The Impact of a Moderate CAlorie and Protein REstriction PROgram (CARE-PRO) as an Efficient and Affordable Therapeutic Strategy in Patients With Barrett's Esophagus.
Phase: NA
Conditions: Barrett's Esophagus, Overweight and Obesity
Sponsor: Istituto Oncologico Veneto IRCCS

                    Regione del Veneto 
                Istituto Oncologico Veneto 
                   Istituto di Ricovero e Cura a Carattere Scientifico 
 
 
 I.O.V.  I.R.C.C.S.: Ospedale Busonera, Via Gattamelata 64 35128 Padova 
                         Tel. +39 049 / 8215773 
 
 
 
 
U.S.D. Endoscopia 
Digestiva 
 
Responsabile f.f.: 
Dr. Stefano Realdon 
 
 
 
Segreteria Endoscopia:  
Tel. +39 049 8213182 
Fax +39 049 8211707 
 
 
 
 
Staff informatico: 
Francesca Giacomini 
Tel. +39 049 8211719 
endoscopia@iov.veneto.it 
 
 
 
 
Coordinatore Inf.: 
Sig.ra Chiara Zampieri 
Tel. +39 049 8213164 
chiara.zampieri@iov.veneto.it 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CLINICAL TRIAL PROTOCOL 
 
Title 
 
The impact of a moderate calorie and protein restriction program (CARE-
PRO) as an efficient and therapeutic strategy in patients with Barrett’s 
Esophagus. 
 
 
 
Approval number: CESC IOV2015/68 
 
Version 2.0,  11/11/2014 
 
Sponsor: Veneto Institute of Oncology IOV-IRCCS 
Via Gattamelata, 64 – 35128, Padua, Italy 
 
Principal Investigator: Stefano Realdon, MD, PhD 
Digestive Endoscopy Unit, Vento Insitute of Oncology 
IOV-IRCCS 
Via Gattamelata, 64 – 35128, Padua, Italy 
Telephone: 039 049 821 1719 
 
Confidential disclaimer 
The information contained in these document are confidential and may not be used, 
published or redistributed without the prior written consent of the Veneto Institute 
of Oncology IOV-IRCCS, Padua Italy. 
 
Compliance disclaimer 
The clinical trial will be conducted in compliance with the protocol, standard 
operating procedures, Good Clinical Practice (CPMIP/ICH-135/95) and applicable 
regulatory requirements. 

Version 2.0, 11/11/2014 
1 
 
Study protocol 
The impact of a moderate calorie and protein restriction program 
(CARE-PRO) as an efficient and therapeutic strategy in patients 
with Barrett’s Esophagus. 
ABSTRACT  
Introduction: The increasing incidence of Esophageal Adenocarcinoma (EAC) in several Western 
countries can be primarily ascribed to risk factors such as obesity, chronic gastroesophageal reflux, 
dietary habits and alcohol intake. Nevertheless, Barrett’s Esophagus (BE), the precancerous lesion, 
remains the main risk factor for EAC. Several studies supports the role played by the gut microbiota 
on the modulation of metabolic and immunological pathways. An abnormal state of the microbial 
ecosystem seems to be involved in the promotion and onset of various diseases, including cancer. 
In 2009, Yang et al. identified two types of in situ esophageal microbiota (type I and II). Type I 
microbiota was associated with the normal esophageal mucosa and type II microbiota was 
associated with unhealthy conditions of the esophageal mucosa typical of patients affected by 
GERD-related esophagitis and BE. Recent studies have shown that diet and lifestyle have an 
important modulatory role as protective or risk factors for oncological diseases. The World Cancer 
Research Fund (WCRF) and the American Institute for Cancer Research(AICR) released a review of 
the evidence that emerged from published studies in the field of nutrition and cancer prevention 
and summarized their findings into 10 recommendations that everyone should practice to prevent 
cancer. The concordance between adherence to such indications and risk of onset of various types 
of cancer (including cancer of the esophagus) has been demonstrated in a recent large prospective 
study. Several studies have also shown that a moderate caloric and/or protein restriction seems to 
be able to reduce the risk of neoplastic disease development. The primary aim of this study is to 
evaluate the impact of a lifestyle-oriented intervention on body weight, waist circumference, 
biomarkers associated with cancer risk, esophageal microbiota composition and adherence to 
cancer prevention recommendations after 24 months in overweight or obese BE patients.  
Methods and analysis: Patients are randomly divided into two arms, a control arm (CA) and an 
interventional arm (IA).  The CA receives information about a correct lifestyle to prevent cancer. The 
IA is involved in the two-year program of moderate caloric and protein restriction.  
At the time of enrollment, anthropometric and body composition measurements will be recorded 
for each patient and they will be allocated by a data manager in the IA or CA. Blood samples will be 
obtained from each patient and blood glucose will be determined. Serum metabolic biomarkers will 
be measured in each serum sample and total proteins will be extracted from fresh frozen 
esophageal biopsy and will be analyzed to evaluate the insulin signal pathway. 
To assess esophageal microbiota profiling, total gDNA will be extracted from matched fresh frozen 
biopsy. In order to determine a score of adherence to cancer prevention recommendations, 
participants will be asked to complete a self-administrated questionnaire reflecting WCRF/AICR 
recommendations. Measurements will occur also at the end point, after two years from the 
enrollment. 
Ethics and dissemination: Ethical approval for the study has been received from the Ethics 
Committee for Clinical Experimentation (Comitato Etico per la Sperimentazione Clinica – CESC) of 
the Veneto Institute of Oncology (approval number CESC IOV2015/68). This randomised controlled 
trial will generate substantial information regarding the effect of multimodal approach to reduce 

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risk of esophageal adenocarcinoma in high-risk population. The results of  the study will be 
disseminated through publication, reports and conference presentation.  
 
INTRODUCTION 
Despite the general improvement in living conditions in recent decades and the increased (average) 
median age of population, the incidence of certain diseases is increasing,  especially those associated 
with aging. Obesity, central adiposity, type two diabetes (TD2) and insulin resistance are widespread 
in Western countries, and their role as a risk factor for oncological diseases is well documented.[1–
3] 
Among malignant cancers, Esophageal Adenocarcinoma (EAC) is steadily becoming the most 
common esophageal malignancy in several Western countries,[4]. The increasing incidence of this 
tumor can be primarily ascribed to well-known risk factors such as obesity and chronic 
gastroesophageal reflux,[5,6] but other lifestyle aspects, such as dietary habits and alcohol intake, 
are likely involved in the onset of EAC.[6–10] 
Nevertheless, Barrett’s Esophagus (BE) remains the main risk factor for EAC. BE is a precancerous 
lesion characterized by replacement of normal squamous epithelium lining the esophageal lumen 
with columnar-lined metaplastic epithelium. The metaplasia is mainly due to chronic reflux, 
commonly known as gastroesophageal reflux disease (GERD) and it is endoscopically identified in 5-
15% of patients with GERD[11].  BE patients have a 30 to 125 fold greater risk to develop EAC 
compared with non-GERD population,[12] with a EAC risk of 0.1-0.5% per year.[13–15] 
Despite the low rate for EAC development in BE patients, its mortality rate after 5 years from 
diagnosis is higher than 80% and it can be dramatically improved when cancer is diagnosed at an 
early stage.[16] 
Nowadays, BE patients are usually enrolled in expensive endoscopic follow-up programs for early 
diagnosis. These programs are based on endoscopic biopsy standard protocols and/or random 
sampling (four quadrant biopsies taken at the gastroesophageal junction and 2 cm above it) and are 
of dubious effectiveness.[17–21] 
Thus, other factors and approaches need to be considered in a strategy to reduce EAC risk. 
Several data suggest that obesity, particularly central obesity, could play a causative role in the 
development of BE and its progression to EAC.[22] 
Overweight and obesity are associated with a metabolic dysregulation which is part of the  Metabolic 
Syndrome (MS).[23] MS is associated with a chronic pro-inflammatory state strictly related to an 
excessive amount of visceral adipose tissue. Abdominal obesity leads to alteration of the normal 
physiological balance of adipokines with an increase in pro-inflammatory adipokines secretion, such 
as leptin, and a reduction in anti-inflammatory adipokines, such as adiponectin.[24–26] Central 
obesity is associated with insulin-resistance, defined as a condition in which target tissues of insulin 
(liver, adipose tissue and skeletal muscle) have a lower sensibility to insulin action. For this reason, 
the pancreas produces much more insulin to maintain normal glucose levels in the blood. Chronic 
hyperinsulinemia, as well as an increased level of serum leptin and a reduced adiponectin secretion, 
are factors that could play a role in oncogenesis.[27–31] 

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Moreover, a growing body of evidence supports the role played by the gut microbiota on the 
modulation of several metabolic and immunological pathways. Gut microbiota is composed of 
several microbial communities with almost 1014 microorganisms.[32,33] An abnormal state of the 
microbial ecosystem in a host, defined “dysbiosis”, seems to be involved in the promotion and onset 
of various diseases, including cancer.[34,35] The mechanisms by which bacteria can induce 
carcinogenesis include chronic inflammation, immuno-suppression and immuno-evasion.[35,36] 
Like the intestinal tract, even the esophagus is colonized by human microbiota (HM). In 2009, Yang 
et al.[37] identified two types of in situ esophageal microbiota (type I and II). Type I microbiota was 
associated with the normal esophageal mucosa and is characterized by prevalence (about  80%) of 
Gram-positive taxa belonging to  Firmicutes phylum (in particular Streptococcus and Gemella 
genera) and low percentages of Gram-negative taxa belonging to Proteobacteria (Haemophilus and 
commensal Neisseria genera), Bacteroidetes (Prevotella genus) and Firmicutes (Veillonella genus) 
phyla. The type II microbiota was associated with unhealthy conditions of the esophageal mucosa 
typical of patients affected by GERD-related esophagitis and BE. Type II microbiota is characterized 
by high presence (more than 50%) of Gram-negative bacteria.  The more abundant genera in the 
type II microbiota included Veillonella (phylum Firmicutes), Prevotella (phylum Bacteroidetes), 
Haemophylus, Neisseria and  Campylobacter (belonging to Proteobacteria phylum), Fusobacterium 
(Fusobacteriaphylum), Rothia and Actinomyces (belonging to Actinobacteria phylum).[32,33,37] 
Recent studies have shown that diet and lifestyle in general have an important modulatory role as 
protective or risk factors for oncological diseases. In 2007, the World Cancer Research Fund (WCRF) 
and the American Institute for Cancer Research(AICR) released a wide review of the evidence that 
emerged from published studies in the field of lifestyle, including physical activity, nutrition and 
cancer prevention.[38]  WCRF/AICR summarized their findings into 10 recommendations that 
everyone should practice to prevent cancer. Eight out of ten are addressed to cancer primary 
prevention in the general population and two recommendations are appropriate for “special 
persons”, such as mothers who breastfeed their children and cancer survivors. 
The concordance between adherence to such indications and risk of onset of various types of cancer 
(including cancer of the esophagus) has been demonstrated in a recent large prospective study by 
Romaguera D., et al.[39]  
Several studies have also shown that a moderate caloric and/or protein restriction seems to be able 
to reduce the risk of neoplastic disease development by bringing back the altered metabolic-
hormonal status to a physiological condition and stimulating cell autophagy.[40–45] 
Numerous studies have also shown that the effectiveness of a nutritional intervention is greatly 
improved when the informants, besides providing information, also use health coaching techniques, 
giving people the opportunity to practice and share acquired knowledge, for example by attending 
cooking classes, sharing meals and practicing physical activity.[46–58] 
 OBJECTIVES 
In this study, patients are randomly divided into two arms, a control arm and an interventional arm. 
The aim of this two-arms randomized clinical trial is to assess the effect of a moderate CAloric-
protein REstriction PROgram (CARE-PRO) on metabolic-hormonal condition (such as excessive BMI 
and/or waist circumference (WC), insulin resistance, unbalanced esophageal microbiota 
composition, chronic inflammation and adipose tissue-related hormones release) which can 
represent, when altered, a risk factor for the development of esophageal adenocarcinoma in 
patients with Barrett's esophagus. The control arm receives information about a correct lifestyle 

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and suggestions to increase the consumption of fiber and vegetable proteins. The interventional 
arm instead is involved in the two-year program of moderate caloric and protein restriction. 
 
-Overall aim of the study 
 
The main objective of the study is to evaluate the impact of a lifestyle-oriented (diet, physical 
activity, behavior change) intervention on body weight, waist circumference, biomarkers associated 
with cancer risk, esophageal microbiota composition and adherence to cancer prevention 
recommendations (WCRF/ARICR 2007) after 24 months in overweight or obese (BMI ≥ 25.0 Kg/m2) 
BE patients.  
 
-Primary aim 
 
To examine the effect of a dietary and exercise intervention on body weight and waist 
circumference reduction in overweight or obese BE patients. 
 
-Secondary aims 
 
To assess the impact of CARE-PRO intervention on the relationship between anthropometric 
parameters (body weight, BMI and WC), metabolic serum biomarkers, the expression of proteins 
involved on insulin and IGF1 receptors signal transduction and esophageal microbiota composition 
associated with an increased risk of developing EAC. 
 
i) To assess the impact of CARE-PRO intervention on the adherence to WCRF/AICR 
recommendations 
for 
cancer 
prevention.[6,38] 
Adherence 
to 
cancer 
prevention 
recommendations will be assessed by a validated score of adherence.[39] 
ii) To evaluate possible differences on CARE-PRO outcomes between elderly (> 65 years) BE 
patients and  younger BE patients (<65 years). 
iii) To evaluate economic costs of the intervention. 
 
 
 
METHODS AND ANALYSIS 
Study design  
 
-Study population: inclusion and exclusion criteria 
Patients will be recruited from those included in the Barrett Esophagus and esophageal 
Adenocarcinoma Risk (EBRA – Esofago di Barrett e Rischio di Adenocarcinoma) Register. 
 
Inclusion criteria 
i) Histological confirmation of Barrett’s esophagus without dysplasia or cancer aged ≥ 18 years 
with BMI ≥ 25.0 kg/m2 
ii) Willingness and ability to perform supervised Nordic walking session twice a month and self-
planned physical activity at least 3 times a week 
iii) Signed informed consent 
 
 

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5 
 
Exclusion criteria 
 
i) No histological confirmation of Barrett’s esophagus 
ii) Cancer diagnosis within one year before trial begins 
iii) Presence of insulin-dependent diabetes 
iv) Denied informed consent 
-Sample size 
The sample size is based on the primary outcome of a clinically significant change in body weight at 
the end of the study. A 7% weight loss has been shown to be clinically effective in reducing the risk 
of diabetes. According to previous data,[44] it is expected that around 30% of patients enrolled in 
the IA and 15% of those enrolled in the CA will achieve the aforementioned weight loss within the 
time allotted for trial. In order to reveal a statistically significant difference in the rates of 
achievement of a 7% weight loss between IA and CA, at least 95 patients are required for each group 
(power: 80%, type-1 error: 5%). In order to achieve this sample size, we estimate that a pool of 340 
patients will be required for recruitment, to allow a recruitment rate of 70% (n=238), and a 
subsequent drop-out rate of 20% (n=190).  
 
-Trial design 
The study will be a two-arm, randomized control trial comparing CARE-PRO intervention with usual 
clinical approach to BE patients. Study enrollment was started in 2015 and will be complete at the 
end of 2018. The intervention will last 2 years (24 months) and will be accompanied by the normal 
follow up procedures.[59] 
The study team, including research nurses, will be blinded to the patient group allocation until 
completion of the primary outcome analysis. Only the principal investigator, study administrator, 
dietitian and participants will not be blinded considering the nature of the intervention. None of 
these unblinded staff will have a role in data analysis. 
Details of the collected outcomes at different time points are showed in Figure xx. 
 
 
-Randomization 
At the time of enrollment, prior to group allocation, anthropometric and body composition 
measurements (such as height, body weight, waist circumference at the umbilical level, BMI 
[weight/(height)2 (Kg/m2) will be recorded for each patient immediately before endoscopic 
procedure. Patients will be randomly allocated by a data manager in the intervention (IA) or control 
arm (CA), using a permuted-block technique, with block size of four or eight. The Data Manager will 
not be involved in recruitment or intervention process.  
 
-Blood and biopsy sample collection 
Immediately before endoscopy, blood samples will be obtained from each patient (after 10-12 hours 
fasting) and blood glucose will be determined with a glucometer (Abbott Laboratories® , TX, USA). 
Serum will be extracted, aliquoted and frozen in liquid nitrogen. During endoscopy,  4 quadratic 
esophageal biopsies – according to the Levine protocol – will be obtained, fixed in formalin and sent 
to the Medicine, Surgical Pathology & Cytopathology Unit for histological examination designed to 
confirm the presence of Barrett's Esophagus and the evaluation of the presence or absence of 
dysplasia cancer. Additional target biopsies will be obtained from areas affected by Barrett’s 
Esophagus and frozen in liquid nitrogen.  
 

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-Serum analysis  
Serum metabolic biomarkers such as fasting glucose (mg/dl) insulin (pg/ml), C-peptide (pg/ml), IGF1 
(nmol/ml) and its binding proteins IGFBP1 (nmol/ml) and IGFBP3 (nmol/ml), leptin 
(ng/ml), adiponectin (µg/ml), TNF-alpha (pg/ml) and IL-6 (pg/ml) levels will be measured in each 
serum sample with Luminex xMAP® technology (multiplexed fluorescent bead-based immunoassay, 
Luminex, TX, USA); insulin resistance index (HOMA-IR index) will be calculated using the formula: 
[fasting plasma glucose (mg/dl) × fasting serum insulin(μU/ml)/405],according to the method 
developed by Matthews et al.[60] HOMA-IR index ≥2.5 will be selected as cut-off for insulin-
resistance according to Capasso et al.[61] 
 
-Esophageal biopsy analysis: Insulin/IGF1 signal transduction and microbiota composition 
Total proteins will be extracted from fresh frozen esophageal biopsy and will be quantified by 
Bicinchoninic Acid (BCA) assay (Thermo Scientific Pierce, IL, USA). For each sample, 12.5 μg of total 
proteins will be analyzed to evaluate the activation state of Insulin Receptor (IR) and IGF1 Receptor 
(IGF1R) signal pathways using Luminex xMAP® technology. Both the metabolic PI3K/Akt pathway 
and the mitogenic (ERK/MAPK) pathway  will be analyzed.  
To assess esophageal microbiota profiling, total gDNA will be extracted from fresh frozen biopsy. 
Specific primers for the bacterial V3-V4 hypervariable regions of 16S rRNA will be used to amplify 
bacterial DNA [≈ 500 bases pair (bp)] to be sequenced by Illumina Miseq platform with 300 bp 
paired-end approach. BMR Genomics (Padua, Italy) will perform the sequencing.  
Biopsy and serum samples stored in nitrogen will, as a routine, be managed by the Biological Bank 
staff who will provide for their conservation in a totally anonymity (as prescribed by law and already 
authorized by the Ethics Committee with prot. No. P 480 2002)  
The acceptance or rejection by patients to participate in the study will not change in any way their 
established diagnostic-therapeutic procedures and follow-up. 
 
-WCRF/AICR adherence score calculation 
In order to determine a score of adherence to cancer prevention recommendations, participants 
will be asked to complete a self-administrated questionnaire reflecting six out of eight WCRF/AICR 
recommendations: 1) body fatness; 2)physical activity; 3) energy dense food and drink 
consumption; 4) plant food consumption; 5) red and processed meat consumption; 6) alcohol 
intake. 
Some recommendations have several sub-recommendations. To each item of the questionnaire, a 
score of 1 will be assigned when the recommendation is met and a score of 0 will be assigned when 
it is not. An answer that partially satisfies the recommendation will be assigned a score of 0.5. The 
final score will derive from the mathematical sum of the individual scores obtained for each 
recommendation. The maximum expected score will be equal to 6.  
 
Intervention Arm (IA) program 
 
-Dietary caloric-protein restriction 
Patients randomized in the IA will be given individualized dietary advice on the basis of WCRF/AICR 
recommendations.[6,38] The aim of healthy dietary advice will be the reduction of patient’s total 
daily calorie intake up to 600 kcal below their energy requirements. Energy requirement for each 
patient in the IA will be estimated through revised Harris-Benedict formula,[62] which combines 
basal metabolic rate (BMR) and physical activity level. In addition to caloric restriction, dietary 
intervention will aim for a total protein intake to 0.8g of protein/Kg body weight mostly form plant-
origin food. 

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Patients will be required to keep a weekly diet diary that will be analyzed with metaDieta 3.5 
software (Me.Te.Da. s.r.l., San Benedetto del Tronto, Ascoli Piceno, Italy). Once a month for the first 
four months and bi-monthly for the rest of intervention period, patients will meet individually with 
the dietitian for a 45-minute nutritional counselling session. During these meetings, patients will 
discuss their diet diary with the dietitian in order to identify the best strategy to comply with the 
caloric restriction program. 
 
-Health coaching 
After the nutritional counseling session with the dietitian, patients in the IA will meet with a trained 
nurse (coach) for a 15-minute health coaching session. During these sessions, the role of the coach 
will be to empower participants to take control of their own health, to move the attention from 
what professionals want to the patient’ s own objectives, to help patients to achieve their objectives 
through feasible steps, and to challenge behaviors that represent an obstacle to positive change. 
 
-Cooking classes 
Each patient in the IA will be involved in at least three 4-hour sessions of culinary practice (cooking 
classes). Participants will be asked to take part to the cooking classes with a relative, such as a wife 
or husband.  
The aim of this practical part of the intervention will be to provide patients with skills and knowledge 
that they will be able to use to modify their dietary approach and behaviors, and to reach the goal 
of calorie restriction. Every session and every recipes will be developed based on the Mediterranean 
Diet in accordance with WCRF/AICR recommendations and with the Healthy Eating Plate proposed 
by the Harvard School of Public Health using healthy, mostly local and seasonal foods.[6,38,63] 
Cooking classes will be held by a dietitian and professional cook. At the end of each cooking class, 
participants will have lunch together, consuming the meal they prepared, and they will discuss the 
learned knowledge with the dietitian. 
 
-Physical activity 
Patients in the IA, after a medical/cardiac evaluation to assure their physical ability for exercise,  will 
attend Nordic walking sessions of moderate intensity two times per month during the 24 months of 
intervention. A certified expert will supervise every Nordic walking session. 
Patients will be also counselled on how they can perform physical activity of moderate-intensity by 
themselves or in a group in their usual living environment. 
Participants in the IA will be provided with a pedometer (Omron walking style IV, Omron Healthcare 
Europe B.V.) to check the number of steps or distance (Km) walked each day. 
Nordic walking session will be performed in groups of twelve participants. Every session will start 
with 10-minutes of warm-up exercises and will continue with moderate intensity walking in a green, 
pedestrian area. 
Patients will be encouraged to maintain a good level of physical activity during the rest of the week,  
with 40 minute of brisk walking 4 days/week. 
All patients in the IA will receive reminders, of their appointments for nutritional counseling, cooking 
classes and Nordic walking sessions, through phone call, e-mail or/and text message on their mobile 
phone and will be contacted for any change in the scheduled activities due to unexpected events, 
for example bad weather in the case of Nordic walking. 
 
Control  Arm (CA) program 
 

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Participants in the CA will be given information about the importance of a healthy lifestyle  in 
reducing the risk of cancer and will receive a leaflet based on WCRF/AICR recommendations.[38] 
 
Statistical analysis 
 
Fisher’s exact test will be used for comparison of categorical variables. Numerical variables will be 
expressed as  median and interquartile range (Q1; Q3). The Mann–Whitney U-test will be used to 
evaluate differences between IA and CA groups. Paired Student’s T test will be used to compare the 
difference  in the parameters measured at baseline (at the time of enrolment) and at the end of the 
trial in the same patient. Spearman’s rank correlation coefficient will be calculated to evaluate the 
correlation between two measured parameters. All tests will be two-tailed and a p value lower than 
0.05 will be assumed to indicate a significant difference. Data analyses will be performed with SPSS 
v20 and Stats-Direct. 
 
ETHICS AND DISSEMINATION 
Ethics approval and consent 
Ethical approval for the study has been received from the Ethics Committee for Clinical Experimentation 
(Comitato Etico per la Sperimentazione Clinica – CESC) of the Veneto Institute of Oncology (approval number 
CESC IOV2014/68). 
The study will be conducted in accordance with the principles of the 1975 Helsinki Declaration (6threvision, 
2008) and  written informed consent will be obtained from all patients. The features and aims of this study 
will be thoroughly explained to all patients. 
  
Confidentially  
Information collected directly from participants will be in a reidentifiable form and any information collected 
for, used in generated by this project will not be used for any other purpose. The site principal investigator 
and associated research personnel will have access to information.   
 
Dissemination policy 
Results if this clinical trial aim to be disseminated through peer-reviewed journal articles, conference abstract 
ad presentation, as well as media publications.  
 
Translational relevance and impact for CARE-PRO trial 
The impact of diet in preventing diseases is largely underestimated. If in our BE patients' cohort we will 
demonstrate feasibility and efficacy of the CARE-PRO in bodyweight change and modification of biomarkers 
associated with increased risk of cancer and other lifestyle related comorbidities, we could propose it as a 
low-cost therapy to reduce mortality and morbidity, especially in older patients where endoscopic follow-up 
has been proven to be not cost effective. Ideally the frequency of follow-up endoscopic examinations could 
be dramatically reduced with a significant expense reduction for the NHS (National Health System). 
Moreover, the outcome parameters potentially improved with this approach are associated with an 
increased risk of other cancers and cardiovascular diseases as well, thus the net savings for the NHS could be 
larger than the already substantial ones derived from the optimization of endoscopic follow-up in BE patients 
due to an overall decrease in morbidity. 
 
 
 
Competing interests 
The Authors declare no conflict of interest.  
 
 

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9 
 
 
REFERENCES 
 
1  
Y LC. The Effect of High-Fat Diet-Induced Pathophysiological Changes in the Gut on Obesity: What 
Should be the Ideal Treatment? Clin Transl Gastroenterol 2013;4:e39. doi:10.1038/ctg.2013.11 
2  
Teng JA, Wu SG, Chen JX, et al. The Activation of ERK1/2 and JNK MAPK Signaling by Insulin/IGF-1 Is 
Responsible for the Development of Colon Cancer with Type 2 Diabetes Mellitus. PLoS One 
2016;11:e0149822. doi:10.1371/journal.pone.0149822 
3  
Zhu N, Zhang Y, Gong YI, et al. Metformin and lung cancer risk of patients with type 2 diabetes 
mellitus: A meta-analysis. Biomed Rep 2015;3:235–41. doi:10.3892/br.2015.417 
4  
Jemal A, Center MM, DeSantis C, et al. Global patterns of cancer incidence and mortality rates and 
trends. Cancer Epidemiol Biomarkers Prev 2010;19:1893–907. doi:10.1158/1055-9965.EPI-10-0437 
5  
Vingeliene S, Chan DSM, Vieira AR, et al. An update of the WCRF/AICR systematic literature review 
and meta-analysis on dietary and anthropometric factors and esophageal cancer risk. Ann Oncol 
2017;28:2409–19. doi:10.1093/annonc/mdx338 
6  
World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project 
Report: Diet, Nutrition, Physical Activity and Oesophageal Cancer. 2016. Available at: 
wcrf.org/oesophageal-cancer-2016. 2016. http://wcrf.org/oesophageal-cancer-2016. 
7  
De Ceglie A, Fisher DA, Filiberti R, et al. Barrett’s esophagus, esophageal and esophagogastric 
junction adenocarcinomas: the role of diet. Clin Res Hepatol Gastroenterol 2011;35:7–16. 
doi:10.1016/j.gcb.2010.08.015 
8  
Mayne ST, Navarro SA. Diet, obesity and reflux in the etiology of adenocarcinomas of the esophagus 
and 
gastric 
cardia 
in 
humans. 
J 
Nutr 
2002;132:3467S–
3470S.https://www.ncbi.nlm.nih.gov/pubmed/12421872 
9  
Pera M, Manterola C, Vidal O, et al. Epidemiology of esophageal adenocarcinoma. J Surg Oncol 
2005;92:151–9. doi:10.1002/jso.20357 
10  
Vaughan TL, Davis S, Kristal A, et al. Obesity, alcohol, and tobacco as risk factors for cancers of the 
esophagus and gastric cardia: adenocarcinoma versus squamous cell carcinoma. Cancer Epidemiol 
Biomarkers Prev 1995;4:85–92.https://www.ncbi.nlm.nih.gov/pubmed/7742727 
11  
Shaheen NJ, Richter JE. Barrett’s oesophagus. Lancet 2009;373:850–61. doi:10.1016/S0140-
6736(09)60487-6 
12  
Cameron AJ, Ott BJ, Payne WS. The incidence of adenocarcinoma in columnar-lined (Barrett’s) 
esophagus. N Engl J Med 1985;313:857–9. doi:10.1056/NEJM198510033131404 
13  
Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett’s esophagus patients: 
results from a large population-based study. J Natl Cancer Inst 2011;103:1049–57. 
doi:10.1093/jnci/djr203 
14  
Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with 
Barrett’s esophagus. N Engl J Med 2011;365:1375–83. doi:10.1056/NEJMoa1103042 

Version 2.0, 11/11/2014 
10 
 
15  
Runge TM, Abrams JA, Shaheen NJ. Epidemiology of Barrett’s Esophagus and Esophageal 
Adenocarcinoma. Gastroenterol Clin North Am 2015;44:203–31. doi:10.1016/j.gtc.2015.02.001 
16  
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11–30. 
doi:10.3322/caac.21166 
17  
Gordon LG, Mayne GC, Hirst NG, et al. Cost-effectiveness of endoscopic surveillance of non-
dysplastic 
Barrett’s 
esophagus. 
Gastrointest 
Endosc 
2014;79:242–56 
e6. 
doi:10.1016/j.gie.2013.07.046 
18  
Spechler SJ. Barrett esophagus and risk of esophageal cancer: a clinical review. JAMA 2013;310:627–
36. doi:10.1001/jama.2013.226450 
19  
Zhang HY, Spechler SJ, Souza RF. Esophageal adenocarcinoma arising in Barrett esophagus. Cancer 
Lett 2009;275:170–7. doi:10.1016/j.canlet.2008.07.006 
20  
Corley DA, Mehtani K, Quesenberry C, et al. Impact of endoscopic surveillance on mortality from 
Barrett’s esophagus-associated esophageal adenocarcinomas. Gastroenterology 2013;145:312–9 
e1. doi:10.1053/j.gastro.2013.05.004 
21  
Pohl H, Sirovich B, Welch HG. Esophageal adenocarcinoma incidence: are we reaching the peak? 
Cancer Epidemiol Biomarkers Prev 2010;19:1468–70. doi:10.1158/1055-9965.EPI-10-0012 
22  
Ryan AM, Duong M, Healy L, et al. Obesity, metabolic syndrome and esophageal adenocarcinoma: 
epidemiology, 
etiology 
and 
new 
targets. 
Cancer 
Epidemiol 
2011;35:309–19. 
doi:10.1016/j.canep.2011.03.001 
23  
Alberti KG, Zimmet P, Shaw J. Metabolic syndrome--a new world-wide definition. A Consensus 
Statement from the International Diabetes Federation. Diabet Med 2006;23:469–80. 
doi:10.1111/j.1464-5491.2006.01858.x 
24  
Cowey S, Hardy RW. The metabolic syndrome: A high-risk state for cancer? Am J Pathol 
2006;169:1505–22. doi:10.2353/ajpath.2006.051090 
25  
Festa A, D’Agostino  Jr. R, Williams K, et al. The relation of body fat mass and distribution to markers 
of 
chronic 
inflammation. 
Int 
J 
Obes 
Relat 
Metab 
Disord 
2001;25:1407–15. 
doi:10.1038/sj.ijo.0801792 
26  
Tsigos C, Kyrou I, Chala E, et al. Circulating tumor necrosis factor alpha concentrations are higher in 
abdominal 
versus 
peripheral 
obesity. 
Metabolism 
1999;48:1332–
5.https://www.ncbi.nlm.nih.gov/pubmed/10535400 
27  
Aleman JO, Eusebi LH, Ricciardiello L, et al. Mechanisms of obesity-induced gastrointestinal 
neoplasia. Gastroenterology 2014;146:357–73. doi:10.1053/j.gastro.2013.11.051 
28  
Gallagher EJ, LeRoith D. The proliferating role of insulin and insulin-like growth factors in cancer. 
Trends Endocrinol Metab 2010;21:610–8. doi:10.1016/j.tem.2010.06.007 
29  
Simone BA, Champ CE, Rosenberg AL, et al. Selectively starving cancer cells through dietary 
manipulation: methods and clinical implications. Futur Oncol 2013;9:959–76. doi:10.2217/fon.13.31 
30  
Arcidiacono D, Dedja A, Giacometti C, et al. Hyperinsulinemia Promotes Esophageal Cancer 

Version 2.0, 11/11/2014 
11 
 
Development in a Surgically-Induced Duodeno-Esophageal Reflux Murine Model. Int J Mol Sci 
2018;19:1198. doi:10.3390/ijms19041198 
31  
Arcidiacono D, Antonello A, Fassan M, et al. Insulin promotes HER2 signaling activation during 
Barrett’s Esophagus carcinogenesis. Dig Liver Dis 2017;49:630–8. doi:10.1016/j.dld.2017.01.154 
32  
Di Pilato V, Freschi G, Ringressi MN, et al. The esophageal microbiota in health and disease. Ann N 
Y Acad Sci 2016;1381:21–33. doi:10.1111/nyas.13127 
33  
Snider EJ, Freedberg DE, Abrams JA. Potential Role of the Microbiome in Barrett’s Esophagus and 
Esophageal Adenocarcinoma. Dig Dis Sci 2016;61:2217–25. doi:10.1007/s10620-016-4155-9 
34  
Yamashiro Y. Gut Microbiota in Health and Disease. Ann Nutr Metab 2017;71:242–6. 
doi:10.1159/000481627 
35  
Gao R, Gao Z, Huang L, et al. Gut microbiota and colorectal cancer. Eur J Clin Microbiol Infect Dis 
2017;36:757–69. doi:10.1007/s10096-016-2881-8 
36  
Compare D, G. N. The bacteria-hypothesis of colorectal cancer: pathogenetic and therapeutic 
implications. Transl Gastrointest Cancer 2013;3:44–53. doi:10.3978/j.issn.2224-4778.2013.05.37 
37  
Yang L, Lu X, Nossa CW, et al. Inflammation and intestinal metaplasia of the distal esophagus are 
associated 
with 
alterations 
in 
the 
microbiome. 
Gastroenterology 
2009;137:588–97. 
doi:10.1053/j.gastro.2009.04.046 
38  
World Cancer Research Fund/American Institute for Cancer Research, Research AI for C. Food, 
Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: : 
American Institute for Cancer Research 2007.  
39  
Romaguera D, Vergnaud AC, Peeters PH, et al. Is concordance with World Cancer Research 
Fund/American Institute for Cancer Research guidelines for cancer prevention related to 
subsequent risk of cancer? Results from the EPIC study. Am J Clin Nutr 2012;96:150–63. 
doi:10.3945/ajcn.111.031674 
40  
Fontana L, Adelaiye RM, Rastelli AL, et al. Dietary protein restriction inhibits tumor growth in human 
xenograft models. Oncotarget 2013;4:2451–61. doi:10.18632/oncotarget.1586 
41  
Fontana L, Partridge L, Longo VD. Extending healthy life span--from yeast to humans. Science (80- ) 
2010;328:321–6. doi:10.1126/science.1172539 
42  
Omodei D, Fontana L. Calorie restriction and prevention of age-associated chronic disease. FEBS Lett 
2011;585:1537–42. doi:10.1016/j.febslet.2011.03.015 
43  
Roberts SB, Speakman J. Update on human calorie restriction research. Adv Nutr 2013;4:563–4. 
doi:10.3945/an.113.004317 
44  
Sell C. Caloric restriction and insulin-like growth factors in aging and cancer. Horm Metab Res 
2003;35:705–11. doi:10.1055/s-2004-814156 
45  
Speakman 
JR, 
Mitchell 
SE. 
Caloric 
restriction. 
Mol 
Asp 
Med 
2011;32:159–221. 
doi:10.1016/j.mam.2011.07.001 
46  
Anderson AS, Craigie AM, Caswell S, et al. The impact of a bodyweight and physical activity 

Version 2.0, 11/11/2014 
12 
 
intervention (BeWEL) initiated through a national colorectal cancer screening programme: 
randomised controlled trial. BMJ 2014;348:g1823. doi:10.1136/bmj.g1823 
47  
Demark-Wahnefried W, Clipp EC, Lipkus IM, et al. Main outcomes of the FRESH START trial: a 
sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer 
survivors. J Clin Oncol 2007;25:2709–18. doi:10.1200/JCO.2007.10.7094 
48  
Admiraal WM, Vlaar EM, Nierkens V, et al. Intensive lifestyle intervention in general practice to 
prevent type 2 diabetes among 18 to 60-year-old South Asians: 1-year effects on the weight status 
and metabolic profile of participants in a randomized controlled trial. PLoS One 2013;8:e68605. 
doi:10.1371/journal.pone.0068605 
49  
Peters NC, Contento IR, Kronenberg F, et al. Adherence in a 1-year whole foods eating pattern 
intervention with healthy postmenopausal women. Public Heal Nutr 2014;17:2806–15. 
doi:10.1017/S1368980014000044 
50  
Villarini A, Pasanisi P, Raimondi M, et al. Preventing weight gain during adjuvant chemotherapy for 
breast cancer: a dietary intervention study. Breast Cancer Res Treat 2012;135:581–9. 
doi:10.1007/s10549-012-2184-4 
51  
Demark-Wahnefried W, Jones LW. Promoting a healthy lifestyle among cancer survivors. Hematol 
Oncol Clin North Am 2008;22:319–42, viii. doi:10.1016/j.hoc.2008.01.012 
52  
Hawkes AL, Chambers SK, Pakenham KI, et al. Effects of a telephone-delivered multiple health 
behavior change intervention (CanChange) on health and behavioral outcomes in survivors of 
colorectal 
cancer: 
a 
randomized 
controlled 
trial. 
J 
Clin 
Oncol 
2013;31:2313–21. 
doi:10.1200/JCO.2012.45.5873 
53  
Ligibel JA, Meyerhardt J, Pierce JP, et al. Impact of a telephone-based physical activity intervention 
upon exercise behaviors and fitness in cancer survivors enrolled in a cooperative group setting. 
Breast Cancer Res Treat 2012;132:205–13. doi:10.1007/s10549-011-1882-7 
54  
Morey MC, Snyder DC, Sloane R, et al. Effects of home-based diet and exercise on functional 
outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled 
trial. JAMA 2009;301:1883–91. doi:10.1001/jama.2009.643 
55  
Neuner-Jehle S, Schmid M, Gruninger U. The ‘Health Coaching’ programme: a new patient-centred 
and visually supported approach for health behaviour change in primary care. BMC Fam Pr 
2013;14:100. doi:10.1186/1471-2296-14-100 
56  
Pekmezi DW, Demark-Wahnefried W. Updated evidence in support of diet and exercise 
interventions in cancer survivors. Acta Oncol 2011;50:167–78. doi:10.3109/0284186X.2010.529822 
57  
Vallance JK, Courneya KS, Plotnikoff RC, et al. Randomized controlled trial of the effects of print 
materials and step pedometers on physical activity and quality of life in breast cancer survivors. J 
Clin Oncol 2007;25:2352–9. doi:10.1200/JCO.2006.07.9988 
58  
Wahab S, Menon U, Szalacha L. Motivational interviewing and colorectal cancer screening: a peek 
from the inside out. Patient Educ Couns 2008;72:210–7. doi:10.1016/j.pec.2008.03.023 
59  
Weusten B, Bisschops R, Coron E, et al. Endoscopic management of Barrett’s esophagus: European 
Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2017;49:191–8. 

Version 2.0, 11/11/2014 
13 
 
doi:10.1055/s-0042-122140 
60  
Matthews DR, Hosker JP, Rudenski AS, et al. Homeostasis model assessment: insulin resistance and 
beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 
1985;28:412–9.http://www.ncbi.nlm.nih.gov/pubmed/3899825 (accessed 30 Oct 2018). 
61  
Capasso I, Esposito E, Pentimalli F, et al. Homeostasis model assessment to detect insulin resistance 
and identify patients at high risk of breast cancer development: National Cancer Institute of Naples 
experience. J Exp Clin Cancer Res 2013;32:14. doi:10.1186/1756-9966-32-14 
62  
Roza AM, Shizgal HM. The Harris Benedict equation reevaluated: resting energy requirements and 
the 
body 
cell 
mass. 
Am 
J 
Clin 
Nutr 
1984;40:168–
82.https://www.ncbi.nlm.nih.gov/pubmed/6741850 
63  
Now being served, better nutrition advice. Our Healthy Eating Plate alternative to the government’s 
MyPlate. Harv Heal Lett 2011;37:4–5.https://www.ncbi.nlm.nih.gov/pubmed/27024293