An Exploratory Clinical Study on Autophagy During Fasting

Study Overview
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Brief Summary
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Autophagy is considered one of the key molecular mechanisms for the broad preventive and therapeutic effects of periodic fasting. While it is generally known that fasting induces autophagy, there are no human studies that focus on the size and temporal kinetics of autophagy and its association with fasting specific signaling pathways. The kinetics of autophagy in patients with chronic diseases will now be compared with the kinetics of autophagy in healthy subjects, who both fast according to the same scheme; and further changes in metabolic and inflammatory parameters will be investigated.

Detailed Description
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Therapeutic fasting has been used for many decades in naturopathy and integrative medicine clinically successfully in the treatment of chronic diseases and pain syndromes. In particular, fasting therapy is used for chronic rheumatic, inflammatory, and metabolic diseases with increasing patient demand in specialized clinical facilities (fasting clinics). Within the various historically developed forms of fasting, the fasting program according to the Buchinger Wilhelmi method has established itself worldwide as the most frequently applied method. This involves a subtotal caloric restriction with a daily caloric intake (200-400kcal/day) in the form of liquid components over a defined period of at least 10 days, accompanied by supporting measures of a health-promoting lifestyle program with elements such as exercise therapy, manual procedures, stress reduction and hydro-balneotherapy. In early randomized studies and a systematic review, the effectiveness of inpatient fasting therapy for patients with rheumatoid arthritis was proven with 1a evidence. For the other indications, there is mainly empirical evidence or data from observation or prospective uncontrolled studies. In recent years, extensive basic science research activity has developed in the area of caloric restriction and intermittent fasting. In this context, a large number of favorable animal experimental findings have been demonstrated by defined fasting periods, including reductions in insulin, IGF-1, increases in adiponectins, insulin sensitivity, neurotrophic factors, and, over longer observation periods, a decrease in the incidence of cardiovascular, inflammatory, and metabolic, and more recently oncological diseases in a wide variety of animal species. Numerous experimental studies have demonstrated that fasting or total or subtotal caloric restriction is a potent inducer of cellular autophagy. For autophagy, numerous beneficial effects on chronic diseases or disease defense functions have now been experimentally documented and also hypothesized for humans, including neurodegenerative and metabolic diseases, but also acute infections and inflammatory diseases. Unclear to date is the kinetics of the autophagy enhancing effect of fasting. In theoretical transfer from animal experimental data, an increase is postulated between 12 and 36h of fasting and possibly a decrease after several days. Against this background, autophagy will now be investigated for the first time in blood samples from fasting healthy and diseased individuals in an exploratory clinical study.

Official Title
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The Kinetics of Autophagy During Periodic Fasting in Healthy People and Patients With Rheumatoid Arthritis or Metabolic Syndrome - an Exploratory Clinical Study

Conditions
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Healthy, Arthritis, Rheumatoid, Syndrome, Metabolic

Intervention / Treatment
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* Other: Fasting


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: One of the following diagnoses: rheumatoid arthritis, metabolic syndrome OR healthy volunteer Beginning (first 24h) inpatient treatment or hospital stay at Immanuel Hospital Berlin, Department of Naturopathy OR healthy volunteer Present written declaration of consent Exclusion Criteria: Insufficient linguistic communication Dementia or other cognitive disorder Pregnancy or lactation Simultaneous participation in another clinical trial

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 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: Basic Science
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 3 groups of different inclusion criteria (healthy, metabolic syndrome or rheumatoid arthritis) undergoing the same intervention
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Healthy Participants<br> | Other: Fasting<br>* Patients undergo a 5-10 day fasting period with a dietary energy supply 350-400kcal per day with fruit and vegetable juices or, if not feasible, an established fasting-mimicking diet of 600-800 kcal according to Longo et al.<br>|
| Active Comparator: Metabolic Syndrome<br> | Other: Fasting<br>* Patients undergo a 5-10 day fasting period with a dietary energy supply 350-400kcal per day with fruit and vegetable juices or, if not feasible, an established fasting-mimicking diet of 600-800 kcal according to Longo et al.<br>|
| Active Comparator: Rheumatoid Arthritis<br> | Other: Fasting<br>* Patients undergo a 5-10 day fasting period with a dietary energy supply 350-400kcal per day with fruit and vegetable juices or, if not feasible, an established fasting-mimicking diet of 600-800 kcal according to Longo et al.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Exploratory Proteomics of Autophagy Processes I | - Change in protein levels of autophagy biomarkers (LC3II & p62) of isolated PBMCs (peripheral blood mononuclear cells) by Western Blotting, change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Exploratory Proteomics of Autophagy Processes II | - Change in protein levels and protein phosphorylation by untargeted mass spectrometry-based proteomics and phosphoproteomics of isolated PBMCs (peripheral blood mononuclear cells), change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Muscle mass | Estimation of the body composition via bio-electrical impedance analysis (muscle mass in kg) | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Body fat | Estimation of the body composition via bio-electrical impedance analysis (body fat and visceral fat in %) | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Resting blood pressure |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Cutaneous carotenoid level (CCL) | Cutaneous carotenoid level (CCL), correlating with the overall antioxidant status, measured with a noninvasive skin carotenoid sensor (Biozoom®) | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Heart rate |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Waist to Hip Ratio |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Body Mass Index (kg/m2) |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Disease Activity Score 28 (DAS-28-CRP) | Change from Baseline in the DAS-28-CRP, range from 2.0 to 10.0 while higher values meaning a higher disease activity and below of 2.6 meaning remission | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Health Assessement Questionnaire (HAQ) | Change from Baseline in the HAQ, range from 0 to 3 while higher values meaning a higher grade of disability | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Simplified Disease Activity Index Score (SDAI) | Change from Baseline in the SDAI, range from 0 to 86 with assumed range from 0.1 to 10mg/dL for CRP. Higher values mean a higher disease activity and below of 34 meaning remission. | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Stress questionnaire (Cohen Perceived Stress Scale, CPSS) | Change from Baseline in the CPSS, range from 0 to 4 in each item. Scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 & 4 = 0) to the positively stated items and then summing across all scale items, higher values meaning a higher grade of perceived stress. | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Mindful Attention Awareness Scale (MAAS) | Assessing full scale, range from 15 to 90, higher score values meaning a better outcome. | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Numerical Analog Scales | Assessing stress, back pain, headache, shoulder/neck tension, sleep quality and duration, exhaustion, nervousness, digestive complaints, mood on 0-10 points each. | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Quality of Life questionnaire (WHO-5) | Change from Baseline in the WHO-5, range from 0 to 100 %, higher values meaning a higher grade of well-being | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Hospital Anxiety and Depression Scale (HADS) | Assessing full scale, range 0-42, lower score meaning a better outcome | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| General Self-efficacy Short Scale (ASKU) | Assessing full scale, range 3-15, higher score meaning a better outcome | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Mood questionnaire (Profile of Mood States, POMS) | Change from Baseline in Emotional Distress will be measured using the German Version of the Profile of Mood States (ASTS) short version (19 items, 7-point Likert scale; 0=not at all, 6=extremely). Lower scores indicate more stable mood profiles. | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Sociodemographic Measurements | Age, gender, education level, household income, employment status, marital status, language spoken, complete family history, current and previous illness and co-morbidities, and current medications | Day 1 (baseline) | 
| Behavioral Factors | Physical inactivity, coffee, health promoting activities via Likert Scales, range from 0 to 5 while higher values meaning a higher grade of agreement | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Behavioral Factors: alcohol consumption | Number of alcoholic beverages on average per week in the last month | Day 1 (baseline), after 2 and 6 weeks | 
| Behavioral Factors: smoking | Number of cigarettes on average per week in the last month | Day 1 (baseline), after 2 and 6 weeks | 
| Behavioral Factors: fasting experience | Type, definition, duration and date of previous fasting experiences | Day 1 (baseline) | 
| Expectation questions | For fasting on a 5-point likert scale from 1 (nothing at all) to 5 (very strong) | Day 1 (baseline) | 
| Creatinine in µmol per liter (µmol/L) |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Estimated glomerular filtration rate (eGFR) in milliliter per minute (mL/min) |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Electrolytes | potassium (mmol/L) sodium (mmol/L) | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Blood lipids and fasting glucose | triglycerides (mmol/L) total cholesterol (mmol/L) LDL (mmol/L) HDL (mmol/L) fasting glucose (mmol/L) | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Insulin (mU/L) |  | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| ß-Hydroxybutyrate | Evaluate change in ketone body production by POCT | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| CrP (mg/L) | Evaluate change in CrP levels in participants with RA | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Erythrocyte sedimentation rate (ESR) in millimeters per hour (mm/h) | Evaluate change in ESR in participants with RA | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Rheumatoid factor (RF, IgM) (U/mL) | Evaluate RF status in participants with RA | Day 1 (baseline) | 
| Anti-cyclic citrullinated peptide (ACPA) (U/mL) | Evaluate change in ACPA levels in participants with RA | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Metabolic processes | Targeted and quantitative analysis by mass spectrometry of change in metabolites of plasma, change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Lipid profiling | Targeted and quantitative analysis by mass spectrometry of change in plasma lipids, change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Transcription expression patterns | Change of the gene expression profile by RNA sequencing of isolated PBMCs (peripheral blood mononuclear cells), change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Proteome/phosphoproteome/ubiquitinome patterns | Evaluate proteome expression patterns through blood based proteome, phosphoproteome, and ubiquitinome analysis assessed prior to intervention (pre) vs. after 5-day fasting, day 2 of refeeding and 7 days post intervention | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Epigentic patterns | Evaluate epigentic methylation patterns through blood based epigenome analysis assessed prior to intervention (pre) vs. after 5-day fasting, day 2 of refeeding and 7 days post intervention | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 
| Exosomal protein patterns | Evaluate exosomal protein content through blood based metabolome analysis assessed prior to intervention (pre) vs. after 5-day fasting, day 2 of refeeding and 7 days post intervention | change from baseline over 5 fasting days, to day 3 refeeding and to 7 days follow up | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Fasting, Autophagy