Effect of Probiotic Co-administration With Omega-3 Fatty Acids on NAFLD

Study Overview
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Brief Summary
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One of the potential ideal strategy for NAFLD treatment may be manipulation with gut microbiota. Probiotics are defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Omega-3 fatty acids belong to the family of polyunsaturated fatty acids. They are known to exert a strong positive influence on metabolism and inflammation. The data from animal studies suggested that both probiotics and omega-3 can affect body weight, influence on glucose and fat metabolism, improve insulin sensitivity and reduce chronic systemic inflammation. In respect to experimental data, the current study aim was to provide double-blind single center RCT, for study the efficacy of co-administration of probiotic with omega-3 vs. placebo in type 2 diabetes patient with NAFLD detected on ultrasonography

Detailed Description
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In this single-center double-blind, placebo controlled, parallel group study, 48 type 2 diabetes patients from the Kyiv City Clinical Endocrinology Center were selected. They were randomly assigned to receive Symbiter Omega or placebo for 8 weeks, administered as a sachet formulation in double-blind treatment. Randomization was done by the study statistician based on a computer-generated list. The groups were homogeneous according to age, sex and diagnostic criteria. The assignment of groups was blind to participants, research staff and outcome assessors moreover, to maintain blind parallel study the statistician was not aware of the allocation of participants to intervention. The Symbiter Omega was supplied by Scientific and Production Company O.D. Prolisok. It contains combination of flax and wheat germ oil (250 mg of each, concentration of omega-3 fatty acids 1-5%), supplemented with biomass of 14 alive probiotic strains: Lactobacillus + Lactococcus (6×1010 CFU/g), Bifidobacterium (1×1010/g), Propionibacterium (3×1010/g), Acetobacter (1×106/g) genera. Over 8 weeks of interventional period, the patient received 1 sachet (10 grams) of probiotic-omega and placebo per day. All sachets were identical with similar organoleptic characteristics (e.g., taste and appearance). The pre-randomization period was designed to minimize the effects of dietary changes on metabolic markers. For this purpose, 2 weeks before the study start, after inform consent signed, patients were instructed in one-on-one sessions with a dietitian to follow a therapeutic lifestyle-change diet as classiﬁed by the NCEP. In addition, participants were instructed to continue with stable anti-hyperglycemic treatment and received standardized mild physical training for 1 hour per day. Patients who underwent the study were instructed to take the trial medication as prescribed. Throughout the study, weekly phone follow-up visits were provided for assessment of compliance, adherence to the protocol, as well as the recording of adverse events. The effectiveness of therapy was compared and evaluated separately in the two groups.

Official Title
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Effect of Probiotic Co-administration With Omega-3 Fatty Acids on NAFLD: Randomized Clinical Studies

Conditions
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Type2 Diabetes, NAFLD, Probiotic, Omega-3 Fatty Acids

Intervention / Treatment
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* Dietary Supplement: Symbiter-Omega
* Dietary Supplement: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: adult participants (ages 18-75, BMI ≥25 kg/m2) diagnosed with NAFLD according to the recommendations of the American Gastroenterology Association (AGA) and American Association for the Study of Liver Disease (AASLD); the diagnosis of fatty liver was based on the results of abdominal ultrasonography. Of 4 known criteria (hepato-renal echo contrast, liver brightness, deep attenuation, and vascular blurring), the participants were required to have hepato-renal contrast and liver brightness to be given a diagnosis of NAFLD. type 2 diabetes treated with diet and exercise alone or metformin, SUs and insulin at stable dose at least 4 weeks prior to the commencement of the study; AST and ALT ≤3x upper limit of normal. Exclusion Criteria: alcohol abuse (>20 g/day (2 standard drinks) in women or > 30 g/d (3 drinks) in men over a two-year period); chronic viral hepatitis (associated with HBV, HCV, HDV infection); drug-induced liver disease, Wilson's disease, hereditary deficiency of antitrypsin-1 and idiopathic hemochromatosis; history of decompensated liver disease including ascites, encephalopathy or variceal bleeding; regular use of a probiotic or prebiotic supplement within 3 months prior to enrollment; antibiotic use within 3 months prior to enrollment; uncontrolled cardiovascular or respiratory disease, active malignancy, or chronic infections; use of agents such as vitamin E, omega-3 fatty acids or medications with evidence for effects on NAFLD (pioglitazone, GLP-1 analogues, dipeptidyl peptidase IV inhibitors, ursodeoxycholic acid); and presence of active infection, pregnancy or lactation.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

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: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: probiotic-omega<br>Over 8 weeks of interventional period, the patient received 1 sachet (10 grams) of gel per day. | Dietary Supplement: Symbiter-Omega<br>* Symbiter Omega which contains combination of flax and wheat germ oil (250 mg of each, concentration of omega-3 fatty acids 1-5%), supplemented with biomass of 14 alive probiotic strains: Lactobacillus + Lactococcus (6×1010 CFU/g), Bifidobacterium (1×101<br>|
| Placebo Comparator: placebo<br>Over 8 weeks of interventional period, the patient received 1 sachet (10 grams) of gel per day | Dietary Supplement: Placebo<br>* Over 8 weeks of interventional period, the patient received 1 sachet (10 grams) of gel per day<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| fatty liver index (FLI) | FLI = [e 0.953*loge (triglycerides) + 0.139*BMI + 0.718*loge (ggt) + 0.053*waist circumference - 15.745) / (1 + e 0.953*loge (triglycerides) + 0.139*BMI + 0.718*loge (ggt) + 0.053*waist circumference - 15.745)] × 100 | 8 weeks compared to baseline | 
| liver stiffness (LS) | liver stiffness (LS) was measured by Shear Wave Elastography (SWE) and expressed in kPa. | 8 weeks compared to baseline | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ALT | ALT in IU/L | 8 weeks compared to baseline | 
| AST | AST in IU/L | 8 weeks compared to baseline | 
| γ-GT | γ-GT in IU/L | 8 weeks compared to baseline | 
| Total Cholesterol (TC) | TC in mmol/l | 8 weeks compared to baseline | 
| Tryglicerides (TG) | TG in mmol/l | 8 weeks compared to baseline | 
| LDL-Cholesterol (LDL-C) | LDL-C in mmol/l | 8 weeks compared to baseline | 
| VLDL-Cholesterol (VLDL-C) | VLDL-C in mmol/l | 8 weeks compared to baseline | 
| HDL-Cholesterol (HDL-C) | HDL-C in mmol/l | 8 weeks compared to baseline | 
| cytokines levels | TNF-α, IL-1β, IL-6, IL-8, INF-γ in pg/ml | 8 weeks compared to baseline |