Implications of Insulin Resistance and Cardiorespiratory Fitness in the Metabolic Response to a High-fat Meal Challenge in Pediatrics
Phase: NA
Conditions: Pediatric Obesity, Insulin Resistance
Sponsor: Dartmouth-Hitchcock Medical Center

 
 
 
Metabolic Response to a High-Fat Challenge 
in Children and Adolescents. 
NCT05230433 
VERSION 8.28.2023 

 
 
PROTOCOL TITLE: Metabolic Response to a High-Fat Challenge in Children and Adolescents. 
 
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D-HH IRB OVERSIGHT: 
☒ The Principal Investigator is employed by D-H 
☐ The study will utilize any D-H data or specimens 
☒ The study will enroll D-H patients or recruit from D-H sites 
☒ The study will utilize any D-H resources, e.g. study procedures will occur at  
     D-H locations and/or use of D-H equipment or shared resources 
 
PROTOCOL TITLE:  
Metabolic Response to a High-Fat Challenge in Children and Adolescents.  
 
PRINCIPAL INVESTIGATOR: 
Jennifer L. Meijer PhD, MPH, RD 
Weight and Wellness Center 
603-650-5250 
jennifer.l.meijer@hitchcock.org 
VERSION NUMBER/DATE: 
Version 2.0 / January 3, 2022  
REVISION HISTORY 
 
Revision 
# 
Version Date 
Summary of Changes 
Consent 
Change? 
 
8.28.2023 
Revision to consent & assent language 
throughout for consistency  
No 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Table of Contents 
1.0 
Study Summary ........................................................................................................ 3 
2.0 
Objectives* .............................................................................................................. 5 
3.0 
Background* ............................................................................................................ 5 
4.0 
Study Endpoints* ..................................................................................................... 8 
5.0 
Study Intervention/Investigational Agent ................................................................ 9 
6.0 
Procedures Involved*............................................................................................... 9 
7.0 
Data and Specimen Banking* ................................................................................ 18 
8.0 
Sharing of Results with Subjects* ......................................................................... 18 
9.0 
Study Timelines* ................................................................................................... 18 
10.0 Inclusion and Exclusion Criteria* .......................................................................... 19 
11.0 Vulnerable Populations* ........................................................................................ 19 
12.0 Local Number of Subjects ..................................................................................... 19 
13.0 Recruitment Methods ............................................................................................. 19 
14.0 Withdrawal of Subjects* ........................................................................................ 21 
15.0 Risks to Subjects* .................................................................................................. 21 
16.0 Potential Benefits to Subjects* .............................................................................. 21 
17.0 Data Management* and Confidentiality ................................................................ 23 
18.0 Provisions to Monitor the Data to Ensure the Safety of Subjects* ........................ 23 
19.0 Provisions to Protect the Privacy Interests of Subjects .......................................... 24 
20.0 Compensation for Research-Related Injury ........................................................... 25 
21.0 Economic Burden to Subjects ................................................................................ 25 
22.0 Consent Process ..................................................................................................... 25 
23.0 Process to Document Consent in Writing .............................................................. 26 
24.0 Setting .................................................................................................................... 26 
25.0 Resources Available............................................................................................... 26 
26.0 Multi-Site Research* .............................................. Error! Bookmark not defined. 
 
 
 

 
 
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1.0 
Study Summary 
 
Study Title 
Metabolic Response to a High-Fat Challenge in Children and 
Adolescents.  
Study Design 
Clinical trial  
Primary Objective 
The objective of this study is to classify the metabolome and 
gene expression response to a high-fat (HF) challenge in 
children, identifying predictors of the homeostatic response, 
such as insulin resistance (IR) and cardiorespiratory fitness 
(CRF). 
Secondary 
Objective(s) 
To phenotype body composition, daily physical activity, and 
habitual dietary intake to quantify modifiable behaviors 
associated with CRF, with the long-term goal of developing 
clinical interventions aimed at improving CRF in adolescents 
to preserve metabolic health. 
Research 
Intervention(s)/ 
Investigational 
Agent(s)  
High-fat Challenge (Boost Glucose Control with palm oil)  
IND/IDE #  
N/A 
Study Population 
DHMC Pediatrics  
Sample Size 
50 
Study Duration for 
individual 
participants 
Two visits separated by 1-2 weeks 
Study Specific 
Abbreviations/ 
Definitions  
AC – acylcarnitine 
ADA - American Diabetes Association 
AED - automated external defibrillator 
AHA - American Heart Association  
ASA-24 – Automated Self-Administered 24-h dietary recall 
BIA - bioelectrical-impedance analyses 
BMI – body mass index  
CHaD - Children’s Hospital at Dartmouth-Hitchcock 
cMetS - continuous metabolic syndrome score 
CRC – clinical research coordinator  
CRF – cardiorespiratory fitness  
CVD – cardiovascular disease 
DG – diacylglycerols  
DHMC – Dartmouth-Hitchcock Medical Center  
FA- fatty acid  
FA-COOH – dicarboxylic fatty acid 
GINA - The Genetic Information Non-Discrimination Act 
HbA1c - hemoglobin A1c 
HDL – high-density lipoproteins  

 
 
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HEI - Healthy Eating Index  
HF – high-fat  
HOMA-IR - homeostatic model assessment for insulin 
resistance  
IGF-1 – insulin growth factor 1  
IR – insulin resistance  
LDL- low-density lipoproteins  
MAP - mean arterial blood pressure 
OGTT - oral glucose tolerance test 
OLTT – oral lipid tolerance test  
PA – physical activity  
PBMC - peripheral blood mononuclear cells 
PC – phosphocholine  
PHI – protected health information  
SM – sphingomyelin  
T2D – type 2 diabetes  
TG – triglycerides  
VO2max – maximal oxygen consumption  
WC – waist circumference 
WWC – Weight & Wellness Center   
6MWT - 6-minute walk test  
 
 

 
 
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2.0 
Objectives* 
Cardiorespiratory fitness (CRF) in youth is an independent risk factor for type 2 diabetes 
(T2D) (1) and cardiovascular disease (CVD) (2), and in adulthood, CRF is inversely associated 
with mortality (3). Only 40% of youth in the United States have a healthy CRF (4), possibly 
influenced by increased sedentary time (5), decreased moderate-to-vigorous activity (5), 
increased obesity (6), and lower dietary quality (7). CRF is estimated by measuring maximum 
oxygen consumption (VO2max) during intense exercise, challenging the capacity of the 
respiratory and circulatory systems to supply oxygen to the skeletal muscles for generation of 
ATP. CRF is directly related to mitochondrial respiratory capacity and is associated with fatty 
acid (FA) oxidation (8, 9). Profiling the response of the FA oxidation intermediates, measured by 
metabolomics, and FA oxidation gene expression, measured within peripheral blood 
mononuclear cells (PBMC), to a high-fat (HF) challenge may provide a mechanistic link 
between CRF and risk for T2D and CVD. The primary objective of this study is to challenge 
mitochondrial FA oxidation via administering a HF meal, assessing the relationship between FA 
oxidation and CRF in youth (age 8-17 years). We hypothesize that low CRF will be associated 
with inefficient mitochondrial beta-oxidation, profiled by medium-chain acylcarnitines (AC), and 
increased extra-mitochondrial oxidation, profiled by dicarboxylic FA (FA-COOH). The 
secondary objective of this study is to assess the relationship between FA oxidation 
intermediates and measures of insulin resistance (IR), glucose homeostasis, and cardiometabolic 
risk. We hypothesize that incomplete mitochondrial beta-oxidation and increased extra-
mitochondrial oxidation will mediate the relationship between CRF with metabolic health. We 
will test our hypotheses through these aims: 
SPECIFIC AIM 1. Determine if CRF is associated with modifiable behaviors including 
body composition, daily physical activity (PA), and habitual dietary intake. Children, aged 
8-17 years (body mass index (BMI) percentile ≥ 85% for sex/age, matched with leans [5%≤BMI 
percentile<85%], n=50), will be recruited. Gold-standard stress testing will use a modified Bruce 
multistage protocol, increasing both the elevation and speed over time, to measure VO2 max. 
Body composition will be measured using bioelectrical impedance (Seca, Hamburg, Germany). 
Over seven days, participants will be asked to wear an ActiGraph accelerometer (ActiGraph, 
Pensacola, FL) and complete three dietary recalls using Automated Self-Administered 24-h 
dietary recall (ASA-24). We will assess the interaction between PA and habitual dietary intake, 
measured by the Healthy Eating Index (HEI) score (10), with VO2 max. We will consider if the 
interaction between PA and HEI score modifies the linear association between percent fat mass 
and VO2 max. 
SPECIFIC AIM 2. Following a HF-challenge, assess the relationship between 
mitochondrial and extra-mitochondrial FA oxidation with CRF. After an overnight fast, 
participants will consume the HF-challenge, composed of palm oil supplemented Boost® (15% 
kcal carbohydrates, 15% kcal protein, 70% kcal lipid). Blood will be sampled via intravenous 
line at baseline (t0) and after consuming the challenge (t30, t60, t120, and t180 minutes) and 
analyzed for fluctuations in glucose and insulin. Plasma targeted metabolomics will be 
conducted, profiling AC and FA-COOH metabolites. PBMC will be isolated and mRNA levels 
of genes related to beta- and omega-oxidation will be determined by qPCR. Fold change 
calculations and longitudinal trajectories, measured by empirical Bayes time-series analysis (11), 
will quantify the response of metabolites and expression of genes to the challenge. Mixed 

 
 
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regression models will determine the association between CRF with FA oxidation metabolite and 
gene (1) absolute levels, (2) longitudinal trajectories, and (3) ratios (12), considering the 
influence of age, sex, pubertal status, and BMI percentile. 
SPECIFIC AIM 3. Identify if mitochondrial and extra-mitochondrial oxidation of the HF-
challenge mediates the relationship between CRF and metabolic health. In fasting plasma, 
we will profile the homeostatic model assessment for IR (HOMA-IR), hemoglobin A1c 
(HbA1c), and a continuous metabolic syndrome score (cMetS), composed of waist 
circumference (WC), mean arterial blood pressure (MAP), HOMA-IR, HDL-C, and triglycerides 
(TG) (13). Linear regression will assess the relationship between VO2 max and the metabolic 
markers. Mediation analyses will be used to identify if FA oxidation metabolite and gene (1) 
absolute levels, (2) longitudinal trajectories, and (3) ratios (12) mediates the relationship between 
VO2 max and the metabolic markers, considering the influence of age, sex, pubertal status, and 
BMI percentile. 
The proposed aims will identify modifiable behaviors associated with CRF in youth and 
will assess if FA metabolism mediates the relationship between CRF and metabolic health, with 
the long-term goal of developing clinical interventions aimed at improving CRF in youth to 
preserve metabolic health (Figure 1).  
 
Figure 1. Children (BMI%≥5%) will be recruited (aged 8-17). Assessment of characteristics will 
include blood sampling (glucose homeostasis), a treadmill maximal aerobic capacity assessment 
(VO2 max), anthropometrics (height, weight, bioelectrical impedance, waist circumference), 24-
hr dietary recall, and habitual physical activity measured by an accelerometer. Individuals will 
undergo a high-fat meal challenge (15% carbohydrates, 15% protein, 70% lipid) and blood 
sampling will be collected on an acute time-course.  
 
3.0 
Background* 

 
 
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Cardiorespiratory fitness is the capacity of respiratory and circulatory systems to supply 
oxygen to skeletal muscle during exercise for the generation of energy. Beginning in childhood, 
CRF is predictive IR and T2D (1), CVD (2), and academic performance (14). There is an 
intrinsic, nonmodifiable aspect of CRF, influenced by genetics (15, 16), age (17), and sex (18). 
However, in the past three decades, adolescent CRF has declined (19), with only 40% of youth in 
the United States (aged 12-15 years) maintaining a healthy CRF (4). Global alterations in 
behaviors may be influencing the decline in CRF, including increased sedentary time (5), 
decreased moderate-to-vigorous activity (5), increased obesity (6), and lower dietary quality (7). 
The American Heart Association (AHA) has recently issued a statement (20) emphasizing the 
importance of accurately and reliably measuring CRF “to identify youth who would benefit from 
lifestyle interventions but may have been missed by subjective PA recall, anthropometric 
measures, or CVD risk factor testing, which are current standards of care.” Profiling maximum 
oxygen consumption (VO2max) during intense exercise is the gold standard measure of CRF. 
The first objective of this grant proposal is to measure VO2max using a treadmill protocol and to 
assess the relationship between CRF and body composition, daily PA, and habitual dietary intake 
(Specific Aim 1), with the long-term goal of developing clinical interventions aimed at 
improving CRF in youth to preserve metabolic health. There have been no studies to date that 
considered the cross-sectional interaction between PA, measured by Actigraph accelerometers, 
and habitual dietary intake, measured by the HEI score (10), on CRF in youth (20). We will 
consider if the interaction between PA and HEI score modifies the association between percent 
fat mass and CRF, providing avenues for lifestyle changes in adolescents with overweight and 
obesity. 
To sustain exercise, oxygen is circulated to skeletal muscles to be utilized within the 
mitochondrial via the electron transport chain, supporting the creation of ATP (reference). 
Therefore, CRF serves as a measurement of mitochondrial respiratory capacity and has been 
associated with FA oxidation (8, 9). In rats selectively bread for high running capacity (9), 
Overmyer et al. demonstrated that CRF is associated with a more rapid mitochondrial protein 
deacetylation at the initiation of exercise and a more efficient and prolonged oxidation of FA 
during exercise. The inability to efficiently metabolize FAs is associated with elevated levels of 
bioactive lipids, such as ceramides and diacylglycerols (DG), which leads to cellular stress, 
inflammation, and increased risk of T2D and CVD (21). The second objective of this grant 
proposal is to challenge mitochondrial FA oxidation via administering an acute HF meal, 
assessing the relationship between FA oxidation and CRF (Specific Aim 2). Mitochondria are 
the central hub of FA oxidation (beta-oxidation); however, the endoplasmic reticulum (omega-
oxidation) and peroxisomes (alpha-oxidation) serve as FA oxidation rescue pathways when beta-
oxidation is overloaded (22). Using plasma metabolomics during the meal challenge, we 
hypothesize that low CRF will be associated with inefficient mitochondrial beta-oxidation, 
profiled by AC, and increased extra-mitochondrial oxidation, profiled by FA-COOH (22, 23). 
Beta- and omega-oxidation gene expression will be quantified within PBMC; a cell type 
frequently used in human challenges due to its accessibility and expression being comparable to 
skeletal muscle tissue (24). There have been no studies to date that have used an acute nutrient 
challenge to assess the relationship between FA oxidation and CRF. Morris et al. assessed 
variation in the lipidome in response to an oral lipid tolerance test (OLTT) in healthy adults 
(n=40) observing differences in production of phosphatidylcholines (PC), sphingomyelins (SM) 

 
 
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and ceramides related to CRF (25). Profiling FA oxidation intermediates and PBMC gene 
expression rather than the lipidome will provide a more direct readout of FA efficiency.  
In youth, literature widely suggests that insulin regulation and resistance may lead to metabolic 
alterations inducing the development of CVD (26). IR alters lipid metabolism leading to 
hyperglycemia and dyslipidemia, evidenced by increased in fasting glucose, TGs, and low-
density lipoproteins (LDL) and decreases in high-density lipoproteins (HDL). Currently, the 
American Diabetes Association (ADA) endorses screening for prediabetes and T2D by profiling 
the response of glucose to an oral glucose tolerance test (OGTT), in which a 75-gram glucose 
solution is consumed. However, an OGTT has exhibited notable limitations in the pediatric 
population, including poor reproducibility (27), potentially advocating for new screening tools to 
be developed. In our recent review (28), we have assessed how metabolomics can be paired with 
a nutrient challenge to provide a deeper understanding of the homeostatic ability to adapt to a 
nutrient load potentially identifying pathways and biomarkers of metabolic health. Previous 
pediatric metabolomics studies in fasted plasma (23, 29) have suggested that mitochondrial and 
extra-mitochondrial FA oxidation may be an earlier indicator of IR compared to alterations in 
glucose metabolism. The third objective of this grant proposal is to determine if FA oxidation 
metabolites and genes during the HF-challenge are associated with measures of IR (e.g. HOMA-
IR), glucose homeostasis (e.g. HbA1c), and a continuous metabolic syndrome score (cMetS), 
composed of WC, MAP, HOMA-IR, HDL-C, and TG (13) (Specific Aim 3). We will determine 
if the ability to metabolize the HF-challenge mediates the relationship between CRF and the 
profiled metabolic markers. There have been no studies to date that have considered using a HF-
challenge to understand metabolic health in youth. We propose that a HF challenge may 
complement or enhance the ability of an OGTT to classify adolescents at risk of T2D and CVD.   
 
4.0 
Study Endpoints* 
 

 
 
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5.0 
Study Intervention/Investigational Agent 
The shake will be composed of a mixture of BOOST Glucose Control (Nestlé Products) 
supplemented with palm oil (Table 1). Palm oil contains approximately 50% saturated fatty 
acids (palmitic acid [FA 16:0] and stearic acid [FA 18:0]) and 40% monounsaturated fatty acids 
(oleic acid [FA 18:1]). Each participant will consume a volume of liquid equivalent to 25% of 
their estimated daily caloric needs, calculated by the USDA Dietary Reference Intakes using a 
moderate activity factor. The investigational agent will only be consumed one time, at the second 
study visit.  
 
6.0 
Procedures Involved* 
Assent and Consent: A clinical research coordinator (CRC) or study team member will collect 
consent from at least one parent/legal guardian and verbal assent (ages 8-12 years) or written 
assent (ages 13-17 years) from the participant via a telehealth appointment prior to their first 
study visit.  
0
30
60
120
180
Demographics
Participant self-
report
X
Anthropometrics
RA
X
Dietary recall
Participant self-
report
X
Cardiorespiratory 
fitness
Sports 
cardiology 
X
Physical activity
actigraph
X
Metabolic response 
blood
X
X
X
X
X
Cardiorespiratory 
fitness
Sports 
cardiology 
X
Metabolic response 
blood
X
X
X
X
X
Fasting laboratory 
measures 
blood
X
Response laboratory 
measures 
blood
X
X
X
X
X
Maximal oxidative capacity treadmill test
Actigraph
ASA-24
Time Series (minutes)
Weight, height, BMI percentile, waist 
circumference, blood pressure, and BIA results 
Untargeted metabolomics and PBMC gene 
expression 
Untargeted metabolomics and PBMC gene 
expression 
Variable
Instrument / Measurement 
Source
Questionnaires 
glucose, insulin
Aim 3: HF-challenge response with metabolic health
HbA1C, IGF-1, C-peptide, lipid panel
Aim 2: HF-challnege response with cardiorespiratory fitness
Maximal oxidative capacity treadmill test
Aim 1: Cardiorespiratory fitness with modifiable behaviors 

 
 
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Protocol – Two Study Visits 
Study Visit 1: Participants will arrive at the Clinical Research Unit in Faulkner Building 4M at 
the Main Campus of Dartmouth Hitchcock Medical Center (DHMC) following a two-hour fast. 
Consent and assent documents will be available to re-read prior to study visit. A sample of the 
HF-challenge liquid shake will be available to taste to determine if the adolescents will be 
willing to participate in Study Visit 2. The CRC or other study team member will collect weight, 
height, blood pressure, and waist circumference. Each participant will have body composition 
analyzed using bioelectrical-impedance analyses (BIA).  
The CRC or other study team member will transfer the participants and their Parents/Guardians 
to the Sports Cardiology Unit in Cardiac Services 4A at the Main Campus of DHMC. The CRC 
or other study team member with CPR and BLS training will acclimate the participant to a 
treadmill and metabolic cart to undergo a maximal aerobic capacity test, measuring CRF. The 
maximal aerobic capacity test will use the Bruce Protocol (1), a treadmill multistage incremental 
protocol. Parents/Guardians will fill out electronic questionnaires about demographics, diabetes 
family history, and past medical history. Children will fill out electronic questionnaires about 
puberty status measured by Tanner’s Stages. 
Participants will be compensated $25 for the completion of the study visit.  
Between Study Visit 1 and 2 
Between Study Visit 1 and 2, all participants will receive an Actigraph GT9X triaxial 
accelerometer to objectively assess habitual physical activity for at least seven days. All 
participants will complete three dietary recalls detailing foods eaten. The timeframe between 
Study Visit 1 and 2 will be ~7-14 days.  
Study Visit 2: Participants will arrive at the Clinical Research Unit in Faulkner Building 4M at 
the Main Campus of DHMC after an overnight fast (≥12 hours). Upon arrival, the CRC or other 
study team member will collect accelerometers and data will be exported via ActiLife software. 
A RN will place an intravenous line to collect blood sampling throughout the acute meal 
challenge. The CRC or other study team member will mix and provide the HF-challenge, 
containing approximately 15% calories from carbohydrates, 15% calories from protein, and 70% 
calories from fat. Participants will receive a survey identifying their taste preference for the HF 
shake. Blood sampling will occur prior to the consumption of the HF challenge and 30, 60, 120, 
and 180 minutes after the consumption of the HF challenge. The CRC or other study team 
member will collect a 24-hour dietary recall of the previous day. After drinking the HF 
challenge, the CRC or other team member will collect a brief survey about the taste preference of 
the HF challenge. Metabolomics and assays for gene expression will be conducted across the 
time-course.   
Participants will be compensated $75 for the completion of the study visit.  

 
 
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Protocol – One Study Visit 
Participants will receive an Actigraph GT9X triaxial accelerometer to objectively assess habitual 
physical activity for at least seven days. All participants will complete three dietary recalls 
detailing foods eaten.  
Participants will arrive at the Clinical Research Unit in Faulkner Building 4M at the Main 
Campus of Dartmouth Hitchcock Medical Center (DHMC) after an overnight fast (≥12 hours). 
Consent and assent documents will be available to re-read prior to study visit. The CRC or other 
study team member will collect weight, height, blood pressure, waist circumference, and hip 
circumference. Each participant will have body composition analyzed using bioelectrical-
impedance analyses (BIA). Parents/Guardians will fill out electronic questionnaires about 
demographics, diabetes family history, and past medical history. Children will fill out electronic 
questionnaires about puberty status measured by Tanner’s Stages. 
A RN will place an intravenous line to collect blood sampling throughout the acute meal 
challenge. The CRC or other study team member will mix and provide the HF-challenge, 
containing approximately 15% calories from carbohydrates, 15% calories from protein, and 70% 
calories from fat. Participants will receive a survey identifying their taste preference for the HF 
shake. Blood sampling will occur prior to the consumption of the HF challenge and 30, 60, 120, 
and 180 minutes after the consumption of the HF challenge. The CRC or other study team 
member will collect a 24-hour dietary recall of the previous day. After drinking the HF 
challenge, the CRC or other team member will collect a brief survey about the taste preference of 
the HF challenge. Metabolomics and assays for gene expression will be conducted across the 
time-course.   
Participants will be compensated $75 for the completion of the study visit.  
 
Assessment Details  
 
Physical Assessment  
A physical examination will then be conducted, which includes measurement of height, weight, 
blood pressure, waist circumference, and hip circumference. Measurements will be collected by 
the CRC or other member of the research team.  
Bioelectrical Impedance Analysis  
BIA (SECA, Hamburg, Germany) is a non-invasive test providing the measurement of fat and 
lean mass in each participant. A weak non-detectable electric current will flow through the body 
and the voltage is measured to calculate impedance (resistance) of the body. Body compartments 
(fat, bone, lean mass, water) provide differential resistance to the electrical current flow, 
allowing for an estimation of lean and fat mass.  
Maximal Aerobic Capacity Test  

 
 
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The maximal aerobic capacity test will be performed by the expert staff of the Cardiology Unit, 
including an exercise physiologist, with supervision provided as needed by Dr. Meijer and CRC. 
Participants will be acclimated to the treadmill prior to procedure.  
Stress testing will use the Bruce Protocol (30), a treadmill multistage incremental protocol, 
increasing both the elevation and speed over a duration of time. Stage 1 starts at 10% grade and a 
1.7 mph walking pace. In each subsequent stage, the grade is increased by 2% and the speed by 
either 0.8 or 0.9 mph until the subject is exhausted. Stage levels increase every 3 minutes.  
Participants will wear a mouthpiece to allow for the measurement of oxygen consumption and 
carbon dioxide emission. Participants will wear a heart rate monitor around their chest to 
continuously monitor heart rate. VO2 peak is reached when oxygen consumption remains at 
steady state despite the increased workload. Participants will complete the test until they claim 
maximum exercise and exhaustion. Staff members will provide the same encouragement to all 
participants, to help them differentiate between exercise capacity constraints and lack of 
cooperation in exercise testing. The test will stop immediately if there is an emergency, if the 
subject fails to conform to the protocol, or if the subject experiences signs of discomfort.   
We will adhere to the absolute and relative indications for termination of an exercise test which 
include the following Absolute Contraindications: moderate to severe angina, increasing nervous 
system symptoms (e.g. ataxia, dizziness, or near syncope), signs of poor perfusion (cyanosis or 
pallor), or subject's desire to stop and the following Relative Contraindications: increasing chest 
pain or fatigue, shortness of breath, wheezing, leg cramps, or claudication.  
Previous studies have found success in the incorporation of this protocol in pediatric research 
(31). Additional details on clinical stress testing in the pediatric age group are provided by the 
AHA (32).  
When conducting statistical analyses, a respiratory exchange ratio, the ratio between metabolic 
production of carbon dioxide and the uptake of oxygen, ≥ 1 will serve as an indicator that the 
participant was nearing exhaustion, rather than stopping prematurely.   
Submaximal Aerobic Capacity Test  
To estimate submaximal aerobic capacity, participants will undergo a 6-minute walk test 
(6MWT), where distance walked is measured using a rolling measuring wheel. This test is 
practical and low-tech, requiring a pre-measured hallway (20-30 meters) and allowing 
participants to dictate their own intensity of exercise and rest during the test. The information 
gained from the 6MWT is not considered a replacement for a maximum cardiorespiratory fitness 
test, however, strong correlations have been observed (33). Participants will be instructed to walk 
as far as possible in 6 minutes, back and forth in a pre-measured hallway. Environmental factors 
will be standardized in the test facility and all participants will be encouraged to wear 
comfortable clothing and appropriate shoes for walking. The protocol and encouragement during 

 
 
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the test will be in accordance with the American Thoracic Society (34). Prediction equations to 
estimate VO2 max will be used (33).  
 
We anticipate funding sources to cover the expenses for a maximal aerobic capacity test, 
nevertheless, our protocol includes a submaximal aerobic capacity test as a low-cost estimate of 
VO2 peak in preparation of lack of funding. The 6MWT can be administered in hallways within 
DHMC, on Level 5 due to less foot traffic, by the CRC.  
Surveys  
Parents/Guardians will be asked to fill out electronic questionnaires about demographics, 
diabetes family history, and past medical history. Children will be asked to fill out 
surveys about puberty status using the Puberal Development Scale (35) and a taste 
preference survey after the high fat shake.  
Actigraph  
Participants will be asked to wear an ActiGraph GT9X triaxial accelerometer (ActiGraph, 
Pensacola, FL) for at least seven days after the first study visit to objectively assess habitual 
physical activity. This accelerometer was chosen as it has shown to be a reliable and valid 
measure of habitual physical activity in children with established data acquisition and processing 
methods (36). Participants will wear the monitor on their non-dominant wrist during all waking 
hours. Participants will be asked to remove the monitor during periods of sleeping, bathing, or 
swimming, as well as contact sports. Staff will be available by phone or email to answer device 
usage questions. Participants will complete accelerometer logs, noting the time when the device 
was put on and taken off. Children will return the device. 
Upon collection, data will be exported from the device using ActiLife software, Version 16.3.3 
(ActiGraph, Pensacola, FL). The GT9X accelerometer generates a variable output voltage signal, 
proportional to acceleration in three orthogonal places (vertical, anteroposterior, and 
mediolateral). Acceleration is converted to activity counts and stored on the device. Physical 
activity will be classified into sedentary behavior and light, moderate, and vigorous physical 
activity (37). 
Habitual Dietary Intake 
Three dietary recalls will be administered (two weekdays and one weekend) using Automated 
Self-Administered 24-h dietary recall (ASA-24). The ASA-24 is based on the validated Multiple 
Pass Method (38) and has been validated against standardized interviewer-administered 24-hr 
recalls (39). Children with Parent/Guardian supervision will report all food and beverage 
consumed during the previous day (midnight to midnight). The ASA-24 uses the USDA’s Food 
and Nutrient Database for Dietary Studies to calculate dietary intake and HEI scores (40), which 
is composed of a thirteen component scoring system adhering to the 2015-2020 Dietary 
Guidelines for Americans.   
Participants will have a 24-hour dietary recall during the HF challenge to assess food intake the 
previous day. 

 
 
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High-fat Challenge  
 
The HF-challenge will be started between 7:00 
AM and 10:00 AM. To increase the comfort level 
of the participants, a topical anesthetic will be 
applied to numb the location of the needle. An 
intravenous catheter will be placed, and blood 
drawn prior the consumption of the shake 
(baseline). A liquid HF shake will be consumed 
over a 10-minute period. Participants will be 
highly encouraged to consume the entire shake; 
however, pre- and post-weight of the shake will be 
taken if entire shake isn’t consumed. The shake 
will be composed of a mixture of BOOST Glucose 
Control (Nestlé Products) supplemented with 
palm oil. Palm oil contains approximately 50% saturated fatty acids (palmitic acid [FA 16:0] and 
stearic acid [FA 18:0]) and 40% monounsaturated fatty acids (oleic acid [FA 18:1]). Each 
participant will consume a volume of liquid equivalent to 25% of their estimated daily caloric 
needs, calculated by the USDA Dietary Reference Intakes using a moderate activity factor. 
Maximum volume of the HF shake will contain 54 grams of fatty acids. Blood samples will be 
taken at 30, 60, 120, and 180 minutes. A maximum volume of 46 mL of blood (approximately 4 
tablespoons) will be collected from each participant during the 3-hour meal challenge. The total 
blood amount accounts for 1mL of ‘flush blood’ at each timepoint, to account for the small 
amount of blood left in the line and flushed out with saline between draws. 
 
Figure 1. Sample collection timeline.  
 
 
 
 
Figure 2. Sample collection details. 
 

 
 
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Office of Research Operations - Plasma samples (2.0 mL K2 EDTA tubes)  
 
Collection Timepoints: baseline (pre-shake, fasting), 30 minutes, 60 minutes, 120 minutes, and 
180 minutes  
 
Sample Collection details: 
Amount blood drawn: 2.0 mL  
 
CRU Post-Sample Collection:  
1. Following venipuncture, invert the collection tube 10x 
2. Transfer collection tube on ice.  
CRU Staff will transport sample to ORO Lab (Borwell 7) after each blood draw  
ORO Sample Processing:  
1. Centrifuge: 2000g for 10 minutes at room temperature. No brake.  
2. Extract plasma. Aliquot 200L. Evenly distribute remainder of plasma.  
3. Store at -80C in 2mL screw top cryovials with 0.5mL inserts.  
The CRC for the High-Fat Challenge will label all plasma storage tubes. Nomenclature is:  
Subject ID_Timepoint_Sample type_date  

 
 
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Eventual shipping for Metabolomics:  
Attn: Kari Bonds  
University of Michigan  
Metabolomics Core  
1000 Wall Street  
5305 Brehm Tower  
Ann Arbor, MI 48105-5714 
Shipping conditions:  
Samples should be shipped frozen, in a secondary container, on dry ice. Tubes 
should be clearly labeled with sample identifiers (described in the Sample 
Submission Form) and include a hard copy of the Sample Submission Form with 
the shipment 
 
 
Center of Molecular Epidemiology – RNA extraction (2.5 mL PAXgene tubes) 
 
Collection Timepoints: baseline (pre-shake, fasting), 30 minutes, 60 minutes, 120 minutes, and 
180 minutes  
 
Sample Collection details: 
Amount blood drawn: 2.5 mL  
 
CRU Post-Sample Collection:  
1. Following venipuncture, invert the collection tube 10x 
2. Store and transport at room temperature  
CRU Staff will transport all samples to Williamson 6 after the visit. 
Pathology - HbA1c  (2.0 mL K2 EDTA tubes) 
 
Collection Timepoints: baseline (pre-shake, fasting)  
 
Sample Collection details: 
Minimum blood drawn: 0.1 mL  
Amount blood drawn: 0.5 mL *Please use a syringe to collect this small amount of 
blood.  
 
CRU Post-Sample Collection:  
1. Following venipuncture, invert the collection tube 10x.  
2. Transport specimen at room temperature.  
 

 
 
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CRU Staff will transport sample to Pathology Main Lab after the baseline blood draw 
 
 
Pathology – glucose and lipid panel (2.0 mL lithium heparin tubes)  
 
Collection Timepoints: baseline (pre-shake, fasting), 30 minutes, 60 minutes, 120 minutes, and 
180 minutes  
 
Sample Collection details: 
Minimum blood drawn: 0.1 mL  
Amount blood drawn: 1.0 mL *Please use a syringe to collect this small amount of 
blood.  
  
CRU Post-Sample Collection:  
1. Following venipuncture, invert the collection tube 10x.  
2. Transport specimen at room temperature.  
 
CRU Staff will transport sample to Pathology Main Lab after each blood draw 
 
 
Pathology – insulin (5.0 mL SST tubes)  
 
Collection Timepoints: baseline (pre-shake, fasting), 30 minutes, 60 minutes, 120 minutes, and 
180 minutes  
 
Sample Collection details: 
Minimum blood drawn: 1.0 mL  
Amount blood drawn: 2.0 mL *Please use a syringe to collect this small amount of 
blood.  
 
CRU Post-Sample Collection:  
1. Following venipuncture, invert the collection tube 10x.  
2. Transport specimen at room temperature.  
CRU Staff will transport sample to Pathology Main Lab after each blood draw 
 
Metabolomics Analysis  
Plasma untargeted metabolomics profiling will be done by the MRC2 (www.mrc2.umich.edu, 
Directed by Dr. Burant), which has extensive experience in production and analysis of 
metabolomics data. For untargeted metabolomics, samples are analyzed on an Agilent 1200 

 
 
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liquid chromatography/6530 quadrupole Time-of-Flight mass spectrometry system (Agilent 
Technologies, Inc., Santa Clara, CA USA) using the Waters Acquity HSS T3 1.8 μm column 
(Waters Corporation, Milford, MA). The eluent is analyzed in both positive and negative ion 
mode electrospray ionization. Each participant will provide five plasma samples for 
metabolomics after the intake of the high-fat dietary challenge. 
Genetic Analysis  
The study is looking for an association between a genotype or a biomarker and a specific disease 
or condition, but at this point it is not clear if the genetic marker has predictive value. RNA will 
be isolated by the Center of Molecular Epidemiology within Dartmouth College and gene 
expression will be quantified using PCR for genes related to beta-oxidation, omega-oxidation, 
and entry into the mitochondria.  
 
7.0 
Data and Specimen Banking* 
 
Clinical data / protected health information (PHI) including will be kept under appropriate D-H 
firewalls through Epic and encrypted institutional computers and on secure REDcap (Research 
Electronic Data Capture) database. REDCap is a secure, web-based application designed to 
support data capture for research studies, providing 1) an intuitive interface for validated data 
entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export 
procedures for seamless data downloads to common statistical packages; and 4) procedures for 
importing data from external sources. Datasets with linked identifiers will be stored on 
institutional servers and password protected. Users of clinical data will have D-H training in 
privacy protection as well as human participants training, and only aggregate de-identified data 
will be used in presentation or publication. Separate study identifiers will be assigned to 
participants at enrollment and will be used for all questionnaires, blood samples, and 
measurements. Only the primary investigator and research team members who directly contact 
the participants will have access to the information necessary to link them to their de-identified 
data. Data will be maintained confidentially and destroyed at the end of the study per NIH 
policies. 
 
8.0 
Sharing of Results with Subjects* 
 
The team will encourage communication with participants’ primary care provider if any medical 
concerns arise from laboratory measures, specifically if the participant has an HbA1c ≥ 5.7%. 
Within network, we will contact the primary care provider via eD-H. Outside of network, we will 
contact the primate care provider via telephone or fax. Should any participant endorse any 
symptoms, we will immediately contact the nursing staff of the patient’s D-H primary care to 
coordinate evaluation. During this study, participants who take part will not have access to the 
study data.  
 
9.0 
Study Timelines* 

 
 
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The study will last from January 2022 through December 2023. We anticipated to start 
phone recruitment in March 2022. Both study visits will begin at that time. The study 
team is flexible and can begin human subject interactions once DH-IRB deems 
appropriate. Primary analyses will be conducted during 2023 with the objective of 
sharing results by conferences and publications.  
10.0 Inclusion and Exclusion Criteria* 
 
Inclusion Criteria  
 
Children ages 8-17 years with a BMI-percentile ≥ 5th. 
Inclusion of minorities: Every effort will be made to include minorities in the study population. 
Recruitment of both boys and girls will occur. 
 
Exclusion Criteria  
Previous diagnosis of type 1 or 2 diabetes. Use of concurrent medications known to affect 
glucose metabolism (metformin, oral steroids, sulfonylureas, insulin). Evidence of inherited 
disorders of lipid metabolism. Inability to participant in the maximal aerobic capacity test on the 
treadmill. Allergies to palm oils or protein types within high-fat challenge, such as lactose and 
soy. Individuals who cannot speak and/or write in English.  
 
11.0 Vulnerable Populations* 
The research includes children less than <18 years of age. A clinical research coordinator 
(CRC) or study team member will collect consent from at least one parent/legal guardian 
and verbal assent (ages 8-12 years) or written assent (ages 13-17 years) from the 
participant via a telehealth appointment prior to their first study visit. Permission from 
one parent is sufficient.  We are requesting participant consent for participants ≥ 18 years. 
See Section 22 for details. 
12.0 Local Number of Subjects 
 
For our pilot study in 2022, we anticipate the ability to recruit 25 subjects with overweight and 
obesity and 25 leans, recruiting from a pool of ~100 pediatric patients seen within the 
Dartmouth-Hitchcock Weight & Wellness Center (WWC) and ~6000 pediatric patients seen 
within the Children’s Hospital at Dartmouth-Hitchcock (CHaD) (ages 8-17 years). 
 
13.0 Recruitment Methods  
 
Enrollment/Recruitment: Enrollment will begin following D-H IRB approval. Proposed aims 
will be conducted by recruiting children and adolescents (8-17 years) through the CHaD 
(assisted by Dr. Susanne Tanski), the WWC (assisted by Dr. Auden McClure), and, as needed, 
through the community. Flyers have been developed by DHMC marketing. 

 
 
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Recruitment via in person. Providers within CHaD and the WWC will have the opportunity to 
tell patients about the proposed research via in person oral scripts, flyers, and handouts. The 
eligibility screener will be read verbally for the patient to answer. If the patient desires to 
participate and they are eligible, we will send their information to the CRC or other study team 
member to organize a telehealth visit for consent and assent collection.  
 
Recruitment via telephone. The Department of Pediatrics will share a list of eligible patients for 
the research study. A CRC/member of the research team will telephone patients to screen for 
eligibility. The eligibility screener will be read verbally for the patient to answer. If the patient 
desires to participate and they are eligible, we will send their information to the CRC or other 
study team member to organize a telehealth visit for consent and assent collection. 
 
Recruitment via flyer, intranet, and D-H social media. IRB approved study flyers will be 
distributed electronically - over social media and over the intranet – and physically - in any 
public area. Flyers will be distributed by General Ambulatory Services prompting patients to ask 
their provider for more information and clinical teams will assist in identifying interested 
participants. If a patient calls the study team directly, the eligibility screener will be read verbally 
for the patient to answer. If the patient desires to participate and they are eligible, we will send 
their information to the CRC or other study team member to organize a telehealth visit for 
consent and assent collection. If a patient emails the study team directly, the eligibility screener 
will be sent for the patient to answer (RedCap). Upon reception of the survey, if the patient is 
eligible, we will send their information to the CRC or other study team member to organize a 
telehealth visit for consent and assent collection. 
 
Eligibility Screener:  
Upon expression of interest to participate in the study, participants will receive an eligibility 
screener (Redcap) either verbally or written. Screener will address child’s age, pre-existing 
conditions influencing ability to walk/run on treadmill, heart conditions limiting physical 
activity, and diagnosis of any conditions that influence their metabolism or digestion (i.e. 
diabetes, Crohn’s disease, malabsorptive syndrome). Screener will address any food allergies 
that may be triggered by the high-fat challenge, such as allergies to palm oil, dairy protein, and 
soy.  
 
Consent and Assent: A clinical research coordinator (CRC) or study team member will collect 
consent from at least one parent/legal guardian and verbal assent (ages 8-12 years) or written 
assent (ages 13-17 years) from the participant via a telehealth appointment prior to their first 
study visit. See Section 22 for details.  
Incentives: One Study Visit: Children will be compensated with a $75 gift card to Walmart. 
Parent will be compensated with a $10 gas card for traveling <20 miles and a $20 gas card for 
traveling >20 miles. Two Study Visit: Children will be compensated with a $25 gift card to 
Walmart for the first visit and a $75 gift card to Walmart for the second visit, totaling $100 for 

 
 
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the study. Parent will be compensated with a $10 gas card for traveling <20 miles and a $20 gas 
card for traveling >20 miles.  
The child and their parents are spending at least 5 hours of their time to participant in this study, 
The fees compensate for their time.  
Participants have the option of declining such monetary incentives. All individuals receiving a 
monetary payment will need to sign a W9 form at that time in line with institutional protocols. 
Parking: Participants will be able to park at the parking garage at DHMC.  
14.0 Withdrawal of Subjects* 
To minimize dropouts, we will provide frequent contact with participants, study 
incentives, and outreach to primary care providers (to engage partnerships). Reminder 
and follow up calls/emails/ myDH (as preferred) may be made as needed to provide 
additional support to help minimize attrition by assessing and responding to potential 
barriers to regular participation.  
If medical issues arise over the course of the study or if the participant endorse any 
symptoms the obesity medicine specialist who is part of the study team in combination 
with the patient’s primary care physician will be consulted. The study team reserves the 
right to withdraw subjects if the medical team determines it is necessary.  
Data previously collected prior to the point of withdrawal can still be used for research. 
Participants may be asked to provide a reason for withdrawing from the study. Consent 
will include language permitting ongoing data collection and participant contact after 
withdrawal / loss to follow up to compare outcomes and assess barriers to participation.   
15.0 Risks to Subjects* 
Physical exercise capacity: No more than minimal risk.  
During the study, participants will participate in moderate to vigorous activity. As with 
any moderate to vigorous cardiovascular exercise, there are potential side effects. The 
most common side effects (occurring in more than 10% of participants) include 
discomfort during exercise, discomfort while wearing the headgear necessary for this 
study, and potential muscular soreness the day after the test. Rare side effects (less than 
1% of participants) include cardiac complications that could lead to death. The 
researchers will try to minimize these risks by:  
- 
Participants will be required to answer questions regarding their physical activity 
level prior to acceptance into this study. This questionnaire is designed to assess 
the safety of exercise for an individual. Admittance into this study will only be 
granted to those deemed healthy enough for exercise.  
- 
All study personnel are trained to safely complete a graded exercise test (the test 
used in this study).  

 
 
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- 
All study personnel conducting exercise testing and training are CPR/AED 
certified and trained in emergency procedures specific to our facility. An 
automated external defibrillator (AED) is located near the exercise room. In case 
of an emergency, our study team will call 911 and if warranted will use the AED. 
This device automatically diagnoses and treats life threatening cardiac (heart) 
problems.  
- 
All participants will wear a heart rate monitor throughout each session, allowing 
easy assessment of heart rate throughout the exercise tests. In addition, study 
personnel will monitor participants appearance, form and rating of perceived 
exertion throughout the entire test to ensure the participant is exercising at a safe 
level.  
- 
If a participant feels he/she cannot complete the test, study personnel and/or the 
participant can easily stop the test.  
High-fat meal challenge: No more than minimal risk  
People on rare occasions may feel nausea or vomit from drinking the high-fat solution, 
due to the taste of the solution. We will screen for allergies to palm oils or protein types 
within high-fat challenge, such as lactose and soy, to ensure against allergic reactions.  
Blood samples: No more than minimal risk 
The known or expected risks are those associated with using a needle to place a plastic 
catheter (IV) for drawing blood from a vein. These can include discomfort at the site of 
puncture; possible bruising and swelling around the puncture site; rarely an infection; 
and, uncommonly, faintness from the procedure. There will be one needle stick to place 
the plastic IV. The researchers will try to minimize these risks. Sometimes it may require 
multiple needle pokes (limited to three in this study) to place the plastic IV, but to try and 
avoid this we will have experienced nurses place the plastic IV.  
Breach of confidentiality: No more than minimal risk 
As with any study collecting information that can be traced back to the participants, there is a 
risk that the information we collect may be seen by persons other than the study team. We are 
taking careful measures to prevent this from happening. For example, we will use coded 
identifying numbers rather than your name, birthdate, or other identifying information. Further, 
we will store all data that we collect in password protected files and only the study team will 
have the passwords to these files. Collaborators both inside and outside Dartmouth-Hitchcock 
Medical Center may only have access to samples that have been coded but do not contain any of 
your personal information. Blood samples will be labeled with a unique code rather than your 
name and will be kept in a freezer in a locked laboratory; no person other than the investigators 
involved with this study will have access to these samples.  
This project will ultimately involve generation of genetic information. Loss of confidentiality of 
biobank-related information is unlikely, but potential risks are as follows. Information about a 
person’s participation in a genetic study could influence insurance companies and/or employers 

 
 
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about one’s health status. “The Genetic Information Non-Discrimination Act” or GINA protects 
individuals against employers or insurance companies using genetic information to make 
decisions. The WWC and IBR do everything possible to safeguard participant information and 
keep it confidential as described above. Briefly, all samples are coded and locked. The key to the 
code is kept in a separate, secure location. Access to the code is limited to the IBR Manager as 
an honest broker. No study information will be released to family members or published in a way 
that could identify the participant.  
Inconvenience: No more than minimal risk  
There could be inconvenience to the subject to schedule these procedures. We will try to make 
every accommodation to them in terms of their schedule. 
COVID-19: No more than minimal risk 
We anticipate that the risk of contracting the virus because of participating in the study is low. 
The study team plans to follow all institution guidance on COVID related protocols. This 
includes but is not limited to current and ongoing recommendations for masks and eye protection 
for study team members and universal masking of participants as vaccination status cannot be 
assessed. We will allow for appropriate spacing between participants and study 
coordinators/RNs.  
Participants will have to remove their masks for the maximal oxidative capacity test to use the 
mouthpiece. Mouthpieces will be discarded after use. Minimal members of the research team 
will be within the room during the maximal oxidative capacity test.  
As with any research study, there may be additional risks that are unknown or unexpected.  
16.0 Potential Benefits to Subjects* 
The proposed study’s main objective is to identify individuals at a young age with a high 
risk for developing T2D and other metabolic diseases. Classifying the response to a high-
fat meal challenge may complement or improve current screening methods.  
No direct benefit will be received by patients.  
17.0 Data Management* and Confidentiality 
 
Our team is experienced in survey / protocol development, training of study team members, 
intervention delivery, and data management. Regular research meetings and PI supervision will 
assure quality and consistency. Questionnaire data anthropometric and laboratory data will be 
stored on a HIPAA compliant Redcap database. Clinical data / PHI including will be kept under 
appropriate D-H firewalls through Epic and encrypted institutional computers and databases. 
Datasets with linked identifiers will be stored on institutional servers and password protected. 
Users of clinical data will have D-H training in privacy protection as well as human participants 

 
 
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training, and only aggregate de-identified data will be used in presentation or publication. 
Separate study identifiers will be assigned to participants at enrollment.  
 
18.0 Provisions to Monitor the Data to Ensure the Safety of Subjects* 
The proposed study presents no more than minimal risk to subjects. As children are 
vulnerable population, our study team want to ensure extra caution for the safety of 
the research participants. Guidelines are as follows:  
Maximal oxidative capacity fitness test: The study team member running the maximal 
oxidative fitness test will have CPR training and basic life support certification. The 
maximal oxidation capacity test will occur at DHMC. A cardiologist will be available 
to interpret the results of VO2 max test. An adolescent sports medicine pediatrician is 
a collaborator in the proposed project and helped decide on the appropriate VO2 max 
test. In the rare event that a participant has a medical issue and needs assistance, the 
study team will follow CODE protocols for DHMC to alert medical personnel. In 
addition, the study team can access the HERT (Hitchcock Early Response Team) 
team to provide early medical assistance. 
Adolescent Sports Pediatrician: Dr. Keith Loud  
Pediatric Obesity Medicine Specialist: Dr. Marc Hofley 
Blood draw: The clinical research unit has an established protocol for responding to 
uncommon occurrences (e.g. fainting from blood draw) including contacting the 
pediatric HERT team.  
Lab results of concern: Dr. Hofley will work with Dr. Loud to provide medical oversight 
including screening of all fasting lab results, including glucose, insulin, HbA1c, and 
the lipid panel and contacting patients’ primary care providers with any abnormal 
results or other concerns. Dr. Meijer’s medical advisors are part of pediatrics and well 
connected to primary care triage and provider teams which allows for easy 
communication. 
Pediatric Obesity Medicine: Dr. Auden McClure will provide oversight for development 
of recruitment and clinical protocols 
Other Concerns: Other participant concerns can be directed to Dr. Meijer and her research 
coordinator. Participants will also be provided contact information for IRB as oart of the consent 
process 
Principal Investigator: Jennifer Meijer, PhD, RD, MPH  
Email: jennifer.l.meijer@hitchcock.org 
Phone 603-650-5250 

 
 
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Clinical Research Coordinator: Sara Stiverson 
Email: sara.d.stiverson@hitchcock.org 
Phone: 603-653-2282 
 
19.0 Provisions to Protect the Privacy Interests of Subjects 
 
The only people who will have access to the study information are those who are study team 
members. The PI will endure that the disclosure of PHI obtained during this study complies with 
the Federal Privacy Regulation. All data will be stored behind institutional or equivalently 
approved firewalls and password protected. 
  
20.0 Compensation for Research-Related Injury 
N/A  
 
21.0 Economic Burden to Subjects 
We foresee little economic burden to the subjects outside of mileage to drive to DHMC 
for the study visits, which our incentives will accommodate.      
 
22.0 Consent Process 
To participate in the study, both parent/legal guardian written consent and participant assent will 
be required. Verbal assent will be required for participants ages 8-12 years and written assent 
will be required for participants ages 13-17 years. Separate consent and assent forms were 
created. Signatures will be obtained from at minimum one parent/legal guardian prior to the first 
study visit via a telehealth appointment, facilitated by the CRC or other study team member. The 
signature will be obtained via RedCap surveys including the consent and/or assent document. 
The study team will verbally read the consent form, highlighting details of the study and 
potential risks. The study team will answer any questions and will use a teach back method of 
consent to ensure the parent/legal guardian and the participant understand the breath of the study. 
HIPAA Authorization to review the child participant’s medical record is embedded in the 
consent document. Parent/legal guardians and participants will be provided with a copy of the 
consent and assent forms. They will be permitted to ask any questions to study personnel. The 
contact information for study personnel is provided on the consent/assent form.  
We will be following SOP: Informed Consent Process for Research (HRP-090) and SOP: 
Legally Authorized Representatives, Children, and Guardians (HRP-013).  
Non-English-Speaking Subjects 
Participants who are non-English speaking will not be enrolled. 

 
 
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23.0 Process to Document Consent in Writing 
Consent and assent documents will be emailed/presented via RedCap and signed 
electronically. We will be following SOP: Written Documentation of Consent (HRP-
091). 
24.0 Setting 
Potential research participants will be recruited through the CHaD and the WWC at 
DHMC. All study visits will be conducted at DHMC through the Clinical Research Unit 
or the Cardiology Unit.  
25.0 Resources Available 
For our pilot study, we anticipate the ability to recruit 25 subjects with overweight and 
obesity and 25 leans, recruiting from a pool of ~100 pediatric patients seen within WWC 
and ~6000 pediatric patients seen within CHaD (ages 8-17 years). Dr. Jennifer Meijer 
will dedicate 0.4 FTE towards conducting and completing the research. The clinical 
research coordinator will dedicate 0.2 FTE towards conducting and completing the 
research. We anticipate ~50 hours will be needed for recruitment of 50 participants. The 
research will utilize the CRU’s exception nursing staff and resources. All study team 
members are required to read the protocol and all related study documents.  
References  
 
 
1. 
F. B. Ortega, J. R. Ruiz, M. J. Castillo, M. Sjostrom, Physical fitness in childhood and 
adolescence: a powerful marker of health. Int J Obes (Lond) 32, 1-11 (2008). 
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G. Hogstrom, A. Nordstrom, P. Nordstrom, High aerobic fitness in late adolescence is 
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K. Mandsager et al., Association of Cardiorespiratory Fitness With Long-term Mortality 
Among Adults Undergoing Exercise Treadmill Testing. JAMA Netw Open 1, e183605 
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J. M. Gaitan et al., Two Weeks of Interval Training Enhances Fat Oxidation during 
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S. Krug et al., The dynamic range of the human metabolome revealed by challenges. 
FASEB J 26, 2607-2619 (2012). 
13. 
J. C. Eisenmann, K. R. Laurson, K. D. DuBose, B. K. Smith, J. E. Donnelly, Construct 
validity of a continuous metabolic syndrome score in children. Diabetol Metab Syndr 2, 8 
(2010). 
14. 
C. C. A. Santana et al., Physical fitness and academic performance in youth: A 
systematic review. Scand J Med Sci Sports 27, 579-603 (2017). 
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C. Bouchard et al., Familial resemblance for VO2max in the sedentary state: the 
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M. H. De Moor et al., Genome-wide linkage scan for athlete status in 700 British female 
DZ twin pairs. Twin Res Hum Genet 10, 812-820 (2007). 
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N. Armstrong, J. Welsman, Development of peak oxygen uptake from 11-16 years 
determined using both treadmill and cycle ergometry. Eur J Appl Physiol 119, 801-812 
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R. J. Winsley, J. Fulford, A. C. Roberts, J. R. Welsman, N. Armstrong, Sex difference in 
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