Phenotyping of Adult Crohn's Focusing on Sarcopenia

Study Overview
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Brief Summary
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Inflammatory bowel disease (IBD) includes two idiopathic chronic relapsing and remitting inflammatory conditions affecting the gastrointestinal (GI) tract: Crohn's disease (CD) and ulcerative colitis (UC)Malnutrition and significant alteration of body composition are common in inflammatory bowel disease patients, whereby the prevalence of malnutrition may be up to 82.8% in CD patients with active disease, and up to 38.9% in CD patients in remission. Many CD patients have low muscle mass and function (sarcopenia) with drivers of such pathophysiology unknown. 41.6% of CD patients with sarcopenia require surgery, with the surgical trauma and resulting inactivity leading to further muscle mass loss such that the chronic inflammatory insult associated with refractory disease may be linked to advanced muscle mass depletion. The majority of adult CD patients have low muscle mass even in clinical remission indicating the poorly reversible nature of this phenomenon. Chronic disease burden may therefore be important in the accentuation of muscle loss. Muscle mass is maintained through the daily balance of MPS and muscle protein breakdown (MPB), with the essential amino acid (EAA) components of a meal and muscle contraction being the primary stimulators of MPS. Patients with active CD show a significant decrease in the expression of proteins in hypertrophic signalling pathways (Akt, P70S6K1) with no change in the expression of atrophic signalling (MAFbx, MuRF1). Also, adult CD patients with established disease consume less protein compared to matched healthy volunteers (HV). Furthermore, the intestinal motility, measured using cine-MRI, is reduced in active CD, possibly further decreasing intestinal digestion and absorption of dietary peptides. In general, the malabsorption is a major contributing factor to malnourishment in CD. It has been shown that in male paediatric patients with long-term CD, muscle metabolism is perturbed by a negative branched-chain amino acid balance in the forearm, with this variable linked to lower appendicular muscle mass, higher muscle fatigue and reduced protein intake, CD may have a significant effect on protein digestion and absorption, and blunt the MPS response to feeding, leading to a chronic muscle mass reduction that may persist even when in remission. The EAA components of a protein meal are crucial for the stimulation of muscle protein synthesis (MPS), and all the EAA/leucine play a key role in driving MPS. Low serum levels EAA/leucine have been reported in CD but their role in the aetiology of sarcopenia in CD is unknown. Further, how CD affects the protein digestion/absorption and how this contributes to low EAA/leucine unclear. Recent advances in stable isotope tracer techniques using a dual tracer methodology now enable a more accurate determination of protein digestibility. By following the appearance of intrinsically labelled AAs into the blood upon digestion of the intrinsically labelled protein, alongside the appearance of label-free AAs, protein digestibility can be accurately determined. Further, by collecting a muscle biopsy postprandially, the direct incorporation of AA from the digested protein into the muscle can be determined- providing a gold standard method for investigating anabolic resistance. Project aim is to use an intrinsically labelled casein to investigate protein digestion, absorption and MPS responses in CD patients. To achieve this, investigators will investigate protein digestion, absorption and muscle protein synthesis responses in Crohn's disease patients and healthy volunteers by utilising intrinsically labelled protein.

Official Title
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Deep Nutritional Phenotyping of Adult Crohn's Disease Patients: a Focus on Protein Intake and Sarcopenia

Conditions
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Inflammatory Bowel Diseases, Sarcopenia, Digestive System Disease, Nutrition, Healthy, Protein Malabsorption, Crohn Disease

Intervention / Treatment
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* Dietary Supplement: Intrinsically labelled protein


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for Healthy group Aged 18 years or older BMI <30 kg/m2/ No previous known bowel disease Be able to provide written informed consent & participate fully in all aspects of the study. Inclusion Criteria for Crohn's group: Aged 18 years or older. BMI <30 kg/m2 Documented diagnosis of CD previously confirmed by endoscopy and histology at least 2 years prior to enrolment. Active CD defined as HBI >4 and CRP >5g/l or FCP >250ug/g or as deemed through endoscopy or cross sectional imaging. Previous biologic or immunosuppressant exposure Previous CD-related intestinal surgery Able to participate fully in all aspects of the study Written informed consent obtained and documented Exclusion Criteria for Healthy group Aged 18 years or older BMI <30 kg/m2/ No previous known bowel disease Be able to provide written informed consent & participate fully in all aspects of the study. Exclusion Criteria for Crohn's group A current diagnosis of ulcerative colitis, indeterminate colitis, microscopic colitis, or diverticular disease-associated colitis A diagnosis of short-bowel syndrome Use of systemic corticosteroids for CD (2 continuous weeks or more) within 3 months prior to enrolment, or use of any medications for HVs and CD, in the opinion of the investigator, may interfere with the subject's ability to participate fully in the study. Serious underlying disease other than CD that, in the opinion of the investigator, may interfere with the subject's ability to participate fully in the study. History of active alcohol or drug abuse that, in the opinion of the investigator, may interfere with the subject's ability to comply with the study procedures. Pregnancy or breastfeeding. Contraindications for DEXAscanning e.g. x-ray within last 7 days. Allergy to milk, , or casein

Ages Eligible for Study
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Minimum Age: 18 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
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Healthy group (Control group )<br>This group will include healthy participants matching Crohn's group | Dietary Supplement: Intrinsically labelled protein<br>* It is a protein drink that includes Intrinsically labelled Casein ( from Arla Foods), 13C/2H-labelled Spirulina (from CK Isotopes), and 13C/2H-labelled amino acids (from CK Isotopes)<br>* Other names: Intrinsically labelled Casein;|
| Experimental: Crohn's group or patients group<br>This group will include patients with Crohn's disease. | Dietary Supplement: Intrinsically labelled protein<br>* It is a protein drink that includes Intrinsically labelled Casein ( from Arla Foods), 13C/2H-labelled Spirulina (from CK Isotopes), and 13C/2H-labelled amino acids (from CK Isotopes)<br>* Other names: Intrinsically labelled Casein;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postprandial muscle protein synthesis. | Postprandial muscle bound [ring-D5]-Phenylalanine, [5,5,5-D3]-Leucine as measured through mass spectrometry | Change from baseline 4 hours (Two time points) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Appearance/ digestibility of plasma Amino Acid in blood. | Postprandial plasma [ring-D5]-Phenylalanine, [5,5,5-D3]-Leucine as measured through mass spectrometry | blood samples will be taken at regular intervals up to 240 minutes (max 120ml total blood draw post protein drink). 12-time points | 
| Muscle mRNA expression of anabolic and catabolic | The mRNA expression of transcripts involved anabolic and catabolic signalling pathways as measured through RT-qPCR (Applied Biosystems). | Change from baseline at 4 hours (Two time points). | 
| Muscle protein expression of anabolic and catabolic pathway. | Muscle protein expression of anabolic and catabolic pathway signalling proteins | Change from baseline at 4 hours (Two time points). | 
| Serum Cytokines levels of IL-1 | As measured using ELISAs | Only at baseline. | 
| Serum Cytokines levels of IL-6 | As measured using ELISAs | Only at baseline. | 
| Serum Cytokines levels of IL-10 | As measured using ELISAs | Only at baseline. | 
| Serum Cytokines levels of CRP | As measured using ELISAs (IBDQ) | Only at baseline. | 
| Serum Cytokines levels of TNF | Daily energy intake and dietary macronutrient composition | Only at baseline. | 
| Appendicular Lean Mass (ALM) to Height Ratio (Kg/Height2) through DEXA scan | - It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scan will be a whole-body scan for total body composition measurement including ALM to height. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Appendicular skeletal muscle index (ASMI; kg/m2) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scan will be a whole-body scan for total body composition measurement including ASMI. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software | Only at baseline | 
| Skeletal muscle index (SMI; kg/m2) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scan will be a whole-body scan for total body composition measurement including SMI. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Skeletal Muscle Mass Percentage (SMM; %) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Total Body Fat Percentage (BF; %) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Fat Mass Index (FMI; kg/m2) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Resting Metabolic Rate (RMR) through DEXA scan. | It will be assessed via DEXA scan using a GE Lunar Prodigy DEXA scanner housed in the University of Nottingham's David Greenfield unit. The scans will be analysed using the scanners inbuilt Corescan software. Regional measurements will be taken post scan using custom analysis functions within the Corescan software. | Only at baseline | 
| Muscle Strength through Handgrip | Handgrip Dynamometers are instruments for measuring the maximum isometric strength of the hand and forearm muscles | Only at baseline | 
| Muscle Strength through Cybex Dynamometer | A CYBEX Isokinetic Test is used to measure the maximum strength of a joint throughout its available range-of-motion (ROM). | Only at baseline | 
| Daily physical activity | Physical activity as measured with IPAQ | Only at baseline | 
| Quality of life for Crohn's disease patients | measured through the Short Quality of Life Questionnaire for Inflammatory Bowel Disease | Only at baseline | 
| Dietary intake of one day before the experiment day. | As analysed by using intake24 website; https://intake24.co.uk/info/output . The participant will be received email included the link to fill it by what they intake on this day. | Only at baseline | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Labelled protein, protein, muscle protein synthesis, muscle mass, sarcopenia, Inflammatory bowel disease, Crohn's disease, nutrition, DEXA, 13C/2H-labelled amino acids