OsteoPreP: Food Supplements for Postmenopausal Bone Health

Study Overview
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Brief Summary
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To evaluate the effect of 12 months of supplementation with a probiotic (probiotic plus prebiotic; 2 capsules per day) on relative change (%) in total volumetric bone density (measured using high resolution peripheral quantitative computed tomography [HR-pQCT]) of the distal tibia.

Detailed Description
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It is well established that bone loss occurs throughout life after the attainment of peak bone mass which is usually reached by the end of the second decade of life. During the first 5-8 years following menopause, women experience an accelerated bone loss, which is then followed by a slower phase of decline in bone mineral density (BMD). As over 40% of all women in Australia will suffer an osteoporotic (fragility) fracture in their lifetime, investigating interventions that can prevent bone loss in postmenopausal women is a critical focus. The menopausal transition is also associated with an increased risk of cardiovascular disease, diabetes, and cognitive decline. These conditions and their treatments can also affect bone health. Previous research has indicated a potential link between the gut microbiome and bone health. Animal studies indicate that interventions affecting the gut microbiome may be successful in reducing bone loss, but human data is limited. Moreover, there is an emerging body of evidence linking the gut microbiome to cognitive, muscle and cardiometabolic function. Such studies indicate that probiotics (healthy gut bacteria) or prebiotics (food for healthy bacteria, e.g. fibre) can increase the amount of short chain fatty acids - such as butyrate -produced by the bacteria in the gut which may mediate the beneficial effects of improving gut health. The proposed study is a double-blind, placebo-controlled randomised trial, which will investigate whether consuming a probiotic supplement containing inulin (a prebiotic soluble fibre) twice daily for 12 months will improve bone health in postmenopausal women. In addition, secondary outcomes will measure the effect of the intervention on immune system modulation and cognition as well as musculoskeletal and metabolic function as potential mediators. One hundred and sixty postmenopausal women who are at least one year from their final menses will be recruited from the community via a mail out, advertisements in newspapers, social media, flyers as well as a landing page on an ACU managed website. The investigators have also applied for assisted mail outs through Services Australia for recruitment purposes. Services Australia is able to extract names and addresses of some target study demographics (females living in Melbourne aged between 40 and 65) from the Medicare database and mail them the study details on our behalf. Those wishing to participate will undergo a series of baseline assessments inclusive of bone mineral density scans, blood and stool sampling and physical activity and lifestyle questionnaires. They will then be randomised, in a blinded fashion, to consume one of the following two supplements: Placebo control group (n = 80): Placebo capsule - 2 capsules per day Probiotics group (n=80): Probiotic capsule - 2 capsules per day Study outcomes will be measured at baseline, 6 months, and 12 months. In addition, participants will be contacted via the telephone and email at three-month and nine-month timepoints to report any adverse responses to the supplementation. At the 12-month time point, participants will cease supplementation and immediately (within 24 hours) attend a post intervention assessment and will complete identical assessment measures to those they did at baseline. Finally, at 2 weeks post supplementation cessation participants will be asked to attend an appointment to provide a final stool sample. If it can be confirmed that long term consumption of a probiotic supplement can have beneficial effects on bone health, muscle health, and metabolic health in postmenopausal women, this intervention could be recommended in the prevention of osteoporosis and associated musculoskeletal and metabolic conditions.

Official Title
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OsteoPreP: The Effect of Probiotic Supplementation on Bone, Muscle, and Glucose Metabolism in Postmenopausal Women: A Randomised Placebo-controlled Trial

Conditions
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Postmenopausal Osteopenia, Bone Loss, Age Related, Age-Related Sarcopenia, Glucose Metabolism Disorders, Age-related Cognitive Decline

Intervention / Treatment
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* Dietary Supplement: Pendulum WBF-038
* Dietary Supplement: Pendulum Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Postmenopausal women, 40-65 years old Caucasian (due to significant differences in BMD and bone remodelling between ethnicities) At least one year since final menses Signed informed consent Up to date Covid 19 vaccination status Able to walk without the use of an aid Stated availability throughout the entire study period Mental capacity to understand and willingness to fulfil all the details of the protocol Exclusion Criteria: Diagnosis of osteoporosis T-score of -2.5 or less at the femoral neck or lumbar spine (L1-L4) on the DXA scan at screening visit HbA1c ≥6.5% at screening visit Blood pressure at screening visit of systolic >180 mmHg and/or diastolic >120 mmHg Untreated hyperthyroidism Rheumatoid arthritis Diagnosed with a disease-causing secondary osteoporosis or malabsorption: chronic obstructive pulmonary disease, inflammatory bowel disease, celiac disease, type 1/type 2 diabetes, or chronic liver disease Bariatric surgery Recently diagnosed malignancy (within the last 5 years) Current or recent oral corticosteroid use (any dose within the last 3 months, or 5mg of Prednisolone (or equivalent) or a higher daily dose for 14 days or more 3-12 months prior to screening) Use of antiresorptive therapy, including systemic hormone replacement therapy, bisphosphonates, strontium ranelate (current or during the last 3 years) Use of teriparatide (current or during the last 3 years) Participation in other clinical intervention trials Antibiotics treatment 2 months prior to inclusion Unwilling to cease taking other probiotic or prebiotic supplements (current use)

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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Female

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: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized placebo-controlled trial
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Pendulum WBF-038<br>Pendulum WBF-038, a proprietary formulation of the following strains: Akkermansia muciniphila, Clostridium butyricum, Clostridium beijerinckii, Anaerobutyricum hallii, Bifidobacterium infantis, plus chicory inulin and magnesium stearate - 1 capsule with the morning meal and 1 capsule with the evening meal for 12 months. | Dietary Supplement: Pendulum WBF-038<br>* All bacteria contained in Pendulum WBF-038 are commensal organisms that have been repeatedly documented to inhabit the human gastrointestinal tract under normal circumstances. Pendulum's WBF-038 is a proprietary formulation of the following strains: Akkermansia muciniphila, Clostridium butyricum, Clostridium beijerinckii, Anaerobutyricum hallii, Bifidobacterium infantis, plus chicory inulin and magnesium stearate. The organisms were grown under controlled conditions consistent with Good Manufacturing Practices (GMP) and employ no animal-derived products. All ingredients utilized during manufacturing were food grade and qualified as generally recognized as safe (GRAS). The product is provided as acid-resistant capsules in bottles that are to be stored refrigerated at 4℃.<br>|
| Placebo Comparator: Pendulum Placebo<br>Pendulum Placebo containing Magnesium stearate - 1 capsule with the morning meal and 1 capsule with the evening meal for 12 months. | Dietary Supplement: Pendulum Placebo<br>* Pendulum placebo capsules containing magnesium stearate<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Total volumetric bone mineral density of the distal tibia | Percentage change in total volumetric bone density measured using high resolution peripheral quantitative computed tomography (HR-pQCT) of the distal tibia. | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Bone mineral density of the lumbar spine | Relative change in lumbar spine (L1-L4) bone mineral density (BMD) measured using dual energy X-ray absorptiometry (DXA) | 12 months | 
| Bone mineral density of the hip | Relative change in total hip BMD measured using DXA | 12 months | 
| Tibia and radius trabecular bone volume | Relative change in tibia and radius trabecular bone volume fraction measured using HR-pQCT | 12 months | 
| Tibia and radius cortical area | Relative change in tibia and radius cortical area measured using HR-pQCT | 12 months | 
| Tibia and radius cortical volumetric bone mineral density | Relative change in tibia and radius cortical volumetric BMD measured using HR-pQCT | 12 months | 
| Total volumetric bone mineral density of the distal radius | Relative change in total volumetric BMD of the distal radius measured using HRpQCT | 12 months | 
| Serum C-terminal cross-linking telopeptide of type I collagen (ßCTX-I) - bone turnover marker | Relative change in ßCTX-I in serum | 6 months and 12 months | 
| Serum procollagen type 1 N-terminal propeptide (P1NP) - bone turnover marker | Relative change in P1NP levels in serum | 6 months and 12 months | 
| Serum osteocalcin (OC) - bone turnover marker | Relative change in OC in serum | 6 months and 12 months | 
| Short-chain fatty acids (SCFAs) | Relative change in SCFA levels (including butyrate) in stool | 6 months, 12 months, and 2 weeks post intervention | 
| 16s rRNA genetic sequencing of the gut microbiota | Relative change in species-level gut microbiota composition in stool using 16s rRNA sequencing | 6 months, 12 months, and 2 weeks post intervention | 
| Fasting blood glucose | Relative change in fasted blood glucose levels in circulating blood | 6 months and 12 months | 
| Glycated haemoglobin (HbA1c) | Relative change in HbA1c levels in circulating blood | 6 months and 12 months | 
| Lower leg muscle area | Relative change in lower leg muscle area measured using HR-pQCT | 12 months | 
| Lean body mass | Relative change in appendicular lean body mass measured using DXA | 12 months | 
| Grip strength | Relative change in left and right hand grip strength measured using a hand dynamometer | 6 months and 12 months | 
| High-sensitivity C-reactive protein (hs-CRP) | Relative change in hs-CRP levels in serum | 6 months and 12 months | 
| Regulatory T lymphocytes (Tregs) | Relative change in circulating number of Tregs in blood | 12 months | 
| Oral glucose tolerance test (OGTT) | Relative change in oral glucose tolerance in circulating blood | 6 months and 12 months | 
| Muscle tissue glycogen content | Relative change in muscle tissue glycogen content obtained from a muscle biopsy | 6 months and 12 months | 
| Muscle tissue triglyceride content | Relative change in muscle tissue triglyceride content obtained from a muscle biopsy | 6 months and 12 months | 
| Muscle tissue type 1 fibre composition | Relative change in muscle tissue type 1 fibre proportion obtained from a muscle biopsy | 6 months and 12 months | 
| Lipocalin2 | Relative change in Lipocalin2 (intestinal inflammation) in stool | 6 months, 12 months, and 2 weeks post intervention | 
| Cogstate One back Test Cognitive performance test | Relative change in speed of performance and number of errors in the One Back Test using the Cogstate cognitive assessment tool. Lower score = better performance | 6 months and 12 months | 
| Cogstate Groton Maze Learning Test Cognitive performance test | Relative change in number of errors in the Groton Maze Learning Test using the Cogstate cognitive assessment tool. Lower score = better performance | 6 months and 12 months | 
| Cogstate Continuous Paired Associate Learning Test Cognitive performance test | Relative change in accuracy of performance and number of errors in the Continuous Paired Associate Learning Test using the Cogstate cognitive assessment tool. Lower score = better performance | 6 months and 12 months | 
| Cogstate Social Emotional Cognition Test Cognitive performance test | Relative change in accuracy of performance in the Social Emotional Cognition Test using the Cogstate cognitive assessment tool. Higher score = better performance | 6 months and 12 months | 
| Depression, Anxiety and Stress Scale 21 | Relative change in depression, anxiety and stress measured using the Depression Anxiety and Stress Scale 21 (DASS-21) questionnaire. The DASS-21 has a minimum score of 0 and a maximum score of 63 with higher scores indicating a worse outcome. | 6 months and 12 months | 
| Gastrointestinal Symptom Rating Scale | Relative change in gastrointestinal symptoms measured using the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. The GSRS has a minimum score of 5 and a maximum score of 45 with higher scores indicating a worse outcome. | 6 months and 12 months | 
| Plasma glucagon-like peptide 1 | Relative change in gut hormone glucagon-like peptide 1 [GLP-1] in plasma | 6 months and 12 months | 
| Plasma peptide tyrosine-tyrosine | Relative change in gut hormone peptide tyrosine-tyrosine [PYY] in plasma | 6 months and 12 months | 
| Plasma adiponectin | Relative change adiponectin in plasma | 6 months and 12 months | 
| EuroQol Five Dimensions Quality of life Medical Outcome Survey | Relative change in quality of life measured using the EuroQol Five Dimensions (EQ-5D) questionnaire. The EQ-5D has a minimum score of Level 1 and a maximum score of Level 5 with higher levels indicating a worse outcome | 6 months and 12 months | 
| Social Interaction Anxiety Scale | Relative change in social anxiety measured using the Social Interaction Anxiety Scale (SIAS) questionnaire. The SIAS has a minimum score of 0 and a maximum score of 80 with higher scores indicating a worse outcome. | 6 months and 12 months | 
| The Warwick-Edinburgh Mental Wellbeing Scale | Relative change in mental wellbeing measured using the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) questionnaire. The WEMWBS has a minimum score of 14 and a maximum score of 70 with higher scores indicating a better outcome. | 6 months and 12 months | 
| Continuous blood glucose level monitoring for 10 days | Relative change in blood glucose (area under the curve) over 10 days measured using a continuous glucose monitoring device | 6 months and 12 months | 
| Fasting blood insulin | Relative change in fasted blood insulin levels in circulating blood | 6 months and 12 months | 
| Fat mass | Relative change in total body fat mass measured using DXA | 12 months | 
| Blood metabolomics | Relative change in blood metabolites using liquid chromatography-mass spectrometry | 12 months | 
| Office blood pressure | Relative change in Systolic and Diastolic blood pressure measured using a sphygmomanometer | 6 months and 12 months | 
| The Visual Analogue Scale Pain Intensity | Relative change in current pain intensity measured using a visual analogue scale (VAS) pain intensity scale. The VAS has a minimum score of 0 and a maximum score of 10 with higher scores indicating a worse outcome. | 6 months and 12 months | 
| Calprotectin | Relative change in calprotectin (intestinal inflammation) in stool | 6 months, 12 months, and 2 weeks post intervention | 
| Muscle mass | Relative change in total body muscle mass measured using DXA | 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Postmenopausal bone loss, Probiotics, Volumetric bone mineral density, Short-chain fatty acids