside of noted windows in unique/rare circumstances with PI approval without sacrificing participant safety or scientific data. 
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