The Effect High Protein-Fiber Diet With Exercise on Acylated Ghrelin and Leptin in Obese Adolescents
Condition: Weight Loss; Adolescent Obesity
MeSH terms: Pediatric Obesity; Weight Loss
Study type: Interventional

Summary: 
      Obesity has been reported to impair regulation of appetite and lead uncontrollably hunger and
      satiety response. Ghrelin is orexigenic hormone from the stomach meanwhile, leptin is
      anorexigenic from adipose. Interestingly, obesity is associated with acylated ghrelin and
      leptin resistance. Study about the impact of high protein and fiber with combined exercise
      (HPFE) to suppress hunger among young obese still unclear. The hypothesis was that high
      protein-fiber would result in decreased in acylated ghrelin and leptin in HPFE group. Thus,
      the investigator examined the effect of an 8 weeks HPFE on acylated ghrelin and leptin.
      Subjects were randomized into four groups: High Protein-Fiber (HPF; n=15). High Protein-Fiber
      and exercise (HPFE; n=15), Exercise (E; n=15) and control (C; n=15). The diet prescribed 1200
      kcal/day, based on basic energy requirement minus 300kcal, consisted high protein (25%) and
      fiber (30g/day). The exercise is combination aerobic and resistance training, with target 75%
      heart rate maximum. Plasma acylated ghrelin and leptin were analyzed with enzyme immunoassay.
    

Detailed description: 
      1. Introduction Obesity pandemic occurred in both developed and developing countries. The
           prevalence of young obesity is rising among adolescents in developing countries as well,
           rising from 8.1% to 12.9% in 2013 for boys and from 8.4% to 13.4% in girls. The
           Indonesian Basic Health Research showed prevalence of young obesity in Indonesia
           increase from 18,8 menjadi 31% on 2007 till 2018. The prominent problem with young
           obesity is the accumulation of adipose cells in the abdominal which can interfere with
           appetite hormones. Ghrelin is the only known as orexigenic hormon which secreted from
           the stomach. The leptin is one of anorexigenic mainly released by the adipose tissue.
           The orexigenic hormone acylated ghrelin and the anorexigenic hormones leptin are an
           important players in regulating appetite, food intake, energy balance, and adipogenesis.

           Regarding body weight regulation, key element are the control of energy intake which is
           regulated at the simplest level by sensation of hunger. Body weight is controlled by a
           complex system, including both peripheral and central factors. Two of the hormones that
           appear to play a crucial role in the regulation of food intake and body weight are
           leptin and ghrelin. Interestingly, obesity is associated with acylated ghrelin and
           leptin resistance. Hyperleptinemia is blunted response in satiety. Postprandial acylated
           ghrelin levels in obesity abdominal subjects do not fall, so hunger still appears. In
           obese subjects experience leptin resistance because the leptin receptor is disrupted so
           that there is a failure of sending leptin signals to the hypothalamus. Many study
           especially about acylated ghrelin still controversial. Studi Andarini showed plasma AG
           concentration is higher before and after eating at all time points, regardless of food
           type, in obese individuals, as compared with normal weight individuals. Consistant with
           the Ozkan et al reveal the AG increase following obesity status.

           Different types of protein can result in different levels of satiety. Metabolites,
           including certain amino acids, contribute to the food intake is arginine. The ability of
           specific L-amino acids, including L-arginine (L-Arg), to stimulate anorectic agent
           (GLP-1 and PYY) release has been studied previously in vitro. The study Alamshah et al
           showed L-Arg reduced food intake and stimulated gut hormone release in rodents. The role
           fiber affect the release satiety and gastric emptying rate.

           Managing weight loss with modification lifestyle in young obesity actually requires
           paying special attention to high compliance and less hunger more satiety. The study
           aimed to examine the effect of giving a high protein diet rich arginine and fiber diet
           with exercise among adolescent obesity.

        2. Methods and Matherials 2.1 Participants The program was conducted from Juli to Oktober
           2018. Subject were recruited through nutrition screening and campaign mass media. For
           sample size, the investigator calculated previous studies regarding AG with following
           setting: power was set at 80%, p value at 0.5 and standardized difference was 21.2,
           resulting in a sampel size of 12 subjects, including 20% for drop out. Inclusion
           criteria are body mass index > 25 kg/m2, waist circumference >80 cm for female and >90
           cm for male. The investigator exclude who were taking dietary supplements or medication,
           smokers, have pregnancy, lose body weight > 10% before treatment and have chronic
           disease history. The participants consisted of 60 adolescents obesity who were selected
           from outpatient of Universitas Diponegoro, Semarang, Indonesia. Subjects were randomized
           into four groups : High Protein-Fiber (HPF; n=15). High Protein-Fiber and exercise
           (HPFE; n=15), Exercise (E; n=15) and control (C; n=15). All participants has signed
           informed consent and the study was approved by Kariadi Hospital-Diponegoro University
           with provision Declaration of Helsinki (Number 427/EC/FK-UNDIP/VII/2018)

      2.1 Study design and randomization. The study design was randomized clinical trial
      (four-arm). The random assignment was generated by a computerized program. The duration of
      intervention is 8 weeks. It was not possible to blind the dietitians who advised on dietary
      prescribe.

      3.1 Diet protocol The subject were randomly into four of different intervention. The HPFE
      prescribed balanced diet (55%carbohydrate, 25% protein, and 20% fat). Based on the Academy
      Dietetics of Association recommends using the Miflin-St Jeor equation for estimating RMR in
      obese individuals. Subject have body weight means 75 kg, so the total energy was calculated
      1500 kcal,then minus 300kcal. The distribution energy of breakfast (30%), lunch (40%) and
      dinner (30%) and extra 500ml plan water before meal. The investigator choose the protein
      sources rich arginine like all type fish, tempeh, nuts/peas. The investigator serve the diet
      menu everyday in our laboratory. The diet was prescribed with the use of standardazied
      household measure to quatify the food portion in each meal. The subjects were monitored the
      diet everyday with logbook. The control group give nutrition education once a week in
      nutrition laboratory. The nutritional data was calculated by software (Nutrisurvey).

      4.1 Exercise protocol

      One session of training program included the following program component :

      1) 5 min warm-up; 2) 25 min aerobic training; 3) 10 min resistance training, 4) 5 min
      cool-down. The resistance training was performed without weight training machine
      (chalestenic). The movement includes plank, mountain climber, pilates leg pulls, right side
      plank, left side plank, flutter kick, toe touch crunches, crunch, knee tuck crunches and
      russian twist. The muscle strength level by 40 repetition maximum (RM). Rest between the sets
      of the resistance training was set 20reps. The aerobic training was performed koreographic
      for at least 25 min and the intensity was 75% heart rate maximum. The frequency of training
      was five times a week (on alternate day) under professional trainer. Heart rate during
      training was monitored using HR monitor (H10, POLLAR, Kemple, Finland)

      5.1 Body composition Body weight, and percent body fat mass, were analyzed by a bioelectric
      impedance analyzer (TANITA DC-360) with light clothes and no shoes. Height was measured by
      stadiometer (SECA 207). BMI was calculated as body weight in kilograms divided by height in
      meters squared (kg/m2). Waist Circumference (WC) was measured with a inelastic measuring tape
      around the mid-section between the margin of the last rib and the iliac crest.

      6.1 Hormone Analysis Venous blood samples were obtain after 10h fasting. Blood samples for
      insulin and leptin were stored in plain tubes, and acylated ghrelin were stored in tubes with
      EDTA. For active ghrelin, immediately after collection, 40 mL p-hydroxymercuribenzoic acid
      was added to each blood sample. The samples were centrifuged at 3500X at 4C for 10 min. For
      acyl ghrelin, after centrifugation, the plasma was pipetted in 1.5-mL microtubes, and 100 mL
      hydrochloric acid (1N) was added for each 1 mL plasma. For all blood sample, the respective
      supernatant fluids were pipetted and frozen at 80°C for a later analysis by an enzyme-linked
      immunoassay (Elabscience E-EL-H2002 for AG, E-EL-H0113 for leptin). Blood samples for
      trigliserida and HDL were stored in tubes with non EDTA, and analyzed with clinical chemistry
      automatic analyzer (Indiko thermoscientific).

      7.1 Statistical Analysis Data were analyzed IBM SPSS. Variable not normally distributed were
      nonparametric test. Wann whitney U test was used to test for difference all parameter at
      baseline. We compared change in variable (baseline-week8) in each sub group using pair t=test
      or wilcoxon signed rank test to determine the impact of differential change. To test for
      change in parameters between four group used kruskal wallis.
    

Intervention name(s): Modification Lifesyle
Intervention type(s): Behavioral
Intervention description(s): high protein-fiber and exercise
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: four arm parallel group with 56 young obesity:
high protein-fiber diet and exercise
high protein-fiber diet
exercise
control
Masking: Double (Participant, Investigator)
Primary purpose: Prevention
Keywords: high protein-fiber; acylated ghrelin; leptin