Alternate Day Fasting, Exercise, and NAFLD

Study Overview
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Brief Summary
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Approximately 65% of obese individuals have non-alcoholic fatty liver disease (NAFLD), and this condition is strongly related to the development of insulin resistance and diabetes. Innovative lifestyle strategies to treat NAFLD are critically needed. The proposed research will demonstrate that alternate day fasting (ADF) combined with exercise is an effective non-pharmacological therapy to treat NAFLD.

Detailed Description
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Nonalcoholic fatty liver disease (NAFLD) is characterized by an accumulation of fat in the liver (not resulting from excessive alcohol consumption). Approximately 65% of obese individuals have NAFLD, and this condition is strongly related to the development of insulin resistance and type 2 diabetes. While certain pharmacological agents have been shown to reduce liver fat (i.e. thiazolidinediones), there is mounting concern regarding the safety and weight-gaining effects of these compounds. In light of this, recent research has focused on non-pharmacological lifestyle therapies to reduce hepatic steatosis, such as daily calorie restriction combined with aerobic exercise. Evidence from clinical trials suggest that this combination is an effective lifestyle therapy improve liver fat content and hepatic insulin sensitivity. More recently, it's been shown that intermittent fasting may produce even greater improvements in hepatic steatosis and hepatic insulin sensitivity, when compared to conventional calorie restriction. For instance, intrahepatic lipid accumulation was lower and insulin sensitivity was higher in mice fasted every other day, when compared to mice who were energy restricted every day. Moreover, data from human trials show that adults with obesity experience greater decreases in insulin and insulin resistance with intermittent fasting versus daily restriction. These findings suggest that intermittent fasting may be a more effective diet therapy to reduce hepatic steatosis and improve insulin sensitivity, when compared to daily calorie restriction. Although these findings are very promising, these data still require confirmation by a randomized controlled clinical trial.

Official Title
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Alternate Day Fasting Combined With Exercise for the Treatment of Non-alcoholic Fatty Liver Disease (NAFLD)

Conditions
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Non-Alcoholic Fatty Liver Disease, Obesity

Intervention / Treatment
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* Other: Alternate day fasting
* Other: Exercise


Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA: Age between 18 to 65 years old BMI between 30.0 and 59.9 kg/m2 NAFLD (hepatic steatosis ≥ 5% confirmed by MRI-PDFF) Sedentary (<20 min, 2x/week of light activity at 3-4 metabolic equivalents (METs) for 3 mo prior to study) EXCLUSION CRITERIA: Have chronic liver disease other than NAFLD (hepatitis B or C, primary biliary cirrhosis, sclerosing cholangitis, autoimmune hepatitis, hemochromatosis, Wilson's disease, α1-antitrypsin deficiency) Consume excessive amounts of alcohol women: 70 g of ethanol (5 alcoholic drinks per week) and men 140 g of ethanol (10 drinks per week) in the past 6 months) Have a history of known cardiovascular, pulmonary or renal disease Diagnosed T1DM or T2DM Are not weight stable for 3 months prior to the beginning of study (weight gain or loss > 4 kg) Are claustrophobic or have implanted metallic/electrical devices (e.g. cardiac pacemaker, neuro-stimulator) Are taking drugs that induce steatosis (e.g. corticosteroids, estrogens, methotrexate, Ca channel blockers) Are taking drugs that benefit NAFLD (e.g. betaine, pioglitazone, rosiglitazone, metformin, or gemifibrozil) Are taking drugs that influence study outcomes (weight loss medications) Are perimenopausal or have an irregular menstrual cycle (menses that does not appear every 27-32 days) Are pregnant, or trying to become pregnant Are smokers

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Alternate day fasting<br>These participants will consume 600 kcal on the fast day and eat ad libitum at home on alternating feed days. | Other: Alternate day fasting<br>* The diet involves consuming 600 kcal on the fast day and eat ad libitum at home on alternating feed days.<br>|
| Experimental: Exercise<br>These participants will participate in a supervised aerobic exercise program 5 times per week, 40-60 min per session, 60-85% HRmax. | Other: Exercise<br>* The exercise intervention involves supervised aerobic exercise program 5 times per week, 40-60 min per session, 60-85% HRmax.<br>|
| Experimental: Combination alternate day fasting plus exercise<br>These participants will consume 600 kcal on the fast day and eat ad libitum at home on alternating feed days. They will also participate in a supervised aerobic exercise program 5 times per week, 40-60 min per session, 60-85% HRmax. | Other: Alternate day fasting<br>* The diet involves consuming 600 kcal on the fast day and eat ad libitum at home on alternating feed days.<br>Other: Exercise<br>* The exercise intervention involves supervised aerobic exercise program 5 times per week, 40-60 min per session, 60-85% HRmax.<br>|
| No Intervention: Control<br>Controls will be instructed to maintain their weight throughout the trial, and not to change eating or physical activity habits. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in hepatic steatosis | Hepatic steatosis will be measured by magnetic resonance imaging (MRI-PDFF) | Change from week 1 to week 12 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in body weight | Measured by digital scale | Change from week 1 to week 12 | 
| Change in lean mass | Measured by dual-energy x-ray absorptiometry (DXA) | Change from week 1 to week 12 | 
| Change in fat mass | Measured by dual-energy x-ray absorptiometry (DXA) | Change from week 1 to week 12 | 
| Change in visceral fat mass | Measured by dual-energy x-ray absorptiometry (DXA) | Change from week 1 to week 12 | 
| Change in Alanine Aminotransferase (ALT) | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in Aspartate Aminotransferase (AST) | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in fasting glucose | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in fasting insulin | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in insulin sensitivity | Measured by Quantitative insulin sensitivity check index (QUICKI) | Change from week 1 to week 12 | 
| Change in insulin resistance | Measured by Homeostatic model assessment (HOMA) | Change from week 1 to week 12 | 
| Change in plasma lipid levels | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in HbA1c | Measured by a commercial lab (Medstar, Inc) | Change from week 1 to week 12 | 
| Change in blood pressure | Measured by a blood pressure cuff | Change from week 1 to week 12 | 
| Change in heart rate | Measured by a blood pressure cuff | Change from week 1 to week 12 | 
| Dietary intake | Measured by a 7-day food record | Change from week 1 to week 12 | 
| Physical activity | Measured by an activity monitor (Fitbit Alta) | Change from week 1 to week 12 | 
| Hepatokine - Fetuin-A (ng/ml) | Measured by ELISA | Change from week 1 to week 12 | 
| Hepatokine - FGF-21 (ng/ml) | Measured by ELISA | Change from week 1 to week 12 | 
| Hepatokine - Selenoprotein P (ng/ml) | Measured by ELISA | Change from week 1 to week 12 | 
| Sleep quality and duration | Measured by Pittsburgh Sleep Quality Index (PSQI). The PSQI is a 19-item self-report questionnaire that measures sleep quality in the past month, resulting in a total score of 0-21. Scores above 5 indicate poor sleep quality. | Change from week 1 to week 12 | 
| Insonmia severity | Measured by the Insomnia Severity Index (ISI). The ISI is a 7-item self-report questionnaire that rates each item by a 5-point Likert scale, resulting in a total score of 0-28. Scores are stratified into the following categories: no clinically significant insomnia (0-7); subthreshold insomnia (8-14); moderate severity insomnia (15-21); and severe insomnia (22-28). | Change from week 1 to week 12 | 
| Risk of obstructive sleep apnea | Measured using the 10-item self-report Berlin Questionnaire which estimates % occurrences of sleep apnea | Change from week 1 to week 12 |