Pilot Data Collection for Activity, Adiposity, and Appetite in Adolescents
Conditions: Physical Activity, Sedentary Lifestyle, Metabolism, Energy Balance
Sponsor: Children's Mercy Hospital Kansas City

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Pilot Data Collection for Activity, Adiposity, and Appetite in Adolescents   
 
Principal Investigator: 
Robin Shook, PhD 
Research Assistant Professor of Pediatrics 
Director, Weighing In  
Center for Children's Healthy Lifestyles & Nutrition 
Children's Mercy Hospital 
610 E. 22nd St.  
Kansas City, MO 64108 
rpshook@cmh.edu; 816-234-9443 
   
Study Coordinators: 
Kelsey Dean MS, RD, LD, CCRP 
Center for Children’s Healthy Lifestyles and Nutrition 
Children’s Mercy Hospital 
610 E. 22nd St.  
Kansas City, MO 64108 
816-234-9235; kmdean@cmh.edu 
 
Amy Papa, MS, CCRC 
Center for Children’s Healthy Lifestyles and Nutrition 
Children’s Mercy Hospital 
610 E. 22nd St.  
Kansas City, MO 64108 
816-234-9230; aepapa@cmh.edu 
 
Please see the MARS application for additional staff not listed on the protocol. 
 
Study Site(s): Children’s Mercy Hospital (Don Chisholm Center) and University of 
Kansas Medical Center (Hoglund Brain Imaging Center) 
 
Protocol Version: (1.0) Protocol Date:  08/14/2017 
 
1.   STUDY OBJECTIVES/HYPOTHESIS 
We hypothesize that low levels of fitness and MVPA result in impaired metabolic 
function in adolescents. For this pilot study, we will quantify variations in metabolic 
characteristics using a 2 x 2 cross-sectional study design, stratified by bodyweight 
(normal vs overweight/obese) and physical activity (sedentary vs. active). Our goal is to 
identify metabolic factors that influence the energy balance system to directly inform 
interventions designed to prevent or reduce the prevalence of pediatric obesity. 
 
Aim 1: To quantify the independent effects of physical inactivity and obesity on 
metabolic responses at rest, after a meal, and during exercise using indirect calorimetry.  
 

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Aim 2: To determine whether physical activity level impacts appetite control independent 
of obesity status via metabolic function. 
 
Aim 3: To explore the hormonal and neurocognitive mechanisms of appetite control.  
 
2.  RATIONALE 
At the most basic level, obesity is the result of a chronic energy surplus within the energy 
balance system. However, an assortment of physiological, psychological, and 
environmental factors are related to energy intake and expenditure, resulting in highly 
variable individual responses to identical intervention strategies [1, 2]. For example, a 
recent rigorous 10-month weight loss study observed a 5.6% average reduction in body 
weight, yet individual weight change ranged from a 22% weight loss to a 4% weight gain 
[3]. Physiologically, differences in energy metabolism likely explain much of this 
variation [4, 5], and identifying those individuals metabolically at risk for obesity or 
resistant to traditional weight loss strategies is a ‘key challenge’ of obesity researchers 
[6]. Thus, there is a critical need to identify metabolic factors that influence the energy 
balance system in order to develop effective interventions to treat obesity or prevent its 
occurrence.  This project will clarify the relationship between physical activity, obesity 
status, and appetite control in adolescents. 
 
3.  STUDY DESIGN 
The proposed pilot study consists of a 2 x 2 cross-sectional study design (Table 1), which 
will maximize statistical power despite a small sample size. Inclusion/exclusion criteria 
for MVPA and body weight are based on established criteria from governmental agencies 
and clinical practice.  
 
4.  TARGET STUDY POPLUATION SPECIFICS 
Participants will include 60 adolescent males (aged 14-18 years, Tanner stages III- IV), 
equally enrolled based on physical activity and body weight status (Table 1).  
 
 
 
 
 
 
 
 
Table 1. Enrollment criteria based on physical activity and body weight status 
Adolescents males (age 14-18 
years & Tanner stages III- V) 
Normal weight 
(≥5th to <75th percentile)  
Overweight/obese 
(≥85th to <99th 
percentile)41 
Inactive (<30 min/day 
MVPA)  
n= 15 
n= 15 
Active (>60 min/day 
MVPA)42 
n= 15 
n= 15 

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Inclusion Criteria  
 
 Males (Tanner Stage III-IV), ages 14-18 
 Weight stable (5% weight change) over the previous three months as assessed by 
self-report.  
 BMI ≥5th and ≤ 99th percentile 
 Physically healthy for exercise as assessed by self report Physical Activity 
Readiness Questionnaire (PAR-Q) for children. 
 For fMRI testing, all participants must be right handed and must have normal or 
corrected to normal vision (as they will be viewing pictures in the fMRI procedure).  
 
Exclusion Criteria 
 History of restrained eating, eating disorders, bariatric surgery, or other significant 
medical diagnosis that could impact metabolism. 
 Participants taking thyroid medications, beta blockers, or other stimulants 
(medications are known to affect physical activity level and metabolism). 
 Due to fMRI procedure requirements, children with a history of Attention Deficit 
Hyperactivity Disorder (ADHD) or other diagnosed psychiatric issues will be 
excluded.  
 
5.  DATA COLLECTION 
Data Collection Procedures 
The study will include 4 visits and 1 home assessment window: 
 Visit 1 - Orientation (Consent, Screening Questionnaires) at Don Chisholm 
 Visit 2 - Clinic Measurements 
o Body composition, via dual energy X-ray absorptiometery (DXA) 
o Resting metabolic rate (RMR), via indirect calorimetry; 
o Metabolic responses to a meal, via thermic effect of feeding (TEF) 
o Subjective aspects of eating behavior using the Three Factor Eating 
Questionnaire (TFEQ) and Control of Eating Questionnaire (CEQ) 
o Appetite, via visual analogue scales (VAS) pre- and post a prepared fixed 
meal and hormones related to satiety and hunger (insulin, leptin, ghrelin, 
peptide YY, glucagon-like peptide-1) obtained during blood samples 
(BLOOD) from an indwelling catheter.  
o All measurements will occur at the CHLN (<9:00am) following an 
overnight fast.  
 Home assessments - Data collected at home during a 14 day window 
 Visit 3 - Fitness Test (VO2submax and VO2max), grip strength, and DXA at Don 
Chisholm 
 Visit 4 - fMRI at University of Kansas Medical Center 
 
 
Please see Figure 1 below for schedule of measures: 
 

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Figure 1.Description of Measures: 
 
Metabolic function.  
 Resting metabolic rate (RMR) will be assessed via indirect calorimetry using a 
ventilated hood following an overnight dietary fast and ≥24-hours since structured 
exercise (e.g. sports participation).  
 Thermic effect of feeding (TEF) will measure the energy expenditure resulting 
from digestion following the fixed meal using the ventilated hood.  
 Submaximal oxygen consumption (fitness test) (VO2submax) and maximal oxygen 
consumption (VO2max) will be assessed with a full-face mask with headgear via 
standard protocols using a treadmill. Measured during visit 3. 
 
Body composition.  
 Assessment of body composition, including fat mass, fat free mass, and visceral 
adipose tissue, will be completed using dual energy X-ray absorptiometry (DXA). 
All anthropometric measurements will be performed with the participant dressed 
in surgical scrubs and in bare feet. BMI (weight [kg]/height [m]2) will be 
calculated from the average of three height and weight measurements using a 
wall-mounted stadiometer and electronic scale and recorded to the nearest 0.1 cm 
and 0.1 kg, respectively. 
 
Fixed/Ad libitum meals. 
Appetite (see below) will be assessed following a fixed standard breakfast of 500 kcals. 
The fixed breakfast will be administered while the participant is in a fasted state (≥12 
hours since last meal) and at least 24 hours since the last bout of exercise, and they will 
be asked to consume the meal within 15 minutes. Food intake (total kcals) will be 
assessed using an ad libitum pizza meal served three hours after the fixed meal. 
Participants will be instructed to eat until comfortably full and informed that they can 
request more of the pizza meal. Meals will be provided in 900 kcal portions, and each 

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plate of food will be weighed before and after serving, without the subjects’ knowledge, 
and the amount consumed recorded. All meals will be served in a quiet dining room free 
from distractions located at the NWRC.  
 
Appetite and Eating Behavior. 
 Subjective assessment of hunger and palatability will be completed using self-
rated visual analogue scales (VAS). Each scale consists of a 10 cm long line 
separating statements such as “not at all hungry” and “extremely hungry”. 
Assessments will occur prior to the fixed meal, and every fifteen minutes for the 
first hour and every thirty minutes for the next two hours.  
 Perceptions of dietary restraint, disinhibition, and hunger will be assessed prior to 
the fixed meal using the Three Factor Eating Questionnaire (TFEQ). The Control 
of Eating Questionnaire (CEQ) will be used to assess hunger, fullness, cravings, 
the desire to eat certain foods, and the ability to resist urges to eat. Assessed at 
visit 2. 
 Blood samples obtained from an (insulin, leptin, ghrelin, peptide YY, glucagon-
like peptide-1). Blood will be drawn at the following approximate times: -15 min 
(x2), 15 min, 45 min, 60 min, 90 min, 120 min, 180 min. Due to the number of 
blood draws, for participant safety and comfort a flexible, vacutainer accessible 
catheter will be placed by a registered nurse (who will also perform all blood 
draws). A total of 32 mL (1.08 oz) of blood will be drawn. 
 
 
Lifestyle Assessment. 
 Energy intake will be assessed using two methods: 1) objectively, as measured by 
amount of kcals consumed during an ad libitum meal (see above, section 
Fixed/Ad libitum meals), and 2) subjectively, assessed via interviewer-
administered dietary recalls. Three dietary recalls will occur on randomly selected  
non-consecutive days over each two-week treatment condition (including at least 
one weekend day) to minimize preparation that could bias recall by the 
participants. All interviews will be conducted over the telephone, will ask about 
all foods consumed over the previous 24 hours using a multi-pass approach, and 
energy intake will be calculated using the Nutrient Data System for Research 
software (NDSR Version 2014). 
 Energy expenditure will be estimated using an arm-based monitor (Sensewear™), 
which calculates energy expenditure using tri-axial accelerometry and measures 
of heat flux, galvanic skin response, skin temperature, and near-body ambient 
temperature. Assessed continually (day and night) over the 14 day home 
assessment period. 
 Sedentary behavior will be assessed using a leg-mounted triaxial accelerometer 
with inclinometer (ActivPal™) which classifies time spent in sedentary, upright, 
and stepping activities. Assessed continually (day and night) over the 14 day 
home assessment period. 
We will assess MVPA using a wrist-worn activity triaxial accelerometer (Actigraph 
GT9X Link™) which quantifies time spent in light activity and MVPA. Assessed 
continually (day and night) over the 14 day home assessment period. 

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SmartPhone prompts to assess cravings, anticipation of eating, and hunger 
The SmartIntakeTM smartphone app will be used as a photo-based ecological momentary 
assessment (EMA).  
 Craving: We will use a single-item craving prompt to assess current food craving 
level: “Please rate on a scale from 0-100 the extent to which you agree with the 
statement: I am craving food.” 
 Anticipation of eating: We will use a single item from Nijs et al (2007) General 
Food Craving-State Questionnaire to assess anticipation of eating: “Eating 
something tasty would feel wonderful.” We have chosen this prompt because it is 
agnostic as to the rationale for anticipating eating. 
 Hunger: We will assess pre-meal hunger to account for the temporal relationship 
between hunger and craving in deprived and non-deprived states (Cepeda-Benito 
et al., 2000). Although hunger is sometimes conceptualized as an aspect of 
craving, our purpose is to distinguish physical hunger from craving to avoid 
confounds. We will use an adapted prompt from Goldschmidt et al (2014) “Please 
rate the extent to which you agree: I feel physically hungry, on a scale from 0-
100, with 0 being not hungry,100 being extremely hungry.” 
 
 
fMRI Procedures. 
 The fMRI study visit will take place at visit 4. Children will be met at the Hoglund 
Brain Imaging Center, part of the University of Kansas Medical Center, for the 
fMRI portion of the study. This visit to Hoglund will take approximately 1.25 
hours. Children will take complete a computized  behavioral food-rating task which 
asks the child to rate sixty food images on how the food tastes, how much the child 
would like to eat the food, and how healthy is the food.  Then the child will 
complete a food-decision task while in the MRI. The child will see a picture of a 
food on the screen, and will choose which foods he/she would prefer to eat. Stimuli 
include items often consumed by children, and were selected to include a wide 
range of tastiness and healthiness attributes (for example, apple, broccoli, 
asparagus, glazed donut, French fries and marshmallows). This test will measure 
how the brain responds to making decisions about food. All food pictures are high-
resolution (72 d.p.i.) color images with a size of 300300 pixels. The stimulus 
presentation and behavioral response collection will be controlled by Presentation 
software (Neurobehavioral System).  
 Additional questionnaires collected at this visit include Monetary choices, Flanker, 
and Consideration of future consequences. 
 
 
Records to be kept 
Data collected will be deidentified with a subject ID number. A linking list will used, which 
will contain the subject ID, subject’s name, gender, and date of birth. This log will only be 
accessible be the PI and the study team. 
 
Secure Storage of Data 

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Consent statements and participant data in separate locked file cabinets so that individuals 
are not easily connected to the study results. All digital data will be stored on a firewall 
and password-protected project server at Children’s Mercy Hospital. Data collected at the 
CMH Don Chisholm Center CMH will be analyzed and stored in secure shared drive at the 
Don Chisholm Center. Blood samples will be collected at Don Chisholm and shipped to 
Quest for processing. fMRI data will be collected at Hoglund Brain Imaging Center at 
KUMC and will be analyzed by KUMC study personnel at KUMC. This data will be 
deidentified, and will be sent back to the PI at CMH using secure file transfer.  
 
SmartIntake App Data Security: 
 
The app was developed and validated by Dr. Corby Martin and colleagues at the 
Pennington Biomedical Research Center (PBRC) at Louisiana State University. The 
company Rapid Development Productions (RapDevPro) worked with Dr. Martin and 
colleages to develop the app. By design, Dr. Martin and colleagues set up this app and 
secure data hosting platform to be available to researchers nationally and his team provides 
researchers data analysis services for the dietary intake data. Reseachers can sign a 
contractagreement to utilize the app for research purposes. No identifying information will 
be collected through the SmartIntake photo-EMA app. 
 
SmartIntake is used to capture images of food and beverage intake before and after 
consumption. Photos are sent directly to a secured data server (see details of server security 
below) for analysis of dietary intake. Participants initiate each photo by opening the app, 
taking the picture, and then submitting the picture through the app. The app sends a 
reminder email 15 minutes after submission of the first photo to remind participants to 
submit their post-consumption photo. The app sends photos to the secured server by email, 
thus an email address is required to send the photos. Participants will be provided a secured 
email address that does not contain or link to any identifying formation, such as their 
names, etc, that the app an use to send the images. When images are sent to the server, the 
email address is stripped from the images before they are stored; thus all data stored on the 
PBRC server is deidentified. The app does not utilize, store, or transfer info from other 
mobile phone data sources including contacts or geolocation.  
 
To minimize the risk of caputring identified data in the photos, participants will recieve a 
training. Participants will be told that they should never include pictures of other people or 
their surroundings (bar signs, etc) in their photos. We will emphasize that we have a 
responsibility to collect strong research data while protecting those around them from 
inadvertently being included in photos without their consent. Participants will be shown 
that once the photo is taken, it will be stored on their phone’s photo app. We will show 
participants how to go into their photo app and delete the picture taken with SmartIntake. 
We will tell them they should do this immediately after sending the photo in SmartIntake. 
 
Photo data stored on the secured PBRC server: The only data stored with photo images is 
the unique participant ID. Email address is stripped from the data before storage to the 
server. Thus, only non-identifying info is stored on the PBRC server for analysis. The 
server that the data is stored on is in the PBRC domain and requires PBRC user credentials 

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to access the files stored on that server. Only Dr. Martin and his staff who directly manage 
or analyze the app data have access to the files where the images are stored. All PBRC 
logins are required to have a password of 15 or more characters and must be changed on a 
regular basis.  
 
NOTE: The photo image data collected by the SmartIntake app will NOT be transferred to 
CMH at any point. The study PI will receive the deidentified dietary intake data that will 
be transferred through the PBRC secured data transfer system. 
 
6.  STUDY DURATION/STUDY TIMELINE 
Target start date is May 2017   
Stage 2, recruitment and data collection, June- November 2017 
Stage 3, data analysis and grant/manuscript development, December 2017- May 2018 
Total study duration will be 1 year. 
 
We anticipate 4-6 waves of enrollment, with each participant enrolled for 4 weeks. 
Following an orientation (visit 1) during which informed consent will be obtained, 
individuals will participate in a clinic measurement session (visit 2), a 14-day free-living 
lifestyle assessment period, a 2nd laboratory visit (visit 3) for an exercise testing session, 
and conclude with a fMRI assessment (visit 4) All laboratory activities will occur at the 
CCHLN research facility, and the fMRI will occur at KUMC Hoglund Brain Imaging 
Center.  
 
7.  STATISTICAL CONSIDERATIONS 
 
Measures 
 Primary measures: Metabolic function and body composition 
 Secondary measure(s): Demographics, appetite, food cravings, and eating 
behaviors, lifestyle assessment, fMRI, energy intake 
 
General Design Issues  
The proposed pilot study consists of a 2 x 2 cross-sectional study design, which will 
maximize statistical power despite a small sample size. This pilot study will generate data 
needed for a larger study. 
 
Sample size determination  
As a pilot study, we will have resources to collect data from N=60 participants. We will 
use this data to determine power requirements for a larger study. 
 
Data Analyses 
Statistical significance for comparison between groups will be tested using analysis of 
variance (ANOVA) for continuous variables and chi-square tests for categorical 
variables. Statistical significance will be set at P<.05 (two-sided) for all analyses. 
 
fMRI Analysis. We will estimate several general linear models (GLMs). All of the 
models allow for first-order auto regression and included six motion parameters, 

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constants, and linear time trends for each run as regressors-of-non-interest. A two-stage 
mixed-effects analysis will be performed in which the regression coefficients for each 
condition of interest will be tested across participants via t-tests. Two-tailed tests are used 
for all statistical analyses. We will perform multiple comparison corrections at the cluster 
level using Monte Carlo simulations with the AlphaSim program.  
 
EMA-Food Craving Analysis. A regression model will test whether mean EMA ratings 
of anticipation (craving) and reward (pleasantness rating, ate more than intended, ate 
beyond satiety) are correlated with postprandial glucose surge and area under the curve 
for glucose following the standardized lab meal. 
 
We will use a hierarchical mixed model to examine the nested association between EMA-
measured craving, food pleasantness, and overeating within eating episodes in free-living 
conditions. Pre-meal craving and within-meal pleasantness ratings will be used as 
predictors in models with overconsumption rating post-meal. Food photos will be used to 
distinguish HF from non-HF (fat/carb: 25%+/25%+; sweet/fat: 15-35%/30%+; salt-fat: 
0.5-2.5%/10-35%) using the detailed NDSR nutrition data output we will receive from 
the app.  
 
We will conduct a series of Pearson correlations to test whether craving and reward 
symptoms measured in the standardized meal and free-living conditions are significantly 
correlated. 
 
We will use a linear regression model to test the degree to which anticipation (craving) 
and reward (food enjoyment, eating despite satiety) as measured using photo-EMA, and 
intensity of glucose surge during the standardized lab meal will be associated with % fat 
mass and visceral adipose tissue as measured using DXA. 
 
 
8.  HUMAN SUBJECTS 
Institutional Review Board (IRB) Review and Informed Consent 
The IRB of record is Children’s Mercy Hospital. 
 
This protocol, and any subsequent modifications, will be reviewed and approved by the 
Pediatric IRB at The Children’s Mercy Hospital & Clinics.   
 
Potential participants will be recruited from our various weight management programs at 
the Center for Children’s Healthy Lifestyles & Nutrition (CHLN), from our electronic 
medical records at Children’s Mercy Hospital and the University of Kansas Medical 
Center, and from the community. We plan to use the available patient registries at CMH 
and KUMC to mail our recruitment materials to a random number of patients who meet 
the inclusion/exclusion criteria. We will also place out recruitment materials in the Primary 
Care clinics at CMH and KUMC. Recruitment materials will be distributed in the 
community through our partners via the Weighing In and Healthy Lifestyle Initiative 
listserves. Based on past experience recruiting for similar studies, we anticipate needing 

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174 initial contacts and 82 screens + dropouts to achieve our goal of 60 completed 
participants.  
 
Parents of potential subjects will contact the study team using the phone number or email 
address on the recruitment flyer. The study team will do a 10 minute phone screening 
with the parent to determine eligibility, and will schedule a time for the parent and child 
to come in for an orientation.  The parent and child will them come to the Don Chisholm 
center at CMH for an orientation. The consent form will be reviewed and ample time will 
be given for the parent and child to consider participation. Prior to drawing any blood or  
performing any other procedures related to this study, the permission/assent form or 
consent form will be reviewed carefully with the participant and parent in person. If the 
parent and child agree to participate, further screening questions will take place. The 
family will then schedule a time to come in for the measurement session (Visit 2).  
 
Subject Confidentiality 
All records will be kept in a locked file cabinet.  Human subject’s names will be kept on 
a password protected database and will be linked with a study identification number for 
this research.  All computer entry and networking programs will be done using study 
identification only.  All data will be entered into a computer that is password protected. 
Data will be stored in a locked office of the investigators and maintained for a minimum 
of three years after the completion of the study.  
 
Subject Payment 
Subjects will be paid via ClinCard $75 when the activity monitors are returned at visit 3 
and upon completion of the study at visit 4. Total payment per subject is $150. SSN is 
required for payment, and will be entered directly into the Greenphire secure website. 
SSN will not be retained in the subject’s study file.  
 
9.  PUBLICATION OF RESEARCH FINDINGS 
 Results are intended to be presented at pediatrics or physical activity-related 
conferences by the study team within the next year. 
 Results are intended to be published in a physical activity or public health 
journals. 
 
 
10.  REFERENCES 
1. 
Shook, R.P., Obesity and energy balance: What is the role of physical 
activity? Expert Review of Endocrinology & Metabolism, 2016. 11(6): p. 
511-520. 
2. 
Shook, R.P., G.A. Hand, and S.N. Blair, Top 10 research questions related to 
energy balance. Research Quarterly for Exercise and Sport, 2014. 85(1): p. 
49-58. 
3. 
Donnelly, J.E., J.J. Honas, B.K. Smith, et al., Aerobic exercise alone results in 
clinically significant weight loss for men and women: midwest exercise trial 2. 
Obesity (Silver Spring), 2013. 21(3): p. E219-28. 

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4. 
Shook, R.P., G.A. Hand, X. Wang, et al., Low fitness partially explains 
resting metabolic rate differences between African American and white 
women. American Journal of Medicine, 2014. 127(5): p. 436-42. 
5. 
Shook, R.P., G.A. Hand, A.E. Paluch, et al., Moderate cardiorespiratory 
fitness is positively associated with resting metabolic rate in young adults. 
Mayo Clinic Proceedings, 2014. 89(6): p. 763-71. 
6. 
Lam, Y.Y. and E. Ravussin, Indirect calorimetry: an indispensable tool to 
understand and predict obesity. Eur J Clin Nutr, 2016. 
7. 
Shook, R.P., G.A. Hand, A.E. Paluch, et al., High respiratory quotient is 
associated with increases in body weight and fat mass in young adults. 
European Journal of Clinical Nutrition, 2015.