Impact of Cold Exposure on Metabolic Regulation in Children With Non Alcoholic Fatty Liver Disease (NAFLD)

Study Overview
=================
Brief Summary
-----------------
The aim of this project is to generate pilot data for a grant proposal to evaluate the impact of intermittent cold exposure (ICE) on brown and white adipose tissue (BAT/WAT) function in children with non-alcoholic fatty liver disease (NAFLD). The condition NAFLD is the most common liver disease in both adults and children. There are many emerging drug therapies for NAFLD but at considerable cost in terms of potential side effects. In a mouse model of diet-induced obesity, ICE was shown to help activate BAT, which may help NAFLD and other obesity associated health risks. Given that children have more BAT than adults, we hypothesise that intermittent cold exposure via a cooling vest in children with NAFLD will increase BAT stores or function. We will investigate whether intermittent cold exposure via a cooling vest device will stimulate BAT and also establish whether the cooling vest is acceptable to children and young people. If it is acceptable and has an impact on BAT function this could be a new treatment to reduce the severity of metabolic disorders associated with obesity, particularly fatty liver, e.g. hepatic steatosis. In stage 1, we will investigate the impact of intermittent cold exposure (ICE) on brown and white adipose tissue (BAT/WAT) function in young people aged 16 to 26 years old, as a feasibility study to optimise the cooling process. In stage 2, we will investigate the impact of ICE on BAT and WAT function in 8-16 year olds with non-alcoholic fatty liver disease (NAFLD) and matched controls. Participants will have thermal imaging, MRI scans and provide samples before and after wearing the cooling vest.

Detailed Description
-----------------
ICE BAT is a single centre pilot study. In stage 1, 12 young people aged 16-26 will be recruited into the study. Participants will use a cooling garment (for 1-2 hours). MRI scans and thermal imaging will be performed before and after ICE to evaluate BAT size and activation. Liver steatosis will be evaluated using MRI Proton Dense Fat Fraction (PDFF). Serum markers of BAT activation and glucose/lipid metabolism will be measured before and after ICE. In stage 2,12 children with NAFLD and 12 age- and sex-matched controls will be enrolled in the study. In stage 2a, healthy controls will use a cooling garment (for 1-2 hours) and undergo MRI scan and thermal imaging before and after ICE to evaluate BAT size and activation. Liver steatosis will be evaluated using MRI PDFF. In stage 2b the NAFLD patients will be asked to attend for one day and if they are happy to continue, will use a cooling garment (for 1-2 hours/day for a further 4 days). MRI scans and thermal imaging will be performed before and after ICE on day 1 and day 5 to evaluate BAT size and activation. Liver steatosis will be evaluated using MRI PDFF. Serum markers of BAT activation and glucose/lipid metabolism will be measured on day 1 and day 5. Participants with NAFLD, will be asked to give a faecal sample for analysis of their gut microbiome before the study and after day 5 of ICE treatment.

Official Title
-----------------
Impact of Cold Exposure on Metabolic Regulation in Children With Non Alcoholic Fatty Liver Disease (NAFLD)

Conditions
-----------------
Non-Alcoholic Fatty Liver Disease

Intervention / Treatment
-----------------
* Device: ICE


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Stage 1: Young Adult 16-26 year olds Individual must be aged 16-26 years Individual who has voluntarily signed informed consent Stage 2: Children 8-16 year olds Child aged 8-16 years old with NAFLD attending the paediatric clinic at Kings College Hospital A control group of children with a BMI z score <1.5 and no diagnosis of liver disease Individual willing to participate in the study with informed consent. If the participant is under 16, the parent should provide informed consent. Exclusion Criteria: Stage 1: Young Adult 16-26 year olds Individual who is thought to be too unwell to participate by the study team, e.g. if participant has a fever or infection requiring treatment with antibiotics. Individual who has a medical condition that requires treatment with a drug that could alter BAT function, e.g. thyroid disease (thyroxine, carbimazole, propylthiouracil, beta- blockers), liver disease (ursodeoxycholic acid), any condition requiring treatment with peroxisome proliferator-activated receptor gamma (PPAR-γ) agonists or 4 beta 3 adrenoceptor (β3-AR) agonists. Individual has smoked/vaped 5 days before participating in the study. Stage 2: Children 8-16 year olds Participant who is thought to be too unwell to participate by the study team, e.g. if participant has a fever or infection requiring treatment with antibiotics. Individual who has a medical condition that requires treatment with a drug that could alter BAT function, e.g. thyroid disease (thyroxine, carbimazole, propylthiouracil, beta- blockers), liver disease (ursodeoxycholic acid), any condition requiring treatment with peroxisome proliferator-activated receptor gamma (PPAR-γ) agonists or 4 beta 3 adrenoceptor (β3-AR) agonists Individual has smoked/vaped 5 days before participating in the study

Ages Eligible for Study
-----------------
Minimum Age: 8 Years
Maximum Age: 26 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Other
Intervention Model: Single Group Assignment
Interventional Model Description: ICE BAT study will be performed in two stages. In stage 1, we will recruit 12 healthy volunteers aged between 16-26 years. In stage 2, we will recruit 12 children aged between 8-16 years with NAFLD and 12 age- and sex-matched controls (healthy volunteers).
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intermittent Cold Exposure (ICE)<br>Stage 1- healthy volunteers aged 16-26 years will receive ICE for one day. stage 2a - controls aged 8-16 will receive ICE for one day. Stage 2b- NAFLD patients aged 8-16 years will receive ICE for one day or choose to continue for 5 days. | Device: ICE<br>* Intermittent Cooling Exposure using cooling garment for 1-2 hours<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Stage 1: Effectiveness in participants aged 16-26 | Assess the ability to deliver ICE via a cooling garment using a probe to measure skin temperature at regular intervals during ICE treatment. | One day | 
| Stage 1: Acceptability in participants aged 16-26 | Acceptability will be measured by the sum of participants' responses to questions 1-5 of the questionnaire. Responses to individual items will also be presented. | One day | 
| Stage 2: Effectiveness for 8-16 year old participants. | Assess the ability of ICE to deliver cooling, using a probe to measure skin temperature at regular intervals during ICE treatment. | One to Five days | 
| Stage 2: Acceptability for 8-16 year old participants. | Acceptability of the cooling jacket will be measured by the sum of participants' responses to questions 1-5 of the questionnaire. Responses to individual items will also be presented. Patients will be given the choice as to whether they are willing to attend for 5 days and undergo a further MRI, thermal imaging and blood sampling on day 5. | One to Five days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Stage 1: BAT dimensions: Measured using MRI before and after ICE. | Measurement of brown adipose tissue depots will be recorded using MRI scans before and after ICE. | One Day | 
| Stage 1: BAT and WAT function: Assessed using MRI measurements before and after ICE. | Using measures of blood flow, fat fraction and water fraction taken during MRI, analysis analysis algorithms are used to distinguish between BAT and WAT, with blood flow measurements used as a surrogate marker of BAT function. | One Day | 
| Stage1 : BAT activity: Measured using thermal imaging before and after ICE. | Thermal imaging will be analysed for average temperature of the BAT region of interest and the upper chest area before and after ICE treatment. | One Day | 
| Stage 1: Acceptability of study protocol and cooling garment: Measured using an acceptability questionnaire at the end of the study. | As above | One Day | 
| Stage 1: Autonomic function measured by the Empatica E4 device for the duration of the study. | As above | One Day | 
| Stage 1: Dietary information: Assessed using a 24 hour dietary recall at the beginning of the study day 1. | As above | One Day | 
| Stage1: Lipid profile: Measured through analysis of blood spot (collected before and after ICE, mandatory) by a secondary laboratory. | As above | One Day | 
| Stage1: Glucose measured before and after ICE (mandatory). | Glucose measured (in mmol/l) before and after ICE. | One Day | 
| Stage1: Metabolic hormone profile: Measured before and after ICE (optional). | Metabolic hormones measured before and after ICE, on serum samples by research laboratory. | One Day | 
| Stage1: Serum lipids measured before and after ICE (optional). | Serum lipids measured before and after ICE (optional) through Viapath Laboratory, King's College Hospital. | One Day | 
| Stage 2: BAT dimensions measured using MRI before and after ICE. | Measurement of brown adipose tissue depots will be recorded using MRI scans before and after ICE, on day 1 for stage 2a and day 1 and day 5 for stage 2b participants. | One to Five days | 
| Stage 2: BAT and WAT function assessed using MRI measurements before and after ICE. | Using measures of blood flow, fat fraction and water fraction taken during MRI, analysis analysis algorithms are used to distinguish between BAT and WAT, with blood flow measurements used as a surrogate marker of BAT function. | One to Five days | 
| Stage 2: Liver fat fraction(proton dense fat fraction (PDFF)): Measured in percentage using MRI before ICE on day 1 for stage 2a and before ICE on day 1 and after ICE on day 5 for stage 2b (PDFF measured using MRI). | As above | One to Five days | 
| Stage 2: BAT activity: Measured using thermal imaging before and after ICE on day 1 for stage 2a and day 1 and day 5 for stage 2b participants. | As above | One to Five days | 
| Stage 2: Acceptability of study protocol and cooling garment. | Measure using an acceptability questionnaire at the end of the study. The willingness of the participants to attend for 5 days is also a reflection on the acceptability of the study. | One to Five days | 
| Stage 2: Autonomic function measured by the Empatica E4 device. | As above | One to Five days | 
| Stage 2: Activity measured using the Fitbit for NAFLD patients completing 5 days of ICE. | As above | One to Five days | 
| Stage 2: Dietary information: Assessed using a 24 hour dietary recall, completed at the beginning of study day 1 (and on Day 5 for NAFLD patients who continue to five days). | As above | One to Five days | 
| Stage 2: Lipid profile: Measured through analysis of blood spot (collected before and after ICE on day 1 for stage 2a and day 1 and day 5 for stage 2b, mandatory) by an external laboratory. | As above. | One to Five days | 
| Stage 2: Serum lipid measurements before and after ICE (optional) | Serum lipids measured before and after ICE (optional) through Viapath Laboratory, King's College Hospital. | One to Five days | 
| Stage 2: Metabolic hormone profile before and after ICE (optional). | Metabolic hormones measured before and after ICE, on serum samples by research laboratory. | One to Five days | 
| Stage 2: Glucose measurements before and after ICE in stage 2 participants | Glucose measurements before and after ICE in mmol/l. | One to Five days | 
| Stage 2: Gut microbiome evaluation in NAFLD participants (optional). | Bacterial DNA will be isolated from faecal samples to study 16S RNA sequencing. | One to Five days |